Google
tiber dieses Buch
Dies ist ein digitales Exemplar eines Buches, das seit Generationen in den Regalen der Bibliotheken aufbewahrt wurde, bevor es von Google im
Rahmen eines Projekts, mit dem die Bucher dieser Well online verfugbar gemacht werden sollen, sorgfaltig gescannt wurde.
Das Buch hat das Urheberrechl uberdauert und kann nun dffenllich zuganglich gemacht werden. Ein dffentlich zugangliches Buch ist ein Buch,
das niemals Urheberrechten unterlag oder bei dem die Schutzfrist des Urheberrechts abgelaufen ist. Ob ein Buch offentlich zuganglich ist, kann
von Land zu Land unterschiedlich sein. Offentlich zugangliche Bucher sind unser Tor zur Vergangenheit und stellen ein geschichtliches, kulturelles
und wissenschaftliches Vermdgen dar, das haufig nur schwierig zu entdecken ist.
Gebrauchsspuren, Anmerkungen und andere Randbemerkungen, die im Originalband enthalten sind, finden sich auch in dieser Datei - eine Erin-
nerung an die lange Reise, die das Buch vom Verleger zu einer Bibliolhek und weiter zu Ihnen hinter sich gebracht hat.
Nutzungsrichtlinien
Google ist stolz, mit Bibliotheken in parlnerschaftlicher Zusammenarbeit offentlich zugangliches Material zu digitalisieren und einer breiten Masse
zuganglich zu machen. Offentlich zugangliche Bucher gehdren der Offentlichkeit, und wir sind nur ihre Hiiter. Nichtsdestotrotz ist diese
Arbeit kostspielig. Um diese Ressource weiterhin zur Verfugung stellen zu kdnnen, haben wir Schritte unternommen, um den Missbrauch durch
kommerzielle Parteien zu verhindem. Dazu gehdren technische Einschrankungen fur automatisierte Abfragen.
Wir bitten Sie um Einhaltung folgender Richtlinien:
+ Nutzung der Dateien zu mchtkommerziellen Zwecken Wir haben Google Buchsuche fur Endanwender konzipiert und mochten, dass Sie diese
Daleien nur fur persdnliche, nichtkommerzielle Zwecke verwenden.
+ Keine automatisierten Abfragen Senden Sie keine automatisierten Abfragen irgendwelcher Art an das Google-System. Wenn Sie Recherchen
iiber maschinelle Ubersetzung, optische Zeichenerkennung oder andere Bereiche durchfuhren, in denen der Zugang zu Text in groBen Mengen
nlitzlich ist, wenden Sie sich bitte an uns. Wir fdrdern die Nutzung des offentlich zuganglichen Materials fur diese Zwecke und kdnnen Ihnen
unter Umstanden helfen.
+ Beibehaltung von Google-Markenelementen Das "Wasserzeichen" von Google, das Sie in jeder Datei finden, ist wichtig zur Information iiber
dieses Projekt und hilfl den Anwendem weiteres Material iiber Google Buchsuche zu finden. Bitte entfemen Sie das Wasserzeichen nichl.
+ Bewegen Sie sich innerhalb der Legalitdt Unabhangig von Ihrem Verwendungszweck miissen Sie sich Ihrer Verantwortung bewusst sein,
sicherzustellen, dass Ihre Nutzung legal ist. Gehen Sie nicht davon aus, dass ein Buch, das nach unserem Dafurhalten fur Nutzer in den USA
dffentlich zuganglich ist, auch fur Nutzer in anderen Landem dffentlich zuganglich ist. Ob ein Buch noch dem Urheberrechl unterliegt, ist
von Land zu Land verschieden. Wir kdnnen keine Beratung leisten, ob eine bestimmte Nutzung eines bestimmten Buches gesetzlich zulassig
ist. Gehen Sie nicht davon aus, dass das Erscheinen eines Buchs in Google Buchsuche bedeutet, dass es in jeder Form und iiberall auf der
Welt verwendel werden kann. Eine Urheberrechlsverletzung kann schwerwiegende Folgen haben.
tiber Google Buchsuche
Das Ziel von Google besteht darin, die weltweiten Informationen zu organisieren und allgemein nutzbar und zuganglich zu machen. Google
Buchsuche hilft Lesem dabei, die Bucher dieser We lt zu entdecken, und unterstUtzt Au toren und Verleger dabei, neue Zielgruppen zu eireichen.
Den gesamten Buchtext kdnnen Sie im Internet unter http: //books . google. coiri| durchsuchen.
This is a reproduction of a iibrary book that was digitized
by Googie as part of an ongoing effort to preserve the
information in books and make it universaiiy accessibie.
Google" books
https://books.googie.com
]89i
1
V
'iNiiimiimijLimijmmjiiimjis
[ V l■'l|^||lMl»nlllmil;|i I
':;i»lll11lll|lll:|in|llll'.:|illi;illll’
UlllllliliHI'lUllll'
WiiMllllllllliliilMiililiniiiiiiiiiiiii^ ?!yj'Mllliiti|llMiliiiMtllMIJIilik'jl!ii]g
Digitized by
Digitized by
Google
Digitized by icjOOQle
Digitized by
6
L'x^
Digitized by
Google
Digitized by
Tan Lanc3t,]
[JlTNE 27, 18k..
THE LANCET.
91 3o\mml of asn'tiss^ anli ^foretsn ■ ilelriime, ^urgerp, P6ps(feIogp>
Cf)emfetrp, ^{)armatolo3p, fubltc ^raltj), nriis ^elosi*
IN TWO VOLUMES ANNUALLY.
VOL. I. FOE 1891.
SIXTY-NINTH YEAR.
EDITED BY THE PROPRIETORS:
THOMAS H. WAKLEY, F.RC.S. Em,
AND
THOMAS WAKLEY, Jun., L.R.C.P. Lond.
LONDON:
FEINTED AND PUBLISHED BY THE REGL'^iTEEED PKOPIUETOBS, AT THE OFFICE OF “THE LANCET," 423, STRAND..
MDCCCXCr.
Digitized by LjOOQle
Digitized by
Google
THE LANCET, Jaj^uaey 3, 1891.
Ilmitrb
THE OPEEmON OE ILEOSTOMY FOE
ORGANIC DISEASE. OF THE CAECUM
CAUSING OBSTRUCTION.
By THOMAS BRYANT, M.Cii.,
raiCSIDIiM' OK 'HIE ROYAI. COI.I.EOH OK SOIUjEONS, CON.SUl.TINO
aillWEON TO fJOV’S HOSPITAL, ETC.
The operation of enterostomy as lirsfc performed by
Ndlaton, and strongly advocated by Trousseau, has never
found much favour VKith British surgeons, and at the pre¬
sent day, when a general experience tells us that we may
deal as boldly with the peritoneum and the viscera it
encloses as with any other portion of the human frame, it
is never likely to become common, since at its best it
can rarely bo more than a temporising measure, and only
indirectly a curative one. That it may he the means of
relieving some of the most urgent and distressing symptoms
of obstruction as well as of prolonging life is not to be dis¬
puted, and that by so doing it may give nature an additional
chance of removing the cause of the obstruction is equally
clear; but it can do nothing in a direct way towards re¬
storing the continuity of the intestinal tract when me¬
chanically closed. JSevertheless, the principle of the
operation is good, and tho measure itself, even as it has
been practised, has a distinct place in surgery, and
must be regarded as a valuable audition to the surgeon’s
means of giving relief, when applied to the right
class of cases and carefully performed. As an operative
measure it has, however, a weak point, and that is the
uncertainty which the surgeon always feels as to the
anatomical position of the coil of distended intestine which
he may have opened, for N61aton’s directions were to open
the coil of bowel which presented at the wound which was
made in the right iliac fossa. If the coil which presented
happened to be low down in the ileum, all might be well ;
but if it happened to he a coil of jejunum, failure must
soon follow, for the patient would die of inanition. It
follows, therefore, that some method is wanted by which
the surgeon can be guided towards the lower part of the
ileum; and as in the following case I think I have cUs-
covoved a way by which this desirable ond may generally
bo secured, I have taken the present opportunity of bring¬
ing it before my professional brethren. The operation I am
about to describe may well be called “ileostomy.”
On Nov. 25th I was asked by Dr. Knaggs of Camden-
road to see with him a lady aged sixty-two, the mother of
nine children, who, although for three years subject to a
winter cough, had otherwise been healthy up to last May,
whoD, to quote Dr. Knaggs, who kindly favoured me with
the history of the case, “ she had a severe attack of flatu¬
lent dyspepsia, followed by diarrhoea, and for which all the
usual remedies were tried in vain, including opium, sul¬
phuric acid, chalk mixture, calomel in small doses, &o.
By careful dieting and the frequent use of starch and opium
enemata the diarrhoea subsided, and she became sufficiently
well to get about again. At that time there were no signs
of any tumour or of any abnormality of the abdomen. The
patient then went out of town and returned apparentlywell.
A month afterwards, on Oct. 20bh, tho diarrheoa again re¬
turned and a swelling made its appearance in the right
iliac fossa; this gradually increased in size, but subsequently
appeared to vary according to the state of the bowels—that
is, after relaxation the tumour became smaller, and after
a starch and opium enema it increased. Tho abdomen
generally was distended.”
On my visit on Nov. 25th I found a spare woman of fair
power with a distended and tympanitic abdomen, tho en¬
largement being very central and below the umbilicus. Tbc
loins and epigastric region were comparatively flat. Coils
of small intestine were very visible through the thin abdo¬
minal parietes, and perist^sis was very visible. In the
right lilac fossa there was an irregular swelling with
ridge-like projectionsuponitsanteriorsurface; firm pressure
upon this caused pain, but made no impreesion upon the
No. 3614.
outline of the swelling. I regarded this swelling as being
due to tumour, whicn I feared was of a carcinoma¬
tous nature. Under these circumstances 1 advised her
to undergo an operation, based on the lines of colotomy
for rectal stricture, and determined to open the lower
part of her ileum before it joins the cseoum at the ileo-cmcal
valve. Whilst arrangements were being made for this
operation I advised the external application of belladonna
and glycerine to the abdomen, the use of a four-ounce
nutrient enema with opium in it, alternating with a
nutrient suppository, every four hours, and a little fluid
to be given by Ihe mouth iu spoonfuls every half-hour.
For the purposes of operation I had her removed to Boling-
broke House, Wandsworth Common, a nursing home, in
which she could be well nursed and looked after.
On Dec. Ist I performed the operation, aided by Mr.
F. Burghard and the house surgeon, Mr. Lyster, by making
an incision about two or two and a half inches long in the
direction of the right semidunar line, with its centre corre¬
sponding to a line drawn across the abdomen from one
anterior superior spinous process of the ilium to the other.
Each layer of tissue was divided seriatim, and all bleeding
was arrested by torsion and hot iodine sponges. When
the peritoneum was reached it was carefully picked up
by forceps and opened the whole length of the wound,
when a coil of distended small intestine appeared at
the wound. The two edges of the parietal peritoneum
; were now seized with tenaculum-pointed catch-forceps
, and held aside whilst I introduced my right index finger,
which, having pushed aside the coil of intestine which pre¬
sented itself, came down at once upon the cascum, a.na in
less time than I can write this line I hooked up the ileum
just as it was about to join the caecum at the ileo-cmcal
valve. The bowel was distended, and its walls were very
thick—this condition clearly indicating the chronicity of
the obstructing cause.
I stitched Ibis portion of the bowel to the parietal
peritoneum by means of fine chromicised catgut sutures,
and passed the sutures through only the serous and muscu¬
lar coats of the bowel and the free edges of the divided
parietal layer of the peritoneum. I then brought the angles
of the wound together by sutures, and introduced two silk
loops into the walls of the bowel to serve as guides to the
second part of the operation, when the intestine will have
to be opened iu the course of two, three, or more days. The
wound was finally dusted with iodol and boracic acid (one
part to four), covered with some cut-up fragments of
iodoform gauze and a layer of wood-wool tissue, and
bandaged up. A suppository of one grain of the extract
of belladonna and of opium was administered, and direc¬
tions were given that the patient should be fed every
three or four hours by nutrient four-ounce enemata,
alternating with nutrient suppositories, and brandy and
water was to be given by the mouth, in spoonful doses, if
required.
Dec. 2nd,—The patient had passed a quiet night, and
had slept at intervals. She had taken some spoonfuls of
brandy and water. At 8 a.m. the temperature was 100°;
pulse 88. Suppository of belladonna and opium (half
strength) to be given.
3rd.—Had had a quiet twenty-four hours; very little
pain; no sickness. Temperature 99-4°; pulse 80; urine
normal.
4tli.—This being the third day after the operation, the
wound was examined, and it looked well. The intestine
was then opened. Tho line of incision into the bowel was
rendered easy by means of the guiding silk loops that had
been introduced for the purpose. If tliese had not been in,
much uncertainty would have been felt as to the right
point of puncture. Flatus passed freely from the bowel,
which at once collapsed. Some motion also soon passed by
the rectum, which was then washed out, and food was
ordered to: be given by the mouth.
Gth.—Doing well, though troubled with some bladder
irritation. Temperature normal.
A daily report of the progress of this case is not necessary,
as the operation wound went on well, and within three
weeks the artificial anus was fairly established, and the
motion which escaped from the wound was healthy and
semi-solid. Tlie patient herself improved in spite of her
bladder trouble, which was a source of distress. The abdo¬
minal swelling and pain also disappeared, and the prognosis
of the case may be said to be favourable.
Remarks .—In the cose related it will be noticed that
A
2 Thb Lancet,]
DR. ROBERT SAUNDBY ON TOXIC HYSTERIA.
[Jan. 3,1801.
th« object I had in view was to open the ileam just above
the Ueo-caccal valve; for the working diagnosis made of the
case was that of oardnoma of the caecum. The operation
determined upon was therefore on the lines of a lumbar
oolotomy for rectal stricture—that is, it had for its object
the formation of an artificial anus above the seat of the
intestinal obstruction. With this view I made my incision
la the right semilunar line, its centre corresponding with
a horizontal line drawn across the abdomen from one
anterior superior spinous process of the ilium to the other,
tuid the incision made was about one and a half to two
inches in length. Through this incisioD, when all bleeding
had been arrested, I passed my index finger, and pushing aside
a coil of distended small intestine, and coming down upon
the inner border of the cseeum I at once hooked up the
ileum and brought it to the surface. It is to be
noted that the coil of small intestine which first pre¬
sented itself was not the coil which was wanted.
The bowel was very thick, and felt like a stomach.
It had evidently, from over-work, become much hyper¬
trophied. The bowel was then sutured to the parietal
peritoneum by six fine chromicised catgut sutures, three on
each side, and care was observed not to pass the sutures
deeper than the muscular layer of the intestine. Where
the wound tailed off at either end, a suture was passed
through both edges of the divided parietal peritoneum, as
well as through the muscular walls of the bowel itself. The
outside wound was then brought together at both ends by a
few sutures introduced through the skin and muscles of the
opening. The bowel was not opened at the time of opera¬
tion, bnt two guiding loops of silk were passed through the
serous and muscular coats of the bowel, to indicate to the
surgeon the exact position at which, later on, the opening
into the bowel should be made. And let me add that with-
oat this aid great difficulty would have been experienced, and
conset^uently danger, in completing the operation; for on
the third day the whole surface of the wound when exposed
was covered with granulations, and there would have been
no guide whatever to indicate the point at which the punc¬
ture could, with safety, be made, whereas with the guidethe
completion of the operation was effected with certainty and
precision. In anurgentcasethe bowel would have to be opened
Jit once; the opening, however, need not be a large one, and
N61aton’0 directions to make it about a quarter of an inch
long should be followed. At a later period the opening can
easily be enlarged and without pain, the bowel having no
sensitive nerves. In ray own ca.se I made the opening
about half an inch long. For the first three days after
the first stage of the operation was completed the [jatient’s
powers w'ere kept going by means of small nutrient
enemata alternating with nutrient suppositories, adminis¬
tered every three hours, and a teaspoonful of brandy and
water by the mouth every half-hour. A belladonna and
opium suppository was given after the operation. After
the bowel was opened and relief ivas afforded to the
obstructed intestine, food was ordered by tbe mouth, and
was well retained. The patient is now, nearly five weeks
after tbe operation, convalescent, and her general condition
has much improved. The bowel empties itself without pain
through the artificial anus as well as through the normal
channel. This operation which I have just described, and
which for purposes of clearness may be called “ ileostomy,” is
as applicable to examples of chronic obstruction of the cjl^cum
from organic disease as is left lumbar colotomy for chronic
obstruction of the rectum. It is, moreover, applicable to
ca^es of acute orchronic ileo-cmcal intussusception in which,
from some cause or other, the opportunity for opening the
abdomen has been lost, or the time for doing it has passed,
jiud in which relief to symptoms is urgently called for.
It will also, in practice, be doubtless found to be applicable
to other cases when no other means of giving relief
can be suggested. Should tlie lower end of the ileum
in any given instance be found not to be tbe right
coil to be opened, the most distended one which presents,
as advised by Nclaton, may be taken as a substitute,
and the operation turned into one of Nclaton’s enterotomy
cases. The operation is nob a difficult one, and in extreme
cases, where an ansesthetic is likely to be dangerous, it
might bedone even without its aid. If the surgeon follows the
method I have just described in this paper, ho will, I am
convinced, be as pleased with the operation as 1 was ; and if
he gives his patient the relief my operation of ileostomy has
given mine, he will not be unwilling to repeat the measure
in an appropriate case.
CKitttitl • ■
ON
TOXIC HYSTEKIA.
Delivered at the General Hospital, Birmingham, on Monday^
March Srd, 1S90,
By KOBERT SAUNDBY, M.D., r,R.C.]\.
I’lIVSICIAN TO THE VIOSPllMI,.
Gentlemen,— The case I am going to sliow you to-day
belongs to a curious group of nervous diseases which have
been described as toxic hysteria. So far as I am aware, it
haa never been recognised in this country, and the only
reference of the sort in any English journal is a brief
account of a case of hemianmsthesia ascribed to lead poison¬
ing, included by Dr. Allen Sturge in a paper published in
the British Medical Journal for 1878, vol. L, p. 783.
This case was seen by him in Paris under the care of
Dr. L6pine; and it is entirely to French authorities
that we owe the recognition of the curious relations
that appear to exist between chronic intoxications—
e.g., by lead, alcohol, ike., and certain hysterical phenomena.
These have been almost exclusively observed in male
patients, and under circumstances where, as in the case I
am about fo relate, an error of diagnosis might easily be
made by anyone unacquainted with these relations, or at
least great difficulty might be experienced in forming a
conclusion as to their true nature. I am therefore glad of
this opportunity, as one that may nob soon recur, and I
trust you will store this case in your memories as a remark¬
able illustration of that protean disease, hysteria, which lurks
under so many strange shapes, to the confusion of our art
and not seldom to its discredit.
John W. T-, aged thirty-fcvou, storekeeper, ivas
admitted Jan. 2nd, 1800, complaining of Btifinesa, weak¬
ness, and numbness of the left leg, arm, and band, and.
also of sonic numbness and stiffness of the right hand.
Family history. —His father died aged forty-two, his
mother aged twonty-iive; causes of death unknown. One
brother living, aged forty-two, in good health; one sister
died, aged thirty-two, of dropsy and jaundice.
rrevinus history. —The patient remombers no illness, except
a feverish cold with which he was confined to the house lor
a fortnight when he was seventeen, until twelve years and
a half ago, when he had a quinsy, followed by what he calks
“lock-jaw,” for which he was treated in the Queen’s Hos¬
pital. This got well, but about the same time a numb¬
ness or tingling sensation came on in the foet, legs,
and tiiighs, which gradually disappeared. Ilis present
illness began two years and a half ago with severe
headaches, which were always worse on Sunday morn¬
ing. On Saturday nights he worked until 11 o’clock,
but on all other evenings he left work at G o’clock.
After six mouths the headaches left him, but he
began to feel a tingling in the left forefinger, which in the
course of three mouths spread to all tho lingers of the left
hand, and by the fifth month had spread to the wrist. At
the end of a year the left arm was affected by numbness,
tingling, coldness, and loss of muscular power. Tho left
foot and leg wore then attacked by similar symptoms, wliich
gradually reached as far as tlic knee. Six months ago the
right hand began to be similarly affected, bub in a much
slighter degree. Por the last two years his bowels had
been very constipated, being opened about once a week, and
then only by means of medicine. His work had been to serve
out stores, and amongst these he had to give out white lead,
which was kept in a barrel, from which he dug it out with a
spade, causing a good deal of dust. He also had to give
out turpentine, and to this he himself attributes his illness.
He was constantly exposed to changes of temperature. He
was a very moderate drinker, and denies having ever had
syphilis.
Present corulilion. —Tlie patient is a fairly well-developed,
sparely nourished man, with an anxious expression of face.
His left arm is firmly flexed at the elbow, wrist, and lingers,
the thumb being adducted and Hexed under the lingers.
T^ebh carious, no blue line on gums ; tongue clean; appetite
,L.oogle
Die;.
Tns Lancet,]
DR. ROBERT SA.UNDBY ON TOXIC HYSTERIA.
[Jan. 3,1891. 3
.j^ood; bowela conliutjd ; liver and spleen normal; heart
normal; lungs normal; pulse 72, regular ; respiration 18.
He complains of frequency of micturition and that he
cannot hold his niiiio so well as he did ; quantity normal;
contains no albumen, sugar, or bile, but ihereis il,-, gr. of
load to the pint. Generative functions normal.
Nervoua nystem .—Special senses normal. No diminution
•of held of vision or colour-blindness in either eye. Plantar
rellex diminished on the left side. Ankle clonus present on
both sides, but more marked on the left. Patellar rellex
exaggerated on the left side. Complete analgesia ■without
•an:i!sthesia over the left forearm and hand; elsewhere
sensation unallbcted ; electrical reaotion.s of muscles of fore¬
arm and leg are quite norma). Both the left arm and left
leg are weauened. In bod he keeps his leg stillly extended
at the knee and Hexed at the ankle to a right angle, and in
'walking ho maintains the leg in this position, although,
■when asked, he can Ilex the knee, dravv up the thigh, and
•extend the anklo. If one attempts to ilex the knee, it is
•easy to feel that the resistance increases witli the force used.
'There is very slight wasting of the muscles of the forearm
and leg. Girth of forearms, right O.'i’in., left in.; girth
•of calves, right 1.1 in., left 12;,' in.
On Jan. 2.^)fch he was put under chloroform, •when the
spasm of the left arm became quite relaxed. The limb was
.put-on a splint, and when consi'.ioivsness returned the spasm
•did nob recur. lie says his leg is “ alw.ays worse in the
morning (visit hour) and when anybody Is looking at him.”
When asked to execute particular inovenients of his leg, or
4i.rin, the limb is often thrown into violent clonic spasms,
which may extend to the whole of the same aide and are
•attended by obvious nervous exeiteinent.
March 2ad.—Ills hand and arm are still cyanosed, bub
the .spasm has entirely gone. He still Avalks iiadly, holding
the luub in the same rigid position. The analgesia seems
to bo almost if not entirely al)3ent.
This is a case of hysterical spastic hemiplegia. It may
be disbinguiahed from the -spastic paralysis of organic
,'<li 80 ase by the following circniu3tance.9: 1. ‘Primary spastic
hemiplegia is unknown as a disease of adult life; there is
no history hero of an apoplectic seizure, hut of a slowly
progressing paralysis. 2. There %va3 analgesia of the
afFectod forearm; whereas in organic disease sensation
would bo unaireebed. 1. The gait dill'ers from that of
organic disease in the foot being Hexed instead of being
extended in the talipes oquino-vani.s position, t. The
spasm is not constant; -when .standing he can point his
toes and Hex his knee. 5. Very slight wasting has occurred
'in spite of the paralysis Iiaving existed more than eighteen
months. 0. The spasm I'elaxcd completely under ciiloro-
foru), and has not recurred at the wrist and elbow. 7- The
•continued improvement which has taken place under simple
■treatment.
Some years ago I mob with .a very similar case, which I
recorded at the time in tho Binninghnub Medical lieviow
'{vol. ix., 1880, )). 27‘!). The patient, Jo.seph W-, aged
thirty, wag a house painter, who attended as ;iu out-patient
in May, 1880, complaining of pain in the chest. He had a
strong blue line on tiis gums, and was treated for leatl poison¬
ing. Six weeks after coming under objorvation bo came up
'to show his left hand, which was lirmly clenched and cya¬
nosed. lie stated that three days previously, while he was
at supper, both hands became spasmodically (lexeJ -so that
■“ho could nob let go his knife and fork.” This passed oil' in
■ about an hour, but the following morning the loft hand,
as ho e-\'prcssed it, “ went altogether.” The lingers were
'Jirmly Hexed on tho palm, tho tiiiiinb lying over'tiro fingers.
The skin of tho all'cctod hand was cyanosed, and felt colder
t])an on tho opposite side. There was slight numbness, but
no anicsthesia at lirst. On applying gold to the all'ectcd
arm for twenty minutes tlioro was complete amesthesia
of the opposite (right) forearm and hand; while, on
applying tl]e gold bo the light arm .sensation completely
returned, but disaiipearod in the corresponding parts on the
opposite (left) side. This is the hysterical iilicnonienon
described by Gliavcot as “ traiisfcreuce.” The muscles
reacted well to faradaisni, and under bToatniont hy this
current tho power of cxtemMng the lingers gradually
returned, while tho anmsthesia ilisappoared; but he began
to complain of pain in the course of the sciatic nerve, with
jerking of his log. .Soon after this ho was brought into
the hospital and treated in the surgery for what was
regarded as a “hysterical” lib, and a few days later he
returned with liis hand as lirmly contracted as ever, lie
then complained of a choking sensation, “as if a ball was
coming up in his throat” (the familiar globus hystericus).
Still later in the same year he was brought into hospital
in a cataleptic condition, having had a fit in the
street. Ilis hand was easily moulded, placed on a
splint, and fixed so as to maintain the extended
position. After a few days the splint was removed,
without the hand showing any tendency to resume its
contracted state, and he was dismissed with a caution,
lie was known to have kept well up to December in the
same year, after which time be was lost sight of. There
could be no doubt as to the bystorical nature of this
case, but, influenced by the writings of tho French school,
1 was at first inclined to attiibute the contracture and
amrsthesia wholly to the lead poisoning. Later on, after
he had been brought to the hospital in a hysterical fit, I
learned ho had been subject to such fits since he was fourteen
years of ago; he himself called tho attacks “hysterics.”
'Seven or eight years previously he had had an attack of
tremor in thd right arm. His family history was
free from any evidence of neuropathic tendencies, but
he waa a house-painter before his first fit occurred.
In the light ot the second case, and for the reasons already
given, 1 have no hesitation in classing the first case as one
of hysteria, but I had considerable doubt as to the import¬
ance to be attributed to the influence of lead, to which he
had been exposed, and which the analysis of his urine
showed had, to an appreciable extent, entered his system.
Iiaving looked in vain for any recent reference to the subject
in the books at niy disposal, I wrote to Frofessor Debove,
who eleven years ago published two cases under the name
of “Saturnine Hemiplegia,^ and got in reply a reference
to a more recent paper of hi.s own, which I have not been
able to obtain, and to a pamphlet by a Dr. Hischmann,®
entitled “Intoxications et Hystcrie,” in which may be
found a very clear account of what has been written on the
relations of hysteria to chronic poisoning by lead, alcohol,
and mercury. It seems to be now fully admitted by Pro¬
fessor Charcot and his followers that the nervous pheno¬
mena are truly hysterical and depend upon a fundamental
hysterical diathesis. The part played by the poison is now
regarded as merely that of an exciting cause. In reference
to this Dr. Ilischmaim says : “ It is even permissible to ask
whether, in 1he absence of the poison, the hysteria would
haveshowu itself? The question is dillicult to answer, bub
one may suppose that, had there been no poisoning, it
would have probably found some other exciting cause, such
as a traumatism or a vivid moral'imprcssion.”
Dr. Hisclmiann especially points out that these hysterical
paralyses cannot be confounded with true toxic paralyses,
us the electrical reactions, as we found in the present case,
are always normal, wlieceas it is well known that in true
toxic paralyses—e.g., in lead palsy—Ihefaradaiccontractility
is more or less lost. Besides the symptoms described, cases
have been recorded of apoplectic and epileptic seizures,
transitory aphasia, hemiamesthesia, oculo-motor paralyses,
unilateral blindness and colour blindness, mutism, and even
paralysis of tho extensors of the hand and wrist simulating
in its localisation the ordinary drop-wrist of lead palsy, yet
all of these of a hysterical nature. It is remarkable that
this association of hysteria with lead has been almost .ex¬
clusively observed in men, so far only one female ease having
been rooordeil.
I’rognoais .-—A cure may always he looked for in all
hysterical ailcctions, but it may bo a long time coming. I6
is of the greatest importance to bo sure of yonr diagnosis,
and tlicu to insist upon the essentially curable nature of
the disease.
TrcatiiiciiL —Tlio ti eatiuent of these cases should bo two¬
fold. By the administration of iodide of potassium we may
promote tho elimination of the lend which has accumulated
in the system, while, perhaps, acting through the imagina¬
tion, wo seek to get rid of the motor trouble. Several of
tlie French eases have been cured by the application of a
largo magnet to the allected side, and in several cases the
characteristic phenomenon of transference, or passago
of the analgesia to the corresponding limb on the
opposite .side, has been observed. Others have been
cured by the douche, others, again, by a w’oak gal¬
vanic current, especially when applied to tho skin by
moans of a brush electrode. We have tried tho douche
1 Le I’rogvts MdJ., 1870, Nos. f. .iiui 0
- Paris, O. Stointhoil, 1888.
: Goosle
4 The Lancet,] DR. P. MANSON: FILARIA SANGUINIS HOMINIS MAJOR AND MINOR. [Jan. 3,1891.
for our patient, and he has ereatly improved under
it; he is now getting galvanism aaily. He has also taken
a mixture containing iodide of potassium and magnesium
sulphate. We bare not used isolation and massage, the
value of which we have so often demonstrated in female
hysterical patients, because we have no male isolation ward
in which it could be carried out, but we have no doubt it
would prove equally effective.
THE FILAKTA SANGUINIS HOMINIS MAJOR
AND MINOR, TWO NEW SPECIES OF
HHilMATOZOA.
By PATRICK MANSON, M.D., M.K.O.P., LL.D.
On the lObh of November last Dr. Stephen Mackenzie
very kindly invited me to examine the negro Mandombi,^
then lying in the London Hospital, sufl'ering from the
“ sleeping sickness of the Congo.” Dr. Mackenzie told me
there were filaria embryos in Mandoinbi’s blood, and
that he had remarked certain peculiarities about them—
viz.: 1. They did not observe the periodicity characterising
filaria embryos in the human blood, but could be found
there at all times, whether by day or by night. 2. The
embryos did nob appear bo be all of the same size. 3. They
could nob be kept under continuous observation during
several days, as hitberto had been frequently done with
similar parasites in other cases of filarial infection, but dis¬
appeared in some mysterious way from the slides after a
very few hours.
On the occasion of ray first visit—made about 3 i*. M.—
being principally interested in his “sleeping sickness,”
and nob suspecting anything unusual about his parasites, I
made bub a very cursory examination of Mandombi’s blood.
I did, however, examine one filaria embryo with a high
power, and I have a distinct recollection that it possessed a
sheath, and seemed in every other respect like the ordinary
filaria sanguinis hominis I was familiar with. On the 2Qd
of December Mandombi was reported to be dying, and
Dr. Mackenzie, with a view to the anticipated post-mortem
examination, again very kindly requested me bo see him
and to examine his blood, especially in reference to the
blood parasites. I visited the patient at '.) I'.M, and
remained with him till 11 jmw., examining and preparing
many slides of his blood. The first slide examined was
a large one—one inch and a half by one inch. In it I
counted thirty-three active filaria embryos. Although
this examination was made with a low power, 1 could
easily see that some of the parasites were much smaller
than others ; and I also saw that the style of movement
indulged in by the smaller variety differed somewhat, in
some instances, from that of the larger. The latter, winch
I propose for the lime being to designate “ filaria sanguinis
hominis major,” resembled the ordinary filaria of the
blood, as described by Lewis and others ; and, at tliis time,
1 had no doubt it was this parasite. The smaller parasite,
which I propose to call “ filaria sanguinis hornitiis minor,”
exhibited a greater locomotive tendency than its larger com¬
panion. This circumstance, together with the dill'erence I
observed in the sizes of the parasites, led me to make a
Very careful examination with higher powers of the micro¬
scope of Mandomhi’a blood worm.s. As a result of this ex-
aimnation, and of subsequent study' of the filaria embryos
in the blood of three other negroes, I have come to the con¬
clusion that man is liable to be the host of at least two, if
not three, distinct species of filarial hiematozoa.
Mandombi died a few hours after my visit. Although at
the post-mortem examination, made next day, there was no
diliiculty in procuring innumerable specimens of the two
> Kf.r a report of tliis case see 'J.’iiK J.AXt'K'i' of Nov. 22tifl, 181K)
(Cliuk'al Society's meeting of Nov. 14tli, I8W).
; species of embryos, the parent form of neither could be dis-
i covered, notwithstanding a prolonged and careful search in
' every likely situation. All further study of Mandombi’s
I parasites—at all events, of their behaviour in the blood
during life—being at an end, it seemed that the oppor¬
tunity of working out a very interesting point in helmintho¬
logy had escaped us. Fortunately, however, within a very
few days of this man’s death 1 had the satisfaction of con¬
firming, in an irrefutable manner, the truth of my conjec¬
ture as to the specific difference of filaria sanguinis hominis
major and minor. For this opportunity I have again to
thank Dr. Stephen Mackenzie. He informed me that he had
had another Congo negro, S. C——, under his care in the
London Hospital some time ago, but that, as the patient
had begun to exhibit symptoms of insanity and was noisy and
troublesome in the wards, he had been removed to a lunatic
asylum. There Dr. Mackenzie and I visited him on
Doc. 7ch, and in blood drawn from his finger about 9 r.M.
we found several filaria embryos exactly like the filaria
sanguinis hominis minor of Mandombi, Thoiigli at that
time, and many times subsequently, many slides of this
man’s blood were examined, I have not encountered in it
one specimen of filaria sanguinis hominis major. This
last, in conjunction with other considerations, was sullicienfc
to prove that the one type of embryo is not a transition
form of the other, nor in any way connected with it, bub
that the two forms of bicmacozoa are specifically distinct-.
This is further borne out by the result of an examination I
subsequently made of tlie blood of three other negro lads
from Old Calabar. For this opportunity 1 am indebted to
the kindness of Dr. Grattan Guinness. In the blood of one
of these I found nothing abnormal, but that of the other
two contained filavim; one of them, K. M-, bad, like
S. C-, only filaria sanguinis bomini.s minor, but the
other, R. H-like Mandombi, had both filaria sanguinis
hominis major and minor. And, strange to say, just as in
Mandombi, the major filaria was observed to be ciiculating
in the blood during the clay, although R. II-was in
perfect health, and went to bed and got up at ordinary
liours. I have carefully scrutinised and measured this lad’s-
rilari:o sanguinis hominis major with the view of a.scertain -
ing if they are in any respect different from the ordinary
filaria ; but, as far as I can make out, with the exception
of some slight differences, they seem nearly identical.
The slight differences I allude to are the absence in K.
H——’s lllariaiof the granular aggregation so frequently seen
about the middle of the body of the filaria sanguinis
hominis as described by Lewis and others, a more delicate
investing sheath and more marked oral movements. The.se
slight differences, together with a different periodicity,
lead me to suspect that tlie African filaria sanguinis
hominis major is not the same as the filaria sanguinis
hominis of India, China, America, &c., but, like its com¬
panion, the filaria sanguinis hominis minor, that it, too, is
an entirely new species. And if this is the case with
R. H-’« major filaria, it was probably the case with Man
dombi’s, and we may conclude that the disturbance of
periodicity remarked by Dr. Mackenzie was not an ah- *
normality, but quite in conformity with the usual habit of
the worm. The fact that Mandombi and R. H-came
from the same district on the Congo bears on this. As the
filaria sanguinis hominis minor was alone found in the
blood of S. C-and R. M-, we are justified in regard¬
ing the concurrence of filaria sanguinis hominis major and
filaria sanguinis hominis minor in Mandombi and R H--
as a coincidence simply, just as we would the concurrence
of two separate species of ascaris in the same intestine. A
fortunate coincidence, it is true, as by presenting the two-
species together, and in contrast, attention was called to
th(;ir specific differences, which otherwise might have been
overlooked, as they liave probably been overlooked by
otiier observers less fortunately circumstanced.
To facilitate comparison I have arranged tlie distinctive
features of these two .species of hiematozoa, as far as I
have made them out, and of l/ewis’s filaria, in the follow¬
ing table:—
f ilaria Scmff uin'U nondnvs.
{Lewis )
1. Measure.s l -SOin. by 1-3.300in., or
thereabouts. (Lewis.)
2. Is provided with a elieath.
Filaria SanguiaiN Hominis Major-
Fig. 1.
1. Measures! 80 in. by 1-3500 in., or
thereabouts.
2 . Is provided with a more delicate
sheath.
Filaria Sanguinis Hominis Minor.
Fig.
1. Measures 1-125 in. by 1-5500 in.#
or tbei cabouts.
2. Has DO sheath.
Digitized
Google
The Lancet.3 DR. P. MANSON: FILARIA SANGUINIS HOMINIS MAJOR AND MINOR. [Jan. 3,1801. 5
3. Caudal end tapers gradually for
about one-fifth of the entire length of
the animal, and terminates in a sharp
or nearly sharp point.
4. Cephalic end is rounded off and
has obscure oral movements of a
pouting character.
.'3. No tongue-like organ visible.
(). Appears in the blood at night,
disappearing during the day.
7. Has a wriggling bub no loco¬
motive movement.
8. Many specimens have a granular-
looking aggregation about the middle
of the body.
3. Caudal end tapers gradually for
about one-ilfth of the entire length of
the animal, and terminates in a sharp
or nearly sltarp point. Fig. 3.
4. Cephalic end is rounded off and
has distinct oral movements of a
pouting character. Fig. 2.
6. No tongue-like organ visible.
G. Appears in the blood during the
day, disappearing during night.
7. Has a wriggling but no loco¬
motive movement.
8, No. granular-looking aggregation
about the middle of the body.
3. Caudal end tapers more gradually
for two-thirds of the entire length of
the animal, and is abruptly truncated
where it has tapered to about one-third
of the diameter of the thickest part of
the body. Fig. 8.
4. Cephalic end is either conical or
truncated, passing from one form to the
other rapidly by a peculiar jerking,
extruding, and retracting movement.
Figs. 5, C, 7.
5. From time to time a minute
tongue-like organ is rapidly protruded
and withdrawn at the extremity of the
cephalic end. Figs. 5, 6.
G. Observes no such periodicity.
7. Has a locomotive as well as a
wriggling movement.
8. No such appearance is visible.
In fresh specimens the body is, through¬
out, perfectly homogeneous and trans¬
it is desirable to add a few words in explanation and
amplification of each of these points of contrast.
1. The measurements of filaria eangnini.s bominis vary in
different specimens and according to different observers.
Tho.se I have given are Lewis’s, and tliey apply to African
filaria sanguinis hominis major as well as to its Asiatic
congener. They are not easily made on account of the
restlessness of the animal during life, and the rarity with
which it dies in a favourable attitude, as it generally
ceases to move in a bent or contorted position. Filaria
sanguinis hominis minor is usually well extended when
death approaches, and can therefore be measured with
accuracy. Its size varies within very narrow limits; and
the largest specimens never approach in size the smallest
examples of lilaria sanguinis hominis major. The filaria
sanguinis hominis major is about the breadth of a blood-
corpuscle; the filaria sanguinis hominis minor rather more
than half of this. But, though widely different in size, the
proportion of the breadth to the length is very nearly the
same in both species—viz., 1 to 45, or thereabouts,
2. The sheach, which is so distinctive a feature in filaida
sanguinis hominis major, is nob represented in filaria san¬
guinis hominis minor. I have looked for it most carefully
and with high powers, and in all states of activity and
torpor of the embryo, but have never seen any indicabon of
it whatever. Dr. Stephen Mackenzie showed me a very
effective method of demonstrating the sheath in the ordinary
filaria sanguinis hominis. By adding an equal quantity of
the warm urine of the filaria-bearing patient to a little of
his linger blood, on examining the mixture with the micro¬
scope it is seen that by a process of endosmosis from the
mixture of urine and serum and of exosmosis from the
body of the filaria into the sheath, this becomes so dis¬
tended with Iluid that it stands out tense, distinct, and
sharply defined, and is now no longer dragged after the
animal as a lash, but moves with it as a rigid tube. It
then looks like a piece of blown-out and transparent intes¬
tine. Owing to the peculiar and rather intractable mental
state of S. C- 1 was unable to apply this beautiful
and conclusive test to his filaria sanguinis hominis minor
embryos ; but from what I saw, both m fresh and stained
specimens, I am convinced it has no sheath.
3. The abrupt, truncated caudal end of filaria san¬
guinis hominis minor is strikingly unlike the pointed
tail of the larger embryo fdaria. Figs. 3 and 8. For pur-
po,s 0 s of diagnosis this feature is sufficiently distinctive,
and in future, when a hicmacozoon is seen in the hlood, it
will probably be found that the shape of the tail is the only
test necessary to apply to distinguish the smaller species.
4. Oral movements of a pouting character may be dis¬
cerned in filaria sanguinis hominis major, bub they are
by no means distinct, though, I think, more so than
in Lewis’s lilaria; in filaria sanguinis hominis minor
similar but much more distinct movements are readily
made out. In addition to these a rapid extension and
retraction of this end of the animal are distinguishable.
It looks as if the extreme anterior end (if I may use the
expression) is suddenly drawn hack, involuted, and short¬
ened by some sorb of muscular contraction, and then ns
suddenly allowed to spring forward as if by its own
elasticity. (Figs. 5, C, 7.)
5. I have never made out any kind of oral appendage
in lilaria sanguinis hominis major or in Lewises filaria.
parent.
But in filaria sanguinis hominis minor, by careful focusing
and' the use of a high power, one can see that from
time to time a miniue organ i.s shot out—snake-tongue
fashion—from tbe presumed position of the mouth, or,
perhaps, rather to one side of this. It is as suddenly
retracted as it is protruded. Owing to extreme minute-
nes.s and quickness of movement the exact shape uf
this organ is dillicult to make out. Sometimes I have
fancied that it is long and filiform, with a broad and
hemispherisal base; at other times ib has seemed to be
spatula shaped. At one time ib will project further
than at another, perhaps to a distance equal to about
half tbe diameter of the head. Should the animal turn
towards the observer this so-called tongue appears as
a circular black speck; and if the head is very carefully
watched as it lies fiat in profile on the slide, a similar hlacic
speck is often perceived moving up and down in what I may
term the mouth and phaiynx. Fig. 7. Nothing like a
mouth or pharynx can be seen, and probably do not exist;
I use these terms merely to indicate the position of the
little moving^speok. I may mention that Sonsioo figures a
somewhat similar organ as being present in certain canine
hjcinabozoalie found in Ibaly.-
G. The phenomenon called “filarial periodicity” is now
recognised as a characteristic peculiarity of filaria sanguinis
hominis as met within India, China, America, &o. I made
a aeries of observations on the embryo lilaria sanguinis
hominis minor in S. C- and of the major and minor
embryos in R. H-, bub failed to remark any correspond¬
ing periodicity in the case of the minor embryos. Embryos
were found at any time. I have no record of observations
in S. C- from midnight to 7 A.M., bub as tbe parasite
was found At the latter hour, and was also seen at midnight
and at lOl’.M., there is every probability it was present
during the few hours ib was not sought for. The ins^nity
of the patient and the scantiness of his stock of embryos
rendered him rather an unfavourable subject for studying
the question of periodicity; but the observations on
R. H-, backed as they are by Dr. Mackenzie’s observa¬
tions on Mandombi, are conclusive as to the absence of
periodicity in the minor embryos. The point is of some
importance, as ib will, when properly determined, servo
to guide us in a measure to the intermediary iiost of
S. C-’s parasites.
The following is the record of my examinations of
S C-’s blood. I would premise that a “slide” means the
amount of blood under a three-quarter inch cover glass : —
Dec. 7th.— 9 i*.M.: Many slides yielded 3 minor embryos.
nth. — 4 P.M.:
10
n
5
„ 0 P.M.:
6
3
11.55:
12th.— 7 a.m.:
1
1
•2
1
„ llA.M.:
2
1
9t
„ 3 p.m.:
4
ff
1
ff
., 11 P.M.:
•2
0
13th,— 7 a.m.:
2
O
„ 11 A.M.:
1
ff
2
„ 3 p.m.:
2
0
,, 11.15.P.M.:
14th.—11 A.M.:
1
0
3
5
1 1
,, 4 p.m.:
1
if
2
a t
^ Itccborcbo siigll Emiitozoi del Cane, Pb>^ J8SS,
Dig;: zed b. iC
6 TheLanckt,] dr. [\ MANSON: FILARTA SANOnNIS HOMINIS MAJOR AND MINOR. [Jan. .1, 1891.
The following record of my examinations of R. II-’s
blood also demonstrates the persistency of the presence of
the lllaria sADgiiinis hominis minor embryos both by ilay
and by night. It also shows that the law of periodicity for
the appearance of the major embryo is just the reverse of
that which has hitherto been found to apply to the iilaria
sanguinis hominis of Lewis.
Istday, liinoon: 2 slides 37 major embryos 1 minor embryo.
3 >
4 I'.M.
>> 93 >•
0
J) r. M.
22
» 22
0
2&d day,
1 A.M.
„ 0 ,,
0
fi A.M.
>. 0 ,,
1
j )
9 A..M.
II >•
1
ft
1 P.M.
1 , 2(i ,,
1
ft
5 y M.
II ,,
1
3rd day.
9 P.M,
1 A.M.
1 M 17
no examination.
0
.'■> A.M,
0
9A.M.
i> I 11
slide! „
0
>>
1 P.M.
poor
1)
5 P.M.
1
.. 12
9
I,
9 P.M.
0
49
0
4th day.
1 A.M.
I
n »»
1
TrA.M.
0
1
9 A.M.
I
„ 9
1
„
2 noon
4 slides 33 ,,
2
II
5 P.M.
3
35
1
I may state that the first two and the last two examina¬
tions were nmdo in fresh hlood; all Ihc otliers were of blood
which had been dried on a slide, and afterwards stained
with eosiiie and mounted in glycerine jelly. If carefully
done this latter plan seems to give as accurate results as
the examinations of fresli blood, and is infinitely more con-
venieut, as ir. may be undertaken at any time. 'I'he blood
must not he dried over a lamp or passed tlirough the Hnme.
Before definitely irronouncing on this inversion, in the
case of lihiria sanguinis liommia major, of the law of
periodicity which has been found to apply to tlie iilaria of
Lewis, it wouhl be well to repeat the observations I have
made in R. 11-on other cases of Iilaria sanguinis liominia
major, for it is just possible there may be sornething
peculiar ahoat R. II-, producing a disturbance of the
rhythm of his parasites, and (he parasite 1 have designated
“filaiia sanguinis hominis major” may, after all, be only ani
abnormnl Lewis’s Iilaria I do not think so, however. If
future observations contirm mine, we may conclude that the
(iluria sanguinis hominis major enters the general circulation,
some time between 9 .\.m. and noon, keeps in ft all day,
and disappears from it for the night some tiine between
1) I’.M. and miilnight. This, of cour.«e, has an important
hearing on the question of the intermediary host, to whose
^aidtsthis peculiar periodicity is undoubtedly an adapta¬
tion.
7. If specimen of iilaria sanguinis liomlnis major is
I'l^. 1, 3, 8 , Hlarla ssriKuirils lioininiH turdor; FigH, 4, &, u, 7, H, fllariii ssnguiDis homlnU ininur; Fig, 0, ho'iDiito/.oa of tho gouia aoroBata;
Figs. 10 11, of pica uwlia; Fig. 12, of the dog; Fig. 13, 9 giuuupica n'grlooUis; I'igo. 14 A 15, of uorvuir torrjuati m.
Digitized by
Google
Thb Lancet,] DR. P. MANSON : PILARIA SANGUINIS HOMINIS MAJOR AND MINOR. [Jan. 3,1891. 7
■watched, although it is seen to wriggle about very actively,
it does not appear to materially shift its position in the
held. Filaria sanguinis hominis minor behaves somewhat
•differently in this respect. It wriggles about just as
actively; but, in addition to this, it exhibits a tendency to
bore its way among the blood-corpuscles in a more or less
•definite direction, and unless, as frequently happens, it
becomes entangled in a rope of fibriae, it will in a very short
•time move off the hekl, if that is a small one, altogether.
Ibis to be presumed, therefore, that when in the human body,
•and in perfectly fluid blood, tins locomotive habit is a con¬
stant one, and in some way subserves the interests of
the filaria. I have watched the embryo entangle itself
in the librine in the manner I have just alluded to.
'The locomotive tendency probably contributes to bringing
this about—a result, by the way, very much in the
interest of the observer, who otherwise might have a
‘difficulty in following the little animal in its pere-
.grinatioDS. It seems to push the threads of fibrine in
front of it for a time, and then, wriggling over the
accumulating fibres with its tail, twists them into a strand
which presently constricts it, usually at a point .a short
•distance from tiie iiead. In this way it is kept a prisoner to
•one spot. The movements are now no longer locomotor,
bub are made round the constricting poioc as round a
-centre. In some instances the string of librine from con¬
tinued twisting becomes so tense that it produces a manifest
constriction at the point where the filaria may be said to bo
hungup; sometimes it looks as if almost decapitated. My
ihberprebatiou as to how this appearance is brought about
may be wrong; but there can be no question as to the fact
and frequency of this striking occurrence. As regards the
•duration of the movements, they slow down distinctly in
twenty-four hours, become very languid in forty-eight
ihours, and usually cease entirely during the third day.
I have seen the minor embryo .alive, however, as late as
ninety-six hours after its removal from the body, and
probably by careful arrangements they could be kept
alive much longer, just as in the ease of filaria
sanguinis hominis major. The disappearance of the
embryos, remarked by Dr. Mackenzie in Mandombi’s
■case, was probably owing, at least partly owing, to the
locomotive propensity I have described loading the filaria
sanguinis honiinis minor to the edge of the slides, whore it
became dried up and invisible, or under a mass of corpuscles
which concealed it. I believe the slides which Dr.
Mackenzie watched and saw this disappearance in were
^slides that had been prepared from blood containing prin¬
cipally filaria sanguinis hominis minor, and only excep¬
tionally specimens of filaria sanguinis hominis major. I
'have not seen anything to warrant the supposition that
the embryos disintegrate rapidly on removal from the
?)ody.
8 . Along the central axis of the body of filaria sanguinis
'hominis of Lewis, about the junction of the oral and caudal,
halves, a line of granular aggregations is often to be made
out. I have never detected anything similar in these
African filaviic., major or minor. The body of the filaria
sanguinis hominis minor is perfectly transparent and
homogeneous when fresh. It refracts the light less
powerfully than filaria sanguinis hominis major does.
Probably the absence of a double outline, which the
presence of the aheatk produces in filaria sanguinis hominis
major, contributes to this effect. When first drawn from
■the linger there .'.u-e no markings visible ; but after a time,
as the moveruents slow down, a delicate lacevvork-like
■pattern of Ughlor and darker shading is developed; and,
just as happens under similar cireumstanceB in filaria san¬
guinis hominis major, though k’.ss uiarke<lly, the integument
of the animal is thrown into innuiiicriible, minute, closely
set, transverse rugio. This is probably jiroduccd by the
contraction of the desiccating body.
Doubtless in time other points of contrast in the
two or three species of human luoinatozoa will be found,
the parent fonu.s of the new species, and the inter¬
mediary bust or lu)stis will be discovered, and the complete
life history of the p.arri-sites worked out. As regards the
intermediary hosts, the absence of periodicity in the appear¬
ance of the minor embryo in the blood and the diurnal
habits of the major—which I venture to assume as prac¬
tically estabUsiied—and the probable limitation of this
form of parasitism to a particular district of Africa indicate
that tlicintermediary host in both insb-inecs is a blood-sucker
of a correspondingly limited geographu^al distribution, and
a blood-sucker whose operations, unlike the species of mos¬
quito which acts as intermediary host to the filaria san¬
guinis hominis of Asia, which is nocturnal in its habits, are
conducted by day in the one case and by day or by night
indifferently in tlie other. Some naturalists may be able,
even at this early stage of the investigation, to indicate
these animals.
It has long been known that a filaria, the filaria loa,
freipiently takes up its fjnarters under the conjunctiva
of the inhabitants of certain parts of Africa. This par¬
ticular j)osition does not seem favourable for the escape of
the offspring of the parasite from the body of the host; yet
such escape is necessary for the continuation of the species.
Might it not be that the worm, in the oases in which it is
found lying under the conjunctiva, is one which has lost its
way, so to speak, no uncommon occurrence with parasites,
and that its proper habitat is one more calculated to favour
the liberation of the embryo—viz., somewhere in connexion
with the lymphatic or general circulation ? Might it not be
that the smaller of these new hmmatozoa is the embryo of
the filaria loa ? This, of course, in the present state of the
inquiry, is almost purely speculative; but, nevertheless, it is
a point worth investigating. It is to be remembered that
filaria loa is principally confined to negroes. Leuckart,
speaking of a mature specimen which he examined, says
that its embryos were enclosed in thin egg-shells, and bore a
close resemblance to filaria sanguinis (meaning filaria san¬
guinis hominis, Lewis), but were smaller (0'21 mm.).
In 188(5 Magalhaes described certain filarioi—mature
worms, male and female—-which he found coiled up in a clot
of blood in the left ventricle of the heart. He believed
they were the parent form of the filaria sanguinis hominis
(Lewis), and the description of their anatomy which he gives
seems to bear out this opinion. Rut the situation they were
found in is an unusual one for the parasite he believed
them to be to occupy and, judging from the short notice
of his paper in the London Medical Record, there seems to
have been no particular care used to ascertain the exact
characters of the embryos free in the blood. Possibly these
may have been one of the new forms I describe, and the worms
in the heart the mature form of this parasite. Again, “ craw-
craw,” a papulo-vesicular disease found in negroes, and
characterised by itching and an exudation of a serous-like
fluid containing embryo filarim, has been desetibed. But
the exact character of the embryos found in it have not been
carefully laid down, as far as I know. They have been
rather careles.sly assumed by some authors to be the filaria
sanguinis hominis of Lewis ; but the measurements are not
given, nor are any of the details that are so necessary to deter¬
mine the species described. Might not this “ craw-craw ”
embryo worm be the filaria sanguinis hominis major or
minor ? It is evident from this that it would very much
conduce to accuracy and the advance of helminthological
knowledge if observers gave exact descriptions of any
strange parasite they may encounter, and, if possible,
accompanied their descriptions with drawings and accurate
nieasuroments.
As regards the pathological significance of the new para-
fiite.s, it is as yet premature to venture on any opinion. Most
animal jiarasites are, as a rule, innocuous when in their
normal position. Only under unusual conditions of numbers,
location, or disease do they become a source of real danger
to their hosts. Whether these new lilarim sanguinis hominis
have any pathological importance we ns yet cannot tell.
Certainly the occuitchco of the minor worm in two of the
four instances in which it has hitherto been found, being
in connexion with cerebral disease in both cases—in onb
instance cerebral disease of a peculiar and endemic descrip¬
tion—is not without significance. It is true that at the
meeting of the Clinical Society, at which Mandombi’s case
was discussed, I did say that I agreed with l)r._ Stephen
Mackenzie in regarding the presence of the filaria in the
patient’s blood as simply a coincidence, and in no way
related to the disease. But I did not know at that time
that lie had the filaria sanguinis hominis minor in his blood
as well as possibly a now aj'ecies of the major filaria. I had
never soen .any case of cerebral disease, attributable to the
worm, in the many instances of tlie-ordiiiary filarial infec¬
tion wliich I had studied. The Asiatic Jiiaria sanguinis
hominis gives vise to lymphatic disease of various kinds,
never, as far as I am aware, to any affection of the central
nevvousi system, such as Mandombi and S. C- auffeved
from. Blit thoiigli I have no knowledge of the pathological
bearings of the filaria sanguinis hominis minor, I would
Coogle
D'
8 The Lancet,] DR. THOMAS OLIVER: ANEUEYSM OF THE SUBCLAVIAN ARTERY. [Jan. 3,1891.
now, in the light of this new discovery, be inclined to modify
somewhat the opinion 1 then expressed.
There is a natural tendency at first to exaggerate the im¬
portance of any new discovery. Whilst this temptation
ought to be resisted, a certain amount of speculation is,
perhaps, justifiable under the circumstances, more espe¬
cially if it may tend to direct to fresh investigation. I feel
tempted to suggest that these new tilarim may supply the
key to an inter-relationship possibly existing between cer¬
tain pathological entities almost peculiar to the negro,
especially the negro in Africa. The pathological entities
I allude to are the two I mentioned above—“craw-craw”
and the filaria loa—and the “ sleeping sickness.” In the
first place the geographical distribuiion of the three seems
to coincide. Next, “craw-craw ” and the “ sleeping sick¬
ness” have been found associated with embryo filarim in the
fluids, and it is most probable that the filaria loa is similarly
associated. “Craw-craw” is a papulo-vesicular and very
itchy eruption. Strange to say, a similar eruption is fre¬
quent in “sleeping sickness ’’according to Corre^ and others
who have carefully studied the disease. Mandombi
complained of excessive itching. Finally, “ sleeping
sickness ” may develop years after the patient has left
the endemic area, where, it is to be presumed, it
was contracted. In S, C-•, whose case is regarded by
some of his friends who have experience of “sleeping
sickness” as a maniacal variety of this disease, it did not
break out till five years after he left the Congo, I lately
heard, through Dr. Grattan Guinness, of another case in a
young negro lad who had come from the same district to
England to be educated. He kept well for eighteen months
and then became aftectei with the characteristic symptoms
of “ sleeping sickness,” of which he died after a year. The
delay in the appearance of the disease is apparently more in
keeping with a parasitic origin and explanation than with
any other. The filaria^ evidently lived a veiy long time, as
proved by their presence in S. C-six years and a half
after he left Africa. To supply an explanation of the way
in which filarijo could produce cerebral disease is another
matter. One can imagine how it might occur, and should
tilarbe be found in the future to be responsible for the
deadly disease called “sleeping sickness,” it will most
likely be discovered that it is in consequence of some
abnormality in their position or health that they become
pathogenetic. Doubtless, they are very common in Africa,
and therefore it can only be in rare instances that they give
rise to disease ; but that they have a pathological relation¬
ship of some sort is more than likely, and such a suggestion
is encouraged by analogy.
For further information on this as on many other points
in connexion with the new parasites, we must look to
medical men whose work lies in the regions where they are,
presumably, endemic; that is, in the Congo country and '
tropical Africa generally. And it would be well for observers
there to bear in mind the necessity for accuracy in their
descriptions, and also to be alive to the possibility that ju.sb
as man has been found to have two, or perhaps three, species
of hcematozoa, it is quite possible that he may have four
or even more. Certainly some of the lower animals possess
more than one species of blood worm. The dog has at least
three, one (Fig. 12) of them being the progeny of the well-
known filaria iminitis, and the others of some as yet un¬
known parents. I have found two (Figs. 14, 15) distinct
species of inematozoa in the Chinese crow (corvus torquatus),
and two (Figs. 10, 11} species also in the blood of the
Chinese magpie (pica media). One of the crow h;ematozoa
(Fig. 15) resembles very closely, as regards shape, size,
and the possession of a truncated tall, the filaria sanguinis
hominis minor. _ I only know of one h.-ematozoon (Fig. 9)
besides the filaria' sanguinis hominis which has a sheath ;
this I found in the blood of the great crested pigeon of
Java, the goura coronata. The fauna of the blood of man
and animals ofl'ers an interesting and almost unworked field
to the naturalist, and it is evident that its study is not
wanting in interest and importance to the i)athologi8t and
the practical jjhysician.
I would suggest that anyone located in the endemic area
of the filaria sanguinis hominis major and minor who may be
desirous of working out the facts of 'this form of helminthiasis
should first make himself familiar with the appearance of
the forms of the hmmatozoa of man and of tlie Incmatozoa
of some of the lower animals, and also of the best vray of
Maladies des Tay-s CJirj.uds, imr Dr, A. Corru, Karitc, 1S,S7.
rapidly and surely ascertaining their absence or presence
in any given case.^ That he should then systematically
examine the blood of a large number of natives, noting
their individual physical condition, and especially the
presence or absence of peculiar diseases, such os sleep¬
ing sickness, craw-craw, ike. Search might then be
made for the intermediary host of the new filarice among
the various blood-suckers attacking negroes in the endemic
area; studying, in the first instance, at all events, those
whose habits are not nocturnal. The embryo parasite
will be found to be ingested by most of these, and will
be discovered in the contents of the stoniach in a state of
digestion more or less advanced ; but in some one or more
species of blood-sucker it will be found that this digestion
does not occur, and that the filaria embryo undergoes a
metamorphosis similar to that of the filaria sanguinis
hominis of Asia in the mosquito, or of Sonsino’a dog haima-
tozoon in the flea. In the event of a post-mortem examina¬
tion being obtained in a filariated subject, no pains should
be spared to iind the parental forms; all bloodvessels—■
especially of the liver, lungs, right heart, the largo
intracranial sinuses, and the arteries at the base of the
brain—being split up for this purpose. The lymphatics,
too, ought to be carefully scrutinised.
Qiweii Aiiiio-.strcet, W.
ANEUKYSM OF THE SUBCLAVIAN ARTEEY
SPONTANEOUSLY CUBED BY SLOUGHING.
By THOMAS OLIVER, M.A., M.D., F,li.C.V.,
I'ROl'ESSOU OI' IMirSIOLOUV, UNIVKUSri'V 01' OUlllIAM, .VNI) I'lIVSICU.S
TO TUK UOYAI. INl'iaMAUY, NKWCA.STI.E.UI-ON-TYM':.
This cure of aneurysm, either by medicine alone or by
surgical procedure, is a circumstance of which we are justly
proud, but it is seldom that we see or hear of an aneurysm
of a large vessel working out its own cure by sloughing.
The case I am about to report is one in which this occurred.
Michael T-, aged fifty-two, a labourer, was admitted
into the Newcastle Infirmary under my care on June 8th,
1888, complaining of pain in his right shoulder and of a pul ¬
sation in the neck of three months’ duration, lie has been
a heavy drinker, of beer principally ; bad a slight attack of
rheumatic fever three years ago. I'vventy years ago he had
gonorrhcca, but there is no history of his ever having
sulfered from syphilis. Ilis father died at the age of fifty •
six from the bursting of a bloodvessel; his mother died of
old age ; Lis brothers and sisters are healthy. Patient has
been losing flesh rather rapidly of late. The pain he com¬
plains of shoots down the right arm from the clavicle to the
elbow ; it is worst at night, and scarcely allows him having
any sleep. The pain is mostly of an aching character. He
has never received any injury to bis shoulder, but thinks
that he may have strained himself. There is neither
difficulty of 'breathing nor of swallowing; his pupils are
equal, and respond to light. There is no cough or ex¬
pectoration. His voice is unaffected. The veins on the
right .side of the neck are distended. Immediately above the
outer half of the right clavicle is seen a swelling about the
size of a pigeon’s egg ; it exhibits expansile movement, is
tender to the touch, and on auscultation a systolic mur¬
mur j.H heard over it. The right arm is numb. In addition,
he complains of it being colder than the left, and that he
periodically loses nenaation in it, but never over the
whole arm’ at one and the same time. There is anresthesia
over the outer aspect of the forearm in its upper two-
thirds, particularly in patches. The right radial pulse is
weaker than the left, but appears to be synchronous with
it. The carotid arteries pulsate equally. There is no
dulness detected in the chest on percussion, except just
under the right clavicle in its outer half. The apex beat of
the heart is rather indistinct. Over the mitral area the
first sound is prolonged, whilst over the aortic area the first
is rough and murtnurish, and the .second is accentuated.
A coarse and somewhat lengtliened systolic murmur is
heard, as already stated, over the pulsation above the
clavicle, where it is followed by a sound of a thudding
character. His pulse varies from 52 to GO. Beyond a
degree of eoar9ene.ss in the respiratory murmur nothing
•' Triivolk'rs or oUier.s witli no leisuro fov ini<Toscopi<! work iniRlil.
oasil.v inako ii useful oolloction of Nlides of ilriecl b!oo<t, which could h«
stiiiii'r-d, mouiitod, .and oxainiiicd /t-s opportunity olfei'od.
I^jOOglC
The Lancet,] DR. THOMAS OLIVER : ANEURYSM OF THE SUBCLA.VIAN ARTERY. [Jan. 3,1891. 9
abnormal ij detected in the lungs. The two sides of the
chest are equal in their measurement. Urine has a specific
gravity of 1020, is acid, and does not contain either albumen
or sugar. He was treated by means of iodide of potassium,
commeucing with live grains for a dose thrice daily, and
gradually increasing it until he took 100 grains three times
a day.
After taking the iodide of potassium for a month, I find
it stated in my votes that the excruciating pain has practi¬
cally gone, that a degree of it is occasionally felt running
along the course of the musculo-spiral nerve and its branches
down the forearm, where the sense of numbness and cold¬
ness is complained of. It is noticed, too, that the right arm
has become thinner than the left by three'tjuarbers of an
inch, and that its muscles are softer and exhibit the signs
of myoidema. It cannot be said that the tumour above the
clavicle has undergone any diminution in size. The dulness
previously described as noticed under the outer half of the
right clavicle has extended somewhat towards the manu¬
brium stemi. The sounds heard over the cardiac area and
the aceurysni have undergone no alteration. The pulse is
78; the right pupil issmaller than the left; the temperature
is normal. By the middle of August the aneurysm bad
become decidedly smaller; its pulsation was less extensive,
and pain as a symptom was very little complained of. At
this stage in the treatment of his case the patient of his own
accord left the infirmary. I saw nothing more of him until
two months afterwards, when on Oct. 9cb, 1888, he was re¬
admitted suffering from pain in the right shoulder—more
•excruciating even than before,—and of complete paralysis
of the right arm. After the patient left the infirmary he
got employment as a drainer; bis work required a good deal of
muscular effort, digging, as he was amongst heavy clay. On
finishing his work he mei to throw his spade over his right
shoulder, and carry it in this fashion. He followed riiis
occupation until five or six days ago, when, owing to
increasing severity of the pain, he was forced to relinquish
it. The pain now complained of extends through to the right
shoulder blade and runs down the outer side of the arm to
the hand. For three weeks after leaving the infirmary he
tells us that ho was practically free from all pain, and thus
he worked hard and drank heavily. On examination it is
noticed that the swelling above,the right clavicle is larger,
that it is extremely painful, and that it is not pulsating
eo visibly. The tissues around the aneurysm are red,
brawny, and very painful to the touch. The systolic murmur
is still audible, but the diastolic thud has disappeared.
A systolic murmur is detected over the aortic area, the
second sound is accentuated, and the temperature is 103°.
iftis clear that the patient has been irritating the aneursyin,
j)artly by his work and by carrying his implements on hia
shoulder ; and from the rise of temperature, the increase in
the size of the tumour, the sudden paralysis of the arm, the
redness and infiltration of the tissues all round the aneurysm,
it seemed to me as if he were going to have suppuration of
the sac or of the. tissue in its immediate neighbourhood.
Large doses of opium given internally afforded relief to his
pain. By degrees all the redness and swelling around
the aneurysm disappeared, pulsation gradually returned
in the aneurysm, aud correspondingly it increased in size.
The paralytis of the right arm was permanent; the arm
now measured three inches less than the left, and the
finger ends of the right hand were becoming clubbed and
•claw-like. Now that the aneurysm was again pulsating
freely the fystolic murmur was only heard at its lower
border, particularly underneath the clavicle. The murmur
entirely disappears during inspiration, returning again
during expiration ; the right pupil is extremely contracted ;
the muscles over the right scapula are rapidly losing tlieir
fullness and are tender.
At this stage in the illness I exhibited the patient at a
meeting of the Northumberland and Durham Medical
Society, with the view of getting a surgical opinion as
to the further treatment of his case. The foreign
examiners in medicine and surgery of the University of
Durham were present, and I was naturally wishful to have
the benefit of their opinion. The man was seriously ill;
medicine could do next to nothing for him. It was sug¬
gested that the clavicle should be sawn through, the whole
arm removed, and the vessel ligatured. This, however,
seemed to me too sweeping and radical an operation;
one so unlikely to be attended by recovery that I decided
to try galvano-puncture, knowing that whilst I could in no
way remove the paralysis, I might so induce coagulation
of blood within the aneurysm and prevent it becoming
larger. Accordingly, within a few days after this, my
colleague, Mr. Williamson, performed galvano-puncture.
The passing into the aneurysm of an electrical current from
four to six cells was almost immediately followed by an
arrest of pulsation in the sac. The tumour soon felt hard,
and for weeks afterwards it remained hard and was
free from pulsation. A slight diminution in size of the
aneurysm occurred during this period. By degrees, how¬
ever, pulsation reappeared in the sac; it was first noticed
at the upper border posteriorly, and from this it gradually
spread well over the whole of the tumour. Pain, which
was experienced immediately after the galvano puncture,
and which had previously somewhat abated, again assumed
the excruciating character already described, and was only
controlled by large doses of opium and by the hypodermic
administration of morphia. The only position in which the
patient now got relief from pain, or was able to woo sleep,
was by laying himself flat across his bed, face downwards.
From this period the details of the case need not be
further gone into. The aneurysm gradually increased in
size, a pulsating mass the size of a walnut began to show
itself under the outer half of the clavicle, and with the
development of this the pulsating tumour above the clavicle
correspondingly increased in size. Fig. 1, taken in the
Fig. 1.
early part of last year, shows very well the two pulsating
tumours—both parts of one aneurysm,—separated by the
clavicle. By the middle of the summer of 181)0 the tumour
above the clavicle was the size of a very large orange. At
this time the patient was attending the inlinnarj' only as an
out-patient, On the evening of June 20th, whilst I
was leaving the infirmary roy attention was arrested by the
pale and collapsed appearance of a man who was being
carried into the accident room. I did nob at first recognise,
owing to the pallor and the alteration of the features
through collapse, that it was the patient T-He was
pulseless and cold, and could only speak in a whisper.
A few hours previously it appeared that T- had sud¬
denly become worse, and that the aneurysm had rapidly
increased in size. It was now as large as a cocoanut,
was soft and yet tense. The skin for more than two
inches along its upper border was extremely thiu, was of a
deep bluish-black colour, and seemed to be just on the point
of rupturing. There was very slight pulsation at the base
of the aneurysm. Ills condition was extremely critical, and
we expected every hour that the aneurysm would rupture
externally. He was kept under the influence of opium and
received only a very small quantity of milk and soda
w?.ter to relieve his thirst. For the next two days he
M’as very ill. A large bleb appeared on the upper surface
of the tumour where the skin was most discoloured, and
from this a few drops of thin, watery blood kept oozing.
Next morning, when visiting at the infirmary, I found that
p- Google
10 The Lancet,] DR. POLITZER ON PILOCARPINE IN Al?F£CTIONS OF THE EAR. [Jan. 3,1891.
the p&tient, ill as he 'was, had been removed by his friends.
He was subsequently visited at home by Dr. Bailee of the
Newcastle Dispensary, who, seeing the serious condition of
the patient, called in the assistance of Dr. Ridley, the resi-
dentniedicu officer of that institution. Each day these two
gentlemen expected to hear that the sac had ruptured and
that the man was dead. Additional blebs now appeared on
the surface, and from these, too, blood kept oozing. Tiie
bleeding was now such that it had to be arrested
by the application of tannin and collodion. Patient,
who bad by this time quite recovered from the
Fig. 2.
effects of shock due to the rupture of the sac already
described, and the conversion of the aneurysm into
one of a diffused character, whose only covering was the
skin, was given the styptic, and taught how to apply it
from time to time. He applied it very freely, with the
following results: that whilst on the one hand bleeding
had been controlled, his shirt had become so firmly adherent
to the surface of the tumour that it could not be removed.
A few days after this free application of the tannin and
Fig. 3.
collodion the tumour was felt to be rather loose and movable
under the shirt. The patient thought he could remove liis
shirt, and in doing so ho lifted olF at the same lime the
huge aneurysm — now only a large mass of sloiigli, coin-
E osed of skin, blood-clot, a portion of artery, clavicle, and
rachial plexus. By tlie one act he had lifted off both his
shirt and his disease, and the remarkable thing is that in
doing this very little blood escaped j the two ends of the artery
were seen to be plugged with clot. The mass removed was>
over one pound in weight, was much decomposed, and had a
mostoffensive odour. A deep breach of surface was all that
reminded one of the situation of the aneurysm; projecting
into this on either side were tlie ragged ends of a very
denuded clavicle, the middle third of which had disappeared
with the aneurysm. The surface of the wound soon began
to granulate, and it is now being quickly obliterated. Thus
has been cured a very large aneurysm in a manner that we-
never expected. The man is now in good health, and, bub
for the paralysis of the right arm, would be perfectly well.
Newcastle-on-Tync._
THE EMPLOYMENT OF PILOCARPINE IN
CERTAIN AFFECTIONS OF THE EAR
AND THE ABUSES OF THIS REMEDY.
By Dr. ADAM POLITZER,
rUOl'ESSOR 01' OTOLOGY AT THE UNtVERSITV Oi' VtH.VNA.
Txik favourableresulta obtained in a series of cases of severe-
eye affections, particularly of acute irido-cyclitis, bmmor-
rhages into the anterior chamber of the eye and opacity of
the vitreous body, induced mo in 1879 to give tins remedy
a trial, selecting to begin with several cases of labyrinth
affection of an undoubtedly syphilitic nature. The rationale
of this measure was that in virtue of the rapidly occurring
change of matter the reabsorption of unorganised exuda¬
tion products might be brought about. Tho results of
this experiment were so satisfactory that at the second
Olological Congress at Milan in 1880 I was able to recom¬
mend a continued trial of this method to my colleagues in
cases of recent affections of the labyrinth. Since that time
I have employed subcutaneous injections of pilocarpine in
every variety of recent and chronic affections of the
labyrintii, the results obtained by myself and others (Moos,
Lucae, Wolf, Poliak Barr) being in several instances so
favourable that the ^'alue of nmriated pilocarpine in laby¬
rinth affection must not be under-estimated. I have been
in the habit of using a 2 per cent, solution, two drops of
which are injected subcutaneously in the forearm, and thC'
dose gradually increased a drop at a time to eight. Follow¬
ing rapidly upon the injection there is a considerably
increased secretion of saliva and sweat, which ceaseS'
after the lapse of from thirty to forty-live sninutes. Rarely
it is accompanied by disagreeable symptoms, such as
nausea, vomiting, giddiness, fainting, coil.apse, spasm of the
bladder, which can be antagonised by taking from two to-
three drops of atrop. sulphurici 0-03, aqua destillata lO'O.
The injections are to bo made daily. If after the lapse of a
fortnight the use of this remedy does not produce an im¬
provement in hearing, it must be, regarded as ineffectual
and be abandoned. But if, on the otlier hand, an early and
distinct improvement in hearing can be observed, tho injec¬
tions should be continued as long as there is a progressive
increase in the faculty of bearing to be elicited upon exami¬
nation. The period in which tlie maximum of the hearing,
distance is attained varies from six to forty days. It is to be
noted that the increase in tho hearing power is rarely
regularly proportional, since it is usually most rapid in the
first week or fortnight, while in tho subsequent course of
the treatment it progresses very slowly. In rarer cases the
reverse is true, the hearing power at first increasing slowly
and later more rapidly.
Vacillations in the hearing distance are not infrequently
observed in the course of treatment, a rapid improvement-
of several days being promptly followed by a rapid diminu¬
tion of it, lasting also for some days. The use of sub¬
cutaneous injections of pilocarpine, which was at first
limited to syphilitic diseases of the labyrinth, was extended
later also to those cases of deafness which wei'e found to be
dependent upon an affection of the auditory nerve apparatus.
This proceeding was indicated by the rapid development of
deafness apart from any discoverable anatomical damage
in tho middle oar, and confirmed by the result of the
examination with the tuning-fork, the latter affording,
I consider, important indications for the employment
of pilocarpine. If the examination with the tuning-
fork proves that in a case of extreme deafness tho sound is
lieard perceptibly longer opposite the ear (air conduction),,
Digitized by
Googic
The Lancet,] MR. WALTER WHITEHEAD ON DIVERTICULUM OF (ESOPHAGUS. [Jan. 3,1891. H
than from the mastoid process (positive experiment of Rinne);
also that low tones are oetter perceived by air condaction than
high ones 5 and, lastly, if there is a history of symptoms
pointing to the implication of the labyrinth, such as giddi¬
ness or total inability to hear the ticking of a watch
through the head bones, then the existence or an affection
the labyrinth is very probable, and it is in such a case that
the subcutaneous injection of pilocarpine should be em¬
ployed. I use but rarely subcutaneous injections of
pilocarpine in certain forms of acute inllamraations of the
middle ear.
In the first of my works mentioned below I have cited
several cases of acute inflammation of the middle ear in
which perforation had not taken place. Where a protracted
local treatment failed to produce reabsorption of the
hardened exudation products lying in the cavity, and where
after three or four subcutaneous injections of pilocarpine
a constant improvement could be observed, the effect must
be referred to the speedy solution and absorption'of such
exudation products. In like manner the subcutaneous
injection of pilocarpine is to be recommended in those
cases of acute suppuration of the middle ear in which per¬
foration of the tympanic membrane has occurred, and in
the course of which deafness supervenes, dependent upon
some complication of the labyrinth.
Within recent years I have used muriated pilocarpine
locally in afl'ections of the labyrinth and the middle
ear, injecting from six to eight drops of a 2 per cent,
warmed solution through a catheter into the Eustachian
tube and cavum tympani. When pilocarpine is tlius
employed in the above-mentioned concentration and
quantity no unpleasant results fupervenc ; it is only
in rare cases that salivation and abundant diaphoresis
are observed, and these soon after injection. In chronic
catarrhs of the middle ear I inject pilocarpine into
the tympanic cavity, particularly in those cases where
the power of hearing is distinctly improved after infla¬
tion of the middle ear, and where a slight swelling in
the Eustachian tube can still be discovered upon auscul¬
tation. The object of the local application in these cases
is to bring about a slight reaction in the mucous membrane
of the middle ear, and in this way to cause the absorption of
inflammatory products. And, as a matter of fact, in some
particular instances the improvement of hearing following
these injections has been more pronounced than thac
obtained by the use of 10 per cent, solutions of soda, which
until now have been most frequently employed. On the
whole, the cases in which the local injections of pilocarpine
produce a notable result are but few; in most cases the
faculty of hearing does not improve at all, or the improve¬
ment is only iudifterent and of short duration. Here, too, the
treatment must not be extended beyond two or three weeks.
It is quite otherwise with the so-callcd cases of chronic
catarrhs in the middle ear, 'where tlio adoption of this
method of treatment must bo deprecated. I have already
shown that, in the year 1885 {JVzener Med. Zeit. 4, 5, 6), and
again in my Text-book of Ear Diseases (1887), the treatment
of dry catarrhs of the middle ear with pilocarpine is worth¬
less. The position to-day has not changed. It must also
be insisted upon that in every case ot extreme deafness
where the tuning-fork can be lieard longer from the mastoid
process than opposite the ear (air conduction, negative
experiment of Kinne), and, in addition, where low tones
are not at all or only faintly perceived through the medium
of air, while high ones are a: the same time very distinctly
heard, the subcutaneous treatment with pilocarpine is
strongly contr-aindicated.
The above remarks have been found necessary from the
circumstance tiiat for some time past I (I am not singular
in this experience) have been consulted by many patients
suffering from extreme deafness who had been previously
treated by other auiista for several weeks, or even for
several montiis, with subcutacieons injections of pilocarpine
without the slightest benelit, in the cases of which an
examination showed the presence of a marked sclerosis of
the mucous menibrane of the middle ear.
"While it is true that the subcutaneous injections of pilo¬
carpine iiaunlly can be tolerated by the patient for several
weeks without any unpleasant consequences, still there are
cases in which its protracted use has produced loss of
appetite, fauitnes.s, and considerable emaciation. When
I consider the abundant salivation and diaphoresis, so
disagioeablc to the ])ationt, which are associated with the
daily use of this remedy, I feel it my duty to say that
those practitioners who in all cases of extreme deafness
indiscriminately—that is, without a previous careful exa¬
mination by means of the tuning foric and consequentiy
without any difl'erential diagnosis between affections of the
middle ear and those of the labyrinth—subject their
patients to a long and wearisome course of treatment with
pilocarpine are not too conscientious in the discharge of
their calling.
The following is-a summary of the above: 1. The sab-
cutaneous injections of, pilocarpine are particularly indi¬
cated in recent affections of the labyrinth, be they of
a syphilitic nature or not. In protracted diseases of the
labyrinth these injections, if tried, must be abandoned if
no improvement results after from ten to fifteen injections.
2. The subcutaneous injections of pUocarpine are but rarely
employed in otitis media acuta, where tbe cavum tympani
contains hardened exudative products, which resist reabsorp¬
tion; moreover, in panotitis gemina diphtheritica, or m
other diseases produced by infection. 3. The subcutaneous
injections of pilocarpine are decidedly contraindicated in
cases of dry sclerotic catarrhs of the middle ear. 4. Injec¬
tions of several drops of a 2 per cent, solution of muriated
pilocarpine through the catheter into the tympanic cavity
are beneficial in some cases of catarrlts connected with
swelling and a slight secretion of the mucous membrane
of the middle ear, continued from one to three weeks alter¬
nately, with inflations of air by Politzer's procedure. The
purpose of the present communication is to reduce to a just
measure the therapeuticvalue of thoaubcutaneous injection
of muriated pilocarpine in diseases of the ear, and to draw
attention to the fiequent abuse which has been made of
this remedy for some time past.
DIVEKTIOULUM OF (ESOPHA.GUS CAUSING
OBSTRUCTION; GASTROSTOMY; DEATH
SIX YEARS AFTERWARDS.
By WALTER WHITEHEAD, P.R.C.S,, F.R.S. Edin.,
3 ICXIOR SUimiiOiV, UOV.U. INriRMARV, MANt'UI'STRR; I.KCTUUKH 0^
CLINICAL SURCURV, VlCTORl.! UKlVliKSITV.
The follo'wing is a good example of a rare lesion of
the cesophagus; it is also of interest fs affording an
opportunity for the examination of a gastrostomy many
years after operation. The patient, a married woman
having had previously good health, began in her forty-
ninth year to have difficulty in swallowing, which gradually
increased in severity. On Nov. ISbli, 1882, eight years
later, when deglutition had almost become impossible, the
patient came under my care. Hbo was then unable to
swallow any solid food, and even liquids invariably regur¬
gitated. Attempts to pass bougies of various sizes uniformly
failed, There was no history of syphilis, or of any kind of
injury to the cosophagus, and tbe duration of the sym¬
ptoms rendered the probability of cancer to be unlikely.
The patient’s condition was so critical that gastrostomy
appeared the only method of averting imminent starvation,
and this was in consequence performed four days later.
Convalescence was rapid and complete, and the patient
returned home on Dec. (ith. J''or two years she systematically
used the gastric fistula for all alimentation, and her healto
continued excellent without suffering any inconvenience from
tbe operation, or being conscious ot any unusual condition
of the gullet. She gaioed in weight, and was to all appear¬
ances in robust health—in fact, was so convinced that her
old trouble had disappeared, and naturally objecting to the
inconveniences of her singular mode of feeding, she com¬
menced, by degrees, to take food by the mouth. For
several months she was unconscious of any return of her
old trouble, but gradually, and at first almost insensibly,
she became aware that her power of swallowing was
becoming less natural and her old symptoms steadily
reviving. About this time (Deceniber, 1880) she consulted
Dr. Watson of Burnley for sciatica, witliout,-however, at
first drawing his attention to the difficulty she experienced
ill swallowing. During his attendance he accidentally noticed
that she swallowed inapEculiav manner, which he subse¬
quently de.scribed as follows When taking liquids the
patient tossed hor head backwards, gulping down the fluid
at one mouthful. This was immediately followed by some
Dkjr ..
12 Thb Lanokt,] MR. WALTER WHITEHEAD ON DIVERTICULUM OF (ESOPHAGUS. [Jan. 3,1891.
thickening and congestion of the neck and slight congestion
of the face. On applying a stethoscope over the cricoid
cartilage the usual gurgling sound was heard, immediately
followed by eructations and a crackling noise, the latter
being, perhaps, due to the meeting of the eructated gases
with the descending fluid. When taking solids the same
phenomena occurred, with this difference, that the eructa¬
tions were accompanied by a whistling noise. Vomiting
took place sometimes in a few minutes afterwards; at other
times it was deferred for half an hour.” Dr. Watson
further informed me that the patient rapidly became
anmmic, attacks of acute neuralgia became frequent, and
eventually she died, apparently from sheer exhaustion, in
January, 1888, without the obstruction of the (Esophagus ever
again becoming complete. He was fortunate in obtaining
a post-mortem examination, and although not successful in
securing the important parts removed, he was happily able
to make a sketch of the cesopbagus, which is here reproduced.
Dr. Watson also furnished me with a copy of his post¬
mortem notes, which are too valuable to be omitted. “I
found,” he states, “the different organs of the body smaller
than normal, especially the stomach. The aorta, however,
was enlarged. At the commencement of the cesophagup,
just at the inferior constrictor, I found a large pouch, fully
three inches in length and two inches in breadth. It
apparently consisted of all three coats of the (esophagus, and
projected from its posterior wall so as to lie between the
(esophagus and the vertebral column. It was half full of
partly digested food. There was a cicatricial scar and a
email fistulous opening on the abdomen, indicating the point
where gastrostomy had been performed. The attachment of
the stomach to the skin con.sisted of the merest filament,
and the opening into the stomach was almost closed.”
Pressure or acquired diverticula—and this
appears to be a typical example of that condition—are,
according to authority, rare in women, for out of twenty-
two reported cases collected by Zenker and von Ziemssen
in which the sex was stated not one was recorded as
occurring in a female.^ The reasons which appear to justify
this case being considered in the category of a pressure
diverticula, in preference to regarding it as one of con¬
genital origin, are; the late period of life when the sym-
i Von Ziomasen's Cyclopa-dia, vol. viii., p. 01 .
ptoms commenced, their slowness of development, and the
position of the pouch—viz,, at the back of the pharynx—at
its junction with the oesophagus. Zenker and von Ziemssen,'^
in an article based upon a series of thirty-four cases, twenty-
seven of which were verified by necropsies, foun<l that m
pressure diverticula the commonest situation was, as in this
case, the posterior wall of the pharynx at its junction with
the cesopbagus, where the tube becomes suddenly narrower
and more liable to injury. They further point out that the
pouch in these cases is formed by a protrusion of the
mucous membrane, through the separated fibres of the in¬
ferior constrictor, and is, in fact, a simple hernia of the
mucous membrane—a pharyngocele—and that these occa¬
sionally attain dimensions of five inches and a half long by
two inches broad. The only other possible alternative is to
assume that the malformation may have originally been con¬
genital, for when we remember that the gullet is developed
by the union of the ingrowing pouch of the pharynx witli
the alimentary canal it is conceivable that if the upper end
of the (Esophagus were to open only a little in front into
its anterior wall instead of exactly into the apex of the
pharyngeal pouch, a small cul-de-sac would he left behind
the (Esophagus at its junction with the pharynx, and such
a cul-de-sac might eventually form the commencement of
a large diverticulum. It may be stated that Hamburger,^
Rokioansky,'* and Ziegler^ consider the acquired forms to
be due to the lodgment of foreign bodies in the (esophagus
leading to weakness of the muscular fibres, and subsequent
protrusion of mucous membrane as the result of pressure.
The reasons for excluding the possible congenital origin of
this case are based upon the fact that the congenital
varieties are chiefly found upon the anterior wall of the
(esophagus and low down, whereas in this instance the
pouch was situated high up and on the posterior wall. An
excellent example of the congenital class is reported by
Dr. Norman Moore in The Lancet, vol. i., 1882, p. 482;
and Mr. Howard Marsh and Dr. Ilott describe two cases in
the Transactions of the Pathological Society, vol. xxvii.
Hamburger, Rokitansky, and Ziegler also mention traction
diverticula, which, although they regard of no practical
importance, are found, they state, in the front of the
(Esophagus low down, and generally opposite the bifurcation
of the trachea. These also may arise as the result of the
traction of cicatricial tissue on the (esophagus—e.g., a
bronchial gland becomes inflamed and adherent to the
(Esophagus, the inflammatory material cicatrises and con¬
tracts ; by the contraction the (esophageal wall is drawn
outwards into a small pouch. If we hazard a conjecture as
to the development of an acquired diverticulum, we may
assume some injury inflicted upon this particular portion of
the (esophagus, which from its anatomical formation is
most exposed to accident, atrophy of some muscular fibres
occurs, and a weak spot is formed in the wail of the gullet
which eventually leads to the formation of a small pouch,
and this, by repeated distension, ultimately increases to
the dimensions of a considerable sac. Once having in¬
creased beyond a certain size, other factors would naturally
come into play, food would collect in the sac, and by sheer
weight drag it further downwards behind the (Esophagus,
tending to make its axis directly continuous with that of
the pharynx. The distended sac meeting with the resistance
of the vertebral column would push forwards and compress
the (esophagus and close the route to the stomach below
the opening into the diverticulum, and at the same time
keep open the mouth of the sac, and thus facilitate
increased influx of food. There are a few other features of
the case which appear to possess too much practical
importance to be entirely neglected. There can be no
doubt that gastrostomy saved and prolonged the patient’s
life. For two years the patient was nourished and
her health maintained solely by alimentation conveyed
by the gastric fistula. During tliis period the cosophagus
had the advantage of absolute rest, and it would be
difficult to fine! a better example of the power of rest as a
therapeutic agent. The condition of the adhesion between
the stomach and the abdominal wall six years • after
gastrostomy had been performed and four years after the
gastric fistula had been made use of affords material for
reflection. In six years the originally broad, firm
adhesion between the stomach and abdominal wall
had been converted into a long filamentous band
2 Ibid. 2 Kllnik dor (lisophiigu.ski .’uikhoiton, p. 170.
< XiOhibuch dor Patliologiscliun Anatumiu, vol. iii., p. 12(3.
0 Zicgl(jr's Pathology, vol. ii., p. 2t8.
Di,.; ,G oogle
Thb Lancet,]
DR. EMIL PFEIFFER ON TESTS FOR LATENT GOUT.
[Jan. 3,1891. 1 S
traversed by a narrow channel, illustrating how readily
broad adhesions become in time attenuated into uan'ow
bands. How far the disuse of the sinus had a tendency
to induce the atrophy is difficult to estimate, but
it would appear that in all cases of gastrostomy there are
agencies at work which have naturally a tendency to
weaken the adhesion between the stomach and the
abdominal wall—the contraction of the abdominal muscles,
the movements of the diaphragm depressing the stomach,
and the distension of the colon raising it &c. There is an¬
other and hnal lesson to be learned from this case. In the
events of its ever being necessary to dilate or enlarge a
gastric opening of long standing, judging by this case,
there would be considerable risk of opening the peritoneal
cavity, and it almost imperatively suggests that under such
circumstances it would be much safer to perform gastros¬
tomy danovo, rather than attempt to utilise an old channel
of such doubtful stability.
Manchester.
ON TESTS FOR LATENT GOUT.
By Dr. EMIL PFEIFFER,
OK WIESBADIfiN.
Sir William Roberts, in a communication which ap¬
peared in The Lancet of Jan. 4th, 1890, writes upon
“Pfeiffer’s Test for Latent Gout.” I am extremely
thankful that the eminent writer has occupied himself so
thoroughly with the very interesting question of “ free uric
acid ” and its bearing on the theory and practice of gout
and urolithiasis, and especially that he has communicated
my investigations as well as his own opinions regarding
the subject to the English members of the profession so
eminently interested in everything concerning gout and
uric acid diathesis. As the result of my investigations loads
me to the belief that the question of “free uric acid in the
urine is one of very great importance in the diagnosis and
treatment of gout and urolithiasis, I deem it advisable to
bring to the notice of the readers of The Lancet a transla¬
tion of the remarks which I have published in the “ Ver-
handlungen des Congresses filr innere Meclicin (VIII. Con¬
gress, Wiesbaden, Bergmann, 1889)”on the same subject in
June, 1889. My experiments and deductions therefrom are
given as follows :—•
“When the whole twenty-four hours’urine of a person
is collected and two equal portions are separated from the
whole quantity, to one of which is immediately added (the
tenth part of its quantity) strong hydrochloric acid (of
Heintz, sp. gr. 1 '12), while to the other, previously passed
through a filter on which some chemically pure uric acid
has been placed, is also added the hydrochloric acid of
Heintz, we find that after forty-eight hours, when we
collect on separate filters and weigh the uric acid which
has been deposited, the two portions have thrown down in
many cases very different quantities of uric acid. In
children, women, and old men you find as a rule equal
quantities of uric acid thrown down, while in healthy male
adults the portion passed through the uric acid is found to
yield in most cases a considerably smaller quantity of uric
acid than the portion that has not been in previous contact
with it. As I have shown in former papers, this diminution
of precipitated uric acid is caused by its being retained or
abstracted by the uric acid placed on the filter. This
abstraction of uric acid from the urine by the acid filter
(Eartisaureftlter) takes place to the greatest extent in cases
of patients suffering from uric acid diathesis—i.e., uric
acid urolithiasis and gout.
“ In cases of uric acid urolithiasis, when the patients are
not yet in a cachectic state, we find as a rule that the
whole of tho uric acid is abstracted from the urine even by
small quantities of uric acid—at least, as far as it can be
thrown down by hydrochloric acid. When we pass in such
cases 100 com. of the whole twenty-four hours’ urine through
from 0‘2—0'5 grm. of uric acid, the filtrate mixed with the
hydrochloric acid of Heintz yields no traces of uric acid.
This examination is of great diagnostic importance, and
one can in doubtful cases entirely exclude the presence of
uric acid urolithiasis by the absence of this symptom;
■while, on the other hand, its presence proves the existence
of this disorder. The same symptom is of almost equal
importance in the diagnosis of gout; and this comes out
very clearly in the case of gouty subjects, from whose urine
the HarnsdurefilUr abstracts the whole of the uric acid,
when at the time of the examination they are not ailing,
but present the appearance of perfect health. In clinical
examinations of the abstraction of uric acid from the
urine the following rules must, however, be observed:—
Above all, the urine must be always a part of the whole
passed in twenty-four hours* Single portions of urine
collected at different times during the day may behave
alike in gouty and in healthy cases. Of the whole twenty-
four hours’ urine three portions of lOO com. are separated,
and the first and second portions passed through two
filters, on one of which 0'5 grm. of chemically pure uric
acid has been placed, on the other, 0-2 grm. When the
filtrations are finished, the three portions are mixed with
the hydrochloric acid of Heintz and put aside for forty-
eight hours.
“ A further rule is to make the examination only in the
interval between the attacks, at a time when the gouty
person feels quite well. Then it will be found that in
gouty subjects—still liable to acute typical attacks—all, or
almost all, uric acid is retained by the HarnsdurejilUr, and
that therefore the portions of the urine passed through it
yield with hydrochloric acid no uric acid, or only traces of it.
Numerous examinations of urine have shown that this
symptom — viz., that on several consecutive days all
the uric acid precipitable by hydrochloric acid is
abstracted from 100 ccm. of the twenty-four hours’ urine
by 0'6 grm., or even by 0’2 grm., of uric acid—is
only found in cases of uric acid diathesis—i.e., uro¬
lithiasis and gout; also that it is never found in cases of
healthy persons or in patients suffering from other diseases.
I think, therefore, that the following deduction may safely
be made: When in the filtrates from the two Harnsciure-
filter no trace, or at least no appreciable quantity, of uric
acid is thrown down by hydrochloric acid, we may con¬
clude in doubtful cases that we have to deal with gout,
provided the patient has not been taking one of the drugs,
such as salicylate of sodium (hydrochloric acid), which are
found to produce a similar condition of urine. The rule to
take two Harnsaurcfiltcr, one with 0 5 grm. and one with
0'2 grm. of uric acid, is founded on the following fact.
When ■we pass several portions of 100 ccm. of the twenty-
four hours’ mine of a healthy adult through increasing
quantities of uric acid—viz,, one portion through 0 2 grm.,
a second through 0 ^5 grm., a third through 1-0 grm., a fourth
through L5 grm., and the remaining through 2'0 and 2'5 grm.
respectively, we find in most cases, even in the urine of
healthy persons, an upper limit, where the Harrisdurefilter
abstracts from the 100 ccm. of urine all the uric acid
capable of being precipitated by hydrochloric acid. It
follows from this that the amount of uric acid abstracted
from the urine varies, being in proportion to the quantity
of uric acid previously placed on the filter; and it is only
the great proneness of the urine of persons subject to gout
to part with its uric acid which is characteristic of that
disorder, and not the mere abstraction itself. While from
100 ccm. of the mine of healthy persons the uric acid is
only abstracted by 2'0 or 3'0 grm. of uric acid, from the-
urine of gouty persons it is withdrawn by 0 2 or 0-5 grm.
In order to estimate this proneness to deposition it is advis¬
able to pass two portions of the urine through two different
filters, containing 0‘2 and 0^5 grm. respectively, for a urine
that loses all its uric acid by passing through the 0‘2 grm.
filter, certainly contains it in a state more prone to precipi¬
tation than one which retains a certain portion and only
parts with the wholeof it to tbeO Sgrin. filter. More thanO‘6
grm. of uric acid should not be used, as larger quantities can
abstract all the uric acid from the urine, even of healthy
persons. Bat I have never found a case of a healthy
person, or one suffering from a disease other than gout
(with the exception above mentioned), in which 100 ccm. of
the twenty-four hours’ urine lost all its uric acid for several
days in succession by passing it through the 0 5 grm. filter.
I therefore reaffirm my contention, that the entire abstrac¬
tion of the uric acid precipitable by strong hydrochloric
acid from 100 ccm. of urine by 0'5 grm. of uric acid
proves gout in doubtful cases ; and this proof is still more
certain when the same result is obtained by 0'2 grm. of uric
acid.
The abstraction of all the uric acid from the urine of
healthy persons by large quantities of uric acid has been
proved by means of exact experiments made by Dr. W.
14 Thb Lancet,]
DE. EMIL PFEIFFER ON TESTS FOR LATENT GOUT.
[Jan. 3,1891.
Kiihler, consalting physician to the hospital of Offenbach,
■with the newly found ICaiaer Friedrich Spring at that place.
Posner and Goldenberg, in a paper, ‘Zur Auflbsung earn-
saurer Concretionen ’ {Zcitschri'ft fur klinischc Medicin,
voi. xiii., 6th part), had some lime before expressed the
opinion that this might be the case. The abstraction of
uric acid from the urine of gouty persons does not de¬
pend on the degree of acidity of the urine. Although the
urine of gouty persons which "contains the uric acid in the
state of proneness to abstraction {ausschsidhar) is always
very acid, the degree of acidity is nevertheless not greater
than that of the urine of many persons in a good state of
health. You find sometimes in the urine of a healthy
person in which the uric acid is not at all prone to abstrac¬
tion {ausschcidbar) just the same degree of acidity as in
the urine of a gouty subject, the uric acid of 'which is com¬
pletely taken up by the HamsdureflUr.
“In the following table are shown the results of subjecting
various samples of urine of different degrees of acidity to
the action of the 0’2 grm. filter:—
Source of urine.
Degroe of acidity in ccm. of
potash solution (1-10 nornuU).
Uric acid in lOOccra. before
passage through filter.
Uric acid in 100 ccm. alter
passage tlirough filter.
llealtliy person .
4-5
0-0637
0-0004
TJric acid diathesis .. ; .
3-0
0-0605
0-0297
Healthy person (to whom litliia had I
been administered)./i
1-0
0-0429
0-0316
Ditto Ditto .
1-0
0-0270
0-0272
“ It is also seen that the comparative richness in uric acid
is of no importance, for of two samples of urine containing
equal quantities of uric acid one may hold all, or almost all,
of it in the state of proneness to deposition, while in the
other there is no trace of uric acid exhibiting this tendency.
The above table would seem to show this. The uric
add prone to abstraction by the Earmdurejilter has been
called by me ‘free uric acid’; but it must be noticed that
the nric acid cannot be considered as chemically free, as
urine, according to Brlicke, contains no free acid ; but that
it is only in a loose state of combination. The uric acid more
fixedly combined with bases in the form of urates may on
tbe other hand be conveniently termed ‘ bound uric acid.’
The proneness of the urine to deposit uric acid is perceived
in clinical observations by a sediment appearing on the
sides and bottom of the vessels containing it presenting the
well-known reddish brick-dust appearance. This precipitate
is composed of crystals of ‘free uric acid ’; while, on the other
hand, the amorphous loamy sediments, which give the
urine a muddy appearance, consist of urates, in which the
uric acid is for the most part in the ‘ bound ’ state.
Although excessive proueness of the urine to deposit its
uric acid is, as I have shown, a sure indication of the
presence of gout, it cannot on the other hand be maintained
that this characteristic obtains in every case ; and, aUbbugh
this ‘free acid’ is! present in large quantities in the urine
of almost all cases of gout, still cases are met with in which
the abnormal proneness to part with it is less developed.
Besides there are cases of gouty cachexia which do not
present any sign of this proneness for the simple reason
that uric acid is not present in tbe urine, or at least only
traces of it can be detected.
“ Now tbe question arises whether in the case of gouty
subjects this proneness to precipitation is peculiar to the
uric acid in the urine alone, or if it is a quality common to
that present in all tbe body and in the blood as well. The
gouty deposits in tbe joints and surrounding tissues would
seem to indicate the latter hypothesis, although no direct
proof of it can be given.
“ With reference to Sir A. (larrod’s well-known thread
experiment, by which he ascertained the presence of uric
acid in the serum of the blood of patients suffering from
gout, I should here remark that this experiment merely
indicates its presence in a state of greater proneness to pre¬
cipitation than is found to obtain in the cases of healthy
persons. The conclusion arrived at by him, that there is an
excess of uric acid in gouty blood, cannot be accepted as
proved, because similar results ore not obtained when the
experiment is performed ■with blood serum in which this
acid has been artificially dissolved inconsiderable quantity.
From blood serum so treated when it is rziixed with acetic
acid crystals of uric acid are thrown down in large quan¬
tities, bat they are not attracted by the thread.”
From the perusal of what I have written in tlie foregoing
account in .June, 1880, it will, I venture to think, bo learned
that the objections brought forward by Sir William Roberts
in January, 1890, against the validity of my test for latent
gout have received due consideration ; and also that the
results of my investigations on this subject cannot be
disposed of by experiments made only on the urine of
healthy persons. With the view of verifying tiie conclu¬
sions arrived at by me in this connexion it is necessary
that similar experiments be made on tbe urine of gouty
subjects. The plan proposed by the same eminent
observer to estimate the degree of proneness of the urine
to deposit uric acid according to the time at which
crystals begin to make their appearance in specimens
of the twenty-four hours’ collection kept in corked phials
is certainly an important one; but daily experience shows
that this time depends chiefly on the comparative richness
of the urine in uric acid, and that the urines of healthy
persons rich in this acid show crystals after several hours,
although they contain little “free uric acid”; while the
urines of gouty persons, which contain only little uric acid
in “free ” state show no crystals after one or two days. To
raise this method of observation to the level of a test for gout
very many accurate observations of the time at which the
crystals begin to appear in the urine of both healthy and
gouty persons would have to be made—a method which,
if carried out systematically, would entail too much time
and trouble to be of practical use. Again, in addition to
the different degrees of richness in uric acid, the influence
of temperature and acidity would have to be considered as
disturbing factors with regard to the time at which deposits
would make their appearance.
To the above-mentioned tests (the Harnsdurefdtcr and
the “ thread experiment”) I would add a third, as described
in my paper above referred to.
“ When I tried some years ago to decide these questions
by experiments I was convinced that, although inve.stiga-
tions made to ascertain the influence of warm baths on
healthy subjects may claim a certain value, their real in¬
fluence on the urine in tbe gouty state can only be studied
on subjects of that disorder. Having made all my
experiments at Wiesbaden with the Kochbriinnen waters,
it is to be understood that the following remarks refer
solely to the results obtained by their use. Not having
had any experience of their use, I say nothing as to the
effects produced by other baths, which may be equally
effective in the treatment of gout. My first investigations
speedily revealed the fact that tlie urine in many gouty
cases, after about twenty baths had been taken, presented
a considerable diminution of the secretion of uric acid; and
on prosecuting the experiments still further I found in
numerous instances the following results. After about
twenty baths of Kochbrunnen w.ater of lialf an hour’s
duration each, and at a temperature of 27“ R. (92" F.),
had been taken on twenty consecutive days, the quantity
of uric acid secreted during the twenty-four hours
is never essentially diminished, but in tbe majority of
cases is, on tlie contrary, greater than before commencing
the baths. If the uric acid at the beginning of the
aeries of baths should happen to be in the ‘bound’
state, it becomes almost entirely ‘free ’ towards the end of
the cure ; or at least the quantity of ‘free’ uric acid shows
an increase over that obtaining at the commencement of
the treatment. In gouty cases under a regular course of
the baths a remarkaVde diminution in the quantity of uric
acid daily secreted is seen to take place. In a certain
number of cases the diminution goes on until only traces of
the acid are left, wliile in others—and these are the most
numerous—the decrease takes place to bub half of the
original amount. At the same time tlic uric acid secreted
in ‘ free,’ or almost free, state at the beginning of the
Digitized Ljy Google
The Lancet,]
DE. H. MONTAGUE MURRAY ON AN EPIDEMIC OP MEASLES. [Jan. 3,1891. 15
baths is partly or completely ‘bound,’ and remains so for
some considerable time after leaving them off. This
behaviour in the secretion of uric acid in the healthy and
gouty state respectively, besides being of considerable
iniportance from a therapeutical point of view, is of great
value as an aid to diagnosis. There are a great many cases
in which the gouty nature of the ailment is not quite clear
from the clinical symptoms, and inVhich the examination
of the urine with the Hamsciurafiltcr does not give any
certain results. In such cases the systematic use of baths
will demonstrate the gouty nature of the disease. When a
remarkable diminution of uric acid—say to one-half or less—
is seen to take place by the time the twentieth bath has
been reached, the case must bo considered as one of gout.”
I would add that, as in the case of healthy subjects, the
urine of patients suffering from rheumatic complaints shows
no diminution in the excretion of uric acid under a course
of baths, and that this diminution is only found in cases of
gout. By this circumstance the method of distinguishing
gout by a course of baths proves to be one of the most sure
“tests for gout,” and enables us with certainty to separate
obscure cases of gout and rheumatism.
ON AN EPIDEMIC OF MEASLES AT THE
FOUNDLING HOSPITAL.
By H. MONTAGUE MURRAY, M.D., M.R.C.P.,
S/JNIOIl CONSULTING I’lIYSICIAN TO THE EOUNOLINO HOSJ’ITAL ;
LECTURER ON I'ATIIOLOOY AND ASSISTANT I'lIYSICIAN, CHARING-
CROHS HOSPITAL ; PHYSICIAN TO OUT-PATIENTS, VICTORIA
HOSPITAL EOR CHILDREN.
In an epidemic of measles which occurred at the Found¬
ling Hospital during the present year, 107 children were
attacked. I propose to classify the results then obtained,
that they may he compared with the statements usually
made in books. But in order that the following statistics
may be intelligible, it is necessary to explain that the
Charity maintains rather more than 500 children. All
are admitted as infants, and are kept in the “country
after the age of four. The latter alternative is, however,
unsupported by other evidence.
3, Period of incubation. —The first case was admitted
into the Infirmary on March 23rd. The rash appeared
the same day. Each of the succeeding cases was admitted
on the day the rash appeared, according to the following
table. The appearance of the rash is taken as the point of
comparison, because it is the only feature in the onset which
could be in all cases fixed with absolute certainty.
In the first series of cases, those admitted from April Ist to
April 4th, the incubation period seems to have been either
exactly nine or to have varied between nine and twelve
days. If it be assumed that the possibility of infection is
synchronous with the commencement of the invasion
stage, then this series may represent the number
whicli took the infection on each of the three to four
days of the invasion stage which must have preceded
the appearance of the rash in the first case, and dur¬
ing which the girl was at large. There is no clear
evidence showing how far individual peculiarities may affect
the length of the incubation period. With a source of in¬
fection extending over a possible four days more definite
results cannot be obtained. If nothing be allowed for such
peculiarities, the period would be from nine to twelve days ;
bnt if any allowance be made, the'effect would be to reduce
proportionately the larger limit. Nor can nine days be
taken as the absolute measure of the shortest incubation
period, for some of the earliest cases might have derived
the infection from the first child during the later days of
the invasion stage. On the whole, however, I am inclined
to consider that the numbers admitted from April Ist to
April 3rd represent different days of infection, and that
those admitted on the following two days more probably
represent individual peculiarities. But this is little more
than an assumption. This conclusion would make theincuba-
tion period from nine to eleven days. Some probability is
given to this view by the fact that in the second series the
mean of these numbers seems to represent the length of the
incubation period. The drop in the number of cases ad¬
mitted on the 13th and 14th is, however, of little value, jw
at that time there were no more unprotected children left.
Mai'cli,
D.ate
. 23
24
20
20
27
'll
CJivlM ..
. 0 .
. 0 .
. 0 .
. 0 .
. 0
Boys
Case
ad-
mitte
0
. 0 .
. 0 .
. 0 .
. 0 .
. 0
Total ,.
. 0 .
. 0 .
. 0 .
. 0 .
. 0
29 30 31 1 3 a 4 6 0
.. 0 .. 0 .. 0 .. 9 .. 13 .. 18 .. 6 .. 3 .. 0
.. 0 .. 0 .. 0 .. 3 .. 10 .. 11 ,. 0 .. 0 .. 0
.. 0 .. 0 .. 0 .. 12 .. 23 .. 29 .. 11 .. 3 ..
April.
7 8 9 10 11 12 13 14 15
.. 1 .. 0 .. 0 0 .. 0 .. 0 .. 0 .. 0 .. 0
.. 0 .. 0 .. 1 .. 2 .. 10 .. 4 .. 3 .. 0 .. 0
1 .. 0 .. 1 .. 2 .. 10 .. 4 .. 8 .. 0 .. 0
cottages ” until from three to five years of age. They are
then brought to London, and live at the Foundling Hospital
until suitable occupations are found fiir them. This
is generally between the thirteenth and sixteenth year.
The present epidemic began in March, 1890. No case.s of
measles had occurred during the interval which elapsed
between this and the immediately preceding epidemic in
the spring of 1884. About 43 per cent, of the children
admitted from the country homes are certified as having
had measles while under observation—that is, during the
first three to five years of their lives,
1. Liability to infection. —When the outbreak of measles
occurred there were in the hospital 313 children. Of these,
107 were attacked. The remaining 206 were all certified as
having had measles in the country, or as having suffered in
the previous epidemic. In other words, no child, unless
protected by a previous attack, escaped. It would seem
therefore that exemption from the disease after exposure to
the infection is very rare, and that, within the limits with
which these statistics deal, the age of the child exposed is
of no etiological importance. The facts here adduced do nob,
of course, bear on the alleged partial immunity of infants.
2. liarity of second attacks. —Seven out of the 107 coses
were stated to bo second attacks. In each of these the first
occurred in the country. In no case did a child who had
had measles in the 1884 epidemic at the Foundling Hospital
have it a second time in the epidemic this year. If the
occasionally great difficulty of distinguishing in infants
between isolated cases of robheln and rubeola be borne in
mind, it will be seen that these results point either to the
extreme and generally recognised rarity of second attacks,
or to the greater protective influence of measles acquired
The readiness with which the infection spreads may be
gathered from the fact that some boys were among the
earliest cases, though at no time, except in chapel and in the
playground,- are the children near one another, and even on
those occasions are separated by a considerable space.
4. The rash, —In the majority of the cases in which the
onset of the rash was observed it was noted that it
appeared behind the ears before it could be seen on the
forehead. In one case (a boy aged ten) the rash followed a
hot bath, and took the for.u of a general, intensely purple
eruption, consisting of conlliient patches, suggestive of the
malignant variety; but the patches disappeared on pres¬
sure. The rash gradually faded and in five days had dis¬
appeared. The boy made an uninterrupted recovery.
5. Complications and sequeUc. —These I have grouped
together in one table, as no clear distinction could be made
between them.
From the table on the next page it will be seen Uiat one-
third of the cases .suffered from complications or sequelse;
that of those bronchitis and broncho-pneumonia make up
more than half the list, and that one-third of the cases of
brpneho-pneumonia proved fatal. Tlie dates given of the
appearance of the broncho-pneumonia are not accurate;
they are really those of the onset of the bronchitis, which
in all cases preceded and accompanied it. One child had
stomatitis in the second week and a subcutaneous abscess in
the ninth, and appears therefore twice in the list. In both
cases of “abscess’’the subcutaneous tissue of the gluteal
region W'as the part involved.
Cases of functional neuroses following measles are, so far
as I can discover, very rare. I have therefore appended the
notes taken almost in full.
A2
Digitized by
Google
16 ThbLakcet»]
CLINICAL NOTES.
[Jan. 3,1891.
F. 0-, a fair, healthy-looking girl aged twelve, com¬
plained on April 2Qd of headache. In the evening she had
a warm bath. The same night she was attacked by more or
less rhythmical rolling movements of the head from side to
side. With these there occurred alternating flexions (with
elevation) and extensions of the right shoulder-joint, the
elbow remaining to a varying extent flexed. The muscles
principally involved were the sterno-mastoids, trapezii,
splenii, and pectoralea. The movements were coarser and
less rhythmical than those of pure clonic spasm, but much
more regular than those usually observed in chorea. They
varied in intensity, were not aggravated by observation,
and ceased only during sleep. The movements of the arm
were less rhythmical than those of the head. On waking next
iiioming they recommenced. At the end of two days (the
4tb) the arm was restored to its normal condition, and the
rolling of- the head was mainly to the right, and due to the
contractionsof the left sterno-mastoid. Nextday(the5th)the
rash and other phenomenaof measles made their appearance.
On the 6bh the movements were barely perceptible, and by
the 7th they had completely disappeared. The rubeola ran
its usual course, and the patient wasquite convalescent when,
on May 5th, more than a month after the beginning of the
Complication
or sequela.
Date of appearance.
Total
No. ^
1
i Per¬
cent¬
age.
Deaths.
' 2 on first day "N
3 on second day 1
Jiroacbo-pneumonia
3 on fourtli day 1
1 on fifth day (
1 on eightli day
\ 1 on ninth day )
f 3 on first day ]
1 1 on third day I
11
10-38
4
iJroncbltis .. ..
J 1 on fourth day 1
1 1 on tenth day (
1 on twenty-first day I
1 1 on thirty-first day J
( 1 in first week S
8 ,
7-55
0
Ophthalmia .. .,
J 3 in third week 1
1 1 in filth week f
1 2 in ninth week )
f 1 first week \
1 in second week [
7
1
(1-0
0
Stomatitis .. ..
•! 1 in sixth week ;-
1 1 in seventh week I
' 1 in eleventh week J
5 1
4-72
1
Otitis.
Abscess .
1 in eighth week
/ 1 in fourth week \
\ 1 in ninth week /
See report of cases.
1 !
2
0-£)5
1-0 1
1-0
0
0
0
Total number of
3G
34
complications, 7
attack, the movements recommenced. Beyond the fact
that this time the arm and shoulder were less involved, no
difference was noted. There was headache as before, and a
temperature of 100'4®F. In two days (May 7th) the tem¬
perature was normal, the headache had disappeared, and
the movements had begun to diminish. By the 19th they
had entirely ceased, and they have not recurred since that
time (six months). There was never any loss of motor
power, disorder of sensation, or increase or diminution of
reflex action, nor indeed any further evidence of disease.
In the case of L. H-, aged six, a fair, thin, weak-looking
girl, the rash appeared on April 2ad. The disease ran its
course favourably. The highest temperature recorded was
103" F. There were no lung complications. At the end of a
week the child seemed unduly pale and languid, and was
ordered two ounces of wine daily. On the 12th she got up.
Two days later (14bli) it was found that she could not stand.
If put on her feet, and encouraged to try, she kept her legs
together, and, allowing all her joints to flex, sank to the
floor much after the fashion of a hysterical patient. There
were no sensory defects, no disordered action of the
sphincters, and no loss of any movement while lying in
bed, but those of the lower extremities seemed defective in
power. The knee-jerks were extremely well marked—
perhaps excessive—but there was no ankle clonus. Super¬
ficial reflexes were normal. The patient was kept in bed,
iodine was applied to the spine, and strychnine given
internally. For nearly a week her condition remained
unchanged. On the 22nd she was encouraged to walk.
Improvement from this time was slow hut continuous. The
strychnine was gradually discontinued. By May 12fch her
gait and muscular power were completely restored.
I have to e.xpress my obligation to Mr. Statham,
Medical Officer to the Foundling Hospital, and to many of
the other oflicials of that institution, to whose kindness I
am indebted for most of the figures on which these
statements are based.
Sftvile-row, W. _
Clinkal Itaks:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
THE PAROXYSMAL HACKING COUGH OF
CHILDREN.
By Frances Warner, M.D.Lond., F.R C.P.,
PHYSICIAN AND LECTUUKR ON THERAI’EUriCS AT THE LONDON HOSPITAL.
Sir Andrew Clark’s paper on the “ Hacking Cough of
Puberty,” read before the Medical Society of Loudon,
having drawn attention to this subject, it may be worth
while to describe an affection, apparently of a similar
nature, commonly met with in children. I refer to children
from six to eleven years of age who are over-mobile, with
wandering eyes, frequent change of expression ; the bands
when held out present finger twitches and a balance which
I have described as the “nervous hand,” the wrist being
somewhat flexed, the metacarpus arched or contracted
laterally, the metacarpo-pbalangeal joints extended back
with slight flexion of the internodes, while the thumb is
extended.^ The finger twitches are of individual digits,
and fine lateral movements are the most . character¬
istic. The balance of head and spine is usually
asymmetrical, and exhaustion is often indicated by
fulness under the eyes due to relaxation of the orbicu-
lares oculorora. These children are usually well made
in body, and free from those minor defects in form of head,
ears, palate, &c., which indicate low development. They
are frequently the offspring of neurotic parents, or of a
nervous mother. I have preferred thus to describe the class
of children in whom the “hacking cough” is found in
lace of speaking of these as nervous or delicate, because I
0 not think that they necessarily have any tissue delicacy.
Advice is commonly asked in such cases on account of
“paroxysmal cough” with emaciation, disturbed nights,
and loss of appetite. Inquiry and examination indicate,
in addition to the signs given above, that the child is a
tooth grinder and has ground teeth, body weight is below
the average (often 7 Ib. or 141b. under), appetite is variable
—usually defective, and may be accompanied by vomiting;
but at times the same child may have voracious appetite
with sudden “ravings for food.’’ The urine is generally
clear, with a specific gravity of 1030-35, and crystals
of nitrate of urea are readily obtained on mixing with
an equal volume of the acid, while the addition of strong
sulphuric acid produces a deep purple line of staining at
junction of the fluids. The troublesome hacking cough,
usually worse at night, the emaciation and exhaustion,
suggest to the nervous mother that the child is consump¬
tive, but diagnosis can be made by a normal temperature
and the physical signs of healthy lungs. As this affection
is common, it is important that it should be recognised.
From an examination I have made of 22,000 children in
schools, it appears that from 1 to 2 per cent, of the children
present the signs of over nerve mobility as given above, and
of these a large proportion suffer at some period of their
childliood from “hacking or paroxysmal cough” without
lung disease.
As to the pathology of this alTection, I do not think that
it is commonly reflex from peripheral irritation, either from
intestinal worms, affection of tonsils or pharynx, &e., but
it appears to be due to an unbalanced central nerve action.
Among other nerve centres, the pneuniogastric appears
profoundly disturbed, as indicated by laryngeal irritation,
gastric perversion, and dense urinefnotcopiousas in hysteria).
As to treatment, these thin children lose their morbid sym¬
ptoms when they gain a normal body weight, and this is best
encouraged by residence in the country, a quiet and regular
life under discipline, by hydro-carbonaceous diet, which
should be plentiful and forced on them if necessary. Among
useful drugs may be included belladonna, arsenic, and
1 See author’s Mental Faculty, Cambridge University Press.
TOOg[e
Diaitir-
The Lancet,]
CLINICAL NOTES.
[Jan. 3,1891. 17
bromides, with tonics, cod-liver oil, and malt; alcohol
should, I believe, be strictly avoided. All sources of
mental anxiety and excitement should be removed, while
a quiet but firm government of the child is provided. The
prognosis of these cases is good under proper manage¬
ment, and parents may be encouraged by icnowledge of me
fact that these nervous children often make the best
men and women in later years, though a source of
much anxiety in childhood.
Kensington, W._
ECZEMA CAUSED BY VIRGINIAN CREEPER.
By E. Lycett Burd, M.D. Cantab., &c.
A CORRESPONDENCE having recently taken place on the
subject of eczema caused by the primula obconica, 1 think
the following ease will be of interest.
Mrs. W -, a lady of middle age, consulted me on
Oct. 15th last on account of an attack of eczema then com¬
mencing. The cheeks were highly inflamed, the chin and
parts round the nostrils covered by a weeping vesicular
eruption; there was also a partly papular and partly
weeping vesicular eruption on the back ot the neck, wrists,
arms, breast, and legs, with much irritation, heat, and
pain. The eyelids were greatly cederaatous, and were for a
time completely closed. There was, however, no rise of
temperature, and but little constitutional disturbance. No
cause for the attack was then assigned, nor could I discover
any. Under treatment, the patient being a good one and
strictly cariying out all instructions, the attack quickly
subsided, and me became convalescent. Suddenly, how¬
ever, on Oct. 29th, the disease returned with, if possible,
increased virulence, the face becoming again swollen and
cedematous, and the vesicular weeping eruption appearing
on that and other parts as before. On further consideration
it was now recollected that on the day previously to each
attack Mrs. W-had been occupied in packing up and
sending away to an artist friend a quantity of the leaves of
the Virginian creeper (Ampelopsis Hoggii). This seemed
to me hardly an adequate explanation, but the governess
had on both occasions been helping her, and on both
occasions had been similarly attacked. The gardener, too,
who had picked the leaves was also attacked with some
similar eruption, but as he was not under my care I cannot
vouch for the identity of the disease in his case. I then
learnt that towards the end of September Mrs. W-had
had similar dealings with the same leaves, followed by a
similar though much slighter attack of eczema. This is to
me an entirely unknown agent in the causation of eczema,
nor can I find reference to a like case. I should be glad to
hear if others have had a like e^:perience.
Shrowabury.
A NEW EPIGLOTTIC RETRACTOR.*
By Dr. J. Mount Bleyer,
OF NEW VOUK CITY.
While busy several years ago in testing iny tongue
tractor for the purpose of forced laryngoscopy in children,
and studying the action of the muscles, ligaments of the
tongue and epiglottis, I found that if a firm pressure was
made with the leaf-like projection of this instrument upon
the glosso-epiglottic ligament, a tension was produced, and
thereby the epiglottis raised and retracted against the base
of the tongue. This knowledge led me to construct the
epiglottic retractor, of which the illustration is a facsimile.
It needs no further description than the one of its applica¬
tion. Often patients are presented to ns with an epiglottis
either misshapen or pendulous, and thereby obstructing our
> Detnonstrato l before the German Surgical and Jloaical Society of
New York, October, IBDO.
view of the interior of the larynx, thus making a diagnosis
difficult. In order to retract the epiglottis, a 10 per cent,
solution of cocaine is necessary to avoid reflex action of
the muscles. The patient is instructed to hold his own
tongue firmly by its end. The retractor, under the guid¬
ance of a laryngeal mirror, is passed upon .the glosso¬
epiglottic ligament, dii-ect pressure is then made upon it,
toe direction of this pressure ' being against ^be base
of the tongue. The epiglottis is seen immediately
raised and retracted against the tongue, giving thereby a
thorough view of the interior of the larynx. Some prac¬
tice is necessary, as with all instruments for intra-
laryngeal work. This instrument, no doubt, will find
its way into the armamentarium of the laryngologist. It
is manufactured by the well-known firm of Messrs. George
Tiemann and Co , New York City.
New York. _
DEFORMITY OF THE FEET IN AN AGED WOMAN.
By J. J. G. Pritchard, L.R.C.P. Lond., &c.
The accompanying illustrations faithfully depict the
appearance of the feet of an old woman who was admitted
into the Lancaster County Lunatic Asylum recently, exhibit¬
ing the effects of neglect, and showing the way in which
some people still exist in civilised England.
A. L-, aged seventy-four, was admitted last November
in a very dirty condition. She is quite blind from sym¬
pathetic ophthalmia, and is nearly deaf. Her feet presented
the appearance seen in the enlravings, with the adaition of a
large amount of dirt filling up the interspaces. She walked
with great difficulty on this account. She had lived with
her son, a farm labourer, and badly off, for the last five
years, and had not had her toe-nails cut for the whole of
this period. She bad worn her stockings both day and
night until they were worn out, and they were never
washed. The lost pair she bad worn six months. She had
frequently asked to have her nails cut, as they hurt her,
and she could not do so herself, but it was never done.
She was troubled with sickness at first, complaining that
the diet was too rich. She was accustomed to have a drop
of ten and a little bread, some dry potatoes for dinner,
and a taste of meat on Sundays, sometimes porridge
Digitized by i^ooQle
18 Thb Lakcbt,}
HOSPITAL MEDICINE AND SURGERY.
[Jan. 3,189).
with very little milk. Her only comfort was a pipe; she
had smoked for thirty years. The nails were removed
easily* some coming on in bed, and leaving an ordinary¬
looking nail underneath. The photographs were taken
by my colleague, Dr. Harbinson.
Lancaater. i __
AN OVERDOSE OF STRYCHNIA TREATED BY
BROMIDE OF POTASSIUM.
By W. B. Calby, L.S.A.
On Oct. 25tb, at 9.10 a.m., I received a message that a
patient had taken “ a little more than a tablespoonful,
instead of a teaspoonful, of his medicine.” The day before
I had sent him two ounces of Easton’s syrup, labelled “A
teaspoonful to be taken in water three times a day.” At
9.501 found the patient (a muscular man, twenty-nine years
of age) in bed, in a darkened room. He lay on his back,
with the bedclothes pushed up over his eyes. His arms
w'ere flexed across his chest, and rigid ; his legs were
extended, abducted, and rotated outwards. His face was
distorted, the angles of the mouth were drawn down,
exhibiting the risus sardonicus. On attempting to speak,
his articulation was indistinct. The eyes were open, but
the darkness prevented observation of the pupils. Respira¬
tion was suspended, save for an incomplete inspiration. The
skin felt very warm, and was bathed in profuse sweat.
The pulse was small, soft^, and too rapid to admit of
counting.
On relaxation the patient spoke distinctly, and complained
of such little light as enteied through the drawn blinds.
He begged me not to touch him. After two minutes
another paroxysm set in. Finding that he had taken more
than one ounce of the syrup, at about 8.30—symptoms
developing about twenty minutes afterwards, and increas¬
ing in violence until my arrival—I decided to give half an
ounce of bromide of potassium. On offering this, dissolved
in two ounces of water, the patient cried out he should bite
the glass tumbler. A strong convulsion ensued. At 10 A.M.,
as soon as it was possible, he opened his mouth, and I poured
in one ounce of the solution. This was swallowed with
great and convulsive effort, accompanied by rigidity
of the limbs. The remainder was swallowed in like
manner. During the next fifteen minutes he yawned
several times and shuddered, closing his mouth with a
decided snap. At 10.20 a.m. the skin was perceptibly
cooler; the pulse stronger, and 70. There was complete
relaxation, much sweating, and salivation. The saliva
saturated two handkerchiefs. At noon he got up, and sat
in a darkened room. At 1 I’.M. he had lunch. There was
no difficulty in swallowing, but he felt twitchings at the
corners of the mouth and brought his teeth together with
exaggerated force. Besides this no other symptom occurred.
The large amount of the bromide and the concentrated
form in which the salt was administered caused nausea and
a feeling of “burning” at the epigastrium. The patient
sat up, read, and conversed until 9 P.M., and said that “ he
felt quite himself.” The sedative caused no drowsiness.
On measuring the remaining syrup, I found he had taken
ten drachms in one dose, equal to i^jth gr. of phosphate of
strychnia. The tablespoon used held exactly one fluid
ounce.
This case suggests theunadvisability of dispensing Easton’s
syrup, and simitar potent medicines, in undiluted form ; and
also the danger arising from the use of domestic measures, of
such nncertaiu and varying capacity as the spoon mentioned.
New Swindon.
The Animals’ Institute. —The Committee of the
Institute has organised an Exhibition of Appliances to
supersede Muzzling. The Exhibition is open to the public
daily (free) at the Animals’ Institute, 9, Kinnerton-street,
S.W., and the principal feature of it is a humane sanitary
collar, invented by Professor Atkinson.
A Centenarian. —On the 18th ult. Mrs. Gillard,
of Reckleford, Yeovil, died at the age of 108. She was
born in London in 1782. With the exception of slight
deafness she was in possession of all her faculties, but
practically bedridden. Since 1844 she has resided with her
youngest daughter, who has reached an advanced age.
OP
HOSPITAL PBACTICE,
BRITISH AND FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quaraplurlmaa et moi-
borum et dlssectionuia historias, turn aliotum turn propviaa collectas
habere, et inter ae comparare.—MORQAONi De Sed. et Caue. Uorb.,
lib. iv. Prowmium. ■ ■
THE ROYAL FREE HOSPITAL.
a case of gastric ulcer simulating cancer op the
PYLORUS ; GASTEO-ENTEROSTOMY ; DEATH ; REMARKS.
(Under the care of Dr. Sainsisuuy.)
Thb chief reason for recording this case is the diagnostic
difficulty presented by it. It was regarded as a case of
cancer because of the presence of a well defined epigastric
tumour, though the history of the case was in favour of
gastric ulcer. It Is, we imagine, generally held that where
symptoms point either to ulcer of the stomach or to cancer
of this organ, the presence of a tumour possessing certain
characters belonging to tumours of the stomach is decisive
in favour of the latter affection. That it is not absolutely
decisive the present case will demonstrate.
James H-, aged fifty, was admitted to the Royal Free
Hospital on Sept. iSbb, 1890, under the care of Dr. Sainsbury.
He complained of pain in the stomach, increased or brought
on by food; of vomiting, the pain being relieved by tliis
act; and of emaciation. The family history was negative.
There was no definite tendency to disease. The personal
history was good until nine or ten years ago. Since that
time he bad suffered from “ weakness at the chest,” showing
itself as heartburn and aliability of the stomach to be upset.
During this period he had suffered occasionally from vomit¬
ing, and on four or five occasions he had brought up blood,
recognisable as such, and of about one tablespoonful in
quantity. There was a (questionable history of mekona
antedating the stomach symptoms, and accompanying them
later. Ten to fifteen years he mentioned as the duration of
this symptom. In addition there was a history of hiomor-
rhoids. Patient had been a heavy drinker of beer. For two
years there had been an aggravation of the stomach sym¬
ptoms. He was an in-patient at this hospital for a few days
at the commencement of this period ; then he entered the
infirmary, and during six months suffered much from vomit¬
ing, the vomit resembling coffee grounds. The motions
were very dark. The sboraach pain was very severe. For
the nexo nine mouths, after leaving the infirmary, he was
well and free from pain. Then he became an out-patient
here, and subsequently at the Great Northern Hospital,
with a return of the stomach troubles. At this time the
taking of food, for which there was a great craving, was
nob followed by pain till half an hour bo an hour afterwards.
On admission it was noted that the patient usually lay
on his back, though he could lie wibn comfort in any
position. His face had a suffering expression, the com¬
plexion was somewhat sallow though the cheeks showed
colour. He was much wasted : his present weight being
7 8t. 91b., as against his normal weight lOst. lib. On
careful examination of the abdomen, which was soft and
flaccid and somewhat sunken, there was found, in the
epigastic region just above a line midway between the
xiphoid cartilage and the umbilicus, a rounded, well-
defined tumour, which about filled the hollowed fingers,
and measured 2 in. in diameter. There was but little
tenderness; and hence manipulation was quite easy, and
it was possible to define the tumour between the finger
and thumb. The tumour was found to vary its position
longitudinally, being sometimes felt on the left of the
raid-line, sometimes well to the right near the costal margin.
A stomach note was obtainable in the left axilla as high as
the fourth rib. There were no other physical signs of im¬
portance in the abdomen or in the chest. The vomit was
chieily coffee-ground in character ; it was not bulky, and on
no occasion in the past could the patient remember any
very copious vomiting. The bowels acted irregularly, the
abient suffering much from constipation. The stools were
ard and dark in colour. The case was diagnosed as cancer
of the pylorus, with secondary dilatation of the stomach,
Dipii z:d : Google
Thb Lancet,]
HOSPITAL MEDICINE AND SURGERY.
:Jan. 3,1891. 19
thou^Ii the poBibive si^s of the latter condition were not
very decided. So well oefined was the tumour that, in view
•of the hopeless nature of the affection, the question of pylo-
reotomy was considered, not for the purpose of relieving
.symptoms—for vomiting was not urgent at the time, and,
as before stated, the evidence of dilatation of the stomach
was not pronounced,—bub with a view to actual removal of
the malignant mass. Mr. Barrow then saw the case at Dr.
Sainsbury’s request. He fully agreed as to the presence of
a well-defined tumour, but thought that a new growth
blocking the pylorus ought to have given evidence of more
•distinct dilatation of the stomach. At his suggestion it
was agreed that we should wait a week or ten days, and
watch the symptoms. At a second consultation at the end
•of about ten days the patient presented the same symptoms,
but his general health was worse. There were no more
•distinct signs of obstruction, but the evidence of the tumour
was very definite. We then proposed an abdominal explora¬
tion with pylorectomy if feasiole. The patient, however,
would not agree to any kind of operation.
The subsequent record of the case showed an almost
daily presence of pain ; this in general was worse towards
mgbt, and it was so severe and caused so much sleepless¬
ness that hypodermic injections of morphia were called for.
These alone afforded relief. The vomit was in general
coffee ground in character—on one or two occasions clots
were found,—but at times it consisted only of curdled milk
of a light buff or fawn colour. Sarcinm were not discovered.
The bowels were constipated throughout, and up to Oeb. 21sb
enemata were required every two, three, or four days. Tliere
is no doubt, from the character of the motions, that some
blood was lost by the bowel, but meltena was nob a feature
•of the case. This was the more unexpected that the rapid
increase of pallor during this period suggested bleeding
as a probable cause. During the last fourteen days to
three weeks the patient grew rapidly worse, the pallor
became much more marked, also the emaciation. It was
then suggested to the patient that a more simple opera¬
tion—viz., gastro-enterosbomy—would probably give great
relief, and to this he assented. The operation was per¬
formed on Oct. •24th by Mr. Barrow. An incision was
made through the linea alba, commencing below the
xiphoid cartilage, and extending downwards for about
six indies. On introducing the hand the tumour could
be distinctly grasped in tbe situation of the pylorus, and
felt about the size of a turkey’s egg—the head of the
pancreas being intimately connected with it, and an enlarged
lymphatic gland could bo felt behind and below it. TJie
omentum having been turned aside, a coil of small intestine
was followed until its junction with the third part of the
duodenum could be made out. That portion of jejunum
was selected which was found to lie easily on the surface of
the stomach, and its contents were squeezed out by
drawing the gut two or three times through the fingers
and thumb, and then a ligature consisting of india-
rubber tubing was applied around each end of the emptied
portion of bowel. An incision about an inch and a half
long was made both into the stomach and into the
•emptied portion of bowel, the two openings were then
accurately approximated by silk sutures, these passing
•only through the muscular and serous coats, and not
involving the mucous membrane. The sutures uniting
the posterior and lateral parts of the openings were so
•passed and tied that their knots were towards the mucous
-aspect, whilst those uniting the anterior portion were
•towards the serous. The process of suturing was a little
prolonged on account of the bulging of the swollen mucous
membrane of the bowel, a condition which Mr. Barrow
attributed to his not having emptied a sufficient length of
bowel, and thus the two ligatures were too close to tise
•opening. An outer second row of sutures was also intro¬
duced. Then the abdominal wound was closed and dressed.
Every care was taken tliroughoufc the operation to ensure
its aseptic character.
On Oct. 26th, tlie day after the operation, the patient
slept from 3 A.M. till nearly (i A.M. He then felt less pain
than he had previously experienced, and he appeared to be
progressing quite favourably. He was fed with nutrient
enemata at lirat every two hours, then every three hours,
then^every four hums. At 5 P.M. he began to vomit, the
vomit being The vomiting then continued until
5 A.M. on the ‘2{Hli; at 4 A.M. the vomit had become black.
Tbe patient died at 10.15 a.m. on the “iGtli, having been un¬
conscious for one hour before his death.
At the necropsy, which was performed forty-three hours
after death, the external abdominal wound wa^ found clean
and its edges adherent throughout. The stomach and small
intestine in the immediate proximity of the gastro-enteros-
tomy were adherent to the anterior abdominal wall by
recent lymph. The rest of tbe peritoneum was perfectly
healthy. The stomach was much distended, its position
was nearly vertical (parallel to tbe spinal column). The
duodenum and commencement of the jejunum were much
distended as far as the enterostomy wound which had been
madeiuto the upper partof the jejunum. The gut had been
brought up in a loop around the transverse colon on tothesur-
face of tbe stomach. The stomach and duodenum were filled
with a thin, blackish-brown fluid evidently containing much
A, Duodenum laid open. Ji, Ulcer at pylorus, c, Probe leading into
gastro-enterostomy opening.
altered blood. On dissection the condition of parts shown
n the diagram was discovered—viz., a large, sharply cut
and thick-edged ulcer, situated exactly at the pylorus.
It was oval in shape, the long axis lying across the pyloric
orifice, and it involved the whole of the posterior surface
of the outlet. The floor of the deeply excavated ulcer was
formed by tlie eroded head of the pancreas, which latter, of
very firm consistence, was closely bound to the pylorus. In
the retroperitoneal tissue near the pancreas were one or
two (?) enlarged glands. The gastro-hepatic omentum was
nob thickened, nor was there any evidence in any of the
organs of the body of any new growth. The opening into
the jejunum was patent when probed by the linger; but
that there was an impediment, which must have been
valve-like, is proved by tbe distended stomach, and
the fact that water injected into the stomach before
dissection did not escape into the jejunum. There was
evidently an impediment to the passage of fluid from the
duodenum across the sutured portion of the intestine into
the jejunum, for the proximal portion of the gut (duodenum)
was found much distended.
itemarks by Dr. Sainskuky.— It is of interest to note
that, though fed by the rectum only, the stomach and
duodenum were distended with fluid. The vomit in the first
instance was green, and I suppose this must be explained
by regurgitation of bile poured into the duodenum and
unhble to escape into tbe jejunum, this flow of bile
accordingly taking place independently of the stimulus of
food passing into the stomach and duodenum. In the end,
no doubt, blood in quantity must nave been poured into
the stomach, almost certainly from the ulcer; but from
the sequence of events—viz., primarily bilious vomit,
then black vomit—I am inclined to think that there
was intestinal obstruction as a first event. It is im¬
possible to assign the part played by this and by
Uccmorrbage in the causing of death. Again, I would
Di:
L-oogle
20 Thb Lancet,]
OPHTHALMOLOGICAL SOCIETY.
[Jan. 1891.
draw attention to the very definite presence of tumour,
which was felt not only through the abdominal walls,
but also with the hand in the peritoneal cavity. From
first to last there was no doubt as to the tumour. It
was owing to this tumour that the history was strained a
oint, for the latter indicated a much longer duration of the
isease than was compatible with tumour. This difficulty,
however, was got over by supposing that malignant disease
had started at the site of an old ulcer. This is said to occur.
The sense of tumour was no doubt greater during life than
after death, when vascular turgescence had subsided. The
head of the indurated pancreas wmed one with the adherent
and thickened pylorus, and I can only suggest in explana¬
tion of the unuoubted mobility of the tumour during life
that the movements of the stomach as it filled or emptied,
continued through a period of years, had loosened the
posterior attachments of the pylorus. This point was,
unfortunately, not tested at the post-mortem. Dr. Brinton,
speaking from bis large experience, has stated that in a
few cases he had found it impossible to decide between
cancer of the stomach and gastric ulcer. This case may
serve as a commentary to this statement, and it will enforce
the danger in clinical medicine of relying too much on one
symptom or sign. The hose of the ulcer and its edge were
examined microscopically, but no evidence of malignant
disease was obtained. As to the treatment, I do not see in
what it erred, for gastro-enteroatomy is a recognised treat¬
ment both for new growth and ulcer of the stomach.
MANCHESTER ROYAL INFIRMARY.
TWO CASES OV GA.STROSTOMY FOR STRICTURE OF THE
(ESOPHAGUS ; REMARKS.
(Under the care of Mr. SOUTIIAM.)
In the following cases the operation of gastrostomy was
performed for obstruction of the ccsphagus, which was
probably of a malignant character. Although surgeons are
generally agreed as to the advisability of performing this
operation at an early stage, before the patient is exhausted,
it is not often possible to gain the consent of the patient
to the performance of the operation until a very late stage,
when exhaustion is so extreme that much benefit cannot be
expected. Gross collected records of 167 cases of gastrostomy
for malignant disease, of which the mortality waS' 29'34
per cent.; most of them died quickly, but forty-six survived
for more than a month. Of 207 examples of this operation
performed for various conditions the mortality was 29 47,
and the average prolongation of life was about eighty-two
days.
Case 1.—Edward T-, aged fifty-eight years, was
admitted under Dr. Sbeell, on Feb. 10th, 1890, suil'ering from
dysphagia of about six months’ duration. During the last
two months he had rapidly lost llesh, and about four weeks
previously he began to lose his voice. When admitted he
was unable to swallow solid food, and was much emaciated,
weighing only 8st. Ulb. On exploring the (esophagus, an
obstruction was encountered nine inches from the teeth,
and a second one about four inches lower down, through
which it was impossible to pass the finest bougie. On
examining the larynx the left vocal cord was found to be
paralysed. During the first fortnight after admission the
patient gained four pounds in weight. At the end of this
period, as he began to lose weight, and also to experience
considerable difficulty even in swallowing Huids, he was
transferred to the surgical wards to undergo the operation
of gastrostomy. .
March Sth.—Gastrostoiuy was performed by means of an
incision three inches long, coinmencing at the outer edge of
the left rectus and carried parallel with and about a finger’s
breadth below the margin of the ribs on the same aide; tlie
stomach whs readily exposed. It was then drawn up and
attached to the margins of the wound by six catgut sutures,
which included, on the one hand, the entire thickness of
the abdominal parietes, and, on tlio other, the serous and
muscular coats of the stomach, care being taken to bring
the opposed serous surfaces well into apposition. Two silk
sutures were then passed, thiougli the serous and muscular
coats of the Htoiiiach to act as a guide wlien the visens was
opened. On the fourth day, the patient liaving meanwhile
been fed entirely by nutrient enemata, a small puncture
was made into the stomach with a tenotomy knife, and a
piece of a No. 7 Jacques’ catheter was passed through the
opening and secured. Through this the patient was after¬
wards fed, two ounces of warm milk neing introduced
every two hours. On the sixth day the tube was removed
and left out of the wound, being reintroduced every three op
four hours for the purpose of feeding. The patient left the
hospital on the twenty-eighth day, being able to feed him¬
self through the gastric fistula, having gained twelve
pounds in weight during the last three weeks. He attended
several times as an out-patient, but eventually died
at home just three months after the performance of the
operation.
Case 2.—Thomas L-, aged forty-two years, was ad¬
mitted on June 28th, 1890, in an extremely emaciated con¬
dition, weighing only 8 st. 2 lb. About six months pre¬
viously he had commenced to experience difficulty in
deglutition, and at the time of admission could only
swallow fluids in very small quantities. On exploring the
cosopbagus, an obstruction was met with at a distance of
thirteen inches from the feeth, which would not admit the
smallest bougie. During the first week, as the result of
careful feeding, he gained 4^ lb. in weight. During the
second week, he was suddenly seized wirh complete in¬
ability to swallow, and though he was fed with nutrient
enemata he lost 17 Ib. in weight. It was accordingly
thought advisable to perform gastrostomy without further
delay. The operation was performed on July 12th, in the
same manner as in the preceding case, and the stomach wan
opened on the third day, as the patient was becoming ex¬
tremely exhausted from want of food. On the following
day, at the request of his friends and contrary to advice, he
was removed to his home, a small cottage in one of the
poor quarters of Manchester, where he was unable to be
supplied with proper nourishment. Though he continued
to be fed through the gastric fistula, he gradually sank,
death taking place exactly three weeks after the perform¬
ance of the operation.
Remarks dy Mr. SoUTllAM. —According to recent statistics
the rate of mortality after gastrostomy is still very high,
being not less than 72 per cent. In a large proportion of
cases death takes place within the first twenty-four or
forty-eight hours, and is due to shock, which is not well,
borne by the subjects of stricture of the cesophagus, for
they are usually worn out by exhaustion and inanition at
the time of operation. As rapidity of operation is always
an important factor in lessening the effects of shock, the
simpler and the more speedy the method of attaching the
stomach to the abdominal walls the greater is the pro¬
bability of a successful result. The simple plan adopted
in the preceding cases, where a single row of sutures
was employed, not only ensures sufficiently accurate
apposition of the serous surfaces, but it also has the,
advantage of great rapidity, for in both instances the
operation was performed in less than fifteen minutes.
Though the duration of life after operation was not very
great in either patient, yet it was undoubtedly prolonged
by the performance of gastrostomy, and in addition the
pangs of hunger were relieved, and the comfort of the
patients was also increased. In neither case was there
inconvenience from regurgitation of food or escape of gastric
juice from the fistula, these complications being avoided
oy the formation of a small opening and by not retaining the
tube for a longer period than forty-eight hours. No post¬
mortem examination was obtained in either case, but from
the rapid course wliich the disease ran tliere can be little
doubt that the strictures were of a malignant nature.
IHdtkal Stririits.
OPHTHALMOLOGICAL SOCIETY.
Some Fo’inls in the 'Development of Cataract.—Diphiherilic
Paralysis of External Recti.—Paresis of External Recti.
—Supposed Case of Sanguineous Lacryinaiion..
An ordinary meeting of this Society was held on Dec. 11th,
the President, Mr. Henry Power, F.ll.C.S., in the chair.
Mr. W. A. Buaii.ey read a paper on Some Points in the
Development of Cataract, in which he said that, excluding the
congenital and zonular forms, and also the cataracts secondary
to other conditions, whether local, following glaucoma or
iritis, or general, as from diabetes, 7 per cent, of the total
Dig Google
The Lancet,]
OPHTHALMOLOGICAL SOCIETY.
[Jan. 3,1801. 21
coses seen in his private practice during the lost two years
were found to have some degree of opacity of the lens.
But only one on the average out of these seven patients had
bis cataract sufficiently advanced to justify the operation of
extraction. From examination of the records of Ml patients
with immature cataract who had been re-examined within
the last two years, it was found that 45 per cent, of them
remained absolutely unchanged for the worse, the intervals
between examination and re examination varying between
three months and eight years. Four other cases had even
become slightljr better as regards vision, thus making 58
per cent, in which the sight had not deteriorated. Twenty-
three per cent, were decidedly worse, inclusive of 4 cases
<13 per cent.) in which the cataract was sufliciently advanced
to justifyremoval under ordinary circumstances. The slight
improvement of vision in 1.3 per cent, of the cases was
attributed to the hygienic measures adopted with regard to
the use of the eyes, lo was observed that the cataracts
which had remained stationary or improved were mainly of
the cortical variety, as shown by the presence of peripheral
©trice or fissures in the lens, whereas those getting slowly and
steadily worse were mainly nuclear. Other differences were
found between the two groups, the cortical variety being
attended, in about two-thmis of the cases seen, both at the
onset and for long afterwards, with irritative symptoms, such
as conjunctivitis, photophobia, lacrymation, slight redness
of the optic discs, and by aching in the eyes and head,
©specially on use of the eyes. There was often also a slight
Increase in the refraction, and some augmentation of the
power of accommodation, with occasionally slight spasm of
accommodation. Finally it was suggested that while the
senile nuclear cataract was a degenerative change, the
cortical exhibited often the characters of aninllamraation.—
The President said the remarks made by Mr. Brailey
were in accordance with general experience. He men¬
tioned cases under his own care, and recalled the axiom of
Sir William Bowman, “Never operate for cataract while
the patient can see to read with either eye.” The rate of
development of cataract depended much on constitutional
causes, but in come degree might be delayed, he thought,
by hygienic precautions. He was unaware that any case
had been met with in which partial cataract had ever dis¬
appeared. With regard to laminar cataract, Mr. Power
mentioned the case of a young man whose vision bad been
good till eighteen years of age; his sight failed after two
yeais of oUice work, and it was necessary to wait another
year for full development before operating. He did not
Know that anyone could hold out auy promise of recov'ery
without operation.—Mr. Silcock. said that suchcases as those
described by Mr. Brailey were familiar to most ophthalmic
surgeons, but he thought the association of symptoms met
with in one class of case.s of which he had spoken might have
been of value in prognosis.—Dr. W. J. Collins mentioned
an instance of cataract which had been twenty-feight years
maturing, and was not now complete. The original diagnosis
and a sketch had been made by Sir William Bowman.
The primary stria; were posterior, and there was some
myopia. The latter might be referred to the increased
density, the refractive index increasing with the percentage
of solids iu, apart from swelling of, the lens,—Mr. Warbn
Tay was interested in Mr. Brailey’s account of the sym¬
ptoms, in addition to failing vision, which were present in
cases of immature cataract.—Mr. McHardy thought there
was insnllicient evidence that free use of the eyes appre¬
ciably hastened the maturation of cataract, and that there
was therefore no advantage in recommending a limitation of
the use of the eyes. In his experience there was usually a
change iu the refraction of the eyes, in the direction of
myopia, which varied with the state of tone of the patient,
'and was, ho considered, chiefly dependent on the higher
refractive index of the altered media. He recognised the
possibility of improvement in vision, and cited the case of a
unan iu ofUcial position who relinquished his employment
on account of defective vision through the development of
cataract, and was able a mouth afterwards to read the
newspaper regularly. He eventually died some time later,
without any necessity for operation having arisen.
Mr. DoYNE (Oxford) exhibited and read notes of a case
he had brought before the Society last session under the
title of Paresis of the External Recti. He now thought
the condition was move correctly described as “spasm of
convergence.” The patient, a lad aged seventeen, had vision
of with each eye separately, ana Jaeger 8 when holding
the types at three inches fromliis face. His eyes were usually
in a normal position, but as soon as examination was begun
spasmodic convergence showed itself. The refraction was
always myopic, though the degree varied; under atropine,
however, a low degree of hypermetropia became manifest.
Extreme restlessness and sighing and profuse perspiration
when under observation were noticeable symptoms. Mr.
Doyne thought the case was one which mignt be classed as
neurotic, but suspected also that there was deliberate
maliDgering.
Mr. A. Stanford Morton read notes of four cases of
Paralysis of the External Recti due to the poison of
diphtheria. Three of these patients came under his
observation daring the last ten months, and the fourth was
a patient of Mr. Tay in 1876. They all complained of
somewhat similar symptoms, such as “ crossing ” of the eyes
and “seeing double,” together with more or less defective
sight, weakness of the limbs and staggering gait. From a
study of the oases it appeared that the par^ysis of the ex¬
ternal recti came on in from four to seven weeks after the
sore-throat. Its shortest duration was four weeks, and in
one case it is still in existence, having been present twenty-
six weeks. In addition to the paralysis of the external recti
there was in one case defective action of the superior and
internal recti. The pupils acted well to light and con¬
vergence in all the cases. The accommodation was affected
in three of the cases, being absolutely paralysed in one.
Loss of the patellar-reflex was very marked, 'the shortest
period in which this symptom was recovered from was three
months. In two of the cases the reflex was still absent.
after a period of twenty-six and sixteen weeks respectively.
These cases were reported because of their apparent in¬
frequency.—Dr. Sidney Taylor (Norwich) referred to a
ease of paralysis of the external recti following an attack of
epidemic InnuenKa.
Mr. Richardson Cross road an account of a case of
S osed Sanguineous Lacrymation, occurring in a lady
twenty-one, who was seen in June, 1889, on account
of slight follicular conjunctivitis of the left eye and some
discomfort referred to the inner pait of the upper lid. On
July 2ad she returned saying that a lotion of cupric
sulphate and cocaine ordered at her first visit bad caused
considerable inflammation, and that on two or three occa¬
sions blood or a blood-stained tear had suddenly suffused the
eye and fallen down the cheek. A cold douche for the eye
and an iron tonic were prescribed, and some days later the
atient again presented herself directly after a drop of
lood had fallen. There was a small red-stained fibre in
the canaliculus and a similar thread under the lower lid.
No ulcer or hiemorrhagic spot could be discovered, but the
eyeball looked redder thau before, and the plica semilunaris
was swollen and congested. After the lapse of a year,
daring part of which period the symptom was absent, in
spite of somewhat impaired health, the patient returned
complaining that one or more drops of blood-stained tears
or blood, such as might come from the nose, suddenly
suffused the eye and fell down on her book or her work, at
all sorts of times, every two or three days, and even two
or three times a day. The tear had been observed to come
as if from under the inner part of the top lid, to run mainly
along the plica and caruncle under the lower lid ; and left
a blood-stain on whatever it fell. Blowing the nose showed
that a mere tinge had passed through the lacrymal canal.
Stooping seemed to encourage the blood flow. It had often
occurred while kneeling in church, and the mother had on
soveral occasions taken little red films or clots from under
the lower lid or B'oni the inner side of the eye. The bleed¬
ing continued in spite of treatment by large doses of iron
which improved the general health.' In October the patient
came again immediately after some blood-stained teai© had
fallen; there was still a small red fibre or clot between the
plica seitiilunaris and the caruncle, and another under the
lower lid. The conjunctiva, especially at the plica, was
congested. At the end of the month the patient was
walking with her mother when she stooped down to tie
her shoe-lace, and at onco the eye bled. Within a few
minutes she was seen by Mr. Cross. The eye looked blood¬
stained, and a red film was in the conjunctival sac as
before. Several spots of blood were on her handkerchief,
which were tested with guaiaciim and hydrogen peroxide,
and gave a definite blood reaction. The eye sac was care¬
fully examined; no spot could be detected froiif which the
bleeding seemed to have occurred, the caruncle was slightly
swollen, the plica distinctly so, and its vessels congested.
Mr. Cross said there could be no doubt of the accuracy of
22' The Lancet,]
MIDLAND MEDICAL SOCIETY.
[Jan. 3,1891.
the facts as stated by the patient. The symptom was a most
exceptional one, and the literature in connexion with it very
scanty. Hasrerand DeWecker had alluded to it, the latter
in connexion with scorbutus. There had been no tendency
to other hmniorrhage, no indication of hysteria, and the
K '.ent was very anxious to get rid of the malady. She
been at times distinctly anmraic.—Mr. Waren Tay
inquired if a microscopic examination had been made of
the blood spots.—M. Hartridqe asked if the lacryroal
gland had been investigated from the conjunctival surface.—
Mr. Cross, in reply, said the spots had not been examined
with the microscope, and that no abnormal appearance
could be detected beneath the upper lid. The patient was
not a bleeder.
The following living and card specimens were exhibited:—
Messrs. Critchett and Julkr: Microscopic Sections of
Epithelioma of Cornea and Conjunctiva.
Mr. Treacher Collins : Kupture of the Posterior Capsule
of the Lens following a Blow on the Eye.
Mr. Beaumont: Macular Coloboma(?).
Mr. Lawford ; A Case of Subhyaloid Hmmorrhage.
MIDLAND MEDICAL SOCIETY.
A MEETING of this Society was held on Wednesday,
November 2(jbh, Mr. A. Messiter, President, in the chair.
Congenital Absence of Ribs on Left Side. —Mr. MESSITER
showed a most remarkable example of this condition.
Fractured Olecranon; Stiture Jor Fibro^^s Union. —Mr.
Barling showed a case of a man aged twenty-four on whom
he had operated after fracture of the olecranon nine inontlis
after the injury. The fragments were separated by an
interval of II in., and the muscles were extremely
wasted, the measurement round the injured arm being
2^ in. less than on the opposite side. The surfaces of
the fragments were freshened and brought together by one
median silver wire suture, and the arm put up in the
extended position. Union by first intention followed, and
now, nine weeks after operation, the movements of the
elbow joint are free in all directions, and the difi'erence in
circumference' between the arms is only II in. The
union between the fragments consisted only of some fibrous
bands, and the upper fragment was so fixed by retraction of
the triceps that it had been suspected that it was ankylosed
to the lower end of the humerus. The suture remains in
situ, and causes no inconvenience.
Hydatid Cyst of Kidney.—yii:. CHRISTOPHER Martin
showed this specimen, removed from a lady aged forty-six
by Mr. Lawson Tait. The cyst was first noticed two years
ago, and the chief symptom was frequent micturition,
'l^ere was no history of renal colic or of hydatid vesicles
passing in the urine. The cyst was as large as a man’s
head, filling up the entire right costo-iliac space. It was
globular, tense, elastic, fluctuating, and painless. The
abdomen was opened by a lateral vertical incision
9iin. long and the cyst enucleated, but the kidnev was
so disorganised that it was also removed. The pedicle was
secured with a wire serre-nccud and treated extra-peri-
toneally. The patient made an uninterrupted recovery.
PlacentaPr(cvia.—M.r. ChelstopherMartin also showed
a uterus at the seventh month of pregnancy containing a
placenta prievia removed post mortem by Dr. Malcolmson
from a widow aged twenty-eight. No suspicion of pregnancy
was entertained until the woman was found dead in bed lying
in a pool of blood. The uterus was opened from above, and
the child extracted. The cervix was partially dilated and
the placenta detached for about an inch round the os
internum.
Dr. Malins showed the following speeiinens :— (1) Fibroid
Tumour of Cervix; (2) Channelled Polypus of Cervix;
(3) Fibroid of Uterus ; (4} Membranous Cast from Vagina.
Gall-Stones removed by Cholecystotomy,—Mr. F. Mailsii
exhibited nine gall-stones removed from a woman aged
fifty-three They were irregular in shape and of an average
diameter of five-eighths of an inch. The patient had-a good
family history, and had always been temperate. Her last
pregnancy occurred eighteen years ago, and terminated by
a miscarriage. Since then she has had prolapse of the
uterus, and has suffered from pains in the epigastric
region, associated with flatulence and vomiting. Her
bowels have generally been constipated. She has never
had jaundice, though her complexion has often been yellow.
Eight months ago she noticed a lump in the abdomen which
was tender on pressure Examination showed a rouodedi
prominence extending for a few inches below the right
seventh costal cartilage of the siise and shape of a kidney.
Microscopically the urine showed a quantity of minute
crystals of oxalate of lime, with a few blood-corpuscles.
The diagnosis lay between a distended gall-bladder, a.
movable kidney, and a renal J;umour. An exploratory
incision was made over the most prominent part of the
tumour, which proved to be a distended gall-bladder. It was
drawn into the wound and four ounces of sero-purulent fiuid
evacuated. The opening was then enlarged and the stones
removed. A drainage-tube was placed in the bladder and
the opening closed witli a purse-string suture and fixed
to the sides of the wound. Bile flowed through the tube
for forty-eight hours, and was then replaced by a serous
discharge. On the third day the tube was removed and
the superficial edges of the wound brought together.
The patient made a good recovery and is now quite
well.
ExfoUa.tion of Mucous Membrane of Gall-bladder from
Suppurative Cholecystitis. —Mr. John W. Taylor, showed
a specimen from a case of Suppurative Cholecystitis. Com¬
plete exfoliation of the mucous membrane of the gall¬
bladder had taken place, and on opening the latter, which
contained a pint of pus, a slough consisting mainly of the-
mucous coat was found lying free within the gall-bladder,
and was removed. Five or six gall-stones, black in colour,,
were removed at the same time. As soon as the contents-
of the gall-bladder had been discharged the ducts became-
K bent, bile flowing freely from the day of the operation.,
e patient made a good recovery.
Mr. Jordan Lloyd read a paper on Gononhooal Spermato-
cystitis (inflammation of the seminal vesicle).
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
At a meeting of this Society, held on Oct. 23rd, 1890,
Mr. W. Dale James (President) in the chair, Dr. Martin
showed a Multilocular Ovarian Cyst, interesting from
the rapidity of the growth, the increasing emaciation,
and the very marked appearance of cachexia in the
patient from' whom he removed it.—Mr. Dale James-
showed a case of Lupus Verrucosus of sixteen years’ stand¬
ing, and a patient with a Small Tumour, probably hydatid,
at the lower part of the posterior scapular border.—Mr.
Garrard exhibited two specimens of Mulberry Calculi and
one of Uric Acid Calculus, removed by lateral lithotomy.—
Mr. K. P’avell showed a specimen of P’ibro-myoma of the-
Vagina. The tumour, which he had removed from the-
posterior vaginal wall, measured two inches and a quarter'
transversely, and one inchand a half from before backwards.
Dr. Gwynne read a paper on the Epidemic of Pneumonia,
which occurred in Sheffield during the first half of the
present year. After reading notes of a dozen cases, all of
which presented features of special interest, he summed up-
by recording the following distinctive features of the
epidemic as derived from a review of numerous cases that?
came under bis care :—1. The tendency in the case of many
individuals, attacked by influenza, for a slight patch of
pneumonia to appear suddenly, generally at the case of the
lung, with very slight rise of temperature, and almost as
suddenly to disappear. 2. The common occurrence of
blood-stained sputum. 3. The weak asthenic type of the
disease that prevailed, many cases being subacute from the
first and convalescence tedious, and many more assuming
from the very commencement a typhoid character; the
patient, in many instances, dying from the fourth to the
seventh day of the disease. 4. The tendency to unusual
complications ; illustrated by cases where relapses, parotidi¬
tis, phlebitis, pericarditis, and abscess of the lung super¬
vened. The fact that in some instances the attack could
he traced to distinct infection. 0. The marked immunity
enjoyed by children.
At the meeting on November Gth the President exhibited'
a patient sullering from Syphilitic Ulceration of the Outer
Surface of the Nose, as well as of the Palate and Pharynx.
The unusual situation, and asuperficial similarity of appear¬
ance to lupus before the scabs had been removed, were the
points of interest in the cose.—Dr. Sidney Hobert-s:
showed specimens from a case of Carcinoma of the Stomach
and Liver. The patient, a soldier, aged fifty-four, the sub-
The Lancet,]
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
[Jan. 3,1891. 23
jeob of atheroma of the aorta, had been struck Id the stomach
in April, 1889, and had bad profuse hajmatemesis for two or
three days afterwards, but not subsequently. He bad cora-
.plained of some pain and fulness after food since, but had
not vomited. The stomach presented on its inner aspect a
large, more or less triangular patch, with ulcerated surface
.and thickened raised margin, affecting the middle of its
.anterior wall from the leaser to the greater curvature,
about three inches in breadth below and one
inch above. The peritoneal coat was not affected.
The liver was uniformly enlarged, weighed TJlb., and was
(stv.ddod on its surface and throughout its substance with
various-sized carcinomatous nodules. The spleen was not
affected. The pancreas was indurated. The mesenteric
.glands were enlarged, soft, and pultaceous. The aorta was
Atheromatous. Dr. Roberts announced that he hoped to
exhibit some microscopical sections of the growth at the
next meeting.—Dr. Burgess showed a Large Saccular Aneu-
(lysm of the Abdominal Aorta, which had burst into the pos¬
terior mediastinum, and the patient had lost flesh. Although
there was a large pulsating tumour, yielding a superficial
■“whizzing” thrill, the patient himself had not remarked
any swelling or beating. In a year the disease remained
almost stationary. The symptoms had been relieved for a
■time by iodide of potassium.—Dr. Keeung related a case
of a female patient aged twenty-eight, in the Public Hos¬
pital and Dispensary, in whom the left arm had been
amputated for Malignant Disease commencing in the Cica¬
trix of a Burn. The side of the trunk and the left arm had
been badly burnt in childhood, and a cicatrix bad remained
in front of the elbow-joint, limiting its extension. This
scar had several times broken down and healed again, but
on the last occasion (eight months previously) a large ulcer
was left, which ultimately became malignant. For this,
the arm was amputated midway between the shoulder and
olbow, and at first with apparently good result. A few
weeks afterwards, however, the disease. reappeared in the
armpit, and the stump was removed at the shoulder-
joint, the axilla being thoroughly cleared out. The
oisease was, however, only temporarily checked; it had
•since appeared in the surrounding skin, and would soon
have a fatal issue. The amputated limb with the growth,
aonie microscopic sections, and a photograph were ex¬
hibited.—Mr. Pyk Smith read a paper entitled “ A Review
■of ray Death Certificate Counterfoils.”
At the meeting on Nov. 20th, Dr. Porter and Dr. Burgess
were appointed a deputation to proceed at once to Berlin
for the purpose of investigating Dr. Koch’s treatment of
'tubercle, and reporting the result of their visit to the
^Society, —Dr. CociciNO showed a case of Favua of twelve
years’ duration in a Russian Jew, aged seventeen, who had
been one month in England. The duration of the disease
was twelve years. There were bright yellow cupped crusts
•of all sizes up to a tlireepenny piece, and large irregular
crusts, without central depression, scattered over the whole
‘Scalp. They had an offensive “ mousy ” odour. The hair
was scanty, dry, dull, and brittle. There was no favus
•of the trunk or limbs- The nails were normal.—
Mr. Atkin showed a patient with an Exostosis from the
■Cervical Vertebraj.—Mr. W. H. Brown (Leeds) read Notes
of a second case of Hystero-pexia, an operation which he
'had now performed twice successfully for retroflexed
•uterus, and which consisted in laying open the abdominal
■cavity and suturing the fundus uteri to the anterior
abdominal wall. — Mr. Atkin read a paper on some
'-Surgical Complications of (lout, and raised the question as
to the difficulties in signing accident assurance certificates
where slight accidents had been followed by gouty
•symptoms. He expressed his disbelief that gout was ever
a cause of iritis, but that it occurred along with chronic
■deforming rheumatism there ■was no doubt.
On Dec. 4bh Dr. T. H. MORTON exhibited a Male Anen-
•cephatous Fictus, stillborn on Dec. 1st. It was well
•nourished, weighed 8ilb., and was 20in. in length. The
-cranium was contracted, with arrested bone development,
an opening existing in the posteiior third of the vertex, and
.projecting therefrom was a livid clot-like tumour, enveloped
by thin membranes.—Mr. TiiORPE exhibited a large Uric
Acid Calculus encrusted with phosphates, and twelve
-smaller ones, which he had removed from the bladder by
the supra-pubic method of lithotomy.—Dr. Dyson read a
paper on Therapeutic Incidentals. He called attention to
tlie frequency of the incidental effects of drugs, both those
which frequently and ordinarily occurred, and which were
not part of the effects aimed at in their administration, as
well as those effects which occurred rarely and less fre¬
quently. A caution was administered against the too in-
aiscriminate use of drugs on account of this frequent inci¬
dental action, which was often troublesome, and sometimes
harmful. Individual peculiaiities and idiosyncrasies were
next discussed, and the diagnosis between real Idiosyncrasy
and pseudo-idiosyncrasy. The etiological considerations
leading up to incidental action were then dealt with
in some detail, special reference being made to alteration
in the quality of drugs, to the peculiar susceptibility of
certain classes of patients, and to the time and season
of administration of the drug. Examples of incidental
effects were mentioned which had come within the experi¬
ence of the writer. These were bismuth, antimony, chloral,
opium, iodide of potassium, bromide of potassium, iodoform,
nux vomica, iron, iron and quinine, calumba, caffeine,
podophyllum, and others.
At the meeting of Dec. 11th the report was read of Dr.
Porter and Dr. Burgess, the Society’s representatives at
Berlin, on Dr. Koch’s treatment for tubercular lesions.
After very cordially acknowledging the courtesy and frank¬
ness with which they had been treated by tJie profession in
Berlin, and some preliminary remarks on the fluid itself,
the syringes used, and the situation chosen for the injec¬
tion, the question of dose was dealt with at some length.
Among the possible dangers rrom the reactionary effects of
full doses might bo mentioned obstruction of the urinary
passages in tubercular affections of the prostate and ureters,
and the possibility of perforation in tubercular ulceration
of the bowels. A case in Dr. Levy’s clinic was alluded to
in which facial palsy had followed injection in a child aged
three, probably due to the existence of tubercular disease
of the middle ear. The symptoms of the reaction were
then dwelt upon, instances of delayed and prolonged reac¬
tion being cited. The diagnostic value of Dr. Koch’s fluid
was then discussed at some length, and the principle laid
down was that whereas the appearances, or definite sym¬
ptoms, of local reaction might be regarded as conclusive
evidence of tubercle, constitutional reaction could not be
BO regarded. In situations, such as the. skin, larynx, or
joints, where the local effects were actually visible, there
was little or no room for doubt. In internal parts local
reaction, as a rule, was less evident, but in particular
instances in the lungs, bowels, or urinary passages, injec¬
tion might clear up a doubtful diagnosis. An instance was
given of a patient suffering from retraction of one side, the
result of old pleurisy, in whom no tubercle had been
suspected. On the ocher hand, failure to react to
doses of O'Ol gramme, or even more, did not exclude
tuberculosis. Several instances were given of cases
with well - marked physical signs of phthisis, and
bacilli found in the sputa, in which injections of con¬
siderable strength had failed to produce any effect what¬
ever. The local effects in phthisis included various sensa¬
tions referred to the affected part, and sometimes even
distinct alterations in the physical signs during reaction ;
also increase in the quantity of sputa, and, according to
some observers, alterations visible in the bacilli themselves.
With regard to the most important question, the curability
of phthisis, no opinion could dt present be expressed. Dr.
Fraentzel, who had treated phthisical cases by Dr. Koch’s
method longer than anyone ^se, had distinctly stated that
the treatment would have to be pursued for months, and
that the patients would have to be kept under observation
for a longer period still, and every now and then be sub¬
jected to teat injections. As in phthisis, so in joint diseases,
it was too soon yet to come to any definite opinion as to
the curative or even remedial value of Koch’s treatment.
The local effects, on the whole, had been even less positive
than in cases of phthisis. The action of the remedy in
destroying the tubercular tissue within the joint might
culminate in the formation of an abscess requiring surgical
interference, and in many cases no doubt surgery would
have to step in and clear out the tubercular ddbris from the
joint. Dr. Koch’s fluid therefore could only be regarded as
having an indirect effect in the cure of joint lesions, but it
might be expected to avert the tendency to relapses. In
conclusion, the deputation regretted their inability to
secure some of the lymph for their respective hospitals, but
they announced that they had applied for some, and had
been promised an early attention to tbeir request. In the
meantime, until there had been a sufficient material
accumulated upon which to draw some definite conclusions,
they must remain “free to prove all things and hold fast
the best.”
e
24 The Lancet,]
NOTTINGHAM MEDICO CHIRURGICAL SOCIETY.
[Jan. 3,189L
CLINICAL SOCIETY OF MANCHESTER.
At a meeting held on Dec. 16fcb, Dr. Braddon, President,
in the chair, the following communications were made.
Lymphccdema, —Mr. C. E. Richmond showed a case of
lympboedema involving the whole of the left lower limb.
It exhibited the characteristic firm elastic swelling, the
diameter of the aftected limb being greatly in excess of that of
the sound one. After enumerating the obstructive causes of
lympbojdema, Mr. Richmond said that the only one
ascertainable in this case was syphilis, where the tertiary
sclerosis and gummatoirs changes in the lymphatic glands
of the limb and pelvis might produce the necessary obstruc¬
tion. The glands in the lelt groin, though not markedly
enlarged, were still considerably more hardened and
promment than those of the right side. There was a fair
history of previously acquired syphilis.
Opearation for Catarrh of the Middle Ear. —Dr. Milligan
and Mr. Hekbert Lund showed a case in which the
antnim mastoideum had been opened for suppuration fol¬
lowing acute catarrh of the middle ear. The patient, a
woman aged forty-seven, had a sharp attack of influenza,
during which symptoms of acute inflammation of the right
middle ear supervened. This was followed by extension to
the mastoid process. The principal symptom complained
of was extreme pain just behind the attachment of the
auricle. Mr. Lund opened the antrum, and evacuated
about one drachm of pus. A silver drainage-tube was
inserted. The wound healed up in three weeks. The per¬
foration in the membrana tympani closed and perfect
hearing power was regained. Mr. Lund’s suggestion, that
in cases of chronic discharge from the middle ear which
had resisted the usual methods of treatment it would be
advisable to trephine the antrum and thoroughly drain the
cavity, and so relieve the patient from a possible source of
future trouble, led to a discussion in which Messrs. T. Jones,
S. Bishop, Drs. Simpson, Bury, and others took part.
Mr. Bishop showed a case of Charcot's Disease of the
Knee-joint.
Mr. T. Jones mentioned a aeries of cases of Intestinal
Obstruction treated by Laparotomy.
NOTTINGHAM MEDICO-CHIRUIIGICAL
SOCIETY.
At the meeting on Dec. 17th the following paper was
read :—
Difficulties and Obscnrilies of Diagnosis in A bdominal
Disease. —Dr. Brookhouse illustrated his subject by citing
the foHowing cases:—A case of a boy aged thirteen,
whose symptoms were difficult to interpret, and did not
lead to suspicion of the conditions revealed post mortem—
viz., perforation of appendix and suppurative peritonitis.
The case of a woman whose symptoms pointed for a long
time to flatulent dyspepsia ; but finally obstruction of the
bowels set in, for which a colotomy was done. A malignant
growth starting from the mesentery was then discovered.
The case of a woman aged fifty-one, in which tumours
existed in each loin, thought to be kidneys. Whilst under
observation a swelling developed in the left groin, which
was operated on for femoral hernia. No hernia was found.
After death the cystic duct was found blocked by a gall¬
stone and the gall-bladder was distended ; there was seir-
thus of the left adrenal, and the lump in the groin turned out
to be a malignant tumourgrowing from the pubic bone. Two
cases, which recovered, in which obscure tumours existed in
the iliac region. A case in which partial obstruction existed
for a long time with abdominal pain. After death there was
found stricture of the ascending colon, and adherent to the
strictured portion was the duodenum, which had apparently
been drawn down by a band. After insisting that great
caution is necessary m forming and expressing an opinion
in obscure cases. Dr. Brookhouse concluded with the
following rules for investigation : To learn the family
history, especially if the patient is young ; to obtain the
clinical history and note the order of symptoms; to learn
what can he made out by physical examination ; and,
lastly, to appraise the value of what is spoken of as the
physiognomy of disease. Remarks were made by the
President, Messrs. Hatherly, W. B. Ransom, and llandford.
On the motion of Dr, Aplin, seconded by Dr. Handford, the-
Society passed a hearty vote of thanks to Colonel Seely,
High Sheiiifof Notts, for his mnnificent offer of £10,000 for
the provision of convalescent homes and hospital for the.
needy convalescents of Nottingham and the county.
ROYAL ACADEMY OF MEDICINE, IRELAND,
A MEETING of the Obstetrical Section was held om
Nov. 28th.
Notes on the Operative Treatment of Uterme Cancer .—
The President read a paper on the above subject. Having
alluded to the negative treatment pursued some years ago
and then to the treatment by Chian turpentine, he pro¬
ceeded to describe the various operative procedures practised
in the present day, as well as the cases suitable for each.
He expressed an opinion adverse to Marion Sims’ operation
on account of the diiliculty of judging the . amount of
sloughing action which would take place, and strongly
approved of the removal of the entire uterus, or a portion
of it, for cancer of that organ. The removal of the entire-
uterus by Freund’s and the vaginal operation were de¬
scribed, and a case of the latter operation was noted
where catch-forceps were largely employed to secure the-
vessels in the broad ligament. The relative merits of the
operations were then compared, and in suitable case where-
the cancerous disease can be removed by it the supra-vaginal
method was recommended as being the best.—Dr. A. Smith
said it seemed to him that the question as to how and when
a case should be operated on was always one of diagnosis.
During his time in the Rotunda Hospital he had several,
cases of carcinoma; and in view of the desirability of
operating he had divided them into certain and doubtful
cases of carcinoma. The first class consisted of the cases in
which there were both clinical and microscopic indications
of carcinoma. The second class he found it necessaiy to
subdivide into two others: one being a class in which
there were clinical symptoms of carcinoma, whilst the
microscope failed to indicate it; and the other being
one in which the clinical symptoms were perfectly
benign, but typical* cancerous conditions were shown
by the microscope. As regarded the first principal class
of cases of the cancerous conditions where extensive
operative interference was not possible, palliation only
• could be resorted to. In cases where the carcinoma was-
limited in extent, whether confined to flie cervix or not, a
point on which he desired information was as to whether
there should be complete removal of the uterus or not.
Statistics showed that in the majority of cases of cancer of-
the cervix there coexisted a very curious condition of the
mucous membrane known as sarcomatous degeneration. It
was therefore recommended that in eveiy case there should
be complete removal of the uterus.—Dr. B.'\.GOT stated that-
there were a few points regarding the operative treatment
of carcinoma to which he wouhl like to draw attention.
First as to the simple amputation of the portio vaginalis,
j No one would now dream of doing it as a radical opera-
! tion even for an apparently very limited carcinoma of the-
vaginal portion. As to the supra-vaginal amputation or
high operation of Schroeder, Dr. Mason had spoken of ib
as being the proper procedure in cases where the carci¬
noma was limited, or rather, he should say, apparently
limited, to the cervix, and stated, as one of his reasons, that
this operation was so much easier and less dangerous than
vaginal hysterectomy. Now, as far as he (Dr. Bagot)
knew, the latest statistics both with reference to the imme¬
diate mortality after the operation and regarding the period
of immunity before the return of the disease did not
quite justify this statement. The latest statistics whicli
he had seen were those given by Dr. Fozzi in his
“Traitide Gyndcologie,” 1890, where it was stated that
the operation of supra-vaginal amputation was followed
by a mortality of not less than 11 per 100 in the hands of
good operators both in France and other countries, while
the mortality after vaginal extirpation in France was,,
according to the same writer, about 5'88 per cent. Leopold,
in Dresden, had performed eighty vaginal hysterectomies,
with a mortality of 6 per cent., not losing a single patient-
out of the last fifty-two cases of this series. Imitri de Ott
had performed thirty vaginal extirpations without a death.
I The reason that supra-vaginal amputation was preferred in
I cases where the disease appeared to be limited to the cervix
The Lancet,]
ROYAL ACADEMY OF MEDICINE IN IRELAND.
[Jan. 3,189i. 25
by some operators, of whom Dr. John Williams was fore¬
most in England, was because the various forms of cervical
-carcinoma usually tended to spread outwards towards the
vagina, parametrium, &c., rather than upwards towards
the body of the uterus. This was true in the majority of
cases; but he maintained that it was impossible to deter¬
mine with certainty, either before or during the operation,
to what height the disease had spread. As to Freund’s
operation. Dr. Bagot thought that Dr. Mason had hardly
brought clearly beJoi’e the meeting the necessary indications
for the performance of this operation, which, as far as he
could judge, was only applicable to eases where the uterus
was too large to be extirpated per vaginam, or where
there was great fixation due to ola perimetritic adhesions,
as the uterus consequently could nob be drawn down.
Under such conditions one had--to choose between Freund’s
abdominal and Martin’s abdomino-vaginal or mixed method
of operation, or else to have recourse to removal of the
qrterus by means of the parasacral incision of Wblflex or the
sacral incision, as in Kraske’s operation for extirpation of
the rectum.’As to early diagnosis, he thought that in all cases
where there was the slightest suspicion aporbion of thegrowbh
should be submitted to a competent pathologist._The
Chaieman remarked tliab in the lirsb of the President’s cases
the woman was stated to have been only twenty-three years
of age, and to have had no children. He had nob heard it
stated that a microscopic examination was made, and
therefore he felt at liberty to entertain a doubt that she
had carcinoma. He had looked over authorities as regarded
oases of total extirpation in which the disease had been
only supposed to affect the vaginal portion of the cervix,
and had found that Leopold, in seventy-eight cases of
carcinoma, removed the whole uterus in fifty-seven of them
in which the cervical portion was involved. Dr. Smith
had said that in a large number of cases the first stage
was a sarcomatous degeneration of the mucous membrane.
He had at present a case in which he had scraped out
the uterus carefully and got no indications of cancer;
nevertheless, the woman was bleeding and losing llesh,
and he believed he would have to deal with the case on
the clinical symptoms alone. He was surprised to hear
that the President considered supra-vaginal amputation
to have afforded better permanent results than total
removal; but, judging by the reports of Leopold’s cases,
and those of others that he had been looking over,
he hardly thought that they would have resorted, in
200 or 300 instances, to total extirpation of the uterus if
they thought they could have got as good results from the
supra-vaginal operation, which was an easier one to per-
torni. He considered it to be practically almost settled that
unless the diagnosis of carcinoma of the mucous membrane
was excluded by positive observation of matter scraped out
frorn the uterus, their duty, in cases of carcinoma of the
cervical portion, was to extirpate the whole uterus.—The
President replied.
Complete or Annular Prolapse of the Urethral Mucoiis
Membrane.—Ur. Bagot read a paper on the condition de-
ficribed as annular or complete prolapse of the urethral
mucous membrane. In describing the conditions and the
symptoms to which it gave rise, he alluded to the
contributions to the literature of the subject by M'Clintock,
Tavignot, I>abroo, Winkel, Huge, Holfmeir, Beuicke,
Pozzi, Sbdermark, Skene, and otiieis. Since Dr. Bagot’s
appointment as assistant physician to the Rotunda
Hospital three cases of the disease had come under his
notice. The lirst, a woman aged thirty-three years, com¬
plained of a swelling at the orifice of the vulva, from which
there was a discharge. She .suffered from intense pain on
•trying to pass uriue. A dark-red tumour the size of a
walnut projected from the vestibule. The central anil
most prominent part was sloughing, and in the middle of
the sloughing mass the meatus urinarius was found. The
tumour .sloughed off and a spontaneous cure re.sulted. The
secondcase was a child aged five years, who suffered from pain
during micturition, and for some weeks her undorlinen had
been constantly stained with a sanguino-purulent discharge.
A tumour of a bright-red colour, about the size of a large
cherry, projected from the vestibule and filled the vulvar
oriQce. The external meatus of the urethra, dilated and
funnel-shaped, was situated on the central part of the
tumour. It bled easily on being touched. He removed
this tumour with a scalpel, and stitched the urethral to the
external mucous membrane by a few interrupted fine silk
sutures. Dr. Earl had made microscopicalexaminationsof the
tumour; part showed the characters of a fibro-myoma, and
art consisted of prolapsed and hypertrophied mucous mem-
rane. Aperfectrecoverj resulted. Thethirdcasewasachild
aged seven years, who had suffered from hacmaturia. A
dark-red or purple tumour about the size of a cherry
projected from the vestibule; this was removed as in
Case 2. The child made a perfect recovery. The tumour
was found, on microscopical examination, to be of angio¬
matous structure. In none of the patients was there a
history of any affection of the urinary organs, nor was there
at the time when they came under his notice any constitu¬
tional trouble. All seemed to enjoy fairly robust health.
The disease appeared to be quite local.—Dr. Kidd remarked
that during the time he was assistant master at the Coombe
Hospital he saw a case of an old woman of about sixty
years of age who had three prolapses—one of the rectum,
one of the uterus, and an annular prolapse of the mucous
membrane of the urethra.—Dr. Macan said he saw the
case in which Dr. Bagot mentioned that the sloughing had
taken place, and he did not recognise it a-s a case of pro¬
lapse.—Dr. Bagot, in reply, said there was no authen¬
ticated case of prolapse of the bladder.
Dr. William Smyly exhibited appendages removed
from a case of Myoma U teri. The tumour was about the size
of his two fiats. He determined to remove the tumour itself.
He was prepared for a very difficult operation, as the tumour
was well down in the pelvis; but on opening the abdo¬
men he found that, in addition to the large myoma, there
were a number of small nodules, so that he had to confine the
operation to the removal of the ovaries. The operation
was an easy one, and the patient had made a good recovery
from it.
Dr. Macan exhibited a Fcctus which had been retained
for three months after the normal termination of preg¬
nancy. He believed it to have been a case of post¬
poned labour. Four years previously she had had a
similar experience, and carried a fcctus for eleven montlis.
He cross-examined her carefully as to the case now
submitted, but got no history of labour having come
on at the end of the ninth month and gone off again. She
said she had no pains until the morning on which she was
delivered. She had been in good health; but about the
present retention she consulted Dr. O’Brien of Tipperary,
who was acquainted with her previous history. In her
former delivery her vagina was a good deal torn, and
became enlarged afterwards. Dr. O’Brien recognised
that the child had been dead for three months and
that the vagina was closed, and therefore thought that
ordinary delivery would be more dangerous than that
: by abdominal section, and thought that Porro’s opera¬
tion should be resorted to in order to remove the child
and to prevent the accident from occurring again. When
she came to him there was notliing bub the history of the
eleven months’ pregnancy. He examined her carefully
under ether. She had a profuse secretion of milk in th'e
breasts ; and he could feel through the vaginal walls a hard
irregular tumour, but nothing that resembled a collapsed
head, for if the child had been then dead two months there
should have been considerable softening of the head; so
that at first he was under the impression that she had a
fibrous tumour. He went to the country, and after his
return he received a message by telephone that she was in
hard labour with strong pains. During the extra three
months she had had good health, but in the last week she
had a feeling of greatlassitude. On a vaginal examination
ho found that the top of her vagina was funnel-shaped, and
he could not feel where it was continued upwards into the
uterus. He put her under ether and inserted a catheter,
which brought away some decomposing blood. He then
tried to break through tlie thin partition of the vagina
with his finger and felt the bard bone of the child’s bead.
He dilated the vagina with Barnes’ bags. The extraction
of the child was a very difficult process and occupied four
hours and a half. Since the operation she had got on very
well, but had had a rise of temperature to 101°, and washing
out the uterus was attended with a fetid smell not of the
ordinary kind. The placenta was flattened out by the
tremendous compression it had undergone.
Dr. William Smyly exhibited appendages removed from
a case of Double Pyoaalpinx. The patient was admitted
into the Rotunda Hospital on July 7th. She had had live
miscarriages and had suffered from gonorrhcca. Five years
after her last pregnancy she complained of menorrhagia
and dysmenorrhcca, and she also had leucorrbma. On
-^8
26 ThbLakcbt,]
REVIEWS AND NOTICES OF BOOKS.
[Ja\, 3,1891,
a physical examioation he found the uterus anteposed,
with an elastic swelling in the posterior cul-de-sac. Con¬
sidering the physical character of the tumour and the history
of the case, lie concluded that the tube was distended with
us, and he determined to remove it. Daring the operation
e put his linger to the back of the uterus and found that
the tube was brittle and that it broke. Fearing that fluid
would get into the wound, he clipped the tube. It seemed
to be almost of the consistency of wax. On proceeding to
remove the appendages they proved to be very brittle, and
broke in two places, and a considerable quantity of pus
escaped. After having washed out the parts with hot water
he inserted a drainage-tube, which was left iu for seven
days, during which there was a considerable discharge from
it. When Dr. Bagot tried to remove the tube he found
that it had become fixed by granulation having taken place
at each end of it. He curetted the inside of the tube and
got it away easily. The patient had noriseof temperature,
had made a perfect recovery, and had enjoyed good health
ever since.
GLASGOW OBSTETRICAL AND GYNJilCO-
LOGICAL SOCIETy.
The second meeting of the session was held in the
Faculty Hall, St. Vincent-street, on Wednesday evening,
Nov. 26th, Dr. Robert Park, President, in the chair.
Dr. Milroy showed several beautiful Microscopic Pre¬
parations made from the Cancerous Uterus, which Dr.
Stuart Nairne had exhibited at the last meeting. In his
remarks Dr. Milroy pronounced the tumour to be a very
malignant form of sarcoma, and pointed out that the
sections illustrated very clearly how such tumours spread
by means of spider-like cells, which projected into the
blood spaces, becoming detached and carried on by the blood
stream.
Dr. Robert Jardine read a paper on Puerperal
Eclampsia, giving details of a case and discussing the
whole subject ac great length. The patient, a prinii-
para aged thirty, had one lit at the onset of labour,
and after recovering from it was completely blind until
delivery was completed, some hours subsequently, by .means
of forceps. Albumen was present in the urine in large
quantity, and she was veiy cedematous, but the ccdenia
and albumen both disappeared within a week. She made
a good recovery, except that her eyesight remained affected
to a slight extent. She became pregnant a few months
afterwards, and this pregnancy lasted until the 305bh day
from the cessation of menstruation. The external os was
found to be completely occluded at her second confinement,
and it was deemed necessary to incise it before <lelivery
could be effected. Dr. Jardine read notes of this preg¬
nancy at the last meeting of the Society last summer.
While not attempting to advance any new theory
as to the causation of eclampsia, the speaker pointed
out the great similarity between these convulsions
and those of childhood, especially in those cases where
the urine is normal. He quoted many cases from
various authors showing that unomia was not by any
means always present. In these cases shock to the nervous
system, irritation of the alimentary track or of the uterus,
«c., is generally the immediate cause, acting upon a highly
strung nervous system, and causing an explosion or nerve
storm.—The paper was very favourably commented upon by
Drs. Sloan, Cameron, St. Clair Gray, liicbmond, Cullen,
and the President, and Dr. Jardine replied.
At an extraordinary meeting of the Society, called to
consider the Midwives’ Registration Bill, it was unani¬
mously resolved—“ That, whilst approving generally of the
said Bill, this Society recommends that there be inserted in
the Bill clauses to provide (1) for the efficient supervision of
midwives by a registered medical practitioner, to be a])-
S ointed by the County Council, and (2) for erasing from the
lidwives’ Register the names of women, and for suspending
any women from acting as mid wives who have unwarrantably
delayed or failed to send for a registererl medical prac¬
titioner when the labour is or has become abnormal.”
Fire at a Havre Hosi’ITAl.—A part of tlie new
hospital at Havre has been destroyed by fire. Those
portions which were occupied by patients were, however,
undamaged.
lleMttos ani Itotias of j^ooks.
Anatomy, Descriptive and Surgical. Bv Henhy Gray*
F R.S., kecturer on Anatomy at St. George’s Hospital*
Medical School. Twelfth Edition. Edited by T.
PiCKERiNi; Pick, Surgeon to, and Lecturer on Surgery
at St. George’s Hospital Medical School. Longmans.
1890.
Quoin’s Elements of Anatomy. Edited by E. A. SciiArER,,
F.R.S., Professor of Physiology and Histology in Uni¬
versity College, London ; and G. D. Thane, Professor of
Anatomy in University College, London. Tenth
Edition. Lonemans. 1890.
The chief alterations iu this edition of Gray’s Anatomy
are the introduction of sections on Topographical Ana¬
tomy, short paragraphs on the surface form of the various-
parts or organs, and an enlargement of the sections on
Surgical Anatomy: the editor lias to be congratulated
on this new departure. We could wish, however, that he-
had shown more boldness, and have amplified the book in
this direction even much more than he has done. The-
surgical anatomy of fractures and of the ligature of arteries
is very thorough and complete, but that of the viscera is-
very meagre ; indeed, of such important organs as the eye>
nose, and ear there is none. There is no reference to any
facts connected with surgery or medicine in the descrip¬
tions of the veins or of the lymphatics. Applied anatomy
should be given more fully, so as to render special works on
the subject unnecessary, or it should be omitted ; and this
edition falls between two stools by containing too much for
the ordinary second and third year student, and not enough,
for him in his later years or for reference after he is qualified.
Diagrams of the cranial nerves after Flower have been
introduced, but they are on too small a scale to be as useful
as the originals, and are not nearly so clear as the older
schemata of th@ brachial and lumbar plexuses, which is the-
scale to which the newer diagrams should have been drawn.
Mr. Pick has found himself in a curious dilemma in naming,
tlie descending branch of the hypoglossal nerve ; for>
although he reckons the hypoglossal as the twelfth cranial
nerve, in accord with Soemmering and most modern
anatomists, he still calls this branch “ descendeus noni,'''
after Willis, for fear of leading into confusion. Surely the
descending branch of the ninth nerve coming from the
twelfth is sufficiently confusing to the new student. The-
name “descendens cervieis" has been suggested ; but Mr.
Pick does not like it, and we agree with Mm. Why not
“descendens hyj'ogloss'i," which is definite and accurate?’
Notwithstanding tiie.se slight criticisms, Gray’s “Anatomy,”
as edited hy Mr. Pick, preserves its advantages of clear¬
ness ivf .style and beauty of illustrations, and will still
deservedly remain the favourite text-book of the majority
of medical students and tlie easiest work of reference on any
point of anatomical detail for medical practitioners.
The tenth edition of Qaain’s Anatomy is to bo divided
into throe volumes, and the first part of the first and second
volumes have been published. These deal with embryology
and osteology; tlie former has been written by Professor
Schilfer, the latter by Professor Tliane. TJiia division into
numerous parts and volumes is very perplexing to the-
student, and, although common in Germany, is very rare in.
this country. It must load to the purchase of separate parts
by every student in accord with his individual necessities,
and is very likely to prejudice tlie sale of the work as a
whole. This, however, is a question for the publisher and
the authors, rather than for the student or reviewer. There
is no preface to either of these volumes, and we miss the
kindly notices of the writers of tlie preceding editions to
which we are accustomed when a text-book such as Quain’s
enters on a new career under the sole charge of new
Die' lOO^lC
I
The Lancet,] REVIEWS AND NOTICES OF BOOKS. [Jan. 3,1891. 27
editors. A reference to the connexion held by the late
Professor Allen Thomson with the last edition would have
been a graceful tribute to his memory, as he was responsi¬
ble for the embryoiogical section in the last edition. For
vol. i., part 1, dealing with Embryology, we have nothing
but praise. The text is as clear and precise as is possible
when dealing with a subject which accuracy and clear¬
ness can alone render intelligible, and the numerous well-
engraved figures, many of which are excellently coloured,
area valuable addition to the text. A complete description
of Human Embryology is given in 170 pages, and we know
of no better account to which a student might be directed
than is to be found here. The list of recent works
dealing with the subjects of each section is a most com¬
mendable innovation. The first part of the second volume,
which is devoted to Osteology, is very little different
from the text of the last edition; the small importance '
attached to the markings for muscular attachments on
the bones, which has always been a conspicuous feature
in Quain os compared with Gray and Holden, is again
maintained, although not with quite so rigid a consist¬
ency. The figures of most of the bones are, however,
new, and although we still consider that they are inferior
diagrammatically to some figures in other text-books, we
must at the same time admit that they are very faithful to
nature, and a great improvement on those in former editions.
In representing some of the bones, such as the small bones
of the carpus and tarsus, additional clearness would have
been gained by a larger drawing than even that of full
size. In the next edition we hope to see a further
replacing of the old plates by some new engravings repre¬
senting the different stages of ossification, especially in the
bones of the skull. The morphological details, which are
so valuable to the advanced student, are well given, and
will keep up the well-deserved prestige of “Quain’s
Anatomy.” __
Lehrbuch der Chcmischm Untersuchwigsmcthodm zur dia-
gnostik Innci'cr Krankhciten. Von Dr. Feiax WesENEII,
iMvat-docenten der klinischen Medicin und I. Assisten-
zarzte an der Poliklinik zu Preiburg i. B. Berlin:
Friedrich Wreden. 1890.
It can scarcely be said that, amongst the numerous special
text-books chat have flooded the schools at home and abroad,
there is an absence of good text-books in any particular
branch of medical study, though it would be unsafe to say
that in many branches there is still no opening for a first-
rate text-book. Without entering into this question we
may at once admit that Wesener’s text-book of chemical
methods of research, to be used in the diagnosis of disease,
is essentially a good one, and may bo studied with advan¬
tage alike by both student and practitioner.
Until comparatively recent years it has been considered
quite suHicient that a medical student should be able to
detect albumen in urine; and perhaps also that he should
be expected to know the process for the determination of the
amount of sugar and of urea if he is being examined for
something more than a mere pass ; but beyond these, and
the recognition of a few crystals such as cholestevin or uric
acid under the microscope, very little was expected, and
consequently little more was taught. The examination of
the blood, of special dropsical or other fluids, such as pus or
iluid from hydatid or other cysts, save for the number of
corpuscles or for the quantity of common salt or albumen,
was never dreamt of except by those who might almost be
termed experts; it was sufiicient to determine the acid or
alkaline reaction of the contents of the stomach, and it was
certainly never thought necessary to find out, by either,
qualitative or quantitative metliods, the kind or amount of
acid or alkali in such contents.
Fortunately, however, all this is now changed. Chemical
methods have been elaborated, the spectroscope is now con¬
stantly made use of, and a new field is being gradually
opened up in diagnosis and therapeutics. Professor
'Hamilton’s admirable address on the “ Pathology of Gastric
Dyspepsia,” delivered in August at the annual meeting of
the British Medical Association, may do something to
stimulate workers in this fertile field of chemical research ;
and for those students and practitioners who desire to fit
themselves to investigate many of the points mentioned by
him Wesener’s book will come most opportunely, as it takes
the place in the study of clinical chemistry that Dittmar’s
book at present holds for gas analysis. In the space of
270 pages the author gives a capital description of the
methods of examination of the blood, not only generally, but
I in certain diseases of transudations and exudations, and of the
contents of various forms of cysts. A considerable portion
of the book is, very naturally, devoted to the subject
of examination of the urine and of the various concretions
that occur in the urinary tract. This part of the work is
perhaps more exhaustive than any other; it is brought well
up to date, and some valuable information as to the inline
in various diseases is appended. The examination of the
secretions of the salivary glands, of the contents of the
stomach, of the fjeces, of the mucus, sweat, and other
secretions, are all treated in more or less detail, though in
some cases the accountsare somewhat too sketchy; so sketchy,
indeed, that we are bound to conclude that the author
describes the work of others rather than the results of his
own observations. It is due, however, to him to say that
this is very seldom the case.
An exceedingly useful chapter on the technique of
methods, and a list of the various reagents and the methods
of their preparation, conclude what must be looked upon as
an exceedingly valuable practical text-book. As we have
spoken so freely of the excellences of this book, it is the
more necessary that there should also be pointed out certain
features thatmighteasily be improved. Any text-book should
beusedmerelyasameansof introduction to workand for handy
reference to that done by others on special lines of research.
In the book before us the first requirement is met, but as
regards the second, although names are freely mentioned,
not a single reference to an original paper is given, and
many students and busy practitioners who, with a list of
literature on any special subject before them, would be
tempted to carry their investigations further, will, unless
they have access to other sources of reference, be compelled
to leave their work at the point to which this text-book
leads them. As regards arrangement of the chapters it
would have been better had the general technique and the
list of reagents been introduced at the beginning, instead
of at the end of the work. These, however, are mere
details which the experience of the author would probably
lead him to improve should a second edition be called for,
an event that from the general character of the book should
occur at no very distant date.
The Nerooits System and the Mind: a Treatise on the
Dynamics of the Human Organism. By CHARLES
MERCliiR, M.B. London: Macmillan and Co.
r In this work on the nervous system and the mind Dr.
Mei'cier’s object is to provide “ an exposition of the normal
on a chart on which the aberrations of the morbid could be
picked out.” The linos upon which he desires to set out
his task may be taken as those which would bring into a
working harmony the philosophical teachings of Herbert
Spencer, and the demonstrations in practical neurology of
such masters as Hughlings Jackson. Beginning with the
functions of the nervous system. Dr. Mercier tells us that
the first most important and most imperative duty of the
student of psychology is to recognise the impassable
Digitized by i^ooQle
28 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
fJAN. 3, 1891.
galf, the fathomless abyss that separates the world of
coDscipusness from the world of material tbiogs—that
separates, in short, mind from matter. The student’s next
duty is to appreciate the association between these two
orders of phenomena; an association which is to be taken
as expressing the existence of an invariable (but unexplain¬
able) concomitance of a mental change with a bodily
change.
Dr. Mercier includes in his task the investigation of the
facts of consciousness, the description of the mode of work¬
ing of the nervous system, and the examination of the con¬
ditions under which, the extent to which, and the manner in
which the changes of the one accompany the operations of
the other. The introspective study of mental operations in
one’s self leads up to the broader study of the minds of
others as inferred from their conduct. The scientific scope
of Dr. Mercier’s book is the following, as given by him¬
self : — “ The psychological unit is a wr^ous process, which
when transmitted to muscles issues in a movement, and is
accompanied by a mental state. Kaise this unit to the
highest power, and we find our subject falls into three
natural divisions ; the study of nervous processes, the study
of conduct, and the study of mind.”
When dealing with the physiological relations of the
nervous system to muscular action and muscular movement
Dr. Mercier makes some very interesting observations on
coordination, which, he truly says, “is not a special function
located in an isolated portion of the grey matter of the brain,
and interfering only on occasions and in particular move¬
ments. It is an indispensable constituent of every move¬
ment whatever, and is a function of every portion of grey
matter.” A general location is also given to the element
of control or inhibition which plays so important a part in
healthy nervous action.
The author gives an excellent and forcible account of
the rationale of the muscular distribution and nervous
origin of the spasm in Jacksonian epilepsy; and he con--
trasts the clonic jerky paroxysmal character of this cerebral
form of spasm, beginning in the periphery, with the con¬
tinuous nature of the cerebellar spasm, which commences
in the most central muscles, and is first evidenced by opis¬
thotonos and retraction of the head. After dealing with
the physical and with the physiological functions of the
nervous system, Dr. Mercier proceeds to discuss its psycho¬
logical function so far, in the first instance, as it relates to
matter and motion, and without reference to conscious¬
ness. From this standpoint the function of the nervous
system is, in the language of Herbert Spencer, to effect
the adjustment of the organism as a whole to its
environment; the term organism being taken as synony¬
mous with “individual human being”; and the term
environment as meaning the whole of the circum¬
stances that act upon him or that he can act upon,
whether those circumstances are physical, social, or moral.
A study of the adjustment of the processes that occur
within the organism to the conditions that exist outside of
it involves a study of movements and of acts (both simple
and coordinated)—processes which are effected by means of
the nervous system. In short, the study of the ptycho-
logical function of the nervous system is the study of
conduct, which is the only criterion of intelligence. The
nature and quality of the adjustment referred to becomes a
test of the intelligence of the individual organism. After
dealing with intelligence as manifested under various
phases in relation to this adjustment, Dr. Mercier proceeds
to deal with the constitution of mind, dwelling more espe¬
cially upon those portions of introspective psychology that
are of urgent importance to the alienist in his practical
work.
The complex machinery of human conduct is in these pages
well and skilfully handled, and the component parts are
described and analysed with a sioiplicity and exactness
which bring the subject within the grasp of readers who lay
no claim to philosophical training. Without being common¬
place or lax in hU method, Dr. Mercier has the faculty of
presenting hia somewhat technical and involved subject in
a pleasing and attractive form by the use of happy and
pertinent word-illustrations of his meaning.
Dr. Mercier has succeeded in building up a scheme of
practical neurology and psychology which cannot fail to
interest and to instruct every student of mind, and which
ought certainly to be in the hands of every student of
insanity. There is no doubt that if the contents of this
book were mastered by all asylum medical officers we
should he spared much of the vagueness which sometimes
characterises descriptions of mental processes in the
insane.
A System, of Ohstcirics hy American Authors. Edited by
Baiiton Cooke Hiest. Edinburgh: Young J. Pent-
land. 1888.
Tins work is uniform with Dr. Mann’s system of gynae¬
cology. It is some 1700 pages long, and its articles are of
unequal value, as is almost inevitably the case with
“systems.” If this “system” “has its day” now and
“ceases to be” some day, it at least cannot be called
“little.” It begins with a history of obstetrics by Dr.
Eng'elmann, which is interesting, especially the refer¬
ences to existing savage tribes, whose customs Dr. Engel-
mann has carefully studied. Among the best articles is
one on Ovulation, Menstruation, and Fertilisation, by
Dr. Newell Martin. The article by Dr. Penrose on the
Mechanism of Labour is unfortunate, we think, in describing
six positions instead of the generally recognised four. The
movement appears to us retrograde, and, even if it were
not, a change is too late. The result of the perusal of this
article by students would be to get them hopelessly confused.
The chapter on the Use of Anajstheties, by Dr. Reeve, is
interesting, and includes a discussion of many of these drugs.
Among other interesting chapters may be mentioned that
on the Forceps, by Dr. Edward Davis; that on the
Caisarean Operation &c,, by Dr. Robert P. Harris ; that on
Puerperal Infection, by Dr. Garrigaes; that on the
E'iology of Puerperal Fever, by Dr. Ernst; that on Com¬
plications of the Puerperal State, by Dr. Hirst; Insanity
&c , by Dr. Lloyd; and. the Management and Diseases of
the New-born Infant, by Dr. Lewis Smith. There are in
the work two kinds of illustrations, apparently by different
hands. The Minute Anatomy and Microscopy, and the
article on the Forceps, are apparently by one hand, the
chapter on Pelvic Abnormalities by the other. The former
are good, the latter are poor. The work is not a book, but
a library, and can only take position as a work of reference.
Whether it will displace such works as those of Spiegelberg
in Germany, or of Tarnier in France, we doubt. Mean¬
while, we are glad to be able to refer to many parts of it.
We think it would have been more convenient if authori¬
ties had been collected either at the beginning or end of
the chapters, instead of being scattered through the work.
The paper and printing are excellent.
OUR LIBRARY TABLE.
On Bacteriology and its Results. A Lecture delivered by
Dr. R. Kocil at the first General Meeting of the Tenth
International Medical Congress, Berlin, August dch, 1890.
Translated by Thomas Whiteside Hime, B.A., M.D.
London : Bailli^re, Tindall, and Cox. 1890.—In convenient
pamphlet form Dr. Hime has given a good translation of
Koch’s admiiahle work. He has appended one or two
Digitized by
Google
The Lancet,]
OUR LIBRARY TABLE.—NEW INVENTIONS.
C-Jan. 3,1891. 2^
explanatory notes, and has placed within the reach of those
who are too busy to refer to the original German a paper
which, as we have stated in a previous review, should be
read with the greatest care by all medical men, and most of
all by sceptic94ind bacteriological agnostics.
Electricity m Facial Blemishes. By Plym S. Hayes,
A.M., M.D. Chicago: W. T. Keener.—This is a*work of
some 120 pages, of which nearly one-half is occupied with
the histology of the skin and the description of the neces¬
sary apparatus. When the author gets to work he gives
a good practical chapter on the removal of superfluous
hairs. He recommends the employment of a blunt,
slightly bulbous-headed needle in preference to one with
a sharp point, uses from flve to ten cells, and relies more
upon the amount of the babbling round the needle than on
the ammeter to measure the strength of the current. He
has found in some cases, but not in all, that the use of a
cocaine, menthol, and chloral ointment previous to the opera¬
tion diminishes the pain, and recommends xiuc ointment
as the best application to facilitate healing. Chapter 5 is
devoted toport-wine marks, moles, and other facial blemishes,
such as xanthoma, acne vulgaris, and rosacea, showing
in what cases it is likely to be useful, and the book con¬
cludes with a series of “ Don’ts,” a popular American
method of conveying cautions. On the whole, this little
work is a reliable guide to electrolysis in the treatment of
skin affections, although it may well be asked whether a
monograph on such a small matter was required.
Illustrations of Diseases of the Skin and Syphilis. By
Tom IiOBiN.soN, M.D. Fasciculus I. London: J. and A,
Churchill. —As there is no preface we are not informed what
is to be the scope of the work of which this is the first
number. It contains three coloured plates of large quarto
size, illustrating (1) A Case of Congenital Syphilis; (2} Two
figures, one of the late Palmar Sypbilide, and tlie other of
Palmar Eczema; (3) Kerion of the Scalp. The figures can
scarcely be called fine examples of chromo-lithography; the
best is Plate 2, but the colouring is crude. Plate 1 has the
disadvantage of being from a drawing taken twenty-four
hours after death, when the colour of the eruption was, of
course, materially altered. Congenital syphilis in the form
represented is such a common condition that one would have
thought a drawing from life would have been readily pro¬
curable. The plates are accompanied by a history of the
case and the treatment considered advisable by the author.
Etude sur la Syphilis, et son Traitcment. Par le Dr. SiMON
Smirnoff. Pp. lOt. Paris: G. Masson.—The author is
the president of the Russian Society of Balneology at
Piatigorsk in the Caucasus. Within a space of forty kilo¬
metres there are, he tells us, four distinct groups of mineral
waters: Ferruginous, at G61(izaovodsk; sodium bicarbo¬
nate, at Essentouki {the Caucasian Vichy); Narzane and
Kisslovodsk are highly charged with carbonic acid; and
Piatigorsk contains sulphur waters with a temperature of
-10° C. It is these last which are so highly valued by the
author as an adjuvant in the treatment of syphilis, though
he relies on mercury as the true and only curative agent. He
gives it chielly by inunction either of the grey ointment
or of the oleate of mercury in from two to four gramme
doses. He thinks it advantageous to leave the mercui-y in
the organism for some time, and deprecates the simul¬
taneous use of sulphur baths or other eliminauts, reserving
them until after the mercurial inunction course is finished.
He objects, therefore, to the mixed treatment. The author
is strongly in favour of the unity of the virus of the soft
and hard chancre, explaining the fact that most people with
a soft chancre escape constitutional symptoms by the in¬
tensity of the process destroying the tissues before they
can absorb the virus. The work shows evidence of inde¬
pendent thought and careful observation, and is illustrated
with several interesting cases.
Practical Sanitary and Economic Cooking, adapted to
Persons of Moderate and Small Means, By Mrs.
Mary Hinman Bell. Pp. 182. Published by the
American Public Health Association. 1890.—This work
was selected as the best of seventy essays received
in competition for a prize of 500 dols, offered by Mr.
Henry Lomb of Rochester, N.Y. Written for the
instruction and use of the working classes in America, it
contains occasionally matter which is inapplicable to this
country, but there is a large amount which is of great
practical value. The introductory portion of the essay
la devoted to a discussion of “ food principles,” which
we are disposed to think somewhat over the beads
of the class for whose use the hook was written, but
is useful as showing the principles upon which standard
dietaries should be founded. The instructions which
follow on the cooking and re-cooking of meats appear
very practical, and many useful hints are given for the
avoidance of waste and the introduction of variety into the
daily meals. In accordance with the conditions of com¬
petition thirty-six bills of fare are given of economical
dinners for a family of six, twelve each for—(1) those of
moderate means, (2) those of small means, (3) those who
may be called poor. There are also twelve cold dinners,
six for summer and six for winter. The book may be
studied with advantage by those to whom economy, com¬
bined with comfort, is an object, and might be taken as a
model for a similar work in this country. We may point
out one defect in the recipes. Many of them give the
somewhat vague quantity of a cup or half a cup of either
solid or fluid to be uged; it would be much better were a
defined measure substituted for this term.
Tempting Dishes for Small Incomes. By Mrs. Db Salis.
Pp. 88. London: Longmans and Co. 1890 .—this brochure
differs from many of Mrs. Do Salis’ other works in that the
materials of the tempting dishes are inexpensive and the pre¬
paration of them is within the powers of a good plain cook.
There are about 250 receipts given, with full and intelligible
directions for their preparation. There are also some
excellent instructions on the subjects of boiling, broiling,
frying, roasting, and stewing, and some “ hints to cooks,”
which would undoubtedly prove valuable if only that very
independent class could be persuaded to study them and
carry them into practice. A very full index makes the
book thoroughly available.
We have received from Messrs. Burroughs, Wellcome,
and Co. a copy of their Pocket Diary and Memorandum
Book. It is a handsome and convenient little volume, con¬
taining space for notifications for each day of the year, and
blank pages in alphabetical order. There is a cosh account
and a number of blank pages in each. We have also been
favoured with a specimen of their Physician's Appointment
Blocks, which cannot but be useful to practitioners. Any
medical practitioner may, we understand, receive either or
both of these diaries by sending his postal address to the
offices of Messrs. Burroughs and Wellcome, Snow-hill
Buildings, London, E.C.
A SPLINT FOR THE TREATMENT OF FRACTURES
AND DISLOCATIONS OF^THE ELBOW IN THE
EXTENDED POSITION.
The frequent occurrence of more or less deformity
following the at present generally accepted methods of
treatment of injuries about the elbow-joint has led me to
treat all such cases, with the exception of fracture of the
coroDoid, which is most rare, in the extended position with
the hand prone. This position, as has been shown by the
researches and experience of Drs. Illingworth and Nunn in
Digitized by Google
30 The Lancet,]
NEW INVENTIONS.
[Jan. 3,1891.
this country, and of Dr. Carl Lauenstein abroad, has many
great advantages over the plans usually ado{)ted. It is
most important that tlie treatment of dislocations should
not be detrimental to a possible fracture. The extended
osition obviates the danger of a fracture which is marked
y swelling, and consequently overlooked, being left in
such a portion that union is either faulty or absent alto¬
gether. As a means of carrying out this method of treat¬
ment I have devised a splint which is simple, light, and
portable. It is comfortable to the patient, and is likely, I
think, to be of great value in compound injuries of the
elbow. It consists of three pieces, arranged as follows. A
splint, A, for the arm ; K, one for the forearm, extending
down to the linger tips, and on which the hand lies
prone; C, a third for the inner side, tapering below to suit
the narrowing of the forearm. The space d between
A and B is for the internal condyle ; c keeps A and n in the
same straight line, and is so hinged to them that it can
swing round to either side, and thus the same splint will
serve for either arm. When the splint is applied, C is at
right angles to A and B. Messrs. Arnold and Sons, who
have my original design, are the makers.
A. Hanbury Erere, M.B., C.M.
DIRECTOR AND TUBES FOR THE DRAINAGE OF
DEEP ABSCESSES.
Messrs. !Mayeii and Met-tzer, of 71, Great Portland-
street, have made these for me. They may, 1 think, be
found useful in cases of abscess of the brain, the lung, or
the liver, or in cases of pelvic abscess, The director is
without any handle ; it is exactly 7 in. long, sharpish, and
boldly grooved along its whole length. It is graduated in
half inches, so that one can tell exactly at what depth it
finds the abscess. The tubes are IJ, 2, 2-^-, and .3 in. in
length ; they slip down easily over the director. As soon as
the surgeon has, with the director, found and opened the
abscess, knowing exactly how deep it lies below the surface,
he chooses a tube of the right length, and slips it down over
the director. Thus he never loses the track; he is saved
from the necessity of poking forceps down by the side of the
director; his tube cannot go astray or get plugged, or fail to
be exactly the right length. There is no haaraorrhage, no
bruising or tearing of the tissues.
Messrs. Mayer and Meltzer have made a fine solid probe,
eight inches long, to run down inside the director, as a guide
and handle in slipping the tubes down over it. Also a
shield, to fit the tubes, for convenience in tying-in. I ven¬
ture to think that such a director as this—without a handle,
somewhat sharply pointed, grooved right down to the end,
of known length, and graduated in half-inches,—may be a
useful addition to our surgical instruments. The tubes,
probe, and shield may be dispensed with: a bit of india-
rubber drainage-tube, large enough to slip lightly over the
director, and cut to the exact lengtli indicated by the scale
marked on the director, would perhaps answer all purposes.
Wiiupole-streot, Dec. 1890. STEPHEN PaGJOT.
IMl'ROVEMENTS IN CRUTCHES.
There have recently been some improvements in the
manufacture of crutches, which are of interest to the pro¬
fession, and which will some of tliera render the fate of
those who have to use such aids to progression {whether
temporarily dr permanently) more endurable. These, which
are the patented invention of a retired army olficer, Mr. E. A.
B. Beaumont, afiect the make of a crutch in all its com¬
ponent parts. One alteration is the attachment of the
cross-piece of the crutch to the shank by means of a ball-
and-socket joint. This has been devised with the object of
diminisHing the wear and-tear of the clothes caused by the
friction of the crutch and the heating of the body by the
constant rubbing. Another is the attachment of a handle
to the shank of the crutch, to be grasped by the hand of
the patient. This can be fixed to the required height.
We consider that great care will have to be exercised in
accurately adjusting this handle, which can be used with a
cheap wooden crutch, for unless the band reach this com¬
fortably, there will be greater instead of diminished risk of
crutch palsy. In the present form of crutch, as used by
hospital patients, the hand grasps the shank, and can be
easily moved up or down if the patient requires it, and the
user can thus relieve pressure at once. The handle is
useful, for more weight can be transmitted directly to the
hand, and there will be less fatigue caused. Increased
lightness is given by forming the shank of hollow metallic
tubing; it is also made in a telescopic form. The foot of
the crutch is also arranged according to the wish of the
applicant, shod with leather, inibber, or other material to
prevent its slipping, and fixed to the shank by means of a
pin-joint, a binge, or a ball-and-socket joint. The cross
piece of the crutch may be obtained shaped in a manner
different from that usually made, the solid part form¬
ing more or leas of a half circle, the concavity of
which is arranged with a cross piece of leather or more
elastic material on which the weight of the body is borne.
The label which at present accompanies and is attached to
the cnitch as sent out requires alteration in several particu¬
lars. Inquiries about these crutches should be addressed
to 32, Egremont-place, Brighton, or bo 39, Wellingbon-
street, King’s-cross, London, N.
llcmbs.
WARRINGTON CHLOROFORM.
(A. ir. Mason, 40, Ji.;\vin-8tbeict, e.C.)
Warrington chloroform, as we had occasion to point out
a short time ago, is interesting cRielly because it is obtained
by a special process from ketones. We have since had the
opportunity of examining the following specimens from the
same firmI'ure chloroform without absolute alcohol,
chloroform containing one-fifth of a i per cent, absolute
alcohol (for medicinal use), and a sample of the alcohol so
used. Pure chloroform is liable, as is gene¬
rally known, to slowly decompose when
exposed to light, and to render it more
stable a minute amount of absolute alcohol
is added. This reduces the gravity to
U497, the specific gravity of ordinary chloroform being at
least 1-500. The samples gave excellent results when
submitted to examination. The specific gravity of the
pure chloroform was found to be almost exactly 1-500, the
medicinal chloroform 1-497, and the alcohol 0-799, cor¬
responding to 99 per cent, absolutely pure alcohol. We
were able to confirm, by testing, the entire absence of the
impurities which are enumerated in the Pharmacopoeia,
and notwithstanding the minute amount of alcohol present
in the medicinal samplo, iodoform was obtained and iden¬
tified, on agitating a pint of the chloroform for several
hours with two ounces of pure distilled water,, then
pipetting off the water and treating it with iodine and
alkali. Tliis furnishes excellent testimony to the delicacy
of tlie “ iodoform test ” for alcohol.
•sskim
& MELTZCR
Digitized by CjOOQle
The Lancet,]
ANALYTICAL RECORDS.
[.Tan, 31
CHLOEOPHRNOE FLUID, POWDER, AND SOAP.
(.1. Haiuiivkavus and Sons, los, Fvi.dk-road, Pheston.)
It haa been noticed not infrequently that the addition of
bleaching powder to carbolic acid in dressing wounds causes
healing to take place more rapidly than when the acid alone
is used. This led to the notion that iiossibly the carbolic
acid interacted with the chlorine of the bleaching powder
to form chloropbenols, and subsequent experiments showed
that chloropbenols are readily obtained either by treating
carbolic acid with hypochlorites or with chlorine gas itself.
Chloropbenols present the advantage over ordinary phenol
of being less corrosive and poisonous, and they form soluble
and easily decomposable compounds (chlorophenates) with
the alkalies. The above firm have sent us samples of their
Huid, powder, and soap containing a chloroplienol of
special CQinposition and manufacture as the antiseptic
and disinfecting base. The Iluid is miscible with
water, and strongly alkaline. With acids, a liquid
emulsion is obtained which is cleared by the addition
of ether. Tlie ether on evaporation yields tlie chlo¬
rinated oil, which possesses a persistent smell resemhling
iodoform. It burns with a smoky, greenish flame and gives
a reddish-brown colour with perchloride of iron. The soluble
powder in which sulphate of soda with a trace of starch is
used as a vehicle and absorbent contains 10 per cent, of the
liquid antiseptic. The soap is excellent in composition,
perfectly neutral, and evidently superfatted, as we find
ether dissolves out an appreciable amount of free fat. On
submitting the soap, after treating with acid, to the action
of steam, the antiseptic oil distils over. Chioropbendl has
been stated to be specially effective in the treatment of
nettlevash.
SNEI-T.ING'S PATENT HOP TEA.
(TIIK IIOI* TEA {'0., ST. flICOllQE'S ItOl'SE, EASTCIIEAI’,)
Novelty, if nothing else, may be justly claimed for the
idea of blending Indian and Ceylon tea with English hops.
It is interesting to recall and compare the therapeutics of
each constituent. Tea is credited with the property of re¬
moving languor and sleeplessness, large or strong doses,
however, causing a kind of narcotism. The action of hop
depends upon the presence of two important substances—
(I) an aromatic oil which acts as a primary stimulant and
secondary soporific and sedative: and (2) the hop bitter,
lupulinic acid, which serves as a stomachic and tonic. 'I’lie
flavour of the infusion is that of a sound tea to which has
been contributed the delicate and bitter taste of the hop.
The hop leaves are readily distinguished by the aid of a lens,
and may be easily picked out. We succeeded in extracting
(with alcohol) the oil (valerol, and the bitter jirin-
ciple (lupulinic acid) from the separated leaves. The tea
used in the blend is of unquestionable purity, as indicated
by our analysis, which is as followsTannin, l()-44 per
cent.; mineral matter, 5‘‘M- per cent.: insoluble mineral
matter, 2-.% per cent.; alkalinity in terms of potash, 1--13
per cent.
l‘l';RrODATK, SODA-WATER, AND LEiMONADE (WEAVER).
(The Akiiatkd nEvnnAtiK and Hui-’i'i'ri’ Dojieaw, l.iMr i'no, Wiik-xiiam,
NoK'i'u Wai.es.)
Whether or not it is to be attributed to the presence of
so-called periodate we do not know, but the taste of these
mineral waters is peculiarly smooth and soft. The residues
on evaporation gave a blue colour with hydrochloric acid
and starch, which was intensified by the addition of
hydrogen peroxide. The soda-water contains bicarbonate
of soda. Dr. Klein, E.li.S., is responsible for the statement
tliat periodate instantly kills cholera and typhoid fever
germs. I'eriodate is undoubtedly antiseptic, but it is just
a question whether a continued course of antisepsis is
(l^dirable,
IRON MALRSCI.
(Dll. MAi.r.srt, Ciiemicai. a.nd Viiahmaceuttcaj, LADOUAroiiY,
FlAmiiKCE.)
Iron Malesci is described as being made so as to
resemble the combined iron existing in the animal organism.
It is a pale green fluid, exhibiting a strongly acid reaction to
test paper, and contains, according to onr examination,
proto chloride of iron and common salt. The iron is readily
precipitated by reagents such as ammonia, as dirty green
hydrate, and the fluid from which the iron has been so
separated gives no evidence on testing of the presence of
any other substance than salt. Iron Malesci may be used
doubtless witli advantage in cases where iron salts are
indicated, but it can scarcely be regarded as an organic
compound of the metal.
CRROLIN (FOR DLSPENSINO PURPOSES ONLY).
(JBVEs' Sanitahv Compounds Company, Limited, 43, Cannon-
stkket, E.C.)
The manufacturers have made further improvement in
their product, now well known under the name of creolin.
The sample submitted to us is adarkbrown, butnon-tavbid,
oily fluid, which exhibits an alkaline reaction to test paper,
and forms with water a soapy emulsion, smelling strongly
of crude tar. Acids liberate an oil from it which does not
give the carbolic reaction with perchloride of iron. Creolin
is a useful and convenient disinfectant and deodorant, and
possesses the undeniable advantage of being non-poisonous.
It is, in fact, used for internal administration.
LIQUOR SENN;12 LBOUMINUM (PRESTONS).
CREMOR ANTI-SEPTICUS (J^RKSTONS).
(Tims. llDuoKiNsoN, I^hestons, and Kind, 81, Bishopsgate-.stbeet
Without, a.nd 26, Dukk-stkf.et.)
Liquor Sennro Legurainum is prepared by a special
process without heat from senna pods, and it is claimed not
unreasonably that on this account a laxative is obtained
which is free from the resinous matter, and consequently the
griping principle, of the leave.s. It is an opalescent fluid,
sweet, and devoid of disagreeable taste. On beating the
fluid clears, spirit distils over, and a prune-like smell is
given off. Perchloride of iron gives a slight black reaction
which would indicate tannin.
Oremor antisepticus consists of a semi-solid petroleum,
probably vaseline, in which is incorporated the powerfully
antiseptic and pleasant-smelling thymol. Steam readily
expels the thymol, which gave a faint violet colour with
iron perchloride, and a reddish purple with acetic and
sulphuric acids. Cremor antisepticus is a convenient and
safe form of antiseptic lubricant for surgical use.
RODINS’ RKAliy-MADE LINSEKD VOUL'ITOK,
(SICAIIURV A- .rOHNSON, 4li, .TBWIN-STREKT, K.C.)
We regard this as an important addition to cataplasmic
medicaments. The poultice consists of a dried coating of
linseed meal founded on soft white felting, and is covered
with aseptic gauze like coarse muslin. The addition of a
mild and harmless antiseptic, the presence of which we were
able to oonflrm, renders the meal lees liable to decomposi¬
tion, and so avoids any objectionable smell that may other¬
wise arise. Other medication which may happen.to be pre¬
scribed, such as mustard, may easily be sprinkled over the
linseed coating. The advantage and convenience of being
able to prepare a linseed poultice ready for use in three
minutes which will properly retain its heat and moisture
are obvious.
A ClirLDREN’S SUllUIOAL HOME FOR SlTANKLIN.—
An institution of this kind is, it appears, through the bene¬
volence of an anonymous lady, to be established m Shanklin.
The benefits of the Home will be restricted to children
between the age.s of three and fourteen, who will receivp
treatment free of cost.
Digitized by
Google
82 Thb Lakcbt,]
“THE LANCET" FOR 1891.
[Jan. 3, 1891.
THE LANCET.
J.ONDON: SATUrMY, JANUAHY .1, mi.
The new year which dawned on Thursday last brings
round to day the familiar occasion for an address to our
readers upon ourselves, our work anti our j)rojects. The
subject is of course one which is never absent from our own
thoughts, hut it is not often that we can permit ourselves
to descant \ipon it. Yet in the hurry and pressure of the
perennial task time slips by so largely unobserved that this
anniversary occasion seems to recur only too frequently and
at intervals too short. Yet, measured by the progress of
events, it is not so. No new year finds us exactly where
its predecessor found us when it broke, or ])resent8 us with
the identical tasks and problems which have been dealt
with in the past. The Laureate has described a land so
“sleepy” that
“ .... beneath the eelf-eaiuo wheel
The self-same vut did deepen year by year."
Bub the day has long gone by when any such description
could portray the region which stretches beneath the gaze
of workers and chroniclers in the field of the medical
sciences and arts.
To-day many circumstances conspire to make this truth
apparent, and to emphasise its significance. The profound
impression produced alike within professional circles and
beyond them by Kocii s great, though incomplete, work in
Berlin; the quickened interest of society at large in the
moral and physical well-being of the more neglected classes;
the rapid growth of an enlightened sense of the intimate
relation between moral depravity, social degradation, and
physical disadvantages; the greatly accelerated develop¬
ment of that local government which is mainly con¬
cerned with problems of public healtli—all these are
facts, and facts of capital importance, which must, and
already do, modify profoundly the relation in which
the profession of medicine stands to society at large.
To-day it is its duty to lead opinion in paths which,
ten years or five years ago, it was striving to open
up to the mind and thought of the nation. Nay
more, it may confidently be said that the past year has
witnessed a great awakening of the popular mind, and that
the immediate aims with which we addressed ourselves to
the discussion of many questions connected with the treat¬
ment of outcast sections of the community, and the preven¬
tion of disease and crime in the beginning of 1890 would be
obsolete to-day.
What, tlien, in view of the present posture of discussion
and of allairs is our duty to one another and to the society
about us We ask ourselves the question, not as medical
journalists alone, or even chiefly, for we clearly recognise
that The Lancet derives what weight and influence it
possesses far less from any literary or scientilic merit that
it may be able to boast of than from the fact that it enjoys,
and is known to enjoy, in a quite unique degree, the con¬
fidence of the whole medical profession througlioul tfie
British Islands and the English-speaking world. It always
has been and will continue to be our endeavour to secure
from the large circle of our friends the best available talent
to deal with the various departments of our work ; though
if we could in this respect succeed to the full height of our
desires, that alone would not suffice to secure euccess.
On the other hand, so long as The Lancet retains the
confidence of its jwesent subscribers or of their successors
in professional rank and work, it must of nece-ssiby he a
powerful factor in tfie formation of public opinion. More,
perhaps, than any other journal in the land, Tnic Lancet
depends upon the support, that is the moral support, of its
readers, and thus the question which we have proposed to
ourselves becomes iu eflect a question as to what is tfie
public duty of the medical profession in reference to the
stimulation and guidance of opinion upon these great public
questions.
The question is more easily asked than answered, yet the
difficulty of finding an answer arises less from the nature
than from the multifarionancss of the answer sought. It is
plainly our duty, in reference to the discoveiy and utilisa¬
tion of new remedies, to provide facilities for the fullest
discussion of their merits within the compass of the technical
press. The mischief which may resvilt from the communica¬
tion of mere guesses, hopes, and ill-founded expectations to
the general newspapers has been strikingly illustrated within
the past few weeks. It is sm^l blame to the editors of
these papers if they do not correctly and at once distinguish
between what is known and what is only surmised,
or to their readers if they are led away by technical state¬
ments into delusive hopes and mistaken courses. B\it in
proportion as we deprecate this untrained disc\i8sion of ab-
struse scientific que.stions, we are bound to provide as its
better and sufficient substitute a full and impartial treat¬
ment of the facts and theories by more instructed hands.
■yVith this object it has been our practice to obtain indepen¬
dent communications from our own correspondents in all
parts of the world, and in a ease of importance to commis¬
sion a special representative to any place where interest may
for the moment centre. To such efforts avc shall continue
to devote ourselves with unremitting attention, and tltis the
more because the extent and nature of the correspondence
which appears from week to week in our columns from
volunteer contributors afford the best possible guarantee
that, when once the facts have been brought to a focus, any
shorlcomings in the editorial treatment of them are sure of
a speedy and effective redress.
Very much the same principles apply, with modifications,
to the other matters of public interest to which we have
referred. At every point at which our studies or our ex¬
perience have given us special qualifications foi' the dis¬
cussion of public questions, we recognise a public duty to
make our garnered results available for the common good,
and we recognise, moreover, that the present attitude of the
public mind makes this duty more pressing than ever.
But, after all, the bulk of every medical practitioner’s
energy must be bestowed upon his private practice, nor can
it be pretended, seeing how intimately the due discharge of
his functions affects tiie well-being of his patients, that
his more private duties are, in importance any more than
jn volume, suboj'dipqte to these move jinblic ones tq
Digitized by ' OO^ IC
'rflB Lamcbt,
ThI-: tiUals of Kocirs hemjcdy
[Jan. 3. 1891. 33
which we have hoen alluding. In this view the duty
whicii medical men owe to one another as fellow members
of a great and beneficent profession looms large and
magnificent. To assist one another by the communication
of ascertained facts and fruitful suggestions, to support one
another by helpful countenance and serviceable aid—these
are more than mere expressions of a good nature or con¬
formity with professional rule. They are substantial con¬
tributions to the common work, and that a work than
which no worthier falls to tlie lot of man, AVe are proud to
believe that Tub liANCKT has in tlie past contributed not a
little to such interchanges of reciprocated good offices,
and we trust that it will never become less efficient to
this end.
Tt is now nearly two months since Professor IvOCH pub¬
lished his memorable statement upon the anti-tuberculous
action of the liquid di8co\ ercd by him in his laboratory work;
and although he himself could not have had very much expe¬
rience with it in human tuberculosis, he felt that he had
gained sufficient knowledge of its properties to give it to the
world. Since then the “remedy’’has been largely circu¬
lated—somewhat indiscriminately, it is true—and has been
tested in all quarters. The result has in the main been
confirmatory of Professor Koch’s declarations, which, it
may be remarked, hardly went so far as some of his en¬
thusiastic followers would have had us to believo. Even
now it is difficult to find an unequivocal case of cure, but
there are scores of undoubted instances of striking ameliora¬
tion in symptoms after treatment by the remedy. This is
surely sufficient to justify the continued employment of this
novel method of treatment, and we confess to some sur¬
prise at the statements made in some quarters, notably by
fll. HucHAiin, that nothing but failure has attended its
use. For what, in brief, are the facts, no far as they can be
gathered ? In dealing with them it may be convenient to
speak separately of the local and general “ reaction,” and,
as the former indicates best the specific action of the
remedy, we will take it first.
Undoubtedly the most striking and obvious of these local
ofiects have been witnessed in cases of lupus. In hardly
any case has the reaction been wanting; severe inflamma¬
tory icdema, followed by exudation and scabbing, with
destruction of the lupoid nodules, has with unfailing cer¬
tainty occurred after the injections, and the rapidity with
V'liich reparative action is set up has been no less surprising.
Nevertheless, it is said that recurrence has not been >
obviated, and that a definite cure has not Ijoen established.
It is suggested that the remedy which acts so intensely
upon the tubercular tissue, but spares the tubercular bacilli,
may set these free to exert tlieir action upon fresh soil, and
tliat no case can be expected to be cured without resort to
surgical measures of extirpation, so as to rid the subject
entirely of the foci of disease. Again, it has been argued
that the selection of the lupoid patch by the remedy is no
absolute test of the specific quality of the latter, but only
that it exerts its effect ou a part already weakened by
disease. 'I'his is .sufficiently disproved by the ineflicacy of
the treatment in any form of local disease other than
tubercular. U must be conceded that this substance ha.s
a I'pcdhe alliuity fur lubcrciiloui'i tissue, caii.'iiiJg il.s rapid
necrosis. Many cases of tuberculous gland affections and
joint disease have also been treated; but with less regular
results than in the case of lupus. Still, it may be said
that in by far the majority there has been evidence of in¬
dubitable “local reaction,” and that in some few cases a
very great improvement lias taken place in the condition
of the affected joints after the acute inflammatory dis¬
turbance has passed away. It would, indeed, have been
unreasonable to expect that where the structures of a joint
are greatly disorganised any such means should be capable
of restoring their integrity; but yet it maybe hoped that
the necrotisation of the tuberculous tissue will facilitate its
subsequent removal by the surgeon. The larynx affords
opportunities for observing the local operation of the remedy
hardly inferior to those given by the skin; and, although
statements as to the therapeutic efficacy are here also
somewhat conflicting, that the injections are followed by
inflammatory oedema and increased ulcerative action admits
of no doubt. Moreover, in several cases, the treat¬
ment has brought into view unsuspected foci of tubercle
in the pharyngeal and laryngeal mucous membrane, and in
one case, cited by Dr. Fbaenkel in a paper read before
the Beilin Medical Society on the 17th ult., perichon¬
dritis of the aiytenoid developed after three weeks’ treat¬
ment. Such an occurrence, together with the continuance
of the appearance of fresh foci, might seem to militate
against the use of the remedy, or throw doubt upon its
efficacy. On the other hand, it may be that in deep-seated
infiltration the effects of its action are for a time con¬
cealed from view. As regards pulmonary phthisis, the result.s
have certainly been equivocal, owing, it may be, in large
measure to the different stages of the affection at which it
has been applied, and the difficulty in determining from phy¬
sical signs the degree of local reaction that takes place. AVo
may disregard in this connexion the alleged disintegrative
changes in the expectorated bacilli; but there is the greatest
diversity in the records of the physical signs. In ,somo
cases these have indicated an apparent arrest of tuber-
culisation; in others a no less obvious extension of it;
in others, again, no change has been detected at all. The
vaguest surmises have been proffered to explain tiiese
diversities. Some, iulluenced perhai's by inherent doubts
as to the wisdom of the practice, have not hesitated to
affirm that tlio “remedy” is liable to excite fresh tuber¬
cular activity and to jeopardise life itself by awakening
into action a dormant focus of disease. Nevertlielesjs other
equally credible authorities declare that, subjectively as
well as objectively, the injections have been followed by
distinct amelioration of symptoms. In may be noted as
singular that two of the most frequent complications of
actively progressive phthisis—hiemoptysis and pneumo¬
thorax—have been comparatively little excited by this treat¬
ment. As regards other forms of tuberculosis—pleurisy
excluded—there lias been little that is encouraging; and
we may take it that tlio use of the agent is distinctly
contraindicated in acute tuberculosis or in tubercular
meningitis.
Turning now to the so-called “ general reaction,” notified
mainly by the influence on temperature and pulse, it
may be os well to remember that there are probably at
least two factors at Avork iu its production. There b
Digitized by
Google
34 The Lahcet,]
THE SANI'i’ARY STATE OV MELBOURNE,
tJAN. 3,1891.
(1) the toxic effect of the matetial itself, and (2) the
secondary effect due to the local disturbance excited by it,
including the absorption of the necrotic tissues. The first
ii common to the non-tubercular and the tubercular alike;
the second is special to the latter. Now one of the most
curious circumstances which further study of its effects has
revealed is that the degree of this “general reaction” is not
invariably proj>ortionate to the amount of tubercular disease
present. In some few obviously tubercular cases no
reaction bus been produced after considerable doses; in
others, where the disease is apparently limited, the reaction
has been mosb severe. Allowance must of course be made
in this, as in the case of all toxic agents, for idiosyn¬
crasy ; but yet we hear of patients who have been tolerant
of the fluid during several trials suddenly becoming
markedly susceptible to it. No doubt there is an explana¬
tion for all these vagaries, but it is too soon yet to hazard
one. That which is obvious is the very powerful toxic effect
produced by the material as seen not only in the high
temperatures produced, but in the symptoms of cardiac
enfeeblemenfr—the rapid pulse, collapse, cyanosis, and
other alarming symptoms—which have unfortunately in
some coses been fatal, and which prove how great is the
need for caution in the use of the agent and for vigilance
in the observation of its effects. These grave symptoms
ntay arise in the absence of any notable temperature reac¬
tion, and apart from any very severe local reaction. No
doubt their gravity is increased in the anicmic and debili-
tihted subjects of certain forms of tubercular disease. All
other symptoms of the period of reaction sink into
iaeigniflcance beside these, which show that the fluid
is more or less a direct cardiac poison ; for, although
such cerebral symptoms as stupor, and even coma
or digestive disturbance, as anorexia and vomiting and
jaundice, or the appearance of a cutaneous rash, or of
albuminuria, have been noted, not one of them so imme¬
diately threatens life as the undoubted disturbances excited
in the circulation. We believe that although for some
of the anomalous symptoms which may characterise the
reaction an explanation may be found in the local dis-
turbanco excited around an unsuspected tubeieular focus,
yet for others, and these the most serious, it is the general
toxic effect of the remedy itself that is responsible.
We repeat it is too soon to appraise the value of the
treatment, but it would be unwarrantable to reject it
altogether. The year on which we have entered will
bring with it the issues of a trial of a remedy for which
much has been claimed. It will be a test not only of
the remedy, but of the acumen and impartiality of those
who use it; and it were well perhaps if all who do use it
were to exorcise scientifle scepticism as well as caution.
Now that the first excitement has passed away, we may
hope that the enthusiasm of the moment will yield to a
calm, dispassionate study of the phenomena of tubercular
disease under the influence of the drug, and that conclusions
will be drawn which can be accepted with confidence.
Meanwhile, we must deplore the decision of the German
Government to retain aa secret the mode of preparation
of the remedy. It places that State in an invidious
and unenviable position; it embarrasses the freedom of
every user of the remedy; whilst it camrot fail to
strengthen the hands of the empiric, who finds therein
a justification for keeping his precious secrets. Once more
we appeal—not to Professor Koon personally, for wo
understand he has no longer the control of the matter-
to the German Government to allow Professor Koch
to do that which ho originally intended, and de¬
clare how his investigations led him to thrae re¬
markable issues. Such a step cannot surely lead to a
greater likelihood of fraud than at present exists. The
method of preparation is doubtless diflicult and tedious,
only to be pursued, perhaps, by a mere handful of experts;
but if so, what barm could accrue from revealing it?
Surely there are ways and means of safeguarding the
public and the profession from imposition other than by
retaining as a State secret the description of a bac¬
teriological process which could be undertaken only by
an expert.
When tbo Government of Victoria selected Dr. D.
A.s'I'ley Gressweli, as their chiefliealthoflicer we ventured
to congratulate them on the choice they had made. But
our congratulations fell short of that which the Victorian
Government deserved, for they alone knew all that was
involved in the appointment of an oflicer amongst whose
known characteristics no place whatever could be found for
attempts either to exaggerate or to gloss over the injurious
influences and the evils of which he became cognisant in
the performance of his duties. Dr. Gresswbll has now,
after several months of inspection, reported on the sanitary
circumstances of Melbourne and its suburbs, which together
constitute a. city of 420,120 inhabitants, and, notwith¬
standing the existence of defects on a stupendous scale, the
remedy of which must involve a great expen(^buro of time
and of money, the thanks of the Board of Public Health
have been expressed to him in a significant manner for the
laborious but very outspoken report that ho has laid before
them.
The great excess of mortality from enteric fever which
Melbourne has been experiencing for years past can no
longer be a matter of surprise to anyone who has the
most elementary knowledge of the laws of health. Many
comparatively modern cities have profited by tlie experience
wliich had been purchased at so great a cost of life in the
more ancient ones of the old world; but there is little
evidence that this has been the case as regards Melbourne.
True it is that the houses are as a whole scattered over a
wide area; but whilst this is the case we read of densely
packed localities, of back-to-back houses erected so recently
as 1888, and of the consequent lack of ventilation both
around and within dwellings. Land must, at some time at
least, have been reasonably cheap, for a large number of
tiie houses, consisting of a number of rooms, are single-
storeyed ; and yet the report tells us of sites that are swampy
and lllthy, of no attempt to make their surfaces impervious,
of ground water within a foot of the floors, of the absence
of dampeourses, and the existence of drain gutters around
that are made of wood which is rotting, and that favour
soakage into the subsoil. Hurface channels are largely
relied on for drainage, and the story told of their defective
construction, deficient cleansing, ami of the facilities for
soakage oi filth which they provide is truly lamentable.
Digitized by Google
The Lancet,]
[Jan. 3,1891. 35
THE EYUA.Ul)-BOMl’AUD TRIAL IN PARIS.
Of so-called “ closed drain.? ” it will Le enough to say that
some of these are made of wood also, and that many arc so
contrived that drain air is continually being drawn from
them into the houses. Catch-pits in gullies and in sewers,
defective by-laws, and regulations as to building so designed
that there is practically no moans of enforcing them—and
this in a district whore in the city area alone nine or more
new buildings have been erected every week for six years—
all meane an amount of accumulating mischief which it is
deplorable to think of in the case of the capital of an
Australasian colony. Rut it also goes to show that if ever
there was a case in which active interference was called for
with the greatest urgency it is that of the city to which
the report relates.
Coming next to the question of conservancy, it would
appear that a groat change was made some years back from
a coss-pit to a pail-closcl system, But as to this a mistake
was made which has also been common in the past history
of this country; for the plan inaugurated was that of a
single- as opposed to a double-pail syteni. The result is
obvious. The scavengers cannot take away a single pail to
cleanse it, and the result is accumirlating filth and oftensive-
noss. The refuse, too, is becoming an intolerable burden
in the localities where it is deposited; houses are built on
it, as also on excremental fillh; and destructors are
evidently needed at once. Thus, the health officer for
Preston says that his district is used as a deposit for excreta
and refuse, and that all over the area resorteil to for that
purpose the inhabitants have suflored severely from enteric
fever. Withregardtosewerageweneedmakenodetailodcom- !
ments. The system admittedly needs reconstructing anew;
and although, in consequence of the scattered nature of the
city and its suburbs, the cost must be an exceptionally
heavy one, the Victorians ha\ e not hesitated to face the
difficulty, and they have already engaged the services of
Mr. Mansergh to deal with the matter in a thorough
manner. A list of local conditions illustrative of the need
for such action is given by Dr. Gresswei-i.., who states that
the inhabitants complain of them as “terrible,” “sicken¬
ing,” and “ enough to breed any fever.”
We were always under the impression that Melhourne
had reason to boast of its water-supply, which is brought
in from without, and is known as the Yan Yean service.
And even now we hope that there is ground for satisfaction
in so far as the sources are concerned, for Dr. Gresswell,
not having had time to examine these, has nothing as yet
to say concerning them. Bub, however admirable the
water may be before it reaches Melbourne, all chance
of safety from its use is pub aside by the vicious
arrangements which admit of suction of filth into the
mains in their passage through the city. Not only
may this result he brought about from the pollutions
in the surrounding soil ov’ing to leaky pipes, to direct ser¬
vices into watercloset pans, and also when new connexions
are made; but it actually appears that the liro-plugs are so
contrived that the contents of tho street channels, which
are hut drains, can get into the water service through the
ball-plugs and boxes with which the mains are fitted, both
under conditions of low pressure and of such intermissions in
the svrpply as aro unavoidable. Well may the report refer
somewhat ominously to the possibility of the Melbourne
water-supplies playing a part “in detenuining the vital
statistics ” of the capital.
Many other matters arc referred to in the document
before us. They all have a bearing, more or less important,
on the state of public health, and they one and all show
jiow imperative it is that a new sanitary organisation
should' he set on foot. Even the sanitary oHicoiing is
defective. Tho medical oflicers of health can hardly ho
e.Npected to act independently under the present unsatis¬
factory arrangements as to tenure of office, and thoxigh the
sanitary inspectors are evidently intelligent and Jiard-
working men, yet their sanitary functions seem to be
regarded as of secondary importance only. Thus nine-
tenths of the time of one inspector is occupied in looking
after stray cattle and in collecting the dog tax.
On the part of some it was felt that the recent report of
the Royal Commission on the Sanitary State of Melbourne,
which was compiled under the chairmanship of Professor
AiXEN, was needlessly severe in some of its strictures. But
it is clear that the statements of tlie Commissioners are
more than endorsed by the report which Dr. Gkesswell
has felt it his duty to present to the Board of Health. It is
evident that the whole matter will now he fully submitted
to the inhabitants and to the authorities of Melbourne, and
we sincerely trust that the occasion will he utilised for
making a new departure such as will put an end to evils
which must necessarily become aggravated as the city
becomes more prosperous and hence mote populous. Professor
Allen has been spending much time in examining into our
English public health system, and now that he has returned
to Victoria he will he able, together with Dr. Gresswell,
to indicate to the inhabitants of his native city how they
may save life and health if they will hut profit by the
dearly bought experience of the mother country. Of this
experience Dr. Gresswell’s past career makes him a
. trustworthy and excellent exponent. Melbourne has now
the opportunity of taking the lead in regard of sanitation
amongst the capitals of Australia, and the attitude recently
adopted by those holding office in the State and in tho
Public Heath Department is, happily, full of much promise
in this direction. Thus, the Earl of Hoi'ETOUN, Governor
of the Colony, has publicly stated that Dr. Grksswell’s
report is admirable as a public document, and altogether
“ untinged with exaggeration,” and the public press, in
urging immediate reform, admits that the neglect of the past
“has dug graves enough and raised tombstones enough.”
During one whole week pirblic interest in Paris may bo
said to have been concentrated upon the proceedings in tho
AssRe Court, where a sensational murder case was being
tried. Miuiiel IA'kaud and Gauriei.le Bomcauu were
arraigned for the murder of Toussaint Augustin GouI'T'e,
a writ-servei' of the courts, and the circumstances of the
case, involving as they did some most intricate legal and
Hcicutilic dillioulticH, oxxitod an extraordinary interest in
the Prcnch capital. About the general facts of the murder
there was no dispute. Evraud had apparently at one time
lived a steady and reputable life, but subsequently became
associated avLUi BOMr.UG), a wuman of loose character, and
Digitized by <^ooQle
36 Thi£ Lanckt,]
THE EYXlAUt) HOMl‘AllD TUlAl. IN i'AEtS.
[Jan. 3,
the pair, being in financial straits, looked round for some
wealthy dupe to decoy and rob. Several abortive attempts
were made, but at length CJouff]'; was enticed by the
female prisoner into an apartment in the liue Tronson
Decoudray, and there murdered. The body was cut up and
packed in a trunk, and it seemed for a time as if justice
was to be defeated. lJut the guilty pair became alarmed,
they Heil to America, wore tracked by the police,
arrested and brought back to Paris, and put upon
their trial. KvitAUU admitted his guilt and the
extraordinary interest of tlie trial turned entirely upon
the part played by ClAr.Riici.r.i-; IlOMi'Ano. She acknow¬
ledged having been in the room at the time when the
murder was committed, but denied having taken any
actual part in its commission, and alleged that in so far as
she had been tlie accomplice and assistant of Evrauo
she had acted under the influence of hypnotism. There
was some doubt as to the precise means employed to
bring about the death of the victim. The theory of
the prosecution was that the agent used in strangling
Gout'i'io (strangulation having been undoubtedly the
cause of death) was a cordclUrc, or waistcord, belonging
to a dresHing-gown of Bomi’ard, and that she had
thrown it round GouI''Kk’s neck while he was held by
EvRAUi). Her own statement was that while slio was
talking to Goui’i'i';, Eyraud glided befiind the sofa on
which Guur’Vi'; was sitting, seized him by the neck, and
strangled him by the pressure of his bands. The medical
evidence, especially that of Dr. l-Ac^\ssACiNl•: of I-yons,
though not quite decisive, favoured the story put forward
by Bompabi).
'I'he chief point at issue, however, was the degree of re¬
sponsibility of Bompaw), aJid whether there were sufiicient
grounds for believing that the series of complicated acts in¬
volved in tlie crime could be perfonned under Jiypnotic
suggestion. Dr. UnouARDKn was the chief witness regard¬
ing the mental condition of Bomi’AKD. According to his
evidence, she did not show any trace of mental alienation.
■\Vhen eight years of age she was tall for lier age, but then
stopped growing suddenly ; at seventeen slie was plump and
fat, but afterwards became thinner. Slie was a vicious
girl, given to lying, but at the same time intelligent and
capable of expressing herself well in writing. Sire was
constitutionally hysterical and subject to crises dcs nerfs,
one of which she bad liad during the course of the
trial. 'J'his hysteria was not, in Dr. BKOUAnnMi.’.s opinion,
of a nature to produce intellectual “ dislocation,” and in no
way diminished her sense of responsibility. Dr. Bernhkim
of Nancy having suggested that Bompakd might have
acted under hypnotic influence. Dr. Buouardel made some
experiments, and found that the culprit was hypnotisable,
but only to a very small extent. She was easily put into
the hypnotic trance on being told that she would not he
questioned regarding Iier share in the murder, but only
about the events of her childhood. These experiments
did not alter Dr. Brouakuel’s conviction of, the
prisoner’s responsibility. He believed lior to be lack¬
ing in moral sense, and compared this defect to a
malady like blindness or deafness. The counsel for
the defence having pointed out that BojMI’ARD bad halln-
ciuatioua during her “attack'; of nerve;.-,” Dr. Uiiut'iUcuEL
gave it as his opinion that this fact did not alter tlie
culprit’s responsibility. He found that even in the hypnotic
sleep the moral sense remained intact up to a certain point.
At the Salpctriure two women, who had often been sent to
sleep, were told while in a hypnotised condition to undress
and go into a bath. One immediately did so, but the other,
who had a stronger sense of shame, resisted the suggestion,
and bad an “ attack of nerves.” Moral consciousness thus
remained to a certain extent. The witness further statcil
that he and his colleagues found that only simple acts could
be done under such circumstances, and they were of opinion
that a crime could not be thus committed.
Dr. Sauue.s' 1 'e’s evidence went to show that ho had fre¬
quently liypnotiscd Gahrielle Bomi’Ard, that she was a
good hypnotic subject, and that the hypnotic trance pro¬
duced on one occasion had been sulliciently deep to enable
him to perform a painful sui'gical operation upon her. He
was of opinion that while she could not be considered
wholly irresponsible, she was not altogether a free agent.
As regards the present crime, he could not say whetlier
hypnotism had anything to do with it. Me did not think
a crime could be committed under its influence, although a
subject migitt be gradually habituated to the idea.
Dr. LikfiEOi.S of Nancy gave evidence at great length
regarding the hypnotic theory put forward by Bompari)
and her counsel. He stated that ho and his colleague,
Dr. BEitNJiiciM, found that in a state of profound hypno¬
tism there wa.s a complete absence of will in the subject,
' and that any suggestion made by the hypnotiser passes
into the subject and inspires him or her to actiojj.
' He gave instances of hypnotic subjects being excited
to commit thefts, to fire a pistol at a friend, ikc.
■Afi regards tlie jiresent case, ho thought tliere was
reason to believe tliat Bomi’ARU might have acted under
hypnotic suggestion. The fact of her having passed the
whole night near the body of a man who had been murdered
suggested that she was under some secret inlluence. .fn
I’iew of the proofs given that she was i cadily liypnotisable,
and his conviction that it was possible for Eyraud to have
hypnotised her to act as bis accomplice, he thought the
jury could not ignore this theory.
Di'. Ballet and Dr. Mottet having given m idence to
sliow that in their opinion the alleged acts could not lia' o
been performed under hypnotic 8Ugge.stion, tlie larions
counsel replied on the whole case. Maitre Doue'v, who
represented the Goui' i-'io family, pitliily remarked that the
theories hold by .Ur. L(Wii:oi.s could only lead logically to
the closing of the I’alais de -lustice, as it would be cosy for
an accused murderer to say when brought to justice “I was
under the influence of evil suggestions.” The jury found
both Eyraud and Bomi'Ard “Guilty,” the latter, how¬
ever, “with extenuating circumstances.” Eyraud was
condemned to death, his accomplice-to penal servitude for
twenty years.
We have given the facts of this strange case as they
have been reported in the public press. Sucli re]>orts
are not always quite fair to expert witnesses, and we
must take the reports of the evidence of the medical
witnesses with some caution. The general facts are,
hoivovcr, clear, and there does not scctn much doubt
U; to the I'jciculilie Lijeoiic;; pul fonvurd rc;|>ctLi'el.y
Digitized by ^ooQle
Thb Lancet,]
ORIGIM OF VERTEBRATES.
[J.\N. 3,1891. 87
by the representatives of the Nancy and the Paris
schools of hypnotism. According to the former, the most
complicated acts, such as those involved in an elaborate
murder, may be committed under hypnotic influence, and
the moral sense may be reduced to complete abeyance.
According to the Paris school, only simple acts
(!an be done under hypnotic induence and the moral sense
remains sufficiently awake to make the hypnotised sub¬
ject resist immoral suggestions. We need hardly dwell
upon the importance of the distinction thus drawn, or
upon the far-reacliing, and indeed revolutionary, results
likely to ensue if the Nancy doctrine should be generally
accepted. Tlie responsibility of teachers who put forward
Much views is very heavy, and they owe it to their fellows
to put their theories to the most searching and ex¬
haustive tests. It is hardly too much to say that such
doctrines are sufficient to shake criminal procedure
to its foundations. Nevertheless, such a reflection must
not prevent us from weighing the (juestion impartially, and
istening patiently to what may be said on behalf of the
views of Drs. Beiiniteim and kfEOKOis.
I'he odd point about this trial is that there seemed to be
practically no evidence that Gaurikelis Bompard had
acted under hypnotic suggestion. The most that was proved
was that she was a hysterical subject, that she had been fre¬
quently hypnotised, and that in the opinion of a minoriSy of
the medical experts her participation in the crime might
have been due to hypnotic suggestion. That it was actually
due to this cause there was no positive proof whatever.
The theory put forward with so much ingenuity has given
Paris one of its greatest sensations, and may have conferred
some additional fame upon Maitre Rofucirr, wlio defended
BoMi'AiM), but it has not cast much new light on the puzzling
jihenomeua of hypnotism, and is hardly likely to exercise
much real influence on the future of criminal procedure.
In the last number of the Quaiietiy Journal of Micro-
arupical Science two memoirs a]')peav which are of great
interest, as showing the efforts made by the scientific
naturalists of the present day to bridge over the cliasm
that separates the vertebrate -subkingdom from the inverte¬
brate, and the willingness they exhibit to modify precon¬
ceived views, however high may be the authority on which
they rest. The “ annelid ” theory, says Professor PA'I’ itjn,
after fifteen years’ of dextrous modelling, is now as far as
ever either from fitting the facts of vertebrate structure or
from shedding any direct light on the great problem of the
origin of vertebrates, Ifc certainly is nob without significance
that of all those who, with willing eyes and minds, have
grappled with the annelid theory, not one has <liscovered a
distinctively annelid feature in vertebrates, neither the
me.soblastic somites, nephridia,-segmental appendages, nor
the segmental sense organs, which arc found in nearly
all segmented animals. Further, since the annelids are
characterised by their typically unspecialised segments,
it cannot he expected that their study should eluci¬
date that profound spocialisatiou of the vertebrate
bead which it is the goal of vertebrate nrorphology to ex-
pomul. On the contrary, concentration and specialisation
pf liead segments are greatest ip the arachnids; and hence it
is in these, on a priori grounds, that we should expeet to
find traces of the characteristic features of the vertebrate
head.' Finding from time to time confirmation of this idea,
as the unexpected complexity of the arachnid cephalotborax
revealed itself, Professor Patten feels justified in formu¬
lating a theory that vertebrates are derived from arachnids.
He accordingly proceeds to point out that the cephalo¬
thoracic neuromeres, nerves, sense organs, and mesoblastic
somites of the scorpion present in a general way not only
the same specialisation and the same ^lumerical arrange¬
ment in groups, but also the same difl'erence as a whole
from the body segments as do the corresponding parts in
the vertebrate bead; that the cartilaginous sternum of the
arachnid represents the primordial cranium of vertebrates ;
that in the trilobites and merostomata, which include
certain forms qf entomostracous Crustacea, the internal
structure of the cephalotborax resembles in some respects
that of Scorpio and limulus ; that the remarkable fish-like
pterichtbys and related forms, judging from their external
structure, are closely related to the merostomata, and
serve to connect arthropods with vertebrates; and lastly,
that the embryology of vertebrates in its main features can
be reduced to the arthropod type.
Professor Gaskbli. has attacked the problem from
another point of view—that, namely, of the development of
the nervous system,—and has thus been led to consider that
this system has been formed by the continual increase of
segmentnlly arranged nervous structures situated on the
outside of and in close connexion with a non-nervous un-
segmented tube. Now, this segraentally arranged nervous
system presents certain i)eculiaritie8, which b.T.ve to he
taken into account and, if possible, explained : such, foi-
exauiple, as its tubular character; its curious dilatation in
front, forming the ventricles of the brain; the large anrount
of non-nervous substance in its interior in the form of an
epithelium, and its approximation to the surface at the
infundibulum. All these peculiarities admit, Professor
Gaskei.i. tbiijks, of an easy explanation if we regard the
epithelial tixbe lining the central canal of the nervous
system as representing the alimentary canal of the inver¬
tebrate from which the vertebrate sprang. He takes the
alimentary tube of a proto-crustacean as a type, and points
out that the fine tube leading from the surface of the
tuber cinereum to the cavity of the infundibulum in tlie
vertebrate represents the msophagus of the invertebrate;
the cavities of the ventricles, with their simple epithelial
roofs, as seen in the choroid plexuses of the third and fourth
ventricles, represent the large globular cephalic stomach;
and the spinal cord, terminating in the anus by the
neurenteric canal, and Hired by ciliated columnar epithe¬
lium, represents the straight narrow intestine of the
crustacean. The brain of the vertebrate as a whole corre¬
sponds to the ganglionic masses of the avthro])od, the
crura cerebri corresponding to the u'sophageal commissure;
the brain proper, with the olfactory and optic lobes, to the
supra-icsophageal ganglia; the hind brain and cerebellum
to the infra msophageal ganglia; and the medulla oblongata
and spinal cord to the thoracic and A’entral chain of ganglia.
Professor G AsKv;!-!, fully recognises the difficulty that imme¬
diately suggests itself, if his explanatiou is to be accepted
of tlie disappearance of so large and important an orgaq
Digitized by i^ooQle
38 Thb Lancet, j
PREPARATIONS FOR THE ENGLISH CENSUS,
[.Tan. 3, 1891.
as the liver. He proceeds to solve it by demonstrating that
careful examination of the head of one of the lowest of the
vertebrata, the ammociutes, or young of the lamprey, shows
a brain case that is not nearly occupied by the brain, but
which presents in the space between the case and the brain
a bilateral mass of glandular looking tissue composed of
cells, and characterised by a large quantity of pigment
ramifying between the cells. This he terms “arach¬
noidal tissue,” and regards as a ceplialic liver. Pro¬
ceeding further, lie^ explains the formation of the neuroglia
and other parts, as tlie median eye; and, on the whole,
may he said to have nrade out an extremely good
case in support of his theory. It is only by such
work as this, and the ciitlcism to which it will be
exposed, that some sure knowledge of the mode of origin
of the vertebrata from tlie invertebrata will be obtained.
“ Ne quid nimis.”
PREPARATIONS FOR THE ENGLISH CENSUS.
DUBINO the last few days of 1890 were distributed to the
632 superintendent registrars and to tlie 212G registrars of
births and deaths the official instructions relating to their
various duties in connexion with the approaching English
census in April next. These instructions have been pre¬
pared by the Registrar-General, and have, in accordance
with the Census (England and Wales) Act, 1890, been pre¬
scribed by tlie Local Government Hoard; they relate
generally to the duties of superiutendent registrars and
registrars, by whom the local census arrangements
will he made and controlled, ami tliey include special
instructions for the enumerators who will hereafter be
appointed. Registrars of births and deaths are siieci.ally
instructed concerning the important duty of revising what
is technically called the “plan of division” of their sub-
districts into enumeration districts, which was adopted for
the last census in 1881, in order that it may be made
applicable to the present condition of the subdistrict, and
as suitable as possible for the enumeration of the entire
population of the subdistrict. This duty, upon which the
success of the census so much depends, will have to be
completed during the present month. In the arrangement
of a thoroughly good plan of division, in which the boundaries
not only of each enumeration district, but of the portions of
the diflerent, and so often conflicting, local subdivisions of
the covintry which these enumeration districts may contain,
registrars will necessarily need, and will, it is hoped, will¬
ingly receive, the assistance of tlie various local authorities.
The registrars of births and deaths, and their superinten¬
dent registrars, who in most ciises are the clerks to the
guardians, are, or certainly should be, well informed as to
the boundaries of civil or separately ])ooi -r,ated parishes,
although these bcundaries have in recent years been much
altered by the operation of the Divide<l Parishes Acts, b'or
the precise boundaries of urban sanitary districts, of
municipal wards, and of ecclesiastical parishes and
districts, however, registrars will in many cases have
to depend in great measure upon information fur-
nislied by sanitary and municipal authorities, and by
the incumbents of the various ecclesiastical parishes.
The accuracy of the census returns is of so much
importance to all these various authorities that it may
he confidently hoped that any assistance required by
registrars in the matter of boundaries will be rea/lily
afforded. It has been estimated that the number of
enumeration districts at the approaching census will be
about forty thousand, to each of which an enumerator will
be selected by the local registrar during February
next, each registrar furnishing to his superintendent
registrar by the middle of that month a list of pro¬
posed enumerators. The superintendent registrar, having
satisfied himself that the list includes none but duly
qualified persons, is empowered by the Census Act
to appoint the enumerators, and will then have to
transmit the list for the approval of the Registrar-General.
The registrars are instructed to select from among the
applicants for the post of enumerator those best qualified
by character, local knowledge, and education for the duties
that have to be performed. It cannot, therefore, be too
generally known that anyone willing to undertake the
onerous and not highly paid duties of an enumerator
at the census in April next should apply to the registrar
of births and deaths for the district in which the applicant
resides. Anyone, moreover, who will recommend to the
notice of the local registrar an applicant for an enumerator-
ship who is thoroughly qualified for the duties will thus to an
appreciable extent increase the prospect of a complete and
successful enumeration of the English population at the
tenth national census.
HEAT-DIFFUSING FIREPLACES FOR
SICK ROOMS.
DuBiNG the recent severe weather it has been wellnigh
imppssible, with the ordinary bedroom grate, to keep the
temperature of tlie sick room up to 60° F., which is needful
for the efficient treatment of acute lung diseases ; thus any
improvements in domestic fireplaces which combine economy
in first cost, efficiency in action under the care of an ordinary
domestic .servant, and power of difTusing into the room the
largest amount of heat generated with the smallest con¬
sumption of fuel, become a matter of interest to anyone
called upon to treat disease requiring a well-regulated
temperature. A good deal has been written since the late
Lord S. G. Osborne and the late Mr. Mechi, in 1877, first
called attention in The Times to a grate manufactured on
artistic principles with firebrick fire baskets, insuring slow
combustion, absorption of beat by the firebrick, and its
economical diffusion into the room, and which marked a
distinct advance in the construction of domestic fireplaces.
Since that time various improvements have been sug¬
gested, and a correspondent informs us that by a careful
comparison of several fireplaces, lie considers none of
them are nearly so efficient as the invention of Mr.
Rinney of Wokingham, known as the “ Heat-diffusing
Fireplace.” The construction is so simple that it admits
I of application to a cottage as well as to a larger house.
It consists of a tire-hasket of firebrick, the sides sloping
from before backwards at an acute angle, so that the heat
rays “decussate ” and warm opposite sides of a room. The
back firebrick slopes at a similar angle to the perpendicular,
thus arresting the heat rays and directing them at right
angle.s to the floor of the room. The sloping back fire¬
brick stop,s short at a line horizontal with the top bar of
the fire-basket. Here it rests on the edge of ordinary fire¬
brick, under which there is a vacant space or recess
about three inches in depth from before backwards,
into which the heat of the fire plays, thereby raising the
firebrick to a white heat. This white heat is conducfcetl
to the sloping firebrick .sides and back of the fire-basket,
and from them is reflected into the room. So simple is the
construefion that at first sight the efficacy of this heat-
generating recess can scarcely be credited. If, however, it
Is put to the practical test, it will be found that it not only
adds to the heat-diffusing power of the whole of the firebrick
in the basket, but that it also keeps the burning fuel, like
Digitized by L^ooQle
The Lancet,]
THE VALUE OP TIME.
[Jan. 3,1801. 39
itself, at a white heat. The space for the escape of smoke is
-about two inches in width, which is almost a certain cure
for a smoky chimney, and insures at the same time efficient
ventilation with the least possible loss of heat and the
^smallest attention. The invention deserves to be more
widely known. In connexion with this subject, our atten¬
tion has been drawn to the scientific discoveries made by
Mr. 0. Clausen, Ilussian civil engineer, having for its
object the complete combustion of fuel, with the consequent
abolition of smoke (soot), and the efficient and economic
distribution of heat. This invention we expect to be in a
j> 08 itioa to test, and to analyse its chemical action, at an
■early date, and the result will be laid before our readers.
THE VALUE OF TIME.
A C0KR]iSPONDENT, writing from alarge commercial city,
■informs us that he remembers seeing many years ago the
^following in some mercantile offices : “Call upon a business
man at business time only, and on business. Transact your
business and go about your business in order to give him
■time to finish his business.” Our correspondent feelingly
•asks whether a notice similar to the above, with the neces-
■sary modifications, might not be hung up in tbeconsulting-
a-oom and surgery of every busy consultant or general practi¬
tioner. Much has been said as to the rapidity with which
'the out-patients of hospitals are disposed of. But
this rapidity is perfectly compatible with correctness of
diagnosis, prognosis, and prescribing by an experienced
jiractibioner, and there is something to be said on the other
side—the time wasted by patients in prolix descriptions
and tedious repetition. The quaint story of the lady who
consulted Abernethy and, knowing his impatience of such
verbosity, held out her wounded linger and answered in
monosyllables is well known, and the example might be
followed with great advantage. The lady in question was
(rewarded by Abernetliy’s impromptu praise, that she was
the most rational woman he had ever met in hie life. Those
patients who are most considerate for their doctor’s time
4ire certainly the most welcome.
THE AIR OF PUBLIC BUILDINGS.
TnE senses of most persons have borne frequent testimony
•to the defective aeration of public buildings. It is needless
to say that in this respect churches enjoy no exceptional
privilege. Some of them, indeed, appear, in the light of
p;ecent exact observations, to stand out as illustrations of
^atmo8phel'ic impurity. Thus, accoiding to Dr. Stewart
Hunter, the air within one church in Edinburgh on a
Sunday contained an amount of carbonic acid varying
'from 0'0048 to 0'00<)3, in another the proportion was 0'0(H.3,
^ind in a third 0-0030. The close air of a schoolroom which
was also tested, and gave O'OOIC, seems pure in comparison.
The significance of such figures is obvious when wc con¬
trast them with the normal standard of 0'0004, and it
•argues a need of reform which is probably not limited to
any one section of the kingdom or to one form of building.
Tlic importance of efficient ventilation, nnfortnn.ately, is
only equalled by the tUlliculty of maintaining it as a con¬
stant condition. Much may <loubtless bo done by altera¬
tions of structure; and we have before suggested in this
•connexion the necessity of providing reliable roof venti¬
lators, and gallerie.s, where those are indispensable, of light
■though strong construction. It must also be remembered,
■however, that no architectural changes can correct the ill
cflects of overcrowding^ and long-continued gas consump¬
tion. Did those who build and those who occupy our
-idinrclies, halls, and theatres duly appreciate the connexion
(fjetween a close atmosphere and the insidious growth of
oliost diseases, we niiglttplead with more evident acceptance
for additional floor space, more and larger outlets, the
abolition of heavy gallenes, and a strictly regulated
attendance.
RINGWORM IN FIJI.
Mr. Bolton G. Corney, the chief medical officer of Fiji,
favours us with the following in reference to a paragraph
which appeared in The Lancet of Aug. 16th last“The
disease mentioned in Tii]*: Lancet of Aug. 16tb, p. 355, as
having been made the subject of study by a French Com¬
mission sent by the Governor of New Caledonia to our own
colony of Fiji for the purpose was the ordinary Tokelau
ringworm (tine v imbricata of Manson). Its only connexion
with leprosy originated in the mind of a certain journalist
of Noumda, by whom some coses there met with were
alluded to in an alarmist aud sensational newspaper article,
which was afterwards copied into a leading Paris paper, and
reproduced in brief in telegrams from Europe to Australia. ,
There is no reason to believe that leprosy, which is endemic
in all the larger groups of islands in the South Pacific, is of
greater importance in New Caledonia now than it was
formerly. Tinea imbricata was originally introduced both
to Fiji aud to New Caledonia on the persons of immigrant
labourers—to the latter colony from the New Hebrides, and
to the former, in 1864, from the Gilbert group; though the
Solomon Islands, which form one of its principal fields, have
also sent their quota to Fiji annually from 1868, when the
‘labour traffic’ began, until the present time. Tinea
imbricata is easily controlled by chrysophanic acid, when
cleanliness is'observed as well.”
LECTURES AT THE ROYAL COLLEGE OF
SURGEONS.
During the coming year the lectures at the Royal College
of Surgeons will be given as follows, the lectures to be given
on dates to be determined later:—Mr. William Anderson
will give three lectures on the “Varieties, Pathology, and
Surgical Treatment of Contraction of the Fingers and Toes”;
Mr. James Berry, three lectures on the “Pathology,
Diagnosis', and Surgical Treatment of Diseases of the
Thyroid Gland ” ; Mn Reginald Harrison, three lectures on
“Subjects taken from the Surgeiy of the Male Urinary
Organs”; Mr. Watson Cheyne, three lectures on the
“Pathology of Tubercular Diseases of the Bones and
Joints Mr. B T. Lowne, on the “ Structure and Develop¬
ment of the Head Capsule, Nervous System, and Sensory
Organs of the Insecta in relation to recent Views on the
Origin of Vertebrates from Arachnoids”; and Mr. J. R.
Bradford, on “The Physiology of the Vaso-niobor System.”
The subjects to be taken by theotherlectuvers—Prof. Stewart
and Messrs. Plowright and Sutton—are not yet announced.
Mr. Hutchinson, F.R.S., will deliver the Hunterian Oration
in February. _
THE CAMDEN TOWN MURDERESS.
On the 23rd ult. Mary Eleanor Wiieeler underwent the
extreme penalty of the law for the murder of Mrs. Hogg.
The appeal made to the Home Secretary on behalf of the
condemned .woman led to the appointment of a medical
commission to inquire into the state of her mind. The
main issue, of course, turned upon the question of criminal
responsibility. It had been reported that the convict was
subject to epileptic seizures, aud that on more than one occa¬
sion she ha(l attempted to take her own life. The existence
of the epileptoid state wherein a person may be seized with
an irresistible impulse to commit murder has long been reco¬
gnised by the medical profession as beyond all possible doubt.
This “impulsive insanity” may show itself as a sequel or
as a substitution of an ordinary epileptic fit in an individual
who has previously exhibited evidence of perverted brain
Digitized by i^ooQle
40 The Lancet,]
function; or it may be tbe initial manifestation of suci^
disturbance, either as the primary explosion of nerve
energy or the sequence of “hidden seizures,” the. un¬
observed attacks of petit mal. Whatever the exact order
of events, the history of such cases demonstrates that
after the criminal act there is usually a complete
absence of memory of the commission of the deed
Another important feature is that the epileptic makes no
attempt to conceal his crime. The storm of madness has
passed, and left the penetrator of the deed, for a time at
least, oblivious to the part he has played in the tragic
event. Moreover, in such cases there may be not only a
want of apparently sufficient motive, but the victim may
be, and not infrequently is, a person bound by the strongest
ties of affection and esteem to the insane person in bis sane
condition. Now Wheeler had a powerful motive for taking
the life of Mrs. Hogg. Moreover, the murderous act
was followed by elaborate preparations for disposing of
the bodies of the victims, and, again, by protracted attempts
to conceal the evidence of guilt. The wretched woman
persisted in the statement of her innocence until just
before her execution, when she admitted that the sentence
passed upon her was a just one.
INFECTIOUS DISEASE AND DISCARDED MILK
, SUPPLIES.
The recent outbreak of diphtheria at Surbiton is, we
trust, a matter of the past in so far as Surbiton is concerned,
unless diffusion of the disease should be maintained as the
result of direct infection. The source of mibchief .having
been detected in a special milk supply, and further dis¬
tribution of this milk having been suspended in Surbiton,
it is stated by Dr. Coleman, the medical officer of health, that
no fresh cases occurred after a lapse of live days from the date
of discontinuance of the implicated milk. So far so good ;
but for the general public other considerations of import¬
ance are involved. How did the milk service become,
contaminated at the farm whence it was derived, some
fifty miles away from Surbiton ? And, above all, what
is being done with the milk which formerly went to
Surbiton, but is no longer received there? Our pre¬
sent system of health administration, in so far as infec¬
tion is concerned, is too localised in its responsibilities.
Whether a sanitary district or a county be concerned it
matters not; the evil is shunted over the border, and there
it is left to produce the mischief over again which it has
produced before. Surely some central organleatton ought to
take cognisance of such occurrences as that of Surbiton with
a view to some inquiry as to the cause of the disease, and to
the protection of localities that may be imperilled from the
very circumstance that Surbiton is now avoii^ing risk.
SHAKING PALSY.
Dr. Frederick Pkterson of New York, in a clinical
analysis of forty-seven cases of paralysis agibans, while
throwing no additional light on the etiology and pathology
of this disease, draws attention to some interesting points
in connexion with its symptoms. Thus he finds that the
most common age for the disease to manifest itself is
between fifty and sixty, although cases occur as early as
thirty, and as late as from seventy to eighty. His figures
also (twenty-nine and eighteen) bear out the generally-
accepted opinion that males sufFcr more frequently
than females; and his observation of its occurrence
in a brother and sister, and still more in a husband
and wife, seems to point to some predisposition to the
malady in those who from a close contemplation of the
tremor are, perhaps, led to an unconscious imitation of it.
The left hand he finds to be most frequently affected, and
the rate of the tremor varies from 37 to 5‘6 per second. It
CJan. 3, 1893.
is strange that among so many cases none should have
occurred without the tremor, a type of the disease now well
recognised. Among other symptoms noted were exaggera¬
tion of reflexes, muscular wasting, in one case diminished
faradaic irritability, parmsthesie, and hyperidrosis. These
are ascribed to vaso-motor changes. As regards treatment,
Dr. Peterson has nothing fresh to say, bub he emphasises
the usefulness of hydrobromate of hyoscine in controlling
the tremor. In some cases, at least, the depressing effects
of this drug are so great as to completely outweigh any
advantage that is gained from the cessation of the tremor.
BURIAL REFORM.
A SPECIAL MEETING of the Church of England Burialp
Funeral, and Mourning Reform Association was held on the
19bh ulb. at the Church House, Dean’s-yard, Westminster.
The subject was discussed bhi’oughoub in its more sanitary
aspects, Sir A. Rollib, M.P., who presided, reported that
at the request of the Association he had brought before
the Association of Municipal Corporations the memorial;
which theformer had prepared for theHomeSecretaryandth©
President of the Local Government Board. This memorial
urges (a) the discontinuance of already overcrowded
burial grounds; (6) the enforcement of adequate sanitary
precautions when death has been the result of an infectiou.“>
disease; (c) the more frequent inspection and more thorough
supervision of all burial grounds ; [d) the prevention of over¬
crowding by more stringent regulations; and (c) the pro¬
vision, where necessary, of properly appointed mortuaries.
The Association of Municipal Corporations unanimously
adopted a large part of the memorial, and empowered Mr.
Byron Reed, M.P., and Sir A. Rollit to support it before
the Horae Secretary and the Local Government Board.
Those gentlemen promised to consider it carefully.
THE DENTAL HOSPITAL OF LONDON.
In our last issue we referred to the establishment of a
mechanical department to the Dental Hospital for the supply
of artificial teeth to the necessitous poor, and now we have
to record a further widening of the usefulness of tbi&
institution. Notwithstanding the fine premises at their
disposal, it has been found for some time past extremely
difficult for the staff and students to meet the demands of
the steadily increasing number of patients applying for
relief. It has, therefore, after considerable discussion, been
decided to increase the working hours, and keep the hos¬
pital open till four o’clock, except on Saturdays; also to
add five new members to the beaching staff. This arrange¬
ment will be of great value to the students (now close upon
one Imndred) as well as to the patients.
THE POLLUTION OF THE WEY.
Tne Sanitary Committee of the Surrey County Council
recently held a conference as to the pollution of the Wey, at
which were present delegates from the various sanitary
authorities of Guildford, Godalming, and Hambledon. The
Mayor of Guildford said that the Corporation had had
under consideration for a long time the question of pro ¬
ceeding with the draining of the borough. Plans had been
submitted by Mr. Lailey, and these had been adopted, an«J
negotiations had been entered into for the purchase of land
for outfall works. It was proposed to treat the efiluent-
chemically, and the. total cost would be £25,000. The
Mayor of Godalming said that the Godaiming Main Drainage
Board were in treaty for the purchase of twenty acres ofl
land at Unstead Farm, and they would, on the completion
of the purchase, commence at once; bub in case of failure to»
acquire this land they had another site in view, The
Board had decided to ask engineers from Acton and
INFECTIOUS DISEASE AND DISCARDED MILK SUPPLIES.
Diylii^ed by
.oogic
The Lancet,]
HEATH AFTER VACCINATION.
[Jan. 3, 1891. 41
Wimbledon to explain their processes, and to give them
their opinion as to the best method of treating the efiluent.
Mr. Welch, who represented the Hambledon Rural Sanitary
Authority, stated that his authority was doing nothing,
and that it had no scheme in operation in any of
the districts, except Cranleigh, where one was carried
out some years ago, but this was not found to answer very
well now, as there was not sufficient land; attempts were,
however, being made to effect an improvement. The
authority did not contribute much to the pollution of the
fltreara, as the pollution took place some distance from the
river, and was therefore purilied by the tributary stream
before it reached the main stream. In each case it was
stated that there was no intention to enter into a joint
scheme with any other authority. Godalming, it was said,
received certain trade effiuents, and other districts would
probably refuse to receive these effiuents. The Hambledon
Board would be willing to take the drainage of Shalford to
the same site as the Godaiming Board, but this was all.
Admiral the Hon. F. Egerton, who presided over the
nneeting, said the matter would be discussed by the sanitary
committee of the Council, and the conclusion arrived at
would be made known at the next Council meeting.
DEATH AFTER VACCINATION.
Dr. Danford Thomas held last week at Islington an
Cnquestonthe body of a child who died on the ninth day
after vaccination. It was stated the child bad had a rash
from birth, and was very delicate; six weeks before its
death it suffered from bronchitis. The chairman of the
local Anti-Vaccination League argued that the child was
delicate from birth, and asked whether the doctor was
justified in vaccinating it. The medical man who performed
the operation stated that when the infant was brought to
him to be vaccinated, he saw no reason why this should
wot be done, and gave it as his opinion, after a i^ost-mortem
examination, that death was due to convulsions following
bronchitis. The jury returned a verdict in accordance with
the medical evidence.
MOTHER SIEGEL” TO PAY A MEDICAL MAN
£1000 FOR LIBEL.
A VERY instructive case was tried at the West Riding
Division of the Yorkshire Assizes, showing the ways and
methods of vendors of patent medicines, first as to the dis¬
paragement of the medical profession, and, secondly, the
flbimulanta they apply to the admiring consumers of their
mysterious drugs. The case was au action for libel in which
the plaintiff was Mr. Richard Dacre Fox, F.R.C.S. Edin ,
M.R.C.S., L S. A., formerly of Manchester, now of Leeds,
And the defendants, Messrs. A. T. Whitehead, Limited,
fjroprietors and vendors of a patent medicine known as
“Mother Siegol’s Curative Syrup.” The patient in the
■case was Mr. Edward Perrin, a guard on the Manchester,
J^hellield, and Lincolnshire Railway. His case was described
in a pamphlet, “ The Doctor’s Terrible Mistake,” which was
fiaid to consist in certifying that the man had catarrh and
phlhiais. Mr. Dacre Fox was consulting surgeon and prin¬
cipal medical officer to the Manchester, Sheffield, and Lin¬
colnshire Railway. It was alleged in the pamphlet, of which
7,500,000 were published, that Mr. Fox examined the anxious
,guard, and then wrote out his death warrant in the following
(impressive style: “ In the case of Guard Perrin. This man
is evidently frightened. He is suffering from phthisis and
"flyspepsio. Cod-liver oil and iron are indicated.” The
pamphlet then shows, of course, how the medical man’s
sliagnosis was all wrong; that there was no phthisis, only
“indigestion and dyspepsia,” which error of diagnosis and
of treatment would soon have driven the poor guard to
bis grave had some providential friend not directed him to
Mother Siegel's Syrup, which also of course cured him at
once. The short answer to this charge by Mr. Fox was that he
had never written any such certificate. He examined Perrin
in 1879, and reported on his case to the secretary of the
Provident Society. He never wrote any document which
contained the statement complained of. The jury were
satisfied of the truth of this evidence, in spite of Mr.
Waddy’s efforts to justify the defendant, and awarded the
plaintiff, who said he had been much injured by the libel,
£1000. No better use could be made of such unholy profits
as those of proprietors of vaunted quack medicines than the
compensation of medical men whom they insult and libel.
Bat the interest of the case does not end here. A little
interesting light was let in on the ways in which such
useful oases as Perrin’s are kept up to the mark of admira¬
tion and advertisement. Money was repeatedly paid to
him. In cross-examination he admitted having twice re¬
ceived £2, and having made an offer to distribute their
printed matter in his journeys through the country. Again
in March, 1890, he applied for more money, and he got in
all £14. It is evidently worth a poor man’s while to take
Mother Siegel’s Syrup, and even to be the subject of a few
satirical remarks in connexion therewith. Similar revelations
have been made in regard to another notorious quack ; but
whether they will have any effect on people that believe in
patentees of secret medicines and their ways is another
question. We can only rejoice in the verdict in this case,
and regret that the damages were not more. To be held up
to ridicule before 7,500,000 people is rather serious.
NORTH-EASTERN SANITARY ASSOCIATION.
The North-Eastern Sanitary Inspection Association is
evidently by no means a mere mercantile institution. It is
true that it makes it a prominent business to urge inspec¬
tion of the sanitary circumstances of dwellings and of their
drainage, and that, at a cost which must be deemed very
reasonable, it provides the inspection and the subsequent
advice as to the remedies that are needed. But, if this
were its only objects, it could be left to fight its own way
without calling forindependenb support. It seeks, however,
to promote sanitary science “in any manner whatsoever”;
and in this connexion it has fitted up exhibitions of sanitary
appliances, open daily and free to thepublic; and it has recently
set on foot an inquiry into the character and constitution of
the air of public elementary schools. The importance
of this latter subject can well be judged of when it is re¬
membered that a vast proportion of the growing children
of this generation spend the greater part of the day in the
institutions referred to. Such a service doubtless tends
to promote one of the principal objects of the Association,
which is to lower death-rate and to increase health-rate.
HIGH ALTITUDES AND NERVOUS DISEASE.
In a paper read before the American Climatological
Association at its recent meeting in Denver, Dr. Eskridge
discussed the effect which living at the high altitudes of
Colorado has pQ nervous and mental diseases. While it s
evident that in the absence of statistics much more com¬
plete and extending over a longer period than are now
available, any results obtained must be somewhat un¬
reliable, yet the impressions of physicians who have prac¬
tised on ofdinaiy levels and subsequently at the high levels
of Colorado are not without their value. Dr. Eskridge is
of opinion that persons suffering from insomnia derive more
benefit from a stay in Colorado than they would from
residence for a similar time at au ordinary seaside resort, so
long as the insomnia is nob due to organic brain disease, la
persons naturally nervous and initable, on the other hand,
he believes that prolonged residence at. high levels is dele*
Di; :!ed - CTOOglC
42 Tas Lancet,]
EPIDEMIC CHOREA.
[Jan. 3.1891.
terioua. la the couree of ordinary aervoas diseases do
difference seems to be observable, bat both alcoholism and
the opium habit seem to prevail to an alarming extent. It
must be borne in mind, however, that many addicted to
such habits either go or are sent to Colorado in the hope of
being weaned from the habit, while many suffering from
chronic alcoholism naturally drift westward. No reliable
statistics as to insanity are obtainable, and consequently
no opinion as to undue prevalence or absence of this con¬
dition can as yet be formed. Strange but temporary
mental effects, however, following ascents to high altitudes
in Colorado, have been noted, and the occurrence of those
is perhaps significant. _
EPIDEMIC CHOREA.
A CURIOUS epidemic of chorea occurred some time ago in i
a school at Wildbad, of which the particulars are given in .
a paper by Wichmann in the Deutsch. Med. Wochemchr.,
Nos. 29 and 30. Twenty-six children in all were affected,
eighteen girls and eight boys, the girls being first affected,
some more severely, some very slightly, while in all the
boys the manifestations were slight. The patients con¬
tinued to attend school, and there seems little doubt but
that the contemplation of those who were affected with the
disease had considerable influence in evoking the symptoms
in the other children. This is confirmed by the fact that
rapid improvement and subsequently complete restoration
to a normal condition took place in those who were kept
away from school. _
EXCITABILITY OF NERVE-ROOTS.
In the Sperin. di Firenze two Italian observers
have recently related the results of a series of experiments
undertaken to determine the influence which the posterior
nerve-roots have on the excitability of the anterior roots.
In the first series of experiments the posterior roots were-
treated with cocaine; in the second the posterior roots
were divided ; in the third the posterior roots were stimu¬
lated electrically; while in the fourth series the cord was
divided below the medulla. It was found that when the
posterior roots were rendered funotionless the excitability
of the anterior roots was diminished ; but when the pos¬
terior roots were stimulated in any way there was produced
an over-excitability of the anterior roots, which went on in
a short time to diminished or even abolished irritability,
and the same results were found when the cerebro-spioal
•system was intact and when the cord was divided below the
medulla.
THE EFFECT OF INJECTIONS OF OXYGEN.
Dr. Francesco Yalenzuela, physician to the Provincial
Hospital, Madrid, has just published in El Siglo M4dico
a paper on new methods of administering oxygen with
especial reference to the treatment of senile pneumonia.
Believing that oxygen inhaled in dyspnma fails frequently
to relievo because it does not come in contact with a
sufficiently large vascular surface, he began administering
the gas per rectum and also hypodermically. In every case
in which the oxygen enema was given the dyspnma was
relieved in a decided and permanent manner. The ease and
rapidity with which the gas was absorbed by the intestine
were very remarkable. Oxygen, indeed, appeared to be as
readily taken up by the intestine a,s by the lungs, four
injections of five litres each being absorbed in an hour, thus
proving the intestinal mucous membrane to be capable of
serving as a most valuable adjunct to that of the lungs. In
employing oxygen hypodermically Dr. Valenzuela believes it
to be important to introduce the gas in its nascent state.
The situation selected for the puncture was the arm, and
the quantity of gas introduced varied from half a litre to a
litre. Cellular emphysema was of course produced, and a
sensation of heat was complained of, but both disappeared
entirely in the course of a few hours. There was no calma-
tive action or slowing of the respiration, but there wa»
a marked stimulating action on the heart, such as is indicated
in the collapse that follows pneumonia or fevers of a
typhoid character, also in cerebral congestion and asphyxia.
No indication is given of the temperature at which the
oxygen is introduced, a point which, according to Dr. B. W.
Richardson, is of great importance. Perhaps the Spanish
observer, who does not appear to be aware of Dr. Richard¬
son’s work,^ is mistaken in ascribing the advantage gained
by using oxygen prepared ad hoc to its being nascent,
whereas it is probably due to the temperature being high..
It will be noted that Dr. Valenzuela confirms Dr. Richardson’s
statement that oxygen is relaxant and eliminative.
A NEW SOCIAL DANGER.
Opponents of dancing have had a somewhat nove) argu-
]nenb suggested to them. Some person whom we cannot
but regard as over-cautious has discovered that even tlie
drawing-room carpet is the home of dangerous microbes,
and must not be disturbed, lest the infective swarm should
arise and poison the atmosphere. With every allowancci-
for the unknown components of dust, the objection is, in
our opinion, certainly as whimsical as it is probably original.
Such regular cleansiag as a carpet undergoes ought to free-
it from any seriously morbific influence, the more so
that a dancing room is less than any other expo.sed tO'
such mischievous agency. Far more real is the disqualifica¬
tion from which this otherwise healthy form of amusement
has always suficred in the opinion of medical men in conse¬
quence of its customary methods. The excessively late
hours, the indigestible suppers, the needless glasses of wine,
the close heated air, and the frequent after chill, though by
no means essential to dancing, have done far more to injure
its repute among reasonable people than any fancied bacillus
or morbid spore is likely to do.
THE COLD AND ITS VICTIMS,
A.S might have been foreseen, the inlluence of mere expo¬
sure upon health and life has been unusually noticeable
during the rigorous close of the past year. Several cases-
of this kind have been reported in the metropolitan daily
press, and we cannot doubt that their number would be
largely increased if the facts respectiug this matter were
fully kno wn. The robust and the well-provided feel the nip-
of winter, but how much more do those in whom illne.sj,
age, or Want have weakened the defence of bodily vigour
In a case recently noticed in the press, intemperance had
lowered the vital force, and exposure was followed by frost
bite and fatal syncope. In another, want of work was the
suggestive antecedent. It should be noted that in these, as-
in most other instances of mortal chill, it was the heart
which gave way. The explanation is not diificulb. The
nerve panic induced by extreme cold acts unchecked;
the cramping resistance of numberless contracted vessels
and a stagnant blood stream provoke no adequate
reaction, and the stifled organ stops and life with it.
Freventioc here is everything, and its appropriate methods,
if they were clearly recognised, are probably nob, oven iri»
the presence of poverty, so dillieult of attainment as may
be supposed. Discretion in the matter of exposure is nob-
indeed possible to all; but it might certainly be exercised
by, or on behalf of, many persons, especially at the ex-
treme.s of life, much more commonly than it is. The
spectacle of an aged man or infant out of doors in such
biting weather as the present must in very many cases lack
1 Tiiii: Lancet, vol. ii. 1S70, p. 7-10.
Digitized by
Google
The Lancet,]
THE HOSPITAL SUNDAY FUND COLLECTION.
[Jan. .3, is&i. 43
the excuse of necessifcy. It is, however, where poverty or
illness brings privation that the pinch is most felt, and the
safeguards afforded by food, fire, and warm clothing are most
difficult of attainment. Yet the poor and their charitable
helpers may take heart from the fact that the maintenance
of sufficient artificial warmth does nob call for elaborate
measures or lavish expense. The hand of brotherly help
will certainly be appealed to, but it need not squander or
exceed in providing such absolute necessaries as ffre, plain
bedding, and flannel underclothes. Food of the simplest is
alone requisite, if it be sufficient in amount and warm; while
the absence of alcohol is an excellent guarantee for needful
economy and for more sustaining provision. Much of this
care is within reach of the frugal poor; but the time is fully
ripe for charitable organisation in relief of their pressing
necessities.
THE HOSPITAL SUNDAY FUND COLLECTION.
The Council of the Hospital Sunday Fund have been able
this year to record the largest amount which has ever been
entrusted to their hands, the total sura received having
exceeded £42,000. This very gratifying success is the more
remarkable because the discussion which about the time
that the collection was made began to rage on the subject of
the administration of the London Hospital, seemed only too
well calculated to have an adverse effect upon the pecuniary
result. It is, of course, possible that if no unfavourable
influences bad been at work the growtli of the fund would
have been larger than it actually was; but, on the other hand,
the circumstances of the hour undoubtedly caused all the
friends of the fobd to redouble their efforts to avert a
threatened disaster. The result at least is highly satis¬
factory, and as the circulation of our Special Hospital
Supplement, to the number of a hundred thousand copies,
can hardly have been without effect to this good end, we
may fairly congratulate the readers of The Lancet on the
result of an effortin which they have borne no inconsiderable
share.
THE INFLUENZA IN CHIU.
Dr. Molinare, who was coraniisaioned by the Medical |
Society of Santiago (Chili) to draw up an account of the
epidemic of'influenza, has published his report in the
lievista M6dim, in which he states that the epidemic was
rife during the months of January, February, March, and
April. More than 150,000 individuals, or 70 per cent, of
the population, were affected, 20,000 being on some days
confined to bed from it. At first it was of a slight character,
but towards the end of the epidemic the cases became much
more severe. There do not seem to be any exact atatistics
of the deaths from influenza, but that the fatal oases were
very numerous may be inferred from the high mortality
during the first four mouths of this year as compared with
that of the corresponding period of other years when no
epidemic was present. Tne number of deaths during this
•period was 3787, or about 900 more than in the first four
months of 1889, and it is thus probable that about 900
persons died either directly or indirectly in consequence of
the influenza. _
BEER-DRINKING EXTRAORDINARY.
BEER-DRiNKiNO amongst students in Germany and other
continental countries is proverbial, and we may say that
the average Englishman is a beer-drinker if not a teetotaller.
In Ireland and Scotland alcohol in the form of spirits
is the chief beverage. In the prosperous times of 1H73
and 1874 in this country the working collier was 8.aid
to have forsaken his beer and taken to drinking cham¬
pagne, but the ensuing depression soon put an end to
this. Now, however, with a retum of prosperity in the
coal trade, we find his beer-drinking propensities developing.
An extraordinary state of matters was proved to have
taken place at loce, near Wigan (during an inquiry by Mr.
Brighouse, the county coroner, into the death of a man who
liad been drowned in the Leeds and Liverpool canal). A
comrade of the deceased stated that he had^enhim the
previou.? afternoon, and up to that time he might have had
a dozen pints of beer (six quarts). At night they bad two
glasses, and afterwards four small glasses of whisky. It
was farther shown that in the course of the afternoon and
evening the deceased and another man bad a wager as to
who could drink three pints of beer in the shortest time, and
that he drank these three pints in under, five minutes’ time—
in fact, in half the time it took the other man. No wonder-
this man, when he started to go home, lost his way in the
darkness and fog, and that when he fell into the canal he was-
unable to help himself out. The beer drunk by the Germans
and Bavarians is a much lighter beverage, and, therefore,,
probably contains less alcohol. Could not the British
brewer concoct a beverage which would be less intoxicatiug?'
It is a popular notion that no harm can result from the
use of beer, that delirium ajjotu never follows its employ¬
ment. But this is a delusion; gastric and hepatic derange¬
ments are common from its abuse, and in the cases of con¬
tinuous beer drinkers, such as beersellers and draymen^
delirium tremens is nob unknown.
NEW YEAR HONOURS FOR MEDICAL MEN.
The medical profession will learn with pleasure that Her-
Majesty has been pleased to confer the dignity of a-
baronetcy of the United Kingdom upon liiehard Quaint
Esq., M.D., F.U.S. Sir Richard Quain is well kaowm
as a distinguished member of the medical profession, as-
a Crown representative to and treasurer of the General
Medical Council, and as Extraordinary Physician to Her
Majesty. Professor George Murray Humphry, M.D.,F.R,S.,
Professor of Surgeiy at Cambridge, has received the honour-
of knighthood; T. F. Odling, Esq., M.R.C.S., Assistant
Medical Superintendent of Government Telegraphs for
Teheran, is made a Companion of the Most Distinguished
Order of St. Michael and St. George ; Brigade Surgeon-
Thomas Edwin Burton Brown, M.D.,and Surgeon-Major
Thomas Holbein Hendley, have become Companions of the-
Most Eminent Order of the Indian Empire ; and James
Desmond M'Carthy, Esq,, M.D,, Chief Medical Officer of
the Gold Coast Colony, is made Commander of the Order
of St. Michael and St. George of the Third Class.
THE WINTER DROUGHT.
The universal frost has already taught many liouseholds-.
how real is the loss entailed by an ice-bound water-supply..
The picturesque aspect of a Canadian winter, in the eyes of
most persons, affords no adequate compensation. A frozen,
cistern and sealed water-pipes, with a prospect that the
coming thaw will bring relief, and with it perhaps ruinous
excess of water and of plumbers’ expenses, are assuredly-
pressing considerations. How, then, shall we prevent these
awkward concomitants of a fine old-fashioned Christmas i-
The question is more easily pub than answered. Un¬
doubtedly the cistern out of doors with unprotected pipes-
is the primary cousideration. In spite of the advantage of
obtaining cooler drinking water during summer, the incon¬
venience of this arrangement in cold seasons, notwithstand¬
ing any protective measures which may be adopted, re¬
quires no comment. Under any conditions, however, the
house pipes also must in severe weather form a con¬
stant source of anxiety. Freeze tlrey will sometimes^
in spite of every precaution, though a trickling tap»
with exposure as free as possible of the pipes to house-
Die:: zed by Google
44 Thb Lancet,]
EOYAL MEDICAL BENEVOLENT COLLEGE.
[Jan. 3, 1891.
air warmed by the fire, gas, or lamps judiciously
placed, will go far to obviate this perplexing emei-gency.
The constant risk of such accidents 'under the system of
household storage, however, is one of the best arguments
in favour of a direct water-supply. The danger from frost is
not indeed tl!us easily obviated, but it is distinctly lessened,
and the means of its prevention much simplified. The
condition of waste pipes is of no small moment in this
connexion. The possibility of sewage accumulation in
drains, and of a consequent reflux of sewer air, is a con¬
tingency which must not be overlooked. Fortunately, most
of the available waste water of the household is made to
enter the waterclosets, and the regular cleansing of each of
these by this means should be carefully provided for. A
disinfectant is an advisable, almost a necessary, addition.
By such means of prevention the very sensible privations
.and dangers induced by a water drought, if not removed,
will at all events be materially modified.
ROYAL MEDICAL BENEVOLENT COLLEGE.
The special effort which was inaugurated in the spring
of last year with the object of placing this institution in a
'better position to carry on both its educational and its
charitable work, is being, we are glad to learn, happily
carried forward. The raising of so large a sum as £50,000
may well be a work of time, but we learn from a comrauni-
• cationfrom Dr. Holman that a second donation of £600 has
been received from an anonymous contributor to meet the
contribution of £1000 conditionally promised by the Pro-
.prietors of The Lancet. The sooner the condition is
fulfilled and the whole amount of our contribution earned,
4he livelier will be the satisfaction which its payment
will occasion certainly to the givers, and we doubt not to
trbe receivers also of the donation.
SCARLET FEVER IN THE METROPOLIS.
The returns continue to show a satisfactory reduction in
‘fihe cases of infectious diseases, and especially of scarlet
tfever. In the fortnight ended Dec. 20tb, the number of the
latter reported to the Metropolitan Asylums Board was 528,
a reduction of 155 upon the preceding return. Diphtheria
shows a reduction of G7, the cases having been 267. The
admissions of fever patients into the hospitals of the Board
were 255, as against 374 in the preceding fortnight. On
the night of Dec. 23rd, there were 2002 patients in the
hospitals, including 544 convalescents in the Northern and
'Gore Farm Hospitals. Of the cases, 1673 werescarlet fever,
and 152 diphtheria; there were 473 beds ready for the
reception of scarlet fever, and 07 for diphtheria. There
diave been no cases of small-pox notified during the fort¬
night. Two cases of typhus fever were notified, one of which
was admitted into the Eastern Hospital. Owing to the
'Christmas holidays, there was no meeting of the Asylums
Board last Saturday._
LIFE ASSURANCE AND THE MEDICAL
PROFESSION.
It is said to be the common experience of insurance
•offices that the present season of the year is tlie most
‘favonrable to their operations. The reason is probably to
'be found in the circumstance that in the ordinary course of
business large sums of money change hands at the end and
beginning' of the year, and that many people consequently
oome into the possession of funds, and are naturally ntore
•disposed then tlian at other times to contemplate a form of
-expenditure which is in the nature of an investment. This
will be the case with many of our readers, and tho occasion
^ seems, therefore, not unsuitable for drawing attention afresh
•to a subject to which we have within the past few
■weeks devoted a large amount of space—namely, Life
Assurance and the Medical Profession. The result of the
inquiry which we recently instituted under this title was
to show that the wise choice of an office with which to
effect his assurance is a matter of very great importance to
a medical practitioner. Not only is there the vital question
of the solvency of the company in which he is about to
repose his trust—a question which cannot be too carefully
considered,—but there is also the subordinate, but only sub¬
ordinate, question of the terms which the selected company
will offer him. Some lay themselves out to meet his re¬
quirements; others decline to recognise that he has any
special needs. Speaking in general terras, then, the follow¬
ing may be indicated as salient points under this view.
First, a medical practitioner should be sure that he gets his
policy commission free, either by insuring with a company
which does not employ commission-paid agents, or by
making an arrangement that the agency commission
on his own premium shall be paid to himself. Next,
he should be very suspicious of high-rated investment
policies. The thing which above all other things a
life assurance company is fitted to do is to assure
lives. When it superadds to this function the func¬
tion of investing its policyholders’ money, it usually per¬
forms this latter part of the work at an inordinate expense
to the customer. A charge of 10 per cent, upon tho pre¬
miums received to defray working expenses is a moderate
charge according to the practice of the Life Offices ; but if
such a charge is made upon money simply received in trust for
investment, the arrangement is distinctly a disadvantageous
one for the beneficiary. We pointed this out in our Life
Assurance Supplement, and we observe that the foremost of
the insurance papers have not only recognised the justice of
the criticism, but have also urged upon the offices the im¬
portance of reconsidering their rates for such policies—i.e.,
for Endowments and Endowment-Assurance Policies—in
the light of the principle which w^e have cited. The
President of the Institute of Actuaries also, in his in¬
augural address, delivered a few days after the appear¬
ance of our Supplement, made some remarks in much the
some strain, though without express reference to our
criticisms. It may be hoped, therefore, that in time the Life
Offices will correct this anomaly; but at present it is probably
wise to select a sound office for life assura'nce proper
but to keep one’s investment operations in one’s own hands.
ALCOHOL AND SOCIAL TRAGEDIES.
We make no excuse for referring to two or three terrible
social tragedies which within the last few weeks have
shocked the public, and in which alcohol has figured as the
principal factor. We feel the more compelled to do so as
representatives of a profession which sees many such
tragedies that never meet the public eye ; which, moreover,
has a special responsibility in regard to the use of alcohol.
Moreover, we grieve to have to add that in two such dis¬
tressing cases medical men have been principal figures.
Murder, suicide, inhuman neglect, accidental death, are all
found in every day’s papers associated with drinking.
We do not care to go into particulars. We warn all
persons that drinking for drinking’s sake — drinking
else than the small quantity that can be taken with
a meal—is as dangerous as it is discreditable. The
new year may be an excuse for an appeal to our
own readers, and we entreat them to take into their
consideration the social and moral as well as the medical
bearings of this national vice, and to resolve to discourage
it alike in practice and by example. The leaders of the
profession have done much in this way. But they can do
more, and the general practitioners can do most of all, in
the multiform relations of their position, to abate this
terrible evil. We have no intention to dictate the dietetic
oog e
Dic..._3d I
The Lancet,]
CHOLERA INTELLIGENCE.
[Jan. 3, 1891. 45
or the therapeutic use of alcohol. But we feel that we
should be unworthy of our function if we did not express
from time to time our sense of the high responsibility of
medical men to do what in them lies to help men, and
women too, to overcome what is almost a racial diathesis
engendered by long centuries of habit. For children the
profession is agreed that the use of alcohol should be
restricted to strictly therapeutical purposes.
CHOLERA INTELLIGENCE.
Cyprus has removed all quarantine restrictions as re¬
gards arrivals from the Red Sea, and has substituted
medical visits in the place of quarantine in the case of
arrivals from Spain and the Balearic Isles. Cholera still
prevails in Syria, but it is said to be limited in degree. The
localities still infected in Syria are Alexandretta, Antioch,
Kills, Haram, Aleppo, Maarat, Edlib, lUhanieh, and
Hama ; and in Northern Mesopotamia, the town of Orfa, at
the head of one of the branches of the Euphrates, is also a
seat of the disease._
TAXATION AND SANITATION.
We have been favoured with the copy of a paper on the
above subject, which was read at the Sanitary Institute by
Mr. S. M. Burroughs (Burroughs and Wellcome). He
holds that levying rates on houses is wrong, and that all
rates ought to fall on the land upon which the house is
built. The man M’ho is the lucky possessor of a free¬
hold and lives upon it will obviously have a difficulty in
discovering the advantages of this suggestion. Never¬
theless, it is, unfortunately, a fact that many persons have
refrained from putting their houses in a suitable sanitary
condition, fearing that such improvements would be con¬
sidered as having increased the value of the property and
therefore entail an increase of taxation. We take it that
there should be no increase in the taxation of a house
because the drains have been put in order, better venti¬
lation or light provided, and damp prevented. For a local
authority to increase taxation because a house has been
put into proper sanitary condition is a confession on the
part of tiiat authority that it has grossly neglected its
duty. Theoretically, every house is to be regarded as in
proper sanitary order, because, if it is not in such a
condition, then the sanitary authority should prosecute
the owner and make him rectify every defect. If the
local sanitary authority neglect to do this, then such
authority ought to be dealt with. Such is the law, though
it is not always applied. If the owner or occupier of a
house finds that the law has not been strictly enforced
in his case, if he discovers that damp comes through
his walls, that there is not sufficient air and ventila¬
tion, and that the drains are not in order, he does
not increase the estimated value of the property by
causing these evils to be remedied. Ho only corrects
an error; he makes the house really worth the value at
which it was estimated, and which it did nob possess
before it was in a proper sanitary condition. Though
we know that it too often occurs in practice, we cannot
theoretically admit that a house is taxed when in bad
sanitary condition. Far from increasing the taxation of
an owner or occupier who puts his house into a satis¬
factory sanitary condition, the local authorities should
express their gratitude to such a person, as his care¬
fulness in these respects may save the local authorities
from blame. Another point dealt with in Mr. Burroughs’
paper is that of a remedy for overcrowding in large cities.
Here his views seem open to criticism. Mr. Burroughs
conjures up a vision of “ free railways ” paid for
by the landowners to take the workora in these
congested areas to and from the suburbs. Has he
ever contemplated the cost of taking the 500,000 persons-
who daily work in the City of London to and fro? If-
we reckon that on an average each man is half an hour-
in getting from his dwelling to his office and half an hour
getting back, and that his return fare costs sixpence and the
time lost is worth sixpence (taking the “docker’s tanner
as the standard of time value), then the daily cost of transit
is £25,000, the weekly cost (not counting Sunday) is<
£150,000, and the yearly cost £7,800,000. The money thus
spent is as unproductive as expenditure can he, and ie-
necessitated by the fact that in all our sanitary measures
we so foster overcrowding that our cities are becoming unin¬
habitable. If we had “free railways,” the result would be ai>
increase of the congestion and such overcrowding on the
lines that the time occupied in transit would be doubled.
The sanitary millennium does not, we opine, lie in the direc¬
tions in which Mr. Burroughs is pointing. We must disr
courage overcrowding, and this is not to be done by trying
to make it cheap for persons to live or work in overcrowded
districts.
THE LANCET RELIEF FUND.
It will be seen from the annual report of the Almoners
of The Lancet Relief Fund, which appears in another part
of this impression, that during the past year this, unlike*
most otlier charities, has proved more than sufficient for the
demands made upon it, the account having been closed-
with a substantial balance of £125. It is no doubt the caso
thatthisbalance might have been distributed if the Almoners
had been free to entertain applications for the relief of chronic
distress, but such cases are excluded by the rules of thel'and.
It is expressly appropriated to the assistance of personal
placed incircumstancesofsuddeneraergency, and hence many
applications, otherwise deserving, are rendered ineligible..
It is, however, no small satisfaction to the donors of the-
Fund to know that the relief actually administered is much
more than commensurate to the mere sum distributed, for,,
coming as and when they do, these small grants of money-
are at times si mply invaluable to those whom they benefit.
We should be glad to think that every suitable case had
been relieved du ring the past year, but that is too much to-
hope, and with a view to the more complete utilisation-
of this resource during the year 1891 we will venture to sug¬
gest to our readers that they should cooperate with the-
Almoners of the Fund by making its existence known to-
any within their knowledge of those whom it most con •
cerus. A form to be used in making applications for grants,
will appear in next -week’s impression of The Lancet.
THE MANSFIELD HOSPITAL AND ITS MEDICAL
STAFF.
The honorary medical staff of the Mansfield HospitaX
have resigned in consequence of a dispute with the com¬
mittee as to payment for their services to a patient in the*
hospital who, or whose friends, were able to pay. The-
matter is one for arrangement. It cannot be the interest of'
the managers of a hospital any more than of'the honorary,
medical officers to let those be treated on terms of charity
who cah afford the ordinary charges.
THIRD REPORT OF THE ROYAL COMMISSION^
ON VACCINATION.
A THIRD report has just been issued by the Royal Com¬
mission on Vaccination. Like the two former ones, it-
contains evidence only; but it is of considerable interest,,
in so far as it includes the evidence of three leading anti-vac¬
cinationists—namely, Dr. Alfred Russel Wallace, D.C.L.,
F.R.S., who may be regarded as the scientific opponent oi'
vaccination ; Mr. Alexander Wheeler, who has largely
waged his war through the medium of the public press ^
Digitized by Googk
46 Thb Lancet,]
PHARMACOLOGY AND THERAPEUTICS.
[Jan. 3, 1891.'
and Mr. William Tebb, who is president of the London
Society for the Abolition of Compulsory Vaccination. The
report reaches us too late to be dealt with this week.
A CORRESPONDENT writes: “The profession at Meran
has been amply provided with Kocli’s liquid, and sixty
phthisical patients are now under treatment. The phe¬
nomena elicited are the same as those announced from
Davos. The minimum dose yields no response; stronger
•doses induce prompt reaction ; while no serious danger has
:arisen from the latter. Cases of marked improvement have
been noted; cases in greater number, also, of diminished
■expectoration, and bacilli in the sputum. Two sanatoria
•have been erected in Meran itself, and one in Obermais.
A MEETING of the West London Medico Chirurgical
Society will be held on Friday, January 9bb, at 6 P.M., in
the Board-room of the West London Hospital, at which
'Several cases which have been treated by the injection of
.Koch’s fluid will he shown, to be followed by a discussion.
Mr. Bruce Clarke, Mr. Edwards, and Mr. Keetley will
■exhibit cases. _
We understand that a meeting will shortly be held at
4,eeds to consider the most suitable way of founding a
memorial of the late Mr. M'Gill of Leeds, whose recent
death was noticed at the time in our columns. The date of
ithe meeting will be found in the advertisements.
An Italian hospital has just been opened in Tunis to
meet the w'ants of the increasing immigration from Italy.
0 eds are also set apart for the sick and injured of other
aiationalitiee. __
Information has arrived through Reuter’s Express that
.■a virulent epidemic of small-pox of a confluent type has
broken out in Transcaspian territory.
sitb
DISINTEGRATING TABELL/K.
We have received from Messrs. Allen and Hanburysseveral
samples of the disintegrating tabellm introduced by this
firm. These have been submitted to a prolonged trial and
have given the most satisfactory results. Although they
•retain their form in the dry state, on the addition of water
1 ;hey readily break up into fine particles, thus facilitating
.and ensuring the prompt action of the remedy. The ease
with which they disintegrate entirely frees these prepara¬
tions from the charge, so often brought against compressed
•drugs, of passing through the body unchanged. Tlie
tabellje are supplied at very moderate cost, and will doubt-
dess find favour with the profession. A large number of
drugs are now prepared by this firm in this very convenient
•form. We can speak most highly of the compound sulphur
'tabellm, which in their mild laxative action have given the
■utmost satisfaction.
URALIUM OR CULORAL-UKETHANE.
Uraiiura or chloral-urethane, which was very strongly
•recommended early last year by Dr. Poppi of Bologna as
Tjeing a better hypnotic for insane and neurotic patients
‘than most other drugs of this class, has recently been care¬
fully tested by MM. Schmitt and Parisot of Nancy, who
administered it in an alcoholic solution in a variety of
•cases where tlie patient suffered from insomnia. The
smallest dose that was at all effectual was fifteen grains, but
doses of even thirty-eight grains were by no means always
successful; indeed, less so than chloral or opium. Added
to the uncertainty of its effects, it was very disagreeable to
take, and often disordered the digestion, and sometimes
•caused vomiting, followed by nausea which lasted for some
•days. In two cases, too, vertigo was complained of. It
would seem, therefore, that Dr. Poppi’s good opinion of
uralium is not shared by the French ooservers.
INSTABILITY OF DIURETIN.
M. Lambei;t, from his experiments with diuretin, ques¬
tions the advisability of administering it by the mouth.
He points out that it is decomposed by all acids, and that
even exposure to the carbonic acid of the atmosphere is
sufficient to render it partially insoluble through the forma¬
tion of sodium carbonate. It is also decomposed by bicarbo¬
nates, biborates, and other acid salts. Since it is therefore
likely to be decomposed by the acid of the gastric juice, he
believes it would be preferable to prescribe it enclosed in
cachets, or as a clyster dissolved in lime-water.
TYOKTANIN.
Professor Stilling has given, in three recent numbers of
March's Bulletin., a valuable report upon pyoktanin. He
summarises its qualities in tbefoliowingterms : 1. Pyoktanin
is an antiseptic surpassing all remedies of this kind hereto¬
fore known in regard to both development-arresting and
germ-destroying effect. Tlie two strongest antiseptics
employed in medical practice are sublimate and iodoform.
The bacteriological researches have shown blue pyoktanin
to be about tnree times as strongly antiseptic towards
anthrax bacilli as sublimate is, and to be quite as efficacious
as sublimate towards the staphylococcus aureus; while
the inefficacy of iodoform towards pus cocci is a generally
acknowledged fact. 2. Pyoktanin is an absolutely non¬
toxic substance. Herein it possesses a most desirable
advantage over all the other antiseptic remedies, whose
toxic effects are known to hold, generally, a pretty direct
ratio to their anti-bacterial action. 3. In consequence of
this non-toxicity of pyoktanin it is a matter of indifference
in very many cases whether somewhat weaker or stronger
solutions, or even the pure drug, be employed. (This prin¬
ciple is good pre-eminently in tiie treatment of wounds and
ulcers; but of course it cannot apply to ophthalmology.)
4. Pyoktanin does not coagulate albumen—a negative
quality of high value physiologically, which pertains
to not a single one of the antiseptics heretofore
known. 5. Pyoktanin possesses an extremely high degree
of diffusibility; it permeates the interior of the eye like
atropine, and acts similarly in other tissues. As far as
surgery is concerned, Professor Stilling believes that his
researches have demonstrated that suppuration can be cut
short by bringing pyoktanin into intimate contact with
the suppurating tissues. After giving details of his ex¬
perience of this substance in many branches of ophthalmo-
logical work, he concludes by remarking that even here,
though somewhat less so than for general medicine and
surgery, the entire matter is still in ^atu nascendi.
l-IIARMACOLOGY OF CURARINE.
Dr. J. Tillie {Journ. of Ariat, cmd Physiol.) has recently
given the results of his experiments upon the action of
curarine on the blood-pressure. He finds that the injection
of watery solutions of curarine into the bloodvessels of
rabbits, cats, or dogs causes an almost immediate fall of
blood • pressure. When the dose is small or medium,
the fall of blood-pressure is temporary, but in rabbits
especially the initial fall may be followed almost im¬
mediately by a rise above normal. When the dose is
very large — i.e., from 50 to 100 times the minimum
paralysing dose—the immediate decrease of pressure is
marked, of long duration, and the original level of pressure
is not u.sually regained. The primary fall of blood-pressure
appears to result from a direct action of curarine on the
peripheral nerves, or on the muscle of the bloodvessels.
An enormous increase of the reflex excitability of the vaso¬
motor centres occurs in rabbits after the administration of
small doses of curarine. If the blood-pressure is not
already too high, slight sticnulation.s affect, either directly
j or indirectly, the cardio-inhibitory centre as well as the vaso-
j motor centres, so thattheliearb greatly slows as the pressure
I rises. If theblood-pressurereachesavery high level,thevagus
j pulse disappears and the heart beats very fast, and the
I waves caused by the artificial respiration almost disappear
' also; but whenever the pressure falls somewhat both
! reappear. During the period of low blood tension pro¬
duced by a maximum dose of curarine the following fail to
produce any alteration of tlio curve: (1) Stimulation of the
skin; (2) stimulation of the central end of the divided
sciatic nerve ; (3) suspension of artificial respiration
(4) stimulation of the spinal cord by induction current
Dir Coogle
The Lancet,] SPECIAL SANITARY COMMISSION ON DISINFECTING IN LONDON. [Jan. 3, 1891. 4?
From a olinical point of view it is interesting to find that
albumen, and frequently also blood pigment and blood in
considerable q^uantity, could be readily caused to appear in
the urine of a perfectly healthy rabbit paralysed by a small
dose of curarine, if simply severe vaso-motor spasms were
induced by slight stimulation (blowing the breath) of the
skin.
REPORT OF THE LANCET
Sptrid Sattitarjj (Smitmissira
ON
DISINFECTING IN LONDON.
The progress simultaneously achieved in bacteriological
science and in sanitary legislation has raised the problem of
disinfection to a higher level. The compulsory notllication
of infectious diseases on the one hand, the Prevention of
Diseases Act on the other hand, will necessitate a careful
and in many cases a very radical revision of the methods
employed by local sanitary authorities to purify infected
bedding &c. When the necessity of disinfection was first
acknowledged, but little was known concerning the germ
life it was proposed to destroy. It was then generally sup¬
posed that if the objects to be disinfected could be exposed
to dry heat equal to that of boiling water, the germs of
infectious diseases would be annihilated. The construction
of some box or chamber that could be heated to, let us say,
about 250'" F., was considered sufficient to meet all require¬
ments. Now, however, Dr. Franklin, Dr. Parson, Dr.
Buchanan’s reports for the Local Government Board, the
works of Davaine, Feltz, Baxter, Erdt, Koch, Pasteur,
Dujardin-Beaumetz, Lbfller, and other eminent authorities,
prove that many known germs of infectious disease are
not destroyed by dry heat. Such germs, after being
placed in the old-fashioned disinfection stoves, produced
colonies in culture broths of a very virulent character.
But, on the other hand, numerous experiments have de¬
monstrated that these same microbes were destroyed when
exposed to super-heated steam umler pressure. What,
then, in the face of tliese facts, should be the system of dis¬
infection employed, and what are the methods actually in
use? It must at once be acknowledged that disinfection
has been carried on in a very perfunctory and unsatisfac¬
tory manner.
We have known cases where infected clothing was
thrown out into the garden, and remained there a long
time before it was fetched away and taken to the stove.
Also the stoves are sometimes so unsatisfactory that they
even fail to kill the vermin. The sanitary inspector of a
West-end district declared chat he had seen “ bugs come
out of his stove livelier than over.” The attendant of the
disinfecting stove in a very important central metropolitan
district confessed that he often'contented himself with
allowing the temperature to reach 212°F., and then turned
off the gas burners, “in case he should be called away
aud forget to return in time to prevent the things being
scorched.” The attendant in question is an old man, quite
incapable of performing a scientific operation, such as dis¬
infection. Also dry heat often injures, and sometimes
totally destroys, the objects to be disinfected. For instance,
chamois leather will wrinkle nt only 180°; a lady’s seal¬
skin jacket would be completely spoilt at 220", though
the same jacket would not bo damaged in the slightest
by 240“ of moist heat. There are also many articles of
clothing which come out of a dry-heat stove apparently
uninjured, but when these are worn it will be found that
they tear and come to pieces very rapidly.
As a result of all these risks and inconveniences, the dry-
heat stoves have fallen into comparative disuse. For in¬
stance, the stove belonging to the City of London is not
very often employed, and yet there is a boiler attached
whence steam can be discharged upon the objects that
are being disinfected. This stove is heated by gas and
Bunsen’s burners. The steam when used is not unaer pres¬
sure, for it comes out through the chinks of the door >fcc.
The City authorities, however, much prefer their sulphur
chamber. This measures about 9 ft. by 9 ft., and is 9 ft.
n height. Bedding &c. is placed within upon racks,
sulphur ignited underneath, and this box remains closed for
about five hours. When the bedding is considet’ed espe¬
cially foul or dangerous, it is nob disinfected, but destroyed-
For this operation a very convenient destructor has been
built; there is a small chamber on a level with the ground;.
above it is a grate, on which the fire is^ placed. The incan¬
descent cinders fall from the grate, ignite the bedding, and
the smoke and ellluvia from the burning bedding must pass¬
through the furnace before it can reach the shaft or chimney.
In Marylebone also greater faith seems to be placed in
fumigation than in their dry-heat stove. Here chlorine is
employed. A receptacle containing chloride of lime is-
put on some high piece of furniture and hydrochloric
acid poured in. This is a somewhat delicate operation ^
the disinfectors might injure themselves by breathing the.
chlorine, especially when their clothes are damp, for the
fumes follow them even when they have left the room..
The stove, manufactured by J. C. Bacon and Co., is heated
by small pipes of wrought iron of special manufacture and
strength, capable of resisting very high hydraulic pressure-
They are charged with water and heated by a small brisk
furnace constructed outside the chamber. The manu¬
facturers declare that the apparatus is capable of producing
a very elevated temperature, “ but usually an exposure
during two hours to a heat of 220“F. is found Sufficient-
One of the sanitary inspectors told us that, though he
heated this stove to 260' F. to disinfect milk cans, when
dealing with bedding, clothing, «S{c., he found that 220' was-
“ quite enough for anything.” It is needless to observe that
these assertions are absolutely opposed to the modern,
theories of disinfection. For St. George’s (Hanover-square)
a dry-heat stove is also employed. Here there is an
ingenious device by which 'w^eu the heat reaches 210' F. a
metal bar melts and [the gas burners are automatically
extinguished. At Hammersmith dry heat is also used, hut-
in combination with sulphur fumes. Here a strange-
looking metallic cart is brought to fetch away the infected
linen, Its appearance might cause considerable alarm to
nervous neighbours. At the stoneyard the body of the-
cart is lifted from the wheels and pushed into the stove.
The working of a crank opens out the sides of this cart in
such a manner as to readily admit fumes and heat. Then
sulphur is burnt in the chamber and the temiserature is
raised to 250° F. The whole thing looks clumsy and
theoretically incorrect, but it seems to have rendered good
practical service. During the last thirteen years the-
apparatuB has been used for more than 3000 cases of small¬
pox.
In contrast with the above vague, unscientific, and un¬
systematic methods of disinfection we will take the means
adopted on behalf of the sanitary districts of Fulham,.
Sb. Marbin’a-in-the-Fields, Willesden, Wood Green, Rich¬
mond, Sbreatham, and till quite recently Sb. Faucras. Mr.
W. G. Lacy, formerly medical assistant at a London fever
hospital, disinfects for these districts and for a great number
of private houses, schools, <Sjc., within a radius of twenty
or more miles round London. Considering the immense
amount of disinfection done at Mr. Lacy's establishment,
we made a point of very carefully examining his works.
These are conveniently situated by the water’s edge near
Wandsworth Bridge. Here no business, no beating of
carpets, no cleaning or dyeing or other work except dis¬
infecting is allowed. Every object brought to the works
is disinfected before it is returned to its owner. This is an
important consideration, for there are contractors who not
only disinfect, bub underbake other work. For instance,
carpets that merely want beating are brought dangerously
near to infected bedding. The carts that carry infected
goods and those used for ordinary goods are stabled close
together,' and the men who beat carpets, arrange mat¬
tresses, &c., have constant intercourse with the men
engaged in disinfecting work. Undoubtedly the first prin¬
ciple of all is that no other business shall be allowed on or
near the disinfecting works. This rule is rigorously observed
at Mr. Lacy’s establishment, and whatever is brought to-
these premises, however clean and pure it may be, is dis¬
infected before it can be taken away again.
As a scientific and professional disinfector, Mr. Lacy does-
not employ dry heat. He has two stoves-—one for articles
where penetration is not required, such as boots, books,
mantelpiece ornaments, spring mattresses, &c., or for
articles of clothing that'can be spread out in such a manner
as to expose all their surfaces. In this stove a moist heat
of 270° F. is produced. This heat, though high, is nob in¬
jurious, because of the moisture. For instance, wax
Coogle
48 The L,\.ncet,]
THE LANCET RELIEF FUND.
[Jan. 3, 1891.
matches melt, but the phosphorus does not iguite. The
-disadvantage of this process rests in the fact that the power
of penetration is not always sufficient; and, secondly, that
ut is a slow process. It takes lialf an hour to heat the
stove, and then the things should be kept in the stove for
two hours at the very least. On the other hand, the stove
is very large, and can disinfect the contents of about three
»ooras at a time, so that, on an emergency, infected articles
taken from thirty to thirty-six rooms might be disinfected
in this one stove during a full day of the twenty-four hours’
continuous work. More effective, more certain in its
scsults, and more useful is the other stove, where Mr. Lacy
applies super-heated steam under pressure. Here the canvas
bags—containing infected clothing, bedding, &c.—are put
in without it being necessary to open them, or to spread
ont what they contain, because the steam under pressure
will penetrate any distance, even into compact mate¬
rials. Mr. Lacy fumigates the rooms first. This in itself
is not sufficient, but it is an excellent precaution, so as to
disinfect the outer surface of the linen, carpets, &o., about
to be removed. These objects, especially the bedding, are
placed in large canvas bags, and are put without unpack¬
ing into the steam high-pressure stove. This stove is of
great strength in structure. Indeed, this is indispensable,
otherwise it would blow up. It is heated to about 260° F ,
and the steam within it is at a pressure of 251b. to the
square inch. The huge, thick, heavy door bulges out under
the force of the pressure. No steam whatsoever can be
seen coming out. Where steam is visible the temperature
falls to 212° F., but there is a safety valve to prevent
explosions.
To be satisfactory, adisinfecting stove should be as strong
as a bomb shell, but a safety valve must be provided to pre¬
vent accidents. The doors must be screwed down and
closed so as not to permit the escape of any steam whatso¬
ever. Nor does it suffice to produce a pressure of 25 lb. to
the square inch. This great pressure wul compress the air
in the thickness of mattresses, &c., and the moisture will
not penetrate these bubbles of compressed air. To break
them up, they should be made to rapidly expand by letting
off some of the steam and then turning on again more steam.
This method of disinfection is the most powerful known;
superheated steam under pressure will penetrate layers of
blankets and thick mattresses, while dry heat has been
{ >roved not to reach the centre of such articles. It is there-
ore nut necessary, as is the case with the moist-heat stove,
to open the bags, to take and spread out their infected con¬
tents, as the steam under pressure will penetrate such bags.
Thus for each operation a greater number of articles can be
disinfected, ana the process is accomplished much more
rapidly. The superheated steam under pressure is applied for
only from thirty to forty minutes, while moist heat should be
applied for at least two hours. Scientilic experiments have
demonstrated that germs, even when placed in tho centre
of a thick mattress, are killed in fifteen minutes by steam
under pressure, at a temperature of 240° F. Mr. Lacy’s
steam pressure stove has the advantage of being excep¬
tionally large. It will hold 5 cwt. of clothes, linen,,&c ,
and has disinfected for the single district of Fulliam more
than nine tons of articles during the Christmas quarter.
In this respect we might mention the very excellent rule
which is enforced at Fulham whenever a case of infectious
fever breaks out in a laundry. The sanitary authority at
once seizes all the linen that may be found in the laundry,
and it is disinfected by steam under pressure. After that
the linen is sent to the persons to whom it belongs ; but, so
as not to create unnecessary alarm, they are not told what
has occurred.
Seeing that disinfection is done in a scientific and satis¬
factory manner for some of the London sanitary districts,
we would urge that this important public service should bo
performed in a uniform and equally perfect manner for all
parts of the metropolis. It is necessary that the authori¬
ties concerned should inquire into this matter more closely
than they have done hitherto. The district of St. Pancras
has built for itself a steam pressure above which is a copy of
the stove employed by Mr. Lacy, who formerly did all their
disinfecting work. The Port of London, St. George’s-in-the-
East, Bethnal Green, Hampstead, and St. James’s employ
Lyons’ steam pressure stove, and are therefore scientifically
correct in their method. Perhaps, in some instances, the
stove is rather small to meet an emergency ; but, in that
case, a second stove might without any great difficulty be
brought to the rescue. In other districts of the metropolis
the means of disinfecting are very unsatisfactory and un¬
certain. We would urge upon these latter districts to take
immediate steps to place themselves on a level with the pro¬
gress accomplished in bacteriological science. Such authori¬
ties should see : First, that disinfecting is carried ont on pre¬
mises devoted exclusively to that purpose, walled off, and
carefully separated from other businesses; that the carts used
for conveying infected linen &c. are not used for any other
purpose and are stabled apart. These precautions, un¬
fortunately, are not at present always observed. The
disinfecting premises should have an entrance on one side
for infected articles. A wall built round the stove should
completely cut off the portion of the building where the
infected articles are introduced into the stove from the
part where the purified linen &c. is taken out of the
stove. For this purpose, of course, the stoves must have
two doors : one for the admission of the infected articles,
the other for the withdrawal of the things that have been
purified. Secondly, except for certain articles to which we
have already alluded, where moist heat without pressure
may be used and for which a separate and special stove
may be constructed, the stove for the general work should
be a steam stove with pressure equal to 251b. to the
square inch. If a sanitary authority is not prepared
to establish works of this description for itself, to be
managed by its own officers, under its own strictly
exercised control, then no contract should be made with a
private firm of disin fectors unless the sanitary authority,
represented by someone technically competent to judge in
this matter, has personally visited the premises where the
disinfecting is to be done and made sure that the operation
will be performed strictly in accordance with the principles
enumerated above. If action were taken at the present
moment on these lines it would, we fear, reveal that a veiy
deplorable state of affairs prevails in many districts of the
metropolis.
THE LANCET RELIEF FUND.
SECOND ANNUAL REPORT OF THE ALMONERS.
The Lance'I’ Relief Fund, which has for its Almoners the
President of the Royal College of Pliysicians (Sir Andrew
Clark, Bart., F.R.S.), the President of the Royal College
of Surgeons (Mr. Thomas Bryant), the President of the
General Medical (Jouncil (Mr. John Marsiiau,, F.II.S.),
Mr. Thomas Wakley, F,R.C.S., and Mr. Thomas
Wakley, jun., L.R.C.P. Lond. (Hon. Sec.), with Sir Henry
P iTM.AN, M.l). Camb., F.R.C.P., as Honorary Auditor, came
into operation on the 1st of February, 1889.
In presenting tlie second annual report, the Almoners think
it well to again direct attention to the objects for which
the Fund was established.
For the sustentation of the Fuiid the sum of at least
£300 will be pi’ovided every January by the Proprietors
of The Lancet, and administered free of cost, for the
purpose of affording immediate pecuniary assistance to
registrable medical practitioners, or to the widows or
orphans of members of the profession in cases of distress
and emergency, by the grant of money by way of loans free
of interest, or gifts, as tlie circumstances of the various
cases may require.
When the Fund was inaugurated considerable mis¬
apprehension existed as to the precise objects for which it
had been established; and, as a result, the majority of tlie
earlier applications, being cases of v.hronic distress, and
not coming, therefore, unJer the designation of emergencii,
could nob be entertained. Attention was called to thts
fact in Tiik Lancet of Feb. IGth, 1889, in the following
words:—
“We are requested by the Almoners to state that, from
the character of a number of the applications received,
both personally and by letter, for relief, it is evident that
in many eases the object for which this Fund has been
established is not quite clearly understood; and if relief
liad been afforded in the cases of those who suffer from
chronic distress, the Fund would have been completely
exhausted within the first few days of its existence. They
would therefore be greatly obliged if those readers of TUE
The Lancet,]
THE LANCET RELIEF FUND,
[Jan. 3, 1891. 49
Lancet who may be asked to endorse applioafcions would
carefully peruse the Application Form and explain the
S reciso object of the Fnna to those applicants whoso cases
0 not seem to come within the scope of the purpose for
which the Fund has been established, which is to afford
prompt aid to registrable medical practitioners, or to the
widows or orphans of members of the profession, who,
in consequence of the supervention of some unexpected
exigency which is not likely to recur, have pressing need of
immediate and temporary pecuniary relief.”^
The balance in hand at the end of 1880 (after deducting
a then uncasbed cheque for £10) amounted to the sum of
£74 195. Qd. On January 1st, 1890, the Proprietors of
The Lancet placed to the credit of the Fund the sum of
£300. During the course of the year repayments to the
amount of £29 have been made. The sum of £278 has been
ranted in relief either by way of loan or of gift, leaving a
alance of £125 195. Qd.
There have been received altogether during the twelve
months ending Dec. Slst, 1890, forty-five applications for
relief. In twonty-6ve cases assistance was afforded, either
as a loan or as a gift, according to the request of the appli¬
cant, the amounts of the grants ranging from £5 to £25.
Case 58.—One of genuine emergency—viz., that of a
medical man dying from blood poisoning, contracted in the
exercise of his profession, and leaving his widow with live
children utterly penniless, and without the means of burying
him. Gift of £20, and a subsequent gift of £5 ; total, £25.
This gift fully succeeded in its purpose in tiding over the
temporary di'ificulbiea she had suddenly encountered, and
was unable to meet.
Case 64.—Applicant in great pecuniary difficulty, con¬
sequent upon just starting in practice and inability to meet
a bill of £25, part of the purchase money. A loan promptly
made enabled the applicant to tide over his difficulty, and
the loan is in course of punctual repayment.
Case 87.—Distressing case of a medical man dying after
long-continued illness, leaving a widow and two daughters
in impoverished circumstances. Kelief was promptly sup¬
plied.
Instances naturally have occurred in which the assistance
given has been abused and the recipients have shown
themselves unworthy of the help afforded them.
In some cases of extreme u rgeocy the application has been
considered by the Almoners, a grant sanctioned, and a
cheque for the amount forwarded to the applicant on the
same day that the application was received.
The following are extracts from a few letters received
from some of the recipients of the Fund t—
Case 58.—“ I am more thankful than it is possible to
tell. I was totally unable to move in any way, as I was
without the means to do anything. Now, thanks to your
kindness, I shall be able to go to work at once. 1 received
your kind gift, for which I am truly thankful. I was very
nearly penniless when it came, and I am more grateful than
T can tell you.”
Case 64—“I beg to thank you most sincerely for the
cheque received this morning from The Lancet Relief
Fund. I feel that I cannot adequately express my gratitude
for the kindness and promptitude displayed in granting the
loan. Such a fund as you have instituted must prove a
veritable godsend to many a struggling medical man in
these days of penny, even halfpenny, clubs. Again thank¬
ing you,” &c.
The following letter was written by the lady who intro¬
duced the case to the Almoners:—
Cask 87.—“ I duly received your kind letter and cheque,.
£25. I cashed the cheque ana took it at once. When I
placed the money before dear old.she was quite over¬
come. It would have done your heart good to have seen her
and her daughters—the intense relief that shone in their
faces. Please convey ray and their warmest thanks to the-
Almoners for their handsome consideration of our applica¬
tion ; and I fear I cannot give expression to what I feel. I
can only say it is full of gratitude to you all for your
great kindness and ready sympathy.”
Upon the retirement of Mr. Hutchinson, F.R.S., from
the Presidency of the Royal College of Surgeons, his successor,
Mr. Thomas Bkyant, as Presiaent of the College, became
an Almoner of The Lancet Relief Fund.
The present Almoners desire to record their cordial appre¬
ciation of Mr. Hutchinson’s services as an Almoner, and
also their thanks to Sir Henuy Pi’i’Man, the Hon. Auditor.
(Signed)
Andrew Ceaek, M.D., Thomas Waki-ev,
Jonathan Hutchinson, Thoma.s Waklby, Jun.
Thomas Bry.ant, (Hon. Sec.)
[We regret that, through indisposition, Professor Marshall
was unable to be present at the meeting of Almoners.]
Dr.
Staitmcnt of Accounts for the Year ending Dec. Slst, 18D0.
To
Balance at Bank Jan. 1st, 1890 (less out¬
standing cheque £10) .
Proprietors of The Lancet.
Repayment of Loans :—
Case No. 25. £13 0 0
„ 62. 10 0
04 . 15 0 0
74 10
300 0
29 0 0
£403 19 6
By Loans
Case No. 52
„ 5.3
„ 56
„ 64
„ 67
„ 77
79
By Gifts
By Balance at Bank Dec. 31at, 1890
£ s. d.
20 0 0
5 0 0
20 0 0
25 0 0
7 0 0
20 0 0
20 0 0
,, 51 ...
5
0
0
„ 57 ...
... 10
0
0
,, 58 ...
... 20
0
0
„ 69 ...
5
0
0
,, 60 ...
... 10
0
0
„ 69 ...
... 10
0
0
„ 73 ...
... 20
0
0
„ 76 ...
6
0
0
„ 78 ...
... 10
0
0
„ 83 ...
... 10
0
0
„ 85 ...
5
0
0
„ , 86
6
0
0
„ 87 ...
... 25
0
0
,, 88 ...
... 10
0
0
Cr.
£ 5. d.
117 0 0
161 0 0
125 19 C
£403 19 6
I find by the Banker’s Book that the actual balance on Jan. Ist, 1890, to the credit of the Almoners of The Lancet
B elief Fund, at tho London and Westminster Bank (Westminster Branch), was £74 195. 6d., and that on the same date
the sum of £300 was placed to their credit by the Proprietors of TilJi Lanobt ; and in addition during the year the sum
of £29 was received in ropaynieutt of Loans, making a total of .£403 195. (id.
I have examined the Banker’s Book, and find the balance at this date to be £126 195. 6<f. I have also checked the
receipts for disbursements, and find the above account strictly accurate.
December 26bb, 1890. Hknry A. PiTMAN, Hon. Auditor.
Digitized by i^ooQle
50 Thb Lancet,]
PROFESSOR KOCH’S TREATMENT OF TUBERCULOSIS.
[Jan. 3, 1891.
PROFESSOE KOCH’S TREATMENT
OF TUBERCULOSIS.
LECTURE BY Peof. VON BERGMANN.
PnoKESSOR VON Bergmann, who was the first to. lecture
on the results of Koch’s method of treating tuberculosis, and
whose opening address was reported in the Lancet of
Nov. 22ad,p. 1120, gave a few days ago his last public lecture
•and demonstration of cases under treatment. As a lecturer
Professor von Bergmann is most successful, possessing the
^f t of a ready and abundant How of language, combined with
a clear and concise mode of expression, as well as the gift of
engaging and maintaining the attention of his audience from
the outset to the finale. His last lecture was quite as well
attended as his first, but the audience was not the same.
At the former he was surroiinded by the most eminent
medical men of Berlin and of almost every great medical
centre in Germany, from Greifswald and Kiel in the north,
to Munich, which sent its most eminent physician and
clinical teacher, von Ziemssen, to learn the new treatment.
These eminent listeners had returned, each to his own
city, to carry on the observations and treatment they
had heard expounded so ably by Professor von Bergmann,
the present audience being much younger and less known,
but not less attentive listeners. This last lecture was
more clinical and less discursive than the first; because,
•although the demonstration of patients at the first was
•even more numerous, there was greater need then of ex¬
planation, description, and theory, as the whole subject
was perfectly novel to the audience. Since then there have
been many lectures and demonstrations by medical men
who have been employing Koch’s remedy, with all the
advantages of Professor von Bergmann’s description of his
•experiences.
At the commencement of his last lecture Professor von
Bergmann stated that the tuberculous nature of lupus was
mow placed beyond doubt He did not particularly rely
on the fact that it gives the characteristic reaction of tuber¬
cular tissue when subjected to the induence of Koch’s
liquid as a proof of this ; but quite apart from that fact he
said he formed his opinion from: I. The structure and
- organisation of the lupus tissue, with its giant cells. The
latter were not pathognomonic, but when taken in con¬
nexion with other evidence they afforded strong evidence.
2. There was the irrefutable argument from successful
inoculations of animals made with lupus tissue. Like all
inoculations with tubercular material, they must be made
by skilled hands, and when so made and in a suitable
medium—e.g., the rabbit’s eye—a specific and indubitable
result was obtained. Hueter had provetl that the tubercle
bacillus was developed in consequence of such inoculations.
3. He relied on the observations of Koch, who had found
the specific bacillus of tubercle in lupus nodules.
Lupus was one of the most interesting forms of tuber-
-cular affections in which to employ Koch’s method, because
not only was tJiere less risk of violent and serious reactions,
local or general, but the case progressed under the observer’s
eyes, and could be seen from hour to hour. But even in cases
•of lupus it was necessary to be very careful at the outset
to observe the mode in which the patient reacted, and
whether there were any acquired or congenital peculiarities
in the patient with reference to Koch’s liquid. Above all,
the patient should be thoroughly examined,in order to ascer¬
tain as far as possible the extent of the tubercular disease
in tlie body, and the extent and situation of tubercular
deposits. One should be particularly careful to examine as
to the existence of pulmonary or laryngeal tuberculosis, as
there might undoubtedly be deposits of tubercle in those
parts which escaped notice until an injection was given
with Koch’s liquid, and then suddenly its existence became
demonstrated by local reaction, which might be even of a
serious kind. If a case of lupus was presented for injection,
which bad only the local sore, and had no other deposits in
the lungs ike., he would commence with an injection of one
centigramme.^ If several deposits were found in the body,
he would not give moi'e than O'OOfigrni. It was im¬
portant also to examine the sputum, as well as the state of
he intestines.
1 Or 1 cc. of the 1 por cent, solution.
The fatal case at Innsbruck was that of a patient with
extensive and multiple deposits of tubercle in the body.
There was dulness on percussion at both apices, and other
evidence of pulmonary tuberculosis; there were deposits
of tubercle also, in the legs, arms, and in the intes¬
tines. In fact, the patient was extensively tuberculai'.
Although only 0002 grm. was injected, the tempera¬
ture reached the great height of 4U C. {lOS'S'E,) in
eighthours. This dose, 0'002grm,, was, as stated, far less
than was frequently given by himself (von Bergmann) in
cases of lupus without any ill effects. The mischief arises
from the resorption of the products of the necrotic process set i
up by the action of the injected liquid. When the intestines ^
were examined after death in this case, each of the tuber¬
cular ulcers in them was found to be red and swollen, and
to present distinct symptoms of local reaction. There were
also pneumonic spots scattered through the lung.
A woman was presented to the audience with lupus of the
nose and cheek, and also r.^lcs in the apices of the lung and
other symptoms of pulmonary tubercumsis. Owing to this
complication, only 0'008 grm. was injected instead of
O'Ol grm. The temperature rose to 30°C. (102-2°F.) during
the night, and a few hours later to 39'!° C. (102'^4;° F.); next
day it fell to37°C. (98'0°F-), rising the following day to
38" C. (100'4° F.) On the following day the ulcers were well
scabbed over, and by the end of the week the local sore
was looking very well, and the patient felt so well that
O-Ol grm. was injected, the temperature rising in conse¬
quence to 39-5° C. (103-1° F.). This patient had a very
rapid, weak, compressible pulse, vomiting, and a tendency
to collapse. But although such symptoms had been noticed
in some cases, and rightly called for careful attention, he
(the lecturer) had fortunately seen no serious results in
his practice. Where there was extensive tuberculosis small
injections only should be administered at the commence¬
ment.
Among the cases of lupus longest under treatment was a
man who had received sixteen injections, the first on
Nov. 8fch, the fourteenth having been given on Dec. 5th
and the fifteenth on Dec. Sth, the quantity then injected
being 0-01 grm. This injection produced slight local
reaction, but the now skin on the nose was becoming paler
and more like natural skin; the new tissue formed was
perfectly smooth, and looked as if free from tubercle. He
would that day receive an injection of O'OO grm., or six times
as much as the first injection. This last injection was
administered on the thorax.
A woman exhibited now had a perfectly smooth and soft
skin where a lupus ulcer had existed on the nose and
cheek. She had reacted most severely after an injection of
0-01 grm., and consequently it was thought advisable to
abstain from injections for several days. She had received
ten injections since November Gch, and could now endure
0-08 grm., which was injected in the back.
It'was necessary to be very careful with children, as they
reacted strongly. Among the comiilications which he
had observed in the reactions of children was profuse
diarvluca, which miglit last five or six days, and bo rather
troublesome. It was desirable to stop the injections while
it lasted.
An old man was presente<l to the audience with lupus of
the nose, in whom the local reaction had been intense, the
nose becoming greatly swollen and almost black, so that
there appeared to be 'danger of gangrene setting in. But
the general and local reaction had diminished, and the scabs
had fallen from the ail'ected part and left a fine healthy
granulating surface. He would continue the injection so
long as there was local reaction. At present there was no
general reaction after 0-06 grm.; and now the patient
would get 0-08 grni.
A boy was next presented, with lupus of the nose, who
had suffered from very severe reaction at first, with
somnolence, and collapse. Now no reaction occurred after
the injection of 0-04 grm.
A little girl, presented to the audience, had scrofulous
glands of the neck. These were truly tubercular, as proved
by Koch, but apparently the number of bacilli were not
very large. They lay in the giant cells, not in the cheesy
matter. In cases of this kind the injections produced the
same general reaction, but only a slight local reaction. In
lupus the fever was pretcy high seven hours after the injec¬
tion, while in cases of scrofulous glands it rose much more
slowly, and might not appear for from twenty-four to forty-
eight hours. He had never seen severe local reaction in
the case of scrofulous glands, but only a slight tenderness I
The Lancet,]
PROFESSOR KOCH’S TREATMENT OF TUBERCULOSIS.
CJan. 3,1891. 51
land Bwelling. In the case of one man there had been none
whatever. In one case the glands increased in size soon
after the injection, and then became smaller again. So far
he had not noticed any permanent diminution In the size of
glands, but they had become much freer and softer. The
girl shown to the meeting with scrofulous glands had re¬
ceived ten injections, and was now injected with 0 05 grm.
A man presented to the meeting with enlarged glands of
the left side of the neck received a first injection of
'0'004 grm., and had in consequence a temperature of 39 O* C.
<1027“ F.). After the ninth injection of 0‘004 grm. the
temperature was only 37'9“C. (100‘2° F.). As a rule there
was no veiy high temperature after injection of cases with
tubercular joints. But tliere Avore exceptions to the rule,
And there were cases of tumor albus and hydrops tuber-
culoaus of joints in both of which the general reaction
showed a very high temperature.
A little boy was shown under treatment for coxitis since
.Nov. 29bh, since when he had received only four injections.
After the first injection of 0'005 grm. he had rigors and a tem¬
perature of 397° C. (102'2“ F.). After the next injection of
the same amount the temperature rose only to 38'1°C.
<100-5° F.) He could now raise both legs off the table and
bend them at right aogles. A number of other cases of
various forms of tuberculosis were shown, but which pre¬
sented no special features, except one, which Avas the only
one in which any pulmonary reaction of a serious kind had
■occurred. Dulneas and some pneumonia were noticeable iu
■the right lung in this case. He thought time alone could
■decide whether the apparent cures would prove to be per¬
manent. Possibly it might be January, 1892, before they
■could decide the point. But if no recurrence returned
before then, it was a great boon to the patient.
Report of Cases under Treatment in the
Glasgow Koval Infirmary.
On Thursday, Deo 4th, Drs. Wood Smith, Lindsay
Steven, and Charles Workman received from the Empress
Frederick of Germany a portion of Koch’s lluiiT for
the treatment of patients in the wards of the Glasgow
Royal Infirmary. On Sunday, Dec. 7th, the treat¬
ment was commenced on three patients. The gentlemen
who ’had received the fluid proposed to hand it over for
■tliviaion among the members or the staff, but at a meet¬
ing of that body held on Monday, Dec. 8tli, it
was decided, in the meantime, to ask the three
gentlemen who had obtained the remedy to use it
in cases which might be selected by the physiejans
And surgeons of the house, who formed themselves into a
medical and surgical committee respectively for this pur¬
pose, Dr. Lindsay Steven to act as secretaiy to the former
■•and Charles Workman to the latter committee. Twenty-
•cight cases in all are now under treatment—viz., 17 of
.phthisis pulmonalis, 3 of lupus, and 8 of tubercular disease
•of the bones and joints. The following members of the
infirmary staff have selected patients for treatment—
viz,, Drs. Wood Smith, Alex. Robertson, Wallace Ander¬
son, i;D. C. McVail, James iDunlop, W. Mucewen, Henry
'Clark, D. N. Knox, and W. J. Fleming. The present re¬
orb deals in some detail with four of the cases that have
een longest under treatment, and which illustrate very
well the reactions, both local and general, that have been
•observed in the infirmary. The progress of these cases, and
•reports of the others under treatment, will be published in
due course. With regard to the method of observation, it is
'bo be noted that each physician or surgeon retains the entire
chargeof his case, the subcommittee undertaking the irjec-
•tions and the recording of the results in a medical and surgical
■minute-book respectively. Tlie temperatures are taken in
the rectum every three hours, the pulse and respiration
being recorded at the same time. Notes of the progress of
the cases are made at short intervals. The examination of
the sputa has been kindly undertaken by Dr. James Wilson
Cameron, who has been Avorking in the bacteriological
laboratory of the infirmary during the past year.
Cask 1.—The first case was one of suspected phthisis.
No bacilli could be found in the sputa, and no reaction
•occurred after the injections. He received injections of quan¬
tities varying from O'OOl to O'Ol grm., but as the absence of
reactions seemed to indicate that the ease was nob tuber-
-cular the treatment was discontinued. His temperatures
have since remained normal or subnormal, and his cough
And expectoration have almost entirely disappeared.
Case 2.—W. L-, aged twenty, single, tailor, admitted
to ward 1 under Dr. Wood Smith with marked physical
signsof phthisis. He was injected with O'OOl grm. of Koch’s
fluid at 11.30 a.m , which produced a decided reaction, the
temperature rising all the evening till 3 A M., when it
reached the maximum of 102°, after which it slowly de¬
clined to 97° on the morning of the 9th. Two days after-
Avards 0'002 grm. of Koch’s fluid was injected at 11 A.M.;
marked reaction as before, the temperature beginning to
rise at 8 f.m , and reaching 102° at midnight, when the
pulse numbered 88, and tlie respiration 24. The treatment
was continued up to Dec. 22nd, when 0'008 grm. was ad¬
ministered. On the whole the general health of this patient
is considerably improved since the treatment was commenced.
Case 3.—J. McD -, aged thirty-four, potter, married.
Admitted to the Avard, under Dr. Wood Smith, Nov. 21st,
1890. Cough and expectoration of eight months’ duration,
accompanied at the outset by deb llty, were prominent signs.
Night sweats had never been severe. There has been no
great los« of weight, and the cough has been accompanied
by a small amount of Avlnte frothy jnucus, but on admission
the expectoration was noted to have been muco-purulent.
There Avas no memoptysis, and no bacilli were found in the
sputa. The reactions produced by the injections on this
patient were extremely slight. The injection on Dec. 11th
of a centigramme of the fluid only raised the rectal tem¬
perature to 102'6°, the pulse to 93, and the respiration
to 34. The subsequent injection Avas given on Dec. 16tli,
liut was reduced to ,0'0U7. The tempBrature rose to 103“,
and remained up for several hours. Severe constitutional
disturbance accompanied the reactions. On the 19th
O'OOS M'as injected, and on Dec. 22ad O'Ol, and the general
condition of the patient is reported to be fair.
Ca.SE 4.—I. S- was admitted complaining of lupus
of the nose of three years and a half’s duration. On two
previous occasions the patient had been an inmate of the
ward. The present condition shows that the ulcerative
processes are chiefly marked on the septum nasi, and on
the mucous membrane of the upper lip and skin of nose, and
the surrounding parts were erythematous, not ulcerated,
bub covered here and there Avith crusts. On Dec. 6bh, Dr.
John MacIntyre made a careful note of the condition of
the mouth and throat. The soft palate and uvula
had been destroyed by the disease in the part; tivo
large swollen masses were observed, one on each
side of the dorsum of the tongue, and extending to the
hyoid fossa, were observed. The epiglottis was much
thickened and showed the cicatrices of old ulceration. The
nostrils are so altered by the destructive processes that a
thorough examination of the nasal fossie could not be made.
The naso-pharynx is also involved. The disease has extended
forwards from the soft palate, and there are also traces of
it on the posterior wall of the pharynx. The diseased
patches on the left shoulder and right hip are cicatrised,
the only abnormality observed being a slight tendency to
tubularity over the region of the right shoulder behind.
For two days before commencing the treatment the tem¬
perature varied between 98“ and 99'G“. The injection of
0’002 grm. produced a temperature of 104°, a pulse rate of
120, and a respiration rate of 36. The usual manifestations
of lupus under this treatment appeared, and on Dec. 22nd
the patient received 0'003 grm., avIucIi produced a tempera¬
ture of 101“ and a slight local reaction.
North London Consumption Hospital.
Dr. J. E. Squire has some cases of phthisis under treat¬
ment at the North London Consumption Hospital, Hamp¬
stead. The first injections Avere given on Dec. 4bh.
Birmingham Skin and Lock Ho.spital.
W.s learn that the lymph is being used by the staff of the
Birmingham Skin arid Lock Hospital on eight cases of
facial lupus, and that all the cases are doing well, and show
signs of improvement.
UOYAL HOSPITAV- FOR CONSUMPTION, VENTNOU.
Dr. Sinclair Coghill, Avho was recently received in special
audience by the Empress Frederick, has returned from
Berlin, where he has been studying Koch's method, with
an ample supply of the “Iluid.” The treatment of a
number of selected cases of tubercular phthisis in all stages
was commenced on Saturday, the 27thult.,at 9.30 A.M.,
at the Royal National Hospital for Consumption, Ventnor.
Members of the profession are invited to be present at the
inoculations, Avliich will take place daily at the same hour,
and during the reactions.
c Google
52 The Lancet,]
DUNEDIN HOSPITAL.
[Jan. 3,1891.
DUNEDIN HOSPITAL.
An important inquiry has jast heen completed, and a
valuable report published, on the sanitary condition of the
Dunedin Hospital, New Zealand. In July Dr. Batchelor,
one of the medical officers of the hospital, addressed a letter
to the trustees on the subject of two cases upon which be
had operated, one of whicli died and the other made a very
slow recovery, results which he believed to be “ entirely due
to unhealthy hospital inlluences.” The trustees, conceiving
that this statement reflected upon their administration of the
hospital, though Dr. Batchelor disavowed any such inten¬
tion, applied to his Excellency the Governor to appoint a com¬
mission to inquire into the subject. In compliance with this
request Sir James Hector and Mr. E. H. Carew, E.M., were
nominated, and appear to have made a very thorough and
impartial inquiry, having held , nineteen meetings and
examined twenty-five witnesses, besides receiving docu¬
mentary evidence and making a personal inspection of the
various wards and offices. Dr. Batchelor and the trustees
were each represented by counsel. The building had
heen erected in 1864 as part of a large group of
Government and Parliamentary offices, and was used
in 1865 for the New Zealand Exhibition; in 1866 it was
converted into a hospital. The Commissioners after a
careful inquiry reported that they “ were satisfied that the
complaints made have been largely supported by the testi¬
mony, and that some of the alleged defects are of a serious
nature, and require immediate remedy.” They have gone
at some length into all the details, and have in a very clear
and able report stated the grounds on which they based
their conclusions. The.se may be briefly summarised. The
site is objectionable, being situated on low ground in the
most unhealthy part of the city, and the foreshore of the
bay is in a very offensive condition; the original plan of
the building was faulty; the system of ventilation,
lighting, and heating imperfect; the floors are much
worn and full of open cracks, and were described
by a witness as being “as good contrivances as could
be got for harbouring germs”; the walls in many
of the wards are rough and absorbent, and are periodi¬
cally coated with whitewash containing size; the wards are
overcrowded, and on this point the Commissioners make
the following remark: “ It was attempted to be shown that
in such matters there is a theoretical and a practical
standard, but in our opinion this is rot a fair statement of
the circumstances. It is rather that the best results cannot
be attained in the economical treatment and for the com¬
fort of the patients in a hospital without perfect provision
being made, hut under some circumstances the administra¬
tion must he prepared to expect less perfect results, and
trust to extra diligence and precautions in the nursing and
skilled treatment as a means of preventing epidemics and
similar accidents. It is quite fallacious to suppose that
there is one successful theory of safety and another
successful practice of safety.” There is no subsoil
drainage of the hospital; the closets are only separated
from the ward by double doors, and their ventilation
is defective. There are no proper urinals. The baths
and lavatories are actually in the wards only sepa¬
rated by a low screen; there are no special wards for
infectious diseases, and no special case rooms ; the kitchen
is in the basement, is very unsuitable, and the arrangement
for serving the food to the wards is described as “very
crude and unsatisfactory”; the accommodation for the
nurses is very defective, and there are no convalescent wards
for patients. With such a list of defects the Commis¬
sioners were fully justified in condemning the hospital as
insanitary, and it must be very satisfactory to Dr.
Batchelor that the Commissioners state that the proofs
from outside evidence “amply support the allegations of
his own evidence.” The Commissioners recommend the
removal of the hospital toabetter site; butif it be decided to
improve the present building rather than construct a new
one, they have made suggestions which would probably
have the effect of rendering it more suitable for the pur¬
poses of a hospital, more sanitary, and therefore better
adapted for the treatment of sick and wounded. We
think Dr. Batchelor is entitled to much credit for having
brought the subject under the consideration of the au¬
thorities, and the hearty thanks of the public of Dunedin and
of the Government of New Zealand are due to the Commis¬
sioners for the able, exhaustive, and impartial manner in
which they carried out the important duty confided to them.
CHRISTMAS AT THE LONDON HOSPITALS.
UNIVER.S1TY College Hostital.
On New Year’s Eve a Christmas entertainment was
given to the patients at this hospital. The wards were
very prettily decorated, and the presents to the patients
were numerous and well considered. A glee party visited
the various wards, singing in each a number of well-selected
pieces. A concert was given in the consulting room to the
convalescent patients. There was a large number of visitors,
the centre of interest being the children’s wards.
London Hospital.
Christmas week has passed very joyously for the patients-
of the London Hospital. The resident staff have worked
hard with the sisters and nurses to make the poor patients
forget their sufferings as far as possible. On Christmas
Day the Coiinuittee dinner of roast beef and plum pudding
was provided for all to whom the medical men could allow
such a privilege. The latter part of the afternoon was
devoted to small entertainments in the separate' wards,
when magic lanterns, theatricals, and ventriloquism afforded
great pleasure. The Christmas dinner of the nurses was
provided on the 26lh, and all appeared happy and bright.
The wards throughout the building were most tastefully
decorated with evergreens. The Chairman (Mr. E. Murray
Ind) made a few remarks to the assembled guests. Amongst
the gifts received were a large assortment of toys front
Truth and from her Itoyal Highness Princess Mary of Teck.
Westminster Hospital.
At Westminster Hospital Christmas Day was kept as a-
day of festivity. The resident medical officers, the matron,
and the nurses devoted themselves to the entertainment of
the patients, who appeared to enjoy themselves very
thoroughly. With the sanction of the medical staff the
ordinary diet table was su.spended, and every patient was
provided with a dinner of turkey or chicken, with plum
pudding for those able to partake of it. In each ward a
Christmas tree was provided, from which the men received
a packet of tobacco, the women and children sweets and
oranges and toys ; for every patient there were warm, use¬
ful articles of clothing. The number of patients in the
hospital was 175, and, owing to the kindness of many friends,,
ample provision was made for their comfort and happiness ;
the presents received this Christmas having been more than
usually numerous, and all of them most useful and appro¬
priate.
St. Thomas’s Hospital.
On Christmas Day the patients had the usual dinner of
roast beef and plum pudding, with oranges &c. for dessert.
The treasurer and his family, with the other resident officers,
visited all the wards, distributing cards aud saying a few
seasonable words to the inmates. In the evening the
Nightingale nurses sang carols in the various wards, to the
delight of the patients and officers. On Wednesday evening
there was a “tea,” with music, and a large Christmas tree
covered with presents for the children in Victoria Ward.
Next week there will be an entertainment in one of the
theatres for the amusement of such of the patients as are
able to be moved from the wards, and later on the nurses?
concert in the governors’ hall.
St. George's Hospital,
At the Convalescent Institution at Wimbledon, in con¬
nexion with this hospital, a large Christmas tree was pro¬
vided through the kindness and liberality of residents-
in the neighbourhood, a sufficiency of presents being
contributed for all the patients (about ninety), and all the
staff' of nurses and servants. A concert has also-
been provided to take place on Friday, when the gifts on
the tree will be distributed. On Christmas Day the
patients at the Convalescent Hospital were all supplied
with roast beef and plum pudding &e., and a concert took
place in the evening.
The German Hospital.
The annual festival at the German Hospital, Dalston,
took place on Boxing Night, when a number of friends and
subscribers visited the hospital for the purpose of witnoasing
the distribution of Christmas presents to the inmates, and
a company of about 150 ladies and gentlemen attended the
party. At the end of each ward was a monster Christ¬
mas tree literally covered with lighted candles and
sparkling balls and stars of every imaginable colour.
'G- le
The Lancet,]
LONDON POST-GRADUATE COURSE.
[Jan. 3,1891. 53
The fixing of the decorations had to be left chiefly to
the officers, most of the patients, numbering about 120,
being too ill to leave their beds. Special care was
bestowed upon the children’s ward, in which there are a
number of dUtrassing cases. There were, however, some
half-a-dozen of the little patienfs sufficiently convalescent
to be able to sit at a table and enjoy the multitude of good
things that Santa Claus had sent them, whilst three little
girls interested the visitors by singing a carol in German.
With all the brightness that sympathising friends had been
able to import to the wards, however, the sight was sad,
and brought tears to the eyes of not a few of the visitors.
Each ward was separately visited, and a carol having been
sung in German by the nurses and the medical officers,
presents of clothing, together with cake and oranges, were
distributed to the adult patients.
City of London Hospital for Diseases of the Chest.
Christmas Day was spent at this hospital in the usual
manner. Appropriate Christmas cards, supplied by friends
of the institution, were distributed amongst the patients.
The wards were tastefully decorated. A large number of
the patients were able to sit up for dinner, and were regaled
with the customary roast beef and plum pudding, while
those in bed were furnished with a dinner of game or
poultry. In the afternoon the patients’ friends were ad¬
mitted, and in the evening music was provided for the
amusement of all the inmates. A small fund had been
raised for the nurses and servants. The presents—as far as
possible useful ones—were distributed in the course of the
aay.
Paddington Green Children’s Hospital.
On Friday there was a magic-lantern display, kindly
[given by Mr. R. Melvill Beaohcroft, a Punch-and-Judy
show, and a Christmas tree.
King’s College Hospital.
1. A Christmas dinner — roast beef and plum pudding
and the usual Christmas fare—was given to the patients
2. On Boxing Day a Christmas tea was given, the wards
being illuminated and decorated. The patients thoroughly
enjoyed the Christmas cheer. Owing to the generosity of
many friends, Christmas presents were given, with a good
-supply of toys for the children. On the 15bh ulb. the
resident medical officers gave their annual Christmas
tree entertainment to the patients and friends in the
central hall.
LONDON POST-GRADUATE COURSE.
The annual general meeting was held on Dec. 30bb, at
16, Cavendish-square, Mr. Jonathan Hutchinson, F.R.S.,
LL D,, President, in the chair. The report of the
Committee of Delegates for the year 1890 was read.
The committee reported that during the year three
courses of lectures and demonstrations, each of eight
weeks’ duration, had been given. The first course,
■from Jan. 13bh to March 8th, had consisted of seventy-
two lectures given at the Hospital for Consumption,
Brompton, the Hospital for Sick Children, the Royal
London Ophthalmic Hospital, the Hospital for Diseases of
the Skin, and the Hospital for the Paralysed and Epileptic,
by members of the staff of each hospital. The course was
attended by thirfy-tbree practitioners, of whom nineteen
entered for the whole course and fourteen for special hos¬
pitals. The second course, from May 5th to Juno 27bh,
-consisted of eighty-eight lectures given at the five original
hospitals and two other institutions, the Bethlem lioyal
Hospital for Lunatics and the Paddington Infirmary. At
the Bethlem Hospital a course of lectures and clinical de-
tuonstrations on Mental Diseases weio given by the resident
physician, Dr. Percy Smith. At the Paddington Infirmary
a course of lectures on Clinical Medicine and Surgery was
given by Dr. Broadbeiit and Mr. J. Hutchinson, and
supplemented by pathological demonstrations by Dr. Savill,
the medical superintendent. This course was attended by
thirty-three practitioners, of whom eleven entered for the
’full course and twenty-two for special hospitals. The third
course, from Oct. 13bh to Dec. 6tli, consisted of seventy-two
lectures given at the five original hospitals and at the
Paddington Infirmary. The lecturers on Clinical Medicine
and Surgery at the Paddington Infirmary were Dr. Briatowe,
Dr. Uheadle, Mr. Jonathan Hutchinson, Mr, R. Harrison,
and Mr. Frederick Treves. The course was attended by
fifty-four practitioners, of whom twelve entered for the
full course and forty-two for the special hospitals. The
total number of practitioners who entered in the year
either for the whole or special courses thus amounted
to 121. Of these there were 106 holding British quali¬
fications, including five medical officers of the army
and one of the navy, two holding Indian qualifications,
seven colonial and seven American practitioners. Ladies
being qualified medical practitioners were admitted to the
classes at those hospitals of which the medical staff con¬
sented to their attendance, and eleven ladies availed them¬
selves of these opportunities. The total number of lectures
and demonstrations was 221, given by forty-five lecturers,
nearly all of those belonging to the staffs of the hospitals
mentioned. Tlie committee regarded the number as
very satisfactory, considering the novelty of the scheme
and the difficulty of making its operation widely known.
The committee believed that the instruction and clinical
opportunities afforded by the course had been highly
appreciated, and many expressions of satisfaction with
its working and good wishes for its success had reached
them. The recommendation of those who had attended
and profited by the teaching would, they thought, do
much to aid the progress of the scheme. The enlargement
of the scheme of instruction by the introduction other
subjects than those included in the original programme
was another point bo which the committee desired to draw
the attention of the meeting. It was announced that the
lectures at the Bethlem Hospital would be resumed by
Dr. Percy Smith and Dr. Savage. The committee had
also made arrangements for a course of lectures and
demonstrations on Diseases of the Throat and Use of the
Laryngoscope at the London Throat Hospital during the first
term of 1891. It was also announced that Mr. Hutchinson’s
lectures on Diseases of the Skin would be given by permission
of the Laboratories Committee in the Lecture Theatre of
the Examination Hall of the Royal College of Physicians
and Royal College of Surgeons. Other subjects had been
suggested as desirable additions to the course; and the
committee were unable at present to provide instruction in
these subjects; they regarded the widening of the curriculum
as an object to be kept immediately in view. In conclusion,
the committee expressed their high opinion of the valuable
services of their secretary. Dr. Fletcher Little. The trea¬
surer’s report, stating the expenses, was then read. It was
regarded by the committee as satisfactory and encouraging.
On the motion of Mr. Bnid^nell Carter the report of the
committee and the treasurer’s report were approved and
adopted. After some further business, and votes of thanks
to the president and secretary, the meeting separated.
anl( fata.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF MEDICAL OFFICERS OP HEALTH.
West Sussex Com.hincd Districts .—This extensive district
includes four urban and seven rural sanitary districts, which
taken collectively had during 1889 a general mortality of
I2'6p0r 1000 living, the rates varying from 9 3 in West
Worthing to 17'0 in Arundel. But taking the whole
district the rate was lower than in any previous year. The
vital statistics are discussed at considerable length by Dr.
Charles Kelly, who shows, amongst other things, that the
zymotic rate for the whole area last year reached the lowest
known point—namely, 0 8 per 1000. Taking the mean
zymotic rates far 1880-89, the highest have been : Sbeyning,
1 '9 ; Thakeham and Arundel, 1 ti; and Worthing, 1 5. The
various meteorological conditions that have prevailed are
set out in tabular form, as are also records or soil tempe¬
rature ; and a detailed account of the various sanitary
circumstances, the prevalences of disease, and the
sanitary measures adopted is set out as regards each
sanitary district separately. Amongst the occurrences
of disease deserving attention was an outbreak of diphtheria
in the autumn of 1889, which seemed to begin at Pulborough,
whilst its chief incidence was in the small parish of West
Chitlington. The people of this locality live chielly in an
area in which there is much low-lying brook-land, but it was
Di(j zed by tOO^IC
54 The Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Jan. 'i. 1891.
rattier those who dwelt on the higher ground who were
affected. No very clear explanation of the circumstances
under which the disease spread seemed to be forthcoming.
Much the same may be said of a similar occurrence at Wick,
in the district of East Preston.
Wolverhampton Urban District. —Dr. Malet draws atten¬
tion in his report for 1889 to the influence of isolation in the
borough hospital as having materially reduced the scarlet
fever mortality in Wolverhampton, and it is certainly satis¬
factory to find it recorded that in cases where such isolation
was carried out no further attacks in the families concerned
took place after the removal to hospital. Unfortunately,
the hospital which has such a record is stated to be used for
scarlet fever only, a circumstance M-hich seems to imply
that theinstitution does not properly admit of the isolation
at one and the same time of cases of more than one disease.
Happily sucli diseases as enteric fever and diphtheria were
not very prevalent during the year. The general death-
rate was low for Wolverhampton—namely, 16'9 per 1000,
and the zymotic rate was also low, but the deaths amongst
children were above the average. The sanitary circum¬
stances of the town are referred to in a general way, which
seems to indicate negligence and default, but that part of
the report hardly conveys information sufficiently explicit
to be understood by outsiders.
Ncwcastlc-upon-Tyne Urban District .—The mortality re¬
turns for 1889 do not bear favourable comparison with those
of 1888, and one-third of the increase which has taken place
is attributed to zymotic ailments; the general death-rate
being 25'0 and the zymotic rate 3'Opsr lOOO. Amongst
the cases of infectious i^iseases heard of during the year there
were of scarlet fever 601, enteric fever 136, diphtheria 96,
and typhus 7 ; and both these cases and the vital statistics
based on them and other causes of death are dis¬
cussed at some length hy Mr. Henry Armstrong.
Amongst the preventive measures adopted, removal to
the excellent new isolation hospital played a prominent
part; and in the case of some diseasefa, such as typhus,
nearly all attacked were so removed. But even with tlie
excellent organisation existing in this northern city the
percentage of removals to hospital of all the cases of in¬
fectious fevers heard of did nob reach more than 15'6. The
general work of the Health Department is set out at some
length, and it is evident that considerable importance is
attached to the question of the association of diseases in
the lower animals with the health of man, the inspection
aod supervision of dairies, cowsheds, inilkshops, and
slaughter-houses receiving much attention. During the
year house accommodation was newly provided for 963
families, in 217 self-contained houses and 373 houses of two
flats each; and perusal of the defects, which were noted
when the plans were first submitted bo the corporation,
shows that increasing attention is being given to this im¬
portant subject of the wholesome housing of the working
classes.
VITAL STATISTICS.
HEALTH OF ENGLLSH TOWNS.
In twenty-eight of the largest English towns 3898 births
and 5186 deaths were registered during the week ending
Dec. 27th. The annual rate of mortality in these towns,
which had been 21'3 and 2r5 per 1000 in the preceding
two weeks, further rose to 27'8 last week. The rate was
26 3 in London and 29'lin the twenty-seven provincial towns.
During the past thirteen weeks of the current quarter
the death-rate in the twenty-eight towns averaged 21'6
per 1000, and exceeded by 0'6 the mean rate in the
corresponding periods of the ten years 1880-89. The lowest
rates in these towns last week were 15-2 in Brighton, 16-6
in Hull, 207 in Derby, and 21’8 in Plymouth; the
highest rates were 34'9 in Liverpool, 41'3 in Halifax,
43'6 in Manchester, and 44-0 in Preston. The deaths
referred to the principal. zymotic diseases, which had
increased from 430 to 611 in the preceding four weeks,
declined again last week bo 472; they included 199 from
measles, 90 from whooping-cough, 55 ~frora diphtheria, 51
from scarlet fever, 39 from “ fever” (x>rincipaUy enteric),
38 from diarrhcea, and not one from sinall-pox. No deatlis
from these diseases were recorded in Plymouth, Wolver¬
hampton, Derby, and Hull; wliile they caused the highest
death-rates in Sheffield, Bolton, Bristol, and Preston. The
greatest mortality from measles occurted in Birkenhead,
Manchester, Salford, Bolton, Bristol, and Preston; from
scarlet fever in Preston, Sunderland, and Halifax; and(
from whooping-cough in Norwich, Cardiff, and Sunder¬
land. The mortality from “fever” showed no marked
excess in any of the twenty-eight towns. The 56'
deaths from diphtheria included 31 in London, 5 in
Manchester, 5 m Portsmouth, 2 in Norwich, and 2 in.
Bitmingham. No death from small-pox was registered
in any of the twpnty-eighb towns ; and no small-pox
patients were under treatment in the Metropolitan Asylum
Hospitals or in the Highgate Small-pox Hospital on
Saturday last. The number of scarlet fever patients in.
the Metropolitan Asylum Hospitals and in the London
Fever Hospital at the end of last week was 1685, against-
numbera declining from 2122 to 1752 on the preceding
seven Saturdays; the patients admitted during the week
were 78, against 125 and 108 in the previous two weeks.
The deaths referred to diseases of the respiratory organa
in London, which had increased in the preceding three
weeks from 444 to 753, farther rose last week to 806, and
exceeded the corrected average by 296. The causes of 146,
or 2-8 per cent., of the deaths in the twenty-eight town®
were not certified either by a registered medical practi¬
tioner or by a coroner. All the causes of death were duly
certified in Leicester and Derby. The largest proportion®
of uncertified deaths were recorded in Salford, Sheffield^
Huddersfield, and Liverpool.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,,
which had been 20‘1 and 20'9 per 1000 in the preceding
two weeks, further rose to 24'6 during the week ending
Deo. 27bb, bub was 3-2 per 1000 below the rate that prevailed
daring the same period in the twenty-eight large Englisii>
towns. The rates in tlie eight Scotch towns ranged from
10‘6 in Leith and 19 4 in Aberdeen to 287 in Paisley and
29 •! in Glasgow. The 637 deaths in the eight Scotch
towns showed an increase of 71 upon the number in the-
preceding week, and included 22 which were referred to
whooping-cough, 19 to measles, 9 to diphtheria, 8 to
diarrhcea, 7 to “fever,” 5 to scarlet fever, and not one to
small-pox. In all, 70 deaths resulted from these principal'
zymotic diseases, against 46 and 54 in the preceuing two-
weeks. These 70 deaths were equal to an annual rate
of 27 per 1000, which was 0'4 abov'e the -;can rate last
week from the same diseases in the twenty-eight English
towns. The fatal cases of whooping-cough, which had oeeis
16 and 12 in the preceding two weeks, rose again last
week to 22, of which 13 occurred in Glasgow and 5 in Edin¬
burgh. The deaths from measles, which had been 12 and
11 in the preceding two weeks, rose again to 19 last week,
and included 8 in Glasgow and 8 in Greenock. The
fatal cases of diphtheria showed a slight further increase
upon those recorded in recent weeks, and included 4 hr
Glasgow. The deaths referred bo “fever,” which had been 2;
and 6 in the preceding two weeks, further rose last week
to 7, of which 4 occurred in Edinburgh and 2 in Glasgow.
The 5 fatal cases of scarlet fever included 3 in Glasgow
and 2 in Aberdeen. The deaths refen-ed to diseases of the
respiratory organs in the eight towns, which liad been
137 and 139 in the preceding two weeks, further rose-
last week to 182, but were 7 below the number in the
corresponding week of last year. The causes of 69, or nearly
11 per cent., of the deaths in the eight towns last week
were nob certified. _
HEALTH OF DUBLIN.
The death-rate in Dublin, which had been 25'6 and 28'2'
per lOOO in the preceding two weeks, further rose to 31’S-
during the week ending Dec. 27th, and exceeded the rate
recorded in any week since February last. During the past,
thirteen weeks of the current quarter the death-rate in the
city averaged 24-3 per 1000, the rate for the same period
being 20'0 in Lond^on and 18’6 in Edinburgh. The 212f
deaths in Dublin showed an increase of 21 upon the
number in the preceding week, and included 6 which
were referred to different forma of “fever,” 4 to whooping-
cough, one to diarrhoea, and nob one either to small-pox,
measles, scarlet fever, or diphtheria. Thus the deaths from the'
principal zymotic diseases, which bad declined in the preced¬
ing four weeks from 17 to 9, were 10 last week; they wore
equal to an annual rate of 1 '6 per 1000, the rate from the same
diseases being 2'3 in London and in Edinburgh. The deaths-
referred to “ fever,” which had been 5 and 4 in the previous
two weeks, rose again last week to 6. The fatal cases of
Loogle
TiiE Lancet, ]
THE MIDWIVES’ REGISTRATION BILL.
[Jan. 3,1891. 55
whooping-cough, which had been 4 and 1 in the preceding
two weeicB, rose again to 4 last week. The 212 deaths in
the city included 3.3 of infants under one year of age, and
59 of persons aged upwards of sixty years ; the deaths both
of infants and of elderly persons exceeded the number re¬
corded in the preceding week. Four inquest cases and
■3 deaths from violence were registered; and 70, or nearly
■A third, of the deaths occurred in public institutions.
The causes of 21, or nearly 10 per cent., of the deaths
in the city were not certified.
THE SERVICES.
Aemy Medical Staff. — Brigade Surgeon Edward
<lorrigan Markey, C.B,, to be Deputy Surgeon-General,
ranking as Colonel, vice J. Landale, M.D., retired (dated
Dec. 10th, 1890); Surgeon-Major John Maturin, F.R.C.S.I.,
Tanking as Lieutenant-Colonel, to be Brigade Surgeon, vice
E. C. Markey, C.B. (dated Doc. 10th, 1890); Surgeon-Major
Hamilton George Gardner, M.B., retires from the Service,
receiving a gratuity (dated Dec. 24th, 1890).
Naval Medical Service,— The following appointments
have been made at the Admiralty:—Deputy Inspector-
'General Alexander Turnbull to Hong-Kong Hospital (dated
Dec. 20bh 1890); Surgeons John Lowney and Henry F.
Illiewicz to the JDuJce of Wdlington, additional for disposal
<dated Dec. 29th, 1890).
Cffrrrspitkita.
“ Audi altorwn partom."
THE MIDWIVES’ REGISTRATION BILL.
To the Editors of The Lancet.
Sirs,—A s this Billisnowbefore Parliament and maypossi-
"bly become law in some shape or other, and as the subject it
■deals with is important, I venture to trespass on your space,
■the more so as, having had great expei-ience in the training
of midwives, I can speak with some confidence on the
■subject.
The Bill, in my opinion, is not alone objectionable in
many of its details, but is radic.ally wrong as being founded
on a false principle. Its title indicates this, and the framers
•evidently think that “ registration ” is all that is needed
to improve the present class of midwives, whereas the
“ education ” of these women should be first thouglib of,
and registration, if it comes at all, should not come into
operation immediately, or indeed till after the lapse of at
least some years. Wliat would have been thought if Parlia¬
ment had passed the Medical Registration Act before
'medical schools or licensing bodies had been established
and in full working order, so that all who desired to prac¬
tise had an opportunity of obtaining the necessary educa¬
tion and qualifications to lit them for so doing ? Yet this is
what the advocates of the Bill under consideration want
now to do. '
No one can more sincerely desire that the education of
midwives should be improved than I do, but I protest
-against their being registered at all until it is shown that
means exist for educating them, that their education be
conducted under the supervision of properly qualified
medical men, and that when this has been eonjpleted they
be examined by persons in whom both the public and the
S rofession have confidence. The Bill under consideration
008 not in reality provide for any one of these essentials. It
is, as its title st.ates, simplya “ Registration Bill,” with this
addition, that the General Council, or, failing it, the Privy
Council, shall make rules for fhe admission to examination
and course of study to be pursued previously &c. ; but not
one word as to when, for how long, how, or by whom these
women are to be educated, while the proposed examination
is certain to bo most unsatisfactory.
If the Bill become law it is evident that a large number
of women will at once seek to bo educated as midwives. To
whom are they to apply for this purpose? What qualified
staff of teachers exists ? If facilities for their education do
not exist, it is manifest that cither—(a) it will bo impos¬
sible for them to pass the examination, assuming it to be of
a standard sufficient to prove that they possess the necessary
knowledge and skill” which the Act is assumed to requite;
(6) or that the examination will become a mere form, if not a
farce; or (c) that the number of women passing it will be
so few that the number of midwives who become registered
will be altogether inadequate to supply the demand. My
own opinion is that the second of these alternatives will
prove to be the actual result, and that the Act will have
the effect of actually inflicting an injury on the public, for
the women who at present act as midwives are known to
be uneducated, and possess no title to pose as being
educated, whereas those who become registered will produce
their certificates of registration, and will pose as qualified
practitioners in inidwitery; while all the time they will be in
no way superior to their predecessors save in this: that they
may have picked up a few medical terms, by the use of
which they may farther impose on the illiterate poor
amongst whom they will chiefly practise.
Bat let it be assumed that the difficulties as to education
and examination are got over, and that a sufficient number
of educated or partly educated women are annually put on
the register, it will be admitted out of the thousands of mid¬
wives on it a good many will be guilty, or atleastbeaccusedof
being guilty,of “drunkenness,” “incompetence,” “infamous
or disgraceful conduct,” or of some of the causes for which
their names are to be erased from the register. The Privy
Council are “ to make regulations ” “ for providing ” for the
erasing of the names of those convicted of being guilty.
But by whom are the charges to be investigated, where are
they to be heard, and by whom is the cost to be defrayed?
A magistrate or county court judge Avould manifestly be
unfitted to investigate the purely professional matters
which would crop up in all and be the chief ground for the
charge in the majority of the cases. Of necessity there
should be some form of medical court or courts: not the
General Medical Council; it would not undertake the office.
The court should be composed of, or at least in the chief
degree consist of, medical men of experience and repute,
who must be adequately paid for their services. It must be
easy of access, for it would be unjust to compel a midwife
to lose time and incur expense in travelling long distances.
The membei-.s of this court Avould have a most irksome and
difficult task to perform, and the expense attending it
would be proportionally great; but unless they discharge
their duties efficiently a number of most unworthy
and dangerous midwives would be allowed to practise,
not alone with the authority given them by holding
the certificate of registration, l)ut also with almost
absolute impunity, for the Bill contains this extraordi¬
nary provision, that “no private person, except with
the consent of the Attorney - General or of a County
Council,” may prosecute a registered midwife. Imagine the
case of some poor labourer whose wife has died from the
incompetciicy or in consequence of drunkenness of a mid¬
wife. How could heapply to the Attorney-General or have
liis voice heard in the County Council ? No such protection
is extended to registered medical men. Why should it be
to midwives ?
Next, how will the register be kept accurate? The
Registrar of the General Medical Council will testify to the
difficulty in this respect in the case of medical practitioners,
all educated men and comparatively feAV in number. What
will be the case of these nearly illiterirto women, who Avill
be likely to change their residences frequently, and how
will personation ho prevented ?
But perhaps the greatest objection to the proposed
system of registration of midwives is this, “that every
woman who at the pa.ssing of the Act is homX fide acting as
a midwife ” shall be registered, provided she claims to be so
Avithiu eighteen months. She may be a drunkard, she may
bo grossly ignorant, may have carried infection from house
to hou.se, regardless of the deaths which have followed in her
Avake, yet she ia at once to be placed on the register, and
her certificate of registration will be by the public accepted
ns a qualiiication to practise, and she will, moreoA^er, prac¬
tise Avibh the impunity Avliich the provisions of the Bill will
confer. It will bo said that bo exclude the.se Avomen Avould
he unfair, as amongst them will be some fitted to act as
mklwiA’es. But why indict an injury on the public for
the sake of a few deserving ones, especially Avheii regis¬
tration is at best a very doubtful advantage, and under
existing circumstances a positive evil? This loads me to the
question, Is registration of midwives necessary at all? I
Irave endeavoured to shoAv that it is doubtful if it will lead
Digiii/i'■
56 The Lancet,]
PROFESSOR KOCH’S REMEDY FOR TUBERCULOSIS.
[Jan. 3, 1891.
to improved education, and without improved education
registration can be of no avail. Let us see how edncation
without registration works where this latter system has
been tried. In Ireland, thanks to the existence of the
Rotunda and Coombe Lying-in Hospital and of maternities
attached to general hospitals, a large number of mid wives
have for years been annually trained there, a number
much more than sufficient for the requirements of that
f tortion of the kingdom. There is now hardly a Poor-
aw Union in Ireland to which there are not one
or more midwives attached ; these women are paid
small salaries, and supplement it by private practice.
The country districts are too poor and too sparsely in¬
habited to support a midwife without the help of a salary,
but in the towns educated midwives are to be found sup¬
porting themselves without this aid. In fact, Ireland is
fairly well olf for mid wives; as a rule they are efficient and
well conducted. Each woman on passing her examination
at the end of her term of training is given a certificate, and
this, with testimonials from medical men, must he pro¬
duced by candidates for the poor-law appointments I
have referred to; but registration of mid wives does not
exist in Ireland, nor is it needed. Why should nob the
same system be introduced into England? If an Act of
Parliament is acquired, and I believe it is needed, it should
be in the direction of encouraging the establishment of
maternities in large towns, where mid wives could be trained,
and of enforcing their proper supervision during training by
duly qualified medical practitioners and their subsequent
examination by impartial examiners. lo time these
educated midwives would spread over England, as they
have over Ireland. Doubtless the process would be slow,
but it would be better to be so than to register, cn masse,
a number of women, ignorant, illiterate, and in many cases
drunkards, whose presence on the register would lower it
in the eyes of the public.
The chief advantage which registration under the proposed
Bill confers is that, without it, mid wives will be unable to
recover fees. This is a small boon. It does not prohibit,
nor could it without great cruelty to the poor prohibit, a
woman from acting as a midwife without registration, and,
as it in no way provides or even suggests improved means
of educating women, I look on it as worse than useless, and
affirm that if it becomes law, instead of benefiting, it will
injure the poor, for whose benefit it is supposed to have
been introduced.—I am. Sirs, yours faithfully,
LoMiiE Atthill, M.D.,
Dublin, Dec. 18tb, 1890. Ex-Master o ( the Rotunda Hospital.
PROFESSOR KOCH’S REMEDY FOR
TUBERCULOSIS.
To the Editors o/Thb Lancet.
Sirs,—I observe that in the course of some editorial com¬
ments on Professor Koch’s treatment for tuberculosis which
appear in your issue of Dec. 27th, you express approval of a
report which has reached you to the efi'ect that the distribu¬
tion of the lymph is to be limited to hospitals exclusively,
on the ground of the extreme care which it is necessary to
exercise in its use. The view which is thus laid before the
public with the weight of your authority can mean nothing
less than that the necessary care is not likely to be exer¬
cised in jjrivate practice, and that the conditions of any
other than hospital practice are not likely to be favourable
to its successful use. As one of those who are involved in
that implied rcHoction I crave your permission to make a
rejoinder.
In the first place, I would invite your attention to the
fact that, although the question of ultimate cure must
remain an open one for many months to come, it has been
established by the results of many hundreds of experiments
that the Koch medium is a therapeutic agent of the
highest value in the treatment of both medical and surgical
tuberculous disease, and that its diagnostic use affords a
means of recognising the presence of the bacillus with a
certainty which is of the utmost importance in regard to
the arrest of disease in its earliest stages. Therefore the
restriction of which you express approval must deprive prac¬
titioners of a means of both diagnosis and treatment, which
would be of incalculable value to the public in averting
disease and either deformity or deatli. Now I would
submit that in private practice the Koch treatment is
likely to be of greater utility than in hospital wards,
for it seems to me impossible to doubt that the hygienic
conditions which prevail in the spacious and well-ordered
sick rooms of private houses, and tiiat the exclusive care of
one or more well-trained nurses whose attention is concen¬
trated on one patient,' offer advantages which it must be
difficult or impossible to secure in the wards of n hospital,
especially in those in which the aggregation of a number of
tuWroulous patients load the atmosphere with germs of
disease. If proof of my contention were needed, it would
suffice to point out that the lymph has already been exten¬
sively used with satisfactory results in private practice; for
it is well known that numbers of patients are already under
treatment at Davos, St. Moritz, and in the lllvieran health
resorts. Further, it has just been announced that a supply
has been forwarded to Montreux, and reported from Berlin
that some physicians in that city are realising as mucli as
two thousand marks a day by the treatment of private
patients. It should also be noted as highly significant that
the deaths which have followed the injection of the lymph
have occurred in hospitals, and not in private practice.
Iq view of these considerations, it appears to me to be
sufficiently obvious that any limitation in the distribution
of the lymph which may not be necessitated by the scarcity
of the supply roust involve grave injustice to that greater
part of the anxious and suffering public whose relative
affluence precludes their having recourse to hospitals for
the relief of their maladies.—I am, Sirs, yours faithfully,
f!l6(lho\y-gardons, S.W., Dec. 2Vtli, 1800. W. Bezly ThOIINE.
*** .We by no means wish to imply that the treatment
cannot be carried out in private practice. But we should
have thought it more conducive to the interests and welfare
of all concerned if the profession were fully enlightened
concerning its efficacy before the treatment were generally
adopted. This decision must largely rest upon the results
of dosG and prolonged observation of cases submitted to the
method, anti it is therefore perhaps to be regretted that the
“lymph” has been utilised in private practice to the extent
that it has been hitherto, not to speak of the absolute im¬
possibility of the supply being made equal to the demand.—
El). L. _
To the Editors o/The Lancet.
Sirs,— The excitement caused by the announcement of
Koch’s experiments, and particularly on his promised cure
for “tubercular diseases,” pervades all classes—medical and
non-medical alike. In fact, we have become hysterical on
this matter, and no wonder that the poor sufferers from con¬
sumption are in the same state. It is time, therefore, that
those of us who have not quite lost our beads should look
at the subject impartially, in the hope of calming down the
over-excited public mind at present existing. First let me
say that I regard Koch’s experiments with the greatest
respect, and look upon his labours as worthy of all praise
as feats of careful and incessant industry. Buthere I pause
and wait for further light, for up to the present time neither
the much-vaunted remedy nor the results of its use have
been sufficiently investigated. Until this is done I confess
I am sceptical, and still believe in the old methods for doing
battle with the foe—consumption. Moreover, there is one
thing about the proposed remedy which puzzles me exceed¬
ingly. I can understand, for the sake of illustration, how
vaccination acts in the prevention of small-pox on physio¬
logical and pathological principles, for as I understand
its operation it destroys all that in the system which
the contagium of small pox would otherwise be fed
upon; but, mark the dilFerence, this inoculation for
consumption is used for a disease already existing; and
vaccination is hopelessly useless when a person is already
labouring under small-pox infection. The same may be
said of charbon, anthrax, or hydrophobia, for there is no
evidence that the prepared and diluted contagium, used by
Pasteur for inoculation, has the least inlluence aRer these
diseases have seized their victims, nor has anything of the
kind, so far as 1 know, ever been suggested. There is plenty of
proof that consumption in its early stage is amenable t<i>
treatment, and its prevention by hygienic and other means
is well established.
Dr. MacCorroac so long since as 1865 wrpte a valuable
treatise on consumption, now, it is to be feared, too little
known, or at least too little read, from which I transedbe a
sentence that should be posted in big letters in every house.
Difj zed by IV.
Thb Lancet,]
DENTAL LAW IN ITALY.
[Jan. 3,18^1. 57
•where there is any intelligence. He says : “ Only breathe
re-breathed air, and sooner or later the uneliminated,
ecause unoxidUed, carbonaceous waste •will be deposited
as tubercle. Do not breathe pre-breathed air ever and you
shall not incur tubercle, you or yours—no, not though you
should survive a thousand years,” Here the great ant agonist
of the foe, which the refined civilisation of the age fosters,
is free ventilation, more particularly in our bedrooms
during sleep. But, instead of providing for this, we shut
our windows and doors, not allowing the fresh air to enter,
and breathing a vile, impure, and pestiferous atmosphere
for many hours. It is the same in many of our offices,
workshops, and business places where many people are
etoployea and much gas is consumed. We prevent, by
persistent and ill-advised endeavours, the ingress of fresh
air, and yet expect to be healthy and vigorous. We pass
over the habitations of the poorer portion of the com¬
munity, where our fellows are huddled together like beasts,
or, worse, are breathing an atmosphere of disease and death,
with the single observation that they are a disgrace to the
civilisation of the age, and of which we make our boast.
Mr. G. W. Hambleton, whose recent papers on Consump¬
tion should be carefully studied, follows very much in Dr.
Mac Cormao’s steps. He says, speaking of modern civilisa¬
tion, “Instead of walking we drive, instead of carrying we
are carried, instead of running we are carried by train, in¬
stead of hunting we go to the salesman. Every day some
new invention is discovered for saving labour, and thereby
spoiling life. Indeed, the conditions of modern life are
rapidly approximating to those of a cage at the Zoo, in
which the animals have everything done for them; or, to put
the matter in another light, modern life is essentially life in
a hothouse. ...We live with closed windows and over-heated
rooms, we mullle ourselves up when we go out, and we take
less and less exercise. Nature is not slow to visit the conse-
quencesuponus. Fromdisusethewayisshorttodisease. The
lungs not being healthily used become a prey to disease.”
Having a due regard for your space hero, I conclude with
the remark that for Koch’s remedy there is no raison d'iHre ;
but from exercise in the open air, the free and full ventila¬
tion of our houses—our bedrooms especially—and from
means which aid in giving free expansion to the lungs, we
may hold out very fair hopes to consumptive patients of
the future,—I am, Sirs, yours obediently,
King’s I.ynii, Dec. 29fcii, ISOO. Wm. DaLP:, M.D.LOND.
To the Editors of The Lancet.
Sirs,—T he great harm done by the manner in which
Dr. Koch’s remedy has been advertised is very serious. It
is unfair to any who may come after with a remedy more
effectual, but who may not possess the means of such
wholesale advertisement. The tendency of the age is to fol¬
low a name. But I cannot understand men with a scientific
training having their mental vision clouded by the unre-
strainea enthusiasm which so often warps the judgment of
the ordinary mind. For my own part I recognise only
truth and fact. What are the facts which present them¬
selves in the case of Dr. Koch’s discovery'? 1. The
“ remedy ” will not cure consumption in advanced stages,
and in early stages it has only been that temporary
benefit has been derived. 2. The remedy is a secret one.
I could name two drugs at least under which phthisis in
the early stages shows great signs of improvement. Our
mode of treating phthisical patients in hospitals by huddling
them all together is a very clumsy one, but in private prac¬
tice, where everything desirable can be obtained, many cases
are cured. I know of a case where a cavity was filled up
with new scar tissue. This was discovered on post-mortem
examination, the patient having died of another disease.
The remedy is a secret one. Do you not agree with me,
'Sirs, that the medical profession will place itself in a very
false posUion and lose respect if it be content to use this
remedy unless [it be put on a different basis to that of a
quack medicine? Is Dr. Koch to become the “General”
Booth of the medical world? Are the scientific men of this
country like children that they may not be trusted with
the secret? Let us stand up for the truth, and in science
at least be no boro-worshippers, bub worahippevs only of
truth. Dr. Koch may be the most pure-uiindea man under
♦he sun, but there is a great smirking of the commercial
'<element in the manufacture of this mysterious fluid.
I am, Sirs, yours obediently.
West Kensington, W., Doc. 20Ui, 1800, W. S. KlCUMOND.
DENTAL LAW IN ITALY.
To the Editors of The Lancet.
Sms,—I notice in your issue of Dee. 20bh a comment
upon the dental law of Italy, in which you express approval
of the fact that in future a degree in medicine and surgery
must be taken by those who wish to practise dental surgeiy'
in Italy. Will you allow me to express my entire accord
with you up to a certain point? I would certainly advise
every dentiit whose means, whose time, and whose capa¬
bilities will allow him, to take the highest degrees in
medicine and surgery, as well as his dental diploma, but I
do most strongly protest against the medical and surgical
degree being made compulsory. I think it is quite possible
to formulate a dental curriculum which shall run, pari
passu, with a medical and surgical curriculum up to a
certain point, so that all the general medical education
is practically the same for both diplomas, but, in the
place of certain medical subjects, dental subjects are sub¬
stituted. We have aimed at this desideratum in recent
alterations in the curriculum- for the licence in Dental
Surgery at the College of Surgeons, and I am hound to say
that this scheme, when carried out in its entirety, and with
efficient education and examination, will provide the public,
in the future as it has done in the past, "with a body of
reputable and skilful practitioners in dental surgery.
In conclusion, I would only add that the present curri¬
culum offers every inducement to students to take the
double qualification, whilst at the same time it gives them
ample time to procure that manual dexterity which two.
years’ constant practice is none too little to secure, even at
the cost of giving up certain brauches of medical educatiun,
not so esaential to a dentist as to a doctor.—I am, Sirs,
yours faithfully, S. John Hutchinson,
Dental Suigeiin to Uiiivoraity College Hospital,
Examiner in Dental Snrgeiy, Roj'jU College of Surgeons, England.
Brook-street, W., Deo. 181)0.
LEAD POISONING FROM DRAUGHT
BEVERAGES.
To the Editors of The Lancet.
Sirs,— Your interesting annotation in The Lancet of
Dec. 20th recalls to my mind a similar case Iliad in February
of this year. An old patient of mine sent for me about the
middle of that month, and at niy visit I found her suffering
great pain in the bowels, especially about the umbilicus.
After careful examination, and more particularly looking at
her gums, where I discovered a very distinct blue line, I
came to the conclusion that she was suffering from
lead colic. Now this was a comparatively easy matter,
but it was a more dillicnlt one to Oud out how she
contracted the complaint. I cross-questioned her in every
possible way as to what she drank, but could not get anything
satisfactory. At the end of the third day she expressed
a wish to go to the hospital; and as she was a poor
woman who did a little washing I let her go. It was
thiough the kindness of Dr. Cheadle that I learned the
further history of the case. It seems that at the hospital
she disclosed what I could not get from her—that she was
in the habit of drinking largely of ginger-ale, which she
bought on draught from a small beer shop near where she
lived. This fluid was tested and found to contain a large
quantity of lead, no doubt produced by the free carbonic
acid acting upon the lead pipes of the engine. She was
soon dischai-ged cured. I do not know the treatment
adopted, but X always use potassium iodide in these cases.
1 am. Sirs, yours very truly,
llavrow-i'oad. Dee. IDth, A. L. GRIFFITH.
“ HORSE EXERCISE FOR SCHOOL GIRLS.”
To the Editors o/Thb Lancet.
Sirs, —Many in our profession, in which there are so
many horsemen, will have read with pleasure the admir¬
able annotation of last week, in which you comment so
practically upon points of posture in riding. May I give a
stanza which is in my memory, and which appears to be a
better version of the true old apophthegm you quote?—
Videlicet :—
Yoiu- hoad and youi- breast keep tip,
Your innds and your liools keep down,
With your logs well in to your horae’a aldos,
And your elbows woU in to your own.
I have also met with another sound observation about
Di, : Google
S8 Thk Laitcbt,]
THE FOUNDEK OF “ THE LANCET.
[Jan, 3,1891.
riding with propriety upon horseback, the truth of which
horsemen recognise—namely,-if a man make sure of keeping
his heels down, all things else in riding will be added; that
is to say, if the heels be right, all other excellences of
equestrian posture will take care of theuiselves.
I am. Sirs, yours faithfully,
BinninghaDQ, Dec. 2Stb, 1S90. JAMES SAWYER.
THE FOUNDER OF “ THE LANCET.”
[The early history of The Lancet, the tierce conflicts in
which it was used hy its founder as the weapon by which
he achieved suceeasive victories over selfishness and wrong,
and thus made comparatively smooth and easy tire path for
reformers in after years, form a subject which ought not to
be allowed to pass into oblivion. We have no hesitation,
therefore, in allowing to appear in our columns the following
communication from the pen of a correspondent who is in a
position to appreciate the advantages to the profession
gained hy the indomitable energy and persistent efforts of
the great medical reformer.—E d. L.]
I have recently had the curiosity to go through the files
of The Lancet with the object of discovering and recording
if possible the tone and aims of that journal from its incep¬
tion, and the enormous labour has been amply repaid by the
discovery of the rich mine of wealth which the volumes
' contain. 1 believe I have discovered the secret of the
unparalleled success and the high reputation of the chief
organ of the medical profession. In one of the volumes
I came across what may be called The Lancet’s con¬
fession of faith. “The Lancet will perpetuate the
memory of Thomas Wakley—the founder of this journal—
by cherishing after his death the principles to which
he consecrated his life.” The solemnity of expression
in the passage on the occasion of the death of the
founder led me to further inquire by what motives he
had been actuated, what such a memory and example
required of his successors, and how far the solemn promise
had been fulfilled by them. What had he to gain in
requiring that medical men should be adequately rewarded
for their labours ? “I have,” said Mr. Wakley in a public
K>eech—“I have foresworn medical practice. I use only
the lancet, and that in the form of a quill.” From that
time he became the champion of medical reform of all
kinds. If we turn to The Times of 1827 we find that
at that early period The Lancet gave the first blow
“to cupidity and corruption by establishing a free
medical press, and rousing the profession to a sense of
its injuries and indignities, and to a spirit of resistance.”
Mr. Wakley’s great aim was always to uphold the rights
of the profession as a whole by the adoption of straight¬
forward courses of action. What lias be gained for medical
men ? In former days, when scarcely a week passed without
furnishing instances of imbecility and ignorance on the
part of coroners, and reports of insults borne by medical
men who were, without; fee or reward, coinpelled to attend
these “worthless, expensive, and pernicious exhibitions,”
he raised his voice with no uncertain souud against such
palpable abuses, and earned for himself no small share of
obloquy from those who considered themselves injured i
by his fearless exposure of base principles. Unmistak¬
able deaths from poisoning were recorded by coroners’
juries from time to time as “Deaths by the visita¬
tion of God.” Abuses so apparent soon roused him to
most energetic action, resulting in his candidature and
election for the oilico of Coroner for the Western Division-
of Middlesex at the enormous cost to himself of many
thousands of pounds. From that time The Lancet
has consistently supported the appointment of medical
coroners, and now scores of medical men occupy that
position. The Coroners Act, allowing tiie appointment
of a permanent deputy coroner, and the Medical Wit¬
nesses Bill were introduced to I’arli,ament on bis instiga¬
tion and passed in consequence of his exertion-s. As a
direct result of his personal patience, an inquiry into
the flogging to death of a soldier at Hounslow Barracks
led to the abolition of Hogging in the army. His
keenest shafts, however, were aimed at empiricism and cant,
“the prima materia of the devil,” as Carlyle called it.
He hated shams, and loathed the feebleness which
succumbs to mere authority. He succeeded to a great
extent in rescuing the very inslicutions which were estab¬
lished to prevent quackery from the quagmire of empiricism
into which thev tliemaelves had fallen. His attack on
the faults and aosurdities connected with medical education
should tender the medical student of to-day, perhaps more
than anyone else, grateful to the founder of The Lancet,
for it is through his instrumentality that every student has-
now secured to him able aud earnest teachers, and the right
of using freely the opportunities which public hospitals
afiford mm for his improvement. The first great battle by
which the rights of a free medical press were established
was won by Mr. Wakley on their behalf. Up to the year
1825 no clinical lectures were delivered in the hospitals,
and no reports of the cases which occurred in them were-
published. The famous action of Abernethy v. Wakley
established the right of the medical journals to print public^
lectures, and was a triumph for the press, the influence of
which has been great and lasting. With regard to the
decision in the case of Bransby Cooper v. Wakley, Sir James
Scarlett, the opposing counsel, admitted “ that the example
of this proceeding has given to the periodical press a triumph
and an influence which it never had before.”
Mr. Wakley was one of the first to urge upon his medical
brethren the necessity for their being represented in Parlia¬
ment by members of their own profession ; and, ever ready
to practise what he preached, he submitted himself as-
Parliameutary candidate for Finsbury. Twice ho went to
the poll, and twice was he defeated. Undaunted, he-
went again to the poll at the next election and was
returned by an overwhelming majority. Before he bad
been many weeks in the House he began to manifest his
care for the interests of the profession by asking ques¬
tions of the greatest importance to its members, and'
throughout the whole of his Parliamentary career of
twenty-four years was he the staunch champion of medical'
men, influencing the House to appoint select committees
to inquire into abuses, introducing Bills, moving amend¬
ments, and in many other ways acting in their interests.
He established a life assurance office for the purpose of
enforcing the payment by the various offices of the fees for
the medical examination of their clients, urging that, as
medical reports were given in the interests of the offices,
payment of the fees should therefore be made by them.
Wiiat is the direct result of this action at the present
day? Every office now pays the medical fees, and I
observed in a recent issue of The Lancet that during
the past year one office bad paid as much as £50,000'
in recognition of the services of mediral officers. In
his threefold capacity of Member of Parliament for Fins¬
bury, Coroner for West Middlesex, and Editor of The
Lancet, he wielded a power unequalled by any other man
in the profession, and was not slow to use it for the
advancement of its interests and welfare. Perhaps one of
the most important public functions performed on behalf
of the poor by Mr. Wakley was the establishment of an
Analytical Commission which exposed the adulteration of
food and converted the press into an instrument of police
by establishing in The Lancet the precedent of publishing,
fearless of all legal consequences, the name aud address of
the establishment where adulteration was carried on. In
many cases he would add : “ This is the third article which
we have found adulterated—the public should avoid this-
shop.” As a result, legal actions bristled around him, but
such was the genuineness of his work that iu not a single
instance was an unfavourable verdict recorded against Iiirn.
Some years after the establishment of his Analytical Com¬
mission an Act of Parliament was passed requiring the
appointment of public analysts throughout every district of
the country. The public benefits resulting from this work
cannot, indeed, be overrated.
What did he gain by the exertion of his indomitable
courage on behalf of his professional brethren ? Either as
plaintiff or as defendant in the law courts Mr. Wakley
must have fought some twenty-five or thirty actions, con¬
testing in his own person with some of the leading barristers
of that day over matters connected with the advancement
of the profession at so great a personal expense that on
several occasions the very existence of The Lancet was
imperilled. He lent his aid in reforming the Lunacy Laws,
and was always the defender of the rights and privileges
of the medical ofiicers of the united services and of the
Poor-law administration. He was the champion of the
Fellows and Members of the Iloyal College of Surgeons,.
Dk z ^ : / ^-OOglC
The Lancet,
BIRMINGHAM.—LIVERPOOL.
[Jak. 3,1891. 5 ^
who were unfairly treated by a Council then wholly irre¬
sponsible and self-elective. In regard to this body he main¬
tained that when a few individuals were appointed to
watch over the interests of a large body of men, it was
quite necessary, in order to secure upright conduct on their
part, that the interests of those few should be identified
with those of the many. To this end he laboured, exposing
and denouncing the procedure of the “ minacious oligarchy
of our mismanaged tomplo,” as be called the Council, and
characterising certain of the by-laws then in force as “ in¬
struments of corporate iniquity.” To attack abuses uncom¬
promisingly wherever they existed, to spare no effort, toil,
or trouble to effect reforms wherever they were required, to
raise the profession as a whole from the lowiy position it
then occupied to such a level as it has now attained in
public esteem, were some of the labours of a life remarkable
at once for uprightness and disinterestedness of purpose.
“ I’vo heard of hearts unkind.
Kind deeds with cold returning.
Alas I tile gratitude of men
• Hath oftenor left me mourning.”
The memory of Thomas Wakley should be written in letters
of gold on the mind of every medical man. Examples and
principles such as these are surely those which all should be
proud to follow and adopt, for even now necessity for
further reform in each and all of the directions I have
indicated is not wanting. I earnestly hope and believe
that you, the successors of so worthy an ancestor, will
persist in tbo noble endeavour to carry out the promise
made at the time when he ceased to labour among us, and
in 30 doing—though you may easily fall short of the rare
excellence which he at all times displayed—neverthe¬
less you will have adopted a course which shall be honour¬
able alike to yourselves and of the highest utility to the
noble profession you have the honour to represent.
BIRMINGHAM.
(From our own Correspondent.)
Hospitcd Sunday Collection.
The accounts of this collection for the present year have
been made up, and give a total of £4712 3s. 2d , which
goes to the Queen’s Hospital. The institution is in need of
funds, and the authorities will hail this liberal contribution
with much satisfaction.
Death of Mr. Thomas Taylor.
On Dec. .30th died the oldest member of the medical
rofessioD in the Midlands, at the ripe age of ninety-
ve years. Though for some years past he has not,
as might be expected from his age, taken an active part
in life, he still preserved an interest in professional
matters. Of sound knowledge, firm faith, and a character
unsullied by any dark spots, he maintained to the last his
reputation aa a high-minded and honourable man. His love
of literature was constant, and he took the greatest pride
in the preservation and intimate acquaintance with the
books he possessed. Ili-s habits were active even to his
own hurt, for he refused to be conveyed by train or by
carriage if ever there was a possibility of walking to his
destination. Of him it is said that he had no enemies,
and it is hardly possible to pictxire a more merited or
worthy distinction. Quiet and gentle in manners, of the
greatest probity in all transactions, he htis left a name
which remains untarnished by the long lapse of years.
Christmas at the Hospitals.
As usual, the annual festivities of the season find
expressions of happines.s and hope amid the surroundings of
disease aud sufl'ering. The difl'ereiit hospitals have vied
with each other in making bright and cheerful the interiors
and the wards. Captious critics have even questioned the
propriety of nurses devoting their time to decorations, and
have hinted that someone must suffer in consequence. It
would be ill to deprive them of the pleasure it evidently
gives, and he would bo a morose and gloomy man who
sought to deny to the sick and suffering the gleam of hope
and comfort which such associations afford, and the pass¬
ing interest which tends to cast self into oblivion, if even
for the short apace of Christmas time.
Nurses' licsponsihilities.
An inquest was held on Dec. 30bh on tlie body of a
pauper lunatic, who met her death under circumstances
which gave rise to a verdict of manslaughter against the
nurse in charge. The patient, it appeared from the evi¬
dence, was carried from bed into the bath-room, placed in
a bath of very hot water, and died a few hours afterwards.
It is a rule of the asylum that no patient must be placed
in a bath with the taps turned on while the water is still
running in. There is another rule, also, that the attendant-
must previously ascertain the temperature with a thermo¬
meter, and that it must not exceed 98°F. Unfortunately
both these wise rules appear to have been violated.
Itesignation of Sir Walter Foster.
The Committee of the General Hospital, at their meeting
on Jan. 2nd, will proceed to fill up the vacancy caused by
the resignation of Sir Walter Foster. Dr. Simon, who hoA
been assistant physician for eight years, is considered to
have a good claim to the succession, but no doubt it wUl
be declared open and the appointment given to the best
candidate who applies.
Birminghaiu, Dec. 30th.
LIVERPOOL.
(From our own Correspondent.)
Christmas Hot-pots it-c. for the Poor.
Some years ago Sir David Iladclitfe, when mayor of this
city, conceived the happy idea of sending a large number
of hot-pots, each containing a sufficient quantity of meat
and potatoes to serve as dinner for a family of deserving
poor persons. The custom has been followed by each suc¬
cessive mayor, aided by the liberality of the public, and
Sir David itadclili'e’s generous concepiion has now become
a hardy annual. Like other generous acts, it has expanded,
and by the generosity of some leading firms each recipient
of a hot-pot also has a packet of tea and a jar of preserve.
In addition to these, a large number of the poor are pro¬
vided with free breakfasts on Christmas morning. The re¬
cipients are carefully selected by ministers of religion, care
being taken to select the most deserving. This year the
distribution was even more generous than usual, and a
large number of the hungry were filled with good things.
The Weather: Accidents and Fatalities.
During the present month the weather has been intensely
severe, the thermometer registering 22° of frost in one
of the suburbs, and even 10° in the city. On the 19th
there was a very heavy fall of snow, with dense fogs and
hard frost. Hence many accidents and fatalities from
falls in the frozen streets. The practice of salting the
streets, though justified by the authorities on account
of the ease with which it melts the snow, is much con¬
demned by the public for the injury ic causes to boots,
and the cruel suffering it causes to horses, dogs, and cattle
by the intense cold it causes. On Saturday, the 27th inat.,
six patients were taken to the Northern Hospital in the
horse ambulance, three of whom were carters. One was
suirering from a fractured leg and crushed hand, the second
from a fractured leg, and the third from wounds in the chest,
neck, and thigh, by stabs from an assailant, who has been
arrested. An elderly women died soon after admission from
the effects of burns, as did also a man who fell into the fire
while under the influence of drink. The sixth case was
that of a man sixty years of age, who was found in an
apoplectic lit.
I'lie Bolton Murderer.
The young man, Macdonald, who murdered the school¬
mistress near Bolton, was banged to-day within the walls of
Il.M. I’riaon, Kirkdalo. But for the confession of the
prisoner the evidence would have been purely circum¬
stantial, and there might have been some difficulty in
securing a conviction. There has been an entire absence of
that mawkish sentiment which was displayed towards the
notorious Mrs. Maybrick, the Crewe, andtheNew Brighton
murderers. Macdonald’s crime was so atrocious that no
attempt was made to secure any remission of the capital
sentence. A new gallows has been erected, and was used
for the first time. It is in accordance with recommendations
of the committee appointed by the Government, and bos a
length of chain to which the rope is affixed.
Strikes, Elecmosjinary Belief, and Fever Epidemics.
In a former letter allusion was made to the great hard¬
ships inflicted by strikes, which mean hunger and evea
60 Thk Lancet,]
NORTHERN COUNTIES NOTES.
[Jan. 3, 1891.
starvation to wives and children, resulting too probably in
an epidemic of typhus fever; while last, but by no means
least, there is the necessity for increased eleemosynary
relief from the charitably disposed and for gratuitous
medical advice at the hospital, dispensary, or home.
Garston, a small thriving town within a few miles of Liver¬
pool, has lately been the scene of a strike among the
employis of the London and North-Western Railway.
The consequences of.this strike, which was wholly un¬
justifiable, will be very serious and far-reaching. A
number of men, estimated at 800, who with their wives
and families have lived for years in Garston, will have to
leave, the London and North-Western Company having
firmly resolved not to re employ any striker. Much has
been done by kind-hearted people to relieve the distress
caused to wives and children as well as to the strikers them¬
selves; but in such severe weather the consequences must
be very serious, if not fatal. Like many other good things,
eleemosynary relief does harm, encouraging many an idle
fellow to strike orto be a hanger about public-house doors,
living by begging and leaving wife and children to the
cbaii table.
The Approaching TwenUj-first HospitalHandoij in Liverpool.
The second Sunday in the New Year, the 11th of January,
1891, will be the twenty-first recurrence of Hospital Sunday
in Liverpool, the first having occurred on Sunday, the 8th
of January, 1871. The result will be awaited with much
interest, the collections having increased steadily daring
the last few years, owing to increase of trade and commerce.
The Mayor (Mr. Morgan) takes much interest in the
welfare of the medical and other charities, and is seeking
some means by which they may be more systematically
organised.
The Murder of a Prostitute.
Before the recent assizes had concluded, a murder was
committed in this city which has attracted much notice
throughout the whole country. The victim was one of the
many so-called “unfortunates” with which this city
abounds; the accused, a young man who comes from the
south of England, and had been in the deceased’s company
for some days in a house of ill fame. The murder was com¬
mitted in a cab, and the prisoner was arrested “red-handed,”
the murderous weapon with blood on it being found
in his trousers’ pocket. Dr. Jay Gould, house surgeon at
the Royal Infirmary, stated that the deceased only lived
twenty minutes after her admission, and had six punctured
wounds just above the left breast. At the post-mortem
examination two of the wounds were found to be superficial,
while the remaining four penetrated the chest. Of these,
two entered the heart, one going through it and into the
liver. All the four wounds were between the ribs. A
verdict of wilful murder against the prisoner was returned.
Liverpool, Doc. 30tli.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
T]ie Koch Cases at the Newcastle Infirmary.
There is little new to be reported regarding the cases
under Koch’s treatment at the Newcastle Royal Infirmary.
I visited the wards yesterday, and saw the first case (one
of tubercular lupus under Dr. Philipson) in which it was
tried, and there appeared to be a considerable alteration in
the appearance of the eruption. I also saw a new case of
lupus, under Mr. Page, in which an improvement was
taking place. The cases of pulmonary phthisis appeared
to be in statu quo, except in one case. The sputa were in¬
creased in most cases. There has been an increase in the
amount of urea excreted, but not, I believe, in the volume
of urine. None of the patients, and there are now six
under treatment, appear to have received the least detriment
to their health, which is at least as good as before the
treatment was commenced.
“Pm/c Eye ” in Newcastle.
We have just expeiieqced a severe epidemic of influenza
amongst horses in the north (commonly known as “ pink
eye,” from the eanguineous sullasion of the conjunctiva).
T^he epidemic has given great concern to owners of horses.
The North-Eastern Railway Company have been great
losers from this epidemic, as the disease got amongst their
stables of valuable draught horses. Mr. Clement Stephenson
informs me that carriage horses have also been attacked,
but not with such bad results, as isolation and ventilation
could in their case be carried out with greater facility,
Jan'ow.
Dr. Hugh M. Smellie, late house surgeon of the Jarrow
Memorial Hospital, has received a handsome testimonial
subscribed by 5000 workmen in Messrs. Palmer’s Jarrow
and Howden Works. Dr. Smellie gave some statistics
as to accidents to workmen, and showed that during
his three years of office at the hospital about 4000
accidents had been treated.—Mr. Jennings, surgeon, of
Jarrow, has done good service in bringing a matter
of some importance to the poor, and also to the pro¬
fession, before the magistrates. In the case of a poor
mother summoned for her child’s non-attendance at school,
Mr. Jennings contended that it was unfair to ask these
very poor people to pay for medical certificates, and it was
also unfair to ask the profession to do so, to satisfy the
behests of the School Boards, without remuneration. Mr.
Jennings believed that the profession would furnish them at'
a very small and fixed charge to be arranged by the Board.
The magistrates appeared to give the matter their favour¬
able consideration, and it is to come up again.
Nowcastle-on-Tyne, Doc. t-ltli.
SCOTLAND.
(From our own Correspondents.)
Edinburgh Mcdico-Chirurgical Society.
Tins society held a special meeting on Wednesday of last
week. The first business on the programme was the ad¬
journed debate on Dr. W. Russell’s paper on The Charac¬
teristic Organism of Cancer. A number of the younger
members spoke, and all of them advanced objections and
difficulties to the acceptance of the conclusions in the
paper, while there was a general expression of appreciation
of the work. Some suggested the fuchsine bodies were
nucleoli, or degenerated leucocytes; others pointed out
that cornified epithelium, red blood-corpuscles, fat granules,
granules of chromogeo, or granules of fucheine might ex¬
plain the appearances; another regarded them as due to
hyaline degeneration ; while otlier speakers dealt with the
subject more generally, dwelling on the difficulty of be¬
lieving that all forms of cancer could be due to the same
organism, and that the organism must be carried by the
blood; some expressing their total disbelief that cancer
was due to an organism, or that it v/ould ever
be proved to be so. Dr. Russell, in his reply, dealt
with the various difficulties that had been advanced,
and said that he had faced them all months before lie bad
stated in his paper that the nuclei of certain cells retained
fuchsine; some protoplastic masses and horny epithelium,
and certain parts of red blood-corpuscles and other struc¬
tures, also retained it; but he had succeeded in discharging
the colour from all these, and leaving the bodies in queskon
stained. He had tested other degenerations and found they
did not give the special colour reaction. Some suggestions,
as that they were fuchsine granules, he passed by as not
requiring special notice. As to the more general question,
some of the objections were the same as had been advanced
against all instances in which it was contended a microbe was
the cause of a disease. He sympathised with the view that
cancer would not be found to be due to a micro-organism,
for he bad contended for the same view. Referring to the
figures illustrating the appearances of the organism in
epithelial masses, that part of the work was clone to bring
it into line with work which had been done on the Continent,
where it was contended that somewhat similar appearances
were due to psorosperms. Although there might be
differences between the fungus here and the better known
yeasts, still the budding was distinct, and the connexion of
the individuals could clearly be seen, and he knew no
athological process and no degenerative process in the
ody where this budding took place, and, whatever the
differences might be, he maintained the process was more
like that of the unicellular fungi than anything else. He
suggested that they might be found in the morbid pro¬
cesses, and this was an important point which might be
investigated by others, as he had not all kinds of patho¬
logical material at his disposal. The discussion lasted over
two hours, and thereafter the first paper on the programme,
Dir oogle
The Lancet,]
IRELAND.—PARIS.
[Jan. 3,1891. 61
a “ Contribution to Venesection as a Remedy, from Notes
of Practice,” by Dr. Siiand, was read. At the beginning of
the meeting, Mr. A. G. Miller, one of the vice-presidents,
and occupying the chair, requested reporters not to report
the proceedings to the lay press.
Tht Edinhurffh Training Home for Nurses.
The Training Home for the Edinburgh branch of the
Jubilee Institution for Nurses was thrown open to sub¬
scribers for inspection on one of the days of last week. The
Home is comfortably furnished, and has accommodation for
eight nurses at present, but it is hoped to be able to increase
it sufficiently to accommodate seventeen.
Edinburgh Health Lectures.
Mr. K. J. Mackenzie, Rector of the Edinburgh Academy,
lectured on Saturday last on “ Methods of Physical Educa¬
tion, Ancient and Modern,” and dwelt upon the necessity of
physical training.
Edinburgh Royal Infirmary.
The first of the festivities of the season at the Royal
Infirmary was given on Christmas Eve, and consisted of a
treat to the children and their friends. The entertainment
comprised songs and recitations, and a Christmas-tree,
with a gift for each child. It was held in the large theatre.
Cullen's Lectures.
A paragraph has appeared in the Scotsman stating
that the MSS. of Cullen’s lectures oii medicine have been
found in Nottingham. They consist of two volumes
containing about 800 pages, and are dated 176(). This will
be a find of interest to the Edinburgh Medical School.
Health of Edinburgh.
The mortality last week was 99 and the death-rate 19
per 1000. Diseases of the chest caused 46 and zymotic
diseases 10 deaths, of which 4 were from typhoid fever and
5 from whooping-cough. The intimations for the week in¬
cluded 00 cases of typhoid fever, 3 of diphtheria, 14 of
scarlatina, and 7 of measles. Prom this it will be noted
that the epidemic of typhoid is still extending ; there are
about 100 cases in the City hospital, and many more in
private houses. One of the best known medical men in
town is down with it, and several of his liousehold as well.
It is to be hoped that the public health authorities will
find a satisfactory explanation of this epidemic.
Doc. .sofch.
IRELAND.
(From our own Correspondents.)
The Irish Census.
Till!: Registrar-General (Dr. Giimshaw) and Messrs. Bel¬
lingham Brady and Robert Matheson liave been appointed
to bo Conirniaaioners for carrying into ell'ect the provisions
of the Act .'IS and r>4 Victoria, cap. 46, entitled, “ An Act
for taking the Census of Ireland."
The late Dr, Harrison, Roscommon.
This gentleman, who was one of the leading practitioners
in Roscommon and adjoining counties, died last week,
and his funeral, w'hich took place on Saturday, was very
largely attended. Dr. Hanison, who was a doctor in
medicine of the University of Edinburgh, and a Fellow of
the Royal College of Surgeons in Ireland, was well known
for his professional skill, and highly esteemed for liis many
excellent qualities. Immediately after the funeral, a public
meeting was hold in the grand [jury-room, to consider in
what way the memory of the deceased could beat be per¬
petuated. The meeting was presided over by Lord Crofton,
and a resolution unanimously adopted of condolence with
Dr. Harrison’s relatives in their great sorrow. The follow¬
ing resolution was passed :—“That a general committee,
consisting of the present .subscribers, with power to add to
their number, be appointed to make such arrangements as
may be determined on, to enable hia ma?iy friends to place
on record their testimony to Dr. Harrison’s great profes¬
sional ability, bis unlimited charity, and his untiring zeal
in the interest of all classes of the community.” A sub¬
scription list was opened and nearly :t:400 was obtained.
Reopening of Galway County Infirmary.
Owing to the non-compliancc of the governors with the
Act of 1‘atliament, as to appointing a surgeon, the grand
jury could not pass a presentment for the maintenance of
the hospital. Colonel O’Hara, one of the governors, in¬
stituted legal proceedings to compel the governors to elect
a surgeon, and a mandamus was obtained in the Court of
Queen’s Bench. Many difficulties arose, and for two years
matters remained in abeyance, and as funds were not forth¬
coming, it was feared that the infirmary would have to be
closed. However, the chairman of the board, Mr. Perese,
supplied the funds necessary for one year. Again the court
ordered an election, but a quorum not attending, the
matter again fell through. Subsequently the President of
the Queen’s College, Galway, in the interests of the stu¬
dents, offered the governors £500 to enable them to open
the infirmary for the winter and spring session; and after
some negotiation, all arrangements have been settled, and
the infirmary will be opened next week.
Poisoning from Carbolic Acid.
A case of suicide from taking carbolic acid occurred last
week at Bangor. The deceased lady swallowed about
seven ounces of the acid.
Dec. 80th.
PARIS.
(From our own Correspondent.)
French Opinion of Koch's Method.
The editor of the Revue GMralc de Clinique et de Thira-
•peutique — Dr. Huchard—the same gentJeman who so
strongly opposed the formal appointing of French repre¬
sentatives to the late Berlin Congress, and who also had the
passage of arms with Virchow as to some of the latter's long
forgotten utterances about France and the French, has an
article in his paper this week in which he sums up veiy un¬
favourably the results so far obtained from the employment
of Koch’s system of injections. He goes so far as to say
that these injections are not only useless but positively (so
far as observed in Franco) harmful. He admits that Koch
is himself an investigator and observer of the highest order,
and attributes what lie calls the hysterical rush to this so-
called remedy in a lar^e measure to an abuse of the tele*
graphic system, by which garbled and feverish messages are
llashed across the globe and acted upon without any further
detailed information. But as to the fact that the remedy is
a complete failure he has no doubt, and he adds that he
fears siiflering humanity can only regard it as one deception
the more. True science, he says in conclusion, such as men
like Laennec, Claude Bernard, Davaine, Pasteur, and
Charcot have advanced, has need for longer and more sober
study.
Statistics of Hypnotic Treatment.
The appearance in the reports of a London hospital of the
statistics from the hypnotic in-patient and out-patient
department would probably be looked upon as a startling
novelty. Here, on the contrary, it is otherwise, we
have given us amongst the records of the Charity Hospital
the result of M. Luy’s treatment in what may be considered
the department devoted to hypnotism in this leading
clinical hospital. Tlie treatment is styled “therapeutic
methods derived from hypnotism,” and is divided into
“fascination,” “transference,” and “magnetic currents
combined with electricity.” The number of patients
treated was 128, and of these sixty-seven are returned as
cured, fifty-one as ameliorated, and ten in whom no change
was produced. The hysteiies of course figure largely in
this number, amounting to forty-nine. Paralysis agitans
comes next, and of these three out of nine were cured.
According to this, high as the percentage of non-cures is,
it would almost appear that those spending )>ours over the
hopeless task of searching for the pathology of this
disease would be more profitably employed in administering
hypnotism to their patients. Epileptics were equally bene¬
fited by “transference.” The same applies to cases of
neuralgia, Avriters’ cramp, tabetics, &c. In obstetrics, women
were delivered without pain or danger by the ‘ ‘ fascination ”
method, and even in organic diseases of the heart “ trans¬
ference” was attended with marked improvement. In con¬
clusion, it is declared that these methods of hypnotic treat¬
ment give in acute or chronic diseases of the nervous system
50 per cent, of cures.
Compulsory Revacaination.
As your readers are probably aware, vaccination is not
Dir; ■ .lad i;
.Google
■62 The Lancet,]
PARIS.—BERLIN.
[Jan. 3,1891.
yet absolutely compulsory in France, although compulsion
is practically secured in other ways, with the result that
vaccination is the rule. Revaccination, however, has
iutherto been almost optional. This is no longer to be the
case, at least so far as medical students are concerned. The
Superior Council of Public Instruction has just issued the
following regulations: 1. Aspirants to the diploma of
Doctor of Medicine or officUr de sant6 will henceforth be
■admitted to the Faculty Schools only on the condition that
they produce a certificate of successful revaccination.
2. Students who have already commenced their studies will
be debarred from taking up their next inscription unless
they produce a like certiticate.
The Paris Policlinique.
The Municipal Council of Paris has made a grant of
SOOOfr., or £200 per annum, to the Policlinique, which not
•only gives advice and medicine free of charge, but also dis-
tiibufos clothing to the poor through the medium of a
committee of ladies.
Skating Fete in Aid of the Poor.
The Society of “Parisian Commercial Fdtes,” aided by
the Municipal Council, had organised a grand display to
take place on the ice in the Bois de Boulogne on Sunday
week, when unfortunately it thawed, and the project had
to be postponed. It will probably now take place, liow-
ever, as it is freezing as hard as ever. The fUtc will include
balloon ascents, military concerts on the ice, illumination of
the Boia with Bengal lights &c., and a grand torchlight pro¬
cession by the garrison of Paris. The Bois will bo closed for
twenty-four hours beforehand, and during the J6tc admission
will be charged at the rate of 1 fr. for foot passengers, 10 fr.
reserved places, and 20 fr. for vehicles. The proceeds will
be distributed amongst the poor, and unless another thaw
spoils the good intention from being carried into effect, a
handsome sum may be anticipated.
Paris, Dec. 30th. __
BEKLIN.
(From our own Correspondent.)
J)iscussio'n upon Koch’s Treatment for Tuberculosis at the
Berlin Medical Societies.
During the past week three medical societies in Berlin
have occupied themselves with Koch’s method. Tire first
•of these was the Society for Internal Medicine, of which
Leyden is president, in which Dr. Lubiinski introduced a
fellow-physician who has been suffering from laryngo-
traeheitis since 1887. After alternate changes for the better
and for the worse, there appeared on examination a few
weeks ago a thickening and redness of the posterior ex¬
tremity of the left vocal cord, with ulceration of the posterior
wall of the larynx and tubercular symptoms in the lungs.
The patient has received seven injections, and his condition is
very considerably improved. Dr. Jtirgens then reported on
the post-mortem results of two cases of phthisia treated by
Koch’s method ; the very far advanced processes in the
lungs showed no alterations caused by the injections, but
on ulcerations of the various mucous membranes a decided
tendency to granulation was observed. One of these
patients had received four, the other eight injections.
At the Berlin Medical Society, Dr. B. Fraenkel, as the
speaker of the evening, said chat he could not allow the year
to pass without Koch’s method being discussed in their midst,
which had not been done before. Dr. Fraenkel bad therefore
undertaken to report on his results. Within tlie last four
weeks he had treated fifteen cases of phthisis with affections
of the larynx and pharynx, seven cases of uncomplicated
phthisis, and five of lupus with Koch’s fluid. In the
laryngeal cases the well-known general phenomena were
accoDipanied by redness and swelling of the affected parts.
These phenomena .soon passed away, and were followed by a
rocesH of necrosis, .sometimes with, sometimes without,
isintegration of the ti8.sues; in the former case the ulcers
soon cleanr-icd themselves and sliowed a tendency to granu¬
lation. In the cases of pulmonary phthisis Fraenkel observed
diminution or cessation of bronchial respiration and dulness,
better appearance of tl)o sputum, and improved gener,al con¬
dition. He summed up his experience in the statement that
general iinprovement was obtained ahrng the whole line, and
tliat in many cases there was a prospect of cure. He urged
caution in the selection of the cases (a good degree of general
strength being highly desirable), objectivity in observing,
perseverance, and careful treatment. With reference, how¬
ever, to the sceptical tendency which is now observable, he
declared with emphasis that he had no hesitation in calling
Koch’s fluid a remedy. The cool reception which the
Society gave the somewhat enthusiastic close of Fraenkel’s
lecture seemed to prove that the majority of those present
were unable as yet to share his optimism.
The report given by Dr. Paul Guttmann in the Hufeland
Society was of special interest, owing to the circumstance
that his experiments took place under the auspices of Koch
himself. It is probably known to the readers of Tue Lancet
that the magistrates of Berlin have placed 150 beds at Pro¬
fessor Koch’s disposal in the hospital of which Guttmann is the
head. Guttmann discussed ia the first place the importance
of Koch’s fluid as a reagent. As an example of the prompti¬
tude of the reaction he cited the following cose. A phy¬
sician, not belonging to Berlin, but on a visit here, had got
a slight wound on the right index finger at a post mortem a
year and a half ago, which led to an induration hardly half
the size of a pea, which was entirely indolent. He sub¬
mitted to an injection of O'OOS cc., after which fever sec in, the
induration reddened, became painful, and swelled to more
than twice its size. After ten hours these phenomena
passed away; it was therefore probably a case of inoculated
tubercle. The speaker then discussed the therapeutic value
of the medicanjent in tuberculosis of the lungs. He has now
treated 109 patients, some of them for twenty-six days,
besides whom there are six patients in his hospital who
have been treated by Koch himself since the end of Sep¬
tember. In a small number of the patients of the first
category Guttmann was already able to affirm improve¬
ment, and some of that number had gained in weight.
In 5 per cent, of the cases the tubercle bacilli had dis¬
appeared. Of the six patients treated by Koch some had
gained considerably in weight, one four kilogrammes in
three weeks; two girls who sufl'ered from infiltration of
the apex seemed to be cured. Guttmann summed up to
the effect that in cases of pulmonary tuberculosis in which
there is only infiltration of the apex there is hope of cure,
and that in time considerable improvement may be effected
in more advanced cases also, but that noi success is to he
expected in far advanced cases. Great loss of strength,
amyloid degeneration, and albumen in the urine are to be
regarded as contraindications, hmmoptysis as a temporary
one. The lectirre was followed by a very lively discussion, in
which Dr. Ewald took a prominent part. Ho pointed
out especially tliat the maximal dose for tubercular
patients who do not react at first, and for healthy persons,
the possible duration of the interval between two injections,
and the question of a cumulative effect of the medicament,
were not yet determined ; further, that it was not yet clear
how long one should inject if there were no reaction, and
what was to be done against the hectic fever. He had not
yet been able to ascertain retrogression of the physical
phenonienQ. In answer to questions addressed to him,
Guttmann stated that Koch himself does not regard alight
affections of the heart as contraindications, and that
the pulse is considerably accelerated very soon after
the injection, long before the rise of temperature. In
this discussion expression was also given by two phy¬
sicians of their displeasure at the fact that the medicament
has not been placed at the disposal of practitioners, a feeling
veiy widely shared in medical circles here. The Berlin
physicians especially have had occasion enough to make
thcnrselvea familiar with the medicament, and have
taken advantage of their opportunibie.s with the keenest
interest. It is practitioners, above all, who are called
upon to treat those e.arly stages of the disease which
afford the best prospect of successful treatment, and
cases can be observed by them with just as much
care as in hospitals. The present method of distributing
the fluids robs practitioners of a part of their practice, and
is calculated to diminish the prestige of the medical pro¬
fession in the eyes of the public. Efforts, however, it is
said, are now being made with .a view to producing the
medicament in larger quantities, but as to their success or
failure nothing is yet known.
I must mention, in conclusion, that the efficacy of Koch’s
lliiid in tuberculosis of cattle is about to be tested; a
successful result would be of far-reaching importance.
I availed myself of the opportunity afforded me by a
Christmas trip bo Hamburg to visit tlio General Hospital
there, which is the largest in all Germany, and to inform
The Lancet,]
VIENNA.—NEW YORK.
[Jan. 3, 1891. 63.
myeelf as to the results which have heeo obtained there
with Koch’s fluid. The chief physician, Professor Kast,
received me with the greatest amiability, and gave me the
following information:—In surgical tuberculosis improve¬
ments, consisting in retrogression of inflammatory pheno¬
mena and improvement in functional capacity, have un¬
doubtedly been obtained in the six weeks or so during
which the treatment has lasted. No complete cure,
however, ha.s yet been effected. Professor Kast has
treated consumptive patients in all stages. In the
cases in which the disease was just beginning retrogression
of the local phenomena took place, the general condition
improved, appetite and weight increased ; but the improve¬
ments were not much greater than those obtained by the
methods hitherto in use. In the advanced cases a favour¬
able influence of Koch’s medicament was not observed.
With reference to the ther^eutic value of the remedy in
pulmonary consumption, Professor Kast agrees on the
whole with the opinions bitlierto stated by physicians in
great hospitals. Professor Kast also expressed his dis¬
pleasure at the manner in which the treatment of
patients is being carried on here in Berlin by the few
privileged doctors who are in possession of the fluid.
The indignation which this preference shown to in¬
dividuals, and the fact that the remedy has not been
placed at the disposal of practitioners, have excited, is spread¬
ing further and further in Germany. Numerous letters from
all manner of places to the daily papers give evidence of this.
The Medical Society in Breslau has accepted a resolution
protesting against the manner in which the fluid is dis¬
tributed as deeply injurious to the honour and prestige of
the medical profession, and this protest has been sent to the
Minister of Religious, Educational, and Medical Affairs, to
Professor Koch, and to the Silesian Chamber of Physicians.
The district unions of medical men in Berlin also, which
have madeittbeirtask to defend and promote the professional
interests of physicians and surgeons, are now beginning to
take an attitude in tlie matter, and it is to be hoped that wey
also will call upon the Chamber of Physicians, the officially
recognised body representing the medical profession, to
protect their rights and their prestige. Professor Koch Inm-
self is said not to be in the beat of moods, because probably
the course the whole affair is taking does not answer his ex¬
pectations. Be that as it may, he goes daily to see his
patients in the hospital in Moabit which has been placed at
his disposal. The building of the hospital to be erected for
him at the expense of the P.-usaian nation is being pressed
forward with great zeal, despite the very severe cold, so
that it may be expected to be opened in spring. Dr. Cornet
is about to open a hospital of ir)0 beds, which has been
erected expressely for this purpose at Charlottenburg near
Berlin, and will then assemnle his patients, who have been
scattered about hitherto in various parts of the city, there.
Projessor Wieffer,
The Emeritus Professor of Medicine, Dr. Priedrich
Wieger, who died the other day, was one of the oldest
teachers in the University of Strasburg. He was born in
1821, and studied there. In 1850 he was appointed o,gHg&
of the Medical Faculty, and in 1805 Professor of Internal
I’athology, an office which he retained when the University
was reorganised in 1872. His most important work is the
“History of Medicine and of the Medical School of
Strasburg from 1497 till 1872.”
Dr. Karl Seitz.
Dr. Karl Seitz, of Munich, has been appointed head of
the University-clinic there for the diseases of children, in
laco of the late Professor Alfred Vogel. Dr. Seitz has
een a private lecturer since 1886. The most interesting of
his contributions to clinical medicine is his account of tlio
relations between inflammation of the lungs and the
meteorological conditions of Munich. Of late he had
occupied himself chiefly with bacteriological studies, with
special reference to typhus. He is in his thirty-third year.
German Death-rates,
In the week which ended on the 0th ult. the death-rates
of the principal German cities were as follows: Aix-la-
Chapelle, 16’8; Altona, 21'3; Barmen, 17‘1 ; Berlin, 19;
Bremen, 16‘5; Breslau, 26; Chemnitz, 26'6; Cologne, 24'1;
Dantzic, 25; Dresden, 20'5; Dusseldorf, 20-9; Elber-
feld,24-8; Frankfort, 17’4; Hamburg, with its suburbs, 23'_9;
Hanover, 14-4; Koenigsberg, 24'0; Krefehl, 20‘3; Leipsic,
18-5; Munich, 29‘8; Nuernberg, 23; Stettin, 27‘3; Stras¬
burg. 21 •4; and Stuttgart, 16'i
Boilln, Doc. 30Ch.
VIENNA.
(From our own Correspondent.)
Koch's Treatment of Tuherculosis.
Last week the sanitaiy chiefs of the Austrian Army were-
called to Vienna, where a series of demonstrations and
lectures on the use of Koch’s remedy were given to them,
at the General Hospital and at the Garrison Hospital.
The use of the remedy in private practice has been now
more restricted by a recent order or the Austrian Govern¬
ment, by which the practitioners are ordered to notify
every case of death ocenrring during the stage of reaction,
or which may be caused by the reaction, and to submit-
all such cases to a post-mortem examination. The prac¬
titioners are also made responsible for any fatal event-
resulting from the use of Koch’s treatment Iw neglect of
the necessary attention to the symptoms. Onfy the use of
lymph supplied by Dr. Libberfcz of Berlin is permitted, and
tne attention of the physicians is called to the prescription
supplied by Dr. Libbertz with every bottle. For preparing
the solutions the use of 0-5 per cent, of the aqua car-
bolisata of the Austrian Pharmacopccia is recommended.
The results obtained up to the present by Koch’s treat¬
ment at the General Hospital are very various, especially in.
regard to the cases of pulmonary affections. Jn some cases
of surgical tuberculosis a well-marked improvement could
be stated, and the cases of lupus seem to become better as-
far as the local affection is considered; but some of the
patients have lost as much as from three to six pounds in
weight at Kaposi’s clinic.. Some of the smaller hospitals in
the country, and the garrison hospital here, have been sup¬
plied with the lymph last week. Two deaths of patients-
treated by Koch’s lymph occurred at the Rudolfs-Spital
here last week, but both were cases of highly advanced
pulmonary phthisis which should not have been subjected
to the treatment, and the fatal result was found to be due
to the advanced state of the tuberculous process itself.
Koch's Treatment in Leprosy.
As I am informed, one of the leprous patients, under the-
eare of Prof. Neumann, mentioned in my last letter to The
Lancet, shows signs of slight improvement after the injec¬
tions. The tuberous nodules have become more flattened
since the treatment commenced, and slight desquamation is
to he observed at the same places.
Peptonuria after Koch's Injections.
According to a communication made by ProFfsscir Koehler
at the last meeting of the Vienna Society of Physicians,
the toxic effect of Koch’s lymph is marked in some cases
by the presence of peptones in the urine of the patients
who have been injected. In 33 out of 200 cases the presence
of peptones could be tested; also in two cases of non-
tuberculous patients who had been injected for control,
peptonuria occurred after the injection, though no reaction
could he observed.
Vienna.
NEW YORK.
(From our own Correspondent.)
Opening of the Neio York Academy of Medicine.
The most notable event of the medical year in this city
was the opening of the new building of the Academy of
Medicine. This event occurred on Nov. 20th, when a recep¬
tion was given to the public, and congratulatory addresses
were made. The Academy was organised nearly half a
century ago by men whose names are now historical—
viz., Valentine Mott, John Stearns, John W. Draper, John
W. Francis, and others of scarcely less note. It has
steadily grown in favour with the profession and the
public, until it now takes rank with the mosb favoured
institutions of the city. The new building is located in-
the present and, apparently, future centre of greatest
activity, of social, scientific, and philanthropic societies
and clubs, and is in itself one of the most conspicuous
architectural structures in that vicinity. The huilding is
unique in its exterior form, while its interior arrangements
are adapted for large general meetings, for the meeting of
its ten or more sections, for a pathological museum and
rooms for pathological studies, and, finally, for its large
and rapidly gr owing library. The membership is about 700^
Dig
Tbe Lakoet,]
OBITUARY.—MEDICAL NEWS.
[Jan. 3,1891.
and the seating capacity of its main room is for GOO. Its
library consists of 40,000 volumes and 400 current medic^
periodicals.
Supervision of Immigration.
The constant arrival of immigrants from European
nationalities who belong to the dependent classes has led
to the preparation of a Bill in Congress which will provide :
for a careful inspection of every emigrant in foreign ports ,
before embarkation is allowed. Tlie Bill provides that
there shall be a physician attached to each consular ofhce,
who shall pei'^onally inspect the emigrants. The consul is
rei^uired to ascertain the necessary facts in regard to tbe
conditions under which the emigrant leaves his home —
whether as a pauper, criminal, or assisted; and each emi¬
grant must have the consul’s certificate as to these facts.
The steamship companies will be held to rigid account¬
ability in transporting uncertified immigrants. !
Assassination of a Medical Officer of an Insane Asylum. '
An insane man, who had escaped from the King’s County
Insane Asylum, returned after a few days and, with pistols
pointed at the head of the superintendent, demanded his
clothes. They were given to him, and he was allowed to
depart, meantime threatening the life of persons whom he
connected with his confinement. No effort was made to
arrest him, and several days later he returned, fully armed,
and, entering the office, inquired of tbe assistant physician
for the superintendent. On being informed that he was
out, the assassin shot the physician, killing him instantly.
He then deliberately walked away, everyone present
having fled, but was subsequently arrested. This occurrence
has led tbe Commission iu Lunacy to issue timely iustruc-
tions in regard to the care of dangerous insane patients.
Koch's Discovery.
A veritable craze exists over Koch's discovery. Hundreds
of young men have gone to Berlin from every part of the
country, and elaborate preparations are being made for the
immediate application of the remedy. The offers of
wealthy men to build hospitals for the cure of tuberculosis
is asbonUhing, and, if tbe remedy continues popular after its
trial, there will be an immense increase of hospital accom¬
modation.
Compound Lard.
Congress has lately been much engaged in discussing
what is popularly known as the “ Compound Lard Bill.^
The object of the measure is to regulate the manufacture,
sale, importation, and exportation of compound lard. This
article has been sold in market as pure lard, and has thus
come in competition with the pure lard made from swine.
Tbe Bill undertakes to define and regulate the manufacture
and sale of compound lard, under the pretence that, as a
food product, it is a fraud, made so by false brands and sold
for what it is not. The discussion has elicited many
opinions from scientific men as to the value of this material
as a cheap food. Compound lard is composed of beef sbearine,
cotton seed oil, and bog fat. The contention was chiefly in
regard to cobton-seed oil as a food. Many scientific men
testified before the committee, and the general opinion was
favourable to the compound lard. The analyst to the
Department of Agriculture, who analysed many specimens,
stated that the preparations were nutritious, and that tbe
cotton seed oil .waa as digestible as lard. Several State
analysts regarded tbe compound as a proper food to be sold
in the market, and that the cotton-seed oil was as digestible
and nutritious as olive oil. It appears from one report that
cotton-seed oil within the past ten years has almost entirely
taken the place of olive oil in our markets, and, though still
sold as olive oil, chemical and microscopical examinations
show it to be pure cotton-seed oil. It is a well-known fact
that Immense quantities of cottou-seed oil are sent to Italy
only to come back as olive oil.
-New York, I>ec. 1st._
MR. HENRY CRIBB, L.R.C.P. LOND., M.R.C.S.,
OJ- JlISlIOl’ STOKTI-OttD.
The natural gloom of recent winter days at Bishop
fjtortford has been much deepened by the untimely death of
Mr. Henry Cribb, whose genial nature and presence were
so familiar in tbe place. Eew deaths appeal more power¬
fully to tbe community of a country town than that
of a favourite medical man, in the prime of life, from
an acute disease, which removes him almost before his
neighbours and patients realise that he is ill. Such was
Mr. Cribb’s case, at the age of fifty, dying from typhoid
fever, the source of which could not be made out.
Mr. Cribb was the second son and youngest child of the
late John Jennings Cribb, formerly practising at Cambridge.
Having to retire early from practice, owing to failure of
health, with slender means, his family were mainly supported
by his brother, Henry Cribb, surgeon of Bishop Stortford,
who immediately adopted his namesake and nephew
“Harry.” The deceased was mainly educated at the Non¬
conformist School at Bishop Stortford. On leaving school
he was sent for twelve months to Germany, to acquire the
language, being then intended for a commercial life, and on
his return was articled to a firm of stockbrokers. On the
expiration of his articles he failed to find such employment
as he wished for, and his uncle, having no one to succeed to
his practice, suggested to his nephew that he should study for
the medical profession. He entered as a pupil at Middlesex
Hospital, and on becoming qualified was taken into partner¬
ship by his uncle and his partner Mr. Hodson in 1866. His
uncle survived only a few months, from which time up to
his death the practice was carried on by Mr. Hodson
and himself. Being of a very happy, genial disposition
from his early boyhood, he became a general favourite,
and formed many friendships which continued to the last.
He took a prominent part in the public business of the
town, and by his thorough truthfulness, honesty, and in¬
tegrity of purpose became, to use the words of some of his
friends, “the most popular and best beloved man in the
place.” His kindness and perfect straightforwardness in his
dealings with his professional brethren secured for him their
regard and unhesitating trust. The esteem in which he
was held by all classes was strikingly manifested on tbe
day of his funeral by the entire suspension of busi¬
ness and closure of every house, and by the attendance at
the cemetery of several hundreds of rich and poor, who came
to do him honour in spite of the inclemency of the weather.
He was an ardent supporter of the Essex and Herts Medical
Benevolent Fund, of which his uncle was one of the earliest
and staunchest supporters. Mr. Cribb M-as the brother of
Dr. Cribb of Highbiiiy, and leaves, besides a wife, six
children to mourn for him. Sorrow for his death extended
to the neighbouring towns, especially Cambridge, by the
consultants of which the late Mr. Cribb and his partner
were highly esteemed.
Society op Apothecaries of London.—T he
following, having passed tlie qualifying Examination in
Medicine, Surgery, and Midwifery, were granted the
diploma of the Society, entitling them to register and to
practise in tbe same:—
C. M. Baxter.
■I. M. JJeimett.
E. Boardman.
I'’, n, B. Brown.
H. B. Kcclea.
W. A. Eden.
A. A. Grosvonor.
C. P. I.ovell.
Luptoii.
C. A. .Moi'giui.
B. Naiitli,
B. S. Norris.
\V. B, J’assiiiore.
I*'. (!. lingurs.
■J. T. West.
C. S. Woodd.
In the Examination in Arts laat month there were 190
candidates, of whom IG received certificates, having passed
in all the subjects required for registration as medical
student. 109 passed in one or more ot the subjects.
Surgery.— A. Bock, Bonn University and Middlesex Hospital; J. M.
Boiinott, Liverpool University Uolloge and Sliefiiold ; E. Board-
man, Madras University and Eoyal Free Hospital; F. H. B, Brown,
B.A.Oxon,, Oxford and Guy's llospitJil; .1, II, Uenipster, Iving’s
College; II. B. Eccles and A. Craydon, St. Tlionias's Hospital;
A. A. Grosveiior, B,A.Cantab., Canibridgo and (iiiy’-s Ifospital; S.
Melville, University ColIeKo, Liverpool ; W, L. ({. Morgan, St.
Tliomas’s Hospital; .1. S. Newington, Edinburgh University; B. S.
Norria, Queen’s College, Biniiiugham; W. E. I’aasnioro, VVesb-
iniiistor Hospital; II. tie V. Staepoo!, .St. Mary's Ilospitul; .1. '1'.
West, Queen’s College, Birmingliani; C. .S. Woodd, St. Bartholo¬
mew's Hospital.
iledieine, J-'cn-enific Hei/icine, and Sfidwi/en/. —C, K. Baxter, Sheltield
and Charitig-cross Hospital; F. H. B. Brown, B.A., Oxon., Oxford
and Guy’s Hospital; W. A. Eden, King's College ; M. ,1. lioughlon,
Queen's College, Birmingliiim ; C. P. Lovell, B.A. O.xon., Oxford ami
Kt. Thomas's Hospital; J. Luptou, Owens College, Manchester;
Die;', -'ad b
.Google
The lancet,']
MEDICAL NEWS.
[Jan. 3,1891. 65
C. A. Morgan, fi;. Thomas's Hospital; B. Nauth, L. M. S. Punjaub
UnivQvsily, Lahore; B. S. Norris, Queen’s College, Birmingham;
]i. li/. Parkhurst, B. A. Oxon., Oxford and St, Mary's Hospital; 1*'. C.
Rogers, Owens Collage, Mancliestor; P. .1. Kyan, University College ;
J. 'r. West, Owens Collego, Birmingham ; C. S. VVoodd, St. Bartholo¬
mew’s Hospital.
The following passed in the subjects as indicated.
FomiHc Mediciii-e mid JUiduii/uri/. Hi. H. Knapp, St. Mary’s
Hospital.
Medicine .— C. A. Lapthorii, Middlesex Hospital; S. Melville,
University Collego, Liverpool; C. T. Standring, King’s College.
ForetiHic Uedivine. —II. B. T. Symons, Aberdeen University and
Charing-ovos.s Hospital.; A. L. Wykham, M.D., Harvard Univer¬
sity, Washington.
Faculty of Physicians and Surgeons at
Glasgow. —At the December sittings of the Doard of
Examiners in Sanitary Science, the following candidates,
having passed the necessary examinations, were admitted
diplomates in Public Health :—
David P. Gage, L.R.C.P. & >S. Ed., &e., Kilwinning; llainilton C,
Reid, M.B., C.M., Coatbridge; William Spenco, M.B., C.M.,
Dollar.
Epsom College.—D r. Holman, the lion, treasurer,
has just received a second cheque for £500 from the
anonymous benefactor of Epsom College.
Mansfield and Mansfield Woodhouse Hos¬
pital, —The Treasurer has received the first annual sub¬
scription of £25 from the Duchess of Portland for the
endowment of a bed at this hospital.
Football Casualty. — During a match on
Saturday at Blackburn, between the Blackburn Rovers
Reserve and the Accrington Reserve, a player sustained a
fracture of his leg.
Sewerage Scheme, Knaiiicsborough. — The
Knaresborongh and Tentergate Improvement Commis¬
sioners aod Local Board of Health have adopted a scheme
of main sewdrage and sewage disposal for the town of
Knavesborough. The sewage will be purified by the
process of intermittent land filtration, without the use of
clieniicals.
Middlkmork Post-Graduate Lectures. — Mr.
Eales delivered two lectures on Dec. 9ch and 16th re¬
spectively, at the Birmingham and Midland Eye Hos¬
pital, on the subject of Headaches, and other Results of
Ocular Strain and J)istress, in which ho explained the im¬
portance of good illumination. Ho then dealt with the
subject of asthenopia, including the neurasthenic type
and presbyopia; subsequently explaining bow hyper-
iiietropia, myopia, and astigmatism were each liable to
cause headache from ocular distress, the question of
insufficiency of convergence and heterophoria being also
discussed. The lectures were fully illustrated by working
models and diagrams, the work of the resident surgeon,
Mr. C. Armstrong .Luniley. .
LitkriVRY Intelligence. — Wo learn that the
Jonmal of Laryvfjology and Ithinoloyy will henceforward be
published by F. A, Davis, 40, Bevce'rs-street, London, W.—
Mr. Ed. Stanford has announced the publication, on
Jau. 12th, of “Studies in Statistics, Social, Political, and
Medical,” by G. B. Longstalf, M. A., M.B., I'cc. The work
is to be illnstrated with maps and diagrams.—The editor of
the Nursing Record announces that from henceforth the
price of the journal will be one penny, instead of twopence
as heretofore, and will contain several additional features
of interest .—llygimischc Ritndsc/iau is the title of a
new fortnigiitly publication, edited by Dr. Cail Fraenkel
and Dr. Erwin von Esmarcb, and published by A. Hirsch-
wald, Berlin. It is compiled after the fashion of the
numerous CcntralbliUtcr which has become so characteristic
a feature of modern medical journalism in Germany. It
would seem almost indispensable that such summaries
should be published, so wide and varied is the literary
activity of our age. No do«bt there is room for such a
periodical as this, although the department of Hygiene
includes many subjects—e.g., bacteriology—for which
special publications of a like kind exist. This first number
contains a leading article by Dr. von Esmarch on Dis¬
infecting Apparatus, and concise abstracts of published
articles on Infective Diseases, Drainage, School Hygiene,
l<'’ond Supply, Clothing, State Medicine, and other cognate
topics
National Health Society.—A complete course
of twenty-four lectures on health subjects at local centres
attended by some 500 ladies, has just come to a close.
Another course begins in the present month at the follow¬
ing centres: Westminster, Hampstead, Higbgate, Dulwich,
and Maida Vale.
Presentation,—A t the conclusion of the examina¬
tion at the Bolton Infirmary, on Saturday last, of a class of
thirty females in the first aidambulance course, Mr. E.
Claude Kingaford, L.R.C P.Lond., M.R.C.S., was pre¬
sented with a handsome timepiece, bearing an appropriate
inscription, by the members of the ambulance class, in
recognition of his services as lecturer.
Queen Victoria Jubilee Institute for Nurses.
Her Majesty has approved of a list of names which has
been submitted to her previous to being entered on the roll
of the Queen’s nurses for the purpose of nursing the sick
poor in their own homes. The list includes the names of
seventy-one nurses and twenty-two superintendents. The
inspector of nurses is Miss Rosalind Paget.
Society of Apothecaries.—T he results of the
Examination in Arts qualifying for registration as medical
student, held in the Hall of the Society on the 5th and
Gth ult,, have just been published. There were 189 candi¬
dates, and fron'i the Pass List it appears that 16 were placed
in the second class, and 110 were certified as having passed in
some subjects, but not in all. The next examination will
be held on March Gth and 7th.
Medico-Pkychologicad Association. — At an
examination held on December 16bh, in the Royal Edin¬
burgh Asylum, the following gentlemen were found en¬
titled to the certificate in Psychological Medicine granted
by the Association Stuart McCalium, M.B., C.M., Car¬
lisle County Asylum; Alexander Mitchell, M.B., C.M.,
Stirling District Asylum; John Simpson, M.B., C.M., Royal
Asylum, Edinburgh; A. K. Urquhart, Hon. Sec.
Open Spaces.—A t a recent meeting, held at the
Mission Hall, New Cross, in support of the proposal to
provide a public recreation ground on ten acres of land
on Pepys Hill belonging to the Haberdashers’ Company’s
Hatcham Estate, New Cross, a resolution was adopted
expressing the appreciation of the parishioners of St. Paul’s,
Deptford, for the generous ofler of the Haberdashers’
Company, and also for the liberal ofler of Mr. Livesey of
£2000 for the object in view, and that energetic efforts be
made to carry out the scheme.
Experimental Study of Atmospheric Impurity.
Tlie Manchester Eield Naturalists’ Society have, it is
announced, resolved to set up apparatus for analysis of the air
of Manchester, at the Town Hall, Owens College, in Huhne,
in Ancoats. in Strangeways, and in Salford. The experi¬
ments will be conducted so as to afford definite information
on : 1, The composition of the air in densely-populated
districts, as compared with tliat in thinly-populated and
suburban districts. 2. The relation between_ atmospheric
impurity and prevalent sickness and mortality. 3. The
amount'and distribution of those impurities which are known
to be specially prejudicial to plant life—for example, sul¬
phurous acid. 4. The extent to which smoke and noxious
gases are due (a) to dwelling-houses, (i) to factories. 5. The
nature of fog aud the character of the air during the pre¬
valence of fog. To cover the necessary expenses £200 will
be reqni?ed. The sub committee propose to work in concert
with a si«iiilar body in London.
Sveeetfiful applicanU /or Vacancies, Secretaries! t/PwWic Institutions, and
others possessina ii\fi>nnalion suitahle/or this eolvinn.-are invited to
forward <£ to TiiK Lancet Office, directed to the Sub-Editor, not lat^
than 9 o'clock on thi Thursday inomhiy </ each week /or pubiioation wi
the n’At number. •
Ai.DV.uSON, F. IlEiuiia.r, M.B.Duvh., L.R.C.P. Lnnd., M.K.C.S., ho*
been appointed lion, o Phvslcian to the West London I lospital.
Cl.OWES, VVm. F. a., M..VC.S., L.U.C.P., has been appointed Houno
.SurReon to the Easox and Colchester HospitaL
Dig^-ized by Google
66 The Lancet,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, & DEATHS. [Jan. 3,1891.
Haviss, D. L., M.B. Glas*., L.R.C.P., L.R.C.S. Edin., has been ap¬
pointed Medical Officer for the Firat Central District and the Work-
house of the Neath Union.
Ensob. Edwin T., M.D., L.R.C.P. Irel. <ft L.M., L.P.P.S., has been
appointed a Medical Officer for the Parish of Kensington (No. 2
Relief District), yice C. M. Frost, resigned.
Eustace, J. N., M.B., B.Ch. Dub., has been appointed Resident
Assietant Clinical Clerk to tho Richmond Asylum, Dublin.
-Oabriei., ARkatoon, L.R.C.P., L.B.C.S. Kdin., has been appointed
Medical Officer for tlie Borough of Dunolly, Victoria, vice Manson,
resigned.
Godfrey, G. P., L.R.C.P., L.R,C.S. Kdin., has been appointed House
Surgeon to the Mansli^d and Mansfield Woodhouse Hospital.
■Godfrey, Thos., M.R.0 S., has been appointed Consulting Surgeon to
tbe M.anatield and Mansfield Woodhouse Hospital.
Gordon, T. E., M.D. Duvh., M.R.C.S., has been appointed Medical
Officer for the Fifth Disti'ict of tire Strond Union.
HaSwei.L, .T- F.. M.B., C.M. Edin., has been appointed Medical Officer
for the Workhouse and the First Division of tbe Penrith District of
the Penrith Union.
Hughes, S,, M.B., C M., M.R.C.S., L.S.A., has been appointed Medical
Officer of Health for Coalville City, Utah, U.S.A.
Lindsay, D. Moore. L.K.Q.C.P., L.E.C.S. Irol., & L.M., has been
appointed Medical Officer of Health for Wasatch County, Utah Ter¬
ritory, U y.A.
J.ITTLKWOOD, H., F.R.C.S.,L.R.C.P.Lond., has been appointed Honorary
Assistant Surgeon to the I/Cods General Infirmary.
McLachlan, S. P., M.B., C.M. Glasg,, has been reappointed Medic-al
Officer of Health for the Longtown Rural District of tho Longtown
Union.
Moore, Geo., M.B.C.S., has been temporarily appointed Medical Officer
for the Shire of Moorabbin, Victoria.
Morrison, J. T. J., M.A., B.C. Cantab., F.R.C.S. Eng., has been
appointed Assistant Surgeon to the Royal Ortbopicdic and Spinal
Hospital, Binninghani.
•Odepl, Koukht, 1 M.U.C.S., L.R.C.P. Lond., has been appintod Medical
Officer to the Second and Third Districts of tho Hertford Union.
O'Dwyer, Jas. J., L.lv.(J.C.P., L-II.C.S. Irel., ha.s been appointed
Government Medical Officer and Vaccinator for til© District of
Gttiidagai, New South Wales.
Parsons, George G.. L.U.C.P. Loud., M.R,aR., h.as been appointed
Assistant House Surgeon to the Royal Albert Hospital, Devonport,
vice Dr. Fraser, resigned.
Pearce, A., M.R.C.S., has boon reappointed Medical Officer of Health
for the ISalcombe Urban Di.strict of the Kingsbiidge Union.
Rennkv, Henry, M.D. Durb., has been appointed a District Medical
Officer of the Sunderland Union.
Saunders, F. H., M.B., C.M.Aberd., has been appointed Meib'c.al Officer
for the Ripley District of tire Knaresborough Union.
.Stock, W. II.. L.K.(i.C.P. Irel., L.F.P.S. Glasg., lias been appointed
Medical Officer for tho Shire of Yea, Victoria.
Thomson, W. A. U., F.R.C.S., L.K.(J.O.P. Irel., has been appointed
Medical Officer for the Henley and Bmy Districts of the Cookham
Union.
"V/CKERS, John B., L-R.G.P.Bond., M.R.C.S., has been .appointed
llouso Surgeon to tho Hospital, Barrow-in-Fiirnc.s.s, vice J)r M C
Watson, resigned.
Wai.ker, II. Seckur, F.R.C.S. Kng., has been appointed Assistant
Oplitlialinic and Aural Surgeon to tho Ooiieral Infirmary at
Leeds.
Warren, Wii.ijam, M.K.<i.r:.P., L.R-C.S. Irel., has hcon appointed
Medic-al Officer for tlio Borough of Kow, Victoria, vice Walsh,
• resigned;
WII.I.IAM.S, A. WrMCEUUKD, M.B., C.M., has been appointed Patholo¬
gist to St. John's HospiUil for Diseases of the Skin, Leicester-
square.
Williams, Lewis, M.B., B.S.Lond., M.R.C-S.. L.R.C.P., has been
appointed IIou.so Physician to Univer.sity College fln.spjtal.
Young, Mr. W. J., has been roappointed Analyst to tho Wliitocljanel
District Board.
Far further information regarding each vacancy reference skmild he mado
to the advertkement.
A. The I,ancet Office, •(2:!, Strand, London.—Medical Officer to an
A.ssociation in the Midland Counties. Salary and allowances
about ,i;220 per annum.
Bismu‘’s S'l'ORTFOiii) Union.—M edical Officer to the Union Workhoiiso
Salary offered is fKI per annum (U> include all medicine.i) and .ES
per cent, on that siiiii for supplj iiig wd-liver oil and quinine, mid
the usual extra fees for midivifory aosu.s. (ripply to tliu Clerk to
the GuardiaiiH, Bwhop's StovLford.)
Bishop’s Stortfoiuj U.NioN.—Medical Officer and Public Vaccinator
for thoIIailingbiiryDistiict. .Salary offered is .607 10«. peraiiiiiiin
an<l.€r> percent on that sum for supplying cod-Jivoroiland quiniiio’
and the usual vaccination and extra fees for midwifery and .sur-
CTj;|j'^«tses. (Apply to the Cleric of tire Gua diaiis, Bi.shop’s .Stort-
■CITT Hospital tor Infectiou.s Di.sea.ses, Nervcastle-upon-Tyne.-
itesiflent Medical Assistant for one year. 'J'erins £r>il for the first
year, and, if reappointed, .€70 for tlie aecohd year, with board lodg¬
ing, and washing. ; ’ ”
Counties OF Stirling and Dumbarton.—M edical Officer to act for
the two counties and their districts. Salary £600 a year, witli
necessary travelling expenses, to be regulated by the County
Councils. (Apply to Mr.Welsh, County Clerk, Sirling, or Mr. Babtie
County Clerk, Dumbarton.)
County of DuMFRiES.~Mod«cal Officer for the County. Salary
.€300 per annum. Ho tvill I’eceive tho outlays necessarily inciuTed
in the dischar-go of his duties. (Apply to Mr. Robson. County
Clerk, Dumfries.)
Denihgusiiire Infirmary, Denbigb.—House Surgeon. Salary to
commence at £S5 per annum, with board, residence, and wastiingiii
tho house.
Diontal Hospital of London, Leicester-sqnare.—live Additional,
Dental Surgeons. '
East London Hospital i^or Children, Hhadwell, E.—House Sur¬
geoncy. No salary, but board and lodgin.g provided.
Hospital inir Con-sumption and Dlsease-s of the Chest, Brompton.
llouso Pliysicians.
INSPHCTOK OF Poor, Ronsay, Orkney, N.B.—Resident Parochial
Medical Officer. Salary .€60 per annum.
Kent and Canteruury Hospital.—A ssistant Ifouse Surgeon and Dis¬
penser (one offleo). Salary €.60 per aniimn, with board, lodging,
and washing.
Lancashire County Asylum, Rainham, near Livei-pool.—Pathological
Assistant Medical Officer. Salary £200 per annum, with furnished
apartments, board, attendance, and washing.
London Hospital Medical College, Turner-street, Mile-end, E.~
Assistant Demonstrator of Anatomy. Salary £00 per annum.
Medical association of Ronsay and ICgilshay. — Resident
MediciU Practitioner. (Apply to tho Secretary, Ronsay, Orkney
Isles.)
Messrs. A.skin^ Caiu)ITA.s, <fe Turing, r,8, Sackvillo-street, London, W.
Medical Olficor and Bnr.sar for an important I'ublic College. Salary
£200 j)ci' annum, in addition to board and residence, and small
amohunonts from I’ rivate Practice, which may amount to an addi¬
tional £100 per annum.
.Staffordshire General Infirmary.—A ssistant House Surgeon.
No salary, but board, lodging, and washing provided.
West RiniNa Asylum, Wadsley, no.ar Sheffield.—Pathologist, who will
also bo required to act as Fourth Assistant 6iodical Officer.
.Salary ,€100 per annum, rising .€10 a year up to £150, with
board Jic.
Wilts County asylum, Devizes.—Assistant Medical Officer. Salary
£120 per annum, with an amiual increase to .€160. Board, residence,
attendance, ami washing.
^liijrs, Piiniiigw, aiiii Dta.t!),s.
BIRTHS.
Bigger.—O n Dec. 21sfc, at Queen’.s-pai-k-gardens, Streatliam, tlio wihi of
/)r. W. Grimshaw Higgor of a son.
Heddy.—O n Dec. noth, at •!(>, Redclilfe-gardens. South Kensington, the
wife of William .lack.son Heddy, M.R.C.S. Kng., of a son.
Lewtas.—O n Doc. litli, at Simla, the wife of Surgeon-Major J . Lewtas,
M.D., of a .son.
Paramore.—O n Doc. 28tli, at Gordon-squaro, W.C., tho wiCo of Uiclid.
Paruniore, M.D., of a son.
MARRIAGES.
Caiidell— RirriiiE.-On Dcccinbcr 2i)th, at Trinity P^jsliytorian
Cliiirch, Clapliam-roail, .S.W., Arthur .Jolin Cardoll, Surgeon-
Dentist, Viotoria-.street, Wostiiiinstcv, to Helen, only daiiglitor of
Alexander Ritchie, C.C., Kelvin JIoiwo, South Lainhcih-ro.ui,
Clai>lram.
Clarke—Douglas.—O n Dec. mh, at St. Thomas’s Churcli, BrainpUm
liy tho Roctor, tho Bov. K. H. Shuttloivortli, A1..4.,and the lion, amt
Rev. R. K. Adderley. M.A., Vic.ar of St. Mary’s and All Saints,
Cliesterliclii, Kdmimd Woanno Clarke, B.Sc., M.B., C.M. Kiliii.,
M.R.C.S. Kng., to May, youngest daugluerof Bowery Douglas, JS.so.,
'i'he Cottago, Che.sterliuld.
Mackenzie—.Mar.sdin.—O n Doc. 22nd, at St. lUargaret’s, West¬
minster, Hector William Gavin Mackenzie, M.J)., to Kiimia
Nowcombe, widow of tho lato Septimus Marsdln, of Hull.
Salmon—Dunn.—O n Dec. 22ncl, at St. .John’s, Crii.nston-hill, Gl.asgow.
Charles Edward Salmon, J..H.C.P., I..R.C.S.K, only siirviviii;'
son of .John Morgan Salmon. Ksq., to Madge, older daiigiiter of the
lato Hugh Diiiui, Ef«i., Town Clerk of Darlington, Durham.
DEATHS.
Baii.lie.—O n Doc. 2r.th, at Roeiiampton, Cheltenh.ara, Herbort Baillio,
M.D., F.R.C.S., Surgeon-Major H.M. Indian Army, retired, aged 71.
Lowe.—O n Dec. 2(ltli, at Trinity Collego, Glenalmond, llow-ard (Jrilliths
J.owe, M.R.C.S., J..S.A., Bursar and .'Vledical Officer of tho College,
ageil 37. »
Solly.—O n Dec. 21 st, at 'ir.-i, Commorcial-rnad, London, .Stophon Francis
Solly, L.B.C.P. lidiii., AI.R.C.S. Kiig., L.S.A., aged 61.
Wjlkin.^ON.—O n Dec. 2tith, .at Feriilea-road, B.alham, Cliarle.s NoBon
Wilkinson, F.ll.C.S., L.S.A., lato of Upper Tooting, in the 7;hd year
of his ago.
F.F.—A fee cf Bs. is charged for the Insertion (f Notices of lilvths,
XtMTiages, and Deatiis.
Dig]jzed by
Google
Thb Lancet,]
BOOKS ETC. EECEIVED.
[Jan. 3,1891. 6T
BOOKS ETC. EECEIVED,
Cassei-l & Company, London.
Hygiene and Public nealbli. ByB. A. Whitolegge, M.D.jB.Sc.Lond.
tnustrabed. 1890. pp. 581.
'CnuBCHlLL, J. & A., NewBuflington-.qfcreet, London.
Handbook to Hr. Kocli'a Treatment :n Tubercular Hisoaao. By
Edward F. Orlin, M.R.G..S., and Walter I). Severn, A.R.C. Sei.
pp. 58. Price 8«. (id.
•GOVERNMENT PRINTING OFFICE, Washington.
Index Catalogue of tho Library of the Surgoon-Qoneral'a Office,
United St.i.ios Army. Authors and Subjects. Vol. XI.; Phie-
dronu.s—Edgont. 1890. pp, 1102.
LEcaosNiER ET Bade, Paris.
(Buvvos ConipEtos de J. M. Charcot: Homorragie ot Itamollissemont
tlu Corveau Mdtallothdvapie et Ilypnctisuie Kloctrothiirapio.
Tome IX. 1890. pp. 644.
I.Ewrs, H. K., Gowor-atreet, London.
Manual of Bacteriology. By ISdgar M. Crookshanic, M.B. Third
Edition, revised and enlarged. 1890. pp, 400.
Antiseptics in Obstetric Nursing. By John Shaw, M.H. Lend,
Illustrated. 1890. pp. 129.
Illustrated Locturoa on Nursing and ITygiono. By R. Lawton
Roberts, M.D. Bond. 1890. pp. 101.
LONGMANS, Green, & Co., London.
A Text-book of Chemic.al Pliy.siology and Pathology. By W, T).
Halliburton, M.D., B.Sc., M.ll.C.P. Illustrated. isOl. pp, 874.
Price 28s.
PnihiF, George, & Son, Floot-street, London.
Tlie Practical Guide to Algiers. By Geo. W. Harris, pp. 174.
.SMITH, Bi.EEH, & Co,, Waterloo-place, London.
Dictionary of National Biography. Kdited by Leslie Stephen and
Sidney 1 a)o. Vol. XXV. Harris—Uenry I. 1891. pp. 457.
•Stanford, Edward, Cockspur-stroet, Cliaring-crosa, London.
Studies in Statistics, Social, Political, and Medical. By George B.
Longstaff, M.B. Oxon,, L.R.C.P. With Maps and Diagrams.
1891. pp. 465.
THE S. S. WHITE Dental MANiiKACTURiNa Company, Pliiladelphia.
Tho Micro-organisms of the Human Mouth. By Willoughby D.
Miller, D.I).iS,, M,D. lllustr.iUjd. 1890. jip. SG4.
Lehrbuch <lor Arxneimittcllohre nnd Arzneiverordnungslehre; von Dr.
H. TVippeiiier (F. C. W. Vogel, LeipKig, 189(1).—Casuisiisch-Statistisehe
Beitriige xur Patliologio lind Chirurgio cler (.{allenn-ege; von Hr. L.
G. Courvoisior (F. C. W. Vogel, Loipy.ig, 1890).—Tile 1‘ublialiei-s’ (Sr-
oulav Cliristmas Numlier, 1890 (Sampson Low & Co., London).—Die
Tuberkulose'dov ICnochen und Golenko; von Dr. Med. Fedor Krause
(F. C. W, Vogel, Laip'/.ig, and William.s & Norgato, London, 1891).—
Foster's Bijou Guido to rifracombe and Neighbourhood, 1890 (W. R.
Foster, Ilfracombe).—Eightli Annual Repoit of the Metropolitan
Public Gardens Association, 18!>0; llvstedition(Ilutoliings&Crowsley,
Limited, South Keiisiiigtoii).—Klinisch-lSxporimeatolle Studien uber
Olunirgisciie Infectionskraiikhoiten; von Dr. .iulius Fosslor (Hr. C.
Wolf & Soiin, MUnclien, 1891).—Dio yEtiologio mid das Woson dcr
ftkiiten eitrigon ISutr-tindung ; von Dr. Albert Kronaoliei' (G. Fi.scher,
Jena, 1890).—Indox-Medicus; Authors and Subjects; Vol. XII. No, il,
November, 18!H) (Trlibnor & Co., and Lewis, London).—Tiio Abuse of
.a great Charity; by George M. Gould, M.H. (reprinted from tho
Medical Nows, Nov., 1S90).—Addresses delivered on Die occasion of
the Commoncement ICxercisos of Cooper Medical College, November,
1890; by L. C. Laiio, A.M.,M. D.,aml l»y ltdwd. 11, Taylor (Goodwin anil
l^ylor, San Franuisco).—Your First (/amo of Golf; by G. Ifillintliorii
^ay Son, Berners.street, London).—Pi-ocoodings of the Society for
Psychical Itesoarch, Doceinber, 1890 (Kogan J’aul, Trencli, Trubnor,
(jO., l.ondon; price Iki.—'I'lio .loiirnal of Mental Science, Jan.,
1891; New Series, No. 120 (J. & A. Giiiirchill, London); price 8,s'. (W.
METROPOLITAN ASYLUMS BOARD.
Beh m of Patients remaining in the several Fever ffospitais
of the Board at midnight on December 30th, 1890.
Hospital.
Beds occupied.
Total accommo¬
dation.
V
T{ V
g£
OT —
4
s
5
O.
(3
1-
\Q V
Enteric
fever.
Other
diseases.
■i
o
H
Eastern Hoapltal .. ..
"wthjWestern Hospital
South-Western ' ”
South-Eastern
Northern
<5ore Farm ”
288
299
15(i
214’‘
244
8;il
121
4(;
29
1(1
It
29
28
1
03
9
20
1
63
IS
0
1
2
1
401
329
194
22(1
327
877
121
442
443
262
340
402
480
800
Totals
1044
159
1
104
10
1078
2729
* 1 infant and mother.
Slt!bical Jiarg for maiitg ®wfe.
Monday, January 6.
Royal London Ophthalmic Hospital, Moorfields. —Operationa
daily at 10 a.m.
Royal Westminster Ophthalmic Hospital.—O perationa, 1.80 p.m.,
and each day at the same hour.
Chelsea Hospital for Women.—O perations, 2.80 p.m. ; Thursday, 8.80
St. Mark's hospital.— operations, 2.S0 p.m. ; Tuesday, 2.80 P.M.
Hospital for. Women, SoHO-S(iUARE.—Operations, 2 p.m., and on
Thursday at the same hour
Metropolitan Free Hospital.—O perations, 2 p.m.
Royal OR’rrioPiCDic Hospitai _Operations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 8 P.M., and
each day in tho week at tlio same hour.
University College Hospital.—K ar and Throat Department, 9 a.m. ;
Thursday, 0 a.m.
Medical Society op London. —8.80 p.m. Dr. .Stephen Mackenzie:
Aruemia, its Pathology, Symptoms, and Treatment. (First
Lettsomian Lecture.)
Tuesday, January 6.
Kino’s College Hospital—O perations, 2 p.m. ; Fridays and Saturdays
at tho same hour.
Guv's HosPiTAL.~Operation8,1.80 P.M., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 p.m
St. Thomas's Hospital,—O phthalmic operations, i p.m. ; Friday, 2p m.
Cancer Hospital, Brompton.—O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.30 P.M.
St. Mary's Hospital.—O perations, 1.30 P.M. Consultations, Monday
2.30 P.M. Skin Department, Monday and Thursday, 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Electro-
therapeutics, same day, 2 P.M.
Royal Institution.— y p.m. Prof. Dewar : Frost and Fire. (Adapted
to a Juvenile Auditory.)
Patkolocicai. Society of London.—8.30 p.m. Sir'Hugh Beevor;
Note on Media for Cultivation of Tubercle Bacillus.—Dr. F. J.
Smith : Chyloais Aseitea.—Mr. Hurry Fenwick: Largo Hydatid in
Pelvis obstructing both Ureters,-Hr. William Hunter : Subacute
Gastritis.—Dr. S. West: Multiple Tubercular Tumours in Brain
nnd Viscera.—Mr. .Stephen Paget; Imperforate Rectum.—Dr. B.
Maguire: Acute Verrucose Aortitis. — Mr. E. C. fttabb : Two
Specimens of Dermal Cy.sts. t.'anl Spocimena : Mr. H. B. Robinaon •
( 1 ) Webbed Fingers and Toes ; (2) Oy-stic Disease of Testicle ;
(;i) Coluranar-celleil Carcinoma of Small Intestine.—Mr. W. G
Spencer: (1) Lympho-sarcoma in Dog sniTounding Trachea ami
Bronchi; (2) I.ympho-sarcoma in Dog siiriwinding Aorta; (y)Leuco-
oythemia in Cat. —Dr. G. Gnlllver: Acute EndocArditis of tho
Right Side, with Pulmonary limbolism.
Wednesday, January 7.
National Ortuop^:dic Hospital.—O perations, 10 a.m.
Middlesex Hospital.— Opoiationa, 1 p.m. Operationa by the Obstetric
Physicians on Thiiradaya at 2 P.M.
St. Bartholomew's Hospital.—O perations, 1,80 P.M.; Saturday, same
hour. Ophthalmic Operations, Tuesday and.Thui'sday.d.SO p.jj.
Surgical Consultations, Thursday, 1.30 p.m. •
Charino-cros.s Hospital.—O perations, 8 p.m., and on Thursday and
FYid.ay at the same hour.
St. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same hour
l/ONDON Hospital.—O perations,2 p.m. Thursdav&Saturday.saniehour
JST. Peter’s Hospital, Covent-gauden.—O ponations, 2 p.m.
S-iMARi'i'AN Free Hospital for Women and Children.—O perations
2.30 P-M.
Great Northern Central Hospital—O perations, 2 p.m.
University College Hospital.—O perations, 1 .:jo p.m. ; Skin Depart¬
ment, 1.45 P.M.; Saturday, 0.15 a.m.
Royal Free Hospitai..—O perations, 2 P.M., and on Saturday.
CHILDREN'S HoSPi'iUL, GREAT Ormond-strket.—O perations,9.80 a.m. ;
Surgical Vi«ita on Wednesday and Saturday at 9.16 A.M.
ODSTimviCAL Society of 1,oni>on (20, Hanover-square, W.)_S P.M.
Specimens will be shown by Dr. llanddold-Jones, Dr, John Phillips,
and others. Dr. W. S. Playfair : On Removal of the Uterine Ap¬
pendages in c.asea of Functional Neurosis.—Dr. .lohn I’hillips : On
a ca-ie of Death following Vaginal liijoctimi of Acid Nitrate of
Mercury.—Di’. W. S. A. Griffith: Case of Obstructed labour in
which a largo Fibroma of tlie Ovary was mistaken for the Head of
au Kxti a-uterine Fwtus.
Thui’sday, January 8.
St. George’s Hospital.—O perations, l p.m. Surgical Consultations,
Wedneaday, 1.80 p.m. Oplithalmic Operationa, FYiihiy, 1.80 P.M.
University College Hospital.—O perations, 2 p.m. ; Bar and Throat
Department. 9 A.M.
Royal Institution.—3 p.m. Prof. Dewar : Fi'ost and Fire. (Adapted
to a Juvenile Auditory.)
British GYNASCOtOGiCAL Hocietv.—S.30 p.m. Annual General Meeting.
Jtioction of Oftjeeva. Prcaiiient'a I’aiodictory Address. Dr. 11. T.
Smith : On Lacevation.s of tiro tiervix Uteri.
IIARVEIAN SOCIETY OF LONDON.—8,30 P.M. Dr. J. Kilward Squil-o:
llemark.a on cases of Tubercirlusis treated by Koch's Method.
Friday, January 9.
Royal South London ophthalmic hospitai,.—O perations. 2 p.m.
Clinical Society of London. — 8,:jo p.m. Annual Meeting. Dr.
Whipliaiu and Mr. O. R. Turner : A ease of Intussusception, with
Volvulus of the Small Intestine in Two Places. — Mr. G. B.
I.ockwdod : A case of Acute Intussusception in a Child four years
old ; resoction ; death from shock twenty hours after operation.
Saturday, January 10.
Middlesex Hospital.—O perations, 2 p.m.
University Coli.ege Hospital.—O perations, 2 P.M. j and Skin Depar
ment 9.16 am
Diy!. _U(j by Coogle
68 Tbb Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
fJAN. 3, 1891.
METEOROLOGICAL READINOa
(Taken daily at 8.t0 a.m. by Stewards Inetrwnents.)
Thb Lanost Office, Jan. 1st, 1681,
Data.
Barometer
reduood to
Soft Levs!
and 89’F.
Dlreo-
tlon
of
Wind.
Dry
fiulD.
Wet
Bulb.
Botor
Sadia
Id
Vaouo,
Hail-,
mum 1
Tomt).
Shade.'
Min.
Temp
Bain-
falt.
Bemuks at
ass i.M.
Dec. 26
30 31
S.E.
S3
38 :
27
Foggy
.. 27
3i)'33 ■
K,
34
33
40
82
Overcast
.. 28
30’If.
E.
33
34 .
36
31 !
Overcast
.. 29
30-26
N.E.
31
82
80 ;
Overcast
., .30
30-27
E.
27
29
27
Overcast
.. 31
30-19
K.
27
37
22
Overcast
Jan.1/91
30-17
E.
37
SO
39
27
Overcast
Itotes, i It
^tomsponittnis.
It is especially requested that eas-ly intelligenee of local
events having a medical interest, or which it is durable
to bring v/naer the notice of the profession, may be sent
dnrect to this Office.
All eom/nvwmcations relating to the editorial business of the
journal must be addressed “ To the Editors."
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private in¬
formation, must be authenticated 6 ^ the names and
addresses of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed ''To the Sub-Editor."
Letters relcding to the publication, sale, and advertising
depavtments of The Lancet to be addressed "To tiU
Publisher."
We cannot undertake to return MSS. not used.
Tiiio Lancet during isoo.
It is interesting (\vritQ3 a correspondent) to observe tlio steady growth
in the uipacity of The Lancet, wliich is well illustrated by the
following statistics. In 1880 it was onlargod to 90 pages, and in 1S8S
tolOL In 1888 The Lancet beat its previous yearly records by .'512
pages ; ii] 1889 it leaped beyond tlial lo the oNteiit of 27 jtages ; and
dnritig the year just past it Ims exceeded even that figiii'e by 304
pages in the year. This huge volume contains in jiIl 14,032 columns,
uf wliieh ri8-l8 are allotted to litevaturo concerniug medicine and its
rognate subjects, and SplS-l columns are devoted to advertisements.
The index alone occupies 101 pages. Calculating from these figures,
it will he found that the average number of pages allowed
for eacli number has been 130, showing an average iiicroaso
of 9 pages ill each issue over last year’s volumes. On examining the
sixe of the individual impressions it is found that the first number of
the yeai' and the .Students’ Number (Sept, iftb) contained 184 pages,
tlie largest number of The Lancet ever iasuod. The next largest is
tlie num)>er coiitainigg the special supplement on life assurawte and
tiiR inoJical profession, which contained 170 pages. Tlie i.ssiio of
March l.st, containing the report of the Hyrlcrabad Commission on
Chloroform, contained ICO pages; six numbers contained 144 pages,
sixteen contained 13C pages, there were thirteen niimljorsof J28 pages,
and several containing 120 pages each. This reprosonls the in¬
crease of 304 pages over the previous year. A Special Jidition
of TiiK La.ncet was published in connexion with the Hospitu-I Sunday
V'uiiil, and there were three special supplonienLs. The columas of
literary matter include reports of clinical lectures extending over
r)32 (X)Innins; nearly 931 columns liave boon devoted to clinical
articles, and the cases recorded in the Mirror of Hospital i’ractice
reriuifcd 270 columns. Tho columns devoted to analysis last year
amounted to 13 only; while tliis year <'lose upon 139 columns
have been devoted to this important branch, and 130 eolnrans
have been used for notifying new inventions. Annotations have
taken up 940 columns, and loading articles have reacliod over
.Wi columns, while special articles have extended to 1304 columns.
About 153 columns have been devoted to tho interests of public
health, and reviews and notices of books occupy 178 columns. Cor¬
respondence has received space to the amount of 400 columns, and
the aiLswers to correspondents monopolises 160 columns; mi.scellaneous
medical news cover some 416 columns of The Lancet. ' Ihirther, tho
Students' Numberroferredto above contained 128 columns devoted to in-
foi-nmtion concerning the regulations and arrangements of the various
medical schools and examining bodies. Notices and reports of the
British Medical Association have occupied 40 columns, the reports
of tho General Medical Council amount to over 07 columns. Over lOQ
columns have been devoted to obituary notices, and 40 columns to
foreign and university intelligence; special lectures have occupied 80
columns. Thus 5300 columns of matter have been accounted for, and
the remaining 439 have been taken up with special supplements,
reports of medical societies, law cases, and parliamentary news of
interest to the members of the profession, and medical news of a
general character.
M. 0. II .—The details given do not suffice to enable us to judge of the
grounds on which the refusal was based. But if it was on the
assumption that the duty lay with the medical officer of health, the
practitioner in question was altogether in error. A glance at the
prescribed duties of health officers will at once show that the -
granting of ceitiflcates of fitness to attend school forms no part of
such duties. Whore parents require certificates, there would be no
objection to the medical officer of health granting them as an expert
and for a proper fee, unless the terms of his appointment debar him
from such practice.
Jfr. IJ. Jones.—tio classification of the causes of insanity, so far as wo
are aware, includes the one mentioned by our correspondent.
THE TREATMENT OP CONSUMPTION.-A PROTEST.
To the Editors of THE LANCET.
Sms,—In the advertisement columns of your last issue I see iodide of
gold mentioned as “ the true germicide and virus neutraliser ” in rela¬
tion to the tubercular bacillus, and attached to this somewhat sweeping
title are the names of two analytical chemists, in brackets', from which
I gather they desire to brand the discovery as thoir own. If any person
interested will refer to The Lancet of July 21st, 1888, he will find, at
the end of my original article on the treatment of tubercular phthisis
by hydrarg.perchlor., the following passage“I believe the persalts of
some other metals (e.g., gold) might be found to have as good a germi¬
cidal effect, if preferred to the mercuric salt.” In view of this com¬
munication, an attempt to claim the use of gold in the treatment of
tuberculosis as a separate invention would be an infringement on my
discovery, and doubtless I have only to draw attention to the matter
for the gentlemen in question to acknowledge that they are about two
years and a half too late. I may mention that long ago I tried both
the chloride and iodide of gold in the treatment of con-suroption, as
well as tho persalts of mercury and other mefals, and that I have been
preparing a paper to submit to you wherein tho results so obtained arc
mentioned, but whicli, through family beimvement, I have not had
time to finish. I am, Sirs, yours obediently,
Lavender-lull, S.W., Dec. 22n(l, 1809. P. T.vvLOii SiMSON.
MicDic'Ai. Practice in South America.
J. A. C.—Opinions about the openings for practice in South America
for English medical men ■'■ary, but that there are many such
already settled there may be gathered by a glance at tho pages of the-
Medical Directory. By comparing tho list in the volume just pub¬
lished with those in former issues, it would seem that tlie number of
British practitioners in South America is increasing. In Buenos
Ayres there are now twonty-ono, and in Monte Video nine. Most of the
Soutli American Republics refuse to recognise foreign diplomas, and
insist upon ail who wish to practise passing an examination; and the
examiners, being already established, are freriuently none too ready,
it is said, to recognise the merits of new aspirants. In British Guiana
British diplomas are locognlsed. We have, however, never iioard that
there is any paucity of practitioners thero. As wo are frequently asked
about openings in South America, wo should bo voi'y glad of any
authentic information from any of our readers in that part of tho
world.
An Old Header,—As regards the general liteiuture on scarlatina, the
article by Thomas in tho second volume of Ziemsson’s Cyclopaalla of
' tho Practice of Medicine may be referred to. It embodies, amongst
other things, a fairly complete record of other writers on tho same
subject. One modern contribution to scarlatina is Dr. D. A.
Gresswell's “Contribution to the Natural History of Scarlatina’'
(Clarendon Press, Oxford, 1890), The etiology of the disease from
the point of view of the Medical Department of tho Local Govern¬
ment Board is partly summed up in a separate issue, to bo obtained
from Messrs. Knight and Co., 00, Fleet-street, price id,, and entitled,
“ Milk-Scarlatina, 1388,” and from tho annual reports of tlie Medical
Officer of the Local Government Board for 1888 [C6I71I and for 1887
[C6526-IJ, procurable from Messrs. Eyre and Spottiswoodo, Ea.st
llarding-stroet, E.C
Digliized by
Googic
Tbb Lakcbt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS,
[Jan. 3,1891. 69
Women’s Ouganisations for Prevention of Intemperance.
The Women's Societies in Ireland ifor discouraging; intempoiunco have
addressed tliomselves to the members of the medical profession in
Ireland to use their professional influence in favour of the diminished
use of alcohol. We cannot doubt that the profession will gravely
consider the representations made to thdm by the women of Ireland.
They may not adopt all their conclusions, but they will not ignore
the amount of drunkenness among men and women, which it should
be the object of all parties and profossions to abate.
TT. <?. S.—The practilionois in the neighbourhood should bring the
case under tlie notice of the Apothecaries’ Society, the Dentists’
Association, and the Medical Defence Union.
MILK IN UONNKXION WITH SEPTIC DISEASE.
To the Editors of THE IiANCEt.
Sirs,—W hen an epidemic of infectious disease arises, and nothing can
be made out as regards its origin, we are often inclined to blame the
milk-supply, and a poor, unfortunate inillcman is set upon and ruined,
without anything of a positive proof being produced tliat the milk is at
fault. Now I venture to put forward a test whicli will at any rate help
ns, in some degree at least, as to the direction in which we should malce
our inquiries. If by far the larger pi'oportion of individuals attacked be
children, it would only be natural to suppose that the milk was in some
way or other the cause, inasmuch as childi-en are by far the larger milk
drinkers, If, on tlie other hand, grown-up people furnish the larger
number of victims, it is not unlikely defective drainage is the c.ause.
As illu.strations of the correctness to a certain extent of the pro¬
posed test, I will adduce the facts connected with two different
epidomics. In the first, by far the greater number of tliose attficked
were chihlren, and it was proved that tho person wlio .served out
the milk also nursed a girl who was dangerously ill with diphtheria in
the house at the very time. In tho socond instance, no person under
nine years of age was aiTected ; generally there were about two in each
house attacked, and these, whore tiiere were baaemonts, were the
.servants. At the time there was a heavy barometric pressure prevailing
and tho road ventilators were smelling badly. Nothing could bo found
wrong with the cows, labourers, water, or sanitary arrangements con¬
nected with the farm or dairy from which the suspected milk came, and
hence Ithinkthedrainagemay fairlybe set down as having been thecau.se
of tlie outbreak. From a review of these two epidemics I think, where
notification is inforce.theageof thopevaoiisattacked should be given with
the other information. Now, on almost every occasion when an out¬
break of infectious disease arises, we are counselled by the authorities
to boil the milk in order to destroy any germs that may possibly exist;
but as regards tlie advantage of this I have always been rather
sceptical, knowing that they witlistand a very higli as well as low
temperature : and a few days hack I consulted various chemical text¬
books as to the point at which milk usually boils, but from none could
I olitaiu tho iufonnation, I then asked one or two persons whom I
thought would bo sure to know, with ex.actly the same result.
However, I subsequently learnt the temperature was from ai-i" to '218 '.
After this I wrote to Mr. Watson Choyne of King’s College, one of onr
best authorities on micto-orgatii.sms, to know whether tho boiling
of milk was sufficient to destroy all existing germs, and his answer was
as folh)Ws :—“ Tho temperature necessary to kill depends upon whether
tlie bacteria are in tho adult or spore condition. In tho spore <mnditi<)n
in milk it would need somewhat prolonged exposure to a boiling tcmpeiu-
ture (in a water bath) to destroy tiiom, hut wliou I worked with these
things I found tho only certainly successful way was to boil for ton or
fifteen minutes for three successive ilnys, tlius giving tho siioros a
chance of sprouting in the interval and catching them as adults.”
What tho value of the milk would bo under these circumstances it does
not require mucli knowledge to make out. However, whenever an
epidemic arises, I think we should seize upon the opportunity to per-
-sutido tho people, at any rate whoso houses are attacked, to get their I
sanitaiy [irrangoments looked into by someone duly <iualittod for tho
task, and not allow dofleiencies to remain uncorrected till another out¬
break of infectious disease arises.
I am. Sirs, your obedient servant,
Surbiton. F. Atkin,SON, M.D,
An Ai)VEiiTisiN<i PracjtitiojNkr at Exeter.
The quiet respectability of medical practice at Exotor has been
naturally shocked by the distribution of handbills among tho patients
of other pra<^titionoi-s, aimounciug tho establishiueiit of the Polsloo-
I'oad Provident Dispensary, :i, llegcnt’a-terrace, and the attendance
tliore of physician and surgeon at certain houv.s, at a cliargo of 1 ». !i
week. Wo must I'oniiiid tho practitioner that such an innovation in
tho methods of practice is not justified hy calling the house a dis¬
pensary, or by tlie omission of the names from (lie bill.
A. F.i,.—Whilst “erysipelas,” as such, is a notifiable disease under
■Section 6 of the Infectious Disease (Notification) Act, 1880, pharyngitis
qualified by the adjoctivo “ erysipolalous''is nob referred to in the
Section, Where statutory rights i re claimed, the terms of the
-statute in (luostion should be complied with.
Work Exhibition.
An exhibition, arranged under the direction of Messrs. Cassell, Fetter,
and Galpin, was opened this week at the Polytechnic Institution in
Regent-street. It maybe said to represent in a practical form the
outcome of that firm’s most noted publications — the Popular
Edueator and the Technical Educator. The exhibits include drawing,
building construction, manufactures in wood, plaster, and metal,
tools, &c. The exhibition was opened by Sir John Lubbock, Chairman
of tlie London County Council, who, in the course of an able speech,
said that such exhibitions not only were a great boon to exhibitors,
but also helped to promote commerce and manufacture. He believed
that the next fifty years would witness as great and marvellous dis
coveriesas tho last half century had produced, impossible though such
a result might seem. Tlie meeting was also addressed by Mr. Arnold
Foster (representing Messrs. Cassell and Co.) and Sir Lyon Playfair.
The latter gentleman thought the exhibition was a happy idea, as it
was a means of tho Polytechnic students showing what they could
do with their hands. The exhibition promises to be one of con¬
siderable attraction and a means of instruction in a most interesting
form.
A SubHC7-iber.—The matter should bo formally brought under the notice
of the committee of the hospital.
Principal.—Ovir correspondent should show the form to his solicitor.
ASSISTANTS.
To the Editors of The Lancet.
Sirs,—T here seems to mo to bo one phase of t.ho question in regard
to the extension of the term of study of medical students to five years
which has not yet been touched on by any of your correspondents—
viz., What elfect will this extension to five years have upon qualified
and unqualified assistants? Qualified assistants will be scarcer; con¬
sequently they will roquire at least £!00 per annum, in-door. Two years
ago I had aboiic twelve applications for a vacancy as qualified assistant;
last October I had to wait thveo weeks for one, give .620 per annum more,
and allow second-class rajlway fare. Wha^ will it be in four or five
years? I fear this scheme will financially improve the position of un¬
qualified men ; instead of getting a man who has had, under the old
system, three years' training by imictical nieu, a gi'eab number of
general practitioners will liave to get unqualified nion (who must be in¬
ferior), and perhaps have to pay them .600, in-door. I tliiuk it is time
that those gentlemen in authority either did not allow those unqualified
men to bo omployed ordeftned their position, so that tliose who cannot
afford to keep an M.R.C.S. might employ them. It seems a paradox
that a medical man is allowed to keep a man to visit, dispense, and
attend midwifery who perhaps has never been in a hospital as a
.student. Yet if a phthisical patient had a fatal hannoptysis in tho
principal's absence, or otlior sudden doatli occurred from a clear cause,
the patient not having been attended hy a qualified man—if tlie
principal gives a certificate ho may lose liis diploma. Those in authority
should speak out very plainly on this matter; they are putting qualified
assistants out of our reach. Lot thorn either sanction or not these
men's services as assistants ; otherwise, many a well-intentioned prac¬
titioner takes a step in the dark wliich may bo his destruction. As far
as my iminble opinion goes. I think the medical profession in ten years'
time, in tho uianufacturing town.s, will be worked entirely by unqualified
as.sistants. 1 am. Sirs, yours faithfully,
December, 1890. (!. P.
The Meeting of tub Association of Fellows of the
College of Surgeons.
Dr. Collins asks us to state that in his remarks at the above-named
meeting on tho 20bh ult. lie made reference only to Fellows, not to
Members of the College.
A. B. C. should consult a registered medical practitioner.
DIET IN DIABETES.
To the Editors of The Lancet.
Sirs,—W hen diabetic patients are getting on pretty welt and the urine
is free from sugar, or nearly so, they often wish to have a little more
latitude in their diet. The question then ai'ises, Which foods are the
lejiat injurious to begin with ? If physicians who have devoted special
attention to this disease would kindly inform us, it would he very
helpful to many general practitioners. Tho lists wliicli are given by
consultants of foods allowed and forbidden do not help us at this stage.
Last year I allowed a patient peas as a change from cabbage, and now
ho is going on with lentils. I presume those articles are loss injurious
than other cereals. But are they? An authoritative answer would
oblige, Yours obediently,
December, 1890. M.R.C.S. Ac.
Erratum.—I n our annual summary last week, iiiider tho heading
"Army, Navy, and Indian Medical Services,” page 139-1, in the
enumeration of the members of the reconstituted Army Sanitary
Commission, the name of Sir C. Cameron was erroneously given in
place of Sir Joseph Fayrer, K.C.S.I,
Digitized by
vaoogle
70 Thb Lancbt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 3,1891.
COMHiTNiCATioxs not noticed In oui present number will receive atten-
Ucn in onr next.
OOHHimiOATiONS, LErrsRS, &o., have been received from—Dr. Warner,
London; Dr. Bexley Thorne, London ; Sir Jamea .Sawyer, Blrming-
bam; Mr. S. Paget, London; Dr. W. Squire, London; Rev. Horace
Waller; Dr. Macdonnell, Montreal; Dr.Wolf-Smith; Mr. Edward
Mark, London; Mr. Blenkame, Leicester; Dr. J. W. Wlilte, Toronto ;
Mr. Urquhart; Dr. J. E. Squire, London ; Dr. Pardington, Tunbridge
Wells; Mr. Bmenson, Scotter; Mr. G. Smith, Birmingham; Dr. Leslie
Phillips, Birmingham; Mr. F. Venrace, Birmingham; Messrs. Condy
and Mitchell, London ; Dr. S. Coghill, Ventnor; Drs. J. L. Steven and
Workman, Glasgow; Mr. E. Cotferell, London; Mrs. Gardiner, East
Dulwich ; Mr. P. A. Davis, London; Dr. Rentoul; Messrs, Krohno
and Sesemann, London ; Dr. Halliday, Paisley; Signor S. Fiyos, San
Joa(?; Dr, Philpotts, Birkenhead; Dr. Coagrave, Dublin; Dr, Lombe
Atthlll, Dublin ; Mr. E. J. Poivell, London ; Dr. Hartshorn, Junction
City; Dr. W. Wallace, Ventnor; Mr. Hiwch, London ; BIr. Young
J. Pentland, Edinburgh ; Dr. Ashby, Manchester; Messrs. Anderson
and Co., London; Mr. B. Q. Corney, Fiji; Dr. J. M. Atkinson, Hong-
Kong; Dr. Briggs, Liverpool; Mr. Haywood, Notts ; Messrs. Oliver
and Boyd, Edinburgh; Dr. E. Stevenson, Birkenhead; Messrs. King
and Co., London; Dr. J. C. Simpson, London; Mr. Wethered, Great
Marlow; Mr. W. Whitehead, Manchester; Messrs. Wm. Clowes and
Son, London; Mr. W. S. Richmond, London ; Mr. John.son, Kansas
City; Dr. Collin.s, London ; Dr. Hunter, Matlock; Messrs. Bach and
Co., London ; Mr. Angus, Burgley; Mr. Cole, Holywell; Messrs, Leo
and Nightingale, Liverpool; Mr. Haley, Wakefield ; Dr. Wyeth, New
York; Mr. H. Burton, Murple ; M. Berthier, Paris; Messrs. Lloyd
and Co., Leicester; Mr. U. J. Rope, Shrewsbury; Dr.W. Dale, King’s
Lynn; M. Jankowski, Switzerland; Mr. Blair, Leeds; Messrs. Allen
and Hanburys, London ; Mr. Henderson, Sussex; Messrs. Cassell and
Co.,London; Mr. Green, Derby; M. Schulz, Paris; Messrs. Keith
and Co., Edinburgli; Mr. White, Chippenham; Messrs. Wright and
Co., London; Mrs. Faitbfull, Wimbledon-park; Messrs. Hewlett and
Son, London; Mr. Blount, Paris; Mr. Gorman, Wilts; Messrs. Mason
and Co., Chelsea; Mr. Russell, Liverpool; Mr. Browne, Douglas, Isle
of Wight; Mr. Groves. Kilburn; Dr. Storms, Canada; Messrs. Benson
and Co., London: Mr. Eaton, Birmingham; Messrs, G. Street and
Co.,London; Mr. Armstrong,Nowcastle-on-Tyno; Messrs. Muranyand
Co., Paris; Mr. Sale, Salop; Mr. Sella, London; Messrs. Mitchell and
Co., London ; Dr. Metcalfe. Yorks ; Dr. Yoman, Wilts ; Mr. Martin,
Bolton; Mr. Watson, Glasgow; Mr. Watt, London; Di'. O’Hanlon,
Durham ; Dr. Sorphioti, Golitz; Mr. Shipton, Stafford ; Mr. Saunder’
Manchester; Mr. Newell, Ipswich ; Mr. Lewis, Rainhill; Mr. Scott,
Manchester; Mr, Mason, Sheffield; Dr. Zangzer, Zurich ; Dr. May,
Hanwell; Dr. Hughes, Holyhead; Mr. Welsh, Stirling; Mr. Cant,
Lincoln ; Mr. Birchall, Liverpool; Mr. Brown. ChaHord ; Mr. Roberts,
Sheffield ; Miss Arm.strong, Ventnor ; Messrs. Oppenheinier, Sons, and
Co.,London; Jlr. J. Williamson, Lincoln ; Messrs. Kogan Paul and
Co., London ; Mr. Milos, Charing-cross ; Dr. Barbour ; Dr. Lee, Now
South Wales ; Messrs. Bentley and Son, London ; Messrs. Barker and
Sod, London ; Messrs. May and Co., Piccadilly ; Clinical; Goddes
Manufacturing Co., London; J. A. C.; Oynwcologist; G. P. ; Maltine
Manufacturing Co., Bloomsbury ; Alpha, London ; Jeye.s’ Sanitary
Comp. Co., London ; Pharm. Chem., London ; Secretary, St. Andrew’s
Hospital, Nortlmmpton; A. H., Bedford ; X., Enfield ; Secretary, The
Hospital, Canterbury; Box, London; Queen Charlotte's Lylug-in<
Hospital, London ; Spero, Sheffield; M.D,, Finchley-tyad.S.anitos
Co.. London; C. E. D., London; Principal; A Subscriber; Monis.
T'ube Co., London; Matron, Bury St. Edmund's.
Lbttsks, eaoA with enclosure, are also acknowledged from—Mr. Wilson,
Belfast; Dr. McCulloch, Guernsey ; Mr. Pineo, Merton; Mr. Hodder,
Cork; Mr. Godwin, Oxford; Mias Liittlchau, London; Mr. Hamilton,.
Stoke-on-Trent; Mr. Winckworth, Shelford.; Miss Carson, Burton-on-
Tront; Mr. Pollard, Blackburn; Mr. Banks, Bedford; Mr. Parsons,
Burnley; Mrs. Davies, Liverpool; Mr. Smee, Ryde ; Dr. MrDougall,.
Runcorn ; Mr. Wilson, co. Down ;• Dr. Allen, Durham ; Dr. Hughes,
HoJyliend; Mr. Pollard, Woollton; Mr. Oliver, India; Mr. Uey^od,
Manchester; Mr. Jones, Aberystwith; Mr. Pearce, Eday; Dr. Qtais,
Greece ; Mr. Tully, Hastings; Dr. Stanley, Attercliffe ; Dr. Pjrdey,
Tasmania; Dr. Hazleton, Essex; Mr. Jones,Dowlais; Mr.St.A.ubyn,
CO. Wexford; Mr. Wells, Cuckfleld; M. Corby, Paris; Mr. Barcroft,
Wilts; Miss Tozer, Wimborne; Mr. Owen, Fishguard; Dr. Singh,
Bombay; Mr. .Tones, Colchester; Dr. Waldo, Paris ; Messrs. Bryant'
and Co., Toronto; Dr. Venis, Benares, India; Miss Rogers, North
Wales; Mi'. Tait, Golspie; Mr. Ilinde, Bloxam; Messrs. Rphinaon.
and Co., Chesterfield; Mr. Davies, Lampeter; Messrs. Watklqs and
Osmond, London; Mr. Debmold, Bournemouth; Mr. Hanson,iBouth
Hampstead; Mr. Cornish, Manchester; Professor Buchanan’,'Wat¬
ford ; Mr. Howard, Norfolk; M. Rogosinskl, Warsaw; Mr. Rucker,
St. Petersburg; Mr. Tyte, Minchinhampton ; Mr. MacRae,,-Heniel
Hempstead; Mr. London, Acton; Messrs. Marclon Bros.,'Bishop
Stortford; Mr. Gonnan, Mere; Mr. Cullman; Miss Hooper, Upper
Baker-street; Mr. Williams, Carmarthen; Dr. Drummond, Malvern;
Mr. A. Smith, Croydon; Miss Sloan, Pittsburg; Mr. Homibrook,
London; Dr. Milton, Cairo; Mr. Myer.s, Birmingham ; Mr. Clouting,
' Thetford; Mr.Wynne,Nottingham; Mr.Backland, London; R.G. B.;
Elder, London; Surgeon, London; W. T., Manchester; Inspector
of Poor, Orkney; U. C. S., London; Alpha, Birmingham; Letture
Scientiflsche, Geneva; Lorna, London ; C. R., London; Surgeon, East
Dulwich ; 21C,Commercial-road,Pockham; Fides; Surgeon,Rhondda
Valley; J. S. R., Sandwich ; 1, Richmond-place, Manchester; South
Yorkshire, London; Leeds, Lon<lon; Oldfield; Secretary, Orkney
Islands; J. G.,Tenbury; X. Y. Z., London; H.B., London; M.D.,
Birmingham; G. W. M., London; M.B., Birmingham; Vendor, Blr-
mingliain; Binaural, London; H. T. G., London; Alpha, Bourne¬
mouth ; Surgeon, Liverpool; Medicus, London ; East-end; H. W. H.,
Leeds ; A. A. L., London; Delta, London ; A. C., London ; Borough,
Malvern; Sylvanus, London ; M.B., Chard; A- B., London; Studens
Latinus,London; Zion,Antrim; J. A.,London; X.L.,London; Public
Health, Edinburgh ; Medicus, Margate ; Medicas, Newark.
NiiWSl’APEliS .—Cork ConjiHUUion, West Swsex Gazette, Birmingham Boot,
■ Manchester Qiuirdian, Belfast News Letter, Bristol Times, Surrey Comet,
Teesdale Mercanj, Leicester Post, Kilkenny Journal, Sheffield Daily
Tdegra.pk, Leeds Mercury, Architect, Liusrpnol Daily Post, Spectator,
MetropolUan, Surrey Adoe.rtiser, Law Journal, Ony's Ilotpital Gazette,
Builde.r, J‘haniiareiUical Journal, CHy Press, Mining Journal, Bury
Free Prats, Cheshire Fxamiiier, ifnadtw/ Mercury, Weekly Free Press
and Aberdeen Herald, Local Oovcmmciit Chronicle, Retford and Gains¬
borough Times, Carlisle Journal, Jlehdcn Bridge Times, Belgian News
(Brussels), Sanitary Journal, Windsor and L'ton Express, Hertfordshire
Mercury, Argosy (Georgetown, Demcrara), Zoophilist, Bolton Weekly
Journal, llfracondta Chronicle, Journal des Etrangers, Ac., have been
received.
SUBSCRIPTION.
Post Free to any part op thk United Kinodom.
One Year.12 61 Six Months.. £0 18 8
To China and India ._..One Year 1 10 ig
To the Continent, Couinies, and United
STATES.. Ditto 1 It S
Post Office Orders and Cheques should be addressed to The PobllBher,
The Lancet Office, 128, Stiand, London, and crossed “ London and
Westminster Bank St. James's-square.”
ADVERTISING.
Books and Publications (seven lines and under) .£060
Official and General Announcements .. . .060
Trade and Miscellaneous Advertisements ... .040
Every additional Lina 0 0 0
Front Page ..... per Line 0 1 0
g uarter Page . . . . _ . .110 0
alf a Pago . . _ . . . .2160
An Entire Page .. .. .. „ _ 6 6 0
The Publisher cannot hold himself responsible for the return of testi¬
monials (kc. sent to the office in reply to advertisements; copies only
should be forwarded.
NoTiCli.—Advertisers are requested to observe that It is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
feature of “ The Lancet General Advertiser" is a special Index to Advertisements on pages 2 and 4, which not only
aflordsaready means of findmg any notice, but is in itself an addiltonol advertisement.
Advertisements (to ensure insertion the same week)should bo delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
addresl^ Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subsciiptiona sboold bo
AdvMttei^Agente received at aU Messrs. W. H. Smith and Son’s EaUway BookstaUa throughout the United Kingdom f-^d aU othes
Aftitt for tta« Advorfeioemoiit Hepartmont in x^aQee--J. ASTIEB, 69, Bat Oamnartln, Farlr;
Digitized by i^ooQle
THE LANCET, Januaky 10, 1891.
Otlimcal %tdm
OmmO ENLAllGEMENT OF THE TESTICLE.
Dcliverediit University College Uospital, Oct. ISth, 1890,
By CHRISTOPHER HEATH, F.R.C.S,,
JIOI-MK rROPlCSSOll Ot' CUNIC'AI, SUlUIKKV.
We have had lately, geatlemen, a large number of cases
of chronic disease of the testicle; in fact, at the present
moment wo have three such cases in the wards, and I
therefore take the opportunity of saying aomething on the
subject.
In the first place with regard to the diagnosis; when
you get a large scrotum before you, the first tiling is
to examine it carefully and see whether it is simply an
enlarged testicle or whether there is anything else. You
will therefore follow the rule, which I have so often im¬
pressed upon you, to examine the spermatic cord and see
whether there is anything more than the cord protrud¬
ing from the abdomen—whether, in fact, there is not
a hernial protrusion. If there is nothing of that kind, and
if the tumour is clearly in the scrotum, you will then pro¬
ceed to examine the cord a little more critically, with the
view of making out what is the exact condition of the vas
deferens, because it is as well to ascertain that before you
proceed to examine the testicle at all. If you find the vas
deferens enlarged, then comes the question, Is that an en¬
largement which has spread from the urethra downwards to
the testicle, or is it an enlargement spreading upwards
from the testicle towards the body? A good deal will
depend upon the history of the case. If you find that
the individual has had acute epididymitis, generally
following upon gonorrhena or, at all events, some urethral
dnitation, which has subsided and has left a thickening of
the cord behind it, the case is pretty obvious. You would
•expect 'to find, when you examine the testicle, that a
thickened vas deferens leads down to an enlarged epididymis ;
and that is a very common condition of things, but one
M’hich is often misunderstood, because it is not remembered
•that the disease spreads from the urethra downwards to the
testicle in a great many cases. Y'ou may not haveseen the
case ill the acute stage, but there is the chronic thickening
left; and pray remember that there are plenty of cases of
urethral irritation, stricture, or what not, where there is an
enlargement of the vas deferens spreading down to the epi¬
didymis and causing its enlargement.
In such a case it is of no use treating the aymptoina;
what you have to do is to treat the cause, to put b'heurcthra
^iia healthy condition, and the testicle will almost take
care of itself. But sometimes it does not, and tlien you
have to treat the testicle. These cases of chronic enlarge¬
ment of tlie testicle due to local causes are conqiaratively
easy to treat. You can strap the testicle carefully or rub
■lu a little mercurial ointment, or in very obstinate cases,
and particularly where the body of the testicle has already
become enlarged, you may find it necessary to give a course
•ol mercury before yon clear up the efl'iision which lias taken
place in the testicle itself. It is an inllamniatory ellusion
between the tubes of the testicle due to inllammation
spreading down along the vas deferens, and of course, if it
aas gone on for any length of time, it may become to a
•certain extent organised, and it will never' entirely clear
ip. btill, no liarui comes of it; it remains there very much
( 2 '«y ; and if you gob the urethra into a healthy state,
I ’'bstiele will probably give the patient no trouble. But
^bnditioii is very dill'erent when we find the cord very
..Li; it down and find that the
evidently the primary seat of disease. Of that
lave examples at the present moment in the ward.
-iviw. L •^“'^.^6 fellow, whom I will show you presently,
ill fi..f ^ S'beautiful example of a single nodule of tubercle
1 are also two patients whose
Tim.vi, they are good examples of a
Inn “f*®,,®'‘i''anced disease of the epididymis spreading
remember that in
i‘ patients are still in the ward-I have
I No 3515 ^ ’ but there is,
unfortunately, another testicle left which is also dieeaaed,
and with which I have dealt in a manner that I will explain
presently.
Tubercle of the testicle is a disease which appears
in the epididymis, and which lends to spiead in both
directions, upwards along the vas deferens, and forwards
to the body of the testicle, and will lead eventually to
the disorganisation of the body of the testicle. Ic is,
of course, a deposit of tubercle in a patienb wbo has a
tendency to that ilUease, and it is a disputed point whether
I the mischief begins in the inbertubular or in the intra-
tubular structures. I myself believe that ic is within_ the
tubes that the disease begins, and I think the jiroof of it U
how readily it spreads from the tubes up the vas deferens
and in the opposite direction along the tubuli aeminiferi
from the globus major to the body of the testicle, and
alPects all parts of the organ. However, it is a disputed
point, and it is not nccfssary to labour it; but I tbiok that
cliuical evidence is distinctly in favour of ihe mischief
beginning within the tubes. No one doubts that it begins
in the epididymis first, and, as I say, ic spreads both ways.
In one of the testicles which I rehioved, and which I show
you. we have an example of disease developing in the
epididymis and running ou to abscesses; but you will see
that the body of the testicle is still perfectly healthy,
whereas in this other testicle, so far from the body being
healthy, the giouter part of it is outHide the skin altogether,
forming what wo call a benigu fungus or hernia testis.
This disease beginning in a patient with a tendency to
tubercle is very often not recognised until there are distinct
knots in the epididymi.s. The patient has no pain, and does
not particularly notice it until his attention is accidentally
called to it, and then he consults his medical man. In the
early stage of the disease, such as in the young man I have
mentioned, I think there is no doubt that, under very
favourable circumstances, absorption may take place; the
whole thing may clear up, and the testicle bo practically
restored to a healthy condition. But you require exceedingly
healthy conditions for that. A hospital, 1 need hardly say,
is not the very best place for these cases, and the patients
cannot from their peciiniaiy position take every advantage
with regard to their healtb. Bub when you have patients
of the better class, and you find that a young fellow has one
nodule in his testicle, or perhaps two, the proper line of
treatment is to send him for a voyage—I mean a voyage to
the Antipodes, to Australia, and in a sailing ship. He
should be put under the most favourable circumstances as
regaids hygienic arrangements—I mean the thing should
noC be clone cheaply, hue he should go in a good shin, where
he will have a good berth and plenty of good food. You may
then find that after he has been away six or eight months
he will come back, and the nodnlc may have disappeared.
If you get a patient under circumstances which_ do nob
adiuibof such treatincnb as that, what is the beat thing bo be
done ? It may be said that the best thing would be to remove
the tcibicle. But then you will find that people do nob like
having their testicles removed, and it is rather a severe opera¬
tion for a disease which certainly at the moment only atl'ects
a very small portion of the organ I propose, therefore, in
the case of this lii'l, next Wednesday to cut down upon the
nodule in l»is epididymis and scoop it out very mueb in the
same way as you saw mo the other day treat the opposite
testicles to both of these, in the two patients who are still
in the ward. I removed the worst testicle in both eases and
scooped out the nodules of tubercle in the better one, and
fortunately this youth ban only one testicle affected. Bub
theu you may say, “ Surely the damage done to his opidi-
ilymis will prei’cnt that, testicle being of much service after¬
wards.” Very likely it may ; still there is something satis-
factoiy in keeping a portion of the testicle. An individual
is not emasculated, although his testicle may not be of very
much use to him, if he has a portion of the body of the tes¬
ticle left. I will nob say that be is capable of propafi'ating
hi.s species with that testicle, and perhaps it is as well that,
lie should not; .still, he has the feelings of a man, and, as I
say, he is not emasculated. There is another advantage
that lie gets from scooping out the mass in the e]iididyniis :
tinit any .secretion taking place in the bo<ly of the testicle
will find a vent either through the natural tube, or it
may be through a small siuus. That i.s a_ point of_ import¬
ance, because patients who liavo nodules in the epididymis
blocking it «p completely' get an uncomfortable feeliug_ of
fulness about the testicle, duo no doubt to .secretion going
on iu the bodv of the testicle and not being able to find its
72 TheLanoet,] MR. C. heath on chronic ENLAKCEMENT of the testicle. Jan. 10, IBW-
way out. The testicle is apt to get enlarged, swollen, and
distended with seminal lluld, and unless there is a vent for
it the patient suffers a great deal.
Then, supposing that vce have a case more advanced than
that. Let me remind you that the disease spreads up the
vas deferens, and that in cases where you have abscesses
forming in the epididymis the tendency of the disease is to
spread up along the cord towards the urino-genital organs,
•-tpecially towards the neck of the bladder, and to form one
• ■r two nodules in the prostate, to invade the vesicuhe
seminales, eventually, in the later stages, leading to most
painful ulceration about the neck of tlie bladder. Let me
remind you of the case of a man we had here from South
Wales at the beginning of the session. He had both testicles
even more advanced in disease than these are. On exa¬
mining the rectum with the finger, I found he bad most
extensive disease about the neck of tbe bladder. The
prostate was diseased and the vesicuho seminales, and
altogether the man was in such a low condition that I
refused to operate on him, and sent him home again. I am
quite sure I did right. If 1 had done anything for that man
probably he would have died, but now he will go home and
die among his friends, instead of dying here as the direct
result of an operation.
Here is the testicle of the man in whom I did interfere.
This testicle was practicallv disorganised. Let me remind
you that the opposite testicle had a large mass in tire epi¬
didymis, and I ventured to treat that by cutting down
ilirough the opening made for castration upon tbe epididymis
and scooping out all the disease I could (iud. He has done
very well, except that he had an abscess in his inguinal
canal, I have no doubt from the height at which I tied the
e»rd. That I opened la.sb week, and the patient is now
doing exceedingly well, and seems likely to make a good
recovery. This is a good example of the disease creeping
uD the cord without affecting the body of the testicle at
all, for I may point out to you again that the body of the
testicle is perfectly healthy. Here wo have a specimen
from the lasD case, which I operated upon last Wednesday,
with another condition of things. This man had disease
spreading up the cord, for the vas deferens is enormously
thickened; but unfortunately he had the disease creeping
forward in the body of the testicle, setting up suppuration
and leading to tbe destruction of the tunics, and eventually
to protrusioo of this mas«, which is made up, of the seminal
tubes, together with some granulation tissue. Let me
point out how completely the whole body of the testicle is
outside the skin, forming this fungus, wliilst behind we
have really nothing more than the epididymis. Now, under
those circumstances, there could be no question about
removing it. I removed this testicle, and I dealt with the
opposite testicle in exactly the same way that I dealt with
the former one—namely, I cut down upon the epididymis
aud scooped out all the disease I could llnd there. That
patient also is doing well, but unfortunately be has some
♦oilargement about his prostate and vesicuhe, though not so
sdvauced but that I thought I should be justified in doing
1 1m best I could. I am afraid I have not cured him, though
I am sure I have given him relief, and he may tide on tor
.some considerable time.
Now let us follow in imagination what will be the outcome
of these cases. Very probably they will each have a fistula
left in the scrotum. That is a very small matter, and can
be treated by injections if you like, but I do not know that
there is any very great object in troubling about it. But I
am afraid there is in one of these cases already disease about
the prostate and vesiculm which will steadily make progress,
and probably before many months are over the patient will
<j unplain of a good deal of pain when be micturates, and he
may have great frequency of micturition, and the two
things together will wear the patient out. It is one of the
most trying conditions a patient can be in to have tubercular
disease about the neck of the bladder, which leads eventually
to ulceration of the mucous membrane of the bladder. In
fact, the two diseases go on together; and eometinies
I'erforation takes place, and then we have in addition the
annoyance of a urinary fistula. At other times that does
not take place, and the patient goes on until he is worn out
by the constant suffering.
I need hardly say that in a case of advanced tubercular
testis you would find other organs almost certainly in¬
volved, Now, this man from whom I removed the fungtiH
testis is a man of forty. Since the operation he has spat
some blood, and we knew that be had some consolidation
of the apex of his lung. Very possibly the disease in tlia
lung may make more rapid progress than the disease in th»
testicle, and be may die from the disease in his luDg„.
which perhaps will be the more merciful death of the two...
Still, I think we give him Relief for the time, and we get riib
of a certain amount of disease; and supposing that had.
been the only disease, we should have had the great-
advantage that we should have got rid of the nidus of'
tubercle before it became generalised through the system^
You see in the bottles here specimens of tubercular testia.
which show extremely well, because they have been injected'
with line injection. The injection does not run into the
tubercular masses, therefore the contrast between the re(0
injection and the yellow tubercle is well seen.
To come to another subject, and that is the syphilitic-
testicle. Of late years .syphilis has been found to bave a.
much more important bearing upon disease of tbe teaticle-
than used to be supposed. If you read the older books, yom
will find that a great many of the cases which are put
down 08 chronic orchitis are clearly from tbe history of the>
cases syphilitic disease. It is only comparatively recently
that the two forms of syphilitic disease have been recognised.
There is the secondary and there is the tertiary. The*
secondary form is one of the later manifestations of secondary
syphilis ; so that when the eruption on the patient’s skim
has died away, and he fancies himself quite well, he noticesj
that both his testicles are beginning to enlarge. When 1 say
both, possibly one may have a little start of the other, but-
it is common to find both of ^hem enlarged. You find that-
the enlargement is very general, and that it clearly begins'
in the body, and you have a uniform enlargement obscuringi
and hiding the epididymis completely. When you feel the
cord you find it is quite healthy, and there is no mischiek'
spreading up it. The disease is entirely confined to the^
body of the testicle, and not infrequently is complicated by
a small hydrocele. Now, pray remember, when you get a.
patient before you with a large scrotum, and you find there
IS distinctly fluid there, that there may be something more-
behind. It may be a case of pure hydrocele, or it may be
what is termed a “ hydro-sarcocele,” and these hydro-sarco-
celes are almost invariably syphilitic. If there is any amount-
of Iluid it is well to tap the hydrocele at once, in order that-
you may be able to examine the testicle more readily. You/
will find then, as I have said, that there is a uniform enlarge ¬
ment of the body of the testicle, and that the epididymia-
is not affected, or is so rarely affected in syphilis that yoi?^
may practically ignore it.
These cases are remarkable for having completely lost that-
peculiar testicular feeling, as it is called, which is charac¬
teristic of the healthy organ. If yon take a healthy testicle
and squeeze the body of it, the patient will natu?ally feeb
an uncomfortable sensation, wliich we are all familiar with
if we happen to give our testicles an accidental squeeze..
Bub the patients with these large testicles have no sensatiom
whatever. You may handle them or do anything you like^
and the uniform absence of testicular feeling is very remark'
able. On investigation you will always find that some two-
or three years before the patient has had syphilis. Very
likely be was properly treated, but still there w a remnant-
of it hanging behind; and you must make up your mind
that you will not cure that form of testicle without mercury.
It is of no use to give iodide of potassium alone; you must
combine it with mercury, but I think the best plan i.s to give-
the mercury in the form of bichloride. At the same time,
you may let tbe patient rub in some mercurial ointment by
wearing a scrotal bag and smearing the scrotum with mer
curial ointment. Some of these patients, although,they have-
no testicular feeling, have a great deal of tenderness about
the testicle, with a sense of weight or dragging, which may
be relieved by combining belladonna ointment with the mer--
curial ointment. There are no cases more satisfactory for
treatment than these purely syphilitic testicles. You may
be sure that you will cure the patient—that is to say, yom
will bring the testicle down to about its normal size. But I-
cannot say that you will be equally sure of restoring the
function of the organs, because it may happen that tbjs»
inflanimatory deposit between the tubules may have gone-
to such an extent that it has become organised into a low-
form of fibrous tissue ; and although you will clear away by-
means of the mercury all the recent deposit, you may not-
be able quite to clear up tbe whole of the fibrous tissue,
and that has a tendency to contract and produce atrophy of
the testicles afterwards. You will find in tbe older booka-
that the authors speak there of fibrous disease of the testicle-
Thb Lancet,] DR. STEPHEN MACKENZIE ON ANEMIA AND ITS PATHOLOGY. [Jan. 10,1891. 73
Hlat then sorp'eons did sot recognise that that was simply
A late stage of syphilis; and there is do doubt that if the
.deposit has hod time to thoroughly organise, the pressure
4 ]iay be suthoient to destroy the tubules, and practically the
■-teBticle will be lost. That is the form of syphilis which it
is most important to distinguish from new growth; for a
youngish man may come before you with a large testicle,
^nd it may be a case of sarcoma, and it is not at all easy
always to be sure which disease it is. A good deal will
.depend upoa the history. If there is a distinct history of
eyphilis, you may, at all events for the time being, give the
j»atient the benefit of the doubt, and hope that it is syphilis,
which you may clear up by mercury. If you are in doubt,
ut is better, unless the tumour is rapidly growing, thereby
ebowing its malignant nature, to give the patient a course
of mercury than to remove bis testicle unnecessarily. But
•of course if you have a lapidly growing tumour of the
testicle, the sooner you remove it the better—there is no
(question about that; whether it is sarcoma or carcinoma, it
lis better for the patient that it should be taken out.
Tlien supposing we have a later stage of eyphUi*. Of
oourse in the later stages we have what is familiarly kno wn
iis gummatous deposit—that lowly organised form o’^ deposit
that we find so common in various organs, and particularly
those which are vascular. If you think for a moment how
■vascular the testicle is, you can easily understand how we
may have large gummatous deposits in the organ. Here is
an example. It is an injected testicle, but the injection
^las not run very well, and you can see above and below a
large mass of yellow tissue which is a syphilitic deposit.
Here also is a good example of a large gumma tilling up the
'■(body of the testicle in two sections, one above the other.
This occurs, of course, very much later on in syphilis. You
£nd that the patient has been in good health and getting
•on perhaps in life, but hia health breaks down a little,
and he begins to show manifestations of tertiary syphilis
^n various organs. That is one way in which it occurs, but
»you may have it quite at the other extreme of life—in
children. A syphilitic child will sometimes develop a
igumma in the testicle which is apt to be mistaken for
malignant disease, because we know that malignant disease
also occurs in quite young children, and it is very dillicult
isometimes to be sure which it is. The tendency of a
gumma in the testicle, like a gumma in the tongue or any¬
where else, is to break down. You may only see the patient
when the gumma has broken down, presenting very much
ithe appearance of an abscess, and involving the skin ; or if
you see it late enough, the skin may be already open and
presenting the characteristic yellow slough which we see so
■•commonly in connexion with gummata. We had a good
example of it here Ixst summer. I do not know whether
YOU remember it, but I remember the man extremely well,
^ile had double syphilitic disease of the testicle and a sinus
and discharge from the gumma in one testicle. The whole
•thing cleared up under the inlUience of large doses of iodide
•of Dotassium, and he was here the other day perfectly well.
Now, given a case where you have reason to think it is a
(gummatous deposit, there can be no question as regards
treatment. But it is not always easy to be quite sure. I
may say at once that 1 had a patient here some few months
•ago in a private ward, who had a tumour of the testicle and
>alBo a tumour of the arm. lie came to my house liret, and
■siiowed me his testicle, which I thought was syphilitic. I
•<iuite made up my mind, and wrote in my notes that it was
riyphiliiLc, but just as he was going away he showed me his
anu. It looked so like a sarcomatous growth upon liis arm
that I was shaken in my opinion, and rather came to the
conclusion that it was a sarcomatous disease of the testicle,
’aud that he had a secondary sarcoma forming on Ids arm.
He was a very intelligent man, and utterly denied anything
^ike syphilis. lie acknowledged that he had had some
'reneveal troubles many years before, but utterly denied
that he had ever had anything like syphilis. I took him
'into a private ward in the hospital, and advised Mm to
'have the testicle removed, and there could I'ot have been n
more typical gumma of the testicle than there was in tliat
CQ-se it was so good that I took it to the College of
'.Surgeons to be mounted in a bottle, in order that we might
have a well-marked undoubted specimen of gumma of the
■testicle to examine upon. Tlie moment I found the patient
hod gumma of the testicle, of course it was quite clear what
ougVit to bo done for his arm. 1 put bim on full doses of
nidide of potassium, and the whole gumma cleared up, and
G hcaow that ive is now in perfect health, I do not think he
was much harmed by losing one testicle. It was a damaged
testicle, and most likely it would have shrunk up and
become merely a nodule; for this disease of the testicle
when it shrinks up is apt to lead to extreme atrophy.
This brings me to say a word about sarcoma, though we
do not happen to have had a case veiy lately of sarcoma of
the testicle. ’Until late years sarcoma was not differen¬
tiated from carcinoma, an<i therefore all the older cases of
sarcoma are put down as cases of carcinoma. Sarcoma of the
testicle exists in the form of round'celled or apindle-celled,
but is more generally, I think, of a mixed variety; anif
you will find that it is a rapidly growing tumour which
has a tendency to form cysts, and that is important, because
these cysts in the testicle in former days used to be called
cystic disease of the testicle. There is no doubt that most
cases of so-called cystic testicle are really cases of sarcoma
with cysts developed ; and the cysts seem to be developed
very much as renal cysts are from obstruction of the
tubules. The tubules cannot empty themselves because of
the sarcomatous growth pressing upon them, and thus they
become distended with their secretion, and form a series of
cysts. Now a rapidly growing tumour of the testicle of that
kind cannot bo removed too soon ; the thing should be done
withoutanyhesitationatall, and jet you never can guarantee
that the patient shall not have further trouble. I remember
an officer from India a few years ago from whom I removed
a testicle which was distinctly cystic, but which was also
sarcomatous. He got perfectly well and went back to India,
but died within two years with growths in the neck and
chest, and with just the ordinary history of sarcoma develop¬
ing in other parts of the body. The form of cancer that
you meet with is generally etcephaloid. Scirvhus is ex¬
tremely rare, blit encephaloid cancer is not very uncommon.
In these cases of encephaloid cancer we have very rapid
growth ; there is also a tendency to fangate, and the fungus
is the true fungus hmmatodes of the older surgeons, by
which I mean a large bleeding mass protruding from the
scrotum, very different from the benign fungus, which is
perfectly callous, and does not bleed at all. It is a great
misery to the patient, and tends of course to shorten his life
by the irritation which it sets up. In thc-^se cases of malig¬
nant disease the great tendency is to deposit in the glands
higher up You find the whole cord thickened and the
glands in the lumbar region involved. You ought to re¬
move these testicles in all cases as soon as you see them.
Still, you may be pretty sure the patient will die some
months aHerwaids from depobic in the internal organs.
ABSTK.4.CT Ob’
%\t Jdtsmiiiiui fettm-fs
ON
AN-/1<MIA, ITS PATHOLOGy, SYMPTOMS,
AND TEEATMMT.
Delivered before the Medical Societij of London, 1801,
By STEPHEN MACKENZIE, M.D., E.R.C.P.,
|■|lUSI»KN'r Ol' THK iniNTKlUAN ROClKTy, AND 1‘UY.SICIAN
TO TUB LONDON IlOStMTAt.
LECTURE 1.
Mr. Pre,sii)I!:nt and Centlemkn,— It has seemed to me
that the time has come when the careful and detailed work
on anmmia which has been accomplished in the last few
years by many able observers, both in this country and
abroad, may be usefully brought together, and thus allow of
our taking a comprehensive view of the whole subject. This
necessitates my commencing with some elementary details,
with which you are familiar; but unless wo agree upon
what is to be regarded as the normal condition of the blood,
and its beginnings and endings, we cannot indicate what
are departures from it. Whether regarded as an internal
medium or as a tissue, a mechanism exists, in ordinary cir¬
cumstances, whereby the blood maintains a standard, both
as rpgardsics quantity and quality. Unfortunately we have
no clinical means of estimating the quantity of the_blood, ana
we are obliged to accept the physiological teaching that in
Dig edi Google
74 The Lancet,] DR. STEPHEN MACKENZIE ON ANAEMIA AND ITS PATHOLOGY. [Jan. 10, rSffl.
mao ib generally represents about one-thirteenth of the body
weight of tlie individual. The blood is composed of formed
elemenls floating in a fluid—the plasma.
plasma is a clear fluid consisting of fibrine, or iibrine
factors, and serum. It is alkaline in reaction, owing to the
presence of disodic phosphate, and sodium of bicarbonate.
V. Jakach has recently shown that its alkalinity is dimi¬
nished in pernicious anmmia and leuchiomia. The serum
has a specific gravity of from lOilG to 1029, whilst the specific
gravity of the blood as a whole ranges from lOflS to 107r).
l)r. Lloyd-Jones' has lately made some observations on the
specific gravity of the blood, showing its variations at dif¬
ferent ages, and the influence of food and exercise. It is
probable that marked alterations in the specific gravity of
the blood exercise an influence on the red corpuscles. In
ernicious anocraia the specific gravity of the blood is usually
etween 1028 and 1038. In aniomia, in its higher grades,
there is a marked diminution in the albuminous consti¬
tuents, especially the hiemoglobin, of the blood.
The coloured or red UooU-corpusclcs .—They have in the
adult an average size of 7'5 t.’. (micro- millimetres), but their
range is between 2 f> /x and 14 or ev-Ti 10 fj.. To the smallest
of these the term microcytes has been applied, and to the
largest megalocytes. The size of the red corpuscles is in¬
fluenced by age, and is markedly altered in disease. They
vary also in tbe'amount of htemoglobin they contain.
Nucleated corpuscles, which exist in the embryo, are pro¬
bably never found in the blood in post'embryonal life except
as the result of disease. The number of red corpuscles in
health varies from r),.')00,000 to 4,000,000 ])er cubic milli¬
metre, or from 110 to 80 per cent., being lower in the female
than in the male.
I'hc sources of the red corpuscles .—Passing by their origin
in the embryo, their sources after birth are practically con¬
fined to the bone marrow, the .apleen, and perhaps the
lymphatic glands. Their chief source is the marrow. As
to their mode of origin in the marrow there is considerable
dispute. IJy many it is believed tliat they take thei;
origin in the parenchyma—either from marrow cells
(Neumann, Uder, and others), or from leucocyte.s (Kiilliker,
Malassez, Gibson, and others), whilst Ifizzozero and Torre,
and more recently Denys, maintain that fhey arise entirely
■within the vessels of the marrow. Gibson,-who has studied
the question very carefully, states that they arise from
marrow cells, or leucocytes brought to the ir.’'rrow, and
that the earliest stage is a cell which has at lirst a thin
ring of protoplasm containing hamioglobin at its peripliery.
This gradually increases so as to fill the whole-space between
the cell envelope and the nucleus ; and as the hmmoglobia-
tinted peri-nuclear substance increases in amount, thcnueleus
appears to become smaller and to retreat towards the centre
of the cell ; the cell, as a whole, at the same time becoming
smaller, Ife believes that the nucleus is the active agent
in attracting tiie lucmoglohia to the cell, and that when
this function is fulfilled it disappears. Osier' believes
that the nucleated red corpuscle is derived from the clear-
bordered marrow ce]l,tliere being,in his opinion, no es.sential
difference between the protoplasm of the two cells. He thinks I
the colourless marrow cells are derived from small lymphoid
elements resembling free nuclei (primary lymph cells—
proto-lciicocyfces). O.sler further heUeves in tiie develop¬
ment of red corpuscles from myelo-plaquea and from the
elongated cells of the stroma ; in the latter supporting the
observations of Schiifer. Rizzozero in a 3'ecent papei * has
gone over the ground which he has previously explored,
and insisted so strongly on certain points capable of veri¬
fication that I have obtained the assistance of Dr. James
Gallowav to institute some investigations on the develop¬
ment of tlie red corpuscles from the marrow. These have
been made on the marrow of fowls. Great importance is
attached to the examination of fresh marrow, simple
hardening in Miiller’s fluid, and examination of unstained
sections; but great advantages are also obtained from
staining sections by various dyes after hardening in corro¬
sive sublimate, then in alcohol diluted with an er^ual volume
of a 1 per cent, solution of chloride of sodium, and ulti¬
mately in absolute alcohol. It is insisted njxrn that to
obtain a knowledge of the sources of tlie developing blood-
corpu.seles .sections must bo examined. 'J'he observations
' .iniirnal of l’li>sio!of!:y, 1837.
2 On lilood-foi-minK Oriiiiiis find jlfood-foniiatjoii : .louni. of Anat.
and PliyMiol., voj, xx,, 1880.
n C;iittwr*«fit J.ecnii'KS; Bril.. .Mod. .Toiini,, vol. i , 18,80.
' * Archi'’ fdr Mi.k’i"<kc)pj»che Aiiatotnio, Band xxxv., Heft 4, S. 424.
that Dr. Galloway and I have made agree with those of
Bizzozero, that no ha>nioglobin-tinted cells are to be found
outside the lumen of the bloodvessels. The vascular
arrangement of the marrow is peculiar. The arterial aijd:
venous trunks are situated in the axis, and tiie venules.
converge from the periphery to the axis like the spokes.!
of a wheel. So groat a disproportion exists between.!
the calibre of the small arterial capillaric-s and the
Wge venules that the circulation in the latter must
at all times be very slow, and thus favciur the de¬
velopmental changes in the venules. Moreover, ae.
many observers have demonstrated, but which, owing
to the restrictions placed on experimental researches on
animals in this country, we have been unable to verify,
in animals made aruumic by repeated bleedings the yellow
niarrovv is converted into red marrow. This is causedi
chiefly by absorption of the fat cells and a great dilatation
of the venules. In bealtli.y animals to some extent, and in
a far more marked manner in amcmicones, the corpuscles
in the venules of the marrow presents an ai-rangement not-
observed in other parts of the body. In the axis of the
venules are fully developed red corpuscles; between these-
and the periphery of the vessel are found two kinds of"
cells, leucocytes in greater numbers than are found in other
veins of the body, and young red corpu.scles distinguished
by their round or slightly oval form and the character o£’
their protoplasm and nucleus, many of ■which are under¬
going indirect divison (karyokine.sis) To those developing-;
red corpuscles the name of “ erythroblasts ” has been given.
Ib is stated by Bizzozero that in anamiiated animals three
zones may be readily made out—a centr.al one, of fully
developed red corpuscles; .a peripheral one, of leucocyteE'
and erythroblasts ; and a large middle zone, of greatly in¬
creased numbers of erythroblasts. Denys'' has made similar
I observations, but he and Bizzozero disagree as to the nature
' of the erythroblasts. Denys asserts they are destitute of
hamioglobin, and are transitional forms between leucocytes-
and red corpuscles. Bizzozero, on the other hand, maintains-
that Denys’ observations are founded on error, owing to hie
methods of hardening and staining depriving the erythro¬
blasts of their binmoglobin colouring matter. My ownand Dr.-
Galloway’s observations go to confirm Bizzozero, and by ex¬
amining sections simply hardened in Miitler’.s fluid, or stained
by means of Miiller’s or Boa’s reactions, one may convince
himself that the erythroblasts at all stages really contain.,
hauiioglobiu. To summarise Btzzozcro's conclusions, with
which our own observations agree, ib may be stated as re¬
gards the marrow: (1) That blood formation is entirely endo
vascular: (2) that the young red blood-corpuscles arise
from pre-existing red corpuscles; (3) that tliey arise by a
process of indirect division (mitosis). Colourless corpuscles
also arise by mitosis from the cells of the parenchyma and
from leucocytes within the venules of the marrow. Bizzozero-
has years ago shown that the development of red corpuscles
in the marrow is the same in all vertebraba as in birds. All
observers are agreed that the nucleated red corpuscle is the
immediate precursor of the fully developed non-nucleated
red corpuscle. There are still djil’erences of opinion as to-
the jirocess by which the nucleus disajipcars, some believing,
with Rinclfleisch that ib is extruded from the cell ; others,
with Kfilliker and Neumann, that it undergoes disintegra¬
tion. No satisfactory explanation is aflbrded of how the
young cell eventually acquires its oharacteri.stic discoidat’
form on the theory that the red corpuscles are developed
from leucocytes. j.f, however, it is ailmitted that they are
developed from pre-existing red corpu.scles, this is easily
understood as a consequence of their ultimate and complete
development.
I’dood-Jorndnfj Junctions of the spleen .—The spleen appears
to take t)ut little share in the formation of red corpuscles in
health, bub its latent capacity .apiiears to 1>e called intc"
activity in some r:i.9efi of anmmia. This has been shown by
Bizzozero and Salvioli, and more recently by Gibson. The
lytnphatic glands .also appear to have, according to Gibson,
slight powers of generating red corpuscles, bub there i»-
no convincing evitienco that the thyroid body has any suclt-
fnriclion.
The scats of desirvetion (f red corpuscles {hrcmolysis). -
fiargo nurahers of red corpuscles are being constantly
destroyed in the formation of bile, urinary pigments, and
other colouring matters derived from hmmogiobin. The
chief seat of destruction is xvibhin the portal system, and!'
I.a Hti'uctuve do la MoLdio dos Os et la Ocni';si) du cUez. G' ‘
Oiseaiix J/ii UuUulo, toin. iv., fas. 1.
The Lancet,] DR. STEPHEN MACKENZIE ON ANAEMIA AND ITS PATHOLOGY. [Jan. 10,1891. 75
oufcside this in the bone marrow. The difficult problem of pensate for the loss. On the other band, the blood-
blood destruction has been very carefully studied by Dr. forming capacity may be defective, and not keep pace with
William Hunter.® He has shown that it is of two kinds: even a normal degree of blood destruction. Or, lastly,
-(1) Passive destruction,' the ultimate destiny of the red defective hminogenesis and excessive hscmolysis may each
corpuscles which live their alloted span of life—it is charac- be in operation, and each aggravate the effect of the other,
torised by the large si^e of the pigment granules, which are Defective hrcmogenesis is indicated during life by the
always contained in leucocytes in the capillaries, and never characters of the blood-corpuscles, especially their deficiency
in the hepatic cells; (2) active destruction, in which the in hcemoglobin, and after death by the condition of in-
hfcmoglobin escapes from the corpuscles into the plasma activity of the cytogenic organa. Excessive htemolysis is
and is secreted from the liver cells, in which it may be indicated by the characters of the blood during life, in the
found, especially in the portal zone. Where active destruc- excessive secretion of dark bile, and the excess of pigments
tion takes place is still disputed. Hunter believes that it (urobilin) and iron in the urine, and post mortem by the
occurs in the gastric, intestinal, and splenic radicles of the evidences of excessive active destruction of blood, in the
f)ortal vein, bub Mott^ and Schiifer have lately thrown doubt liver and kidneys especially. Defective blood formation
on the share taken by the spleen. In the spleen, marrow may be due to a great variety of causes: insufficient
o(and lymphatic glands?) are found “blood-corpuscle- quantity or unsuitable quality of food; failure of the mas-
holding cells,” in which are found red corpuscles under- licatory, digestive, or assimilative powers; unfavourable
going disintegration. - ‘ ' ' ..“SI hygienic conditions; the presence of growths intercepting
The colourless or white hlood-corpuscles (lericoctjtes).— the material for blood formation; and failure, congenital or
Many additions to our knowledge concerning the white acquired, of the cytogenic organs. Excessive blood destrnc-
corpuacles have been made in recent years, especially by tion may be duo to the processes of fever and inllamraation,
Ehrlich.® It has been shown that the white corpuscles or to the presence of deleterious matters in the blood acting
differ much amongst themselves—certainly as regards their upon and destroying the red corpuscles,
morphological characters, and probably as regards their Anosmia thus depending on such a variety of causes, it
.physiological functions. They take their origin from becomes necessary to arrange the cases in some order, and
iymphabic structures, the spleen, and the marrow. In the classification which clinical convenience and patho-
■••jevere anaemia Ehrlich has shown there is an increase of logical propriety suggest, and which I shall adopt, is into
the poly-nuclear, and later of the mono-nuclear leucocytes. (1) Secondary and Symptomatic Anmniia, (2) I’rimary and
They ultimately undergo disintegration, forming “ele- Idiopathic Aniomia.
^nentary granules.” In Secondary and Symptomatic Anminia we have condi-
Mood platelets. —As many theories have been advanced tions in which the blood deficiency is nob the essential
■regarding these formed elements as the bodies themselves characteristic of the disease, and in which there are other
‘have received names. They cannot all bo regarded as symptoms present which are not explained by the existence
-artifieial, as they have been seen by several good observers of the anremia. In Primary and Idiopathic Aummia, on the
'in the liowing blood where care has been taken to guard other hand, the anmmia constitutes the main characteristic
•against injuries to the blood and bloodvessels. Hayenj and of the disease, and the otlier symptoms are all dependent
'I’ouchet believe them to be developmental form's of red upon it. Dr. Hunter'" has well defined what characterises
corpuscles, but the majority of observers regard them as O'Q idiopathic aiuemia. Dr. Pye-Sraith" would make a
‘broken-down red or white blood-corpuscles. They are tliivd division of cases of anamiia, “formed of all cases of
markedly increased in moat forms of anaimia, especially in anmmia associated with disease of the cytogenic organs,
Che primary anmmias. whether or not leuchir.mic.” These, which undoubtedly
HceiKogloHn. —It is shown that whilst in health there is form, clinically and pathologically, a compact group, should,
•igenerally a fixed relation between the amount of haimo- I think, be included under idiopathic ancemia In leucocy-
.globin and the number of red corpuscles in the blood, this tliiemiathere isnotonlyagreatexcessof colourlesseorpuscles,
■is liable to be disturbed in disease. Dr. Oslei'* has well but a marked deficiency of red corpuscles, to which many of
-summarised the variations that occur: “(1) In chlorosis the symptoms are due. As long as the question of the
t!»e haemoglobin is reduced out of proportion to the number origin of the red corpuscles from the white ia unsettled it is
■of corpuscles, so that the individual worth of each red dillicult or impossible to decide upon the relation of these
•corpuscSe in colouring matter may be greatly lowered, changes. If, as many believe, the red are transformed
Tims, the true ancemia (or functioning properties of the colourless corpuscles, an arrest of developfneut is a ready
■blood.) may be very much greater than the number of explanation. If, on the other hand, as seems tome more
■corpuscles per cubic millimetre would indicate ; (2) in probable, all red corpuscles arise from pre-existing red cor-
ordinary aoKsmia, from bmmorrhage or organic disease, the pnscles, this inviting hypothesis is no longer tenable. I
average wortli of haimoglobin of each corpuscle usually would merely draw attention to one point which appears to
•remains unaltered, and the percentage of colouring matter I'® militate, against the view that the deficiency of the
corresponds with the percentage of corpuscles; (3) in certain corpuscles is due to a non-transformation of colourless
cases of pernicious anminia the interesting fact has been ”'to red corpuscles, and this is the condition of the marrow,
■ascertained that the percentage of lucmoglobin is increased, Iri leueoeythiumia the marrow is usually in a condition of
•and the ana3Ini.^ is in reality not so great as the reduction in hyperplasia, which is favourable for the production of
“the number of corpuscles would appear to indicate.” colourless corpuscles, especially of the “ eosiuopliile leuco-
Havingaow considered the blool in health, wo are in a cytos,” which Ehrlich has shown are always increased; but,
‘PositioM to discuss the departures from this standard, in so growing as this does at the expense of the bloodvessels, it is
'far as they relate to ana'oiia. ADiciuia may be defined as unfavourable for the productioji of red corpuscles, which we
a diminution of the quantity of the blood, of its cor- have seen arc formed in the venules. Somewhat similar
.ipuscles, or of its colouring matter. To the first the term arguments might he used regarding “ anamiia splenica,”
“ oligwiwia ” is applied, to the second “oligocybhiwmia,” and “ anasinia lympliatica,” and “ anicmia myelogenica.”
•to the third, “oligochromaimia.” They all have this in Thus, I consider all cases in which anauiiia is not sym-
•couimon.-: tiiat they indicate “a poverty of the blood in ptomatic should be regarded as idiopathic. The term
'•lormal functional' red corpuscles ” (Cohnheim). We have ‘ ‘ idiopathic anjomia ” was, as is well known, first applied
seen that there is a constant using up and building up of hy Addison to that form of anamiia of which he gave such
blood. In health a balance is maintained. In ana-mia a masterly description. Others besides myself-have urged
•there is a failure of adjustment between the gains and the that it should bo restricted to the class of cases described
losses, a want of balance between the income and expendi- hy Addison. The progress of our knowledge, in niy opinion,
'Sure. Until recently so little was known concerning blood ''"'v 'renders it advisable to enlarge its meaning so as to
formation and blood destruction that it was ilillicult to say embrace all primary anmmias, ami to use it as a generic
whore wo should look for evidence as to which of tliese pro- term, iucludiDg several species. Of tliose species two are
cesses was at fault. Our knowledge is now reaching that well defined—clilorosis and the form described by Addison,
point where we can make defective biomogenesis or which has by common consent come to be called “ pernicious
excessive hiumolysis the basis of our pathology. Auiomia anasmia,” and which name I now think it is useless to
may depend upon excessive destruction of red corpuscles, resist. Probably besides tiiese two species there are other
«o that the blood-forming powers are unable to com- distinct forms of idiopathic amoiiua, to which I shall have
- - .occasion to allude in subsequent lectures.
<• Arris and (iii.lo l.onturoa : Brit, Mod. .Tom-., vol. ii, ISBlt. -- ---- •- --
„ ^ I’ractitionor, Aur. iBnO. i» is Porniciow Aimmiia a Spocial Diseaso'' Practitionor, August,
8 /-oitach. fur Klin, Modiein., Baiuli,, tSBl), S. r.C3. 18S8. H C-iuy's llospitanioports, vol.xxvi,
•’ Cartwright Loctuvos ; Brit. Motl, .Jour., vol. i. 138(1, p. StiB. vj 'I'mi Lancot, vol. U. 1878, p. 797.
76 Thb Lancet,] MESSRS. PITTS AND BROOK: STENOSIS OF THE TRACHEA.
[Jan. 10, i8»l.
ON THE
STENOSIS OF THE TRACHEA AND LARYNX
WHICH OCCASIONALLY FOLLOWS THE
USE OF A TRACHEOTOMY TUBE;
WITH REMARKS ON THE PRESENT POSITION OK INTUBATION. ’
By BERNARD PITTS. M.C. Cantab , F.R.C'.S.Eng,,
AM) .
WILLIAM F. BROOK, F.R.C.S.ENa.
The main object of this paper is to illustrate some of the
causes which may prevent the return to the natural channel
for breathing—after the use of a tracheotomy tube for a
prolonged period—and to draw attention to the treatment
of such cases. Most frequently the dilliculty arises from a
want of confidence on the part of the patient, and by a little
encouragement and by the use of a tube with an upward
opening it is easy to overcome this very common trouble.
In the four cases we narrate the obstacle to natural breath¬
ing was some form of definite mechanical occlusion of the
upper part of the trachea or of the lower laryngeal aperture.
Such reil obstruction is, fortunately, not of cjmmon occur¬
rence, and the difficulty of overcoming it is very .great, and
in some cases insuperable. Some lessons may, we think,
he learnt from a study of these oases. At any rate, we
feel that we have gained experience, and are in a posi¬
tion to deal with any future cases with more preci¬
sion and with quicker success. Tracheotomy in young
children is usually performed high, and the cricoid is
probably often divided. Unless the tube happens to fib
the particular case exactly, a good deal of irritation of
the back of the trachea, or even of the lower laryngeal
aperture, is apt to be occasioned by the angle of the tube.
The tube rarely fits comfortably if the cricoid has been
divided, and it seems important to avoid this division if
possible. No doubt much friction by this part of the tube
is occasioned by movements of the larynx in swallowing
and by restlessness on the part of the patient, and this
friction would be greatly diminished if a tube with a
inovable collar, such as a Durham’s tube possesses, were
more universally adopted. Unless there be uliowance for
variation, a tube which fibs well in a child of a certain age
will be mofct unsuitable for a child of the same age, bub
with a more deeply placed tracliea. At (Jreab Ortnond-
street Hospital an ordinary bivalve has been in most fre¬
quent use, and possibly this may have occasioned some of
the irritation in two of the cases requiring after-treatment
■for stenosis. The pi-essure sore tliac is too often found on
the front wall of the trachea, and which is caused by the
end of the tub?, has not had in any of our ca®es anything to
do with the after trouble; it is, however, evidence of the
use of a tube of unsuitable shape.
Case 1.—Edward F-, aged three, was admitted to
Great Onnond-streeb Hospiral on Dec. llrd, 188G, under the
care of Dr. Cheadle, with difficulty of breathing and marked
stridor. He had been an in-patient for a short time early
in the year for a similar attack, from which he recovered
without operation. On examination, the throat was fDiind
congested, _ but no membrane was to bo seen. There
was no evidence of any syphilitic trouble in the family.
The symptoms gradually became more urgent, and on
Dec. 14bh tracheotomy was performed by the house surgeon
with insbant relief. The tube was removed on Dec. 17th
for live hours, but had to be replaced. The child now bad
a sharp attack of scarlet fever with high temperature and
some lung complications, and was oViligod to wear tiie tube
continuously through the attack.—Feb. 15th, 1887: Trace
of albumen ; child pale and wasted. Tiie tube was taken
out, and on h'eb. 18th the wound had nearly closed and the
breathing was satisfactory.—March lat: Right side dull;
breath sounds weak ; much stridor. Aspirator used, and a
few drops of pus drawn off.--8th : TJie dilliculty jji breathing
became suddenly urgent, and the house physician bad to
perform fresli tracheotonjy, and only just managed to pull
the child round.—April 20th : Better; running about the
ward ; gaining /lesli, but still obliged to wear the tulro.—
June 20bh ; The tuba was left out on trial ; spasm of glottis
one hour after, and the tube had to be replaced.—24th;
J Re.'wl Before Llie Medical fsociety on Monday, Doc. 1st, 1890.
Mr. Lewis, the bouse surgeon, under chloroform, passed fa.
Macewen’s tracheal catheter with a little difficulty up from
the wound through the mouth, and then pushed the lo.wor
end downwards into the trachea below the wound; the-
cabheter was retained, but during the night the child held)
the tube so tightly with his teeth as to prevent the entry
of air, and it had to be removed. During the next three-
months Mr. Lewis repeatedly passed these catheters, and
wlren the wound became smaller he introduced the tube froirb
the mouth down the trachea beyond the site of the tracheo¬
tomy wound. Tire boy could not retain the tube long,
rarely more than one hour at a time, and it occasioned great.
distress. There is no doubt, however, that he improved,,
the tracheotomy opening closed, and for a short interval he
was able to breathe comfortably. Mr. T^ewis makes a note-
that he always had great difficulty in introducing the tube
through the mouth.—Oct. 17th: Had a bad attack of
dyspnma in the night, fifteen days after the last dilatation.—
liltb: Tracheotomy was again necessaiy. The house-
surgeon cut through a quantity of cicatricial tissue, and
had some difficulty in getting the tube to pass into the-
trachea, owing to the narrowing of the lumen of the-
trachea.—Nov. .‘Ird: The child left the hospital for the-
Higligate Convalescent Home, still wearing a silver tube,,
and spent the next year either at the Convalescent Home-
or at his own home, wearing the tubs continuously.
He was readmitted to Great Ormond-street Hoepibaf-
on Marelr lab, 1889. He was then in fair condition, and
able to phonate fairly well by putting his finger over
the opening of the tube.—March 4bh: The tube was left-
out for four hours; the opening rapidly contracted, making;
the leintroduction of the bivalve tube difficult.—5bh: The-
tube was taken out as usual, and a sponge tied over-
' the opening. After forty minute.?, whilst the child was.
' playing on the ward velocipede, lie became distressed
and tiic .sponge was removed, but without any relief.'
He suddenly luy on the floor and became cyanosed, evert-
to Ills finger tips. After a short struggle he became quite-
still, and the staff nurse inserted the tracheal dilator, and
, by smacking the child succeeded in making him breathe;
The tube was inserted by the house physician so soon as he-
arrived on the spot, and the little fellow was soon comfort¬
able again.—Aug. 2l3b; By request of Dr. Cheadle Mr.
Pitts took charge of the case, and under chlorofoim intu-•
hated the larynx with an O’Dwyer’s tube. There was no dif¬
ficulty in passing the tube, and the end could be felt through
the tracheotomy opening, but the breathing was not satisfac ¬
tory, and it was evident that the tube did not lie straight iib
the tracliea, but the lower end was tilted forwards and
to one side. Several sizes of intubation tube were now^-
tried, but without success; and, as the child was rather
exhausted, the tracheotomy tube was replaced, and he-
was put to btd. The next day, Aug. 28tb, chloroform.
was administered by Mr. Priestley, the surgical registrar,
and the following is his description of the operation. Tbe-
wound was extended upwards, and the thyroid partially
divided. Retracting the parts with blunt hooks, it was-
found that there wa.s a rather thick pinky-white band of'
fibroid tissue, whicli started from just below the cords and
extended obliquely downwards from riglit to left, and thus'
a sort of diapliragm was formed, nearly blocking up the-
lower aperture of the larynx. There was also a general’
overgrowth of fibroid tissue round the coiiimencenjent of
the trachea, and at this point the trachea was seen to bond-
backwarda. It was found necesfury to paint the interior^
of the larynx with cocaine, as the irritation of the manipu¬
lations caused vomiting, but this was entirely kept under
by the cocaine. 'With a pair of curved scissors the hand)
was now dissected away and as much of the surrounding
fibroid thickening as possible. The cords were examined-
from below, but no growth or thickening was found higher
in the larynx. A long curve 1 tracheotomy tube was intro".^
duced and the thyroid brought together by a silver-
suture. Two sutures were placed below tlie tube, so-
as to raise the height of the tube, and thus try to-
keep dilated the part where the dibsectioa had been,
carried out.—Sept. 7th: Tube removed.—I4th: Wound-
healed, voice improved, and breafciiing easy and with¬
out stridor,—Oct. lObh: For the last fourteen days there
has been increasing inspiratory stridor and oecasionab
distress during the night. Tracheotomy was performed and.
patient allowed to resume bis old tube life till Dec. JGili,
when it was determined to again try the effect of intuba¬
tion with O’Dwyer’s tube. Under an anrcsthelic the largesfc.
Cooglc
Din-
The Lancet,]
MESSRS. PITIS AND BROOK: STENOSIS OF THE TRACHEA. [.Ian. 10, 1891. 77
size intubation tube was easily passed by Mr. Brook, house
surgeon, and a tracheal plugwas applied to tlie opening in the
Deck. This tube was well tolerated and allowed to remain
in till Dec. 18th. During this time the boy was quite com¬
fortable, playing about the ward, and taking minced food
and pudding. Ho remained without further intubation till
Jan. 2ad, 1890, the tracheal wound being then quite healed.
The intubation tube was passed without an anassthetic by
Mr. Brook, and left in twenty minutes. Intubation without
an amcstbetic was again done at the end of the month, once
during February, and for the last time on March 4th, 1890;
the tube passed with great ease and was left in ten minutes.
He was now allowed to go home, and has never been in¬
tubated since. Daring the last nine months he has
remained quite well, and has been constantly helping his
father as a fish hawker; he uses his voice constantly in
crying his father’s goods. He is here to-night, and if we
can get him to shout, he will show that—notwithstanding
his various tracheotomies, thyrotomy, and intubations—he
has a remarkably loud voice, and one well suited for his
profession as a hawker.
We have narrated the case of this boy rather fully, for it
was the first of the series. For more than three years he
hafiied all the numerous efforts made to do away with the
tracheotomy tube, and it was only after the thyrotomy that
it was possible to determine the exact nature of the ob¬
struction. Dilatation of his larynx by Macewen’s catheters
was most carefully carried out by Mr. Lewis, and all
ordinary means were tried to get rid of the tracheotomy
tube and failed, except for brief periods. It was never
quite clear what was the primary cause of the dyspncea.
Shortly after the original tracheotomy he had a bad attack
of scarlet fever, and probably this explains the irritation
set up by the tube. In the twentieth volume of the Clinical
Society’s Transactions several very interesting cases are
recorded by Mr. Bilton Pollard where he succeeded
by the use of Mncewen’s tracheal catheters in estab¬
lishing natural respiration. In the case of E. F ,
success at first seemed to attend this method, but
relapse always speedily followed, By reference to the
diagram (Fig. I) it is quite easy to see why this failure
Fig. 1.
occurred, and also why dilatation by O’Dwyer’s method at
first was useless. The cicatricial band formed almost
a complete diaphragm, and the result of any form of
intubation was merely to dilate the lumen of the dia¬
phragm or else to push the diaphragm before the tube. The
lesson that was learnt is that with failure by simple intuba¬
tion to restore the natural passage, a free exploration of the
tracheal wound should be made, and all cicatricial tissue at
once bo thoroughly removed, and the passage thus prepared
for intubation, which should bo then again employed and
repeated from time to time, until all tendency to teeen-
traction has passed away. After the thyrotomy andexcision
of cicatrix in E F-’s case, too long an interval was allowed
before intubation was again used; with more confidence in
intubation the last tracheotomy would have been unneces¬
sary. The advantages of O’Dwyer’s method over Macewen’s
tracheal catheters are sufficiently obvious. An O’Dwyer’s
tube has an increased circumference at the part wanted for
such dilatation. It is well tolerated by the patient for a
lengthy period, andfood can be taken without difficulty.
Case 2.—Charles C-, aged nine, was admitted on
I Aug. 24th, 1889, under Dr. Cheadle, with membrane on soft
palate and difficult breathing. High tracheotomy was
performed by the house surgeon, with relief of symptoms.—
Au". 2Gth: Progressing favourably till last night, when the
child suffered from frequent cough and bleeding from the
tube. An anmsthetic was given, and several bleeding
points in the depth of the wound were secured. During
the next three months all attempts to remove the tube
were attended by immediate distress, even when an antcs-
thetic was administered. — Dec. 10th; Transferred by
Dr. Cheadle to the care of Mr. Pitts. The tracheal wound
was enlarged, and a quantity of granulation tissue was
found at the front and sides of the trachea at the lower
border of the wound; this was removed with scissors and
a sharp spoon. The largest sized intubation tube was
introduced and a rubber plug put into the tracheal woiiniL
The tube was coughed out in half an hour and the tracheo¬
tomy tube M’as replaced.—11th : The house surgeon, Mr.
Brook, intubated without an anresthetic —12bh; String was
removed, as it occasioned some cough and discomfort. This
tube remained in situ from Dec. 1 Ith till the 18th; it was
then removed and not replaced.—Jan. 1st, 1890: 'Tracheal
wound healed; voice natural.
On Jan. lObb (twenty-fourdays since last intubation) he had
a rise of temperature, and some pneumonia at the left base.
No further intubation was done, and he was discharged well
on March 6bh, and the voice and breathing were quite
normal. He has been kept under observation since, but no
further intubation has been necessary. At the present time
his voice is clear, and there is nostririor even after exertion.
In this case, since dyspnoea had for four months constantly
attended every effort to dispense with the tracheotomy tube,
it was thought right to make an exploration of the wound
before employing intubation. Possibly the removal of the
granulation tissue might have been sufficient, but we
thought it advisable to keep up some dilatation until the
surface, laid bare by the removal of the granulation tissue,
had completely healed.
Case .3.—Albert H-, aged three years and three
months, wasadmitted on July Jlst, 1889, undei the care of
Dr. Cheadle, sufferingfrom diphtheritic membrane on tonsils
and marked dyspncea. Tracheotomy was at once done by the
house surgeon, and a large quantity of membrane was removed
from the trachea —Aug. 4th : The wound was covered with
membrane, and during the next week great sloughing of the
wound went on.—9th : Much of the lluid taken by the
mouth escaping by wound, sore rapidly increasing, and at
the bottom of the wound the trachea to be seen lying
hare for more than one inch of its extent, and through
the large opening in it the posterior wall of the trachea
can be seen.—lOth : Kect.al feeding necessary.—11th:
Enemata returned, so nasal feeding substituted. Child very
collapsed and almost pulseless.—Sept. 9th ; Child has
slowly improved ; gets up wearing tube. — Oct. 28th : Unable
to plionate or to do without tube; bougie passed through
larynx.—Dec. 12bh : Dr. Cheadle transferred the patient to
the care of Mr. Pitts. Intubation under chloroform. Tube
retained three days, and then removed on account of rise of
temperature. Tracheotomy tube replaced.—23rd : Both
tonsils and some adenoids removed by Mr. Brook to
facilitate intubation. —Jan. 2nd, 1890: Intubation again
under chloroform, Inrt the tube was removed next day, as
there was a rise of temperature. Small tube difficult to
pass.— nth : Intubation under chloroform. Tube retained till
Kith, when a larger one was passed without an ancestlietic ;
this was retained until Jan. 20th, and then the largest tube
but one was introduced.—28th: The largest tube was
passed—i.e., one suitable for a child of twelve.—Feb. 3id ;
The tube was taken out, and ten minutes after the child
was unable to breathe, and the tracheotomy tube was put
in, the opening having been kept patent by tracheal plug. *
Intubation after this was several times tried, but became
more difficult, and on Feb. llitli the child was placed under
Dig]../ed by ^oogle
8 Thk Lancet,]
DR. JOHN WORTABET : CHOLERA IN NORTHERN SYRIA.
[Jan. 10^ 1891..
ohloroform'and examiaed, and the tracheotomy wound was
freely enlarged ; an exainination showed that at the level
of the tracheal opening there was a dense collar of cica¬
tricial tissue encroaching on the lumen of the trachea.
The trachea at the same point appeared to bend back¬
wards, the part below forming an angle with the part
above the obstruction collar, as shown in Fig. 2 The
Fig. 2.
A, 'I'lio cicatricial tiHSiic in Lliis case extuinlod a long way ilowii
ttie back asid siiles of the trachea.
cicatricial tissue was dissected away very freely, together
with the lining of the tracheotomy opening. A large
tracheotomy tube was then introduced. Intubation was
recommenced on Feb. 27th ; the largest size but one was
left in. It was coughed out next day, but although the
tracheal wound was plugged the patient could breathe
comfortably through the mouth. The tracheal wound was
allowed now to heal; intubation was repeated every few
days until May 7th. when the child developed measles. At
this period phonation (an extremely deep note) was just
possible with great eflbrt. During the attack of measles it
was found necessary to keep the intubation tube almost
constantly in. Intubation was frequently done during
June, and on July 14th the child was sent home, as it was
thought ho mignb be intubated as an out-patient. lie
returned in three days after his discharge, a tube was put
in, and he wore this at home for ten days, taking ordinary
food as usual. The tube was now left out sixteen days,
and then again worn for ten days ; it was then taken out
and replaced and retained for another week. During the
lasit two months the mother neglected to bring the child to
the hospital. By special request the mother brought the
child to see us on Nov. 2;ird. There was then some stridor
and dyspncoa on exertion. Phonation only by great effort.
Re,iaarks .—This case shows the great difliculty that may
be experienced in the restoration of natural breathing.
Oonsitlering the extensive sloughing of the tracheal wound
and the necrosis of portions of the tracheal rings, it cannot
bo wondered at that an extensive formation of cicatricial
iisBue arose. Some kinking of the trachea opposite the
tracheal opening is, we believe, of not infrequent occur¬
rence, and this, combined with the cicatricial stricture,
made the case remarkably intractable. Much time was
wasted in the treatment by not attending to the lesson that
ought to have been learnt from the first case—namely,
where intubation is not at once satisfactory, to explore for
and remove, as far as possible, all mechanical obstruction.
We were unwilling, after the extensive .sloughing that had
becurred, to meddle with the wound if we could avoid it.
This cf se must be considered as still under treatment.
T\ere must be as much necessity for constant dilatation os
in a bad cicatricial stricture of the urethra. We believe,
however, if the mother had not neglected to bring the child
for the last two months it would now have been in a
more satisfactory condition than he is at present. The
parents unfortunately considered the child so well as nob
to require further treatment.
{To be concluded.)
CHOLERA IN NORTHERN SYRIA.
By JOHN WORTABET, M.D,,
CORIU'ISI’ONUINO MKMUEROI'TllK KPlDEMIOI-OOICAf. SOCIETV 01' I.ONDON,
.INI) 01' Tim MEDlCO-t'lllRUROiCAI. SOCIETY OK EUINDUROU.
The present epidemic of cholera in the north of Syria
originated from Mesopotamia, where it was well known to
have been for some time previously. It appears to have
been imported bo Aleppo by a nomadic tribe of Bedouins
from a point on the Euphrates about fifty miles from that
city, and where its first appearance was ollicially reco¬
gnised about Sept. 13th. From this point it spread north¬
wards, implicating KilUs, Aintah, Barejeck, Orfa, and
Marash ; and to the south, where the principal places
attacked were Hamath, Antioch, and Homs. The informa¬
tion about the former of these regions is too meagre and
unreliable to enable me to give any details, and it is quite
possible that the infection may have been brought to some of
the places mentioned directly from some Mesopotamian focus.
But there can be no doubt as to the extension of the disease
from Aleppo southwards, and it is with this that I wish to
deal in the present communication. This extension took
place in spite of the so-called cordons and quarantines
which the Government imposed between infected and sound
spots. And yet it is equally certain that, to the unusually
vigorous measures of this kind taken by the governors of
Damascus, Beyrout, and Mount Lebanon, isolating these
tracts from Aleppo, Hamath, Homs, and Antioch, the im¬
munity, so far, of these places is due. It remains, however,
to be seen whether they will succeed in warding off the dis¬
ease permanently, or whether they will be useful only in
retarding its approach until the cold weather sets in, when it
is hope<l its violence may be mitigated. That cordons and
land quarantines carried out effectually, and under scientific
and favourable conditions, will preventthediffusionof cholera
and destroy it on its way, has, I think, been satisfactorily
proved this year in the case of the Hejaz pilgrims, who
were pub into quarantine at distant spots from any inhabit¬
able land, and from which cacapo was impossible. Those
pilgrims coinicg from Mecca, Medina, and Jeddah, and
bearing with them the disease, were gradually freed from it
during their forced detention on the waste shores of the Red
Sea; and it was thus that, so far as can be seen, Egypt,
Syria, and Turkey were saved from what seemed at one
time to be an inevitable fate. The land pilgrims coming
from Mecca to Damascus by short stages, isolated through
an open and uninhabited route, and taking some weeks on
the way, became free of it, and returned to that city in
perfect health. But it is far different in a populous land
where themeansofconimunicationaresogreat.wherecordons
have been repeatedly tried and always failed, and where, on
the other hand, thevalue of public and private .sanitation has
'been proved beyond all doubt. Tliesimpler hygienic moans,
such as cleanliness of dwellings and sL'oets, prevention of
the sale of unripe and rotten fruits and unwholesome food,
&c., were probably ordered and partially executed in the
infected places by the local authorities ; but in the equally
important matters of drains, gutters, and cesspools, where
more scientific and drastic measures are called for, it is to
be feared that very little, if anything, was done. Still, it
appears that the violence of the present epidemic in Aleppo
is very considerably less than that of previous visita-""
tions. This is probably due to improved methods of sani¬
tation, while it is certain that in Aleppo there had been up
to Oct. 26th no case of cholera among the Europeans and
better class natives, whose lives and surroundings were
made as unfavourable to infection as possible.
Aleppo is a city of Northern Syria, having an estimated
population of about 100,000, and lies in a plain 1600 feet
above the sea-level. Its water-supply comes from a small
stream which is used up in irrigating the gardens, and its
drinking water comes from a spring near Aintah, which is
Digitized by
Google
TftB Lancet,] MR. A. W. MAYO ROBSON: CHOLECYSTOTOMY FOR GALL-STONES. [Jan. 10, 1891. 79
carried \n a covered conduit. On the appearance of cholera
about Sept. I2th, and up to the 220d of that month, no
ollicial bulletins were issued, but the oflicer of health esti¬
mated the fatal cases at 21. A local sanitary commission
was then appointed, and the following weekly returns are
drawn up from its daily reports. It is generally believed,
however, tliat the rate of mortality is very much under¬
stated, while a few Hold that it is somewhat above the
real number of deaths. The number, tlierefore, is only
approximately true, and is given as a fair idea of the
natural course and duration of the epidemic in the East,
and especially as regards its periods of rise, height, and
decline. The last accounts from that city show at this date
(Nov. 2()bb) that the epidemic has entirely ceased.
Estimated cases of death from Sept. 13tb to 22Qd ... 21
Sept. 23rd to 29bh (say, second week) . 42
,, 30th to Oct. 6th (third week) . 120
Oct. 7th to „ 13bh (fourth week) . 190
„ 14th to „ 20th (fifth week) . 165
,, 2lst to ,, 28th (sixth week) . 47
„ 29th to Nov. 4th (seventh week) . 11
Nov. r)th to ,, Util (eighth week) . 37
„ r2th to ,, 18th (ninth week) . 21
Total .054
Hamath, a town of about 40,000 inhabitants, lies about
three days’ journey south from Aleppo, and is built on the
two sides of the Orontes, which, taking its rise from a point
near Baalbec, runs due north, passes about a mile west of
Horn?, and at Hamath turns to the west, supples Antioch
with its waters, and empties itself into the bay of the
ancient Seleucia. Its elevation above the level of the
sea is a little more than 1000 ft. Though the official
records give Oct. 15th as the earliest date of the appear¬
ance of cholera in it, and thus a heavy mortality for
the first week, it is more likely that it began pome days
before it was recognised and officially announced, and that
its first cases were few. Tiie following is tlie record which
I have been able to obtain from the ollicial papers :—
First weelv
Oct. 15th to Oct. 2l8t...
,, 22Qd to „ 28th..,
„ 29th to Nov. 4th ...
Nov. .5th to ,, 11th ...
„ 12bhto ,, 16th.,,
... 88
.303
... 213
... 76
7
Total .
... 087
From Nov. 12th to this date (Nov. 26bh) I have been
unable to obtain any definite information, bub the number
of daily deaths has been gradually diminishing, and the
epidemic there is said now to have ceased.
Of Antioch, whose population is estimated at 12,000, the
records are as follows
Oct. 29tU to Oct. 26bh.
. 22
,, 27th to Nov. 2od.
Nov. 3rd to ,, 9th.
. 159
. 36
,, 10th to ,, 12ch.
. 5
Total .
. 2-22
This is evidently very imperfect, but I give it for what it
is worth.
The following are the returns from Horns, a town of
25,000 inhabitants and a day’s journey south of Hamath:—
Oct. 27fch to Nov.
2Qd
. 63
Nov. 3ril to ,,
9tli
. 234
,, 10th to „
loth
. 1G9
„ 17bh bo „
24th
. 130
Total
. 596
En it appears that the epidemic has almost
entirely ceased in Aleppo after a duration of about ten weeks,
the third, fourth, and fifth showing the highest number of
deaths. A late telegram from Hamath gives the same
news, tltough it is quite possible that fresh cases may still
break out, as may be observed in the eighth and ninth weeks
of the march of the disease in Aleppo, and that a slight rise
during the period of decline may be an ordinary phenomenon
in the hisboiy of cholera epidemics. If, however, the dura¬
tion of the disease in Hamath, Homs, and Antioch is to bo
short, this may be due to an unusually long storm of rain and
cold which has overrun the whole of Syria since the Jr)bh of
this month to this date, or to the unusual severity of the
epidemic in those places, which has exhausted itself sooner
than it did in Aleppo, where the relative rate of mortality
was much milder. Judging from previous cholera visita¬
tions in Syria, it seems that the ordinary duration of an
epidemic is rarely less, if ever, than ten weeks, and it looks
very much as if it had, when the population is stationary, a
definite course to run, like a case of typhoid fever and
most of the acute diseases. How much tliis has to do with
the life history of the cholera bacillus in a given place
is difficult to say in our present state of knowledge.
The whole coast of Syria^ and the whole of its southern
part are so far intact, and I do not know how this can
he accounted for except by believing that the measures
of isolation taken by the authorities have been unusually
rigid, and thus effectual in warding off the spread of the
disease to these parts up to this date.
Beyvout, Nov. 20tli, 181M).
CHOLECYSTOTOMY FOK GALL-STONES,
PERFOEMED ON ^i’HE STRENGTH OF
SYMPTOMS WITHOUT PHYSJGAL SIGNS!
Bv A. W. MAYO ROBSON, F.K.C.S.,
IIONOU.MIV SUiUiKON TO TUH I.EKDS (iKNKUAI. 1 Nl'ft<M,\RV, I’llOKKSSOR
<»!'SUROHRV IN TMIO YORKSHIRK COl.I.KClO .\NI) MXAMINER
IN Till-: VlCTORl.V UNIVURSITV.
On Oct, 25tli of last year I had the honour of rending
before the Clinical Society of London a paper based on
foin'tcen cases of cholecystotoniy. Since that time I have
performed the operation nine times without a death, making
in all twenty-three cases. In my former paper I gave brief
histories of five c-ase-s operated upon on the strength of
symptoms alone. I have now to add to that series two
more cases, notes of which I now give.
Mr. P. B-, aged twenty-nine, residing at Wyke, near
Bradford, was sent to see me by ray fiierul Dr. Doarden
early in June of last year, when he gave the following
history:—He had been quite well up to twelve months
ago, when he was seized whilst at work with a sudden
attack of severe pain on the right side of the abdomen just
below the ribs, which compelled him to return home. The
attack lasted for several hours. No jaundice followed, and
he was able to return to hU duties in a day or two. Ever
since that time he had been subject to similar attacks, but
on no occasion liad ho been jaundiced, and he had never,
noticed any swelling in the region of the liver. The attacks
did not recur periodically, he having had once an interval
of a month without an attack, whilst on other occasions
he would have several in a week. On several occasions
the spasms had come on when he was in bed. The attack
which he had just previously to admission, lasted six hours.
At no time had the motions been clay coloured or the urine
specially dark. He was admitted to the infirmary on
June 0th, in order that he might be M'atched for a time, but
beyond having several attacks of pain of a similar charac¬
ter no physical signs were noticed. On June lOth chole-
eystotoiny was performed. The gall-bladder ii’as found to he
small, and lying well under cover of the liver. One gall-stone
was found loose in the gall-bladder, and five others were re¬
moved from thecystic duct by means of forceps within, aided by
fingers on the outside of the duct. The gall-bladder was so
far from the surface that the lower edge of the incision could
nob be brought to the parietal peritoneum, hence the
omentum was made use of to shut out the general peritoneal
cavity. This was effected by bringing up_ the right border
of the omentum, stitching it to the incision in the gall¬
bladder and then to the parietal peritoneum. A drainage-
tube was inserted into the gall-bladder, and bile commenced
'■() How as soon as the operation had been completed. On
June 2.5th the drainage-tube and sutures M'ere removed.
On July 4th the discharge had diminislied considerably. On
the 12th the- wound had almost healed, and on the 2Cth it
had perfectly closed. The patient was seen in September,
when he was looking and feeling perfectly well, and said
that he had not had an attack of pain since the operation.
Mr. U-, aged fifty, was sent to see me by my frieml.
Dr. Britton of Harrogate, in April of last year. He gave
the history of having been perfectly well up to June, 1880,
when he had a severe attack of pain in the region of the
Digitized by
Google
80 TheLancktJ
MR. HORATIO P. SYMONDS ON ANEURYSM.
[Jan. 10,1391.
liver, which lasted for several days, but which was not
fallowed by jaundice. He had no further attack until
November, and between November and Christmas he had
hve similar seizures. Between January and his seeing me
in April he had bad seven attacks, only once having been
slightly jaundiced, the yellowness of the eyes then only
lasting three days. Having very little doubt that the
attacks were due t'o gall-stones, we had the motions care¬
fully examined, and on May 5th, although there had been
two attacks since Mr, R-saw me in April, no gall-stone
had been found, although carefully searched for. It
was thought that during the attacks of pain a swelling
had been noticed on the right side of the abdomen, but this
point was not very deficite, and when I saw Mr. R-
there was an entire absence of physical signs. Cholecys-
totomy was recommended and performed on May 6bh, when
one gall-stone, the size of a cherry, without any facets, was
removed from the gall-bladder. Bile flowed at once, and the
drainage-tube was removed on tlie third day, the stitches
being taken out on the eighth. At the end of a fortnight
the wound had quite healed, and Mr. R-returned to his
home at the end of three weeks. He has remained quite
well since, and is now in perfect health. The interest
in this case lies in the fact that all the symptoms were
dependent on the one calculus.
Besides these cases which I have operated on, I have seen
a considerable number of patients whose symptoms were
similar to the above, and where I made a diagnosis of
cholelithiasis and recommended operation; and 1 believe
that by far the greater number of patients who are sufFer-
ing from repeated attacks of so called spasms are in reality
suffering from gall-stones, and can therefore be relieved if
their symptoms are so severe as to require active inter¬
ference. It must always be borne in mind that unless the
gall-stones are small and can be passed, they tend to in¬
crease in size and number, and may ultimately lead to most
serious complieationp, among which may be mentioned:
(l)Exhau3tion from repeated attacks of pain, (2) fatal collapse
from acute agony (I have known in one case death to ensue
from pain alone, as proved by post-mortem examination);
(3) fatal jaundice, (4) dropsy of the gall-bladder, (5) em¬
pyema of tbe gall-bladder, (6) abscess of liver, (7) local
peritonitis, (8) perforation of the gall-bladder or ducts,
causing abscess, peritonitis, septicaemia, intestinal ob¬
struction, or hieiuorrbage. Bearing in mind these dangers
of cholelithiasis, and knowing with what little risk the
operation of cholecystotomy can be performed if done care¬
fully and with due precautions, 1 have no hesitation in
recommending operation whenever there are repeated
attacks of biliary colic apparently due to gall-stones, which
do not yield to a definite course, not necessarily very pro¬
longed, of medical treatment.
Loed.^.
A CASK OF
ANEURYSM OF THE EXTERNAL ILIAC
ARTERY CURED BY COMPRESSION.
Bv HOllATIO F. SYMONDS,
SdlUilOO.N TO THE RADCI.Il-T-Ti I.M-TIIMAHY, OXKOUD.
G. S-, aged forty-eight, a sawyer, was admitted to
tbe Radcliffe Infirmary, Oxford, on July 2nd, 1890. The
'history was that on Feb. 26tb, 1890, he felt a sudden
cramp in his left leg, after which it became perfectly cold^
and felt as if it had been frozen. His power of moving it
was also impaired, and siuce then be has been unable to
work. He has, however, been able to move about, but has
snllered from great pain in tbe limb, especially in the sole
of the foot, and at times in tbe region of the left Foupart's
ligament. About three weeks before admission, while the
patient was passing bis band over this region, he felt a
pulsating swelling, and, failing to find anything corre¬
sponding on the right side, he came to the infirmary, where
he was admitted, as above stated. On examination, there
was observed just above the left Foupart’s ligament a
marked prominence, with a heaving expansile pulsation.
A similar pulsation was also plainly seen continued from
the swelling down tbe thigh as far as the apex of Scarpa’s
triangle. On palpation a round, smooth swelling about tbe
size of a hen’s egg was felt, apparently well defined above,
but below somewhat fusiform, and passing into the com¬
mencement of the femoral artery. It exhibited uniform
expansion, and over it a well-marked systolic bruit was
audible. The pulse at the ankle on both sides was
very weak, but the left was decidedly feebler. With
regard to the heart, there was no visible cardiae impulse
in tbe front of the chest, the apex beat could not be
localised, and the cardiac dulness was masked by emphysema
of the lungs. Tbe heart sounds werefeeble, but no murmur
existed. The pulse was 74, slightly irregular, and of low
tension. There was marked pulsation visible in the brachial
arteries at the bend of the elbows and in the radials at the
wrists. The vessels rolled under the fingers like cords. There
was no history of syphilis.
After consultation it was determined to apply com¬
pression to the common iliac aitery with a view to curing
the aneurysm. On July 22Qd accordingly, at 10.35 A.M.,
the patient being put under the influence of bichloride
of methylene, given from a Junker’s inhaler, a Lister’s
abdominal tourniquet was applied on a line with the
highest points of the iliac crests and a little to the left of
the middle line. On tightening it up the aneurysm ceased
to pulsate, though pulsation continued in the right limb.
Pressure was kept up till 5 P.M., when the tourniquet was
slackened for a few seconds; but as pulsation slightly
returned in the aneurysm, it was again tightened. At
7 P M. pressure was again gradually taken off by loosening
the screw of the tourniquet by a quarter of a turn every
fifteen minutes till 10.15 p.m., when the instrument was
entirely removed, tbe aneurysm showing no sign of pulsa¬
tion, and being hard and firm to the touch. A sixth of a
grain of hydro-chlorate of morphine was given hypodermi¬
cally and tbe methylene discontinued. Tiie patient slept
till 2.30 A.M., when he became very violent and restless.
There was no return of pulsation in the tumour. On
July 25th there were some symptoms of peritonitis and
enteritis. On tbe 26bh some swelling of the left parotid
was observed, which next day had increased to the size of a
pigeon’s egg, and on the 28th there was a similar bub
smaller swelling of the right parotid. The urine contained
a small trace of albumen. The temperature, which had
hitherto been normal, rose to lOO'S®, but again fell
on tlie following day to 99'2‘’, the left parotid swell¬
ing being slightly larger and more inflamed, but the
right smaller. The tumour in the groin was smaller
and harder. On Aug. 1st the left parotid was still in¬
flamed and swollen, but there was no fluctuation. The
swelling on the right side had subsided. On the 3rd the
left parotid was much more swollen and inllamed, and there
was distinct fluctuation. On the 4th the evening temperature
was 101-13°, and the following day the left parotid was
incised under ether and a quantity of thick pus situated
deeply in the gland evacuated. On the 6lh it was found
that the tourniquet had caused a slough of the skin at the
poiut of application. From this time the patient went on
well. On Sept. 1st he sat up in bed for the first time. On
the 7th lie got up for four hours, and next day was taken
out into the garden. On the 20bb he walked a few steps.
By Oct. 24th he could walk about the garden. After being
up for six or eiglit hours he had slight mdema of the left
leg. Go Oct. 30th he was improving in every respect.
With regard to the treatment of this case, what chiefly
led to compression being adopted was that the statistics of
the results of this method were much better than that by-
ligature of tbe common iliac. The only objection that
could be urged against it was that prolonged unsuccessful
conipres.sion sometimes appears to make less favourable the
prognosis of a subsequent operation for ligature. The
statistics of the result of ligature of the common iliac, as
given by Erichsen, show that the earlier cases were
singularly successful. Later, however, the cases collected
by Stephen Smith show only eight recoveries out of
thirty-two operations, and in Kiimraell’s table forty-one
are recorded to have died against fourteen who recovered.
The chief causes of death appear to be exhaustion and-
hmmorrhage.
A most interesting point in the case was the occurrence
after the operation of inflammation and suppuration of the
parotid gland. The occurrence of such as a sequela or con¬
comitant of injury or disease of the abdomen or pelvis is
well recognised. Erichsen* says: “Inflammation of the
parotid ^and, frequently terminating in suppuration, has
long been known to be a not uncommon complication of
> Surgery, f)lh edit. vol. ii, p. 680.
Di; Tzeit LjOOgle
Thb LAKCET,] dr. F. HEWITT ON THE ADMINISTRATION OF ANAESTHETICS. [Jan. 10,1891. 81
injuries of the abdomen and pelvis, and has usually been
regarded as pyeemic. Stephen Paget has, however, shown
by a careful analysis of 101 such cases that this explana¬
tion is not altogether satisfactory. Of the 101 such co.se8,
10 followed injuries or diseases of the urinary tract; 18 in-
juries or diseases of the alimentary tract; 23 injuries or in-
llammation of the abdominal wall, peritoneum, and pelvic
cellular tissue; 60 injuries, diseases, or operation on the
generative organs; 27 of these being operations on the
ovaries. After a very prolonged search Stephen Paget
succeeded in finding only 13 cases of secondary parotitis
arising from operations or injuries of other parts of the
body, and in all of these it merely formed a part of general
pyiemia. In the histories of the 101 cases the presence of
septicaemia or pytemia is mentioned in only 14, and in
7 only of the fatal cases were secondary centres of suppura¬
tion found elsewhere. The iniiammation of the parotid
commenced at very varying periods after the operation or
injury of which it formed a complication. In 78 cases
in which the fact was definitely recorded suppuration
occurred in 45, the remainder undergoing resolution; as a
rule, the parotitis was not accompanied by very severe fever,
and rigors were very rare. Of the 101, 37 died, 13 from
septiciomla or by pyseinia, and the rest from various causes
not directly connected with the parotitis.”
Mi'lonas, at a meeting of the St. Petersburg Medical
Society last year,^ related an interesting case of swelling
of the parotid gland occurring in a nervous and debilitated
patient a few hours after it had become necessary to
catheterise him while suffering from a prostatic abscess.
In about a week, when it became necessary to empty the
bladder, this was rapidly followed by the development of a
suppurative parotitis of the other side. Daring the dis¬
cussion which followed this communication, Batinaky re¬
lated three cases of reflex parotitis which had occurred in
his own practice, the patients being women who had under¬
gone some operation for the relief of general troubles.
Hilton Fagge^ suggests, only, however, to dismiss the
opinion as not having sufficient foundation, that this
“ metastatic ” parotitis is perhaps, after all, due to dryness
of the buccal mucous membrane leading to an obstruction
of Steuo’s duct, with decomposition of the retained salivary
secretion. He states that the prognosis is better if it
occurs late as a secondary affection in any disease; if early,
grave. The theories as to the cause of this curious Con¬
dition are: First, that it is pya^mic. In the present
case we may admit that, probably from the injury in¬
flicted by the tourniquet, peritonitis was set up, and thus
an opportunity was given for septic material to enter
the circulation ; but here, as in the records quoted
above, wo miss the general pycemia which we should expect
to follow such an occurrence. The other theory is that the
parotitis is secondary to some disturbance in the innervation
of the gland. In connexion with the above patient it was
suggested by some who saw him that this might he due to
the prolonged inhalation of bichloride of methylene. If this
theory were correct, we should expect to get parotitis in
the condition known as xerostomia, a complication which
does not appear to be recorded. Looking at the records of
cases that have been given, and considering the fact that
there seems to be gome special connexion between injuries
and diseases of the abdominal cavity and inflammations of
the parotid, it seems probable, seeing that in this case there
was undoubtedly pressure on the nerves of the abdomen,
that tlie parotitis from which the patient suffered was due
to an affection of the still hypothetical connexions between
the sympathetic ganglia and the parotid secretions.
Oxford.
2 Msjdit. Pribav. Ifmorn. Sboz, Aj>n], 13S0.
'• Moilicinc, vol. ii., p. 306.
Dkvonshikk Hospital and Bux'L'On Bath
Charity.— The medical report of this institution for the
year 1890 shows there were during the year 2.38() in-patients,
of which 501 were cases of rheumatism complicated with
heart disease, (58 of diseases of the nervous system, 41 of the
respiratory system, 5 of the circulatory system, 23 of the
digestive system, -and 221 of general diseases, which com¬
prised _ amomia, debility, evytliema nodosum, ec/ema,
psoriasis, Bright’s disease, diabetes, blood-poisoning, cancer,
spinal disease, morbus coxm, old injuries, and uterine and
ovarian disease, besides 14 accidents.
REMARKS ON THE ADMINISTRATION OP
ANiESTHETICS IN ORAL AND NASAL
SURGERY.
By FREDERIC HEWITT, M.A., M.D.Cantab.,
INSTROC’roa in AN4;STHETICS at the I.ONDON IIOSPITAI-, AUMINISIRATOn
OE AN.IJSTHETICS AT CHARING-CllOSS HOSPITAL ANU THE
DENTAL HOSPITAL OP LONDON.
Tiik following remarks are not intended to apply to such
brief operations as may be performed under nitrous oxide,
but to those necessitating an anesthesia of longer duration.
The administration of the anesthetic for operations within
the upper air passages often requires considerable fore¬
thought and judgment; and it is therefore hoped that a few
practical suggestions may not be without interest.
1. Choice of anccsthetics. —Putting exceptional cases aside,
it is best to place the patient well under ether, and to keep
up the anfcsthesia, if necessary, with ehloroform, great care
being taken not to substitute the latter for the former
anmstlictic till the patient commences to siiow signs of
emerging from the ether narcosis. By administering nitrous
oxide, or a small quantity of the A.C.E. mixture, before
ether, the disagreeable eflects of the latter anmsthetic may
be obviated. Ether has many advantages in these cases.
Firstly, it is possible to charge up the patient, so to speak,
with such a quantity of ether that for many operations no
more of this or of any other anmsthetic is necessary.
Secondly, there is as a rule no objection to the etherised
patient being well propped up, or even in the sitting posture
should the operator desire it. Thirdly, should any difficulties
in respiration (dependent upon the presence of morbid
growths &c. witinn the nose or mouth) arise during the
administration of ether, there is not that liability to circula¬
tory depression which undoubtedly exists during the use of
chloroform under similar circumstances. Should the anms-
thesia from the dose of ether be of inaufficient duration for
the performance of the operation, unconsciousness should be
maintained by small quantities of chloroform, given with
the precaution already referred to,
2. Position of the ■patient.' —This should primarily depend
upon the nature of the operation and the convenience of
the operator. Very often, however, the arrangement of the
patient is left to the anretbetist, the operator having no
special wish in the matter. Under these circumstances the
administrator of the amTisthetic should place the patient in
that position which is most favourable for the escape of
blood. Apart from the inconvenience caused by the presence
of blood during these operations, the patient may be saved
much after discomfort from nausea or vomiting if a little
care be taken to prevent blood from being swallowed. When
very little hemorrhage is expected, the position of the
patient becomes a matter of small moment, but it is not so
under opposite conditions. "When considerable hemorrhage
is anticipated one of two positions should be chosen if
circumstances permit: (I) The etherised patient should be
slowly raised into tlie sitting posture, and his head and
shoulders thrown well forward.^; or (2) he should lie upon his
side with one arm under him, and his head being near the
edge of the table his face should be directed downwards ;
the mouth being well opened by some form of gag in
either case. The former position, originally suggested, I
believe, by Mr. Braine, is an excellent one for scraping
away post-nasal adenoids ; it should only be adopted, how¬
ever, under ether—not under chloroform. The latter position
may with advantage be chosen for such cases as the removal
of nasal or naso-phaiyngeal polypi.
3. Points to be observed in administeri7iq the ann-sthetic .—
Should there be complete or nearly complete nasal obstruc¬
tion, it is a good plan to place a small mouth gag between
the teeth before commencing the administration. Partial
nasal occlusion is liable to become complete during anres-
thesia by reason of increased vascularity of parts. If tliis
simple precaution be not adopted, it may become necessary
to forcibly open the mouth during the administration—a
procedure sometimes attended by difficulty, more especially
in vigorous subjects and in those with accurately meeting
teeth. When respiration prior to the administration is in
any way embarrassed, either from the presence of morbid
growths or other causes, the amustbetic should be given
veiy cautiously and the breathing watched. I have lately
Google
82 Thb Lancet,]
CLINICAL NOTES.
[Jan, 10,1891.
brought before the Royal Medical and Chirurgical Society
many facta in connexion with this branch of the subject,
and shall therefore refrain from any further remarks
here.
4. Points to be observed during the performance of the
oper'ation —When the required degree or narcosis has been
reached, the mouth should be well opened by some form of
gag. The one which I find best suited for general use is
here figured, It is a modified Mason’s gag, possessing two
small tubes for the transmission of chloroform vapour to
the back of the mouth. The rubber exit tube of Junker’s
chloroform apparatus is attached to the bulbous extremity
of one of the mouth-tubes shown in the engraving. Chloro¬
form vapour may thus be made to pass in the direction of
the arrows. It will generally be found advisable to attach
the indiarubber tube of Junker’s apparatus to that arm of
tlie gag which comes in contact with the upper teeth. The
mouth-tubes of the gag are bent slightly backwards at
their non hulboua ends, in order to throw tire vapour to the
back of the mouth. The gag shown has arms sufficiently
long to keep the mouth of au edentulous patient well open,
and the clip arrangement for keeping the arms apart is
superior to the ordinary screw, as it is simpler to manage,
and takes but a fraction of a second to adjust.^ The gag
can, of course, be used as an ordinary mouth gag—i.e.,
without being attached to a chloroform inhaler.
In cases in which there is very free hsemorrhage, it is beet
not to maintain very deep anesthesia, the abolition of
corneal reflex not being necessary as a general rule. In very
delicate operations, however, as well as in those in which
the bleeding.is slight, deep anesthesia should be kept up
throughout the operation.
Oeoi'fre-street, H;inovov-«tiu.aie, W.
Clinual
MEDICAL, SURGICAL, OBSTETRICAL. AND
THERAPEUTICAL.
CASE 0 ¥ M Y X Gi D JC M A.
JiY A. M. STAl.KKIt, M.D.,
I’UVSIC'IAX TO THI! DUNDKH UOVAr, INriRMARV.
The following case of myxedema seems worth}’’ of being
placed on record.
Mrs, C-, married, forty years of age, is tlie eldest of a
family of nine, all of whom are healthy. She is the mother
of four children, whose ages run from seventeen to eight,
and all of whom appear in sound health. No miscarriages.
The husband is alive, and appears strong and active. She
has lived during the greater part of her life in the country.
Has had poor health during the last fifteen years. About
that time the sight of the left eye began to fail, with severe
headaches and pain in the affected eye. The failure passed
into complete blindness five years ago. Two years before
that the eighty of the riglit eye gave way with similar sym¬
ptoms, and this, too, has resulted in all out complete blind¬
ness About four or five years ago, perhaps longer (it is
always difficult to be sure of the time within a year or two
‘ M(i.s.srs. Kmiineaiid Seseiiiiinii of Dtiko-strool, Manchoster-iariuaro,
are tlie makers of the «.ag. '
of the commencement of a myxrodema), swelling began
about the face and limbs, with change of voice and growing
irritability of temper. Since then the general strength has
become more enfeeoled, though the loss of sight is still her
chief complaint. From the commencement of the eye trouble
she has taken large quantities of iodide of potassium.
At present (October, 1889) her condition is as follows;—
She has myxeedematous facies; teeth good ; hair thin
and wiry ; skin dry, her stockings sometimes being emptied
in the evening of quite a quantity of branny scales ; hearing
good ; eye symptoms peculiar. In the left eye iris is
n and blurred, adherent all round; pupil about 2 mm.
readth ; fundus cannot be illuminated; no vision in
this eye. In the right eye iris slightly blurred, adherent at
one side; pupil about 4mm., and can be dilated with
atropine to Gnim. ; good view of the fundus j disc is dead
bluish-white with large posterior staphyloma surrounding
it on all sides, on an average double its own breadth:
vessels normal ; at extreme periphery large patches of
black pigment; in the middle distance similar smaller
patches, situated in the midst of brilliantly white patches
of choroidal atropiiy; only vision possible is that she can
discern the position of the window in the room, or of the
lamp in the evening. The other symptoms present nothing
novel. She is subject from time to time to hemorrhages
from the bowel, probably from the rectum. The mental
condition is fair; querulous and garrulous, but no illu¬
sions or suspicions. Disturbing dreams, but no morbid
terrors.
The interest of this case lies in its associations, first, with
chronic irido-choroiditis, and, secondly, with the long-con¬
tinued use of iodide of potassium. With regard to the
former very little can be added by way of remark to the
mere fact of the association. It is tolerably certain that
there is no syphilitic taint in the case, and apart from
syphilis, the relations of irido-choroiditis are little known
and ill defined. The fact of the long use of iodide of potas¬
sium, on the other hand, gives rise for rather more specula¬
tion. Mr. Hutchinson in his “Archives of Surgery” (vol. i.,
p. 142) dwells for a moment on this as a possible factor in
a case of acromegaly, but does not press it. There is one
consideration, however, Avhich may specially justify llie
observation in a case of myxeedema. The use of iodine
in the treatment of true goitre is always mentioned
in the books, though the proof of its efficacy turns out
on inquiry to be very doubtful. Bat a tolerably large
body of testimony is given to the benefits of inunction
with biniodide of mercury ointment in simple bronchocele;
and the “ discutient ” effect of this, taken along with the
general consensus that iodine in some form is beneficial in
all enlargements of the thyroid, is a clear enough indication
of an effect of the drug on one or other of the elements of
the gland. And it is precisely in such a disease as the
form of irido-choroiditis described above that we may hope
to see what, if any, are the results of continued saturation
of the system with iodine. The ophthalmic surgeon is con¬
fessedly at a loss what to do apart from the use of iodide of
otasaium, and even when there is no hope of checking the
isease the treatment is pursued throu^ long years with
the vague expectation that its course is, at any rate, being
slowed. In a case treated in this way the occurrence of
symptoms indicating atrophy of the thyroid is worth noting,
Dundee. _ __
FOREIGN BODY LODGED IN THE ORBIT FOR
FORTY-SIX YEA.RS; REMOVAL.
By C. HIGGEN.S, F.R.C.S.
Mil. II-, aged fifty-two, consulted me on Aug. 20th,
1890, for ulcer of the cornea of the left eye. I found that
the ulcer was due to exposure caused by retraction of the
upper eyelid, which was firmly fixed by a puckered cicatrix
to the roof of the orbit some distance behind its margin.
Bad smelling discharge escaped from a sinus near the centre
of the cicatrix. A probe passed through the sinus came in
contact with a rugged surface. I noticed a scar at the
outer margin of the orbit, and on inquiring about it
Mr. H- casually remarked that it was made by his
falling on a knife when six years of age. The blade of the
knife—or the knife, as he described it—was never seen after¬
wards, but the wound healed without giving him any trouble.
Ho, however, admitted that there had beendiscliarge for many
Digitized by Google
Th» Lancet,]
CLINICAL NOTES.
[Jan. 10,1891. 83
years, about which he had not troubled himself. I told him
chat I believed the kuife-blade was still in the orbit, and
arranged to make an exploration. On the following day I
cut down through the cicatrix and after some difficulty
removed a piece of much-corroded metal, evidently the
remains of apiece of the knife-blade, -i\in. in length, -,Vin.
in breadth at its wider end, and in. at its narrower
extremity. It had evidently been fixed partly in the orbit and
partly in the frontal sinus. I cleared out a quantity of rust
andplecesof rough bone,closed the wound, leavingadrainage-
tube at either end, and united the margins of the eyelids.
The patient had no bad symptom j at the end of a fortnight
the wound was soundly healed and there was no discharge.
Brook-street, W. _
TREATMENT OF ENURESIS.
By W. E. Steavenson, M.D. Cantab,, M.R.C.P.,
IN CHARGE OF THE EI.ECTIUCAI. DEI’ARTMENT, ST. HARTHOi.OMEW's
iiosi’ital; imiysician to the grosyenoh Hosi’mi, for
WOMEN AND CllimUEN.
The numerous questions which have recently been
addressed to The Lancet on this question, and the anno¬
tation which appeared in the issue of November 22ad
(p. nil), have induced me to again bring before the profession
the undoubted benefit which is derived from the treatment
of enuresis by electricity. I wrote a short paper on Trouble¬
some Frequency of Micturition^ as far back as 1883, and I
have had no reason to alter the opinions there expressed.
I agree with the opinion of Dr. Kupke of Posen, mentioned
in the annotation above referred to, that the cause of
enuresis is, among others, due to “diminished activity of
the vesico-spinal centre in the lumbar part of the cord, or
partial anscsthesia of the sensoiy nerves of the bladder,
both of these conditions preventing prompt information
being conveyed to the cortex of the cerebrum when the
bladder is ibecoming full.” Cases of incontinence of
urine from difterent causes are frequently referred to
me for electrical treatment, and tbe greater number
of them have been cured. Nine cases are mentioned
in the St. Bartholomew’s Hospital Reports for 1883,
pp. 2415, 246; and thirty-one cases in the Reports for 1886,
p, 85. The affection is by no means confined to children, It
is a frequent complaint in young women, and in married
women who have received some injury during parturition.
Some cases have been due to pressure on the neck of the
bladder during pregnancy, especially when associated with
anteflexion of the uterus; others to dilatation of the urethra
for exploration of the bladder. Several patients were un¬
able to retain their urine when in the erect position or when
making theslightesb exertion, such as going up stairs, lifting
weights, and even when laughing or crying. Some are
similarly affected when riding on horseback. I do nob re¬
member any of these cases which have failed to be cured by
electricity. I am not including the cases of old women in
whom violent bronchitic cough is so often accompanied by
an escape of urine, although these would also probably im¬
prove.
The reason why this class of case can be so successfully
treated by galvanism is in my opinion due to the fact that
the whole of the lower nervous supply of tbe bladder and
sphincter vesic.a3 can be so easily included in the circuit.
M.y method of treatment is not exactly the same as that
followed by Guyon and Unverrichb, described in the
annotation alluded to above. It is seldom that I have
to pass an electrode into the urethra ; and it seems to me
that failure will often ensue if the second electrode is
“moved from place to place over the pubes.” Tbe ten¬
dency of all electrical currents is bo take the shortest route
possible to complete the circuit, always of course choosing
the road offering the least resistance. If one electrode is
placed on the lower dorsal spine and the other above the
pubos, the sphincter vesicm is almost completely without
the circuit, and then receives very little direct intluence. In
cases where there is weakness of the sphincter, unless an
electrode is placed in the urethra itself, the most advan¬
tageous position for the second electrode is the perineum.
It is seldom that I use the interrupted current, although it
is strongly recommended by Erb. My usual plan is
to place a pad connecteil with the liegative pole
^ Blit. Mc(l. Jour., Oiiii. OHi, 18fW, p. 1).
of a continuous current battery over the lower dorsal
region of the spinal column, and a small button
electrode on the perineum. I advise that the elec¬
trode connected with the negative pole should be tbe
fixed one, because of the senaitiveneEs of the parts to which
the second electrode has to be applied, and the small space,.
and therefore the difficulty experienced in moving the-
electrode about. In all cases a very weak current is used,
and therefore the fixed negative electrode, being of wide
surface, does nob painfully affect the back ; whereas, if the
current were reversed and the button electrode in the peri¬
neum made negative, a weaker current still would have
to he used to enable the patient to bear it. Therefore,
in these cases we get the greater advantage by placing the
electrodes as 1 have mentioned. In tbe treatment of atony
of the blader, incontinence of urine, or undue frequency of
micturition,'! usually employ the current for eight or ten
minutes every day or every other day; the great majority
of cases only requiring about eight or ten applications. In
some cases when galvanism fails the interrupted current
may be employed with success, lb is then best to place an
electrode in tbe urethra.
Mansfleld-street, W. _
TRAUMATIC ENCEPHALO-MENINGOCELE.
By Haery Burton, M.R.C.S., L.R.C.P. Irel , &c.
On Aug. 7th I was sent for hurriedly to see A. H-,
aged eight, who had been knocked down by a swing boat.
Tbe following were her injuries: Compound fracture of
frontal bone, about two inches above the centre of the right
orbit, with contusions over the occipital bone of the same
side. There was a cleaa-eub wound over the side of the
fracture, one inch and a half long. The fracture was
circular, but not depressed. It appeared that the edge of
the swing boat knocked her down, causing the fracture,
and the contusion was caused by the head striking a peg
in the ground. As the girl was conscious on my arrival,
and recovering nicely from the shock, and as there were no.
symptoms of compression, I simply sutured the wound and
dressed it with salicylic wool. The wound healed by first,
intention, after which apeculiar brain of symptoms developed.
The skin began gradually to bulge over the fracture, and a
tumour formed, pulsating and semi-translucent. This in¬
creased in size until it oecame as large as a walnut, the
integuments gradually thinning over it, bub remaining
intact. By exerting pressure upon it it gradually disap¬
peared, and a circular opening about the size of a two-
shilling piece could be felt in the bone, corresponding to the
situation of the fracture. The child suffered from convul¬
sions and strabismus, and po pressure could be borne without.
a convulsion occurring. I aspirated, but only succeeded in
drawing off a small quantity {about two drachms) of cerebro¬
spinal fluid. I found some cerebral substance on the needle,
thus showing that brain was protruding. Strange to say,
the girl improved after the aspirating, and Mr. Wright of
Manchester having seen her and again advised pressure, it
was applied very gradually, with success, the tumour gradu¬
ally disappearing and the hole in the hone becoming
partially filled with fibrous tissue, until now, with the
exception of alight weakness of vision and slight failure
of power of the left arm, the girl is enjoying good health
and attending school regularly. She wears a silver plate
over the site of injury as a precaution. Abscesses
formed over the occipital region; they were laid open
and necrosed bone gouged away, Mr. Jenkinson of
Marple Bridge kindly giving chloroform on three occa¬
sions. During the healing of these great difficulty was
experienced in keeping down the large flabby granula¬
tions which grew so luxuriantly.
This case appears to be unique. It was certainly not
the hernia cerebri of books, as there was no open wound,
the skin having healed, and, although much thinned,
remaining sound. It also dift’ers entirmy from the trau¬
matic meningocele described by Mr. Clement Lucas and
Mr. Golding Bird.^ The only way to account for it is that
the fractured bone, becoming necrosed, must have been
absorbed, and the membrane and brain substance were pro¬
truded through the opening. I may state that the face and
* Uuy'.-i Hospital Reports for lb70, ISTS, 1S81, 1884, luul 1880,
Digitized by Google
84 Thb Lancet,]
HOSPITAL MEDICINE AND SURGEEY.
[Jan. 10,1891.
left upper extremity were chiefly affected by tlie con-
vulsione, showing that the inflammatory processes must
have involved their cortical centres.
Marple. _
EXTRA-PERITONEAL HAEMORRHAGE DURING
PREGNANCY; C^iSAREAN SECTION; DEATH.
By Sidney A. Bontor, M.D.,B.S.
A SHORT time since I was called at 10 A.M. to K. L-,
the wife of a labourer. She was a tall and ill-fed woman,
aged forty-three, and eight months pregnant with her ninth
child. I was told that she had been quite well the previous
day, but had felt some abdominal pain during- the night,
that this had passed off towards morning, that she had
prepared and partaken of breakfast, and was attending to
her domestic duties as usual, when she was sei/.ed with a
sudden and very violent pain in the right side,'causing lier
to scream out and almost fall down. She was assisted up
to the bedroom, and 1 was sent for. I found her blanched,
with cold and clammy akin and almost imperceptible pulse.
She was quickly undressed and putintobed. On examination
a well-marked resistance was felt in the right iliac region
quite distinct from the uterus, while feeble contraction
of tliis organ could be felt; the abdominal wall^, except in
the region indicated, were not at all tense, and manipula¬
tion of the abdomen did not produce pain; per vaginam,
there was bulgin'of the posterior cul-de-sac, and the cervix
was high up and soft, but not dlla'ed. I concluded that
perforation either of intestine or of a vessel had taken
place, that what chance there was of saving the patient’s
life was offered by immediate abdominal section, and that
shorrld this be unsuccessful in respect of the woman, at all
events there was considerable hope of saving the child. I
therefore had preparations made for the operation, and in
the meantime called in my friends Drs, Mackay and Penny ;
they agreed as to the necessity for the operation, and very
kindly assisted me with it. An exploratory incision
was first made, but no blood or faecal matter was
found in the peritoneal cavity, and the peritoneum appeared
natural. The incision was therefore extended, when the
right broad ligament was seen to be filled with blood-clot.
The woman w’as sinking rapidly, so we abandoned the hope
of saving her, and decided to remove the child, which, how¬
ever, on removal we found to be already dead. Unfor¬
tunately in opening the uterus I came upon the placenta,
and the hremorrhage which ensued, though but slight, was
aulfleient to carry off the patient. An examination of the
abdominal cavity throtxgh the wound showed that e.\ tensive
hiemorrbage bad taken place outside the peritoneum, and
bad spread from the under surface of the liver to the pelvis,
forming collections about the kidney and in the cavity of
the pelvis, and distending the tight broad ligament, while it
had separated the peritoneum from the emeum and ascending
colon. The source of the haemorrhage could not be found,
and, as far as we could trace, the vessels and viscera were
natural, with the exception that in the anterior wall of the
uterus there was a small cancerous nodule about the size of
a hazel nut. There were no varicose veins either of the legs
or in the broad ligament. Permission for a necropsy was un¬
fortunately not obtained. Notwithstanding the unfavourable
result, the case appears to be of interest, not on account of
anything exceptional in the operation, but from the large
amount of ha‘.morrbage and from its sudden appearance in a
woman whose health up to the occurrence had shown no
unusual change. In view of the cancerous nodule found in
the uterus, it is possible that a growth which we were
unable to make out bad eroded one of the vessels. The
death of the child was probably due to the sudden diminution
of the blood-supply to the uterine sinuses, for it was well
formed and had apparently been dead buta very short time.
Great Berkhaiosted.
■Water-supply, Kotiikrham.— It has been found
necessary to curtail the night water service, partly in con¬
sequence of a deficiency during the past niontn, amounting
to nearly 41,000,000 gallons in the Ulley Reservoir,
Rotherham, together with the waste, which has been very
large from letting the water run from household sinks and
taps throughout the ti^ht tj obviate the f eezing of the
pipes.
% Pirwr
OP
HOSPITAL PBACTICE,
BRITISH AND FOREIGN.
Nulla autem est alia pro certo noscendl via, nial quamplurlmas et mor-
borum et diasectionuin hiatoriaa, turn alioruin turn propriaa coUectaa
habere, et inter se comparare.—MonGAGNl JDe Sect, et Cave. Morb.,
Ub. iv. Prooemium. -
KING’S COLLEGE HOSPITAL,
A CASE OF OPHTHALMOPLEGIA EXTERNA AND INTERNA ;
REMARKS.
(Under the care of Dr. FaRitiEii)
DuRiNfi the last few years much has been added to our
knowledge of the various affections which are manifested
in the eyes of patients suffering from locomotor ataxy.
In this case a condition of paralysis of the extrinsic and in¬
trinsic muscles of the eyes was found with optic atrophy in
a man not yet presenting the characteristic ataxic gait.
Dr. Bergeri has recently written on the visual disturbances
in tabes dorsalis, and given an analysis of 109 cases. He
says that the cases occurring in the very voung and in the
very old are exempt from grave ocular com plications, and that
in those w'ibb a history of syphilis the disease begins with
cerebralsympboms. Opticatrophy usuallybeganintheataxic
stage, and was more frequent in the cases with paralysis of
tlia ocular muscles. Paralysis of these muscles existed in
38 per cent., about equally divided between the syphilitic
and those in whom no evidence of the disease could be
found. Dillman, in an inaugural dissertation,* says that
among 100 cases of tabes paralysis of the ocular muscles
was present in 41, and optic atrophy in 42, There was a
preceding sypliilitic history in 08 cases. Dr. Howard'* has
recorded a case of ophthalmoplegia externa and interna
associated with tabes dorsalis, bulbar paralysis, and loss of
vUioa and hearing. We refer our readers'to Dr. Ferrier’s
remarks on the case. For the following report W’e are in¬
debted to Dr. G. Francis Ewens, medical registrar.
G. T-, aged forty-three, wasadmibted into King’s College
Hospital under the care of Dr. Fenier on Oct. 9tb, 1890. He
has been for the last twenty years a Covent-garden porter,
and was for five years previously to that a soldier. He is
married, and has bad two healthy children. His father and
mother were both healthy, and died, one at ninety and the
other at sixty years of age. There is no history of insanity or
any nervous disease in his family, but two out of his three
sisters died of phthisis. The patient, when a boy, suffered
from severe headaches, but since that time has had no
illness whatsoever, except about twenty-four years ago,
when he contracted syphilis. He has never been in¬
temperate. Six months before his admission to hospital
(May, 1890), when feeling quite well, and walking in
the market with a load on bis head, he suddenly felt
sick and vomited, and was obliged to go home to bed,
remaining there three days. Several times since he has
had similar sudden attacks of vomiting, lasting about the
same time, accompanied with intense epigastric pain of a
griping character, shooting pains down both legs, constipa¬
tion, and a burning pain during defecation. For about
the last six months he had also suflered from diplopia and
occasional dizziness, both of which he now complains of con¬
stantly, together with an inability to raise the eyelids. He
has also during the same time been subject to sudden
attacks of shooting pains, very acute and intensely painful,
down both legs, usually worse at any changes of tlie
weather ; but he has never had any dilliculty in walking at
any time, or perceiving the ground with his feet, nor has
he had any trouble with his bladder or rectum. When
examined, the patient presented the appearance of a fairly
well nourished man, not anmmic; complaining of sudden
attacks of very severe vomiting coming on at variable in¬
tervals ; of constant sense of constriction, “ as though rones
were lied round” his trunk from axillae to umbilicus. 'This
feeling is much aggravated during the attacks of vomiting,
and is then accompanied by intense epigastric pain, con-
I Archives of Ophthalmology, vol. xix., No, i. Sajous, vol. iv., H.iai.
8 lelpslc, 1889.
3 Inteniat. Journal of the Medical Sciences, p. 238,1880. See also
ClakKowskv, Archives of Ophthalmology, Sept. 1889. Paiinaud;
Recuoll d'Oplitlial—ologie Oct. ISW.j ^
Thb Lanobt,],
HOSPITAL MEDICINE AND SUEGEEY.
Jan. 10,1891.
iscipation, and pain in the rectum during defecation. He
has no headacues, and has never had any convulsions.
There is ptosis of both eyelids, most marked on the leftside.
Both pupils are very large, the right more so than the
left; neither react to light, accommodation, or cutaneous
stimulation. The eyes are slightly divergent, and cannot
be moved in any direction whatsoever, except slightly down¬
wards and outwards. Both optic discs are in a condition of
grey atrophy. The sight is defective, especially for near
.objects. There is no facial palsy or weakness of the
muscles of mastication, the movements of the tongue and
palate are normal, and speech and swallowing are per¬
fect, as are also all movements of the arms, hands, fingers,
thighs, legs, feet, and toes. He can perceive and accurately
localise the slightest touch on the face or any part of the
3imbs and trurdc. He can perceive a painful injpression
and hot and cold, and knows with eyes closed the posi¬
tion in which any of his limbs may be placed. The knee-
jerks are both present, though not always easy to de¬
monstrate, being only obtainable while the patient
strained. All the superficial reflexes are present and
normal. There is great wasting of the muscles of
the legs, as also of the palmar interossei, and to a less extent
of the thenar and hypothenar eminences; but they all react
to a faradaic current and normally to galvanism. The heart
and lungs are normal, and tlie urine .is 1015 specific gravity,
and contains no albumen or sugar. He walks steadily, but
has some dilEculty in maintaining his equilibrium when
keeping to one straight line or standing with the eyes
closed. While in the hospital he has had two severe
attacks of vomiting, with intense epigastric pain and con-
•sti'iction, causing him to groan so loudly and continuously as
to require his removal from the general ward to prevent his
-disturbing the other patients. The first of these attacks
began on Nov. 4th and lasted six days, during which time
subcutaneous injections of morphia had to be frequently
administered. At the end of this time the crise gastrique
had quite subsided, and the patient again felt comparatively
well, and was able to resume his usual place in the ward.
Another attack of a similar nature occurred on Dec. 3rd,
which lasted five days.
ItQmArlcs by Dr. J^’iCRRiiiR. — In a clinical lecture on
this case I remarked on the common association of
ophthalmoplegia with other affections of the nervous
system, particularly with tabes, and occasion.ally with
muscular atrophy more or less general. The present case
is an example of almost complete ophthalmoplegia
externa and interna, the only ocular movement persisting
being a slight downward and* outward movement of the
eyeballs. Under ordinary conditions, except for this move¬
ment, the eyeballs are absolutely motionless, and the eye¬
lids are incapable of being raised. It was observed, how¬
ever, during the second crise gastrique which the patient
had in the hospital, that he became able to raise the right
■eyelid and fully expose the eyeball. This, however, was only
transitory, and the ptosis returned when the attack subsided.
The case is in all probability due to degeneration affecting
'the nuclei of the ocular muscles, and nob peripheral lesion,
under which condition similar symptoms may arise.
Associated with this there were clear indications of tabes.
The patient is not .obviously ataxic, nor are the knee-
jerks abolished, but the gr-ey atrophy of the optic discs,
the absolute immobility of the pupils, the lightning pains,
epigastric constriction, and the crises gastriqnes are all
symptoms characteristic of tabes. And the. probability is,
as in a recent case reported by Peterson {Ncurohyinrhcs
'Centralblatt, Oct. Ist, 1890), that the degeneration will
•advance to well-marked ataxy. In tliis case also there
are indications of _ degenerative changes in the nuclei of
the spinal nerves similar to those of the ocular nerves, as
shown by the extensive wasting of the intrinsic muscles of
the hands, and those of the lower extremities, particularly
of the legs. The etiological factor in this, as in most cases
of the kind, is undoubtedly specific disease.
royal infirmary, NEWOASTLE-ON-TYNE.
A CASK 01'’ TUMOUR Ot'’ THE PAUATE; OPERATION;
REMARKS.
(Under the care of Mr. Paoe.)
Adenomata of the palate arc not growths frequently met
With in surgical practice—indeed, in 1886, Mr. Hutchinson i
I Path, Soc. TrwiN., 1S8(J, p. 4l)C.
remarked on bringing forward a case that up to that^
time the Pathological Transactions did not appear to con¬
tain any reference to adenomata of the palate. Since
then several examples have been brought before tb'at
Society or reported elsewhere. This case is an example
of that form of growth situated, as they appear most ire-
quently to be, on the left of the middle line, encapsuled,
without ulceration of the covering mucous membrane, and'
of slow growth. For the report of this case we are indebted
to Mr. T. M. Kempster, house surgeon.
M. H-, a puddler, aged forty years, was admitted,
under the care of Mr. Page, on Dec. 16bh, 1889, complaining
of difficulty in breathing, more particularly at night, and of
inconvenience in swallowing. His symptoms had existed
for two years, but it was only three weeks before admission
that he became aware they were due to a growth in the
mouth. Upon examination, the isthmus faucium was seen
to be occupied by a tumour the size of a hen’s egg, springing
from the left side of the throat. It was firm, regular, and
fixed. The finger could be passed readily round it on
the right side, but its deep connexions could not be defined.
The mucous membrane was stretched over it and thinned,
but there was no sign of ulceration. No enlarged glands could
be felt. On Deo. 20th, the patient having been placed
under chloroform, laryngotomy was performed and the
throat plugged with sponge so as to prevent blood finding
its way into tlie air passages. The mouth was kept open
with a gag and an incision made through the mucous mem¬
brane o.ver the centre of the tumour. The growth was
readily enucleated from the submucous tissue in which it
was situated with the finger. Free general oozing from
the bed of the tumour followed, but no vessel required
to be tied. The cavity was then filled with lint, the
tube removed from the larynx and the sponge from
the throat. At night the lint was removed, and
in fourteen days the patient was discharged cured.
The engraving, from a drawing kindly made by Dr. Baigent,
is a good representation of the naked-eye appearance of the
rowth. Microscopically, spindle cells were found sparsely
istributed among tissue closely resembling glandular tissue.
On Oct. 20th, 1890, the patient presented himself, and there
was no return of the growth.
llanarks by Mr. PAGE. — In the St. Bartholomew’s
Hospital report for the year 1880, a number of cases similar
to the above liave been tabulated by Mr. S. Paget under
the head of Adenomata, which he tells us, though historically
suspicious, are clinically “innocent as the babe unborn.”
The subsequent history, so far as it goes, tends to confirm
Mr.Paget’s observation that the growths do not recur.
KASR-EL AINI .HOSPITAL, CAIRO.
LIGATUIM') OF THE ABDOMINAD AORTA FOR RUPTURED
ANEURYSM OF THAT VViSSEU ; DEATH.
(Under the care of Mr. H. Mil ton.)
Tins case is a most important contribution to our litera¬
ture on the ligature of large arteries in their continuity,
making only the eleventh instance on record of the applica¬
tion of a ligature to the aorta, and the first occasion on
which the artery has been ligatured for aneurysm involving
only the vessel itself. The methods which may be em-
Diri" lOOgut
8S The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[Jan. 10, isar.
ployed are tbetransperltonealand thepoat-peritoneal, audit
v^l be obvious that in this instance the encroachment of
the aneurysmal tumour to the left prevented the enlploy-
roent of the latter, and, further, the fact that escape of
blood was rapidly taking place from the raptured sac into
the cellular tissue around made the selection of the quicker
method of operating imperative. The patient was not under
observation for a long time before the sac ruptured, but the
diagnosis had been made, andevidentlytbecondition carefully
considered, for Mr. Milton has given us a plan of treatment
which he had proposed to try kad no untoward symptoms
develop^, and which could only be carried out where there
is a Bumcient length of vessel above and not involved in the
aneurysm. The plan suggested is a bold one, and worthy
of careful consideration should a similar case present itself
for treatment. There are, however, many objections which
may be urged against it, and which will present themselves
to the minds of those reading the case. Snould any surgeon
after due consideration carry out the plan suggested—that of
temporary compression against the spine—probably kan¬
garoo tendon, which would not require to be removed had
the purpose been fulfilled for which it was introduced,
would answer best, for drainage-tube would be difficult to
extract. That the operation of ligature of the abdominal
aorta is a most formiaable one there is no doubt, but that
it is necessarily a fatal operation is hardly proved by
the evidence before us- True, all the cases on record
died after the operation, and, with one exception,
within a few hours. MonteiroV patient, however, lived
for ten days and died from secondary hromorrhage ; but
when we recollect that the case occurred in 1842, was
treated by the long silk ligature, and that although the
method was the poat-peritoneal one suppuration followed,
we cannot compare the conditions with those which
would obtain now were this vessel ligatured. Abdominal
aneurysm- is a very fatal disease, and although other kinds of
treatment have been employed sometimes with success, and
few cases admit of ligature, we hardly think that the pos¬
sibility of the successful application of the hidden absorbent
ligature should be forgotten.
An Egyptian, aged about forty-five, who was admitted
to the hospital in July, 1890, had noticed for some sixteen
months a pulsating tumour in his abdomen, accompanied
by severe paroxysmal pain. He had had syphilis, but had
received no injury in the region of the tumour. Slightly to
the left of the middle line and a little above the umbilicus
was a tumour the size of an orange, pulsating and expanding
with each heart beat. There was a slight bruit, and the
tumour increased slightly in size when the aorta below it
was compressed. The pulsation in the two femorals was
equal. He sliowed old syphilitic scars, and his radial
arteries were a little rigid. His lungs, heart, and urine
were all normal. The patient was very anxious to have
something done for him, and it was decided to attempt an
operation as follows:—To incise the abdominal walls for
anout live inches in the middle of the linea alba, to expose
and incise the peritoneum covering the aorta one inch
above the aneurysm, to separate the aorta from the
vein, and then to pass a blunt director close on either side of
the vertebras, and to force it gradually backwards through
the tissues until its point could be cut down on in the back,
then to make a similar passage on the other side; then
to pass a small drainage-tube along the two channels made
by the director, forming a loop across the aorta, the two
ends of the tube presenting in the back on either aide of the
vertebral column—the tube being in position to close
the peritoneum over it with catgut stitches, and finally
to completely close the abdominal incision. The idea
was to leave the patient a few days, and then to com¬
press the aorta against the vertebral column by traction
on the two ends of the drainage-tube. The amount of
pressure to be applied and the period of its application were
to be regulated by the efl'ect produced on the patient.
On Thursday morning (July 3rd), however, before any
treatment bad been commenced, the patient awoke with a
severe pain in bis left side, and when seen somewhat less
than an hour later, it was evident that the aneurysm had
ruptured. The founded tumour which had formerly existed
could no longer be differentiated, but formed part of a
pulsating mass extending from the umbilicus to the lateral
i Kov. do Paris, 1862.
2 7'lip mses in wliic’U liuatiiro of the aorta lias boon employed bava
been mostly of iliac and inguinal aneurysm ; once for hiemorruapie after
gunsLot, once for liieniorrh'agc after nephrectomy.
limit of the abdomen, filling up the whole left hypochondriac-
region. The patient was watched for a few minutes, during
which the pulsating tumour increased slightly, the patient
showing the usual signs of severe hromorrhage. Abdominal
section was at once performed. An incision five inches long
was made in the linea alba, its centre being a little above-
the umbilicus. The omentum and intestines were pushed
aside, and the right side of the aneurysm exposed. A small
incision was made in the peritoneum covering the aneurysm,,
and a linger passed into this easily made its way under the
peritoneum, and guided by the aneurysm to the aorta
readily recognisable by its size and its pulsation. It was at
once compressed, and, the compression being maintained,
it was isolated for about one inch above the aneurysm, the
exposed portion feeling quite healthy. An aneurysm needle
waspassed round the aorta without diflioulty abouteight lines
from the origin of the aneurysm and the vessel tied with thick
silk. The peritoneum was dry sponged and the wound closed
in the usufu way without drainage. As the whole of the
effused blood was found to be behind the peritoneum, it was
left untouched. The time occupied by the operation from the-
first incision to the completion of the dressing was twelve-
minutes. Pulsation ceased immediately after ligature in
the aneurysm, in the effused blood, and in both leraorals.
The patient was kept going during the operation with ether
and brandy. He rallied about an hour later, and was kept
alive with some difficulty for just twenty-four hours, and
then died of anaemia and shock. He complained of intense
pain and tingling in both legs until death, which occurred
somewhat suddenly. He passed 13 oz. of urine quite free
from albumen or blood.
Post mortem the aneurysm was found to be purely of the
aorta, its lower limit about three-quarters of an inch above
the bifurcation and its upper limit one inch and a half below
the renal arteries, both of which were well above the point
of ligature. The aneurysm presented a small rupture just
at the left edge of its under surface, and from this point
very nearly 41b. of blood had been'poured out behind the
peritoneum, entirely obliterating the left renal fossa. All
the organs were anfcmic, but otherwise healthy. The-
kidneys showed no signs of change whatever.
Pdfkal -gomtics.
PATHOLOGICAL SOCIETY OF LONDON.
Media for Cultivation of Tubercle Bacillus. — Cki/lous
Aseites.—Pelvic Hydatid Obstruciiug Ureters.—Acute
Verrucoic Aortitis.—Dermal Cysts.
An ordinary meeting of this Society was held on
Jan. 6bh, the President, Dr. Dickinson, being in the chair.
Sir Huon Buevor read a note on Media for Cultivation-
of the Tubercle Bacillus. The results he had obtained
showed how diverse might bo the media that could bo em¬
ployed, and how wide the variations of temperature in
which the bacilli would grow. His observations on potato
cultivations agreed with those of other'obeervers—that the
growth was very alow, there being from twenty days to a
month before the first sign of growth appeared. .It was stated
that cultivations on the potato for three generations did
not diminish the virulence of the organism. He found
that the bacilli grew in broth to which glycerine had been
added at a temperature lower than they did on potato or in
glycerine agar-agar, and liesliowed tube.s which had been kept
at a temperature not exceeding 60° F. Bacilli cultivated in
glycerine ogar-agar to which corrosive sublimate in the
proportion of 1 in 200,000 had been added were hindered
slightlyin their growth. This proportion of perchloride when
compared with the average body weight of a man equalled
from five to six grains. The demon.stration of the wide
range of tempenituve at which the organisms would grow
was interesting in suggesting that their habitat was pro¬
bably -wider than had been supposed.—Dr. CjaooKSirANVC
said that the paper had involved a very great amount of
labour, the growtiis being very slow and requiring constant
watching. The results of inoculation of animals with
these subcultures when published would prove of great
interest.
Dr. Fred. J. Smith read notes of a cose of Chylous
Ascites in a woman aged sixty-seven. She had suffered
. iX-oogle
The Lancet,]
EPlDERtfOLOGICAL SOCIETY.
[Jan. 10,1891. 87
•from dysmenorrhcoa all her life and occasionally with dys¬
peptic symptoms. The final illness began in 1889 with
similar dyspeptic trouble, culminating in ascites in July,
1890. Masses of cancer were thought to be present during
life, both abdominal and pelvic. The necropsy revealed
primary growths in both broad ligaments, chronic perito¬
nitis, with small nodules of new growth. The liver was
much displaced, its capsule thickened, and two large stones
blocked the cystic duct. The thoracic duct was perfectly
healthy. Dr. Smith was inclined to attribute death to a
simple, not a malignant, chronic peritonitis, basing his belief
oii_(l)the comparative numerical deficiency of neoplastic
nodules; (2) the verified presenceof asimple irritant; (3} the
long duration of the case.—Mr. Spencer inquired if the
freees were examined for fat, and if the intestinal wall
had been stained with osmic acid. — Dr. Maguire
said that a considerable proportion of cases of chylous
'ascites had been associated with carcinoma of the peri¬
toneum, and dilated lymph vessels had been demonstrated
near cancer nodules. Two distinct varieties had been de¬
scribed, and in one of these the milkiness of the fluid appeared
to be due to the cellular elements derived from breaking
down malignant growth.. He had known of an instance in
which a rupture of the reoeptaculum cliyli had been found
post mortem.—The President asked if the molecular basis
of chyle was found in thefluid. He supposed thabtliecondition
was due to obstruction to the lacteals in the mesentery or
in its neighbourhood.—Dr. SMITH, in reply, said that under
•the microscope there was seen finely divided fat, with a few
'leucocytes. The foaces had not been examined, and there
was no suspicion of filaria as a cause.
Mr. Hurry. Fenwick detailed the history of a Large
Hydatid Cyst of the Bladder. The patient, aged twenty-
five, had been treated for six months for persistent head¬
ache, occasional morning vomiting, and increasing emacia¬
tion. Six days before uis death great irritability of the
bladder, culminating in suppression of urine, supervened.
A large, tense, semi-fluctuant tumour was discovered on
rectal examination, filling the entire true pelvis. It was
separated from the prostate by a narrow interval, but it
bad pressed the vesicuhe seminales and vaea deferentia
backwards. The bladder had been dislocated upwards and
to the right, and a catheter could be passed after a slight
hitch at the prostate, but the bladder •was found empty.
It was obvious that both ureters had been strangled at the
brim of the true pelvis by the tumour. lu order to tem¬
porarily relieve the obstructive suppression, he aspirated
the cyst per rectum and drew off some ounces of hydatid
fluid. The ureters immediately emptied their accumulated
contents, for two ounces of urine ■were drawn off at once by
catheter and the patient passed thirty ounces voluntarily
during the next day. It -was then arranged to attack
the cyst supra-pubically, but a few hours before the pro¬
posed operation the patient fell back in bed, and died of
suppression of urine. Post mortem a very large mono-
locular hydatid cyst was found blocking up the pelvis
and nipping the ureters against the pelvic brim. Both
ureters and the renal pmves were greatly distended
and the kidneys much destroyed by backward pres¬
sure. No other hydatids were found. The brain was
normal. Many such cases existed in the literature since
1787. Most of the cysts were situated under the peritoneum
at the back or base of the bladder. Practically the cases
might be divided into those cysts which were placed low
down (basal), and caused retention by direct pressu/e upon
the prostate, and into those which were situated higher up
on the posterior wall (parietal), and evoked but few urinaiy
symptoms until dangerous renal changes iiad ensued from
backward pressure upon one or both ureters. The former
variety were perhaps more successfully treated, for they
attracted notice before great damage was done. Koctal
asmration was the usual treatment. .
Dr. ItoBERT Maguire showed a specimen of Acute
Verrncoso and Ulcerative Aortitis, with the formation of
an acute aneurysm. The patient was in St. Mary’s Hos¬
pital for four months, and efuring life presented a systolic
niurmurat both the apex and base of the heart, and a soh
diastolic murmur at the base. He had frequent rigors,
with vory irregular temperature. The splenic dulness was
increased, but tho spleen could not be felt. After death
tUOTo was found ulcerative endocarditis of the auricular
of the mitral vnlve, and on the ventricular surface
sugob recent ulcerations. The aortic valves were thickened,
nut showed no recent changes. At the junction of the
ascending and transverse portions of the arch of the aorta
there was a loculated dilatation of the vessel, with thin
fibrous walls, and containing no fibrinous deposit. On the
edges of the dilatation and of the loculi were large fibrinous
vegetations, in which, on microscopic examination, there
were found numerous streptococci. The spleen was en¬
larged, and contained a pale but not softened infarct. The
case was looked upon as one of malignant endocarditis, in
which the morbific matter had established itself in the
aorta, and had caused verrucose and ulcerative aortitis
with the formation of an acute aneurysm. He did
not believe that the condition was caused by the
organisms found in the v^etations, for so many different
' varieties were present.—Mr. Shattocic thought that, in
his views as to causation, tho autlior was at vaiiance with
the majority of observers. The disease usually originated
in patches of chronic infiammation, and was due to a
secondary infection of them.—Dr. Smith asked if it were
considered that the cardiac vegetations seen in chorea were
due to micro-organisms. In deaths from many acute dis¬
eases he had seen small vegetations on the cardiac valves.—
Dr. Crookshank thought there was a great deal pointing
to the fact that these micro-organisms were epiphytic.
By what means did they gain access to the circulation.—
Dr. Hale White said that the ratio of ulcerative endo¬
carditis to chronic lesion on the pulmonary side of the heart
was very much greater than it was on the aortic side, and
this fact seemed to him very significant in connexion with
the presumed parasitic origin of the disease.—Dr. Maguire,
in reply, said that in the case related there was old mischief
in both mitral and aortic valves. Though the starting
point was usually in an old patch, many of the secondary
lesions appeared to attack healthy lining membrane.
Mr, E C. Stabb showed two specimens of Dermal
Cysts. The first came from a blacksmith aged thirty. He
punctured bis finger with a rusty nail, and the cyst which
formed was tapped but refilled. It was then removed,
together with the adherent skin, and was found to be com¬
posed entirely of squamous epithelium. The second occurred
in a carman aged twenty. Nine months previously he had
sustained a lacerated wound of the finger, which healed
readily. Four months later a swelling formed, and this on
removal presented microscopical appearances similar to the
one above described. It was interesting to note that they
both followed punctured wounds, which drove the epithe¬
lium into the deeper structures.
The following card specimens were shown:—
Mr. H. B. Robinson: (1) Webbed Fingers and Toes;
(2) Cystic Disease of Testicle; (3) Golumnar-celled Car¬
cinoma of Small Intestine.
Mr. W. G. Spencer; (1) Lympho-sarcoma in Dog snr-
roundingTracheaand Bronchi; (2; Lympho-sarcoma in Dog
surrounding Aorta ; (3) Leucocythoemia in Cab.
Dr. G. Gulliver : Acute Endocarditis of the Right Side,
with Pulmonary Embolism.
EPIDEMIOLOGICAL SOCIETY.
TAe Caiise of Enteric Fever in India.
A MEETING of this Society was held on Doc. 17bh, 1890,
Jos. Ewart, M.D,, F.R.C.P., President, in tlie chair.
The Secretary read a communication from Brigade-Sur¬
geon H. Skey Muir, M.D., on the Cause of Enteric Fever
•n India, in which he took exception bo certain allegations
made by. Surgeon-Major J. Pringle, M.D. respecting the
sanitary conditions of tlie hill station of Cliakrata in a
paper on the same subject read before the Society in May
last. He denied that the place was “ cold and bleak,” that
“it had nothing to recommend it except n magnificent
water-supply 1000 feet above it,” and that the authorities
“had neglected bo avail themselves of this,” having re¬
course, instead, to tanks inevitably exposed to pollution.
He gave n table showing the mean and absolute maxima
and minima of temperature for five yeare, from which it
S eared that the extreme range was between 23° in February
88 ° in June, with a mean temperature of 60° in the
summer and 40° in tho winter half of each year, and a rain¬
fall of from 50 to 80 inches annually. Very few men were,
however, stationed there in the cold season. The “mag¬
nificent water-supply” from the Deobund had, he stated,
been in use since 1870, though until 1887, when iron pipes
were laid, it bad been brought to the barracks in open
Cjoogle
88 The Lancet,]
WEST LONDON MEDICO-CHIIiURGICAL SOCIETY.
[Jan. 10,1891.
channels. The spring below the barracks, which Dr. Pringle
had denounced, was only used occasionally in hot weather,
and never during the monsoons. He denied that the out¬
break of enteric fever in 1888 could have had any connexion
with the water-supply, since the pipes had been laid in
the previous year and the water contained only 1 ‘8 grain
of chlorine in the gallon and no ammonia or nitrates,
and he argued that the disease occurring exclusively among
new-comers within a fortnight of their arrival must have
been contracted on the march through the plains. He gave
a graphic description of the roadside wells from the railway
station at Sanaranpore and of the river, from one er other
of which the troops obtained their supplies on the march of
seventy-seven miles, as well as of the camping grounds,
entirely in agreement with Dr. Pringle’s account and
familiar to all Anglo-Indians, and, though not absolutely
exonerating the water-supply at Kailana as he did that of
Deobund, ascribed the annual occurrence of some ten to
twenty cases in nearly every instance to infection con¬
tracted on the way to the station. — Dr. Pringlb, in
reply, entirely concurred with Dr. Muir in his condem¬
nation of the filthy sources to which soldiers were com¬
pelled to have recourse on the march, which he had
vainly urged the authorities to protect from contamina¬
tion ; but with regard to Chakrata itself, he said that the
open conduits consisted of two planks sunk obliquely in the
ground along a mule path, and were exposed to every kind
of pollution. He was pleased to learn that pipes had now
been substituted, but the outbreak to which he nad referred
as originating in the station was that of 1888 (the date 1888 in
the abstract which appeared in the British Medical Journal
being a printer’s error). He knew that at that time
the tank alluded to was in constant requisition, and he
had urged in vain the utilisation of the rain water from
the galvanised iron roofs. Dr. Muir’s temperature tables
fully justified bis condemnation of the climate, so did the
telling admission that the scarcity of wood for fuel
necessitated the abandonment of the station in the cold
season, the very time when such sanatoria were most
useful. Its position, also, N. and S., was bad, exposing
it to the direct influence of the hot winds from the
plains, and the cold from the .snow-capped mountains,
whereas an E. and W. aspect afforded shelter from these ex¬
tremes while giving the full benefit of the wind currents.—
Sir Joseph Payree maintained that too much stress
was laid on a supposed specific cause of enteric fever,
believing that other influences akin to those concerned
in the production of malarial fevers should be taken into
account.—Sir W. Moore held that the specific germ was
a pure assumption, and that enteric fever was multiform,
indefinite, and due to a variety of causes.—-The President
argued that the pathological identity of the disease, as
shown, especially by post-mortem examination, throughout
the world disproved a multiplicity of causes, that the
bacillary theory was proved by an overwhelming mass of
evidence, that the diversity in the non-essential phenomena
was explained by individual peculiarities of age, constitu¬
tion, &c., and that all alleged factors other than the
specific cause were but predisposing influences rendering
the individual more susceptible to infection.,
WEST LONDON MEDICO-CHIRURGICAL
SOCIETY.
Hahitual Ahortion.
At an ordinary meeting held on Jan. 2od, T. (funton
Alderton, Esq., President, in the chair, Dr. Leith Naiter
read a paper on the Treatment of Habitual Abortion. The
term “habitual abortion” being limited to a recurrence of
abortion three or more times, Dr. Napier discussed in an
exhaustive manner the various methods of treatment,
classifying them under four headings: (J) Rest or exercise,
insisting on the necessity of absolute rest for at least six
days iu the month ; (2) local cure of uterine disease, chronic
endometritis being regarded as the chief cause of abortion,
in that retroflexion and other displacements, with atony of
the mucous membrane, leucorrhcca, d;c., were regarded as
resulting from chronic uterine inflammations or congestions;
(3) constitutional treatment; and (4) drug treatment. The
value of local treatment was strongly urged, and in esti¬
mating the comparative utility of drugs the prolonged
exhibition of mercury, even in cases of a non-speciflc
nature, was extolled above all other therapy; while
as a uterine sedative viburnum was preferred to any
other drug by the author of the paper, in whose prac¬
tice 77 per cent, of habitual aborters bad borne living
children after treatment by local methods and drugs.—
A discussion ensued in which Dr. Handfield Jones
thought that too great stress had been laid by Dr. Napier
on local treatment. He regarded heart disease as the
primary cause of chronic uterine disease and retroflexion,
and pointed out that the commonest epocli for abortion
was that at which the gravid uterus was striving to rise
out of the pelvis, cardiac disease generally causing abor¬
tion between the fourth and fifth month, failure of the left
ventricle leading to uterine stasis, congestion, and petechial
h.Tjmorrhages.—Dr. Napier replied.
The General Secretary, in the absence of the author,
read Dr. Macnaughton Jones’s paper, entitled “A Plea for
the Obstetric Art,” and the meeting adjourned.
SOCIETY OF MEDICAL OFFICERS OF HEALTH.
A MEETING of this Society was held on Dec. 12th, Mr.
H. E. Armstrong, President, in the chair.
The consideration of the sanitary legislation of the past
session was resumed with the Infectious Diseases (Preven¬
tion) Act. Section 4 wasseverely criticised, Dr. WiLEOUCiinY
deprecating the repeated introduction of the limiting phrase
“ within the district,” one effect of which was that a dealer
prohibited from selling his milk in one town was at liberty
to send it to another, which in most cases would be London.—
Dr. Newsiiolme objected to the production of proof of
disease having been actually caused by the milk being
required as a condition of puttingin force the Provisions of the
clause, which was thus deprived of all value as a preventive-
measure—e.g., when scarlatina or other fever was as yet
present at the dairy only.—Dr. Sykes expressed his belief
that the sources whence a retail dealer obtained his milk
afforded far more important information than could bo
derived from a list of his customers.—Mr. Blytii deplored
the delay necessarily following from the procedure enjoined
by this clause, and Mr. Armstrong, having never bad any
difficulty with the evidence furnished by the list of cases-
notified in inducing the dealer to state the sources of
his milk and in stopping the supply at once, was
convinced that this section would only serve to
interpose impediments in the way of his action in
the future. On Section 5 Mr. Lovett stated that
the delay apprehended by some was obviated in hi®
district by his having received a general authority from-
his Board to act at any time without a previous order. No
charge was made for disinfection, except when the occupier,
to avoid publicity, desired it to be carried out after dark.
The general feeling was that no disinfection should, or
indeed could, be deemed efl'ectivo unless performed by, or
strictly in accordance with the instructions of, the sanitary
authority. Section 8 was considered unsatisfactory, no-
instructions being given as to the mode of enforcing it,
especially since, as Dr. Willoughby remarked, deaths were
rarely registered within the specified period. Section l.T gave
rise to a lively discussion as to the best manner of providing-
for an obvious want, the extent and nature of the accommo¬
dation requii'ed in different communities, and the necessity
fordisinfecting theclothing of the individuals temporarily un¬
housed.—Dr. Newshoi.me said that at Brighton they hired
empty houses for a few days, the Corporation providing
furniture, bedding, &c.; and Dr. Yarrow that in St. Luke’s-
a house had been taken and fitted up as a permanent refuge,
one of the cmploy6s of the vestry being appointed care-
talcer. Several caiaes were mentioned in illustration of the
urgent need for such provision, among them one of a woman
with her child, who liad conveyed the infection of scarlatina
to the family of a friend at whose house they had passed
the niglib while their own was being disinfected. The-
Public Health (Amendment) Act elicited unqualified
approval except as to its permissive character, and a reso¬
lution was carried unanimously that Mr. Ritchie be re¬
quested to obtain the compulsory extension of Part III. to-
Londoa, or to incorporate its provisions into his Metropolis
Management Bill, referred to in the speech from the-
throne.
H i .C-oogle
The Lancet,]
CLINICAL SOCIETY OF MANCHESTER.
[Jan. 10,1891. 89
CLINICAL SOCIETY OF MANCHESTER.
The Treatment of Tuberculosis by Koch's Method.
An ordinary meeting was held on Dec. 23rd, 1890, Dr.
Braddon, President, in the cliair.
Dr. JUDSON S. liuRY opened the discussion, and gave a
•detailed account of the method from personal observation
during a recent visit to Berlin. Dr. Bury strongly advised
■the use of very small quantities of liquid in commencing
'treatment.
Dr. Gumi’ERT remarked upon the extraordinary power of
selection of tuberculous material displayed by the liquid,
and pointed out the immense benefit which would be
-obtained by the early use of the remedy in doubtful cases,
before the disease had progressed too far for treatment to
•eradicate it. From observation made in Berlin Dr. Gumpert
urged the importance of using small injections to commence
with, increasing gradually until the exact quantity re¬
quired to produce the desired local change had been deter¬
mined. A dose of one milligramme or even less was suffi¬
cient at first. With half a milligramme distinct reaction
had been obtained. Dr. Gumpert afterwards showed a
patient of Mr. Southam’s in whom he had injected three
milligrammes each time on December 8th, 12th, and 18th.
The patient, a lad of sixteen years of age, had numerous
((over thirty) patches of lupus in the face, on the
neck, the back, and the legs. He had had a tuberculous
-affection of the left knee in early childhood, which had pro-
•duced total stiffness of the joint thirteen years ago. The
reaction after this comparatively small dose had been very
•severe headache, pain in the chest, and very severe pain in
the strumous knee; rigor about nine hours after the first
injection, but not after the others; high temperature—
104’4°, 104'2‘’, and 104'O’ respectively; repeated vomiting
fourteen, fifteen, sixteen, and seventeen hours after the
'first injection, but not after the others. The stiff knee
became slightly movable in the evening of Dec. 9bh, and
could be bent to an angle of about 120'’ on the following
■day. It became painful and stiff again some hours after
the second and third injections, and more movable after
the disappearance of the reaction, and can now be bent
without the slightest pain to a right angle. The lupoid
patches were all markedly improved.
Dr. Coi.iN Camthell (Saddleworth), after thanking the
Society for their kind invitation to be present, said he re¬
gretted that his observations of the results of Koch’s treat¬
ment did nob enable him to agree with the very favourable
opinions expressed by Dr. Bury and Dr. Gumpert. They
■spoke of “cures” as if they were undoubted facts. He
had grave doubts about these cures, and a consideration of
the theory advanced to explain the working of the new
remedy did not diminish these doubts. He bad seen a great
amiuberof cases in Berlin, and carefully noted a few in each
class. The cases of glandular enlargement were certainly
nob benefited. Scrofulous joints appeared to be improved,
but as much improvement often tooK place from rest alone;
•and as regards lupus, ho saw only one ease in which a cure
was claimed, and be thought Dr. Sutcliffe could give them
•later news about that one case. The other cures he noticed
were also observed sixteen days later by Dr. Sutcliffe who
still reported “no improvement.” Where then were the
“ cures'’? He had several patients anxious to try the treat¬
ment; but on the evidence before him, and hisown observa¬
tions, he was unable conscientiously to recommend it
-otherwise than as an experiment.
Dr. SUTCLIKFE (Stalybridge), from personal observation
■of cases, thought that the time had not yet arrived for
formulating any definite rules as to the best method of
Msing the liquid or the results of its action. Probably the
best way to treat phthisis would be by small doses iniecteti
•at intervals of a fortnight spread over a long period of time,
and conjoined with all hygienic, tonic, and climatic treat¬
ment available. He showed an asbestos syringe largely used
m Berlin in preference to the one used by Dr. Koch.
Dr. BnrERLEv deprecated following a “method” and
using a preparation the composition of which was not
Known to the profession, and was of opinion that English
practitioners would be chary about putting this sensational
treatment of tuberculosis into practice. Since the method
Was purely experimental at present, he thought the treat¬
ment should be carried out only in hospitals, where the
patients could be constantly under the immediate care of
skilled workers.
Dr. SiMp-soN, though disliking the secrecy, at present
perhaps unavoidable, of Koch’s preparation, ^ considered
that we should not be justified in passing it by. Its use
required great caution, and its curative value was not
as yet firmly established. In many advanced cases, or
where pulmonary tubercle was extensively distributed, it
was contraindicated, and could only be used with the
utmost possible caution in any threatening of meningeal
tubercle. Then, too, there was some evidence that it
might set up activity in some cases where tubercle might
have remained. This raises the question. What becomes of
the bacilli? They do not share, it seems, in the death of
the tuberculous tissue. Are they in some cases, by the
absorption of this, simply set free with their active pro¬
perties unimpaired?
Dr. Braddon and others also addressed the meeting.
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
A MEETING was held on Dec. 18th, the President, Mr.
W. Dale James, in the chair.
Typhoid Fever. —Dr. DYSON showed the ileum from a
case of typhoid fever. The patient was a girl aged seven¬
teen. She died on the forty-seventh day of the disease of
exhaustion and hypostatic pneumonia. She had been ill
fourteen days before admission to the infirmary, and suffered
throughout from vomiting and gastric irritability. In the
early part of the case the vomiting was largely biliary ;
hence great difficulty was experienced in feeding tbe patient
and in the administration of antipyretics. The ulceration
of the bowel was extensive; some of the ulcers were cica¬
trising, others appeared recent, and several were deep, the
floor of the ulcer being formed by the serous coat of the
bowel.—Mr. T. Robinson, Dr. Burgess, Mr. A. Jackson,
Mr. Baldwin, Dr. Martin, Mr. Garrard, Dr. Mathews, and
Mr. B. Walker joined in the discussion.
Miners' ^iystagmas. —Mr. Snell introduced a patient
suffering from miners’ nystagmus. He said that an im¬
pression was cuirent, particularly among the miners them¬
selves, that the use of safety lamps was the cause of this
affection. A case like the one introduced was in direct
opposition to such an opinion. Tlie patient had worked with
safety lamps for fourteen years, and experienced no dis¬
comfort with his eyes. For the last three years and a half be
had, however, been working entirely with naked lights—
candles,—and it was during the last year or so only that his
symptoms had developed and necessitated his leaving bis
work. It was a very well marked case of nystagmus. Mr.
Snell remarked that he had seen several otber cases occur¬
ring in men using naked lights. Fewer men, however,
worked with naked lights than with the safety lamp ; hence
the cases of nystagmus met with were most freq^uently
in those employing the safety lamps. Mr. Snell said,
after an experience of several hundred cases, that
the affection was occasioned by the position a pro¬
portion of coal getters were compelled to assume at their
work. He had expressed these views in a paper before the
Ophthalmological Society (Transactions, 1884) and else¬
where. The position (head and eyes obliquely upwards)
was assumed cbieily by men engaged in “holing.” The
patient introduced was a “ holer,” both when using safety
lamps and later when employing candles.—Remarks were
made by Mr. Goodall and Mr. Boynton Lee.
Mr. B. Walker read the notes of a Cerebral Case.
The patient, a woman aged sixty-three, had a fit of
apoidexy, resulting in right hemiplegia, six years ago.
The leg, as usual, recovered more rapidly and completely
than the arm, the latter shaking so when she attempted
to lift anything that it became practically useless. On
Nov, 4bh last she had a second apoplectic seizure, remain¬
ing unconscious for forty-eight hours. After sinapisms
had been applied to the lower extremities and a blister to
the back of the neck, consciousness gradually returned, and
the first thing the patient did was to lift a cup of water to
her lips with the hand which had been so long disabled,
and the power of using the arm had continued. Mr. B.
Walker spoke in defence of the old-fashioned practice of
counter-irritation, and even bleeding in some cases of
cerebral apoplexy.—Mr. James, Dr. Martin, Dr. Dyson,
Mr. Jackson, Mr. W. F. Favell, Dr. Mathews, Mr. E.
Barber, and Dr. Sidney Roberts spoke.
. .X-oogle
90 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
fjAN. 10, 1891.
sob llfl&ts tf §00ks.
Transactiom of the Medical and PhysicalSodety of Bombay.
No. 12, New Series. Publie^ed at the Education
Society’s Press, Byculla. 1890.
In this volume a most interesting record is given of work
brought forward at the meeting of the Society by its
members. Amongst the most interesting of these is a paper
by Dr. H. Vandyke Carter, principal and professor of medi¬
cine in the Grant Medical College, entitled “ A Brief
Description of Micro-organisms present in the Blood of
Ague Patients.” Dr. Carter, whose elaborate researches on
the spirillum of relapsing fever marked him out as one who
would act the part of a strictly impartial observer, arrives
independently at the conclusion that it is impossible to
cast doubt on the accuracy of Laveran s observations on
the so-called htematozoa of ague. He confirms Osier’s
additional evidence, and gives drawings and descriptions
of the organisms which should prove of considerable value,
although he appears to have missed the peculiar radiate
arrangement that has more recently been observed in the
breaking up corpuscles. After careful examination of
Lewis’ h^matozoon of the Indian rat and Steel’s organism
found In “Surra’’disease, he recognisesbetweentbemand the
ague organisms of man an analogy, as far, at any rate, as the
monad character of the organism is concerned. One curious
feature observed by Dr. Carter, and one well worthy of
careful consideration in connexion with the relation of the
organism to disease, is that there appears to be ao definite
relationship between certain symptoms of malaria and the
actual presence of the blood organism. He says, for instance,
“ I find that the more persistent phenomenon is the presence
of the blood organism, whilst the febrile state may be only
occasional; indeed, fever seemed unfavourable to abundance
of the monad; and I have ascertained that it may be
checked (by quinine) without at once entailing the dis¬
appearance of the parasite.” Another interesting observa¬
tion he has made, one that appears to have a considerable
bearing on the phagocyte theory, and which may be brought
up as evidence against the strict accuracy of Metchnikoffs
theory, is that the organism during two stages of its
existence — the pigmented spheroids and the flagellate
forms—might be devoured by “ coarse-grained leucocytes
wandering in the liquor sanguinis ; these marauding phago¬
cytes always, however, sparing the crescents, whose
persistence might, perhaps, serve to account for subsequent
febrile relapses.” Although so much has been written on
the subject of phagocytes, and it has been so frequently
discussed at recent congresses it does not appear that
Metchnikoffs theory is yet fully understood by those who
have used it to explain certain phenomena in disease, and
certainly the arguments put forward by some more recent
writers do not strengthen Metchnikoffs main contention
that phagocytes are able to remove living organisms. Dr.
Carter’s observations are certainly not in accordance with the
views held by the strict disciples of Metebnikoff. Although
he mentions the phagocyte theory, and speaks of it as
explaining the above features noted by him, those who
read what Dr. Carter has written will be inclined to agree
that, however highly the function of scavenging is developed
by the phagocytes, their power of devouring living foreign
protoplasm is surrounded by very distinct limitations.
Dr. Carter considers that the peculiar conditions of molan-
aemia and urobilinuria, when the result of ague, are due,
not so much to changes in the liver, but to changes in the
spleen, which, in certain cases observed, was far more
seriously implicated than the liver itself, and he says:
“Doubtless, hepatic derangement ensues on the malaria)
infection, yet secondarily, I should say to the splenic; and
I would connect, in this instance, at least (mentioning a
case), the state of the urine with that of the blood.” This
record of the occurrence of Laveran’s ague organisms
is interesting as being the first that has come from
India, and as opening up a new Held of scientific in¬
vestigation for British workers, which has hitherto been
left almost entirely to the French, the Italians, and
the Germans, and we hope that under Dr. Cartei-’s careful
direction his British assistants and Indian pupils may
corroborate and extend the series of observations that he
has commenced. In the meantime Dr. Carter promises
further contributions on the pathology of ague and on the
therapeutics of quinine in a paper to be published in the
Scientific Memoirs (Official), vol. iii., Calcutta.
Another paper by Balchanora Krishna, L.M. & S.,
which will be read with interest at tJie present juncture,
deals with Leprosy in Bombay in its Medical and State
Aspects. It appears to have been brought forward
specially to answer some of the questions raised by tho
Draft Leper BUI. Mr. Krishna contends, in opposition
to the assumption of the Bill, that every case of leprosy is
not contagious, the non-tuberculated or an.-esthetic form
which is most prevalent in India being seldom contagious,
except, perhaps, during the ulcerating stages. He considers
that, although leprosy is prevalent throughout India,
it is impossible to obtain satisfactory statistics to show
whether the disease is increasing or on the decline. That it
is endemic he does not doubt, and also that it may be
transmitted hereditarily. He does not agree with Mr.
Hutchinson in his theory of a “ peculiar specific poison ” in
fish, nor does be allow that the disease is communicable
by aerial infection. He insists on the extreme difliculty
of diagnosis during the early stages of the disease, and
shows that even qualified medical men are apt to make
mistakes unless they have had a wide experience in the
treatment of leprosy; the powers suggested to be given
to medical men in general under the Bill are, he thinks, too
extensive. WhUst holding that certain clauses in the Bill
are really the result of a scare, that they are ill considered
and ill timed, he maintains that if these be deleted it would
“ be a desirable measure, in so far that when it becomes an
Act it will serve pre-eminently to calm the public mind,
which has been excited to the highest pitch, because it will'
be the means of removing vagrant lepers from the public
gaze; but whether it will serve to stamp out the disease I
am not sure.” As to the question of asylums, he considers
that they are unnecessary, except for those poor and
diseased wretclies covered with innumerable and loathsome
ulcers and otherwise disabled, whose sufferings might
indeed be greatly alleviated by care, protection, and food ;
but otherwise an equally strong cause might, he thinks, be
made out for the construction of asylums for phthisical and
syphilitic patients.
Mr. Krishna’s paper is well timed, and will be extremely
valuable if it will only enable people to think of “ lejirosy ”
without being panic-stricken. It is only one of several
diseases the very names of which strike terror in the hearts
of those who hear them. In this country, at any rate, it
must be admitted, such terror lives on the reputation of the
disease and not on any actual danger that there is of con¬
tagion or infection. In India, and in other countries where
the disease is still endemic, it is now recognised that we must
look to well-considered sanitary measures for any improve¬
ment in the nature and course of the disease, and as this
fact is accepted, and as hygienic precautions are taken to
prevent the spread of the disease, leprosy, like cholera,
will become more and more restricted in its sphere of
operations,
Digiti.'ed by
TsB Lancet,]
REVIEWS AND NOTICES OP BOOKS.
[Jan. 10,1891. 91
Ijiflmnza or Epidemic Catarrhal Fever. An Historical
^Survey of Past Epidemics in Great Britain. Being a
New and Revised Edition of Annals of Influenza,” by
Theophilus Thompson, M.D,, F.li.CP,, F.R.S. By
E. Symes Thompson, M.D., F.R.C.P. 8vo, pp. 490.
London : Percival and Co. 1890.
Tub recent epidemic of influenza has shown the great
value of the “Annals” compiled for the Sydenham Society
'by the late Dr. Theophilus Thompson. In looking through
those records from 1510 to 1837 we see the likeness of the
various outbreaks of the last four hundred years. Of
these the live that have occurred during the present century,
and the ten in the last, are illustrated by our greatest
medical writers, while those of 1C58 and of 1675 are tftated
of by Willis and by Sydenham.
The republication of so important a work, beyond the
limits of the Society’s volume, is well deserved. The care
and industry of its compilation are everywhere conspicuous :
the views of each author are clearly set forth within quota¬
tion marks, and the editor’s observations, distinguished in
the original by brackets, but now unmarked, have a value
of their own ; the revision by the author’s son. Dr. Symes
Thompson, lias been well and ably carried out; the present
volume, in shape, size, and typography, is very like the
original; it is handy and well printed, and the pages very
closely correspond. The omission of some meteorological
details has been judiciously managed, so that no important
part of tlie old records is wanting. The new matter, includ¬
ing Dr. Peacock’s account of the 1847 epidemic, is a worthy
continuation of the “Annals”; that on the recent epidemic
'by the present editor is of great interest, but, though ex¬
tending to seventy pages, necessarily falls short of its obj'ect.
This may be noticed further on. The assumption of the two
S)arts of author and of editor are diflicult to sustain, and
must be regarded separately in any review. The editorial
part is on the whole well done, but some details of it have
to be questioned. Would it not have been well for the new
editor to have used brackets when additions of his own are
inserted in the work '• And some note of alteration should
appear where alterations are made in the text, and such
should be very restricted. In the preface, why retain the
paragraph on Sir (leorge Baker and omit that referring to
the great writers from Huxham to Heherden ? The last
Simrt of the original preface rightly gives place to notices
of the 1847. and 1889 epidemics, but why not in their
order of sequence ? Tlie introduction has more than
a page of new matter, replacing much of the original
that need not have been omitted, with nothing to indicate
the extent or limit of the change. If in the concluding
part it is allowable to substitute “micro-organism” for
“ some virus ” introduced into the system, we might surely
have had “typhus,” near the beginning, replaced by
“ typhoid or enteric fever,” the substitution in both cases
preferably being made by added words in brackets. Other
modilioations of the vigorous original are less defensible,
such as “coincide” for “combine” in the very true
•observation that influenza modifies any pre-existing disease
with which it may combine; this would not be true
of any coincident disease, and if coincident how can
either be pre-existent ? Two lines are added to the same
paragraph not closely pertinent, and without any remark it
18 impossible to distinguish the .son’s from the father’s work.
As to traits of authorship, a family tendency is observable.
The plea for including vague possibilities, well urged in the
original, is too much adopted in the sequel, where ozone,
cosmic dust, and Chinese inundations have more than their
full share of notice. Siberia is referred to as a source of
influenza, and cholera (p. 415) as a concomitant. The
coexistence of disease among animals is not very critically
treated. The summary of this last epidemic is very im¬
perfect, not only as to extension but as to symptoms.
Coryza, in some degree nearly always present, is given as
“generally absent”; vel i.-es are omitted, though atp. 449
“ many,” and at p. 453 ' 6 per cent,ate reported ; rashes,
mostly exceptional, and very seldom with any desquamation,
are said to be of “frequent occurrence”; while any lessened
prevalence of the epidemic in London coincident witli “or
after strong gales ” is not evident in the preceding account.
Some statement as to the large amount of original matter
added by the new editor should in our opinion have been
inserted in the title page, which otherwise might have been
retained in its original form, and not have been so altered
as to displace “Annals” from the heading or leading
feature of the title.
The Medical Shident's Mamial of Chemistry. By R. A.
WiT’i'HAUS, A.M., M.D., Professor of Chemistry and
Physics in the University of New York, Professor of
Chemistry and Toxicology in the University of Vermont,
&c. Third Edition. New York; William Wood & Co.
The new edition of this work has been carefully revised
and, to a great extent, rewritten. It is an excellent text¬
book for diligent medical students—those who wish to
acquire a real sound knowledge of chemistry,—as well as
for medical practitioners. It is lucid in style, contains a
great amount of matter in a small space, and is disfigured
by few inaccuracies. Chemical and physical theories as
well as facts receive fair recognition, and although the
applications of chemistry to physiology, medicine, and
toxicology are systematically kept in the foreground, the
science of chemistry is presented as a whole without regard
to mere utility or the exigencies of an examination. The
book is divided into three parts, the first devoted to general
Chemistry and Chemical Physics, the second to Special
Chemistry, and the third to Chemical Technics. The appli¬
cations of physics to chemistry are of such great and in¬
creasing value that they require more space than the thirty
pages here allotted to them, and it would have been well
if they had been discussed at greater length, even at the
cost of subsequent curtailment. The accounts of spectro¬
scopy, polarimetry, and galvanic electricity are well written,
and give good general ideas in regard to those powerful aids
to research ; but they are too short to afford sufficient
guidance for practical work. Raoult’s law of freezing points
is described, though somewhat imperfectly; but we find no
allusion to thermal or refractive equivalents or to the mole¬
cular volume of liquids. The omission of thermal chemistry
is peculiarly unfortunate, as it is more than ever essentia
to physiology.
In the second or descriptive part of the book more than
half the space is devoted to the chemistry of carbon com¬
pounds—that is, to what is commonly called organic
chemistry. Throughout this part the matter is well
selected and well arranged, and the physician not less
than the student will find in it much that will be of prac¬
tical use to him. In addition to the ordinary toxicological
and physiological methods, many suggestions, evidently
founded on personal experience, are scattered through the
pages. As examples we may quote the remarks on the
physiological action of copper compounds (ji. 214), on the
ptojiiaines (p. 455), and on the precautions to be taken by
the physician in cases of suspected poisoning (p. 130). The
account of “ laboratory technics,” to use the author’s
phrase, in I’art 3 may be described as neither very bad nor
remarkably good. Here and elsewhere unnecessary con¬
fusion is introduced by the use of diagrams in which the
illustrative letters do not correspond to the descriptions in
the text. The diagrams themselves are not of a high order
of merit.
For the peculiar and irritating nomenclature adopted in
this edition Dr. Witthaus cannot be held responsible. A
committee of the chemical section of the American Associa¬
tion for the Advancement of Science bos decided that in
Dig'- /ed b> ViOO^IC
92 Thb Lancet,]
REVIEWS.—NEW INVENTIONS.
[Jan. 10,1891.
latute chlorine shall be written and pronounced chlorin,
a chloride a chlorid, and ,so on. Alterations of nomen¬
clature always involve inconvenience, and are only justi¬
fied when they present some substantial advantage. We
do not think that anything is gained by calling an old
friend “iodid of potassium,” and object altogether to the
change. We neither can nor will describe the chief alkaloid
of cinchona as quinin with the second vowel short; in short,
there is really no possible reason for doing so.
Anmiol Report on Meteorological Observations in the Straits
Settlements for the Year 18S9. By Max. Y. Simon,
Acting Principal Civil Medical Officer, Straits Settle¬
ments.
This bulky Blue-book gives a very full and exhaustive
record of the meteorological features of the principal places
in the Straits Settlements—viz., Singapore, Malacca,
Penang, and Province Wellesley. The results are interest¬
ing, as the localities mentioned all lie very near the Equator.
So we may take the figures given as constituting one type
of the equatorial climate. The several localities all lie very
near the sea level—thus the site of the observations was
ten feet above sea level at Singapore, twenty feet at Penang,
twelve feet at Malacca, and forty-three feet at Province
Wellesley. The first table gives the atmospheric pressure,
which at Singapore showed a maximum of 30 075 inches,
a minimum of 29'740, and a mean annual range of
29'89I. This shows that the pressure was remark¬
ably equable. At Malacca and Province Wellesley
the equability was even greater, while at Penang it was
somewhat less, than at Singapore. The next table
gives the temperature. The highest recorded at Singapore
was 93‘S", the lowest 68'7% the mean was 8P4“, and the
average range of the thermometer for the year was 13'4°.
These are shade temperatures. The figures for Malacca
are almost identical with those for Singapore, while Penang
showed a maximum of 95-5", a minimum of 70 0% a mean of
82'2^, and a range of 13'6°. Province Wellesley showed
somewhat less equability, as might bo expected from the
slightly greater elevation. The maximum there was 96 ■O®,
the minimum 69-0% the mean 82'3'', and the range le-O".
Further evidence of the equable warmth of the climate is
afforded by the figures showing the temperature of nocturnal
radiation on grass. These show that the lowest point
touched dft any season was 65'4° on Jan. 4th at Singapore,
69*0° at Malacca on April 22ad, 04'0®on March Ist at Penang,
and 67*5'’ on Feb. 28th at Province Wellesley.
The relative humidity table brings out some figures for
which we were hardly prepared. The maxima are what
might have been expected in a warm marine locality near
the Equator. These are for Singapore 98, and 100 for the
remaining three localities. The minima, however, are some¬
what surprising. These were for Singapore 5G, Malacca 76,
Penang 48, Province Wellesley 47. We were by no means
prepared to find them so low. As the means for the year
are somewhat high—viz., 81 at Singapore, 89 at Malacca,
76 at Penang, and 86 at Province Wellesley—probably the
minima refer to some brief period during the prevalence of
dry continental winds.
Very full information is given regarding the prevailing
winds. We learn that north-east winds predominated
during the months of January, February, and March. In
April the directions were principally sonth-south-west,
north-west, and south-west, the last continuing steadily
till July. From August to November, variable in south¬
east, south-south-west, west-south-west, and we.st pre¬
vailed. In December, north-east winds set in, with
heavy gusts, interrupted by gusts from the nortli-west
towards the close of the day. The mean velocity of
the winds in 1889 was 143 miles, and the greatest
velocity was 235 on May 28th. In general, the winds in the
localities under consideration are from the north-east
during the winter, with clear, dry weather, and from the
south-west during the summer, with rainy weather. The
rainfall is everywhere heavy, but varies much according to
season. Thus at Singapore 84'13 inches of rain fell upon
174 days. The maximum monthly fall was in November—
viz., 18'24 inches; and the minimum monthly fall in-
March—viz, , 1 '20 inches. The greatest fall in twenty-four
hours was 5*90 inches, a large amount. At Malacca the
mean fall was 87*67 inches, but at one of the localities of
observation in this district there was a fall of 144*23 inches.
In this same spot the fall for October was no less than
42'50 inches. In Penang the mean fall of several localities,
was 110'02 inches. The greatest monthly fall was in
October—viz., 22'04 inches, and the least in February—
viz., 0*52 inch. In Province Wellesley the mean fall of
several localities was 94'01 inches, the maximum monthly
fall was in Novembei'—viz., 18'76 inches, and the minimum
in February—viz., 1'42inches.
Taking the climate of the Straits Settlements as a whole
it will be seen that it is hot and equable, that the rainfall
is large and at some seasons excessive, and that the pre¬
vailing winds follow the general laws which obtain in the
regions of the monsoons. The localities under con.sidera-
tion are not of any importance from the point of view of the-
therapeutic hearings of climatology, as invalids are very un¬
likely to resort to them; but Singapore and some of the other
places mentioned are so important from a commercial, and
to some extent also from a military, point of view, that the
figures educed will be found interesting. Such climates as
those here described are necessarily trying to tlie Anglo-
Saxon, and are probably incompatible with the thorough
vigour and fertility of our race. They seem to exercise their
inimical inlluence most in the early years of life. In the
case of adults there is always room for speculation
how far the injury to health which a residence in
the tropics frequently entails is due to some essential
feature of the climate, and how far' to the persist¬
ence under changed conditions in the dietary and general
habits of life suitable to Great Britain. There can be no
doubt that many of the diseases which prevail among our
countrymen in India and elsewhere in the tropics are of
dietetic origin, and that an approximation to the natioDP.l
habits of the native population would rob ntany of these
diseases of much of their virulence. On the other hand, we
can never shake off our racial peculiarities, and the attempt
to make the Anglo-Saxon eat the same food and lead the
same life as the Hindoo or the Malay would certainly end
in disaster. The most we can do is to effect a reasonable
compromise between our racial tendencies and the necessities
of climate.
Stfo Infeiitions.
BATH LIFT FOR THE PARALYSED AND HELP¬
LESS AND FOR PROLONGED IMMERSION.
Tins bath lift, to which I would call the attention of the
profession, was designed with a double object—(l)to pre¬
vent those accidents which from time to time occur during
the bathing of the paralysed and otherwise helpless, and
make the bathing of the .most helpless patient by a single
nurse at once possible and safe; and (2) with a view to the
better carrying out of prolonged immersion—a mode of
treatment frequently resorted to at present in various-
diseased conditions. The accompanying diagram gives a
very good idea of the apparatus. It consists of a light,,
rigid frame supporting a strong net, and raised at the end
to form a pillow. This net can be elevated to the level
Digitized hv
Google
The Lancet,]
NEW INVENTIONS.
[Jan. 10,1891. 93
of the top of the bath and lowered at will by means of
the bandies attached to the revolvinR bar. A rack-
and-pinion arrangement makes it impossible fur the net to
“ go down with a run,” and the bent crossbars (shown
through the net in the engravingl keep the net three inches
from the bottom of the bath tub when at its lowest. In
use, when the patient is brought alongside the bath,
the net is raised, the patient comfortably placed thereon,
and gently lowered into the water prepared for him beneath.
Bathing over, the neb is raised again to the level of the
top of the bath, the patient rubbed dry, and pre-
paW for bed. Nurses and others who have single-handed
attempted to lift a helpless person from the bottom of
a bath will be able to appreciate the usefulness of this
contrivance. The advantages of the lift in cases of pro¬
longed immersion are many, nob the least of which
is that the patient is supported in mid-water, his weight
being equally distributed, and no portion of his body being
allowed to come in contact with the bottom of the tub.
Should the patient be delirious or maniacal, the limbs can
easily be secured to the net, and all dangerous struggling
is obviated. There is sufficient space between the edge of
the neb and the side of the bath to prevent injury to the
fingers should the bather grasp the rods. The apparatus
can be made to fit any size or shape of bath, and can be
fixed to an ordinary batli in a few minutes. It is also to
be noticed that the net and revolving bar can be removed
in a moment, so that in a private house the bath may nob
be monoplised by Ihe invalid. The machine should, I
think, prove of great value both in the private house and
in the public institution. It is manufactured by Mr. J.
Ward, 240, Tottenham-court-road, London, W.
S. A. K. Strahan, M.D.
COTTON-WOOL HOLDER FOR THE APPLICATION
OF LACTIC ACID TO THE LARYNX.
This holder is very similar to the ordinary laryngeal
probe. The end {a) is screw shaped, and made of silver.
The stem is rather thick, so that it does nob easily bend.
The handle (c) is made of wood, and can be screwed off, so
that we can thoroughly disinfect the stem in boiling water
or some strong antiseptic. The whole of the holder can
also be made of aluminium. The' advantages of this holder
a
are—(1) that the cotton-wool can bescrewed on and off very
easily ; (2) that we can regulate the thickness and length of
the cotton-wool to suit eacli individual case (we can thus
carefully localise the application of the acid, and also get
diseased parts which lie in the vertical piano);
(3) that we can easily disinfect the holder; and (4) that it
is very simple and cheap. The ordinary camei'H-hiiir brush
is much too large! and the stem too flexible, so that the
application of the acid cannot be properly localised or
energetically enough carried out. The cotton-wool bolder
of Heryng has the great disadvantage that part of tbe
cotton-wool is covered by the metal sheath, so that we can¬
not easily get at those parts which lie in the vertical plane.
It is also often very difficult to remove the cotton-wool from
the loop after use. The holder is made by Messrs. Down
Brothers, St. Thomas’s-street, London.
Adolf Bronnee, M.D.,
Bradford. Surgeon to blio Bradford Eye and Ear Hospital.
AN IMPROVED INSUFFLATOR WITH ADJUST*
ABLE TONGUE DEPRESSOR.
The original insufflator of Dr. Osborne has two great
disadvantages: one, that the powder has to be blown into
the patient’s mouth by the operator—an unpleasant and
in certain cases {e.g., diphtheria) a risky thing to do. The
improved Osborne insufflator, introduced to the profession
by Mr. Alexander Duke, does away with this danger and
unpleasantness by replacing tbe use of the operator’s mouth
by an indiarubber ball. But in both of these tbe left band
of the operator, whilst holding such instrument, gets into
the line of vision; so, at my suggestion, Messrs. Arnold
Md Sons, of West Smithfield, nave made for me the
insufllator which is depicted in the engraving, and which,
by a species of evolution which it has gone through, is, I
think, as perfect as such an instrument can possibly be-
The tongue-depressing part is separate front the insufflator
proper, which runs through a metal loop or bridge on the
upper surface of the depressor, and, there being plenty of
“ play,” by the slightest movement of the band the powder
can be ejected to all points of the fairces. Moreover, the
handle of the depressor, which is of roughened ebony, being
made at right angles, not only is more handy to hold,
but—and this is its especial advantage—the left band is
well out of the line of vision. Again, the tongue-depressor
can be used as a separate instrument for ordinary inspec¬
tion of the fauces.
W. LTIeureux Blenkaene, M.R.C.S., L.S.A.
Huinbcrstonc-roai!, LeiccHtor.
Digitized by ^ooQle
94 The Lancet,]
THE EOYAL COMMISSION ON VACCINATION.
[Jan. 10, 1891.
THE LANCET.
LONDON: SATURDAY, JANUARY 10, 1S91.
The third report of the Royal ComtnisBion on Vaicina-
tion is in one sense the most important that has been
wsued as yet, for it contains the evidence of three wit¬
nesses, who have been selected by the party opposed to
vaccination to set out their case from different points of
view. The subject necessarily involves a number of ques¬
tions which can only be satisfactorily dealt with by men of
scientific training; and when the veteran scientist, Dr.
Alfred Russel Wallace, D.C.L., E.R.S., was openly
enlisted into the ranks of the anti-vaccinationists, an
immense gain to that cause from the scientific point of
view was held to have been achieved. Naturally Dr.
Wallace was chosen as a leading exponent of the views
held by liis colleagues; and, having regard to his position,
it must be evident that his evidence was looked upon as
likely to influence a number of less scientific people. Dr.
Wallace occupied four entire sittings of the Commission
in setting out hw views, which were enforced by an abund¬
ance of diagrams and tables which have been reproduced in
an appendix.
The first point which the witness brought forward had to
do with the small-pox mortality of London during the
period 1780-1883. During this century it was admitted
that there had been much diminution in the rate of mor¬
tality from small-pox ; but it was contended that this
diminution could not in the earlier half of the period have
been due to vaccination, because it was too great to he
thus explained. This subject was discussed at great length,
but when it is remembered that there were no accurate
statistics either as to the population of London or as to
deaths—burials alone being recorded, and the causes of
death beiog often set down by ignorant won*en “searchers,”
—such ancient history can hardly be regarded as having
much bearing on the results of the administration of the
Vaccination Acta in the present day. Indeed, were it not
for that which later on followed in his evidence, we should
have thought that Dr. Wallace would have been the
last witness who would have founded an argument on
such imperfect data.
The next point was that, a “ very general vaccination”
being in operation from 1822 onwards, there had been no
diminution of small-pox down to 1883; and apparently
this view was largely based on the occurrence during this
period of the small-pox epidemic of 1838 and that of 1871.
Dr. Wallace altogether ignores the fact that the neglect
of “general vaccination ” was such that as late as 1871 it
was found necessary to pass an Act setting in operation a
new machinery for the enforcement of the law in this
respect. He declined, when asked, to consider the influence
of the increased amount of registration of death and of
accuracy in recording its causes which set in in 1838, when
the Registration Act first came into operation ; and he
certainly failed to take sufficient account of the fact that
bis own diagram shows an immense reduction in the amount
«f London small-pox in the second as compared with the
first half of the century to which his remarks relate.
Next followed evidence as to Sweden, Austria, and
Prussia; and when Dr. Wallace was asked why he had
failed to continue bistable of small-pox statistics for the
latter country beyond 1873, and this in face of the influence
of the well-known compulsory law of 1874, he, professing to
speak as an exponent of the subject of vaccination, made the
astpunding statement that though he “ had heard of that
law” he had not seen “any evidence” that it had made
“ any important difference.” Naturally Lord Hekschell,
as Chairman, seemed anxious to get on to the “next
point,” and this point deserves the serious consideration of
those who are induced to accept statements relating to
vaccination merely on the ground that they emanate from
an authority who happens to have acquired eminence in
some entirely different branch of science.
In laying before the Commission the evidence relating to
that which Dr. Wallace described as his “most im¬
portant” diagram—a diagram which, we may explain, has
appended t'l it no less than fifteen closely-printed foolscap
pages of statistics relating to small-pox in France—the
witness was careful in a long proem to lecture the Commis¬
sion on the vital importance of arriving at true conclusions,
and the need, in seeking after causes, to have experiments
that shall be strictly comparative. Tyndall and his
researches were appealed to in this connexion, the experi¬
ments of Darwin upon the fertility of seeds were recalled,
and it was urged that accuracy of the same sort, and an
absolute test and determination of a kindred character, were
necessary to true knowledge on the point under considera¬
tion. “Fortunately,” said Dr. Wallace, “we have an
approximation to that condition of things in France”;
and then followed an exposition of an enormous mass
of detailed statistics prepared by his own hand. The
Commission appears to have been much impressed with
the voluminous evidence brought before them, and which
at first sight almost seemed to imply that, under some
peculiar idiosyncrasies attaching to the French race,
vaccination bore no such relation to small-pox death as it
is known to bear in this country. But at the next sitting
the Commlssihn had had time to examine both the statistics
and the sources whence they were derived, and the result
was to show that Dr. Wallace’s theory was based upon a
series of blunders that one would hardly have expected
from a school-boy. The statistics as to one French depart¬
ment were recorded twice over. The detailed figures in
this ca.se of repetition were with one or two obvious errors
alike, and yet a difference of some 3000 was made in
adding up the data. Oddly enougli, Dr. Wallace was
not even aware that he had dealt with the same depart¬
ment twice over, although the two columns stand side by
side in his tables. It was next i)oir 2 ted out to the witness
that for the department of Sarthe he had entered that
there were no small-pox deaths during a long series of years,
whereas in the single town of Le Mans in that department
no less than 1179 such deaths had been recorded in two out
of the years in question. As to this. Dr. Wallace had no
answer; but it subseciuently turned out that wherever.
Digitized by '^ooQle
The lancet,] KOCH’S TREATMENT: SANATORIA FOR PHTHISICAL PATIENTS. [Jan. 10,1891. 95
owing to the difficulties attendant on the Franco-German
War, no official returns could be obtained, and a blank was
left, Dr. Wallace had taken upon himself to make an
entry to the effect that no deaths had occurred, and this for
the very years when small-pox was most fatally prevalent.
Again and again was the witness taxed with inaccu¬
racies of this and an allied sort, and the feelings
which were elicited by the fact of his having sub¬
mitted such evidence to the Commission may be judged
of by Lord Herschell’s retort on one occasion, to the
effect that “one does not accept statistics blindfold”; by Sir
William Savory’s question, Whether the witness would
like his table to go forth as worthy of his “scientific
reputation,” and by a string of questions put by Sir Guyer
Hunter, ending in a demand whether Dr. Wallace
regarded the data which he had brought before the Com¬
mission as “having the accuracy of a Darwin or a
Tyndall.” Happily, after some hours of discussion, Dr.
Wallace was constrained to admit that “the whole thing
is valueless,” and he even refused to respond to Dr. Collin.s’
suggestion that some remnant of good might yet have been
found in his tables.
In the main Dr. Wallace’s evidence was statistical;
but when modern statistics were submitted to him, showing
the enormous diminution of small-pox in children—that is
to say, in the years immediately following vaccination,—he
declined to go into the matter on the ground that it involved
a question of “medical statistics”; and when it was urged
that the fact was one of prime importance, his answer was:
“I have nothing to do with either disputing or affirming
it.” On another occasion, when urged to explain further
what he meant by declaring that the comparison between
the vaccinated and unvaccinat^d mortality ‘ ‘ in official and
medical statistics must be rejected,” he stated that on
“great points” like that “other gentlemen” would be
called. As yet, however, these other gentlemen have not
turned up to give the needed explanation.
Although we have at some length dealt with Dr.
Wallace’s evidence, we would urge all who are interested
in the question to read it for themselves. Its significance is
immense. Modern statistics emanating from our own
country, and which can be at once verified, were
avoided, whilst returns for a past century and for distant
places, the verification of which is well-nigh impossible,
were set out instead, the story being preceded by a glowing
account as to their scientific accuracy and importance,
which the result showed to be altogether unwarranted.
The truth is that in one sense we feel some sympathy for
Dr. Wallace. He surely must have been primed by
persons of no standing, who were either ignorant or
unworthy of credence, and he has suffered the consequences.
His own statistics—which he stated he had prepared him¬
self, and had indeed gone over “ all of them twice”—ho is
of course responsible for; and with regard to them wo
cannot but feel" that if this is all that science can do for
the anti-vaccinationists the scientific value of the operation
stands more than ever confirmed.
Nowhere have the reports from Berlin excited a deeper
and more painful mtereaC than at the various sanatoria
devoted to the treatment of phthisis. Climatic change,
coupled with tonic and hygienic measures, has hitherto
been our mainstay in the treatment of pulmonary
phthisis; hut it cannot be denied that the results thus
obtained, though occasionally brilliant, are more fre¬
quently partial and palliative than curative, and always
require much time and patience. It is only natural
that patients should look with eagerness to a new
line of treatment, which would seem to offer a short
cut to that goal of recovery to which, even under
the most favourable circumstances, they were hitherto
travelling only by tedious and interrupted stages. Hence
the flight to Berlin, of which the results cannot fail to
he in many cases disappointing, if not disastrous. We
propose to consider the points which should be weighed
most carefully before exchanging the brilliant atmo¬
sphere of the higher Alps or the sunlit shores of the
Mediterranean for the raw air of the German capital in
midwinter. We do so entirely without attempting rashly
to prejudge the value of the treatment of Professor Koci^
and while adhering to the view frequently expressed in
these columns that the facts already elicited give solid
grounds for hoping that a genuine advance in therapeutics
has been achieved.
In the first place, the painful fact should he realised
that no good authority has hitherto held out any con¬
fident hope that the new method of treatment will
be available for advanced cases of pulmonary tuber¬
culosis. At the various sanatoria a very large proportiod
of cases are far gone in the disease, with the lungs
extensively infiltrated and with excavation going on.
Whatever future investigation may establish, all the
evidence at present at our disposal tends to show that tha
injection of the KocH liquid in such eases is both
excessively dangerous and almost certainly futile. The
reaction set up seems most severe, and the risks of rendering
necrotic large portions of pulmonary tissue would seem so
great that it is still a question whether the application of the
treatment to such cases is justifiable at all. We fear the
subject of advanced pulmonary tuberculosis will be com¬
pelled to realise the bitter truth that the new hope which
has been diffused through the world is not for him. He will
do well, at least for a little longer, “to bear the ills he has”
rather than “Jlyto those he knows not of.” In many cases
such patients have, perhaps after many failures, found the
climate most suitable to their condition, where they may
" Draw in easier breath from larger air,”
and where, if complete recovery be bejond their hope, they
may at least look for a lengthened span of days free from
serious suffering. It is impossible to contemplatfe the spectacle
of hosts of such patients hastening pell-mell to the bleak
plains of northern Germany without the saddening thought
that even the gre atest boons conferred on suffering humanity
bring some counterbalancing evils in their train. For such
evils we do not hold Profeseor Kocii responsible. His own
words have been most careful and guarded, and altogether
worthy of his unique scientific reputation; but much has
been written, especially in the lay press, which has already
been disproved, and random assertions have been made
which can only result in disaster to the classes whom it is
sought to benefit. This is probably the first occasion in the
history of medicine of the merits of a great discovery being
Digitized by i^ooQle
96 The Lancet,!
FOOD PKESEllVATIVES AND ADULTERATION.
[Jan. 10,1891.
submitted not to experts but urhi ct orbi, and the spectacle
suggests that the old ways of professional reticence and
cautious progress were better than the now.
The case of patients in the early stage of the malady
is different from the one we have been considering. For
them a great hope has arisen, and if they snatch at it
too hastily and greedily no one need wonder at what is
altogether natural. But such patients, now comfortably
established at Davos, St. Moritz, Cannes, San Remo,
Arcachon, Palermo, Malaga, Algiers, Egypt, Madeira,
and a host of other such resorts, should consider,- first,
whether such a journey as that contemplated to Berlin
can be undertaken by them without the most serious risks;
and secondly, whether they are likely to lose much by sub¬
mitting to the delay which may ensue before the remedy
ean be made available for them in their present quarters.
As regards the first point, the change from Davos, San
Remo, or Algiers to Berlin must be regarded as full of
danger, even if the journey itself be left out of account.
As regoi-ds the second, the patients whose case we are now
discussing are in many instances making progress in their
present chosen resort, and a delay of a few weelcs or months
is not likely to be seriously hurtful.
There is one motive for repairing to Berlin, the force of
which we would not attempt to minimise—viz., the desire
to be under the care either of the illustrious discoverer
l^mself or of some of his trained assistants. This is quite
natural, but we may well pause to reflect that the treatment
is quite new, even in the place of its birth, that the most dis¬
tinguished observers in Berlin are only feeling their way to a
secure doctrine on the subject, and further that in a very
short time the experiments now proceeding in Vienna, Paris,
London, Glasgow, and elsewhere will have created an inde¬
pendent mass of evidence available to everyone. Science
knows nothing of monopoly, but even the apparent
monopoly which circumstances have temporarily created
in Berlin can only, we sincerely trust, be of very brief
duration.
The question as to whether the addition of preservative
agents to foods constitutes adulteration within the meaning
of the Act was discussed in two interesting papers read at a
recent meeting of the Society of Public Analysts. It ap¬
pears that a milk-seller was summoned not long since
before one of the metropolitan police magistrates for selling
milk partly deprived of its cream, and which contained
boracic acid, described in the summons as a poisonous in¬
gredient. In one of the papers referred to, Mr. Hehner
stated that so far as he was aware this was the first case
under the Sale of Food Acts in which the use of a food
preservative is condemned as an adulteration. Con¬
viction, however, was obtained mainly on the evidence
of the abstraction of 30 per cent, of the original fat,
altliou'gb the Bench severely reprimanded the defendant
concerning the addition of boracic acid. From the fact
that not only milk, but other foods, as butter, cream, fish,
meat, and meat preparations prepared for the exclusive use
of the invalid, are frequently preserved by the addition of
boric acid or borax, this question becomes one of considerable
importance. The addition of other antiseptics to various
articles’of diet is al^o well known. Such are, for example.
salicylic acid, sulphurous acid, bisulphites, and benzoic acid
or benzoates, which, according to Mr. Hbiiner, are
gradually taking the place of salicylic acid. In analyses of
food, too, made from time to time by The Lancet, atten¬
tion has been directed more tlran once to the presence of
salicylic acid, boracic acid, and borax in milk as well as
in many prepared foods. From investigations which have
been made it is found that 1 gramme of boracic acid per
litre of milk retards tire coagulation {when the temperature
throughout is IS^C.) for from twenty-four to thirty-six hours;
0'5 gramme for only twenty-one hours; whilst at 35° C.
this quantity is without effect, and 1 gramme retards the
coagulation under these conditions for ten hours. It would
be necessary, then, to employ not less than 1 gramme of
the acid per litre of milk. Mr. Heiiner finds that in the
case of butter a mixture of boracic acid and borax is mostly
used. One sample contained, for example, 0'41 per cent,
boracic acid and 0’55 per cent, borax. Stress is laid
upon the fact that in almost every country in the
world, with the exception of England, which was the first
to frame food laws, this question has been taken up
and the use of antiseptics in food prohibited. France was
the pioneer in this direction. The beer imported into that
country from Germany was found to contain almost in¬
variably salicylic acid, and the French brewers, in their
own interests, of course started action. The Paris Court of
Appeal decided that salicylic acid was to be regarded as an
adulterant, and to the prejudice of the purchaser—a de¬
cision which was based on the report of a Commission of
the Acad6uue de M6Jecine of Paris, appointed to inquire
into the action of salicylic acid in food. The commission
reported that the use of this antiseptic in food had in many
instances been known to produce serious efiacts, and that
sntall but continued doses were likely to result in grave
gastric aud hepatic disturbances. In 1888 all addition of
salicylic acid to food was prohibited by the Dutch Govern¬
ment, and the Italian Government, in 1887, forbade its addi¬
tion to wine, and regarded it as an adulteration. The
Spanish Government prohibited the use of antiseptics in
wine, and the Austrians also regarded salicylic acid in the
light of an adulterant. This general prohibition of the use
of salicylic acid in particular gave rise to the employment of
other substances. In France benzoates were chiefly used,
and in Germany sulphites and borates.
Mr. Cassal read at the same fiieeting a not less interest¬
ing paper on the adulteration of food with boracic acid.
Both authors were of the opinion, it is evident, that the
addition of a preservative to food constituted an adultera¬
tion within the meaning of the Act. If this be so,
then a tremendous subject for the consideration of
public analysts and medical authorities is opened up.
The question will depend largely upon medical opinion as
regards the nature of the action of antiseptics (such as have
been alluded to) when taken internally. There appears to
be little known about the action of boracic atid and borates
on the human economy. It has generally been considered
the mildest and most harmless of antiseptics. In large
doses boracic acid is a gastro-intestinal irritant, and the
action of borax is described as being similar. The dose,
according to the Pharmacopccia, i^from five to thirty grains.
The properties of salicylic acid and its sodium salt are.
Digitized by i^ooQle
The Lancet,]
CHARITY V. CRITICISM.-THE TRAINING OF NURSES.
[Jan. 10,1891. 97
of course, better known. In the stomach it behaves as a
local irritant, causing heat, pain, nausea, and vomiting, unless
taken in moderate quantity and well diluted. But then it
has been quite recently shown that salicylic acid, according as
it was natural or artiliclal, exhibited dillerent properties, and
attention has been called to the fact that injurious physiolo-
•f^ical action has followed the useof the artificial variety, which
commonly contains cresotic acid, and to this substance the
injurious effects were attributed. There can be no doubt
that the presence of an antiseptic in food would prove in¬
jurious tomanyperBons;‘but, on the other hand, few object
to the addition of a minute amount of preservative to cream,
butter, and milk, for instance, which are, especially in hot
weather, so liable to become unpleasant and objectionable
by reason of putrefactive change. The question is an
important one, and calls for immediate investigation. The
.consensus of medical opinion must be gained, and when it
has been definitely decided that the addition of antiseptics
to foods (added with the avowed object of preserving them)
is injurious to health in general, then it will be the duty of
^analysts to report accordingly, so that the proper authorities
may take the necessary proceedings against the vendor of
the article. Meanwhile, it is desirable that analysts should
mot omit to report in their certificates the presence of any
preservative which may have been added to any article of
food examined.
“ CuAMTV,” says a great authority, “never faileth,” and
it never will. Even the criticism of this last decade of a
•critical century, which is meant to chasten and guide it^
•and which occasionally seems to chill it, only changes its
methods and its objects. Last year we had to report an
apparent falling off in the great gifts of the charitably
disposed. Thus, in 1888 the total of London donations and
bequests, according to au article in our contemporary the
■Charity Record, was ,£840,000. In the year 1889 this total
fell to £330,000. This was a fall in one year of £510,000.
But in the following year—i.e., 1890—the pendulum of
•charity swings up again to £709,000, or £439,000 more than
in the previous year. There are, so to speak, accidental
a'easons for this variation, but of late years the searching light
of criticism has been very great, and has successfully shown
that while there is no excess of kindness on the part of the
•strong to the weak, there is carelessness of administration
in the year. In Fiance, M. Parent dE Ro.son left
£70,000 for the Paris poor. Prince Doria left £120,000
for various philanthropic institutions. The Presbyterian
charities of Canada and Victoria benefited to the extent of
£102,069 and £150,000 respectively by the wills of the late
Miss Niciiolls and Mr. J. Thompson. The Emperor of
Austria and the Archdukes gave £180,000 to the sufferers
from the terrible floods. General Saliverstopp left £119,047
to be used for charitable purposes. It is desirable for our
British philanthropists to note that they are well rivalled in
our colonies and in continental countries. It must not be.
supposed that in noticing these large sums we either forget or
disparage the smaller contributions, often much more meri¬
torious, from less wealthy givers. Mr. W. F. Howe, the
editor of the ‘ ‘ Classified Directory to the Metropolitan Chari¬
ties,” reckons roughly that these institutions have had in the
last year an income of nearly five millions, or £4,918,652. The
following are the rough estimates of the income of the medical
charities: For incurables, £02,045; for general hospitals,
£337,251; consumption hospitals, £61,258; ophthalmic
hospitals, £9845; orthopedic hospitals, £4963; akin hos¬
pitals, £5^498; hospitals for women and children, £61,805;
lying-in hospitals, £10,538; miscellaneous special hospitals,
£107,112; general dispensaries, £28,453; provident dispen¬
saries, £9063; for surgical appliance institutions, £26,968;
convalescent institutions, £58,355; and nursing institu¬
tions, £11,685.
We have said enough to show that charity is not failing.
It need not stop at its present figures, and it would not
if the administrators would be a little more confidential
with each other, and cultivate more discrimination as to
those whom they relieve. Such sums as we have mentioned
are a mere drop in the bucket of wealth of a country which
pays income tax on over£590,000,000 a year. Once assure the
rich that their gifts are needed, and that they are used, not
to degrade, but to elevate those who p-re helped, and we
should not see rich people waiting for others to give, but
out of their own piles building hospitals and convalescent
homes, and making them therewith independent of suh-
srrii>lionii, as our italics show the Earl of Leicester wishes
the Norfolk Home to be. There is a parsimonious-
nesa and a paltriness about the gifts of some rich
men—nob to say women—which are best rebuked by
the munificence of others.
which discredits even charity, and which hinders its gifts from
•attaining still larger dimoasions than they have ever reached.
There have been some very noticeable individual gifts in the
past year, as our contemporary points out. Thus Mr.
Pktkr Reid gave £100,000 to found a convalescent hospital.
Mr. B. E. Fletcher offered to build a convalescent home for
the patients of the Norfolk and Norwich Hospital, and to
endow it with £100 a year, to which offer the Earl of
i/sicester added a promise of an endowment of £1.5.000, with
a further £5000 should it be needed to render the home
■^dependent of subserijdion^. Mr. U. Cadijury' presented
to the people of Birmingham Mosely Hall, together with
twenty acres of land and a sura of money, equal in
all to £30,000, to be used as a convalescent home.
Mr. W. 11. Barry’, s legacy of .£60,000 to the Groat
‘Ormond-street Hospital for Sick Children, besides a
further £5000 for the new wing, were announced early
A writer in the Westminster Review, somewhat fond of
paradox, has put forward what will strike most of his
readers as being a very fanciful proposal for improving the
conditions under which nurses can be trained for theii' work.
According to his view nursing is “ a privileged profession,
since a large proportion of those who annually seek admission
to the ranks of probationers are refused for the reason that
the hospitals to which they apply have fewer vacancies
than applications. His assertion is that, on the one hand,
there is an uusatisliod demand for trained nur.ses, and, on
the other hand, a large supply of untrained material is offered
attliedoors of the training institutions; but that the facilities
which these latter afford are insufficient to convert the raw
material into the linished product in quantity etpial to the
demand for it. There is, no <loubb, some ground for both
Digitized by
Google
98 Ths Lancet,]
DEATHS UNDER CHLOROFORM.
tJAK. 10, 1801.
the propositions on which this statement mainly rests—
that is to say, the snpply of volunteers is at the present
moment ample, and the demand for trained nurses is brisk ;
hnt we greatly doubt whether either of these facts is
capable of wearing precisely the aspect which is necessary
for the purpose to which the writer would apply them.
He proposes to organise the nursing services of our
hospitals upon the footing of medical schools, and thinks
that if this were done the women who have under
the existing arrangement been turned from the hospital
doors as superfluous would return as paying probationers,
and find room in that capacity where, when they offered
themselves as stipendiaries, they were crowded out.
Stated in this bare form, the proposal does not appear
promising, and we do not find much to recommend it, even
in the arguments put forward in the pages of the IVest-
minster Jicvlew. Indeed, when carefully considered, the
contention of its advocate turns rather to its disadvantage
than otherwise. The argument on which he chiefly relies
is that since the students for other professions, and notably
for the medical profession, are trained at their own expense
in self-supporting schools, “ if ‘ nursing ’ is really worthy of
the name * profession,’there can be nothing very harsh or
unreasonable in making its members conform to the general
customs and methods adopted by the other professions.”
A very striking illustration this of the tyranny of mere
words, for the only thing which gives to this sentence even
the semblance of argument is the fact that nursing is
styled a “profession.” The term is strictly appropriate,
hut that is only because it is a term of large significance
and comprehends many widely different vocations. To
say generally that “other professions” than nursing
adopt the academic mode of training is not only
incorrect hut wildly bo. In what are known as the
liberal professions it is so, but it is by no means the case
with the minor professicns as a whole. Accountants,
for example, form a large and influential profession,
hut they receive their professional training not in self-
supporting schools, hut in offices as stipendiary clerks.
Mutatis mutandis the same thing might be said of the non¬
commissioned officers of the army and navy who are trained
hy service in the ranks. In fact every craft must adopt
the form of apprenticeship which is beat adapted to the
circumstances in which it has to be carried on. Bearing
this in mind anyone would come to the conclusion, we
think, that the probationer system is the only practicable
way of training nurses. Their hours of study cannot he
arranged to meet the convenience of the student nor are their
studies for the most part of the kind that can be pursued in
the class-room and the theatre. On the contrary, they must
learn their craft hy practising it, and it would be a height
of unreason if anyone should propose to assimilate the
mode of conducting a nurse’s studies to that which has
proved eminently successful with medical students.
A profound difference at this point implies a difference all
along the line. It is not reasonable to expect that the
routine work of a nursing department can be done by
amateurs ; and certainly such attempts as have from time
to time been made to effect such an arrangement have
not worked out so as to encourage their repetition. Even
if women were forthcoming who could and would devote
their time to this occupation free of charge to the
institutions which they served, the arrangement would
be an inequitable one. But what reason is there to
suppose that it is even practicable ? The writer argues,
that because 1650 women applied last year for 160
vacancies in one of the London hospitals, the vacancies
having occurred in a staff of salaried probationers, there¬
fore plenty of women would be forthcoming to provide
a staff of paying volunteers. The inference seems to
us inverted. All analogy goes to show that the 1660
women who applied for salaried poets would not have
volunteered for uuremunerated service, and we should have-
thought that so far as the reviewer’s figures had any beai'*
ing at all upon his proposal they tended to prove it imprac¬
ticable. From our point of view this is the one merit in a
scheme which, if practicable, would be very likely to be
tried, and if tried could hardly fail of doing mischief.
^nnotalions.
•' Ne quid nimls."
DEATHS UNDER CHLOROFORM. .
In recording more deaths from this ansesthetic we must'
repeat what we have before urged: that more systematic
accounts of such occurrences should be given. The lay
press, to which we owe most of our information, cannot,
for obvious reasons, be expected to give scientific state¬
ments as to such fatalities. Coroners are not always,
unfortnnately, possessed of the special medico-legal know¬
ledge requisite for putting the necessary questions, and.
it is neither likely nor indeed desirable that reporters for
the lay press should be entrusted with systematic state¬
ments concerning the facts of the case. It seems to ua
most important that in every instance cases of death
occurring under anassthetics should be reported in the
medical journals, and that there should be stated
(1) The standing and special experience of the chioro-
furmist, the amount of the anicsthetic given, the method
adopted, the time required to eli'ect aniusthesia, the amount
of struggling ; whether hearty or respiration failed first;
some particulars as to the patient’s previous history,
whether, for example, he was addicted to habits of intem¬
perance 5 whether he suffered from any general disease—
eg., such as causes lardaceous change, syphilis, tuber¬
culosis ; whether evidence of cardiac or arterial degenera¬
tion existed. Under the head of “ post-mortem appear¬
ances ” it seems to us far more important to have lucid
statements as to whether the signs of death from-
asphyxia or from primary cardiac syncope were perceptible,
than whether, for example, cardiac valvular disease was-
met with: while renal and arterial disease, fatty and
atheromatous changes, should in every case be noted. Of
the deaths recently reported it will nob be necessary to
detail all. St. Mary’s Hospital lost a patient named
Amos Wilkins whose finger was to he amputated. The-
anrcsthetic employed was stated to be a mixture of ether
and chloroform, and was given by one of the resident
medical officers; death occurred while the operation was
proceeding. Further, neither the method employed nor the-
precise cause of death is given, bub we gather from the
verdict, “ Death from syncope,” that it was clue to heart
failure. Another death is noticed which occurred at the
Wolverhampton General Hospital. The patient, a healthy
lad aged nineteen, was placed under chloroform preliminary
Digitized by i^ooQle
THE LANCET,]
THE KOCH LIQUID IN SWITZERLAND.
[Jan. 10,1891. 99
to an operation for removal of necrosed bone from liis leg.
The patient appears from the evidence at the inquest to
have entertained a dread of the anccsthetic, and to have
been permitted to select chloroform in place of the ether
■with which presumably the anmsthesia was being com-
Tiienced. Dr. McMunn, who made the necropsy, suggested
struggling may have occurred, the strain of which might
have prejudicially affected the heart. Anyway, after anfcs-
thesia was produced, and as the operation was being com¬
menced, the patient became pallid and the heart’s action
could not be felt. Prompt measures succeeded so far that
slight cardiac and respiratory restoration occurred, only to
be completely stopped after three or four minutes, and this
in spite of forty minutes’ artificial respiration. After a
careful post-mortem examination Dr. McMunn stated that
in his opinion death had resulted from syncope pro¬
duced by the action of chloroform vapour upon the
heart. The Guest Hospital, Dudley, was the scene
of a fatal chloroform case. The patient, aged forty-six,
was to have an operation performed on his arm. The
anassthesia-, it was stated, was produced in seven minutes,
•one drachm of chloroform being used. The operation was
then commenced, but in two minutes had to be stopped, as
the heart’s action and respiration were found to liave
ceased. The breathing, it is mentioned, became ster¬
torous ; bub what was the cause of this, whether mechanical
•or whether due to an accumulation of chloroform in the cir¬
culation, is not explained. Dr. Higgs, writing to a local
paper, expressly denies that an over-dose of chloroform was
given, or that any reflection could be cast upon the ehloro-
formist. The post-mortem examination gave no evidence
of organic disease. _
METHYLENE BLUE AS AN ANODYNE.
It seems not improbable that a “cellular” theory of
therapeutics may arise which will certainly open new fields
for investigation. The reseamhes of Professor Ehrlich
into the action of methylene blue as a staining reagent for
‘the central nervous system are well known. He has proved
■that this stain has a peculiarly selective action on the axis
cylinders of motor and sensory nerves. Together with
Dr. Lippmann, Professor Ehrlich has been led by his pre¬
vious investigations to try experiments with methylene
blue on living animals, with the result that these observers
have found that this dye possesses analgesic properties of
some considerable power. Their results are published
in the Deutsche, Mcdicinische Wochenschrift, No. 23, 1890.
For their researches they used a preparation of methy¬
lene blue which was chemically pure and quite free
from chloride of zinc. A 2 per cent, solution of the
drug 'was taken, and injected hypodermically in doses
ranging not higher than 0'05cc. It was also given in
gelatine capsules, containing a finely powdered preparation
in doses of 0‘1 to 0‘5 grm., the maximum daily dose being
Igrm. Given in this way it produced better results than
when administered hypodermically. The injections were
painless and produced no local results beyond some slight
swelling at the point of puncture. No bad symptoms were
produced. The appetite, digestion, pulse, and general
strength underwent no change; vomiting occurred in two
•cases only. The methylene blue was absorbed very quickly;
A quarter of an hour after the smallest doses (subcutaneous
■or by mouth) were administered the urine became a bright
green, after two hours dark green, and after four hours dark
blue. The urine at no time contained any albumen or other
pathological constituent. In the saliva a bluish tinge was
noticed, and the same appeared also in the fieoea; there
were no changes of colour in the mucous membranes or
conjunctiva). In certain forms of painful local affections
the therapeutical results were remarkable ; the drug acted
as an anodyne in all neurotic processes and rheumatic
affections of the rauscles, joints, and tendons. The action
of the drug commenced about two hours after it had been
administered. Its effects were gradual, but after some time
pain was greatly lessened or entirely abolished. Its action
was purely analgesic, having no effect on the actual inflam¬
matory processes. The drug did not seem to lose its effect by
repeated doses—that is to say, the patient did not become
intolerant to it. It had no antipyretic properties ; it
was found useful in angiopastic migraine. As regards a
comparison between it and other anodynes, no definite
conclusions have yet been arrived at. Compared with
antipyrin it has the advantages of smaller doses, painless
injections, and cheapness. Owing to the time which
elapses before its action manifests itself it might probably
be used with advantage in combination with other drugs—
as, for instance, witlr morphia—so as to prolong the time of
freedom from pain. _
THE KOCH LIQUID IN SWITZERLAND.
At Zurich on the 22nd ult., at a meeting of the Medico-
Chirurgical Association, Professor Eicbhorst read a paper
on his experiences of “Kochin,” which he injected in
twenty-five cases occurring in the medical wards. No
appreciable result followed these injections, and the pro¬
fessor, after a full account of the circumstances in which
each injection was indicated and practised, declined to
commit himself to any definite or final opinion as to the
remedy. He was followed by Professor Kronlein, who had
injected the “Kochin” in upwards of forty-five surgical
cases. According to him, the results were favourable,
and the local reaction answered expectations to the
full, placing the diagnostic value of “Kochin” in the
clearest light so far as surgery is concerned. Professor
Ktbnlein did not aim at any specilic cure by his injections,
but yet in eight of the patients the improvement was
incontestibly marked. On the whole, the profession in
Switzerland seems to share the opinion just pronounced on
Koch’s treatment by the well-kno-wn bacteriologist. Dr.
Prior, who has injected the liquid in more than one hundred
coses : “The remedy, in the patients for whom it is indi¬
cated, lias its effect in every seat of the special malady, and
contributes an unmistakable diagnostic teat in tuberculosis.
Its effect in all such cases is a healing one, whether the
malady be internal or external; but it is only in the com¬
mencing stage that a complete cure by it can be hoped for.
In cerebral tuberculosis the swelling it induces causes
death.”
THE EFFECT OF AGE ON THE ABSORPTION
OF DRUGS.
Du. Yat-suty, having been struck by a remark of Pro¬
fessor Manassem on the influence of age on the rapidity
of absorption of drugs, selected this subject for his M.D.
tlieais, which has just been published. His experiments
were conducted in the Zhitomir Municipal Hospital, of
which he is medical officer, and were made on healthy male
subjects of from eight to over eighty years of age, tlie
drugs experimented with being iodide of potassium and
salicylate of soda. The dose was made to depend upon tlie
body weight, a grain being allowed for each 10 kilo¬
grammes. Thus a boy weighing 25 kilogrammes was
given 2^ grains of iodide of potassium or salicylate of soda
as the case might be, a man weighing 55 kilogrammes being
given a 5^ grain dose. The drug was administered in a
gelatine capsule, and the urine examined every three
minutes in the case of both salts. With tlie iodide the
saliva was also examined every two minutes. This was not
done in the case of the salicylate, as in no case was any
evidence of salicylic acid detected in the saliva. Dr.
Digitized by lOO^Ic
100 Thb Lancet,]
THE SUSPENSION TREATMENT IN WARSAW.
[Jan. 10,1891.
Yatsaty gives a tabiilar view of the experiments, the
general result being that the younger the subject the more
rapidly had absorption, as evidenced by testing the secre¬
tions, occurred. Thus a boy of nine, weighing 25 kilo-
graiimes, taking a dose of 2^ grains of iodide of potassium
generally gave the reaction in the urine in nineteen minutes;
a man of thirty-six, weighing 66 kilogrammes, and taking a
dose of 6^ grains, showed no reaction in the urine until
thirty-one minutes had elapsed; and a man of seventy-six, of
about the same weight, and taking the same dose, showed
no reaction in the urine for thirty-seven minutes. Salicylate
was absorbed in hoys and young men in about fifteen
minutes, while in middle-aged men it required about twenty
minutes, and in old men about twenty-five minutes. There
were some exceptional cases. Thus, some lads of eighteen
showed no iodide in the urine until thirty-one minutes; one
man of seventy-seven showed it in twenty-eight minutes;
so that, although the average rapidity of absorption dis¬
tinctly diminishes as age advances, it is not possible to say
with certainty that a particular individual will absorb one
of the drugs mentioned more rapidly than another who is a
great deal older. _
THE SUSPENSION TREATMENT IN WARSAW.
Dr. Avrokratoff, who has tried the suspension treat¬
ment on a number of cases of various descriptions in the
Warsaw Military Hospital, is by no means inclined to en¬
dorse the opinions of those enthusiasts who would have us
believe that by this method serious organic disease of the
spinal cord, which has hitherto been considered as beyond
the reach of treatment, has become curable ; bub he is not,
on the other hand, desirous of denying any usefulness to the
method. Of six cases of locomotor ataxy five were in no
way improved ; but the sixth presented a very marked im¬
provement after suspension had been practised thirty-five
times. In contrast to this it was found that functional
disorder was affected much more commonly. Thus,
all the patients, six in number, who were suffering from
neurasthenia present a decided improvement both in their
mental and in their general condition after ten sirs-
pensions. He is disposed to attribute the good effects of
enspensioD, when they occur, largely to the psychological
influence exerted on the patient, a dynamic change being
produced on the nervous system. Besides which, the novelty
of the process and the exaggerated reports that patients
are sure to have heard about the wonderful efficacy of the
new method in cases that have hitherto been considered
incurable cannot be without effect on the patients who
furnish subjects for the suspension treatment. A real
physical effect is probably produced on the respiration
and circulation ; bub Dr. Avrokratoff does not think that
there is as yet evidence to warrant us in saying that it
extends bo the spinal cord._
MULTIPLE NEURITIS AFTER INFLUENZA.
The sequela! of influenza which have been observed and
described are numerous and varied, and a fresh contribution
is made to those by H. Westphol in a recent number of the
Petersburger Med. Wochensv.hr. The author describes two
cases of typical multiple neuritis, of which the first sym¬
ptoms were manifested in one ease .seven days after the
commencement of the illness, and in the other, eight days.
The first pabienc was a man of twenty-nine, who had first a
feeling of coldness and numbness in the fingers and toes,
and subsequently weakness of the limbs with difficulty of
swallowing, abolition of the knee-jerk and of the triceps-
jerk, retention of the abdominal, the cremasteric, and
plantar reflexes. Tliere was also slight paralysis of the
right side of the face. Under treatment with valerianate of
zinc, bathing, and faradisation, the symptoms gradually
disappeared, hut the knee • jerk remained absent for
several months. The second case was also that of
a young man. The symptoms in this patient were
more severe, and were ushered in by an attack of
urticaria. In the course of a few weeks there were
general muscular weakness, paralysis of one side of the
face and paresis of the other, dilliculty in swallowing, and
abolition of the kaee-jork. There was also wasting of
muscles, both in the upper and lower extremities, and the
reaction of degeneration was present, preceded, however,
by an increased electrical irritability. There was also
ain on pressure over affected nerve-trunks and muscles.
There was no impairment of sensibility, and there was
rapid improvement after a few weeks, accompanied by signs
of considerable vaso-motor disturbance.
GROWING KNOWLEDGE.
Tub editor of the Educational Times has been insisting
in a recent article upon the importance, as he pubs it, of
“ growing knowledge ” in the minds of children. The lesaon
is one which teachers as a body are, perhaps, slow to learn,
but it has certainly obtained a considerable amount of re¬
cognition in recent times. Bab, that notwithstanding, the
parable of the Educational Times, is always seasonable.
It is there pointed out that knowledge must be apprehended,
appropriated, and assimilated by the luind very much as
the elements of vegetable tissue are apprehended, appro¬
priated, and assimilated by a plant. There is a sense in
which every student may adopt the aphorism maliciously
attributed to the “ Master of Baliol College,” that
" What I don’t know isn’t knowledge.”
The binomial theory is useful information for anybody,
and indispensable knowledge to the mathematician, but to
such as have but little mathematical faculty it is informa¬
tion, and nothing more. So with Greek syntax or Latin
composition. To the classic they are elemeabs of know¬
ledge, to the pedant mere shreds of information which never
germinate in his mind, and are incapable of ever becoming
fused into a coherent habit or scheme of thought. In the
acquisition of such indigestible materials there is much
pain and very little profit, and it cannot, therefore, be too
often or too forcibly brought bo the minds of teachers that
their true function is not to fill a vacant mind, but to pre¬
side over the birth and development of nascent faculties.
If the faculties are supplied with suitable pabulum they
will spontaneously exercise th6mselve.s upon it. The wise
teacher is he who happily discerns what faculties are
dominant in his pupil, and what treatment is best adapted
to stimulate and develop them. This view of a teacher’s
work receives, we believe, a much more general and effective
recognition al the present than at any former period, and
we are glad to find it from time to time put prominently
forward in the accredited organs of the teaching profession.
TYPHOID IN TUSCANY.
An Italian correspondent writes under date the 5bh inst.
“Typhoid, closely resembling that which had prevailed in
so severe a form during the last four months in Pisa, began
to be reported in Florence about the 15th ult., and tlie
municipal authorities lost no time in minimising the
conditions of its spread. Every case was vigilantly noted
and announced, with the result that from the 15th ult. to
the 2Dd inst, in a population of about 200,000, resident and
migratory, 764 cases in all were reported, with a mortality
of 7 per cent. Within the last forty-eight hours there has
been a steariy decrease in the numbers attacked, and of
these, since the first appearance of the malady, few, if
any, have occurred among the English-speaking colony.
Certainly, no death from typhoid in the latter section of
Dir ' :ed by CjOO^IC
Thb Lancet,]
TREATMENT OF ERYSIPELAS.
[Jan. 10,1891. IQl
the Florentine population has yet been announced. On
the whole the sanitary condition of Florence has been
better this year than last, and better last year
again than during its predecessor. The alarm sounded
since the 15th ult. has had the salutary effect of
putting the more enlightened part of the population,
including the foreign community, on its guard, and,
the water-supply having been suspected, the precaution of
boiling it (and boiling it tlioroughly) before use has been
taken in private houses, as well as in the numerous hotels
and pensions. To such and similar measures must be
ascribed the fact that at no time since Dec. 15tb has the
malady attained anything like the proportions it assumed
in Fisa; and, indeed, as already stated, the number
of cases within the last twenty-four hours has been
less than during the same period immediately pre¬
ceding. The fact that other communes in Tuscany,
and other towns in those communes, have been visited
by typhoid as well as Florence, seems to dispose of
the supposition that the water-supply of the latter city
is exceptionally tainted. No doubt it is not in every
quarter above suspicion, and there is far too extensive a
use of well-water instead of the ‘acqua potabile.’ Even
this latter has been said to have become contaminated by
sewage, and the municipality is at present investigating
whether and to what extent the report is well founded.
But the travelling public need be under no apprehension of
visiting Florence, the local sanitary authorities having taken
every precaution to minimise the conditions favourable to
typhoid, and especially to suspend the supply of water from
smy source which is not above siispicion.”
SIR WALTER FOSTER.
Sir Walthr Foster has resigned the physiciapship of
the General Hospital at Birmingham, after twenty-two
years’ service. He previously had been physician for eight
years to the Queen’s Hospital. The occasion called forth
an illuminated address from the committee containing
every expression of respect and gratitude, as well as hope
for the continuance of Sir Walter’s “ honourable and useful
career.” Sir Walter, on receiving the deputation to present
the address, assured them it was painful to him to leave the
duties of the hospital, but that he did so to give other men
the opportunities and advantages he had enjoyed. The
motive is a good one, and tl|e action worthy of imitation.
Sir Walter has many other outlets for an energy that is
still unabated. He is lured to other than professional fields
of labour. But he is a good physician, and we still venture
to hope that in the study and practice of medicine he will
find recreation and even rest for himself, as well as time to
promote the interests and the eificiency of the profession.
MUSCULAR ATROPHY AND ARTHRITIS.
The existence of muscular atrophy in connexion with
joint changes is familiar to all, and the explanation of its
occurrence which is usually offered is that it is dependent
in the first place on the suspension of physiological activity
necessitated by the diseased condition, and in the se<;ond
place on neuritis following the affection of the joint. The
close interconnexion of nerves and joints is manifested
under various conditions—in none more grnpiiically than in
the class of cases to which Weir-Mifcchell has drawn atten¬
tion, those, namely, in wiiich joint changes follow on the
direct injury to nerves. Raymond (^ItevuG dc Mi'd , No. 5,
1890) has recently made experimental researches with aview
to elucidating the pathology of the condition. He calls atten¬
tion to the conditions usually found after injury to a joint—
VIZ., functional weakness of the limb, increased superficial
and deep reflexes, muscular twitchings.araised irritability to
faradaic stimulation, disturbances of sensibility, and, most (
important of all, muscular atrophy, related especially to
changes in the interfibrillary substance of muscle. He
found experimentally that this atrophy did not take place-
when the posterior roots of the cord were divided or de¬
stroyed. He found also that the physiological defe^ in the
lateral columns in newly born animals and division of one-
of those tracts in full-grown animals favoured the progress
of atrophy in the limb a joint of which had been injured g
while hemieection of the cord in a case in which a sym¬
metrical joint injury was infiioted favoured atrophy on the-
side on which the bemisection had been performed. No
anatomical change was discovered in the anterior horns of
the cord or in peripheral nerves ; so that the results of th&
researches of this author seem to point to a reflex trophic con¬
dition as the cause of the atrophy in this class of cases. It
remains to be seen whether future experiment and clinicall
observation will confirm this view.
TREATMENT OF ERYSIPELAS.
An elaborate research, clinical and bacteriological, has-
recently been published by Professor Nussbaum’s assistant^
Dr. Julius Fessler, on the treatment of erysipelas by
ichtbyol, a plan which has been for some years extensively
adopted in Munich. From laboratory experiments it was
evident that, though ichthyol has only a slight effect in pre¬
venting the development of staphylococci, it has a very
potent deterrent influence on the multiplication of strepto¬
cocci, and it is well known that it is the latter kind of
bacteria that are the cause of erysipelas. The method
of treatment consists mainly of rubbing a strong ichthyol
ointment energetically, and for ten minutes at a
time, into the affected surface and its neighbourhood?
ichtiiyol in the form of pills may also be given internally.
Where there is a wound it must be very carefully disin¬
fected, and an antiseptic dressing applied. The results of
this treatment as compared with ordinary methods are
embodied in several instructive tables. From these it- ,
appears that while the mean duration of the cases treated
by other methods from 1880 to 1888 was about twelve days,
in no single year falling below nine days, the cases treated
by ichthyol from 1886 to 1388 presented a mean duration of
under seven days, while in the first half of 1889 it fell to 5'(>
days. _
EARLY MARRIAGES IN INDIA.
The Government of India has decided to legislate on the-
subject of the age of consent by a sijuple amendment to the
penal code, substituting the age of twelve for that of ten.
It has been wisely determined to couple the announcement-
with the assurance that no interference with social or
religious customs affecting early marriage is contemplated^
a course which it may be hoped will satisfy those who saw
in the suggested reform a covert attack on ancient customs.
POISONING BY BROMIDE OF ETHYLENE.
A CURIOUS, but unfortunately fatal, mistake of a chemist-
has occurred in Poland, in consequence of an order for
bromide of ethyl, which was required by a surgeon for use-
as an anaesthetic. This substance has been, as is pretty
well known, a good deal used by dentists and surgeons in-
Switzerland and Germany instead of ether or chloroform,
especially for small operations, and it has generally proved
fairly satisfactory. la the ease in point the operation pro¬
posed was external urethrotomy in a strong young man, for
whom bromide of ethyl seemed to the operator to be
peculiarly suitable. The chemist, however, sent a bottle of
bromide of ethylene, a very different substance, but thef
mistake was not recognised, and so the patient was
made to inhale some ten drachms of it. No anmsthesia.
Din-'-zed by Google
102 Thb Lancet,] INSUFFICIENT RECORDS OF THE OUT-PATIENT DEPARTMENT. [Jan. 10,1891.
'was produced. At night uncontrollable vomiting came
on, and there 'was suppression of urine. The next day
■the vomiting continued, in spite of every remedy that
could be thought of until the patient died. No urine was
passed, and the bladder was quite empty. At the post¬
mortem examination bypera:mia of the meninges of the
brain and of the lungs, spleen, and kidneys was found.
The liver was much enlarged, and was of a dirty yellow
colour, the cells were affected by granular degeneration,
•and the viscera smelt strongly of the garlic-like odour of
bromide of ethylene. The puzzle is, how a pharmacist
came to have such a substance as bromide of ethylene.
Had the name suggested by Merck—cether bromatus—been
employed, there could not well have been any mistake;
but ccthyl might perhaps, if badly written, be confused with
yxihylen. _
THE INSUFFICIENT RECORDS OF THE OUT¬
PATIENT DEPARTMENT.
An inquest has been necessitated at Hanley by Mr. G. S.
Hatton, assistant surgeon of the North Staffordshire Infir¬
mary, refusing to give a certificate of the death of a child on
Dec. 24th, which he believed he had not seen since Nov. 18 bb,
'though the mother gave evidence that she had taken the
child to the Infirmary on Dec. 16bh, and seen the junior
iresident surgeon. The coroner complained of the effect of
the refusal necessitating an inquest and delaying the funeral
A week. The jury called the attention of the Infirmary
'Committee to the insullicient records of the visitj of out¬
patients, and as to their identity, and they considered that in
the case of death there should be some record of the disease
when last seen by the surgeon, and also that the latter
should give a certificate when applied to. This is a most
doubtful recommendation. The jury would have done
better to condemn the out-patient system as inapplicable to
serious cases with fatal tendencies, and calculated to cover
aeglecb of all sorbs. _
DISEASED PRIZE CATTLE.
The annual exhibition of prize cattle, which is now held
at the Agricultural Hall, would seem to have reached per¬
fection, in the sense of demonstrating the best methods of
breeding and feeding cattle, sheep, and pigs to the maximum
of fatness, at the earliest age for obesity. The mountains
of fat recently exhibited were, as Dominie Sampson would
have said, “prodigious!” But the production of quality,
coo less than quantity, in a given time, for the speedy return
of capital to the owners, should be the true aim of a system
which has for its object tlie rearing of animals of the highest
•nutritive value as human food. For this purpose the Smith-
field Cattle Club was instituted in the year 17!)8—nearly
100 years ago. It will be in the recollection of our senior
readers that in 1857, or after more than fifty years’ trial of
the system which had been pursued, the question was first
subjected to the test of scientific investigation by Mr. Gant,
whose post-mortem examination of the animals then ex¬
hibited disclosed the diseased state of nearly all the vital
organs in the specimens which had been reared in the
school of over-feeding, had graduated, and taken the liighest
honours. In them the heart especially had undergone
either true fatty degeneration or excessive fatty infil-
«tration, and the circulation of the blood, therefore, was so
feeble as would soon have caused the death of the prize
•beast—Devon, Hereford, or Shorthorn,—whose vast bulk
delighted the eyes of its bucolic admirers, and attracted
the poking curiosity of the public. Sheep were even more
>diseased than their fellow-sufferers, and in a few days
replenished the wasteful grease-pot. Pigs had borne the
experiment of over-fattening better than either their bovine
or ovine friends, but they lay dying of asphyxia. The
results of Mr. Gant’s observations were republished in
nearly all the London and provincial newspapers, and
The Lancet prominently drew attention to the sub¬
ject. Subsequently these investigations appeared in the
form of a “New Inquiry” by the author, fully illus¬
trated by coloured lithographs and woodcuts of micro¬
scopic drawibgs (John Churchill). For some years after¬
wards fat diminished, and flesh came on, with of course
a due proportion of the former texture, as showing
the character of tho breed. But the recent show was
probably more notable for tho pathology tha,n the physio¬
logy of its exhibits, and an after-death examination would
have revealed some uupalatable dietetic truths. The monster
beast of all, who carried the palm, was too weak to stand,
and having been removed from the scone of its temporary
triumph, lay down iu piteous appeal to future breeders,
feeders, judges, and exhibitors of cattle.
SANITATION IN AUSTRIA.
The provincial sanitai'y authorities in Austria would
seem, judging from recent revelations in the Reichstrath, to
be even more remiss than the authorities in most parts of
this country in carrying out their duties. With us the
authorities in health resorts, generally at least, make some
show of zeal regarding the sanitation of their di.stricbs, but
some of the more important health resorts in Austria, such
as the neighbourhood of Salzburg and Styria, are shown by
statistics to be anything but healthy. It is said that more
than 100,000 persons die in a year in Austi-ia from prevent¬
able diseases. It is proposed by the Government to appoint
inspecting ollicera to visit the provinces and urge or compel
the local sanitary bodies to exert themselves.
EARLY SPONTANEOUS RUPTURE OF THE
UTERUS,
A CASE of rupture of the uterus is reported from Mexico
by Dr. Eduardo F. Phi in the CrCnica M^dico-Quirurgicu,
which is in several respects almost unique. The patient
was a married woman of twenty-one years of age, who had
had only one previous pregnancy, which terminated satis¬
factorily five years before, since which time she had had no
illness. A medical man was summoned hastily, as she had
been suffering intense pain, and had suddenly become cold
and collapsed. When he arrived she was dead. The official
post-mortem examination was entrusted to Dr. Plu, who,
after noting the absence of any marks of violence, opened
the abdominal cavity, and found a quantity of blood
and coagula, also tho amnion containing a four months’
fmtus, with umbilical cord and placenta. This had escaped
by an irregular rent across the fundus of the uterus three
inches in length. There were coagula in the cavity of the
uterus, but no pus or evidence of inflammation in the
pelvic organs. The uterine wall was found to be ex¬
tremely thin in the neighbourhood of the rupture—under
two millimetres,—though in other parts it was as much
as eighteen millimetres in thickness. A microscopical
examination, which was made by Dr. San Martin, showed
that in the region of the rupture the muscular coat was
practically absent, being represented by a very few
attenuated fibres ; the mucous coat, too, was absent, being
replaced by fibrous tissue without glands and with scarcely
any vessels. Altogether tho appearance was that of a
cicatrix, but no history of any injury or disease could be
obtained. The placenta was perfectly normal. Charpentier
mentions eight cases of uterine rupture at or before the end
of the fourth month of pregnancy, and Dr. Phi mentions
two cases cited by Burns in addition; these ten being all
that be could find in literature. In most of these cases the
patient was much older and bad bad difficult previous
Digitized by 'vjOO^Ic
Thb Lanobt,]
HOSPITAL REFORM AND PROVIDENT DISPENSARIES.
[Jan. 10, 1891. lOS’
labours, aod, again, the seat of the rupture was much less
commonly the fundus than the lower segment. In the
present case, being over the insertion of the placenta, the
hiomorrhage was great, and so led to the immediate fatal
termination, whereas several of the other cases died later
from peritonitis, and in one, that recorded by Dr. Drake,
the totus ultimately made its way out through an abscess
in the umbilical region. _
ALCOHOL AND DIGESTION.
Fkom experiments made on himself by Dr. Eichen-
berg some further knowledge of the effect of alcohol on
digestion is obtained which contrasts strongly with the
teetotal lecturer’s experiment showing how digestion in a
glass vessel is retarded by alcohol. Dr. Eichenberg found
that a small dose of strong alcohol—e.g., brandy—shortens
the time thatfood in general, whether animal orvegetableor a
mixture, remains in the stomach by more than half an hour.
A similar but not quite so marked an effect is produced by
a dose of dilute hydrochloric acid or mustard. Pepper and
condurango diminish the time the food remains in the
stomach by about a quarter of an hour. Boer and an
infusion of rhubarb had no effect.
COMPRESSION MYELITIS.
In a aeries of experiments on dogs Rosenboch and
Ascherbach (Virchow’s ./IrcA, cxxii., Heft 1) observed the
changes in the spinal cord subsequent to compression by
small silver balls and rods. The symptoms developed were
weakness of both extremities, greater on the side of opera¬
tion, spastic or ataxic gait, increased rellexes, and delayed
sensibility to pain in both extremities. The operations
were carried out on the lower dorsal and upper lumbar
divisions of the cord ; accordingly the extremities affected
were the hind legs. Pathological changes were confined
to the point of compression or its immediate vicinity,
except in cases in which the animal lived more than
a month, in which case ascending and descending de¬
generations were found to be present. The cases
roughly divided themselves into two classes. In one the
chief changes were in the white matter, consisting of
destruction and disappearance of the axis cylinders chiefly,
the grey matter showing infiltration of its network and
degenerative changes in the large cells. In the second
class there were few, if any, changes in the white matter,
hut in the grey matter there was an exudation, and around
it cracks and holes, apparently the result of the absorption
of the network. Alteration of the neuroglia and of the
connective tissue elements was observed apparently as a
secondary effect of irritation by the products of the destruc¬
tive process. _
HOSPITAL REFORM AND PROVIDENT
DISPENSARIES.
The evidence before the Birmingham Hospital Reform
Committee was closed early in December. One of the last
witnesses examined was the Rev, Joseph Wood,whoeulogi8ed
the Leicester Provident Dispensary. In Leicester only one
in twelve of the population became out-patients, whereas
in Birmingham one in three did so. There were ;15,000
members in the Provident Dispensary of Leicester, and
only fifteen were reported unfit by the medical men. There
were twenty medical men, and the average amount re¬
ceived by them for this enormous quantity of work was
£150 each. We regret that Mr. Wood did not express any
dissatisfaction with the inadequate and paltry subscription
of the members—per week for the father and \d. more for
the mother and all children under fonrtoen. The reverend
gentleman advocated the withdrawal of the whole of the
Hospital Saturday Fund of Birmingham from the hospitals
and the establishment with it of provident dispensaries, om
the ground that working men feel that they had a claim
to medical relief. This is a bold proposal, and one nob-
very complimentary to working men. The Hospital Satur¬
day movement was distinctly meant to give working merk
the opportunity of contributing to hospitals. Even if their-
out patient department were completely abolished, as Mr.
Wood advises, hospitals would still be entitled to the-
liberal subscriptions of the working classes, whd^rincipally
benefit by them. We shall refuse to believe that any great
number of working men take the mercenary view that in a
contribution to the Hospital Saturday Fund they are-
paying for ordinary medical attendance. Mr. G. Franklim
of Leicester said there were many members of the Dis¬
pensary who had no right to be such on social grounds.
He thought a larger weekly payment could be made, and'
that \\d. could be afforded as well as 1(^.
ADVICE TO HUNTING MEN.
During the past five weeks the continued frost has-
rendered hunting Impossible, to the intense disappointment
of all men given to uhe chase of the fox, stag, or hare. The-
owners of beagles may have had a run in the snow more for
exercise than for sport; but hounds, horses, and men must,
have sadly lost condition and put on useless flesh in the-
place of muscle, for there is no exercise that will give the.
same condition as actual hunting. Besides, many men past-
middle life are able to bear long-continued exercise in the
saddle without fatigue who could not possibly undergoi
‘-other exercises which would place them in the same hard
condition and good health as does actual hunting.
Younger men may skate and undergo other athletic
practices which replace their accustomed horse exerciaep,
but the older man’s heart and respiratory powers, and often'
stiffened joints, exclude him from this advantage. What-
ia he to do ? We fear there is but one alternative for him
when he cannot hunt, and that is to take physic, or, in suit¬
able cases, the occasional use of the Turkish bath. A well--
known titular member of the profession, whose name we need
not mention, after a life-long experience of practice among
hunting men, arrived at this conclusion, and we believe it-
to bo a right one. “ Nimrod,” in his famous book on the
conditioning of hunters, came to the same conclusion in¬
reference to the horse; indeed, he goes further, and statea
that the best condition can only be obtained by giving the
animal an alterative dose of medicine every month or
six weeks to carry off the humours which are apt to result-
from the high feeding necessary to condition. The-
.sarne conclusions may be arrived at in the case of the
rider. The old practice of giving a blue pill and black
draught was not wrong in principle, though it was probably
too indiscriminately resorted to. Improved methods and’
more refined medicine have naturally come into use with
the advance of our knowledge of drugs ; but the principle®
to be kept in mind remained the same. The liver should
he acted on, the intestines stimulated, and the accumulated
humours purged from the blood. A combination of hepatic-
stimulants and saline aperients', proportioned in activity to
the requirements of the individual, taken once or even
tivice a week, will be found to check grossness, and fit a man.
to resume the saddle—when weather permits—with lessened
inconvenience and an alacrity for the sport which he would
not otherwise experience._
BOARD SCHOOLS AND FILTERS.
Hostile critics of School-Board expenditure could hardly
be expected to pass over in silence the statement of sur¬
charges lately brought forward in the half-yearly audit
of the Tottenham school accounts. These amounted-
Digi zed by Google
104 The Lancet,]
THE REPEiLL OF THE MUZZLING ORDER.
CJan. 10,1891.
to the sum of £17 18s. 6d. for various scientific instru¬
ments, such os a cyclostole, hectograph, microscope, &c.,
besides £53 expended on filters. The payments, though
supported by several ratepayers, and, as far as related to
the purchase of filters, by a medical member, were
vigorously opposed by tlie official auditor. The dispute
«s regards instruments, which must be considered as
luxuries of education, may best be left in the hands of
those immediately interested. A more vital significance
attaches to the arrangements for ensuring a pure-water
•supply. The necessity for filtration, however, is a matter
still open to discussion, and this fact was illustrated in the
•case quoted by a considerable divergence of opinion.
Analyses by Dr. Frankland were , stated to have shown
the excellent quality of the Tottenham drinking water.
Assuming that this statement is correct, it is obviously
impossible to maintain the existence of any real neces-
rsity for filtration (though its advantage is no leas
-obvious), provided that due care be observed in regularly
■cleansing any cisterns connected with the water-supply of
the school. The argument that the school children use un-
filtered water in their homes is of little value, since the
hygiene of a public institution can allow no standard but
that of purity. It is for the local authorities, therefore, to
•decide how far Dr. Frankland’s observations are still justified
•and whether they have been modified by any unhealthy
conditions connected with the school itself. The proved
existence of any impurity or seriously qualifying circum¬
stance would necessarily call eitlier for its immediate re¬
moval or for the introduction of a filter which, whatever its
Scind or its cost, must suffice for its intended purpose.
FATAL STOVE FIRES.
The French authorities cannot be blamed for the acci-
•dents which have recently occurred in consequence of the
use of stoves. Early this winter the walls of Paris were
posted with official bills, issued by Government, warning
the population against the danger that might result in the
mse of stoves for warming purposes. Many of these stoves,
if kept in perfect order, are not dangerous; but they get
■out of order, and then give off so large a quantity of oxide
•of carbon that fatal resiiUs ensue. This week three lives
-have been lost in Paris in consequence of tlie use of such
'Stoves- in sleeping apartments. Last year eight seara-
istresses fainted while employed in a workshop in con¬
sequence of the fumes escaping from the stove that
warmed the room. Yet fuel, too dear in London, is so
much dearer in Paris that it is not surprising so many
'Stoves are used. They ensure a more complete combus¬
tion of the fuel, and give much more heat than an open
grate. It is not surprising, therefore, that accidents
have.happened during so severe a winter as the present;
but these calamities point to the necessity of further
practical progress in the science of warming and ventilating.
LONGEVITY IN THE SOCIETY OF FRIENDS.
The 'Society of Friends in the United Kingdom have
■recently issued their annual obituary of raembeva, and the
report includes a table showing the mortality statistics of
the Society during the last three years, which contains
-some figures M’hich are not without interest, although
they cannot be accepted as satisfactory evidence of
'the longevity of members of that Society, if that term
is used in its correct sense—namely, the mean duration
•of life. Tlie report states that the number of mem¬
bers of the Society is about 15,500, and as the deaths
in the three years averaged 256 per annum, the mean
annual death-rate may be calculated to have been IG‘5
per 1000. Bearing in mind the strong evidence that
is supplied by the figures of the high mean age of the mem¬
bers, this mean death-rate may. be accepted as proof that
the health condition of the Society is eminently satisfactory.
It may be noted that 480> or 61 per cent., of the 769 deaths
in the three years were of persons aged upwards of sixty
years, and although this remarkable fact, without informa¬
tion of the proportional age-distribution of the living
members of the Society, gives no clue to the mean dura¬
tion of life among Quakers, it affords conclusive evidence
that the death-rate at all ages of the members is re¬
markably low. Accurate and complete mortality statistics
of the Society of Friends would possess much sta¬
tistical value, and it is to be wished that it might
be found possible another year to supplement the in¬
formation now given concerning the ages of deceased
members, by a statement of the numbers of the members
living in each of the same age-periods. Taken as an
abstract fact it is certainly remarkable that only fifteen
deaths of children aged under five years occurred during
the year 1888-89 among the 15,500 members of the Society
of Friends. From a statistical point of view, however, it
is essential to know whether this is due to the fact that
the rate of mortality among the young children of Quakers
is so abnormally low, or to the more probable fact that the
members of the Society of Friends include a very abnormally
small proportion of young children.
THE REPEAL OF THE MUZZLING ORDER.
Now that the dog-muzzling order has been withdrawn,
opinions respecting the necessity for maintaining this
effectual preventive measure appear to be as much divided
as ever. During the period of nearly two years within
which the use of the muzzle has been compulsory the annual
number of reported cases of hydrophobia among dogs in the
metropolis has fallen from 400 to nil. The last quarter of
1890 was entirely free, but in that preceding there were eight
cases. The fact of immunity during three months is, in our
opinion, hardly sufficient to justify the total discontinuanceof
a well-proved preventive method. It were no excess of pre¬
caution to have allowed another quarter to elapse in order to
provide against the conveyance of the disease by dogs coming
from the provincial districts. It should not be forgotten,
however, that one, if not theprincipal, advantage obtained by
muzzling—namely, the discovery and removal of ownerless
curs, the class of dogs most usually affected by rabies—is
provided for under the new regulation, which abandons the
muzzle only to substitute the labelled collar. Time only
can show whether this change, which is a concession to the
urgent protests of dog owners, will equally suffice for the
intended purpose. Meanwhile, we shall await the issue
with interest and hope, but not without a certain misgiving.
STREET MAN-TRAPS.
The ordinary traffic of the streets is surely associated
with dangers enough without the addition of such as
result from careless mismanagement of the very roadway
itself. Yet these are not wanting. We do nob refer merely
to any risk of the sea-son such as that occasioned by, non-
clearance of snow-laden thoroughfares, but to a cause of mis¬
chief ever latent and even more hazardous—namely, the
trap-door which ought to cover the entrance to the cellarage
of many warehouses, but which is too often left
agape, with no sufficient barrier or voice of warning
to turn the steps of any unwary foot passenger.
Such neglect is highly culpable, even in broad day¬
light, but the degree of blame as well as the possibility
of most serious injury are immensely increased by such
perilous conditions as are added by the twilight of evening
or the too common incident of a London fog. Mere business
caution should remember, if humanity beforgetful, that the
injured wayfarer who may suffer by such neglect has a.
Dic!..^ed by
The Lancet,] DEMONSTRATIONS OF DR. KOCH’S TREATMENT IN LONDON. [Ian. 10,1891. 105
claim to compensatiou for the damage done to him, and
business prudence alone might suggest the wisdom of care¬
fully closing such man-traps whenever they are not under
the actual supervision of e.mploy6s. Almost identical in
character with this form of street danger is that arising
from the half-open coal-cellar plate, which may be occa¬
sionally noticed in front of private dwellings. This is
understood to be kept fastened at all times except during
the actual delivery of coal. It is liable to be opened never¬
theless by heedless domestics as a ready means of obtaining
light in the cellar. Need we remind householders that the
near prospect of a bruised or broken limb which conse¬
quently menaces every casual visitor is not justified by any
assumed necessity for sunlight underground.
Dr. Lorica has been commissioned by the Department
of Public Health at Rome to go to Tuscany, armed with
special powers as “medico provinciale,” to draw up a
report on the sanitary condition of the province. The
typhoid epidemic at Pisa, now transferred to Florence and
its environs, invests Dr. Lorica’s mission with more than
ordinary importance. ___
Wk are asked to state that it is proposed to send to a
convalescent home three of the patients now undergoing-
treatment by Professor Koch’s method in^Dr. Heron’a
wards in the City of London Hospital for Diseases of the-
Chest, Victoria Park, E., and that these patients may be seen
at tlie hospital by medical men on Monday and Tuesday^
between 3.30 and 4 o’clock r.M.
THE LANCET RELIEF FUND.
In consequence of a communication from the Secretary of
the General Post Office, it appears we are not permitted to
publish the “application form” of The Lancet Relief Fund
as a “supplement.” It will therefore be found in our “General
Advertiser” columns. It may, however, be easily removed,
and can be filled up and forwarded to the Hon. Secretary,
Thomas Wakley, jun., The Lancet Office, Strand, London.
FOREIGN UNIVERSITY INTELLIGENCE.
Bttda Pcsth. —Dr. Karl floor, regimental surgeon, has
qualified as privat-doccnt in Ophthalmology.
Dorpat. —Dr. Fiiratner has resigned the professorship of
Mental Pathology, and Dr. Kraepelin has been appointed
in bis place.
Munich. —Dr. Karl Seitz has taken charge of the Uni¬
versity Policlinic for Children’s Diseases.
St, Petersburg [Military Medical Academy), —Dr. Lipski
has qualified privat-doccnt in Medicine. •
Vienna, —Dr. Egon von Braun-Fernwald has qualified
as privat-doccnt in Midwifery and Gynmcology.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. K. L. Sirski, Ordinator of the Tifiis Military Hospital,
and formerly assistant in Professor PolotebnofTa derma¬
tological clinic in St. Petersburg. He had been offered
the professorship of dermatology in Tomsk, but as he
suffered from phthisis he felt unable to accept it, preferring
to remain in the far warmer climate of Tifiis.—Dr. Albitski,
Assistant in the Military Medical Laboratory for the
Caucasus.
We are asked to state that, by permission of the
managing committee of the two Colleges, the lectures
which Mr. Hutchinson will give in connexion M’ith the post¬
graduate course will be delivered in the now premises of the
Examination Hall. The first lecture will be on Tuesday
next, the 13th, at 5 o’clock, and its subjecton “TheNature
of Lupus with special reference to its Connexion with
Tuberculosis.” All members of the profession will be
admitted on presenting thoir cards. Succeeding lectures
will be on Tuesdays, at 5 r.M. The entrance to the theatre
is in Savoy-street.
pROKKssou Virchow, lately elected by acclamation an
honorary member of the Uegia Accademia Medica di Roma,
has just acknowledged the compliment paid to him in a
letter to the president. Dr. Guido Baccelli—“lam proud
and happy to find myself so united by a new tie to Italy-
proud to be affiliated in Rome to a body so learned and
80 distinguished, happy to feel myself among new
friends. ,
At the Medical Society on Monday next Dr. William'
Duncan will read a paper on Chronic Disease of the Uterine
Appendages, with short notes of thirty consecutive cases
treated by Abdominal Section. It is expected that Sir
Spencer Wells, Drs. Playfair, Priestley, and Cullingworbh,
Messrs. Lawson Tait, Meredith, Doran, and others, wil!
take part in the discussion.
We regret to have to announce the death, on the 4th
inst., of Mr. Edward Bellamy, F.R.C.S., senior surgeon of
Charing-cross Hospital, at the age of forty-eight. We
shall, in our next issue, give a sketch of the life and pro¬
fessional career of the deceased surgeon.
Professor Pfuul, Professor Koch’s son-in-law, is to-
have charge of the new institute for experimental medicine-
in St. Petersburg.
DEMONSTRATIONS OF DR. KOCH'S TREAT¬
MENT IN LONDON.
PROGRESS OF THE CASES.
(Continued from p. IhlO, vol. ii. JS90.)
City of London Hospital for Diseases of the Chest.
Dr. Heron continues to attend with the utmost en¬
thusiasm to those patients undergoing Koch’s treatment in
this hospital, and it is most satisfactory to record that in
the large number of eases which have been treated by him not
one has ever given him cause for alarm on account of the
treatment. On the other band, several of the patients have
improved to such an extent as to be able to be removed
to a convalescent home, and Dr. Heron thinks in a few
weeks any assurance office would accept them as first-class,
lives. Dr. Webhered expressed his conviction that this treat¬
ment completely changed the feelings with which the prac¬
titioner now approached this malady, and shed a very
distinct ray of hope over what had formerly been regarded,
even by the most skilful, as a condition in which
“ Hope novel- comes which comes to all.”
'fhe throe cases alluded to {Nos. 1, 2, and 7) will be
submitted on Monday and Tuesday, between 3.30 and
4 o’clock I’.M., in the hospital to any medical men who-
may wish to see the progress which has been attained
during the treatment.
Case 1.—G. M -. This patient, on admission, suffered
from a cough, which was very severe, but which has now
entirely stopped. Dr. Heron thinks if the fluid can relieve
symptoms to that extent, itsutility and power are sufficiently
proved. From the ‘21st ult. the patient showed no reaction
until a (lose of O'OG was administered, and even then it was
very slight. Tlie dose was therefore increased rapidly
until the regulation standard of a decigramme was reached,
beyond which it was not deemed advisable to proceed. He
has injectetl several doses of a decigramme without any
reaction whatever being produced. On the right side the
physical signs are completely cleared, and on the left aide tlie
crepitations have greatly diminished, and the breath sounds
Digitized by
Google
106 Tbe Lancet,] DEMONSTRATIONS OF DR. KOCH’S TREATMENt IN LONDON. [Jan. 10,1891.
formerly rhoncbial have now become harsh. He has gained
'Gib. in weight since the treatment began.
Case 2 —A. D-. This patient has now fewer moist
erepitatioQs. He had lost weight to the extent of a stone.
Since the treatment began he has gained 10^ lb., of which
.51b. were gained during the last ten days. The patient ia
to be removed to a convalescent home on Monday.
Case 3 —B. W- has been under treatment for four
weeks, and is now taking decigramme doses. The case illus¬
trates what has been noticed in several instances, that in
diubercular disease accompanied by any other specific disorder
the reaction is so extremely slight that it is scarcely possible
to be certain that there has been any reaction at all. This
patient has had very low temperatures, reaching to 9G•4%
■S6°, and 98®, all of which were checked by Drs. Scott and
Adamson by a test thermometer. On the administration of
tbe remedy the temperature rose to 102‘2®.
Cases 4 and 5.—L. F- and E. R-. The lupus
cases continue to show marked improvement.
Case 6.—H. D-, aged fourteen. This patient has had
an attack of pleurisy, which came on on Dec. 18th wibhdis-
•tinct signs of septic inflammation of the left base. Injec¬
tions were stopped on Deo. IGth and were not resumed
until the 30tb, exactly a fortnight, when a small dose of
0'003 was given. No reaction is manifest, although 0-01
is now administered. In ordinary cases of phthisis attacks
of pleurisy frequently occur, and Dr. Wethered has
found tubercle bacilli in the clear serous effusions in
phthisical cases which afterwards disappeared without any
treatment. A case of this kind was communicated by
iDr. Douglas Powell iu a paper entitled " Tubercle Bacilli
of the Serous Membranes,^’ read at the Leeds Congress.
Case 7.—H. B-. This patient has now received
thirty-one injections, and is regarded as one of the most
successful cases which have been treated in this hospital.
She has been subjected to the full dose of a decigramme
without any further effect, and the physical signs have
•considerably improved.
N.B.—We have to express our thanks to Dr. Scott and
Dr. Adamson for the assistance they have so kindly given
to our representative from time to time in rendering these
.reports as accurate as possible.
King’s College Ho.si‘iTAL.
Dr. Watson Cheyne has resumed the charge of these
.patients along with his house surgeon, Mr. R. T. Hewlett,
to whom we are indebted for much assistance in preparing
the following notes of thb cases.
Case 1.—E, C-. Since our last notice this patient has
been injected five times without any reaction, and tbe
wound now resembles a slowly healing sinus. One deci-
..gramme of the fluid has now been administered, and the
patient has apparently ceased to react. No bare bone can
now be felt. There does not now seem to be any disease in
the part.
Case 2.—H. F-reacts but slightly to the fluid, and
the lupus patches in the axilla look very much improved,
although the patch on the leg is not so satisfactory.
Case 3.—R. F-, aged thirty. This case of enlarged
glands has now received six injections, after the last two of
which there has been no reaction. All observers agree
that the glands have diminished much in size. Mr. Cheyne
will go on for some time longer with the fluid, before con-
-•sklenng whether he will remove tlie glands by surgical pro¬
cedure or allow them to be absorbed. Some of them are now
quite separate and distinct, and appear as though they could
be easily shelled out.
Case 4 —W. K--. Strumous disease of the left knee-
joint. Has had injections of a dose of 0-012, and there is
practically no reaction. The leg can now be flexed without
any pain, and the measurement of the joint has diminished
by nearly an inch.
Case 5.—J. H-. A case of hip-joint disease. At
first very little movement could be obtained without
moving the pelvis, and no rotation or adduction was
possible. Now both these movements are very apparent,
and no case of this disease treated in the ordinary way by
rest and Thomas’s splint could show so much improvement.
The patient failed to react to the last two injections. The
case 18 considered to show one of the best results j et obtained
in King’s College.
Case 6.—M. (J -. Disease of the left elbow-joint. Tbe
reactions in this case continue to be very slight, both
locally and generally. There does not seem to be much
improvement in the mobility of the joints, probably from
the existence of adhesions. The outline ot the joint is
becoming more defined.
Ca.ses 7, 10, and 11.—These lupus cases are showing
a rate of improvement equivalent to that usually observed
in such cases.
Case 8 .—F. G-. Strumous disease of the right elbow-
joint. This patient has had five injections, and O'Ol has
now been reached. There is a very slight general reaction,
and the power of pronation and supination is much
improved. The size of the joint has diminished by nearly
half an inch.
Ca.se 9.-0. K-. Strumous dactylitis of the ring
finger. In this case a sinus in the buttock had existed
for years, and it entirely healed up about ten days after
the treatment was commenced. Since our last report six
injections have been aclminiscered, but they have produced
but slight reactions.
Case 11.—N. L-. This patient has now gone for
a holiday, promising to return to undergo the treatment in
a month. There is a marked improvement in her condition.
Ca.se 12.—The case of ana'sthetic leprosy. Much
smaller doses are being given, which continue to produce
the feeling of suffocation so marked in some of the re¬
actions. Leprosy cases frequently have a laryngeal infil¬
tration which gives rise to this feeling. She expresses
herself as feeling much better since the treatment began,
and is well satisfied to continue it. The.patient seems to
have lost a good deal of the melancholy expression she
formerly wore.
Case 13.—W. F—aged thirty-two, suffering from
disease of the knee-joint, which has lasted for four years,
has been under this treatment, and has received twelve
injections. The last injection was of the strength of 0'02.
The knee is now the same size as the sound one, and very
little seems to be amiss with it.
Ca.sb 14.—S W-, suffering from a large lumbar and
iliac abscess, which was opened about two months ago. On
admission, two large sinr^es remained open behind and one
in front. He has received eleven injections, and is now
being given O'Ol. Tliey produced considerable reaction, and
all the sinuijes healed up within ten days of the commence¬
ment of the treatment.
Royal Hospital iou Childeen and Women,
Waterloo-bridge-road.
Case 1.— M. L-, twenty-two years of age. Lupus of
nose (under the care of Dr. Sunderland). Duration about five
years. Has been scraped twelve times. Family history good.
Admitted on Dec. 11th, with well-marked lupus of nose,
affecting the whole of the right ala, partof which is destroyed.
Nine injections have been given, beginning with 0-002 and
increasing to 0'012. Tlie lupoid patch now presents a
shrivelled appearance; the area covered by scales is smaller;
the right nostril which was formerly obstructed ia now per¬
fectly free, and healthy-looking skin has appeared at the
margin of the right ala and left side of nose, where lupoid
tissue previously existed. The throat is now healthy in
appearance. The patient is much pleased with her im¬
proved appearance. A point of interest is the development
of granulations on the palate and fauces which has been
noticed by foreign observers, and which possibly indicates
early disease of these parts.
Case 2, —A. D - , thirty years of age ; phthisis of left
apex. Admitted on Dec. lOtli. Niue injections were
given, beginning witii O'OOl (after which distinct reaction
occurred}, increasing to 0-01. No change im physical signs
until after third injection of 0 004, 'ifiien crepitations
appeared at left base; and expectoration, which liad
diminished since admission, increased again to two ounces,
and showed afew baciUiof normal appearance, others headed,
and numerous granule-like bodies staining like bacilli.
Night sweats liave been absent since the commencement of
tlie treatment, with less anmmia, cough, and expectoration.
The patient expresses herself as feeling stronger and better,
but has lost up to the present J21b. in weight. No changes
noticed in the urine throughout.
Case 3.—^H. S-, aged six years and a half; tubercular
glands of neck (under the care of Dr. Sunderland}. On ad¬
mission there were large masses of glands extending like a
collar on both sides of the neck from ear to ear, in several
places ulcerating and covered with adherent scabs; these
were also enlarged. The first injection of i mm. was followed
by serous exudation from beneath the scabs and injection
Di(-' 3dby^jOO^[C
The Lancet,]
SOCIETY FOR THE STUDY OP INEBRIETY.
[Jan. 10, 1891 107
of the scars left by the former operation. After the fourth
injection of 4 mm. marked swellinR of the glands, liyper-
temia of the palate, and exudation fropi beneath the scabs
occurred, with marked constitutional disturbance. The
scabs were thrown oiF, leaving moist weakly-granulating
surfaces. After each subsequent injection the glands
became smaller, and are now not more than one quarter of
the size they were on admission.
-Case 4.—P. W-, aged four; adenoids of pharynx
(under care of Dr. Sunderland); admitted Nov. 14th, 1890.
As a theory has been advanced that adenoids are of tuber¬
cular origin, this case was injected. He received seven in¬
jections, reaching to 0‘008. There was marked hyperiomia
and swelling of muces and palate, and a halo of congestion
appeared around each adenoid growth after each injection,
but they have remained apparently unaffected. There
have been very little signs of constitutional disturbance,
and the highest temperature was 99 8*.
Case 5.—K. G-, aged six. Old excision of hip, with
sinuses (under care of Mr. Jacobson). Admitted in 1887,
when diseased bone was- removed from the tarsus with
successful result. While in hospital disease of the hip
developed on the same side, for which excision was per¬
formed in October last. Six injections were given, the
first on Dec. 16bh. Well-marked reaction followed each,
with increased discharge and swelling around the hip
after the first three injections, but subsequently the
discharge diminished, the wound healed, and i^he sinus is
gradually closing up and the discharge from it is very
slight.
Case 6. —E. M-, aged five. Early catarrhal phthisis
(under care of Dr. Sunderland). Cough, haemoptysis, and
wasting for some mouths only. A thin child (weight,
2st. 3^1b,), with flattening at'right apex, deficient move¬
ment, impaired resonance and crepitations, and tubular
breathing posteriorly. Five injections were given, the first
on Dec. 22ud. Very little reaction followed (hichest
temperature, 100'2"). No evidences of any local action in
lungs ; the signs at the right apex have gradually cleared
up, and there is now nothing abnormal to be heard in the
lungs, although flattening and impaired movement con¬
tinue on the right side of the chest. Unfortunately no
expectoration could be obtained, so that bacilli were not
detected. The temperature still continues slightly.raised
and irregular. There has been a gain of 2 lb. in weight. The
subsequent history of this case will be of great interest, and
the inj^ections have now been discoutinuea.
Case 8 ,—A. K-, aged ten; tubercular peritonitis
(under the care of Dr. Haig); admitted Nov. Ist, 1890.
Well-marked nodular band passing across abdomen, owing
to extensive abdominal disease. Three very small in¬
jections have been given, beginning with half a milligramme,
out distinct reactions have been obtained, with increased
swelling of the abdomen and marked peristalsis and dis¬
tension of the intestines.
KlDIlERMINSTEXt HOSPITALS.
Five cases have been injected at the Kidderminster In¬
firmary and Children's Hospital, and six at the Kidder¬
minster Workhouse Infirmary, and, so far as can be judged
iu a week, with satisfactory results.
Royal National Hospital, Ventnor.
Ten carefully selected patients were inoculated at the
lloyal National Hospital with Koch’s fluid. The cases
were very carefully diagnosed, and the lesions graphically
delineated on outlined figures. Spliygmograpluc tracings
have been taken at the extreme of reaction, and in the
interval, affording v^ry inloresting results. The parallel
tracings of pulse, breathing, and temperature in red, blue,
and black inks have been taken every three hours.
Koch’s Methoo in the Provinces.
We learn from the lirdilj^ord Observer that immediately
after his return from Berlin witli a supply of Koch’s liquid
Dr. Hime of Bradford offered to Dr. Proctor, medical
oflicer to the union workliouse of that tow-n, the free use^
of his supply fiir any suitable pauper cases. This vei-y'
generous offer will no doubt bo largely availed of. Dr.
Hime is also treating eases at the Infinnaiy and Children’s
Hospital and otlier poor people in the town. His results
Rp to the present have been thoroughly typical of the
results obtained in Berlin.
A small quantity of Dr. Koch's lymph is being sent this
week to Madeira by the Cape mail steamer Castle,
HEALTH OF THE IMPERIAL NAVY
OF JAPAN.
The average strength of the Imperial Navy of Japan in
1889 was 8954; the cases of disease and injury amounted to
3621, of which 1038 were treated in and 2583 out of hos¬
pital; the number constantly under treatment was 120-36
in-patients and 171'47 out-patients, making a total of'
291'83; there were 52 deaths, and 49 men were invalided.
These numbers give the proportion of 404 cases, 5'^ deaths,
5'47 discharges by invaliding, and 32-69 constantly non-
effective per 1000 of mean strength. The cases'and mean
sick were slightly higher, but the deaths and invaliding
lower, than in the preceding year. Of the deaths 9 were by-
accidents and violence, including one by a fall from alofc,
3 by drowning, and 6 by suicide, and 43 were by disease.
The only epidemic disease which prevailed was rbbheln,.
which broke out on Jan. Slat on board the Kaimon in
the harbour of Yokosuka. It spread to other ships and
to the barracks, and did not cease till June 6bh.
There were 174 cases treated, all of which recovered
106 of them occurred in March, 33 in April, and 24 in
February. Venereal diseases were the cause of the greatest
amount of sickness. Mr. Takaki, in his report, says there
were 772 cases and 4 invalided, but the tables show 70il'
case's of syphilis, 421 of gonorrhcca, 2 of stricture, and 80 of
orchitis; if the latter were gonorrhccal, it would give a
total of 1212 cases, or one-third of the whole number in¬
cluded in the returns, and a proportion of 13.5 per 1000 of
the strength. There were 27 cases of enteric fever, with 8
deaths, the former being higher and the latter lower than
in the preceding year. Diseases of the lungs were the most,
fatal class, having caused 16 deaths, of which 8 were from,
phthisis, 1 hfemoptysis, 4 pneumonia, and 3 pleuritia. There
were 3 cases of kalckd (beri-beii), but it is stated that 2 of
them, of which one died, “ occurred after the men had rum
away from the navy.” The judicious changes in the dietary
effected by Mr. Takaki in 1884, with subsequent modifica¬
tions, seem to have been effectual in getting rid of a disease
which w-as previously a source of much sickness and mor¬
tality. lb was nob found necessary to make any important
change in the food of the men during the year. No in¬
formation is given in the report as to the num'ber of recruita
for the navy who were rejected as unfit for service.
SOCIETY FOR THE STUDY OF INEBRIETY.
A MEETING of this Society was held on the 6th inst., in the
rooms of the Medical Society of London, the President,.
Dr. Norman Kerr, in the chair,
Dr. Cre8pi(Wimborne) said that though he at one time
regarded drunkenness as a purely moral vice, he was now-
satisfied that, in a later stage at least, it was a disease.
Confirmed intemperance was a disease, and it was impera¬
tive that there should be changes in the law to empower
any relative to obtain a compulsory order to seclude the
inebriate in a home for special treatment. There should
also be provision for the poor in institutions conducted by
County Councils, and paid for out of the rates.
Dr. T. L, 'Wright (Beliefontaine, Ohio), in an elaborate
E ' on the Psychology and Responsibility of Drunkenness,
ased the nature and relations of alcoholic intoxication.
1. If insanity was mental aberration consequent on a cause
beyond volitional control, then a person drunk on alcohol is,
during the drunken fib, truly insane. The laws claim that
the drunkard is a voluntary madman. This is incorrect.
The inebriate does not voluntarily renounce control. On-
the contrary, he believes be can control his actions,
while he cannot. Though he does not know it, alcohol
paralyses inliihition. 2. Alcohol assails every element of
human character, every organ and portion of human
structure. Alcohol acts os an anaesthetic, and the various
alterations in the eye, the features, tlie gait, and the flow
of ideas and talk are not symptoms of increased but of
decreased intelligence and control. The perception and the
senses are clouded. There are distorted and debased sensa¬
tions. The insane have similar perversions. 3. In drunken¬
ness there are also instability of movement and incoordina-
OOgNC
Die
108 The Lancet,]
REPORTS OF MEDICAL OFFICERS OF HEALTH.
[Jan. 10, 1891.
4Ion of fuDCtioD, leading to mental confusion, maniacal
tumult, and incoherence of thought. The unity of purpose
is destroyed. In most cases of crime under alcohol there
has been no criminal intent.
CHRISTMAS AT THE LONDON HOSPITALS.
In addition to those mentioned in our last issue, the
following notices of Christmas festivities have been re¬
ceived :—
Hospital for Epilepsy anb Paralysis,
Regent’s Park.
Through the kindness of several friends the patients at
this hospital passed an exceptionally happy Christmas.
After an excellent dinner, various games were indulged in,
■and all enjoyed a homelike evening. Two bagatelle-
hoards, recently obtained through the liberality of friends,
also provided sources of amusement.
Royal Free Hospital.
The students of the London School of Medicine for
Women gave an entertainment to the nurses and patients
■of the Royal Free Hospital on Dec. 18bh, 1890. A stage
■with proscenium and footlights was erected in the large
Hecture-room, and an excellent performance, consisting
partly of tableaux and partly of songs and amusing recita¬
tions, was given. Whilst tliese performances were going on,
Father Christmas,” with eight attendants, visited each of
the wards and sang carols and distributed sweets for the
benefit of the patients unable to be moved downstairs.
Guy’s Hospital.
At Guy’s Hospital the wards were gaily decorated with
■evergreens and Chinese lanterns, and the patients were
regaled with roast beef and plum padding, to which a
bountiful dessert was contributed by the students. A band
of negro melodists, mainly students, visited the wards
during the day and afforded infinite amusement to tlie
patients. There were several Christmas trees, and a supply
of articles of clothing were distributed among the children
and the more needy of the patients.
National Hospital for the Paralysed and
Epileptic, Bloo-mspury.
An entertainment and Christmas tree distribution took
place at this hospital on Jan. 2nd, the patients enjoying a
very pleasant evening.
IPnHic anlt fato.
LOCAL GOVERNMENT DEPARTMENT.
reports of medical officers of health.
Bradford Urban District. —Estimating the population of
this Yorkshire, borough at 235,056, Dr. Jas. MacLintock
puts the birth-rate for 1889 at 20'G and the death-rate at
19'1 per 1000; and, after discussing the incidence of the
deaths in age, sex, and locality, he points out that, com¬
pared with the mean for preceding years, the amount of
<ieath from zymotic causes was very excessive; measles,
whooping-cough, and diarrhusa taking precedence in this
respect. It is curious that, whilst diphtheria is so largely
taking hold of our urban areas, Bradford remains practically
free from this invasion, and only 39 cases were reported
under the Notification Act last year. As to enteric fever,
this disease, as usual, selected houses and localitie.s having
sanitary defects involving nuisance from excreta; and in
one special neighbourhood, the condition of which is
described as deplorable, scarcely a house had its drains
disconnected, the sewer was unventilated, the yards were
foul, the privies and ashpits dirty, and houses were built
back-to-back. Naturally, Dr. MacLintock was not surprised
at the outbreak of enteric fever; but some surprise may be
expressed as to the existence of a series of conditions which
seem almost contrived to invite a filth disease. A good
deal of attention is given in the report to the subject of
destructors and to the question of their causing nuisance;
but since arrangements were made for the erection of two
more of these structures, witli a view of reducing the
necessity for the dangerous “ tipping” still in progress, we
majy assume that the sanitary department of the borough is
satisfied that such appliances can be managed without
nuisance. Unfortunately, lead-poisoning still goes on in
the borough, and the cause of it remains unsolved. It is to
be hoped that the inquiry now set on foot by the Local
Government Board into this matter will clear up the diffi¬
culties by which it is surrounded. A large amount of current
sanitary work is in progress in the borough, and a detailed
account of it is embodied in the report.
Bradford Isolation Hospital. —A separate report is issued
as to this institution by Mr. Herbert Humphreys, the
resident medical superintendent. The hospital has under¬
gone a number of structural improvements, and it is now
one of the most complete in the Kingdom. The number of
patients admitted daring 1889 was 490. Of these, .367 were
cases of scarlet fever, and 102 cases of enteric fever.
Amongst the tables appended to the report is one showing the
percentage of deaths per admissions during a terra of years
from each of the diseases received into the hospital. The
varying mortality in scarlatina is striking, and we trust the
table will be annually kept up, and a mean drawn of
the lesulta shown. So also, more letterpress in amplifica¬
tion of the numerous diagrams would add to the usefulness
of the report.
Worcestershire County Area. —Mr. Fosbroke, the county
medical officer of health, has recently issued a volume, in
which he deals, by way of digest, with the various local
heal til reports, and his perusal of these reports has evidently
led to the gathering of a conference of Worcestershire
health officers, at which he communicated his views as to
the desirability of carrying out the health work of the
county and of reporting on certain definite lines. He
especially advocated some uniformity in the preparation of
annual reports, although he admitted that it would be in¬
expedient to frame all such reports precisely on the same
model. Some attempt at, uniformity has been already aimed
at iu the instructions of the Local Government Board, and,
whilst we can conceive that the matter may with some
advantage be extended somewhat further, we can also
readily understand that uniformity may be carried too far,
and that the mere need for making a summary of such re¬
ports would nob .justify a change that would hamper the
individuality of the reporter. There are certain tables and
statistical returns that should be made on the same lines,
if only for purposes of comparison, and wo do not imagine,
from the nature of Mr. Fosbroke’s own reports in tlie past,
that uniformity is likely to be pressed by him beyond
bounds that are reasonable.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6328 births
and 5343 deaths were registered during the week ending
Jan. 3rd. Tlie annual rate of mortality in these towns,
which had increased from 21 -3 to 27 'S per 1000 in the pre¬
ceding three weeks, further rose last Aveek to 28'7. The
rate was 297 in London and 27'9 in the twenty-seven pro¬
vincial towns. During the thirteen weeks of the quarter
ending on 2i)bh ultimo the death-rate in the twenty-eight
towns averaged 21'6 per 1000, and exceeded by O'G the mean
rate in the corresponding periods of the ten years 1880-89.
Tlie loAvest rates in these towns last week were 16'2 in
Leice.ster, 17'1 in Bradford, 19'6 in Derby, and 20'2 in Hull;
the highest rates were 33’1 in Salford, 33'6 in Liverpool,
36'7 in Manchester, and 43'6 in I’reston. The deaths
referred to the principal zymotic dfeeases, which had
been 511 and 472 in lire preceding two weeks, were last
week 476; they included 191 from measles, 106 from
whooping-cough, 51 from diarrhcea, 49 from scarlet fever,
40 from “fever” (principally enteric), 39 from diphtheria,
and not one from small-pox. The lowest daalh-rates from
these diseases were recorded in Portsmouth, Hull, Wol¬
verhampton, and Derby ; the highest in Oldham, Salford,
Bolton, and Preatou. The greatest mortality from measles
occurred in Salford, Bristol, Oldham, Preston, and Bolton;
from whooping-cough in Newcastle upon-Tyne, Sheffield,
Birmingham, Preston, and Salford; and from “fever” in
Derby. Tlie mortality from scarleb fever showed no
marked excess in any of the twenty - eight towns.
The 39 deaths from diphtheria included 25 in London,
Di. Coogle
THB LANCET,]
MILK IN CONNEXION WITH SEPTIC DISEASE.
[Jan. 10,1891. 109
3 ia Manchester, 2 in Oldham, and 2 in Leeds. No death
from small-pox was registered in any of the twenty-eight
towns; and no small-pox patients were under treatment
in any of the Metropolitan Asylum Hospitals or in the High-
<yate Small pox Hospital on Saturday last. The number of
scarlet fever patients in the Metropolitan Asylum Hospitals
and in the London Fever Hospital at the end of last
■week was 1693, against numbers declining from 2122 to
1685 on the preceding eight Saturdays; the patients
admitted during the week were 107, against 125, 108, and
78 in the previous three weeks. The deaths referred to
the respiratory organs in London, which had increased in
the preceding five weeks from 375 to 806, further rose last
week to 927, and exceeded the corrected average by 427.
The causes of 156, or 3‘0 per cent., of the deaths in the
twenty-eight towns were not certified either by a regis¬
tered medical practitioner or by a coroner. All the causes
of death were duly certified in Portsmouth, Derby, and
Oldham. Tlie largest proportions of uncertified deaths
were recorded in Brighton, Sheffield, Preston, and Liver¬
pool. _
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had increased from 20’1 to 2t'6 per 1000 in the pre¬
ceding three weeks, further rose to 24-8 during the week
Jan. 3rd, but was 3'9 per 1000 below the rate that
S id during the same period in the twenty-eight large
towns. The rates in the eight Scotch towns ranged
from 14'6 in Leith and 17‘8 in Greenock to 29'5 in Pai^ey
and 30'2 in Glasgow. The 643 deaths in the eight Scotch
towns showed an increase of 6 upon the number in the
preceding week, and included 22 which were referred to
whooping-cough, 14 to “fever,” 12 bo measles, 7 to diarrhcea,
<5 bo diphtheria, 4 to scarlet fever, and not one to small-pox.
In all, 65 deaths resulted from these principal zymotic
diseases, against numbers increasing from 46 to 70 in tne pre¬
ceding three weeks. These 65 deaths were equal to an annual
rate of 2'5 per 1000, which was slightly below the mean rate
last week from the same diseases in the twenty-eight English
towns. The fatal cases of whooping-cough, which had been
12 and 22 in the preceding two weeks, were again 22 last
week, of which 14 occurred in Glasgow and 5 in Edinburgh.
The deaths referred to different forms of “fever,” which had
increased in the previous three weeks from 2 to 7, further
rose last week to 14, and included 7 in Edinburgh, 4 in
Glasgow, and 2 in Dundee. The 12 fatal cases of measles
showed a decline of 7 from the number in the preceding
week ; 6 occurred in Glasgow and 4 in Greenock. The
deaths from diphtheria, which had risen from 6 to 9 in the
previous three weeks, declined again to 6 last week, and
included 4 in Glasgow. Of the 4 fatal cases of scarlet fever
2 occurred in Edinburgh. The deaths referred to diseases
of the respiratory organs in the eight towns, which had
increased rn the preceding three weeks from 137 to 182,
further rose last week to 191, but were 14 below the number
■in the corresponding week of last year. The causes of GO,
or more than 9 per cent., of the deaths in the eight towns
last week were not certified.
HEALTH OF DUBLIN.
The death-rate in Dublin, which had risen from 25'6 to
•31'3 per 1000 in the preceding three weeks, further increased
to 40'G during the week ending Jan. 3rd, a higher rate
than in any week since February last. During the
■thirteen weeks of the quarter ending on the 27th ulc., the
death-rate in the city averaged 24'3 per 1000, the rate for
t^ue same period being 20’6 in London and IS'G in Edin¬
burgh. The 275 deaths in Dublin showed an increase of
63 upon the number in the preceding week, and included
7 which were referred to different forms of “fever,” 2 to
measles, 2 to whooping-cough, and not one either to small¬
pox, scarlet fever, diphtheria, or diarrheea. Thus the deaths
worn the principal zymotic diseases, which hadbeen 9 and 11 in
the preceding two weeks, were again 11 last week; they were
^ual to an annual rate of 1 -6 per 1000, the rate from the same
niaeases being 2'4 in London and 2'9 in Edinburgh. The
tleaths referred to “fever,” which had been 4 and 6
in the preceding two weeks, further rose last week to 7.
ihe 2 fatal cases of measles were the first recorded in the
■<1% since the beginning of October. The 2 deaths from
■wiiooping-cough showed a decline of 2 from the number in
we previous week. The 275 deaths in the city included
44 of infants under one year of age, and 74 of persons aged
upwards of sixty years; the deaths both of infants and of
elderly persons showed a further increase upon the numbers
recorded in recent weeks. Six inquest cases and 7 deaths
from violence were registered ; and 77, or more than a
fourth, of the deaths occurred in public institutions. The
causes of 27, or nearly 10 per cent., of the deaths in
the city were not certified.
” Audi alteram partem."
MILK IN CONNEXION WITH SEPTIC DISEASE.
To the Editors o/The Lancet.
Sirs, —A letter appears in your issue of Jan. 3rd under
the above title, aod signed by Dr. F. P. Atkinson, in which
the age of the patients attacked is suggested as a test
whether an epidemic be due to infected milk or to other
causes. Dr. Atkinson says that, “ if by far the larger pro¬
portion of individuals attacked be children, it would
be only natural to suppose that the milk was in some
way or other the cause, inasmuch as children are by
far the larger milk drinkers. If, on the other hand,
grown-up people furnish the larger number of victims, it
is not unlikely defective drainage is the cause.” He
illustrates his proposition from two outbreaks of diphtheria,
and in all probability he was correct in his conclusions in
regard to these instances. I would, however, desire to
point out that the test does not hold good in regard to
typhoid fever, where it will be found that young adults are
affected to far the greatest extent. This has been my ex-
l^erience in two considerable epidemics I have recently had
the opportunity of investigating. In fact, the average age
of the patients corresponded with the average age of those
attacked by typhoid from all causes as given in Murchison’s
book.
In an epidemic of scarlet fever traced to milk recently a
large number of adults were attacked in proportion to
children. In this instance the adults partook of the poison
in the form of cream in tea, a mode of administration
which seems ia certain cases to increase the virulence of the
poison. I know of several outbreaks both of typhoid and
scarlet fever traced to milk where the milk has been taken
only in tea or coffee, and has produced severe attacks of the
disease. The conditions which inlluence the incidence as
to age, of infectious disease due to contaminated milk,
appear to be : (1) The age of greatest prevalence of the par¬
ticular disease—e.g., scarlet fever, typhoid fever, diphtheria:
(2) the quantity of milk consumed ; (3) the form in which it
is taken ; (4) the health of the person at the time.
In conclusion, let me mention that in Edinburgh, ^ no
doubt also in many other places, our notification forni.s
include both the age and sex of the person attacked, and
this information is given in every instance.
I am, Sirs, yours faithfully,
Harvey Littlio-joiix, M.B., B.Sc.
IleiiUIi Oflice, Milinbni-gh.
To the Editors of The Lancet.
Sirs, —The point raised by Dr F. P. Atkinson, under the
above heading, in your issue of Jan. 3rd, is of very consider¬
able practical importance. He says he has always been
sceptical as to the value of boiling milk in order to destroy
“germs,” and he adduces certain arguments evidently
intended to enforce this doubt on his part. But I would
submit that his data, as given in his letter, are but of little
value. His letter relates to “septic disease”; one of hia
two recorded illustrations has to do with “diphtheria”;
and as regards the other, the nature of the disease is not
specified, but it savours rather of enteric fever. And then, to
add to the confusion, he writes to Mr. Watson Cheyne to
know how far the boiling of milk suffices to destroy “all
existing germs” ; and this is capped by a statement of the
opinion >vhioh was lield by that expert at a date when he
worked with “ these things.”
May I venture to ask what “ things ” and what diseases
are in question ? The point is of the more importance
because Dr. Atkinson laysdown the general rule that if the
incidence of “infectious disease” is mainly on children, it
= !h, Coogle
Dir:
110 THBljANCBf,]
MALARIA.
[Jan. 10,1891.
'will only be natural to suppose that milk ia ‘‘in some
way or other the cause,” but that the reverse is probably
the esse if gi-own-up people furnisli the larger number
of victims. The adoption of a gratuitous assumption of
the above sort may well have made Dr. Atkinson
sceptical. The specific diseases with which milk is best
known to have causal relation are scarlet fever, diph¬
theria, and enteric fever. The two former are essentially
diseases of childhood, the latter is more especially a
disease of young adults. Acting on the rule laid down, diph¬
theria and scarlet fever occurrences would as such raise
suspicion of milk infection, whilst occurrences of enteric
fever would have just the opposite eftect. But, whilst
awaiting further information on the points raised in Dr.
Atkinson’s letter, may I venture to question whether Mr.
Watson Cheyne’s answer related to the specific org.anisms
of either of these diseases; and until we learn that I am
•wrong in this surmise may I be allowed to state that my
experience ia entirely in accord with that of “the autho¬
rities ” referred to by Dr. Atkinson. In short, as a matter
of practice, it is well known amongst investigators of in¬
fectious diseases that persons who use nothing but cooked
milk do very largely escape from attacks of the three
diseases named during epidemics in which members of the
same households who use uncooked milk are specially
attacked by them.—I am. Sirs, yours faithfully,
Jan. 1801._T’UBhic Health.
MALARIA.
To the Editors of The Lancet.
SiRS,^—In The Lancet of Dec. 13bh Brigade Surgeon
G. Yeates Hunter mentions beat and malaria as the two
great depressants of the nervous system in tropical climates,
and these depressing iniluences are regarded as intensified
by the injudicious use of quinine. There are, however,
other agencies especially affecting the European in a tropical
climate. These are the extreme liability to chill arising
from the skin being debilitated by excessive action resulting
from heat; the prevalence of a scorbutic taint which may
ffie latent, or only evidenced by conditions not always appre¬
ciated as scorbutic ; disturbed sleep from very many causes;
and not infrequently a syphilitic taint. Continued heat,
however, is the most important factor. Even in a tempe¬
rate climate, a season of extraordinary heat causes loss of
appetite and debility by its depressant effect on the nervous
system. But the heat of a tropical climate acts still more
injuriously. As a con,sequence the introduction of oxygen
into the lungs is lessened in several way.s, while the
excretion of carbonic acid is diminished, and hepatic
engorgement is favoured. Neither with a smaller quantity
of urine is so much effete matter passed with that Huid.
All this leads to blood deterioration. Dr. Forbes Watson,
of the Bombay Army, some thirty-five years back de¬
monstrated that the red blood globules of the European in
Indig^ (especially during the season of rain moisture and
heat) become smaller, lose their smooth appearance, and
are studded with refracting granules, which were regarded
as of a fatty nature. Had Dr. Watson possessed more
modern instruments, it does not appear improbable tliat we
would then have had a description of those changes which
have been since noted to occur in connexion with the so-
called bacillus malariin. But continued high tempera¬
ture, moisture, and other depressing influeuces incidental
to residence in the tropics are quite sufficient to induce that
anamiiafrom which so in any suffer in a hot climate (and which
is usually termed “malarious cachexia”) without malaria.
With regard to quinine, 1 long since wrote that it does
not deserve the praise which has been accorded to it, and
that a very sliort experience in tlie tropics will show that
quinine is not the panacea which text-books make it.
Paroxysmal fevers often terminate in restored health;
hence many things have been credited with antiperiodic
powers because fevers have ceased after their use. Amongst
such agents are nicotine and cliarcoal, arsenic and cobwebs,
opium and nitrate of potash, fuming nitric acid, strychnine
and neem bark, carbolic acid and barbery, hyposulphites
and black pepper, alcohol and coffee, also water labeled
peroxide of hydrogen. As many have written enthusiasti¬
cally of quinine, so Hare forty years ago wrote of mercury :
“No doubt that if not calomel, certainly salivation is an
antidote to malarial fevers. The instant a patient’s mouth
is sore the fever leaves him ; from that moment the disease
vanishes as if charmed the change is as if from life-to
death.” I have seen patients recover as rapidly and welli
without quinine as with it, either because there was not
any quinine to give them, or because they declined to-
take European medicine. It has been advanced that
the diminution df the death ratio from fevers in India
is to be attributed to the extended use of quinine. But,
as a matter of fact, the death-rate from all Indian
diseases has diminished, 1 think, chielly from better
sanitation, from better personal hygiene, and from the-
abandonment of the spoliative treatment of former times.
I have met many native halceems in the East, and most,
have no confidence in quinine. They assert it “ drives
thje fever inwards ” And I think Brigade Surgeon Hunter
is quite correct when he observes that “if fever is kept in
abeyance [by quinine] a highly irritable condition of the
nervous system is established.” For instance, a'person
suffers from irregular or masked ague which he cannot
shake off, accompanied by anomalous nervous symptoms. On
inquiry it will be found that he has taken large quantities-
of quinine, which, although credited with the power of curing
fevers, is nevertheless capable of exciting a febrile condition.
Such a patient will not recover until quinine is discarded,
and probably not until Carlsbad sails or some other similar
medicine has been prescribed. Then lemon juice may be
often taken with advantage. Waring long since remarked,
that “ quinine is inadequate to eradicate malarious poison
when it has become engrained, as it were, in the sjstem ; it
appears probable that its continued use exercises an
injurious influence on the brain and nervous system.” I
will not enter on the qiiaisUo vexata of the action of
quinine further than by remarking that a sufficient
dose will generally lower the temperature, and some¬
times delay or even prevent an ague lit. This, how¬
ever, ia rarely accomplished without toxic effects of quinine
being manifested, which have often appeared to me to-
counterpoise the advantage. Sir Samuel Baker wrote of
his travels in Africa that when he arrived at a place where
he could procure sweet potato whisky, “ Every day I drank.
hot toddy I became strong, and from that time the fever
left me,’' quinine having failed. Both alcohol and opium
have been regarded as antiperiodics, and I certainly have
known expected paroxysms escape by taking a strong glass
of brandy-and-water on the first symptom presenting. It
is, however, more with regard to the prolonged use of
quinine that I write in support of Brigade Surgeon.
Hunter’s views. He has great confidence in kreat, or
chiretta, as a substitute for quinine, and many Indian
hakeems use this agent in preference to quinine. Years
back I often used in dispensary practice, as I think both
with economy and advantage to the patients, a tincture of
kreat made by macerating 24 oz. of kreat in the same
q^uantity of alcohol, and administering in doses of two or
tliree drachms. I am, Sirs, yours obediently,
W. J. Moore,
•Ian., isai._Surgeon-Gonoral.
“ MIDWIVES’ REGISTRATION BILL.”
To the Editors of The Lancet.
Sirs,— After reading Dr. Attbill’s letter I have come to
the conclusion that he has not seen a copy of the Amended
Midwives’ Bill, but that he has contented himself with
collecting from the medical press the opinions of others and
presenting them to us in the uninviting form of a rCchavfi
dish. I have been led to believe this because he says the-
“title” of the Bill indicates that its framers think
“registration” all that is needed. Now, the title is-
described in the first clause as follows This Act may,
for all purposes, be cited as the Midwives Act.” This is a
comprehensive title, and includes education, examination,
certification, and registration. These are only means to an
end, and that end is lost sight of by many—viz. ,the prevention
of women calling themselves mid wives who are not competent
to act as such. Dr. Attliill proposes that an Act should be
passed to encourage the education of midwives and enforce-
their examination, but he says notliing about granting
certificates or registering them. Examination is of little
use unless the person passing it can prove the possession of
it by certificate, and the certificate is of no value to one
who holds it if others can declare they have it and there ia
no register to refer to for proof against them. Dr. Atthill
is satisfied with “Home Rule” in Ireland as far as mid¬
wives are concerned, and kindly wishes to help us with the
management of ours. The King and (iueen’s College of
Physicians of Ireland obtained &.charter in 1673, enabling
e
THE LanobtJ
EESULTS OF COMPULSORY NOTIFICATION.
[Jan. 10,189L m
them to examine and license mid wives, and punish all who
practised without a licence. Mid wives have certainly
received more attention and been better educated in the
sister isle. “As a rule,” Dr. Attbill says, “they are
efficient and well conducted.” He, however, thinks
the English mid wives we propose to educate and
•register will not be so satisfactory, for he says “a
ood many will be guilty, or at least be accused of
eing guilty of drunkenness, incompetence, infamous or
disgraceful conduct, &c.” Let us hope this fear is ground¬
less. Some of the objections which Dr. Atthill mentions
have already received attention, and will be remedied after
‘the Bill has been read a second time; but a number of
them are due to incomplete knowledge or misapprehension
of the intention and powers of the Bill. These will most
certainly disappear with further enlightenment.
I am. Sirs, yours faithfully,
■Upper Wimpole-atroet, Jan. 1801. JaMBS H. AVELING.
To the Editors o/The Lancet.
Sms,—Every member of our profession will cordially agree
-with thefirst part of your leading article on the above subject,
but with the sentence, “ We are not prepared to say that
the State should refuse all recognition of mid wives,” objec¬
tions begin. Indeed, the tenour of the first part of the
article is contradictory to the latter. Everyone is
agreed that the lying-in woman should have the bast
available attendance—viz,, the registered medical prac¬
titioner. The diiliculty is as to the means which will
ensure this desirable end. This difficulty will surely
not be met by providing a second-rate uneducated class
to compete with him on terms which make competition
impossible on his part. Now the difficulty that has arisen
in connexion with this Bill is due to the method of its
introducers and backers. It is almost incredible that
■certain members of our profession should have allied them¬
selves with a body like Due Midwives’ Institute to legislate
for us in this matter, instead of taking their own profession
into their confidence and ascertaining in a reasonable way
first whether legislative steps were necessary or desirable.
The course adopted demonstrates clearly the necessity of
the better representation of the views of the profession at
large, and a representative body to give expression to those
views. At present the only views which have a ready
-expression are those of cliques and corporations, which are
not representative. Now, Sirs, I am entirely opposed to
legislation on this subject, and I do not agree with the
statement that we cannot permanently avert it. We can, if
we are sufficiently of one mind in the matter. The reasons '
-of my opposition are ; First, no one has made out any ease |
in favour of the necessity of legislation. Dr. Aveling, at the
British Gynecological Society, based his case on figures and '
facts wliich were clearly shown to be erroneous, and I have
been at present unable to find anyone who can produce
•either figures or facts upon which to base the plea. My
second reason is that it is impossible to provide any legal
machinery to prevent the enfranchised class outstepping the
'limits of its province, and, at any rate, there are no pro¬
visions in the Bill at present before us which are sufficient.
I will simply, by the way, remind you what lias happened
in the case of the pharmaceutical chemist. My third
reason is, that tlie establishment of a second grade of prac¬
titioners will be detrimental to the science and the profes¬
sion, and the first part of your article clearly points in this
•direcfciop. The old apothecary class was, t presume, done
away with, because it was found unsatisfactory. It appears
to me that it is for the authors and backers of the Bill to
show that legislation is necessary, and that what they
propose to do is adequate to produce the desired result and
la for the benefit of the science of midwifery. Until they
can bring sufficient evidence to prove these points the Bill
iJuust be opposed to the bitter end.
I am. Sirs, yours faithfully,
llatlloW, Doc. 1800 . LOVELL DrACG.
^ON THE TREATMENT OF CANCE]^ BY THE
INJECTION OF ACETIC ACID.
To the Editors of The Lancet.
Sirs,— It is several years since I first injected acetic acid
to cancerous glands. One of the first cases occurred at
i Ueorges Hospital. Some months after amputating a
scirrhous breast, the patient presented herself with enlarged
axillary glands. In consultation, it was advised that they
should be extirpated. I proposed, however, to inject them
with acetic acid, and, with the consent of my colleagues,
this was done. On the following Wednesday she again
presented' herself, when it was found that the enlarged
glands had disappeared, and that the axilla was in a
perfectly normal condition, there being no tracp of enlarged
glands, either superficial or deep. This patient returned
several times to the hospital, but I never saw any further
appearance of disease, and, so far as 1 know, she re¬
mained perfectly well. Also, having removed a cancerous
breast, assisted by Mr. Pick, Mr. Ceesar Hawkins being
present, the enlarged axillary glands were inj^ted, and the
result was equally satisfactory as in the former case. I have
frequently since employed these injections, and with varying
results; but lately I have used them to the breast itself. In
a case now under my care the breast has resumed its normal
character except that it has become smaller, and seems yet
to be undergoing atrophy. With your permission I will
send you detailed reports of some of these cases.
I am, Sirs, yours faithfully,
Grosvenor-street, W,, Doc. Kith. 1800 , B. E. BRODIIUEST.
RESULTS OF COMPULSORY NOTIFICATION.
To the Eddtora o/Thb Lancet,
Sirs,—W ith your kind permission I should like to make
a few remarks on two contributions which have recently
appeared in The Lancet —namely, the letter of Dr. Russell,
medical officer of health of Glasgow (Nov. 29th, p. 1188),
and the annotation on Dr. Cameron’s report to the Corpora¬
tion of Leeds (Deo. 20bh, p. 1345). In both pre-notification
and post-notification figures are contrasted, and we are left
to infer that notification is triumphantly vindicated.
In the case of Glasgow eighteen weeks only of each of two
years are taken, and reference is made to but one disease—
scarlet fever—with the following result:
Caso,>i. Deaths.
^ - _ X ^
Ho.sp. Home. Total, lloap. Homo, Total.
18 weeks, 1880 .. 410 .. 821) ,. 124.') .. 62 ., 101 .. 213
18 woeks, 1800 .. 0i)7 ,, 434 .. 1131 .. 24 .. 16 .. 30
It is difficult to determine what this table was intended
to establish, except that more cases have been removed to
hospital in 1890,. that the death-rate per case treated in hos¬
pital is lower, and that the epidemic lias not been nearly so
severe as in 1880 (that is, of not nearly so virulent a type).
Of those taken to hospital, 1 in 8 (bed in 1880; but in 1890,
during a similar period, only 1 in 29. The figures in 1880,
though probably reliable as regards the deaths at home, are
misleading as regards the number of cases. But it is an
interesting fact that in 1890 the proportion of deaths to cases
is the same at hospital as at come: in both 1 in 29. So
much for sanitation at Glasgow.
Coming now to Dr. Cameron’s report, I see that he selected
eiglit large boroughs with an aggregate population of
1,293,305 m 1881, but the average density is not before me.
The mean annual death-rate from the four notifiable diseases
—viz , small-poxj scarlet fever, diphtheria, and “fever”—
was 21 per 1000 living before notification and 0-8 after. This
represents an annual saving of life per 1000 of 1-3. But it
is a singular fact that in Liverpool, Birmingham, Bristol,
and Wolverhampton even more was effected without notifi¬
cation. The aggregate population of these four towns in
1881 was 1,239,872, and their average density 57'3 persons
to an acre. In the period 1871-76 their average death-rate
from the diseases above named was 2'64 per 1000 (or 0'5
above that of Dr. Cameron’s eight towns in the pre¬
notification period); whereas for 1881-86 it was reduced to
I'Ol, and in 1887 to 0-82. The saving of life indicated
between 1871-76 and 1881-86 was 1-63 per 1000 annually,
and, if we take 1887 alone, it reached 1'82. Taking every¬
thing into consideration, Leeds and Brighton may well
g uise before incm-riDg the expense of the Notification Act.
oncaster and other wary towns have decided to do as they
have done, and calmly await the promised proof of the
efficacy of the mucli-belanded system, a proof which cer¬
tainly seems long in coming.
I am, Sirs, yours faithfully,
Kiiig9ton-on-Thameij, Dev. 22itd, 1803. D. BlDDLE.
Coogle
112 The Lancet,]
URTICAKIA DUE TO PRIMULA OBCONICA.
[Jan. 10,1891.
URTICARIA DUE TO PRIMULA OBCONICA.
To tht Editors of Tub Lancet.
Sirs,—T hree cases of urticaria, one followed by ery¬
sipelas, occurred in my practice last year, all undoubtedly
due to the handling of primula obconica. In all three cases
the usual characteristic symptomsof urticaria were present—
violent irritation, followed by appearance and disappear¬
ance of wheals and erythematous rash, going on in one
case to severe erysipelas of the face, necessitating the
usual treatment. The patients were ladies who, with
their brothers, had started a market gardening busi¬
ness in this county, and were all (with two other
sisters and the brothers, who did not suffer), con¬
stantly handling this useful but obnoxious plant. I
quite failed to discover the cause of the complaint,
until attention was called to similar cases oc¬
curring ml America, and recorded in a gardening paper.
I was unable to discover what part of the plant was the
irritant, but suspected the very numerous stiff hairs with
which the leaves and stems of the plant are covered. I
always found that when any of the patients left home for
a few days they quickly got well, and the disease returned
on rehandling the flower. As soon as I had read of the
cases that occurred in America the primula obconica was
banished, and neither it nor the urticaria has been seen
since in my patients’ house. The mother of the two
younger patients, who were under twenty-five, was middle-
aged. The late correspondence on the subject of eczema
caused by primula obconica escaped my observation,
though I see The Lancet every week, and 1 was only in¬
clined to offer for publication my cases after reading
Dr. Bard’s (Shrewsbury) remarks in your last number ana
the appearance of his case of eczema due to handling of the
leaves of the Virginian creeper.
I am, Sirs, yours faithfully,
PantyroUin, Llandebie, Jan. Ofch, 1S91. GERALD SOUTHERN.
SOUTH AFRICA AS A HEALTH RESORT.
To the Editors o/The Lancet.
Sirs,—D uring the past eighteen months or more an
unusually large number of phthisical patients have been
induced to visit South Africa in search of its reputed
health-restoring iniluences, and perhaps it is not out of
season now to observe that the effect upon those who elected
to try this inland high (4500 feet) and dry (’’) district has nob
been by any means encouraging, a large percentage dying
during the first year or so after landing in this colony, the
cause of death being chielly due to the exhausting in¬
fluence of repeated and severe attacks of bjcmoptysis.
Pew seemed equal to the vicissitudes of the climate, but
one might add here such non climatie, injurious, pre¬
ventable influences as bad housing, a defective and same¬
ness of diet, unskilled nursing, aosence of paternal care
(nostalgia), the want of inclination or ability for taking
plenty of out-door exercise, absence of invalid appliances,
continued detention in ill-ventilated rooms, with terribly
defective or indeed total absence of proper sanitary con¬
veniences. Again, there may be undue excitement, in¬
dulging in late hours, kept up frequently by incessant and
untimdy visits of curiosity seekers, anxious to see new¬
comers from the mother country. These attentions Hatter
the invalid to renewed exertion, to produce the impression
“Oh,I’m not so ill,” <&c. Whatever the cause or causes,
the result is not encouraging. Again, I have witnessed the
most distressing anxiety and depression caused by the
knowledge of the funds being well-nigh exliau.sted, with
no prospect of replenishment—a condition enough to worry
the strongest. It seems to me that some young patients
arrive from “ homo ” with the idea that they have but to
step upon African soil and to sniff tbo air to effect a perfect
cure, when they will be able to support themselves. Alas !
when these false hope.s or ideas die out, life as a rule dies
out also. It should be clearly understood by invalids that
South Africa is probably one of the moat expensive health
resorts, with no quid fro g\i.o in the shape of comforts, A:c.
It might be well to note also that one inllnence this climate
appears at first to exert upon sufferers in the secontl or
third stage of this disease is that of a marked feeling of
benefit. Such patients, as a rule, speedily succumb. There
seems to be no intermediate influence, and those in an
early stage of the disease, if they can only battle through
the first eighteen months or so, generally experience per¬
manent benefit. The rule seems to be to improve quickly
or die quickly. This fact considerably increases the re¬
sponsibility or selecting the right cases. It should also be
remembered that during the changes of seasons the tempera¬
ture may vary from much below freezing-point up to 92°,
100% to even 120° F. in the shade, and that within twenty-
four hours it may be necessary to change thin for thick
clothing, or vice versd, more than once. The altitudes
range from 15. ft. to over 6000 ft. above sea level.
We have also hot, dry, stifling, and hot, moist, relaxing
winds, with dust storms and fly pests thrown in as a
change—in other words, we experience the extremes of heat,
cold, draught and moisture and their consequences; still,
we are frequently indulged w-ith delightfully cool morning
and evening breezes during the hot seasons, with a cool,
refreshing shower of rain occasionally. There are some
excellent cases of recovery, following actively various
callings.; but these cases do not include the kind which
have arrived during the past year or more—most of the
recovered cases I refer to came out at the earliest stage of the
disease,—backed up with sufficient means to pilot them
over at least the first twelve months without causing
anxiety on this score. . I learn that some derive most
benefit by travelling about in suitable ox waggons, as I.
have so frequently advocated—this nomadic life is very
pleasant when properly conducted—mixed with a little
shooting and fishing, and not a bit more expensive than
most of our hotels. There is one advantage South Africa,
possesses as a health resort over most others—i.e., those-
wbo recover and elect to become colonists can do so, for,
as a rule, suitable employment can be obtained in the
neighbourhood where they have derived the most benefit,
instead of being obliged to return to the land which may
have given birth to their ailment. This appears to me to
be a boon which should not be overlooked when advising,
invalids.—I am, Sirs, yours truly,
S. Cartwright Keed, M.D., F.R.C.P. Edin.
Hei'schel, Capo Colony, November, 1800.
SECRET REMEDIES.
To the Editors o/The Lancet.
Sirs,—N ow that the first excitement over Dr. Koch’s
fluid has to some extent passed away, I have heasd various-
opinions expressed as to the visits to Berlin by so many
leading physicians and surgeons to obtain samples of and
use a fluid of whose composition they are still kept ignorant.
As a junior practitioner I have to ask if it be wise or even
in accordance with the regulations of University degrees-
and the diplomas of the various Colleges, that British
medical men should thus take upon themselves the respon¬
sibility of using on their patients a remedy which has cer¬
tainly proved fatal in a certain number of cases. Why has
not Dr. Koch put his discovery on the same footing as all'
true and great discoveries for the benefit of humanity have
been put from the very beginning? Why does he stilt
retain the secret remedy in his own bands, receiving
Government grants and making many of his own and our
practitioners come dangerously near recommending, if not
actually using, a secret remedy which, if associated with the
name of a less celebrated man, would most assuredly be
openly called a quack one ? No doubt the widespread and
popular interest has had a great deal to do with the precipi¬
tancy ; but this should not overcome the good sense of tne
medical profession. Already in Austria, and also in some
parts of Prussia, stringent regulations are being made, which
clearly show how rapidly the treatment is turning into the
too long list of empirical specialties. No one wishes to de¬
preciate Dr. Koch’s work, which only great patience, skill,
and perseverance could have overcome ; but it will be hi»
own fault if a reaction takes place which will relegate his fluid
and treatment to the limbo of empiricism. May not this be
avoided by a full and free explanation of the composition of
andtheraffona/cof the treatineutby his fluid, and, if necessary,
a complete cessation of its limited distribution to general
practitioners in his own or any other country until such
time as a sullicient number of cases of indubitable cure or
improvement has been reported ? Doubtless it may ho
argued that it is only by extensive trials that trustworthy
statistics can be compiled, and rightly so, if all those who
use this lymph knew what it is and the rationale ot its
The Lancet,]
DISINFECTION IN LONDON.
[Jan. 10,189L 113
eatioQ. Nothing will bring it more rapidly into disrepute
as a legitimate tnerapeutic agent than the fact that all who
have used it, or intend to use it, are kept ignorant of its
composition. It follows, therefore, that, until such dis¬
closure be made. Dr. Koch’s liquid runs the serious risk of
being classed as illegitimate. May I ask if any of the
universities or colleges has sanctioned the use of this secret
remedy by individual graduates and diplomats, who have
had it supplied to them and have used it, and also if they
have been guilty of any infringement of their qualification
as practitioners ? Perhaps the universities and colleges
may answer this through the columns of your old-estab-
aished journal.—I am, Sirs, yours truly,
J. Christian Simpson, M.B. Edin.
DISINFECTION IN LONDON.
To the Editors of The Lancet.
gjT^< 5 ^—Iq the report of The Lancet Special Sanitary
‘Commission upon this subject, it is stated that “ the dis¬
trict of St. Pancras has built itself a steam pressure stove
which is a copy of the stove employed by Mr. Lacy, who
formerly did all their disinfecting work.” The high pres¬
sure steam stove in use in Sb. Pancras is the Nottingham
patent steam disinfector, and was erected by Messrs.
Coddard, Massey, and Warner of Nottingham. It came
specially under my notice in a paper read in April,
1889, before the Society of Medical Officers of Health by
Dr. Tomkins of Leicester. It is constructed on a prin¬
ciple similar to that introduced by Professor G. van
Overbeck de Meyer of Utrecht. The Sanitary Committee
of the St. I’ancras Vestry visited the Fever Hospital at
Ilornsey and there saw the chamber in practical working.
TheSb. Pancras machine, like each of its predecessors, had
suggested improvements of detail introduced during con¬
struction. It was erected in the months of September and
October, 188)), displacing a hot, dry-air chamber, and
came into use concurrently with the Infectious Disease
Notification Act. During these two months Mr. Lacy dis¬
infected the bedding, clothing, &c., the parochial officers
doing the fumigation «&c. The cost of disinfecting the
bedding &c. during this period nearly equalled the coat of
the new chamber. TdeaearethefactsconcerDingSt. Pancras.
I am, Sirs, yours obediently,
John F. J. Sykes.
. Medical Officer of Health.
Vestry Hall, Pancra«-roa(l, Jan. Ctli, 1891.
P.S.—As to the methods pursued in St. Pancras, I beg
Sierewith to enclose you copies of my Annual Report for
i889, and would refer you to pages 18-20.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Workmen's Dwellings in Neiucastlc.
Canon Franklin, who has given much attention to
the housing of the working classes in Newcastle, in a speech
an the Central Hall last Saturday gave some of his exjieri-
<0068 in this city, which are not a little startling. He
stated that there Avere four miles of underground dwelliugs
dn Newcastle, places where the light never came in except
filtered through a dark medium, and with dripping walls
Such tenants saw nothing but misery in their houses, and
could not ailord to live upstairs. He believed houses were
dearer in Newcastle tliah anywhere else. To be near their
work men must live in hovels underground, breathing a
damp atmosphere, or pay a higher rout than they could
afford, and were thus, he believed, often driven into the
public-house for comfort. He also nientioned the fact
'that lately more than 1000 people were driven out of one
’Street to make room for post-office and other extensions.
'Canon Franklin in this matter has taken up a great and
important matter, aud it is to be hoped he will continue to
direct public attention to ib, so as to move our rather inert
•and dilatory municipal authorities. He has likewise very
'Opportunely shown that a long-wished-for Actof Parliament
•comes into force this week, which if acted upon must have
before long a beneficial effect. It provides that any four rate-
may sign a requisition calling on the medical officer
•of health to visit any property they consider unfit for
habitation. The medical officer must then visit and report.
If be considers the houses unfit for habitation, the corpora¬
tion is bound to close them, and before closing them it must
provide suitable dwellings for the dispossessed tenants. He
suggests that a small association of independent citizens
might be formed into a vigilance committee to look after
the insanitary dwellings of the poor.
Sunderland.
The sanitary state of Sunderland is not at present good,
as evidenced by the death-rate of last week—viz., 32'5 per
1000. This, I believe, is the highest rate of the past year,
and exceeds the birth-rate. It is to be hoped that this state
of things is exceptional, and depends upon the climatic
changes we are experiencing in the north now m common
with the other parts of England. Mr. T. W. Bac^ouse has
forwarded a cheque for £200 in aid of the building for the
Sunderland Bye Infirmary. Mr. Arthur Backhouse has
sent a cheque ifor a similar amount, and £100 has been con¬
tributed by the Wearmouth Coal Company. The secretary
of the Sunderland Infirmary has also received £500 from
Mr. Arthur Backhouse in aid of that institution.
A Consumption Hospital for Newcastle.
Mr. Arthur T. Wear, of this city, aud one of the honorary
medical officers of the Chest Hospital, has written a letter
to the Newcastle Joui-nal, pointing out the need for a
properly equipped consumption hospital for Newcastle. He
cites the death tables, which indicate that in the year 1889
the deaths from consumption in this city, out of a total from
all causes of 4038, were 387, and also that the industries of
the district and its geographical situation favour consump¬
tion and all pulmonary affections. Mr. Wear has done
good service in drawing the attention of our citizens to
this acknowledged want, which, if once properly taken in
hand, could be soon supplied, and the present prosperous
times are most opportune. I believe that the working
classes of Newcastle—I mean, of course, the artisans—
could easily build and support such a hospital, but it will
require time and work before they see its necessity^
South Shields.
I regret to notice the death from typhoid fever, after a
very brief illness, of Mr. T. M. Hall, the secretary of the
Ingham Infirmary at South Shields. Mr. Hall was a son of
the late Mr. J. L. Hall, J.P., and at the time of his death
was only thirty years of age. He was much respected by
the profession at South Shields and deeply regretted by all.
It is reported that there is another extensive outbreak
of typhoid fever at Stockton, and that the distribution of
the cases points to a common cause.
Newcastl®-on-Tyne, Jan. 7bh.
SCOTLAND.
(From our own Correspondents )
EDINBURGH.
Health of Edinburgh during 1800.
The mortality of Edinburgh last year was 4990, making
the death-rate 18'4 per 1000. Of the total deaths, 1880 were
under five years, and 1237 above sixty years of age; of
these, 243 were above eighty, 26 above ninety, and 1 above
a hundred years. Diseases of the chest caused 1660 deaths,
aud zymotic diseases 695, of which 44 were due to typhoid,
85 to diphtheria, 46 to scarlatina, 241 to measles, 243 to
whooping-cough, aud 35 to erysipelas. The iutimationa for
the year numbered 6825, and included 6 cases of typhus fever,
500 of typhoid, 361 of diphtheria, 1197 of scarlatina, and 4761
of measles. In the City Hospital 1578 cases had been treated.
There were 7177 births registered daring the year.
The Edinburgh Public Health Committee and the Koch
System.
A little time ago the committee of the Victoria Dispen-'
sary made an application to the Public Health Committee
to have some beds set aside in the City Hospital for the
reception of cases of phthisis to be treated with Koch’s
liquid. The committee resolved to recommend the magis¬
trates and Town Council to decline to receive such cases.
They will certainly have the support of the profession here
in this decision.
Edinburgh University Returns for 1890.
During the past year the total number of matriculated
Digiiized by v-J
oogic
114 Thb Lancet,]
, SCOTLAND—IRELAND.
CJan. 1(S 1895.
sbadents was 3503, as against 3160 in 1880 and 1768 in
1870. Of the total number, 1979 were in the faculty of
medicine ; of these, 814 belong to Scotland, 687 to England
and Wales, 58 to Ireland, 99 to India, and 270 to various
British colonies. In the same faculty 54 candidates received
the degree of M.D., and 219 the conjoint degrees of
M.B., C.M. The annual value of medical scholarships
and bursaries amounts to £2560.
Annuol Be-port of the Edinburgh Boyal Infirmary.
The annual meeting of the contributors to the Royal In¬
firmary was held on Monday, and had submitted to it the
annual report. From this report it appears that between
October, 1889, and October, 1890, the total number of in¬
patients was 8695. Of these, 3648 were dismissed cured,
3121 relieved, 685 dismissed on other grounds, while 634
died in the hospital. Of the cases brought to a termination
3619 were medical, and 4478 were surgical coses. The
average daily number of patients in the hospital was 64.3,
the greatest number at any one time being 699. The per-
centage of deaths was 7‘0, and, deducting cases which died
within forty-eight hours after admission, ic was only 5'3. The
ordinary income was £31,552 6^. 9<f., and the expenditure
£37,945 15s. Legacies and donations of £100 and upwards
amounted to £12,993 1.9. St/. This report completed the
first decade of the New Infirmary, and during that time the
medical cases had increased by 67 per cent., and tho sur¬
gical by over 88 per cent. It was further intimated that an
increase in the accommodation at the Convalescent Hospital
was under consideration and was much needed.
Health of Edinburgh.
The mortality last week was 112, and the death-rate 21
per 1000. Diseases of the chest caused 50 deaths, and
zymotic diseases 16, of which 7 were due to typhoid fever and
5 to whooping-cough. The intimations for the week com¬
prised 31 cases of typhoid, 2.3 of scarlatina, 5 of diphtheria,
and 7 of measles.
Illness of Surgeon-General Fnsson.
Surgeon-General Fasson, the superintendent of the Royal
Infirmary, is so seriously ill that the annual gatlrering of
nurses and other entertainments which take place at this
season have been postponed. Last year they experienced a
similar disappointment by the illness of the matron.
Edinburgh, Jan, Otli. _
ABERDEEN.
Boyal Infirmary Hospital Sunday.
The 4th inst. was Hospital Sunday for the Royal Infir¬
mary, and the collections already intimated show that the
total amount will at least equal that of last year. An
abstract of the number of patients received into and dis¬
missed from the Royal Infirmary was annexed to a letter
sent by the directors to the dill'erent churches to show that
the “institution deserves in fullest measure the support of
the public.” The abstract shows that on Jan. lat, 1890,
there were 155 patients in the hospital, and that during the
year, up to Dec. 2lst, 2015 were admitted, 955 were cured,
631 were improved, 269 were dismissed at desire or as unfit,
and 148 died. On Dec. 2l8t there were 167 patients in the
hospital. In their special appeal the directors state that
the ordinary income will fall considerably short of the ex¬
penditure, a circumstance arising almost entirely from
additional cost under the beads of medical and surgical
requirements, and increased outlay in connexion with
laundry Avork. The church collections for 1890 amounted
to £1640.
Health of the City.
The following cases of zymotic diseases were notified last
week to the medical officer of health; Measles, 7 ; scarlet
fever, 17 ; and diphtheria, 1.
Is Cheese Meat ?
Last week the sanitary inspector petitioned the magis¬
trates to grant an order to have forty-seven cheeses de¬
stroyed which be considered unfit for human food. The
agent for the owner of the cheeses objected to the petition
being granted because cheese was not included in the
section of the Public Health Act under which the petition
was made. After an adjournment, the magistrates decided
that “the objection was well founded.” “The 26th section
of the Public Health Act, under which the petition is
brought, mentions specifically,” they said, “the various
articles which, if unfit for human food, may be seized by
the sanitary inspector. Amongst these cheese is not men¬
tioned, and although it was maintained that, having regard
to and intention of the Act, such an article of food as
cheese might fairly be held to be included under the
term of ‘meat,’ we do not see our way to give effect to>
that contention. We accordingly sustain the objection
and dismiss the petition.”
Jan. Cfch.
IRELAND.
(From our own Correspondent.)
TlbO Public Health of Belfast.
Mr. Conway Scott, C.E,, the executive sanitary officer
for the city of Belfast, has prepared a very interesting and
able report on the question of the removal of refuse matter
from the dwellings in the city. After pointing out that
Belfast has a population of nearly 250,000, with 48,000'
dwelling-houses, besides workshops, warerooms, factories,
and mills, he shows that at present each house has an-
ashpit in the yard in which usually more than a ton of
refuse matter can be held. When it is full the pit is
cleansed and its contents removed on payraept of Is. per
load. In cases of sickness and poverty no charge is made.
The objections to this plan are : First, that the pit is not
cleansed until it gets fall, aud in this way a pollution of the
atmosphere takes place in the vicinity of the dwelling
secondly, to save the cost of removal tenants in small houses
tlirow the contents of the ashpit into tlie adjoining passage,
lane, or street (a most objectionable practice); and, thirdly,,
as the floor of the pit is rarely concreted, liquid matter
percolates the subsoil with offensive material. Starting
with the maxim that in sanitary matters “prompt
filth removal ” is of primary importance, Mr. Scott points
out what has been done in Rochdale, Edinburgh, aud
Birmingham, and states that his opinion, after fifteen^
years’ careful study of the subject, is that the system of
disposal which he would recommend for Belfast is the rail¬
way system, which can be utilised to transfer the filth of a
city, from where itis a nuisance and a danger, to thecountry>
where it is a source of prosperity. He recommends that-
four small experimental districts be formed, and that during
next year a daily or weekly removal of filth be carried ouC-
in each by the city scavengers, and that the refuse matter
be removed to the nearest railway depfit, and thence to the
country. (During the past year 10,000 tons of city manure-
were sent to the farmers in the country by rail, and the-
domand exceeds the supply.) At the end of the year the
sanitary condition of those districts, with their death-rate,
can be compared witli other parts of Belfast, and the prac¬
tical details of the system of filth removal best suited to-
Belfast can be gradually fixed and the cost ascertained.
Ofirer of Health, for Belfast.
I understand that the Local Government Board have-
approved of the appointment of Dr. Whittaker as medical
superintendent officer of health for the city of Belfast.
The Belfast School ami the Boyal University.
Owing to the death of Dr. Anthony Corley of Dublin, a-
surgical Fellowship in the Royal University becomes vacant,
and for the post Dr. John Walton Browiie, senior surgeon
to the Royal Ho.spibal and to the Belfast Ophthalmic
Hospital, is a candidate. The Belfast students have sent a
memorial to the University urging that Dr. Browne should*
be appointed, on tlie grounds that, while the Belfast School
of Medicine contributes nearly 50 per cent, of the candidatee
for the M.B, of the Royal University, there is only on©
examiner from that school at this examination.
PARIS.
(From our own Correspondent.)
Experimental BescarvJies on Cow-pox Vaccination in the.
Calf
MM. Straus, Chambon, and M6aard reported to th©
Academie des Sciences on Dec. 22nd, 1890, the results of
the experiments conducted by them for the past two yeara
on the above subject. They find that the inoculation of
cow-pox lymph into the cornea provokes, in six or seven
Toogle
Dlyinicu uy
The Lancet,
PARIS.-BERLIN.
[Jan. 10,1891. 115
.days, keratitis, characterised by opacity of the coruea,
intense congestion of the conjunctiva, pliotophobia, and
lacrymation, the operation conferring immunity, but not
sd rapidly as in subcutaneous inoculation. The same
operation practised on a calf previously rendered immune
by subcutaneous inoculation leaves the cornea unatlected.
Inoculation into the anterior chamber is as surely, and
almost as rapidly, protective as the ordinary subdermic
operation, a considerable degree df inllammation of the
.cornea and iris being excited. The intra-venous transfusion
of even a feeble quantity of vaccine confers complete
immunity without producing either local or general dis¬
turbance. The same immunity was conferred on a calf
into whose veins the blood of another calf presenting the
characteristic eruption of cow-pox at its height had been
injected. The weight of blood transfused, however, must
not be less than from 4 to 6 kilogrammes. The transfusion
ef Si kilogrammes of the blood of a calf previously protected
by vaccination, and weighing 148 kilogrammes, failed
to protect an animal of the same species, tuns proving the
’interesting fact that the transfusion of nearly the whole of
the blood of a protected animal is inefficacious as a pvophy-
iactic measure. Pinally, cow-pox vaccine mixed with an
equal volume of sterilised houillon, and then filtered, proved
-to be worthless as a protective agent.
Therapeusis of Be,vr.o-phoiwnoid.
M. Galezowski read, on the 27th ulb., to the Soci6te de
flJiologie, a communication on the application in ophthal¬
mology of this new bactericide, discovered by him and M.
Retit. They have succeeded in producing, by the decom¬
position of an aniline dye, a definite compound (tebramethyl-
diapsido-benzo-phenoid), which they propose to call by the
'less formidable name of benzo-phenoneid. This product is
•endowed with the same powerful microbicide properties as
pyoktanin, whoso chemical composition is unknown. Soluble
in lOOparts of water, the solution, further diluted a huiidred-
'fold, vs neither caustic nor irritant. Applied locally, it
has proved very efficacious in causing the rapid and painless
-cicatrisation of ulcers of the cornea M'hich had resisted all
other methods of treatment. It has given also good results
-'in purulent keratitis and chronic phlyctenular ophthalmia.
Deaths of Dr. Baillarger and M. E. Richard.
An eminent alienist, whose name must he familiar to all
•students of mental medicine, has just been removed by
death in the person of M. Baillarger. M. Emile Richard,
who died of broncho-pneumonia on the 27bh ult., aged
forty-seven, was better known as a militant politician than
•as a practitioner. He occupied at his death the onerous
•and important post of President of the Paris MunicipoJ
-Council, and was also the political editor of the daily paper
La CiU. He recently presented to the body over whose
deliberations he presided a somewhat elaborate report,
subsequently published in volume form, on prostitution.
Retirement of Pans Hospital Phydeians.
The fidlowing eminent Mcdecins des Hdpitaux de Paris,
having attained the age of sixty-five—the limit prescribed for
•compulsory retirement—are this year, with two exceptions,
a-eleg.ated to honorary functions: MM. Charcot, Potain,
Mesuet, Vidal, Laboulbbne, and Edrcol. The exceptions
are_ Professors Charcot and Potain, who, in virtue of their
position as clinical professors of the faculty, are exempted
'from the application of the above rule until they reach the
age of seventy. Even then M. Charcot, who adds to his
numerous honours that of being a Member of the Institute,
will be at liberty to retain bis post at the Salphtrihre for a
further period of five years—Lo., until 1900. The numerous
admirers of this famous pioneer in the scientific study of
diseases of the nervous system will rejoice to learn that the
regulation affecting less known colleagues will nob, for some
considerable tinve, debar him from continuing the researches
■which have shod such lustre both on himself and on the
school of neurology, the creation of which is largely due
to his genius and initiative.
Koch's Liijidd.
Your readers will have gathered from these pages th
Preuch physicians find it dilliculb to become reconciled
tlio secrecy observed concerning the convposibion of Koel
Ri'atique, Dec. 18t
S89U) tormulates an opinion that the appearance of tl
liquid as a therapeutic agent has been premature, and 1
conaiders that its employment should, for the present, !
confined to the laboratory. Assisted by MM. Cdrdmonie
and Gautrelet, he has subjected Koch’s fluid to analysis
and found that the active principle is an amine. These
observers have succeeded in reconstituting, synthetically, a
substance — christened patriotically by them la lymphe
Fran(;,aise —which presents the same organoleptic, physical,
and chemical properties as the German liquid. The com¬
position of this indigenous product will be divulged as soon
as the results of inoculatory experiments now proceeding
on sound and tuberculous animals of divers species have
been verified.
Animal v. Human Lymph.
In reply to the question propounded by the Board of
Health of the .Department of the Seine by tba Prefect of
that territorial division as to the advisability of sub¬
stituting animal for human lymph in vaccination, Dr.
Lancereaux, specially deputed to report on the subject,
pronounces decidedly in favour of the animal product, and
recommends the discontinuance of human lymph. The
reasons adduced in support of this conclusion are the
immunity from risks of communicating syphilis, erysipelas,
lymphangitis, &c., and the greater facility of procuring the
calf lymph in a pure state, the source being picked animals
placed under the most favourable hygienicconditions. M. Lan¬
cereaux attributes to the general employment of calf lymph
the increasing favour with which the practice of vaccination,
and especially revaccination, is regarded in France.
Paris, Jan. 0th. __
BERLIN.
(From our own Correspondent.)
Ferdinand Cohn and Robert Koch.
At a time when all the world is talking or has just been
talking about Robert Koch, the following word portrait of
him by a distinguished man of science who has known him
for many years is likely to interest many. It is from the
January number of the Deutsche Revue, and its author is the
famous botanist, Professor Ferdinand Cohn, of Breslau.
“ When I made Koch’s acquaintance,” he writes, “ he was
already the great investigator whom all the world now knows
and aamires. On the 22nd of April, 1875, I received a
letter from the district physician, Dr. Robert Koch, of
Wollstein, in the district of Bomst, in the grand-duchy of
Posen, asking whether I would allow him to visit me in
Breslau, and perform before my eyes the chief experi¬
ments relating to anthrax and its characteristic bacilli,
the history of the development of which he believed
he had now discovered after prolonged investigations, and
with it the etiology of that destructive disease. I had
been myself engaged for yeara past with bacteriological
investigations, and liad consequently often received an¬
nouncements from dilettanti or their alleged discoveries
in that field, which was then being cultivated with but
little i^recision; the expectations, therefore, which that
letter from an utterly unknown physician in a Polish
country town inspired in me, were of the smallest. I of
course wrote, however, that I should he very glad if Herr
Koch would visit me and show me his things (“seine
Sachen”). Koch came to my institute on April 30th, and
I can truly boast that in the first hour of our intercourse I
recognisoa in him an unequalled master of scientific investi¬
gation ; his method, proceeding with rigid consistency from
step to step, the elegance and certainty of his experi¬
ments, the classic clearness of his statements, were all
as perfect in his first, then just completed, work on
anthrax as in all his later researches. For Koch’s
works are distinguished from those of most investi¬
gators by the circumstance that he does not publish
them till they are finished to the last point. Others
cart up stones to be used in the building up of science,
or draw a new plan or add a now wing, a new storey, a
new roof, but they finisli only the brickwork, and leave
it to others to complete the building and make it habitable.
Koch,‘on the other hand, does not let his scientific
fabrics leave his hands till he has made them com¬
pletely fit in all their details as well as in the main
for the use of other.s_, who have then nothing more
to do than to add this or the other little furnishing.
All Koch’s works have been so complete in form
and contents that nothing remained for those that
followed but to confirm them, for it was not po.ssible to add
Di(.
lift Tbb Lancet,]
VIENNA—NEW YORK.
[Jan. 10,1891.
anything essential. Snch were tlie first work of 1876 on
anthrax, that on wound infection, the numerous treatises
in the communications of the Imperial Ofiice of Health,
the magnificent researches on the tubercle and cholera
bacilli, and such beyond doubt his latest discovery will
prove. On his first visit in May, 1876, Koch stayed
only a short time in Rreslau, and 1 availed myself of the
opportunity to make my llreslau colleagues personally
acquainted with him and his researches. I then remained
for years in occasional correspondence with him. His
letters generally filled several sheets. He repeated his visits
to Breslau too ; and when the place of a medical expert in
the law-courts there fell vacant in the summer of 1879, we
succeeded in getting him appointed to it, with the prospect of
an extraordinary professorship in the University. But
already in January, 1879, themedical faculty of theUniversity
of Berlin had of its own accord proposed to the Minister
Koch’s appointment to an extraordinary professorship, and
the establishment of an institute for him. Some papers
say that Koch wished to establish himself as a private
lecturer in Breslau, but was refused permission. That
is utterly untrue. The proposal of the Breslau faculty
had been made without Koch’s knowledge. His worlc
as a medical expert in the law courts could not satisfy him
either scientillcatly or pecuniarily, and he returned aher a
few months to Wollstein, where his place as district phy¬
sician had been kept open for him. That he did not remain
there long, but was called to the newly founded Imperial
Office of Health in Berlin in 1880, did great honour to the
German Government, and was of great advantage to science—
nay, to all mankind. But if you ask me for reminiscences of
conversation with Koch, 1 can only say that in personal
intercourse Koch makes the same overpowering impression
as in his writings by the clearness, depth, and novelty of his
thoughts, only chat this impression is greatly enhanced by
the simplicity and amiability of his manners, the look of
hu deep-set eyes, his fine smile, and the euphony of his
voice. In conversation with Koch one is often positively
dazzled by occasional remarks or short questions, indicating
still unknown researches that he has been working at for
years, and revealing new scientific liorizons. But of details
of the conversations which I and my then assistant, Dr.
Eidam, had with Koch, and which sometimes lasted deep
into the night, I have no remembrance.”
Professor Martins.
Dr. Friedrich Martius, private lecturer in the University
of Berlin, has been summoned to Rostock as an extra¬
ordinary professor. Dr. Martius studied in Berlin, and
graduated here in 187-t with a treatise “on prophylactic
tracheotomy in the field.” After his graduatiou he served
as a surgeon in the army. In the beginning of the eighties
he came as staff-surgeon to the Friedrich Wilhelm Institute
here for the training of army surgeons, and was at the same
time appointed one of the Charitc physicians. He was also
for some time assistant in Professor Gerhardt’s clinic. Ills
last post was that of a physician in the railway regiment.
Dr. Martius’ scientific studies have been directed mainly to
diseases of the nerves and of the heart. He has made dis¬
coveries concerning the motion of the heart and heart heathy
means of the so-called “marking method ” devised by him.
His writings on tetanus, tabes dorsalis, electric diaguosis,
and the direction of the fibres in the central nervous system
are of special importance. lie is in his forty-first year.
Berlin, Jan. Cth.
VIENNA.
(From oue own Corebspondent.)
The Chemical Analysis of Koch's Liquid.
A SECOND chemical examination of Koch’s remedy has
been carried outliereat a private laboratory. The results
obtained by the first analysis, and repotted to The I-ANCKT
some weeks ago, have been confirmed thereby. It may
only be added that the liquid was found to contain 60 11 per
cent, of water. Wlien the liquid is treated with nitric acid
at ordinary temperature no change is to be observed, but if
boiled with nitric acid a light greenish-yellow colour
appears, and by adding a few drops of ammonia this
solution assumes a beautiful golden - yellow colour,
which, spectroscopically examined, then exhibits an
absorption band between h and F (at the limit of the
green and violet field), while the original solution of
the lymph, when treated with ammonia alone, does nob
yield such a reaction. When Koch’s lymph is treated with
an aqueous solution of tannic acid the albumins are per¬
fectly precipitated. The white, voluminous precipitate
formed in this way is perfectly soluble in hot water, and’
precipitates again oy cooling. It dissolves also in a solutioD
of common salt. When the precipitate obtained by tannicr
acid is treated with a few drops of diluted potassic hydrate
it disappears, and the solution thus formed assumes a
yellowish-brown colour, which becomes gradually reddish-
brown by the contact with air. This brown solution,
examined spectroscopically, exhibits also an absorption-
band between b and F, which is extremely similar to the
spectrum of urobilin. By elementary analysis the quantity
of carbon was determined to be 35 19 per cent., the quantity
of water 7’02 per cent., and the nitrogen, determined by
Dumas’ method, amounted to .I’90 per cent. The quantity
of the lymph being too small, it was impossible to separate
the different albumins, but the chemists believe that ther
active principle belongs to the class of toxalbumins.
Koch's Treatment.
The progress of the cases of lupus towards recovery re¬
corded in my former letters to The Lancet w’as observed
also during the last week here. At Schroetter’s clinic tho
cases of tuberculous laryngeal affections which have been
treated by Koch’s lymph for some weeks have shown no
sign of any improvement, and in one of them tracheotomy
had to be performed on account of the severity of the re¬
action. In the majority of the cases of pulmonary phthisis
I have seen here under treatment, a considerable loss of
bodily weight, amounting even to four kilogrammes in the
course of two weeks and a half, could be stated. My atten¬
tion has also been drawn to the fact that, besides the other
changes produced in the tuberculous tissues by the-
injections, the frequent occurrence of some micro¬
organisms has been observed, the nature of which is>
to be studied here now, as they are said to differ from-
the other micro-organisms observed in inllammatory
processes and from the tubercle bacillus. According to a
communication made before the Prague Medical Society by
Professor Chiari, who made the nost-mortem examination
of three cases treated by the lymph, the pathological
changes produced by the injections consist chiefly of
hyperamiia, with hemorrhages, leucocytic infiltration,,
and fibrinous exudation. A peculiar distribution of the
tubercle bacilli has also been observed by Professor Chiari,
as tlie bacilli were to be found In greater abundance in the
lumen of the bronchi in tlie cases of pulmonary phthisis and'
on the bases oftheulcers intliecasosorincesbinal tuberculosis.
Vienna, ./an. 0th. _
NEW YORK.
(From our own Correspondent.)
Execution by Electricity.
The report of Dr. MacDonald, a State Commissioner, om
the execution of William Kemmler by electricity is tlie
first authentic and fall ollieial account of that transaction
which lias been given to tho public. From this report it ia
shown that the apparatus consisted of a stationary engine,
an alternating current dynamo and excitor, a Carder’s volt¬
meter, with extra resittanoe coil, calibrated for a range of
from .’$0 to 2000 volts ; an ammeter for alternating currents
from 010 to 3’00 amperes, a Wheatstone bridge, rheostat,
bell signals, and necessary switches; a death chair, with
adjustable head-rest, binding straps, and two adjustable
electrodes. The instant the circuit was dosed the body
was thrown into a state of marked rigidity, every fibre of
the entire muscular system being apparently in that fixed,,
rigid condition resembling tonic spasm; motion and con¬
sciousness were absolutely suspended, and remained so
while electrical contact continued. At the end of seventeen
seconds Kemmler was pronounced dead and the circuit
was broken. The condition of rigidity instantly ceased,,
and was succeeded by complete muscular relaxa¬
tion. Superficial discolourations resembling post-raorteiit-
changes appeared on the surface of exposed portions of the
body, especially the face. The body remained motionless
and appaicntly lifeless for half a minute, when there was
a series of slight spasmodic movements of the chest, with
the flow of mucus from the mouth. Though there was no>
Dini/i •
oogie
THE Lancet,]
OBITUARY.
[Jan. 10,18M. 11^
evidence of a return of coneciousneas or senaation, yet, leat
life was not wholly extinct beyond resuaeitation, the
current was reapplied and continued seventy seconds, when
amuke was seen to ieeuo from the spinal electrode, due to
scorching of the edge of the sponge, from which the
moisture had been evaporated; there was also some burning
of the body under the electrodes. The necropsy, made in
three hours, exhibited few important changes. The burned
integument on the back showed the spinal muscles under-
neaui to be cooked like overdone beef throughout their
entire thickness. The commissioner regards this method of
execution as a complete success, and advises certain modiQ-
cations of the law in order to perfect the system. Public
opinion, however, is by no means so decidedly in favour of
the new method. On the contrary, the shock which the
first accounts of the execution gave still indueuces the
masses, and it will require many really successful executions
by this means to create a favourable public sentiment.
Death of the Surgeon-General.
The sudden death of Surgeon-General Baxter removes
from official circles at Washington a man who has for many
years been one of the most prominent candidates for that
office. For a quarter of a century he has aspired' to that
position, and on several occasions the coveted prize has
seemed within his grasp, when by some singular chance it
has eluded him. Once he saw Ins nomination made out in
the Executive Office, and he thereupon went to the Senate
to receive the congratulations of his numerous senatorial
friends. Bub when the nomination was announced be was
amazed to find that he had been superseded. At length
success crowned liis efforts, and a few months since he
received the appointment. He expressed himself as in¬
tensely gratified, having attained the object of his life¬
long ambition. He had scarcely composed himself in his
official chair when he was stvic'ken with cerebral hmmor-
rhage, and died after three days’ illness. J)r. Baxter was a
man of indomitable energy and perseverance, and won
praise from his superiors in whatever position he was
placed. His death gives rise to the usual scramble of can¬
didates for tlie office, and it is impossible to predict who will
win the nomination.
Koeh's Ttemedg.
The profession and public are just now greatly excited
over the trials of Koch’s liquid at the several hospitals. There
ha.sbeenmuch rivalry in obtaining the firsbsupply of the liquid,
bub a neighbouring city, New Haven, proved bo be the suc¬
cessful applicant. Several packages have now been received
in this city, and the practice is being carried out with great
skill and cave in four or live hospitals. The results thus far
are the same as have been reported from Berlin. In due
time full reports will be made by the several operators.
hone Transplantation.
A novel method of transplanting bone is in progress in
the Charity Hospital. The patient is a boy who has lost by
necrosis a certain portion of a long bone. To supply the
deficiency a dog has been encased in a plaster-of-Paris
dressing, except Ids head and urinary and hucal outlets ; a
dissection of one leg has been made so as to expose the bone,
thefoothas beenamputated, and thebone placed in the already
prepared vacant space in the boy’s limb, the dog lying by
his side. Tlie progress of the case is said to be favourable.
New York, Dec. _
THE SERVICES.
Army Medical Rrservb of Officers. — Surgeon
James Mackay, 6ili (Fifeshirc) Volunteer Battalion, the
Black Watch (lioyal Ilighlande-i''), to be Surgeon, ranking
as Captain (dated'Jan. 7bh, 18i)l).
Naval Medical Service, — The following appoint¬
ments have been made at the Admiralty:—StaiV Surgeon
Edward Ferguson to the Forward (dated Sept. .'lOtli, 1S!)0).
Surgeons; George .Edwards to the Duke of Wellington,
additional; llicbard F. Bate to the Pembroke, additional;
H. W. Finlayson to tlie i/r*7«nri.jVf, for temporary service;
Richd. C. Munday to the Impregnable, addil.ional; Edwd.
C. Crldland, Frank Bradshaw, and Matliew J. OTtepan to
we Ftoirf, additional (all dated Jan. Obh, 1891); and Edwd.
I. Cook to the Spe.edice.ll (dated Jan. 2nd, 1891).
Vor.UNTKER Coiii'S.— Artillery: 3rd Kent (Royal
Arsenal): Surgeon S. Davies, M.'n., from the Volunteer
Medical Staff Corps (Woolwich Division), to be Acting
Surgeon (dated Jan. 7r.h, 1891).—let li'orfarsbire: John
Frederick Sturrook, M.B, to be Acting Surgeon (dated'
Jan, 7ih, 1891). — 1st Essex (Eastern Division, RoyaD
Artillery): Surgeon-Major (ranking as Lieutenant-Coloneil)
J. B. Kennedy resigns his commission; also is permitted
to retain his rank, and to continue to wear the uniform
of the Corps on his retirement (dated Jan. 3rd, 1891).—
9bh Lancashire: Acting Surgeon A. Jones to be Actingr
Surgeon (dated Jan. 1st, 1891), and will be considered'
to have received a commission of the same rank and date-
as that previously held by him in the 3rd Lancashire-
Artillery Volunteers.—19th Middlesex; Acting Surgeon
W. C. Adams resigns his appointment (dated Jan. 7th,
1891).—2Dd Volunteer Battalion, the GloucestefSliire Regi¬
ment: William More Hope, Gent., to be Acting Surgeon,,
(dated Jan. 7bb. 1891).—IsbSurrey (South London): Acting
Surgeon S. G. Milner retires on account of ill-health (dated
Jan. 7bh, 1891).—1st Cadet Battalion, the King’s (Liver¬
pool Regiment): William Evans, Gent,, to be Acting Sur¬
geon (dated Jan. 7bh, 1891).— Infantrij: Dover Brigade::
Surgeon and Surgeon-Major 0. F. Lewis, 2nd Volunteer
Battalion, the Royal Sussex Regiment, to be Brigade Sur¬
geon, ranking as Lieutenant-Colonel (dated Jan. 7bh, 1891).
Harwich Brigade; Surgeon and Surgeon-Major G. Sj
Elliaton, lat Volunteer Battalion, the Suffolk llegiment,
to be Brigade Surgeon, ranking as Lieutenant-Colonel,,
(dated Jan. 7th, 1891).— Hoytd Engineers (Submarine
Miners): The Mersey Division: Kichard Williams, Gent,,,
bo be Acting Surgeon (dated Jan. 3rd, 1891).—Ist Lanark¬
shire: Fredk. Vasey Adams, Gent., to be Acting Surgeon*
(dated Jan. 3rd. 1891).—2nd Volunteer Battalion, the-
Gloucestershire Regiment: Acting Surgeon A. F. Turner'
resigns his appointment (dated Jan. 3rd, 1891).
Volunteer Medical Staff Corp,'?.— The Maidstone-
Division: Charles Pye Oliver, M.B., to be Acting Surgeon,
(dated Jan. 3rd, 1891).
JOHN MARSHALL, F.R.S., F.R.C.S., LL.D., M.D.,
By the death of Professor Marshall we have lost one of the-
ablest of British surgeons, one of our keenest scientific in¬
tellects, and one who stood high as a medical politician.
John Marshall was born seventy-two years ago in the amall^
catliedral city of Ely, where his father, William Marshall,
was in practice as a solicitor. He and his two brothers were-
all of them men of mark in their respective professions. The-
eldest, William, succeeded to his father’s practice, and also-
served as coroner of Ely. He was a man of very remark¬
able ability, but in the quiet sphere in which his life was-
passed lacked opportunity'to display it to the full. Ho was-
an admirable naturalist, and, in particular, we may mention
that he it was who first traced out the life history of tb©
American pond weed, which suddenly made its'appear¬
ance in this country and blocked up ponds, canals, and
rivers; and he showed that it had been introduced-
into our waters from across the Atlantic. The youngest
brother, Charles, also a very clever man, was for many
year.s vicar of Harpurliey, near Manchester. Joim was
sent bo school at Hingham in Norfolk, and suhsequentlv-
was apprenticed to Dr. Wales of Wisbech. In connexion
with tiiis, it is of interestto note that Mr. Marshall's recollec¬
tion of these apprenticeship days was nob such as to*
induce him to support the movement to reintroduce
the syafom. From Wisbech he came up to University,
College, London, when about twenty-one years of age, and
passed through his classes there with considei'able distinction -
lathe hospital lie served as house surgeon to Liston and
subsequently acted as liis private assistant. On leaving th©-
hospital ho started in practice at 8, Crescent-place,
Morningbon-crescent, aa a general practitioner, and wliilc-
tliere was appointed assistant surgeon to University College
Hospital. Subsequently he moved to Coorge-street,
ILauover-squaro, and then to Savile-row, where ne lived’
until he quite recently retired to Cheyne-walk, Chelsea,..
11(5 married in 18.’).'), and leaves a widow, two daughters,
and a son.
Mr. Marshall was alwaysa very busy man, and his activities
extended over a remarkably wide range—literary, scientific,
and educational—and a brief notice of the many directions
in which his energies found an outlet will he the best testL
Coogle
Dir: ri(j •
118 The Lancet,]
OBITUARY.
moov both to his brilliant powers and the great use he made
of them. In University College he was curator of the
Anatomical Museum for three years, demonstrator of
anatomy for two years, demonstrator of practical surgery
ioT eight years, holding the first class of the kind in London;
then demonstrator of operative surgery, and finally, pro¬
cessor of surgery for sixteen years. In the hospital he
eerved as assistant surgeon for fifteen years, was then sur-
,geon, and finally consulting surgeon. His ap^pointment on
the surgical staff was strongly urged by Dr. Sfaarpey, with
whom he was a great favourite. He was also surgeon, and
then consulting surgeon, to the Hospital for Consumption,
Brompton.
Mr. Marshall was an excellent anatomist and had great apti¬
tude for teaching anatomy, and throughout hi^rofessional
life took the keenest interest in this subject. He took part
in the preparation of the early editions of Quain’s Anatomy,
Cor twenty years he was lecturer on anatomy as applied
to art in the Government schools, first at Marlborough
House, then at South Kensington, and in this class ho
showed that it was practicable to lecture on this subject to
mixed classes of men and women without giving oftence.
He was also professor of anatomy in the Royal Academy
•of Arts for the last sixteen years, and here be instituted
the practice in the Academy of admitting lady students to
•the lectures. His energy was characteristically shown by
■his doubling the number of lectures in this course. Physio¬
logy claimed almost as large a share of his time and interest
AS anatomy. For four years he was Fullerian Professor of
Physiology at the Royal Institution, and for two years he
lectured on physiolog;^' to ladies and lady teachers at
University College 5 this, again, was the first course of the
kind given in London. In 1867 he published the “Outlines
•of Physiology, Human and Comparative.” This is now
out of print, but, although an excellent text-book, was
not so popular as to justify the issue of a further
■edition. To assist his work among art students he
prepared and published life-size diagrams, ten in the
physiological series, and seven in the anatomical. These
have been very popular; their accuracy and complote-
iness leave nothing to be desired, and show the care with
which they were designed. He also published “Anatomy
■for Artists,” and a paper on “Proportions of the Human
Body.’ At the College of Surgeons Mr. Marshall had a long
•career of usefulness. He obtained the Fellowship in 1845.
He was a member of the Board of Examiners in Anatomy
ifor seven years, and of the Court of Examiners in Surgeiy
for another seven years, and on his re.signation of the
chair of surgery he was appointed Emeritus professor.
He was thr^ times elected a nieniber of the Council
■of the College, and served the ollice of President of the
College in 1883. He it was who introduced and estab¬
lished an examination at the end of the first year of the
medical student’s curriculum. He also took a leading
part in bringing about the Conjoint Scheme of Examina¬
tions by the College of Physicians and the College of
Surgeons, and he championed this scheme at the General
Medical Council. He moreover devoted a good deal of
attention to the finances of the College of Surgeons
and rendered great assistance in this way; indeed, it was
largely owing to his efforts that tlie coat of the diploma
was reduced. He was one of the Committee of Management
of the Conjoint Examining Board of London, and for a
'time was its chairman.
At the University of London lie was Examiner in Surgery
•for three years; be took a leading part in the movement
ito found a teaching university for London, and was chair¬
man of the Executive Committee of the Associationappointed
for this end. Twice he served on the Council of the Royal
Society. He was President of the Royal Medical and Cliirur-
•gical Society for two yeans, and in this position rendered
most valuable services by reviving the Society and infusing
mew life into it. For eight years Mr. Marshall was the
representative of the College of_ Surgeons on the Ceneral
Medical Council, and the best evidence of tlie great value
■of the services he rendered tliere is that when Sir H.
Acland resigned the presidency of this body Mr. Marshall
•was at once chosen to succeed him. The Council was
remarkably unanimous in the election of Mr. Marshall.
This was on May 10th, 1887. 'The term of election
was five years. The choice of the Council was fully
■vindicated, for Mr. Marshall discharged the duties in a
way to uphold the honour of the chair, which had pre¬
viously been filled by Sir Benjamin Brodie, Mr. Joseph
Henry Green, Sir George Barrows, Sir George (then
[Jan. 10,1891.
I Dr.) Paget, and Sir Henry Aeland. His impartiality was
never questioned, his courtesy never failed, and his adminis¬
trative faculty was great. His own associations were with
the corporations of me profession, but the direct representa¬
tives will gladly testify that he welcomed them as cordially
and as courteously as the representatives of the most
ancient institutions. His addresses to the Council at the
beginning of sessions were always clear and helpful to the
members, and he showed an interest in each subject of
debate that was remarkable. His unexpected death will
nowhere be more regretted than IntbeMedical Council, and
it will not be easy to fill bis place.
Foremost amongst Marshall’s scientific writings must be
named his paper in the Philosophical Transactions, on the
“Development of the Great Veins, including an account of
the remains of the primitive vessels and of a * vestigial
fold ’ not previously described.” This was the outcome of
entirely original work, and was an admirable study in
embryology and morphology. Equallj’’ valuable was his
p^aper on the “Brain of a Bushwonian and on Two Idiot
Brains. ” In the former part of this paper he mapped out
the convolutions of the brain, and was a pioneer in that
field of research which has yielded such a rich harvest in
cerebral localisation. His descriptions of the idiot brains
are some of the very best extant.
In his Bradshaw lecture on Nerve - stretching he
attempted to elucidate the rationale of this mode of
treatment, and it was in connexion with this, and as a
result of investigations undertaken at his instigation, that
Mr. Horsley discovered the nervi nervorum. In his
Morton lecture on Cancer in 1889 be suggested that the
cause of cancer might lie in a loss of nervous control over
cell growth. His Hunterian oration at the College of
Surgeons was a very eloquent tribute in honour of the
founder of the great museum. He was the first in this
country to suggest and apply the galvanic cautery in surgery;
he also introduced the operation of excision of varicose
veins, and drew attention to the value of the oleates as
external applications. Turning now to quite another class
of study, it is interesting to recall the tact that he it was
who, in a joint report with the Rev. Mr. Whitehead on the
outbreak of cholera in Broad-atreeb, St. James’s, in 1854,
showed the inlluence of water in diffusing disease. Whether
we regard the mere intrinsic value of this report—the care
with which it was prepared and the soundness of the con¬
clusions drawn—or the great importance of the fact it first
revealed, we must regard this as atruly splendid piece of work.
At this time (1864) Mr. Marshall also contributed to a report
of the College of Physicians a letter on the microscopical
appearances of cholera evacuation.•^, and the appearances he
describes are of especial interest in connexion with Koch’s
discovery of the comma bacillus.
The construction of hospitals was a matter in which
Mr. Marshall took great interest, and he suggested the
construction of circular wards. He advocated his views with
great ingenuity and zeal, and they have been adopted in
several instances—viz., at Greenwich, H.anipstead, Burnley,
Hastings, Liverpool, and the Central Northern HospitH,
London. The results have gone far to ju.stify the hopes
expressed by Mr. Marshall, and tliere can be no doubt that
bis suggestion is one of value.
Such is a brief outline of Mr. Marshall’s public work; but
it leaves much to be said of the man himself. When only
a student at University College he was distingui.shed for “a
remarkable clearues.s of perception and a grasp of mind,
and steady, persevering industry,” and bis mind was well
stored by extensive reading, not only in matters directly
connected with his profession, bub in general liberacure,
and especially in subjects connected with art, history, and
points of antiquarian interest. His contemporaries speak
of him as modest and retiring, and “in tone, manner, and
conversation he was the perfect gentleman.” These
characteristics remained with him to the last. He pos¬
sessed a keen scientific intellect, that took a special delight
in tracing effects to their causes; and with this he com¬
bined a wide range of view, so that every fresh problem
was studied from many sides, and regarded in a broad and
independent spirit. This habit of mind and his sagacious
insight made him a tower of strength on a committee.
Bub his grasp of details was as striking as his scientific
insight, and when we can add that with these he combined
great industry, it is clear that in him was the stuff of which
the great men of science are made. He had a great power
of work, his days were to the last always full, and certainly
it was true of him that whatever his hands found to do he
^■oog;:
The Lancet,]
ROYAL COLLEGE OF SURGEONS-
[Jan. 10,1891. 1
did with his might. As a surgeon hU chief character¬
istic was that he was scientilic, and that too at a time
when the claims of surgery to rank as a science were far less
ostabliahed than they are to-day. His practice was founded
on a minute knowledge of anatomy and sound physiology,
hacked up by a thorough acquaintance with pathology. With¬
out brilliancy’as an operator, he was, what is better, success¬
ful, and when required was bold, even to daring. Ever on the
alert to improve surgical therapeutics, he welcomed the
early development of the antiseptic treatment, the scientilic
basis of which made it specially attractive to him. He at
once put it into practice, and, at a time when the majority
of London surgeons were throwing doubts on the antiseptic
system, Mr. Marshall was painstakingly investigating the
subject and carefully testing it, and he was one of the flrst in
London cordially to support Mr. Lister’s views. It is right
to mention also that he exhibited unfailing courtesy to nis
house surgeons and dressers, and to all the students of the
hospital; while his kindness and gentleness to his patients
were no less marked. As a lecturer he excelled by bis
enthusiasm, by his faculty of clear description, and by his
tact in arranging and in limiting his discourses. It was,
perhaps, in his lectures on anatomy that he specially shone,
and he took the keenest delight in extending a knowledge
of anatomy to artists and others outside the profession.
Of his worK at the Royal Academy Sir F. Leighton says :
“ I cannot tell you more than you already know of bis great
abilities as a lecturer, of his firm grasp of facts, of his facile
gift of luminous exposition, of his power of kindling in
others the interest he felt himself in the fascinating scudy
of anatomy. I can only, therefore, say that his general
kindness and unfailing zeal, even under bodily difficulties,
drew our students to him, and that in his loss they regret
a valued friend as well as a stimulating teacher.” His
appointment at the Academy was a peculiarly happy one,
for he was profoundly penetrated with a love of art and of
everything beautifitl, and from early life was a discriminat¬
ing art critic. His work at the College of Surgeons and
on the General Medical Council shows him to have been
ifted with admirable business faculties, and to have
een one who brought to the questions of medical politics
the same scientific insight (and foresight), earnestness of
purpose, industry, and singleness of aim that animated him
m other branches of his work. For ourselves, we feel espe¬
cially indebted to Mr. Marshall for his services in connexion
with the establishment of Tmc Lancet Relief Fund. When
the question was first mooted, he at once said that he per¬
sonally would do all he could to carry out our views, that
he would propose at the (reneral Medical Council that its
inembers should consent to their President becoming one of
the Almoners of the Fund, and wc know with what care
and anxiety he performed the duties connected with the
post of Almoner.
His old pupils will not need to be reminded of hia
striking face, and especially of bis keen dark-brown eyes
of remarkable lustre, which once seen were not likely
ever to be forgotten. Ciuite lately advancing ago and liis
many labours left their mark in a slight stoop and a slower
step; but it is pleasant to know that to the end of life he
possessed all his faculties unimpaired, and that his inbere.st
in life and keen industry were never for a moment
slackened. His fatal illness—bronchitis with albuminuria—
lasted but a few days. He was buried at Ely on Tuesday
last. On closing this impeifect and unworthy notice of Mr.
Marshall we must again pay a tribute of affection and
honour to so kind a man, so true a friend, so keen a thinker,
so accurate and industrious an observer, so enthusiastic and
cultured a teacher. His work was great and will be per¬
manent, and if we cannot all rival him in his brilliant
powers and noble use of them, we cau honour and cherish
his memory and find in it an inspiration.
ROBERT GEE, M.D. Hkid., M.R.C.P. Lond ,
or I.IVF.HI’OOI..
The deceased, who was in his seventy-second year, was
a native of Denbigh, and received his medical education in
University College, London, Edinburgh, J’aris, and Heidel¬
berg, He settled down in liiverpool rather more than
years ago, Laving graduated and obtained the
old double qualilioatiou of M,R.C.S. Eng. and L.S.A.
in 1842. Subsequently in 1859 he became a Member
or the Royal College of Physicians of London. He
became one of the resident surgeons of the Liverpool
Workhouse soon after going to Liverpool, and bis
connexion with that institution continued until severed
by his death, he becoming visiting physician and consulting
physician, which office he held to the last. He was also-
consulting physician to the Hospital for Infectious Diseases
and to the Hospital for Consumption and Diseases of the'
Chest. For many years he was connected with the schoot
of medicine as lecturer on pathology and diseases of
children, and enjoyed a considerable private practice. Dr.
Gee was always extremely popular, both with his pro¬
fessional brethren and the public, and on the death in 1867
of Mr. Philip Finch Curry, then coroner for the city, a
meeting was neld in the medical institution to promote his-
candidature for the vacant office, which, howevel^ was not
successful. Some years ago he was appointed a Justice of the
Peace for the city, and tookhia place on the bench regularly
when his -turn came. By his connexion with the work-
house, which is one of the largest in the kingdom, the
deceased had experience of epidemics of cholera, typhus,
relapsing fever, scarlatina, diphtheria, and measles. Hia
contributions to medical literature were not very numerous,
but he enjoyed a fair share of consulting practice in those-
diseases of which he had so large an experience. He was
a prominent figure among the Calvinist Methodists, of
which body he was a member and, later on, a deacon.
He took also a prominent part in politics, having
been for eighteen years the Liberal chairman for Aber-
croraby Ward. On his retirement from that position
Mrs. Gee was presented with her husband’s portrait painted
by Mr. R. E. Morrison. Dr. Gee possessed a very kind,
genial manner, and bis'loss will be much felt. His funeral'
took place at Oswestry Cemetery on the 5bh inst., in the
presence of a large number of relatives and friends. Appro¬
priate references to the deceased were made at the Police-
court, Liverpool, by Mr. Raffles, the stipendiary magistrate,,
and by Mr. Clarke Aspinall, the coroner. On Sunday the
chaplain of the workhouse, the Rev. E. Smith, alluded in>
touching and appropriate language to one who had been for
so many years professionally connected with the institution..
ROYAL COLLEGE OF SURGEONS.
At a quarterly meeting of the Council, held on.the
8 th inst., the minutes of the Ordinary Council on Dec. lltb
•were read and conlirmed.
The Secretary reported the death, on the Ist inst., of
Mr. John Marshall, F.US., past President, Member of
Council, and Member of the Court of Examiners of the
College, and Representative of the College on the General
Medical Council, and avote of condolencewith Mrs. Marshall
and family was unanimously passed. The President stated
that the office of Representative of the College on the
General Medical Couneil would be filled up at a future-
meeting of the Council, of which due notice would bC'
given.
The minutes of the Museum Committee on the 2nd inst.
were read as the report from that committee.
The minutes of the Library Committee on the 5thinst.,
as the report from that committee, were read, and it waa
agreed that, as recommended by the committee, the library
in future be open to readers on each week-day, except-
Saturday, between the hours of 11 .v.M. and 7 i’ M. during
ten months of the year, but that during August the
library be closed at (i.r.:u., and be closed as usual duiing:
September.
The President reported on behalf of himself and the vice-
presidents that the Bradshaw Lecture had been duly and
properly delivered by Sir T. Spencer Wells, Bart., and the-
best thanks of the Council were given to him for his lecture,
and he was requested to publish the same.
A letter of tlie 11th ult. from the Honorary Secretaries of'
the International Congress of Hygiene and Demography
was read, statiug that the Congress will open on Aug. lOtb
in London, and expressing the hope that the Council would
make a contribution to the funds of the Congress. To this-
the Council replied that there were no funds at the disposal
of the Council for such purpose.
A letter of the 12th ult., from Mr. W. O. Reader, was
read, requesting the Council to make a subscription towards
defraying the expenses incurved by his Committee in opposing
the Betterment Clauses of the Strand Improvement Bill, ana
»the Council voted the sum of £10 towards the expenses.
ogic
420 The Lanckt,]
MEDICAL NEWS.
[Ian. 10,1891.
A letter was read from the honorary surgical secretary of
the Medical Society of London, requesting by direcraon of
the Council of that Society that the Council of the College
would consent to nomioate the president of the College for
the time being to serve on a committee .of seven Members
iot the adjudication of the Fothergilliah Medal and Prii^e.
To this the Council replied that they regretted their
inability to do so.
Permission was given to Dr. Anderson Stuart, who
applied on behalf of the University of Sydney, N.S.W., to
have casts taken of the busts of Sir i^tley Cooper and
John Abernetby on the usual conditions.
A letter was read from Dr. E. R. Rentoul requesting the
Council to petition the Government against the Midwives’
Registration BUI. This letter was referred to the Presidents
and Vice-Presidents for their consideratloo.
It was moved by Sir W. Savory, on behalf of Mr. Hulke,
and seconded by Mr. B. Hill: “That it is desirable that
the present form of report presented to the Fellows and
Members of the College be modified, and that a committee
be appointed to consider what, if any, modiScalions appear
desirable, and to report unon these or any other matters
connected with the report.” A committee, consisting of Sir
W. Savory and Messrs. Hulke and Hill, was appointed to
consider the subject^_
Pfbiral Itcfos.
University of London. — The following candi-
<dates have passed the recentB S (Honours)Examination:—
Fimt ClasK .—Rdwanl Victor Hugo (Gold Medal), St. Bartlioloinew's
Hospital: W. II. Evans, M.D., .B.Sc., Univeraicy College.
Secona —Thomas .lames Dyall, .St. nurtholojuew’a Hospital, anrl
Arnold William W. Lea, Owens College and Manclie.ster Koyal
IntlriBary (equal); Fredeiick William Hall. Guy's Hospital,
University of Cambridge.— The following can¬
didates, who presented themselves at the Third Examination
rfor Medical and Surgical degrees, were approved:—
Part I.—Ds. Abram, Cai.; Da. Addison, Cai.; Ds. Anderson, Cai.;
Ds. Bindloss, Jnh.; Da. O. Calthrop, Cai.; Ds. Carling, .Job.;
Carling; Ds. Craig, Cai.; Ds. Crosby, Cai.; Ds. Crump, liiiiinaii.;
Ds. Donnan, Clare; Mag. Dumbleton, Pet.; Ds. Eccles, Down.; Da.
jrolce, Jesus; Ds. Fisher, Cat.; Ds. Fisher, H. Cav,; Ds. Fooks,
.lesus; Ds. A. H. Godson, Job.; Ds. Gornall, Cath.: VV. Hawker,
‘Triu. H.; Ds. Haydon, Cai.; Ds. Horne, Clare; Ds, Ilulbert,'I'riii.;
Ds. Kellock, Einnian,; Ds. Latter, Pemb.; Ds. R. Langdon-Down,
Trin.; Ds. S. Lewis, Joh.; Ds. Pridhain, Cai,; Ds. Uobetts, H. Cav,;
Ds. Rowland, Cai.; Mag. Samways, .Toh.; Ds. Savory, II. Cav.;
Shaw. Jesus; Ds. .Stirritlge, Cai.; Mag. A. H. Thompson, Ti'in.;
Ds. Turner, 'Trin.; Ds. G. Wilkinson (juii.), Emman.; Ds. Wood,
Christ’s; Wrench, H. Cav.
J^art I/.—Ds. Batten,Trin.; Ds. Belben, Chrisf-s ; Ds.Blaker, H, Cav,;
Buss, Sid.; Mag. Connolly, Cai.; Ds. Cordeux, Cai.; Ds. Fosbery;
Ds. Gillett, Sid.; Ds, Grabham, Job.; Ds. Greaves. Cai.; Mag.
W. S. Griffith, Trin, II.: D.s. Hale, King's; Ds. Hardwicko; Ds.
S, N. Harrison, Trin.; Ds. Haydon, Cai.; Ds. Kellett, Joh.; Ds.
Kellock, Emman,; Ds. Knox, H. Cav,; D.s. C. H. Leaf, Trin,;
Ds. Martley, Trin.; D.s. Metcalfe, Trin;; Ds. Miller, Queens'; Ds.
E. J. D. Mitchell, Cai.; Mol.son, Emman. : Ds. Molieno, Clare;
Dfl. Newman, Cai.; Mag. Panting, King’s; Ds. K. S. Puck, Christ’s;
binder. Queens'; Ds. Pope, H. Cav,; Ds. Rolfe, Clare; Mag.
Samway.s, Job.; Ds, W. W. Simmons, Joh.: Ds. II, K, Smith, Cai.;
Ds. Sutton,Clare; Ds. Thomas, Jesus; Ds. Usiier.Cai.; Ds. Waggett,
Pemb.; Dn. Wellferd. Trim: Mag. C. P. Wliite, Clare; Ds.
G. Wilkinson (.inn.), Emman.; Ds. W. Winslow, Cai.; Ds. Wright,
•Toh.; Mitg- Wyman, Trin.
Medical Magistrates.— Tlio names of Mr. H.
Dobie, M.B. Edin., M.R C.S., and Heory Stolterfoth,
M.A. Cantab., M.D. Edia, have been added to the Com¬
mission of the Peace for the city of Chester.
British Nurses’ Association. --- II.R.H. the
Princess Christian will to day (Frida>i) be presented by Sir
William Savory, Bart., with the lirst copy of the first
liegiater of Trained Nurses.
Presentation.—O n Wcdnesclay, tiio. 7tli inst.,
Mr. E. Claude Kingsford, L,R.C.P.IiOLd., M.R.C.S , senior
honse surgeon, Bolton Infirmary, was presented by the
resident officers and nursing staff with a handsome gold
watch, suitably inscribed, as a mark of their esteem of, and
regret at his resignation after three years, and of gratitude
iot his kindness.—Dr. Geo. H. Temple, of the Provident
Dispensary in connexion with the hospital at Weston-
euper-Mare, has been presented with a handsome marble
timepiece, the spontaneous gift of his patients, in recognition
of h& kindness and attention to them during his appoint¬
ment as medical officer to the dispensary.
The Koch Trioatment in Leprosy.—T he con¬
dition of the three lepers recently inoculated at Madrid
with Dr. Koch’s liquid in the Hospital of St. Jean de Dieu
is stated to be satisfactory.
Open Spaces.—T ho Enrl of Meath has received
the promise of £1000 towards the cost of laying out
Victoria Pai’k Cemetery a.s an open space, provided that
the balance of £1300 is forthcoming within the current
month, in order that work may be found for the unemployed.
Literary Intelligenck.—S wan Soimcuschoin and
Co. announce the early publication of a new and enlaced
edition of Mr. Alfred Haviland's book entitled “ The Geo¬
graphical Distribution of Heart Disease and Dropsy, Cancer
in Females, and Phtbisis in Females in England and
Wales.” The work will be illustrated by maps.
Medico-Psychological Association.—T he follow¬
ing were successful at tbe examination for the certificate
in Psychological Medicine, held at Bethlem Hospital on
Dec. ISth, 181)0:—Frederick W. Pilkington, L.R.C.P.,
M.R.C.S ; Robert Hitchings, L.K.C P., M.R.C.S.; James
G. Boutar, MB, C.M.; Jane B. Henderson, L.R.C.P.,
LRC.S.; Robert S, Black, M A., M.B,, C M.; John A.
Hicks, j un., L. B. C. P., M. R. C. S.
Pollution of Eiverp, West Surrey. — The
Surrey County Council has arranged for a conference at
Newington on the 16th inst. to consider the desirability of
formulating a comprehensive scheme for the disposal of the
sewage of the towns and districts in the valley of tbe river
Wey. The sanitary authorities in West Surrey interested
in the question of the contamination of the Wey have been
invited to send lepresentatives.
Alleged Baby Farming.—A t Lambeth Police-
court on the 2ad inst. a woman was charged with having
under her custody and control two boys and four girls, and
with having wilfully neglected them. The case had come
under the notice of the Society for the Preveniion of Cruelty
to Children. Dr. Reid of Walworth-road reported that he
found all the children in an emaciated condition, and that
they appeared to have been grossly neglected. The accused
was remanded.
Honour to a Medical Student.—M r. Cuthbert
Rutherford was entertained at a banquet by the citizens of
Bedlington, Northumberland, on Monday last, which was
presided over by Mr. James Trotter, and was there publicly
presented with several cases of medical instruments as a
token of the earnestness and ability be had displayed on
behalf of many public interests connected with tbe neigh¬
bourhood. In presenting the gift the chairman said that they
could not but highly appreciate tho keen interest taken by
Mr. Rutherford in the educalion'of the people in scientific
truth, and admire the uncompromising opposition he offered
tocomplacent orthodoxy wherever id was to be found. Mr.
Rutherford has almost complefed bis curriculum at the
Royal Infirmary Medical School, Glasgow, and the public
presentation will, no doubt, bo much appreciated by his
kllow-students.
METROPOLITAN ASYLUMS BOARD.
Bettvrn of Patients remaining in the several F&ver Hospitals
of the Board at midnight on Jan narg (ith, 189}.
Hospital.
Scarlet n
fever.
Diphtheria.
leds 0
Is'
cuplei
o
•c
0) 4.
B.2
Other
diseases.
TotaL J
i
E
I
S
c
d
0
1
Eastern Hospital .. ..
26:t
dS
C2
370
442
North-Western Hospital
2l)H
S4
!)
1
3(2
448
Weetevii ..
Ilf.
Kl
20
182
202
South-Western „
mu
1)
1
200
840
South-Eastern „
2:jl
•28
CU
sur,
402
Northern
8111
22
M
855
480
Gore Farm „
mr.
105
800
Totals.
1057
ir .2
1
100
)87-I
2729
1 Small-pox,—. id g(U hospital ship, l.
Digil zed by '"OO^Ic
THE Lancet,] APPOINTMENTS.-VACANCIES.-BIRTHS, MARRIAGES, & DEATHS. [Jan. 10,1891. 12>1
^ppintmcnts.
wpvVMntifor Vacancies, Secretaries nf Public iTUtilutions, and
poMessinff ir^onnation svitable for this column, are invited to
forward it to THE LANCET OJtce, directed to the Sub-Jsditvr, not laUr
than 9 o'clock on the Thursday morning q/ each week Jor publication in
the next number. -
ANNINQ 80 N, BUSHELL, M.D. Caiiih., M.R.C.S,, Ikws been reappointed
* Medical Officer of Health for the CauibridKO Urban District.
BiiERETON, JaS. B., L.K.Q.O.P., Ji.R.C.S. Ivel., has been reappointed
^ Medical Officer of Health for the OilderaomB Urban District,
Tressy 0. J., L.E.C.P. Loud., M.tt.C.b , has been appointecl Medical
Officer of Health for the Warsop Urban Sanitary District of the
Mansfield Union.
Crompton, A., M.E.C.S., has been appointed Medical Officer for the
BenioRton District of the Boston Union.
CoNNiNOilAM, John, M.B., CM.Ulaag., has been appointed Medical
Officer of Health for the Royal Burgh of Sanquhar, Duiofrlea-
shire, N.B.
DKLAHUNT, James J., L.RC.P., L.R,C.S. Edin., has beon appointed
Medical Officer of the Balliiiasloo District, County Galway.
Drake, T. G., L.K.Q.C.P., L.U.U.S. Irol., has beon appointed Medical
Officer of Health for the Thornton Urban Sanitary Authority of the
North Bierlcy Union, vice Rawaoii, deceased.
Edwarps, B. K. j., M.B., C.M.Edin., has been appointed Medical
Officer of Health for the Southowram Urban Sanitary District of
the Halifax Union.
OiU’iN, F,, M.R.C.S., has been appointed Medical Officer of Health for
the Rural and Urban Districts of Stratfovd-on-Avon, Evesham, and
Alcester, vice Fosbrolce.
GODl'REY, G. P., L.R.C.P,, Tj.R.C.S. Kdin., has been appointed Visiting
House Surgeon to the Mansfield and Mansfield Woodhouse Hospital.
OOSSAGE, A. M., B.A. Oxon., M.R.C.S., L.R.C.P., has been appointed
Resident Obstetric AsHishvnt to the Westminster Ho.spital.
Herrick, Uoin', W., M.B., B.Ch.Dub,, has been appointed Assistant
Honorary Surgeon to the Tliroat and Ear Hospital, Nottingham.
James, G. B., M.B.CS., L.R.C.P., has been appointed Senior House
Surgeon to Westminster Hospital.
Johnstone, J., L,I).S.R.C.S. Kdin., has been appointed Honorary
Dental Surgeon to the Throat and Ear Hospital, Nottingham.
KiTClIiNG, J. L. W., L.R.C.P. Lond., M.R.C.S., has been appointed
Medical Oftieor for the Mildenhall District of tlio Mildonhall Union.
Knights, Jas. W., F.C.S., has been reappointed Public Analyst for
Cambridge.
LuNN^ P. T., L.S.A., has been appointed Medical Officer of Health for
tfie Launceston Urban Sanitary District of the Launco.ston Union,
vice Brooke.
MuiL, William, M.D. Aberd., has been appointed Medical Officer for
the Workhouse of the Kirkby Moorsido Union.
ODEi.iy Rout., L.R.C.P. Lond., M.R.CS,, has been appointed Medical
Officer for tlie Third and Fourth Districts of tiro Hertford Union,
vice T. Odell, resigned.
Penbkuthy, Wm , L.R.C.P. Lond., M.R.C..S., has boon appointed
Assistant Medical Officer for tlie Central Lunrlou Sick Asylum
District.
PICKWORTH, A, J., L.R.C.P. Edin., L.F.P.S. Glasg., has been appointed
Medical Officer for the Lakenheath District of the Mildonhall Union.
SHARMAN, Eric H., M.R.C.S., L.R.C.P., has been appointed House
Surgeon to tlie Westminster Hospita'.
SHARMAN, Mark, M.B., C.M. Glasg., M.R.C.S., has boon appointed
Medical Officer for Rickmausworth.
SMITH. J, H,, M.B., C.M. Edin., has boon appointed Assistant Medical
Officer to the Cruinpaali (Manchester) Workhouse, vico Fryer,
rasigaod.
SiiENCKR, Walter, L.R.C.P., L.R.C.S., has been appointed Medical
Officer of Health for the Borough of East Retford, vico William
Ptitchard, M.D,, resigned.
Stokes, J., M.B. Durh., M.R.C.S., has beon appointed Medical Officer
for iho I'Trsb District of the Ecclosall Bierlow Union, vice Willington,
resigned,
Storrs, a., M.D. McGill, Canada, M.R.C.P., L.R.C.S. Edin., has been
appointed Medical Officer for the Southport District of the Ormskirk
Union.
Thomi’son, F.. j., M.R-C.S., has been reappointed Medical Officer for
the 'i'wycross District of the Market Bosworlh Union.
M.R.C.P. Hdiii., M.11.0.8., has hoen appointed Medical
Officer to tlie West Middlesex Waterworks Company, vice W. T.
Wyatt, resignecl.
WOOiiiUMS, John a., M.R.C.S,, has boon appointed Medic.al Officer of
llealth for the Rye Urban Sanitary District of the Rye Union, vice
Vidler.
"'0% H. B., M.D. St. And., M.R.C.S., has beon reappointed Medical
Oltieor for the Frittendon District of the Cranbrook Union.
f'lttmtrics.
For further ij^fomatton regarding each vacariey reference sAouZd he made
to the adoerlisoment,
Carlisle Disi'Ensarv.—H ouse Surgoon. Salary £180 per annum,
with apartments, not board. (Apply to the Honorary Socrotary,
’yiank-street. Carlisle.)
WTY Hospital por Infeci'ious Diseases, Newcastle-upon-Tyne.—
Resident Medical Assistant for one year. Terms £50 for the first
year, and, if reappointed, £70 for the second year, with board, lodg-
lug, and washing.
U0ONTIF5OK STIRLING ANi> DuMiiAHTON,-Medical Officer to act for
tne two counties and their iHstvicts. Salary £500 a year, with
necessary travelling expenses, to bo regulated by the County
(Apply to Mr. Welsh, County Clerk, Stirling, or Mr. Babtie
County Clerk, Dumbarton.) ’ ^
County Borough op St. Helbns.—A ssistant to the Medical Officer.
Salary £200 per annum. (Apply to the Town Clerk, Town Hall,
St. Uelons>)
County Council ok Ayrshire.—C ounty Medical Officer. Salary at-
the rate of .£450 a year. Expenses will be paid as they ms.y b»
vouched and passoil. (Apply to the County Clerk, County Build¬
ings, Avr.)
County ok Dumkrii-s.—M edical Officer for the County. Salary
.£800 per annum. He will receive the outlays necessarily Incun'ed
in the discharge of his dutios. (Apply to Mr, Robson, County'
Clerk, Dumfries.)
CuMiiEiu.ANi) INKIRMARV, Carlisle.— H0US6 Surgeon. Salary £70 per-
annum, with board, lodging, and washing,
German Hospital, Dalsion.-llonorary Assistant Physician.
Oenbiul Hospital, Birmingham.—Assistant House Surgeon for six
months. Nosalary, but residence, board, and washing provided.
Hospital kor Oonsomition and Diseases ok the Chest, Brompton.
House Physicians. ^
Inoiiam Inkirmarv a,\i) South Shields and Westoe Inpirmary.—
Senior House Surgeon. Salary £60 per annum, rising to £70, with>
board and residence.
Kent and Cantkruury Hospital.-A ssistant House Surgeon and Dis-
penser (one office). Salary £50 per annum, with board, lodging,,
and washing.
Lancashire County Asylum, Rainhnin, near Liverpool.—Pathological
Assi.stanb Medical Officer. Salary £200 per annum, with furnished'
apartments, board, attendance, and washing.
MetroPolita.x Hospital, ICingslancl-road, K.—Dental Surgeon.
Parishes ok Kirruean and Colvbnd and Soutiiwick.—M edical
Officer. Salary £50, together with dwelling-house free. (Apply tO'
Ml-. James McLelland, Inspector of Poor, Colvend-hy-Dalbeattie.)
Stockpor'I' In i-'iRM ary.—Q ualified Assistant to the House Surgeon for
six montJis, witbboardand residence.
marriagts, aab Jcatljs.
BIRTHS.
Mills.—O n Doc. ICth, at Meerut, N.W.P., India, the wife of B. Langley
Mills, F.R C.8., Army Medical Staff, of a son.
Moore.—O n Dec. ard, at Stony Hill, St. Andrew, Jamaica, the wife of
York T. G. Moore, L.R.C.P. Ed., M.R.C.S., of a son.
Penny.—O n Jan. Jivl, at Morton House, Halliford-street, N., the wife of
William Lowry J’enny, M.D. Cantab., M.R.C.S.E., of a son.
MARRIAGES.
Dawson—Scott. — On Jaii. Ist, at Redcar, by the Rev. James^
Wallace, M.A., Alfred stanhope Dawson, L.R.C.P. <fe L.R.C.S.Edin,,
of Castlogate House, Cockermouth, to Helen Paton Scott, eldest
daughter of Andrew Scott, of Coatham, Yorkshire.
Fox—H ay-Nkwto.n.—O n Jan. Isb, at St. Barnabas, Pimlico, by the Rev.
Alfred Fox, brother of the bridegroom, Thomas Colcott Fox,
B.A.Cantab., M.B.Lond,, M.R.C.P., of 14, Harley-streot, to Ida
Mary, youngest daughter of the late J. S. Hay-Newton, Ksq., of
Newton I-Iall, Haddington, N.B.
Jackson—Bennett,—O il Jan. Isb, at St. Stephen’s, Clapliara-park, by
the Rev. M. O. Fitr.manvice, Ba.sil Frederic Forrester Jackson,
M.R.C.S.E., L.R.C.P., son of the late Oeo. Fiederick .lackson, Ksq.,
solicitor, of Plymouth, to Kate, only daughter of tlie lat« William
Bennett, Member of the In.stituto of Painters in Water Colours, of
Clapham-park.
Lenox-Conynhiiam—■Ruadsiiaw.-O n Nov, I6th, at riirist Church,.
Rawal Pindi, ]’uii,}iib, by the Rev. A, .Spens. Chaplsin of llawal
Pindi, asaisU’il by ihc Rev. C. Gillinore, Chaplain of Ks.rachl, Gerald
Ponsonby, Royal Kngineer.s, fifth son of Colonel 8ir William F.
Lonox-Conyngham. K.C.B., of Spring Hill, c-o. Derry, Ireland, to-
Klsie Margaret, eldest daughter of Deputy Surgeon-General A. F.
Bradshaw, Anny Medical Staff.
Lii’scoMii—H andy, '-Gii Nov. 24th, at Chertsey. by the Rev. Canon,
i’attcnden, A. A. Lipscomb, M.R.C.S., .son of the late J- K.
Lipscomb, .M.R,(\8., Alrosfonl, Hants, to Mary, daughter of Jolin
Handy, of SliipUui, Gloucestershire.
DEATHS.
ANnEu.soN.—On .Ian. .'ird. at Leamington-road Villas, Westboui-ne-park
W., James Andin-son, M.D,, Retired Inspector-Goneral of Hospitals
Calcutta, in his TSkli year,
Bellamy.-O n .Ian. 4ih, at Wimpolo-Ntreet, Cavendish-square, Edward
Bellamy, F.H.C.S., aged 48.
BUKT.—On Dec. 81st, at liis residence, The Roses, Warren-road, Bexley-
heath, Kent, John J. K. Burt, aged 84.
CrawkORD.—O n Jan. 4th, at Di-ayton-green voad, Ealing, Dr. Cooper
Hayes Crawfonl, 8urgoon-M8jor North Stafford Militia, aged 63.
Duncan,—O n Jan. 4th, Bartholomew Arcedeckne Duncan, M.D.,
M.R.C.P., of -20, Wimpole-stroel, aged (>2.
Marsiiall,—O n Jan. 1st, at Belle Vue House, Cheyno-walk, Professor-
John RIarshall, F.R.8., President of the General Medieval Council,,
aged 72.
MOOrk.—O n Jan. 8rd, at Roseneath, Wust Kirby, Dr. Moore, late
Canning-street, Liverpool, aged 77.
RUGG.—On Jan. 2nd, at 1, Grove-rnnd, St. John's-wood, Henry Hodsoii-
Rugg, M.R.C.S., in his 70th year.
Strange.—O n Jan. Dth, at Worcester, William Strange, M.D.,.
L.R.C.P. Edin., aged 75.
TavLOU.—O n Dec. -iUth, atSuUon Coldfield, Thos. Taylor, F.R.C.S.Kng.,
aged !I0.
Thomas.—O n Jan. 0th, at Great George-street, Liverpool, Hugh Owom
'i'homas, M.D. 8t. Louis, M.R.C.S., aged 67.
fee <y 5s. is <*arp«i for the Insertion qf Notioei qf Births,.
Marriages, and Deaths.
Diu:.-:;
Google
1.22 ThbLakost,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS,
[Jan. 10,1891.
SljJiifal giarg firr tnsaing-®ali.
Holiday, January 12.
BOYAL London ophthalmic Hospital, Moorpiblos.—O perations
dally at 10 a.u.
flOYAL Westminster Ophthalmic Hospital.—O perations, 1.80 p.m.,
and each day at the same hour.
Chelsea Hospital for Women.—O perations, 2,80 p.m. ; Thursday, 2.80.
St. Mark's Hospital.—O perations, 2.30 p.m. ; Tuesday, 2.30 p.m.
Hospital for Women, 8oho-3<)iiars. — Operations, 2 p.m., and on
Thursday at the same hour.
Metropolitan Tree Hospital.—O perations, 2 p.m.
BoYAL Orthopaedic Ho-spital.—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.m., and
each day in the week at the same hour.
University College Hospital.—B ar and Throat Department, 9 a.m. ;
Thursday, 9 a.m.
London Post graduate Course.—R oyal London Ophthalmic Hospital,
Moorflelds ; 1 P.M., Mr. R. Marcus Gunn: External Examination
of the Eye.—London Throat Hospital, Gt. Portland-sbreet: 8 P.M.,
Mr. W. R. H. Stewart; The Examination of Ear Cases.
Odontologicai. Society ofGiie,vt Britain (40, LeIcostov-sq.,W.C.).—
8 P.M. Annual General Meeting. Election of Officers. Casual Com¬
munications by Messrs. S. J. Hutchinson, C. Robbins. C. F. Ritot,
W. H. Woodruff, F. J. Colyor, Browne Mason, Storer Bennett, and
others. Valedictory Address by the President.
Medical society of London.—8.30 p.m. Dv. 'Willi,am Duncan: Chronic
Disease of the Uterine Appendages, with Short Notes of Thirty
Consecutive Oases treated by Abdominal Section.—Mr. Alban povan:
The Treatment of Chronic Disease of the Uterine Appendages.
Tuesday, January 13.
Bing’s College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
Out’s Hospital.—O perations, 1.80 p.m., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.30 and Thursdayat 2 p.m.
St. Thomas’s Hospital.—O phthalmic operations, 4 p.m. ; Friday, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.m.; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
St. Mary’s Hospital.—O perations, 1.30 p.m. Consultations, Monday
2.80 P.M. Skin Department, Monday and Thursday, 9.80 a.m.
Throat Department, Tue.sdays and Fridays, 1.80 P.M. Electro¬
therapeutics, same day, 2 P.M.
London Post-graduate Course.—B ethlom Hospital; 2 p.m., Dr.
Savage : Hypochondriasis and Melancholia,—Examination- Hall :
Mr. Hutchinson on the Nature of Lupus in special reference to its
connexion with Tubeyculosis.
Royal Medical and Chirurgical Society.—8.30 p.m. Mr. R. Clement
Lucas: On a case of Nephro-lithotomy (following Nephrectomy) for
Total Suppression of Urine lasting five days ; complete recovery and
good health five years after the operation.—Mr. Rickman .1. Godlee:
Removal of largo Calculi, tirst from one kidneyand afterwards from
the other ; death from Hmmorrhage after the second operation.
Wednesday, January 14.
National Orthop.«dic Hospital.—O perations, lo a.m.
Middlesex Hospital.—O perations, l p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, 1.30 p.m. ; Saturday, same
hour. Ophtlialmic Operations, 'Tuesday and Thursday, 1.80 P.M.
Surgical (;onauUation«, 'Thursday, 1.80 p.m.
Charinq-cross Hospital,—O perations, 8 p.m., and on Thursday and
Friday at the same hour.
St. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, sarab hour.
London Hospital.—O perations, 2 p.m. ThursdaydtSaturday.samehour.
BT. Peter’s Hospital, Covent-gauden.—O penations, 2 p.m.
Samaritan Free Hospital for Women and Children.—O perations,
2.80 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.30 p.m. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 0.15 a.m.
Royal Free Hospital.—O iierations, 2 p.m., and on Saturday.
Children’s Hospital, Great Oumond-street.—O perations,9.80 a.m, ;
Surgical Visits on 'Wednesday and Saturday at 9.16 a.m.
London Post-graduate Course.—H o.spital for Consumption, Bromp¬
ton : 4 P.M., Dr. J. Mitchell Hruce : Tlie Treatment of Cough.
Hunterian Society,—8 p.m. Mr. Symonds; 'Three cases of Hydro¬
nephrosis, and their treatment.—Ur. JC. G. Gilbert: Some Remarlcs
on Colds.—Dr, G. N. Pitt; 'Tuborcalar Lesion,s in Alcoholics.
Society op AR'JH.—8 p.m. Mr, J, F. Green: Steam Lifeboats.
IThuraday, January 1(5,
6 t. George’s Hospital.—O perations, l p.m. Surgical Consultations,
Wednesday, 1.80 P.M. Ophthalmic Operations, Fiiday, 1.80 p.m.
University College Hospital.— Operations, 2 p.m.; Ear and,Throat
Department, 9 a.m.
HARVEIAn Society of London.— Address by the retiring President,
Mr. T. Bryant.
London Post-graduate Course.— National Hospital for the Paralysed
andEpileptic; 2 p.m., Dr. Howard Tooth: The Anatomy of the Spinal
Cord. —Hospital for Sick Children, Gt. Ormond-at.: 4 P.M., Dr.
Voeicker : Demonstration of Pathological Specimens. — London
Throat Hospital, Great Portland-streot: 3 p.m,. Dr. Ed, Law: Tho
Jiixamination of the Throat and Nose.
Friday, January 16.
ROYAL South London Ophthalmic Hospital.—O perations, 2 p.m.
London Post-graduate Course.—H ospital for Consumption, Bromp-,
ton: 4 P.M,, Dr. J. Mitchell Bruce: The Troatmout oi Ilmmoptyals. ‘
Saturday, January 17.
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations. 2 p.m. ; and Skin Depart¬
ment 9.16 A M
London Post-graduate Course.—H ospital for Diseases of the Skin,
Blackfriars: 2 p.m.. Dr. Payne: Erythema and Allied Affections.— ,
Betblem Hospital: 11 A.M., Dr. Percy Smith; Clinical Domonstra-
tion.
METEOROLOGICAL READINOa
fTaksn daily at B.IO a.m. by Steward's Instrvmmts.)
The Lancet Office, Jan. 3th, 1891.
D«ta
Boiometsr
reduced to
Soft Level
and tt’F.
Dlreo.
tlon
of
-Wind.
Dry
Bulb.
Wet
Bulb.
BoUr
Badia
In
-Vaoue.
Haxi-
icum
Tomii.
Min.
Temp
Rain¬
fall.
Eemarki at
aaOAKi
2
30-22
S.E.
31
85
20
Foggy
3
30-27
S.E.
81
40
21)
Foggy
30-()7
W.
39
38
40
31
•ii
Cloudv
5
80-17
N.W.
32
r>:$
88
81
Cloudy
(i
80-37
N.
28
42
33
27
Cloudy
7
30-29
N.
2S
Hi
84
27
Cloudy
>1
8
30-04
N.W.
31
80
83
27
•08
Overcast
Ittttfs, i to
Corasponknts.
H is especially requested that ea/rly intelUgence of local
events having a medical interest, or which it is desirable
to bring tender the notice of the profession, may he sent
direct to this Office.
All cornmimications relating to the editorial business of the
journal must be addressed “ To the Editors."
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whethet' intended for insertion or for private in¬
formation, must be authenticated by the names a/nd
addresses of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed “To the Suh-EdAtor."
Letters relating to the publication, sole, and advertising
departments of The Lancet to be addressed tha
Publisher.''
We cannot undertake to return MSS. not used.
ASSISTANTS.
2’o tJie Editors of Tub Lancet.
Sirs,—T he question of the qualified assistant and tho unqualified
assistant, or, in otlior words, the dispenser wlio poses as a medical
practitioner, I think does not recoivo anything like a due amount of
attention from the profession generally. Wo hoar much about the
“hard times" we are having ; but do we hear enough about the cause.s
which produce these results ? I maintain that tlie unciunliliod Jissistant
is largely respoasible for the low opinion which is beginning to be held
by tlio public in some quarters of tliose on wlioni devolve.^ the duty of
upliolding tho dignity of our calling ; for (I .speak from Imiirsay) is it
not hinted at that he is frequently to bo found in the bar parlour of liia
district, the centre of an admiring tiirong, wlio lilce to talk to tho
“doctor"? And who scans with .so critical an eye the failings of otliov
practitioners, who, forsooth, tlilnk that they “know their work”
liecause they happen to have a diploma or so? 'riioii his rocoul of
midwifery cases always going on towards four figures; his easy niothocl
of performing version, and tho doxlority with which he handles tho
forceps, would, I foar, arouse tho envy of some of our leading ob-
Htotricians, if they had tho advantage of his acquaintanco. Again,
without the unqualified assistant tho sixpenny dispensary would not
pay so well.; for the young qualified man, possibly through mistaken
pride, is not eager to assist in these oniHjrprisos, most of which require
the aid of one or more assistants, as is obvious when ouo considers the
amount of work which would bo required in order to make ovon a
moderate income. The writer knows of an instance where, in a mining
Digiiized by
Google
Thb Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 10, 1891. 123
district an average of from twenty bo thirty visits a day vvas kept up
by an unquallfled man who managed a branch (chiefly club) practice,
and who had sole charge of the consulting-room each evening. I liave
reason to know positively of this, because I attempted to oppose the
man in question, but was ignominiously defeated by him, ho being my
senior in years, and possessing that bland and persuasive manner
which so easily enables a man bo hold his own If ho has an introduction,
simply because it is not guessed at that he Is anything other than
that which ho represents himself to be. At all events, the result is that,
iu spite of an appeal to the Medical Council, I remain,
January, 1801. A Qualified Assistant.
To tlie Editors q/ THB Lancet.
gins _it is indeed time the cause of the poor overworked unqualified
assistant was taken itp. No wonder medical men fliicl It a difficulty to
obtain the services of qualified assistants. They will not work for next
to nothing, as the unqualified man of to-day does. No wonder, then,
tliat unqualified men never qualify or do any good. I will endeavour to
(five you briefly an account of my experiences as an unqualified
assistant. I have been in the noble position for ten years. It has been
hard work, and night work, too, £26 a year, and, worst of all, no time
for any kind of study. I am a registered medical student, licentiate
in midwifery, and assistant of Apothecaries' Hall, Dublin. Your readers
will say, “ How did you get time to go to Dublin for the six months’
practice for the Coombe, &c. Did your employer give you a holiday ” ?
No. I had to leave my employer each time I wanted to work for
examination. My experience is this: the more you serve yourprincipal,
the longer you remain unqualified. If you are taken ill whilst in the
employment of a medical man, out you go. Medical men never consider
the unqualified assistant is the mainstay of the practice. After a ten
years' life of this kind, one finds ha is getting loss active, and conse¬
quently is discharged for being lisy, and then nothing more is heard.
Perhap.s the poor honest assistant dies in the workhouse. The sooner
something is done to help us the better. I see the sorvant.s’ cause is
being taken up. If unqualified men wore allowed in for the respective
examinations on producing certificates of ten years’ practice, they
would be able to share the practice of the many grasping, ungrateful
principals. I am, Sirs, yours obediently,
January, 1801. K. Pooley, L.M.Ch. Dub.
To the Editors of Thb Lancbt.
Sms,—“G. P,,” in a letter published in your last issue, brings forward
a very important matter—viz., the employmentof unqualified assistants,
and the failure of the General Medical Council In laying down some
law on the subject. I quite agree with your correspondent on this
point, and suggest that the following bo the law;—‘'Every medical
practitioner to display, either on his door-plate or in a conspicuous
place in his waiting-room, the names and qualifications of himself and
all his assistants. If anyone of tlie above be unqualified, ho should
have ‘unqualified to practise medicine, surgery, midwifery' (any or all,
as the case may be) iu bold type after his name.” The practice at
present is for the practitioner to hold out his unqualified assistant as
qualified, and always speak of and to him as “ doctor,” This is nothing
short of a fraud on the public ami obtaining money under false pre¬
tences. This disgrace and scandal to the profession sliould not be
allowed to continue. I have no objection to the employment of
unqualified men if patients know them to be such. Every coroner will
bear me out in the statement that a frequent complaint of surviving
relatives is; “ Dv.-’s assistant attended the deceased. We believed
him to he a doctor, and only now find that he is not.”
I am, Sirs, yours truly,
Nov, fith, 1800. X. Y. Z.
Medical Auveutising nv Men or many Titles.
Thu following is a striking illustration of the fact that many and
even respectable titles do not always hinder a medical man from
pushing practice by advertising. The physician and surgeon, it will
bo seen, boasts of no less than seventeen letters of title.
The National Di.spensary, conducted by Dr. R. H, Foot (A.B.,
M.IV, M.D., L.R.C.S.L, L.M.C.R.S.I,), phy.siciaii and surgeon, who
roside-s on tlio premises. Dispensary Patients—Hours of attend¬
ance : Mornings, 0 to II; Eveiiing.s, 0 to 8. Sundays, 11 to 12 A.M.,
and 7 to 8 u.m. Advice and Medicine for one week, l.s. If Visited
at their own Homes, 3». per week. Midwifery from lOs. Od. At
home to Private Patients until 12 a.m. and after 0 i>.m. Removed
from 10, Whimplo-stroot to 29, Flora-street, Plymouth.
J’uUic VavitinaloT.—Tlio Sanitary Council of Paris, in view of tho out¬
break of small-ppx in the south, have issued a code of instructions
to ho hung up in dl.spensarios and other public places. Vaccination
and rovacuiiiation arc chiolty relied upon u.s a means of combating
the disoasci, 1mt isolatioii and disirtfoction are not overlooked.
corrospoiidonb should consult his solicitor. Wo pre¬
sume damn,gos and coats wouhl be consequential, and possibly there
might 1)0 an injunction from the High Court, to bo followed by
unpvjsonment in case of disoliediouce.
•S'. C. has not enclosed his card.
The ODDI'ELIXiWS OF Sandbach.
The Emiwich Guardian reports the proceedings at the animall
dinner of the Loyal Faithful Lodge of Sandbach. Tho chairman
very properly magnified the Order, and said that It had 700,000
members', and that it and similar societies had done more for
England than Free Trade. In response to the toast of his healthr
Dr. Rice expressed satisfaction with a recent change in the medical
arrangements by which three medical offleors had been appointed to*
the lodge, so as to give tho members a choice. This seems to us an
example that may well be followed by large friendly sooietloB.
Dr. Rice finished bis speech by a remark in more doubtful taste—
viz., by expressing his readiness to attend " any number of members '
connected with any society in Sandbach for tho ordinary club pay.'*-
In the light of bis previous remarks we can believe that this was
said in a somewhat playful spirit; but there was an air of business-
about his words which might take effect on the patients of other
medical men.
3fr. William Wallace.—The date of the death of Mr. pfter Marshall,.
F.R.C.S., was March i2th,' 1877, and an obituary notice of that
gentleman will be found in The Lancet of April 7th of that year.
Tj/ro will find all the information he needs in our last Students' Number^
published September Cth, 1890.
3fr. CTLi«6nd«‘n(Gravesend).—Dr. Fothergill died in tbe summer of 1888..
STAMMERING.
To the Editors o/ THE Lancet.
Sins,—A gentleman asked in a recent issue of THE Lancet for help*
in tbe treatment of stammering. The chief points are : (1) Seek for
peripheric points of irritation and remove them, defective teeth,
adenoids, polypes, hypertrophied tonsils, worms, phimotic ad¬
hesions, <fcc. ; (2) forbid the nervines ; (3) educate the breathing;
(i) teacli tho subject to completely compose a sentonqo before com¬
mencing ; (6) after taking a long breath, close the mouth, press the'
tongue up to tho palate, throw open the mouth widely, and quickly
close tho lips again; (G) if the lower jaw cannot be protruded, electrify
the internal pterygoid muscles; (7) practise inFrench.asit is a language'
demanding great lip play, I’ery defective in most cases. If this gentle¬
man would pay me a visit any morning I shall be most pleased to-
practically demonstrate all these manoeuvres in a friendly way,
I am. Sire, yours faithfully,
Edward Blake, M.D'.
Berkeley Mansions, Hyde-park, Dec. ICth, 1800.
A New Venetian Blind.
Mr. Frederick. EKOELUACir, L.R.C.P., of Moroton-Hampstead, Devon,
has invented an improvement of the Venetian blind, by which the-
webbing, ladders, and supports are replaced by chains and vvire
transverse supports hooked into the cha,jns. The blind thus con¬
structed is much more free from dirt than when webbing is used,
and the damage from which the webbing suffera owing to exposure to-
tho sun is avoided. Mv. Bngelbach’s blind is thovoforo more cleanly,
more durable, and is, moreover, more elegant in appearance, and is-
especially well arlaptod for public institutions, where it is important
that labour should be saved.
5«ititari‘cwi.—Tho matter has not escaped our attention, but there are-
some points which require elucidation.
O. P. is referred to The La.\cet of last woelc, on page 08 of which he-
will find an answer to his question.
Sir. G. A. TVrtp/if.—Tho paper has been received, and is marked for-
insertion.
Studms should ropresent liis case to tho Secretary of the Oollege.
General Practitioner should send us the original card.
THE INFLUENZA.
To the Editors of The Lancet.
Sirs,—I think it probable that the outbreak of influenza which has-
afflicted the world in 181)0 will be traced is all its curious wandering.^.
by those wliose duty it Is to compile a careful record. May I, then, con¬
tribute the following item '!
I have a letter to-day from Consul John Buchanan, C.M.G., who lives
on Mount Zomba, upon the Shii-d Highlands of Central Africa—our new
Protectorate. He writes on Oct. 11th—about tho hottest time of year—
that lie has had a very severe attack of influenza comivined with fever.
Centi-ai Africa is,” he say.s, “ about tho la.st place on earth where one-
would expect to meet witti inliuonza, but it has been a most severe-
opidoinic hero. A good many people have died, both young and old.
Most of the Europeans at Ulantyre have' had it in a less or more .sovere-
fovm.” I am, Mira, yours faithfully,
Twywoll Rectory, Doc. 3'Hh, It-W. Horace Wai.i.er, F.R.G.S.
Digitized hy
Google
Thb Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 10. ISfil
Communications not noticed In our present number will receive atten-
tion In our next.
>G JHHUNICATIONB, LsTTBHS, Ao.,bave been received from—Sir W. Foster,
Bimingham; Dr. Steavenson, London ; Dr. Eddowea ; Mr. Symonda,
Oxford; Mr. J. Uutohinaon, London; Dr. Arthur; Sir F. Leighton,
Ix>ndott; Dr. J. Mackeiixio, London; Mr. S. J. Campbell; Dr. Sykes,
■London; Dr. Littlejohn, ICdinburgh ; Mr. Pitts, London; Mr. Butler-
'Smythe, London ; Dr. F. Hewitt, London; Mr. J. Toppin, Pernam-
•1'nco; Dr. Stalker, Dundee; Mr. T. Bryant, London ; Dr. Wheaten, ,
I.ondon; Dr. S. Mackenzie, London; Mr. G. Higgens ; Dr. Fletcher
Beach, Dartford; Surgeon-Major Lawrie, Hyderabad ; Dr. Cranstoun
•Cliarles, London; Mr. Haviland, Douglas, I.M.; Professor Mayo
Robaon, Leeds; Dr. F. Little ; Dr. J. B. Ball, London ; Mr. Mayo
Collier, London; Mr. H. P. Hawkins, London; Messrs. Pease, Sou, and
<70.,Darlington ; Mr. Litchfield ; Messrs. Mabane and Graham, South
Shields; Mr. Pooley, Frodaham ; Mr. Power, Cork ; Meaera. Austin
and Son, Briatol; Mr. Jno. Spring, Grimsby; Mesnre. Barker and
'Son, London; Mr. Thompson, Welbeck-street; Messrs. Keith and
<'o., Edinburgh: Mr. Pringle, Notting-hill; Mr. Milton, Leiceater-
s<luaro ; Mr. C. Besley, Waltham; Mr. Lewis, London ; Mr. Hustell,
Carlisle; Mi. Olivet, Doncaster; Mr, Andrew, Stockport; Mr. F. B.
.fessott, London ; Mrs. Levick, Paris ; Mr. Jeeves, St. Helens ; Mr. W.
Mathew, Clifton ; Mr. Hornibrook, London; Mr. Powell, Bourne¬
mouth ; Dr. Delijpine, London ; Messrs. C. Griffin and Co., London ;
Dr. Tomkins, Leicester; Mr. H. A. Reeves, London ; Messrs. Severn
and Griin,London ;Mr. Lunn.Ladbroke Grove ; Messrs. Maclehose and
Sons, Glasgow ; Dr. B. W. Stone, Hopkinsville, Ky. ; Messrs. Brady
and Martin, Newctmtlo; Dv. A. Yule, London; Dott. P. Sonsino, San
Xoron/.o; Dr. M. Murray, London ; Mr. Shawe ; Messrs. Richardson
and Co., Leicester ; Dr. Crooke, Biviningham ; Messrs. Watkins and
■Osmond, London; Mr. O. A. Wright, Manchester; Messrs. Savory
and Moore, London; Mr. J. P. Richards, Hanwell; hfessrs. Blondeau
■«t Cie, London; Mrs. Cunningham, Scarborough; Messrs. D. Currie
:and Co., Londen; Dr. Johnstone, co. Kilkenny; Messrs. Gallais and
Co., London ; Mr. Wavburton, Treherbert; Messrs. Woolley, Sons, and
•Co., Manchester; Dr. Calder, Queensland, N.S.W.; Messrs. Keene
.and Co., London; Dr. Appleton, Cornwall; Messrs.White, Druco, and
Brown, London ; Mr. Warner, Sheffield ; Dott. S. Di Oiorgi, Mazzara
•del Vallo; Mr. Griffin, Bath ; Mr. Bigg, London ; Messrs. Kent and
Co., Grimsby; Mr. Hendry, Eastbourne; Messrs. Howard, Lloyd, and
Co., Leicester; Surgeon-Major Hotter, Southampton; Messrs. Dodd
and Co., London ; Mr. McLelland, Dalbeattie, N.B.; Messrs. Cowle
and Co., London ; Mr. Muthusawny, Madras ; Messrs. Street and
Co., London; Dr. Mitra, India ; Mr. Hugo, Reading; Mr. Wiggins,
llotherhithe ; Mr. Waters, London ; Dr. Harris, London ; Mr. Read,
Canterbury; Mr. Darke, London ; Mr. Hyde, London ; Mr. Teague,
Manchester; Mr. Atkins, Kilburn; Mr. Lucas, Cambridge; Dr. Hall,
•Brighton; Dr. Cripps, London ; Mr. Stanford, London ; Mr. Coghill,
Birmingham; Miss Zimpel, London ; M. Welter, Paris; Mr. Keay,
Kastbourne; Dr. Calwell, Belfast; Mr. Laver, Sheffield ; Mr. Crow,
Canterbury; Messrs. Johfiston, Edinburgh; Miss Armstrong, Vent-
nor; Mr. MacAlister, London ; Mr. Hart, London ; Mr. Thomlinson,
Partick ; Mr.Blair, Leeds ; Mr. Edwards, Peterborough ; Dr. White,
Sheffield; Mr. Armstrong, Newcastle-on-Tynp; Dr. O’Conor, Buenos
-Ayres; Mr. Williams, Swansea; J. T., S. Q.; Mercuitj Office, Leeds;
B. S. R-; X. Y. 7j. ; A. B., Queen-square ; Maltine Manufacturing
Co., Bloomsbury; W. N., London ; J, B., London ; Assistant; Nur.se
-Lloyd, Camborne; Medicus, Sheffield ; May, London ; A Qualified
Assistant.
Lettbrs, tach with mclomre, are also acknowledged from—Dr. Ogle,
London; Mr. Tully, Hostings; Mr. Mason, Newark; Messrs. Lee
and Martin, Birmingham; Dr. Owen, Gloucestershire ; Messrs. Bailly
and Coates, I>ondon; Mr. Griffith, Carnforth; Messrs. Hargreaves
and Son, Preston; Mr. Greville, Devon; Dr. Hocken, Dunedin, New
Zealand; Dr. Langyer, Zurich; Mr. Ley, London; Mr. Powell, South
Wales; Mr. Shaw, Bombay; Dr. Shepherd, Usk; Mr. Webb, Ponder's
End; Mr. Aspinall, Cheshire; Mr. Low, Orkney; Messrs. Hooper and
Co.,London; Messrs. Ralll Bros., Manchester; Dr. Lee, New South
Wales; Mr.Trouibetta, Messina; Dr. Howe, Croston; Dr.Rake,Guy’s
Hospital; Dr. Dripple, Suffolk; Mr. Cant, Lincoln; Dr. Nelson, New
Zealand ; Dr. Hazleton, Walton-on-the-Nazo ; Mr. Taylor, Surbiton
Hill; Mr. Settle, Yorkshire ; Mr. Evans, Radnor ; Dr. McLeod, New
South Wales; Rev. Mr. Cleveland, Selby; Mrs. Faithful, Wimbledon
park; Mr. Harding, Loughborough ; Mr. Cox, Southport; Mr. Dyer,
Ilfracombe ; Mr. Westmoreland, Manchester ; Mr. Medcatfe, Clap-
ham ; Dr. Mitchell, Taunton; Mr. McMahon, Cork; Mr. Stenhouse,
Glasgow; Dr. Sheppard, London; Mr. Oliver, Doncaster; Mr. Miller,
Dartmouth; Mr. Fielden, Belfast; Dr, Ritchie, Otley; Mr. Dawson,
Cockermouth ; Mr. Stilliard, Birmingham ; Mr. Tyte, Minchinhamp-
ton; Mr. Lockwood, Allerton; Mr. Gillingham, Chard ; Mr. O’Meara,
Leicester; Mr. Smith, London; Mr. Gray, Shrewsbury; Mr. Stone,
Manchester; Dr, Sharp, Walsall; Mr. Jones, Shropshire; Mr. Lee,
Bristol; Dr. Deelcy, Blackpool; Dr. Moiison, Hartlepool; Mr. Denby,
Bradford; Mr. Wallace, Glasgow; Dr. Stewai-t, Cornwall; Dr. Kelso,
Alloa, N.B.: Mr. Strelton, Kidderminster; Surgeon-Major Bradshaw,
Punjab; Mr. Hammett, Taunton; M. Boranni, Paris; Mr. Mnrroll,
Manchester; Mr. Edwards, Peterborougli; Mr. Lipscombo, Strat-
fowl; Mr. Brettell, Dudley; Mrs. Sutton, London; Messrs, Condy
and Mitchell, London; Mr. Heywood, Manchester; Messrs. White
and Co., Brook-street; Dr. Stanley, Sheffield; Dr. Galbraith, Great
Yarmouth; Mr. East, London; Mrs. Merlin, Ely; Mr. Robson, South
Shields; Dr. Macnab, Portree; Mr. Beckton; Dr. Griffith, Milford
Haven ; Mr. Morris, Basingstoke; R. M,, London; Oldfield, Ventnor;
Alpha, Birraingliam ; Chemist, London ; Forceps, London ; Flintshire
Dispensary ; Alpha, London ; Surgeon, Manchester; Clerk, St. Asaph
Union; Medicus, Sheffield; Omega, Leeds; X.B,, London; Lady
Superintendent, Bath ; X., Enfield ; Alienist; National Orthopiedic
Hospital, London ; Mason, London ; Solicitor, London ; B. M. T. A.,
London ; Dowker, London; Assistant, London; Medicus, Ormakirk ;
M.B,, Loughborough; Lancet, London ; Midlands, London; Elder,
London ; E. J., Tring; Beta, London; S. L., London ; A. B. C., South
Norwood; A. B. C., London; M. H., London; W. X., London ; Vicor,
London.
Newspapeus,—D aiiy Columbian (New )i'eiilminKter, J3.C.), Manchentcr
Examiner, Irieh 'I'-imes, Sussex Daily News, Western Mercuty, Local
Government Chroniele, Scotmnan, Leicester Daily Post, Windsor and
Eton Gazette, Drislol Mcirnry, Dundee Adoei-tiser, Yorkshire J’ost
City Press, National Bulletin, Mininy Journal, Jleadiny Mercury,
Liverpool Daily Post, NcweasHe Chronicle, Bi-nuinyham Post, Public
Health, South Africa, Electrical Eiyjineer, Windsor and Eton Express,
Architect, Surrey Advertiser, Jsle of Sian Times, Spectator, Suffolk
Times, Chennst and DruyyisI, Pharniaeeulical Gazette, Eve-niny News
and Post, East Kent Gazette, Slalta Chronicle, Nantwich Guardian,
Bombay Gazette, Laiv Journal, fAverpoot Courier, Paternoster lieview.
Times of India, The Schoolmaster, South Wales Daily News, A-c., have
been received.
SUBSCRIPTION.
Post Free to any part of the United Kinodoh.
One Year..£1 12 6 | Six Months ... _ £0 10 8
To China AND India ....One Year 116 10
To THE CONTINPINT, COLONIES, AND UNITED
States .. _ Ditto 114 8
Post Office Orders and Cheques should be addressed to The Publbher,
The Lancet Office, 423, Strand, London, and crossed “ London and
Westminster Bank St. James's-square."
-£0
- 0
0
0
0
ADVERTISING.
Books and Publications (seven lines and under)
Official and General Announcements .. ^
Trade and Miscellaneous Advertisements ... _
Every additional Lina
Front Pace ~ _ per Line
Quarter Page .m _
Ball a Page ~ ^ .
•An Entire Page .. .. ... .. ... „ -
The Publisher cannot hold himself responsible for the return of testi¬
monials <bc. sent to the office In reply to advertisements; copies only
should be foi'warded.
Notice.—A dvertisers are req^uested to observe that It is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
5
6
4
0
1
1 10
2 16
6 6
An original and novel feature of “The Lancet General Advertiser” is a special Index to Advertisements on pages 2 and 4, which not only
afiords a ready means of finding any notice, bub is in itself an additional advertisement.
Advertisements (to ensure insertion the same week) should be delivered at the Office not later than Wednesday, accompamed by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Seiial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should bs
Aiddressed.
Advertisements ate now received at all Messrs. W. H. Smith and Son’s Railway Bookstalls througbont the United Kingdom and all otbet
AdverUslng Agents. _
Agent for tbe Ad’rertlBement Department In France'-J. ABTTER, m< Bne Oanmartln, Pnrli,
Digitized by
Google
THE LANCET, January 17, 1891,
fmikit ^rat-Kntkstc CmtMc
ON TKE
NATURE OF LUPUS,
WITH ESPECIAL BEFEUENUE TO ITS RELATION
TOjTUBERCULOSlS.
Delivered at the Examination Sail, Jan. ISth,
;By;JONATHAN HUTCHINSON, F.RS., LL.D.
Gentlemen, —Ifc has long been the hope of some of ua
that diseases of the skin may some time take their true
,f>lace in medical studies as affording better opportunities
than any other department of pathology for the elucidation
of the laws of morbid action. Respecting lupus in particular,
I have myself always held that it affords facilities better than
those offered by any other disease for examination of the
•conditions which are known as scrofula, and for ascertaining
the relations of these one to another, and, above all, to
-what we now recognise specifically as tuberculosis. Recent
'histological discoveries have done much to confirm this
•opinion, and to show that an accurate and detailed know¬
ledge of the remarkable group of maladies known as lupus
,18 of very great importance, not only to the clinical observer
but to the experimental pathologist also. Dr. Koch’s
•discovery of a specific form of vegetable organism as the
attendant of all that we recognise as specific tuberculosis,
sand the agent by which it can be artificially produced, has
been followed after a few jears’ interval by another of
'Scarcely less importance from the same fertile brain. Dr.
Koch has now given us a fluid possessing beyond all doubt
most remarkable powers, and respecting which it was claimed
at first that it attacked tuberculous tissue only. Almost
-from the beginning lupus came to the front as the malady
■in which, above all others, the virtues of this remarkable de¬
tector and destroyer of tubercle could be demonstrated. It
was alleged at first that, given a case of true lupus, tlie in¬
jection of Koch’s fluid would cause the patches to inllanie,
and subsequently to cicatrise and disappear. Althougli this
assertion has possibly not been fully confirmed either on its
Xosibive or negative side, although we are obliged to suspect
chat the fluid may cause high temperatures in some cases in
which probably the lupus process is not bacillary, and
that in others in which it probably is so it may fail
to cure, still in the main the original statement bolds
its ground. On all hands we have confirmation of it
in a general way, with, as has been said, certain excep¬
tions. Yon will see that this remarkable discovery opens
up two different lines of investigation, both of them of
•surpassing interest. In the first place, as practical surgeons
we have to ascertain how far it can be made to siipevseae the
old, and more or less clumsy, methods of local treatment;
and next as pathologists, making some pretence of zeal Lr
the scientific aspects of our subject, we hope to gain from it
much help in determining the real nature of the maladies in
•question. Is lupus in its common and well-known type
always a specifically tubercular disease (i.e., bacillary in
■origin)? and, next, are the various associated affections
which differ more or less from common lupus really cognate
■with it?
I purpose, gentlemen, to leave tn the las-t of the three lec¬
tures, which, with your permission, I intend to devotetolupus,
■all clinical discussion of the principles and details of its tieat-
ment. In to-day’s lecture I have to ask your attention to
certain general considerations as to tlie real nature of
the lupus process, and in next week’s lecture I shall return
to this topic, with the intention of giving you more detail
as to the various forms of disease which ought in my opinion
to be included in the lupus family. It is perhaos scarcely
necessary to say that I shall approach tlie subject almost
^«olely from the side of clinical observation. I shall have
"lit little to tell you from my own knowledge as to his-
tology, and nothing as to experiment; not that I entertain
•a the slightest degree disrespect for these directions of
^earch, but simply that my own line of work has taken
elsewhere. I may confess, moreover, that it appears to
“C to be not unimportant that on this and many other
No. 351G.
questions the clinical evidence should be fully stated, quite
apart from any theories as to pathological laws which may
have taken possession of our nriods. The clinical, the
histological, and the experimental investigator need not
always be one and the same person, but by honest and
detailed work each may help the labours of the other.
Before we proceed to undertake an examination as to the
nature of lupus, permit me to say that much of what I
shall have to bring before you I have already said and pub-
! lisbed three years ago in my Harveian Lectures. Of these
^ lectures the present may be considered as a sort of revised
' edition.
! Foremost amongst the questions as to the doctrinal
pathology of lupus is that as to whether the typical form of
lupus vulgaris is always of bacillary origin. ^In respect to
this two possibilities must always be kept clearly before our
minds. It may be that the lupus process is always due to
tlie implantation of the parasite bacillus in the tissues ; or,
secondly, it may be that the process takes its origin as a
variety of inflammation, and D induced by any one of many
local causes of irritation and nutritional change. This latter
theory by no means wholly excludes the influence of the
parasite, for it is easily conceivable that a certain condition
of local irritation may be the almost necessary precursor
of the implantation of the parasite. It may do for the
tissues what the farmer does for his field when be ploughs
and manures it preparatory to sowing seed. It is, perhaps,
better that I should be candid at the outset, and admit that
the attitude assumed by my own mind, as a consequence of
long familiarity with the facts in reference to lupus, is a
belief that this latter hypothesis expresses thq truth. It
seems to me highly improbable that all true lupus is the
result of contagion, and much more likely that it usually
begins in inflammatory action made peculiar by the special
proclivities of the individual.
If anyone has come here with the belief formulated that
there is a disease which to the exclusion of all others deserves
the name of lupus, and that it needs only skill in diagnosis
to separate it from all resemblances, let me beg of him to
lay it aside. Only those of narrow experience or of narrow
habits of thought can entertain such an idea for a moment.
No symptom, and no set of symptoms, will enable anyone
to recognise with certainty all cases of lupus, and to pro¬
nounce with confidence what shall and what shall not taxe
rank under that name. The explanation is simply that the
diseases which have been classed under it are not well
specialised. We can all of us recognise well-marked ex-
atnples, but by the side of these there are many which are
ill marked, and in which the disease, as ifc were, shades off
into obher conditions. I am aware that this statement may
seem strange to some, and that not a few will be inclined
to assert that if there is any disease which can be readily and
confidently diagnosed, it is this same lupus. I trust, however,
before I have finished to convince all that it is often quite
impossible to diagnose between scrofulou.s ulcers and lupus,
and between ulcerating chilblains and lupus—to say nothing
of the rare forms known as acne-lupus, sebaceous lupus,
and the not infrequent cases in which it cannot be said
with certainty whether the case should count as lupus
erythematosus or vulgaTis. In proof of what I have said, I
make my appeal first to observation of the cases themselves,
and, seconaly, to the recorded statements of authorities and
the names which have been applied to published portraits. On
the other hand, it is nob so difiicult to define what is meant
hy the lupous process. .Whenever a chronic inflammation
of skin or luucous niembraHe not'due to syphilis shows a
persisting tendency to spread at its edges, to produce
satellites near to it, and to leave a condition of sear
behind it, such a process is for me one of lupus. In a few
cases the production of satellites may he omitted and the
patch may remain absolutely single, bub its infective edge
and the resultant scar are essential. No form of lupus is
without them, although it must perhaps be admitted that
in a few the demonstration of the scar may he difficult.
There is another condition which, when present, is to trained
minds definitely diagnostic of lupus. I refer to the presence
beneath a thinned layer of epidermis of a deposit or growth
a semi-translucent granulation material, often in con¬
siderable thickness.
I fia4 that I am credited by some authors with the
introduction of the term “apple-jelly deposit” to this
growth. I am by no means certain that I was really the
first to apply it, but suspect rather that I borrowed it from
some forgotten source. It is. however, very appropriate.
126 The Lancet,] MR. JONATHAN HUTCHINSON ON THE NATURE OF LUPUS.
[Jan. 17,1891.
anti will probably hold its ground. This apple-jelly is,
when present, dehnitely diagnostic of common lupus, but
unfortunately is not to be recognised in a large number
of cases. Ic is only when the disease is quiet and free
from indammation. On some parts, as, for instance, on
the hands and the feet, it is scarcely ever seen, for the pro¬
ducts of inllammation almost invariably conceal it. It is, I
believe, in this growth that the bacilli when demonstrable
are present. Although as a rule the apple-jelly charac¬
terises common lupus, aod may possibly be held to
imply the presence of bacilli, yet on a small scale I have
often seen it in some of the thicker discs of a lupus which
certainly belonged to the category of erythematosus. Several
other minor and less characteristic features of the lupus
process may be luentioned which are of some use in making
a diagnosis. If the surface does not ulcerate, it is usually
seen to be covered with flakes of adherent epidermis, which
are white and papery, but yet do not fall oil' as do the
scales of psoriasis, if the patch is ulcerated, but the in¬
flammation yet only moderate, a bed of firm granulating
masses is formed, between the small polypoid growths of
which the dried crust, partly epideiinic, dips by numerous
processes. If this crust be torn away, the process always
lacerates the papilhn and causes bleeding. Hence a diagnostic
rule of our forefathers that a lupus crust could not be de¬
tached without causing bmmorvhage. The special parts which
are affected in lupus afford some help in diagnosis, for the
disease is much more prone to attack some than others.
The end of the nose perhaps takes precedence of all others,
and next to it the cheeks. Lupus is not uncommon on the
limbs, hue very rare on the trunk. When it occurs on
the hands and the feet, which is far from common, it
assumes, as has been said, peculiar conditions. You will
understand that all which I have just said applies only to
common lupus. I am for the present leaving the other forms
aside. I may add further as to common lupus that, although
it is often multiple, and may in some instances cover the
head and limbs, and even to some extent the trunk, yet
that its patches are never arranged with any approacii to
exact symmetry.
The older surgeons had only common lupus. Fiftyyears ago
lupus erythematosus had not been observed, and at a much
later period than that it was by some called an “ ery tlieaia-
tous Bcrofulide,” whilst lupus sebaceus was named sebor-
rhuja sicca or acne sebacea. Our forefathers had, however,
many adjectives which they applied to different conditions
which occurred to common lupus. If the nose were affected
and its tip and a'.'o destroyed, the term “exedens” was
applied. If the patches were free from ulceration and covered
with papery scales, itwas spoken of as “ lupus exfoliativus.”
If the patches spread more rapidly and extensively than
usual, the term “ serpiginosus” was used; but a strong
objection may be made to this, because, as already seen,
it is of the very essence of all lupus to be serpiginous.
It would not be lupus of any kind if it did not show this
quality. The designation “lupus bypertropMcus” was
employed for those cases in which a large amount
of solid cedema was present. It was but seldom
applied excepting to cases in which the upper lip was
the part affected ; but, as may be demonstrated from the
plates of it v/hich have been publisiied, it was sometimes
given to cases which did not specially deserve it. There
was also a lupus vorax ; but this was not a true lupus, but
in some cases a rodent cancer and in others a syphilitic
phagedasna. We may conveniently pub aside most of these
terms, or at any rate wo must recognise that they do not
denote varieties of lupus, but rather local and often tem¬
porary conditions of one and the same disease. Different
eases of common lupus difler one from the other chiefly with
reference to the degree and amount of inflammation and
ulceration consequent upon it present. These, again, are
much inffuenced by the part affected. Thus in the bands and
feet and on the nose—parts very liable to feel exposure to
cold—inflammation and ulceration are likely to occur,
whilst they are rare on those more advantageously placed
as regards the circulation and the protection of the dress.
If we were to divide Inpus cases into two groups, taking for
our guide in the separation the presence or absence of in¬
flammation, we should find that the state of the health, and
especially the vigour of the circulation, had much to do with
it. We have seen that the part affected i.s important, and
it may be added, season also exercises much influence. In
many subjects of lupus the patches inflame and ulcerate in
winter and heal in summer.
The statements which have been made have been intendedi
to introduce more deflnitely the discussion of the question
as to how far clinical evidence supports the hypothesis that
lupus vulgaris is of bacillary origin.
In reference to this a few other general statements
remain to be made. Lupus vulgaris is not a diseaser
which attacks infants or young children. In exceptional-
cases it may occur even to the youngest, but com¬
monly it waits until childhood i.s well advanced, or
even until the period of puberty is passed. It is said
by some never to begin in old age, but this is a mistake.
We often see it begin at or after middle life, and in a few
I instances its subjects are advanced in years. When the
latter is the case, it displays somewhat peculiar features,
and may probably be ranked with that group of maladies to.
which Sir James Paget has given the name “senile scrofula.”
Although in many cases it is niultipie in its manifestations
in tlie skin, several, or perhaps very many, patches being
produced, there is, with the fewest possible exceptions, no
tendency to infect other parts. The lymphatic glands do-
not sufl'er, nor do the lungs, the bones, the joints, or the
intestines ever become affected. Nothing is less common
than to see a lupus patient pass into phthisis. Thus we
may believe that the infective material, bo it what it may,
is one which finds a suitable home only in cutaneous or
mucous structures. If it be a bacillus, it is a selective one,
and it keeps to the tissue in which it bad its first development.
The most typical forms of common lupus are often coin¬
cident with good health on the part of the patient, and the-
absence of any family history of tendency to tuberculosis.
Of course, there are many exceptions to these statements,
but all observers agree that they express the general truth.
If, indeed, it were asked whether the clinical evidence morc^
favoured the belief of the alliance of lupus with tuberculosis
or with cancer, I am inclined to think that the reply would
have to express hesitation. Tuberculosis and the cancerous-
process have hitherto been held to observe towards each
other something of a position of antagonism. Those who-
are liable to the one are not prone to the other, and the two-
are but very rarely found together. Almost all who have
written on lupus have, however, been struck by the fact that-
parts affected by it not very infrequently take on cancerous
growth. The evidence on this point has recently been col¬
lected by Dr. Bayba of Tubingen, who from his own experi¬
ence has collected no fewer than four cases. I doubt much
if many observers could collect from their own observations
as many as four cases of lupus in whi(!h the patients had
subsequently succumbed to any form of internal tuberculosis.
In making these remarks I am far from wishing to ignore-
either the general impressions or the collected facts which
favour the belief that there is some bond of connexion
between tubercular affections and lupus. What I contend
for is that it is far less close than is generally believed.
The impressions which most of us have, I exj)ect, formed
on this subject go far ahead of any proof of a statistical
kind which we could sujmly. If I may bo permitted to-
anticipate a little what I shall have to say in my next
lecture, I may here mention the unexpected fact that statis¬
tical results are different in respect to lupus erythematosus.
In this latter no observer has, I believe, succeeded in detecting:
the bacillus, yet itis far more frequently in close association
with tuberculous conditions than is lupus vulgaris-
Some light may perhaps be obtained for the elucidation of
this difficult question by observation of the very earliest
stages of lupus. We are so accustomed to see this chronic-
malady after it has been long existent, and when its
ecnliaritics are well declared, that very little has been
one in the attempt to describe, still less to depict, its.
initial conditions. I much suspect that if we knew them we
siiould have to acknowledge that they are often such as
cannot be recognised as lupus at all. The disease may, and
often does, originate in a condition of chronic or recurrent-
congestion and swelling not in the lirat instance to be
distinguished from a chilblain. Or it may start from what
looked like tuberous acne at the end of the nose, or front
patches in the middle of the cheek, which bad been often
congested in the act of blushing or in the flush which
attends indigestion. Slight injuries, insect stings, bruises,
burns, *!cc., may become its starting point. In almost
all cases something not distinguishable from a chronic
papular inflammation is, I believe, the earliest local!
condition which is observed. The apple jelly may form
before the disease is far advanced, but it is never pre¬
sent at the very first. Nor do we ever see anything ia
The Lanoht,]
MR. JONATHAN HUTCHINSON ON THE NATURE OF LUPUS. [Jan. 17,1891. 127
'the least resembling a tuberculous ulcer. The early stage
'is in many cases insidious and prolonged, but it is not so in
all. In some a tendency to rather rapid infective spreading
is early manifested, and while it is so the conditions pro¬
duced resemble rather those of common in/Iammation than
anything which could be recognised as specifically lupus.
Let me here invite your consideration to a very curious fact
in the history of common lupus. It is that after the disease
has well declared itself we have little or no cause for anxiety
as to infection spreading in distant parts. Satellite mani¬
festations will, of course, appear, but no one fears for his
patient with lupus of the face that unless it is promptly cured
'ft may cause other patches to appear on the limbs or body.
It is quite different in the case of lupus erythematosus, in
which reproduction on distant parts may be observed at any
stage. When lupus vulgaris is multiple, when it occurs in
anany separate patches scattered over the limbs and body, I
believe that the history invariably is that the dissemination
occurred in the very earliest stage. Later on there comes
rather a tendency to diminish multiplicity than to increase
it. 1 am fortunate in being able to bring before you a very
conclusive instance in proof of this, and to illustrate it by
portraits showing the disease at dilierent stages. I will
show you the latest portrait first. You will see that it
•exhibits many large patches of what has been called “lupus
non-exedens” or “lupus exfoliativus” on the face, neck, and
limbs of a boy of almost eight. The disease is well charac¬
terised ; the areas involved show a tbiu scar over the
greater part of their surfaces, but at their borders is a
tuberculabed margin with small formations of apple jelly
and a tendency to superficial ulceration and the forma¬
tion of a dirty pus crust. Although so numerous
the patches are not arranged with symmetry. The
boy 18 in good health; he has no signs of scrofula
other than his lupus, and there is nob the least reason
to suspect sypliiUs. Now, when this boy was first
brought to me, three years before the portrait which I have
ehown you was taken and one year after the commencement
of his malady, the nature of the disease as lupus was by no
means declared. He was covered witli ulcerations wWli
resembled a mild rupia, and with pustules and chronic
ilichen-papules. No one (and he hadueen seen by several
authorities) had suggested that the disease was lupus. It
-had begun by an iiillamed patch on one arm, and from this
the others had by a process apparently of general blood
infection been developed. Daring the next six months the
pustules, liclienoi<l papules, &c., disappeared, and with them
oome of the smaller ulcers; but the larger of the latter,
losing theiv inllammatory conditions, settled down into
patches of lupus, aggressive at the edges, but incapable of
distant infection. You will see, by comparing the draw¬
ings, that, although the patches have much increased in
size, no new ones have been produced during the last three
■or four years. I have nob had the opportunity of observing
any other case of multiple Inpus in its earliest stage, but
■of many others which I have seen I can assert this, that
in none was there in the later stages any tendency to
increase in the multiplicity of distant manifestations.
1 do not know whether any argument against the bacillary
•origin of common lupus will bo admitted bo be legitimately
based on the acknowledged fact that syphilis can simulate
it. The fact itself is illustrated in everyday practice, and
those who wish to refresh their memories luive only to
glance over the series of portraits which I exhibit. The
portrait wldch one authority publishes as lupus another
'takes to resemble syphilis, and all will agree that rospect-
■ing many nothing but the history could decide the question.
Wio has not met with cases in practice in which, even with
the aid of a carefully obtained histoiy, he has felt in doubt
whether the malady should be named “serpiginous syphilis”
■or “superlicial lupus”? The argument which I base on this
'fact is that, since syphilis in its tertiary stage (as syphilitic
lupus) is only a chronic infective inllamniatlon deriving
peculiarity from the specific antecedents of the patient, and
haying nothing whatever to do with tuberculosis or
bacilli, it is resonable to suspect that lupus itself, which so
•exactly resembles it, may in turn bo a process of chronic
inUamiuation made peculiar by the vital proclivities of the
patient. I may add that syphilis can imitate, not alone
common lupus, but in turn most of its various forms.
Let us next ask whether there are, apart from the aft’oo-
wons known under the name of “lupus,” any diseases of
he skin which are supposed to be in association with, first
croiula, and secondly specific tuberculosis? The reply, as
regards scrofula, must be that in connexion with suppura¬
tive disease of the lymphatic glands, and sometimes with
suppuration of cellular tissue only the skin is often and
extensively involved, and that in such cases it does not as
a rule assume the conditions known as “lupus.” These
affections are those which are responsible for the ugly
seamy sears which disfigure the necks of those who have
suffered from “scrofula’’ in childhood. They are totally
distinct from lupus in most instances, although in a few
the two are seen together. The scrofulous ulcers usually
begin under the skin and involve the latter secondarily,
whereas lupus is a disease of the skin itself primarily,
and only secondarily affects the subcutaneous cellular
tissue. Now on the hypothesis that lupus is a tuber¬
cular disease — i.e., bacillary in originis certainly
extraordinary that in gland-struma the skin does not
assume a lupus state, nor conversely do the glands suffer
in lupus. If I say anything as to a true tuberculosis of
skin as distinct from both lupus and scrofulous ulceration,
I shall have to boiTow from the observations of others; I
have no facts of my own. Authors, especially of the French
school, have, however, described certain rare conditions of
primary ulceration of the skin itself which they have
deemed tuberculous. Such ulcers have occurred in the
subjects of true tubercle, and by the microscope giant cells
and other elements supposed to be diagnostic of tubercle
have been found in them. Respecting thd occurrence in the
mucous membranes of tubercular ulceration and of lupus as
quite distinct things easily diagnosed the one from
the other, there can be no manner of doubt. Tuber¬
cular ulcers in the laiyn.x, for instance, are frequent,
and they are very different from lupus of the same part.
They appear to result from direct infection by the secretions.
In the mouth, on the tongue, gums, and cheel'is, we occa¬
sionally, though very rarely, see true tubercular ulceration,
and it presents appearances and runs a course wholly
divergent from those of lupus. Such affections are usually
rapid in their progress, whereas lupus is very slow. I do
not think that I have ever seen such conditions excepting in
association with tubercular disease of the viscera.
I must mention briefly in connexion with possible
forms of tuberculosis of the skin the affeetiion described
by Hebra as “lichen scrofulosonim,” and that known
as lupus verrucosus, or “tuberculosis verrucosa cutis.
There is no doubt that children affected by scrofula
are liable, as Hebra stated, to present a condition of
general and very chronic enlargement of the hair-follicles
over the abdomen and sides of the chest. I am not aware
that any histologist has succeeded in demonstrating tuber¬
cular elements in these papules of lichen scrofalosorum. That
they are scrofulous in their nature I do not doubt. They
are distinct from lupus, but by far the best marked
example of the disease which I have seen occurred in a
child who was at the same time the subject both of pul¬
monary phthisis and iupus. I may acknowledge that I
cannot distinguish lupus verrucosus from lupus necro-
genica, or necrogonic warts, nor in some cases from common
lupus affecting the extremities. The microscopic proof that
these forms of disease are attended by giant cells and some¬
times by bacilli must be held to be complete. That they
occur to persons nob otherwise scrofulous is admitted by all,
and further, that they do nob lead to infective tubercinisa-
tion of other parts or organs. They are often much under
the inlluence of the general health, and mosb emphatically so
under that of warmth. AH exposure of the affected parts
to cold makes them worse, and as a rule systematic and
ellicient protection cures them.
Thus, gentlemen, I have endeavoured to bring in review
before you the principal facts wldch from the clinical stand¬
point appear likely to help us to answer the question
whether lupus vulgaris shoula be regarded as tuberculosis
of the skin. We have seen that there is no evidence that
it ever begins from the implantation of tuberculous matter,
that it is only exceptionally associated with tubercle in the
viscera, and that it never causes infective gland disease.
Wo have also seen that there are other affections of
the skin which do not resemble it which are much
more closely associated with tubercle and with scrofula.
We have seen also that its remarkable preference for
certain regions and parts seems to imply that the in-
lliience of cold is by far tho most common of its excit¬
ing causes. I may own that the sum of the evidence
' Ilielil aii'l T'altauf.
128 The Lakcbt,] MB. T. BEY ANT ON INTERNAL INTESTINAL STRANGULATION. [Jan. 17,1891.
seems to me much la favour of the belief that lupus is a
specialised form of chronic inflamroatioD rather than the result
of infection. In suggesting this I am well aware that it is
merely a negative conclusion which is liable to be over¬
thrown at any time by the accumulation of positive
evidence. It may be that in the future the presence of
bacilli in lupus-products may be demonstrated in earlier
stages, and much more constantly than has yet been the
case. The results of Koch’s injection treatment may
possibly force us to believe that there is something about
lupus which connects it far more closely with tuberculosis
than I have admitted. I prefer for the present to say nothing
about the results of that treatment already obtained; I
shall leave that for our last lecture. In our next I shall
snbmit for your consideration in some little detail the facts
which connect different forms of lupus, one with another,
and include even certain forms of disease of the skin which
have not as yet been acknowledged as lupus at all. My
argument from these facts in reference to our present
qnestion will be that, seeing that a considerable group of
maladies are inseparably associated together in tbe lupus
family, it is probable that one and all should be regarded as
forms of chronic infective inflammation deriving their
peculiarities from the proclivities of the individual attacked
and not from specific elements of contagion.
OM TIIK
TEEATMENT OF ■ INTERNAL INTESTINAL
STRANGULATION ANI) OBSTRUCTION.
Delivered on retiring from the chair of the llaroeio.n Socictu,
Jan. 15th, ISOl.
By THOMAS BRYANT, F.R.C.S. Eng.,
I’RESIUKN'r 01 ' Tl!12 llOYAf. C0I-LE<;K OI' .SVlUiKONS.
Gentlemen; —In vacating the chair in which by your
kindness I was placed a jiear ago, and in resigning the
duties of an offic? which by your courtesy has been rendered
both profitable and pleasurable, allow me to assure you
that I have cordially appreciated the honour you conferred
upon me, and thank you for tbe pleasant and friendly w'ay
in which you have supported me during the past year. To
show my gratitude for past favours, I propose therefore to
anticipate another, and to tax your kindness once again ;
whilst in returning to the subject of my Harveian Lectures
of 1884, I place before you tome few practical remarks on
the treatment of internal strangulation and obstruction.
To make matters clear, I shall consider the subject from a
clinical point of view, and with this purpose divide iny cases
into three main groups. The first includes examples of what
are usually called, but as I bold wrongly called, cases of acute
obstruction. The second, cases of chronic colonic or rectal
obstruction, and of acute symptoms grafted upon tbe chronic.
The third, cases which cannot well be placed in either of tbe
two former groups, and the nature of which is obscure. To
tbe last group my remarks will chielly be directed after a
brief consideration of the two former groups.
It may be within the recollection ot some members of this
Society that in the year 1884, when discharging the duties of
your Harveian lecturer, I pointed out tbe expediency of sepa¬
rating cases of acute intestinal strangulation from those of
obstruction ; “Since in examples of intestinal strangula¬
tion, obstruction is only one of its symptoms, but neither
the cause of danger nor of death ; whereas in cases of intes¬
tinal obstruction, the obstruction is the prominent and dan¬
gerous feature, and from it, or it chiefly, the consecutive
changes which lead to death are brought about.” I dwelt
likewise upon the mechanism of strangulation, and illus¬
trated from the familiar example of a strangulated external
hernia the changes which the bowel undergoes when
strangulated within the abdomen, in either the shape of
an internal hernia, volvulus, constiicbing band of any kind,
or acute intussusception. I showed, moreover, how in all
tbeen o^onditions the pathological changes are identical;
that in all there is more or less sadden or complete inter¬
ference with tbe venous circulation of the part, and that>
this, if not relieved, will of necessity end in complete blood
stasis, and, as a consequence, “static gangrene” and death
of tbe part strangulated; death under these circumstances,
taking place from these pathological causes, and not from
obstruction. I showed also how this point was well illus¬
trated by the not unfamiliar fact met with after the reduc¬
tion of a strangulated hernia, when all the acute symptoms,
of strangulation subside, but obstruction from paralysis,
of the strangulated segment of bowel remains for days, and
at times for weeks—I have known it do so for three weeks—
without giving rise to one bad symptom.
When, therefore, we are called to a case of what you maybe
disposed to consider as one of acute obstruction, Imt to which.
I would prefer to consider as one of acute strangulation—and
it matters not whether it be one of internal hernia, volvulus,,
strangulation by a band or acute intussusception—we sljould.
mentally see either the gradually increasing venous con¬
gestion of the strangulated part or its rapid congestion; and.
we should picture to our minds the venous blood congestion
passing on to a more or less rapid complete blood stasis
when we cannot be too alive to tbe fact that death of the
strangulated bowel, if not of the patient, is not far distant-
This condition of mind helps our practice. It does not con¬
duce to help the practitioner to depend upon a surgery of
hope, based upon the administration of drugs which mask,
symptoms, but do nothing towards the relief of the.
mecbanical conditions upon which the symptoms depend ;.
but it encourages him to act with foresight and decision,
as he would do in an example of external strangulated!
hernia, and to deal with his case of internal etrangulatiou.
by the only means that can save life, and that is, by-
laparotomy.
In the case of a patient suiTering with symptoms of stran¬
gulated bowel—that is, a sudden abdominal pain>accoai-
j)anied or soon followed by vomiting oC a gushing and-
persistent cliaracter,—if this patient be tbe subject of an.
old hernia, the rule of surgical practice is to explore the-
hernia, whether or not it presents the local features of
strangulation. Should notbiug be found in the hernial,
swelling to explain symptoms, tbe surgeon then explores-
the neck of tbe hernial sac, and on this exploration yielding:
DO result, be is often and should always be led to explore,
the abdominal cavity.
I In the case of a patient suffering with symptoms of
I strangulated bowel, but without any external hernia, I bold
that a like rule of practice should be followed and that on,,
the diagnosis of a bowel strangulation being made, the sur¬
geon should at once proceed to explore the abdomen, first, to.
find out tbe exact cause of the strangulation, and, secondly,.,
to relieve it. It is true that failure often follows the attempt,
but it is equally true that success is more likely to attend
an early eifort than it can be expected to follow a late one;,
and under all circumstances it should be remembered that
where success ensues, it means thatalife has been saved which,
under other circumstanceswould to a certainty have been lost.
I would, however, like to remind you that as in practice we-
meet with cases of irreducible hernia in a condition of
obstruction as well as of strangulation, and that these
conditions are indicated by general symptoms which var,y
only in degree of intensity, so we must expect to meet with
cases of internal hernia or their equivalents under pre¬
cisely similar circumstances, and that these dilferent condi¬
tions will be indicated by diflerent symptoms. Indeed, it is
important to remember that an internal hernia, like an ex¬
ternal one, may be either obstructed or strangulated. I
would point out also that even in cases of external and in¬
ternal strangulation there are degrees of strangulation. In.
one case it may be so .sudden and complete as in a few hours
to bring about blood stasis in the portion of bowel which is-
implicated; whereas in another the strangulation is more
slowly brought about, and two or three or more days may
be passed before the strangulated intestino undergoes any
serious organic changes. Between these two extremes there
are also many degrees.
With a due recognition of these facts, we can therefore
fully understand how it is that in practice symptoms of
bowel obstruction and of strangulation,, whether within the-
abdomen or within an external hernia, are found to vary.
We comprehend how it is that in the most acute cases^.
besides the sudden onset of the symptoms, accompanied
with vomiting of a persistent and gushing character, we
meet with early collapse and speedy death ; and how it is
where the process of strangulation is less- complete amJ.
Di,: ;::j,C00gIe
The Lancet,] MR. T. BRYANT ON INTERNAL INTESTINAL STRANGUI^ATION. [Jan. 17,1891. 129
more gradual, the general symptoms are less severe, the
vomiting less marked and persistent, and the collapse
more or less absent until the close of the case. I have
known a case of scrotal hernia of the congenital variety,
in a young man aged twenty-six, terminate in gangrene
of the whole strangulated bowel in twenty-four hours, and
I have known a coil of bowel in a young woman about the
same age, which had become strangulated by a peritoneal
band cupping the coil at the brim of the pelvis, become
gangrenous in the same period, in both these cases operative
interference having proved iutilebecause undertaken toolate,
relatively to the amount of changes which had taken place
in the strangulated tissues! A portion of bowel acutely
strangulated within the abdomen is no more likely to relieve
itself by natural processes than is a strangulated coil in
an external hernia, and although we know that in very
exceptional cases such a happy result may take place, no
thoughtful surgeon would on that account delay surgical
assistance in the one case more than in the other; whereas
a loop of bowel, when only nipped by a band or partially
strangulated, like an obstructed hernia passing on to stran¬
gulation, may suffer but little from some hours’ delay, or
may even hnd an escape by natural processes when well
aided by art.
In the most severe example of acute strangulated hernia
even the taxis may be injurious, and nothing but operative
interference can be considered to be good surgery. In the
more slowly developing examples the taxis is the right treat¬
ment, opium and local cold may be justiliahle measures,
and operative delay not open to censure. Jiy a like argu¬
ment, in an acute internal strangulation nothing but
laparotomy ought to be entertained; whereas in the more
slowly developing cases a few hours may be spent in veri¬
fying diagnosis and in the employment of measures which
may tend towards good. Laparotomy should therefore
always be undertaken as soon as the diagnosis of acute
intestinal strangulation is made, and there need be no
delay for the formation of a specific diagnosis of its cause.
In the less severe cases, where the symptoms are those of
obstruction, and where the diagnosis may not be clear, the
lapse of a few hours may be justifiable. The treatment of
these cases during the period of delay will he considered
under our third beading.
The second gro^ip of cases, or thatwhicli includes examples
of chronic obstruction of the rectum or colon from cancerous,
syphilitic, tubercular or simple ulceration, need not detain
us long. Practitioners who are in the habit of making
rectal examinations in all patients wlio complain of bowel
troubles soon recognise these chronic affections ; and if the
histories of the cases which present symptoms of an acute
nature are carefully gone inco, the difficulties of diagnosis
are not as a rule insuperable. The digital discovery of
growth or ulceration when the disease is low down, and the
ballooning of tlie rectum when it is higher up, afford with
the history of the case and other symptoms ample evidence
upon which a working diagnosis can be made in the majo¬
rity of cases; and when the diagnosis has been made, the
line of treatment to be followed is neither uncertain nor
complicated, since it can be summed up in the use of laxa¬
tives to ward off symptoms of obstruction, and a well regu¬
lated diet, with colotomy (lumbar if possible) as soon at
least as the first symptoms of impending blockage appear;
and in time to anticipate those further changes in the bowel
above the seat of obstruction upon which the mortality of
all cases of obstruction, as well as so many of colotomy, so
much depends. When acute symptoms have been grafted
upon the chronic, some difficulties in diagnosis may be ex¬
perienced; but such cases rarely if ever simulate those of
internal strangulation, and under such circumstances some
delay for purposes of investigation can generally be sanc¬
tioned, as long as a line of expectant treatment such as I
am now about to consider, and which is not calculated to
do harm, is steadily pursued.
The third group of cases must now occupy our attention,
and it includes all cases which cannot be well placed in
either of the two former groups, and in which therefore
the diagnosis of the cause is in a manner obscure. It
includes also for treatment certain examples of the two
former groups, The group comprises, therefore, for pur¬
poses of treatment, examples of the first group in which
operative delay is justifiable from doubtful diagnosis, or
necessary from want of consent or other cause; cases
of the second group in which acute symptoms have been
grafted on to the chronic; cases of ficcal impaction of
the caecum or colon (I exclude rectum as this condition is
so readily detected); cases due to some local peritonitis,
the result of injury, or the extension of inflammation from
a pelvic or other organ ; also cases of chronic intussuscep¬
tion or of early stricture; cases in which the diagnmis of
internal strangulation is not sufficiently clear, or of colonic
obstruction from stricture sufficiently evident, and yet in
which symptoms of obstruction are markedly present—
that is to say, abdominal pain exists in various degrees, and
more or less abdominal tenderness and distension. Peri¬
stalsis may or may not be visible—if very visible it suggests
chronicity. Vomiting may be present or persistent, and this
is aggravated by food. Constipation, more or less complete
or prolonged, may coexist, and a repeated examination of
the rectum fails to give any evidence of local disease. How
is such a case to be treated ? Are pirgatives of steadily
increasing power to be regularly administered? Are enemata-
of gradually increasing quantities and strength to be con¬
secutively employed? Is our old friend the long tube to
be called into requisition, and are we still to delude our¬
selves that by means of it the sigmoid flexure may be
washed out? Is the patient, when under an an.'estbetic to
be inverted, succussed, and his abdomen manipulated by
abdominal taxis for thirty or forty-five minutes with the
hope that some good may come from it ? For my own part,
1 say away with all these measures as a routine practice.
In some few cases they may be applicable, but in most they
are surely full of grave danger. When the diagnosis of the
case is that of colonic obstruction from faecal impaction,
purgatives and enemata may possibly be right in the minds
of some ; I am disposed to think otherwise. Where the
obstruction is probably due to organic stricture, purgatives
and enemata are unquestionably wrong.
In most cases of obstruction, and in examples of uncertain
strangulation, an enema at the early period of the case to
clear out the lower bowel, and to facilitate a rectal exami¬
nation, is of advantage, but the employment of the long
tube is under all circumstances a delusion, a danger, and
unnecessary ; for when the surgeon wishes to wash one the
colon or to fill it, this is best done by using the enema
syringe or a long rubber tube and funnel, with the pelvis
of the patient well raised on a high pillow, in order to make
the injected fluid pass into the bowel by its own gravity.
It is true that when purgatives are given in cases of internal
strangulation, as in those of hernia, nature herself expels
them by vomiting, and in this way the harm they may do
is muchdiminisbed. But why give them ? Is not the bowel
above the seat of obstruction in every case of intestinal
strangulation, as well as of obstruction, already goaded
enough, and is it not full to overflowing with liquid feces?
Is not also this liquid motion ready to flush the lower
bowel as soon as the mechanical cause of obstruction is
removed? So far as purgatives and aperients are con¬
cerned, they can therefore do nothing but harm. As to
abdominal taxis, snccussion, and inversion, I am at a loss
to know what to say, since these measures have a powerful
supporter in the distinguished surgeon who advocates their
use as a routine practice, and who tells us that it is hardly
likely to be prejudicial to any case. I shudder, however,
to think of the harm these measures are calculated to pro¬
duce iu all cases of internal strangulation, and believe it
cannot be less than forcible taxis is known to bring about
in the treatment of an external strangulated hernia.
1 am, however, sure that, in a modified form, abdominal
kneading is in certain cases of value; indeed, I have employed
it with success ; in the same way as it is useful in cases of
large obstructed, but not strangulated, hernia. Thus, in
cases of oostvucted bowel from some mechanical cause, such
as a band, when symptoms are not severe ; in coses of fecal,
cwcal, or colonic obstruction; in coses of obstruction <lue
to matting together of the intestine from some antecedent
peritoneal inflammation the practice may be of use. In
any case of acute trouble in which bowel strangulation
is suspected the practice must be full of danger, and
should be condemned, fn these cases an exploratory
abdominal incision is far less likely to do harm, and is far
more likely to do good if undertaken in time. Under ’ liese
circumstances I would wish to replace these unscientific, if
not dangerous, routine jiractices by another, which has some
reasonable arguments in its fa\’our, and not the least of
which is its succe.ss.
1 propose to illustrate this method by briefly quoting
three fairly typical cases, and 1 choose them because they
have all passed under my care during the last year, iu an
180 tab Lancet,] PROFESSOR R. VIRCHOW : KOCH’S REMEDY IN TUBERCULOSIS. [Jan. 17,1891.
excellent home for middle-class patients with which I am
BOW associated at Wandsworth Common, known as Boling-
hroke House
Case 1.—Mrs. R-, a lady aged sixty, spare but healthy,
who for years had at times experienced trouble with her
bowels, necessitating the frequent recourse to medicine,
came under my care witii a distended, tender, and tym¬
panitic abdomen, showing central coils of intestine in a
marked manner, frequent vomiting of a bilious character
(aggravated by food), and complete constipation of ten days’
standing. Pulse normal, but feeble. Temperature sub¬
normal. Urine scanty. A rectal examination gave no
evidence of local trouble. The case was supposed to be one
of stricture of the large bowel high up. Not feeling suffi¬
ciently sure of this aiagnosis, I determined to wait before
proceeding to operate, and ordered her to have her abdomen
covered with a mixture of one drachm of the extract of
heiladonna and an ounce of glycerine, and to be fed by a
4-oz. nutrient enema, alternating with a nutrient
meat suppository every four hours, and a teaspoonful of
warm water by the mouth every lialf hour. Relief to pain
and alleviation of all her symptoms soon followed this
treatment, and on the fourth day—that is, on the four¬
teenth of her symptoms—.‘’ome flatus passed. On the sixth
day of treatment, or sixteenth of obstruction, some feculent
matter of a grey colour came away. On the seventh day,
after a small glycerine enema, a moderate motion was dis¬
charged, when food by the mouth was recommenced, and in
another two weeks the symptoms had disappeared and the
bowels gradually recovered their normal action.
Case 2.—J. - , a man aged thirty-two, came under my
notice with abdomin^ syiuptpras suggestingthe thought that
he had an intussusception. Hehad been ill four days and had
been constipated for a week. Three days before I saw him
he took a dose of castor oil which caused vomiting, and this
was soon followed by straining and the passage of blood
and mucus from the bowel, but no fences. Since then be had
bad abdominal pain of a somewhat paroxysmal character.
"When seen his abdomen was slightly distended and tender
on the light side. No lump could be felt; nothing was to
he felt on examination per anum. I ordered him to be kept
warm in bed and to lie still. He was not to take any food
by the mouth, only a teaspoonful of water every half hour,
but to be fed by nutrient enemata (four ounce) alternating
with a meat suppository every three liours. The iirst enema
to have twenty drops of laudanum in it. During the next
twenty-four hours he passed blood and mucus seven times,
accompanied with tenesmns but no fmces. The enemata
were continued, but each one was to contain twenty drops of
laudanum. On the fourfchdayof treatment, buttheeleventh
of obstruction, a liquid motion with ilatus was passed, with
relief; on the fifth day the same relief : on the tenth day
some solid motion came away, bub with a blood-clot, and
in three weeks his ai>domiDal symptoms had disappeared.
I cannot but think that if any of the lines of routine treat¬
ment to which I have alluded had been applied to this case
that a different result would have taken p^ace. As it was,
I left nature alone and siu’ply kept the machinery of life
going by rectal alimentation, and checked peristalsis by
opium.
Case 3. —AnneB-, aged nineteen, who for some weeks
bad suffered from diflicuity in obtaining relief from her
bowels, after seven days’ complete obstruction, was seized
with abdominal pain, distension, and tenderness, with
vomiting. These symptoms continued and increased in
severity for four days, when she came under my care. Her
abdomen was then very tense and tender. Nothing could
be made out by palpation. She vomited everything she
took, and even without food. Nothing had passed the
anus for eleven day.s, not even flatus. There was no abnormal
temperature and nothing could be felt in the rectum. 1
ordered her the belladonna externalapplication, as in the first
case, and a nutrient 4-oz. enema of milk and egg, alternating
with a meat suppository every three hours, and a teaspoon-
fnl of fluid by the month every half hour to relieve thirst.
On the second day the symptoms wfre improved, the abdo¬
men was less tense and painful, and vomiting had ceased.
On tiie fourth day of treatment, or fifteenth of obstruc¬
tion, she was erill better, consequently a few ounces of thin
broth were allowed. On the fifth day of treatment and
sixteenth day of obstruction the bowels acted, and continued
to do so, when an enema was given to clear out the rectum of
the solid motion which had passed down, and a rapid
recovery ensued.
The results that followed the treatment which these cases'^
illustrate were satisfactory, and I am induced to think they^^
were better than any that would have followed the use of
powerful purgatives, large enemata, or the abdominal taxis.
The treatment, moreover, was simple, and, though expec-'
tant, it did no harm. Of such treatment we may reasonably
say that it gives time in the only class of cases to which
it is applicable—viz., those of a not urgent but doubtful
nature—for the case to develop, and the surgeon to frame a
more exact diagnosis; whilst it leaves nature every chance
of making right, where this is possible, what may have been
wrong in the abdominal machinery. Should the symptoms
in any given instance fail to be speedily relieved by this
treatment, more active measures can be resorted to as soon
as a clearer working diagnosis has been made.
In some cases opium may be more freely given than these
three cases indicate; but I hold that where belladonna as
an external application arrests peristalsis and soothes pain
opium is not needed. In many cases it is, however, most
valuable; the form I like best is either the solid opium or
the bimeoonate of morphia. It should, however, always be
given with caution. I prefer to employ it with belladonna
as a suppository made with gelatine—half a grain of the
extract of belladonna and half a grain or more of solid
opium. Warm fomentations to a swollen abdomen often
give comfort; when employed they should be placed over
the glycerine and belladonna application already mentioned.
In a case of obstructed bowel from a supposed band with
mild symptoms I have known relief to follow the elevation
of the pelvis on a firm pillow, so as to allow gravity to act
towards the tiiorax; and 1 believe that with this treatment,
combined with starvation and the use of belladonna and
opium, I have had cases of natural recovery. I claim no
novelty in the treatment I am advocating. I only want to
enforce its value, and should indeed be pleased to know
that it had superseded the routine practices to which I have
drawn attention, and which liave for too long occupied the
field. The principle upon which it is based was first re¬
commended by Sydenham ; it was reintroduced by Brinton,
and more recently enforced by Thomas, with some modifi¬
cations. It may be summed up as follows. The recumbent
position with elevation of the pelvis, abstention from all
rood by the mouth, rectal alimentation, the external use of
belladonna and glycerine, and the administration of bella¬
donna and opium to check peristalsis and soothe pain.
ON THE ACTION OF KOCH’S REMEDY UPON
INTERNAL ORGANS IN TUBERCULOSIS.^
By professor R. VIRCHOW.
Limiting his remarks to facts determined by anatomical
investigation, Professor Virchow said that from the time
at which the practice commenced until the end of December
he had examined post mortem twenty-one cases in which
during life injections of Koch’s fluid had been practised,
and to these might be added some six or seven more examined
during the present year, [A large number also have been
examined by bis assistants in other hospitals and elsewhere,
and had yielded important facts.]
There is an obvious difference between those cases in
which the changes taking place in superficial parts can be
observed clinically, and those where the internal organs
are affected to an extent difficult to estimate by the most
careful clinical investigation ; and it is of interest to con¬
trast the latter with the former. Of the twenty-one cases
referred to, sixteen were cases of phthisis in the limited
sense—i e., in which the lungs were especially involved.
The remaining five cases comprised: (1) A well-marked
case of tuberculosis of bones and joints; ( 2 ) a case present¬
ing the rare concurrence of cancer of the pancreas with
small smooth-walled cavities in lung and apical induration;
(3) an empyema in a puerperal case, which would probably
have proved fatal apart from the injections; (4) per¬
nicious amemia, with very limited old lesions in lungs and
tuberculous pleurisy; and (5) a case of arachnitis tuber¬
culosa. In the remaining sixteen, strictly pulmonary cases,
all showed more or less extensive phthisical ulceration.
' Abstract of remarks made duiing the debate on Dr. B, FraenkeT
paper at the Berlin Medical Society, Jan. 7th, 1891. (From full text
given in the “ Berliner Klinisch© Wochenschrift," No. 2,1801.
’8
THit lancet,] professor R. VIRCHOW : KOCH’S REMEDY IN TUBERCULOSIS. [Jan. 17,1891. 131
Reservinjf for another opportanifcy a detailed statement
cf these cases, Professor Virchow proceeded to make some
f meral remarks on the experience derived from them.
Ast as observation of external parts bad shown that the
remedy acts as a severe irritant, exciting redness and
swelling, so the same effects had been well seen in the
infernal parts. He showed a preparation from a case of
arachnitis tuberculosa in Henoch’s clinic, in which there
were also some old caseo-pneumonic areas in the lungs
(the probable focus]of the meningeal metastasis), together
widi recent inflammatory changes. After four injections,
amounting in all to two milligrammes, the last being six¬
teen hours before death, the patient (a boy two years and
a half old) died. Professor Virchow did not remember ever
, having seen so “colossal” a hyperemia of the pia mater,
and even of the brain itself. The pia matral vessels were
extremely distended, and the brain tissue of a dull reddish
tint. In this, the only case of the kind in the series, he
personally examined the tubercles in the arachnoid, but
could detect no degenerative changes in them: they
were well formed and of the ordinary character. Similar
conditions of acute hypermmia and swelling were also
to be found in other internal organs. They had often
noted an unusual deep injection of the granulation
•layers of old pulmonary cavities; sometimes a hmmor-
rhagic infiltration of the walls, or evidence of recent
haemorrhage into the cavity. In a man thirty years of age,
with an old rectal fistula and numerous tubercular ulcers in
the colon, death followed upon h.Tmoptysis from an old
ulcerating focus; he had been injected seven times, the
last occasion when the heemorrhage set in, being thirteen
days before his death. But these visible changes were not
confined to such marked hypermmic swellings, which
obviously might be very transient, for there was not the
least doubt that actual inflammation^ with active prolifera¬
tion, occurred to a considerable extent. This is well shown
at the margins of ulcers and in the neighbouring lymphatic
glands, especially the bronchial and mesenteric. The glands
were most markedly swollen, that form of medullary swelling
peculiar to acute irritation, and due to a rapid proliferation
of the cells within the gland. This change is often associated
with obvious leucocytosis, which may be assisted by the
infiltration of white blood-corpuscles around the tubercle.
Sometimes these inflammatory swellings are dangerous.
Thus in the larynx, although the ulcers may become
healthier, the neighbouring tissue enormously swells, and
may produce a critical degree of stenosis. Sometimes the
change may assume a phlegmonous type, comparable to
what is seen in cedema of the glottis and retro-pharyngeal
abscess, as illustrated in a case seen this month (January).
No doubt it is difficult to assert that any such inflammation
is due to the injections, for there is no criterion for
any differentiation; nor was he pi epared to say precisely
how this kind of inflammation may be recognised ani
distinguished from other inflammatory lesions arising in
the course of phthisis. But in the lungs certainly theie are
lesions which are exceptionally peculiar.
Among the fatal cases of ulcerative phthisis the great
majority showed widespread changes of recent date, mostly
in the lungs, but also associated with pleurisy of very
severe type, simple and tubercular, hmmorrhagic and
not rarely bilateral. The lung changes may be separated
into two seemingly very different categories. The one cor¬
responds to whatisstyled “caseouspneumonia,”oranatomi¬
cally, “caseous hepatisation.” It might be thought very
doubtful whether this change was in any way connected
with the injections. Professor Virchow woiild himself
have doubted this were it not that some of the cases
showed it in a special degree, and be exhibited a portion of
lung which had undergone caseous hepatisation to an extent
the like of which he nad not seen for years. The lungs
were large, their lower lobes, especially the right, as volu¬
minous as in ordinary hepatisation; but the foci were so
thickly massed as to leave hardly any parenchyma between
them. It was like a piece of black sausage richly laden
with fat. The non-oaseous parts were blackish and sharply
demarcated from the caseous. Themanwastliirty-thveeyears
old; he had had six injections, the last four weeks before
death, and theinjections were suspended because ofsuperven-
tionof continued fever andinfilbrationof thelowerlobes. This
infiltration started just after the injections, for previously
there were only signs of induration at one apex, where was
^terwards found an old indurated focus. In other cases,
also, the condition of the lungs similarly differed from what
is usually seen in phthisis ; in five of the cases there were
more or less large masses of caseous hepatisation, but not
approaching the extent of the case related.
Another change, which is certainly inflammatory, is of a
more diffuse character, although again not absolutely dis¬
tinctive. The types of pneumonia liable to arise in the
course of phthisis may be placed in three different categoiies.
There are the caseous, the ordinary fibrinous, and the
catarrhal, so-called smooth pneumonias-—marked essentially
by cell accumulations in the alveoli. One may see all these
forms in a case of pbthbis, but in not one of the injected
cases was simple fibrinou.-i pneumonia pre«ent.^ In fact,
the “ injection pneumonia” resembles the catarrhal type,
but with certain differences. Catarrhal pneumonia, as
ordinarily met with in phthisis, exhibits a moderately
fluid collection in the alveoli, which can only be slightly-
expressed from them. Sometimes tbf contents are much
more watery, like brine, and it was this which led Laennec
to speak of gelatinous infiltration preceding tubercular
infiltration. But the product in these cases is not gela¬
tinous ; it is rather watery and turbid; it might be called
cloudy infiltration, and calls to mind a phlegmonom con¬
dition. In some parts it is more opaque ; in parts it has a
superficial likeness to caseation, but without its dry cha¬
racter, and there is no difficulty in distinguishing the two.
The.catarrhal phlegmonous condition is softer, moister, and
laxer, as in a specimen shown, where around large ulcera¬
ting cavities in the apex of lower lobes were caseous masses
and catarrhal inflammation. Two other specimens also
showed caseous and catarrhal hepatisation, which con¬
dition occurred in seven out of the sixteen cases examined
last year. A further point of difference from ordinary
catarrhal hepatisation consists in the occasional occurrence
of areas of softening in the midst of the bepatised foci,
producing rapid excavation ; for instance, in the middle of
the lower lobe, just as in gangrenous broncho-pneumonia.
This result seems to point to the operation of a stronger
irritant than that whicn is usually regarded as the cause of
catarrhal pneumonia. Professor Virchow is of opinion
that, in some of these cases at least, the inflammatory pro¬
cesses are analogous to those excited in the external parts
after injection, which vary in intensity with the individual
and the special features of tbe case.
Another plienomenon has been noted which requires con¬
firmation by thorough clinical observation; it is the outbreak
of recent tubercles in these patients. He could only speak
with much reserve on this point, since we have no fixed data
■ as to the duration of small tubercles—Le., the
I form —and cannot judge positively as to their age. Gene-
I rally they are regarded as being of recent formation.
! Clinical observation in certain cases has shown an eruption
of tubercles on the laryngeal mucous membrane after in-
I jection. Small tubercles have become almost suddenly
visible in places which appeared to be perfectly free from
them, and they have rapidly given rise to fresh ulcers. It
is asserted that thb shows the tubercles to have existed
prior to the injection, but that they have not been visible.
They have been attacked and de.stroyed by the remedy, and
thereby changed into ulcers. I’rofessor Virchow was un¬
able oo controvert this statement as regards the recorded
cases, but in his own examination of those parts, which he
ha.H always regarded as most suitable for the observation
of these recent formations—viz., serous membranes—has
revealed the eruption of very recent iuhereles tmiUr con¬
ditions 'which render it very unlikely that these were of old
date. This is especially seen in the pleura, pericardium,
and peritoneum. He has never been able to confirm the
notion that the tubercles were strongly attacked by tbe
remedy and mortified, for in all these cases tbe submiliary
tubercles in question were quite intact, even following in¬
jections made some weeks previously. Hence he is tbe
more inclined to the notion that i-lieir eruption first took
place after the injection.
Owing to the great difficulty in discriminating precisely
these very tine forms of tubercle in the lungs themselves,
he would speak only of regions, such as the mucous membrane
of the larynx, where miliary tubercles first appeared after
injection, or where after more prolonged injections quite
recent tubercles have been seen in the membrane. Ha
showed an intestine—procured this month—in which theie
was a very recent submiliary eruption in tlie vicinity of old
ulcers; the patient, a man forty-one years old, also had
recent tubercles in the pericardium. ^
2 Semi-tibriiioiis liopati.salioii occurred .-ussociatwl with other cliiuifiea.
132 The Lancet,] DR. W. DUNCAN ON DLSEASE OF THE UTERINE APPENDAGES. [Jan. 17, 1891.
lo endeavouring to explain these fresh eruptions he
remarked that if one admits that every tubercle is due to
bacilli, the study of such remote parts as the pericardium
deserves special attention. In another case the epicardium
had at one spot, not in contact with the affected part
of the lung, a small group of four such miliary tubercles
surroundea by marked hypersemia. There seemed no
other explanation than that their germs had come
there by metastasis; and why, be asks, should not
the metastatic transference of liberated bacilli be deemed
a source of more generalised infection? For Professor
Koch states thht the bacilli resist the action of the remedy,
nor indeed are they destroyed, and therefore the possibility
must be recognised that the softening process excited by the
remedy makes the degenerative products more fiuid and
more liable to be carried away to create foci elsewhere.
This idea is not far fetched, and is linked with another—
viz., the infiltration, under the treatment, of a whole lower
lobe into foci of caseous hepatisation, suggesting that
material set free from the upper lobe by the destructive
processes, and not coughed up, has been sucked into
the lung and has excited a kind of caseous “Shluck-
piieumonia.”
Professor Virchow said he felt bound to express these
ideas in order to unite with them the warning that still
greater caution should he used in operating on cases
where the patient has not the strength or the habit of
completely coughing up the softened material, and where
there is great possibility of the conveyance of this
material to other parts of the lung to excite therein fresh
foci. Another point on which Piofessor Koch lays stress as
the main ell'ectof his remedy is the destructive process itself.
There is no doubt that sucii an action does take place in
many parts ; but it is not quite clear wh^ this mortification
does not always occur, as, for instance, in the cases of sub-
miliary tubercles referred to. Professor Virchow admitted—
as had been described by some earlier observers—in tuber¬
cular pleurisy, for instance, that, especially when the
tubercles increased in size, they assume an unusually
cloudy, yellowish aspect, and show definite microscopic
changes. Rut at other times, even when injections are
continued to the day before deatli, this change does not
occur. Large tubercles may even appear very resistant.
They had lately a very remarkable case of a boy three
years of age, with tuberculosis of the vertebrm and long
bones, and where large tubercles were found in the brain.
The injections had reached 0'0l2gr. It was a surgical case,
in which spinal caries with psoas abscess and much disease
of the joints and bones of the lower limbs existed. At the
necropsy there were as many as seven so-called “solitary
tubercles”—i.e , large caseous masses—in the brain and
cerebellum ; but neither in them nor in their vicinity were
any marked changes to be seen. There were a few spots of
.softening, but not of special import, and certainly none of
the nodules .showed any marked destruction.
Professor Virchow next drew attention to the conditions
observed in cases of phthisis, in ulcars of tlieintestinc and in
tile %Ucers of the respiratory oryans, especially in the lungs.
As regards the intestine, there could be no question as to
the occurrence of mortifying processes similar to those
observed in lupus, especially in the older ulcers of wide
extent and thickened margins, where there is much fresh
submiliary eruption to be seen together with extreme
mortification. He showed the specimen from the case
which also had pericardial tubercle, in which tbedestruction
of the intestinal ulcer had invaded the serous coat. Had
the man survived two days longer perforation must have
oecnned. This was so in another case lately related
by Professor B, Fraenkel where death occurred from per¬
foration. Although such mortification and perforation do
take place in tubercular ulceration, yet it was remarkable
to have two such instances within two months of severe
cases where the mortifying process was in rapid progress.
The same is true of ulcers in the organs of respiration, in
which very rapid destruction takes place, and the unusually
large size of the detached masses must obviate the possi¬
bility of their being expectorated, and thereby favour their
retention and aspiration with its consequences. Professor
Virchow showed also a specimen of very severe larynge^
tuberculosis (from the same case as the pericardial and in¬
testinal specimens referred to) in which twenty injections
had been practised, the last on the day preceding death.
The specimen showed a recent eruption involving the whole
extent of the larynx, of most exceptional severity. Another
preparation showed recent caseous hepatisation, from a
case in which six injections were made, the last four
days before death ; another where three injections, the
last one week and a half before death, and in which
cheesy foci and tracts of difi'use inllammation were present;
and lastly a preparation obtained that morning show¬
ing a spreading abscess in the lung starting from bron¬
chiectasis in the lower lobe.
ON CHRONIC DISEASE OF THE UTERINE
APPENDAGES;
WITH SHORT NOTES OP THIRTY CONSECUTIVE CASES
TREATED BY ABDOMINAL SECTION.^
By WILLIAM DUNCAN, M D., F.R C.S.Eng,,
ODSTICmiC PHYSIC!,IN TO, AND LECTURER ON OIISTETRICS AND
GYN/KCOLOGY AT, Tllli MIDDLESEX IIO.SPITAL.
Before entering on the systematic consideration of the
various diseases, I propose to relate briefly the notes of one
or two cases out of the thirty on which I performed abdo¬
minal section, seven of these being in private and twenty-
three in hospital practice. For convenience of reference I
have arranged all the cases in a tabular form.
Case 6. Small suppurating and adherent dermoid tumour
of right ovary. —Mrs. S-, aged twenty-six (an Australian
lady), was sent to me by Dr. Cory of Guildford for chronic
pelvic pain and dysmenorrhceo. The patient is a tall, tliin,
and delicate-looking woman. The catamenia began at
sixteen, were regular and normal until four years previously,
when she began to suffer pelvic pain, especially on the
right side, and radiating through lo the back; this pain
has decidedly increased since her marriage two yeais
ago; she has not been pregnant, and latterly there has
been much dyspareunia. On examination nothing is felt
abnormal in the lower abdomen. Per vaginam the uterus
is not enlarged, but is pushed somewhat to the left side, by
a Vounded, tender, somewhat elastic, and fixed tumour,
about the size of an orange, in the right posterior quarter of
the pelvis. This was diagnosed as an enlarged ovary, and
the patient was kept in Bed for two months. Hot iodine
douches were used mght and morning. Blisters were applied
over the right ovarian region, and small doses of corrosive
sublimate with iodide of potassium given thrice daily. No
improvement resulting, abdominal section was performed,
when the tumour proved to be a suppurating dermoid, with
universal adhesions, so that its removal was exceedingly
dilliculb. During the operation some of the purulent con¬
tents escaped into the pelvic cavity, and there was oozing
from the tom adhesions. The pelvic cavity was flushed
with a hot 5 per cent, boracic soludon and a glass drainage-
tube inserted. The tube was removed in thirty-six hours.
The patient progressed satisfactorily until a week after the
operation, when a small hminatoeele occurred where the
tumour had been. This made the patient’s recovery tedious,
but I saw her a year after the operation, when she expressed
herself as feeling perfectly well in every respect, ana she is
putting on flesh. At the time of the operation the left tube
and ovary had a few adhesions binding them down, bub
otherwise they appeared healthy; so the adhesions were
divided, and the appendage left intact.
CasI': 24. Pelvic peritonitis; right hydrosalpinx, left
ovary and tube matted together ; care. —Mrs. H-, aged
twenty-seven, married threeyeais; has never been pregnant.
Catamenia commenced at fifteen, always more or less painful,
worse since marriage. In 1888 she was operated on in
Australia for the cure of the dysmenorvbcoa, which she was
told was due to her womb being bent. She was ill after the
operation from “ inflammation.” On coming to England in
1889 she consulted me. I found “ uterus normal in posi¬
tion, but its mobility is impaired. In the left posterior
quarter of the pelvis the ovary and tube feel matted together
and enlarged; in the right quarter is a cystic swelling which
feels like a dilated tube.” On Dec. 7th, 1889, I performed
abdominal section, and found the left appendages universally
adherent, with much thickening of the tube from chronic sal¬
pingitis. The right tube was dilated into a thin-walled cyst,
and contained four ounces and a half of serous fluid; there was
1 Road at a meeting of tlie Medical Society of toiidon.
Di(. zod by C^iOO^lc
TheLa-NCET,] dr. W. DUNCAN on disease of the UTEKINE appendages. [Jan. 17,1801. 133
rather free oozing ftooi the torn adhesions, but it was soon
controlled by sponges. The patient’s subsequent history is
very interesting. Two hours after the operation sickness
commenced, and continued, despite all treatment, with
great frequency for six days, during which time the
patient vomited 103 times. Thirty-six hours after the
operation the retching was so severe that the wound
was partly torn open and secondary hjcmorrhage ensued.
Harelip pins were used to give greater support. From
the tbircf to the sixth day the vomit was black. On
the seventh day an enema of fifteen ounces of olive oil
was given, as well as a dose of white mixture every
two hours by the mouth. These acted freely, and from
that date all sickness disappeared. The patient was
up on a couch on the nineteenth day. Since then she has
been to Australia and back, and now (January, 1891) she
is perfectly well, and enjoys violent exercise on horseback.
The next two cases are very interesting, inasmuch as
they presented symptoms and physical signs of tubal gesta¬
tion. Both are young married ladies, living close to one
another in Hertfordshire, and were under observation and
treatment at the same time.
Case 26. Le.ft hmmato-salpinx, with apoplexy of ovary .—
]V£rs. E-, aged twenty, married six months. She was
regular for three periods after marriage; she then saw
nothing for seven weeks, and had morning sickness, with
pains in the breasts and lower part of the back. At the
end of the seven weeks she was seized with severe pains
in the left side of the abdomen and in the back, accom¬
panied by hemorrhage. A clot was passed, but this was
not shown to her medical attendant, Dr. Ambler of
Hemel Hempstead. Under treatment and rest the loss dimi¬
nished for a time, but the pain still remained. The hemor¬
rhage again increased, so Df. Ambler asked me to see her.
I found on examination the uterus somewhat enlarged, the
os uteri admitting the finger tip. In the region of the left
Fallopian tube, and extending somewhat behind the uterus,
was a tense, elongated cystic swelling, apparently about
the size of a sausage. Tlie sound was not passed. I
diagnosed a tubal pregnancy, and, in view of its possible
rupture at any moment, recommended that abdominal
section should be done without delay. I operated next
morning, and without much dilficulty removed the specimen
I now hand round. The ovary is much enlarged, and on
section is seen to be filled with blood ; the Fallopian tube is
distended to the size of a banana, and it also is full of
blood, partly fluid, partly clotted. (Fig. 1.) The patient
Fig. 1.
TUSE
Cask 20 ; Hfoniato-sii.lpmx and apoplexy of ovary.—Tube dis-
toiidud with blood and blood-clot. G^'al•y enlarged. Haunor-
I'hage into {probably) a greatly distended Oraallaii follicle.
made an uninterrupted recovery, and is now (January, 1891)
in perfect health.
Case 27. Double tubercular pyo-salpinx, -with tubercular
diseasao/bothovaricaandapoplexyofleftovary. —Mrs. M-,
aged twenty-two, married two years and a half; never
pregnant. The family history is good, except that one
maternal uncle died of phthisis. Previous history good.
Catamenia began at fifteen, regular every four weeks, and
lasting one week; hut ever since the onset of the periods
there has been pain in the left ovarian region. Since
marriage the dysmenorrhoja has been much worse, and clots
have been passed. On June 9th, 1890, she consulted her
medical attendant, Dr. Russell Steele of Hemel Hempstead,
as the pain was so severe. She then bad amenorrheca for
six weeks with some morning sickness, and thought she
was getting stouter. On making a vaginal examination,
Dr. Steele felt an irregularly shaped mass, very tender to
the touch, to the left sideof, and slightly behind, theuterus.
Bimanually little could be made out, owing to the thick¬
ness of the abdominal parietes. Rest in bed with sedatives
was ordered. Fourteen days later Dr. Steele was suddenly
summoned to see the patient, and on arri^l Avas informed
that she had been to the watercloset, and was there suddenly
seized with the most excruciating pain in the lower abdomen.
“ Something” passed from her into the pan of the closet
during the pain, but, unfortunately, it was not kept.
Dr, Steele found the patient faint and collapsed, but
after administering stimulants and a hypodermic injection of
ether she quickly rallied. When I saw the patient, in con¬
sultation with Dr. Steele, the condition was just as described
above, and I concurred in his opinion that most likely it
was a ruptured extra-uterine gestation ; but as I thought
it had ruptured between the layers of the broad ligament,
I recommended strict confinement to bed and watching the
progress. As a week later she seemed getting worse, pain
more severe, pulse feebler, I performed abdominal section,
with the help of Dr. Steele and Mr. Battle. On opening
the abdomen the peritoneum was seen to be studded with
rice-like bodies. The left broad ligament was apparently
distended by a tense, bluish, elastic swelling, Wt after
tearing down many adhesions (a process which took more
than an hour) the swelling proved to be a distended
Fallopian tube and enlarged ovary matted together. These
were removed after transfixing the broad ligament in the
usual way. The appendages on the right side were removed
in the same manner after breaking down many adhesions.
A drainage-tube was inserted and the wound treated in the
ordinary way. On examining the parts removed (see Figs. 2
and 3) the left Fallopian tube Avas distended with thick-
inspissated pus to the size of a sausage. The left ovary was-
as large as a small Tangerine orange, cystic, and with,
hmmorrhagic extravasation into it. The right tube was-
about as thick as a man's thumb, and contained the same
kind of cheesy pus as the left. The right ovary was double
the normal size, and was studded with collections of pus
the size of peas. The patient made a rapid and complete
recovery, and is how putting on flesh and feeling well.
The next case is instructive and interesting, as the-
pedicle ligature slipped soon after completion of the opera¬
tion. Hmmorrhage (which was not diagnosed) took place,
and death followed two days later.
Case 29,—Mrs. J- was admitted to hospital com¬
plaining of dysmenorrhoja, pains in the bacK and the
left side, leucorrhoca, and general ill-health. Married
thirteen years; has had three children. On admission
the uterus was refcroverted, and not easily replaced;
there were thickening and tenderness in the region of
both broad ligaments. She was treated for several weeks
with hot douches, glycerine tampons, blisters, and aperients.
When readmitted two months later the patient was no
better, so abdominal section was performed. The ovaries
and tubes were adherent in the pelvis; they were removed and
the pedicles were treated in the ordinary way. Half an hour
after the operation the patient was very collapsed ; pulse
feeble, regular (70); unconscious ; no distension of abdomen.
Temperature 96'4“. Hot blankets were applied, ether
injected, and as she seemed to rally I AA-as not sent for. An
hour and a half after the operation reaction had well set in ;
lips good colour; pulse strong and full (80). A morphia
suppository of a quarter of a grain Avas given. I saw the
patient three hours and a half after operation. She appeared
quite satisfactory, no signs Avhatever to indicate internal
hajmorrbage. The next day she seemed comfortable j the
temperature was 100'. Slight tenderness of abdomen ; n©
distension ; resonant all over ; no sickness. Towards even¬
ing the temperature went up to 102'4°, and next day (the
second after the operation) the patient was evidently Avorse ;
pulse rapid, weak (136); ahdomiDal jrain, tenderness, and
distension. Diagnosing peritonitis, I reopened the abdomen
to wash out the cavity, and was horrified to find it full of
C 2
- r.Cooole
134 The Lancet,] DR. W. DUNCAN ON DISEASE OF THE UTERINE APPENDAGES. [Jan. 17, 1891.
blood ; the broad ligameot was rapidly seized, the blood and
clots cleared out, pedicle securely retied, abdominal cavity
irtiffated, a drainage-tube inserted, and the wound quickly
reclosed. In spite of all efforts at stimulation the patient
never rallied, but died six hours after.
. Let us now consider, seriatini, the different diseases of
the uterine appendages included under the title of this
paper. It is obviously unnecessary to touch upon large
tumours which rise up out of the pelvic cavity, as nowa-
FiQS. 2 & 3.
Cask ‘27 ; ovary anti tuba.—Ouai'jy enlargeil, atUioreiil to
tulia, and full of blood (u). Wuhe distendad with inapissatod
tubercular pus (a).
Case 27; Ilight ovary and tube.— 0va1^| twice normal size
containing deposits of cheesy pus. Tube distended witli a
like deposit.
days almost everyone agrees that their proper treatment U
by abdominal section. Such, however, is unfortunately
not the case with diseases which give rise either to small
pelvic tumours or to none at all, but which often entail
intense suffering, which are sometimes overlooked (either
accidentally or designedly), and about the treatment of
which there is (unluckily for the sufferer) a great diversity
of opinion.
chronic salpingitis is in the majority of cases due to
extension of catarrhal or purulent endometritis; sometimes,
however, it is doubtless secondary to a pelvic peritonitis.
Each Fallopian tube consists, as is well known, from with¬
out inwards, of peritoneum, circular and longitudinal mus¬
cular fibres, with a mucous membrane, which is lined by a
layer of columnar ciliated epithelium, and thrown into
numerous longitudinal folds or plicaj. Glands have been
described as present, but there is a complete absence of
them. Probably the folded appearance of the mucous mem¬
brane led to tbe error. The changes which take place
in the tubes when subject to chronic inflammation are well
shown in this drawing (Fig. 4) taken from the beautiful
plates of Wyder of Berlin, The mucous and muscular
layers are hypertrophied. The folds of the mucous mem¬
brane do not show the normal complicated appearance.
Single papillary elevations are seen separated from one
another by gland-like invaginations of the mucous mem¬
brane, some shallow, some deep. The papillm are com¬
pletely bared of epithelium, but it may stul be seen in the
recesses between the folds. On the surface of the mucous
membrane is a zone of closely packed round cells like
granulation tissue, whilst beneath this the deeper
portion of the mucous membrane is specially charac¬
terised by the presence of a large number of spindle
cells. Thick-walled vessels are present in great num¬
bers in the wall of the tube. I believe a salpingitis
may exist like this for an indefinite period, tlie fluid exuded
gradually making its way through the patent uterine end
into the uterine cavity, but what happens far more often is
this: the inllammation extends to the limbriated end; a
little of the fluid escapes into tire peritoneal cavity and sets
up a pelvic peritonitis of varying degrees of severity, accord¬
ing to the virulence of tbe exudation; then the ostium gets
closed up by adhesions, and the tube becomes transformed
into a shut sac by the-uterine end also becoming closed.
The further changes in the tube depend on the character
of the primary inflammation. If it be catarrhal or due to
extension of a peritonitis, then serous fluid collects in the
tube, the coats of which get gradually thinned out, and
finally we have ahydro-salpinx with a very thin transparent
cyst wall. When the inflammation has been purulent (as
in extension upwards of a gonorrbma), then the same
changes take place, with tbe important difference that the
cyst contents consist of pus forming a pyo-salpinx. In other
cases the capillaries of the diseased mucous membrane
become engorged with blood, then some of them rupture cud
blood gets extravasated into the tube, forming a hcemato-
salpinx. This condition is shown in some of the speci¬
mens on the table, and the microscopical appearances are
well illustrated in this drawing of Wyder (Fig. 4).
I said just now that as a result of salpingitis and pelvic
eritonitis both the uterine and limbriated ends of the tube
ecome closed, and then dilatation takes place ; this, how¬
ever, does not invariably happen, for it is a positive fact
that in some instances tbe uterine end of the tube remains
patent, and that at certain times the distended tube dis¬
charges some of its contents through the uterus and vagina.
This interesting condition is known as intermitting hydro-
or pyo-salpinx, and may go on for an indefinite time unless
cured by abdominal section. To explain tbe phenomena
we have only to remember that dilated tubes sometimes
undergo axial rotation in precisely the same manner as
ovarian tumours ; this rotation occludes tlie uterine end of
the tube, which, when further dilated, partly unwinds itself
and thus allows the escape of some of its contents.
This specimen (Fig. 5), which 1 removed quite recently
from a patient in the Middlesex Hospital, is such a typical
example of intermitting hydro-salpinx, and, as it cannot
fail to convince the most sceptical, I will briefly relate
tbe case.
M. A-, aged thirty-six, was married at twenty, and
had one child a year later. About a fortnight after her
confinement she got up, and two or three weeks later took
cold, and was seized with great pain in the left side of tbe
lower abdomen, for which she had to lay up three weeks.
Nine months afterwards she began to have a white dis¬
charge between tlie periods, and this continued. In
March, 1888, she began to have a profuse watery discharge
from the vagina at intervals on walking any distance, and
she also had much pain in the back. Tkis intermittent
watery discharge continued until her admission to Pnidhoe
ward on April lObh, 1889. On examination, my note was :
“Left ovary and tube enlarged to the size of a amall
orange, and displaced below and behind the uterus. The
Digitized by ^OOQlC
Thirty consecutive Cases of Abdominal Section for Chronic Disease of the Uterine Appendages (one fatal from Hemorrhage).
Mb Lancet,] DE. W. DUNCAN ON DISEASE OF THE UTEBINE APPENDAGES. [Jan. 17,1891. 135
Digitized by i^ooQle
Ca.se 21 -was operated on twice; first time, the appendages were so firmly adherent and the abdominal parietes severai inches thick, that it seemed imposaihle to remove the disease. TronblMome suppmstion &
abdominal wall retarded convalescence. Four months later patient retorned, begging that something more should be done to relieve her pain. On again opening the abdomen, the omentnm and intestines were so
4natted to the parietes that I was conyielled to de^st. Patient TF^t opt a month later in statu qua, . .. '
136 Thb Lancet,] DK. Vi. DUNCAN ON DISEASE OF THE UTERINE APPENDAGES. [Jan. 17, ISdl.
right tube can be felt thickened and displaced downwards.
The uterus is normal.” I ordered hot vaginal douches night
and morning, followed by glvcerine tampons; also a
mixture of quinine, iron, and sulphate of magnesia. Nine
days after admission a watery discharge commenced, and
went on for a week, at the end of which time the swelling in
the left posterior quarter of the pelvis was found to be much
considerably reduced in size, and she said that she
had had a large gush the previous day. On performing
abdominal sectionT removed tbe hydro-salpinx now shown.
There were no adhesions. I tied the tube close up to the
uterus, and on cutting it across the contained iluid began
to flow opt, showing that the tube was patent right up to
the uterus, and doubtless the uterine portion was so fike-
Fig 4.
A
B
A Section of Fallo])ian tiihe in case of pyo-sn-lpinx (Wyclei).—Mucous and innsculai' coata hypertrophied ; ciliated epithelium lost,
except in depressions hetween papillre ; supoiilcial layer of mucosa rciilaccd hy I'oimd coll Kraniilation tissuu ; doop layer made
up of spiiidle-collcd tissue. Ii, Hection of Fallopian tiilie in case of hicmato-salpinx (W.vdor). Foss of epithelium, except in the
depressions between the papilla); round-colled tissue not so well marked as in a. ilicli network of capillaries engorged with
blood, and extending close up to the surface of the inucosa. lixtiuvasations of blood at dill'oreiit jiarts.
diminished in size; three weeks later she was discharged con¬
valescent. On Oct. 20th, 1890 {seventeen months after), she
came again complaining of much pain in the back, left side
of tbe ^domen, and left leg, with profuse gushes of watery
fluid. On examination I then found a large cystic swelling
flUing up tbe left side of tbe pelvis. When the patient was
to the hospital three days later the swelling was
wise. The right tube and ovary were found to be diseased,
and were therefore removed. The patient’s convalescence
was retarded by some troublesome suppuration in the
abdominal wall, which latter was thickly loaded with fat.
Another condition, which has been erroneously thought to be
the explanation of these cases of intermitting hydro- or pyo-
salpinx, is that in which a dilated tube becomes adherent to
:-It. Coogle
The Lancet,]
MESSRS. PITTS AND BROOK: STENOSIS OF THE TRACHEA. {Jan. 17,1891. 1S7
the bottom of Douglas’s pouch, and thus discharges its
contents into the vanna, rectum, or bladder. A most in¬
teresting case of this hind I saw some years ago in consulta¬
tion with my brother, Dr. P. T. Duncan. The patient, a
widow, was seized periodically with attacks of pelvic in¬
flammation, followed by a profuse discharge of pus per
vaginam. On examining the lower abdomen, 1 found on
either side, rising up above Poupart’s ligament, a tense
elastic swelling, that on the right neing mobile, but that on
Fia. 6.
Intonnittiiig hydro-salpinx : Left Fallopian tube and ovary.—
Tube greatly distended and coats thinnud; abdominal
ostium closed ; uterine end (through which bristle is
passed) patent. Ovary enlarged, aclherent to tube. It
contains a corpus luteum and a blood-clot.
the left was fixed, and it was noted that the left tumour
•diminished in size coincidently with the discharge of pus.
Little could be made out on vaginal examination, owing to
the pelvic inflammation. I diagnosed double pyo-salpinx,
the left tube being adherent and forming a fistulous cora-
anunication with the vagina. She refused to run the risk
•of operation, and I do not know what has become of her.
{To be concluded.)
ON THE
STENOSIS OF THE TRACHEA AND LARYNX
WHICH OCCASIONALLY FOLLOWS THE
USE OF A TRACHEOTOMY TUBE;
WITH REMARKS ON THE TRESENT POSITION OF INTUBATION.
By BERNARD PITTS, M.C. Cantab., F.R.C.S.Eng.,
AND
WILLIAM F. BROOK, F.R.C.S.Eng.
{Concluded from -page 7S.)
Case 4.—Arthur P-, aged nine, was admitted on
July 12bh, 1886, to the West London Hospital, with dyspnoea
necessitating tracheotomy. He remained in the hospital
till I'eb. 18bh, 1886, when he was discharged, wealing a
silver tracheotomy tube, all attempts to dispense with the
Wbe having failed. In June, 1886, he was admitted to the
<jreat Ormond-street Hospital, under the care of Mr. Marsh.
For sLx weeks frequent attempts were made to remove the
tube, but it always had to be replaced, and he was dia-
^harged and told to come again in a year’s time. He was
readmitted to the Great Ormond-street Hospital, under the
care of Mr. Morgan, in November, 1889, and we are indebted
to that gentleman for permission to inmude the case in this
series. — Dec. 1st: Mr. Brook tried to intubate, but failed
to pass even the smallest sized tube.—10th: Mr. Brook exa¬
mined under an anmsthetic, and, after enlarging the wound,
found that the trachea jimt above the level of the tracheo¬
tomy tube was obstructed by a collar of cicatricial tissue,
forming a web, with an aperture towards the right side of
the mid-line. After dilating the aperture with probes and
catheters, an intubation tube was passed by the mouth; the
end appeared opposite the wound, but projected forwards and
against the lower border of the tracheal wound. The tube
was therefore removed, and the tracheotomy one replaced.—
I4th: Under chloroform Mr. Morgan divided the collar
vertically with scissors in two or three places, after which a
large intubation tube was passed.—Jan. lltb, 1890: ^ has
been found impossible for the boy to retain the intubation
tube for any prolonged period, the point of the tube getting
pushed against the anterior wall of the trachea. The wound
was therefore enlarged, and Mr. Morgan dissected away a
considerable portion of the collar of fibrous tissue. lutuoa-
tion was carried out at intervals by Mr. Brook during the
rest of January and February, but not much progress was
made.—March Ist: Mr. Morgan again enlarged the tracheal
wound, and more completely removed the remnants of cica¬
tricial tissue. After this the wound was allowed to close,
and intubation went on more satisfactorily. On May 8th
the boy was sent home on account of an epidemic of measles.
He recurned in five days, and was intubated for six hours.
He came up once a week for intubation during the next
two months, and afterwards at intervals of three weeks.—
Nov. 23rd : Still some stridor on exertion. Sleeps well. No
loud breathing. Can pbonate with an effort. The largest
tube can be easily passed, but there is still some slight
obstruction.
B&marhs .—The tracheotomy tube in this case had been
worn over five years continuously. The diaphragm-like
web was of much the same character as in the first case
narrated, except that it did not extend so high into the
larynx, and that the lumen was much smaller. Like the
first case, too, the necessity for complete removal of all
cicatricial tissue is shown before satisfactory progress can
be made Avith intubation. The case will probably require
further intubation, and, owing to his age, with a larger
sized tube than has yet been employed. It is interesting
to note that, after a period of five years’ inability to
talk, he now, at the age of nine, articulates like a child
of three.
General remarks on the cases .—It may be again stated
without much fear of contradiction that when ordinary
means have been used to leave out the tracheotomy tube,
intubation by O’Dwyer’s method should be at once given a
trial, and that if ditQculty arises, or no definite improve-
Digitized by i^ooQle
138 The Lancet,] MESSRS. PITTS AND BROOK: STENOSIS OF THE TRACHEA.
[Jan. 17,1891.
xaent speedily ensues, then a thorough exploration of the
parts should be made, cicatricial tisane should be freely
and completely removed, aud then intubation again be
tried without allowing time for recontraction. The advan¬
tages of O’Dwyer’s method over any other form of dilatation
are so obvious, and the riska in such chronic cases are so
small, that if this form of intubation were only applicable
to such cases we would still owe a debt of gratitude to
O’Owyer for placing this means of treatment at our disposal.
It may be in place here to draw attention to a few special
points in the intubation for chronic stenosis. 1. As regards
the force required in introducing the tube; In dealing with
acute inflammation any attempt to use force w'ould be
likely to end in disaster, hut in these stricture cases a
certain amount of force iS absolutely necessary, and if used
in the right direction can be safely employed. It is often
necessary to press continuously the point of the tube against
the contraction, and so there may be a danger of causing
asphyxia. It is a practical point of some moment to get
over this difficulty, and this can be done by withdrawing
the introducer for a short distance, keeping the tube in
place with the forefinger, and so allowing some slight
passage of air through the tube; pressure is then again
applied, and the stricture as a rule yields. 2. A much
larger tube can be tolerated, and is desirable, than is laid
down for the treatment of acute cases. 3. The time that
the tube may be left in is well shown in the cases. The
boy H-frequently wore his tube for a fortnight, and
on two occasions did so at home without the slightest
discomfort or any alarm to his parents. 4. Use of the
string: In all cases where the tube was expected to
remain in for more than twelve hours the string was
removed. This plan was adopted at the request of
the older patients, who said they could eat better with¬
out it, also that its presence made them cough. 5. Feed¬
ing : As in acute cases, immediately after the first com¬
mencement of intubation pulp food was found to be the
best, fluids causing cough. After a short experience all
these children were able to take ordinary diet without any
trouble. 6. Extraction of the tube with the extractor is
always the must difficult part of the operation, and it cer¬
tainly is so in these cases, owing to the unusual length of
the tubes employed. This special difficulty is caused by
the length of the tube, the length of the beak of the
extractor being greater than the distance between the cords
and the hard palate, against which the angle of the extractor
will thus impinge before the point of the tube is out of the
larynx. This difficulty was overcome by having a shorter
beaked extractor made, and by pushing the point of the
extractor as far as possible into the tube before attempting
to remove the tube.
Bema/rks on the instruments used .—The following slight
modifications in the intubation instruments have been made j
by Messrs. Weiss at the suggestion of Mr. Brook:—The intro¬
ducer (Fig. 4) used is the same as altered by Mr. Staveley,
the only diflerence being that the tube is held on by a string
passing over a button at the angle instead of a ring. The
introduction of the tube was found to be easier with this
than with O’Dwyer’s introducer, and its advantages over
the latter complicated instrument as regards cleanliness
and cheapness are obvious. The extractor (Fig. 5) shown
is much shorter in the beak than O’Dwyer’s, for reasons
already stated, but was quite long enough for use in
diphtheritic or any other cases under twelve years of
age. The special form of gag was found very useful,
it was easy to introduce, and inasmuch as the flat
bandies lay in close contact with the face over the left
malar bone and temple, tbe band of the assistant which
held the head on that side, having the gag beneath it,
effectually retained the latter in position. The plug
used for keeping tbe tracheotomy wound open is shown
in the diagram; it is made of vulcanite with a rubber
collar.
We conclude this paper with a few remarks on the present
position of intubation.
A. It is obvious that intubation is unsuitable for the
following class of cases: (1) Obstruction caused by presence
of foreign body, (2) active ulceration (syphilitic or tuber¬
cular) of larynx, (3) new growths, especially malignant
ones, (4) obstruction due to alteration in shape or posi¬
tion of trachea caused by goitre or other tumour of
neck, (5) obstruction by post-pharyngeal or other abscess
of neck.,
B. Cases where intubation seems to be directly indicated:
(1) Simple cicatricial stenosis, such as in the cases described
or resulting from old syphilitic disease, (2) scald of larynx,
(3) codema of larynx, (4) acute laryngitis, and (5) for sudden
spasm of glottis, such as may sometimes arise during the
coarse of operations under anaasthetics provided tbe instru¬
ments be at band; in fact, in all cases where the trouble is
likely to be of only short duration, and where there is no
evidence of associated chronic ulceration of the larynx. It
may also be employed as a means of diagnosis when it is un¬
certain whether the dyspnoea arises from obstruction in the
upper air' passage, or to some condition out of reach—
e.g., pressure from mediastinal tumour, bronchitis, &c.
We now come to the question of intubation or tracheotomy
in diphtheria, and we trust ou this point to gain some
information from those who have had experience on this
question. We may start by saying that we have come to
no absolute conclusions, and it seems to us that in this
country, at any rate, there has not as'yet been a sufficient
trial of intubation to enable anyone to speak with great
confidence on this question. We could quote a large amount
of American statistics, but we think the question must be
Fia. 4.
settled by the success which attends the treatment of tho
disease as possibly modified by climate and conditions of
life in this country. No short experience of incubation can
be of much value in determining this question. We all
know how in some epidemics a very varying degree of
success has attended tracheotomy. At times there is a
uniformly raised pei-centage of recoveries all round, at others
most of the cases die; and even at tho same period' one
hospital may be showing a comparatively large percentage
of recoveries, whilst others are losing almost ail their cases,
and this may depend on the severity of the disease and the
condition of the patients brought to the particular hospital,
and also upon whether tracheotomy is done early or only
in extremis. All this applies equally to the treatment by
intubation, and as intubatiou has as yet been so little
practised in this country, probably the operators have much
experience to gain in the necessary manipulations and in
the after-management of the cases.
We give the statistics of the results of intubation in diph¬
theria from three hospitals, and we h^e that others will be
forthcoming. Victoria Hospital for Children : Sixteen In-
Digitized by
Tub Lancet,]
MR. W. ARBUTHNOT LANE ON EPILEPSY.
[Jan. 17,1891. 13^
tubated, seven cured (no aecood tracheotomies); nine deaths
<tbree second tracheotomies, all fatal); percentage of re¬
covery, 43. We have given these results first, for we
Relieve that Mr. Staveley, formerly house surgeon there,
was the first to give intubation in diphtheria a systematic
trial in London, and he has already published a most
excellent account of his experience. At St. Thomas’s Hos-
pitel, up to the present time, thirty cases have been intubated
4or diphtheria; of these eight had subsequent tracheotomy,
four recovering. Of the twenty-two cases where intubation
alone was em^oyed eight recovered. This is a percentage
of 40 on the w-hole number intubated. At Great Ormond-
street Hospital eleven cases were intubated by the house
physician, with one recovery. It is only fair to add that,
owing to the' unfortunate early mortality, intubation was
reserved for those cases which were least likely to recover,
and tracheotomy practised for the more favourable ones.
We may mention here that Cheatham of Louisville has
recorded thirty-two cases with ten recoveries, and of the
first fifteen of these only one recovered. All willallow that the
resvilts obtained at the Victoria Hospital and St. Thomas’s
Hospital are far more favourable than those usual after
tracneotomy, since 25 per cent, recoveries after tracheotomy
may be considered good, and we may safely argue that in
the face of these results we are bound to give treatment by
intubation a most serious consideration and an exhaustive
trial.
The following may be mentiohed briefly as some of the
advantages gained by intubation :—1. The friends are not
frightened by the idea of an operation, and their consent is
not so necessary as for tracheotomy. 2. Intubation does
not require any aneesthetic, and this we consider a most
important point ; for often the necessary giving of an
anmsthetic in cases of tracheotomy is a direct cause of
death, and always of much anxiety. .3. The operation mdj^
be undertaken at a much earlier period than is usually con¬
sidered justifiable for tracheotomy, and can be far more
easily performed without skilled assistance. 4. The avoid¬
ance of the hasniorrhage and other dangers attendant on
tracheotomy, and the avoidance of a fresh wound, which
may become infected. 5. The air before entering the lungs
is warmed and filtered by passing through the natural
passages, instead of entering straight through the opened
trachea. 6. The question of the advantage of being able to
do without a skilled nurse is a debatable one. If all goes
well, her presence is not so necessary as in tracheotomy,
if the tube gets blocked it is always coughed out, and
generally urgent symptoms do not return for a period of
an hour or longer. But, on the other hand, if difficulty of j
breathing arise at once, the skilled nurse is helpless, and '
the child must die unless the medical man is promptly on
the spot. This is a danger which must be well considered
before doing intubation in private practice. j
We will now briefly refer to a few of the arguments ;
against intubation in diphtheria :—1. It does not give that
complete rest to the larynx that is obtained by tracheo- j
Corny. 2. If there is much membrane in the trachea it
cannot be cleared out by forceps in the way that is most
desirable after opening the trachea. It is, however,
astouisbing what large quantities of membrane may be
coughed up by the child through an intubation tube or
after its expulsion. Though the lumen of the tube is small,
it is straight, and does not get foul as a tracheotomy tube
does, since it is kept constantly warm and moist. 3. The
presence of a tube fixed tightly in an inflamed passage may
of course, in such a disease as diphtheria, aggravate the
iooal mischief or produce ulceration at any of its points of
contact; and physicians who examine the fatal cases in the
f oat-morbem room may well draw unfavourable conclusions.
‘ortunately such ulceration is not of very frequent occur¬
rence, but certain cases of ulceration produced py the tube
have come under our notice, more particularly amongst the
fatal cases that have occurred at St. Thomas’s Hospital.
a case at one of the London fever hospitals this
ulceration went on to necrosis of the cartilages, and
the tube, having lost its support, dropped into the trachea.
We have also heard of one case in a provincial town
where, although recovery took place (after subsequent
tracheotomy), permanent occlusion of the larynx resulted,
no doubt from ulceration caused by the use of tlie tube.
Among the ten fatal cases which occurred at Great Ormond-
street there was only the slightest abrasion of the mucous
membrane in three or four cases, and definite ulceration
in none. We understand also that this has been the
experience in the post-mortem observations at the Victoria
Hospital, Chelsea. A recent preparation of the larynx and
lung is here shown, taken from a child aged three years
and a half, who was admitted into St. Thomas’s Hospital
under Br. Ord three months ago with diphtheria. In¬
tubation was performed and the tube worn for four days,
and the chila apparently recovered, but continued to
expectorate small quantities of ofFensive matter, and died
at the end of the thiee months from symptoms of gangrene
of the lung. The larynx is healthy, but the trachea snows
a healed ulcer about the size of a threepenny piece, with
evidence of destruction of cartilage beneath. The lung
shows several large patches of wml-marked gangrene, and
it is fair to assume that this was occasioned by the ulcer,
which corresponds to the position of the end of the
intubation tube. 4. The frequently mentioned objection,
and one which is especially in the tiifbughts of a beginner
at intubation, is that of the possibility of detaching
membrane and pushing it before the tube, and so making
an obstructive flap. This may occur, but we believe from
published accounts it is very uncommon, and no one should
do intubation without being prepared to proceed to tracheo¬
tomy if required. Possibly, as experience in the operation
of intubation is at present very limited, by abetter selection
of cases and of tubes of a proper size, and by the improve¬
ments which are constantly being made in the shape of the
instruments by the inventor, many of these objections may
in time be lessened.
It seems to us, with our present limited knowledge, that
(1) tracheotomy is advisable in those cases where there is
evidence of great malignancy, or of a tendency to great
extension of membrane; (2) that intubation should be em¬
ployed in cases which present themselves with dyspnoea as
the most marked symptom of the disease, that it should
be performed at an early period, and that should there be
necessity for retaining the tube for a lengthened period, or
evidence of any direct irritation set up by it, then tracheo¬
tomy should be substituted, and we may here remark that
tracheotomy is rendered safer and easier of performance
when an intubation tube is in situ.
A CASE OF
EPILEPSY FOLLOWING ON A DEPRESSED
FRACTURE PRODUCED BY FORCEPS AT
BIRTH AFTER AN INTERVAL OF
FOURTEEN YEARS;
REMOVAL OF DEPRESSED BONE WITH VERY CONSIDERABLE
BENEFIT.
By W. ARBUTHNOT LANE, M.S., F.R.C,S.,
ASSISTANT SUaOliON, OUY’S HOSPITAL, AND TUP. HOSPITAL POtt SICK
CHILDHPN, GREAT ORMOND-STUEET.
A. A-, aged sixteen years, was sent to me at Guy’s
Hospital by Dr. Garbutt on March 6th, 1890, with a view
to some operative interference. There was no epilepsy or
insanity in the family. The child was delivered with
instruments with much difficulty. After he was horn a
deep depression was noticed on the right side of the skull,
and the skin over the depression was very sore and bruised.
His relatives state that the depression was relatively much
more marked when he was an infant than it was on his admis¬
sion, allowing for the growth of his hair, and that a few
months after he was born the deformity had become much less
conspicuous. His friends and relations do not appear to have
noticed anything unusual about the boy till he was fourteen,
when on March 5bh, 1888, while sitting at breakfast, he, with¬
out any warning, fell off his chair in a fit, and was unconscious
foranliour. He was put to bed, and three hours later he had
another fib, preceded by a well-marked aura. He was un¬
conscious for less than an hour. These attacks were fol¬
lowed by great weakness and d^ression, which confined
him to his bed for a fortnight 'The third fit occurred six
months afterwards, on April 17bh. This was preceded by
a short but distinct aura. The fourth fit took place while
he was in bed on the morning of May 4th. It was preceded
by a long, continued aura, accompanied by preliminary
twitching of the foot. During the fit he could hear
people talking, and understood what they said. He
^8
140 Thb Lancet, J
CLINICAL NOTES.
[Jan. 17, 1891.
waB, however, unable to answer their questions. Three
weeks later he had a fifth fit. This lasted twenty minutes,
during the whole of which he was quite unconscious.
This was followed by many fits, varying in severity and sepa¬
rated by very variable intervals of time. The worst attack
he had occurred while out walking six months ago, without
any warning whatever. From 1.30 to 9 o’clock he was
quite unconscious, and after recovering consciousness he
suffered from severe frontal headache, sickness, and weak¬
ness for three or four days. After this he had at varying
intervals several mild attacks, during all of which he was
conscious.
A fortnight ago ten severe attacks occuned in the one
night while he was in bed. He was semi-conscious during
the fits, becoming quite conscious in the intervals. He
had three attacks after these two, coming on at the
same hour in the day. Before these the usual aura
and twitchings were felt; he was conscious throughout.
When about to have a fit the boy notices a twitching at the
junction of the middle and lower thirds of the leg on its
outer aspect, his foot and knee then jerk in a similar manner,
which, he says, resembles ankle-clonus and knee-jerk. A
pain then runs up the outer side of the leg and thigh,
through the left side of the trunk into the left arm, from
that into the left side of the face, and if the fit is a severe
one it extends into the right arm. The twitching in the
leg extends up the thigh into the left arm or left side of
the face. If a severe fit, it extends to the other side of
the body, and when it does so the lad loses consciousness.
After the fit he feels ill and fit for nothing, and suffers from
severe headache in tlie forehead and pain in and about the.
depressed area. For several days after the fit he is
unable to walk properly owing to the weakness
in the left leg, and in the same manner the left arm is so
unsteady and irregular in its movements that he is unable
to use it usefirlly. This, together with the pain in the head
and a dull, stupid feeling, have prevented him following any
occupation.
Condition on admission {March 6th, 1S90 ).—He was a
dark-complexioned, pale lad, whose speech was not affected,
and who appeared to have moderate memory and mental
power. On the right side of his head there was a groove
about three inches and a quarter long, extending from an
inch behind the coronal suture to about the same distance
in front of the lambdoid suture. Its anterior extremity was
f daced vertically above the extei-nal meatus, and its lower
imit reached to just below the temporal ridge. From this it
extended downwards and backwards towards the external
occipital protuberance. The floor of the depression did not
appear to oe more than a quarter of an inch below the general
level of the scalp. The left arm was weaker than the right,
its grasp being about two-thirds that of the right. The
several manipulative movements of the left hand and fingers
were performed with distinct clumsineES. This was most
marked In the case of rapid movements. The movements
of the right arm and hand were quite normal. The measure¬
ments of the circumference of the right arm and forearm
each exceeded that of the left by a quarter of an inch.
Besides this variation in circumference, there was a
distinct difference in the firmness of the flexor supinator
muscles in particular. There was no difference in the
measurements or in the feel of the muscles of the leg.
The patient states that he had never the same con¬
fidence in his left leg that be had in the right one, apart
from the great weakness which was present in it for several
days after a fit. By simply raising the left foot to a right
angle, a very rapid clonus could be obtained. It could be
stopped by the patient. By using more force a clonus could
be produced in the right ankle. It was, however, of short
duration—about twenty seconds,—and was not so quick as
that on the left side. The knee reflexes were very much
exaggerated. This was more marked on the left side, where
a patellar clonus could be readily obtained. The plantar
reflexes were very much exaggerated, especially on the
left aide. This was also the case with the abdominal
reflexes, except the cremasteric, which were very slightly
marked. This exaggeration on the left side was very con¬
spicuous.
There was apparently nothing abnormal about the reflexes
of the arms, nor was there any wasting or asymmetry of
any portion of the facial muscles. The optic discs were
both normal, and the pupils reacted readily to light and
aoeommodation. There was no evidence of congenital
syphilis. On March 9th the exaggeration in the reflexes.
though very marked, was not quite so excessive as it wao
when the hoy was admitted. Dr. Laureston Shaw kindly
saw the case with me, and after carefully examining him he
confirmed me in my opinion as to the probable advantages
that would follow removal of the depressed area of
bone. On March 10th, the depressed area of bone having
been exposed throughout its whole extent, it was seen
to be abnormally vascular. By means of a gouge and
a pair of Hoffman’s forceps the bone which formed the-
floor of the depression, together with a portion of the-
surrounding margin of bone, were removed. The bone¬
forming the depression was very thin and vascular, scarcely
measuring a sixteenth of an inch; while the hone about
the depression was of normal thickness. It seemed that
the floor of the depression was not concave on its inner-
surface, but that it was flatter than normal, and therefore-
apparently encroached a very little upon the area of
the intra-cranial cavity. The dura mater was quite normal
in appearance, as also was the subjacent lorain. Th&
bone bled very freely, and on that account it was necessary
to use a drainage-tube for twenty-four hours. The wound
healed by primary union. On March 20bh he had three-
fits, which he stated were less severe than before the opera¬
tion. They were not followed by the same stupid feeling-
and by the headache and pain which before unfitted him for
any occupation. On April 9bh, after a long exciting day,
he had a series of fits and was unconscious for several hours..
Since that date he has had fits at intervals of a month.
They are slight and cause him little inconvenience. He-
and his friends express themselves as much pleased
with the results of the operation. I may say that
since the operation be has quite lost the unsteadiness
and clonus in his left leg, which gave him so much trouble,
and the capacity of rapid movement of the lingers of the
Idft band has improved very considerably. The difference
in the measurements of the forearms is also very much les.y
than it was. He never suffers from headache nor has he
any pain about the depressed area. He has also become
much sharper and brighter, and can follow an occupation.
I am in hopes that the fits, which are now comparatively
slight and infrequent, may cease shortly.
St. Thomaa’s-street, S.E.
Cliitkal :
MEDICAL, SUKGIOAL, OBSTET'KIOAL, AND
THEEAPEUTICAL.
UNUSUAL CASES.
By Henry Lee,
CONSULTING SURGEON TO ST. GEORGE'S HOSPITAL.
Ca.se 1.—During the last autumn I saw a lady at
Constance who, ten years previously, had been frightfully
burnt through the upsetting of a lamp. Among otheP
injuries received the skin of nearly the whole front of the-
left leg had been destroyed. A large raw surface was left,
which did not heal. After a time several skin grafts-
were tried. The majority of these failed, but at the time
I saw this patient one of them had grown so as to
unite the opposite edges of the natural skin. This was
situated directly in front of the leg, and was the size of tho
palm of a child’s hand. It was thick, and appai-ently well-
nourished, but rather paler than the natural skin. The
point of interest in this case was that this skin graft, which-
did such good service, was apparently devoid of sensation.
A prick with a needle could not be felt. The fact is thus,
demonstrated that animal tissues may live and grow inde¬
pendently of ordinary sensation, and of nervous supply. In
the lower forms of animal life the nervous system is very-
simple, and is analogous to the sympathetic system in man.
Structures supplied by the ganglionic system iii man have nob
the sensation of the skin, or what is usually known as
ordinary feeling. Nitric acid may bo applied to the mucous-
membrane of the bowel without giving pain. We may
therefore believe that lobsters, crabs, and oysters, being
protected from injury in other ways, have not ordinary
sensation-such as is conveyed to our minds by impressiooa
on the skin, -- In -the above recorded case, from the tensioiv
:: r Coogle
The Lancet,]
CLINIOAL NOTES.
[Jan. 17, 3891. ui
of the skiQ and from want of uae, the left leg appeared to
be about what might be supposed to be half its natural
•circumference. By the contraction in the process of cicatrisa¬
tion and by the assistance of smaller skin grafts, at the end
of ten years the wound had entirely healed with the ex¬
ception of two or three small fissures ; tliesiB remained with
rounded, thickened, and indurated edges. The right leg,
which had been less severely injured, was also much
■diminished in si^e.
Cask 2.—A patient being treated for ascites in one of the
medical wards of St. George’s Hospital had an umbilical
hernia. This when distended was the si/e of a small orange.
The hernia was easily reduced and the sac left empty.
Three hare-lip needles were introduced through the neck of
the sac and a figure-of-S ligature applied loosely over the
■extremities of each. After two or three days the needles
were removed, and firm adhesion at the neck of the sac
appeared to have taken place. The skin which had covered
’it became shrivelled, of dusky brown colour, and remained
the sise of a small nut. So far as could be known there
was no return of the hernia. A drawing of the parts by
©r. Westmacott as they were left after the operation is
preserved.
Cask 3.—A gentleman had been treated for some two
years and a half for dysentery. As thei-e was some irrita¬
tion about the rectum, I examined it. A bone, which sub¬
sequently proved to be a fish-bone, about two inches and a
half long, was found to be impacted across the bowel about
two inches from its orifice. By means of a long pair of
forceps one end of the bone was got into a speculum. The
bone was then withdrawn without difficulty. The symptoms
from which this patient bad so long suiiered immediately
^Ceased.
PASTEUR’S PREVENTIVE TREATMENT FOR I
■ HYDROPHOBIA. ' i
By Hv. Tomkins, M.D., B.Sc.,
MEDICAL Ori-'iCEH OE inCAL’I'U, LEICESTER.
Perhaps one of the most reasonable objections made to
the treatment by Pasteur of persons bitten by rabid animals,
or rather, one may say, to the results recorded by him of
•such treatment, has been the fact that in a considerable
(number of the cases treated, evidence that the animal by
which the patient had been bitten was actually and un¬
doubtedly rabid is not forthcoming, and opponents have not
been slow to urge that it is highly probable in many instances
patients have undergone treatment when the dog which had
•inflicted the bite was quite healthy, or, at least, not suffering
(from rabies. In the following record of three cases treated
at the Pasteur Institute last year it is placed beyond all
'doubt that the animal, at the time of inflicting the injuries,
was suffering from rabies. On Jan. 8tli, 1890, a stray dog
■came into the borough of Leicester from the adjoining
■suburbs and on its way bit two school children, a boy and a
•girl, on the face and hands, the wounds upon each of the
■children’s facesbeing of a very extensive, lacerated character.
This occurred outside the borough boundaries, and almost
at the same time it bit also a small terrier dog. Continuing
'its course into the town it bit a young man severely on the
•hand, and shortly after this it was killed. The patients
were seen by medical men and the wounds cauterised, but
not until after the lapse of some little time; in one case
nearly an hour elapsed. I saw all the patients on the
'following day, and, with the assistance of Mr. Fraser,
the veterinary inspector to the corporation, made a post¬
mortem examination of the dog. The pathological appear¬
ances to the naked eye were practically nil, but the
stomach contained some pieces of straw and other debris.
The cord and medulla were removed. On Saturday, the
Slth, I took the three patients to Paris (taking with me the
cord removed from the dog), and on Sunday morning they
were seen by M. Pasteur, and treatment commenced in the
usual manner. From the cord several rabbits were inocu¬
lated, and before the end of a week these succumbed to
wliat M. Pasteur declared to be rabies. The man was kept
Under treatment fourteen days, bub the two children,
■owing to the severity of the wounds, were kept for
'twenty-five days before being sent home. The small
'terrier bitten by the dog was kept by me under
-close observation shut up, away from all other animals,
and oo the fifteenth day from being bitten it began to
show signs of indisposition (having in the interval been
apparently in good health), which soon declared itself
as undoubtedly rabies, and the animal succumbed on the
third day from the first onset of the symptoms. Being kept
secluded and alone, it showed but few signs of excite¬
ment, but crawled about, refusing to eat or respond when
called to, paralysis of the lower jaw and hind limbs soon
supervening. It should be noted that the wound on its
hind leg was but a small one, not larger than a threepenny-
piece, and at the time of its death was healed.
Here, then, we have indisputable evidence that the
animal which bit these three patients was suffering from
rabies, and the probabilities are, seeing bow easily the
second dog was infected, that ab least one or other of the
three would have developed symptoms of hydrophobia if
the treatment for prevention had not been adopted. As
more than twelve months have now elapsed since the
occurrence, and all of them remain in good health, we
may conclude they have now quite escaped from any
untoward consequences.
Leicestoi'.
NOTE ON TRAUMATIC CEPHALHYDROCELE.
By R. Clement Lucas, B.S., F.R.C,S.,
SUIIOEON TO GUY’S IIOSI’ITAL, AND TO THE EVELINA HOSPITAL
I'OU CUILDIVEK.
In The Lancet of January 10th, under the title of
“ Traumatic Encephalo-roeningocele,” an interesting cose
is reported by Mr. H. Burton of a child who, after a severe
injury to the head, developed a pulsating tumour of the
scalp containing cerebro-spinal fluid. The writer, in his
remarks, states that “it differs entirely from the trau¬
matic meningocele described by Mr. Clement Lucas
and Mr. Golding-Bird.” So far from this being the
case, it is precisely of the kind which falls within
that category; and had the writer found the oppor¬
tunity of referring to the original papers, I think he could
not have failed to be struck with the resemblance. The
only difference, indeed, lies in the fact that in bis case the
fracture was in the first place compound ; but the primary
union of the wound which took place allowed the fluid to
accumulate beneath the scalp as if that covering had not
been torn. Little was known of these rare and interesting
tumours till the publication of my first case with a drawing in
the Guy’s Reports of 1876, and the pathological conditions
requisite for the production of the tumour were not under¬
stood. Subsequent years placed two post-mortem exami¬
nations within my reach, which are related in the
volumes of the Guy’s Hospital Reports for 1878 and
1884, and I was able to show that these subcutaneous
fluid tumours communicated directly with the ventricles
of the brain, and I further ventured the statement,
based upon the study of these and other cases,
that they could only be developed in childhood. Mr.
Golding-Bird, in reporting a case in the Guy’s Hospital
Reports for 1889, gives his own experience in support of my
contention. Another very remarkable circumstance which
often happens in these cases is a rapid absorption of
the bone in the neighbourhood of the fracture, and
as a consequence a permanent pulsating mass with heaped
up and everted edges of bone may in some cases remain.
Such conditions were found in cases reported by Mr.
T. Smith, Mr. Godlee, and Mr. Silcock. The escape
of the fluid from the ventricular cavity is apparently
secondary, to an increased secretion resulting from inflam¬
mation of its lining membrane and absorption of the
damaged brain tissue along the track of the injury, for the
fluid is seldom noticed till some days after the accident. The
term traumatic cephalhydrocele would seem preferable to
traumatic encephalo-meniogocele or meningocele, as the
meninges and the brain are both perforated, and do not
cover the cyst. As regards treatment, I am convinced that
the less done in the way of active interference the better.
Aspiration may be used for diagnostic purposes, but can be
of little service to the [patient, for the fluid invariably
re-collects. Pressure during the inflammatory stage may
lead to grave symptoms, as in the case detailed. The
surgeon should bear in mind the very serious laceration that
has taken place in the brain substance, and should ensure
j absolute quiet and brain rest for a lengthened period. In the
G- lOgle
142 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Jan. 17,18W.
later stages gentle pressure may be of service in preventing a
permanent bulge; nut I am inclined to think the cases which
result in chronic tumours are those in which the serious
nature of the injury was not in the hist instance understood.
Pinsbury-aquare.
ECZEMA CAUSED BY VIRGINIAN CREEPER.
By W. Stuart Palm, M.B., M.C., M.R.C.S.
The publication by Dr. Bard of a case of eczema caused
by contact with the leaves of the above plant recalled to
my mind a similar case. A lady patient’s maid bad been
gathering and arranging the leaves of Virginian creeper, and
the next day acute papular eczema appeared, first on her
hands and then on her whole face and neck, where it pro¬
duced intense heat and irritation, and cedema of the eye¬
lids. Under treatment the attack subsided in a few daj’s.
I was much puzzled to find the cause. The patient had
never had a similar attack before, and it was only on close
questioning that I elicited the fact that she had been touch¬
ing the leaves of this plant, and could assign no other cause
for it. I was very sceptical as to this alleged cause until
the summer after, when the butler in the same bouse had a
similar though slighter attack of eczema after gathering the
leaves of the same plant for the table.
Largo, Fife. _
% Ithrar
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla antem est alia pro certo noscendi via, nial quamplmimas et mot-
borum et dissectionum tiiatorias, turn aliorum turn proprias collectae
babere, et inter se comparare.—M orqa.qni De Sea. et Caus. Morb.,
lib. iv. I^oemluni. -
ST. THOMAS’S HOSPITAL.
A CASE OF RUPTURE OP THK LARGE INTESTINE WITHOUT
EXTERNAL WOUND ; A BDOMINAL SECTION; REMARKS.
(Under the care of Mr. Croft.)
There are few injuries to any region of the body which
prove, in proportion to their number, so fatal in their
results as contusions of the abdomen attended with rupture
of the intestine without wound of the abdominal wall. To
the eye there may be in the early stage nothing more than
a bruise of the part struck, and the shock which attends
such injury may not be sufficient to prevent the patient
from going a long distance before the inevitable septic
peritonitis supervenes. As we have already observed,^
we doubt if there is anyone of large experience in surgery
who cannot from his own practice cite striking examples
of the misleading appearance of harmlessness these
lesions often present. As these lesions are so extremely
fatal, the very difficulty of diagnosis imposes the duty
upon the surgeon of clearing up the doubt and of
determining with certainty whether or not they are
present. This is the first point that needs to be made plain.
To wait until the diagnosis is certain is to miss the golden
opportunity for treatment and to allow the onset of septic
peritonitis to rob the patient of nearly every chance of life.
Mr. Croft, who has had unusual success in the treatment of
these intra'peritoneal ruptures of the intestine, having had
partial success in one case,'^ in which the patient died after
secoodaiy resection of artificial anus four weeks aRer the
original injury, and another case in which a brilliant success
was reached^ by immediate resection and suture, the only
one on record, gave M his reasons for attempting an imme¬
diate radical cure in these cases 1. That existing peri¬
tonitis, although septic, might be abolished, and the parts
might be rendered aaeptic. 2. That existing peritonitis
did not essentially prevent union of the peritoneal
surfaces, for experience had now amply shown tliat these
soiled parts might be purified and rendered fit for union.
3. That the empty and paralysed state of the recently
1 The Lancet, toI. i. 1887, p. 937. 2 Ibid., p. C37.
» Ibid., vol. i. 1890. p. 650. * Ibid.
ruptured and contused bowel (small intestine) was favour¬
able for the technique of the operation. 4. It saves th©
patient from the consequences ot an almost uncontrollablo
anus in the small intestine. 5. It also saves him from the
very serious risks of a second long and dangerous operation.
As our readers will remember, Mr. Croft’s successful case,
on which these remarks were founded, was treated by
resection of the injured part. Since then another case of
similar injury has been treated by Mr. Watson Cheyne,?’
who operated about twenty hours after the accident on a
patient aged eighteen, and sutured a rupture in the
jejunum. The youth died nine hours later. Here the
edges of the wound are described as gangrenous when they
were examined post mortem. The case which we give
below is only the sixteenth of the kind on record in which
a surgeon has performed abdominal section for rupture of
the intestine, and the only one in which raptured large
intestine was discovered. The advantage of operation
where no ruptnre was found is shown by a case under
the care of Dr. King,® who operated on a boy aged
twelve, who, after a kick in the abdomen from a horse,
developed symptoms of acute septic peritonitis. On the
third day—that of the operation—there was a sudden fall of
temperature to 97% the pulse was 140, the abdomen enor¬
mously distended, tympanitic above and dull below the
umbilicus. He looked pinched, pale, and anxious, and was
tossing and moaning in bed. Acute peritonitis, with con¬
tused omentum and intestine, was found, and after cleansing
the peritoneal cavity and drainage, ultimate recovery
ensued. There was no doubt in the minds of those who saw
the patient that he would have soon died without the opera¬
tion, which was undertaken with but little hope of success.
E. J-, aged twenty-three, was admitted on the after¬
noon of New Year’s Day into the Edward ward of
St. Thomas’s Hospital in a state of modified collapse, about
an hour and a half after having been severely kicked in the
abdomen by a horse. He was in a state highly unfavour¬
able for recovery from any serious injury. After a search
for work for a fortnight, he had at last, when in a half-
starved condition, obtained “ a job” at a tramear station. At
4.30 P.M. on Jan. 1st he was kicked in the abdomen by a
horse. The blow knocked him down, and he was uncon.-
scions for a few seconds. He was picked up in a state of
collapse, with cold sweat, dyapncca, and pain in the left
side. He recovered to some extent from that condition,
and was sent in a cab to the hospital.
On admission, he was found to be still suffering from
shock. His pulse was feeble at 80, his breathing was
gasping at 40. The abdominal wall was rigid and very
tender to the touch, and the skin on the left side of
the umbilicus showed a small mark like a subcutaneous
bruise. There was no movement of the diaphragm. He
kept his thighs drawn up. The pain on pressure was
i chiefly on the left side and about the level of the umbilicus.
' He was still pale to the lips, the skin was cold and clammy,
and his temperature was 97'4°. A catheter was passed and
drew off about two ounces of normal urine. He vomited a
short time after admission about two drachms of brownish
fluid free from blood or odour. The treatment consisted of
sedatives internally and externally. At midnight the
temperature was 98-4° and pulse 100. At 4 o’clock the
following rooming (Jan. 2nd) the temperature had risen to
101° and the pulse was 110, and the tongue had become dry
and coated. After 5 A M. a messenger was sent to Mr.
Croft, who reached the hospital at 6.45 A.M. On examina¬
tion of the patient, he decided to explore the abdomiral
cavity immediately. The patient at that time manifested
well marked symptoms of acute .septic peritonitis. Th©
incision was made so that the umbilicus formed its centre.
When the peritoneal cavity was opened it was found to
contain a large quantity of turbid fluid witli a few soft
clots of lymph. The omentum between the colon
and the stomach was found severely ecchymosed, and
on turning up this stincture a rent was discovered
on the transverse colon. The edges of the rupture were
ragged and fmcal. The opening was about three-quarters
of an inch in diameter and situated on prominent
surface of bowel. The surrounding peritoneum was tom
and stripped up. It was remarkable that the fluid exuda¬
tion was not very obviously stinking, and that very little
feculent matter clung about the rupture. The omentum
had been tom through near the colon, so as to leave a
8 Brit. Med. Jour,, vol. i. 1890, p. 789.
fi Med. News, Philadelphia, 1890, Ivi., p. 227.
Ljoogle
Die:'
Thb Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Jan. 17, 1891. U3
fringe which could be conveniently made to cover over the
'bowel when the suturing had been completed. The edges
«Dd area of the rupture were purKied, and then the rent
was sutured up with eight Lembert sutures of fine silk, so
that the line of sutures ran somewhat obliquely along the
length of the bowel. A second row of five sutures was
added, to ensure perfect coaptation and closure; and,
'lastly, the fringe of omentum above-mentioned was sutured,
so that it quite covered over the part of the colon just
operated upon. A laceration of the peritoneum was closed
by three sutures. The peritoneal cavity was carefully
irrigated with warm boracic solution and then sponged
<dean and dry. The parietal wound was closed and dressed
in the usual manner. The spray was not used. The
-operation lasted one hour and a half. The patient was
very ill during this time, and required first a hypodermic
injection of brandy and then of ether. He was cyanotic
and his breathing was gasping. Soon after he had been
put back in bed another injection of brandy was required.
Later an enema of brandy was given, but, in spite of all
attempts to revive him, he sank at 6.20 p.m., or about nine
Lours after operation.
At the necropsy a few ounces of blood-stained fluid were
found in the peritoneal cavity. No other intestinal lesion
was discovered. The portion of injured and sutured bowel
w’as removed, and the suturing tested by injections of water
and air. It bora both tests, and resisted a much greater
f )res8ure than it would ever be subjected to in life." The
iver exhibited slight subcapsular heemorrbage on the upper
•surface near its free edge. There was slight subperitoneal
bleeding around the upper end of the left kidney. The
lungs were intensely congested and oedematoue, especially
•on their upper lobes. This was probably the result of long
aniesthetisation.
Bemarks —Had this young man been in an ordinary con¬
dition of health, Mr. Croft believes that he would have
made a good recovery. The lesion on the intestine had
been effectually closed, iind the peritoneal cavity had so far
as the eye could see been sufficiently purified. The cold
and starvation which the poor fellow had suffered during
the preceding week had rendered him incapable of com¬
bating such a sequence of events as shock, rupture of
intestine, peritonitis, and the long operation with aneee-
thesia. The two cases of Mr. Croft’s, already reported
'in this journal, were pointed to by him as indicating
the propriety of early exploratory operation in similar
injuries to the abdomen. This case particularly empha¬
sises the value of the measure. A surgeon would have been
justified, had he made an exploratory incision on the admis¬
sion of the patient into the hospital. As the lesion had oc¬
curred bo the large intestine, feeding by the mouth might
have been commenced at a relatively early peiiod—indeed, at
■once. Would it have been better to have made an artificial
anus in this case? Empliatically no. The purification of
the peritoneum and the suturing of the intestine to the
parietal wound would have occupied nearly as long as the
proceeding adopted by Mr. Croft.
SOUTH DEVON AND EAST CORNWALL
HOSiHTAL, PLYMOUTH.
MALFORMED ANUS AND LOWER BOWEL; RIGHT INGUINAL
COLOTOMY; PLASTIC OPERATION ON ANUS; CURE.
(Under the care of Mr. Sw'Ain.)
Such a condition as that described below as a cause of
chronic obstruction of the bowels at the age of this patient
is almost, if not quite, unknown, for as a rule patients the
subjects of these malformations undergo operation in early
infancy. Of the varieties of malformation of the rectum,
as classified by most standard writers on the diseases of this
region, tliis is an example of the sixth—namely, that in
which the bowel ends in the bladder, urethra, or vagina,
and the anus is absent. Of these modes of ternuDation,
that in the vagina is the most common, and Kelsey^ says
that in females the opening is seldom if ever into the
bladder, but is sometimes into the urethra. The treatment
of this case was very successful. It will be noted that the
plastic operation resembles that performed by Rizzoli, w^ho
makes an incision backwards from the vaginal anus towards
the coccyx, not opening the rectum, then carefully dissects
out the end of the rectum and its orifice, transplants it to
1 Diseases of the Rectum and Anus.
the perineum, and repairs the vagina and perineum in front
of it by deep sutures. Por the following notes we are
indebted toMr. W. Giffom Nash, house surgeon.
M. J-, aged six, wa^ airaibted to hospital on Nov. 20bh,
1889. Her mother stated that she was born with a small
misplaced anus, from which a slight feecal discharge was con¬
stantly oozing. For several years she has haa a swollen
abdomen, and has suffered agonising pain in it. She also
has frequently had feverish attacks.
On admission the patient was a large, pale-faced, emaci.
ated child, with a swollen abdomen. The rectum opened
by a small orifice on the posterior wall of the vagina,
just within the sphincter vaginse. The opening barely ad¬
mitted the tip of the little finger, and frfm it a f:eeal dis¬
charge was constantly oozing. There was a large swelling
in the abdomen, extending up out of the pelvis into the
hypogastrium, and thence upwards along the right side of
the spine to the right hypochondriac region, from which it
passed to the left across the epigastrium to the left hypo-
chondrium, where it ended. It was largest at its lowest
part, and gradually tapered off as it ascended. It was
hard, but could be indented by the fingers. There was no
accumulation in the normal position of the descending
colon. Castor oil was given three times a day, and the
bowels were considerably relieved. On several occasions
before the bowel was opened the temperature ran up to
103% 104% or 106%
Jan. lObb, 1890.—An incision was made in the left loin as
for colotoray, bub the colon could nob be reached. The peri¬
toneum was opened, and the abdomen explored, but the
colon could not be found. The peritoneum was stitched
up again, and the wound closed.
Feb. 6bh.—The abdomen has become much more distended
by faecal accumulation.
7th—An oblique incision was made in the right iliac
region parallel to Poupart’a ligament. The peritoneal
cavity was opened, and the omentum presented The
enormously distended and hypertrophied large intestine was
felt extending downwards into the pelvis and upwards
towards the liver. It lay rather to the right of the spine.
The edges of the peritoneum were sutured to the edges of
the skin; then the peritoneal and muscular coats of the
bowel were sutured to the abdominal wall. The intestine
was not opened.
15Ch.—The bowel was opened and the stitches removed.
After this for weeks there was an enormous evacuation of
fmcal matter. The feces were washed out daily from the
colotomy wound by a catheter passed through the anal
aperture. Much of the fecal matter was so hard that it
had to be removed under ansesbhetics by scoop and fingers.
The catheter could be passed in at the anal aperture, and
out through the colotomy wound, four inches from entrance
to exit.
April lObh.—She was sent to the convalescent home for
change of air to pick up strength for further operation.
She was readmitted on April 30bh very much improved in
health by her stay at the Saltash Convalescent Home.
There was a large, hard fecal accumulation below the in¬
guinal opening, which showed a tendency to close.
May 8bh.—Methylene was given and the fecal mass
broken down by the fingers introduced one at the groin and
the other at the anus.
llbh—Since the bowel was cleared out the child has had
an attack of peritonitis,
13bh.—Rapidly improving.
24tli.—Methylene was given, and the rectum dissected oft
the posterior vaginal wall for over two inches. An incision
was made in the perineum from the hack of the vagina to
near the coccyx. The anus was then stitched as far back as
possible, and a new perineum made between the anus and
the vagina. Considerable traction was required to drag the
rectum down to the level of the skin of the perineum.
June 3rd.—There is fair union of the opposing surfaces of
the new perineum.
20bh.—The index finger is passed daily into the anus.
July Ist.—The bowels act partly through the anus. The
motions are kept loose by castor oil, and the lower bowel is
washed out daily by introducing the irrigating tube at the
anus or the colotomy opening.
22od.—The inguinal wound is a mere pinhole. The
feces are passed by the natural way with the help of a daily
enema.
Aug. 2nd.—Child discharged.
Oct. 15tb.—The child has grown quite strong and fat.
Her mother says that the bowels act nearly every day*
C
144 The Lancet,]
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
[Jan. 17,1891.
and only occasionally require opening medicine or injec¬
tions. She has complete control, except after a dose of
castor oil, when there is slight staining of the diaper.
There is no discharge from the vagina, and no trouble
with micturition. There is no collection of freces felt on
palpating the abdomen. The inguinal colotomy wound is
quite healed, and at its site there is a little tendency to
hernia. The index finger passes easily into the rectum.
Just inside the vagi^nal orifice is a small fistulous opening
into the rectum. There is a small perineum between the
vagina and the anus.
Peliiral SflAitts.
ROYAL MEDICAL & CHIRURGICAL SOCIETY.
Ncphro-lithotomy for Total Suppression of Urine. —
Ecemorrhage after Neplvro-lithotomy.
An ordinary meeting of this Society was held on Jan. 13th,
the President, Mr, Timothy Holmes, in the chair.
Mr. Clement Lucas read a paper on a case of Nephro¬
lithotomy (following nephrectomy) for Total Suppression of
Urine lasting five days, with complete recovery and good
health five years after the operation. This case was men¬
tioned by the editors of the medical journals at the date of
the operation, in 1885, as a case of exceptional interest, but
the details of the case have never been before published,
nor has the patient, or her kidney, or the stone which caused
suppression, ever been exhibited before. The author had de¬
layed publishing it because those to whom he mentioned it,
whilst applauding the attempt to save a life on the extreme
verge of dissolution, threw the coldest doubt upon the
patient’s future, maintaining that even if she recovered from
the immediate effects her life must be a short and painful
one; that the one remaining kidney, having been opened
and drained, would rapidly degenerate, or another stone
would quickly form and bring about a final catastrophe.
After the lapse of five years the author thought he might
be acquitted of any attempt to claim an incomplete success.
The patient was skll living and enjoying the best of health,
and a freedom from pain, discomfort, and hmmaturia, which,
for seventeen years before her right kidney was removed,
were almost constantly present. The operation for total
suppression of urine was one that the author had long con¬
sidered justifiable, and be had on more than one occasion
previously publicly advocated its performance. The patient
had been under the care of Mr. F. D. Atkins of Sutton,
Surrey, to whom much credit was due, both for the original
diagnosis and for the promptitude with which he acted
when total suppression occurred. F. F-, aged thirty-
seven, was first admitted into Guy’s Hospital on June 22oa,
1885. There was a strong family history of consumption.
For seventeen years she had suffered from haematuria at
intervals, and for nine or ten years this had been accom¬
panied with pain on the right side of the abdomen, and for
seven years a tumour diagnosed as a floating kidney had
been felt on this side. On July 14th the right kidney was
removed by lumbar incision. It was a mere shell containing
masses of stone, and weighing 21 oz. The wound healed com¬
pletely, and she left the hospital convalescent on Aug. 10th,
just within a month of the operation. All went well for
three months. She had returned to her household duties,
was free from pain and htematuria, and much satisfied with
the result of the operation. On Sunday morning, Oct. 24bii,
1885, she was suddenly seized, between seven and eight
o’clock, with most violent and agonising pain in her back
and left loin. The pain passed through the loin to the front
of the abdomen and groin. About eight o’clock she passed
a little urine, but from that time all secretion stopped.
Vomiting commenced about half-past eight on the
same morning, and was continued at intervals and when¬
ever anything was taken. Mr. Atkins was called to see
her and found the bladder empty. Vomiting and anuria
continued throughout Sunday, Monday, and Tuesday. On
Tuesday Mr, Lucas met Mr, Atkins in consultation, and
advised operation. The symptoms continued without
cessation on Wednesday, when she was brought to London,
but Mr. Lucas’s medical colleagues still advised him to
postpone operation till a further trial had been given to
diuretics, and in deference to their opinion he waited
another day. On the afternoon of Thursday, the fifeb
day of anuria, the patient became drowsy and weaker, so
that it was difficult to rouse her to obtains answers to
questions. Her pulse was weak, her temperature 99°, and
she had become less sensitive to pain, and indifferent to what
was passing around. Ether was given, and Mr. Lucas out
down on her remaining kidney and discovered a conical
stone acting as a ball-v5ve to the top of the ureter. The
stone was racher more than three-quarters of an-inch in
length and from three-eighths to five-eighths in diameter.
Urine began to drop away out of the wound as soon as the
pelvis of the kidney was opened, but the pelvis was not
found much dilated. The patient recovered well from the
anmsthetic, and was sick once only after the operation. For
twelve days all urine was passed by the wound in tho
loin. Then an ounce and a half was passed with great
pain from the bladder, and the quantity gradually increased.
After the nineteenth day all the urine was passed naturally.
The wound ran an aseptic course, and the patient’s tem¬
perature scarcely rose above normal. Healing was complete
ten weeks after the operation. During the last five years-
she has been employed in household duties, and lias enjoyed
good health. The patient was exhibited, together with her
right kidney, which was excised, and the stone removed
from the left kidney for total suppression of urine.
Mr. Rickman J. Godlee relatedacaseof Removal of Large
Calculi, first from one kidney and afterwards from the other»
in which death occurred from haemorrhage after the second)
operation. The patient was a gentleman aged thirty-seven,
who first complained of renal symptoms in 1886. In the
autumn of 1888 a diagnosis of left renal calculus and left-
pyelitis was made, but mischief on the right side was
suspected also. In November, 1888, a large quantity of
stone—uric acid and phospbatic—was reraovecT from the-
left kidney. The patient made a rapid recovery, but the
closure of the wound was not permanent, and after several
febrile attacks it was found best for the patient to wear a
plug permanently in the fistula, to prevent periodical
accumulations of pus and urine in the kidney. At one time
the ureter became completely blocked, and an operation
was undertaken to remove a stone which was supposed to-
be obatmebing it. None was found, but the ureter became
again patent after the operation, and the state of the
kidney very much improved. The patient now became
convinced that he had stone in the right kidney. The riske
of an operation were explained, but he was recommended te
submit to it, and on Nov. 19th. 1890, large masses of uric
acid stone were removed. No bleeding followed the
first incision into the kidney, but tihe laceration that was-
caused by the removal of .the stones gave rise to very free
venous ha-morrhage, which wa.s easily controlled by pres¬
sure. At the completion of the operation there was little-
or no bleeding, but it was thought safer to plug the pelvi©
of the kidney. The patient remained in fair condition for
an hour and a half after the operation, and then suddenly
died, as the result of fresh haemorrhage from the kidney.
The rarity of the accident was dwelt upon, and attempts-
were made to suggest means of combating it if it arose.
Mr. Goui.EE read a letter from Mr. Mayo Robson of
Leeds, mentioning that, in a caseof nephro-Hthotomy which
he had operated upon three years ago, he had made a small)
incision into the renal substance, which was followed by
violent hicmorrhage. This, for a time, he was unable to-
restrain by ordinary means, and finally he had to excise the
patient’s kidney in order to save his life. The source of the
hmmorrhage was an abnormal vein in the capsule, which
bad been wounded. He said that he knew of another case
in which violent hemorrhage had followed the same opera.,
tion. As it appeared to cease, however, the wound was
closed in the usual way, but it recurred the next day, and
in this case, too, it had become necessary to excise the-
kidney, but with a fatal result.
Mr. Aebuthnot Lane mentioned a case in which there
had been severe hmmorrhage after an incision into the
kidney which he had been enabled to control by snturee
passed through the kidney substance.
Dr. G. HAltLEy congratulated Mr. Lucas upon the bril¬
liant result which he had obtained. In doing so, however,
he was bound to state that it rellected upon medicine, for if
physicians had diagnosed and treated the case in proper
time, there would be none of these calculi for surgeons to
remove. The difficulty lay in the diagnosis. When renal
calculi were small, and there was no haemorrhage and very
little pus, tlie cases were very apt and very frequently were
The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Jan. 17,1891. 145
mistaken for something else. He showed a calculus from a
patient who had been seven years under treatment for
lumbago, who all the time bad calculus in the kidney,
though this was never so much as suspected. He
handed round twelve specimens of small renaJ calculi
which would bo instructive both to surgeons and physicians.
His object was to show that the formation of renal calculus
was not due merely to local causes, but that there was a
predisposing condition. He had been enabled in some cases
to trace this family predisposition for three generations,
bat beyond that it was usually diilicult to get. He also
exhibited specimens to demonstrate that the danger to life
was not commensurate with the size of the stone. Calculi
were often passed by babies unnoticed. He brought three
further calculi to show the dangers of treatment by acid or
alkaline medication, and a group of specimens were shown
to illustrate the fact that stones might go on being passed
for years without giving rise to any discomfort.
ftir. Turner mentioned a case of Double Pyo-nephrosis
upon which he had operated. The patjent was a woman
who was admitted to St. George’s Hospital with two large
renal swellings, anuria, vomiting, and great prostration.
There was a well-marked history of renal calculus, and Dr.
Whipham had asked him to relieve the suppression of urine.
He had obtained permission to cut down upon both kidneys,
and he began with the right. He found it lull of malodorous
pus, with calculous formations weighing an ounce. The
same condition was found on the other side. The woman
recovered very well indeed from the immediate eftects of
the operation, and lived for thirteen days. She eventually
died, not from suppression of urine, but from asthenia. He
thought that this was the only case on record in which both
kidneys had been cut down upon at the same time at one
sitting. The eventual result of operative interference must
ba dependent upon the condition of the kidneys at the time
of the operation, aud he attributed Mr. Lucas’s success to
the operation having been performed before any purulent
collection had formed in the organ. In the post'inortem
records of St. George’s Hospital for twenty-one years past
he had found mention of forty-three cases of renal calculus.
Of these, nineteen were cases of multiple stones, the
number in one case reaching twenty-six. Both sides were
affected in nine instances only. Of these, two had been
operated upon for calculous suppression of urine. Of the
one-sided cases the calculus was on the right side in seven¬
teen and on the left in fifteen. Pyo-nephrosis was present
in twelve cases. In nine the ureter was completely blocked,
and in eight of these the obstruction was at the renal end.
In one case the stone was bin. in length. With regard to
the condition of the unaffected kidney in those cases in
which only one side was calculous, it was granular and
cystic in nine, lardaceous in two. There only remained
eight cases in which the other kidney was either healthy,
hypertrophied, or normal. The two points to be considered
in the prognosis after operations upon the kidney were:
{!) The local condition as to the presence of pus; and
(2) the condition of the other organ. He thought that in
a very large proportion of the cases the other kidney, if not
actually calculous, would be found granular or undergoing
some other form of degeneration.
Mr. T. Smith observed that the most perplexing dia¬
gnosis for the surgeon to make was between renal calculus
and tuberculosis of the pelvis of the kidney, and he asked
Dr. Harley how he arrived at the differential diagnosis. He
asked Mr. Godleewhat part of the kidney had been incised,
and as to the dressing that was employed 'when the urticarial
rash had followed. He remarked that he had known this
to happen when iodoform dressings were used. He men¬
tioned a patient of his own who had suffered severely from
symptoms of calculus in one kidney, attended with much
discharge of pus, in which he had preferred to remove the
kidney forthwith with a very successful result. He thought
that in many of these cases in which there was pyelitis and
general damage there would be less risk in removing the
kidney as a whole than in attempting to remove the stone
only.
Dr. Harlev, in reply to Mr. Smith, said that he had not
alluded to the tuberculous or strumous kidney among those
the conditions which it was possible to distinguish from
calculus, and he admitted that he knew of no means of so
doing.
The President, after thanking the authors for their
valuable communications, said that ho did not think that
the discussion had turned quite sufficiently upon tbe treat¬
ment of the hsemorrhage; whether it was better to suppress
it by removing the kidney altogether or to leave the wound
open, and trust to its arrest either spontaneously or by
treatment. That was an interesting question, and so was
tbe source of the haemorrhage in these cases. Lastly, how
best to open tbe kidney whan it was necessary to explore it
more freely. As tbe experience of surgeons in these cases
increased these moot points would doubtless be cleared up.
Mr. Lucas, in reply, said that Mr. Turner’s statistics
were very interesting, as showing how often renal calculus,
was one-sided. His reference to the greater gravity of.
cases in which there was suppuration was borne out by
experience. He agreed with Mr. Smith that the kidneys
might be degenerated as the result of calciilas, and he was
sure that some cases had been sacrificed to tbe kidney
having been left. He thought that Dr. Harley was a little
sanguine as to the future of the treatment of these cases,
but he would be glad to think that the time was coming
when renal surgery would be no more. He hoped, however,
that Dr. Harley would not keep his patients under treat¬
ment as long as in Mr. Godlee’s case, for he attributed
Mr. Godlee’s want of success to the case having been
allowed to go on too long. He referred to the diffi¬
culty which there always is in distinguishing between
strumous kidney and calculus, but suggested that the best
thing the physician could do in cases of doubt was to call-
in a surgeon to cut down and examine the kidney, a pro¬
cedure which was not attended by any appreciable amount
of risk to the patient.
Mr. Godlee, in reply, said the question of plugging the
wound was one of very great importance in these operations.
Although the hremorrhage after incision into the kidney was
free, it nearly always stopped after a little pressure by the
finger. He thought that Mr. Lane’s suggestion to suture
the kidney was a good one, and he regrettea that it had not:
occurred to him ac the time of the occurrence. He agreed
that people often went about with enormous stones without
inconvenience, and he gave an instance of this. He thought
that it could not but be better for the patient for tbe kid¬
neys to be operated upon separately. He explained that
he had cut into the outer part of the kidney as he had
always done, except when he suspected a small stone in
some other situation. It facilitated the examination of the
whole of the kidney, and the only difficulty was if the
kidney M’ore small. He did not remember what dressing
had been employed in the case in which the urticarial rash
had followed. It was probably either carbolic lint or
boracic acid gauze. Moreover the rash was not confined
to the neighbourhood of the dressing, but was general all
over the body. It was quite out of the question to remove
the kidney at the first operation, because there was a strong
suspicion that the opposite kidney was damaged. It was
a lees formidable operation, too, removing the stone than
removing the Kidney; so that he would in any case remove
the stone first, and then later on, if necessary, he would
take the kidney away.
MEDICAL SOCIETY OF LONDON.
Chronic DUeasc of the Uterine Appendages.
An ordinary meeting of this Society was held on Jan. 12th,
the President, Mr. Knowsley Thornton, in the chair.
Since the last meeting three of the Fellows have died—
Mr. Bellamy, surgeon to Charing-cross Hospital; Dr. Arce-
decline Duncan; and Dr. Gulliver, assistant physician to
St. Thomas’s and the London Fever Hospitals. Dr. Gulliver
died after an illness of only a few days, and his personal
qualities and intellectual attainments rendered it likely
that he would have attained a most distinguished position
in the profession of medicine.
Dr. William Duncan read a paper on Chronic Disease
of the Uterine Appendages, with short n^tes of thirty con¬
secutive cases treated by abdominal section. It appears in
another part of our present issue.
Mr. Aldan Doran read a paper on the Treatment of
Chronic Disease of the Uterine Appendages, which was
designed as a brief review of the whole subject. He stated
that statistics and clinical records were alike out of
place. An operation like salpingostomy could not as
yet be advocated or deprecated by statistics, since it
had only been performed by two operators. Treatment by
rest, most efficacious in many eases, was yet more difficult
to illustrate by statistical records, which were serviceable
146 The Lancet,]
OBSTETKICAL SOCIETY OF LONDON.
[Jan. 17, 1891.
enoug'i ia the case of a widely performed operation like
odphorectomy. The different remedial measures more
or leas in vogue were rest, electricity, massage, curet¬
ting of the uterus, Emmet’s operation, oatlieterism of
the tubes, vaginal puncture of cystic tubes, and abdo¬
minal section, which included oSphorectomy, drainage
of a bydro-salpinx, breaking down of adhesions and
drainage, simple opening of the peritoneum, and plastic
operations on the tube (salpingostomy). The author
insisted that rest roust be intelligently carried out, and
showed that some therapeutic agents were not free from
danger. The advantages of electricity and massage were
roblematical. Curetting of the uterus, ethcacious no
oubt in some forms of endometritis, was objectionable in
disease of the appendages. It was based upon the doubt¬
ful theory that the disorder in question was caused by the
extension of endometritis into the tubes; moreover, it often
made the patient worse. Emmet’s operadon was based on
yet more uncertain doctrines. Vaginal puncture of the
tube was admitted to be dangerous and unsatisfactory by
Leopold and Reverdin, who had advocated it. Oophorec¬
tomy was then discussed. In many cases it cured tlie
patient, but there were several objections to the operation,
which were noted. A hydro-salpinx was often best treated
by incision and drainage. A part of the tubal wall and its
capsule should be trimmed away, in order to avoid all
chance of closure and refilling Ttiis and all other “incom¬
plete” operations had advantages over oiiphorectomy. No
unhealthy ligatured stump was left behind, and there was
no danger of the serious nerve symptoms which occasionally
followed the more complete operation. When the ovaries
and tubes were found to be relatively free from disease,
whilst pelvic adhesions were abundant, it was best to leave
the ovaries and tubes alone and to break down the pelvic
adhesions. The abdominal cavity should be well flushed
with hot water, and a drainage-tube passed into Douglas's
pouch. It must not be forgotten that these cases wore not
so often reported as oophorectomies. Operators were apt
to look upon incomplete proceedings as failures, even when
the patient was cured. Simple incision through the abdo¬
minal walls sometimes cured all the symptoms, especially
when local chronic peritonitis existed. Salpingostomy liad
been practised by Martin and Skutsch. It consisted in the
formation of an artificial tubal ostium by a plastic opera¬
tion. Perhaps it was an operation of the future, but it had
as yet been but seldom performed. In conclusion, Mr. Doran
expressed his belief that oophorectomy was an operation to
be avoided whenever possible; yet cases where it was neces¬
sary existed amongst women o^ all classes
The President asked Dr. Duncan if the table represented
the whole of his practice.—Dr. Duncan replied that it in¬
cluded hb last thirty cases up to tbe date of writing the
paper.
Professor Sinclair, of Manchester, referring to the sub¬
ject of causation, said that since there had been a diminution
of puerperal sepsis there had been a decline in the amount
of tubal disease. Gonorrhoea was no doubt a fertile cause
of salpingitis and ovaritis. He confirmed the statement that
a dangerous amount of injudicious gyna'cological treat¬
ment was prevalent, and be quoted cases which illus¬
trated the disastrous results of such treatment. 'The
possibility of intermittent hydronephrosis had been called
10 questiOQ, but he had met with instances of it. It was
a bad practice to use a stem pessary where previous uterine
disease existed, but in cases of ill-developed uterus
where the symptoms were aggravated by marriage its
judicious employment was followed by good results, He-
bad peiforuied operations on the tubes for tbe last ten
years, and the oroceeding was difficult and dangerous. The
admirable results whiuh had been attained should not be
used as a ground for any practitioner to undertake the re¬
moval of adherent tubes. A guarded prognosis should in
all cases be given^ The Staflbrdshire knobought to become
obsolete, for it was not to be trusted. He thoroughly be¬
lieved in flushing tbe peritoneum, and had seen nothing but
advantage accrue from it.
The President referred to the remarks in his introduc¬
tory address condemnatory of the treatment of these cases by
inexperienced practitioners, and stated that one of the pro¬
minent abdominal surgeons in tbe United States had re¬
cently published a paper on this subject denouncing it in
tbe strongest terms.
The d^ate was then adjourned to tbe next ordinary
meeting.
OBSTETKICAL SOCIETY OF LONDON,
Removal of the Utenne Appendages in cases of Functional
Neurosis.
A MEETING of this Society was held on Jan. 7th,
A. L. Galabin, M.D., E.E.C.P,, President, in the chair.
Dr. Playi-’air read a paper on the Removal of the
Uterine Appendages in cases of Functional Neurosis.
Ca.ses that had come under the author’s observation
were detailed : 1. A case of neurosis treated by removal
of the appendages, without beneflt, subsequently cured
by systematic treatment. 2. A similar case in which
the operation was recommended, and about to be per¬
formed, when the patient refused her consent, likewise
cured by systematic treatment. 3. A ease of neurosis,
in which there was distinct evidence of structural dis¬
ease of the appendages. In this instahee the neurotic
symptoms were first dealt with, in the hope that the
patient would be sutliciently bettered to avoid the neces¬
sity of operation. 4. The subject of hystero-epilepsy and
mania treated by removal of the uterine appendages was
considered, and an illustrative case given. The general con¬
clusions arrived at are: 1. That the removal of the-
appendages is not a legitimate procedure in cases of purely
functional neurosis. 2. That when marked structural
disease of the appendages co-exists with severe neurotic con¬
ditions the latter should be treated in the first instance in
tbe hope that operation may be avoided. 3. That in
hystero-epilepsy and hystero-mania the results of operation
have been so unsatisfactory that it ia a procedure of very
doubtful expediency and not to be recommended.
Sir Spencer Wells referred to a pamphlet by Dr. Ross of
Toronto, on the Failure of the Removal of the Tubes and
Ovaries to relieve symptoms. He says: “Tooperateon organs
not diseased for the relief of indefinable pain symptoms,
hysterical symptoms, cataleptic symptoms, epileptic sym¬
ptoms, is, to my mind, unjustifiable. A craze seems to
nave taken hold of the profession. The axiom seems to have
become, if a woman has indefinite pains and local sym¬
ptoms take out her ovaries. This axiom requires a radical
change.” Dr. Roe.s went on to say: “ I have seen these un-
justitiableoperations done both in Europe and America.
many cases in which ovaries and tubes are removed to
relieve certain nervous symptoms remain unrelieved.
Many cases I hear of as cures are nob cures.From our
many failures fo remove nervous diseases, as hysteria and
epilepsy, by castration, we can see that the ovaries play but
a part in their causation, and I believe that we might as
well hope for relief of these diseases by enucleation of both
eyes as by removal of both ovaries, or both tubes, or both
tubes and ovaries, or even tubes, ovaries, and uterus."
Dr. Ross related a case where he removed the ovaries in
1886 In 1888 he was able to report that his patient had
been in splendid health ever since the operation, but in 1890
had to say her mental condition is nob wbat it was before.
She seems lazy, indulent, and fat, and is not tbe bright little
woman she was before the operation, even when she had
her aches and pains. Sexual intercourse U only indulged
in as a marital duty. It gives neither pain nor pleasure.
Then, Dr. Ross proceeded, “many deaths from these opera¬
tions have been recorded.A girl’s prospect of marriage,
maternity, and a happy life are blasted for ever by such
a proceaure.” He then referred to a case where a
lady of his acquaintance was operated on at Birmingham,
and her case was brought before the Gynecological
Society in December, 1888, very soon after the operation,
as a practical cure. He (Sir Spencer Wells) had seen that
lady to-day. She had never "been well since the operation,
but very much worse than before, and her case, instead of
being a cure, was a deplorable and disastrous failure. He
had seen other cases almost as discreditable, and he fully
concurred in all that Dr. Playfair and Dr. Ross had said
against unnecessary and unjustifiable mutilation for transi¬
tory disease.
Dr. Priestley referred to the debate on the subject at
the International Medical Congress held in Copenhagen six
yeers ago. Tbe preponderance of tbe best opinion was
adverse to operation. His own experience was not favour¬
able to it. It was not free from danger, and was not easy.
Nor did it cure, proving that severe ovarian pain without
disease ia but the expression of a general neurosis. The
proposal to remove the uterine appendages arose really
The Lancet,]
HARVEIAN SOCIETY.
[Jan. 17,1891. 147
from mistaken diagnosis, and was comparable to creating
as the real ailment the pain in the knee associated with
hip-joint disease in children, or the pain in the calf of the
leg so often experienced by women who are the subjects of
phlegmasia dolens, I6 was well known that neurotic cases
often got better spontaneously. Alteration of sinroiind-
ing'i, an engagement to marry, or other occurrence, was
sufficient. Dr. Priestley said that neuralgia of the testicle
was not treated by castration, therefore wby was castration
performed in women? He referred to the remark of the
late T)r. Matthews Duncan about the dangerous precedent
of allowing a patient to decide upon an operation. He con¬
tended that tliese cases were best treated by medical and
moral treatment as recommended by Dr. Weir Mitchell.
He would lay it down as a rule that the appendages should
only be removed when there was distinct local disease
ascertainable by examination, and he would put still some
further limit to this, for it was well known that both ovaries
and tubes might be considerably enlarged and yet return
to their natural size without operation. In those formid¬
able diseases mania and epilepsy he did not venture to give
an opinion.
Dr. Gervis said he agreed with the first and third con¬
clusions of Dr. Playfair, but in the second he should be
influenced by the interpretation to be put on the word
“marked.” If it signified organically and permanently
affected, then he failed to see any object in hesitating at
operation unless the local conditions gave rise to no sym-
pcoma of importance; but if it meant only a condition
which came within the limits of what was curable, then
certainly systematic treatment should be tried before any
idea of operation was entertained. He believed systematic
treatment, combined with massage, was often of real value,
nob only in curing the general neurotic condition, but the
local malady.
Dr. HORROCK.S said it was necessary to remember that
a functional neurosis was a complaint without an organic
lesion toaccounbfor the symptoms. It was always difficult
to prove a universal negative. Hence, when a woman com¬
plained of pain in the ovarian region, it was nob easy
to say that she had no disease in the pelvis to
account for such pain. If no disease could be found,
and yet the patient complained persistently of pain and
distress which remained unrelieved by systematic treat¬
ment, it became a (juesbion whether it was not justifiable to
open the abdomen and examine the pelvic viscera, with the
'object of discovering if possible the source of the pain,
and removing it; in such a case, if the ovaries and tubes
were found to be healthy, ought they not to be dropped
back into the pelvis and left alone 1 He mentioned a case
now in Guy’s Hospital, under his own care, which had been
treated twelve months without benefit. She was waiting to
have abdominal section performed to relieve lierovariau pain,
although on careful examination no disease could be found
in the pelvis. He did not think that healthy ovaries and
tubes should be removed in cases of true functional neurosis.
Mr. ALn.\N Doran said there was a great difference
between *the removal of the appendages for disease and
their removal for a neurosis. In the first case, even when
the patient might have recovered without operation,
structures absolutely diseased were removed, the ligatured
pedic'cs remaining as relatively small sources of irritation.
In removal of the appendages for neurosis, structures only
assumedly morbid were cut away, whilst the ligatured
pedicles remained as definite sources of irritation in these
neurotic patients. Some believed the induction of the
menopause cured the neiiroais; but the menopause was
always more or less of a shock, and a premature menopause
was a still greater shock.
Dr. Hkywood Smith said that in his experience many
cases had been entirely relieved from intense neurosis of the
ovaries by their removal. He mentioned a ease of inter¬
mittent melancholia cured by removal of the uterine
appendages. One ovary was beginning to undergo cystic
degeneration.
Dr. Hayes thought neurotic symptoms were nob usually
present where there was disease of the appendages, and
even if they were present they were not relieved by
removing the diseased appendages. When these organs
were diseased they should be removed for other reasons.
He was led to believe that patients often submitted to
these operations in order to escape from the inconveniences
of menstruation and child-bearing.
Dr. Playfair, in reply, said Dr. Heywood Smith had
misunderstood him. His paper was not written with the
view of opposing operations in suitable cases of structural
disease, which he himself constantly practised, but to
show its inefficiency in cases of purely functional nervous
breakdown. He could only repeat his conviction that these
cases had generally nothing to do with the reproductive
organs. In mixed cases operation should follow, nob pre¬
cede, the attempt to cure the neurotic symptoms.
The following specimens were exhibited -
Dr. Phillips : Genital Organs from a fatal case of Purpura
Hmmorrhagica.
Dr. Dakin: Tubercular Uterus and Appendages.
Dr. Hayes: (l) Distended Fallopian Tubes; (2) Fibroid
Polypi. _ _ _
... ■■■' f
HAllVEIAN SOCIETY.
Some cases of Phthisis treated on Dr. Koch's Method.
A MEETING of this Society was held on Thursday, Jan. 8th,
Mr. Thomas Bryant, President, in the chair.
Dr. J. Edward Squire, in a paper on the injection method,
said the success of Dr. Koch’s researches in the laboratory
justified the use of the fluid he bad prepared in cases i<f
human tuberculosis. The fluid has a selective affinity for
the pathological products of a specific inflammatiou, itself a
product, as is stated, of the micro-organism associated with
thisspecialdisease. ItisfiveorsixyearssinceDr. Wooldridge,
from a pure culture of the bacillus anthracis in a liquid
proteid material, separated the bacillus by filtration, and
found that inoculation of this fluid in animals was pro¬
tective against the anthrax virus. Encouraged by the
success, he bad commenced similar researches on the tuber¬
cular bacillus, which were interrupted by his untimely death.
The effect of the remedy on the bacilli may be that they
are shrivelling from inanition, and so die and are cast out.
Dr. Squire defined active tuberculous tissue as tissue in a
condition of inflammation produced by the specific irritation
of the products of the vital activity of a colony of tubercle
bacilli. Dr. Koch’s liquid was believed to contain as its
active principle these products of the bacilli, and thougn
not sufficiently powerful to set up a specific inffaramatory
action in healthy tissues, it was sufficient, when added to
the actively inflamed (tuberculous) tissues, so to increase
the morbid changes in them that death of the part resulted
from the intensity of the inflammation (i.e., by sloughing).
Dr. Squire’s remarks were illustrated by eight cases under
treatment, all of whom were so far benefited. Seven are of
phthisis, one a child with lupus under Dr. Barlow’s care in the
Hospital forSick Children. In all these cases marked reaction
followed. A tolerance is soon established, and the reaction
becomes less after repetition even with increased doses.
The dose must be in proportion to the amount of active
tubercle diagnosed rather than to the age of the patient.
Children are given a smaller dose to begin with than young
adults with limited or I'ecent tubercular deposit, as they
are more easily depressed, aud in some children a weak and
very frequent pulse follows; in others the reaction is not
such as to interfere with their sleep at nigbt. There was
marked difference in this to the effect of chemical drugs.
The site of the tubercular deposit was of importance, as a
degree of local disturbance in the skin around lupus could be
tolerated that would be very dangerous in the larynx or the
brain. As to dosage, instead of oeginning with the largest
dose that could safely be borne, equally good results might
probably be obtained by using a minimum dose at first and in¬
creasing it gradually. In two of Dr. Squire’s lung cases the
large dose of one centigramme was first used ; in these a
severe reaction occurred. After repeated smaller doses the
patients now bear the large dose without any trouble. The
same results were obtained by gradually increasing the dose.
The reaction was in most cases marked by a rise of tempera¬
ture. In a few cases a fall to below the normal for a time
was occasioned; the pulse, at first full and soft, became
quick and weak ; arterial tension was diminished, as was
shown by its being easily compressible. Various rashes
and slight jaundice had been observed, and in one of Dr.
Squire’s cases double vision occurred during the reaction.
The effect on the lungs affected by tubercle was manifested
by increased rapidity of breathing, pain over the seat of
deposit, increased cough, and marked stethoscopic signs.
The signs were suggestive of a localised pneumonia. As
bearing out the contention that only tubercular material is
Coogle
D
148 The Lancet,]
KEVIEWS AND NOTICES OF BOOKS.
[Jan. 17,1891.
affected by the remedy, Dr. Squire mentioned two cases
■where the inflamed area produced by blisters showed no
changeafter injection, whilst a lupus patch in close proximity
became red and swollen, Fresn air, good food, and cod-
liver oil were important aids to the treatment by Dr. Koch’s
liquid which should not be neglected. In conclusion,
Dr. Squire again emphasised the necessity for a careful
selection of cases, and competent supervision of patients
throughout the treatment, and especially during reactions.
The remedy might be discredited by its indiscriminate or in¬
cautious use before there had been time to determine its
value in appropriate cases.
Mr. D’Akcy Power said that he had seen one of the
lupus cases mentioned by Dr. Squire after the third in¬
jection of six milligrammes. He was quite appalled by the
severity of the reaction and by the amount of collapse
which was produced. He thought that if this case was to
be in any way taken as a type of what usually occurred,
the very greatest care should oe exercised in the selection of
suitable patients, and injections should only be given when
very skilled nursing could be obtained.
Mr. Noble Smith had watched Mr. Watson Cheyne’s
cases with great interest, and thought that he had wit¬
nessed a marked improvement after Injections in cases of
tubercular disease of the hip and elbow.
Dr. Waterhouse narrated a case of aiacly with advanced
phthisis, whose life, he thought, had been undoubtedly
prolonged by Koch’s treatment as it was carried out by
Mr. Watson Cheyne. After the injections the temperature
decreased, there were no night sweats or diarrhma, and the
bacilli disappeared from the sputa, though she still coughed
up much lung tissue. A herpetic eruption appeared over
one trochanter, however, apparently as a result of the treat¬
ment, for it was nob a bedsore.
Dr. O’Connor, in watching eases which had been injected,
was struck by the effect which appeared to be produced
upon the mucous membranes of the body. He asked Dr.
Squire whether in his patients the treatment had produced
any symptoms of pneumonia.
Mr. Edmund Owen was present at the meeting solely
■ that he might express his thanks to Dr. Edward Squire for
the kindness, care, and discretion with which he bad carried
out the injection treatment upon the patients at the
Children’s Hospital. On the inauguration of the treatment
Mr. Owen bad stated that his mind was quite open upon
the subject of Koch’s remedy, lb was still open—wide
open. He would briefly say that, as regards the children
who were injected, their tubercular joints bad undergone
no more improvement than might nave reasonably been
anticipated from treatment in hospital upon the old
lines—that is, M’ibh rest in bed and flxation of the limb.
There was one child with tubercular ophthalmia, tuber¬
cular dermatitis of the Up, and tubercular disease of
the knee. The eye got worse under the injections,
the lip got better, and the knee swelled a little. It
was customary, however, for tubercular dermatitis to im¬
prove under ordinary treatment. As regards the knee,
when the local excitement subsided the chronic affection
seemed to be unaltered. During the progress of the injec¬
tions, in a case of tubercular disease of the hip-joint, an
anomalous rash appeared upon the child’s body. It was
shown as a ease or “ Koch eruption,” and as such was re¬
garded with considerable interest. In due course, how¬
ever, several other children in the ward broke out in un¬
mistakable measles, on which the real nature of the first
eruption was manifested. Had they been ignorant of the
fact that Koch’s treatment was occasionally associated with
a morbilliform eruption the ward would not be—as was now
unfortunately the case—in quarantine. Probably this
evening’s meeting was the first occasion of an able and
scientific paper on a medical subject being illustrated by a
quotation from the Morning Post. He did not blame the
author of the essay for malcing the quotation, but he could
not refrain from expressing Ids regret that members of the
profession had so widely used the public press for purposes
of advertisement. There seemed to be a desire to struggle
into the heaven of notoriety by the aid of Professor Koch’s
coattails.
Mr. Mortimer said that as registrar to the Hospital
for Sick Children in Great Ormond-street he had carefully
watched the cases which had been injected by Dr. Squire.
He believed that if the treatment was to be of service acute
and not chronic cases should be selected.
Surgeon W. A. Morris said that during his stay in Berlin
he endeavoured to see all he possibly could ofthis treatment.
By the courtesy of Professor Ewald he visited his cases as
well as those under the care of Professor Bergmann, and
though the selective action of the drug was very apparent
in lupus ; he did not see a single case where there was a
distinctly favourable result.
Dr, Squire briefly replied.
lleHffes anlj ftotms of j^ook.
A Dtsori'pUoz Catalogue of the Pathological Museum of the
London Hospital. London: Taylor and Francis, 1890.
A Descriptive Catalogs of the Pathological Collection in the
Museum of St. Thomas's Hospital, London. Second
Edition. By Samuel G. SHA'm’OCK. Parti. London:
Adlard and Son. 1890.
Descriptive Catalogtie of the Specimeiis illustrating Medical
Pathology in the Mzisetcm of University College^ London.
By Charles Stonham, F.R.C.S. At the Office of the
College. 1890.
The educational value of a well-arranged museum is
universally admitted, and there are no subjects in the
domain of science to which this method of objective in¬
struction cannot be applied. In pathology there is in the
association with every hospital of importance a collection of
specimens which in the aggregate is of enormous extent,
and is significant of the ardour with which the subject is
studied. In London especially there are pathological
museums, under the charge of skilled experts, which
abound in carefully prepared specimens illustrative of
the common as well as the rare types of disease. For
no museum worthy of the name should be a mere collection
of cariosities ; its contents should embrace the whole field
of-the subject it is intended to illustrate, and the indi¬
vidual specimens should be so prepared as to tell their own
tale. It is obvious too that a good catalogue is indis¬
pensable to a museum ; and we note with satisfaction that
of late years so many of the London hospitals have followed
the example set by the older institutions, and issued such'
works from the press. The advantage to the student is
very great, whilst to the investigator it is no less valuable ;
and it may he noted that, since the plan pursued is mainly
the same at all the hospitals, there is great facility
given for the comparison of specimens and the collation of
facts of morbid anatomy.
The catalogue of the London Hospital Museum forms a
handsome volume of about 630 pages. The preparations
are continuously numbered, a plan which is decidedly the
best, and is now generally adopted; the descriptions are care¬
ful and accurate, often with instructive clinical details of the
case yielding the specimen. The general editing and much
of the compilatioQ are due to Dr. F. C. Turner, Mr. F. S.
Eve,, and Mr. T. H. Openshaw, the curator of the museum ;
but the cooperation of several of the members of the
hospital staff has been obtained in particular sections. A
feature of the collection is the series of 200 specimens
illustrating general pathology, containing selected specimens
to stand as typical examples of hypertrophy, atrophy,
degeneration, injury and repair, necrosis and gangrene,
inflammation and its results, specific diseases, and morbid
growths. Of the rest of the collection it is diflicult to
select specimens from series so well stocked, but we may
indicate a few of special interest. No. 206 is a specimen
of an old separation of the odontoid with a false joint
between it and the axis; and No. 207 an example of disloca¬
tion of atlas and odontoid, in which the subject survived
for three >veelcB. Nos. 215 and 216 show fibrous and osseous
union of fractured vertebrcc. The collection is particularly
rich in fractures of all kinds; and in the section of joint
disease -we notice an excellent series of chronic rheumatoid
Dit Coogle
The Lancet,]
KEVIEWS AND NOTICES OF BOOKS.
[Jan. 17,1891. 149
arthritis. Historical interest attaches to a specimen of
hydatid in the left parietal lobe of the brain {838)—a ease
recorded by Dr. Abercrombie. Among cerebral new growths
may be observed two of the pituitary body (857,858) and
one of the pineal body (859). The conditions of acute
poliomyelitis and syringomyelia are illustrated. There arc
excellent series of diseases of the eye and ear; but that of
the teeth consists of a single specimen (an odontome). The
series of gastric ulcer is extensive; there is one specimen
showinggastro-colio fistala(1105) and one of perforation of
the stomach “from without” (1107). There is a specimen
of ulceration of the stomach in typhoid fever (1113), and
such rare neoplasms of this organ as lipoma (1116), fibroma
(1117), and sarcoma (1118,1119), and a curious example of
cystic growth in the pyloric region (1139). In the museum of
the hospital to which the late Mr. Curling was attached
it is nob surprising to find some specimens illustrative of
duodenal ulceration following burns or scalds. Typhoid,
tubercular, and dysenteric ulceration is abundantly exempli¬
fied. No. 1209 shows congenital absence of the rectum.
The subject of hernia seems well shown, including two
specimens of Llbtre’s or Richter’s hernia. There are two
specimens of pylephlebitis (1359, 1360), one of actinomycosis
(1305), and another of atrophy of the pancreas in diabetes.
The series of diseases of the heart and bloodvessels are
abundantly stocked, and so are those of the lungs. We
note many specimens of new growths of the supra-renal
bodies and a rich collection of tubercular and syphilitic
disease of the testis. There are four specimens of malformed
uterus—viz., one of uterus unicornis, one of uterus bicornis,
and two of uterus didelpbys; whilst there is a large number
of pelvic deformities amongst malformations. The collec¬
tion numbers 2433 specimens. Casts, models, urinary
calculi (179 in all, which have been analysed by Mr. F. J.
Page, n.Sc., and Mr. Openshaw), ciliary and other calculi,
and a series of plates of diseases of the .skin (arranged
by Dr. Stephen Mackenzie) are also comprised in
the museum, which is thus seen to be extremely well
equipped.
St. Thomas’s Hospital Museum has long possessed (since
1859) an excellent printed catalogue; but the lapse of time,
which brings with it so many changes in pathology as in
every other progressive science, has necessitated the pre¬
paration of a new edition, which has doubtless also been
called for by the growth of the collection. Tne energetic
and able curator, Mr. S. G. Shattock, has thrown himself
heartily into the work; and this, the first instalment,
promises well for the whole. This Part I. comprises as many
as 742 specimens, covering the comparatively limited field
of injuries and diseases of muscles, tendons, synovial
sheaths and bursco, cartilages, bones, joints, and the jaws.
A novel feature is the prefixing to each series a normal pre¬
paration of the structure to which the morbid specimens
belong. The catalogue appears to have had much pains
bestowed upon it, and the collection contains some
unique preparations. There is a most valuable series
of gunshot fractures (78 to 112), mostly contributed by
Sir W. MacCormac from the Franco-German War. An
instructive series is that of specimens showing the “ideal
process” of repair of fracture of bones and “ deviations from
the ideal process of repair” (55 to 72). The aeries of frac¬
tures of the skull and spine are extensive, and one notes
with interest several examples of fracture of long bones
presented by Sir Astley Cooper. Rickets and osteo-malacia
are well illustrated, as also are the subjects of caries and
necrosis, and of tumours of bone, the last classified according
to their histological structure. The collection is rendered
very complete by the inclusion of specimens of parasitic
disease ofbonc—namely, hydatid, actinomycosis,andMadura
foot. Amongst joint diseases, the museum is veiy rich in
specimens of tubercular arthritis, and also in osteo¬
arthritis, the latter including some preparations from cases
of tabes dorsalis presented by M. Charcot, who also
gave to the museum (825 a) a life-size wax model of
a woman the subject of tabetic arthropathy, which was
exhibited by him at the International Congress in London
in 1881.
The third catalogue on the above list is that which deals
with the medical part of the pathological series in University
College Museum, the surgical having been issued a few
years previously. The present volume is mainly the
work of Mr. Stonbam, hut its preparation ha^been shared
in by Drs. Barlow, H. Sainsbury, and A. Money. The
chief point of difference between it and the preceding lies
in the introduction of succinct descriptions of the morbid
anatomy of the textures and organa, which are illustrated
by the specimens that follow. This must be of especial
value to the student. But considerable care has also
been taken to render wider service, in the clinical facts
given of several of the cases from which the specimens
have been derived. Amongst the specimens illustrating
intestinal disease we note one showing the follicular
hypertrophy met with in Addison’s disease (3070), a
considerable series of dysenteric and typhoid intestines,
and some from cases of cholera. There are some interesting
specimens of rupture of the heart—viz., three of the left
ventricle, and two of the right ventricle—one of the latter,
as well as one of rupture of the left auricular appendix,
being traumatic in origin. Specimens illustrative of
pleurisy and empyema are included, and the subject of
phthisis is fairly well illustrated — although here, as
in many museums, the illustrations are not so abundant
as the number and variety of coses dying in hospitals
might be thought capable of affording. There is a
particularly good collection of morbid growths of the
lungs and pleura. Amongst the specimens of Addison’s
disease is a remarkable one of atrophy (with gumma) of the
supra-renal bodies. The collection also contains a good
aeries of specimens of thrombosis of cerebral vessels, and of
tumours of the brain and membranes.
OUR LIBRARY TABLE.
Physiological Quantities or Constants. By V. H. Wyatt
W iNGUAVE, M.11.C.S. London: Henry Kimpton. 1890.—
“A list of quantities,” as the compiler of this hrochnre
remarks, “has formed an important feature in the note¬
book of every student of pbysiologj'.” Such a compilation
is necessarily of great use both to the practitioner and
student. This little work is conveniently arranged, and the
statements are very accurate. One of its chief advantages
is that it is so easy of reference, the heads under which the
various subjects are placed being concise and methodical.
The object of the compiler has been to facilitate work—to
refresh and stimulate the memory by associating ascer¬
tained facts with ideas through frequent repetition. This
has been most ably and completely carried out, witli the
result that the student will find placed in a small and com¬
pact volume all the physiological quantities, which other¬
wise he has to search for in various text-books on the
subject.
Bibliograph'ia Franraise dc I'Art Dentaire. Par Le
Docteur Tn. David. Paris: Genner-Baillibre et Cie.—
This work is a catalogue of the manuals, brochures, and
casual papers read at congresses and societies on dental
subjects, and extends back as far as the commencement of
the present century. In the first section the matter is
arranged under the names of the authors, and, considering
that there are 289 pages, in each of which there are on an
Dig h lOOglC
150 ThbLancbt,]
OrR LIBRARY TABLE.-NEW INVENTION.
[Jak. 17.1891.
average ten subjects, it is surprising that so large a field of
literature should be but little known to the students of
dentistry, with the exception of the works of Magitot and
those of the compiler. The second section consists of a
well worked*out subject index.
My Friends at Sant’Ampelio. By J. A. OooDCHiLD.
London: Keean Paul, Trench, Trubner, and Co. 1890.—
Encouraged by the cordial i-eception awarded to a
previons book, entitled “Chats at Sant’Ampelio,” the
author has reprinted it, together with a new second part of
somewhat greater length ; this is tei'med ‘ ‘ The Sage of
Sant’Ampelio, and it is of a much graver ca^t than its
companion. To disarm criticism, a sage is defined as “ one
who has found the equilibriwn of life. ” Many of those who
formerly took part in the entertaining and fascinating chats
pass in and out of the life of the second part, but the real
backbone of it is the sage himself, who in quiet and courteous
manner corrects so many of the vague aspirations and
statements of those about him. The sage, of course, has a
history, which has to be unfolded by degrees to account for
the curious calm of his equilibrium ; but the charm of the
book lies, not in simple narrative, but in the stimulating
power it possesses. No one can read the chapter upon the
College of St. Sophia without feeling grateful to the author
for presenting, in an allegorical form, so useful a
help to those perplexed by the supposed difficulties of
harmonising revealed religion with the progress of science.
The serious nature of many of the topics touched upon in
this second part does not preclude interest, or even an
occasional light-hehrted witticism. Verses of some merit
are scattered through the volume. The book is thoroughly
healthy and vigorous in tone, and should be the more warmly
welcomed by our readers, since it comes from the pen of a
medical man.
Dictionartj of National Biography. Vol. XXV. (Harris-
Henry L). London : Smith, Elder, and Co.—The instal¬
ments of this stupendous work continue to be issued at the
usual intervals. Tlie twenty-fifth volume has now been
reached, which, however, only brings the work up to the
middle of the letter H. A’ great drawback to the work as
one of reference arises from the fact that the index gives as
a rule no clue to distinguish professionally tiie large groups
of individuals bearing the same surname. For example,
in the present issue there are forty-nine individuals
described bearing the name of “Harris,” and thirty
with the name of Harrison, without means of distin¬
guishing the particular avocation of the respective owners
of those names. A biographical description of William
Harvey, discoverer of tlie circulation of the blood, forms one
of the most fascinating articles in this volume, and the
short account of Dr. William Hawes, the founder of the
Humane Society, is of scarcely less interest. Dr. Thomas
Haweis, Dr. John Hawkins, of Jesuitical renown, are also
mentioned. The Irish representatives of medical work are
Sir John Hayes, who was in 1791 appointed physician
extraordinary to the Prince of Wales; Thomas Healde, a
famous Harveian orator ; Richard Helsam, a medical man
mentioned by Swift in 1733 as “the most eminent phy¬
sician in this city and kingdom”; and, finally. Dr. John
Hennen, whose statue, erected in honour of his heroism as
an army officer, graces the fortress of Gibraltar, where it
was placed by public subscription. Other professions are,
however, in this particular volume much more largely repre¬
sented. The work fully maintains the expectations it excited
on the publication of the first volume.
Blackie's Modem Cydopadia of Univenal Ir\jormation.
London, Glasgow, Edinburgh, and Dublin: Blackie and
Son.—This handy hook of reference on all subjects and for
all readers has now with the eighth volume reached its con-1
elusion, and it need scarcely be said cannot fail to prove
a most convenient work of reference. It is comprehensive
in scope, moderate in size, beautifully printed, and illus¬
trated with much skill. It contains articles on all imaginable
subjects, amounting in number to nearly 28,000. The
scientific articles are as a rule carefully written by experts
in the various branches of science dealt with in the work.
In respect of scope, utility, and convenience, this Cyclo¬
pedia will favourably compare with similar works of much
greater bulk and pretensions, and will doubtless on that
account be correspondingly appreciated by the numerous
class of readers and writers whose labours it will serve
materially to minimise.
Symptomologie vnd Histologic, dcr Hauth'ankkeiten. Von
H, Lklcxr unci E. ViDATn Parti. Translated into German
by Eduard SchifI''. Hamburg and Leipzig; Leopold Voss.
1890.—This important work is here presented in German in
exactly the same style as the French original, and Dr.
Schiff's well-known reputation as a dermatologist and his
knowledge of the French language are a sufficient guarantee
that the book loses nothing by its presentation in a German
dress.
Wb have Sell's Dictionary of the World's Press
(Henry Sell, 107, Fleet-st., E.C.), which is quite as interest¬
ing and instructive as heretofore, including as it does
articles by G. A. Sala and other well-known writers.
Although the work is primarily of value to the advertiser,
it contains much that may also be found of interest by the
general reader.
NEW HOT-WATER BOTTLE.
Specimens of a useful modification of the ordinary
hot-water bottle have been submitted to us, which
are worthy of commendation. They are made of tin
or copper, covered with indiarubber, and of a size and
shape to render them fitted for application to any part of
the body, to whicli tliey may be attached by means of
tapes passing through loops fixed to the bottle. The
vessels are supplied on one side with a raised border
to admit of the insertion of a pad of spongio-piline
or a poultice, the warmth of which is maintained by
the hot water within. The convenience and utility of such
an apparatus as that above described must be apparent,
especially to those whose duties lie in tlie sick room. They
are manufactured by Mr. C. W. Shepherd, Brook-street,
Ilkley.
The Shirley Chilrren’s Hospital.—T he sixth
annual report of this institution shows that twenty-four
surgical and thirty-one medical cases were treated as in¬
patients, of whom thirty-six were discharged cured, nine
reatly improved, two died, and seven remained in the
ospital. Since July last there have been thirty-four
patients and over 300 out-patients attended.
Royal Hospital for Incurables, Putney.—
The annual meeting of the subscribers and election of
inmates to this institution was held at the Cannon-street
Hotel recently. Mr. J. D. Allcrolt presided. The report,
which was adopted, stated that the receipts from ordinary
sources bad been fairly maintained, while the legacies hail
been exceptionally large by the payment under the will of
the late Mr. John Chapman of i;l.3,300. £8000 had been
invested, and £0000 placed on deposit. Under these cir¬
cumstances, the board bad raised tne number of inmates to
be elected from thirty to thirty-five. The inmates at the
end of the year numbered 231, and the pensioners 588,
making a total of 768 beneficiaries,
Di' -:ed by vjoogie
tikE LANCiit,^
MOlJ’ESSOR VlRCHoW- Obi kOCH^S RfiMkDV.
fJAN. 1% 1891. 151
THE LANCET.
LONDON: SATURDAY, JANUARY 17, 1891.
The important statements made by Professor ViECiiow
at the meeting of the Berlin Medical Society on the 7th
inst.—a full abstract of which we publish elsewhere—mark
a distinct period in the history of the employment of the
anti-tuberculous fluid discovered by Professor Kooii.
Hitherto investigations have been mainly clinical, and the
few cases in which the results of post-mortem examination
have been published have not permitted of any deflnite
deduction as to the action of the remedy upon internal
organs. Professor ViRCiiow now brings forward his ex¬
perience based upon an examination in the Patholo¬
gical Institute of twenty-one cases which have proved
fatal during or after the treatment. Coming from so
high an authority, his statements will have the greatest
weight, and tiiey must be carefully analysed, in order,
if possible, to determine whether the treatment of in¬
ternal tuberculosis by this method is strictly chargeable
with increasing the liability to a fatal termination; and, if
so, what are the circumstances which should favour or
interfere with so disastrous an issue. It is imperative that
the question should be fairly faced and impartially
handled} otherwise [there may be witnessed as great a
revulsion against the use of the “remedy” as there has
been of indiscriminate enthusiasm at its first adoption.
In the first place, it must be pointed out that Professor
Virchow’s results confirm in a striking manner the accu¬
racy of the original statement of Professor Koch. With
certain exceptions as regards miliary tubercle and “soli¬
tary” tubercle of the brain, to which he afterwards
referred, I’rofessor Virchow admitted that the “remedy”
acts in a remarkably selective way upon tuberculous
tissue, leading to its rapid necrosis, preceded and accom¬
panied by inflammatory hyp8r{Bmia and exudation. That
which is so strikingly shown in the local reaction pro¬
duced by the injections in cases of lupus and articular
tubercle does undoubtedly occur in the deeper parts of the
body. Some of these changes have been so marked as to
astonish even one of the wide pathological experience of
Professor ViRCiiOW. Naturally, but little opportunity
is afforded of observing the hypertemio swelling after
death, owing partly to the time that has generally elapsed
between the discontinuance of the injections and death, and
partly to the transient character of the phenomenon. We
mostly judge post mortem of hypercemia by its effects, bub
occasionally the vascular engorgement and distension are so
marked as to leave no doubt of its presence. Professor
Virchow was struck by the extremely congested state of
the cerebral membranes and brain substance in the fatal
case of tubercular meningitis that had been treated by the
injections; and he has noted also undue vascularity and
even haemorrhagic infiltration in the walla of phthisical
cavities, or actual haemorrhago into the cavity itself. Loss
equivocal evidence of the specific power of the fluid may,
however, be found in the very marked indications
of inflammatory action around ulcerated areas and in the
contiguous lymphatic glands. The degree of inflammatory
“reaction” is sometimes such as to merit the term
“phlegmonous,” and it is associated with distinct leuco-
cytosis. These anatomical descriptions tally precisely with
the conditions observed in skin and mucous membranes
during life, and the liability to grave laryngeal complica¬
tion from the use of the remedy in tubercular disease of
that organ was early pointed out. f-
The greatest interest attaches to Professor Virchow’s
statements concerning the condition of the lungs in cases of
phthisis treated by the injections. This is a matter
which from the first has riveted attention, and fears were
early expressed on all sides lest in dealing with so complex
a structure as the lung the reactive changes might lead to
grave symptoms or possibly to extension of the disease. It
is notorious that our methods of physical diagnosis, how¬
ever carefully applied, are not of such exactitude or nicety
as to inform ua of the precise changes that are going on in
the lungs ; and, indeed, that they are sometimes liable to
lead to erroneous conclusions concerning the actual compara¬
tive extent of excavation and consolidation. Surprise is
excited, in reading the records of some of the cases of
phthisis treated by Koch’s method, at the scanty amount
of evidence of a local reaction in the affected lung as
contrasted with that observed in other regions. But there
have not been wanting cases in which not only has no good
resulted from the treatment, but in which physical examina¬
tion has pointed to a distinct advance of the disease.
Professor ViRCHOW’s careful study of the lesions met with
post mortem throws much light upon such cases. He finds
a remarkable tendency to an undue extension of caseous
and of catarrhal pneumonia. One case exhibited most
extensive tracts of “caseous hepatisation” in the lower
lobes, although when the treatment commenced there were
only signs of limited induration at one apex, and several
other cases showed similar changes to a less marked
extent. The type of “catarrhal” pneumonia, which also
extensively prevailed in some cases, was notable for the
fluidity of the alveolar contents, differing in this respect
from what is usually observed in phthisis, and for being more
widely diffused throughout the lung. Ordinary croupous
pneumonia did not occur, at least in a simple form. These
pneumonic changes are indeed part of the natural history
of phthisis, and it might be contended that the injections
had nothing to do with their production, such peculiarities
as were noted by Professor Virchow being not so specifi¬
cally distinct as to base thereon an affirmation of any
relationship to the treatment. Nevertheless, there is
nothing improbable in the views enunciated by that
eminent pathologist. The “remedy,” which acts by causing
disintegration of tuberculous tissue, may conceivably set
free so much material which cannot he got rid of in the
ordinary way; and the infection of the lower lobes, although
paralleled in many cases of phthisis apart from any use of
the “remedy,” is, under these circumstances, most likely
(indeed we might say “most certain”) to supervene. It
will be difficult to explain away these facts, which empha*
Digitized by
Google
i52 The Lakcet,]
DISEASES OF THE RESPIEATORV ORGANS.
[.^AN. 17,1891.
sue the necessity for careful selection of cases submitted to
treatment.
There remains, however, another, and even graver, danger
in the use of the remedy, the possibility of which has been
suggested since the time of Professor Koch's declaration
that the bacilli themselves are unaffected by the action
of the remedy. We mean the risk of disturbing a localised
tubercular focus, and setting free the virus to disseminate
tubercle in other parts. There is no mistaking Professor
Virchow’s opinion on this head. Ho adduces evidence of
c[uite recent miliary tuberculosis in serous membranes and
elsewhere in cases treated by the injections to show that
such dissemination may have arisen from the disturbance
of old foci. He seems to consider that the appear¬
ance of fresh tubercles on the larynx or other mucous
surface is not due, as suggested, to the diagnostic
powers of the remedy, but to its having initiated
fresh infection. Some of the examples he cites—e.g,,
of recent tubercles in the serous surface opposite to in¬
testinal ulcers—are less convincing than others, since they
are among the ordinary concomitants of the local process ;
but pericardial tubercle is rare enough, and its existence in
two cases is a curious coincidence, if nothing more. The
risks of intestinal perforation from rapid necrotic action in
tubercular ulcers must also be borne in mind.
It is, of course, possible to assert that the important
facts adduced by Professor Virchow have no relation to the
injections of Kocii’s remedy, since they are in harmony with
the known progress of the disease. But when we remember
that this fluid has been shown to have such powerful disin¬
tegrating action upon tuberculous tissues in other parts of
the body, and also that such action in the lungs would
explain the appearances detailed by Professor Virchow, it
seems almost idle to dismiss the notion that the lesions are
consequent on the remedy. • Does it therefore follow that
the remedy is useless, and should forthwith be discarded?
Surely not, for it conhrms its power for good as well as for
evil, whilst it emphasises the need for the greatest circum¬
spection in its use, in selection of individual cases based not
only upon the stage of the disease, but also on the general
strength of the patient. It suggests too the inadvisability of
using it in chronic and quiescent cases on the one hand, and
in the actively progressive on the other. Altogether it tends
to limit very much its applicability to pulmonary phthisis.
But we are not prepared to say, from the evidence so far
offered, that it will have to pass into the limbo of other less
worthy “ cures of consumption.”
Since the above was written wo learn that Professor
Virchow continued hie statement at the meeting of the
Society on the 14tb, and that in the debate which fol¬
lowed Drs. A. Fraenkel and Bahinsky related cases in
which the disease extended whilst under the treatment,
thus confirming Professor Virchow’s statement. However,
Dr. Guttmann was able to adduce other instances in
which the improvement was so marked as to leave no
doubt of the efficacy of the remedy in some cases. Pro¬
fessor Virchow, in closing the discussion, remarked that
he did not question its powers, but only desired to M’am
against its indiscriminate employment. We note too with
satisfaction that the ** secret ” of the nature of the remedy
has at length been divulged. Thus, then, we may look for¬
ward witli increased hope for the future of the remedy, in
ampler knowledge of its nature, and of its effects on tlie
human body ; and believe that, although its scope may be
more limited than has been imagined, it will be of the greatest
service in the treatment of tubercular diseases, when applied
under suitable conditions in carefully selected cases.
In our annual bills of mortality respiratory diseases
occupy one of the most prominent places. If we take the
Registrar-General’s returns for England and Wales for the
ten years 1871-80, we find that the deaths from all causes
amounted to 21-27 per 1000, and that of this mortality 2-12
was attributable to'phthisis, and 3-76 to other diseases
of the respiratory organs. It would thus appear
that maladies of the pulmonary organs carry off from
a third to a fourth of our population. The proportion
of deaths from this cause is, as might have been antici¬
pated, higher in the large cities than in the country
districts. Thus in London, during the period already
mentioned, the mortality from phthisis was 2-51 per 1000,
and from other respiratory diseases 4-60 per 1000. As com¬
pared with the previous decade (1861-70), the deaths from
phthisis in England and Wales showed a notable decline—
viz., 359 per 1,000,000 persons living; but, on the other
hand, there was an increased mortality of 308 per 1,000,000
from other respiratory diseases. An analysis of the rates
of mortality at the various ages would seem to show that
this difference is not to he accounted for on the supposition
of the transference of deaths from one heading to the other,
as at first sight might be suspected, but that the decline in
one case and the increase in the other are real and bond-Jido.
Of the various diseases Included under the heading of
respiratory diseases our information is the most complete
regarding pneumonia. According to HiRSCii, the deaths
from this affection in London during a period of eight years
amounted to 1-7 per 1000 living. The average for the
British Islands, as for the other countries of the colder
and the temperate latitudes of Europe, is probably about
1 -5 per 1000. Bronchitis is responsible for the major part
of the balance of the mortality from respiratory diseases,
being especially fatal at the extremes of life, and when
assuming the capillary form. The mortality from pleurisy
and from the minor respiratory diseases is relatively small.
It is highly interesting to compare, so far as the very
imperfect statistical data at our command will permit, the
comparative mortality of the British Islands and other
countries from respiratory disease. The widespread idea
that diseases of the respiratory organs are peculiarly fre¬
quent and fatal in this country, is no doubt, on
the whole, correct, but probably our liability in
this regard is somewhat less decided than is generally
believed. As regards phthisis we have ample data. Our
mortality of 2-12 per 1000 from this cause may be compared
with that of Norway, 2-21 per 1000 ; that of Sweden, 3-5
per 1000 5 that of Belgium, 3-5 per 1000; or that of Switzer¬
land, 1’86 per 1000. These figures, which we take from
Hirsch, are approximate only, and a considerable
variation may be observed according to the period
selected for examination, but they bring out clearly
the fact that there is nothing exoeptiqnal in the
Diy....ied by iC
tHB
Diseases tttfi EEsl^ifeAtoIiV oRCAiiS.
t^AN. 17, 1861. 168
mortality from phthiflis in the British Islands. The,
high rate for Belgium and, the low rate for Switzer- i
land are most probably accounted for by the density
of population in the former country and its sparseness in
the latter. Nor is our mortality from pneumonia excep¬
tionally high. The rate for London (1’7 per 1000) is ex¬
ceeded by that of Paris, 2‘5 per 1000 ; that of Brussels, 2’2
per 1000; and that of Hamburg, 2-1 per 1000. On the
other hand, Christiania, Berlin, Geneva, and Boston show
rates varying from 1‘3 to T5 per 1000. It is rather to
those respiratory diseases in the causation of which
exposure and chill play a prominent part, and especially
to bronchitis, that we must look to account for our some¬
what heavy comparative mortality from this group of
affections. This leads us to glance at the etiological
relations of respiratory diseases—a large subject to which
it would not he possible to do justice in a few words. As
regards phthisis, there can be no doubt that the most potent
factor in its causation is overcrowding and the consequent
breathing of vitiated air. The various trades, such as knife-
grinding, earthenware manufacture, cotton and woollen
works, printing, &c., which claim the heaviest mortality
from this cause, have all this point in common—viz., that
they are pursued under mal-hygienic conditions. Other
causes, especially mal-uutrition, and any condition of
general lowered vitality, serve to swell the mortality from
phthisis.
The etiology of pneumonia is a much more difficult
question, and has been the subject of much controversy.
Different authorities make very different estimates of the
proportion of cases that may be fairly attributed to chill.
ZiEMSSEN estimated that of 186 cases only 10 were due to
this cause, whereas other authorities place the proportion
as high as a fourth, or even higher. There can be little
doubt, however, that the great majority of cases of pneu¬
monia are not attributable to atmospheric causes. Lati¬
tude and locality seem to have a very slight influence
in the causation of pneumonia; but, on the other
hand, the influence of season is very decided. Two-
thirds of the cases occurring in Europe are found to arise
during the months from December to May, and only one-
third during the other half of the year. The opinion that
pneumonia is not a simple inflatamation, but a specific
febrile disease, probably of parasitic origin, has steadily
gained ground within the last few years, although the
results of bacteriological research in this matter have been
conflicting and inconclusive. If this view he correct, we
must assume that the cold and variable weather of spring,
which has undoubtedly great influence, acts rather ns a
predisposing condition than as the actual cause.
We are not in much doubt regarding the causation of
bronchitis. In this case the influence of temperature and
moisture is undoubtedly the chief factor, although many
constitutional states operate as powerful predisposing
causes. Bronchitis increases in frequency from the equator
to the poles, and attains its maximum in climates charac¬
terised by frequent and sudden oscillations in temperature
and hygromotric condition. Hence the British Islands
suffer in a notable degree. Exposure and chill probably
play a considerable part in the causation of pleurisy also,
although this has been denied. The view widely held,
especially upon the Continent, that pleurisy is always due
to a specific cause, such as rheumatism, tubercle, or
pymmia, and that exposure is not of itself sufficient to
excite the disease, does not seem a tenable position.
Speaking generally regarding the British Islands, we may
say that of those respiratory diseases traceable to cold and
exposure we have a heavy proportion in our midst ; that to
an affection like pneumonia, whose etiological relations ate
still undetermined, we have no special proclivity; and that,
while the amount of phthisis existing amongst us is ex¬
tremely large, it does not exceed that found among other
dense populations, and that its prevalence is in close con¬
nexion with the habits, occupations, and mode of life of
the people.
There are few more important questions than the pre¬
ventive treatment of respiratory disorders. Much has
already been done in this department, and much more may
yet be accomplished. As regards phthisis, our information
is most encouraging. According to Hirsch, the mortality
from this cause was 3 0 per 1000 during the years 1848-55,
2'5 per 1000 during 1859-69, and 2‘2 per 1000 during
1872-76. This decline, which is corroborated from other
sources of information, is exceedingly satisfactory, and re¬
presents the results of much intelligent work in medical
and sanitary science. As regards the measures for the pre¬
vention of phthisis, the first place must be assigned to the
improvement in the hygienic condition of the dwelling-
houses and workshops of the labouring classes. Perfect
cleanliness, sufficient cubic space per individual, adequate
ventilation, proper drainage, and in general the conditions
of a healthy home, are of prime importance in this
matter. Considerable weight must also be attached to the
provision of a more wholesome and generous dietary for
the poorer classes. The general dissemination of knowledge
regarding the dietetic values of the various food-stuffs, and
a lessened consumption of tea, alcohol, and other stimu¬
lants, might be expected to have a favourable influence.
The drainage of wet soils has been shown to diminish the
phthisis rate. The prevention of the sale of the flesh of
tuberculous animals is an obvious precaution, to which in
this country we have been too long strangely blind.
As regards the prevention of pneumonia, it cannot be
said that much has been done, or that the requisite
measures are very clear. The disease seems often to attack
the typically healthy, so that we cannot feel sure that a
generally improved condition of the public health would
do much to lessen its frequency amongst us. The influence
of cold and exposure is doubtful, but in view of the decided
influence of season we cannot afford to ignore atmospheric
causes. Some cases probably arise by contagion, and wo
can bo on our guard regarding this possibility, and take
measures accordingly.
As regards those cases of bronchitis and pleurisy fairly
attributable to chill, no doubt much might be done to
diminish their number. Attention to clothing, habits,
diet, &c., will be here the chief indications. Many lives
are annually lost among infants and young children by the
neglect to provide them with proper woollen clothing for
all parts of the body, and by the thoughtless exposure of
them to vicissitudes of weather, under the erroneous idea
that by such means the constitution may be “hardened.”
Digitized by Google
154 tHSLAlTOXT,!]
THfi RfiLATlOi; OF lUPUS iTO TUfeEkCUtOSiS.
t^AN. ISM.
In the case of the aged, we should forewarn them that
inflammatory affections of the respiratory organs are
among the accidents especially to be dreaded, and that
the obvious precautionary measures, however irksome,
must be submitted to. By such means, simple as they are,
there is no doubt the amount of respiratory disease
might be very largely diminished, and the general average
of the public he^dth materially raised. Respiratory disease
is not only a heavy item in our general mortality, but it is
an indirect source of much impaired health and diminished
usefulness. Hence efforts put forth to lessen its frequency
amongst ns cannot be too earnest or too unceasing.
Few diseases of the skin have excited so much interest
and attention as lupus vulgaris and the affections cognate
to it either in name or nature. At the present moment this
interest has been intensified, because the influence of
Koch’s fluid upon tissues affected with tubercle bacilli was
in this disease exhibited most remarkably, and the phe*
nomena could be most easily observed. The effect of
Koch’s fluid upon it has been regarded as a conclusive
proof, from the clinical side, of the bacillary origin
of lupus vulgaris, which Koch himself had already
demonstrated on the microscopical side, though the
bacilli were so few and far between as to leave many
observers of large experience still unconvinced. It is not,
therefore, to be wondered that Mr. Hutchinson should
have taken this subject for a series of post-graduate
lectures, and should tread again the path which bis foot¬
steps have so often traversed, each time tiying to do some¬
thing to smooth the way for other travellers; and it is not
without interest for us to learn what effect the new light on
the subject has upon the mind of so able and experienced an
observer.
The lecture before us shows that Mr. Hutchinson still
considers common lupus “ as a variety of inflammation in¬
duced by any one of many local causes of irritation and
Inflammation,” the peculiarity of the inflammation being
due to the special proclivities of the individual, tlie parasite
being at most a secondary phenomenon ; but it is not easy
to gather to what extent he ascribes a modifying iuiluence
to the presence of the bacilli. That this influence is not a
very strong one in his view may be inferred from this obser¬
vation : “If, indeed, it were asked whether the clinical
evidence more favoured the belief of the alliance of lupus
with tuberonloais or with cancer, I am indlned to think that
the reply would have to express hesitation.” A little
further on he says that parts affected by lupus not
infrequently take on cancerous growth, and lie quotes
Dr. Bayha of Tubingen, who had met with four cases of
such a combination in his own practice, and then says: “ I
doubt much if many observers could collect from their own
observations as many as fonr cases of lupus in which the
patients had subsequently succumbed to any form of in¬
ternal tuberculosis.” These are strong statements to make,
and coming from so careful an observer cannot fail to attract
much attention. It is to be hoped, therefore, that in one of
the lectures which are to follow he will give us his own
experience as to the number of cases in which he has
observed cancer associated with lupus. The number of
cases on record is certainly not veiy great, and there is a
remarkable paucity of cases in English literature, most of
them being reported from France or Germany. With regard
to the association of lupus and phthisis, Besnibr observed
it eight times in thirty-eight cases of lupus—i. e., over 20 per
cent. No doubt further observations are desirable on this
point, but we must look for them amongst physicians who
see much of phthisis, rather than from dermatologists, as
when phthisis has set in the lupus becomes a matter of
secondary importance. Even as regards the family
history, Mr. Hutchinson tells us that statistical proofs
fall far short of our general imptessions as to frequency of
the connexion, but that it is otherwise as regards lupus
erythe matosus; but on this head he promises us further
information. Statistics whicli are to upset so completely
the general opinion held on this subject will be awaited
with interest. It is clear, therefore, that Mr. Hutchinson’s
views are not yet materially altered by any facts furnished
by the eflect of Koch’s injection, though he admits
that farther knowledge of it may compel such an altera¬
tion. He concludes his lecture by saying that, seeing
that a considerable group of maladies are inseparably
“associated together in the lupus family, it is probable
that one and all should be regarded as forms of chronic
inf ective inflammation deriving their peculiarities from the
proclivities of the individual attacked and not from specific
elements of contagion.”
Whether we agree with Mr. Hutchinson or not, it is in¬
structive to note that there are still two sides to the ques¬
tion, and although the influence of Koch’s fluid lends a
strong support to the bacillary theory, our experience of it
is at present far too limited to found any pathologically
strong argument upon it. Already we hear of other
diseases, such as leprosy, showing decided reactions after in¬
jections, and Koch himself is of opinion that it is nob
BO much a bacillus destroyer as a destroyer of certain ill-
formed tissues in which the bacillus resides, and if other
imilar tissues, due to the action of other bacilli, break
down after injections of tbe fluid, its diagnostic value is
pro tanto diminished, and we shall still have to discuss the
origin and nature of lupus on the other and older grounds.
Many of the moot points might be cleared up by collective
investigation. If, for example, each of the members of the
Dermatological Society would carefully inquire into the
family history and note the complications of every case of
lupus vulgaris anderythematosuswhich came before them and
c ontribute them to either the secretaries or anyone appointed
by the Society, a sufficient number of cases to afford really
reliable data would soon be collected. Common as lupus
is supposed to be, its frequency is overrated on account of
the chronicity of the disease and the way in which patients
wander from one hospital to snother. Some means, there¬
fore, to prevent the record of a case several times over would
have to be adopted. Again, tbe registrars of consumption
hospitals might be applied to, to furnish the oases of phthisis
and lupus which have occurred during, say, ten years; and,
conversely, they might well inquire whether in any of the
relatives of phthisical patients cases of lupus or other form
of local disease of supposed tubercular origin existed. In*
Digitized by
Google
ThbLanobt,] ‘'CHARITY” CRITICISM OF LONDON AND GUY’S HOSPITALS. [Jan. 17,1891. 165
vestigatioQS on these and similar lines would settle this
nmch-vexed question in a way that would be found impos¬
sible by any individual observer.
- 4 -
Some of our contemporaries who claim to represent
“charity ” are making themselves peculiar by writing very
uncharitably of one or more of London hospitals. Surely in
its Christmas number the Chanty Record could have done
something more helpful to the cause of hospitals than raking
up charges which are still stib judice against such insti¬
tutions as the “ London Hospital.” But the staple food pro¬
vided for the readers of the ''Charity Record Christmas
Appeal Supplement” is a leading article on the alleged
faults of administration of the J^ondon Hospital, especially
with reference to its treatment of nurses; and, secondly, an
article with the sensational and threefold heading: “ The
Scandal of Guy's Hospital: Meant for the Masses-Used for
the Classes. An Appeal to Mr. Gladstone." The chief basis
of these articles is the evidence taken before the Lords’
Committee. This evidence was taken six months since. It
is still under the consideration of the Lords’ Committee.
And Christmas is a season for being
"To their faults a little blind,
And to their virtues very kind.”
We are by no means wishing to say that there should be no
criticism of hospitals. We shall show our contemporary
immediately that we largely share his objections to the
administration of Guy’s Hospital. But we maintain that
such criticisms are queer material out of which to make up
Christmas appeals, and that the more kindly way, as well
as the more just, would have been to accentuate the enor¬
mous amount of good done by these institutions, while
urging that there were Haws and faults in their administra¬
tion. *Our contemporary makes much of the scandal of an
alleged assault at the London Hospital, apparently by a
runaway student, on one of the female patients. He might
have enlarged on the statement of Mr. Buxton, the chair¬
man, that every assistance was being given to the police in
their investigations. He might also have found place-in his
reflections for that statement of Dr. Stekue in regard to such
offences at Guy’s Hospital, that such a charge against a
student had never occurred. Wo never hesitate to criticise
the discipline or administration of hospitals, but we place
their virtues in the forefront, and on the strength of this
feel the freer to point out their faults.
The great faults which our contemporary finds with
Guy’s—and that in his Christmas appeal—that whereas
Guv intended his hospital “ to entertain 400 poor persons
or upwards labouring under any distempers, infirmities, or
disorders thought capable of relief by physic or surgery,”
payment is now exacted of the out-patients, and that
some in-patients pay as much as £3 Ss, and there
are never fewer than from twenty to thirty beds
whose occupants pay £3 3s. a %oeeh: that in the
admission even of out-patients poverty is never inquired
for; and, thirdly, that the hospital is “run” largely in
the interest of the medical school, students, and teachers ;
that £1026 are paid by lady nurse pupils ; and that £10,000
or £12,000 are divided among the medical staff. This is, of
course, a very one-sided statement. Whatever compensa¬
tion the staff of Guy’s Hospital get for their teaching work
we may be sure they earn, and are well deserving of. No
hospital has conferred more benefits on the public and on the
poor by its medical teaching than Guy’s Hospital. The petty
charges to patients, giving them a feeling that they are
paying for their advice and medicines, and thus bringing
the great hospital into competition with the struggling
practitioners of the neighbourhood, is fair subject of severe
complaint. Exception, too, may justly be taken to the
selection of a number of cases without any reference to
the poverty of the patient, and at the discretion of a
medical student. That 3000 midwifery cases a year^hould
be attended gratuitously, of which Dr. Steblb admitted that
many could pay a modest fee to a neighbouring practitioner,
is a matter obviously open to criticism. The scale of the out*
patient department is seen in its proportions, as in other
hospitals, to be careless and demoralising. Finally,
the expropriation of wards meant for the poor for people
that can pay at the rate of 60 guineas, or even 180 guineas,
a year is a violent distortion of the charity. We denounce
these arrangements as much as our contemporary does, and
shall continue to do so until they are altered and abandoned.
And especially we shall continue to condemn the blind and
deaf treatment of all complaints from the outside, even from
those who, like ourselves, realise that a hospital, well used,
! and not abused, is the highest and noblest form of charity.
These faults—we will even say these vices—of hospitals are
so glaring that, save from the point of view of one or
two “ interests,” they cannot be defended, and can
scarcely survive the investigations of the Lords’ Committee.
But let us be careful how, in exposing the faults of hos¬
pitals, we damage the charity which should sustain them
for their high uses—and sustain them generously; and let
us not pick out one or two hospitals as if they were greater
sinners than the rest. If Guy’s Hospital has too large an
out-patient department, St. Bartholomew’s Hospital has
one three times as large—150,000! If the London Hospital
has been somewhat niggardly in its provision of nurses and
for nurses, it has had much excuse for being so, in the
enormous responsibilities of its committee and in the scant
provision by the public for its wants. It has had to do the
work of St. Bartholomew’s Hospital and of Guy’s Hospital,
and, moreover, without their splendid properties. Let
those who are so ready to blame the committee take some
blame to themselves for not sending more generous sub¬
scriptions and immediately give this form to their criticism.
Finally, let the authorities of hospitals take warning in
time, and eliminate from their work all abuses, and espe¬
cially those appertaining to the Out-patient Department.
^nnolatwns.
“ Ne quid nlmlg.'*
THE COLLEGE OF SURGEONS’ LIBRARY.
As we stated in our issue of last week, it has been decided
by the Council of the Royal College of Surgeons to keep the
library open until? I'.m. in the future. This resolution was
arrived at after a consideration of a report by the librarian
on the evening of opening the library. This report was
briefly as follows:—“In compliance with the resolution of
council the library has been open to readers during the year
Digitized by ^OOQ C
156 Thb Lakost,]
THE HAMBURG HOSPIPALS.
[Jan. 17,1891.
1890 on each week day, except Saturday, from 11 A.M. to
8 P.>r.,witb the exception of tire months of August and
September; during August the library was closed at 6 P.M.,
and was shut altogether in September. In the past year the
library was open on 274 days; the number of readers for
that period was 10,040, or an average of over 36 for each
day, including Saturdays. The library was open on 214
evenings. At 6 p.m. (the old time for closing) 1813 readers
were at work and 402 entered after that hour; this gives a
total of 2215 evening readers, or an average of just over 10
each time the library was open. No note was taken of
readersinat 7 p.m. during the early part of the year, but they
have been carefnlly registered since March I2bh; after
that date the library was open at 7 on 164 evenings, and
the total number of readers then present was 543, or an
average of about three each evening. Very few visitors
have remained until 8 P.M.” To those of our readers who
only remember this library under its old conditions, the
change indicated by the above extract will come as a
surprise. Those going to read at the College library may
be certain of a comfortable well-warmed and well-lighted
room, and the help of the librarian, Mr. James £. Bailey,
or his assistants, should it be required. To Mr. Bailey’s
suggestions many of the improvements are due, and to his
tact and management we owe the present state of efficiency
of what is rapidly becoming the model library of London.
HISTOLOGICAL CHANGES IN THE TISSUES
AFTER INJECTIONS OF KOCH’S FLUID.
Although many papers have already appeared upon the
clinical aspect of Koch's treatment of tuberculosis, very
little is as yet known of the changes which take place in
the affected tissues. Dr. Browicz of Korakow has made
some investigations in regard to this point, and his results
are published in the Ccntralblatt fur die Medicinischm
WissenscJiafien, 1891, No. 1. The first case examined was
that of a girl aged eight, suffering from caries of the left
metacarpus and elbow. There were some fistulous openings
leading to the dead bone, which diacbarged a small
quantity of thin pus. The edges of the sinuses were pale.
Six milligrammes of the liquid were given, with the result
that there was a well-marked reaction, with local pain, and
considerable redness and swelling around the neigh¬
bourhood of the siniises; brownish crusts soon commenced
to form. Sixteen hours after the injection a small piece
of tissue was removed from the circumference of one of
the sinuses and submitted to careful microscopical examina¬
tion. It was first placed in alcohol, when a small piece of the
scab floated off; under the microscope this exhibited
epithelial scales and numerous leucocytes. Sections cut from
the original specimen showed the following characteristics.
The epidermal layer contained numerous leucocytes, which
were partially distributed between the epidermal cells and
were partially collected in groups, these being largest in
the most superficial layers. On the surface these gave the
appearance of small vesicles, in many places they bad
given way, and the contents had escaped; in other places
the cells of the epidermis had been detached and heaped
together, enclosing leucocytes in their interstices. In such
situations the epidermis presented very much the same
appearances as in a small-pox vesicle. The capillaries
were also crowded with leucocytes. In the deeper layers
of the skin a copious infiltration of small round cells
was again to be seen, sometimes so thick as to almost
hide the tubercular nature of the disease. Here and
there the tissue had broken down, so that small abscesses
were formed. Numerous small hmmorrhagic patches
were noticed, the structure of the tissue being quite
obscured. Specimens taken from another patient presented
similar appearances, and the same have been described by
Israel and Kromeyer. Dr. Browicz draws the following
conclusions1. That the changes occurring in tuber-
culous tissues after an injection of Koch’s liquid are diffe¬
rent from the necroses which usually accompany them.
2. Thata specific form of inflammation is induced. 3. That
this may assunve a htemorrhagic form. 4. That, finally, the
inflammation results in the destruction of the tuberculous
tissue, and that this result is due to a distinct chemical
action. Dr. Browicz considers that the tubercle bacilli may
either be carried away by the exudation which is poured
out, or else, if the disease is deeply seated, there is great
danger of the organism being carried by the blood stream to
healthy tissues, so setting up local or general tuberculosis.
THE HAMBURG HOSPITALS.
A VOLUMINOU.S report of the Hamburg Hospitals for the
year 1889 has recently been published, which, from the
minute statistics and the numerous monographs on impor¬
tant subjects included in it, is a very valuable work. It is
a good deal larger than the annual report of any of our
London hospitals, but then it deals, not with one establish¬
ment alone, but with the whole hospital system of a great
city. This comprises four distinct hospitals 1. The old
general hospital, originally built about 1820, and containing
at the present time 110 wards and 1409 beds. 2. The new
general hospital in Eppendorf, a suburb between three and
four miles from the centre of the city. This splendid
building, which was only opened in 1889, is on the pavilion
system, there being no lees than seventy-three one¬
storeyed buildings, all separated from one another, and
containing 224 wards with 1340 beds. 3. The seaman’s
hospital, near the St. Paul’s landing stage, with sixty beds.
4. The Priedrichsherg lunatic asylum, accommodating 1282
insane patients. The first of the reports is by Dr. Schultz
on the enteric fever cases in 1886 and 1887, amounting to 3686.
The number of tlrese cases in the hospitals is always greatest
in winter and spring; indeed, the variations according to
the months of the year were almost exactly the same as
those recorded by Murchison in the statistics of the I^ndon
Fever Hospital. There is an instructive section on the
immunity conferred by enteric fever against a subsequent
attack, mth regard to which the Hamburg experience
seems to have been pretty similar to that of Freundlich,
Goth, and others—that is to say, 2 ’4 per cent, of the patients
contrf^cted the disease a second time, and one man certainly
had it three times, and probably even four times. The
time intervening between the first and second attacks was
very various, in a few cases being as little as nine months
and in two about forty years. The mortality in 1886 was
11 '5 per cent, and in 1887 only 6’8 per cent.
SANITARY MATTERS IN BUENOS AYRES.
Thio council or consultative committee of the public
medical service of Buenos Ayres has commenced a monthly
periodical in which will be recorded a large amount of
information which comes under the notice of the medical
and sanitary officials, and which has hitherto been, as a
rule, lost to the scientific world in general, even Argentine
medical men being, as is remarked in the introduction,
much better acquainted with the medical climatology of
Europe than with that of their own country. In the first
number of the Antdes, just received, there is a paper by
Dr. Castailo on the Treatment of Syphilis in the Hospital
of San Roque, from which we learn that, instead of follow¬
ing the plan now so much in favour in some continental
syphilitic clinics of injecting mercurials subcutaneously, he
prefers to bring the system under the influence of the drug
by administering pills. The pill he most approves is composed
of protiodide of mercury ^ gr., iodoform !5- gr., crystallised
sulphate of iron 5 gr-> extract of opium gr-j made
„. Coogle
The Lancet,!
AN UNEXPECTED CAUSE OF PUERPEKAL FEVER.
[Jan. 17,1891. 167
up with extract of gentian. Two of these are given
daily, and of 600 cases so treated scarcely any instances
of salivation occurred. An improvement was always
evident after a week, and in a month all external mani-
tfestatioDs of the disease had generally disappeared. In
grave cases, with rupia or ecthyma, and where there are
?arge ulcerated surfaces, a similar pill with double the
quantity of green iodide and of iodoform is prescribed.
Mercurial inunctions are only ordered in cerebral forms.
As adjuncts to mercurial treatment Turkish baths are
•ordered. Dr. Castaflo remarks that he has had several
•opportunities of observing cases where patients who had
contracted the disease in warm climates, and had while
there only presented slight symptoms, on coming into a
colder place, such as Buenos Ayres, immediately experi¬
enced a serious aggravation. From another paper in the
flame number of the journal we learn that in the previous
month (October, 1890) no less than fifty-two women
were inscribed on the prostitutes’ register, and that more
than 5000 inspections had been made, with the result
that sixty-four women had been found diseased, and sent
by the authoriliea of what is euphemistically styled “the
Sanitary Dispensary” to the sifilocomio, or lock hospital.
5t is sad to think that, in a city whose population is under
half a million, girls are passing the line officially drawn
jTOund those who make vice a profession at the rate of about
<twelve a week. In connexion with this it is noteworthy
that the officials of the National Vigilance Society have for
«ome time been aware that a very large trade is being
carried on in European girls for the purposes of prostitution
un Buenos Ayres. Great legal difficnlties have been found
in checking this, though something has been done in the
way of warning innocent girls decoyed across the Atlantic
by false pretences, and means are taken where possible to
save them from the terrible form of white slavery for which
they are intended. _
AN UNEXPECTED CAUSE OF PUERPERAL FEVER.
FROii'ESSOK Pauamucju has reported a case of puerperal
fever in which a very unexpected cause was brought to
'light—that is to say, the putrid remains of a tapeworm in
4he uterus. No untoward symptoms seem to have occurred
until the tenth day after delivery, when the patient became
feverish and prostrate, and lost her appetite. The locbial
secretion was very foul. Large doses of quinine were
ordered, but no effect was produced on the temperature,
which the next day was 104-2". The uterus was conse¬
quently washed out, two catheters being used for the
purpose, as a regular uterine instrument was not at hand.
The outlet catheter, after discharging some very fetid fluid,
was choked up by what was found to be a putrid tapeworm.
This was of course removed and sublimate irrigations given,
and the symptoms soon disappeared. Regarding the ques¬
tion of how the tapeworm came to be in the uterus, inquiries
■elicited the fact that a few days before her confinement the
patient had been suflering from dysenteric symptoms, and,
in view of her condition, had nob taken any medicine. It is
probable that the worm managed to migrate after delivery
from the rectum to the vagina, and that there it died and
became putrid. _
METROPOLITAN ASYLUMS BOARD.
Till', return,s submitted to the Metropolitan Asylums
Board on Saturday last afford satisfactoi-y evidence of the
•continued decrease of infections fevers in the metropolis.
In the fortnight ended Jan. 3rd there were 406 cases of
^!carlet fever notified, being a decrease of 123 upon the
numbers of the preceding return, and 190 cases of diph¬
theria, being a reduction of 77. The admissions of fever
patients into the Board’s hospital were 2'i9, or (i under the
preceding fortnight; and the number under treatment on
the night of Jan. 8tb was 1837, including the convalescents
in the Northern and Gore Farm Hospitals. Of the
total cases, 1528 were scarlet fever, being 145 under the
preceding return, and there were 151 cases of diphtheria,
being a reduction of 1 only. There were beds ready for 818
patients, 617 being for scarlet fever. In consequence of the
satisfactory reduction in the admissions and in the number
of cases under treatment, it was decided to discontinue
sending convalescents to the Gore Farm Hospital. Onecase
of small-pox was admitted into the South-Eastern Hospital
and transferred from it to the Small pox Hospital ships at
Darenth.
A SCARLATINOID RASH AFTER A SMALL
DOSE OF QUININE.
Professor Glax of Abbazia, writing in the Medicinisch-
Chirurgische Rundschau, reports a case of soarlatinifoim
eruption following not on large doses of quinine, which is
nob a very exceptional occurrence, bub upon a small dose,
one grain and a half, combined with three grains of caffeine
prescribed for migraine. This combination had been taken
night and morning by the patient, who was an otherwise
healthy middle-aged woman, for some days with great
benefit, when one morning, as the medicine had been for¬
gotten before, she took it immediately after breakfast,
which consisted of a cup of tea and some melon. Ten
minutes afterwards a severe attack of vomiting came on,
and she had a rigor and a rise of teifiperature, the whole
surface of the skin being covered with a scarlatinoid erup¬
tion 5 the throat too was very red and swallowing painful;
some of thejoints were painful to the touch, and thepatient
bad all the appearance of one with scarlatinoid rheumatic
Jever (polyarthritis scarlatinosa). In a few hours thewhole
of the symptoms disappeared. Caffeine is generally con¬
sidered an antidote to quinine, and as the same powder had
been taken with impunity for some days previously the
affection could hardly have been due entirely to it. The
same may be said of the melon, which had also been taken
for breakfast the previous days.
OPERATION FOR GRAVES’ DISEASE.
Dr. Lencke of Hamburg, in the last number of the
Dmtsvhe Med. Wochenschr., discusses the subject of exoph-
thalouc goitre with special reference to its treatment. He
claims that as the treatment of this condition by medicine
is remarkable for nothing eo much as its inefficacy, if the
surgeon can offer even a chance of relief his interference is
justifiable, and he relates two cases in which surgical
interference seems to have had the best results. The
first patient was a lad of seventeen, who had the classical
symptoms of the disease—rapid heart, palpitation, pro¬
minence of the eyes, and goitre. He came under treatment
on account of a sudden access of the swelling, which by the
pressure it exerted produced great distress with extreme
cyanosis. The heart was rapid and irregular, no rest
or sleep could be obtained, and the patient was in
imminent danger of asphyxia. Tracheotomy was per¬
formed, and a week later one-half of the tumour was-
extirpated. The operation was accompanied by much
hamiorrhage, which, however, stopped spontaneously, and
recovery was uninterrupted. The symptoms rapidly
vanished, the exophthalmos disappearing, and the heart
becoming quiet and regular in action. The improvement
was maintained until the time at which the paper was
written. Operation was undertaken in the second case,
\-^hich had long been under observation, because of the good
result in the first. The patient in this case was older, the
symptoms were similar, and the operation was the same
The improvement was also very marked, and the patient
Digitized t; Lioogle
158 ThbL4N0BT,] the reconstitution of the university of LONDON.
[Jak. 17, 1891.
four mouths ago was able to resume bis occupation. It is
yet too early to estimate the full value of the procedure
adopted, as regards cure of the disease ; but if relief can be
afforded in other cases as great as was apparently obtained
in those just related, a strong case will have been made out
for the surgical treatment of this distressing malady.
THE RECONSTITUTION OF THE UNIVERSITY
OF LONDON.
The Special Committee of the Senate of the University of
London were engaged on Wednesday, the 14th inst., on
the consideration of their latest scheme, which will include
representatives of the provincial colleges on the Senate
and in the Faculties. The Councils of University and
King’s Colleges will, we understand, wait until the details
of the new scheme are before them, and will then determine
how far these will affect their position in the reconstituted
University. The new scheme will also be laid before the
Royal Colleges after it has been passed by the Senate.
MODEL BY-LAWS UNDER THE PUBLIC
HEALTH ACT, 1890.
Messrs. Knight and Co., the well-known publishers of
Local Government literature, and whose Annotated Model
By-laws on a number of subjects affecting public health
already constitute a standard work for sanitary authorities
and their officers, have wasted no time in the issue of such
by-laws as can be made under the Public Health Act of
last session. Indeed, they are in advance of the Local
Government Board themselves, who have not yet published
any model code relating to these matters. In one sense the
help thus afforded to sanitary authorities will be consider¬
able, for some definite idea is given as to the methods by
which the several matters can be properly regulated. Bat,
on the other hand, it will have to be remembered that,
unlike the other model by-laws, they are not yet supported
by precedent, and they may nob all stand the test of official
criticism at Whitehall. Some of the matters to which
the new codes relate have a direct and important bearing on
health, and they are such as must soon come under tbu
cognisance of authorities and their officers. Thus, certain
by-laws may now be made as to streets and buildings which
were formerly not possible, the height of rooms may be regu¬
lated, scavenging arrangements may be better controlled,
and the flashing of closets may be more effectually enforced.
As a skeleton guide for carrying into effect these and other
provisions the new issue will be of material value.
THE NAILS IN NEURITIS.
Modifications of the normal appearance of the nails
are present under various morbid conditions. Often a
serious illness leaves its mark in a peculiar modification of
nail growth, apparently corresponding to the period during
which the disease exerted its most powerful effect. This
peculiarity is usually manifested as a band, varying in
length with the duration of the illness, in which the
normal appearance and colour of the nails are changed.
»Sach a condition is seen inuring fevers and after injuries of
nerves. A more general modification of the appearance of
the nails occurs also in such conditions as those of Raynaud’s
disease—a disease in which, whatever the ultimate explana¬
tion of its phenomena may be, there are evidences of pro¬
found trophic disturbance. In such a disease as multiple
neuritis changes in the nails were to be expected, and
in the Neurolog. Cmtralhl, No. 24, 1890, Bielschowsky de¬
scribes such a cose recently under his observation, in which
nail changes were a marked feature. The case was one
characterised by the usual signs and symptoms of peripheral
neuritis-—viz., weakness, wasting, tenderness of nerve
trunks, and absence of reflexes, with changes in the elec¬
trical reactions. The change which is described occurred
in the finger-nails only, the toe-nails being unaffected^,
although the neuritis was present in the lower limbs. There
were observed at first small white points in all the finger¬
nails. These occurred simultaneously, and gradually ex¬
tended both in length and breadth, until a white band over
a milUmebre in breadth was formed, dividing the normal
substance above from that below. As the nails gradually
grew those bands were pushed to the periphery, and
were finally removed and examined with the microscope.
Examination seemed to show that the discoloration was
due to the presence of air, and that the condition was thus
similar to M'hat is found in hair which has become grey or
white.
CHOLERA IN TRIPOLI.
Dr. F. J. MACKINNON of Beyrout writes under date^
Dec. Slst, 1890: “According to official information)168 deaths
from cholera occurred in Tripoli from Dec. 8th to Dec. 2l8t.
The attack now seems to be dying out, no new attack
having taken place within the last twenty-four hours.
The latest information states that the disease has now
broken out at Nebk, sixteen hours due north of Damascus.”'
THE REGISTRATION OF TRAINED NURSES.
The simple bub important ceremony which took place
last week in the rooms of the Royal Medical and Chi-
rurgical Society, and which is reported in another column,,
marks a new departure which is of the highest interest to
medical men nob only in this country but throughout the
civilised world. Every year the value of skilled nursing in
the treatment of disease becomes more universally reco¬
gnised, and every year larger numbers of educated gentle¬
women are adopting the calling, and pursuing it as earnestly
as their brothers study and work ab medicine, law, or
divinity. It has consequently become increasingly essential
that nurses should be organised and controlled by some
professional authority. Our readers are aware that front
the inception of the British Nurses’ Association we have
strongly supported and advocated its proposal bo in¬
stitute a register of trained nurses, upon which only
the names of those who bad obtained a thorough hos¬
pital training could be placed, and from which the names of
any who proved themselves untrustworthy could be removed ;
because it is unhappily notorious that until now any
woman, even if “destitute of knowledge or of character, or
of both, has been able, if she so pleased, to term herself a
trained nurse, and to obtain work in that capacity.
On the other hand, instances are unfortunately not few
where women holding the certificates of leading Iiospitale
have been convicted of crime; and yet, owing bo the
absence of any body responsible for their control, have had
no difficulty in obtaining work upon emergence froni
prison. The British Nurses’ Association, founded just
three years ago, immediately obtained the invaluable
assistance of Her Royal Highness Princess Christian as
its president, and at once commenced to organise nurses,
and to inquire as to the best methods of carrying out ita
scheme of registration. In spite of difficulties and opposi¬
tion, the Association, and especially its chief workers,
have steadfastly pursued their way, and now have suc¬
cessfully commenced the system by the publication of tbo
first Annual Register of Trained Nurses. It contains
the names of more than 1700 women, the great majority of
whom have evidently undergone a thorough hospital train¬
ing. "We venture to congratulate her Royal Highness
Princess Christian on this eminently useful work in which
she has taken so large a share, and which will always be
Digitized by i^ooQle
The Langbt,]
AUDITORY CENTRE.
[Jan. 17,1891. 159
connected with her natue. The advantage to the public at
large and to the sick, of the richer classes in particular,
of thus being able to discover es^sily and with certainty
whether their attendant is a trained nurse or not, will be
great. But to a medical man such knowledge of a new
worker, obtained perhaps from a strange institution, will be
invaluable. And for the first time too he will be able to
-report a nurse who has proved herself to be entirely un¬
trustworthy to a tribunal as impartial as powerful to pro¬
tect the public against such women by removing their
■names from the register. We would call the attention of
our readers throughout the country to this register, and
ioT their own sakes and that of their patients ask them to
accord it their cordial support. If every medical man would
purchase a copy of the register, and only employ nurses
who were registered, who therefore were attested as efiicient
ond under complete professional control, nearly all the
nursing difficulties which have occurred in the past would
be rendered impossible in the future.
AUDITORY CENTRE
In i\xQ Journal of Anatomy and Physiology an interest¬
ing case in connexion with the localisation of the centre for
hearing is somewhat briefly reported by Dr. Ferguson of
Toronto. The patient had suffered for eight years from
chronic inflammation affecting the right ear. This resulted
in deafness on this side for sounds conducted through the air,
but perosseous conduction, although considerably impaired,
was still present. Two years ago the patient began to suffer
#rom what are described as symptoms of a tumour of the
right temporo-sphenoidal region, among which were sub¬
jective auditory sensations referred to the left side. The
hearing on this side became gradually impaired, and during
the last six months of his life there was complete deafness
affecting both sides, although he continued to have subjective
auditory sensations referred to the left ear. The necropsy
revealed, as was expected, a large tumour involving the right
temporo-sphenoidal lobe, the superior convolution being
completely destroyed, while the second was also affected.
The case is an extremely important one, conflrming as it
<doe8 the results arrived at by experiments on monkeys, and
it is to be hoped that an account of it will be forthcoming
which will go a little more into details than does that to
which reference has been made.
AN ATTEMPT ON THE DIGNITY OF THE
PROFESSION.
A LAY contemporary has circulated amongst the medical
men in London a “card” intimating that it has instituted
a series of special articles entitled “ Medicoes under the
Microscope,” with the idea that “the effect will be
'that of a guide to the leading medical men of the
metropolis which will steer the ‘neophyte’ clear of
incompetent or semi-incompetent men” into the con¬
sulting-room of those men whom the very much inexpe¬
rienced journal is delighted to honour. “Physicians,
surgeons, specialists, and general practitioners will be
noted in their correct order.” The first on the card is
f^ir Andrew Clark, President of the Royal College of
Physicians. Some time ago a “lady” consulted Sir
Andrew Clark with reference to some medical ailment,
and, being about to leave, gave him a fee with the intimation
that he might hear something of that interview on a future
■occasion. Some time afterwards one of the “cards” in
-question reached him, and we have authority for saying
that within an hour of its receipt the matter had been
referred to his solicitor. Counsel’s opinion was taken, and
the editor of the journal was desired to refrain from pub¬
lishing any such article. The editor, however, declined abso¬
lutely to accede to the request, and stated that the matter
was ready for the press, and would forthwith be pub¬
lished. Leaving for a moment the strictly legal aspects of
the case, we would advise those of our readers who
have received copies of the “card” in question to send
without delay to the editor a registered letter abso¬
lutely forbidding the insertion of any article whatever
referring to them, seeing that such publications, con¬
taining as they do most erroneous and ridiculous state¬
ments, are calculated to do immense harm. Here is one
illustration of our conteoaporary’s incapacity for seriously
judging of either medical men or medical matters : In his
younger days at the London Hospital it used be a
reproach that Andrew Clark was never to be met with in
the post-mortem room, that he never verified his diagnosis.
Time taught the cavillers that it was unnecessaiy—
he never made a mistake.” We need hardly remind our
readers that Sir Andrew Clark was for thirteen years
pathologist at the London Hospital! This is only the com¬
mencement of the series, and we earnestly trust that,
the matter having been brought under the notice of
those responsible for the conduct of the journal in question,
they will see the propriety, notwithstanding their announce¬
ment, of refraining from publishing any more records of
this nature. We know that such effusions are extremely
distasteful to all medical men concerned, and to *’he younger
members of the profession it is possible much harm may
be wrought by persisting in ther publication.
IODINE INJECTIONS IN TUBERCULOSIS.
Dr's. Heneage Gibbes of Michigan and E. L. Shirley of
Detroit, who hold to the old dogtrine that pulmonary phthisis
is distinct from tuberculosis, or rather that many cases of
phthisis are non-tubercular {Amer, Jour. Med. Sci., 1890),
have been making experiments upon the best means for
depriving phthisical sputa of their infectivity {Med. News,
Dec. 27). Chlorine was an agent which, mixed with
sputum, rendered it harmless when inoculated in the
guinea-pig; but its therapeutic use was out of the question.
They then found that iodine and iodide of potassium in
solution with glycerine and water could, when injected
into guinea-pigs, protect them from inoculation; and
that the same property was possessed by the chloride of
gold and sodium. They have applied this treatment to the
human subject, using iVgr. of iodine with Vugr. to ^^gf- of
the gold and sodium salt as a hypodermic injection; or
commencing with the iodine alone (slightly increasing the
dose) and substituting for it the gold and sodium salt if not
well borne. About twenty-five cases of phthisis have been
so treated, the results being such as to encourage their
further use of the plan; but we’prefer to await fuller
details before judging the value of the treatment.
LIFE ASSURANCE AND THE MEDICAL
PRCFESSION.
A LETTEii from Mr. James Chatham, an actuary having
many qualifications for the exercise of his profession,
gives the results of what has evidently been a very
painstaking inquiry into the death-rate of medical
practitioners, with the view of showing that the pro¬
fession is nob entitled bo claim reduced premium rates
from life offices on the ground of exceptionally favourable
mortality. Our correspondent is no doubt correct as to the
figures which he gives, and which we are quite prepared to
accept on his authority. But be is mistaken in supposing
that they will appear very startling to our readers. It is
perfectly well understood by medical practitioners that
their vocation is one that promotes the health of
the community at the expense of their own, and we
Dig-ii/ed by oogle
160 The Lancet,]
“TRAUMATIC NEUROSES. "
Jan. 17,1891.
thought that this had been quite clearly expressed in the
editorial comments which prefaced our Life Assurance
Supplement on Nov. 15th last. We then wrote : “ Speak¬
ing generally, it may be said that the broad result of the
communications which we have received is to show that
Life Offices, for the most part, are not prepared to concede
rednced rates to medical men. In this we readily
acquiesce. Some of our correspondents have insisted
upon the arduous and risky nature of a medical prac¬
titioner’s duties. We are by no means desirous to
shut our eyes to the fact. We think that it would he
very unwise on the part of any Life Assurance Office to
assume that medical men may be expected to enjoy a
lighter mortality rate than that which befals the average
policyholder.” Mr. Chatham’s researches do not seem
to have carried him much beyond this point. He does,
indeed, refine to the extent of proving that the lives of
medical practitioners are worse than those of a more or
less selected body of men like the persons assured
in Life Offices, to an extent represented by an addition of
one-half of one per centum to the annual premium. But
then Mr. Chatham’s material seems to have been somewhat
casually collected, for we observe that the greatest deviation
from the normal standard that he sets up occurs among
“physicians &;c.” of the tender age of twenty years. Of
course, these young gentlemen may have been excellent
substitutes for medical practitioners, but there is a statutable
difficulty in the way of their recognition as being of that
body while still under age. Mr. Chatham’s figures would
have been more impressive if they bad not betrayed at this
point the inclusion among his data of facts which cannot
possibly have any bearing on the mortality of medical
practitioners. ’
“TRAUMATIC NEUROSES.’’
Tins is a convenient term, but, like other terms which
are convenient, it is apt to include far too much. In this
country the most important traumatic neurosis which is
met with is no doubt the so-called “ railway spine,” and it
may be that cases placed in this category are as varied as
those which Hoffmann {Berlin. Klin. Woch., No. 29) found
among a series of twenty-four cases of “ traumatic
neurosis.” Of those twenty-four ten were found to have
undoubted signs of organic mischief ; in six the symptoms
were partly the result of exaggeration and partly of simu¬
lation ; in eight there was malingering, proved to be so
after careful observation for several weeks. The author
protests against the use of the term for such varied condi¬
tions, pointing out that in a so-called traumatic neurosis
we may have to deal with organic nerve injury, with
hysteria, the result of.injury, with shock to the cerebro¬
spinal system, with neurasthenia, or even with a true
psychosis.
THE HEALTH OF SOUTHEND.
Dr. Thresh has submitted his report on the serious pre¬
valence of enteric fever in Southend to the Local Board of
that town, and he lias arrived at the conclusion that the
disease has nob been brought about by any accidental con¬
tamination either of water or of milk, but that it is due to
the defective and inadequate system of sewers of the town.
The immediate effect of such a conclusion as this should be
the employment of an engineering expert to prepare an
exhaustive report on all the details of the existing system
in so far as structural points are concerned, and we some¬
what regret to observe a tendency towards piecemeal work
instead of much more coraprebensive action. Already it
has been decided, first, to go bo work at one end of the
defective system by altering the outfalls j and, secondly, to
do some work along the mains by increasing the amount
of ventilation. Another step has been taken which we
hardly like to criticise, and yet is one which, if carried
out now, is almost certain to be upset when the imme¬
diate panic is over. It is the appointment of a medical
officer of health for Southend who shall devote his whole
time to his duties, and who shall receive £300 a year. As
to this, we would observe that the annual remuneration
offered ought to be regarded as insufficient to cover
the services of a professional man who gives his whole
time to the authority, and who is competent to perform pro¬
perly the technical duties of a health officer. Then, again,
Southend had in 1881 less than 8000 resident population,
and though it is crowded by visitors during a brief space
in the summer, yet we haidly see how a medica] officer of
health could, when once Southend has put itself in order,
occupy his whole time in dealing with such a town, unlese
indeed he were expected to do work which should nob
attach bo his office. If Southend would join an Essex com¬
bination a first-class officer could probably be obtained on a
permanent footing.
THE ROYAL COMMISSION ON TUBERCULOSIS,
This Commission has been meeting regularly during the-
last few months, and much evidence from experts andl
clinical physicians bearing on the matters referred has been
collected. It has now been decided to pursue the inquiry
in a different direction by a careful examination into the
various systems of meat and milk inspection abroad, by the
collection of statistics bearing on the subject, and probably
by the initiation of further researches of an experimentaJ
nature, to settle some of the doubtful points concerning 'the
degree of infeebivity of the products of tuberculous animals.
TYPHOID FEVER IN FLORENCE.
An Italian correspondent writes :—“ The decrease in the
daily number of cases progresses steadily, while the incidence
of the fever is confined almost entirely to the Italian popu¬
lation, and in that to the leas favoured class. On the
lObli inst. official rebutns were issued up to the 8bh insb.,
the mean number on the 5bh inst. being 49 per diem, and
on the 8bh 33 per diem. So that, if in the first twenty-one
days of the epidemic the mean of the cases reported was-
as I bo every 4000 of the inhabitants, the mean has now
fallen to 1 in every 6000. Notwithstanding this progressive
decrease, the sanitary authorities have provided for every
possible contingency, leaving open for the reception of case®
of typhoid fever those wards in the hospital hitherto occupied
by chronic or incurable patients, for whose accomraodation
certain pavilions of the old Manicomio of Bonifazio have
been set apart. Concurrently with these measures, pre¬
ventive precautions have been energetically adopted, and th&
Amminisfcrazione Comunale, commencing from bo-day (12th
inst,), will distribute to every applicant a sufficient quantity
of the acqua fotahiU boiled. Stations for the serving out
of this drinking water have already been established!
in every quarter of the town, while official directions for
boiling and filtering the water, with appliances for the?
process, are also available for all who wish tlie same. The
distribution of acqxia potabile from the tainted source has.'
been absolutely closed, and if typhoid fever continue to de¬
clare itself its origin must be different from that to which
it has hitlierto been officially traced. In schools for Italiarip
children, in barracks for soldiers, and among domestic
servants—among those classes of the community which,
more Jtalico, are huddled together in confined spaces, where
the want of fuel and heating is made up for by closeness of
contact and exclusion of fresh air~ib is in these that the
greatest number of cases has occurred. Among the English-
speaking residents hardly a single case—certainly nob a
single death—has been reported. Nor is there the slightest
Digi: zed by
Google
Thb Lancet,]
THE LATE PROFESSOR MARSHALL.
[Jan. 17,1891. 161
care sufficient to deter new comers. On the contrary, the
hotels and pensions are adding to their inmates in sucii
numbers as to give promise of as crowded and as brilliant
a season as has lately been known in the City of Flowers.”
THE LATE PROFESSOR MARSHALL.
At the monthly meeting on Monday last of the Council
of the Sanitary Assurance Association, .'5, Argyll-place,
Regent-street, W., Sir Joseph Fayrer, M.D., F.R.S., the
President, in the chair, a vote of condolence and sympathy
was passed on the death of Professor John Marshall, F.R.S.,
a member of the Honorary Council. It may be here men¬
tioned that to the honours stated in our last as having been
gained by Professor Marshall should he added the honorary
degree of M.D. of Trinity College, Dublin, and that of
Master of Surgery of the Royal University.
TIPPLING IN THE CITY.
The City Press of Jan. .3rd says that the pernicious habit
of tippling seems on the increase in the City. Our con¬
temporary says that at all hours of the day, at frequent
intervals, young and middle-aged men of splendid physique,
strong mental capacity, and sound judgment on all points
hut one—viz , the habit engendered by falsely called hos¬
pitality of drinking at odd hours—are to he observed pass¬
ing in and out of the City public-houses and wine stores.
This is a most disappointing and distressing statement.
We should have hesitated to repeat it, or aid its circulation,
had it appeared in any journal less likely to be correctly
informed of what goes on in the City. Rather we should
have said that City men were alive to the advance of
science and common sense, which alike dictate that tippling
is disastrous to both health and business. We were aware,
of course, that there were soakers in the Ciby—men satu¬
rated with alcohol, and even young men—bub that such
should be on the increase surprises us. Can there not be
some City movement, apart from the austerities of teeto-
talism, to remedy this great evil, and to discourage drink¬
ing “ whenever a stroke of business ” is attempted or done ?
Such drinking is a veritable delusion, as our contemporary
suggests, and all sane men should discountenance it. It is
thought that some who would nob think of such practices
for themselves connive at them in their agents on business
grounds. There is little distinction in morals between a
drinker and one who allows another to drink for the good of
his business. _
THE DISCONTINUANCE OF MUZZLING.
A SIGNIFICANT protest against the withdrawal of the
muzzling order has just been issued by the Society for the
Prevention of Hydrophobia. It expresses at once briefly
and very plainly the reasons which had invested the now
obsolete and naturally somewhat odious regulation with
the sanction of popular tolerance, and had enlisted the
support of many gentlemen of known intelligence whose
names it hears. It reminds us that both in 1886 and 1890
the use of the muzzle was followed by the apparently
complete suppression of rabies. Freedom from this
restraint during the intervening period was associated
with a marked recurrence of the disease, and ib is to
he feared that 1891 will witness a similar return. We are
also reminded that collar registration, as practised on
the Continent and at Bradford, has proved an inefi'ectual
safeguard. Its future success among ourselves is therefore at
best doubtful. Secondary advantages attained by the muzzle,
such as the prevention of dog fights and indiscriminate feed¬
ing, have not been forgotten in the circular above .mentioned.
We must admit that our own sympathies are with the
framers of this memorial. A period of three or four months’
immunity within the metropolis is certainly [inadequate as
an assurance that hydrophobia has been exterminated. Yet
thelast quarter of the past year can alone show this happy
condition—a direct result in all natural probability of the
muzzling order. During the last quarter of 1890, eleven
eases were reported in the provinces. We must therefore
express our own regret that this useful measure has been so-
early dispensed with, and join the Society in advising that
it be resumed for a further period, and he made general in
its application. Mr. Chaplin objects to this latter proposal
on the following grounds. He maintains that it would not
suffice to guarantee protection unless the importation of
suspected dogs were prohibited, and also that the more
limited system has thus far worked successfully. Sis
argument, however, only suggests the still greater success
to be expected from a general order, which would virtually
constitute a form of quarantine.
DEATH OF DR. GEORGE GULLIVER.
We regret to announce the decease of Mr. George-
Gulliver, M.A., M.B. Oxford, F.R.C.P., who died of acute
pneunionia on Sunday last at his residence, 16, Welbeck-
street, Cavendiali-square. He was senior assistant physician,
lecturer on comparative anatomy, and demonstrator of
morbid anatomy at St. Thomas’s Hospital, and physiciaxn
to the London Fever Hospital. He was the only son of the-
lato George Gulliver, E,R.S., the well-known naturalist,
who was professor of anatomy and physiology at the Royal
College of Surgeons, and surgeon to the Horse Guards. A
fuller account of the late Dr. Gulliver’s medical career wilB
be given in our next issue.
FROZEN WATER-PIPES.
Those householders who aspire to the luxury of a hot
and cold water system have during the recent severe frosts-
had to undergo in many instances a series of severe shocks-
to their nervous system through the repeated scares caused
by frozen pipes. The principles of sanitary engineering,,
as applied to the domestic water system in our houses, are-
either so imperfectly understood or the elementary prin¬
ciples of hydrostatics, as applied to our domestic require¬
ments, are so entirely ignored, that even in an ordinary frost-
considerable inconvenience and danger arise from the almosb
inevitable frozen pipes. During such prolonged and severe-
frost as we have recently had this troublehas necessarily beea
greatly aggravated. Many a household has been suddenly de¬
prived of their water-supply, and have been obliged to borrow'
or beg even the water for drinking purposes from their more
fortunate neighbours. Apart from the inconvenience, the
shock to the nervous system of the cook, who has been re¬
peatedly instructed what to do in case the supply to her
kitchen boiler should be found, in the early morning, to-
have been cut off by a frozen supply pipe; the still greater
shock to the master and mistress of the household
when an earlier tap than usual at their bedroom door
rouses them to hear the unwelcome news that there is-
no hot water and no cold water, and that the cook ia
so frightened at the noise the pipes are making she does-
not know what to do. There is actually very grave-
danger in such defects in our domestic arrangements. The
kitchen boiler may actually burst and explode with fatal;
violence, and such occurrences are matters of actual iact-
Yet all this is avoidable by the simple observation of the
most elementary principles of sanitary engineering a&
applied to water-supply. Every workman ought to be-
educated in these elementary principles, and every master of
workmen engaged in business connected with sanitation or
water-supply should be held responsible and rendered liable
for any damage resulting from defects of workmanship or
faulty construction.
Di-jiLized by Google
1.62 The Lancet,] THE KEGISTRAR-GENERAL’S FIFTY-SECOND ANNUAL REPORT. [Jan. 17, 1891.
FOREIGN UNIVERSITY INTELLIGENCE.
Berlin .—The title of Professor has been conferred on Dr.
Burchardb, privat-doccnt in Ophthalmology.
Breslau. —Dr. Wernicke has been promoted to the Pro¬
fessorship of Mental Diseases.
Erlangen. —Dr. Joseph von Gerlach is retiring from the
active duties of the chair of Anatomy, and Dr. Leo Gerlach
has been appointed Professor of Anatomy and Director of
'the Anatomical Institute.
Salle .—Professor von Mebring of Strasburg has been
appointed to the chair of Medicine.
Kiinigslterg .—The chair of Zoology and Comparative
Anatomy has been offered to Dr. M. Braun, professor of
'the same subjects in the University of Rostock.
Lausanne. —The University, which is, in fact, the ancient
“Academy" greatly improved, is now in working condi¬
tion. The medical faculty, which was formerly represented
hy a few professors, and which was only a section of the
faculty of science, has recently been converted into a com¬
plete and independent faculty. The total number of pro¬
fessors and lecturers in all the faculties is now sixty-six.
The language of all except the law lectures is French.
Leyden. —Dr. Nolen of Rotterdam has been appointed
Professor of Internal Pathology and Pharmacodynamics, in
succession to Dr. Huet, who has resigned.
Rostock —Dr. Martius of Berlin has been appointed Pro¬
fessor of Internal Medicine.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
M. Vhd'ao\iQT,profes8evr agrtgC in the Montpellier Faculty of
Medicine; Dr. Gori, docent in Military Surgery in the Uni¬
versity of Amsterdam ; Dr. Grimm of Teplitz, in his seventy-
'ointb year; Dr, Lucca of Marienbad, in his eighty-ninth
year; Dr. Szokalski, formerly Professor of Ophthalmology
in Warsaw; Dr. Santiago Lopez, Professor of Medical
Pathology in Granada; and Dr. Borelli, Lecturer in the
Medical School of Turin and Senator of the Kingdom of
Italy.
The analysis of 167 samples of water collected by the
^examiners during the past month shows that, excepting two
samples, which were recorded as “ very slightly turbid,"
•all were found to be clear, bright, and well filtered. The
seasonal variation in the composition of the water supplied
to the metropolis, for the most part too slight to constitute
a variation in character, has, with the coming on of winter,
to be looked for and taken note of. As regards the November
supply, however, the less favourable meteorological con-
■ditions prevailing during the month, including occasional
•periods of frost, were not found to have any significant
•effect on the analytical results obtained. Both absolutely,
and still more in relation to the season, these results were
■entirely satisfactory._
At the celebration of the twenty-fifth anniversary of the
.foundation of the Society of the Friends of Science in Posen,
•the Medical Section elected Professor Koch, Sir Joseph
Xister, and M. Pasteur honorary members.
The British Medical Association will meet this year at
Bournemouth.
Measles at Worthing.—O wing to the great
prevalence of measles at Worthing, the Town Council, on
the recommendation of the medical officer of health, has
addressed a communication to the various school managers
/>f the town, requesting them to close their schools for a
lortnight.
THE REGISTRAE-GENERAL’S FIFTY-SECOND
ANNUAL REPORT.
The Registrar-General of Births, Marriages, and Deaths
in England and Wales has just issued his fifty-second
annual report dealing with the vital statistics for the year
1889. Nearly ten years having elapsed since the last
census, considerable difficulty inevitably arises in estima¬
ting the number of the population on which the rates of
births, marriages, and deaths should be calculated. It is
well known that it has long been the practice of the
Registrar-General’s department to assume that the rate
of increase which prevailed during the last completed
intercensal period has since been maintained, and it
has often been pointed out that in so large an area as
England and Wales, or even as the metropolis, this method
supplies very approximately accurate estimates. It is
povutecl out in the present report that by adding to the
enumerated population in 1881 the excess of births over
deaths that occurred between that date and the middle of
1889, the population of England and Wales would become
29,041,753; whereas by the official method the estimate is
29,015,613. In order that this estimate should be correct,
it would follow that the balance between immigration and
emigration during this period of eight years and a quarter
resulted in a loss to the population of only 26,145 persons.
Before another annual report of the Registrar-General will
be due, the results of the census in April next will be known,
and will give a far more assured value to the Registrar-
General’s figures. In the meantime, however, there is no
good ground for suspecting that the rates published in the
report now issued are to any serious extent affected by
the extent of error in the estimated population adopted as
their basis.
The English marriage-rate in 1839 was 14-7 per 1000 of
the estimated population. This rate exceeded the low rates
in the four preceding years, which ranged between 14-1
and 14'4, but was lower than the rate in 1884, when it was
1.5'0. The increase in the maniage-rate last year was very
slight in London, whilst it was largest in Northumber¬
land, Westmorland, Bedfordshire, and Monmouthshire.
Simultaneously with the increase of the marriage-
rate last year there was a further increase in the
ratio both of exports and of imports {affording evidence of
increased employment of labour), and also a further marked
decline in the price of wheat, which was considerably lower
than in any of the preceding thirty years. The birth-rate
in 1889 fell to 30'5 per 1000, and was lower than in any
other of the fifty years 1840-89. The English birth-rate
reached its maximum (34'6) in 1876, since which it has con¬
tinuously and steadily declined to the 30'5 in 1889. The
local birth-rates ranged in 1889 from 24'7 in Rutlandshire,
24'8 in North Wales, and 25'0 in Sussex, to33-8 in Stafford¬
shire, 33'9 in Durham, 35 0 in Essex, and 36 8 in Monmouth¬
shire. These wide variations may, however, be partly due
to inaccuracy in the estimates of the local populations on
which the rates are calculated. The proportion of illegiti¬
macy, whether measured in relation to total births or to
population, corresponded with that recorded in the previous
year, but with this exception was the lowest on record ; 4-6
per cent, of the registered births were recorded as illegiti¬
mate.
The registered deatlis in 1889 were equal to 17'9 per 1000
of the estimated population, against 17’8 in 1888 ; the rates
in these two years were considerably lower than the rate
recorded in any previous year on record. The nearest
approach to it was in the immediately preceding year 1887,
when the rate was 18-8. The Registrar-General calls
especial notice to the remarkable fact that “in each of the
nine years of the current decennium (1881-89) the English
death-rate has been under 20 0, whereas in no previous year
had it ever fallen so low as that point." The county
rates ranged from 13‘7 and 14'0 in Sussex and Surrey
(extra metropolitan) to 20-3 in Monmouthshire, 20-9 in
Northumberland, and 21 0 in Lancashire. The death-rate
of males was 18-8, and that of females 16'9 per 1000 living
of each sex, these rates being respectively 8‘3 and 77
f er cent, below the average rates in the preceding ten years.
D equal numbers living of each sex, there were in 1889
1113 deaths of males to 1000 deaths of females, the excess
in the rate of male mortality being below the average. The
, ^oogic
Dig;u.:ed b'
The Lancet,]
BRITISH NURSES’ ASSOCIATION.
[Jan. 17,1891. lea
death-rates both of males and of females were in 1889 the
lowest on record at each age period between five and forty-
five years, and although the same cannot be said as regards
children under five years, or for persons aged over forty-five
years, the rates were at these age periods considerably
below the average rates in recent years. The report furnishes
some interesting and suggestive statistics bearing upon the
relative rates of mortality in subdivisions of the first year of
life, to which we shall on occasion refer. We shall also defer to
another opportunity notice of that portion of the report
dealing with the causes of death in England and Wales in
1889, and more especially of a further interesting contri¬
bution to the valuable statistics of cancer mortality which
recent annual reports of the Registrar-General have from
time to time furnished.
BRITISH NURSES’ ASSOCIATION.
On Friday, the 9th inst., a meeting of the General
Council of the British Nurses’ Association was held at
20, Hanover-square, under the presidency of H. R. H. Princess
Christian.
The report for the past year was submitted by the
Secretary, from which it appears that the Association has
made considerable progress, the number of trained nurses
now on the books being 2919, as against 1679 at the end of
the previous year. It was stated that the pensions for
nurses which are being established would be called the
“ Princess Helena pensions for nurses,” out of compliment
to the Royal patron of the Society. The first Register of
trained nurses would be ready for circulation in about a
month’s time.
Sir William Savory, the chairman of tbe Executive
Committee, then, addressing the Princess Christian, said:
“Your Royal Highness is not only the head of this Associa¬
tion, but you have taken a warm personal interest in the
work and given a very large share of thought and care to
it. How shall 1 express the sense of courage and devotion
with which your Royal Highness was pleased to come
forward and help our Association when it was yet compara¬
tively unknown, and struggling iu the face of much
active opposition and misrepresentation?” Sir William
Savory then presented her Royal Highness with the first
copy of the first Register of Trained Nurses.
The Princess Christian, in reply, said: Sir William
Savory, I am afraid you have said a great deal too much in
my praise. I can only say that my whole heart is in this
work, and anything 1 can do to further ic will only be my
pride and my pleasure.
Sir Richard Quain moved a resolution thanking her
Royal Highness for the great personal interest which she
liaa taken in the Association.
Sir Dyce Duckworth seconded the motion, which was
unanimously carried.
A vote of thanks was given to Sir William Savory for his
services as Chairman to the Executive Committee, on
the motion of Sir E. Sieveking, seconded by the Princess
Christian, and the proceedings terminated.
DEMONSTRATIONS OF DR KOCH’S TREAT¬
MENT IN LONDON.
PROGRESS OF THE CASES.
(Continued/romp. lOii, uoZ. i. 1591.)
City q/ London Hospital for Diseases of the Chest.
In the previous report it was mentioned that three of the
cases now being treated by Dr. Heron at the City of London
Hospital for Diseases of the Chest, Victoria-park, were
about to leave that hospital aud enter a convalescent home.
It was stated that Dr. Heron thought that “in a few weeks
any assurance office would accept them as first-class lives.”
These, however, were not his exact words, and convey an
erroneous impression, lieferring to the case of H. B. (No. 3
below), he said : “ This case, as I find it now, is one which,
so far as physical signs are concerned, and without refer¬
ence to any previous history, might very well pass as a
first-class life for an insurance office.”
Dr. Wethered, who is still investigating the action of
the remedy, has asked us to state, with reference to our
last report, that he did not mean to imply that phthisis^
was a disease absolutely irremediable Iw all known
means, but simply that its treatment by Koch’s method
lent an additional ray of hope to a successful terminatiooi
of the malady. The cases were shown to a great number
of medical men on Monday evening. The following i8<
a complete synopsis of the three cases :—
Case 1.—G. M-, a naval shipwright aged twenty-
three, was admitted to the hospital on Oct. 28tb, 1890;
with no family history of phthisis. The patient was healthy
until five years ago, when he had a fever. Five months ago-
in Cyprus he had an attack of remittent fever, whiej^
invaliaed him for two months. He was sent to MaltC
and there be was discovered to be suffering from phthisis,,
in consequence of which he was invalided from th©^
service. When admitted to the hospital his cough was very
troublesome and his breath short, hut night sweats, hemo¬
ptysis, and pains in the chest were absent, and tubercle'
bacilli were numerous in his sputum. The percussion not©'
over the left front was much impaired, and crepitations-
were abundant over the upper half of the lung, but more
sparse over the lower portion. He has received thirty eight
injections, the last fourteen of which were doses of O'l co.—
i. e., 100 milligrammes. Only once, however, had he any
reaction from even so large a dose, and that might have-
occurred in any person wnether tubercular or not. The
injections have been administered in a portion of skia
measuring 6 inches by 4, and there is no tenderness or irri¬
tation of any kind over that region. The patient has now
greatly improved in appearance, and his sputum has become
less purulent. His cough has much- improved, but there
are occasional paroxysms. His breathing shows marked
improvement, and he can walk all the way from the grounds
up stairs to the ward without resting. His appetite
is very fair. The percussion note over the whole of the leftr
front is markedly impaired. The impairment is especially
pronounced over the upper half of the lung. Numerous
crepitations are audible in the left front, some of which are-
distinctly moist in character, while others are dry. No-
rilles are audible over the right'lung. He has gained 3 lb.
in weight since undergoing tbe treatment, and he has ex¬
pressed the opinion that, “so far as he could tell, the treat¬
ment has done him more good than the ordinary treatment
which he formerly underwent.”
Case 2.— A. D-, a dock labourer forty years of age,
was admitted into the hospital on Nov. 27th, 1890. His-
father and mother died of phthisis. Until four years ago
he enjoyed good liealth, and was then attacked witb
“winter cough.” Twelve months ago his cough became
very troubltsoine and was accompanied by considerable'
expectoration and pain below the right clavicle. His
night sweats have lasted for two months, and be has bad'
slight attacks of hremoptysis His breathing had'
been very much impaired for four months before
his admission to the hospital, and tubercle bacilli were-
found in large numbers in his sputa. Iu front marked’
impairment is found over the right apex, and numerous
moist sounds are to be detected as low as the level'
of the nipple The same physical signs can be made-
out posteiiorly. The left lung is resonant through¬
out, and there were no adventitious sounds. He Iras'
undergone the whole course of treatment recommended,
and has had eleven decigramme doses without pro¬
ducing any reaction whatever. The twelfth injection-
produced a reaction, which, however, was said to be purelyf
physiological in its nature. The sputum during the firsts,
week measured 2 oz , the second week l^o/ , the third week
1 OZ-, the fourth ^ oz , the fifth \ oz , and for the last three-
or four days it only measured from 2 to 3 drms. Occasionali'
night sweats appeared during the first and second weeks
since then they have been entirely absent. Tbe cough,
at first most troublesome, has gradually improved, and
there are now many days when the cough is entirely
absent. His appetite has been very good for the last four
weeks, and he has gained weight to tne extent of 10 Ib. Oii')
Tuesday evening there was found to be practically no altera¬
tion in dulness elicited by tho percussion note, an observa¬
tion which would apply to all cases in the hospital witb
the exception of tlie one following. On auscultation no sign®
were found excepting some moist sounds underneath tho
Dig]../ed "OO^Ic
161 The Lancbt,]
BRITISH MEDICAL BENEVOLENT FUND.
[Jan. 17,1891.
righb clavicle on coughing, the rest'of the chest being per¬
fectly clear. The breathing was harsh oyer the whole of
the chest, nrosv markedly so on the right side.
Case 3.—H. B-, a general servant aged twenty-eight,
was admitted to the hospital on Oct. 28th, 1890. Her
father, mother, and two uncles had died of phthisis.
The patient is very ansemic, and has had troublesome cough
and night sweats for the last few weeks. There was an
-attack of hfomopbysis and winter cough about two
yeaxs ago. Gastric symptoms and vomiting have been
present during the lest six weeks. Regarding the
5 )hysical signs on admission, a systolic hremie murmur
was audible. Over the upper portion of the right
5uDg a considerable degree of bronchial breathing could
be heard. Posteriorly a few rfiles could be heard over
•the supra-scapular region after coughing. Over a consider¬
able area of the left lung crepitations after cough could be
anade out. Before the injections the sputum was consider¬
able in amount, and of a muco-pnrulent nature, containing
a few bacilli. Atropine was administered to check the
night sweats, and the weight of the patient on Nov. 22Qd,
1890, was 8st. Between Dee. 27th, 1890, and Jan. 7bh,
1891, the patient has had administered 1100 milligrammes of
theii'iid. She has taken almost daily doses of a decigramme.
On Dec. lOth her weight was 7 st. 121b., although mean¬
time her appetite had much improved, and the night sweats
had disappeared. The sputum diminished in quantity, and
the patient’s general condition improved, until, on Deo.
■27th, the moist sounds had disappeared from the lungs and
the tubercle bacilli from the sputum. The sputum itself
had then become almost all mucus, and was very scanty.
■The weight increased to Sat. 31b., and the catamenia ap¬
peared for the first time in six months. On Jan. 12th
the cough had almost disappeared, the weight was
then Sat. 4ilb., and the patient had a good appetite
aid felt well. Crepitations reappeared over the left front.
The signs, however, are apt to change their character
from time to time, more especially towards the end of the
treatment, when they are becomingfewerin number. Thus,
rilles may be heard at an examination made within a few
fiiours of the time when they were found to be absent at the
:3ame point.
BKITISH MEDICAL BENEVOLENT FUND.
The annual general meeting of subscribers to this Fund
■was held at 34, Seymour-street, Portman-square, W., the
ffesidence of the treasurer, at 4 r.M. on Tuesday, Jan. 13bb,
when Sir James Paget, Bart., F.R.S., President, occupied
■the chair. The treasurer’s financial statement and the
report of the committee were submitted to the meetiDg.
'From them it appeared that £1208 18s. 6rf. in subscriptions,
•and £.076 13.s. 3d. in donations, an increase of £33 over the
:same item last year, together £1785 11s. Od., had been
received in the donation departments, and £1768 10s. had
been voted in grants to 159 applicants. In the annuity
•department fifteen new annuitants have been elected,
making a total of eighty-five. Six of these being medical
men have the £20 annuity raised to £26 from the special
•fund dedicated to that purpose. The eighty-five an¬
nuitants absorbed £1617 13s. 4c^. Investments to the
-amount of .£9114 8s. 2c^. have been effected, and the income
resulting will afford a means of materially lightening the
burden upon the grant department, by allowing for a large
increase in the number of annuitants. One bequest alone,
that of tbe late Mr. Chapman, obtained for the Fund by the
personal influence of Dr. Cooper Rose, has already produced
£12,300; £1000 has been received from the estate of the
•late Miss Ling, £100 from Mr. C. Pooley of Cheltenham,
and £90 from Miss Anne Hadfield Rae. The working
•expenses have been kept in the same ratio as before to the
income and expenditure, tbe heaviest item being that for
the printing and distribution of the report. The committee
was then reappointed, and Sir Andrew Clark, Bart., Dr.
Cooper Rose, and Mr. Thomas Smith were elected vice-
jiresidents. The officers were re-elected, and votes of
thanks given to tbe auditors, Messrs. Parker Young and
Kiallmark, to tbe treasurer and honorary secretaries, and
to tbe medical press for their valuable services.
A proposal made by Dr. Urqubart, honorary local secre¬
tary for Perth, having reference to the place for holding the
annual meeting, was considered, but the subscribers present
were unable to agree with the proposal. A very cordial
vote of thanks to the president, Sir James Paget, for hie
invaluable services to the Fund, and for his kindness in
taking the chair, terminated the proceedings.
The committee wish to bring prominently before the pro¬
fession the characteristics of the Fund, which, intended for
qualified medical men and their families, extends imme¬
diate help to applicants properly recommended, without
any publicity or canvassing, and is worked upon the most
economical principles, all tlie officers, with the exception of
the collector, giving their services gratuitously. Subscrip¬
tions may be sent to the treasurer or to the non. financial
secretary. Dr. Sidney Phillips, 62, UpperBerkeley-street, W.
LOCAL GOVERNMENT DEPARTMENT.
EBPORTS OP INSPECTOBS OP THE MEDICAL DEPARTMENT
OF THE LOCAL GOVERNMENT BOARD.
On Scarlatina in the Rural District, by Mr. Spear.
During the first nine months of 1890 there were 181
attacks of scarlatina, with 31 deaths; and of these, 81 and
21 respectively occurred at Coedfrano, where the principal
interest of the epidemic centred. The number of cases
was ascertained by means of the adoption throughout the
year of the system of compulsory notification, and the
results indicate how meaningless such adoption is by some
authorities. Had the Act been compulsory the attitude to
be noticed might have been intelligible ; but why sanitary
authorities want to preface their inaction by an endeavour
to learn facts calling for activity it is difficult to say. Any¬
how, this rural sanitary authority required notification from
the beginning of 1890 ; they learned month by month how
scarlatina was increasing in their midst, until in July no less
than 59 attacks were recorded ; they watched the disease on
to the end of theyear,and here their action practically ended.
As Mr. Spear reports, no disinfecting work was adopted
that is worthy of the name ; no proper means of isolation
I were carried out; the schools which were adding materially
to the diffusion of the disease were not interfered with;
in fact, “the notification certificates received were simply
filed.” This attitude is, however, not special to notifica¬
tion. Thus, when the sanitary circumstances of Coedfrano .
came to be looked into, they were found to be deplorable.
Houses were unfit for habitation by reason of dampness,
dilapidation, and want of ventilation; and there was also
overcrowding. In one tenement, for example, the storm
water welled up through tbe floor and formed a pool
beneath the beds, and here a child had recently died from
scarlatina. Mr. Spear seems to have met the authority and
to liave given them <lefinite advice as to the action needed
under three headings ; but the result does not as yet look
very promising. Under the first two headings the surveyor
was instructed to “report,” and under the third one the
clerk was requested to “report.” It is to be hoped that
something more than mere reporting will bo done, and that
the authority will deal with the grave nuisances they have
allowed to grow up around them, and will also in the future
make some proper effort to control infectious disease when
they hear it is prevailing in their midst.
On the Sanitary Condition and Administration of the
Pembroke Rural District, by Mr. Si’EAH. — This report
contains but little that is of interest beyond the confines
of the area to ivhich it more directly applies. The visit
in question was the third paid by the medical staff of the
Local Government Board, and yet we learn that the
authority have practically delegated their powers to a
sanitary committee which has so limited a sense of its
responsibility as only to meet four times a year. Even
with special meetings the average only comes up to six
annually. Hence one place where the defective sanitary
state is made obvious to all by reason of its well-nigh
“intolerable stench” is stated to have remained as it is for
years; and a detail is given of abounding nuisances
of the grosser sort. Speaking of the village of Jamestown,
Mr. Spear says that “ in its general state of filthiness ” and
in other allied respects it finds its counterpart in the village
Digiti.<ed by Lioogle
The Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Jan. 17,1891. 165
of St. Florence. And amoDgst the conctusionB at which he
arrives is the fundamental one that if the sanitary authority
intend to do their duty towards their constituents they
must meet sufliciently often to indicate soma interest in their
work and to supervise the labours of their officers. One of the
most unfortunate results of constituting poor-law guardians
the sanitary authorities for unions has been the maintained
attitude of indifference which some of these bodies show to
sanitary as opposed to poor-law work, and this seems to be
one of the instances in point.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6247 births
and 6304 deaths were registered during the week ending
Jan. lOtb. The annual rate of mortality in these towns,
which had increased from 21-3 to 28-7 per 1000 in the pre¬
ceding four weeks, declined last week to 28*1. The rate
was 29'1 in London and 27’3 in the twenty-seven pro¬
vincial towns. During last quarter the death-rate in the
twenty-eight towns was 22-1 per 1000, and exceeded by 1-1
the mean rate in the corresponding periods of the ten years
1880-89. The lowest rates in these towns last week
were 15'7 .in Derby, 18'8 in Nottingham, 20 2 in Hull,
and 21*2 in Huddersfield; the highest rates were
32-9 in Newcastle-upon-Tyne, 33‘9 in Birkenhead, 35'5
in Manchester, and 39 8 in Preston. The deaths
referred to the principal zymotic diseases, which had
been 472 and 476 in the preceding two weeks, further
rose lost week to 485; they included 183 from measles,
1.34 from whooping-cough, 64 from scarlet fever, 46 from
diphtheria, 40 from diarrhcoa, 28 from “ fever” (principally
enteric), and not one from stnall-pox. The lowest death-
rates from these diseases were recorded in Wolverhampton,
Derby, Hull, andCardiff; the highest iuBirkenhead, Halifax,
Bolton, and Preston. The greatest mortality from measles
occurred in Oldham, Huddersfield, Bristol, Birkenhead,
Halifax, Preston, and Bolton; from scarlet fever in Ply¬
mouth ; from whooping-cough iu Preston, Halifax, and Nor¬
wich ; and from “fever” in Halifax. The 46 deaths from diph¬
theria included 28 in London, 3 in Norwich, and 3 in Man¬
chester. No death from small-pox was registered in any of the
twenty-eight towns ; one smaJl-pox patient was under treat¬
ment in theMetropoli tan'Asylum Hospitals, butnot one in the
Higbgate Sraall-pox Hospital on Saturday last. The number
of scarlet fever patients in the Metropolitan Asylum Hos¬
pitals and in the London Fever Hospital at the end of
last week was 1524, against numbers declining from 2122
to 1593 on the preceding nine Saturdays; the patients
admitted, during the week were 92, against 78 and 107 in
the previous two weeks. Tlie deaths referred to the
diseases of the respiratory organs in London, which had
increased in the preceding six weeks from 375 to 927,
farther rose last week to 991, and exceeded the corrected
average by 408. The causes of 126, or 2‘3 per cent., of the
deaths in the twenty-eight towns were not certified either
by a registered medical practitioner or by a coroner. All
the causes of death were duly certified in Norwich, Wolver¬
hampton, Sunderland, and in three other smaller towns.
The largest proportions of uncertified deaths were recorded
in Shelfield, Liverpool, Leicester, and Brighton.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had increased from 20‘1 to 24‘8 per 1000 in the pre¬
ceding four weelcs, further rose to 28‘8 during the week
ending Jan. 10th, and was 07 per 1000 above the rate that
prevailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns ranged
from 19'4 in Dundee and 20'0 in Edinburgh, to 347 in
Paisley and 391 in Glasgow. The 7-55 deaths in these
eight towns showed an increase of 112 upon the number
in the preceding week, and included 19 which were re¬
ferred to whooping-cough, 15 to measles, 13 to diarrhcoa,
8 to scarlet fever, 8 to “fever” (principally enteric), 6 to
diphtheria, and not one to small-pox. In all, 68 deaths
resulted from these principal zymotic diseases, against 70
and 65 in the preceding two weeks. These 68 deaths were
equal to an annual rate of 2'G per 1000, which slightly
Exceeded the mean rate last week from the same diseases in
the twenty-eight English towns. The fatal cases of whoop¬
ing-cough, which had been 22 in each of the preceding two
weeks, declined last week to 19, of which 12 occurred in
Glasgow and 3 in Edinburgh. The 15 deaths from measles ex¬
ceeded by 3 the number in the previous week; 8 were recorded
in Greenock and 7 in Glasgow The fatal cases of “fever,’'
which had increased from 6 to 14 in the preceding three weeks,
declined last week to 8, of which 3 occurred in EdinburgH
and 3 in Leith. The 8 deaths referred to scarlet fever showed
an increase of 4 upon the number in the previous week,
and included 4 in Glasgow and 2 in Aberdeen. The fatal'
cases of diphtheria, which had been 9 and 6 in the preced¬
ing two weeks, further declined to 5 last week, all of-
which occurred in Glasgow. The deaths referred to diseasee
of the respiratory organs in the eight towns, which had'
increased m the four previous weeks from 137 to 191,
further rose to 240 last week, but only slightly exceeded! .
the number in the corresponding week of last year. The>
causes of 65, or nearly 9 per cent, of the deaths in the-*^
eight towns last week were not certified.
HEALTH OP DUBLIN.
The death-rate in Dublin, which had increased in th&
preceding four weeks from 25 6 to 40'6 per 1000, declined
again to 36‘0 during the week ending Jan. lOth. During
last quarter the death-rate in the city was 25'4 per 1000,
the rate during the same period being 21 3 in London and
18'8 in Edinburgh. The 244 deaths in Dublin showed a.
decline of 31 from the unusually high number in the pre¬
ceding week, and included 0 which were referred to
whooping-cough, 4 to “fever,” 2 to diphtheria, 2 to diar-
rbeoa, 1 to measles, and not one either to small-pox or
scarlet fever. Thus the deaths from the principal zymotic
diseases,'which had been 11 in each of the previous two
weeks, increased tolSIastweek; they were equal to an annual
rate of 2*2 per 1000, the rate from the same diseases being;
2‘5 in London and 1'5 in Edinburgh. The deaths referred
to whooping-cough, which had been 4 and 2 in the pre¬
ceding two weeks, rose again to 6 last week, a higher-
number than in any week since March last. The fatal cases
of “fever,” which had risen from 4 to 7 in the previous
three weeks, declined to 4 last week. The 2 deaths from-
diphtheria exceeded the number recorded in any recent
week. 'The 244 deaths in the city included 38 of infants-
under one year of age, and 79 of persons aged upwards of
sixty years ; the deaths of infants showed a slight decline,
while those of elderly persons showed a further increase
upon those recorded in recent weeks. Three inquest cases
and 4 deaths from violence were registered ; and 66, or
more than a fourth, of the deaths occurred in public
institutions. The causes of 17, or 7 per cent., of the-
deaths in the city were not certified.
THE SERVICES.
Greenwich Hospital Pension. —The Greenwich Hos¬
pital pension of £50 a year, rendered vacant by the death-
of Deputy-Inspector General William Gunn, M.D., has-
been awarded to Deputy-Inspector General Henry Piers.
Army Medical Statp.—I t has been decided to hold
an examination for commissions in the Army Medical
Staff in London on Feb. 9bh and following days. It is
understood that there are twenty commissions to be filled. —
Surgeon Vere Edward Hunter has been placed on tem¬
porary half pay on account of ill-health (dated Dec. 29tb,
1890).
Indian Medical Service.— The following Surgeons to
be Surgeons-Major on the Bengal Medical Establishment
(dated Sept. 30th, 1890): — Terence Humphiya Sweeny;
Daniel Francis Barry, M.D.; Geo. Francis Angelo Harris j.
John Anderson; Charles James Bamber; and Malachi-
O’Dwyer.—The Queen has approved of the transfer of
Surgeon-Major Joseph Blood, Bengal Medical Establish¬
ment, to the Half-pay List (dated Dec. 21st, 1890).—The
(iueen has also approved of the retirement from the Service
of the undermentioned Officers: —Brigade Surgeon Benj.
Thomas Suffrein, Madras Medical Establishment (dated
Oct. 12bh, 1800); Snrgeon-Maior William Duncan, Bengal
Medical Establishment (dated Dec. 4th. 1890); Surgeon-
Major Edwin Sanders, Bengal Medi ^ Establishment-
(dated Jan. 1st, 1891).
Digiti -pd bv Google
a66 ThsLakcbt,]
MILK IN CONNEXION WITH SEPTIC DISEASE.
[Jan. 17,1891.
Naval Medical Seevice. — The following appoint¬
ments have been made at the Admiralty:—Staff Surgeon
Gerard J. Irvine to the Vivid (dated Jan. 10th, 1891); Sur¬
geon Phillip N. Kandall to the Warspite (dated Jan. 10th,
1891).
Volunteer Corps. — Artillery: let London (City of
>London): The following announcement is substituted for that
•on the same subject which appsared in the London Gazette
of Oct. Slst, 1890—viz.: Surgeon J. J. A. V. C. llaye
resigns his commission.—3rd Lancashire : Edwin Haworth,
M.B., to be Acting Surgeon (dated Jan. 10th, 1891).
(Jjrrjspnktttt.
Audi alteram partem.”
MILK IN CONNEXION WITH SEPTIC DISEASE.
To the Edit<yrs o/The LANCET.
Sirs,—W ith regard to my letter to Dr. Atkinson, to
•which “ Public Health ” referred in your columns last week,
J may say that I was not alluding to any specihc infective
organisms. The question as to the effect of boiling milk
containing these organisms can be readily settled, with
reference at least to two of them, by making the experi¬
ment ; the organisms of diphtheria and typhoid fever can be
obtained from most bacteriological laboratories. It would
'be of even greater importance to determine whether tubercle
bacilli, when present in milk, can be destroyed by boiling ;
because it is very probable that, in children at any rate,
tubercular disease is frequently induced by the milk from
tuberculous cows. It is quite likely that experiments of
this kind have already been made, but I do not happen to
"have read of them.
I am, Sirs, yours faithfully,
W. W'ATSON ClIEYNE.
"Welbeck-street, CaveiuH.sh-squai'e, W., Juii. 13th, 1891.
it is wrong. At any rate, some of our great microscopists
should be able to satisfy us upon this point, and put an
end to all doubts on the subject.
I am, Sirs, yours obediently,
Surbiton, Jan. 13th, 1801.
F. P. Atkinson.
To the Editors of THE Lanoet.
Sirs,—T he character of the second epidemic mentioned
in my previous communication ought certainly to have been
given. It was one of follicular tonsillitis, and I ought to
have stated that my patients (though the epidemic was
said to be due to milk) were ordered larger quantities of
unboiled milk than usual; and yet, in spite of this, nearly
all got well in about three days. The state of health of
the population, in nay opinion, has more to do with regu¬
lating the size and severity of epidemics than anything else,
and thus we see the weakly affected first, then those that
possess slightly greater power of resistance, whilst the per¬
fectly strong and healthy escape altogether. Children may
be said to have less resisting power than adults. Enteric
fever may in the ordinary way be said to be more
an illness of adult life, because young children do
not travel about so much, and are not in consequence
exposed to so many fresh zymotic influences. Kecent
comers into an infected district are most likely, it is said, to
take on the disease, and we certainly notice that the
visitors to noblemen’s mansions that are Sofective as regards
sanitary arrangements are often the chief sufferers. But
•where enteric fever is caused by contaminated milk the
cases, I fancy, would be found to be more numerous in the
young than the old, because the glandular system is parti¬
cularly active in early life, and the intestinal glands are
very easily irritated. It is all very well to say that such
and such a disease is more common at such and such a
period of life; under certain circumstances it may be so,
Wt under others the statement may he entirely wrong. Our
knowledge with regard to milk epidemics is even now so
•very imperfect, and the ages of persons who have suffered
■from various causes so mixed, that at the present time and
for the present purpose they are utterly unreliable. I have
known several epidemics in recent years put down as due
to milk, while the drainage has been shown to be
thoroughly defective. “ Public Health” may call in ques¬
tion Mr. Watson Cheyne’s statement, but surely, if he
doubts it, he ought to bring forward some sort of proof that
MIDWIVES’ REGISTRATION BILL.
To the Editors o/The Lancet.
Sirs,—I had hoped that any discussion on so important a
subject as the above would have been conducted seriously,
and I have read Dr. Aveling’s letter with both regret and
surprise. He seems to consider it sufficient to meet my
criticisms of the Bill by, in the first place, making two
assumptions, both of which are absolutely erroneous;
secondly, by a statement which is obviously equally in¬
correct, and concludes with a “hope,” which he will find,
by reason of the frailty of human nature, never can be
reslised. Dr. Aveling says I have “not seen the Bill,
and have contented myself with collecting the opinions
of others.” I beg to inform him I have the Bill before
me, and that it was sent to me bj^ a member of Parlia¬
ment immediately on its introduction, that I have read
very little of what has been written on the subject, and
therefore if I reiterate the opinions of others, it only shows
that if those who judge for themselves, as I have done,
arrive at the same opinion as to the demerits of the Bill,
there must be some good grounds for our objections. That
I state mine in an “ uninviting” form is a matter of regret
to me; it is my misfortune that it should be so, but not my
fault. Next Dr. Aveling says I would “ enforce their ex¬
amination [i.e., of mid wives], but say nothing about grant¬
ing certificates or registering them.” Had he read my letter
with any care, he would have observed that I state “in
Ireland” each woman on passing her examination at the
end of her term of training is given a certificate,” and re¬
commended that this system be introduced into England;
and as to “ registration,'” I really thought most of my letter
was about it. Finally, Dr. Aveling “hopes” my “fears
are groundless” that amongst the many thousands of
women whom the Bill proposes to put on the register “a
f ood many will be guilty, or at least be accused, of
runkenness, incompetence, See." In fact, he appears to
infer that the moment a woman is registered she will be
freed from the vices and defects .which detract from the
merits of ordinary mortals, and of which anyone who reads
the papers knows that the women at present acting as mid¬
wives, and who are all to be registered as soon as the Bill
becomes law, seem to have their full share. Among
medical practitioners many are annually accused of
“drunkenness, incompetence, and disgraceful conduct.”
Nor are such accusations confined to members of our pro¬
fession ; the Bar, and even the Church, have amongst tneir
members not a few “black sheep.” But amongst the
15,000 uneducated women whom the Bill proposes to put
on the register Dr. Aveling appears to believe that “ the
fear” that any such should be found is “ groundless.”
Dr. Aveling admits that in Ireland “midwives have cer¬
tainly received more attention and been better educated”
than in England, but he appears to be annoyed that one
who for forty years has taken an active part in bringing
about this desirable state of affairs should “ kindly wish to
help (Englishmen) with the management” of theirs, I am
a registered medical practitioner, and mjy name appears on
the same Register as does Dr. Aveling^, and I refuse to
admit that anything touching the welfare of the poor in
any portion of the United Kingdom is alien to me; and
more, it augurs ill of the spirit in which the Bill is drawn if
the authors of it refuse to accept “aid” in this new de¬
parture from, or even to listen with patience to the opinion
of, those who, whetiierthey are foreigners or only inhabitants
of a distant portion of the same kingdom, have experience
in the matter equal at least to their own. Unbounded
self-confidence has ere this wrecked many a good cause.
Dr. Aveling informs us that “some of the objections have
already received attention,” but no intimation has been
given as to what these are; that alterations will be made
grudgingly and in consequence of the opinion of others,
which I am glad to find must have coincided with my own,
is evident; but when we are favoured with the knowledge
of what these concessions are, I fear they will be found
insufficient to meet the requirements of the case, and I
trust that those who are really interested in endeavouring to
Diyl
u/Googic
THK LAKOBT,]
THE INQUEST AT HANLEY.
[Jan. 17,1881. 16T
establish a class of properly educated raidwlves throughout
the whole of the United Kingdom, and who are not tied to
the opinion that registration alone will affect this, will
unite in their efforts to have this Bill remodelled. Be-
member all that is at stake, that it is the lives of helpless
infants and nearly as helpless women whom this Bill pro¬
poses to hand over to the tender mercies of uneducated
women, protected ae they will be by its provisions, except
perhaps under extraordinary circumstances, from the fear
of any punishment for misconduct.
I am. Sirs, yours faithfully,
Lombe Atthill, M.D.
Merrlon-aquar© W., Dublin, Jan. lOf.h, 1891.
To the Editors o/Thb Lanoet.
Sirs,—A s Dr. Drage, notwithstanding the explanation
I have given, continues to cast doubt upon the approximate
accuracy of the figures I have given in connexion with this
subject, will you allow me to ask bira which of my figures
he thinks incorrect, and what round numbers he would
supply in their place ? My wish has been to be sufficiently
accurate for all practical purposes, and to understate rather
than overstate the figures which supported roy arguments.
If I have failed in my intentions, and have fallen into
error, I shall be thankful for corrections, and happy to
frankly own my mistakes.
I am, Sirs, yours faithfully,
James H. Aveling.
Upper Wimpole'.street, W,, Jan. 13th, 1891,
To the Editors o/TllE LANCET.
Sirs,—D r. Drage, who wrote to you last week on the
subject of the Midwives’Registration Bill, and the desir¬
ability of the subject being taken up by the medical pro¬
fession only, perhaps does nob know that ever since the
Obstetrical Society drafted a Bill in 1882 the question has
been more or less before the profession, but that while the
registration of mid wives by Act of Parliament has received
the approval of such men as Dr. Playfair, Dr. Priestley,
Dr. Graily Hewitt, Dr. Robert Barnes, Dr. John Williams,
Dr. Galabin, Dr. Cullingworth, and others, the profession has
not seen its way to underbake the matter, but has advised
the midwives themselves to do so. The midwives were not
strong enough till 1890, when, through the initiative of the
Midwives’ Institute, a Bill was brought into Parliament.
We feel that in consequence the subject can never again
sink into the same oblivion, or be viewed with such indif¬
ference by the public, as has been the case in the past.
I am. Sirs, yours obediently,
M. Niciiol,
Secrottiry, Mielwives’ Institute.
Buckingliam-street, Strand, Jan. 13th, 1891.'
THE INQUEST AT HANLEY.
To the Editors of The Lancet.
Sirs,—A s the recommendation of the coroner’s jury at
Hanley referred to in your issue of Saturday last will be
discussed by the general and medical committee of the in-
urmaiy, I do not propose to enter into details ; but as your
comments on the case may be open to misconception if un¬
explained, permit .me to make the following statements.
The child became an out-patient three months before death,
its prescription paper was written “badly fed,” and
cod-liver oil niixtuvo was prescribed. This paper was
hailed to the jury. No disease likely to have caused death
on pec. 24bh could have been recorded on this paper, as no
evidence of any disease existed. The cliild improved under
treatment, and presented no serious symptoms. It is not
our custom to treat serious cases v’ith fatal tendencies as
out-patients ; they are either taken in or directed to obtain
medical attendance at home. I refused to give a certificate
of death, as also did Dr. Prendergasb of Hanley, who pre-
sciibed for the patient a month betove death.
I am, Sirs, yours faithfully,
G. S'l’OKEs Hatton, M.S.,
Assistant Hui'jteon, North Slaffonlsliiro Infirmary,
Nowcastio, 8ta)rovdsliire, January, 1891.
INSURANCES ON THE LIVES OP PHYSICIANS.
To the Editors o/The Lancet.
Sirs,—T he recent articles and correspondence in your
columns as to insurances on the lives of physicians &c. have
induced mo to send you some figures relating to the*
death-rate among that class, which, I think, will be in¬
teresting, though perhaps rather startling, to many of your-
readers. I wished to see whether insurance offices would
be justified in granting more favourable terms to physicians
than to the general body of assured lives on account of the-
mortality among them being lower, and I was surprised to
find that not only can they not do so, but that they ought
in fairness to the other members to charge physicians &c.
an extra premium of about 10^. per cent, per annum.
The basis upon which I have come to this conclusion is as
follows. I took the numbers of physicians, surgeons, andt
general practitioners living at the censuses of 1861, 1871,
and 1881, and the numbers dying in 1860-1, 1871, and
1880-2; and I calculated the deaths which might be ex-
ected to occur among the numbers living at these various
ates according to the Institute of Actuaries’ Healthy Male&
Table—that is to say, the deaths which would have taken
place had they been subject to the same mortality as assured
lives generally. 1 found that at each census the actual
deaths were considerably in excess of the expected, and were
even in excess of the deaths that might be expected accord¬
ing to a mortality table applicable to the general popula¬
tion. Special care was taxen with the census of 1881
and the deaths for 1880-2 to ensure accuracy, and great
reliance may be put upon the figures for that period; but
indeed, they are entirely corroborated by the figures for the
other two censuses. Adding the results for the threecensuses
together, the following table shows the numbers living, the
actual deaths, the deaths which might have been expected
to occur according to the Institute of Actuaries’ table, and
the extra premium per cent, per annum which ought to be
charged at each group of ages and for life.
Ages.
Numbers
living.
Deaths.
Expected
deaths.
Difference.
Extra
pi'omium.
20 .
2191 .
25 .
.. 14 ..
. n ...
lOs. Od.
25 .
21,714 .
288 .
,. 190 ..
.. 98 ...
93. Od.
45 .
15,612 .
.. 404 .
,. 337 .
67 ...
88. 7d.
05 .
4673 .
.. 453 .
.. 405
. 48 ...
208. 6d.
All ages
44,190 .
,. 1170 .
,, 946 ..
,. 224 ...
lOs. 2d.
I may mention that I took out tlie figures for a number of
other classes, ond I found the results to agree entirely with
lyhat might have been anticipated. For instance, the mor¬
tality among the clergy was much lower than that among
assured lives generally, while the mortality in the civil
service was just about the same. The mortality among
physicians, however, was worse even than that among coal
miners, notwithstanding the unfavourable conditions under
which the latter class labour and their liability to accident.
Now, a coal miner is charged an extra premium. Why not
a physician ?—-I am, Sirs, your obedient servant,
James Chatham,
Follow of tlie Institute of Actuaries, Fellow of the
Faculty of Actuaries, Pi-ize Essayist (First),
Institute of Actuaries, 189U.
Edinburgh, Jan. lOtb, 1891.
Liverpool Medical Institution.— At the annual
meeting, held on the 8th inst., the following list of oflicers,
council, and Microscopical Committee was adopted :—
President: W. Mitchell Banks, F.R.C.S. Vice-Presidents:
DarnerHarrisson.F.R.C.S.E.; D.M. Williams,M.K.Q.C.P.;
J. Nelson Cregeen, L.R.C.P. ; and F. W. Lowndes,
M.R.C.S. Hon. Treasurer: J. W. Warburton, M.D.
Hon. General Secretary. E. W. Hope, M.D. Hon. Secre¬
tary of Ordinary Meetings: A. Barron, M.B. Hon.
Lilirarian; Peter Davidson, M.B. Council: H. Briggs,
F.R.O.S.; William Carter. M.D. ; G. G. Hamilton,
F. R.C.B.Ed.; A. Samuels, M.D.; J. Wiglesworth, M D.;
'T. Bushby, L.KC.P. ; R. Caton, M.D. ; Charles Hill,
M.D.; J. R. Logan. M.B.; Frank T. Paul, F.R.C.S.;
G. G. S. Taylor, M.D. ; and Glynn Whittle, M.D.
Microscopical Committee: A. Barron, M.B.; T. B. Grims-
dale, M.B.; G. (L Hamilton, F.R.C.S. Ed.; F. Johnston,
M.B.; F. C. Larkin, F.R.C.S, ; J. R. Logan, M B,; F. T.
Paul, F.R.C.S.; and Arthur Wilson, M.R.C.S.
Dig', 'ed by Google
168 ThbLancbt,] the composition and preparation op PKOF. KOCH'S fluid. [Jan. 17,1891.
THE COMPOSITION AND PREPARA¬
TION OF PROF. KOCH'S FLUID.
Telegraphing on Thursday morning, our Special Corre¬
spondent informs us that Professor Koch has made known,
through the Deutsche Medicinische Wochenschrift, the method
ofpreparinghisauti-tuhercularliquid. Inthemainitappears
that the fluid is prepared by making an extract of pure
'Cultivations of the tubercle bacillus by means of a solution
<40 to 50 per cent.) of glycerine. The effective agent is
insoluble in absolute alcohol, and seems, according to
Professor Koch, to be derived from and allied to albuminoid
substances but he states that it is not of the class of tox-
albumins. Its action upon tuberculous tissue is due to the
power it possesses of converting the living cell-protoplasni
into the condition termed by Weigert ‘ ‘ coagulation necrosis. ”
From the statement following, it is certain that Professor
Koch has succeeded, by a simple method, in extracting the
agent which appears to be the cause of the familiar process of
tubercular caseation. One cannot but be struck with the
simplicity of the process followed, as well as with the scien¬
tific acumen with which the investigation has been pursued.
That the “remedy” was of the nature of a bacillary
product concerned in caseation was suggested in The
Lancet of November 22nd, when it was stated that
“in a sense the alleged specific effect of Koch’s injec¬
tion is to hasten the process which is carried on more slowly
in the natural way by caseation, sometimes leading to a
spontaneous cure.” Surprise cannot bub be felt thatitshould
have been thought necessary to withhold from the profession
for so long a period the statement of the nature of the^
remedy, which has now been shown to be of so simple
a character. The following is a translation of Professor
Koch’s article:—
Since the publication, two months ago, of the results
of my experiments with the new remedy for tuberculosis,
aiiany physicians have received the preparation, and have
been enabled to make themselves acquainted with its pro¬
perties through their own experiments. As far as I have
been able to see and consider tlie statements which have
been published, and the communications which have been
addressed to me by letter, the statements which I have
formerly made regarding the fluid have been fully and com¬
pletely confirmed. There is a general consensus of opinion
that the remedy has a specific effect upon tubercular tissues,
and is therefore applicable as a very delicate and sure agent
•for the diecoveiy of latent and doubtful tuberculous pro¬
cesses. As regards also the curative effects of the remedy,
most reports agree in stating that, notwithstanding the
comparatively short period in which patients have been
subjected to the treatment, many of them have shown
an improvement more or less pronounced, and in not a
few cases jt lias even been affirmed that a cure has
been established. The statement that the remedy is
dangerous in advanced cases may at once be conce<led.
But it is also said that it actually promotes the tuber¬
cular process, and its application is therefore injurious.
I have myself during the past six weeks had the oppor¬
tunity of collecting the experience of various physicians
concerning the effects of tlie fluid from a diagnostic and
curative point of view. I have also had under my observa¬
tion in the City and Moabit Hospitals some 150 cases of
eufferers from the most varied forms of tuberculosis, and
I can say that what I have latterly seen confirms
my previous observations, and that I have nothing to
modify in what I have previously recorded. So long
as it was only a question of proving the accuracy of
the results indicated in my former paper, there was
no need for anyone to know what the remedy con¬
tained or whence it was derived. On the contrary,
the subsequent testing would necessarily be the more
unbiassed the less people knew of the remedy itself.
Bat now that this confirmatory testing has been suffi¬
ciently carried out, and the importance of the remedy suffi¬
ciently proved, the next thing to be done is to extend the
e-'Udy of the remedy beyond the area of its present applica¬
tion by seeking to apply the principles underlying the dis¬
covery to other diseases. This task demands a full know¬
ledge of the composition of the remedy, and I therefore
consider the time has come when that secret should be
divulged.
Bemre I go into the remedy itself, I deem it neces¬
sary, for the better understanding of its mode of opera
tion, to state briefly the way by which I arrived at
the discovery. If a healthy guinea-pig is inoculated
with the pure cultivation of the tubercle bacilli, the inocu¬
lation wound is generally closed by a viscid exudation,
and at first appears to heal up. In from ten to fourteen
days a bard nodule presents itself, and this soon breaks
down and forms an ulcerating sore, winch becomes deeper
and deeper until the death of the animal occurs. On the
other hand, if a guinea-pig already suffering from tubercle
is inoculated, quite a different condition of things will
result. To show this in the best possible manner, animals
which have been successfully inoculated from four to
six weeks previously are selected. In such animals the
exudation at the seat of inoculation assumes the same
viscid appearance to begin with, but no nodule forms.
On the contrary, the part on the second day becomes
hard and assumes a darker colour, which spreads
to the neighbouring parts until a diameter of GO’S era. to
I'Ocm. is reached. Within a few days the skin at the
affected part becomes more obviously necrotic, and then
deaquamates, leaving a shallow ulcer, which generally heals
with rapidity without infecting the neighbouring lymphatic
glands.
It thus appears that the effect of injection of tubercle
bacilli on the skin is very different in the healthy guinea-
pig from that which is produced on one already tubercular.
This effect is nob limited to living bacilli, for the result is
the same when the dead microbes are used, no matter
whether—as I ascertained at the commencement of my
inquiry—they are killed by exposure to prolonged low or
boiling temperature, or by chemical agents, In view of the
singular nature of these facts, I was led to continue my re-
'^earches, testing the truth of the facts in all manner of ways,
with the further result tliab I discovered that pure culbiva-
tion-s of tubercle bacilli triturated in water might be
injected in large amount under the skin of healthy guinea-
pigs without any other effect than the production or localised
suppuration.^
On the other hand, tuberculous guinea-pigs are killed by
the injection of very small quantities of the triturated
mixture, death occurring in from six to forty-eight hours,
according to the dose. If, however, the dose be not large
enough to kill the animal, it may cau,so extensive necrosis
of the skin at and around the seat of inoculation. If more
water be added to tlie mixture, so that this becomes faintly
turbid, the inoculated animals survive and soon present
marked signs of improvement. If these injections be
continued, with one or two days’ interval, the ulcer
arising from the inoculation diminishes, and ultimately
cicabrisen, a result which would never otherwise occur.
Moreover, the swollen lymphatic glands diminish in size,
the nutrition of the animal improves, and the morbid pro¬
cess is arrested, unless it is already too advanced, when the
animal dies from exhaustion. In this way a foundation
for a method of curing tuberculosis was laid. The applica¬
tion in practice of these dilutions of dead bacilli was, how¬
ever, discouraged by the fact that tlie bacilli remain
unchanged and unabsorbed at the points of inoculation,
giving rise to more or less extensive suppuration. Any¬
thing, therefore, that was required to produce a healing effect
on the tuberculous process should be a soluble substance,
which niiglitto a certain extent bo lixiviated by the juices of
the body with which they are in contact, thus being in a short
period of time taken up into the lymph-stream, whilst the
pyogenic element apparently remains in the tubercle bacilli,
or else is very slowly dissolved. The problem therefore was
to imitate cx corpore the process which was going on within
the body, and if possible to extract from the tubercle bacilli
the curative agent per sc. Much time and trouble were
expended in this endeavour, until I at length succeeded,
by using a 40 to- 50 per cent, solution of glycerine, in
extracting the efficient agent from the tubercle bacilli.
I then made further experiments on animals with these
fluids, and finally on human beings, and gave samples of
them to other physicians to enable them to repeat the
experiments.
1 By such Injections suppuration may be iivoduced in the simplest and
surest way without the agency of living bacteria.
Di-
I; Google
The Lancet,]
LIVERPOOL.
[Jan. 17,1891. 169
The remedy employed in this new treatment of tuber¬
culosis consists, therefore, of a glycerine extract from pure
cultivations of the tubercle bacilli. Into this simple extract
there must naturally pass from the bacilli, in addition to
the effective agent, all other matter that is soluble in 50 per
cent, of glycerine, such as certain quantities of mineral
(Salts, colouring matters, and other extractives, some of
which can bo removed without much difficulty. The agent
itself is mainly insoluble in absolute alcohol, and can be
precipitated by it in combination with other extractives
which are likewise insoluble in that fluid. The colouring
matter may also be removed so that the extract may be
made to yield a colourless dry material which con¬
tains the active principle in a much more concentrated
form than the original glycerine solution. It is unneces¬
sary to attempt the purilication of the glycerine extract,
as the materials so got rid of are inoperative in the
human body, and the prcAcess, though practicable, would be
very costly. As regards the composition of tbe active
r rinciple, it is at present only possible to hazard a guess.
t appears to me to be derived from proteid bodies and to
be closely allied to them. It does nob belong to the group
of so-called toxalbumins, because it resists high tempera-
itures and can be readily and rapidly dialysed. The pro¬
portion of the substance in the extract is apparently very
small. I estimate it at fractions of 1 per cent. Should
any view prove correct, we should be in the possession of a
material the action of which on organisms attacked with
tubercular disease far exceeds the action of any drugs known
4o us at present.
Regarding the manner in which the specific action of the
o'emedy on the tuberculous tissue is to be understood,
various hypotheses may naturallv be put forward. Without
wishing bo affirm that my view affords the best explanation,
I represent the process to myself in the following manner ;
The tubercle bacilli produce, when growing in living
tissues, just as artificial cultivations do, certain substances
which in various ways unfavourably influence the living
elements in their vicinity. Amongst these is a substance
which in a certain degree of concentration kills the living
protoplasm, and so alters it that it passes into tbe condition
described by Weigort as “coagulation necrosis.” In the^
tissue which has thus become necrotic the bacillus
\finds such unfavourable conditions of nourishment that
it can grow no more, and sometimes ultimately dies. This
us how I explain the remarkable plienomenon that, in
organs which are newly attacked with tuberculosis, as,
■for instance, in the spleen and liver of aguinea-pig, which are
•covered with grey nodules, numbers of bacilli are found,
whereas tliey are rare, or wholly absent, when an enormously
enlarged spleen consists almost entirely of a whitish sub¬
stance in a condition of coagulated necrosis, ns is often
found in cases of natural death in tuberculous guinea-pigs.
The single bacillus cannot, therefore, bring about necrosis
at a great distance, for, as soon as the necrosis has attained
a certain extension, the growth of the bacillus subsides, and
therewith the production of the necrotising substance ceases.
There thus occurs a kind of reciprocal compensation, which
causes the growth of isolated bacilli to remain so much
restricted, as is shown, for instance, in lupus, scrofulous
glands, I'icc. In such a case the necrosis generally extends
•only to a part of the cell, whicli then, with further growth,
assumes the peculiar form of the giant cell.
Thus, in this interpretation, I follow the first explanation
given by Weigert of the production of giant cells. If, now,
one were to increase artificially in the vicinity of the bacillus
the amount of necrotising substance in the tissue, thenecrosis
would spread to a greater distance, and thereby the condi-
'tions ot nourishment for the biicillus would become
much more unfavourable than usual. In the first
place, the tissue, which had become necrotic over a
larger extent, would decay, detach itself, and, where
such were possible, carry oil' the enclosed bacilli and
eject them iroo> the body; and, in the second place, the
bacilli would be so far disturbed in their growth that
they would be killed much more speedily than under
ordinary circumstances.
It is just in the calling forth of such changes that the
■ellect of the remedy appears to me to consist. It con¬
tains a certain quantity of necrotising substance, a
correspondingly large dose of which injures certain
tissue elements even in a healthy peraon, and, perhaps,
the white blood-corpuscles or the cells adjacent thereto,
and consequently produces fever, and a quite remark-
iable complication of symptoms. "With tuberculous
patients, on tbe other hand, a much smaller quantity
sulfices to induce at certain places—namely, where the
tubercle bacilli are vegetating and have already im¬
pregnated the adjacent region with the same necrotising
matter—more or less extensive necrosis of the cells, together
with tbe phenomena in the whole organism which result from
and are connected with it. In this way, for the present at
least, it is possibly to explain the specific inliuence which
the remedy, in accurately defined doses, exorcises upon the
tuberculous tissue, and, further, the possibility of increasing
tbe doses with such remarkable rapidity, and the reme¬
dial effects which have been unquestionably produced under
not too favourable circumstances.
Regarding the duration of the remedy. Professor Koch
observes in a note that, of the consumptive patients who
were described by him as temporarily cured, two have been
again received into the Moabit Hospital for further obser¬
vation, that no bacilli have appeared in tbe sputum for
three months past, and that the physical symptoms hale
also gradually but completely disappeared.
LIVERPOOL.
(From our own Correspondent.)
Hospital Sunday.
The second Sunday in the new year has now for twenty-
one years been set apart as Hospital Sunday in Liverpool
and its suburbs. This twenty-first recurrence, or the coming
of age of Hospital Sunday here, as some have called it,
though this would be more correctly applied next January,
was an event watched with great interest. The local press
had called attention to the auspicious event in excellent
leading articles which appeared on the previous day. The
secretaries and treasurer had made every arrangement for
the due advertisement of the approaching Sunday outside
every place of worship where a collection was to be made,
and for providing tbe clergy and congregation with sheets
giving full details of all the medical charities selected forpar-
,ticipation in the fund and their financial condition. The
treasurer has already acknowledged receipt of advices to
the amount of £3107. This comprises some collections of
very great munificence—e.g., that of the Sefton Park
Presbyterian Church was £C36, and that of the Kenshaw-
atreet Unitaiian Church £601. Besides these there are five
additional instances where the collection exceeded £100.
The Northern Hospital.
This hospital has recently received a ve^ welcome gift
in the shape of £100 for the purchase of a library, scientific
and recreative, for the nurses. These latter will not have
too much leisure for reading, but this will make what little
they can have the more welcome. The gift is a most praise¬
worthy one, and the example well worthy of imitation else¬
where. The donor is Mr. R. C. Kerr of Fall River, Mass.,
and Glasgow, w!\o has lately‘married a recent member of
the nursing staff of tbe hospital.
Deaths of Liverpool Medical Pract itioners.
The deaths of Hr. Robert Gee and Mr. Hugh Owen
Thomas have removed two very prominent members of
the profession in this city. They were both men who will
be much missed by all who knew them. Hr. Gee's pro¬
fessional brethren were prevented by the distance as well
as the inclement weather from following his remains to
their last resting place at "Wrexham. The funeral of
Mr. Thomas was largely attended by professional and lay
friends, and was one of the largest funerals which has been
seen for a very long time.
Deaths from Chloroform.
The Liverpool Echo, in its issue of tlie 12th inst., refers to
the remarks made in The Lancet some time ago respecting
the meagre information given in the reports of inquests
where death has resulted from chloroform. It also alludes to
the increasing number of deatlis from this cause, or, perhaps
more correctly, under these circumstances. After quoting
in exten^o the suggestions made in The Lancet for
securing full details of these fatalities in the medical
journals, the writer calls upon the city coroner, the county
coroner, and the Cheshire coroner, each by name, to please
to take notice. It must not be forgotten that there
inquiries are of a very painful nature to all concerned, and
the wish to spare the feelings of relatives, the administrator
of the ana'sbhetic, and, if it occurred in a hospital, its
Coocle
O
170 The Lancet,]
MANCHESTER.
[Jan. 17,1891,
managers, is a lau(}able one- Nor must the probable eifects
upon the public be lost sight of. It is in cases like these
wnere a medical assessor to the coroner or medico-legal
referee would be of much value.
Liveipool, Jan. I3th .
MANCHESTER. ■
(From our own Correspondent.)
Air Pollution.
The town gardening section of the Manchester Field
Naturalists’ Society are attempting to set on foot a most
useful movement, having for its object the examination
and analysis of the air of Manchester and Salford in relation
to its effect upon animals and plant life. The investigations
and experiments will involve some considerable outlay, and
a sum of at least £200 to commence with, and they ask for
help from the public to carry on the work, and it is in¬
tended to work in unison and correspondence with a
similar society in London having the same objects in
view. Whilst these gentlemen are directing their attention
to the air we breathe, the County Councils of Lancashire
and Cheshire are looking after our streams and rivers, and
last week a public inquiry was held before a Local Board
inspector asking for powers to unite their forces in dealing
witn the question of livers pollution. Surely, with all the
activity now displayed by private bodies, municipal corpora¬
tions, and county councils, an improvement in our physical
surroundings should result ere many years pass away.
Infirmary Extension.
The proposal to practically rebuild the present infirmary
on an enlarged scale has been under the consideration of
the governing body during the past three months, and the
outcome of their deliberations as expressed at the last
meeting of the Board is that they find there is a pressure
upon the present accommodation which at times is difficult
to meet; they suggest that the building as it exists
should be enlarged to the extent of 120 additional beds, and
the opinion of architects is now to be obtained as to the besb
way in which this can be carried out. If tfce Board are, how¬
ever, going to appeal to the general public for funds to
carry out this scheme, several points will require a little
more light thrown upon them. First, is it desirable to
further curtail the open space of the infirmary grounds,
already much diminished in area by the erection a few years
since ofanutses’ home and out-patient department, and thus
considerably increasing the aggregation of patients on a
limited area? Is the demand from acute cases, or are not
the majority of patients requiring admission such as could
be with ease and comfort to themselves treated in a suburban
hospital with purer air and more apace than can possibly
be obtained in the centre of this smoky city ? Do the
atlents who cause the pressure belong to the city and
istrict, or do not they come from long distances,
even so far as Wales? And seeing bow many good local
hospitals now exist, is it fair to Manchester to be called upon
to provide for such patients? And, lastly, will not the generous
benefaction of the Whitworth {rusteea to establish a large
hospital in connexion with Owens College sufiice to meet
all reasonable requirements for increased hospital accom¬
modation for some years to .come, to say nothing of the
advantages to the medical school of having a field for
clinical work near at hand, and in connexion with their
own alma mater ?
College Extension.
The pressing need for increased room in various depart¬
ments of the medical school has compelled the college
authorities to take steps to enlarge the present buildings,
which have already received considerable extension since
their first erection in 1873. The new buildings will extend
along Coupland, in a line with the present medical school,
as far as Lloyd-sbreet, and the departments of physiology
and pathology will especially be benefited by the increased
rooms and laboratories thus provided. One feature in the
plans of the new buildings is the ample window space pro¬
vided, so that all the light that can he got from our fog-
and-smoke-obscured sun shall be obtained.
Poor-law Hospitals.
At both the Manchester and Salford Workhouse hospitals
important changes in the medical administration are about
being made. At Manchester, Dr. Reynolds, who for some
years has he£R resident medical officer at the Royal Infir¬
mary, has been appointed visiting physician at a salary of
£200, to attend the medical cases; whilst Mr. Hardie con¬
tinues visiting surgeon in charge of the surgical ones. At the
Salford Workhouse changes of a similar nature are contem¬
plated, though some little hitch has occurred in the settle¬
ment by the demand of tho Local Government Board that-
two medical men should be appointed on the visiting staff
instead of one, as proposed by the guardians.
Federation of Sanitary Associations.
One of the pioneers of voluntary sanitary a3sooiabion»
was that of Manchester and Sal/ord. Since the increase of
these societies in the country has occurred, it has been-
thought desirable that they should in some way work more'
in unison. In Manchester this has long been strongly felt,
and on Monday last the honorary secretaty attended a,
meeting in London at the Sanitary Institute of Great Britain,
when the preliminary steps were taken for bringing about
this useful result.
Infanticide.
From time to time some little attention is drawn to the-
loss of infant life by culpable carelessness. Bat a short-
time since the Salford coroner had four cases in one day of
infants suffocated by overlaying. The coroner for Man¬
chester has on more than one occasion expressed him¬
self strongly when similar cases have come before him-
During last year he held no less than ninety-eight inquests-
on infants under a year old found dead in bed, and of these
sixty-four were insured.
Horse Infi'uenza.
These two weeks past a severe epidemic amongst horses,
resembling in some respects influenza, has been rife in
Manchester and district, with a considerable mortality
therefrom. The disease is sudden and acute in its onset,
and frequently proves fatal in twenty-four hours. No
true influenza has been prevalent in the human subject,
but our local mortality returns have been largely swelled
by diseases of the respiratory organs during the recent,
severe weather.
Death of Mr. E. A. Birch.
Amongst those who have succumbed to diseases of the
lungs is, unfortunately, a member of the medical profession
well known in Manchester medical circles. Mr. Ed. Arnold
Birch, after a short illness from pneumonia, died on Christmas
Day. Mr. Birch was a successful student of our medical
school a dozen years ago: he held mostof the resident appoint¬
ments at the Royal Infirmary, and since then had been in.
practice at Longsight. He leaves a widow, but no children,
Manchoster, Jan. l-lfcb.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Death of H. B. Brady, LL.D., F.B.S.
I REGRET to announce the death of Dr. Ji. B. Brady, of
the firm of Brady and Martin, of this city, at Bourne¬
mouth, on Saturday last, in his fifty-fifth year. Dr. Brady,
although not a medical man, was intimately connected-
with the profession, his father being Mr. Henry Brady of-'
Gateshead, a well-known surgeon in the north of England,
and his brother (Dr. George Brady) is in active practice at
the present time in Sunderland. Dr. Brady was an expert-
with the microscope, and his report on Foraminirera
dredged by H.M.S. Challenger during the years 1873 and
1876, in two quarto volumes, is well known, as likewise
his other worn in natural history, which resulted in Ms-
being elected F.R.S. and receiving the degree of LL.D.
from the University of Aberdeen. Dr. Brady, considering
his feeble health, as he was a sufferer for most of Ms life'
from bronchial asthma, accomplished much work in his
special departments. He was compelled to pass most of
recent winters in the soutli of England ; but even there the-
recent severity of the season was too much for him. Dr-
Brady was unmarried.
Presentation to Dr. A. C. Munro at South Shields.
Dr. Munro, who has been medical officer of health afc
South Shields for some years, and has been promoted to a
similar office by the County (Council of llemrewshire, has
been presented with an address by the members of the
South Shields Literary and Scientific Society, together with
a handsome and valuable gold watch and chain, and a
diamond ring for Mrs. Munro.
Dir-- zed by Google
The Lancet,]
SCOTLAND.-lBELA.ND.
[Jan. 17,1891. 171
The Health of Hexham.
The health of Hexham would appear to be iu a satis-
'factory condition, as evidenced by the report of the Sani¬
tary Committee, which shows that the death rate for 1890
was 16 8 per 1000—less even than that of 1889, which was
remarkable os the lowest annual death-rate previously
recorded at Hexham, thus showing that Hexham had
attained to the position of one of the healthiest towns in
the kingdom.
The Outhreul: of Typhoid Fever at Stockton.
At a special meeting of the Stockton rural authority,
Mr. Blandford stated that there had been twenty-six cases
of typhoid fever notified since Dec. 20tb. Mr. Clegg, in
his report to the Stockton urban sanitary authority, thought
•that the epidemic was practically abating, and that its
oause could not be attributable to atmospheric conditions.
Newcaetle-oii-Tyne, Jan. 13th.
SCOTLAND.
(From our own Correspondent.)
Homo for Inebriates: Qneensbcrry House and Quecnsberry
Lodge, Edinburgh.
The annual report of these institutions has just been
g>ublished. One side of the work done by them is of
interest to the profession, and is not generally known.
Hoth institutions are under the same management but
•occupy separate buildings, and the grounds of each are also
strictly separated. They are both in part hospitals or homes
[for aged or infirm persons, or persons suffering from chronic
diseases; but the side to which reference is made here is
dihe function they perform as homes or retreats for intem¬
perate persons of both sexes. Queensberry House was in¬
stituted in 1832, and is commonly known in Edinburgh as
•the House of Itefuge. During the past year the report states
that 138 persons of intemperate habits have been boarded
an the institution by tneir friends for the purpose of
protection and reformation. The directors point out
'that the importance and value of this department are
witnessed to by the number of respectable tradesmen
and others who have availed themselves of, and expressed
•their thankfulness for, the existence of such a place of pro-
■tection. The rates of board are from 4s. 6c^. to lOs. per
week. Queensberry Lodge, on the other hand, is a newer
anstitution, having been opened in 1866. It is entirely for
ladies whose friends are able to pay from £60 to £100 per
annum, and there is accommodation for about thirty ladies
at a time. Between 1866 and 1890 661 ladies have been
admitted as hoarders, and of these there belonged to England
118, Ireland 63. and Scotland 480 The directors say that
■"' the results of treatment, when time has been afforded by
a sufficient length of residence, continue to be satisfactory.
(Information cannot in all cases be obtained as to the benefits
deriv.ed, but good accounts have been received in regard to
a large number of the boarders, particularly those who have
•resided in the house for a period of four months or longer.”
Health of Edinburgh.
Lost week the mortality was 104, and the death-rate 20
•per 1000. Diseases of the chest caused 50 deaths, and
.■zymotic diseases 7, of which 3 were typhoid and 3 whooping-
cough. The intimations for the week were—typhoid, 26;
•diphtheria, 2; scarlatina, 16; and measles, 9. In Leith the
<leath-rate was 21-3 per 1000.
Meritorious Attendance on the Insane.
On the recommendation of Dr. T. S. Clouaton, the
Oouncil of the Royal College of Physicians, Edinburgh, has
awarded the M.orison prizes for meritorious attendance on
tho insane to Mary Ann Anderson, Midlothian and Peebles
Asylum, eleven years’ service, and to David Robertson,
Murray Royal Asylum, Perth, thirty years’ service.
.Edinburgh, Jan. 13tli. _
IRELAND.
(From our own Correspondent.)
The Irish Census.
In the last census, that of 1881, the population of Ireland
was 6,144,983; but it is estimated that the returns this
year will show a total of 4,700,000, or a decrease amount¬
ing to 444,983.
Royal College of Physicians.
The President entertained the Fellows and some friends
to dinner at the College on Monday’ evening. The guests
included his Excellency the Lord Lieutenant, the President
of the Royal College of Surgeons, and others.
Poor-law Relief in Ireland.
The return of expenditure on poor relief for the year
ending Sept. 29th last has been issued by the Local Govern¬
ment Board. The number of persons who received in-door
relief amounted to 333,307, and out-door relief 114,704, or a
total of 448,011, at an increased cost of £43,091. Thecost of
out-door relief was £194,814, and for the support of the
blind and deaf-and-dumb institutions and extern hospitals
£13,661. The total poor relief expenditure was £860,000,
and the expenses under the Medical Charities Act £169,774;
while the Public Health Act cost £63,942.
Death of Dr. John A. Byrne, of Dublin.
A couple of weeks siuce reference was made in these
columns to the serious illness of Dr. Byrne, and'the anxiety
then expressed has proved to have been well-founded, as he
succumbed on Tuesday, the 13th inst., at his residence,
Merrion-square, North. Dr. Byrne was a Graduate in Arts
and Medicine of the Dublin University ; Honorary Fellow,
San Francisco Obstetrical Society ; Professor of Midwifery
in the Medical School of the Catholic University ; Gynreco-
logical Surgeon to Vinoent’s Hospital; Examiner in Mid¬
wifery, Royal University of Ireland ; and formerly exa¬
miner in the same subject in the Queen’s University in
Ireland ; physician to Grand Canal-street Dispensaw ; and
ex-assistant master. Rotunda Lying-in Hospital. He was
also a Fellow of the Royal Academy of Medicine in Ireland,
and an ex-president of the Dublin Obstetrical Society. His
contributions to medical literature included “ Fatty and
Hydatiginous Degeneration of the Placenta”; Rupture of
the Vagina during Labour, with Recovery”; “ Observations
on Puerperal Fever and Puerperal Mortality”; “Bipolar
Version and Induction of Premature Labour by Hydro¬
static Dilatation,” &c. Dr. Byrne was an accomplished
obstetric physician, and held a high position in the city in
which be practised.
Dr, H. Bayer was entertained at dinner at the Wicklow
Hotel last week and presented with a case of surgical
instruments, on the occasion of bis severing his connexion
with the Ardee-streot Brewery.
The govern''r8 of the House of Industry Hospitals will
ne.xt week elect an assistant surgeon, who will hold office
for fhree years. Mr. Burgess, ex-assistant surgeon, is, I
understand, a candidate.
The widow of Professor Davies, late of the Queen's
College, Galway, has been granted an annuity of £100 from
the Literary Fund of the Civil List.
Jail. I3th.
PARIS.
{From our own Correspondent.)
Pyoktanin in Octilar Affections.
This substance, according to M. Galezowsky, gives
remarkable results in the treatment of various forms of
ocular ulceration. Chronic corneal xrlcers especially, which
prove rebellious to all other treatment, are quickly arrested
m their spreading course and cured in about four weeks by
the regular application of a solution freely applied.
Fire at the PUit Hospital.
This old structure ran some danger of being burnt down
last week. Were tiie possible if not probable consequences
not so dreadful, this would, from a sanitary and other points
of view, bo matter for congratulation, for a more hopwessly
ramshackle and altogether antiquated pile serving as a
modern home of antiseptic surgery and medicine it would
be difficult to imagine. Luckily the fire broke out ia a part
of the hospital well removed from tho wards, and was
speedily got under before the patients became aware that
anything unusual had happened.
Epidemie of Small-pox.
We do not yet enjoy the blessings of compulsory vaccina¬
tion to the full in this country. As a result, we are visited
from time to time in various parts of the country with
terrible outbreaks of this loathsome disease. At a place
called Aigues-Mortes, a somewhat, suggestive and for once
appropriate name, there is a violent epidemic of the disease
Dip-: z?:’ t: Google
172 The Lancet,]
PARIS.—BERLIN.
[Jan. 17,1891.
juBt now. As many^ as a hundred cases are reported, with
several deaths. It is supposed that the pest was imported
by a steamer from Spain, which, mixed up with her cargo
of wine and oranges, cai-xied an additional cargo of small-
ox microbes. The oranges and wine are not said to have
een confiscated, but were at once transported further
inland, to be there disposed of to a confiding public !
Curious Medico-legal Cases.
In the Parisian suburb of St. Denis there practises a
member of the profession who, if in common with the rest
of humanity he commits an occasional error of judgment
or of prognosis, must at all events be credited with rave
single-mindedness of purpose. Our worthy confrere was
called to see a patient. After the third visit he solemnly
informed the friends that the patient’s condition was so
hopeless that conscientiously he did not feel justified in
putting them to the expense of what must henceforth be
useless visits. The friends did not insist, but, as might be
anticipated, on the exit of the first doctor they sent for
another. In the result the patient did not die, but re¬
covered, whereupon our singular confrere demanded his fees
for the three visits, which the patient and his friends
promptly declined to pay. The doctor thereupon had
recourse to law. Now, as the amount was not excessive,
being only 9fr. for the three visits, it must be supposed
that our confrere was only striving to be consistent with his
frame of mind by fighting on principle; otherwise we cannot
well imagine him playing so closely a game hardly worth the
candle. But he gained his point and also recovered his 9 fr.,
and had, moreover, the satisfaction of hearing an elaborate
judgment delivered on his case, and this was no doubt
much. Another case was of a somewhat different character.
A quack was convicted and heavily fined for illegally prac¬
tising medicine at Albertville. No sooner did this happen
than several of his numerous friends and patients opened a
subscription list in a local caf6, with the view of meeting
the fine and legal expenses. The subscription list was,
however, seized by the police, and those who had so far
subscribed were prosecuted by the State and fined. But
the staunch defenders of the quack determined not to let
the matter rest here. They appealed to the higher tribunal
in Chamb6ry, where, however, the decision of the lower
court was confirmed. This tribunal, in giving judgment,
laid it down that the prohibition enjoined by the law
against opening a public subscription for the purpose of
covering the expenses and fines inflicted by judicial
authority and judgment in matters criminal and correc-
tionnelle applies to the illegal practice of medicine. 'The
defendants were now further mulcted in the expenses of
appeal thus dismissed. Our quack will hardly retire from
practice after this manifestation. The proverbial coach
and four of O'Connell will carry him through yet.
Survival of Medical Sorcery.
Some time_ back I gave in these columns some curious
examples going to prove that sorcery and other forms
of mediaeval superstition were by no means extinct in this
country yet. Another example of this kind has lately been
made public in a small, out of the way country commune
named Serralongue. In December last a child was bitten by
a dog that was afterwards proved to have been rabid. The
father of the child informed the enlightened mayor of this
enlightened commune, at the same time summoning, not a
doctor, hut a sorcerer to treat the disease, in which action
the mayor appears to have entirely acquiesced. The
treatment consisted, amongst other diabolical details, in
shutting the unfortunate child in a darkened chamber for
forty days, during which time be was denied meat and
water. At the end of this time the child’s condition can be
better imagined than described. Luckily the police now
got wind or the affair, and put a stop to the cruelty prac¬
tised upon the unfortunate hoy. Tlie law is further, I
gather, about to shed a little light on these benighted
people—none too soon, apparently.
Paris, Jan. 18 th. _
BERLIN.
(From our own Correspondent.)
Professor Virchow's Address.^
Amono lost week’s publications concerning the applica-
tion of Koch’s reme dy Virchow’s speech in the Medical
* A full abstract of this address will be found in another portion of
our present issue.
Society was unquestionably the most important. Virciiow
has dissected about twenty corpses of patients who had
received injections for a longer or shorter time. He illus¬
trated his lecture by demonstrating a large number of pre¬
parations, which were inspected by his hearers with the
Keenest intere.sb. After the great pathologist had con¬
cluded his discourse his audience dispersed, discussing what
they bad heard with great excitement, and there can be
no doubt that this utterance will form an important mile¬
stone in the history of the question at issue.
Koch's Treatment of Tuberculosis.
I have received from Dr. M. Cohn the following account
of a visit which he paid to the Hospital am Urban, one of the
hospitalsbelongingtothecity of Berlin: “The chief physician
of the internal department, Professor A, Fraenkel, had the
goodness to communicate to me his experience of Koch’s
remedy, which he has been applying these six weeks past.
In order to make his observations and examinations of the
excretions, the phenomena in the diseased organs, &c., as
careful and frequent as possible, he has treated only forty-
two cases, mostly in the first stages of the disease. Patients
with extensive cavities and whose strength is far gone
have been excluded from the treatment. lu some of the
incipient cases an improvement of the physical condition
(clearing up of dulness, diminution or cessation of rhonchi)
was observed, and improvement in general health was appa¬
rent. Increase of weight has been but inconsiderable, and very
fluctuating. Influence on night sweats or change of the
character of the sputum was not observed. The quantity oi^
bacilli in the sputum is very variable ; in the beginning of
the treatment it is usually greater, but the bacilli afterwards
often disappeared for a while, to reappear sooner or later.
Three of Fraenkel’s patients, who were received into the
hospital with incipient infiltration of the apex, have for
eight days past ceased to react on the maximal dose of a
decigramme, have no longer bacilli in their sputum, and no-
demonstrable physical phenomena. They are to be dis¬
missed, and will then visit the hospital once every week for
' some months to have their capacity of reaction tested by
an injection. In the advanced cases of tuberculosis of the
lungs the objective improvements hitherto obtained have
been but small, and spread of the processes in the course of
the injections, in one case even the formation of a cavity,,
has been observed. In two cases of laryngeal tuberculosis
but little change could be affirmed ; when old infiltrations
disappeared, new ones soon appeared at other places. In the
case of one female patient with intestinal tuberculosis the
evacuations became somewhat less copious, and the quantity
of bacilli evacuated considerably increased. With reference
to the diagnostic value of the remedy, it deserves to be
mentioned that there were indisputably tuberculous patients
whose sputum contained innumerable bacilli who never
reacted, even when the maximal dose was given.
The converse process, on the other hand—namely,
reaction in non-tuberculous patients,—was not observed.
The lowest dose capable of producing reaction is veiy dif¬
ferent in difl'erent persons, and it is not yet known on what
circumstances this depends. One thing, however, seems
certain—namely, that it does not depend on the extent of
the tuberculous affection. The question of the manner io
which the nationalisation of Koch’s fluid, which Minister
von Gossler announced in hi.s well-known speech is to take
place, is being thoroughly discussed at present, with the
assistance of competent outsiders, in the Prussian Ministries
of Finance, and of Religion, Education, and Medical
Affairs. It is intended to establish institutions for
the production and distribution of the fluid, on the
model of the existing establishments for the produc¬
tion of vaccine. As to the manner of the production
of the fluid Dr. Bernheim of Wurzburg, a former
pupil of Koch’s, has put forth the following hypo¬
thesis. The basis of the fluid, he thinks, is bouillon or
horseflesh, which contains more albuminoid substances
than any other kind of flesh. In this bouillon a colony of
tubercle bacilli is placed, whereby a poisonous substance is
developed by fission of the albuminoid bodies. 'The bacilli
die, and the bouillon containing the poison is pressed through
coarse porcelain for the inspection of bacilli that may still
be present. To this bouillon is again added a colony of
bacilli, and this process is repeated four or five times. TIii&
highly poisonous bouillon (to which a i per cent, solution
of carbolic acid is added to prevent putrefaction) is Koch’s
fluid. Dr. Bernheim supposes that the animal tissue cel)
affected by the bacilli dies under the influence of the poison,
while the still healthy elements of the tissue remain un-
The Lancet,
BEllLIN.-EGVPr.
[Jan. 17,1891. 173
affecbed. The readers of The Lancet may remember that
a committee of emioent medical men was formed here at
Leyden’s suggestion about the end of last winter for the
purpose of founding large sanatoria for patients suffering
irom pulmonary disease. The operations of this committee
were somewhat arrested by the publication of Koch’s dis¬
covery, as it was not known how the method would have
to be applied. Now that it has become clear that the
•application of the renredy in closed establishments is best,
the committee will resume its labours, and will, it is to be
hoped, successfully perform its task.
At the Free Association of the Berlin Dermatologists
Dr. KosentJial spoke of his experience of the application of
Koch’s remedy in cases of lupus. This experience has re¬
ference to a number of oases clinically observed for about
six weeks, some of which the speaker showed to the
meeting. He is of opinion that the diagnostic value
of the fluid is beyond all question. The reaction is
absolutely characteristic. In all cases a rapid cure
began. The ulcerous patches skinned over; the nodules
'disappeared by resorption or exfoliation; the elephan-
tiastic places began to return to their normal condition.
Complete cure has not yet been obtained, but seems
to be possible. The duration of the treatment and the
•amount of the single dose depend on the individuality of
the patient. In the discussion which followed Dr. Kosen-
thal’s report, Dr. Lassar remarked that it was unquestion¬
ably possible by means of Koch’s injections to make lupus
nodules disappear, ulcerations skin over, and hypertrophic
tracts of skin exfoliate ; but that, though the treatment
had now lasted a quarter of a year, no cures had been
elfected, but only ameliorations. The weaker the reaction
became as patients got accustomed to the remedy, the more
•slowly did the improvement progress. Kelapse also was
not impossible. Dr, Kbbner deemed it advisable, iu
contradiction to Koch, to reduce the initial dose to 0-001,
and then discussed ^tbe striking rapidity with which
patients get accustomed to the remedy. He then men¬
tioned two lupus patients who have been under tieatment
for almost three months, in whom, notwithstanding strong
general reaction at first, the local aflection remained
unaltered ; in both cases the nodes lay in old cicatrised
connective tissue. It seemed that a healing process set in
only where vessel-bearing connective tissue adapted for
inflammation existed round the tubercle. In lupus
erytbematodes no demonstrably therapeutic influence was
perceptible, and in leprosy only general reaction seemed to
take place.
Professor Bardeleben and his assistants have reported to
'the Free Surgical Association on fifty-nine oases of surgical
■tuberculosis and skin tuberculosis treated by them, and
showed a number of the patients. The demonstration
favoured ,the impression that in a number of diseases of
the bones and of the joints, especially after operation,
the injections really accelerate the healing process;
whether the removal of all tuberculous matter from
left scars is completely successful is a question which
it is well to leave unanswered for the present. As
a diagnostic aid also Koch’s fluid has proved ellecbive
in a number of etiologically doubtful cases. Cases of
'lupus were also shown in which quite striking ameliora¬
tions, and in some places complete healing, had taken place;
but on this occasion also, though the treatment had lasted
more than three months, no case of complete cure of lupus
was shown. In the discussion Dr. James Israel remarked
that a case of lupus, treated by him Avith Kocli’s fluid, had
shown no reaction whatever, though giant cells and bacilli
were histologically demonstrated in the diseased tissue.
The negotiations with the Government with a view
to the nationalisation of the medicament are said to have
been interrupted ; perhaps the Government has resolved,
after all, to await the teaching of further experience before
taking upon itself so important an obligation.
Berlin, Jan. ISth. __
EGYPT.
(From our own Correspondent.)
Koch's Treatment of Tuberculosis.
Three weeks ago Professor Koch was kind enough to
•send a bobble of his “ precious liquid” to each of two friends
in Alexandria, and as one of tliem was at once put at the
disposal of Kasr el-Aini Hospital, some experiments had
been made by Messrs. Milton and Sandwitb, and by Dr.
Hassau Pacha Mahmoud. Up to the present thirteen
cases have been injected, including one of lupus, one leper,
two of diabetic phthisis, one of bone disease, three
f ;landular cases, and five of pulmonary phthisis. The
upus case is a boy aged ten, with disease of nose, face,
and neck, who had been previously scraped five times, and
had had several other kinds of treatment; so far he has
had seven injections, rising gradually to eight milligrammes;
his temperature rose once to 101“ F., and though there has
as yet been no great typical redness or swelling, the scabs
have discharged a little serum, and present a cleaner
appearance after being oiled. The leper has been attacked
for five years, and seems to be a fair case for trial, his
numerous tubercles being in a clean condition. He has
only lately been admitted, with a special view to this ex¬
periment, and has had two injections, up to five miil>
grammes, without any result. The first case of diabetm
phthisis has very slight lung signs, and absolutely no
cough, so that injections increasing to one centi-
ramme have never sent his temperature above 99-6“;
ut once, after six milligrammes had been reached,
the patient had great pain and a glandular swelling at
the base of the right posterior triangle of the neck.
From its sudden appearance and its complete disappear¬
ance the following day it would almost seem as if
it were due to some slight reaction among unsuspected
tubercular tissues. The second case of diabetic phthisis
has incipient but more evident signs, and, though there is
considerable cough and expectoration, bacilli have never
been discovered in the latter. The man has had four
injections, rising to six milligraiumes, and, though his
temperature twice rose to 102“, it was not by any means a
typical reaction. It may in the future be settled what
action Koch's fluid has upon the phthisis occurring
as a complication in diabetic patients, and similar ex¬
periments ought to be able to decide for us what
percentage of such cases is at its origin tubercular.
The case of tubercular bone disease is in the tibia of a
woman upon whom Mr. Milton has already operated.
Since Dec. 18tb there have been six injections, the
strongest being of six milligrammes and the temperature
having risen to 102“. This is one of the most satisfactory
of the experiments, for the wound is decidedly better,
the granulations are healing and are more healtby-looldng,
and there is less discharge. In a previous letter ic
was prophesied that this new treatment would prove of
great value in the numerous coses of swollen lymphatic
glands which enter the hospital for extirpation, and
the three cases already injected confirm this view,
though it is too early to decide whether anything like a
permanent cure can take place. A girl with a chain of
glands in both groins and in both sides of the pelvis got a
typical reaction for some hours and fever amounting to 104“
after an injection of one milligramme. Another girl with
similar cervical glands got a temperature of 102“ after
the first injection of one milligramme. A case of axillary
glands already operated upon with a fistulous sinus remain¬
ing has had three injections increasing up to four milli¬
grammes with slight fever (100'5“); and as yet no alteration
in the fistulous wound. One of the first phthisical cases
injected was a woman Avith incipient signs at one apex and
masses of enlarged glands in both axillae and on both sides
of the neck. She bad very characteristic reactions, fever
to 104-8“, and great swelling and pain for some hours in the
previously dormant glands, which now seem less evident
after six injections, none stronger than two milligrammes.
An Egyptian Avoman with incipient phthisis has had seven
injections, rising to three milligrammes, as the result of
which her temperature has twice risen to 102-5“, and her
cough has certainly diminished. Anegressfrom the Soudan,
Avith a distinct cavity in one lung and commencing disease
in the other, has had three injections, rising to two milli¬
grammes, and the orthodoxfeverrisingto 104-2“. Thefourth
case of phthisis had before the injections a range of fever from
normal in the morning to 101“ in the evening. She has had
only two injections of one milligramme each. After the first
her temperature rose to 104-4“, and after the second to 102-4".
The remaining case is perhaps the most interesting, for the
patient bad sull'ered one year from bronchitis, and though
bacilli were never detected in his sputa, it was thought that
his physical signs at the right apex were suspiciously like
phthisis. The first trial oi a milligramme and a half
produced no result, but after three milligrammes and
a half he had for several hours fever of 102", falling
174 The Lancet,]
OBITUARY.
[Jan. 17,1891.
again to 98°, and be spent part of the evening groaning
with ^ain, like that of pleurisy, in hia right side. Another
injection of similar strength produced again fever (102°),
and a milder degree of pain in the side, without cre-
itation and without friction sounds. Since then he has
ad five ’ milligrammes injected without fever and with¬
out pain. This case seems to be illustrative of the diagnostic
value of the new discovery. Some experiments are also
being made by some of our German, Swiss, and Austrian
colleagues upon cases of lupus and of phthisis at the two
private hospitals here supported by the European com¬
munities.
Professor Koch's Visit.
It is said that Dr. Koch him.self is coming to Egypt next
month for a holiday, and intends afterwards to proceed to
■Syria to study the reported cases of cholera there. It will
he remembered that he spent some time in Cairo and
Alexandria in 188.3 daring the last epidemic of cholera in
Egypt.
Surgical Operations at Kasr-cl-Ami.
Surgery continues to be well carried out in the hospital
wards, and the number of operations is nearly a hundred a
month, besides some fifty eye operations performed by Dr.
Scott and his native colleague. Mr. Milton, who does the
lion’s share of operating, has during the month performed
three ovariotomies, amputation at the shoulder, Pirogoff’s
amputation, five lithotrities, lithotomy, mastoid trephining,
ligature of the axillary artery, and operations for abdominal
cancer, vesico-vaginal fistula, strangulated hernia, and
polypus of uterus. During the same month the native pro¬
fessor of surgery has done four lithotomies, amputation of
thigh and of forearm, and several minor operations. A
suprapubic lithotomy was lately performed successfully in
which the calculus was found to weigh very nearly fourteen
ounces. Among other interesting but unsuccessful opera¬
tions were abdominal section for a ruptured bladder and for
a ruptured aneurysm of the abdominal aorta.
Improvements at Kasr-el-Aini.
Little by little English influence is being extended, and
the various departments of the hospital are becoming more
and more civilised. A steam laundry has been established
now six months, and the whole laundry has been placed
under European supervision, to the manifest improvement
of the clothes washed. The kitchen is still in sad need of
reform, but this will be taken in hand directly funds for
building permit. It the meantime some medical comforts
for the patients are supplied by the English nurses from
their private kitchen at the expense of the hospital. The
dispensary lias lately been placed under a competent German,
who is gradually reducing the chaos in which his native
predecessor lived and moved. Post-mortem examinations
are now regularly made of patients dying in the hospital,
and those bodies unclaimed by their friends are previously
injected and then utilised for the dissecting-room under the
superintendence of Dr. Keatinge.
Cairo, Jan. 5th.
EDWARD BELLAMY, E.R.C.S. Eng.
Mb. Bellamy was born at Blandford St. Mary’s,
in Dorsetshire, in 1842. Ilia father was rector of that
parish, and subsequently of Balham. He was educated
at Clapham Grammar School, and at King’s College
School, and in January, 1859, entered the Applied
Science Department in that College. His attention was
specially given to mathematics, mechanics, chemistry, and
drawing, and in all these subjects he exhibited marked
proficiency. At this time he was studying for the com¬
petitive entrance examination for the Royal Engineers, but
ID October, 1860, having determined on a medical career,
he exchanged from the Applied Science to the Medical De¬
partment. He soon showed himself to he a good anatomist
and a most dexterous and rapid dissector, and was suc¬
cessively appointed Prosector and Assistant Demonstrator
of Anatomy by the late Professor Partridge. His surgical
bias also attracted the especial attention of Sir William
Fergusson during his dressership under that distinguished
surgeon. In 1863 be became a Member, and in 1867
a Fellow, of the Royal College of Surgeons. Having
filled the post of Surgical Registrar at King’s College
Hospital, Mr. Bellamy accepted the appointment of
Demonstrator of Anatomy to the Charing-cross Medical
School in 1867, and in 1871 was appointed assistant surgeon
to the hospital and teacher of operative surgery. In 1874
he succeeded to the lectureship on anatomy, and in 1878
became full surgeon. In the same year he was elected lecturer
in surgery, and this appointment, with the senior surgeoncy
of the hospital, he held at the time of his death. He was
also elected professor of artistic anatomy at South Ken¬
sington on the removal of the late Professor Marshall to
the chair at the Royal Academy, and in this post his
artistic leanings and capacity had full scope. In ISSO
he was elected a Fellow of King’s College, and he had been
an examiner in anatomy at the Royal College of Surgeons,
and in surgery at the University of Durham and at
the Victoria University. Mr. Bellamy made many con¬
tributions of value to anatomical and surgical literature.
His “Students’ Guide to Surgical Anatomy” was very
attractive, and the illustrations were nearly all drawn on.
wood from nature by the writer. This book was one of
the first of its kind m this country. But the English ana¬
tomical student is even more indebted to him for nis excel¬
lent translation of Braune’a Topographical Anatomy, os by
this book the relative anatomy of the various structures, as-
shown by sections of frozen bodies, was for the first time-
practically placed at the disposal of British students and
surgeons. This study, whicli is now so rapidly being,
developed, owes its first start in Great Britain to Mr.
lieUamy, He also contributed articles to “ Quain’s-
Dictionary of Medicine” and “Heath’s Dictionary of
Practical Surgery,” besides many cases of interest to the
Transactions of the various medical societies and to our owm
columns. Mr. Bellamy delighted in his profession; he was
a fluent if somewhat discursive lecturer, clue perhaps to the
example of Professor Partridge, under whom he had studied;;
a striking, and in many respects original, clinical teacher,
beloved by most of his students, to whom he was recipro¬
cally attached, and in whose welfare he always took
a keen personal interest; and a brilliant operator, His-
weakness, perhaps, was tlie desire to emulate the rapid and
decisive style of Sir William Fergusson, and to this he was
tempted by his great manipulative skill and readiness of
resource. Mr. Bellamy had the strongest sympathies with
science, art, and athletics. He was a very' fairmatheniatician,
a thoroughly good nmeician, and his skill in drawing,
was quite of the first class. Many of his droll sketches
and caricatures are treasured by his personal friends, and
in rapid anatomical sketching he was probably unrivalled by
any contemporary lecturer. He had most excellent artistic
taste, and collected many curiosities, especially in old
armour. He possessed a striking and banusome presence,,
was ever kind and genial, and his social qualities and
extra-professional knowledge made him always a welcome
companion and guest. He was speaking, apparently in the
best of health and spirits, to a friend at the Savile Club so-
late as the afternoon of Friday, the 2nd inst., and on
Sunday, the 4th, in spite of every attention from bisfriende
and colleagues, Drs. Green and Bruce, he died of acute
pneumonia, at the early age of forty-eight, leaving a wife
and several children to mourn his loss. IIo was interred at
Highgate Cemetery on the 8th inst.
HUGH OWEN THOMAS, M.D., M ll.C.S.
A GEIEI'' SO profound and widespread as that which was-
manifested at Liverpool on the 10th inst., when the remain®
of Dr. Hugh Owen Thomas were laid bo rest, is seldom
witnessed. There can be no more eloquent or touching
testimony to the worth of a man’s character than the tears
of the poor among whom he had lived. The toilers at our
docks and warehouses are not sensitive beings, and the
daily struggle of their lives is too earnest to admit of much
display of sentiment. To see thousands of these, then,
men as well as women, as anyone might have done in
Liverpool on Saturday last, stirred to tlieir very depths by
an emotion that found expression in passionate sobs and
tears, as they lined the streets or 'pressed forward to gaze>
into the open grave, proved that its silent occupant had
won his way to their hearts. Dr. Thomas was in every
respect a remarkable man. The frail health, often
disturbed by acute bodily suffering, with which he
entered upon practice some thirty-three years ago, gave
Dir oogle
The Lancet,]
OBITUARY.-MEDICAL NEWS.
[Jan. 17,1891. 175 -
little promise of fvuitful labour. But his uaturally
^xeat ability, and the force of a quietly dauntless
character enabled him to overcome every obstacle and to
win his way to the very front rank in the department of
surgery, to which he more especially devoted himself. He
metamorphosed the treatment of diseases of the joints, and
thousands of sufferers throughout the world are benefiting
to-day from the universal adoption by surgeons of ‘ ‘ Thomas’s
splints.” But his mmd was so active and many-sided that
there was no department of his profession on which it did
not advantageously exercise itself, and those who were
privileged with his friendship—and he was the. most ap¬
proachable and friendly of men—were often astonished at the
profundity and onginality of his ideas on some of those pro-
Wems of medioine which his large general practice brought
before him. Thus he did more than any other modern
medical man to restore, if he did not even originate, a
rational'treatment of intestinal obstruction; and, curiously,
about three months before his death from pleuro-pneuraonia
on the 6th inst., he was brought into great peril by this
very affection, and owed his recovery to the successful
application of his own well thought out principles.
Epilepsy was also a disease which engaged much of his
thou^ts, and the success with which he treated many
obstinate cases was often a matter of surprise to those who
watched them. Probably the true secret of the success of
his wonderfully useful and active life lay in the intense
interest which he took in every subject which presented
itself to him, and in the pleasure which he experienced in
viewing it in all sorts of unconventional lights, Thus his
profession, instead of wearying, never ceased to delight
him, and the greatest distress which he could have expe¬
rienced would have been forced retirement from it, even for
the purpose of a short holiday. Yet his range of interest
^and reading extended far beyond surgery or medicine. In
politics, in history, and in antiquities (especially those of
Egypt) he was an enthusiast; while his love of practical
mechanics was shown by hours of healthy work passed in
his elaborately fitted lathe and machine room, where he
constructed many of the ingenious contrivances which he
had devised for use in his practice. And his devotion to
practice displayed the peculiar loveliness of his most
unselfish character, for it was not with a mere sordid
■desire to accumulate wealth that he laboured as he did.
The great majority of the subjects of his unwearying
industry were poor people. The rich, of whom many from
all parts of the world sought his professional aid, never
found their riches a superior passport to his attention. He
'loved the poor, and without stint, or hope, or expectation of
4iny other reward than the consciousness of having aided
them, and apparently without the least idea that he was
doing anything unusual, devoted all the resources of his
most ingenious and inventive mind to their benefit. One
day in'every week—the only day, indeed, on which these
poorer people could visit him without loss, but the day on
which most professional men seek some repose from work—
was, during many of its hours, given up exclusively to
them. Hough fathers tenderly carrying crippled children
and women wheeling home-made perambulators of the
strangest type could be seen in crowds at his house every
Sunda.y the whole year through; and none of them went
away without attention. But this kind of work did
not exhaust his sympathy for them. Strange old
crippled men, youths with broken health, and such¬
like were again and again taken into his lathe room
or into some other department of his busy establish¬
ment, and either retained there for years and treated
with tenderness and affection or provided with places
at his solicitation. One final circumstance which helped
towards the great results which, in the short life of fifty-five
years, he was able to achieve must be noticed. It is the
peaceful and loving character of his inner home life. He
had no family, but the unwearying and loyal devotion of a
wife, who sympathised with him in all his undertakings
and shared in his affection for the poor, and the love, almost
amounting to veneration, of nephews and nieces and old
and attacned servants, made this inner home one of the
most restful and beautiful places upon earth. It was im¬
possible for anyone to known him intimately without
being moved to admiration by the purity and unselfishness
of his life, and even the little eccentricities that played
over the surface of his character, and which some, who
ilooked no further, thought to constitute it, were of the
iovable kind, and served but to bind him more closely to
the affection of his friends.
B. ARCEDECKNE DUNCAN, M D., M.R.C.P.
Dr. Duncan was born in 1828 in co. Kilkenny. Com¬
pleting his education at Trinity College, Dublin, he came
to London, and established and carried on for many years a
large general practice in Gower-street. A steadily increasing
practice in the west of London necessitated his removal to
Wimpole-street, where in 1881-2 he took the position of
a consulting physician on diseases of the heart, a subject
which had engaged his attention for some time, and on
which he had contributed several papers and essays to the
Medical Annual. He was also founder of, and for some time
physician to, the North-Western Hospital for Diseases of
Women and Children. A keen sportsman and crack shot,
he was at home by riverside or covertside, and held th$
challenge cup for two years at the Gun Club. His death
occurred on the 4th inst. from septic pneumonia of several
weeks’ standing.
Sljbiral Itefes.
Examining Board in England by the Royal
Colleges of Physicians and Surgeons.— The following
candidates passed the Second Examination of the Board
in the subjects indicated at a meeting of the Examiners
on the 12th inst.:—
Anatomy and Ph.ynioloyy.-~-3M\\QB Prior, Frederick Xloreenian, Richd.
Cofttee. and Carlton Oldfle'ld, students of Yoi'kshire College, Leeds ;
.)olm W. Naylev, Edward Bower, and David W. S. Muir, of Queen’s
College, Bimiinghani; John M. Hall and James McConnell, of
Queen’s College, Belf.ost; JCrnest A. Fraser, of St. Mary’s Hospital;
Francis J. Sadler, of Oxford University; William Barwrse, of Owona
(Jollege, Manoheator; James F. Ruilall, of St. Thomas’s Hospital;
Percy Armstrong Dykes and Wm. P. Gwynn, of Bristol Medical
School; Robert Charles Badhara, of Sydney University and London
Hospital; John H. Sannder.s, of Molbouriie and Mr. Cooke’s School
of Anatomy and Physiology; Francis H. Langlands, of Middlesex
Hospital; Winslow Anderson, of the University of California.
Anatojny only .—Alfred Herbert JIavdciistlu, of Yorkshire College,
Leeds; .l ohn Moses and William 8. Nowton, of London Hospital;
Saiiiuol C. C. Fenwick, of St. Mary’s Hospital.
Pliyuiotoyy nnly.—Toxn B. Abbott, of Yorkshire College, Leeds;
h’enwick 1), M. Williams, of Bristol Medical .Scliool; Brian Watts,
of Sholhold Medical School; Wintliorpo T. TiUbot, of Boston
University and London Hospital.
PasBcd on the 13bh inst.:—
Anatomy and Phyniology .—John B. Winloi', of Cluy's Hoyjital ; John
L. M. Buncli, of University College; .lames Evans, John 8ten'y,
and John K. K. Benjamin, of St. Bartholomew’s Hospital; Percy
W. Spaull and Il.'rrnld Hnskinson, of St. Thomas's Hospital;
Charles M. Mathew, of St.George’a Hospital.
Anatomy mtfj/.—Herbert B. Emerson, of Leeds and Mr. Cooke's School
of Anatomy and Jdiysiology : John W. ’Taylor, of Bristol Medical
Scliool; Cooi'go H. Tomlinson, of Queun’.s College, Birmingham;
Reginald Alcock and Uorhovt 0. Renshaw, of Owen’s College, Man-
<-hostor ; Francis R, E, Milman and Arthur E. Scott, of Middlesex
Hospital; Walter Allingham, of St. Coorgs’a Hospital and Mr.
Cooke’s School of Anatomy and Physiology: James A, Crump,
Daniel D. Brown, and Arthur George Kwbamc, of St. Bartholomew’s
Hospital; li’i-oderick A, Stephen.s, of King’.s College; Albert B.
Coupons and Alfred Hewetson, of St. Mary's Hospital ; Henry
Shophoard and (iuilford Davidson, of .St, Thomas’.s Hospital ;
15. .1- Eodlc, of Charing-croas Hospital: Thomas W. Ooldiiuy, of
Charing-crosH Uiopital and Mr. Cookes School of Anatomy and
Pliysiology ; I'Vank B. Webster, of Owens College. Manchester.
Pliydnlnyy mily ,—Percy R,, Ash, Artliur Rnowlos, and William
Parkinson, of Yorkshire College, Leeds; Albert Knapuian, John
Brown and G’oin Clegg, of Owens College, Manchester; Thomas
P. Stokes, of Shelliold and Mr. Cooke’s School of Anatomy and
J’hysiology; Francis B. Cooper, of Sheffield Medical School;
F.dward O. Walls, of Queen’s College, Birmingham ; Alfred G.
Cooloy, of Durham University: Vincent J. Robin, of Adelaide and
Mr. Cooke’s School of Anatomy and Physiology; Johns. Williams,
of J/ondoii Hospital; Charles M. .Spain, Herbert S. 'Taylor, and
William E. Kirby, of University College; C. W, Graut-Wilson and
John S. JIudaon, of St. Thomas's Hospital; Herbert W. Joyce, of
King's College and Mr Cooke’s School of Anatomy send Physiology ;
Edward C. Drake, of Westminster .Hospital and Mr. Cooke’s School
of Anatomy and Physiology ; Jamas Tliomas, of St. Bartholomew’s
Hospital; Frodoiick H. Dayna, of St. Mary's Hospital; Frederick
H R. .1. U. Walker, of St. (loorgo’s Hospital and Mr. Cooko'a
School of Anatomy and I’hysiology ; Joseph VV. Culuier, of Guy's
Hospital.
Passed on tlie Idth inst:
Analouiy nnd Physioloyy .—Cecil E. Carpmael, Arthur H. Trevor, and
Charles H. Harding, of Guy's Hospital; Hurherl .1. Finch,
of Westminster Hospital; Edward S. Winter, I’liilip L. G. Skip-
worth, and Frederick 15. A. W’ebh, of St. Bartlioloineiv’s Hospital;
Troscillian O. Anderson, of Adelaide and Mr, Cooke’s School of
Anatomy and Physiology; li^'ancis S. Boacheroft, of Middlesnx
Hospital; Cliarlo.s Howai'il Stowart, of St. Thomas’s Hospital;
John R, P, Phillips, of St. Thomas's Hospital and Mr. Cooke's
.School of Anatomy and Physiology; Franela R. S. Gamaii, of
University College Ho.spllal.
Anatomy onfy.—Lancelot M. Breton and Henry Knight, of St.
Thomas’s Hospital; Herbert T. Jenkias, of University College:
Google
176 The Lancet,]
MEDICAL NEWS.
[Jan. 17,1891
■William J. BurrouKhB and Gerard E. Lockyer, of Ouy’a Hospital;
Thomas Sinitii and Richard Bebb, of London HoKpital.
Physuilogy Samuel TL Wright, of Chariiig'cross Hospital;
Edward S. Obilcott, of St. Mary’s Hospital; William S. Mayne. of
University College: Frederick E. Feilden, of St. Bartholomew’s
Hospital; Rupert W. Dillon, of St. Thomas’s Hospital.
The Presidency of the Medical Council.—
We understand that it has been determined to let the
appointment of a successor to Mr. Marshall stand over tUI
the statutory meeting of the Council in May.
Pharmaceutical Society of Ireland.—T he
following have obtained the Licence of the Society
W. J. Meredith, G. McGuire, E. M. McSwiney, F. J.
Miller, T. J. Frazer, R. Lynch, and W. M. Bleakley.
Presentation.—U pon his retirement from the
office of senior resident medical officer at the lioyal Free
Hospital, to take up the post of surgical registrar to St.
Thomas’s Hospital, Mr. E. C. Stahb was presented by the
nurses with a handsome silver cigar case, engraved with bis
initials, as a token of their esteem and goodwill.
The “Animals Cruelty Cover Catcher.”—T his
humane and ingenious contrivance for catching rabbits &c.
will, it is to be hoped, replace the cruel steel trap which
has been in general use for some years. The Animals’
Institute medal has been awarded to the inventor, Mr, K,
Lloyd Price. A specimen may be seen at the Institute,
Wilton-plaee, Belgravia, S.W.
Lincoln County Hospital.—T he annual meeting
of the governors was held on the 9th inst., the liev. Canon
H. W. Hutton occupying the chair. The financial position
was satisfactory. The income during the past year had
been adequate to meet the expenditure, to discharge the
deficit brought forward from the previous year, and to leave
a balance in hand of £285. A resolution was adopted ex¬
pressing regret at the resignation of Mr. T. M. Wilkinson,
who for thirteen years bad fulfilled assiduously and sucess-
fully the duties of surgeon.
The British Hospital, Buenos Ayres.—A t a
special meeting of the board of management, John O’Conor,
M.A , M.D. Dub. Univ,, surgeon to the West Argentine !
Company, and late house surgeon to the Royal Portsmouth
Hospital, was elected resident mecIicaJ officer, vice Hugh
Jamieson, M.D., resigned. There were 130 applicants for
the appointment. Dr. O’Conor, after nine months’ residence
in the Argentine, has passed the three necessary medical
examinations in Spanish, in the University of Buenos
Ayres, and has been admitted into the Doctorada” of the
"Hepublic.
Bequests and Donations to Hospitals.—T he
late Mr. K. D. Catchpool of Reading bequeathed £100
each to the Essex and Colchester Hospital and the Essex
County Idiot Asylum. Mrs. Emma Holland, late of the
Gables, Osborne-road, Windsor, left by her will £100 to
the Royal Windsor Infirmary, and £60 to the Royal Hospital
for Incurables. The late Mr. George Taylor, of Noel-road,
Edgbaston, left legacies of £150 each to the General Hos-
pitu and the Queen’s Hospital, Birmingham, and £100
each to the Children’s Hospital, the Women’s Hospital, and
the Dental Hospital, Birmingham. The Saddlers’ Livery
Company has made a grant of 10 guineas to the British
Home for Incurables. The Salters’ Livery Company has
sent a donation of 10 guineas to the Queen Cliarlotte’s
Lying-in Hospital, Marylebone-road, London.
University of Cambridge.—A course of instruc¬
tion in Practical Hygiene at the Chemical Laboratory, to
be given by Mr. H. Robinson, M.A., assistant to the
Professor of Chemistry, and beginning April 17bh, has
been announced. It complies with the requirements of the
University for candidates seeking the diploma in Public
Health. The course will consist of practical instruction in
the sanitary examination of water, air, and foods, chemically
and microscopically, and in the laws of heat, the principles
of pneumatics, hydrostatics aud hydraulics, having special
regard to the requirements of medical officers of health.
It will also include the preparation of different media used
in the cultivation of micro organisms, and their cultivation
therein by inoculation from air and water. Short lectures
will be given in explanation of the above subjects, and of
analytical reports in genefal relating to water, air, and foods,
and the interpretations to be put on them.
Metropolitan Hospital Sunday Fund. — A
donation of £500 has been received from a gentleman who
withholds his name from publicity.
Small-pox in Guatemala.—O ver 20,000 persons-
are stated to have died from the small-pox epidemic which
recently ravaged several cities in the Republic. The disease'
is now reported to have abated.
Holmesdale Cottage Hospital.—T he seven¬
teenth annual general meeting of the Holmesdale Cottage
Hospital was held at the hospital, Sevenoake, on Dec. 27th,,
and a very satisfactory report was presented.
Royal Meteorological Society.—A t the ordi¬
nary meeting to be held at 25, Great George-street, on the
21st inst., the following papers will be read:—“ Note on a
eculiar Development of Cirrus Cloud observed in Southern'
witzerland,” by Robert H. Scott, M.A., F.R.S. “Some
Remarks on Dew,” by Col. W. F. Badgley, l^R. Met. Soc.
The annual general-meeting will be held at the conclusion^
of the ordinary meeting.
The Sanitary Institute.—D onations to tho-
amount of £600 have been made to the institute during the
year by the bon. officers and members of the Council, and a
considerable portion of this amount has been devoted to
rearranging and improving its museum of sanitary appli¬
ances and to the preparation and printing of a catalogue.
The museum being open free to the public, want of funds
has, we are informed, hitherto prevented the Council from
undertaking this much needed work.
Housing of the Working Classes.—A t a meet¬
ing of the County Council this week the recommendation
of the Committee on the Working-classes ‘Act, 1890, that
they should be empowered to enter into a conditional con¬
tract on behalf of the Council for the purchase of the free¬
hold of a site at the corner of High-street and Calvert-
street, Shoreditch, for a sum not to exceed £3000, was re¬
jected, on the motion of Messrs. Hutton and Marsland.
Earl Compton spoke in favour of the Committee’s recom¬
mendation.
Royal Institution.— Professor Victor Horsley,
Fullerian Professor of Physiology, R.I., will on Tuesday
next begin a course of nine lectures on “ The Structure
and Functions of the Nervous System” (part 1, the spinal
cord and ganglia). Mr. Hall Caine will on Thursday,
Jan. 22nd, give the first of a course of three lectures on
“ The Little Manx Nation and Mr. Martin Conway will
on Saturday, Jan. 24th, deliver the first of a course of three
lectures on “l^rc-Greek Schools of Art.” The Friday
evening meetings will begin on Jan. 23rd, when Lord
Rayleigh will give a discourse on some applications of
photography.
The Library of the Bristol Medico-Chirur-
GICAL Society.— The opening of this library was formally
declared on Monday, the 5bh inst., by Mr. S. H. Swayne,
the president for the year. There was an influential
attendance of members, and after the president bad re¬
viewed the history of medical libraries in Bristol, Mr.
Augustin Prichard, Dr. J. G. Swayne, Dr. Sbingleton
Smith, and Mr. Nelson Dobson spoke on the advantages
and possibilities of the library and reading-room that day
opened. A good room haa been obtained in the club-house
of the Literary and I’hilosophic Club, at 28, Berkeley-
square, and all present were emphatic in praise of the
accommodation provided. Mr. L. M. Griffiths, the
honorary librarian, will be glad to receive communications
from any interested in the matter.
The National Health Society.—U nder the
auspices of this Society a drawing-room meeting was held
on Saturday at the residence of Mrs. Fleming Baxter,
Hampstead, Sir Spencer Wells, Bart., presiding, with the
object of establishing in Hampstead a class for the hygienic
education of women. Dr. A. T. Schofield delivered an
interestiiJg address on the importance of a knowledge of the
laws of health, and Sir Spencer Wells bore testimony to the
valuable work the Society was doing, and attributed the
increase of the average duration of life to the instruction
now carried on in physiological subjects. The examination
for the certificate of the Society will take place on Jan. 20th,
at 53, Berners-atreet, W. This is a special examination
for the 500 ladies who have lately aitended Dr. Schofield’s
cou'sea on “Domestic and Personal Hygiene.”
>o^ie
The Lancet,]
APPOINTMENTS.—VACANCIES.
[Jan. 17,1891. 177 ,
Gkhsham Lectures.—T he lectures to be delivered
in Gresham College, on Jan. 20^h, and three following days
by E. Symes Thompson, M.D., F.R.C.P., will be on the
subject of the Preservation of Health.
Naval Medical Supplemental Fund.—A t the
quarterly meeting of the Directors of this Fund, held on
the 13bh instant, T. Russel Pickthom, Esq., Inspector
General, in the chair, the snm of £81 was distributed
among the several applicants.
A Rural Nursing Association, Yorkshire.—
At a well and influentially attended meetiim held on
Monday at the Station Hotel, York, Earl Fitzwilliam
presiding, it was resolved to establish a Yoi^kshire county
centre of the Rural Nursing Association, to supply trained
nurses in the rural districts. A county committee was
formed and the oiBcers of the centre were chosen.
Hydrophobia in Cape Colony.—T he Cape Argus,
the leading paper of Cape Colony, reports the following
case of death from hydrophobia resulting from the bite of a
wild cat, which, being worried by dogs, jumped in at the
open window and bit the hand of the lady so firmly that
the animal could not be removed until it had been killed.
The signs of hydrophobia speedily set in, and the woman
died after two days’ agony.
Royal Victoria Hospital, Bournemouth.—T his
institution is carrying on a large benevolent work. The
annual report, just issued, after alluding to the visit of the
Prince of Wales and the opening of the hospital, states that
duringthe past year 2303 cases were treated as in- and out¬
patients, includiog 171 minor casualties. The lioanoial
statement shows a small deficit of £76 13.s. 9c?. due to the
treasurer. The sum of £362 10^., received from life governors
qualifications, had been by resolution of the committee in¬
vested, and of the £216 16s. received from the purses on the
occasion of the Prince of Wales’s visit £158 l.s. 9c?. bad been
added to the endowment fund, and £67 14s. 3c?. carried to
the maintenance account.
METROPOLITAN ASYLUMS BOARD.
Betvm of Patients remaining in the several Fever Hospitals
of the Board at midnight on Janvam/ ISth, 1891.
Beds occupied.
6
BospltsT.
2|
K!‘~
Diphtheria.
Typhus
fever.
Enteric
fever.
& 1
4
Total
P
0
H
Eastern Hospital ..
?r.(>
40
2
62
4
870
442
North-'Western Hospital
276
37
10
822
443
Western
160
36
20
T
180
262
South-Western
18 fi
10
2
2
lOi)
840
South-Eastern „
221
Hi
48
1
280
462
Northern „
8(i7
21
11
839
480
Gore Farm „
so
-
89
800
Totals.
1480
145
2
163
8
1794
2729
SMAi,i.-i'OX.—Attox liospital ship, I.
^pprintmciits.
SucunfifulapplicanUlor Vacancies, Secretaries o/I*ublic Institutions, and
others possessinir ii^ormation sttitaMe for this column, are invited to
forward it to THE LANCET Ofloe, directed (o the Sub-Jiditor, not later
than 9 o'clock on the Thursday morning of each week for publication in
the next number. - ■
Adams, .Tames. M.D., F.R.C.S., has been reappointeil Medical Officer
of Llio Kastbom-ne B<u-ougli Saiiatoiiuin.
Baldwin, 1’. A,, M.D. I)«h., L,H,C.S. Irel., has been appointed tem¬
porary Medical Officer for the Parish of Cottiiighara, liull.
liABCi.AY, .T., M.J)., C.M. Aberil,, has been reappointed Medical Officer
lo tilt! Si. Ihuiidon Loilgo of Oddfellows, Banff.'
Beale, Pkvton T. B., 1'Ml.C.S. Eng., has been appointed Surgeon to
tho Out-patients at tho Great Northein Coiitral Hospital.
Bell, T. R W., M. B,, C.M Abevd,, has been appointed Medical Officer
for tlie Nuimeys Bistrict of the Fronie Union.
Bennett, J. R. A., has been appointed Junior Aasistanb
Medical Officer of the Smithdown-road Workhouse, Toxtefcb.
Betts, F. B., L.R.C.P., M.R.C.S., late Senior House Surgeon, has been
appointed Junior Iiouee Physician to the Westminster Xlospital.
Brickwrll, John, M.R.C S., has been appointed Medical Ofiicer for
the Stoke District of the Eton Union.
Brown, Edwd., L.R.C.P. Lond., M.B.C.S., has been appointed Medical/
Officer for the Sapperton District of tho Cirencester Union, vice
Palmer, resigned.
Brunton, Walter Eeyner, L.R.C.P. Lend.. M.B.C.8., has been
appointed Assistant Medical Officer to the Borough of Portsmouth
Lunatic Asylum, vice Nathan Raw, resigned.
Canal, Mr. C. E., has been appointed by the Administrative CounciV
Public Analyst for Parts of Kestoven, Lincolnshire.
Cato, A. M., L.R.C.P., M.R.C.S., lias been appointed Senior House
Physician to the Westminster Hospital.
Cressy, George J., L.R.C.P., L.R.C.S. Irel., has been appointed
Medical Officor of Healtli for the Warsop Urban Sanitary District
of the Mansfield Union. (In our announcement last week this
appointment should have been “G. J.,” as now corrected, instead of-
“ C. J." OresBy.)
Daniel, T. P., M.R.C.S., has been appointed Medical Officer for the
Bearoinster District 01 the Beaminster Union.
Dennino, R. N., MD.Dub., L.R.C.S.Irel., has been reappointed
Medical Officer of Health for the Elland Urban District.
Drai’er, j. W,, L.R.C.P. Lond., M.R.C.S., has been appointed Senior
Assistant Resident Medical Officer of the Smithdown-road Work¬
house, Toxteth.
Gilpin, Frank, M.B.C,S., has been appointed Medical Officor of Health
to the Stratford-on-Avon Urban and Rural Authorities. (Not in¬
cluding, as stated in our announcement last week, Evesham and
Alcester, the district having been redivided.)
Hands, Arthur, L.R.C.P.Lona., M.R.C.S., has oeen appointed Medical
Officer for the Cottage Homes of tho Wolverhampton Union.
Hunt. .J. A., L.R.C.P. Edin., M.R.C.S., has been appointed Medical
Officer for the Spondon District of the Shardlow Union.
Jf.nner, Wm., M.D. St. And., M.R.C.S., has been reappointed Medical
Officer of Health for the Baldock Urban District, Herts.
Kauepmann, Otto J., M.D.Lond., M.R.C.P., has been appointed
Resident Medical Officer to the Manchester Royal Infirmary.
Knapp, Edwd. M. M., Ii.R.C.P. Edin., M.R.C.S., has been appointed
Medical Officer of Health for the Rural Sanitary District of the.
Ross Union.
Limerick, W. S., L.R.C.P., L.R.C.S. Edin,, has been reappointed.
Medical Officer of Health for the Waterloo-wlth-Seaforth and Great
Crosby Urban Districts.
Plummer, Seldy W., M.B., B.S. Dunelm, has been appointed House
Surgeon to the Royal Infirmary, Nowcastlo-on-Tyne, vice Burdon.
Cox, resigned.
Rouse, E., L.E.C.P. Edin., M.R.C.S., has been appointed Medical
Officor for the Barnstaple Port Sanitary Di.strict of the Barnstaple
Union.
Scott, R. J. H., F.R.C.S. Edin., M.R.C.S,, has beenappointed Honorary
Surgeon to the Royal United Hospital, Batli.
Skinner, B. W., M.B., C.M. Edin., Iias been appointed Medical Officer
for the No, 3 District of the Rye Union.
Spencer, Mathew H,, M.A., M.B., C.M. Camb., has been appointed'
Resident House Physician to the Seamen's Hospital, Greenwich.
Stephenson, P., L.R.C.P., L.R..C.S. Irel., has been appointed Medical
Officer for the Ballyduff Dispensary District.
Thompson, C. S., M.B,, C.M. Edin., has been appointed Medical Officer
for the Workhouse of tlie Bideford Union, vice J. Thompson,
resigned.
YouNd, E. II., M.D.Dur., J,.R.C.P. Lond., M.R.C.S., has been re¬
appointed Medical Officer of Health for the Okohampton Rural.
Sanitary District.__
fiitsitncs.
For further information regarding each vacancy reference should be made-
to the advertisement.
Bhixton, Streatham, and Herne Hill Di.spENSAH-i.—-Resident
House Surgeon. Salary £160per iiiinum, with furnished apartments,
attendance, coal, and gas.
Central London Ophthalmic Hospital, 23Sa, Gray's-inu-road, W.C.—
House Surgeon.
CiiARiNu-CROSs Hospital, London.—Assistant Surgeon,
City liuspiTAL eor Ineecitous Diseases, Newcastle-upon-Tyne.—
Resident Medical Assistant for one year. Terms £60 for the first
{ 'ear, and, if reappointed, £70 for the second year, with board, lodg-
ngi and washing.
City o^e London Lunatic Asylum, near Hartford, Kent,—Assistant
Medical Officer. Salary £lbO per aimnni, with board, lodging,
washing and attendance. (Apply to the Clerk to tho Committee,
Guildhall, London.)
County op Dumfries.—M edical Officer for the County. Salary
.£300 per annum. He will receive the outlay.s necessarily incurred
in the discharge of hi.s duties. (Apply to Mr. Robson, County
Clerk, Dumfries,)
County Borouuh op St. Helens.—A ssistant to the Medical Officer.
Salary £200 per annum. (Apply to ilio Town Clerk, Town Hall,
St. Helens.)
CuMiiERLAND Infirmary, Carlisle.—House Surgeon. Salary £70 per
animm, with board, lodging, and washing,
Devon and ICxeter Hospital. Exeter.—Assistant House Surgeon.
.Salaiy £10 per annum, witli board and lodging, not including
alcoholic liciuors and aerated waters.
Dundee Royal Lunatic asylum, Dundee, N.B.—Resident Clinical
Assistant. No salary, but board &c.
Dundee Royal I.unatic Asylum, Dundee, N.B.—Assistant Medical
Officer. Salary £100 per annum, witli board, apartments, and
wiisbing.
General Hospital, Birmingham,—Assistant House Surgeon for six
months. Nosalary, but residence, board, and washing provided.
Dig->ed by Google
178 The l.A.NCEr,] BIRTHS, MA.BRUGES, AND DEA.THS.
[Jan. 17,1891.
- iNPiaMAIlY rOR OONSVMPTION AND DISEASES OF THE CHEST AND
Throat, 28, Margaret-ati-oet, Cavendish-square, London.—Visiting
Physician.
Ingham Infirmary and South Shikuds and Westob Infirmary.—
Senior House Surgeon. Salary £60 per annum, rising to £70, with
board and residence.
Kent and Canterbury Hospitat..—A ssistant House Surgeon and Dis¬
penser (one ofSco). Salary £60 per annum, with board, lodging,
and waging.
Lancashire County Asylum, Rainhara, near Liverpool.—Pathological
Assistant Medical Officer. Salary £200 per annum, with furnished
apartments, board, attendance, and wasliing.
Metropolitan Hospital, Kingsland-road, E.—Dental Surgeon.
Newcastle-on-Tyne Dispensary. — Visiting Medical Assistant.
Salary £120 per annum,
Parish of St. Matthew, Bethnal-green.—Dispenser (non-resident) for
the Dispensary at the Guardians’ Offices. Salary £130 per annum,
rising £10 annually to a roaximum of £150. (Apply to the Clerk,
Guardians'Offices, Bishop's-road, B.)
fftOYAi. Albert Hospital, Devonport.-Assistant House Surgeon
for six months. No salary, but board, lodging, and washing pro¬
vided.
Royal Portsmouth, Portsea, and Gosport Hospital.—H ouse Sur-
S eon. .Salary, with board and residence, £70 per annum.
eorge’s Hospital.—L ecturer on Midwifery.
St. Luke’s Hospital.—R esident Clinical Assishint for six months, with
board and residence.
Stockport Infirmary.-Q ualiflert Assistant to tJio House Surgeon for
six months, with board and residence.
'Turner’s Hospitai., Kirkloatham.—Surgeon. No salary, resiiionce at
the Hospital rent free. (Apply to Mr, Rutherford, Kirkloatiiam,
Redcar, Yorkshire.)
^irtljs, damages, ait^ gtaifjs.
BIRTHS.
•Chapman.—O n Jan. 4th, at Fitzjohn’s-avenue, Hampstead, N.W., the
wife of Charles W. Chapman, M.D., M.Il.C.P.Lond., of a daughter.
Don.—O n Jan. 0 th, at Cannekl-gardena, West Hampstead, the wife of
Deputy Surgeon-General W. G. Don, of a son, stillborn.
Emerson.—O n -Ian 3rd, at Talgarth-road, London, W., tho wife of
Surgeon-Major G. A. Emerson, I.M.S-. of a son.
Facey.—O n Jan. 11 th, at Maldon, tlie wire of W. B. Kacey, M.ll., of a
daughter.
Jessop.—O n Jan. 7th, at the Red House, Homcastle, the wife of J. W.
Jessop, L.E.C.P.Lond., M.R.C.S.Eng,, of ason.
Mac Dermott.—O n Jan. 13th, at Petwoith, Sussex, tlie wife of Ralpii
Jean MacDemott, B.A., M.B., of a daughter.
Moore.—O n Dec. 3rd, 1890, at Stony Hill, St. Andrew, .Jamaica, tho
wife of York T. G. Moore, L.R.C.P.Bcl,, M.R.C.S., of a son.
Rake.—O n Jan. 4th, at St. Ives, Fordingbriclge, Hants, the wife of
Herbert V. Rake, M.R.C.S., of a son.
MARRIAGES.
Bennett—Dowse.— On Jan. 14tlj, at St. Pancras, Frederick Thomas
Bonnett, M.R.C.S., son of the late Edwin Bennett, M.R.C.S., of
Worksop, Notts, to Henrietta Mary Horvey, eldest daugliter of
Henry Archibald Dowse, of Gordon-squoi'o.
Boxall—Watkins.—O n .Tan. 7th, at Christ Church, Albany-street,
Frank Boxall. M.It.C.S., of Rudgwick, third .son of Frances Boxall,
of Horsham, to Mary Certrude, second surviving daughter of
Charles Watkins, of 1 !), Oakley-square, N.W.
Fernie—Graves.-O n Jan. 8 th. at St. Andrew's Church, Ashloj’-place,
William Thomas Fernie, M.D., of 61, Seymour-streot, Portinan-
square, to the Hon. Jane Adele, daughter of tho third Baron
Lord Grave.s.
Mosse—Boileau.—O n Dec. lOtli, at St, John'.s Church, Meerut, Bengal,
Surgeon Charles George Di-ummond Mosse, F.R.C.S.I., M.S., second
son of Deputy Surgeon-General Charles Benjamin Mosse, C.B., M.S.
(retired), Chief Medical Officer, Colonial Service, Jamaica, to Bertlia
l.illian, eldest daughter of Brigade-Surgeon John Peter Boileau.
B.A.,M.S.
Nkatijy—Fisher.— On Jan. 7th, at Groenwicli, Andrew M. Neatby,
k L.K.C.P., of Chestnut Lodge, Chingford, to Ada, daughter of W. Ji,
risher, of 3‘lrfurt Lodge, Greenwich. No cards,
RearMAN—HOLLISTER-SIIORT,— On Jan. 3rd, at All Saints’ Church,
Fulham, S.W., Horace V. Poarraaii, M.D., C.M., of Halifax, Nova
Scotia, to Elizabeth Kate, daughter of tho late William Hollister-
Short, of Painswick, (iloucestorsliire.
Ross-Brolochan.—O n Jan. 8 th, at Rosehall Church, Edinbui'gh, by
the Rev. Wm. Morison, assisted by the Rev. T. McEwan, of Hone
Park U.P. Church, R, Russell Ross, M.B., O.M., Rio Tinto, Spam,
third sou of Lt.-Colonel A. A. Ross, formerly 17th Leicestorshire
Regiment, to Agnes Helen, youngest daugliter of Andrew Brolochan,
Esq .,.% Spenew-street, Edinburgh.
DEATHS.
OrawfoRD.—O n Jan. 4th, at Ealing, Cooper Hayes Crawford Ml) St
And., M,R.C,S., aged03. , • . .
•CROS 8 LEY.—On Jan. Ota, at Scaftcliffe llous^ Leicester, Charles Ricliard
Crosaley, J.P. for town and county of Leicester, M.R.C.S., L.S.A.,
aged 60 .
^HILLIVEB.—On Jan. 11th, at Welbeckstreot, W,, George Gulliver, M.A
■ M.B. Oxon., F.R.C.P., Asai.stant Physician to St.'rhomas'a Ho.spitai
and Physician to the London Fever Hospital, aged 39.
SP?NFOLD.—On Jan. 7th, at Rainham, Kent, Henry Penfold, surgeon, in
his 60th year. __
<tf Be. i$ charged for the InaertUm o/ Ifoticea of Births,
- Mahiages, and Deaths.
lltiiial giarg for % tnsaing
Monday, January I9.
Royal London Ofuiualmio Hospital, Moorfields. — Operations
daily at 10 a.m.
Royal Westshnster Ophthalmic Hospital.—O perations, 1.80 p.m.,
and each day at the same hour.
Chelsea Hospitalfor Women.— Operations, 2.80p.m. ; Thursday, 2.80.
St. Mark's Hospital.— Operations, 2.80 p.m. ; Tuesday, 2.80 P.M.
Hospital for 'Women, Soho-s( 1 uarb. — Operations, 2 p.m., and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.m.
Royal ORTiiOPiEDlc HosPiTAL.-^Operations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.m., and
each day in the week at tho same hour.
University College Hospital.-E arandThroatDepartm6Dt,eA.M.;
Thursday, 9 a.m.
I London Fos'r-GRADUATECouR8E.—RoyalLondonOphthalmic Hospital,
I Moorfields: 1 P.M., Mr. Win. Lang : Lacrymal Diseases.—London
TbroatHospital,Gt.Poitland-st. ;81>.M., Mr. G.Bailey: Anassthetics.
Medical Society of London.—8.80p.m. Dr. S. Mackenzie: An»mia,its
Pathology, Symptoms, and Treatment. (Second Lettsomian Lecture,)
Tuesday, January 29,
King’s College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
Guy’s Hospital,—O perations, 1.80 P.M., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursdayat 2 P.M.
St. Thomas's Hospital.—O plithalmic operations, 4 p.m. ; Friday, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London hospital.—O perations, 2.S0P.M.
8t. Mary's Hospital.—O perations, 1.30 P.M. Consultations, Monday
2.80 P.M. Skin Department, Mond^ and Thursday, 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Bleolro-
therapeutics, same day, 2 p.m.
j London Post-graduatf. coursp,.—B elhlem Hospital: 3 p.m., Dr.
Savage : Hysteria, Delirium, Mania.
Royal Institution.—3 p.m. Prof. V. Horsley: The Structure and
Functions of the Nervous System.
Royal Statistical Socif/I'Y (Lecture Theatre, Mu.seum of Practical
; Geology, Jennyn-st., S.W.). 7.46 P.M. Inspeotor-General Robert
I Lawson ; 'The Opemtion of tho Contagious Diseases Acts, from
I their Introduction in 186t to their ultimate Repeal in 1880,
; Pathological .society op London.—8.so p.m. "Dr. DelOpine: Mela-
1 notic Sarcomas of tho Liver.—Mr. T. F. Chavasse ; Divorticiilum of
! the (Esophagus —Dr. S. Oopoman: Iln>inato-porphyt'in in Urine.—
I Dr. W. Uuiitev : Subacute Gastritis.—Dr. S. 'West: Multiple Tuber¬
cular Tumours in Brain and Viscera.—Mr. Steplion I^aget: Imper-
' forato Rectum.— Dr. Job Collins: Hypertrophied Kidney.—Dr.
Rolleston : Mediastinal Tumour, Card Spochnons: Mv.L. A.Dunn:
Caries of ihoScapula,—Dr.Delopine: Charcot's Crystals and Leprosy.
Wednesday, January 21,
! National OrthoP/Edic Hospital.—O perations, 10 a.m,
Middlesex Hospital.— Operations, l p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m,
St. Barthoiximew's Hospital.—O perations, 1.80 p.m, ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.30 p.m.
Surgical (Consultations, Thursday, 1.80 p.m.
Charino-cross Hospital.—O perations, 3 p.m., and on Thursday and
EYiday at tlie same hour.
St. Thomas’s Hospital.—O perations, I.SOp.m. ; Saturday, same hour.
LondonHospital.—O perations, 2 p.m. Thursday&Saturday,samebour.
St. Peter’s Hospital, Covent-garden.—O perations, 2 p.m.
Samaritan Free Hospital for Women and Children.-O perations
2.80 p.m.
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1,30 p.m. ; Skin Depart¬
ment, 1.46 p.m. ; Saturday, 9.16 a.m.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great OaMOND-sxREE'f.—Operations, 9.80 a.m. ;
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
London Post-qraduati-; Course.—H ospital for Consumption, Bromp¬
ton : 4 P.M.,Dr. J. Mitchell Bruce : Demonstration of Cardiac Cases.
Royal London Ophthalmic Hospital, Moorfields; 8 P.M., Mr. J. B.
Liiwford : Optic Neuritis.
Epidemiological Society of London.—s p.m. Sir W. Moore: Is
Colonisation in Central Africa by Europeans possible 'I
Royal Microscopical Society,—8 p.m. Annual Meeting. President’s
Address. Election of Council and Oflicors.
Thursday, January 22.
8t. George’s Hospital.—O perations, l p.m. Surgical Consultations.
Wednesday, 1.30 P.M. Ophthalmic Operations, Friday, 1.80 p.m.
University College Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 a.m.
London Post-graduate CoursF/.—N ational Hospital for theParalysed
and Epileptic: 2 p.m.. Dr. Boevor : The Anatomy of the Brain,—Hos¬
pital for Sick Children, Gt. Onnond-st.: 4 P.M,,Dr.Voelcker; Demon¬
stration of Pathological Spoeimons.—London Throat Hospital, Great
Portland-stroot; 8 P.M., Mr. Goo. Stoker : Noumso.s of tW Larynx
Royal Institution.—3 p.m. Mr. Hail Caine; The Little Manx Nation
Britlsh GvnA'ICOlooical Society.—8.30 p.m. Dr. R. t. Smith : Two
cases of Tubercular Salpingiti.s. Introductory Address by the
President (Dr. Cliapman (irigg).
Neurological Society of London (National Hospital, Queen-sq.).—
8.80 P.M. Annual Meeting. Election of Officers. Address by the
Pre.sident-elect (Dr. Bristowe) on Tho Eolation of Mind to Brain.
lOOj^le
Thb Lancbt,]
NOTES, COMMENtS, AND ANSWERS TO CORRESPONDENTS. [Jan. 17,1891. 17»
Frida?, January 28,
’ BOYAL SrtUTU LONDON OPHTHALMIC HOSPITAL.—Operations, 2 p.m.
London Post-gkaduatb Course.—H ospital for Consumption, Bromp-
ton: 4P.M., Dr. J. M. Bruce: Demonstration ol Pulmonary Case.s.
Clinical Society op London.—8p.m. Living Specimens:—Mr. S. Paget:
A case of Acromegaly.—Dr. B. Squire: A case of Lupus which has
recovered undertreatment. 8.80 p.m, President’s Address. Papers:—
Dr. Sidney Phillips; Two cases of Typhoid Fever fatal at a late
' period of tlie disease without Ulceration of the Intestine.—Mr. C.
. Slanaell Moullin; Tlivee cases of Septiciemia due to Sewer Gas.—
Dr. Hale White and Mr. W. A. Lane: A case of Stricture of tho
Pylorus following upon Hydrochloric Acid Poisoning in which a
modified Loreta’s operation was performed.
, lUJVAL Institution.—9 p.m. Lord Rayleigh: Some Applications of
' Photography.
Saturday, January 21.
Middlesex Hospital.—O perations, 2 p.m.
' UNlVEasiXY COLLEOE HOSPITAL.—Operations, 2 p.m. ; and Skin Depart¬
ment, 9.15 a. M.
London post-graduate Course.—H ospital for Diseases of the Skin,
Blackfriars: 2 P.M., Dr. Payne: The Diseases called Lichen.—
Bethlein Hospital: 11 A. M., Dr. Percy Smith; Clinical Demonstration.
.Royal Institution.—3 p.m. Mr. W. Martin Conway: Pre-Greek
Schools of Art.
METEOROLOGICAL READINGS.
(Taken dailt/ at 8.S0 a.m. by Stewaa-d'e InstrumentB.)
The Lancet Office, Jan. lOth, 18tl.
DaM.
Baromsber
reduoad to
Sea Level
and
Dlreo-
.tlon
of
Wind.
Bu^
Wet
Sulb.
Solar
Badia
in
Vaouo,
Maxi'
mum
Temp.
Sliade.
Uln.
Temp
Rain-
faU.
4
Betnarki at
8.80 A.u.,
30-10
.s.
80
48
34
29
Overcast
„ 10
.%-64
.S.
22
34
21
' .
Foggy
,1 If
30 67
S.
28
3t
21
Foggy
„ 12
30-67
S.W.
28
44
24
Foggy
„ 33
80 04
N.E.
43
4-2
45
28
Foggy
.. 14
30-68
N.U.
30
39
58
43
37
Cloudy
„ 16
30-51
N.K
33
63
83
32
Cloudy
Ilotfs, Comwts, 1^ ^nsters to
Corrapoitkiits.
It is especially requested that ea/rly intelligence locaX
e/vents hxvi/ng a medical interest^ or which it is desirable
to bring under the notice of the profession, may be sent
direct to this Office.
All communications relating to the editorial business of the
journal rmst be addressed “ To the Editors."
Leisures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private <»•
foimation, must be authenticated b^ the names and
addresses of their writers, not neeessa/nly for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
he marked and addressed *'To the Sub-Editor.”
Letters relating to the publication, sale, and advertising
departments of THE Lancet to be addressed "To the
Publisher."
We cannot undertake to return MSS. not used.
Medical Literature.
It is interesting to compare tho progress of medical science measured
liy the literature pulilished on the subject last ye.ar with that of the
previous year. In ISSO about 133 now medical and surgical works
emanated from the press, and forty-nine new editions of old or
slandai-d works. In 1800 tho number ran up to 143 new works, and
tiiero wore fifty now editions. On the other hand, theological,
llclinnal, and liistorical literature shows a marked decrease in the
nuinbev of now volumes published.
Inquirer .—Wo are not aware of any seientiflc observations to sub-
shantiate the popular idea.
I’RACTlCJi IN THE AUSTRALIAN COLONIES.
To the JSditora of THE Lancet.
Sirs,—W ould any of your readers kindly inform mo as to tho openings
for practice in tlie Australian colonies V Whicli is tho best colony to go
to? And whether a practice could bo acquired by purchase, .as at home?
Also whether tlie climate would be suitable for a man sulfering from
clironic Inryngi-al eat-arrh and winter cough, without wasting or other
symptoms 7 1 am, Sirs, youi-s truly,
Jan. 9th, 1891. F. O. G.
PEROXIDE OF HYDROGEN IN DIPHTHERIA.
To the JSditors of The Lancet.
Sirs,—I t has been stated in a newspaper that a 10 per cent, .solutiom
of peroxide of hydrogen injected into animals renders them proo
against diphtheria. Whether this be so or not, I am glad attention baa.
‘ been called to the subject. When I was in tho United States four
years ago an American doctor (whose name I unfortunately cannot
remember) told me of the marvellous ofiect of peroxide of hydrogen
used as a throat spray in diphtheria. Since then in two epidemics I
liave been able to tost its value with very satisfactory results, never
losing a case. The spray should be used I’ery frequently, and when
symptoms of dyspnma come on the application of the spray will bring
away the false membrane in large <iuantities. In one case the nurse
told me the patient became so asphyxiated she thought he would die
at once. There was no time to send for mo; so sho used the spray,
which brought away large flakes of false mombranei, and the patient
was relieved and ultimately recovered. Its action seems to bo to seize
on the false membrane, quickly detaching its superficial layers. It, of
course, has no effect on tho healthy membrane. Other remedies should-
be used at the same time, but tlie spray cannot be used too often.
Half an hour should elapse before painting the throat with any other
application. I am, Sirs, yours obediently,
Tunbridge Wells, Jan. 3rd, 1881. W. Stei’hknson Richmond.
A Subscriber for Twenty Fears.—Trephining in epilepsy >vas suggeate*!
by a speaker in a discussion which ensued on tlie rea<ling of a paper-
by Dr. C. L. Dana at the American Neurological Society a short
time ago.
Case.—The offer is not a generous one. But a qualified man managing
a branch practice for one unqualified is in siidi a false position that
we see no remedy.
A. B. C. should consult his usual medical attendant. We do not
prescribe.
M. is referred to a paragraph on page 63 in The Lancet of .fan, 8rd last.
INSOMNIA.
To the Editora of The Lancet.
Sirs,—I am a great sufferer from insomnia. I have tried every con¬
ceivable remedy. By medical advice and under careful supervision I
have used opium by mouth and by smoking, morphia by hypodermic-
injection, chloral, bromide of potassium, and coca in every form, with¬
out one particle of benefit. If I am not unreasonable, I hope some of
tho readers of THE LANCET will suggest a remedy for my wearisome-
complaint. I am sixty-nine years of age, and I enjoy fair healtli. I
eat moderately, particularly of meat. My daily drink consists of two-
ounces of old whisky, freely diluted. All iny functions are regular,
and I do not suffer from any feeling of indigestion, flatulonce, or palpi¬
tation. I get gout once a year, but not severely.
I am, Sirs, yours truly,
J. Thompson,
Cheltenham, Jan. 7tl), 1S91. .Surgeon-Qenoral, retired.
' Hyoscine, paraldehyde, or sulphonal might be tried.—E d. L.
ASSISTANTS.
To the Editora of THE Lancet.
Sirs,—I am surprised on reading The Lancet of last week to flndi
two qualified medical men ignoring what hundreds of able men have
been—that is, unqualified ivssistant.s-whilst walking the hospitals. I
for one have to thank myself for becoming an unqualified assistant
whilst attached to my hospital. I learnt whilst in that capacity many
useful things which 1 could never have attained at the hospital.
There are bad mon in every rank, botli qualitlocl and unqualified, and
you will never be able to get rid of them. A friend of mine will publish
shortly a pamphlet on the "Usefulness of Unqualified Students to-
Medical Men." Ho is F.R.C.S.Edin. and surgeon to a cottage hospital.
This pamphlet will set at vest a voxwl question.
I am, Sirs, your obedient servant,
Jan. 13th, 1891. JUSTUS (M.B.Edin.).
St. Kitta.—Wo do not think any risk is likely to arise from contact with',
paper handled by a person suffering from the oi dinary auwsthetic-
loprosy.
C. A. L.—Tlio custom varios in different piace.s. It i.s well to ascertain-
tlio local etiquette and follow it.
Ahtmaii.'!.—1. .cs.—2. Tho subject is optional.—3. The question should-
bo referred to tho Registrar.
U. S. r.—The matter is under consideration, but is .scarcely one of
urgency.
X. F.—Facts are wanted in proof of tho liypothcsis.
Erratum.—I n the remarks by Mr. Page appended to tiie report of the-
case of tumour of the pal.ate at the Newcastle Royal Infirmary pub¬
lished last week, p. Sr>, the word “historically’’ should read hi.ato-
lo'iicatly.
Digitized by
Google
180 The Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 17,1891.
Dkntal Hosi’iTAL 01' London.
The advertlaemeiit in our issue of Juu. 3rd relating to the Dental
Hospital of London should read that five Aseixta/iit Dental Surgeons
are required, and not five " Dental Surgeons," as printed. For cor¬
rected advertisement -s^e this week's issue.
C0HHUN1CATI0N3 not noticed In our present number will receive atten¬
tion In our next.
■CouMUNiCATiotvs, Letters, dto., have been received from—Mr. Bryant,
London; Mr.Hutchinson,London; Dr.Horrocke,London; Mr.Watson
Clieyne,London; Dr.MacAlister, Cambridge; Messrs. Grace, Bristol;
Dr. W. S. Palm, Largo ; Mr. Foulerton, Cliatham; Messrs. Bailey
and Son, London ; Mr. E, W. Wlilte, Birmingham ; Messrs. G. Street
and Co., London; Mr. J. P. Gray, Nottingham; Messrs. Burrouglis
and Wellcome, London ; Mr. Piggott, Clare; Messrs. Opponhoiiner
and Co., London; Mr. J. Chatham, Edinburgh; Messrs. Battle and
Co., Paris; Mr. Slenvan, London ; Dr. Collie, London ; Mr. D'Arcy
Power, London; Mr. J. II. Potter, Collumpton; Mr, Brown, New
York ; Mr. W. Jones, Liverpool; Dr. Mackinnoii, Tripoli; Mr. E. Du
Cane, Hull; Dr. Aveling, London ; Mr. Mason, Bow ; Messrs. Black
and Co., London ; Dr. McLauchlan, Edgbaston ; Messrs, Longmans
and Co., London; Mr. Shawe, Bath ; Mr. G. S. Bigg; Mr. Clement
Lucas, London ; M. Borthier, Paris ; Mr. Mosse, London ; Dr. W.
Carter, Liverpool; Mr. Walker, Surrey ; Mrs. Bovlll, London; Dr. L.
Atthill, Dublin; Rev. Mr. Tooth, Croydon; Mr. Neene.s, Hammer¬
smith ; Dr. Waldo, Paris ; Dr. Greonwell, Finchley-road; Mr. Sisson,
Newcastlo-on-Tyne ; Mr. Neatby, Hampstead; Dr. Ronnie, Harro¬
gate; Mr. Cottingham, London; Mr. Dripple, Suffolk ; Mr. Byerley,
•Portsea ; Mr. Hawson, Swindon ; Mr. Lewis, Raiiihill; Mr. Bayes,
Wellingborough ; Mr. Coghill, Birmingham ; Messrs, RIcliardson and
Co., Leicester ; Mr. Tippett.s, Birmingham ; Messrs. W. H. Smith and
•Son, London ; Dr. Barlow ; Dr. Mackay, Spain ; Mrssrs. Richardson
Bros., Liverpool; Mr. Halford, sen., London; Messrs. Horner and
Sons, London ; Mr. Gravatt; Mr, Greville, Buxham ; Messr-'i. Brown
and Son, Douglas ; Mr, Powell, Boiiniernouth ; Messrs. Blondeau
• et Cie,, London ; Mr. Moreland, London ; Mr. Ford ; Messrs, Beal and
Son, Brighton; Mr. Wright, Thirst; Mr. W. S. Richmond, Tunbridge
Wells ; Mr. Holland, London ; Dr. Cartwright Hoed, llerschel, Cape
Colony; Mr.Weatberby, Bath ; Mr, Byerley, Portsea ; Messrs. W. and
C. Davies, London ; Mr. Bromgoole, St. Helens ; Mr. W. Turner, West
Brighton; Mr. Tomlinson, Glasgow; Mr. Wright, Penzance ; Mr. E.
Bast, London; Dr. F. P. Atkinson, Surbiton ; Dr, T. T. Reynolds,
Liverpool; Dr. Garden, Aberdeen; Mr. McAlister, London; Dr. S.
Mackenzie, London; Dr. O’flanlon, Durham ; Mr. F. R. Humphreys,
'London; Mr. J. E. Lane, London; M. Nichol, London; Mr. Thies,
London; Dr. Tomkins, Leicester; Mr, Shaw ; Dr. Handford, Notting¬
ham; Mr. Krohne, London ; Mr. Orifliths, Clifton ; Mr. Keyworth,
Bouthport: Mr. Phillip, Newcastle-on-Tyne; Messrs. Hoplrinson and
'Co., Notts ; Mr. Hatton, Hanley; Dr. Evans, London; Messrs. Barker
and Son, London ; Mr. Williams, Machynlleth ; Messrs. Griffin and
Co,, London; Herr Kornfeid, Berlin ; Dr, Browne, London ; Rev. J.
SpittaJ, Eyde; Dr. Whittle, Belfast; Mi-. Roberts, London ; Dr. .Saul,
'Lancaster; Mr. Roland, Barcelona ; Mr. Hornibrook ; Mr. Boulton,
Plumstead ; Mr. Lewie, London ; Alumnus ; A Subscriber for Twenty
"Years; F. O. G.; Devon, London; Secretary, Kent and Canterbury
Hospital; A. li. B. ; Dowker, London ; Secretary, Devon and Exeter
Hospital; Delta, London; Dr. G., Kilbum ; Secretary, Norfolk and
Norwich Hospital; J. H., Scarborough ; Imperial Qranum Co., Now
York; Royal Medical Benevolent College, London; Coombs Eureka
Co., London; S. S., London; Gyneecologist; Malbine Manufacturing
Co., London; B. ; M. X., London; Matron, Canterbury; Sleigh,
London; W., London; C. A. L.; A. B. C.; G. S. T.; X. Y.; Case;
M.; A Reader.
Letters, eaoh with enelosu^, are also acknowledged from—Dr. Mitra,
Kashmir; Mr. Spurr, Batley ; Dr. Power, Cork; Mr. Newsholme,
Sheffield: Mr. Welch, Stirling; Mr. Kemp, Castleford ; Mr. Owen,
Fishguard; Mr. Hankinson, Bournemouth; Rov. Mr. Carr, Snod-
land; Mr. Neatby, Greenwich; Mr. Orchard, Dublin; Mr. Windle,
Halifax; Mr. Tully, Hastings; Dr. Hoffman, Swansea; Mr. Tyte,
Minchinbampton; Dr. McCulloch, Guornsoy; Mr. Detmold, Bourne¬
mouth ; Mr. Hugo. Reading; Mr. Mitchell, Taunton; Mr. McEweii,
Mossbank, Pooleme; Mr. Cbadderton, Haslingden ; Messrs. Keeno
and Asluvoll, Loudon; Mr. McLelland, Dalbeattie; Messrs. Aitchesoii
and Co., Manchester; Mr. Williamson, Lincoln; Messrs. Tayler and
Co., London ; Dr. Calder, Queensland, N.S.W.; Dr. O'Connor, Buenos
Ayres; Mr. Bnidburn, Holloway; Mr. Maberley, Ivanhoe; Dr. Evans,
Llanerchymodd; Mr. Evans, Radnor; Mr. Jonos, London; Mr. Hill,
Edinburgh; Rev. Mr. Smith, Ely; Mr. Lucas, Cambridge ; Mr. Qabe,
Glaiuorganshire ; Dr. Bigg, London ; Mr. Joll, Liverpool; Dr. Martin,
Walkden; Mr. Lockwood, Allorton; Dr. Mercier, Catford ; Mr. Wise,
Trowbridge; Dr, Holmes, Southara; Mr. Hinde, Banbury; Mr. Hay,
null; Mr. Jackson, Leicester; Mr. Saunders, Eton ; Mr. Martindale,
London ; Mr. Tayloe, St. Leonards-on Sea; Messrs. Taplin and
Tanner, Winchester; Mrs. Reynolds, Kensington ; Mr. Adams, West
Mailing; Dr. Monckton, Marden ; Mr. George, Preston; Mr. Clegg,
Windermere; Mr.Loxton,Bristol; Mr.Warnor,Sheffield; Mr,Walker,
Camberley; Mr. Wright, Lancashire; Mr. Blair, Leeds; Mr. Niven,
Oldham ; J)r. Windle, Halifax ; Mr. Meacham, Manchester; Dr. Kite,
Sheffield; Mr. Halford, London; Mr. Miller, Dartiuonth ; Dr, Owen,
Micheldean ; Mr. Heywood, Manchester; Messrs. Mottershead and
Co., Manchester; Mr. Warburton, Treherbert; R, O. B., London;
Malins, London; A. M. D., London ; J. F. A., Clioshire: Sanitary
Co., London; J.B., London; Mason, London; Hackney Furnishing
Co., London; Practitioner, London; Matron, Eastbourne; Bryant
Co., Toronto; Beeches, Yorks ; Elder, London; A. W., London; T.,
London ; Immediate, London ; Medicua, Manchester; Auxilium,
London; Moschus, London ; Vigo. London ; Viola, London ; Omega,
London; Surgeon,NortliA’ich; Assistant, London ; J. C., St. George's-
road ; Modicu.s, London ; E. C., London; Alpha, London ; D. W. Z.,
Liverpool; Physician, London; Medicus, Sheffield; Alpha, Uptoii-
park; Gamma, London; T. R., London; Forceps, London; M.B.,
Southport; Aurelius, London, Fidelis, Essex.
Newspapers,—TT esJtm Marcury, Newcastle Daily Chronicle, Liverpool
Daily Post, South Eastern Qazelte, jS'(!o^Kj/ta7i, Sydney Daily Telegraph,
lieadiny Mereury, Minhig Journal, Leeds Merenry, Weekly Free Presa
and Aberdeen Ilerald, The Tocsin, Surrey AdmrtUcr, City Press,
Personal liiyhls Jouimal, Bristol Mercury, Hertfordshire Merai/ry,
WimUorand Eton Gazette, Sunday Times, Sheffield Daily Telegraph,
Metropolitan, Builder, West Middlesex Standard, Law Jotimal, Spec¬
tator, Chemist ajid Druggist, Colchester Mercury, Banffishire Journal,
Architect, Phaamiaoeutical Journal, Windsor and Eton Express, Cape
Argus, Manchester Exammer, Melbourne Argus, Cape Times, The
British Weekly, Liverpool Courier, Oldham Weekly Advertiser, Bury
E'rce Press, Neweaslle Daily Journal, Le Temps (Pa,-is), Devon Daily
Gazette, Durham Chronicle, La Presse Mddicale (Bjuxelies), Jsc., have
been received.
SUBSCRIPTION.
Post Free to any part of the United Hinodoii.
One Year.£1 12 6 | Six Months ... _ £0 16 B
To China and India .....One Year 1 16 10
To THE Continent, Colonies, and United
States. . Ditto 1 16 8
post Office Orders and Cheques should be addressed to The Publisher,
Thb Lancet Office, 623, Strand, London, and crossed ** London and
Westminster Bank St. James's-square."
-£0
0
0
0
0
ADVERTISING.
Books and Publications (seven lines and under)
Official and General Announcements ..
Trade and Miscellaneous Advertisements .. «
_ _ Every additional Line
Frontpage per Line
Quarter Page - —
Half a Page - —
An Entire Page .. .. .. .. .. _ 6 6 0
The Publisher cannot bold himself responsible for the return of tesM-
monials &c. sent to the office in reply to advertisements; copies only
should be forwarded.
NOTiCK,—Advertisers are requested to observe that it Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
6
6
«
0
1
1 10
2 16
An original and novel feature of " The Lancet General Advertiser" Is a special Index to Advertisements on pages 2 and 4, which not only
affords a ready means of finding any notice, bub is in Itself an additional advertisement. '
Advertisementii (to ensure insertion the same week)8hould be delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet,
Terms lor Serial Insertions may be obtained of the Publisher, bo whom all letters relating to Advertisements or Subscriptions should be
Addressed.
Advertisements are now received ab all Messrs. W. H. Smith and Son's Railway Bookstalls throughonb the United and all other
■Advertising Agents.
Ag«nt for tlM AdyertlBoment Department in France--J. ASTISB, 80, Bne Caumtrtin. Parte,
Di, edbyCjOO^IC
THE LANCET,
funton ^0st-Krakate Course:
ON TUB
NATURE OF LUPUS,
WITH ESPECIAL REFERENCE TO ITS RELATION
TO TUBERCULOSIS.
Delivered at the Examination Hall, Jam. SOth,
By JONATHAN HUTCHINSON, r.R.S., LL.D.
Gentlemen, —In oar last lecture I did my best bo intro-
•fiuce you to a knowledge not so much of lupus as of a lupus
family. I denied that there was any one disease which
could be detached from all others to which that name was
appropriate. Even under the name “lupus vulgaris,” and
putting aside all the affections known as erythematosus, I
tried to show that we have a group of diseases which offer
very considerable differences amongst themselves. We con¬
sidered the cases in which through a long series of years,
perhaps a whole life, the disease restricts itself to a single
patch, and contrasted them with others in which it spreads
in multiple manifestations over face, limbs, and to some
extent over the trunk also. The remarkable differences in
character and course which are presented when the hands
and feet are its seat were pointed out. By the production
of numerous portraits I endeavoured to prove that in some
cases lupus of the vulgaris form is attended by such an
amount of oedematous swelling as to earn the epithet “hyper-
trophicus,” whilst inothers it creepsslowlyover a large extent
of surface, causing no swelling whatever. We discussed also
the different conditions under which the disease begins, its
preference for special parts, and the probable causes of such
preference, and passing from these we made a few general
statements as to the connexion or otherwise of the malady
with previous disorder of the patient’s health. Lastly,
certain other affections—lichen scrofulosorum, scrofulous
ulcerations, and tuberculous ulcerations—were mentioned
as being examples of disease of the skin quite apart from
lupus, but in close connexion with the tendency to tubercle.
Une definite object was kept in view in all that was said.
It was to answer the question as to whether lupus could
fairly be considered as a term synonymous with tuberculosis
of the skin. This question I was inclined, for the present
at any rate, to answer in the negative and to allege that
all the various lupous affections are examples of a chronic
infective inflammation, depending upon the action of irri¬
tants, cold, and the like, upon the tissues of individuals of
somewhat specialised tendencies as regards tiieir cell nutri¬
tion. You will see tliab the question is, to put it in other
words. Is lupus due, directly or solely, to bacillary in¬
fection, or is it an example of chronic inflammation
occurring in those predisposed to receive the implantation of
bacilli, and, it may be, itself much favouring their growth ?
If 1 seem to trouble you with much detail, and possibly
some iteration on this point, my excuse is ready. The
subject is one the import of which extends far beyond its
apparent bounds. We are on a battleGeld of rival doctrines,
and of doctrines too which embrace a very wide patlio-
logical domain. We are, indeed, seeking to determine the
relationship between scrofulosis and tuberculosis. The
iatter name we now all of us restrict to conditions charac¬
terised by the presence of the tubercle bacillus, and we are
Mvestigating the facta as to whether there is or is not a
special condition of nutrition, or of general health, which in
many instances precedes the introduction of these parasites,
and which may, in many others, bo itself the eflicient cause
of many others. If there be such a state, then I think we
may conveniently continue to recognise it under the old
name of scrofula. It must be remeinberod that we are as
yet only on the threshold of inquiry as to the relations of
lese minute vegetable forms with the animal organism,
i erhaps, after all, when we call them indiscriminately by
the name of parasites, we are dealing rather hardly wibn
them, lb may be tJiat in some sense, or some form, they are
almost constantly present, and need only suitable concomi¬
tant condition^ to evoke their ascendant activity. Botanists
uave, I believe, in the case of lichens, devised the term
consorbism instead of parasitism to denote the inextricable
January 24, 1891.
and invariable union of an alga with a fungus which occurs
in that class of plants. Let me remind you of the strangely
wonderful facts as the possible duration of periods of
lateDc,y even of the best specialised forms of particulate
conbagia. In syphilis two months, or nearly, may elapse
before the local lesibn is produced ; in hydrophobia there
may be two years or more between the date of the bite and
the outbreak of the disease; and in leprosy the patient may
have left the place where he acquired the taint and may have
lived at home in England for ten years before the fiik sign
of contamination appears. Or, to turn to a vegetable
growth of larger size and higher organisation, there are
those who believe, in the case of ringworm and alopecia
areata, that tbe fungus which caused the one may, after an
apparently perfect cure extending over twenty years, pro¬
duce the other also. In none ot these instances of long
latency of a specific parasitic organism is there, I freely
admit, much reason to suppose that anything in. the
state of tbe general health induces or precipitates the
final outbreak, but it may easily be that with aqme
other organisms such changes may be waited for. In
this way it w’ould be very easy to construct a plausible
theory of the relationship of tubercle bo scrofula, and
to hold that the one, a constitutional condition wholly
independent- of tlie parasite, produces the states which
favour the growth or the latter from germs previously
present, but wholly latent. That the tubercle bacillus can
remain latent for very long, probably for wholly indefinite
periods, is almost certain, and it is further quite impossible
for anyone to deny that it may perhaps be conveyed from
parent to child at the time of conception or during the
period of intra-uterine life. Everything favours the belief
that the particulate poisuns of small-pox and syphilis may be
so conveyed.
To return to lupus: I need scarcely again remind you that
one of the boons which we hope that we have received at
the bands of our Berlin confrire is that his discovery has
given us a means of ascertaining, respecting any given case
of lupus, whether or not the bacillus has been developed in it.
We will now, if you please, proceed with the clinical
description of different forms of lupus, and in so doing shall
keep constantly in view the question as bo how tar all
varieties of it may be held to prove that those in whom
they occur are in a state of health predisposed to the
development of the tubercle bacillus. In order that I may
make these lectures as useful to you as possible in a prac¬
tical way and apart from all doctrinal controversy, it will,
I think, be convenient that 1 should take a portrait as
illustrating a type-form of each. We will begin with the
type which stands at the greatest distance from lupus
vulgaris, the most purely erythematous variety of lupus
erythematosus. Tbe portrait .published by the New Syden¬
ham Society in its “Atlas of Skin Diseases ” is tbe best
that I can produce. The subject of the case was John B.,
a delicate lad of fair complexion, aged sixteen, in whose
family there had been no proved occurrence of tuberculosis.
His affection had been present nearly a year. As you see,
it consisted of dusky red areas, involving the whole of lua
nose, and in bat’s wing or butterfly form the whole of bis
cheeks also. There was a conspicuous disc in his upper lip
and other erythematous patches on his ears and chin. Those
on the nose and cheeks were continuous, bub those on the
ears, lips, and chin were nob po. Tiie arrangement
was one of precise symmetry. Nowhere was there any
crust whatever, and with the single exception of the very
characteristic disc on the upper lip was there any appreciable
thickening of the affected parts. The affected surfaces
were simply red, dry, and slightly rough and desquamating.
On minute inspection of the margins of tbe patches small
conlluenb papules could be distinguished, and in a few
places an ill-marked scar. So little were the conditions
suggestive of ordinary lupus, or even of some forms of the
©lythemabous type, that several who saw the patient asked,
Why not call the disease dry eczema, why lupus at all? In
reply to this, its persistence, its arrangement, its spreading
qualities, and the production of discs sufficiently charac¬
terise it.
When lupus erythematosus spreads to other parts than the
face and ears it usually attacKs next the bands. I show
a portrait of the condition produced on the hands froin-
anofcher patient, for the lad whose face is portrayed did not
suffer from them. In this second case the subject was again
a very delicate boy, and the disease had as usual begun in
the face. I believe that he died of chest mischief not very
" -oogie
182 Thb Lancet,] ME. JONATHAN HUTCHINSON ON THE NATUKE OF LUPUS.
[Jan. 24, 1891.
loDg after the sketch was takes. Yoa will see that the
sketch shows dusky erythema of all the fingers and of parts
of the bands. It is partly in margined patches and
partly diffuse. The disease had been present seven years,
and the boy had previously suffered terribly from chil¬
blains. As a rule, lupus erythematosus affects only the
exposed parts, and in this conforms to the rule of lupus
vulgaris. Not infrequently, however, its patches occur in
the scalp, and every now and then we see a crop on the
upper part of the chest. In yet more infrequent cases the
feet are affected, and last of all it may become diffuse, and
travel over the whole body. Sometimes its patches are
very large and erythematous only; in others they consist
of a number of confluent discs. Unlike what occurs in
common lupus, symmetrical arrangement is the rule. There
are cases, however, which are not symmetrical, and a few
in which the original patch remains for a long time single.
It is liable to attacks of febrile exacerbation, often amount¬
ing to erysipelas, and after these not infrequently some of
its patches disappear. It is made worse by exposure either
to cold or heat. Its origin is very frequently in a sort of
chilblain on the nose, and I think still more frequently in a
sunblain. When once a patch has been produced ib is
clearly infective, and others are sure to follow. Lupus
erythematosus is a far more serious disease than lupus
vulgaris. Its subjects are not, as a rule, destined for
long life. It reveals delicacy, and is, very often indeed, in
association with a strong history of phthisical antecedents in
near relatives. Its subjects may die of an attack of erysipelas
or of pneumonia, or may pass into extreme debility, with or
without tuberculous disease of tlie lungs. I regard it as far
more frequently associated with definite tuberculous ten¬
dencies than is lupus vulgaris, and I speak from carefully
collated statistics of both. Permit me, however, here to
interpolate an addition to what I said in my last lecture on
this point, as I fear I may have conveyed an erroneous
impression. When I spoke of its being comparatively rare
for the subjects of lupus vulgaris to pass into phthisis, I was
thinking or my own experience and of that of some of my
London friends. I ought to have told you that a different
mcture has been drawn by several continental authorities.
Dr. Block, Dr. Leloir, and others have collected statistics
which, on this point, differ very widely from mine, and show
that in their experience lupus and tuberculosis of internal
viscera are often associated.* It is difficult to explain the
discrepancy completely, but it may perhaps be due in part
- to our facts having been collected amongst patients whose
social conditions were not similar.
Two or three main features distinguish lupus erythema¬
tosus from vulgaris; its symmetry and the absence, which
is all but universal, of any tendency to open ulceration, are
among the chief. It restricts its action to a large extent to
the more superficial layers of the skin, and the scats which
it leaves behind it are far less conspicuous than those of its
sister malady. Although its tendency to disorganise and
leave scars is undoubted, yet in not a few instances ib is
difficult to demonstrate them. The more simply* erythe¬
matous the eruption, in any individual case, the less will be
the resultant scars ; it is chiefly the so-called “discs” which
leave them. Lupus erythematosus begins, as a rule, some¬
what later in life than vulgaris. Although ib has been reco¬
gnised almost in infancy, it is rare until after puberty, and
It may be suspected that the influence of the sexual system
upon the forces of the circulation takes some share in its
production. It appears to be very closely connected with the
liability to chilblains; and in some of the cases, especially
in those in which the extremities are affected, a liability
to disturbances of the circulation of the same nature as that
whichoccursin Raynaud’s disease is observed. Sofaraslam
aware, no demonstration of tubercular bacilli has ever yet
been made in this disease. Sections of the skin show, as a
matter of course, great dilatation of bloodvessels, and they
also, in many instances, especially where thickened discs
have been developed, show a cell infiltration into the spaces
of the corium very similar to that seen in vulgaris. It
must be remembered in relation to these facts that far
fewer opportunities occnr for microscopic examination in
this malady than in the other.
1 do nob purpose to trouble you with any detailed
grouping of the cases which come under the name of
“ lupus erythematosus.” It must be sufficient to say
that no two cases are exactly alike, and that the limits
1 Tbeee statistics were re'erred to in njy Uarveian Lectures.
of variability are wide. I will illustrate this pictorially
by bringing'before you the original portraits of Cazenave,.
next those of Hebra, and then a number, of others by more
recent authorities. You will see that the chief differences
are as to whether the erythema is attended by thickening;
in the form of little discs or not, and as to the arrangement
of the patches. There is, however, one definite peculiarity in
many cases, which is sufficient, I think, to constitute a sort of
sub-species. I refer to the implication or otherwise of the-
sebaceous glands. Let me ask you to contrast for a moment
the portrait which I have already shown you with that pub¬
lished by Hebra. The subjects of both are young men, and
in both the patches extend in their usual bat’s-wing forhii
over nose and cheeks. The local conditions are, however,,
very different. In mine there is simply a dusky redness,
with roughness and slight desquamation. In Hebra’s the-
patches are pitted all over with minute depressions, the-
orifices of dilated sebaceous glands, and they present, in>
addition, an innumerable number of black comedones. It
is perfectly clear that in Hebra’s case the sebaceous glands
are very conspicuously, if not primarily, affected; whilst
in mine they have wholly escaped. Another portrait of
Hebra’s stands about half-way between the two. To this
variety of lupus we may suitably give the name of
“ sebaceus,” one which has been used by former writers, and
which I well remember in my student’s days was constantly
employed by the late Mr. James Startin. Its conditions-
are depicted in a portrait in Willis’s Atlas, which bears the
title “ hypertrophia folliculoruni,”but which shows the face
of an adult man whose nose and cheek are roughened over
by enlarged and plugged sebaceous glands, arranged in
the bat’s-wing form. The same statements are true
concerning a portrait of Cazenave’s under the name of
“ acne sebacea,” in which there is an abruptly margined
patch involving the whole of the middle of the nose
from root to lip, and which is covered with a dry
sebaceous crust. There is another isolated patch near the-
middle of the cheek. Some of the cases which liave been
named “ seborrhma sicca,” and especially those in which the-
disease occurs on the face only, and the patches are abruptly
margined, belong to this malady. The test questions in
diagnosis between seborrbcca and lupus are. Can the patches-
be easily cured ? and Do they leave scars ? Although lupus
sebaceus is clearly a form of erythematosus rather than of
vulgaris, yet in some of its characters it approaches the
latter. It is very slow in its advance, has comparatively
little of erythematous congestion, often i-emains for a-
long time as a single patch, often develops, by the local
production of satellites, in an unsymmetrical manner,
and shows little or no tendency to become diffuse.
In addition to these features we must note that in many
cases it develops closely adherent crusts which cannot be
removed without bleeding, and beneath which little papil¬
lary buds are found. The comparison of skin roughenetl
by lupus erythematosus to a piece of orange-peel is some¬
times very apt, and we -nay note that when in connexion,
with lupus erythematosus of the most characteristic forms,
when s;ymmetrical patches are developed in the concha of the
ears, these almost always take the sebaceous character and
assume the orange-peel condition.
The next portrait which I have to introduce to you is-
that of a lad named Philip H-. He was twelve years
old when the portrait was taken, and was delicate and
liable to a bad cough. He had suffered very much from
chilblains, and had the scar of an old scrofulous ulcer
under the right side of the jaw. His grandfather had
been the subject of psoriasis. I must ask you to look
at the portrait of one of his arms, as well as that of
his face, for the eruption occurred symmetrically on the
upper extremities and face, and presented almost similar
characters in both. You will see that his cheek showe
numerous little acne-like pustules which occur in groups,
and are surrounded by tufts of dilated capillaries. You will
observe that the conditions are most severe in the middle of
the flush patch, where, as I have already demonstrated in so
many cases, lupus is so apt to begin. In this part you will
see that there is a certain amount of solid infiltration
beneath and around the spots, and that a certain amonnt of
scarring has been left. If we turn to the ear we shall find
that almost the whole of it—helix, antihelix, and concha—
is congested and covered by numerous very small semi¬
transparent papules, accompanied with some desquamation.
I will not trouble you wiw a detailed description of the
appearances shown on bis hand and forearm, but just
The Lancet,]
MR. JONATHAN HUTCHINSON ON THE NATURE OF LUPUS. [Jan. 24, 1891. 183
ask you to observe that the little papules leave cicatricial
pits, and that as regards the parts affected—for instance,
the tips ot the elbows,—the lesions are located much as in
psoriasis. We must remember that his grandfather had had
psoriasis. As regards the history of the case, the eruption
was said to have begun on his face, hands, and arras during
the first years of infancy, when the doctors called it “red
um. ” ^n some slight degree it persisted through childhood,
eing worse, as his mother said, in spring and fall. At the
age of ten be was first brought to me, and he remained
under my observation occasionally until he was sixteen,
when I lost sight of him. I believe I have not told you
that there were spots on his lower extremities similar to
those on his arms, but less numerous, and a few even on his
buttocks. I must add, also, as proving that the disease
was not wholly one of sebaceous glands, that red spots
would occasionally occur in the palms of his bands. I claim
this case, so far as his cheeks and ears are concerned, as
an example of lupus, and should give to it on account
ef its having been preceded by infiammation of sebaceous
glands the name of “ acne-lupus.” You will have noted that
it was definitely connected with constitutional delicacy in
the direction of scrofula, and also that there was a remark¬
able tendency to chilblains; nor am I willing to forget
that the boy had a possible inheritance of psoriasis. My
hypothesis is that the disease was a composite one, and re¬
sulted from a partnership of inheritance in the three direc¬
tions named.
In the group of cases illustrated by the above narrative
4ind portraits, I place the cases of Miss H-already nar-
rabea, and, as a third, that of a Miss S-, whose case I will
not trouble you with, but which presented exactly similar
features. I have seen also several others, for the most part,
however, somewhat less well characterised. Under the
name of “ acne-lupus” we should have to group certain
other rare cases, m which, so far as the face is con¬
cerned, the conditions were much like those shown in
Philip H-’s portrait, but without the accessory con¬
dition of eruption on the extremities. In some of these the
condition of lupus growth—i e., apple-jelly d^osit—at the
base of the acne pustules was much more definite than in
H-’s case. Some of these cases verge towards lupus
vulgaris in that the patches remain long local, and show
little or no tendency to symmetry; whilst in others, as in
the case of the hoy H——they are symmetrical, and seem
to form a connecting link between lupus erythematosus and
vulgaris.
I have next to ask your attention to a variety of lupus
erythematosus which is well illustrated in the portrait
which Dr. Stephen Mackenzie has kindly allowed me to copy.
He has published it under the name of “lupus psoriasis”inthb
Transactions of the Clinical Society. You will be struck by
the remarkably symmetrical arrangement of the eruption, as
shown on the face, chest, upper arms, and forearms. No one
will, I think, doubt that the disease is one essentially of lupus
erythematosus ; but it is remarkable not only on account of
parts being affected which very rarely suffer in that disease,
but that on the face .there, is much more tendency to
ulcerate, form scabs and leave scars than is usually seen in it.
I take next the portraits of the arms and face of a bey,
named Hilliev, who when aged nine in March, 1887. was under
my care in the London Hospital. He has been subsequently
under that of my friend, Mr. Malcolm Morris, hut I believe
that neither of us has seen him forseveral years. We should
both be very glad to find him again. By the side of the portrait
of Hillier’s arm I place that of a young lady who has,
like him, been under the cave successively of several London
specialists. I am sure that you will admit that the con¬
ditions shown in the two arms illusttrate the same disease.
I put the cases of theboyllillier andMissN-together, feel¬
ing sure that no one will dispute that they are examples of the
same disease; and as far as I knew they are the only examples
of it as yet published. I possess a third portrait of the forearm
Ufa girl showing almost similar conditions, but my know¬
ledge of the facts of that case are not aullicient to justify its
being placed in the same category. In the two cases adduced
the disease has run a similar course. Their chief difference has
been t^t iu the boy Hillier the face has been attacked,
whilst in Miss N-the arm alonehassuffered. In both cases
i have had the patient under the observation either of myself
or my friends for a long series of years, and am able
w state something as to the progress of the malady,
the portrait of the boy Hillier was taken in March, 1877.
^ind that of Miss N-in July, 1882. Roth patients are
still living and in good general health. In both the disease
has made exceedingly slow but gradual advance in some
parts. In neitlter has there been any tendency to ulceration or
increase of inflammation, and in both it must be remembered
that the tendency to natural increase has been kept back
by treatment with caustics.
Have I any right to claim this disease as belonging
to the lupus mmily ? To substantiato such a claim I refer
you not so much to the arm as to Hillier’s face, upon which
you will see numerous irregularly-shaped patches spreading
serpiginously by a narrow border of minute tubercles, and
leaving a thin scar behind them as advance. Such
conditions constitute a lupus process. Were we to exclude
these cases from the lupus family, we should certainly have
to invent another name for them, for they present no simi¬
larity to anything else.
The consideration of the above cases takes me by what
is, I think, a quite natural line of connexion to certain
others, concerning which there is yet more dispute as to
whether they can be claimed as having affinity with lupus.
I allude to certain very rare cases in which conditions some¬
what resembling those of n®vus spread serpiginously during
many years. 1 show you the best portrait I possess illus¬
trating this condition. It is that of the arm of a young lady
of title, in whom the condition had been present from early
infancy, and had possibly advanced from a congenital port-
wine stain. It had ultimately, at the age of fifteen, when
the portrait was taken, spread over the upper arm, forearm,
and down to the hand. Now, apart from the fact that
indefinite spreading is not one of the tendencies of ordinary
na'vi, I must ask you to notice in the portrait that the
conditions, although obviously vascular, are not like those
of lupus. You will see that the patches are like little
rings or discs, which are often confiuent at their edges, and
by the enlargement of which the disease advances. It is
obviously an infective process with which we have to deal,
and the rings are very like those shown in the boy Hillier
and others which are often seen as parts of the process of
lupus erythematosus. Two cases quite similar to my own
have recently been placed on record—one by my friend
Dr. Jamieson of Edinburgh, and the other by Dr. Lassar of
Berlin. The arm of Dr. Lassar’s patient was in every
detail exactly like the portrait which I have shown to you;
and I am very glad to have Dr. Lassar’a support to my
diagnosis of lupus, supported as it was by the most
important fact that in his case the patient had sym¬
metrical patches on the cheeks. Both in Dr. Jamieson’s
case and my own the changes were wholly restricted
to one limb. Neither in Dr. Jameison’s nor Dr.
Laasar’s was there any history of congenital n.'cvas,
whilst in mine that history was unquestionable.
I trust that I have succeeded by the citation of these cases
in proving that a serpiginous and infective process, some¬
times resembling nocvus, and sometimes in direct associa¬
tion with it, may assume conditions whicli may compel us
to associate it with lupus. In some cases the association
seems to be with lupus vulgaris, and in others with lupns
erythematosus. This step is for me a nib.st important one,
for I wish now to make a yet further one, and to ask you
to allow roe to bring into the lupus group a form of disease
in which part of we changes consist in dilatation of the
lymph spaces; whilst others, but less conspicuous ones,
involve the bloodvessels. This is the disease, to which
I have ventured to give the name “lupus lymphatious,” a
name which, allow me to mention, has by no means been
accepted by my dermatological confreres. This disease is
sometimes developed in connexion with congenital nmvus
or port-wine stain ; but in some of its most marked
examples there is no such history. Its characters are well
marked and very similar in all cases, and that its anatomical
features are those of lymphangioma no one, I believe, dis¬
putes. It is when we turn from its pathological anatomy
to its clinical features that we become, as I think, forced to
acknowledge that it is one of the lupus group. Let us
note that its alliance is with lupus vulgaris, and not with
lupus erythematosus. Its patches, so far as I know, never
became symmetrical, nor is it ever generalised. It is a
local malady, beginning from some local irritation, and com¬
mencing usually in young subjects. It spreads serpiginously,
produces satellites abundantly, is attended by more or less
of inflammatory action, ana is attended by recurrent
attacks very like erysipelas. It is curable only by just
the treatment one would adopt for lupus—free erasion or
destruction by the cautery. Like lupus, it is remarkably
184 The Lancet,] DR. STEPHEN MACKENZIE ON ANEMIA AND ITS PATHOLOGY. [Jan. 24,1891v
pereisbent; aod unless the cautery has been very freely used,
or often repeated, it quickly springs up again at the margins
which have been left. Such is lupus lymphaticus; its
clinical features are wholly different from those of any
disease hitherto described under its anatomical name
lymphangioma, and they correspond very closely with
those of lupus vulgaris. I have to add to this sketch of the
malady the statement that conditions precisely similar are
not very infrequently seen on the tongue. Of this I show
you two or three portraits. I have not as. yet‘observed
them on any other parts.
A very interesting case has recently been published by
Df. Prince Morrow of New York, with good portraits, to
which he gives the name of “tuberculosis papillomatosa
cutis.” The patient was a young Italian. In 1885 one
of his hands was amputated on account of scrofulous disease
of the wrist and carpus, and at that time a warty tubercle
was observed on his nose. In May, 1887, the disease on
the face had advanced, aod his conaition is shown in the
engraving, taken from a photograph, which 1 place before
you. Tne state in 1888 is exhibited in the coloured portrait.
The disease (which, as stated, bad begun on the nose) had
advanced by infective spreading over the upper lip and
over both cheeks, and saiellite patches had been produced
on the upper eyelids and forehead. The nose bad been to
some extent destroyed, but a feature upon which Dr. Morrow
insists strongly is that no ulceration preceded the papillary
formations. The peculiarity of the cose consists in the fact
that the affected parts were covered all over at an almost
uniform level by florid papillomata. These vegetations easily
bled, and when exposed to the air the surface smarted much.
By microscopic examination Dr. Morrow proved the presence
of tubercular elements with a few bacilli in the papillse them¬
selves. Thepatientwasinfairbealth andsbowednosymptoms
of internal tuberculosis. Now a** to the nature of this case
there can be not the s'igbtest hesitation. It was an infective
inflammation of the skin of a destructive kind attended in
small quantity by tubercular elements. The development
to some extent of vascular papill® is a well-recognised part
of the process in most cases of common lupus. The special
feature in this case is simply their immense number and their
presence in all parts aod in all stages. I cannot feel any
doubt that the case belongs to the lupus family, although,
of course, differing greatly from the ordinary conditions of
common lupus. Its name should, I think, be “lupus papillo¬
matosa” of Morrow.
In close juxtaposition with Dr. Morrow’s remarkable case
I place the disease described by Dr. McCall Anderson of
Glasgow under the name of “lupus verrucosus,” and close
t-o it comes Ii^us necrogenicus or verruca necrogenica of
Dr. Wilks. These are varieties of the same affection,
but occurring in connexion with different exciting
causes. They are for the most part peculiar con-
(litiODS which lupus takes when occurring on the
hands or feet. The one is a disease chiefly incident to
medical men and post mortem assistants, and is caused
by needle or knife point pricks received whilst making
necropsies. Whether infection by bacilli is necessary, or
whether simply irritation by morbid fluid is sufficient, is an
open question. I have seen many of them on the hands of
surgical friends, and have cured many. They often cause
gland abscesses in the axillm, but these do not, I think,
show any specially scrofulous characters. A friend of mine
had several of these patches on both hands when a student,
and a succession of axillary abscesses in consequence. He
cured most of the patches completely by applications of
acid nitrate of mercury. The treatment being inconvenient,
however, he failed to cure one rather large patch. This
patch he has now had in statu, quo for forty-live years. In
winter it always swells and inflames, and sometimes
suppurates, hut in summer gets nearly well. If covered by
plaster ic always softens and improves, and it would no
doubt have been cured long ago had his vocation permitted
of rest to the hand and systematic treatment. Although
lupus necrogenicus has been proved in many cases
to be tubercular, yet during this very prolonged period
no signs of infection have occurred. The condition
of the patch has olw'ays been a good test of tbe state of its
possessor’s health.
The “lupus scldreux” of Vidal is closely connected with
the disease just described. It is not connected with any
necrogenic poisoning, but then it must be remembered thH.*-
this history is by no means invariable in tbe so-calle>1
necrogenic lupus. Tbe tuberculosis verrucosa cutis of Kiehl
and Paltauf is clearly for those who approve the construc¬
tion of a lupus family one of its members. It ocouvs on the
hands of those who handle animal products, and is charac¬
terised by the production of warts without conspicuous'
ulceration. The absence of the latter has probably much to
do with tbe vigour of health of the patient.
ABSTRACT OF
C|c fdtsmitimt ftthtOT
ON
AN^^MIA, ITS PATHOLOGY, SYMPTOMa
AND TREATMENT.
Delivered before the Medical Society of Lmdon, 1891,
By STEPHEN MACKENZIE, F.R.C.P.,
I’HESIDENT OK THE FUNTRUIAN .SOflETV, PHYSICIAN
TO TUB LONDON HOSl’IT.^1..
LECTURE II.
Mr. President and Gentlemen,— Before proceeding to
describe the symptoms of anmmia, I must briefly remark ois
one form of secondary anmmia which has important bearings
on the pathology o( amemia in general—viz., paroxysmal
hiemoglobinuria. To Dr. Copeman^ we owe some exceed¬
ingly valuable observations on the changes in the blood in
this remarkable disease. He has shown that in the attacks
a loss of from 129,000 to 824,000 red corpuscles per cubic mm.
may occur, and even the largest of these numbers was de¬
stroyed in a quarter of an hour. At the same time the
percentage of hremoglobin fell from 53 to 49, Equally
important changes took place ia the arrangement and
forms of the corpuscles ; rouleaux formation was partially
or entirely lost, and poikilocytosis was observed. The fact
iliat such rapid changes may take place in the form of the
corpuscles is of extreme importance, and goes to show that-
the poikilocytosis met with in other forms of aammia may
be due to destructive changes.
The symptoms of ancermn, — Whenever ha-morrhage of
more than a trilling extent occurs there must be a reduction
in tlie volume of the blood—oligo^mia. The water is soon
replaced by tbe plasma from the lymphatic system, the
deficient albumen and salts are supplied by tbe fwd, but
riie globular deficiency, which mainly affects the red cot*
puscles, remains for a time. The number of red corpuscleo
continues to fall for some days after tbe hicmorrhage. In
neatly all forms of anmniia oligocythemia is present. The
only form of primary anrcmia in which this does nob
necessarily occur is chlorosis. The greatest reduction occurs
in pernicious anosmia, traumatic amemia, and in some cases
of anmmia due to malignant growths. Hayem has recorded
a case of puerperal hmmorrliage iu which the corpuscles
were as low as 850,000 (17 per cent.)(.iuinquaud, a case of
purpura with 740,000; H6rard, one in which they fell ta
620,000 ; and I have published a case of purpura- in which,
there were only 290,000, or 5-8 per cent., the day before¬
death. To what degree may the corpuscles be reduced
without death necessarily occurring ? 1 think we may fiM
7’5 per cent, as the lowest limit to which the corpuscles
may sink without a necessarily fatal result. It is convenient
in practice to have a scale of the degrees of ansemia.
Anivinia commences at 80 per cent.; it is decided between
66 and 50, grave at 60, very grave at 35, and fatal at
7'.5 per cent. I have pointed ouV that below 50 per cent,
there occurs a tendency to bumiorrhage, pyrexia, and other
serious consequences of anaemia. Hayem has given a.
much more exact scale, which takes cognisance of the
functional value of the blood and the worth of the individualr
coniuscles. ■*
The size of the corpuscles —In anmmia the range is much
greater than in health. Microcytes, corpuscles from 2-5 to
4 ii, and megalocytes from 9 to 16 ix are met with in aD
forms of anmmia, primary and secondary. “ Eichorst’o
‘ 'J'rans. Med. Soc,, 1889, p. 258, and Practitinnor, Sept., 1890, p. 101..
Rrit. Med. .lour., vol. ii. 1.83;).
-J TiiJ; Lanckt, vol. ii. 1883, l>. 1017. * Dii .SiVJig, p. 107..
Dig Coogle
TSB Lancet,] Dll. STEPHEN MACKENZIE ON ANEMIA AND ITS PATHOLOGY. [Jan. 24,1891. 185
•«orpu8clee” are microcytes, of deep colour, believed by
Eiciiorst orieinally to be peculiar to pei-nicious anaemia,
but several observers have shown they are present in other
varieties, and may be absent in pernicious aoiemia. .They
are, however, very frequently found in the latter. “ Poikilo-
cytis,” the name given by Quincke to the variously deformed
corpuscles, are found in all forms of anaemia, though more
marked in pei'nicious anjomia than in other varieties;
pear-shaped, battledore, rod-shaped, bent, and irregularly-
outlined shapes are met with. Nucleated corpuscles are
iilso occasionally found in the blood in anaemia. These
.alterations in shape show that some change has taken place
in the blood, constructive or destructive, but the observa-
4;ion3 of Boas and Copeman in paroxysmal hemoglobinuria
teach us caution as to the inferences drawn regarding their
origin. The colourless corpuscles are not increased in
ordinary anaemia except as a premortal phenomenon. The
Jiccmoglohin richness was dealt with in my first lecture, and
I will here only add that the reduction is sometimes below
that of the corpuscles in cases of cancer.
Haimorrhages.—la. anaemia there is a liability to hsemor-
rbages, external and interstitial. Amongst the former epis-
taxis, bleeding from the gums, and metrorrhagia are the
most common; and amongst tbe latter htemormages into
the retina and skin. Betinal haemorrhages have not tbe
significance at one time attributed to them, and Ibave shown
that they are dependent on the degree of anaemia, and not
.on its nature.^ Corpuscular deficiency has more to do with
their occurrence than deficiency in heemoglobin, hence their
•frequency in pernicious anuemia.
Circulatory organs —Anaemia tends to produce dilatation
of the heart and gives rise to murmurs heard over the heart
:&.nd in the veins of the neck. Eichorst has recorded a dia¬
stolic murmur in some cases of pernicious anaemia, which
Dr. Ernest Sansom'’ and Sckrwala have explained as due to
the venous bum in the neck being conducted downwards
and beard duriog tbe diastole. The increased arterial ten¬
sion described by Broadbeut, Sansora, and Bramwell is
accounted for by Cobnheim’s explanation that anaemia is an
exciter of tbe vaso-motor centre. In extreme degrees of
anastnia the artery is exceedingly compressible, and empty
between the beats. The oedema of anmmia is cbiefiy due to
•the failure of the heart caused by fatty degeneration, but
ibydraeraia and hypalbuminosis must favour its occurrence.
The urine is more fully considered under pernicious
■anicmia, but in amemia generally it is pale and wanting in
•solids. Functional disturbances occur in tbe alimentary
and nervous systems, which are characteristic of aniomia.
Pyrexia occurs in all forms of severe ancemia. It is some-
(times considerable in pernicious anmmia, but is not wholly
wanting in chlorosis.
CMorosui —Duncan first pointed out that in chlorosis the
•essential feature of tbe disease is the deficiency in tbe
amount of bocmoglobin, and all subsequent workers have
confirmed tbe accuracy of his observations. In some cases,
■which Laache would call “pseudo-chlorosis,” there is no
■deficiency in the corpuscles ; in others which he would call
“true chlorosis,” tbe corpuscles as well as tbe hEcmoglobin
are deficient, though not to the same degree. The cor¬
puscular worth is reduced to 0’60 or 0'30 as a rule, the
normal — 1 ’0, In severe cases of chlorosis the corpuscles may
be reduced to as low as 9.‘17,360, 187 per cent. (Hayeni),
What is especially characteristic of the corpuscles besides
their deficiency in biemoglobin is their small size, a great
many being between 3 and 6 fi. Poikilocytosis occurs even
in cases not severe, as in a drawing exhibited of the blood
of a girl, aged eighteen, with 85 per cent, of corpuscles and
35 per cent, of bjnmoglobin. lletinal hmmorrhages are
not common in chlorosis apart from inflammatory changes,
but papillitis and papillo-retinitis are comparatively fre¬
quent, especially in hypermetropes, “Febrile chlorosis”
only occurs, according to Hayem, when the corpuscular
iichfiess, expressed in healthy corpuscles, is below 14 millions,
hut slight perturbations of temperature are not uu-
^ranioD. Constipation is often associated with chlorosis,
but the frequency with which constipation occurs in
young people who are nob anfomic, indicates that its im-
VortBDce as a cause has been over-estimated. Chlorosis is
occasionally hereditary, and possibly congenital, and the
•ohanges described by Virchow in the heart and bloodvessels
point to developmental defects. The character of the blood,
MS poverty in hjeriioglobin, comparative richness in other
albuminates, the markedly renovating influence of iron, all
indicate a defective hmraogenesis—a “hypoplasia” of the
blood as well as of the bloodvessels (Inrmermann), There
is little or no evidence of increased blood destruction. On all
these grounds we are justified in regarding chlorosis as due to
defective blood formation, often associated with, and pos¬
sibly in some cases due to, disturbances in the generative
system. Most probably both are due to inherited or
acquired developmental feebleness of the blood-forming
capacity, which, treated promptly and properly in most
cases, is of transitory duration, bub which, more profound
in degree or imperfectly treated, may prove a life-long com¬
plaint.
Pernicious anmmia .—First described by Addison in his
lectures in 1843, which were published in 1853, the disease
was known to few until .Guseerow in 1871, and Biermer, who
gave it the name of “progressive pernicious anmmia,” in 1872,
drew attention prominently to the subject. Since then
numerous observers have added to our knowledge, amongst
whom must be specially mentioned in our own country Pye-
Smitb, Frederick Taylor, Coupland, and William Hunter.
The latter has added more to our knowledge than any
other individual worker since Eichorst published his valuable
monograph in 1878. The disease begins insidiously with
increasing pallor and weakness, without loss of tlesh. This
specific gravity of the blood is lowered to from 1038 to 1028,
its alkalinity is lessened, and the solids of the blood are
greatly reduced. Great attention has been devoted to the
red corpuscles. Their cohesiveneas is lessened, so that
rouleaux formation is usually absent. The numbers are
extraordinarily reduced, so that when the disease is first
recognised they are below 50 and often below 30 per cent.
(24 to 14 millions per cubic mm.). In fatal cases they may
sink as low as 378,000 per cubic mm. (Lupine), or .300,000
(Worm-Miiller). Quincke has published a case in which
they were reduced to 143,000 (2'8 per cent.) without death
resulting, but Quincke’s numbers read much lower than
those of any other observer. It may be stated that in fatal
cases the numbers generally sink to 18 or 16 per cent, before
death. Poikilocytosis is usually very marked and more
extreme than in most other forms of anaemia. As regards
their size, few are normal, the majority are larger than
natural, whilst in most coses microcytes (Eichorst’s cor¬
puscles) are present. Their vulnerability is increased, as
shown by the separation of the hfemoglobin from the stroma
in some cases (Mackern and Davy, Bramwell), and the
readiness with which blood crystals are formed (Bond and
Copeman). Their hiumoglobin capacity is in moat cases
increased, so that the worth of the individual corpuscle is
increased. This is neutralised to some extent by the fact
that the amount of hasmoglobin being distributed among a
smaller number of large corpuscles, must expose a smaller
superficies than the same amount distributed among a larger
number of small corpuscles, lletinal btemorrhages are as a
rule present, and papillitis occasionally occurs. Petechise
occur in the skin in some cases, whilst external haemor¬
rhages, such as epistaxis, bleeding from tbe gums, and
uterine haemorrhage, frequently are met with. After death
haemorrhages beneath the serous membrane and into the
brain and its membranes are not uncommon. The circu¬
latory phenomena of anaemia are pronounced. Pyrexia is
present in the majority of cases at some period of the
disease, and the temperature may be as high as 104° F.,
but does nob continue long. Some cases are apyrexial
throughout.
The urine presents peculiarities which, according to some
observers, are of the highest importance with regard to the
diagnosis a/nd pathology of the disease. Several observers
(Pagsre and Pye-Smith, Bristowe, Osier, Eichorst, Hunter,
and Mott) have noticed that the urine is sometimes dark in
colour, and this boa been shown by Huntei^ to depend on
the presence of large quantities of “ pathological urobilin,”
whiUt Mott® has stated that ib may be due to normal
urobilin. Dr. Hunter considers that the excretion of large
quantities of pathological urobilin is valuable evidence of
excessive destruction of blood-corpuscles. He has also found
in the urine pigment granules in renal cells and casts, and
after death similar pigment granules in the epithelium of
the convoluted tubes, which show tlie'r blood origin by
staining blue witli ferrocyauide of potassium and hydro¬
chloric acid. Dr. Hunter finds, too, a remarkable increase
in the amount of iron in the urine—a fact which had also
'fclphdhal. Kedetys Transaotiona, vol. iv,, p.
0 /Aitvfnosia oi Diaoasos of the Heart, p. IW.
" ObsorTiitiona oji the Urine in Pemicioua Annemia, Practitioner, 1889.
8 The Lancet, vol. i. 1890, p. 287.
186 The Lancet,] DR. W. DUNCAN ON DISEASE OF THE UTERINE APPENDAGES. [Jan. 24, 1891.
l)een observed byFinnyfrom analyses by Professor Reynolds.”
So many important inferences resting upon the occurrence
in this disease of dark-coloured urine containing an exces¬
sive amount of normal urobilin or pathological urobilin, I
wish to raise the question whether dark urine is present in
all cases of pernicious anmmia at some stage, in several
of my own, confirmed by post-mortem examination, the
urine was never noticed to be dark, being “amber” or
“straw-coloured” tlirougbout. Moreover, in several pub¬
lished cases by others the urine was not observed to be
dark. Thus it is stated to have been “pale” in a fatal
ease by Ryrom Bramwell and a fatal case by Mott; “ very
pale” in two cases (one fatal) by liramwell, and “ natural”
in four cases (one fatal) by Bramwell and one by Musser.
Eicborst found it dark in some cases, but says it is usually
of a bright-yellow colour. In Laache’s corefulJydetailed cases
the urine was in some instances always pale. It is true that
in my own cases observations were not specially directed
to this point, but the many observations made are against
the dark colour having been overlooked. The same remark
applies to those of other observers. The colour of the
unoe, the nature of its pigments, and the amount of iron it
contains are clearly points to wbieii future observers must
direct their attention. It is possible that the cases in which
the urine is dark may constitute a separate category from
those in which this peculiarity is wanting.
Dr. Hunter, struck with the similarity of the hmmolytic
rocess in pernicious an.'Bmia with that induced in animals
y the action of toluylene-diamine, more especially from
the limitation of its action to the portal blood, was led to
the conclusion that the poison causing the blood destruction
was of a cadaveric nature, and produced within the gastro¬
intestinal tract and absorbed thence. Accordin^y, he
instituted investigations which led to very important and
interesting results, and has demonstrated that in a case of
pernicious anaimia there was found in the urine a large excess
of the aromatic sulphates derived from the proteids of the
food. He has, farther, been able to obtain from the urine
two ptomaines identical with putrescine and cadaverine
obtained from putrefying meat, and a third ptomaine which
appears to be a special diamine body, distinct from
putrescine and cadaverine. Putrescine and cadaverine are
not poisonous, but have this special importance, that they
are the products of bacterial action, and their presence
suggests the possibility of the existence in this disease of
other micrd organisme. Some of the symptoms of pernicious
wsemia suggest the presence of a poison. Exacerbations
in a ease of Dr. Hunter’s occurred from time to time,
ol^acterised by nervous phenomena, pyrexia, intestinal j
disturbance, and the evidence of increased blood destruc-
tion in the increased colour of the urine and the presence
of blood pigment granules, dark froces, and a deepening
of the lemon tint generally present. Dr. Hunter, there- .
fore, feels justified in drawing the conclusion that the i
special factor required to initiate the symptoms peculiar
to this form of anmmia is the presence, under certain
favourable conditions, of organisms of specific nature
within the gastro-intestinal tract. These favourable con¬
ditions are such as have been met with in the organic
diseases and functional disturbances which have been found
in tills disease. Dr. Mott does not allow that there is
always a relation between the pyrexia, diminution of cor¬
puscles, and the colour of the urine. He writes ; “ It does
not seem to me certain that this theory is proved, for in
many diseases in which there is ulceration of the intestines
lasting for months or jiears, and in which tbewbolecontents
must swarm with micro-organisms of many kinds, with
everything to favour absorption, there is no pernicious
anosmia. Constipation and anmmia certainly go together,
Md by curing the former the latter is much benefited, but
in such cases of fiocal poisoning the corpuscles are not broken
down, but insufficient colouring matter is made.”
The_ condition of the organs after death in pernicious
anmmia indicate tbe operation of three processes. 1. The
effects of the aneemia, in the bloodless condition of all parts,
with tbe exception of the spleen in some cases, and in the
fatty degeneration in tbe heart and bloodvessels. 2. The
activitjr of the cytogenic organs, especially the marrow,
which 18 generally found red and vascular, and containing
many developmental forms of red corpuscles, in parts where
it is normally yellow and fatty. S. The evidences of limmo-
lysisand of efforts for tbe removal of the broken-down blood-
^ Brit. Mod. Jouin., vol.!. 1880, p. ii.
corpuscles: the former shown in the large amount of iron io'
the liver, and sometimes in the spleen; and the latter in
the blood pigment found in tlie epithelium of the kidneys.
Thus the evidence clearly points to blood destruction being
tbe cause of pernicious anmmia in certain cases. Tbe patho¬
logy suggested by Dr. Hunter is so complete and coherent,
and receives so much support at various points, that I am'
convinced of its adequacy and accuracy in certain cases. In
cases in which the urine is pale throughout, containing no¬
excess of normal urobilin, or pathological urobilin—if such
should be proved to exist—some different evidence of blood
destruction, or of imperfect blood formation, must be found.
Ehrlich’” remarks, “ Degeneration and regeneration course
side by side in uncomplicated anivmia: it depends upon the
preponderance of one or other process whether this simple
amcmia ends in a cure or in the progressive pernicious form.”'
ON CHRONIC DISEASE OE THE UTERINE
APPENDAGES;
WITH SHORT NOTES OF THIRTY CONSECUTIVE CASES-
TREATED BY ABDOMINAL SECTION.
By william DUNCAN, M D., F.R.C.S.ENG.,
OBSTETRIC rnySICIAN TO, A^D LECTOREK ON OBSTETRICS AN1>
OVN.ECOLOOY AT, THE MIDDLESEX HO.Sl’ITAL.
(Concluded ffom 2 >ci(/e J.),'.)
Pa-ssing on now to diseases of the ovary, the first and
moat common is chronic, ovaritis. This may either be
secondary to the acute form, or it nlay be due to extension
of inflammation from tlie uterus and tube, or as a result of
peritonitis and peri-ovaritis. The last is a by no means
uncommon cause; the ovary gets bound down by adhesions,,
which after a time contract and produce a cirrhotic con¬
dition (Fig. 6). In other cases the ovary is enlarged, but as-
Fig. 0.
Ovaries and tulics matted together !)y adhesion.-*.—Oao.nfis cirrhotic';
coats of tubes thickened from chronic salpingitis.
a result of the chronic inliammation there is an increased
development of fibrous tissue in the stroma (Fig. 7), with-
tbe formation of small cysts. In either case it is obvious
that ovulation can only proceed with great diiliculty, and
the follicles as they enlarge may be unable to reach the
cortex.
Congenitally ill-developed ovaHes are not common ; when
they do occur the uterus is, in mj' experience, likewise ill-
developed. The subjects of this condition may be fine hand¬
some women, but they sufier-from dysmenorrheea, and if
married are sterile. This drawing (Ing. 8) shows the con¬
dition well. I removed the specimen live years ago from a
young woman aged twenty-one, who consulted me for in¬
tense dysmenorriicca. She began to menstruate at seven¬
teen, always lost onlv very Rttle for two days, but she-
described the pain slie suffered as “fearful agony.” It
began a week before the period, and readied its acme two
days after the period was over. She was a tall, fairly healthy
looking, dark gill, apparently not at all neurotic; she lived
in tbe country, and took plenty of exercise in the intervals,
of the attacks. She has never bad any illness beyond the
I" Cbai’ltc Annalen, lS8(i.
Die Google
ThbLaucbt,] dr. W. DUNCAN ON DISEASE OF THE UTERINE APPENDAGES. [Jan. 24,1891. 187t
diseases of childhood. On examination (under nitrous
oxide) I found the uterus small and acutely anteflexed; the
sound entered two inches; nothing else abnormal detected.
The ovaries or tubes could not be felt. I recommended
that the uterine canal should be dilated, and this I did up
to No. 12, Hegar. Subsequently to this the following two
periods were less painful, butt then all the old trouble
returned. After fully explaining the nature of the opera-
ttion to the parents I performed abdominal section, and
removed a pair of small ovaries with the tubes. The
Fig. 7.
OVARY
Ubi'onic ovaritis and salpinRitis.—Tulie thiciconcd; ovary hyper¬
trophied, flbi'ouH, and full of cysts in its interior.
patient recovered without a single bad symptom, and she
is now in perfect health. . .
Yet another case. A few weeks back a lady from Wales
was brought to me by her brother-in-law (a medical man).
She is thirty-one years of age, bos been married ten years,
and has never been pregnant. The catamenia began when she
was sixteen years old; they have always been very scanty,
lasting from one to three days; she has suffered pain both
during and between the periods; the pain is such that she
has to lead more or less the life of an invalid, and it has
increased in severity for the last two years. On examina¬
tion, the uterus is small and normal in position ; the right
■ovary can be easily palpated, and feels about half the
normal size; the most careful examination failed to detect
Eic. 8.
Congenitally ill-developod and cystic ovaries.
the left ovary. In this case I suggested that electricity
®night be tried for a couple of months with a view of endea¬
vouring to stimulate the ovaries ; but if (as was most pro¬
bable) this failed, then, provided the patient suffered suffi¬
cient pain to justify her running the risk, the only course
was removal of the appendages.
When mentioning electricity, I meant its application by
the introduction of one pole into the uterine cavity, and
placing the other on the abdomen: /lot by using the so-called
-galvanic stem pessary; for all stem pessaries are fruitful
sources of pelvic inllammation, and should only be used ou
the rarest possible occasions, whilst with regard to this par¬
ticular variety I think moat gyniecologists consider it abso¬
lutely worthless as a generator of electricity.
“Apoplexy of the ovary,” or, as it might more appro¬
priately be termed, “ hremorrhage into the ovary,” is a con¬
dition which has been described by various observers,
especially by Winckel and Olshausen. Olsbauaen mentions
two varieties: (a) hfcmorrbage into the stroma, and
(6) bmmorrhage into the follicles. That the condition
cannot be so rare as is usually considered is seen from the
fact that it occurred four times in my thirty cases. When
an ovary is diseased (as in Case 27, in which it is tubercular)
it can be readily underetood that extravasation of blood
into the stroma might without difficulty take place; that
such an extravasation, even though of limited extent, can
give ri®e to great pain, collapse, and fainting was well
exemplified in the same case, for on Dr. Steeled arrival he
found the patient so collapsed that he had to inject ether.
In Case 26 the hiemorrhage apparently took place into an en¬
larged follicle and was associated with an effusion into the
Fallopian tube of the same side. Probably some extraneous
cause in this young married lady, such as coitus close upon
the onset of the catamenia, induced excessive hypermmia of
the ovary and tube, resulting in hasmorrhage into these
organs.
The symptoms of diseased appendages are essentially two—
viz., pam and inenon-hagia. The pain is variable.; in some
cases it may only come on at the periods and then be
quite bearable; in others the dysmenorrhcea amounts to
intense agony. As a rule, in these cases there is more or
less constant pelvic pain, which increases in severity for
about ten days or a fortnight before the period comes on,
reaching its height at this time, and diminishing after the
flow has been fully established. The pain is referred to the
side most affected ; it is often described by the patient as of
a gnawing, tearing character, shooting through to the back,
and perhaps down the thigh to the knee. In some instances
it has been described to me by patients as feeling “asif
someone had seized hold of their insides and was trying to
tear them out.” In my experience the greatest amount of
pain is felt as a rule in those cases where, from extensive
pelvic peritonitis, the ovaries and tubes are matted down in
the pelvic cavity. In these cases a vaginal examination
may reveal nothing beyond some impaired mobility of the
uterus with tenderness on pressure. Usually in chronic
disease of the appendages there is pain on coitus, aud this
may be of all degrees of severity; not a few of my patients
have told me it was so intense that they have been com¬
pelled to lead a single life for months.
The hamorrhage also varies in amount. In most cases the
loss at the period is increased ; women will say that their
periods, instead of lasting four or five days, now go on
(perhaps) for a fortnight, that whilst half a dozen diapers used
to be sufficient, now they require from eighteen to twenty-
four ; others will say wtn regard to their periods that “ they
are hardly ever free from them.” I believe the loss is
greatest in cases of chronic ovaritis and salpingitis; but
where the tubes are dilated with serum or pus there does
not appear to be much alteration in the amount lost.
Another symptom to be remembered is, as already men¬
tioned, the occasional discharge “in gushes” of water or
matter in those cases of intermitting bydro-salpinx or pyo-
sa^inx.
The physical sigvs are of the greatest importance. There
is a good deal of difference of opinion respecting them; some
able observers never, or hardly ever, find diseased tubes and
ovaries on examining their patients, whilst others are con¬
stantly diagnosing thorn. In many instances the signs are
sufficiently obvious on making an ordinary bimanual exami¬
nation, whilst in others it is essential to give an anresthetic
and to examine per rectum as well as per vaginam. _ Can a
normal ovary be palpated when iu its usual situation? I
answer unhesitatingly Yes in the majority of cases where
the abdominal walla are thin and lax; not only so, but
atrophied or congenitally ill-developed ovaries can be made
out, so also can the Fallopian tube, especially near the
uterine end. When the tube is thickened from chronic sal¬
pingitis and is about as large as one’s little finger, it feels
not at all unlike a varicocele in the male, giving the sarne
sensation to the finger that a bag with a few worms inside
does. Not infrequently the ovaries and thickened tubes
are prolapsed into the pouch of Douglas; then their detection
is possible even to the tactus non eruditns. When enlarged
ovaries and tubes are matted together by old pelvic od-
Digiii -d
Google
188 The Lancet,] DR. W. DUNCAN ON DISEASE OF THE UTERINE APPENDAGES. [Jan. 24, 1891.
heaions (eee Fig. 9), they give rise to a firm rouodish or elon*
gated tumour, felt in one or other posterior quarter of the
? elvis, and perhaps extendiog somewhat behind the uterus,
t is only within comparatively the last few years that the
pathology of these tumours has been rightly understood. In
my student days they were almost invariably described as
cases of nelvic cellulitis in one or other broad ligament; but
since abaominal section has been more frequently performed,
it is deally proved that cellulitis does not exist except as
part of a septictemia or as secondary to a pelvic peritonitis.
Those tumours, then, which are detected at one or other side
of the uterus, and which do not depress the vaginal roof or
materially displace the uterus, are in the vast majority
of cases the result of pelvic peritonitis following upon
chronic disease of the ovaries and tubes, whereby
these organs are matted together and to the different struc¬
tures in their vicinity, simh as broad ligament, uterus,
omentum, and intestines. When a hydro salpinx or pyo-sal-
Fig 9.
(-'hronic peritonitis.—Ovary and tube maUeil tnpptlnjr;
ovary (shown in section) much eulargetl and full of
blood; tul)e dilated.
pinx exists, it feels (in a typical case) an elongated tortuous
elastic swelling, extending from the side of the uterus out¬
wards in the bioad ligament, and backwards into Douglas’s
fossa. In many cases, however, the dilated tube is roundish
instead of being elongated. This is probably due to ad¬
hesions. On the othe'- hand, tliere may be a large hydro- or
pyo-saJpinx which the most careful examination under an
an^tbetic fails to detect. This-is due, 1 believe, to the
fact that the dilatation is not a tense one. In two cases ou
which I operated for disease on one side, I found in each,
after removing the affected parts on that side, a large
dilated tube on the other, which had. previously escaped
detection. When the ovaries and tubes are matted to the
pelvis by adhesions, examination per rectum is very im-
f iortant. Ry this means also we can ascertain whether pro-
apsed ovaries are free or adherent.
The prognosis depends on the conditions present in any
individual case. A woman with a pyo-salpinx is in con¬
stant danger of its setting up acute and fatal peritonitis;
even a hydro-salpinx may do tbe same, although the risk is
much lesF. In most of the other conditions, whilst they are
not necessarily fatal, they as a rule render life one long
state of chronic invalidism, accompanied hy greater or lesa
suffering, which may certainly be alleviated by medicines,
but which, I fear, can usually only be cured by abdominal
section. When this operation is resorted to, tbe prognosis is-
very good, as seen in the thirty cases recorded, where there
was only one death, and this from the distressing accident-
of sUpping of the pedicle ligature and fatal bsemorrhage.
Tbe ultimate prognosis as to sound health is also good, but
it must not be forgotten that the full benefits of the opera¬
tion are not usuE^ly felt for several months after, as tbe
patients have to pass through the sympathetic disturbances
incidental to the bringing on of the menopause.
Treatment. —1. When a definite tumour of the appendages
is found in the pelvis of a woman who complains of pain and*
perhaps hmmorrhage, I am strongly of opinion that the con¬
dition should as far possible be described to her, and
abdominal section recommended after tbe risks attaching to
it have been fully explained. 2. If the tumour be a dilated
tube, the same course should be adopted, as even a hydro¬
salpinx may set up peritonitis. The old methods of treating
dilated tubes either by tapping per vaginam or by elec¬
tricity are not only unscientific, but also more dangerous
than abdominal section. In any case where the symptoms-
and physical signs lead one to suspect tubal gestation, it
is our duty to insist on operation without delay. 3. In
ca«es where the tubes are thickened from chrome salpin¬
gitis, wifh perhaps the ovaries enlarged and tender, or
even prolapsed, tonics, apeiiects, repeated blistering, hot
vaginal douches, and glycerine tampons should be tried
for a couple of months, and if at tbe end of that time-
there be no improvement, then I do not hesitate to advise
the removal of the appendages, provided the patient suffers-
sutiiciently to run the risk of the operation. 4. If after one
or more attacks of pelvic inflammation a woman suflers
jielvic pain, dysmenorrhcca and dyspareunia, and perhaps
iiienorrhauia, ihe great likelihood is that careful pelvic
examination will detect the ovaries and tubes matted
together and to the surrounding structures and the mobility
of tbe uterus impaired, but where probably no definite'
tnmour can be made out. What should be our line of
practice in a case of this kind ? Are we to pin oiir faith oa
Kps'>m f alts, like some do, and when this drug fails to fold
our hands, expiess the deepest sympathy with the sufferer,
hut on no account suggest any operative interference?
Surely, this practice is just as reprehensible as tbe opposite
one, where the appendages have been removed without ob¬
vious dUease, but for eome neuralgic affection. From personal
experience of these cases, I know that notliing short of
abdominal section will cure, that the operation is usually ex¬
tremely difficult, and tl at the ultimate result is correspond¬
ingly satisfactory. 5. In cases of congenitally ill-devemped'
ovaries with an acutely antellexed uterus associated wilFii-
marked dysmenorrbceaand sterility,! would first under anics-
thesia widely dilate the cervical canal by means of Hegar's
dilators; this failing, electricity might be tried, and as a
last resource nothing is left to be done but removal of the
diseased ovaries. With regard to tbe question of unsexing
.1 woman by the removal of her appendages, it need not
influpnce our treatment in the conditions mentioned undes
tbe above five headings, seeing that she is already unsexed,
as tbe appendages are practically useless as far as procrea¬
tion is concerned; and the subsequent history of those of
my patients who are married bears out the statements of
other observers that the sexual appetite is not usually dimi¬
nished by the operation ; indeed, in some cases the opposite:
result ensued. G. Whenever on opening tbe abdomen the
operator finds the ovaries and tubes fixed by adhesions, he-
should break down the latter with his fingers, and then,,
having brought tbe appendages into view, carefully ex¬
amine them for any well-marked visible or tangible signs
of disease. If no marked departure from tbe normal be
made out, tlien it is the operator’s bounden duty to
stay bis band from removing the appendages. I firmly
believe that the cau.se of the patient’s symptoms is, in
not a few cases, the presence of adhesions, and that when
these are broken down it is unnecessary to proceed further ;
but how many operators have the moral courage to do this ?"
One or two dilated follicles seen on the surface of an ovary
are thought sufficient to justify the spaying of the patient.
7. Inaaniucb as there is usually an absence of disease of the-
appendages in cases of ovarian neuralgia occurring in neurotic
subjects, any local interference is not only unnecessary, but
absolutely unjustifiable, and tbe same remark applies i/v
Digiiized by
The Lancet,] DR. W. DUNCAN ON DISEASE OF
reat measure to cases of bystero-epiiepsy and other mental
isorders.
It cannot, 1 think, he too strongly enforced that removal
of the appendages for chronic disease is in most cases
much more difficult than performing ovariotomy ; indeed,
in a very small proportion the operation may nave to be
abandoned, as occurred to me in Case 21. Hence the
tyro in abdominal surge^ ought not to attempt operating
on these cases. Again, it is most essential that the patient
and her immediate relatives have the nature of the operation
and its risks fully explained to them, as well as the change
in life which will be produced by it.
Before concluding, I wish to make a few remarks on the
techniaue ” of the operation.
Anccstnctic .—With regard to this, almost every operator
has a predilection for, a particular one. Until compara-
_tively recently I preferred my pationts to have other, but
"now it seems to me that chloroform given either on a piece
of lint or by Junker’s inhaler is the best, as it produces
more complete relaxation of the abdominal parietea and
there is no risk of lung complication following. A few
years back a patient on whom I performed ovariotomy died
two days later from acute bronchitis induced by the ether
administered.
Antiseptics in the Listerian sense of the term are un¬
necessary in abdominal operations; indeed, I would go
further, and say that the spray may be positively injurious,
The great thing is strict cleanliness. The routine practice
I carry out is as follows. Having thoroughly washed my
bands and forearms in soap-and-water, using a nail-brush
vigorously, I then dip them into a. 1 in 2000 solution of
corrosive sublimate for one minute. The patient’s abdomen
is scrubbed with soap-and-water, and afterwards washed
with the corrosive solution. The sponges are wrung out of
boiled water, and boiled water is poured over the instru¬
ments. Nothing else, except that my assistant treats his
hands and arms in the same manner as I do. One great
element of success in these operations is that, if possible,
no lingers hut the operator’s should he allowed to enter the
eritoneal cavity, and on no account whatever should any
ystauder examine the case or give help until he has rigidly
rendered bis hands aseptic.
Ligaturing the broad ligament in these cases requires more
care than the pedicle in ovariotomy, and I believe it would
he safer in all cases to tie it in three portions with strong
silk (Chinese twist). The StalTorrishire knot seems not to
he so safe as the ordinary method of dividing the double
ligature and tying in two parts after crossing the threads.
A few weeks back I very nearly lost a patient from
hasmorrbage after ovariotomy. The pedicle was rather
thick and Tong, and I thought I would show Dr. Noakes of
Nice, who was present, the ease with which the Stafford¬
shire knob can he applied. Having removed the tumour,
cleansed the peritoneal cavity, and lied all the abdominal
sutures but two, I saw a little blood at the bottom of the
incision. On separating the edges, sure enough the abdo¬
minal cavity was full of blood. I rapidly seized the pedicle,
and found the ligature had slipped; so after retying
securely, I washed out the peritoneal cavity as quickly as
possible with a 5 per cent, boracic acid solution, removing
m doing so large clots from near the liver and spleen. Had
half a minute more elapsed I should have closed the
abdomen, and most likely the b.T3morrhage would not have
been discovered, as the patient was in a very feeble and
collapsed condition all through the operation ; as it was,
she luckily recovered without a bad symptom.
Drainage .—A good deal of differeuce of opinion exists on
the value or otherwise of drainage. Personally I never use
a drainage-tube in simple cases, hut where numerous adhe¬
sions have been torn through causing free oozing of blood,
or where some of the contents of a tumour have escaped into
the abdomen, then I insert a glass tube for from thirty-six
TO forty-eight hours, and with the happiest results. One
^*®®''^vantage of using the drainage-tube is that that part of
the aWominal wall through which it passes seems to unite
teas firmly than the rest, so that later on the scar has a
teMency to give, causing a ventral hernia.
. ^^'^hing Inc peritoneal cavity is, I think, a proceeding of
tiSK; at the same time it is very valuable in cases where
pus or other irritating Iluid escapes into the cavity. 1
use a 5 per cent, boracic solution at a temperature
1 ? iut*‘^‘^uced through a large indiarubber tube
tached to a douche tin. It is necessary after flushing to
use a drainage-tube. The immediate effect on patients
THE UTERINE APPENDAGES. [JAN. 24.1891. 189
varies; some appear stimulated and others markedly im¬
pressed, but I know no way of flnding out beforehand whioh
will happen in any given case.
The after-dressing is important. The abdomen having
been thoroughly cleansed with a sublimate solution, I place
over the wound a strip of oil silk which has been dipped in
the solution; this strip is about an inch and a half wide, and
long enough to extend a little way beyond the extremities
of the incision. Boracic acid is next dusted over the edges
of the silk and over the rest of the abdomen; plenty of
sal alembroth or salicylic wool is next laid on, and the
whole firmly fixed by wide strips of adhesive plaster,
reaching from below the hips up to the epigastrium. It
will be noted that nothing but the oil silk touches the
wound ; this, I find, gives every satisfaction, and when the
first dressing is removed on the eighth day it causes no
pain to the patient. Formerly, I used to dust iodoform
owder over the wound, but it is not free from risk. I
ad a succession of cases in which troublesome suppuration
took place in the abdominal parietes along the tracks of
the stitches; this I could not account for nor prevent until
1 discarded the iodoform, when the succeeding cases pro¬
gressed in the normal manner. In other cases it produced
delirium.
After-treatment —My plan is the following:—Nothing
whatever passes the lips for twenty-four hours ; but if the
thirst is distressing I have the mouth washed with warm
water frequently, and, provided there be no sickness, a tea-
spoonful of hob water given every two hours. I believe ice
is not so good as hot water, audit certainly produces flatulence.
In cases where the operation has been very severe, or in elderly
women, a nutrient suppository is administered per rectum
every four hours. If there be decided pain, a one-third grMn
morphia suppository is given and repeated when necessary.
Morphia should nob, be given as a routine practice, and many
cases do perfectly well without it; but I think it is distinctly
cruel to deny it, as some do, to patients suffering decided
pain. After twenby four hours an ounce of milk-and-soda
is given every two hours, increasing gradually, and with some
beef-tea the next day. As a rule, a small cup of ordinary tea
with milk is longed for by, and most grateful to, the patient.
The urine is drawn off every eight hours for a few days,
but when patients have a desire to pass it naturally (even
two days after the operation) I always allow them to do so.
An aperient is given on the seventh day (before the stitches
are removed), and the patient gradually takes solid food.
She is turned on the side occasionally after the seventh day,
and at the end of ten days sbe is allowed to sit up in bed.
So much for ordinary cases. When complications arise, the
treatment requires modification. Vomiting is the moat
common, and the ordinary sickness from the anresthebic is
best treated by letting nothing be taken for twenty-four
hours. Recently I have adopted (and with distinct success)
a plan of Mr. Howse’s suggested to me by Dr. Moss, the
able resident medical officer at the Royal Hospital for
Women and Children. It is to administer per rectum at the
termination of the operation an ounce of pore wine in an
equal quautity of hot water. In some cases there may be
severe vomiting, nob from any inflammatory condition of
the peritoneum, bub probably from mere atony of the
bowel. If in addition to the vomiting there be flatulent
distension of the abdomen, the cose simulates closely
one of peritonitis, and it is hero that an aperient of
sulphate of magnesia or soda acts like a charm. One
of my patients (Case 9), a thin, neurotic lady, had fre¬
quent vomiting for six days after the operation (on four
oays it was black) which nothing would allay. At last I
thought I would give an aperient, but as she was very low
I called in coasultation an eminent obstetric physician, who
did not think it advisable to purge. Next day, however,
as slie continued getting worse, I gave her a dose of white
mixture, and repeated it every two hours until the bowels
acted. The effect was marvellous. She was only slightly
sick, oDca after the first dose, and from that time
recovered steadily. Flatulence is a frequent and often
troublesome complication. I make it a routine practice to
have a soft indiarubber tube passed into the rectum for
several inches at least twice a day, and find it gives relief.
In a case of Porro’s operation which I performed at the
Middlesex Hospital (and reported in The Lancet, vo). i.
1889, p. 16) there was enormous flatulent distension a few
days after the operation, giving rise to all the signs of
acute peritonitis, but on passing a long stiff tube into the
colon a tremendous escape of flatus put an end to the
190 Thb Lancet,]
DR. SOLOMON C. SMITH ON FRACTURE OF SCAPULA.
[Jan. 24, 1891.
tinfavourable symptoms. In slight cases a teaspoonful
of brandy in half an ounce of hot water gives much
relief. My patients suffer little from flatulence since I
have discarded the use of ice. Peritonitis is the only other
oomplication about which I shall speak. It may, of course,
have existed before the operation, or it may be due to the
escape, at the time of operation, of some pus or irritating
fluid into the abdominal cavity; but when it sets in after a
straightforward case of abdominal section 1 cannot help
thinking that the operator has to reproach himself that the
measures he adopted to ensure strict cleanliness werewanting
in completeness. Although when once it has set in it need
not necessarily be fatal, I believe the best chance is given
to the patient by reopening tbe wound without delay and
irrigating the cavity thoroughly with the boracic acid solu¬
tion and inserting a drainage-tube. The only case in which
I did this for acute peritonitis coming on two days after I
bad performed abdominal section recovered completely, and
is now, three years after, perfectly well. Mr. Lawson Tait
recommended tbe use of saline aperients, but 1 cannot help
thinking that even such an experienced and able observer
as he may have mistaken flatulent distension and vomiting
for peritonitis.
In conclusion, I would remark that simple cases of abdo¬
minal section seem to recover equally well if put back
immediately after operation into the general ward as when
isolated in a special ward for several days.
FRACTURE OF SCAPULA AND FIRST THREE
RIBS, WITH RUPTURE OF SUBCLAVIAN
ARTERY AND VEIN.
By SOLOMON G. SMITH, M.D.,
SURGEON TO THE IIALIl'AX INI'IUMAHV.
A. L-, aged thirty-five, was brought to the Halifax
Infirmary on Nov. 6th, 1890. Tbe only history which could
be obtained at the time was that at the quarry at which
be worked there bad been an accident. A crane had fallen
down, and he bad been found lying on the ground. He
arrived at the infirmary about an hour and a half aftpr
tbe accident, , and 1 saw him half an hour later. He was
then profoundly collapsed; the pulse was quick and small;
he was conscious, but not easily roused; conjunctival reflex
was absent; the right eye was closed, but the left partly
open ; there was a superficial wound above the right malar
bone, and another wound above the occipital protuberance,
baring the bone, each being about an inch long. The left
arm was cold and white, no pulse being perceptible in either
the radial, brachial, or axillary artery on that side; pul¬
sation could, however, be felt in the subclavian. Below
the clavicle in the region of the pectoral muscles, and
also on tbe left side of the chest, there was a large,
soft, squashy swelling, evidently effused blood, but no
bruising of the skin, no tension or pulsation. Above
the clavicle and in the axilla there was only
very slight swelling. There was no fracture of the
clavicle or of the humerus; pressure carefully applied
over each rib in succession gave no evidence of fracture
and produced no complaint of pain; he did, how-ever, seem
to suffer some discomfort in the region of the scapula when
the arm was being moved, and he tended to turn over towards
the right side, as if to relieve the pressure on the left shoulder.
There was a small contusion over the outer end of the pos¬
terior border of the acromion process, but no injury to be
seen lower down ; an irregularity of outline was, however,
noticed in tbe posterior border of the left scapula just
below its spine, but pressure there did not rouse tbe
patient to make any complaint; nor was there any bruising
of the skin, the blade of the scapula moved freely
with its upper part, no movement between them could be
perceived, nor could crepitus be elicited. There was a slight
abrasion on the outer side of the right knee, and several on
tbe back of tbe right hand. The diagnosis was made that
tbe last portion of the subclavian or the first portion of the
axillary artery had been torn across, that the rupture was
complete, and that no more arterial bleeding was going on.
It was also thought probable that there was some injury to
his brain from the fact that the left pupil was smaller than
tbe right, that tbe left eye persisted in not closing so com¬
pletely as its fellow, and that be also seemed to move the
right upper lip more than the left when he spoke; tbe
tongue, however, was protruded straight, and tbe difference
between the two sides of tbe face was but slight. The
important point in the diagnosis, so far as regarded possible
treatment, rested on the absence of pulsation or even
hardness in the bloody swelling, showing that the artery
was not only ruptured but plugged.
Under the influence of hot external applications he got
warmer, but at the same time became very restless; after a
few hours the effused blood showed as an ecchymosis of the
skin below the clavicle and on the left side of the chest, but
its amount did not seem to have increased. He died about
sixteen hours after the injury. At the post-mortem examina¬
tion, on Nov. 8bh, blood was found over the front of the left
pectoralis major, having apparently come out of the axilla be¬
tween the pectoral and deltoid muscles. Ondividing and turn¬
ing back tne pectoralis major a large quantity of blood was
found, which had evidently come from under the pectoralis
minor, and on dividing this muscle a further large effusion*
was discovered extending from the top of the axilla upwards
under the clavicle and far downwards on the side of the
chest, but only in very small quantity down the arm, and
that only as an infiltration of the sheath of the vessels.
The axillary vein was immensely distended, and on the
clavicle being removed the subclavian vein was found to be
torn across at its outer extremity, the clot within it, as
thick as tbe little linger, being continuous with the large
effusion already described; several nerve trunks were also
completely torn across, and the artery was found divided
opposite tbe outer edge of tbe first rib; the outer coat of
the artery had not been severed, but lay as a connecting
cord between the retracted ends of its inner layers,
whose tom extremities were drawn nearly an inch apart,
the upper one being filled with firm clot. The first
costal cartilage was separated from the sternum, and
the first rib was broken about one inch further out¬
wards and again just external to the neck. The two next
ribs were broken outside the neck. There was a com¬
minuted and impacted fracture of tbe scapula, the line of
fracture commencing at the posterior border just below the
spinous process, running forwards parallel with it for a
couple of inches, then, without touching the axillary
border, turning round backwards again, and ending at the
posterior edge just above the angle. This fractured portion
was also comminuted and depressed, thus altering the
contour of the posterior border, and was firmly impacted
into tbe base of the spinous process, so that tliere was no
mobility or crepitus between the fragments. The was no
fracture of the skull and no hremorrhage in the dura mater,
arachnoid, or brain, but the veins or the pia mater over
the posterior lobes on both sides, especially the right, were
very full, and seemed in places to have produced eccTiymoses.
At the inquest it turned out that the crane which caused
the accident was a derrick, and that in failing the heavy
chain swung round in a large curve and hit the man
in the back as he was running away in a stooping
attitude. It is probable that the fracture of the blade or
tbe seapula and the posterior fractures of the ribs were the
result of the direct impact of the lieavy chain by which the
man was felled, that the anterior fracture of the first rib
and the separation of the cartilage were indirectly due to
the same violence, and that the artery, vein, and nerve
were divided by the upward pressure of the loosened
rib against the clavicle. Tbe absence of bruising, at
the point where the blow took place by which all this
damage was done, is a point of very great interest, and at
the time led us to think that in falling he must have caught
at something and swung by his loft hand, and thus by a
violent strain ruptured his vessels, but the post-mortem
examination and the inquest both negatived this supposi¬
tion. Perhaps of even greater interest is the fact that, not¬
withstanding the complete separation of the inner coats of
the artery, the outer coat allowed no sign of having been dis¬
tended by effused blood; it lay as a narrow cord in the
midst of the venous clot, and it would appear almost certain
that the retraction of the inner coats bad sufficed to imme¬
diately plug the vessel without allowing any blood to escape.
Fracture of the first rib is an accident of very great rarity,
in consequence, no doubt, of its deep position, protected by
the clavicle and scapula with all their attached muscles;
but in this case the man by his attitude, as he ran in a
crouching position with his arms hanging forwards, removed
from the back of the rib the protection of the scapula, and
then, as ill luck would have it, the blow fell just on the
exposed portion, fracturing tbe posterior edge of the
scapula and crushing in tlie ribs.
Halifax.
Di;iiiz3d b'/
’8
The Lancet,] - MR. E. M. LITTLE: ROTATION OF THE VERTEBRA IN SCOLIOSIS. [Jan. 24,1891. 19 1
ON THE CAUSES OF ROTATION OF THE
VERTEBRAE IN SCOLIOSIS.^
By E. MUIRHEAD LITTLE,
SUnOEON TO THE HATIONAL OHTHpi’AJDlC HOSPITAL.
The question, ^V'hat is the cause or what are the causes of
rotation of the vertebrie in scoliosis, or so-called lateral
curvature of the spine ? has always been a troublesome one
to answer, and although for many years the subject has
been fruitfully studied by orthopecdic surgeons both in
Europe and America I believe that we may say that the
question has never been fully and satisfactorily answered.
In all diseases, wheHier they most concern the physician or
the surgeon, it is to the evidence from the dead house that
we look to solve the diilicult problems that they present,
and this is more especially true of diseases involving the
skeleton and those in which mechanical problems are
the most important. In scoliosis, however, it is very
rarely that we have an opportunity of dissecting the subject,
for the disease is not a directly fatal one, and most of the
few recorded necropsies have been on advanced cases of
great deformity, the subjects having died by accident or
from some disease long after the beginning of the distortion.
These considerations have led me to make some observa¬
tions on the spine in children and young adults in order to
find out under what circumstances if any rotation can
occur in the dorsal and lumbar regions of the column.
My first observations were, made on the normal
spine in the living, in order to ascertain whether rota¬
tion normally accompanies lateral flexion. I found that
in the erect position, both in children and adults, on
extreme voluntary lateral flexion of the spine apparent
rotation occurred; but that this appearance of rotation was
due to the muscles on the convexity contracting to support
the trunk, and that it did not appear when flexion
was produced voluntarily or passively in the prone position,
although the flexion was such that the spinous processes
deviated from the straight line as far as in extreme scoliosis.
I next examined the phenomena of lateral flexion in the
dead body, in which, however, the natural conditions were
so far altered that the sternum and cartilages of the ribs
had been removed, together with all the viscera. On
forcibly bending the trunk laterally, the body resting on its
hack, no rotation accompanied the movement, and I then
divided the anterior common ligament between each of the
vertebrie, and finally also the intervertebral discs and
posterior common ligament, without, however, succeeding
in producing any evident rotation.
The next experiments were undertaken with a view to
determine the effect of vertical pressure on the spinal
column in producing flexion and, if possible, rotation. The
scarcity of available subjects in London prevented my
trying this on the trunk as a whole, and 1 had to content
myself with experiments on the dorsal and lumbar regions of
the spine removed from the body en masse, with portions of
the ribs in situ,. The subjects were children of from three to
seven years of age. The spine was placed on a carpenter’s
bench, its posterior surface resting as far as regards the
dorsal region on the bench, and pressure was applied by
means of a powerful wooden screw cramp. A single general
curve was the result without rotation. The twelfth dorsal
vertebra was then held in the middle line by a cord, and
pressure again applied. A double curve was thus produced
the radius of which in the dorsal region in one case was
only seven centimetres, the transverse processes nearly
touching on the concavity. .There was no rotation, the line
of the spinous processes being as curved as that of the
bodies. I now examined the effect of fixing the spinous
processes in the middle line by inserting them into a narrow
groove in a piece of deal. Pressure was applied until the
WMd gave way, without producing rotation. Oak was then
substituted for deal, and as much force applied as possible,
but distinct rotation was not produced. The ends or the ribs
were removed, and first the ontenur common ligament and
“terwards the discs and posterior common ligament and all
tne_ tissues between the transverse processes on one side were
divided, bub the result was still negative. On removing
the spine, a very alight twisting effort of the hands was
^ Read at the TenUi International Medical Congress, Berlin, 1800 .
enough to separate it into two or three portions, 'with
separation of the bodies of the vertebrae. The principal
obstacles to this rotation appeared to be the articular pro¬
cesses, which obstacle was overcome by the overriding of
the superior by the inferior processes of the vertebra next
above, with consequent separation of the vertebree. 1 q
the spine with the ligaments intact the greatest twisting
force that 1 could apply with my hands did not produce at
most a greater rotation than 25”. It would thus appear
that, while a certain limited amount of rotation is possible
in the normal spine, it is not a normal accompaniment of
flexion, and, indeed, that it is diflicalt to produce
artificially. We know also that in lateral curvature of the
spine, resulting from pleuritic adhesions, rotation is absent,
as it is also in those temporary curves which occur in those
whose lower limbs are of unequal length.
It is surely a fair inference to draw from the foregoing
observations that there is some pathological condition
present in scoliosis from the first whicn allows of the gradual
production of rotation, and this condition I believe to be a
certain tendency of the ligamentous structures to yield,
that is generally known as want of tone, and which is
evidenced in the flat-foot which so often accompanies it.
But this laxity of the fibrous structures is not enough to
account for rotation, and I believe that it is to the muscles
that we must look for au explanation. On the first occur¬
rence of lateral yielding of the column the erector muscles of
the spine are called into play to correct the deformity and
maintain the spice in tlie erect position, and the mueoles
situated on the convex side of the curve have obviously to
perform the greater amount of work. Of these muscles,
some, such as the spinalis dorsi, are attached at both ends
almost entirely to points in the middle line; these can have
little effect in producing rotation, although they may, and
do, tend to keep the spinous processes in the straight
line. Others, however, and these form a large part of the
muscular mass occupying the vertebral groove, are
attached at one extremity to tbe middle line, and at
the other to tbe transverse processes, and the angles of
the ribs, running obliquely from one part of the verte¬
bral column to another. Sach are the erector spinso,
longissimus dorsi and sacro-lumbalis, multifidus spinm,
semi-spinalis dorsi, and rotatores spinin.
Now it is obvious that when the muscles of both sides
actequally to straighten tbe spine there is no tendency to |}ro-
duce rotation. When, however, there is a lateral yielding
of the spine the muscles on the convexity alone are called
into action ; and although they tend to straighten tbe line
of spinousprocesses, they have also a distinct rotatory action,
which long exerted on a column whose fibrous tissues are in¬
clined to yield produces a twisting, their action being un¬
balanced by any muscles on the anterior portion of the spinal
column. Absorption of bone takesplacewWethereisconstant
pressure, and adaptive secondary deformity of the articular
processes and bodies follows, while in some cases the trans¬
verse processes are bent in towards the middle line. This
process, as we see it going on in the living subject, is of
course a most gradual one, tbe change being almost im¬
perceptible from month to month, but that such a force
as that exerted by the muscles must tell in time must he
admitted. It appears probable that some alteration in the
nutrition of the bone occurs in these eases, perhaps such as
the “late rickets” described by Macewen, but I am nob
aware that any direct evidence of this has been produced.
Park-street, Grosvenor-squaro, W.
REMARKS ON VACCINATION, WITH THREE
CASES OE ACCIDENTAL VACCINATION.
Bv ROBERT STEEL, L.R.C.P. &S. Ed., L.F.P.S. Glas.,
UOCSE SURGEON, ROYAL INEIKMARY, GLASHOW.
At the present time, when public interest in the success
or failure of compulsory vaccination is widespread and is
manifested by all classes of the community, and when we
have a Royal Commission at present engaged in the deter¬
mination of the value of vaccination as a national institu¬
tion, 1 presume that contributions that throw light on the
subject will be welcome.
It is undeniable that since the institution of vacci¬
nation, small pox has practically disappeared in this
Coii' le
O
192 The Lancet,]
CLINICAL NOTES.
[Jan. 24, 1891.
country. That the one is the result of the other is for
the most part called in question only by those who
lack the requisite knowledge and training to form a
just opinion on the subject. If, however, we conclude
that the relation between vaccination and the practical
elimination of small-pos is a causal relation, vaccination
should be thorough; and if it is still to be enforced,
stringent rules ought to be laid down to ensure this. Single
vaccination is now held by most antborities to be insuffi¬
cient as a variolous prophylactic. Medical practitioners are
far too apt to yield to the feelings of an anxious mother
who is most importunate that he will make only one
“pock," or, if two are required, that he should make
them very small; for unless the practitioner humours
the maternal feelings in the matter, he runs a risk
of losing bis position as family physician. Every
practitioner should, in niy opinion, be legally required to
make three punctures, and forbidden under a penalty to
sign any vaccination paper unless three good vaccine
vesicles or cicatrices can be shown over the part vaccinated.
Until such a standard is made compulsory, we cannot hope
to prevent {small-pox from stealing into our midst from
time to time. The chances of communicating disease by
means of the operation have, however, to be considered
This grave circumstance, 1 regret to say, has unquestionably
happened to my certain knowledge even within my own
brief experience. Now with so many first-class establish¬
ments for the preparation of lymph, there is not much diffi-
cnlty in procuring pure calf lymph, and if all medical
men were to vaccinate direct from the calf or from
child to child only when there is undoubted proof
of clear family history, disastrous sequences from vaccination
would seldom occur. I think if this point were more care¬
fully attended to such diseases as scrofula and syphilis, the
diseases most commonly transmitted in this way, would
much less frequently be seen as the apparent result of
heredity. The following short clinical report and history
of three cases of accidental vaccination, which recently
came under my notice in the south of England, may be in¬
teresting to the profession.
Case l.—Mrs. J-, a young married woman about
twenty-five years of age, with an infant, which bad beenvacci-
nated only ten days previously, sent to consult me regard¬
ing a very painful and rapidly swelling condition of the
face. On examining the patient I found her suffering
from an erysipelatous inflammation of the left cheek, hut
on inquiring into the case I suspected that it was not a case
of true erysipelas. At the left ala of the nose I observed a
small red papule, becoming vesicular as it developed, and
on the ninth day it was distinctly pustular in appearance.
After this the inflammation rapidly subsided, and a scab
formed which fell oft’ about the eighteenth day, leaving a
very typical vaccination cicatrix.
Case 2,—Mrs. B-, a married woman aged thirty-five,
was believed to be suffering from the “ rose ” in the face.
On examination I found the very same condition as in the
former case. Theerysipelatousiutiammation had commenced
on the right cheek and was much more marked. The right eye
was already closed and the ioflammatorycondition had passed
over the bridge of the nose and also affected the left side
of the face. In this case also there was a distinct red papule
at the side of the nose. Having considered the condition in
the light of the experience gained from my former cose, and
from the fact that I had vaccinated her infant only ten
days before she complained, I diagnosed the affection as
erysipelatous inflammation due to tne irritation of vaccind
matter accidentally got direct from the child’s arm. In both
these cases, there was distinct history of a scratch at the
side of the nose, and of the mother having fallen asleep
with her nose on the vaccinated arm of the child.
Case 3. —J. W-, aged thirty-nine, a cowman, con-
salted me. It was a similar malady to the preceding cases,
but as be was an unmarried man t had to look for some¬
thing else than a vaccinated child for the explanation
of the condition. Oa inquiring into the patient’s history I
found that his daily occupation was to attend the cows
at a farm, and that he helped to milk them morning
and evening. Having some difficulty in milking some of
the cows he observea they were suffering from bladder¬
like vesicles on their teats, which, after a few days,
became pnstular, and then formed scabs, which shortly
afterwards fell off. At the time he observed the vesicles on
the cows’ teats, he aavs he had a small sore at the side of his
nose, and as It slightly itched he sometimes rubbed it daring
the process of milking the cows. A condition very similar
to the two previous cases soon appeared on bis face. I firmly
believe that the cows were suffering at the time from cow-
ox, and that this man’s case was one of true vaccination
irectly from the cow-pox. All these patients had previously
been unvaccinated, and now I believe they have accidentally
got the full protection of vaccination, and thereby most
unlikely to ever have an attack of variola. If, however,
they should contract the disease, it will be in a highly
modified form. The treatment in each case was alike, a
saline aperient being given occasionally, and small doses of
quinine and iron being given four times daily, and the parts
protected from cold. ^
1 hope that the record of these observations will stimulate
more eminent men to endeavour that so important a
national institution as vaccination shall be put upon a
proper basis, to secure protection at least for the innocent
and for those who possess too little knowledge to enable
them to form a reasonable opinion for themselves on
this important subject.
Glivsgow.
CMcal Itrfis:
MEDICAL, SUEGIOAL, OBSTETEIOAL, AND
THERAPEUTICAL.
ATTEMPTED SUICIDE BY MEANS OF OXALIC
■ACID.
Bv K. Beginald Sleman, B.A. Cantab., L.S.A. Lond.
I was recently called to see H. L-, aged sixty, care¬
taker. On arrival at his bouse I found him in severe pain
and much collapsed; pulse 50, small, and easily com¬
pressible ; face pallid and anxious ; extremities cold. The
friends suspected that poison had been swallowed for the
purpose of committing suicide, and on taxing him with this he
admitted having taken three teaspoonfuls of oxalic acid half
an hour previously. I was luckily able to get, within a few
minutes, a pint of lime-water, the whole of which the patient
was induced to swallow, with the result that there ensued
copious vomiting of blood, mucus, and a little food, &c. A
further dose of lime-water was administered after the lapse
of two hours, and the patient was then put on fluid diet,
and opium given internally, as there was constant gastric
pain, In the second week after the attempt an attack of
vomiting with brnmatemesis set in, which, however, yielded
to ice and other astringents. A month later the patient was
convalescent.
This case is interesting on account of oxalic acid being
rarely used for poisoning purposes, and more rarely still with
suicidal intent. When first summoned to the case, the
extreme depression of the man’s pulse at once showed
me the gravity of his condition, and I am of opinion that
the prompt action of the lime-water saved his life. An
important point in the prognosis was the fact that the
oison was not taken on an empty stomach, the patient
aving breakfasted about an hour previously. The motive
for the act could not be discovered. He was in poor health
previously to the attempt; but, on the other hand, was in a
good position and well to do.
St. Benefs-place, E.C.
DOUBLE PRIMARY AMPUTATION ABOVE MIDDLE
OF THIGH.
By W. a. MacKay, M.D., F.R.C.S.Edin.
I desire to place on record the following case as an
instance of recovery from a very grave injury.
W. E-, an English sailor, aged twenty-six, was run
over by four waggons of a mineral train. The wheels passed
obliquely over both legs well above the knees. At 8 p.m.
on Oct. 4th, 1889, in the English Hospital, the right leg
was amputated just below the trochanter, and the left a
little above the middle of the thigh. The circular
operation was performed in both instances. I was
assisted by my friend and colleague, Dr. Garcia Lopez.
The patient was wildly delirious trough the night. On
Di[' zed by CjOO^Ic
The Lancet,]
CLINICAL NOTES.
[Jan. 24, 1891. 193
the following day, at 8 A.M., the temperature was 104’2°;
pulse 120. By 12 noon the temperature had fallen to 98‘4“;
pulse 112. Dry absorbent dressings were employed through¬
out, and no opium was at any time administered. White
of egg and brandy were freely given during the first week.
A slight necrosis of the bone delayed the healing of the
left stump. By the end of January both wounds were
soundly healed. The above engraving is from a photo¬
graph that was taken six months after operation, the
patient being then in perfect health.
Huelva. _
CASE OF LARGE PULMONARY ABSCESS SUR¬
GICALLY TREATED; RECOVERY.^
By Fkancis W. Greene, M.B. Univ. Dub., L,R.C.S.I.
The patient, a little boy six years old, had pneumonia of
the left lung, the whole of which by degrees became
hepatised ; a crisis occurred, and the temperature remained
normal for some time. Tbs posterior portion of the lung
partially cleared, and the tubular breathing lessened, but
the anterior part remained solid and the respiration tubular
in character. In the fourth week hectic set in, the
evening temperature rising to 103", generally normal in
the morning. The expectoration gradually became puru¬
lent, and moist sounds were audible. In the fifth week
he suddenly expectorated about half a pint of pus. For
sonic days he bad complained of pain in a spot in the
anterior axillary line between the fifth and sixth riba.
There was tenderness on pressure and apparently slight
bulging, though the skin was not reddened, with hollow
urgUng rilles audible over it after the abscess had
urst. I diagnosed pulmonary abscess, and determined
to explore in this situation. The physical signs for
the days immediately preceding the operation were the
following. The posterior portion of the chest was dull in
patches, with comparatively clear spaces between them; re¬
spiratory murmur fair, with increased vocal resonance over
the dull parts; coarse moist crepitations throughout. The
anterior portion was absolutely dull, which did not alter on
changing position; loud tubular breathing audible, and in¬
creased vocal resonance. There was no evidence of fluid in
the pleura. On June 29th, being the second day after he
had_ expectorated the large quantity of pus, the abscess
having filled again, I operated. Under chloroform, and with
antiseptic precautions, I pushed a fine trocar and cannula
slowly between the ribs, withdrawing the trocar twice to see
if pus exuded. At the depth of littleover an inch I.struck the
abscess, the pleural surfaces being adherent; and using
the cannula as a guide, I made an incision about
^ Rend before the Cork Medical and yurgicnl Hociety, Nov. SOtli, ISOO
an inch and a half long parallel to the ribs; through this I
then pushed a trachea director forceps, and opening it the
pus flowed freely to the amount of about half a pint. When
the abscess was empty air escaped with each expiration, and
I then passed a bullet probe directly inwards to the depth of
fouil nches, to measure the length of tube required to drain
it. A flanged rubber one of this length was introduced
and tied in with tapes round the body. Over the mouth of
the tube I applied a dressing of wood-wool wadding covered
with waterproof. Next day I found the dressing
saturated with pus, but the cough and expectoration had
ceased, and that evening the temperature was normal, and-
remained so. I dressed the wound daily. The discharge
rapidly decreased, and finally becarne mucous in character#^
I shortened the tube gradually, and removed it on the
tenth day, and the incision was closed on the twelfth.
The lung quickly cleared, and by the time the tube
was removed the percussion sounds were nonnal. The
boy recovered perfectly, and was running about in a fort¬
night from the time of the operation.
Mallow, CO, Cork.
ON HOT WATER FLUSHING OF THE UTERUS
AFTER DELIVERY.
By Alexander Duke, F.R.C.P.I.,
EX-ASSI.STANT MASTER, ROTUNDA HOSPITAL; GYNyECOLOOIST
STEEVENS’S HOSPITAL.
In every case of labour I now attend I make it a rule to
wash out the uterus {at once when the placenta has been
expelled either by expression or by the natural efforts) with
hot water. The advantages claimed are these: (1) General
stimulant to the patient; (2) produces contraction of uterus
(3) removes shreds of membrane, clots, &c.; (4) prevents after
pains; and last, but not least, sets the practitioner’s mind
at rest by ensuring a permanent contraction of the, uterus,
and the certainty of knowing when the water returns clear
of leaving a clean and untainted uterine cavity. The
facility with which a uterus can be washed out
directly after labour is a strong argument in favour
of tire proceeding. When attempted forty-eight hours
later it will he found much more difficult, and not
nearly so effective. In several cases that I observed
while assistant physician to the Rotunda Hospital, the rise
in temperature suggestive of puerperal fever was found to
be entirely due to the retention of a portion of membrane or
placenta in utero, as the washing out with hot water proved.
Nothing can be more mischievous than the plan adopted (I
regret to say by most midwives)—viz,, that of “making a
rope of the membranes”; and I am sorry to see this has not
been condemned by any of the text-books on midwifery or
nursing manuals with whieh I am acquainted. The fact of
rotating the placenta when extruded {or partially so) brings
on a uterine contraction, and on the membranes being
tightly grasped by the os and cervix {though unseen),
the twisting is continued till the membranes break ofl',
a portion being left behind, giving rise to after pains,
which when not sufficient to expel the offending caitse
become an undoubted source of danger to the patient,
by decomposition, as shown by the extreme rise in tem¬
perature, rigors, &c. I am so convinced of the value
of washing out the uterine cavity with hot water {pre¬
viously brought to boiling point), that I hope I shall be
excused for saying that, in my opinion, it should be made a
routine treatment in all cases of labour, whether in hospital
or in private practice. The little additional trouble involved
by this proceeding will amply repay the practitioner who
adopts it, and who will, if wise, not trust it to the hands
of the nurse. It is remarkable how suddenly the high
temperature falls, and the dangerous symptoms vanish,
when a decomposing piece of membrane {often of con¬
siderable size) has been washed out. The hastening of
involution by the clean,sing and stimulating effects of
plain hot water is most satisfactoiy.
Dublin.
Lewes Naval Prison.—T he sanitary condition of
tlie Lewes Naval Prison is stated to have become so unsatis¬
factory that arrangements are being made to transfer the
whole establishment to Chatham, and the prison is to be
permanently closed.
DigiiizeO by
Google
194 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Jan. 24, 1891.
% Pirror
OP
HOSPITAL PRACTICE.
BRITISH AND FOREIGN.
Nulla autem eat alia pro certo noacendi via, nisi quamplurimas et mot-
t>onun et dlsseotionum Hatorias, turn allorum turn proprina collectas
habere, et inter se comparare.— -MOBOAONi X)e Sea. et Cans. Morb.,
Hb. iv. Prooamium. -
NORTH-EASTERN HOSPITAL FOR CHILDREN
SPONTANEOUS DISLOCATION OF THE HIP ; REDUCTION ;
SUPPURi^.TION IN THE JOINT; INCISION ; COMPLETE
RECOVERY.
(Under the care of Mr. Bilton Pollard.)
This case is an example of the rare condition known as
pathological dislocation of the hip-joint, and is very notable
for the extremely satisfactory result which followed the
treatment. Interesting as the case is from the severity of
the early symptoms dependent upon the disease of the
humerus, and the fact that the pyasmic condition which was
manifested ended in recovery, it is to the complete restoration
of function in the hip after the displaced head of the femur
had been reduced that we would direct attention. The
published cases of “ dislocation by distension ” of the hip-
joint are comparatively few, and have been observed as
complications of fevers, especially typhoid, acute rheu¬
matism, pymmia, after scarlatina; also after effusion in the
joint following injury. Many of the so-called spontaneous
displacements appear on investigation to have been due to
tubercular disease, and some of those recorded in adults
read much like the accounts of tabetic arthropathy of
the hip; in both of these more or less destruction of
the structures entering into the formation of the joint
has taken place. To these, which come under the “pseudo-
dislocations” of Malgaigne,^ and the second heauing in
Billroth’s"'' classification —Destructions hiaationen —we do
not now refer, but to those dislocations, without appreciable
alteration of the bones from relaxation and distension of
the oapmle and of the ligaments. As Mr. Morrant
Baker^ writes, “It is not the spontaneous dislocation
that is the rarity, but its happening without the occur¬
rence of those ulcerative changes •which, in such a
large majority of cases, seem to precede of necessity
the exit of the head of the bone.” We cannot, how¬
ever, enter upon a full consideration of this subject. In
some cases manipulation of the limb was followed by re¬
duction of the displacement and recovery, but these are not
numerous. In others the attempt at reduction basfailed, the
head of the bone has been excised, or the displacement has
recurred. Of dislocation occurring during typhoid fever and
successfully treated, a case is recorded in “Holmes’ System
of Surgery,”* the bone being reduced six weeks after it was
noticed. During scarlatinal dropsy'' a boy of six manifested
signs of disease in the left hip, and reduced dislocation was
found 5 no suppuration ensued, and the joint recovered. A
woman® of nineteen had spontaneous displacement of the
hip which came on live weeks after confinement, and which
was successfully treated by manipulation eleven months
later. In a case under the care of Dr. Ashmead^ the disloca¬
tion, which was into the foramen ovale, was preceded for
three months and a half by symptoms of disease in the hip-
joint, and after the femur liad been displaced for a month
it was reduced, and a perfect result is said to have been
obtained. We are indebted for the notes of this case to Dr.
Randall, late house surgeon to the hospital.
E. D-, a girl aged six years, was admitted on
April 14th, 1890. Four days before admission she was ill,
and cnniplaiued of pain in her right upper arm. The
next day she was worse, and during the following night
she was very feverish and delirious. No cause could be
assigned for the illness.
I Traitu ties tVact. &c., I8C>5.
'i V. PJtlia and V. Billrolh, tome ii., p. 6.07.
3 St. Barth. Hosp. Reports, 1874, p. 287.
4 Vol. ii., p. 366, Mr. Barker.
* Mr. JoHGpli Smith, Brit. Med. Journal, vol. i. 1872, p. 200.
Dr. Tliorniiike, Boston Med. and Surg. Journal, 1888.
7 Trans. CoU. Pbys. Philadelphia, 1840, vol. i., 205.
On admii=sion at .S P.M., the child looked extremely ill;
she had a dusky tint, was very drowsy, and took no notice
of anything, and only feebly resisted when her arm was
firmly palpated. Her lips were diy and coated with sordes;
her tongue was dry, and covered with a thick brown fur.
Pulse 142, respiration 44, temperature 104-8° F. The middle
portion of the right upper arm was uniformly swollen and
indurated, and the skin was slightly red. The shoulder
and elbow-joints were not implicated. No swollen or
tender spots were found in other parts of the body. Heart
showed no signs of disease. Large rftles could be heard
over both lungs. Urine febrile, but otherwise healthy.
At 7 r.M. an incision was made on the outer side of tlio
humerus rather above the middle. No pus was found.
The periosteum, which easily stripped off, was raised
from the bone all round, bnt no pus was found. The wound
was swabbed out with a 1 in 500 solution of perchloride of
mercury, drained, and dressed with sal alembrotb gauze
and wool. On the following morning the temperature had
fallen to 100-8°; the pulse was 142. The general condition
was improved, and the child said she was better. On the
evening of the second day after admission the temperature
bad again risen, and stood at 105°. During the next
three days the child got w’orse, her tongue necame dry
again, and her pulse got weaker. The swelling of the
arm increased, extending upwards to the shoulder,
and downwards beyond the elbow. The temperature
ranged between 103° and 105-4°. On the fifth day
after admission an incision was made down to the
bone along the posterior border of the deltoid muscle,
and half an ounce of pus was evacuated. The abscess
cavity -was mainly outside the periosteum, but a
piece of bone about a quarter of an inch square was
found. The wound was mopped out with 1 in 500 solution
of perchloride of mercury, drained, and dressed antisepti-
cally. The temperature now fell very gradually, and the
child began to look better. On the day after the second
operation (the sixth after admission) the child complained
of pain in her left hip and thigh. On the seventh day there
were distinct signs of inflammation in the joint. The
swelling of the upper arm subsided and the child’s general
condition and appetite improved, though her temperature
still reached about 103° in the evening. On the thirteenth
day after admission there was no spontaneous complaint of
pain in the hip ; the joint was still rather stiff, but gentle
passive movement was painless. On the twenty-sixth day
the first operation wound had healed, but the second was
still ‘discharging pus; the temperature now ranged be¬
tween 98 0° and 101°; the left hip was still swollen,
but the position of the bones was normal, and was
known to remain so till the twenty-ninth day; during
the following night the child was noticed to be un¬
comfortable, but she made no complaint of pain. On
tlie thirtieth day after admission the left hip presented
all the typical signs of dislocation on to the dorsum
ilii, and any attempts at movement produced great pain.
The dislocation was readily reduced by manipulation whilst
the child was under the influence of chloroform, and the
limb was secured in its proper position by means of a
Liston’s long splint. The temperature at once fell a degree
lower and gradually reached the normal, at which level it
remained from the forty-fifth to the forty-ninth day, and
the swelling in the region of the left hip-joint subsided. On
the forty-eighth day a little fulness in front of the joint was
again noticed, and the temperature began to rise again,
ranging in the evening from 100° to 102°. On the
sixty-first day after admission the hip-joint was opened
by the anterior incision and some pus evacuated.
The epiphysis of the head of the femur was not
loose, and the cartilage appeared to be healthy. The
joint was syringed out with 1 in !500 solution of per¬
chloride of mercury and then with 1 in 3000 solution of the
same ; the wound was drained with a small tube and dressed
with sal alembroth gauze and wool. A Thomas’s hip splint
was applied. The temperature now fell, but it was not
altogether normal until three weeks after the operation.
The wound had healed a month later. Four months
after admission three small sequestra were removed
from the humerus. A fortnight later a soft semilluctuat-
ing spot was noticed on the scar of the hip incision.
This was opened and scraped. No further operations
were required. The child was sent to a convalescent
home six months after admission. Both arm and hip
were then soundly healed. The child continued to
D, - Google
The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Jan. 24, 1891. 195
wear a elngle Tbouiae’ei spliot for two months longer, and
after that time eh© was allowed to walk without any
support. Now, nine months after admission to the hos-
E ita), eight months after the spootaneuas dislocation of the
ip, seven months after the joint was drained, and seven
weeks after the splint was left off, the child can walk with¬
out any limp. There is no shortening of tlie affected limb,
and the movements at the joint are free in all directions.
The only movement which is restricted is flexion, and that
can be made through about eighty degrees.
Remarks hy Mr. Pollard. —The case recorded above
S resents several points of interest. The primary focus of
iseas© was very limited, not niore than a (luarter-inch
square of the surface of the huinerns being exposed as
the result of the disease, but the child was so ill that
for ten days it seemed hardly possible for her to recover.
At the first operation the bone was exposed rather below
the diseased spot, and the periosteum was raised for
about two inches from the entire circumference of
the shaft of the humerus, hub no pus was found, and
no necrosis of the bone took place at this part of the
humerus. The left hip was dislocated, owing to softening
of the ligaments and acute distension of the capsule
with fluid. The exudation at that time was appa¬
rently serous, for the fever diminished and the general
condition of the child improved after the escape of
the fluid from the joint into the peri-articular tissues,
at the time when the dislocation occurred. More than a
fortnight elapsed between the reduction of the dislocation
and the onset of symptoms suggestive of suppuration in the
joint. The pus was let out by the anterior incision, and
the cavity of the hip-joint was washed out with mercurial
lotion. There was no need for the removal of any bone.
The recovery of the joint has been so complete that the child
walks without the least limp, and the movements are nearly
as free as those at the healthy hip. That such a perfect
recovery has occurred after suppuration in the hip-joint is due
to the fact that the disease was not, as is usually the case, of
a tubercular nature. It is well known that the early evacua¬
tion of pus from the knee-joint in pyieinic arthritisfrequently
arrests the destructive changes, and is followed by a perfect
recovery of the joint. Such success is more rarely met
with when the hip-joint is diseased, as the diagnosis is
often not made until irreparable damage has been done.
But still, it is desirable that a earefnl differentiation should
be made between pymmic and tubercular arthritis, for
whilst the former may be cured by simple evacuation of the
pus, tlie latter will usually need an extensive removal of
the diseased tissues in order to secure a rapid recovery, and
even then the function of the joint will be greatly impaired.
BRADFORD INFIRMARY.
A CASE OF ADENOMA OF THE PITUITARY BODY; NECROPSY ;
REMARKS.
(Under the care of Dr. Major.)
Tumours of the pituitary body are rarely met with, and
the account of this ease will therefore be read with interest.
Rokitansky wrote of the diseases of this body under the
three headings—(1) anomalies in size, (2) diseases of texture
(3) adventitious growths, but the literature on the subject
is limited. Dr. Scott Orr wrote a paper in 1852,^ in which
eases were given and reference made to patients described
by Di\ Heslop and by the brothers AVenzel. He has also
described^ the history and post-mortem examination of a
patient who died from cancer of this part. Dr. Harvey^ bad
a patient under his care, suffering from sudden and complete
amaurosis, in whom an abscess of the pituitary gland with
caries of the temporal bone was seen. Lancereaux^ found a
tumour of the base which had its origin in this gland. Drs.
Loeb and Arnold® describe and illustrate an adenoma, many
f characters of which resemble the case under the care
or i)r. Major. Dr. (lowers" writes with regard to tumoui-s
of this part: “Tumours of the pituitary body cause usually
vague symptoms.with very frequent failure of sight,
and indications of a lesion of the chiasma are present in
many case*. Sometimes, however, the tumour causes very
slight symptoms, and may run an almost latent course, and
this although the size attained is very considerable.” For
the notes of this case we are intlehted to Mr. James
Kerr.
C. S-, aged twenty-five, married. The previous
history of the patient was uneventful. She ceased to
menstruate in May, 1889. She had “caught cold,” and
bad had intense headache for a week when ^e became an
out-patient in July. She was treated for the headache,
with other symptoms described as hysterical, for four
months, and she was admitted to the infirmary in October
under the care of Dr. Major, her chief complaint being of
headache. Her beljaviour was irrational and her mental
condition flighty, occasionally even maniacal. During
November she became apathetic, slept nearly constantly,
became dirty in her habits, and, after three or four
fits of hjysteroid character (eyes turned up, limbs extended,
unconscious), she improved, became reasonable, took an
interest in things, and began to assist in the ward. The
headaches became better, and, towards the end of the month
she went to a convalencent hone. No optic neuritis was
noted at any time.
She passed out of sight till the spring of last year, when,
on account of headache and various pains, she again became
an out-patient. In June some occasional vomiting was
complained of; there was no optic neuritis. In July the
pains were very bad; purposeless vomiting was present;
and about the middle of the month optic neuritis was dis¬
covered. On readmission to the infirmary she was fairly
nourished, with slight anosmia. She kept quiet and motion¬
less, moaned occasionally with pain, had frequent yawning
and shivering attacks, without fever or sensation of cold.
The temperature was subnormal; the urine free from sugar,
with an occasional trace of albumen. Double optic neuritis,
with greatest swelling in right eye, was found ; blindness of
the right eye first noticed by patient a few days previously,
and left temporal hemianopsia; no paralysis or other
localising symptom was present. She had delusions, got a
little delirious and weaker j became wasted ; the limbs
flaccid, but not paralysed; passed evacuations uncon¬
sciously ; had left ptosis for a few hours ; and after four or
five days passed in a semi-comatose condition became quite
unconscious, and died on Sept. 28th.
Necropsy, thirty hoxirs after death. —The cerebral con¬
volutions were somewhat flattened, the ventricles contained
an excess of clear fluid, and on examination of the base of
the brain a bilobed, flattened tumour about the size of a
chestnut was seen projecting in the interpeduncular space,
the posterior surface of the optic chiasma was half buried,
and the right optic tract was slightly displaced outwards
and half buried in the tumour ; to the finger it felt cystic,
like a distended gall-bladder with gall-stones. The tumour
was sessile, had not grown into the ventricles or caused
absorption or marked displacement of tissues around it.
Microscopically it was made up of thick fibrous trabeciiliv*,
carrying large vessels, and covered with flattened endo-
theloid cells. The alveoli filled with parenchyma made up
of large epithelial cells with granular and fatty matter.
Compared with sections of normal pituitary body, the details
of structure were similar. There was no atrophy of the
optic nerves on examining sections.
Remarks hy Mr. Kerr, —For the first six months the
symptoms were hysterical, later they became those of intra¬
cranial tumour. Optic neuritis was late in appearing;
sometimes it never occurs. Atrophy without neuritis has
been noted in cases of acromegaly where there is frequently
hypertrophy of the pituitary body, associated with fattening
and glycosuria, which last two symptoms are described by
authorities as common in cases of pituitary tumour, but
were wanting in this case. The tumour is probably an
adenoma of the pituitary body.
Kdin. Mod. and Surs. Jounia!, vol, IxxvH., p. 2B1.
,1 Dlttugow Mud, Joitnml, 1SC3, vol. i., p. 417 .
■’ Dnbliii tiuartoi'ly .fouviial of tliB Med. Sc., 1855.
Bull. Sou. Aunt, d.) I’ai'ia, 1850, vol, xxxiv., p. 106
« ni . Arch. fUr Path, Anat., Berlin, 1873, vol. Ivii'., p. 172.
NorvoiH Sjatein, vol. ii,, p. 481, See alao an lute
Jour.®A^at??ud PhydoL, SS in the dissecting rooir
New Lunatic Asylum for Govan.— Ex-provoat
Dick, the chairman of the Govan District Lunacy Board, on
the 13th insb. performed the ceremony of cutting the first
sod at Hawkhead, near Paisley, in connexion with the
erection of a new asylum for this board. Accommodation
will be provided for 400 patients. The estimated coat of the
building is £70,000.
DiciT ZBj t
196 The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[Jan. 24, 1891.
PATHOLOGICAL SOCIETY OF LONDON.
Melanotic Sarcoma of Liver.—Diverticulum of (Esophagus .—
Scsmatoporphyrin in Urine. — Subacute Gastritis .—
Multiple Tubercular Tumours in Brain and Viscera.
An ordinary meeting of this Society was held on Jan. 20fch,
the President, Dr. W. H. Dickinson, in the chair.
Dr. DELitPiNE read a paper on a case of Melanotic
Sarcoma of the Liver, which had been previously shown as
a card specimen. . The patient was a man aged sixty-three,
who had been feeble and melancholic, and died in an
asvlum in 1885. His abdomen had -been noticed to be
enlarged for only a fortnight before bis death. He did not
complain of pam, but rapidly emaciated and sank. At
the necropsy the liver was found to be enormously enlarged,
the capsule thickened and increased in several places,
penetrating along the capillaries between the hepatic
cells. The vessels were much altered, some of them
containing large masses of micrococci. The portal
and intralobular veins also showed changes, the former
having the fibrous tissue surrounding them greatly in¬
creased, and the endothelium of the latter having under¬
gone extensive proliferation. Some of the appearances
found suggested an explanation for the occurrence of
melanuria. The hepatic epithelium was much atrophied,
either owing to the llattening of whole sets of lobules at the
periphery of large sarcomatous masses, or else due to the
intravascular growth of sarcomatous nodules in the same
lobule. The growth was of the nature of a fasciculated
spindle-celled angio-sarcoma; some of the nodules were
entirely or partly pigmented, and it was alveolated, owing
to its mode of origin. The following points were of interest:
The whole of the liver was involved in changes beginning
in the vessels of the nature of proliferative endophlebitia;
these changes were limited to the liver ; the contents of the
vessels were being gradually replaced by an embryonic tissue
similar to that from which both the blood and bloodvessels
had originated, and which was actively multijalying. The
distribution of the growth seemed to indicate clearly that it
was started by some irritative process. Dr. Delbpine asked
whether the melanine or some antecedent of it might not be
brought to the tumour by the bloodves.sels or lymphatics, and
whether, when not utilised in the usual way, it might not
become precipitated. The changes which occurred in the
urine in cases of melanuria showed that it was only after
the urinehad become oxidised that itassumed its dark colour,
and possibly a similar process occurred in the tissues,—
Dr. Penrose referred to a card specimen of melanotic
sarcoma be was showing that was taken from a woman
aged forty-four, who was much emaciated and who
had been ill for eighteen months. The urine had been
repeatedly examined and was discovered to be occasion¬
ally dark in colour and to contain uro-melanin. At
the necropsy the melanotic tumour in the liver was
found to be of a sarcomatous nature, and the only
other growths were tiny spots on each side of the ven¬
tricular septum of the heart.—Mr. Roger William.s
inquired if the rectum had been examined for a primary
growth.—Dr. Hale White said that in all the cases he had'
found on record of primary melanotic growth death
had ensued in four months. Dr. Penrose’s cases seemed to
be exceptional in the long duration of the symptoms.
The eye as well as the rectum should be carefully examined
for primary growth.—Dr. Cayley referred to a case re¬
corded in the Transactions of melanotic hepatic tumour in
which ten years before death one of the patient’s eyes had
been removed for a melanotic growth. This showed how
long a time might elapse before the development of a secon¬
dary deposit.—Dr. Delepine, in reply, said that he was
informed that other growths were looked for in every part
of the body with a negative result, and there had been no
history of a primary CTowtb. The tumour appeared to grow
very rapidly during the fortnight before death, and all its
characters were those of a primary growth.
Mr. T. F. Ohavasse showed a specimen of Diverticulum
of the G^sophagus from a male patient, much emaciated,
aged forty-nine, on whom gastrostomy was performed at the
^neral Hospital, Birmingham, in July, 1890, as an attempt
to avert starvation. He gave a histo^ of dysphagia ex-
tendiog over a period of ten years, death taking place two
days ^ter the completion of the operation from pneu¬
monia and exhaustion. The necropsy revealed a posterior
diverticulum four inches deep from the level of the
arytenoid cartilages, three inches and a half broad, and two
inches and a half thick, with a mouth one inch in diameter
and a capacity of six ounces. The walls of the sac were as
thick as those of the CESophagus, and lined throughout with
mucous membrane. When filled with fluid the opening in
tho cesophagus was firmly closed by the pressure of the
distended sac. There was no malignant growth present.
It was pointed out that the absence of muscular tissue,
except at the mouth of the sac, supported the contention of
Zenker and von Zienissen that these posterior diverticula
were primarily due to the effects of pressure, and not to a
congenital defect, as held by some authorities. The various
lesions giving rise to such diverticula and the rarity of the
condition were discussed. Reference was mad© to the ages
and modes of death in the cases recorded.
Dr. S. M. COPEMAN showed specimens of Urine con¬
taining riosmatoporpbyrin from two cases under the care
of Dr. Ranking, one of which died, while the other had
recovered. Reference was also made to two other cases
recently published in which the symptoms were similar
and the pigment, although its true nature was not at the
time determined, was apparently identical. All four
patients were highly neurotic women of middle age, who
had suffered from habitual constipation, sleeplessness, and
abdominal pain, although no organic mischief could be
detected. Great prostration, and sometimes apparent
inability to move the limbs, vas accompanied by the
excretion of small quantities of urine only, which had a
dark purple-red colour, but contained neither haemoglobin,
bile pigment, albumen, or sugar. Finally, three of the
four patients died, collapsed and comatose, within a week
of the appearance of severe symptoms. The absence of
blood from the specimens of urine was determined by the
spectroscope, which showed a four-handed spectrum, at first
sight not unlike methmmoglobin, but which underwent no
change on the addition of reducing agents such as
ammonium sulphide. Measurements of the wave-lengths
of the absorption bands showed that the pigment was
hrematoporpbyrin. The use of simple chemical tests, such
as the guaiacum test, gave no reaction; while boiling, the
use of nitric acid, and saturation with magnesium sulphate
also gave no result, showing tbat proteids were absent.
Strong sulphuric acid brought about a change in colour of
the fluid, while the spectroscope showed that the pigment
had become converted into acid hcematoporphyrin. Maps
were shown of the spectra yielded by the fluid both before
and after the addition of sulphuric acid. The addition of
y-inc and ammonia gave no distinct fluorescence, thus proving
the absence of urobilin. "Wibh the same reagents the band
at F did not sliift, so that the pigment had not) reached the
stage of urobfematoporphyrin. The bands of the unaltered
fluid did not, however, exactly correspond to those usually
assigned to hmmatoporphyrin, as far as could be judged by
comparing spectra of alcoholic and aqueous solutions
of the respective pigments, that present in the urine
having probably undergone a slightly less degree of
metabolism. It might, however, fairly be called neutral
bsematoporpbyrin. All the specimens of urine had a
peculiar smell resembling acetone, and did not undergo
putrefactive change for months. The suggestion was
made that the disease from which the patients had
suffered was allied to pernicious anojmia, in which also a
considerable excess of pigment, apparently derived from
abnormal bcemolysis, is present in the urine. The obstinate
constipation, Avhich was a marked symptom in all the cases,
might have led to the absorption of poisonous products from
the intestine, in which case the blood destruction would be
likely to take place in the portal system—a theory sup¬
ported by the absence of proteids in the urine such as are
found together witli the pigment after a paroxysm of hemo¬
globinuria.—The PiiESiDiiNT said that the disease bore
some points of resemblance to ordinary hemoglobinuria.
He wondered what local influence could cause this rare
disease to attack two persons in the same house. He
inquired if there were any discolouration of the skin or any
suspicion of malaria.—Dr. Hunter said that the observa¬
tions as to acidity of urine and resistance to putre¬
faction suggested alliance with pernicious ana3)nia rather
than with paroxysmal hiemoglobinuria. That two of the
patients came from the same house suggested some form of
^8
THE Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[JAN. 24,189L 197
moisoning. The liver was no doubt the chief seat of the
changes which led to the formation of pigment in the urine,
though muscular and other tissue might occasionally serve
c,8 a source.—Mr. E. Willett asked if the iron-containing
•waters of Tunbridge Wells had anything to do with the cause
ia these cases.—Dr. Beenard O’Connor said it would be
interesting to hear the opinions of those who had had ex¬
perience of poisoning by coal-gM.—Dr. Copeman, in reply,
(said that there was no discolouration of the skin and no
history of malarial poisoning. The two patients who were
in the same house were in a private hospital, and there was
no suspicion of poisoning by food or by coal-gas. The re-
•sistanco of the urine to putrefaction was very marked,
Hajmoglobin or methocmoglobin always had some proteid
jitcached to it; but that was not the case in the present
instance, or in cases of pernicious anjomia. In these
ipatients obstinate constipation was a marked symptom,
and therefore there was a possibility of self-intoxication.
Haimatoporpbyrin was iron-free hcematin, and therefore
its appearance was probably not caused by ferruginous
waters.
Dr. William Hunter then described a case of Subacute
Gastritis, occurring in a man aged fifty-nine, who during
the last three years of his life presented all the features of
pernicious ancetnia. Throughout the entire course of bis
illness there were none of the usual symptoms of dyspepsia,
6he only sign pointing dubiously in this direction being a
raw and tender condition of the tongue from time to time,
the surface of both tongue and fauces presenting angry red
patches, sometimes going on to vesicle formation. Shortly
'Ufore death these subsided, leaving the tongue pale and
■flabby, its mucous membrane presenting a smooth and
atropliied appearance. The necropsy revealed characteristic
changes in the liver, spleen, and kidneys connected with
•excessive destruction of blood. The stomach eliowed no
obvious morbid appearances to the naked eye except
that it was very thin. Microscopically, there were
'found localised in patches at the cardiac end of the
stomach changes both in the mucous and submucous
coats. The changes wore partly of simple atrophic
and partly of subacute inllamraatory character; in the
■former case the tubes being fewer in number and replaced
by fibrous tissue, while in the latter the tubules were also
reduced to a state of atrophy by the pressure of active pro¬
liferating connective tissue cells, by which they were closely
aurrounded. Around these inflammatory foci the capil¬
laries were greatly distended. The submucous coat was in
parts greatly thickened, especially in those parts opposite
to the inflammatory areas in the mucous membrane. The
vascular changes involved not only the arteries and veins,
but extended also to the arterioles and capillaries, and the
walls of the vessels were greatly thickened and infiltrated
with active cells, tlie thickening being at parts almost so
great as to lead to occlusion. These changes in the sub¬
mucous coat were also continued to the cardiac end of the
■stomach; in the pyloric region the changes were of the
•more chronic character usually found in persons dying
after the age of fifty, the thickening of the coats of
'the vessels and the slight increase in connective tissue
being unaccompanied by any active proliferation of cells.
The appearances were demonstrated by a series of micro¬
scopical specimens, showing the ghanges around the
gastric follicles and in the vessel walls. The case raised
the question as to the nature and causation of certain
iorms of gastritis, which ran their course unattended
'ey any special gastric symptoms, and it also suggested
into the relation between the gastric changes
And hmiiiolytic changes in the blood, which constituted the
aiHtingiushing pathological feature of tlie pernicious aummia
with which they were not infrequently associated. The
actors which brought about the simple atrophy of the
"'Mch was common in people dying above the ages of
•of'ff ^tlty. were the same as operated at this period
-h/e to induce similar changes in other organs—namely,
minibhed blood-,supply and impoverishment of blood. In
blood and the
iixilfoi thickening of the vessel walls might both be
■Rnf as factors in causing a certain degree of atrophy.
change was the subacute inllanuuatory
which was pre.sent in both the mucous and aub-
'inn« in these two coats did not
, ,',V” i’tand to each other in the relation of
snr>f.L.f'° , 1 ®* seemed to be the result of some
• i lai inllammatory process localised in certain portions of
the mucous membrane. Certain of the veins and lymphatics
in the inflamed area were filled with large numbers of
bacilli, which stained readily; while the numerous bacilli
and bacteria on the surface of the mucous membrane,
where putrefaction had already set in, failed to do so.
Evidence of mycotic infection had been found in a few
other cases, and these suggested the possible relation¬
ship between organised infection and certain subacute
processes in the stomach which ran their course, as in the
present case, without any of the usual symptoms of stomach
disease. The relation between the gastric and the heemo-
lytic changes, no less than the nature of the former, was
also a matcer of pathological importance, and in this con¬
nexion he mentioned that he bad isolated from the urine
during life certain products of bacterial activity not usually
found in the urine either in health or in most diseases.
Two of these he had identified as well-known putrefactive
alkaloids—oadaverine and putrescine, and the third also
was, like these, a diamine body, but distinct from them.
He was inclined to connect the destructive changes in the
blood with the absorption and presence of these bodies, and
these in turn with the inflammatory changes in the gastric
walls.—Dr. N. Moore remarked that the lymphatic glands
near the stomach were said to have been enlarged, and
asked if the rectum had been examined, or any other start¬
ing point for malignant disease looked for.—Dr. Hunter,
in reply, said he had found no cancer anywhere, and if he
had it would nob have accounted for the pernicious anasoiia
any more than the gastritis did.
Dr. Samuel West then described a case of Chronic
General Nodular Tuberculosis, there being multiple tuber¬
cular tumours in the brain, pleur®, peritoneum, and other
organs. The patient, a male aged fourteen, was admitted
for headache and optic neuritis, and the diagnosis of cerebral
tumour, probably tubercular. He had been ailing for a
year, bub had no definite symptoms until one month before
his admission. He then had headache and vomiting, and
in a few days his eyesight began to fail. The patient was
delicate and anaemic, but except for a few enlarged glands
in the neck, axillto, and groins, presented no abnormality
except double optic neuritis. The patient died five months
after admission—i.e,, six months after the first deflnite
symptoms. Nothing occurred except gradual failure of
strength. Headache was frequently complained of, and was
often severe, and vomiting occurred occasionally. Three or
four fits occurred at irregular intervals of slight intensity.
They were never severe, and threw no light on the case.
At the post-mortem examination caseous nodules, varying
in size from a pea to a nut, were found in many parts of the
body on the parietal and visceral layers of the pleurro and
peritoneum. The lungs were studded with small nodules.
The bronchial glands were as large as Tangerine oranges,
and very liavd. On the peritoneum, the nodules wore found
on the intestines, on the stomach, and on the capsule of the
liver and spleen, bub did nob involve the deeper structures.
The mesenteric glands were enlarged. Ulcers existed in the
intestines of the ordinary tubercular character, but were
peculiar in having no secondary tubercular nodules on
the peritoneal surface corresponding with them. One
sm.all gland had formed a communication with the intestine,
and was discharging into it. The kidneys were studded
with nodules, but the capsules were free. The swelling in
the left wrist was filled with caseous substance. In. the
brain there were twelve tumours of varying size, nearly all
in the white matter and in all parts of it; one only readied
the surface. The left optic thalamus seemed to be entirely
converted into a tubercular mass. Tlie cerebellum contained
nodules in both lateral lobes, and a largo one in the middle
lobe. The disease might be called chronic general nodular
tuberculosis ; it was rare in man, though resembling what
was common in some animals. Clinically it was of interest
on account of the entire absence of symptoms until six
months before death, and they were then limited to those
general ones of cerebral tumour, which did not aullice to
suggest this position of the lesion,
The following card specimens were exhibited:—
Mr. L. A. Dunn : Caries of the Scapula.
Dr. DELKriNE: Chavcob’.s Crystals.
Dr. F. Teniuksic ; Melanotic Growth in Liver.
Dr. Kolleston : (1) Communication between Ventricles
of Heart; (2) Aneurysm bursting into Loft Bronchus.
Dr. J, Gai.i.owav : Aneurysm of the Superior Mesenteric
Artery Avitb Haiinonhoge into the Mesentery and Peritoneal
Cavity.
198 The Lancet,]
CLINICAL SOCIETY OF LONDON.
[Jan. 24, 189L
CLINICAL SOCIETY OF LONDON.
AnivuoX Meeting.—IntusamcepHon with Volvulus.—Acute
Intussusception.
The annual meeting of this Society was held on Jan. 9th,
the President, Mr. Christopher Heath, being in the chair.
Dr. Whipham and Mr. G. R. Turnek communicated a
aper on a case of Intussusception, with Volvulus of the
mall Intestine in two places. The patient was a cook aged
twenty-nine, who was admitted into St. George’s Hospital,
under the care of Dr. Whipham, on Jan. 29th, 1890. She
had 8uffere,d many years from “indigestion.” 'Three weeks
before admission she suffered from iniluenza, and soon after
the onset of the disease experienced sudden acute pain at
the umbilicus for about ten minutes ; uncontrollable vomit¬
ing followed this. The attack passed off, and it was not
until Jan. 28th, during the act of defecation, she again felt
intense umbilical and lumbar pain. Tliere was a doubtful
history of blood in the motions. She vomited and bad hic¬
cough. The symptoms were somewhat relieved by morphine
before admission. Catamenia irregular. On admission, she
was restless with an abdominal aspect, distended abdo¬
men, quick pulse, pelvic tumour. An enema brought away
some foul smelling blood-stained frecal matter. Abdominal
section was performed by Mr. Turner. The pelvic tumour
proved to be the uterus enlaiged to the size of third month
of pregnancy. Volvulus of the small intestine in two places
was found, at the lower place (the upper ileum) of one coil
of bowel round another, and higher up a twist of the
jejunum on its mesenteric axis. These were unravelled,
and then in the right hypogastric region an intussusception
involving the jejunum (some five feet from the pylorus) was
discovered. There was no difficulty in relieving this, but
the intussusception, though not entirely lustreless, was
deeply congested and on the, verge of gangrene. The question
of excision of this portion of the intestine was considered, but
the state of the patient was evidently such as to forbid the
attempt. The peritoneum was Hushed and drained by one
of Keith’s tubes, the wound being united in the usual way.
The patient had no further vomiting, but died some twenty-
four hours after the operation. Post-mortem exaniination
showed the intussusception to have been caused by a poly¬
poid growth of the small intestine, all causes of the obstruc¬
tion had been removed by the operation. The uterus was
filled with blood-clot, and was about the size of third month
of pregnancy ; there was a true corpus luteum in the right
ovary. It was suggested that the volvulus was secondary
to the intussusception. Some remarks were made as to the
diagnosis and rarity of the case, and as to the necessity in
cases of obstruction requidug abdominal section for the
operator to be quite certain that all the possible causes of
obstruction have been removed. In this case there were no
less than three, and in many there were more than one.
Mr. Lockwood read a paper on a case of Acute Intussus¬
ception in a child four year old, in which resection was
performed, and death resulted from shock twenty hours
after operation. The patient, who was a strong and healthy
female, four years of age, bad been seized with purging
and vomiting five days previon.sly, but no blood or slime
was passed with the motioos. The sickness continued, and
the abdomen became distended, but nevertheless a tumour
about three inches long could be felt in the right iliac fossa.
An intussusception was diagnoned, and the abdomen opened
by an incision in the right linea semilunaris, with the faint
hope of being able to wif.hdraw the invaginated bowel.
There was slight peritonitH, and the invaginated bowel,
which was part or the ileum, was firmly adherent to its
ensheathing intestine (which was also ileum), and the
peritoneum split at every attempt at withdrawal. It was
therefore decided to resect the intussusception, and with
this end in view the peritoneal sac in the neighbour¬
hood of the wound was washed with sponges, and the
intestines above and below the diseased part controlled
with an elastic band. The intussusception and a wedge
of mesentery were removed, and alter the distended
intestines had been empti>d of flatus and fmces, sutur¬
ing was done by the CzHrny-Lembert method. The
abdomen was closed after bf-ing irrigated with hot water,
but this increased the shock instead of diminishing it.
There was exhaustion before the operation, and consider¬
able collapse after it was finished, and from the latter the
child never rallied, and died twenty hours after the opera¬
tion. The examination showed that the Inmen of the bowel
was quite pervious, and that the line of sutures was secure.
In commenting upon this case, the fatal result was attri^
buted mainly to the time occupied in the operation. Th©
resection of a portion of mesentery had much to do with this,
as it caused troublesome bleeding and seemed unnecessary.
The emptying of the distended bowel was of great import¬
ance, both as an aid to the performance of the opera¬
tion, and as adding to the subsequent security of the
stitches and relief from obstruction. The literature of
the subject seemed to show that out of fifteen cases of
resection of intussusceptions three had recovei-ed. How¬
ever, a distinction should be made between acute and
chronic cases. Finally, the desirability of adopting
other methods of operating with a view of saving
time and diminishing sliocK were alluded to. — Dr.
Oemsby of Dublin related a case of obstruction of the
bowels which came under his notice in August, 1889. iB
was that of a woman aged ihirty-five, who had been recently
confined. Some peritonitis had followed, together wii-b
intestinal obstruction, the bowels being confined for forty
days. Abdominal section was performed, multiple punc¬
tures being made to let out flatus. A band of Ivmph wae
found, stretching from the broad ligament of the uterus
across the descending colon. This was broken down, and the
patient made a good recovery.—Mr. Harrison Cuirrs said
the treatment Mr. Lockwood had adopted gave the patient
the best chance of recovery. He .referred to a case of intus¬
susception in which the ileo-c.'ncal valve protruded through
theanua. Abdominal section was performed, andhereduced
almost the whole of the gub by pushing it up from below
by pinching the large intestine between the finger and
thumb; tbw was preferable to pulling on the gut from
above. If he could not have returned it thus he would
have made an artificial anus just above tire ileo-crecal valve.
He had seen a case of intussusception in which the gut pro¬
truded through the anus, and was cut off inch by inch.
The child made a good recovery, but died later from an¬
other affection. At the necropsy it was found that the whole
of the large gut had been passed per anum.—Mr. Howsifl
said that in those cases in which the ileo-crecal valve pvo-
tiTided from the anus adhesion usually took place about the
valve, and this rendered reduction difficult. He therefore
advocated cutting away the ileo-caecal valve, sewing iLo cni:
edges of the gut, and then reducing the rest with the
help of an abdominal section. He had found puncturing
the intestine to allow of the escape of llatus to bo an
unsafe proceeding, as thin feculent matter was apt to
ooze from the pricks, and the puncture did not admit of
easy suture.— Mr. Parker, in a case of abdominal section,
aaia he got rid of the gas by passing a soft tube per anum
and emptying the intestine by manipulation. He had
recently seen a child aged eighteen months, in whom aa
acute intussusception had become grafted upon a chronic one.
At the operation he was unable to completely reduce the
gut, but the child recovered and he afterwards watched the
gradual absorption of the lump in the abdomen.—Dr.
‘Whipham said that great care was necessary in administ'O--
ing opium in these cases. It was proper to give it in t!ie
early stages, but later, when constipation was established,
and vomiting had occurred, it should be cautiously
administered or withheld altogether. It tended to
mask symptoms, to obscure diagnosis, and to lend
to a deceptive calm, encouraging delay in operation.—
Mr. Barker alluded to a method of treating those cases
where the intussusception could not be reduced. A
longitudinal incision should be made through the intus-
suscipiens, and then the inner intussuscepted part should
be cut away, the original incision being closed with sui.iu'es.
The natural process of cure was thus imitated, but ho had
not had an opportunity of trying it. In one case wh<re
the gut was largely distended he incised it with a knife,
let out gas and fajces, and afterwards stitched it up.—
Dr. Kingston Fowler referred to the case of a youth aged
twenty, who had been in St. George’s Hospital, where some
glands in the neck affected with melanotic sarcoma had been
removed. He came later into Middlesex Hospital, com¬
plaining of pain and abdominal distension, and complete
obstruction developed. On consultation, an abdominal
section was recommended, but this the patient objected to.
A few days later he passed a mass of intuasuscepted bowel,
the seat of an annular gi-owth of melanotic sarcoma.
Most surgeons would admit that the results of operation
in many forms of obstruction were not all that could
be hoped for, and when physicians could remember ca'-e»
that were relieved naturally at the last moment, this
made them delay sometimes before transferring the
The Lakcbt,3
habveijvn society.
[Jan. 24,1891. 199
patient to their eurgical colleagues. With regard to
intussusception, however, physicians certainly ought not to
be reproached with tardiness in calling in surgic^ aid, fr>r
iu this class of cases it was commonly done quite early.—
Mr. Lockwood, in reply, could not believe that the making
an artificial anus above the intusauscepted gat was a good
measure, for in nine recorded cases it had been followed by
a fatal result, and a fa;cal fistula in the small intestine was
very distressing. The objection to Mr. Barker’s proposition
was that the gut was probably nob in a sufficiently sound
state to bear the suturing of the longitudinal incision. He
preferred an incision to a puncture in letting out flatus.
The members then proceeded bo the business of the
annual inoebing- The Secretary read the report of the
Council, which showed that tlie membership and finances
were in a very satisfactory condition. The customa'y votes
of thanks to tbe retiring officers having been passed, the
following officers were declared duly elected for toe ensuing
year:—President: Sir Dyce Duckworth, M.D., LL.D.
Vice-Presidents: Drs. Charlton Basbian and Alfred B.
Duffin; Messrs. H. G. Howse, M.8., Henry Gawen Sutton,
Berkeley Hill, and Septimus Sibley. Treasurer: Dr.
William Miller Ord. Council: Dra. John Abercrombie,
Thomas Barlow, Charles E. Beevor, Robert L. Bowles,
Thomas Churton, E. Diver, Donald William Charles Hood,
Percy Kidd, Arthur Edwin Temple Longhurat, Thomas
John Maclagon, William Pasteur, and P. H. Pye-Smith;
Messrs. W. H. A. Jacobson, William Anderson, A-nthony
A. Bowlbv, George Buokaton Browne, John R. Lunn,
Malcolm Morris, Robert William Parker, and J. Knowsley
Thornton. Hon. Secretaries: Dr. David White Pinlay
and Mr. William Henry Bennett.
HAHVEIAN SOCIETY.
Annual Meeting and Conversazione.
The annual meeting of this Society was held on Thursday,
January 14th, at the Stafford Rooms, Tichborne-street,
Edgware-road. A ballot was taken for the election of
officers for the ensuing year, and the following gentlemen
were declared by the President, upon the report of the
scrutineers (Messrs. Sedgwick and Sidney Phillips), to have
been unanimously elected President: Mr. Henry Cripps
Lawrence. Vice-Presidents : Dr. M. liandfield-Jones, Mr.
J. E. Lane, Mr. C. B, Lockwood, Dr. Stephen Mackenzie.
Treasurer; Mr. Malcolm Morris. Hon Secretaries: Mr.
D'Arcy Power, Dr. G. Wiiliam Hill. Council: Mr. Thomas
Bryant, Mr. Watson Cheyne, Mr. G. P. Field, Dr. J. F.
Goodhart, Mr. C. D. Bowditeh Hale, Dr. Wm. Winslow
Mr. W. H. A. Jacobson, Dr. Robert Maguire,
Mr. Herbert W. Page, Dr. Sidney Phillips, Dr. Marmaduke
Inekett, Dr. C. Theodore Williams.
"^l^^ oiitgoing President, Mr. Thomas Bryant, then gave
hm address on the treatment of Internal Intestinal Strangu¬
lation and Obstruction. This address was published in our
issue of last week.—Dr. Maguire, the senior secretary, read
toe annual report, which indicated that the financial con¬
dition of the Society was prosperous, and that a large
amount of good work had been done duiing the preceding
year.—Mr. Thomas Bryant then left the chair, and iuducted
the newly-elected President, Mr. Cripps Lawrence. A vote
m thanks to the retiring I’resident was proposed by Dr.
WortOD, and seconded by Dr. Wall; and a similar vote to
he retiring Vice-Presidents and inembors of Council was
Reposed by Snrgeon-Geaerai Harris, and seconded by Dr.
Eastes regretted that Mr. Field felt
1 resign the office of Treasurer, which ho
fi,« .i* years, and Dr. Blenkinsop seconded
tf. *^e8t thanks of the Society be temlered
which he had rendered in the
TOcityof Treasurer.-Dr Beale proposed, and Mr. Malcolm
of thanks to the Secretaries.—
R^^’;^he3s of tlio evening had been concluded, the
thnir Z- a large number of its members and
toeir hiends at a smoking concert.
the bodies shown were not fungi. With this opinion the
members taking part in the discussion coincided.
Dr. MURPHV, according to notice given, proposed the
resolution: “The members of the Northumberland and
Durham Medical Society de^ly regret that a report of a
portion of the transactions of last meeting has been com¬
municated to the Newcastle daily papers, and they trust
that this expression of their disapproval of such proceeding
will prevent its repetition.” Seconded by Dr. Anderson
(Seaton Delaval), and carried nem. con.
Cases. —Dr. ADAMSON showed a lad, who, he believed,
bad recovered from tubercular meningitis.—Dr. Limont
showed two boys suffering from lupus, whom Mr. Page had
treated for a month by Koch’s fluid. The usual reactions
had followed injection, and,the boys were considerably im-
E roved. Dr. Limont said scraping would have given a
etter result, in less time and with less discomfort to the
patient; the permanency of cure effected by Koch’s treat¬
ment had yet to be proved.—Dr. C. L. Lightfoot showed
a girl whom he treated for lupus of the nose three years
ago by free scraping, followed by the application of equal
parts of lactic acid and kaolin; the wound healed in a
week, and had remained so ever since.—Dr. Angus showed
a woman aged fifty, on whom Dr. Arnison had operated for
fmcal fistula resulting from a Libtre’s hernia, which had
become gangrenous and formed an abscess. Tiie opening,
which was in the small intestine, was closed by LemberPs
sutures, and the patient made a good recovery and now
suffered no trouble of any kind.—Dr. Murphy showed a
man aged forty-five on whom he had performed cholecysto-
tomy.—Dr. Hume showed a man on whom he had success¬
fully operated for relapsing typhlitis.
Specimens. —Dr. A. E. MORisoN showed a Gangrenous
Penis. The patient, aged sixty-six, had been laid up for
two weeks with subacute bronchitis, and had noticed pain
in micturition for a few days before the penis became black
and swollen ; half an inch of penis was left. The patient
had previously lost both legs from gangi-ene after exposure
at sea.—Dr. A. E. Morison showed a Pelvis removed from
a woman who had died of pelvic hcematocele. The patient
was aged twenty-five, and was still suckling her last child,
aged fourteen months. She died with typhoid symptoms.
The specimen showed left pyo-salpinx and a hajmato-salpinx
as large as the fist on the right side, with a ring-like
swelling passing round the rectum.—Dr. MORISON also
showed a Rectum Excised for Cancer; before excising he
performed inguinal colotomy. The patient now had gained
two stones in weight, and the inguinal opening formed a
very satisfactory anus.—Mr. Morgan showed a Varix of
the Saphena which was attended by pain, vomiting, and fever,
and somewhat resembled a femoral heinia. He tied both
ends and excised, and the patient made a rapid recovery.—
Mr. Rutherford Morison showed the temperature chart
of a case of Ovariotomy. The patient was aged seventy,
and no rise of temperature followed the operation. Mr.
Morison also showed a specimen of old-,standing Fracture of
the Radius in its upper part.—Dr. Squance showed a
specimen of Malignant Disease of the (.Esophagus and
Stomach. The patient, a man aged seventy, was found to
have one obstruction six inches and another fifteen inches
from the teeth. First stage of gastrostomy was performed,
but too patient died suddenly thirty hours later. Post
mortem two patches of scirrhus were found in the sites
diagnosed.—Dr. Hume showed a Tibia operated on in 1883
for ununited fracture. The patient lately came to Dr.
Hume, and as the leg had become useless through deformity
it was amputated. A section showed the ivory pegs lying
in the bone unchanged.—The President showed a number
of .Hpecimena and drawings illustrating varietie.s of Cirrhosis
of the Liver, and drew attention especially to an example of
acute cirrhosis with jaundice, the result of alcohol.
llAwtos Sofias of
NORTHUMBERLAND AND DURHAM MEDICAL
SOCIETY.
Md“iS® hold on Jan. 8tii, David Drummond,
terisrin '^®'"««^8brated Dr. Russell’s alleged charac-
iBtic organism of cancer, and expressed his belief that
Foods and Dietaries: a Manual of Clinical Dietetics. By
R. W. Burnet, M.D., M.R.C.P.L, Pliysician to the
Great Northern Central Hospital. London: Cluis. Criflin
and Co. 1890.
The subject of food and diet has of late .years received in¬
creasing attention from the profession, and many excellent
books have been written thereon. The works of Parkes,
of Sir William Roberts, of Sir Henry Thompson, and of
ooge
200 The Lancet,]
EEVIEWS AND NOTICES OF BOOKS.
[Jan. 24, 1891.
Dr. Bumey Yeo are in point, ami one and all deserve the
attention of practitioners. The hook before us is in the same
line, but professes to treat only of diet in disease or, in
other words, to be a manual of clinical dietetics. It is
impoasible, of course, to write such a hook without intro¬
ducing a large amount of physiological matter touching
food and its uses. But still. Dr. IBurnet adheres pretty closely
to his text; and under the head of each principal class of
disease gives the reader not only the general principles on
which the patient’s dietary should be constructed, but
details as to the time and materials of individual meals.
He also adds an appendix with useful recipes. Some
medical men of high therapeutic reputation are known to
have good judgment in regard to the best modes of cooking
food. Others are rather deficient in this kind of know¬
ledge, and to such, as well as to all who have much cooking
for invalids to do. Dr. Burnet’s book will he of great use.
It will be found all the more valuable by busy men in that
it does not go too deeply into debated questions of the
physiology of alimentation, but deals with broad and
accepted views.
There are large classes of disease which, if not caused solely
by errors of diet, have a principal cause in .such errors, and
can only be removed by an intelligentapprehension of their re¬
lation to such. Gout, scurvy, rickets, and alcoholism are in¬
stances in point, and they are all treated with admirable sense
and judgment by Dr. Burnet. He shows a desire to allow as
much range and variety as possible, and occasionally he seems
to us to go to the verge of concession—as, for example,
where, while discussing wines and malt liquors for gouty
patients (p. 86), he adds that in some cases “ where a very
small amount of meat is eaten a little malt liquor seems to
be taken with impunity.” The careful study of such books
as this will very much help the practitioner in the
treatment of cases, and powerfully aid the action of
remedies. It is possible, of course, to he too punctilious in
prescribing diet and to make the patient so in regard to
his food. This extreme must be avoided, but hitherto the
common error has lain in too much laxness of directions on
the part of physicians. The very diathesis of the race has
come to be affected by popular and deeply rooted errors
which it will take many years of enlightened practice to
correct. Such hooks as this are a contribution towards
this correction.
The Throat and Nose and their Diseases. By Lennox
Browne, F.R.C.S. Edin. Third Edition. London:
Baillibre, Tindall, and Cox. 1890.
In reviewing a hook which has reached its third edition,
it is incumbent upon us to take note mainly of those points
which are new, and the alterations that have been
made. In this volume a large s^ace is devoted to
diseases of the nose, a subject which in former editions
had escaped the notice it deserved. Consequently our
remarks will apply in the first place to the matter con¬
tained in the latter portion of the volume. Here it would
seem that the substance consists mainly of a compilation
from the innumerable writings on the subject that have re¬
cently appeared. So far the work is deserving of little but
praise, except that the reader may doubt whether due
discrimination has been used. Observations less worthy
of general acceptance have in some cases more space assigned '
to them thanothersofgreaterclinical value. Such points are
conspicuous in the author’s treatment of nervous reflexes_
e.g.,in “the bond of union which exists between the various !
erectile structures of the body” {p. 539 et seq.) We find
also statements offered as matter of fact when at heat they
can be but theoretical surmises. For instance, we are told
that congestion and hypertrophy of the erectile tissue may
culminate in atrophy of both membrane and bone (p. 541)—
an opinion which, although frequently accepted, has, we
believe, never been substantiated by competent clinicians'
or pathologists. We think that a little more attention'
might have been paid to pathological facts, and a smaller
portion of the work devoted to quotations from more or less
worthy writers. Occasionally, however, Mr. Browne ad¬
vances views, as the result of his own clinical experience,
adverse to those of established authorities. Witness, for
instance, his remarks on the cure of asthma by the re¬
moval of co-existent nasal polypi (p. 649). In his conclu ¬
sions we believe that most practical, as distinguished from
theoretical, rhinologists will concur. The descriptive
portions of the work are fairly good, though the classifica¬
tion of nasal diseases leaves much to he desired. The
methods of treatment advocated are generally such as have-
found favour with specialists, though, considering the fact
that the hook is ostensibly written for the information of
the general practitioner, intelligible particulars are often con¬
spicuous by their absence. Thus, in rhinit is caseosa, we are-
instructed to “curette the sphenoid and ethmoid cells,
although we are informed neither of the manner in which
these cavities should be reached nor of the certain risks
attending such a procedure. The only instruments for
treating bony or cartilaginous septal excrescences advo¬
cated are Curtis’s nasal trephines. Of these, however,
there is neither description nor illustration, while no
mention is made of the motive power. Bosworth’s
saws, which need hut comparatively little experience-
for their safe and successful use, are not mentioned,,
while the dilliculties in the after-treatment of such
operations are ignored. In some respects the author’&
experience would appear to have been somewhat limited.
On page 599 he says : “ In five years I have only seen two
cases which could be described as caries of the ethmoid
bone which were not either syphilitic or malignant.” While
he further adds, somewhat recklessly : “ I find that my ex¬
perience is in accord with that of every otologist and rhino-
logist of note.” Here, >V6 think, ho is probably misled in-
his desire to discountenance the bogus “ necrosing
ethmoiditis,” for surely many cases of hone-disease occur,
associated with suppuration, which are nob syphilitic.
Actual necrosis of the ethmoid is occasionally encountered as--
the consequence of simple inflammation. We also ques¬
tion whether Mr. Browne’s explanation of the so-called
cleavage of the middle turbinated is sufficient. As w©
have already remarked, the arrangement and classification
of nose diseases are somewhat haphazard. Thus rhino-
scleroma follows hypertrophic rhinitis, preceding atrophic ?
while the latter includes lupus, leprosy, and tuberculosis.
Concerning tuberculosis, the only remark made is that
it does not call for special comment. Why not? We should
have imagined that it was at least as important to English'
readers as rhinoscleroma, of which no case has probably ever
originated in this country. The account given of polypus iS'
very meagre, while we do not consider that the question of
antral disease is quite fairly stated when we are informed
that suppuration in this cavity is, “ as a rule, uncon¬
nected with any ulceration or inflammation of the rhinal
raucous membrane of the aflected side” (p. 614). The
question is still sub judke. Yet in view of the expressed
opinions of such authorities as Krause, Zicin, Zuckerkandl,
Hartman, MacDonald, Bronner, and others, the alternative
view should he stated. Mr. Bnowne, moreover, tells us
that next infrequency to diseased teeth, as causes of antral
disease, are undoubtedly intra-antral polypi. Of this con¬
dition he claims to have seen two cases, though he affordS'
us no indications as to how the condition may be diagnosed.
We do not quite agree with him as to the very limited
applicability of Voltolini’s method of illumination of th©'
antrum, and are of opinion that some account should have
been given of this help to diagnosis. There is some
Digiiized by
Google
THE Lakobt,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 24,1891. 201
confusion in the directions for “catheterisation of the
infundibulum under the anterior extremity of the middle
turbinated body at a point in front of the hiatus semi-
iunaris ” (p. 617). Examination of a skull will show that
the infundibulum makes its exit at the upper point of the
hiatus, and is distant from the anterior extremity of the
middle turbinated at least half an inch. Upon anatomical
^nd clinical grounds we doubt the possibility of passing a
catheter into the frontal sinus unless the infundibulum be
feroken away.
Our remarks upon the other portions of the book
must necessarily be brief. We are glad to find the author
almost admitting his error in former editions in attribut¬
ing the possibility of benign laryngeal growths becoming
'malignant as a result of operative interference. In the
face of Dr. Semon’s valuable statistics such an admission
was inevitable. In connexion with this subject we regret
•to find Mr. Browne still adhering to the rules laid down ,
by himself in 1875 for intra-laryngeal operation. He
tells us that attempts at the removal of laryngeal growths
■intra-laryngeally are not infrequently attended with fatal
'■(results! that “the cardinal law that an extra-laryngeal
method ought never to be adopted unless there be
.-danger to life from suffocation or dysphagia should be
applied with equal force to intra-laryngeal operations ’
(p. 457) ! We are the more surprised at the reiteration of
■these opinions in view of the enormously increased facilities
afforded by the use of cocaine. His directions for applying
the latter would prove, we believe, inadequate in the hands
-of most operators. Although the author is usually very
tenacious of his opinions, in justice it must be admitted that
hesometimes modifies his earlier views with advantage. For
instance, he now admits that it is “probable” (sic) thatdiph-
theria germs are the true “ element of contagium ” and not
a ptomaine,” as “ was put forward as a tenable hypothesis
•in the last edition of this work” (p. 335).
The book is certainly not without merit, and, in spite of
■defects of style and the want of careful revision of the proof
sheets, will be useful as a guide to the treatment of the
diseases with which it deals. A word of praise must be
accorded the publisher for the elegant dress in which the
work is presented.
The Student's Chemistry. Vols. I, and II. Poona:
Printed at the Orphanage Press. 1890.
The author of this work makes such honest admissions
an his preface as to relieve the critic of much of his task.
He modestly abstains from subscribing his name, and on
the title-page quotes Sir G. C. Lewis to the effect that “the
author may have deemed it prudent to withhold his name
from the public,” and then cites George Eliot’s utterance
that “ private criticism has more chance of being faithful
than public.” Following the preface is a complete list of
the authorities quoted. The list embraces some hundred
names, and includes, as a matter of course, those of Thorpe,
•Miller, lioscoe, Tilden, Muir, from whose works in par¬
ticular 'much has been taken. There is little claim, it
evident, on the part of the author to original writing,
hut he has without question succeeded in putting together
-a mass of valuable and interesting facts—and facta which
we find are in strict accordance with the present state
■of the science. More than passing mention is made, for
^stance, of the recent isolation of the element fluorine,
Haoult’s comparatively new method of fixing formulm,
and we meet with the announcement of T. Gross in Vienna
hat sulphur is not an element, but a compound containing
■carbon, a statement which chemists have not yet generally
accepted. The now well-known Solvay method of obtain-
tDg soda carbonate is described, and on page 176 is a
capital list giving the percentage composition and uses of
the alloys of gold, silver, copper, tin, lead, zinc, antimony,
and aluminium, as well as miscellaneous alloysand amal¬
gams. The account of the theoretical portion of the science
which generally proves to be the pons asinorwm to most
students is clearly and simply told. The book is intended,
though not exclusively, for the use of the medical student,
and to that end stress is laid upon the application, prepara¬
tion, and purification of the inorganic substances used in
medicine. But the author has surely overlooked the fact
that organic chemistry, or the chemistry of the carbon com¬
pounds, an account of which finds no place in the work,
occupies a considerable part of the medical student’s study.
The immense proportion of organic bodies now used in medi¬
cine, including alkaloids, makes this branch of the study
every day of increasing importance. Should the author
add at some future time an account of the more important
facts of organic chemistry in the same clear way in which
he has linked together the inorganic facts, the book
would then be admirably adapted to the requirements
of students of medicine. The work was, however, under¬
taken more with a view of supplying the chemical student
with a cheap and authentic text-book, and so we regard it.
Volume I. (414 pages) is divided into Book L,■‘devoted to
theory, and Books II. and III., to non-metals, metalloids,
and metals; while Book IV. forms the second volume
(63 pages), which treats of practical chemistry, containing
useful analytical tables and notes on the grouping of the
metals. The only typographical errors to be noticed are
“preeace” for preface in Vol. I., and “strychinine” for
strychuiue on page 61 of Vol. II. We are not inclined,to
agree with the author when he says that the great principle
of the indestructibility of matter is difficult of cognisance
and proof, as several simple experiments are known which
go to demonstrate this.
The Veterinarian for January is chiefly taken up with
the reports and discussions of the various veterinary and
agricultural societies. Mr. Albert Batt, M ll.C.V.S., con¬
tributes Notes on a case of “Quarter Evil,” and also of
Tetanus in Cattle; and Mr. J. C. James, M.R.C.V.S.,
gives an account of an Interesting case of Threatened
^suffocation (Apnma) through Displacement of the Epi¬
glottis. Commenting on the Bleuro pneumonia Order of
1891, which is published in extenso in the journal, the
editor points out that the new order “revokes all regu¬
lations of local authorities in Great Britain relating to
movement of cattle and also of fairs and markets on account
of pleuro-pneumonia, and does not re-enact the articles
which conferred the powers to make such regulations.” The
main principle that underlies the whole structure of the
order is that of closure of centres of infection and the
removal of restrictions from parts of the country which
remained free from disease. Tbe order deals with
the questions of detention of cattle, compensation, move¬
ment licences, and the offences against the Act of 1878.
Koch’s discovery, it is reported, gave rise to a special
meeting of the Council of the Royal College of Veterinary
Surgeons, to consider the advisability of sending a delegate
to Berlin, and it was unanimously resolved to appoint
a committee of seven with full powers to act. A
report of a paper by Dr. Herbert Manley on the Joint
Sanitary Work of the Medical and Veterinary Profession is
given, and also a couple of papers by Mr. Clement Stephenson,
one on the Working of the New Pleuro-pneumonia Act
and Orders, and another, Notes on Endocarditis in the
Pig; there is also a paper by Mr. George R. Murray,
M.B., B.A,, Notes on the Condition of Three Hearts taken
from Pigs Dead of Endocarditis; all of which were given
at the joint meeting of the Northern Veterinary Medical
Associations.
Diniti^ed hy Google
202 The Lancet,] COMPOSITION AND PREPARATION OF PROFESSOR KOCH’S FLUID. [Jan. 24,1891.
THE LANCET.
LONDON: SATURDAY, TANUAEY 1891.
It waa with feelings of very great satisfaction that we
placed before our readers on Saturday last Koch’s state¬
ment respecting the composition and preparation of his
anti-tubercular inoculation fluid, conveyed to the medical
world through the Deutsche Mcdicinische Wochensch'Hft
on Friday, Jan. 16th. We felt that a certain element of
reproach had been removed from the substance now that it
could no longer be classed amongst secret remedies, and we
are convinced that the satisfaction will be shared by those
who, like ourselves, have the greatest admiration for
Koch’s genius, but who have been of the opinion that
he had made a mistake in scientific ethics. This opinion
will not be entirely lost even after the perusal of the
statement that “so long as it was only a question of
proving the accuracy of the results indicated in my former
paper, there was no need for anyone to know what the
remedy contained or whence it was derived,” for it could
not but be felt that men who are not inspired with the same
honesty of purpose that characterises Koch’s work, who
have not the same ability, and who do not enjoy the same
confidence of the profession, may adduce bis example in
justification of similar methods of procedure, but with veiy
dissimilar reasons for carrying them out. The proclama¬
tion of the full knowledge of the remedy and the partial
description of the method of preparation are now before us,
and though so anxiously awaited by all who take the
slightest interest in their profession and in their patients,
it has brought with it little that was not already antici¬
pated; for although Kocii had kept back the actual
description of bis liquid, he bad made it evident from
the description of its mode of action that it was in some
way a product of the tubercle bacillus itself; and,
reasoning by analogy, most bacteriologists had come
to the conclusion that the inoculating fluid contained
some special product of the tubercle bacillus, although few
guessed how this was obtained or separated. The hints
that had been dropped by Koch were very broad, but now
that the whole truth is out we cannot but admire the pro¬
cess of reasoning by which he was led to experiment on
the lines that are now familiar to the medical world. Com¬
mencing with inoculations of pure cultivations of tubercle
bacilli, be found that the action of a second inoculation of
tubercle bacillus was very different from a primary inocu¬
lation, the chief differences being manifested at the seat of
injection. Led no doubt by the success of those who had
worked with other diseases, and who had induced partial or
complete immunity in certain animals against the effects of
specific organisms by injecting the sterilised pure cultures
of these same specific organisms, Kocu carried his experi¬
ments a step farther, and showed that the peculiar pheno¬
mena above mentioned were also obtained when pure
cultures of the tfearf microbes (previously killed by exposure
to heat or to chemical agents) were injected, and that they
acted in exactly the same fashion
The next step, however, is that in which the real experi¬
mental genius of the man comes out. Pure cultivations of
tubercle bacillus, when triturated with water and injected
into the subcutaneous tissue of a healthy animal, he found
produced no eft'ect beyond a localised suppuration; but
injected into a tuberculous animal it gave rise to such
marked local and constitutional disturbances that the
animal died in from six to forty-eight hours. If the dose
be diminished so that it is not sntBcient to kill the animal,
the ulcer that forms first extends as in the case of the ex¬
periments with the living bacillus, and, after sloughing,
cicatrises. The swollen lymphatic glands also begin to
diminish in size after one or two inoculations, and the
general condition of the animal becomes distinctly improved.
He found, however, that the presence of the dead bacilli
gave rise to intense suppuration, and therefore it
became necessary to get rid of these from his inocula¬
tion fluid or to separate the useful principle from
that which caused suppuration; for by this time it
bad become evident that the substance that was useful was
readily dissolved out from the bacilli by certain fluids, the
best of which was found to be a 50 per cent, solution of
glycerine, whilst the material that gave rise to suppuration
was more tenaciously held by the bacteria.
Koch works, then, with a glycerine and water solution
of pure tubercle bacilli, from which the bacilli and certain
other materials have been .separated, and which contains
the substance to which the inoculating fluid owes its virtue,
but none, or comparatively little, of the suppuration-
causing substance. The separation of this active material
must evidently be rendered much easier by the fact that it
will withstand a considerable amount of heat, and that
it is readily dialysable. It thus diflers both from the
enzymes and the toxalbumins, to both of which sub¬
stances have been ascribed, though without sufficient
reason, the protective potency of the products of such
bacteria as those found in septiciomia, tetanus, and
diphtheria. The substance, whatever it may he, is present
in exceedingly small quantities, and it appears to act bene¬
ficially only under certain conditions. Acting alone on
healthy tissues, it probably has some effect in stimulating
the leucocytes and connective tissue cells; but when acting
in conjunction with the products of bacilli already present
in tubercle nodules, and on cells that have been already
weakened and altered so far by the products of these
bacilli that they are undergoing a process of coagulation
necrosis, the changes are exceedingly well marked and the
process is completed comparatively rapidly. Some cello
in which the changes have not already commenced
have this same process determined in them ; whilst
immediately outside the necrotic area the tissues
appear to be only so far stimulated that a mild specific
inflammatioD is set up — an inflammation which differs
little in character from an ordinary reactive inflam¬
mation such as is set up around irritant foreign bodies
or mosses of dead tissue—which appears to localise the
slough when it lies in the substance of a tissue or organ,
and to separate it from the deeper tissues when it is near a
free surface. We have in all this an entirely new depar¬
ture, both as regards the methods used and the principle
involved in the treatment of a specific infective disease. Ii>
Digitized by
Google
Thb Lancet,] THIRD REPORT OF THE ROYAL COMMISSION ON VACCINATION. [Jan. 24, 1891. 203
the first! place, tubercle—a disease chronic in its course and
accompanied by a loss of tissue which cannot be repaired—
ie attacked as followsIn place of trying to antagonise
tb*e effects of the bacillus, Koch, with his fluid, steps
in and does two things: he kills off rapidly and com¬
pletely those tissues in which the bacilli are present,
and in so doing cuts off from these areas the lymph and
blood-supply, the outflow at the same time of course being
stopped, so that the bacilli are both starved and poisoned
in situ. There is in addition, a priori, less chance of
their being carried from the dead tissue in which they now
lie into the surrounding tissues. Along with this, however,
there is set up around this dead mass a barrier of actively
gtimulated connective tissue cells and leucocytes, the result
of inflammation which, under ordinary circumstance?, and
if left sufficiently at rest, may become converted into a
fibrous zone such as is found in cases where tubercle has
undergone spontaneous cure. Wo have here, in fact, simply
an acceleration of those processes that occur in the normal
processes of cure of this disease. Where the slough is on a
free surface, and when it can obtain a free exit, the dead
tissue with its contained bacilli may bo thrown off almost
at once; but where the tubercle occurs embedded in solid
tissues such as bones, or in such cases as tubercular cold
abscesses, operation becomes necessary, in order that the
latent tubercle may not be left to be again brought into
action in case of accident, or to set up suppurative changes
as the more insoluble pus-exciting products are set free to
act on the surrounding tissues.
A most important point to be borne in mind is the
difference between such free surfaces as those met with in
the lung and fiee cutaneous surfaces. In tubercle of the
skin treated by Kocii's method the slough is cast off as
soon as it forms, and may be rendered harmless at once by
the use of antiseptics; but in the lung the process of
‘localieation and sloughing at one point may he the indirect
cause of infection at others, from the fact that the fragments
of the slough with their contained bacilli may not be ex¬
pectorated at once, but may be drawn into the terminal
bronchioles of other parts of the lung, and so set up much
more extensive tuberculosis, similar in character to the
acute catarrhal tuberculosis that may follow the inspiration
of material from an ulcerating apical cavity into the lower
parts of the lung of the same or even of the opposite side.
Although Koch apparently does not claim to produce any
immunity against tuberculosis in those treated by his
method, it is possible that some such immunity may play a
part in the subsequent history of these patients. This of
course cannot be proved for some time to come owing to
the extreme tardiness with which the disease runs its
course; but in connexion with this question it may he
remembered that in the case of anthrax and diphtheria an
ejection of the albuiuose or of the soluble products during
the course of an attack of one or other disease accelerates
rather than interferes with iU regular course. The method
that Koch uses is strictly analogous in this respect, but
<^wing to the different nature of the diseases the effects are
Qot manifested in the same way.
The publication of the details of this method marks a new
advance in bacterio-therapeutics, which must influence in a
very great degree the study of bacteriology. It may be
anticipated that it will give a stimulus to such study in
this country—a stimulus that is still much needed, though
scarcely so much as it was ten years ago. A new field of
observation and research is opened up to both bacterio¬
logists and clinicians, and it leads us to hope that other
diseases which at present are looked upon as incurable
may be brought witliin the pale of therapeutics. KoCH
has made known his method of treatment; be has
placed in the hands of medical men a most potent agent for
good or ill, according as it is used with intelligence and
discretion, or without regard to the principles on which it
is based. The method will suffer, and has suffered, through
a neglect of the elementary principles that guide the
bacteriologist even in his experimental work, and it can
only he by careful attention to the most minute details, as
insisted upon by KocH himself, and then by a most accurate
observation of the symptoms and course of the disease in
tuberculous patients treated by inoculation, and by most
careful deductions therefrom, that the results already ob¬
tained can be corrected or corroborated. That the clinical
part of the work will be carried out with the greatest care
and with the utmost impartiality in this country no one
can doubt; but there is also promise that the bacterio¬
logical side of the question may receive something more than
scant justice at the hands of some of our scientific workers.
In an article which appeared in our issue of Jan. 10th,
we dealt with Dr. Alfred Russel Wallace’s attempts
to put before the Royal Commission on Vaccination -the
views of the anti-vaccinationists from the scientific aspect,
and we showed how his evidence was permeated with
blunders that must be obvious even to those who are
devoid of all scientific training. Dr. Wallace was suc¬
ceeded by Mr. Alexander Wheeler, another leader in
the same cause; and he followed his predecessor’s example
by first occupying several hours of the Commission with
inferences drawn from statistics of a past century and of
distant countries, the former of which at least have been
shown to be untrustworthy, and-which, as we have already
pointed out, cannot have any particular beating on
the question of the inflaence of our present vaccina¬
tion laws iu controlling small-pox. But as he proceeded
he enunciated views of a very curious character,
which led Sir William Savory at last to sum them
up in these words:—“Then it comes to this, that,
if people escaping small-pox died of something else, it
would not be worth while to check small-pox?” At a sub¬
sequent sitting some attention was given by the witness to
years since registration of deaths came into operation, but
bis main effort seems to have been to show that small pox
needs no State intervention, that it exerts little or no in¬
fluence on the general death-rate; and that the “best
authorities”—whom the witness forgot to name—“are
agreed that, in epidemic years, small-pox is not diminished
by vaccination or greatly affected by it.”
The point previously indicated was next enlarged upon,
on a question from Mr. Bradlaugh “ Do you suggest,
then, that the people who took small-pox would have taken
some other disease if they had not had small-pox?” to
which the witness answered, " That is so.” In other words
Digitized by ^ooQle
204 The Lancet,] THIRD REPORT OF THE ROYAL COMMISSION ON VACCINATION. [Jan. 24.1891.
his evidence, dealing as it does with onnaEiI death-rates,
actually propounds the theory that, if people in a given
year had not contracted fatal small-pox, they would have
taken and have died of some other disease—a theory which
naturally struck Lord Herschell as being “ a singular
one.”
The following are some of Mr. Wheeler’s views on this
point. Being asked whether the Commission properly
understood his proposition as being “ that there is a certain
amount of total death-rate . which is uninfluenced
by the greater or lesser amount of small-pox death-rate?”
he answered, “I put it so.” But when asked whether he
would say this of every disease, and, if not, why of small-pox
in particular, he ignored that latter part of the question,
and said, “ I should not say so of every disease,” adding
that he did not think such an assertion would apply to
measles, for example. And on being pressed by Sir Wm.
Savory as to whether it was, under such circumstances,
** worth while to try to reduce the mortality hy small¬
pox by any means,” the difficulty was evaded hy an
answer to the eflect, “That is not my object.” This
aspect of the question does not seem to have been thought
worthy of further detailed investigation, but it involves an
opinion that Mr. Wheeler says he does not hold alone,
and which we know is advanced hy a certain class of
persons. Hence, we will endeavour to set out the real
meaning of it if pushed to its logical conclusion.
Seemingly, the thesis may, and this without violence to
Mr. Wheeler’s representation of it, be enunciated in pro¬
positions as follows:—1. That in a given year there is a
certain amount (greater and smaller in different years) of
small-pox death which is “proper” to the year. 2. That
similarly, as regards each and every cause of death there is,
in each year, an amount of mortality proper to the year.
3; That if, in a particular year the amount of small-pox
death proper to the year be diminished by human inter¬
ference, an equivalent amount of death in the same
year will occur from other cause or causes. 4. That if
in a particular year the amount of death proper in that
year to measles, to scarlatina, to enteric fever—^or, indeed,
bo any cause other than small-pox—be diminished hy human
interference, such diminution of death is clear gain ; it will
not be balanced, as in the case of small-pox, by extra deaths
under other headings. 5, That the vicarious deaths which
thus come to balance the deficit of small-pox deaths brought
about in the particular year by human interference with
that disease will affect (in the same year) those individuals
and those alone who have by such agency been withheld
from small-pox. These supplementary deaths, therefore, will
bewcan'oiis as regards cause, nof asrej 7 «r£^spersons. 6. That
the vicarious deaths in question will nob beforthcomingunless
the human interference with small-pox has been intei'fer-
ence by means of vaccination; that, indeed, small-pox death
prevented hy segregation of small pox cases in hospital, hy
quarantines and the like, will not be balanced by an equiva¬
lent amount of death by other causes.
Bub by the time the fifth proposition has been reached
Mr. Wheeler’s thesis tends to become unthinkable, and
for the reason that every cause of death is by hypothesis
proper to the particular year, and the balance, tbere-
Kte, of vicarious death is not to be had, unless, indeed,
absolutely new causes of death are, so to speak, created to
satisfy the demand for them. In short, it would seem,
according to Mr. Wheeler, that whilst all other measures
for the promotion of health and the prevention of disease
can properly be allowed to work out admittedly good
results on mortality, vaccination could only be regarded a&
a means of prevention on the condition that it conferred
immortality. We may fairly leave Mr. Wheeler and hi&
“singular” views to the Commission and to the ordinary
intelligent reader.
But whilst we do this we would by no means imply that-
Mr. Wheeler is devoid of a certain kind of cleverness-
He has to an exceptional degree a gift, which he shares
with his fellow anti-vaccinationists, of avoiding questions,,
that sap the very foundations of his theories, by giving such
answers as the following“ If I rtiight defer that till
later on,” “ I will come to those afterwards,” “ That I shall
come to by-and-bye,” and then instantly going on with
something else. Mr. Bradlaugii, who is courteous in
the extreme to witnesses, and is little disposed to say any¬
thing that would hurt anyone who thinks he is aggrieved by
the Vaccination Acts, very aptly summed up the difiiculties-
raised by Mr. Wheeler’s mode of giving evidence when he
addressed him thus; “I only put this for yoxir guidance,
whether it may not be possible that the valuable points in#
your evidence are embedded in a mass of details from which
even the Commission may fail to extricate them.” We
trust Mr. Bradlaucii may be able hereafter to unearth
the “ valuable points,” for they have sunk altogether beyoncS
our reach.
The president of the London Society for the Abolition of
Compulsory Vaccination, Mr. William Tebb, was the
next witness. He told some “ hideous ” stories, mainly of
sypliilisation and other allied calamities, largely obtained-
from snob sources as foreign newspapers, and collected
from such distant places as France, Holland, (Jermany,
Algeria, the United States, the West Indies, and
British Guiana, which stories, even if all were true,,
would do little more than prove that in certain parts
of the world there is much negligence in the perform¬
ance of vaccination. As to our English experience in
this matter, we would recall an answer given in August,,
1887, to Mr. PlCTON in the House of Commons hy the Pre- '
sident of the Local Government Board. Mr. Ritchie said =
“ The Board have the authority of Mr. Hutchinson for
saying that, though he has been diligently on the look out
' for similar cases during the ten years’ interval [since 1871J,
he has failed to meet with any. In his recent work, pub¬
lished this year on the subject, Mr. Hutchinson says
‘There certainly cannot be any difficulty, under ordinary
circumstances, in procuring vaccinifers which are absolutely
free from risk.’ Mr. flUTClllNSON’.S experience is, in these-
respects, entirely confirmatory of that of the Board, which
is to the effect that, although three-quarters of a million of
children have been vaccinated annually for many years
past, not a case of the communication of the disease in
question by vaccination has come under their observation.”’
When Dr. Wallace found himself confronted with the
difficulty of having to explain how it was that there bad
been “ an enormous decrease of the mortality from small¬
pox amongst children under five years of age since the
Digitized by LjOOQle
The Lancet,] THE LUNACY ACT OF 1890,—THE MEDICAL DEFENCE UNION. [Jan. 24, 1891. 205
introduction of vaccination,” and that no similar diminution
had taken place as regards “ any other disease to which
children are subject, such as measles and the like,” he said
to the Commission, “ You will have a gentleman before you
who will explain it far better than I can, if it is to he
explained.’’’’ We hope that the point embodied in the words
which we have taken the liberty to italicise will not
permanently affect the obvious hesitancy which the gentle¬
man in question has hitherto exhibited in coming forivard.
The point is the vital one at issue.
In the last number of the Journal of Mental Science is
published a paper by Dr. Pebcv Smith, oiiginally read at a
meeting of the Medico-Psychological Association for the pur¬
pose of introducing a discussion on the working of the Lunacy
Act of 1890. It may be said at once that the paper contains
a very strong indictment of the Act as regards certain
clauses. No donbt such regulations as the Act contain are
subjected to the most severe strain at a hospital like
Bethlem, which admits more private patients in a year
than any similar institution in the country; but that the
inconvenience has been, if not quite as great at other places,
still suflicient to give rise to much unnecessary trouble and
worry, is abundantly shown by the discussion which took
place at the meeting at which the paper was read.
The chief dilliculties in regard to the working of the
provisions of the Act seem to depend upon the manner in
which justices have acted in regard to petitions presented
to them. They have for trivial reasons refused to sign,
and they have done so without fixing any future time for
consideration of the petitions. In one case a stipendiary
magistrate refused to sign, certifying that to do so would
interfere with his judicial functions. It can be imagined
that ,sach a coirrso is not calculated to lessen the anxiety
or allay the apprehension from which the friends of a
lunatic may naturally be supposed to be suffering. In
another ease a magistrate refused to sign a reception order
unless the medical men who had signed the certificates
were present to be put on oath, although the Act ex¬
pressly states that every medical certificate for the
purposes of the Act is equivalent to evidence on oath.
Then, again, the provision that no justice shall sign unless
the patient be in his own county seems to be an unnecessaiy
limitation of the powers of justices, and, as may be
supposed, it gives rise to endless trouble in practice. The
same may be said of the appointment of justices to act
specially, for there may be ignorance of the names of such
justices on the part of the asylum superintendent, on
account of delay in the circulation of the list ; and
ordeis, invalid by reason of being signed by a justice
not authorised to do so, have actually been presented. It
might bo supposed that a magistrate himself would know
whether, in a given case, ho was the proper person to
sign the order ; but so far is this from being the case that
not only have justices signed for patients in the county
of London who had no jurisdiction in that county, but,
08 has just been said, on more than one occasion it has
happened that a magistrate actually not appointed for the
purpose has signed a reception order, and the whole
matter has had to be gone over again from the heginniug.
Asylum superintendents, in addition to their numerous
duties to the patients under their cate, have to find a
specially appointed magistrate—no easy task in the holiday
season, when they are nearly all out of town—and are also
expected to see that they perform their duties properly. To
judge from Dr. Smith’s recent experience, this will lead to a
considerable increase in their work. No one would wish to,
curtail in any way the right of an inmate of an asylum to
be examined by a judicial authority; but when such a
procedure is prefaced by the service of a notice it can be
imagined what a prejudicial effect the reception of a
probably unintelligible official document is calculated to
iiave on a person of unstable mind, and in the paper before
us Dr. Smith gives more than one instance in which such
an effect was produced.
Such arc some of the difficulties which so far have arisen in
the workingof this Act, and weeannot doubt that some means
of surmounting them will be found. The means, we think,
are such as Dr. SMITH indicates—viz,, the multiplication
of justices specially appointed for the purposes of the Act,
provision for a sufficient number to be available during the
holiday season; that their jurisdiction should uot be limited
' in the way it is; that the list of appointed justices should
be circulated immediately after the appointments are made,,
and that some means should be taken to inform them of the
nature of the duties which are required of them and the
manner in which they are expected to carry them out.
The annual report of the Medical Defence Union
(Limited) is a document which has interest for our readers.
Our professionis a very undefended profession. The examining
bodies are the natural custodians of the medical body. They
prescribe the terms of admission. It is the possession of
their diplomas that entitles to medical registration. They
were charged with disciplinary powers over their members.
Unfortunately, they have shown little power of discipline,
and a strange reluctance to use what little power they have.
They have piled up examinations for the applicant for
their diplomas, and increased wonderfully the examination
fees, but they have then left their diplomates to take care
of themselves. If they did well it was without much
encouragement from their alma mater; if ill, they met
with no remonstrance. In the legal profession, if a member
misbehaves himself and dishonours his profession be
will soon hear of it from the Incorporated Law Society
or the Inns of Court. But iu the medical profession irre¬
gular behaviour is little noticed by the authorities of the
profession, and the Cleneral Medical Council is without
power in such a case unless the behaviour can be charac¬
terised as “infamous in a professional respect.” Whenever
an adequate amendment of the Medical Act takes place
it must impose on each professional body which grants
degrees or diplomas the stern duty of insisting that those
who hold such high credentials shall act in harmony with ,
them.
The Medical Defence Union is in the meantime doing
some of the work that the medical authorities ought to do
in the way of instigating prosecutions of those who dis¬
grace the profession by irregular methods of practice and by
a;8ociation with quacks. But it does more. Medical men
Digitized by
Google
206 The Lancet,]
HOUSING OF THE WORKING CLASSES.
[Jan. 24, 1891.
are liable to all sorts of attacks, some curious illustrations
of which are given in the annual report, attacks from un¬
gracious patients, or possibly even from unprincipled and
cowardly rivals, and anonymous attacks through the medium
of the Post Office. The Medical Defence Union undertakes
to help its members in unearthing such dastardly and
malignant enemies, and succeeds in getting the co-operation
even of the Postmaster-General, and in two instances it has
succeeded in stopping the grievance, if not in detecting the
criminal. Audacious quacks are so conscious of the power
and determination of the Union that in several instances
they have forestalled the trial of their case, and paid large
penalties and costs.
There is one great drawback to the efficiency - of the
Medical Defence Union in the metropolis—viz , that by an
inadvertent defect in the Medical Act of 1858 fines imposed
for violation of the Medical Act go, not to the General
Medical Council, which would doubtless apply them to the
payment of the expenses of the prosecution, but to the Re¬
ceiver of Police, by whom they are kept for the relief of the
Exchequer. The Defence Union feel this to be very hard,
and have determined to postpone metropolitan prosecutions
till the law is amended. They cannot be blamed. They
have brought the matter under the notice of the General
Medical Council, which ought without delay to apply for an
amendment of the Act.
The steady growth of the Union in financial stability and
in the confidence of the profession is shown in various ways.
In 1868 the membership was 442; in 1889, 8.S4; in 1890,
1446. The guarantee fund on Dec. Ist, 1888, was £538;
1889, £1249; 1890, £2173. These are fine figures, but must
involve a large amount of personal trouble to the Union,
and especially to the honorary secretaries, Dr. A. G.
Bateman and Dr. Leslie Phillip.s. It is difficult to
estimate this, but one is helped by learning that in 1888
they wrote 571 letters; in 1889, 4186, and in 1890, 5936.
The Defence Union has wisely adopted the rule of refusing
to undertake the grievances of those who are not members
of that body. It would be monstrous to add to enormous
labours for the members similar labours for those who will
not contribute the small sum for membership. The moral
is that this Union should be joined by all members of the
profession, who will then be less exposed to suffer injury
from libel and other causes than at present.
^nnctations.
“ Ne quid nimla."
HOUSING OF THE WORKING CLASSES.
Eael Compton, as Chairman of the Committee of the
London County Council on the Housing of the Working
Classes, has presented to the Council a report on the method
of dealing with the Bethnal Green area, which it may be
expected will be cleared under Part 1 of the Act of 1890.
On this area there are now resident nearly 6000 persons, and
the question the committee has had to consider is that of
dealing with tlie area in such a way that these persons maybe
put to the least inconvenience. The committee, on obtain¬
ing possession of the property, will at once proceed to close
the worst houses in whatever part they maybe situated, and
from these about 288 persons will be removed ; afterwards
the area will be dealt within three sections—i e., one sect ion
will be cleared at a time, and the second section will he left
untouched until the first is covered with houses; so, again,
the third will not be cleared until dwellings have been erected
upon the second. By this arrangement the maximum
number of persons who will be displaced at any one time
is about 2000, and, with the exception of those resident in
the part to be first cleared, there will be abundant provision
made. An inquiry which the committee has instituted
shows that there is accommodation for more than 2000
persons in rooms situated about five minutes’ walk from
stations within the limit of the workman’s 2cf. return fares.
Farther, by next year the Guinness trustees will have pro¬
vided for 1600 people on a site in close proximity to the
area under consideration, and cottage accommodation for 200
persons will be provided by other bodies on another area,while,
beyond this, there is at the present time accommodation for
1580 persons in empty rooms in the neighbourhood. The
committee, moreover, recommends that the Council should
acquire another adjoining site and erect on it dwellings
for 500 persons. It cannot be urged that the acquisition
of this last site is a necessity, but the committee has
pointed out that it can be purchased for a sum which is
equivalent to an annual rental of not more than 2c?.
a foot, and that should there he no necessity for the devo¬
tion of the whole of the represented area to artisans’
dwellings, it would enable the Council to utilise some
portion of it for other purposes. This last argument appears
to ns to be that which can be most properly urged for the
acquisition of further land. The scheme devotes for all
time some fifteen acres for dwellings for the working
classes, and the Council are certain before they have con¬
cluded this work to find need for bathing and laundry
accommodation for this largo population. It may he
expected that the committee’s proposal will meet with
some opposition from those who will see in it oppor¬
tunity for the Council to undertake building operations;
but it by no means follows that they will not deal with
this land in the same manner as has hitherto been
done with that acquired under Cross’s Acts. There
is of course no expectation that the occupants of houses
on the represented area will in any large number
themselves migrate into the new buildinga; but there is
certain to be an upward movement among the more orderly
persons in the immediate neighbourhood, and thus vacancies
will occur in the class of house to which the former persons
are accustomed, and into which it may be expected they will
remove. There is therefore much reason for allowing the
committee to have a free hand in dealing with this subject,
and especially as their proceedings, so far as the acquisition
of additional land is concerned, will not eventually impose
increased expense on the ratepayers.
THE FUTURE OF KOCH’S REMEDY.
Now that Professor Koch has so far satisfied legitimate
curiosity as to the nature of the Iluid which has such
marked influence upon tuberculous tissues, and as thereby
any scruples regarding the employment of the remedy on
account of its “secrecy’ may be set aside, it remains
more than ever imperative that we should have clear
knowledge concerning its elfects and its utility. We
trust that, if the College of Physicians continues to
be of opinion tliat it is beyond its province to undertake
the investigation of the treatment of tubercular disease
(thus, in its scientific capacity, practically drawing the line
at leprosy), one of our leading medical societies will take
up the question. The report of an influential committee of
physicians and surgeons, based upon several months’
observation of the eflects of the injections, would he of
Digiiized by
Google
The Lancet,]
THE CHAIR OF HYGIENE AT OWENS COLLEGE.
[Jan. 24,1891. 207
inestimable value in iudicatlap' more precisely the circum¬
stances under which it is safe to administer so powerful an
agent, and the extent to which its action may be deemed
curative. Of individual records there will doubtless be
enough and to spare, and all these must be carefully
collated and analysed ; but the best and mpst reliable
inquiry would be one undertaken as we suggest, where the
members of the committee might act on certain definite
lines, and meet frequently to discuss the progress of their
cases, and any new points that may come up for considera¬
tion. The warnings uttered by Professor Virchow may
also, it is to be hoped, act beneficially in restraining the
indiscriminate use of the remedy, the risks of which are so
grave and manifold. Another matter of some importance
is that of the sources to which we must look for supplies
of this glycerine extract of the tubeicular bacillus, the
precise formula for which has not been made known. It is
obvious that great difficulties may lie in the way of pro¬
curing samples of constant strength and purity (within
limits); and we do not see how this can well be tested,
except by physiological means. If, then, the “lymph” is
to be prepared in this countiy it should be done under the
protection of some central authority that could attest the
genuineness of the supply. Until this can be effected no
one should venture to make any injections except with the
Iluid prepared in Professor Koch’s laboratory.
THE CHAIR OF HYGIENE AT OWENS COLLEGE.
The chair of Hygiene and Public Health in Owens
College, Manchester, has been offered to and accepted by
Mr. John Tatham, M.A., M.D. Dr. Tathanfs caveerin the
department of public health, as medical officer of health
(lirso for Salford and now for the cily of Manchester), as
exponent of the principles of health in connexion with local
scientific or other societies, and as examiner in the Uni¬
versity of Cambridge, has throughout been an exceptionally
distinguished one, and it would have been difficult to have
filled this chair at Owens College iu a more appropriate
manner. _
BARON HAUSSMANN.
The death of Haron Haussmann, recorded recently, is
not only a political event, but concerns all who ate
interested in the cause of sanitary reform. From IS.I.S to
1870 Baron Haussmann held the reins of office as Prefect of
the Seine; and, in those days of absolutism, there was no
popular control to check his actions. The Emperor-
Napoleon III. gave him a free hand, and he set to work,
regardless of expense, to regenerate Paiis. Broad boule¬
vards were cut right through overcrowded districts. Light
and air were let in upon quarters where epidemic dis¬
eases had become endemic. So mighty were the changes
wrought, that a new word had to bo coined to describe
the work, and all Euvtrpo talked of the Huasmannic-ation
of Paris. The great changes effected have not, however,
proved an unmixed blessing. The financial situation they
created supplied M. Jules Ferry with the materials for the
pamphlet which first brought him into political fame, and
which he humorously entitled “ Les Coiiiples Fantastiques
de M. Haussmann.” The debts then incurred are now so
great abnrden that they prevent the realisation of .sanitary re-
formsrnoreurgent than those achieved by Baron Ilauismunn.
It is nob for us to criticise the artistic faults and merits of
the new Paris Baron Haussmann built. The msthetic side
of the question is nob our phase of .the subject. Though
opinions widely differ among artists, sanitarians can only
mete praise for the giving of lungs to the town by
creating the beauties and attractions of the Bois de
Boulogne and the Buttes do Chaumont, &c. The
splendid markets, slaughter-houses, and kimilar buildings
of public utility Baron Haussmann caused to be built, have
greatly contributed to the improvement of public health.
But, on the other band, there can he no doubt as to the
evil tendency of sacrificing to external appearances financial
resources that should bo devoted to internal improvements.
The magnificent dwellings raised on the new boulevards are
constructed in defiance of all laws of hygiene, while hut
little was done to improve the sanitary condition of the old
houses left standing. Judged by external appearances,
nothing can he more vast, more splendid and sweeping than
the new thoroughfares pierced by Baron Haussmann. The
eye is fascinated, the imagination exalted, by these changes,
realised so rapidly as to suggest the wave of a magician’s
wand, rather than the slow evolution of municipal pro¬
gress. But there is a theatrical element about this
that fails to satisfy the scientific mind. The worse con¬
sequence, however, was the spread of Haussraannisation
to provincial towns, and especially to health resorts. For
instance, at such towns as Cannes, Nice, &c., the public
money was freely spent to cut broad boulevards, to raise
handsome theatres and casinos, hut the sewers were left
in a deplorable condition, and domestic drainage utterly
neglected. To the credit of the Third Republic it must be
acknowledged thatmore interest is now taken in real sanitary
improvements and less is expended on mere external show.
Nevertheless, and in spite of all and numerous criticisms
to which Baron Haussmann exposed himself, he gave an
immense impetus to the cause of municipal progress. All
the errors, the extravagances committed, the political
motives that may have inspired some of the improve¬
ments initiated by Baron Haussmann, will not suffice to
efface the glorious record of great works achieved by the
late Imperialist Prefect of the Seine.
RESPONSIBILITY IN AN/ESTHETISING.
Mr. E. H. Davies, deputy district coroner, was certainly
right iu the remarks he is reported to have made during an
inquest held upon the body of "William "Woods, aged forty-
nine, a labourer, who died from the effects of chloroform at
Newport. The coroner's inquiry elicited the facts that
Woods was admitted into the Newport and County In¬
firmary on Nov. 27th, suffering from disease of one of his
tibim, for which an operation was about to be performed,
when the patient died. The house surgeon, according to
the evidence before us, gave the man chloroform in the
presence of a nurse only, with the view of subsequently
performing the operation. The patient’s heart was duly
examined and pronounced not to he contraindicative to
chloroform. “After two whiffs,” says the report, “be suddenly
fell back upon the bed and died.” The necropsy, carefully
made, gave evidence, it is said,that the man died from syncope
due to chloroform acting upon a fatty heart. Two drachma
of chloroform were given, a quantity which the report
sajs the house surgeon stated “was scarcely enough to
kill him” (i.e. ,lhe patient). The coroner could not hut call
attention to the dangerous and reprehensible practice here
adopted of one medical man under taking the duties of chloro-
foruiist and operator, and working single-handed. It seems
hardly credible that, when the death-rate from anrosthetics
is so lamentably high, all medical men do not recognise
the grave responsibility wliich must devolve upon anyone
who undertakes the duties of anaesthetising another human
being. It has been pointed out again and again that the whole
of one person’s energies and attention are required to induce
and maintain anivsthesia, so that we cannot but hold it as
most dangerous for anyone to undertake the double r6h of
anesthetist and operator. And further, even with care
and skill, patients are liable to contingencies under an amea-
thetic whicli, although not perhaps absolutely fatal in
themselves, yet become so should prompt and accurate
Dini1i.^ed hy Google
208 Thb Lancet,]
THE HEALTH OF SOUTHEND.
[Jan. 24,1891.
measures not be taken to combat them. Bub when the
administrator is single-handed, or aided only by a nurse,
such aid as may be necessary is wanting, or unobtainable
until too late. In the report before us the statement that
two drachms is not enough chloroform to cause death is
distinctly misleading, for, if administered in too concen¬
trated a form, even less is capable of killing. The moral is
plain. Let no one undertake the responsibility of giving
chloroform unless fully able to devote the whole of his atten¬
tion and skill to the matter, and never unless in the presence
of another medical man. _
THE HEALTH OF SOUTHEND.
A LAMENTABLE want of discretion and even of worldly
wUdom seems to have been exhibited by the Southend
Local Board. In view of the serious prevalence of enteric
fever in their town, they called in Dr. Thresh, as a sanitary
expert, to advise them. He explained his views as to the
disease prevalence, and made certain definite recommenda¬
tions with regard to the need for consulting a skilled
sewerage engineer, for providing a hospital for infec¬
tious diseases, for the adoption of proper measures of
control in the construction of houses &c. Unfortunately,
the Local Board proceeded to issue what has been
called a “rejoinder,” and this document is stated by
Dr. Thresh to be misleading. It is reported, amongst
other things, that tliis Board first assert that the sewer
outfall is adequate, and then, as we noted lost week,
proceed to pass a resolution to provide another one. As the
Essex County Chronidc well puts it: “ It seems a pity that
a body of men who feel themselves competent to criticise
the work of an expert did not long ago frame and carry out
the resolutions passed at the last meeting of the Local Board
•without waiting for an epidemic of typhoid fever and a
special report to rouse them to action.” The attitude
adopted is hardly likely to encourage visitors to seek health
at Southend. _
H/EMORRHAGE AFTER TOOTH EXTRACTION.
Db. B. J. KicnARDSON read a paper upon this subject at a
recent meeting of the Odontological Society. The compara¬
tive rarity of bcemorrbage following the extraction of a tooth
in recent years he ascribed to modern improvements in dental
instruments, especially the abandonment of the “ key,” the
greater surgical knowledge possessed by dentists generally,
and to the fact that the Ljeniorrhagic diathesis is greatly
reduced amongst the members of the community. There
are three distinct conditions leading to dangerous hicmor-
rhage: (1) Abnormal fluidity of blood—purpuric hamor-
rhage ; (2i deficient contractile powerof the divided vessels—
vascular hcemorrhage; (:i) mechanical lesion favouring the
flow of blood—mechanical hsemorrhage. In the purpuric
class there is generally a history of hereditary predisposition,
the blood is abnormally (luid (due to excess of water), and
does not coagulate when taken from the body, and purpuric
eruptions present or past, though not a constant symptom,
are a very frequent one. In other cases the extreme
fluidity of the blood is caused by excess of soluble saline
material such as has been observed on a large scale in
scurvy produced by too long a subsistence on food preserved
by salt. Vascular lijemorrhage is due to the wart of con¬
tractile power of the bloodvessels. The subjects are persons
of enfeebled constitutional and nervous type, showing
relaxed circulation in sudden blushing and suffusion of the
face, or they are anmmic, alcoholic, or the victims of specific
degeneration. Mechanical btnmorrhage is due to accidents
connected with the extraction of a tooth, such as fracture
of the alveolus. In the treatment of bosmorrhage of the
second and third classes, styptics with pressure are most
immediately useful, the best being tannin and perchlonde
of iron, either of which may be applied by means of a plug
of gutta-percha. In purpuric hmmorrhage, should ordinary
styptics fail, coagulation must be induced by the electric or
actual cautery, which is allowed to cool down to a tempera¬
ture just below redness, and, applied with care, gives little
pain. In all cases alcoholic stimulation is unadvisable, as
it acts after the manner of a salt in destroying the coagu¬
lating power of the bloody and, what is more serious, in¬
creases the heart’s action, stimulating it to throw out more
blood through the divided vessels.
THE FROST AND ACCIDENTS.
We understand that the results of the recent frost in the
shape of numerous accidents due to the slippery condition
of the roads have not only been felt e.t all the great hos¬
pitals both in London and the provinces, but also by the
Insurance Companies, one of which reports 305 claims
traceable to this cause during a single week. It is true
that the office in question, the Hallway Passengers’ Assur¬
ance Company, is the largest of its class, and transacts a
much greater proportion of the kind of business which
would be affected in this way than any other society; hut
when it is considered that the persons who carry accident
policies, though absolutely a large number, are few in com¬
parison with the uninsured community, it will probably be
felt by those of us who have so far passed through the frost
without fracture or contusion that we have escaped a
greaier peril than at the time we appreciated.
THE RESPIRATORY CENTRE.
The details of a research of considerable importance,
undertaken by Laborde with a view to determining the
situation of the centre for respiration in the medulla, are
given in a recent number of the Com 2 '>tes Rendus. Full
particulars are promised in a more elaborate form. It was
found that superficial destruction of the alte cinerecc pro¬
duced impairment of respiratory movements ; deeper injury
produced slowing or temporary cessation of breathing, while
destruction, at least down to the centre, gave rise to com¬
plete suspension of respiration. This condition was pro¬
duced with the greatest certainty when a particular part of
the floor of the fourth ventricle was removed. This part
in rabbits has a diameter of 0'5 mm,, in dogs of 1-2 mm.;
bub the instrument must penetrate at least half the thick¬
ness of the substance of the medulla, and pass to the
raphe immediately above the calamus scriptoiius. De¬
struction of this region on one side suspends temporarily
respiratory movements of the opposite side of the body.
Division of the medulla just below the calamus always
suspends the respiratory movements of the trunk, those of
the head persisting for a time. The movement never re¬
turned if nothing was done, hub it did so if artificial
respiration were kept up for a long time. The spinal reflexes
remained present, were even increased, and there were
superficial, irregular, bub ineffective contractions of the
respiratoiy muscles. In newly born animals the exaggera¬
tion of the reflexes was especially marked. All parts above
the medulla, includingthe cortex, thecorpora quadrigemina,
and the optic tbalami, were found to have no particular
influence on respiration. _
A CENTRAL MORGUE FOR LONDON.
It is stated in an evening contemporary that the London
County Council will shortly consider the advisability of
erecting and maintaining a central morgue for London. It
is probable the statement is well founded, for the Council
obtained powers last session for making this provision. Tiie
General Powers Act of the Council enables them to make
arrangements for the reception into a suitable building of
Digitized by
Google
Thb Lancet,]
THE TEES-SIDE EPIDEMIC AND LOCAL PANIC.
[Jan. 24,1891. 2 09
unidenfcified bodies, which will be removed there on the
•order of coroners, and inasmuch as it will be used by all
the coroners in the county, each will be able to follow there
any body to which his attention is directed in any district.
If the Council in making its arrangements is guided by
careful medical opinion both in the erection and raanage-
nient of such a morgue, it is probable that it will serve an
exceedingly useful purpose in giving increased opportunity
'for medico-legal investigations, and that eventually in¬
creased knowledge, useful for the detection of crime, will
be the result. _
THE TEES-SIDE EPIDEMIC AND LOCAL PANIC.
At the last meeting of the Middlesbrough Corporation
Alderman Hugh Bell, J.P., brought forward a number of
statistics which show that in 1874 a typhoid epidemic in
Middlesbrough led to 104 deaths, whereas the 1890 epidemic
•only led to 59, and that during the intervening period the
fatal attacks of this disease varied from 12 to 69 annually.
Properly interpreted, this would go to show that typhoid
fever is a constant endemic cause of disease and death, and
that in certain years, such as 1890, some special influence
•came into play to cause rapid diffusion of the poison
.amongst the people. But this is not the lesson the alderman
would teach. He relies on two circumstances to urge that
there is no cause for “panic.” Oddly enough, one is the
jpicking out of “five or six years” in which the mortality
“ had rarely reached a score”j and the other is to quote a
report of Dr. Thorne Thorne on the Cleveland Iron
Districts—not on Middlesbrough—in which it is shown
that typhoid fever some sixteen years ago was “ in
large measure ” due to local defects of sanitation
in those Cleveland districts, and not to the public water
service. Great stress was then laid by Alderman Bell on
tthe need for improving the sanitary condition of the town,
and in the end he exclaimed, “ In heaven’s name do not let
'them give up panic-stricken!” It so happens that Alderman
Bell is “ Chairman of the Stockton and Middlesbrough
(Corporations Water Board,” and that the water supplied
by this company has been credited by Dr. Barry with being
^he cause of the\recent epidemic. The alderman, who
actually referred to the late outbreak as “a matter of
■ordinary occurrence,” frankly admits that he is unable to
say that (he “ present supply was above suapicioi ,” and to
bis promise that the Water Board would welcome any
suggested remedy we would advise that they should get rid
of the excrement and sewage which are admitted into the
ffiver which the Middlesbrough people are given to drink ;
and at the same time go on by all means improving the
anteinal sanitary state of the town.
MICROBE OF EPIDEMIC CEREBRO-SPINAL
MENINGITIS.
At the present time very few opportunities occur of
studying epidemic cerebro-spinnl meningitis. Dr. Bonome
bas had such an opportunity, and made careful investiga¬
tions as regards the anatomy and etiology of this disease.
The outbreak occurred near Padua. Ilis conclusions,
together with an account of his experiments, are published
■in Ziegler’s Beitnige zur patkologUche Anatoinie und zur
'allgemcinc Pathologie. Dr. Bonome was able to examine
thoroughly the bodies of five patients who had died from
the disease, and the meningeal exudation from a sixth.
In addition, in several other cases the blood and catarrhal
■secretions from the throat and nasal cavities were sub¬
mitted to investigation. He succeeded in isolating from
the exudations of the cerebro-spinal meninges, and from
• baiinorihogic collections in the lungs, a streptococcus, which
<.lid not, however, grow readily on artificial media, and when
so cultivated, or after being preserved in a dry state.
soon lost its pathogenic characters. In white mice and
rabbits the micro-organism produced the same efiects as
those brought about by injections of the pneumococcus
or meningococcus, fibrinous inflammations being in¬
duced, whilst in guinea-pigs and dogs the micro-organism
scarcely reacted at all to the pure cultures. This strepto¬
coccus found by Dr. Bonome differs from the pneumo¬
coccus and meningococcus again in the ball-shaped appear¬
ance of the colonies on agar-agar plate cultivations, in
its inability to grow on blood-serum, and in the difficulty
which is experienced in carrying the cultures through
five or six generations. Also it fails to produce true
septicicmia in white mice; and when rabbits are inocu¬
lated, the micrococci obtained from the blood are
arranged in chains surrounded by a capsule, and the
same forms are obtained from the gelatinous transudation
met with in mice, guinea-pigs, and dogs which have been
artificially infected with the disease. The streptococcus,
again, is distinguished from the streptococcus of erysipelas
by its action on animals and by its failure to grow on
gelatine and blood-serum, and also by the appearance of
the colonies on agar-agar plates. In contrast with other
inioro.organisnis which are morphological analogues many
differences can be made out. Thus, it dift'ers from the
streptococcus pyogenes and from the septic streptococcus
found in earth by Nicolaier and Guarnieri; also it can be
clearly distinguished from the streptococcus found by
LoelHer in cases of diphtheria, and from the organism found
by Weichselbaum in some cases of pneumonia. After
careful consideration of all the points in connexion with
this epidemic at Padua, and the results of his bacteriological
examinations, Dr. Bonome claims that he has substantiated
the existence of the microbe of epidemic cerebro spinal
meningitis. ____
LIFE ASSURANCE AND THE MEDICAL
PROFESSION.
We gladly give space in our correspondence column for the
letter which Mr. Chatham has addressed to us in further
discussion of the death-rate among medical practitioners,
for the subject is one in which our readers have the best
reason to take a lively interest. It does not, however,
appear to us that our correspondent’s defence of his results
goes far to establish them. It now appears that in forming
Ilia estimate of the deaths that might be expected to occur
within a year be has bad to deal e«-with a group of
persons whose ages varied from twenty to twenty-five years,
with another group whose ages varied from twenty-five to
forty-five yeais, with another group whose ages varied from
forty-five to sixty-live years, and with yet another group, about
which the only thing to guide him was that its members
were of the ages of sixty-live years aud upwaids ! Now, if
any one of these group.s comprised only persons who were
subject to one uniform annual death-rate, or to several
approximately equal annual death-rates, an actuarial
estimate of their mortality might have significance. But
that is not the case here, unless in respect of the first
group, which wo have special reasons for mistrusting, since
it is evident that the stress of medical practice cannot he
exhibited by the mortality of youths under twenty-five
years of age, whether they arc legally qualified or nob.
But, on referring to the mortality table from which Mr.
Chatham has deduced his estimates, wo observe that
between twenty-five and forty-five years of age the death-
rate varies from under 7 to over 12 in the 1000. How can
Mr. Chatham or anybody else tell what rate within
these wide limits would be applicable to the p.articular
group of persons under discussion without any knowledge
of the age distribution within the group—that is to say,
I without knowing how many of its members are subject to
Digitized hy .oogle
210 The Lancet,]
THOMSEN’S DISEASE.
[Jan. 24,1891.
the higher and how many to the lower mortality rates?
The next group aifurds a more striking illustration still of
the copjectnral character of Mr. Chatham’s data. From
forty-five to sixty-five years of age the death-rate varies
from 12 to 43 in the 1000, Mr. Chatham seems to have
assumed 21 in the 1000 for the purpose of his calculation,
but why ? It is within the tabular limits truly, but so
is 26 in the 1000. If he had assumed 26, his expected
deaths would have been exactly what the actual deaths
were; and who can say that this is not just as trust¬
worthy a conclusion as the one which he has brought
out? The case of the last group is one of conjecture
pure and simple, since no superior limit of age is given, and
need not be discussed. To put our ciiticism in onewoid,
we decline our correspondent’s conclusions because we are not
satisfied that the age distribution of the “ physicians &e.’’
whose mortality he has essayed to examine was at all con¬
formable to that of the table with which he has compared
them. Unless this were so his results are valueless. The
numbers of persons in his various groups afford some rough
indication of the age distribution, and, comparing these with
the table on which he builds, we gather that the two are
about as unlike one another as is possible.
THOMSEN’S DISEASE.
Anothee case of this curious disease is recorded by
Seifert in the DcrtfscA. Arch, fur Kim. Med. The patient
was a j oung man of live-and-twenty, who had no history of
predisposition from heredity. He had suffered from the
malady from childhood, and while he had a sister in every
respect healthy, a brother was the victim of the same
disease. In his case also the condition dated from childhood.
The patient exhibited more than usually well-developed
muscles, but bis muscular power was not in proportion to
the bulk of the muscles. The usual condition on electrical
stimulation was observed—viz,, that a momentary stimula¬
tion of the neive caused a momentary contraction of the
muscle, while a continued stimulation set up the usual tonic
contraction; while the characteristic slow wave-like contrac¬
tions passing from the negative to the positive pole were
produced by a strong unbroken current. Microscopic ex¬
amination of an excised part of tlie biceps showed the
presence of large muscular fibres, an increase of nuclei, indis¬
tinctness occasionally, absence of striation, increase of con¬
nective tissue, and infiltration of granular material. No
vacoolation of the librillaj was detected. The same
phenomenon was observed in this ease as has been noted in
others—viz., tnat by frequently repeated stimulation the
contractions, at first slow, became shorter and quicker,
until at last nothing unusual could be observed in their
character.
FIGHTING THE FROST IN FRANCE.
The action of the French Government and the Pdris
Municipality in dealing with the exceptional distress caused
by the prolonged winter constitutes a brilliant example
which other civilised nations should hasten to follow. For
once the cause of humanity has not been sacrificed to the
exigencies of red-tapeism. On Tuesday the Chambers and
the Senate voted nm. con. £160,000 for the relief of distress,
which, with the £80,000 already granted, makes a total of
£240,000. Better still, it has been decided to dispense with
all administrative formalities, so that the money will
reach the poor and the suffering in about twenty-four
hours. The Government Las also is.sued orders that
persons imprisoned for vagrancy may remain in prison
till the frost ceases if they so desire; and it is a proof of
the severity of the distress that no less than seven hundred
vagrants have preferred the scientifically ventilated and
warmed colls of the Nanterre prison to the hardships and
hazard of freedom during the frost. I’enuission also haa
been given to tlje poor to gather dead wood in all State
forests. The-Municipality of Paris, in organising night
refuges, showed equal energy. What remains of the great
Exhibition of 1889 has been converted into a refuge for the
destitute. The huge machine gallery is a day refuge. Here
are soup kitchens and large fires, where warmth, shelter,
and food can be obtained. The fine arts galleries are con¬
verted into vast dormitories. More than six thousand
mattresses and rugs have been provided by the Minister of
AVar, so that plenty of good beds were prepared in a very few
hours. As the Daily News correspondent very aptly re¬
marks “ The Fine Arts Palace is an abode of wretched¬
ness, but a spirit of thoughtful and tender humanity is so
evident that, to my mind, the spectacle presented there to¬
night is more creditable to the Kepublic than all the
glorious sights presented by the last Universal Exhibi¬
tion.” There is a special pavilion for women, and
those who are suffering from colds &c. are gratuitously
given hot infusions and placed nearest to the fires.
Above all, there is a total absence of Bumbledom.
No questions are asked that are likely to humiliate
the deserving poor or to make them hold aloof from
the aid the IState so freely gives in the hope of saving
life and preventing illness. In tho streets also large
braziers are burning day and night, so that pedestrians
may warm themselves, and thus j-ecover strength when
their vital powers are impaired by the excessive cold. The
energy and promptitude with which all this has beum
organised will certainly save many hundred lives ; and tho
authorities who govern London should feel in no small
degree humiliated by the contrast thus established between
what has been done in the metropolis of France and whab
has been left undone in the capital of England.
THE MEDICAL. STAFF AND THE COMMITTEE
OF THE GERMAN HOSPITAL.
Cue readers will remember that a very proper attempt
was made last year to gain some representation of the
medical staff on the committee of the hospital. Unfor¬
tunately, the attempt failed. It is to be renewed in a
somewhat different form this year. The committee will move
“ that the senior honorary physician and the senior honorary
surgeon shall be cx-ojficio members of the committee.”
The objection to this is that it gives a permanent positiors
on the staff to the senior officers, who may not always be in
touch or sympathy with the younger ones, and who after a
time may lose interest in their committee work. Another
proposal will be made, and it is so reasonable that it ought
to be accepted by the governors—viz , “ that two members
of the active medical staff should by rotation be elected
members of the committee every three years according to
seniority.” This proposal will give freshness and interest
to the medical representation, and will be acceptable
to the majority of the staff. The governors will find that
they lose nothing and that the charity gains much by
putting two medical colleagues on the committee. To ti-eab
honorary officers as if they were not honorary, or to give
them anything short of an effective voice on the committee,
is to court discord and disruption.
CHLOROSIS AND ITS TREATMENT.'!
Du. Feedeeick Scholz of Bremen has published a
remarkable work on chlorosis, tho outcome of obaervationB
made during the last twenty years. Instead of regarding
the deficiency of iron or hiemoglobin, or even that of the
red corpuscles, as tlie primary affection, he states that
contraction of the vessels is always present in these cases,
as indeed was observed by Bamberger, Itokitausky, and
Digitized by LjOOQle
The Lancet,]
“COVERING” IN MANCHESTER.
[Jan. 24,1891. 211
Virchow ; and this, ho contends, is not to be regarded as a
ooinplication due to an altered condition of the blood, but
as the primary condition which is followed by the morbid
change in the blood. As a matter of fact, the vessels are,
he says, too fall, or in the condition termed by the
older physicians “plethora ad vasa,” the blood being—or
becoming—abnormally serous. Long ago his attention
was struck by the cold and livid condition of the
skin in auccmic subjects, and he was led by this
to employ hot baths, together with gentle friction, in
the treatment, with the view of acting directly upon the
skin, so as to improve the vitality and nutrition generally.
The success of his first attempts was so marked that he was
encouraged to persevere in this line of treatment, and he has
since had many opportunities of extending his experience
with it. Hot baths diminish the plethora by relaxing the
tension of the vascular system, which is high, quickening
the circulation, and thus relieving the palpitation, dyspncca,
and other symptoms. In thirty cases where the distress of
the patient was very great, Dr. Scholz has gone a step
farther and supplemented the hot bath by venesection.
Paradoxical as this treatment may appear, it was followed
by marked benefit, and if the theory of the pathology of
chlorosis above mentioned be correct, there can he little
doubt that the novel line of treatment practised by Dr.Scholz
is justifiable. _
THE OUT-PATIENT QUESTION &c. AT
CAMBRIDGE.
An interesting discussion on the abnormal growth of
the Out-Patient department at Addenbrooke’s Hospital took
place at the recent quarterly meeting of Governors. The
Eev. II. Hall showed that the out-patients had increased
by 1000 in the last five years, as compared with the pre¬
vious five, an increase out of all proportion to tlie increase
in population. Dr. Macalister testified that the patients were
not only more numerous but more gaily dressed, the ladies
on. more than one occasion being in plush, the gentlemen in
broadcloth. He advocated a Provident Dispensary Scheme.
Sir George Humphry said, truly enough, that in many such
cases persons were in depressed circumstancas, and great
care was necessary in judging. Unfortunately the chair¬
man voted the discussion, though interesting, out or order,
and it was abruptly closed. Dr. Latham then raised
another question proposing as an alteration of rule that no
physician or surgeon, after seventy, should be eligible for re-
election. The question is a fair one, bub it requires great
delicacy of touch. Aud there are places in which it is not
an easy one and where the detachment of such seniors would
be a veritable disadvantage. The motion was not seconded,
and the matter dropped. _
THE RELATION OF BACTERIA TO PRACTICAL
SURGERY
pROVESSOR J. B. Roberts, in his address on surgery
delivered before the Medical Society of the State of
Pennsylvania, gives a very concise and accurate statement
of the facts in bacteriology that have a special bearing on
the surgical treatment of wounds and on the practice of
obstetrics. He gives the rules to be observed in operations
at his Clinique at the Woman’s Hospital at Philadelphia,
which are eminently practical, and he considers that sucli
irules “ought to be taught to every medical student and
'every physician entering practice, as earnestly as the para¬
graphs of the catechism are taught the Sunday school pupils.’’
That such efforts are not always successful in America,
even in the case of the surgeons, must ho considered pos¬
sible, as Professor Roberts informs us “ that there is unfor¬
tunately a good deal of abominable work done under the
name of antiseptic and aseptic surgery because the simplest
facts of bacteriology are unknown to the operator.” Things
must certainly be much worse in America than they are
here, for we find that at the beginning of his paper Professor
Roberts goes out of his way to give the plurals of “coccus ”
and “bacillus,” information which should scarcely be re¬
quired by men who are supposed to have sufficient education
to enable them to engage with success in the profession and
practice of medicine and surgery.
“COVERING” IN MANCHESTER.
Tjie deputy city coroner for Manchester, Mr. Sidney
Soult, made some very important remarks on the prevalence
in Manchester of a system by which the poor are attended
by unqualified assistants. In one case a certificate of death
was signed “E. Gilmore, pro Dr. Bourke, Oldfield-road,
Salford.” The coroner said he could not find Mr. Bourke’s
name in the Directory, and he believed he had recently
left Salford and left Gilmore a number of signed blank
certificates. Gilmore, in evidence, said that on the death
of the patient he sent the certificate for signature to
Mr. Bourke. In connexion with another case, the coroner
said he knew of a man who had as many as sixteen places
in Manchester, and unqualified assistants at all of them.
He intimated his intention of reporting the facts of
Gilmore’s case to the Registrar-General. He will only be
doing his duty in acting so. And his remarks on un¬
qualified practice should receive the attention of all
practitioners who, except under their own observation and
supervision, employ unqualified assistants.
THE EFFECTS OF OREXIN ON ASSIMILATION.
The effects of hydrochlorate of orexin on the assimilation
of nitrogen and fat and on tbe nitrogenous metabolism in
healthy as well as in diseased subjects has recently been
studied by Dr. E. T. Kobliar, chief of Professor Manassein’s
therapeutic clinic in St. Petersberg, the pathological cases
comprising three of chronic gastric catarrh and one of carci¬
noma of the stomach. The results obtained are thus sum¬
marised. Orexin given in quantities of from five to twelve
grains daily for four or five days increases the assimilation
of nitrogen both in healthy and in diseased subjects. It
increases the assimilation of fat in diseased subjects. The
nitrogenous assimilation is lessened to a marked degree in
bealtby persons, but much less so and less constantly in
diseased subjects. In both classes of individuals the
appetite is improved, the sensation of hunger not, However,
being always increased. _
THE WORTLEY ACCIDENT.
However we may recognise the good intention of those
who organised the Children’s New Year Entertainment at
Worbley, which was attended by such fatal consequences,
wo cannot but endorse the verdict of culpable negligence
pronounced upon them by the coroner’s jury. It seems
almost incredible that the circumstances connected with
this disaster should not have produced in the minds of
ordinarily intelligent persons any marked impression of the
risk involved. All the conditions of a serious conflagration,
the cotton-wool clothing, the highly inflammable lamps
carried in childish hands, the crowded passage, and the insuffi¬
cient stage area, were present, and yet no prudent misgiving
seems to have dimmed, no precaution to have secured, the
fair prospect of such precarious festivity. We need not now
revise in detail the evidence brought forward ; but we must,
in common with most, if not all, persons who have followed
it, regret that the position occu])ied by the responsible com¬
mittee was so purely ornamental. Had there been more of
counsel in the preparatory stages which preceded this ill-
fated gathering, its method and its issue might have been
very different. The suggestion made by the jury that
Digitized by ^ooQle
2-12 The Lancet,]
NIGHT EXPOSURE OP SENTRIES AND POLICE.
[Jan. 24,1891.
^angemeots for &choolrooiu entertainmente, hitherto
exempt, should henceforth be subject to the supervision of
local authoiifcies, is eminently sensible and should
not be overlooked. In the course of his observations,
the coroner, Mr. Malcolm, referred to a chemical process
by which clothing materials could be rendered fireproof.
Doubtless this refers to their' impregnation with tungstate
of sodium, a process to which we have directed attention in
a former issue, though its application to cotton-wool
would probably be difficult. Ball and stage dresses
should be thus treated before they are worn, if the
never distant risk of fire is to be prevented. The lessons of
experience are often bitter. To many those of the Wortley
accident will be painfully so; but it is most profitable to
remember that their smart in any case knows no relief so
realas that which comes of their candid acceptance and
application. _
NIGHT EXPOSURE OF SENTRIES AND POLICE.
In former days the military authorities of tliis country
were nob remarkable for the attention they bestowed upon
the necessary comfort of the private soldier. The old order
which they represented is happily passing, if it has not
already passed away, and our army organisation, even in
this matter, may now safely venture a comparison with any
other European system. Well clad, well fed, and well
housed as he commonly is, the soldier on active service now
encounters the necessary hardeliips of his vocation with
odds in his favour. This needful care is but right as welt
as politic. It implies no coddling process, but merely
aims at preventing the fruitless dissipation of physical
energy. We can hardly believe therefore that the blame
attached to such an alleged incident as the desertion
of responsible duty in order to escape the trying
ordeal of sentry duty during the present extreme
cold should rest entirely with the War Office. Night
policemen and sentries are much exposed at all times,
and their lot in a winter of exceptional severity is
enough to test the sternest quality of endurance. It
is reported, indeed, that in Holland night-watchmen,
though warmly clad, have been found frozen to death.
This experience alone should teach us that some further
protection besides thatafforded by clothes is called for. We
may therefore be allowed the suggestion that in addition to
an ample equipment of thick woollen and cloth material,
with sound and solid boot leather, particular care be taken
wherever possible to afford convenient access to warm food
and drink, the latter non-stimulant, and also to promote
brisk movement and a system of ready and frequent reliefs.
THE POLLUTION OF THE LEA,
An important legal decision has been given affecting the
statutory powers of the Lea Conservancy Board for pre¬
venting the pollution of the Lea, It will be recollected
that since 1884 the Conservancy Board has been dissatisfied
with the action of the Tottenham Local Board in reference
to the purification and disinfection of the Tottenham sewage,
and that the Home Secretary came to the conclusion that
the method of treating the sewage was insufficient.
Alterations in the works were then made, and eventually
a Joint Drainage Committee of the Tottenham Local
Board and the Wood Green Local Board was constituted.
Subsequently the Conservancy Board proceeded against
the Tottenham Board for continued pollution of the Lea,
the Conservancy Board adopting this course because,
although the value of the property apportioned to the local
boards of Tottenham and Wood Green and the price to be
paid by the latter had been duly settled by arbitration i
under the Tottenham Local Board Act of i888, the I
sewerage works used for the purposes ol sewage treatment-
or disposal had not been included in the arbitration. The
result of the proceedings was that the magistrates dis¬
missed the summons, taking the view contended for by the-
Tottenham Board, that, under the circumstances, the dis¬
posal and treatment of the sewage and effluent water from;
thesewerage works had been removed from the control of the
Tottenham Board. A case was, however, stated, and this
has just been heard before Mr. Baron Pollock and Mr.
Justice Charles. Mr. Baron Pollock, in giving judgment,
said that the offence charged was not an offence at commoiit
law, or under any public Act, as the Public Health Act,
but was only one under Section 93 of the Lea Conservancy
Act, and he held that the Tottenham Board were not-
responaible, and that the decision of the magistrates must-
be upheld. Mr. Justice Charles concurred. Applicatioa
was made for leave to appeal, but the court said there wao
no appeal, this being a quasi-criminal proceeding.
THE RHYTHMIC ACTION OF THE HEART.
From some researches made by Dr. Hamel, under the
direction of Professor Kronecker of Berne, on the circula¬
tion and the pulse, some new facts have been added to*
our knowledge on the subject. The vascular system of
animals (frogs and crabs) was connected with an artificia)
heart, and it was then found that the more nearly the
natural condition of intermittent pumping was imitated
the more blood could be driven through the vessels. When)
continuous pressure was employed, less blood was caused
to circulate; but, on the other hand, there was a greater
tendency to injury of the vessels, permitting exudation of
fluid into the surrounding tissues, and thus causing oedema.
It would appear that the elasticity of the arteries is kept-
up by the rhythmical dilatation they undergo. Hemicius*
and Kronecker have also shown that the regular movements
of respiration act as a kind of beneficial massage on the
heart muscle, and it is suggested that the rhythmical move¬
ment of the pulse may act in the same way on the arteria.
walls.
LONG HOURS ON RAILWAYS,
Whatever view may be entertained with regard to
strikes as a means to an end, the opinion of all who have
some knowledge of human physiology must be absolutely
in favour of a reduction of the hours of labour actually im¬
posed upon railway servanls. This is so obvious that it con¬
stitutes a truism requiring no argument. Only those who-
are not acquainted with the number of hours actually workedi
by railway servants can entertain any sort of doubt on the-
subject. The facts, however, are very clearly stated in
the Return of Railway Hours just issued by the Board
of Trade. From this official document we learn thab
last March, when the statistics were taken, there were
1593 engine drivers and firemen employed by the North
British Railway Company. Out of this number 1121 were
on duty for more than twelve hours at a time, and in that-
month there were 4001 instances where the duration of the
work exceeded fourteen hours in the day. Thus 70'37 per¬
cent, of the men were on duty more than twelve hours.
The Caledonian Railway Company employed 1420 engine-
men and firemen, of whom 1210 worked more than twelve
hours, and there were 2968 cases where the work exceeded
fourteen hours. No less than 330 cases are given where the
men.hadonly seven hours’rest between theintervalsof labour.
"Very frequently the men work eighteen hours and upward©
at astretch, and this we state on the authority of the Blue-
book. It is, wo repeat, absolutely futile to argue as to-
the iniquity of thus prolonging labour beyond the limits of
human strength and endurance. The fact that the work i&
actually done does not prove that it is not injurious. On the
Digitized by
Google
The Lancet,]
CHOLERA AT VLADIVOSTOCK.
[Jan. 24, 1891. 213
contirary, it muet of necessity undermine the constitution
even of the strongest, particularly when we remember that it
is incessant toil performed men who are exposed to all
the inclemency of the weather. Under such circumstances,
we are glad to see that Mr. Channing, M.P., will move in
the House of Commons that tbeBoard of Trade should possess
thelegialative power “ to issue orders,where necessary, direct-
ing a railway company to limit the hours of special classes
of their servants.” Our Factory Acts protect the health of
women and children by limiting the hours of labour ; but
railway servants who work eighteen hours at a stretch not
only endanger their own lives, but also the lives of those
who travel on lines so insuthciently manned. If the men
are not able to obtain a remedy for this state of things, and
if the railway companies are so inhuman as to tolerate its
continuation, then there will be a good case for legislative
interference on behalf of public security and public health.
CHOLERA AT VLADIVOSTOCK,
Cholera is still causing great ravages at Vladivostock
on the Russian North Pacific coast, the Mansas and the
Coreans being the chief victims. There seems to be an
utter disregard of sanitary precautions, unless under this
term quarantine can be included, whilst such abuses as
the casting of the dead into tlie bay still go on. The
Mansas settlement is stated to be desolated, more than half
the colony being believed to have already died.
DEATH OF THE DUKE OF BEDFORD.
It has now been announced that the late Duke of
Bedford committed suicide by shooting himself during a
paroxysm of pain, and a coroner’s jury have returned a
verdict of “temporary insanity.” It will be remembered
that the remains of his Grace were cremated, and we may
have to offer some remarks later on on the important bearing
the sad event has on the legal restrictions which should
safeguard cremation. It is certainly to be regretted that
the true cause of the death of such a prominent member of
the community should not have been at once announced.
RECENT HOSPITAL APPOINTMENTS.
Mr. J. Astley Bloxaim, F.R.C,S., has been unanimously
elected to the post of senior surgeon and lecturer on surgery
at Charing-cross Hospital, vacant owing to the recent death
of Mr. Edward Bellamy, F.Il.C.S. Dr. F. H. Champneys,
M.A. Oxon., F.R C. I'., has been elected as obstetric
physician and lecturer, and Dr. W. S. Grillibh, F.R.C.S., as
assistant obstetric physician, at St. Bartholomew’s Hospital.
ST. BARTHOLOMEW’S HOSPITAL.
With reference to the charges recently advanced by a
Society contemporary against this hospital, and more espe¬
cially with regard to the accusation thatconsideration had not
been given to the prevalence of diphtheria among the nurses,
we are able to give the following facts1. The authorities
have been already for two months engaged on the question.
2. Six weeks ago the beds in the diphtheria ward were re¬
duced by one-half—namely, from sixteen to eight—in order
to diminish the chances of direct infection. 3. Seven weeks
ago a sanitary inspection and report were made by the
architect attached to the hospital. 4. An improved system
of dietary for the nurses was established several weeks ago.
6. A more searching medical examination of candidates for
the office of nurse was adopted, in tlie article in question
there is norefereiice to tliefact thatdiphtheria is contagious,
and that cases are admitted freely from outside (140 cases of
diphtheria were received last year). We understand that
amongst the twenty-six nurses who have suffered from
diphtheria there has been no fatal case, and that the cases
remaining (four in number) are now convalescent. Four
eases of typhoid fever occurred amongst the nurses during
1890, and one ended fatally. Previously to this there was
no death amongst members of the nursing staff for three
years. With regard to the state of the building, we learn,
that an eminent expert in sanitary science bas been engaged
to make an exhaustive inquiry into the matter.
DIPHTHERIA AT TOTTENHAM.
Diphtheria has again broken out in Tottenham, and it-
is associated with conditions of nuisance that ordinary^
sanitary inspection, if effectually organised, should keep-
under. It is useless to assert that such conditions have no
causal relation to this disease so long as their retention ia
the midst of a population places them in constant associatioa
with preventable disease.
FOREIGN UNIVERSITY INTELLIGENCE.
Berlin .—Professor Fliigge of Breslau has been recom¬
mended by the Faculty of Medicine for the appointment to
the chair of Hygiene vacated by Professor Koch.
Lcipsic. —Dr. P, SchibCer has been promoted to the rank of
Extraordinary Professor of Ophthalmology. Dr. M, Sanger,
Superintendent of the Gyntecological Clinic, has also been
granted an extraordinary professorship,
Vienna .—Professor von Schrbbter having taken charge of
tlie Third Medical Clinic, Professor C. Stoerk has been*
appointed to the Laryngological Clinic, which the former
gentleman vacates. _
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. G. Leopardi, Extraordinary Professor of Pathology iQ
Florence.—Dr. Garrigat, a member of the Frencii Senate.
As will be seen by the report of the meeting of the-
Northumberland' and Durham Medical Society, publishotE
on another page, the objectionable practice indulged in by
a portion of the lay pros.s of printing intelligence of a purely
medical character, which must necessarily be caviare to the
general public, has evoked a protest from the members of
that Society. Dr. Murphy’s resolution, though bearing
primarily in this connexion on the transactions of thes
Society and local newspapers, will admit of a much wider
application, and conveys a hint which might wisely and)
properly be taken by the non-professional press at large.
The Cambridge Medical Graduates’ Club bas invited
Sir George Murray Humphry to a congratulatory dinner tc»
beheld on Feb. 24bh. Sir George Paget, K.C.B , President of
the Club, will preside. Among the distinguished and in-
lluential guests invited to meet Sir George Humphry are i
the Vice-Chancellor of the University of Cambridge, the-
Provost of King’s College, Cambridge; Sir James Paget, Bart, j
Sir Joseph Lister, Bart. ; Sir William Bowman, Bart. j.
Sir Henry Acland, Bart.; and Professor Liveing.
Mr. Hutchinson’s third lecture, to be delivered on.
Tuesday next, at tbe Examination Hall, will deal chiefly
with the results of the treatment of lupus by Koch’s fluid.
The demonstrations will commence at 4.30 P.M., and
patients who have been under the care respectively of Dr..
Heron, Mr. Watson Cheyne, Mr. Colcott Fox, Dr. Gayton,
Dr. Abraham, and others, will be in attendance.
We bear that the Swiss Federal Diploma, which gives
the right of practice, has been granted to Dr. Holland of
Sb. Moritz. This gracious act on the part of the Swiss
authorities ends satisfactorily a long controversy.
Digitized by
Google
2'U The Lancet.]
THE UNIVERSITY OF LONDON.
[Jan. 24, 1891.
THE UNIVERSITY OF LONDON.
MEETING or CONVOCATION.
There was a tolerably large attendance of gradnatea at
the meeting of Convocation of the London University on
Jan. 21st. The Chairman of Convocation, Dr. F. J. Wood,
presided. Mr. Henry E. Allen, LL.B,, B.A., was re-elected
clerk of Convocation. Before entering on the agenda,
the Chairman read a memorial which had been addressed
by the Association of Fellows of the Royal College of
Surgeons to the Registrar of the University of London,
and was published in our issue of Dec. 13tb, 1890.
The Chairman said that on the 19th inst. the Special
Committee concluded their labours in connexion with the
scheme for the reconstitution of the University, which
was to be placed before the Senate on the 21sb. It
would not be possible to say what the Senate would do
with it. They might either reject or accept it. In the
latter case they might go to the Lord President with
the scheme and ascertain his views ; or they might confer
with the Colleges, more particularly University and
King’s, or lay it before Convocation. It is possible the
Lord President would decline to give any opinion, and
would want the final scheme. As regards the choice of
laying it before the Colleges or Convocation, the former
had put some pressure on the Senate, which required
'no further delay in conferring on the scheme. It was
.probable that no action would be taken on the
2iat beyond ordering the draft to be printed and cir¬
culated before being brought before the meeting of the
Senate, who were most anxious to give the fullest
information.
Dr. W. J. Collins then presented the report of the
Annual Committee and moved its reception, being seconded
by Dr. O’Reilly. He (Dr. Collins) then moved the adop¬
tion of the following motion, recommended on page 1 of the
report of the Annual Committee:—“That, in view of the
ffecentchanges made in the examination iu subjects relating
to public health, this house respectfully urges upon the
■Senate the equity of conferring the degree M.D. (State
Medicine) upou those M.D.’s who had, previously to 1889,
been awarded the diploma in Public Health, and upon those
M. B.’s who had, previously to 1889, been awarded the diploma
dn Public Health, and who shall subsequently pass in the
Mental Physiology of the M.D. examination.’’ This resolu¬
tion differed slightly from that moved on May 13bh. 1890, and
•as the degree m Public Health was not veiy well known,
Dr. Collins proceeded to explain that it was founded in
3875, and continued to 1889 to he known by the initials
3D. P.H. Lond. In 1889 the M.D. (State Medicine) was
established, and the former title became obsolete, so
that those who had already passed the examination
were in a position of nob being capable of compari¬
son with other degrees, and it was desirable that the
more modern title, M.D. State Medicine, should be
-conferrred upon them. The scope of the former
-examination was equal to, or even beyond, that required
for the present degree.
Dr. Baines, in seconding the motion, said that inasmuch
as the former examination had been even more extensive
than the present one, it was only just to admit those who
had passed to equal privileges, provided they passed in
Mental Physiology. The fairness of the matter seemed
acceptable to the Annual Committee
Dr. TiiOMr.soN said the question was not one of equity
alone, and that, although the former examination was
olaimed to be of a higher grade than the present, he would
like to ask whether any precedent existed for going hack
in history in conferring degrees.
Dr. Collins suggested that an excellent precedent
existed, in that, those women who had passed an Arts
examination before the date at which w'omen were admitted
to matriculation had been subsequently included in the
’list of those matriculated. The change advocated, theie-
dore, did not require the exercise of any new power.—The
motion was carried nem. con.
Mr. Nesjsitt then moved, “ That, in the opinion of Con¬
vocation, it is desirable that special examiners should he
i^pointed to conduct tiie Matriculation Examination.” He
.said that the whole tone of the examination was such as
would be addressed to much older students than those
for whom it was intended. Ha quoted examples from
the papers last set, and said that the points of
scholarsliip were too minute, and that there was much
inequality in the dilliculty of pieces set for translation
at sight.
Mr. Napier, LL D., seconded the motion.
Mr. Tyler then proposed an amendment, which was
seconded by Mr. Lynn. It referred to a further modi¬
fication of the examination by the appointment of
moderators and the arrangement of successful candi¬
dates in three divisions. This was the substance of
Mr. Tyler’s motion at the last meeting before it was
referred to the Annual Committee; but was now with¬
drawn, owing to lack of time for discussion in addition
to the original motion.
Dr. P'lTCH said that the wishes pub forward were fulfilled,
in that special assistant examiners, such as those referred
to, looked over the papers. The questions were supervised
by members of the Senate specially deputed before being
linally laid before the candidates. He considered it was
necessary to maintain the unity of system with the higher
examinations. He thought the harder questions were more
likely to be set by the younger examiners, and that the
proposed remedy was not likely to improve matters. It
was the aim of examinations to do simple justice to the
humbler students, whilst offering more advanced ones a
chance of distinguishing theruselvea.
Dr. R F. Weymouth expressed his dissatisfaction with
Dr. Fitch’s remarks, and said that the examiners should he
in sympathy with the examinees.
Mr. Paul objected to the style of the questions. He said
a separate staff of examiners were required for matricula¬
tion, and urged as a reason that many candidates set that
examination as the limit to their work, and did not go on
to the others.
Dr. Thompson said that nearly all the speakers
approaciied the subject from the point of view of teachers.
This was of course not to be neglected, but the training of
examiners was an important feature. From personal ex¬
perience he was nob in favour of moderators. He urged
that a paper should fulfil three requirements: (l)To test
the candidate’s knowledge ; (2) to test his mental power to
deal with the questions ; and (3) to test his training. He
thought that the setting of questions on very modern sub¬
jects kept the teaching up to the mnrk, and that the style
of the examiner had an immense influence on that of the
teaching. There was room for considerable choice among
those who applied for exaroinerships, and sometimes men
were appointed on account of their fitness to examine for
matriculation, with diminished regard for higher examina¬
tion. If tlift ordinary examiners were relieved of the labour
of testing ,3000 matriculation candidates, men could be
obtained more suitable for the more advanced examinations.
Sir Phillip Magnus considered the term “special
examiners” very indefinite, and that if the proposed motion
were carried into force, the examination would be lowered
to meet schoolboys.
Mr, Nesbitt, in reply, said there was no desire to lower
the standard, but only to keep in touch with the candidates.
The motion was carried.
Dr. Collins moved that the clerk of Convocation he
requested to moke application to the Senate for their
latest revised scheme for the reconstitution of the Univer¬
sity as soon as it may be completed, and that he be
instructed to post a copy of the same to every member of
Convocation.
Dr, Tiiomi’SON seconded the motion.
The Chairman said the Senate bad gone beyond the
recommendations of the Royal Commission in order to con¬
ciliate the Colleges, and evinced a strong desire to get the
scheme adopted.
The motion was carried, and, as many members left, the
rest of the business was adjourned
Medical Magistrate.—T ho namo of Dr. James
Alfred Harris, of Chorley, has been placed on the Commis¬
sion of the Peace for the county of Lan^astor.
Ti-ie London Water Commission.—T he Bill pro¬
moted by the Corporation of the City of London to establish
a public authority to promote Bills to provide the inhabitants
of London with an improved and cheaper water-supply,
having been found to comply with the Standing Orders, will
now be allowed to proceed.
Dir:' ad^v' rOOglC
Tub Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Jan. 24,1891. 215
THE DEBATE ON KOCH’S REMEDY AT THE
BERLIN MEDICAL SOCIETY.
The debate at the Berlin Medical Society upon the paper
on Professor Koch’s remedy read by Professor B. Fraenkel
on Dec. 17th,^ which was followed by Professor Virchow’s
demonstrations and remarks (vide The Lancet, Jan. 17ih)
on the 7th inst., was continued on the 14th (vide special
verbatim report in the Berliner Klin. Wochenschrift, No. 3,
1891).
Dr. Bernhard Praenkel referred to some of the
cases which he had exhibited on Dec. 17th. One of
these, a case of tubercular disease of the pharynx, had
died since that meeting, having two days later been
attacked with acute peritonitis from perforation. The
intestine showed numerous ulcers, one of which, two metros
above the ileo-ceecal valve, was perforated, whilst in others
the serous coat was exposed by the necrotic process. There
were extensive cavities in the lungs. The larynx showed
widespread destruction. In the pharynx, behind the
arytenoid cartilages, could be seen the margins of clean-cut
ulcers. The soft parts of the epiglottis were destroyed, only
the cartilages remaining, the destruction corresponding to the
infiltration previously noted. There were no miliary tubercles
around the ulcers. Bacilli could be obtained from the base
of the ulcers, showing that Koch’s remedy, which destroys
the tuberculous tissue, does not affect the bacilli. Professor
Fraenkel then exhibited cases shown on the previous occa¬
sion : I. Phthisis of the right Lung with changes in the
Larynx: Here a dose of 01 grm. had been attained with¬
out exciting any general reaction. His appearance bad
much improved and the physical signs had greatly
diminished. The larynx was unaltered. Since Dec. 14th
the patient had gained 6Ib. iii weight. The sputum still
contained bacilli. 2, Lxvpus of the Nose: This showed a
notable progress in healing, although but few injections had
been practised. Slight reddening remained near the infiltra¬
tion, whilst the nose and ala were quite cicatrised.
3. Ulceration of Larynx on posterior xvall and on Aryte¬
noids: There still remained some of the pseudo-mem¬
branous formation on the posterior wall, but the lateral
ulcers were healed. The pulmonary condition had improved,
and so had the patient’s general health. 4. Lupxcs of
the La/rynx: A few;| injections had been practised, but
further swelling of nodules could be perceived. 6. The
case of a patient from Moscow who on the last occasion pre¬
sented a peculiar swelling on the posterior wall of the
larynx, which was breaking down. For some time he
had been injected with a decigramme dose. The tumour
had disappeared; the lungs, so far as physical signs went,
seemed healthy. Bacilli were no longer to be found in the
sputum, and during the last fortnight he had gained about
four pounds in weight. Dr. Fraenkel considered this case
as cured, although there might perhaps be a recurrence.
Dr. Albert Fraenkel said lie showed a case of lingual
txiberculosis which, he reminded the Society, occurred under
two forms—the one as firm nodules of conglomerate tubercle
in the substance of the tongue, which, as they increase,
break down into ulcers; and the other in tiie form of
scattered miliaiy tubercles beneath the mucous membrane;
these enlarge and eventually form lenticular ulcers. The
patient in question, a waiter twenty-live years of age,
showed a combination of these two forms; he also had both
lungs and the larynx affected. The treatment was com¬
menced on Nov. 22nd, and had been continued for seven
weeks and a half. Commencing with O’OOl grm. the dose
had now reached 0'04gvm., after a total number of thirty-
five injections (or 3G0 milligrammes in all). Very slight
effect had been produced on the temperature curve, the
highest rise noted not exceeding 1° C. above the previous
pyrexia (viz,, SO'S” instead of 38-5°). On Dec. iOtU the
tongue, wiiich had previously appeared to be normal, showed
some aphthous-IooUing ulcers on its right anterior margin.
Another lung case also developed similar ulcers on the
tongue and cheek, but tliey rapidly healed ; whilst in this
case they slowly increased in size. But at this time no
bacilli could be obtained from them. On Dec. 18th there
appeared painful infiltration and intense redness, with
swelling of the right border of the tongue; and about a
' Reference to tliis article will be fouml in onr Berlin letter of
Jan. 3r(l, p. 62.
week later, during which time the ulcers had still further
enlarged, and had become partly confluent, there were seea
some yellow deposits of the size of millet seeds on their
margins. Then the base of the ulcers, which had been
coated with a greyish deposit, cleared up, but became
deeper; and now bacilli were abundantly found in tho
secretion. The infiltration continued to spread, so that
now a firm nodule as large as a small walnut could be felt m
the tongue; and, further, within the last few days therei
had been an eruption of miliary and submiliary tubercles-
on the mucosa not only around the ulcers, but in what-
seemed to be healthy membrane at a distance of 1 cm.
from them. There .seemed no doubt that the virus had
been disseminated. [The same patient had also just de¬
veloped an abscess near the anus, the pus of which con¬
tained numerous tubercle bacilli- Dr. Fraenkel proposed
to excise some of the lingual tubercles and examine them-
for bacilli,]
Dr. B. Baqinsky exhibited the case of tuberculous
aliection of the gums which Professor Litten bad shown to-
the Society of the Charitd Physicians on Dec. 4th, 1890;
The patient had apparently been infected nine years pre¬
viously through the medium of the pocket-handkerchief ofi
her tunercular sister, and an ulcer had formed on the septun^
narium. This had been taken for lupus and scraped.
Three years later an ozccna was traced bo ulceration on th&
nose; and some time afterwards there also appeared ulcora--
tion of the gum on the upper jaw, which was painless, and
for a long time had not been treated. She came under
Dr. Baginsky’s care on Nov. 26th, 1890, having then a-
granulating ulcer of the gum involving the left side^
of the jaw, and partly extending bo the right half. The
granulations were covered with yellow puritorm secretion,
and amongst them were many well-defined miliary nodules ia
process of disintegration. Twoulcerswere found on theleft o&
the septum narium and ala. The palate, pharynx, and larynx
were normal. There were signs of infiltration of both pulmo¬
nary apices. In a portion of the granulations that was exciaech
giant cells were present, but notubercle bacilli could befound.
Treatment by Koch’s fluid was commenced on Nov. 28th_, andJ
the patient had received altogether twenty-three injections,
the last on Jan. 13th, 1891—viz., 13 milligrammes. There
had been severe general and local reaction. The tempera¬
ture rose to 40-9^C., and there was great swelling of the-
nose and gum; then, as the necrotic portions liquefied,,
fresh nodules appeared in the deeper parts. Neveitheless-
bacilli could nob be found. During the treatment, after
the fourteenth injection, a painful glandular swelling ap¬
peared in the left cheek, and, at the same time, the sun-
maxillary elands became swollen, but under continued
treatment these swellings diminished and the tenderness-
ceased. But suddenly, after the twenty-first injection,,
there was pain in the left side of the neck, and next day
it was found that there was redness of the left arch of the-
palate, with redness and swelling of the tonsil, in which-
SQiall grey nodules could be seen. The redness subsided,,
and omy a few of the nodules remained visible. The disease-
of the gums, however, remains just as before, or ia even
worse than before treatment. The nasal ulcer seemed to-
have cicatrised.
Professor Virchow desired to add a few facts to those oP
his demonstration at the previous meeting. He first showed-
a specimen kindly sent to him by the physicians of the^
Jewish Ho-'-pital. The case was one of phthisis, which had
received two injections the last four weeks before death,
and showed a most unusual degree of change in the intes¬
tine. Amongst the efiects which he had considered to be-
due to the injection of Koch’s remedy was the occurrence
of marked medullary proliferation occurring in lymphatic-
glands and their vicinity. This case exhibited such a-
change to the greatest extent he hti.d seen. There was so-
much medullary infiltration in the parts usually attacked'
in typhoid fever that he himself at first thought the cose-
waa’ one of typhoid. On both sides of the ileo cwcal valve,
especially in the ileum, were follicular ulceiarions; and
around the ulcers, as well as in parts where tho ulceration-
bad Just commenced, and also where tho mucosa was-
still mtacb, wore circumscribed swellings. Peyer’s patches,
and groups of follicles approaching them in size, were-
converted into raised whitish medullary plaques, the
surfaces of which were more or less irlcorated. The proceas-
differs essentially from that ordinarily seen in typhoid, forr
the ulcers begin at several points, then become rapidly con¬
fluent, and gradually break down in the centre, a clmnge-
Di(,:,..
216 Thb Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Jan. 24,1891.
often interrupted by direct sloughiog, causing a rapid ex¬
tension of the destruction. In some parts subject^ to a
stream of water the surface presents a sieve-like aspect from
the rupture or destcuciion of separate follicles. The case
was also remarkable for the considerable swelling and semi-
caseation of mesenteric glands in the vicinity of the ileo-
■csecal valve, a change also analogous to that seen in typhoid.
Over the largest of these glandular swellings lay a zone of
recent submiliary peritoneal tubercles. Professor Virchow
then showed some preparations exhibiting quite recent sub¬
miliary eruption on the serous coat of the intestine in cases
of phthisis. One specimen was from the body of a patient,
a Russian merchant, aged thirty-seven, and was sent by Dr.
O. Israel. It was a portion of the ileum near the ileo-
csecal valve, having two old tuberculous ulcers of the size of
ten-pfennig piece with clean but indurated base and thick
margins.- On the serous surface were small submiliary
tubercles in exceptionally large numbers. Another from the
■Charite, a working woman twenty-three years of age, with
.ulceration of larynx and lungs, who had bad four injec¬
tions, the last on Deo. 10th. Tracheotomy had to ho per¬
formed on Nov. 23rd, a week before Koch’s treatment was
commenced. The large laryngeal ulcers showed a smooth
base, with recent miliary nodules in margins and vicinity.
On the ileo-cmcal valve were some older partly healed-
.ulcers, and the serosa in this region showed a large tract,
rof delicate, transparent, grey, submiliary nodules. On the '
j)osierior surface of the liver and near its lower margins the ;
.capsule presented a group of very line barely visible nodules
in a thin inllaramatory exudation. He tlven showed the
.lungs from the first of these two cases, illustrating the
anarked extension of disease in the form of foci of caseous
hepatisation scattered throughout. In this case nine injec¬
tions had been made from Dec. 18th (Img.) to Jan. 5th
<5mg.). The first examination yielded a tympanitic dull
mote in the left first interspace and the infraspinous fossa;-
on the right, above, some rough expiration, normal resonance
.anteriorly, and some moist rdles. The condition now pre¬
sented was that of smaller and larger cavities filled with
aoft creamy contents. Had all these foci been emptied
•of their contents nothing would have been left of the
'lung but a framework of a few bands enclosing cavities
in all parts of the lung. It is obvious that under
-such circumstances the action of the remedy must he un¬
favourable. Professor Virchow added that in citing these
-cases he expressly desired nob bo impugn the remedy as
euch; it was a question rather of testing its employment.
We must be convinced that there is a very definite limit to
the action of art, where no possibility exists of a restoration
•to the normal or even of a tolerable condition. Professor
Virchow next showed some specimens from the body of a
etudent, twenty-five years of age, who had been injected
mine times, the last on Dec. 25th. The case was under the
..care of Dr. Lazarus at the Jewish Hospital. It was a case
,in which perforation of the pleura leading to pneumothorax
■had rapidly occurred after the injections bad ceased. The
left lung was quite free from tubercle, as well as the middle
-Jobe, the major part of the lower lobe and apex of the right
lung. But below the apex was a walnut-sized ulcerating
•cavity witli gangrenous contents, reaching to the pleura
and perforating at a minute spot. In the neighbourhood were
•caseous pneumonic nodules ; in the pleura, recent and old
tubercle; and scattered in the lung some foci of softening to
the size of a cherry, with loose necrotic contents of yellowish-
white colour. He also showed two lungs from an indubitable
case of phthisis, the right organ showing at several points
-connected areas of dilfuAe hepatisation, upon which he spoke
last time as a relatively rare appearance. He related this
case because, so far, he had nob been able to ascertain that
injections had been practised. The patient bad been
transferred from the surgical wards in the Charite—where
-he was admitted for a wound of the arm~-to the medical
wards, owing to his phthisis, from which he succumbed
After twenty-four hours. There was widespread hepatisa¬
tion, very different from the ordinary form, resembling the
caseous form, but of a moist, yellowish character, reminding
cue of phlegmonous conditions. If it should turn out that
euch cases occur without injections, then the opinion given
(last week must be modified, for it would have to be
determined in what cases such a type of inilammation
ehould be regarded as a result of the injection and in what
AS a mere complication. Whether the man was injected
before the time of his admission into the Charitd—where lie
was for eighteen days—was not then kno>^'n. Professor
Virchow concluded by showing a specimen of induration at
the apices of the lungs of a case of congenital heart disease
(a woman aged thirty), a change often regarded as healed
tubercle, but which he attributed in this instance to
interstitial pneumonia due to syphilis. In these cases, too,
he remarked, the bronchi may become ulcerated, or form
bronchiectatic cavities.
Dr. Lazaku.s gave some details of the case of pneumo¬
thorax referred to by Professor Virchow. The patient was
admitted into the hospital at the end of November, with
abundant bacilli in the sputum, but only slight dulneas at
the left apex. He was a robust, powerful young man of
healthy parentage, and injections were commenced on
Nov. 30lh, and up to Dec. 24th nine injections were given.
The highest reaction was 39 '4° C., and 5 milligrammes was the
largest dose given. Although his appetite had improved,
the temperature began to have more tendency to rise,"the
respiration became shorter, and the pulse very rapid;
The injections were discontinued, and the' area of dulness
increased from above downwards. On Jan. 6th the tem¬
perature rose suddenly to 40* C., and remained at this level
till the 9th, after which for three days the fever rapidly
subsided. Then appeared signs of pneumothorax on’ the
right side, which soon increased. • . . ,
These demonstrations having terminated, the discussion
on Dr. B. Fraenkel's paper on the Employment of Koch’s
Remedy in Tuberculosis was resumed by
Dr. Paul (Iuttmann, who gave his experiences at the
Moabit Hospital, where 170 cases had been treated, of
I which number '120 were in the part assigned by the city
; authorities to Professor Koch. Forty-one cases of pul¬
monary tuberculosis were in a relatively early stage of the
disease—i.e., with infiltrations at the apices,—and had been
under treatment for from three to six weeks. The great
majority of these had notably improved. First, there was
gain of weight from ^ to Gljkilogr.; some remained of the
same weight as before injection; live had lost weight.
Second, in no small number were there favourable changes
in the physical signs, the number of rfiles manifestly
diminishing; and in some patients there had been moderate
clearing up of the dulness on percussion. ' Third, all the
patients felt subjectively better. Dr. Guttinann said he
had only selected the initial cases for his statistical inquiry,
because Koch had affirmed that such cases could be cured
by his remedy. The two girls mentioned as cured in his
(Dr. Guttrnann’e) previous communication remained still
free, and may be regarded as cured of tuberculosis. To
them he now added a third patient, who for four weeks had
suffered from cough and sweating, and in whom over both
apices were scanty fine rfiles. After three weeks’ treat¬
ment, in which the injections reached Offgrm,, she had lost
cough and night-sweating, and only now and then could
any rfiles be heard. Manifest improvement also took place
in some of the'other cases. Favourable results were also
yielded in laryngeal cases, of which there were more than
thirty, comprising all varioirs forms, from simple infiltra¬
tions to ulcers and perichondritis. All these cases,
examined once or twice daily by the laryngoscope, show
marked tendency to improvement, and in fact towards cure.
The cases of simple infiltration improved the most rapidly,
ulcers less so; bat their bases became clearer and margins
thinned, and in some cicatrisation took place. He believed
that the results of the treatment depend largely on the
selection of the cases. Only the early stages of pulmonary
tuberculosis are suitable for it; by no means should very
advanced cases be treated, and when such selection is made
he thought ocher hospitals would attain similar results to
those which were to be found at the Moabit Hospital.
Dr. Kuiite, jun., said that since Nov. 22nd there had been
twenty-eight cases treated in the surgical department of the
Urban Hospital. So far no defiuitiveresult liad been noted,
but the treatment had probably not been long enough em¬
ployed. No case had exceeded Off grm. dose. The injections
had also been used for diagnostic purposes in doubtful ulcera¬
tions, without reaction, save in one case of actinomycosis.
There had been eight caae.-j of lupus. One had been treabedfor
four weeks and showed improvement, but was not cured; the
rest had marked reaction, but had nob been long under treat¬
ment. Of three cases of tuberculosis of soft pares, one—a case
of suppurating gland—at the end of four weeks’ treatment
had the same characters as before. Only waberdressingwas
emplo;yed, and at first the wound enlarged, suppurated freely,
then diminished, and then took on the usual characters of
such glandular wounds. Of two cases of intestinal tuber-
^8
The Lancet,]
INTERNATIONAL MEDICAL CONGRESS AT BERLIN.
[Jan. 24,1891. 217
culosis, one improved, the other died from pulmonary
phthisis. There were also treated ten cases of bone and
joint tubercle, and hve others associated with lung disease;
and lastly two cases of pulmonary tubercle which happened
to be in the surgical wards. Dr. Korte advocated startins
with small doses, which should be slowly increased; and
said that the very severe symptoms which followed the
earlier injections when larger quantities were used had led
them to adopt that plan, and also to allow a sulftcient
interval between the injections. In a few cases there was
loss of weight, but in some a slight gain; whilst in several,
especially children, who had no general tuberculosis, but
OQ^ local disease, marked anmoiia developed during the
treatment. In one case of a boy there was a measly
eruption, with herpes; and in another, a case of recent
tubercle of the knee-joint, marked hallucinations, lasting
for a day, followed an injection of 8 milligrammes. Some
of the cases had been already treated by resection or iodo¬
form injections, and it was to be noted that in the latter the
reaction was much delayed. As a rule the febrile movement
began on the second day; but the height of this did not cor¬
respond with the intensity of the disease. Patients with
extensive lesions reacted very slightly, until perhaps a dose
of 5 milligrammes was reached, when there was a strong
reaction. In two cases dyspnoea occurred after 8 milli¬
grammes and 9 milligrammes respectively, although up to
that point they had shown nothing abnormal, and only
very moderate reactions. This dyspnoea led him to leave
off the injections, but it continued until the deaths of
the patients, which took place in the one case ten days
and in the other four weeks after the last injection. Still,
he was not disposed to attribute the deaths to the injections.
They were cases of advanced tuberculosis, and were in¬
jected in order to see if any improvement could take place.
One was a case of fistula, the other a large abscess of the
hip-joint, and both had considerable lung disease. The
injections had no notable effect on the suppuration. A boy
with tuberculous abscess of the knee-joint, and in the true
pelvis, which had been opened, did not react to the remedy.
An epileptic seizure followed one injection, but he appears
to have been previously subject to such attache. The dose
was raised to 8 milligrammes without any effect on the
fistula or the cicatrix. One case of actinomycosis of the
face was treated. It was a young lady twenty years of age,
who suffered from an abscess of the cheek, at first thought
to he connected with dental caries. There was dulness at
the left apex, and a history of haemoptysis. The diagnosis
rested between tubercular ulcer and actinomycosis, and she
was admitted into hospital and treated by injections, com¬
mencing with one milligramme. There was marked general
reaction, and local redness and swelling, with increased
discharge, but no improvement. Dr. Israel detected
actiiiomyces in the discharge, and extirpation had been
followed by healing of the wound. The general reaction
was attributed to the lung affection, but no bacilli were
found in the sputum, which was very scanty. At any
rate, the case showed that a local reaction could be pro¬
duced by the remedy in actinomycosis. Dr. Korte then
I'eferred to the fatal cases. Two of these, as already said,
were cases of pulmonary tuberculosis with surgical affec¬
tions, and were injected without any hope of effecting a
cure. Dr. Hansemann found much recent tubercle in the
organs, together with older caseous foci. A third case was
that of a child four years old, with fungous disease of the
knee, which had been treated by iodoform injections. The
condition of the joint had much improved, but the disease
was nob quite gob rid of, and from Nov. 22nd to Dec. 5t)i he
was given six injections up to (i niilligraiames. Reactions
were marked, not excessive, the fever never exceeding 89'6“.
Tlie knee became swollen and painful, and the child lost its
colour and appetite. Continued fever setting in, the treat¬
ment was stopped at the sixth injection. Then occurred
vomiting, hypermsthesia, and headache, followed by marked
symptoms of cercbro-spinal meningitis, from which he auc-
cuiiil)e<l thirteen days after the last injection. There was
quite recent meningitis, with grey transparent granulations
in the arachnoid, and the brain substance was somewhat
fndeniabous and moderately hypera'inic. The lungs were
healUiy, hut there was recent miliary tubercle in the liver.
The knee-joint showed some tuberculous granulation tissue
in the inner surface of its capsule, some erosion of
cartilages, and a tuberculous focus in the head of the
tibia. Dr. Kiirte next referred to a case of knee-
joint disease recently treated on Koch’s method, with very
severe local and general reaction, the joint swelling from
the first; but, whilst the general reaction became lees, the
local reactions continued severe. There was so much pain
and inflammation, and the patient losing ground, that
resection was had recourse to. The joint showed an
abundance of recent synovial tubercle, which was invading
the cartilage. Lastly, he mentioned the case of a man
for whom laparotomy had been performed. No tubercle
was seen in the peritoneum, hut bacilli were found in the
pus. He recovered from the operation and increased in
weight, but there remained some resistance in the inferior
region of the abdomen. He was transferred to Dr, Fraenkel’s
ward, and injections with Koch’s fluid were given, bub
with hardly any reaction. Occasionally he had a slighb
dragging in the abdomen. The injections were increased
up to OT grm., but without any recognisable result; whilst
the exudation which had been felt after the operation
remained, but in less amount.
INTERNATIONAL MEDICAL CONGRESS AT
BERLIN.
RESUMlil OF THE PRINCIPAL PAPERS READ
IN THE SURGICAL SECTION,
Abstracted from the MSS. for The Lancet.
By C. LAUENSTEIN, M.D. Hamburg,
ONF. CW' TUE SECRKTAJUFS TO TIIK SECTION.
Resection of the Stomach and Intestines; gastro¬
enterostomy <&c.
Billroth details an experience of 124 cases, 83 of which
were operated upon hy himself, the rest by bis pupils..
There were 41 resections of the pylorus (7 males and 34*
females); 28 cases were for carcinoma ; 1 for sarcoma ; 12’
for cicatricial stenosis ; 19 healed, 22 died. The operations
lasted between one hour and a quarter and three hours and
a half. The resected pieces were from 4 to 21 centimetres.
Twenty-seven typical resections were made, with 12:
successes and 16 deaths. Twice, after removing a very
large carcinoma, the stomach and the duodenum were both
closed, and gastro-enterostomy performed. One patient
died, and one recovered.
Results. —Of the 13 cases which recovered after resectior#
for carcinoma, 5 died within ten months, 2 after a year,
1 after one year and a half, 1 after two years and a half, i
after five years and a quarter, and 3 females are still living.
One of these was operated upon a year ago, and under the
cicatrix a knot is now felt; 2 of them arc quite well; they
were operated upon four years and a half and two years and
a half ago. Of the patients who were operated on for
cicatricial stenosis, one woman died three months and a half
afterwards horn peritonitis, a young man died five years
after from intercurrent disease, and four women are living in
perfect health. Oastro-enterostomy was performed in 2&
cases for carcinomatous stenosis {13 males and 16 females);
14 were .successful, 14 died. Life lasted from one to eight
months, the patients being greatly relieved. Resection of
small gut: 11 patients were successfully operated on. Re¬
section of c.'ocura; 24 cases; 11 died, 13 recovered. Re¬
section of the colon (transverse and sigmoid): 8 resections,,
with 4 deaths and 4 recoveries. Billroth always uses inter¬
rupted silk stitches. The inequalities in the lumina were
equalised by folding in the larger viscus and fixing it thus-
1 with sititches. Occasionally the gut was cut obliquely to
I make it wider, or it was implanted laterally.
Novaro (Siena) records 20 similar operations. His con-
clnaions are (1) Pyloroplastic operations are indicated in
cicatricial stenosis ; (2) in cases of uyloric tumour, nylorcc-
tomy is necessary, but it is advisable to remove a little of
the tumour for microscopical examination first.
Postompski (Rome) records 5 cases: (1) A successful
Loreta in a woman aged forty-six; (2) an excision^ for
round anterior wall ulcer—perfect recovery; (3) stenosis of
CEsophagus and pylorus—^^dilatation of the former and pyloro¬
plastic operation, with recovery ; (4) same operation, with
success, in a man aged forty-three ; (5) gastro-enterostomy
for cancer, with death six months after.
Lauenstein (Hamburg) gives 25 cases of pyloric stenosis s
218 The Lancet,]
INTERNATIONAL MEDICAL CONGRESS AT BERLIN.
[Jan. 24,1891.
12 cases were resected (4 successful, 8 died); 11 cases had
^astro-enterostomy {9 recoveries, 2 deaths). Success depends
on asepticism, the patient’s condition, and rapidity of opera-
'tion. Dry hands and instruments are advised.
Czerny (Heidelberg) refers to 3 cases of sarcoma of the
•gut -which he had resected successfully.
Maydl mentioned that he had made 40 resections. Out
of 9 cases of resection of the colon, 2 died. He advises the
Czerny-Lemhert suture.
The Newer Operations in Cancer of the Bectum.
Axel Iversen (Copenhagen) formulates the following con¬
clusions upon 247 cases oi excision of the rectum operated
'Upon in Denmark, Sweden, and Norway: 1. The older as
well as the more recent methods of amputation and resec¬
tion of the rectum are only palliative procedures. They
give a longer tenure of life than colotomy affords, but they
axe more dangerous. 2. The extirpation of the entire
rectum, together with the regional glands, is the rnost
reasonable of the procedures, for in favourable cases radical
cure is obtained. But as of 19 cases of Kraske’s operation
8 died (5 in collapse), the method is very dangerous where
cancer is far advanced. 3. The greatest number of cases
must still, as formerly, be treated palliatively (colotomy,
rectotomy, " tvidement”), because most patients present
'themselves too late for radical operations. 4. Colotomy
should be performed by the Madelung, Maydl, or Reclus
methods.
Bryant submits that excision is only applicable to cases
in which the disease is limited to the lower two inches and
a half, and all can be removed; otherwise colotomy or
rectotomy should be performed.
Konig (Gottingen) does not deem the Krasko method so
dangerous. As regards the prognosis, after the older and
newer operations, out of 96 extirpations on the older
plan he lost 27. Of 16 patients operated upon by this
method he has lost only 4. His mortality has latterly
dropped to 12 per cent., and he thinks it due to the '
fact that he has given up uniting the gut section to the
ekin.
Czerny (Heidelberg) reported that he has performed 18
rectal extirpations (with resection of sacrum), with 4
deaths. In all the fatal cases the peritoneum was opened.
He advises that the peritoneal wound should be imme¬
diately sutured. His experience goes to prove that a better
prognosis as regards recurrence is afforded by a carcinoma
which affects the upper parts of the rectum. One of
his cases has lived twelve years. The cancer was situated
12 cm. from the anus. The best prognosis obtains in case
of carcinoma of the mucous membrane which infect the
glands late, and in scirrhus strictures which induce pain
«ar]y.
Resection of the Thorax in Empyema.
Schede (Hamburg) demonstrated several patients in
whom he had resected the greater part of one side of the
thorax for inveterate empyema. The incision is begun at
the external border of the peetoralis major on a level with
the fourth rib, and is continued downwards to the post-
axillary line on a level with the tenth rib. It is then
carried upwards along the middle edge of the scapula. The
soft parts are raised from the ribs, which are resected sub-
periosteally. The whole thorax hollow is now laid bare
and upholstered with the skin-muscle flap. Healing takes
more than a year before it is complete.
Sabbotin (St. Petersburg) recommends the following:—
Two longitudinal parallel incisions are made in the side of
the thorax; several ribs are divided, each once or twice.
This movable flap is now pressed into the pleural cavity and
the external wound closed.
Kiister (Berlin) is an advocate of rib resection. He
advises such to be done in two places, the posterior being
placed low down at the lowest level of the pleura. He has
thus treated 1.86 cases with 78 recoveries (57"3 per cent.);
41 died (301 per cent), and 17 were unhealed (12'5 per
cent.).
Osteogenesis.
Ollier (Lyons) has performed 500 subperiosteal resections
and verified many of his results by necropsy. The
humerus, radius, and ulna are reproduced in the form of
the normal bone. After removal of the lower end of the
humerus, the length of the bone is restored by the activity
of the upper epiphyses, provided that the stump is used.
He has never observed the absorption of newly produced
bone. Antbeptic treatment of wounds does not prevent its
production. In extensive resection for tubercular disease
the bone does not reproduce itself; hence in such cases the
tubercular focus only must be removed. Ollier says that
the periosteal production of bone is but slight; ttie results
are better if a thin layer of bone is preserved under the
periosteum. It is as yet too soon to judge of the utility of
transplanted bone. His experimental work on animals
tends to show that such bone disappears. It only sets up
tissue irritation in which it is implanted. It would be more
logical if ivory pegs or platina pins were used instead.
Rubio (Madrid) has used decalcified bone in two cases
with excellent results; he advises the vault of an ox’s
cranium for repair of skull defects.
Klimell (Hamburg) transplanted decalcified bone in
twelve cases—’Viz., into bone cavities, trephine hollows, for
replacing phalanges, for defects in i-adius, to close opening
of the canalis vertebralis after operation for spina nifida,
and to fix the bone fragments after resection of the knee.
His experience is that bone chips unite in spite of
suppuration.
Abdominal Section f<yr Tubercular Peritonitis.
Konig (Gottingen) has collected 131 cases of laparotomy
for tubercular peritonitis (11 male, 120 female). His per¬
sonal experience consists in 14 of these, of which six were
soundly cured; most of the patients (70 per cent.) were over
twenty years. He states that laparotomy will cure a
quarter of all cases; 107 were much ameliorated; some have
remained well for lengthy periods—viz., twenty-five,
thirteen, nine, eight, and seven years. The danger of the
operation is not great—only 3 percent, mortality—as opposed
to the fatal nature of the unattacked disease. The chief
elements of success appear to be the employment of nob too
small an incision and the thorough evacuation of fluid and
removal of tubercular masses and organs. Lavage with
' strong antiseptic solutions was performed in 80 cases, and
without such in 50 cases. It is noticeable that more cases
healed xaithoxit antiseptic lavage. In the future, careful
micro?copical examination should be made of the evacuated
ddbris in every case in order to explain the mystery of the
healing process. Konig gives the following valuable
statistics from the Gottingen Pathological Institute. Out
of 2230 post-mortems there were 107 cases of tubercular
peritonitis (4 per cent.). Of these 89 were males and 18
females. In 99, tuberculosis of the lungs was coexisting,
only 8 cases were therefore free; 60 bad more or less severe
pleural complication ; 80 had ulceration of the gut (74 per
cent.); 44 had affection of the mesenteric glands (41-6 per
cent.); 38 had tubercle of the kidneys; 40 had the spleen
affected; 4 of the 18 females had tuberculosis of the tubes
and ovaries.
Kumeli (Hamburg) records eight cases. He uses sponges
and antiseptic fluids in the abdominal cavity with the view
of setting up adhesions, believing that such proceedings pre¬
vent ascites recurring. One of his case.s has remained well
for four years, another for two years, two of the healed
cases have listuku still.
Diseases of the Thyroid in Sweden.
Rossander (Stockholm): In Sweden degeneration of the
thyroid is rare ; out of 141,045 patients only 84 had disease
of the thyroid, whilst out of 31,312 operations only 102 were
directed against disease of this gland. Rossander states
that in suitable cases injection of iodine is a valuable treat¬
ment. Although relapses occur, yet this treatment is better
than enucleation in cystic goitre, which variety forms 40
per cent of the cases. In 32 cases total extirpation was
performed (25 at one sitting, the rest in 2 sittings). No
consequences followed, neither myxocJenia nor tetany.
Cretinism is unknown, myxujdema also. The enucleation
after Socin’s method is warmly recommended if enucleation
is adopted ; ia thyroidectomy the division of the operation
into two stages ia advised.
Biondi (Bologna) states that the special secretion of the
thyroid gland in reptilia, aves, and mammalia is produced
by the columnar epithelium lining the acini; that thence it
is discliarged into the lymphatic spaces. lie further holds
that the sub-capsular and peri-capaular layers arc capable
of regenerating' or reconstructing the gland, and therefore
that in all excisions the capsule mioukl be left.
Calculus D'isease.
Lewschin (Kasan), upon a review of 30,000 cases of stone
which the author lias collected from reliable sources, the
Dii Google
The i»ANCBf,]
THE INTERNATIONAL CONGRESS OF HYGIENE.
[Jan. 24,1891. 215
following conclusions are based :—1. For the most part
calculus occurs in the infant and child. 2. Calculus disease
i.s distributed very unequally in Russia. Thus, in the Baltic
provinces, Finlauc), Yolynsk, and elsewhere, the disease is
almost unknown; whilst in the province of Moscow alone
14,000 cases have been recorded (there it may be said to be
endemic), and in the divisions Kaean, DanilefF, Tamboff;
each affords more than 1000 cases. 3. Etiological condi¬
tions are not clear; the vegetable food of the Russian
peasant and heredity are the two factors suggested.
Aretaos (Athena) believes arthritis plays an important rOle,
in the production of stone. He finds the children of the
poor most often affected. Litholapaxy is the preferable
operation. He has treated 256 cases. His mortality in
lateral lithotomy is 24'4 per cent.; in sectio alta it is 44 per
cent.
Pathogenesis of the Popliteal Cysts.
Poirier (Paris) has studied 500 knee-joints, of which 200
were injected. He has found, contrary to the text-book
teaching, that popliteal cysts are for the most part in com¬
munication with the joint, and are of joint origin. His
conclusions are (1) the cyst between the inner gastroc¬
nemius and the semi-membranosus is extended and
rendered larger in extending the joint, and diminished in
flexing it; (2) the cyst of the bursa of the popliteus muscle
appears as a rule like a tumour in the deeper part of the
calf; (3) cysts in the neighbourhood of the condyles on a
level with the insertion of the gastrocneniii are in com¬
munication with the joint.
Diaphragmatic Hernia.
Postempski (Rome) read a papar on Suture of the Dia¬
phragm in cases of Traumatic Hernia through this Muscle.
He forms a flap on the side of the base of the thorax, resects
one or two ribs, opens the pleural cavity and sutures the
gap in the diaphragm after replacing the escaped abdominal
viscera. The flap closes the pleural cavity without drainage.
Six cases have been successfully treated by this method in
the hospitals of Rome.
BuHed Horn Ford pressure Forceps.
Tantini (Modena) submitted that horn was a suitable
substance for leaving in the tissues if need be. He has
made artery clamps of horn, which are easily disinfected
and can he left in the body. He showed a clamp which
he had used seven months previously in removing the spleen
of a dog. The foreign body had caused no reaction.
Absorbable Drainage-tubes.
Weeks (Portland, U.S,A.) demonstrated the prepared
arteries of different animals (preferably the ox) which he
uses as drainage-tubes. He contends that they have qualities
superior to the decalcified bone drainage-tubes.
The Blade of a Knife as a Nucletis of a Vesical Calculus.
Lavista (Mexico): Two years before coming under treat¬
ment for symptoms of stone the patient was stabbed in the
supra-pubic region. On removal by sectio alta of the
calculus the blade of a large knife was found as its nucleus.
Artificial Production of Hernia.
Bornhaupt (Krew) stated that in Russia the Jews pro¬
duce inguinal hernia in order to avoid military service. An
instrument is used similar to an ordinary glove-stretcher,
and by it the canal and ring are gradually enlarged.
THE INTERNATIONAL CONGRESS OF
HYGIENE.
The first of the Sections of this Congress to complete its
organisation and issue its programme is that of the “Rela¬
tion of the Diseases of Animals to those of Man”—a subject
which has of late achieved considerable development in
view of the recent discoveries of Dr. Koch, and the discus¬
sion with regard to tuberculnsis, which has culminated in
the appointment of a Royal Commission to inquire into the
subject.
The Section proposes to consider, amongst other subjects,
the Infectious, Contagious, Parasitic, and other Diseases com¬
municable from animals to man, and vice versd; the methods
of the propagation of diseases affecting mankind by means
of animals ami animal products: the infection of meat,
milk, and other comestibles, and the restrictions to be
placed upon the sale of infected food and the movement of
infected animals.
The President of the Section will be Sir Nigel Kingseote,
K. C.B , Chairman of the Board of Governors of the Royal
Veterinary College ; and the Vice-Presidents will be Prof.
G. T. Brown, C.B., and Dr. E. Klein, F.R.S. They will
be assisted by a Council containing amongst other members
Dr. Edward Ballard, F.R S. ; Dr. Edgar Crookshank; Dr.
George Fleming, C.B,; Mr. J. T. Reeves, representing the
Company of Grocers, which has for a considerable period
made munificent grants in aid of scientific researchij
Professor James McCall, F.R,C.V.S. ; Professor John
McFadyean, M.B., B.Sc., F.R.S.E. •, Shirley F. Murphy,
MR.C.S., Medical Officer of Health for tne County of
London; Dr. J. Burdon Sanderson, F.R.S.; Sir John
Thorold, Bart.; Dr. George Turner ; and Sir Jacob Wilson*
The Secretaries of the Section are Mr. W. Duguid,
FR.C.V,S.; Dr. G. Sims Woodhead, F.R.S.E.; and Mr.
Ernest Clarke, Secretary of the Royal Agricultural Society
of England, to the last-named of whom communications
relating to the Section may for the present be addressed,,
at 12, Hanover-square, London, W. Sir George Harris,
L. C.C., Mr. H. H. Collins, F.R.I.B.A., Fellow of the
Sanitary Institute, and Mr Mark H. Judge, A.R.I.B. A.,
Fellow of the Sanitary Institute, have been elected to-
represent the Vestry of Paddington at the Congress.
IPnWit fraltl stilt fala.
LOCAL GOVERNMENT DEPARTMENT,
REPORTS OF MEDICAL OFFICERS OF HEALTH.
City of DitWin.—Dublin is now estimated to have a*
population exceeding a quarter of a million and a death -
rate as high as 27 9 per 1000 living, and amongst the causes
of death to which Sir Charles Cameron especially adverts
is phthisis, which he says shows no falling off in its ravages
as compared with recent years. It is somewhat curious
that the proportion of deaths in infants under one year
of age in Dublin distinctly exceeds that for England and
Wales and for London. Irish communities in English-
towns often stand out in favourable contrast with the
English in this respect, and the difference has generally
been regarded as being influenced by the practice of feed¬
ing Irish infants on breast milk. But Dublin differs from
such other communities in this respect. The Municipal
Council have adopted the compulsory notification of disease,
and it came into operation in March last. In an account of
the sanitary work carried out, it is stated that much atten¬
tion is being bestowed on the inspection of dwellings and
other buildings ; duinfection is gratuitously carried out, a
laundry has been established for washing and making up
infected linen &;e., a large number of offensive ashpits
have been abolished, and unwholesome tenement houses
have been closed. All this tends to. sanitary improvement,
and we may hope that it will not be long before Dublin
gets finally rid of still more of the factors of a high death-
rate which it possesses, including the deplorable condition'
of its river.
Hull Urban District. —The annual death-rate from all
causes in 1889 was 19-9 per 1000, the zymotic rate 2
per 1000, and the infantile death-rate 191 per lOOO
births registered. There were 157 deaths amongst infants
from diavrheoa, and of this number only 22 had received
their mothers’ milk. Dr. Ballard’s report on this latter
subject is quoted at great length by Dr. Mason, and it is
certain that if the Town Council act upon the practical sug¬
gestions which are the outcome of it, there will be a
diminution of death from more than one cause as th©
result of such action. The hospital for infectious
diseases received 314 patients during the year, and, the
institution having been largely extended and improved,
the Corporation, it is stated, may congratulate themselves
on possessing one of the finest isolation hospitals in th©
kingdom. House-to-house work is steadily in progress,
4149 premises having been inspected during the year, and
this with the result of securing many sanitary improve¬
ments. The night-soil and scavenging department is in
the hands of contractors. This plan is wmost universally a
bad one, and we gather from Dr. Mason’s remarks that the
Coogle
Dir:'
220 Thb Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Jan. 24, 1891.
adoption of this duty by the Corporation themeelves would
be attended with advantage. Other current work is re¬
ferred to in detail, and the report is well illustrated by a
number of useful tables and diagrams. Appended to it is
a disease chart, one of the most useful forms of recording
preventable disease occurrences.
Portsinoutjt Urban District .—The death-rate for this
borough during 1889 was lower than in any year since 1879—
•namely, 18-2 per lOOO living; and Dr. Mumby gives an
.account of some excellent sanitary work done. Thus the
subsidiary sewers are being dealt with at a reasonably rapid
rate, and additions are being made to their means of
ventilation. Scarlet fever was, however, very prevalent
during the year, and the deaths from diphtheria numbered
33, as opposed to 17 in the previous year. In one case Dr.
Mumby ascribes five attacks of diphtheria to the use of
impure water, an experience which is exceptional, water¬
borne diphtheria infection never having been conclusively
proved. In connexion with the diphtheria, it should be noted
that 12 deaths occurred from croup other than those entered
under the name of laryngismus stridulus. There were 309
cases of enteric and continued fever reported, which is
eomewbat less than in the previous year. Their occurrence
led to the discovery and remedy of a number of local sani¬
tary defects. A public abattoir is again urged as necessary.
General improvement is in progress as to dairies, cowsheds,
and milksbops, the old-fashioned, dark, dirty buildings
being replaced by clean, light, well-ventilated, airy, and
properly drained atiuclurea. The public scavenging de¬
partment is unsatisfactory in so far as the disposal of the
town refuse is coucerned, and Dr. Mumby strongly advises
tbat the cause of complaint M’hich results should be met by
the provision of a destructor.
Oldham Urban District. —Dr. James Niven opens his
annual report for 1889 with the important statement tbat
•the unremitting attention devoted to the emission of black
smoke from chimneys gives every prospect of success, and
tbat without loss to mill owners and others. The questions
of insanitary dwellings and the prevention of tubercular
phthisis have also received much attention, and the
action taken in tliese directions is of a sort tbat tends
generally to the improvement of the public health. Fortu¬
nately great changes for the better are taking place, the
general death-rate lias been almost continually falling, and
the remaining causes of disease are discussed in a manner
calculated still further to promote progress in this direction,
Much, indeed, in the report will repay perusal by persons
interested in public health and preventive medicine. The
statistical portion of the report is voluminous, and well
handled; and it is evident from other appended matter
that good results are following the sustained liouse-to-
fcouse inspection that was organised some time back.
VITAL STATISTICS.
HEALTH OP ENGLISH TOWNS.
In twenty-eight of the largest English towns 6077 births
and 6240 deaths were registered during the week ending
Jan. 17th. The annual rate of mortality in these towns,
which had been 28'7 and 28'1 per 1000 in the preced¬
ing two weeks, were 27'3 last week. The rate was
29‘2 in London and 25-8 in the twenty-seven provincial
towns. During last quarter the death-rate in the twenty-
eight towns was 22-1 per 1000, and exceeded by IT the
mean rate in the corresponding periods of the ten years
1880-89. The lowest rates in these towns last week
were 14-9 in Hull, 17'7 in Derby, 19-0 in Nottingham, and
19T in Hrigbton; the highest rates were 29-9 in Bristol,
34'4 in Preston, 35 0 in Manchester, aD<l 3r)'2 in Halifax.
The deaths referred to the principal zymotic diseases, which
had rifen from 472 to 485 in the preceding three weeks,
declined again last week to 404; they included 141 from
measles, 113 from whooping-cough, 54 from scarlet fever.
35 from diphtheria, 32 from “ fever” (principally enteric), 29
from diarrhcca, and not one from small-pox. The lowest
death-rates from these diseases were recorded in Hull, Derby,
Plymouth, and Portsmoulh ; the highest in Oldham, Salford,
Preston, and Halifax. The greatest mortality from measles
occurred in Leeds, Bolton, Oldham, Halifax, and Preston;
from whooping-cough in Preston, Huddersfield, Sunderland,
Leicester, Salford, and Birmingham ; and from “fever” in
Norwich. The mortality from scarlet fever showed no
marked excess in any of tlie twenty eight towns. The
35 deaths from diphtheria included 23 in London, 2
in Birmingham, and 2 in Salford. No death from
small-pox was registered in any of the twenty-eight
towns; one smallpox patient was under treatment
in the Metropolitan Asylum Hospitals, but not one
in the Highgate Small-pox Hospital on Saturday last. The
number of scarlet fever patients in the Metropolitan Asylum
Hospitals and in the London Fever Hospital at the end of
the week was 1469, against numbers declining from 2122
to 1524 on the preceding ten Saturdays; tbe patients
admitted during the week were 112, against 107 and 92
in the previous two weeks. The deaths referred to
diseases of the respiratory organs in London, which bad
increased in tbe preceding seven weeks from 375 to 991,
further rose last week to 1018, and exceeded the corrected
average by 412. The causes of 123, or 2’3 per cent., of the
deaths in the twenty eight towns were not certified either
by a registered meaical practitioner or by a coroner. All
the causes of death were duly certified in Norwich,
Plymouth, Derby, Birkenhead, Preston, and Cardiff. The
largest proportions of uncertified deaths were recorded
in Bristol, Liverpool, Blackburn, and Huddersfield.
HEALTH OF SCOTCH TOWNS.
Tbe annual rate of mortality in tbe eight Scotch towns,
which had increased fioin 20T to 28'8 per 1000 in the pre¬
ceding five weeks, declined again to 27'8 during the week
ending Jan. 17th, and was 0'5 per 1000 below the rate that
prevailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns ranged
from 19-3 in Leith and 20 G in Edinburgh to 35-6 in
Glasgow and 42 8 in Paisley. The 729 deaths in these
eight towns showed a decline of 2G from the number
in tbe preceding week, and included IG which were re¬
ferred to whooping-cough, 12 to measles, 9 to diph¬
theria, 8 to diarrheea, 7 to scarlet fever, 1 to “fever,”
and not one to small-pox. In all, 53 deaths resulted
from these principal zymotic diseases, against 65 and
68 in the preceding two weeks. These 5.3 deaths were
equal to an annual rate of 2T per 1000, which corresponded
with the mean rate last week from the same diseases in
the twenty-eight English towns. The fatal cases of
whooping-cough, which had been 22 and 19 in tbe pre¬
ceding two weeks, further declined last week to 16, of
which 12 occurred in Glasgow. The 12 deaths referred to
measles showed a decline of 3 from tbe number in
the previous week, and included G in Glasgow and
4 in Greenock. The fatal cases of diphtheria, which
bad declined from 9 to 5 in the preceding three weeks,
rose again last week to 9, of which 3 occurred in Glasgow and
2 in Edinburgh. The 7 deaths from scarlet fever were within
one of the number recorded in the previous week, and in¬
cluded 3 in (Jlasgow. Only 1 death resulted from “fever”
in tlie eight towns last week, against 14 and 8 in tbe preced¬
ing two weeks. The deaths referred to diseases of the
respiratory organs in these towns, which had in¬
creased in tbe previous five weeks from 137 to 240,
declined last week to 228, and were slightly below
the number in the corresponding week of last year. The
causes of 66, or more than 9 per cent., of tbe deaths in tbe
eight towns last week were not certified.
HEALTH OF DUPLIN.
The death-rate in Dublin, which had been 40'6 and
3C‘0 per 1000 in the preceding two weeks, rose again to
37T during tbe week ending Jan. 17th. During last
quarter the death-rate in the city w.as 25'4 per 1000,
the rate duiing the same period being 21'3 in London and
18'8 in Edinburgh. Tlie 251 deaths in Dublin showed an
increase of 7 upon the number in tlie preceding week, and
included 4 which were referred to “fever,” 2 to diph¬
theria, 2 to whooping-cough, 1 to diarrhoea, and not one
either to sinall-pox, measles, or scarlet fever. Thus tbe
deaths from the principal zymotic diseases, which had
been 11 and 15 in the previous two weeks, declined
to 9 last week; they wore equal to an annual rate of
r3 per 1000, the rate from the same diseases being
1-8 in London and rS in Edinburgh. The deaths referred
to diilerent forms of “ fever,” which had been 7 and 4 in
the preceding two weeks, were again 4 last week. _ The 2
fatal cases of diphtheria also corresponded * with the
number in the previous week. The deaths from whooping-
Google
The Lancet,]
EECENT DEBATES ON GYNAECOLOGY.
[Jan. 24,1891. 221
cough, which had been 2 and 0 in the preceding two
weeKs, declined again to 2 last week. Tbe 251 deaths
in the city included 42 of infants under one year of age,
and 83 of persons aged upwards of sixty years; the deaths
both of infants and of elderly persons exceeded the numbers
in the preceding week. Five inquest cases and 5 deaths
from violence were registered ; and 88, or more than a
third, of the deaths occurred in public institutions. The
causes of 24, or more than 9 per cent., of the deaths
in the city were not certified.
CDr«sp«nkit«.
" Audi alteram partem."
KECENT DEBATES ON GYNECOLOGY.
To the Editors o/The Lancet.
SiKS,—On page 146 of your issue of to-day, my friend
BProfesaor Sinclair is reported as saying “the Staffordshire
knot ought to become obsolete, for it was not to be trusted.”
Surely there must be some mistake. I have tied the knot
certainly nearly four thousand times, and I know of its eon-
etant use by others with equal success when it is properly
tied. Professor Sinclair must have meant that there were
hands who could not be trusted to tie the S taffordshire knot.
If it is tied according to the instructions I have given its
failure is an absolute impossibility. On the same page
Sir Spencer Wells alluded to a case operated upon here, and
seen by him that day (Jan. 7th) and characterised by him
as a deplorable and disastrous failure. He had seen other
cases as discreditable.” I confess I see nothing discreditable
to the operator in one or two failures out of every hundred of
such cases, for there is not a single surgical operation which
knows no failure. If there is anything discreditable in the
present case the discredit must He at Sir Spencer Wells’ own
door, and not at mine ; for if the original account^ of the case
be read it will be seen that “ During the last seven years
flhe had been the patient of a distinguished gynecological
baronet, who had, however, failed to relieve her. Ultimately
•she had been referred to him (Mr. Tait) and he hadoperated.
She bad double pyo-salpinx of old standing, and it was very
•difficult to say which was tube and winch was ovary. There
were absce.sses in both ovaries, and if be had attempted to
tap them from the vagina, he would have been obliged to tap
several cavities. Instead of doing anytliing of the kind he
opened the abdomen a month since and the patient wa.s now
practically cured. A case like that was worth a dozen
^lypothetical imaginations. There was a woman who had
been an invalid for years who could have been relieved at
any time, who had been under the care of all the well-known
specialists of London, many of whombad declared that there
was nothing the matter.”
If anybody is to blame for the “ deplorable and disastrous
failure . . . discreditable” it is Sir Spencer Wells, who,
■during seven long years, treated this poor woman uselessly by
pessaries &c., instead of employing the only remedy possible,
removal of the diseased organs. The reason, probably, why
Sir Spencer Wells did not do this I am prepared to argue if ,
he cares to prolong the discussion. Hut the most interesting |
.part of the case remains. Sir Spencer Wells saw the case
<m Jan. 7tlj, because of my absence in Italy. On my return
I saw the patient on the 14th. I take the liberty of con¬
tradicting every word Sir Spencer Wells says about the case.
It is not a failure at all. So far an the tubal and ovarian
abscesses are concerned the patient i.s not only “practically
cured,” bat she is absolutely cured, for 1 have the diseased
parts in a bottle. On the LHli I asked the patient to tell
4ne what Sir Spencer Wells’ opinion of her case was, and her
ffeply (taken down at the time) was, “ He said he could make
■neither head nor tail of loy condition.”
I believe to be a perfectly exact statement on the
part of Sir Spencer Welis, for the patient is now sull'ering
irom another condition altogether, which Sir Spencer Wells
cannot have discovered, or 1 am sure he would honestly have
mentioned it and not have fallen into the absurd mistake
wcv..ded as part of his speech at the Obstetrical Society,
ilie whole story of this case is so interesting, and will prove
J Trails. Clyiiii.'eology (or 1888, ji, 467.
BO full of instruction for others as well as Sir Spencer Wells,
that I shall, in due season, give it in full detail.
1 am, Sirs, yours truly,
Birmingham, Jan. l7th, 1801. LAWSON TAIT,
ILEOSTOMY, AND DIGITAL DILATATION OF
SMALL INTESTINE.
To the Editors of The Lancet.
Sirs,—I t must be more than a year ago since I operated
on a case of cancer of tbe cascum in a manner almost
identical with that described by Mr. Bryant. The patient
was a man about forty, and a consultation resulted in
differences of opinion as to the nature of the growth and as
to the advisability of operation. As there were recurrent
attacks of pain with alternations of constipation and
diarrhcca, I proposed to the man that I should, if possible,
excise the diseased part of the bowel if exploration proved
it to be malignant, and that if this were impossible or un¬
hopeful that I should open the small bowel near to the seat
of disease. He having consented, I proceeded much in the
same manner as Mr. Bryant depicts, previously explaining
to the class that if the conditions were unfavourable for
excision I would perform ileostomy (using this word), on
the same principle as one performs sigmoidostomy for rectal
cancer. Mr. Hurry Fenwick kindly assisted, and Mr. Riving-
ton and Mr. Evewere present. Finding the mass immovable
and the lumbar glands involved, removal seemed out of the
question, not only because of fear of shock following a
long operation, hut because of the cerfainty of a speedy
return of tbe disease. The ileum near its termination was
readily picked up, after being traced to tbe csecum, and
stitched to the abdominal wound, and opened a few days
later, there being no obstruction or distension at the
I time. The patient was several weeks in the hospital,
I and there is nothing special to note except that there
I was some excoriation around the lower parts of the
.skin surrounding the wound, and that for some days
he passed motions by the rectum. When he could get
about, he went, I believe, to the infirmary. At the time I
thought the operation was novel, and intended to publish
the case; but priority in this respect is Mr. Bryant’s.
Whether either of us is a pioneer in this operation I leave
it to those who have more time than either he or I possess
to delve into surgical literature to decide. I am content to
reniark that ileostomy is a palliative procedure, comparable
and of equal value to sigmoidostomy, when more radical
proceedings are unjustifiable.
At about the same period Dr. Wilson of Hackney asked
me to see a case of chronic intestinal trouble. The patient,
aged forty-four, had had the benefit of advice from Dr. S.
Fenwick and the late Dr. Habershon. I came to the con¬
clusion that the cause of bis trouble was mechanical,
and probably due to a growth or a stricture, and told
him I could do nothing but operate and act according to
circumstances. With this view Dr. Wilson readily coin¬
cided ; in fact, the operation was his intention in calling a
consultation, and the poor fellow, worn out with suffering,
readily acquiesced. Assisted by Drs. Wilson and J. Oliver,
I opened the abdomen in the mid-line and traced down a
distended piece of bowel to the narrowed portion. I then
opened the distended bowel near to the narrowed part and,
having introduced niy linger, found an obstruction M'hich
the apex of my index could uot enter without force. There
were irregularities about the seat of stricture of the nature
of which 1 could not make sure ; but I determined to dilate
the stricture with my fingers, and this was done by sup¬
porting tbe gut with the lingers of one hand and gradually
insinuating, first the index', then the second finger, applied
to the <lorsum of the former, as far as the second inter-
phalangeal joint, and then rotating them. The opening in
the distended portion of bowel—which was much thickened—
was stitched to the abdominal incision. As soon as the
patient began to vomit, a fast and free gush of intestinal
contents of a light yellowish aspect escaped from tbe bowel.
The patient is alive and well, and has gained I'lesh, though
he has been troubled with excoriation about the wound,
as is common when secretions from the small intestine
come in contact with the skin. For a short time
a small quantity passed per rectum, but since then the
artificial anus has entirely acted. I believe the stricture
was in the ileum or low in the jejunum, and I think the
eurvivul of the patient for so long, added to the fact that
Coogle
222 -Tke Lanobt,]
MALARIA.
[Jan. 24,1891.
he baa gained in weight, point in tbia direction, unices onr
physiology is wrong, and we can live and do well with only
a few feet of small gnt. A few weeks since I heard from
Dr. Wilson that the patient was doing well, and, in reply,
suggested that 1 should excise the stiictured part. To tiris
proposition I have nob had a reply, so I hope and presume
that patient and doctor are satished. It may be said that
I should have excised the strictured part at the time and
have narrowed the hypertrophied and dilated bowel above
the obstruction prior to circular enterorrhapby, and, had
this proceeding succeeded, perhaps it would nave been the
better course; but, after all, an operation, like a surgeon,
must be judged by results, and up to date our patient
is satisfied (being fitted with a suitable obturator), and it
may have been that a more radical proceeding in a debili¬
tated patient would have bad a diilerenb result. It is still
open to me, should occasion demand, to excise and suture.
I do nob know if the small gut has ever been digitally
dilated; but, carefully performed, the proceeding is safe ;
and, though in this cose the opening above the seat of
digital dilatation prevented the latter from having its
full eflfecb, there may occur cases in which the plan may be
more effective. Digital dilatation of the rectum in many
cases of stricture and also in some cases of malignant
disease, as a temporary measure, was advocated by me
seventeen years ago. Loreta’s operation is an extension of
a similar proceeding, much higher up the alimentary canal,
with the important addition of opening the peritoneal
cavity and the stomach. The operation just described is
an application of the same idea about midway between the
points mentioned.—1 am, Sirs, yours faithfully,
Grosvenor-atreet, W., Jan. Otli, 181)1. H. A. IlEEVES.
MALARIA.
To the Editors o/The Lancet.
Sirs,—T he poison of malaria is responsible for so much
loss of health and life amongst Anglo-Indians that a full
discussion of the disease and its treatment rn^ist nece-searily
prove beneficial. Associated with it is the effect of beat,
and these two factors require mutual consideration. The
influence of a hob climate is to increase the action of the
skin, diminish the number of respirations, to lessen the
force of the circulation, to impoverish the blood, and to
induce a torpor of the liver and other organs. Further, the
heat extracts the products of putrefaction, and the humidity
of the air retains them, so that it is impossible to obtain
fresh and pure air. This contamination, together with
the diminbhed number of respirations, interferes with
the proper oxygenation of the blood and the due
elimination of the carbon. In addition the heat produces a
rarefaction of the atmosphere, and thereby diminishes the
amount of oxygen inhaled at each inspiration. The results
are at first functional derangement, and later on organic
disease. The impairment of health is an insidious process,
since between the various organs a sympathetic balance of
functions exists, so that the muggishness in one set is com¬
pensated for by increased activity in the other organs, or
vice versd. As long as the state of equilibrium is main¬
tained the progress of disease is masked and no appre¬
ciable ill effect is noticeable, but as soon as the balance is
disturbed disease more or less severe inevitably develops.
A sound constitution is able to resist the poisonous effect
of malaria (unless the strength of the miasm is intensified);
but, since the heat is slowly undermining the health, the
power of resistance becomes more and more enfeebled.
The aim of preventive treatment is to obviate this con¬
stitutional deterioration, and not any drugs have the
desired effect. Removal from the heat is the only remedy
to enable the various organs to resume their normal
functions, and a change from a hot to a cooler climate, at
least every alternate year, but better still annually, is a
necessity for the preservation of health. But even this
recuperation is insufficient, and at the expiration of five
years a return to Europe for at least twelve months is
imperative. The disregard of this latter injunction
accountB for the frequent deaths of old Anglo-Indians
who on retirement return to Europe. The organs, which
from the prolonged effect of the heat have become
excessively torpid, are suddenly requisitioned to resume
their normal functions, and, enfeebled by comparative
disuse, are unequal to the task of accommodating themselves
to the strain. The medicinal treatment should aim at the
restoration of the functions of the various organs to their
normal condition. In an ordinary case of fever dependent
on the poison of malaria, a liver pill or draught at the onset
is suflicient to restore the health and enable the constitution
to throw off the miasmatic poison, and subsequently on©
drug is as good as another, and no medicine is equally good
treatment. When, however, the liealtli is below par and
the patient is unable to shake off the fever, then quinine
acts as a charm. I protest that the condemnation of the
value of this drug ny Surgeon-General Moore, Brigade-
Surgeon Hunter, and others is too sweeping. The indis¬
criminate administration is indisputably a mistake, but the
judicious use in suitable cases is undoubtedly beneficial. I
quite agree with them, as every observer must do, that
when the system is saturated with malaria, quinine, except
in tonic doses, is not only useless but injurious, because the
fever is secondary to the disorder of the functions of the
various organs, and that in treating the fever the cause of
its presence and severity is overlooked.
’ There are several other points which exercise a marked!
influence on the Anglo-Indian’s health. The early rising,
the over-indulgence in meat, the dislike to water, and the
necessity for exercise, are details of great importance. The
early morning is the coolest, and therefore the most pleasant
time for work or pleasure, but ib is also the most refreshing
and invigorating for sleep : and when it is borne in mind
how frequently the night is spent in restlessness and tossing
about, the importance of a good sleep cannot be over-esti¬
mated. Theamountofmeateatenfarexceedsthephy Biological
requirements, for, since animal and fatty foods are heat-pro¬
ducers, the necessity for this class of food is small. Good
drinking-water plays an important r6U in the preservation of
: health, for the incessant drain of fluid from the system by
perspiration requires a liberal supply of water, and thougti
the result is prickly heat, the benefit to health is ample
compensation. A long drink of cool—not iced—water
before and after exposure to the sun is an almost certain
protection against sunstroke, provided the water is nc-t
diluted with a little spirit. Exercise in strict moderation
is essential to health, as it promotes the action of the liver,
I but exercise amounting to fatigue assuredly excites an
^ attack of fever. Although it is quite impossible for a
European to become acclimatised, nevertheless, with due
regard to these details, a change to a cool climate annually,
and a twelvemonth’s residence in Europe every live yeatsi,
an Englishman can exist in a hot country without the risk
of permanent injury to health.
I am, Sirs, yours faithfully,
G. Sherman Bigg., F.R.C.S. Edin.,
Formerly .Start Surgeon, Allahabad, India..
Victoria-.-itroet, Jan. 10th, 1801.
ANAESTHETICS IN TRACHEOTOMY.
To the Editors o/The Lancet.
Sirs,— In this week’s portion of the very interesting
paper on Stenosis of the Trachea by Mr. Bernard Pitt©
and Mr. William F. Brook they write regarding the advan¬
tage of intubation against tracheotomy that it does not
require any anmsbhetic, “ and this we consider a most im¬
portant point, for often the necessary giving of an anaes¬
thetic in eases of tracheotomy is a direct cause of death, andi
always of much anxiety.” I cannot insist on the value
of intubation, but with regard to giving an anicstlietio for
the operation of tracheotomy I consider it nothing less than
sinful for a surgeon to permit it; and feeling so strongly on
this point, I am glad to note these surgeons’ remanca on
the dangers accompanying anaesthesia, although differing
from them that it is often—ay, over—necessary to aDa?e-
thetise. In the work I wrote in 1876 on tracheotomy it
was recommended that chloroform should not be used,
but that freezing the skin was suflicient for the avoidance
of any acute pain. I had then performed tracheotomy
thirty-eight times, but I have not changed my opinion
since that time, and have now operated over one hundred
times. A surgeon, even if alone, can safely manage
tracheotomy on a child if it is wrapped up in a sheet. The
dangers with an anaesthetic are that the patient, especially
a child, may suffocate whilst it is being given, or that after
the windpipe is opened the unconscious patient is unable to
cough up the blood which is blocking up the air-tubes.
I am. Sits, yours faithfully,
Canterbury, Jan. 16th, 1801. PUGIN ThORNTON.
P.S.—After reading this letter through, I would add that
Co ogle
T«E Lancet,]
“ MIDWIVES’ REGISTRATION BILL.
[Jan. 24,1891, 223
I hope every surgeon may he encouraged to open the wind¬
pipe without an ana*.athetic, believing that sometimes it
may be kind to be cruel; and I further hope that some
future day surgery may insist that every operation of
tracheotomy be performed without ancesthesia.
“ MIDWIVES’ REGISTllATIOH BILL.”
To the Editors o/Thb Lancet.
Sirs, —Dr. Drage seems entirely to forget that so far from
producing a second-rate uneducated cla88{i,e., of mid wives),
we have them already with us, and no one can say we have
much competition with midwivea at present, as he suggeste
will bo the case; and he actually puts the diiliculty with
these uneducated midwives down to “certain members of
our profes'iion” who have “allied themselves with a body
like the Midwives’ Institute instead of taking their own
{ uofession into their confidence, &e.” Does Dr. Drage
enow that midwives are to be found practising all over
S ’" land? What sort of a body does be consider the
wives’ Institute to be? Does he know anything about
it personally ? Does he not know that your journal has
kept the necessity of the legislation about midwives before
the eyes of the whole profession for many years
without exciting their active interest in the matter?
Are we not to try to improve what we cannot at once cure ?
Dr. Drage evidently represents the “Do-nothing” party.
He will allow uneducated midwives to go unchecked ad
injinitwn. Is this not quite an impossibility under our
modern conditions of life? I should like to know what
Dr. Drage considers to be a good case in favour of legis¬
lation. The midwives desire it, the public and leading
journals, lay and medical, are in favour of it. What good
will legislation do ? It will cause all future midwives to
receive a minimum of education, will define their powers,
and control them. If the methods of control suggested
are thought had, if it is difficult to prevent a few mid-
v/ives from stepping over the traces (we ourselves are not
absolutely free from reproach), is not that rather a plea for
legislation than against it. In any_ case difficulty of legis¬
lation can be no excuse for not trying to remedy a crying
evil. Whether Dr. Drage agrees with me or not, he should,
I think, withdraw his insinuations with regard to the Mid¬
wives’ Institute and those medical men who think it their
duty to stand by it-—of whom I am one—till he can do
more than insinuate.—I am. Sirs, faithfully yours,
Queen's-crcscent, N.W., Jan. 13th, 1801. !'• R- HUMPHREYS.
TREATMENT BY SUGGESTION.
To the Editors of The Lancet.
Sirs, —The following cases illustrate the power of sug¬
gestion as a sleep producer and anodyne. All of them were
patients whom I ha<l frequently hypnotised before by the
fixation method and suggestion, and had more or less
relieved from intense pain and other symptoms. But in
all the pain returned after a certain time if the hypnosis
and suggestion were discontinued, and I found it irksome
to have to visit them every day or several times a week.
Not thinking it advisable to instruct the friends of the
atients in the method of producing the hypnotic state,
was forced to have recourse to a plan whicli I thought
would answer the purpose. 1 took to each of them a
small quantity of tincture of valerian in a gieen bottle
labeled “ten' drops in water,” and assured them that
this would produce sleep similar to that I had brought
about, and that on waking their pain would have disappeared
■or, at least, be lulled. 1 then gave them the “ drops,” as
they now term the tincture, and in all four cases the desired
efl'e’et was produced. The patient passed at once into the
hypnotic sleep. 'They were told to take it at night if they
could not sleep, or during the day if the pain was very severe.
On nearly every occasion sleep and* relief from pain have
been brought about. The cases are in detail.
1. C. W-, fifby-three; locomotor ataxy of twelve
years’ duration, with almost continuous and excruciating
lain. Hypnosis and suggestion relieved him greatly. Has
lad more pain since I have ceased to visit him, and if the
pain is very severe “the drops” do not always produce
sleep. As a rulo they do, and he told me the other day
that when ten drops had failed to produce sleep he increased
the dose to fifteen, and slept at once. This patient some¬
times takes six drachms of liq. morph, hydroolor. in the day,
but this does not relieve the pain.
2. Mrs. H-, forty-three; soirrhus of mamma. In this
patient the result never failed to follow, and she would
sleep all night or three or four hours during the day after
taking “ the drops.” If she did not take them she generally
passed sleepless, restless nights, even though she had a
large dose of opium. The pain was also much relieved.
This patient died a few days ago.
3. Mrs. S-, thirty-two; carcinoma uteri. She takes
small doses of morphia, hut if pushed it induces extreme
sickness and nausea. The “drops” generally make her sleep,
and control the pain in a wonderful manner. At night, if
the morphia fails to relieve her, she takes some “drops” and
goes to sleep. She takes a few minutes to go to sleep, and
during that time she says she feels the medicine “creeping
all over her and lulling the pain.”
4 E. D-j twenty-two; hysterical fits with hemiplegia
of long standing and athetosis. In this patient sleep is
produced immediately she shuts her eyes after taking the
medicine—even during an attack; but as she visits me and
is hypnotised by me personally, I am unable to judge what
effect the indirect treatment has on her.
In conclusion, I would say that all these persons are from
the poorer and uneducated class, and are accustomed to be
hypnotised, which probably accounts for the success of this
innocent deception.—I am, Sirs, yours faithfully,
R. Arthur, M,B.,
Wesleyan East-end Med. Miss., Cable-street, B., Jan. 12th,'1891.
MILK IN CONNEXION WITH SEPTIC DISEASE.
To the Editors of Thb Lancet.
Sirs,— Although I believe the law relating to the sale of
milk in Sydney is superior to that in force in this country,
yet, owing to adulteration &c., outbreaks of typhoid fever
due to milk may occasionally occur. In an interesting report
(August, 1890) by Dr. J. Ashburton Thompson, chief
medical inspector, N.S.W., on an outbreak of typhoid at
Waverley and Randwick.two adjoining suburbs of Sydney,
the outbreak was clearly proved to he caused by con¬
taminated milk. Eighty-nine households are stated to
have been attacked. Taking the first case only in each
household, I find the eighty-nine consisted of forty-nine
females and forty males. The average ages are as follows t—
Age. No. attacked.
One to five years. 9
Five to fifteen years .32
Fifteen to thirty years .33
Above thirty years.16
From the above figures the incidence in this epidemic did
nob especially fall on children.
I am, Sirs, yours obediently,
G. L. L. Lawson, M.R.C.P.Edin., D.P.H.
To the Editors of The Lancet.
Sirs,—W ith regard to Mr. Watson Cheyne’a letter on the
above subject in your current issue, the following extract
from a paper by Dr. Bang of Copenhagen, in the Devtsche
ZeitschriftJur Thiermedieinlox3xi\y last, may be of interest:
“ The result of the entire series of experiments thus shows
that heating of milk to 80° C. does not always suffice to kill
the tubercle bacilli (or their spores) in it. On the other
hand, heating up to 85°C. appears to suffice to kill tubercle
bacilli and their spores. Heating up to 100° likewise
renders it innocuou>'.” Observations of my own upon
clotted cream and the bye product, “scald” milk, tend
to corroborate the above.
I am, Sirs, yours faithfully,
Kxmouth.Jnn. 17th, 1891. FeAS. E. PLACE, M.R.C.V.S.
INSURANCES ON THE LIVES OF PHYSICIANS.
To the Editors of Tim Lancet.
Sirs,—I have read with much interest your editorial
comments on my letter in last week’s issue, and will be
glad if you will allow me to correct a slip on the part of
the printer, who has omitted to insert a hyphen mark after
each of the ages in the table. Each group given by me
Din' ad ^ ■ Google
224 The Lancet,]
l^ORTHERN COUNTIES NOTES.
[Jan. 24, 1891.
embraces physicians &c. between twenty and twenty-live
years of age, twenty-five to forty-five, forty-five to sixty-
five, and sixty-five and upwards, these being the groups of
ages used by the officials when extracting the deaths in
various occupations corresponding to the numbers living at
the last census. There need not, therefore, be any of the
tender age of twenty years, although I am told that as a
matter of fact some do practise under the statutable age.
The excess for the group twenty to twenty-five, however,
is small; but it shows that they are more likely to succumb
than those of maturer years. You say I am mistaken in
supposing that my figures will appear startling to your
readers. I may mention, however, that an eminent member
of the medical profession here considered the results
startling; and certainly they are startling to insurance
offices, as I am not aware of any who charge an extra pre¬
mium to physicians, although they do so to those engaged
in various occupations where the mortality is not so high.
I am, Sira, yours faithfully,
Edinburgh, Jan. 19th, 1801. JAMES CHATHAM.
NOETHEEN COUNTIES NOTES.
(From our own Correspondent.)
Neivcastle Boyal Infii'mary.
The report as to the condition of the four patients origi¬
nally subjected to Koch’s treatment at the Infirmary is as
follows. Case 1, lupus, still continues to improve; the skin
in the situation of the patches, especially on the arm, is
almost normal in appearance. Case 2, phthisis, continues to
improve slowly. Case .3, diseased elbow-joint, appears to be
stationary. Case 4, diseased cervical glands, seems to be
still improving. The most important change for the better
is observed in the case of lupus. St. Luke’s Chapel, as the
beautiful little chapel attached to the infirmary is named,
was reopened yesterday by the Bishop of Newcastle. It has
been undergoing extensive decorative changes, and is well
worth seeing by all visitors to the infirmary.
2'he late Nitric Acid Disaster in Mosley-street, Newcastle.
It will he remembered that I mentioned in these notes
the accident at Messrs. Mawson and Swan’s, chemists, of
this city, on Sept. 23rd last, through the breakage of a
carboy of nitric acid ; nitrous acid fumes were evolved, and
an alarm of fire was raised. Several firemen, although
warned of the danger by the manager, rushed in, and three
of them suffered.so much from the corrosive fumes that they
died in consequence at.the time, or soon afterwards. I have
now to record another or the fourth death as an indirect
consequence of the accident. A young fireman about
twenty-seven years of age had so ^ar recovered that he
had resumed active duty, but about a week ago he
caught cold which developed into pneumonia, and he has
died after a very short illness. Even in the cases which
have recovered the patients appear to have passed through
an insidious form of pneumonia.
The New Home for Incurahles in Newcastle.
At a special meeting of the Schools and Charities Com¬
mittee held a few days ago at the City Hall tJie plans for
the new hospital for incurables to be erected in Newcastle
were passed and approved, and ib was decided to ask for
tenders at once. The new hospital will give accommodation
for sixty-eight beds, and, aa mentioned in these columns on
a former occasion, it will be built and supported by the
accumulajtion of funds from- an ancient charity, the Mary
Magdalene, originally founded for the benefit of Ifjjers ; but
the property haa so vastly improved in value, and is so likely
to still increase, that the hospital seemed. ,bo all to be the
best direction in which to employ the funds.
Glendale Dispensary, Wooler.
The sixty-seventh annual meeting of the Glendale Dis-
E ensary, Wooler, has been held, and, as wa.s stated, it
efriends families and individuals at their greateiit time of
need, and very often enables them to bide over an illness
without applying to the guardians for help or becoming
chargeable to the rates. Altogether in this scattered
mountain district ICO cases were relieved in 1890.
Sunderland.
The secretary of the Sunderland Eye Infirmary has re¬
ceived a cheque from Mr. Backhouse for £300, and from Mr.
S. P. Austin one for £50, towards the proposed new build¬
ing. It is also stated that as a result of the Sunderland
Infirmary ball £160 has been realised.
Proposed Lunatic Asyhim for Middlesbrough.
A deputation appointed by the Middlesbrough County
Council have been to York to meet the committee of the
Clifton Lunatic Asylum on the subject of founding a similar
institution in the neighbourhood of Middlesbrough, and the
deputation Wve resolved to recommend to the County
Council at a special meeting the erection of an asylum on
the Clifton model. At present “ pink eye ” is rife amongst
horses at Middlesbrough.
NewcaBtlo-upon-Tyne, Jan. SOtli.
SCOTLAND.
(From our own Correspondent.)
The Board of Supervision and Medical Officers die.
The Board of Supervision has sent a most important
communication to county councils dealing with the appoint¬
ment of medical officers and sanitary inspectors. It begins
by intimating that it has been in communication with the>
Secretary for Scotland as to the conditions under which the
grant of £15,000 from the local taxation account towards
the cost of these officers should bo distributed, and the
general principles which are tw regulate the distribution are
as follows. They consider it their duty to see that the pro¬
visions of the Act are carried out in the spirit intended by
its *framers as regards sanitary administration, and that-
the distinctive feature of the scheme is the appoint¬
ment, with an adequate salary, of a duly qualified
county medical officer and a duly qualified county sani¬
tary inspector; and if the counties are too large or-
too populous the appointment of additional officers, or
the other smaller counties may combine and elect-
joint officers. The circular states very explicitly that it
was the obvious intention of the framers of the Act that
the persons to be appointed to these important and respon¬
sible posts should be of high standing in tbeir respective
professions. Scientific attainment and considerable prac¬
tical experience are among the qualifications required, and
the services of persons so qualified cannot be obtained
unless adequate salaries are attached to the offices, and
persons should be selected who are able to devote their
whole time to the discharge of their duties ; that is, jnedicaR
officers should not be permitted to engage in private
practice. The district committees are advised to appoint
the county officers the chief officers of their districts,
and the amount of assistance within each distriet-
which the chief medical officer may require must
depend upon the circumstances of each district; and
the Board expresses its readiness to agree to any proposal
which primd facie appears to be reasonable, and in the
public interest, and which is approved by the chief medicali
officer. Similar arrangements are suggested with regard to
the chief sanitary inspector. It is also pointed out that
I these officers can be removed from office only with th©
sanction of the Board of Supervision, and that they cannot
be appointed for a limited period, or during the pleasure ol!
the County Council. As if anxious to make their meaning,
abundantly clear it is specifically stated at the end of the
circular that they cannot recommend a scheme by wliicb
the medical olfieer of a county, or the chief medical oificer
of a district, is permitted to engage in private practice; or
that the medical officer of a district sliould thereafter be-
appointed medical olfieer of the county for that part of th©
county which is embraced in bis district. Similar suggestione-
are made with regard to the sanitary inspectors. Th©
wisdom of these suggestions will be fully recognised by the
profession, and are in accordance with the resolutions passed
by various medical corporations and societies. It is only
to be regretted that the appearance of this coinmunicatioQ
is so late, coming as it -does after most of the appointments
have been made. Its earlier appearance, backed by the
knowledge that local grants would depend upon appoint¬
ments and arrangements being satisfactory to the Boanli
of Supervision, might have smoothed down a number of
difficulties.
Edinburgh Health Statistics for December,
The total number of deaths in Edinburgh during:
December was 479, making the death-rate 21*19 per 1000,
Google
Die
The Lancet,
IRELAND.—PARIS.
[Jan. 24, 1891. 225
which is rather above the average of the preceding five
yeara. As regards age, 27'13 per cent, were under five
;years and 30‘68 per cent, above sixty years. The deaths
from diseases of the chest were 41 -54 per cent, of the whole,
while zymotic diseases caused 8'34 per cent.
Ihalth of Edinburgh.
The mortality last week was 104, n^aking the death-rate
20 per 1000. Diseases of the chest accounted for 39 deaths,
and zymotic diseases for 6, of which 2 were due to diph¬
theria, 1 to scarlatina, 1 to measles, and 2 to whooping-
oough. The intimations were—typhoid fever 23, diphttieria
3, scarlatina 25, and measles 8.
Koch's Liquid at the Edinburgh Eoyal Infirmary.
A quantity of liquid has been received by the authorities
at the infirmary, and it has been left to the medical and
surgical staff to determine its distribution.
Meeting of Contributors to the Edinburgh Royal Infirmary.
On Monday an adjourned meeting of the contributors to
the Royal Infirmary was held. The report, of which an
abstract has already appeared here, was submibMd, and special
attention was also directed to the increase in the number of
out-patients; and it was proposed that a record of these
cases and the circumstances of the patients be made for a
year. The necessity for increased hospital accommodation
was also strongly represented, and it was suggested to the
managers that they should open negotiations with the
directors of the Sick Children’s Hospital with a view to its
possible acquisition for purposes of extension.
Edinburgh, Jan. 20th^_-
IRELAND.
(From our own Correspondent.)
Ligature of both Lingual Arteries.
On Tuesday, the 20th inst., I had an opportunity of
peeing Mr. H. Gray Croly, president of the Royal College
of Surgeons, at the City of Dublin Hospital, tie both
lingual arteries as a preliminary to excision of the tongue
tfor cancer. The patient, a man aged fifty, about six months
since noticed a growth on the left side of the tongue, due to
some irritation of an adjoining tooth, and on being admitted
to hospital the base of tne tongue was found to be involved
and some of the glands under the jaw. The left lingual was
first tied, an incision being made from the angle of the jaw
to thq upper part of the hyoglossus, and then to the sym¬
physis ; the artery was very deeply situated, and required a
tedious dissection. The submaxillary gland was removed,
also a gland under the chin. The right lingual artery was
then ligatured, the time occupied from the commencement
of the incision utitil the ligature was placed on the vessel
'being twelve minutes. By this procedure the danger of
secondary hceinorrhage in cases of excision of the tongue is
•obviated, and by giving an opportunity for the removal of
any contaminated glands a better chance is afforded the
patient of esc^ing recurrence of the morbid growth. Next
Tuesday Mr. Croly will excise the tongue.
Koch's Treatment of Tubermlosis.
Koch’s treatment is in full swing in the various hospitals
an Dublin, and cures have been reported as having occurred.
Some are very sanguine, but time must elapse before any
definite and decided opinion can be given as to the positive
benefits to be derived from using the lluid. Professor
Virchow’s assertion that injections with Koch’s fluid may in¬
fect healthy portions with tubercular disease is a very serious
statement, and hospital physicians ought to be extremely
careful in the cases selected for the treatment, and not
unduly sanguine as to the ultimate good eftects of the pro¬
posed remedy.
National Eye and Ear Infirmary.
The Committee of Management have issued an appeal
ifor funds to enlarge this hospital and render it available to
accommodate sixty intern patients at an estimated cost of
£7000. The long-talkod-ot amalgamation between the two
ophthalmic hospitals in Dublin bas not yet been carried
out, although all concerned are anxious to have a single
institution. It is stated that there is some legal difliculty
involved, a solution for which has not yet been found.
Death of Samvel Bigger, F.lt.C.S.I.
Last year this gentleman was attacked with paralysis.
and lingered ou until Tuesday, the 20th inst, when he
succumbed at his residence in Harcourb-street, at tbe
advanced of eighty-two. He bad been surgeon to
Simpson’s Hospital, but resigned shortly after his illness
commenced. He was a graduate in medicine of the Uni¬
versity of Dublin, and obtained the Fellowship of the
Royal College of Surgeons in 1844. He was a Kind and
benevolent man, and attended many indigent sufferers with¬
out fee or reward.
Dtiblin Hospital Sunday Fund.
The total sum collected in 1890 for the Dublin hospitals
amounted to £4188 2s. 11c?., being an increase of £32 Yls.ld.,
as compared with the previous year. In this is included a
sum of £60 105. \d., the proceeds of the annual football
match.
South Dublin Union.
By tbe death of Dr. J. A. Byrne a vacancy has arisen for
a medical officer to the Grp,nd Canal-street Dispensary,
which will be filled'up on the 4bb prox. Tbe emoluments
of the post are £125 a year, and the usual vaccination and
other fees.
Numerous cases of mumps—an epidemic on a .omall
scale—have occurred during the past few weeks iii Dublin.
The Mitchelatown guardians nave applied to the Local
Government Board for a provisional order to sanction the
expenditure of £5000 for supplying the town with water.
Mrs. Mary Jordan died this week at her residence in
Warrenpoint, at tbe advanced age of 101 years.
Jan. 20tli.
PARIS.
(From our own Correspondents.)
Koch's Treatment at the Hdpital St. Louis.
At this hospital the excellent plan has been adopted of
constituting the medical and surgical staff into a committee,
whose duty it will be to famish a concise report on tbe
results obtained on their patients by tbe application of
Koch’s method. In anticipation of the expression of their
views by each individual member of tbe committee, pro¬
mised for the next meeting of the Societo de Dermatologic
et de Syphilographie, M. Vidal, one of their number, com¬
municated at last Thursday’s stance a preliminary expost of
their collective opinion. It appears that thirty-two patients
have been inoculated since Nov. SOtli, 1890, each receiving an
averageof fromfour to six injections, with an interval between
each of from four to eight days. The committee find that with
the shorter interval (two or three days) advocated at Berlin
tbe subjects remain more feeble and become anremic; and
that, moreover, both the local reaction and the specific action
on tuberculous I elements become less and less pronounced
at each inoculation. The three points to which M. Vidal
desired to call particular attention were(l) the irregularity of
the general reaction; (2)its dangers; and(3) the precautions
indicated in order to obviate, or at least diminish, these
dangers. The general reaction has not been found to pre¬
sent the regularfeatures ascribed to it by Berlin physicians,
nor is the local manifestation of the activity of the lymph
always proportionate to the general reaction—this remark
applying more particularly to cases of lupus. In several
instances general reaction had been intense after as small
a dose as half a milligramme ; and this intensity bad been
observed in them after repeated inoculations. In one
patient an injection of half a milligramme, practised after
an interval of twelve days, determined a greater reaction
than that induced by two preceding injections of double tbe
strength. The duration of febrile reaction is variable. In
most coses the temperature becomes normal within twenty-
four hours ; but it is by no means uncommon for it to reascend
in the afternoon of the next day, and for this recrudescence
to exceed in violence the primitive fever. A repetition of
this vesperal ascent has been noted in a few cases
on the third and even fourtli day. Koch’s liquid
acts as a powerful pyrotegenous agent, exciting eon-
estinn of the whole system, but so unequally that it is
illiculb to predict its intensity, and which organ is destined
to bear the brunt of the attack. This capriciousness has
even been noticed at different inoculations in tbe same
patient. Viscera previously diseased (the disease not neces¬
sarily being of a tuberculous nature) are particularly
prone to this congestion, and even organs apparently
226 The Lancet,]
PAKIS.-llEBLIN.
[Jan. 24, 1891.
a aite healthy may become intensely congested. During
ae first four days the bronchi and the lungs at their
bases are frequently congested. Symptoms of myocarditis
and endocarditis have several times been recorded, as also
swelling of the spleen, albuminuria, and (in three cases)
hmmaturia, lasting three or four days. In two women
affected with lupus the injections gave rise to a tumefaction
(lasting six ana five days respectively) resembling that of
erysipelas, which invaded the cheek, forehead, aod scalp.
These patients bad already had facial erysipelas. Examina¬
tion of the blood failed to reveal the streptococcus, nor did
an attempt at cultivation succeed. The precautions taken
at St. Louis consist in beginning with a half-milligramme,
increasing the dose at each succeeding injection by a half¬
milligramme until the temperature reaches 102'2°F. The
quantity producing this effect is then talcen as the maximum
permissible dose for that patient. As seen above, an
interval of from four to eignt days is allowed to elapse
b^ore an inoculation is repeated.
The New Milita/ry Law and Students of Medicine.
One of the clauses of the military law which has recently
come into force ordains that all medical students shall at
twenty-one years of age serve one year under the Hag. It is
also enacted that if, at twenty-six years of age, the student
^all have failed to attain to tiie rank of doctor of medicine
or interne des hCpitauic, he shall serve during a further
period of two years. Now, as the curriculum is not
generally commenced before the age of twenty, it follows
that the aspirant’s studies are interrupted by Bellona just
as he has got — to employ a current expression—“into
Idle swim.” The Temjjs, in a temperate article on the sub¬
ject, points out that, as a consequence of this measure,
the future French medico will, in many cases, he
debarred from competing at all for the intemat, and
that the foreign student, unhandicapped by such pre¬
occupations, and enjoying, conseq^uently, more leisure to
prepare for this really difficult ordeal, will easily oust his
French rival. Moreover, the student, returning to his
studies at twenty-two, will, in his anxiety to escape a
further term of service, endeavour to scramble through his
examinations anyhow, thus laying the foundation for the
creation of an inferior class of practitioners. Inspired by
the foregoing considerations, the General Council of the
Fhculties and Schools of Paris have, at the instance of Pro¬
fessor Brouardel, the Dean of the Faculty of Medicine, sub¬
mitted to, the Minister of the Interior the following
modifications in the obnoxious regulation: (1) to extend
the limit’of age (from twenty-six to twenty-seven or
twenty-eight) at which candidates may compete for the
intemat; (2) to accord to students of all the
faculties the privilege now enjoyed by those of the
Nicole Normale of fulfilling their duties as citizen soldiers
b^ore the commencement of their studies, or of obtaining
a respite, so as to join their regiments at the close of
their studies. Professor Brouardel further asks what, in
the name of common sense, is the use of instructing
medical students in the managemqnt of the rifle—a weapon
he will never be called upon to wield—instead of initiating
him into tlie principles and practice of military medicine
and surgery. Seeing that the chances are extremely
problematical of obtaining, out of the 11,500 practitioners
of France, the 7500 military doctors under fifty years of age
requisite in the event of mobilisation, tlie question put by
the Dean admits of only one answer.
Prophylaxis of Smallpox, Enteric Fever, and Diphtheria.
In conformity with the recommendations of M. Dujardin-
Beaumetz, tho Board of Health of the Department of the
Seine has submitted to the Prefect of Police a code of
instructions calculated to prevent the spread of the above
diseases. It is a reflection on the sanitary instincts of
our gifted neighbours that such regulations should not
already have the force of law. The principal clause of the
proposed regulations provides for compulsory notification,
presumablyl>y the friends of the patient. The authwities
will undertake the isolation of the cose or his removal in a
special vehicle to a fever hospital, as also the disinfection
of the room. Instruction as to efficient isolation is given,
and the employment of solutions of sulphate of copper at
1’25 and 5 per cent, recommended, the weaker solution for
washing the hands of the attendants and soaking the
nnsoiled linen, and the stronger for disinfecting the
soiled linen and the excreta. Commissaries of police
provide any applicant with packets of cupric sulphate,
together with instructions as to the employment of that
substance. Information as to the mode of propagation of
the disease in question is contained in the code of
instructions. The ca.so terminated, the duty of disinfecting
the room and its contents (fumigation, removal to public
disinfecting ovens) will devolve upon the local eommiaaary
of police, a medical man being specially delegated to certify
to the proper carrying out of these measures. To combat
the ravages of scarlatina, measles, and whooping-cough tho
board had not deemed ‘ it necessary to apply for special
powers, contenting themselves with issumg a table of
information to the public as to the best means of limiting
their spread. At a subsequent meeting M. Ollivier strongly
urged the including of scarlatina in the category of danger¬
ous zymotic diseases (variola, typhoid fever, and diphtheria),,
and his arguments finally prevailed.
The Number of Students Studying in Paris.
With its five faculties and the High School of Pharmacy,
the University of France counts inj Paris] more alumni than
any other in the world. In 1890 there were no less than
10,174 students on the rolls, these figures including 986-
foreigners, 759 of whom are studying medicine. In 1889
the number of students registered was 10,376. These
figures do not include men pursuing their studies at the
(/oilbge de France, the Museum d’Histoire Naturelle, the
Ecole de Chartes, and kindred special establishments.
Smallpox at Marseilles.
The following statistics of the mortality from small-pox
at Marseilles, given by Professor Proust at the last meeting,
of the Comit6 Consultatif ^d’Hygiene de France, are not
calculated to allay the fears of the public regarding the
insanitary conditions of that town:—
Isl quarter. 2ii(l quartor. ;!i'd quarter, itli quarter. Total.
1889.. . .39 ... 36 ... 46 ... 75 ... 196
1890.. . 121 ... 125 ... 135 ... 168 ... 549
Lorain is responsible for this trite reflection: “Dan©
20 ans, on jugera du degve de civilisation d’une ville au.
nombre de ces d^chs par variole.” There is evidently
‘ ‘ something rotten in the state of ”—Marseilles.
Paris, .Tan. 2lJtli. _
BERLIN.
(From our own CoiiREfePONOUNT.)
Koch’s Remedy for Tuberculosis,
I HAVi-: already more than once informed the readers
of The Lancet of the wish pretty generally entertained
among medical meu here that expression should be given
in the Chamber of Physicians and Surgeons to the well-
founded complaints as to the manner in which the medica¬
ment has been distributed. At the last meeting of that
body ProfosBor Mendel stated that the great enthusiasm
with which Koch’s discovery was greeted had been
followed by deep dissatisfaction among medical men. He
pointed out that the statements about the dangerous
character of the remedy and the necessity of clinical'
observation were by no moans tenable, as the use of it had
been permitted to some private doctors on terms which
were far from securing clinical observation. By thi&
kind of monopoly a state of things had been brought
about for which it was impossible to find a parlia¬
mentary expression. It was Incumbent on the Chamber
of Physicians and Surgeons, which had to guard the-
interests and the prestige of the medical profession,
to protest against this mode of procedure. No resolu¬
tion was taken on this matter. The supply of Koch’s
fluid being insufficient for the general demano, it was, how¬
ever, evidently the mere dictate of common sense and
liumanity to take care that it got into the most competent-
hands. If, after all the care that has been taken to secure-
this result, one hears that, despite the emphatic warnings
of Koch and other great authorities, advanced cases of
phthisis have been treated with the fluid, and i)eople sent
to their graves in conseq uence months sooner than necessary,,
what would the result have been if the medicament hM
been accessible to all medical men? Bene faccre et male
audire regivm est. It is probable that Koch’s wise resolu¬
tion has saved many patients from premature death and
many of bis professional brethren from ruin in the shape of
an action for culpable homicide. Professor Koch will leave
Berlin in a few days for several weeks’ holiday. He will go-
ogle
The Lakoet,]
VIENNA.-NEW ZEALAND.
[Jan. 24, 1891. 227
to Egypt, 'which he visited in 18S3 as leader of the German
cholera expedition. He will return in March to undertake
the management of the institute for infectious diseases,
the building of which, as I convinced myself yesterday hy
ocular inspection, is progressing rapidly. An eminent
Australian physiolomst suggested to me yesterday that
the true inference from Virchow’s observations may be,
not that the bacilli wander from their burned-out homes
to new ones in healthy tissue, but that Koch’s fluid renders
them more easily visible to the microscopisD.
Berlin, Jan. 17th. _
VIENNA.
(From our own Correspondent.)
Thu Chemistry of the Tubercle Bacillus.
At the clinic of Professor Nothnagel a very interesting
investigation on the chemical composition of the tubercle
bacillus has been carried out by Dr. Hammerschlag, who
had commenced bis studies on the bacillus at Professor
Nencki’s chemical laboratory at Berne. For the chemi¬
cal examination of the bacillus, glycerine-bouillon and
lycerine peptone agar cultures were used. The fresh
acteria had a rose-red colour, and a smell resembling
the odour of fruit. Two analyses of two different
culture series were made. The cultures were 0'2-3
months old, and 7‘5 and 2'2 grammes moist bacteria
were obtained for the analyses. They contained between
88 "7 and 83 •! per cent, water, between 28'2 and 26'2 per
cent, substances soluble in alcohol and ether—i.e., leci¬
thin, fats, and a poisonous substance which injected
eubcutaneously into guinea-pigs produced clonic spasms of
the muscles, acceleration of pulse and respiration, and
minally general convulsions and the death of the animal
from twelve to fifty-one hours after the injection. The
residue which remained after the extraction with ether and
alcohol contained an albuminoid body and cellulose^
Therefore the tubercle bacilli seem to dififer from other
bacteria by the high percentage of substances soluble in
alcohol and ether, as they contain between 26 and 28 per cent.,
while bacterium termo contains only 7’3, Friedliinder’s
diplococcus only 17, the bacillus anthracis only 7 8 per
cent. Concerning the specific reaction of the tubercle
bacilli, and their resistance to acids, it was found that
this property must bo due to a specific morphological
distribution of the albumins and the cellulose in the body
of the bacillus, the presence of both substances being neces-
aary for the production of the characteristic staining. It
haa been found that the presence of carbohydrates and
glycerine is necessary for the growth of the bacilli, and that
^Wmins alone are not 8u:fficieDt as nourishing media for
the tubercle bacillus, which differs thereby from the other
bacteria. By experiments on rabbits it was proved that a
oisonouB albuminoid body is formed in the cultures by the
acilli, which (the dose used varied between 0 2 and
0*4 gramme) produced, a few hours after the injection, a
rise of temperature amounting to 1° or 2° C., lastingfor one
or two days, without any other effect, even after repeated
injections. The glycerine bouillon cultures lost their
virulence on being kept for eight months at a tempera¬
ture of 39” C., but they retained their vital activity.
In experiments made on animals with such cultures of eignt
months’standing only negative results were observed with
regard to the production of immunity in animals by such
cultures, and Hammerschlag, Falk, and Charrin have failed
to produce a protective inoculation.
The Composition of Koch's Fluid.
As has been reported in a previous letter to TheLanckt,
an Austrian professor has made experiments on animals
with Koch’s liquid and with a liquid prepared hy himself.
Now these experiments have been brought to an end, and
Professor Hueppe and Dr. Scholl of Prague have made a
communication on their experiments to the Berliner
Klinische Wochenschrift nearly at the same time as Koch’s
article appeared. They found Koch’s liquid to contain,
besides albuminoid bodies, glycerine in large quantity, and
themselves made experiments with extracts made from
tubercle bacilli cultures with peptone (3-8 per cent.),
glycerine (5 per cent.), common salt {0‘5 per cent.}, and
extract of beef (O'l per cent.), on tuberculous animals,
which gave positive results.
Viouiia, Jan. 2Cth.
NEW ZEALAND.
(From our own Correspondent.)
Increase of Cancer.
Dr. Gordon Macdonald of Dunedin has recently
published in the New Zealand Medical Journal information
regarding the steady and alarming increase of cancer in the
colony. In 1879 the estimated population was 507,324; in
1889, 646,830. In 1879 deaths from cancer to the number
of 68 were registered at the ofilce of the Registrar-General,
while in 1889 the number amounted to 136, or as Dr. Mac¬
donald puts it, “ the mortality from cancer exactly doubled
itself in ten years, although the population had only in¬
creased about a fifth.” Sir Spencer Wells, in bis Morton
lecture in 1888 on “Cancer and Cancerous Diseases,” makes
special reference to the same steady increase of the disease
in Great Britain and Ireland. He states that he has found
the mortality from cancerous diseases to have almost
doubled itself during the past ten years. In a table com¬
piled by Dr. Copland, house surgeon to the Dunedin
Hospital, it seems that at this hospital during the same
ten years 233 cases of cancer occurred. In males the
seat of the disease was in the following order—(1) lips,
(2) stomach, (3) liver. In females the commonest seat was
in the uterus, and next to that the breast. During the ten
years 42 cases occurred in the lips, almost entirely m males,
40 in the uterus, 33 in the breast, 33 in the stomach (all but
three in the male), 21 in the liver (all but four in the male),
9 in the tongue (all in the male). Two cases are recorded
as occurring in the brain, and one in the spleen. In the
males epithelioma predominated, and in the females
carcinoma and scirrhus.
Report of the Royal Commission on the Dv/nedin Hospital
InquiTif.
Sir James Hector, M.D., and Mr. E. H. Carew, II,M.,
the commissioners appointed by his Excellency Lord
Onslow to hold an inquiry touching complaints made con¬
cerning the Dunedin Hospital’s insanitary condition, have
submitted their report. Both the hospital trustees and
Dr. Batchelor were represented hy able counsel, and a
amount of medical evidence was brought before the court.
The report begins by stating that the commissioners -were
empowered to hold an inquiry touching complaints which
have been made that the hospital known as the Dunedin
Hospital, or certain parts thereof, are in an insanitary con¬
dition, and dangerous to the health of the inmates, and par¬
ticularly the allegation that certain cases of blood-poisoning
havearisenfromthegeneralconditionof certain wards. Tbere-
port itself is voluminous. In brief it amounts to this, that the
inquiry itself, as a trial between Dr. Batchelor os a presumed
plaintiff (for Dr. Batchelor made these charges on his own
authority in a letter written to the trustees, and dated
July 22nd ult.) and the hospital trustees as defendants, ended
unsatisfactorily, for both sides are commended in the course
of the report. ’I'he report, nevertheless, is an able one. The
Commissioners spared do pains in thoroughly investigating
the matter, and offered many valuable suggestions. The
only unfortunate part connected with the whole affair is
that the result is not considered satisfactory by either side.
Indeed, at a meeting of the hospital trustees, held at
Dunedin on Nov. lObhnlt., the report was read and dis¬
cussed. All the members who spoke condemned the report
of the Commissioners as unsatisfactory and valueless. As
a trial between Dr. Batchelor and the hospital trustees this
expression of opinion may be true as regards its unsatisfac¬
tory termination; but that the inquiry was valueless I
venture to deny. As a matter of fact, I quite agree with
Sir James Hector’s closing speech at the inquiry itself,
when he stated “that the result of this inquiry will be to
show to the public that a mass of evidence bearing on the
questions of uospital management and construction has been
accumulated that will form a State paper of very high value
for thefutureguidance of thoseconcernedin themanagement
and care of hospitals in all parts of the colony ; and I think
that the manner in -which the evidence has been brought
forward, the carefulness with which all sources of informa¬
tion have been drawn on, and the impartial way that the
evidence has been put in, reflect the very greatest credit on
both sides.
Wholesale Poisoning at Wanganui.
Since I last wrote the medical men practising at Wan-
D'
228 The Lancet,]
OBITUAKY.
[Jan. 24, 1891.
gaDui have been busy attending a considerable number of
families, the members of which exhibited all at the same
time symptoms of poisoning by an irritant. Several cases
were of an alarming nature, but happily no deaths occurred.
On investigating the matter it seems that all the patients
had eaten on that particular day “ tapioca.” Samples of the
tapioca were forwarded to Wellington for analytical pur¬
poses, and the Government analyst reported that the
tapioca was impregnated with arsenic. It appears that
the tapioca was forwarded to Wanganui from a wholesale
firm at Dunedin, and that this special consignment was
received by two separate grocers, who, unknowingly, of
course, purveyed the poisoned food to their customers.
The matter is being further inquired into.
Bequest.
The late Mr. Thomas Reid has left the sum of £.1000 to
the Wanganui Hospital. Mr. Reid came to New Zealand
in the very early days, and gradually accumulated a fortune.
Curiously enough, bis first billet in the colony was that of
custodian to the hospital to which he left this handsome
bequest. __
(Dbitiiiirtt.
SURGEONlJENERAL T. GRAHAM BALFOUR,
M.D., F.R.S.
It is with sincere regret that we have to record the death
on the 17th inst,, at Coombe Lodge, Wimbledon Park, of
Surgeon-General Dr. Thomas Graham Balfour, F,R.S,,
F.R.C.P., Honorary Physician to the Queen. If it did not
fall to the lot of the late Surgeon-General Balfour to dis¬
charge great medical and administrative services in the field,
he certainly rendered very exceptional and distinguished
scientific services to the army and nation ; and his name was
probably better known and more highly regarded in scientific
and professional circles than that of almost any other
member of the Army Medical Department. Dr. T. Graham
Balfour’s busy and, we may say, eventful life embraced
many points of considerable interest. He sprang from that
family of Balfoura which traced its descent from a
minister of Sb. Giles, Edinburgh, in the end of the
sixteenth century, and was born on March 18bh, 181,3.
He waj educated first at the High School, then at
the newly established academy, and finally at the Univer¬
sity of Edinburgh, where he graduated as Doctor of Medi¬
cine in 1834. He consequently rememberod Edinburgh
when Sir Walter Scott was still to be seen in its streets,
in the days of 'Jeffrey and Cockburn, and when Alison,
Chalmers, Wilson, and Christison were the leading teachers
at the University, Tait, the late Archbishop of Canter¬
bury, though a little senior to him, was one of his con¬
temporaries, and with Dr. John Brown—of “Rab and his
Friends” celebrity—he formed a life-long friendship.
Dr. Balfour entered the army in 183(3 and was gazetted to
the staff in order to assist his friend Dr. Henry Marshall
and Lieutenant (afterwards Sir Alexander) Tulloch in col¬
lating a vast number of medical and statistical returns
which had been accumulating for twenty years at the head-
c^uarters of the army. These formed the basis of the first
five volumes of the “ Statistics of the British Army,” pro¬
duced by Mr. Tulloch and Dr. Balfour, Dr. Marshall
having soon retired from ill-health. Dr. Balfour was
gazetted Assistant-Surgeon to the Grenadier Guards in
1840, and in 1848 was nrometed to be Surgeon of the Duke
of York’s Asylum, Chelsea. In 1853 Dr. Balfour and
Lieutenant-Colonel Tulloch published another volume of
statistics.
In 1857 Dr. Balfour was appointed Secretary to Lord
Herbert’s Commission following the Crimean War, the
report of which brought about a complete reorganisation of
the Army Medical Department. In 1855, during tlie same
war, Dr. Balfour showed no little courage and force of
character by appearing daily to aid and advise his friend
Colonel Tulloch in a struggle against vested interests and
Horse Guards’ influences which were brought to boar against
an official report by Sir John McNeill and Colonel Tulloch,
with the result, in the end, that the unanimous vote of the
House of Commons successfully vindicated and praised their
conduct. In 1859, when the Army Medical Department
was reconstituted, and consisted of a Dlrector-GeneraL
aided by three branches—statistical, sanitary, and medicalj—
Dr. Balfour became the head of the former branch, wliich
he organised. He originated those army statistical reports
which, for their accuracy and comprehensiveness, have not
been surpassed, and for fourteen years compiled the Blue-
books relating to the health of the British array all
over the world. In 1866 be was nominated by Lord
de Grey to represent the War Office on Mr. Skey’s
Committee. In 18C7 be represented the War Office at
the International Statistical Congress at Florence. In
1873, on his promotion as Surgeon-General, he occupied the
post of principal medical officer at Netley, and subsequently
went to Gibraltar. He proved an excellent administrator,
and was deservedly very popular at both stations, and there
is no doubt he would have made a capital Director-General.
In 1876 he retired after forty years’ service, but be was far
too energetic and able a man to remain idle. In 1859 he
was elected a Fellow of the Royal Society, and in 1860 a
Fellow of the Royal College of Physicians. He was a
foreign corresponding member of the Acaddmie Royal de
M6decine de Belgique, was tliree times Vice-President of
the Statistical Society, and was chosen President of that
Society in succession to the present Chancellor of the
Exchequer. In 1887 he was appointed honorary physician
to Her Majesty. In 1889 he served as a memW of Lord
Camperdown’s Committee as the representative of the
Royal College of Physicians, and in the same year he
attended the International Statistical Congress at Paris.
In 1890 be was nominated a manager of the Metropolitan
Asylums Board. In addition to his interest in statistics.
Dr. Balfour was one of the earliest sanitary reformers, and,
notwithstanding that he was always thorough in what he
undertook, his versatility was shown by his researches in
spirometry, meteorology, and anthropology, and by his in¬
quiries into the health statistics of the horses of the army.
The late Dr. Balfour lost his wife about two years ago,
and to his intimate friends it was plainly discernible that
this wa-s a sore trial, and had left its mark upon him. He
had exhibited some signs of failing strength and health
during the last year or two of his life. He complained from
time to time of attacks of dyspepsia attended with palpita¬
tion and irregularity of the heart’s action, but these attacks
were easily relieved by careful dieting and simple remedies.
He dwelt with evident satisfaction on the amount of
walking exercise he had accomplished in Scotland during
the past summer, and on the satisfactory state of his
health. The intense cold of the present winter, how¬
ever, tried him very much, and he was more than com¬
monly troubled witii his usual winter cough. He recently
noticed, too, that his pulse, which had usually been
rather quick, and sometimes irregular and intermittent, had
become large, voluminous, and regular, and had fallen
to 40 in the minute. Shortly afterwards the amount of
urine passed began to diminish and was of high specific
gravity and albuminous, and some mdema of the ankles ap¬
peared, The pulse, which was one of increased arterial
tension, was from 38 to 40, and on the morning of Ms death
only 36, and intermittent. He suffered also much from
liatnlence and acid dyspepsia. There was no cardiac bruit.
Although his physical strength, spirits, and appetite re¬
mained fairly good, the above symptoms were, of course,
regarded as grave indication.s in a man of nearly seventy-
eight years of age, but his death, when it occurred on the-
afternoon of the 176h inst., was somewhat unexpected,
and resulted from a sudden cardiac failure. He was assidu¬
ously and most kindly attended by his old friend Dr.
Martyn, F.R.C.S, and at his own-request Dr. Jeffery
Marston, whom Dr. Balfour had been in the habit of con¬
sulting for many years and for whom he had a creat regard,
was asked to see him, which he did on four or five occasiona
during the last week or ten days of his illness.
The late Dr. Balfour was a really able man, of excellent
common sense and remarkably sound judgment. He pos¬
sessed a vigorous and highly cultivated intellect, was sincere,
and honest in all things, genial, and endowed with a keen
sense of humour, a firm friend, and an excellent colleague.
We are proud to say that for many years past, and almost
up to the date of his death, he was a regular and highly
valued contributor to The Lancet, On Dr. Balfour's-
judgment and experience in militaiy medical matters, vital
statistics, sociology, and many scientific and literary sub¬
jects, the Editors were wont to place the greatest con¬
fidence. He will be mourned and missed by a large circle
Coogle
Tbs Lancet,]
OBITUARY.
[Jan. 24,1891. 229
of friends and acquaintances, but by none more than by his
late colleagues on The Lancet, to one and all of whom he
had much endeared himself.
GEORGE GULLIVER, M.A., M.B. Oxford, E.RC.P.
Dv. GEORGicGULUVERdiedofacutepneumoniaon Jan. 11th
afteraweek’8illne8B,atl6,Welbeck-Btreeb, Cavendish-square.
He was the only son of the late George Gulliver, F.R.S.,
the celebrated naturalist, who was Professor of Anatomy
and Physiology at the Royal College of Surgeons and
surgeon to the Horse Guards. George Gulliver, jun.,
was born at Windsor in 1851 and was educated at King’s
School, Canterbury, whence he proceeded to Pembroke
College, Oxford. Inheriting his father’s love of science, and
specially of oiology, he selected the latter subject for his
degree examination, and became a pupil and admirer of
the late Professor Rolleston. In 1873 he gained a
first class in the Natural Science School, and took
his Bachelor of Arts degree. For some time he held
the post of Demonstrator to Professor Rolleston, who
formed a high opinion of his character and abilities, and by
his influence secured for him the post of assistant naturalist
to the Venus Expedition, which called for Rodrigue;; in
1871. On his return he wrote a report on the zoology of the
island, for which he received the thanks of the Royal Society.
He entered St. Thomas’s Hospital as a student in 1875, and in
1879 took the degrees of Master of Arts and Bachelor of
Medicine in the University of Oxford, and tlie Membership
of the Royal College of Surgeons of England. During his
student’s career be made his mark as a man of great ability,
and was elected in 1880 to the important poet of resident
assistant physician. During 1880and 1881 beheld, together
with this, the medical registrarship, and gained a very wide
and accurate knowledge of medicine. He then took the
Membership of the Royal College of Physicians, and, a
vacancy occurring on the medical stall'of the hospital in 1882,
be was elected assistant physician. Shortly after this, in 1883,
when the cholera was rife in Egypt, he was sent out and
became attached to the Ibrahim Pacha Hospital at Cairo,
but later, at his own request, be was transferred to Assouan
tocarry out whatever sanitary measures he might think neces¬
sary. While there his dragoman was attacked with cholera,
and Gulliver, who was the only European on the spot, nursed
him successfully through Ins illness. The epidemic soon sub¬
sided and he returned to J/ondon, where he read a valuable
paper on the Etiology and PalUoIupy of Cholera before the
Epidemiological Society. In 1884 he was elected Lecturer
on ComparativeAnatomy.and subsequently Demonstratorof
Morbid Anatomy, at St. Thomas’s Hospital, appointments
which be still held at the time of hie death. In 1886 he
became a Fellow of the Royal College of Physicians. In
addition to the various posts which he held in suc¬
cession at his own hospital, he also filled in the earlier
part of his career those of clinical assistant at Vic¬
toria Park Hospital for Diseases of the Chest and at
tlie Bronipton Consumption Hospital. Later on he was
elected assistant-physician (1883) and subsequently phy¬
sician (1889) to the London Fever Hospital, and only a few
weeks before bis death he entered into an agreement with
his publishers to bring out a book on Fevers. In 188.5,
1886, and 1887 he edited with Mr. Clubton the St. Thomas’s
Hospital Reports. He was a member of most of the Medical
Societies in London, at which lie read from time to time
papers of considerable value. But that which probably gave
him the greatest pleasure of all was his Fellowship of the
Zoological Society. He visited the Zoological Gardens on
many Sundays in the year, and thoroughly enjoyed his
stroll among the animals which he knew so well and so
often talked about.
The foregoing summary of Dr. Gulliver’s career shows
what splendid opportunities he had, and how he used them
as steps for rising higher and higher in his profession.
Those who knew him intimately were well aware what a
wide knowledge of medicine he possessed, and how skilful
he was at the bedside, both in diagnosis and in treatment.
But all had not this intimate acquaintance with him. One
of his most striking characteristics was his modesty—one
might even say his shyness. He seemed.averse to showing
his knowledge and skill before a large number of people,
and seldom opened out much before the students in bis
out-patient room; wliile in the summer, when he was doing
temporary duty in the wards, he seemed particularly
anxious to avoid having a large following. Bat in the
comparative privacy of the lecture-room, where a small class
assembled to bear Pis lectures and demonstrations on Com¬
parative Anatomy, he felt more at home, and took evident)
delight in teaching In addition to his purely professional
accomplishments. Dr. Gulliver had a very wide acquaintance
with English writings, both in prose and verse, and took
great pleasure in the lighter varieties of French literature.
The general information which he thus had at his command,
and the genuine humour he was wont to display, proved &
charm and often a surprise to those who conversed
with him. He was a man of strong likes and dislikes,
but he rarely allowed himself to • be betrayed into
an unkind expression of antipathy to anyone. His viewe
on questions of general interest, and on tnose which came
up from time to time in his own hospital, were often very
decided, and be supported them with vigour; but, on tbo
other hand, he was often apathetic about things which
roused the feelings of many around him. From whatever
point of view one contemplates Dr. Gulliver, whether as a
as man or a physician, one cannot but feel that those who
knew him well will mourn that so staunch a friend and
genial companion has been taken from them ; while the
medical profession must also deeply deplore the loss of so-
able a physician and comparative anatomist, and a man of
such wide literary culture.
THOMAS TAYLOR, F.R.C.S.Eng.
Mr. Thomas Taylor of Sutton Coldfield, near Bir¬
mingham, died on Dec. 20th, in the ninety-fifth year of
his age. He was the oldest medical practitioner in the
Midlands probably—possibly the oldest in England. He
was bom at Redditch in 1796, and in 1806, in his twelfth
year, he went to Birmingham with his uncle, who had been
apprenticed to a notable Birmingham surgeon, Mr. Hector,
of the Old Square, the schoolfellow and lifelong friend, and
not infrequent host, of Samuel Johnson. From bis uncle Mr.
Taylor’s earliest training was derived. From Birmingham
Mr. Taylor went to London to complete his professional
training—to walk the hospitals,” as the phrase then was.
Probably at the suggestion of Mr. Freer he chose St.
Bartholomew’s, where Abernethy was then the chief of the
surgical stall, and for Abernetby he contracted an intense
regard. One of the oldest and most venerable of Birming¬
ham surgeons writes that “ he preserved bis faith, as be
often told me, in three books only—the works of Jeremy
Taylor, from whom he said he was descended; John
Abernethy’s works, which I think be must have learned by
heart; and the Bible.”
In 1821, at the age of twenty-five, Mr. Taylor finished
his course at St. Bartholomew’s Hospital and became a
Licentiate of the Apothecaries’ Company and a Member
of the Royal Cqllege of Surgeops. He became a Fellow
of the College in 1861, the necessary fees being then,
as a mark of personal respect, contributed by some of
his medical friends, on his retirement from the office of
honorary secretary to the Midland Medical Benevolent
Society. He was appointed to the office of resident
surgeon at the General Dispensary, which he resigned
to enter upon private practice. In 1876 he removed
to Sutton Coldfield, to reside near bis daughter, the
wife of the Rev. Albert Smith, Head Master of Sutton
Grammar School. He was much esteemed by his medical
colleagues and personal friends, and those who knew him
never failed to arrest his attention for the sake of a cordial'
greeting, ending with tlie familiar “ God bless you !” with
which, in tones of manifest sincerity, it was hia wont to-
close the passing interview. There was in this life nothing
that was striking in the ordinary sense, very little incident,
no public manifestation; and yet it is especially worthy of
record, as a memorial of one who constituted a fink
between (he present and the remote past, and who was
emphatically a good, honourable, and honoured man ; one
who did his duty thoughtfully and quietly, and who carried
with him to the age of well-nigh a century the esteem and
regard of all who knew him, and the affection of those
who enjoyed the honour and the pleasure of his intimacy-
By hi.s professional brethren he was lield in great esteem as
a high-minded, honourable gentlenian of the old school,
retiring in disposition, courteous in manner, and of great
amiability. A medical man who had known him for sixty
years says, “ I should think ho never had an enemy.”
t Coocle
O
2S0 TheLanoet,]
MEDICAL NEWS.
IJan. 24, 1891.
HENRY PENFOLD, L.R,C.P.Ed., M.R.C.S., L.M.
On Jan. 7tb, Henry Penfold died at Rainharo, after a
short illness due to the severity of the winter. For those
who knew him bat little more need be added. The sorrow
of his family—deep though it must needs be—is shared by
All who have ever come in contact with him whom we have
oiowlost. Mr. Penfold, at the termination of his student
iife at Guy’s Hospital in 1856, became a Member of the
Royal College of Surgeons. Shortly afterwards he was
^pointed surgeon in charge of the works of the London,
Gnatbam, and Dover Railway, which was then being laid
■down. On the completion of the railway he settled
in general medical practice at Rainham. Amongst other
appointments be subsequently held for many years the sur¬
geoncy of the Ist East Kent 11. V. For twenty years his
skilled service as honorary surgeon to St. Bartholomew’s
Hospital at Chatham was given with untiring zeal. His
private and professional life at Rainham was one of unalter-
ing kindness and self-forgetful labour for those who most
needed his help. In Masonic circles be will long be remem¬
bered as a true brother, a Mason in heart and in deed. To
^all his genial manner and sincerity endeared him. Generosity
in him was a part of his very nature, no less were kindliness
•of heart and honesty of purpose. And “ these riches shall
■not pass away with life.’* _
JOSIAS WILSON PATRICK, L.R.C.P. & S.Edin.
We regret to announce the death, at the early age of
•forty-eight, of Mr. Patrick of Carrickfergus, county Antrim,
which occurred on Jan. 9th. Mr. Patrick, who was a
licentiate of the Royal College of Physicians and Surgeons
•of Edinburgh, began practice on the death of his brother,
Dr. W. H. Patrick, twenty-five years ago, and succeeded
'him as medical officer of the Carrickfergus dispensary
Jistrict. At the time of bis death he was medical officer
•of health for Carrickfergus, and medical attendant to
the troops stationed there, also medical officer under the
Factory Acts. He was an honoured member of the Masonic
Order, and, owing to his exertions, a new lodge was estab¬
lished in Carrickfergus, of which he was first master. He
■had a very large private practice, and, in addition to enjoy¬
ing the respect and confidence of the public, he was on
■terms of inpimate friendship with the other medical men in
his district. Mr. Patrick was buried on Monday, an immense
•concourse of people following his remains.
THE SERVICES.
An order recently issued from the War Office notifies
lihat in future recruits for the Medical Staff Corps will have
the option of enlisting either for seven years’ army and
■five years’ reserve service or for three years’ army and nine
years’ reserve service.
Army Medical Staff. — Deputy Surgeon-General
'Chamney Graves Irwin, M.B., has been placed on retired
pay (dated Jan. 46h, 1891); Surgeon John Robt. Stevenson
Robertson, M.B., resigns his commission (dated Jan. 2l8t,
1891).
Army Medical Reserve of Officers.— The following
notification is substituted for that which appeared in the
■Gazette of Nov. 25th, 1890: Surgeon J. J. A. V. C. Raye,
having resigned his Volunteer appointment, ceases to be
-an Officer of the Army Medical Reserve (dated Nov. 26tb,
1890).
Naval Medical Service, — The following appoint¬
ments have been made at the Admiralty;—Fleet Surgeons:
lEdwd. E. Mahon bo the Imp6ricuse (dated Jan. 27tb, 1891);
Frederick M'Clement, MD., to the Iron Duke (dated
Feb. 12th, 1891). Staff Surgeons: Frederick A. Trevan to
the Bingarooma, and Charles W. Bucbanan-Hamilton, to
the Ttmranga (undated); Henry G. T. Strickland to the
Boscmeen, additional (dated Jan. 27tb, 1891). Surgeons:
Henry F. Iliewicz and John D. Hughes to the Jmp6rieuse,
and R. Barnard to the Ganges (all dated Jan. 27th, 1891);
a,nd William Hayes to the Boipoise (undated).
Volunteer Corps. — Engineers (Submarine
Miners): The Forth Division: Henry H^, M.B., to be
Acting Surgeon (dated Jan. 17th, 1891); lues. P. Grosart
Wells, Gent., to be Acting Surgeon (dated Jan. 17th,
J891).— ArUUery: 2nd Lancashire: Acting Surgeon H. R.
Jones, M.B., to be Surgeon (dated Jan. 17bh, 1891).—
.Srd Volunteer Battalion, the Cheshire Regiment: Alfred
Herbert Marsh, Gent., to be Acting Surgeon (dated
Jan. 17th, 1891).—3rd Volunteer Battalion, the Hamp¬
shire Regiment: Surgeon and Suigeon-Major H. R. Smith
is seconded whilst serving as Brigade Surgeon in the
Portsmouth Infantry Volunteer Brigade (dated Jan. 17tb,
1891).—1st Volunteer Battalion, the Princess Charlotte of
Wales’s (Royal Berkshire Regiment): Alexander Gordon
Paterson, M.I)., to be Acting Surgeon (dated Jan. 17th,
1891).
Volunteer Medical Staff Corps. — The London
Division: Surgeon H. G. Read resigns his commission
(dated Jan. 17th, 1891).
SlrMral Ittfei
Examining Board in England by the Royal
Colleges of Physicians and Surgeons.- The following
candidates passed the Second Examination of the Board
in the subjects indicated at a meeting of the Examiners
on Thursday, the 15th inst.:—
Anatomy and Physiology. —Daniel S. Owen, Ambrose .T. Ruseeli,
Angus B. Kennedy, and Hugh P, V 'Wiggins, students of London
Hospital; Fran]; E. Reynolds and John £. H. Davies, of London
i Hospital and Mr. Cooke’s School of Anatomy and Physiology;
Alexander W. Quait, of St. Thomas’s Hospital; Alan Murdoch, of
St. Bartholomew's Hospital mid Mr. Cooke's School of Anatomy
and Physiology ; .John A. I’roctev and .Tohn P. Atkinson, of King’s
College ; Arthur W. Denny, ol Chaving-cross Hospital; Alexantfer
H. M. Hood and Henry Witliam, of Westminster Hospital; and
.John D. Seller, of St. Maty’s Hospital.
Anatomy only. —William 11. Read, of Grant Medical College and
King’s College; John J. Culiner and Alfred Alexander, of Guy’s
Hospital; Edgar C. Pern, of St. Thomas’s Hospital; William E. E.
J’owles, of London IlospitaJ; Charles W. 'Williams and D. D. Brown,
of St. Bartholomew’s Hoapitfvl.
Physiology onlj/.—James B. Bettington and George H. Steele, of Guy's
Hospital; Harold W. Clarke, of St. Mary’s Hospital; George R.
Hannon, of King’s College; li’i'ederick W. .). Qoodhne, of St.
Thomas’s Hospital; Charles Corhen, of St. Bartliolomow’s Hospit^;
and Percy C. Spark, of Charing cross Hospital.
Passed on the 16th inst:
Physiology onfi/.—Basil E. Church and Philip T. Jones, of St. Bar¬
tholomew’s Hospital; Charles M. Welburn, Alexander 'W. C.
Lindsay, Cecil W. Smith, and James A. EdaelJ, of .St. Bartholo¬
mew’s Hospital and Mr, Cooko’s School of Anatomy and Physio¬
logy ; Harry Andreao, of University College; William F. C. Dowd-
ing and Henry N. N. Dodd, of St. George’s Hospital and Mr. Cooke’s
School of Anatomy and Physiology ; Ernest K. S. Silver, Janies
O. B. Colman, Ernest S. Tuck, and Alexander B. Creak, of Guy’s
Hospital; William Pell, George E. Kiimersloy, Frank W. Mason,
and William G. Macaulev, of St. Thomas’s Hospital; George R.
Swinlioe, of St. Thoma-s’s Hospital and Mr. Cooko’s .School of
Anatomy and Physiology; Francis Wlutelaw, of St. Mary’s Hos¬
pital; George Edward WillianiH, of London Hospital; William H.
Go.ssage, of Westminster Hospital; and (Charles M. S. Farnum, of
King’s College.
University of .Cambridge.—A t a congregation
held on the l.^th inst. the following degrees were conferred:—
Bachelors of Medicine and Bachelors of Walter Winslow,
Gonvllle and Caius; Roliert Stanley Thomas, Josus; .Termyn
Francis Gillett, Sidney, Sussex; William Hubert .Sale Kosherry,
non-collegiato.
Sir G. M. Humphry, Professor of Surgery, has been
appointed a member of the General Board of Studies.
National Health Society—A cour.se of six
lectures on Domestic and Personal Hygiene will commence
on Friday, Feb. 6fch, at 3 p.m., in the Committee-room,
53, Berners-street, W.
Football Casualties.—I n a Rugby matcli at
Montrose, on the 3rd inst., a player sustained a fracture of
his left leg below the knee.^—At an inquest held at Liver¬
pool, on Dec. 3l8b, on the body of Thomas Hebley, a verdict
was returned that the deceased died from the effects of a blow
received in a football match on the previous Saturday._
Last week a Wombwell Main player had his collar-bone
iractured during a game at Wombwell Main.—On Jan. 12th
two players named Cawley and Mumford, of the Wednes¬
day team, accidentally collided with each other in a match
at Bramall-lane, Sheffield, and sustained slight concussion
of the brain, Mumford also sustaining an injuiy to his
eye —In a match on Saturday between Llanrwst and
Trefriw with Bettwys-y-Coed combined, a Llanrwst player
broke his collar-bone.
Digitized by ^ooQle
The Lancet,]
MEDICAL NEWS.
• Epsom College.—E. M. Corner' of Epsom College
gained an exbibibion last week of £30 at Sidney Sussex,
Cambridge, for Natural Science.
Cremation in Denmark.—I n pursuance of a
decision recently pronounced by the Supreme Court of
Copenhagen, cremation will be prohibited in Denmark
pending the passing of the new law for the disposal of the
dead.
The Regulation of Overhead Wires.—T he
Bill promoted by the London County Council for dealing
with overhead wires came before one of the examiners
on Standing Orders at the House of Commons on the
19th inst., when compliance with the Standing Orders was
proved.
Anonymous Gifts to Hospitals.—A n anony¬
mous donor has forwarded two bank notes for £1000 each
to the Essex and Colchester Hospital and the Eastern
Counties Asylum for Idiots respectively. Similar munifi¬
cent anonymous donations were received by the two institu¬
tions last vear.
Royal FREJi Hospital, Gra'v’s-inn-road.—T he
Lord Mayor presided over a meeting held at the Mansion
House on Monday, in aid of the movement to raise £20,000
for the purpose of rebuilding the front portion of this in¬
stitution. The hospital was founded in 1827, and 2,000,000
sufferers had been relieved within walls. Three sides
of the building had been reconstructed, but the fourth,
the front, remained in its old form, with all its faults
and defects. A resolution was carried, pledging the meet¬
ing to use every endeavour to obtain the funds required.
The secretary announced that about £2000 had already
been contributed.
Presentation.—M r. William Blasson, M.R.C.S.,
who was in practice at Edgwave and Mill-hill, Middlesex,
for twenty-eight years, has been presented, on his leaving
Edgware, with a massive silver bowl on an ebonised stand,
a handsome walnut sideboard, and a cheque for £140 by his
friends and patients, in testimony of tbeir esteem and
appreciation of his professional skill.—Mr. Martin Howard
L.A.H., L M.Dub,, has been presented by the members of
the St. John Ambulance Class, formed under the auspices
of the London and North-Weafeern, Lancashire and York¬
shire, and Oldham, Ashton, and Guidebridge Railway Com¬
panies, with an artistically illuminated address, expressing
the indebtedness of the class, for his kindness, and simple
system of instruction, as their lecturer.
The late Professor McGill.—A well-attended
and representative meeting' was held last week, in the
board-room of the Leeds General Infirmary, to decide upon
the form of memorial to perpetuate the memory of the late
Professor McGill. Mr. R. Benson Jowitt, chairman of the
infirmary board, occupied the chair, and in opening the pro¬
ceedings expressed the loss the infirmary had sustained, and
assed a high eulogium upon the late professor. After some
iscuasion, it was resolved that the form of the memorial
should be a prize in surgery, to be awarded to students of
the medical department of the Yorkshire College and of
the Leeds Infirmary. A committee, honorary secretaries,
and a treasurer were appointed, to promote the object in
view.
Odontological Society of Great Britain.—
The following members were elected on Jan 12th as officers
and councillors for the year 1891 r—President: Mr. S. J.
Hutchinson, Vice-Presidents : Messrs. J. Stocken, David
Hepburn, T. H. G. Harding, W. Bowman Macleod (Edin¬
burgh), J. H. Redman (Brighton), and R. T. Stack (Dublin).
Treasurer: Mr. Thomas Arnold Rogers. Librarian; Mr.
Ashley Gibbings. Curator : Mr. Storer Bennett. Editor
of the Transactions : Walter Coflin. Honorary Secretaries :
Messrs. J. Ackery (Council), W. A. Maggs (Society), and
F. Henri Weiss. Councillors: Messrs. C. S. Tomes, i'.R S ,
Willoughby Weiss, W. H. Woodruff, W. Hern, E. Newland
Pedley, C. J. Boyd Wallis, F. j. Bennett, Cornelius
Robbins, E. G. Betts, M. do C. Dickinson (St. Leonards-on-
Sea), A. A. de Lessert (Aberdeen), Alex. Fothergill (Darling¬
ton), W. B. Bacon (Tunbridge Wells), H.B. Mason (Exeter),
Mordaunt A. de C. B. Stevens (Paris), T. S. Carter
(Leeds), Edm. Binns (Middlesbro’), and W. S. Woodburn
(Glasgow).
[Jan. 24, 1891. 231
St. Thomas’s HospitaIj.—A handsome brass
lectern has been presented to the hospical chapel by the
new treasurer, Mr. J. G. Wainwright.
Water-supply, Colwyn Bay.—A scheme has
been adopted, involving an expenditure of £21,000, to secure
for Colwyn Bay a new and abundant supply of water from
Llyn-Cowlyd, situated on a branch of the Snowdonian
range of mountains, on the Carnarvonshire side of the river
Conway.
Society for Relief of Widows and Orphans-
OP Medical Men.—T he quarterly Court of Directors of
the Society was held on Wednesday, Jan. 14th, at 20,
Hanover-square. The President, Sir James Paget, pre¬
sided. Five new members were elected, the resignations
of two were accepted, and the deaths of two reported. An
application for a grant was received from a widow, and
assistance was given her. It was resolved to distribute
£1418 10s. among the sixty-four widows, fifteen orphans,
and three orphans on the Copeland Fund now receiving
grants. The expenses of the quarter were £80 5s. Qd. The
treasurer announced that a sum of £360 had been given in-
presents to the widows and orphans at Christmas, and that
one orphan had through age ceased to be eligible for further
grants.
North of England Obstetrical and Gyne¬
cological Society.—T he annual meeting of this Society
was held at Owens College, Manchester, on Friday,
Jan. 16th, when the office-bearers for the ensuing year were
elected. Dr. Braithwaite (Leeds) was elected President in
plabe of Dr. Wallace (Liverpool), whose term of office has
expired. The following were elected Vice-presidents r
Drs. Lloyd Roberts and Nesfield (Manchester), Drs. J. E.
Burton and McFie Campbell (Liverpool), Mr. C. J. Wrighb
and Dr. Hellier (Leeds), and Dr. BLeeling and Mr. Arthur
Jackson (Sheffield). Dr. Sinclair (Manchester) was appointed
honorary general secretary, and Dr. Walter (ManchesterV
hon. treasurer. The following gentlemen were appointed
local secretariesDr. Donald (Manchester), Dr. Briggs
(Liverpool), Mr. Sydney Rumboll (Leeds), and Mr. Richard'
Favell (Sheffield).
Co-operation in Nursing.—A scheme formulated'
by Miss Napper and Miss Belcher, “to supply private
nurses, thoroughly trained and certificated, to practitioners
and the public through the agency of nurses who have
combined for their mutual benefit and welfare,” was set on
foot on Tuesday evening last by a meeting held in New
Cavendish-street. The cooperation had secured the services
as lady superintendent of Miss Philippa Hicks, the late
matron of the Hospital for Sick Children, Great Ormond-
street, who is well known on account of her labours at-
Sb. Thomas’s Hospital, King’s College Hospital, and during
the Egyptian campaign. Each nurse wUl be paid her owit
fees, less a charge of 7i per cent,, which will be placed to-
a common fund for working expenses, and -if the nurses
wish they can reside in the institute. It is also proposed
to start immediately lectures and clinical instruction for
assistance of the nuises.
Manchester Medical Society.—L ast week the-
annual meeting of this Society was held at Owens College-
Dr. J. Rosa presided. The report stated that twenty-two
new members had been elected during the year. The com¬
pletion of the new library catalogue, involving considerably
cost, was recorded with satisfaction. The cash statement-
showed a small balance in hand. The report was adopted,
and the following were elected office-bearers for 1891
President: Dr. Thos. Jones. Vice-Presidents; Drs. Samuel
Buckley, John Dixon Mann, F. A. Southam, and Grahanij.
Steell. Treasurer; Dr. C. E.'Glascott. Secretary: Dr.
T. C. Railton. Ex-officio Members of Committee: Dr.
Henry Browne, Dr. J. Dreschfeld, Mr. James Hardie,
Mr. F. A. Heath, Dr. D. J. Leech, Dr. David Little,
Mr. Edward Lund, Dr. J. E. Morgan, Dr. Arthur^
Ranaome, Dr. D. Lloyd Roberts, Sir William Roberts,
Dr. James Ross, Dr. Henry Simpson, Mr. Thomas-
Windsor, and Mr. Walter Whitehead. Elected Members,
of Committee: Dr. J. S. Bury, Mr. William Coates, Dr.
Archibald Donald, Dr. A. M. Edge, Dr. S. J. Graydon, Dr.
A. H Griffith, Dr. A. Hodgkinson, Mr. F. W. Jordan, Dr.
Siegmund Moritz, Dr. C. J. Kenshaw, Mr. C. E. Richmond,
and Dr. G. A. Wright.
Digitizod bv Google
332 Thb Lancet,]
BOOKS ETC. RECEIVED.—APPOINTMENTS.
[Jan. 24, 1891.
Tjm MmwivEs’ Registration Bill —At the annual
tneeting of De^^on and Exeter Medico-Chirurgical Society,
held at the Exeter Hospital on the 16th iost, the following
resolution was passed:—“The members of the Devon and
Exeter Medico-Chirurgical Society strongly disapprove of
the Midwives’ Registration Bill (amended”).
Cottage Hospitals.—T ho annual report, just
issued, sketches the satisfactory progress of the Tamworth
Cottage Hospital, established ten years ago. The financial
position is satisfactory. Considerable sanitary improve¬
ments had been effected during the year.—A new Cottage
Hospital was formally opened at Goole on the Idth instant.
It is a commodious stone building, centrally situated, and
was formerly used as the court bouse, and has been pre-
«wted to the committee. The necessary structural altera¬
tions end furnishing have been defrayed by other generous
'Supporters of the sohenie, and it will provide a long felt
want in the town.
METROPOLITAN ASYLUMS BOARD.
BUwm of Patients remaining in the semeraX Fever Hospitals
of the Board at midnight on Jamm'if 20th, 1891,
Beds occupied.
1
Hospital.
1*:
4
sa
I'S
1
■9 9
St
i
3-3
Easteni Hospital .. ..
267
44
2
ei
4
868
448
North-Western Hospital
282
85
8
826
448
Western
IvO
16
18
T
184
262
Gouth-Westem
176
13
2
103
840
Bouth-Bastem „
226
14
41
281
462
Northern
28(j
19
16
820
480
Gore Farm „
63
-
>•
63
800
Totals.
1487
141
146
0
1734
2729
Small-pox,— lioapital ship, 1.
BOOKS ETC, RECEIVED.
Black, Adah & Ciiahles, Bdinbut/rb.
The Collected Writings of Thomas Do Quincey. By D. Masson.
Vol. XIV. New and Enlarged Edition. IsBO. pp. iM.
Bickers & son, London; Counisii Brothers, Birmingham.
Constance Naden; a Memoir. By W. B. Hughes, F.L.S. 1800.
pp. 01.
CHCBCHILL, J. a a., New Burlington-street, London.
Year-book of Pharmacy, and Tmnsactions of the Britlsli Pliarma-
ceutical Conference at Leeds, 1800. pp. 012.
Qrevel, H., & Co., King-street, Covent-garden, London.
The Student's Atlas of Artistic Anatomy. By C. H. Both. Edited
by C. K. Fitzgerald, M.D. With Plates and Fignves. 1801.
■Griffin, Ckas., & Co., Exoter-street, Strand, London.
Railway Injuries in their Medico-legal and Clinical Aspects. By
Herbert W. Page, F.R.C.S. 1801. pp. 148.
jLEWiS, H. K., Gower-strect, London.
Pocket Medical Lexicon. By J. M. Keating, M.D. (Pa,), and H.
Hamilton. 1801. pp. 280.
CiviNQSTONE, E; & S., Edinburgh.
The Urine, in Health and in Disease. By H. A. Husband, M.B.,
F.R.C.S. Bdin. With Plates. Second Edition. 1801. pp. 71.
CoNOMANS, Green, & Co., London.
Aphorisms in Applied Anatomy and Operative Surgery. By Thos.
Cooke, B.Sc., M.D. (Paris). 1801. pp. I7;i. Price 88. Od.
Studies of Old Case-books. By Sir James Paget, Bart. 1801.
Price 88. Od.
i^iuPKiN, Marskall, & Co., London.
Bvolution the work of a great Intelligence. By W. A-. In Two
Parts. Part I. 1800. pp. 128.
Bmith, Elder, & Co., Waterloo-place, London.
Transactions of the Patbolo^cal Society of London. Vol. XLI.
1800. pp. 416.
^AB, Prosperim, Padova.
Tito Vanzotti. 1601. pp. 851.
Dr. Killlay's Aertzlichev Alniiinach, 1801 (Wilhelm BrauniUller & Solin,
Wien, 1801).—De ITntervention Chiruvgicale dans le P^ritonites
Tuborculenses gdndi'allsiios ot localisdes; par le Dr. Adrien Pic (J. B.
Bailli^ro et Fils, Paris, 1800).—Biennial Report of the Alabama Insane
Hospital at Tuscaloosa for the years ending September, 1880 and 1800
(The Brown Printing Company, Montgomery, Ala).—The Philosophy
of Cookery; by Fredk. Pearso, M.D. (Holbrook & Son, Portsea).—
Saint-Rapiiael, with Valoscuro and Boulourie as a Winter Health
Resort; by Howard D. Buss, M.R.C.S. Chailan, Saint-Raphael,
1890).—'J’he Dog Owner's Annual, 1801; illustrated (Doan and Son,
Ixindon); price 1*.—Etude expilrimentaJo sur les Microbes des Itaux;
par le Dr. Victor Despeignes (J. B. Builli^re et Fils, Paris, 1801).—
Catechism Series : Materia Medica, Part I. (E. & S. Livingstone,
Edinburgh, 1891); price Is. nett.—Hunterian Lectures on Intra¬
cranial Inflammations: by A. E. Barker, F.R.C.S. (H. K. Lewis,
London, 1890); price 3«. nett.—Social Diseases and Worse Remedies;
by T. U. Huxley, F.R.S, (Macmillan & Co., London, 1801); price le.—
Dr. Koch's Hemedy, the Treatment of Consumption; by A. E.
Bridger, M.D. (John Hogg. London, 1801); price le.—Archives of
Siu'geiy, by Jonathan Hutchinson, LL.D., F.R.S., January, 1891
(J. <fc A. Churchill, London); price 2s. Ud.—Magazines for January:
Good Wortls, Sunday at Home, Leisure Hour, Sunday Magazine
(labiater), Boy’s Own Paper, Girl’s Own Paper (Religious Tract
Society), Scribner's.
SuceesifvZ applicants /or Vacancies, SecretaHes of Public Institutions, and
ethers possessing infortfiation suitable for this coiu/mn, are i-nvited to
forward it to The Lancet OJlce, directed to the Sub-Editor, not later
than 9 o'clock; on Thursday tnoming of each week for puhiietOion in
, the neat number. '
Beasley, J. G., LK.C.P. Edin., L.F.P.N, Olasg., has been appointed
Medical Officer of Health lor the Rowley Regis Urban Sanitary
District of the Dudley Union.
Benjai'IEI.d, W. B., M.B. Erlin., M.B.C.S., has been appointed Medical
Officer for the Workhouse at Edmonton, vice Day.
Berry, James, B.S, Lend.. F.II.C.S., has been appointed Surgeon
to tho Royal Free Ho.spital, vice F. J. Gant, F.R.C.S., re¬
signed.
Beveridur, Arthur J.. M.B., C.M, Eilin., has been appointed
Medical Officer for the Paiish of Assynt, Sutherlandahire, vice
McFadyen.
Brown, Roiiert, M.B., C.M., hna been appointed Medical Officer
and Public Vaccinator for the Parish of Duirnish, Skye, vice
Dewar.
Brumwell, G. W., L.R.C.P. Edin,. M.R.C.S., has been reaeppointed
Medical Officer for tlie Scaltliwailerigg District of the Kendal
Union.
Cook, J. W., M.D. Aberd,, M.R.C.S., has been reappointed Medical
Officer of Healtli for tho Tendring and l.oxdon and Wlnstree Rural
Districts.
Crick, Wm. T., L.R.C.P. Loml,, M.R.C.S., hn.s been appointed Medical
Officer for the Western District of tho Billesdon Union, vice Fewkos,
deceased.
; Crosse, Reginald E., M R.C.S., L.U.C.P., has been appointed House
Surgeon to the Norfolk and Novwicli Hospital.
Edward, Victor.H ur.o, M.B.,B.S. Loud., has been appointed Assistant
Medical Superintendent to tlie Paddington Iiillruiary, London, vice
T. Ernest Hillier, M.B., M.A. Cantab., resigned.
Evans, Wilmott, M.D., B.S., B.So. Lone!., F.R.C.S , lias been appointed
Registrar to the Royal Free Hospital.
Evershei), Arthur, M.B.C.P. Loud., M.R.C.S., has been appointed
Medical Adviser to the North London Railway Company.
Fuller, G. E., M.D,Irel., has been appointed Medical Officer for the
Uheswardine District of tho Drayton Union.
Gant, Mr. F. J., lato Senior Singeon, has been appointed Consulting
Surgeon to the Royal Free Hoepiiai, Gray’s-inn-ioad.
Green, C. D., M.D., L.R.C.P. Lond., has been appointed District
Medical Officer of the Edmonton Union.
Hawkins-Amhi.er, Georoe A., M.R.C.S,, L, & L.M.R.C.p. Irel., has
been appointed District Medical Officer and Public Vaccinator for
the Kirkburton District of tho HuddersUeld Union, vice H. A.
Lowndes.
Hill, Hedlev, L.R.C.P.Li>nd., M.R.C.S., ha.s been appointed Medical
Officer to the Bristol Dispensary,
Hill, J. S., M.B., C.M. Edin., lias been appointed Medical Officer for
the Fifth District of tlio 8t. Saviour's Union, vice Wingate,
resigned.
Iredale, j., L.R.C.P., L R.C.S, Edin., has boon appointtd Medical
and Vaccination Officer for the Saltlleetlry District of the Louth
Union.
Kean, Hugh J,, M.D., L.R.C.S. Irel., lias been appointed Medical
Officer for the Meigh Dispensary District.
KlLNER, C. S., M.D., C.M. Edin , has been appointed Assistant Medical
' Officer to tho Suffolk General Hospital.
Lancaster, W. C., L.R.O.P., L.U.C.S. Edin., ho.s been appointed
Medical Officer for the Balljtoggan Dispensary ot the Edonborry
Union, vice Purdon.
Lawson, F. D., L.K,Q C.P., L.R.C.S. Irel., has been appointed
Medical Officer and Public N’accinator for tb* Chiddingfold District
of the liambledon Union.
Digitized by <^ooQle
The Lancet,] APPOINTMENTS.-VACANrTES.-BIBTHS, MARRIAGES, & DEATHS. [Jan. 24, 18 B 1 . 238
Leach, J. C., M.D. Durh., M.B.C.8 , has been appointed Medical Officer
for the Workhouse of the Stunninster Union.
McCall, A., M.B., C.M. Olasg., has been appointed District Medical
Officer for the Conisborough District of the Doncaster Union, vice
Hills.
Macdonald, David, M.B,, C.M. nias.. has been appointed Medical
Officer for the District of i^tratherrick, Iiivei-ness,
Mackay, William, L.E.C.P. Ertin., L l''.P.a. Ulaeg , haabe.en appointed
Medical Officer of Health for the Noiton Urban iSanitary District of
the MaJton Union.
MACi.AaBN.WFDDKRiJURN. M.D. Abord., has been appointed Medical
Officer of Health for the County of I'orfar.
Macnaughton, W, a., M.D. Edin., has besn appointed by the
County Council Medical Officer for the County of Kincardine.
Martyn, Eeginald, M.E.C,S,, L.R.C.P. Loml., has been appointed
House Surgeon to the Devon and E.veter Hospital.
Mason, F. J., M.R.C.S., has been appointed Medical Officer for the
Fifth District of the Cheltenham Union, vice Cottle, resigned.
Noble, Samurl C., M.B.C S., has been reappointed District Medical
Officer of the Kendal Union,
RiGDEN, Brian, M.B.C.S., has been reappointed Assistant Surgeon
to tire Canterbury Dispensary.
RiODEN, George, M.R.C.S., has been reappointed Surgeon to the Can¬
terbury Dispensary.
Roden, Percy A., M.B., C.M. Aberd.. bas been reappointed Medical
Officer of Health for the Borough of Droitwich.
ROUGKTON, Edmund W., B.S.. M.D.Lond., r,R,O.S.. has been appointed
Assistant Surgeon to the Royal Free Hospital, Gray’s-inn-road.
SOLLY, Ernest, M.B. Lond., F.R.C.S., has been appointed Senior
Resident Medical Officer to the Royal Free Hospiial, Gray’s-inn-
road, vice E. C. Stabb, F.R.C.S.; resigned.
SOMKKSET, Edward, M.R.O.S.. L,R.C.P. Lond., L.SA., has been
appointed House Surgeon to the Carmarthen Infirmary, vice Hedley
Hill, resigned.
Thompson, M.. L.R.C.P. Edin., M.R.C.S.. has been reappointed Medical
Officer for the Puddletown District of the Dorchester Union.
Turner, C. Byron, M.R.C.s., L.R.C.P., has been appointed Demon¬
strator of Anatomy at Unlvei-sity College, London, vice O. B. M.
White, F.KC.S., resigned.
Turner, Pricderick. M,R.C.S.. has heen reappointed Medical Officer
of Health for the Buxton Urban Sanitary District.
Whitaker, H., M.D. Irel., M.R.C.S., has been appointed Medical
Superintendent Officer of Health to the Belfast Corporation.
Williams, C. R., M.B , C.M Edin.. has heen reappointed Medical
Officer for tlio Second and Third Districts of the Ashby-de-la-Zouch
Union.
Williams, J. D,, M.D. Edin., has been appointed Assistant Medical
Officer for the Workhouse of the Cardiff Union.
Woodiiouse, Edwd. R., m b.. C.M. Edin., has been appointed Medical
Officer for the Stafford Union.
%umm.
Forjwther ivjormation reaardinf/ each vaca/ncy r^erenee tkould he made
to the advertisement.
Blackrurv and East Lancashire Infirmary, Blackburn.—Junior
House Surgeon.
Central London Ophthalmic Hospital, Gray's-inn-road, W.C.-
House Surgeon.
Charing-cross Hospital, I,ondon.—Assistant .Surgeon.
CliEiMSRORi) Union,—M edical Officer, including tho office of Public
Vaccinator for tho sixth district of this Union. (Apply to tlie
Clerk, Chelmsford.)
Chelsea Hospital tor women, Fnlham-road, S.W.—Physician to tho
Out-patients, The office is honorary.
CmciiEaTHR Infirmary.—H ou'e .Surgeon. Salary £f() per annum,
with board, lodging, and washing.
City Hospital for iNi-'ECTioim Disea.sfs, NewcaaUe-npon-Tyne.—
Resident Medical A.s.siwlant for one year. 'I'ernis £00 for the first
year, and. if reappointed, £70 for the second year, with hoard, lodg¬
ing, and washing.
CiTv OF London Lunatic Asylum, near l)a,rtford. Kent.—Assistant
Medical Officer. Salary £1()0 per aiinnni, with hoard, lodging,
w.aahing. and attendance. (Apply to Mr. Youlo, Clerk to tho Com¬
mittee, Guildhall, London.)
OnosvENOR Hospital for Women and CiiiT.DnE.\, Vincont-sqiiare,
tf-W.—Surgeon,
Hospital for Women (London Scnooi of Gyn-ecology), Soho-
square, W.—Clinical A.ssistaiit.s in the Out-ps.tient Departments.
London Fevkr irospiTAl,. l-ivorpool-road, N.—Phvsidan.
LONnoN T-'EVER Hospital. Llvcrpoohroad, N.—Ass'istanb Physician.
General Infirmary,—.T unior House Surgeon. Salary
*•<() per annum, with hoard and residence in tho institution.
Na'J'ional Hospital for the Paralysi-^d and Epileptic, Queen-
square, Bloomshury,—Surgeon.
Hospital. Devonnort,—Assistant House .Surgeon
vided salary, hut hoard, lodging, and washing pro-
Rovai, OuTiiop.Fmc IfospiTAl,, Oxfoiil-Street, London.—Bc.sident
lionso Siirg-’on and Apothe.-ary. Salary £1(10 per annmn with
partial hoard.
Royal Portsmouth, PORT.SEA, AND Gosport Hospital.—H ouse Sur¬
geon. Salary, with board and residence, £70 per annum.
Smali.burgh Union,—M edical Officer for the Sm^lburgh District anJ
the Smallhurgh Workhouse. Salary £00 per annum for the dletrirb
and £80 for the Workhouse, with the usual extra medical fees. The
person appointed for these offices will also be appointed Public Vac¬
cinator and Registrar of Births and Deaths for the Smallburgb
District, with the ubusI fees payable in each case. (Apply to Mr.
Davies, Clerk, North Walsham.)
St. John’s Wood and Porti.and Town Provident DisPENaART.—
Surgeon. (Apply at the Dispensary, 1, Henstridge-villas, Ordnance-
road.
St. Mark's Hospital for Fistula and other Diseases op thr-
Rectum, City-ioad, London, E.C.—Aniesthetist. Honorarium £60'
per annum.
University of Sydney.—D emonstratorship in Physiology. Salary
£850 per annum. £60 allowed for passage expenses to Sydney.
(Apply to the Agent-General for New South Wales, 9, Victoria-
street, London, S.W.)
Winchcomii Union.—M edical Officer for the No. 2 or Vale District of'
this Union. Salary £65 per annum, and In addition, midwifery.
Surgical, and vaccination fees. (Apply to the Clerk. Winchcomb.)
Wirrai, Children’s Hospital. Woodchurch-road. Birkenhead.—Resi¬
dent Houre Surgeon (Lady or Gentleman). Salary £60 per annum,
with board, lodging on the premises, and washing.
WORCFSTF.a General Infirmary.—P hysician.
§irt|s, Proiages, aitii
BIRTHS.
CHETWOOD.—On Jan. 14tli, at Christopher-atreot, Mnsbury-square, the*
wife of William Cbetwood, M.R C.S., of a son.
Edwards.—O n .Tan. Hth, at Waverley. Sydney, the wife of Charles A-
Edwards, L.R.C.P. Ac,, of a daughter.
Elkington.—O n -Tan. 15th. at Newport, Salop, the wife of E. A.
Elkington, M.B. Lond,, of a son.
Hallkn.—O n Dec, 2lst, at Tres Arrovoa, F.C.S., Argentine Republic;,
tho wife of A. E H. Cornelius Hallen, M.B., C.M. Edin., of a son.
Mason.—O n Jan. I7th, at Boaemont, Maidenhead, Berka, the wife of
David James Mason, M.D.Edin., of a son.
Mathews.—O n .Tan. 17th. at Tandour Bolinghroke-grove, Wandsworth*
common, the wife of E. Dewar Mathews, of a daughter.
Richardson.—O n Jan. 14th. at Bryngwy Rhayader. Radnorshire, the
wife of Frank L. C. Richardson, surgeon, of a daughter.
Welt-s,—O n .Ian. I4tli, at Belsize-park, N.W.,the wife of Poulett Wells,
M.B., of a son.
West-Symes.—O n Jan. 15th, at Hope Hall, Halifax, the wife of
Edmond West-Symea, M.D., of a daughter.
West—O n Jan. lf>th, at Wimpole-atreot, Cavendish-squaie, W., the-
wife of Samuel West, M.D., of a son.
MARRIAGES.
Clarkf.—Joplin—O n .Tan. 14tb, nt st. Matthew’s. Thorne ITatnlet;
Norwich, W'lHani PYedeHck ClavVo, M D.. B.8. Lend., to Amy
Robertson, daughter of tho late Rev. J. J. Joplin, of Halifax,
Nova Scotia.
Lawson—Tavlor.—O n Jan. I4th, nt Almondburv Parish Church, near
I-rudderafleld. Doctor F. Duncan I^twann, of Burrell House, Chid-
dingfold, Siirrev, eldest son of William Lawson, Eso.. of 88,
Pahiierattm-vond, Dublin, to Crace Crosland, daughter of the late
John William Taylor, Esq., of Mooi-fleld, Huddersfield.
PEMiiEUTON— Hooper.— On .Tnu. 14th, nt Nt. Mnry Abbot’s, Kenstng-
-4> ton. Robert Pemberton, Surgeon-Maior IT.M.'s Indian A'roy, to
Mabel Constance, younger daughter of Mrs. Sydney Hooper.
Randlf.—Davies.—O n Nov, ifith. iSflO, at St. Paul’s Church, Bread-
fniit, Lagos, West Africa, bv the Honournlde and Rev. .Tames
Johnson and Venerable Archdeacon .Tohnson. .Tobn Randle, M.B.,
C.M. Edin., Assist.ant Colonial Surgeon, to Victoria Davies,
daughter of Capt. J. P. I.. Davies,
South—.T uPF.—On Jan. 20th, at St, Jude’s, .South.‘'ea, Henry Rrskino
.‘^oiith. Surgeon, R.N.. to Annetta Helena, youngest daughter of
Alfred .Tupp, of Saxon House, Southsea.
DEATHS’.
Balfour.—O n Jan. 17tb. at Coombe Lodge, WimWedon-park. T.
Graham Balfour, M.D., F.R.S., Surceon-General. Honorary Phyi
sician to the Queen. Int.e Pre.siilent of tho Royal Statistical Society,
in the 78th year of his age.
CuEHSY.—On Jan. 15th. at Hayesden, Wnllington, Surrey, William
Kvoranl Creasy, M.R.C.S., L.S.A., aged 70,
Rowan.—O n Jan. Hth, at Ladywell Park, Lewisham, Dr. Andreiv
Rowan, aged 82.
ViANT.—On -Tan. 17tli, nt Flinsfteld, Tottoii, Henry Viant, L.R.C.P.,.
M,R.C.S., L.M., L.S.A., in his noth year.
WiNSTANiKY.—On Jan. 17tb, nt “The Limes," Trgatcatone, Essex,,
Clement Winstanley, M.R.C.S. A L.S.A., aged 50.
y.B.—A /« of Bt. is l•f<ltr'Tfd■ for the T^itern'en of NoHeee of Births,.
Marriages, and Deatlts.
Digitizeij by
Google
,234 Thb Lancet,] NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 24,1891
grars for % mninf Mwfe.
Konday, Jaimazy 26.
Both. Loiodon Ofhtbhhio Hosfitai., Moorfields. —Operations
dally at 10 a.m.
BOTAL WESTUiNSTER OPHTHALMIC HOSPITAL.—Operations, 1.80 P.H.,
and each day at the same hour.
Ohslsba Hospital fob Women.—O perations, 2.80P.H.; Thursday, S.80.
Bt. Mark’s Hospital.—O perations, 2.80 p.m. ; Tuesday, 2.80 f.h.
Hospital fob Women, Soho-sqvare. — Operations, 2 f.h., and on
Thursday at the same hour.
USTBOPOUTAN FREE HOSPITAL.—Operations, 2 p.m.
BoYAL Orthopedic Hospital.—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 f.h., and
each day In ^e ^eek at the same hour.
Cnitersity Colleob Hospital.—E ar and Throat Department, 9 A.H.:
Thursday, 0 a.u.
London Fost-oraddatb Course.-R oyal London Ophthalmic Hospital,
Moorflelds : 1 P.H., Mr. B. M. Gunn : Affections of tlio Cornea.—
Ismdon Throat Hospital, Great Portland-st.: 8 P.>1., Mr. W. R. H.
Stewart: Otorrhcna.
BOCTBTY op Arts.—8 f.h. Mr. A. J. Hipkins: The Construction and
Capabilities of Musical Instruments, (Cantor Lecture.)
Ubdical Society of London.—8.30 p.m. Adjourned Discussion on Dr.
William Duncan’s and Mr. Alban Doran’s papers on “The Operative
Treatment of Chronic Disease of the Uterine Appendages."
Tuesday, January 27.
Sing’s college Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
OuY’s Hospital.—O perations, 1.80 p.m., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 f.h.
St. Thomas's hospital.—O phthalmic operations, 4 p.m. ; Friday, 2P.H.
Cancer Hospital, Brohpton.—O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
St. Mary’s Hospital.—O perations, 1.80 P.M. Consultations, Monday
2.80 P.M. Skin Department, Monday and Thursday, 9.80 A.M.
^roat Department, Tuesdays and Fridays, 1.80 P.M. Electro-
therapeutics, same day, 2 p.m.
London Post-graduate Course.—B etUem Hospital: 2 p.m.. Dr.
Savage : Mental Stupor, Dementia.
BOYAL Destitution.—8 p.m. Prof. V. Horsley; The Structure and
Functions of the Nervous System.
Society of Arts.—8 p.m. Mr. William Simpson : Lithography, a
Finished Chapter of Illustrative Art.
BOYAL Medical and Chirubgical Society.—8.30 p.m. Dr.P. H.Pye-
Smith: The Therapeutical Value of Venesection, its Indications and
its Limits.—Sir G. M. Humphry: On Macrodactyly and some other
forms of Congenital Overgrowth, and their Relation to Tumours.
Wednesday, January 28.
National Ortboprdic Hospital.—O perations, 10 a.m.
Middlesex Hospitau—O perations, 1 p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
BT. Bartholomew’s Hospital.—O perations, l.30 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 P.M.
Surgical Consultations, Thursday, 1.80 p.m.
Charinq-cross Hospital.—O perations, 8 p.h., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 P.M. Thursday ASaturdayisamebour.
St. Peter’s Hospital, Oovent-garden.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Children.—O perations,
2.80 P.M.
Oreat Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.80P.H,; Skin Depart¬
ment, 1.45 P.M.; Saturday, 9.15 a.h.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations,9.80 a.h. ;
Surgical Visits on Wednesday and Saturday at 9.15 a.h.
London Post-oraduate Course.—H ospital for Consumption. Bromp-
ton: 4 p.H.jDr. C. Y. Biss: Asthma and its Be.sults.—Royal London
OphthalmlcHospital,Moorflelds; 8 p.m., Mr. A.Q. Sllcock: Glaucoma.
Hunterian Society.—8 p.m. Clinical evening. Dr, Dundas Grant;
Epithelioma of Larynx treated by Thyrotomy, wid other cases (by
limelight).—Mr. T. Mark Hovell: Multiple Papilloma in Larynx of a
Boy aged three years and a half removed by Forceps.—Mr. John
Polana: Rheumatoid Arthritis in a Child.
Society ok Arts.—8 p.m. Mr. C. Thomas: Illustrated Journalisin.
Thursday, Jaauary 29.
St. George’s Hospital.—O perations, l p.m. Surrical Consultations,
Wednesday, 1.80 p.m. Ophthalmic Operations, lYiday, 1.80 P.M.
University CIolleoe Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 A.H.
LONDON Post-graduate Course.—N ational Hospital for the Paralysed
and Epileptic: 2P.H.,Dr.C.Ba8tian: SomeVarieties of Hemiplegia.—
Hospital for Sick Children, Great Onnond-st.: 4 p.m., Dr.^riow;
Morbid AnatomyofRlckets.—London Throat Hospital, Gt.Portland-
street; 8 P.M,, Mr. Geo. Stoker: Malignant Disease of the Larynx.
BOTAL Institution.—3 p.m. Mr. Hall Caine; The tittle Manx Nation.
Ophthalmological Society ok the United Kingdom.—8.3() p.m,
PatientsandCardSpecimensatSi’.M. Dr.B6rry<Edinburgh): (1) An
Unusual Result of Cataract Extraction; (2 )Od the Connexion between
Accommodation and Convergence.—Mr, T. Thompson (Cavdil!'):
(1) Miners’ Nystagmus amongst the South Wales Colliers; (2) Case of
Emphysema of the Conjunctiva.—Mr. Lawford (for Mr. G. D.
Johnston of Vancouver): Penetration of Eyelash into Anterior
Chamber; removal by operation.—Mr. Hartridge: (l)Caae of Chronic
Glaucoma, with Hmmorrbage into Cup; (2) Set of Models for Demon¬
strating Errors of Refraction.
Friday, January 80.
Royal South London Ophthalmic hospital.—O peratlona, 2 p.m.
London Post-graduate Course.—H ospital for Consumption, Bromp-
ton: 4 P.M., Dr. C. Y. Biss: The Treatment of Asthma.
Royal Institution.—9 p.h. Sir Edward Fry: British Mosses.
The Sanitary Institui'E (Parkes Museum, Margavet-st., W.).—8 p.m.
Sir Douglas Galton: Ventilation, Warming, and Lighting.
Saturday, January Si.
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O peratlona, 2 p.m. ; and Skin Depart¬
ment, 9.15 A.M.
London Post-graduate Course,—H o^ital for Diseaseaof the Skin,
Blackfrlars: 2p.M., Dr. Payne: The Diseases called Acne.—Bethlem
Hospital: 11 a.m., Dr. Percy Smith: Clinical Demonstration.
Royal Institution.—S p.m. Mr. W. Martin Conway: Pre-Greek
Schools of Art.
METEOROLOGICAL READINGS
(Taken daUv <U 8.tO a.m. by Steunrd'e Inatrumenta.)
The Lancet Office, Jan. 22nd, 1861.
Data
Bwometar
reduced to
Bee Level
and Sa°F.
Dlreo-
tloa
o{
Wind.
&.
Vet
Bulb.
Bolar
Radis
In
Vacuo.
Maxi¬
mum
Temp.
Bhode.
Min.
Temp
Rain¬
fall.
Bemorkiat
6.U A.M.
Jan. le
soil
N.E.
82
45
83
31
•06
Snowing
>• 17
30-80
N.B.
28
40
30
26
Cloudy
„ 18
SO'43
N.E.
26
52
81
23
Bright
M 19
30-31
N.W.
27
80
87
24
Overcast
„ 20
80'06
S.W.
37
30
56
45
27
Overcast
.. 21
29'60
w.
86
84
59
42
81
•18
Bright
„ 22
29-47
w.
36
36
62
44
84
Cloudy
Butts, Cffmmtnls, ^ ^itsters tu
(fflmspnhKts.
It is especially requested that mrly intelligenee local
events having a medical interest, or which it is durable
to bring vmaer the notice of the profession, mevy be sent
direct to this Office,.
All comnvumcations relating to the editorial business gf the
jmmal must be addressM “ To the Editors,"
Lectures, original articles, and reports should he written on
one side only of the paper.
Letters, whether intended for insertion or for private in¬
formation, must he authenticated by the names and
addresses of their writers, not necessa/my for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressm ''To the Sub-Editor.”
Letters relating to the publication, sale, and ad/vertising
departments of The Lancet to he addressed "To the
Publisher.”
We cannot undertake to return MSS. not used.
KOCH’S TREATMENT OF TUBERCULOSIS.
To the JSAitora of The Lancet.
Sirs,—I see by your report of tbe recent discussion at the Harvoian
Society that I am credited with having said that I bolieved that if
Koch's treatment was to be of service (in surgical caaes) acute, and not
chronic, ones should bo aelected. I cannot venture to make any such
statement. My remarks wore to the effect that for certain reasons the
definite conseiuences noticed in comparatively active dieoaae could not
be expected in the very chronic cases which were treated by injection
at this hospital.
I should not trouble you with this correction but for the widespread
interest shown in the subject,—I am, Sir.s, yours faithfully,
Hospital for Sick Children, Great Ormond- J. D. Mortimer
street, W.C., Jan. 17th, 1891.
R. JI. F.—\. The report appeared as a separate folio volume, entitlod
“ Supplement in continuation of the Report of the Medical Officer of
the Local Government Board for 1887 on Diarrhma and Diphtheria
|C. 66381,1889” (Eyre and Spotttswoode, East llarding-street, E.C.)—
2. The annual reports of the Local Government Board, and also of
the Medical Officer of the Board (which are a distinct aeries), can be
obtained of the same publishers. Their prices vary according to
their contends.
Mr. W. M. Roooro/f.—Application had better bo made to the hon. secre¬
tary of the Cremation .Society of England, Mr. J. C. II. Swinliourne
Haiihan, 8, New Cavendish-atreet, Portland-place, W.
Ncvn.o,—Our correspondont'a tiuery is not sufficiently explicit. More¬
over, the flr.st two rjualiilcationa are diplomas, not degrees.
Dr. John W. Keyworth Is thanked.
DigiLi£^:d
.oogic
Tbb Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 24, ISfll. 2a5
“TAXATION AND SANITATipN.”
To the Sditora of The Lancet.
Sins,—I have read with much intorost tlie criticism upon my paper,
which appeared In an annotation in your issue of Jan. 3rd, under tiie
above heading; but the brevity of the paper prevented my giving
a more comprehensive or complete statement of my views. In order
to make it clear to your readers, will you allow me to say: 1. I
hold it is unnecessary to tax houses or improvements at all if a just
tax be levied upon land values arising from the growth of population,
and in proportion to the increase in the wealth of the cammunity.
2. That the present system of the taxation of houses is a very great
hindrance to the construction of substantial houses, and distinctly con¬
duces to the use of bad materials and of cheap and inefBciont sanitary
appliances. 8. That one result of the taxation of industry is simply
the enrichment of tho groat landlords, who thus receive as a present
the unearned increment of the land which is created by tho public.
That the neglect to tax land values puts a premium upon with¬
holding land out of use until the enhanced value enables ground land¬
lords to get tbelr price. So much land is kept idle or put to an inferior
use that a monopoly value is given to lands which are in the market.
6. If taxation could be transferred from the improvements to land
values generally, the result would be to “ the man who is the lucky
possessor of a freehold and lives upon it" that the taxation being
shifted—if the house be of the same value as the land—he would pay
the same amount of tax on the land as be now pays upon the improve¬
ments, but lie would bo free to further improve or completely rebuild
liis house without his assessment being augmented pari pa/fsu. His
taxes would probably be considerably loss than at present, because the
taxation upon land values generally would bring into the field of taxa¬
tion a great deal of land either not built upon or held out of use. The
present system encourages the landlord to tiold valuable land out of
use until the growth of population near it enhances its value. It
imposes a fine upon the landlord who builds upon or otherwise improves
his land by taxing him in proportion to the intelligence and energy lie
exercises. Such a system, 1 would urge, is therefore unjust and inex¬
pedient, existing for the benefit of tlie bad landlord wlio does nothing
and to the detriment of the landlord who is disposed to make improve¬
ments in buildings and sanitation.—I am. Sirs, yours truly,
London, Jan. 7th, 1891. S. M. Buiuioutjus.
A. H. £.—It is difficult to answer our correspondent's question in
general terms, as a large number of gas undertakings are regulated
by private Acts of Parliament; but, generally speaking, the statutory
penalties for default In respect of the Rutfidency or quality of the
supply may be enforced either by the local authority or any aggrieved
consumer.
Qwne.—X. No general rule can be laid down.—2. The decision must rest
on the circumstances of eacli individual case.
F. C. might consult Huth’s boolc on “Mai-riageof Near Kin,’’ published
by Longmans.
1-ONGEVITY.
To the ISditors (tf THE Lancet.
Sirs,—S eeing in the Pall Hall Budget for Oct. 23rd, 1890, an account
of a Widow Morfew, wlio is reported to be the oldest woman in tho
world, 1 thought a few particulars about a late patient of mine might
interest some of your readers.
Mrs. George Davis died at Gounyan, near Yass, N.S.W., on Aug. 20th,
1889, at the reputed age of 113 years. I knew her personally for six
years, and my late partner, Dr. Oampbell, for nearly fifty years. She
was a native of Dorsetshire, and arrived in this colony in 1803, at tlie
ago of twenty-seven. She was marrietl in England, and ivas a widow
when she came out. She married for the second time George Davis,
about the year 1809. Hot eldest child by him, a daughter, would, if
she had lived, have been seventy-nine years old last year, and tho
second child, the present George Davis, sen,, is alive and well, aged
seventy-seven years last year. Her son George Davis, lier grandson
George Davis, and her great grandson George Davis I know personally,
all being patients of mine. Her husband died in 18C7, aged eighty-nine
years, and her son lias often assured me that his mother was two years
older than his father. She was the first wliito woman to cross the Gap
Itanges, separating Yass from Goulburn, and tlie first white woman to
see and cross tho Yass Plains, which she did in 1828. Tlioy made tbeir
home at Gounyan, ton milos from Yass, where she had constantly
resided since. Her son Thomas, now dead, was tho first white child
born between Goulburn and Port Pliillip (now Melbourne). She always
enjoyed most excellent health, and up to ton years previously to her
death drove into Yass regularly every week to sell dairy and garden
produce. A few months before her death I saw her in Yass,she having-
been driven in to transact business about land, which she was quite
J^ipable of doing. Ilor hearing, siglit, and memory wore somewhat
impaired during the last few years; but she was able to walk about the
house and garden up to a fortnight of iiov deatli, whicli was caused by
uryslpelaa and senile decay. That she was considerably over 100 years
old there can bo no reasonable doubt, as her second child by her second
husband was sevonty-sevoii years old at her death, 8he lived to see
her childron’schildron (by her second husband) to tlio fourth generation,
and her descendants, I am told, number over 6GO, With her, the oldest,
was buried a groat grandchild, a babe of only a few hours, the youngest
of the Davis family. I am, Sits, yours faithfully.
Yaes, N.S.W., Dec, 12tb, 1890. P. T. T.
The Manufacture of Drcqs from Crude Chinese Products.
Much Ingenuity is freqiftntly exercised by practitioners in eastern landff^
whose knowledge of botany, chemistry, and of the native language
and customs is considerable, in taking as much advantage as possible'
of drugs which are always obtainable on the shortest notice. An
instructive paper has recently appeared in the Chitia Medical Kisalon-
ary Journal by the Rev. A. W. Douthwalte, M.D., on the use of
native drugs. Arsenic trioxide may be prepared by subliming tho
crude mineral (Sing ahih), and condensing the fumes on the inside of a
basin kept cool by means of ice, or a cloth wrung out of cold water.
For the manufacture of sublimed sulphur all that is required is an
iron pan in which to bum the native sulphur, and a tube to convey the
fumes to a large wooden box, on the sides of which the fiowery
crystals will be deposited. Rectified spirit can be made in a native
still from native whisky, with half its weight of freshly burned lime.
Chloroform, too, can be thus made: From native sulphate of irooi
you obtain sulphuric acid by distillation; from this and salt you.
obtain hydrochloric acid; from this and native oxide of man¬
ganese, which is used by painters in drying oils, ns with us,
you obtain chlorine; from which native lime you obtain chloride of
lime, and this distilled with -native spirit gives you chloroform.
Spanish fly is common in some provinces, and the natives believe that
their preparation of it is stronger than ours. A valuable styptic feni.
was mentioned which is as yet but little known out of China, the
Pangar Djambi, or goldon lion hair, the soft down on the stalk of
which has a romarkable effect in arresting hromorrhage, a hard
coagulum being formed on the surface of the down.
Mr. J. 5in-inp.—Application might be made to Mr. P. D. Coghill, Royat
Veterinary College, Camden Town, London, N.W., who will probably
be able to supply our correspondent with the loan, at any rate, of any
slides lie may require.
Dr. S. W. Smilk.—MoBsva. Kogan Paul, Trench, and Co., Ludgate-hill,
London, K.C.
ASSISTANTS.
To the JBditore of The Lancet.
Sirs,— “Justus” accuses me of “ignoring’’ unqualified assistants,
when what I did was to draw attention to them; I said I had no¬
objection to the employment of unqualified assistants if the patients
knew them to be such, and merely drew attention to the fi-aud that is-
perpetrated through and by them on a confiding public by their being
palmed oft as fully qualified. About his friend’s pamphlet, which is
going “ to set at rest the vexed question of the usefulness of unqualified
assistants to medical men,” I have not heard of anyone denying their
usefulness to their employers. I consider tliem very useful, especially
to that unprincipled section which does not hesitate to palm them off
as fully qualified; though their usefulness to patients may well
be questioned. I am not an assistant, and do not want to be. 2
only draw attention to the fraud so that it may be remedied for the
honour of the profession and tho protection of the public. Tho only
time 1 acted as unqualified assistant was during a vacation. I had not
been at my post many hours before my employer represented me os-
fully qualified, and wished me to do tho same; and great was his sur-
p rise at my objection to being a party to this gross fraud. Ho said all
the students he had bad previously had represented themselves os fully
qualified. I resigned, and left the same day. Since then I have found
that this fraud Is almost the invariable rule. I agaan repeat, I have no
objection to unqualified assistants if they are known to the patients as
such. I am. Sirs, yours truly,
Jan. -ITth, 1891. X. Y. Z..
To the Editors of The Lancet.
Sirs,—'W ill you kindly allow me briefly to reply to the letter signed
“Justus,” which appeai-ed in last week’s issue of TiiE Lancet?
I think that “ Justus”—of course, .inadveitently—will^ivo rise to an
orroneou.-j impression with many who are considering the important
subject of the unqualified assistant; for he .assumes that they aro
medical students walking the hospitals. I think I am justified in
saying that three-fourths of the men complained of ate not students at
all, or, if so, are not medical students, but phaimaceutical students,
who enter tho ranks by taking appointments as dispensers to general
practitioners. Even in the case of medical students it cannot be just
and right that persons should seek and pay for advice at a legnily
qualified practitioner’s consulting-room, and, without knowing it, receive-
and pay for the advice of one who is not so qualified. I think it will be
long before we hear of a pamphlet from the rector of a parish on “The-
Uaefulnoss of the Bogus Clergyman as Cumte."
1 am, Sirs, yours faithfully,
Jan. 10th, 1891. A Qualified assistant.
B. A. C.—The suggestion'is a judicious one, but a vessel should bo
selected which is especially fitted up and destined for the reception
of persons who aro subject to the inflnuity referred to byourcorre-
spondout.
Mr. J. II. Heron.—From what is icnown of tho disease we fear that
there may bo some slight risk of contagion in the case of tubercular
leprosy with ulceration under the conditions mentioned.
. . Google
286 Thk Lanobt,] notes, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 24,1891
A Dangerous Remedy for Malthusians.
An American physician is reported to have t 2 ;fVen the following teeti*
mony;—“Mrs.-had been Buffering with uterine troubles for ten
years. She also had leucorrhosa. One bottle of-effected a com¬
plete cure, also causing conception, and a fine child after twelve
years of barrenness.”
Zi.it.C.P.—Our correspondent must exercise hla own judgment in the
matter. AVe may say we do not repeat any announcement of the
kind in respect of which we receive any complaint.
Seolus.—It seems to us very doubtful whether such an inq\ui'y would be
attended by any useful result.
Jfr. 0. W. B. Stevens.—The scheme was noticed in Tiik Lancet of
Oot. 11th last.
Dr. Daniel TTWis.—Our correspondent probably refers to Professor
Seegen.
Mr. 0. ifudson.—-The lecture was not reported in THK Lancijt.
COMHUNICATIONS, LETTERS, &0., have been received from—Mr. Bland
Sutton, London; Dr.Willoughby,London; Dr. Steavenaon; Dr.Leslie
Phillips ; Dr. Stewart, Whitby ; Dr. Crawford, London ; Mr. Lawson
Tait, Birmingham ; Mr. Hutchinson, London ; Mr. Howarth, Bedford ;
Dr. Stoker, London ; Dr. Apostoli, Paris; Messrs. Keith and Co., New
York ; Dr. Kirk, Paitick ; Mr. W. A. Lane, London; Mr. Lawrence
Hamilton, London; Dr. Stevenson, Carlisle ; Messrs. Merryweather
and Sons, London ; Mr. J. D. Mortimer, London ; Messrs. Wood and
Co., New York ; Messrs. Livingstone, Edinburgh ; Messrs. Laughton
and Co., London; Mr. Heron, London; Mr. Blackett; Dr. Kingston
Fox, London ; Mr. T. Cooke, London; Mr. Sloroan ; Messrs. Horner
•and Sons, Aldgate; Dr. R. M. Moffat, Jersey; Mr. W. Furrier, West
Brighton ; Mr. Mackeson, London ; Mr. Foulerton, Chatham ; Mr. Le
Feuvre, Jersey; Mr. Warren, Bxraouth; Mr. Barlow; Messrs. Black
and Co., London; Mr. E. N. Davies,Pontypridd; Mr. Cuinining, Great
Harwood; Mr. Atkinson, London; Messrs. Pimms; Messrs. Qrlthn
-and Co., London; Messrs. Kells, London; Messrs. Richardson and
Co., Leicester; Mr.Wright,Tbirsk; Messrs. Burgoyne, Burbidges,and
Co., London ; Mr. Brooks, Hull; Mr. Hall, Woking; Messrs. Austin
and Son, Bristol; Messrs. Keith, Edinburgh ; Messrs. Cassell and
<3o., London; Dr. Luff, London; Mr. Pead, Dulwich; Messrs. Bates
and Co., London; Mr. Thonilinson, Partick; Mr. F. Davies, North
Walsham; Mr. Gravatt, London; Mr. Ilall, Surrey ; Messrs. Isaacs
and Co., London; Mr. Scott, jun., Dundee; Messrs. G. Back and
•Co., London ; M. Huffkine, Paris; Mr. Bradley, Leeds ; Mr. Lauphin,
Alford; Dr. Ross, Tarrilf ; Mr. Church, Maidstone; Mr. Soper, Dart-
•mouth ; Messrs. Morley, I/ondon ; Dr. Hehir, Hyderabad; Dr. Knox,
Paris; M. Castoldi, Brescia; Professor Rose, London; Mr. A. Neve.
Kashmir ; Mr. B. Pollard, London; Dr. Blomflold, Exeter; Mr. F. E.
Place, Exmoutli; Mr. Batten, Loudon; Dr. Money, London; Mr. H.
Burton, Marple ; Mr. Richardson, Radnorshire; Mr. St. V. Mercier,
London ; Dr. Sinclair, Manchester ; Mr. Mason, Manchester ; Mr. A.
Hunt, London; Dr. Drage, London ; Mr. Adam, Glasgow ; Dr. J. W.
Carr, London ; Mr. Browne, Liverpool; Messrs. Hockin, Wilson, and
Co., London; Dr. Younger; Mr. Denman, Beaconsllold ; Mr. Wand,
Leicester; Secretary, General Infirmary, Macclesfield; A Qualified
Assistant; Kcotus ; M.D.; P, T. T.; R. H. F.; Secretary, Blackburn
Infirmary; Lorna, London; Eovd., Ipswich; Maltine Manufacturing
Co., London ; U. S., Lewisham ; Devon, London ; Eagle Range and
Foundry Co., London; Dowker, London; The Clerk, Winchcombo
Union ; T. D., London ; Alienist, London ; Alpha, Mancliester ; Lady
Superintendent, Forest-hill ; Chichester Infirmary; Medical Officer
of Health ; Alpha, Chesterfield ; L.ll.C.P.
Lettbrs, each vnth enclosure, are alao acknowledged from—Dr. Bastlan,
London; Mr. Smith, Bradford ; Dr. Broiinor, Bradford; Messrs. Ellis
and Co., Staffs; Messrs. Riininington, Bradford; Messrs. Richardson
and Co., Liverpool; Dr. Arnison, Newcistle-on-Tyne ; Messrs. Brown
and Son, Douglas; Mr. Naylor, iliekley ; Messrs. Vanderpump and
Son, London; Dr. White, Sheffield; Messrs. Oppenheimer Bros, and
Co.,London; Dr. Ritchie, Otley; Mr. TuUy, Hastings; Messrs. TapIIn
and Tanner. Winchester; Mr. Edgeworth, Bristol; Mesers. Curtis
and Co,, London; Mr. Burke, Wolverhampton; Mr. Hyatt, Shepton
Mallet; Dr. Deane, Ellesmere; Miss Wendon, Essex‘.Messrs. Blondeau
et Cie , London ; Mr. Detmould, Bournemouth; Mr. Cuthbert, West
Bromwich; Mr. Tyte, Minchinhampton; Dr. Philip, Newoastle-on-
Tyue; Mr. Jones, Eckington ; Mr. Lewis, Birmingham; Mrs. Davies,
Liverpool; Mrs. Gregory, Swindon; Mr. Elliott, Devon; Mr. Oliver,
Doncaster ; Mr. Mouth, Somersetshire ; Dr. Gunther, Massachusetts,
U.S.A.; Mr. Simpson, Norwich; Mr.Wright, Lambeth; Mr. Scott,
Felling-on-Tyne ; Mr. McKeay, Eastbourne ; Mr. O’Meara, Lough¬
borough; Mr.Dyer,Ilfracombe; Mr.Rowlands,Towyn; Mr. Jennings,
Manchester; Mr. Croydon, Iiigatestone ; Mr. Fletcher; Mr. Johnson,
Forest-hill; Mr. Barclay, Glasgow ; Mr. Shimold, Ilford ; Mr. Isaac,
Wokingham ; Mr. Bannatyne, Greenock ; Mr. Williams, Machyn¬
lleth ; Mr. Cross, Sheffield; Mr. Maegregor, Glasgow; Mr. Lockwood,
Allurton; Mr. Sullivan, Tralee; Mr. Rutherford, Redcar; Dr. Hinde,
Banbury; Mr. Williams, Bristol; Dr. Tizard, Weymouth; Mr. Roe,
Somerset; Mr. Williams, Birkenhead; Mr.Bonlter; Miss Shrubshall,
Laugliton; Mr. Heywood, Manchester; Mr. J. W. Adam; Dr. Owen,
Gloucestershire ; Mr. Macaulay, Leicester; X. Y., London; R. O. B.,
London ; Sultan, Hampstead ; D. G ; Secretary, Clinical Hospital for
Women, Manchester; Medicus, Strand; Trobor, London; Rotherham
Hospital; //., London; Medicus, Choltenliara; Secretary, Norfolk and
Norwich Infirmary; Loxton, Bristol; X. Y. Z., London; Worcester
General Infirmary; X. Y., Leeds; E., Kilburn; Secretary, Warneford
Asylum, Oxford ; B. A., Staffs; J., Barnsley; Liverpool Convalescent
Institution; M., Accrington ; H. S. C., London; Branch; Royal Isle
of Wight Infirmary, Rydo ; Assistant, London ; T. S., London; Box
14, Uttoxeter; Student, London; Practitioner, London; Physician,
London; Tarau.s, London; Delta, London; H. W., London; Fides,
London; M. E. M., London ; Fibula, London ; Thorax, London ; M.,
London ; Ciomwell House, Yorkahiro ; Alpha, Kidderminster ; B. B.,
London; Devon, London; Dr. O., Manchester; Single, London; J.,
London; Durham, Newcastle; Sigma, Broewood ; Imperial Dairy
Co., Old Kent-road : Alpha, Manchester ; A. F. C., Seaforth ; Nurse
: Farrington, Drogheda ; Viola, London; Beta, London; M.D., Swan¬
sea ; T. D., London ; Matron, Ventnor ; A. B., London; A. B., Dept¬
ford ; A. B. C., London ; F. O., London ; C. M., London.
Newspapers. — Evening Telegraph {Dublin), Rangoon Times, Norfolk
Daily Standard, Jiastem Morning News, Newcastle Daily Chronicle,
Glasgow Herald, Scottish Leadtr, Windsor and Eton Express, Reading
Merewry, City Press, Weekly Free Press, Mining Jo'tvrnal, Hertford¬
shire Merev/ry, Scolsnum, Liverpool Daily Post, Leeds Mcrcur;/, Law
Jounia', Eilkenny Journal, Windsor and Eton Gazette, West Middle¬
sex Standard, Bristol Mercury, SDCclator, Architect, Guy's Hospital
Gazette, Surrey/ Advertiser, Laily News, Saturday Review, Pho/rma-
ceutical .Tournal, Dorset County Chronicle, Derby Mercury, Bilston
Weekly Herald, Birmingham, Daily Post, Madras Times, Boston Inde¬
pendent, Corriore d'Halia, Haddingiotishire Advertiser, Loughborough
Herald, Blackpool 'limes, Hawick Advertiser, Leek Post, Bedworlh
Guardian, Rugby Adve7'twer, Braintree Advertiser, Wiadoniosci
Faimaceutycznych, Work, The Therapist, <t'c., have been received.
SUBSCRIPTION.
Post Free to any part of the United Rinqdoh.
One Year...£1 12 6 | Six Months ... _ £0 16 8
To CHINA AND India ...One Year 110 16
To THE Continent, Colonies, and United
STATES .. Ditto 1 14 8
Post OfficeOrders and Cheques should be addressed to The Publisher,
The Lancet Office, 428, Strand, London, and crossed “London and
Westminster Bank St. James’s-square."
ADVERTISING.
Books and Publications (seven lines and under) _ £0 B 0
Official and General Announcements .. ^ » 0 6 0
Trade and Miscellaneous Advertisements _ .040
Every additional Line 0 0 6
Front Pitfe . _ m . . per Line 0 10
Quarter Page .. » . .110 0
Half a Page . . . . .2 1fi0
AnEntlrePage .. .. _ .. .. .. .660
The Publisher cannot bold himself responsible for the return of testi¬
monials Ac. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are requested to observe that it la contrary to
the Postal Regulatious to receive at Post Offices letters addreaaea to
Initials only.
An original and novel feature of “ The Lancet General Advertiser " is a special Index to Advertisements on pages 2 and 4, which not only
affords a ready means of finding any notice, but is in itself an additional adveotisement.
Advertisements (to ensure insertion the same week) should be delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should be
addressed.
Advertisements are now received at all Messrs. W. H. Smith and Son's Railway Bookstalls throughont the United Kingdom and all other
Advettlsing Agents. __
Aceat for ttie AitTertlaement Department in France--J. ASTIRR, 89. Bns CaumarUn, Pam.
Digitized by
Google
THE LANCET, January 31, 1891.
^fjjuir^n ipost-grakate €mxu:
ON TllK
NATURE OF LUPUS,
WITH ESPECIAL REFERENCE TO ITS RELATION
TO TUBERCULOSIS.
Delivered at the Examination Sail, Jan. 27th,
®Y JONATHAN HUTCHINSON, F.RS., LL.D.
LECTURE III.
'Gentlemen, —I have yet several other forms of lupus to
unention to you if time permitted. I should like to have
shown that in some cases its processes very closely resemble
those of an eczema, and that in others the follicles of- the
larger hairs may be attacked by preference, and that a sort
.of lupus-sycosis is the product. We juight also have
brought under consideration the curious and very interest-
ling malady which Hebra has named “ rhino-scleroma,”
in which the nostrils and upper lip become involved in a
lumpy, thick, indolent growth, which is certainly infective,
almost as certainly inflammatory in its beginning, and very
prone to return after operations. This disease is not abso
futely restricted to the parts from which it takes its name.
Although very different in many features from other forms
of lupus, I could, I think, have easily proved to your satis-
'faction that in its main features it comes much closer to
lupus than to any other malady, and that it has good claims
rjio be one of the family. My motive in bringing before
yon the different forms of disease which were the subject
of our last lecture has been double. First, I have thought
that these various types of morbid action, although most of
'them very rare in practice, are yet of sufficient interest to
«laim our careful recognition and study. Next, and for the
present occasion chiefly;, I have wished to convince you of
'the statement, with which I set out, that it is quite impos¬
sible to restrict the term “lupus” to anyone form. We
-can no longer say with any regard to pathological accuracy
that the disease which eats away the tip of the nose and the
•al® nasi, and is attended by the brownish-yellow apple-j elly
deposit, is “ lupus,” and that the others have nothing to do
^ with it. We can no longer speak of a “ true lupus ” and place
'^the other maladies apart as if they bore resemblance only,
and had no real relationship. No, the relationship is real,
•and its bond consists in this, that all these various maladies
depend upon inherited tissue-vice. That inheritance renders
'its possessors liable to chronic inOamniations, which assume
'Specialised peculiarities in each in connexion with the in¬
heritance of other tendencies, and modifiable also by the
.part of the body on which they are first displayed. In some
^jonnexion, tis yet very ill understood, it would appear that
these inflammations are peculiarly apt to be attended by
the development of the tubercle bacillus. Our knowledge
•does not permit of our being in any way definite as to what
the relationship of the two really is. AVe must wait for
further facts. I am bound, however, to repeat what I have
already said, that, looking at the facts as we have them
from a clinical point of view, they do not seem to favour
the belief that infection with the tubercle bacillus is the
sole and efficient cause of the disease which we call “lupus.”
The possession by inheritance of peculiarities as regards
cell nutrition, and proclivity to its disturbance, seems to me
at the basis of all maladies which assume the lupus type.
It is also, doubtless, of many others. In lupus that which is
'inherited seems to be a susceptibility to external influences,
above all to that of cold, but sometimes to that of heat also.
This appears to me to be the key to areal knowledge of the
nature of tlie disease. I have suggested over and over again
'that lupus erythematosus is after all only a modified form
of chilblain. Amongst the modifications which it haareceived
there is one which I admit to be all important. It is this
'that the products of the inflammatory action, or perhaps it.
would be safer to say its attendants, become capable of
spreading the disease by contagion. Cliilblain inllamraation
'is but little if at all capable of infecting the adjacent tissue;
but it has become so when it assumes the name of lupus
•erythematosus. This is its chief peculiarity. Since I had
'the pleasure of addiessing you last week a case has come
No. 3518.
under my notice which so emphaticallv illustrates these
views that you will almost suspect that I have invent^ it.
I show you the drawings from the case of a lady residing in
Essex, a little past the middle period of life. Yon wilfsee
that her hands are covered with patches of dusky ery¬
thema which affect the palmar surfaces more than the
dorsal ones. Her fingers are swollen, and their tips
peeling and excoriated. The nails are thin, softened, and
flattened out by the swelling of the fingers. Her hands are
disabled, and she cannot dress herself without the assistance
of her maid. We turn to her face, and on the nose and
cheeks we find the characteristic bat's wing patches of
lupus erythematosus, and a similar condition involves both
her ears. Her affection began in the beginning of the
present winter, which, as you know, has been exceptionally
cold. In reference to the possible influence of season, how¬
ever, it must be remarkea that the patient has been living
in warm rooms and surrounded by every comfort. Shall we
call the diseash lupus erythematosus or acute erythematous
chilblains ? In one sense it matters but little Avhat we call
it; for in the beginning I hold that they are the same
thing. As regards prognosis, however, very much depends
upon the name. If it Le chilblains only, it will probably
{ lass wholly away when the warm weather comes. If it be
upas, it will be relieved by warmth, but not cured. It
will demonstrate infective qualities, other patches will occur
on adjacent parts, and it may probably prove incurable.
I have myself no doubt whatever that the disease has to
some extent passed into the lupus condition, and that the
prognosis just suggested will be the one realised. At the
same time, 1 have no doubt that the red patches which you
see on the hands are to all intents and purposes acute chil¬
blains, and that they will pass away when the warm
weather comes. In saying this 1 am not speaking at hap¬
hazard. A lady whom I have been attending for the last
three years for patches of lupus erythematosus on her nose,
cheeks, and chest bad her disease begin during cold weather
by an attack of inflammation of the bands, attended by
cracking and excoriation of their tips. Very soon after this
a patch formed on her nose, and although her hands have
long since got well and continued so, the disease in most
typical conditions still continues on her face. This will be
a suitable place for me to tell you that both these ladies
had enjoyed very fair health through life up to tlie date
of the attacks which I have described. Both of them bad
suffered from chilblains in childhood, but in neither had the
proclivity been severe, nor bad it persisted in adult age. In
both of them, «s I hold is usual in lupus erythematosus,
there was an overwhelming family tendency to tubercu¬
losis. Miss, G-, the first patient, had lost a brother and
a sister from phthisis, and, to use her own expression, “ all
her father’s family excepting himself had died of it.” She her¬
self, on account of chest delicacy, bad been obliged to take
cod-liver oil for six months. In Mrs. K-^s ease (the
second one) the facts were almost equally strong, and she
lievself, although a lady of great energy, was fragile and
delicate. You will ask, on the hypothesis that lupus
erythematosus is uot a bacillary disease, and on the more
than hypothesis that chilblains have nothing to do with
bacilli, what is the bond of connexion between tubercu¬
losis, lupus erythematosus, and chilblains V I must reply
with what is only a conjecture. The lupus and the chil¬
blains are directly and essentially connected as depending
on the same kind of cell organisation and vascular endow¬
ment. They are influenced by the same kinds of disturb¬
ance of vascular eciuilibrium—such, for instance, as sex,
inherited delicacy, (.'fee., which are at the basis of Raynaud’s
symptoms. Their connexion with tuberculosis is probably
indirect and non-essential. They imply and reveal a state
of constitution in which the bacillus, once implanted, will
easily flourish. The discoveries of the future may perchance
demonstrate a closer connexion than this, but for the present
this is all that we can say.
Amongst the best established and yet tlie most remarkable
of the laws regulating the transmission of tendency to
disease are those whicli produce what are called “family
diseases.” By this term, in the special and conventional
sense, it is not meant that there is tendency to the recurrence
of the same malady in successive generations, but that in one
and the same family of children several examples of the
same malady are produced.
Family diseases, using the term in this sense, are all more
or less peculiar ; although they approach and resemble, they
I arc never exactly the same as those which are transmitted
. icogle
[Jan. 31,18&1.
288 The Lancet,] MR. JONATHAN HUTCHINSON ON THE NATURE OF LUPUS.
from generation to generation. Ichthyosis is one of the
best examples of what is meant; but deaf-mutiBin, colour¬
blindness, retinitis pigmentosa, and a host of other maladies,
also afford examples of it. Family diseases are by no means
always congenital; indeed, as a rule, they are not so, but
wait until the patient has attained a certain age, and until
the tissues have been subjected, so to speak, to a certain
amount of trial in the highway of life, before they are
developed. Then it is found that they will not bearordinary
exposure. The skin becomes dry and harsh in the case of
ichthyosis, or the retina speckled with pigment in the case
of that of retinitis pigmentosa. Although, as just said,
these family maladies are never the exact reproduction of
any other recognised disease, yet they have, I think, in¬
variably their prototypes, which they resemble, and which
probably stand to them in some mode of parental relation¬
ship. We must suppose for their explanation that in the
father and mother of children so affected certain peculiar
inheritances meet and become welded together in their
offspring. Amongst the minor forms of disuse which come
under this law of family production I believe that we must
count some cases of exaggerated tendency to freckles and of
some others to chilblains. Probably there is a family form
representative of nearly all the types of intrinsic disturbance
of health. I exclude by the word intrinsic all maladies caused
by accidents or due to contagion. Now it happens that there
is a family disease of which the following are the main
features ;—The children, several in the family, and always
all of them apparently healthy at the time of birth, become
in early childhood liable to the production, on a most extra¬
ordinary scale, of freckles. At first the disease is thought
to be ouly freckles, and in many cases it stops there ; but in
some others the freckles inllame and become vascular, and
ulcerations occur, and when they heal little vascular tufts—
stigmata—remain. The face is always the part most
severely affected, and exposure to either sun or cold are
the influences which exaggerate the disease. The tip and
aim nasie are often attacked, and then sometimes to a con¬
siderable extent destroyed. In later stages bossy masses of
granulation tissue may form on the ulcerated surfaces, and
later still, in exceptional instances, the ulcers may assume
the condition of epithelial carcinoma. Some of the milder
cases of this malady recover, and many probably survive
without actually recovering ; in not a few, nowever, it ends
fatally in an early period of adult life. It fell to my lot,
through the kindness of Mr. Balmanno Squire, to have the
opportunity of examining two children who were the sub-
t 'ects of this malady, and who were the first in whom it had
leen observed in Britain. I cannot tell the interest
•which they excited in me. “ Here,” I exclaimed, “ we have
the family form of lupus.” It was a disease certainly
not common lupus, hut partaking of all its characters,
affecting the same parts, evoked by the same class of
causes, and tending to the same results. Subsequently,
when I became acquainted with coses which were attended
by pigmentation only, I was inclined to modify the
expression, and to say that it was a family form of freckles.
But, later still, reviewing the facts which have since been
80 ably collected by numerous observers, I am inclinsd to go
back to my original position, and to hold that Kaposi’s
disease is really and essentially a family form of lupus.
You will see that it unites in itself lupus vulgaris and
lupus erythematosus—being symmetrical, but at the same
time showing a tendency to destroy by ulceration. Its
relationship to freckles is, of course, undoubted, and I put
it aside, not as in any degree ignoring it, but simply
because the relationship to lupus is much more important.
Probably after all the tendency to freckles, when extreme,
reveals an irritability of cell structures of the same kind as
that which lupus discloses. I need scarcely remind you,
for it has been often remarked, that strumous children are
very liable to freckle.
The argument which I adduce from this demonstration of
a family form of lupus is that the latter cannot be a disease
due to the accidental implantation of a parasite. If it were
80 it could nob have a family form. As to what the value
of the argument may be, and as to the cogency of the facts
on which I have built it, I leave them for your considera¬
tion. I have, however, much interest in showing you,
especially as I omitted them in their proper place, a series
of drawings illustrating cancer as it occurs in the ulcerations
of lupus. Some of them are taken from a report by Dr.
Bayha of Tubingen. By their side I show a beautiful
drawing lent me by Dr. Radcliffe Crocker, showing a fun¬
gating mass in Kaposi’s disease. I think you will find their
comparison instructive.
It remains to say a few words in defence of the attempt
to constitute a family of lupus diseases, instead of allowing
one single member of it to arrogate that name and leaving
a whole series of cognate affections to receive each for itself
a distinctive designation. It is quite possible that I hav©
not succeeded in convincing you, or at any rate all of you,
that the maladies of which descriptions have been given are
really all of them in their essential nature lupus. I may, how¬
ever, claim to have brought before you clinical evidence
that these several maladies do exist. Even of the very-
rarest I have been able to produce more than one aae&
(with the exception, perhaps, of Dr. Morrow’s), and thus
to prove that the malady m question keeps close to its-
type. Whilst this keeping close to type is true of a certain
number of cases in each group, I think I may also claim to-
have proved by deiponstration that there are ill-marked or
mixeu examples of every one of these type-forms which
constitute connecting links between them. If now we^
refuse to recognise a lupus family, if we continue to insist
that there is a true lupus,” that lupus erythematosus is
distinct from lupus vulgaris, and that the other diseases*
which I have claimed as belonging to the same family are
yetfurther apart from it, what is ourposition ? It seems to me
to be this: that we shall have bo continue to use a number of
separate names, and to invent many new ones, burdening
the memory of, the observer in each instance with detailed
descriptions, and at the same time nob throwing the least
light by nomenclature on the real nature of the thing»
described. We shall be involved in what is surely an a priori
improbability—the suggestion that there are a large number
of separate maladies resembling each other in some of their
features, but in reality wholly difl'erenb, having neither
known parentage nor relationship, and being in many in¬
stances sm* gicnem. Such would certainly be the position,
if we refuse to accept a lupus family, of the maladies known-
as rhino-scleroma, lymphangeioma pigmentosum, Kaposi'©
disease (or xeroderma pigmentosum), tuberculosis papulo-
matosa cutis, and a number of others. If we accept, on the-
other hand, the word lupus as the family name for them all,
coupling with it in each instance some distinctive epithet, this-
laboriously contrived confusion is avoided. The diseases in
question, ns I have already, and, I fear, at too great a length,
endeavoured to prove, have all of them these features in
common. They attack chiefly those parts of the surface of
the body which are exposed to the influence of cold and'
irritants, and they occur by preference to those who are by
inheritance or acquisition of somewhat feeble organisation,
and who are proved to be in greater or less degree liable to-
the attacks or the tubercle bacillus. Every one of the diseases
named is developed most commonly in the period of adoles¬
cence. They are all infective in their local qualities, and con¬
tinue to spread slowly for an indefinite number of years-;,
and it is possible in every one of them that after pro¬
longed duration as a non-malignant chronic inflammation a,
tendency to cancer may be shown. Every one of them dis¬
organises the tissues which have been affected by it, and
leaves behind it a scar. Concerning almost all of them, wc-
freely admit that 8yi>hilis may produce very close simu¬
lations, and, at the same time, we utterly deny that their type-
forms have any connexion, remote or otherwise, with such
taint. Finally, and most importantly, it is true that if the
word lupus were used in the sense for which I have pleaded,,
it woulil in every case to which it is applied afford a clue to
a correct treatment. With the exception only of the moat
erythematous forms of erythematous lupus, destruction by
local measures of the infective material is required in every
case, and, without any exceptions at all, attention to the
general health by the use of a liberally tonic regimen is
requisite, together with the protection of the parts from all
external irritation, and more especially from cold. A«
regards prognosis, it is, speaking in general terms, the same
in all. Very few cases will be really cured, and in almost
ail instances, even under the most careful and persevering
treatment, an inveterate tendency to relapse, or to a repro'-
duction of the malady, will be witnessed.
I might add that all diseases of the lupus family are liable
when inflamed to have the inflammation assume the charao-
tera of ervsipelas. This is a point which many observers
have noted; and, further, it has been generally agreed that
after attacks of erysipelas the lupus is usually in a much
improved condition. This was an article of creed which the
late Mr. Startin was very fond of expressing, and excepting.
The Lancet,]
MR. JONATHAN HUTCHINSON ON THE NATURE OR LUPUS. [Jan. 81,1891. 239
in erythexnatostu (in which such attacks may prove fatal), 1
have always been accustomed to hail erysipelas in lupus as
a direct gain to the patient. We must, I think, keep this
fact in mind when we examine the results of Koch’s treat¬
ment.
Before proceeding to endeavour to estimate the different
measures of success attending the different plans of treatment
for lupus, it may be well to say a few words as to the
grounds upon which such plans have been based, and to
what may be reasonably expected of them. My argument
has been that lupus processes of inflammation originate in
persons who are locally or constitutionally of feeble cell
nutrition and prone to vascular disturbance. That a
parasitic bacillus attends many of them is to be freely ad¬
mitted ; that its implantation constitutes the initial stage
of lupus may be strongly doubted. The influence of
enfeeblement of the general health, of exposure to weather
and to cold as causes of the aggravation of lupus must be
admitted by all without a moment’s hesitation. It is an old
observation that those who live in country districts and are
exposed to weather su^er more from lupus than those who
dwell in towns. It is also a matter of quite general know¬
ledge that most forms of lupus become worse in winter.
Applying those facts to the development of principles
of treatment, we should expect that much might be
done by attending to the general health of the patient,
and by protecting Mm from the influence of cold. Such is,
I may say, undoubtedly the fact. Whatever increases the
general tone does tend to restrict the lupus process and to
favour the healing of its ulcers. If the patient can be
allowed to remain in warm rooms during the winter, or still
better, if by changes of climate he may be enabled to enjoy
summer weather all the year round, the chances of recovery
from lupus will be very much increased. As regards lupus
vulgaris 1 cannot think that it is reasonable to expect a
cure, unless advantages of this kind can bo obtained. If
the patient is still to be exposed to a defective dietary and
a hard life, if the vigour of his nutrition is to diminish rather
than increase, there will then be no chance of his recovery
from his lupus. The causes which set it agoing still remain
in action, and they, in conjunction with his constitutional
tendency, would begin the disease anew, even if by success¬
ful surgery it had been completely cured. As well hope to
prevent the recurrence of chilblains in cold weather as that
of lupus in a patient who has once suffered from it, and in
whom no changes can be made in the conditions of life. In
reference to these assertions I might ask attention to the
results of treatment of lupus in two special classes of cases
in which I think nothing even approaching a cure is ever
obtained. I allude to those first, a large class, in whom
lupus begins in young persons who are obviously of very
feeble health ; and secondly to those, a small class, in whom
it begins in the aged. Senile scrofula in all its forms is less
amenable to treatment than that of young pereons, for it
occurs at a time when the powers of life are on the wane,
and when it is impossible to do anything definite in the
way of their reinvigoration. On the other hand, the cases
of lupus in which we do obtain cures, or in which we approach
them, are those in which the disease begins in young persons
or in early adult life, and is not associated with any con¬
spicuous enfeeblement of health or of circulation. In these
cases the advance of years is, if accompanied with suitable
local and constitutional treatment, in our favour. The
patient gets to eat and to drink more, and as the period of
growth ceases the constitution often settles down into a
state of more assured vigour. To use a popular phrase,
“ he grows out of his delicacy.’
In what has just been said I have been speaking solely of
the constitutional element in lupus; but we must not forget
for a moment that there is another, and even more important
one—I refer of course to its locally infective tendencies. In
a few cases constitutional treatment, or the improvement in
health stamina which comes with advancing years, is suffi¬
cient to put an end completely to the lupus process.
Examples of perfectly healthy scars without the least
fragment of lupus tissue remMning, and without any
tendency whatever to relapse in winter, may not infre-
q^uently be seen under these circumstances. Very often
they are in patients who have aullered from the disease on
several parts at once, and in wlioni some patches have under¬
gone cure, whilst others have persisted. Although not
very common, they are abundantly sufficient to prove the
point that the lupus process may, in exceptional instances,
come spontaneously to an end. In the majority of cases.
however, it may be freely granted that whatever be done
for the benefit of the general health it does not cure the
lupus patch. The latter continues in virtue of its own
infective elements to spread at its edge and to produce fresh
satellites. It is here that surgery comes to our aid. By
treating the lupus nodules exactly as we should those
of cancer or any other material known to be infec¬
tive, we can do very much towards effecting a cure.
Undoubtedly the surgeon takes the most conspicuous
if not really the principal share in the cure of lupus.
If I speak a little doubtfully on this point, and if I
seem to rate measures of constitutional treatment more
highly in comparison with local ones than I have done in
some of my former writings on lupus, it is because I have
become more and more convinced that it is absurd to expect
a permanent cure of a disease by measures which do not
include the removal of its original causes. The results of
surgical treatment, however careful and persevering, are, I
fear, on the whole, strongly confirmatory of this impression,
for however excellent may be the cure at first obtained, the
disease almost invariably relapses on fresh exposure to cold.
I will now pass to consider the details of the local
measures which have been chiefly employed. We will, if
you please, consider that enough has been said as to the
paramount importance of protection from cold and attention
to the geperal nealth. The different measures of local treat¬
ment have all had acommon object—that, namely, of getting
rid of the infective material. When I was a student at the
York Hospital 1 was taught to use for this purpose a chloride
of zinc paste, sparingly and thinly applied, and I have
never since seen better results from any treatment than, as
far as my memory serves me, we occasionally obtained from
this. Its use, however, Is inconvenient on some of the parts
which lupus most commonly attacks—the nose, for instance.
When I came to London and worked as assistant to the late
Mr. Startin at the Biackfriars Hospital, we treated all our
lupus patients by repeated applications of the acid nitrate
of mercury and an arsenical paste. If the surface were
not broken, the acid nitrate was applied; but if there
was an ulcer, then it was our practice to fill it
with the paste. These applications were made over
and over again. Our cases were very numerous and attended
frequently, and half my occupation many an afternoon
consisted in making these applications. Tlie patients always
took tonics and cod-liver oil, and often, for many years
together, minute doses of mercury. The results were on
the whole very satisfactory, but the treatment was tedious
and the periods of attendance very long. When some years
later the patients at this hospital passed under my own
care, and I had also at the Metropolitan Free and at the
London Hospital many other cases, I tiled'to expedite
the cure by the use of the actual cautery instead of the
acid nitrate. I had cautery irons of various sizes made,
and we used them, under an anmsthetic, very freely.
This was long before the introduction of M. I’aquelin’s
ingenious little instrument, and at that time we used to
heat our irons in the lire. At the time I thought
this method, as regards expedition, a great improvement,
and wrote strongly in its favour. I recollect that
my friend Dr. McCall Anderson of Glasgow also took
it up, giving figures of ray cautery irons. Somewhat
later Mr. John Gay made tlie radical proposal that lupus
nodules should be cat out with the knife, and treated ex¬
actly as we would those of cancer, but unfortunately the
inapplicability of this excepting to a small number of cases
was only too obvious. You could not cut away the greater
art of a man’s nose or cheeks. Later still came the intro-
uction of the process of erasion by means of VolckmanMs
scoops. This attained a very wide popularity, and it is
indeed a very efficient method. The general verdict would,
I think, appear to bo in its favour over all other methods of
local destruction. For myself, I may admit that I doubt if
it possesses any advantages over the use of the actual
cautery or the acid nitrate of mercury. 1 was accustomed
some years ago to use it frequently, but I find myself now
falling back more and more on tho older methods. Instead
of the arsenical paste which Mr. Startin employed so
much (Dupuytren’s paste), I now use the liquor arseni-
calis. The latter may be painted on with a camel-hair
pencil, and if the surface be not too largo the patient may
be trusted to do it himself. It does not perhaps matter so
much which of the several methods of getting rid of the
lupus tissue we adopt, provided we do it very freely, and
repeat it as often as is necessary. I have a decided impres-
240 Thb Lanokt,] MK. JONATHAN HUTCHINSON ON THE NATURE OF LUPUS.
[Jan. 31,1891.
lion, however, that the sores left after the acid nitrate or
the actual cautery heal better than after the scoop. In
many instances undiluted carbolic acid, freely and repeatedly
applied, is very efficient, and it has the great advantage
that, if the patient be intelligent, he may be trusted to
make the applications. 1 am quite aware that in this
sketch I have not enumerated by any means all the methods
which are employed in the local treatment of lupus. There
are many others, but 1 think that for the most part they
are of the same class. I must not, however, omit to men¬
tion that Dr. Unna of Hamburg some years ago introduced
a method by the application of plasters containing salicylic
acid, which for a time obtained great favour with some
well qualified to judge. I cannot speak from much personal
experience regarding them, but have formed the impres¬
sion that they are not less troublesome nor more efficient
than some of the other methods. In this connexion it
may be well to state that whatever in the nature of a
plaster or other application protects a lupus patch from
we influence of air and keeps it warm invariably does good.
This is of especial importance in reference to lupus necro-
genicus and to all lupoid afPections of the extremities.
As regards the prognosis of lupus, it is at once to be candidly
admitted that examples of complete and permanent cure are
rare. At the same time it is to be asserted that under
favourable conditions and peraeverence on the part of both
patient and surgeon, great improvement may b4 obtained,
the disease kept in abeyance, and a condition secured which
nearly approaches a cure. In cold weather, however, and
if through any influence the state of the health is lowered,
relapses are almost certain to occur in almost all cases. I
have recently had under observation a lady who when young
was quite cured of lupus under the old methods by the late
Dr. Anthony Todd Thompson. She enjoyed thirty years of
immunity, and has only now relapsed when her tissues and
her circulation have become enfeeoled by age.
We must now engage in the most interesting question of
all in reference to the treatment of lupus—that is, the effect
upon it of the injections of Koch’s fluid. As all are aware,
it is now about three months since this remarkable fluid—
a glycerine solution of substances resulting from the pure
cultivatioQ of the tubercle bacillus—was placed in the hands
of the profession. It wus reputed to have the power when
used by means of hypodermic injection in most minute
3 uautitles of causing the cell structures adjacent to bacillary
epoaits to inflame. Very soon after its introduction it
was announced that the most remarkable demonstrations of
its effects were to he obtained in cases of lupus vulgaris. In
these it caused the ]>atches to inflame, and certain small frag¬
ments to undergo necrosis, and after this a process of
healing set. in which left tbe patient, if not absolutely
cured, at any rate in a greatly improved condition. During
the last three months trials of this remedy have been very
extensively made, and I now purpose to attempt some sort
of brief Hsumi, of their results. 1 know that it will be said
that it is too early to arrive at any conclusions, and, in a
certain sense, this must he admitted. Very definite results
have, however, ou some important points been obtained,
and it is highly desirable that, for the guidance of future
investigators, these should be stated. My own personal
experience—that is, as regards patients under my own care—
has been very small, but through the kindness of many friends
I have had opportunities of collecting facts over a tolerably
wide field. In endeavouring to report upon them it may, I
think, be stated in the first place that the original statement
that the injection of Koch’s fluid does cause lupus patches
to inflame has been well home out, but nob without some
striking exceptions. In a case under my own care, the
portraits of which I have shown you, and concerning which
the diagnosis of lupus vulgaris cannot come into any
question, no effect whatever was produced on the patches,
although the patient’s tenaperature ruse on every occasion
after nine or ten aucceasive injections. In this case
Dr. Heron made the injections and examined the patient
at all stages with the utmost care. I avail myself of his
skill as a diagnostician in reference to diseases of the lungs
to assure you that the patient had no indications of pul¬
monary tuberculosis which would explain the recurrence of
febrile reaction. After about a month’s treatment, the
injections having ceased to produce fever, we laid them
aside, and the patient is now exactly as he was before they
were begun. I have received information concerning more
than one case in which somewhat similar results were ob¬
served. In one, about which Dr. Abraham is my informant,
neither febrile reaction nor local reaction resulted, although
the patient displayed nodules of tbe apple-jelly deposit of
lupus in considerable abundance. Without an exception
all my friends report that in the cases in which the lupus
patch has been made to inflame the results, as regards
its subsequent improvement, have been very definitely
good. Large areas, which had been previously swollen
and covered with scab and crust, have been made to heal,
and the resulting scar has been flat and sound. No one,
however, ventures to report an instance of complete cure. Of
tbe cases which have been shown to me as tbe most satisfac¬
tory'', I am bound to say that in every one there has been evi¬
dence at some part of the edge of the remains of lupus tissue,
ready, I do not doubt, to start into fresh growth on the
slightest provocation. In reference to this point I have to
make a most important assertion, and that is, that tbe treat-
mentdoesnot always influence tbe essential element of lupus.
The brown apple-jelly-like deposit which is universally
acknowledged as the most characteristic of tbe lupus con¬
ditions sometimes remains untouched. This assertion is
illustrated by a case which Dr. Heron was kind enough to
show me, and in which he had practised injections some ten
or twelve times. In this instance the inflammatoiy swelling
of the parts affected had been quite got rid of and the
patient considered herself very much benefited. Nodules
of lupus were, however, scattered about her cheeks in a
conspicuous manner, and had slie come under ray care
without my knowing anything of the previous treatment I
should certainly have regarded her as an ordinary case of
lupus, still standing in need of efficient treatment by either
the cautery or spoon. In the case which Dr. Gayton was kind
enough to send us last week—and which had been under
Mr. Watson Cheyne’s treatment in King’s College Hospital,
and bad received great benefit—you had equal opportunities
with myself of judging whether it could be called a cure. The
lupus edge was still there. A.s substantiating my statement
that the treatment does not always destroy the most charac¬
teristic part of the lupus formation, I might quote from a
letter from Mr. Waren Tay, of the Loudon Hospital, who,
speaking of a case in which great benefit has been obtained,
remarks “that there still remain nodules which I should
much like to attack with the scoop.” The cases which
appear to derive the greatest benefit are those in which there
is most of inflammatory swelling, and in which tbe more
specialised elements of tbe lupus process are least abun¬
dant. You will see the bearing of this statement. Should
it be supported by future facts we shall be obliged to
suspect that the remedy is, after all, one for certain
conditions of tbe inflammatory process, and not for tuber¬
culosis. Even in this position, however, it is possible
that it may still prove of great help to us in the
treatment of certain forms of lupus. lam not aware that
it has yet been tried in any of the cases of what has been
described as perfectly quiet lupus—such, for instance, as
those of which Ishowed two porcraits illustrating single patch
lupus occurring on the cheeks of healthy persons, charac¬
terised by a thick growth of apple-jelly, and by the entire
absence of any surrounding inflammation, 'rhese cases
would be very suitable ones in which to test the power of
the fluid in attacking the lupus growth itself; and from
what I have seen thus far I quite expect that they would
escape its inlluence. In the more rare forms of lupus
the remedy has nob yet been tried. On lupus erythema¬
tosus, however, a good many experiments have been made.
It was foretold by tliose who believe that what they call
“ true ” lupus is bacillary, and that lupus erythematosus is
not so, that the fluid would have no effect on the latter;
and, in the main, this prognostication has been fulfilled. In
a very imuked case under my own care, and in which
Dr. Heron was kind enough to carry out the treatment, the
atient had good febrile reactions after repeated injections,
ut without any iDllamniation of her lupus patches. This
remarkable result was perhaps explained by the supposition
that the lady had tuberculosis of the lungs as well. She
was, as is usual in lupus erythematosus, of a phthisical
family, and she had herself been treated for suspicious
syni]>toms. In her case, a week after wo had abandoned
the injections in the belief that they were doing no
good, the erythematous patches on her face suddenly
disappeared almost wholly. A number of discs on the upper
part of her chest, however, some of wliich were so thick and
definite that some observers were inclined to regard them as
lupus vulgaris, remained wholly untouched. She had had
nine or ten injections, and latterly in full doses. I have
The Lakcbt,]
DR. SHERIDAN DELEPINE ON BACTERIAL DISEASES.
[Jan. 31,1891. 241
seen this patient to-day, and her lace patches are already
retnming to their first condition.
Apart from the q^uestion of its direct influence on the lupus
itself, some collateral observations of much interest have
been made as to the possible results from Koch’s fluid. 1
am told that it has repeatedly caused general erythematous
eruptions on the skin, and,in some, nodular effusions into the
cellular tissue. In one case the inflammation of the lupus
(on the face) passed into unquestionable erysipelas of a
rather severe type, and the patient was for some time_ in
danger. In two cases, at least, during the febrile reaction
old chilblains became again inflamed. ^
If we are obliged to report that nothing that can he called
a cure of lupus has yet been obtained in London practice,
it may seem unnecessary to ask whether cures are lasting.
On this point, too, however, I am sorry to say that some
evidence is already forthcoming. I fear it is the fact that
relapses occur very quickly. The patient who was taken
to Berlin by Mr. Malcolm Morris and Dr. Pringle, and was
for a time supposed to be almost cured, is now, I am
assured by both the gentlemen concerned, in a condition
almost as'bad as before the treatment.
If, on the whole, we are obliged to return a qualified
verdict as regards this method of treatment in London, it
by no means follows that it may not in the future be
S ut to some use. On the contrary, it has in many cases
one very great good, and no one can doubt that the
fluid possesses very remarkable powers. It may be that
in the future we shall learn to combine the older
methods of destruction of the lupus deposit by means
of cautery or caustic, with suppression of the attendant
inflammation by injections. What I have seen would
certainly lead to the belief that some patients are by
the injections brought into a condition much more favour¬
able for surgical treatment than they were before. The ill
effects of the treatment on the general health, altliough
obvious and considerable for a time, seem to pass away.
No one has reported to me any instance of permanent
damage. I may confess that nothing which I have seen
leads me to be hopeful that very prolonged periods of treat¬
ment will avail more than sliort ones. If febrile reaction
has ceased to occur, I do not think that there is any further
hope that the lupus nodules will be attacked. On this
point, however, as well as on many others, we need further ex¬
perience. Amongst those to whom I have been most indebted
for the facts upon whicli the preceding statements are based
are Dr. Heron, Mr. Watson Cheyne, Mr. Waren Tay, Dr.
Gayton, Dr. IladclifFe Crocker, Dr. Pringle, Mr. Malcolm
Morris, Dr. Colcott Pox, Dr. Abraham, and Mr. James
Startin. To these gentlemen you and I^re alike indebted
for the opportunities they have afforded us for seeing tiieir
cases this afternoon. For myself I cannot sufficiently
express my sense of the compliment they have paid me in
placing their facts at ray disposal and giving me leave
to make ray own criticisms. I hope that I have not
been premature in expressing the opinions which I have
done. If I have spoken with less enthusiasm of the
results of Koch’s treatment of lupus than it really
deserves, I can only say that it will give me great
pleasure in the future to change my opinions. By the
kind permission of the two Colleges we shall meet in
this well-lighted and beautiful theatre every Tuesday
afternoon for the next five weeks. On any of these lecture
days cases illustrating Koch’s treatment'of lupus will he
welcome by whomsoever they may be sent, and those will
be most welcome, which come nearest to demonstrating
completeness of cure. It is only by combined effort and by
the public examination of the facts tliat satisfactory con¬
clusions can be reached. Although, as you know, these
lectures are not in any way under the sanction of the
Colleges, nor does their committee of management incur
any responsibility in connexion with them, yet I feel sure
that this use of the theatre which they so liberally allow us
to occupy is in entire consonance with its original destina¬
tion. We are doing our best to elucidate one of the most
important pathological questions of the day.
West Cornwall Infirmary. —Mr. T. Bedford
Bolitho, M.P., has forwarded to the West Cornwall Infir¬
mary a scheme for a convalescent home in memory of his
late father, Mr. Edward Bolitho. He pro]> 08 es a first
endowment of £10,000 for eight beds, and more money will
be available to render thoroughly useful the proposed
home.
% Into
ON
DEVELOPa™! OF MODERN IDEAS ON PRE¬
VENTIVE, PROTECTIVE, AND CURATIVE
TREATMENT OF BACTERIAL DISEASES,
AND ON IMMUNITY OR REFRACTORINESS
TO DISEASE.^
By SHERIDAN DELEPINE, M.B. Edin.
Gicntlemen, —The intense excitement and the unbounded
hopes created by the announcement that a cure for con-
I sumption has at last been found have led me to lecture
I to-day on a subject which I generally relegate to the end of
' my course of pathology. For, after discussing the various
pheuomeua which are brought about by disease, and
attempting to connect these phenomena with their cause,
apparent or real, it is natural to try to explain why these
causes do not always bring about the results which are
observed only in a certain percentage of cases.
Effects of individuality, age, sex, family, race, species .—
It is a matter of common experience that in times of epi¬
demics persons equally exposed to infection are not all
affected. The weak members of the community are gene¬
rally more readily affected than the strong ones, the starved
than the well fed, the intemperate than the temperate, the
fearful than the fearless ; buc, apart from these often doubt¬
ful distinctions, some other influences must be at work in
helping some to resist, for many a man or woman of weak
constitution has been able to pass through plagues that had
carried away more than one of powerful frame. This
resistance of some individuals to disease has probably at all
times attracted the attention of men, and very early in the
history of civilisation observations have been made which
by gradual extension have led to some of the moat striking
triumphs of medicine. It will he my object in this lecture
to show you how immunity to disease, at first supposed to be
due to individual peculiarities or supernatural influences, has
gradually become connected with certain external circum-
stancesaetingdirectlyor indirectly. Among the factors which
are generally discussed in medical books as influencing the
liability or immunity of certain individuals to disease I may
mention age, sex, family, and race. These, as far as we can
see at the present time, have an inliuence “n the occurrence
of disease which is in many instances difficult to explain.
Some facts, however, tend now and again to lighten our
ignorance, and to show that even these apparentljr inherent
qualities are perhaps the result of the transmission of ac¬
quired pr^erties tnrough generations of cells or of indi¬
viduals. This will be more evident perhaps if, by extending
our field of observation from one to several kinds, we con¬
sider how the immunity of certain species, orders, or even
classes of animals is brought about. Take, for instance,
the remarkable immunity of the fowl and of the frog to
anthrax. At first sight it seems impo8,sible to understand
why a small animal like a frog or a fowl should be able,to
resist a disease that is so rapidly fatal to such large animals
asthesheep.nian.oreventheox. Pasteur, however, more than
twelve years ago recognised that the diflerence of the body
temperature of the various animals was enough to affect the
development of the parasite. He immersed a fowl for two
days in water, bringing the temperature down to 28° C.,
and showed that the fowl was as liable to anthrax as any
other animal. A similar observation was made later on by
another observer, who by raising the temperature of a frog
rendered it also liable to the disease. Thus it was demon¬
strated that certain conditions of temperature were neces¬
sary for the anthrax bacillus to attain its fuH virulence.
What temperature does in these cases chemical products,
special to certain animals, can also bring about in othei'S.
This is well proved by tbe influence of various culture
media on the growth of micro-organisms. The presence ot
chemical compounds of well-known nature, even m very
small quantities, has been shown by a greet many obsen^re
to influence much tbe mode of growth of bacteria. It has
I A locturo ilellvoroa at St. CJcorgu'-i irospital on Nov 20tli, on the
occasion of the pnbli,-ation of Koi-li's iiiothort for the cure of tuberculoSM.
Digitized by
242 The Lancet,]
DR. SHERIDAN DELEPINE ON BACTERIAL DISEASES.
[JAN. 31,1891.
eren been proved that bouillon obtained from the muscular
Ussue of various animals, notwithstanding the absence of
any very definite active chemical compound causing marked
dinerence, gave cultivation media more or less suit¬
able for the growth of certain organisms. I will only
mention out of a large number of other observations the very
recent experiments of Hippolyte Martin on the bacillus
tuberculosis. This observer found that animale-can be classi¬
fied roughly in rhe following way, according to the ease
with which the bacillus grows in bouillon made with their
tissues : herring, oyster, mussel, monkey, horse, calf, rabbit,
^ birds, dog, cat, rat. It would be difficult in the present
state of our knowledge to ascribe these difierences to the
presence of any definite compound, yet it cannot be doubted
that they are due to certain physico-chemical pr^erties.
We have thus distinct evidence of marked difierences
between animals of different classes, orders, and species;
and if we admit the truth of the doctrine of evolution, we
must admit that such differences are in great part the result
of the iniluence of external circumstances. We might infer
from this that differences between animals of the same
species, but of different races, families, sex, or age, are like¬
wise the result of similar infiaences; we have, however,
better evidences than these in support of the view that
either extreme liability or immunity to disease may be
acquired. Indeed, I shall be able to show you that it is the
gradual development of that knowledge which has prepared
men for the reception of Pasteur’s discoveries, and of their
recent momentous extension by Koch.
1. Refractory state resulting from a first attack of certain
fevers. —It was very early recognised that after a first
attack of many infectious fevers, such as small-pox, measles,
typhus fever, <fcc., a second attack seldom occurred. This
fact seems to have been observed more specially in connexion I
with small pox, or at any rate to have led to practical i
application first in connexion with that disease. We learn
that the inducement oj a first attack of small-pox was an
antique practice iu Africa, Persia, and China, and that
the method of inoculation was brought from there to
Constantinople iu 1673, and from that town to England
by Lady Mary Wortley Montagu. The idea was evi¬
dently to produce a mild attack of the disease io indi¬
viduals placed under circumstances most favourable to
recovery in order to induce immunity. The practice,
although open to serious objections, must have had no little
success, and was much resorted to iu the middle of the last
century. Another practice which is nob so rare as one
might be inclined to believe is the inducement of measles.
Many people are under the impression that unless children
have had all the ordinary exanthematous fevers it is almost
desirable that an opportunity should occur for them to have
mild attacks of these fevers, and I have known of instances
in which, one out of several children being attacked with
measles, no attempt has been made to isolate the sick child,
for, it was argued, it was as well for the other children bo
have the fever also and be done with it as soon as possible.
Since this has been done under the influence of a popular
belief, I think I am justified in suspecting that the practice
of inducing measles for protective purposes is far from un¬
common, although not generally carried out by professional
men. Boeck and Sperino introduced about 1854 the prac¬
tice of syphilisation, aod these authors recognise clearly
that this method is nob only a prophylactic, bub also a truly
therapeutical one. The inducement of a certain disease in
order to prevent its recurrence, and even to modify the
course of an attack, was therefore a method early recognised
in this century both in connexion with stnall-pox and
syphilis.
JUfractory state produced hy inoculation of an allied
disease less fatal, or of the disease modified by peussage
through another animal. —Certain country people had early
suspected that a disease affecting cows was communicable
to man, and that individuals thus affected were nob so
liable as other people to small-pox. History tells us that
an English farmer and a German schoolmaster in the course
of the last century, under the influence of that belief, had
resorted to inoculation of that cow disease in preference to
the inoculation of true variola. Jenner was the first
medical man who discovered the immense importance of
these traditional beliefs and practices, and after devoting
all his energy to the study of the subject became so con¬
vinced of the value of the method of vaccination that after
a long struggle he has succeeded in convincing others, and
has become thus one of the greatest benefactors of the human
race. From 1798—when Jenner brought vaccination before
the world—up to 1880 very little was done to extend the scope
of the principle thus discovered. Then Pasteur arose, who,
after studying for many years the nature of the virus causing
several diseases, became gi-adually conviuced that this virus
may become intensified or attenuated at will, and in 1880
was able to state positively that the production of an attack
of definite intensity of many infectious diseases was a
thing not only possible, but also practicable and capable
of application for the prevention of disease. In 1880, also,
Buraon Sanderson suggested that the attenuation of the
virus of anthrax for the purpose of vaccination might be
obtained by using the guinea-pig as an intermediate host.
Greenfield experimented also at the same time and in the
same direction with very satisfactory results. In 1883,
Pasteur and Thuillier m^e experiments in the rotigct des
pores, showing clearly that by causing the virus to pass
through a series of pigeons it became gradually more
virulent for the pig; whilst the reverse was true when series
of rabbits were used as intermediates, sbowing thus at the
same time how disease may originate or be modified. The
principle of vaccination as introduced by Jenner seemed
therefore to have become a fact capable of general application
by this time. All that seemed necessary was to find a suitable
intermediate host for the parasite. By growing the para¬
site in a series of such intermediate animals one was able
to obtain a “vaccine” or “lymph,” which, like that of
vaccinia, was capable of inducing immunity, as well as an
attack of the unmitigated disease would have, but without
the same danger. Another fact of great importance has
also been noticed by several observers—viz., that the occur¬
rence of certain febrile affections may modify the course of
other febrile affections previously established. Daniellsea
and Boeck were perhaps the first to notice this fact, and
to record the beneficial influence which an attack of small¬
pox might have on thecourse of tubercular leprosy. I need
not refer to the numerous attempts which have been made
since in that line.
3. Refractory state produced by inoculation of a virus
modified by cultivation outside the body. —Another discovery,
more fertile in results, although similar in principle, was,
however, made known by Pasteur in 1880. He showed
that by cultivating the microbe causing chicken cholera at
a temperature of 33°, with free access of oxygen, he could
obtain in from two to eight months an attenuated virus,
which would cause the disease in a form mild, but sufficient
to produce immunity. Toussaint and Chauveau were ex-
periraentingat the sametime on the anthracis bacillus. Tous¬
saint made the important discovery that by heating cultiva¬
tions of the bacillusjunthvacis rapidly to a comparatively high
temperature its virulence was attenuated. In 1881 Pasteur
roduced attenuation of virulence of the bacillus anthracis
y cultivation for nine days at a temperature of from
42° to 43° C., and produced immunity by vaccination with
the modified virus. Koch, Gaffky, and Loeffler repeated
Pasteur’s experiment in 1884, confirmed his results, and
extended them, differing from him only with regard to the
influence which he attributed to oxygen. In 1882 Pasteur
and Thuillier applied to the bacillus of “ rouget ” the same
principle as that used in the case of the chicken cholera
and splenic fever, and succeeded in attenuating that virus also.
During the whole of this period Pasbeurwas occupied in trying
to isolate the virus of rabies. Although hedidnobaucceed iu
doing so, he discovered that the nervous tissues acquired in
that disease virulent properties which indicated the presence
in them of some unknown virus. Not being able to obtain
the virus itself, Pasteur used the nervous tissue as he would
have a nutrient medium, and having discovered the method
of obtaining spinal cords having a constant virulence (fixed
virus), he dealt with these cords in the same way as he would
have with ordinary cultivations, and thus succeeded (1886) in
attenuating the virus and being able to produce immunity
by vaccination, as in the case of the other diseases. Many
other methods have been proposed for attenuating the
virulence of organisms than those introduced by Pasteur.
We have already seen how Toussaint and Chauveau used
rapid heating. Paul Bert showed that oxygen under
high pressure (20 atmospheres) kills the bacillus autliracis.
Toussaint, Chamberland, and Roux (1880-86) added dilute
carbolic, chromic, and sulphuric acids to nutrient media
for the same purpose. Klein (1888) used also very small
quantities of corrosive sublimate for the same purpose.
Arloing (1886) showed that bright sunlight has also an
attenuating effect on cultivations in fluid media. It is
:e-J by
Google
The Lancet,]
DK. SHERIDAN DELJiPINE ON BACTERIAL DISEASES.
[Jan. 31, 1891, 243
useless to go into the further developments of these methods,
that of Pasteur being the only one which has had very
extensive application as yet as far as man is concerned.
4. liefractorii state produced hy the introduction into the
system of definite chemical products resulting from the
action of pathogenic organisms on cultivation media .—
Salmon and Smith (1883) seem to have been the first to
realise the practical importance of the injection of the
products of growth of organisms independently of the
organisms themselves. They showed that the injection of
cultivations of the microbe causing hog cholera produces
the effects of attenuated virus after beingsterilised by heat,
at any rate in the case of pigeons. (It was, however,
accepted before that time that micro-organisms generate
products which are deadly to themselves and are capable of
arresting their growth, a fact which has also long been
known in connexion with fermentation organisms.) Pasteur
very early showed also that filtered chicken cholera bouillon
injected into a bird produced the symptoms of the disease,
although no organism was present in the fluid. He showed
also that the same is true of the blood of animals affected
with anthrax.
In attempting to explain the effects of inoculation with
spinal cord for rabies, Pasteur also alluded in 1885 to the
probable existence of some chemical compound in the cords
which he used for protective inoculation, and suspected
that this compound was instrumental in bringing about
immunity. It was only about 1887 that these facts and
views acquired fresh significance by the work of Toussaint,
Chauveau, Wooldridge, Chambeiland, and Roux on anthrax,
of Charrin on the pyocyanic bacillus disease, of Chamberland
and Roux on acute septiccemia &c., of Brieger, Chantemesse,
and Vidal on typhoid fever, cf lioux on symptomatic anthrax,
and of Roux and Yersin on diphtheria. In moat of these
experiments the material used for inoculation was the
cultivation medium modified by the growth of the organism,
and sterilised either by heat, by filtration, or by both
methods. The work of Charrin, Woodhead, Cartwright,
and Wood has also shown that protection may sometimes bo
obtained not only by injection of the products of the
growth of the pathogenic organism itself, but also of some
quite different ones (bacillus anthracis and bacillus of blue
pus).
The products used were therefore of a very complex
nature, and it was nob known to what kind of compound
they owed their property of conferring immunity. Roux
aud Yersin had in 1888 tiied to prove that their chemical
vaccine for diphtheria owed its properties to an albuminoid
body allied to unorganised ferment, but this last sup¬
position is nob generally accepted, although not disproved.
(In order to understand the origin of the following
improvements it is important to remember that the work of
l*anum (1856), Gautier, and Selmi(1873) had revealed the
production of very poisonous alkaloidal substances during
putrefaction. Tlie more accurate researches of Nencki, and
still irore of Brieger, demonstrated clearly the existence of
an important class of poisonous alkaloids produced by the
micro-organisms of putrefaction. Gautier (1881), on the
other hand, was trying to prove that animal tissues are also
capable of producing by their metabolism poisonous sub¬
stances of allied nature. The experiments of Lauder
Brunton and Sir Joseph Fayrer on cobra poison (1873) should
be kept in mind in relation with this subject. It was soon
found that, besides these poisonous albuminoids, other more
or less poisonous products might be manufactured either by
animal or vegetable cells; these products were found to
belong to the ill-defined class of albnmoses. I need only
refer to the work of Weir Mitchell (1800) and Reichert on
the albumoses of snake poison; of Sydney Martin on
phytalbumoses—i.e., albumose.s produced by vegetable
cells, whether bacterial or obhens—an important work,
which led him to infer later on that albumoses were products
intermediate between the noc-poisonous albuminous sub¬
stances of the culture media and the most poisonous alkaloids.
Buchnev, Wooldridge, I-Iankiii, and others were also discover¬
ing toxic albuminous substances in various Iluidsor tissues of
the body, some of which were deadly lo bacteria.) Returning
now to preventive inoculation, we find that in 1889 Sydney
Martin in London, and Hankin of Cambridge working in
Koch’s and JJrioger’s laboratories, had isolated from cultiva¬
tions of the bacillus anthracis albumoses wliich were
found by Hankin to produce immunity from the disease
when injected into the body. Possibly under the inllu-
ence of Hankin, certainly later in the year, the important
researches of Fraenkel and Brieger on the toxalbumins of
diphtheria, typhoid fever, cholera, tetanus,- &c., were
published. Thus, just as in the case of many remedies used
for centuries in the shape of powders, extracts, decoctions,
infusions, tinctures, &c., active principles have ultimately
been discovered by cliemists, it was now found that out
of the material used for the last ten years by Fastev/r a/nd
his school, it was possible to isolate some active products
of definite composition, to which the lymphs or “vaccins”
owe their prophylactic and curative properties. SuchwB^the
state of science when, in the course of last year, it was
announced that Koch had found tbe means of curing
phthisis hy inoculation. All minds were to a
certain extent prepared for such an announcement;
yet the fact that one of the greatest scourges affecting
human kind had at last come within the pale of treat¬
ment has created immense sensation. The little that
is known of the treatment and of its effects seems to point
clearly to the fact that Koch is using some of the chemical
products which have just been discussed, and therefore
there is good reason to expect that a certain amount of
success will attend the method. The results of previous
experimenters show, however, that it would be wrong to
hope too much from a system which has always been
attended with a certain proportion of failures.
I have carefully avoided in this exposi to enter into many
details, some of which ate of great importance, in order
that you should be able to follow the mam line of observa¬
tions and thoughts which have led to the recent discovery.
I will therefore not attempt to discuss on what basis vac¬
cination, essentially prophylactic in principle, may become
a curative method when the modilied virus answers certain
requirements. There is a very distinct connexion between
these two methods of treatment." It may, however, be
interesting to consider for a moment the methdds which the
knowledge of pathogenic organisms has introduced in
medicine.
These methods can be subdivided into three classes:
(I) The preventive, (2) tbe protective, (3) the curative.
Tliey have all something in common, and yet they all differ,
as will be seen in the following brief enumeration :—
1 . preventive method CQ'ae.if.is, in destroying or aiienua-
ting the cause, or avoiding it in some way or other so that
tbe body may remain unaffected, (a) The antiseiiiic method
introduced by Lister is a good instance of the methods
which aim at destroying the cause before it has acted.
(5) Residence in high localities, drainage, &c., are instances
of tbe methods by which tbe cairses of disease may he so
attenuated or diluted as to become harmless, (c) Absolute
cleanliness. Ase^hic methods are based on the possibility of
avoiding certain causes entirely without destroying them.
2 . Prw^eciitfon consists in modify ing the possible host ao
as to-render it able to resist virulent parasites. This can be
done either by (a) increasing its strength and activity, as by
diet, warmth, functional activity, and other hygienic con¬
ditions (VVargunin); ((^ rendering its tissues and fluids
unsuitable media for tbe growth or Jail development of the
parasite. Inoculation and Jenner's vaccination are good
instances of that method, which has been further extended
by Pasteur and others; (c) by establishing tolerance
(Sewall, 1887).
3. The curative methods consist in attenuating or entirely
destroying the virus causing tbe disease after it has pene¬
trated into the body, (cr.) The actual dcsiruciion of Utc
parasite within its host is apparently still a desideratum.
(6) Attenuation of the virulence can be obtained by intro-
duciog into the blood and tissues some product either
interfering with the full development of the parasite
, or modifying the tissues and Iluids of the body so as to
increase their resistance to the extension of tbe parasite
or to its products. This seems to be the chief principle
• at the root of Pasteur’s vaccination for hydrophobia, *&c.
(c) Neutralising the physiological action of the virus by using
its physiological antagonist. Muscariu, for instance, may
be antagonised byatropin. Lauder Brunton (1873) directed
attention to the possibility of applying this principle to tbe
treatment of cholera. (Tbe same idea has been applied to
the treatment of poisoning by snakevonom. Wynter Blytli,
1877 ; Lacerda, 1881). (f/) Destroying and removing the.
substratum or ground which has become contaminated by
t'or expiiiuafciou as to llio modi) of action of tho products used in
viicciiiation soo I-iiudcr iintntoii's ]i-i-t«ros on Chemicivl Structure and
■J'liysioloKical Action, esiurialiy i.cctnrc II. (Brit. Med. Jour,, vol. i.
1S89, i>. 1380),
E 2
Cjtiogle
244 The Lancet,] DK. HARRINGTON SAINSBURY ON HODGKIN’S DISEASE.
[Jan. 31,1891.
the parasite. , This is oppai-ently the view tvhich Koch has
taken of the action of his lymph. Tlie action of the product
on the tissues is, however, of the tame kind as that of the
substances used in some of the methods already mentioned,
but more intense, and Koch’s views will probably have to
be modilied.
In this attempt to analyse the methods which have been
proposed I have separated processes many of which may
act concurrently. This is, however, of little consequence,
for my object was less to give au account of any single
method than to trace the development of the ideas which
are at the basis of the treatment of bacterial diseases. In
this way I hope I may have been able to show you how
science prepares the way for the highest branches of the
art — yiz., preventive, protective, and curative medicine.
HODGKIN’S DIvSEASE; PYREXIA; SUDDEN
DEATH. WITH COPIOUS SANGUINEOUS
EFFUSION INTO THE LUNG.
By HARRINGTON SAINSBURY, M.D., M.R.C.P.,
SENIOR ASSIS’I'ANl' riiVSICIAN I'O THE VICTOIUA-I’AUK IIOSl'ITAI, TOR
CHEST DISEASES ; I'llVSiCIAN TO THE ROVAI- EIIEE IIOSI'ITAL.
The following case is of interest on account of its some¬
what puzzling nature during life, but more particularly on
account of its very unusual mode of ending. The patient
was admitted under Dr. Thorowgood, but she was subse¬
quently seen by me during his absence; it is at his kind
request that I place the case on record.
Annie A—r-, aged eighteen, tingle, a matchbox maker
by occupation, was admitted into the Victoria-park Hospital
on Aug. 7tb, 1890. She complained of pain in the left
hypochondrium and of weakness. She stated that she had
been ill four weeks sull'ering from feverishness and weakness;
for three days there had been headache; the bowels had
been rather constipated during the whole period, acting
some two to three times a we^. There had been slight
pain in the lower part of the abdomen ; she had never
vomited. On admission, there were a Hushed face, hob
skin, and dry glazed tongue, showing posteriorly a little fur.
The temperature was 101-2°; pulse 114, and of low tpnsion.
The abdomen was normal in appearance, there was no
tenderness, but the spleen projected one inch and a quarter
below the costal margin. There were no symptoms pointing
tobheche3b,neither cough nor expectoration, and the physical
signs were negative for both heart and lungs. In the neck the
glands were enlarged, especially on the right side in the
supra-clavicular region ; but they were nob conspicuous, and,
though the enlargement was decided, they were to be felt
rather than seen. There was slight enlargement of the
glands in the axillte and in the right groin. The en¬
larged glands were hard, well-defined, and freely movable.
The urine was acid ; sp. gr. 1010, and free from albumen.
In the absence of any delinite symptoms—rliarrhica, spots,
&c.,—but in the presence of the fever and the enlarged
spleen, the patient was pub on typhoid treatment, and, so
far as the diet was concerned, this treatment was main¬
tained for some time after it had become clear, from the
temperature curve, that the case was not one of enteric
fever. The patient was examined on several occasions up
to the time of her death, which occurred quite suddenly
and unexpectedly, but no fresh signs developed. On
Aug. 14bh the spleen showed slight increase in size, and
some scybalous fmcal accumulation in the descending colon
was noted. Throughout the bowels were ratlier consti¬
pated, and in the early stages glycerine eneriiata were
required. On Sept. 12t)i the glands on the right side of the
neck above the clavicle were larger. On the20bh the glands
in the left infra-niaxillary region were enlarged, but the
spleen had diminished somewhat. On Oct. 1st the spleen
was again somewhat larger. Death occurred on Oct. 2nd.
In the chest some creaking sounds were heard near the
angle of the right scapula on Sept. 27th, and on Oct. Ist
the note under the left clavicle was doubtfully impaired. On
this date a systolic bruit was beard at the base of the heart.
Nothing more delinite was discovered in the chest. On
the two occasions that the blood was examined it was found
to contain 75 per cent, of the normal corpuscular richness
and no excess of white cells. The amount of hamioglobin
was unfortunately not estimated, The temperature curve
was very interesting. There was fever the whole of the eight
weeks during which the patient was in hospital; ib was,
however, markedly remitting, the lowest records falling
just above or just below 99° F. (98-8° and 98'6° were frequent
records) On six occasions only did the curve touch 98-4°
or dip just below it. The inaxitnal temperatures were
102°, 10.1°, 100°; on two occasions 102-8° was reached. The
remissions and exacerbations were very regular, the former
baking place about 8 A.M., the latter between 8 and 12 P.M.
The range of temperature was about 4° during the first
week, about .3° during the second week, and about 2°, or a
little over, during the third week. During the fourth week
the temperature was at its lowest, and the pyrexia appeared
to be gradually breaking up ; hut in the fifth week the range
again increased, and it mounted still more during tlie fol¬
lowing three weeks, averaging 3° to 4°. If to the hospital
period we add the four weeks of feverishness, of which she
gave the history on admission (she had been on milk diet
for two weeks before admission), we have a total period of
three months of pyrexia. In spite of this prolonged pyrexia,
the patient did not seem seriously ill; so little, in fact, that
it was thought well to allow her to get up to tea in the last
days of September, and according to her own statement she
felt better. On Oct. Ist the last examination was made,
with practically negative results. The enlarged spleen and
lymphatic glands were the only positive signs.
Mode of death. —At about 2. IOp. M. the patient went to sleep
afterdinnev, and nothing unusual was noticed until 3.30 P.M ,
when the nurse’s attention was directed to her. The head
and neck were then rigid, and the eyes fixed in an upward
direction. There was slight turgeeoence of the face ; no cry
was uttered. There was no evid^ence of blood in the mouth
either immediately before or after death. Five sighing
respirations took place, and death happened in about thirty
seconds.
I unfortunately could not be present at the necropsy, but
the following is the post-mortem record by Dr. Ruffer, the
pathologist to the hospital: — Body emaciated; staining
well marked ; rigor mortis well marked. In the pericardium
about half a pint of clear serum. The left lung adlierent
everywhere by white adbesions; soft over the greater part
of the lung, but tough behind ; at the back part the lung
was torn during removal; the lower lobe filled with blood,
which oozes from every pore, so that the whole lung looks
like currant jelly; portions excised sink in water; the
upper lobe normal; the bronchial glands not increased.
The right lung normal, except at the oaae, where there has
been a much lees extensive but similar hiemorrhage to that
on the left side ; no adhesions on this side. The spleen red,
22 oz. in weight; no infarcts; its substance was highly
coloured, but fairly hard. The retro - peritoneal glands
larger than natural; some attain the size of a walnut. The
liver 59oz. in weight; smooth; tough. The kidneys very
large, tough, and firm. The intestines healthy. The
pancreas healthy.
Remarlcs. —As to diagnosis little need be said. Ib is true
that in the first stage some hesitation as to the possibility
of typhoid was felt, but this was abandoned later upon
studying the temperature curve, and the pyrexia was re¬
ferred to the enlarged lymphatic glands and spleen in the
absence of any other lesion—the case being diagnosed as
one of lymphadenoma or Hodgkin’s disease. The tempera¬
ture curve corresponded with the third or remittent type of
pyrexia described by Gowers as occurring in lymphadenoma
the other types met with, according to this authority, being
the continuous and the alternating types. Pyrexia is of
course not a necessary feature of the disease, but this case
accords with Gowers’ statement that there is fever in nearly
all cases under twenty years of age. The absence of mucli
pallor helped to mask the case, nor did the microscope give
any very striking proofs of anmmia ; the observations on this
point were, however, too few to base any conclusions upon,
and the liaunoglobin percentage was not estimated. We
may, however, mention the fact, according to Gowers, that
glandular enlargement may occur and advance before any
signs of deficient blood formation present themselves. Real
amcmia maybe present even to the extentof arediictionof the
red cells to 00 per cent., whilst the face is well coloured.
The urine was not watched, but the note on admission
records a specific gravity of 1010 and the absence of albumen.
As to the mode of death, tJiis is, I believe, very unusual.
Gowers mentions h.-mnorrhage from the nose and mouth
*■ Eeynolds'.System of MeiUclne, vol v.
Digitized by VjOOQIC
The Lancet,]
DR. W. R. THOMAS ON HiEMORRHOIDS.
Pan. 31, 1891. 245
as a cause of death in one case. Birch-Hirschfeld'^ writes
of a tendency to profuse hcemorrhage from nose and mouth,
but he gives no details. Coupland® mentions hremorrhage as
less common in lytnphadenoma than in leuktemia and per¬
nicious ancemia But I have not been able to come across
a case quite similar to this. That the lungs should to a
g reat extent fill with blood without the appearance of any
lood in the mouth seems astonishing, and the only explana¬
tion for this, at all plausible, seems the suddenness with
which death took place. 1 understand that at the necropsy
the main bronchi did not show any blood in their lumen,
Was it really a hasmorrhageor an acute sanguineous ccdema?
In either case the sudden death in association with this
remarkable condition of lungs is surely worth recording.
Welbeck-atrset, W. _
■HiEMORRHOIDS.
CAN OPERATIVE INTERFERENCE CE AVOIDED BY EFFICIENT
MEDICAL TREATMENT ADOPTED IN TIME?
By W. R. THOMAS, M.D., M.R.C.P.,
LATK LECTUBER ON MEDICINE, SHEFFIELD MEDICAL SCHOOL; CON¬
SULTING PHYSICIAN TO THE SHEFITEI.D PUULIC HOSPITAL.
Foe many years I have felt very confident that the
majority of cases of haemorrhoids we meet with, some of which
we treat with medicine, others by operation, are entirely
preventable, and that many of those even which are far
advanced can be cured by medical treatment alone, bub it
is necessary when treating them to give due consideration
to all the causes, and to treat each one. I have found
during the last few years, when I have met with a patient
willing entirely bo submit to medical treatment, that such
treatment has always been a success; bub unfortunately
the majority of patients are self-indulgent, and quite
wanting in perseverance; and in such cases treatment,
because incomplete, is often a failure. In my remarks
I refer to both internal and external hmmorrhoids, but more
particularly to the internal. I select three out of the last
sixty cases I have had to deal with as fair examples of all.
Case 1.—Agentleman, aged forty, aniomic, great debility,
functional cardiac symptoms, »&o. He has suffered from
internal hemorrhoids for six years, with frequent hemor¬
rhage when at stool, the mass, when protruded, being the
size of a small orange. Cause: sedentary life, laziness,
constipation. Treatment: Daily walk insisted on, more
vegetable food, friction to abdomen, white mixture or
u^^lsculap in^the morning when required, injections daily,
local sponging. After three months’ treatment he was
quite well.
Case 2. —This patient, a female, has had si.x children ;
very weak ; hgemorrhoids for years, which now protrude
at each evacuation and bleed, causing anaimia. Treat¬
ment : Daily walks, more vegetable food, white mixture
when required, injections of lukewarm water at first, and
then cold water, local applications of cold every morning.
At the end of two months there was no protrusion at
all when at stool; no local discomfort whatever ; quite
well.
Case 3.—The patient, a male, aged forty-two, stout and
llorid, is a heavy drinker and eater. Liver and abdomen
enlarged ; he suffered from hremorrhoids for the last four
years; they protrude, bleed, and are about the size of a
small orange. Hajiuorrhoids always worse after drinking.
Cause: Excess in eating and drinking, want of exer¬
cise, constipation. Treatment: Abstinence from drink,
almost total; injections of cold water every morning.
White mixture when required. Local applications of
cold.
There are a number of factors which have to do with the
productioQ of hemorrhoids which it would bo well for us to
remember, as it is only by considering each one which has
helped to bring on the disease that we can hope to effect a
cure. Tliese are : the valveless condition of the portal veins,
gravitation, obstruction owing to hepatic disease, obstruc¬
tion from heart or lung disease, sedentary habits, exces¬
sive eating and drinking, straining from any cause,
■■I Ziemsseii’H CyclopseiUa. ® Foivlfr’s Dictionary.
excessive obesity, and taking purgatives too frequently.
Owing to the valveless condition of the veins, there is not
any jiropulsion forwards from the contraction of thesurround-
ing tissues, and a congested condition of the radicles of the
portal veins is the result, giving riee, perhaps, ultimately
to hemorrhoids. Gravitation wul tend to increase, the size
of the lowest veins. Obstructions from liver, heart, or lungs
will have the same effect. Sedentary habits induce a
diseased condition of the liver, with consequent obstruction
to the passage of portal blood through it.' The abdo¬
minal muscles do not, by their contractions, assist in pro¬
pelling the contents of the intestines forwards, a con¬
stipated condition of bowels and dilated state of veins being
thus produced. Excessive eating or drinking proauces disease
of the liver, obesity, and other injurious consequences.
Straining at stool from any cause is a factor of importance;
for the pressure brought to bear upon the intestines
generally, by the abdominal muscles, diaphragm, and other
muscles, tends to produce a very dilated condition of the
lowest vessels, those of the rectum, which, often during the
act of defecation, give way and hsemorrhage ensues. Exces¬
sive obesity aggravates, by its pressure, this tendency to
congestion. Many people are in the habit of taking pur¬
gatives daily. They do not seem to appreciate, or to be
aware of the fact, that ordinarily only a certain amount of
fiecal matter, that which is in or near to the rectum, should
be expelled daily; and that if, by taking purgatives, several
feet of intestine be evacuated, proper purgation cannot be
expected the next day ; time must be allowed for reason¬
able accumulation, which will generally be a sufficient
stimulus to the whole intestinal canal. Now when treating
haemonhoids, I believe that if we take into consideration
and treat each one of the several causes we shall often meet
with most satisfactory results. Many of the recommenda¬
tions appear to be trivial; but success very frequently
follows attention to them, and operative treatment follows
neglect of them.
Daily action of bowels .—Owing to hurry many sadly
neglect the bowels, which act very irregularly. It is very
important that they should be trained to act once a day
from childhood, say, imniecliately after breakfast, and those
who have paid proper attention to this rule but seldom re-
qiiire treatment. Sponging the anus and surrounding parts
with soap and cold water is a very efficient application.
Acrid fluids &c., which during the ensuing day would irritate,
tlie skin, are removed.
Diet <i;c .—In this country we, as a rule, eat far too much
meat and too little vegetable food. I am confident that this,
habit lias much to do with the costive state of bowels and
the formation of lunmorrhoids. I have seen cases of-
hfcmorrhoids with constipation cured by such attention
alone, by taking apples or pears after breakfast, by increas-.
ing the quantity of cabbage, cauliflower, &o., taken with,
dinner and with luncheon, and by at the same time diminish-.
ing the amount of meat eaten.
Exercise.—l believe that this is a most important cause,
and that if a reasonable amount of physical exertion were
undergone by the nation generally, constipation and hojmor-,
rhoida would very seldom require treatment, the liver would,
be well kneaded daily, inspissated bile would be propelled,
and the action of the intestines would be assisted by the
abdominal muscles.
Injections .—It is astonishing how much relief some
patients obtain by an injection daily of as much water-
as can be retained for four or five minutes with comfort. I
generally begin by recommending lukewarm water, but as
soon as the patient can bear cold I order it. This seems to,
stimulate the whole bowel from above downwards, to act
as a tonic on its interior by daily removing large mosses,
which lodge in the rectum, to enable its walls to regain
their elasticity and contractility, and by removing irri¬
tating secretions and pressure, to prevent hyperplasia of
cellular tissue which accompanies a dilated condition of
veins.
Alcohol .—Those who suffer from hicmorrhoida should, if
possible, give up taking stimulants entirely ; for tliey tend to
produce a dilated condition of vessels everywhere, and by
causing disease of the liver of an obstructive character give
rise to dilatation of all the small branches of the vena porta,
and those of the rectum suffer more than any.
I may here repeat what I have alrea<ly said, that nearly
all cases of hamiorrhoids, both internal and external, con
be cured by proper, simple, rational medical treatment.
Bournemouth
Digitized by Google
246 The Lancet,]
DR. J. L. W. THUDICHUM ON FIBROMATA.
[Jan. 31,1891.
FIBROMATA OF THE NASO-PHARYNGEAL
SPACE, THEIR SUCCESSFUL TREATMENT
BY NEW METHODS.!
By J. L. W. THUDICHUM, M.D., F.RC.P. Lond.
These tumours of the naso-phavynx were formerly
described as polypi, of which they represent the most
severe forma. But they differ from tumours now commonly
termed polypi in this, that if they are not removed by art
they mostly lead to a fatal termination. Of the pernicious-
neas of these tumours the literature of the subject contains
ample evidence; death occurred most commonly by hmmor-
bage, spontaneous, often repeated and long continued; some
cases perished from the progress of the tumour to the base of
thebrain, others from suffocation, wbateverwas the temporary
symptomatic relief—e.ff., by tracheotomy. Not a few cases
perished in or after the attempt to effect relief by sur¬
gical means; many perished of secondary effects succeeding
an operation effective or attempted—pymmia, pneumonia,
ancemia, and other accidents. The second prominent
peculiarity of the fibroma is its frequent recurrence after
It has apparently been extirpated; an accident which
necessitates periodical examination of such patients. The
third peculiarity of these fibromata is that they occur
in an active>tate, mainly in males below the years of man¬
hood; they most frequently come under observation in fast
growing lads, but are also observed in a quiescent state in
older men, when from the liistory of the cases it can be
ascertained that they were carried by the bearers from
adolescence into manhood. They mostly become quiescent, at
least as regards increase, after the age of twenty-one years or,
physiologically speaking, after the completion of the struc¬
tural development of the head and face. The tendency to
hemorrhage continues a few years longer, but ceases with
the atrophy of the base of supply by pressure. The rate of
growth of these tumours is quick, and is increased, as is
also the tendency to hemorrhages, when they are interfered
■with unsuccessfully. The tumours quickly send arms into
the anterior nasal fosscc, the antrum and ethmoid, and
sphenoid cavities; they appear under the zygomatic arches,
or in the orbits, and produce blindness by pressure on the
optic nerves.
The anatomical place from which the first growths which
enlarge to these tumours mostly originate is probably the
posterior end of the middle turbinated body, more rarely
the pharyngeal rudiirientary tonsil. The extraordinary
hasmorrhage which takes place in most of these cases is not
rarely the first symptom which tells the patient that there
is something wrong in his pharynx. In some cases it was
the only symptom observed by the medical attendants.
Obstruction of the meati, or even of one of them, is not a
necessary symptom of the early stage of the disease; on the
contrary, tumours of considerable size may exist in the
pharyngeal space without the breathing being notably
interfered with, and without the voice being more
than slightly altered. A frequent result of the existence
of the tumour is ulceration, either on the tumour
itself or on the mucous membrane. This simulates ozeena,
and is sometimes mistaken for it. But in reality it
is the almost constant cause of the hiemorrhages. Bleed¬
ing from mere congestion, so common in cases of polypi
of the uterus or rectum, seems an exceptional sequence of
nasal fibromata. The fibromata have a remarkable effect in
this, that by mere pressure, with and without ulceration, they
effect the absorption, without purulency or expulsion or
sequestration of dead particles of bones adjacent to the nasal
cavity. I liave known the osseous palate underneath the
tumour to be as soft and movable as the soft palate itself ;
I have seen it pressed down low into the mouth, and pulsate
synchronously with tlio tumour in the nose. In sucli cases
quick relief is required to prevent perforation with all its
attendant evils. When the tumour is removed, the hone is
again rather quickly restored; the thin bones, such as the
papyraceous lamina; of the orbits are not restored, hut sup¬
planted by imperfect membranes. Sometimes all molar
teeth are lost on the most affected side.
The pernicious fibroma effects a higlily vascular adhesion
* Substance of a paper read before the Weil London Medico-
Cbirurglcal Society.
to all parts of the mucous membrane with which it comes in
contact. This adhesion becomes universal over its surface
in contact, and results in the formation of a vascular layer,
which is the source of all the fearful hemorrhages as well
during the progress of the disease as during any operation
for its removal. The substance or body of the fibroma is
remarkably free from bloodvessels of any kind. The mere
touching of the adhesions with a blunt probe for the purpose
of ascertaining the extent or firmness of the adhesion not
rarely causes a rush of blood, for which it is difficult to
suppose the lesion adequate. These bcemorrhages are the
principal impediment ■v\mich the surgeon meets with in his
attempt to remove the tumours.
Surgical literature contains many descriptions of a great
variety of operations which were instituted for the removal
of these tumours. There is no possible anatomical direction
which has not been taken to get at the root of the evil, and
all are avowedly mainly modulated under the fear of
hoimorrhage in front. One can easily see that the means
chosen were desperate expedients applied to cases judged to
be equally desperate. After the introduction of anmsthetics,
during the last thirty years, a very common set of operations
was the following. The first step was tracheotomy and the
insertion of an inflated plug in the larynx. Next the nose
was split up from tip to root, the nasal bones were broken
aside, or temporarily or permanently severed. The tumour
was then attacked with forceps, scissors, and knives, and
the bleeding was from time to time diminished by actual
cautery. In this way the nasal meati might be cleared
roughly, but the pharyngeal part could not be reached.
This was therefore attacked through the mouth ; the soft
palate was divided, and the tumour—or rather as much of
it as would yield—was cut away with scissors and twisted
with forceps until a tolerable passage was produced.
Of the cases attempted to be thus treated a number were
left uncompleted owing to hoemorrbage; some operations were
retracted, in the hope of excising tlie tumour, overfourteen
ays, one known to me over thirty days, during which
time the slit nose was kept open. In fact, when John Bell
described the operation as a “horrid scene from which
most surgeons had to retire in confusion and dismay,” he
stated the bare truth. About a third of the patients succumb
to anmmia ; another third die from the immediate conse¬
quences—pneumonia and pyaunia; and about a third escape
death after a long and complicated run of septiciumia. Of
these many have relapses. Wutzer (of Bonn) had seventeen
cases of relapse out of a total not stated. Ndlaton added
a special severity to the operation, with the intention
of destroying the root, by removing permanently a portion
of the osseous palate. Middeldorpf applied the electro-
cautery to some such tumours, but he 'was confined to such
as were pendulous and could bo surrounded by the wire
loop. For a tumour which filled the nostril entirely and
adhered to a large surface he had no remedy. Moreover,
be had no remedy for the profuse bleeding, which even
the electro-cautery as commonly used flowed of in
these cases. Even the monograph of Dr. H. Benscb,
composed under the influence of the late Professor Voltolini,
did not advance the subject, and its only novelty, a burner
invented and depicted after the essay had been printed,
“ did not possess the advantages of the fundamental idea.”
In my operations the electro-cautery is the operative tool
by which the tumour is dissected, divided, cub out, and
destroyed; at the same time, the bleeding is either pre¬
vented or arrested by the cautious injection into the bleeding
adhesions of a concentrated solution of ferric chloride. The
electro-cautery is employed in two forms—one the fork-
burner, which cuts into the parts like the sharpest chisel;
the other the electro-cau.stic loop, used white hob, as an
6 cra8eur. The styptic is injected with a small syringe,
armed with a long hollow platinum needle, the point of
•Nvhich is guarded, so that it can penetrate only to a
measured depth. My patients are ordinarily not placed
under any general a'n.'osthetic, bub, solaced with cocaine,
give an intelligent aid to the operator; but where
desirable a general anu'Sthetic is easily applicable. There
is no tracheotomy, no plugging of the larynx, no splitting
of the soft or hard palate, no dividing of the nose, no break¬
ing of the nasal bones, no resection of the nasal ramus of
the upper maxillary. Almost the entire operation is per¬
formed through the nose, whatever may be diagnosed or
introduced through the mouth. Consequently, this new
operation makes the patients absolutely free from the
fearful risks to which, as the statistics of results show, the
The Lancet,]
DK. W. S. FENWICK ON ACUTE LOBAR PNEUMONIA.
[Jan. 31,1891. 24f
former intrepid operation would make them liable. I
adduce a few cases from private and hospital practice to'
}jdar out my general statement.
A young gentleman aged sixteen had his right meatus
^obstructed since June, 1885. Severe epistaxis set in, which
oonfined the patient to bed during four months, when, in
May, 1880, I saw him in consultation with Dr. Fyfe. I
diagnosed a large bipartite choanal tumour, sending projec¬
tions into both nasal canals, which were adherent throughout
their course. When tonched gently with the probe for dia¬
gnostic purposesthe tumour bled profusely. I removed several
pieces of the tumour, one of which was ulcerated, and
effected a permanent passage for air. In June a serious
ihieraori’hage occurred, which was arrested by Dr. Fyfe by
plugging. In consultation with Sir James Paget, it was
■decided to continue the operation by my method. This
was done after the patient had recovered in October, 1886, ^
when a large tumour was removed from the right nostril
and choana by the electro-cautery. The patient continued
well till April, 1887, when a slight relapse occurred, accom¬
panied by bleeding. The anterior right turbinated was
greatly swollen and adhered to the septum by fibrous union,
while the choanuc were clear. Both anterior parts of the
Bower turbinated bodies were removed after discussion, and
now a bleeding stump of the tumour could he seen ; it was
cut out, and found ulcerated and covered with a dry
sanguineous crust. On July 7th, 1887, a movable piece of
tumour, covered with di-y blood, was cut off by electro-
cautery; another in December, 1887. After this, with the
aid of alterative and tonic treatment, the patient recovered
perfectly. His breathing, articulation, and strength became
perfect, and he is now a candidate for admission to the
medical profession.
Another case, that of a lad aged seventeen, was sent to
cne from a midland town. An attempt had been made to
operate upon the bard, large, bleeding tumour ; the nose had
been fissured all the way, but the bleeding became so
appalling that the operation was arrested. Tamponade
was applied, and the patient was discharged as hopelessly
incnrable. I removed piece after piece of the tumour
through the right nostril, the enormous bleeding being
arrested by the inflated obturator and ferric chloride in¬
jections. !!Now remained only the choanal pharyngeal part
of the tumour of the size of a hen’s egg. It was grown
both to the soft palate and back of the pharynx ; the soft
palate stood perpendicular, and respiration was carried on
(noisily through a narrow round hole between the left base
of the tongue and the tumour. There was evident dyspneoa.
The choanal tumour was removed by the white-hot loop ;
the wire was passed through the mouth, both ends passing
through the nostril were placed into the tubular carrier,
and thus the adhesion to the soft palate was severed; in
the same manner the adhesion to the back of the pharynx
was severed, when the tumour was discharged through’the
mouth. The patient _had a perfect passage, the septum
wiiich was preserved sprang back, and the patient could
smell with the left nostril twenty-four hours after the
operation. In 1889 the patient was perfectly well, and
able to follow his business.
A case of this kind was sent to me from New Zealand,
and after much correspondence between myself and the
patient’s guardians he arrived in T.ondon. Bub some
relatives here disobeyed the guardians, and book him to a
metropolitan hospital. There the patient died of the
intrepid operation. I relate this case only because the
hospital nia(.le me some amends for having taken this
patient from me by leaving me another. WheQ tlie
surgeons attempted Uo operate in this case the lunmor-
rhage was such that as soon as feasible they got rid
■of the patient as incurable, and sent him home to
■die. He was received in the Queen’s Jubilee Hospital,
operated on and cured, and is now quite well. In
this case no doubt the Ineraorrhages were extraordinary,
for the tumour was complicated with much destruction of
the posterior part of the nose; the vomer and a piece of the
•sphenoid bone lay as dead sequestra in the middle of the
tumour, and added fetor to the other borburea. The
cartilaginous septum was saved, the exophthalnius dis¬
appeared, the arch of the palate, which was soft and
■depressed, resumed its place, grew bone, and became hard.
The hearing of tlie right ear, which had been hard, and
from which blood had been discharged for some hours,
became restored. In this case the innor sphincter of the
lacrymal duct was paralysed, for when the expanding obtu¬
rator was applied to the nose to arrest bleeding the eye
became filled with blood over the conjunctival space. The
patient learned to prevent this by pressing his nnger upon
the sacculus lacrymalis before the application of the pmg.
In this case the right facial nerve was partly par^ysed by
pressure, and the expanded cheek was nearly mottonlesB.'
After the operation it resumed its mimic contractility.
Another cose was that of a clergyman in whom the
tumour had existed for several years and produced much
destruction. The nose was distended and thickened, the
bony palate was soft and pulsating; all molars were lost
from the right upper jaw. An abscess had burrowed from
the ethmoid region through the orbit down the face in front
of the antiura, and risen outside to the height of the zygo¬
matic arch, in this case the first attempt at an (meratlon
produced much hremorrhage; several subsequent bleediMs,
unconnected with any operation, were arrested. Tne
tumour was gradually removed entirely; the patient has
now for three years been quite well and able to follow his
profession.
Another case is that of a merchant from the city of
London. The anterior parts of the meati were closed by
impassable hypertrophies, and enormous deviation of the
septum to the left. The hypertrophies were removed with
the electro-cautery, and the bones ablated; when these
wounds bad healed a large cyst was found in the posterior
part of the left meatus, opened and removed. Only then
the pharyngeal tumour presented itself, and was removed
through the right nostril. In both cases respiration and
phonation were completely restored.
In the case of a young gentleman aged sixteen, a
pharyngeal tumour of the size of an egg was removed
entire, us in the first case. I might quote a number of
similar cases, all of which were cured by the operation here
insisted upon, without a single death and without severe
reaction. In some the tumour was cut in pieces in the
pharyngeal space through the nose by a cutting instrument
like a lithotrite, and removed in pieces through the nose
with the wire loop. The operations are laborious, hut their
safety compensate for all drawbacks, and their hitherto
invariable success is a great recommendation, particularly
in those cases which were formerly left unoperated upon or
declared incurable. In about a dozen cases abscission of the
lower turbinated bones, of one or both sides, had to precede
the final operation; but all patients were practically, most
of them completely, cured, and are now active and useful
members in various spheres of society.
Pembroke-garJona, W.
THE TREATMENT OF ACUTE LOBAR
PNEUMONIA;
PROM AN ANALY.SIS OF A THOUSAND CASES TREATED AT THE
LONDON HOSPITAL DETWEEN THE YEARS 1880-1899.
By W. SOLTAU FENWICK, M.D., B.S.Lond., &c.
The treatment of acute lobar pneumonia has always
proved an exceedingly discordant topic in the science of
medicine. From time to time various new remedies have
been strongly advocated, and their beneficial influence
upon the course of the malady apparently demonstrated
by an appeal to statistics. Bat each new departure
has in its turn met with the same fate at the hands of
further inquiry, with the result that the statistical litera¬
ture upon the treatment of the disease is chitlly remarkable
for its extraordinary contradictions, and for the opportunity
it aflbrds to modern writers for unanimity upon one point—
namely, that no reliance whatever should be placed on
statistics as a guide to the future treatment of the malady.
Bub however just such a conclusion may be, a more ex¬
tended inquiry into the etiology of acute pneumonia has
gone far to demonstrate the cause of these paradoxical re¬
sults; and it is now an appreciated fact that the disease in
question varies in its clinical features, and consequently
in its reaction to treatment, not only in different countries,
but even in the various parts of the same land. And hence
it is that the practice of venesection, combined with large
doses of tartar emetic, although now totally condemned in
the treatment of the malady as it occurs in large towns,
still proves itself the moat i>otent of aU_ remedies when
employed in that fype of the disease which is commonly
ogle
248 The Lancet,]
DR. W. S. FENWICK ON ACUTE LOBAK PNEUMONIA.
[Jan. 31,189J.
met with in agricultural districts. It will therefore he
admitted that, in order to form a just estimate of the
influence of various remedies upon the progress of the
disease, it is necessary that the cases submitted to obser¬
vation should belong to the same clinical type. It may
conseq^uently prove of some interest to examine in detail
the eftects of various methods of treatment upon that class
of the disease which presents itself in a metropolitan
hospital, and accordingly I have collected the records of
one thousand cases which have been treated at the London
Hospital during the course of the last ten years. But
before proceeding to the subject of my paper I must offer a
few words of explanation upon the somewhat unusual
method that has been adopted in the following analysis.
It is well known that some degree of fever is an almost
invariable accompaniment of acute pneumonia; and since,
as I shall have occasion to show, the danger to life during
an attack of the disease bears a definite relation to the
amount of fever which accompanies it, I have arranged the
varions cases according to the average degree of temperature
which they presented. It may also be shown that those cases
which present an average temperature of about 103° F.,
are usually attended with the minimum degree of mortality,
the states of hyperpyrexia and apyrexia corresponding to
the maximum of danger to life. I have accordingly drawn a
line through this thermometric point, and by it divide the
cases into two great closes, which, in default of better
terms, I shall designate as “sthenic” and “asthenic.” But
it must be clearly understood that such a division is chiefly
one of convenience, and that no attempt is made to deter¬
mine whether any particular case should be styled ‘ ‘ sthenic”
or “asthenic” by a glance at its temperature chart. The
main object of the analysis is to prove that the success of
all treatment depends upon the individualisation of the
patient instead of the disease from which he suffers. By
thus arranging the various cases according to their average
temperatures, I venture to think that several sources of
error may be avoided, and that by examining the influence
of the various remedies upon cases of approximately equal
severity, we may arrive at a juster estimate of their relative
value. The absolute duration of the disease is estimated by
the length of time which elapsed between the initial rigor,
or gastro-intestinal attack, and the first subnormal reading
of the thermometer. The average duration of the malady,
calculated in this way, was almost exactly eight days.
In order that a remedy may be able to exert its supposed
influence upon the disease, a certain length of time must be
allowed for its action. I have therefore included in my list
only those cases in which the crisis occurred after the lapse
of twenty-four hours from the time of admission into the
hospital. On the other hand, more than one hundred cases
were admitted during the same period of time, in which the
disease terminated before the lapse of twenty-four hours,
the patients having in all cases been previously nursed at
home. No less than 49 per cent, of these cases terminated
fatally, showing conclusively the high rate of mortality
attending an expectant treatment when unaccompanied by
proper nursing and attention. It is hardly necessary to
state that all cases of so-called secondary pneumonia have
been carefully distinguished from the primary or idiopathic
form of the disease, and eliminated. Taking, in the first
place, those cases which exhibited an average temperature
exceeding 103° F., I shall proceed to examine them in the
following order1. Cases in which the treatment con¬
sisted in the application of hot poultices to the chest, com¬
bined with the internal administration of various expectorant
and tonic remedies. 2. Cases whose medicinal tre^i-tment
consisted entirely of quinine in large doses. 3. Cases in
which the disease was combated upon general antipyretic
principles, similar to those employed in the treatment of
other acute specific fevers.
Class I. —Sthenic Cases.
_ This group includes 602 cases, the treatment of which con¬
sisted in the administration of various medicinal remedies,
while the local application took the form of hot fomentations
or poultices. As I have already indicated, the cases have
been arranged according to the average temperature observed
during the course of the attack, the results being shown in
the following way:—In 324 cases the average temperature
ranged between 103° and 104°, and of these 60, or about
18‘5 per cent., died. In 109 eases the average temperature
ranged between 104° and 105°, and of tliese 61, or 30 per
cent., died. In 10 cases the average temperature exceeded
105°, and of these 9, or 66‘2 per cent., died. Witboufr
wishing to draw any exact conclusions from these figures,
two facts are sufficiently obvious to allow of specia)
mention—first, that the rate of mortality is a high one,
and, secondly, that the death-rate increases with every
degree in the average temperature. When, however, tho
clinical features of this group of cases are examined at.
greater detail, we are struck at once by several points of
obvious interest, and a brief consideration of the most im¬
portant of these may, perhaps, serve to throw a more*
concentrated degree of light upon the relative value of the
various methods of treatment.
Death may occur at almost any time during the course
of the illness, but it appears to be more apt to supervene ab
certain periods than at others. Thus, when the various*
cases are tabulated according to the day of the attack on
which the case terminated, the proportion of deaths to
recoveries is shown in the following way. Of the
cases which terminated on the third day of the disease,.
25 per cent, died; on the fourth day, 20 per cent, died;
on the fifth day, 41 per cent, died; on the sixtii day, 16 per
cent, died; on the seventh day, 12 per cent, died; on the
eighth day, 16 per cent, died; on the ninth, 32 per cent,
died; on the tenth, 66 per cent, died; on the eleventh,
61 per cent, died; on the twelfth, 70 per cent, died; on the
thirteenth, 84 per cent. died. But perhaps the most notice¬
able feature of all is, that among the entire number of 115
deaths, no fewer than 40 occurred at the crisis of the disease ^
in other words, 35 per cent, of all the deaths coincided in
time with the sudden defervescence of the temperature-
The following facta are, therefore, obvious from a perusal of
these figures : first, that during an ordinary attack of acute
pneumonia death is most apt to supervene about the fifth
day—i.e., at the height of tlie fever; secondly, that after
the eighth day the danger to life increases enormously with
each day that the crisis is deferred ; and thirdly, that the-
crisis itself is a period of very considerable danger. In tho
vast majority of cases some trace of albumen may be (lis-
covered in the urine before the third day of the disease.
But I believe that the amount of albumen which can time
be demonstrated is in itself a point of very consider¬
able prognostic value, and one which seems to have
been much overlooked by systematic writers. I find*
that the quantity of albumen present in the urine during
the first three days of tho disease bears a definite
relation to the attendant mortality. Thus, of cases-
which presented one-fourth of albumen, 32 per cent,
died; of cases which presented one-third of albumen,
52 per cent, died; of cases which presented one-half or
more albumen, 86 per cent. died. Again, in three cases
death was directly attributable to pulmonary embolism -
in each case the sudden dislodgment of clot being due to
premature exertion on the part of the patient. In two cases
the saphena vein was the seat of the thrombosis, while in
the third the clot had evidently formed in the right ven¬
tricle of the heart. Another point of'interest may be found
in connexion with the initial symptom of the disease. In.
about 65 per cent, of all the cases a distinct history of an,
initial rigor was obtained; but in seventy-six cases the dis¬
ease is distinctly stated to have commenced with a severe
gastro-intestinal attack. Now the rate of mortality among
those cases which commenced with a rigor was about 23 per*
cent.; but of the seventy-six cases alluded to where blie dis¬
ease was ushered in with severe vomiting and diarrhoea, no-
fewer than thirty-six died—i.e., nearly one-half.
There are only two other points to which I would hero
draw attention. Digitalis was administered in forty-three
cases, and of these nineteen died. This extreme degree of
mortality would appear to condemn the remedy outright,
but it must be remembered that in these cases the heart
was probably failing from the commencement, and it is
well known that such cases are exceedingly prone to die, in
spite of treatment. A preliminary venesection was practiseii
in six cases, a fatal result supervening in live. Some form
of alcohol was administered in 68 per cent, of all tiie cases.
Class II.— Quinine.
This drug appears to have been administered with the
view of exerting some special influence upon the exciting-
cause of the disease, and I find that in fifty-two cases it
constituted the entire medicinal treatment, in doses varying
from twelve to forty grains daily. In thirty-two oases tho
average temperature varied between 103° and 10-1°, and
of these six, or 19 per cent, died. In twenty cases tho
The Lakobt,]
DR. D. LOWSON ON GASTROTOMY.
CJan. 31, 1891,
249
average temperature varied between 104° and 105°, and
of theee five, or 26 per cent., died. Stimulants were
administered in thirty-nine cases; nevertheless, two out
of the eleven deaths occurred from collapse, when the
fever suddenly defervesced at the crisis on the seventh
day. From these facts it would appear that quinine, in
the afore-mentioned doses, exerts but little beneficial in-
l^uence in these cases; and after very careful examination
of the various temperature charts, I have been unable to
satisfy myself that the exhibition of the drug had tended in
any way to modify the degree of fever. When these results
are compared with those in the previous section, several
(points of similarity become apparent. In both cases the
total ^eath-rate exceeds 20 per cent.; under both methods
of treatment the mortality bears a constant relation to the
severity of the symptomatic fever; and both emphasise the
same important fact—namely, that fatal failure of the heart
at the crisis is of frequent occurrence, and results from the
sudden withdrawal of the stimulating action of fever.
CLAs,g III.— Antipyretic Treatment.
J will now pass on to consider the results which have accrued
from tlie application of general antipyretic principles to the
treatment of acute pneumonia. And it might be well to
At the outset that the object of these measures is to
efiect a reduction in the useless expenditure of cardiac force
by annulling as far as possible the profligate influences of
fever. The reduction of temperature may be brought about
by the agency of two distinct classes of remedies—either by
the administration of the various so-called antipyretic
■drugs (of whose mode of action we are still in ignorance), or
by the employment of some method which can effect the
reduction of temperature by the direct abstraction of heat.
Unfortunately, I have only been able to discover ten cases
among our clinical records in which the treatment of the
•disease was confided solely to such drugs as antipyrin and
phenacetine. And since it is quite impossible to d^i-aw any
practical deductions from an examination of so small a
Hiumber of observations, I shall have to omit the considera¬
tion of this method of treatment, and confine the inquiry to
the results which have attended the systematic efforts to
control the symptom of fever by the direct abstraction of
heat, and in so doing it may be well to commence at the
beginning.
A. The ice-baf /.—The local application of ice in cases of
acute pneumonia has long been a favourite remedy with
many continental physicians, and it is now some years
eince the ice-bag was introduced into the London Hospital
^ a substitute for the poultice in the treatment of cases
belonging to the sthenic type. As in the case of every
other innovation in the practice of medicine, many ob¬
jections have been urged against the application of an ice-
hag over the consolidated lung ; and it would seem as if its
most ardent advocates, by not insisting sufficiently upon
the class of case in which the ice-bag can be used with
success, and also, perhaps, by a tendency to somewhat over¬
estimate the real value of the procedure, have unconsciously
enabled these objections to exert an undue influence upon
public opinion. I think,liowever, that everybody who has had
much experience in the use of the method will admit the truth
■of the following statements:—First, that it is in the acute
sthenic cases, and in these alone, that the ice-bag can be
applied with any hope of success, and that those cases which
'oelong to the secondaryor asthenic variety of the disease are
not only totally unfitted for, but actually affected injuriously
by, its application. Secondly, that many patients exhibit a
marked idiosyncrasy with respect to the local application of
cold, and in these cases, however suitable they may appear,
the ice-bag proves absolutely intolerable, and should there-
Jore be at once removed. Lastly, when the individual
peculiarities of each case has been inquired into and
respected, the ice-bag proves itself of singular efficacy, and
not only is the phantom failure of the heart conspicuous by
Its absence, but in the majority the heart’s action becomes
actually stronger, and the general condition of the patient
undergoes considerable improvement. The antipyretic value
of the ice-bag is uncertain. lu the broncho-pneumonia of
■eluldren a fall of temperature certainly does follow its use,
but in cases of acute pneumonia I have never been able to
•detect any constant or decided effect as the result of its
■application.
Among my series of cases I can find only twenty-six in
which the disease was treated solely upon this principle;
*or although a very large number of others received the ice-
bag as a local application, the temperature was at the same
time moderated by some accessory means. Of this number
eighteen exhibited an average temperatureof from 103* to 104 °’
with two deaths; while in the remaining eight, the tempera¬
ture of which exceeded 104°, two cases ended fatally. In
no case did any bad symptom result from the use of the
cold application. The value of the ice-bag (or Lieter’s tubes)
may therefore be summarised somewhat as follows :—As a
local application in some' sthenic cases it proves itself of
more practical value than the linseed poultice, the pleuritic
pain being relieved, while at the same time the general
condition of the patient undergoes improvement. Its mani¬
pulation is simple, and by its lesser weight it does not tend
to hamper the movements of the chest like the jacket
poultice. As a general antipyretic remedy its value is
inconsiderable. The mortality attending its use is probably
lower than that which results from the previously described
methods of treatment.
(To be concluded.)
GASTROTOMY; REMOVAL FROM THE STO¬
MACH OF A SKEWER WHICH HAD BEEN
SWALLOWED, AND HAD PENETRATED
THE THORACIC WALL; RECOVERY.
By D. LOWSON, M.D.
The mental vagaries of the insane often lead them to
swallow, sometimes with suicidal intent, bodies entirely
unsuitable for digestion or deglutition. Of these some are
so irregular in shape that it is difficult to understand how
they reach the stomach at all, and others so formidable in
appearance that one wondera they are not immediately
fatal. It is not an unusual thing at asylum autopsies
to find in the stomach a miscellaneous collection of
odds and ends, whose presence had been till then
unsuspected. In a remarkable ease, which I have seen
recorded in more than one work on surgery, a couple of
pounds’ weight of such articles as nails, knife-handles, iron
shoe heels, pebbles, screws, buttons, &c., was discovered
for the first time post mortem. The motives influencing a
diseased mind are often past finding out, but in such cases
there is probably some local disease or neurosis, and in
cramming things down the throat they are making an
ignorant and impatient effort to relieve pain or satisfy a
craving somewhat akin to that of early pregnancy. Suicide,
however, is doubtless the intention in the majority. Certain
things,ofcourse,caunotbeswallowedwithirapunity. Asharp
I instrument like a knife may be expected to prove fatal from
' hmmorrhago or visceral injury; metal palates have occa¬
sionally penetrated, the tlioracic aorta; and even the
swallowing of a coin, usually looked upon as a harmless
accident, has been known to cause death, as in a case
occurring some years ago in the practice of Mr. Rudd of
Witherusea, where a halfpenny by becoming impacted in
theileo-cfccal opening caused complete and fatal obstruction.
A sharp-pointed body like a skewer may, if directed
upwards, enter lung or heart, or if downwards, may injure
some viscus in the abdominal cavity. On the other hand,
it may take a leas perilous course and discover itself
by penetrating the abdominal wall or the margin of the
thoracic parietes, as in the following case:—
On Sept. 14th, 1886, I was summoned to a case at the
Hull Borough Asylum. I)r. Mevson, the medical superin¬
tendent, gave this history: “ W. A-, aged thirty-seven,
labourer, had previously to admission been for a number of
years off and on an inmate of the Sculcoates Workhouse.
Four months before coming to the asylum he had become
more reserved and sullen, and latterly suicidal. A fortnight
before admission he had tried to choke himself by cramming
a handkerchief down his throat, on another occasion to
pusli a poker down, and once he attempted to twist off his
testicles. On admission. Sept. 2nd, 1886, lie was rather
thin and nmxmiic. His muscles were flabby, he had
small boils on the back of his neck, and the epigas¬
trium was reddened evidently from a blister. Heart
and lungs were normal; pulse 58, regular and full; the
breathing was somewhat rapid, otherwise normal; the
tongue was flabby and covered with a moist brown fur, and
the fauces were rod and congested. He complained of pain
Dic-::zad b/ Google
250 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Jan. 31,1891,
in the lefd side, and he manifested considerable sensitive¬
ness when touched in that re^on, though the tenderness
was not limited to one spot. There was neither sickness
nor vomiting, nor any other symptom specially pointing to
the stomach except an aversion to food, which he took
in small quantity and after much pressing. He con¬
tinued to complain of pain in the left side, but no
abnormal appearance could be seen till four days
after admission, when a small nodular prominence
appeared under the seventh costal cartilage. It was pain¬
ful when touched, and disappeared with a jerk on slight
pressure. There was neither redness nor discolouration at
this time, but later it became gradually more prominent
and diffuse; redness began to appear around it, and abscess
seemed to be forming. Poultices were now continuously
applied, and on the evening of the 13th, a week after the
local prominence was first observed, a small opening
appeared in the centre, and thu underlying tissue was
apparently gangrenous. No foreign body Avas seen at this
time, but next morning there projected from the opening
an iron wire resembling a knitting needle, about six inches
long. It could be pushed back and rotated to a certain
extent, but could be pulled further out.” I saw the
patient in consultation with Dr. Merson on *'he same
day, and found matters as above stated. A stiff iron
wire protruded from the centre of a block slough between
she seventh and eighth costal cartilages on the left
side. It moved up and down with respiration, could be
pushed back a little and rotated, but could not be with¬
drawn. As the cause of the obstacle to withdrawal was not
apparent, and as there was no possibility of extracting from
the patient any information on the point, no force was used.
There was no pleurisy or peritonitis, so that it Avas evident
that, whatever the thing was, its passage through the wall
of the stomach and the other structures penetrated had set
up sufficient adhesive inflamiuation to glue together the
various layers and effectually prevent the escape of the
contents of ihe stomach into the peritoneal and pleural
cavities. Two modes of dealingwitb the case were advanced.
One was to enlarge the opening and extract; the other to
open the stomach through the peritoneal cavity and pull
the wire back into the stomach, and then remove it
through the abdominal wound. The first plan was rejected
for two reasons. By enlarging the opening through which
the rod projected we should certainly enter one serous
cavity, perhaps both, and allow the gastric contents to
escape, with the usual result; and in addition we had no
knowledge of the magnitude of the obstruction at the
other end, beyond the fact that it was small enough to
pass the gullet. We therefore decided to open the stomach.
An incision was made parallel to the left margin of the
substernal triangle, and having divided the muscles and
opened the peritoneum, I got hold of the anterior wall of
the stomach, which, with a small piece of the great omentum,
presented at the wound. Making an inch-long incision into
the stomach, I introduced my linger, and behind the lower
end of the sternum I felt the rod, and, attached to it, some¬
thing resembling a handle. I hooked my finger round this
and brought it out through the external incision, and with
a slight amount of traction drew out the following: A
skewer, 7-^ in. long, with an oval eye, through which passed
a fragment of a stem of a clay pipe, 2^ in. m length. One
end of this bad evidently been broken oJl’closo to the bowl,
and was thus a little larger in circumference than the rest
of the stem. This, together with the oval shape of the eye
of the skewer bad prevented it from slipping quite
through. I stitched up the wound in the stomach with
Lembert’s sutures, and closed the abdominal incision in
the usual way.
Dr. Merson’s report on the subsequent progress of the
case may be summarised as follows:—The iHough sepa¬
rated, and the wound looked clean and healthy on the
fourth day. The abdominal wound healed in the greater'
part of its length by first intention, and was completely
cicatrised on the sixteenth day. Eor nine days the
patient was fed entirely by the rectum, and after th&,
eleventh day by the mouth alone, the diet consisting at
first of milk and beef and milk and egg. On the tAventieth
day solid food was resumed. The temperature on the
evening after the operation was 100'2*; next morning S)9'6°,.
evening 99•4'’, after which it remained normal. The pulse
was 98 on the first day, on the second 92 and 90, third 84-
to 78, gradually falling to 04. The operation Avas per-
Wmed on Sept. 14th, 1886, and the patient has remained
until now in good health, and is still an inmate of the asylum..
It would he idle to speculate on the manceuvrej and
somersaults of the skewer and pipe stem during their
sojourn in the stomach, or to attempt to estimate the pro¬
bable number of failures before the latter accomplished its-
final and successful pass. The patient has always mani¬
fested an unwonted shyness, even when gently approached
or questioned, with regard to the way in which the skewer
was swallowed, and we have never been able to find out
which end 'went first, or if the two articles were swallowed
separately, or together as in the drawing.
Hull.
% lliOTr
OP
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autem est alia pro certo no.sconcH tla, nisi quamplwHmasetmor-
boruin et disaoctionum historias, turn aliorum tu>n proprias collwctas
babeve, et inter ae compavare.— Morgagni De Sea. et Caua. Morb.,
lib. iv. Procemium. -
KING’S COLLEGE HOSPITAL.
CASES OF ABDOMINAL COLOTOMY; KEMAUKS.
{Under the care of Professor Rose,)
We give below notes of four cases in which it wa»
necessary to open the bowel and establish an artificial anu&
for the relief of symptoms due in three cases to the presence
of new growth in the bowel, and in a fourth for acquired
communication between the rectum and bladder. In these
cases the operation was performed through the wall of the
abdomen, a procedure which jiresented many advantages,
especially in Cases 3 and-t. Mr. Rose draws attention in
bis remarks to points in the technique of the operation to-
which he attaches most importance. Various nietho(l&
having the same object in common—that of drawing the
loop of intestine well forward and preventing its retrac¬
tion—have been suggested. Maydl^ passes a bard rubber-
cylinder covered with iodoform gauze through au open¬
ing in the mesentery close to the bowel. Lauenstein^'
effects the same result by closing the abdominal wound
by passing sutures through the meso-colon or mesen¬
tery, and secures the extremities of the loop by careful
suturing. Allingham^ recommends a ligature passed through
the raeso-colon or posterior border of the gut; and Verneuil;*'
employs two large pins and resects two-thirds of the wall
of the’bowel protruding from the wound. Koenig*’ does the
operation in a manner similar to that of Verneuil, but
empties and closes the lower end before attaching the upper
one to the wound. KelseyV method is Homewhat like that
of Verneuil. Cripps^ secures the bowel by making tAVo-
thirds of the circurniercnce of the exposed part project beyond
the opening. For notes of these cases wc are iudohfed to
Mr. Oheatle, surgical registrar.
Case 1.—W-, a gamekeeper aged sixty, -was admitted
under the care of Mr. Rose in January, 1890. A brother
is said to have suffered from cancer of the lip. The patient
stated that his health had always been good until about
June, 1888, when he had a severe attack of diarrhoea and
abdominal pains, the latter relieved by pressure, the
attack lasting only a few days. Since then ho had
' 8>i,)ouH: Annual cf the UnlvevNal Modicul Scioncen. Cciitnil. fur
Chir ISSS ^ Ibid.
3 Brit. Mod. Jour., 1887. * La Franco Mcilicalo, 1887.
0 Medical Hress and Circular, 1887.
e Med, Record, vol, ii 1880. ? Brifc. Med. Jour., vol. i, 1880.
Digiti.^3d
e
-The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Jan. 31,1891. 251
•experienced general abdominal uneasiness and the passage
at intervals of blood with his motions, the blood being
bright red and clotted. No other definite symptom could
be obtained. He complained on admission of dull, aching,
abdominal pains, which were relieved by pressure of the
hand firmly upon the abdomen; also of flatulence and
weakness across the loins. The abdomen was distended
and very resonant on percussion, especially over the
.region of the ascending and descending portions of the colon.
Perrectum the finger could just reachan irregularconstriction
which encircled the gut, and the examination caused pain,
which lasted for some time. He complained of severe pain
during and after the passage of each stool, which was
tgenerally accompanied with much mucus and stained with
blood. He passed six or seven loose motions a day. On
Peb. 8th inguinal colotomy was performed as follows:—
Taking an imaginary line from the umbilicus to the anterior
superior iliac spine of the left side, an incision about fo\ir
inches long was made at right angles to it, and about half
an inch external to its centre. The abdominal wall,
which was fairly free from fat, was then divided carefully,
■and the peritoneum opened to a corresponding extent. The
small intestine presented at the wound and was pushed
back. The omentum was now seen and followed to the
stomach ; this in its turn was pushed back and the trans-
verie colon exposed and traced down to the descending
■colon and sigmoid flexure. A thread of catgut was then
passed through one of its longitudinal bands at the spot
•selected for future fixation, and the whole returned into the
4 ibdominal cavity, the catgut acting as a guide. The parie¬
tal peritoneum was then stitched to the skin with a continuous
dine catgut suture. The sigmoid flexure and lower part of
the descending colon were then pulled out of the wound
by gentle traction, the guiding thread indicating the re-
■quired portion of bowel. A long piece of thick catgut
threaded on a bandied needle slightly curved was passed
through the abdominal parietes about one inch from the outer
-edge of the centre of the wound, then through the meso-
■colon and abdominal parietes on the other side ; the needle
was then withdrawn, and the suture repassed parallel to,
and about one-third of an inch from, the first, in an exactly
•similar manner. The efi'ect of tightening up and tying this
suture was to briug.into apposition broad surfaces of parietal
peritoneum with the meso-colic visceral layers, thus bringing
the abdominal parietes well behind the protruded colon,
.and_ eli'ectually preventing its return to the abdominal
•cavity. About six inches of the gut were thus allowed to
protrude. At the upper and lower angles of the wound a
•few additional fine catgut sutures were introduced, fixing
the gut to the edge as an additional precaution, with a view
to prevent further protrusion. The wound was then dressed,
the bowel being covered with purified oil-silk protective,
and the whole by the double cyanide gau/e and salicylic
wool. The patient still continued to pass loose blood-
•stained motions per rectum until the sixth day, when the
protruded colon was opened by a small incision ; fmces were
■squeezed out, and the peristaltic action thus induced led to
a copious evacuation. The patient passed no more stools
per rectum, and was discharged on March let with his
artificial aperture acting efficiently. There was little or no
•alteration in the condition of the growth to be detected on
rectal examination. Tlie patient was exhibited at the
Medical Society of London on March 17th, 1890.
(Jasic 2.—J. W -, a female aged twenty-three, was
admitted in May, 1H90, suffering from vesico-vaginal and
■recto-vaginal listulfo. When ten years old she was, as
■she describes it, “cut for stone.” The wound did not heal,
and the patient lost control over micturition, a condition
which has since persisted. Three years later, according to
Lev account, an abscess formed, probably in front of the
rectum, which burst and left a fistulous communication,
allowing the passage of fmees into the bladder. For this
■distressing condition many plastic operations had been
attempted, without success. So finally Mr. Rose performed
anguiual colotomy in the manner described above. The result
is satisfactory on the whole, though the lower opening has
.given some trouble in consequence of the occasional passage
of fmcal matter.
Cask .q,—C. L-, a compositor aged sixty-three, was
admitted on Nov. 27th, 1890. On Nov. 10th, whilst
•standing at work, he was attacked with violent abdominal
pain, which was relieved by pressure; there was no vomiting,
•collapse, or faintness. Was nob lifting or doing any laborious
work at the lime. The pain passed oil', and lie was able
to walk home. Vomiting commenced on Nov. 11th, after
every meal; the material vomited was simply food, with no
fcBcal odour; this, however, soon subsided. No motion
had been passed since Nov. 9bh, when, as far as he was
able to judge, the action was normal. No abdominal
pain was felt after the first attack. The patient was thin
and emaciated, but with no anxiety of countenance. He
seemed verr comfortable, lying on his back, with knees and
hip extended. Abdominal respiration was present. Exa¬
mination revealed no abdominal distension; no pain on
manipulation; no dulness on percussion. The liver was
symmetrically enlarged, painless. Per rectum a small
nodule could be felt high up in front of the anterior wall,
suggesting an enlarged gland. On Nov. 30th vomiting
reappeared, and became fmcal in odour. Constipation
throughout this time had been absolute, and resisted treat¬
ment by castor oil and copious eneraata, and so without
delay operation was decided on, and from the uncertain
situation of disease median laparotomy was performed. A
tumour was found involving the sigmoid flexure and the
intestine above it. The transverse colon was drawn out
of the wound and treated in the manner described above.
The case, as far as the colotomy is concerned, is doing well,
but the probable presence of secondaiy deposits in the liver
and bin general cachectic condition do not justify his leaving
the hospital.
Case 4.— Although this is not a true case of colotomy,
for in consequence of the situation of the disease such was
impossible, still it is included with the above as the method of
operation was precisely the same. M. D-, a violinist aged
fifty-two, was admitted on Dec. 1st, 1890. No history or sym¬
ptom could be clearly obtained prior to Nov. 24th, when he
was seized with violent pains in the right iliac region of the
abdomen,which hestated were relieved oypressure; the pains
increased gradually until Dec. 2nd. Vomiting (not faecal)
commenced early, and increased in frequency pari passu
with the amount of pain. His last motion was on Nov. 23rd,
which was, as far as he knows, normal. The man was
thin and emaciated. The abdomen generally was slightly
distended, no pain on percussion or manipulation; per
rectum nothing could be detected. There was vomiting after
food, together witli complete constipation. On Deo. 2nd
the abdominal distension had greatly increased, and as the
vomiting, pain, and constipation still continued, Mr. Rose
opened the abdomen in the right inguinal region, as the
symptoms pointed to disease near the caecum. On ex¬
amination, the disease was found to aflect the upper
part of the ascending colon, so a portion of the small
intestine was brought out and fixed. In consequence of
the excessive distension of the abdomen, it was necessary
to open the gut on the operating table, when a copious
evacuation ot fmcal material took place, care being taken
to protect the wound from contamination. The patient’s
condition improved (vomiting and pain ceasing) up to
Dec. 5th, when his respiration became rapid, temperature
subnormal, and dulness was detected at the bases of the
lungs. The chlorides in the urine were decreased. He died
on Dec. 7th. At the post-mortem examination the bases of
the lungs were solid, swollen, and red, and the pleurm
covered with much lymph, and in the area of inilammation
were hmniorrhagic patches. The top of the ascending
colon was surrounded by a ragged ulcer with hard and
abrupt edges, which encroached upon the lumen of the
bowel, and only permitted the insertion of the tip of the
finger. The wound appeared perfectly healthy,
jaemai'/cs htj Mr. Rose.—T he above cases, supplemented
by others treated in a like manner elsewhere, have con¬
vinced me of the great advantage of the mesocolio or meso-
sigmoid suture described above, and for the following
reasons: the operation is simplified, less time is taken in
its performance, the separation of the upper and lower
openings is tlcfinite, and the tendency to retraction of the
spur avoided, thus preventing the passage of firces into the
lower part of the gut, one of the great troubles after such
operations. The deep suture should not be removed until
it is considered that the adhesions are sufficiently firm.
In one case, however, I left it in longer than necessary,
and suppuration occurred along its track, though this
fortunately subsided after removal of the suture. Unless
urgent circumstances arise, as in Case 4, the opening in
the bowel slioukl nob be made before the fifth or sixth day.
The occasional use of opiates or morphia hypodermically
is sometimes necessary, especially when there is a tendency
to vomit.
252 Thb Lancet,]
KOYAL MEDICAL AND CHIRURGICAL SOCIETY.
[Jan. 31,18OT.
' BELFAST ROYAL HOSPITAL.
A CASE OF LIGATURE OF THB LEFT COMMON CAROTID
ARTERY FOR IIAiMORRHAOE; RECOVERY.
(Under the care of Dr. Henry O’Neill.)
Although it is some years since the operation described
below was performed, it will be noted that the patient was
recently seen in good health ; and a record of cases where
important surgical interference has been required, illus¬
trating the effect locally and on the general state of health,
is often desirable. Although it was considered advisable to
ligature the common carotid artery for the arrest of the
hmmorrhage, the surgeon secured later the ends of the
vessels in the wound. The mortality after ligature of
the common carotid for brcmorrhage has been somewhat
high. Pilz gives 335 cases, with a mortality of 51 per cent.;
Nunn’s statistics gave a mortality of 50 per cent.; and those
of Fischer a still higher death-rate, that of 66 per cent.
During the American War, 81 out of 116 for whom this
operation was performed died.^ A case in almost every
respect resembling this one, as regards position,-cbaracter
of wound, method of treatment, and result, was under the
care of Dr. Goddings.
John C-, aged forty years, a pipe-maker, was admitted
to the Belfast Royal Hospital, at 12.40 A.M., on Sept. 1st,
1885, suffering from an incised wound one inch and a half
long andone inch deep, and about one inch below the lobule
of the ear, and close behind the angle of the lower jaw on
the left side. The patient on admission was pale and
collapsed. No pulse could be felt at the wrist, and there
was sighing respiration. It was reported that be
had lost a great quantity of blood, but none was' escap¬
ing from the wound on admission. On being placed
in bed, however, a sudden gush of blood escaped,
which was promptly arrested by Mr. Norman Smyth, re¬
sident pupil, who inserted his thumb into the wound, and
pressing backwards, upwards, and inwards, effectually
controlled the hcemorrhage until Dr. O’Neill arrivea,
who, on considering the position of the wound and the
extensive haemorrhage, decided upon ligaturing the com¬
mon carotid artery and jugular vein on a level with the
cricoid cartilage. This was successfully accomplished, as
the haemorrhage was controlled. The original wound was
carefully examined and the divided ends of the external
carotid artery and jugular vein were secured by forceps
and ligatured; all hcemorrhage now ceased. Carbolised
silk was used as ligatures, no sutures were used, and the
wound was dusted over with iodoform, and a light gauze
bandage applied. Considering the collapsed state of
the patient, no ancesthetic was given. The patient
was restless, thirsty, and occasionally delirious for the
next two days. On the third day the temperature
rose to 102° in the evening, and after the fifth day it
was nearly always normal. From the third to the eighth
day he perspired freely, causing sudamina over the cheat
and back. He complained of a severe pain over the whole
left side of his head. The ligatures came away at various
times up till the seventeenth day, when the ligature of
the common carotid came away. He suffered from slight
facial paralysis for almost four months. The wound
healed oy granulation. About six week after admission
he was walking in the corridor of the hospital when he
became chilly, and was suddenly seized with an attack of
acute laryngitis, which caused such severe dyspnoea that it
was feared tracheotomy would be required, hut by prompt
use of inhalation of steam and hot stupes to the neck and
the administration of five grains of calomel, in a few hours
he was free from danger.
i2emar/«.—When we consider the high mortality which is
recorded after the ligature of the common carotid artery,
this case ended satisfactorily, and notwithstanding the
great loss of blood from a patient who had indulged freely
in alcoholic stimulants for a long time previously to the acci¬
dent. For the past four years and a half he has been able
to perform his usual duties without a single unfavourable
symptom. On Nov. Gth, 1890, he came under observation
again, and Dr. O’Neill, wbo examined him then, found but
little scarring to indicate the position of the former wound.
* Cliarleaton Meil. Journal, Sept. 1840.
SltMral Sflridks.
ROYAL MEDICAL & CHIRURGICAL SOCIETY.
The Therapeutical Value of Venesection.
An ordinary meeting of this Society was held on Jan.
27th, the President, Mr. Timothy Holmes, in the chair.
Dr. Pye-Smith communicated a paper on the Thera-
f ieutical Value of Venesection, its indications and its
imits. The writer recorded cases iu which he had useiJ
bleeding from the arm, amounting to nearly fifty in number.
The patients were suffering from bronchitis, acute and
chronic broncho-pneumonia, lobar pneumonia, miliary
tuberculosis of tile lungs, valvular disease of the heart-
and pericarditis, Bright’s disease, aneurysm, apoplexy and
epilepsy. The general results were stated, and the remedy
was then- considered, not as one adapted for any single dis¬
ease, but as useful in meeting certain indications of patho¬
logical states. These indications were stated as follows-:
First, cyanosis with distension of the right side of the heart,
whether from pulmonary or from some other obstruction to
the circulation; secondly, the intense pain of aortic
aneurysm; and thirdly, urmmic and prolonged epileptic
convulsions. The counterindications for bleeding were
then considered, and criticism was offered of its use in
fevers, in inflammatory disorders, in acute pneumonia, in
hcemorrhage, and in apoplexy. An appendix of cases con¬
cluded the paper.
Dr. Stephen Mackenzie thought that the time was ripe
to reconsider the question of venesection. The pendulum
of professional opinion with regard to it had swung from
one extreme to the other. In many cases be had found ib
of great practical beneflt, but its main use was in the Arab
of the classes which Dr. Pye-Smith had mentioned—namely,
in cases of over-distension of the right ventricle. In thi&
dangerous condition, when the patient was in great peril,
with blue lips and slow, feeble pulse, it did great good. ri>
cases of heart disease it was often only of temporary benefit.
In capillary bronchitis it gave great relief, and was some¬
times curative ; hut it was iu pneumonia that it often gave>
its best results. He quoted the case of a lady who was
suffering from a very severe attack of pneumonia, with high
temperature, rapid pulse and respiration, and cyanosis.
Blee<ling to twenty-six ounces proved of marked benefit. A
second relapse was treated by leeching, which caused five
ounces of blood to flow, and this did good, but, when bad
symptoms returned for a third time, on the removal of
twelve oirncea of blood she rallied and recovered. He knew
of a more extreme case, one of hasmoptysis, in which
cyanosis was induced by the blood running down into the
bronchi; in this also venesection was followed by recovery.
The indications for its use might he generally stated to be
venous congestion, with a struggling right ventricle He
had not used it for the pain of aneurysm, for he had found)
that iodide of potassium, amyl nitrite, or nitro-glycerine
usually gave the relief required, and he referred to a case in
which thirty grains of iodide entirely relieved the pain. H&
had bled many patients with urremia, but the results were
not encouraging. But the arterial tension in that case, was
produced by a toxic agent, and morphine, by acting as a.
chemical antidote, seemed to relieve it. Venesection in
such cases he did not regard as the best mode of treatments
for it removed a minimum of the poison, and it took away
blood which might be useful to the patient.
Sir George Humphry said that hia first experiences were
at a time when bleeding was largely used, and he had lived
to see it almost entirely forgotten. In his early days,
when he was apprenticed, he used -to bleed a great many
people every week, especially in the spring and fall, to the
advantage of his master and to no particular detriment to>
the patients. Many, indeed, came heavy and oppressed as
if about to be ill, but they went away well; it therefore
seemed to be valuable as a preventive measure. In those
days they bled largely for inflammatory affections, espe¬
cially for acute pleurisy, and he quoted two cases, in one of
which recovery seemed to be due to this measure, while in
another similar case in which it was not adopted a fatal
result ensued. A small firm clot was held to confirm th®
necessity of bleeding, while if a large soft clot formed the
indications were more doubtful. He asked how it was that-
one of the most important agents in the treatment of disease
Digitized by
Tab Lancet,]
CLINICAL SOCIETY OF LONDON.
[Jan. 31,1891. 253
should have so completely gone out of use, and he came to
the conclusion that it was because it had been greatly over¬
done. Many other excellent remedies had similarly fallen
into disuse because they had been applied too indiscrimi-
jiatelyand too generally. The same thing happened with
trephining, and might, he feared, happen also with anti-
isepticisni.
Dr. BuoADiJiiNT could name an additional reason why
venesection had been abandoned, and that was that the
human medical mind was always under the dominion of
theory, and theoretically it had been decided to be a wrong
practice. The battle was decided on the worst of fields—
pneumonia; for it was only applicable in that affection in
the first stage of the disease, when there was interference
with the pulmonary circulation and embarrassment of the
heart. He was brought up in an anti-venesection school,
and later he saw it.practised in Paris in cases of rheumatic
and other fevers with disadvantage; but since he had been
dn practice there had not been a year of his life in which he
hau not performed it; He had employed it repeatedly in
aneurysm, though he admitted that the free employment of
iodide of potassium had now done away to a great extent
with its necessity. In cases of right ventricular over¬
distension his experience had been good, and he had seen
life saved in both mitral stenosis and mitral regurgitation.
In bronchitis, when cyanosis was present, he had not
formed a favourable opinion of it; he preferred an emetic
in such cases, which freed the bronchial tubes and com-
nressed the right side of the heart, giving that relief to the
latter which was required to see tne patient through the
-emergency. It should always be remembered that the
eight ventricle should bo in a condition to profit by vene¬
section—a strong powerful impulse with a small, almost
imperceptible, irregular, short, low-tension pulse. In
urremia his experience of venesection had been almost
oiniformly favourable. He did not attribute that affection
to the direct effects of a toxic agent, but rather to the
secondary effects of the toxic agent upon the circulation,
►producing high tension, and hence it was that venesection
relieved it. He had also bled in cases of high tension
without uraemia with good results. He once tried to arrest
.•an ingravescent apoplexy by venesection, but he could get
no blood from the vein owing to the excessive peripheral
spasm. In another case of uriumic dyspnoea with acute
■distension of the heart the same difficulty arose, though
the patient got better under the use of nitro-glycerine.
Mr. Hulke said that he was brought up in a practice
where the patients consisred largely of seafaring men or
agricultural labourers, and he testified to the relief which he
had seen follow in cases of broken ribs or pleurisy. Great
^ood also bad followed bleeding in cases of aneurysm, and
it was of immense value in certain cases of head injury.
He mentioned a case of the latter class in which the
abstraction of more than a pint of blood entirely relieved a
•condition of cyanosis and convulsion.
Dr. Bateman had used venesection, but only in healthy
people, for head injuries, and he gave the details of two
cases in which a good result had followed this practice.
Mr. Pollock had always felt the great importance of
bleeding in certain classes of surgical injuries, especially in
chest cases where rib.s were fractured and lung perforated,
there being luemopbysis and a condition of great distress.
He quoted the case of a deformed cripple with such an in¬
jury, in whom immense relief followed the abstraction of
blood from the arm. He regretted much that students
nowadays were not taught liow to bleed.
Mr. Hutchinson, in connexion withthesubjectof venesec¬
tion, mentioned the fact that surgeons were constantly seeing
patients who had lost much blood and who were apparently
oone the worse for it. He had found that iodide of potas¬
sium took the place of bleeding in cases of aneurysm,
though one of the best specimens of cured aneurysm in the
London Hospital Museum owed the result to repeated
bleedings. He too had been born in the bleeding era,
and had alternately renounced and recommended it.
Latterly, he had found that a very simple measure gave
all the advantage of venesection, and that was placing the
.patient’s feet up to the knees in a bath of very hot water
'for a considerable period. This local determination of
blood appeareil to him to act just as efficiently as venesec¬
tion in cases of head and chest injury.
Dr. Angel Money considerei it inadvisable to bleed in
■cases of bronchitis with cyanosis in the very old and very
young. He had seen relief follow dry-cupjnng, but par¬
ticularly desired to recommend a plan of Dr. Barlow’s, of
rapidly applying an Esmarch’s bandage to the lower ex¬
tremities, and then, on removing it, a considerable conges¬
tion of the limbs would result, with relief to the patient.
Dr. Robert Lee said that there had been a great want of
breadth of philosophy in dealing with this subject. Bleed¬
ing went out of fashion because common experience waa
against the practice of it, and common experience likevriee
must bring it in again if it ever were to be reinstated in
favour. He hoped the whole subject would be worked out
from the beginning, and he felt that in the arrest of local
inflammation bleeding would again be resorted to with
advantage.
Dr. Berry said that general practitioners would, as a
rule, be content to leave the lancet in the pocket of the
consultant, who then might get the blame if any were
incurred for its use. The only case in which he
performed the operation was for the purpose of demonstrating
the fact of death.
Dr. Pye*Smith, in reply, expressed his gratitude for the
general support his views had received. It appeared to him
that the time had come to say that a valuaWe weapon, if
rightly used, had been thrown away. Everyone would be
sorry if its revival were to lead to abuse. The indications
were probably the recognition of the anatomical and physio¬
logical condition of the organs at the time venesection was
proposed rather than the consideration of the pathology of
the disease. Bleeding had been done in the cases of
aneurysm in addition to treatment by iodide of potassium.
The combined accumulation of experience would soon lead
to the formation of an opinion as to the cases in which
this measure was desirable. He had seen in Paris the
pernicious consequences of bleeding in acute rheumatism
and typhoid fever, and the error then was due to theory; if,
however, we followed merely clinical experience, this error
would be avoided.
CLINICAL SOCIETY OF LONDON.
Lv,fus successfully treated hy Scarification. — Acromegaly .—
Jiitateral Adductor Spasm, with Unilateral Congenital
Dislocation of Uip.—Congenital Cleft of Nose. — (%rvi<^
Swelling. — Enteric Fever [fatal] without Intestinal
Ulceration.
An ordinary meeting of the Society was held on Jan 23rd,
the President, Sir Dyce Duckworth, being in the chair.
Dr. Balmanno Squire exhibited a case of Lupus which
had recovered under treatment. The patient was a woman
aged thirty-five; the disease had lasted twelve years, and
she had remained well for seven years after the treatment
ceased. The method adopted had been erasion and multiple
linear scarification.
Mr. Stephen Paget showed a case of Acromegaly. The
patient was a man aged forty-two, in whom the disease
had been in progress for ten years. • There was extreme
lengthening of the face, with overgrowth of the facial
bones, especially the lower jaw. The hands and feet were
greatly enlarged, and the patient had lost six inches in
height by the advance-d deformity of the spine. The
thyroid was enlarged. Vision was defective. There were
molluscous growths on the trunk, and osteophytes in the
knee-joints, The voice was thick and guttural and there was
loss of strength. Mr. Paget regretted that he had not yet
been able to make detailed notes of the case, or to get the
patient photographed- He showed photographs, lent by
Sir William Turner, of a skull in the Edinburgh Museum.
Mr. Raymond Johnson showed a girl, aged eight, with
bilateral adductor spasm of the lower e.xtremities, associated
with congenital dislocation of the right femur. 'The head of
the femur lay forwards almost beneath the anterior superior
iliac spine. There was a history of malpresentation at birth.
Mr. AiinuTHNOT Lane showed a case of unusual Con¬
genita! Cleft of the Nose in a male child.
Mr. \V. G. Spencer exhibited a boy aged eight, who had
a swelling at the root of the neck on the right side of obscure
nature, wliich it was proposed to puncture for the purpose of
diagnosis.
Sir Dyce Duckworth then delivered his inaugural
address. After thanking the members for the honour done
him in electing him President, he proceeded to refer to the
duty of clinicians to cultivate the best methods of the
clinical art. He undoubtedly was the best practitioner who
saw most of disease, and had most to do with trying to
G-oogle
254 The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Jan. .31,1801.
alleviate it. He referred to the pernicious and growing craving
among the public for medical knowledge, and dwelt on the
unwholesome practice of publishingpseudo-soientificarticles
by medical men in the lay journals. He then gave some illus¬
trations showing how fluctuating were the waves of fashion
with regard to remedies during his own medical life. When he
was a student it was taught that brandy was a specific for
all conditions of fever; and later, as a clinical clerk, he was
told that mercury was of absolutely no benefit in the treat¬
ment of the lesions of syphilis. He next proceeded to refer
to Dr. Koch’s method of treating tuberculosis. He thought
that that physician had been very unfairly pressed at first
to disclose his research, for the work of bacteriologistj, like
that of philosophers, could nob he hurried. A most un¬
wholesome excitement had been fostered in the ranks of the
medical profession, and an undue haste had been shown to
carry out a plan of treatment nob yet recommended for wide
application by Koch himself. It would have been better to
have waited till the results of his researches had been
formally laid before the profession in the usual manner.
After the publication of his recent communication, we could
only regret that he had placed himself in an unprofessional
position, and that he had been unwisely counselled to pursue
a course which probably no one more than himself now
more bitterly regretted. He regarded the practice of the
Koch treatment at present as unwai'rantable, and the time
bad not yet arrived for its general application. Referring to
the bacillary theory of tuberculosis, he wondered what its
position would be in ten years’ time. With regard to the
causation of tuberculosis, as of other diseases, it was of the
highest importance to pay attention to the diatheses, to the
tissue proclivities, of families and individuals. He next
referred to the regrettable tendency on the part of many
medical men to prescribe prepared chemical foods and
medicines without adequate inquiry as to their composition
and suitableness. He concluded with some remarks on the
preparation for a medical career, expressing his sorrow at
the present neglect of the study of botany, and advocating
for general culture the study of the classical writings.
A vote of thanks to the President for his address was
proposed by Sir Andrew Clark, seconded by Dr. Ord, and
carried by acclamation.
Dr. Sidney Phillips read a paper on two cases
of Typhoid Fever fatal at a late period, without
intestinal Ulceration. The first case was a male, who,
after fourteen days of illness with diarrhcea came into
St. Mary’s Hospital on So^. 6th, 1896, with spots and
other signs of typhoid fever. For some days there
was nothing noteworthy in the course of the case, bub
on the 20bh the temperature rose to 104'4°, the delirium
greatly increased, and there appeared a copious eruption of
many fresh spots; the tremor, already marked, became
much more severe. On the 25th the signs of the typhoid
state became marked, and the pulse-rate 150 a minute.
There were never more, often less, than three stools daily,
never any melcena. He died on Sept. 28th. The necropsy
showed that Peyer’s glands in the lower third of the ileum
were in the stage of deposit, as well as the mesenteric
glands. No ulceration existed anywhere in the intestine.
The second patient, a male, came to St. Mary’s Hospital
after eight days’illness with typhoid fever. On Sept. 23rd,
eight days after admission, spots were seen on the abdomen.
Four days later the pyrexia increased to lOP, with com¬
mencing pneumonia of the tight base. The signs soon
became more marked, the patient sank into the typhoid
state, and died on the fifteenth day after coming into hos¬
pital. Throughout the illness the tremor bad been extreme;
there was never diarrhcea nor melmna, but the stools were
of typhoid character. The necropsy showed Peyer’s glands in
a stage of deposit, but no ulceration of the intestine; there
was red hepatieation of the right lung. Dr. Phillips remarked
that ulceration usually occurred in tj phoid fever by the tenth
day; the first patient died some time after the twenty-fourth,'
the second some time after the twenty-first day of the
disease, but in neither case was there any ulceration of in¬
testine. Since writing the paper, be had found a similar
case was recorded \n La Somaine M6dicaleolM.&rc'k\&%i, and
though there was always a presumption of ulceration after
the tenth day, epidemics of typhoid fever varied in type, and
these cases showed that ulceration might be long deferred and
perhaps never present throughout the course of even a severe
attack. Dr. Phillips also drew attention to the fact that
though severe tremor in typhoid fever was usually regarded
as associated with deep ulceration, it was not necessarily
indicative of it, as the cases proved. The existence or non ¬
existence of ulceration in any given case of typhoid fever
was of great importance. These cases showed that it
must not be taken for granted, either on account of the-
late stage tbe disease had attained, or on account of
tremor, that ulceration was present; the signs more to be
relied upon were mel^na, excessive diarrjicca, and tym¬
panites, and if these were absent there was no roason<
bo abstain from aperients if otherwise indicated.—
The President askea the author if he said that he was-
able to make a diagnosis and lay down definite rules for
distinguishing between the presence andabsence of ulceratioo
in cases of typhoid fever, and if be proposed to treat these
classes differently. He himself would prefer to give the
patients the benefit of the doubt, and treat them all as if
ulceration were present.—Dr. Ewart said that among the
cases which were labeled as enteric fever a certain number
presented slight symptoms ; a little fever, a few rose spots,
and some tenderness in the iliac fossa. Such cases might-
mean nothing more than glandular reaction to enteric
infection, and they would run a very mild and short course^
The symptoms were due to nothing more than irritatioi>
from absorption of the poison. In other severer cases much
of their gravity was due to auto-inoculation. He asked
Dr. Phillips if tbe diagnosis of these cases had been placeii
on an unassailable footing, and if Ehrlich’s reaction had
been obtained.—Dr. Kingston Fowler had never seen a-
fatal case of enteric fever without finding some ulcera¬
tion of the intestine, but many cases of mild and abor¬
tive typhoid fever which recovered might not go on to-
ulceration. In treatment he would certainly be inclined to-
follow tbe rule the President had laid down, and not-
administer purgatives. He asked what measures had
been taken to lower the temperature in the cases related.
He himself had not seen the “typhoid state” for years,,
and thought its absence due to antipyretic treatment.
He regarded abdominal symptoms as more valuable than
tremor as indicative of deep ulceration.—Dr. Glover asked
Dr. Fowler what special antipyretic measures he relied on
to prevent the development of the “typhoid state.”—
Dr. Fowler replied that he was speaking of general anti¬
pyretic means, such as cold bathing, the application of ice-
bags, sponging with iced water, and the covering of the-
patient simply with a sheet. The drugs used had been anti -
pyrin, antifebiin, and quinine.—Dr. Sidney Phillip,s, in
reply, defended the diagnosis of typhoid fever in these cases ?
the general symptoms during life and the enlargement of
the agminate and mesenteric glands found after death were-
suilicient to establish it. Both Ins cases lasted more thau
fourteen days, and therefore could not be classed as abortive.
As to treatment, they were sponged every hour when the-
temperature was high, and they were given quinine, as-
both antifebriu and antipyrin he regarded as unsatisfactory.
He was not reedy to formulate rules as to the administra¬
tion of purgatives. Calomel might bo highly injurious if-
ulceration was present, but what he wished to call attention/
to in the paper was that there might he little or no ulcera¬
tion in case.s where blood-poisoning symptoms threatened
life; in such cases calomel might be the only means of
saving it._
MEDICAL SOCIETY OF LONDON.
Adjourned Debate on Cluronie Disease of the Uterine
Appendages.
An ordinary meeting of the Society was held on Jan. 20th,
the President, Mr. Knowsley Thornton, in the chair.
The President, in reopening the debate, asked Dr.
Duncan his reasons for selecting only the last thirty cases-
from bis practice. Though .statistical records were not of
great value, because they did not show in individual cases-
the factors which led to success or failure, yet it was well
to study the whole experience of any individual operator
and to ascertain the amount of his failure before he attained
fair success in operating. Whatever value might attach
to the comparison of masses of statistics, a limited list-
such as that presented by the author was likely to give
a false impression as to his practice and as to the-
dangers of these operations. He pointed out that these-
operations were not entitled to rank with ovariotomy for
tumour, because tumour always killed if not removed,
whereas a large proportion of those women would certainly
nob die and would most of them get well at the menopause.
’8
Thb Lancet,]
MEDICAL SOCIETY OF LONDON.
[Jan. 31, 1891. 255
He allowed, however, that there were many eases in which
these operations of expediency might wiDh justice be
performed. He then proceeded to criticise the paper
in detail. With regard to Case 6, he thought tnia
should not be included in a list of chronic diseases
of the uterine appendages, for it was an ordinary
ovariotomy for dermoid tumour. He preferred to re¬
verse the order of events as described by the author in the
formation of cystic tubes, either hydro-, hajmabo-, or pyo-
salpinx. He thought that the narrow uterine orifice first
became occluded, then morbid material escaped at tlie open
peritoneal end, setting up adhesive peritonitis, and hence
cystic dilatation of the closed tube followed. He doubted
if cirrhosis of the ovary resulted from the pressure of adhe¬
sions, for such adhesions were often absent in cases of ova¬
ritis in the course of the exanthemata. In the great majo¬
rity of cases of what might be called “adhesion tumours” the
ovaries were large, thickened, and (edematous. He thought
that in most cases the cirrhosis preceded tlie adhesive peri¬
tonitis. The cases described by the author as congenitally
ill developed were probably the result of acute disease during
childhood, especially about puberty. In these cases he
would avoid dilatation of the cervical canal, as likely to set
up inflammation. Amenorrheea he regarded as a more im¬
portant symptom of diseased appendages than menorrhagia.
Many cases which suffered from pain and menorrhagia
would cure without surgery, bub none, so far as he
knew, with pain and anienorrhaia would do so, even
if the appendages were removed. He differed from the
statement that the pain was referred to the side most
affected, his experience having been opposed to this.
Personally, he bad found, contrary to Dr. Duncan, that
moat cases with a palpable tumour presented a marked
increase of flow, whereas it was by no means a constant
symptom in the milder cases of chronic inflammation of the
appendages. He agreed that rectal examination was very
valuable, often more so than vaginal. The first finger in
the vagina and the second in the rectum enabled most
accurate knowledge to be arrived at as to the size, relations,
and amount of fixity of a swelling. Anaesthesia as a rule
should be avoided for the purpose of examination, for the
following reasons: (1) Its own inherent risks; (2) the
abolition of pain allowed examination to be pushed to
dangerous lengths; and (3) the absence of the patient’s
sensations were a loss to the examiner in forming a correct
' opinion as to the need for operation. Sometimes, however,
it might be necessary in a very neurotic patient. Though
he did nob deny the occasional existence of intermittent
hydro- or pyo-salpinx, yet it was a very rare condi¬
tion. It was often years, rather than months, before
patients experienced the full benefits of these operations.
In certain cases of tubal gestation waiting and watching
was the only proper course, and he alluded to cases
diagnosed as prob.ably tubal gestation which recovered
perfectly with rest and care. Ho found that ergot given in
a bitter tonic mixture for long periods in combination with
eflicient hob douching was very valuable. Blistering and
tampons did no good, and he saw no benefit likely to follow
dilatation and electricity. He affirmed that the removal of
the ovaries unsexed a woman and destroyed her sexual
desires, baaing his statement on the results of careful in¬
quiry as to the after-history of his patients. He added that
it was often extremely dillicult to determine, even by the
aid of the microscope, whether ovaries were diseased or nob.
He had only once failed to complete the operation for removal
of the appendages, in consequence of the matting together
of the parts. He thought it was unadvisable to tie the
pedicle in three portionsj as the middle loop was liable to
be left loose. The transfixion should bo macle through the
ntero ovaiian ligament, using fine silk and tying slowly,
lie drained at present more frequently than he used to, but
left the tube in a much shorter time, lie had seen little
good and much evil from flushing the peritoneal cavity, and
he was glad to find he was nob alone in his experience. He
had discarded oiled silk as a dressing many years ago, pre¬
ferring gauze next the wound. He had not had half a dozen
cases of stitch-hole suppuration in his whole practice. He
bad seen so many cases recover from subsequent peritonitis
without opening, and he had seen so much evil from inter¬
ference in the acute stage, that in most cases he w()iild
adopt expectant treatment with opium and atropine.
Passing to Mr. Doran’s paper, he did nob think massage
■was likely to be of service, but decidedly dangerous in uiaoy
cases. He agreed with his remarks as to the absurdity of
relying on the efficacy of electricity to destroy adhesions,
open up closed tubes, and kill gonococci without damage to
the individual; he preferred to leave catheterism of the
tubes to abler manipulators than himself. Vaginal puncture
had nothing to recommend it, and much to contraindicate
its use. He thought drainage of a hydro-salpinx far more
dangerous than salpingotomy, but mere separation of
adhesions sometimes gave good results. Speaking gene¬
rally, he would encourage these patients to lead a
natural life, and not one of chronic invalidism. The
curette might, be useful in endometritis before the
tubes and ovaries became involved, in which latter
case its use must be very dangerous. Without thorough
asepsis, the curette was more likely to set up disease
in the appendages than cure it. He did not believe that
the mental conditions and after-effects referred to by
Mr. Doran were at all common. The disappointing con¬
tinuance of pain which sometimes occurred after operation
usually arose from inflammato^ troubles resulting in adhe¬
sions, especially of the intestines, often due to imperfect
asepsis. The artificial opening in salpingotomy would
probably be closed within twenty-four hours. He thought
that persistence of menstruation after these operations was
due either to imperfect removal or to the presence of a super¬
numerary organ; his own experience of it was practically nil.
Even after complete removal, however, periodic metrostaxes
might occur from habit or irritation of nerves by ligatures.
He never read a more absurd or misleading statement than
the words of Dr. Mary Dixon, quoted by Mr. Tait with
approval at a diecusaion at this Society in 1888, in re¬
ference to the operation for removal of the appendages:
“ It will save more lives than ovariotomy, because more
need it.” The diseases for which ovariotomy was per¬
formed always killed in time without operation; while
the diseases for which the appendages were removed
rarely killed, bub in the vast majority of cases did not even
shorten life, though they often rendered it very wretched.
The two operations could not, therefore, be fairly compared.
The views promulgated by many authorities as to the
amount of sterility due to these chronic diseases of the
appendages were exaggerated and misleading, and he said
that both ovaries and tubes were too often removed when
only one side was diseased. Many of the cases in which
pain recurred on the other side were neurotic cases which
should never have been touched at all, and of the others
most were the result of bad surgery and of imperfect asepsis.
Dr. C. H. F. Eouth said that in the epitome of cases
which, had been circulated nothing had been mentioned as
to the previous treatment, and though the gynajcologists
had been accused of setting up inllanimation in these
cases, yet they brought about many recoveries without
removal of the tubes. He quoted a case of pyo-salpinx,
in which the matter became consolidated, and later a
collection formed on the other side. The latter burst
in attempting removal, with a fatal result. He advocated
puncture, followed by aspiration either per vaginam
or per rectum, injecting the sac with iodine and draining.
He had treated seven cases thus without a fatal result.
The average age of Dr. Duncan’s thirty cases was only
twenty-seven; the lives of these women were saved,
but they had been castrated, their matrimonial love and
future desire for having children were gone, and this mutila¬
tion gave rise to a moral question which they were bound to
consider. He confessed he looked with horror upon cases
treated with this result which might have got better by
other means. The same remark did not apply to
clitoridcctomy, which did not appear necessarily to destroy
the sexual appetite. Salpingotomy, which had been per¬
formed successfully, might perhaps have been adopted in
some of these cases. He quoted a case of gonorrhma in
which, on examination at about the third day, he felt the
tubes to be swollen. Electricity was applied to the
interior of the uterus, and the patient was cured.
Dr. Heywood Smith said that his own experience was
in favour of menorrhagia, and not ainenorrbma, being the
common accompaniment of ovarian disease. He frequently
found the pain greatest on the opposite side, and this he
thought might be accounted for by uterine displacement.
He was surprised to hear the President say that he would
wait in eases of tubal pregnancy, and he asked how long
they shb ilil delay, and how, in case of delay, the patients
got' well.' lie found it was quite the exception for the
sexual app stite to be lessened after removal of the append¬
ages. In cases of sexual excitement, removal of the
256 The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Jan. 31, 1891.
clitoris was more likely to be curative than the appendages.
As to the moral question, the important point was that the
operation was done usually either to prolong life or to re¬
duce the sufferings of the patient. Relief was a necessity
to the poor, to enable them to earn their living. If a tube
were removed, and the ovary left, he wondered what the
effect would be as far as menstruation was concerned.
Mr. Lawson Tait w'as glad to find himself in the main
in agreement with the auinor of the paper and with those
who had spoken. He ridiculed the moral view of the ques¬
tion which Dr. liouCh had put forward, and failed to see
why an operator should be appealed to as a Christian to
promote the development of the sexual faculties. In his
own experience he had restored more sexual appetites than
he had destroyed, and he could give numerous instances of
patients who had led a single life before operation who had
returned with cheerfulness to their marital duties after¬
wards. It was nonsense to say that a woman was ashamed
to appear before mankind after her ovaries had been re¬
moved, and he believed that Dr. Routh would gladly make
himself a eunuch if he suffered the pain endured by
patients with ovarian disease. He was surprised to hear
the President say that Hushing did harm, for he was in
the habit of using it most days of the week, and he had
never had a mishap from it. The same remark applied to
drainage. Sir Spencer Wells had said that the drainage-
tube should be done away with, but he found it most
valuable, especially in giving warning of the beginning of
hremorrbage. He kept it in a much shorter time than he
used to—two or three days, instead of five or six. As to
the Staffordshire knot, like other knots, it could not be tied
with negligence. Once or twice he had failed with it,
through not attending to his own directions for ita use. ,It
was not fair to say that the knot was not to be trusted ; it
was the man who tied it who was not to be trusted.
Referring to the quotation of Dr. Mary Dixon, he
called to mind the fact that at the time it was made
there was great scepticism as to the very existence of
pyo-salpinx, and Dr. Fowler's remarkable figures from
the Middlesex Hospital records showed bow fatal that
disease was. Hence it was not unfair at that time
to say that more women would be saved by removal of
the appendages than by ovariotomy. Now, however, the
fatality of this disease was not so great, because many cases
were treated early. He was constantly protesting against
the mixing up of cases which ought to be operated upon
with those which should not,and because someof his critics
were unable to recognise those which should be treated by
operation they accused the operaCova of practising ignorant
empiricism. He emphasised the essential difference between
cases like those neurotic ones which demanded a guarded
opinion and those cases of clear diagnosis in whicli operation
was the only thing to save life, or at any rate to relieve
Buffering. In cases like those of menstrual epilepsy, where
be bad once removed the appendages he now hesitated to
do so ; but still, from recent) experience, he was inclined to
think that a vast field lay before them in these neurotic
cases where operation might give relief. The gain at any
rate would probably bo greater than the evil, moral, Chris¬
tian, or other, likely to result therefrom. Referring to the
treatment of pyo-salpinx by electricity, he said it required
a very robust faith to believe that this measure could cause
pus to dry up. Let the advocates of it try a whitlow or
a suppurative arthritis, where one could see and judge
the result, before making assertions which could not bo
proved-
Dr. Lkwbes said it was most important to inform our¬
selves as far as possible as to the natural course taken by
cases of diseased Fallopian tubes when not operated on.
He referred to a series of seventeen cases of dilafeil tubes
which be liad described in a paper read before the
Obstetrical Society as bearing on this point. The late
Dr. Matthews Duncan had commented on the comparatively
advanced age of the patientr in tJiis series, and had argued
that, as fifteen of ihe seventeen died from causes uncon¬
nected with disease of the Fallopian tube, it was probable
that in many of the cases the disease bad undergone a
process of natural cure. Dr. Lewers believed tlii.s to be
the true explanation He considered, therefore, that a pro¬
longed course of palliative treatment—one year and a lialf
to two years—should precede operative interference. He
commented on a case of ill-developed ovaries and uterus
described in Dr. Duncan’s paper. He could not agree that
beciuse the sound passed only two inches in a virgin of bweiiby
the uterus was ill developed, as this measurement was the
normal length of the uterine cavity in the virgin according
to all standard authorities. The specimen of the appendages
removed in this case had been shown, and he felt bound.to
say that as to size and all other obvious characters they, in
his opinion, showed no abnormality.
Dr. Amand Routh desired to emphasise the value of
palliative treatment, and be quoted a case in which opera¬
tion had been advised, but the patient’s husband dying and
sexual rest being thus gained, the patient got permctly
well. The measures he adopted were rest, aamimsbvation
of ergot, hob douches, and the occasional painting of ihe
posterior cul-de-sac with strong iodine.
Dr. llUTHERii'ORD alluded to the paucity of cases of
ovarian cysts in Dr. Duncan’s list. In the case of ill-
developed uterus with chronic dysmenorrhcca he thought
the treatment by dilatation of the cervix would fail to
relieve the patient.
Dr. CULUNGWORTH agreed in the main with the paper
and the treatment. In speaking of chronic inflammation of
the uterine appendages great importance should be attached
to a history of recurrent attacks of peritonitis. As to pre¬
liminary palliative treatment, in many cases it was nob
at all desirable, and he certainly should not prolong it
in the way Dr. Lewers bad suggested. Vvhab could
tonics and aperients do to cure a pyo-salpinx ? Repeated
blistering was an absolute barbarism, whetlier applied
outside or inside. Hot vaginal douclies were fashion¬
able and did no barm, bub they did no good. Glycerine
tampons were mere child’s-play. It was the rest in
bed that did the good, and outside this no treat¬
ment other than surgical was of avail. A comparison of,
treatment by rest and by operation would be very falla¬
cious, for rest constantly only temporarily alleviated a
mischief which later broke out afresh. As to thepropo,sition
that adhesions should be separated and the parts not
rcnioveil if normal, it should be remembered that a healthy
looking tube might be full of pus. In casSs of unilateral
pyo-salpinx the opposite tube should be also removed,
whether it looked healthy or nob. He was open to con¬
viction, but he did nob at present countenance or teach that
tubes or ovaries should be removed unless there was distinct
evidence of gross physical lesion. He agreed with Mr. Tait
as to drainage and flushing, and he concluded by stating
his opinion of the absurdity of believing that curetting,
so largely practised in France, could possibly cure tubal
di-jease.
Dr. Duncan, in reply, was very glad to find that in the
main the various speakers agreed with the views expressed
in the paper. lie said the thirty cases tabulated began
some two years ago, from the date when the obstetric
physicians at the Middlesex Hospital obtained the right bo
perform abdominal section. Prior to that date he had re¬
moved diseased appendages nine times, with one death
from septic peritonitis. Since the last-published cases he
had operated ten times, with, unfortunately, two deaths,
the first from slipping of the pedicle ligature and fatal
luemorrhage, and here he emphasised the importance of
tying the broad ligament in three places. He could nob
agree witii tlie President that doing so was dangerous, and
he meant in future, iii those eases where the broad ligaments
were bound down by old inllaminatioD, to follow out this
method, and trusted by doing so to eliminate one cause of
death. The last death occurred a week ago, owing to a bit
of the omentum getting strangulated, first in the drainage-
tube, and then in the abdominal wound after the tube was
removed. He still maintained that wnenever tubal gesta¬
tion was suspected an immediate operation was called for.
He could nob agree that dilatation of the cervix was attended
by risk, provided tlie sbricbe.sb antiseptic precautions were
taken. He had never bad any ill result. Ilis experience was
similar to that of Dr. Ileywood Smith, who said that amenor-
rhn;a was the exception and menorrhagia the rule in cases of
diseased appendages. He was sorry to hear Dr. Routh
advocating puncturing a pyo-salpinx per va.ginam, as it was
a most dangerous proceeding. He mentioned a case on
which he intended performing abdominal section the follow¬
ing morning where a pyo-salpinx had been punctured two
years ago, causing general peritonitis and not curing the
disease He did not think the operation of making an
artificial ostium was of practical use, and he had no inten¬
tion of performing it. He was sorry to hear Dr. Lewers
lecommeuding that these cases should be treated by an
expectant treatment for eighteen months. Indeed, he was
Di:
The Lancet,]
ROYAL ACADEMY OF MEDICIJJF, IRELAND.
Jan. 31,1891. 257
in complete accoid with the forcible remarks of Dr. CulllDg-
worth, who insisted that the time mentioned in the paper
(two months) was too long. He also quite agreed with the
last speaker as to the frequency of recurrent attacks of
pelvic peritonitis in the causation of chronic disease of the
uterine appendages.
Mr. Doran, m reply, said that it did not necessarily
follow that adhesions would re-forin after they had been
broken down. The conditions under which they originally
formed were unfavourable, but not so after the operation for
breaking them down. Scraping out the uterus was useless
and empirical in tubal disease. He much regretted the idle
talk that had been indulged in with regard to the sexual
condition after ablation of the appendages. He concluded
by advocating delay rather than decision in dealing with
cases of chronic disease of the appendages, just as, on the
contrary, they should be decided and not dilatory in dealing
with patients with ovarian tumour.
ROYAL ACADEMY OP MEDICINE, IRELAND.
A MEETING of the Obstetrical Section was held on Jan. 2nd,
the President, S. R. Mason, in the chair.
Exhibitions. —Mr. M'Ardle exhibited a subperitoneal
fibroid tumour which had been removed from a patient
aged thirty-two, and a ruptured ovarian cyst taken from a
patient aged twenty-four. He also exhibited a large
ovarian cyst. — Dr. W. J. Smyly showed a large
fibro-myouia which he had removed on account of
hicniorrhage. The pedicle was treated extra-peritoneally,
and the patient made a good recovery. He showed the
tubes and ovaries removed for gomirrhceal salpingitis.
There was extensive perimetritis, and the uterus was retro-
verted and adherent. The adhesions were broken down
and the uterus was anteverted and stitched to the abdo¬
minal wall. The patient did well. Au ovaiian tumour
removed in July. The patient iiad been aulFering great
agony. The tumour was found universally adherent, and
the pedicle was twisted four times on its long axis. The
patient made a good recovery.—Dr. Macan showed a case
of fibrous tumour removed from a patient who was sent up
to Dr. Bennett for abdominal tumour. She had been two
months married, and was about two months pregnant. The
operation was not a difficult one, hut the peritoneum became
infected from the stump, and she died on the fifth day after
operation.—^Dr. Macan read a paper on a case on
which he had performed abdominal section three times,
and removed an ovary each time. He then drew atten¬
tion to the fact that a great many similar cases to this
had becQ explained by a separation of one ovary into two
parts by some constricting band, and that Professor
Winckel, in his work on the “ Diseases of Women,’’eays
that no case is absolutely proved to be one in whicli three
ovaries are present unless the three ligaments of the
ovaries are also found. As his case did not fulfil this con¬
dition, ho was obliged to place it in the second class, where
there was a greater or less probability of three ovaries
being present. The chief points of interest in the case
were: (1) The peiformanco of laparotomy three times on
the same patient; (2) the probability of three ovaries being
present; (3) the occurrence of a hwnia in the abdominal
waifs, wliicli would, in any case, have called for operative
inrerference—Df. F. Kidd thought that the title of the
paper whs based on an assumption—as no microscopical
examination of the tumour had been made at the time—
nor was any descriptiou given as to where or in what
manner the pedicles of these various tumours liad been
ligatured with reference to their attachments to the uterus.
Dr. Kidd was surprised that Dr. Macan did not find that
there still remained two ovaries when ho operated on the
so-called ovarian tumour, as moat operators adopted the
precaution of examining the condition of the uterus and
the ovary before closing the wound. Dr. Kidd believed
that there never had been demonstrated the presence of a
third testicle, and there was a great analogy between tiie
testicle in the male and tlie ovary in tlie female.—Dr.
Houne wished to know if both Fallopian tubes had been
removed, and thought the occurrence of menorrhagia sub¬
sequently to the removal of two ovarian tumours os very
unique and difficult of explanation. — Dr. Bacot said tha'.
Dr. Macan had stated that this was the first case in Ireland
in which a third laparotomy had been performed. He
thought that it must have escaped Dr. Macau’s memory
that he had previously performed a third laparotomy in the
case in which he mentioned that be bad operated for abscess
of the bladder wall. As to the method of flap-splitting
the abdominal walls in operating for hernia, he had seen
patients operated on by this method by its orginator.
Fcacal Fistula. —Dr. W. J. Smyly said this fistula was the
result of coitus, and passed through the navicular fossa
upwards and backwards into the rectum. The case was
cured by dividing the perineum, and thus splitting,flaps on
the lateral walls and uniting them by continuous catgut
suture. The accident is one of extreme rarity.—Dr. Mason
said a patient had recently been in the Coombe Hospital
who had been locked in a room by a man who had forcible
connexion with her. She had lost an enormous quantity of
blood, and when admitted to hospital the posterior fornix
of the vagina was found to be torn transversdy ; the rectum
was uninjured. She made a good recovery, the vagina
being kept clean by frequent injections.
, At a meeting of the Surgical Section on Deo. 12th, the
President, H. 0. Croly, occupied the chair.
Treatment of Lupus by Koch's Method .— Mr. Thornley
Stoker exhibited two patients in whom Inpus had been
treated by Koch’s method.
OiJcrative Treatment of Sympathetic Ophthalmia. —Mr.
Story read a paper on operations on ejes blinded by
sjimpathetic ophthalmitis, and gave the details of several
cases operated on by various metliods. His conclusions
were that during active sympathetic inflammation no opera¬
tion should be performed, and that after the subsidence of
the inflammation the best operation was that proposed by
the late Mr. Critchett, in which the lens capsule is divided
by two cutting needles. If glaucoma occurs during active
sympathy, and an operation is absolutely necessary, he
would incise the cornea or sclerotic, but not do an iridectomy.
His object was to call attention to the operation described
in his paper, though the result could not be regarded as
very satisfactory. No doubt, had the injured eye been
removed ip time there would not have been any occasion for
an operation on the sympathising eye.
Transfusion and Intravenous Injection of Milk and
Saline Fluid. —Dr. Meldon read a paper on this subject.
Having reviewed the history of transfusion, he expressed
his opinion that the evil results which have at times caused
this operation to fall into disrepute have been occasioned
by the employment of dissimilar blood. The author then
narrated several successful cases of direct transfusion, as
also one case saved by the injection of carbonate of
ammonia and water.—The President, with reference to
one df the cases, asked whether introducing the hand
iuto an empty uterus—if hremorrhage was not going
on—was nob, in a case of collapse, a most dangerous
proceeding. The late Alfred M'CIintock taught that
if the pTaceiita was retained with any symptom of
collapse it was dangerous to introduce the hand into
the empty uterus to remove it. He had himself been
taught caution in an interesting cose in which he was about
to perform (with the late Dr. Robert M'Donnoirs instrument)
transfusion to save a woman’s life. Her husband said he
was willing to give some of his blood for the purpose; but
having taken the precaution of examining him, the man
proved to have valvular <lisease of the heart. In like
manner, he should make sure that the kidneys were not
diseased.—Dr. CRANNY said he had had experience of three
cases of transfusion done by the late Dr. Robert M'Donnell
for posb-partum liicmorrhage. In two of them the result
was perfectly successful, but the third patient died.
There was au immediate increase in the volume of the
pulse, and the general condition of the patient was so
improved as to be noteworthy. It was a well-recognised
principle that when there was bleeding from the uterus,
ami either a portion of the placenta or clots remaining
inside, the uberu.s should bo emptied ; but if there was
collapse at the moment the medical attendant should wait
till the collapse was over. There would be no Im'-morrhage
during the momentary collapse, but if a piece of placenta
were left in tlie uterus it would bleed.—Dr. Meldon, in
reply, said he had injected saline fluid once, and on that
occasion he had no time to obtain any other than what he
carried to make the milk injection alkaline—namely, a
ten-grain powder of carbonate of ammonia. He used Dr,
M'Donnell’s transfusion apparatus; but for the Mreotr
•^8
258 Thb Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 31,1891.
transfusion he bad Aveling’s, substituting Dr. Robert
M'Donnell’s cannula for the ordinary one supplied. At
each contraction of the ball he assumed that about half an
ounce was injected._
INFIRMARY MEDICAL SUPERINTENDENTS’
SOCIETY.
The usual monthly meeting of this Society was held on
Saturday, the 24th in3t,,at Camberwell Infirmary. Mr.
Herbert Chabot exhibited two cases of Joint Disease in
Children much improved by treatment. Also a well-marked
case of Duchenne’s Paralysis in a boy eleven years of age, and
another of Jacksonian Epilepsy. A specimen of Aneurysm of
the first part of the Arch of the Aorta extending backwards
into the posterior mediastinum and rupturing into the peri¬
cardium was also shown. The members had an opportunity
of inspecting the new block of infirmary buildings erected
on the circular system, and the remainder of the afternoon
was occupied in discussing matters relating to the improve¬
ment of infirmary administration.
Iltliidas anlt |loti«s (tf ^oob.
A Text-book of AjiimcJ Physiology for Students of Human
and Comparative {Veterinary) Medicine and of General
Biology. By Wesley MiELs.M A.,M.D.,L.R.C.P.EDg.,
Professor of Physiolosr in M‘Gill University and the
Veterinary College, Montreal. With more than 500
Illustrations. Pp. 700. London and New York : Appleton
and Co.
It is felt by some that in physiology, as in anatomy,
the facts ascertained are too numerous for any student
to retain in his memory, and that it is more im¬
portant that he should obtain a good general view of the
subject, a knowledge of principles rather than of details.
It is, however, extremely difficult in physiology to single
out those facts that are the most important, and still more
to discard theory. What one teacher thinks important
another passes lightly over. In most physiological treatises
the coagulation of the blood is considered at great length.
Here it is briefly treated, and we could imagine a student
reading through the section devoted to it without noticing
that the exudation of serum is a very remarkable feature
of the process. The work commences with a description of
the ceil and the phenomena' of karyokinesis. Examples
are given, with short descriptions of the life-history of
unicellular organisms and of the lower fungi, vorticella, and
hydra.
An instructive comparison is drawn between the forms that
belong to the organic and the inorganic worlds respectively,
and we give a quotation from this to show that Professor
Mills writes in an attractive manner : “A modern watch
that keeps correct time must be regarded as a wonderful
object 5 a marvellous triumph of human skill. That it has
aroused the awe of savages and been mistaken for a living
being is not surprising. Now, however well constructed
the watch may be, there are waste, wear, and tear, which
will manifest themselves more and more, until finally the
machine becomes worthless for the purpose of its construc¬
tion. If this mechanism possessed the power of adapting
from without foreign matter so as to construct it into steel
and brass, and arrange this just where required, it would
imitate a living organism ; but this it cannot do, nor is its
waste chemically different from its component metals; it
does not break up brass and steel into something wholly
different. In one particular it does closely resemble living
things in that it gradually deteriorates, but the degradation
ofa living cell is the consequence of an actual change in its
component parts, comuionly a fatty degeneration. The one
is a real transformation, the other mere wear. Had the
waich the power to give rise to a new one like itself by any
process, especially a process of division of itself into two
parts, we should have a parallel with living forms; but the
watch cannot even renew its own parts, much leas give rise
to a mechanism like itself. Here, then, is a manifest dis¬
tinction between living and. manimate things. Suppose,
further, that the watch was so constructed that after the
lapse of a certain time it underwent a change in the inner
machinery and perhaps its outer form, so as to be scarcely
recognisable as tbe same, and that as a result, instead of
indicating the hours and minutes of a time reckoning
adapted to the inhabitants of our globe, it indicated time
in a wholly different way ; that after a series of such trans.
formations it fell to pieces, took the original form of the
metals from which it was constructed, we should then have
in this succession of events a parallel with the develop¬
ment, decline, and death of living organisms.” Professor
Mills carries out the parallelism to a greater length, but
we have quoted enough to show that his power of illustra¬
tion is considerable and bis writing attractive.
The last section is that on the brain, which is well given,
and is illustrated by many and very good engravings. Even
here, however, there is some pleasantry, as in the
imaginary conversation in which the author supplies the
answers that would probably be given by a man after section
of his semicircular canals in the following terms: “How
do you feel?” says the operator; “why can you not rise
and remain standing or walk?” To which the subject of
the operation replies: “I feel all confused. I cannot
stand or walk, because I do not seem to be able to make
out what I should do. I have no clear idea of things about
me, and so do not know how to proceed.”
All the senses are dealt with well, but the section on the
eye is written in a specially interesting manner, yet even
here we notice some indications of want of care ; for under
the head of astigmatism ic is stated that “in this defect
the vertical meridian is supposed to be more convex than
the horizontal,” a statement that requires qualification,
for the opposite condition is often o'ljserved. Tbe work as
a whole, tiiough by no means exhaustive, supplies the
student, and especially the veterinary student, with all the
facts he is likely to require.
Zxtr Lehre von den Contagiusen Infectionskrankheiten.
Von Dr. Eknst llEfiER, b'tabsarzt am Cadectenhause zu
Potsdam. Berlin : H. Kornfeld. 1890.
In the work before us are embodied the results of a series
of moat careful investigations on the specific contagious
diseases carried out under most favourable conditions by
one who has gradually built up for his own use a method
of noting and tabulating certain features connected
with the spread of infective diseases from individual to
individual. The main interest of the work lies in the
sixty-three tables that accompany the text; but in the
text itself the author puts forward certain general conclu¬
sions at which he has arrived in the course of his investiga¬
tions. Having charge of the cadet barracks at Potsdam,
he was able to obtain an exact record of all the cases of
infective disease that came into the hospital, the rooms in
which the patients had slept, washed, eaten, or attended
classes, and even the men with whom they had been most
intimately associated ; and from these data he was able to
trace from patient to patient outbreaks of measles, scarlet
fever, parotitis, and similar maladies, and to follow
tbe modifications through which tlie disease went as
it was passed onfrom individual to individual. On reference
to the sixty-three tables given, it is easy to follow the
author’s arguments, but it will be found that he is in¬
clined to generalise somewhat too freely from the facts that
he has at his disposal, in some cases his facts not appearing to
bear out the whole of his conclusions. For instance, he holds
Digitized by
Google
The Lancet,]
ANALYTICAL RECORDS.
[Jan. 31,1891. 259
that becauee there is a general agreement as to the period
of incubation in such diseases as scarlet fever, measles,
rutheln, diphtheria, and mumps (with perhaps the exception
of measles), and because all of them have many features in
common, they are all species of mixed infection in which
there is a common organism, and that the special medifica-
tions in each disease are the results of the presence of cer¬
tain other specific bacteria. He holds that this common
organism under certain circumstances loses its virulence,
and regains it when placed under favourable condi¬
tions; that it and the other organisms which play a
prominent part in the production of the special symptoms
produce poisonous substances which may cause rapid in¬
toxication of a patient, whilst through the spores that are
formed the infection may be transferred to others, or they
may give rise to a second crop of the organism in the
original host {Auto-infection)', that the producers of the
mixed infection belong to the suppuration-causing group;
and that they give rise to difl'erent symptoms and patho¬
logical conditions according to the tissues that tliey attack—
the glands of the skin, the subcutaneous connective tissue,
lymphatic glands, and lymph vessels, the mucous mem¬
brane, the serous surfaces, or other elements of special
organa.
A short account is given of the relation of these facts to
treatment, and then the writer records his observations on
inlluenza and its relation to the diseases already mentioned.
The tables are models in their way, and a careful study
of them will be well repaid, nob only by the acquisition of
a new method of tabulation by the reader, hut also by
the knowledge gained of the evolution of diseasq through
a series of most interesting genealogical trees. Although
we do not agree with the whole of the conclusions arrived
at by Dr. Reger, we can heartily recommend his work to
the careful study of practitioners, more especially of medical
officers of health.
lltrorlts.
PURE CANK SUGARS.
{.Tames Piiii.ii' and Co., Puive Cane Sugar Comiunv, 4, Fenciiurcii-
S'l'llEET.)
We have received and examined the following samples of
sugar from the above linn—icing sugar, castor sugar, refined
lump, white crystals, Demerara crystals, and Barbadoes
moist. They are neatly put up in 7 lb. bags, stamped, and
guaranteed as pure cane sugars, free from beet. Beetsugar
is now very largely consumed, but it is generally admitted
to be not quite a perfect substitute for cane sugar, and,
weight for weight, it does not possess the same sweetening
power as the product of the sugar-cane (saccharura ollici-
narum), whilst the keeping or antiseptic properties of cane
sugar are certainly superior to those of the beet. There seems
little doubt that a large proportion of sugar sold in
London as cane is in reality beet sugar, or, at any rate, an
admixture of beet. A distiuct advantage is thereforeolFered
to consumers of sugar by this excellent plan of Messrs.
Philip and Co,, who guarantee and label their sugars as
consisting of nothing but the real cane variety. We
have determined the amount of cano sugar in a few of
the samples, which were merely selected as representative
ones. The following figures wore obtained : Castor sugar,
09'73 per cent. ; white crystals, 98-8(> per cent. ; refined
lump, 98'07 per cent. ; Barbadoes moist, 92'00 per cent.
The sample of white crystals, on drying in the oven and
then allowed to cool, exhibited a bluish-green colour. On
treatment with acid this was more marked. Caustic alkali
discharged the colour to a light yellow. The addition of a
minute amount of colouring material to sugar for the
purpose of making it of a purer white and more attractive
in appearance is admitted by manufacturers, who, Indeed,
state that it would he somewhat extraordinary to find a
sample of sugar that was not coloured. It is also known
that chloride of tin—of course in very minute quantity—is
occasionally used to impart a bright golden yellow to the
raw product. The results above are very satisfactory, the
percentage amount of cane sugar, it will be noted, being as
high as it can well be.
KEPLER EXTRACT OF MALT,
(BuRaouGiis, Wellcome, * Co., 8 no\v Hill Buildings, E.C.)
The therapeutic value of extract of malt rests not only
upon the presence of important food elements, as dextrin,
maltose, and alkaline phosphate, but on the peculiarly active
substance, diastase, which is concerned in converting the
starch of farinaceous food into the more assimilable pro¬
ducts. The masterly researches of Messrs. C. O’Sullivan,
Brown, Heron, and Morris have shown that diastase is
without action upon unaltered starch, or starch as it occurs
enclosed in the cell. As soon, however, as the cellulose en¬
velope of the granule is broken either by bruising or boiling,
the starch granulose rapidly undergoes conversion or hydro¬
lysis, even in the cold, into maltose and a variety of dextrin
called erythro-dextrin. It is sometime now since we had occa¬
sion to examine the well-known and much used Keplerextraet
of malt. Messrs. Burroughs and Wellcome evidently keep
pace with the newest scientific facts, which every day con¬
tribute towards making this kind of preparation perfect.
This is shown by the following analysis of a specimen
which was recently submitted to us. One part by
weight of the extract was found to completely convert in
one hour at 100“ F. seven times and a half its weight of
starch into maltose and dextrin ; in two hours at the
same temperature fifteen times its weight of starch, and in
three hours no less than thirty times its weight. Probably
at a higher temperature Kepler extract would be capable of
converting a still larger quantity. Moisture, 18'41 per
cent.; solid matter (diastase, albuminoids, maltose), 80'37
percent.; mineral matter (for the most part soluble phos¬
phate), r22 per cent. The flavour has been further im¬
proved, and the delicacy of the colour contributes largely to
its attractive appearance.
EFFERVESCENT BRAIN SALT.
(F. NicwnEiiv & Sons, l and ;j, King Edwaud-street, E.C.)
Chief amongst the constituents of effervescent brain salt,
according to our analysis, are bromide of ammonium and
caffeine. The atatenients which are made, therefore, in
favour of its efficacy as a remedy, used of course under
medical direction, in the treatment of headache, nervous¬
ness, sleeplessness, and sea sickness, are not without
foundation. Its composition reminds us of an excellent
preparation of the same lirm which we had occasion to
examine a few years ago, and known as “ bromo-soda.”
Brain salt is an elegant specimen of tlie art of granulating.
IVORINE-AN E.MOI.LIENT cream to rREVENT CHAP.S,
CHILBLAINS, &C.
(Baker & Co,, 305, Oxford-stres^t, W.)
A preparation which can he said to possess properties of
alleviativo vahre to the skin will be regarded with satisfac¬
tion by the many who suffer from the tiresome affection of
chaps or chilblains. The efficacy of ivorine is stated to be
increased by the addition of an oleaginous extract obtained
from the leaves of the ivor shrub, wliich is imported from
the Pacific Islands, where, through its continued use, the
natives are said to be enabled to withstand atmospheric
changes. Mere chemical examination shows it to consist of
a purely oleaginous substance which is entirely free from
E 3
Digi: zed by
Google
260 The Lancet,]
THE NATURE OF PERNICIOUS ANAEMIA.
[Jan. 81,1891.
iojurious ingredient. In a case of badly chapped hands,
the use of ivorine was found to be attended with distinctly
beneficial results.
DKAG l%ES ]<KEUUGINKU.SKS DU DOC’l'KUE llAliUTEAU.—
CAPSULES AU BllO.MINB DE CAMPHRE DU DOC’I'EUE
CUN.—PILULES ANTI NKVRALCKiUES DU
DR. MOUSBTTE.
(Cl-IN Er ClE., I’ll-VRIIACIUNS, PaIU.S.)
These are all excellent prejiarations of the skilled phar¬
macists Clin et Cie. of Paris. The dragees ferrugineuses
consist of white sugar-coated pills, containing a pale-green
nucleus, which is somewhat obstinately soluble in water,
the solution exhibiting an inky and sweetish taste. Accord¬
ing to the reactions which were yielded on examination we
regard the medicament to consist of a peculiar organic form
of proto-iron salt. Dragdes ferrugineuses are stated to be
specially useful in anaemia, chlorosis, &c. i
The capsules au bromine de camphre are thoroughly i
genuine preparations, from the fact that we succeeded by ;
means of sodium-amalgam in regenerating both camphor
and bromine. Bromide of camphor has been recently advo¬
cated as of service in heart affections, asthma, nervous and
mental disorders. It is prepared by adding liquid bromine
to camphor and distilling. So obtained bromide of camphor
(CioHi,-,BrO) is insoluble in water, but soluble in alcohol,
ether, and chloroform, and crystallises in colourless pris¬
matic needles which possess a smell resembliDg camphor
(CioHioO) and turpentine (CmH],;).
The red sugar-coated pilules (anti-n^lvralglques) readily
yielded the two alkaloids, aconitine and quinine, on suitable
treatment Avith alkali and a solvent, as ether. The former
alkaloid was recognised by its well-known effect on the
tongue, and the latter by the characteristic chemical.
reactions.
FINEST OLD SCOTCH WHISKY (SPIOCIAT, DIETETIC).
(CEOiKi'E CAVE.NDl.'^n, 4, CliI.I,l’M.,Sl'REE-r, E.C.)
If persons of diabetic, dyspeptic, or rheumatic tendencies
drink whisky at all, it should at least be a spirit of un¬
questionable purity and free from acidity and saccharine
matter. How far this is the case with Cavendish whisky
will be seen from the following items of our analysis:
Absolute alcohol, 40'G0 per cent, by weight, 48-00 per cent,
by volume 5 equal to 84-00 per cent, proof spirit. Acidity,
reckoned as acetic acid, 0'012 per cent.; total solid matter
0-075 per cent,, and mineral matter 0-005 per cent. There
is a remarkable absence of solid matter, and the amount of
acid goes for nothing. The whisky is smooth in taste, and
the presence of traces of tannin shown by the iron test
would indicate it to be a spirit which has been matured
in wood casks.
THE NATIIPJ-: OF PERNICIOUS AN/EMIA.
To the Editws o/Thb Lancet.
SiE.s,—Will you kindly allow me to make a brief explana¬
tion with reference to a statement which appears in your
abstract of the second of the able lectures now being de¬
livered before the Medical Society hy Dr. Stephen Mackenzie.
The prominence given in that lecture to ray work regarding
the nature of pernicious anamiia must he iny apology for
HO doing. The result of that work lias heen, step by step,
to trace back the characteristic changes in the blood to
antecedent changes of a chemical character occurringwithin
the gastro-intestinal tract, and to identify, as the basis of
these changes, the various pathological conditions, such as
cancer, atrophy of the gastric mucous membrane, gastritis,
t'ce., which have been most usually met with in this disease.
Since all these conditions are relatively common, while
pernicious anfcmia is rare, the conclusion is natural
that when they coexist a new factor must have been intro¬
duced which still continues to operate from the same tract;
and my latest observations have led me to the conclusion
that this factor is the result of specific infection. It is with
reference to this conclusion that the present explanation
becomes necessary.
For in the lecture referred to as given by you in
abstract, an objection to this view, raised by Dr. Mott,
is quoted to the following effect: “It does not appear
to me certain that this theory is proved, for in many
diseases in which there is ulceration of the intestines
lasting for months and years, and in which the whole
contents of the intestine must swarm with micro-organisms
of many kinds, with everything to favour absorption,
there is no pernicious anosmia.” Merely remarking in
passing that the above statement tends to prove the
specific nature of the intestinal changes in pernicious
ansumia, assuming that such changes are the real cause of
the disease, I desire to add tliat the above statement of
facts, so clearly put, more especially that portion of it I
have italicised, expresses very accurately the grounds on
which, in part, my conclusion is based. For, as I have
shown, an important ditt’erence exists between the intes¬
tinal changes under such circumstances and those found iu
pernicious anaemia. AVhile in the former tlie amount of
intestinal putrefaction is, as might he expected, not only
relatively, but also absolutely greatly increased; in the
latter the absolute amount of putrwactive change may
be, and not infrequently is, actually loss than in
health. Nevertheless, in pernicious anjcmia I have found
certain poisons of bacterial origin in the urine, for whose
presence the action of ordinary putrefactive organisms is
inadequate to account, since they are absent in such con¬
ditions as those above raentionea hy Dr. Mott in which
these organisms abound. The absence of these substances
from the urine when intestinal putrefaction is increased in
amount, and their presence when it is not increased, were the
grounds on which 1 based my conclusion as to the specific
nature of tbeniicro-organismal infection which I believe to
occur in pernicious anamiia.
This conclusion is one, as I have further shown, which
accords very well with the mode of onset of the disease in
many cases, and explains at the same time its rarity. The
pathological conditions of thegaatro-intestinal tract may have
existed, and frequently do exist for a long time, without
giving rise to pernicious anaemia,—as is well exemplified in
the frequent occurrence of cancer of the stomach, unaccom¬
panied by pernicious ana;mia. Whenever the latter is
superadded to the former its origin can, I think, in most
cases be traced to some antecedent exposure to sucii condi¬
tions of defective sanitation and the like as are well known
to favour infection in the case of other specific diseases--
such as typhoid fever and diphtheria. The explanation 1
have thus ventured to give is one which I feel to be due to
Dr. Mott, to whom I have failed to make the grounds for
my conclusion sufficiently clear, no less than to Dr. Stephen
Mackenzie, whose admirable critical exposition has been
the immediate occasion of directing attention anew to the
subject. I am, Sirs, yours truly,
U'impolo-Htrooti, W., .Ian. 2Gth, WILLIAM HUNTER.
Liverpool Northern Hospital.—T he work
accomplished in this hospital during 1890 has been satisfac¬
tory. The horse ambulance bad attended 1001 cases in the
year. The average number of beds occupied was 1.30. The
in- and out-patients numbered respectively 1947 and 5440.
The balance sheet shows a debt to the bankers of the hos¬
pital amounting to £1782 ‘Is. 4rf, and the committee appeal
to the public for additional funds.
Registration of Plumbers. — The Mayor of
Cork presided at the first annual public meeting of the
Munster District Council for the National Training and
Registration of Plumbers. Dr. Corby, in moving the
adoption of the Council’s annual report, said ho wished to
call attention to the fact that the national system of
registration of plumbers had been founded for the purpose
of specially examining and registering plumbers in the
interest of the public health. From his own knowledge he
could say that the connexion between plumbing and the
public health was very marked. He detailed a number
of eases in which deaths had occurred througli defective
sewerage, and among the diseases produced by this cause
he mentioned diphtheria and typhoid fever. He strongly
urged the corporation of Cork to appoint duly qualified
plumbers to inspect the sanitary arrangements in dwell¬
ings where infectious diseases broke out, 7
ogle
The Lancet,]
1'llOBA.BLE POSTPONEMENT OP THE MIOWlVES’ BILL.
[Jan. 1891. 261
THE LANCET.
LONDON: SATURDAY, JANUARY SI, 1891.
According to present appearances there is every prospect I
that the Midwives’Bill willnotbe rushed thi'ough Parliament.
We are assured on good authority that an understanding
has been arrived at between influential men on both sides
of the House that time and opportunity shall be given for
ascertaining the facts of tlie case—both those which, in the
opinion of some, constitute a reason for legislation, and those
which, in the judgment of others, constitute a reason for
declining all legislation on the subject. It would go far to
satisfy all parties if the evidence of experienced and
responsible persons were taken on both sides of the question,
such as coroners, registrars of births and deaths, medical
practitioners, and others. Such an inquiry would have the
further advantage of raising the question into an
impartial atmosphere. We ourselves would suggest the
appointment of a select committee of the House of Commons.
It need not occupy any great length of time. The facts to
be ascertained are not in their nature abstruse or difficult;
but they are very important. They involve enormous issues
of life and death and suffering. It is greatly to be desired
that they should be thoroughly ascertained. If legislation
must take place, it should not exceed the demands of the
case, or be unmindful of the principle so fully recognised by
Parliament in its last Medical Act that midwifery is a part
of medical science, and cannot be practised satisfactorily
excepting by persons trained in the three great branches of
our art—^medicine, surgery, and midwifery.
Borne of the opposition to the Bill in our own ranks is
reasonable enough from the medical point of view. Medical
men know the risks of maternity, and know well that no
cases in practice require more care or more judgment, or
more medical insight and skill than puerperal cases. A
painful case was reported in all tlie papers last week,
where a midwife was committed for manslaughter by
conveying puerperal fever—and so death—in three cases,
though it is .stated that she was warned by medical
men, and even generously promised their assistance
if she would desist from practice. It transpired that
she knew nothing of puerperal fever, and thought all
pymmic conditions implied a cut linger. Yet this
woman had attended 900 cases of midwifery ! The
whole character of the obstetric art has been raised since
it passed from the bands of midwives into those of medical
men, and became a recognised part of medical practice. On
the other hand, tho existence of midwives to the number
of many thousands cannot be ignored, the majority of them
being uneducated and untrained. The compulsion of law
in medical matters is very light. If a man breaks his
leg, it does not compel him to have a regular surgeon. If
a woman is to be confined, it does not and it never will
compel her not to employ a midwife. The compulsion
can only take the form of requiring that persons
calling tbemsolve.s “midwives” shall show some justifica¬
tion for using the title and of restricting their practice to a
simple class of cases, and in default of compliance with these
conditions of imposing penalties. These penalties sLould be
explicit and effective. It will be far better for the State
to leave the subject untouched than to legislate on it in a
half-hearted way, and, while giving a kind of status to
trained midwives, either permit them to exceed their func¬
tion, or allow others to practise and to pose as “ midwives."
If, as we hope, a select committee should be appointed,
the profession should try to agree on a rational and har¬
monious representation of the medical aspects of the case.
Those who are altogether opposed to such legislation should
candidly eay so in the meetings of the profession or in its
press. Their arguments point in this direction, though they
seem to think it better policy to appear as only opposing
this particular Bill, which, by the way, is practically
the same as the Bill of last year. It is not easy
to believe that the bulk of the medical profession really
propose to prop up and perpetuate an order of “Gamps,”
and to allow women without intelligence or principle
to go on attending a large number of cases. We can
see no proof that medical men generally are prepared to
undertake so great a responsibility, or to argue before a
committee of the House of Commons that the correction
of this evil will be fraught with danger to the medical pro¬
fession. The attempts to commit the profession to so ex¬
treme and undignified a view have signally failed.
It may be argued that there is a deeper opposition to
legislation tjian finds expression. We cannot deny the
possibility of such a feeling, but unless those who
believe in its existence can produce proofs of it they
should seriously ask themselves whether they would not
do well to combine with the rest of the profession to
get the Bill .so amended as to restrict midwives to tho
simplest cases and to take some guarantees of their respect¬
ability and training. If the profession goes before a com¬
mittee harmoniously with such view's, it will have much
influence in controlling the shape of the Bill. If extreme
views are pressed, it will lose all such inlluence and place
itself in an undignified position. Though we report a disposi¬
tion in l*arliament to in^'estigate all tlie bearings of this
question, we have heard nothing to lead us to doubt that
some such legislation will sooner or later take ])!ace.
Dr. Purdy of C'hicago has recently published in tlie
columns of the New York Medical Journal the results of his
researches into the distribution of Bright’s disease in the
United State?, with the special object of showing the in-
liuence of climate upon the malady in question. He takes
the year 1880 for a standard of comparison, and finds that in
this year the deaths from morbus Brightii were 75,386—a
proportionate mortality of 7 ’ll per 1000 deaths. The heaviest
mortality is found in the States of NeAv Jersey, New York,
I Connecticut, Massachusetts, and New Hampshire, while
the lowest mortality is found in the States of Tennoesee,
Georgia, Nebraska, North Carolina, and Arkansas. Speaking
generally, the eastern coast line of the Union would seem
the most affected (its muidle region most of all), then the
northern portion, and, lastly, the southern. The first of
these districts shows a mortality of 19’73 per lOUO deaths,
and tho uorthorn coast region 17'38 per 1009 deaths, or, in
Digitized by
Google
262 Tns Lancet,] DISTRIBUTION OP BRIGHT’S DISEASE IN THE UNITED STATES. [Jan. 1891.
other words, the rate is here from twice to three times the
general average. In the south-western States the mortality
from Bright’s disease falls to from 1‘5 to 2 per 1000 deaths,
or about a fourth of the general average.
Prom these statistics Dr. Purdy draws certain conclu¬
sions regarding the influence of meteorological conditions
upon the causation of Bright’s disease. He relies upon hia
facts to prove that the conditions which favour the genesis
of the malady are cold, damp, and variability of tempera¬
ture, and that, on the contrary, heat, dryness, and equability
tend to diminish the liability to Bright's disease. He
believes that cold is effective chiefly when associated with
a high degree of humidity, and that a low temperature is
readily tolerated when the air is dry. Similarly he main¬
tains that humidity is inoperative if accompanied by heat
and equability.
These conclusions do not present any feature of novelty,
and are quite in accord with established opinions and reco¬
gnised facts. It seems obvious a \-irioH that the subject of
renal disease needs above all things such conditions of
climate, occupation, clothing, and diet as will promote a
free action of the various emunctories, above all of the skin.
A dry climate, not too prone to sudden oscillations of
temperature, permitting a maximum amount of exercise
in the fresh air, and affording abundant sunsliine,
•would seem best to meet the indications of the
case; bub it must be remembered that in very
dry climates equability of temperature is simply a meteoro¬
logical iiiipossibility. 'We pay for abundant sunshine and
dryness the price of great differences between sun and shade
temperatures, and between the thermomotric range of day
and night. This cannot be helped, and the obvious lesson
is that we must strive to obtain the maximum advantage
from a climate of this class by a very careful regulation of
clothing, habits, hours of exercise, »!v;c. It is by no means
so clear tliat a hot, moist, and equable climate is adapted
to cases of Bright’s disease. Such a climate tends to de¬
press the system, bub it has the very great advantage of
protecting against chills and inflammations; and since wo
know how prone albuminuric patients are to inflammatory
affections of the seroirs and mucous membranes, and to fresh
exacerbations of the renal malady, it is obvious that a
climate of this class may have its utility in some cases of
Bright’s disease. Its effect is probably less curative than
palliative, and tends to protect the patient against the acci¬
dents and complications of his malady rather than to exer¬
cise any decided influence over the disease itself.
"We are, however, disposed to doubt whether Dr. Purdy’s
statistics afford any sure ground for attributing a pre¬
ponderant influence to climate in the etiology of Bright’s
disease. It is significant that by far the Jieavicsb mortality
is found in those portions of the States which were first
colonised, where, consequently, the density of population is
greatest, and the struggle with mal-hygienic conditions of
existence probably most severe. To compareBoston and New
York with Arkansas and Tennessee, and to attribute all the
differences in liability to disease simply to geographical posi¬
tion, would be an obvious fallacy which Dr. Purdy would
certainly not perpetrate. The question, so far from being
a simple one, is really most abstruse. It can be decided
only by a careful attention to such points as proportionate
density of population, the occupations and habits of the
people, their food end drink, their clothing, amusements,
&c., as well as climate and geographical position, which are
n many ways, direct and indirect, very influential factors ;
it is only by such an exhaustive survey of the subject that
we are likely to throw any light upon complicated questions
of etiology. The race factor, again, cannot be left out of
account in a country presenting such a multiplicity of races
as the United States. The varying liability of different
races to diflerent diseases is a well-known and significant
fact, and although the evidence on the subject is at present
scanty, it will no doubt be some day thoroughly worked
out. What can be more striking than the comparative
immunity of the negro from yellow fever and his remarkable
proclivity to small-pox? It is said that the Irish in America
present a liability to Bright’s disease out of all proportion
to their numbers; but we cannot feel sure how far this
liability is racial, and how far due to destitution and
poverty.
On the whole, the evidence regarding the etiology
Bright’s disease would incline ns to the view that the most
important cause of the malady is improper food, unwhole¬
some occupations, and insanitary dwellings. The study of
the question leads us, in fact, to the same conclusion as the
study of phthisis—viz., that the chief danger of humanity at
the present day is that the growth of great cities may lead to
the neglect of some of those primitive conditions of health—
fresh air, light, exercise, plain food, healthy housing,—
without which the vigour of the organism cannot be long
maintained. It does not follow that large cities are
necessarily and inevitably unhealthy, but there can be
little doubt that the concentration of great masses of
population makes the attainment of the primary conditions
of health more difficult. It is one of the hopeful features of
this age that we are becoming more and more alive to these
difficulties, and more solicitous for their removal.
A Sun-COMMITTEK was appointed by the Glasgow Town
Council a few months since to inquire into the greening of
French vegetables witli sulphate of copper. The committee
approved of the report which was presented to them, and
recommended that intimation be made to dealers in canned
vegetables that the sanitary officials would institute pro¬
ceedings whenever the circumstances in connexion with
their re-greening were suflicient to warrant a prosecution.
The report is signed by the medical officer of health, the
sanitary inspector, and the analysts of the city, who, in the
evidence they furnish, quote the opinions of the French
authorities upon the subject. That preserved peas are in
many instances greened by means of a salt of copper seems
well established. This treatment with copper salt, it may
be remarked, is not at all necessary for the preservation of
the vegetables. Scaling them up hermetically after ex¬
posure for a time to a temperature above boiling-point is
all that is required. This was the simple method discovered
by Ai’I’ert at the close of the lost century, and early in the
present century it was put into practice on a large scale,
and rapidly grew, particularly in France, into an impor¬
tant industry. The preserving process, as might be ex¬
pected, causes the vegetables lote their natural
Digitized by LiOOQle
l-HB LAWcnrj THE GREENING OP VEGETABLES WITH SULPHATE OP COPPER. [Jan. 31, 1891, 263
colour and to acciuire a somewhat stale flavour. Hence,
and in order that the preserved article may become
more attractive to the public eye, reverdissage or re-greening
is resorted to, and this is accomplished by steeping the vege¬
tables for from five to fifteen minutes in a hot solution of
sulphate of copper of variable strength, the proportion used
depending apparently on the caprice of the manu¬
facturer. In actual practice the vegetables are washed
and placed in tin boxes, which are filled up with sea-
salt and sugar, soldered down, and subjected to a tem¬
perature varying between 220° P. and 239° V. The quan¬
tity of copper salt retained undfr this treatment amounts
to from 8 to 27 parts per 100,000 of the dried vegetables.
Compounds of copper are unquestionably poisonous, and
small doses continued for some time are known to produce
severeabdoininalpain.impairraentof digestion, and diarrhoea.
Bearing in mind well-known toxicological facts like these,
it is surely absurd to suppose that small quantities taken
continuously in food arc harmless. The oction of the
French Government in this matter in 1853 was somewhat '
experimental. They prohibiced the use of copper salts in
preserved articles of food, at first in Paris, but the prohibition
seven years lator was extended to the whole country on
the recommendation of appointed experts, who wore of the
opinion that, although the quantities extracted from certain
samples were small and not likely to produce serious
accidents, yet the presence of a highly poisonous sub¬
stance in proportions without a fixed limit involved a
risk which should not be permitted to exist. But here [
was a pronouncement calculated to be fatal to the
successful working of an industry which employed no less
than 20,000 persona, and representing a business of
40,000,000 francs. Appeals were, of course, made against
this decision, and toleration was urged to the extent indi¬
cated in the following curious conditions; (1) That a
maximum limit of the quantity of copper salt should
be fixed; (2) that on every box the nature of the agent
should be legibly inscribed; (3) that greening for export
should be permitted, but not for home tise. At length it
was reported by the Consulting Committee in 1889 that
the position of the information which they possessed as to
the noxious influence of salts of copper, there was no real
ground for prohibiting the practice of re-greening preserved
vegetables with those salts. The prohibition was with¬
drawn, and the practice of rocrdlssufie continues to the
present day. The cultivation of vegetables such as peas in
this country, it is pointed out, is considerably handicapped
by the substitution of the re-greened, stale, and probably
less digestible article of. foreign growth, which there
is good reason to suppose is not infrequently palmed
oir as the genuine, fresh, home-grown product. The
majority of those who have any concern in the im¬
portant question of food in its relation to health will
share generally in the views which are ex]>re88ed by
the medical oHicer of health, sanitary inspector, and
the analysts of the city of Glasgow in the concluding sen¬
tences of their report. They are of the opinion that the
process of re-gteening is fraudulent in its intention and :
injurious in its commercial results; that re-greening with
sulphate of copper does not make vegetables more but ))ro-
, ] bably less wholesome; that the public ought when pur¬
chasing preserved vegetables to ask for ungreened or at
least vegetables free from copper; that the guardians of
the public health ought to come to an understanding as to
the sale of vegetables containing copper, while holding them¬
selves free to act according to the circumstances of the case
and the scientific evidence obtainable from time to time.
A coNFERBNCiv was held at Spring-gardens last week
between members of the Housing of the Working Classes
Committee of the London County Council and delegates from
the several vestries and district boards. The meeting received
a report from the medical officers of health of the dillerent
authorities, prepared in compliance with a request that they
should endeavour to prescribe the conditions which may
render a house dangerous or injurious to health so as to be
unfit for human habitation. We recently pointed out that,
seeing that the question of degree enters largely into the
consideration whether a house is be regarded in this light,
it is impossible to define these conditions so that any
fixed rule may be laid down. The medical officers of
health have themselves pointed this out to the con¬
ference, but they have, besides, given some account
in the briefest manner of the principles which guide them,
^ and have enumerated such conditions as faulty site, insuffi¬
cient light and ventilation, and dilapidations, as those upon
which they rely. They have also expressed a preference for
dealing with filth and defective drainage under the Nuisances
Removal and Sanitary Acts, but liai'e stated their opinion
that where these are associated with other conditions
they justify proceedings under the Housing of the Working
Classes Act.
Although they have not been able to carry into effect
the wishes of the conference, their labours cannot be said
to be wholly wasted if they have made clear to the
representatives of local authorities that houses faulty in
one and another particular must be dealt with on their own
merits, and that it is therefore nece.ssary to exercise inde-
I pendent judgment in each case. The medical officer of
health may recommend proceedings for the abatement
of nuisances, and the improvement of houses under the
Nuisances’ Removal Act, and he must necessarily be guided
by the whole of the circumstances whether the house should
be closed.
But the question arises whether the closing, if this be
necessary, should be effected under the Nuisances’ Removal
Act or under the Housing of the Working Clas.ses Act—
whether, in fact, the latter statute gives greater powers than
tire former. Tliere does not appear to be very much
difference between the two, but under the Housing
of the Working Classes Act, if the house after closing
becomes dangerous to the health of the neighbourhood, the
local authority may make an order for its demolition.
With this possibility hanging over the owner, and w'ith
risk of greater penalty, he is more likely to comply witli
the requirements of the authority. The newspapers have
afforded considerable evidence that the Act of last year lias
been systematically enforced in many parts of London, and
probably it will not be long before its effects come to be
Digitized by i^ooQle
264 The Lancet,]
RAILWAY SERVANTS AND LONG HOURS OF D’UTV.
[J an. 31, 1891.
fully appreciated. We observe, however, that magistrates
have Id many instances not imposed penalties. This leniency,
we think, is unfortunate, for if a reasonable standard of house
conditions is to be maintained in Ivondon, owners must be
made to recognise that it is their interest not to allow
houses to fall into bad condition. The Act, to be useful
in the best sense, must be preventive as well as curative,
and for this purpose the willingness of the magistrates to
punish offenders must not be a matter of doubt. We desire
to commend this thought to their attention; without
such assistance as they can vender, the maintenance of a
staff of inspectors, imposing considerable expense upon
the ratepayers, is unavoidable.
“ Ne quid nimlfl."
RAILWAY SERVANTS AND LONG HOURS OF
DUTY.
The report made by Major Marindin upon the collision
which occurred on the illst ult. at the IMndle Heath Junc¬
tion of the Lancashire and Yorkshire Railway, coming as it
does while the railway strike for shorter hours is pending in
Scotland, will have, it may be hoped, a salutary effect in
riveting public attention upon what is a crying abuse in*
railway management. The collision was a very serious one,
involving injury to twenty-five passengers, and in at least
one instance a fatal result. The blame of it is cast
by Major IVTarindin entirely upon a goods train driver
who had been on duty for twelve hours and three-q^uarteis,
and had still another two hours to work. The excuse is a
lame one, for although such hours are excessive, tliey are
not so excessive as to ailord an explanation of the very
culpable incompetency which the driver appears to liave
exhibited. Rut in awarding blame it is impossible
not to feel that a share, and not a small share withal,
is due to the managers, who are responsible for a system
so thoroughly bad as that which imposes fourteen hours’
continuous labour upon men entrusted with the heavy
responsibilities which devolve upon locomotive engine
drivers. Moreover, not only is a share of the blame their ,
due, but it is at the present moment a matter of tlte
greatest public interest that they should receive it. The
criminal law deals, and deals fairly effectively, with
delinquent railway servants, but the responsibilities in this
connexion of directors and managers can only be enforced
by public opinion. Public opinion, moreover, labours
under the peculiar disadvantage of being very badly
informed upon the point. Such a conclusion is, at least,
inevitable if we may trust a communication which appears
in one of our provincial contemporaiies, and has been
brought to our notice by a correspondent. The following is
given there as an actual instance of a week’s work
Time on ilufcj-,
On duty Monday morning, oir Tuesday ... 21 hours.
On Weclne.sday midday, off Thursday morn¬
ing. If n
On I'Viday night, offSaturday afternoon ... Iff „
Total . .'>0 hours.
Now it will be seen that these men were on duty three
times during the week for an “excessive number of hours at
a stretch,” bub their total hours were only 56. Instead,
therefore, of having “overtime pay,” they will get four
houns less than a week’s money. Whether the public
danger or the private injury involved in the imposition
of such excessi^'e labour is considered, the conclusion is
equally inevitable that means must be found of ending
the system. _____
THE ILLUSTRATION OF DISEASE.
The methods at our disposal for recording the aspect of
disease at some particular period iu its progress, if that
disease presents features which cause alteration in the out¬
line or the colour of the surface of the body, have mucli
improved of late years. The faithful representations which
we owe to photographic skill or the trained pencil meet the
requirements in many instances where mere change in out¬
line or form is required to be shown ; but where one wishes
to closely represent affections, much of the successful ex¬
position of which depends upon the colouring of the repro¬
duction, for fidelity to nature and close resemblance to the
original there is nothing equal to the models in wax or com¬
position material. The museum of St. Louis, Paris, stands
pre-eminently.in advance of those of all European or other
hospitals. It possesses some two thousand models in wax
or other material prepared by M. Baretta. This represents
thirty years’ M'ork of this celebrated artist. Guy’s Hospital
Museum has also procured this important aid to teaching
through the work of the late Mr. Toune. However, although
most medical museums have a few of such models, they
are usually only copies of foreign works, and generally of
an anatomical character, and are easily and cheaply
reproduced. Not so with clinical and pathological
specimens, which, being original, require expert handling.
We have had an opportunity of inspecting two wax models
which have lately been purchased by the Royal College of
Surgeons from Messrs. Baillicre, Tindall, and Cox, the
medical publishers; they are very beautiful and artistic
productions, and appear both in form and colour to faith¬
fully represent the respective original diseases to which
they refer. The above linn have established a studio at
their publishing establishment for the production of anato¬
mical, clinical, and patliological models in wax or other
suitable materials. The studio is under the supervision
of Mr. W. Swainaon and an expert stall'. Fnr the teaching
of our students such models are invaluable, and should, wo
think, form part of the equipment of all the museums
connected with our medical schools. We trust, therefore,
that the authorities of the schools will at once see their
way to take advantage of acquiring such useful adjuncts
to their teaching. ____
THE BETHNAL-GREEN AREA.
E.vul COMi’TON carried through the London County
Council on Tuesday the recommendations of the Housing
of the Working Classes’ Committee as to the procedure iu
dealing with the area in Bethnal-green and Shoreditch,
represented under Part 1 of the Housing of the Working
Classes Act. The proposals of the committee were sub¬
mitted to severe criticism, and in some instances the
speakers discuased the desirability of the scheme. One of
the recommendations of the committee, that a compara¬
tively small proportion of the houses should be closed as
soon as the Council obtained possession, was thought by
some to indicate that the houses in the area \v6re not in so
unsatisfactory a condition as had been represented, and appa¬
rently the point was overlooked that the Council would desire
to displace as few as possible of the inhabitants at once,
and would do such temporary repairs in many of the houses
as would give longer time for the inhabitants to find other
homes. No doubt much of the opposition was due to the
fear that the committee, in seeking for permission to acquire
a neighbouring site, was desirous of undertaking building
operation-s, which would eventually place the Council in the
Digitized by i^ooQle
The Lancet,]
PENALTY FOE SELLING DISEASED MEAT.
[Jan. 31,1891. 265
positioa of being responsible for tlie provision of dwelling
accommodation for a vast section of the community. This
would undoubtedly be disastrous, but there is no reason
why the additional site should not be used to release the
Council from the obligation of covering the whole of the
represented area with houses for the working-classes, and
why it should not give the Council the opportunity of
devoting some portion of this area to purposes which
would be more beneficial to this class than the erection of
dwellings. The activity the Council has shown in con¬
sidering the wants of the several classes of the community
is ample reason for thinking that many uses for any spare
land will abundantly occur to them.
SHEFFIELD AND THE MIDWIVES’ BILL.
A DEPUTATION from the Sheffield Medical Society, con¬
sisting of Dr. Keeling, Dr. Martin, and Dr. Porter,
lion, sec., waited on Mr. Stuart Wortley, M.P., complain¬
ing that the Midwives’ Bill was ill drawn and faulty in
several particulars. They had not confidence in the special
knowledge of midwifery of the Medical Council, on whom
tiie Bill placed the duty of framing regulations; still less
in that of the Privy Council. Only those mid wives who had
had ten years’ experience should be registered as existing
midwives. If a large number of midwives were to be
trained it would interfere with the clinical material, already
scanty enough, for the teaching of medical students. It
will be noticed that none of these objections touch the prin¬
ciple of the BUI or constitute a radical objection to some
legislation to abate the evil of ignorant and untrained
women practising midwifery.
POISONING FROM “BLACK-DAMP.”
Some of those who chance to escape from the explosion
of the dreaded “fire-damp” in mines survive only to fall
victims to the equally dreaded after-damp. After-damp
consists of a mixture of carbonic acid, watery vapour,
and nitrogen in varying proportions. It is in fact the gas
which results from the combustion of lire-damp. Fire¬
damp is a mechanical mixture of carburetted hydrogen
(CH,|), nitrogen, and carbonic acid. In an atmosphere con¬
taining 22 per cent, of the gas a man may still breathe for
.Homo considerable time, the only feeling of discomfort
experienced being that of mental lassitude. But in an
atmospherecontainingone-third fire-damp the human subject
is rendered insensible. On the other hand, in air contain¬
ing 10 per cent, of carbonic acid gas, life can only be main¬
tained for a short time, and a lighted candle for a still leas
time. The late Dr. Angus Smith has shown that .‘1 per
cent, carbonic acid gas is fatal if the oxygen in the same
atmosphere falls below 18 per cent. Coal has the peculiar
jiroperty of occluding marsh gas or iire-damp, and again
giving it oif when the external pressure happens to be re¬
duced or the temperature increased. This probably
occurs in coal-mines and, likely enougli, in the bunkers of
a ship. One hundred grains of coal have been known to give
oir as much as 200 cubic centiraetres of gas consisting of 90
per cent, marsh gas (0 H.,), 9 per cent, nitrogen, and 1 per
cent, of an equal volume of oxygen and carbonic acid.
In the coal bunkers of a ship this liberation of occluded gases |
would, it seems probable, take place when any sudden fall ,
in the barometer occurs, and also when the vessel passes into !
warmer regions. Hence, unless the coal bunkers are ade¬
quately ventilated serious explosions may ensue, culminat¬
ing in the loss of the vessel. A very curious case of poison¬
ing under peculiar circumstances, resulting from the
inhalation of carbonic acid gas (known to miners as after¬
damp, choke-damp, black-damp, dampie, according to the
origin and character of the gas), was recorded in a contem¬
porary In,at week, Itwa'ipoticed, that a house ip DaHastonj
near Wolverhanipbon, which was occupied by a greengrocer
and his family, remained for a longer time than usual shut up.
Fortunately, it was decided to break into tbe house, and
when this was done the inmates were found lying in bed
in a state of insensibility. On making an examination the
cellar of the house was found to be full of “black-damp,’’
which is believed to have emanated from the ground, which
is in close proximity to the workings of an old coal mine.
So noxious was the foul air that many who endeavoured to
render assistance were overcome end fainted. Two birds
and a cat were found dead from the same cause, and the
people occupying the adjacent houses, it was ascertained,
had been attacked with sickness and prostration. Through
the timely and prudent action of the neighbours any fatal
consequence, which might otherwise have happened, was
averted. So far as regards the predisposing cause, the
case is one we think without precedent. The lesson it
teaches is clear. Great care should be taken in the con¬
struction of bouses close to disused coal mines, in
order that the possibility of ingress of any form of
“ damp” may be avoided. It would be well perhaps to stop
up any holes hard by a dwelling so situated, with slaked
lime, that the poisonous gas may be to a large extent ab¬
sorbed. Miners take the precaution of placing casks of
lime-water at intervals in the mines, so that in the event of
explosion they may dip a cloth in the lime, and hold it
loosely fo their mouths. This procedure removes much of
the carbonic acid, and gives the miner a better chance of
reaching the main shaft. _
PENALTY FOR SELLING DISEASED MEAT.
There is nn obvious justice in the strict supervision
exercised by those authorities who control the importation
of provisions intended for consumption in the metropolis.
Neighbouring towns of large size ate virtually robbed in
order that London may be satisfied, and the superabund¬
ance thus forced upon the market is in some respects hardly
justified even by the requirements of a colossal population.
It is at least natural that under such conditions of supply
quality of material should be a primary consideration. To
sanction or overlook any neglect in this particular would
i especially injure the laborious thousands whose absolute
' necessaries, under pressure of work and in an atmosphere of
indiffierent purity, are sufficient rest and wholesome food.
The sentence of six weeks’ hard labour infilcted a few days
ago on a salesman at the Guildhall Court, for sending dis¬
eased meat to the London market, though severe, was pro¬
bably not unduly so. In comparison with one of three
months, which we have already noticed in connexion with a
similar ofi'ence, it appears almost lenient. The dealer
punished on the present occasion had previously ollended in
the same way, and had paid a heavy fine. We may fairly
conclude therefore that the prospect of a market profit had
in his mind overcome the dread of a mere money penalty.
Perhaps a few weeks’ enforced absence from business jnay
supply a stronger incentive to the belief and practice of an
honest policy in future. _
COUNTY HEALTH OFFICER FOR DERBYSHIRE.
Wk are glad to learn that the Derbyshire County Council
have decided to appoint a county medical officer of health.
Many counties somewhat naturally feel that the elimina¬
tion from the Local Government Act, 1888, of so much that
had to do with public health administration justifies a
postponement of the appointment of county health officers,
llut in counties where questions of river pollution arise
there is no justification for any such delay. Indeed, there
aro few questions which are involved in greater difficirlty,
and at every turn that class of scientific knowledge which
is especially the possession of the skilled medical officer of
Dic...^3di. .OOg'L
S66 The Lancet,]
BOLTON FEVER HOSPITAL.
[Jan. 31,1891.
health is needed in order to deal with the subject. In the
West Riding of Yorkshire and in Lancashire this need has
been felt, and it has been met. It is now the same with
the County Council of Derby, who find themselves face to
face with questions involving the pollution by sewage and
manufacturing processes of streams which take their rise
in Derbyshire, and which are concerned with the pollution
of the Irwell and Mersey and of the Manchester Ship
Canal. The Council hope by this appointment so to deal
with streams within their own jurisdiction as to render
joint action with other counties and its attendant cost
unnecessary. If this result is to be attained, a first-class
appointment should be made, and the officer elected should
be certain of the support of his Council in such actioA as
he may advise or take._
THE VASO-DILATOR ACTION OF UREA.
The researches of Abeles and Munk on the elfecb of
urea in the blood upon the renal vessels, causing them
bo dilate, have recently been supplemented by Drs. Cavazzani
and Rebnstello, who have made a series of observations
in the physiological laboratory of the University of Pavia
upon the ellecb of urea when circulating in the blood
on other vessels in different parts of the body. They
find that a vaao-dilator action is produced similar to
that observed in the renal vessels, but less marked in
extent. The greatest effect is observed in the cerebral
vessels, and the least in the vessels supplying th'e limbs,
the hepatic vessels being affected to an extent inter¬
mediate between the two. Generally speaking the efiect is
directly proportionate to the amount of urea in the blood ;
bub the hepatic vessels seem to present an exception to this
rule, for the dilatation in them appears to be about the same
whether the percentage of urea in the blood is high or low.
The greater the quantity of urea, and the more marked its
action, tJie sooner the effects pass off. With reference to
the various organs, the effects pass off first in the cerebral
vessels and in the vessels supplying tlie limbs, next in the
renal vessels, and last in the hepatic vessels. In tlie renal
vessels the acceleration of the circulation produced by the
urea is most marked when the blood-pressure is low. The
smallest dose of urea which will produce vaso-dilator effects
is not the same in different parts of the body; thue, one
part per thousand of blood is necessary in most of the
viscera, but in the kidneys half that amount is sufficient.
BOLTON FEVER HOSPITAL.
Some months ago the Fever Hospital belonging to the
Corporation of Bolton, Lancashire, came rather prominently
before the public in connexion with a dance or party given
there by some members of the staff, and indignant protests
were made at what was said to be expenditure of public
money from the rates for any such purposes; but last week
a more serious allegation was made concerning its internal
administration and supervision. The Rev. S. Bond recently
had his little girl removed there suffering from scarlet fever,
and he now complains that she was sent home whilst in an
infectious condition and conveyed the disease to anotlier
child. But he farther complains that the child returned
home in a dirty condition; that the conduct of boys and
girls placed together in the same ward was indecent and
disgusting, the supervision lax, even approaching neglect;
that some of the patients had insufficient clothing, were set
to fetch in coal and that foods sent to the hospital
never reached the patients for whom they were intended.
The Sanitary Committee of the Corporation have insti¬
tuted an inquiry into these charges, and as hitherto
the hospital has had a good reputation os regards the
treatment of patients sent tiiere, it is to be hoped a
different complexion may be put upon the above statements.
In the meantime it may be pointed out that the fact of a
child having infected another after leaving the hospital
with such an intensely infectious disease as scarlet fever,
unless there is shown to have been some neglect on the part
of the hospital staff', is scarcely a fair ground for a sweeping
condemnation. In all fever hospitals it is customary for
boys and girls of nine or ten years of age to be mixed ; and
fetching in coal or otherwise assisting in the wards by con¬
valescents, who often for two or three weeks prior to their
discharge are in perfect bodily health, is no hardship. The
absence of supervision, rude or indecent conduct, and want
of cleanliness, are, if they prove to be true, serious matters,
and should receive the prompt attention of the managing
committee, otherwise the usefulness of the institution in
checking tlie spread of infection will be greatly interfered
with, as in almost all cases the admission of patients is
voluntary, and often effected only by considerable pressure
being brought to bear upon the friends to secure permission
for their removal. _
COMPLIMENTARY DINNER TO MR, GANT.
On Wednesday evening, the 28th inst., the members of
the medical staff and several of the governors of the Royal
Free Hospital, together with past and present Presidents of
the hospital, entertained Mr. Gant at dinner at Limmer’s
Hotel. Mr. Gant, whose name is widely known in connexion
with surgical work, has recently retired from the staff'of this
hospital, and been elected consulting surgeon after a term of
service of thirty-sevenyears’duration. Dr. S. West, the senior
physician, occupied the chair, and a most cordial reception
was given to the guest of the evening. This is the first
occasion on which the medical staff of the hospital and
members of the governing body have met together in this
manner, and it is hoped that a Royal PYee dinner will be
an annual event, the good relations between the medical
ami lay elements of the hospital beingtheroby strengthened.
THE OPTIC THALAMUS AND SENSATION.
In the Philadelphia Mediced Neios, Dr. Hugo Fngel
describes a case of considerable importance with reference to
the relation of the optic thalamus to the special senses and
to common sensibility. The patient was a middle-aged
man with a definite history of specific disease. Before
coming under observation he had had more or less vague
symptoms of affection of the central nervous system during
the previous year. Those consisted chiefly of pain in the
head with occasional acute exacerbations, and giddiness.
On getting up one morning he found that he staggered.
The patient asciibed this to loss of sensation in his right
foot. He next found that the whole of the right aide of his
body was ana'-sthetie, and that he had lost tlie power of tasting
and smelling on the same side. Nine days later there was
complete loss of taste and smell on both sides, and deafness
of both ears. Two days later he suddenly became blind in
both eyes, and bad frequent convulsions, in one of which-he
died. At the necropsy, characteristic changes wore found
in the cerebral arteries, and a large gummatous growth was
discovered growing apparently from the fornix and spreading
back over both optic thalami. The growtli was more
extensive and apparently older on the left than on the
right side, pointing to a previous involvement of this side
in the morbid process, and thus corresponding with the
earlier symptoms on the right side of the body. The author
points out the existence of four collections of cells in the
thalamus described by Lays : the most anterior, which is
highly developed in the dog, and is most probably in some
way connected with smell; the second possibly connected
with hearing; the third with general sensibility; and the
fourth, in the region of the pulvinar, connected with the
visual tract. Wliile the situation and extent of the growth,
Digitized by Google
Thb lancet,]
COLLEGE OF SURGEONS LECTURES FOR FEBRUARY.
[Jan. 31,1891. 267
coupled with the clinical history of the case, make the
explanation which is offered, of a gradual involvement of
those groups of cells in the order mentioned, a plausible one,
it must not be forgotten that, even granting the existence
of such isolated groups of cells, their function is probably
only intermediary, so that pressure upon fibres, either con¬
ducting to them or from them, as well as upon others
running in or near the thalamus, would produce the same
effects as involvement of the cells themselves. In other
words, we must, in any growth such as the one desoiibed,
allow for pressure symptoms, and we must'not lose sight of
the fact that the growth started in the fornix, a struoture
which some authorities agree in connecting very intimately
with the conduction of sensory impressions.
COLLEGE OF SURGEONS LECTURES FOR
FEBRUARY.
The Hunterian oration will be given by Mr. Hutchinson
<in Feb. 14th, in the lecture theatre, at 3 p.m. Mr.
J. Bland Sutton, F.R.C.S. (Erasmus Wilson Lecturer),
will give three lectures on the Value of Comparative Patho¬
logy to Philosophical Surgery, on Monday, Wednesday, and
Friday, Feb. 9th, 11th, and 13th. Professor C. B. Plowright,
M.R.C.S., will give three lectures on Fungi in relation to
Plant Disease, on the 16bh, 18th, and 20th ; and Professor
W. W. Cheyne, F.R.C.S., three lectures on the Pathology
of Tubercular Disease of Bones and Joints, on the 23rd, 25th,
and 27bh. All these lectures will commence at 5 p.m.
THE CARE OF EPILEPTICS.
In the Boston Medical and Surgical Joy-rnal Dr. Bullard
•discusses and attempts to answer the question, What is
to be done with chronic epileptics? Everyone will agree
with him that there is no disease more distressing to the
sufferer, or more full of anxiety to his friends, on account of
the liability to accident during an attack, as well as on
account of the mental disturbance (slight and temporary it
may be) which is so often the sequel of a paroxysm. The pre¬
sence of epileptics, in short, among the ordinary community
without any special protective provision is a standing
<langer nob only to the patient, but to other members of the
•community. And this is true not only of the patients who
•can legally be transferred to an asylum; there are un¬
doubtedly many others whom it would be impossible to treat
an this way, and it is with regard to those that the difficulty
as to what should be done with them arises. Three methods
■of dealing with them are open to us, according to Dr.
Bullard. We may establish institutions in connexion with
.asylums, separate to a great extent but under the same
management; or we may have a large number of small estab-
Jishments grouped together and all under one management;
■or we may have an epileptic colony in which the patients
n.re boarded out in families. In this last plan it is evident
that there are many disadvantages. The patients are not
onder trained care or experienced treatment, and they are
on the one hand liable to accidents, while on the other
they may also become dangerous to others. Then the asso-
•ciation of epileptics, not as a rule mentally affected,
•or at all events whom it is impossible to certify, in au
'institution, however independent, yet connected with a
lunatic asylum, is apian which, we fear, will notveconiniend
'itself either to the friends of epileptics or to the laity
generally. Dr. Bullard concludes that on the whole
the cottage hospital system, as he calls it, is be.sb. In this
there would be a large number of small buildings, with a
few patients in each, and attendants according to the
number. It is evident that in Massachusetts there exist
diniculbios similar to those we have here. Whether an
.itbempb will be made to solve them in the manner
indicated in the article under consideration remains to be
seen. For our part we see fat fewer disadvantages, and far
more advantages, in the establishment of institutions in
the nature of hospitals of considerable size than in the
multiplication of smaller refuges. And there is no doubt
that, iu course of time, some provision will have to be
made for the cate of a class of patients who are unable to
care for themselves, and who, moreover, may at any time
become dangerous to others.
SANITARY REFORM IN FRANCE.
We have to congratulate the Revue d'Hygidne, which is
the official organ of the Socidtd de Mddecine Publique et
d’Hygi6ne Professionnelle, on the tw'elfth anniversary of its
publication. “L’Etudeet les Progrfes del’Hygibne en France
de 1878 k 1882,” by Dr. Napias and Dr. A. J. Martinris a
bulky and interesting volume, which shows that some good
work had been achieved before the twelve years in question.
Nevertheless, this work was more of a tentative, theoretical
character, and the cause of hygiene was thea only advo¬
cated by a few sanitary reformers. The Second Inter¬
national Congress of Hygiene, held in Paris during the
Universal Exhibition of 1878, gave a great impetus to the
consideration of questions of public health; and the
Society, which had so successfully organised this congress,
felt that it was necessary to give the public periodically a
record of its endeavours. With the foundation of the
Revue d'Bygitne really dates the modern revival of sanitary
science in France. This revival has been affirmed by con¬
gresses and expositions, and by the formation of numerous
societies for the promotion of sanitary science, both in
Paris and in the provinces. The practical results have
been the creation of museums of hygiene and sanitary
bureaux iu a large number of towns, together with
municipal laboratories for the analyses of food-
sapply, &c. Many hospitals have been reconstructed, the
water-supply of towns has been more carefully organised,
sewers and latrines improved, especially in schools and
barracks, more care is now taken to isolate fever patients,
and the practice of disinfecting is gradually coming into
vogue. Tiie question of sanitary reform is no longer
reserved solely for the consideration of experts, it is a
subject of general conversation. Hygiene has become
popular, and even constitutes one of the planks of many
a political platform. Those who knew France before the
Exhibition of 1878 will admit that this is indeed a great
change, and that the Society of Public Medicine and Pro¬
fessional Hygiene, which has been instrumental in bringing
about this great progress, has “ hieth mCriU de la ‘patrie."
‘'PERIODIC PARALYSIS.”
In the Wiener 3fcdicinisc7ie Presse, No. 30,1890, Dr. Gold-
llam describes a peculiar form of paralysis which is periodic,
hereditary, and, according to him, auto-toxic. The case
which he describes occurred in a lad aged seventeen, who,
three years previously, had been attacked in the night with
a sudden paralysis affecting the extremities and trunk. This
lasted three days, and since then had frequently recurred,
more especially in the spring of the year. The attacks
generally commenced in the evening. The first symptom
noticed was an almost unbearable itching over the site of the
paralysis; there was always constipation. The paralysis was
not absolute, the knee reflex was lessened, the plantar reflex
lost; sensibility was not affected. There was no tenderness
over the musclesor nerves, and no bladder symptoms. 'Ihe
backward and forward movements of the head were deficient.
The muscles of the face, tongue, eye, and ccsophagus were
not attacked; speech and movements of respiration were
normal. The faradaic irritability of the large nerve trunks
in the upper extremities Avas greatly dimiuished during the
Die!..zed by Google
268 The Lancet,]
SUICIDE AMONGST GERMAN CHILDREN.
[Jan. 31, 1891.
attacks, and slightly so in the louver extremities. There was
complete absence of direct muscular irritability. Reaction
to the galvanic current was also considerably weakened.
The attack lasted forty-eight hours, and concluded with
profuse perspiration. The peroneal muscles alone remainod
affected for some time. After the attack all the nerves and
muscles responded promptly to both currents. There M'as at
no time a rise of temperature. Examination of the blood
and urine gave negative results. One of the most interesting
facts in connexion with this case is that eleven other members
of the patient’s family were subject to similar attacks, but
only on the mother’s side; the father’s family was completely
free. The hereditary character of this disease followed no
regular course; occasionally all the females were attacked,
leaving out the males, and sometimes the reverse was the
case. The frequency of the attacks in the different sufferers
also varied considerably, but they did not seem to affect the
ordinary duration of life. Dr. Goldflam has collected several
such cases from medical literature, and the following is a
summary of his investigations: In the intervals between the
attacks there was some diminution in the electrical reac¬
tion in the smaller muscles of the hand, together with the
reaction of degeneration. Although improvement occurred
in most of the cases, this was interrupted by relapses. As
regards the pathology of the disease, Dr. Goldflam believes
that the muscles themselves are affected, or, perhaps, the
nerve-endings, such as occurs in poisoning by cocaine. Experi¬
ments were made by injecting into rabbits the urine of the
patient between and during the attacks, with the result that
in the latter case the secretion possessed distinctive toxic
properties, although actual paralytic attacks were not
induced. Further investigations showed that the organic
constituents of the urine contributed the toxic material,
perhaps owing to the condition of the muscles. In one case
the attacks were successfully warded off for two months by
small daily doses of atropine.
“PHYSIOLOGICAL ABERRATIONS IN EUROPEAN
INHABITANTS OF THE TROPICS.”
Refeering to the observation of Braco, that an adult
of normal development weighs as many kilogrammes
as he measures centimetres after deduction of the first
metre, Dr. Glogner, in a contribution to Virchow’s
Archiv under the above heading, contends that Braeo’s law
does not apply to the European inhabitants of the tropics,
because numerous examinations have proved that they
almost always lose weight in proportion to their height.
Dr. Glogner believes that part at least of the decrease in
weight is due to a decreaseof fat, the resulbof food which is
not so rich in fats as that in Europe. He also found another
difference in the temperature of the body, whicli from
seven to nine o’clock in the morning was half a degree
centigrade higher in the tropics than in Europe. Another
interesting observation was that, with the same tempe¬
rature, warmth radiates more easily from the native
than from the European, possibly through the stronger
pigmentation of the skin in natives and the greater changes
of the temperature in Europe.
SUICIDE AMONGST GERMAN CHILDREN.
A CURIOUS return has been made co.ucerning some 289
instances of suicide by school children in the German
Empire during the six years 1883 to 1888 inclusive. The
interest of the return centres in the motives assigned for
these extraordinary acts. Among the cases which could be
so explained the largest proportion appear to have been
attributable to fear of punishment. This, perhaps, might
have been expected, nor is it altogether surprising that
such extreme terror should be chiefly exhibited among
pupils of the elementary schools. The fact that 20 per cent,
of all the collected cases fall into this particular close
should, however, afford food for reflection. It is certain
that undue severity has been practised, or, at least, undue
apprehension has been aroused, in every one of these
instances, seeing that the little victims were so far thrown
off their balance by it as to be driven to the extremity of
suicide. It would be unjust to assume that for these
exaggerated fears the teachers are wholly, or even mainly,
responsible; but, on the other hand, no really efficient)
teacher would ever leave upon a child’s mind an impressiors
so horrible as to precipitate such a crisis as this. The
child who takes his own life rather than face an angry
teacher must believe, rightly or wrongly, in the ferocity of
the teacher; and it is much to be feared that children of
tender years, even when they are not so terror-stricken as
this, are apt to nurse a suspicion that most strangers an<l
some friends—the teacher in particular among the latter—
are human wolves. To eradicate this mischievous mis¬
apprehension ought to be one of the first tasks of a suc¬
cessful preceptor. Among the high school pupils the suicides
are almost exclusively boys, and here the most common
motive is dread or disappointment in connexion with exa¬
minations. Mental derangement and thwarted ambition
come next in order, while precocious sentiment claims its
share to the extent of four boys and one girl, whose
unhappiness is recorded as due to une affaire de ccem\ It
is some satisfaction to be able to add that these emotional
young people were all past the elementary school stage.
INOCULATION BY MOSQUITOES AGAINST
YELLOW FEVER.
Drs. Finlay and Delgado of Havana have published m
the lievista de Viencias M6dicas some statistics of their
practice of inoculating persons newly arrived in Cuba against
yellow fever by means of mosquitoes which have been caused
to contaminate themselves by stinging a yellow fever
patient. These observations have been carried on for the=
last ten years, and, in addition to a certain number which
are still incomplete, may be said to consist of fifty-two case®
of mosquito inoculation which have been fully followed up.
Of these, twelve experienced between the fourth and the
twenty^sixtli day after inoculation a mild attack of
yellow fever, with or without albuminuria; twelve ex¬
perienced no symptoms of yellow fever either within
twenty-live days afcer the inoculation or during three years
subsequently ; twenty-four experienced no symptoms within
twenty-five days, but contracted a mild attack before the
end of three years, either uncomplicated by albuminuria
altogether or with only a very transient appearance of it j
three who had had no symptoms within twenty-five day&
contracted well-marked yellow fever within th ree years
one patient who had a mild attack in consequence of inocu¬
lation contracted a severe attack later on, which proved
fatal : that is to say, that of those who had been
inoculated only about 8 per cent, contracted the disease ia
a well-marked form, with a mortality of under 2 per
cent. In order bo enable us to appreciate the signift-
cance of these figures, the authors mention that
they observed sixty-five monks who from time to time-,
arrived in Havana, where they all lived under similar con¬
ditions. Thirty-three of these were inoculated, and thirty -
two were nob. Only two of the inoculated contracted well-
marked attacks, which, however, did not prove fatal
whereas eleven of those tliat had not been inoculated were
severely attacked, no less than five dying. It is remarked
that inoculations performed in the cold weather are not
entirely trustworthy, and that they should be followed up
by a rei)etition in the spring; also that experience shows
Digitized by Google
The Lancet,]
THE DIAGNOSTIC USE OF KOCH’S FLUID.
[Jan. 31, 1891. 269
that a person who has been three years in the city without
contracting the disease ^has become “acclimatised,’’ and is
very unlikely to be attacked at a subsequent period.
THE DIAGNOSTIC USE OF KOCH’S FLUID.
Professor Pick, at a meeting of the Prague Society
•of German Physicians, related two cases in which injec¬
tions with Koch’s fluid had been useful for diagnostic
purposes. One was a case of Addison’s disease, and, in view
of the fact that in by far the majority of such cases there is
tuberculous disease of the suprarenal capsules, sometimes
associated with tubercle in other organs, the injections were
made to see if any reaction would follow. A first injection
of O'Ol grm. was without effect, which was explained on the
hypothesis that old caseous tubercular foci may not react
very readily. A second injection was therefore made, and
was succeeded byasevere general reaction,the patienbat the
same time complaining of great localised pain in the lumbar
cegioQ, which was increased by pressure over the spot. The
other case was one of syphilitic condylomata on the labia
and the buccal and pharyngeal mucous membranes, together
with extensive induration and enlargement of lymphatic
iglands. The patient had also for twelve years had a tuber-
■culous warty growth (lupus verrucosus) on the arm, with cica-
itrices over the site of glands that had previously cicatrised.
An injection of 0-01 grm. was followed in six hours by severe
■general reaction; and whereas the syphilitic disease showed
no changes, the tuberculous area on the forearm and the
(glandular cicatrices on the arm became in four hours
swollen, reddened, and painful, with the appearances of
tender nodules hitherto unobserved.
CHOLERA INTELLIGENCE.
At the close of the past year the state of affairs in Upper
Syria still caused considerable anxiety. Beyrouth and
Libania generally were still threatened by cholera; cases
were recorded from Aleppo, and the disease was progressing
in the direction of Masachi and Adana. The last intelligence
that comes to hand points to a very marked diminution io
the spread of the epidemic. In the second week of
January only eight cholera deaths occurred at Aleppo, five
at Adaua, and two at Momoureb-al-Aziz; besides which,
the entire villayet of Diadbekir was reported free. At
Beyrouth the condition of aff’airs was, however, much less
promising, 139 attacks having taken place in the preceding
tforfcnighb. Bab on the whole a hope was locally expressed
that the epidemic might possibly altogether subside before
the coming spring. _
A MIDWIFE COMMITTED FOR MANSLAUGHTER.
An inquest at the Town Hall, Wandsworth, held by
Mr. A. Braxton flicks, mid-Svirrey coroner, on the 22nd insc.
unto the cause of death of Emma Spicer, aged thirty-four,
iresulted in the jury finding, after a few minutes’ delibera¬
tion, a verdict of “Manslaughter” against the midwife,
SLlizabebh Sarah Berry, the wife of a labourer. It transpired
at the inquest that three deaths from puerperal fever had
happened in patients under Mrs. Berry’s care, aud that she
was distinctly warned by the medical practitioner and his
■assistant in the second case not bo attend others. She
‘Confessed to not knowing what puerperal fever was, and
■as to blood-poisoning, her only idea about it was that
ut was connected with a cut finger. Yet this ignorant
woman had attended 900 cases. A fine point in medical
obhics arose out of this series of cases—viz , that of the
■duty of medical men who are called to see the cases, boo
generally when they are too far advanced to allow of
jiinch being done. Are they bound to withhold certifi¬
cates? Is it their duty to inform the authorities? In the
first case the medical man did not give the midwife advice
to desist from practice, perhaps thinking that a single case
did not show the midwife to be at fault. Another medical
man advised her to desist from practice for a month
or two. Another thought the peiiod should have been
two months. It is a part of the lawlessness of the mid.
wives’ position that, as they need no qualification, they
are under no discipline. A medical man has no disciplinary
function. It is to be remembered, however, that under the
Notification Act he is bound to notify cases of puerperal fever.
The sanitary authority should then become responsible for
any necessary investigation into the facts. In all similar
cases the medical man will do well to speak plainly to
midwives as to the duty of desisting immediately from
practice. The midwife may promise to obey and yet go on
practising, but the medical practitioner will have done his
duty, _
BOYS AND FIREARMS.
Another sad accident which recently resulted in the
death of a lad of eleven shows the need of something more
than occasional supervision where boys are entrusted with
loaded firearms. In this case a pistol held by a still
younger brother aged nine, while learning to shoot, went
off, with the consequence above mentioned. The lesson
here taught requires no lengthy explanation. It does not,
of course, imply that young lads as a rule are in¬
capable of learning to use a gun or pistol. For
some whose lot is cast in outlying corners of the
colonies an early training in the management of such
weapons is almost a necessity, and this fact, supported by
a generally successful experience, might reasonably sanction
tlitir careful use by youths brought up in this country.
What the sad occurrence does very forcibly suggest, however,
is the mistake of entrusting the possible means of so much
mischief to mere children. A boy of thirteen or fourteen
would be quite young enough to have this privilege allowed
him, and only then sufficiently old if possessed of steady
nerve. The presence, io addition, of a responsible adult as
instructor is always advisable, and usually indispensable,
aud nothing could be more hazardous than to allow firearms
without such supervision to any one, however cautious, of a
group of boys. _
CREMATION AND ITS SAFEGUARDS.
Unfortunate circumstances connected with the death
of the late Duke of Bedford have brought into prominence
an important question respecting the procedure of the
Cremation Society, of which the late Duke was a prominent
member, in cases of death from other than purely natural
causes. It is clear that iu the case of the Society absolute
certainty as to the cause of death when other than natural
can alone justify the preferential application of its method.
It will therefore be interesting to examine the practical
value of the safeguards adopted by the Society to prevent
the chances of fallacy in a matter so important. These are
three—namely: (1) the certificate of the medical prac¬
titioner in attendance on the deceased during bis last
illness; (2) a second independent certificate by another
practitioner after careful inquiry into the circumstances
attending the illness; and (3), should any doubt remain,
the evidence afforded by necropsy. A further, though
possibly less permanent, security exists in the resolution of
the Society to refuse cremation in any case where the least
doubt exists respecting the cause of death. Such doubt, as
observed by Sir Henry Thompson, could remain after necropsy
only in an extremely small number of cases, and would, in
face, be virtually abolished. Nob actuallyso, however. There
still remains a iiiininium uncertainty, and this, it is appa¬
rent, is much greater where certification, oven on the very
Digitized by i^ooQle
270 Thk Lancet,]
TYPHOID FEVER IN FLORENCE.
[Jan. 31,1891.
careful system employed by tbe Society, is alone relied upon.
The practitioner in attendance might, in spite of diligence
and skill, be misled~for example, in a case where the signs
of poison were obscurely blended with those of real or
stipposed disease. In this connexion the case of the late
Mr. Maybrick is suggestive. Is it then to be believed that
a second medical testimony, which would be independent
of the former, could be relied on to guarantee the dii'
ference of opinion which would necessitate an appeal to the
coroner ? We should rather expect that this latter evidence,
divested as it must be of various technical premisses which
guided the statements in the first certificate, would be at
beat a carefully weighed and usually confirmatory assertion
of moral certainty. After all it is probable that the most
reliable safeguard against a too precipitate practice of crema¬
tion which we possess is to be found in tbe resolutions of
the Society above mentioned. Cremation therefore under
its present rules is certainly a valuable means of promoting
accuracy in certification. As afibrding an absolute guarantee
of such accuracy it cannot be depended on, while it must in
all cases destroy every trace of moibid or mischievous
agency contained in tlie tissues. While therefore we
freely admit its practical security against any miscarriage
of justice in the vast majority of cases, we cannot admit
that it stands in this respect on a level exactly so high as
the practice of burial. Moreover, while we also recognise
its more absolute and destructive purity in the disposal of
the infectious dead, we do not see that it possesses any such
advantage in comparison with burial in other cases, provided
that burial be conducted, as it increasingly is conducted, on
a rational or “ earth to earth ” system.
THE DISSEMINATION OF TUBERCLE UNDER
KOCH’S TREATMENT.
Tiib important and suggestive statements made by Prof.
Virchow upon the possibility of the use of Koch’s remedy
being the means for the dissemination of tubercle through¬
out the body by the liberation of bacilli from a localised
focus, seem to receive some confirmation from the discovery
by Dr. Liebmann of Trieste {Berl. Klin. Woch., No. 4, 1891)
of tubercle bacilli in the blood of patients under this
treatment. The method employed was to carefully dis¬
infect by hydrochloric acid and alcohol the cover-glasses &c.
employed, and to take a drop of blood from the finger,
previously thoroughly cleansed with pure alcohol and
ether, and the needle also having been previously
heated to redness. The preparations were placed in
warm carbol-fuchsine for half an hour, then washed in
distilled water, stained for one minute in Gabbot’s
solution, and examined in water. {Dr. Liebmann used
a modified Gabbet’s fluid, viz., methyl-violet, lu parts;
absolute alcohol, 30 parts; concentrated sulphuric acid,
20 parts; and distilled water, 50 parts.) Nine cases
are given; all the patients reacted markedly to small
doses; and bacilli, sometimes granular or broken, were to be
found in the blood on the evening of the day of the injec¬
tion or the next day, but they disappeared if the injection
was not repeated. Dr. Liebmann states that be could never
find bacilli in tbe blood of tubercular patients not treated
by this method, and considers his observation to prove that
the employment of Koch’s remedy may lead to the entrance
of bacilli into the blood in patients not suffering from
generalised miliary tubercle. It remains to determine
whether this occuis at a definite time after the injection,
and for how long it may persist. Already these investiga¬
tions have been repeated by Dr. Ewald at the Augusta
Hospital, the preparations being heated to llO’C., and the
blood taken during and after the fever, bat without in any
case confirming Dr. Liebmann’s results.
TYPHOID FEVER IN FLORENCE.
An Italian correspondent writes: “ There is little to ad(J
to my previous communications on the appearance off
typhoid fever in Tuscany, except the fact that, in Florence
particularly, the malady has shrunk to proportions certainly
not greater than those ever present in a populous town.
On the 16bh inst. the number of cases was in the ratio of
3 to 100,000 inhabitants—six patients in all out of a popu¬
lation of 200,000 having been, within the twenty-four hours,
reported to the sanitary authority. At no time, indeed,
during the last four weeks has there been enough typhoid
fever in Florence to justify the alarm that existed, or
the stampede that, among the American portion of the-
English-speaking community especially, almost emptied
the hotels, if not the pensions. Many of the cases reported
at sanitary headquarters were at best suspected to be of
the nature of typhoid fever; some of them turned out to-
have quite another origin. All the same, the measures set-
on foot by the municipality to secure absolute purity of
drinking-water have nob been relaxed, and the whole city,
in every hygienic aspect, is now under a surveillance to-
which, if the truth must be told, it has long been a.
stranger. A laudable endeavour to minimise tbe suffering©
of the poorer typhoid fever patients has been the formation
of a committee to supply them with appropriate aliment,
and, in the case of convalescents, to aid them with all the
requisites for a complete recovery. This has become the-
more urgent as the cold during the last three or four days
has been Siberian in its intensity, and the misery caused
among a proletariat poorly clad at the best of times and
scantily provided with fuel proportionately severe. With
ice-floes on the Arno, and the tramontana blowing ‘ sharp
as Shylock’s knife’ from the snow-clad Apennines, Florence
may claim to be a ‘ winter city ’ in quite another sense>
than that in which she poses in fiction.”
FOREIGN UNIVERSITY INTELLIGENCE.
Berlin. —Staff Surgeon Dr. Renvera has been granted tbe
title of Professor.
Leyden. —Dr. Wijsman has been appointed to the chair
of Pharmacy and Toxicology, in succession to Dr. van dor
Burg, deceased.
Munich. — Professor Trendelenburg of Ktinigsberg hao
accepted the chair of Surgery, vacant by the death of
Professor von Nussbaum.
St. Petershurg (Medico-Vkirurgical Academy). —Dr.
CheltsofF has been recognised as privat-doeent in Medi¬
cine.
Valladolid. —Professor Garfu of Valencia has gained the
chair of Obstetrics by competition.
Vienna. —Dr. Weidel has been appointed Extraordinary
Professor of General and Pharmaceutical Chemistry.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Karl Ileyher, from an accident while hunting. He was
one of the best known surgeons in Russia. In Edinburgh,,
where he went in 1873 in order to study under Lister, b©
made many friends. He was very active during the Russo-
Turkish Wav, and by his unwearied attention to antiseptic-
methods was the means of saving many valuable lives.—
Dr. Dmitri KoshlakofF, formerly Professor of Medicine in
the Medico-Chirurgical Academy, St. Petersburg. He
b.ad written largely on the subjects of diseases of the
throat and of the kidneys. — Dr. Jules Baillarger, a.
Digitized by L^ooQle
The lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Jan. .H, 1891. 271
well-known French alieniat, who waa a favourite pupil
of Esquirol, at the age of eighty-one. — Dr. Nicolaa
Gutierrez, founder of the Cuban Academy of Medi¬
cine, and also of the medical press of that island, the
first professional journal published there being the Reper-
torio M6dico, which was commenced in 1840. He com¬
menced practice in 1821, and in 1835 was appointed Pro¬
fessor of Pathology in the University of Havana. Many
years subsequently he became rector. He preserved his
faculties to the last, and never ceased to take an active
part in the work of the Academy of Medicine. —Dr. Augustin
W. Reyes, a well-known physician and medical writer
in Cuba.
At the annual meeting of the Obstetrical Society of
London, on Wednesday, Feb. 4bh, there will be a ballot
for the election of S. Tarnier, M.D,, Professor of Obstetrics,
Facultd do Mddecine de Paris, as an Honorary Fellow
(foreign subject), to replace Professor F. C. Faye, of
Christiania, deceased. The number of foreign Honorary
Fellows of the Society is limited to ten. At the same
meeting, after the address of the President, a discussion
will take place on the Midwives’ Registration Bill.
Dr. Tarnowsky, professor in the St. Petersburg Medical
Academy, has published a work on “Prostitution and
Aboliamus,” in which he contends that prostitution should
he regulated by law, and points to the state of this country
as a Varning to those who on the Continent favour the
doctrine of “ abolismus ”—that is to say, the abolition of
all State regulation. _
The death is announced of Dr. Warlomont of Brussels,
whose work in connexion with the advocacy of the use of
animal lymph in vaccination is well known to the medical
world. As an ophthalmologist his skill and experience
were of no mean order. Dr. AVarlomont was one of the
chief organisers of the International Medical Congress, held
in Brussels in 1874.
We are informed that Dr. Prowde, the medical officer of
the Sunderland Union Infirmary, has received from Berlin
a supply of Koch’s fluid, and that it will be employed on
several suitable patients who are at present under his care
in the infirmary. _
There will shortly be published (Springer, Berlin) a first
series (ending Dec. Slst, 1890) of official reports on the
action of Koch’s remedy for tuberculosis, from the clinics,
polyclinics, and pathological inabitutes of the Prussian
Universities.
The Milan Correctional Court is engaged in trying a
medical man for having caused the death of five persons
who had been bitten by rabid dogs by inoculating them
according to a system based on Dr. Ferran’s method for
cholera.
The Russian Government has prohibited the sale of
“sperrain” by pharmacists, even when prescribed by a
medical man. _
Mr. Sydney Jones has retired from tlie post of surgeon
to St. Thomas’s Hospital, his term of office having expired.
Mr. Croft now becomes senior surgeon.
The Council of the Metropolitan Hospital Sunday Fund
have received a further donation of £100 from Ludwig
Mond, Esq.
THE DEBATE ON KOCH’S REMEDY AT THE
BERLIN MEDICAL SOCIETY.
The discussion^ on Professor Fraeukel’s paper at the Berlin
Medical Society was further continued on the 21st inst.,'
the first portion of the proceedings being again taken up by
demonstrations of cases subjected to the treatment, and
specimens of organs from those who had been treated.
Dr. Alurand exhibited a case of Tuberculosis of the
Conjuctiva—a very rare affection—from the clinic of
Frotessor Scholer. The tuberculous infiltration waa
confined to the conjunctiva of tlie right upper eyelid,
some glands in the cheek, the preauricular glands,
and those at the angle uf the jaws. The patient-
was a girl of seventeen, with some family history of
lung disease, but having no lung symptoms herself, and the
disease commenced at the beginning of 1890. In the summer
she was under the care of Prof. UhbholF, who excised a portion
of the growth, and proved its tuberculous nature. The
condition at the time of commencement of treatment by
injections of Koch’s fluid (in December) was some redness
and swelling of the upper eyelid near the outer cautbus,
wheie there was a scar surrounded by greyish-yellow tuber¬
culous nodules. At this time, too, slight dulness wa&
detected at the apex of the right lung, but no respiratory
symptoms, beyond some dyspneea and cough, were excited
by the injections. The dose of the injections ranged at first
from 0 015 to 0'04grm., the degree of general and local
reaction increasing with the dose. Together with increased
local swelling and redness, there appeared an increase in
the tuberculous nodules, which became conilu^t. Gradually
these conditions subsided, until a dose of 0 16 griu. produced
no general or local reaction, the conjunctiva became pale,
and the nodules disappeared. The affected glands shared
in the local reaction, and then some suppurated, and otbera
were treated by scooping. They were found to contain
abundant bacilli.
Professor Virchow showed specimens from the body of a
man, aged fifty-four years, who was admitted into La
Charite last October for pleurisy, with effusion. From
Oct, lObh to Nov. 26th he remained in a satisfactory state i
no fever or loss of weight. Then injections were com¬
menced, five in all, each five milligranimes. and each time
with marked reaction (temperature 104°). From this time
he began to lose weight, and after the last injection tobave
continued fever. He died, and the exaniinalion made that
morning {21st) showed, in addition to old induration at both
apices and the remains of pleurisy, a widespread miliary
tuberculosis in lungs, spleen, kidneys, and liver.
Dr. G. Behrend showed a case of Lupus, premising that
lupus was a local tuberculosis of the skin which may often
arise from infection of eczema in early life. The patient bod
suffered for six years with pulmonary and laryngeal tuber¬
culosis, the latter having been cured by the local application
of iodo-glycerine and sozoiodol. The affection for which he
was now about to be treated by Koch’s remedy was a lupua
arising out of inoculated tubercle of the hand.
Dr. Ewai.d resumed the debate on Professor Fraenkel’s
paper, confining himself to the cases treated attheAugusta.
Hospital under his personal supervision. These omount to-
114, and there had been used no less than six flasks and a
half of the “lymph”—i.e., about 32,000 milligrammes in
all. On no single occasion had any inflammation or sup¬
puration occurred at the site of injection. Of these eases
thirty-six had been discharged, and five had died. Two of
the fatal cases were advanced in the disease, and wern
treated during the early period when “enthusiasm” was
at its height; but they only received one or two injections,
being obviously unsuitable. Another was a severe case of
laryngeal and pulmonary phthisis, which succumbed five
days after the injections were left off. In the other two-
cases there was a probable connexion between the injec¬
tions and the fatal result. One was a case of phthisis with
amyloid nephritis; the temperature rose rapidly the day
after 1 milligramme injection; there was profuse hamio-
pf-ysis and death the following day. The other was a man
with .slight apex affection, who came from America,
for treatment. He was very carefully examined _ by
some English physicians then in Berlin, and only slights
1 See Thk Lancist, .Tan. 2.tUi. p. 216.
2 Viile ISorl. Klin. Wocheii.sch., No. .|. ISDl
DiijiLized by Google
272 The Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Jan. 31, 1891.
infiltration of the right apex was detected. He had
A number of injections, up to 10 milligrammes, with the
ordinary reactions, and felt well, when he was suddenly
attacked with hemoptysis, and at the same time signs of
excavation appeared in the opposite lung. In one of these
cases there was a recent eruption of tubercles on the pleura,
such as bad been described by Professor Virchow. He
(<Dr. Ewald) did not feel competent to judge whether this
was post hoc ergo propter hoc, but Professor Virchow’s
statement had strengthened his feeling that the condition
was a result of the injection. Of the thirty-six cases which
•laad been discharged, seven of them had left before com¬
pleting the full series of injections—viz , up to 100 milli-
<graromes; some because they were not satisfied with the
rate of progress; and four owing to their hopeless condition
from the first. Dr. Ewald then read reports furnished
^jy patients since leaving hospital upon their condi-
'tion of health, especially as regards cough, expectoration,
night-sweats, weight, and general state, the majority being
■favourable on the whole; but he gave some reports in which
there had been retrogression in one or other or these points.
However, he remarked that the actual state is a different
thing from the reported condition. For, although an improve¬
ment in cough and expectoration is necessarily associated
with diminution in rriles, yet he was bound to say that, so far as
regards the percussion signs, no case had since lus discharge
cshown any change from the conditions carefully noted just
before he left the hospital. This does not apply to pleuritic
effusions, which were rapidly absorbed. He pointed out
that a “ clearing up ” of dulness, noted by many, does not
•necessarily imply the cure of a tuberculous process. Such a
change may be owing to the absorption of intra-alveolar
,products, or the re-entrance of air into parts previously
closed by exudation; also to the formation of cavities.
The two factors in phthisis—intra-alveolar exudation and
'inter alveolar tuberculous formation—are on a different
footing in this respect; and a clearing up of dulness due
•to the removal of the former may not prove in the least
that the latter has also disappeared; on the contrary, the
•curative process in tubercle consists in the production of
new tissue, the inspissation and calcification of the con¬
tents of cavities, and destruction of the affected part. These
•changes give rise to dulness and not to improvea resonance;
and therefore a “clearing up” of dulness does not mean
the cure of the tubercle. Moreover, the lesions are not
•superficial, but more or less concealed by a layer of healthy
tissue. Hence he affirmed that he had not yet seen one
■case which he could say was cured. The same applies to
the finding of bacilli, which varies so much with the con-
•ditions of the secretion. Bacilli may be undetected for a
long period, and then suddenly appear in large numbers.
Turning to the reverse of the medal, he said that there were
undoubtedly unfavourable effects as well as favourable
He did not deem it necessary to recount all the severe and
even fatal accidents which had been noted in the course of
the injections, sometimes of metastatic nature, at others
due to the direct injuries caused by the hyperremia of the
•affected parts. But he referred to a paper which was about
to appear in the Berliner KliniscJiA Wochenschrift, whiclr con¬
tained statements that, if confirmed, were of the highest
importance. Dr. Victor Liebmann of Trieste had dis-
-covered tubercle bacilli in tlie blood during and imme¬
diately after injections. These observations had been
repeated at the Augusta Hospital, with negative result.
■Summing up, he said the conviction was borne on him that
in no single case, with the exception, perhaps, of a few in
the very earliest stages, and then not with positive cer¬
tainty, can one say how the case will go, either in respect to
-the character of the reactions, or to the ultimate resxdt.
As he had remarked in a recent debate at the Hufeland
-••Society, the cases show a most variable character. Dr. T.
(juttraann had said that only slight cases should be injected,
and that no cases with severe signs, whether afebrile or
(febrile, should be treated. In many cases the slight
•character could be positively affirmed ; but there were
•others—for instance, where the disease was in the centre of
the lung—where this was not possible. Even in Moabifi
such cases occurred, as shown by the case of “cured”
ijntestinal tubercle brought forward by Dr. Guttmann.
According to present experience, the physician is in the
.•position of an operator who cannot foretell the issue of a
•difficult operation. The patient must be told that the
•remedy may produce the most severe effects, and even
•cause a fatal result. A case, to be published in the
Berliner Klinische Wochenschrift, shows the supervention
of tubercular meningitis with comparatively slight lung
affection. Again, there was one series of effects not
hitherto mentioned—viz., cases in which, free from fever
at the commencement of treatment and in which
for some time only slight reactions were produced,
a permanent fever had been set up and the injections
had to be abandoned. Here, again, one cannot abso¬
lutely affirm tlieposf hoc ergo propter hoc; but the proba¬
bility of a causal relationship was very great. Still, it can
be said that in a certain number of cases there was a
notable improvement, and that in a shorter time than
ever observed after the use of any other remedy. Further,
by careful selection of cases and judicious treatment
the chances of a favourable issue were increased, although
in some it is impossible to foretell what may happen.
The patient must decide whether he will undergo the
treatment or not. Dr. Ewald concluded by quoting
the authority of Fraentzel on the marked improve¬
ment in phthisis from treatment by creasote in a
report published by him in 1887, and compared the
results then given with those affirmed in the reports he
had just read of the cases treated by Professor Koch’s
remedy.
Dr. James Israel gave an account of 36 eases of sur¬
gical tuberculosis treated by the method. Subtracting
2 cases of cured joint resection which did not react, and
9 in ■which the treatment did nob extend beyond twenty
days, he said that one of the remainder (a case of hydrops
tiiberculosus genu) was cured ; but before beginning Koch’s
remedy the joint had been twice injected with iodoform
glycerine. Two patients had died, both being affected with
extensive lung disease; one was a case of lingual tuber¬
culosis, the other of synovial tubercle of the elbow. Five
cases had not shown the slightest local reaction or any thera¬
peutic effect from the injections, but in all there ha(f been a
general reaction. These were—(1) lupus of face, pulmonary
tubercle; (2) tuberculous ostitis of wrist; (3) synovial tubercle
of elbow, pulmonary tubercle ; (4) tuberculosis of bladder ;
(5) tuberculosis of bursa over trochanter, pulmonary tubercle;
cases in which the total quantity injected varied from
931 milligrammes to 43 milligrammes. A case of tubercle
of prostate had no reaction, either general or local, after
injections up to 4 c.g. Of the remaining eighteen caees,
six had notably improved—viz., two cases of facial
lupus, one of fistula after old hip resection, one of tuW-
cular epididymitis, one of lingual tuberculosis (but fatal
from lung disease), and one of tubercular teno-synovitis.
Three cases of joint disease primarily cured by excision gave
veiy slight reactions without notable change. The rest
either showed no improvement (three of coxitis and two of
spondylitis), or had relapses (one a resected knee-joint, and
one caries of skull), or grew worse (one tuberculous testis, one
artUrectomy of hip, and one apparently healed excision of
hip). Summing up his experience, he said that one of the
cases of lupus of the face showed no improvement, although
the dose had beeu raised to O^l gramme, the tetal amount used
being 896 milligrammes. Microscopic examination of ex¬
cised nodules showed giant cells and no regressive change.
In another case, a cancroid engrafted on the lupoid tissue
had rapidly increased under the iujeebiona. In another,
where the lupus had been excised, and a plastic operation
performed, the injections caused the development of fresh
nodules beneath the healthy skin. Only one case of
joint disease, that of hydrops tuberculosus genu, had a
good result. After each injection tliere wa's increased
effusion, which ultimately became absorbed when the
reactions ceased. In some cases latent foci in the
bones seemed to be excited into activity; in others
fresli disease appeared to l)e started. Details of some
of these cases were given, and reference was made to
two cases of tuberculous epididymitia Dr. Israel’s con¬
clusions were: (1) The remedy, even apart from caseous
foci, does not in all cases act on tuberculous tissue ; (2) the
remedy does not invariably excite obvious necrosis, but
inflammation; (3) there is no proportion between the
degree of the local reaction ana the intensity of the
general reaction; (4) the degree of local reaction is
DO measure of curative effect; good results may ensue
upon slight local reaction; in spite of marked local
reaction no curative effect may be observed. Sufficient
time had not elapsed to enable a judgment to be formed
of the therapeutical value of the remedy in surgical
caaes.
Digiiized by Google
The Lancet,]
THE MIDWIVES’ REGISTRATION BILL.
[Jan. 31, 1891. 279
THE MIDWIVES’ REGISTRATION BILL.
A MEB.TINO of registered medical practitioners was held
at the GroBvenor Hotel, Victoria Station, oa Saturday,
Jan. 2'tbh, at 4 pm., for the purpose of taking steps to
oppose the Midwives’Registration Bill, which is down for
second reading in the House of Commons. meeting
was nob very numerously attended. Mr. John Dewar
occupied the chair.
Dr. Crawford moved: “ That this meeting strongly
disapproves of the Midwives’ Registration Bill now
before Parliament, as it attempts to dissociate mid¬
wifery from medicine and surgery in the persons of
unqualilied midwives.' This being so, it is wrong in
principle, and will consequently be fraught with danger to
the public, and cannot but be opposed to the high aims of
the medical profession. At the same time this meeting
feels the great need there is for a better system of medic^
aid and competent nursing of necessitous poor women,
during and after labour, in town and country districts.”
In speaking to the resolution, be felt that these subjects
should not be separated as this Bill proposed to do. If it
passed, they would have midwives practising independently
of medical men. This he objected to. He maintained that
in all such cases the medical man should be the lirst to be
called to the case, and not the last, as this Bill proposed.
In cases of labour, should a midwife be engaged in preference
to a medical man, she herself would require an assistant to
attend to the mother and the child, and would consequently
be in the same position as the medical man at present is, and
the expense would be the same in both cases. General practi¬
tioners would see that this would tend to cut up their
practice, and that would be very much ag^nst their own
interests and also destroy public confidence in them. The
high aim of the medical profession is to uphold the unity
of the profession as practitioners of medicine, surgery, and
midwitery. His notion was that, there should be trained
nurses in every district to look after all cases of illness,
but that they should be under the immediate supervision
of registered medical practitioners. He pointed out that
registration was not a cure for the “old w’omen” who were
called in to cases now and then, as those who preferred them
could still have them.
Mr. W. E. G. Pearse seconded the motion, and fully
concurred witli its views.
Dr. H. A. Des Vceux could • not support a motion
which thought the Bill to be wrong in principle, or
fraught with danger to the public. At present poor women
were attended by unqualified mid wives—that is, by women
only fit for charing work in a house, but totally unfit to
take even a simple case of midwifery. Unless registration
were substituted, the poor in the towns and rural districts
would never have any better attendance. Mid wives, good
or bad, would always be called in to attend the poor, and
it seemed to him that by being registered they would not
be such a danger to the public. What was wrong with the
Bill? If it decreased mortality, which must follow upon
increased education, he could not see how it was opposed to
the high aims of the profession. He save illustrations of the
kind 01 questions put to candid ate.s by the Obs bet deal Society,
and proceeded to define natural labour, which the Bill per¬
mitted the midwives to deal with only. Midwives were
taught to recognise natural labour, and those whom he
taught had a whole lecture upon cases which they ought
not themselves to attend.
Mr. John Cahii.l pointed out that the Bill before Parlia¬
ment did not propose to drow distinctions between the
different cases of labour, bub to insist that no woni'en
shall legally practise as midwives without having received
a certain minimum of practical education. This was a
very wise provision for many thousands of women in this
country. There was no doubt that uneducated raidwives
attended a vast number of lying-in women, and in a large
proportion of cases the attendance was successful. Certain
cases would arise with which the midwife was unfit to deal.
The Obstetrical Society wished that those women should have
sufficient education to know when a doctor should be called
in. In poor districts it would enable medical men to relegate
to the hands of midwives a proportion of the lowest class
of patients upon whom a great deal of labour and time has
to be expended gratis. The profession were bound to consider
any method which tended to the greater good of the health
of the community. He thought the Act would be a valu^
able measure for the protection of a class of women whom*
they, in the west of London, knew very little of. He'
therefore moved as an amendment: “That this meeting;
of medical practitioners recognises with much satisfaction-
the circumstance that it appears likely that the efforts of
the Obstetrical Society to improve the education of mid¬
wives will receive the practical support of Parliament.’'’
Dr. Harry Scott seconded the amendment.
Mr. John Dewar (chairman) thought that London con¬
sultants were not very familiar with the details of the^
work done by midwives. In connexion with public dis¬
pensaries he nad seen a great deal of their work, and he^
could not remember any serious injury as having occurred
in their practice, although they were not registered. They?
had no special training beyond attending a lying-in bospitab
for two months or so, and had gone before the public with
a certificate. He could not therefore see the advantage
that would result to the public by registering them as a.
class of practitioners. In poor districts there were very
many struggling practitioners who would be glad to attend'
cases for the same fee as midwives charged. Midwives, if
registered, would regard themselves as aclass of practitioners,,
and, so far from sending for a doctor in difficult cases, it was-
just likely that they would themselves try to remedy those
conditions which were dangerous to both mother and child.
The poor in the district would begin to think that there was-
no necessity for a doctor at all, the poor women themselves-
would nob be benefited, and the general practitioner would'
be very much injured. He agreed that practitioners had
to consult the satety of the public before their own 'well -
being. But he asked, Would registration lend any
safety to the public which at present the public did not-
possess ? He maintained that from the very fact of their'
better education they would attempt to relieve patients-
whose condition was critical and demanded skilled assist¬
ance, and then, as now, when it was too late the practi¬
tioner would be called in. The profession ought to be^
considered, when it was remembered that in every parish
and small village in England there was a practitioner able’
and willing to attend to the patient. He could not seei
the necessity for encouraging a class of women already
far too numerous. The amendment was then put to the'
meeting, when three voted in its favour, and the mobioni
then was declared carried
Dr. Crawford next submitted the following motion, to-
the effect: that this meeting calls upon the direct repre¬
sentatives of the General Medical Council and others who-
have maintained that medical students after a four years’'
medical education are imperfectly educated in the subject of
midwifery, and that their attendance on lying-in women is-
fraught vvitU danger bo the public, to oppose a Bill which
legalises the attendance of women, designated midwives,
at the bedside of puerperal patients, notwithstanding the
fact that their imperfect education has only extended ovcb-
a period of three months.
The motion was agreed to, and the meeting terminated
with a vote of thanks to the chairman.
A petition against the Bill was lying on the table, and
was signed by most of those present. It has now been.-'
forwarded to Mr. Burdett Coutbs, M.P. for'Westminster,,
signed by about thirty practitioners in the district.
THE MEDICAL DEFENCE UNION.
A MEETING of the Medical Defence Union 'W’as held on>
Wednesday last at 429, Strand, when the annual report for'
the year ending Dec. Slst, 1890, was considered. The Pre¬
sident, Mr. Lawson Talb, occupied the hair.
In presenting the report, Mr. Lawson Taib thought that-
very few bub would agree that the growth of the Union had
been very satisfactory, and equally so was the amount _ot'
work done by it. All the undertakings they had engaged in
80 far, with one exception, had been uniformly successful.
In financial ability and in range of influence the Union had
steailily developed. A matter which had given the council’’
anxiety and which was still in hand was the strange way in
which the Union was hampered in the metropolitan area oir
its work in the prosecution of irregular practitioners, by
the fact that as the law stands at present the Receiver cf
D, : Google
274 The Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Jan. 81,1891.
Police was legally entitled to the penalties imposed,
And that debarred the Union from obtaininj^ repay¬
ment of the expenses to which it was put in these
cases; so that the more the Union succeeded in its
work the more they were hampered by this enactment.
The council had determined to approach the Home Secre¬
tary in order to find out whether this condition of things
could not by some arrangement be altered, inasmuch as its
■existence rendered the action of the Union a dead letter.
He believed a private arrangement of the Home Office with
the police would be sufficient for the purpose, and hoped
within a short time to report to the council that a private
Arrangement had been made.
Dr. Mead (Newmarket) suggested that it would be much
more convenient to the raen^bers of the Society if the chief
■offices of the Union were removed to London; and after
-some discussion
Mr. Tait pointed out that the branches of the Union
were perfectly autonomonic. The;y ought to wait until
they were in a very flourishing condition, with'a secretary
At £500 a year, and then it would nob matter a straw where
the offices were. The report was approved.
In receiving the financial statement the Chairman
referred to the item under the bending — To law and
■detective expenses (including costs of reconstruction,
£i0i 16^. Sd. The chairman pointed out that these were
nob the costs which had been incurred in a single year, bub
represented the sums paid to the lawyers for three yeais’
work.
On the motion of Mr. Felce, it was agreed that the
president and other officers should press upon the Home
Secrebaiy to take such action as would enable the fines
in question to be paid over to the General Medical
UouDCil.
Formal votes of thanks were awarded to The Lancet
and various other journals for publishing from time to time
statements in connexion with the work of the Union.
Dr. R. R. Rentoul brought forward the subject of the
Midwivea’ Registration Bill, and a discussion followed.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of ,the largest English towns 68.50 births
and 4816 deaths were registered during the week ending
Jan. 24th. The annual rate of mortality in these towns,
which had declined from 287 and 27‘3 per 1000 in the pre¬
ceding’three weeks, further fell to 25-1 last week. The
rate was 257 in London and 24-6 in the twenty-seven pro¬
vincial towns. During the past three weeks of the
current quarter the death-rate in the twenty-eight towns
averaged 26-8 per 1000, and exceeded by 3 0 the mean rate
in the corresponding periods of the ten years 1881-90,
The lowest rates in these towns last week were 13-8
in Hull, 15'9 in Bradford, 18'2 in Derby, and 20'8 in
Leicester; the highest rates were 20'9 in Bolton, 31'G
in Wolverhampton, 38'8 in Preston, and 39-0 in Halifax.
The deaths referred to the principal zymotic diseases, which
had been 485 and 404 in the preceding two weeks, were
again 404 last week ; they included 133 from measles,
fil6 from whooping-cough, 50 from diarrhcca, 44 from
scarlet fever, 3G from diphtheria, 20 from “ fever ” (princi¬
pally enteric), and not one from small-pox. The lowest
death-rates from these diseases were recorded in Cardiff,
J-’lymouth, Hull, and Huddersfield ; the highest in Bolton,
Manchester, Birkenhead, and Halifax. The greatest mor¬
tality from measles occurred in Leicester, Leeds, Birken¬
head, Oldham, Brighton, Bolton, and Halifax ; from scarlet
^ever in Halifax ; from whooping-cough in Preston, Halifax,
Newcastle-upon-Tyne, and Birkenhead ; ami from “fever”
'in Wolverhampton and Birkenhead. The .36 deaths from
diphtheria included 17 in London, 3 in Manchester,
and 3 in Salford. No death from small-pox was re¬
gistered in any of the twenty-eight towns, and no
small-pox patients were under treatment either in the
Metropolitan Asylum Hospitals or in the Highgate
Small-pox Hospital on Saturday last. The number of
scarlet fever patients in the Metropolitan Asylum
Hospitals and in the London Fever Hospital at the
end of the week was 1427, and showed a further con-
eiderable decline from recent weekly numbers; the patients
admitted during the week were 103, against 92 and 112
in the preceding two weeks. The deaths referred to
diseases of the respiratory organs in London, which had
increased in the preceding eiglit weeks from 375 to 1018,
declined last week to 845, but exceeded the corrected
average by 252. The causes of 114, or 2‘4 per cent., of the
deaths in the twenty-eight towns were not certified either
by a registered meaical practitioner or by a coroner. All
the causes of death were duly certified in Norwich,
Plymouth, Derby, Birkenhead, and Sunderland. The
largest proportions of uncertified deaths were recorded
in Liverpool, Salford, Brighton, and Sheffield.
health of scotch towns.
The annual rate of mortality in the eight Scotch towns,
which had been 28‘8 and 27'8 per 1000 in the preceding
two weeks, farther declined to 24’9 during the week ending
Jan. 24tih, and was slightly below the rate that prevailed
daring the same period in the twenty-eight large English
towns. The rates in the eight Scotch towns ranged from
13‘6 in Greenock and 18'2 in Dundee to 31‘0 in Glasgow
and 40'4 in Paisley. The 651 deaths in these eight towns
showed a decline of 78 from the number in the pre¬
ceding week, and included 27 which were referred to
whooping-cough, 18 to scarlet fever, 10 to diarrhcoa, 9 to
diphtheria, 7 to measles, 6 to “fever,” and not one to
small-pox. In all, 76 deaths resulted from these prin¬
cipal zymotic diseases, against 68 and 53 in the pre¬
ceding two weeks. These 651 deaths were equal to
an annual rate of 2'9 per 1000, which exceeded by 0'8
the mean rate last week from the same diseases in
the twenty-eight English towns. The fatal cases of
whooping-cough, which bad been 19 and 16 in the pre¬
ceding two weeks, rose last week to 27, of which 10
occurred in Glasgow, 9 in Edinburgh, 4 in Dundee,
and 3 in Leith. The deaths referred to scarlet fever,
which had been 8 and 7 in the previous two weeks, rose
again to 18 last week, and included 14 in Glasgow and
3 in Edinburgh. The 9 fatal cases of diphtheria corre¬
sponded with the number in the preceding week ; 5 occurred
in Glasgow and 2 in Edinburgh. The 7 deaths from measles
showed a further decline from the numbers in recent weeks,
and included 5 in Glasgow and 2 in Greenock. Of the 6
fatal cases of fever 3 were recorded in Edinburgh. The
deaths referred to diseases of the respiratory organs in
these towns, which had been 240 and 228 in the preceding
two weeks, further declined last week to 210, but exceeded
by 29 the number in the corresponding week of last year.
The causes of 55, or more than 8 per cent., of the deaths in
the eight towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate in Dublin, which had been 36 0 and
371 per 1000 in the preceding two weeks, further rose to
38-4 during the week ending Jan. 24bli. During the
first three weeks of the current quarter the death-rate in
the city averaged 37'2 per 1000, the rate during the
same period being 28'0 in London and 20'1 in Edin¬
burgh. The 200 deaths in Dublin showed an increase
of 9 upon the number in the preceding week, and
included 5 which were referred to "fever,” 2 to diar-
rheea, 1 to whooping-cough, and not one either to
small-pox, measles, scarlet fever, or diphtheria. Thus the
deaths from the principal zymotic aiseasea, which had
been 15 and 9 in the previous two weeks, further declined
last week to 8; they were equal to an annual rate of
1'2 per 1000, the rate from the same diseases being
17 in London and 197 in Edinburgh. The deaths referred
to cUlferent forms of “ fever,” which had been 4 in each
of the preceding two weeks, rose to 6 last week. The
fatal cases of whooping-cough, which had been G and 2 in
the previous two weeks, further declined to 1 last week.
The 2G0 deaths in the city included 40 of infants under
one year of age and 92 of persons aged upwards of sixty
years ; the deaths of infants showed a slight clocline, while
those of elderly persons showed a further increase upon
those recorded in recen t weeks. Throe inquest cases and 54
deaths from violence were registered; and 72, or more
than a fourth, of the deaths occurred in public institutions.
The causes of 40, or more than 10 per cent., of the deaths
in the city were not certified.
Digitized ky Google
Tub Lakobt,]
FAILURE OR CURE?
[Jan. 31, 1891. 275
“ Audi alteram partem.”
FAILURE OR CURE ?
To Editors of The Lancet.
Sms,—For several years past I have taken some pains to
condemn the unnecessary performance of mutilating opera¬
tions upon women, and have endeavoured to caution the
rising generation of medical men against any teaching or
example which might tend to lower the standard of surgical
ethics and endanger the character of British surgeons.
Last month, at the College of Surgeons, I expressed my fear
that the operation of odpliorotomy has been “ performed
without due explanation of the consequences; that advan¬
tage has been taken of the susceptible and impressionable
condition of women in certain states of health to overstep
i^e hounds of deliberative and consultative practice; that
recoveries from the operation have been untruly tabulated
as cures of the diseased condition ; and that failures have
not all been recorded.” On the 7th of this month, after
Dr. Playfair’s paper on “Removal of tho Uterine Appendages
in Cases of Functional Neurosis,” I read extracts from a paper
by Dr. Ross of Toronto on “The Failure of the Removal of
the Tubes and Ovarie? to relieve Symptoms,” in which he
says, “Many cures I hear of as cures are not cures”; and in
support of that statement I referred to one (among several
others “almost as unsatisfactory”) which had been re¬
ported as a “ practical cure” less than a month after the
operation, hut has proved to he “adeplorableanddisastrous
failure.” A letter from the operator in this case appears on
page 221 of your last number, in which he refers to the
original account of the case in the British Gyntecological
Journal for 1888, vol. iv., p. 457. The following is this
account given at the meeting of the British Gynsocological
Society, Dec. 12tih, 1888 :—
“ Mr. Lawson Tait said he had a specimen to show which
bore very much upon what had just been said ; he showed
the appendages from a lady, thirty-nine years of age, with a
very remarkable history. She had been married at the age
of seventeen or eighteen, and had two children within
twenty months of her marriage. Soon after her second
conilnement she contracted gonorrh<ua from her husband,
and she had never known what it was to be well since.
She had led a life of single misery for several years. Then
she married again, but her health did not improve, and she
never became pregnant by her second Imsband, so that ever
since nineteen or twenty she had been absolutely sterile.
During the last seven years she had been the patient of a
distinguished gynecological baronet, who had, however,
failed to relievo her. Ultimately she had been referred to
him and he had operated. She Kad double pyo-salpinx of
old standing, and it was very dilliculb to say which was
tube and which was ovary. There were abscesses in both
ovaries, and if he had attempted to tap them from the vagina,
he would have been obliged to tap several cavities. Instead of
doing anything of the kind, he opened tho abdomen a month
since, and the patient was now practically cured. A case
like that was worth a dozen hypothetical imaginations.
There was a woman who had been an invalid for years, who
could have been relieved at any time, who had been under
the care of all the well-known specialists of London, many
of whom had declared that there was nothing the matter.”
In the letter you published last week, the operator adds
tliat if anybody is answerable for this failure “it is Sir
Spencer Wells, who, during seven long years, treated this
poor woman uselessly by pessaries t^c.” And he adds that
tho case is “not a failure,”.the patient is “absolutely
cured, for I have the diseased parts in a bottle.” This lady
is now in London. I have submitted the folio wing questions
to her, and I add her replies :—
1. During tho seven years 1881-88 were you under my
care, and did I fail to relieve you?— licply: I consulted you
in 187'.), after Dr. Palfrey had failed to do me any good.
You operated on mo in the summer of 187!); I was in good
health after that until you again operated on me in 1880.
After that I enjoyed good health until 1887.
2. Had you before 1888 been “an invalid for years,” or
“led a life of single misery for several y&tLX&f’—Ecply:
Except between my second coniinement and 1879, I had
been in good health.
3. After your second confinement had you “been abso¬
lutely sterile”?— Reply: I had two children after my second
confinement—one born dead, one lived two weeks, and 1
bad one miscarriage at three months.
4. Have you been “ under the care of all the well-knowa
specialists in London, many of whom declared that there
was nothing the matter”?—iZcjify; You are the only medical
man I consulted in London between 1879 and 1888, and no
one ever told me that there was nothing the matter.
5. Did I treat you “for seven long years by pessaries
&c.’’?— Reply: No, yon never used a pessary.; nor, after
your second operation in 1880, treated me except for slight
ailments, and that seldom. In 1887, while you were abroad,
I was treated by Mr. Smith of Brighton after a cajriage-
accident and was recovering when you returned.
6. Remembering your Mate before and after ihe operation
performed at Birmingham in November, 1888, has that
operation proved to be, in your opinion, a “ practical cure ”■
or a “deplorable and disastrous failure ?: A decided
failure.
I need only add to this the fact that the operation I per¬
formed in 1879, assisted by Mr. Thornton, was amputation
of part of the elongated cervix uteri. Dr. Palfrey had re¬
peatedly injected solution of perchloride of mercury into
the substance of the cervix, and it was feared that the’
disease was papilloma or epithelioma. ExaminatioD proved
that it was simple hypertrophy of the utricular glands, or
adenoma. About a year after this amputation, the remains
of the cervix showed some tendency to enlarge and
proliferate, and I destroyed the left side by the actual
cautery. For two or three days after this there was a good
deal of pain and some fever, but they soon subsided, and
until 1887—about seven years—the patient was as well aa
most people, and for several months after her second mar¬
riage, in February, 1888, remained in good health, riding,
rowing, and walking four or five miles without fatigue.
Since the operation in November, 1888, she has been &
confirmed invalid. The failure to the husband has been
“disastrous” in expenditure; to two devoted daughters in
health and anxiety from continuous nursing; to the patient
“deplorable” in more than two years’ almost continuous
suffering and shattered health. It is a very poor consolation
to her to be assured that she is “ absolutely cured ” because
her “diseased parts are in a bottle.”
' I am, Sirs, yours truly,
T. Spbnceii Wells!.
Upper Grosvenor-.stroet, Jan. 20th, 1801.
THE LATE SURGEON - GENERAL BALFOUR
, AND THE CONTAGIOUS DISEASES ACTS.
To the E<Mtors of The Lancet.
Sirs,— I should like you to add to your biography of the
late Dr. Graham Balfour that he was a ve3y important
member of the Skey Committee of 1807, which was appointed
to investigate the question of venereal disease as it affected
the army and navy. Dr. Balfonr came to the sittings pre¬
judiced (as he informed us) against any State interference
with women or any moio stringent regulations for the
soldier. At the closure of the committee, however, his con¬
victions were quite changed, and he saw the necessity of
legislative measui'cs for the control of tlie disease. He
tlierefore, with some slight modifications, signed the chair¬
man’s report in favour of them. He subsequently upheld
the importance of the Contagious Diseases Acts, and lamented
their repeal. I am, Sirs, yours truly,
Grosvonor-stroct, Jan. 20tli| ISOl. SAMUKL WiLKS.
*,,■* Dr. Wilks has usefully drawn attention to a part of
the life work of tho late Surgeon-General Balfonr which
M’as bub casually referred ti) in our notice last week. Though
the Contagious Diseases Acts never formed a favourite topic
with the distinguished deceased, yet his convictions to the
last were entirely opposed to the action of tlie late Govern¬
ment in withdrawing the inotection of those nieasuros from
Her Majesty’s forces. That the facts brought out in con¬
nexion with the working of those Acts were capable of
changing tlie views of so acute and honest a rcasoner as
was Dr. Balfour is surely strong evidence of the unwisdom
of maintaining the existing legislative inaction in regard to
the means of controlling this class of contagious disease.—
Ed. L.
Diniii d ./Google
276 The Lancet,]
ILEOSTOMY AND INTUSSUSCEPTION.
[Jan. 31,1891.
ITHE DISCUSSION AT THE MEDICAL SOCIETY
ON THE OPERATIVE TREATMENT OF
CHRONIC DISEASE OF THE UTERINE
APPENDAGES.
To the Editors of The Lancet.
Sins,—HaviDg unavoidably been prevented from attend¬
ing the above aajoumed diacussion on Monday eveninglaat,
•I would like, with your permission, to briefly remark on one
or two points in connexion with Dr. W. Duncan’s paper on
'the subject in question.
In the first place, with regard to Dr. Duncan’s tabulated
eeries of cases, I think it a matter for regret that no indica¬
tion whatever was therein afforded as to the dates on which
the operations thus recorded were performed. Dr, Duncan,
in reply to an inquiry by the President as to whether the
oases—numbered consecutively from one to thirty—coni-
rised all those of the kind which had been thus treated by
im, stated at the meeting on Jan. 12th^tbat “his earlier
■results in ell cases of abdominal section had been so awful
that he would not like to publish them.” In other respects
‘the cases were said to be consecutive up to the date of
writing his paper. While giving Dr. Duncan full credio for
the frankness of his avowal on this point, I venture to think
that his omission was an unfortunate one, since statistics
thus compiled cannot be of much scientific value as to the
comparative risks and advantages of the operation to which
they refer. If we turn back to the history of ovariotomy
in this country thirty years ago we learn that what chiefly
tended to establish the operation upon a firm basis as a well-
recognised surgical procedure in the eyes of the profession
at large was the fact that each case in the practice of Mr.
Spencer Wells, whether successful or unsuccessful, was
•duly and faithfully recorded by him from the commence¬
ment of his work in this field; and, so far as I know,
the good rule then initiated has up till now been followed
by nis successors when bringing forward statistical
results of their work in any special branch of abdo-
■minal surgery. It seems to me that any departure
from such a rule must inevitably destroy the value of
statistics in any given instance, and it is therefore to be
hoped that the plan here adopted by Dr. Duncan may not
be followed by other operators. The remaining subject to
which I would allude, in connexion with this paper is the
comparatively large number of operations which appear to
have been found necessary in Dr. Duncan’s practice for the
relief of sulfering presumably connecced with the state of
the uterine appendages The absence already noted of any
indication as to the period covered by the work recorded
makes it impossible to judge as to the relative proportion
which these operations might bear to the total number of
Dr. Duncan’s abdominal sections during the same period,
or from the date when he first began to operate. On neither
of these latter points, however, does his paper afford us any
information.
In order to estimate the comparative frequency of these
operations in other hands than those of the author of
this paper I have examined the register of the Samaritan
Free Hospital, with a view to ascertaining some definite
information on this subject. I find that in 1890, out of a
■total of 141 abdominal sections, the number of operations
for removal of diseased uterine appendages (one or both)
was exactly fourteen—a proportionate rate of as nearly as
.possible 10 per cent, on the total. These figures, considered
in relation to the twenty-three hospital operations recorded
by Dr. Duncan—which comprise seventeen cases of complete
-and three of incomplete removal of the uterine appendages,
to the exclusion of two cases of ovarian cyst (Nos. 5 and 17)
and one exploratory operation (No. 21)—would apparently
indicate one or other of two things : either that the surgical
•etaft' of the Samaritan Hospital do not frequently enough
resort to operative treatment for the cure of the diseases
in question, or else that the number of urgent cases
of such nature, unrelievable by rest and medical treat¬
ment, who apply at the Middlesex and Waterloo-road
Hospitals, is greatly in excess of those to be met with at the
Samaritan Free Hospital. In my own belief neither of
these interpretations can be considered correct. The true
■explanation lies in the spirit of restless surgery now so
prevalent that, unless restrained, it will, I fear, bring into
1 See Brit. Mod. Journ., Jan. 17tli, 1891, p. 113.
disrepute an operation which, when judiciously undertaken
in properly selected instances, may prove a most valuable
means of restoration to health.
. I am. Sirs, yours faithfully,
Queen Anne-street, W., Jan. 28th, 1891. W. A. MeREDITH.
ILEOSTOMY AND INTUSSUSCEPTION.'
To the Editors o/The Lancet.
Sirs, —In your issue of last week, page 221, my friend
Mr. Reeves gives a short description or a case in which he
had performed ileostomy in a man suffering from cancer of
the ccecum, on similar lines to those described by Mr. Bryant
in a former number of The Lancet. By adopting this
method of treatment a ftecal fistula is formed, which is
most distressing to the patient, and, being situated in the
small intestine, somewhat difficult to manage. To obviate
this I would strongly advocate the operation of ileo-
colostomy, either by approximation of tlae ileum to some
portion of the colon below the disease by means of decalcified
bone-plates as suggested and practised by Dr. Senn, or by
dividing the ileum some three inches above the ileo-cascal
valve, closing the distal end and implanting the proximal
end into the colon below the disease. This latter operation
I performed upon a patient some eighteen months ago,
details of which will shortly be reported in your columns.
By adopting this operation a fmcal fistula is avoided and
the patient placed in as comfortable a position as possible
for the remainder of his life. In the discussion at the
Clinical Society on Jan. 9bh, which followed Mr. Lockwood’s
paper on a case of Acute Intussusception, I was pleased to
see Mr. Barker alluded to a method of treating those cases,
when the intussusception could not be reduced, by making
a longitudinal incision through the intussuscepiens and
then cutting away the inner intussuscepted part, the
original incision being closed by sutures. This is a plan of
treatment which I have advocated for some time, but, like
Mr. Barker, have not had an opportunity of putting it into
practice. In carrying out the operation, however, I would
suggest that a few Lembert sutures should be inserted, to
unite the intestine at its junction with the intussuscepiens,
for fear of the accident of its slipping after the removal of
the intussuscepted part; this part, if small, might be with¬
drawn through the incision made in the intussuscepiens, or,
if extensive and extending low down in the colon, might by
manipulation be passed downwards and withdrawn through
the rectum.—I am. Sirs, yours faithfully,
Fred.' Bowreman J'essett, F.R.C.S.
Upper Wiuipolo-atreot, W.
“THE THROAT AND NOSE AND THEIR
DISEASES.”
To the Editors o/The Lancet.
Sirs,— In thanking you for the lengthened and, on the
whole, very favourable notice of my work, I am sorry to be
obliged to point out that there are certain numerous
instances of misrepresentation of matters of fact. These are
due probably to the circumstance that your reviewer has
imperfectly read the book, since an entirely different con¬
struction would have been placed on some of my quoted
remarks had he even read the word before or the lino follow¬
ing some of those that are criticised. To cite only two
instances of a minor character—when he asks why I do not
treat tuberculosis of the nose at length, he does not reco¬
gnise that I immediately proceed to say that “ it is but
rarely if ever primary’*' (p. 580), and he also ignores the
circumstance that I Lave exhaustively treated the subject
of tubercle as affecting the throat, independently of the
considerable attention given to lupus both in the throat and
nose. Again, in speaking of my modified views with regard
to the etiology of aiphtberia, he quotes the word “ probable”
with a parenthetic “«c,” whereas the words I use are “ more
probable” (p. 335).
To come, however, to something more serious. Your
reviewer says, “The only instruments for treating bony
or cartilaginous septal excrescences advocated are Curtis’s
nasal trephines . while no mention is made of the
motive powerand that “Boaworth’s saws are not men¬
tioned.’’ As a matter of fact, after referring to Adams’s
operation of refracburing the septum, I commence my re¬
marks on treatment by recommending “removal of the
Di L_tC Og
The Lakoet,]
THE MIDWIVES’ REGISTRATION BILL.
[Jak. 31,1891. 27*2
obstructiag parb of the Beptum by means of a nmal saw, or
by circular trephine driven by a surgical engine or electro-
motor." It is true the nasal saw is not mentioned as that
of Bosworth, and this is intentional, for the right of that
surgeon to priority^ of invention is really in dispute;
but marked attention is drawn by me to the practice
and opinions of Bosworth on this particular method
of treating nasal spurs, and he is quoted repeatedly
as the authority most worthy of respect on this and all
nasal questions, his name occurring no less than fourteen
times in the chapter devoted to nasal diseases.
further mentioned, described, and illustrated Dundas
Grant’s nasal splint for straightening deflections of the
septum, especially in young children; Hewetson’s dilator
for forcible stretching of astenosed nostril; and Hill’s modi¬
fication of the same mstrument (p. 590); all of these being
for the purpose of treating that special condition for which
your reviewer says I only advocate Curtis’s trephine. As a
further evidence of the carelessness of this criticism, I
must remark that in twenty detailed cases of septal
deformity, each of which is illustrated, thirteen were sub¬
mitted to operative treatment; in most of these the
nature of the operation is indicated by dotted lines
on the portrait figures, and in not one was the trephine
alone used; while the trephine and saw combined were em¬
ployed in eight cases, and the saw alone in three. As a
matter of fact, in the ten pages devoted to treatment and
relation of cases use of the trephine is alluded to thirteen
times, whilst that of the saw is mentioned eighteen times.
Finally, your reviewer is of opinion that “ the difficulties
in the after treatment of such operations are ignored.” In
reply I must say that nob only am I careful to give every
necessary detail, but that I conclude my remarks under
this beading as follows: “It is of the utmost importance
to forewarn a patient that he must be prepared to give up
so much time (fourteen days) for rest at nome. While it is
difficult to over.estimate the amount of improvement to be
gained by removal of septal obstruction in suitable cases,
nothing is more likely to bring the operation into disrepute
than an under-estimation of the mischief which might occur
from want of care during convalescence” (p. 598).
In making this remonstrance I would, with all respect,
point out that your reviewer endeavours to prejudice me in
the opinion of general practitioners by complaining that I
do not give sufficient details of treatment, as instances of
which he selects curetting the sphenoid and ethmoid cells
for rhinitis caseosa, this rare disease and its treatment both
coming absolutely within the province of a specialist.
Lastly, his only allusion to my illustrations, which have
generally been considered a feature of the book, is a com¬
plaint that I do nob illustrate a trephine or a saw.
I am, Sirs, yours faithfully,
Weymouth-streot, W., Jaii. 27th. 1801. LeNNOX BrOWNE.
On referring to the passages in his book to which
Mr. Browne draws our attention, we cannot see, in the first
place, thac his omission to discuss tuberculosis of the nose
is justified by his having written on the same disease as
observed in the throat. Nor do we perceive that his re¬
tractation of his theory that diphtheria was propagated by
ptomaines is affected by the criticism. He would apparently
have us indicate precisely that he does not quite consider
it probable “that germs are the true element of con¬
tagion”; but that he holds this “more probable” {sic)
than that the ptomaine spreads the disease, as he formerly
maintained. Bat, so far as the treatment of septal ex¬
crescences is concerned, we willingly admit a slight
inaccuracy in the critique. For we find that, as Mr.
Browne indicates, mention of the saw is made, though
we fail to discover either description of the instrument or
directions for its use. No reference was made in the review
to simple deviations of the septum, and hence the author’s
apparent compiaint that several instruments for this
purpose were overlooked is uncalled for. We also con¬
cede that Mr. Browne has not altogether omitted
the mention of after-treatment in such operations. We
can only account for our reviewer’s inaccuracy by the
fact tliab the subject U separated from the discussion of
the treatment by four pages of cases. We disclaim on
the jiarc of our reviewer any desire to prejudice the author
in the opinion of general practitioners; yet we cannot bub
think that when the curetting of such regions as the
ethmoidal and sphenoidal cells is recommended some refer¬
ence should be made to the hazardous nature of the pro ¬
cedure, although such a line of treatment be declared to falV
“ absolutely within the province of a speciaUsb.”—E d. L.
THE MIDWIVES' REGISTRATION BILL.
To the Editors of Thb Lanobt.
Sirs,— I will refer Dr. Aveling to my letter in a con¬
temporary of last week, and further explain that the
figures and facts which I alluded to as erroneous were those
wnich he brought forward at the British Gynecological'
Society, and were those be was unable to substantiate ii>
his reply at the close of the debate. If be bad been able to-
do so he would nob have voted for the resolution, “That
this association, while recognising the necessity for such
legislation as shall prevent incompetent women acting as
midwives, does not approve of the proposed Midwives'
Bill.” Since my letter was written be has published other
figures. It appears that the present Bill isintended to serve
two purposes—(1) To advantage the training schools of mid¬
wives and to make mid wives competitorsfor practice with the-
registered medical practitioner. (2) To curtail the practice of
untrained midwives. As it stands it would accomplish the
former, but not the latter, which it is the object of every one to-
effect. Id seems a pity that the medical promoters of the Bill
should have allied themselves with the Midwives’ Institute,
for it is evidently their iniluence which has ruined the Bill.
Now I cannot believe that the eminent authorities men¬
tioned by Mr. Nichol have been so disloyal to their pro¬
fession as to countenance anything which would favour the
former, though they may have approved of some scheme to-
effect the latter object. I should like to ask Mr. Nichol at
what tffiie and in what manner has the profession advised
his Institute to take up the matter? I am very much
obliged to Mr. Nichol for his piece of ancient history, toler¬
ably well known as it is, but I would point out to him that-
he should have said the Council of the Obstetrical Society.
The matter has never been discussed at a meeting of the
Society. We are now practically asked to sanction a com¬
plete revolution in the practice of midwifery because the
death-rate—the general death- rate—is slightly in excess of
that in the out-door departments of some lying-in charities
in London. It seems to be quite as reasonable to demand
a complete revolution in the management of such institu¬
tions as the General Lying-in Hospital because the death-
rate there was twice as high as that of Queen Charlotte’s
Hospital in 1889. It is a matter of great regret that this
subject had not the advantage of free and open discussion
before the introduction of a Bill on the subject into Par¬
liament. The result has been that many members of our
profession have been misled as to the scope of the present
Bill, and that many outsiders have been led to believe that
the death-rate in childbed is excessive, though it will
compare favourably with that in any other county.
I remain, Sirs, yours faithfully,
Hatfield, Jan. 20tli, ISOl. LoVELL DrAGB.
INSURANCES ON THE LIVES OF PHYSICIANS.
To the Editors o/The Lancbt.
Sirs,— In reply to your editorial comments on my letter
in last week's issue, I have to explain that in ascertaining
the expected deaths I did not take the average of the death-
rates in the table you refer to, but employed the ratio of the
sums of the numbers dying to the numbers living in each-
group of ages, which allows for the age distribution. Thi»
assumes that the physicians are a stationary class; but the
error involved in this assumption must be extremely small,
as the numbers living at all ages at the census of 1861^
was 1-1,415, while in 1871 it was 14,684. I would remind
you too that before publishing, the results 1 obtained
I tested them by taking out the figures for other
classes, such as the clergy and the publicans; and I fcnuid
that the method I adopted yielded results which agree<l'
substantially with what had been brought out by other in¬
vestigators with better materials and more exact methods.
There is no reason to believe that the age distribution m
the case of physicians differs materially from that in other
: Goocle
278 TnaliANOET,]
“THE HEALTH OF SOUTHEND.’
[Jan. 31,1891.
classes ; but the numbers living 'e'ill not agree with those
in the table by which I tested them, because the law of
mortality is aifferent. I gather, however, from your
remarks that you would be satisfied if small groups of ages
were used where the death-rates do not differ to any great
extent. It is a pity that such wide groups of ages were
taken when compiling the censuses of 1871 and 1881,
especially the latter; but in the censusof 1861 the numbers
living are given for groups of five ages ; and although the
deaths are only given there for groups of ten ages, that will
not matter. As you say the subject is one in which your
readers take a lively interest, I give in the following table
the numbers living after age twenty-five, one-half of the
deaths which occurred in the two years 1860-1, and the
deaths which might be expected to have occurred according
to the Institute of Actuaries Healthy Males Table calcu¬
lated in the manner above described.
Agos.
Number living.
Expected
deaths.
Actual
deaths.
25 to 30 .
.... 1558 ...
. in
37
30 to 35 .
.... 1593 ...
. 13/-
35 to 40 .
.... 1566 ...
. 151
48
40 to 45 .
.... 1932 ...
. 21/
45 to 50
.... 1883 ...
, 261
73
50 to 55 .
.... 1597 ...
. 28/
55 bo 60 .
.... 1186 ...
291
59
60 to 65 ,
937 ...
32/■
65 to 70 .
669 ...
. 33 \
65-
70 to 76 .
376 ...
. 28)
75 to 80 .
217 ...
. 251
... 62
80 to 85 .
92 ...
. 15/
85 to 90 .
32 ...
7)
90 to 95 .
9 ...
10
95 to 100 .
1 ...
. iJ
13,648 ....
.. 287
... 344
Here the results are not quite so regular as in my last
table, as we are dealing with very small groups of ages and
with the figures for one census only; but it will be seen
that, with two small exceptions, the actual deaths are
throughout the table considerably in excess of the expected,
and, taking all ages together, the extra premium which
physicians should be charged comes out 8s. Sd. per cent,
per annum. I think, therefore, that I have proved beyond
all doubt that the mortality among physicians is much
higher than that among assured lives generally. It is even
higher than that of the ordinary population; and I say,
all honour to the profession which alleviates the sufferings
of humanity at the risk of their lives.
I am, Sirs, yours faithfully,
KdinburRh. Jan. 20th, isni. JAMES CHATHAM.
*,* Our correspondent has in the above letter very frankly
admitted in effect the force of our criticisms, and it will be
observed that he has now reduced his extra premium from
10s. 2c?. to 85. 5c?. On further consideration, we think he
•will see that he still exaggerates -what may be called tlie
professional mortality of physicians, and we say so on two
grounds. First, he has compared a miscellaneous body of
men with a select body—i.e., with persons canning life
assurance policies who have been selected from the general
population by medical examination. Secondly, the age
distribution whicli his estimates assume does not obtain
in the groups of which he has estimated the expected
mortality. The first group in his table given above wall
make this clear. Seeing that the second group outnumbers
the first, it is reasonable to assume that the older men are
more numerous than the younger men within the first
group—that is to say, it contains more men of twenty-nine
than of twenty-five years of age. But the corresponding
•group in the H'“ Table contains more men of twenty-five
years of age than of twenty-nine. It is plain that
this is most material to consider when an estimate of
expected mortality is to be formed, for a group con¬
taining a preponderance of men aged twenty-nine must
have a higher mortality rate than a group containing a
preponderance of men of twenty-five years of age. Mr.
Chatham’s method of estimating assumes that twenty-five
years of age predominate. Therefore, his estimate is not
a correct one according to bis data, and it is incorrect to
the disadvantage of the physicians. On the other hand, the
two groups from fifty-five to seventy-five show an age
distribution too favourable to the physicians, and it is to
be observed that over this important period the expected
deaths are practically equal to the actual deaths. We do
not seek to make this point against our correspondent, be¬
cause we think that he is entitled here to the benefit of the
argument which we have urged against him on the former
part of his table; but we think that if he will apply his
industry to the correction of tlie two defects which we have
indicated in his present materials, he will probably be able
to show that there is a distinct professional mortality
among physicians, hut not at all commensurate to the figure
which he has put upon it.—E d. L.
“ THE PIEALTH OF SOUTHEND.”
To the Editors o/The Lancet.
Siiw,—Will you allow me, without touching on contro¬
versial matters, to state, with reference to the article under
this beading in your last week’s issue, that the local board
did and do cordially agree with all the recommendations of
Dr. Thresh, and are already proceeding to carry them into
effect to the full. The necessary steps for ^the provision of
a permanent hospital, and of the new sewer and outfall you
refer to, were already in hand some time before Dr. Thresh
was called in. The other recommendations have since been
taken up, and the board hope that all will be completely
carried out before next summer. Trusting to your fairness
to give this letter equal prominence to the article I have
alluded to,' I remain, Sirs, your obedient servant,
Southend, Jan, 27th, 1801. WlI.LIAM GREGSON, Clerk.
LIVERPOOL.
(From ode own Correspondent.)
The Death of Mr. T. S. Baf/les, Stipendiary Magistrate.
Much regret was felt by all members of the medical
profession when they heard of the death of Mr. Thomas
Stamford Rallies, for nearly thirty-one years the stipendiary
magistrate of Liverpool. During chat period many thousand
cases where medical evidence has been required have been
before him, and his attitude towards medical witnesses has
always been extremely affable and courteous. He was
always most considerate in releasing them from attendance
as soon as possible, and was instrumental in securing them
payment in non-committal cases.
The Annual Meetings of the Hospitals.
During January and February the annual meetings of
most of the medical and other charities are held. With
the exception of the Royal Infirmary these annual
meetings take place in the town hall, unnder the pre¬
sidency of the mayor for the time being. Those of the
Nortliern Hospital and Infirmary for Children have already
been held. The story is the same, slightly varied. The
Liverpool public are proverbially liberal and generous
to medical charities, even to the extent of munificence. Bub
tins is true cf only a part of the public. The population of
Liverpool is now'600,000, and it has been calculated that
the annual subscribers to all the medical charities would be
amply included in round numbers varying froxn 5000 to
10,000, leaving a very large number who subscribe nothing,
though well able to do so. This arises partly from
indifference, partly from a belief that anytliiog short of the
conventional “guinea” would not be acceptable. The
present mayor, Mr. J. B Morgan, has a scheme for
organUing a better support to the chaiities in future, which
it is hoped will be successful.
TIte Society for the Prevention of Cruelly to Cldldrcn in
Liverpool.
Liverpool has the proud distinction of having been the
first city to establish a society for the Prevention of Cruelty
to Cliildren. But there is a cruel irony in the fact that
it was nob established, even here, bill long after the estab¬
lishment of the Society for the Prevention of Cruelty to
Digitized hy <^ooQle
The Lancet,]
BIRMINGHAM —NORTHERN COUNTIES NOTES.
[Jan. 31, 1891. 279
Animals. Even now cruelty to children is regarded by too
many persons with much more indifference than cruelty to
a horse or dog would be. The local society is doing its best
to prevent one form of cruelty—the employment of young
children on the streets late at night by their unnatur^
parents for begging purposes.
Liverpool, Jan. 28tb.
BIRMINGHAM,
(From our own Correspondent.)
Scarlet Fever.
It is satisfactory to know that the recent severe weather
has produced a marked effect upon this epidemic. The
number of cases admitted during the past week into the
Fever Hospital was twenty-six only, while there were sixty
discharges. The total number of inmates was 311, which
appeared to be a large number, but when the epidemic was
at its height this was exceeded, on two occasions being
over 500.
The New General Hospital.
Considerable enthusiasm was manifested at the town’s
meeting held on the 29th inst. towards the furtherance of
the interests of this hospital. The amount already promised
•exceeds the most sanguine expectations of the promoters.
To ask for £70,000 from the public and to get it before the
first meeting is held marks an era in the history of local
charities. To the energetic action of the chairman, Mr.
J. C. Holder, the result is mainly due, while his efforts
have been assiduously seconded by the committee. It is to
be hoped that little time will now be lost in commencing
operations on the new site. Necessarily a work of this
magnitude must be protracted over some years. Abeginning
made with such zeal, however, augurs well for the future,
and commands confidence in the undertaking.
Children's Hospital.
The annual meeting of the governors of this hospital was
field on the 2Gbh inst., under the presidency of Mr. C. A.
Smith Ryland. Some interesting and elaborate statistics
were given as to the cost and administration in various
•directions. Among others it was shown that the average
detention rate during the last ten years was twenty-eight
days; the average death-rate 9'5 per cent. The number of
patients treated during the last ytar was hi,799, or 414
more than in the previous year. The income for the year
was £4413 and the expenditure £4510. The usual votes of
thanks were passed.
Hospital Sunday.
The annual meeting in connexioawith the periodical collec¬
tions was held on the 22nd inst., when the various officers
were elected, the Mayor being fi.ppointed chairman.
Birmingham, Jan. 27th.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
University of ’Durham.
I HEAR that at a Convocation held to-day the University
■of Durham resolved to institute two new degrees iu Sani-
faiy Science—viz., a Bachelorship and Doctorate in Hygiene.
I have not yet heard upon what terms these degrees are to
be granted,'but no doubt full particulars will soon bo issued.
3n the alterations of existing rules no degree of Doctor in
Hygiene shall be granted unless the petitioner is a Bachelor
iu Hygiene, and has, subsequently to the date of his acquir¬
ing the degree of Bachelor in Hygiene, been engageil for
two years in practice as medical officer of health, and shall
have passed such examination as the warden and Senate
shall require.
The Newcastle lliroat and Ear Hospital.
The Newcastle charities are commencing their annual
meetings, and the Throat and Ear Hospital is one of the
first to report upon last year’s work at the meeting held
on the 23rd inst,, the Mayor presiding. It was stated
that the new cases entered were 1948 ; treated at the
Surgical Home, 153; old cases under treatment, 41.5: making
together 251G cases treated. The patients had contrihuted
X31G. There had been an increase in the subscriptions and
donations, but as the year’s work had involved increased
expenditure there was a small balance due to the treasurer.
Sir J. Crichton Browne on ‘‘Brain Rtwf.”
Sir .T. Crichton Browne lectured in Newcastle last night
on “Brain Rust.” Dr. Frederick Page, surgeon to the
Royal Infirmary, presided. There was an immense audience,
at least 2000 people, who listened with rapt attention to
the eloquent and learned lecturer. He mentioned his own
well-directed efforts against brain pressure and its resulting
evils to the brain and general health, when the body was in
an immature and youthful condition; but warned his
audience, on the other hand, of the evil effects of torpor or
misuse of the brain comprised in the term “brain rust,”
and instanced his own experiments on the brains of duc^
in illustration. He showed that, while the wild and tame
duck were incontestably the same, the brain of the wild
duck was absolutely heavier than that of the domestic
duck, and in proportion to its body nearly twice as heavy.
He thought that no one would hesitate to attribute the
diminished size and arrested development of the domestic
duck’s brain to the influence of domestication; few calls
had been made on its intelligence; it had not its energies
invoked by a free existence, and it had been dragged through
eighteen centuries to a lower level. Of this eliWt in man
be gave many instances, including the ill effects on the
minds of boys through lack of stimulus; andalso the baneful
effects of solitary confinement on prisoners, believing that
to shut an habitual malefactor within his own meagre,
narrow, and depraved thoughts could only aggravate his
viciousness and weaken his self-control. In the maximum
period of three days’ solitary confinement, and on bread-
and-water diet, prisoners lost on an average from 21b. to 31b.
in weight. He anew no surer method of producing prema¬
ture senile decay than for a man of active habits to retire
and do nothing when just past the zenith of life; and, on the
other hand, he did not know a surer way of enjoying green
old age than to keep on working to its close.
I learn that the Lord Chancellor has accepted the
nomination of Mr. C. Clark Burman of Alnwick as deputy
coroner for North Northumberland.
No\vcastle-on-Tyne, Jan. 27tl).
SCOTLAND.
(From our own Correspondents.)
EDINBURGH.
Royal Hospital for Sick Children.
The thirty'Second annual meeting of the contributors to
this hospital was held on Monday. The report stated that
during the year the number of patients treated was 7811, of
whom GIO had been treated in the wards, 6561 in the dis¬
pensary department, 487 as outside surgical cases, and 163
children had been vaccinated. The income (exclusive of
legacies) was £.3921, which was a decrease of £284 compared
with the preceding year. Reference was made to the out¬
break of typhoid fever in the hospital and the removal
of the patients and staff to Morningside. The change to
the fresher and purer air of the suburbs had been much
appreciated by the nurses and patients. Clinical lectures,
which had been interrupted, have been resumed, and the
directors have sanctioned female students obtaining in¬
struction in the hospital on the condition that it be at a
different hour from that for the male students.
The City Hospital.
At the meeting of the Edinburgh Town Council last
week, Bailie Russell, M.B., referring to the typhoid epi¬
demic, said it was decreasing, but that it liad shown that
tiie city hospital was not large enough for the needs of the
city, for at present there was hardly room for another
patient in it.
Mcdico-Chiruryieal Society.
At the meeting of this Society last week several patho¬
logical specimens were exhibited, after which Dr. Halliday
Groom made a communication on some Recent Work in
Abdominal Surgery, in which he reviewed llie results of
treatment in a large number of his own cases. This was
followed by a paper from Dr. Harvey Littlejohn on an Out¬
break of Typhoid Fever, in which the source of infection
was traced to a dairy farm. Both papers gave rise to con¬
siderable discussion.
Dig:../ed by Google
280 Teib lancet,]
SCOTLAND.—IRELAND
Jan. 31,1891,
Scottish Microscopical Sodcty,
The fourth meeting of this Society was held in Edin¬
burgh on the 16th inst., Professor Ilutheiford, F.R.S., in the
chair. The President referred to the loss the Society had
sustained by the decease of one of its vice-presidents, Mr.
Adolf Paul Schulze, a native of Saxony, who settled as a
merchant in Glasgow, and devoted his leisure time to
microscopical optics, more especially to photomicrography,
in which he acquired very remarkable skill, his article on
the subject in the Bntish Journal of Photography for
May 24th, 31st, and June 7th, 1889, being one of the beat
expositions of the practice of that difficult subject that has
yet appeared. Mr. G. W. Watson, L.D.S., made a com¬
munication on pathology of dental caries, vi-hich was
illustrated by sections and photographs of carious teeth
prepared by himself,^ and which were shown on the screen
with the oxyhydrogen microscope; the destruction of
dentine by the growth of micrococci and bacilli in the
tubules was clearly demonstrated. Mr. James Hunter,
F.R.C.S.Edin., gave an interesting lantern demonstration
of the properties of simple lenses, some of which had been
devised by himself. Professor Macfadyean, B.Sc., gave an
account and a demonstration of the morphology of actino-
myces.
Health of Edinburgh.
The mortality last week was 90, and the death-rate
19 per 1000. Diseases of the chest accounted for 35 deaths,
and zymotic diseases for 15, of which 2 were from typhoid
fever, 1 from diphtheria, 3 from scarlatina, and 9 from whoop¬
ing-cough. The intimations for the week were from typhoid
fever 15, diphtheria 6, scarlatina 31, and measles 10.
Edinburgh, Jan. 27th. _
ABERDEEN.
Aberdeen University Court.
At a meeting of the Aberdeen'University Court held on
Friday, 23rd inst., the Marquis of Huntly, Lord Rector,
presiding, Dr. Angus Fraser raised the question as to
whether the court had not the power to appoint all
examiners and lecturers. Ail were agreed that it was the
duty of the Court to appoint examiners, but there was con¬
siderable doubt with regard to the appointment of lecturers.
The question came before the Senatus in the case of the
appointment of the next Gifford lecturer, and a communica¬
tion from that body was read at the meeting, requesting
the University Court to join them in obtaining the opinion
of counsel as to the right under the Act of 1889 of electing
the Gifford lecturer. In discussing the question Dr. Fraser
suggested that it might be well to have the opinion of
counsel upon the point; but it was ultimately agreed, on
the motion of Mr. Edmond, “ That the Court communicate
with the Courts of the other Universities with the view of
arriving at a common understanding as to the respective
rights of the Courts and Senabus of the Universities to
appoint examiners and lecturers, and especially the Gifford
lecturer.”
Students’ Representative Council.
A statutory meeting of the Students’ Representative
Council was held at Marischal College on the 24th inst.
A considerable amount of routine business was transacted,
and it was also agreed that the council should offer to the
University Court to conduct all the arrangements for the
rectorial address on March 6bh, as was done by the Council
in 1888, provided the University Court paid the neces¬
sary expenses which were on that occasion paid by the
Senatus.
Koch’s Treatment of Tuberculosis.
Professor Smith Shand and Dr._Blackie Smith, physicians
to the Royal Infirmary, have procured a supply of Koch’s
liquid, and in their wards several cases of lupus and
phthisis are being treated. So far the results have been
characteristic and, on the whole, satisfactory.
Health of the City.
During the week ending Saturday, 24bh inst., the follow¬
ing cases of zymotic diseases were notified to Professor
Matthew Hay, the medical officer of health : Measles, 1;
scarlet fever, 16; diphtheria, 2; whooping-cough, 2. In
his report for the mouth of December Dr. Hay states that
the death-rate was 20'48, as against the average of 22-52
for the same month during the past ten years ; it is also
lower than in any individual year except 1888. About thm
time last year tie directed attention to the exceptional
prevalence at that period of puerperal fever. In hia
present report he says he regrets to have again to note
a recrudescence of this disease. During the month
there were five deaths from puerperal fever—an unusually
large number, seeing that the total number for a whole
year is usually not beyond six or seven.
Aberdoen Jan. 28bh.
IRELAND.
(From odr own Correspondent.)
British Medical Association: Dublin Branch.
The fourteenth annual meeting was held last week at the
Royal College of Physicians. The annual report of tho-
Council, which referred to the admittance of Irish graduates
to English hospital appointments and the condition of
army medical officers, was adopted. The new President,
Dr. Walter Smith, delivered an address which dealt with
the administration of hospital extern departments and
their special importance as a means of developing in the
best manner the education of students. The following
resolution, proposed by Dr. Atthill and seconded by Mr.
Horne, was adopted :—“ That in the opinion of this Branch
the registration of mid wives as proposed by Parliament will
not tend in any marked degree to render more efficient the
nurses practising as midwives, unless steps be first taken to
improve their eaucation ; that the question of registration;
be postponed till it is shown that facilities exist for the
education of such women as may desire to practise as mid¬
wives, and that the proposed registration of all women at-
present practising as midwives would be a most dangerous
proceeding. This Branch is further of opinion that any
legislation on the subject of improving the education or
status of midwives should not be undertaken without
serious consideration, and desires to urge on the Govern¬
ment the necessity of having it referred, in the first in¬
stance, to a select committee for consideration and report.’"’
The annual dinner took place the same evening in the hall
of the College of Physicians.
The Rights of an Unborn Infant.
In the Queen’s Bench Division judgment was given last
week in the case of Mrs. Walker v. the Great Nortberr>
Railway Company, which involved an important point—
viz., the rights of an unborn child. The plaintiff was &
passenger in the excursion train that was wrecked last
year at Armagh, and was enceinte, the child being born
deformed. She alleged that the child which she was carry ¬
ing at the time of the accident was injured, and as a result
was born deformed. The railway company, by counsel,
demurred, alleging that an unborn child had no right of
action or interest to recover damages for personal iniuries..
The plaintiff’s case was lost, the demurrer being allowed.
It may be mentioned that a sum of £800 had already been
given to the mother by the company as compensation for
injuries received by her.
City of Dublin Hospital.
The patient whose lingual arteries Mr. Croly tied as a
preliminary step to excision of. the tongue, referred to last,
week in these columns, died suddenly while incautiously
sitting up in bed to eat.
Magrath, the Irish Giant.
Professor D. J. Cunningham this week read a paper at-
the Royal Irish Academy on the skeleton of the Irish giant-
Cornelius Magr-ath, at present in the museum of Trinity
College. He Ijelieves it was a case of acromegaly, there
being undue development of various portions of the
skeleton—viz., abnormal size of the liands, feet, and lower,
jaw, which projected greatly below the upper jaw, while
the head itself was not in equipoise with the vertebral
column, and in this respect resembled the negro head.
Magrath’s height was said to be 7 ft. Sin., but Professor
Cunningham, from a careful examination of the skeleton,
believes it was 7 ft. in.
Mr. Michael Joseph Bulger has been elected assistant
surgeon to the House of Industry Hospitals.
Jan. 27th.
Diglii-ad •'■/
The Lancet,]
PARIS.—BERLIN.
[Jan. 31,1891. 281
PARIS;
(From our own Correspondents.)
Treatment of StrictvAres of the Ileo-ccccal Valve.
At a recent meeting of the Academy of Medicine M. P6an
made a communication on the Operative Treatment of
Strictures of thelleo-csecalValve. Stricture of this vaive was
rare; the speaker had met with but eight cases. They might
bedivided into two main divisions—those of an inflammatory
origin and those of a neoplastic origin. M. P6an had devised
o,n operative procedure which consisted in creating, without
the removal of any part of the bowel, a dilatation at the
■exact seat of stricture. Having incised the abdominal
wall above Poupart’s ligament, the neighbourhood of the
valve is quickly reached. The adjacent portions of large
and small intestine—that is, on each side of the valve—are
then ligatured. Next, an incision is made into the ileum and
cajcum respectively above and below the valve. The valve
being thus brought into view is itself resected in such a
manner and to such an extent as to render the strictured
portion again normally patent. This done, the extremities
of the intestinal wound are brought together so that the
ileum and cnocal incisions may be in close juxtaposition and
next sutured. The abdominal wound is treated in the
ordinary manner. M. P6an bad recently operated in this
way in two cases, which gave excellent results. The
advantages be claims for the method are: that it serves
•squally well for inflammatory strictures of the small intes¬
tine as for those of the emeum and ileo-cmcal valve; that it
presents none of the inconveniences arising from an artificial
anus; that it is comparatively easy of execution; that it '
requires fewer sutures than a resection, which lessens the
length of time required for the operation and diminishes
•the chance of perloration, fmcal listula, and septic peri¬
tonitis ; that it runs no risk of leaving a circular stricture,
as follows sometimes after resection; and that, finally, it
•establishes in the place of the stricture a passage sufli-
ciently largb for fascal matters to pass freely.
Action of Betinol on other Substances.
M. Vigier communicated at a recent meeting of the
Therapeutical Society some observations on the power of
retinol to dissolve various substances ordinarily insoluble.
He dwelt especially on its property of dissolving phospharen,
a substance for which it was difficult to find an excipient.
Retinol he found to act admirably in this way, and being
unoxydiaable the solution remained unaltered. Thus a
email piece of burning phosphorus thrown into a solution of
retinol was at once extinguished. He pointed out that the
preparation of phosphorus thus prepared could be adminis¬
tered with advantage. perhaps in rickets, scrofula, anmniia,
■cblorosis, locomotor ataxia, occ. Amongst other substances
which retinol will also readily dissolve are salol, iodol,
oiaphthol, avistol, cocaine, &c.
A New International Clinique.
Seeing that the giving of medical assistance to the various
foreigners of all nations who inhabit this city was no special
part of the State system of medical relief, a number of
medical men have formed themselves into a society called
rihe Society of Medical Assistance to Foreigners, for the pur¬
pose of (1) organising a system of hospital relief to all
foreigners, (2) to give them gratuitous consultation, and
<3) bo take advantage of the clinical material which will be
thus collected bo give practical instruction in all the branches
of medical art. This establishment, it is hoped, will meet a
great want in this cosmopolitan city, and will, it is trusted,
form the basis of an international Parisian hospital. The
Society is already assured of the hearty concurrence and
assistance of a number of French and foreign notabilities.
The Siege of Mayencc.
The Archives of Military Medicine recently gave an
'interesting account of the medical history of this siege in
1793. The medical oflicer in charge of the hospital says:
“On the nth of April there was a dreadful cannonade.
Amongst the number brought us with enormous wounds—
and the number was not inconsiderable (in less than
an hour, eight for various amputations)—was a little
volunteer with great courage, albliougli suffering terribly.
I ordered that he should be undressed while I went
round the ward to glance at the various operations
which the assistant surgeons were performing. Iveturuiug
to him with Citizen Bivibre, who was to .perform the
operation, we perceived an enormous lower limb, enormous
from the unusual amount of swelling. Manipulating the
limb, we came across a bard swelling, which we took to be
caused by a grapeshot ball lodged in the limb. Our
astonishment was great when we found that an incision
of five or six fingers’ breadth was insufficient to extract
this enormous foreign body, which, on being finally got out,
turned out to be a Prussian ball weighing no less than
131b,! How could a mass of this size have just the
amount of force necessary to lodge in a thigh and not pass
through it 1 This problem I leave to natural philosophers,
but I admit it to be almost necessary to have seen such
things to believe them. Of course there was nothing for it
but to operate on this poor fellow or leave him to certain
death; we therefore amputated high up. When we had
finished he asked if it was done, and on being told that it
was, he cried out loudly, ‘Long live the nation !’ Anms-
thetics had not then seen the light, it must be remembered.
On another occasion the firing of a mine caused a tremendous
explosion, which shook the hospital building terribly. At
that moment I was engaged amputating the limb of a
soldier. As I was sawing the bone amidst the general con¬
fusion caused by the first shock, a second occurred which
brought down the whole of a glass skylight over the patient
and myself. Not knowing whence all the glass came,
I asked those standing round what was the matter. The
patient overheard me, and said, ‘Go on, don’t alarm
yourself, you will see plenty of this kind of thing.’ When I
had finished the operation he cried, ‘ Vive la R6pub]iqu6! ’ ”
Pari.s, Jan. 27th.
BERLIN.
(From our own Correspondent.)
Koch’s Remedy at the Medical Societies.
During the past week the medical societies have been
more than ever occupied with Koch’s treatment; demon¬
strations, papers, and discussions upon it have taken place
at the Society for Internal Medicine, at the Medical Society,
the Society of the Charit6 Iffiysicians, and the Hufeland
Society. At the first-named society, Dr. Guttmann exhibited
the intestine from a case at the Moabit Hospital, where
twenty-five injections had been given before death occurred.
The intestine showed marked healing of the tuberculous
ulcers; they were free from caseous masses, the bases
and margins being quite clean. In this situation the tissue
destroyed by Koch’s remedy could be wholly removed. The
proceedings in the Medical Sooi*'ty are fully reported in the
Berliner Klmische Wochonschriff, ‘ The discussion occupied
the whole evening, and was most attentively listened to,
the chief speakers being Drs. Ewald and James Israel;
whilst Professor Virchow showed specimens of miliary
tuberculosis from a case of pleurisy treated by this method.
At the Society of the Charitd Physicians Drs. Senator and
Sonnenberg were the speakers. They both showed some
interesting cases. Senator’s case was that of a young lady
with very marked infiltration of one apex, in whom, in spite
of the effect of high doses (commencing at 0-003 grm.),
rapidly increased (in twelve days up to 0-1 grm,), not the
slightest rise in temperature occurred, although the lung
affection retrogressed. During the treatment some laryngeal
disease arose, but this gradually disappeared. The
pulmonary signs, at first so favourable, had latterly shown
some tendency to get worse. Sonnenberg reported on five
patients in whom ho had opened cavities before commencing
the treatment by injection. Three of the patients were
apparently cured, and he exhibited them before the Society.
In one of them there could he seen below the right clavicle
a small pulmonary cavity which appeared to be in course of
contraction. Sonnenberg’s fourth patient showed no im¬
provement; the fifth was operated on only a short time since.
Sonnenberg had the opportunity of comparing a patient
whose pulmonaiy cavities had been opened, and who wm
not; inoculated, with those who wore inoculated, and could
affirm that in this the changes in the cavities do not take
place. He spoke of the great difficulties in formulating
indications for such operations, but thinks that eventually
this will occupy a wide field in the treatment of tuberculosis.
One view depends on wliether, with the destruct ion and
1 This is fully abstrarteil in another column.
Google
282 The Lakcet,]
VIENNA.—CANADA.
[Jan. 31,1891.
shrinking of a cavity, tuherculoeis ia made to disappear from
the organism. In the Hufeland Society Dr. Heymann
brought forward a patient in whom the ulceration of tlie
larynx had extended very much, but at the same time
stated that he had in the rest no more striking features,
but also no cures. Dr. Hanseraann, Virchow’s assistant,
then spoke, clearly and lucidly, upon his pathological and
histological experiences in the treatment by Koch^s liquid,
and explained bis remarks by a demonstration of macro-
scopical and microscopical preparations. Hanseniann
agreed in the main with Virchow’s well-known state¬
ment, but emphasised still more plainly the injportant
proposition that after the increase of necrosis in the
lungs the unaffected tubercle bacilli must be absorbed and
thereby propagated, to the great danger to the patient.
The speaker summarised the position in the followiog
terms :—The condition which is excited by the injection
of Koch’s remedy is curable. Still, the method may doubt¬
less destroy life. The remedy does not destroy all the
tuberculous tissue, and even if this be destroyed the
organism may suffer severe changes from its reabsorption.
Berlin, Jan. 24th.
VIENNA.
(From our own Correspondent.)
Koch's Treatment,
Koch’s second publication has caused considerable sur¬
prise in medical circles, and especially the first passages of
bis paper in which all the publications made by clinical
observers on the action of the remedy were ignored, lie-
collecting the statement of Minister von Gossler, that the
preparation of the remedy could not be described (a unique
statementinviewofthegreatadvancementof natural science),
the physicians were somewhat astonished by the simplicity
of the preparation of Koch’s liquid, the more so as Koch
was found to be following the directions initiated by
Pasteur’s school, and by the worksof thelate Dr. Wooldridge,
Hankin, and others, without mentioning even the names of
his scientific predecessors. It must be assumed that Koch’s
second publication has not been less premature than his
first one, and that it has been provoked by Virchow’s
reports. Tlie effect of suggestion on the subjective sym¬
ptoms in patients could not be better illustrated than in
the recent era of Koch’s treatment. At first it was rare to
find a patient subjected to the cure who did nob feel better
at least in some way after the injections; but after Virchow’s
publication, wliich has been widely circulated by the lay
press, the majority of patients in the General Hospital com¬
menced tqcomplainof different new subjective troubles which
were ascribed by them to the action of the liquid, and tliere
were frequently cases where the patients, formerly highly
enthusiastic, declined to be treated further by Koch’s
method. Certainly the General Hospital, with its constant
pressure of space, has not been a suitable place for such an
extensive trial as has been made here at the clinics,
where about 30 per cent, of the beds were allotted to
tuberculous and lupus cases—that is, to cases which
would nob have applied for admission to hospital wards
under ordinary circumstances. It cannot be said that
any case has been cured by the treatment, bub it
must be stated that improvement has taken place
in some of the cases of surgical tuberculosis. New
eruptions of lupus nodules have made their appear¬
ance in Professor Kaposi’s improved cases. There is also
a difficulty in the improved cases as very large doses (5 centi¬
grammes and more) do nob produce any reaction, and one
does not know how far the dose of the iDjection can be
raised. It is extremely difficult to say anything about the
pulmonary cases. It seems that there are two different
types. In one of them the temperature curve rises after
every injection corresponding to the reaction, bub returns
to the previous level; while in the other the tem¬
perature curve does not return to its former level,
and the patients remain feverish after the reaction has
passed. The latter type is the leas favourable for
the treatment, and to it belong most of the fatal
cases. Not leas difficult is the explanation of ti)e
anatomical facta, as the pathological changes occurring in
the course of tuberculous disease have not been fully
recognised till now, and there is no other disease
which has been more neglected by pathologists on the
Continent on account of its frequency. But in slight
cases of lai-yngeal tuberculosis, where the changes could
be observed clinically by the laryngoscope day by day,
it could be stated that the injections of “ Kochln” caused
the rapid and extensive appearance of new ulcerations,
sometimes of highly destructive tendency, and at the
last meeting of the Medicinisches Doctorencoliegium a
case was shown where the ulcerative process occurring after
the injections was an extensive one, which has never
been observed by any of the Viennese professors. These
observations seem to corroborate Virchow’s statement that
a dissemination of the tuberculous virus takes place
in the body due to the injections, lleferring to the dia¬
gnostic value of the fluid, it has been reported already to The
Lancet that it produced local and general reaction in cases
of leorosy, actinomycosis, and fever (with small doses, one
to two milligrammes) in apparently healthy persons. The
explanation of the action of his liquid given by Koch in
his recent publication was also not believed to be satisfac¬
tory in medical circles here. It seems to me that the
specific action of the liquid must correspond to a specific
chemical substance contained in the mesoblastic tissues
under certain pathological conditions—e.g., tuberculosis;,
lupus, lepra, actinomycosis,—and Koch’s discovery will
certainly stimulate the hitherto neglected study of
pathological chemistry. At present wo know only a
single chemical substance peculiar to tuberculosis—viz,,
cellulose, or at least a substance exhibiting all the reactions
peculiar to cellulose, which was discovered some years ago
in the blood and in the tissues of tuberculous cases by
Dr. Freund of Vienna. This discovery, reported in Tiiie
Lancet of 1887, confirmed later by Dr. Kabrhel of Prague,
and which is also highly interesting from the naturalist’i*
stand-point, did not receive much attention.
Vienna, Jan. 26tb. _
CANADA.
(From our own Corre,sp(>ndent.)
Koch’s Liquid.
Ul’ to this date the only hospital where Koch’s fluid
being used in Canada ia the General Hospital, Montreal,
where seven patients are under treatment.
Amalgamation of Medical Teaching Centres.
Thevexed question of the amalgamation of the Montreal
Branch of Laval University with Victoria Medical School
has at last been amicably arranged and settled by ttie
passage of a Bill through the Quebec Legislature. It»
quietus was a cablegram from the Pope to Premier Mercier.
Medical Rennions.
The fourth annual banquet of the Toronto University
Medical College was held on the evening of Dec. 4th, aoin©
2r>0 guests being present. The Chancellor, replying to the
toast of “Toronto University,” compared it to a sturdy
oak, whose growth, lacking in symmetry, preserved th©
elements of strength and at the same time peculiarities in
its constitution which time alone could remedy; the dean.
Dr. W. T. Aikins, advocated the founding of a chair in
Sanitary Science.—Tiinity Medical School held its annual
dinner on Dec. 5bh. The attendance was large, many of it&
graduates, in happy reunion, drinking to the prosperity of
their alina mater.
Malignant Cutaneous EpithcUomaia.
Dr. Ilohinson of New York read a paper on this subject
before the Toronto Medical Society, at the regular meeting”
on Dec. 17th. Discussing more particularly tbe treatment,
he has found arsenious acid in the form of a paste more suc¬
cessful in many cases than the knife, scraping, or caustics.
Post-graduate Lectures.
■ The most interesting event in medical circles during the
mouth of December was a series of post-graduate lectures
and denionstvatioDs given under the auspices of the Univer¬
sity of Toronto The attendance of praolitioners from,
without the city was largo, and testified to the appreciation-
of the efforts of the Medical Faculty in this new lieparture.
The chief features of the programme were lectures by men
of prominence from the United States, one of whom, Dr. A.
II. Robinson of New York is a graduate of the University.
He delivered two lectures on Eczema—Cal arrbal Dermatitis..
Dr. Abbe, New York, delivered three lectures, the subjecta
'ed by CjOO^IC
The Lancet,]
EOYAL COLLEGE OF PHYSICIANS.
[Jan. 31,1891. 283
being (a) the Limitations of Spinal Surgery; (2>) Mas¬
toid Pyeemia, Jueular Thrombosis, Ballance’s Operation;
<c) Technique of InteBbinal Anastomosis. Perhaps the most
important sulnect for the general practitioner was that
discussed by Dr. Vaughan, of Ann Arbor University, of
Typhoid Fever. Certainly great interest centred in the
address delivered by Dr. J. W. White (Philadelphia) on
the Present I’osition of Antiseptic Surgeiy, a reply to Mr.
Tait’s recently published criticism of Sir Joseph Lister’s
Berlin address. It was a careful review of the progress
and development of the Listerian treatment, the results of
its adoption in the practice of leading surgeons, and a dis¬
cussion at some length of Mr. Tait’s arguments and
reasonings. The other lectures of the course were given by
local practitioners. It is to be regretted that so many lec¬
tures should have been crowded into the brief space of
three days, partaking of the nature of a medical revival.
The Pathologicai Society.
This Society held its regular meeting on the evening of
Dec. 18th. Dr. Robinson (New York) read a paper on
Psorospermosis Follicularis Vegetante. Specimens were
•exhibited of Paget’s Disease of the Breast; Cirrhosis of
Liver and Suppurating Mesenteric Glands, in a case
aimulating Typhoid Fever; a Dermoid Cyst of the Orbit
and Recurrent Sarcoma of the Orbit.
Toronto, Jan. Ist.
THE SERVICES.
Naval Medical Service. — The following appoint¬
ments have been made at the Admiralty:—Surgeons: Geo.
T. Broatch to the Duke of Wellington (datea Jan. 22Qd,
4891); Robert Hardie to the Defiance (dated Jan. 24th,
1891); John Grant to the Firebrand{fizAoA Jan. 27bh, 1891);
and Alfred E. Weightman to the Duke of Wellington,
^additional (dated Jan. 12th, 1891).
YjiOMANRY Cavalry. —Lanarkshire (Queen’s Own Royal
Glasgow, and Lower Ward of Lanarkshire): Surgeon and
Honorary Surgeon-Major R. D. Reid, M.D., resigns his
commission; also is permitted to retain his rank, and to
•continue to wear the uniform of the Regiment on his retire¬
ment (dated Jan. 24th, 1891).
Volunteer Corps. — Artillery: Ist West Riding of
Yorkshire (Western Division, Royal Artillery); Acting
Surgeon W. Gay, M.D., resigns his appointment (dated
Jan. 28bh, 1891).—1st Gloucestershire; Surgeon and Sur¬
geon-Major (ranking as Major) T. S. Ellis resigns his com¬
mission : also is permitted to retain his rank, and to con¬
tinue to wear the uniform of the Corps on his retirement
<dated Jan. 28th, 1891); Acting Surgeon T. M. Wilkinson
resigns his appointment (dated Jan. 28tb, 1891).—2ad Hamp¬
shire (Southern Division, Royal Artiilery):—Acting Surgeon
J. Hill resigns his appointment (dated Jan. 24th. 1891).—
Royal Engineers: IsbDarham: Acting Surgeon W. Munro
Jenning.s is ^pointed Second Lieutenant (dated Jan. 6th,
1891).—The lyne Division : The services of Surgeon R. K.
Tait are dispensed with (dated Jan. 24bh, 1891) —Ist Lanark-
ehire: Robert Cowan Lees, M.B., to be Acting Surgeon
<dated Jan. 24th, 1891); Acting Surgeon M. F. Anderson,
M.B., resigns his appointment (dated Jan. 24bh, 1891).—
Ist Volunteer Battalion, the Essex Regiment: Surgeon A.
Wright is granted the rank of Surgeon Major, ranking as
Major (dated Jan. 24th, 1891).
W. ORLANDO MARKHAM, M.D., F.R.C.P.
Tub announcement of the death of Dr. Markham, whicli
took place at Clapbam Common on the 23rd Inst., will
awaken but few memories in the minds of the younger
members of the profession, i^’or a good many years past
his name even will have been unfamiliar, save to those
whose professional work lay for the most part amongst the
sixties and seventies of the present century. He was, how¬
ever, a man of striking ability and originality, and his book
on Diseases of the Heart marked a distinct advance in
knowledge, and may, with his papers in the Medico-
Chirurgical Transactions on points in Cardiac Physiology
and Pathology, be still read with profit. Being possessed
of ample means, and his health breaking down, he retired
early from active professional life, but be long continued to
take a keen interest in medical matters. Dr.
was bom in 1818, and waa the son of Charles Markham,
formerly clerk of the peace for Northampton. HU pro¬
fessional studies were carried on in Edinburgh, ParU, and
Heidelberg, and in 1840 he obtained the M.D. Edin. In
1854 be was elected a Fellow of the London College of Phy¬
sicians, and delivered the Goulstonian lectures in 1864.
Two years thereafter he was selected by Mr. Gathome
Hardy as medical inspector under the Poor-law Board, of
which be was also medical adviser. Dr. Markham was for
some years physician to St. Mary’s Hospital, Paddington, and
lecturer at the school, and was from 1860 to 1866 editor of
the British Medical Journal.
SENATOR G. B. BORELLt.
On Saturday, the lOtb inst., after a long and severe
illness, died at Cuneo in Piedmont the Commendatore
Dr. Giovambattista Borelli, Senator of the Kingdom of
Italy. Born at Boves in the province of Cuneo in August,
1813, young Borelli followed up bis classical studies at the
University of Turin by enrolling his name in the medical
school, and after a brilliant academic course graduated in
medicine and surgery. He was shortly thereafter nominated
^iinaris in the Hospital of SS. Maurice and Lazarus.
There he laid the foundation of that clinicaJ accomplish¬
ment which was ere long to place him in the front rank of
Italian oonsnltants, and which seemed enlarged and refined
rather than diluted and weakened by his studies in those
physical and natural sciences of which he was passionately
fond. His masculine power of work and his philosophical
love of sound generalleation made him singularly popular
with the successive relays of students who for nearly
forty years repaired from all parts of Italy to bis sur¬
gical ciinique. His fame spread beyond the Italian
frontier, and numerous learned bodies, foreign as well as
domestic, elected him Honorary or Corresponding Fellow. In
America particularly be had many admirers, who classed
his work, expository and operative, on the lesions of the
genito-urinary organs with that of Marion Sims. His
publications were frequent and in great request with the
profession in Italy, those on the Hernias, on the Angular
Ankyloses of the Knee, on Nasal Polypus, and on Tumours
of the Mouth, still retaining authority even with the gene¬
ration that succeeded his own. He competed for the gold
medal offered by the Medical Society of Toulouse on Iodine
Injections, ana gained the prize from many able com¬
petitors. Another distinction ne won from France was that
of the Cross of the Legion of Honour, for surgical services
rendered to the French wounded in the campaign of 1859,
at the battles of Palestro and Magenta. “John Baptist
Borelli,” writes an Italian correspondent, “was a man of
iron will, with an intelligence luminous and serene, and
with a soul ever ardent and young. As a citizen he was
devoted to bis native land, and his fellow townsmen, reco¬
gnising in him the qualities of the publicist and the legis¬
lator, elected him as their representative in the Parliament
of Italy. For some time, however, he withdrew from the
political arena, but in 1876 he re entered Parliament, this
time for the constituency of Fossano, which be represented
with liberal enlightenment and statesmanlike ability tiU
J881, when he was created a Senator of the Kingdom. In
him the country loses a man of great worth, a savant of
high reputation, a politician of weight, one of the most
revered of its senators, and one of the most independent
and upright of its sons.”
ROYAL COLLEGE OF PHYSICIANS.
The ordinary Comitia of the College of Physicians was
held on the 29 Dh inst., the President, Sir A. Clark, Rirt., in
the chair.
In opening the proceedings the President made a graceful
allusion to the honour conferred by Her Majesty upon one
of their most distinguished Fellows, Sir Richard Quain,
Bart.
The following gentlemen were admitted Members of the
College:—H. J. Campbell, M.D. Lond.; E. C. Carter,
M.B. Edin.; E. L. Fox, M.D. Camb,; H. G. Turney,
M.B. Oxon.
Communications were read from the University of
London and the secretary of the Royal College of Surgeons,
Di; zed by CjOO^IC
284 The Lancet,]
MEDICAL NEWS.
[Jan. n, 18M.
and from the Medical Society of London. The last-named
referred to the alteration in the terms of the disposal of the
Fotbergillian Fund, and the Society asked the College to per¬
mit its President to act on the hoard for awarding the
prize. On the motion of Dr. C. T. Williams, seconded by
the Senior Censor, it was resolved to accede to the request
of the Society provided that the President be empowered to
invoke the assistance of one of the Censors if necessary.
The opinion of the College solicitors on the Bradshaw
bequest having been given, it was resolved to apply to the
Charity Commissioners to permit the College to change
the date of the delivery of the lecture.
A communication from Dr. itentoul was ordered to lie
on the table; and on the motion of Dr. Farquharson,
seconded by Dr. Priestley, it was resolved to appoint
a committee to watch the progress of the Midwives’ Begis-
tration Bill. The President nominated Drs. Farquharson,
Priestley, Douglas Powell, and Sturges.
The following Fellows were elected to serve on the
Council: Drs. W. H. Ransom, Tbos. Stevenson, C. T.
Williams, and Whipham.
Dr. C. T. Williams moved the following resolution:
“That it be referred to the Council to consider how far the
services of non-resident Fellows connected with provincial
medical schools can with advantage be made available for
the College examinations.” This was seconded by Dr.
Leach, warmly commended by the President, and carried
unanimously.
A report on certain mineral waters forwarded from Persia
by Dr. Carson was read. It was signed by Drs. H. Weber
and Burney Yeo, and was to the effect that all the speci¬
mens were mainly feeble sulphurous waters of no special
value.
The usual quarterly report of the Finance Committee was
read; also that of the Examiners for the Licence. On
the recommendation of the Committee of Management the
University of Adelaide was recognised as fulfilling the con¬
ditions of the Board for the complete curriculum of profes¬
sional study. Its graduates will therefore be admitted to
the Second and Final Examinations on the same conditions
as those of other recognised universities.
University of Cambridge.— At a congregation
held on the 23rd inst. the following degrees were conferred:
Bachelors o/Smyery and Werfitww.—tYeclerick Eustace Bitten, .Sydney
Nevill Harrison, and Frederick Cliarlea Martley, 'I'rinity ; Chas.
^bert Arnold Sutton, Clare ; .laiiie.s .Jenkinson Knox, Cavendish
Hostel; Edwin Webster Hardwick, non-collegiate.
University of Glasgow.— Tho following is a list
of gentlemen who have received the degrees of M.B. and
C.M. since the general graduation in July, leOO:—
Thomas Primrose Anderson, 1‘artick, (ilasgow ; Alexander Andrew,
Tarholton, Ayrshire ; Alexander Percy Agnew, Burnley, Lancashire ;
Thomas Berry, Langside, (Ilasgow ; .fames Cordiner, M.A., Losma-
hagow, Lanarkshh-e ; George Henry Kdington, Hillhuad, Glasgow ;
M^colm Gillies, Easdale, by Oban ; .fames Kirkwood, Greenock ;
Hugh j>ang, Wooilside, Ciirrtvoss, Humbiirtonshire; Georgo J.owson,
J)undee; Arthur Henry Lucas, Carinyle, near (Basgow ; ThmiiiLS
Dryden Mofl'at, Glasgow; Robert .lames Novin, West Aucklainl,
county Durham ; Douglas Wills Russell, Paisley ; William .fohii
More Wlowiin, Hilton, Kilinalcohu, llenfiewBliire; .fames .Sim
Wallace, B..Se., Shawlands, Glasgow ; .fames Alexander Wilson,
Langley Moor, Bmham ; .lohii /.uiil, M.A., Biiclilyvie, Stirling,
Royal' College of Surgeons in Ireland.—
P'ELLOWSHIP Examination.— The following gentleman,
having passed the necessary examination, has been ad¬
mitted a Fellow of the College:—
Patrick Joseph Murphy (Thoinastown, co. Kilkenny), L.R.C.S.l. ISSI.
and L.B.<;.P,I. 1881.
Children’s Hospital, Pbndlebury.— The medi¬
cal statement for the past year states that disease of the
digestiveorgans, the result of improper feeding and insanitary
conditions, directly or indirectly, was the most fatal of any
class of disease with which they had to deal, giving rise to
some 35 per cent, of the fatal cases of infants under two
years of age. With reference to infant insurance, it was
found, of the fatal cases occurring at the Dispensary, that
out of 213 cases in which information was obtained, 144
were in a club at the time of death, and 70 were not. Mr.
Wm. Agnew has announced his intention to endow another
cot with a sum of £1000. The financial position shows an
accnmnlated deficit amounting to £2300.
Superannuation Grant.— Mr. F. A. Willington,
M.R.C.S., lately medical officer for the district and work-
house of the Ecclesall Bierlow Union, has been granted a-
superannuation allowance of £80 per annum.
Bath Royal United Hospital.— The Mayor of
the borough on Monday opened the new Children’s Ward
of this institution. The buildings just completed form an
adciitional storey to the Albert Wing, and will accommo¬
date twenty beds. The cost is £2060, towards which
£1680 has been raised.
Football Casualties.—A t Gateshead, on Satur¬
day, whilst playing at football, a youth aged fourteen, in a
scrimmage, broke his right leg.—At a league match at
Sunderland, on the same day, between Sunderland and Notts
County, a Sunderland player, to score a goal, charged the
Notts goal-keeper, the latter sustaining a fracture of his
right leg.
Westminster Memorial Hospital, Shaftes¬
bury,—T he annual report for 1890 shows that the work
during the year was exceptionally heavy and expensive.
Twelve operations were performed in the hospital, and the
number of patients averaged six a week of five weeks each.
There were sixty-five patients during the year, making a
total of 846 since the hospital was opened. The endowment
fund now amounted to £3589. The income and expenditure
statement showed a balance in hand of £94 lOi-. 6a.
City of London Dispensary.—M r. F. P. Alliston
presided at the annual meeting held last week at
the dispensary. The institution was founded in 1789,
and continues to maintain its usefulness and efficiency.
During the year 11,865 patients received treatment, and
10,848 were discharged cured or benefited. The balance-
sheet of receipts and disbursements shows a sum of £221 in
the treasurer’s hands, but there were liabilities amounting
to £500.
College of State Medicine. — The following
gentlemen, having been duly proposed and seconded,
were elected Associates of the College at a meeting of
Council held on Jan. 22nd:—William Geo. Barras, M.B.,
C.M. Glas., L.y.8. Durh. Univ., Govan, N.B.; Robert
Oattley, M.B., CM. Edin., D.P.H. Camb., Monkgate,
York; Dr. Alexander Macindoe, D.P.H. Camb., Willough-
bridge. Market Drayton; Dr. William Francis Menzies,
B.Sc. Edin., County Asylum, Rainhill; Hamilton C. Reid,
M.B., C.M. Glas., D.P.H. Fac. P. andS. Glasg,, Coatbridge.
Metropolitan Hospital Saturday Fund. —
A largely attended meeting of the delegates of this Fund
was held at the offices, P'arringdon-street, on Saturday last,
for the purpose of considering a report relating to the office
staff and the salaries paid, which had been prepared by a
, special committee. Mr. Acland, chairman of the Fund, pre¬
sided. The committee reported that what was required was
one efficient person as secretary, whose duty should be to
direct the whole of the work, and make recoinmendations-
I as to the future office staff', which would effect a saving of
£300 ayear. On a motion for the adoption of thereport, a
long and desultory discussion ensued. Ultimately an amend¬
ment was carried, to the effect that so much of the report
as referred to the question of dual control should be ad¬
journed for six months. Meantime the secretaries should be
provided with sufficient clerical assistance.
Ojwtetrical Society of London. -The follow¬
ing list of officers for tlie ensuing year has been recom¬
mended by the Council:—President; Dr. Watt Black.
Vice-presidents; Drs. Percy Boulton, Cony (Belfast),
Hayes, W. A. Meredith, and Tapson; Mr. Evan Jones
(Aberdare). Treasurer: Dr. Ernest Herman. Chairman
of the Board for the Examination of Midwives: Dr.
Cbanipneys. Honorary Secretaries : Mr. Alban Doran and
Dr. Peter Horrocks. Honorary Librarian: Dr. William
Duncan. Other members of Council; Drs. Frederick.
William Coates (Salisbury), Charles James Cullingworth,
W. Radford Dakin, S. Houston Davson, John II. Galton,
Henry Gervis, Wiliam Lenton Heath, Joseph Johnston,.
Henry Ambrose Lediard (Carlisle), Henry Colley March
(Rochdale), Thomas Cargill Nesham (Newcastle-on-Tyne),
Joseph Henry Philpot, .John Baptiste Potter, iind Herbert-
R. Spencer; Messrs. Albert Charles Butler-Smythe, Henry
W. Freeman (Bath), G. R. Turner Phillips, and Harry
Speakinan Webb (Welwyn).
Dir z:^ 1: L_TOOgIC
The Lakcet,]
THE HOUSE OF LORDS’ COMMITTEE ON HOSPITALS.
[Jan. 31,1891. 2^5
The Animals’ Institute. — At a recent special
meeting of the Council of this Institute it was decided to
appeal to the public for subscriptions to enable them to carry
out their scheme of rendering aid to injured horses on
the London streets. They propose to have ambulance
caniages in available places, fully equipoed with necessary ;
appliances. Attention was specially called to the cruelty
of the practice of mixing salt with the snow on the streets.
Subscriptions and donations may be sent to the bon.
treasurers, Lady Florence Pelham Clinton and Lady
Frances Trevanion.
Presentations.—D r. Robert Lunan of Blair-
f owrie, Perthshire, has been presented, at a public meeting
eld in that town, on the occasion of his retirement from
the profession, with an illuminated address and a silver
dinner service, together with a diamond and pearl necklet
for Miss Lunan.—Mr. P. F. Sturridge, L.KC.P. Ed.,
M.R.C.S., has been presented by the railway employ6s at
the Kendal station with a silver-mounted umbrella, suitably
inscribed, in recognition of his services as lecturer to the
class in connexion with the St. John Ambulance Association.
The Metropolitan Hospital. — The annual
meeting of the governors of this hospital was held on
Wednesday at the institution, Kingsland-road. Mr. Joseph
Fry (chairman of committee) presided. The secretary
{Mr. C. H. Byers) read the fifty-fifth annual report of the
committee, which stated that the in-patients had increased
'from 489 in 1889 to 709 last year, and the new out-patient
cases from 9482, representing 16,411 attendances, to 14,104,
representing 23,074 attendances. In th^ provident depart¬
ment there had been 43,208 attendances. The receipts for
the year had amounted to £0132 and the expenditure to
£7528. To close up all the accounts connected with the
building of the present hospital the committee had been
obliged to borrow £6000 on mortgage.
Metropolitan Asylums Board.—A t the last
meeting of the board the announcement was made that the
admissions to the hospitals of the board during the last fort¬
night numbered 250, showing a decrease of 114 as compared
with those of the preceding fortnight. Mr. Mann was elected
secretary in place of Mr. Jebb, deceased.
National Association of Sanitary Inspectors,
YORKSHiiiii Centre. —The third annual meeting was held
at Leeds on Saturday. Representatives of upwards’ of
thirty sanitary authorities attended from all parts of
Yorkshire. The president, Mr. T. Pridgin Teale, occupied
the chair, and in his address congratulated the Association
•on its continued satisfactory progress. Of the public
matters which were of interest to the meeting, he specially
urged the adoption in Leeds of the Act for the Compul¬
sory Notification of Infectious Disease, which was sup¬
ported by other speakers. Mr. G. Paul, of Knareaborough,
read a paper on the relation of meteorology to public
health. An interesting discussion followed. Mr. Tarvis,
of Halifax, was elected chairman, in the place of Mr.
•James Chambers, resigned.
METROPOLITAN ASYLUMS BOARD.
Retvm of Patients remainvtuf in the several Fever Hospitals
of the Board at midnight on January S7th, 1891.
Hospital.
® b
"h
3 ^
M'S
1
£
il
ads oc
Is-
h
cupied
o
^ &
•gs
s-
Other
diseases.
Total J
6
1
o
H
Eastern Hospital .. . -
250
4.5
54
850
442
North-Western Hospital
209
35
8
812
448
157
10
10
1
ISIli
flouth-Westeru „
109
11
i
3
187
840
^outh-Eastein „
227
12
4U
1
280
402
Northern „
278
10
21
318
480
Gore Farm „
.88
-
:t3
800
Totals.
1389
138
2
148
107!)
2729
THE HOUSE OF LORDS’ COMMITTEE ON
HOSPITALS.
Tub Committee of the House of Lords, which was, appointed last
Session, met again on Monday lost to continue their mquliry. The
reference to the committee is to Inquire with regard to all hospitals and
provident and other public dispensaries and charitable institutions within
the metropolitan area for the care and treatment of the sick poor which
possess real property or invested personal pre^erty in the nature of en¬
dowment of a permanent or temporary nature, and to receive evidence
tendered by the authorities of voluntary insttiutions for like purposes,
or with their consent in relation to such institutions, and to inquire as
to what amount of accommodation for the sick is provided by rate and
as to the management thereof.
Lord Sandhurst, as before, presided, and the other members of the
committee present were—Earl Cathcart, the Earl of Arran, the Earl of
Lauderdale, Lord 8aye and 8elo, Lord Zouche of Haryngwoi-th, Lord
Thring, and Lord Monkawell.
Qvy's Huepital. '
Mr. Edward Luahington, treasurer of Guy's Ilospitill, was the first
witness examined. In reply to the Chairman, ho said he had been for
fifteen years treasurer of Guy’s, and previously to that he had been for
twenty-seven years in the Bengal Civil Service, in the financial depart¬
ment of the Government of India. Quy’s Hospital was founded, he
said, in about the year 1726, by a person named Guy, who made a will
in which he defined what, in his opinion, should be the constitution of
the hospital, and his will formed the basis of an Aqt of Parliament
passed In 1720 or 1727. The constitution was as follows; There were
sixty self-elected governors and a court of committees, consisting of
nineteen members, selected from amongst tlie governors; and if any
special necessity srose subcommittees wore appointed to deal with par¬
ticular matters. When he first became treasurer the sisters in charge of the
wards were not trained nurses. They knew little or nothing about their
duties when they came to the hospital, but learned them as they could.
The matron, the medical superintendent, the chaplain, and assistant
physicians and surgeons were elected or dismissed by the general body.
The matron, whose duty it was to go round the wards every day, recom¬
mended to him the appointment of the sisters when a vacancy occurred,
and they were selected from amongst the lady pupils who had had not
less than a year's training in the hospital and who knew all about the
work of the hospital and their respective duties. The probationers
wore appointed by the matron, and became nursoii after eighteen
months, provided that they conducted themselves properly, During
their period of probation they could be dismissed by the matron. For
the first month they had tlie option of terminating their engagement,
but after that pei-iod they had to sign a paper saying that they would
serve in the hospital for three years. The nurses were expected to be
out of their dormitories at twenty minutes past seven; they
breakfasted at half-past seven, and they entered the wards at eight
o’clock; they dined in two batches, half-an-hour being allowed for
dinner, froin'lialf-past eleven to twelve, and from twelve to lialf-past;
they had tea from half-past four to five and from five to half-past; they
had supper from half-past eight to nine and from nine to halt-past, and
they left the wards at a quarter to ten. The income from the estates
had fallen from iLbout£e 0 , 000 ayoar to .£20,000, owing to the agricultural
depression, before wliicli tliey had never asked the public for a single
sixpence. They had leceivoil altogether from the public £100,000, from
wfiidi they took whatever was necessary to meet ,any deficiency.
When they received a large donation of £400 or £500 they advertised
the fact in ilie newspapers, and asked for Uirthev subscriptions.
Mr, Edward Cooper Perry, M.l)., assistant physician to Guy’s Hos¬
pital, Dean of the Medical School, itenionstrator in morbid anatomy,
and warden of the residential college, was tiion examined. In answer
to tiio clrainna'n, he explained the duties of the staff engaged in the
residential college and the system of niannsement. Last year the fees
of the students at Guy’s amounted to £11,000, of whicli £8000 was
devoted to the expenses of the scliool, irrespective of the salaries of the
lecturing staff.
St. BaTtholomew'K Uonpital.
On Tliursday Mr. W. A. Gross, clerk to vSt. Bartlioloniew’s Hospital,
was oxaiuined. Uo stated that tlie affairs of the hospital were cou-
chu'ted by an executive committee. He was a salaried officer.
The ste^^•avd would I'eport to him.—The Chairman; As a general
rule, <lo yon not think it is inconvenient to have two heads, as
in the caso licro ? You are supreme iu the absence of the treasurer, and
at tlio sanio time you have a very important official who is indirectly
under you, — 'I’ho Witness; It wouhl he much better to have one
on the spot wlio had supreme authority. Tlie system of accounts
having boon explained, ami the method of clrecking them dealt with, the
witness .stated that the House Committee dealt with the estates of the
an agent i... — .
(.he rate per hod was a just one, as each individual hospital should be
judged according to its own circumstances. Ho did not, however, mean
'to imply that a uniform system of keeping accounts in the various hos¬
pitals should not be tried. The figures representing the cost per bed
published by the Charity Organisation 8ociety were not trustworthy as
tar as St. Bartholomew’s wms concerned,—Lord Sandhurst: Have you
liad an outbreak of diplithovia recently iu the hospital V—The Witness:
Yes. Wo took into the hospital last year fiom the outside 140 casas
of diphtheria, being douhlo the iiumhor that wo revolved on the
prei'ious year, ami several of our nurses—twenty-three nursea and
three ward assistants—liave heoii attacked with mcio or less severe
forma of diphtheria. The mattor lias engaged the very anxious
attention of the tveasuvor ami the almoners fuom the (wriiest
dovelopmeut of that disease, and it is still under consideration.
I.oril Sandhurst: Do you admit all eases of diplitlioria V—llio witness :
Wo have admitted all cases of diplitlioria. We coimnoiiceil tills year
to put diphtheria patients into a sopamte ward.—Lord Sandliur.st. Do
you take advaiuago of all the availahlo space in your hospital for these
pationtsV-Tho Witness; Oli, yos.—Lord Samlluirst; Hava not you
a magiiificoiit liall in (he ooiilro of llio thin! lloor '.'-The M ttuoss : Y®* •
the liall is not available for patioiits.- Lord .Sandhurst; What is the
Dioii
286 The Lancet,]
APPOINTMENTS.—VACANCIES.
[Jan. 31,1891.
use of that hall ?—The Witness: The governors hold their meetings—
their court, and occasionally hold their annual dinner there.—liord
Sandhurst; Is thatthe only place where the governors could hold their
court?—The Witness: According to the present arrangement.-Lord
Sandhurst: How often does the Court of Oovernors meet ?—The
Witness: Once every three months, sonmtimes more frequently.
After some further questions from the Chairman, Lord Cathcart
pointed out to the witness that there was an idea abroad that the
nurses in the hospital were suffering from something being wrong
in the quarters given to them in the hospitals, and asked if the
witness uad any reason to suppose that that was so. The Wit¬
ness : We had no reason to suppose that. Two months ago the sur¬
veyor was instructed to make a complete examination of the
building.—Lord Cathcart; And then aid you move the nurses
away from the places they had formerly occupied ?—The Wit¬
ness : From some cubicles tliey were occupying.—Lord Cathcart;
I suppose you removed the nurses for some reiuson V — The
Witness: We moved the nurses away, as some scarlet fever bad
broken out in the room, for the purpose of disinfecting tho whole place.
Another reason was tliat we had increased accommodation for them,—
I^rd Cathcart: In the treasurer’s house ? The Witness: No, that is
at present used by the night nurses.—Lord Catlicart; And tho removal
had nothing to do with it,V The Witness; Nothingat all.—Lord Cathcart:
With regard to the accounts, do you not think that if tho cash book dis-
se^ions were made on a uniform principle throughout the hospitals
the cost per bed would be a good standard of comparison as
between one hospital and another? Tlie Witness: 1 do not quite follow
your lordship, but there would be great difficulties in doing so, and the
disturbing element of the out-patient department would have to be got
rid of. Lord Cathcart further examined the witness on the nature of
the supervision exercised by the steward in reference to tho food
supplies for the hospital.
Lord Zouebe: I suppose your buildings are ve^ old? The Witness:
They were erected lor the most part in tho middle of last century.
The rebuilding of the hospital began in the first quarter of the last
century.—Lord Zouche: Do you think that any danger arises in con¬
nexion with infections diseases from the antiquity of the building?
The Witness : I do not think there is any evidence of it so far as our
hospital is concerned. The wards are frequently cleansed and re¬
painted. Lord Zouebe: Because it has been suggested that the walls
might become impregnated with infection, and that might be
communicated to sick persons. The Witness: 1 believe that our
statistics of surgical results are very good indeed, which would
hardly be the case in a hospital impregnated with infection.—Lord
Zouche: I suppose every care is taken to keep everything clean—the
paint of the wards &c.,—is it not ?—The Witness; Oil, yes; and if there
IS any case of infectious disease in a wanl, and the surgeon suggests
that it is desirable to clean it, there is never any hesitation about
doing 80 .—Lord Zouche: You would not state that this outbreak was
in consequence of the antiquity of the building.—The Witness : Per¬
sonally 1 have never beard it suggested.
In answer to Lord Monkswell. the witness stated that the governors
did not contemplate enlarging tne hospital until they got an extended
area. With reg.ird to the outibreak. Lord Monkswell aske<l what the
surveyor had discovered wrong with the hospital. The Witness: He
could not discover anything to account for the illness, but he pointed
out that some of the appliances were not of the most modern type,
and that they should be made so. We at once gave orders for the sub¬
stitution of newer appliances In their stead.—Lord Monkswell; Do
the ward assistants sleep in the hospital? The Witness : I think there
are two wlio sleep out, but as a rule they sleep in the hospital.—Lord
Monkswell: Are the ward sisters put up in sanitary bedrooms ?
The Witness: Yes, I think so.—Lord Monkswell: Are not they some¬
times made to sleep in a rooq^ low down in tho building, almost on the
ground ?—The Witness: No. 'J'lie ward assistants sleep, some on the
upper floor, and some on the second floor in the nurses home.—Lord
Monkswell: But is thero no person connected with tire hospital
who sleeps in bedrooms partly below ground?—The Witness:
I think I know what your lordship refers to. tjome of the
male attendants in connexion witli the re.sident staff sloop below
ound, bub the rooms are at present being raised. — Lord
onkswell: Did they suffer from illness?—The Witness: There
was one attendant there who last summer hail diphtheria.—Lord
Monkswell: And might not this be traced to tho insanitary nature
of his bedroom ?—Tho Witness: I say I do not know.—Lord Monks¬
well : Was there any other case of illne.ss arising from bedrooms
being partly underground?—Tho Witness : No, none that I have ever
beard of.
Lord Cathcart: Can you toll mo exactly what is being done regard¬
ing the sanitary condition of tho hospital?—Tho witness stated that a
different kind of waste trap for tho sinks .situated in a little room off the
wards liad been provided. Thewatorclosets had not been objected to.—
Lord Cathcart; Have the sanitary arrangernenta below ground been
altered ?—Tho Witness ; No. Merely the traps .and the sinks have been
altered.—Lord Catlicart; Can yon suggest some other things which
have been done?—Tbe Witness ; I am afraid I cannot charge my
memory with the details of the impi-ovemonts in ven ilation, in wasto-
pipes, and putting speei.al traps under ground.—Lord Cathcart: Are
you going to do that ?—The Witness: That is being done. In addition
to this report from the surveyors, the governors have called in an export
in sanitary matters to advi.so them gehemlly on tlie drainage. There i.s
no ground, I believe, for thinking the drainage has had anything to do
witn the outbreak.
Dr. Norman Moore, warden of St. Bartholomew’s Hospital, was tho
next witness. Ouestionedby thePresiilentas tothe out-patient depart¬
ments in hospitals, witness thought their demolition would inflict serious
injury on tbe progress of medical study in tliis country. In reply to Lord
Tnring, tlio witness thought there was some risk of infection lioing
spread by the congregating of large mimheca of people in out-patient
departments. The income of tlie school attached to St. Batholomew’s
Hospital last year was about £U,0(W and the expenso.s £4000, tho
remaining £ 10,000 being divided among the lecturers.
Mr. Cross having been recalled, said the day nurses went on duty at
7 A.M., remaining till 9 P.m., time being allowed for hineli, dinner, and
tea. Some part of the nurses’ duties consisted of ward sweeping, but
they were relieved to a very great extent by tho 'vard maids.
The Committee adjourned till Monday next.
Succeaifvlapplieantafor YacaneU«,Seoretarie»ofPvhlicInstitv,tlon»,<inA
others posaeteing im,fomMtwn mitahle Jor Oiis eolv/mn, art invited, to
forward it to TUB Lancet OJJlce, directed to the Sub-Editor, not later
than 9 o'clock on the Thursday morning qf each toeek for puilMOtion in
the next number. •
ABBOTT, C. E., L.R.C.P,, L.H.C.S. Irel., has been reappointed Medical
Officer of Health to tho Braintree Urban and Rural Sanitary Dis¬
tricts.
Bale, Wm., M.B.C.S., has been reappointed Medical Officer for the-
Heaton Norris District of the Stoelcport Union.
Bury, a. T., L.B.C.P. Edin., M.R.O.S,, has been appointed Medical
Officer for the Butterton and Grindon District of tne Leek Union.
Carline, W. A., M.D. Aberd,, M.R.O.S., has been appointed
Surgeon to the Lincoln County Hospital, vice Wilkinson, resigned.
Cooke, W. C.. L.R.C.P. Edin., M.R.C.S., has been appointed Medical
Officer of Health for tho Urban Sanitary District of Bognor.
Cranstone, W. L., M.B.C.S., has been appointed Medical Officer for-
the Shire of Swan Hill, Lower Murray Riding, Victoria.
Cross, W. J., M.B. Toronto, L.R.C.P., L.R.C.S. Edin., has beei>
appointed Medical Officer for the Central and South Ridings, in
lieu of the whole Shire of Arapiles.
Dakeyne, T. B., L.R.C.P.Bdin., M.R.C.S., has been appointed Medical
Officer for the Leckfrith District of the Leek Union'.
E9LER, A. W., M.D., M.Ch. Irel,, has been appointed Medical Officof
for the Borough of Heathcoto, Victoria, vice Scobell, deceased.
Fox, J. A., L.B.C.P. Lond., L.E.C.P. & L.R.C.S. Edin., L.F.P.S. Glasg.,
L.S.A. (1885), L.S.A. (Med. Act, 1889), has been appointed Honorary’
Surgeon to the West Cornwall Infirmary and Dispensary, Penzance.
Fbaney, Edward, M.R.C.S., has been reappointed Medical Officer of
Health for tbe Banbury Rural District.
GaILEY, j. a., M.D. Edin., has been appointed Medical Officer for the
Norton and Endon Districts of tho Leek Union.
Hart, D. B., M.D. Edin., F.R.C.P., has been appointed Medical Officer
of tho Edinburgh Royal Maternity and Simpson Memorial Hospital..
HaSLETT, W. j., M.B.C.S., L.R.C.P. Lond., has been appointed Resident
Clinical Assistant to St. Luke's Hospital for Lunatics, E.C.
HOOLE, John, M.B.C.S., L.S.A. Lond., has been appointed Medical
Officer to the Anglo-Chilian Nitrate and Railway Company at
Tocopilla, Chili.
Kei.ynacic, T. N., M.B., ChB., has been appointed Pathological
Registrar to the Manchester Royal Infirmary, vice R, B. 'Wild,,
resigned.
Marshall, G. B., M.B,, C.M. F,din., has been appointed House Surgeom
to the Edinburgh Royal Maternity and Simp.son Memorial-
Hospital.
Nunn, P. W. G., L.R.C.P. Lond., M.R.C.S., has been appointed
Medical Officer of Health for tho Borough of Bournemouth.
Ross, C., M.B., C.M. Edin., has been appointed Medical Officorforthe
Shire of St. Aniaud, Warnacknaboal'Division, Victoria.
Sanders, W. G. W,, M.B., C.M. Edin., has been appointed Patho¬
logical Assistant Medical Officer to the County Asylum, Ratnhill,
Edinburgh.
Seable, G. C., M.R.C.S., has been reiippoinfcod Medical Officer o6
Health for Brixhaiu.
Shaw, Cecil Edward, M.A., M.D., M.Cli., has been appointed
Honorary Laryngeal Surgeon to the Hospital for Consumption,.
Belfast.
Shields, (Jeorue, M.B., C.M.Edin., has been appointed Medical Officer
for the First Division of the Ureystoke District of tho Penrithi
Union.
Shirre.s, George, M.B., C.M. Aberd., has been appointed Assistant
Medical Officer to the Board of Health, Victoria.
SOMERvn.LH, A., M.D,, L.R.C.P., F.R.C.S. Edin., has been appointed!
Medical Officer for the Longnor District of the Leek Union.
SOULBV, C. JiRNKST, L.R.C.P. Lond., M.R.C.S., L.S.A., has been
appointed House .Surgeon to tbe Middlesex Hospital.
Stei'IIEN.s, RiciiAiU) J., M.R.C.S., L.S.A., has been appointed Assistant-
Medical Olficor to the Wilts County Asylum.
Swindells, J. A., M.R.C.S,, has been appointed Medical Officer for
the Shire of Olenlyon, Victoria.
Thomas, Robert .Stanley, M.A., M.B., B.C. Cantab., has been,
appointed House Surgeon to tho Middlesex Hospital.
faraiims.
For further information regarding each vacancy rtferenoe ehould be made-
to the advertisement.
Addbnbuookk’s Hospital, Cambridge.—Resident' House PhyMicion..
Salary .805 per annum, with board, lodging, and washing in the
Hospital.
Central London Ophthalmic Hospitai., Gray’s-inn-road, W.C.-
House Surgeon.
Central London Sick A.sylum District.— Assistant Medical Officer
and Dispenser for tlie Asylum in Cleveland-stroci. S^ary £100
S er annum, with hoaril and residence. (Apply to the Clerk to tho
iauagera, Clevuland-street Asylum, Clevelanil-stroot, W.)
Chelmsi-'Ord Union,— Medical Officer, including the office of Public
Vaccinator, for tiie sixth district of this 'Union. (Apply to tho
Clerk, Chelmsford.)
The Lancet,]
BIRTHS, MARRIAGES, ATHV DEATHS.
[Jan. 31, isgi." 287
Chelsea Hosmtal fou Women, Fulhatn-road. S.W.—Physician to the
Out-padenta. The ofiBce is honorary.
City of London Hospital fou Diseases of the Skin, Victoria-park,
E.—House Physician for six months. No salary, but board and
residence, and an allowance for washing provided. (Apply to the
Secretary, 21, Finabuiy-ciroua, JS.C.)
County Council fob the County op DEBBY.—Modical Officer of
Ileakh for the Administrative County of Derby. Salary £600 per
annum, with £200 extra for travelling and other expenses. (Apply
to the Deputy Clerk to the County Council, 40, St. Mary s
Gate, Derby.)
County OF Fife.—C ounty Medical Officer for the counties of Fife and
Clackmannan, to act also as Medical Officer for the four districts of
the County of Fife and for the County of Clackmannan. Salary
for the combined offices £000, with travelling expenses. (Apply
to Mr. Patrick, County Clerk, Cupar, Fife.)
DOBSET County Hospital, Dorchester.—House Surgeon to reside and
board in the hospital. Salary £70.
East Suffolk and Ipswich Hospitai,.—A ssistant House Surgeon.
Salary £20 per annum, bosr<l, lodgings, and washing allowed.
(Apply to the Secretary, Thorofare, Ipswich.)
Fabbinodon General Dispensary and lying-in Chabity, 10, Bart-
lett'a-buildings, Holborn, E.C.—Honorary Physician.
Hospital fob Sick Children, Great Ormond-stroet, Bloomsbury,
W.C.—Eeaidsnt Medical Officer required as House Physician for
one year. Salary £60 per annum, with board and residence in tiie
hospital.
HUDDERSFIEI.D Infirmaby.—J unior House Surgeon. Salary £40 per
annum, with boai'd, lodging, and washing.
London fever Hospital, Liverpool-road, N.—Physician.
London Fever Hospital, Liverpool-road, N.—A8Sl.stant Physician,
National Hospital fob the Paralysed and Epileptic (Albany
Memorial), Queen-square, Bloomsbury.—Surireon.
National Sanatorium fob Consumption and Diseases of the
chest, Bournemouth,—Clinical Clerk forfour months. No salary,
but board, lodging, and wishing provided.
Nottingham General Hospital.—R esident Surgical Assistant for
six months. No salary, but board, lodging, and washing provided
in the hospital.
Nottingham General Hospital—R esident Medftal Assistant for
six months. No salary, but board, lodging, and washing provided
in the hospital.
Royal Academy of Arts.-P rofessorship of Anatomy. (Apply to the
Secretary.)
St. Mark’s Hospital fob Fistula and other Diseases of the
Rectum, City-road. London, B.C.—Anresthetlst. Honorarium £60
per annum.
WiNCHCOMB Union.—M edical Officer for the No. 2 or Vale District of
this Union. Salary £66 per annum, and in aildition, midwifery,
surgical, and vaccination fees. (Apply to the Clerk, Winoheomb.)
Proiagts, anir gtalljs.
BIRTHS.
Mom.—On Jan. 22nd, 'at CassiUis-road, Maybole, N.B., the wife of
.lames Moir, Physician and Sui-geon, of a son.
PiucoCK.—On Jan. I7th, at Fitzjohn's-avenno, Hempstead, the wife of
O. Douglas I’idcoc-k, M.A., M.B-, M.R.C.V., of a son.
Wakefield.—O n Jan. 20th, at The Beacon. Guildford, tho wife of
Horace Wakoflold, M.R.C.8.B.. L.R.C.P., of a daughter.
MARRIAGES.
Brown—Maplestone.— On Jan. 2ist, at tho Parish Church, St. Mary’s,
Aldeby, Novtolk, William Henry Brown, B.A., M.R.C.S,, of Nortli-
umberlaud-square. North Shields, to Fanny Sophia, only child of
John Maplestone, 'riio Ovovo, Aldoby, Norfolk,
Ciarke—Joplin.— On Jan. 14th, at St. Matthew's, Thorpe Hamlet,
Norwich, William Frederick Clarke, M.D., B.S., to Amy Robertson,
daughter of the late Rev. J, J. Joplin, of Halifax. Nova Scotia.
Moore—Palmer.— On Nov. llth, at South Yarra, Melbourne, George
Ogle Moore, M.R.C.S., eldest son of J. J. Ogle Moove, to Ethel
M'Crae, second daughter of the late T. W. Palmer.
Wai.sh—Pennell.— On Jan. ‘21st,, at St. Paul’s Chuvcli, Sheeriiess,
.limes Joseph Walsh, Suvgfnn, R.N., to Eveline Mary, eldest
daughter of Col. Ponnell, K A.V., of Sheernoss.
DEATHS.
Carmichael,— On Jan. 24th, at 227, Oldfleld-road, Salford, William
Cai-niicbaol, B.A., M.R.C.S., aged 44. No cards.
FeBNIE.—O n Jan. 22nd, at Macclesfield, Henry Mortlock Feniio,
F.R.C.S., youngest son of the late Rector of Yelden, Bods, aged 56.
Markham.— On Jan, 23vd, at Niglitingalo-lano, Clapham-coiniiion, W. O.
Markham, M.D., F.U.C.P., m the 7;trd year of his age.
Moseley.—O n Jan. •22nd, at his residence, Wilbury-road, West Brighton,
George Moseloy, F.R.C.S.R., aged 65.
Waring,— On Jan. 22nd, at CUttoii-garden8,W.,Siirgeon-Miioor (Retired)
Edward John Waring, M.l)., F.U.O.P.,F.R.C.S., C.I.E., late Indian
Medical Service, Madras, aged 71.
WiiLi-S.—On Jan. 2l8t, at Randolphs, Bkldendon, Kont, Robert Wells,
F.R.C.S., in his 84th year. _
Jf.B.—A Jee of t« charged for fJie Innerfiwi (if NoHees <■/ Sirthi,
MarriageSt and Deaths,
Sflijcal fiarg fer t|t ensaiitg
Monday, February 2.
BoTAL London Ophthalmic Hospital, Moobfields. —OperaMono
daily at 10 a.h.
Royal Westminsteb Ophthalmic Hospital.—O perattons, l.80 P.si.,
and each day at the same hour.
Chelsea Hospital fob Women.—O perations, 2.80P.U.; Thnteday, 2.80.
8t. Mark's Hospital.—O perations, 2.80 p.m. ; Tuesday, 2.80 p.h.
Hospital fob Women, SobO'S^uabe. —Operations, 2 p.h., and on-
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.m.
Royal ORTiiopiiDic Hospital.—O perations, 2 p.m.
Central London Ophthalmic hospital.—O perations, 2 p.h., and’
each day in the week at tbs same hour.
Univebsity College Hospital.—B ar and Throat Department, 9 a.K:.
Thursday, 9 a.m.
London Fost-gbaduate Course.—R oyal London Ophthalmic Hospital,
Moorflelds; 1 P.M„ Mr. W. Lang: Conjunctival Diseases.—Londom
Throat Hospital, Great Portland-street: 8 P.M., McNeill Whistler;
Syphilis as it affects the Larynx.
Royal Inwitution.—6 p.m. General Monthly Meeting.
UDONTOLOGICAL SOCIETY OF GREAT BRITAIN (40, Leicester-sq., W.C.).—
8 P.M. Dr. F. Silk: Clinical Observations on Bromide of Ethyleasan
Antesthetic in Dental Surgery, with recorded cases.-Mr. Sevrill::
The Etiology of Empyema of the Antrum.—Mr. Charters White: A
New Method of Demonetrating Dental and Osseous Structures iiv
Microscopical Specimens.—Mr. Stoivr Bennett: A case of Alveolar-
Abscess of three years’ duration caused by tbe perforation of the-
side of a root,—Mr. Ackery: Some cases of Eruption of Teeth in
Abnormal Positions. Short Inaugural Address by the President.
.Society of Arts.-8 p.h. Mr. A. J. Hipklns : The Construction and»
Capabilities of Musical Instruments. (Cantor Lecture.)
Medical society of London.—8.80 p.m. Dr. S. Mackenzie: Antemia, ita-
Pathology, Symptoms, and Treatment. (Third Lettaomiau Lecture.)>
Tuesday, February 8.
King’s College Hospital.-O perations, 2 p.h. ; Fridays and Saturdays-
at the same hour.
Guy's hospital.—O perations, 1.80 P.M., and on Friday at same hoar.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 p.h.
St. Thomas’s Hospital.—O phthalmic operation8,4p.M.; Fiiday,2P.K.
Cancer Hospital, Brompton.—O perations, 2 p.h. ; Saturday, 2 p.h,
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
St. Mary’s Hospital.—O perations, l.S0 p.h. Consultations, Monday
2.80 P.H. Skin Department, Mondi^ and Thursday, 9.80 a.hl
T hroat Department, Tuesdays and Fridays, 1.80 P.M. Electro¬
therapeutics, same day, 2 p.h.
London postgraduate Course.—B ethlem Hospital; 2 p.m., Dr^
Savage : Delusional Insanity, Moral Insanity. i£ w-
Royal institution.—3 p.m. Prof. V. Horsley: The Structure and
Functions of tlie Nervous System.
SOCIETY OF Arts.—8 p.m. Mr. William Simpson : Lithography, a>
Finished Chapter of Illustrative Art.
The Sanitary Institute (Parkes Museum, Margaret-st, W.),—8 p.m.
Mr. H. Law : Principles of Calculating Areas, Cubic Spaces, *c. v
Interpretation of Plans and Sections to Scale.
Pathological Society of London.—8.80 p.m. Professor Crookshank:
Researches on the Morphology, Cultivation, and Products of the-
Tubercle Bacillus.—Professor Crookshank and Dr. Phlneas Abraham:
Tubercular Guinea-pigs treated by Koch's Method.-Mr. Stephett
Paget: Imperforate Rectum.
■Wednesday, February 4.
National Orthopedic Hospital.-O perations, 10 a.m.
Middlesex Hospital.—O perations, l p.h. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, l.80 p.m. ; Saturday, same
hour. Ophtbalmio Operations, Tuesday and Thursday, 1.80 p.h.
Surgical Consultations, Thursday, 1.80 p.m.
Cbaring-cross Hospital.—O perations, S p.h., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 P.M. Thursday&Saturday,8amehoui.
St. Peter’s Hospital, Covent-garden.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Children.—O perations,
2.30 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, i.80p.u. ; Skin Depart*
ment, 1.46 p.m. ; Saturday, 9.16 a.m.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations, 9.80 a.m. ;
Surgical Visits on Wednesday and Saturday at 9.15 a.m.
London POst-giuduatb Course.—H ospital for Consumption, Bromp-
ton: 4 P.M., Dr. C. Y. Biss; The Diagnosis of Intrathoracic-
Aneurysms.—Royal London Ophthalmic Hospital, Moorflelds::
8 p.m., Mr. J. B. Lawford : Optic Neuritis.
Obstetrical Society of London (20, Hanover-square, W.).—8 p.m.
Specimens will be shown. Annual Meeting. Flection of Offleorsand
Council. ThePr 0 siilent(Dr. Galabin) will deliver tho Annual Address.
Discussion on tho lixamination and Registration of Midwives.
Society OF Arts.— 8 P.M. Mr. J. 14. Dowson : Decimal Coinage, Weights,
and Measures. Thursday, February 6.
St. George's Hospital.—O perations, 1 p.m. Surgical Consultations,
Wednesd^, l.SO p.m. Ophthalmic Operations, FYiday, 1.80 p.h.
University College Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 a.m.
London Post-graduate Course.-N atlonalHoapltalfor the Paralysed
and Epileptic: 2 p.m., Lecture by Dr. Gowens,—Ho.spital for Sick
Children,Great Ormond-st.: 4 p.m., Dr. Barlow: Tlie Clinical Aspects*
ofRickots.—London Throat Hospital, Gt.Portlanci-st.; 8 p.M.,Dr. E.
Law ; Catarrh of the Middle Ear, and Methods of Inflation.
Eoyal Institution.—3 p.m. Mr. Hall Caine: The Little Manx Nation.
Harveian Society of London.—8.30 p.m. Sir Edward H. Sievekinp:
Falmouth as a Health Resort.
iG- (e
288 Thb Lakoet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 31,1891.
Frldi^, February 6.
BOTAL BOtTTH LONDON OPHTHALUIC HOSPITAL.—OpentloiU, 8 P.M.
London Post-oraddatb Couisb.—H ospital for Consumption, Bromp*
ton :4P.M.,Br.G.Y.Bifia: The Treatment of Intrathotacic Aneurysms.
Thb Sanitary lN3TlTUTE(ParkesMuseum,Margaret-st.,W.).—ep.M. Dr.
Louis Parkes: Water Supply, Drinking Water, Pollution of Water.
West London Medico-Chiburoical Society (Board-room, West
London Hos^tal).—8 P.M. Oi-dinary Meeting. Mr. Peroy Dunn will
show some ^tliological Specimens. Dr. Clemow: Observations
upon the Treatment of certain cases of Fatty Heart.—Mr. Rickard
iloyd: Practical Notes on the Administration of Ether and Chloro-
foiTQ —Dr. Alderson; A case of Attempted Suicide by Chloroform.
BOYAL Institution.—9 p.m. The Bight Hon. Lord Rayleigh: Some
Applications of Photography.
Saturday, February 7.
UiDDLESBZ Hospital.—O perations, 2 p.h.
Dniyersity COLlSSB Hospital.—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.16 A.H.
London Post-graduate Course.—H ospital for Diseases of the Skin,
Blackfriars: 2 p.m., Dr. Payne: Tlie Different Forms of Alopecia.—
Betblem Hospital: 11 a.m., Dr. Percy Smith; Clinical Demonstration.
EOVAL Institution.—8 p.m. Mr. W. Martin Conway ? Pre-Greek
Schools of Art.
METEOROLOQICAL READINGS.
(Taiat doily of S-SCa-m. by Steteard's IrutrumMtiJ
The Lancet Office, Jan. 29th, 1891,
Data
BarMovtor
rsduMd to
Sealievel
and »9*r.
Dlrao-
tloQ
ot
Wind.
Wet
Bulb.
Belar
Badla
In
Taouo.
Maxi¬
mum
Temp.
Shade.
Min.
Temp
Raln-
faU.
Bamaika at
a»A.ii.
Jao. 23
29-71
W.
41
40
66
60
36
•01
Overcast
H 24
29-69
s.w.
40
48
64
60
41
•28
Overcast
„ 25
80-00
S.W.
39
88
66
60
88
•27
Bright
20
80-10
H.W.
42
41
72
49
37
„ 27
29-94
S.W.
44
42
50
49
42
>■ 28
80-08
S.W.
47
40
59
62
44
•01
Cloudy
„ 29
29-94
S.W.
48
47
49
47
■07
Raining
Itirffs, €mmnis, ^ ^nskrs Id
€sxxt&pr^mU.
it is tspe<Adll^ requested that early intelligence oj local
events hxwina a medical interest, or which U is desirable
to bring vnaer the notice of the profession, may be sent
direct to this Office.
All communications relating to the editorial business of the
journal must be addressm “ To the Editors."
IdSctures, original articles, and reports should be written on
one side only of the paper.
SdcUers, whether intended for insertion or for private in¬
formation, must be authenticated by the names and
addresses of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
fjocal papers containing reports or news paragraphs should
be marked and addressed "To the Sub-Editor.”
Letters relaling to the publication, sale, and admerUsimg
departments o/T he Lancet to be addressed "To the
Publisher."
We cannot undertake to return MSS. not used.
PHYSrCAt, Traixinvi.
Jk. correspondent, under the pseudonym “ Dragoon,” favours us with
the following interesting note on the results of n case of systematised
physical training observed at the Gyinnasinin Cavalry Barracks,
I Canterbury.
"Corporal A. U-joined a hussar regiment a.s a recruit in tho
spring of 1888. He went through a three months’ recruit’s (gymniistic)
course in England, through a si.\ month.s’ course in India, anti has
just finished another six months’ course in ICngland. He is now a
qualified instructor. Tho following table shows the results of
these gymnastics upon the man's frame.
Date.
■ Age. :
Height.
Weight.
'Girth of
1 Chest.
Fore¬
arm.
Upper
Arm.
July 6,1888.
Oct. 6, 1 ,
Jan. 20,1891.
19,^5 yrs.
»
21A
6ft. (li in.
Not taken
6ft. Sin.
lost. 7ilb.
list.
list. 11^ lb.
1 36:,'in.
1 38 „
41 „ ,
11 in.
1 12S „
1 i3j; „
11,1 in.
12 „
16 „
Thus it will be seen that in two years and a half this man lias
gained li in. in height, 18 lb. in weight, Sj in. in girth of chest, 2il in.
in girth of forearm, and 33 in. in girth of biceps. Ttiose figui'es are
more eloquent than words.”
Afr. A. Webster .—Goodliart or Angel Money, or the fuller treatises of
Eustace Smith and Meigs and Pepper.
, Mortality from the Bites of Snakes and Attacks of
Wild Animals in India.
According to the latwt official return, the number of deaths from snako-
bitesand attacksof wild beasts in India is still on the increase, in spite
of the large sums which are spent yearly on rewards for the destruc¬
tion of these scourges. In 1888 the number of human victims to snakes
and ferocious beasts was 22,970, and of cattle 76,271. Of the former
number 20,671 deaths were due to snake-bites, 976 were caused by
tigers, 184 by leopards, 189 by wolves, 110 by bears, 67 by elephants,
hnd the remainder by other animals (scorpions, dogs, foxes, crocodiles,
lizards, wild boars, &o.). In 1881, on the other hand, the number of
cattle killed was 43,069; in 1886, 60,020; and in 1887, 68,840; while
the number of persons killed each year since 1880 varies from 21,000
to 24,000. During the same period the work of destruction of wUd
beasts and snakes has advanced, as has also the extiendlture for
rewards. In 1888 20,709 wild beasts were destroyed, and 611,918
snakes. The total amount paid in rewards was Rs. 159,268. In 1880
^-4,890 wild beasts and 212,776 snakes were killed, at acostof Bs. 99,992-
In 1884 and 1886 tho expenditure exceeded two lakhs of rupees.
Dr. E. 0. you7i!/er ,—llie best treatment of such articles is, probably, to
take no notice of them. It is sad indeed for the readers of the
periodical quoted if tho stuff given in the ciuotations constitutes the
most interesting article in the January number.
Nemo.—The L.S.A. is certainly not tiie highest qualification. The value
of degrees must depend on the completeness of the examinations after
Svhich they are granted.
d!R,C.P.—T he information desired will be feiind In Martindale's Extra
Pharmacopecia.
ASSISTANTS.
To the Editors of THE Lancet.
Sius,—This will be the last letter from me on tho above subject, as I
start abroad this evening, Wlieii I return perhaps I shall have more
to say. The letter of the writer “X. Y. Z." in The Lancet of
; Jail. 24th, I characterise as a senseless piece of sarcasm, evidently
written by one of no practical experience as an assistant, as he admits
himself ‘‘tliat he never was one, nor should ho be.” Such an ad-
I mission proves his utter inability to co]>o with the subject. I have
! been both an unqualified and qualified assistant, and, before I entered
, University College Hospital In Clower-street, served a pupilage to a
I surgeon attaclied to a large Union Infirmary and lying-in hospital,
after whicli I was fortunate enough to obtain an assistnney in the
neighbourliood of Rnssell-square during tlie four years at the hospital.
The statement “ X. Y. /,.” mentions about his principal wanting him
to " dub ” himself to his patients as a qualified man whilst he was a
student is the exception. I deny in toto that it is the invariable
rule. It is a gross calumny to level at practitioners who employ
them. Why did he not, for tho sake of tlio profe.ssion, expose
this gentlomaii ? My principal was quite a different man to that.
“X. Y. Z.” talks about "protecting tho public against unqualified
persons.” I am sorry to say, before the law stops in, something
should bo done to protect tho public from qualified assistants, who
enter the ranks perfectly ignorant of midwifery—at least, any operative
part. Whilst acting !Ui assistant in the W.C. district iny principal, who
was away, had a locum (L.ll.C.P., M.U.U.S.) who attended a lady near
Bedford-square in confinement. I’ost-partuni htemorrhago sot in to an
alarming extent from a retained placenta. Tho locum sent for me.
Now, I was tlie unqualified assistant. Ought I to have introduced
iiiy.self as the unqualified assistantV In all probability, if I had done
so, 1 should havo been told to go. Now, ‘‘X. Y. Z." wishes all iiiiqualifled
assistants to be known as such to their patients. Instead of doing that,
I helped my friend, and introduced my hand and emptied the uterus.
Did 1 do rightly Y Several other cases I could mention. As to pharma-
coii'tical mon acting as assistants, that, again, is an exception, not the
rule. Apologising for thus troubling you witii sucli along letter,
- 1 am, Sirs, your obediimt servant,
Jan. 26lh. 1801. Justus, M.B. BniN.
To the Editors of THE Lancet.
Siit.s,—I, for one, do not think unqualified assistants ought to be
ignored, hilt that the employment of them should bo ru.strictod as much as
possible. Your corrospondoiit, " X. Y. Z.,” considers them very nsolul.
Well, so they aro to a man holding many public appointments in
addition to a large private priictico; too many appointments, indeed,
for him to attend to personally, so ho obtains an uiiqualifiod assistant,
who does work—alter a fashion—tliat ought to be performed only by a
qUmlillcd man. Also, tho employer takes very good caro to hide tho
. fact that his assistant is—to put it in tho ouphomiatic terms of an
■.ulvorUsemonb column—“mK! diploma.'’
I think it ought to bo a law with tho I.ocal Government Boar<l that
they do not siuicLioii any man holding a plurality of appointments
unless lie does (not ran) attend poisoiiaily to thorn, or has a properly
qualified assistant to help him in tho discharge of his duties, ami that
no man jiolding aiiypulilic appoiniment shall employ any unqualified
person other than a dispenser, who, under no circumstances, shall
visit, attend to, or prescribe, to assist him in the porfonnaiico of his
duties either in private or public practice. If the above were tho law,
tlioii there woul I be few, if any, uiKiualiiiod men acting os assistants,
tjualified men would got employment at a fair remuneration, fees would
Coogic
Die;
Tbb Lancbt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 31,1891. 2B9
improve all the way round, and laet, but not leaet, the social statue of
the profession would bo vastly higher in a very few years than it ie at
present.
Here is avase in point. Near me livos a medical man who has all the
usual district appointments, an extensive country practice, and be is a
medical offlcer of health to a large rural district and to a town seveml
miles away from his residence. Ifow can he attend to all his duties
himself? If he were like Kir Boyle Itoche's bird, bo might be able to
attend to all his duties at the same time ; but to help him he has an
unqualified assistant. Now I say that if it is worth while having these
many appointments, surely it ought to bo worth while to have a pro¬
perly qualified assistant. I think I ought to say that 1 am not an
assistant “ out of place." I am, Sirs, yours truly,
Jan. 28rd, 18D1. Dii'W.ma.
To the Editors of TUB Lancet.
Sirs,—I n reference to my letter, published ii\ jcur Issue of the
8rd lost., first, I have to thank you for the readiness with which you
inserted it, and opened up this imoortant subject. Upon further con¬
sideration I fear that no member of the Medical Council will reply to
it To my mind the reason is that the Medical Council, as a body,
are out of touch with the hard-worked general practitioner. I
would he inclined to think that there is nob one member of it
who ever was so placed as to require the services of an un(]u,alifiecl
assistant. If this be so, how then can they speak on this subject?
Fi'om which I infer that until the general practitioners of England,
Ireland, and Scotland are represented (why not?) on tlie Medical
Council this question will remain in statu <y«o. At present the con¬
sultants, hospital surgeons, professors, and specialists, in my opinion,
are only on it—where is tho general practitioner wlio can only put
M.B.C.S. after his name on the Medical Council? England, Ireland,
and Scotland should have at least one general practitioner on tho
Council; then tho subject of lione-settera, consulting phronologist.s,
travelling quacks, and un<iualified assistants—they ate all about one—
would receive attention. I venture to think that it would not then be
so easy for any man to pub on a tall hat and pair of gloves, and go
visiting. I remain, Sii-s, yours faithfully,
.Ian. 27th, 18D1. (i,P.
To the Editors of TUB Lancet.
Sirs,—Y our corre.spondont's—" X. Y. Z.’’—letter has raised a point
which I have often tlionglit of niy.self. Ilis principal, I consider, did not
wish him to be a“party to a gross fraud.” It all arises from our technical
use of t ho word “ qualified." If patients aro told that the a-s.sistant i.s
unqualified, they are apt bo take it in the general sense of not being
fitted to treat cases, and natui-ally object to his attendance. This is a
fact. I am myself a qualified assistant, successor to six or eight un¬
qualified men, and on various occasion?—for instance, taking a mid¬
wifery case that my principal had promised to attend personally—I
have had occasion to explain tlio ditt'eronce between myself and my
predecessors. The easiest way I liavo generally found was to say that,
comparing our profession to the church, I was like a curate in full
priest’s orders, whereas tho men before me were like doacon.s; ami to
give the example that an unqualified man could nob sign a death cer¬
tificate or examine for life assurance, just as a deacon could not read
the absolution in church. It would bo well, I think, to limit the bom
“as.sistant’’ to unqualified men, and to call the qualified a.saistant
" salaried partner," or better still, “ temporary partner,” which would
at the same time tend to neutralise the prejudice at first against “ the
young doctor." I am. Sir.s, yours faithfully,
Jan. 24tli, 1801. U. A. L.
THE KTAEFOEDSIIHll'l KNOT AND ITS ADVANTAOES.
To the Editors of The Lancet.
Sirs,—H aving during an extensive practice of some years tied daily
tho Staffordshire knot in preference to all otlier forma, reof or surgical,
I deem it tlie ideal knot if properly manipulated, so much so tliat I
receive it, as part of iny surgical creed, to be absolutely infallible and
to be superior to any otlier fora, wliotlior practised by the most
brilliant operator or an ordinary luiskillod liaud. The following cases
aro demonstrative-viz. : 1. As to its rapid execution if performed
according bo Tait'.s first method, to its alisolute safety, and to its easy
manipulation. i2. Comparative sni-gory. On animals I have Icnowu
the prolapsed utoru.s to l>e successfuily removed with on ordinary
pocket knife and whipcord ligature (tied with the .Staffordshire knot)
by an ordinary imsldlled farmer. ;i. Tlie SUffordshire knot is in
common use among farmers as a mode of castration among malo
animals, and is reported lo be without any mortality.
I am, .Kirs, yours obediently,
Jan. 27tb, 181)1. Ptodc.mais.
J. S. i>.—There can bo no doubt, we think, as to our correspondent’s
clear legal right to a notification foe, The law gives the medical
officer of health no power to annul that claim. lie would <lo a service
to the profession, having tho strong mens cojurur recti, by iiressing i
the claim in the,county court. The leading article in question, on
tho duties of medical officers of hcaltli, will be found in Tiiic Lanckt
of Kept. 27th last.
Dr. J. Stewarf.—Scarcely. Wo cannot deny tho right of patients to
change their medical man, even in tho ciremastawces named. But li
should act with the utmost reluctance, suggesting cooperation and
consultation with A.
Barkauous Treatment of Lunatics.
A MEDICAL man who was proprietor of a private lunatic asylum in the
neighbourhood of Wiesbaden has just been sentenced to eix months'
imprisonment for inhuman treatment of patients. The case against
him was brought to light by one of the attendants, who was so dis¬
gusted by the practices that wont on that he left and informed thn
authorities. It seems that the doctor really believed that corporal
punishment was the best treatment for insane patients, and he used
to administer it freely to both males and females, the instrument
used being an indiarubber tube. In one case evidence was given that
a patient who was suffering from disease both of the brain and of tha
spinal cord was chastised severely on the very day on which he died.
I For the defence several experts were called, who stated that corporal
punishment is considered to be an admissible method of treatment in>
lunatic asylums!
Medical Offlcer of Bealth.—It appears from a table published in th»
Begistrar Oeneral's fifty-second annual report, just published, that
the moan annual death-rate in England and Wales during the ninO’
years 1881-8H was equal to 18'9 per 1000, the rate in the individual
years ranging from 19-0 in 1882 to 17-8 in 1888. It may be pointed,
out that the mean annual death-rate in England and Wales was.
j equal to 22-6 per 1000 in 1801-70 and declined to 21'4 in the following
' docennium, lS71-80j while In the fli-at nine years of the last ten
years, 1881-00, the mean rate as above stated further fell to 18i>.
Tho publication of the Registrar-General's quarterly return for the
last quarter of 1800, which is due on the Istprox., will afford the
means for ascertaining the mean death-rate during the whole of the
next docennium, 1881-00.
Fairplay is thanked for ills communication. He will see that the sub¬
ject of it has not escaped our attention.
Dr. Arnison (Newcastle-on-Tyne).—We shall be pleased to receive the.
paper.
VALUE OF ISINGLASS IN DIPHTHERIA.
To Che Editors of The Lancet.
Sirs,— During a recent epidemic of diphtheria in this district I have
been nmcli sbnick witli tho value of isinglass in tho treatment of the
<^ases. When the patients, in consequence of the severity of tlio throat
symptoms, were unable to swallow, I used it in enotnata with beef-tea.
In one case, where for days tho patient absolutely swallowed no food
whatever, I depended entirely on injection of peptonised beef-tea (half
a pint with two drachms of isinglass). The patient’s streilgth was main¬
tained under this treatment. The isinglass causes tlie enema to be much
longer retained. Sir Morel! Mackenzie points out that Dr, Massie (who
had .seen a great deal of this disease at Naples) proved that milk ia
often digested witli great difficulty in these coses, and that he used
lime-water to render the milk move easy of digestion. I have found
isinglass has just t!i o same power. It readily dissolves in warm milk ,
and patients seem to liavo an iiiatiiictive fondness for this substance.
I am, Sirs, yours truly, '
Cogglosliall, Essex, Jan. 27th, 1891. B. A. AI’PLEDE, L.R.C.P.
Justice will find in THE Lancet of Aug. 8th, 1836, an extract from the.
Justice of the J’eace,in which the opinion is expressed that there is-
nothing in the J’lducation Art roquiilng a medical certificate without-
a fee.
DEATH CERTIFICATES.
To the Editors of The Lancet.
Sirs,—T he enclosed illustrates the in,iustice wo lie under in giving
our certificates gratis, and tho registrars convert them into a source of
revenue. 1 never saw tlio patient referred to in tlie registrar’s letter-
alive, so of course my cortifleate would be out of tile question.
I am. Sirs, yours faithfully,
James Gilroy, M.B.
Watorbock, Ecciefochan, N.B., Jan. 26th, 1891.
Jan. 24tli, 1801.
Dear Slir,—A geutleman lias called for a certificate of his motiier’s-
doath for the purposos of an iii-iirancB society. A certificate from mo-
is of no uso for that purpose uiiles.s it contains a copy of the modicol
coi ciflcate with cause of death, i enoloso a form, and tlio gentleman
will probably call for it on Monday, 1 am sorry to-trouble you, but
cannot liolp it.—Witli kind regards, I remain, yours very truly,
Dr. Gilroy, Watoi'beck. __,
THE CAT AS A CARRIER OF INFI-ICTION.
To the Editors <f THE Lancet.
Sirs, —In tbo prograuiiiio of tho coming conference I do not notice
any allusion fo tlie consideration of the ■ ‘ domestic cat ” as a microbe
carrier. Will not a cat lap up tho ejecta from infected cMldreu,
.Moratcli over the rofiiso liaapsami eat tlio “ plate seniping-s” from houses,
where there aro infectious diseases, and then after Iravolling over a.
largo area return to its owner'.s liouso, perhaps carrying the germs of
dlseaso with it? I think tho numlier of cats alioiild ho coiisidorably
diniiuishod; o.'ceoptions for keeping them could be m.ado for corn stores,
or farms, or whoro they might be of some service; there are plenty o£
ingenious contrivances for dc.stroyiiig mice in private houses.
I am, Sirs, youra tiaily,
New Brompton, Kent, Jan. 27tli, 1891. J. Morton, Surgeon,
Dir:' 'ed ’
Google
£30 Thb I<anost,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
(Jan. .31,1891,
Rfbpiiutory Ckstre.
are indebted to a correspondent for calling our attention to an
inaccuracy which appeared in our annotation of lost week. Instead
of saying that destruction of the alee cinereee caused cessation of
respiration, it should hare been stated that it was destruction of the
•grey matter in this neighbourhood which did so—strictly speaking,
the V-shaped ^y matter above the point of the calamus scriptorius.
In the middle of the annotation it is stated that “ destruction of this
region mitpends temporarily respiratory movements of the opposite
side.” It is manifest from the context that " suspends " has been
printed instead of “permits.” We hope again to refer to this inter¬
esting subject when Laborde has given full details of the experiments,
of which only a preliminary statement has as yet come under our notice-
OOMUUHicaTiONS Bot noticed In our present number will receive atten-
tdon In our ne^.
COHHITNICATIONS, LbttbbS, &o., have been received from—Sir Spencer
Wells, London; Dr. Broadbenb; Dr. Prout, Edinburgh; Mr. Alban
Doran; Dr. Sainsbury; Dr. Boobbyer, Nottingham; Mr. Marinaduke
• Sheild, London; Dr. W. Hunter; Dr. Pisani, Malta; Mr. Braxton
Hicks; Dr.Baughton, Clapham; Mr.Humphreys,London: Sir James
Grant, Ottawa; Dr. W.G. Spencer; Mr. Hill, Crickhowell; Mr. Lloyd
Bruce, New York; Dr. Weir, Erycobo; Mr. St. Dalmas; Messrs. Gale
and Co., London ; Mr. Mortimer,London ; Messrs. Bates, Hendy,and
'Co.; Mr. C. Stretton; Dr. Castle, Botberbam; Messrs. Hertz and
Collingwood ; Mr. Hodgson, Ecclefecban ; Dr. Gilroy; Messrs. Salt
-and Son, Birmingham; Dr. Thomas, Brighton; Messrs. Mitchell and
Co., London; Mr. Chatham, Edinburgh; Messrs. Evans, Lescher, and
Evans; Dr. Dutt,Scarborough ; Mr. W. Gregory; Messrs. Maclean
•And Sons, Edinburgh; Dr. Prowde, Sunderland; I^fessrs. Blondeau
et Cie.; Surgeon-Major Lawrie, Hyderabad; Messrs. Llppincott and
Co., Philadelphia; Dr. Arnison, Newcastle-on-Tyne ; Messrs. Sutton
and Co. Preston; Dr. L. Kidd, Enniskillen; Messrs. Richardson and
Co., Leicester; Mt-. L. Mark; Mr. H. B. Whitehead; Messrs. Harris
and Sons ; Mr. Applebe, Coggeshall; Mr. Cardew; Messrs. Christy
and Co.; Dr. A. H. Robinson; Dr. Pergusson, Banff; Messrs. Keith
■and Co.; Mr. Meredith, London; Mr. J. H. Thompson; Mr. Hughes
Hallet, Derby; Dr. Grose, Melksham; Messrs. Smith, Elder, and
Co.; Mr. W. S, Watson ; Dr. Ormiston, Glasgow ; Mr. Morton, New
Brompton ; Mr. Mansell Moullin; Dr. Webster; Messrs. Reynell aud
.Son, London; Prof. Rutherford; Dr. J. F. Little; Messrs. Duncan
and Co., Edinburgh; Mr. Coles, London; Mr. Saxon; Messrs. Mann
and Co.; Mr. Gottlieb; Dr. Collins, Manchester; Messrs. Shelley
and Son; Dr. C. Purvis; Mr. Durlacher; Mr. Black; Messrs. Smith
•and Son, London; Dr. Bowie, Blantyte, E.C. Africa; Messrs. Dawson
and Sons; Dr. P. P. Atkinson ; Mr. Jessett; Messrs. Reynolds and
Branson ; Dr. Aulde, Philadelphia; Mr. C. H. Robinson ; Mr. R. II.
•Elliot; Dr. Bampton; Dr. Mackinnon, Damascus; Kev. S. Wigan,
Maidstone; Mr. Knox; Mr. Campbell, Melbourne; Dr. Chaudhury,
Calcutta; Mr. Johnson, Leicester; Mr. Bonney; Mr. Hay; Mr. Kelly,
London; Mr. Hope ; Mr. W. Scott; Mr. Wand; Mr. Scott, Blooms¬
bury ; Mr. Bayley, Walsall; Dr. Isaac, Wokingham; Dr. Mooriiead,
■Carrington; Dr.Waters, Liverpool; Mr. Greenish; Mr. Roberts, West¬
minster ; Mr. BIrchall, Liverpool; Dr. Hime, Bradford ; Mr. Bradley,
•Leeds ; Dr. Duncan, London ; Mr. Roberts, Sheffield ; Mr. Phillips,
Birmingham; Mr. Henderson, Dundee; Mr, J, J. Tate; Dr. Gilbert,
Germany; Mr. Hamilton, Brighton; Mr. T. B. Maliew ; Dr. Mersvan,
Austria; M. Boland, Barcelona; Mr. Shaw, Edinburgh; Mr. Decley,
Blackpool; Prof. Le Montais, Detroit; Mr. Armstrong, Newcaatle-
•on-Tyno; Mr. Parsons, Hastings; Dr.Thomson, Oldham; Mr.Brown,
Moseley ; Dr. Anderson, Newfoundland ; Mr, Cooke, Totnes; Mr. P.
Plggott; Mr. McNidder, Menston; Mrs. Forrest, Blackburn; Mr. R.
Coombe; Mr. BlsohoS; J. S. D.; Justus; Diploma; Secretary, Jessop
Hospital for Women; B. S.; Nemo; Ptolemnis; Secretary, Chichester
Infirmary; Justice; General Practitioner; House Surgeon, Norfolk
and Norwich Hospital; Zeta, London; F.B.G.S., London; County
Clerk, Co. of Fife; Matron, Manchester ; Jurisprudence; Durrant’s
Press Agency; H. W. B., Soutbsea; Melville; Clerk, Dorset County
Hospital; L.R.C.P., Oxford; Dragoon; G. A. L,; Fairplay; An
Observer.
Lbttbbs, each with endom/re, are also acknowledged from—Slr Andrew
Clark, Bt., London; Mr. Bush, Bath; Messrs. Blake, Sandford, aud
Co., Piccadilly; Mr. Evans, Llanercbymedd; Messrs. Ormiston and
Sons, Glasgow; Mr. Edwards, Sunbury-on-Thames; Messrs. Watkin
and Osmond, London ; Mr. II. Sell, London; Mr. Cornfield, Stoke
Newington ; Mr. Tliin, Edinburgh; Messrs. Roberts and Jones, North
Wales; Mr. Tully, Hastings ; Mr. Saunders, Eton ; Mr. Clarke, West
Kensington; Dr. Whitla, Belfast; Dr. Ritchie, Otley; Messrs. J. and
B. Motley, London; Mr. Lockwood, Huddersfield ; Messrs. Waltham
Bros., Stockwell; Mr. Tyte, Minchinhampton; Mr. Cuthbert, West
Bromwich; Mr Orchard, Dublin; Mr. Ernst, London; Messrs. Eilner
Bros., King's-cross ; Mr. Sheen, Fernhill Heath; Messrs. Homer and
Sons, Aldgate; Rev. C. Sutcliffe, Halstead; Messrs. Robbins and
Co., London; Miss Scott, Newcastle-on-Tyne; Messrs. Hogg and
Son, London ; Mr. Maturiu; Mr. Maitindale, London; Mr. Davies,
Pontypridd ; Mr. Saunders, Manchester; Miss Howarth; Mr. Bayes,
Wellingboro'; Mr. Shea, Chesterfield ; Dr. Liveing; Dr. Burton, Here-'
ford; Mr. Haslett,Liverpool; Mr. Cressy, Mansfield; Dr. Mouat,Ken¬
sington ; Mr. Baker, Brixton; Mr. Evans, Penybont; Mr. Rowlands,
Merioneth ; Mr. Catella; Mr. White, Haughley ; Mr. Booth, Man¬
chester ; Mr. Scriven, London; Dr. Peters, Timperley; Dr. Nickoll,
Australia; Mr.Blackburn,Hong-Kong ; Mr.Keary; Mr. Thorallnson,
Partick; Dr. Sealy, Weybridge; Major Pead; Mr. Zeppenfeldt, West
Indies; Dr. Owen, Ruardoaii; Mr. A. C. Coles; Miss Roger,s, Colwyn
Bay; Mr. O'Meara, Leicester; Mr. Buncle; Messrs. Richardson and
Co., Liverpool; Mr. Ricketts, Liverpool; Dr. Hughes, Ashton-under-
Lyne; Mr. McAdam, Glasgow; Mr. Deane, Shropshire; Mr. Single,
London; Mr.Gordon,Llandudno; Dr.Hardwick; Dr.Galbraith,Nor¬
folk ; Mr. Guinness, Bow ; Mr. Heywood, Manchester; 0. M.; X. Y.;
Delta,London ; Z., London; Matron, Royal National Hospital for
Consumption, Ventnor; M.D., Bournemouth; Sister Louise, Tulse
Hill; Caledonia, London; W. X. Y., London; Secretary, Royal Albert
Hospital, Devonpovt; F. B. Y,, Sheffield; X. Y. Z., Holloway; Bryant
Co., Toronto; Physician, Loudon; Cordis, London; Alpha, Ebb'w
Vale; B.A., Brewood; Thor, London ; Assistant, London; Medicus,
London; C. G. 0., Croydon; W. K., London; Domum; X. B.; V. B.,
Soaford; Alpha, Hull; Zircon ; Rural; Duplex; Astragalus ; Lady
Superintendent, Bath; M.D., Manchester ; Pulsometer Engineering
Co,, London; Midlands; D. M. S. ; Delta, London; F. C.; Salford
Royal Hospital; Climate, London ; Dextrose; Sydney; Children's
Hospital, Bradford ; Dr., Manchester ; Practioe ; L.R.C.S.; P. B. D.,
London.
Newspapers.—F orii'Airc Pont, Brad/ord Daily Telegraph, Melbourne
Daily Telegraph, Reading Mercury, Mining Journal, Windsor and Eton
Express, Bradford Observer, Surrey Advertiser, Scottish Leader, Hert¬
fordshire Mercury, Leeds Mercury, Liverpool Daily Post, Bristol Mer¬
cury, Law Journal, Essex County Chronicle, Architect, Sheffield Daily
Telegraph, Spactalor, Jsdmlmrgh Evening Disjiateh, Worcester Daily
Times, Staffordshire Sentinid, Public Ophiion, Alliance News, Bornbay
Gazette, New Zealand Herald, Kentish Gazette, Courrier dc Londres,
Derby Mercury, Northampton Daily Reg/orter, Mirror, Cambrian News,
Coleshxll Chronicle, Salisbury Journal, Newbury Express, Bristol Times
and Mirror, Ac., have been received.
SUBSCRIPTION.
Post Free to ant part op thb United Kingdom.
One Year.. £112 6 [ Six Months ^ _ £0 10 B
To CuiNA AND India ...One Year 1 16 IB
To THE Continent, Colonies, and United
States ....- Ditto 1 14 I
Post Office Orders and Cheques should be addressed to The Publisher,
Che Lancet Office, 428, Strand, London, and crossed “London and
Westminster Bank St. Jamea’s-square.”
.£0
» 0
0
0
0
ADVERTISING.
Books and Publications (seven lines and under)
Official and General Announcements » m
Trade and Miscellaneous Advertisements _ _
Every additional Line
Front P^e - - ^ - per Line
Quarter Page
Half a Page ^
An Entire Page .. ... » .. .. .. .
The Publisher cannot bold himself responsible for the return of testd.
monials &c. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are requested to observe that it Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
6
B
4
0
1
1 10
2 16
8 6
--^
An original and novel feature of “ The Lancet General Advertiser” la a special Index to Advertisements on pages 2 and 4, which not only
aSords a ready means of finding any notice, but is in itself an additioTtai advertisement.
Advertisements (to ensure insertion the same week) should be delivered at the Office not later than Wednesday, accompamed by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should be
addressed.
Advertisements are now received at all Messrs. W. H. Smith and Son’s Railway Bookstalls tbroughonb the United Kingdom and all obhe*
Advertising Agents. _
Agent for the AdvertlBement Department in France--J. ASTIEB, 86, Sue Caumartln. Parlii
Google
THE LANCET, February 7, 1891
ABSTRACT OF
ITritsiimisii: Jatans
ON
MiEMIA, ITS PATHOLOGY. SYMPTOMS,
AND TREATMENT.
JOelivered bifore the Medical Society of London, 1891,
By STEPHEN MACKENZIE, M.D., F.R.C.P.,
PRESIDENT OP THE HUNTERIAN SOCIETY, AND PHYSICIAN
TO THE LONDON IIOSPITAI..
LECTURE III.
Mr. President and Gentlemen,— I have already men¬
tioned that there are cases of idiopathic ancemia which
differ from the type of chlorosis and the general type of
pernicious anmmia. To these I must now direct your
attention.
Scorbutic anccmia. —I have recorded* a case of a young man
aged eighteen who had had meat and potatoes daily and
green vegetables once a week, bub who became affected
with swelling and bleeding from the gums, petecbim in
the skin, and headache. When admitted, examination of
his blood showed C. 51, H. 27, W. 0'52.' hlis urine was
’free from blood and albumen. Notwithstanding the history,
scurvy seemed possible, and he was vigorously treated with
antiscorbutics. In spite of these and all other treatment be
got worse. The gums continued to be spongy, ulcerated,
and bled; retinal hmmorrbages, which were absent on ad¬
mission, developed and became more profuse than in any
-case I have seen. Frequent and distressing vomiting set in,
murmurs developed, and a slight amount of albumen
occurred in the urine, but no oedema took place. The red
corpuscles sank to 13 per cent.; they varied much in size,
some presenting cracks and fissures, and he sank after an
illness of a little over two months’ duration. After death,
small haemorrhages were found in the pia mater, lungs, and
heart; all the organs were anicmic, the heart muscle was
pale and mottled, the solitary glands of the large intestine
were prominent, and in the latter were two small ulcers.
Micrococci were found in the capillaries of the liver, kidneys,
*nd heart, but only in small colonies, without changes in
’the surrounding tissues, and they probably only gained ad¬
mission bo the blood shortly before death. The patient had
had a recent attack of syphilis, but no specific lesions were
'found in the viscera. I have recorded another somewhat
similar bub more acute case, and Dr. Gowers® has published
two cases of the kind, one fatal, and suggested the appro¬
priate title of “ scorbutic anaemia.”
I must next call attention to two cases of what may be
called “relapsing pernicious aniemia.” The first case is
that of a man aged thirty-nine, who had repeated attacks
of the most profound ancemia, which always yielded
to arsenic, but after repeated relapses he ultimately
died at home. Another case is that of a man aged
forty-eight, at present under treatment for a relapse of
-severe anmmia, now, as on the first occasion, recovering
under the administration of arsenic. These cases differ
from some recently published in the absence of dark-
coloured urine, except occasionally, when recovering, and
when it is conjectured it is due to arsenic. They are im¬
portant also in relation to apparent cures of pernicious
amemia by arsenic. Dr. Hale white, in a paper about to
appear in Guy’s Hospital Reports, of which he has allowed
me to see a proof, draws attention particularly to the fact
that such cases frequently relapse ami ultimately die from
^e disease, and has been able to find in the records of
■^^y’s Hospital only two cases in which a real cure was
•effected—one of Dr. Pye-Smith’s, where the patient was
well at the end of two years, and one case of his own, where
the patient remains quite well at the end of nearly four
years.
Diagnosis. —The diagnosis presents no difficulty if M'O
I Oplibh. Hoc. I’l'an-i,, vol. i, p. 1.1.
3 For brevity the following sign.-) are eniployeil: corpuscles
(percent., ii=l)tcinoglobin per cent., W-worth or valiio of iiulividual
•corpuscles.
® Medical Ophtlialiuoacopy, third edition, p. 24d,
No. 3519.
make the reservation that pallor does not exactly indicate
amemia. Having established the existence of true antemia
by actual examination of the blood, we have next to deter¬
mine whether it is secondary and symptomatic, or primary
and idiopathic. To exclude the former we have to consider
the history, and make a careful and complete physical ex¬
amination. There are two diseases in this country in which
ansemia is symptomatic, and in which the signs of local
disease may be wanting for some time. These are tuberea-
losis and cancer, which must be carefully searched for and
exclude^ before the diagnosis of idiopathic ansemia cui be
made with certainty. Still the careful examination of the
blood will go far towards the diagnosis of the variety of
ansemia. Imus the reduction of tbe red corpuscles to or
below 30 per cent., especially if the hfemoglobin exceeds the
corpuscles, is in favour of pernicious aneemia. The other
diseases in which such great reduction in numbers occur are
hcemorrhage, in which usually, though not invariably, the
corpuscles and hmmoglobia are proportionately lowered,
whilst the history of loss of blood is rarely wanting; and
cancer, in which, as in some cases I have mentioned, the
bmmoglohin is sometimes greatly below the corpuscular
richness. In chlorosis the characteristic is the deficiency of
bmmoglobin. I must again repeat that retinal and other
haemorrhages, whilst characteristic, are nob pathognomonic of
pernicious anmmia. They indicate a severe degree of oligocy-
thsemia, in which usually the red corpuscles are below
50 per cent. A rough but serviceable guide, in the absence
of the hmmacytometer, to the recognition of this degree of
amsmla is furnished by the nail-bed of the lingers. It will
generally be found that as long as any pink colour is seen
through the nails 50 per cent- of red corpuscles are present,
and that when less than 50 per cent, are present, all trace
of pink has disappeared from the nail bed. Tbe recognition
of this degree of ancemia is a warning that the grave con¬
sequences of amemia may be expected.
Treatment.
The treatment to be rational must be based on a sound
pathology, and accordingly we have tried to work out the
pathology of amemia, and have shown that anmmia depends
upon either defective hmmogenesis or increased hiemolysis,
or upon the two combined. The principles of the treatment
must, therefore, follow upon these lines. It will be con¬
venient to consider treatment under three heads—dietetic,
hygienic, and medicinal.
In defective hcemogenesis,y!YLethet the amemia is idiopathic
or symptomatic, the diet should be liberal, and contain a
considerable amount of animal food. A small quantity of red
wine, such as burgundy, port, or claret, or malted liquor, as
light bitter ale or stout, is often useful. The patient should
get out into the open air, and take gentle exercise when tbe
strength permits; but in profound amemia absolute rest is
imperative to save the fatty and weakened heart. The
patient should be encouraged to take a tepid sponge-bath
m the morning if not too ill. Warm, but not tight, clothing
should be worn. Coming now to the medicinal treatment,
the following remedies have to a greater or less degree the
property of increasing the rapidity of, or of perfecting, blood
lormation, and are therefore hccmogcnctics: iron, phosphorus,
potash, manganese, arsenic, oxygen, hydrochloric acid (indi¬
rectly). Iron is the most important of the hmmogenetics; it
is a constituent of hmmoglobin, the physical condition of
which is determined by its state of oxidation. Iron must
therefore be regarded as a food as well as a medicine, and it
must be borne in mind that the ordinary food taken in
sufficient quantity contains all the iron necessary for blood
formation in health. The manner in which iron acts when
administered as a medicine appears to be by first stimulat¬
ing the formation of new or young red corpuscles, and only
later does it go to increasing the amount of hmmoglobin in
the existing corpuscles. All forms of iron are useful in
amomia, but the bland preparations, and probably ferrous
salts, are usually better borne, and can be exhibited in
larger doses and for a longer time. The most convenient
form is by pills which do not blacken the teeth, allow of
easily adjusted dosage, and have been proved to be elfica-
cion.s. Disturbance of tbe stomach and intestine is no bar
to the administration of iron, but in these circumstances a
bitter and alkali mixture should be given between meals
and the iron in pills with, or directly after, food. Consti¬
pation is best combated by a morning saline aperient, as by
one of the natural purgative waters or a teaspoonful each
of sulphate of sodium and sulphate of magnesium (with or
r
292 The Lancet,] MB. L. TAIT : EXPLORATORY AND CONFIRMATORY INCISIONS. [FERi 7,189L
withoat a teaspoonful of chloride of sodium) io half a tumbler¬
ful ofwarni water. Sir Andrew Clark^hasinsistedonthegreat
importanceofpurgativesiDthetreatmentofchlorosis. Fashion
determines in a great measure the choice of the preparations
of iron employed. At the present time, mainly due to the
induence of Niemeyer’s teaching, Blaud’s pill is the general
favourite. The reactions which take place in this pill are
interesting. It is shown by Mr. Martindale that a Gve-grain
Blaud’s pill, according to the additions to the B.P., 1890,
should contain about one grain of true carbonate of iron, as
ferrous carbonate, but it is found that before the pills ean
be dried and coated quite one-balf of this has been con¬
verted into ferric oxide. Mr. Martindale states that the
pill is best made by taking three parts of carbonate of
potassium and five parts of sulphate of iron (crystals), or
equal weights of dried sulphate of iron aud carbonate of
potassium. A Gve-grain pill made M’itb saccbarated car¬
bonate of iron and syrup, instead of confection of roses, or a ,
Gve-grain pill of dried sulphate of iron, also made with
syrup, will contain three times as much iron as Blaud’s
pill. The excess of potash in the latter is not of any thera¬
peutical importance, as potash is so abundantly supplied
by the food. Three points in the iron treatment remain to
be noticed: 1. The importance of pushing the iron to a
considerable quantity when it is tolerated. 2. The value
nf suDshine and fresh air in aiding its remedial effects.
3. The importance in chlorosis of taking iron for two or
three months after apparent cure. The other hcematinics
are much less active, out are of occasional use.
We now pass on to the treatment of h(Bmolytic atKcmia.
Here theoretical considerations suggest that animal food
should be sparingly given from its tendency to increase
bmmolysis io the formation of bile. Dr. Hunter has sug¬
gested, and put into practice in one case, a purely milk, and
a milk and farinaceous diet, with slight bene^t, but the
case was too advanced for striking results. I feel sure
that a purely milk, or milky and farinaceous diet, deserves
a trial in pernicious anaemia. Alcohol is not as a rule indi¬
cated, ana when administered should be given in the form
of spirit very freely dilated. In the advanced stages abso¬
lute rest in bed is necessary, but when the strength permits
sitting or driving in the open air and sunshine are distinctly
of beneGt in combatiug the hfcmolysis. We must not forget
to foster the increased and compensatory b.'cmogenesis which
is struggling to maintain the balance. We now come to
the medicinal treatment of pernicious and other forms of
bicmolytic auaemia. Amongst the remedies which diminish
blood destruction— anti-hcvmolytics —may be enumerated
arsenic, quinine, mercury, phosphorus, ^-napbthol, iodo¬
form, carbolic acid, sulpho-carbolates, menthol.
Arsenic. —Amongst the great gains we have had in tne
treatment of anaemia in recent years arsenic certainly stands
in the foremost position. It was Gist employed by
Dr. Byrom Bramwell in pernicious ancemia in 1877.® Since
tlien abundant testimony has conGrmed its value, and its
action, if not speciGc, is at least very striking. Fowler’s
solution is the most convenient form, iu which the maximum
dose can be given. Beginning with quite small doses (from
two to four or Gve minims) it can, if tolerated, be gradually
increased to ten or even Gfteen minims three times a day, anS
I believe the larger doses are the most successful. It is not,
however, always well borne, though I cannot remember to
have had a case of pernicious anccmia under my own care
in which such was the case. In such cases I should un¬
hesitatingly try it subcutaneously. It is not always of
beneGt even when tolerated. An regards its mode of action
we have no certain knowledge. It was originally tried from
its occasional, tbougli somewhat uncertain, action in
Hodgkin’s disease, in which it is supposed to exercise
some unknown influence on the cytogenic organs. It
has been suggested that it acts locally on the mucous
membrane of the stomach and intestines (Hunter), I
presume as a germicide in preventiog the development
of ptomaines. In malarial anscmia it probably also acts as
a germicide on the plasmodwin malarvc, in the blood-
corpuscles. Arsenic inhibits the glycogenic function of the
liver, and it is possible that it may restrain its hmmolytic
function. A new light has recently been thrown on the
mode of action of arsenic by an interesting observation of
Dr. Copeman’s.® Writing of pernicious anmmia, he remarks :
“When a drop of blood was removed from the Gnger and
allowed to fall on a gloss slide, then when the edge of the
drop had dried somewhat, a cover-glass was gently placet?
upon it, crystals of hmmoglobin gradually formed in th^
Glm of blood in from ten to forty-eight hours without an 3 R
further preparation. The only exception to this was in the-
caae of patients who bad been treated with arsenic for some'
days, after which crj'stals could not be obtained ; although,
if then the arsenic were discontinued for an equal length of
time, they again put in an appearance.” It would appear
from this important observation that arsenic exercises a-
direct influence upon the red blood-corpuscles, lessening tbe^
vulnerability which we have seen is one of the characteristics'
of aoiumia, especially of haemolytic origin. An interesting
point in connexion with the administration of arsenic is itei
occasional effect in causing bronzing or pigmentation of the
skin. How this is brought about is a disputed point, but
it is probable that it acts by increasing the activity of the
pigment-producing tissues. It is possible that the increase
of colour of the urine noticed in sojiie ca^es of pernicious
aoa’.mia during the administration of arsenic is in some way
connected witii this action. Quinine is useful in the-
pyrexial attacks of pernicious anaimia. I’hosphorus proved
successful in one case recorded b^Broadbent, but has failed,
in others. The evidence regarding mercury is conflicting,,
bub Keys has asserted that corrosive sublimate also in¬
creases the number of red corpuscles, ^-naphthol has
been suggested by Dr. Hunter, and I have added bo the list
other disinfectants which may be worthy of trial, but have
no personal experience of their employment in anmmia.
I had intended to deal with Transfusion in the treatment
of anremia, but my time is exhausted, and I must leave-
this undiscussed. This is the less to be regretted as my
experience in this mode of treatment is small and dis¬
tinctly unfavourable. Moreover, the subject has been
very fully dealt with by M. Hayem, and quite recently by
Dr. Hunter,’’ and the outcome of their experiments and
general medical experience is against the employment of
transfusion for anmmia, though cases of recovery after
transfusion in pernicious anmoiia have been recorded.
Inbra-periboneal and subcutaneous injections of blood have-
also been tried, especially on the Continent, but Cohnbeim
has shown that such treatment, even in the most skilful'
hands, is not free from danger, fatal peritonitis having,
occurred in several cases after intra-peritoneal injections.
But I must now bring my lectuies to a close. I am deeply
conscious of the imperfect manner in which I have accom¬
plished my task. I feel that in trying to cover so wide
a Geld I have dealt in a very sketchy and imperfect manner-
with many parts of my subject. Still I cannot but believe-
that it is desirable that an endeavour to consider the sub¬
ject of anemia as a whole should be attempted, so as to-
Gt the many and detailed observations of the numerous
workers into one harmonious whole. The enormous amount
of work that has been done in recent years and the com¬
plexity of the subject render the office a difficult one,,
requiring an abler exponent than myself.
In conclusion, I desire to express to you. Sir, and the-
Council of the Society, my sense of the honour conferred
upon me in inviting me to deliver these Letbsomian
lectures, and also to thank the Fellows and gentlemen who-
have patiently listened to them.
ON -run
PRINCIPLE OF EXPLORATORY ANI>>
CONFIRMATORY INCISIONS.
Delivered to the. Obstetrical and Gynaxoloyical Society of
Glasgow, Feb. 2nd, 1891 ,'
By LAWSON TAIT, L.Jt.C.P., Edin.,
nONORAItV I’lilCSIDBNT OR THK SOt'riiTV, I’KlCSmENT 01' MASON’S
coi.i-i-:gk, nniMiNfiiiAM.
Gentlemen,— it has been stated by an authority of bho-
highest order that a prophet has no honour in his own
country—a general rule which, like all of its kind, ha.s an
exception, certainly in the present instance a notable one
in my own case ; for the honour which you confer upon me
r.o-night, taken with that which I have to receive to-morrow
* THli lA.NCET, 1887, vol. if., p. 1003.
B Edinburgh Med. Joiini., Nov. 1877, and Med. 'riraea and Gaz., 1877,
Tol. if., p. 131. 0 St. Thomas's Hospital Reports, vol. xviii., p. lOi.
7 Arris and Gale Lectures, Royal College of Surgeons: Brit. Med,
Journ., vol. ii., 1889.
Coogle
TflElANCBT,] MR. L. TAIT: EXPLORATORY AND CONFIRMA.TORY INCISIONS. [Feb. 7,1891. 293
\in a neighbouring and xny native city, ought to satisfy any
mind for the ordinary period of lifetime which belongs to
the profession which we all practise. To me such honours
rank far higher than the titular distinctions which are so
much run after by some of our brethren ; for those which I
diave received have been given by the votes of my brethren,
in the land of my birth, by men, some of whom taught me
in my youth and brought me up, some who have watched
my growth with mingled feelings of alarm an4 satisfaction,
others who have worked and fought in our young army by
any side, whilst there are others amongst them who have
honoured me by being my pupils. Such distinctions are
better than those of Uie titular order, arising as the latter
■do from far different sources, and from motives so mixed as
'to be little calculated to please the independent spirit of a
tJcotchman, and too strongly tinctured with the doubtful
savour of Court inSuence to be grateful in a healthy pro-
'vincial atmosphere.
I need not say, therefore, that I am grateful to you for
this great distinction, the greater that it was as entirely un>
.expected as it was unsought, not only because it is a distinc-
diion of a high personal order as because it is a mark of
.approval of the work and struggle of the last twelve years
\for the advance of the special objects of study in which in such
a Society as this you are engaged. The work has been hard
land the straggle nas been keen, and I fear it is by no means
over yec, for even within the last few days there has been a
violent overrtow of the vials of wrath on the part of one or
two of the old conservatives who represent the departing
^school, and, as usual, I have been the chief object of the
outburst. I feel also that there is a large element of honour
du the office you confer upon me by reason of the fact that,
4is a matter of history, it was in your city, at least in its
meigUbourhood, and by a Glasgow man, that there first was
.achieved the idea of an exploratory incision so far as abdo¬
minal surgery was concerned, and it is a matter of historic
fact that from the incident in question, by direct descent
drom master to pupil in generation after generation, do we
'derive our present splendid positiou. So far as historic
■investigation has yet gone, it was Robert Houstoun, who,
un August, 1701, extended the idea of tapping an ovarian
'tumour into that of an exploratory incision. He was
■driven by the exigencies of the case to a complete
€,Qd successful removal of a gelatinous tumour of the left
ovary, curing the patient, who lived for thirteen years
<ifterwards. This was the first ovariotomy, the story of
which I have told completely in my book on Diseases of the
'Ovaries.
The interest for us is that the story of the case,
passing through William and John Hunter, reached John
Hell, whose pupil Ephraim McDowell was in the year 1793.
John Bell in his lectures alluded to the probability of
•ovarian tumours being some day successfully removed,
basing his prophecy on the suggestion of William Hunter.
McDowell carried the idea into the back woods of Kentucky,
4i,nd there he worked it out in its completeness. The story
-of his first experience he sent in manuscript to his old master,
John Bel], in the year 1810 ; but John Bell was then upon
his death bed in Rome, where I visited his grave but a few
weeks ago, and the manuscript fell into the hands of Lizars,
who was at that time doing Boll’s work, and this accounts
'for the fact that Lizars was the first to follow McDowell’s
'footsteps on this side of the Atlantic. From this point of
■course your knowledge of the history of the operation for
■the removal of ovarian tumours is complete, and I need not
dwell upon the matter further, as it is not pertinent to the
'issue which I have to lay before you. But I cannot help
■auggesling that a Society such as this, in a city which was
the birth place and, during the best part of his life, the
'residence of Robert Houstoun, ought not to rest till some
public memorial of this great man has been brought into
■existence. If you study his life and writings, you will find
Abundant reason, in addition to that which I have given
■you, to characterise him as a man far in advance of the
■days in wiiich he lived. You know that up to the year
1872 there was nothing practically attempted in abdominal
surgery outside the removal of ovarian tumours. Anything
iliat did happen beyond that was the result of blundering,
■so that we may take it that all the cases of uterine tumours
■and other things of the kind which were removed before
■that year were the result of mistaking them, as in Lizars’
instance, for ovarian tumours ; for it had become the fixed
impression and the ruling practice in this department of
w’ork that nothing was to be touched as long as the patient
could get about, nor until life was really actively and acutely
threatened. Ovarian tumours were therefore tapped, and the
evil hour of the operation was put off till its risk was greatly
enhanced. Between the years 1872 and 1878 a revolt from
this practice occurred in various directions. It was sought
to establish for the work of abdominal surgery a duty lar
higher than merely saving half-dead women from the grave—
a duty of relieving suffering as well as of saving life. And
with this higher object in view, the new school of gynse-
cologists claimed the right of removing tumours long before
they threatened life; claimed the right of removing diseases
which did not threaten life at all, hut made it a burden ;
claimed the right of interfering with diseases which were
nob mere ovarian tumours; and, finally, claimed the right
of interfering in eases where there was great doubt os to the
very nature of the disease, and after a good deal of struggling
in the dark this idea became crystallised. In the year 1875
1 formulated a proposal quite new in this department of
surgery, to the effect that we were entitled to open the
abdomen in all cases where there was disease present which
threatened life or made it a burden, for the purpose of
seeing in what direction the diagnosis could be made more
certain, and how the line of effectual treatment could be
opened up. This was a new doctrine as far as abdominal
surgery was concerned, bub it was nothing new in surgery.
A good many years ago I saw a gentleman remove
a breast, after 'having given a long harangue upon the
nature and methods of diagnosing the scirrhous tumours of
the breast. After he had the gland in bis hand, he made an
exploratory incision into it to find about three tablespoon-
fuls of pus occupying a perfectly non-malignant mass; and
then he told us that it was a “chronic abscess.” So
far as the patient was concerned, it would have been far
better if he had acted upon my principle of exploration—
that is, if he bad made an exploratory incision before he
completed his operation. In all casesof abdominal surgery,
as you can easily understand, this is a matter of necessity,
but it does not seem ever to strike our critics that inasmu^
as in all other departments of our art they have been
acting upon the principle of exploration, though sometimes
they put the cart before the horse, as in the instance
I have just given you in the tumour of the breast, we very
naturally ask them the question—Why do you object
to the adoption of the principle within the cavity of the
abdomen?
The new principle introduced, and certainly alluded to on
the other side of the Atlantic, as “ Tait’s law ” was first of
all subject to a great deal of misrepresentation, and even
within the last few years I have heard with my own ears
the president of a distinguished London society say that
“Taib’s law’’was that when you are in doubt you must
open the abdomen. I have constantly had to repudiate any
such statement, because I hold that in every case in which
an operation is performed the serious risk to the patient’s
life is to be justified by the incidence of suffering which
she is undergoing, or the degree of risk of life to which she
is being continuously subjected by the disease, either imme¬
diately or in prospect. To open the abdomen for the fun of
the thing, or merely as a matter of curiosity, is a proceed¬
ing to wiiich I have never given the most remote sanction.
I once heard Professor Huxley say he thought that all men
of science ought bo be painlessly extinguished at the age of
fifty-five; and the explanation of this singular view was that
the learned speaker at that time was himself about forty-
eight years of age, and he was suffering from the recent
attacks of the old school of terabologisbs, who so much and
for so long hampered the progress of the evolutionary school
of philosophy ; who, in fact, kept it back for the first fifteen
years of its existence. In gynmcology we are going through
exactly the same kind of struggle; we are hampered
and watched and vexed perpetually by elderly persons,
who ape a juvenility which they nave long since lost
and a wisdom which they never possessed. To be
serious for a moment, the struggle of the revolution
in gynaicology is really a matter of age. In London
it seems to be an impossibility to get any man over fifty-
five years of age to see things in the new light, and there¬
fore we must wait patiently for that process of natural
extinction which seems there to be the only road to progress.
I saw the announcement of the death of my old friend and
master, Dr. Matthews Duncan, and I read the obituary
notice of him, which caused me no little surprise. I
have a great respect for the old saying that it is nob desir¬
able to say anything but good of the dead, but I have&■
294 The Lakcbt,] MR. L. TAir: EXPLORATORY AND CONFIRMATORY INCISIONS. [Fbb. 7, 1891.
still greater respect for justice for the living, and the benefit
to them of holding up to their inspection of everything
that should not Le. In what 1 have to say of him
there is nothing that I have not said publicly of Dr.
Matthews Duncan, and nearly all of which I have said to
him by word of mouth, face to face; for his faults wore
those of judgment and not of the heart, and he liked no
man the leas for a fight with him. We fought every time
we met, and were at constant war by letter in public and in
private, and the estimation I had of him he was perfectly
familiar with. In 1886, in an address delivered to the
Medical Society of London, I said: “When I find Dr.
Matthews Duncan and Sir Spencer Wells interfering With
what I believe to be the steps proper to be taken alike for
the relief of our patients and the advance of our art, I
utter prayers that they may soon be brought into a better
light, oat I also tell my patients to avoid them and consult
some more reasonable men.” His faults were those of
judgment based upon a constitution of mind that was
essentially illogical. He had a blunt, honestdooking
manner, which carried of course, by reason of his con¬
victions, a real honesty with it, and this commanded the
respect of his clientele and to a very large extent of his
f irofessional brethren. AVe can call to mind that so
ate as 1860 he condemned ovariotomy as quite un¬
justifiable, and took an active part in an agitation to get
it prohibited in the Edinburgh Infirmary. He never en¬
couraged operative interference to the end of his life, save
in straightforward ovarian tumours, and not always in them,
and he ever counselled such operations to be deferred as long
as they possibly could. Concerning the new-fangled opera¬
tive proceedings, he would listen to nothing in tbeir favour
and wonld countenance none of them; and of this I can give a
strange and almost terrible example. In 1884 Dr. Chapman
Grigg was consulted in a case which had been under
Duncan’s care, and in which Dr. Grigg at once diagnosed
pelvic suppuration, and on my confirming his opinion the
atient and her friends assented to an operation. Almost
y force of arms we compelled Duncan to be present at the
operation; and in a very few minutes I 2 >roved to him, by
handing to him two huge suppurating ovaries and tubes,
how grotesquely he had blundered, and how terribly the
patient had suffered by bis obstinate refusal to listen to the
voice of progress. He admitted all I had said, but he
mended his ways not one bit, for in a few weeks he made
the same objection to a similar operation in a precisely
similar case, and I have never heard that since that memor¬
able morning he altered bis custom in the least, or even
admitted the necessity of such a perfectly legitimate and
much-needed abdominal section; and he certainly to my
own knowledge succeeded in mischievously postponing, and
even in entirely preventing, many which were quite as
much needed. Let me give in detail a case which illus¬
trates the foregoing remarks.
In November, 1890, Dr. Boulton of Horncastle sent to me
a lady aged twenty-eight, married about four years, and
who had been twice pregnant. In her first labour Dr. Boulton
discovered a tumour which blocked up the pelvis and
impeded labour. He turned the child and delivered it, but
it died in the process. Dr. Matthews Duncan was consulted,
and his advice was characteristic. She had a lump in her
womb, for which no operation could be performed, but
perhaps she might have a living child if premature labour
was brought on. Tliis was done in the second pregnancy,
but with the result that the infant lived only a few
hours. Dissatisfied with the advice given and the expe¬
rience derived from it, Dr. Boulton sent the patient to
me, and with no difficulty at all I recognised the tumour
as cystic, and as being fixed to the back of the uterus.
From its peculiar feeling, I suspected that it was a
dermoid cyst with a short pedicle, but in any case I
felt perfectly certain that it could be removed, even
if there was doubt about this. I explained to patient and
doctor alike that it was an instance for the adoption of niy
new rule of exploratory incision. I advised tJie patient, ;
therefore, to submit to operation, and I arranged with her
and her medical attendant that if I were wrong, and the
case should turn out to be really a lump in the womb which
conld not be removed, I should remove the uterine appen¬
dages so as to prevent its growth and prevent the patient
again becoming pregnant. On operating, the tumour turned
out to be a dermoid cyst of the ovary, and was removed
with the greatest ease, and with a perfectly successful
result. The other ovary was quite healthy, and was of
course left, and now therefore she is quite as well off an
she ever was iu all her procreative organs, and has had the
fatal obstructions to her labours removed. We can learn a
lesson from this case in two ways. First, no man, however
eminent and experienced, has a right to be so sure of hi»
adverse diagnosis in abdominal diseases as to tell his patient'
to go home hopeless and helpless, that nothing ban be done.
I say an “adverse diagnosis,” because with that the door-
is closed, whilst in positive diagnosis an error, even if it'
occurs, amounts to nothing more than that an exploratory
incision of an infinitely small risk has revealed the conclu ¬
sive nature of the error, has placed the case beyond all'
doubt, and justifies everyone in saying to the patient, “You
must bear tlie fate which is in store for you. ” The diagnosis
in this particular instance just given was easy ; but even if
it had been difficult, I hold that his duty was to recommend
an exploratory incision to make that conclusion certain or-
to alter it for ever. He had what he was pleased to call
conscientious objections to surgical operations, but he had
no objection to the operation of the obstetrician with thfr
induction of premature labour, fatal to the cliild and more
risky to the mother than the removal of the tumour was.
The lesson to be drawn from the attitude occupied by
Dr. Matthews Duncan in the instance I have narrated, and>
in very many others which I could give in detail, is that by
opposing the application of the principle of exploratory in¬
cision he inflicted upon tlie patients a very serious positive
harm, risking lives needlessly, and destroying lives oF
children the parents of whom were most anxious to pre¬
serve. Further than this, he hindered very materially the
progress of our art. But there is another side to-
the picture, iu which the passive resistance on the part-
of men who ought to know better to this common-
sense proposal of exploration is seen to be as mis¬
chievous, perhaps even more mischievous than in the
illustrations I nave already afforded. In the passive'
evil we have the immediate cause of a most insane outcry
against unnecessary operations, an outcry which I abso¬
lutely believe is nob so much directed against measures as
against men. My own experience is that the evil to bci
guarded against in the performance of unnecessary opera¬
tions does not lie in this direction at all, but really in the-
opposite. Personally, I have seen infinitely more harm
done by delayed operations and by advice given to the-
effect that operative interference was either unnecessary or
impracticable at a time when it was really easy and safe,,
the result being that cases come up for our surgical treat¬
ment at a time when the difficulties are enormously
increased and the risk correspondingly greater. Let me-
give an illustration of this kind, pointing out to you at
the very beginning that the origin of the evil is the same—
that is, the resistance to the principle of exjdoratory
incision.
An unmarried lady, aged thirty-five, came to me
in October last with an enormous solid tumour occupying,
the whole abdomen and pushing up the diaphragm.
It was perfectly solid, pushed down into the pelvis,
and a small uterus was pressed down in front of it,,
but apparently no part of it. The uterus was, however,
immovable. The tumour was discovered in 1884, at which
time it was of small size. In that year her inedica&
attendant took her to Sir Spencer Weils, who said
that no operation could be accomplished because the
uterus was so fixed and implicated. The unfortunate-
girl was at the time engaged to be married, and when this
doom was pronounced she and her intended husband resigned*
themselves to their unhappy lot, maintaining, however, their
hopeless relation of betrotnal. The tumour slowly grew till
it reached the monstrous size it had when I saw her. During
these long, weary years incalculable suffering was borne by
this poor woman, physical as well as mental; and the latter
was shaved by parents, numerous relatives, and perhaps
roost of all by the man whorti she is now about to marry..
When I examined the patient last October I came to only
one conclusion, and that was that it was a case of solid non-
malignanb tumour, and I felt my duty clear to take it out.
This I did by an eleven inch incision with the greatest of ease>
for it was only a solid ovarian tumour without a scrap of adhe¬
sion, and with a thin pedicle nearly three inches long. The
patient made an immediate recovery, and only waits for the
firm cicatrix to enter the state of holy Tnatrimony and reward
her lover foraconstancy greater than that of Jacob for Rachel.
The lessons of this case are, like the former, conclusive that
no one can be sure of an abdominal or pelvic diagnosia.
D : t F.oo<^le
Thb Lancet,] MR. L. TAIT : EXPLORATORY AND CONFIRMATORY INCISIONS. [Feb. 7,1891. 295
The mistake made by Sir Spencer Wells in the diagnosis of
this case migbtt be made by anyone, but I think there are
few surgeons—I am sure there are none of the modem
school—who would have refused the poor woman the
chances of an exploratory incision, and the great question is
(HOW close at hand, Shall we not rise and protest ? If it were
an isolated case X would not speak so strongly of the subject
nor of the person, but it is only one instance of a long
eeries of cases where the same iniluential surgeon has
{proved -himself deaf to the reasonableness of our doctrine.
To use his own words concerning another matter and
another person—to wit, myself-it “was a deplorable and
disastrous failure. I have seen other cases almost as dis-
creditable.” Now, I want to put it seriously toSir Spencer
Wells, Is it not a deplorable and disastrous failure of our
great art to occupy six of the best years of a fair young life
■simply because he will not listen to the voice of a genera¬
tion coining after him? Is it not discreditable beyond all
expression that an obstinate and wilful disregard to the
•contin uous advance of our profession sliould be the only
cause why he spreads such wholesale misery for six years
into a wide family circle? Yet that is the language he
uses when he fancies he has found one of his brethren
tripping.
I would not lay such stress upon this principle of explora¬
tion were it not that the whole progress we have attained in
the last few years has arisen out of it. It is not merely
that its adoption must of necessity confer benefit on indi¬
vidual patients, but no kind of farther progress could have
been possible without it. It is the basin of our new school,
■and unless we are prepared to abandon all that we now
achieve, we must lay this down as the first rule of our prac¬
tice. It is a rule which evidently must be, to a large extent,
its own destruction, for just as its adoption is ueely ad¬
mitted on the one baud, so must the facility of experience
when thediagnosishasbeen correct tend to diminish the neces¬
sity of its application; and, on the other hand, the humilia¬
tion of the mistake when the diagnosis has been erroneous or
incomplete equally and alike tend to limit the necessity of
-exploratory incisions, and to reduce them more and more
to the performance of operations of confirmation. Here I
begin to open out ground that is rather new, and upon
which I am very likely to be misunderstood. I shall try to
make myself clear even by redundancy of explanation and
illustration; but with all that 1 may say now I know quite
well that within a month some one will write a letter to
some journal accusing me of saying exactly the opposite of
what 1 have said, and of meaning something quite dilferent.
The meaning of an exploratory incision must be perfectly
appreciated before I discuss the other. An exploratory
incision is one in which, having done your best to make an
-exact diagnosis, you have honestly to say that you hesitate
between two conditions—say, between an ovarian tumour
which is pretty solid, and a soft (edematous myoma. The
difierential diagnosis liere is very important, because if you
.^0 prepared to do on ovariotomy and find you have to com¬
plete a hysterectomy, you may be handicapped by want of
■efficient preparation or provision of the proper instruments.
Besides this, the patient and her friends will, in all proba¬
bility, have asked you to give an estimate of the risks,
.an(l if you have given that estimate on the basis of
belief that you are going to deal with an ovarian tumour,
and find you have to deal with a uterine myoma, you
may have trouble afterwards. You confess, therefore,
’that you have to make an exploratory incision to clear
4ip the doubt, and then you must be prepared for any¬
thing. It is quite certain that as your fingers become wiser,
■such exploratory incisions will become much fewer. I know
that in my own case I do not make one now for eight or ten
that I made some years ago. Confirmatory incisions, on
the other hand, become more common with me because of
the same reason, that the exploratory incisions are fewer,
^tnd they are limited to a class of cases where the majority
suffer from hopeless disease. You will at once ask me why
I should operate on cases of hopeless (lisease, and that is
precisely the point on which I am sure to be misunderstood
■and misrepresented. Let me give three illustrations of con¬
firmatory operations and the reasons for them and I shall
make my meaning clearer; certainly I shall prevent all
reasonable men from misrepresenting me.
A patient, aged fifty-three, was sent to me from London
•with a large abdominal tumour,, and an absolute (liagnosis
was sent with her to the effect that it was a case of ordinary
■ovarian tumour, which I was to remove. Bub id was not a
case of ordinary ovarian tumour. My own diagnosis was
that it was a large mass of cancer of the omentum, and I
gave both patient and friends that adverse opinion. They
were, of course, greatly disappointed and disposed to doubt
the correctness of my opinion, whereupon I at once proposed
a confirmatory incision. I explained to them that if they
took their patient elsewhere, they could only get a multitmle
of opinions; whereas by a small opening they could have
the matter settled beyond all possibility or shadow of doubt,
and that with a mere bagatelle of risk. They at once
accepted the proposal, my diagnosis was confirmed, and
there was an end of all difficulty or doubt. The patient
went home, and died in the course of the disease within two
months. If she had been taken to half-a-dozen surgeons
she would inevitably have come on one who would blunder,
and who would say, “Certainly it is an ovarian tumour anci
can be removed.” He would make an “exploratory” instead
of a “confirmatory” incision.
In all coses, therefore, when a conviction is forced upon
me that the disease is malignant, I tell the patient so, but
at the same time say that all such opinions are liable to
error, and that a confirmatory incision is the only and best
way to give security. Sanguine patients accept the offer,
and they are the majority; and I nave bo confess to such a
percentage of error that I am determined to continue my
practice—that is to say, every now and then a case which
seems to be cancerous with perfect certainty, is not so, and
none could have been discovered to be so without, not a
confirmatory, but a corrective incision. A second illustra¬
tion is the instance where ascitic effusion with a fixed uterus
is clearly due to papilloma. Here I always recommend a
confirmatory incision, because the evacuation of the fluid
with subsequent drainage often cures these cases—cures
certainly one-third of them,—and no kind of chemical
examination of the fluid, no microscopic investigation of
the peritoneal growths, has yet enabled us to aetermine
which cases will prove curable and which malignant. The
confirmatory incision becomes here an essential and most
valuable method of treatment, and has come to be a matter
of course in my practice. The third illustration is perhaps
the best, but nob the most satisfactory, for the majority
of the parties concerned. I was sent for by an eminent
practitioner in the country to remove a tumour from a
lady which had, a few days before, been pronounced
to be an ovarian tumour by a titled metropolitan phy¬
sician. I was not thought worthy by my metropolitan
brother to be admitted to the dignity of having an opinion
of niy own. “Send for Taib, and have the tumour re¬
moved.” The fee was paid, and I was sent for. I went
prepared. The patient was anresthetised, and placed on
the table, when I examined her for the first time, and
finding a tympanic note just below the umbilicus, I was at
once satisfied that I had nob to deal with an ovarian tumour
at all, bub with ascitic effusion. As I made my incision I
said so, and further said that I was merely making a con¬
firmatory incision to put the matter beyond doubt. The
matter was speedily settled, for we found only a few pints
of serum, and no tumour. The dropsy turned out after¬
wards to be due to kidney disease, of which the patient
ultimately died. In such a case as this you may, perhaps,
ask me—Why did you go on with the operation when you
saw that a mistake bad been made? My reply is—firstly,
because I was sent for to do an operation, an operation had
been arranged for and everything was ready ; a tremendous
commotion would have been the result of my refusal to pro¬
ceed, the titled physician would have been sent for again,
might have persisted in his mistake, a second surgeon would
have been sent for who might or might not have acquiesced
in the physician’s mistake, and very valuable time would
have been wasted. The confirmatory incision did no harm,
it really rather benefited the patient than otherwise, and it
buried in oblivion a ludicrousblunder which ought not to have
been made, and the exposure of which could have done no
good to anybody. Finally, it taught my colleague a
wholesome lesson and made him more than ever my friend.
It is, of course, an easy matter to condemn such operations
as unnecessary, but I for one am perfectly satisfied that the
good gained by them in having a settlement, beyond dis¬
pute, of a point in diagnosis which would only be the cause
of needless quarrelling and subsequent and unnecessary
distress on the part of the patient and friends by far
counterbalances any slight risk that may be run.
In my opinion there is no field in which the principle of
exploratory operations has proved more beneficial than in
296 The Lancet,] DR. EDGAR M. CROOKSHANK ON THE tUBERCLE BACILLUS. [Fkb. 7,1891.
the numerous cases of ailment from chronic inllamniatoiry
disease in the pelvis. Until they were boldly attacked by
the band of the operating surgeon they were the subject
of much speculation in the mind of the obstetric physician.
What was more unfortunate, the patients were tbe victims
of great waves of disastrous experimental treatment, each of
which had its origin in some fashionable but quite mistaken
view of their pacnology. We can all remember when the
uniform treatment for menstrual distress, no matter what
its origin, was a wide division of the cervix. After that all
pelvic troubles were due to some mysterious displacement,
and the mischievous pessary was omnipotent; then came
tbe caustic stick; and, hnally, the false notions about pelvic
cellulitis introduced the soluble pessary and the hot douche.
Now that we can investigate the real nature of tbe trouble,
we know that there existo a vast number of cases of chronic
inflammatory disease of the uterine appendages for which
there exists no remedy except their destruction. My own
special contributions to this department of surgery have
constituted me a sort of court of final appeal, and cases of
first instance rarely come under my notice, save occasionally
in hospital practice; and hospital patients seem so long-
suffering, seem to bear their maladies so much as a matter
of course, that I hardly ever see even these cases in their
early stages. It is not surprising, therefore, that 1 never
see them in their curable stage, a coudition spoken
of very glibly by men in whose statements generally I
confess I have not the slightest confidence, aud sometimes
I feel disposed to wonder if they ever really do get cured.
My experience in the other direction is so great that my
scepticism need not surprise anyone. Women come to me
from all parts of the globe with tbe^e damaged appendages,
they give histories of all sorts of treatment, persevered in
for months and years, and they give the names of those
who have conducted the treatment. I often write to these
gentlemen, and, as a rule, I get confident and satisfactory
replies from them to tbe effect that when the patients in
question left their hands the cure in each case was complete
and undoubted; and I believe that they honestly believe
this. The poor pa'ients, however, come to the apparently
inevitable treatment by surgical interference, and I find, as
a result, that my corresi)oudents have been mistaken
about the supposed cure. The pelvic organs of women
are singular in this respect, that it is perfectly im¬
possible to apply directly to them the greatest of
all remedial agents /or any inllammatovy damage—rest.
You may keep a patient in bed indefinitely, to the creat
uetriment of tier general health, with a vievv of benefiting
a chronic inflammation of her uterine appendages, but witli
every returning menstruation the inilaiiimatory condition
is maintained intact. Hjmptoms are relieved undoubtedly,
and the evil day may be deferred ; but 1 am so sure, from
a uniform and .steadily increasing experience, that a cure
is rarely efl'ected, that I look upon cases of alleged cure as
cases of initial mistake. I need not say that this explana¬
tion is not one which justifies us in rm-hing into ill-
considered surgical interferenf’c; bu*', on the contraiy, it
constitutes the strongest of all rrarons for tbe more care¬
ful examination of our cases at the outset. There can be
no doubt whatever that within a very short time there has
been a large amount of grave nialpraxia upon this point,
and a lart-e number of patients have been operated upon
who ought never to have been touched. A few years ago
I had to pay a professional visit to a town of fair size,
not very far removed from the spot where I now am,
and where there is a county hospital somewhat famous for
its surgical activily. I there met a gentleman for whose
many virtues I have much respect, though one virtue,
that of surgical enthusiasm, I think he carries to the
point of error. To my great delight be professed himself as
one of my ardent disciples, and be triumphantly brought
out a series of some two dozen bottles containing the results
of wliathe was pleased to call “Tait’s operation.” As soon as
I had him by himself, I informed him in very ardent language
that he must never, under any circumstances whatever,
attribute to me the awful proceedings involved in the display
of these dreadful bottles. They contained sets of uterine
appendages in almost every instance free from guile, not
such as I should have undertaken to remove save under
circumstances so exceptional as to be hardly worth an
estimation. As for their being the result of “Taits
operation,” I entirely disowned tbe suggestion. And
this brings me to tbe repetition of views and warnings
which I have uttered over and over again, and which,
I see clearly, I shall have to go on enunciating fop
some years to come. Tbe immediate need is growing lesa
and less perhaps, but recurrent outbreaks of objectionable
misrepresentation, if not of mistaken practice, are still
occurring, and need to be corrected. The so-called
“ laparot^omy epidemic ” has probably been stopped in thi&
country at least—I certainly hope it has—for nothing could?
have been more disastrous in its effects than such a pro¬
ceeding as I have illustrated. But nothing could be more
stupid or discreditable than the persistent misrepresenta¬
tion to which the real pathology and surgery of the uterine
append^es are still occasionally subjected.
[Mr. Tait here alluded to the matter which was discussed
by himself and Sir Spencer Wells in our last two issues^
and which is further commented on by Mr. Tait in ouc
present number.]
ON THE MORPHOLOGY, CULTIVATION, AND*
TOXIC PRODUCTS OF THE TUBERCLE
BACILLUS.
By EDGAR M. CROOKSHANK, M.B.
[Abstract of a Communication to the Pathological'
Society, Feb. Srd, 1891.)
Morphology.
In 1888, while investigating the transmission of tuber¬
culosis by the milk of tubercular cows, I was led to study
the morphology of the bacillus in the manifestations of thie-
disease in different animals.^ It is well-known that the
bacilli in tissue sections of bovine tuberculosis are shorter
and less granular than those in human tubercular sputum-
On examining milk from tubercular cows my attention was
arrested by the appearance of the bacilli in the preparations
which I have placed under the microscopes before you>
They do not possess the familiar appearance of the bacilli)
in tissue sections. They are longer and very distinctly
granular or beaded, and are thus brought mneh closer,
morphologically, to the bacilli in human sputum. IS
we take individual bacilli in cow’s milk, some are even
longer and more regularly beaded than the bacilli in
most preparations from a human source. Speaking:
generally, however, the average length of the humau
bacilli is greater than the average length of the bacilli in
cow’s milk, but the longest of the bovine bacilli cannot be
distinguished in length from the longest human bacilli. There
are, however, exceptional eases, and I would illustrate this by
drawing your attention to a particular preparation of pus
froDi human lungs in which the bacilli are remarkable, no&
only for their thinness, their uniformly beaded cliaracterp
but more particularly for their extraordinary length. This
may he compared with another preparation in whicli tho
bacilli, though in human sputum, are much more distinctly
rod-shaped, much shorter and thicker, with complete-
abyence of any beaded appearance. In short, neither length
nor granularity afford characteristics wliich are suflicient to-
denote any specific differpnee between human and bovine-
bacilli. i''ollowing up tl)e same line of inquiry I have
examined minutely the bacilli in tuberculosis of obhei-
animals, such as the horse, pig, and cat; and of birds—tbo
fowl, guinea-fowl, pheasant, and ostrich, Here, again^
minute morphological differences can be observed. For
example, in many cases in fowls the bacilli are conspicuously
{-bort and straight. In the liver and lungs of an ostrich,
for which I am indebted to Mr. Bland Sutton, I found-
packets of short rod-forms, while in other parts of the same-
sections the bacilli attained a greater length than 1 had at>
that time observed in any other tubercular specimen.
Many of the long sinuous forn)s exhibited a peculiar
terminal enlargement. There were also short rods with a.
similar appearance, and free ovoid bodies singly and in.
groups, which, from their connexion with the bacilli,
and their sharply defined outline in tbe free state, are very
suggestive of spores. Thus morphological differences arei
found under different circumstances, and within limits the
5 Annun.1 Report of the Ag)-icultural Department for the year 1888 r
Kepoit on Tuliei-cular Mammitis in Cows, with Expei-iuienU relating t«-.
tho Infectivlty of the Milk, and Rcinoiks on tbe Tubercle Bacillus.
Digiti. i' /CjOO^Ic
ThbLancbt,] Dll. EDGAR M. CROOKSIIANK on the TUnEKCLE BA.CILLl'8 . [Feb 7. 1891. 2^.7
morphology of the tubercle bacillas varies with its environ-
ment.
Having sncceeded in producing tuberculosis in a calf
by inoculation with human sputnm, the next step in my
investigation was to ascertain the effect of inociilatioo
of calves with a pure cultivation of the tubercle bacillus. I
was thus at the same time led to study the morphology of
tbe bacillus under different conditions outside the animal
body.“
Cui-TIVATIONS.
Blood serum, — Koch® attempted to cultivate the
bacillus on nutrient gelatine, without success and con¬
cluding that ic was necessary to employ a high tenijierature
he substituted sterilUed blijod serum. The blood serum
was prepared hy an elaborate process involving enormous
expenditure of time and labour, and very few were able to
verify his researches. In about ten or fifteen days a growth
began to appear and minute dry scales were visible to the
naked eye. In liquid blood serum a thin film formed on
the surface of tbe liquid, easily broken by agitation. In
neutralised broth tliere was very little indication of success ;
a triturated culture was added to the broth ami agranular,
sandy, whitish deposit collected at the bottom of the vessel
with indications of an increase in amount. Koch also tried
nutrient agar-agar, which did nob prove to be at all a
favourable medium. Some increase took place, but there
was no continuous growth over the inoculated area.
Glycerine agar-agar. —Nocard and Roux* were among
those who worked at the subject and confirmed Koch's
observations. Nocard attempted to get cultures of avian
tuberculosis on blood serum to which peptone, salt, and
cane sugar had been added. The results were more success¬
ful than with ordinary serum. But he enoiintered a
ditllculty in the rapid drying of the surface of the medium
which rendered the tubes unfit for use. It occurred to
Nocard and Roux to obviate this by tbe addition of a
hygroscopic agent, and accordingly they added sterilised
glycerine. The result, which far exceeded their expecta¬
tion, evidently was not solely attributable to the prevention
of desiccation. Following up their discovery, and being
anxious to find a medium more euiily prepared than blood
serum, they added G to 8 per cent, of glycerine to ordinary
nutrient agar-agar. The bacillus grew so abundantlv in
this mixture that a culture in fifteen days equalled in
extent a culture on blood serum which was several weeks
old. The bacillus was found to grow abundantly in veal
broth to which glyceiine had been added in the proportion
of 5 per cent., the bottom of the flask being covered in about
three weeks witli a flocculent deposit having some resem¬
blance to anthrax cultivations in liquid media. In beef
broth, chicken broth, and in Cohn’s liquid, cultures were
obtained after the addition of glycerine.
Confirmation and extemion of the results obtained hi/
Noexxrd and Jtoux —Through the kindness of M. Roux 1
had an opportunity the same year (1888) of examining his
cultivations at M. i’asteur's laboratory, and 1 am also in¬
debted to liiiii for a cultivation from which subcultures have
been kept up in my laboratory during the past year to
tbe present time. I have another distinct series of cultures
which I shall also show you ; cultures up to a ninth sub
culture, originally obtained direct from human tubercular
sputum. I propose first to supplement tbe statements of
Nocard and Roux by a more detailed detoripbion of tbe
macroscopical and microscopical appearances of cultivations
in difFerent media.
Deseriplioii oj eultirations on glycerine agar-agar. _The
cultivations on the sloping surface of obliquely solidified
glycerine agar-agai® begin to appear in from four to six
days as very niinuto white colonies. These steadily in¬
crease in Slice, and either look moist and smooth, or, even
at this early stage, appear dry and crinkled. This early
growth can be seen in the tubes of the ninth generation
which were inoculated twenty-five days ago. According t<i
the number of bacilli inoculated, the crJonieH will either
remain isolated or coalesce and form a more or less cod-
tinuouB film. If tlie nutrient agar-agar has only recently been
prepared, there is usually a quantity of liquid present, and
the bacillus forms a white coacing over tlie inoculated area
and beyond it. The appearances are much more ebarac-
Fia. 2.
FiiiiTth Milx ulturcH im aear-nKar, iirjirly ten nuniths
nlil, fniiti Iiiitiiaii tulicrciiliir Himtmn. liioi'tiliitrd . fuillTth,
ISUii. (l•'|'(l|u pliiiU)f;ia|)lia.)u
teristic when this medium is, comparatively speaking, dry.
A semi-transparent inembranous growKfi develops, tliicken'*,
and assumes a characteristic lichenoiia appearance. Sncli
a culture, cxaniioed with a pocket leus, resembles a niudrl
in wax in miuiature of the folds of the gastric mucous meiti-
brnno. This appearance is especially well seen in Fig<. I
and :i. In about six weeks to two months the culture has
Fi<i. 3.
Flu. -1,
^ Tliw itidciilation of the liai-illns in (ho liviiia; niiiiiml—in ctlvos.
rabbits, (luiiK'ii jiipH, and firtps—must iio loft f<)r tiituro cimsiiU'riiliim.
Hut, hi order to oxiiliiin dome of tlio iirqiaratioiis utidor tlio iiiioro-
sropoB, whii'h aro labelled “ Taborclo barilli and Mi'tschuikoirw pliaRo-
cytus,” I may say Unit I have Htiidiod tbcsi* pln'iiomoiia by iujevtiiiv; a
few nilniniH of a liiiuiil niltnri' of tubori'li’ baialli into the (iorsal lyiiii>h
sai'ii of fropH and runiuv inp at Intorvalii a diop of llio lymph by niiaiiia of
a capillary tube.
3 Alittlieiluiipt'ii auH dom KaiBorllclion (lemindlioitsanit, 1884.
* Annalos do I’liiMtitut PaMlour, 1887 : " Siir In Culture du Bacille do
laTuberculose."
4 The nutrionb apfar-apar is prepared in the ordiniiry way, and by pro-
fereni'o I add tbe plycoriiie in the propoition of A lar cent.
'' Kip. I has boon already published In iny Miiuuiil of B.ii leiiolopy,
t'liul edition
Klii. .1.- Auothor Hubciilturc on plyoorine upnr-ii^nr of Iho
HUiio spe and sourco as Kips. I and V.
Km. 4.--Kiflli subculliiro on alyccriiio apar-apm', mure tlmii
nix nioiitliH obi. Inoculated .Inly 2Jnii, IJ-S'o,
Digitized by LjOOQle
(Feb. 7,1891.
898 The Lancet,] DR. ED(;AU M. CROOKSIIANK ON THE TUBERCLE BACILLUS.
fnlly developed. In old culturee, especially wUen the indi*
vidtial colonies remain isolated, the appearance id very
characteristic (Fig. 7, A and n.) Some ciutores in appear¬
ance closely resemble cultivations on blood Hemm. The
consistency of the growth depends upon the character of
the soil and the age of the culture. If the medium be moist
the growth is moist and viscous, but more often it is dis¬
tinctly tallowy, and in old and dry cultures scaly and friable.
Cultivations in (jlycrrinc broth .—From subcultures on
glycerine agar-agar 1 have obtained luxuriant growths in
glycerine broth. In a few days minute llakes are visible.
Fig. 5. Fig. G.
rni. 6.—Sixth sulx'iiltuTi! from Hio Hnno houfco, more thJin
MiriH: moiitiis old. luooiilateil Uctoher I6lli, ISiru. (From
(liiotoprftiihH.)
Kio. 6.—Eixhth sulioiilturc, nearly two montlin old. Inocti-
liU’il Decviuber 8tli, llStlD. (From pliuto^'midis.)
Tlicy rapidly increase in sue, and form in four or 6ve weeks
a copious depo-tit at the bottom of the llask. When shaken
the il )cculent deposit rises in stringy niaases, and this appear¬
ance is ouite characteristic (very marked in the glycerine
broth cultures prepared Nov. llth and 28tb). The liquid
in the lla^k remains clear. Turbidity ii a sign of contami¬
nation. If tlie cultures are left absolutely undisturbed for
two or three weeks the whole of tlie surface of the liquid is
covered by a delicvte greyish-white veil, easily broken up
Fig. 7.
contirmed the observation of Nocard and Roux that sub¬
cultures from glycerine agar-agar or from glycerine broth
will give cultures in ordinary broth without glycerine.
Ordinary broth with egg-albumin and without glycerine
will also give a good growth when inoculated from previous
Bubcuiturea, altbougb the attempt to produce primary
cultures in these media has hitherto failed.
CuUivatiom in glycerine, viilk, and other media. —In milk
I find there is only a slight increase in the number of bacilli
inoculated, but milk with glycerine in the proportion of 5
per cent, forms a more favourable medium. 1 have also
attempted to cultivate the bacillus on sterilised urine and
glycerine, and ordinary nutrient gelatine with 5 per cent,
of glycerine.
Examination of cultivations .—To examine the bacilli in
these various preparations I prefer to use Neelsen’s method,
lloating the cover-glasses for from live to ten minutes on
warm carboliaed fuchsine and passing them through diluted
sulphuric acid. In some cultures the bacilli are shorter
and thicker than na commonly observed in human sputum,
and they are for the most part without the beaded appear¬
ance. In old cultures on glycerine agar-agar the number of
granular or headed bacilh increases, and there are^ also a
number of peculiar forms. These are long bacilli, in some
cases two or three times the length of an ordinary bacillus,
provided with a club-shaped enlargement at one or both
extremities (Fig. 8). I regard these as corresponding with
Fig. 8.
A. IdoKteh coltmles on glycerine aii;ar-iiKar niter nearly ton
■iioiillis' growth. Su1>cuItiiro fioin Iiinnitii Hputiiiii (lourlli
Htilii-ultnre). n. iHoliited rolotiy after Heveii iiionUit’ growth.~
(I'Viiin phutogra]ibH )
by gentle agitation, and forming flakes whicli gradually
stuk !ri the liquid. If undisturbed for several weeks this
him increases in thickness, is irregularly lisaiired, and lias
more the a(>p<;Araoce of masses of tallow lloating on the
surf ice. The growth also may he seen to extend up the
■ide of the llaek above the liquid. I’astenr or Krlenmeyer
ilaski can be employed for these cultures. I prefer
the former. Solidified egg-albiiuiin ad<led to tlie gly¬
cerine broth seemed to increase the amount of growth
which clings to the albumin aoil waves to and fro in
the liquid when the llask is gently shaken. I have also
r plintngmph (li) uiih from it vury ch.amctnri.itic iniltnre innculatvil
by Nir Hugh llst'vur from my I’Arh hui'Ios,
Cover-glnss preparation Htaiiiud with I'arholl.Htnt fnchKiiie and
treated with anlpluirlc arid, from a cultivation on glycorine
agar-agar. :■ FJiiii. (Powell and Lealand apochrom., o.i.
E.P. 10 lamplight ilium., edge of liame.)
the so-called involution forms, and they are no doubt
identical with the bacilli with swollen extremities observed
by Nocard and Roux.
In milk the appearance is very striking, many bacilli
attaining in old cultures a great length, and all are more
uniformly beaded than in any other cultivations (Fig. 9).
Staining preparations by the method of Gram in all cases
exaggerates this appearance. The important part played
by the environment is shown by the morphological diffe¬
rences observed in artificial cultivation under varying con¬
ditions, and by the fact that by successive cbltivation the
bacillus can be educated to grow upon a medium which is
unsuitable for obtaining primary cultures.
Microscopical preparations of the bacilli from these
various cultures, and the cultures themselves, I will de¬
monstrate to you.’’
Impression preparations of the growth of the bacillus on
the surface of glycerine agar-agar in capsules, show a
s Tlir> iiiiper was ilhiHtratud by uunierouH lulcroscnploal nreparatlons
and tho varlnuH culMvultons dexmLed. and by pliotogjaplis projected
by the uxyhydrogon lantern.
Digitized by
Google
The Lancet,]
DK. EDGAR M. CROOKSHANK ON THE TUBERCLE BACILLUS. [Feb. 7, 1891. 299
tendency to the formation of serpentine colonies, composed
of bundles of more or less parallel bacilli.
Toxic Products.
In August last Koch” announced that affcer failing with
ethereal oils, and with metallic substances such as com¬
pounds of cyanogen and gold, to check tuberculosis in
animals, he had hit upon a substance which prevented the
S th of bacilli, not only in tube cultivations, but in the
of an animal. On Nov. 14th Koch>” published a
er communication describing the effects upon lupus
and other tuberculous processes. It had occurred to
me as possible that Koch had been working on the same
lines as Wooldridge, Hankin, and Martin. On the other
hand, it was equally possible that Koch’s researches were
in an entirely new field. I was therefore stimulated to
investigate the products of the tubercle bacillus in glycerine
broth cultures, as in any case the results could not fail to
be of interest. I prepared glycerine broth cultures in bulk,
and having by Dec. 5th obtained abundant growths of
the bacillus, I separated the bacilli from the liquid cultures
by filtration. Before, however, describing and demon¬
strating the methods and the apparatus which I employed
and the results which followed, I will venture to remind
you in a brief historical sketch of the work which had pre-
Fig. 9.
CoTor-gliiss prepaiution of a cultivation in glycerine milk stained l>y
Neelaen's method (carbolisod fuchsino and siuphuvic add), x 1200.
viously been done in this field of physiological and patho-
lomcal chemistry.”
Ftomaincs, toxines, and alhumoses. —In 1822 Gaspard and
Stick found an intensely poisonous principle in cadaverous
extracts. In 1866 Panum discovered a poisonous substance
in putrid material, and in 1863 Bergmann and Smiedeberg
found a nitrogenous crystallisable substance in putrid beer
which they named stpsin. Zuelzer and Sonnensebein
isolated a venomous nitrogenous body from putrid meat.
In 1872 Gautier found that the decomposition of fibrine
lead to the -formation of various complex alkaloidal
substances, and in 1875 Dr. B W. Richardson^” obtained in
py.'i’.mia an alkaloid, septine. This subject, however, received
most attention from the classical researches of Selmi, the
Italian toxicologist. Selmi, in a celebrated poisoning case,
demonstrated the presence of an alkaloid as the result of
post-mortem changes. Similar substances were found in
alcohol in which morbid specimens had been preserved.
Thus the researches of Gautier and Solmi established the
fact that albuminoid material undergoing decomposition
leads to the formation of cadaveric alkaloids. These animal
alkaloids Selmi named ptomaines. To several investigators,
but to Nencki and Briegor particularly, we owe the additional
knowledge we have obtained of these poisonous animal sub¬
stances. Brieger, finding the bases derived from the pro-
" An Address on Bacteriological Research; International Hledical
Congress, August, 1890.
A Further Communication on a Remedy for Tuberculosis:
Deutsche Mod. Woch., Nov. Uth, 1800.
u I would refer the reader interested in this subject to Animal Alka¬
loids or Ptomaines and Ijeucomalnes, A. M. Brown : Uobev Ptomaine,
Brieger ; Chemical Physiology and Patliology, Halliburton.
ri'niiiLANcaT, April, 1876.
ducts of putrefaction lees poisonous than those obtained
from the pathogenic bacteria, suggested the term’ toonms
for the latter. Ptomaines have been divided into two
classes—tliose which are non-oxygenous and are liquid
and volatile, and those which are oxygenous, solid, and
crystallisable. They are for the most part precipitated by
the ordinary reagents for alkaloids such as chloride of gold,
double iodides of mercury and potassium, picric acid, and
tannin. Phospho-molybdic acid precipitates them without
exception. They are powerful reducing agents. Feni-
cyanide of potassium is converted into ferro-cyanide in their
presence, and the addition of ferric chloride gives the Pmssiaa
blue test. Selmi discovered this test, and Brouaidel and
Boutmy regarded it a.s absolutely characteristic of
ptomaines; but this is uot the case. Some vegetable
alkaloids, for example, behave in the same way.
As examples of the ptomaines already investigated, I
may refer to parvoUne, from putrid mackerel and horse-
ilesh, an oily base of an amber colour; hydro-coUidiste,
from the same source, and compared by Gautier in its toxic
effects to the venom of the cobra di capello; collidini,
from putrid gelatine and pancreas of a bullock; neuridine,
from flesh, fish, and decaying cheese; cadaverine, from putre¬
faction and from herring brine; putrescine, from the same
sources. These are non-oxygenous.
As examples of oxygenous alkaloids there are neurine in
cadaveric putrefaction, choline in Idle, muscarine in a
poisonous mushroom and putrid fish, gadinine in putrefying
cod-fish. Poisonous alkaloids are of great importance in’
connexion with those cases of meat poisoning produced Iby
sausages, hams, and poultry. Tyrotoxicon is an alkaloid
obtained from cheese. But the poisonous substances of most
interest to the bacteriologist are those isolated from pure
cultivations of pathogenic bacteria, such as cadaverine
and putrescine, isolated by Brieger from cultivations
of Koch’s comma bacillus ; typhotoxine and tetanine,
and poisons which are not aJlcaloids — the albumoset
or tox. albumins —poisonous substances allied to the albn-
mose of snake poison. Pasteur’” suggested that in anti-
rablc inoculations the immunity resulted from thejaction
of a substance secreted by a hitherto undiscovered
microbe. Salmon” produced immunity from hog cholera by
the injection of the filtered culture fluids. Cbairin,"
and later Woodbead and Wood” and Blagovestclieneky,’^
worked with bacillus pyocyaneus. Roux and Chamber-
land” performed similar experiments with the bacillus of
malignant oedema; Roux” with symptomatic anthrax;
Chantemesse and Widal” with the typhoid bacillus. Roux
and Yersin” worked on the same lines with diphtheria, and
Brieger and Fraenkel'" obtained a tox-albumin from their
cultivations. Anrep;’ found an albumoso in the medulla of
rabid animals, and Babbs”” claims to have found an albn-
mose in both rabies and glanders. It is not, however, too
much to claim for our own countrymen priority in the
scientific investigation of the poisons of pathogenic bacteria.
Wooldridge's rcscarches.~\M 1887 Wooldridge”” succeeded
in protecting rabbits from anthrax by a new method. A
proteid body obtained from the testis and from the thymus
gland was used as the culture lluid. This proteid substance
was dissolved in dilute alkali and the solution sterilised
by repeated boiling. This was inoculated with the anthrax
bacillus and kept at 37° C. for two or three days. A small
quantity of the filtered culture fluid injected into thecirco-
latiou in rab'bits produced immunity from anthrax. Sul^
cutaneous inoculation of extremely virulent enthrax blow
made at the time of the injection of the protecting fluid
and subsequent inoculation remained without effect, and
Wooldridge concluded that the growth of the anthrax
bacillus in special culture fluids gave rise to a substance
which when injected into the organism protected against
an immediate and subsequent attacks.
Hankin’s researches. — In 1889 Hankin-' worked under
the guidance of Professor Koch in the Hygienic Institute
of Beilin. The acquiied tolerance of the effect of ordinaiy
albumoses and the experiments of Sewall,”” who produced
i:' Comptos Reiidns, tonio ci., p. 7011,1885.
n Aineric. Vet. Rev., 1880; Roports. Agricultural Department, D.B.,
1S87. IB LaMaladiePyocyanique, 1889. w TiiK Lancict,
17 Aiinalea do I’InstItut Pastonr, 180u. i'* llnd., 1887 .and 1S88.
>» Ibid., 1888. 7® Botlmor Klin. Woch., 1890.
Vraeh, nnotod by Brit. Mod. Joimial, 1889.
2B Quoted by Hankin, Brit. Med. dour., July. 1800.
23 Tran.sacMoiis of the Royal Soeiotyj xxii., p. 812, received April lOin,.
1887, Arclilv fill' Auatomio niid Pbysmlop., 1888.
M Brit. Med. .Toutnal, Oct. IStb, 1880. and July 12th, ISOn.
at Journal of Physiology, 1887.
800 The Lancet,]
MR. G. A. WRIGHT ON ABDOMINAL ABSCESS.
[Feb. 7,1891.
immunity against lethal doses of the albumose of snake
poison by the injection of minute doses, led Hankin to
expect that if an albumose developed in anthrax cultures
such anthrax albumose would probably confer immunity
from the disease. Such an albumose Hankin succeeded
in isolating from culture fluids. It was precipitated by
addition of excess of absolute alcohol, well washed in alcohol
to free it from ptomaines, filtered, dried, then redissolved
and filtered through a Chamberland filter. With this
albumose Hankin succeeded in producing immunity in mice
and rabbits.
Martin's researches. —Sidney Martin,-'^ working quite in¬
dependently, grew the anthrax bacilli in a solution of
pure alkali ^bumin made from serum proteids. After ten
or fifteen days the organisms were removed by filtration
in a Chamberland filcer. The filtrate contained proto-
albumose and deutero-albumose, a trace of peptone, an allca-
laid, and small quantities of leucin and tyrosin. The mix¬
ture of albumoses proved poisonous to mice. The anthrax
alkaloid produced symptoms and lesions similar to tbe
albumosee, bat much more rapidly and severely. Martin
concluded that tbe anthrax bacillus in digesting the alkali
albumin formed albumoses and an alkaloid. And he sug¬
gested that the alkalinity of tbe albumoses explained tbeir
toxic properties, tbe alkaloid probably being in a nascent
condition in tbe albumose molecule.
Toxic products ofglycerine-culturesofthetuhercle hacillxhs .—
I will now proceed to describe my own experiments. Having
obtained by December 5th several batches of cultures in
glycerine broth, tbe next step was tbe separation of the
bacilli by filtration. 1 employed for this purpose a simple
apparatus constructed for me by Becker. It consists of an
exhausting apparatus in which the bell-glass is cylindrical
in form. Tbe mouth of tbe cylinder is plugged with a
perforated indiarubber stopper, which tightly grips a
porous pot of white porcelain. To prevent putrefaction
during the process ot filtration I add 5 per cent, solution
of carbolic acid in the proportion of 1 per cent. Tbe filtrate
is perfectly transparent, alkaline in reaction, and yellowish-
brown in colour. As it was probable that any toxic sub¬
stances were present in very minute quantity, I evaporated
■down the filtrate in a vacuum over sulphuric acid and at
a low temperature. This proved to be a very tedious pro¬
cess, and occupied from Dec, 8th to Jan. i2th. In the
meanwhile I prepared additional filtrates in the way I have
already described. On Jan. 12th tbe filtrate was reduced
to a brownish viscous residue consisting piincipally of tbe
glycerine from the original culture fluid. I diluted this
viscous residue with ten minims of sterilised water
and injected two minims subcutaneously in a guinea-pig.
There was no doubt that I was in possession of a very
toxic substance. The effect was almost immediate. The
temperature began rapidly to fall, the coat was erect, and
the heart’s action extremely irregular. This was followed
by irregular muscular spasms. There was loss of control
over tbe extremities, and death ensued. The temperature
before injection was 09- j!''; at I P.M., 93°; 2 P, M , 94°; 3 P M.,
9.3 (V”; 4p.m,, 92°. In alechal dose in the healthy animal this
toxic extract is therefore a powerful hypothermic agent.^
The separation and effects on animals of pure materials will
he the subject of a joint paper with my friend, Mr. Herroun,
and I will therefore only hrielly refer to the tests applied to
the culture filtrate, Phospho-tungstic acid gives a copious
■white precipitate. I’otassic bismuthic iodide a distinct
orange-yellow. Potaseic ferri-cyanide gives after standing
a few minutes a beautiful blue (Prussian blue test) on addi¬
tion of ferric chloride. Iodine in potassic iodide solution
gives a precipitate after standing for an hour; more
marked after twenty-four hours. The precipitate examined
microscopically is composed of boat-shaped and acicular
crystals; examined after some hours the crystals are in
varied forma of a highly characteristic appearance. There
is also under other conditions an amorphous precipitate.
Phosplio-molybdic acid gives a yellowish precipitate, and a
blue colour on the addition of ammonia, which disappears
on boiling.
The tubercle bacillus probably produces from proteid
substances a complex proteid poison in which, as in
anthrax, tbe alkaloid ot tubercle, or ttiberculine, is in a
2H Nature. May 29th, 1890, p. 118.
Throe days afterwai'ds (Jan. l.'ith) Koch announced tliat the sub-
.'rto.noe lilted in his anti-tubercular treatment wa.s a “Klycorino extract
of pure cultivations of the tubercle bacillus,’’—Deutsch. Med. Woch.,
Jan. 1801. '
nascent condition. According to different stages of cultiva¬
tion, we should therefore expect to find either a complex
proteid substance of tbe nature of an albumose or this
complex substance together with free ptomaine, or the
ptomaine alone; the ptomaine being a later pioduct of the
splitting up of the proteid substances.
Glycerine infusion of tubercular tissue. —I have also pur¬
sued another line of inquiry. I obtained on Dec. 10th
masses of tubercular glands from the lungs of a cow suffer¬
ing from Perlsucht. The lungs bad been sent to the Royal
Veterinary College for examination. These masses of tuber¬
cular new growth were cut up, rinsed in distilled water,
finely minced, left in ice overnight; the turbid extract
obtained by squeezing through a cloth was finally filtered
through porcelain. A perfectly clear amber-coloured fluid
was obtained. I must defer a detailed account of tbe ex¬
periments with this infusion; but one result of interest,
proving that the virus of tubercle is particulate, is that
guinea-pigs inoculated with the infusion before filtration
contracted tuberculosis; guinea-pigs inoculated with tbe
clear filtrate remained free from tubercle. To ascertain
whether there is protection given in the latter cases th^
have since been inoculated with fresh tubercle, and the result
remains to be seen. More recently I have prepared a similar
filtrate by another method. Masses of tubercular glands
from another case of 'Perlsucht, amounting in weight to
about 51b., were cut up, finely minced, mixed with 4 oz. of
glycerine, and left in ice overnight; 15 oz. of a turbid in¬
fusion were obtained. Solution of phenol (5 per cent.) was
added in the proportion of 1 in 10. This was filtered through
porcelain, and a clear yellowish filtrate obtained. This
nitrate gives similar chemical reactions to artificial cultures
of the bacillus.^®
Koch has not yet published the details of the effects of
bis liquid upon animals when administered in non-lethal
and lethal doses ; and we await with patience his account
of tbe chemical and physiological properties, and the exact
mode of preparation and the regulation of tbe dose. But it
is not undesirable at this time to take an opportunity of
pointing out tbe toxic effects of the concentrated extract of
cultures in glycerine broth as a precaution to any who
might be disposed, without exhaustive experiments on
animals, to make the details I have given in this purely
pathological iuvestigatioQ tbe basis for tbe preparation of
material intended for injection into the human subject.
ON SOME FORMS OF ABDOMINAL ABSCESS.
By G. a. WRIGHT, B.A. OxoN., F.R.C.S.,
Sl-;N10a ASSISTANT SUnOEON, nOYAL INl'lRMAHY, MANCHESTER, &C.
Ar.scESSE.s may form in many positions in tbe abdominal
walls or cavity, and may be produced by avariety of causes.
They may, in the first place, be intra-peritoneal or extra-
peritoneal ; tbe latter may be 2 >aiietal or visceral. Of
visceral extra-peritoneal abscess—i.e., abscess in tbe sub¬
stance of the liver, spleen, kidneys, pancreas, &c., I do not
propose to treat, nor shall I further allude in the present
2 )Qper to abscesses connected with tbe female genital organs.
Abscess in the anterior abdominal wall, int^r-muscular or
subcutaneous, though often met with and sometimes puzzling
in origin, is a less obscure subject than that of tbe deeper
forms of suppuration, and may for the present also be set
aside. Tbe cases I wish to bring forward now are certain of
those in which suppuration occurs either io tbe structures
immediately outside tbe peritoneum, whether pro-peritoneal
or letro-peritoneal, and those in which there is localised
intra-peritoneal abscess. Many extra-peritoneal abscesses
are due to visceral lesions—i.e., are peri-visceral—such are
peri-nephritic suppurations, &c ; otnera are due to bone
or joint lesions—spinal disease, sacro-iliac disease, and
so on. A few arise from the tracking downwards
of eriipyemata or other intra-thoracic collections of pus;
tts The following are the results obtained when the same reagents are
added to the licjuifl Muppliod by Koch:—Alcohol added in cxcosa
reduces a turbidity, pJiospho-tungstic acid a wliito precipitate, potassie
iainuthio iodido slight orange precipitate. I'otassic fern cyanide, after
standing a few minutes, gives the Prussian blue tost on the addition of
ferric clilorido. Iodine in iodide of potassium gives aftor standing an
amorphous precipitate. Phospho-molybdie acid gives a yellow precipi¬
tate ; blue colour on addition of ammonia, which disappears on boUing.
The Lancet,]
MR. G. A. WRIGHT ON ABDOMINAL ABSCESS.
[Feb. 7, 1891. 301
some are obviously traumatic. Bub after excluding all
these, there is still a large residuum that requires con¬
sideration ; that receives very scant, if any, notice from
most writers, and that ought to be, I believe, recognised as
due to inllammation of lymphatic glands. Part of the
object of this paper is to illustrate this proposition.
Intraperitoneal abscesses are usually due to visceral lesions
in which the mischief has spread to some part of the sur¬
face of the affected organ that is covered with peritoneum.
Others result from a primary peritoneal lesion j such are
some of the tubercular abscesses. Others are obscure in
origin—for example, subphrenic abscess. Others, again—
rimarily extra-peritoneal (parietal)—reach the peritoneum
y direct extension. Diffuse suppurative peritonitis is no
doubt most frequently due to the escape of certain irritating
material into the peritoneal cavity. Such a condition is
seen when one of tlie hollow viscera becomes perforated and
its contents leak into the general peritoneal sac. Occasionally,
of course, diffuse purulent peritonitis arises from other causes.
Local peritoneal abscess has frequently a similar origin to
that given in the case of the more widely spread suppura¬
tion ; thus we constantly see it occurring as a result of
appendicular inllammation. Subphrenic abscess and some
of the local tubercular abscesses are instances of other
forms. Why in some cases the suppuration is diffuse and
in others strictly localised is at times difiicult to explain.
Usually it is a question of time, of the acuteness of the
process ; it takes time to form a firm barrier of adhesions
around the irritating material. Sometimes apparently the
feeble condition of the patient, sometimes what might be
called the “indolence” of the peritoneum, its lack of reaction
to irritation, is the reason of a failure to localise the
mischief. In considering the subject of abdominal abscess
it must of course be remembered that any form of localised
suppuration may by extension affect other parts or become
diffuse.
The following cases illustrate several of the varieties of
abdominal abscess, and I have in most of the cases given
ray own view of the origin of the mischief, though it is often
quite impossible to be sure, without wholly unjustifiable
manipulations, whether the case is one really of extra-
peritoneal abscess or of localised peritoneal suppuration.
Some of these abscesses disappear without operation and
without discharging externally; probably most of those
that recover without operation burst into some adjacent part
of the bowel or other viscus, and are thus emptied. In other
instances they no doubt dry up. My own opinion is that
they should be opened and drained as soon as they are
recognised. So far as I have seen the great majority do
well, and it is certainly more reasonable to treat them in
that way than to wait for the chance of any other mode of
cure. I have, however, inserted the notes of two cases
which were allowed to subside spontaneously. I recognise
of course that many of the cases of so-called typhlitis get
well by resolution, but more die for want of an incision
than fall by the surgeon’s knife.
I have said that I believe many of these abscesses are
glandular in origin. I do .so because we know how readily
lymphatic glands become inllamed and suppurate, especially
in the young, in whom these abscesses are common, and be¬
cause it is often possible to find some sources of irritation
in connexion with the intestines or other parts, comparable
to those which we see causing glandular abscesses in other
more accessible regions of the body. I was not fully alive
to the probability of this explanation of my earlier eases,
and so no doubt in many of them overlooked the primary
source of irritation.
Case 1. Jitz/At iliac abscess, probably glandular, possibly
appendicular .—John H-, aged nine, was admitted on
May 19th, 1887. A doubtful family history as to tubercu¬
losis. Ten days ago, while walking, he was seized with
sudden pain in the right groin. Four days later a swelling
appeared. He continued to limp about. There was con¬
stipation, with loss of appetite. On his admission to the
Children’s Hospital an abscess was found in the right iliac
fossa, lying above the outer half of Poupart’s ligament.
The hoy’s legs were drawn up, but there was no general
abdominal pain and no bulging in the loin. The abscess
was opened and found to contain thick olfensive pus. No
cause for the abscess was found on exploring the cavity.
The wound speedily healed U 2 >, and he was discharged on
June 9bh. In this case there is little clue to the source t>f
the mischief; it may have been an “ appendicular abscess,”
and from the character of the pus probably lay adjacent to
the bowel, though not in direct communication with it. If
not due to irritation of the appendix, it should, and as I
think with more ptobabillty, be classed with the glandular
abscesses.
Case 2. Eight ilio-pelvic abscess {glwndMlar). —A male,
aged one year and one month. Previously a healthy child,
luiree weeks before admission it “lifted its leg and cried.”
It was then found that the leg could not ho straightened.
Sixteen days later some swelling appeared. No cause for
the mischief could be found. On admission (June, 1881), a
large abscess was found pointing above Poupart’s ligament
on the right side. The abscess was opened, and five ounces
of inoffensive pus were discharged. A probe passed into the
opening went downwards and backwards into the pelvis.
Extension was applied to the right leg, and in a little over
three weeks the abscess was healed. There was a tuber¬
culous family history, but there was apparently no disease
of any bone or joint.
Case .3. Abscess of lumbar glands; psoitis {,?) —Aboyfive
and a half years old. Four days before admission (April, 1882)
be began to stoop in walking, and two daj^slatercomplained
of pain in both hips; the left thigh became drawn up, and
he had pain and cried in his sleep. On admission, he lay on
his left side, with both knees flexed. Movement of the
right limb was unrestrained and painless; the left thigh
was kept semi-flexed and somewhat abducted, and passive
movement was resisted. There was great tenderness, with
some heat around the left hip ; no swelling anywhere. Exten¬
sion was applied to the left leg, which soon became straight;
the pain was also relieved. Twenty-six days after his ad¬
mission an abscess suddenly appeared below the anterior
superior spine of the ilium ; this was opened, and a drainage-
tube, eight inches long, passed readily upwards from the
opening. Fifteen weeks after admission he was discharged
well, there being little or no limitation of movement of the
leg. This possibly may have been one of the cases described
as simple psoitis, and the length and direction of the abscess
cavity may be urged in support of this view. I, however,
think it was more likely due to glandular inflammation.
Case 4. Pelvic glandular abscess. —A boy of three years
and a half had an abscess above Poupart’s ligament on the
left side. His illneas was of fourteen days’ standing, and
came on without known cause. The symptoms were much
as in the last case. On opening the abscess it was found to
extend into the pelvis, and a tube passed into it could be
readily felt through the wall of the rectum. The child was
well in eighteen days. He had a tubercular family history,
and phimosis, witla much retained smegma. Though the
superficial penile lymphatics go primarily to the inguinal
glands, it must be remembered that these drain into the
Siac glands, and that we often see abscess, not of the nearest
glands, but of those more remote from the source of
irritation.
Case 5. Lumbar abscess {glandular) from irritation of
ascarides. —A boy of five years and eleven months old.
Five weeks before admission be complained of pain in the
left side on moving or breathing deeply. A fortnight later
there was swelling in the left loin. He had passed ascarides.
On admission, there was an abscess reaching from the last
rib nearly to the iliac crest, and there was dulness nearly
to the angle of the scapula. The urine contained a good
deal of mucus and much albumen. The abscess was
opened) no cause for it was found. A week later all
albumen disappeared from the urine. A month later the
wound was almost healed and quite superficial, and all that
remained was a little dulness at the left base. It will be
remembered that the lymphatics of the colon and rectum
drain to the lumbar and not to the mesenteric glands.
Ca.se 6-— discharging into the bowel. —A male,
aged two years and five monchs. He had scarlet fever seven
months before his admission in April, 1883, and has never
been well since. There has been pain in the abdomen for
five weeks. On admission, there was a large abscess on the
left side of the abdomen, reaching past the middle line and
up to the margin of tlie ribs. There was considerable
swelling of the left thigh, with rigidity and flexion. The
swelling subsided, and nine days later about an ounce of
pus was discharged in the motions, and a day or two after
there was no sign of the abscess.
Case 7. Left iliac oLsccss, cause obscure. —Wm. Thomas
W_, aged six, was admitted into the Children’s Hospital
on July 29bli, 1890. He had always been a delicate child,
. though his family history was good. Three weeks before
admission he complained of nain in the left side of the
E 2
302 The Lancet,]
DR. W. S. FENWICK ON ACUTE LOBAK PNEUMONIA.
[Feb. 7, 1891.
abdomen, and was noticed to limp in his walking. Urine
and bowels have been apparent^ natural; no worms have
ever been seen in his motions, never bod an attack like
the present one before. He was found to be in poor general
condition, and in the left iliac fossa was an abscess. The
hip-joint, spine, and sacro-iliac joints showed nothing
abnormal. He was a little feverish ; the bowels were
regular. The abscess was opened the same day by an
incision an inch and a half internal to the left anterior
superior spine of the ilium. A small quantity, of pus
escaped. The cavity lay within the venter of the ilium,
and no bare bone or other cause for it was found. He got
well, though somewhat slowly, being discharged on Sep¬
tember IStb.
Cases. Le/tiliacabscess,glandular; worms —Wm.T-,
aged three, was admitted on July 25tb, 1890. He had a
tuberculous family history, but was personally healthy,
except for an attack of bronchitis. Three weeks before
admission he bad pain in the left iliac fossa. His urine
was noticed to be thick and white on standing, and bis
stools contained worms. When admitted there were fulness
and fluctuation in the left iliac fossa. The left leg was
Hexed, and great pain was caused by attempts to extend it.
There was no evidence of any joint lesion. Urine phos-
phatic : stools natural; no pus. Under treatment by rest
in bed all the symptoms suosided, and he was discharged
well on Aug. 26bb. No pus was ever seen in hie motions.
Case 9. Abscess around urachus .—A boy two years and
two months old was admitted in July, 1883. Ten days
before admission he had pain in passing his urine; this con¬
tinued until his admission, when he complained of pain
about the lower ribs and front of the abdomen, and it was
found that he had only a pin-hole orifice to his prepuce. A
catheter drew off about an ounce of urine from the bladder.
On examination per rectum and externally, a swelling the
size of a Tangerine orange was found apparently in the
anterior wall of the bladder. The swelling was firm and
passed down beneath the upper border of the pubes; it
reached upwards to the umbilicus in the form of a pyramid
with an enlargement at the apex which corresponded with
the umbilicus in position. There was a soft area midway
between the umbilicus and pubes, and on pressing this
a little more urine flowed from the catheter. The child was
circumcised, and a few days later the swelling was opened
in the middle line close to the umbilicus and about two
ouncesof pusescaped. On exploration the cavity of theabscess
led down to the oladder, and its walls seemed to be con¬
tinuous with those of the bladder. The child was discharged
well a month later. Probably an imperfectly obliterated
urachus became distended with urine by back pressure
caused by the obstruction of the phimosis, and an abscess
resulted.
Case 10. Subphrenic abscess. —Wm. S-, aged twenty-
seven, was admitted to the infirmary on March 8th, 1889 ;
died March 24th, 1889. He was a healthy man, and worked
^alabourer in a blast furnace until the day before admission.
On March 7th he had unusually heavy work, and drank a
great deal of cold water. He first noticed shooting and
striking pains in the abdomen while at work. He was sent
home and put to bed, but early on the morning of the 8bh
be was seized with severe pain in the right hypochondriac
and lumbar regions. The pain got worse and he was sent
to the Royal Infirmary. On admission, he was found to be
very ill, in great pain, his face pinched and anxious, and he
was collapsed. He remained very ill, but with no material
alteration in his condition, up to the 23rd, when be had a
rigor, followed by vomiting, and died the next day. At
the necropsy a large abscess cavity was found in the sub-
phrenic region, its walls being formed by the left lung, liver,
^leen, stomach, intestines, and posterior abdominal wall.
The diaphragm was perforated, and there was a cavity in
the base of the left lung and double basal pneumonia, with
pleurisy and local peritonitis. On referring to the post¬
mortem records of the Royal Infirmary on the medical side
from March, 1886, up to date, and on the surgical side from
July, 1882, up to date, I find only one other case—a patient
of Dr. Ross—in which the abscess was apparently tubercular
and associated with a peri-typhlitic abscess. There have
been, however, Dr. Reynolds tells me, two or three other
cases of subphrenic abscess in the inlirmarv in the last four
or five years—all, with one exception, fatal.
Case 11. Local peritoneal (wscess; appendicular peri¬
tonitis .— Ebenezer W-, aged thirty-five, was sent to
me at the Royal Infirmary by Dr. Stallard on Aug. 16th,
1887. He had suffered from pain about the umbilicus with
irregularity of the bowels for five years, but had never been
very ill. in February, 1887, be had pain in the right side ;
indeed, it seems that for some montns before this he bad
occasional shooting pains in the side at night. His bowels
were confined, and the pain increased in March and April,
and prevented his working. There was tenderness on
ressure in the right iliac fossa in May and June. In July
e was in bed for a month ; there was some hardness in the
groin with flexion of the thigh on the abdomen, and a relaxed
condition of the bowels. He got worse up to the time of
admission. On his arrival at the infirmary I sav/ him, and
opened an abscess in the right iliac fossa. A second incision
was made later. The wound was healed in eight weeks,
and he has remained quite well since, except that the side
“does not feel so strong as it did before.” His bowels are
now regular.
This and the following three cases illustrate well the
different courses taken by the inflammation in cases of
appendicular peritonitis They may be compared with the
preceding cases, and also illustrate the value of operative
treatment. concluded.)
THE TREATMENT OP ACUTE LOBAR
PNEUMONIA;
FROM AN ANALYSIS OF A THOUSAND CASES TREATED AT THE
LONDON HOSPITAL BETWEEN THE YEARS 1880-1890.
By W. SOLTAU FENWICK, M.D,, B.S. Lond,, &c.
(Concluded from page SJ,9.}
B. The cold pack .—In 26 cases of the entire number an
attempt was made to control the temperature by repeated
applications of the cold wet pack, the antipyretic properties
of the method being sometimes increased by tbo inclusion
of pieces of ice among the folds of the sheet. The results
are shown in the following way In 8 cases the average
temperature varied between 103*-104‘’ F., with one death.
In 17 cases the average temperature ranged between 104°-
105°, with 3 deaths. In 1 case the average temperature
exceeded 105°. The medicinal treatment of these cases
chiefly consistetl in the administration of some preparation
of ammonia, stimulants being given in 21 case-s. When
compared with the other antipyretic methods at our com¬
mand, it must be admitted that the wet pack is certainly
of inferior value ; for we seldom find that the actual reduc¬
tion of temperature entailed by its use amounts to more
than half a degree. But, on the other hand, the method
possesses certain special properties which render it of great
practical value. Not only does it always prove agreeable
to the patient, but it also tends to soothe that form of
mental irritability which is often so marked a feature in
cases of acute pneumonia; and it is constantly found that
a patient who has experienced no rest for several days will
fall into a refreshing sleep soon after he has been enveloped
in his first pack. In addition to this, the wet pack is some¬
times of use in limiting the muscular movement in those
cases where violent delirium is a prominent feature, and
thus preventing to a certain extent the unnecessary ex¬
haustion which would otherwise ensue. It is for these
reasons that the wet pack, although in itself but of limited
utility, proves itself of such value when used as an adjunct
to the more powerful measures subserving temperature
reduction.
C. Sponging —Although the use of the tepid bath in
cases of acute pneumonia seems to have met with consider¬
able success at the bands of many German physicians, it
has never yet become a favourite remedy with pr&otitioners
in this country, and we accordingly find that the most
popular method consists in the systematic sponging
over of the body with tepid water.' The reduction of tem¬
perature that can be attained by this procedure necessarily
varies in different cases ; but it may be stated as a general
rule that by energetic sponging the temperature in a case
of acute pneumonia may be reduced about two degrees, and
I It is the <'U.stoin at the I.onrloii Hospital to employ water at the
temperature of about llC' F,, this degree of warmth boiiij; not only more
grateful to tlio patient, but actually more eHicioiit in elt'octlng a reduc¬
tion of teinpcrature.
Diaiti.ir,'j
Google
The Lancet,]
DR. W. S. FENWICK ON ACUTE LOBAR PNEUMONIA.
[Feb. 7, 1891. 303
that within one hour the mercury will have regained its !
former level. The following chart represents fairly well
the effect of sponging in these cases; the temperature being
recorded at the commencement of the operation, and again
at an interval of ten minutes from its completion, lb is
therefore obvious that, in order to maintain a constant
reduction of temperature, the operation ought to be repeated
at intervals of at most an hour. I might also remark that
the readiness with which the teniperature of a case responds
to sponging is often a very fair indication of its general
severity ; and it is found that an unfavourable prognosis in
cases whose temperature is stubborn and difficult of re¬
duction is not unfrequently justified by a fatal result.
During the course of the last ten years 65 cases of acute
pneumonia have been treated upon this principle, the
results being shown as follows : In 25 cases the average
temperature was 103“ to 104% and of these 3, or 12 per
cent, died; in 33 cases the average temperature was 104“ to
106% and of these 4, or 12’2 per cent, died; in 7 cases
the average temperature exceeded 105% and of these 1,
or 14'3 per cent. died. Stimulants were administered in
33 cases, the majority also receiving medicinal treatment
in the form of a mixture containing ammonia and ether.
No death occurred at the crisis. Thus we find that in 65
cases treated upon general principles, subserving the
Fig. 1.
Four hour chart from a case of aento pneumonia, showing tlic
infliiouce of hot sponging upon tlio teiupevaturu.
economy of cardiac force, and in which the average tem¬
perature exceeded 103% the mortality attending the disease
only amounts to 12-8 per cent.—a reduction to the extent
of almost one-half.
D. The ice-cradle. —T\\q ice-cradle is an arrangement by
Avhich a constant current of cool air can be brought into
immediate contact with the surface of the body, and thus
bring about a reduction in its temperature by direct
abstraction of heat. This method was originally introduced
by Dr. Samuel Fenwick as a substitute for the cold bath in
the treatment of typhoid fever, and with this object
it has DOW been used for many years in his wards
at the London Hospital, with the most excellent
results. It consists essentially of an iron surgical cradle,
from the central bar of which are suspended several small
zinc pails half filled with ice. The patient lies undressed
upon the betl,^ and the cradle, covered by a light counter¬
pane, is placed over him. In order to prevent any feeling
of chilliness a hot-water bottle is kept in contact with the
patienVs feet. The ice in the pails is renewed at intervals,
and it js found convenient in practice to cover the bottom of
the pails with a piece of lint in order to prevent any con¬
densed moisture from dripping upon the body of the patient.
In default of the iron cradle, a very good substitute can be
easily made with a piece of strong wire, or from two wooden
hoops sawn throu^ the centre. Under such an arrange¬
ment a patient may lie for many days, tlio utmost required
being to replenish the ice-pails, and occasionally to renew
the hot-water bottle at the feet. Although the mean tem-
erature of the cradle can rarely bo reduced more than a
egree or two below that of the surrounding atmosphere, it
usually suffices to effect a reduction of several degrees in
3 The patient may bo covered with a light sheet made of <>pa<jua
gauz(;.
the bodily temperature, and, what is of more importance, to
maintain it at a reduced point. In certain cases where
the pyrexia has been moderate, or where ice was un¬
obtainable, the cradle has been used without the pails,
and it has been found under these circumstances that the
circulation of air at the temperature of the ward was suffi¬
cient to effect a gradual reduction in the temperature of the
body to the amount of several degrees. But in order to
obtain the maximum value from the use of the ice cradle it
is necessary that the attention should be directed to several
indispensable details in connexion with its mode of appli¬
cation. In the first place, the cradle must be of suffident
width, for nottking tends to render a patient so hostile, to
the procedure as the use of a cradle so narrow as to cramp
the free movement of bis limbs. Secondly, it is always
necessary to keep the feet warm by means of a hot bottle;
for by this means any feeling of coldness can be easily
counteracted, while at the same time the general comfort)
of the patient is considerably increased. Thirdly, the free
circulation of air through the cradle is a sine qud non; un¬
less this be attended to the ice is quickly melted, the tem¬
perature of the air in the cradle rapidly rises, and little if
any good results from its employment. Lastly, in all cases
it is well to take the patients’ temperature every three or
four hours, and to remove the cradle should the merdury
Fig 2.
have fallen below 100% or the patient exhibit any inclina--
tion to shiver. When these precautions are observed the-
patient soon becomes accustomed to the method of treat¬
ment, and many severe cases of enteric fever have Iain
beneath the cradle for as long as ten days or a fortnight
with only the happiest results.
The cradle was introduced into the treatment of acute
pneumonia with the view of minimising the injurious
influences of fever by maintaining the temperature
of the body at a "point below 103°. With this,
object it is applied to the case until the tempera¬
ture has fallen to 100°, and when this has oeen
attained the cradle is lifted off and the patient covered
with a light blanket. As soon, however, as the thermometer
again indicates a temperature of 103°, the arrangement is
reapplied ; and this process is maintained until the termina¬
tion of the malady. The effect of this intermitten tapplication
of the cradle is well shown in the following four-hour chart.
But in gome cases in which the pyrexia is exceedingly
severe, the ice-cradle proves insufficient for the immediate
reduction of the temperature ; and it has therefore become
our custom to supplement its action by the employment of
such adjunctory measures as sponging or ice packing. Not
only does the act of sponging excite the skin to the per¬
formance of its normal functions, but the sudden slight
reduction of teniperature it entails seems to provide the
necessary impetus to the action of the cradle; and we
accordingly find that a stubborn temperature will often
begin to give way after the patient has once been
sponged with hot water. During the last eighteen
months 4.3 coses of acute sthenic pneunionia have been
treated with the ice-cradle, with the following result.
In fifteen cases the average temperature amounted to
103-104% and of these one died; in twenty-five cases the
average teniperature amounted to 104-106% and of these
two died ; in three cases the average temperature exceeded
Dig:./ed "OO^Ic
304 The LaIjcet,] DR. W. S. FENWICK DN ACUTE LOBAR PNEUMONIA, [Feb. 7,1891.
105° without a fatal result. !□ no case did death occur at
the crisis, and the percentage mortality only amounts to 7.
The internal remedies usually consisted of some preparation
containing quinine and ammonia. The greatest attention
was paid to the functional condition of the heart, especially
at the time when the temperature fell spontaneously to
normal, and any tendency to cardiac failure was promptly
treated by the administration of alcohol or hy the hypo¬
dermic use of camphor. I may also add that it has latterly
become our custom to resort to systematic sponging of
the body, in addition to the use of the cradle, in all
qases.
Before concluding this part of my subject I would
endeavour to answer the important question whether any
had results have accrued from the use of cold as a thera¬
peutic agent in the treatment of acute pneumonia. The
following facts may help us to frame a satisfactory answer,
jn six cases of tbe’entire number the patient suffered from
a second attack of the disease during the peiiod of his
convalescence; only one case occurred among those who
were treated by the application of cold, the other five
being subjects under the poultice and quinine r6gimc. It
Fig. 3.
Four liour chart from a casH of acu^e pneumonia, showing
the influence of tlie i'ai cmrtie npon the tomperaturo.
Tlie cradle was applied at C and removed at X.
has been stated that the application of cold is apt
to induce the condition of albuminuria in these
cases; but I have been unable to discover among my
161 cases a single instance in which albumen to the amount
of one-tenth was observed in the urine after the crisis of
the disease. On the other hand, the reduction of tem¬
perature seemed nob iinfre(^ent]y to excite an increased
renal action, the diuretic effect of sponging being particu¬
larly well marked. Again, five cases of gangrene of the
lung are recorded among the 552 cases treated by poultices;
while only one case* is to be found in the antipyretic series.
In a few cases treated by the ice cradle or by sponging
pleuritic pain was complained of after the crisis. Such a
symptom would probably be ascribed by opponents of the
method to its injurious influence; but this can hardly be so.
Nearly every case of acute pneumonia is accompanied by
localised pleurisy, and since we know that pleuritic ellusion
ifl but slowly absorbed in the presence of fever, I would
rather ascribe the symptom, and the slight rise of tempera¬
ture which accompanies it, to the result of a premature
absorption of the exudation consequent upon the artificial
reduction of temperature. The symptom is one that can
easily be subdued by the application of strapping to the
affected area of the chest, or by the subcutaneous injection
of antipyrin. I'or these reasons I do not hesitate to assert
that the injurious results from the application of cold in
cases of acute sthenic pneumonia are inappreciable, and
may well be ignored when the great value of the treatment
is taken into consideration. For among 108 cases in which
this method was systematically carried out, we find a
percentage mortality of only 10 instead of 2.1.
3. Asthenic pneumonia.—k-mo-a» the thousand cases
from which my statistics have been drawn, no fewer than
285 exhibited an average temperature below 103°. This
form of pneumonia—presenting all the signs of pulmonary
consolidation, but unaccompanied by any high degree of
fever—is the type which most usuaJly supervenes during
the course of chronic diseases, and to which the fat^
termination of the case is often directly attributable. It is
still a debated (Question whether this form of pneumonia
does not own a different cause from that which inaugurates
.the sthenic type of the disease. But it would appear as if
the clinical aspect of different cases was determined,
not by a difference in the exciting cause of the malady,
but rather by the vital condition of the tissues upon
which that cause is brought to act; in the one type
the high fever and its concomitant symptoms being
the resultant of force and resistance, while in the other
case, the vital activity of the tissues being insufficient to
offer any resistance to the onslaught of the exciting cause,
the signs of organic failure tend from the first to over¬
shadow and eclipse the symptoms characteristic of the in¬
vading force; resembling in this way the transmission of an
electric current, the physical effects of which hear a definite
relation to the amount of resistance offered to it in the form
of the conducting wire. The unsatisfactory results that
have attended the treatment of these asthenic cases depend
directly upon this inability of the system to offer an
adequate resistance to the progress of the disease. The heart,
weakened by privation, myocardial degeneration, or from
disease in other organs, is unable to respond to a sudden
call upon it for increased activity. Its propulsive power is
utterly insufficient to cope with the sudden increase of
resistance in the pulmonary circuit, and, after a alight
initial response, it gives up the attempt. Following quickly
upon the heels of the first symptoms of cardiac failure
there springs up_ that progressive phenomenon of pulmonary
oedema which, increasing rapidly when once started, and
augmenting the resistance offered to each beat of the heart,
increases the tendency to dilatation in the tight ventricle.
And I venture to think that the rapidly fatal course which
the malady so often runs in astlienic cases is often directly
dependent upon the early occurrence of pulmonary eedema.
The great danger to life in cases of asthenic pneumonia
is well known, and a glance at the following figures
fully bears out one of my preliminary remarks—
namely, that the mortality in this form of the disease
bears an inverse relation to the severity of the fever.
Among 240 cases which were treated in the ordinary way
by pomtices, stimulanfa, and tonics, in 213 the average tem,-
perature amounted to 102°-103°, and of these 63, or
30 per cent., died; in 27 the average temperature was
below 102°, and of these 13, or nearly 50 per cebt., died.
In 45 other cases the treatment was supplemented
by large doses of quinine, with the following resultIn'
35 the average temperature amounted to 102°-103%
and of these 9, or 257 per cent., died. In 10 cases the'
average temperature ranged below 102°, and of these 5, or
one-half, died. Thus, beyond affording proof of the fre¬
quency with which this form of the disease terminates in'
death, but few lessons can be gathered from an examina¬
tion of the foregoing figures. Here is, however, one very
obvious deduction: any attempt to employ cold in the
treatment of these cases is not only unscienti/ic bub actually
of danger, from its liability to bring about a fatal result.
For the rest,the treatment mu.'>t be a stimulating one, and
quinine in large doses may prove of some use. Venesection
for tlie relief of pulmonary cederaa is almost certain to
prove useless.
Summary .—Can the study of the foregoing statistics
throw any light upon the immediate cause of death in cases
of acute pneumonia ? It has been conclusively shown that
the mortality from the disease is directly proportionate to the
severity of the symptomatic fever ; and it is therefore but
natural to conclude that the presence of a high temperature
tends to destroy the functional activity of some vital organ.
Standing out as it does in such bold relief to the other
morbid phenomena of the disease, it is hardly surprising
that the condition of the lung has always concentrated
upon itself the attention of the physician, and constituted
the recognised target at which all his remedial treatment
should be aimed. At the present day, however, it is held
by most observers that the symptoms of the malady are not
the direct result of a simple inflammation of the lung, but
rather the outcome of a constitutional affection. And since
it will be admitted by all that, whatever may be the true
pathology of the disease, there exists no dellnite relation
between the amount of the consolidation and the severity
of the fever, it is obvious that the lung cannot be
Digiti/r'd Liy Google
Thb Laitqbt,]
CLINICAL NOTES,
IFbb. 7,1891., 3051‘
•that vital organ upon which a high temperature exerts
each a destructive influence. We must therefore look else¬
where for the immediate cause of death; and every item of
•evidence, whether it be pathological or clinical, points to
the same inevitable conclusion—namely, that the fatal
'termination of acute pneumonia is the direct result of
■cardiac failure.
There are two general factors which are capable of pro¬
ducing the condition of cardiac insufficiency—an increased
resistance to the propulsive action of the heart, and a pro-
.gressive deterioration of its muscular substance. And in
.acute pneumonia both these factors are conspicuously pre¬
sent; the former in the increase of tension in the pulmonary
■circuit consequent on the consolidation of a portion of the
lung, and the latter as the direct result of a high tempera¬
ture. The action of these two forces is to compel the heart
to beat more forcibly and more quickly, while at the same
'time it is steadily deprived of the power to do either. In
'•the asthenic variety of the disease the heart is intrinsically
•feeble from the outset, and hence the malign influence of
•fever is an unnecessary element in the production of its
insufiiciency.
That these a priori considerations are in accordance with
actual facts has already been shown, for it has been proved
'that death is most liable to supervene at two periods in the
disease: about the fifth day, when the fever is at its
height, or at the crisis, when cardiac collapse is apt to
Tesult from its sudden withdrawal. One step further. Two
great methods of treatment have been examined in detail '
as to their influence upon tlie mortality from the disease.
In the one we And that the chief remedies were aimed at
irelieving the condition of the lung; and while stimu¬
lants were freely administered with the object of
whipping up the flagging heart, the cause of its physical
‘lameness was allowed to proceed unmolested. The result
was that among 552 cases so treated the mortality exceeded
•23 per cent., although alcohol was exhibited in no less than
',70 per cent. In the second case a method of treatment was
adopted with one special object; to economise cardiac force
by minimising the injurious influences of fever. In 108
•cases of similar severity to the foregoing the treatment
consisted in the systematic reduction of temperature by
means of sponging or ice cradling. Of this number only 45
•(41 per cent.) received alcohol, and only 10 per cent,
•died.
Again, among the former class 46 deaths resulted from
collapse at the crisis of the fever. Among the latter,
where special attention was paid to this source of danger,
nob a single death is recorded from this cause. Nothing could
be more conclusive, for these facts show to what a consider-
•able extent the mortality from acute pneumonia may be re-
■ducedwhen prophylactic treatmenbis applied with the viewof
■strengthening that vital position against which death almost
'invariably concentrates the force of his attack. And the
•success which has attended this rational treatment of acute
pneumonia appears as a still further argument in favour of
the specific febrile nature of the disease; for it would indi¬
cate that the consolidation of the lung is after all but an
analogue of the typhoid ulcer and of the scarlatinal sore-
throat—a characteristic result, hub never the cause, of the
■disease. It has also been shown that, firstly, the quantity
of albumen in the urine is of considerable prognostic value;
secondly, that the crisis is often a period of great danger to
liife; and thirdly, that those cases which commence with a
•severe gastro-intestinal attack are twice as liable to _end
•fatally as those which exhibit the more usual initial
rigor.
In conclusion, I beg to thank the various members of the
anedical stall of the London Hospital for their kind per¬
mission to publish in this manner the results of their
•cases.
West Kent General Hospital. — The fifty-
eighth annual report records the munificent gift during the
year of the Dowager Lady Howard de Walden. The entire
top floor had been very completely fitted up by her lady¬
ship as a women’s ward for eight beds, together with a ward
for special cases and bedrooms for the stafl'. Ample funds
-(£10,000) had been placed in the hands'of trustees as an
endowment. During the year there had been a consider¬
able increase in tlio number of in-patients. A generous gift
of £200 had enabled the committee to avert any addition to
fche adverse balance.
MEDICAL, SUEGIOAL, OBSTETEIOAL, AISTD
THEEAPEUTIOAL.
A CASE OF GASTEOSTOMY.
• By Henry J. Rope, F.R.C.S.
W. R-, aged sixty-four, a waiter, was admitted to the
Salop Infirmary on Sept. 15th, 1890, complaining of difficulty
in swallowing for the last three weeks. Cannot take any¬
thing solid, and fluids come back through the nose. Rapid
emaciation; weight, 7st. 101b. Has been a free drinker. Has
a soft blowing systolic murmur. CEsophageal bougie passed
thirteen inches, and found a bard unyielding obstruction.
The patient was put on fifteen grains of iodide of potassium
three times a day. Sept 17th: He retains about half of
the fluid.s that be takes. He cannot retain puddings or
arrowroot.—Oct. 4th; He feels much better, and tolces
exercise daily. Bougie has been passed at frequent intervals,
and to-day was passed fifteen inches.—19bh: He does
not complain of any pain, and is always anxidus to have
the bougie passed, as he says it gives him great relief. He
seems weaker. Weight, Tst. 6ib.—28th: He complained
of pain when the bougie was passed, referring it to the
right mammary region. He does not retain his food so
well, and is weaker. Weight, 7st. 3lb. Is unable to leave
his bed.—31st: Gastrostomy (first stage) was petfornMd
under ether. The stomach was easily found, and was
attached to the abdominal wall by Mr. Howse’s method.
He rallied well, but complained of great pain.—Nov. Idt:
No pain ; temperature normal; mouth very dry. Dressing
, soaked; fresh gauze packed over it,—2nd; More pain;
: mouth still very dry. Pulse 90, weak, respiration 30;—
Nov. 3rd: Cough troublesome, with profuse expectoration
of very tenacious, non-aerated sputa.~4bh; Dressings re¬
moved ; wound perfectly sweet, edges almost in contact.
The edges were separated and held apart, and the stomach
was pinched up and carefully opened with sharp-pointed
scissors; two ounces of strong beef-tea and milk were at
once introduced through a catheter, to the intense satisfac¬
tion of the patient, giving him a very pleasant sensation.
The catheter was tied in, and he was fed every two hours.
At each feeding a slight flow of saliva was noticed in
mouth.—5th: Slept well and is cheerful. On coughing
some fluid escapes through wound, bile -stained, very acid.—
6th: Slept well, but is weaker; more cough, more escape
of gastric juice. Skin round wound red and irritated.
Rubber tracheotomy tube used instead of catheter.—7th:
The introduction of food causes a cough, which expels some
of the food again; nutrient suppositories at frequent in¬
tervals.—8th: Pulse quicker and weaker; temperature
101'’, delirium, jactitations; free return of food through
wound.—9bh : Temperature 102°, pulse almost impercep¬
tible; Cheyne-Stokes breathing. He died the following
morning.
Necropsy {Nov. lllh ).—Great emaciation; well-marked
rigor mortis. Stomach firmly adherent by strong adhesions
all round the wound, of normal size and thickness, contain¬
ing a small quantity of brownish fluid. Intestines mnch
contracted. Kidneys small; capsules adherent. Aorta
atheromatous; aortic and mitral valves puckered. The upper
part of the ensopbagus was dilated and much thickened.
Three inches and a half above its cardiac end was a tight
stricture, barely admitting a No. 8 English catheter; and
here the ccsophagus was greatly thickened and as hard as
cartilage. There was ulceration of the mucous membrane
for half an inch above the stricture, with perforation into
the root of the right lung, where there was a sac, the size of
a filbert, containing grumous fluid similar to that found in
the stomach. The bases of the lungs were codematous.
Tlie mediastinal glands were enlarged.
The patient was persistent in his opposition to any opera¬
tion, and when at last his consent was obtained he was too
weak to derive more than a few days’ advantage from it.
The notes were kindly supplied by Mr. Harold McLeod.
^^llro^vsl>ury.
e
306 Thk Lancet,]
CLINICAL NOTES.
[Feb. 7,1891.
A CASE OF EXOPHTHALMIC GOITRE, ENDING
FATALLY FROM SUDDEN PRESSURE ON
THE TRACHEA.
By Hugh Montgomerie, M.D.,
ASSISTANT PHYSICIAN, WEST COHNWALL INI'IRMAEY, PENZANCE,
Through the kiodcess of Dr. Humphry Davy I am able
to record this case, which, so far as my researches extend,
seems to be unique.
In March last I saw the patient, Mrs. X-, aged thirty-
five, who complained of a swelling in the neck, nervousness,
slight difficulty of breathing, wutn stridor and cough. She
stated she was pregnant. Her own health and family
history were good. Her neck, she informed me, had been
swollen for two years (I since hear it was longer), and
measured twenty-three inches in circumference. The
swelling consisted in a softish elastic mass, larger on the
left side than the right, and with a small central mass.
There was no doubt we swelling was a bvonchocele. The
^es showed some exophthalmia and dilated pupils ; Von
Graefe’s sign present to a slight extent; there was no
tremor. The pulse was 120. The larynx showed nothing
abnormal, butit was impossible to see below the cords with
the laryngoscope. From her condition and the deep origin
of the growth no interference was recommended. In
September, 1890, I had another opportunity of examining
her after delivery, and found the symptoms abated, the
neck only measuring twenty-one inches in circumference.
In the early morning of December Ist, 1890, 1 was called to
the patient’s house, and found her lying on a bed uncon¬
scious, breathing rapidly and with considerable stridor, the
lips and face cyanoaed. 'Dr. Davy, Mr. Symons, and
myself were sent for. We learnt that at half-past ten the
previous night she had gone to bed quite well. In about
an hour she got up to attend to the baby, and was seized
with severe difficulty of breathing. She got back to bed,
struggled violently, and became unconscious in the course
of five minutes. Tracheotomy was determined on, though j
the patient was evidently moribund. The tube was inserted
by Dr. Davy, who performed the low operation. There
was scarcely any bleeding during the operation. One
inspiration was taken through the tube, and artificial
respiration resorted to without avail.
A necropsy was granted, which I performed in the
afternoon. It was then found that the right lobe of the
thyroid was attached to the trachea firmly, and the size of
an egg. The left lobe about double the size, and implicating
the deep structures of the neck. The isthmus was much
enlarged, and a supplementary lobe of the gland lay on the
thyroid cartilage. On removing the larynx, trachea, and
thyroid gland, one saw on looking up the trachea that the
right wall was bulged in towards the left, leaving only a-
mere chink to breathe through. The bulging corresponded
with the right lobe of the thyroid gland. On splitting up
the trachea, the cartilages at the obstruction were softened,
and had lost all their resiliency, thus aiding the collapse of
the tube. The mucous membrane was injected.
I have considered this case worthy of record, as showing
that, although the cartilages of the trachea had been
softening for some time, the actual “caving in” was in
the end quite sudden.
Penzance.
A CASE Oli’ TETANUS; RECOVERY.
By a. C. Dutt, B.A., M.B. Cantab., A.K.C. Lond.,
SENIOR HOUSE 3UROICON TO THE SCARnOROUGH HOSPITAL.
On the 22ad September James A-, aged thirty-live, a
fisherman belonging to Peel, Isle of Man, was admitted
under the care of Dr. Everley Taylor, suffering from well-
marked symptoms of tetanus. In August last his left hand
was crushed between two boats, producing a wound three
inches long at the level of the beads of the second and third
metacarpal bones- For this he was treated as an in-patient
at the Berwiek-on-Tweed Infirmary for five weeks, and left
that institution (with the wound not quite healed) to join
his boat. He fished off Hartlepool for some days, whence
he came to Scarborough and sought admission here. On
inquiry the patient admitted he had indulged freely in
alcohol, and had syphilis about twenty years ago. On one
leg there was a fetid tertia:^ ulcer, and on both legs there
were several pigmented cicatrices. He was unmarried.
Patient said that when he was off Hartlepool he hud pain-
in the back of his neck, and then the “ jaws began to con¬
tract”; the legs felt very stiff, and he found he could not
swallow. On examination it was found that he could nob
separate his teeth more than a quarter of an inch; there was
a very peculiar anxious look, and the maeseters and the recti
abdominis were extremely rigid. The wound on the hand was-
covered wlthsmall unhealthy granulations, and was very foul-
smelling. Before he came into the hospital he had takei^
lodgings in the town, where Dr. Everley Taylor had seen him
in a state of opisthotonos. His temperature on admission wa&
98■6°, and waa never above normal throughout the course of
the disease. He was ordered a mixture of ten minims of
the tincture of cannabis indica, fifteen grains of chloral and
bromide of sodium, five minims of chloric ether, with-
mucilage and water, every four hours. As to diet, he had
three pints of peptonised milk, two pints of beef-tea, two
eggs, six ounces of brandy, and six ounces of port wine
daily. The wound on the hand was dressed with starch
poultices for the first fortnight, and then with boracic oint¬
ment ; the ulcer on the leg was also washed and dressed.
The patient complained of “spasms,” but steadily improved
under the treatment. After Oct. 3rd stimulants were
reduced to two ounces each of port wine and brandy daily
minced moat and bread were given on the 7th. On the 15tb,
pills of Calabar bean, one-sixth of a grain (gradually in¬
creased to half a grain) three times a day, were ordered. The
patient could sit up on the 10th, and bad full diet on the
19bh. On the 20bh the wound on the hand had quite cica¬
trised, and the patient was discharged on Nov. Ist.
Remarks .—Of late the theory has been gaining ground that
tetanus is of microbic origin, and that the microbes produce
an alkaloid which acts on the nervous system. The fact
that division of the injured nerve at the seat of injury has
sometimes been found curative does not necessarily disprove
this theory, for doubtless with the division of the nerve
precautions are taken to render the wound aseptic, so as to
prevent the development of the microbes. The absence of any
definite lesions in fatal cases also lendssupport to this view.
According to Dr. George Kemp, there are three essential
objects to be attained in the treatment—(a) The destruc¬
tion of the nidus of development of the bacilli; (i) the
elimination from the system of the products of the bacilli;
and (c) the calming of the nervous system.
Scarborough, __
SPONTANEOUS AMPUTATION OF THE SMALL
TOE IN AFRICANS.
By J. Toppin, L.li.C.S.I., L. & L.M. K.Q.C.P.
Although doubtless this anomaly has been observed by
Englishmen who have visited Africa, it has not hitherto, to-’
the best of my belief, been described in the medical press..
It seems, as far as I am aware of, only to occur amongst
Africans; although 1 have never seen it in those inhabiting
the West India islands, I believe it is common enough in
Brazil amongst the negroes. The cases I have met with
were among Kroomen, who come from a part of the West
Coast of Africa about a day’s journey from Sierra Leone.
These men seldom wear boots, and consequently have very
well shaped feet. The affection commences by a crack ap¬
pearing ontheunderandinnersurface of the little toe; a thing
which IS frequently met with amongst soldiers of whatever
nationality, and which English sailors designate by a name
more expressive than elegant. It, however, never goes
beyond a crack or fissure in Europeans; but with Africans,
whether living on shore away from the sea or on board ship,
there is a progres.sive process, resulting ultimately in'the
toe dropping on. It is in no way connected with leprosy ;
the little toe is nearly always the only one affected, though-
the natives tell me that in rare cases the fourth toe goes
also. I have tried incising the fissure, and then dressing it,
and making them wear boots to keep out the salt water,
but all to no purpose. The process when once commenced
goes on, the fissure gradually extending round the toe. 1
have never allowed it to jiroceed to complete loss of the
toe, because after a few months there is considerable pain,
with some cedema of the foot, and in order to render the
man able to work I have taken the toe off. In their owm
country, however, not having a surgeon at their service,
The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Feb 7,1891. 307
they have to let it run its course, and it then takes about
a twelvemonth before it hoally drops off. The appearance
when the fissure has extended completely round the toe is
■exactly as if a ligature had been bound tightly round it, as
near its junction with the foot as possible. The extensor
tendon can be seen as a white cord marked with a black
ring where the fissure crosses it In two cases where I have
removed the toe, the joint of the ungual phalanx was
wanting. The wound heals quickly after removal, and the
men do nut seem to feel the loss of the toe in the slightest.
Pernambuco, Brazil. _
TRAUMATIC ENCEPHALO MENINGOpELE.
By Harry Burton, M.R.C.S., L.R.C.P. Irel., &c.
Having used the above title for a case I reported
in The Lancet of Jan. 10th, and having read a note in
the same journal of Jan. 17fch by Mr. Clement Lucas
objecting to the name, I wish to give the following reasons
for having done so.
According to Messrs^ Clement Lucas and Golding Bird
traumatic oephal-hydrocele can only be developed in early
childhood, and is caused by cerebro-spinal fluid extravasated
under the healthy integuments, through a fissure or fracture
of the skull, suen fluid communicating with the ventricles
through the perforated meninges and brain. In the case
mentioned by me, the girl was eight years old; ihe fracture
was at first compound, the skin wound healed, absorption of
a necrosed circular portion of the skull occurred, and the
meninges and brain substance were gradually protruded
through the opening. I do nob think the fluid com¬
municated with the ventricles, but was simply increased
inflammatory secretion, os after aspiration the tension
became less, and (which was not the case before) pressure
could be borne. 1 also explained that on withdrawal
of the needle, which was not inserted to the base of
the tumour, brain substance appeared on it. The tumour
also was only partially emptied, which proves that its
contents were not altogether fluid. I quite agree with
Mr. Lucas that traumatic cephal-hydrocele is a better name
for the cases he has published than traumatic meningocele,
as only fluid could come through a crack in the skull,
the absorption of bone being secondary, and therefore no
meninges are contained in the swelling at all; but I must
say, with all deference to him, that the case I described
differs so much in all its salient points that the above
title only thoroughly conveys a right idea of its com¬
position. I may again state that there Is no sign of any
tumour remaining, no heaped-up or everted edges of
bone, tlie skin being perfectly level, the circular opening in
the bone almost filled with dense fibrous tissue, and tliat
the girl is in good health at the present time.
Mixi-plw. _
% ilimr
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autein est alia pro certo noacencll via, nisi quamplurlniasetrQOi-
foonim et di.saeotionum hiatoriaa, tum aliorum turn proprlas eoUectas
habere et inter se compararo.— Moiiqaoni De Sea. et Cara. Morb.,
lib. iv. Prowmlum. -
CHARING-CROSS HOSPITAL.
A CASK OK AURAL POLYPUS ACCOMPANIED WITH MASTOID
.SUPPURATION AND THREATENING THROMBOSIS OF THE
LATERAL SINUS; PERFORATION OF THE MASTOID
CELLS; REMOVAL OF THE POLYPUS; CURE.
(Under the care of Mr. Marmaduke Sheild.)
The attention of the profession has been frequently
directed, more especially during recent years, to the dangers
of a chronic discharge from the middle ear. Such cases,
where treatment has been neglected, are not uncommonly
admitted to our hospitals for mastoiditis or even more
serious consequences secondary to the discharge, especially
if it is decomposing and its escape is impeded, as in this
instance, liy the presence of a polypoid growth. Great im-
provementin our knowledge of the pathology of the inflamma¬
tory affections of tlie mastoid process has resulted from more
careful study, and we recognise that there are in such affec¬
tions especial dangers from the proximity of vital structures.
One direction in which inflammation mav extend is through
the petro-mastoid canal into the cranial cavity, or it may
involve further the transverse sinus and cause thrombosis,
and symptoms of the commencement of this condition were
present in this case. The fatal termination of a purulent
otitis media may be due to many causes—phlebitis, throm¬
bosis, embolism, septicsomia, pyiemia, purulent meningitis,
intra cranial abscess, ^c.—any one of which may be excited
by apparently accidental circumstances. In all these the
chance of life is small without operative treatment, and in
few can such success be obtained, both as regards arrest of
symptoms and restoration of function, as in the case which
we record.
A healthy.lookingyoung man was admitted into Charing-
crosa Hospital on Dec. 3rd, 1890, under the care of Di.
Green. He was supposed to be suffering from some cerebral
disease. A fetid discharge, being found to issue from the
right ear, the patient was transferred to the surgical wards.
The leading symptoms observed were as follows: Great
tenderness over the side of the bead and mastoid region,
but no obviously tender spot or cedema. Marked tender¬
ness also over the course ot the internal jugular vein on the
ri^ht side of the neck, bub no hardness. There was no
e^dence of lun^ complication. Profuse fetid discharge
issued from the right ear. On washing this away a large,
vascular, friable polypus, of the colour of a ripe rasp¬
berry, was seen to nil the auditory canal. The patient
was absolutely deaf upon the right side, and could
not hear when shouted at. A large tuning-fork
placed upon the vertex was heard most plainly on the
affected side. The left ear seemed normal. The patient
was somewhat drowsy and stupid, but answered questions
fairly well. There was no optic neuritis. The pulse was
quiclc, hard, and full, the tongue very foul, and the
bowels constipated, but the temperature was not high. A
reliable history was difficult to elucidate. It appeared that
he had suffered from right otorrhcea for an indefinite period.
For the last few days he had had intense pain in the head,
so severe as to cause him to cry out and entirely to prevent
sleep. He has felt giddy, and was sick several times at
the commencementof the attack.
It was resolved to open the mastoid cells, and this pro¬
ceeding was sanctioned by Mr. Bloxam, who kindly saw the
case in consultation. The operation was performed at
5 P.M, on the same evening. The side of the head being
shaved and rendered aseptic, a free vertical incision was made
by Mr. Sheild over the right mastoid, and the soft parts and
periosteum were turned back from the bone on either side.
An opening was then made immediately behind the upper
margin of the external auditory meatus, by means of a small
sharp gouge and mallet. The bone was exceedingly dense
and hard, and the opening was cautiously deepened to a
depth of nearly one-eighth of an inch before a blunt director
passed into the mastoid cells. Very free bleeding occurred
as soon as the cells were opened, the blood welling out in a
continuous stream, as though some large Vessel bad been
wounded. A strong syringe filled with hob horacic lotion
was applied to the aperture, and blood mixed with a quan¬
tity of thick pus and masses of ddbrls escaped from the
auditory meatus. The bleeding soon spontaneously ceased.
The polypus was next removed by a pair of ring forceps, and
the incision behind tlie ear united with horsehair, a drainage-
tube being inserted into the opening made in the bone.
The parts were dressed with iodoform and sal alembroth
gauze. After the operation the patient lost all pain and dis¬
agreeable sensations in the head and side of the neck. He
made an uninterrupted recoveiy. The wound united
soundly, and the tube was removed on the fifth day. The
after-treatment consisted in washing through the mastoid
with warm horacic fluid and the ap^ioation on three occa¬
sions of pure chromic acid to the remains of the polypus.
The latter had grown from the interior of the tympanum
through a large perforation in the membrana tyinpani. By
the fifth day he could bear the watch at three inches and
conversation fairly well. Treatment was now directed
towards the perforation. Under simple syringing with
warm boracic fluid and cleansing of the ear afterwards with
wool this closed in about three weeks.
A month after the operation the patient was carefully
examined. All discharge had ceased, and the chasm had
^ Google
808 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Feb. 7, 1891.
apparently healed. Hearing was, for practical purposes, per¬
fect. Hehadlostallpainand tendernees about the mastoid.
Remarks by Mr. Shkild. —The combination of a large
aural polypus and “head symptoms” in a case of long-
etanding otorrhosa is often ditlicult to manage. In a large
number of such cases there is retention of pus and caseating
products of inllammation within the mastoid cells. A soft
granulation polypus in a child will often disappear on
opening the mastoid and washing out the cavities contained
in it. In cases like the present there is always considerable
danger of thrombosis of the lateral sinus, and this in itself
is a sufQcient argument for opening the mastoid. Should
there be dednite evidence of thrombosis in the deep jugular
vein, the q;aestion of ligature of that vessel below the
thrombosed parts must arise. These cases are desperate,
and if general pyremic infection has already occurred the
chance of recovery is small. It would seem generally
better to remove the polypus at the same time as
the cells are opened. Thus a free exit is afforded
through the auditoiy canal for pus and the irrigated
fluid. Should there be definite evidence of necrosis of
the mastoid, and the dead bohe be deep and fixed, a per¬
manent opening had better- be established behind the ear
by the introduction of a small lead or silver tube, for in
such cases pus will certainly re-collect. Every effort must
be made to destroy the remnants of the polypus, and to
obtain the healing of a perforated membrane. If this be
accomplished the results may be surprisingly good, as in
the nreseut instance, and bearing may for practical purposes
be completely restored. In most cases, however, such will
not be tne case, the ear remaining permanently damaged, and
needing long-continued care aud attention. Much has been
written lately about the operation of opening the mastoid,
and the position of the lateral sinus. The divergence of
opinion regarding the latter importantanatomical considera¬
tion leads to the practical conclusion that, as one can never be
certain of the exact depth and situation of the sinus in any
given case, the utmost caution should always be employed.
By the method of removing layer after layer of bone with a
mallet and gouge, and carefully inspecting each portion of
exposed bone before going deeper, tbe lateral sinus can
hardly be wounded, and the actual entrance into the cells
can safely be made with a blunt-pointed director. The free
hcemorrhage observed in these cases appears at first sight
alarming. It is due to excessive engorgement of.the vessels
of the inflamed bone, and soon ceases on the application of
hot water with the syringe. Doubtless the local depletion
is most beneficial, and goes far to aid tbe striking relief of
pain and discomfort which the operation usually effects.
HULL ROYAL INIHRMARY.
PAPILLOMA OF BLADDER; SUPRA-PUBIC CYSTOTOMY;
RECOVERY.
(Under the care of Mr. Craven.)
The following account of the removal of a tumour from
the bladder after cystotomy and of its microscopical
characters is of interest and importance. From the dura¬
tion of symptoms, the small size attained by the growth,
and its intimate structure, there is reason for giving a
favourable prognosis as to non-recurrence of the disease.
We hope that the ultimate result will be given on some
future occasion, for growths somewhat resembling this in
site and characters liave recurred and proved fatal, the
recurrences having been of sarcomatous nature. The supra¬
pubic method of operating for the removal of these growths
IS the one which is found to give the most general satis¬
faction. For the notes of this case we are indebted to Mr.
Frank Savery, house surgeon.
G. W-, a labourer aged sixty-four, was admitted as
an in-patient under the care of Dr. Daly on May l.dth,
1890. He had enioyed good health until 18SG, and had
never had any illness of importance previously to that
date. In September, 188G, be was seized quite suddenly
with pain in the right lumbar region, and this was followed
in a few days by tbe presence in the urine of some material
like “ coffee,” and then by bright blood. Since that time the
urine has never been free from blood. The blood, however,
varied considerably in amount; it was generally uniformly
mixed with the urine, but sometimes in clots; tbe clots
were not worm-shaped, and the passage of clots was not
preceded by'pain in the lumbar region. Exercise increased
che amount. There was no pain before, during, or after
micturition, and no dilficulty in micturition except when
clots were present. The frequency of micturition was not-
increased; the amount of urine was not increasing. He-
lost a little weight--about 1 st. in three years. There was
no family history of cancer or new growth.
On admission the patient was a well-nourished man>
but very ansemlc. He complained of pain in the right-
lumbar region. The urine was acid, sp. gr. 1020; it con¬
tained albumen and a considerable quantity of blood, the-
colour being bright red; the albumen was not in excess of the
amount of blood; under the microscope blood-corpuscles were
seen, but no casts. The urine was more darkly coloured
with blood towards the end than at the commencement of
micturition. Temperature normal; pulse weak; other
organs appeared to be quite healthy. The bladder was
sounded, but no stone felt. The prostate was not enlarged-
There was no pain or swelling in the renal regions. Per-
cbloride of iron was given, but the urine remained the-
same ; then hamamelis, with a similar result. Dr. Daly and
Mr. Craven considered the blood came from the bladder,,
probably from a new growth, and, as the patient was-
evidently going down-hill, advised an exploratory operation.
On June 10th, at 9.30 A M., Mr. Craven operated, being;
assisted by Mr. Evans. Tbe bladder was washed out, and
then moderately distended with boracic lotion. The rectal
bag was passed, and filled with eight ounces of water. An-
incision was then made in the middle line of the abdomen,,
four inches long, the lower end being at the symphysis.
The bladder was opened and explored with the finger, when
a small growth was found on the left side of the fundus near
the opening of the left ureter, and possibly surrounding it.
It consisted of several nodules, and had a broad base of
attachment. It was removed by means of scissors. There-
was very little hremorrhage. A few stitches were put in the
upper part of the wound, and a drainage-tube, with a long
tube attached to it, in tbe lower, passing into tbe bladder.
. June 12th.—The patient has an attack of bronchitis, and
is very bad ; he wanders a good deal. All the urine comes-
by the wound, and contains blood.
20th,—Urine alkaline (sp. gr. 1020); contains a trace of
albumen, but no blood; there is a deposit of pus. He
asses some urine by the penis. The bronchitis is much
etter, but he is still delirious at night. Ordered boracic
acid internally.
26th.—Urine acid, contains a little blood ; pus much less.
From this time the urine remained free from blood. lie-
passed more and more urine by the penis, and on July 20th
the wound in the abdomen was quite healed. He slowly
recovered, and was discharged on Aug. Sth to a Convalescent
Home at Jlkley.
On microseopio examination the tumour had the appear¬
ance of a simple adenoma, there being a considerable-
fibrous stroma, with tubes cut across, lined by a single layer
of epithelium. _ _
RKDFORD GENERAL INFIRMARY.
A CARE OF .STRANGULATED HERNIA (JOMI'LICATED WITH
rAROTITLS ; RECOVERY.
(Under the care of Mr. Kinsey.)
This case is an example of inllammation of the parotid
glands following an operation in which not only was the peri¬
toneum implicated, but the testis manipulated to an unusual
extent. We published a paper by Mr. Stephen Paget,’ giving
the result of his investigations as to parotitis supervening on
surgical operations. Of the 101 cases which he had collected,
10 followed injuries or diseases of the urinary tract; 18-
injuries or diseases of the alimentary canal; 2:5 injuries or
inflammation of tbe abdominal wall, peritoneum, or pelvic
cellular tissue; and ,G0 injuries, diseases, or operations on
the generative organs, 27 of these being operations on the
ovary. The chart bears out his observation—that, as a rale,
the parotitis is not accompanied by very severe fever, rigors
are rare, and tbe inllammation does nob progress to abscess,
unless it forms part of a pyicmic infection. For the report
of the case we are indebted to Mr. K. H. Elliot, house
surgeon.
(1 I)-j aged eighteen, was admitted to the Bedford'
Infirmary on August 29bh, 1890, suffering from strangulated
J Tun LakCET, vol, i. 1887, p. 314.
Diy' zed by CjiOO^Ic
Thu Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[Fkb. 7,1891. 309
Tight inguinal hernia. The hernia, which is then said to
have been strangulated, was reduced with difficulty five days
ago. The rupture again became irreducible at 8 A.M. of
Aug. 29tb. His medical men gave opium (?) in the form of
a pill, and made two attempts at reduction. The patient
arrived here at twelve midnight. He had had nausea and
absolute constipation an day, and abdomipal pain during
the afternoon. There was a strangulated inguinal hernia
-as large as a hen’s egg, lying in the scrotum on the right
aide, behind the testicle. Constitutional signs well marked.
Mr. Kinsey came at 2.15 A.M,, and under chloroform cut
having been dressed already on the night of Ang. 30th and
on Sept. Ist. On the eighth day acute left parotitis began,
the right side became affected on the ninth day, the tem¬
perature reaching 102‘4° on the eleventh day and 103*
on the twelfth day, after which it gradudly fell, to reach
normal on the fifteenth day. On the thirteenth day
the right aide of the face was more swollen, and the
eyelids on that side were swollen. The left side was also
swollen. Oh the fifteenth day the pain was much less,
and the swelling on the left side had almost disappeared,
but was still present on both sides on the nineteenth
■down on the hernia. It was exclusively enterocele, and
the strangulating band was long and tight, lying in the
neighbourhood of the internal ring. The gut was red and
{)olished. It was returned, and the sac was dissected off from
the surrounding parts with considerable difficulty, the dissec¬
tion taking a long time. The temperature rose steadily till
it reached 102'’ on Aug. 30bb, at 10 A.M., from which time it
^ell and remained normal till Sept. 7th, on which day the
bowels acted twice after an enema. The patient gave no real
cause for anxiety beyond bis temperature, but the wound
lauppurated freely. It was dressed twice daily after Sept, dtb,
4
UlcMtal Sfldetits.
PATHOLOGICAL SOCIETY OF LONDON.
Kiarcinoma following jAipus of Face — Morphology, Cultiva¬
tion, and Toxic Products of the Tubercle Bacillus —
Tubercular Guinea-pigs ttader Koch's Treatment.
An ordinary meeting of this Society was held on Feb. 3rd,
the I’resident, Dr. W. H. Dickinson, in the chair.
Mr. E. Solly showed, for Mr. Jamoa Berry, a case of
Carcinoma following Lupus of Face. The patient was a
male aged forty-five, who had been cured of lupus of the
tface when aged fifteen, and the present cancerous growth
commenced only two months ago.
Professor Crooicsiiank made a communication on the
Morphology, Cultivation, and Toxic Products of the Tubercle
Slacillns (an abstract will be found in another column). This
was followed by a demonstration of microscopical prepara¬
tions and cultivations. The preparations were shown under
thirty-four microscopes (including twenty-three one-twelfth
■objectives). The preparations included tubercle bacilli
in sputum and pus from different cases in man; in
pure cultivations in glycerine agar-agar, glycerine
broth, broth without glycerine, and glycerine milk ;
in cream from a tubercular cow; in the liver of fowls,
lung of guinea-fowl, luug of ostrich, lung of rabbit,
'in bovine tubercular marnmitia, in miliary tubercu¬
losis in a calf inoculated with human tubercular sputum,
lin lung of liorso, in spleen of tubercular guinea-pig, and
day, after which it gradually subsided. There was no
albuminuria.
Jiemarks by Mr. Elliot. —This case, I think, raises an
interesting point of connexion between the testicle and
parotid. The position of the testicle, the tediouaness of
the operation, the suppuration which unfortunately ensued,
would probably indicate considerable interference with the
cord ; and, on the other hand, the patient could in the fort¬
night or so preceding admission think of no source from which
he could have contracted the mumps, nor did he communicate
that disease to his fellow patients, nurses, or others.
several-preparations illustrating tubercle bacilli and “phago¬
cytes”—from frogs inoculated with pure cultivations of the
bacillus. There were also preparations shown of the
crystals obtained from the extract of cultures and of
tuliercular tissue. More than sixty cultivations of the
tubercle bacillus were shown; on glycerine agar-agar of
different generations, inoculated April 17th, June 28tb,
July 22n(l, Sept. 15th, Oct. 15th, and Dec. 8th, 1890,
and Jan. i4th, 1891; in glycerine broth, broth without
glycerine, broth without glycerine with egg albumin, and
glycerine milk, inoculated Nov. 11th, 1890, Nov. 13th,
and Nov. 28Cb, and filtrates of these cultures prepared
Dec. .^>th and 9th. The chemical tests applied to the
glycerine culture filtrate and to Koch's own liquid were
also shown.
Drs. Auraham and Crook.siiank made a joint com¬
munication on the effect of Kocli’s Treatment on Tubercular
(iuinea-pigs with liquid received by Dr. Abraham direct
from Berlin. Two tubercular guinea-pigs had received six
injections since Jan. 7th in centigramme doses. Similar
doses were at the sante time administered to a healthy
guinea-pig. As further to control observations, two guinea-
pigs in the same stage of tuberculosis were carefully
examined both macroscopically and microscopically after
death as a guide to the condition of the internal organs in
the cases selected for treatment. The lymphatic glands
were caseous, and contained bacilli. There were deposits
in the spleen, which also contained bacilli. The cases
selected for treatment were therefore undoubtedly tuber¬
cular, without the disease being, in the opinion of the
autliors, too far advanced. There were well-marked chains
of tubercular glands, but the animals were nevertheless
active and well nourished. The first injection caused con¬
siderable constitutional disturbance, rise of temperature.
Digitized by
Google
310 Thb Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[FISB. 7,1891,
teoderness, and great swelling of the diseased glands and red¬
ness of the surroundiog skin. The second and subsequent in¬
jections produced a rise of temperature and tenderness, but
no sudden glandular swelling. In one guinea-pig the
tubercular glands had steadily increased in size; in the
other there had been but little change since the first injec¬
tion The temperature reaction was most marked in the
former after the fourth injection, when it reached 107|°F.
in two hours. With the exception of a very slight rise in
temperature the healthy guinea-pig was not affected by the
injection. So far, these cases showed that in tubercular
guinea-pigs Dr. Koch’s fluid in centigramme doses produced
similar phenomena to those observed in the human
tubercular subject. Whether the fluid would arrest the pro¬
gress of the disease remained to be seen, the average life
of tubercular guinea-pigs being sixty days. A cow sus¬
pected of being tubercular was injected on two occasions
with doses of two and three centigrammes. The tem¬
perature, taken hourly, remained normal, but increased
cough was observed for some hours afterwards; the
case was still under observation. Tine authors promised
to continue and extend their observations, and to place
the results before the Society at a future meeting.—
Dr. Phineas Abraham stated that in consequence of the
alarmist reports as to the dissemination of bacilli in patients
under the Koch treatment, he had within the lost week
examined the blood of the two guinea-pigs before and during
reaction. He had also examined the blood of ten human
patients now undergoing the treatment; in some cases before
and also during and after the reaction. They Included five
cases of lupus, two of phtliisis, two of strufnous joints, and
one of leprosy. In no single instance had he been able to
detect any bacilli. He considered, therefore, that if any
such metastasis took place as was indicated by Dr.
Liebmann’s observations, it was certainly not of common oc¬
currence.—Dr. Grun asked if any changes had been observed
in the structure of the bacilli found in the guinea-pigs after
injection by Koch’s fluid.—Dr. Abraham replied in the
tiegative.—Dr. Sidney Martin said that the selection of
proper cultivating media was a matter of much importance.
No bacillus could act mechanically, but only by producing
chemical products which acted as poisons. Often hitherto
unsuitable cultivating media had been used, and therefore
those chemical products had only been found sparsely or not
at all. Substances like glycerine, glycerine agar-agar, and
glycerine broth were not met with naturally in the body, and
one was apt togowrongif these wereusedasmedia. Glycerine,
in fact, was not necessary at all, and an exuberant cultivation
could be obtained if alkali-albumen were used with an amount
of salts added in proportion to those of serum. It was not
necessary to use any other products than those found in the
body, and alkali-albumen was the nearest approach to a
natural medium that could be sterilised and nandled with
convenience. The bacilli seemed to produce their poisonous
products almost entirely from the proteids, the carbo-
^drates and hydrocarbons being apparently unacted on.
He asked if we were on the road to forming any generali¬
sation as to the production of these bodies from the proteids.
He thought we were. Ordinary digestion produced albu-
moses, and, if carried a stage further by artificial dige,stion,
pepto-toxin, a basic body of definite chemical formula, would
be formed. So the anthrax bacillus formed not only albu-
moses, but a specific alkaloid, which could be isolated, and
which produced the symptoms of anthrax. Similarly he
thought it would be found that all virulent organisms
would produce nob only albumoses, but an alkaloidal poison,
which was lethal if injected in large doses. He was nob
convinced that the chemical reactions Professor Crookshank
had mentioned proved that an alkaloid was really present.
It should be separated as a base, salts should be formed
from it, and its reactions in a pure state ascertained. It
was quite possible that with a slowly acting pathogenic
organism the process had been cai-ried no further than to
form a proteid poison, the alkaloidal stage not being reached.
The actions of these bodies in producing the lesions of
their respective diseases should be carefully studied, and all
the albumoses were of interest. Anthrax albumose pro¬
duced fever, but so also did the peptic albumose formed in
ordinary digestion. The fever produced by injection
of Koch’s fluid was like that produced by the in¬
jection of a large dose of peptic albumose into animals,
and this latter might be accompanied by coma in the
animal just as coma had followed some of Koch’s injections
into human beings. He hoped that Professor Crookshank
would go further and isolate the poison he had produced.
The position he himself took at present was that an organism
could not produce a proteid poison sulflciently powerful and
in sulficient quantities to cause death, but that if this
happened some alkaloidal substance must have been
formed.—Dr. Woodhead looked at Professor Crookshank’s
paper from another point of view. In a complete study of
the tubercle bacillus it was necessary to try to trace its
morphological relations in the bacteriological king¬
dom ; to trace out its life history, how it deve¬
loped, and to follow it outside the body as well as
within it; to study it in both its parasitic and sapro¬
phitic aspects. Dr. Crookshank had collected a large
number of facts, but some of bis observations, par¬
ticularly those on the inoculation of tubercular guinea-
pigs, might perhaps have been better if left to a future
occasion. A very large number of experiments bad
already been made on guinea-pigs, and a fair number
on cattle also, and no doubt definite results would soon
be recorded. The study of this question from the
chemical point of view was extremely important.—Dr. JoD
Collins, after referring to the classical experience of
Buchner with bacillus subtilitis and bacillus anthrams,
thought that the position with regard to bacteria would
become cousiderably modified, and that it might be that
their action was comparable to that of the unorganised
ferments of the body. Professor Crookshank’s paper would
lead to more attention being paid to the chemico-physical
results of the presence of bacteria than merely to their
: morphological aspects. They might, indeed, only facilitate
a change which could be accomplished without them.—
Mr. Spencer asked the author if ne had any knowledge of
cultivations in cold media.—Dr. Hunter, in referring to
the historical review of Professor Crookshank, said he had
done wisely in separating the researches concerning
alkaloidal bodies from those regarding proteids. The
former had been studied chiefly by the Italian, French,
and German schools; but these proteid bodies had been
isolated by British study. Wooldridge, indeed, was the first
to study them, but be was unfortunate in his nomenclature,
and his work did not excite the attention it deserved at the
time. Since then Hankin and Martin had conclusively
established their importance in the symptomatology of
disease and in explaining the production of immunity.
Brieger and Fraenkel had afterwards described a series of
bodies isolated from bacterial cultures which they called
toxalbumins. The account of Professor Crookshonk’a
experiments with his extract was interesting ; it produced
at first a marked lowering of temperature, and he bad
observed the same thing ia cases inoculated with Kosh’s-
fluid which were tending towards a favourable result. As'
to the action of these toxalbumins and toxalbumoses in
producing immunity, one of their most marked properties
was to excite the cells around tubercular foci to an activity
they were previously incapable of. At a post-mortem,
examination of a phthisical patient who had died after
Koch’s injection he had seen an intense cellular infiltration
engaged in causing the absorption of caseous matter. The
active principle seemed, therefore, to strengthen the natural
properties of the ordinary cells of the body in combating the
poison. However important the tubercle bacillus was in pro¬
ducing the disease, it should not be forgotten that it was the
inherent weakness of the cells which allowed the body to^
be attacked. The treatment therefore should be in the
direction of fortifying the cells to enable them to resist the
action of morbid products.—Dr. CROOKSHANK, in reply,
said that he had already come to the conclusion that the-
small amount of toxic substance produced was due to the
fact tliat his media were not rich enough in proteids, and he
had therefore begun to use alkali-albumen. He had also
gone further in the separation of the chemical constituents
of his extract than he bad indicated in what he had read of
his paper. He referred to Sir Hugh Bcevor’s important
researches into the growth of bacilli at low temperatures.
He injected cultivations into the dorsal lymph sac of the
frog and the phagocytes could be observed taking up the
bacilli; the contest between the two was prolonged, and
the result at present uncertain. The secrets of success in
such a research as he had been carrying out were to have
carefully prepared media, a good incubator, and a tho¬
roughly reliable trained assistant.
The following card specimen was shown :
Dr. E. Perry : Tuberculosis of the Thyroid Gland,
The Lancet,]
OPHTHALMOLOGICAL SOCIETY.
[Feb. 7,1891. 311
OPHTHALMOLOGICAL SOCIETY.
An Unusual Result of Cataract Extraction. — The Con¬
nexion between Accommodation and Convergence. —
Miners’ Nystagmus among the South Wales Colliers.
An ordinary meeting of this Society was held onJan. 29bb,
■the President, Mr. Henry Power, F.R.C.S., in the chair.
Dr. Berry {Edinburgh) called attention to an unusual
result of Cataract Extraction occurring in a female patient
aged seventy-two on whom he operated. The extraction
was performed on Nov. 27th about midday, and just at the
termination of the operation an escape of decidedly vitreous
fluid took place. About twelve hours later pain began, and
was followed by vomiting. At 11.30 a.m. next day the dressing
was removed, and was found soaked with blood, the eyeball
‘being distended with blood. Shortly afterwards the patient
had an epileptic seizure, followed within the next three hours
by two more. No further fits occurred : the patient had
never previously suffered from them. Dr. Berry brought
the case before the Society in reference to the relation
between iotra-ocular heemorrhage and the epileptic attacks.
He ventured to suggest in explanation that the pressure of
the blood in the eyeball caused an irritation of the iotra-
ocular sensory nerve filaments, resulting first in sickness
and afterwards in a more marked nerve explosion.—
Mr. Critciiett mentioned a case of intra-ocular heemorrhage
coming on apparently six or eight hours after an operation
•for cataract, and probably induced by the reduction of
tension due to gradual leakage of abnormally thin vitreous. —
Mr. Eales spoke of a somewhat similar case, in which the
vomiting ensuing from administration of a general anmsthetic
Appeared to cause the bleeding.—The President cited an
incident in his own experience in which an epileptic seizure
occurred in a patient ]U8t as he had entered the knife in
the course of a cataract extraction. He was able to
complete the section, and then supported the eye until the
lit had passed off, when he finished the operation.
Dr. Berry also read a paper on some points with
reference to the Connexion between Accommodation and
Convergence, in which, whilst admitting that the ordinary
rough method of estimating latent deviation of the eyes
was quite sufficient to afford indications for operative
interference, he indicated that there were very frequently
.present minor degrees of deviation which afforded a study
of much scientific interest, though he deprecated these
being made the grounds for unnecessary operative inter¬
ference or application of prisms, as would appear from
recent American literature to be too often the case. The
apparatus employed in the investigation consisted of scales
for different distances, graduated in metre angles, and a
vertically refracting prism or Maddox’s glass rod held in
•front of one eye. Dr. Berry had previously insisted that
in adopting the metrical notation it was necessary to regard
as the basis of measurement not the whole, but only half
the angle included between the deviated axis and what
should be the normal axis of the eye for binocular fixation,
the entire angle being shared between the two eyes, for the
most part equally. JJr. Berry referred to somewhat similar
methods of investigation by which Bonders obtained his
well-known curves of relative accommodatiou and Nagel
those of relative convergence, and pointed out that it had
been then shown that the amount of dissociation possible
was subject to individual differences and varied with the
■degree of accommodation or convergence, the amplitude of
relative accommodation or convergence being greatest for the
reading distance and beyond it. This also being the range
at which deviation is least governed by association of these
two functions when binocular vision is prevented, the
relative divergence tending also to increase tolerably uni¬
formly as the ordinary near point is approached—that is,
with the amount of convergence required. It is greater
also in myopia than in emmetropia, and in that than in
hypermetropia, though it does not necessarily follow that
the convergence lags behind the accommodation. The
relative degree of these two depends upon the direction of
the axis when convergence begins. For instance, the initial
position might be one of one-metre angle of divergence;
four-metre angles of convergence associated with four
■dioptres of accommodation would tUenstill leave a divergence
•of one-inetre angle on fixation for one-quarter of a metre
distance. Of 120 individuals representing all conditions of
refraction, the emmetropes in large proportion exhibited
almost perfect parallelism for distant fixation, the tendency
being to slight divergence. Tbe myopes showed a greater
tendency to convergent or divergent deviation, the latter
being more conspicuous; whilst in tbe hypermetropes
convergence was more prominent. These results alone would
indicate that there is no necessarily intimate relation between
accommodation and convergence for a distance, and further
investigation indicates that correction of ametropia cannot
be relied on to remove latent want of parallelism, but the
tendency is for accommodative effort, wnether voluntary or
induced bv glasses, to lessen divergence or increase con¬
vergence, Wt not coextensively. That individuals poaseas-
ing this aparalleliam of the optic axes do not see double
under ordinary conditions is due to the establishment of
an innervation equilibrium which serves as the starting
point of convergent movements, and represents the position
of physiologic^ as contrasted with that of anatomical
equilibrium. It is possibly the survival of a portion of this
habitual extra innervation after correction which disturbs
the ratio between accommodation and convergence in some
of these coses. The paper was illustrated by diagrams
representing the relative convergence and accommodation
for fixing points at varying distances, expressed in dioptres
and metre angles.—Dr. Berry, in reply to Messrs.
Hartridge and Frost, admitted that there would probably
be some variation with the age of patients, but that all
those examined by him had been -between thirty-five
and forty. He thought also that the amount of deviation
did increase witli hypermetropia.
Mr. Tatham Thompson read a paper on Miners’
Nystagmus among the South Wales Colliers. He called
attention to the uncertainty existing as to the causation of
the disease. The two most commonly accepted causes
were: First, persistent strain of ocular muscles, especially
in those miners who worked lying on their sides; secondly,
insufficient stimulation of retina from imperfect illumina¬
tion. After calling attention to the statement so frequently
made, that nystagmus only occurred in those engaged in the
process of “holing,” where the miner lies on his side with
the eyes directed obliquely upward, Mr. Thompson said
that m the South Wales district there were special oppor¬
tunities of judging between these two points of position
or illumination. Tbe coal worked there is of two
kinds — house coal and steam coal. As a rule, miners
engaged in cutting house coal worked in their
seams with very little head room, some holing, the
majority working “long wall.” Safety lamps were the
exception. On the other hand, the steam coal miner
bad, as a rule, from six to eight feet of head room,
the seams being thick; no holing, all long wall work,
which, was done principally standing, but with much
poorer illumination, owing to the necessity of using safety
lamps. It was pointed out that in the former group there
were all the conditions which, according to the supporters
of the “ ocular muscle strain ” theory, should induce
nystagmus. As a matter of fact the disease was extremely
rare among the house coal workers, except in a few cases
where safety lamps were used; whilst it was very frequently
met with amongst the steam coal miners. Mr. Thompson
had collected evidence from colliery surgeons, engineers,
mangers, and workmen from all parts of the district, and
held that the general consensus of opinion pointed emphati¬
cally to the imperfect illuraination being a potent, if not the
essential, factor in the causation. Several of the medical
men ■whose experience on the subject he had sought had
been for years in districts where house coal bad been
worked and holing practised, but who, until the
sbirking of the steam coal and the introduction of tbe
safety lamp, had never seen miners’ nystagmus. Cases
were quoted where those suffering from the disease on
using the safety lamps had been relieved on going back
to work with the naked light. The absence of nystagmus
amongst the labourers and “baulyers” was explained by
the fact that their occupation was much more varied,
as a rule with better illumination, and that inuch of
their work was done by “feel,” there beirig^ nothing like
the necessity for continued strain of vision in semi-
darkness. The symptoms experienced were usually dazzling,
difficulty in fixation, and hemeralopia, but the writer
had very rarely found vertigo, vomiting, or incoordi¬
nate movements of the extremities. In trying to induce
nystagmus, attempted fixation of vision in a dark room had
been found quite as effective as the oblique upward vision
with the head flexed. The relation of miners nystagmus
^8
312 The Lancet,]
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
[Flb. 7,1881.
to: that induced by corneal and lenticular opacities and
congenital deficiencies was considered, and the iofiaence of
imperfect stimulation of the retina in both cases pointed out.
Mr. Tatham Thompson went on to point out that errors of
refraction, and especially hypermetropia and hypermetropic
astigmatism, were very commonly met with in those suffer¬
ing IIom miners' nystagmus ; it was exceptional to find it in
the emmetrope. He suggested an inquiry in this direction as
likely to prove of value. His opinion had been strongly cor-
roboratedby the evidenceof Mr. G. A. Brown of Tredegar, who
hadsome years agofoundhypermetropia to be a very constant
accompaniment of nystagmus. In conclusion, Mr. Thompson
said : “ 1 would submit that I have brought reasonable evi¬
dence to show that visual strain, with insufficient illumina¬
tion, is, at any rate, as great a factor in the causation as
strain of the ocular muscles ; that the disease is by no means
confined to those whose work is done lying down, and
that errors of refraction, especially hypermetropia and
hypermetropic astigmatism, are predisposing causes.”—
hlr. Snell (Sheffield) spoke at some length in answer to
Mr. Tatham Thompson’s paper. He said it was a very
curious fact that alt the individuals exhibiting this form of
nystagmus were following one occupation. He did not deny
that defective illumination might have something to do with
the condition, but his contention was that the oblique
position in which the head and eyes were maintained whilst
the man was at work exerted the chief infiuence in its
causation. He thought the South Wales miners were worse
off than those in the north country through lack of improve¬
ment in their lights, their lamps only yielding -iV^ candle
illaminatioD, whilst in the north were attained. In spite
of this advance, however, the disease was more common in
the north row than formerly. The miners he knew were
unanimous in accusing their lamps of being responsible for
the disease j but men working in other departments with
the same light did not suffer, whilst those affected did not
recover when substituting naked candlelight, and others
even developed the nystagmus whilst using candles. Mr,
Snell quoted also three cases which had occurred in
an excellent light, in men subjected to a similar
lateral and upward eye strain whilst occupied in putting
carriages in the cage at the bottom of a shaft. Some
foreign observers had visited the pits, and came to the
same conclusion as himself. The miners occupied in holing
were obliged to adopt a peculiar position, which be illus¬
trated by photographs. Only about 30 per cent, were so
engaged, and those chiefly suffered. There were also many
instances among them of tremors of the face, head, and
neck, which were usually more marked on one side. The
nystagmus could be checked by directing the eyes down¬
wards. Many sufferers bad been advised not to continue
the same work and had improved 5 one especially got quite
well under ordinary work, but relapsed directly he resumed
the constrained attitude.
The following living and card specimens were ex¬
hibited :—
Mr. Hartridge : (1) Chronic Glaucoma with Htemor-
rhage in the Cup; (2) Models for Demonstrating Errors of
Refraction.
Mr. Wray : Binasal Hmmianopsia.
Mr. Doyne : Case of Paralysis of Right Sixth and part
of Right Fifth Nerve, with Partial Optic Atrophy*
Mr. JULER : Congenital Buphthalmos.
Mr. Critchett : Conical Cornea treated by Cauterisation
without Perforation.
Mr. Lang : Absolute Glaucoma with Extensive Retinal
Hmmorrhage.
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
ATthemeeting on Jan. 15bh, Mr. W. Dale James, M.K. C.S.,
President, in the chair, most of the time was taken
up by a discussion on the proposed M idwives’ Registration
Bill. After a legal opinion on the Bill had been read, the
President invited discussion, in which Mr. A. Jackson,
Dr. Keeling, Mr. West Jones, Dr. Martin, Dr. Hargreaves,
Mr. R. Favell, Mr. E. Skinner, Mr. Wrench, Mr. E. Barber,
Dr. Sinclair White, Dr. S. Mathews, Dr. Stokes. Dr. Law,
and Mr. E. W. Thomson took part—all the speakers, with¬
out exception, being opposed to the Bill in its present form.
Dr. Martin proposed and Mr. Arthur Jackson seconded the
following resolution, which was carried unanimously;
<*That this meeting of the Sheffield Medico-Cbirargical
Society is of opinion that the passage of this Bill for the
registration of midwives through the House of Commons-
should be delayed, and that a committee of the Society,,
consisting of the President, Secretaiy, Dr. Keeling, Mr. A.
Jackson, and Dr. Martin, be appointed, to see the members'
of Parliament for Hallamshire and the borough of Sheffield,
aud to take such other steps as may be needful to secure-
delay.”
Dr. Hargreaves showed a Liver, weighing eight poundfe,
with Carcinoma. The cancerous nodules, of the si^e of a
pea, were closely disseminated throughout the liver, those
on the surface being somewhat softened and umbilicated.
During life the liver extended into and filled the left hypo-
chondrium. The patient was a married woman aged
thirty-seven, dark-complexioned, of slight build, weighing
about Tst. Twelve months before Dr. Hargreaves had
showed a tumour removed from the left breast and two-
glands from the axilla of this patient. There had been a.
recurrence of the tumour in the breast, of rapid growth, and
the axilla was filled with enlarged glands, as well as
seoondarj' deposit in the liver.
NOTTINGHAM MEDICO-CHIRURGICAL
SOCIETY.
A meeting of this Society was held on Jan. 7th, Mr. C..
Haydon White, President, in the chair.
Gastrostomy. —Mr. A. R. Anderson showed a man aged
fifty-five on whom the operation of gastrostomy had been
performed six months previously (June 26th, 1890) for
malignaot stricture of the msophagus. The disease was-
situated in its lower portion, close to its termination in the
stomach. At the time the operation was performed the
patient was much emaciated, and could swallow only flnids-
in small quantity and with considerable dilHculty. He-
spat up blood-stained mucus, and any attempt to pass a-
bougie caused bleeding. There was no history of syphilis,
or of injury to the gullet. After the operation he improved
greatly in health and gained weight, but there had, been-
some falling off during the last month.
Mr. Anderson also read notes of a case of a youtJi age<l
eighteen over whose abdomen the wheel of a heavy cart
had passed, the injury being followed by symptoms closely
resembling those of ruptured bowel. An exploratory
laparotomy revealed nothing beyond an intra-peritoneat
ha‘-morrhage of considerable amount. The abdomen was-
washed out, and the patient made a good recoveiy.
Hysterical Lethargy, —Dr. Handford communicated this,
case, which was of interest chiefly from its close simulation
of organic cerebral disease. Tne patient was a young:
married woman aged thirty-seven, and was first seen late-
on the evening of July 20th in conjunction with her usual
medical attendant. She was supposed to be suffering from
either meningitis or urcemia. Her illness began three daysi
previously with headache, delirium, and vomiting. She-
soon improved sufficiently to go about and take solid food»
On July 20th she became unconscious, iu which state she
was first seen by Dr. Handford. It was impossible to com¬
municate with her in any way. At long intervals she cried
out “I shall go mad.” Otherwise she never spoke and
appeared not to understand questions. There was no altera¬
tion of the reflexes, no affection of the sphincters, no optic-
neuritis or ocular paralysis and no albumen in the urine. The
breathing was quiet aud the pulse soft and regular ( 100 ).
The temperature remained normal throughout. She could
swallow a few spoonfuls of milk, but retained it a long time
in her mouth. The limbs were flaccid, but there was no-
paralysis. The physical signs pointed to the absence of any
serious organic disease, and hysterical lethargy, correspond¬
ing to one of the phases of hypnotism in which the uncon ¬
sciousness is deepest, was suspected. Next day it was-
ascertained from some other friends that she had been
subject to hysfcero-epileptic fits since cliildhood, and also-
that she had lately been overworked and underfed, and had
helped to nurse a neighbour’s child who died of tubercular
meningitis, and who had been accustomed to cry out “ li
shall go mad.” The patient gradually recovered conscious¬
ness and mental power, but it was a month or more before-
she talked,readily. The case bore some resemblance to one
of acute primary dementia, but there were well-marked-
differences.-—Dr. Handford also related another private-
case in a boy aged ten, where, after a very trivial injury to-
Coii'Je
The Lancet, ROYAL ACADEMY OF MEDICINE, IRELAND. - [Feb, 7,1891. 313
the head, unconBciousness came on suddenly at the end
of a week, and the boy was thought to be dying. But
during examination he sat up and began to laugh. He
had previously been somewnat wilful. He soon got
well.
On a mode of Sterilising Milk for /nyawfs.—Attention was
drawn to the evidence, clinical and experimental, of the
important part played by milk in conveying pathogenic
micro-organisms into the system and to the probability of
its being a frequent agent in producing tubercular disease
in infants. Soxblet’s apparatus for sterilising milk was
exhibited, and the possibility demonstrated of attaining the
same object with the ordinary boat-shaped bottle and
ordinary domestic utensils.
Dr. Cattle read notes on examination of the Sputum.
Freparations.—'DT. Handford demonstrated the Diazo
Reaction in Ehrlich’s Test for the Urine in Enteric Fever.—
Dr. Ransom showed Micrococci in Ulcerative Endo¬
carditis.—Mr. Anderson showed an Encysted Vesical
Calculus.—Dr. Cattle showed Tubercle Bacilli stained by
different methods.
ROYAL ACADEMY OF MEDICINE, IRELAND.
A meeting of the Section of Pathology was held on
Dec. 5th.
Congenital Deformity.—Hr. E. H. BENNETT exhibited a
dissection of an upper limb congenitally deformed, and a
cast of the limb taken previously to its dissection. The
deformity was one to which special attention had been
directed by the writings of Montgomery and of Sir James
Simpson on intra-uterine amputations, and particularly by
the latter author in his paper on the “Rudimentary lie-
production of Extremities after their Spontaneous Ampu¬
tation.” Farther interest attaches to this description,
as Sir James Paget has, with some slight reserve,
adopted the theory put forward by Simpson in his lec¬
ture on the “Reproduction of Injured and Lost Parts,”
in his “Surgical Pathology.” Later writers have held
opposite opinions as to the explanation of the de¬
formity. Mr. Annandale unhesitatingly adopted the
views of Simpson ; while Dr. Sturges, writing in 1880,
opposes these. While many cases very similar in their
external characters have been recorded, but few records of
dissections of limbs so deformed have been published, the
majority of observations having been made on the living.
The present specimen, and that recorded by Dr. Cayley in
1865, have the merit of exposing Che anatomical details,
and these appear to be similar in all essential details. Dr.
Bennett then detailed the facts of the case—viz , the left
upper extremity of a young man which terminated at the
middle of the forearm in a stump, well formed and plump;
from the palmar aspect a knob projected which carried on
its summit a row of five rounded tubercles; above the
knob and its row of tubercles there was a circular scar on
the limb ; and at either side of the knob, opposite to the
extremities of the bones of the forearm and within the cir¬
cular scar, there were two minute depressions in which the
ends of the bones of the forearm were attached to the skin.
The results of the dissection showed that though atrophic
in a high degree, the nerves, the bloodvessels, and the
tendons, such as they were, passed along through the stump
to reach and terminate in the knob and tubercTea which re¬
presented the hand and fingers. This specimen furnished
additional matter of pathological interest, for the brain,
like the parts of the brachial plexus concerned in the supply
of the hand and forearm, was atrophic at the region of the
motor area .of these parts. The brain will be photographed
and figured by Professor Cuningham.—Dr. Fra/er referred
to a remarkable case recorded by the late Dr. Adams, of a
young boy who gob a blow of an Italian iron which per¬
forated his skull, and caused the escape through the
wound of a considerable portion of his brain. His
arm on the side opposite to the wound ceased to grow
in proportion with his other arm.—Dr. Bkwlicf said
it was difficult to understand how the umbilical cord
could amputate a limb by pressure without interfering with
its own blood-supply.— Dr. Patteson remarked that if the
lesion in question had been produced by a constricting band
it could only have acted by interfering with the blood-supply
of the limb; and that being so, one would have expected to
find the calibre of the arteries diminished. But it appeared
that in the present instance they could be traced of full size
down to the stump. It must have been caused by nerve
disturbance; and if in this case there was a lesion of the
motor cortex corresponding to the disturbance of the nerves
leading to the part, he thought that what they bad to deal
with was, primarily, an arrested development of the motor
area of the brain.
Notes on the Pathology of a Dentigerous Cyst. —Dr. A.
W. W. Baker made a communication on the patholomr of
a dentigerous cyst. A cyst about the size of a small pda
was found attacned to the palatine root of an upper molar
tooth; it presented an unusual peculiarity in being lined with
columnar ciliated epithelium, the occurence of such epithe¬
lium being accounted for by the fact that masses of epithe¬
lium are frequently seen in the root membrane of teeth,
and are thought to be the remains or debris of the enamel
organ, the development of the cilia being a subsequent
process. The cyst gave rise to a good deal of pain,
and bad semi-purulent contents. The communication was
illustrated ‘with microscopic sections and photographs.—
Dr. Frazer exhibited a number of bones from the
Irish elk, and made a communication thereon.—Dr. BIR¬
MINGHAM submitted an example of Spontaneous Enterec-
tomy.
Tricuspid Narrowing. —Dr. H. T, Bewley showed a
heart, the subject of tricuspid narrowing. The heart
was enlarged, weighing 23ioz. ; all the cavities were
dilated and their w^s hypertrophied. At the post-mortem
examination they were all found full of blood. The tri¬
cuspid valves were adherent, the opening measuring Sin.
in circumference (normal, 5^-6 in.). The mitral valves
were also adherent, the opening measuring 2§ in. in
circumference (normal, 4^ in.). The aortic valves were
extensively diseased. The heart muscle was healthy.
Other organs healthy. Dr. Bewley called attention to
the rarity of the lesion, and to the fact that with
tricuspid narrowing mitral narrowing practically always
coexisted, and aortic disease in about 50 per cent, of the
recorded cases.
Scirrhus Cancer of the Male Breast. —Mr. PATTBSON
showed a specimen which had been removed in St. Vincent’s
Hospital by Mr. M'Ardle a few weeks previously. The
patient was a strong, able-bodied man, sixty-seven years of
age, with a good history, both family and personal. Mr.
Patteson referred to the statistics of cancer, and found, as
thei-esultof a total of 1781 cases of carcinoma of breast,*
only 1‘38 per cent, occurred in males. Billroth gives a
somewhat higher percentage—2‘77 in 252 cases. Sarcoma
seemed to be more common in the male heart, but the
available statistics are nob sufficient to establish accurately
the relative frequency.
artli of ^oob.
Notes on Typhoid Fever; I'ropical Life and its S^uelce.
By Jeffery A. Marston, C.B., M.D., M.K.C.P.,
F!R.C.S., Surgeon General, Medical Staff (retired).
London : H. K. Lewis. 1890.
Every conVibution to the natural history of enteric
fever is welcome, more especially when it deals with its
occurrence in tropical climates. There was a time when
the greatest confusion existed regarding this subject, owing
doubtless to the masked and modified forms under which
this disease prevails in those regions. For this reason
alone these “ notes from the pen of an officer of great
experience and ripe judgment are sure to be heartily
welcomed, but in addition he merits our thanks for
the lucid manner in which he has dealt with the sub¬
ject. The essence of his argument respecting the
etiology of typhoid fever may be summed up as a
plea against the too limited doctrine so admirably
sketched by Budd—that, namely, of the specific nature of
the poison, and the invariable dependence of one case of the
disease upon a preceding one. This view, which is now
so generally held, and is seemingly supported by the
history of epidemics, is shown by Dr. Marston to be
inadequate to account for the striking facts of the ex-
Din->Rd by Google
314 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Fi£B. 7,1891.
treme vulnerability of the young soldier in India to the
disease, the immunity of native troops, and the impos¬
sibility in many cases of tracing the disease to a con¬
taminated source. We gather that he has been forced to
the conclusion that altered conditions of climate, environ¬
ment, diet, &c , operating on an organism at the time when
the lymphatic and glandular systems are most active, may,
without the introduction of any specific poison, initiate
typhoid fever. This may be so, but for our pari we should
be inclined to regard all the attendant circumstances of the
young soldier’s life in India as so many factors disposing
him to fall a ready victim to a poison which in many
stations of that country may be considered to be indigenous.
“ Vulnerability ” is a good term to express the condition
induced in the organism by these climatic surroundings.
However, Dr. Maraton cites much evidence from his Indian
. experiences and from the Soudan campaigns which requires,
and will he certain to receive, careful attention upon this
much-debated question of the etiology of enteric fever. It
is interesting to learn from him that the relapsing variety is
not infrequent, hut he expressly repudiates the distinction
of a separate “ typho-malarial ” fever. He states, indeed,
that the malarial stations of India do not furnish the chief
number of cases of typhoid fever; and although, naturally,
cases occur in which the typhoid phenomena are more or
less modified by antecedent malaria, these cannot be
regarded as forming a distinct third class of fever. Another
interesting fact is the comparative frequency of ulcerali m
of the large intestine in tropical typhoid fever—a dysenteric
form. Dr. Marston speaks very confidently upon the occa¬
sional prolonged incubation of typhoid fever, citing cases
from his own experience, and from the hospital returns of
soldiers invalided home from Egypt for other complaints,
and becoming attacked with typhoid fever after their arrival.
The determination of this difficult point must, however, rest
upon the absolute exclusion of any possible source of in¬
fection in the long interval that is here assigned to the
^incubation period. There is so much that is suggestive
in the book that it is difficult to make selections.
We may mention the hypothesis that the rose-rash is the
result of an auto-infection—some absorption from the
diseased iotestioal glands; and that relapses are due to
fresh action, possibly reinfection, of other glands that have
previously escaped- The difficulties in the way of accurate
diagnosis are illustrated especially by the cases of the
Mediterranean fevers,”—prolonged febrile diseases, non-
malarial in character, and not accompanied by intestinal
lesions. ' There is much to he learnt yet concerning the
true nature of these obscure afrections.
The pages devoted to treatment are written in a
thorougly practical spirit, and there is nothing to which
exception can he taken. Indeed, the author’s mistrust of
antipyretic drugs, the use of which seems to him to be
“ unphilosophical” and “occasionally dangerous,” is likely
to be shared by others who, having abundantly tried
them, have found them of doubtful benefit. An entire
chapter is devoted to typhoid fever in India, with especial
reference to its prophylaxis. Dr. Marston’a injunctions
may, we hope, attract the attention of those to whcmi
the health of the army is entrusted. They comprise the
aroidanceof dispafcchingyoungor immature men to India; the
sending newly arrived troops direct to the bill stations; the
regulation of diet in accordance with the climatic conditions;
the necessity of a pure water-supply; and the avoidance of
undue and exhausting drills, especially in the hot reason.
The liability to enteric fever among soldiers newly arrived
in India is greater than that of all other diseases, and the
mortality is very high. To diminish this liability should be
a foremost aim of army sanitarians. The little book con-
talas also an instructive essay on Tropical Life and its
Sequelm, which will he read with as much interest and in¬
struction as will those pages to which we have specially
called attention.
The Geoqraphical Distribution of some Tropical Diseases,
By 1^. W. Felkin, M.D. Edinburgh and London;
Young J. Pentland. 1889
This paper is reprinted from the Proceedings of the Royal
Society of Edinburgh. It forms a brochxire of fifty-four
pages, to which are added sixteen maps. These maps
are the great feature of the wprk ; tliey have been carefully
prepared, and form a very interesting and valuable collec¬
tion. Each map is a chart of the world on Mercator’s pro¬
jection, and on it is shown in colours the extent of
one or more tropical diseases, so that the area of dis¬
tribution can he seen at a glance. The diseases treated
of are:—(1) Malaria, (2) Dengue, (3) Asiatic cholera,
(4) Yellow fever, (5) Oriental boil, (6) Endemic ba?roa-
turia, (7) Beri-beri, (8) Oriental plague, -f9) Dysentery,
(10) Leprosy, (11) Yaws, (12) Fungus disease of India,
(13) Elephantiasis Arabum, (14) Guinea-worm, (15) Filaria
sanguinis homuiiB, (16) Scurvy, (17) Tropical abscess of the
liver.
Thus, if we desire to know the distribution of dengue we
have only to turn to Map 11 to see that this disease has
visited Egypt, Tripoli, and the valley of the Nile; also
Arabia, India, and Further India; and that it has affected
some small islands in the West Indies, and a great part of
the Southern States of the Union, as well as the northern
shores of South America, In a footnote we are informed
that it is “ most prevalent in summer and early autumn,”
and that its incubation period is from five to six days. The
other diseases are treated in the same way, and thus
much valuable information may be obtained in a few
minutes.
In the letterpress we also find much that is interesting.
Each subject is treated on a definite plan. The name of
the disease is first given and its various synonyms; secondly,
a short definition of the disease, and a very brief descrip¬
tion of it; the geographical distribution of the disease is
then sketched out; and finally, its relation to various
physical phenomena as affecting its causation, area, and its
epidemic spread.
The author at the conclusion of the introduction says:—
“I trust that this paper may be of special interest to
members of my own profession, who will be able to see at a
glance the diseases infesting the various districts in the
tropics, and who will therefore be the more able to give the
necessary advice to patients. It should be of special service
to insurance companies, as indicating the areas of compara¬
tive safety or ri-jk for the residence of their clients.” In
addition to these, we thick that it would be extremely
useful to medical officers in the army and navy and mer¬
cantile service.
We strongly recommend this work to all who are interested
in tropical diseases. Though small in size, it contains a
vast amount of information, and we heartily congi-atulate
the author on the success of his labours.
The Twenty-fourth Report of the Trustees of the City Hospital,
Boston, U.S. 1887.
This report, which is an annual one presented by the
trustees in compliance with the ordinances, is accompanied
with the reports of the superintendeDt and medical and
surgical staff, rules for admissions and discharges, pros¬
pectus of training school for nurses, &C. It makes a small
volume of about 100 pages, and gives the expenses incurred
in working the hospital, repairing it, and the proposed ex¬
penditure in new buildings. During the year there were
Digitized by L^ooQle
The Lanobt,]
OUR LIBRARY TABLE.
IFeb. 7,1891. 315
5577 patients admitted ; of these 3113 were medical, 2382
surgical, and 82 ophthalmic. Of this number, 1742 were
discharged well, 2903 relieved, 163 nob relieved, 128 were
not treated, 623 died (185 within forty-eight hours after
admission), and 18 decamped. The net cost per head of
each patient in the wards was 9'69 dols. Daring the
year 14,318 out patients made 48,534 visits for treatment.
It was proposed to add 60 beds for contagious cases, when
the number of beds will be 485 during the winter months,
and 557 during the summer months, owing to the employ¬
ment of tents ; these had been specially utilised for typhoid
fever cases. The number of typhoid cases was large. On
Jan. 1st, 1887, there were 22 patients under treatment, and
245 were admitted during the year ; of these, 188 were dis¬
charged well, 20 relieved, 5 unrelieved, and 43 died. The
number of cases of diphtheria was also large ; at the com¬
mencement of the year there were 7 under treatment and
184 were admitted, of which number 88 died, 2 were not
treated, and 8 were discharged unrelieved. Referring to
the table of surgical operations, we find that tracheo¬
tomy was performed for this disease on 26 males and
11 females; of these, 2 recovered, 4 were relieved, 1
nob relieved, and 30 died. Intubation was practised
on 20 males and 10 females; 3 were discharged well,
4 relieved, 1 remained under care, and 22 died. The
causes of death after intubation are given as follows:—
Sepsis, in from one to six days, 12 ; obstruction, from one to
three days, 6 ; failure, from one to two days, 3. The causes of
death after tracheotomy are given as follows :—Obstruction
lowdowQ.fromtwotoeightdays, 13; general failure, oneday,
2 ; general infection, from one to five days, 12; pneumonia,
from twoto eighteen days, 3. The medical andsurgical reports
have been carefully compiled. We think, however, that it
would be well in compiling such reports that terras de-
siguating particular diseases or methods of operation by
the name of the man who described the disease or practised
a particular operation should be replaced by the clinical
term. It is not necessarily evident that by “Rigg’s
disease" is meant a disease of the gun,s, or by “Heaton’s
operation" a particular method of injecting the hernial sac
with twenty minims of white oak bark, thickened by the
addition of fourteen grains of the solid extract of the same
bark, with half a grain of morphia to relieve the pain. A
return of the various out-patient departments is added, and
the cases grouped according to the nature of the disease ;
many of these would probably be admitted. The report
altogether is highly ereditable, and would serve as a model
for many others.
OUR LIBRARY TABLE.
A Handbook of tlui Theory and Practice of Medicine. By
Frederick T. Roberts, M.D., B Sc., F.KC.P. Eighth
Edition. London: II. K. Lewis. 1890.—The regularity
with which fresh editions of this admirable text-book make
their appearance serves to show that it continues to maintain
its favoured position with the student, who finds it a safe
and reliable guide. Apart from the clearness of style and
its thoroughly practical character, a great feature of
Dr. Roberts’ work is the systematic method with which
each subject is treated. The value of this kind of instruc¬
tion is high, as it enables the student to marshal his ideas
in an orderly manner and to assign to each part its special
importance. The author has not been unmindful of the
necessity of keeping his book “ up to date,” and he has
evidently bestowed much pains on its revision. It is enough
to say that it fully merits its popularity.
Studies from the Biological Laboratory of the Johns
Hopkins University, Baltimore. Editor: H. Newell
Martin. Published by John Murray, Johns Hopkins
University. Oct. 1890. Vol. IV. No. 7. With 7 Plates.—
This part is taken up with two memoirs: (1) Notes
on the Anatomy of Blpunculus Gouldii Pourtalbs
(PbascoloBoma Gouldii), by E. A. Andrews; and (2) The
Relationship of Arthropods, by H. T. Fernald. Of the first
paper we can only say that it gives a very complete and
interesting description of the anatomical characters of a
species that has not hitherto received much attention.
Mr. l^ernald's paper embraces a wider subject. He com¬
mences by a good account of the anatomy of Anurida niari-
tima and with some notes on Lepisma sacebarina, and then
discusses the modern views as to the origin of the Arthropods,
including that of Brauer and Lubbock, who bold that the
Insects are derived from a Campodea-like ancestor;
that of Haeckel, that an aquatic zoea-like form assumed
a terrestrial habit and acquired a tracheal respiration;
that of Gegenbaur, that the ancestors of insects were
aquatic, breathing by a row of metamerically placed
tracheal gills on each side of the body. This worm
became terrestrial, the pairs of gills on the mesothorax and
metathorax became greatly enlarged, and adapted for
locomotion, while the others became torn off, leaving an open¬
ing where the tracheal trunk passed from each gill into the
body, as the representative of the stigmatal opening. These
and many more are referred to, and the author gives a scheme
which represents his own view, the base or root of the
Arthropods being represented by an unsegmented worm, from
which, on 'the one liand, develop the Crustacea, limulus,
arachnida, and insecta, and, on the other, annelida and
peripabus. The origin of theMyriapodshe places doubtfully
between the foregoing two groups, whilst Collembola
represents a degraded member of the Insecta. There is an
excellent bibliography.
The Practical Guide to Algiers. By Geo. W. Harris.
London : Geo. Phillips and Son.—This is a handy little
book, likely to render good service to those who winter at
Algiers There are some excellent phototype illustrations,
and the practical infororation given is so disposed as to be
readily accessible for reference. We are taught not merely
how to travel, but how to travel economically. Mr.
Flarris very justly complains as to the paucity of trains.
For instance, from Algiers to Oran there is but one
train a day. It starts at six in the morning from
Algiers, and reaches Oran at seven in the evening. This
necessitates rising very early, which in dark winter days
is not only unpleasant, but exposes invalids to great
risks. It is the same at Constantine, where but one train
per day starts for Biskra. This is the more unfortunate
as Biskra seems to possess not merely the most remarkable
climate of Algeria, but of Western Europe and Northern
Africa. There is hardly any rain; in January the tempera¬
ture ranges between 70° and 80° F. in the shade, and the
Bureau Mdtoorologique reports that, during the winter of
1889-90, the thermometer never registered less than 70° F.
in the shade. This Desert City is warmer even than
Malaga, where the sugar cane grows in the fields, and there
is already fair hotel accommodation. Mr. Harris’s book
will doubtless embolden many invalids to venture out to
these more distant winter stations.
Hclbing’s Pharmacological Record for January, 1891, is
more therapeutical in nature than its forerunners, but the
subjects touched on are relatively few. A brief note upon
the ketone process for the preparation of chloroform is
followed by a somewhat lengthy account of ichthyol, recent
observations upon its uses in gyniocology, and as an anodyne,
being summarised. Exception is taken to the Pharma-
copcoial name for lanoline, and the researches of Shoemaker
and Unna are noticed. Mr. Helbing returns to the attack
upon the work of Professor Dunsban and Mr. Block on
salicylic acid, and gives numerous farther observations
Digitized by LjOOQIC
[Feb. 7,1891.
316 The Lancet,] REFLECTIONS ON KOCH’S TREATMEIST FOR TUBERCULOSIS.
■which, in hia opinion, outweigh “ the one-experinient
concluaion ” of the physiological action' of patacresotic
acid. Demme of Berne recommends the medicinal em¬
ployment of sodium paraeresotate, and Carl Henne is
of opinion that this salt is less toxic in action than the
salicylates.
Proceedings of the Philosophical Society of Glasgow.
Vol. XXL John Smith and Son, Glasgow. 1889-1890.—
This, which constitutes the twenty-first volume of the
Proceedings, contains a good paper by Dr. James B. Russell
on Sanitation and Social Economics. Another article is by
Mr. Snodgrass, on Demonstsation of Nerve-cells by pressing
a cover-glass on a portion of the grey matter of the
cerebrum on a slide, separating the two, and passing either
the cover-glass or the slide over the flame of a spirit-lamp
till faintly brown, when the form of the cells i8 well
displayed. _
ftefa Infentiira.
AN IMPROVED DISINFECTANT DISTRIBUTOR.
This is an ingeniously constructed self-working apparatus
which is intended to charge the cistern of an ordinary
watercloaet with a definite supply of a soluble disinfectant.
It consists of a closed porous jar of the shape and size of a
common gallipot. A leaden pipe of small calibre serves to
convey the enclosed disinfectant by means of syphon action
to the water in the cistern. The top of the distributor is
Provided with two small holes, one for the admission of
water to dissolve the disinfectant and the other to act as a
vent for the displaced air at the time of setting the
apparatus. Obviously when the water is withdrawn from
the cistern a supply of disinfectant (in this case perman¬
ganate) is syphoned over, and when the cistern is refilled
the flow is gradually checked. The distributor is stated to
contain sufficient disinfectant for a thousand flushings.
REFLECTIONS ON KOCH’S TREATMENT FOR
TUBERCULOSIS.
To the Edit<yrs of The Lancet.
Sirs,. —Reviewing all the phenomena that have been
recounted as having been observed after the exhibition of this
potent fluid, one is compelled to take serious counsel with
oneself in response to the anxious queries of our patients,
and to ask this question, Are we to take it as proven that we
have here a specific remedy for the bacillus tuberculosis ?
It is to Professor Koch that we owe the generally accepted
theory that tuberculosis is due to bacteria. On a priori
grounds, therefore, we should expect the specific for the
disease should be one that would destroy the cause. Pro¬
fessor Koch admits that the liquid does not kill the bacillus,
but that it causes the death of the tissue in which the
bacilli lie embedded—that is to say, it may remove the
effect, or rather cause the death of the effect, and not that
of the cause.
If one of many houses be infested and undermined by a
horde of rats threatening the demolition of the building, it
would not be a cure for rats to pull the walls down—the
vermin would certainly betake themselves to other man¬
sions. Professor Virchow’s observations point the same
moral with regard to the fatal cases that have had necropsies
performed on tubercular patients who have been subjected
to the liquid treatment. Anotljer point: Are we to take
it as proven that the liquid has a specific action on
tubercular tissue? One of the arguments used is that
lesions that before injection of liquid had been diagnosed
as non-tubercular alter an injection inflame and show
signs of activity. Therefore the lesion is tubercular. Is
not this begging the question, and an apt illustration
of arguing in a circle? The onus of proof lies with
the supporters of the theory that this liquid has a
specific action on tubercular tissue in man. There¬
fore, if a competent observer diagnosed a lesion to be
non-tubercular and the lesion reacts to the liquid, the
evidence, as far as it goes, is heavily against the fluid
having a specific action. One wants to know how many
human beings with lesions of another sortbavebeen injected,
an.d what were the results. Also, will no other virus pro¬
duce similar phenomena in tubercular human beings bwore
we can say definitely that Koch’s fluid has a specific
action in man? Furbinger rejjorts five cases where the
fluid was unreliable in diagnosis. Is there no other ex¬
planation of the reaction induced by the liquid than that
it is specific? Was it not a common phenomenon observed
in surgical wards that a languid, non-healing wound took
on a rapidly healing action after an attack of erysipelas? On
the other hand, have we nob all seen old cicatrices
break down and wounds reopen during a violent attack
of one of the exanthemata, or some chronic disorder entirely
clear up after typhoid fever ? In support of this view, I see
that Dr. Laurence reports two cases of phthisis cured by an
attack of small-pox. Yet we do not say that these viruses
have a specific action. If a patient has a weak organ or
any damaged tissue we expect that that organ or tissue will
certainly be picked out, and apparently have to bear the
brunt ot the storm caused by any fever that may attack that
patient; and we rather expect the cancer organism will
attack a scar or mole in preference to more robust
tissue. Koch’s liquid is certainly a potent pyrogenic virus.
Would it not be extraordinary if this virus did not
pick out the markedly devitalised tubercular tissue—
the points of least resistance? But it has not, there¬
fore, necessarily a specific action, or affinity for it.
It almost seems to me that the phenomena observed in
connexion with this liquid in man may be explained on
tlie theory of reactionary or substitutive fever—that is to
say, if the organism is strong enough to respond to this
owerful stimulus, under certain favourable conditions a
ealing process may be set up. Something similar on a
smaller scale to what occurs when an indolent ulcer is
blistered, or burnt, or better still, to the healing process
that follows the inflammation produced by the ferment of
the jequirity bacillus when applied in cases of granular
lids, lupoid growths, and epithelioma. All the reserve
vitality of the human organism is evoked to cope with this
potent foe, and the weak places are made strong as the
wave of inflammation passes over them—the after-glow
that follows the storm. The legions summoned carry heal¬
ing on their wings. Bub it sometimes happens that the
weak places are so many, or the blood poison so powerful,
that the patient sinks after the effort from exhaustion
of the vital forces, or is poisoned by his own dead
tissue.
To sum up: Can we be said to have a specific in Koch’s
liquid for the bacillus tuberculosis like we have in sulphur
for the acarus scabiei, or in mercury for syphilis, or in
quinine for the ni.alarial organism ? Wnen the blood poison¬
ing does good, is it nob by rousing the system to increased
cellular action, and then imitating nature’s process by heal¬
ing such, as has been ob-served under other modes of treat¬
ment, rather than by an action specific? Wo are none the
less indebted to Professor Koch for his patient labours in
adding to our knowledge and extending the limits of our
healing and pathological vision.
I am, Sirs, yours faithfully,
A. H. Bampton, M.Ch., M.D.
IIkIoy-in-Wlin,i'fetlaIo, Jan, 2(3tli, 1891.
Stroijd Hospital.—P rosperity has marked the
condition of this hospital during the past year. Adequate
funds have been raised to cover the cost of the additional
buildings, and an increase in the receipts had enabled the
committee to liquidate the deficiency left over from the
mevious year, and to carry forward a small credit balance.
The endowment fund, which it was hoped would have
reached £10,000 during the centenary year, remains at
£9640 18s. llif. In recognition of the prolonged and efficient
services of the late Dr. Paine, the governors resolved to
name the eight-bedded ward “ The Paine Memorial Ward.”
A brass plate is to be pub in the ward, surmounted by a
portrait of the deceased, presented by his widow.
Din-- z:.'' '■ Google
The Lakcbt,]
THE TUBERCLE BACILLUS.
tFER.7,I89L 817
THE LA^^CET.
LONDON: SATURDAY, FEBRUARY 7', 1891.
Those mciabeis of the Pathological Society who attended
the usual fortnightly meeting on Tuesday night were
amply rewarded by the very complete demonstration of the
morphological varieties of the tubercle bacilli that was
given by Professor Crookshank. The specimens them¬
selves gave ample evidence that Professor Crooksiiank is
a master of the technique of mounting and staining, and
even the most unbelieving had evidence placed before them
which must compel them to accept the fact that tubercle
bacilli are undoubtedly associated with tubercle by that
relation, accidental or causal. Turning from the microscope
to the cultivation specimens, such observers would be
equally impressed with the fact that, as the outcome of the
experiments and observations of a large number of workers,
we have at length gained a certain insight into the condi¬
tions that are necessary for the growth of the tubercle
bacillus outside the body.
The paper itself is given in another part of our present
impression, but it may be useful to indicate in brief
outline the more important conclusions that are to be
gathered from it and the discussion that followed. It is
evident that, although chemists, bacteriologists, and patho¬
logists are working to a common end, each emphasises
somewhat difTeient points. On the one hand, we have the
bacteriologists taking up rather the botanical aspect,
cultivating the tubercle bacillus in different media, obtain¬
ing different forms on these media, and retarding or
increasing the rate of growth and development by the
addition of certain substances. They, in fact, study the
organism as a saprophyte, and are contributing most re¬
markable facta to our knowledge of the history of the
organism outside the body. When, however, on the other
hand, the chemist comes to consider the action of the
organism as a parasite, the facts obtained by the botanist
are for the moment of comparatively little value,
as Dr. Sidney Martin indicated. All the know¬
ledge that has yet been obtained in connexion with
the action of the organisms on the animal economy points
to the fact that tliey do not act in any way except through
tl^eir poisonous products. These products are derived
entirely from the breaking down of albuminoid substances.
It may be, of course, that some of them are only one or
two removes from the higher albumens; whilst others may
be looked upon as the later products of the decomposition
of this same material by special organisms. It is evident
therefore that the specific toxic functions of a parasitic
organism can only be brought into full play when it is
placed in a medium that contains suilicient albuminoid
material on which the organism may act to produce the
specific material. Of course, it may be objected to Dr.
Martin’s statement that alkali albumen (to which he
would add the special salts required) is probably one of
the best nutrient media for the growth of the tubercle
bacillus in all its strength, and that alkali albumen does hot
occur as such in the body, just as fibrin does not; but to
this may he answered that, although fibrin does notoocni* as
such, the constant elements of which it is composed are
undoubtedly present, and that the organism has therefore
only a little more or a little less work to do to obtain the
same results.
To the physician, however, who has to deal with disease
in both its etiological and pathological aspects, something
more than either the chemist or the bacteriologist tells him
is necessary. He has not only to study the oondltibns
under which the organism is developed outside the body,
the method of invasion of the tissues by the tubercle
bacillus, the local changes to which it gives rise, and
the general or constitutional symptoms that result,
but be has also, if possible, to trace the phylogenetic
relations of the organism to see bow its specific activity
may be modified, and to apply the results of the
experience already gained to the improvements of methods
of treatment, whether by inoculation or by other means j
in fact, nothing must escape his notice, and no means of in¬
creasing his knowledge of any phase of the life of the
organisms that produce disease can he neglected or bast
aside as unimportant. The tubercle bacillus within the
next year or two will receive more attention than any
other of the micro-organisms. It' will be studied by
competent and incompetent observers; the most contra¬
dictory results will he obtained ; we shall he told that the
tubercle bacillus forms enzymes, albumoses, tox-albumens f
and ptomaines. It will be argued that its growth takes
place most luxuriantly under certain conditions, and that
certain other conditions are absolutely inconsistent with
any growth at all. Let all such very positive statements
bo taken ,with reserve, for it is becoming evident that
if care is taken to make a transition by sufficiently
easy stages, tubercle bacilli, like many other organisms,
may be cultivated under very different conditions as
regards soil, temperature, &c., and that consequently
the resulting products are equally varied. Thanks to
the younger workers in physiological chemistry in this
country, a new school is gradually being formed, and it is
I evident that much more accurate and valuable data than
I we have hitherto possessed are being gradually accmnulated.
We may, in fact, look forward to a comparatively new
development of bacteriological science as coming within
the range of practical medicine — a development that,
in its bearings on medical practice, must have most
far-reaching results.
Winter cruising for health, pleasure, or both objects
combined w’ould seem to be an increasingly popular
custom. The number of shipping firms both in this country
and elsewhere engaging in the traffic, the high class of ne
vessels withdrawn from the more regular departments of
trade for the purpose of meeting the new demand, and the
variety and attractiveness of the programmes now issued
in such abundance, all testify to the fact that winter
cruising has, to iise the stereotyped phrase, “met a felt
want.” We propose to inquire briefly into the utility of
the custom, from the medical point of view, and to discuss
F 3
Digitized by
Google
818 Thb Lancet,3
WINTER CRUISING—EPILEPSY AND CRIME.
[Fbb. 7, 1891.
the modes in which the winter oroise should he regn-
lated in order that it may yield the maximum of
advantage.
There is much on the surface of the matter to recommend
the practice in question. It aims at withdrawing the
individual from the British Islands at the most trying
period of the year, and at affording him all the pleasure
and variety of travel, with but a very small amount of
its usual fatigues and discomforts. A well-appointed ship,
handsomely fitted up and amply provided with both neces¬
saries and luxuries, cruises in the Mediterranean or among
the Canary Islands, touching at various points of great
natural beauty or high historic interest, and thus affords the
passenger rest, change, and mental stimulation in very
agreeable combination. He can remain on board or
within certain limits prolong his excursions on shore at
will. He can benefit his health by the enjoyment of the
tonic influences of sea air and the restfulneas of life on
shipboard, and at the same time gratify his artistic, literary,
or antiquarian tastes. These advantages are so obvious
that they need not be further dwelt upon. It will be more
to our purpose to inquire for what classes of persons such
trips are advisable and how they may best be regulated.
In the first instance, it is obvious that winter cruising is
not adapted to serious oases of illness or to confirmed in¬
valids. The English Channel and the Bay 'of Biscay are
notvery hospitable regions in winter for anyone suffering from
a grave malady, and even the Mediterranean at that season
will disappoint theover-sanguine person who looksfor smooth
seas and constant sunshine. The Mediterranean basin, from
the fact of its narrowness and the proximity of great ranges
of lofty mountains, is peculiarly prone to sudden and severe,
if usually brief, storms. The winds, too, are frequently
very chilly, and the cold will often surprise the traveller
even as late as the month of April. In order to secure
warm, smooth water and constant sunshine in winter we
have to go further, and seek them in tropical or sub¬
tropical regions. Occasional storms and frequent cold
winds, while a very grave hindrance to real invalids, need
not act as a serious deterrent to those who are simply over¬
worked and those who are already convalescent and seek
only a little farther recuperation. Cruises such as those we
are considering are farther ill adapted to real invalids from
the fact that the mode of life on the ships employed in this
way takes little account of the sick, and almost
exclusive regard to the pleasure-seeker. Diet, hours,
amusements, and all the little trifles that go to make
up the sum of daily life are not modified as the
invalid would desire or require. It would be expect¬
ing too much to demand that they should be thus
modified. Again, the calls and delays at the various points
of interest in the cruise, while one of the principal attractions
to the pleasure-seeker, are apt to prove either hurtful to the
invalid or else wholly beyond his reach. A scamper through
Pompeii or the ascent of Vesuvius would hardly be accept¬
able to anyone seriously ill, nor would ib give him much
satisfaction to remain on board his ship lying in the Piraeus
and lament his inability to undertake the fatigues of visiting
Athens. It is to be feared that mu6h mischief has often
resulted from persons in precarious health eagerly availing
themselves of these brief and precious moments ashore at
some famous locality, and unwisely striving to include in a
few hours an amount of sightseeing that wonld naturally
require days.
On these and many other more or less kindred grounds
we should deprecate the idea that the winter cruise is a
therapeutic agent that can be safely and advantageously
recommended to persons who are still the subject of serious
disease. In such cases as phthisis, unless in the very earliest
stage, we should not anticipate any considerable advantage
from such cruises. The time is too short, the meteorologi¬
cal conditions encountered are too variable, the risks of
trips ashore too serious, to permit us to expect that winter
cruising would prove of much utility in cases of grave
pulmonary disease.
But for that very large, and probably increasing class,
who find frequent spells of rest and change indispensable for
the maintenance of full physical and mental vigour, or for
those who are well advanced in convalescence from
serious illness, the winter cruise presents very great
advantages and attractions. If wisely arranged, its risks
and fatigues may be only nominal, while it may afford
nearly all the gains which we usually anticipate from
well-ordered travel. That these ends may be secured,
the mode of life on board the ships employed for the
purpose should be kept as simple as possible; the dietary
should be ample and varied, but the multiplication of useless
luxuries should be avoided, and some regard should be paid
to the modifications which climate demands in matters of food
and drink; late hours should be eschewed, and that serious
form of gambling which is often so great an evil should be
forbidden. The trips ashore should be so arranged that
adequate time may be available for what it is proposed
to accomplish, and the evils of hurry, hasty eating, and
neglect of meals avoided. The traveller should remember
that after days or weeks of luxurious ease at sea he is tem¬
porarily out of condition ” and unfit to undergo any feats
of sightseeing that call for prolonged effort or great endur¬
ance. By such simple and obvious rules the winter cruise
may be made not only delightful, but decidedly beneficial
to health, and its dangers and disadvantages may be thus
obviated.
A CASE of considerable medico-legal interest is reported
in the Journal of Menial Science by Dr. Elkins. The
patient wa« a young married man of thirty-three, admitted
to the Royal Edinburgh Asylum from the Calton Gaol,
where he had been lodged on account of a homicidal attack
made on a citizen of Edinburgh. The patient bad only a
few days previously been discharged from the asylum, of
which he had been an inmate for three months. When
admitted on that occasion he had just attempted suicide,
and he bad a history of having on at least two previous
occasions tried to kill himself. He had also on one occasion
been admitted to an asylum at his own request, because,
as he said, he had "queer thoughts,” and imagined that
his wife was urging him to cut their child’s throat.
His attacks of mania seemed to bear some relation
to drinking bouts, but he also liad a liiatory of sliglit
"fainting fibs,” probably attacks of petit mal. It is
also worthy of note that on the day before he committed
the offence which placed him in the hands of the police he
Digitized by i^ooQle
The Lakobt,!
ISPlLtePSY CRIMte.
tFEB.% 18 ei. 319
had gone to the asylum to ask to he readmitted, as he felt
himself in a dangerous state. Unfortunately he did not see
the superintendent; hut on leaving the asylum he met a
gentleman who had formerly shown him some kindness,
and he conceived the idea of killing him. He bought for
that purpose a clasp knife, and during that day he appa*
rently watched his victim, and continued to do so until
about the midday following, when, finding him alone in an
unfrequented path, he rushed on him from behind, threw
him over, and stabbed him twice. After inflicting the
injuries and being disarmed, he quietly sauntered away,
and when arrested was on his way to the hospital to have
his hand, which had suffered in the struggle, dressed. To
the police he gave a wrong name, but when taxed with the
assault admitted it.
But for the previous history of this patient, the evident
premeditation, the stealthy way In which the pursuit bad
been carried out, and the choice of a quiet unfrequented
spot in which to commit the assault would all have been
regarded as strong evidence of sanity. Homicidal impulse
is perhaps too often supposed to evidence itself in a sudden
burst of furious violence expending itself on the nearest
and most convenient victim ; but the case cited would
seem to clearly show how erroneous such an idea may
be, for the victim was selected, the weapon deliberately
bought, and the assault planned and carried out with
no little cunning. Yet in this case it is evident that
the aggressor was no more responsible for his action than
is a patient suffering from an acute illness who in an
access of delirium throws himself out of a window. In his
first attack of mental disturbance this patient attempted
suicide by throwing himself overboard from the deck of a
steamer; but it is quite conceivable that his mania might
at that time have taken the homicidal form. In that case
it would probably have gone hard with him before an ordinary
jury, and we fear that any medical evidence in his favour
would have had but little weight. Bat it cannot be too
strongly insisted upon that such things may occur. Every
asylum superintendent knows how dangerous and how un¬
trustworthy epileptics are, how they may talk naturally and
even j'ocosely, and all the time have some deadly weapon
about them which they only want an opportunity of using,
and how, when this attitude of mind has been replaced by
another, they will in all good faith deny any knowledge of
the weapon whioh has actually been found in their posses¬
ion. And it must be remembered that epileptics are not
found in asylums alone, that there are many going about
their ordinary work in every way capable but for an occa¬
sional fit, and the fit may not be the severe and easily
recognised convulsion with which all are familiar. It
may be that a momentary “weird seizure,” a staring into
vacancy, a slight and transient pallor, may be the only out¬
ward and visible sign of the internal disturbance—a dis¬
turbance which may have as its sequel the most profound
mental alteration.
In what we have written so far we have had in view
chiefly the safeguarding of persons who while suffering from
some temporary mental disturbance may have committed
some criminal act. But what of the general community,
who are, so to speak, at the mercy of such sufferers ? How
are they to he protected ? It may be asked, From what is
protection necessary ? The case quoted above shows that
personal violence is one thing, but there are others; for the
post-epileptic distarbance may take the form of delu¬
sions leading to serious but groundless accusations
against innocent persons. A case was lately published in
the North American Review of a man who was admitted to
hospital with paralysis of all four limbs, the result of a
fracture of the cervical spine. To the house surgeon he
recounted how he had been attacked by some men who, he
said, had knocked him down and so maltreated him that
he was now in the condition described. The patient died,
and on the matter being reported to the authorities a
searching inquiry elicited the fact that the whole story was
a delusion that the patient hod been sitting on a wall
talking to 'some friends when he suddenly became pale,
fell off the wall on which he was sitting, and sustained the
injury for which he was admitted to the hospital. In all
probability he had an attack of petit mal, which had as
its sequel the delusion which led him to make the
above astounding declaration ; and it is evident that but
for the fortunate chance that the accident was actually
witnessed by several people, more than one innocent man
would have been in imminent danger of suffering much
inconvenience, if not punishment, for a crime which had
its only existence in the disordered mind of an epileptic.
Such a case shows one of the dangers to whioh the com¬
munity is exposed. The previous case points to another,
and it also shows how easy it would be for an irresponsible
maniac to be treated as an ordinary criminal. Whatl
measures should be taken to obviate such dangers it is
difficult to say, but in view of the occurrence of such con¬
ditions it is necessary that the greatest possible care should
be exercised by all who have to do with criminal trials.
Especially is this true in regard to anyone accused of an
apparently motiveless crime; in snch a case the possible
occurrence of epilepsy should be kept in mind, and a care¬
ful and searching medical inquiry made into the previous
history of the accused, and, it may be, of the accuser.
Allusion has been already made to the magnanimous
attitude taken by the late Surgeon-General T. Graham
Balfour with regard to the Contagious Diseases Acts.
Now that he is gone and his voice will be no more heard, and
his pen no more wielded in their support, it will he well to
produce his own words. As a member of Mr. Skey’s Com¬
mittee he thus expressed himself: “ I cannot concur in the
recommendation to introduce a system of weekly examina¬
tion of all known prostitutes.” Four years later, however,
he expressed a different opinion before the Royal Commis¬
sioners. In reply to the Chairman’s question, “ When
the Act was first introduced, were you very sanguine
in your expectation of success ? ” he answered : “ I
was not. I thought it would be almost a dead letter
the first year or two. Taking all the general results, looking
at all the venereal diseases, I thought that it was likely
to prove a failure. It was only when 1 came to go more
minutely into the matter, and to get at the results by
taking those two diseases which the Act was most likely
Digitized by
Google
^30 Tab Lanobp,] RESULTS OF THE REPEAL OR TflE CONTAGIOUS DISEASES ACTS. Feb. 7,1801.
affect, that I came to see the important part that it was
performing. Under the general bead of venereal diseases
there was snch a large amount of secondary disease which
would not he affected in the first instance by the Act,
although ultimately the results on it would be shown ;
that the results appeared to be inadequate to the amount
of expense and labour bestowed upon the working of
the Act I but on coming to take out the two diseases
which were likely to be affected by the Act, I
changed my opinion completely as to its operation, and
the more so as I found that the form of disease which
had been reduced to under half of what it used to be
wte the only form of disease we know to be followed by
severe constitutional affections—that is, the primary
venereal sore.” Further on be expressed himself even more
strongly in their favour, and frankly admitted that the
great reduction in primary sores among the men in the
protected stations was duo to the periodical examination of
the women and the detection of primary sores at an early |
stage of their progress. He was convinced, against'
his previous conviction, by the returns sent to him,
which were all on a uniform plan, the results of
which as tabulated could not be known to the
medical officers who sent them, He lived to see the
beneficial results of the Acts shown still more stiikiogly
before the Select Committee of the House of Commons, 1879
to- 1882. For all this, however, he lived to see them
repealed, not only in all the home stations, but in all the
colonial stations, with one happy exception—Malta. He
also lived to see the results of this repeal in the fact that
the diseases which had been reduced to more than one-half
in the protected stations returned to their former high ratio—
that which prevailed before the Act of 1864, the first Act,
was passed.
Feeling how very important it was that an authentic
relation of these facts should appear in the journal of the
Royal Statistical Society, since it was certainly an
interesting experiment on public health, Dr. Balfour,
who only vacated the presidential chair a short time
before his death, invited Dr. RoiuaiT Lawson, Inspector-
General of Hospitals, to undertake its preparation. It
conld not have been entrusted to better bands. In¬
spector-General Lawson has had large experience as an
army surgeon, and hie attention was directed many years
ago to the great amount of invaliding among the troops
caused by venereal diseases. He had formerly arranged
the army statistics bearing on it for Mr. Slogoktt, the
inspector of certified lock hospitals under the Acts, and he
gave evidence before the Commons Committee of 1879 to 1882.
Besides possessing ample knowledge of all the details he is
most scrupulously exact and accurate, taking an almost
superstitious care to avoid any source of error, whether in
favour of or against the Acts. This paper {an abstract of
which will be found in another column), which was read
before the Royal Statistical Society on the 20tli ult., and
will be duly published with an explanatory diagram, shows
as plainly as figures and diagrams can do the whole his¬
tory of the Acts, the fearful prevalence of disease before
they were enacted, the gradual improvement as the first
experimental Act of 1804 was amended and improved by
the subsequent Acts of 1866 and 1869, the effects of the sus¬
pension of the periodical examinations in 1883, and of the
final repeal of tbeAots in 1886. Inspector-General Lawson
commenced his paper by indicating the forms of disease
which came under the operation of the Acts, and the
different manner in which separate bodies of men at
the same place and at the same time were affected
by these maladies. With regard to the first, he
defended the classification of primary venereal sores
under one heading instead of dividing them into in¬
durated and simple sores, quoting Mr. James Lane of
London and Mr. Rawdon Macnamara of Dublin, two
observers of great experience, to the effect that it is im¬
possible to tell at tlie onset whether a primary sore is, or is
not, the initial manifestation of syphilis, This is only
what every practitioner of experience in venereal diseases
knows perfectly well. The characteristic induration may
be wholly absent, especially if the seat be cuticular, the
inguinal adenopathy may be slightly marked or absent, both
infective and non-infective sores may be single or multiple,
the period of incubation may be moat difficult, if not im¬
possible, to verify—in short, it would be impossible to classify
these sores at first, and the only certain diagnosis between
them is the appearance of secondary symptoms. Inspector-
General Lawson gives an instance which came under his
own observation in the west of Ireland in 1842 and 1843.
The depot companies of the 47th Regiment, with an average
annual strength of 264 men, marched into Castlebar during
July 20th and 2l8t in a healthy condition. In four months
90 men were admitted with primary venereal sores; from
Nov. 24th to March 16th, 1843, when the depOb left for
Boyle, fresh admissions had almost ceased, and after arrival
at Boyle there were very few admissions of primary sores,
and those of a mild description. From May 20th, 1842,
to July Ist, 1843, there had been 27 cases of hard sores
treated and 49 cases of secondary syphilis; so that,
admitting that every hard sore eventuated in the con¬
stitutional affection, there were still tweUty-two other
instances following sores in which the induration was
not observed. Indeed it was expressly mentioned in the
notes made at the time by Inspector-General Law.hon
that excoriated sores were more frequently followed by the
constitutional disease than other forms. This shows the
importance of both making and preserving carefully pre¬
pared notes of similar cases, and pther army surgeons would
do well to follow so good afi example. That constitutional
symptoms will follow “soft” or “simple” sores, and that
well-marked induration may not be followed by secondary
symptoms, are facts too well known to admit of dispute.
The arrangement, therefore, of these primary sores is a per¬
fectly scientific one, though in accordance with the nomen¬
clature of diseases of the College of riiyaicians the simple
sores are to be separated in future from the primaiy syphi¬
litic. Great care will have to be taken, however, to prevent
errors.
The next important matter is the variation of the fre¬
quency and intensity of disease among different bodies of
men. Thus in 1864, among the cavalry, while the admissions
for secondary disease (4.')-7per 1000) were in the ratio of
1 to 2’G cases of primary, in the infantry the secsondary
Digitized by i^ooQle
The Lancet,]
A THREATENED STRIHE OE MEDICAL MEN IN SCOTLAND. [Eeb. 7,1891. 321
cases were 82, or 1 in 3'4 of the primary; and in the Foot
Guards 33‘5, or 1 in 4‘(3, The variations in simple sores
were equally remarkable. Still more remarkable were
the variations among the men stationed in different
blocks at Aldershot. The ratios per 1000 were among the
artillery~141-l primary sores, 140’4 gonorrhoea. Among
the men stationed in different blocks marked A to F,
respectively, the primary sores ranged from 22‘0 in F to
124’4 in C. Gonorrheea ranged from 66’6 in E -to 234‘7 inC.
This shows the importance of weighing every circumstance
when examining statistics. It was impossible to account
satisfactorily for these variations, and to a great extent they
remain a mystery now.
We must reserve until our next issue further remarks on
Inspector-General Lawson’s interesting paper.
“ Ne quid nlmla.”
A THREATENED STRIKE OF MEDICAL MEN IN
SCOTLAND.
A LARGELY attended meeting of medical men, as reported
mlhQ Edinburgh Evening Dispatch, was held in Edinburgh,
to debate the grievances of over-work and under-.pay so long
felt and hitherto so patiently borne. Practitioners from Ross-
shire, Argyleshire, Dumfriesshire, Inverness, Dundee, John-
o’-Groat, Tobermory, as well as Edinburgh and the mining
districts, were present, and eloquently revived the impres¬
sions produced hy Sir Walter Scott in the “Surgeon’s
Daughter” of the inadequate pay and the incessant work
of the Scotch country practitioner. Sir Andrew Clark
has said he had heard the celebrated traveller Mungo Park,
who had experienced both courses of life, rather give the pre¬
ference as regards hardship to a discoverer in Africa than to
wandering by night and day the wilds of his native land in
the capacity of a country medical practitioner. Park
mentioned having once upon a time ridden forty miles, sat
up all night, and successfully assisted a woman under the
in/luonce of the primitive curse, for which his sole remunera¬
tion was a roasted potato and a draught of buttermilk. We
had hoped that such descriptions were no longer true; but
they were well matched by the graphic accounts whicli some
of the speakers gave of their life work and its inadequate
remuneration. One gentleman said ho had been over
fifty years in the profession. His working day was nearer ,
twenty-four hours than eight or ten, during •which he was .
either actively engaged in the service of the public, or
in anxiety that he might be called forth to mount his
horse, perhaps at midnight, and traverse in darkness paths
dangerous in daylight, or perhaps to cross in a small boat
the stormy waters of some arm of the sea. lie received
annually £40 from the parochial board, for which he was
bound to give his skill and services to any poor person in
his district, though liis doing so might mean a ride of
pevchance twenty miles in the face of blinding snow or
sleet 1 What was the result of half a century of such work?
“ He had earned a living, no doubt, but he had nob saved
one penny I” Another practitioner, from a colliery district,
said that his life was the life of a dog, and his existence
one perpetual worry from '\ve6k’s end to week’s end.
lie received l^f^. a week from some hundreds of miners,
and for this he waS expected to be always ready. The
other speakers bore similar testimony. A strike was
advocated very plainly by some, bub by others was dis¬
countenanced. In the end a committee was appointed
to consider the grievances of Scotch medical men, and
to report on remedies. We greatly prefer the com¬
mittee to a strike. The inadequate payment of medical
men is disgraceful—not in Scotland only. If this committee
will really obtain sound and detailed information of the
disproportion between the education and the work of
medical men and their remuneration, they will do a great
service, and may lead the public and the working-classes
to see that medical labour will have to be differently valued.
A strike of medical men is not to be thought of seriously.
Apart from their number and their competition, there is
something in the very nature and property of medicine to
forbid it. But the public may be shamed into better
recognition of our labours and our lives.
THE LUNGS OF LONDON.
The latest report of the Metropolitan Public Gardens
Association, which has just been published, will compare
very favourably, as regards the importance of the work
, accomplished, with that of any previous year. Since its
formation in 1883 the Association has added forty-three
gardens and nine playgrounds to the open spaces of London,
besides planting trees and placing seats at many con¬
venient spots. During the last twelve months, moreover,
it has been particularly successful in inducing Board School
authorities to throw open to all children on Saturdays 166
playgrounds, amounting to an aggregate area of 100 acres.
It has also effected the transfer of eight gardens and three
playgrounds to the County Council, a step which leaves its
own resources the more free for the execution of new work.
Let us not forget to mention another noteworthy reform in
which the hand of the Association has been usefully active—
namely, the passing of the Open Spaces Act, 1890, which will
assist local bodies in acquiring and maintaining open spaces
as such for the public benefit. It is interesting to observe
also that the wholesome example afforded by these various
efforts has attracted the attention of city populations else¬
where, notably those of Philadelphia, Boston, U.S,, and
Copenhagen. The work of the Association, therefore, has
not so far been allowed to languish, and the report before
us contains a forecast of much further usefulness in the
immediate future. Full details of that work, of its objects
and its necessity in a population which becomes annually
denser and more dependent upon the maintenance of all
available healthy conditions, are well set forth in the
report. The Association is not in debt, neither is it wealthy.
Its ambition to do good is eminently worthy, and as yet
there is ample opportunity for its exercise. We have,
therefore, no hesitation in commending its generous energies
to the helpful attention of all who rightly value health as a
safeguard of national happiness and prosperity.
IMMUNITY OF ANIMALS FROM DIPHTHERIA.
In Deutsche Mcdicinischc Wochcv.schHft, 1800, No. 00,
Behring contributes a second article on immunity from
diphtheria induced iu animals, corroborating the experi-
iiients made liy himself and Kifcasato, an account of whicli
has already been published. Behring’s second scries of
eNperimeuts were supplemented by others on mice and rats,
which enjoy a natural immunity from the disease. He
states that he can produce this insusceptibility iu five dif¬
ferent ways. The first method is that introduced by C.
Fraenkel {Berliner Klinische WochenschHft, 1890, No. 49),
in which the animals are inoculateti with pure cultures
which have been sterilised by heat. In the second process
the animals are treated with injections which have been
submitted to the action of the trichloride of iodine. Two
injections are given, the first containing the chloride iu tlie
proportion of 1 in 500, and the second 1 in 5500. The
third method consists in the injection of from 10 ocm.
Dir ‘:zec! '■
Google
322 Thb Lakcet,]
THE VIRCHOW TESTIMONIAL.
[Feb. 7,1891.
to 15 ccm. of the tranBudation which is often found in the
pleural cavities of animals suffering from diphtheria, this
fluid having been proved to contain no bacilli. Many
guinea-pigs, however, treated in this manner died with
toxic symptoms, but those which survived were shown to be
proof against further infection. Fourthly, the animals can be
invested with an immunity by first infecting them with the
disease, and then as speedily as possible (within six hours at
the latest) staying the action of the poison by therapeutical
means. The most successful treatment is by the chloride of
gold and sodium, carbolic acid, and more especially by the
trichloride of iodine, Previous treatment with the last-
mentioned drug is not sufficient to prevent the animals
becoming affected with diphtheria. Lastly, the immunity
may be conferred by means which have no connexion with
the chemical products of the bacilli—namely, by treating
the animals, previously to inoculation, with peroxide of
hydrogen. It is singular that the use of this compound is
of no value after the animals have developed the disease;
on the other hand, a fatal result seems to follow more
speedily when the drug is employed, and if it be mixed
with the culture of the bacilli the virulence of the in¬
jection of such a culture seems to be increased. All
the animals which enjoy an immunity from diphtheria,
either naturally or artificially produced, also resist the
action of the poisonous products of the bacilli, obtained
either from cultures or from infected animals. That
the acquired resistance to the action of the diphtheritic
poison does not depend upon an accumulative tolerance
is shown by the fact that mice and rats are naturally free
from the disease, and also that Behring never succeeded in
conferring an immunity hy gradually increasing the strength
of the injections. He considers that, as in the case of
tetanus, the cause of the resistance is a special property of
the living cells of the blood to destroy the diphtheritic
poison. This theory is supported by the fact that the blood
of rats which have been injected with the poison is not
capable of conveying the disease, whilst that of other
animals which are susceptible to the disease, and which
have been inoculated, is capable of so doing; and also that
the blood of guinea-pigs which have been rendered proof
against diphtheria possesses the property of being able to
render the poison harndess. On this latter point Behring
promises more information.
CHANGES IN THE SPUTUM AFTER INJECTIONS
OF KOCH’S FLUID.
In Koch’s paper of Nov. 14th of last year Jie described
certain changes which the tubercle bacilli seemed to undergo
after injections of his liquid had been administered. Since
that communication was published various conflicting re¬
ports have appeared as regards the constancy of these
changes, but no very exhaustive and reliable experiments
have as yet been made public. Dr. J. Amann of Davos
has had exceptional opportunities of observing these changes,
and appears to have carried out his observations very care¬
fully. His conclusions are published in the Ccntralhlatt fur
Bakteriologic und Varasitanhundv,-, 1891, No. 1. He has
examined the sputa from 198 patients, who were under¬
going treatment by Koch’s method; frequent examina¬
tion of these sputa was made both before the treatment
was commenced and during the course of the injections.
The results are interesting, and may be summarised as
follows: 1. Tlie quantity of the expectoration is as a rule
increased after well-marked reactions. 2. The tubercle
bacilli are increased in number. In the sputa of
seventeen patients, in which no bacilli could be de¬
tected before the treatment was commenced, on care¬
ful and frequent examinations after injection numerous
rods were found. Dr. Amann considers that in this way
the liquid is of much value in diagnosis. This increase of
bacilli was found in about 70 per cent, of the cases; it is
most probably only transitory, but as the patients in Davos
had (when this paper was written) only been under treat¬
ment about three weeks no definite opinion on this point
could be given. A decrease was only noticed in four coses.
3. The liquid has an undoubted influence on the form of
the bacilli. There seems to be an active destruction of the
rods, BO that they appear as fragments, arranged together
in small heaps. Sometimes this occurs to such a degree
that no rods are visible. Dr. Amann mentions that he
has noticed similar changes after the prolonged use
of arsenic. 4. Another change that sometimes occurs
is that after a few injections the bacilli seem to lose
their characteristic resistance to the action of dilute acids,
so that the stain is in great measure removed from them as
well as from the general ground-work of the sputum; con¬
sequently, only a slight tinge of pink is left, or the bacilli
are often completely decolourised. That this is the case is
proved by adopting other methods of staining in which no
acid is used, such as that introduced by Zielil. Proceeding
in this way, Dr. Amann was able, by preparing large glasses,
to demonstrate the bacilli in one-half of the preparation,
whilst none were to be seen in the other half; the former
being prepared by Ziehl’a method, and the latter by Neelsen’s
solution, and decolourised by dilute sulphuric acid. 6. In
about 40 per cent, of the cases, some time after a reaction,
the quantity of elastic fibres in the sputum was considerably
increased, and exhibited a complete alveolar arrangement.
It will be noticed in the above descriptions that Dr. Amann
says nothing about the swollen state of the bacilli described
by some observers, _
THE VIRCHOW TESTIMONIAL.
Tueue is no name that stands out more prominently in
the history of medicine during the present century than that
of Rudolf Virchow. The great exponent of cellular patho¬
logy, he has not only himself accumulated a large number
of facts from his own observations, and been the means
of a vast extension of our pathological conceptions, but he
has by example and precept been the inspirer of pathologists
all over the world. His influence, then, has been unbounded,
and it is in recognition of this and of the unceasing labours
of a lifetime devoted to the service of science that the oppor¬
tunity of his seventieth birthday, which will occur on
Oct. 13th, 1891, has been embraced to demonstrate the
gratitude felt to such a man. The movement set on foot
in Germany will doubtless spread to every country in the
world, and we are glad to find that Great Britain will be
represented. The nature of the prop osed testimonial and
the steps taken witli regard to it so far in this country will
be found set forth in another column. We heartily com¬
mend the movement to the notice of our professional
brethren, and wish it every success.
KNITTED BANDAGES FOR ULCERATED LEGS.
Staff-Stjugeon Pannwitz reports in a German military
medical journal the success he has had In the treatment of
obstinate chronic ulceration of the leg by using tubular
bandages of knitted material. Decided improvement fol¬
lowed the first dressing, and by persevering with these
bandages a complete cure was obtained. Ordinary anti¬
septics may be used at the same time, and of these he prefers
iodoform. These bandages were also used in varicose veins
and cedema of the leg in the place of the ordinary elastic
bandages or stockings, and produced the best results, while
even in valvular affections and Bright’s disease considerable
improvement followed their application. He thinks them
sufficiently elastic for the lower extremities, and they do
nob cause an injurious constriction of the vessels as rubber
Dir -oog e
The Lancet,]
THE SALE OF TUBERCULOUS MEAT.
[Feb. 7,1891. 328
bandages often do. Uniform pressure prevents a thicken¬
ing of the margins of the ulcer and existing indurations
gradually disappear, The greater porousness of the
bandages is often also an advantage, as the function of
the skin is not interfered with. The skin never becomes
macerated, as is often the case when rubber bandages are
applied, as through the great permeability of the knitted
material part of any liquid disoharged'may be evaporated.
The bandages are also easily cleaned and disinfected, and
do not lose their elasticity for some time.
THE SALE OF TUBERCULOUS MEAT.
A BUTCHER at Landport was heavily fined by the Ports¬
mouth Bench on the 2ad inst. for having in his possession,
for the purpose of sale, six pieces of meat unfit for human
fond on Oct. 23rd, 1890. The animal yielding the meat
was admittedly tuberculous, but there was a conflict of
opinion as to the wholesomeness of the flesh between Dr.
Mumby, the medical officer of health, and Dr. Maybury,
who was called by the defence. Dr. Mumby’s evidence was
to the effect that all the pieces of meat gave marked signs
of advanced tuberculosis, and that the flesh was, decidedly
unfit for human food. In answer to a question whether it
could have communicated disease, he said that bo thought
it could, but that this question was still a moot one, and
was being inquired into by a Royal Com ission. Dr. May-
buiy gave it as his opinion that it was a case of local and
not general tuberculosis, but he admitted that he had not
made so minute an examination as Dr. Murahy. At the
same time, he thought it doubtful if the consumption of
the meat would be dangerous in any case. The Bench
decided against the defendant, who was fined £5 for each
piece of meat, or £30 in all, and £7 18$. Qd. costs.
REMOVAL OF THE GASSERIAN GANGLION.
On Thursday, Jan. 29th, Mr. Rose operated for the
removal of the Gasserian ganglion in the theatre of King’s
College Hospital. The patient was a female aged sixty,
under the care of Dr. Ferrier, who bad sufl'ered for many
years fx-om severe neuralgia affecting chiefly the superior
maxillary nerve on the right side. Chloroform was given,
and after stitching the eyelids together on that side in order
to avoid any accidental injury to the eye, a flap of skin was
dissected forward, the zygoma was exposed, and, after open¬
ings had been drilled with an electro-motor, dividedanddrawn
down with the masseter muscle. The Coronoid process of the
lower jaw was next drilled and divided in a similar manner,
and turned up with the temporal muscle attached. The
external pterygoid muscle was then cut through and the
foramen ovale reached, into which the pin of a half-inch
trephine was inserted, and a disc of bone surrounding it in
this way removed. The bleeding was troublesome, and
persisted for some time. The ganglion was seized by some
specially constructed hooks, one of which had a cutting
edge upon its concave surface; by means of these its
attachments were loosened and divided. Perchloride of
mercury solution (1 in 3000) was used during the
operation. The bones which had been sawn were re¬
placed and secured in position by wire sutures passed
through the drill holes previously made, and a drainage-
tube inserted. Cyanide gauze dressing was applied. The
electric illuminator was found most useful during the deeper
dissections. The patient has progressed most satisfactorily
since theoperation, having had no return of theneuralgic pain,
although it is impossible to say at present that the whole
of the ganglion was removed. The sutures were removed
from the eyelids on the third day; the eye was healthy,
but the conjunctiva insensitive. We hope to publish fuller
details of tins important case later. The operation, which
was witnessed by a large number of members of the profes¬
sion and students, occupied about an hour and a half in its
performance. We are glad to be able to state that the
patient on whom Mr. Bose performed the first operation for
removal of the Gasserian ganglion in April last by a different
method continues free from pain, and is in good health,
ANTI-VACCINATION ARGUMENTS.
Last Tuesday, at the Woolwich police-court, a woman
appeared in response to a summons relating to the neglect
of vaccination of an infant. She explained that her husband
objected to vaccination, and the grounds of his objections
were stated by the vaccination officer. The argument of
the husband was that “ it is well known that bulls go mad
every seven years, and that the cows make them mad;” and
further, that “ the same cows are used for vaccinating the
children, and the children go mad.” He says, observed the
vaccination officer, that “ the madhouses are full of
vaccinated children.” The conclusion of this man, that
the insanity of these children is due to vaccination, is nob
different from that of other anti-vaccinationists, that every
misfortune which follows vaccination must be due to it.
The well-known parliamentary return enumerating the
diseases to which an increased number of deaths have
been attributed since vaccination was made obligatory is
based on the same sort of reasoning. “It is of no use,” said
the vaccination officer at Woolwich, “ arguing with a man
like that.” Is it, we may ask, any use reasoning with anti-
vaccinationists generally ? Eveiy epidemic, every small¬
pox hospital gives evidence which ought to convince the
most sceptical as to the valueof vaccination, hut this evidence
has no value with some anti-vaccinationists. Nevertheless,
there are many who are open to conviction, and it behoves
every medical man who values the lives of his patients to
do his best to make the actual facts as to vaccination
known to them, that as far as possible the disastrous effects
of small-pox may be escaped.
THE LINCOLN WATER-SUPPLY.
A GOOD deal of complaint is going on as regards the
water-supply of the city of Lincoln. Even the medical
officer of health writes to the public press recommending
that the water should be first boiled, then allowed to stand
until cool, and then filtered in a machine that will easily
allow of cleansing. He then shows that some suggestions
as to risk and unwholesomeneas of the supply are not called
for; hut the fact of a public service needing before it
is used all the manipulation to which he himself refers
constitutes a quite sufficient justification for a condemna¬
tion of the existing state of things; and this especially so
when he admits that the water has. an unpleasant smell.
True, this is also, he believes, solely due to a chemical
decomposition ; but his assurances arc hardly calculated to
restore confidence in this river water-service.
PROMINENT MUSCULAR FIBRES MISTAKEN
FOR CALCULUS.
Professor Antal of Buda-Peath describes in a recent
number of the Onosi Hciilap an interesting case of a trau¬
matic affection of the bladder, where the cystoscope proved
of great service. A railway guard received an injury from
getting between the buffers of two carriages, which produced
retention of urine. When catheterised no blood was found
in what was drawn off, and therefore it was concluded that
there was no rupture of the bladder, the retention, however,
continued for some time, but ultimately passed off. Some
two years after the accident, after a beer-drinking bout,
retention again occurred, and the surgeon who was called in
to relieve it, feeling a rough surface in the bladder with the
catheter, thought there was a calculus, and sent the man
into hospital. I’rofessor Antal found that there wasincom-
Dip:: zed by Coogic
324 Thb Lancet,]
ISOLATION OF TYPHOID FEVER AT LEICESTER.
[Feb. 7,1891.
petence of the bladder, and that the urine was free from any
abnormal ingredient. On examination with the cystoscope
the internal fibres of the detrusor, or muscular coat, were
seen projecting above the surface enclosing irregular spaces.
The mucous membrane covering the projecting fibres was of
a pale yellowish-red tint, while that of the more deeply lying
spaces was of a much darker red. The hypermmia of tire
mucous membrane was by no means marked. The fundus
of the bladder presented no abnormal conditions, those de¬
scribed affecting, however, all the rest of the internal sur¬
face. The catheter was passed twice daily, and in a very
short time tlxe incompetence was cured, and a subsequent
cystoscopic examination showed that the trabeculm had
become very much less prominent. Professor Antal believes
that the incompetence and " trabeoularismus ” which came
on two years after the injury are to be ascribed to a dis¬
turbed condition of the innervation first of the detrusor, or
muscular coat of the bladder, and afterwards of the sphincter.
ISOLATION OF TYPHOID FEVER AT LEICESTER.
At last week’s meeting of the Leicester Town Council
what appears from reports published from time to time to be
a vexed question between the Corporation and the Leicester
Infirmary was under discussion. It appears that hitherto the
infirmary has received and treated free of cost to the town the
greater number of typhoid fever cases received into hospital,
both the guardians and the Health Committee refusing as
a rule to take these patients into the hospital under their
charge. Latterly the infirmary funds have been at a low
ebb, and the Infirmary Board therefore aslcs the Corpora¬
tion to relieve them of the burden of treating enteric fever,
which they maintain should be isolated in the public in¬
terest by the sanitary authority, and they threaten at a
very near date to discontinue the reception of these cases
from the town. The Town Council, however, seems to be
divided upon the subject, somewarmly advocating this course
to be adopted, thus following in the wake of most other large
towns, whilst the chairman of the Health Committee and
others appear to be very reluctant to move in the matter. The
whole question is now under the consideration of the com¬
mittee. Probably one reason for hesitating to take
patients suffering from this disease into the Corpora¬
tion Fever Hospital, where hitherto only small-pox,
scarlet fever, and erysipelas have been treated, is the
fact that the hospital sadly needs reconstruction. If
the buildings are tiie same as existed a year or two ago
(when one of our commissioners visited Leicester to
inquire into the “Leicester method ” of dealing with small¬
pox), many of the wards are very little better than barns,
and the like would probably be difficult to find to-day in
any large town in the kingdom. Leicester is wont to pride
itself upon its sanitary enterprise; the sooner it sets its
bouse in order in this respect the better for its credit. To
have no proper accommodation for the treatment and isola¬
tion of enteric fever is bad in the interests of the public
health no less than that of the poor unfortunate sufferers
therefrom.
HYSTERIA AND ORGANIC DISEASE.
As our knowledge of organic disease widens and deepens
the number of cases relegated to the indefinite if convenient
limbo of “ hysteria” will no doubt become fewer and fewer.
In a recent number of the ChariU Annalm the details of a
very instructive case in this relation are recorded. The
patient was a woman of thirty-one, who, after an attack of
typhus fever at the age of twenty-one, began to suffer from a
gradually increasing anaesthesia, concentric contraction of
visual fields, colour blindness, and disturbance of special
senses. The patellar reflexes were present. The manner
of the patient was marked by apathy, and sleep was in¬
duced by merely closing her eyes. There was much
emaciation, the apathy became still more marked, and
finally before death she was delirious, with hallucinations
and delusions. The case was regarded clinically as one of
hysteria, with subsequent mental disturbance, but at the
necropsy an astonishing condition of things was found.
There was tubercle in the lungs, the larynx, and the
intestines, degeneration in the posterior columns of
the cord, and myelitis in those columns in the cervical
region. Such a condition with retained knee-jerk is cer¬
tainly unusual. But there were also changes in Clarke’s
column, a congenital fissure in the medulla oblongata, and
degeneration in the nuclei of file cranial nervesj the
peripheral nerves showing no change. That so many
changes in the nervous system should be present without
obtruding themselves in such a way as to make possible a
diagnosis other than the unsatisfactory one of hysteria is cer¬
tainly strange. The case is of great importance, as afford¬
ing a warning that hysteria is not to be diagnosed without
the utmost care in excluding every possible form of organic
disease.
JHE NATURE OF SCIATICA.
This question is discussed at considerable length in the
Philadelphia Medical News by Dr. Harrison Mettler, who
points out that the nature of sciatica is shown in its etiology
and symptoms to be that of a neuritis. Thus its moat common
antecedents are traumatism, exposure, gout, rheumatism,
syphilis, and malaria. The occurrence of tender points
in sciatica is accounted for by supposing that the tender
points indicate the foci of inflammation. A similar
explanation is given of the tenderness in the whole
length of the nerve' trunk, More unequivocal signs of
neuritis are found in the wasting, the occasional reduction
of faradaio excitability, long ago described by Anstie, and
the altered trophic conditions, such as excessive perspira¬
tions and effusion into joints. Regarding the whole ques¬
tion, the author is strongly of opinion that sciatic neuralgia,
without actual organic change in the nerve trunk, is a very
rare condition.
THE LEPROSY COMMISSION.
Information has been received of tlie proceedings of the
members of the Leprosy Commission, who have been busily
engaged in pursuing their investigations since their arrival
in India in November. Tliey have visited the chief leper
asylums in the Bombay and Madras Presidencies, espe¬
cially at Bombay, Poonah, Belgaum, Hyderabad, Madras,
Trichinopoly, Tanjore, Madura, Calicut, and Bangalore,
and have examined a large number of cases in these insti¬
tutions, as well as those collected for them by the civil
surgeons in the districts^ visited. Dr. Rake and Surgeon-
Major Thomson have proceeded to Rangoon to conduct
inquiries in Burmah. Dr. Buckraaster, Mr. Kanthaok, and
Surgeon-Major Barclay have left Madras for Bombay. The
members will subsequently meet in Calcutta.
THE TREATMENT OF SYPHILIS BY HEAT.
TiHi: treatment of various forms of syphilis by heat has
been advocated even in very early times, but no thoroughly
scientific observations on the subject are to be met with in
medical literature. This fact has induced Dr. Kalashnikoff,
with the sanction of Professor Tarnowsky of St. Petersburg,
to carry out some investigations on patients in the clinical
wards under care of the latter. Several of these ob¬
servations are described in the Vrach. The cases were
all of skin affections of a papular or pustular character,
due of course to syphilis, some of them having been treated
in the ordinary way without result. Portions of the body
affected were subjected to heat, and it was found that a
The Lancet,]
SALTS OF THE SEA AIR.
[Feb. 7,1891. 325
marked improvement took place in those portions, and in
those portions only. The time required for the purpose
■differed of course in different cases, and appeared to depend
on individual idiosyncrasies. About a month was enough
an several cases. Occasionally after a cure had been effected
by beat a relapse occurred, but this was by no means more
frequently the case than it is when a cure has been effected
by ordinary antisyphilitic remedies. Dr. Kalashnikoff pro-
«niaes a further paper upon the physiological action of heat
'locally applied. _
SALTS OF THE SEA AIR.
Dr. Edmund Friedrich of Dresden, in a contribution to
the Deutsche Mcdicinischc Zeitung, combats the view that
■winds, especially easterly winds, cause the removal of the
salts from the sea water and their more or less general dis-
{lersion. The author quotes in support of his own view a
ilarge number of old and modern works, and adds to these
the results of his own experiments. From these it appears
'that sea air as such contains no salts at all, and that
its saltness, both at sea and on the shore, results from in-
fiuitesinial particles of the water dispersed by the waves and
•tide, while currents of air cause the further distribution of
the linest saline particles. Xle denies that evaporation con¬
tributes to the presence of salt in the sea air. The salt
found in plants near the coast has the same origin as that in
plants at some little distance. It is caused by meteoric
water, which always contains chlorides. These chlorides
are present in greater quantity on the coast because the
humidity is greater and more frequent, and larger deposits
take place. The value of the sea air for therapeutic pur.
^oses is also, he believes, not due to the presence of salt,
but to the greater humidity, purity, and density of the air,
as well as to its more uniform composition. In view of
other observations, Dr. Friedrich does not dispute the
favourable inlluenco of the greater quantity of ozone, hut
he lays particular stress on tlio fact that, to be of good and
permanent effect, the treatment of serious cases, especially
of chest affections, must be undertaken in a suitable climate
and a favourable situation. Even there a real improvement
and permanent cure cannot be expected in from four to six
weeks, but requires a repetition of the treatment or a stay
■of some months. The only islands in the North Sea which
he considers appropriate health resorts in winter are
Norderney and Foehr. _
THE ETIOLOGY OF EMPYEMA OF THE
ANTRUM.
Some points of interest were raised in a “casual com¬
munication” by Mr. Sewill, at the last meeting of the
'Odontological Society, with reference to the etiology of
empyema of the antrum. That the vast majority of such
eases are due to dental disease was fairly well established
Rn a paper read by Dr. Felix Semon at the same Society
last year, an abstract of which appeared in our columns.
The only pathological conditions of the teeth which
'in Mr. Sowill’s opinion seem capable of exciting
empyema of the antrum are such as are capable of
■causing direct purulent or septic infection—namely, in-
iliammation, followed by gangrene of the entire pulp,
or of that of at least one root of a molar; and suppuration
■around the apex of a root—peri-odontitis—which may be
attended by necrosis or other morbid changes in the root
end. Mr. Sewill had, however, lately seen a case in which
■dental disease seemed the only possible cause; and yet,
•although a decayed tooth was present, it proved on extrac¬
tion nob to he the seat of either of those pathological
changes which have hitherto, in his opinion, appeared to
be alone capable of giving rise to empyema of the antrum.
The patient, a lady about middle age, had suffered
from characteristic symptoms for about two months.
Considerable toothache had been present, before and
during the antral symptoms, in the second bicuspid of
the affected side. Examination showed the other neigh¬
bouring teeth to bo free from disease. The bicuspid was
extensively carious. The pulp was exposed and about two-
thirds destroyed, but the last third retained its vitality
and was extremely sensitive. The tooth was slightly sensi¬
tive to percussion, but there was no other sign or symptom
of periosteal inflammation. It being necessary in any
event to open the antrum, the bicuspid was extracted.
Examination showed that a portion of recent pulp occupied
the upper portion of the canal; the external surface of the
root exhibited hut slight signs of inflammatory activity. A
communication between the alveolus and the antrum, ad¬
mitting a bristle-wire probe, was found. The opening was
enlarged in the usual way, and the diagnosis confirmed,
when a largo accumulation of fetid inspissated pus was
washed out by the syringe through the nose. The point
of interest in the case was the apparently insufficient
amount of dental disease ; and it would lead Mr. Sewill in
future more strongly than hitherto to insist upon the neces¬
sity of extracting teeth in eveiy case of empyema of the
antrum in which they might he suspected as sharing in its
causation. _
THE CROYDON DIPHTHERIA EPIDEMIC.
Dr. Pihlpot reports that this epidemic, which occurred
mainly in October last, attacked 191 persons and caused 38
deaths. He believes it was due to a special milk service,
and he refers to the occurrence of an eruption on the teats
of the cows which was detected by Dr. Klein. This is by
no means the hrst time that such an eruption has been
followed by the occurrence of diphtheria amongst drinkers
of the special milk in question. Ib would he well if the
veterinary authorities would investigate the subject more
in detail than they have done as yet.
THE GERMAN HOSPITAL.
At the general court of .governors of this hospital, held
on Jan. 30th, the question of giving the medical stall
representation on the committee was again raised, as we
intimated it would The committeeproposed that the bon.
senior physician and hon. senior surgeon should be appointed
for this purpose. An amendment, to the effect that two
members of the staff, not ex officio, should be elected in
rotation, was defeated. We have already intimated our
opinion that a better representation of the views of the
medical staff would be secured by the rotation principle.
Undoubtedly the eonior officers of an institution are apt
to become either too conservative, or too much occupied
with outside matters, to feel much interest in hospital
administration. Still, the principle of medical representation
is conceded in the resolution of the committee, and reformers
roust not expect to carry all their views at once. We
sympathise with those who would achieve a more complete
representation of the medical staff, but we advise them to
be content with the progress already made.
HYPERTROPHY OF THE PANCREAS.
Processor fJENERiscn of Clausenherg recently found, on
making a post mortem examination of a middle-aged man,
that a tumour which could he felt through the abdominal
walls was the greatly enlarged head of the pancreas which
embraced the duodenum. The latter was much contracted,
so that it was only large enough to admit the thumb. The
upper portion of tlie duodenum, however, was enlarged to
about the size of the colon ; the stomach was also dilated
and the muscular coats of both stomach and duodenum were
hypertrophied; the annular portion of the pancreas was
Digitized by
Google
326 The Lancbt,] •
BERI BERI AMONG FISHERMEN.
[Feu. 7,18W.
found to be supplied by special arterial and venous
twigs, and it was famished with a special branch from
the ductus cdmmunis choledochus. This combination of a
ring-like pancreas surrounding a contracted duodenum has
been occasionally noticed before in oases described by
Symington, Ecker, and Aubery, and an approach to the
same condition has by no means unfrequently been observed
where there has been an abnormally developed pancreas
partially surrounding the duodenum which even tlien is
frequently found to be contracted. In both classes of cases
there seems to be a tendency for the stomach and upper part
of the duodenum to become dilated. This dilatation maybe
produced, when there is no contraction of the duodenum,
by a “kink” being formed in the gut, owing to the fixation
of the duodenum, the result being that the stomach and
duodenum become distended with food, and permanent
dilatation and hypertrophy are induced. This is interesting
from a clinical point of view. Further, Prof. Generisch
remarks that in cases of abdominal tumour it is well to
remember that a hypertrophied head of the pancreas might
convey much the same impression by the touch as a
carcinomatous pylorus. _
BERI-BERI AMONG FISHERMEN.
Beei-beri has usually been regarded as a disease of the
tropics, but its occurrence among those engaged in fishing
on the Newfoundland banks, as described by Dr. Birge of
Princetown, Mass., shows that northern latitudes per se
do not secure immunity from the malady. In October, 1890,
no less than twenty coses were landed from vessels which
had returned from the fishing. Eleven of these were from
one vessel, which had a complete crew of thirteen. Of
these two died within twenty-eight hour?, another died
later of bydrothorax, and the rest recovered. One had died
on the voyage home. The symptoms in all the cases were
similar—viz., general mdema, breathlessness, numbness of
limbs, sbulillng gait, and inability to bend the knee. The
knee-jerk was lost in two, and diminished in all tlie sufferers.
The spleen was enlarged in three cases. Before the
symptoms manifested themselves there were prodromata in
the form of depression, weakness, and disinclination to
work. The appetite remained good throughout. The con¬
dition is probably to be assigned to insufficiency and bad
quality of the food, andit maybe that there is some analogy
to scurvy. In eastern countries it has been suggested that
there is a close connexion between the prevalence of the
condition and the rice diet so common, and almost uni¬
versal, where the disease is endemic, and the success
obtained in treating the disease by what are usually
regarded as antiscorbutic remedies lends a considerable
amount of probability to this explanation.
“REFLEX EPILEPSY.”
In the New York Medical Journal Dr. Byron relates a
case of convulsions associated with herpes in the distribu¬
tion of the upper superficial branches of the cervical plexus.
The eruption was preceded by pain in the regions of the
shoulder, neck, and upper part of the chest. The pain was
increased by pressure. Simultaneously with the appear¬
ance of the eruption the patient began to suffer from con¬
vulsions. These were preceded by a warning in the form of
a sensation in the cardiac region, the head and eyes were
turned to .the right, there was tonic followed by clonic
spasm affecting the right side more than the left, with un¬
consciousness, lividity, and foaming at the mouth. The
herpes was treated by an external application, and bromide
and chloral were given internally. The case is described as
one of epilepsy caused by the herpetic eruption. Considering
how very reluctant our best authorities are in granting even
the existence of purely reflex epilepsy, it seems to us that
considerable assumptions must be made before such a caise
as that described is placed in this category. It is manifest
that before classifying it at all fuller particulars should be
furnished aS to the likely cause of the eruption. That th&
convulsions should have been the result of the herpes is of
course possible, but it seems more likely that both condi¬
tions may have been the result of some common cause.
Nor is there any evidence that the cessation of the convul¬
sions was due to the disappearance of the eruption. No-
doubt they disappeared simultaneously, but it must be
remembered that not only was an external application used
for the eruption, but two of our most valuable remedies for
epilepsy were given internally. Even at the time at which
the description of the case was written those drugs wer&
still being administered, so that it is at least premature to-
cite such a case as an example of reflex epilepsy.
BANK NOTES AND INFECTION.
Passing from han(f to hand among all classes of the
people, it would be strange, indeed, if money, and
especially paper money, did not in its transit become from
time to time the vehicle of infectious disease. Even tbei
crisp “ fiver” of the Bank of England no doubt has often
borne the germs of fever in its folds, and how much more-
then the greasy, discoloured, and well-thumbed one pound
note, or the paper fraction of some foreign currencies.
Higher values have bore a distinct advantage. Lesscommon,.
less in keeping of the overcrowded poor, less handled and
soiled therefore they may, perhaps, in many cases run*
their circuit without having done much mischief.
There are, indeed, preservative circumstances which guard
the sanitary credit of all paper currency. One is the very
freedom of circulation and the ventilation this ensures.
Smoothness of surface is another; and a third, which
operates in a minor degree, is found in the fact that adults,
not children, are chiefly concerned in the business of ex¬
change. These qualifications mefy suffice to justify, at least
by a negative verdict, the employment of paper money from
a sanitary standpoint. Still, a certain risk remains, and
careful persons will do well to note this, and on occasion to
disinfect even their bank notes. The danger, such as it is,
should also, in our opinion, be allowed some weight Id
deciding the question whether a small note currency hitherto
not found to be indispensable should or should not be gene¬
rally adopted. _
THE TRAINING OF BLIND AND DEAF MUTE
CHILDREN.
Years have elapsed since the authorities of the Educa¬
tion Department, following established usage in this and
other countries, turned their attention to the school traiuiug
of blind and deaf mute children, and already classes have
been formed in various Board Sihools for the instruction of
these once neglected children. The circumstance is a
practical recognition of the fact that, apart from the
necessity of nsing particular methods, the condition of the
mute and the blind places no exceptional barrier in-
the way of their instruction. A Bill which is about
to be presented to Parliament, and which if passed
will compel the attendance at school of such children,
does not therefore come too soon. The poverty of parent®
will alone constitute an excuse. In this case the cost of
elementary education, of industrial training, and (if need¬
ful) that of board and conveyance, will be defrayed by th©
department, assisted as far as possible by the parents. In
the case of failure to educate from mere neglect the parents
will be liable. Considerable latitude will be allowed in the
selection of a school, so long as it furnishes reasonable
guarantees of efficiency in teaching. If needful, power will
be granted to enlarge any school under the control of the
Digitized h-y' Google
The Lancet,]
THE WHITE INFARCT OF THE PLACENTA.
[Fkb. 7, 1891. 327
^Jeparfcment, in order to meet tlie special requirements of this
clasBof pupils. Unlessit be in thematterof charge for main¬
tenance and conveyance, it is difficult to see how exception
'can be taken to the provisions of the Bill. As regards this
point, however, it should be remembered that the charge
in question may sometimes be inevitable, since only a
limited number of schools can, at least in the meantime,
afford the special method of teaching which is called for,
and also that such limitation is essentially economical. It is
clearly impossible, moreover, for the department to transfer
its teaching function to other bodies. The blind or mute
child, if intelligent, has a right to elementary instruction
by such methods as are suitable to the case, and should in
time repay at least a part of the cost of training by dis¬
charging usefully the duties of citizenship.
THE WHITE INFARCT OF THE PLACENTA.
Dr. Finzi, who has made a number of observations on
placentcB in cases where the children were either stillborn or
died shortly afterbirth, states, in apreliminarynote published
in La Bi/orma Mediaa, that the most frequent morbid con-
•dition found was the so-called white infarct. It is ooca-
•sionally confined to the lacunae, and is due to a thrombosis
occurring in them, which is caused sometimes by a retarda¬
tion of the circulation, at others by necrosis of the villi.
In the latter case the villi may be seen to be invested with
A very delicate mosaic of exceedingly minute polygonal
transparent nucleated cells, which may be an atrophic con¬
dition of the normal epithelium. Generally the infarct is
situated in the tissue of the decidua, and consists of an
exudation rich in white corpuscles and in nuclear detritus,
which elements are found infiltrating the basal layer of the
decidua or collected in foci in certain points in the fibrous
tissue. In other words, the so-called infarct is the result
of a placentitis, hnd sometimes hoomorrhage may be seen
to have occurred in the substance of the decidua, proceeding
from the utero-placental vessels. Secondary thrombosis of
the lacunm, from retardation of the placental circulation, not
infrequently follows this infarct of inflammatory origin ; and
•when this is the case there will generally be discovered a
history of syphilis, tuberculosis, or pelvi-peritonitis.
THE WORKING OF THE CANAL BOATS ACTS.
Some interesting details relating to the Working of the..
Canal Boats Acts, 1877 and 1884, are to be found in the
Annual Report of the Local Government Board for last
year. It is satisfactory to learn from this source that the
work of inspection has in many districte, though nob in all,
been carried out in a fairly efficient manner. As a rule it
has not been opposed, hub rather welcomed with intelligent
interest by the boat population. There can be no question
as to the good thus accomplished, though the evidence seems
to show that abuses of a serious character have prevailed
'Only in a moderate degree. In the majority of cases noted
the contraventions of the Acts have not consisted in grave
•defects of hygiene or in moral delinquencies, but in such
•offences as omissions to register, to produce required certi¬
ficates, and the like. Reported instances of overcrowding
have been less common than might have been expected,
less than 4 per cent, of the total number of infringements
being classed under this head. In this connexion a sug¬
gestion by Dr. Cullingridge, medical officer of health for the
Port of London, that the registration of fore-cabins should
be discouraged, is worthy of remark. These insignificant
■corners add little bo the convenience of a boat. They are,
moreover, close and apt to he damp, are commonly not used
for sleeping, and serve merely to sanction overcrowding in
'the main cabin. As regards cleanliness, the boats afford
proof of progressive improvement. Ventilation, since it can
hardly be had without draught, still interposes a diliicnlty ;
but we note with satisfaction that Infectious disease,
thanks, no doubt, to the influence of a life in the open air,
is rare among the canal population. In spite of the uncer¬
tainties of a nomadic existence, the education department
has been able to secure a fairly regular attendance on the
part of the barge children, and this is only one of several
advantages resulting from a growing tendency on the part
of married boatmen to place their homes on shore, and to
use the boat merely as a means of transit for themselves and
their cargo. _
HEALTH OF PROFESSOR TYNDALL.
We are glad to report a definite improvement in the
health of Professor Tyndall, who has been confined to bis
bed for several weeks at Hind Head, Haslemere. Professor
Tyndall had been prostrated by long-continued difficulty
in obtaining sleep, and was gradually getting the better of
this when be was attacked with inflammation of a super¬
ficial vein of one leg, which occasioned great pain, and of
course rendered absolute rest essential. The vein has
entirely recovered, and Dr. Tyndall would ere now have
left his room but for an attack of congestion of the
lungs, which, although very limited, has necessitated still
further delay. This has now to a great extent subsided.
The patient is under the care of Mr. Whiting of Haslemere,
and Dr. Buzzard has been down to see him in consultation
on several occasions.
THE NEW GENERAL HOSPITAL, BIRMINGHAM.
A ‘VERY large and enthusiastic meeting was held on the
29th ult. to consider the proposal to rebuild the hospital on
the site, in St. Mary’s^ square, chosen by the governors. The
resolution to this effect was proposed by the Right Hon.
Joseph Chamberlain, seconded by Dr. Wade, and carried
unanimously. The sum of £75,000 has already been collected
for the carrying out of the scheme. A fuller notice of this
project will appear in our next issue.
OATH ADMINISTRATION IN COURTS OF LAW.
There are indications that attention is being drawn at
last to the unsatisfactory mode in which the oath is
administered to witnesses, jurors, and others, in all our
courts of law, Scotland being excepted. At the last
assizes Mr. Justice Hawkins remarked at a trial in Chelms¬
ford how very unsuitable the words of the oath as usually
administered were when the witness was a child who could
not possibly understand them. He would substitute, “I
swear that I will tell the truth,” &c., as being more
intelligible to such witnesses. It is unfortunate that
the learned judge did not. while he was about it, take
a wider view, and condemn the whole system—the admini¬
stration of the oath by an officer of the Court, who
gets into a very monotonous and unimpressive mode
of recital, and the handling and kissing of a dirty, greasy
book which has been in indiscriminate use for months, if not
years. This has been frequently alluded to in the columns
of The Lancet during the last few years, and it is now
high time that steps were taken to provide the remedy,
which is extremely simple. In Scotland the presiding
official, judge, or sheriff administers the oath standing,
with the right hand uplifted; the witness, also standing
with uplifted hand, repeats aloud the words of the oath,
which are not only more solemn than that used in England
and Wales, but so simpleas to be suitable for witnesses of any
age. A short Act providing a modification of the Scotch mode
of adjuration would probably pass with little or no opposition.
Our judges, coroners, and magistrates are already too over¬
worked to have additional duties imposed upon them. But
the repeating of the Scotch form of words from a card
and the uplifted hand are reforms to which no reasonable
Dig-ized by Google
328 The Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Ejis. 7, 1891.
person would object, and we commend the suggestion to
medical and other members of the House of Commons. A
prqpos of Mr. Justice Hawkins’s remark, it is a fact, how¬
ever paradoxical it may appear, that the words of the oath
as translated to foreigners by an interpreter are much
more intelligible to them than they are to English wit¬
nesses, though in their own language.
FOREIGN UNIVERSITY INTELLIGENCE.
Rome.—Dt. G. Colosanti has been appointed Extra-
ordinaij Professor of Materia Medica and Experimental
Pharmacology.
Siena. —Dr. Aducco of Turin has been appointed, after
competition, Extraordinary Professor of Physiology.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Heinrich Obersteiner, who had been Body Physician to
the Emperor Maximilian of Mexico. - Dr. Obersteiner was
Doctor of Philosophy as well as of Medicine, and was the
father of Professor Obersteiner of Vienna. He was in his
seventy-first year.—Dr. M. G. C. Goti, Professor of Military
Surgery in the University of Amsterdam.
Tub following lectures for the present year will be
delivered at the Royal College of Physicians on each of
the following Tuesdays and Thursdays at 5 o’clockThe
Milroy Lectures, by Dr. Thorne Thorne, Feb. 17th, lOth,
24th, 26bh, on “ Diphtheria; its Natural History and Pre¬
vention.” The Goulstonian Lectures, by Dr. T. Oliver,
March 3rd, 5bh, 10th, on “ Lead Poisoning in its Acute
and Chronic Manifestations.” The Liimleian Lectures,
by Dr. Broadbent, March 12bh, 17tb, 19bh, on “Struc¬
tural Diseases of the Heart, from the point of view of
Prognosis.” ___
There has just died Alderman William Kirk, M.R.C.S.,
Mayor in 1890 of the borough of Hedon, Yorkshire. Mr.
Kirk was said to be the oldest mayor and the oldest
surgeon in practice in England. He was born at Kimber-
worth in 1807. He was for the first time Mayor of Hedon
in 1870, and in all he held the office on five occasions. A
few months ago his portrait was painted by Mr. T. Tindall,
the funds having been raised by public subscription. It
will be placed in the Hedon Town Hall.
Dr. Heneage Gibbes, Professor of Pathology at the
Ann Arbor University, Michigan, has recently been placed
on the staff of the Harper Hospital, Detroit, as Consulting
Pathologist, in recognition of his researches on the subject
of phthisis. This appointment will enable Dr. Gibbes to
prosecute his investigations into the nature and treatment
of pulmonary phthisis on a larger scale than heretofore. In
our issue of Jan. 17th we gave a brief outline of his views.
We have received from the publisher, Herr J. Casper
(14, Behren-str., Berlin, W.), a proof copy of a photo¬
gravure from a portrait of Professor R. Koch by Herr Hoff¬
mann. Tho engraving is an excellent one, and the likeness
very faithful. There may be many in this country who
would wish to possess such a memento of one whose re¬
searches have aroused universal interest.
The Czar has presented the Imperial Obstetric Physician,
Professor Krasovski, with a gold snuff-box ornamented with
the imperial monogram and crown set in brilliants.
Sir William Cameron Gull, Bart., the son of the
late Sir William Withey Gull, formerly Senior Consulting
Physician to Guy’s Hospital, has founded a Gull Student¬
ship in Pathology at Guy’s Medical School, to commemorate
the long and intimate connexion of his father with the
hospital, and to associate the name of that eminent phy¬
sician with the advancement of one of his favourite studio?.
At the meeting of the Medical Society of London on
Monday evening next. Dr. Douglas Powell will read a
paper on Angina Pectoris. The discussion thereon is likely
to he of considerable interest and importance, and many
London and provincial physicians are expected to take part
in it.
Dr. James Andrew has resigned the post of senior
physician to St. Bartholomew’s Hospital. The vacancy
thus occasioned has been filled by the appointment of
Dr. Hensley, and Dr. Ormerod has become an assistant’
physician. _
We are glad to see that a Select Committee of the House
of Commons has been appointed to inquire into the houre
of overtime worked by railway servants.
Dr. William Radford Dakin, M.R.C.P., was on#
Feb. 4th appointed Obstetric Physician and Lecturer oo
Midwifery at St. George’s Hospital.
THE DEBATE ON KOCH’S REMEDY AT THE
BERLIN MEDICAL SOCIETY.
The subject of Koch’s remedy continues to be debated at’
the Berlin Medical Society.^ We reproduce fron» the
columns of the Berliner Klinisdie Wochenschrift the pro¬
ceedings of Jan. 28th.
Dr. A. Fraenkel exhibited microscopical preparations'
from the case of lingual tuberculosis mentioned by him a
fortnight previously. A section of the margin of tho ulcer
showed moderate bacillary infiltration, whilst one of
miliary nodule, situated at least 3 cm. from the ulcer,
showed giant cells, epithelioid cells, and a few bacilli. The-
ulcer had somewhat increased, and some of the nodules had
ulcerated, others caeeated.
Professor ViRCHOW first referred to a misinterpretation
which had been made of his statement on Jan. 14fch,
that in a case (of suicide) of phlegmonous pneumonia
in a phthisical subject the appearances were such
as be nad found in those injected with Koch’s fluid.
Although he was unable to affirm that this man had
been so treated before he was brought to tho hospital'
for his wound, he still adhered to that opinion. On the first’
occasion he had believed that the injections excited, among:
other changes, a characberistic or specific affection of the
lungs which otherwise does not occur in phthisis ; but on
the next occasion he affirmed the possibility of such a.
change occurring apart from the injections. If so, it would)
be ou a par with a caseous pneumonia, which ho had shown
might ensue on the injections. He had not meant to imply
that a caseous pneumonia was directly caused by the iU’-
jections, except in so far as this was supported by the-
history of the case. For instance, an individual who pre¬
viously had shown nothing pointing to lung changos-
becomes attacked with fever and local lesions after being
injected, eventually dies, and there is found recent caseous-
hepabisabion to quite a “colossal” extent, which, as he
had said, seemed explicable on the view that material from
the ulcerated tracts had been aspirated into deeper parts oi
the lung, giving rise to multiple inflammation. He now
showed a recent specimen illustrating such a consecutive-
non-caseous hepatisation. It was from a man twenty-six.
years of age, who bad a large cavity at the left apex, the right-
' The Lancet, Jan. aist, p. 271.
Digitized by ^ooQle
The Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Feb. 7, 1891. 32.9
lung being almost free. While he was in the Charitc he had
8eventeeninjections(amouQtiDgto0'0635grm.)fromDec. 14th
to Jan. 11th, and death took place on the 24th. There was
extensive implication of the lungs, including this hepatisa-
tion. The larynx and the trachea showed very recent
changes. There were small ulcers on the epiglottis, and an
older one between the anterior processes of the vocal curds.
Below that, especially on the left side, was an extensive
eruption of submiliary tubercle in the mucous membrane,
whilst recent ulcers spread through the trachea to its bifur¬
cation. Such changes could not possibly be older than the
period of injection (twenty-eight days). Again the lungs
and intestine exhibited recent as well as old lesions. In
the ileum there were isolated, large, old tuberculous ulcers,
around which the mucous membrane was markedly swollen
and reddened—an appearance he thought to be in part
ascribed to the action of the injections. In the ctecum and
a.scending colon were recent ulcers, evidently proceeding
from follicular abscesses. So in the lungs: there was the
•large ulcerating cavity (as smooth as a bronchiecbatic
cavity) in the left apex, the wall formed of semi-
cicatricial tissue, and presenting stumps of large arteries,
which had been eroded. Around the cavity were some old
indurations and bronchitic nodules. There were also two
diiferent kinds of pneumonic changes of recent date; in
some parts a few loci of caseous hepatisation. A large
areaof the right lower lobe presented theform of hepatisation
to which he had before alluded, clearly confined within the
limits of the lobules, and presenting the peculiar smooth,
moist, somewhat yellow character which, as the previous
cases showed, usually preceded the breaking down into
gangrenous foci. Professor Virchow added that not from
any ill will, but solely out of regard for truth, he must hold
to the opinion that this form of inflammation, which so
rarely occurs in phthisis, has occurred in these cases with an
unwonted frequency. Even if the case to which he first
referred prove an exception in not having been previously
treated by the injections (and this cannot be positively
aflirmed), it would prove nothing but that such forms of
pneumonia which do arise in large numbers after injections,
may also occur apart from them. He next brought forward
a ease with widely spread secondary lesions. The patient,
a Woman thirty-eight years old, was admitted into the
Charit6 on Dec. 8th and died on Jan. 2r>bh. She had altogether
twenty-two injections (amounting in all to 0'28grm.),
the first (O’OOl grm.) on Dec. 15bh, the last (O'OOC grm.) on
Jan. 18th. It was a severe case, complicated with
amyloid disease, shown in the spleen, liver, and intestine.
There was no evidence of reaction about the amyloid spots,
but there was widespread miliary tuberculosis. The liver
was full of submiliary tubercles (iu another case as many as
five tubercles could be seen in the microscopic field of a
section of a liver), and also a recent eruption in the
marrow of the femur. There was also caries of the temporal
bone. The lungs contained old smooth-walled cavities,
and near them some quite recent caseous hepatisation. In
the larynx there was a large deep but clean ulcer between
the anterior extremities of the vocal cords. The case was
also especially interesting from the marked lesions of Peyer’s
patches, which were swollen, medullary, with caseous
patches here and there—-in fact, tubercular. Lastly, Pro¬
fessor Virchow showed the lungs from a case wliioh had not
been injected. They contained veiy large cavities, which
showed as complete smoothness of their walls as in
bronchiectasis. This shows that not every such cicatrisa¬
tion which occurs after the injections is to be positively
regarded as a result of them.
Dr. Lassah, in view of the statement made as to
failures, brought forward a case which had apparently a
favourable result, a girl, thirteen years old, who had had
tuberculous disease of the hip, and later had a tuberculous
ulcer on the extensor aspect of the thigh, not all’ected by
other treatment. Treatment by Koch’s fluid began early
in December, and after a few injections, which excited
marked reactions, the ulcer cleaned and then completely
healed, after about four weeks’ treatment (amounting to
rather more than 0‘1 grm.). Since then it had undergone
no change, and the cure must be regarded as positive and
solely brought about by the injections.
Dr. Fla’I'AU exhibited a case of tuberculous disease of
the larynx which bad benefited by the treatment, but
stated that he bad occasionally observed the production of
disease in new spots, and the occurrence of severe laryngeal
phthisis in cases where the reaction was prolonged. He
adduced the case of a young lady in whom there was only
slight catarrh, besides a cicatrix from curettage; the
injections were followed by extreme swelling over the
arytenoids and aryteno-epiglottic folds, some perichondritis
of the epiglottis, and recent tuberculosis of the tonsil. In
another case, that of a man thirty years old, the eighteenth
injection (of O'OQ grm.) was followed by the appearance of
yellowish-white nodules around ulcers on the false cords
and over the left arytenoid. These nodules became more
numerous, the epiglottis became thickened, and a larger
number of submiliary and miliary nodules appeared on its
surface. This exhibited in the living subject what Pro¬
fessor Virchow had shown in his preparations. Laryngeal
tuberculosis rarely has this complication and extent.
Dr. FirRBRiNOER said he had published in the Deutsche
Medizinische Wochenschrift at the close of the year his ex¬
perience of Koch’s treatment for a period of four weeks^
and now spoke of his farther trials for six weeks. More
bad been learnt concerning the indications for the treat¬
ment, and he regretted to say that in twelve cases of pul¬
monary tuberculosis it had to be abandoned because no
improvement took place, but the disease grew worse.
The points in common among these cases did not refer to the-
late stage of the disease so much as to the relative acute¬
ness of the process ; and he had arrived at the conclusion
that the more febrile and hectic the case—i.e., the more
florid —so much the more is it unfitted for this treatment. A.
hectic temperature was then of more importance than the
duration and extent of the lung infiltration. If, too, the tem¬
perature, after a treatment lasting at the most for four weeks,,
shows no tendency to become normal or subnormal, the in¬
jections must be given up. It is otherwise with cases where
there is considerable infiltration with many bacilli in the-
sputa, so long as fever is abated. He thought it well not to>-
disturb stationary apex disease by the treatment, except
for urgent reasons. He had treated 100 cases where the
lung disease was prominent, and of these would select forty
which had undergone the treatment for from seven to
ten weeks, the doses varying from forty to 100 milli¬
grammes. He could now add a third case to the two of
“ relative recovery ” previously reported, but whether the
cure was definitive could not yet be said. Then there were
fifteen cases of unusual improvement, in the sense that he
had never seen such progress in cases treated on any other
plan. They were in the first and second stages of the
disease, one with commencing excavation. These cases
were of greater value than the three “ cures,” which were in>
the first stage. There was increase in weight, and in most
the process appeared to become more indurated and station¬
ary. There was a partial clearing up of dulness; and with
reference to Dr. Ewald’s remark that complete dis¬
appearance .of dulness does not mean cure, he said
that the possibility of cure was compatible with per¬
sistence of dulness. This was illustrated in cases of
“ spontaneous ” recovery associated with cicatricial forma¬
tion. Ten cases were slightly or but little improved ; they
were in the first and second stage of the disease, and not-
more improved than they might have been without Koch’s,
treatment. Seven patients had died, in four of whom thfr
method had been abandoned a long time before death.
Miliary tuberculosis was found in several, in others it was*
absent. In one case tbei'e was very marked caseous pneu¬
monia, and in two an exceptional degree of acute catarrhal
f meumonia. But he found it difficult to associate tbese-
esvona with the treatment, since they did not differ from
those present in other cases of phthisis. On two occasions
he admitted, nob merely on anatomical but also on clinical
grounds, that the process was strikingly made worse by
the treatment; the change being so “drastic” ns to leave-
no doubt of the relationship. They were cases in which
the temperature, previously and for a long period normal,,
had become markedly hectic. From the anatomical
appearances he had concluded that the more recent the
tubercular tissue so much the more powerless is Koch’s-
remedy to attack it; and that agrees with the state¬
ment that florid phthisis is unsuitable for the treatment, only
that there we have to do with secondary pyogenic processes
ns well as with miliary deposits and caseous pneumonia.
Referring to the statement made by Professor Virchow that,
acute pneumonic infiltrations were a direct result of the-
treatment, he (Dr. Fiirbringer) observed that he could men¬
tion at least six such oases from his own experience. One
of these he detailed. The patient, thirty-five years of age,
with slight apex disease, who had spent three winters at.
330 ThkLanost,]
THE CONTAGIOUS DISEASES ACTS.
[Fkb. 7, 1891.
Davos, and was much improved thereby, was submitted to |
injections. In the second week oi treatment there de¬
veloped signs of acute pneumonia, with moderate fever and
silbuminous expectoration. But these passed away in a
week, leaving him much better than before. It seemed as
If he had undergone a “perturbatio eritica”; and the con¬
dition was probably one of catarrhal pneumonia. Such
effects of the reaction should induce additional caution in
dealing with the weakly and cachectic. Finally, he advo¬
cated the employment of small and not increasing doses,
with long intervals—e g , a week,—having noticed that the
patients were better for such a plan. Moreover, it reduced
the possibility of the induction of a habit for the drug.
Dr. Paul Guttmann, referring to the discovery by Dr.
Liebmann of bacilli in the blood of subjects under Koch’s
treatment, said that be had, in conjunction with Professor
'Ehrlich, repeated these observations with every precaution
in twenty-eight cases, and in not a single 'one of the
specimens of blood were tubercle bacilli to be found. In
Teference to a remark by Dr. Ewald that the fact of fatal
■cases occurring at the Moabit Hospital showed that selec¬
tion bad not been limited to those in the earliest stage of
disease, Dr. Guttmann adn)itted that it was not always
possible from objective signs to be certain of the latter
point; and in so large a nospital—containing more than
300 c(^es of phthisis—many patients advanced in the disease
desired to be treated by the injections. But of course the
•question was as to what are the precise indicatioua for
treatment, and he adhered to his previous formula, that it
•should only be employed in early cases with limited apex
infiltration. He had compiled fresh statistics of 161
cases, treated from three to eight weeks. Of these 63, or
38 per cent., bad notably improved ; and of 51 cases of early
apex disease 41, or 76 per cent., were similarly benefited.
Details of these cases and accounts of post mortem examina¬
tions would appear in an official report to be published in
the Clinical Year Book, together with the reports from the
Prussian universiUes.
DR. APOSTOLI’S LATEST CONCLUSIONS ON
THE CONSTANT GALVANIC CURRENT
IN GYNECOLOGY.
The following summary of Dr. Apostoli’s conclusions in
regard to the subject of which he is at present the greatest
-authority will be of interest to our readers :—
1. The constant galvanic current, he says, is indicated in
gynrecology principally in endometritis and in fibroid
tumours. It is very cfiective in abnormal conditions
'Of uterine circulation (ameuorrhcca and menorrhagia) as
well as in painful menstruation ; is a powerful aid in
arresting the development of simple neoplasms and in
facilitating the absorption of peri-uterine exudations. It
exercises a salutary action towards resolution in many
peri-uterine pblegmasim, and in certain forma of catarrhal
ovaro-salpicgibis; but it is powerless iu suppurative in-
ifiammations of the appendages, nay, even it is injurious in
strong doses, particularly if the iutra-uterine pole be nega¬
tive. The variable intolerance of the current which increases
with the degree of the inflammatory action of the appendages
serves as a valuable means of diagnosis in determining the
existence and the nature of undetected or only suspected
,peri-uterine fluid collections, bmmic or suppurative, and in
deciding the necessity for surgical interference or not.
2. The effects of the con.stant galvanic current are polar
and interpolar. The interpolar action is trophic and
dynamic, which increases as the square of the intensity of
the current used, and is superadded to the polar action.
The polar action is utilised for a dillerent purpose accord¬
ing to the pole employed, as first shown by Apostoli
himself. A calorific action is developed by the passage
of the current which augments the interstitial circulation ;
and lastly, the antiseptic action of the positive pole has
been recently demonstrated by Apostoli and Laguerri6re.
3. Strong galvanic applications exceeding 50 milUampbres,
employed in a variable manner according to the tolerance
of the iudividual patient and the special clinical indications
form the basis of Apostoli's method, and find their justifi-
-eation in the circulatory depletion, “drainage circulatoire,"
a direct consequence of the calorific action due to the resist-
-ance offered to the passage of the current, and proportionate
to the square of the intensity; in the antiseptic or germicidal
action, which increases with the intensity of the current
used; in the rapidity and efficacy of the effects produced,
which are proportionate to the square of the electric energy,
according to a formula analogous to that of the measure of
energy in other natural forces: in the easier
generalisation of the method as applied to obstinate cases,
as hard fibroids of the subpevitoneal variety or fungous
endometritis, and to conditions in young subjects; and in
lessening the frequency of relapses, which, all other things
being equal, are less to be feared the stronger has been the
current employed.
4. If the vaginal application of the galvanic current (which
is the method introduced by M. Ch6ron for fibroids only, and
applied since by A. Martin, Brachet, M6nibre, Onimus,
Carpenter, Munde, and others) produces certain results,
these are very inferior, to those obtained by intra-uterine
applications, which must remain the method of selection,
because it utilises at once the maximum of the curreut
expended and of its energy, and at the same time the anti¬
septic action of the positive pole, which is entirely local, and
which disappears in the interpolar circuit and at the level of
the negative pole. It also utilises the derivative and caustic
action of the iutra-uterine application, thus treating at the
same time either a simple endometritis or, as is often the
case, one complicating a fibroid or a peri-uterine inflamma¬
tion, and ensuring thereby a more rapid, more complete,
and more permanent cure. It also enables us better than
vaginal applications to palliate pain, and to render the use
of strong doses more tolerable.
5. The vaginal galvano-punctures to the depth of from
two to five millimetres, by means of a filiform trocar made
of gold, insulated in all its extent except at the point,
form the complement of intra uterine electro therapeutics
introduced by Apostoli as a more accurate means of
localising galvanic action, and of increasing the efficiency
in certain coses of the application of small or medium
doses
6. The innocuous character of his intra-uterine electro¬
therapeutics is demonstrated by comparing it with those of
the chemical and operative intra-uterine methods of treat¬
ment, and particularly by comparative statistics. Dr.
Apostoli made from July, 1882, to July, 1890, 11,499 gal¬
vanic applications, as follows 8177 positive intra-uterine
galvano-caustic, 2486 negative intra-uterine galvano-
caustic, 222 positive vaginal galvano-punctures, 614 nega¬
tive vaginal galvano-punctures. He has treated 912
patients, comprising 531 fibroids, 133 cases of simple endo¬
metritis, and 248 of endometritis complicated with peri¬
uterine infiammatioii.
Of these 313 fibroids, 70 cases of simple endometritis,
163 of endometritis complicated with peri-uterine inflam¬
mation occurred in the cUnique, and 218 fibroids, 63 cases
of simple endometritis and 85 complicated, with peri-uterine
inflammation, occurred in private practice. He has had
three deaths attributable to operative defects. Two galvano-
puncture, of which one was for a subperitoneal fibroid, the
other for an ovaro-salpingitis, and one galvano-caustic
application for a cyst of the ovary, mistaken for a fibroid.
He has observed 30 cases of pregnancy which occurred
I after intra-uterine galvanic applications.
THE CONTAGIOUS DISEASES ACTS.
A PAi’EK was read before the Royal Statistical Society
on Jan. 20th, 1891, by Robert Lawson, LL.D., Inspector-
General of Hospitals, dealing with the operation of the
Contagious Diseases Acts among the troops in the United
Kingdom, from their introduction in 1864 to their ultimate
repeal in 1884, of which the following is a brief abstract. The
first Act, passed in 1864, he said, merely provided for the treat¬
ment of such persons as applied voluntarily to have the advan¬
tage of it, or who were speedily reported to a magistrate,
and, while undergoing this, they were at liberty to leave the
hospital whether cured or not. The Act of 1864 was
amended in 1866, and this again in 1869, the additions
being calculated to render tliem more efficient in their
operation. This state of things went on with little altera¬
tion until 1883, when personal examination was stopped,
and in 1885 the Acts were repealed. The records of dUease
r Coogle
The Lancet,]
THE CONTAGIOUS DISEASES ACTS.
CFeb. 7, 1891. 33t
of this nature, both among the troops and the crews of
Her Majesty's ships at the stations where the Acts were in
force and at other points, ate available to show its
progress under the diderent conditions in which these
men lived, and the whole may be regarded as a most
interesting experiment on public health, in which we
may see not only the mailed improvement under the
employment of measures favourable to that end, but the
relapse to its former state on their abrogation. The
Prewdent (the late Surgeon-General T. Graham Balfour) was
desirous that an authentic relation of these facts should
appear in the journal of the Iloyal Statistical Society,
and had invited him to undertake its preparation,
as he had arranged the army statistics bearing on it for
Mr. W. H. Sloggett, Inspector-General of Hospitals, R.N.,
who was superintendent of the lockhospitalsunder the Acts at
the time, and conducted their case before the Parliamentaiy
Committee which sat from 1879 to 1882 to investigate their
working. Before proceeding to the subject proper of
this paper it was necessary to indicate the forms of disease
which came under the operation of the Acts, the different
manner in which separate bodies of men, at the same
place and the same time were affected by these diseases ;
and a very remarkable fluctuation, of an epidemic nature,
extending over several years in spcoession, quite as great as
that of measles, and which occupied a very extensive area.
Mr. Lane of the London Lock Hospital, and Mr. Macnamara,
the medical officer of the Dublin Lock Hospital, stated in
tbeir evidence before the Committee that, in their expe¬
rience, the- constitutional affection did not follow the
indurated sore exclusively, and that in most cases it was
impossible to say whether any given sore would eventuate
in the constitutional affection ; but neither of them was able
to give a numerical statement of the relative frequency
in which each of these sources occurred. In support of
this, Dr. Lawson mentioned the followiog striking instance
which came under his own observation. A regiment, with
an average strength of 254, came to Castlebar in a healthy
condition in the year 1842. In 127 dajs ninety men were
admitted with primary venereal sores. The depOt left
some time afterwards for Boyle, where there were very few
admissions of primary sores, and these of a mild descrip¬
tion. From May 20th, 1842, to July 1st, 1843, there had
been twenty-seven cases of hard sores treated, and forty-
nine cases of secondary syphilis, so that, admitting that
every hard sore eventuated in the constitutional affection,
there were still twenty-two other instances following
sores in which the duration was not observed. Prac¬
tically, it appeared that it could not be shown with
certainty that the eonstitulional affection would follow
a . given sore in any particular instance until the
general system showed unmistakable signs that it was
so affected. He bad prepared tables which showed the
very renia>'kable increase of admissions in the years 1860
to 1864 in all three descriptions of forces. In the
cavalry, while the admissions for the secondary disease
(45 "7 per 1000) were in the ratio of 1 to 2'6 cases of
primary in the infantry, the secondary cases were 32'0,
or 1 in 3'4 of the primary; and in the Foot Guards 33‘5,
equal to 1 in 4‘6. The effect of the establishment
of lavatories in the barracks, where men might have
the opportunity of washing after return to their quarters,
showed that those barracks which had no night lavatory,
yet had by far the lowest admission rate of all the barracks
that were under observation. The intercourse vf&s pretty
general, and the fluctuation in the primary sores was
evidence not that facilities for ablution were useless, but
that in those barracks without night lavatories it was had
recourse to immediately after exposure to infection, when it
was much more likely to prove efficiect, It was pointed
out, however, that large numbers afforded a more reliable
criterion than the investigation of its effects in several small
detachments. From the records it was found that the
statistics of syphilis fluctuate very considerably, just like
other diseases. In I860 the ratio per 1000 of admissions for
primary venereal sores among the troop.s at the whole of the
home stations was 140, and from this date there was a con¬
tinuous fall, though with frequent minor fluctuations, till
1875, when the ratio was 46. A rise then commenced, and
the ratio went up to 125 in 1884, since which it had fallen to
83'5 in 1889. The lecturer pointed out that these fluctuations
might have arisen from the fact that when arrangements
were made for the carrying out of the Act, fourteen stations
were selected as “ stations which came under the Acts ”—
namely, Devonport and Plymouth, Portsmouth, Chatban^
and SheernesB, Woolwich, Aldershot, Windsor, Shorncliffe,
Colchester, Winchester, Dover, Canterbury, Maidstone,
Cork, Curragh, and fourteen others remaining at which am
average strength of 500 or upwards was quartered annually,
were chosen to compare with them. These were named
“the fourteen stations never under the Acts”—namely.
Isle of Wight, London, Warley, Hounslow, Pembroke^
Dock, Sheffield, Manchester, Preston, Edinburgh, Fermoy,
Limerick, Athlone, Dublin, Belfast. When it was found
that other stations never under the Acts had a considerable
number of men distributed amongst them they were added
to the fourteen, and designated “ a.U the stations never under
the Acts.” This arrangement was undertaken with a view
of showing the varying incidence of diseases from year
to year at points where its progress was not interfered
with by the operation of the Acta, so that it might
be eliminated at the stations under them, leaving the
changes due to the Acts apparent. The Act of 1864 pro¬
vided in substance that on information being laid before a.
Justice of the Peace by a police superintendent or inspector,
showing that be had reason to believe that a woman was.
a common prostitute and infected with venereal disease, the-
magistrate could order her to be taken to a certified hospital
for examination, and on certification of disease the justice-
could issue an order for her detention in the hospital for a
period not exceeding three months. By the Act of 1866-
periodical examination of prostitutes once a fortnight was
ordered, and tlie period of retention extended to six months
if necessary. A woman on discharge from hospital well,,
after any period of treatment, was no longer subject to the
order of periodical examination unless under a fresh decision-
of a magistrate. By the Act of 1869 it was provided that if
the examining surgeon had reasonable grounds for believing
a woman was affected with a contagious disease, but found
that she was not in a condilion that he could properly
examine her, she might be detained in a certified hospital
for five days to enable this to be done. In the end of 1873'
an order was issued by Lord Cardwell, then Minister of War,
stopping the pay of soldiers in hospital labouring under
primary sores or gonorrhcea during the period of their treat¬
ment. This continued in force until 1879. In 1883 personal'
inspection was suspended, and in 1885 the division of military’
stations into those under the Acts and those not under them;
ceased. When the compulsory examination began to take
effect in 1867, though there was an increase of the incidence
of the disease in the country, as indicated by rises in the^
ratio of 17 per 1000 in both the “unsubjected” districts,
that at the fourteen stations under the Acta was 4 per IflOO-"
only, and from this year the ratios at the fourteen subjected
stations were always much under those in the whole until
1884, the last year of the comparison.
The stoppage of pay showed its effects in 1874 by a
fall at each class of stations, which was continued in 1876,.
and still traceable up to 1877, after which the advance of'
the epidemic wave caused a rise of forty at the fourteen
“ unsubjected” stations, while at the fourteen “ subjected’
it was only four. In 1880, with the cessation of tl e stoppage
of the pay, there was a general rise, amounting to thirty-
nine at the fourteen unsubjected stations, and to twenty-
seven at the fourteen subjected stations. A portion of
this was due no doubt to an increasing incidence of
the disease over the country, and in great measure
to the removal of the inducement to conceal primary forma
of the disease by stoppage of pay. In May, 188.3, t&e com¬
pulsory examination of women was abolished, and the last
impediment to the increase of the disease at the fourteen
subjected stations having been removed, the ratio of ad¬
missions at these increased 32 per 1000, against a fall of
2 at all the unsubjected stations, and a moderate rise of 9-
at the fourteen unsubjected stations; and in 1884 there
was a further rise of 28 at the subjected stations, against a
fall of 8 at the whole of the unsubjected stations, and of
28 at the fourteen unsubjected stations. This extraordinary
rise in the ratio of primary sores at the subjected stations
placed them in 1884 at 138 per 1000, midway between
those at the two sets of unsubjected stations, and 13 above-
the general mean for all the troops on the home station last-
year. It differed little from the state of things in 1860, and
following, as it immediately did, on the removal of the
lost restriction on its propagation, there can be no doubt
of its cause. Under the Acta the fall in primary sores
was 60 per cent. ; at the unsubjected stations the fall was
26 per cent., and taking this from 60 there remains a fallf
332 The Lancet,]
ARMY MEDICAL SCHOOL, NETLEY.
[Feb. 7,1891.
of 34 per cent, as due to the repressive action of the Acta.
Proceeding in the same way, secondary syphilis showed a
fall of 39 per cent., under the Acts, and in the ease of gonor¬
rhoea the rail under the Acts was 25 per cent.; at all the un¬
subjected stations it was 18, leaving an excess of 7 under
the Acts; while at the fourteen unsubjected stations it was
•36, or 11 more even than under the Acts. The question of
relative frequency of infecting and simple sores could^ be
ascertained only by finding how many cases of constitu¬
tional disease follow the primary sores noticed among a
'large number of persons under observation for a lengthened
period. It was found in 1861 to 1872 inclusive the admis¬
sions showed 1 case of secondary syphilis to 2-95 primary
cases. Subsequent returns gave 1 case of secondary per
.3-27 primary sores. There were two sources of uncertainty—
viz., the effect of treatment and the variation of the
relative frequency of infecting and non-infecting sores from
time to time. The lecturer, in conclusion, saia gonorrhcoa
■had been but little commented on during the course of
this investigation; but in general terms it might be stated
■that, though responding readily to the preventive aid of
the Acts, it nevertheless ultimately was materially reduced
under their operation._
ARMY MEDICAL SCHOOL, NETLEY.
regard—one which is of the greatest importance to the
efficiency and well-being of the army, and without which
the best organised troops could do but little. I hope you
will always set, before you a high standard. You have to
remember that you are officers and gentlemen, and, above
all things, medical officers to whom the executive officers of
the army look for support and advice. I know that you
are just going on leave, and I have no intention of taking
up your time with a long speech; I will only wish you all,
therefore, every success and honour in the service into
which you are now entering.” The remarks of his Royal
Highness were received with much applause.
The Director-General proposed, in some brief and appro¬
priate remarks, a vote of thanks to his Royal Highness for
the honour he had done to the Medical Department of the
army in coming to distribute the prizes; and Sir Joseph
Fay rer seconded the proposal, remarking that it was not only
for his presence on this occasion that thanks were due to
the Duke of Connaught, but more especially were they due
for the very grateful and graceful terms in which his Royal
Highness had expressed his appreciation of the medical
service to which so many of those present belonged.
The Duke of Connaught honoured the Principal Medical
Officer and Mrs. Madden by joining in afternoon tea at
their quarters before re-embarking on the Royal yacht for
return to Osborne.
The winter session of the Army Medical School was
‘brought to a close on Feb. 2Qd. His Royal Highness the
Duke of Connaught, commanding the Southern District,
had consented to deliver the prizes gained in the final
•examinations at the school, and, attended by his staff,
arrived at Netley from Portsmouth on board the Royal
yacht Elfm, shortly after twelve o’clock. The Duke was
received on landing at the pier by the Director-General of
the medical staff, W. A. Mackinnon, C.B., and by the
Assistant Adjutant-General, Colonel Hanning Lee. Sub¬
sequently, attended by the principal medical officer,
^Surgeon-General Madden, and the medical officers of the
hospital, his Royal Highness visited all the wards, inquiring
into the natbre and history of each patient’^ case, and
.afterwards went to the officers’ quarters for luncheon in the
aness-rooin. The proceedings in the lecture theatre of the
school commencea about half-post three o’clock. The
benches were occupied not only by the surgeons on probation
who had been in attendance during the session, but also by
.a large number of officers and visitors. Conspicuous among
the audience were a number of the nursing sisters in their
-distinctive uniforms. Sir Thomas Longmore, after obtaining
the Duke’s permission, read a brief summary of the results
of the session, and the surgeons who had gained prizes being
called to the front, the Duke delivered the prizes to them
■ivith a few words of congratulation to each recipient.
After distributing the awards,
His Royal Highness said: ‘ ‘ Gentlemen,—I wish to express
the pleasure it has given me to attend here to-day and to
listen to what has been read to us, as well as to hand the
prizes to those who have gained them. I congratulate you
•all on the good report we have just heard, and I especially
congratulate the four gentlemen whose names have been
.-several times mentioned in it. Gentlemen, you are entering
upon a very important profession, and one to which I hope
you will all do great credit. There is a great deal to be
learned and seen by the medical officers of the army that
must be new and interesting to them. Many of you may
find yourselves placed in climates that are very trying, and
in positions than will require the exercise of much tact and
determination. I Lope you will not be wanting in these quali¬
ties. My experience in the service has led me to become ac-
-quaintedwithanumberofraedicaloflicers, for whom I have the
greatest friendship and highest respect. You have chances
■of distinguishing yourselves in many ways. The only rime
I have had the high distinction of being commanded by
Her Majesty the Queen to present the Victoria Cross was
when I wa^ commanded to present it to Surgeon Crimmin
of the Bombay Medical Service. Rest assured that the
-officers of the array know how to respect their medical
officers. It depends on themselves whether they will keep
«p a high professional standard, and I entreat you, gentle¬
men, to remember that while you are officers of the army,
you are also medical gentlemen. You are representatives
•of a profession for which we naturally have the highest
THE OBSTETRICAL SOCIETY.
PISCUSSION ON THE MIDWTVES’ KEGISTRATION BILL.
About seventy Fellows were present at the annual
meeting of this Society on Wednesday, Feb. 4th. The
ballot for the election of officers and Council for 1891 and
for the election of Professor Tarnier as an Honorary Foreign
Fellow was taken. A number of specimens were shown.
The reports of the treasurer (Dr. Herman), honorary
librarian (Dr. W.n. Duncan), and the chairman of the
Board for the Examination of Midwives (Dr. Watt Black)
were read and adopted. The retiring President, Dr.
Galabin, tlien delivered the annual address, in which he
paid a graceful tribute to the memory of Dr. Matthews
Duncan. The address was followed by a discussion on the
question of the registration of midwives.
' The President, in the course of his address, observed
that the advice of the Council was asked by the promoters
of the measure as to the provisions of the Bill, and the
Council he.d spent much time in considering them. The
view taken by them was that the prime necessity was to
obtain efficient examining boards, and so to secure that
none but well-instructed midwives should be passed and
placed upon the Register. It was also thought that the
election of examiners by the County Councils might cause
the selections to depend upon general or local politics to
such an extent that it would bo difficult to maintain a
uniform standard of efficiency in all of them. The
Council proposed the establishment of a central ex¬
amining ooard in London, with ten or twelve local
boards in England and Wales in important towns, so that
no midwife would have to travel more than sixty miles for
examination. The Council also advised that there should
be a central register which could be consulted like the
Medical Register. Most of the suggestions had been
adopted by those in charge of the Bill. In the present Bill
he, personally,objected to the clause, “allmidwives now in
practice.” A similar clause with regard to dentists and
veterinary surgeons had been allowed to pass, and had led
I to much abuse. He thought it quite unnecessary in
: the case of midwives, and in the Bill drafted by the
I Council of the Obstetrical Society under the president,
I Dr. West, the assumption of the title “registered midwife”
was made penal. The Bill was also open to criticism on
account of its leaving the General Medical Council
to settle various points which could with advantage have
been defined in theBill itself. Some of the objections to the
Bill were obviously fallacious. It did not seek to legalise
the practice of midwifery by women. That had been legal
from time immemorial, and Parliament had invariably
refusoil to render illegal the practice of midwifery by
persons not on the Medical Register. At the present
there is nothing to prevent any midwife from engag¬
ing in, medical or surgical practice except the liability
Di_,
The Lancet,]
THE OBSTETRICAL SOCIETY.
[Fei5. 7, 1891. 33.5
to aD action if she injured her patient. If a midwife
obtains I the status which registration would give her, she
must in return be ready to assume certain responsibilities;
she ought to be made liable to be removed from the Register
if she exceeds her proper functions. A memorandum, com¬
piled from the minutes of Council and Transactions, had
been circulated among the members of the Society, but it
was not intended now to give any special opportunity for
the discussion on this subject; as some Fellows, however,
had expressed a wish to discuss the matter the constitu¬
tional opportunity followed on the President’s address. As
regards the Bill now before Parliament, the Council of the
Obstetrical Society had nothing whatever to do with its
provisions, and therefore, in criticising the action tof the
executive, it seemed to him the main question was not so
much the provisions of the Bill now proposed as whether
the principle of public and compulsory registration of mid¬
wives such as has been advocated for so many years by
the Society was a good thing or not. He ventured only to
express the hope that the result of any discussion may be
that the opponents of the present Bill would devote them¬
selves rather to devising proper safeguards than to opposing
legislation, which, if carefully guarded, might be of great
public benefit.
Dr. R. Barnes had been brought to the meeting chiefly
by the extraordinary memorandum which had been sent
round to the Fellows. He called special attention to its first
paragraph, whicli contained, to Ms mind, one of the most
extraordinary assertions ever put into a public document,
and which oughtnot to pass without observation. It asserted ;
“ The Obstetrical Society of London was the first in promot¬
ing the education of midwives.” Could anyone possibly so far
forget thehistory of midwifery as to assent to that statement?
The education of midwives meant, in ordinary language,
the training of midwives for their business, and does not
necessarily imply even the granting of a diploma or
certificate of any kind. I-Ie knew something of the history
of midwifery, and he knew that in France and Germany
midwives had been trained, educated, and diplomatised for
more than a century, and also at the London Lying-in
Ho.spital nearly one hundred years before thO' Society
was instituted. The same thing occurred at the
Royal Maternity Charity, where Dr. Hall Davies and
Dr. Francis Ramsbotham lectured, demonstrated, and
clinically educated luidwives before the Obstetrical Society
was in existence. The misstatement had either arisen
through sheer forgetfulness or from admiration of the
services of the Society, which caused the writer to forget
the services of everybody else but those who drew up this
E aper. He recommended that the document -be referred
ack to the Council for revision and reconsideration. He
mentioned that the Midwives’ Bill now before Parliament
had been actually abandoned in deference to the opposing
views of a large body of the profession, an opposition
which he did not at all share. He thought the principle of
registration was good and sound, and ought in some form or
other to be carried out. But this Bill was full of faults, and
was opposed by a large number of the members of the pro¬
fession. The membei-8 of Parliament who had signed their
names to the Bill had withdrawn them, and it would not come
on again this session. Probably there would be a motion to
appoint a committee to examine into the subject, but that
was only a placebo. He thought the Council ot the Society
had been somewhat oblivious of their duty in not liaving
called a meeting of the Fellows to discuss this matter hilly.
He had seen a great deal of the action of midwives and
others, and, so far as his experience went, if properly
trained, they formed an invaluable class of society.
Dr. Aveling had been interested in the subject for
thirty-three years, and had forgotten neither what was due
to the public nor to the profession. Ilis notions were pretty
well known, and he would not reiterate them. Midwivea
were in a far better position 150 years ago, when they used
to be sworn by the bishops, than tliey were now. Hince that
time they had been left to their own devices to act as they
pleased. Parliamentary action had begun with the Duke of
Gordon’s Bill in 1878. It was to amend the Medical Act
of I8r>8, and Clause 25 of that Act contained a scheme
for examining, licensing, and registering miclwives. The
profession was of opinion that it was not politic to unite
the two subjects, and that midwives ought to be dealt with
separately. The clause was consequently expunged from
the Bill. In 1882 the British Medical Association drafted
a Bill for the registration of midwives, which had never
been submitted to Parliament. In 1890 the Midwives'
Association had drafted a Bill to provide for the registra¬
tion of midwives, and Clause 5 of it gave the midwife legal
power to practise midwifery and to recover fees for the-
performance of any midwifery operation. Needless to say,
a clause like that was objectionable, and the Bill was
put before a select committee to be amended. This
amended Bill is still alive, though Dr. Barnes said}
it was dead. He thought the memorandum, with the
exception of the part referred to by Dr. Barnes, was-
too modest in its professions. The Council and sub¬
committee had worked very hard in connexion with the
subject. A scheme had been drawn up by the Society in.
1873, and submitted to the General Medical Council. He
regretted that the Society had not drafted a Bill of its own,,
the expense of which might have been very properly defrayed
out ot the fees paid by midwives for examination. Very few
people appreciated what details had been left to the Privy
Council to decide. He maintained that in any Bill it was
better to make the provisions general. They would notice-
that the Privy Council would make provision as to the admis¬
sion of a midwife alreadypractising, who would be required to-
produce ‘ ‘ the prescribed evidence of her title ” before being
registered as a bond-Jide practitioner. This gave the Privy
Council the power to exclude women who were not suitable.
Regarding the allegation that midwives would oompete-
witn medical men, he asked where the members of
the profession were who received only from 2s. (id.
to 10s. as midwifery fees. They had never appeared to-
oppose this Bill. Those who had done so he was certain
received no such fees, and he thought the class of meu^ho
did so was an exceedingly small one. The certificates
granted to mid wives were of an exceedingly unsatisfactory
character. He quoted examples of bad certificates. He
therefore proposed : “That the Fellows of the Obstetrical
Society approve the policy pursued by the Society for the
last twenty years, and respectfully request the Council to-
continue their efforts to obtain for these women suitable
education and legal registration.”
Dr. Walter Grii-’eiti-is, in seconding the motion, said
he did not wish to discuss the unsatisfactory Bill now in-
Parliament. Any Bill on this subject required much-
thought before it could be drawn up in a suitable form.
Dr. Leith Napier moved: “That four Fellows of the
Society be recommended by the Council to confer with the-
four Fellows nominated by the President of the College
of Physicians, and that these gentlemen be deputed by us
through the Council of this Society to take charge of the
Bill, and to carry out the principle of registration in the-
best way that may occur to them.”
Dr. LovellDrage charged the Council with having carried
on legislation of which the Society was ignorant. The Council
calmly said that the matter had been before the Society fre¬
quently. He would like to know when, during the last five
years, the ordinary Fellows had had any opportunity what¬
ever otdiscussing either the principle of the Bill ot the Bill
itself. No one had attempted to show that there was any
necessity for legislation wuatever. Surely it would have-
been easy for one of the members to put before the Society
some facts and some figures upon which the Society could
found a reasonable opinion. He observed that the Council
were anxious to dissociate themselves from this Bill, which-
bad been thoroughly knocked to pieces. He had heard
recently one of the promoters of this Bill assert in a public
meeting that the Obstetrical Society of London approved
of the Bill, and had been consulted about it. Surely, in
face of that statement, there must have been some com¬
munication between the Council of this Society and the
promoters of the Bill. He thought it was useless to go on
with a discussion unless the Council were prepared to give
some idea of the lines upon wliich they proposed to-
legislate.
Dr. Roreut Barnes asked the President, in his ofiioial
capacity, whether the Council adhered to the first clause in
the memorandum as a matter of fact.
The President pointed out that it simply meant that the-
Obstetrical Society was the first oificial body in this country
to take active steps for the promotion of the education of
midwives by public measures. The great question was the
principle hitherto contended for by this Society, that there
should be some measure enacted by Parliament for the
examination and registration of midwives.
Dr. Aveling contended that it was not the fact that the
majority of the profession were against this Bill. The
; Ht Coo'.'Ie
O
534 The Lancet,]
THE GERMAN HOSPITAL.
[Feb. 7,1891.
<]ueBtion had been tested by the British Medical Associa¬
tion. Every branch had been communicated with, and the
lesult was that 4000 were found to be in favour of the Bil),
«nd 700 against it.
Dr. CuLLiNOWORTH supported Dr. Leith Napier’s recom-
iuendatioo, and mentioned that the subcommittee ap¬
pointed by the College of Physicians consisted of three
general physicians and one obstetrician. That was not
such a body as one would imagine to have the necessary
knowledge of obstetric matters to give this Bill the con¬
sideration it deserves.
Dr. Lovell Drage thought those appointed might run
the risk of being told that the Royal College of Physicians
•did not wish to be biased by the members of this Council.
Dr. John Williams said the question had frequently
been before the Council, and it would be undesirable to bind
libemBelves or to be trammelled in any way by having to act
with any other body. He was extremely glad that the
College of Physicians were going to consider the matter,
-and trusted that those appointed by that body would find
out the real conditions which at present existed, and be able
to supply the College with a valuable report But the
opinion of that body would not be of the same value as the
opinion of the members of the Obstetrical Society. In any
case he should deem it extremely undesirable for the
Society to join any other body for the consideration of this
•matter.
Dr. Macnaugliton Jones having made a few remarks,
Dr. Leith Napier withdrew bis recommendation, and Dr.
Aveling’s motion was carried almost unanimously.
-_____
THE GERMAN HOSPITAL.
The meeting of the Annual General Court of the Governors
of the Germau Hospital, Dalston, was held at Cannon-street
Hotel on Friday, Jan. 30th, when the report and the financial
statement were submitted. Count Deym was invited to
become a vice-president of the hospital. In the absence of
Baron von Schroder, Baron von Deichmann presided. After
some general business had been transacted the rule regu¬
lating the formation of the committee was considered. A
desire was expressed last year that two of the active
members of the medical staff should be elected on the
committee, and_ at the general court a resolution to that
•effect was carried by a majority of five votes. A poll
was demanded, and it was found that 2879 voted against
the proposal and 1040 for it, leaving a majority against
it of 1839 votes. Acting on the advice and with the
concurrence of his Royal Highness the Duke of Cam¬
bridge, President of the Hospital, the committee h^
unanimously recommended “ that the senior hon. physician
and senior hon. surgeon of the hospital” should bo added to
•tlie number. This was moved by Mr. Arthur J. Allen. He
jegretted that Dr. Lichtenberg, who had been connected
with the hosnital for thirty-five years, and Dr. Tuchmann,
one of the oldest surgeons, had found it necessary to move
an amendment to this proposal. Dr. lAchtenberg’s object
•and theirs was to do what v/as best for the benefit of the
hospital, and he thought the matter should now rest. Mr.
James Hasslacber seconded the motion.
Dr. Lichtenberg moved as an amendment, “That
instead of the words ‘senior hon. physician and senior hon.
surgeon of the hospital,’ the words ‘ and likewise of a full
physician and full surgeon of the hospital (not ex-ojicio) to
be elected by rotation, according to seniority, every three
years. In moving the amendment, he did not object to
the senior surgeon and senior physician representing the
medical stafl on the committee pro (em.; but he ivas bound
to oppose a system by which the medical officers, once elected
to sit on the committee, -would remain there for the rest of
their official lives. He did not speak in his own interest,
hut in the interest of his successors. The present action
•would mean that the medical officers so elected would,
besides following their private professional avocation and
medical duties, be saddled for the next fifteen or twenty
years with attendance on the meetings of the committee
and board of management. They would have to be present at
about forty extra meetings a year. He was afraid the duties
•would be too heavy to permit of their conscientious fulfil¬
ment for a term of twenty years at a stretch. The
intended motion would soon become a dead letter. He
had lately had an interview with several high autho¬
rities in the medical profession, who had pronounced
against the action of the committee, but had spoken of
his amendment in favourable terms; and The Lancet,
in last week’s issue, objected strongly to the committee’s
resolution, whilst it was in full accord with the amend¬
ment now proposed. This mode of election would give
freshness and interest to the medical representation,
would be fair to the younger members of the staff, and
enable a larger number of the medical officers to become
acquainted with the actual work of the hospital. If the
committee’s proposal should now become law, he would
be obliged, in order not to commit an act of illegality, to
resign his position, a resolve which the committee had long
been made aware of. In October last seven members of
the staff requested the committee to allow them to be repre¬
sented on the committee, and, he proceeded: “ On Nov. 25th
we informed the committee that we could nob support
the proposal now before the meeting. Mr, Gulich in¬
formed us two days later that the committee bad decided
not to alter their opinion. We then proposed election
by rotation, but were again defeated, whereupon four
of our colleagues retracted their former letter and agreed
to abide by the original resolution of the committee.”
For himself he had not retracted his letter, and if the pro¬
posal should now become law, he as senior surgeon would
eo ipso become a member of the committee, hut as he
declined this honour he could not legally remain on the
hospital staff.
Dr, Tuchmann, in seconding the motion, stated that,
should the resolution be carried, he also would resign his
appointment immediately. Their colleagues, with one excep¬
tion, had condemned the resolution as highly distasteful, and
theyhoped that the resolution would be defeated. The com¬
mittee appeared to act like kings, giving as a favour what
belonged to the staff as a right. They seemed to forget
that the staff did as much useful work for the hospital as
did the committee. They were hon. physicians ; neverthe¬
less, they had not been shown much consideration or
kindness by the committee. He could not believe that the
committee were actuated by kind feelings in framing this
motion ; for what appeared to be a concession was simply a
delusion and a snare. He pointed out thabBaron von Schroder
at the last meeting had said: “We want the subscribers
assembled here not to accept the proposal, because the two
doctors ex officio would have to be elected for life, and you
could never remove them”; and when he was defeated beheld
a poll in order to exclude the medical men. Dr. Lichtenberg
in a few years would cease bo be senior surgeon, and conse¬
quently cease to be a member of the committee. On the other
hand, Dr. Port was likely to remain twenty years or so in
that capacity. He did not say a word against Dr. Port’s pro¬
fessional abilities, but in this political question he had
taken the part of the committee. He baa never assisted
the staff in the least.
The Chairman thought the matter could be discussed in
a friendly spirit.
Dr. Tuchmann ; You are speaking friendly, but you are
not acting so.
Dr. Hess, Mr. Pridham, and Mr. Sonnenberg supported
the amendment.
Mr. Gulich said he was in touch with the committee and
also with the hon. medical officers, and he saw no ground
upon which the committee should alter their views. If the
rule did not act suitably, it could be altered in three years
by the governors. The majority of the medical staff was in
favour of the resolution. He had five letters in his bond
bearing this out. He thought the wording of the amend¬
ment was somewhat ambiguous, and would only lead to
trouble if persisted in. He advised them to let the matter
drop, and not to give the public the opportunity of saying
that the German Hospital was in dispute year after year.
Dr. Hermann Weber supported the original motion, and
on a show of hands it was found that .58 voted for the
amendment and 103 against it. The motion of the com¬
mittee was therefore declared to be carried.
Dr. Lichtenberg announced that in consequence of the
vote his written resignation, as well as that of Dr. Tuch-
mann, would be in the hands of the secretary.
The Montgomkrykhiuk Infirmary.—T he relief
of much suffering and the good woik accomplished in this
institution during 1890 had been liighly satisfactory. The
annual subscription list had been substantially augmented,
and a qonsiderable reduction effected in items of ex¬
penditure.
Thb Lancet,]
1
REPORTS OF MEDICAL OFFICERS OF HEALTH.
IFeb. 7,1891. 335
VIRCHOW TESTIMONIAL FUND.
A MEETING of the' committee of the above-named Fund
was held on Friday, Jan. 30th, at Sir Andrew Clark’s bouse,
in the unavoidable absence of whom the chair was taken
by Sir James Paget. After the report of the preliminary
proceedings and letters expressing regret from members at
their inability to attend had been read 1^ the honorary
secretaries, it was unanimously agreed that Sir James Paget
be asked to take the chairmanship of the Fund, and subse¬
quently Dr. Lauder Brunton was elected honorary treasurer,
and the secretaries were confirmed in their olhce. The sub¬
joined application to the profession was then considered,
and ordered to be issued :—
On Oct. 13th, 1891, I'rofesaor Rudolph Virchow celebrates his
seventieth birthday. Uis pupils and admirers intend to commemorate
this occasion by presenting bun with a testimonial in recognition of
• his splendid services to medical science. A largo and representative
committee has already been formed in Germany with the view of
collecting the necessary contributions, but it has been felt that this
ought essentially to be an international movement, inasmuch as
Professor Virchow’s followers are not of one nation, but of all.
In acftordanco with this view, tlio undoi-signod have formed them¬
selves into a committee, in order to give Professor Virchow’s
British admirers the opportunity of testifying to tlie gratitude
which every member of tho profession feels towards the man
whoso work in “Cellular Pathology" has so vastly contributed
towards the lulvanco of modern medical science, and may fairly be
said to have made every member of the profession his pupil, Tlie form
in which tho universal feeling of gratitude is to find expression has
been decided upon by tho original Gorman Committee. A. large gold
g ortrait medal is to bo presented to Professor Virchow himself, and
ronr.o replicas of tlie same to members of his family and to some
scientific iuscitiitions. Tho surplus, which no doubt will bo large, is to bo
handed over to I’rofessor Virchow for tlie furtherance, subject to his
decision, of .‘Kuontifle work. To carry out this project tlie under¬
signed cordially invito the cooperation of the profession in tho United
Kingdom. Subscriptions, which aro not to exceed two guiiioas, may
be sent to the hon. treivsuror, Dr. Lauder Brunton, 10, Stratford placo,
London, W., and will bo duly acknowledged in tho medical journals.
Clioque.s to bo made payable to the Virchow Testimonial Fiiiid, and to
be crossed. (Signed.)
Jamics I’ACiET, Chairman.
ijAUDiCR Brunton, lion, Troasuror.
Fruax .Shmon,
Victor Horsi.
,u.,}
Hon. Secs.
Cordrihutions received at the meelitig of the Committee.
& s.
d.
£, 3.
d.
Sir James Paxot, Bart. ..
a
2
0
J.Riissioll Reynolds, M.U.,
.Sir Richard Oiia'n. Barb.
•i
2
1)
P.R.S.
2
2
0
Sir JoH. Fayi-or, IC.C.S.I.
2
o
0
lloriiiann Wobev, M.l).,
Clifford Allbutt, M.D..
l>’.R.O.P.
2
2
0
b'.R.S.
2
2
0
T. Lauder Brunton, M.D.,
Sidney Coupland, M.D.,
F.U S.
2
2
0
F.R.C.P.
0
II. T. Butlin, F.R.C.S. .,
1
0
Wm. Ord, M.D,, F.R.C.P.
2
2
0
Victor Horsley, F.R.S. ..
2
2
0
Seymour Sharkey, M.D.,
Felix Seinon, M.D.,
P.RC.P.
0
1>',R.C.P.
2
2
0
K W. Pavy, M.D., F.R.S.
2
2
0
•fan. 30th, 1801.
YORKSHIRE VETERINARY MEDICAL
ASSOCIATION.
At tho annual mooting of the above Association, held at
Leeds on the 3l8t ult., Dr. McFadyean of Edinburgh gave
a lecture on the Minute Anatomy of Tuberculosis and
Actinomycosis,—diseases common to man and the lower
animals, and liable to be communicated from one to the
other. After describing the tubercle bacillus and its effects,
he said that it was difficult to explain why the horse seldom
contracted pulmonary tuberculosis, a disease so common in
man and cattle. As regards actinomycosis, he said that it
had been believed to oe caused by animals feeding upon
barley, and he thought this might have something to do
with the liability to contract and develop the disease.
Some reference was made in the remarks of speakers follow¬
ing tho lecture to J)r. Koch’s treatment of tuberculosis,
hut Dr. McFadyean said it was to veterinary surgeons a'
matter of little interest whether Koch’s fluid was curative
or not. The r6lc of the veterinary surgeon was to endeavour
to prevent tuberculosis rather than cure it, though he did
not believe there was one in a thousand cases of consump¬
tion caused by infection from the lower animals. A dis¬
cussion was raised as to whether the flesh of cows suffering
from milk fever was lit for food or not, in tlie course of
which Dr. Cameron pointed out that the term as used by
cowkeepers embraced more than one disease, including
puerperal apoplexy. The flesh of animals dying from that
disease was certainly unlit for consumption. I’he discus¬
sion was eventually adjourned.
|nWit irnlr fato.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF MEDICAL OFFICERS OP HEALTH.
Sheffield Urban District. —Dr. Theodore Thomson gives-
the pleasing news that never before have the public of this
county borough exhibited so much interest in sanitary work.
The labours of his department have been correspondingly
increased, and he points out that this will involve some
addition to his staff. The general death-rate for the district,
with its population of some 327,000 inhabitants, would not-
be regarded as very excessive at 20’8, but the corrected rat©
raises it to 22'4, and this, with a zymotic rate of 3'39, indi¬
cates room for much improvement. Amongst the diseases-
included in the latter group, diphtheria shows distinct evi¬
dence of increase, and some typhus fever has occurred. The
cause of this fever in Shefiield is involved in some obscurity,
and Dr. Thomson discusses the possibility of a de novo-
origin in this connexion. The midden-privy system as car-
riea out in Sheffield is strongly condemned, and it is evident
that a complete change of administration in this respect is
very urgently called for, trough closets being probably the
beat available remedy. Details of sanitary work include
reference to disinfection, inspection of dairies, &o,, slaughter¬
houses, and canal boats, and finally the question of an in--
sufficient staff for the maintenance of a proper standard of
health is referred to. Dealing especially with inspectors of
nuisances, Dr. Thomson points out that in Sheffield there i&
only one for every 25,187 inhabitants and every 1511 acres.
This is so obvious an absurdity, if any real attempt to pro¬
mote and maintain a standard of public health is desired,
that we feel certain it only needs to be brought forward in-
order to ensure an immediate increase of staff.
Birkenhead Urban District. —The annual death-rate for
this district during 1889 was 17'8 per 1000, and the-
zymotic rate 2'6. The notified diseases numbered 1491,
and only one case became known for the first time after re¬
gistration of the death, as opposed to 18 in 1887 and 7 in-
1888. These numbers, says Mr. Vacher, may be taken as
representing proximately the extent of failure of notifica¬
tion ; a result which can hardly be complained of. Amongst
the sanitary operations carried on during the year it is ex¬
plained, as regards overcrowding and cellar occupation, that-
the absence of a regular night inspector seriously interferes-
with this branch of the work ; a complaint which, if we re¬
member rightly, is not made from Birkenhead for the first
time in this report. A good deal of attention is evidently
given to the regulation of dairies, cowsheds, &c., and special
care is taken that the ventilation, lighting, cleansing, drain¬
ing, and water-supply of these premises are efficient. In one
instance a case of typhoid fever was removed from a rogis-
tend milk-house, tlie licence being suspended during the
disinfection and cleansing of the premises. Tho infectious
hospital now contains thirty-eight beds. But the institution-
is utterly iuadequate to the requirements of the borough,
and was never intended to be more than a makeshift.
During 1889 only eighteen patients were admitted ; but to
know that no single death occurred throughout the year
amongst the number who were received into the institution
should certainly encourage the Corporation to provide and
equip a suitable hospital.
‘Derlishire Combined Sanitary Districts. —This combina¬
tion includes twelve sanitary areas, with an aggregate,
population of 145,655 ; and during 1889 there was a death-
rate of 13'9 per 1000 on the total area, Maidenhead Urban
District standing at one extreme with a rate of only 10'9,,
and Abingdon Urban District at the other with one of 17'S.
Generally speaking, the rates are lower than any recorded-
before, and the fall in Maidenhead is so striking as to-
make one fear that it is also exceptional. Each district is
dealt with separately by Dr. Woodforde, who explains in
much detail the several occurrences of preventable disease.
In dealing with the Windsor rural district a gooddeal of
attention is given to tho subject of diphtheria, of which
disease fifty-two coses in forty-six families came under
notice, twenty occurring in the neighbourhood of Englefield
Green. In one instance special precautions as to disinfec¬
tion were resorted to—bedding, carpeting, toys, &c., all
being burnt, with tho exception of a picture-book, which
was saved and put away after fumigation. Three month©-
afterwards it was taken out again, and given to a child of
DiC:iTZ5d
336 Thb Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
two years of age to play with. Five days afterwards this
child, who had not been away from her home or otherwise
exposed to infection, was attacked by diphtheria.
St. Pancras —Daring 1889 the death-rate for St. Pancras
■district was 18'16 per 1000, and this is the lowest recorded
eince 1856: the zymotic rate was 2 04. In a number of
instances Dr. Sykes is able to state that there has been
diminution in the amount of death from the principal
vsymotic diseases ; but this is not the case as regards diph¬
theria, which shows a tendency to increase here as well as
in so many other large urban communities. A good deal of
disinfection is now carried out, and a new high-pressure
steam chamber has been provided by Messrs. Goddard and
Massey of Nottingham. House-to-house inspections are
still maintained, but of this most important branch of the
public health department it is stated that It is diminishing
on account of increased work in the department. This,
we assume, is the official method of telling the ratepayers
that the increase in question has not been met by a corre¬
sponding increase of staff, and that there is danger that the
work which, of all others, tends to the good of individual
householders is in consequence gradually being neglected.
A considerable amount of work has been done in connexion
with the dwellings of the poor, with a view to their amend¬
ment or their demolition. Attention has been devoted to
the ventilation and flushing of sewers, to slaughter-houses,
milk-sbops, &c,, and in a not inconsiderable number of
cases successful proceedings were taken under the Sale of
Food and Drugs Act. _
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6215 births
and 4284 deaths were registered during the week ending
Jan. 3Isb. The annual rate of mortality in these towns,
which bad declined from 287 to 25 1 per 1000 in the pre¬
ceding four weeks, further fell to 22 3 last week. The
rate was 227 in London and 22'5 in the twenty-seven pro¬
vincial towns. During the past four weeks of the
current quarter the death-rate in the twenty-eight towns
averaged 257 per lOOO, and exceeded by 21 the mean rate
in the corresponding periods of the ten years 1881-90.
The lowest rates in these towns last week were 13 2
in Nottingham, 13'6 in Derby, 161 in Hull, and 18‘0 in
Portsmonth; the highest rates were 27 0 in Salford,
f27'9 in Manchester, 29’5 in Halifax, and 32‘9 in Preston.
The deaths referred to the principal zymotic diseases, which
had been 404 in each of the preceding two weeks, de¬
clined to 379 last week; they included 113 from whoop¬
ing-cough, 93 from measles, 46 from scarlet fever, 45 from
diphtheria, 43 from diarrhoea, 40 from “fever” (princi¬
pally enteric), and not one from small-pox. The lowest
•death-rates from these diseases were recorded in Plymouth,
Wolverhampton, Brighton, and Portsmouth ; the highest
in Salford, Manchester, Bristol, and Preston. The greatest
mortality from measles occurred in Birkenhead, Man¬
chester, Bristol, Oldham, and Preston ; froip scarlet fever
in Preston; from whooping-cough in Birmingham, Salford,
and Huddersfield; and from “fever” in BirkenheaA The
45 deaths from diphtheria included 25 in London, 5 in
Salford, 3 in Manchester, 2 in Preston, and 2 in
Birmingham. No death from small-pox was regis¬
tered in any of the twenty-eight towns, and no
small-pox patients were under treatment eitlier in the
Metropolitan Asylum Hospitals or in the Highgate
Small-pox Hospital on Saturday last. The number of
scarlet fever patients in the Metropolitan Asylum
Hospitals and in the London Fever Hospital at the
end of the week was 1387, and showed a further decline
from recent weekly numbers; the patients admitted during
the week were 112, against 112 and 103 in the preceding
two weeks. The deaths referred to diseases of the re¬
spiratory organs in London, which had been 1018 and 84.5
in the previous two weeks, further declined last week to
€36, but exceeded the corrected average by 71. The causes
of 78, or 1'8 per cent., of the deaths in the twenty-eight
towns were not certified either by a registered medical
practitioner or by a coroner. All the causes of death were
duly certified in Brighton, Portsmouth, Sunderland, Cardiff,
and in three other smaller towns. The largest pro-
g ortions of uncertified deaths were recorded in Preston,
[alifax, Salford, and Hull.
[Feb. 7, ISftl'.'’
HEALTH OP SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had declined from 28'8 to 24‘9 per lOOO in the pre¬
ceding three weeks, rose again to 26*4 during the week
ending Jan. Slat, and exceeded by 47 the rate that pre¬
vailed daring the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns
ranged from 10'3 in Greenock and 16’5 in Aberdeen to
297 in Paisley and 35'3 in Glasgow. The 690 deaths in
these eight towns showed an increase of 39 upon the number
in the preceding week, and included 29 which were referred
to whooping-cough, 10 to scarlet fever, 8 to measles, 7 to
diphtheria, 7 to diarrhoea, 4 to “fever,” and not one to
small-pox. In all, 65 deaths resulted from these prin¬
cipal zymotic diseases, against 53 and 76 in the pre¬
ceding two weeks. These 65 deaths were equal to
an annual rate of 2‘6 per 1000, which exceeded by 0'5
the mean rate last week from the same diseases in
the twenty-eight English towns. The fatal cases of
whooping-cou^, which had been 16 and 27 in the pre¬
ceding two weeks, further rose last week to 29. of which
22 occurred in Glasgow and 4 in Edinburgh. The deaths
referx'ed to scarlet fever, which had been 7 and 18 in the
previous two weeks, declined to 10 last week, and included
6 in Glasgow, 2 in Aberdeen, and 2 in Edinburgh. The
8 fatal cases of measles exceeded by 1 the number in the
preceding week, and included 6 in Glasgow. The 7 deaths
from diphtheria were within 2 of the number recorded in the
previous week; 2 occurred in Greenock and 2 in Paisley.
Of the 4 fatal cases of “fever,” 2 occurred in Glasgow.
The deaths referred to diseases of the respiratory organs
in these towns, which had been 228 and 210 in the preceding
two weeks, further declined last week to 207, but exceeded
by 20 the number in the corresponding week of last year.
The causes of 68, or more than 8 per cent., of the deatlis in
the eight towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate In Dublin, which had increased in the
preceding three weeks from 36‘0 to 38-4 per 1000, declined
again to 32-6 during the week ending Jan. Slst. During the
first four weeks of the current quarter the death-rate in
the city averaged 3G‘0 per 1000, the rate during the
same period being 26 o in London and 21 3 in Edin¬
burgh. The 221 deaths in Dublin showed a decline of 39
from the number in the preceding week, and included
4 which were referred to different forms of “fever,” 1 to
measles, 1 to diphtheria, and not one either to small-pox,
scarlet fever, whooping-cough, or diarrhoea. Thus the
deaths from the principal zymotic diseases, which had
declined from 15 to 8 in the preceding three weeks, further fell
last week to 6; they were equal to an annual rate of
0*9 per 1000, the rate from the same diseases being
1 -8 in London and 1 ‘9 in Edinburgh. The deaths referred
to different forms of “ fever,” which had been 4 and 5 in
the preceding two weeks, declined again to 4 last
week. The 221 deaths in the city included 40 of infants
under one year of age and 65 of persons aged upwards of
sixty years; the deaths of infants corresponded with the
number recorded in the preceding weeks, while those of
elderly persons showed a considerable decline from the
high numbers in recent weeks. Seven inquest cases and 5
deaths from violence were registered ; and 05, or nearly
a third, of the deaths occurred in public institutions. The
causes of 24, or nearly 11 per cent., of the deaths in the
city were not certified. __
THE SERVICES.
Deputy Surgeon-General Alexander Allan, M.D., who
served with the Soudan expedition at Suakin in 3 885, has
been appointed to the post of Principal Medical Officer in
Scotland, in place of Deputy Surgeon-General Irwin.
Army Medical Staff. —Surgeon-Major John Joseph
Crean retires upon retired pay (dated Feb. 4th, 1891).
Milttia Medical Staff.— Surgeon-Major W. S. Love,
4th Battalion, the lioyal Inniskilling Fusiliers, resigns
his commission; also is permitted to retain his rank, and
to wear the prescribed uniform on his retirement (dated
Feb. 4bh, 1891).
Naval Medical Service, — The Admiralty has, we
THB Lancet,] TREATMENT OF DISEASE OF THE UTERINfe APPENDAGES. [Feb. 7,1891. 337’
understand, finally taken over the Naval Hospital at
Gibraltar, which has for seventy-five years been occu¬
pied by the military authorities.—Staff Surgeon Herbert
Mackay Ellis has been promoted to the rank of Fleet Sur¬
geon in Her Majesty’s Fleet (dated Jan. 26bh, 1891).—The
lollowlng appointment has been made at the Admiralty:—
StafiF Sxrrgeon William B. Bruce, to the ColUngwood (dated
Jan. 30bh, 1891).
Volunteer Corps.— Ist Surrey (South London):
John Hammerton Edwards, M.D., to be Acting Surgeon
<dated Feb. 4th, 1891).—16bh Middlesex (London Irish):
Surgeon H. R. H. Bigg resigns his commission (dated
Feb. 4th, 1891).—Acting Surgeon J. H. Griffin to be
Surgeon (dated Feb. 4bb, 1891).
CorrMpnktitb.
Audi alteram partem.
ON THE OPERATIVE TREATMENT OF DISEASE
OF THE UTERINE APPENDAGES.
To the Editors of The Lancet.
Sirs, —The recent discussions on the diseases of the
uterine appendages, at the Medical Society and elsewhere
have brought this subject prominently before the pro¬
fession. Affections of the uterine appendages are nothing
mew; they are comprised under tlie name pelvic peritonitis
or perimetritis, and since the writings of Bernutz m 1860-62
it has been well known, though not till lately current, that
I’ln a large number the route and sometimes the focus of
infection has been the tubes. A change in nomenclature
has arisen, for words ending in “salpinx” have .displaced
the older and more general names. Yet further changes
have arisen in practice in some quarters, *1 in that
these affections have become the objects of innumer¬
able operations. Now, perimetritis is probably the very
commonest of all the serious diseases of women. It
is also perfectly certain that the great majority of
cases get quite well without any operation. ■ We
are far from denying that exceptional cases call for
surgical procedures, or that cases of prolonged suppuration
in the pelvis are properly treated by the application to
them of ordinary surgical principles. But this wholesale
resort to a mutilating operation, advocated by several
speakers at these discussions, calls for serious consideration
by the profession. We have both been in charge for many
•years of the obstetric and gynecological departments of two
of the great general hospitals of London, besides private
practice. During that time thousands of patients have
.passed through our hands, and a very large number of cases
-of pelvic infiammation. We have on tue rarest possible
occasions resorted to removal of the appendages, and
never unless life seemed to be threatened, or the health
had been greatly impaired for many months. We never
have sent patients away after a course of Epsom salts, “and
•when this drug fails have folded our hands and expressed the
deepest sympathy with the sufferer.” On the contrary,
our patients nave generally got well by the use of patience
on their part and on ours. If, after a long course of patient
■treatment, it has seemed to us imperative to operate, we
have been ready to do so, and have done so in rare instances.
Without patience, many women who have had matting of
iUe pelvic organs for months, but •who have perfectly
recovered and have borne children, would have had their
iitovine appendages removed. Statistics on matters of this
land are often given in a manner ■which does not bring out
•important points. For instance, in the discussion at the
Medical Society it would have been interesting to know :
<1) the total number of women seen during the period em¬
braced by the table; (2) the total number of cases of pen-
metritis or pelvic inflammation among them. Sbatisti(i.s
without these facts may give information as to the chances
of the operation ; those indicated would give the chance of
being operated'upon.
A plea for patience is to be found in the declaration of
the operators that the full bcneflts of the operation are not
usually felt for months or years after. If the operator
would exercise this patience before the operation, there
might be the less need for its exercise by the patient after
the operation. To operate after a “couple of months” is
in our opinion quite nnjnstiflable in chronic cases, or in any
except tnose of peril to life. To remove the ovaries in cases
of congenital ill-developraent with • dysmenorrhcca and
sterility and anteflexion of the uterus is a proceeding we
have never seen necessary to recommend. Death from
disease of the appendages is of extreme rarity, but the mor¬
tality after the operation is considerable. It is incon¬
ceivable to us that this amount of operating is justifiable,
and we beg to protest in the strongest manner against
it. This particular operation has already furnished material
for legal proceedings in a well-known,case. It is conceiv¬
able that it might form the object of legislation. We can¬
not think that the good sense of the profession can fail to
be roused against it. The sooner the better. There are
several other questions requiring an answer, some of which
have been referred to by others. For instance, what were
the results in the unoperated cases ? What %re the dates of
the reported cases? What were the results in general sur¬
gery at the Waterloo-bridge-road Hospital during the time
of the unreported cases ? These are questions concerning
the authorities of that hospital. But we prefer to keep to
our point, and to repeat our protest against the remov^ of
the appendages whenever a tumour of them is found accom¬
panied by pain and haemorrhage; or a dilated tube; or affec¬
tions of tbe tubes, with tender or even enlarged ovaries,
after treatment has been tried for a couple of months; or
when a woman suffers from pelvic pain, dystuenorrhcca, or
dyspareunia, after one or more attacks of pelvic inflamma¬
tion j or in cases of ill-developed ovaries with anteflexion
and dyamenorrhcca; or in cases of cardiac dyspncca ; or of
tubercular disease of the tubes associated -with similar
disease of other organs; or in neurotic ■women ■vWthout
disease of tbe appendages. We protest against the view
that any one of the above conditions dia^gnosed before, or
discovered during or after an operation, is in itself a justi¬
fication for the removal of tbe uterine appendages, and such
practice is in our opinion highly injurious to wdmen and to
the profession. In no other department of surgery is in¬
fiammation of an organ considered to justify its removal.
We are. Sirs, your obedient servants,
John Williams,
F. H. ClIAMPNEVS.
To the Editors o/Thb Lancet.
Sms,—It is to be i-egretted that Mr. Meredith did not
attend either of the meetings of the Medical Society when
the above subject was under consideration, as then not
only would those present have had the benefit of his
opinions, but also be would have found it unnecessary to
occupy your valuable space with the first half of his letter,
which appears in the current number of The Lancet. I
explained that my thirty cases began from the time (end of
1888) when the obstetric physicians at the Middlesex
Hospital obtained the right to perform abdominal sections,
that prior to then I operated nine times, with one death
from septic peritonitis, and that since the last case in the
table I nave operated ten times, with two deaths, one from
hremorrhage due to slipping of the pedicle ligature, and tbe
other as a result of strangulation of a bit of omentum in the
wound after removal of the drainage-tube. Since the
meeting on Monday last there is another successful case to
be added, just completing fifty, with four deaths, three
being from accidents which I trust in future to be able to
prevent a recurrence of. When I reach my hundredth case
the whole shall be given with every possible detail. As,
however, I did not profess that the thirty cases in my paper
constituted my whole practice, I was perfectly justified in
putting them forward. If Mr. Meredith chooses to consider
them of nob much value, by all means let him do so,
others probably will estimate them differently. Coming
now to the second and more important part of Ms letter,
I would fain think he has not taken the trouble to read my
paper carefully, as I am unwilling to believe that he would
knowingly distort its contents. It is headed “ On Chronic
Disease of the Uterine Appendages," and in it I say: “It
is obviously unnecessary to touch upon large tumours
which rise up out of the pelvis . such, however, is not
tl-e case with diseases which give rise to small pelvic
tun. -uirs or to none at all, ifcc.” Now three of the cases in my
table, Nos. 6, G, and 17 (not two as stated by Mr. Meredith),
were d.^vian cysts each the size of cm. orange, and are so
described.^ Yet Mr. Meredith and one or two speakers at
^8
Die
338 The Lancet,]
“ FAILURE OR CURE ?”
[Feb 7,1891.
the last meetiag object to their being included. Surely
they are examples of chronic disease of the appendages,
and I defy even Mr. Meredith’s skill to have diagnosed
before operation whether they were distended tubes or
ovaries. Again, he says three of my cases were incomplete
operations (excluding Case 21, which was an exploratory
operation); this I assert is absolutely false, for (except
No. 21) all the others were perfectly complete—a complete
operation being, of course, one where all the diseased parts
are removed, but not necessarily the appendages on both
sides. I ask whether that is a fair and honest or a carping
criticism of my paper?
Mr. Meredith next goes on to compare the number of
cases operated on by me and those operated on at the
Samaritan Hospital respectively, and then tries to explain
the increased number under my care by the astounding
assertion that it is due to a “spirit of restless surgery now
so prevalent that, unless restrained, will bring into disrepute
an operation which when judiciously undertaken in properly
selected cases may prove a most valuable means of restora¬
tion to health,”—that is to. say, whilst the cases at the
Samaritan Hospital are properly selected mine are not.
Now, Sirs, in my paper I lay down seven propositions, two ^
of which read as follows : “ Sixthly, whenever on opening
the abdomen the operator finds the ovaries and tubes fixed |
by adhesions, he should break down the latter with his
fingers, and then, having brought the appendages into view,
carefully examine them for any well-marked visible or tan¬
gible signs of disease. If no marked departure from the
normal be made out, then it is the operator’s bounden duty
to stay his hand from removing the appendages. Seventhly,
inasmuch as there is usually au absence of disease of the
appendages in cases of ovarian neuralgia occurring in neu¬
rotic subjects, any local interference is not only unnecessary
but absolutely unjustifiable.” It must therefore be evident
to any unbiased person who reads the foregoing remarks
and those given in the table of cases, that not only am I
strongly opposed to the removal of the appendages unless
thereto well marked disease, but also that in my cases they
were matted down by adhesions, so that in moat of the
operations their removal was eft'ected with much difficulty.
Under these circumstances I cannot but feel that Mr.
Meredith’s remark is not only uncalled for, hut is also totally
unjustifiable. I gladly plead guilty to a “spirit of restless
surgery” which will not permit me to condemn women to years
of misery when I know I can cure them by operation after
other means have proved useless. It will interest your
readers to know that, with a view of safeguarding ourselves
and our patients, my colleagues and I a year or two ago
passed a rule (brought forward by myself) which ensures
that in all cases operated upon for chronic disease of the
appendages the parts removed are carefully examined by a
subcommittee of three, and their report is read to the
medical committee. Some such rule should be in existence
at all hospitals. I wonder if tliere is anything of the kind
at the Samaritan. Knowing the strenuous opposition met
with by Sir Spencer Wells when endeavouring to establish
ovariotomy as a proper procedure, I have hope that with
increasing experience in cases of chronic disease of the
uterine appendages even Mr. Meredith may become a
supporter of operating upon them. It will afford me much
pleasure to show him, at either of the hospitals to which I
am attached, how these cases are being constantly met with
and diagnosed, how the diagnosis is subsequently verified
by abdominal section, and how the patients are cured
thereby. Apologising for the length of this letter,
I am, Sirs, faithfully yours,
Harley-street, W., Jan. 31st, 1891. WILLIAM DUNCAN.
To the Editors of The Lancet.
Sirs,—T he first part of the letter addressed to you by
my friend Mr. Meredith concerns Dr. W. Duncan indi¬
vidually rather than the operation he was advocating, so
that I may leave Dr. Duncan himself to deal with it. But
about the second part I .should like to be allowed to say
a word or two. It quite bristles with fallacies. The argu¬
ment is that because the proportion of cases of diseased
uterine appendages forms (in a given year) only 10 per cent,
of the whole number of abdominal operations performed aj
the Samaritan Hospital, therefore either the operator who
exceeds that proportion removes the appendages too fre-
q^uently, or the staff of the Samaritan Hospital doesnof- ^move
tnem often enough. In the first place, wo do not know what
the proportion is in Dr. W, Duncan’s practice, for his paper
took no account of cases in which there was a tumour
rising above the pelvic brim. But even supposing it had
been made out that his proportion considerably exceeded
that of the Samaritan Hospital, no such inference, as.
Mr. Meredith suggests, could reasonably be drawn. The
reputation of the Samaritan Hospital is based upon that of
the great ovariptomists who have been or are connected
with it, so that abdominal tumours constitute, and will
long continue to do so, an overwhelming proportion of the.
cases seeking admUsion. This is not the case in the
gynecological department of a general hospital. There
cases of pelvic inflammation, due to or complicated by
Fallopian tube disease, are admitted in at least equal pro-
portion with cases of ovarian tumour. The work in the
one place cannot therefore be fairly compared with the
work in the other. Again, application for admission into o,
special hospital generally means that the case has been
already diagnosed. Now, abdt)minal tumours, if nob
always easy of diagnosis, are, at any rate, easy of
recognicion, so that we have here an additional explana¬
tion of the frequency with which these oases are senb
to special hospitals, as compared with cases of diseased
Fallopian tubes &c., which are difficult of recognition and;
diagnosis, are very rarely discovered before admission.
My cases of diseased Fallopian tubes at St. Thomas’s
Hospital have, for the most part, been discovered either
in the out-patient room or amongst in-patients admitted in
the ordinary routine.
In the last sentence of Mr. Meredith’s letter there is a-
dictum against which, as applied to the operation under
discussion, I feel bound to protest. He ascribed the large
number of cases reported by Dr. W. Duncan to the
“spirit of restless surgery now so prevalent.” This-
utterance breathes more of the spirit of the Pharisee than,
of that of the amiable Samaritan. It comes, too, some¬
what incongruously from a disciple and successor of Sir
Spencer Wells, the story of whose life-work ought to have^
taught an impressive lesson to all who are disposed to carp
and cavil at operators a little more progre.9sive than them ¬
selves. I am. Sirs, yours faithfully,
Brook-street, W., Feb. Gth, 1801. ChAS. J. CuLLINOWORTII.
“FAILURE OR CURE?”
To the Editors of The Lancet.
Sirs,—I f Sir Spencer Wells would confine his criticisms
of those with whom he does not agree to open-air state¬
ments, such as are contained in his letter in your columns
of to-day, they would be easily met. As they stand, they
consist of a series of mutilations (of Dr. Ross’s pamphlet
and of my own statements), and of a series of assertions
based on the inaccurate memory of the patient, most of
them being wholly irrelevant to the issue. Her conclusion
that her case is a “decided failure” will be altered by th&
lapse of time, and the removal of the haimatocele which
she now suffers from. She had one last May; I tapped it,
and she was “ all right” for five months. Such hcematoceles
inteiTupt the convalescence of such cases—eveiybody knows,
that wno has had any experience of them, except Sir
Spencer Wells. That the patient will recover and be an.
absolute cure in course of time is a conclusion that I am
quite certain about; I can demonstrate the probability by
many parallel cases. But it will serve no good purpose for
your columns to be filled by reiterated assertions and contra¬
dictions between Sir Spencer Wells and myself. I have a-
mass of letters, telegrams, and notes about the case which
may or may not esteHilish Sir Spencer Wells’ statements. I
fear they will not. I fear his habit of keeping notes is not
extensive, and I know his memory is not good. Recognising
the importance of the discrepancies between his statements
and mine, the Gynecological Society has appointed a-
conipaittee of investigation at the instance of the ex-
Preaident, who for many years has been a colleague of Sir
Spencer Wells, and who certainly is no partisan of mine.
I took no part in the eelection of the committee, and Sir
Spencer Wells can therefore have no possible objection to
submitting his statement of the case and his. proofs to this
committee. This I now challenge him to do, as I shall do
mine. If I have made a mistake in it or misrepresented
any point on which the evidence is against me, I must
make an apology to the Gynecological Society and_ to Sir
Spencer Wells. lie, in his turn, will surely nob discredit.
The Lancet,]
DEA.TH DURING CHLOROFORM ANAESTHESIA.
tFEB, 7, 1891. 339
the dignified class to which he has been elected by refusing
to do as much.
Meantime let me point out that Sir Spencer Wells has
mot made the slightest attempt to justify the conclusions
he indicates that this was a case of neurotic ailment, and not
one of incurable pyo-salpinx. Even if his own estimate were
correct,if the case were a mere neurotic, whydid he amputate
the cervix in 1879? If the poor woman was suffering then
from suppuration of the Fallopian tubes, and 1 think the
■evidence m my possession will prove that she was, a more
unjustifiable operation, a more “ deplorable and disastrous
failure,” a more “ discreditable ” result (to use Sir Spencer
Wells’ own words) cannot well be imagined.
In any case, Sir Spencer Wells, and he alone, was answer-
able for the operation which I performed in 1888, and this
is proved by a series of telegrams which I have carefully pre¬
served and which Sir Spencer Wells has apparently forgotten.
To refresh his memory I publish the last of them : “ Mrs.
M. is very ill, and in ray opinion the case is urgent. Wells
has been communicated with and declines to advise. We
have decided to operate this afternoon unless you come, in
which case it shall be deferred till your arrival.” If an
operation in this case was unnecessary iu Sir Spencer Wells’
opinion, why did he not intervene to stop it, as he could
have done, and as, if his statements are accurate, he ought
to have done. I am quite prepared to submit evidence
which will show conclusively that if any discreditable
blunder has been committed the responsibility of the same
is to be awarded to Sir Spencer Wells. At the same time
I am satisfied that the right thing was done and that time
•will amply justify this conclusion.
I am. Sirs, yours truly,
Birmingham, Jan. 31st, 1891. LawSON TAIT.
“ FXJCHSINE BODIES ” IN TUBERCULOSIS OF
LUNG.
To the, Editors o/The Lancet.
Sirs, —Whatever may be the significance of Dr. Russell’s
fuchsine bodies in cancer, there can be no doubt that similar
bodies occur in genuine tuberculosis of lung. During the
Christmas vacation I was trying a method of staining sec¬
tions of phthisical lung tissue which had been embedded in
.paraffin by a process which I need not here detail. Suffice it
to say that I used fuchsine, to which a little carbolic acid
ihad been added, as the primary stain, and methyl blue as
the second, or contrast stain, when, to my surprise, I found
in some of the cells which had been detached from the walls
■of the alveoli a red spot (more rarely two or three such spots)
which occupied the centre of a clear transparent area on one
side, but outside of this clear hyaline-looking area was seen
•the nucleus of the cell stained of a faint blue colour. I com-
■paredthese spots with some of Dr. Russell’s figures,' and could
not detect any difference except that the fuchsine bodies in
my section were not so deeply stained. I thereupon cut a few
more sections from the paraffin block (r^irnan. in thickness),
and, having fixed each section to a cover glass with
Schiillibaum’s fixative, I heated and dissolved away the
paraffin in toluol (turpentine, benzol, or xylol wilt do quite
as well) in the usual manner. I then proceeded to stain with
Neelsen’s fuchsine—which only differs from Dr. Russell’s
fuchsine in containing more carbolic acid (5 per cent, fhis a
little alcohol)—just as one does with a dried film of sputum
■on a cover glass. Of course I did not pass the lung tissue
through the Ilarae, nor did I at any stage use any acid
'^iecolourising agent, but simply, after the removal of the
paraffin with toluol, place the cover glasses first into absolute
alcohol for a few seconds and then into hot Neelsen for about
ten minutes ; after this I washed the cover glasses in water,
placed them again in absolute alcohol from one-half to three-
quarters of a minute, and then into a solution of iodine green,
to which I added a little carbolic acid, according to
Dr. Russell’s directions, with this exception, that I did not
•actually weigh out the iodine green and carbolic acid after
•staining with the latter mixture for a little over five minutes.
T proceeded very much in the same way that Dr. Russell has
recommended, and mounted in xylol balsam. On examining
some of my sections I foirnd the following appearances
1. Most of the nuclei of the cells were of a dark colour,
looking more blue than green in ordinary gas light. 2. In
•addition, a few of the cells contained bright-red fuchsine
' Brit. Med. Jour., Doc. 13bh,1890.
bodies, as a rule a fuchsine body to a cell, the fuchsixie body
being surrounded by a clear transparent area, and what
appeared to be the nucleus of the cell was pushed away to
one side of it. 3. Portions of the M'alls of bloodvessels pre¬
sented here and there a sim-ilar red colouration. 4. And last,
but not least, there were seen large numbers of tubercle
bacilli, diagnosed easily enough by their slender forms and
characteristic arrangement.
I am, Sirs, yours faithfully.
Geo Carrington Purvis, M D., B.So.
Edinburgh, Jan. 22nd, 1891.
DEATH DURING CHLOROFORM ANaESTHESIA.
To the Editors o/The LANCET.
Sirs,— As deaths from ausosthetics are always of some
interest, the following case may be worthy of record. On
Dec. 7th, after consultation with Dr. Berry and Mr. Watson
of Queenstown, Dr. Murray made an exploratory incision
over the right hypochondrium of a lad aged seventeen years.
Chloroform was administered by Mr. Watson on a small
wire and lint mask, and was measured by drop bottle.
The total quantity used from first to last was six drachms.
Soon after the administration wasT begun there was a
marked diminution in the number of pulse beats. Gradually,
however, the pulse became stronger, and his breathing
regular. In about twenty minutes the patient’s face
suddenly became pallid, the pulse stopped at the wrist, and
the breathing became irregular and gasping. Respiration
continued spasmodically for fully a minute, and then ceased
entirely. Artificial respiration by Silvester’s method was
immediately begun, and continued for over half an hour.
Ether hypodermically, iuhalation of nitrite of amyl, and
electricity were tried, but without success. Death seemed
to have been instantaneous from refiex paralysis of the
heart. His heart had been auscultated previously by
several medical men, and by the anicsthetist prior to the
administration, and nothing abnormal had been detected.
For six months the lad had suffered from attacks of colic
of uncertain origin, for which morphia had been used hypo¬
dermically and in increasing doses. No necropsy was
allowed. We are, Sira, yours faithfully,
John K. Murray.
Wm. B Berry.
Whibtleaea, Cape Colony, Jan. 8tb, 1891. L. WatSON.
THE ROYAL COMMISSION ON VACCINATION.
To the Editors of The Lancet.
Sirs, —In your zeal for vaccination you have allowed
yourselves to state some curious things, when speaking of
my evidence before the Royal Commission, in your issue of
Jan. 24th. For instance, for the history of the last century,
statistically, as regards small pox, I used Dr. Guy’s paper.
And you must know that he was not an authority to treat
as “untrustworthy.” Yet you say, so I read it, that»these
statistics of Dr. Guy are “ untrustworthy.” Your words are:
“He [Mr. Wheeler] occupied several hours with inferences
drawn from statistics of a past century and of distant coun¬
tries, the former of which, at least, have been shown to be
untrustworthy.” Then you say that I forgot to name the
beat authorities who are agreed that in epidemic years
small-pox is not diminished by vaccination or greatly
affected by it. On page 62 of the third report you will find
that there are names given ; one only I will quote here—
viz, the authority that I have already named, Dr. Guy,
said that in epidemic years the barrier of vaccination was
broken down, and the more and the less susceptible fell
victims to the small-pox. Your own columns, after the
great epidemic of 1871-2, were used to enforce the suscepti¬
bility of the vaccinated to the disease in epidemic years. My
endeavour was to be clear in the statement of my claims
and arguments, and I may have totally failed to be
so, it is true; but when I &ad specially summarised my
claims, it is a little hard, do you not think, that this
summai'y should be entirely set aside by you for a statement
of my case that is at what seems to me total variance witii
all the tenour of my evidence ? Your six points—which,
without “ violence,” you say may present my thesis—are
opposed to it. Thus you say in No. 6 that human inter¬
ference with small pox has been made by vaccination. It
must be perfectly clear to anyone who has done me the
honour to read my evidence that that is a proposition that
D
Google
340 The Lancet,]
VACCINATION IN SKIN DISEASE.
[Feb. 7, 1891.
1 did not permit to be put into my mouth, and combated
all through.
If you ■will allow me, I will again state my conclusions
here. They are; “I have found no reason for crediting
vaccination with the lessening of the incidence of small-pox
in the last 200 years. I believe it to be due, as I have
endeavoured to show, to other causes. Nor do I find that,
given the conditions suitable to its development, vaccination
exerts any influence in proven ting the extension of sirrall-pox
in modern communities, while I claim to have shown tuat
the fatality is practically unaltered during the last
200 years. The great bulk of our hospital small-pox I have
shown to be in vaccinated persons, and those persons I have
shown to be bearers of every kind and degree of vaccination.
1 have shown that even good marks offer no protection
from death by small-pox in its most loathsome and
dreadful forms. That the marks classification is neither
scientific nor true to the theory it is founded on. That the
classification by marks sets aside entirely the legal vaccina¬
tion imposed by law; and substitutes as the only valid vac¬
cination something quite diflerent, and only discriminated
in a fever hospital, where it is to be tried and tested. That
the unvaccinated are, in the confluent cases, often erro¬
neously classed, and I have given grounds for thinking that
this is done in thousands of instances. I have shown that
the classification by eruption is still the only scientific clas¬
sification of small-pox, and that the vaccinated appear in
every shade of severity in this classification, and follow the
usual expectation of the disease. It stands broadly confessed
in official literature, and in evidence officially given Irere,
that the youth and adult population who are vaccinated are
severely attacked by small-pox. That the small-pox follows
them further into life than the unvaccinated. I have shown
that the saving of the small-pox among the very young lives
in recent years is not due, as claimed, to their vaccination,
but to the reduced birth-rate of children, lessening the
infant mortality of which small-pox is one item. I have
shown that the Public Health Acts are doing better work
against disease in other forms than sinall-pox, the small¬
pox offering no superior instance of this. And I therefore
conclude that the Vaccination Acts are & great legislative
error and have been as unnecessary as they have been
oppressive and cruel. I am convinced that it is the bounden
duty of the State to repeal them entirely, and leave vaccina¬
tion to private option alone.” Permit me to say, in con¬
clusion, that it is a great sorrow to me that Mr. Bradlaugh
will nob have a part in the- further deliberations of the
Commission.
I am, Sirs, yours truly,
Darlington, Jan. 31sfc, 1891. ALEX. WIIEELER.
*,* We have nowhere implied that Dr. Guy’s statistics
were untrustworthy, bub we have stated that Mr. Wheeler’s
“inferences ” were so. As to the past century records, if
Mr. Wheeler will look at the index to the third report of the
Commission, he will find many entries under “As to trust¬
worthiness of the London Bills of Mortality,” &c., and if he
will also refer to his own cross-examination of March 19bh,
1890, he will see Iiow largely our view is shared by the Com¬
missioners. Even when Lord Herschell drew the “ general
conclusion that you cannot arrive at any accurate estimate of
the (then) population of London ” Mr. Wheeler had to answer,
“I cannot argue it,” This persistent recurrence to ancient
records for the purposes of 1890 “inferences ” is more than
significant. Then again. Dr. Guy does not state that which
Mr. Wheeler asserts above. Not only is his whole conten¬
tion in favour of vaccination, but even the quotation
referred to only goes to the effect that in certain epidemic
years, such as 1871, vaccination (which was then almost
exclusively a single primary one) did not “act as a sufficient
protection.” Mr. Wheeler does not finish the sentence
referred to, neither does he give Dr. Guy’s opinion, expressed
in the same connexion, that there is nothing even ia the
statistics of that epidemic “which ought to shake onr con¬
fidence in the preventive efficacy of vaccination.” On other
points Mr. Wheeler announces that he has “ shown” certain
things. We admit the attempt; but whether he has suc¬
ceeded or failed we are content to leave to the judgment
of the Commission.—E d, L.
VACCINATION IN SKIN DISEASE.
To the Editors o/The Lanoet.
Sirs,—A s an old subscriber to your valuable journal I
wish to call your attention to a paper of mine on Vaccina¬
tion in Skin Disease which appeared in 18(>3.^ As a London
graduate myself, and interested in the stability and welfare-
of British institutions, I thought well that the subject
matter of this paper should not sleep any longer. Evidently
Koch is not aware of the facts, or some reference would ere-
this have been made.—I am, Sirs, yours truly,
Elgin-street, Ottawa, Jan. 12th, 1801. J. A. GRANT.
*** We have referred to Sir James Grant’s communica¬
tion to our contemporary nearly thirty years ago.^ Four
cases of cutaneous disease, described as “ psoriasis palmari&
of five years’ duration,” “tinea nummularis,” “tubercular
syphilide,” and “psoriasis leprteformis,” are said to have
been cured by vaccination, and it is suggested that the
vaccine lymph may neutralise the effects of “ irritants
circulating in the blood. But we do not quite seethe bearing
of these (unconfirmed?) observations upon Professor Koch’»
work.—E d. L._
GENERAL PRACTITIONERS AND HOSPITAL
ABUSES.
To the Editors o/The Lancet.
Sirs,— For many years past general practitioners in
London have been loud in their complaints as to the abuses-
in connexion with the management of our medical charities,
especially in regard to the out-patient departments. At-
length a Special Committee of the House of Lords has been
appointed to inquire into the subject, but, strange to say,,
now that general practitioners have the opportunity to-
make their grievances known, they, for the most part, treat
the matter with indifference. True a few general prac¬
titioners have given evidence before the committee, bub it
is to he feared that their personal views will have veiy little
weight as against those of the officials and the eminent-
physicians and surgeons attached bo the hospitals who agree
in deprecating the slightest approach to State interference-
with our medical charities.
I would suggest that a Committee of General Prac¬
titioners, representative of every district in the metropolis,
be at once formed to prepare such evidence as may be
thought desirable to lay before the Lords’ Committee now-
sitting, and also to formulate a scheme for remedying the
abuses complained of. Now is the time for general!
practitioners to speak, or we may as well for ever hold our
tongues. Should any of your readers wish to join the pro¬
posed committee, I shall be glad if they will communicate
with me as early as possible.
I remain. Sirs, yours faithfully,
Gkorob Brown, M.R.C.S. &c.
20, Thrcaclneodlo-street, K.C,, Fob. 22na, 1891.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
The Housing of the Poor in Neiocastle.
The rapid increase of the population of Newcastle and
the progress of railway and other extensions have displaced
a very large number of poor from their dwellings during
the last few years, bub it cannot be said that these poor
people have found anything like equivalent accommodation
elsewhere, their lodgings being, as it were, always on iv
down grade. It is true that over 8000 new houses have
been built in Newcastle during the past eight years, hub
they have been at rents far above the means of the poor,
and by the poor I mean the working men earning low-
wages. It ia now proposed by the corporation to erect
some large blocks of one-room tenements for, say, about
.’>00 persons. Tiiis is to be of an experimental nature, and
if fairly successful can no doubt be soon extended.
Newcastle Dispensary.
The annual meeting (the 113th) of this old charity has
been held, and the resident medical officer. Dr. George W,
’ Medical Times and Oaaotfe. • Ibid., March I'ltli, 1803,
Diniti/nd hy Google
The Lancet,]
SCOTLAND.—lEELAND.
[Fkb. 7, 1891. 341
Blidley, reported as followsThat the total number of cases
treated baa been 25,573. There had been an increase in
the home patients department which had ma'le it necessary
to increase the visiting staff to five, the city being now
divided into five districts. In the early spring the wave of
influenza, which had gradually spread over Europe, reached
Newcastle. It spread very rapidly, and reached its climax
about the middle of February; after that date it as rapidly
diminished, and by the end of April bad practically died
away. At the same meeting it was stated that there was
a prospect of an addition of £8000 to the capital of the dis¬
pensary during the next twelve months, and a committee
was empowered to take into consideration the desirability
of establishing an inland convalescent home for the use of
the patients of the dispensary.
Newcastle Lying-in Hospital.
The annual meeting of the Newcastle Lying-in Hospital
feas been held, and the report presented stated that 231
cases had been attended to during the past year, and the
committee rejoiced to say that in all this number no fatal
case had occurred. This is all the more satisfactory as 1
understand that the city has been by no means free from
(luerperal disease.
Tlie Modified Carriage Tax.
It is a good deal owing to the exertions of a Newcastle
gentleman, Mr. John Philipson, J.P., that the modification
■<©! the carriage tax was brought aWut, so that we were
leased in the North to see that Mr. Philipson’s work had
een appreciated all over the country, and that he had been
Cast week presented in London with an address, together
with a cheque for 100 guineas.
Newcastle-on-Tyne, Feb. 4th.
SCOTLAND.
(From our own Correspondents.)
The Royal Society of Edinburgh.
The fifth meeting of the above Society was held on the
2nd inst., Sir Douglas Maclagan, President, in the chair.
The whole meeting was devoted to an address on the Sense
of Hearing, given by Professor Rutherford, F.R.S., at the
request of the Council. He criticised Helmholtz's theory of
the manner in which the cochlea is affected by sound vibra¬
tions, and showed the great anatomical dlfliculties of any
theory that regards the basilar membrane as the transmitter
•of sound vibrations to CortVs cells, and as an analyst of
•complex sound vibrations. The basilar membrane is heavily
■damped by the cellular elements above and beneathit; and,
in the case of the rabbit, by its division into two layers
with a homogeneous tissue between them, and also beneath
the lower layer—an arrangement that must greatly
interfere with any localised sympathetic vibration of its
^bres. The hair cells of Corti are the true nerve termina-
tdons, and are placed in a favourable position for receiving
the sound waves transmitted to them through the super¬
jacent membrane of Corti. The sound wave is probably
considerably damped, and fine vibrations therefore de¬
stroyed, by the granular protoplasm at the lower ends of
Corti’s cells and the granular cement substance between
'their lower ends and the supporting cells of Deicer.
He stated the arguments opposed to the theory of
Helmholtz, and explained his own theory of sound-sensa-
'tion suggested by the telephone, and communicated by
'him to the British Association in 1885. Although no
theory is free from difliculty, he maintained that the most
feasible theory is that the great extension of the organ of
Corti in the mammal is for the purpose of increasing the
number of hair cells, so that the appreciation of the qua-
toies of sound may be more acute, and therefore more intel¬
ligent ; that the hairs of all the cells of Corti are affected
by tones of every pitch, and that the sound vibrations are
translated by Corti’s cells into nerve vibrations similar in
frequency, amplitude, and form to those of the sound ; and
'that the different sensations of tone are due to nerve vibra¬
tions of different frequency and form, periodic or aperiodic,
arriving in the sensorium. He illustrated his address by
{numerous diagrams and experiments, and was awarded at
lithe close a hearty vote of thanks by the Society.
Edinhiirgh Royal Public Dispensary.
The annual meeting of the managers of this institution
was held in the end of last week. The report stated that
8296 persons had been treated during the year, this being
an increase of 1072 cases as compared with the preceding
year. The financial report was satisfactory.
Health of Edinburgh.
The mortality last week was 124, and the death-rate 23
per 1000. Diseases of the chest accounted for 46 deaths,
and zymotic diseases for 9. The intimations for the week
included 36 of typhoid fever, 14 of diphtheria, 55 of scarlatina,
and 23 of measles. The number of patients in the city
hospital last week was 230, 95 of whom were suffering from
typhoid fever and 88 from scarlatina.
Scottish Universities Commission.
The Commission continues its sittings, and at their
meeting on Monday Drs. Keiller and G. W. Balfour,
examiners in medicine in the University of St. Andrews,
and Dr. Sinclair and Professor Paterson, representatives of
University College, Dundee, gave evidence regarding the
schools they represented.
Edinburgh Royal Infirmary and Women Students.
The managers of the Royal Infirmary, at their meeting
this week, resolved to admit women students of medicine,
and it has been remitted to the medical and surgical staff
to give effect to this decision. The conditions are that they
are bo be taught separately from the male students, that
under no circumstances whatever shall any ward be utilised
twice in the same day for clinical instruction, and that, as
far as possible, no interference shall be attempted with
ward clinics and lectures already arranged for male
students. It is not yet known what the attitude of the
staff will be towards this decision.
Death of Mr. Hector McColl, L.F.P.S. Glas.
The west of Scotland has sustained a serious loss by the
death of Mr. McColl, which took place a few days ago. The
deceased had reached the tipe age of ninety-one, having
obtained his licentiateship of the (Glasgow Faculty in 1829.
Up to 1880 he carried on an extensive practice in the island
of Mull, to which island, however, his professional services
were by no means confined. The year 1847 was a period
of great destitution on the island, and Mr. McColl was
chosen to act as almoner for the administration of the
measures of relief provided by the Government of the day.
lEELAND.
(From our own Correspondents.)
DUBLIN.
The Midwives' Registration Bill.
A PETITION has been forwarded to the Houseof Commons
bytbejRoyal College of Surgeons in Ireland against the
Midwives’ Registration Bill, pointing out that it is doubtful
whether any portion of the community would be benefited
by its provisions. The evils which are supposed to justify
the enactment arise, the petitioners point out, from the
want of proper means of educating mid wives. They submit
that all bond-fide midwives ought to pass such an examina¬
tion as shall be considered necessary by the General Medical
Council. The limitation of their work to cases of natural
labour is spoken of as quite impracticable, and their exa¬
mination by County Councils as likely to cause great
variation in the standard of education required in the
various counties. The petition further urges that the Bill
should be referred bo a Select Committee for consideration.
Monkstown Hospital.
The committee of this hospital in 1889, on the advice of
the medical staff, determined to remove the bathrooms,
lavatories, &c , from the main building, and to place them
in a separate wing, and also to provide observation wards
for the treatment of patients suffering from febrile affections,
possibly infectious. Two sums of £1000, one a bequest and
the other a donation, formed the nucleus of a fund for the
required purposes, and last week the new wing was formally
opened. The total cost of the new buildings is £3500, the
balance still due being only £262.
Mercer's Hospital.
The unhappy litigation between members of the medical
staff of this institution has not yet terminated, and last
week, in the Queen’s Bench Division of the High Court of
Justice, before the Lord Chief Justice and three other
judges, the case of Ward and Nixon v, Auchinleck
342 Ths I«anost,]
IRELAND.
[Ebb. 7,18&I.
was resumed. There was a motion on the part of the
relators for a writ of quo warranto directed to Mr. Auchin-
leck, to ascertain by what authority he was appointed to,
and continued to bold, the office of physician to Mercer’s
HospitaL Mr. Auchinleck had been elected by the lay,
members of the hospital board, and it was contended that the
election rested altogether with the medical board who had
appointed Dr. Cosnave. The question raised involved the
consideration of the Meath Hospital Act, the County In¬
firmaries Act, and other statutes. Mr. Justice Holmes
observed that, regarding the office of physician as a public
office created by statute, how could it be said that the person
who gave a consideration for it, or paid for getting “ in” to
it, was legally in “possession” of it? Payment, he said,
would not be illegal in the case of a private office, but it
was a different thing in the case of a public office; and in
order to lay grounds for granting a quo warranto, it should
be shown that it was a public institution.
Etlier Drinking.
A statement recently made by Mr. Ledlie to the Govern¬
ment in respect to the drinking of ether in several parts of
Ireland shows that the vice is one which exists to a large
extent in the counties of Derry, Tyrone, Armagh, and
Fermanagh. About 100,000 people, it is estimated, indulge
in the habit, and consume about 17,000 gallons of impure
ether. Mr. Ledlie suggests as deterrents to the practice
the mixing of naphtha with all ether except that used for
medical purposes, so as to give it a nauseating taste; the
reimposition of the prohibition tax, which was taken off
ether by the Act of 18 and 19 Vic. ; and the making of the
practice of drinking ether or selling it illegal by all persons
except chemists, and by them only for hond-Jids medicinal
or commercial purposes.
National Society for the Prevention of Cruelty to Children.
Branches of this Society have been formed in Cork,
Belfast, and Dublin. In the last-named the branch has
existed over two years, and last week, at a general meeting
of the association, an address w’as delivered of a very
interesting character by the Rev. Benjamin Waugh, bon.
director. Funds are much needed, the London Society
having to pay the Dublin branch about £100 a year.
Pharmaceutical Society of Ireland.
A Dublin Gazette of last week contains an Order in
Council approving of the regulations relating to the School
of Chemistry and Practical Pharmacy which have been
adopted under the authority of the Pharmacy (Ireland)
Act, 1875.
The Irish Cyclists’ Association have resolved to hold an
annual race meeting in aid of the Dublin hospitals.
Feb. 3rd. _
BELFAST.
Koch’s Method for the Treatment of Ttihercnlosis.
This method of treatment is now being tried at several
of the Belfast hospitals, and at a meeting of the North of
Ireland Branch of the British Medical Association, held in
Belfast on Jan. 29th, patients were shown who had been or
who were then under treatment. The inoculation Jluid was
sent in the first instance to the Hospital for Consumption
and Diseases of the Chest, and last week it came to the
Royal Hospital, where the medical staff are giving it a trial.
The Midwives' Registration Bill.
On Thursday, Jan. 29bh, a resolution in favour of the
principle of the Bill—viz., compulsory registration after
due examination—was passed at the North of Ireland
Branch meeting of the British Medical Association.
Hospital for Consumption and Diseases of the Chest.
The annual meeting of the friends and supporters of this
institution was held on Jan. 30th. The hospital was
opened for intern patients in October, and since that date
seventeen cases have been admitted, while there were
during the year 865 new extern cases. Koch’s treatment
has been tried in suitable cases. With the inauguration of
the intern department the following additions have been
made to the stall': Mr. Fagan, consulting surgeon;
Dr. McKisack, surgeon; and Dr. C. £. Shaw, laryngeal
surgeon.
The Belfast Hospital for Sick Children.
The supporters of this charity heUl their annual meeting
on Friday, Jan. 30tli. I find that the income (£977 1 86'. ‘Zd.)
for the year exceeded the expenditure (£960 Us. 9c^.). The
following members of the staff whose term of office had
expired were re-elected: Dr. Byers, Dr. Nelson, and
Mr. J. J. Andrew. Dr. John Campbell, assistant to
Professor Redfern at Queen’s College, Belfast, bos been
appointed assistant surgeon, in place of Dr. Boyd, resigned.
The Queen Victoria Convalescent Home was opened in
October, and since then children have been regularly sent
to it from the Cliildreu’a Hospital. Its existence renders
the hospital complete. Daring the year there were 371
intern and 8536 extern cases at the hospital. Since the
last annual meeting the Senate of the Royal University has
placed the Belfast nospital for Sick Children in the list of
institutions from which the University receives certificates
for degrees in medicine, and in this way the hospital has
become a part of the local medical school. During the
present session a large number of senior students are in
attendance.
The Samaritan Hospital.
From the report presented at the annual meeting of this
charity, held on Jan. 26th, I learn that there has been no-
restriction in the free relief in the out-door department, but
the expense attending in-door treatment, especially in
operative work, prevents the receiving of all suitable free
patients. Towards the end of the year the committee
made an appeal in some districts to pay off the debt, the
interest on which has for many years restricted the useful¬
ness of this charity, and they hope that during the current
year the appeal will be made over a wider area with a good
result. Reference was made at the meeting to the illness,
of Dr. McMordie, the surgeon of the institution, and the
hope was expressed that he would soon be restored to health,
so as to resume his duties. In the meantime Dr. Boyd is
acting as his substitute.
The Ulster Hospital for Women and Children.
From the report read at the annual meeting of the friends
of this hospital on Jan. 29bh I find that in 1890 190 children
were intern patients and 2358 extern. In the women’s
department there were 64 intern and 265 extern cases. The
committee have decided to hold a bazaar daring December,
1891, with the object of raising funds to erect a new
building for the Ulster Hospital. There is a balance of
£80 14s. lid. in the treasurer’s hands to be carried forward
to next year’s account. The hospital is recognised by the
Royal University as granting certificates to students.
The Royal Hospital.
For some time past it has been felt that the Royal
Hospital has not kept pace in the accommodation it affords
with such a rapidly increasing city as Belfast, and sooner or
later it is believed that a new hospital will have to be built.
The most desirable site for such a new hospital would be
the place at present occupied by the Belfast Charitable
Society’s buildings, "We understand that a small com¬
mittee, composed of members of the boards of manage¬
ment of each of these institutions, has been appointed to
consider the whole matter. It is stated that, in case an
arrangement could be made, the inmates of the Belfast
Charitable Institution (who consist of old people who have
seen better days} could be housed as comfortably in a
building in the vicinity of Belfast, where they would have
the advantage of country air. We understand that in any
case it has been decided to hold a centenary bazaar and
fancy fair in November next for the benefit of the Royal
Hospital.
Death of Dr. Higginson.
I regret to announce the deatli of Henry Talbot Higginson,
M.D. Edin., which took place at his residence, Bangor, co.
Down, on Friday, Jan. .SObh. Dr. Higmnson, who was the
youngest son of H. T. Higginson, J.U, of Lisburn, and
Camalea House, Bangor, was born at Lisburn in 1841.
Educated at the Royal School, Armagh, and in England,
he was a pupil of the celebrated Dr. Thompson, of the co.
Antrim Infirmary. Having graduated in Edinburgh in I863>
he became assistant to Dr. John Thompson of Whitehaven
(brother of the late Archbishop of York). He soon went to
America, and in the civil war there he was a medical officer
in the United States army. At the close of the war Dr.
Higginson returned home, and practised first at Donaghue,
then at Lisburn, where he had a dispensary, and in 1870 he
came to Bangor, where he has resided ever since and has
practised. He was an Admiralty surgeon, and bad charge
of several of the coastguard stations. Dr. Higginson, who
was a member of one of the most respected county Down
families, was a man of very varied attainments. He was a
good painter, sang well, and played several instruments.
.cog
Dir
Trc Lanost,]
PARIS.~BERUN.
[Feb. 7, 1891. 343
About a year ago he published a volume, “ Notes by the
Way,” in which he gave a racy account of the various
places which he had visited in his travels. His death is
very much regretted by a large circle of friends. He leaves
behind him two eons, his wife having expired seven weeks
ago, a loss which he felt most keenly.
Feb. 8rd. '__
PARIS.
(From our own Correspondents.)
The Medico-legal Significance of the Gonococcus.
Most experts would probably nowadays be inclined to
interpret the presence of the gonococcus of Neisser in the
purulent discharge of infantile vulvitis aa convincing
evidence of the gonorrhcoal origin of the lesion. M. Vibert,
one of Professor Brouardel’s able coadjutors at the
Morgue, tells us (SoeiiU dcMtdecine lAgale, Jan. 12th) that,
in conjunction with M. Bordas, he has instituted inquiries
on this point in the case of six little girls atrected with
vulvitis, upon each of whom a criminal assault bad been
committed by men found to be absolutely free from any
trace of gonorrhcea. In the vulvar discharge, in each in¬
stance, there were discovered gonococci which, morpho¬
logically and bacteriologieally, differed in no respect from
the micro-organism said to be pathognomonic of blennor-
rhagia. The importance, from a medico-legal standpoint, of
this disappointing fact, already attested to by Fraenkel,
cannot be exaggerated.
Etiology of llidcets.
The views of Parrot, attributing rickets to inherited
syphilis, have met with but scant acceptance at the hands
of clinicians. Nevertheless, any additional evidence in
support of the generally accredited doctrine of the dietetic
origin of what has been denominated the “ English disease”
is welcome, so important from a prophylactic and curative
S oint of view is a right understanding of its causation.
[. Poramay reports to the Socicte de Biologie (Jan. 17th)
that he has succeeded in inducing characteristic rachitic
lesions in the bones of thetruDk,extreiiuties,and skull, as also
spontaneoQB fractures of the long bones, in jays a fortnight
old, by feeding them exclusively on boiled meat deprived of
its juices. The same pathological consequences were noted
in young larks, linnets, and other growing birds by limiting
their diet to bread crushed with yelk of eg.g.
AnhidroUc Properties ofTelluratc of Sodium and
Camphoric Acid.
Physicians are always glad to hear of any new remedies
for the distressing sweats (whether nocturnal or diurnal)
which add so greatly to the general discomfort in certain
affections. If we may believe Dr. Combemale of Lille
{Bulletin G&n6ral de Th6rapeutiqua, Jan. 15th), such new
remedies have been discovered in tellurate of sodium and
camphoric acid. Ho states that the former drug, in daily
doses uf 5 centigrammes, infallibly controls the night sweats
of phthisis, and that this effect is obtained at all stages of
the disease. In the later stages, however, correspondingly
increased doses will have to be exhibited. Dr. Combemale
regards this salt as the best anhydrotic agent we possess.
Camphoric acid he declares to be only a degree less powerful
than sodium tellurate, two grammes daily rarely fiuling to
arrest, or at least considerably diminish, night sweats. The
efficiency of the acid is in inverse proportion to the progress
the phthisis may have made. This observer asserts that
pathological sweats other than phthisical, such as those of
acute rheumatism, typhoid fever, syphilitic caverns, and
dyspepsia, yield to the above remedies.
Inoculation of Dog Serum as a Remedy for Tubcrcxdosis.
In a series of communications made in the course
of the last two years to the Socicte de Biologie, MM.
Hdricourt and Kichet have given the results obtained
by the injection of the blood of au animal refrac¬
tory to tuberculosis, such as the dog, into the economy
of one susceptible to the onslaughts of the bacillus.
They have demonstrated experimentally that such a
proceeding exerts a retarding inlluonce on the evolu¬
tion of tuberculosis artificially communicated, without,
however, stopping it altogether. With a view of intensifying
these partially protective properties of canine blood, they
inoculated the dog with a large dose of very active tuber¬
culous matter, and one month later (the animal having lost
flesh, and exhibiting manifest signs of ill-health) injected
into the peritoneal cavity of three rabbits 70 cc. of the dog s
blood. A week later these rabbits were, with three other
teat rabbits, inoculated with strong tuberculous vims, with
the result that in twenty-five days two of the latter had
succumbed, the rest surviving, 'fheir ultimate fate is not
recorded. Encouraged by these results, MM. Richet and
H6ricourt have extended the application of their method
to tuberculous human beings, employing the sernm only,
and selecting the interscapular region as the seat of
inoculation. M. liichet reports (Soci6t6 de Biologie,
Jan. 24:th) that four phthisical men have, since the early part
of Decemlier, 1890, been subjected to this novel treatment.
The results obtained seem to warrant the assumption that
the introduction of the serum of dog’s blood into the human
economy counteracts, to some extent at least, the noxious
influence of Koch’s bacillus. In all four cases (two being
affected with pulmonary and two with concomitant laryn¬
geal and pulmonary phthisis) eighteen days’ treatment had
the effect of suppressing the night-sweats, improving the
appetite, increasing strength and weight (one patient
put on flesh to the extent of over 9 lb.), and minimising the
physical signs. In the two cases of laryngeal phthisis, the
epiglottis, which was very swollen and motionless, became
much reduced in volume, and regained its mobility, the
distressing agony experienced during deglutition disappear¬
ing. The inoculations (dose, from 1 to 4 cc. every three or
six days) are followed by neither local nor general re¬
action. On two occasions only was pain (lasting twenty-
four hours) complained of. In all the cases the interscapular
region became the seat of itching, developing some time
after the operation, and attaining its maximum eighteen
or twenty-four hours later.
Paris, Feb. 3rd. _
BERLIN.
(From our own Correspondent.)
Professor Koch's Method.
Dr. von Gossler, Minister of Medical Affairs &c., has
requested the heads of the clinics, policlinics, and patho¬
logical institutions of the Prussian universities to report
their experiences of Koch’s metliod. Tlie first collection
of reports will be published in a few days by Springer of
Berlin. Professor Koch arrived in Vienna yesterday, on
his way to Constantinople. Professor Brieger is to be head
of the clinical department in Koch’s new institute, and it is
likely that Dr. Behring, whose valuable researches on the
subject of immunity attracted much attention lately, will
be head of the experimental department.
A New Method of Examining Sputum for Tubercle
Bacilli.
Dr. Biedert of Hagenau, in Alsace, has devised a new
and considerably surer method for the discovery of tubercle
bacilli in sputum. He collects a tablespoonful or more of
the sputum, mixes it well with a glass rod, takes some of
it and stirs it together with two tablespoonfuls of water
and four to eight drops of solution of caustic soda according
to the density of the sputum, and then boils it, stirring it
the while in a shallow cup, gradually adding four to six
tablespoonfuls of water till he gets a pretty thin fluid
mass. This he allows to stand tor two hours in a high
glass tapering as finely as possible downwards, and all the
formed particles sink witli the tubercle bacilli to the
bottom. Then he pours off the fluid, retaining the
sediment, parts of which he takes out with a
platinum needle and rubs them fine on a cover-glass.
When the preparation is dry he passes it through a flame,
stains it with a enrbolised solution of fuchsine, and then
bleaches it with 25 per cent, sulphuric acid. If there are
any tubercle bacilli they remain red, and are thus dis¬
tinguishable under the microscope. Even a single bacillus
is discoverable in this way, whereas the older methods
yielded a positive result only if there were many.
Professor von Bergmann.
An injury sustained in the performance of his professional
duties has compelled Professor von Bergmann to take leave of
absence. The wound, which is on one of thelingersofthe right
band, was not considered to be serious at first, but has
rendered repeated operations necessary. The professor is
confined to his room, and will probably have to wear his
hand in a sling for some time to come.
841 The Lakcbt,]
VIENNA.—OBITUARY.
[Feb. 7,1891.
Wilhelm Knop.
Wilhelm Knop of Leipsic, who died the other day, was
one of the oldest teachers of chemistry in Germany. The
most valuable of his writings are bis Investigation of the
Relation of some Water Plants to Gases, his “ Circulation of
Substances,” his “Text-book of Agricultural Chemistry,”
his “Arable Soil and Cultivable Plante,” his essay on the
“Valuation of Soil,” &o. In his essay on the “Molecules
of Bodies,” he tried to prove that the molecules of modem
chemistry can be imitated atomisticallv by the laying
together of tetrahedrons and octahedrons.”
Philip Carl.
Philip Carl, Professor of Physics, died the other day at
Munich. He founded three periodicals, two of which
attained importance—the Repertonj of Physical Technics
or the Knowledge of Mathematical and Astronomical
Instruments, the Periodieal for Electro-technics, and the
Repertory of Comet Astronomy. He graduated in 1860,
established himself as a private lecturer on physics in
Munich University in 1861, and was appointed professor in
the Academy of War in 1862. He was also Johann von
Lament’s assistant in the Munich Observatory.
German Death-rates.
The death-rate of Aix la-Chapelle in the week ending
Jan. 17th was 267 per 1000; Altona, 22 7; Barmen, 18'6;
Berlin, 19‘9 ; Bremen, 19'9 ; Breslau, 28 5 ; Chemnitz, BO -l;
Cologne, 31'6: Dantzic, 25 6 ; Dresden. 19'2; Dtieseldorf,
23; Elberfeld, 21'5; Frankfort, 19'6; Hamburg, 22;
Hanover, 17-; Kooigsberg, 23 7; Krefeid, 31’4; Leipsic,
19-5; Magdeburg, 25-4; Munich, 21-r); Nuernberg, 26'8 ;
Stettin, 23'3; Strasburg, 29 ; and Stuttgart, 13'6.
Berlin, Fob. tJrd. ___
VIENNA.
(From our own Correspondent.)
The Treatment of Malignant Tumours with Pyoctanin.
At the last meeting of the Vienna Society of Physicians
Professor Mosetig showed two cases of malignant tumours
(sarcoma) which had been treated successfully by him some
montlis ago with pyoctanin. Id one of them, the patient
being fifty years old, the sarcoma was situated in the in¬
guinal region, and was considerabljr shrunken after repeated
injections of solutions of pyoctanin into the tumour and
its neighbourhood. The solutions were prepared from
Merck’s pyoctanin in the strength of 1 in 300 and 1 in 500 of
water respectively. The lecturer said that hehadmade some
years ago experiments with injections of solutions of carmine
into maiiguant tumours, and later M'ith anlliue dyes, based on
the idea that the further growth of the tumour might be
revented by the change excited in its histological elements
y the staining reagent. It is probable that Stilling's ex¬
periments witii pyoctanin in suppuration induced Mosetig
to try this preparation in the treatment of new growths.
In the discussion that followed, it was stated by Professors
Reuss, Neudoerfer, and Lang that they had observed
favourable results from the application of pyoctanin to
suppurating surfaces. Neudoerfer said that he had under
his treatment a case of ulcerating cancer of the breast,
which became smaller after the use of pyoctanin poultices ;
and Lang has obtained favourable results in cases of cystitis
and pyelitis, when the pyoctanin was also administered in¬
ternally. It will be remembered that soon after Stilling’s first
publications, when his therapeutical experiments had been
repeated by other workers, a series of papers were pub¬
lished in which the statements of Stilling with regard to
the curative actioa of pyoctanin were very much disputed,
and that they had been confirmed by but few observers. It
seems to me that the treatment was not suitable for ail
the cases in which it was tried, and that the clifierence of
opinions may also be due to the circumstance that solutions
or pyoctanin are very liable to precipitation. Concerning
the treatment of tumours with injections of pyoctanin, it i.s
probable that such injections may act in a twofold manner ;
at first even injections of indifferent liquids (distilled water),
when frequently repeated under aseptic precautions, may
restrain the growth of the tumours by mechanical pressure
on the histological elements and so lessening the vital
activity of the cells by imbibition ; secondly, the dyes con¬
tained in the solutions may exert a special action on the cell
nuclei, which in selecting the particles of the dye may
conceivably become less active, and even lose their pro-
perty of cell division. On this ground it would seenti
advisable to try also injections of solutions of gelatine,
collodium, &c., for the treatment of such tumours, as they
would exert a more lasting mechanical effect; or, if dyes
should he injected, those materials should be selected tbc’
particles of which are of greater weight—e.g., hoenaa*
toxylio and the alizarin dyes, where the stain could
be fixed by subsequent injection of an innocuous mordant.
At the same time it must be remembered that any
histological dye, when injected into the tissue, indirectly
affects the vitality of the mtima of the bloodvessels and of
the lymphatics, so that local thromboses may occur and
perhaps exert a beneficial effect. As the growth of the
tumour takes place from the apparently healthy tissues in
the vicinity, the injections should be made into them, lit
is to be hoped, also, that when the question of treating
malignant tumours by the new method is taken up the
histological aspect of the question will also be fully
considered, and that histologiscs will not content tbem8elve«>
with preparing only small pieces of the morbid tissue, which
only exhibit the complex structure of the tumour with its-
secondary changes, but will prepare a continuous aeries-
of specimens, in which the whole development of the
tumour may be studied. In addition to the local treat¬
ment of malignant tumours, it will be certainly necessary
to endeavour by general measures to prevent the occur¬
rence of relapses and metastases.
Vienna, Fob. 2n(l.
EDWARD JOHN WARING, M.D., F.R.C.P., F.R.C.S.,.
F.L.S, C.I.E.
Edward John Wauinc;, born 1819, was the son of
Captain Henry Waring, R.N., of Ford, near Shrewsbury,
Shropshire. He received his early education at Lyme Regie
under Mr. GeorgeRoberts(thewell-knownauthor of the “Life
of the Duke of Monmouth”), and afterwards at the Ilminster
Grammar School. His professional training was carried
out in Bristol and at Charing-cross Hospital, London. In
18-11 he was appointed surgeon to a ship sailing to Sierra*
Leone, and went thence on to Jamaica, where he com¬
menced practice, and carried out the duties of medicall
officer of health. In 1842 he visited England, and took his
M.RC.S., but at once returned to Jamaica, where he
remained for a year, and finally left that island to enter the
service of the Emigration Commissioners. In the course of
the duties thus devolving upon him he travelled to the
United States, India, Australia, and Trinidad. In 1847
Dr. Waring again visited England, and married Caroline
Anne, daughter of William Day, J.F., D.Ij , of Haddow,
Sussex, and settled at Uckfield. Obliged by heavy losses
to re-enter professional life. Dr. Waring in 1849 "became
assistant-surgeon in the service of the East India Company.
He was, at the expiration of the probationary period, sent
to Mergui, in the Tenasserim provinces (parbof old Burma),
where he remained throughout the Burmese war. For his
services he was decorated with a war medal. It was at'
this time that he prepared the first edition of his welL
known and highly popular “ Manual of Practical Thera¬
peutics,” a work which saw several editions. Dr. Warinjj
was also led to investigate the native remedies and resources
of the forests as the drug supplies of Mergui became-
exhausted, and the war jirecluded any fresh supplies being
obtained. When, in 1853, Dr. Waring was appointed to-
the office of resident surgeon at Travancore, he continued
these researches and from time to time published his results.
He also made some car'^ful researches into the pathology
and clinif^al characters of hepatic abscess, collating some 300
cases. When he succeeded to the post of durbar physician
to his Highness the Maharajah of Travancore, he exe¬
cuted a most painstaking investigation into the etiology of
elephantiasis, advancing arguments in favour of regarding
the disease as essentially of a febrile nature. About this
time, too, Dr. Waring prepared his “ Bazaar Medicines,”
which was translated into several native languages, and exer¬
cised ft great influence for good among native practitioners.
While at Travancore he was also instrumental in establish¬
ing the first school for children of the slave class. Failing
health drove Dr. Waring to England in 1803, and two
The Lancet,]
MEDICAL NEWS.
[Fkb. 7, 1891. 345*
years later, at the request of the Government, he under¬
took the responsible duties of editor of an Indian Pharma¬
copoeia, 'Which it was determined to issue upon the same
lines as those of our own Pharmacopoeia. In this great
work Dr. Waring was associated with Sir J. Kanald Martin,
C.B., l'Ml.S., Sir W. O'Shanghnessy Brooke, M.D., F.R.S.,
and other well-known men. For the succeeding years his
pen was busy. “The Tropical Resident at Home:” his
important but incomplete work, the “Encyclopocdia Thera-
peutica,” commenced in India, providing material for his
“Bibliotheca Therapeutica,” while several smaller worhs,
some on medicine, some on devotional subjects, were also
given to the world. Dr. Waring was among the first to
advocate cottage hospitals, suggesting this title rather than
village hospitals, as they were at first called. He
threw himself warmly into the e.stablishment of the
London Medical Mission in St. Giles’s, and was on the
first committee. His pamphlet on “Spectacles Missions”
drew attention to these useful works of charity. In 1887
Dr. Waring presented his almost unique collection of books
on Pharmacology to the Army Medical School at Netley,
eliciting from Sir Joseph Fayrer words of warm admiration
and expressions of personal esteem. Dr. Waring's failing
sight caused him for a while to give up reading, bub happily
the blindness was successfully treated, and up to his final
illness he was able to read with tolerable ease. Dr. Waring’s
researches into the natures and uses of Indian drugs have
won for him both an oriental and a European fame, and his
gentle and Stirling nature and kindly courtesy of manner
earned for him a circle of friends who M’ill feel that his,
indeed, was a life well spent, his a rest well earned, and
his a memory to be kept ever green. His public service was
in 1881 recognised by the conferring upon him of the dis¬
tinction of Companion of the Indian Empire.
DR. LOUIS PIACHAUD.
Switzerland haa lost one of her ablest surgeons in
Dr. Piachaud of Geneva, who died there at the close of
last year, aged sixty-six. A Genevese by birth, be dis¬
tinguished himself in classics and philosophy at the
Academic of his native city, and found time also to lay the
foundations of scientific culture, particularly in botany.
From Geneva he proceeded bo Paris as a student of medicine
in October, 1844, and in 1847 he was nominated interne dcs
hGpitanx, faking the sixth place among forty-one competitors.
In the following year he oil'ered himself for examination at
the I'lcole Pratique, and gained the chief prize—a gold
medal—after a severe competition. Professor Orfila, in
awarding the prize, took occasion to compliment the Geneva
school for the brilliant students it sent up to Paris, among
whom none had done it move credit than young Piachaud.
Under Velpeau, nnd for a shorter time under NiilatoD,
Piachaud made admirable progress in surgeiy, for which
the sanguinary events of 1848 yielded ample opportunity.
In 1849 he was attached to the Hospital of Bon Seconrs,
and there during the cholera epidemic he gave bis services
to the patients in the most courageous and at the same
time scientific spirit. He had already made independent
study in amostlipsia, and as early as Feb. ‘iod, 1847,
had experimented on himself with ether, at a time when
such a proceeding was universally regarded as fraught
with danger. This enterprising scientilic spirit attracted
the notice of the great Parisian consultants, Vulpian,
Pr61at, Verneuil, and Charcot, with whom he formed an
intimacy and mutual regard only dissolved by death. In
spite of all their solicitations, and of the prospects of a
lucrative cUrntde in the French capital, be returned to
Geneva in 1852, bearing with him his diploma of Doctor in
Medicine, a degree conferred on him for an exceptionally
briUiant thesis.
bor forty years Dr. Piachaud continued to practise in his
native town, and to extend his knowledge by independent
investigation in tlie laboratory and by observation at the
bedside. Among the publications he put forth from time to
time, his “En Attendant leM6decin”was at once successful,
and remained long in favour. Another, entitled “ L’Emploi
Anesthesiques dans les Accouciiements,” appeared in
18o7, and embodied the rebuUs of those experiments which,
as we have already seen, engaged his attention at the
threshold of his career. It was as a surgeon, however, that
he achieved his greatest successes, and his tenure of the
post of “ Chirurgeon en chef de I’lIOpital de GenOve” was
marked by singular skill as an operator and power as a
lecturer. He had more than bis share of academic and^
courtly distinctions, and, among obbermarksof recognition,
was decorated in 1869 with the Legion of Honour and with
that of Chevalier of theorder of St. Stanislas of Russia. He
was not without artistic accomplishments, particularly in
music, and was, besides, an intrepid “ Alpiniste.” He wa&*
an especial favourite with bis colleagues and his pupils,
while as a public man Geneva mourns in him the loss of one-
of the most liberal and enlightened of her citizens.
Koyal College of Physictans of London.—T ha-
following gentlemen having conformed to the by-laws and
regulations, and passed the required examinations, were, at
a meeting of the College on the 29bh ult., admitted
Licentiates :—
Addison, W. Bragii, St- Bartholo¬
mew’s and ijaiiibi'idge.
’Adler, M., Guy'sond St. George’s.
Andre, J. K. Felix, St. Thoiuivs's
Austin, Ri'g^iald F. K., Biiatol.
Barrett, A. Keppel, St Mary's.
Begble, F. Warburton. St. Bart.’s.
Bltikeman, C. J , St. Tboinas’s.
bluclco, H. F. S., Lharing-croas.
Bowkor, 0. Staiisor, Middlesex.
'• hoyton, E. T. A., St. Bart.’s.
''Biu-t, Will. Charles, Guy’s.
Chambers, W, F., Univ. College.
’Chapman, G. W,, St. Thomas’s.
Chater, A. Reginald, St. Mary’s.
Clark, Win. Adams, St. Bart.’s.
Clift, Hugh, St. Bartholomew’s.
Coouibe, Thomas Saiulby, Guy’s.
Coventoii, < 1 . Arthur, St. BarO.’s.
Cowell, A. Rodgers, St.Thomas's.
Crosskoy, Roger, St. Thomas’s.
Curtis, 11. Jones, Univ. College.
Daniel, W, P. Taylour, .'t. Mary’s.
Dobbs, Matthew, Cliaving-oross.
Dow, J. Hardman, Maneliestcr.
Drake, K. Charles, St. Bait’s.
Dryland, L. Wintei', St. Bart.'s.
’Oner. S. Unwin, Middlesex.
Duffy, P. Josepb, Univ, Coll.
Evans, Percy, University College.
Farquhav.son, W. G. Robertson,
.St. Mary's.
Field, Fiedk. Arthur, St. Bart.’.s.
F'oi'do, T. A. !Vtunro,St. Thomas’s.
'l''osU)r, Friuicis Wh^idale, Guy's.
l''reulaiKl, Regd. Stilwoll, Guy's.
Ganigee, L. Parker, Bii mitigham.
Gji-iioii, Harry, Maiiclidster.
Clrahliain, Mieliael, St. Thomas’s.
Grnham, .1. H. P., St. Bart's.
Green, G. Albert, liinninglwm.
Green, Percy Andrew, J,i>ucioii.
Greenwood. R. E., Univ. Coll.
Griffiths, Gilbert H., Liverpool.
’Griffiths, .lohn Samuel, Bristol.
Grimshaw, John, London.
Gytoii, WalterGeo., Manchester,
'Hawavdon, Samuel. Manchester.
’Haydon, Frank, Westminster,
llayduii,'!’.Horatio, St.Thomas’s
and Cambridge.
IToromiiig, Ghna. Harold, London.
Howitson, John Geo,, Univ, Coll.
Ilird, Fredorictc Robert, Lcod.s.
'H-Inlliind, E. Burke, Middlesex.
‘Howard, A. Wallers, Univ. Goll.
Kellock, Thos. IL, St. Thomas's.
Kidd, Ai'chibald, Middlesex.
J.ang.ston, T. A. t),, St. Bart.'s.
Lovick, 11. Driffield, St.Thoinas’.s.
Lewis, Frederick, St. Mary’s.
Lovell, C. Petre, Si. Thomas’s.
Low, Vincent Warren, St. Mary’.?*
Mactavish, J W., St. Thomas s.
Manwariiig, 15. E., St. Bart.'s.
Warder, Nicholas, St. Bait.’s.
Masteiinan, E. W. G., St. Bart.’s..
Mayor. John B., Manchester.
Mill.s, Varnold Hubert, London..
’’More. John, St. Bartholomew's.
Movt IS, Edwin HaighGvant, Cam¬
bridge and St. Thomas's.
Morris, J. J. N., King’s College:
Mulvany, Tliowas K., London.
Norgate, Robert Henry, Bristol.
Nyulasy, Arthur J., Melbourne.,
Ord-Mackenzie, S. A.. Univ. Colli
Penny, Herbert l.loyd, London.
Perner., George, University Coll.
Powell, T. M. J., St. Bart.'s.
Pritchard, E. L , King’.s College.
‘Quiiiby, Edward Melville, Liver--
pool and St. Bartholomew’s
Reeks, II., St. Bartbolomow’s.
Reynold.s, A. E., University Coll..
Rogers, Leonard, St. Mary’s.
Rogers-'lillstono, J. M,, St, Bart.
Ronaklson, Robert Miller, Edin--
hurgb and Oharing-crosa,
Hound, John C.. St. Thomas's.
Rows, R. G., University Collcga.-
Rygate, Heniy Bertram, Guy's.
Soniways, Daniel ^V<iSt, Guy’s.
Senior, Arlliur W,, Manchester.
Senior, R. VV,, King’s College.
’Sliii-tliff, 15. D,, St. Thomas’s.
‘Suiith, Henry, King's College.
Soulby, GliHilos B., Middlesex.
Stalker, Janies, Lefds.
Stephens, R., St. Bartholomew’^.
Stuideo, Alfred Willmm, London.
Stiireo, William H., London.
Sumniors, Thomas V., I.ondon.
Thompson, Aiahiir Hugh, Cam¬
bridge and l.imdon.
‘Twyford, Walter, Manchester.
T'yler, E. .1. it., St. Thomas’s.
■“Ward, John Alfied, Guy’s.
Wnriiig, J. A., University Coll.
■Weldon, btawell, St, George’s.
Wliitlield, Arthur, King’sCollegft.
Wighlmaii, J. P,, St. Biirt.’s.
Wilks, J. II., St. Bartholomew's.
Willey, 'J'., St. Bartholomow's.
Williams. David J., Middlesex.
Winslow, Walter, Guy's.
Wyman, Cuihbevt, St. Thomas's-
uud Cftinhridge.
Young, John, Guy's.
Candidates who have not- presented themselves under the regulationu-
of the Examining Board.
British Medical Service.—T ho following is a,
list of surgeona on probation of the Medical Stall of the
British Army who were strccessful at both the London and
Netley Examinations:—
Marks.
’Beach, T, B.6»27
Powell, K. E.5-100
Healey, C- W. R. . . . r>J2.‘>
.fonnings, J. AV.5206
William.s, 15. MeK. . . 611*7
Dowse, 11. K.61»3
Connor, J. (.*.6113
Carter, J. 15.6L06
Marks..
Hardy, F. W.6102
Clapham, J. T.60J6
Graham, W, Ap. S. J. .
Shanahan, D. D. . . • 4076
Whilestone, C. W. U. . 4040
Pearso, A.43t-0
D’Alton. C.46.JS
Mason, H. D.4(140
Gained the Horbort PrB.e of .220, with the Montctloro Medal andv
Prize of 20 guineiis.
Dig' zeiJ by CjOO^Ic
546 Thb Lancet,[
MEDICAL NEWS.
[Feb. 7, 1891.
Indian Medical Service.— The following is a
list of surgeons on probation in Her Majesty’s Indian Medical
Service who were successful at both the London and Netley
Examinations:—
’Crawford, J. M.
tWolfe, J. W.
Singh, B. J.
Whitconibe, E. G. R.
Barber, H. R. C. . .
James, C. H.
Marks.
0100
B7SB
.'■>065
6055
6045
6003
lO'Kinealy, F. ...
Cassidy, O. V. . . .
•Murrav, F- E. . . .
Buist-Sparks, A. W. T.
Younger, H. J.
Basu, B. D.
Marks.
.5580
5540
5520
.5500
6480
5160
General
and tlie
Gained the Prize in C'inioal Medicine presented by Surgeon
W. C. Maclean, C.B., with the De Chaumont Prize in Ilygiene,
Montefiore second Prize.
t Gained the Martin Memorial Gold Medal.
I Gained the Prize in Pathology presented by Sir William Aitkon,
®'.R.S.
Lincoln Hospital.— At a meeting of the Hospital
Board this week it was announced that Mr. J. Huston had
jiromised to supply the funds necessary for the addition of
.a children’s ward to the charity.
Sheffield Public Hospital and Dispensary.—
It was announced at the quarterly meeting of the governors
held last week that Mr. W. D. Allen had given £1000, and
the town trustees £5000, towards the building fund in con¬
nexion with the additions intended to be made to the
present hospital.
South Devon and East Cornwall Hospital.—
"Some time ago Sir Massey Lopes gave £4000 to this institu-
■tioD, which was partly expended in the erection of a Lopes
ward. He has now announced his attention to give £5000,
invested in the public funds, towards the maintenance of
‘that and another ward.
The Royal Maternity Society.—D uiing the
ipast year 3325 poor women were delivered by the midwives
•of 3400 children in the eastern and western divisions. Of
the mothers only four died during the time they were
under the care of the charity. Of the 3400 children, 74
■cases were twins, 1 triplets; 50 boys and girls were still¬
born, and 77 cases were attended by the physicians or dis¬
trict surgeons; 18 children died immediately afterbirth.
Burial and Cremation.— Professor Plowcr, C.B.,
presiding at a meeting of the Church of England Burial
[Reform Association last week, said that the ftulacy under¬
lying most people’s notions respecting death and burial was
that their personal identity consisted in the particular
material particles of which their bodies were constituted.
(Every attempt, to preserve the dead body was a violation of
the order of nature. To avoid injury to the living the body
.must be resolved into its component parts. Cremation was
theoretically the most efficient means of accomplishing this ;
but the most practical was the “ earth-to-earth ” system of
burial.
. Presentations.— The employes of Messrs. Henry
'Howell and Co., of City-road, have presented to Mr. Robert
Bruce, of Milford-on Sea, a handsome standard lamp, with
•an inscription expressing their appreciation of his work as
surgeon to the firm for the last ten years.—Dr. J. Eadie of
West Coker. Yeovil, has been presented by his friends in
Teovil and East and West Coker with a large black marble
-dining-room clock, accompanied with an illuminated address
expressing their high appreciation of his character when his
epatienoe and courage were severely tested to repel, which
be did successfully, a malignant slander. Tliis testimonial
'has been purchased by the surplus left from a fund raised
•to defray the legal expenses incurred by Dr. Eadie by the
prosecution referred to.
Queen Victoria’s Jubilee Institute for
Nurses.—A t a meeting of the Council held at St.
iECatharine’s Royal Hospital on Tuesday, it was reported
that Her Majesty had appointed the Marchioness of Lome
to be president of the Scotch branch and Miss Guthrie
Wright bon, secretary of the Scotch branch, and Mr. C. E. D.
Black to be an additional member of the Council. The
following nursing associations are also reported to have
been affiliated to the institute:—Liverpool, Haggerston
and Hoxton, Chelsea, Hammersmith, Hampstead, Ken-
•sington, Newington and Walworth, Bolton (Lancashire),
Westminster, Manchester, Worcester, Camberwell, Bangor,
Glasgow, East London, Coventry, and the Rural District
Nursing Association. Ninety-four nurses, whose names
Her Majesty has approved of, have been entered on the Roll
■of Queen’s Nurses.
A Centenarian.—A t Ballylinan, Queen’s County,
there died last week a woman named Dempsey at the extra¬
ordinary age of 110 years. Up to the time of her decease
she was in the possession of her mental faculties.
A Hospital Burned.—I ntelligence has been re¬
ceived that the hospital at Skopen has been entirely de¬
stroyed by fire and that fourteen of the patients were burned
to death.
Bequests and Donations.— Mrs. Helena Burnet
has left £200 to the Adelaide Hospital, Dublin, and Mr. J.
P. Law has given £50 to the same institution.—A donor
last week anonymously forwarded £1000 each to the Essex
and Colchester Hospital, and the Eastern Counties Asylum.
We have recently announced in these columns similar
; anonymous donations to these institutions.
University College, South Walhs.—L ord
Tredegar, Lord Aberdare, Lord Kensington, and Mr. Arthur
J. Williams, M.F., have each subscribed £100 to foim the
nucleus of a fund for the establishment of a department of
medical science at the South Wales and Monmonthshire
University College. A representative Welsh committee has
been formed to meet in London, with the object of carrying
out the project.
Royal Eye Infirmary, Piamouth.—T he record
of the past year’s work of this charity testifies that its
long career of usefulness is fully maintained. The medical
report for the year shows that during the sixty-eight years’
existence of the institution 07,915 patients had been treated,
of whom 60,586 were cured or relieved. In the past twelve
months 1328 persons received treatment, 620 being cured,
and 816 discharged benefited. The number of in-patients
was 264, and 413 operations had been performed.
Dental Hospital of London.—T ho following
gentlemen have been elected to fill the five addition^
appointments of the Dental Hospital, Leiceater-square,
vacant in consequence of the committee having agreed to
open the Stopping Department duriog the afternoons. The
order of appointment is W. H. Woodruff, L.D.S. Eng. ;
A. C. Woodnouse, M.R.C.S., L D.S. Eng.; F. J. Bennett,
MR.C.S., L.D.S.Eng.; J. F. Colyer, L.R.C,P., M,R.C.S.,
L.D.S. Lag.; and C. F. Rilot, L.R.C.P., M.R.C.S.,
L.D.S. Eng.
North Wales Lunatic Asylum.—I n consequence
of the increase of inmates in the asylum, it has been
decided to erect a new wing, and the special committee
presented their report at the annual meeting recently held.
It is proposed to erect a new dining-hall to accommodate
550 patients, and to supply sleeping and day rooms for 200
more patients. The committee approve of the purchase of
twenty-five acres of land adjoining the asylum, but that
awaited the sanction of the Commissioners in Lunacy, and
suggest that prizes should be offered for plans for the proposed
extension. The report was agreed to.
West Cornwall Dispensary and Infirmary.—
The annual meeting of tho subscribers was held on the
28th ult. The event of the year was the report of the sub¬
committee appointed to inquire into the abuse of the charity
by well-to-do persons. The committee found that many
such patients had taken advantage of the benefits of the
institution. Several suggestions were advanced to remedy
the abuse, which with two exceptions were adopted.
Another noteworthy incident was the munilicent oiler of
Mr. T. B. Bolitho to found a convalescent home in connexion
with the infirmary (which has already been noticed in these
columns).
Harrogate Royal Bath Hospital.— The Earl
of Harewood presided at the sixty-fourth annual mooting,
held on the 29th ult. The patients .admitted to the hos¬
pital in the past year, including 152 readmissiona and
twenty-two who obtained extra extensions, was 812, and
118 were admitted into the convalescent home. The total
number of baths given was 6399. The building fund debt
upon the hospital and convalescent home M’as £11,.897.
His lordship, in moving the adoption of the report, which
was carried, expressed regret that they had had to close
the Jiospital during the winter for lack of funds, and he
trusted a strong effort would be made to clear off the
encumbrances which rested' upon the institution. At the
close of the meeting his lordship offered £100 as a donation
to the committee.
Dig', 'ad ■>'/ Google
Thb Lancbt,}
MEDICAL NOTES IN PARLIAMENT.
[Feb. 7, 1891. 347
Hospital for Siok Children.—T he Duke of
Fife, K.T., president of the hospital, will take the chair
at the annual dinner, to be held on Wednesday, March 18th,
at the HStel M^bropole.
Hunterian Society.—T he annual dinner of the
Society will take place at the Holborn Restaurant on
Feb. 13th, at 7 p.m. The President (Dr. Stephen Mackenzie)
will preside.
Rotherham Hospital.—T he nineteenth annual
report is of a gratifying and encouraging character. The
total number of patients treated for tbe past year was
4708. The committee had again the satisfaction to state
that, as in the previous history of the hospital, in proportion
to its requirements the means for expenditure bad been
generously provided.
Medico-Psychological Association.—A t the
next quarterly meeting of the Association, to take place on
Feb. 19th, at Bethlem Hospital, London, at 4 p.m., Dr.
Clifford Allbutt will give his “Observations on the San
Clemente Asylum at Venice”; Dr. Savage will read a paper
on “The Plea of Insanity”; and Dr. Baker will read some
“ Notes descriptive of a new Hospital-villa recently erected
in the grounds of the York Retreat.” Dr. Hyslop will show
and describe pathological specimens.
The Hertford G-eneral Infirmary. — The
fifty-eighth annual report shows that the benefits bestowed
by this charity are well maintained. During the past year
265 patients had been under treatment. In the out-patients’
department the attendances numbered 7379. The income
from all sources was £2537 5s. Ur?., and the disbursements
(excluding the legacies, which had been invested) was
£2412 lls. Id. The building of a new lavatory and other
improvements had involved an outlay of £229, The actual
deficiency on the year was only £65 5s. Srf.
Halifax Infirmary.—T he annual report for the
past twelve months gives a good record of the work of this
charity. The total number of persons treated during the year
was 6247. There was a debit balance of £137 6s. Id. on the
receipts and expenditure, and the general investment account
showed the sum invested was £26,099 14s. ‘id. Improved
and much needed accommodation had been provided for the
nurses, and appreciable advantage had accrued by the ap¬
pointment of the admission and discharge committee. The
report was carried.
Hospital Sunday Fund.—O n Tuesday last a
meeting of the (Council of the Fund was held at the Mansion
House, the Lord Mayor presiding. A donation of £500 from
“ E. A. H.,” and one of £100 from Mr. Ludwig Mond, were
announced. The following were reappointed as tbo Distri¬
bution Committee for the year : The Lord Mayor, Sir Sydney
Waterlow, Sir Owen Roberts, Mr. J. D. Allcroft, Mr. Bonsor,
M.P., Mr. Thomson Hankey, Mr. Herman Hoakier, Mr.
F. H. Norman, Dr. Sedgwick Saunders, and Mr. Alfred
Willett. The hon. secretaries, Sir Edmund Hay Currie and
Mr. R. B. Martin, were reappointed, as also was Mr. H. N.
CuBtance, the secretary, and a special resolution, appre¬
ciative of the services of the latter, was moved by Sir
Sydney Waterlow and carried unanimously.
METROPOLITAN ASYLUMS BOARD.
Befwm of Patients remaining in the several Fever ffospitals
of the Board at midnight on Fcbruat'ii 3rd, 1891.
Hospital.
Be da occupied.
&
M-
i
efl
P
3^’
Enteric
fever.
si
si
t
a
Hospital .. ..
^®^fi-Westem Hospital'
South-Western ”
South-Eastern
Northern
Gore Farm ”
242
269
xno
1(12
228
278
18
40
88
10
12
13
17
2
63
7
37
18
2
1
2
345
D04
185
180
280
808
18
442
443
254
840
402
480
800
Totals .. „
1337
142
2
133
0
1620
2061
* 1 infant with mother.
MEDICAL NOTES IN PARLIAMENT.
Dr. Koeh.
In reply to Colonel Nolan, the Firat Lord of the Treasxiry sald it must
bo admitted that Dr. Koch did not stand alone aa a learned, patient,
and laborious investigator of the resources of nature for the benefit of
mankind. His great reward is the evident appreciation of the value of
his work by his own profession in all parte of the world, and the sense-
of the benefits he has conferred upon hie fellow-creatures. I do not
think any action of Her Majesty’s Government could really add to the-
satisfaction Dr. Koch must feel at the reception given by the civilised
world to his discovery, and he hesitated therefore to add a now function-
to the responaibllitios of Government.
Sfetropolis Water-supply MU.
Sir A. Borthwick lias obtained leave to introduce this Bill.
Metropolitan Water Companies Bill.
Mr. Causton asked the First Lord of the Treasury whether he would,
give facilities for the passing of tbe Metropolitan Water Companies''
Charges Bill, which contained provisions to prevent tbeconipahios-fromi
raising their rates through the quinquennial revaluation of charges, im
prospect of the early purchase by the public.—Mr, W. H. Smith replied
that it would be impossible for the Government to give facilities for
such a Bill, a.s their respojisibilitie.s must be limited to finding time for
Government measures.
l-’trcci'ji.afioji a?id the Factory A ct.
On Monday, Feb. 2nd, Mr. Fenwick asked whether a lad named
Arthur Brownjohn, who was engaged at the Clarendon I'l-ess, Oxford,
with the view to his becoming an apprentice in the classical composing
department, on making application to tbe medical officer for a certificate-
of physical fitness ns required by the Factory Act, was refused such
certificate on the ground that- he had not been vaccinated; and whether'
the medical oftioer was justified in withholding the certificate on euch
grounds ; and, if so, whether the Government were prepared to amend,
the law in this respect.—Mr, Matthews: No, Sir ; the certificate waa
not I'cfuscd by the medical officer, but signed in the usual way.' It was
stated in the “ Remarks” column of the form that the hd was “ unvac¬
cinated,” The controller of the Clarendon Press considered thi.s to be
an insufficient certificate, and refused to employ tbe lad.
Railway Servants and Hours of Labour.
Sir Mirdiaol Hicks-Beach moved that a Select Committee be appointed
to incinire whether, and, if so, in what way, the hours worked by rail¬
way servants should bo restricted by legislation. Mr. John Ellis said
he did nob sob the necessity for the appointment of a Select Committee.
Mr. Channing said ho hoped that if the Comniitteo reported in favour
of legislation the right hon. gentleman would do aU in his power to-
secure that the legislation should be intioduced during the present
session. Mr. M'Lsreti welcomed the proposal, and the motion was-
ultimately agreed to. _
'I’HF. IIOU.SIC OF LORDS’ COMMITTEE ON HOSPITAl.S.'
The .Select Committoo of the House of Lords on the Metropolitan.
Hospitals re.sumeit its iiKpiivy on Monday, Lord Sandhui-st presidiug.
St. Thomas’s Hospital.
Mr. Robci't Bi'a.'is, the receiver of St. Thomas's Hospital, was the-
first witness e.xamini'd. lli.s salary, he said, amounted to ,eooo, which
represented his whole income from the liospital. He did not live at
the hospital, and received no allowance for hou.se aceomniodiltion.
His duties were to receive tlie rents, examine all accounts presented for
payment, malie up the cash books, draw up a statement of receipts and
payments every year, and genorally to do the work of respon;iible
accountant of the hospikvl. He submitted his accounts to the treasurer-
ami almoners, who checked and criticised t hem. Ltist year they derived
.-614,481 from country estates, spread over ten counties. To all intents and
pnrpo.ses Ht. Thoma.s’s Ho.spital was a free hospital. They had about
840 govoruors, but. the cases recommended by governors wore not neces¬
sarily admitted ; the recommendation for luimissiou was in fact disease..
Tlie worst ca-so was the case which had the best chance of adinisaion.
There were two wards occupied by p.aying patients ; the receipt.s from
these wards last year amounted to .tf-OOH. Owing to want of funds,
tliey had two wants Huocenpied; these wards had accommoilation for
sixty beds. They liacl f-o roliise a great- many patients tlirough lack of
fund.s. Tliey paid ra.tos to iho extent of ,62308 per annum. As to tlieir-
town property, they received in rental in 1880 from Southwark ,611,980,.
the City 611,138, Haclcnoy and Clapton .67140, and \l’’aiiping .61408.
Wliilo tlieir London property had increased in value during the past
ten years, their country property had fallen in annual value from
617,307 to ,614,481. The gros.s receipts for 1889 amounted to 607,000,
and after paying all oxpen.stj.s bo had .640,040 to bring down for hospital
purposes. At the reiiuest of sovoial members of the committee,
Mr. Brass undertook to prepare a detailed statement accounting for
the difference iK-ttwoon 607,000 and .640,040.
Mr. Frederick Walker, steward of St. Thomas’s Hospital, said he Imd
held his present office for forty-throe years. Ilia salary amounted to-
6055, with a residence in the hospital. 'The present building was opened
in Septonilier, 1871. For nino years previously the hospital was carried
on at the Surrey-gardens, and prior to that at London-bricige. The co.st
of the present feuilding and tbo neces.sary land was about .eoOO.OQO, of
which over ,640,000 was laid out on foundations. They had to borrow
6100,000 to meet the cost of the building. The out-patient department
was absolutely free. The assistant physician selected from among tlie-
applicaiits those cases which were fit for admission. From among the-
oinevs be selected the worst cases for regular out-patients, Of the re-
maindei', a small number were prescribed for. A small proportion of
cases wore dismissed as too slight. All the surgical ca.sos were attended,
lu midwifery cases they limitoi thoraaelvea to the area within a radius of
one mile of tho hospital. As matter of fact, they had .at present eighty
vacant bods. When tho hospital was openett all the wards were free. On
account of financial pressure they had tocloso five wardsayearafterwards,
and .since then they had remained cloaed, with the exception of the two“
wards opened ten years ago, for paying patients. They would require au
additional annual income of .60nu0 or 67000, to throw open all the wards-
They had never appealed to the public in the ordinary way. They got
>c-. (e
D
$48 The Lakcet,]
BOOKS ETC. RECEIVED.
[Fkb. 7,1891.
too money from the Hospital Sunday Fund; tiiey took case.^ of diphtlieria
into the hospital; they had eighty-eight such cases last year. Two
'nurses contracted the disease, hut verv slightly. They rarely took in
■cases of scarlet fever. It occasionally happened that scarlet fever
developed in patients after they had been some time in the hospital *
^ey put those patients into the infectious block. Itwas placed beyond
' doubt that the two nurses contracted diphtheria while attending the
.patients affected with that disease. The health of the officials and
"nurses was, on the whole, good. They could easily till the hospital if
at were double its present size. They had to ttirn away “ many good
f iatients.” He concurred in the view that the hospital accommodation
or the poor on the south side of the Thames was lamentably insufhciont
The circumstances of the district had greatly changed In recent years.
Complaints, no doubt, came from the wards from time to time as to the
'food. ’They were all investigated, and steps were taken to remedy any
defects which might be discovered. The matron who had charge of the
nurses was paid a salary of £200. The nurses were trained under tiie
Nightingale Fund, which entailed residence in the hospital during the
period of tuition. In the event of a nurse misconducting herself,
.she was suspended, and I'eported fo the treasurer and almoners.
Hr. W. M. Ord, one of the physicians at St. Thomas's Hospital, said
'that for twelve years he held the office of dean of the Medical Scliool con-
laected with the hospital. In his opinion itwas much better that the large
general hospitals should have their own medical scliools than ihat there
should be one central university for medical edocation. As things
■ advanced, it would clearly be his opinion that the smaller schools
-should be grouped for the earlier subjects. In fact, as an old tospital
'physician, he would not be sorry to see the whole of the teaching in the
earlier suuiecis taken from the hospital schools and relegated to some
•central body. It would secure greater uniformity of study and lend to
drhe employment of the best class of lecturers. A central system would
give the greatest opportunity for practical study. If a phico were
-starved and weak, its laboratories naturally became imperfect, and even
'tbe large hospitals in I.ondon, with all their funds, were not loo rich.
There wore nearly 400 students in the medical school at St. Thomas’s
Hospital. The number had been on the increase during the last few
years, although last year the increase was not so great as usual, The
•lee for the curriculum was i‘25 guineas. The inc-mie of the school last
•year amounted to between £8000 and .£ 0000 , and the expenses to about
£3000. The profits, so to speak, were distributed among the .staff and
Uecturers in certain proportions. He did not think that the presence of
a medical school increased the expenditure of a liospital. The students
performed gratuitously work which in other circumstances must be paid
Jor out of tlie funds of the hospital. He was not there to advocate a
-central school; he merely stated certain advantages wliicli appeared to
tfcim.
1 The Committee mot again on Thursday, Lord Sindhurjt presiding.
Mr. J. Q. Wainwrigbt, Treasurer of St. Thomas's Hospital, said tliat as
superior officer he had control over all the other officers and servants
iin every department of the hospital. Any case of complaint or discovery
of abusive conduct was reported to him. In the event of serious delin-
-quency be would suspend the officer pending inquiry. He was an
honorary official, with a residence at the hospital. The sur)reme autho-
■riby was the full Court of Governors, of whom thirteen made a iiuomm.
Tbe minutes of the Grand Committee were confirmed by the (,'ourt of
Governors. A final court of appeal to any officer who might bo disaati^-
fled was afforded by the Court of Governors. The funds of the hospital
allowed a maximum of 43S patients. In Ht. Thomas's Home they had
paying patients who paid ai the minimum rate of nine shillings per day.
He calculated that every bed cost about £02 per annum. Want of funcl.s
explained the presence of paying patients and vacant wards. No doubt
.dbere was a want of hospital accommodation for tbe poor in the south
•of London. They had a large out-patient system. They made no special
iimuity as to the circumstances of the patients, To appoint inquiry
officers would be very expensive. He himself regarded that depaitment
very narrowly, and if he saw a person whom lie thought ought not to
be there he spoke to him. lie did not think tliat any groat amount of
r-unfair advantage was taken of the hospital. The authorities did nob
bury the dead, but put them in shells.
By Earl Catiicart: He did not think that their income had lioen dis-
•sipated by erecting their present large hospital. It was certainly the
■case that they had borrowed £100,000 to ftieot the cost of building. At
■one time it was suggested that one block should bo left unbuilt, bub
ultimately the govornore decided to complete the plan. Out of their
income they paid about £ii00U a year to the capital account. He did not
•consider that tlie hospital was on too extended a scale.—Earl Cathcart:
i5>o you not think it your duty to make an effort to accominodate the
.poor people who are clamouring for admission? You must romember
-you have five wards either vacant or occupied by paying patients —Mr.
'SVainwright: We thought we were doing well when wo opened those
two wards forpajiiig patients iu order to obtain funds.—Karl Cathc.art:
But would it not bo better to .say to tlie public, " We have made a mis¬
take in building this large hospital, and wo have empty wards : won't
:you assist us-with funds?’—Mr. Wainwriglit: Possibly it iniglib be. On
<ineocca3ionw6appealed to the public. We placed the wlioleiii.'Xttor clearly
before tho public, and we had a great struggle to got £‘20,0iJi), mo.st of
which was subscribed by our own govomor.s.—Earl C'jitiicavt; Was tliat
Tiecaiiso the public had not oonndonco in your management'?—Mr.
Wainwrigbt: I don't know that.
Examined by Lord Thring, tho witness said he know of no economy
•which could be advantageously instituted in connexion with the hos¬
pital expenditure. The architect received a salary of £200 and 2i per
• cent, on repairs. The average annual cost of repairs during the past
'ten years was about £3000, He did not regard tuat sum as too large,
-considering the nature and extent of tlie building, He was not aware
tliat house surgeons were on duty for sixteen or .seventeen hours at a
'time. They mleht be on duty for fourteen or fifteen hours, though
mot absolutely employed all that time. If the surgeons were ovor-
•worked they would not have the same clamour, as he might call it, for
lihe appointments.—Lord Thring: A man will work himself to any
extent in order to get up in tho world.—Mr. Waliiwright submitted
that the house surgeons were not overworked,—The Chairman ; As to
ithis deficit, surely you might appeal to the public?—Mr. Wainwriglit:
We certainly might. Tlie only thing against such an appeal is the
chance of not getting a proper response.—The Cliainnan: Don’t you
think that hospitals are like jilaces of business, tlicy ro(|iiiro a good
deal of a<IvertlBing? Mr. Wainwriglit: The hospital is fairly well
Tknown to tbe public. The building itself is a good adverbiseinout.
Mr. Robert Brass, receiver of .St. Thomas’s Hospital, gave further
evidence as to the funds and accounts of tbe institution. He explained
thattho building debt had been reduced from £100,000 to £33,000. In
addition to the interest, they paid off £3800 a year of capital. They
had no stock tliey could sell. They had capital in the Court of
Chancery and with the Charity Commissioners, for which they received
interest at tlie rate of 2^ per cent., while they paid 3 per cent, for their
building loan. The capital in tho (Jourt of Chancery and with the
Charity Commissioners would suffice to wipe off ttie building loan. The
hospital buildings were rated at £8000, and were Insured for £80,000.
Miss Entwistle, late nurse in St. Thomas's Hospital, said that in her
opinion the bours of nurses in the hospital were excessive, and alto¬
gether their duties were too exacting, A sister wont on duty at eight
o’clock eacli morning and continued there until half-past ten o'clock at
night, ivith two hours off duty and two lialf bours for dinner and tea.
The nurses wont on duty at seven o'clock iu the rooming. She con¬
sidered those hours excessive, for they applied to all the seven days of
the week. She made no complaint for this reason : that St. Thomas’s
Hospital was bettor off than any other in Loudon. The nurses were
bettor cared for. and their food and lodgings were better iu St. Thomas's
than in -any otlier hospital iu London. She would like to see the
number of staff nurses incroa.secl. All the wards in St. Thomas's should
have two stiff nurses during the day and three probationers. On
account of the iiaburo of their work sisters required more rest and
holidays than they now received. In her opinion the trained nurses
suffered most from overwork She had a high opinion of the general
arrangements of St. Tliomas's Hospital, bub she considered that the work
of the nurses was more arduous than women ought to undertake.
Miss Gordon, matron of Si. Thomas’s Hospital, explained to tho Com¬
mittee the arrangemeubs which shucoiitrolled.
The Committee afterwards adjourned.
BOOKS ETC. RECEIVED.
BaiLLiiRE, Tindall, & Cox, London.
Koch's Romedy, in relation .specially to Throat Consumption. By
Lennox Browne, F.R.U.S. Bdin. Illustiuted. 18'J1. pp. 114.
Bl.ACKiK <fc Son, Old Bailey, London.
An Elementary Text-book of Physiology. By Vincent T. Murche,
pp. 202.
CiiurcUILL, J. & A., New Burlington-street, London.
The Westminster Hospital Reports. Vols. IV. and VI., 1888 and
1800,
Transactions of the Ophthalmological Society of the United King¬
dom. I'ol. X. Bessioii 1880-00.
Cornish Bros., New-street, Birmingham.
The Bleraents of Ophthalmic Thurapeutics. By D, C. Lloyd-Owen,
F.Il.C.S.I. 1890. pp. 08.
Davis, F. A., Philadelphia and London.
The Daughter; her Health, I'Mueation, and Wedlock. By William
M. Capp, Mb. 1801. pp. 144.
HiRSCiii'ELD Bros., Bream’s Buildings, London.
A Manual of Organic Materia Mcdica. By -T. M. Maish, Ph.M.
Fourth Edition. Wiih IlluHtratioiis. pp. 530.
Howe & Co., Paienioster-row, London.
General Booth and his Critics. By If. Greenwood, M.A., LL.D.
1800, pp. 128.
Lewis, II. K., Gower-street, Loudon.
The Action of Water on Lead. By J. H. Garrett, M.D. 1891.
pp. 110.
LiiTiNcoTT, J. B,, Company, PliUadelphia.
Cyclopfcdia of tho Disoaies of Children. Edited by J. M. Keating,
M.D, Vol. IV. Illustrated. 1891). pp. 1128.
LONOMANS, Green, & Co., London.
Outlines of Physiological Psychology. By 0. 'T. Ladd. 1891.
pp. 605. Prico 12s.
Macmillan & Co., London.
A Series of Chemical Problems. By T. K, Thorpe, B.,Sc (Viet.),
Ph.D. Revised and enlarged by VV, Tate, Assoc N.H.S. (Honours),
F.C.S. New Edition. 1801. pp. 139. Price 2k.
Index Medicua : Authors and Subjects, Vol. XII., No. 12, December,
1890 (Triilmer A Co , and l.owis, Lonilon).—Studies from the Pliysio-
logical Laboratory of Owens Coilego, Manchostor, Vol. I (.1, E.
Cornish, Manchester, 1891); prico 10»,—L’Asepsio ot I’Antisopsio k
rilftpital Bichat; par Marcel Baudoiiin (E. Locrosnior ot Babe, Paris,
1890) ,—Tr.aiti; Eldmontaire d'Aiiatoniie Mddiciile du Systiime Norveux ;
par Ch. Furd (Lecrosiiier et Babe, Paris, 1801).—East and West: a
Weekly Newspaper and Review (Woodford, Fawcett, A Co., London,
1891) ; prico Id, — Paternoster Review. —Intorno alia Misaiono al
Congres.so Intornazionale Medico di Borliiio, nell' Agoelo del 1890 :
rapporto del Dottoro Felice Santlni (O, Burtoro, Roma, 1391).—
Therapoutisches Lexikon fiir Pi-aktisclie Aorzto; horausgegebeii voii
Dr. Anton Bum ; Ideforaiig 13—10 (Urban G. Schwarzenberg, Wion
uud Leipzig, 1899).—The London Huioko J’laguo, by B, U. Th'svnite,
C.E., A.M. Inst. C.E. (published by " Industries," Limited., Strand,
I.nniloii).—La Sanlta Pubblioa, dal Dott C. Kuata (.S. l.api, Citth di
Oastello, 1891).—Magazines for February; Good Words, Sunday ai
Homo, Leisure Hour, Sunday Magazine (Isbister), Boy's Own Paper,
Orl's Own Paper (Religious Tract Society), Scribner's.
r Coogle
THB lancet,] APPOINTMENTS.-VACANCIES. -births, MARRIAGES, & DEATHS. [Feb. 7, 1891. 349
^pintnunts.
afplioanti/or Yaeancies, SeentaHet ef Publio Instituticna, and
others poagesaitiff Wonnation euitabU fvr this aolvmn, are invited to
forward it to The Lancet 0£loe, direoted to the Sub-Editor, not later
than 9 o’eloek on the Thursday Tnomino of each week for publieation in
the neat number. — ■ —
Ashdown, G. W. W., M.B. Bdln., M.R,0.8., has boon appointed
Medical Officer to the Tetbury Cottage Hospital.
BLUMBERU, Henry, M.D. Prague. L.R.C. P. Lond., hoB been appointed
Honorary Medical Officer to the Southport Hydropathic Hosintal,
BOASE E. D., L.R.C.P. Lond., M.R.C.S., has been appointed Honorary
Surgeon to the West Cornwall Dispensary and Infirmary,
BCLGER, M. J., Lie. Med. L.Ch. Dub., has been appointed Assistant
Surgeon to the Richmond Hospital, Dublin.
BULLOCK, T. W., M.R.O.8., has been reappointed Senior Surgeon to the
Warwick Provident Dispensary and Cottage Hospital.
Cameron, James A., M.D,, M.B,, C.M.Edin., has been appointed by the
Joint County Councils of Banff, Elginshire, and Nairnshire Medical
Officer of Health tor the three Counties. ,
Davies Sydney, M.D., M.B., M.R.C.S., has been appointed Medical
Officer for the Parisli of Plumstead. ,
DAQaETT. H. J., M.B., B.C.Camb., L.R.C.P. Lond., M.R.C.S., has been
appointed House Surgeon to the Ripon Cottage Hospital and Dis¬
pensary, vice Buxton. . .. ,
FOOIT St. John T., L.R.C.P., L.R.C.S. Edln., has beon appointed
Medical Officer for the Thinl District of the Hollingbourn Union,
vice Langston, resigned. , . . ~
FOX, J. A., L.R.C.P.Lon(l., has been appointed Honorary Surgeon to
the West Cornwall Dispensary and Infirmary. , ^ ,
Fry j F., L,U.C.P. Lond., M.R.C.S., has been appointed Medical
Officer for the First District of the Shopton Mallet Union.
Grant, F. W,, M.D,, M.B., C.M.Edin., has been appointed Visiting
Physician to the Gray's Hospital, Elgin, vice Galletly.
Hunter W. L.. M.D., M.B. Dub., lias been appointed Medical Officer
of Health for the Pudsey Urban Sanitary District of the North
Bierley Union, vice Wilson. „, , . . ,
Montgomery, H. M..M.D, M.B., C.M. Edin., has been reappointed
Assistant Physician to the West Cornwall Dispensary and In-
MONTOO^ERY, J. B., M.D. Glasg., F.R.C.P. Lond., M.R.C S.. has been
reyipulntetl Physician to the West Cornwall Dispensary and
Inffiniary. __ , , , , ,
PEARSE, TH03. Fredk., M.D., F.R.C.S., M.R.C.P., has been appointed
Medical Examiner for the Gresham Assurance Company at Soiithsea,
Perkin, R. F. T., L.R.C.P. Edin., M.R.C.S,, has been reappointed
Visiting Surgeon to the Warwick Provident Dispensary and Cottage
Hospital. , . . y „
Pollard, Reginald, M.B., M.R.C.S., has been appointed Honorary
Surgeon to the Torbay Hospital, vice H. Gordon-Cumming,
Powers,' cf n., L,R.C.P., M.R.C.S.,has been appointed House Surgeon
to the Cumberland Infirmary, Carlisle.
Sharpe, Wm. C., M.B., C.M. Edin., has been appointed Junior Phy¬
sician (Resident) to Smediey's Hydropathic Establishment, Matlock
Bridge, vice C. J. Whitby, resigned. . ^ o ,, ,. ,
Shimki.d, Jas., L.R.C.P., L.R.O.S. Edin.. has been appointed Medical
Officer of Health for the Ilford Urban Sanitary Dletnct of the
Romford Union.
Smeeth, Henry G., B.A., M.D., B.Ch.nub,, has been appointed
Medical Officer to the Heaton Norris (No. 2) District of the Stock-
port Union, vice Bale, resigned. , ^
Stopi'ord, R., L.K.ti.C.P,, L.M. Irel.. has been appointed Honorary
Medical Officer of the Southport Hydropathic Hospital.
Symons, J., M.R.C.S., has been reappointed Surgeon to the West
Cornwall Dispensary and Infirmary. .
'rnmiTS, John, M.D. St. And., M.R.C.S., has been reappointed Medical
Officer to the Warwick Provident Dispensary and Cottage Hospital.
Waite, Henry, L.R.C.P., L.M. Edin., has been appointed Medical
Officer for the Upper and Lower District of the Brainley Union.
WaiTiiY, Charles j,, B.A., M.B. Cantab., hasboenappointed Resident
Physician to the West of England Hydropathic Establishment,
Limpley Stoke, Bath. ^
Williams, W. O., L D.S. U.O.S., has been reappointed Honorary Dental
Surgeon to the Warwick Provident Dispensary and Cottage Hospital.
Wilson, Andrew, M.B., C.M. Glasg., has been appointed Assistant
Surgeon to the Glasgow F^ye Infirmary.
firarics.
County Council for the County of Derby.—M edical Officer of
Health for the Administrative County of Derby. Salary £300 per
annum, wltli £200 extra for travelllDg and other expenses. (Apply
to the Deputy Clerk to the County Council, 40, St. Mary's
Gate, Derby.)
County of Fife.—C ounty Medical Officer for the counties of Fife antL
Clackmannan, to act also as Medical Officer for the four districts of'
the County of Fife and for the County of Clackmannan. Salary
for the combined offices £000, with travelling expenses. (Apply
to Mr. Patrick, County Clerk, Cupar Fife.)
County of Lanark.—M edical Officer for the County. Salary £700 per
annum, with travelling expenses &c. (Apply to Mr. Dykes, County
Clerk, Ilamilton.)
Doncaster Ghneral Infirmary and Dispensary.—H ouse Surgeon,,
Salary £l<i() per annum, with board and residence in the hospital.
East Suffolk and Ipswich Hospital.—A ssistant House Surgeon.
Salary £2o per annum, bojrd, lodgings, and washing allowed.
(Apply to the Secretary, Tliorofare,Ipswich.).
Farrinudon General Dispensary and lyinq.in Charity, 17, Bart-
lett’s-buildings, Holborn, E.C.—Honorary Physician Accoucheur.
Hospital for Consumption and Diseases of the Cuest. Brompton.—
House iMiysiciaua.
Hospital for Sick Children, <3reat Ormond-streeb, Bloomsbury,,
W.C.—Resident Medical Officer as House Physician for one
year. Salary £30 per annum, with board and residence in the-
hospital.
Liverpool Infirmary for Children.-A ssistant Honse Surgeon for
six months. No salary, but board and lodging provided.
National Dental Hospital, 149, Great Portlaud-streot, W.—House
Sui'geon. Salary £50 per ailnum.
Nf.wcastc.e-on-Tvne Dispensary.—R esident Medical Officer. Salary
£2.50 per annum, with furnished residence.
Nottingham General Hospital.—R esident Surgical Assistant for
six months. No salary, but board, lodging, and washing provided
in the hospital.
Nottingham General HOSPIXAL—Resident Medical Assistant for'
six months. No salary, but board, lodging, and washing provided
in the hospital.
Owens Coi.lrge, Manchester.—Demonstrator in Pathology. The
stipend is £140 per annum.
Parochial Board of- Fettercairn.—M edical Officer. (Apply to Dr.
Prain, Fettorcairn.)
ScarborouwII Uosimtal and Dispensary. Scarborough.-House Sur¬
geon for twelve months. Salary £ij0 per annum, with board and'
lodging.
Secretary, London Society for Promoting Christianity amongst
the Jews, 10, Lincoln's-inn-flelds, W.C.—Medical Missionary tO'
the Jews at Safe<l.
University of Glasgow.-E xaminers in Medicine. Tlieannual foe to
each of the Examiners is £30. Term of office in each case is four
years.
York FriendlvSocieties'Medical As.sociation.—A ssistantMeoicaii
Officer. Salary £151) per annum, with an allowance of £20 for con--
veyancea, and 7k, accouchement fee. No residence found.
(Apply to Mr. Brown, 23, Markham-street, York.)
Hlaraages, aiilr
BIRTHS.
Coward.—O n Jan. 28th, at Burdett-road, Limehouae, K., the wife of
Christopher T. Coward, L.F.P. AS. Olas. and L S.A. Lond., of a son.
Davy.-O n Jan UUt, at Wolbeck-street, Uavendl-'h-aqiiarB, W., the wife
of Richard Davy, F.R.S.E., of a daughter.
Fraser —On Jan. 3lst, at Drumsheugh-gai-dens, Edinburgh, the wife.i
of Dr. Thomas U. Fraser, F.E.C.P.E.. F.R.S., of a son.
Ryan.—O n Jan, 27th, at The Limes, Northleach, Olosts, the wife of J.
Ryan, L.IC.O.O.IM., of twin daughters.
Sharpe.—O n Jan. ''Oth, at Gloucester-crescent, Hyde-park, W., the-
wife of Win. Salisbury Sharpe, M.R.C.S., L.R.C.P,, of a daughter.
MARRIAGES.
Samuelson—C lREV.- Oil Feb. 2nd, at Sydney, N.S.W,, Gerard S..
Samuelsou, M.B., C.M. Edin., of Bourke, Australia, son of the late
Alexander Samuelson, C.E., to Fon'oster Anne, daughter of the
late John ICdward Ggilvie Grey, of Moiiktoii Hall, ami Gilmore-
placo, Kdinbutgii. (By cable.)
Taylor— Goon.—On Jan. 3Ut, at Christ Church, Woburn-square, w.C..
Sydney .Johnson Taylor, M.B., C.M., M.R.C.S., of Norwich, tO'
JhiylUa Kiiisoy Oood, of Gussage Manor, Cranbouvne, Dorset.
DEATHS.
Por further v>\forrnatwn regarding each vacancy reference should be made
to the adoertieement,
Addeniirooke’s Hospital, Cambridge.—Resident House Physician.
Salary ,£06 per annum, with board, lodging, and washing in the
Hospital.
BRITON, Streatham, ANT) Herne IIiLL DISPENSARY.—Resident
House Surgeon. Salary £100 per annum, with furnished apartmonta,
atLendanco, coals and gas. (Apply to the Secretary, Water-lane,
Brlxton.)
Brown Animal Sanatory Institution.—P rofessor Superintendent.
Salary ,£250 per annum. (Ai)ply to the Hogistrar of the University
of London, llurlington-gardena, W.)
CENTRAL London sick Asylum District.—A ssistant Medical Officer
and Dispenser for the Asylum in Cleveland-stroct. Salary £100
S er annum, with Vioard and roaidenco. (Apply to the Clerk tu the
lauagers, Clevolaiul-Htreet Asylum, Cloveland-stvoet, W.)
CITY OF London Hospital for Diseases of theCiiisst, Victovia-park,
10,—House Pliysician for six months. No salary, bub board and
residence, and an allowance for washing provided, (Apply to the
Secretary, 24, Finsbuiy-circus, E.O.),
linin —On Jin. 3lst, at San Remo. Peter llinckea Bird, M.D.. F.R.C.S.
Kiig., D.P.II. Cantab., aged 03.
0 O[.n _on Jan. 2l)bh, at West Taniug, Worthing, Ricardo Cope,
M.R.C.S. Eng., youngest son of the late Charles Henry Cope, of
Binuiiighaiii, aged (H».
Dayman.—() n .Ian. 2ath. at Mllbrook,Southampton,Barnneld Dayman,.
L. 11.C.P. Loud.. M.U.C.S.
liVANS.—On Feb, 1 st, at Bridport, Dorset, George Moule Evans, Surgeon,.
GKomfiV—On, Jan. 30th, John Wiunall George, M.R.C.S., L.S.A., of.
Malvern liinlc, aged 50. , . , „
lioiouon'—On Dec. Oth, 1890, at Bundaberg, Queensland, Ilonry
llolcrofb, M.B.C.S. Eng., sou of the late William Francis Holcroft,
of Sevenoaks, aged 35. ,
MiiNZiES.—On Jan. 25tli, at his residence, Lothian-road, Edinburgh,
William Mcn/.iea, M.D. St. And., F.R C.S. Edin., aged 84.
Turner—O n .)an. 3lBt, at Stockport, George Turner, M.D. Edm.,
M. R.C.S., Rged 9-1. _
S.B.—A fee qfd8.is charged for the Insertion oj Notices (if Births,
Harriages, and Deaths,
350 Thb LancbtJ
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Feb. 7,1891.
giars for titsninj Mrrk.
Monday, February 9.
BOT^ London Ophthalmic Hospital, Moobfiblds. ~ OperaUons
daily at 10 a.m.
Eotal Westminster Ophthalmic Hospital.—O perations, 1.80 p.m..
and each day at the same hour.
Chelsea Hospital for women.—O perations, 2.80 p.m. ; Thursday, 2.80.
8 t. Mark’s Hospital.—O perations, 2.80 p.m. ; Tuesday, 2 80 P H
Hospital for Women, Soho-square.—O perations, 2 p.m., and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.m.
Eoyal OBTHOP.fiDic Hospital.—O perations, 2 P.M.
Central London Ophthalmic hospital.—O perations, 2 p.m., and
each day in the week at the same hour.
University College Hospital.—B ar and Throat Department, 9 a.m. :
Thursday, 9 a.h.
London Post-graduate Course.—R oyal London Ophthalmic Hospital,
Moorflelds; 1 p.m., Mr. R. Marcus Gunn: Cataract.—London Throat
HoTOitaI,Gt.Portland-at. :8 p.m.. Dr. E.Woakes:TinnitusandVertiffo.
RoyalCollegeopSurqeons OP England.— 6 P.M. Mv.J. Bland Sutton:
The Value of Comparative Pathology to Philosophical Surgery
Throat Hospital (Qolden-sq.).—5.30 p.h. Mr.MarkHovell: Acute In-
nammation of the Middle Ear, and its Treatment. (Post-Graduate
Course.)
SOCIETY OF Arts.—8 p.m. Mr. A. J. Hipkins : The Construction and
Capabilities of Musical Instruments. (Cantor Lecture.)
The Sanitary Institute (Parkes Museum, Margaret-st., W.).—8 p.m.
Professor H. Robinson : Drainage.
Medical Society op London.—8.3u p.m. Dr. Douglas Powollwill open
a Discussion on Angina Pectoris.
Tuesday, February 10.
King's College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
Guy’s Hospital.—O perations, 1.80 p.m., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 p.m.
St. Thomas's Hospital.—O phthalmic operations,4 P.m.; Friday,2P.M.
Cancer Hospital, Brompton.—O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.30 p.m.
St. Mary’s Hospital.—O perations, 1.80 p.m. Consultations, Monday
2.80 P.M. Skin Department, Mond^ and Thursday, 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Electro-
therapeutics, same day, 2 p.m.
London Post-graduate Course.—B ethlem Hospital: 2 p.m.. Dr.
Savage : General Paralysis of the Insane.
Royal Institution.—8 p.m. Prof. V. Horsley; The Structure and
Functions of the Nervous System.
Society op Arts.—8 p.m. Mr. Heywood Sumner: SgrafBto.
Royal Medical and Ciiiruroical Society.—8.8o p.m. sir Geo. M.
Humpliry: On Macrodactyly and some other forms of Congenital
Overgrowth, and their relation to Tumour.s.—Mr. Bnrwell; Rachi-
lysis, its Object and its Method.
Weduesday, February ii.
National Orthopedic Hospital.—O perations, 10 a.m.
Middlesex Hospitau—O perations, 1 p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour, (^hthaimic Operations, Tuesday and Thursday, 1.80 P.M.
Surgical Consultations, Thursday, 1.80 P.M.
Charing-cross Hospital.—O perations, 8 p.m., and on Thursday and
Friday at the same hour.
ST. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 p.m. Thursday ASaturday, same hour.
St. Peter's Hospital, Covent-qarden.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Children.—O nerations
2.80 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, i.30p.m. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 9.16 a.m.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations, 9.80 a.m. :
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
London Post-graduate Course.—H ospital for Consumption, Bromp-
ton: 4 P.M., Dr. R. Maguire; The Diagnostic Indications of the
.Sputum, with Demonstrations.—Royal London Ophthalmic Hos¬
pital, Moorflelds; 8 P.M., Mr. A. Quarry Silcock : Ohoroiditis.
Royal College opSurokonsopEnolanr.—.' jp.M. Mr. J. Bland Sutton:
The Value of Comparative Pathology to Pliilosophical .Surgery.
Throat Hospital (Golden-sq.).—6.30 p.m. Dr. Norria Wol/onden:
Cancer of the Larynx. (Post-Graduate Cour.se )
Hunterian Society.—7.30 p.m.. Annual Meeting. Annual Oration
by Dr. Flotclier Beach.
.Society op Ak'J's.—8 p.m. Sir Roper Lethbridge: The Proposed Irish
Channel Tunnel.
'-l.'Hh WANiTiTUv Institute (Parkes Museum, Maigarot-at., VV.).—8 p.m.
Dy, Louis Parkes : Model Dwellings in London, and Overcrowding
on Space. The paper will bo followed by a Discussion.
Thursday, February 12.
St. George's Hospital.—O perations, l p.m. Surgical Consultations,
Wednead^, 1.30 P.M. Ophthalmic Operations, BViday, 1.30 P.M.
University College Hospital.—O perations, 2 p.m. : Bar and Throat
Department, 9 a.h.
London Post-graduate Cour.se.—N ational Hospital for the Paralysed
and Epileptic: 2P.M..Mr.V.Hor8ley: burgeryof tlieNorvousSystem
Hospital for Sick Children, Gt. Ormond-st.: 4 p.m., Mr B Pitts
Selected Surgical Cases.—London Tliroat Hospital,Gt.Portland-st.
8 P.M., Dr. McNeill Whistler : Phthisis as It affects the Larynx
ROYAL Institution.—3 p.m. ProfessorC. Hubert H. Parry: The Position
of Lulli, Purcell, and Scarlatti in the History of tlie Opera (with
Musical Illustrations).
British Gyn.*colooical Society.—8.80 p.m. Speciinons byDi'. R. T.
Smith and Dr. F. Barnes, and Diawings illustrating Anatomical
Peculiarities of a Symelian Feetus by Dr. Bennington, with Notes.
Friday, February 13.
Royal South London Ophthalmic Hospital,—O perations, 2 p.m.
Cancer Hosittal (Fulham-rd., S. W.).—4 p.m. Dr. H. Snow: The Non
operative Treatment of Cancer; its LlinitatioDs and Fitting Scope
London Post-graduate Course.-H ospital for Consumption, Bromp
ton: 4P.H., Dr. R. Maguire: The Diagnostic Indications of thi
Sputum, with Demonstrations.
Royal College ofSurgeons of England.-6 p.m. Mr. J. Bland Sutton
The Value of Comparative Pathology to Philosophical Surgery.
The Sanitary Institute (Parkes Museum. Margaret-st., W.)7—8 P M
Sanitary Building Construction.
Clinical Society opXondon.—8.30 p.m. Dr. Hale White and Mr. W. A
Lane: A case of Stricture of the Pylonis following upon Hydro
chloric Acid Poisoning In which a modified Loreta’s operation wa
perfomed.—Mr. H. W. Ailingham: A case of Removal of Suppurativ'
Vermiform Appendix.—Mr. J. Bland Sutton; Cases of Excision o
the Vermiform Appendix.—Mr. Andrew Clark; Two cases in wbicl
the Vermiform Appendix was excised.
Royal Institution.-O p.m. Professor A. Schuster: Some Results o
Recent Eclipse Expeditions.
Saturday, February ii
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p.m. ; and Skin Depart
ment^9.I6 A.M.
London Post-graduate Course.-H ospital for Diseases of the Skin
Blapkfriara: 2 _p.m., Dr. Payne: Seborrheea and Allied AfEeotions.-
Bethlem Hospital: 11 a.m., Dr. Percy Smith: Clinical Demonstration
Royal Institution.-op.m. The Right Bon. Lord Rayleigh; The Force
of Cohesion.
METEOROLOGICAL READINGS.
(Taken AMy at S.80 a.m. by Steward's Instrxmtents.^
The Lancet Office, Feb. 6th, 1891.
Data.
Baromster
reduosd to
SaALovol
and 83° F.
Dtreo
Uon
ot
Wind.
Dry
Boll).
Wet
Bulb.
Solar
Badla
in
Vaouo.
Mui-
mum
TecQD.
Sha^.
Hin.
Temp
Kain-
faU.
Remark) at
e.80A.ii.
Jan. 30
30 03
S.W.;
43
42
73
65
42
-22
31
30-02
S.W.5
47
40
78
65
43
-30
Feb. 1
30 06
N.W.
40
45
03
48
46
-08
80-05
s.w.
36
34
60
60
34
I.
30 C2
s.w.
40
45
67
61
86
30-64
w.
49
48
63
60
46
Overcast
• • 9
80-00
N.
42
61
57
49
40
Overcast
Itfltts, Sfeflrf €mmnts, i ^itsfen ti
it is especially requested that early mtelliqence of loca
events hamna a medical interest, or wMch it is desirabl
to bring under the notice of the profession, ma/y be sen
direct to this Office.
All communications relating to the editorial business of tkt
journal must be addressed “ To the Editors.”
Lectures, original articles, and reports should be written ot
one side only of the paper.
Letters, wliether intended for insertion or for private in
formation, must be authenticated by the names one
addresses of their writers, not necessa/nly for publication
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs shoulc
be marked and addressed ''To the Sub-Editor.^
Letters relating to the publication, sale, and ad/oeriisvn(,
departments of The Lancet to be addressed "To ifu
Publisher.”
We cannot undertake to return MSS, not used.
The Vaccination Commission.
Dr. Ilaughiun. — We doubt whether our correspondent has fiillj
apprehended tlio nature of tlio argument set out by Mr. A. Wheeler,
and to which we adverted. The following cpuistion anS answer ox
plain it, perhaps, as well as any isolated statement can :—“Lord
Ilerscliell: You assume that if nobody,had diod of small-pox ihal yeai
thero would have been so many people, 7000, dying from .somoUung
else?—Mr. A. Wheelor ; Most decidedly.” The italics are oiir.s.
B.—The fee seems a full rather than an excessive one. Probably tlie
largest items are tlio two gold crowns, which arc necessarily oxpoii-
sive, since their fitting and adjustment take up so iiiucli time of both
operator and mechanic.
Ur. W. iff. Jackmn should put the rpiostion to iiis usual medical
advisor.
Dr. DeWpiwe.—Instnictions tiavo boon given to tUo printer to forward a
proof.
Mr. Slem<in.—1]iQ paper lia.s been i-ccoived.
Mr. Dmfon.—Next week.
Gooh'ie
O
Tbb Lancet.]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. (Feb. 7, 1891. 351
A Weekly Holiday for Medical Men.
B. S. stroDgly urges tliat medical men should take one day a week as a
holiday, or one day a montli, and thinks that both they and their
patients would find henedt. No doubt there is need of more relaxation
for medical men. Tlioir anxiety is continuous in a greater degree
than that of other callings. Abstractly the advice Is good, and has
our approval. There Isjustadash of impracticability about it (hat
detracts from its force. Even if there wore no financial or professional
difficulties in the way, there is often more disquiet of the mind produced
by leaving anxious coses than relief by hancling them over to anotlier.
But undoubtedly our correspondent is riglit in the main advice of a
systematic and periodical break in the wear and tear of the life of
medical men.
ff. M.—Our correspondent doe.s nob say whether the patient to
whom the circular was sent bad been previously a patient of
tlie author of the circular. This is a. point of importance. It is
not unreasonable that a practitioner retiring on account of ill-bealth
should in a formal communication commend his successor to bis own
patients, or those whom he thinks to be so ; but, of course, such a
communication addressed to the patients of other practitioners would
be highly unsatisfactory.
D. if. P.~k Manual of Nursing, Medical artd Surgical; Dr. CuIIingworth
(Messrs. J. & A. Churchill, 11, Old Burlingbon-street). A Manual of
Nursing, Medical and Surgical; Mr. Lawrence Humphrey (Messrs.
Griffin and Co., Exeter-streot, Strand). Nursing and Hygiene; Dr.
Roberts (Mr. II. K. Lewis, Gower-street, London).
Sir. T. Atkmgon.~l. Books upon the .subject referred to have been pub¬
lished by Dr. Murrell and Dr. Stretch Do w.so. It has also been noted in
Dr. Hale White's Text-book of General Therapeutics.—2. Vacancies
of the nature indicated are rare, but they are occasionally mentioned
in our advertisement columns.
Dr. Ifami (Nuneaton),—Yea, in an early number.
Dr. Profit .—The paper will bo acceptable.
MEDICAL PRACTITIONERS AND CORONERS’ INQUESTS.
To the Editore of The Lancet.
Sirs,—S ome years ego, in a case of acute bronchitis which I had only
seen once before death, bnt in which I was perfectly satisfied that there
had been no neglect and that death was due solely to the disease, I
wrote to the registrar stating tlie facts, and enclosing a certificate in
ease he should not deem it nocossary to refer to the coroner. My letter
was supproaaert and my cortificate forwarded to the coroner, who decided
to hold an inquest. I was not summoned to give evidence, nor did I
heai-. directly or indirectly, from coroner or registrar. It was quite by
accident that I came across a report of the case In The Times, and
learnt that an inquest had been held, that the jury had censured me
for giving a certificate, and that the coroner had applauded the censure.
I wrote to the coroner for instructions to guide me in future. He
replied that "in no case could one visit only be considered os attendance
during the last illness, and that in all such cases I was to notify to the
police or to him, and to receive his express sanction before certifying.”
Ho was good enough also to say that be was sorry for the censure
passed, and that had ho known of my letter to the registrar ho should
have taken an entirely difteront course in the mattov. I was a little
sore about it at the time, No man likes to bo condemned unheard.
However, that soon pas.sod off, and I had a definite rule to guide me in
future, I h.avo followed it very satisfactorily ever since, and have
always found the coroner's opinion and mine coincide as to the necessity
or otherwise of an inquest. Where ho has considered one unnecessary
ho has written to toll mo to certify, or his oIRcor has brought mo verbal
message to tliat effect.
Last Saturday woelt (10th inst.) I was called to a case of bronchitis,
'vliero death occurred a few hours after niy visit. I told the relatives
that tlio case must bo referred to the coroner, and in due timo his officer
called upon mo. IIo made no inquiries as to my opinion of tho case, or
as to whether 1 had formed ono. He simply informed me, in a some¬
what offliand manner, that of course no inquest would be hold, and
that “ Jge [moaning, I presume, himself and bis master] will give tho
necessary cerUfleate,” WoU and good. It was a now method of pro¬
cedure to mo ; but tliis was tho first case I had had in this particular
coroner's jurisdiction. Two days later the relatives applied to mo for a
certificate. They brought with thorn a printed notice from coroner to
mgletvar, stating tliat an imjuo-st was unnecessary; but tho registrar,
in iiddition to this, voquivotl mi/cortillcate. Bearing in mind my former
expofieuco, I refined to give tliis without the express sanction of
^.“■<' 1101 '. As time pressed, I wrote to the coroner for this ontlio
loth inst., and received tho enclosed printed notice on the 19th
Hist. On tliat day also one of the relatives managed to soo the
coroner, and obtained his written sanction to my certifying. You will
observe that tho printed notice, oven when it arrived, did not give what
I asked for—viz., authority to certify. Meanwhile tho funeral was
arranged for tho 17th inst. (Saturday). Bnt the registrar still refused
to give a cortificate: “ He had no autliority to do so." Tho doctor still
refuHod to givo a cortificato; “Hu had no authority to do so." Tho
nndertaker still refused to unilertake : “Ho had no authority to do so.”
It was a case of “stick won't boat dog, dog won't bite pig, pig won’t
get over the stile,” Ac. The funeral was consequently postponed, at;
great trouble and expense to the relatives. 1 may mention tliat they
also were informed by the coroner's officer that the necessary certifica^
would be given by the coroner, not by the doctor.
I enclose, for oompivison, another letter from another coroner, in are
exactly parallel case, in which all trouble was averted by a sti^ght-
forward answer to a civil request.
I should be much obliged if you would give me your opinion as to my
action in this case, and ns to what It should be in future—where a
coroner’s officer tells mo that I am not to certify, and a registrar tella
mo that I am to do so. I was very unwilling to inconvenience the
relatives liorc, and very anxious not to put myself in the wrong with
the coroner; yet I fear I have done both. The relative who saw the-
coroner on the 10th inst. was informed by him that I should have taken
his note to the registrar as an instruction to myself to certify, notwith¬
standing his own officer’s intimation to the contrary ; and the blame
for all the worry and delay is therefore placed upon my shoulders. Witlt
many apologies for troubling you with so long a letter,
: 1 remain. Sirs, yours obediently.
South Hornsey, N., Jan. 20th, 1891. G. Anuus Hunt.
Amedical man must exercise his discretion as to giving a death cer¬
tificate under circumstances similar to those detailed above. The
wording of the certificate allows a certain amount of latitude by intro¬
ducing tho terms “to the best of my belief.” If the case has only been
seen orice, or if the medical pi-actltioner is called in after dcatli, it is
well for him to write to tho coroner stating tho facts and saying that ho¬
is or is not prepared to give a certificate. In this way the responsibility
is left with tho coroner. The registrar lias uo power to decide the
matter. If he has reason to doubt the advisability of registering the
doctor’s certificate, he must refer the matter to the coroner.—E d. L.
Jj.R.C.P.—l. The Medical and Surgical Directory of the United States,
published by R. L. Polk and Co., contains tbe medical laws of tho
different' States and a variety of other information concerning
American universities and colleges.—2. The New York Sledical Becord,
Boston Medical and Suryical Beportcr, Oaillard’s Sledical Journal.
F. W. should consult bis usual medical attendant.
RETIRED ARMY SURGEONS AND MEDICAL HEALTH
OEFICEESIIIPS.
To the Editors <if THR Lancbt.
Silts,—if may escape the notice of senior members of the Army
Medical Department that at tlie present time appointments are being
made in connexion with tiia Local Government (Scotland) Act for
which retiring momhers of the ineiHcai staff would be admiiuhly suited.
Would you, therefore, admit to your eohunus this brief note'/
With exceptions, of course, I cannot imagine any nfembers of the
raedlcai profession better suited for such aptioiutnients than army
medical officers retiring from the service by rotation, although still in
robust health. Tho appointments to wJiich I allude are briefly as
follows Each County Council in Scotland is appointing a county
medical officer, whose duties ivill bo lo attend to all the sanitary and
other matters coming within tho province of medical men, and within
tho jurisdiction of the County Council, Tho salaries are to be liberal,
and graduated according to the importance of each county or district—
liberal because sucii medical officers are to bo debarred from engaging
in private practice. Tho work is admirably adapted to the experience
of Army medical officors, and County Councils would act wisely in
selecting their medical officers from their ranks. Residing in the
county, such officers would enjoy pleasant society, would be interested
in their occupation, and would gain a sub.stantial addition to their
retiring pay, by m> means to be despised.
I am, Sirs, yours truly,
James Joii.NaTON,M.D., J.P.,
Edinburgh, Feb. 2ud, 1891. latte Surgeon, 20th Cameroniaiis.
We print the above letter, but think there is another side to the
question—that, namely, from tho point of view of those gentlemen
who have made sanitary matters a special study, and have passoil
examinations in order to obtain a qualification guaranteeing fitness
for the post of medical officer of health.—En. L.
CONfSTIPAlTON AND GASTRIC DISEASE.
To the Editors of The Lancet.
Sirs,—C an luiy of your readers .suggest a remedy or treatment in the
following case Tho patient, a young lady aged twenty-four, has
siilfered from gastric ulcer and obstinate constipation for five years.
At first the bowels rosiioniled to ordinary aperient votnoJios, now they
with difficulty i-espi>ml to largo watery oneniata. Aloetic preparations,
cascara, and glycerine suppositories take no effect, it seom.s to bo an
atonic condil-ion of tho rectum; and solid food of any description
cannot bo'borne on account of the gastric condition. She has boon
using of late injections iiicroasiiig in quantity, deci-easing in utility.
So far as I citn inako out there is no oljstructiou. She has been treated
in an institution by absolute rest and no food by the mouth for tlie
ga.stric condition, hut without boncHt. Any suggestion as to treatment
of tho couatipation will bo gladly received.
I am, Sirs, youiB obediently,
Feb. 2ud, 1891. Rustic, L.R.C,P.
Digiii.ad 1.-/ lOOglC
652 Tas Lanoxt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Fkb. 7,189I.‘
Medical Advbrtisemekts in the Lay Press,
'(The whole ayatem of medical advertising in the lay preas is open to
crltidaiD, but it is especially so when it has reference to certain cases
.and classes of disease, as in the following advertisement from the
Manchetter Cov,ritr;-~-
Sterillty in Women : its Causes and Cure. By J. B. Ryley, M.D.,
M.R.C.S., London. A new edition of this work is now ready. Price
St. 6d. • post-free St. 6d. London: Henry Renshaw, S66, Strand.
Jtfedieo (Qrimsby).—We regret we cannot assist our correspondent.
^airplay has n'ot enclosed his card.
“A MEDICAL HAT.”
To (As Editort of THE Lancet.
Sirs,—I think it would he a great advantage to many medical men if
•they adopted a medical hat. I have been saved many journeys in the
country by the fact that my hat differs from that of other people, and 1
am recognised even on a dark night, and often saved the trouble of
retracing my steps for several miles. The bat I have adopted is a hard
felt, just the shape of an ordinary straw bat, with low crown and flat
'brim. Of course, the hat is easily changed when on pleasure bent, and
’^tbe cost is half that of a silk one.
I remain, Sirs, yours obediently,
Bracknell, Berks, Jan. 1301. Henry Parson.
Communications not noticed in our present number will receive atten¬
tion in our next.
communications. Letters, Ao., have been received from—Mr. C. H.
Sers, London; Mr. J. Rutherford, Sheffield; Herr T. Zangger, Zurich;
Dr. S. Mackenzie, London; Dr, Mortimer; Messrs. Bates, Hendy, and
Co., London; Mr. A. Duke, Dublin; Dr. Caspar, Berlin; Dr. Dixon
Mann, Manchester ; Dr. Hewetson, Dunblane ; Messrs Richardson
and Co., Leicester ; Mr. Hulke, London; Dr. De B. Hall; Dr. Moru
Madden, Dublin; Mr. Parson, Bracknell; Messrs. Crossley, Moir, and
Co., London ; Dr. H. Port; Dott. F. Grollero, Doneille ; Mr. Lawson
Tait, Birmingham ; Herr J. Springer, Berlin; Messrs. Cochrane and
Walker, Liverpool; Dr. Shuttleworth, Lancaster; Messrs. Dawson
and Sons, London; Dr. Brackenbury, London; Messrs. G. Street and
Co., London; Dr. Nason, Nuneaton ; Dr. Cullingworth; Dr. Burney
Yeo, London ; Mr. Feldman, London; Dr. Murray, Whittlesea, Capo
Colony; Mr. J. M. Clark, London; Mr. G. Brown, London; Dr. A. do
Giacomo, Napoli; Dr. J. Johnston, Edinburgh; Messrs. Blondeau
et Cie., London; Mr. Feeny, London; Mr. Evans, Burma; Me.ssrs. Lee
and Nightingale, Liverpool; Mr. Kingsforcl, Clapton ; Dr. Hingston
Fox, London; Mr. J. W. Taylor, Birmingham; Messrs. Cassell and
Co.; Dr. G. Lyon, London ; Mr. A. H. Jacob, Dublin ; Messrs. Gale
and Co., London ; Mr. Soutter, London ; Mr. Thatcher; Messrs. King
and Co., Combill; Mr. Stallard, Worcester; Mr. Musgrave, St. Jean
de Luz; Mr. V. Horsley ; Mr. A. Cooper, London; Messrs. Lumley
and Son, London; Dr. Horrocks; Mr. Reeve.s, London; Dr. Fletcher
Beach, Dartford; Dr. Williamson; Dr. Hargreaves; Messrs. Squire
and Son, London; Dr. Cunningham, Sussex ; Messrs. Mitchell and
Co., London ; Mr. Perry, London; Mr. Green, London; Di'. Hermann
Beer, Vienna; Mr. Sisson, Newcastle-on Tyne ; Messrs. Wright and
Co., Bristol; Mr. Hornibrook; Mr. Thorpe, Glasgow; Messrs. White
nnd Son, London; Dr. Ashby, Manchester; Mr. Newbolt, Ellesmere
Port; Mr. Baird, Mentone; Mr. Russell, Liverpool; Dr. Paris, Sierra
Leone; Mr. Hammett, Taunton; Mr. Howe, Taunton; Messrs. Hertz
and Collingwood, London ; Mr. Phillips, Birmingham ; Mr. Mitcliell,
Washington; Mr. Anderson, France; Mr. Pentland; Mr. Birchall,
Liverpool; Mr. Roland, Barcelona; Mr. Cooper, Bristol; Dr. Lanen,
Hamburg; Mr. Vickers, London ; Mr. Morton, Glasgow; Mr. Nance,
Colchester; Mr. Wright, Penzance; Dr. Orollus,Italy; Mr. Piggott,
Cambridge ; Miss Wijlis, Plymouth ; Mr. Frost, London ; Mr. Shaw,
Worthing; Mr. Warner, Sheffield; Mr. Clark,Doncaster; Mr. T. B.
Browne, London; Mr. Armstrong, Newcastle-on-Tyne; Mr. Sargant,
Ramsgate ; Dr. Copeman, London; Messrs. Stern; Dr. Skrimshiro,
Monmouth; Mo’sra, Motley, London; Mr. Wolfonden ; Mr. Roberts,
Blaenau Festiniog; Mr. Clark, Doncaster; F. H., Hammersmith;
Condor ; L.R.C.P. ; H. L,; X. Y. Z. ; H. W. R., London; A Qualified
Assistant; Ivon, London; W. B., London; Probyn; Secretary, Queen
Charlotte’s Lying-in Hospital, Marylebone; Mason, London; Meran-y
Office, Leeds; A. E.B., London; Pericles, London; A. W. H., New
Beckenham; Gamma, London; Statim; Secretary, Addenbrooke’s
Hospital, Camba; Assistancy, Bree^vood ; Medicus, London; Anchor,
London ; T. H. L., Brlxton.
Letters, eadh ufith enolotwe, are also acknowledged from—Messrs. Read
and Co., Bristol; Mr. Lockwood, Huddersfield; Messrs. Maythorn
and Son, Biggleswade ; Mr. Tyte, Minchinhampton; Messrs. Hooper
and Co., Pall Mall; Mr, 'fully, Hastings ; Messrs. Reado, Bros, and
Co., Wolverhampton; Dr. Evans, Llanerchymedd; Messrs. Oliver
and Boyd, Edinburgh ; Mr. Burns, Carluke, N.B.; Mr. Nicliolla, Bury
St. Edmunds; Dr. Paterson, Stockton-on-Tees; Messrs. Wilcox and
Co., London ; Mr. Roberts, Sheffield; Messrs. Duncan, Flockhart, and
Co., Edinburgh; Mr. Jackson, Workington; Mrs. George, Malvern
Link ; Mr. Sergeant, London ; Mr. Wallace, Berks; Messrs. Camrick
and Co., London; Mr. Plummer, Newcastle-on-Tyne; Messrs. Harris
and Son, London ; Dr. Day, London; Mr. Hart, London ; Mr. Sheen,
Worcester; Mr. Saunders, Eton; Mr. Ritchie, Oxford; Dr. Harries,
Sussex; Mr. Marshall, Suffolk; Mrs. Forrest, Blackburn; Mr. Blunt,
Leicester; Mr. Howell*, Aberdare ; Mr. Mosse, London; Mr. Malone,
Sheffield; Dr. Stanley, Sheffield; Mr. Prain, Fettercaiin ; Dr. Duke,
Eastbourne; Mr. Davies, Pontypridd ; Dr. Brown, York ; Mr. Wylie,
Potersfield ; Mr. Ramscien, Halifax ; Mr. O’Meara, Leicester ; Mr. E.
Foot, Pulborougb; Rev. Mr. Wigan, Maidstone ; Dr. Waters, Liver¬
pool; Mr. Johnson,Leicester; Dr. Moorhead, Notts; Dr. Detmold,
Bournemouth; Mr. Buller, Martloy; Mr. Hay, Hull; Dr. Drysdale,
London; Dr. Cripps, London; Mr. McLay, Rothsea; Messrs, Savory
and Moore, London; Dr. Macnab, Portree, N.B.; Messrs. Greenberg
and Co., London ; Mr. Parsons, Hastings; Messrs. Schweitzer and
Co,, London; Miss Evans, Warwickshire; Mr. Williams, Regent’s-
park; Dr. O'Neill, Belfast; Mr. Wheeler, Manchester; Mr. Thin,
Edinburgh; Mr. Colson, Lincoln; Dr. Ball, Hounslow; Mr. Crisp,
Nottingham; Mr. Wyckoff, Brooklyn ; Mrs. Theobald ; Dr. Taylor,
Nottingham; Dr. Thurstan; Mr. Harcouit, Shalford ; Mr. Heywood,
Manchester; Dr. Mauintyre, Glasgow; Penshurst, London ; 0. J. P.,
London; Melville; Devon, London ; Chiswick, London ; York County
Hospital; Viola, London ; Delta, London ; Maltine Manufacturing
Co., Bloomsbury; A. B., Blackheath; Hon. Treasurer, Isle of Man
Hospital, Douglas; Q.B., London; M.B., Loughborough ; Resident
Medical Officer, Durham; H. P., London; Litera, London ; Cromwell
House, Yorkshire ; Medicus, Sussex ; Crux, London; A. M., M. B.,
London; L.D.S., London; Assistant, London ; F. T., Devon; D. G.,
London; Experience, London; Culiuer, Ashford; Anthracosia; M.,
Bolton; Sister, Manchester ; O. G. R., Barnet; Gordon; Hamilton
Association, London; Sigma, London; Alpha, Sheffield; Victoria
Carriage Co., London; W. H. II., Ashton-under-Lyne; Dunmore, Bast
Dulwicli; Ebor, London ; E. K. N., Brockley; W., London; T. N.,
London ; Economist, London; F. Q. P., London; Vendor, London.
NEU’SPApr.KS.—Linr;oin»/iir« CAronicle, Yorkshire Post, Cour}-ier de Dax,
BrUlolTimeHyTradeyPinancecindRecreation, MadrasTimes,Cape Argus,
City Press, Worcester Eoening Qazeltc(Mass.), Leeds Mercury, Windsor
and Eton Gazette, Architeot, Scottish Leader, Beadinii Mercury, Law
Journal, Spectator, Mining Journal, Surrey Advertise)-, Public Uealtk,
Western Gazette, South Africa, Guy^s Ilosj/ital Gazette, West Middlesex
Advertiser, liromley Journal, Daily fVee- Press (Aberdeen), Petford
Tiw/ss, Manx Sun, liuyby Advertiser, New Zealand Herald, lnventio)\,
Hawick Advertiser, Ihjyiene, Leicebler Journal, Lutninyham Daily
Gazette, <l-c., have been received.
SUBSCRIPTION.
Post free to any part op the United Rinodok.
One Year.. £1 12 6 [ Six Months _ £0 18 8
To China AND India ____One Year 1 U ll
To THE Continent, Colonies, and United
States .... mtbo 1 ll 8
Post OfflceOrders and Cheques should be addressed to The Publisher,
The Lancet Office, 423, Strand, London, and crossed “ London and
Westminster Bank St. James's-square."
-£0
„ 0
0
0
0
ADVERTISING.
Books and Publications (seven lines and under)
Official and General Announcements .. ..
Trade and MisceUaneous Advertisements — —
Every additional Line
Front Page • . m per Line
Quarter Page
Half a Page —
An Entire Page ...............
The Publisher cannot hold himself responsible for the return of tesU-
menials &c. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are reqiiested to observe that 16 is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
6
6
I
0
1
1 10
2 IB
6 B
An original and novel feature of "The Lancet General Advertiser” is a special Index to Advertisements on pages 2 and I, which not only
affords a ready means of finding any notice, but is in Itself an additional advertisement.
Advertisements (to ensure Insertion the same week)abould be delivered ai the Office not later than Wednesday, accompamed by a remittance.
Answers are now received at this Office, by special arrangement, to Adverti.seniBnts appearing in Tub Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions shoold be
addressed.
Advertisements are now received at all Messrs. W. H. Smith and Son's Railway Bookstalls throughout the United Kingdom and all other
Advertising Agents. _
Agent for tbe Advertlsenient Department In France--J. A8TIER, 69, Bne Caumartln. Paris,
Di: ' led by
Google
THE LANCET, February 14, 1891.
€lmml futou
ON
CHRONIC ULCER OF THE
STOMACH/
By ROBERT SAUNDBY, M.D., F.B.C.P.,
PHT9ICIAN TO THE GENBBAI- HOSPITAL, CONSULTING PHYSICIAN TO TIIK
BYE HOSPITAL ANI> HOSPITAL FOR WOMEN, HIRMINGIIAM.
Gentlemen, —Duriog the last five years I have had a
number of cases of ulcer of the stomach under niy care,
whose progress has been so uniformly satisfactory that I
desire to draw your attention to the treatment employed.
By ulcer of the stomach I mean the round, perforating,
simple ulcer which alone has gained the distinction of a
separate place in clinical medicine. It is a disease which
occurs most frequently in young women, and the series of
cases taken from my hospital note-books for the last four
years and a half consists, with one exception, of this class:—
No.
Name.
Age.
Occupation.
Duration.
Result.
1
Caroline H.
28
Jeweller.
1 years.
Cured.
2
Eliza U.
20
. Penwoi'ker.
6 weeks.
3
Emily A.
38
Houeewifo.
C months.
4
Ellen R.
20
Ponworker.
2 years.
C
Annie S.
20
Clerk.
IS months.
6
Laura H.
22
Schoolmistress,
2i
7
Emily W.
27
Cook.
0 •>
8
Florence T.
21
Penworker.
2
9
Emma H.
82
Housewife.
1 year.
10
Frederick H.
20
Gun-flnisber.
3 years,
11
Annie 11.
82
Cook.
11 days.
si
Thus there are ten females to one male, a much greater
proportion than that given by Dr. Wilson Fox^ (two to one).
The first case on the list was in the hospital three times
before she was finally cured, and Case 4 was in on two
occasions, but in both these instances the symptoms bad
been of long duration before coming under treatment: one
year in the first case and two years in the otlier. The pre¬
valence of the disease amongst cooks has been repeatedly
remarked, and in our little series this occupation has two
representatives. It will be noticed that three of the girls
were penworkers, but this is perhaps attributable to the
neighbourhood of several large pen factories. The disease
is one which may last many years, and it is quite possible
that some of these cases may relapse. 1 show you here a
museum specimen of ulcer of the stomach. The breach of
surface is usually about the size of a shilling, with clean-
cut edges, as if punched out, but funnel-shaped—that is,
wider in the mucous coat than in the submucosa and mus-
cularis. The edges are smooth and destitute of any sign of
grannlations. It is generally believed that the ulcer is due
to thrombosis of a limited vascular area with secondary
necrosis and digestion of the dead part by the action of the
gastric juice. It is supposed that thrombosis occurs as a
result of the state of the blood—'6. g., in antemia,—as the
experiments of Silbermann have shown that gastric ulcers
may be produced in animals rendered anrcmic by artificial
means. But it is also thought that localised inflamma¬
tions may so destroy the vitality of parts of the raucous mem¬
brane that the same result follows, and the frequency of
the occurrence of the disease in cooks has been attri¬
buted to their habit of tasting very hot portions of food.
Mechanical injuries to the mucous membrane of the stomach
of animals are followed by circumscribed ulcers. Another
factor upon which much stress has been laid is excessive
acidity of the gastric juice, but it has been pointed out
that this is quite as likely to be a consequence as a cause
of the ulcer. Tubercle appears to give rise to ulcers quite
undistinguishable at least to the naked eye from the simple
form. The most important clinical fact is that these
patients are generally aniernic and ill-nourished, and this is
of great importance when we come to consider the treat¬
ment, for the starving method now in vogue is calculated to
' Delivered at the (ioneral IlospUal, May 21.st, 1800.
- Ileyncilds' Nyntom of Meiiieino.
No. 3620.
maintain this unfavourable state of things; while I attribute
the success I have met with to the energy with which I
have endeavoured to remedy these conditions. Before pro¬
ceeding to detail the symptoms of this disease I will read
you the account of one of the last oases under treatment.
Case 1. Gastric ulcer, history of one year's duration with
pain, vomiting, and haimatemesia. —Emma H-, thirty-
two, laundress, was admitted into hospital on June 29bh,
1889, complaining of pain in the right bypochondrium and
below the left breasc, of sickness and bsematemesis, with
cough and shortness of breath.
Family history. —Her father was ill with some chronic
affection of the liver, suggesting malignant disease, and her
mother had a cancer (?) of the breast. One brother waa
“consumptive,” two were in good health, and one had died
aged nine weeks of some wasting disease. A sister had
died of consumption, three others were in good health, and
one had undergone an operation, probably the removal of
an ovarian cyst, at the hands of Mr. Lawson Tait.
Previous Aisfory.—She said she had never been strong.
No history of acute rheumatism. Had bad a bad attack of
measles two years previously to admission. Had scarlatina
when fifteen years of age. For the last two years had been
short of breath on exertion. She bad been married thirteen
years, and bad had three children, one of whom died at
the age of two, having never been able to walk. From
tbe age of nineteen to twenty-two she suffered from
“ fits,” which she attributed to a fright. She had an en¬
larged thyroid, which used to get bigger at her monthly
periods, but she did not think it had increased lately. For
the last year she bad not menstruated.
History of present illness. —About a year ago she had
noticed a swelling on the right side of the abdomen, which
caused her pain on sitting. One day she was seized with a
sudden pain in the abdomen, and fainted. A doctor was
sent for, and on recovery she was told that she hod passed
about a quart of blood from the bowel. The pain in the
tumour continued, and a fortnight later she vomited
blood, as much as a pint on one occasion and half a
int on another. For several months before this she-
ad been sick at times. This occurred ten weeks before
admission, and since that time she bad vomited blood two
or three times a week, and food continually.
Present condition. —She was a thin woman, with a fair
amount of colour from dilated capillaries in the skin of tbe
cheeks. She said she had been much stouter up to six months
ago. Temperature 98'6°.
Alimentary system. —Teeth defective, more than half
their number having disappeared. Tongue pale, flabby,
with irregularly distributed fur on the dorsum. Appetite
poor. Complained of pain in the right iliac region,
which prevented her lying on that side. Pain after food,
coming on at once, and lasting about an hour. Tenderness
generiQ over the abdomen, but most marked in the right
iliac region and under the left breast. Vomiting not constant.
No obvious dilatation of stomach. Bowels regular of late.
Liver dulness in vertical nipple line two inches. No
tumour to be felt anywhere in abdomen.
Circulatory sysicw.—Impulse heaving, no thrill. Apex
heat diffused, area of cardiac dulness limited by vertical
nipple line to the left; a booming systolic murmur at the
apex conducted into the axilla, with accentuation of the
pulmonary second sound. Occasional palpitation and short¬
ness of breath on exertion. Pulse small, regular, fair
tension (72).
Respiratory sjistcm .—Respirations 24; percussion and
auscultatory signs normal.
Urinary system.— pain or discomfort or undue fre¬
quency in micturition. Urine, 40 to 60 oz. daily, sp. gr. 1015,
acid, no albumen, sugar, or bile.
Generative system. — Had not menstruated for twelve
months.
Treatment. —Milk and lime water, one ounce every hour.
The following mixture was ordered : one drachm of sulphate
of magnesia, five grains of sulphate of iron, ten minims of
dilute sulphuric acid, to one ounce of peppermint water; to
be taken three times a day.
Progress o/ca.se.—She did not vomit after admission, and
the only alteration in her treatment was to adjust the
quantity of sulphate of magnesia to the requirements of
her bowels. July Gth : She was allowed bread-and-milk.—
8th: Two eggs were added.—11th: A light pirdding was
ordered,—14th: Milk, boiled chicken, light pudding.—
17th : Mutton diet. The mixture at this time caused
a
Dir; jd ■ , Google
354 Thk Lancet,] DR. ROBERT SAUNDBY: CHRONIC ULCER OP THE STOMACH. [Feb. 14,1891.
rather profuse diarrhoea, which continued after it was
stopped, hut rapidly subsided on a diet of milk and lime
water and the use of the bismuth mixture. She was only
OB this treatment for one day.—23rd: Discharged cured.
Tills case, although it presents some unusual features,
perhaps not attributable to the stomach lesion, is, on the
whole, a good example of the disease. What the “tumour”
was must remain doubtful, as no tumour was found in the
abdomen, and it is possible that there never was one. It is
certainly most likely that the hmmorrhage was from the
nicer, and had nothing to do with, any tumour, although
she supposed it had. The chief symptoms by which the
presence of ulcer of the stomach may be recognised are
(1) pain directly after food, (2) vomiting soon after taking
food, and (3) hsematemesis. Unless these are present the
diagnosis is doubtful, and of these the most important is
hsematemesis, which was absent in only one of the cases
I have included in my list. Neverthwess, ulcer of the
stomach may be present in a latent state without giving rise
to any of these symptoms, and perforation may occur without
any history of previous gastric trouble. We will look into
these three cardinal symptoms a little more closely. Pain was
present in all mycases. It was usuallydescribed as “burning”
m character, sometimes as “sharp and piercing,” or “dull
and gnawing,” but I think “burning ” is to be borne
in mind as the typical form of the pain. Tlie pain can
be localised by the patient, who can point out the
precise spot. It was usually referred to the epigastrium or
lower end of the sternum, leas often under the left breast,
or even in the right hypochondrium. I saw a case in con¬
sultation recently, proved by post-mortem examination to
be one of ulcer of the stomach, in which the pain was
referred to the region of the gall-bladder and passed down
to the right. The pain was always worse after food in all
but one case, and in that it was so sometimes ; but in the
case just referred to the patient, a gentleman aged fifty-
three, expressed himself as invariably in less pain after
taking food. This is quite exceptional, and only illustrates
the difficulty that may occasionally occur in diagnosis.
Vomiting after food with relief to the pain is not a very
constant symptom, and is much more characteristic of
hysterical gastrodynia. It was absent in five out of these
eleven cases, and is only stated in one case to be frequent.
This is a point well worth bearing in mind. Hsematemesis
was present in all but one case, Emily W-(No. 7), and
I attach so much importance to this symptom that I admit
that the diagnosis of that case is doubtful. When the
quantity is large the blood may be bright and unaltered,
but when it is small in quantity and has remained some
time in the stomach it becomes darkened in appear¬
ance, resembling coffee-grounds. Beef-tea, cocoa, and prepa¬
rations of iron &c., may produce somewhat similar appear¬
ances. The distinction can only be made by the spectroscope
or by testing for heemin crystals. This is done by drying
the material to be examined on a glass slide, powdering it,
adding a crystal of common salt and a few drops of glacial
acetic acid, and heating gently, when hajmin crystals will
be discernible by the microscope if blood is present. It is,
however, of the utmost importance that the actual fact
of the blood coming from the stomach should be placed
beyond doubt, for it is not uncommon to be told by hysteri¬
cal patients or their friends that vomiting of blood has taken
place, yet when carefully observed this resolves itself into
blood-stained saliva caused bysucking the gums, from carious
teeth, &c. It is a symptom of such importance that you
should always see the vomited matter yourselves, and not
trust to any report from attendants. If you are told that
hfp.matemesis has occurred recently, you should carefully ex¬
amine the stools, because it is almost certain that some of
the blood will have passed into the intestine, and will give
rise to the characteristic tarry stools. Here, again, you
must bear in mind that iron and bismuth blacken the stools,
and if under treatment the patient may very likely have
been taking one of these drugs; but the blackening from
blood is far more intense than that produced by either of
these metals, which are usually present in only small (]uan-
tities. While in the absence of hsematemesis the diagnosis
of ulcer of the stomach is incomplete, it may also be said
that where profuse hsematemesis occurs ulcer of the stomach
is almost certainly present. Such profuse hiemorrhage may,
however, occur from (1) rupture of varicose oesophageal
veins in cirrhosis of the liver, (2) rupture of an aneurysm
into the cosophagus or stomach, and (3) cancerous ulcera¬
tion of the stomach ; but, as a rule, in cancer the hromor-
rhage is not profuse, and gives rise to ootfee grounds
vomiting.
Those cases of cirrhosis of the liver in which profuse
hsematemesis occurs are not uncommonly just those
which may have hitherto remained latent owing to the
great development of the collateral venous circulation
having prevented the occurrence of ascites. Under
these circumstances the patient may appear in good
health up to its occurrence, which may be at once fatal.
The diagnosis must depend upon (1) the reduced size of
the liver as made out by percussion, and (2) the absence of
gastric pain, &o. The latter is of less value; for I
remember a case in ward X of sudden fatal haemorrhage
from a gastric ulcer which had remained quite latent, the
patient oeing under treatment for phthisis. There were
tubercular ulcers in the intestine, and the stomach ulcer
was probably tubercular in its origin, thougli it presented
all the appearances of a simple ulcer. Assistance in dia¬
gnosis is also obtained from the sex and age and habits of
the patient, though these are not entirwy trustworthy.
The rupture of an aneurysm is almost invariably imme¬
diately fatal; so that if it baa not been diagnosed before, it
will probably not be discovered, though it may be suspected
where the bajmorrhage is very profuse. There is not a very
uncommon position for an aneurysm behind the stomach
arising from the abdominal aorta just as it emerges through
the diaphragm, and such aneurysms are exceedingly difficult
to recognise. A thoracic aneurysm rupturing into the
cesophagus might be expected to have revealed itself
beforehand by pressure and other signs; but it must be
admitted that small aneurysms of the descending aorta may
exist without giving rise to any symptoms by which they
can be diagnosed ; fortunately they are not very common.
Cancer of the stomach, if seated in the pylorus, causes a
tumour which can be felt, while cancer of the cardiac end
usually gives rise to symptoms of cosopbageal obstruction,
which, taken with the age of the patient, the cachexia,
and the moderate nature of the haemorrhage, will permit a
correct diagnosis. Fortunately neither cirrhosis of the
liver, aneurysm, nor cancer is liable to occur in young
women ; and it may comfort you to know that you may
diagnose ulcer of the stomach in this class of patient from
haemorrhage alone, with little fear of making a mistake. But
without haemateraesis the difficulties are great, especially
great in this very class, for it is among them that we meet
with nervous vomiting and gastrodynia, symptoms which I
am convinced are constantly incorrectly attributed to ulcer
of the stomach. This is all the more unfortunate as these
patients do not get well, but go from bad to worse, if
starved and treated with bismuth and nitrate of silver.
But I claim that my plan of treatment has the advantage
in a doubtful case that it is apjdicable to either con¬
dition.
The following case is a good example of this affection:—
Case 2. Gastrodynia, pain, voviiting, anorexia; no heema-
temesis ; history of hysterical fits ; amcnorrhcca. — Edith
M. J-, aged fifteen, admitted on Nov. 1,5th, 1889, com¬
plaining of pain in the stomach, sickness after everything
she takes, even after water, for the last two years.
Family history. —Father, aged forty-seven, in good health ;
mother, aged forty-five, subject to “ sick headaches”; one
brother died in infancy ; another biother and a sister living
and healthy. Patient had a good home and plenty of food.
Previous history. —Had “low fever” when a child. Six
years ago she broke her right humerus and dislocated the
shoulder in a fall from a swing. A year later she dis¬
located her left elbow in a fall when walking ; three years
ago for six months she suflered from “struggling fits,”
without loss of consciousness, which occurred about every
two weeks. In August, 1889, she was in Wolverhampton
Infirmary with “inflammation of the right hip,” but it got
quite well six weeks after leaving that institution. She had
been a total abstainer for six months.
Present illness. —Two years ago she began to suffer from
vomiting and headache, without nausea or pain. There was
never any blood. The vomiting generally occurred imme¬
diately after taking food. This lasted about a month, and
three months later she had a second attack, followed by
others at intervals up to the present time. This attack
began two months before admission ; but for the last three
weeks she had suflered pain in the epigastrium, coming on
directly she had taken food. There had also been some
nausea. By lying down she bad managed to control the
vomiting to some extent.
The Lamcbt,] DB. THOS. W. HIME : KOCH’S TKEATMENT OF TUBERCULOSIS. [Feb. 14,1891. 355
Present condition. —A well-developed, well-nourished girl,
looking more than her age. Temnerature 98’3°.
Alimentary s^/stem. —Lips pale; teeth, some molars
decayed; tongue pale and moist; disagreeable taste in
mouth; no appetite; marked thirst; complained of pain
after taking two ounces of milk and lime water; the pain
was increased by pressure and lasted a quarter of an hour.
The pain was localised to a spot the size of a crown-piece,
and the tenderness was manifested on very slight pressure.
Bowels confined. Liver dulness, three inches and a half.
Circulatory system —Apex beat in fifth left interspace,
sounds normal. Pulse regular, rather weak, compres¬
sible (78).
Respiratory system. — Respiration IG; percussion and
auscultatory signs normal.
Urinary system —Urine 1012, acid, no albumen, sugar,
or bile.
Generative system. —Has never menstruated.
Treatment, —Two ounces of milk and lime water, reduced
next day to half an ounce every hour; the following
mixture was ordered, to be taken three times a day,—five
grains of sulphate of iron, one drachm of sulphate of mag¬
nesia, ten minims of dilute sulphuric acid, one ounce of
peppermint water.
Progress of case. —This treatment was continued except
that the dose of sulphate of magnesia was increased or
diminished as found necessary, according to the state of
her bowds.—Nov. 21st; No vomiting after the half-ounce
doses of milk and lime water were instituted, but she com¬
plained of pain. One ounce of bread-and milk every
hour.—24bh : Sick this morning; still in pain. A piece of
lint soaked in liquor epispasticus applied to epigastrium.—
27th: No more sickness; pain better. Ordered house
diet.—Dec. 7bh: Discharged cured.
The points in this case worth noting are—1. The history
of other nervous alleetions. 2. The age of the patient,
which is less than that at which gastric ulcer usually occurs.
.3. The persistence and frequency of the vomiting, which
followed everything, even water. As already pointed out,
vomiting in ulcer of the stomach rarely occurs after every
meal, and it is very exceptional to find the stomach so
irritable as to reject all food. So much has this impressed
itself upon me that I would ask you to pay special attention
to this point. 4. The localisation of the pain, which is
usually given as a sign of some value in ulcer of the stomach,
but which evidently must not be too strongly relied upon.
6. The absence of haetnatemesis. 0. The beneficial effect
of a small blister, so often .observed in nervous pain.
7. The very rapid recovery of the patient under appropriate
treatment.
If you will bear in mind the teaching of this lecture I
have no doubt you will recognise the majority of cases of
gastric ulcer that come before you, while you will also avoid
the mistake of treating stomach neuroses too 8eriousl.y;
but I should nob be doing my duty if I did not warn
you tliab ulcer of the stomach may occur under quite
different circumstances from those which I have told you
are typical. About this time last year I saw with |
Mr. Pearse of Brierley Hill a gentleman who complained of i
pain in the right hypochondrium relieved by food. He was
about fifty-three years of age, very careful in his habits, bub
a great worker and sometimes irregular in taking food.
The pain was described as burning and as radiating down
towards the anterior superior spine of the ilium. Physical
examination revealed nothing. The case was regarded
as one of gastrodynia, the diagnosis being based on the
relief to pain by taking food and the absence of other
indications. He improved greatly on a mixture containing
hydrochloric acid and strychnine. During the winter
^ got very constipated, his pain returned and increased.
Mr. Pearse saw him, and with some difficulty removed a lob
of scybalous ficces from bis bowel, but the pain continued,
and he was said to have passed a galb stone and to have been
slightly jaundiced. When I saw him I heard this history, but
I heard too that lie had on two occasions vomited some coffee-
grounds matter. I confess that 1 did not attach proper import¬
ance bo this symptom. Relying on the history, I agreed in
the diagnosis of biliary colic, and was greatly astonished
to hear next day that he had died in the night, evi-
clently^ from internal bicmorrhage. So far was I from
recognising the true nature of the case, that I then
Delieved that death was duo to the rupture of an aneu¬
rysm which had previously leaked into the stomach. Yet
a post-mortem examination showed that the hremorrhage
' had come from a simple round ulcer on the posterior
' wall of the stomach, near the greater curvature and midway
between the cardiac and pyloric openings. This case does not
showthe consultant ina very favourable light; but our failures
are often the most instructive as well as the most impressive
cases. The points of interest are : (1) the seat of the pain,
which was not explained by the position of the ulcer; (2) the
relief to the pain after taking food, so directly opposed to
what we should expect from an ulcer, though I have already
told you that we had the same statement in another case
(No. 1 in list); and (3) the absence of haematemesia until
within a few weeks of the termination of the case. 1 need
hardly remark upon tbe difficulty created by:the statement
that there had been slight jaundice, followed by the finding
of a gall stone in the Imces. Altogether it was a very
'Puzzling case, and 1 hope you may qqt have many such bo
deal with.
Finally, I must say a few words about treatment, though
you have already heard tbe details in tbe accounts of the
cases submitted to you. As a general rule, I order at first
half an ounce of milk and lime water every liour as the only
food, with the sulphate of iron and luagnetia mixture in
.purgative doses three times a day. Ziemsi^en and Leube
use sulphate of soda or Carlsbad salt in puigative doses,
with the object of removing all remains of food from the
stomach; but I use this mixture simply to remedy the
anmmia and constipation so generally prtseut. If heemate-
mesis actually occurs, or the patient is admitted with a
very recent history of it, I order ice to suck, and feed
per rectum for a day or two, and then proceed as before.
When, as usually is tbe case, vomiting and pain cease
under this treatment I double the allowance of milk and
lime water, then change the diet to soft bread-and-milk,
getting on through pounded chicken and custard and eggs
to ordinary diet as rapidly as possible. The good results
are attested by the table. It may be objected thatthese cases
are not cured, but that there is only a temporary remission
of the symptoms. I do not think this is true, although one
case did undoubtedly relapse three times, as all.tbese patients
were made out-patients under me, and attended for a
longer or shorter time, continuing to take the medicine.
Had they relapsed it is most probable they would have
reapplied for admission to this hospital, where, according,
to the rules, they would have been placed under my care.
It may be thought that there is danger by this plan of
exciting hiemorrhage or causing perfoiatioh, but I think
this fear is sufficiently answered by the record. ,
tdm
ON
KOCH’S TREATMENT OF TUBER¬
CULOSIS.^
By THOS. WHITESIDE HIME, A.E., M.D., &c.
Du. Himk stated that he had felt great reluctance in
accepting the complimentary invitation of the secretary to
deliver an address to the Society on the above subject—
first, because he hardly felt competent to deal with so
important a matter in the brief time available; and
secondly because, so far as he could ascertain, everyone he
met seemed to have his mind definitely made up with regard
to the whole question. Ho had heard many medical men
in Berlin, who had been treating cases of tuberculosis by
Koch’s method ever since the liquid was in use,, say that
they must postpone giving a definite opinion as to its merits
until sufficient time had elapsed to make it possible to speak
with certainty. But he had met only very few persons who
had never seen a case at all who bad nut made up their minds,
and who were nob generous in imparting their conclusions
on tire subject. Professor von Bergmaun said in his last
lecture at Berlin that it might be January, 181)2, before he
J DoHvorod beforo the IJrartford Modico-Ohimi'grical .Pocioty. TIio
loctni'i! was ninatratod by pliotojriuplis thrown on'fclW stji'oeri by a magic
lantern, showing patients at tlitt'erent stages of Mill tiVo
patients sufl'oi'ing from lupu.s were al.so shown, M'Wuli word under
treatiiiont.
Digii -ad ■''/ xjOO^Ic
356 The Lancet.] DR. THOS. W. HIME:'K0CH’S TREATMENT OF TUBERCULOSIS. [Feb. 14,1891.
would be able to pronounce his judgment, although he had
treated a great number and variety of tubercular cases by
Koch’s method. But the writer in the Eatamwill Gazette
was less timid. He did not hesitate to denounce the whole
proceeding as a dangerous imposture, and to declare that
where a person died under Koch’s treatment the doctor who
bad employed it should be indicted for manslaughter ! And
such trash was read with avidity by the million, and unfor¬
tunately also by medical men sometimes. Was it any wonder
that research in such departments of science was at the
lowest conceivable level in this country wlien the press
provided such instruction for the public? Even some medical
men, after a day or two in Berlin, thought it becoming
to write authoritatively to the lay press on the subject—
some against it, others (equally incompetent) in its favour.
However, as he had enjoyed special advantages for studying
the whole subject while acting as Special Oommiesioner for
The Lancet, sent to Berlin to reporc, and had also bad some
personal experience in the employment of the methodof Koch
in his own practice, he would endeavour to lay before them
such points as seemed to him likely to be of interest and value.
His knowledge of the subject was mainly due to the oppor¬
tunities afforded to him by the physicians and surgeons in
charge of cases in Berlin, and he wished to say how greatly
he and thousands of other medical men were indebted to
their German colleagues for their never-failing courtesy and
kindness. There was, indeed, no limit to the cordiality
shown and the opportunities afforded for studying this
most interesting and novel subject; and although it might
seem invidious to name anyone as more distinguished than
his colleague for this good fellowship, still he thought it
right to give utterance to the common feeling of gratitude
felt to Professor von Bergmann for his lavish expenditure
of time and attention on importunate, and often incon¬
siderate, foreign medical visitors. The importance of the
problem which Koch had undertaken to solve none would
deny. It is nothing less then that of victoriously assailing
the microbe of the most deadly of all diseases, and rescuing
its victims already enfeebled by its deadly assault. Un¬
doubtedly tuherculosis is the most terrible of all the diseases
in the nosology, not only from the great number of its
victims, but also from attendant circumstances. It was
estimated that one-seventh of the human race perished
annually from this cause alone.'- The death-rate in
England (1888} per million persons from phthisis alone
was 1540; from tabes, 230: and from “other tubercular
diseases,”406 1 the actual deaths from phthisis being44,248,
and from “other tubercular diseases” 18,434, or altogether
62,082. Against this may be set the whole class of ;cymotic
diseases, which only caused 40,000 deaths, in order to see
the relative magnitude of the fatality from tuberculosis,
which attracts very little attention, and from zymotic
diseases, which seem to absorb the whole energy and attention
of sanitarians and of the public. If a death occurs from
diphtheria or typhus fever in a street, what an excitement!
The inspectors even of the Local Government Board are
immediately set in action, and a report la soon presented to
the authorities. Yet the total deaths in England in 1888 from
typhusfever wereonlyI00,andfromdiphtheria48I.5, as against
02,682 from tuberculosis. The columns of the leading papers
are frequently Oiled with alarming letters as to the
prevalence of diphtheria, as evidenced by perhaps a dozen
cases within a few weeks, and a score of deaths in a year in
some locality ; yet during the same period thousands have
suffered and died from tuberculosis without even a passing
comment from anyone.
The magnitude of the evils arising from the prevalence of
tuberculosis was greatly increased by the terribly long
duration of the disease, which caused its economic import¬
ance to be so much greater than that of almost any other
disease, and by the fact that adults, the most effective
portion of the population, suffered so largely. It was cruel
2 The comtnoiily received opinion that Renerally phthiMis kills raost
victims between the aces of five and tliiity-Ilve has boeii shown by
Wurzburg to be true only of the total number of deaths, but nob true of
tatspToportimnt deaths to those living at various ages. He shows from
large material that the hlgheet mortality is of persons aged from sixty
to seventy years (per 100 living of that ago), and tho lowest of persons
from five to tan years (Mitt, aus d. Kais. Gesundhoitsamt. U ii ) In
England (mean for 1871-80) tho highest rate (3740 per million) occurred
among persons of thirty-five to forby-flve years of age ; and the lowest
rate (SSKper mill ion) among children aged live to ton years. Klebs( Allgem
Pathologi^ considers this greater prevalence of phthisis in adv.anced
age to be due to the generally diminished vitality of the cells, which
yield to the attack of the tubercle bacilli more easily than at more
rigorous ages.
enough to see young children swept off rapidly by measles,
whooping-cough, and other diseases, but it was far worse to
see their parents and adult brothers and sisters slowly
gnawed away by the relentless bacillus of tuberculosis.
The modern discovery that the tuberculous patient is a
source of infection to those around him during the long,
weary years of his wasting disease, certainly has not robbed
it of any of its terrors, although the discovery, no doubt,
will ultimately lead to precautionary measures and pro¬
tection for those exposed to the risk. Up to the present
time it must he admitted that practically we had been
helpless against tuberculosis. Medical science had devised
little more than uncertain methods of giving general tone
and vigour to the tissues of the patient by good food, air,
tonics, exercise, &c., so as to assist it in resisting the
inroads of the organism of the disease. It is unnecessary to
particularise the extent of the success attained. But
certainly no scientific method of contending against the
disease had been even plausibly suggested until the
present. Indeed, only a few years ago a distinguished
authority gave a reason for the theoretical impossi¬
bility of devising a “protective” against tuberculosis—
viz., the fact that one outbreak of tubercular disease
does not protect against a second or farther one.^
Suddenly, it may be said, all theories and opinions on
this subject have been subjected to a rude snock, and
in a most unexpected manner. The excitement and
enthusiasm aroused by the announcement that Koch
had discovered a successful method of dealing with tuber¬
culosis have surpassed all similar occurrences. Within a
few days of the announcement of the discovery thousands
of medical men, including many of the most distin¬
guished in every land, had abandoned their professorial
and private work, and in the depth of winter were
pilgrimaging to Berlin to see with their own eyes the
new method in operation, and with a vague hope of bringing
back some of the liquid for use at home. The goal set
before himself by Koch was one very different from
the other “protective” methods hitherto in use. Jenner
had introduced to the world a method of preventing
small-pox, which consisted in giving to a person an
attack of a mild disease, analogous to, ana probably
identical with, small-pox.^ This artificially imparted disease
protected against small-pox more or less completely, small¬
pox being a disease which rarely recurs in the same indi¬
vidual, and the preventive disease (vaccinia) having the
same characteristic. The remarkable discoveries wfiich
were made by that great genius Pasteur in this realm of
science depended for their success in protecting animals
against certain diseases on the power to attenuate the virus
or those diseases, to eff ect which be employed various means.
The attenuated virus was sufficient, wnen inoculated on an
animal, to give it a mild attack of the disease; and as it
was one which did not usually recur, this one mild attack
was found sufficient to protect the animal against a subse¬
quent attack. The reality of the protection which Pasteur
had been able to secure was indubitable, but it was not
permanent in the case of all diseases. He had succeeded
in attenuating tho virus of fowl cholera by simply keeping
it exposed to the air, while protected from other organisms.
Inoculation with this attenuated virus was protective
against the strongest virus. On March 2l8t, 1881, Pasteur, I
Chamberland, and Roux presented a memoir to the
Academy of Sciences in J’aris, showing how, by cultivating
anthrax bacilli at 42“' to 43'’C. for a certain time, the culture
might be inoculated on animals without serious danger, and
afford them protection against the strongest virus. The
animals became feverish and ill, but not seriously so except
in a small proportion of cases. These great discoveries of
Pasteur had been further worked out by others on the same
lines, and “vaccines’ had been obtained capable of pro¬
tecting against several diseases. The duration of the
protection obtained aj^ainst rabies had been experimentally
proved to be at least five or six years, as some of Pasteur’s
* /,um rterzeitlgen Htandpunkt d. Loiire voii don Scliutzimpfuiigen.
Von Prof, Nauiiyii. Loiiwic. 1888.
•> There are the .Htrongeab grounds for behoving that vacdniii may bo
inipartod to tho ualf by inoculation of human small-pox, Hence vaccinia
is to bo regarded as variola inodiflod by passage tlirough a bovine ; just
as Pastour and Thuihior attenuated tho virus of swine llothlaui by
passing it through rabbits, whorohy it was roiulorod harmless (an<l pro¬
tective) to swine, tliough still continuing fatal to tho rabbit. Similarly,
Pasteur found tliab tlie virus of canine rabies passed through apes in
soi'ies becomes gradually so attenuated as to lo.so tho power of infecting
dogs: while passage througli rabbits in series greatly intensities its
activity.
i-, Coogle
Thb Lancet,] DR. THOS. W. HIME: KOCH'S TREATMENT OF TUBERCULOSIS, [Feb. 14, 1891. 357
protected dogs have resisted repeated efforts to iofect
them either bv subcutaaeous, intravecous, or subdural
iooculation within that period. The anti-rabic method
differed from all the others in that there was do evidence
whatever of a morbid condition being produced in either
men or animals during the production of the refractory
state.
Koch’s anti-tubercular method was something different
from all these. He did not endeavour to protect against
tuberculosis by giving a mild attack of that disease; nor
did he seek to cure the disease by injecting a different form
of bacillus, as had been done successfully by Emmerich,
who injected the streptococcus of erysipelas as a protective
against anthrax; and by Pawlowski, who successfully in¬
jected the pneumococcus of Friedhinder with the same object.
Koch injected a liquid, the nature of which had not been made
known by him,® subcutaneously, and produced an intense
reaction thereby, but he certainly did not give the patient a
mild attack of tuberculosis. The liquid contained no specific
' organism, certainly no living tubercle bacilli or their
spores, attenuated or other. It undoubtedly did find out
and produce a most remarkable series of changes in living
tubercular tissue wherever it was visible, and there was
every reason to believe that in other situations withdrawn
from view the changes produced were similar to those seen
iu lupus, tubercular joints, and other more or less external
forms of tuberculosis.
It seemed to be the general idea that Koch’s discoveries on
this subject were limited to having found out a substance
for which he claims the power of destroying living tuber¬
cular tissue. But he has done far more than this. In the
first place, in his address to the International Medical Con¬
gress® he claimed not to havediscovei'ed such “ a substance,”
but “substances” which are capable of checking the growth
of the tubercle bacillus not only in the test-tube, but also
in the animal body, without injury to the latter. Theirapor-
tanceof this fact, that Koch has discovered raorethan one sub¬
stance endowed with this property, should not be overlooked.
For we have thus the possibility of utilising other substances
than that which is known as “ Koch’s lymph,” and possibly
with as good or better effectp. But another great fact has
been so overshadowed by the curative aspect of the dis¬
covery as to have also been lost sight of—namely, the fact
that Koch has been able to render animals refractory to in¬
oculation with virulent tubercle. This discovery would have
immortalised any other mao ; but seeing that Koch has also
discovered how to stamp out tuberculosis in animals suffer¬
ing from that disease, and that his method was being em¬
ployed with a view to save human beings suffering from the
same disease, people have quite lost sight of this other great
discovery. We may happily congratulate ourselves that Koch
has declared that his “ work is not yet finished,” and hope
that other great discoveries will result from his continued
activity. The power of successfully “vaccinating” animals
so as to render them refractory to subsequent inoculation
with tubercle has also been claimed by Richet of Paris. He
had obtained immunity by means of injections of culture
media of tubercle bacilli which had been sterilised by heating
above 100° C. From two observers, working manifestly in
different ways, we had thus obtained the same great result,
the possibility of rendering animals refractory to inoculated
tubercle. As an illustration of one practical application of
this discovery, he would mention that he had been con¬
sulted by a gentleman as to the desirability of employing
Koch’s method as a prophylactic in the case of two children.
They were orphans, not obviously tubercular, children of
parents both recently dead from phthisis, the mother having
been in an advanced state of that disease during her preg¬
nancy, shortly after the termination of wbich she died. The
proposal was one of groat importance and interest, but he
had hardly satisfied himself as to the answer to be given,
though at present he thought that he ought to yield to the
request which had been put to him, as these poor orphans,
according to all experience, are most probably highly sus¬
ceptible to tuberculosis.
Koch’s liquid had been so frequently described, correctly
/* An ajwiint of ika inoclo of production has Imen published by Koch
Kinco this locturo was dolivoroil.
Aug. 4th, 181)0; tr.aiisl.atod by T. W. Hime, M.T)., and published by
BaiUiCu'o, 'liudall, and Cox. Koch's own words are: “Ich habo
scliliosslicli Sulixiansen (jetroiron, welcho nicht alloin iiii llcagonzglase,
sontlern auch im 'riiierkOriior (las VVaehsthuin der Tnberkelbacillon
auf/.uhalkon im ^ftaiido Hind.” Ho .adds, furthor on: ‘‘Wonii man sic
Imoerschweiuchonj dor Wirkuntr uinor solclion Substanz ansaotzt.”—
U. S. W.
and incorrectly, that Dr. Hime would merely show it and
let them judge of its appearance &c. The mode of its applica¬
tion was the same as that of any other subcutaneous in¬
jection. It was certainly desirable to use for this, as for all
operations, sterilised instruments, and ones which were
accurately graduated. Koch’s syringe having no piston,
was freed from one source of danger. The pistons provided
with plugs of leather or other absorbent material were liable
nob only to retain dirt of various kinds, bub also considerable
quantities of potent drugs, such as morphia, which had been
used. Further, everyone had found such pistons frequently
dry and unusable when wanted. Koch’s syringe was free from
these disadvantages. It was important that the indiarubber
ball should nob be boo thin and weak, and in usingit one should
be careful not to force air into the tissues; even if aseptic it
might cause trouble. The accurate graduation of the
syringe, when so powerful a snbstance as Koch’s liquid was
being injected, was a matter of the first importance. It was
a tremendously powerful subatance. An ordinary injection
represented 0 001 mgr. of the liquid. He had it on the best
authority that this probably contained only about one-
thousanath part of active material, or about the fifteen-
millionth part of a grain ! Yet this infinitesimal fraction could
set the whole body of a man weighing 15 st. in such a state
of change that the whole was raised to a temperature of 104°
to 105°F. The weight of the mass thus affected was infinitely
greater than that of the active agent, the exact propor¬
tion being about 1 to98,000,000,000! That extreme accuracy
was needed in dealing with such a substance was evident,
but the syringes in the market were certainly nob all as
accurately graduated as they should be. The lecturer could
strongly recommend the syringe of Sbrohschein, which bad no
piston or indiarubber ball, and was a marvel of ingenuity
and cheapness. It was a pity that two different ways of
describing' the quantity injected had slipped into use, some
persons giving the volume, or portion of a cubic centimetre
used; others the weight in milligranimes. The latter
seemed the preferable standard. The place selected for the
injection was a mere matter of convenience. Koch had
suggested the loose akin between the shoulder-blades and the
lumbar region as being almost painless and otherwise
suitable.
The noticeable results following the injection have been
grouped together under the term “reaction.” The reaction
is a highly complex combination of phenomena, some local,
and affecting only parts which are iDfected with tubercle,
others indicating more a general affection. It was quite
erroneous to regard the temperature as constituting the
reaction, or even as being its main feature. There is usually
no reaction whatever at the site of the injection. Frequently,
even in cases of strictly limited lupus, where the lungs are
perfectly sound, the earliest indication of the system being
affected is a short, diy cough, which may come on as early
as half an hour after an injection, even in persons absolutely
free from pulmonary disease. It is more like the attempts-
of a person to cough who has no cough than anything else.
It may be pretty constant and annoying, but generally is
not sutDcienbly accentuated to be so. It rarely lasts longer
than two hours or thereabouts, and it gradually subsides
before disappearing. On the other band, the local reaction
affecting the parts where there is livingtubercularmattermay
come on before there are any decided indications elsewhere
showing that the injection is taking effect. This observation
of Dr. Ilime’s harmonised with that of Dr. Lindner of Berlin,
who says^ that general constitutional reaction is not always
observed where there is local reaction. Dr. Hime had noticed
very trivial general effects occurring long after the local re¬
action had come on, and when, in fact, it was passing off'.
Dr. Lindner is also of opinion that a general reaction never is
observed in cases where there is no local reaction, but
Dr. Hime could not confirm this. On the contrary he had
seen general, without local, reaction occur. It may happen,
indeed, that no reaction, either local or general, will follow
the first small injection. Again, there may be none until
several and increasing injections have been given, and then
rather suddenly and unexpectedly there maybeaconsiderable
general and local reaction. This non-occurrence of a reaction
after one or two, or even more, injections must not be regarded
as indicating either indiff'erence to Koch's liquid ortheabsence
of tubercle. It is possibly due to the fact that for some reason
the tubercular deposits are so situated and circumstanced
7 Lecture ilelivered Dec. 8th, JSiw, before tho Oesollscliaft. f. <».
OosunilheitHptlegc, Horlin.
(J ‘2
;{58 Thb Lancet,] Mil. FREDERIC BOWREMAN JESbETT ON ILEO-COLOSTOMY.
[Fkii, 14,1891.
that the injected mateml does not readily act on them, and
that the products of that action, when establisiied, do not
readily enter the circulation. For it seems probable that the
fever and many other elements of the state known as the
“ reaction " are due to the ainorptioii of tissnedisiDtegrated
at the seats of disease by the intluence of the inicctcd
“ lyinpb ” and taken up into the circulation. That similar
general symptoms are induced by such an occurrence is
familiar under other circumstances, notably high bodily tem¬
perature being thus induced. Depage of Brussels assumes
that the injected material contains an agent, ptomaine or
other, which combines with the ptomaine of the tubercle in
Fio. 1.
ever, showed no speoitic characteristic whatever. All these
parts reacted markedly to the first and several subsequfnt
injections. The sniali scar under tlie right eye, however,
only reacted at one point, which shot up red and swollen
from the surrounding wliite tissue. This would suggest the
almost complete success of Mr. M'Glirs attempt to eradicate
the disease at this point. Several small spots on the right
upper eyelid reacted, and have since sloughed out and appa¬
rently healed perfectly. The same has occurred at the spot
above the left side of the mouth. The place between the ei e-
browB swelled and became red, and this was repeated after
several injections ; but there has never been any formation
Fia. 2.
J. C.; Lupus of the face of xovciitcon years’ staiidlnfr.
liufore injection with Kai-h'u liiiuiil. (L'liilor the euro
of Dr. llimc, Bradfurtl.}
J. r. at till* lioiKht nf reartioii, sevoiitcnn hours aftor Iho
first liiJ»s‘tion of Kodi'i! liijuld (U'UOl lugr.). (Under
the care of Dr. Hiwa, Bradford.)
the blood of the injected person. The general phenomena '
of reaction he regards as ueiug due to the introduction of i
this substance in the blood, aud partially to its combina- {
tiou with the small ijuantity of tubercular ptomaine cir¬
culating in tlie blood. But only very exceptionally did the
injected “lymph” produce reaction, except in tubercular
patients.
The appearance of the reacting part is very peculiar and
characteristic. In order to give those colleegues present
who have not seen such as vivid an idea os possible of what
great changes may occur. Dr. Hime produced on the screen
two likeneises of a patient be was treating for lupus—one
showing him before treatment, the otlier taken seventeen
hours later, wiien he was in the height of local and general
reaction, with a temperature of 103'. The features are i
greatly distorted, owing to the extensive swelling of the '
nose, upper lip, aud part of the left side of tlie cheek, the .
eyelids, and the skin between the eyebrows, the ^larts |
all'ected with tuberculosis. The patient bad been sur¬
gically treated for the disease at the Leeds Inlirmary
by the late Mr. M‘Gill more than once. Under the right
eye was a wliitish scar, where he was lost “gouged”; above ,
the left side of tlie mouth was another cicatiix (neither very
distinctly marked in the drawing). The two upper lids
were re<i and pufl’ed before treatmciil, aud made him at
(irst fear some kidney uiischief might coexist, which was
found to be the ca»e. There was a roughened, reddish
condition of the *ktu between the eyebrows, which, how-
of scab, and Dr. llime thouglit that the disease, though
undoubtedly present, was very limited aud superficial. There
was no local reaction whatever in any part of the patient's
body, except those connected with tlie race.
(To be continued.)
IIJCMAUKM OX
THE OPERATION OF ILEO-COLOSTOMY FOR
ORGANIC DISEASE OF TRK C^CUM,
CAUSING ORSTRUCTION.
By FREDERIC BOWREMAN JESSKTT, F.R.C S. Eng.,
SUIlUliO.N TO THE CANCER HOSPITAL, HHOMPTON.
I WAS much interested in Mr. Bryant’s ablo and in¬
structive paper on “ileostomy” fur organic disease of the
cwcuni, which appeared in the columns of Tiiu Lancet of
Jan. Idbli. That such an operation as he describes may
be the means of relieving some of the urgent and dietresBing
symptoms of obstruction, as well as of prolonging life,
cannot be disputed, but the question arises, by adopting
such an operation, does the surgeon place his patient in tlie
best obtaioahiu posiiinn during tiie remainder of his life?
It is on this point I wish to make a few remarks, and 1
Digitized by <^ooQle
The Lanobt,]
MR. FREDERIC BOWREMAN JESSETI ON ILEO-COLOSTOMY. [Feb. 14,1891. ,<^59
shall endeavour to show that the operation of ileo-colostomy
in all cases, excepting when the patient is so reduced and
exhausted as to render such a meeisure undesirable, is
preferable to ileostomy. The following case illustrates well
what 1 mean.
On August 2Qd, 1889, Dr. Hayes of Basingstoke asked
me to see a gentleman with him sufTetiog from a tumour
which occupied the right iliac fossa, extending upwards to
within two inches of the false ribs, and forwards to nearly
an inch beyond the right linea semilunaris. The patient
had suffered considerabV from time to time from irritation
and discomfort of the bowels. Daring the two months
previously to my seeing him he had been much worse;
he complained of constipation, aUernating with irritating
diarrhoea, general uneasiness, and great pain. He had
been seen oy a physician, who pronounced ,hioi to be
sufferingfrom epibheliomaof theccecum, with which diagnosis
I fully agreed. The patient was a tall, spare man, over
fifty years of age, with sallow complexion and good pulse.
He had been losing flesh rapidly, and was very low.
The bowels bad not been opened for some days. The
abdomen was somewhat tympanitic; but he complained
of no tenderness excepting over the tumour. A tumour
was discovered occupying the situation above described ;
hard and somewhat firmly fixed. As the symptoms were
urgent, I suggested that the abdomen should be opened,
and we should be guided by circumstances what operation
should be performed to relieve the patieut of his distressing
symptoms. The removal of the growth appeared to be
impracticable, and I explained to the patient and Dr. Hayes
that I should be prepared to perform ileo-colostomy by
implanting the ileum into the transverse colon, and by
such means trusted that the remaining term of his life
might at least be made more endurable. On August 3rd,
with the assistance of Dr. Hayes and Dr. Purcell, Dr. English
giving the aoiuatbctic, I opened the abdomen by an
incision about thres inches long over the right linea
semilunaris, all bleeding points being caught with pressure-
forceps. I opened the peritoneum along the whole length
of the incision, and immediately came down upon a large
mass of disease, extending from the cjecum nearly as high
as the transverse colon. Ic being quite impossible to remove
this I determined to divide the ileum and implant the
proximal end into the transverse colon. Passing the index
linger of the left hand along the inner side of the crecum, a
portion of ileum, close to the iloo-cfeoal valve, was easily
drawn out of the wound ; I then passed two pieces of india-
rubber cord lightly round the intestine, about four inches
apart, the piece on the distal end being placed about two
inches from the ileo-cmcal valve; I next divided the.intes¬
tine completely across, between the two indiarubber liga¬
tures, caught up and ligatured all bleeding points, and
washed the divided ends thoroughly. The cut end of the
distal part of the ileum was inverted and closed, by stitching
together the peritoneal covering with a fine silk suture.
The next step, in the operation was to line the pioximal end
of the divided intestine with a thin band of indiarubber,
about half an inch wide, which was fastened by a continuous
catgut suture to its cut edge. Two chromicised catgut sutures
about eighteen to twenty-four inches long, and armed at each
end with a needle, were next passed through the indiarubber
band and all the coats of the intestine from within outwards.
The posterior threads were passed one on either side of the
mesentery, and the anterior threads at equal distances apart
through the convex surface of the bowel. A portion of the
transverse colon was next brought out of the parietal wound
and a longitudinal incision made in its convex surface; the
long sutures connected with the ileum were then passed
through the serous and muscular coats of the colon, the an¬
terior threads about half an inch apart at one end of the
opening in the colon, and the posterior threads at a similar
distance at the other end. (Fig.l.) The open endof the ileum
was then thrust through the slit and the sutures firmly tied,
thu.s preventing the possibility of the bowel slipping out;
two Czerny-Lembert sutures, one on each .side, were intro¬
duced, passing through the serous and muscular coats of the
colon and small intestine, and tied firmly. An omental
flap was finally fastened round. The parts were thoroughly
cleansed and dropped back into the abdomen, and the
parietal wound closed and dressed in the usual way. The
operation lasted about one hour.
The patient stood the operation very well, and was re¬
turned to bed, and ordered to be fed with nutritive enemata
and zyininised meat suppositories for the first twenty-four
hours.
August 46h.—Motion passed naturatly by the rectum
to-day, and continued to do so daily. No tenderness over
the abdomen, excepting over the original tumour, the outer
and lower side of which is brawny, and had all the appear¬
ance of deeply seated cellulitis.—5bh : I visited the patient
with Dr. Hayes, and found the bowels had acted naturally
and well and the wound looking healthy. A large abscess
was pointing at the upper part of the thigh ; this was freely
opened, letting out a large quantity of stinking pus ; this
was kept syringed out and drained. The patient takes
his nourishment well, and is kept up with brandy, cham¬
pagne, beef-tea, &c. The patient had not sufficient vital
power left to resist the constant drain of the abscess,
and died on August IGtb, thirteen days after the
operation.
Had this patient been operated on earlier I
am convinced that his life might have been materially pro-,
longed. So far as the operation was concerned, it was,
all that could have been desired. There was no peritonitis
and fio.ces passed freely from the day of the operation until
his death, nearly a fortnight after. This being the case„
this operation must commend itself to all surgeons as being
far preferable to any operation which has for its aim merely
the formation of an artificial anus or a fmcal fistula. In ray
experimental research, published in July, 1889, I bad not
one death after the operation I have described, and the
result, as maybe seen in Eig. 2 (a specimen of which is now
in the Museum of the College of Surgeons), is perfect, and
I have but little doubt at no far distant date, in cases of
obstruction of the bowels, from whatever cause, the con-
\\ v'k-
tinuity of the intestinal canal will be preserved either by a
similar operation to the one described, or by means of
approximation plates, as suggested and practised by Professor
Senn, and that the only cases in which a fmcal fistula will
be justifiable will be in cases in which the patients are too
exhausted to allow of their taking an amusthetic for a
lengthened period.
Pig. 1 is only intended to show how the ileura is implanted
into the colon, but in practice it is always desirable to divide
the colon and invert and fasten up the divided ends, so as to
prevent the possibility of fivees returning over the diseased
surface. In the above case this was not done, as the patient
was in a very low condition, and it was recognised that
tlie operation was only a palliative one.
Upper Wimpole-sli'cek, W.
Digitized by
Google
360 The Lancet,] DR. HENRY ASHBY: MILK STERILISERS FOR DOMESTIC! USE, [Feb. 14,1891.
SOME NEW MILK STERILISERS FOR
DOMESTIC irSE.
By HENRY ASHBY, M.D., F.R,C P.,
PHYSICIAN TO THE OENER.AL HOSPITAL FOR SICK CHILDREN,
MANCHESTER.
hour. The temperature of the milk is in this way main¬
tained at210°F., atemperature not high enough to risk an
explosion, but sufficient to destroy the microbes in the milk,
at least as far as all practical purposes are concerned. No
marked change takes place in the taste of the milk. The
apparatus is allowed to cool, the inner tin is hung up to
the wall of the pantry or other cool place by means of the
At the present time we are only beginning to realise that
one of the most important differences between human and
cow’s milk is that the former is free from living organisms,
while the latter, by the time it is delivered to our houses,
contains many microbes, and this is especially true of
the cheaper classes of town milk. In such mUks we
have only to examine the sediment in the large milk-
cons in order to detect matter foreign to the milk;
thus we may find hay seeds, fragments of straw, fiscal
matter, sand, dirt, epithelial scales, human and cow’s
hairs. And, if we further inspect the milking process and see
the condition of the cows and cowsheds, we shall cease to
wonder at the contamination present; especially if we bear
in mind that in the winter months the cows are milked
before daybreak and after sunset, so that the process goes
on in the dark, or at best by a dingy light. In addition to
these tangible impurities, bacteria in number from
20-100,000 per cubic centimetre may be found in milk
(Escherich), The presence of bacteria in milk is evidence
chat decomposition changes are in progress which sooner or
later, according to the temperature to which it is exposed, lead
to its turning perceptibly sour to the taste, and curdling.
It need hardly be said that the worse class of milk for an
infant is that which “is on the turn,” for not only is the
curd rapidly thrown down in the infant’s stomach, but the
bacteria present are not destroyed, and, especially when
the digestive juices are weak, continue to effect the decom¬
position changes which they have begun outside the body.
The best cow’s milk for an infant is that which is
fresh and absolutely free from microbes. Of other
dangers to the infant and others from taking uncooked
milk there is evidence to show that milk may be
the means of conveying the infective bacillus of tubercle,
diphtheria, scarlet fever, zymotic diarrhcna, &c., from the
farm to the household of the consumer of milk. In order to
avoid these dangers, the advice to boil the milk has often been
given. But boiling the milk over a fire has the disadvantage
of running the risk of “ burning” it; moreover, the taste is
materially altered, and if the milk is only just brought to the
boiling point, it is doubtful if all the bacteria which maybe
present are destroyed. To effectually “ sterilise” milk f’ro-
fessor Soxhlet some three years ago devised his now well-
known apparatus, bub which in this country at least has not
found its -way into any great number of households. It is
undoubtedly efficient, but it is somewhat complicated and
expensive to work on account of the frequent breakages of
the bottle.
More recently modifications of Soxhlet’s apparatus have
been made on the same principle, and if his original appa¬
ratus falls into disuse, we shall nevertheless be grateful to
the Munich professor for having given an impetus to
domestic milk-sterilisation. Of the more recently con¬
structed apparatus which are now to be obtained none
seem better adapted for either family or hospital use
than the one devised by Professor E^sclierich of Graz.
It consists of a cylindrical tin vessel, a, of some three pints
and a half capacity. It has a removable lid at the top,
which can be fastened on, hermetically sealing the tin by
means of a lever and catch arrangement, h h'. When the
lever & is raised the lid can be removed; when forced down, as
in the engraving, the lid is secured. Fixed in the lid is a wool
filter arrangement, c; the passage through the filter can be
opened or snut by means of a stopcock worked by a stirrup
or loop of wire. At the bottom of the tin is a stopcock for
drawing off the milk. The tin fits into an outer vessel, c,
which contains water and is placed on the kitchen range.
To use the apparatus the infant’s daily ration is prepared,
or two days’ rations may be taken. In the latter case
two pints of fresh milk and one pint of barley-water and
sugar are placed in the inner tin and the lid applied,
the stopcocks both at the bottom and in the lid being
turned off. The milk tin is placed in the outer vessel con¬
taining water, the outer lid closed and placed on the
kitchen range, and the water is kept boiling for half an
Fig. 1.
Escherich’s milk steiiliser. a, Tin containing milk, b. Lover;
h'b', catch for securing lid. c, Wool lllter. e, Outer tin
vessel containing water. /, Chain for hanging up milk tin.
chain, /, and the infant’s food is drawn off through the
stopcock as required ; at the same time the stopcock in the
lid is turned on, and as the air enters it is filtered through
the plug of wool present in the filter. The food is of course
warmed up before giving to the infant.
The feeding-bottle suggested by Escherich resembles in
size and shape an ordinary eight-ounce medicine bottle, it
Fig. 2.
Soihoi't’s milk storilisor, consiBbiiig of tin bmyand series of
feeding bottles of different sizes, according to weiglit of
infant.
is graduated, and instructions concerning the amount
and strength of the food to be prepared, and the amount
to be given in each bottle, are engraved on the side. The
maker is Theodor Timpo, of Magdeburg, North Germany.
The price in Germany is 12s. Grf. It can bo obtained in this
countiy from A. Hailwood, St. Mary’s-gate, Manchester.
Another simple form of milk steriliser is one devised by
Digitized by
Google
Thb Lancet,]
DR. J. F. LITTLE ON FRANKLINISM IN DAMP CLIMATES. [Feb. 14, 1891. 361
Dr. A. Seibert of New York. It conaiets of a tray (see
Fig. 2) and ei^ht feeding bottlea, with special rubber
stoppers and a nipple to ht on to the bottle when the infant
is fed. There are six series of bottles, the smallest size
being 3 oz. capacity, and the largest 8 oz., arranged for
infanta according to their weights. The bottles are filled
up to a given mark with milk, and then up to the neck with
barley-water ,or water, and sugar added. They are then
iitted into the tray, and steamed for half an hour in a
saucepan provided with a lid. During the steaming process,
the rubber stopper is fitted loosely into the bottles, so that
the steam escapes by two slots or grooves in the side of the
stopper; when the steaming is complete, the stoppers are
pressed into the bottles, so as to seal them up. When the
infant is fed, a bottle is warmed up and the stopper with-
•drawn, and the nipple placed on the bottle.
Modifications of Soxhlet’s original apparatus have been
suggested by Prof. C. Flu gge ana several others. The most
important change in Flugge’s is that instead of rubber
stoppers with small glass rode fitting into the stopper the
feeding-bottle is provided with a loosely fitting glass cap,
which he has proved experimentally to answer the purpose
of preventing the microbes in the atmosphere entering the
bottles. I have not had an opportunity of examining
Flugge’s apparatus, and I do not know if it is to be had.
The systematic use of some efficient form of milk steriliser
in the household, especially where infants are being arti¬
ficially fed, is, I believe, of the greatest importance; their
use will, I feel sure, tend to the diminished use of many of
the patent foods now so commonly employed, and lessen
infant sickness and infant mortality.
Manchester.
FRANKLINISM IN DAMP CLIMATES.
By JOHN FLETCHER LITTLE, M.B., M.R.C.P.,
I’MYSICIAN TO THE ST. MAHVLEHONE OENEIIAI. DISl'ENSAHY.
The use of statical electricity in this and other countries
where the atmosphere is often laden with moisture has been
greatly hindered by the want of machines which are un¬
affected by hygroscopic conditions. No therapeutic agent
which cannot at all times be turned to account is ever
likely to come into common use. During certain seasons of
■the year, but especially during the spring months, frictional
machines are uncertain in their action, and often fail alto¬
gether. This occurs even in the dry atmosphere of Paris,
where eveiy precaution has been taken, and much more so
in our damp climate. Convinced of the value of this form of
■electricity, after having watched its application in Charcot’s
cliniq^ue at La Salpitriere, I have long wished for an instru*
ment which should always be available. There is now such
a machine made by (iliiser of Vienna. Its constancy also
appears to be perfectly reliable. The electricity is generated
by the rotation of two vulcanite drums revolving one within
the other. The outer drum being air-tight, damp cannot
affect the production of the electricity. Within the inner
drum are two combs, and their position is indicated by
a slit crossing the right end of the central bar, to which
they are attached. The ends of the slit point in the direction
ef the combs. In order to excite the machine, a strip of
vulcanite of the size of a paper knife is rubbed with a piece
•of new flannel, and held across the outer drum in a fine
parallel to one of the inner combs. Half a turn of the
handle is sullicienb to prepare the machine for use. During
'toe first week in April, 1890, 1 commenced experimenting.
The weather was so damp and wet that all my friends using
other statical machines informed me that they found the
•greatest dilliculty in getting their instruments tn work, and
sometimes failed altogether to excite them. The testa I
iipplied were of the severest kind I could devise. The
machine was placed in a room without a lire, and the
windows left open night and day. The machine was never
dusted, wiped, or protected in any way, and yet I was
always able to evoke sparks two and three inches in length
whenever I wished. Another advantage that I found it
Pil®®essecl was that there was no cliange of polarity.
When I placed the strip of vulcanite over the upper
internal comb and turned the handle to the right, the
outer comb marked Sk in the illustration, became posi¬
tively electrified, and remained so as long as the handle
was kept in motion. The two electricities are collected
respoctivelv at the two external combs which are connected
with the discharger. The positive comb is recognised by a
hissing noise as of steam escaping in small jets, and by a
bluish-purple phosphorescent brush extending in a sheet
from the comb over the drum for several inches. This is
best seen when the room is darkened. The negative comb
is distinguished by a row of small, well defined, luminous
spots, and by a slight crepitant sound. The positive knob
of the discharger is known by the purple colour of the phos¬
phorescence wnen sparks are drawn by approaching the two
knobs within an inch of each other. At the same time
the negative knob is indicated by the brightness of its end
of the spark. No attempt should be made to reverse the
polarity of the combs by turning the handle in the opposite
direction. When this is done, it often happens that tne two
ends of each external comb become charged with opposite
electricities. This also occurs if the discharging rods are
slowly separated until the sparks cease to be emitted.
I append an explanation of the letters in the illustration.
1
5*VVWVVVVVW
1
i|, Oiitor th-um. Sh, Ski, Outer combs, r r. Small wheels for leather
atiups, R R,, Hugo wheels, c J\ Ends of axis, a b, n, bu Iron
frame ami stands, k. Handle. Ax, libonite handles of dis¬
charger. m n, Knobs tlir<ii!gh which the liandles glide.
Welhock-stveet, W.
CoTiLiKRY Explosions.—I t is announced that, on
Mr. Secretary Matthews’ recommendation, the Queen has
approved the appointment of a Royal Commission to inquire
into the effect ot coal dust in originating or extending ex¬
plosions in coal mines. The chairman will be the Right
Hon. J. Chamberlain, M.F. The other Cnnimissioners will
be Lord Rayleigh, .F.R S., Professor H. B. Dixon, F.R.S ,
Sir AV. Lewis, Mr. Emerson Bainbridgo, and Mr. C.
Fenwick, M.P.
Toogle
Die :ed '
362 Thk LANOOT,] me. C. J. H. WARDEN ON THE ESTIMATION OP UREA IN URINE. [Feb. 14,1891.
A RAPID METHOD FOR THE ESTIMATION OF
UREA IN URINE.
By C. J. H. warden,
PROFESSOR OF CHEMISTRY, MI5DICAL COLLEGE. CALCUTTA.
As Sutton has remarked, the eodic bypobromite method
of estimating urea in urine has given rise to endless forms
of apparatus, the principle of construction being similar in
all, with the exception, I believe, of Lunge’s
nitrometer, when it is used for the estimation
of urea. In all the instruments hitherto pro¬
posed the decomposition of the urea, and by
the bypobromite, has been accomplished in
one apparatus, and the evolved gas measured
in a separate tube, la the method now de¬
scribed the evolved nitrogen is measured in
the same tube used for the decomposition of
the urea, and the procedure is consequently
much simplified. The apparatus used for the
decomposition of the urea and measurement
of the liberated nitrogen consists of a slightly
modified form of Crum’s well-known nitro¬
meter. Crum’s tube, as usually constructed,
has a total length of 210 mm., an internal
diameter of 15 mm., and a capacity of about
25 cc., the cup at the top having a capacity of
a little over 2'5ce. The modifications desir¬
able in adapting the tube for the estimation of
urea may be thus summarised (a) Trebling
the length of the tube, and thus making it
030 mm. long, the capacity being increased
to 75 cc., while the internal diameter is not
altered ; (6) grinding on to the lower open end
of the tube a glass stopper on which two
narrow grooves have been filed ; (c) increasing
the capacity of the small cup at the top of the
tube to 5 cc., and having it accurately gradu¬
ated to hold 2 5 cc. when filled to a certain
mark ; (cf) using somewhat thinner glass than
that employed in the construction of Crum’s
tubes, as no mercury is used in the process.
The tube is graduated on the principle of
liiTssell and West’s receiver apparatus, which
was constructed to be used with 5 cc. of
urine. It was found that 5 cc. of a 2 per
cent, solution of pure urea evolved 37'1 cc. of
nitrogen, and this volume was taken as the
basis of graduation of the measuring tube.
In the process now being described only
2 5 cc. of urine are used, and as 2 5 cc. of a
2 per cent, urea solution evolve 18'55cc. of
nitrogen, this volume of gas will necessarily
be equivalent to 2 per cent, of urea. One per
cent, of urea is therefore equal to 9'27cc. of
nitrogen, and the 9 '27cc. volumeisdivided into
ten equal parts, each part being equal to O'l
per cent, of urea. These divisions are further
subdivided into twu each, representing '05
per cent, of urea. The graduations should be
continued so as to indicate up to 3 per cent,
of urea. As in Russell and West’s tube all
calculations are avoided, the observed volume
of gas at once indicating the percentage of urea
ia the specimen of urine under examination.
In using the apparatus the following solu¬
tions are required-1. A cold, aqueous,
saturated solution of common salt. 2. Hypo-
broinite solution, made by dissolving 100 grains
of caustic soda in 750 cc. of distilled water,
and adding 25 cc. of bromine; this solution
should be freshly prepared in small quantities
as required for use. 'To use the apparatus, the
stopcock should be first slightly greased and
closed, the tube inverted, and the grooved
stopper removed. The bypobromite solution
is then poured into the tube to overflowing,
the stopcock opened to allow a drop or two
to escape, and thus displace the small column
of air in the base of the stopcock. The
grooved stopper is then pressed home, the
excess of bypobromite solution escaping by
the grooves in the side of the stopper, in the same manner
as the superfluous fluid escapes through the capillary orifice
in the stopper of a specific gravity bottle. In this way the'
tube is filled with the bypobromite solution, all air being
excluded. The tnbe is now inverted, held under a tap of
water, and the ci^ &c. thoroughly washed, and then most
carefully dried. The tube is now stood in a small trouglii
of brine—a finger bowl answers very well,—and supported
by a filter ring or clip. The sample of urine to be
examined is then poured into the dry cup up to the 2 5 cc.
graduation, any excess of urine accident^ly introduced!
being removed by a fine fold of blotting-paper. The cup
is then filled up with brine, which ia well mixed witlx
the urine by a small and slender glass rod. The object of
diluting the urine with brine is to increase its denaitrv. If
ordinary .urine were introduced into the tube it would float'
upon the surface of the bypobromite, and only a slight’
reaction would immediately occur at the point of junction'
of the two fluids; but by increasing the specific gravity of
the urine in the way indicated it flows through the hypo-
bromite solution, and brisk effervescence ensues. If the
urine solution were allowed to enter the tube while closed
with the grooved stopper, a portion of the evolved gaa
would escape through the bore in the stopcock. In order
therefore to avoid losing gas from this cause, the grooved
stopper is first removed before urine is allowed to escape
from the cup into the tube. In allowing the urine to enter
the tube the stopcock should be opened sharply, and a
small amount of urine in a full stream allowed to enter;
decomposition of the urea at once ensues, and the gas
collects at the top of the tube. When effervescence
has ceased, more urine is introduced, and so on until
the cup has been emptied. The cup is then filled with.
2'See. of dilute brine, and rinsed round by means of the
glass rod. The whole of the brine is then allowed to
enter the tube at one operation. The same amount of
dilute brine is then again placed in the cup, rinsed round,
and allowed to enter the tube. The tube is now grasped
by the right hand, the thumb ..being tightly pressed against
the open end and the contents thoroughly agitated. Lastly,
the tube is placed in a vessel of water and the thumb re¬
moved, when the saline solution flows out and water
occupies its place. If while the open end of the tube is below
the surface of water, water from a tap be allowed to flow down
the outside of the tube, the temperature of the gas will be
rapidJyredueed to that of the water. The remaining operation
consists in marking the volume of gas with the usual pre¬
cautions, the volume indicating the percentoge of urea in
the urine without the trouble of any calculation; corrections
for temperature and pressure can, of course, be applied if
necessary. In using the tube, if the evolved gas should
exceed the volume yielded by 3 per cent, of urea, the urine
must be diluted with an equal volume of water and 2'5 cc.
of the diluted urine used in the manner already described,
the percentage of urea as indicated by the volume of gas
being doubled. The points to which special attention may
be drawn in connexion with this method of estimating urea
are: (1) extreme simplicity of apparatus, all the various
operations of measurin g the urine, deconjposing the urea, and
measuring the volume of evolved gas being performed with
one instrument; (2) ease and rapidity of manipulationj
(3) results as accurate as those afforded by any of the various
modifications of Russell and West’s original method.
Messrs. Cetti and Sons, of Brooke-street, Holborn, are
prepared to supply these modified Crum tubes, and the
well-known name of the firm is a sufficient guarantee that
the graduations will be accurate.
ON SOME FORMS OF ABDOMINAL ABSCESS.
By G. a. WRIGHT, B.A.OXON., F.R.C.S.,
SF.NIOR ASSISTANT SURGEON, ROYAL INFIRMARY, MANCHESTER, Ac.
((Junclnded from U03.)
Ca.se 12. Appendicular peritonitis cured by incision ,—
On April 2nd, 1888, while down in the country, I saw a
girl aged thirteen, a patient of Mr. Mercer, of Stanford,
Essex, who fourteen days before had without known cause
been seized with pain in the right iliac region. The pain and
vomiting had continued ever since. There was great local
tenderness; the pain intermitted; the bowels were usually
constipated, but not constantly so; there was no great
fever, the cheeks were flushed, and the abdomen becoming
Dr diry lOOgle
-Z_2j
■0 -
It —•
-
r5-r-3
'B T:
Is¬
is' -
1.5
Thb Lancet,]
MR G. A. WRIGHT ON ABDOMINAL ABSCESS.
[Feb. 14,1891. 363
tympanitic. When I saw her I found a healthy-looking
girl, with a flushed face. She complained of great tender¬
ness in the right iliac fossa extending down to the knee on
the same side. She could not extend or invert tlie leg;
there were also pain and great tenderness in the loin. The
skin was not very hot; the pulse was quick; the tongue
coated slightly and somewhat dry. There was much tension
and resistance in the right iliac fossa; not much tympanites.
The diagnosis was appendicular peritonitis. I made an
incision one inch and a half long, just internal to the anterior
superior spine, and let out half a pint of fetid pus. I put
in a tube and gave a good prognosis. She got well without
any bad symptom, and.reroains so (1890).
Case 13. Typical fatal case of appendicular pGritonitis .—
Willie S-, aged nine, a patient of Dr. Cox of Eccles,
was a fairly healthy boy up till April 22nd, 1890, when he
4imused himself by eating a number of dried peas. He had
never had any previous bowel trouble. Two days later he
-awoke with pain in the abdomen, which continued; the
pain was chiefly in the right iliac region, and was accom¬
panied by vomiting, a quick pulse, and a temperature of
100° to 101° F. The vomiting was not faecal, there was no
intestinal obstruction and no diarrbcca. There was some
vesical irritation, causing frequent micturition. I saw him
first on April 28bh, 1890. He was then lying in bed with a
thin, somewhat pinched face; the right leg drawn up ;
breathing almost entirely thoracic; abdomen moderately
•distended and tender,especiallyintherightiliaoregion. No
distinct swelling in the iliac area was to be made out bypalpa-
tion, but some dulnesa and increased resistance. There was
alight tenesmus, but no blood was passed by the bowel,
and there was no protrusion of any intussusception in the
rectum, which vas empty. Rectal examination revealed
some fulness in the right iliac fossa- The sickness still
continued, but was not fcecal. Our diagnosis was appen¬
dicular peritonitis, and extension to the general peri¬
toneal cavity. Operation was advised. Two hours later I ;
opened the abdomen over the coecal area, and let out several
drachms of thin pus. The cavity seemed to be shut off,
but only by feeble adhesions. No attempt was made to find
the appendix; a tube was inserted and the wound dressed.
There was considerable collapse, which had begun before
the operation. The next morning he had rallied a good
deal; the abdomen was still distended, but somewhat less
so ; there was free discharge of foul sero pus from the tube,
and the edges of the wound were blackened; there was
still tenderness in both loins ; there had been much sickness
and no sleep, and nutrient encmaba bad been given. After
this he failed to get any sleep, became delirious, and sank
exhausted before the next morning.— Nec7’opsy: Dr. Wild,
who kindly made a post-mortem e.xaminatioh for us, reports
•as follows: Abdomen much distended and dark-green in
'colour (thirty-seven hours after death). On opening the
abdomen the entire peritoneum, from diaphragm to pelvis,
was covered with layers of thick, yellow lymph, having a
fojcal odour, but not stained by fjeces. The intestinal coils
were matted together and to neighbouring organs. The
lymph was firmer and more abundant) towards the ctccuni,
•but no distinct cavity could be made out. The vermiform
appendix closely adhered to the outer and posterior wall of
the cfccum, was much bent on itself, and the terminal
three-quarters of an inch formed a soft grey slough, while a
perforation, involving about three-fifths of its circumference,
was closed by yellow lymph. The proximal portion contained
a bard fmcal mass the slise and shape of a small bean, with
■a central brown fibrous body. There was no other intes¬
tinal lesion. This case illustrates the type of appendicular
abscess in which, for some reason, no efficient barrier of
adhesions forms around the irritating material.
Case 14. Fatal case of appc^idicular peritonitis, without
operation .—On April 15th, 1888, Dr. liailey of Stockport
asked me to see Mr. C-, aged twenty-eight. He had a
phthisical family history, but his health had been fairly
good till four or five weelcs before, when he had an attack
of generalised abdominal pain. Nothing local was found ;
there was no sickness or constipation. He got quite well,
and went back to his work as an engineer. On April 11th
he was seized suddenly during the night with epigastric
iPain. This lasted for twenty-four hours, and then became
•inovo generalised. There was no vomiting, and not much
distension. The bowels acted on the 11th. He had no
hernia, no history of any injury, and there was no known
•cause for the trouble, but he had had pain after food for
some days previously. There was no htematemesis, and he
was not a drinker. On the I4th he got w'orse, with
apparently fmcal vomiting and collapse. A long tube had
been passed into the bowel without result. The tempera¬
ture ranged from normal to 102° ; pulse 100, failing
latterly. He had taken opium and bismuth. 1 saw him
on April 15bh, at 5 P.M. He was a thin man, and lay tossing
restlessly in bed; the face livid and congested, hands and
feet cold and clammy ; pulse not very feeble. There had
been no vomiting since the morning, and he had passed
plenty of flatus and urine. The abdomen was uniformly
distended. There were no visible coils. There was re¬
sonance everywhere, including the flanks. There was no
tenderness on pressure except in the right iliac area and
the right loin, where the pain on pressure was extreme.
The skin was not cedematous. Per rectum there was
tenderness and perhaps fulness in the right iliac area. The
tongue was furred but moist; face pinched and haggard.
The abdomen moved freely on respiration. We came
to the conclusion that there had neen an attack of
appendicular peritonitis four weeks before, with recovery.
That there was a second attack of five days’ duration, and
that there was now general peritonitis by extension and,
probably during the last twenty-four hours, leakage of
foul pus. An almost desperate prognosis was given, but
the friends were told that operation gave one, though a poor,
chance. They decided to think it over. The patient died
in the night.
Several of the preceding cases are, of course, open to more
than one interpretation. Thus, of those that I have classed
as probably glandular, it is possible that some may have
been connected with the c.'ucum, and even of those on the
left side, it may be said that they were due to a lesion of a
displaced ctecuni, such displacement being by no means a
rare occurrence, as shown by Mr. Treves. On the other
hand, it is, I think, not improbable that some of the cases
usually classed as typhlitic are really glandular, and this is
probably true in the less severe instances.
Case 15. Localised peritoneal abscess, with abscess in in¬
testinal wall .—Harry P-. aged seventeen, was sent to me
ac the Royal Infirmary by Dr. Massiah on Jan. 19th, 1889.
He was a healthy boy until a week ago, when he was
seized with severe pain shooting across the abdomen ; this
soon became localised in the right iliac fossa. We afterwards
obtained a history of his having been kicked in the abdomen
by a man. There was constipation, which apparently had
lasted the whole week between the onset and his admission.
On his arrival at the infirmary the lad was evidently
seriously ill, and complained of pain across the abdomen.
On examination, a large, brawny swelling was felt in the
right iliac fossa; the part was very tender and be was feverish
(temperature 101°). . I operated shortly after his admission,
making an incision three inches in length a little above
and internal to the anterior superior iliac spine. The
peritoneum was found thickened, and on opening it and
inserting a director a gush of sero-purulent fluid escaped. A
part of apparently the small intestine, at any rate not the
appendix, was seen presenting at the wound, and on it was
a small, round, yellowish patdi—an abscess in the intestinal
wall. On puncturing this patch, a drop or two of pus
escaped, and afterw'ards a little feculent material. The
wound was drained freely ; the bowel was as little disturbed
as possible, no attempt being made to discover any further
collection of pus, or to make out the relations of the parts,
and the wound was dressed. The next dressing was three
days later. He got steadily well; there was no further
escape of fmces; and hewas discharged on Feb. 13bh, and, I
believe, has remained perfectly well since. This was an in¬
teresting and unusual case. Whether the abscess in the
intestinal wall was primary or secondary must remain
doubtful.
Case 16. Local peritoneal abscess of obscure origin .—
On April 3rd, 1884, I was called by Mr. Power to see Miss
A-, aged ten. On March 27th she had been seized with
pain in the abdomen, followed the next day by vomiting,
and on the 29th by purging. Since the 29tli there had
been vomiting and absolute constipation. No blood had
been passed, except a little after administration of an
enema ; there was no tenesmus. She passed a fair quantify
of urine. On inquiry, there was a previous history of
occasional attacks of pain in the left side of the umbilicus.
No immediate cause for the trouble, such as improper food,
was known. There wm no evidence of tuberculosis. I
found the child emaciated, but with a fairly good pulse.
The abdomen was moderately distended, not tender, and
864 The Lancet,] SUEGEON-MAJOR E. LAWRIE ON THE CURE OF CHYLURIA.
[Feb. U, 1891.
there wtis not much pain. Examination of the rectum
revealed nothing except perhaps some fulness in Douglas’s
5 ouch; nothing local could be made out in the abdomen.
'he pain was a little to the left of the umbilicus. Bella¬
donna was ordered internally. On the 4th I heard that she
had had no vomiting till 10 A.M.,but the abdominal dis¬
tension had increased, as had also the fulness in Douglas’s
pouch. There was increased dulness in the left flank,
shifting very slightly on change of posture. The obstruc¬
tion was still complete. I then opened the abdomen below
the umbilicus, and, passing in a finger, broke down some
adhesions at the back of the abdomen and set free some
us. Some of the coils of intestine were collapsed, others
istended. The pus was offensive. The child died the
same night. No post-mortem examination was obtained.
Case 17. Tubercular peritoneal abscess. —A little girl
one year old, a patient'of Dr. Massiab, came of a healthy
stoclc, and had been well till about Jan. 10th, 1887. It was
then dyspeptic, and was seen by Dr. Ashby, who thought it
probably had enlarged mesenteric glantfs. It improved
under treatment for a time. On March 8th, 1887, it began
to vomit, and the bowels were constipated ; all food was at
once thrown up. Dr. Massiah examined the abdomen and
found it full and tense, with some dulness in the hypo-
gastrium. Nothing was felt per rectum, but while he was
examining it some offensive fluid escaped, apparently from
the vulva; it smelt of sulphuretted hydrogen, as did the
vomit. The child was rapidly failing, and had a tempera¬
ture of 100® to lor. At 8 P.M. on the 10th I saw it with
Dr. Massiah. The face was thin and pinched, with dark
hollows under the eyes; the abdomen was very full and
tense; there was some dulness in the hypogastrium, and
greater resistance and pain in the left iliac fossa, and to
tile right of and above tue umbilicus. On rectal examina¬
tion, no sign of intussusception was found, but a mass which
was thought to be matted coils of bowel was felt in the left
iliac fossa. There was no tenesmus, but an enema
returned at once ; no blood or mucus escaped per rectum ;
there was no defined tumour to be felt in the abdomen.
A diagnosis of localised peritoneal abscess and general
matting of intestines was made, and a bad prognosis given.
Abdominal section was advised as giving the only chance.
The abdomen was opened below the umbilicus; the peri¬
toneum was found to be thick and red, and the organs so
matted together that no cavity could be found at first.
After gently separating adhesions a gush of thin, flaky,
fetid pus escaped, in quantity about half a pint; the
swelling of the abdomen subsided. On passing a nnger into
the abdomen the intestines were found all matted together.
A large cavity reaching from the left iliac fossa upwards to
the right beyond the umbilicus was washed out and drained.
The vomiting stopped at once. On the 11th some fcccal
matter came away, and it was evident that the bowel had
given way into the cavity, which was again washed out.
12th ; Temperature 105°. Everything taken by the mouth
comes away almost at once through the wound. Child
sinking rapidly. The temperature rose to 100°, in spite of
antipyrin, and the child died early in the morning of the
13th. Necropsy: General matting of the intestines was
found, except that the colon was nearly free. There was
general tubercular peritonitis. The abscess cavity was well
drained, and it was evident that the lesions were of two
different dates, there being old adhesions and recent abscess |
formation. The opening in the bowel was apparently high
in the small intestine, hut its exact site coulfl not be made
out. There were a few tubercles in the right lung. The
bladder had no communication with the bowel, so the source
of the fluid, which was thought to have escaped during the
first rectal examination, was not made out. Localised
tubercular peritoneal abscesses may probably arise in any
one of three ways: (a) as a result of extension from a tuber¬
culous mesenteric gland; {b) as a result of perforation of
a tubercular ulcer; or (c) as a primary local peritoneal
inflammation.
Case IS. Fibro-neuroma of a lumbar nerve simulating
appendicular peritonitis. —Dr. G-, aged forty, came to see
me on Feb. 20t]i, 1889, and gave the following history. For
two years lie had sufl'ered pain, or rather discomfort, in the
right iliac region. The pain came on in attacks at intervals
of about a month. His bowels were rather loose during this
time, but this was not unusual. Twelve months ago the pain
became more severe and the attacks more frequent, some¬
times occurring almost daily. At this time the bowels were
open twice daiVi o-od there was no vomiting. In another six
months the pain increased in severity and frequency, each
attack lasting a few minutes. When Dr. G-came to see
me the pain was violent, and appeared daily; the bowels
were moved once in two days, and the motions were either
small Bcybala or loose; blood was occasionall^y passed in
small quantity, but no pus. The largest motion was not'
larger than a little finger. Urine normal. Dr. G-’s
family and personal history were both gouty. On exami¬
nation I found the abdomen moderatelj^ full, hut not dis¬
tended ; there were no visible coils, no resistance, no tender¬
ness, except in the right iliac region, where a little above anc!
internal to the anterior superior spine was a well-defined,
very tender nodule the size of a small filbert and fairly
freely movable. There was gurgling in the crecal area.
Liver dulness quite dear of area of pain; no history of gall¬
stone or jaundice. Sir William Roberts, who had sent nim
to me, had advised him to take olive oil, and this he had
done. Any exertion greatly aggravated his trouble, and he
was quite incapacitated from taking charge of his practice.
I expressed the opinion that his trouble probably depended!
upon the presence of a concretion in the vermiform appendix,,
and advised him to take extract of belladonna internally
and lie in bed for a week. If after that time there was no-
improvement, I recommended an exploratory operation.
After some delay, for reasons unconnected with his-
health, as no relief was obtained operation was decided
upon. On May 2nd, 1889, 1 opened the abdomen a little
below and internal to the spot where the mass was felt,
and found that it was not appendix, but a fibro-neuroma-
lying in the subperitoneal tissue. The appendix was drawn
up and inspected and found quite healthy. The tumour was
removed and the abdomen closed. For some days he did not
do very well, and had a little pneumonia, hut this passed off,
and he was very well when, on the tenth day after opera¬
tion, he sat up and strained violently ; the wound gave
way, and a mass of omentum protruded. However, no-
serious symptoms followed, and a week later I removed the
protruding mass. He then recovered without further had
symptom, and remains quite well and free from any sign of
his former trouble. I have added this case to the others as
bearing upon the diagnosis of appendicular mischief, which'
was certainly closely simulated in many points.
The cases here recorded consist of a selection of those
that have been under my care in the last ten years, and
might have been extended ; bub they sufficiently illustrate
the types of case. Cases 2, .3, 4, 5, 6, and 9 were published
some years ago in the Archives of Paidiatrics, in a paper I'
sent to that journal, on Some Forms of Abdominal Abscesa
occurring in Children.
Mivncliestor.
THE CURE OF CHYLURIA, DEPENDING ON
F1LARIH5 IN THE BLOOD, BY THYMOL.
By SURGEON-MAJOR E. LAWRIE,
nJiSIIJKNCy SUIUiEON, IIVDEHAnAD.
In an article on Chyluria by the late Surgeon-Major
T. Lewis in “ Quain’s Dictionary of Medicine,” this passage
occurs:^ “It cannot be distinctly stated that the course of
the disease has been materially modified, much less cured,
by any known remedy.” Ibis, therefore, gratifying to be
able to bring to the notice of the profession the following
cases of chyluria which have been completely cured by the
internal administration of thymol.
Case I.—Nazim Mahomed Beg, aged twenty, was ad¬
mitted into the Residency Dispensary on Sept, libh, 1889j.
on account of retention of urine. A catheter was passed and
asmallquantityof cliylousurine withdrawn. The distension
of the bladder was not relieved, and on Sept. 12bh it was
necessary to perform perineal section. A large quantity of’
white clot was removed, and a lithotomy tube was tied into
the bladder, which was washed out with a solution of bichlo¬
ride of mercury. At first quinine and various other remedies
were employed without any effectthe urine continued
chylous, the patient was never free from fever, and filariic-
were always found in the blood at night. On Sept. 27tli the
administration of thymol in one-grain doses eveiyfour hours
was commenced. On Oct. 12th the dose was increased to
1 Vol. i., p, 203.
Thb Lancet,]
CLINICAL NOTES.
[Feb. 14,1891. 3$5
grains. On the ISth the symptoms began to improve,
4 Uid by Dec. 14bh, 1889, he was quite well, and there was no
trace of filarieo in the blood. When the patient was admitted
into hospital, he was emaciated and almost in a dying state.
He is now (Dec. 11th, 1890) quite well and is fat and strong.
The improvement in his condition might be thought to be
due to the spontaneous cessation of the disease, but no treat¬
ment did the patient any good whatever until the adminis¬
tration of thymol was commenced, and then the improve¬
ment was steady and gradual, and may fairly be attributed
to the action of the drug.
Case 2 —Mahboob Khan, sepoy, aged twenty. Admitted
into the Afziil Gunj Hospital on Oct. 1st, 1890, on account
of stone in the bladder. The patient stated that he had
sulfered from symptoms of stone for ten years. On admis¬
sion be was emaciated, his temperature was 102°, and there
svas a large stone in the bladder. The stone was removed
by lateral lithotomy at 1 P. M. on the day of admission, and
weighed five ounces and nineteen grains. I'he temperature
{remained high after the operation, particularly at night, and
on Oct. (ith the urine was discovered to be chylous. Filarim
were found in the blood, and also in the urine. The
administration of thymol was commenced in two-grain
•doses on Oct. 6th, and increased to three-grain doses on
the 11th. On the 14th the patient was attacked with dysen¬
tery, and the thymol was replaced by scruple doses of ipeca¬
cuanha. On the 20th he had recovered from the dysentery,
add thymol was recommenced. The dose was gradually
increased to five grains three times a day, and the patient
left the hospital cured on Nov. 2.‘lrd. He is now (Dec. 15th,
1890) quite well, and is fat and strong like the first patient.
His urine is normal, and there are no filarim in the blood.
The important practical point in the above cases is the
fact they establish that thymol has the power of destroying
organisms in the blood and tissues, which are actually the
cause of a well-known disease. The destruction of the
organisms cures the disease. On the other hand, I have
tried it extensively in many diseases which are supposed to
be due to organisms, such as l^rosy, phthisis, and
gonorrhoea, but without benefit. Either, then, thymol,
which is such a deadly poison to the filaria, is not a poison
to the bacillus, which is extremely unlikely, or bacilli are
Qot the cause of the diseases 1 have mentioued.
It appears probable that thymol may prove useful in the
elucidation of some of the intricate questions involved in
the relations of micro-organisms to disease, and it is on this
account to be commended to the consideration of bac¬
teriologists.
€Mal |t0k0:
MEDICAL, SURGICAL, OBSTETRICAL. AJJD
THERAPEUTICAL.
EEMOVAL OF THE UTERINE APPENDAGES FOR
THE CURE OF OVARIAN INSANITY.
By Edward Cottehell, M.R.C.S., &c.
The treatment of cases of mental disease dependent upon
come ovarian disorder by the removal of the uterine appen¬
dages has not been, as far as I am aware of, brought
before the profession very frequently. The following case
may therefore interest some whose studies lead them to in¬
vestigate mental disorders, especially those disorders de¬
pendent upon some form or another of ovarian disease.
Mrs. Y-, aged thirty-seven, married nine years; has five
children, eldest eight years, youngest eight months. She
has always been depressed at her menstrual periods. When
^bout eighteen years of age her father died of apoplexy.
For some years after this event she suffered from melan¬
cholia, which was always much worse during the catamenial
periods; at the same time she was firmly convinced that
she had caused the death of her father by poisoning him
with opium. However, she got over this fancy and married,
after a somewhat prolonged engagement. Her husband
informed me that_ after her marriage she at times suffered
* 1 *^ of spirits, and that immediately after the birth
of berlast child she became quite insane for about two months,
fequinng an attendant constantly with her, as she more
than once attempted to commit suicide when left to herself.
When 1 saw her for the first time towards the end of 1886,
her condition was similar to that described above, her sym¬
ptoms becoming much aggravated at each menstrual period;
for though the acuter signs passed away after the men¬
strual flow had ceased, there still remained a good deal of
melancholia during the inter-nienstrual period, which
became aggravated with hallucinations as the succeeding
catamenia approached. The patient had an anxious look,
was very restless, and slept badly. Menstruation very
scanty, and attended with a good deal of pain. She was im¬
bued with the idea that she had poisoned her father and
had caused the death of one of her young friends. She fre¬
quently heard voices which urged her to make away with
herselfi The usual routine treatment having been tried
with little or no effect, I suggested the removal of the
uterine appendages as a means of alleviating the distressing
symptoms. This procedure having been agreed to, I accord¬
ingly performed the operation on March 15th, 1887. The
patient recovered quickly from the operation, but the mental
symptoms were no better—worse, in fact, as the suicidal ten¬
dency became more pronounced. By my advice she was re¬
moved to an asylum, where she remained for aboutfourmonths.
On her return, I found her sane in every respect. She had
quite recovered from the suicidal mania, and the hallucina¬
tions were gone. Since that time she has not bad any
return of the old symptoms, and as nearly three years and
a half have now elapsed since she had any, I hope that she is
cured. The removal of the uterine appendages brought on at
first, in this cose, an acuter stage of toe mental condition, hilt
this is, I think, whatone would beledto expect as most likely
to occur in a patient suffering from ovarian insanity. The
mentalsymptoniBbeingdependentupontheovarian irritation,
any operative interference with these organs islikely to aggra¬
vate matters until the artificial menopause has been tho¬
roughly established. This is how I translate the sequence
of events in the above case, so that if I am correct in my
diagnosis—viz., that the mental symptoms were due, and
due entirely, to the ovarian irritation—there will be no
return of the insanity. I may remark that the ovaries were
rather smaller than normal, whilst the Fallopian tubes were
swollen to about twice their usual size, and very injected.
Woymouth-atrset, W.
SUGGESTIONS ON THE ANTAGONISTIC ACTION
OF COCAINE AND CHLORAL.
By Edward F. Willoughby, M.D. Lond.
Some years ago, when suffering frequently from attacks
of acute coryza, which while they lasted rendered me
almost unable to write from the incessant sneezing and
running from the nose, I found the greatest relief from nasal
injections of a 2 per cent, solution of cocaine, from five to ten
drops to each nostril at intervals of twenty minutes or half
an hour. I could thus cut short an impending attack, or
by usieg them even more frequently arrest—in fact, cure—
one that had set in for some hours with the utmost intensity.
Bub on several of these occasions I noticed that the use of
the cocaine during the evening was followed by absolute
sleeplessness, four consecutive doses of ten grains each of
chloral inducing not more than two or three hours’ light sleep,
though ordinarily, when wakeful from mental overwork,
five grains woulS have given a natural, and ten a sound
and long night’s sleep. Indeed I believe that I have, after
the free use of cocaine, taken even more than the forty
grains of chloral with but very moderate effects. Under
these circumstances no sense of fatigue followed the
sleeplessness, and no headache or drowsiness the sleep
when obtained by these excessive doses of chloral. A
Indy for whom I prescribed cocaine pastilles for a painful
neurotic condition of the glottis having sucked several in
the course of the evening and gone to bed with two more in
her mouth (each iVgr-). told me that she had been “wide
awake” all night, without feeling tired next day ; and in
other cases I have observed the like wakefulness after the
use of cocaine. Bub the evident antagonism in my own
case between cocaine and chloral suggested to me the
probability of its being found useful as an antidote In
chloral poisoning. I applied for and obtained a licence for
undertaking a course of experiments on the subject; bub
finding that I could not be absent from home for so many
hours as the performance of these would require, I allowed
366 The Lancet,]
CLINICAL NOTES.
[Feb. 14,1891.
the licence to lapse. The treatment of chloral poisoning
hitherto has been eminenlly unsatisfactory. Chioral is a
direct antidote to strychnine, antagonising the excessive
muscular irritation of the latter; but the converse does not
hold good, since the action of chloral on the sensoiium
or the mental functions has not its physiological coun¬
terpart in that of strychnine; striycbnihe, in fact, anta¬
gonises only the lesser half of the effects of chloral. I know
that some extreme cases have been successfully treated by
strychnine, galvanism, and artificial respiration, hut the
profound sleep has had to work itself off. Cocaine, which,
if it were found expedient, in very severe cases might be
supplemented by strychnine, would appear to me to be the
antidote required, and, should an opportunity present itself,
I shall not hesitate to try it subcutaneously, at least in the
first doses.
I would invite anyone who may meet a case of chloral
poisoning to do the same, and I shall feel greatly obliged if
anyone having leisure would take \ip my licence and
institute a course of experiments in corporc vili on the
lethal doses of chloral and the efficacy of cocaine at various
stages of the poisoning by chloral from the earliest to immi¬
nent death, with the single condition that he communicate
with me, and give me the credit of priority of suggestion
hy associating my name with his.
finsbury-park, N. _
NOTES ON A CA.SE OF PUERPERAL ECLAMPSIA;
TREATMENT;RECOVERY.
By W. E. Redman, M.R.C.S. Eng.,
ADMIRALTY SOKCEON AND AGENT AT niUDLlNGTON QUAY, ETC.
On the evening of Christmas Day last I received an
urgent message to attend a Mrs. S-at once, as she was
thought by the monthly nurse in attendance to be dying.
On arrival, I found the patient, a stout, florid primipara, in
a semi-comatose condition, dMirious, and not recognising
those about her. Both the upper and lower extremities
were much swollen aud (edematous. She had voided but a
small quantity of urine during the day, and this, on
heating, coagulated into a semi-aolid, muddy-looking,
gelatinous mass. Digital examination revealed an almost
fully dilated 08 and a roomy pelvis; membranes not ruptured;
cranial presentation ; uterine contractions strong and fre¬
quent. Kecogniaing the gravity of the case, and almost
expecting the onset of convulsions in consequence of the
premonitory symptoms at any moment, I at once
ruptured the membranes, and sent for some chloroform.
The labour now proceeded apace, the head rapidly
descending ; but before I received the chloroform the patient
bad a severe convulsive attack, characterised by violent
general muscularcontractions, her features became distorted,
the globes of the eyes turned upwards, the white scleroties
only visible, and the mouth convulsively fixed; the face
became cjanosed, and frothy aaliva tinged with blood
appeared at the mouth. The attack lasted about four
or five minutes. The patient now recovered semi-conscious¬
ness, and by this time the chloroform arrived. About six
or eight attacks of var;yiDg degrees of intensity now suc¬
ceeded one another at frequent intervals; during these I
administered chloroform freely with most beneficial results,
the intensity of the successive attacks being greatly con¬
trolled thereby. As the bead was now making but slow
progress through the pelvis, and its pressure apparently
acting as an irritant to the mother, and being also well
•within reach, I resolved upon instrumental delivery.
Having first administered chloroform freely, I applied the
long forceps, and delivered the patient without difficulty
and without any return of the convulsions. The cord was
twice round the child’s neck. The after-birth rapidly fol¬
lowed the child, which was much cyanosed, and it was fully
an hour before respiration was established in it. After
delivery the mother had two more severe convulsive seizures,
each or which was modified in intensity hy administration
of chloroform as before. From this time all proceeded well,
the patient gradually recovering consciousness, but having
no recollection of what had occurred for some hours pre¬
vious to or during labour.
Certain points are worthy of note in this case—the pre¬
monitory symptoms, a history of mental trouble and distress
a few days before confinement, the value of instrumental
delivery under chloroform in certain cases of puerperal
eclampsia, the great value of chloroform to control and
cut short the attacks, and the farther fact that the
albumen completely disappeared from the urine two or
three days after delivery. Further than this, 1 need
only add that both mother and (ihild have made unintec'
rupted progress towards recovery.
Bridlington Quay. _
THE CHLORAL TREATMENT OF PUERPERAL.
ECLAMPSIA.
By M. H. Feeny, M.R.C.S., L.II.C.P. Lond,, L.M.
As the treatment of puerperal eclampsia is still an
open question, opinions being divided between chloral,
opium, or both combined, and anmstbeticism, I send thia
case as an interesting contribution in favour of the former.
And I take the occasion to express a long-formed conviction
that it would be a wholesome practice, pregnant with much'
practical good towards the settling of such open ques¬
tions, if all practitioners would publish their quota of
evidence when such cases arise. Being happily of rare
and unfamiliar occurrence, we naturally fly for aid tO'
our moat acknowledged text-books. From much observa¬
tion in general practice, I find that the manifestations of
disease are frequently at variance with the descriptions of
books. Nor is this surprising, so much wider is the field
of general practice than that of the specialist, no matter'
how numerous his hospital wards or bow high his title.
The most unerring of all guides are the symptoms of the
disease and the constitutional forces of the patient. By
treating the former under the guidance of the latter, a
successful issue has often taught me that many a formidable
and unpromising case can be thus hrough'c to a happy
termination.
L. C-, aged nineteen, seven months pregnant.
Family history healthy. Father, mother, a brother, and
sister living; no neurotic disease. Mother suffers from
weak heart; no organic miscliief. Patient commenced
menstruating at fifteen; did so regularly for eight
months, when she had her first fit. For the following three
years the menstruation was irregular; general health
fairly good. At eighteen she was treated for severe epileptic
seizure, and made a good recovery. At the seventh month
of pregnancy I was hastily called to see her at 11 A.M. I
found her in a violent general epileptiform fit, grinding the
teeth, which were firmly clenched. 1 ordered a mixture of
bromide of potassium. The pulse was strong, healthy, vary¬
ing irregularly with each paroxysm. Summoned again at
G.SO P.M. I was told the waters had broken and labour had'
commenced. The patient was in convulsions during the
wliole interval. On examination I found the os slightly
dilated, membranes intact. She had passed a large quantity
of hysterical urine. The case seemed desperate, and one for
heroic treatment. Owing to the clenched teeth little of the
mixture bad been taken. On consultation, amesthesia was-
suggested; hue owing to the fixed condition of teeth and
hard laboured breathing it -was discarded. I quickly
decided to make the pulse my helm and chloral my sheet-
anchor. I mixed forty grains, forced the teeth open, and'
she swallowed it. At lOP.M., convulsions still constant ^
os the size of a two-shilling piece, thick, and rigid. Ruptured
membranes. I again gave forty grains of chloral; enema of
one drachm of laudanum, which latter was immediately
expelled. At 12 p.m. gave fifteen grains of chloral; fits
ceased for half an hour. At 2 A M. fifteen grains ; had am
hour’s sleep. At 4 A, M. fifteen grains. Fits returned at
.qA-M., and labour was advancing. G.30A.M. ; Child born
during fit. 7A.M : Fits ceased; placenta expressed ; uterus-
contracted firmly. 11 A.M.: Sleeping quietly; had had
three convuisions; was conscious during inteivals. Ten
grains of chloral to be taken every four hours. Had four
seizures during twelve houre. Slept well during the night.
Was quite conscious next morning, but knew nothing of
what had happened. The child, as might have been expected,
Was stillborn. Ordered mixture of bromide and chloral-
The patient made an uninterrupted recoveiy.
Laiicaster-gate, W. ___
AN EASY METHOD OF FEEDING TER RECTUM.
By Y. M. Jones-Humphreys, L.S.A.
Some months ago, having to treat a had case of gastric
ulcer by rectal feeding &c., I devised an apparatus consisting
of a small funnel, a piece of elastic tubing ^ in. in diameter,.
ft. long, about 4 in. of glass tubing (by which the de-
The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Feb. u, 1891. 367
'scendinp'fluid can be watched), aad joined on to this an ordi¬
nary flexible catheter. The atmospheric pressure is suffi¬
cient to send any fluid into the rectum, and I have never
noticed any return of the fluid, absorption being slow but
efficient. The instrument is an improvement on the old
enema apparatus in use. The claims for this method are—
((1) It is extremel;^ simple, the patient being able to
pass the catheter into the bowel without experiencing
any pain or unpleasantness ; (2) it is cheap and easily nsade ;
<3) after once being shown, the most inexperienced person
can use it, and thus we can be sure that our patient will
have small quantities of nourishment at frequent intervals ;
<4) the fluid is slow in its passage, and thus nearly the whole
quantity becomes slowly absorbed. In any case requiring
rectal feeding I venture to hope that my professional
brethren will find this simple method to be (if use to them
o.nd a source of comfort to their patients.
Ceiumaes, Moiitgomerysliire.
% Himr
OP
HOSPITAL PRACTICE.
BRITISH AND FOREIGN.
Nulla autem est alia pro certo noscendl via, nisi quamplurimas et mor-
borum et diaaectionura hiatoriaa, turn aliomm turn propriaa collectaa
habero, et inter se comparare.—M orqasni De Sed. et Cain. Morb.,
lib. iv, Prooemium. ■ ■ ■■ —
ST. BARTHOLOMEW’S HOSPITAL.
INTUSSUSCEPTION IN A CHILD NINE MONTHS OLD ;
ABDOMINAL SECTION ; RECOVERY j REMARKS.
{Under the care of Mr. Howard Marsh.)
We have alluded in past numbers of The Lancet to the
various methods of treatment of intussusception of the in¬
testine, and we now give a short account of the successful
management of another case by reduction after opening the
peritoneum. It is a further addition to the increasing listof
•cures after abdominal section, a method which is becoming
more frequently resorted to, and at an earlier period, after
failure of other procedures. In the recent discussion at the
Ulinical Society,^ the question as to the best method of
treating the bowel should the intussusception be irreducible
was discussed, and Mr. Marsh refers to it in his remarks.
F. A-, aged nine months, was admitted into St.
Birtholomew’s Hospital on May 8bh, 1890. The patient,
a well-nourished child, was quite well until about 6 p.m.
on the previous evening, when he began to vomit. The
vomiting continued up to the time of his admission, and
blood-stained mucus was passed per anum, bub no fmcal
material. On admission, between 12 and 1 r.M., the child
was pale and collapsed ; expression pinched and distressed ;
pulse quick and feeble. The abdomen was somewhat dis¬
tended, and a sausage-shaped tumour could be felt extend¬
ing across the abdomen, a little above the level of the
umbilicus—that is, in the region of tbe transverse colon.
The child’s condition was so grave that it was determined
to perform abdominal section at once, without resorting to
•either injection or inflation of the bowel. At 2 p.m. he
was placed under chloroform, and an incision was made in
the linea alba, midway between the umbilicus and the
pubes, and the peritoneal cavity was opened. It was then
found necessary to extend the incision upwards to half
an inch above the umbilicus. When two fingers were
'introduced the intuasuaception was plainly felt, and a
great deal of it was easily reduced by pressure on its
sheath, immediately below its lower or advancing end. The
tumour was tlien drawn into the wound, and reduction
was efl'dcted, partly by pushing and partly by drawing
the volvulus out of its sheath. The inversion of the gut
“l-fl ®''idenbly commenced in tbe immediate neighbourhood
or the ileo-oiccal valve. The abdominal cavity was washecl
out with plain water at a temperature of about 100°, and
the wound was closed throughout with silk sutures. Sal-
* M °*^*^*^^ gftuze was applied and covered with a bandage.
May 9th.—The chilcl had passed a rather restless night,
ana two doses of a quarter of a minim of tincture of opium
1 The Lancet, vol. i. isoi, p. los.
had been given. He was fed with milk and lime water,
only a few drops being given at a time. He had not been
sick since tbe operation, and had passed two motions free
from blood.
lObh.—Doing very well; no bad symptoms.
1 Ibh.—Seems quite well ; playing with his toys. Cheeks
full and rosy. Temperature normm.
12th.—Bowels have acted three times since yesterday.
Wound dressed to day. Sutures removed. From this date
there was nothing calling for remark. The child was dis¬
charged with the wound quite healed on June Ist.
Remarks hy Mr. HoWxS.rd Marsh.—T he rteatment of
intussusception by operation is a subject that stands in need
of further discussion. The estimate formed by different
surgeons, as to the ri«k involved in tbe operation itself, is
far from uniform. Some believe that, when resorted to
under favourable circumstances, the operation is attended
with no great risk, but with an amount of success which no
alternative treatment can secure ; while others regard it as
a measure of such doubtful utility that it should be resorted
to only after everything else has been tried and has failed.
The experience I have bad has convinced me that, when the
operation is performed early, it is not in itself a proceeding
that involves serious danger; and secondly, that it is fol¬
lowed by a very large proportion of success. And I believe
that, in the future, we shall be able to point to the opera¬
tive treatment of intussusception, even in young infants, as
one of the most satisfactory developments of abdominal
surgery. The grounds for advocating early operative inter¬
ference seem obvious. The conditions present are very
similar to those that exist in hernia, In both the intestine
is threatened with strangulation, which, if left, will almost
inevitably lead to a fatal result, and which can be removed
only by mechanical interference. In hernia the course to be
adopted is agreed to on all sides. The case is regarded as
one of urgency. The necessary interference consists, first,
in carefully applied taxis, and then, if this fails, in imme¬
diate operation. And the treatment of intussusception
should be pursued on exactly parallel lines. A well-oraered
attempt at reduction by what Mr. Hutchinson bas termed
“ abdominal taxis,” should be made without a moment of
unnecessary delay ; and if this fails (and it should not be
continued for more than ten or fifteen minutes), operative
interference ought at once to be resorted to. Fortunately
the evidences of intussusception—griping pains, sickness, the
passage of mucus and blood, and the presence of a sausage¬
shaped tumour-—are usually distinct, while often the intus¬
susception can be felt by examination per rectum. Thus a
correct diagnosis can in the majority of cases be made at
once. When this point has been reached, the Question
arises, In what manner can abdominal taxis be best
employed ? For myself, I prefer the introduction, when the
patient is under chloroform, of warm water, by means of a
long, soft tube, with which a funnel is connected; but this
apparatus must be used with great care. The amount of
fluid that is being injected should be observed, and the
height to which the funnel is raised above the patient must,
owing to the fact that the pressure on the intestinal wall is
rapidly augmented when the height of the column of fluid is
increased, be carefully guarded. Neglect of this point will
be attended with imminent danger of rupture of the in¬
testine. The abdomen should be watched as to increasing
distension and as to tension of the parietes. These sym¬
ptoms, however, are nob, it must be observed, always a sure
index to the safety of further injection, for if the intus¬
susception bas descended low in the colon and becorhe
adherent there, no considerable distension can of course be
produced. Sliould taxis fail to effect reduction, abdominal
section should be at once performed. As distension is
generally absent or only moderate, and there is little
tendency to the protrusion of the intestines, an incision,
three inches or more in length, should be made in order to
facilitate manipulation and to save time—a matter of the
highest importance in these cases. Reduction is best effected
by taking the sheath in situ just below the advancing end
of the tumour between the index and middle fingers and
exercising gentle pressure upon it, and then shifting the
fingers and repeating the pressure so as to lift the intus-
Busceptum upwards and make it “back out.” By this
means the tumour may usually be quickly reduced until
only the entering end remains. When this is tbe case the
intussusception should be brought forward into the
wound, so that i-eduction may be completed, partly
2 Examination under cliloroform is often advisable to assist tbs
diagnosis. — .. r
Di( I LtOOQIC
368 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Feb. 14,1891.
by pushiog the intussuscept\im out by pressure on
the sneath, and partly by very gentle traction upon it.
It is very important that the parts should be well
in view when tbe swollen head of the tumour is beisg
returned, so that the amount of tension that is produced can
be noted, and so that any laceration of the peritoneum,
should it occur, may be detected and afterwards closed by
suture. I am convinced that in the majority of cases reduc¬
tion can be easily effected in the manner described, if the
intussusception has not been strangulated for more than ten
or twelve hours; but if strangulation has existed for eighteen
hours and upwards, reduction is likely to be dilhcult and
will often be impossible. In the case above related the age
of the patient was nine months, and tbe intussusception
had existed for about eighteen hours. In a successful case
which I recorded in 1875® the child was seven months old,
and the intussusception (which had apparently existed for
fourteen days) had been strangulated for twelve hours. In
both, at the time the operation was performed, the infants
were in a condition of collapse ; the one was pale, bis face
was pinched, his pulse quick and feeble, and vomiting was
frequent; the other “layin his mother’s arms, vomiting
every two or three minutes, with a pale shrunken face,
half-closed eyes, a small and very rapid pulse, and shallow,
hurried respiration.” Yet both recovered without a
drawback of any kind, and were convalescent on the
third day; both, that is to say, notwithstanding their
serious condition, bore the operation perfectly well,
and rallied immediately after it. In tbe case which
I published in 1875 the operation was performed in a
labourer’s cottage, with no antiseptic precautions. The
intestines were foe some minutes lying exposed outside the
abdominal cavity, and the patient was subsequently nursed
by its mother without skilled assistance. The facts
observed in these two cases appear to constitute strong
evidence that even young infants will beat the opera¬
tion well. That failures have hitherto been frequent
has been, I think, quite certainly due very largely to
the circumstance that the operation has been delayed
until the local conditions—swelling, inflammatory soften¬
ing, and adhesions — have precluded success. These
conditions are not usually present in the first twelve or
even the first eighteen hours. I ought, however, to mention
that in a case, under the care of Mr. Gay of Putney, in
which I performed abdominal section about fifteen hours
(so far as could be ascertained) after the occurrence of tbe
intussusception, the volvulus had become universally adhe¬
rent to its sheath, so that although the parts were well in
view, and no inflammatory softening and only very limited
swelling were present, it was impossible to accomplish
reduction. Tbe possibility of this rapid formation of
adhesions is an additional reason for early interference. I
have lately examined the specimens in the museum of
St. Bartholomew’s Hospital, with the view of ascertaining
whether, when it is found that the head of the intussuscep¬
tion is so large and firm that it cannot be returned, it would
be possible with safety to divide the sheath at the seat of
constriction, and then, having effected reduction, to close
the wound in the sheath by suture. The point, however, is
one which I think can only he determined by trials made
in what may seem to be appropriate cases at the time of
operation. Other cases in which abdominal section for
intussusceprion in young infants has been successfirlly
performed have, I believe, recently occurred. Their
publication, I may perhaps be allowed to say, would be a
valuable contribution to this important subject.
LIVERPOOL NORTHERN HOSPITAL.
A CASE OF INTRA-CBANIAL ANEURYSM SUCCESSFULLY
TREATED BY LIGATION OF THE COMMON
CAROTID ARTERY ; R]-;MAHKS.
(Under the care of Mr. Ciiauncy Puzey. )
Intra-cranial aneurysm of suilicient size to present
symptoms permitting of correct diagnosis and the trial of
surgical measures to effect a cure is rarely met with, and
this account of a case of the disease will repay careful
reading. The onset of an audible bruit immediately after
the accident, fourteen months before admission, appears to
accurately define tbe duration of the disease, and the sym-
» Med. Chir. Trans., vol. lix.
ptoms of the condition were unusually well marked. Mr.
Puzey refers in his remarks to Mr. Rivington’s excellent
article on Orbital Aneurysms, and we find there mentioned
that in four traumatic cases, out of fourteen of which the
post-mortem examination is given, there were arterio¬
venous communications between tbe carotid and tbe caver¬
nous sinus. Mr. Rivington refers to thirty-two cases of
pulsating exophthalmos of traumatic origin, twenty-seven
of which recovered and five died after ligature of the
common carotid artery. “Of the twenty-seven patieiitS'
who recovered after ligature, only seventeen were cured
of the aneurysmal affection of the orbit, additional
methods being employed in the others. Ligature of tbe
common carotid is at present the most successful and satis¬
factory means of treating orbital aneurysm. The percentage-
of absolutely successful cases or cures would be about fifty-
five.” We have recently referred to the high mortalitymet
with after ligature of the common carotid, and it is possible-
that in this case the earlier compression of the vessel aided
in the efficient blood supply found after the application of
the ligature.
E. E-, aged thirty-seven, a farm labourer from North
Wales, was admitted into the hospital on May 2Dd, 1889>
and gave tbe following account of himself. He had alwaye
enjoyed good health until fourteen months ago, when he
fell off a horse on to tbe left side of his head. He was semi¬
conscious for a day or two, the only thing he remembers'
being that on the morning after the fall he noticed “ a noise
like a steam-engine puffing in his head,” just above his left-
ear, and this has continued more or less ever since. Both
eyes were swollen at that time, especially in the morning,
the left being the worse of the two. Four or five days after
the accident he went to work, though the noise in his head
much troubled him. He was unable to see clearly unless-
he covered one eye. Six weeks after the accident he went-
to the Liverpool Eye and Ear Infirmary, and remained there¬
under the care of Mr. Edgar Browne.
Mr. Edgar Browne's report. —E. E-was admitted on
May 46h, 1888, his condition being as follows : Right eye ::
Y. =f8, slightly myopic, with - O’SO V. =:fS, T. and appear¬
ance normal; pupil active; nystagmic jerkings on extreme
lateral deviation to either side; ophthalmoscope shows-
I shallow physiological pit. Left eye: V. =idem, slight-
proptosis ; movements in all directions limited, pupil active,,
hut rather less so than the other. Conjunctiva injected,
very large, tortuous, episcleral veins at the outer side; a fulS
cushiony feeling on pressing eyelids. Pulsation of eye¬
ball distinctly felt an pressure. Ophthalmoscope shows-
marked physiological pit, with vessels crowded to one ^ide^
as in a glaucomatous disc, with pale halo, no pulsation of
arteries could be produced even by firm pressure. There
is a loud aneurysmal bruit on the left side of the head,
loudest in the temporo-parietal region, immediately over
the left ear, and extending forwards; the sound becomes-
faiuter on approaching the vertex, again increasing towards
the lower parietal region of the right side. It is stopped
entirely by moderate pressure on the left carotid. Diplopia-
is marked, being due to the left eye, which is unable to-
execute conjugate movements with its fellow, in con¬
sequence of orbital swelling. No implication of any
motor or sensory nerve was observed, mental faculties un¬
affected. The diagnosis of intra cranial aneurysm was made,
and the treatment was—rest, full doses of iodide of potas¬
sium, low diet, fluid restricted to one pint per diem, and
digital pressure on the carotid. Steady improvement went
on for some weeks, interrupted once by the patient rising.
Great relief from the noise resulted on one occasion froni
epistaxifl. The orbital swelling receded and the diplopia,
disappeared so long as recumbency was maintained. The
advisability of ligaturing the carotid was mentioned to the-
patient, but he preferred going home. He remained away
from July 28th, 1888, to April 26bh, 1889, when he returned
with an aggravation of all the previous symptoms. The
operation was now strongly urged upon him, and be wa»
transferred to the care of Mr. Puzey.
Condition on admission into the Northern Hospital .—
There is a swelling in the left orbit^about tbe size of a
Tangerine orange, the eyeball in the centre of it being much
protruded and congested, the cornea hazy, and at one point'
showing tendency to necrosis ; the eyelids are red and
cedematous. The whole swelling pulsates, and the pulsation
can be controlled by pressure on the left common carotid ;
large vessels (apparently veins) can be felt pulsating no
pressing lightly on the swelling between the eye and the
The Lancet,]
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
[Feb. 14, 1891. 369
upper part of the orbital cavity. A loud bruit can be heard
all over the left side of the cranium, from the middle line
as far back as the posterior parietal region; but it is loudest
in the eupra-orbital and anterior temporal regions. The
sound is of a loud “swishing” character, although the
patient describes it as resembling the booming noise or
“ thud ” of machinery, which, he says, prevents him from
sleeping, except when quite worn out by exhaustion.
On May 5bh Mr. ruzey ligatured the left common
carotid artery above the omo-hyoid muscle. The operation
was conducted with full antiseptic precautions, and the
artery was tied with stout chromicised catgut ligature; the
wound was closed with silver sutures, a thin horsehair
drain being laid from end to end, and a small india-
rubber tube passed into the deepest part of the wound.
Pulsation ceased in the swelling as soon as the ligature
was tightened, and never reappeared. As soon as the
patient became sensible ho exclaimed with delight that
the noise had gone. However, on listening through
the stethoscope over the eyebrow or near the root of the
nose, a faint bruit, continuous, but accentuated with each
systole, could be distinctly heard. Next day the dressings
were changed and the hoi'sehair drain was removed. On
May 8th the dressings were again changed and some of the
stitches removed. On the 10th the man had been moving
his head about and had displaced the dressings, which were
found soiled, and that night his temperature rose to 101‘2“.
Next day there was some redness and swelling about the
wound, and the man complained of slight pain in swallowing.
It was evident tuat there was retention in the deep part of
the wound. This was therefore reopened to some extent
by probe and dressings forceps, and a small quantity of
thick pus escaped. Next day all pain had gone and the
temperature was normal, at which point it continued steady,
except on June 2nd and 3rd, when it ran up again, pro¬
bably on account of fu'oal accumulation in the lower bowel.
The cornea had by this time given way, and the iris was
adherent. A troublesome sinus, resulting from the re¬
opening of the wound, caused him to remain in hospital
for some weeks, although he was able to get up and walk
about. He was sent to the Woolton Convalescent Hospital
early in July, and returned to his home in Wales a few
weeks later.
On July 7th, 1890, he wrote saying that the noise in
his head had entirely gone, the swelling about his eye had
completely disappeared, that be was quite comfortable in
every way, and was actively engaged in bis usual employ¬
ment.
llcmarJcs hy Mr. PuzEY.—In the article on “Orbital
Aneurysm,” by Mr. Walter Rivington, in Heath’s “Dic¬
tionary of Practical Surgery,” it is stated that “beyond
question the great majority of the traumatic cases have been
instances of endo-cranial arterio-venous communication,
due to wound or rupture of the internal carotid artery in
the cavernous sinus.” I believe that this case was an
instance. There was, however, one point on Avhich I could
not satisfy myself—that was, as to the continuity of the
bruit; if there was continuity, it was completely masked
by the tremendous and prolonged “swish” during the
systole. But I think that the remarkable dilatation and
pulsation of the supra-orbital branches of the ophthalmic
vein pointed almost conclusively to the nature of the
aflection. And, furthermore, the persistence of the bruit
(as heard through the stethoscope) after the operation, long
after the disappearance of the noise heard by the patient
and of pulsation as felt by observers, seems to confirm that
view of the case. Surely, if this had ..been a case of
true aneurysm the bruit would have ceased simul¬
taneously with the notable pulsation. Although lig^a-
tion of the common carotid is forcibly urged by Mr.
Riyington as the best treatment, this is not the
opinion held by some surgeons of eminence. Hence it
seems desirable that cases nearing upon this point should
be recorded. Some time ago my friend Mr. George Walker
brought before the Oplitlialmolopical Society a patient
Builering from (apparently) a similar condition of affairs.
He proposed to tie the common carotid, but was dissuaded
from doing so by the adverse opinion of two well-known
surgeons, who considered the case one of arterio-venous
communication. This patient was accidentally cured in a
very remarkable manner. He was squeezed and much
frightened (to the extent of fainting) in a theatre crush one
night, and next morning found that the noise in his head
bad ceased. Gradually the other symptoms disappeared.
and complete recovery took place.^ It appears probable
that some fibrinous clot must nave become partly displaced
in the affected part during the excitement and struggliog to
which he was subjected; and so a cure was roughly brought
about in the same manner as by the late Sir AVilliam
Furgusson’smore delicate and delioerate method of “mani¬
pulation.” But, as Mr. Walker observed, it is not advisable to
trust to the chapter of accidents. Perhaps in the next simi¬
lar case hemiplegia, or sudden death, might be the result.
In my case, nothing could be more gratifying than the de¬
light and comfort manifested by the patient from the time
when be first regained consciousness, after the operation, up
to the present. He came to see me some weeks ago (a year
and a half after the operation), and there was notbiog to be
seen of the former trouble except a small leucoma occupying
the lower quadrant of the cornea. The eye had regained its
natural size and appearance, and the pupil was clear. But
the sight was lost, no doubt from long-continued stretching
and atrophy of the optic nerve,—surely an argument
against delay In operation.
ROYAL MEDICAL & CHIRURGICAL SOCIETY.
Macrodaefyly and other forms of Congenital Overgrowth.
An ordinary meeting of this Society was held on Feb. 10th,
the President, Mr. Timothy Holmes, in the chair.
Sir George Murray Humphry communicated a paper
on Macrodactyly and some other forms of Congenital
Overgrowth and their Relations to Tumours, of which the
following is a brief abstract. An account was given of six
specimens and casts of the affection in the museum of the
University of Cambridge, and of nineteen cases published in
various journals. The affection consisted in an overgrowth
of all the tissues of the part—bones, ligaments, tendons, skin,
and more particularly of the fat and connective tissue—
these tissues usually presenting their normal characters, The
overgrowth continued to proceed afterbirth, often at a rale
exceeding that of the rest of the body, and so as to call for
removal of the part. The hands and the feet were about
equally liable, and the digits on the radial and tibial sides
more than the others. In some cases the overgrowth
showed a tendency to spread, more particularly along the
sole. Now and then it was symmetrical, and occasionally
it was associated with fatty growths in other parts. Refer¬
ence was made to eongenital overgrowths of like nature in
lips, tongue, and face; and an analogy was drawn between
these examples of intra-uterine insubordination to the laws
of development and growth, and the growths or “ tumours”
of later life, all or nearly all of which—simple and malig¬
nant—were referable to an abnormal overgrowth of the
normally existing tissues rather than to a starting into
activity of latent embryonic germs.
Mr. R. Williams found that the arguments which Sir
George Humphry had used were almost identical with bis
own. Changes of growth and development which commenced
before birth continued during the whole period of life. The
force in action was of the kind known as “integrating
force,” and the failure of this \Ya8 the cause of all abnormal
growths. He referred to hypertrophy of the breast as
another instance of the kinds which had been mentioned, for
in it there was not only enlargement, but also a repetition
of the normal structure. If growths could arise in the way
described from normal structure, they were even more
likely to do so from “tumour germs.”
Mr. Marmaduke Sheild was anxious to bring before
the notice of the Society a class of cases which he believed
had not ns yet been described. It affected young adults,
and was associated with fiat and sweating feet. There was
an enlargement of the great toe, and much pain and incon¬
venience were referred to the metatarso-plialangeal joint.
The soft parts became very bulky, so that in an instance he
exhibited the patient was discharged from tbe army because
he could not pull hia boots on. He bad excised the joint,
but found that both bone and cartilage presented simple
overgrowth. He asked the opinion of the author as to the
condition of molluscum fibrosum, where large Haps of skin
1 Ophthalmic Roviow, vol. vi., p. 200, ISS".
Digitized by■- oog
370 The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Feb. U, 1801.
sometimes depended from different parts of the body.
Patients in whom this occurred were occasionally also the
subjects of bony and other morbid growths.
Mr. Macnamaiia referred to a case which had been under
his care in 1881 , in which the sclerotic presented a fibro-
matoua growth; there was an exostosis of the lower jaw,
and there were numerous elepbantoid overgrowths of skin
in various parts of the body.
Dr. Eodbrt Lee, while congratulating the author on
his paper, said that the propositions which had been
advanced practically came to this: that congenital deformi¬
ties were tumours and tumours werecongemtal deformities,
aud that all these changes and peculiatibies were due to
the same cause. But cases such as had been described
differed hoto clinically and practically from tumours. He
related a case which occurred thirty years ago of over¬
growth of the arm of a girl, which began suddenly at
seventeen. For this amputation was performed by Mr. de
Morgan two inches below tbe shoulder and two inches
above the diseased tissues. Immediately on removal he
examined the arm, and found that there was a large cyst iu
the forearm connected with the radial nerve, and the latter
M'as found to be degenerated even above the line of the
healthy tissue. He held that cases of congenital over¬
growth were essentially different from ordinary tumours,
and to state otherwise was to go beyond facts. He had
seen very many children with a congenitally enlarged eye
or ear lU whom no other peculiarities developed. Causes of a
subtie*nervou8 kind were probably often at work in producing
these overgrowths, but these causes frequently remained
unnoticed. The theory of “ included germs ” he imagined
was not now believed in greatly by pathologists, and he
concluded by expressing bis conviction that these congenital
intra-uterine departures from the normal were not tumours,
though they might take on the same form.
Sir Georoe Humphry, in reply, said that he had of
course met with many instances of hjpertrophy of the
mammary gland, though he did not remember any cases
which bad existed from birth. He had not endeavoured to
collect the whole of the instances of those forms of con¬
genital overgrowth which had been recorded, specimens of
which existed in several London museums, Mr. Sbeild’a
ca.se was an instance of faulty arch with an elongated inner
side of the foot, the great toe becoming more prominent,
more liable to injury, and hence it became increasf d in size.
He regarded tbe molluscous condition as one of localised
hypertrophies taking place at tbe same time, but in different
parts, in the same way that fatty tumours sometimes
originated. He had not made the statement that these
overgrowths were tumours, but be pointed out that there
was a gentle gradation from simple overgrowth through
nmvi, warts, and polypi to the malignant tumours. A
similarity of morbid phenomena appeared to produce both,
and there was insubordination to the normal laws of
growth. As in malignant neoplasms there was iusuhordi-
natioD to the ordinaiy laws of growth of epithelium, so in
the case of an enlarged toe there was in.subordination to
the normal laws of growth of the fcetus. Thus were brought
into a like gradation those processes which seemed to be
tbe most disfcimilar. He could not agree that tbe theory
of “ tumour germs” had been given up; on the confrary,
it was still commonly accepted, and it was this fact which
had induced him to bring forward his remarks, in the
hope of showing that the pathology of tumours might be
attributed to another cause.
MEDICAL SOCIETY OF LONDON.
Debate on A ngma Pectoris.
The ordinary meeting of this Society, held on Feb. Oth,
the President, Mr. ivnowsluy Thornton, being in the chair,
was occupied with the discussion of a paper by Dr. Douglas
1*0well on Angina Pectoris. The debate was not concluded,
and was adjourned for a fortnight.
Dr. Douglas Powell opened a discussion on the subject
of Angina Pectoris, in respect of which he observed mat
there were many questions awaiting solution, and without
which the moat satisfactory treatment of this anxious and
often deadly malady was hardly possible. He urged that
the subject should be considered on a broader basis than had
8) far been accorded. It was not such a simple malady as
had beeu thought. The characteristic symptoms ranged
between the wide limits of remediable functional disorder
on the one hand and fatal organic lesion of tbe cardio¬
vascular system on the other. He referred to the case of a
lady aged forty-live, of neurotic temperament, wbohad com¬
plained of disturbed cardiac action for five years past.
There was an old history of rheumatic fever fifteen years
before; and five years ago, when riding hard across country,
she was seized with severe cardiac pain which interfered
with respiration. These symptoms recurred on subsequent
occasions. The pulse was peculiar—it was small, cord-like,
and of high tension. On using hard pressure with one finger
the pulse was felt almost as well, if not quite as well, by
a second finger placed further along the vessel. This phe¬
nomenon was due to a back wave from tbe periphery. The
heart’s action was somewhat laboured, intermitting twice in
the minute ; the first sound was mutlled, but there was no
distinct murmur. He then proceeded to give thedefinitions
which had been proposed for this malady by various authors
from the time of Hebei den. The case above related he
regarded as one of the first degree or one of vaso-motor
angina in which tbe vascular system was unduly sensitive,
the arterioles contracting suddenly under slight stimuli, thus
raising the blood-pressure, which habitually tanged high and
caused the heart to labour painfully. He observed that one
noticeable feature in this variety of the disease was a kind of
ambulatory uneasiness, the patient being lidgetty and rest¬
less. In regard to this vaso-motor form of angina, he
remarked that it was of comparatively recent discovery,
and the prognosis in such cases must necessarily depend
largely upon the prior condition of the heart. He regarded
tbe vaso-motor disturhaoeo as an essential factor in the
majority of cases of angina pectoris, jusii as bronchial
byperassthesia was in ca^cs of asthma. He believed it
to be possible for the heart to succumb to these
attacks without itself being affected with any obvious
lesion. He referred to the case of a medical man
aged thirty, who consulted him on account of paroxysms
of breast-pang. He had recently lost his wife and
had been much worried. On examination there was
no evidence of enlargement or disease of the heart, and he
regarded it as an example of vaso-motor angina. A six
months’ rest from work left him in a condition in all
respects apparently sound. He referred to another case in
a gentleman aged sixty-eight, who bad long resided in the
colonies, who could foretell these attacks by the pallor and
deadoess of bis hands, and in whom a marked improvement
in the general condition occurred after an attack of gouty
eczema. He remarked on the rarity of a fatal issue in these
cases, the attacks if unrelieved by art usually coming to a
natural end, probably through the depressor nerve of the
heart, and possibly through some analogous mechanism of
the small vessels, under the stimulus of pressure, inhibiting
and controlling cardiac and vaso-motor spasm. Cases were
met with in which patients subject to this disease, having
died of something else, exhibited no cardiac lesion. Ho
agreed with Dr. Broadbent’s suggestion that some cases of
fatal cramp whilst bathing were probably due to sudden
oppression of llie heart from contraction of systemic
arterioles ; in fact, to vaso-motor angina of an intense
kind, with perhaps a fatigued heart. Though phy¬
siologists maintained that when systemic arterioles
were contracted by cold the visceral were dilated, and
vice versd, yet it was bigbly probable that under certain
conditions of chill and emotion the whole arterial system
might respond. Ue quoted cases which seemed to show
that the tight side of the heart had borne the brunt of tbe
anginal a'tack. The persistent cardiac distress and rigid
arteries of urajmia might almost he described as chionic
persistent angina, though it was with the cases of so-called
cardiac asthma in urjumia that the analogy with vaso-
motory angina was strongest. He then passed on to discuss
the angina pectoris gravior, wheie the vaso-motor disturb¬
ance was associated with degenerative cardiac disease. He
questioned the view that the disease was necessarily caused
by or associated with disease of the coronary arteries. The
prognosis in the first group was favourable for many years,
the probability being that death would ensue from some
other cau.se, such as cerebral hiomorrhoge, while in the
last group an almost certainly fatal result might he
anticipated within a shoit period. Both for prognosis
and treatment it was important to make out the precise
condition of the heart in le-pect of size, position of
impulse, and power. For the treatment of these two
varieties nitrite of amjl and nitro-glycerine were of great
Di:::;zr^::v L-C Og
The Lancet, ]
WEST KENT MEDTCO-CHIRUBGICAL SOCIETY.
[Feb. 14, 1891. 371
value, but far more ao in the graver cardiac cases. In
the first group they required to be associated with nervine
tonics and sedatives, while in the second carminative
stimulants were of special value. He compared the pain in
euddsn cases of death from aegina to that associated with
embolic gangrene in the limbs. Dr. Powell then described
a syncopal variety of angina, which was rare except in
persons over sixty-live, and was usually associated with
gout, the subjects of it having a slow and irregular pulse.
He suggested that some undue acidity of the blood might
be concerned in its causation. The attacks were often
associated with dyspepsia, and the treatment indicated was
careful feeding, peptic tonics, and gentle exercise, with hot
drinks and carminatives during the attacks. In conclusion,
he said he regarded angina as a disturbed innervation of the
heart and vessels associated with more or less intense
cardiac distress and pain, and a general prostration of the
forces, always producing anxiety, and often amounting to
a sense of impending death. The sub-groups were four in
number—viz , angina pectoiis vaso-motoria, angina pectoris
gravior, primary cardiac angina, and syncopal angina. The
first two forma bore a remarkable resemblance to their
respiratory analogue, asthma.
l5r. Ord insisted on the remarkable parallel between
asthma and angina, and he pointed out that the term
asthma formerly comprehended a great number of varieties
of dilliculty of breathing. It had been pointed out by
statisticians that in times past asthma was a very fatal
disease according to the returns, its having become less so
was probably due to better diagnosis. With regard, how¬
ever, to angina the condition was rather dillerent; at pre¬
sent people would have a larger range for angina than
formerly, especially if they adopted Dr. Powell’s conclusion.
The old limited delinition to which he alluded would cer¬
tainly have to be extended to a larger number of cases in
which one or two only of the constituent typical symptoms
of the disease as first desciibed would be present. Such
cases might perhaps he termed “anginous” or “anginal.”
He then entered upon the consideration of the immediate
causes of this condition, comprising vaso-motor disturbances,
arterial tension, heart weakness, either of wall or of valve,
or of both, and, lastly, those duo to inhibitory and depress¬
ing influences. He pointed out that these anginoid
attacks usually came on in the day-time, and the prognosis
was notably aggravated when they occurred at night. He
compared the two classes of cases, one in which the patient
had angina on exertion as the consequence of sudden
arterial tension; these patients very commonly had a weak
heart, and so the extra strain thrown on the right side
of that organ by the exercise precipitated the anginal attar k.
The other group was that of patients who had the attack
independently of muscular exertion, and in these he thought
the mechanism was probably through the nervous system,
either emotionally or by reflex. He had seen illustrations
of both classes. One of the aggravated conditions of attacks
primarily anginous and determined by movement was the
occurrence of these attacks by night. He insisted on the
importance of dyspepsia as a factor in bringiog about the
attacks, and observed that if he were resoricted To one
remedy in the treatment of angina he would prefer sulphate
of magnesia to nitro-glycerine. He mentioned tbefrequent
coincidence of glycosuria with angina, which, he thooghT,
authorised the inference that the visceral bloodvessels were
dilated and not contracted, as the author seemed to suppose,
along with the superficial vessels. He said that the con-
pe.xion of gout with angina ought not to be forgotten,
involving as it did a neurosis and changes in the chemical
constitution of thetisaues. C'lnsequontly treatment directed
to the gout often relieved the angina. He insisted upon
the fact that no sensations of anginous type were to be
treated lightly, or the patient left without a proper explana¬
tion of the danger, with the precautions which became
necessary.
Dr. Broadbent said he had been unable to make up his
mind as to the conditiua of the heart during the paroxysms,
Sometimes the pulse was irregular and small, sometimes
there was high arterial tension, sometimes nor, and some¬
times the pulse was practically unaflected throughout an
attack even of great violence. The central fact, after all,
in attacks of angina was that the heart was beaten, eitlier
by peripheral resistance or on account of failure of its own
powers, and that fact fitted in very well with the author’s
classification. It was especially in chose cases due to weak¬
ness of the heart that great danger a'ose. He pointed out
that vaso-motor resistance alone would not be sufficient to
determine the attacks. The proportion of cases cf high
arterial tension without angina pectoris was very much
greater than the proportion of fatal cases of angina in
which there was no disease of the coronary arteries. He
presumed that di.sease of the coronary arteries acted by
causing degeneration of the muscular fibres. It should non
be forgotten that in bed and during sleep there was the
upward pressure of the abdominal viscera and the curious
running down of the cardiac powers to account for the
supervention of the attacks. Some cases commenced
with acute aortitis, leading to interference with the
coronary circulation, causing a series of anginoid attacks,
resulting in physical evidence of progressive cardiac
failure. He pointed out that muscular exercise lowered
very rapidly the resietauce of the peripheral circulation, and
the effects of exercise were mostly felt on the right side of
the heart. With reference to theneurotic theory, he pointed
out that the vast majority of anginal cas^s did not occur in
the neurotic sex, for it was extrernely rare in women. He
bade them, therefore, beware of attaching too much impor¬
tance to an unexplained neurosis. The occurrence of angina
in gouty people he ascribed to its association with high
arterial tension. He bad also noted the existence of a myo¬
carditis in patients sulfeiing from glycosuria accompanied by
high arterial tension, and this was usually associated with
marked anginal paroxysms. He remarked on the fact that
angina was seldom or never associated with mitral lesions,
and anginal symptoms usually subsided on the supervention
of a mitral lesion in a person subject to anginal attacks.
His own experience seemed to show that the gravest cases
of angina were those in which no reasonable explanation
could be found to account for the symptoms.
WEST KENT MEDICO-CHIIIURGICAL SOCIETY.
A MEETING was held on Friday, Jan. 2nd, Mr. John
Poland, President, in the chair.
Supra-pubic Cystotomy. —Mr. W. JOHNSON Smith,
Saamen’s Hospital, read a paper on this subject. Allusion
was first made to the fact that not only in operation for
free opening of the bladder, in which modern improvements,
such as distension both of bladder and rectum, came into
play, but also in simple puncture and aspiration, most sur¬
geons at the present day operated above the symphysis
pubis and not by way of the perineum. lu cases of reten-
lion in which tlie bladder could not be relieved by way of
the urethra, puncture above the rymphysis and temporary
retention of a fair-sized cannula would, it was held, ue far
preferable to repeated aspiration. Supra-pubic cystotomy
was advocated as being a more beneficial procedure than
the perineal operation in cases in whicli drainage of the
bladder was indicated. After reference to the value of the
high operation in the removal of certain forms of stone and
of new growths from the interior of the bladder, more or less
prolonged drainage by the supra-pubic method was com¬
mended as a valuabie aid to the treatment of severe
stricture, female fistulas and other affections of the urethra,
especially iu cases in which the urine had been rendered
foul by chronic cystitis. Mr. Smith also showed two
very large calculi he had removed by xhe supra-pubic
method.
The Essential Principles m the Treatiwnt of Constitu¬
tional Syphilis, of Soft Chancre, and of Gonorrhcca in.
the Male.—D t. Bohert S. Wainewrigiit, in a paper under
the above title, gave three methods of treating: the earlier
stages of syphilis: 1. The radical cure, or Hutchinson’s
plan : small doses of mercury are given for a very prolonged
period, with a view to prevent the appearance of tertiary
and even secondary symptoms. 2 The ordinary London
plan: treat the symptoms of syphilis os they arise by the
infernal administration of mercury. 3 The expectant, or
Edinburgh plan : use only local applications to cure the
earlier syphilitic manifestations, and avoid giving mercury
internaliy. This he thought the best method of treat-
ment. The tertiary stage of syphilis should be treated
by very large doses of iodide of potassium 130 to GO
grains ter die)- SoH chancre often produces a bubo,
which should be treated at a soft chancre of the gland,
not as a mere inflammation. Clonorrha’a in the male,
if treated in the earliest stage by capsules of sandal
wood oil {10 to 1.'") minima ter die), can often be cured in
a fortnight or lees, as the urine is thus rendered completely
antiseptic. —,
372 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Feb. 14,1891.
lljMtfes anb |totj«s of ^oob.
A Guide to the Operations on the Brain. By Alec Fraser.
London ; J. & A. Churchill, i.890.
Broca’s discovery of the site of the faculty of articulate
speech was first made public in 1861, and Ferrier’a work on
the Functions of the Brain was published in 1876. Many
anatomists abroad and in this country have endeavoured
to lay down rules for defining the situation of the more
important fissures and convolutions. Foremost among our
own countrymen have been Turner, Hare, Reid, Horsley,
Thane, and Cunningham. The keystone of such work has
hitherto been to .define the position of the fissures of
Rolando and of SUvlus and of the convolutions that sur¬
round them.
The work before us is a fresh proof of the energy and
thoroughness with which British anatomists are seeking to
farther the progress of .surgery. Although professing itself
to be a guide to operations on the brain, the plates are of
such excellence and the dissections of such merit that no
teacher of anatomy can afford to dispense with such a
ready exposition of parts of the body which frequently
vary, and concerning the relations of which much difference
of opinion exists amongst writers.
The major part of the book consists of forty-two life-size
plates in autotype, and this is preceded by a short but preg¬
nant description of the mode in which the work has been
accomplished, and of the serial dissections so far as
they have been reproduced. There is no attempt to deal
with the subject of localisation of function, but the method
of demarcation is entirely different from that usually
adopted in the text-books, in that the scalp is marked out
by a series of tapes into sections with which the various
areas of the brain are seen to correspond. This idea is
probably a development of that of Hefftler, who drew his
outlines with different coloured pencils. The tapes are
placed in longitudinal and transverse directions, according
to a prescribed system. It is to be regretted that the
measurement adopted has been by inches, and not according
to the metrical system. By means of composite views, the
lines of these tapes are shown on the skull and their relations
to the parts of the brain exhibited in the succeeding plates
remain. The author finds that the pinna varies so much in
size and position that any result based on lines drawn from
any part of it is of little value from a practical or any
other point of view. The divisions of the convexity of the
brain have, with certain minor additions, been marked
according to the widely-accepted description of Ecker. The
plates which show the external surface of the brain are,
perhaps, the most worthy of study of the whole series, not
only for the artistic manner in which they are produced, bub
also on account of the extreme care and minuteness with
which the dissection of the parts of the cerebrum, cerebellum,
and of the cranial, dorsal, and cervical nerves has been carried
out, though the latter are even better shown in some of the
later pictures. The reproductions of the dissections of the
interior of the brain are unequal, but all are of the greatest
inberost, and many display variations in the disposition of
parts which have not hitherto been accepted. The prac¬
tical value of these plates is well exemplified by the series
exhibiting the course and position of the posterior horn of
the lateral ventricle and the thickness of the hemisphere
between it and the bone through which it maybe reached from
a spot behind the pinna indicated ];y reference to the tapes.
In describing the relations of the deeper-lying structures to
the surface of the scalp, the author points out that althoxrgh
the keynote of his remarks is, that for normal heads after
birth the position of any structure of importance in their
cavities varies proportionately with the variations of the
circumference as given by the circumferential tapes of the
respective beads, yet, as is mentioned later, when indicat¬
ing the plates upon which the author would depend for
guidance in opening the skull on account of lesions of
various specified parts, that as the circumference of the
heads illustrated varies from 20.]^ to 23^ inches, after
shaving the scalp, this being the average variation of
adult heads, the surgeon may dispense with the rule
and select the plate where the measurements are nearest
to that of the patient. Furthermore, the relations of
the cranial sutures to the scalp surface, both in the
adult and the child, are shown to be indicated exactly by
the disposition of the tapes, as are also the relations of the
middle meningeal and its branches with the dura mater,
though the plate illustrating this point is not so distinct as
are most of the others.
The series of plates which will probably be of the greatest
practical value are the composites showing the relations of
the external surface of the brain to the scalp. These are
from every point of view, and were taken from eighteen
different heads. All the relations of the various tapes, as
can be seen at a glance at the several heads, are the same
in the young and in the adult, and exhibit in a very striking
manner the proportional relationships of the external surface
of the brain in heads varying in circumference from 14^ in.
to 2.3iin.
The plates illustrating the central lobes and lateral ven¬
tricles and tbelr relations to the scalp are less satisfactory
than the majority of the series, but their practical utility
is not diminished, since the relations of the island, the
anterior horn of the lateral ventricle, the descending
horn and the hippocampus major to the tapes and
spaces can be seen at a glance, as well as those of the
optic thalami, the caudate nuclei, and other parts in the
lateral and third ventricle. The relations of the lower
part of the lateral lobe of the cerebellum in the adult and
in the child can be better appreciated from the system of
demarcation here adopted than by any description, and
these plates are of the most instructive value. By pro¬
longing the median longitudinal tape to the lower
part of the neck in the adult, and to the lumbar
region in the child, a series of accurate guides are
offered to the surgeon to reach every cranial and spinal
nerve, of which the dissections are most carefully executed
and beautifully shown. With regard to the plates them¬
selves, which are reproduced from the negatives by some
modification of the Collotype process, there is room for no
comment but that of praise. The distinctness of detail
and the expression of light and shadow leave nothing
to be desired in almost every instance, and where these
are deficient the fault was probably unavoidable, and
lay in the negatives rather than in the reproductions.
The photographs were taken from above with a camera
having a draw of 4^ ft., supported on a vertical pillar of
special construction, which can be raised if needed to a
height of lO-Jft., so that the least distance between the
lens and the object is G ft. After focussing with a No. 3
Waterhouse diaphragm, a special one is substituted, having
a diameter of about one centimetre. It seems some¬
what surprising that the author should have found^ it
necessary to resort to this very elaborate mechanism
to obtain his results. No pillar, however well constructed,
can at such length be free from such vibration as must
imperil the accuracy of outline, even in a long exposure
such as is needed with so minute a stop, especially
when the backs containing plates have to be changed.
Again, the idea of making a (different exposure for plates
that have to be kept is contrary to the experience of all
photographic artists, as there is no evidence of the con¬
tinuing action of light upon the film ; and even if this were
Digitized l.'y' Google
fitis IaMcet)]
LAtt: i)K. Matthews DtiHCAN*
[FEb. i4,1891. 373
proved, a very slight experience should allow of its accurate
correction during development. With regard to the lens
adopted—a rapid rectilinear of 29 m. equivalent focus,—
it would seem preferable, upon purely optical grounds,
to use one of very much shorter focus, and to
obtain the diagrams upon a 6:1 x 0 plate, from which
they could be enlarged to the required size. This
would give a considerable saving in time as well as in
expense. Nor need the matter of registration be one of
difficulty if a simple process well known to photographers
be adopted. These, however, are details which the author
has had to consider before finally adopting the process by
which his results have been obtained; and when it
is considered that the work before us represents only
a modicum of the labour which has been undertaken,
and gives no account of the many and inevitable failures
which have been encountered, we must admire the more
the patience and energy which have been bestowed upon
it. The opening sentence of the preface gives hope that
this volume is but the prelude to others, and surgeons
and anatomists will alike look earnestly for every fresh
series of such accurate delineations of human anatomy.
A Manual and Atlas of Medical Ophthalmoscopy. By
W. R. Gowers, M.D., F.RS., P.RC.P. Third Edi¬
tion, Revised throughout, with numerous additions and
additional Illustrations. Edited with the assistance of
Marcus Gunn, M.B., r.R.C.S. London: J. & A.
Churchill. 1890.
The appearance of a third edition of this work testifies
to its continued appreciation by the profession. The present
volume has not been materially altered from the form in
which the book originally appeared. The most noticeable
change is the omission of the appendices devoted to the use
of the ophthalmoscope and to the descriptions of clinical
cases, and the substitution of a brief but useful and
practical account of methods for sketching the fundus oculi.
The whole work has been subjected to a revision sufficiently
thorough to involve additions and alterations on almost every
page and in almost every paragraph, and an endeavour has
been made to embody in it whatever of real value has been
added to our knowledge since the appearance of the last
edition. Considerable development is noticeable in con¬
nexion with the accounts of tuberculosis, malignant disease,
gout, retro-bulbar neuritis, and the congestion and neuritis
in alcoholism. A fuller account is given of the effects of
poisons, and a separate paragraph is devoted to bisulphide
of carbon as the apparent causeof peri-neuritis. On account
of this extension the text now occupies 298 pages instead of
250, but owing to the omissions previously mentioned the
entire book has thirty-two pages less than the second
edition, and is altogether more compact.
In spite of the more widely extended use of the ophthal¬
moscope, with part of which former editions of this work
may he credited, observations relating to the appearance of
the fundus oculi in disease are still scattered and infrequent,
and a complete account of the various changes is more than
can be reasonably expected at the present time. The volume
affords a ready means of reference, and forms a valuable
compendium of such knowledge as we already possess on
the subject. The microscopic figures that were represented
on photo-lithographic plates in preceding editions, have been
le-engraved as phototype blocks, and though they have
osfc somewhat in size, sharpness, and shade contrast in the
^ ransference, they iindoubtedly are more conveniently placed
in the text of the work in connexion wi bh the subjects to which
icy refer. Other ophthalmoscopic figures prepared in the
same way have also been ailded, noticeably sketches illus-
ratiDg septic emboli and hemorrhages in ulcerative endo-
car ifcis. p]jQ coloured plates have been judiciously left as
in former editions. Admirably executed and taken from
well-selected cases, they convey an excellent idea of the
pathological appearances. The adoption of mono-chrome in
the majority of them serves to concentrate the attention
on the form and light and shade effects, and secures a more
exact representation of delicate pathological appearances
than can be obtained by cliromo-lithograpby. The last
edition is certainly an advance on the previous ones, and
the book fills a useful place in medical literature.
THE LATE DR. MATTHEWS DUNOAN.
In beginning his course of clinical lectures on Jan. 29fch,
at St. Bartholomew’s Hospital, Dr. Champneya referred to
his predecessor. Dr. Matthews Duncan, in the following
terms:—
Gentlemen,—The same thought is probably occupying
the_ minds of all of us to-day—the thought that a voice to
which moat of you have listened with pleasure and with
great profit for many years no longer fills this theatre;
that a presence embodying the dignity and the learning
which was characteristic of its owner has disappeared from
among us for ever. This would, in some sense, have been
the position under any circumstances, for bo each of your
teachers, and to me in my turn, must come the time of
retirement, when, in the words of the old Roman poet
Ennius, he
“Senio confoctu’ quieacit."
And yet how different are the circumstances from what
we might have hoped and should have chosen for him.
A man of less indomitable will would perhaps have taken
warning earlier, would have sought relief from some of the
duties which were his greatest pleasure, as they were also
his most engrossing work. But he would not yield; he
struggled on in harness till, as you all know, and some of
you saw, he broke down in the act of instructing you, and
after a vain effort to tide over the few weeks which remained
of last summer session he left the country of bis adoption—
to die. This great hospital has lost, the profession has lost,
the country has lost, the world has lost—bow much can I
say ? But you and I have also lost in a special way,
for had his absence to-day been due merely to his
inevitable retirement, it would have been my endeavour
to try to prevent that retirement from being abso¬
lute; it would have been my endeavour to persuade
him to come among us from time to time and to give us
lectures, which I should have delighted to hear side
by aide with you, and which his great learning and rich
experience would have made, I feel sure, no unpleasant task
for him. But dis alitor visum, and that dream is over.
But besides this I have lost a kind and dear friend, from
whom I might have learnt very much regarding tiie
management of this great department, the changes which
have taken place during my absence of ten years, and the
prospects of the future. These I must learn without this
help. _ Gentlemen, I stand before yon as a stranger, and yet
the kindness which I have experienced on my return seems
to forbid mo to use such a term. Standing as I do in the
place of the greatest obstetrician of our time. I ask you to
continue to me the goodwill wliich I know from him that
you never failed to show, and, as a motto for us all, I
w’ould say, “ May the spirit of James Matthews Duncan
preside over all our meetings.”
Tiik City of London Truss Sooikty.—TIiq
annual report of this Society was submitted to the governors
at a meeting in Einsbury squave last week. The committee
recorded the fact that the income of the Society had been
fairly maintained. The total receipts for the twelvemonth
amounted to £4698. The expenditure was £50.‘10. The
committee acknowledge the aid of the late Lord Mayor in
presiding at the annual festival. The accounts which
accompanied the report showed that, inclusive of the loan
by the bankers, the balance in liand at the close of the year
was £785. Mr. J. W. Long expressed regret that the com¬
mittee had been obliged to recommend the sale of a further
portion of the invested funds, but this hud become necessary
.since they, as in the case of many other institutions, had
been dispensing in tlie form of charity more than had
actually been received.
G 3
Dr :ea tiy GOO^lC
374 The Lancet,]
RECONSTITUTION OF THE UNIVERSITY OF LONDON.
IFeb. 14,1891.
THE LANCET.
LONDON: SATURDAY, FEBRUARY U, 1891.
The “revised sclieme” published by the Senate of tlie
University of London in June, 1890, has provoked so much
opposition from the provincial colleges, and proved so un¬
acceptable to the Royal Colleges of Physicians and Surgeons
—especially to the latter,—that its provisional acceptance
by the Councils of University and King’s Colleges has
not been sufficient to induce the Senate to lay it before
Convocation, which is the necessary preliminary to applying
to the Privy Council for a new Charter on the bases laid I
down by the Senate. That scheme has now been withdrawn
and replaced by another, which was passed by the Senate on
the 4th inst., and it is understood that this will be the final
attempt made by that body to solve the problem referred to
it by the Royal Commissioners j but as it has hitherto proved
so pliable in endeavouring to please everybody by depart¬
ing from its old traditions, we should not be surprised, if
any exception be taken to the provisions of this scheme, to
see still another “ latest revised ” scheme forthcoming. We
publish the scheme on page 391, and invite the careful
attention to its clauses of those of our readers wlio are
interested in university education in London, and in
obtaining degrees for London medical students on similar
terms to those on which they can be obtained in the other
centres of medical education. Doubtless we shall soon
be favoured with an expression of opinion from those
bodies which are specially interested in this scheme of
reconstitution.
We must first point out that the scheme differs in its
very essence from that recommended by the Royal Commis¬
sioners, Their recommendation was, “that the teaching
institutions of a University of London, in the proper sense
of those words,—a university intended to have as to teach¬
ing a proper metropolitan character,—ought in our judgment
to be in or near London. For other parts of the kingdom
(as for the colonies) it is sufiicient that there should be
access, as heretofore, to examinations and degrees. To
bring in from all parts of the kingdom teaching institutions
having no special connexion with London might have results
similar to those of the former system of affiliation, when in
like manner extended. The powers which might be given
to such institutions would greatly, if not wholly, neutralise
the value of the share in them granted to the colleges in
London. The university, so constituted, would not bo what
is wanted; it would not be a teaching university in and for
London. Ontliispoint, therefore, ouropinionisthatthemetro-
politan limit should be adhered to.” In the scheme of last
year, which was accepted by University and King’s Colleges,
this recommendation was adopted ; in the present scheme,
influenced by the powerful opposition of the provincial
colleges, it has been thrown overboard, and clauses are
introduced providing for the admission of provincial Fellows
on the Senate (3, vl. & viii.); for a Standing Committee of
the Senate for the Faculties of Arts and Science in connexion
with the provincial constituent colleges (14) j for the ad¬
mission of provincial colleges as constituent colleges (20);
for the formation of provincial faculties (36), and of pro¬
vincial boards of stridies (44). Their duties and functions
and their relations to examinations and degrees in science
and arts will in every case run pari passic with those
assigned to the London teaching colleges. To the principals
and chief officers of these provincial colleges are allotted
four seats on the Senate, six being given to University and
King’s Colleges, and to the provincial faculties four, against
twelve to be elected by the London faculties. Two ques¬
tions naturally arise from a consideration of this part of the
scheme—(1) Will University and King’s Colleges agree to
this wide departure from the former scheme of June,
1890, and from the distinct recommendation of the Royal
Commission, which is everywhere adverse to the admission
of the provincial colleges as constituent colleges ? If they
accept a practical equality with the provincial colleges, any
hope of a r&al Teaching University in London may be given
up. (2) Will the provincial colleges and faculties be satisfied
with a smaller representation on the Senate than that
allotted to the two London teaching colleges and the London
faculties '{ If not, the scheme, which is already enlarged
to a Senate of fifty-two members, must be recast. The
Royal Commissioners recommended the much more con¬
venient number of thirty-eight, and the former scheme only
formulated a body of forty-two.
We now turn to the provisions for facilitating the
granting of medical degrees to London students on
equitable terms. The words of the Royal Commissioners
on this point are: “As to medical degrees, we think
that a standard of attainment appropriate for honours
ought no longer to be required by the University for
an ordinary or ‘pass’ degree.” To carry out this recom¬
mendation, a Standing Committee of the Senate for the
Faculty of Medicine will be appointed, consisting of
the Presidents of the two Royal Colleges, the two Fellows
elected by the said Colleges, the five Fellows elected by the
London Faculty of Medicine, one Fellow holding a chair in
a provincial constituent College of Medicine, and nine
members to be elected by the Senate. (IG.) The special
clauses laying down the terms on which a “pass” M.B.
degree is to be granted are the following:—
“47. The Senate shall have power to enter into arrange¬
ments with the Royal Colleges for conducting the examina¬
tions in anatomy, physiology, medicine, surgery, and
midwifery, for the pass M.B. degree by a board of
examiners, consisting of the examiners appointed by the
University, and examiners to be appointed by the Royal
Colleges, who shall join in the reports to the Senate on such
examinations. The examiners appointed by the University
may be called upon, if the Senate so think fit, to make in
addition separate reports. Tiiese examinations may, if so
agreed on, be conducted in combination with examinations
for the Royal Colleges. The arrangements for giving efl'ecb
to this clause shall be carried out under the direction of a
committee to be appointed in equal numbers by the Standing
Committee for the Faculty of Medicine, and a committee
to be appointed by the two Royal Colleges. Such arrange¬
ments to be subject to the approval of the Senate and of
the two Royal Colleges. This arrangement for joint ex¬
amination shall not lessen or interfere with the duty of the
Digitized by
Google
The Lancet,] DRS. VAILLARD AND VINCENT ON THE ETIOLOGY OF TETANUS. [Feb. 14, 1891. 375
Senate to be satisfied as to the adequacy of the e.Kamma-
tions in all respects.
“48. Candidates for degrees in the Faculty of Medicine
to sliow that they have passed through the required courses
of instruction in one or more of the constituent colleges in
that faculty, or of the recognised medical institutions.”
The latter paragraph corresponds word for word with that in
the scheme of June, 1890, hut in the former paragraph a most
msiterial alteration has been made. In the older scheme a
board of examiners was to be formed for conducting the
medical examinations for the pass M.B. degree, consisting
of examiners appointed by the University and of examiners
appointed by the Royal Colleges; but in the new scheme it
is added that “ the arrangements for giving eliect to this
clause shall he carried out under the direction of a com¬
mittee, to be appointed in equal numbers by the Standing
Committee for the Faculty of Medicine and a committee to
be appointed by the two Royal Colleges, such arrangements
to be subject to the approval of the Senate and oftha two
Boyal CoUages." The Senate will therefore not only
delegate the conduct of its pass M.B. examination to a joint
Board of Examiners partly nominated by itself and partly
by the Royal Colleges, but will give up the supervision of
the arrangements for this examination to a joint committee
of the University and of the two Royal Colleges. As the
Standing Committee of the Senate for the Faculty of Medi¬
cine must largely consist of Fellows of one or other of the
Royal Colleges, this arrangement will practically and defi¬
nitely place the granting of the pass M.B. degree of
the University into the hands of the Royal Colleges, whose
approval of the arrangements, as well as that of the Senate,
is requisite. Are the medical graduates of the University
prepared for this transfer of the University privileges to
the Corporations? Have the Royal Colleges altered the
arrangements of their examinations on the lines laid down
by the inspectors appointed hy the General Medical
Council, or have these recommendations practically been
ignored ? These questions will probably occur to the
medical graduates when this scheme of the Senate for
surrendering the real control over the most important
part of its duties, so far as medical degrees are con¬
cerned, comes before them in Convocation for their con¬
sideration. The Senate has in this paragraph conceded
the main point raised by the College of Surgeons in its
contention with the College of Physicians, so that now both
of the Royal Colleges will probably agree to the scheme.
We cannot think that the Senate has behaved well to the
Fellows of the Royal College of Physicians by ignoring
their acceptance of the former proposal, which was un¬
doubtedly the just one—i.o., that with due representation of
the Royal Colleges on the Senate, the medical examinations
should he placed under the direction of the Standing Com¬
mittee of the Senate for the Faculty of Medicine, and not
of a body partly under other jurisdiction and control.
Even so late as Dee. 19th, 1890, the committee of that
tlollege unanimously resolved in favour of “a distinct
standing committee, having special charge of the London
Work of the University in Medicine, analogous to the pro¬
vision in arts and scionco”-—that is to say, a standing
committee of the Senate only. Now, apparently, that
standing committee of the Senate as a whole is to have
to do only with honours degrees, and the Royal Colleges
are to have as much power as the Senate in granting
pass degrees. There are two further questions which
were mooted during the deliberations of the Colleges on
the old scheme, which are not mentioned in this—viz.,
the direct representation on the Senate of the London
medical schools, and the amount of fees to be paid by the
candidates for the pass M.B. degree. Will the Royal
Colleges persist in their former demand for direct repre¬
sentation of the London medical schools in addition to
those proposed to he elected by the London Faculty of
Medicine (:Lvii.)? Will the Senate agree to the raising
of its fefes for the pass M.B. examinations in accord¬
ance with the existing scale of fees now charged by the
corporations for their conjoint diplomas, £36 15^.—a larger
sum than is charged hy any other examining board, whilst
its own honours degrees may be obtained at the moderate
cost of £5 for each of the three professional examinations
for the M.B. degree? The future decisions on these
points will he awaited with great interest by the medical
students and medical teachers of London. We cannot
but direct attention to the clumsy arrangements by which
the work of the reconstituted University is to be carried on.
A Senate of fifty-two members is too large for the exercise
of any real control, and hence the future prosperity and
work of the University must depend on the wisdom and
general agreement of no less than six standing committees,
in some cases with opposed interests—viz , that for arts
and science in connexion with London colleges, for arts and
science in connexion with provincial colleges, for arts and
science for non-collegiate students, iu medicine, in laws,
and iu connexion with the Royal Colleges for the pass
I M.B. degree. This is the substitute for London which
is proposed hy the Senate of the University in the place of
a real teaching university modelled on the lines of the
Scotch Universities, the Victoria University, or the older
Universities of Oxford, Cambridge, and Durham.
In the last number of the Annales de Vlnstitut Pastcicf
there appears (from the Bacteriological Laboratory of Val-
de-Grilce) a most interesting paper on tetanus by Drs.
Vaillard and Vincent, which appears to throw very con¬
siderable light on the subject of tetanus, and to clear up a
number of points and observations that have hitherto been
enshrouded in obscurity. After describing the organism,
and identifying it with that already made familiar
through the papers of recent writers, the authors give it as
their firm opinion that in cases of artificial inoculation of
pure cultures it is always the poison introduced along with
the bacillus, and not the organism itself, that acts upon the
animal. This indeed seems to be probable, as they are able
to prove that almost inconceivably minute doses of this
poison, which they compare with snake poison, are quite
sufficient to produce all the symptoms of most acute tetanus;
in fact, it was almost impossible, from some of the cultures
that they obtained, to administer a dose that was not
lethal.
An exceedingly interesting feature brought out in the
course of their work is that la no case was the poison
developed as soon as the organism began to grow j in fact,
Digitized by
Google
376 The Lancet,] DRS. VAtLLAllD AN£) VlNCfiNT
gelatine cultures of the tetanus bacillus were never capable
of producing toxic symptoms until Uq;uefaction of the
gelatine had commenced, when spores were demonstrated
to have been formed, and when the peculiar disagreeable
odour BO characteristic of tetanus cultures had become
perceptible. They associate both the odour and the pep-
tonising power with the formation of the poison in the
cultures. That it was not due merely to the presence
of the spores that the material was poisonous they
demonstrated by heating their cultures to a temperature of
62® C. for a short time (a temperature which is quite in¬
capable of interfering with the vitality of the spores), when
it was found that cultures so heated and introduced by in¬
oculation into a rabbit or a guinea-pig failed to produce any
tetanus, thus proving that although the spores are not killed
the poison had been destroyed by the heat. The spores were
proved to be living by making fresh cultures from them in
artificial media; after a time they grew luxuriantly, and if
left to grow for eight or ten days produced another crop
of the poison. By simply washing away the poison from
the spores with distilled water they also obtained similar
results, for, although the spores could still develop and
form the specific poison in artificial media, they were, -when
inoculated, incapable of giving rise to any symptoms of
tetanus. From the reaction to heat of a substance they
were able to separate, and from its resemblance to the dias¬
tases in other respects, they conclude that they have
obtained from tetanus cultures the true tetanus poison, a
poison, however, that cannot be formed by the tetanus
bacillus in healthy tissues. The micro-organisms are here so
rapidly attacked by the leucocytes that they are rendered
hors de combat before they have time to form their
poison.
It has for long been well known that the tetanus bacillus
could not develop in the tissues except, apparently, in
the presence of other organisms, and the suggestion is
offered that these other organisms act in one of two
ways: they either paralyse the activity of the leucocytes,
or they draw off, as it were, their attention and activity
from the tetanus bacillus, thus allowing lb sufficient
time to develop its characteristic products. It is in-
tere.sting to note that Drs. Vaillaud and Vincent consider
that in many respects the tetanus bacillus is extremely
like the diphtheria bacillus, the method of action on and in
the organism being essentially the same in the two cases,
the above factors in all probability playing a part in diph¬
theria much as in the case of tetanus; and it is evident
that in studying the one poison much light may be thrown
on the other. Behring and Kitasato appreciated this
fact, and combined their forces to work out the question
of immunity in these two diseases. It is obvious, however,
from a consideration of some of the points that are indi¬
cated in this paper, that there are many sources of fallacy
that will have to be eliminated before the ultimate explana¬
tion of the condition of immunity in protected animals can
be given. The facts that this poison is active in such extra¬
ordinarily minute quantities, and that the micro-organisms
are able to grow with such difficulty in the human tissues,
allow us to hope that extremely minute changes in the blood
may be quite sufficient to secure the alteration or breaking-
ON fHE ETIOLOGY OF TETANt)S. [FM U, 189L
down of the virulent poison, even when it has become
diffused throughout the system. So long as the organism
is localised to the wound, there is of course more chance of
coping successfully with the disease, although here, as in
other diseases, there always appears to he the possibility of
the poison exerting such a paralysing influence on the cells
that usually take up foreign substances, that secondaryseptic
conditions may he liable to occur even when the action of the
tetanic poison can he antagonised so far as its primary effects
on the cells are concerned. One question appears to be set
at rest, and that is, as regards tetanus and diphtheria,
the ptomaines have had their day, whatever may become
of the products of other organisms. It may be accepted
that here, at any rate, we have some subtle poison which,
although it has nob yet been actually separated, has been
so far isolated that it may he taken as proved that it is
not an alkaloid or basic poison. A most remarkable
feature is that, in peptonising gelatine with the filtrate
from a meat-hroth culture of the tetanus bacillus, the
poisonous properties are lost to a certain degree in direct
proportion to the amount of gelatine that is peptonised; this,
taken in conjunction with the fact that the properties
are not developed until the gelatine begins to liquefy, has
led Drs. Vaillard and Vincent to suppose that the same
agent that peptonises the gelatine is the active agent in
bringing about the development of the toxic symptoms of
tetanus.
A phenomenon that may give us some cause for concern,
in considering the phase on which recent bacteriological
research has entered, is that many of these poisons by their
presence in extremely minute quantities in tlie fluids of the
body may interfere in a very marked degree with the exer¬
cise of the functions not only of nutrition, but of those of
excretion, by which it is possible that two sets of changes
may be set up. Protected animals or individuals may die
from septicrcmia, just as they may succumb with symptoms
of septic poisoning after the introduction of jequirity
infusion or after mild snake-bites; we may, however,
have a more chronic process similar to that sometimes
described as resulting from the injection of sterilised
tubercle products, a condition which has recently been
described as a kind of marasmus. We shall no doubt pass
through this stage of bacteriological inquiry bo find that in
some cases inoculation may be resorted to after the patient
is actually attacked, as in Pasteur’s treatment of
hydrophobia, though scarcely as a preventive measure;
whilst in other cases—those in which the immunity
seems to be conditioned by other factors—protective
inoculation will still be continued, and with excellent
results.
One lesson to be learned from these inquiries on tetanus
and its etiology is thatwe should he encouraged to continue
the search for the vegetable or animal micro-organism that
is probably the etiological factor in hydrophobia. Of course,
it must never be lost sight of that the hydrophobic virus
may be formed only within the body, and even by the cells
of the body under the stimulation of the special poison or
ferments produced elsewhere; but such a method of forma¬
tion is so utterly diflerent from anything that has yet been
met with in the biological world that for the present the
Digitized by
Google
The Lancet,]
THE RECENT PROGRESS OF SANITARY REFORM.
[Feb. 14, 1891. 377
raicro’Organiamal rather than the humoral pathology of
rabies must be accepted, even though it has as yet not
a single fragment of direct evidence in its favour.
An article of more than usual interest and importance
appears in the current number of the Edinburgh Review
upon the recent progress of sanitary reform. The import¬
ance which the reviewer claims for his subject is by no means
overstated, and his summary of the leading features of the
history in this department of the past fifty years will do
something, and should do much, to awaken and instruct the
public appreciation, both of what has been done and what
can yet be done to improve the conditions under which, espe¬
cially in towns and unhealthy areas, human life has to be
spent. The tone of the present article is none the worse
for being a little optimistic; indeed, optimism is, and always
has been, the inspiration of all successful effort for reform.
It is, perhaps, not desirable that the public at large should
look too complacently upon the existing organisation of
what may perhaps be called the sanitary services, but a
review of the work actually accomplished by what has,
upon the highest estimate, been up to the present time a |
modest legislative enterprise, justifies the confident antici¬
pation that well-directed effort in the future will yield
results of inestimable importance to the community at
large, and in particular to those classes which in the past
have borne the brunt of bad sanitary conditions.
It is not, however, with the reviewer’s summary of past
events that we are chiefly concerned, although these are of
sufficient interest, but with his suggestions for reform.
Even here the field over which he ranges is too large for us
to accompany him throughout its whole extent. And,
indeed, his suggestions upon some parts of his topic are
somewhat too vague for useful discussion in their present
form. Thus, for example, it is by no means necessary that
one should be an enthusiastic admirer of the existing
organisation of the Public Health Department to refrain
from discussing the creation of an independent Secretary¬
ship of State charged with the exclusive care of sanitation.
Such a reform may or may not be desirable in itself, but it
is certainly not the most pressing matter connected with
this subject at the present time. Nor is it even ripe for
discussion. Similarly we may postpone the question, in¬
teresting gnough from our own point of view, whether the
medical profession could be relied on to furnish, if
necessary, a succession of men fitted not only in a profes¬
sional sense, but also in respect of statesmanship, to under¬
take the control of such a department. For the present it
may be sufficient to say that we take a sanguine view of
the matter, and that when the time comes we shall be
prepared to support our opinion in discussion. The con¬
troversy is not, however, of a kind that we have any disposi¬
tion to precipitate.
A matter of more practical importance is the suggestion
convoyed in the present article that hospitals and medical
charities should be brought under the elficient control of a
Central Board of Health. This is a question not only
of capital importance in itself, but one on which at
the present time the public luind is more than usually
exercised. The Committee of the House of Lords, however
strictly limited may be the scope of its inquiries, can hardly
construct a report which will not have a large significance
in relation to institutions beyond the metropolitan area,
and even within that area all the problems which hospital
organisation presents have to be faced and dealt with. But
it is above all things necess ary, in attacking this subject, to
remember that it is complicated by the fact that these insti¬
tutions are very largely dependent upon voluntary public
support. To deal with them in these circumstances is a
matter of no ordinary delicacy. The stream of charity may
easily be diverted by the advent of official directors and the
circumstances of official control. The idea that be who
“pays the piper” is entitled to call the tune is so ingrained
in the mind of the modern Englishman that it would pro¬
bably be found a perfectly impracticable project to com¬
bine official administration with voluntary support. Any
scheme of control by Parliament or Parliamentary officers
would need to be supplemented by a sufficient—that
is to say, a complete—provision of Parliamentary funds out
of which the institutions could be maintained. This is the
crux of the problem, and it is well that it should be frankly
stated and fully realised at the very outset of any attempt
at solution.
But there is, short of public control, the wholly different
matter of the full publication of statistics, sufficient to make
it possible to establish instructive comparisons between
various institutions, which is deserving of the most careful
consideration. We do not discover in the article any
indication that the writer has in view this very material
consideration. It is open to doubt whether at the
present time it would be possible to devise a per¬
fectly satisfactory organisation of the medical charities
upon a new basis. It may well be that a competent central
authority would be able to effect a great, even enormous,
economy of the present overlapping and badly organised
work of these institutions. But he would be a bold man
who should undertake to lay down the lines of any such
scheme upon our present information, A decade spent in
organising knowledge on pucli a subject would be time Avell
employed; and although we confess to some diffidence in
accepting what we understand to be the full meaning
of the writer's somewhat indefinite suggestions, we
shall cordially concur in any steps that may be taken
to secure for the public full access to all the facts which
tend to show how the field of charitable sick relief is occu¬
pied ; to what extent the various workers in it are aiding,
and to what extent they are impeding one another; whei-e
the work is most efficiently done, both in a professional and
in an economic sense, and where and how failures in these
respects are to be detected and remedied. It cannot bo
doubted tb at in the absence of organisation many errors of
administration, and perhaps some of aim even, have crept
in. As matters stand, that, even where most regrettable,
should not be matter for reproach; and nothiog would
tend more both to soften the asperities of criticism and
point the way of reform than the systematic collection
and efiective dissemination of authentic and exhausth’o
statements of fact.
Before continuing our notice of Dr. Lawson’s paper on
the results of the repeal of the Contagious Diseases Acts it
is desirable to correct ao error into which we fell last week.
Digitized by
378 The Lancet,]
THE CONTAGIOUS DISEASES ACTS.
[Feb. H, 1891.
It appears that the paper was prepared at the request of
Dr. F. J. Mouat, the present President of the Eoyal
Statistical Society, and not at that of the late Dr. Graham
Balfour, who was too ill at the time to take any active
part in the Society’s work.
In the paper of Surgeon-General Lawson the records
of syphilis show very considerable fluctuations at various
periods. Thus, among the Dragoon Guards and Dragoons
in the United Kingdom annually from 1839 to 1837,
and those of the same force and Foot Guards (chiefly
quartered in London) from 1837 to 1847, with their
millesimal ratios throughout; among the Dragoon Guards
and Dragoons the mean ratio of primary venereal sores
was 79'5 per 1000. It was 72 per 1000 in 1830, 96 in 1832,
80 in 1833, 95 in 1834; after which it went down to 63 and
02 in 1836-38. Similar fluctuations were observed among
the Foot Guar(^, the ratio varying from 107 in 1837-38 to
217 in 1843-44. Similar fluctuations occurred in gonorrhcea,
but in different years, and not quite so pronounced. All
this was long prior to the year 1864, when the first Con¬
tagious Diseases Act was passed, hence the importance of
these fluctuations when comparing different years with one
another.
It is well known that, for the purposes of comparing
stations under the Acts with those not under them,fourteen
of the latter were selected for comparison, and were called
“fourteen stations never under the Acts.” Thesewere; Isle of
Wight, London, Warley, Hounslow, Pembroke Dock, Shef¬
field, Manchester, Preston, Edinburgh, Fermoy, Limerick,
Athlone, Dublin, and Belfast. The fourteen stations under
the Acts were Devonport and Plymouth, Portsmouth,
Chatham and Sheerness, Woolwich, Aldershot, Windsor,
Shorncliffe, Colchester, Winchester, Dover, Canterbury,
Maidstone, Cork, and Curragb. Besides these two sets of
stations was a third, designated “all the stations never
under the Acts.” In 1860 at the fourteen stations which
came under the Acts in 1864 and subsequently, the ratio of
primary sores was 146; at the fourteen unsubjected
stations 134, and at all the stations never under the
Acts 131. From these points all fell, so that in 1862
they stood at 117, 103, and 99 respectively. In
1863 the admissions at the fourteen unsubjected stations
rose to 117, while those at the fourteen subjected were 107,
and at all the unsubjected 108. The compulsory examina¬
tion began to take effect in 1867, and though there was
au increase of the incidence of the disease on the country
as indicated by rises in the ratio of 17 per 1000 in both
the fourteen and whole unsubjected districts, that at the
fourteen stations under the Acts was 4 per 1000 only ; and
from this year the ratios at the fourteen subjected stations
were always much under those in the whole until 1884, the
last year of the comparison. In 1871 the incidence of the
disease on the country seemed at its lowest, being 93 for
the fourteen unsubjecbed stations, 81. for all the subjected,
and 51 only for the fourteen subjected. The stoppage of pay
showed its effects in 1874 by a fall at each class of stations,
which was continued in 1875, and still traceable up to
1877, after which the advance of another epidemic wave
caused a rise at the fourteen unsubjeeted stations of 40 per
1000, at all the unsubjected of 20, while at the fourteen
subjected it was 4 only. In 1879 there was a slight reduc¬
tion of the ratio at both classes of unsubjeeted stations, but
a rise of about the same amount at the fourteen subjected ;
but in 1880, with the cessation of stoppage of pay, there
was a general rise, amounting to 39 at the fourteen unsub¬
jected stations, to 37 on the whole unsubjeeted, and to 27
at the fourteen subjected stations; a portion of this was no
doubt due to an increasing incidence of the disease over the
country, but a large portion also to the removal of the
inducement to conceal primary forms of the disease by
stoppage of pay. The beneficial effects of the Acts
will be seen by the following figures. In 1860 to 1863,
when no Acts were in force, the ratio of primary sores at
the stations subsequently protected by them was 129 8. In
1870 to 1873, the Acts being then enforced in all, it fell to
52’5. Secondary syphilis fell from 39'9to20'2; gonorrhcea
from 134’G to 100‘3. At all the stations never under the
Acts the fall in primary sores was from 116‘3 to 86'0, in
secondary disease from 30‘5 to 27’4, and in gonorrhcea from
116'1 to 95. At the fourteen unsubjeeted stations primary
sores fell from 120'6 to 107'9; secondary syphilis rose from
31‘0 to 31'8; gonorrhcea fell from 112-1 to 71'6. In 1880 to
1882, stoppage of pay having terminated, the ratio of
primary sores at the protected stations was 75'6, secondary
syphilis 26-6, gonorrhcea 99-0. At all the stations never
under the Acts the ratio of primary sores was 123-0; that
of secondary syphilis 32'5 ; gonorrhcea 110-4. At the four¬
teen unsubjeeted stations the ratio of primary disease was
175-9, of secondary syphilis 38 9, and of gonorrhcea 128-4.
The Acts were suspended in 1883, and wholly repealed
subsequently; the separation of the tables has not been
continued since 1884. The ratios of disease among all the
troops are as follows :—
Primary
Soros.
. 140 ..
In 1860, ratio per 1000 \
of admission / “
In 1886, ratio nor lOOO 1
of ailinisNzon /.
Socontlary
Syphilis.
... 36 ...
27
Gonorrhcea.
.. 133
.. 121
From this it will be seen that the ratio of disease has re¬
turned to what it was in 1860 before the first Act was
enforced.
There are many other interesting points in Inspector-
General Lawson’s paper which show immense pains, great
research and a most thorough knowledge of the whole
subject. Enough has been given to show the benefits
of the Contagious Diseases Acts and the disastrous
results of their repeal. We hope to give later on some
statistics from Malta showing the benefits of this legislation
there, and also some figures on the Royal Navy and tho
civil population of the stations under the Acts, which
Dr. Lawson was unable co adduce previously.
We are informed that the electrical exhibition which is
to take place at Frankfort-on-the-Maine will have a section
devoted to illustrating the medical aspect of the subject.
The applications of the constant and induced currents to
the diagnosis and treatment of internal diseases will be
demonstrated, and models of apparatus for electrolysis and
galvano-cautery will be shown. Rheostats and other
apparatus for the careful application of the current to
medical purposes are to be exhibited. The value of the
latest advances of electricity as applied to medicine will be
shown by several exhibitors.
Digitized by i^ooQle
Tbe Lancet,]
NEW SCHOOL OF HUMAN ANATOMY AT CAMBRIDGE.
[Feb. 14, 1891. 379
Annotations.
" N« quid Dlmls."
NEW SCHOOL OF HUMAN ANATOMY AT
CAMBRIDGE.
This building, which is one of the finest and best suited
for its purpose in the kingdom, with large dissecting room
above, well lighted by northern skylights and side windows,
spacious museum beneath, rooms for study for the students,
rooms for the professors and other teachers, and various
requisite appliances, was inaugurated on the 29th ult. by
an interesting lecture on the History of Anatomy in Cam¬
bridge, delivered by Professor Macalister in the large lecture
room. Beginning with Gains, who on bis return from Padua,
where he graduated as M.D,, and where he was acquainted
with Montanus and Vesalius, introduced the study of prac¬
tical human anatomy into England, and provided for its
being carried out in the College known by his name in
Cambridge, which he founded in 1557, Professor Mac-
alister referred to the probability that Harvey, who was a
member of the College, here acquired his first know¬
ledge of anatomy. He gave a short account of the works
of Glisson, Wharton, and others, who had prosecuted
the science of anatomy in Cambridge, and of the various
persons who had held the chair of Anatomy from the time
of its foundation in 1707 to Sir Busick Harwood, Clark, and
Humphry. The lecture was greatly applauded by the
large audience. At the conclusion Sir George Humphry
congratulated the University on the fact of this spacious
and well-arranged building being devoted to the study and
teaching of human anatomy, on the interest shown in the
event by the large audience assembled in that splendid
theatre, and on the lecture they had just heard from one
who to his many acquirements added that of as extensive
a knowledge of the history of anatomy as that of any
living man. He trusted that tbe classes might long remain
as large as they now are, and that Professor Macalister
might long be spared to teach and direct them.
THE LONDON WATER BILLS.
The present session will have an especial interest for
water drinkera in London, for the reason that the whole
question of metropolitan water-supply will almost certainly
be investigated by a Parliamentary Committee or by a
Commission. Already three Bills relating to this subject
have been published. One promoted by the City Corpora¬
tion proposes to constitute a Water Commission to acquire
the undertakings of the several water companies and to
improve the water-supplies. The constitution of the Com¬
mission is deserving of notice, because, if the Bill become
law, it will be representative of the London County
Council, the City Corporation, and the several County
Councils in the watershed of the Thames. The Corporation
has shown considerable skill in thus bringing to its aid a
number of Corporations and County Councils who may be
expected to view with satisfaction a scheme which would
place the London Council in a position very different
from that it would occupy if the Corporation had to
light it single-handed. It cannot, however, he ex-
pectod that the Bill will pass, nor is this probably
anticipated by those who promote it ; but it serves
to show that the Corporation does not intend to sink
permanently into the position of a district authority
without some effort to prolong its existence. The Bill will
probably not be regarded with favour by tbe sanitary
authorities in the areas of the County Councils to whom
this overture is made by the City Corporation, for it is
obvious it would at once be the occasion of constant
warfare between the councils and the sanitary authorities,
for the latter would no longer be permitted, as now, to
discharge sewage into the rivers. It remains to be seen
whether the Corporation will get more good by the support
of these councils than harm from the opposition of the
sanitary authorities. The second Bill, which is backed by
Sir Algernon Borbhwick and other private members, proposes
the constitution of a Water Trust, consisting of thirty-nine
members; also for tbe purpose of acquiring the undertakings
of the water companies. The members of the Trust are to be
elected by the county electors of the water area. But their
existence is nob to be permanent, for the London County
Council are to be empowered in 1892 to replace them. It
remains to he seen whether the London County CouncU will
be satisfied with this proposal, or whether they will nob
desire to deal directly with the water companies. The
third Bill restricts itself to proposing that all water con¬
sumers shall, if they elect, be supplied by meter. This
Bill is backed by private members, and will doubtless be
considered by the same committee as that appointed to deal
with tbe others. It cannot he expected that any of these
measures will become law, but they will afford ample
fighting ground for the several interests concerned, and it
is probable that the number of such Bills will be increased
before the session has terminated.
EDINBURGH UNIVERSITY CLUB.
The quarterly dinner of this club took place in the
Holborn Restaurant on Tuesday evening, the lOth inst.
Before the dinner the annual meeting of the club was held.
The reports of the secretary and treasurer for the past year
were submitted, and showed the club to be in a most
flourishing condition. Under the presidency of Dr. J. G.
Glover, one of the direct representatives of the profession
for England in the General Medical Council, a very pleasant
evening was spent. In proposing the “Health of
.Alma Mater,” in a most felicitous speech. Dr. Glover
recalled the fact that this was not the first time that he had
had the honour of presiding, and referred to the many
distinguished men who had in his remembrance occupied
the same position, such as Mr. Syme, Sir Robert Christison,
and others. He pointed out various reasons or teats by
which a University system can he judged. Thus a
prominent feature ought to be the fact of exciting in her
graduates gratitude and affection, which he said existed in
all the graduates of Edinburgh University throughout
tbe world. The very existence of this club was a
standing proof of this sentiment taking hold of the
graduates of Edinburgh. A University system ought
also to stimulate the intellectual and educational am¬
bition and ardour of the people of a country. This
was eminently the case with the Universities of Scot¬
land, which had succeeded in getting within the range of
academic influence a large proportion of the people of Scot¬
land. He also showed that the Universities of Scotland
had produced great and exceptionally influential men, and
enumerated many of their sous, as Ilume, Cullen, Joseph
Black, Dngald Stewart, and Lord Brougham, who was one
of the founders of the London University, and many others
who, as students and graduates of Edinburgh University,
had been promoters of education—popular, professional,
and scientific. Dr. Potter proposed the toast of “ Our
Guests,” which was replied to by Mr, Thomas Wakley, jun.,
and Mr. Lamb. Dr. George Harley, ia a eulogistic speech,
proposed health, prosperity, and domestic happiness to the
chairman, who suitably acknowledged the compUmenc.
Digitized by' ■ lOOQle
380 TflBLANCBf,] ACTION FOR MEDICAL CHAEGES. [Feb. 14,1891.
WORK IN DENTAL SURGERY.
Ik his iuteresblDg inaugural address the President of the
Odontological Society, Mr. S. J. Hutchinson, reviewing
last year’s work in dental surgery, said that there had been
fruitful and instructive discussions on antnstbetics, and the
introduction of gas and oxygen as a safe means of
prolonging insensibility ; cocaine had been found by
many to be successful as a local anoesthetic, though he
doubted whether it was as useful as nitrous oxide. He
strongly protested against the aid of hypnotism being
invoked for the purposes of dental operations as long as
the present average of success with nitrous oxide was main¬
tained ; “the influence of ‘gas’ is purely toxic, whereas
hypnotism calls into play both mental and moral phenomena,
which are degrading to the patient and dangerous to the
operator.” The greater scientific knowledge of the power
of antiseptic agents had rendered it possible to make
healthy the roots of teeth which a few years ago would
have been condemned as useless, and render them
capable of carrying artificial substitutes. However, he had
come across a French work dated 1816 which contains an
illustration of a case of “bridge work.” He thought it was
cheering lo watch the efforts which were being made to pro¬
duce for incisors fillings and inlays which imitated the
colour of the natural teeth rather than disfiguring them by
elaborate and extensive displays of gold. Speaking of
antiseptics, Mr. Hutchinson said he had been trying some
experiments with compressed oxygen in the treatment of
septic roots, and hoped that these experiments would be
supplemented by those of others. Mr. Cartwright’s words
in 18.36 with reference to the L.D.S. diploma were, he
thought, fully realised, and it was in the hands of the
dental profession to maintain the prestige of that diploma
by constantly raising the standard of the examination.
OPPOSITION TO THE NOTIFICATION ACT
AT LINCOLN.
The Mayor of Lincoln lately convened a public meeting
in compliance with a requisition largely signed by working
men to discuss the adoption of the Notification Act. The*
following resolution was passed with only three dissentients:
“ That this meeting is of opinion that it is unnecessary to
adopt the Notification of Disease Act, on account of the
low death-rate in the city, and also undesirable on account
of the very great expense it would incur on the ratepayers;
and this meeting respectfully requests the members of the
Corporation not to adopt it.” Wo cannot congratulate the
supporters of the motion on their arguments or even on
their facts. The chief argument used was the invasion of
private freedom involved in the Act, and the enormous
profits that were to accrue to medical men. One of the
speakers stated that one medical man had received for one
week in notification fees £12 IO 5 . in half-crowns, wliilst
another had notified fifty cases in one day. It produced no
effect on this gentleman to have it explained that the fifty
cases received in a day were not from one man, but for a
whole district. He refused to withdraw his statement.
He would have been still more incapable of perceiving that
notification ptops the occurrence of fresh cases, and so
limits the work and profits of medical men. Another
speaker argued that when an infectious case happened in
a crowded house the healthy children should bo all removed
and the sick one left in charge of the mother. There
remains the argument of the “Englishman’s house is his
castle.” The answer to this is twofold. First, that notifi¬
cation is not necessarily any invasion, or leads to invasion.
Secondly, that the castle is already liable to invasion for
sufficient reasons, and that of all reasons none could be more
sufficient than the welfare of the Englishman himself and
his family, and of all the families round about him, and
that the invasion will be conducted always in the most con¬
siderate manner. Dr. Lowe made a candid and powerful
speech. He said that on first looking at the Act he was not
in favour of it, but that since the subject had been com¬
pletely thrashed out be saw a very great amount of good in
it. His estimate of the cost of notification for Lincoln was
£40 or £50 a year. For some time to come, however,
Lincoln is to enjoy freedom to have and to harbour any
amount of infectious disease.
UNREGULATED MEDICAL PRACTICE IN
SIERRA LEONE.
Wk have received from Dr. f. Nichol Paris, Secretary
of the Sierra Leone Medical Association, a very un¬
satisfactory account of the unchecked quackery and irre¬
gular medical practice which obtain in the colony, and
especially in Free Town itself. We regret not to have
space for this letter. Hut we must point out that such a
state of matters is discreditable to the Goverameut of the
colony. Sierra Leone is a colony of whose Government
better things might have been expected. It must be well
on to a hundred years since Winterbottom, the physician
to the colony, wrote a classical book on the diseases of the
natives of Africa. And there are now in Free Town a
dozen well-educated and registered medical men. It is
due to them, as well as to the population, which consists of
9000 Christians, 5000 Mahommedans, and 8000 Pagans, to
enact a Registration Act by which at least the people may
know educated men from bonesetters, herbalists, abortion-
mongers, pill-vendors, and quacks of all sorts.
ACTION FOR MEDICAL CHARGES.
In an action before Mr. Justice Stephen and a special
jury, brought by Mr. O’Reilly of Highgate against the
executors of the late Mr. Ernest Matthews, to recover the
sum of £80 odd for medical attendance chiefly on Mrs.
Matthews, the executors disputed theclaim as excessive and
paid £34 into court. Mr. Kennedy, Q-C., and Mr. T. Smith
were for the plaintiff’; Mr. Waddy, Q.C., for the defendant.
The account was for about seventy attendances altogether.
Mrs. Matthews died; also Mr. Matthews. The charges
were justified by the plaintiff on account of the anxious
nature of the case, taking up much time and involving the
administration of chloroform. The jury found for the
plaintiff for £60, including the sum paid into court. His
lordship gave judgment accordingly, with costs.
THE MIDWIVES’ BILL.
It is remarkable that, amid the rending discords of the
gyncECological and obstetric branch of the profession, there
is one subject on which there seems to be comparative
unanimity. The Obstetrical Society at one of the largest
meetings ever held, while hesitating to endorse the present
Hill, with all but unanimity affirmed the past action of
the Society in the following resolution: “ That the Fellows
of the Obstetrical Society approve the policy pursued by
the Society for the last twenty years, and respectfully
request the Council to continue their efforts to obtain for
these women suitable education and legal registration.”
The demand for some legislation to prevent incompetent
women from practising midwifery is really all that is asked
for. A correspondent in Tuii Lancet of to-day complains
that theopponentsof all legislationforthepresenthavecarried
the war over the Bill into the quiet waters of the Medical
Defence Union. This does seem to be a very questionable
piece of judgment. The Medical Defence Union is doing
admirable work now, with perfect unanimity in the society.
It would be a misfortune if it were distracted from its
own line of duty by being made the arena of every
Digitized by Google
The Lancet,] “ THREATENED MEDICAL STRIKE IN SCOTLAND.” [Feb. 14, 1891. 381
stray agitation that arises in the profession. But this is a which will serve the purposes of light and ventilation, and
matter on which the members of the Defence Union must
make up their own minds. We content ourselves with
pointing out the responsibility of those who endanger the
peace or the efliciency of a society which was founded
for very different purposes than that of supporting
the present race of untrained and irresponsible mid¬
wives. We say irresponsible, for they commence and
continue practice now, to the number of about 10,000, with¬
out anybody's leave, and, apart from the grossest misconduct
or malpractice, are unhindered. Last week, again, a mid¬
wife was committed for manslaughter for her treatment of
a case. But short of such terrible tragedies as this, the
ten thousand go on with a sort of legal status, to the injury
of women and of the profession alike. We revert to our
suggestion of a select committee that should take evi¬
dence on this grave subject in all its aspects. The question
must be disposed of. If the present state of the midwife
class is the highest attainable in a civilised country, where
thousands of women cannot afford the fees that any self-
respecting medical man can take, the question will be set
at rest, and the medical profession, which is now almost
the only depository of knowledge on the subject, will have
transferred to the Legislature its responsibility.
"THREATENED MEDICAL STRIKE IN SCOTLAND.”
However humiliating it may be for the countrymen
of Sydney Smith to admit, we have to confess to being
indebted to Scotch assistance, almost as severe as a sur¬
gical operation, for full perception that the account of a
threatened strike among our brethren in Scotland is all a
hoax. We will not begrudge our northern friends the
sweet revenge tliey obviously feel in the success of their well-
acted part. We may confess that we were not looking for
jokes from that quarter. More remarkable than the
naiocU with which we accepted as serious the description
of hard work and scanty pay in Scotland, which really are
serious in England, is the oversight with which, by an obvious
lapsuspennrv, Sir Andrew Clark’s name was inserted instead
of Sir Walter Scott’s. The quotation was actually made
from one of the novels of Sir Walter Scott, who
was a friend of Mungo Park. Sir Andrew Clark of
course was nob born at that time. It is gratifying to
find that the grievances of unremunerated medical labour
in Scotland are so slight as only to supply material for a
joke. We may by our inadvertence emphasise the fact, and
so suggest to some of our readers who find their work bard
and unremurierabive in England to try their luck in the
more jocose part of the kingdom north of the Tweed.
THE NEW GENERAL HOSPITAL, BIRMINGHAM,
The question of an appropriate site for the new hospital
has caused considerable anxiety to the committee, and has
also given rise to some discussion, or rather expression of
opinion, in the local press. After much consideration, aided
by the experience of two architects, Mr. F. Willmob and Mr.
F. Osborn, the committee selected the site of St. Mary’s-
square as the most suitable, and have recommended it to
the governors for adoption. In the face of the extreme
dilOculty in obtaining a sufficient quantity of land in a
central position, this seems to be the most feasible plan pre¬
sented. It is true that it is nob an ideal site, bub it is also
true that it is the best which could be obtained under the
circunjsbancea. It is central, in the midst of a thick popu¬
lation, fairly near to the two railway stations, is 30 ft.
higher than the present hospital ground, and is on a gravel
foundation. The area obtainable under the promisos of a
good subscription list would bo about three acres and a half,
which would be aullicienb for a hospital of 300 beds built
upon modern principles. There is also free space around,
which might be available for recreation ground. The
position would not interfere with the other large hospital—
the Queen’s—and would be undoubtedly favourable for the
medical school. With the present project of a large central
hospital, it is impossible to resist with reason the con¬
clusions arrived at by the committee that this is the best
obtainable site, and that it bids fair to answer the purposes
for whicli it is intended. ___
EFFECT OF TEMPERATURE ON THE
RESPIRATION.
Dr, R. Oddi, who has been investigating the effect of
external heat upon the gaseous exchange in respiration, has
shown that the exchange is inversely proportional to the
temperature, so that the lower the temperature the greater
the elimination. This fact is by no means new, for Lavoisier
was aware of it; though the interpretation he gave of it was
incorrect, as respiration is nob the simple act of com¬
bustion that he imagined it to be, but a highly com¬
plex series of chemical changes, which have for their object
the nutrition of the cellular elements; for, as Luciani
has shown, it is necessary that all substances should
pass through the living cells of the body tissues in
order to undergo change and decomposition. Hence it is
impossible to haverespirabory exchange without the cellular
elements, and nutrition and the production of heat are not
identical. Moreover, from Dr. Oddi’s experiments it
appears that there is no variation in the relative quantities
of the different substances taking part in the respiratory
changes, and that thei'e is no special nervous mechanism
employed, but that the nervous system as a whole takes
part in it. The same may be said as regards the production of
heat. The experiments alluded to were conducted on rats,
but Dr. Oddi proposes to supplement them by observations
on other animals. ___
THE LINCOLN WATER-SUPPLY.
The subject of the water-supply of Lincoln is engaging
nmeh public attention. In 1885 Dr. Harrison, the medical
officer of health, called attention to the defects attaching
to the present system, and he now again urges that the
matter ought not to be shelved, and this especially in view
of the impurities reaching the service through the river
Witbam. Dr. Harrison’s detailed account of the varying
circumstances by which the present supply is injuriously
affected should suffice to convince the Town Council and
the inhabitants that his recommendation that the time has
fully arrived for providing the city with a sufficient and
wholesome supply is one that cannot be set aside with
impunity. _
"ASTASIA-ABASIA” IN GRAVES’ DISEASE.
Dr. Eueenburg of Berlin discusses in a neurological
journal the state described by P. Blocq as “astasia-abasia.”
The author points out, first of all, that no consensus of
opinion exists between Blocq and otliers who have written
on the subject as to the true meaning of this morbid
condition. Some consider it to be a mere symptom of a
hysterical nature, bile Blocq himself looks upon it aa an
independent morbid condition due bo spinal lesion; Bins-
wanger connects the symptoms with hypochondria, while
Eulenburg observed a case of astasia-abasia during the
progress of Graves’ disease in an anmmic girl of eighteen,
which shows that, apart from hysteria, a morbid condition
may exist, nob only comprising the sjiinpboms represented
by Blocq’s description, bat completely agreeing with their
course and the effect produced on them by treatment. The
girl had been treated for four months, and the goitre had
nob only considerably decreased, but the exophthalmos had
almost entirely disappeared ; palpitation and pulse became
Digitized by
Google
382 Thb Lancet,]
MEDICAL BIBLIOGRAPHY.
[Feb. 14,1891.
less frequent, and her whole nutrition had also considerably
increased, when suddenly both her legs seemed to become
paralysed. She thought she had caught cold in a draughty
passage. No other symptoms supervened. On examining
the patient as to her sensibility and power of walking, the
author diagnosed astasia-abasia, with a kind of self-sug¬
gestion as cause, as the patient had been seized once during
the early part of her treatment with a sudden fear and con¬
sequent inability to pass over bridges. Psychical treatment
was consequently indicated. The author informed her that
a very painful and powerful remedy alone could do her
good, but that this would cure her with certainty in a very
few days. He applied faradlsm for about ten minutes below
the knee and on the leg and foot most energetically, with
rubefacient and of course painful effect. He then recom¬
mended some indifferent liniment and proposed to repeat
the application of the faradic brush on the next day.
Improvement was observed tho same day, and one repetition
of the treatment entirely cured the astasia-abasia.
MEDICAL BIBLIOGRAPHY.
There is no lack of periodicals the purpose of which is
to compile in a well-ordered way a list of the medical and
Bcientihc contributions to literature. Foremost among
these stands the monthly Index Medicus, established in
1879, a work of the greatest value, and one which is de¬
serving of more support than it receives. Of much older
foundation, for it is now entering on its forty-fifth year, is
the quarterly publication Bihliotheea Medico-Cldrurgica,
edited by Gustav Ruprecht (Gottingen), which, besides
being fairly complete, is remarkably cheap. Then
last year appeared M. Rouvier’s Revue Internationale
de Bihliographie, also established as a quarterly, and
published iu Paris and Beyrouth, but which with
the present year comes out in altered form, as a
monthly periodical in which abstracts, and not the mere
titles of papers, are given. It can hardly, however, aspire
to the position attained by the world-famous JahTbiicher of
Virchow, Hirsch, and of Schmidt. Besides these and many
annual publicatious in all countries devoted to the same
object, some of the recently established weekly Central-
bUitter affosd very copious bibliographies. Indeed, the
keeping pace^with the growth of medical literature, with
a view to record merely what is being written, has become
a distinct branch of itself.
THE BONDING OF SPIRITS.
Some interesting evidence has already been given before
the Select Committee of the House of Commons, which was
appointed to consider whether it is desirable that certain
classes of spirits, British and foreign, should be kept in
bond before they are allowed to pass into consumption,
and also to inquire into the system of Mending British and
foreign spirits in or out of bond. It may be assumed that
the object held in view by the committee is to determine
whether it would not be more desirable that new spirit
should, by being held in bond for some time, become
matured, or, in other words, that the fusel oil, to
which are attributed the injurious effects of tho new
spirit, may, on keeping, become so changed or oxidised as
to render the spirit more palatable and more wholesome.
According to the evidence of one expert, the aroma and
flavour of spirits, at least in the case of pot-still spirits, were
dependent upon the character of its own peculiar fusel oil, so
that if fusel oil of any other origin were added the character
of the spirit became quite altered. But it seems very
doubtful if fusel oil is ever purposely added to a spirit, and
as it is invariably present in greater or lees quantity
in new spirit, the objectionable symptoms which are
produced from driuking such spirit are assigned to,
the fusel oil which chemical analysis shows it to con¬
tain. The same witness tried experiments on himself. He
consumed daily for nineteen days three fluid ounces of
brandy to which had been added 0-60 per cent, of fusel oil.
He declared that, apart from the nauseous taste, nothing
objectionable was experienced more than would have
followed from drinking ordinary spirit. Now, from the
experiments made on animals and men by Eulenberg, fusel
oil is held to he injurious in its action, if not poisonous,
and a person taking two fluid ounces of a whisky
which Dr. Dupre’s analysis showed to contain 0T9 fusel
oil to every 100 of alcohol (the whisky itself containing
54'5 per cent, alcohol) would swallow close upon a
grain of fusel oil, and if it contained three times the
quantity, then three grains, which, having in view also tho
active properties of ordinary alcohol, is the lowest amount
with which distinct effects like dyspncca and depression
were obtained. Accordingly some authorities consider the
presence of one grain and a half of amylic alcohol or
fusel oil in one fluid ounce of spirit as likely to be injurious
to health. It is well known, farther, that men engaged
in the manufacture of potato spirit suffer from headache
and general nervous indisposition, unless very eflicient
ventilation is provided. Fusel oil is essential, it would
appear, in the formation of certain aromatic ethers which
give to spirits their characteristic flavour and aroma, and,
in spite of the many modes of accomplishing this change
artificially in a short time, it would be exacting, surely, to
expect results as good as those obtained when a spirit is
allowed to mature by ageing. Meantime the additional
evidence which is to be heard and the decision of tho Select
Committee will be awaited with interest.
REOPENING OF THE LIVERPOOL LOCK
HOSPITAL.
The Liverpool Look Hospital, which, though a detached
and separate building, is a part of the Royal Infirmaiy,
was erected in 1833. Originally it was intended to hold
seventy-two beds, all on the ground floor, but for many
years past the accommodation was fifty beds, twenty-five for
each sex. During the rebuilding of the new infirmary it was
used as temporary medical wards, and some dilliculty was
experienced in its reopening for its original purpose. It
was built to receive the patients formerly admitted into the
lock wards of the infirmary, thus securing at the same
time the enlargement of the infirmary proper, the more
perfect separation of this class of patients, and their treat¬
ment by two surgeons appointed for the purpose. For
upwards of fifty years it has done a very useful work, since,
as may be judged, there must always be in a large seaport
like Liverpool many cases necessitating treatment in such
a hospital. We learn that the difficulty iu the way of its
reopening has been overcome, and that the hospital is to
be reopened at an early date.
THE SOURCE OF ALBUMINURIA.
Du. W. H. Porter, in a paper on the Source and Signi¬
ficance of Albumen in the Urino,^ sums up as follows:—
I. That the albumen found in the urine, excepting that
which occurs in the early stages of an acute exudative or
diffuse nephritis, is a derived albumen, and not serum
albumen. 2. In the early stage of an acute exudative or
diffuse nephritis the albumen comes directly from the blood¬
vessels, due to the inflammatory alteration in their walls,
and is of the serum albumen type. 3. That later in acute
exudative or diflase nephritis, when the vascular walls
have partially recovered from the primary inflammatory
damage, the albumen becomes more abundant in quantity,
bub now it is of the derived albumen type, and has been
) The Poafc Graduate, Jan. 18£H.
Dic!...ied by' lOO^Ic
The Lancet,]
BATHS IN CASUAL WARDS.
[Feb, 14,1891. 383
excreted by the damaged epithelial cells lioicg the urini-
ferous tubules. 4. That ia all conditions, excepting the
acute exudative or diffuse nephritis, where albumen is found
in the urine, it is due to changes in the epithelium, by
which it is unable to do the work properly and excrete, or
allows a derived form of albumen to pass through into the
urine. 5. That the quantity of albumen contained in the
urine is always in direct proportion to the amount of
retrograde change in the epithelial colls. 6. That this
retrograde cliange in the epithelial cells is secondary to an
impaired nutritive condition at large, together with an
overworked state of the renal cells, without a compensatory
nutrition being sustained. 7. Viewed in this light, if we
direct our treatment to improving the general nutrition of
tbe system, and at the same time decrease the amount of
work to be accomplished by the kidneys, we shall see many
cases of complete recovery which must otherwise remain
cases of albuminuria. _
BATHS IN CASUAL WARDS.
The position of parish guardians with reference to the
homeless poor is not without its peculiar difficulties.
Charity, which is ever open to abuse, must especially in
their case equally shun indulgence and hardness; and it
would be remarkable if it did not err sometimes on one or
other side. As regards the matter of baths in casual
wards, which has lately created some discussion, it
cannot he said that the fault of authority has favoured
the bather. We read of several men in one hath at
the same time with a natural feeling of doubt whether
cleansing is, after all, the object of their immersion. If
it is, then an ordinary bath is quite inadequate for
the purpose. In so far it may succeed as to transfer the
responsibility for dirt from one pair of shoulders to another,
and with it the germ-carriers of disease, which form a part
of its imparity. As for ablution the term is, under the
circumstances, evidently out of place in a rational descrip¬
tion. We may, therefore, without any abuse of charity,
express a hope that more care may be taken in our work-
houses to provide clean water for dirty inmates, and, if
possible, even for separate individuals. The purpose to be
attained is worth a reasonable expenditure of effort in the
renewal of water, and might even justify, if needful, an
additional hath or two, with cheap soap in sufficient
quantity.
DECORATIVE PAPER ILLUMINATION.
The growing tendency to make use of what we may call
decorative paper illumination was again the cause of a
somewhat serious fire in the Drill Hall, Cardiff, last Monday
week. The occasion, it will be remembered, was that of a
commemorative banquet given by Lord Bute. Floral paper
and Chinese lanterns were freely distributed among gas and
electric lights, and the immediate cause of much consequent
damage was the contact of a stray lantern with one of the
gas jets. But for the fact that the entertainment was of a
kind which does not usually attract the company of ladies,
we should probably hare had to add the loss of human life to a
serious amount of damage - sustained by the hall itself and
by a valuable collection of temporary furniture. Such an
incident, occurring within a few weeks of the similar but
aggravated disaster at Wortley, may well suggest a doubt
in the most careless mind as to the propriety of thus freely
using in close conjunction such obvious incompatibles as
flame and tissue paper. This custom, however, is neither
new nor unusiial. In almost any house we may notice its pre¬
valence, and every drawing-room and dinner table have wit¬
nessed its common result in petty fires created by some neg¬
lected candle orlamp shade. Happily, thesearecomparatively
trivial,and have usuallyboen early noticed and extinguished.
At the same time they cannot fail to convey an uneasy
impression that much worse consequences might follow if
perchance a lighted shred were wafted towards some mualin
dress or curtain. There are, of course, degrees of risk in
proportion to the caution exercised in decorative arrange¬
ment, and we will not pretend that paper shades are
inevitably and culpably dangerous. Their employment,
however, must certainly weaken the guarantees of safety
and increase the need of vigilance on the part of those who
use them. As for the ordinary Chinese lantern, it scarcely
needs the hard lesson of experience to show that its fittest
place is out of doors. Even there perhaps it is not free
from objection.
POSITION OF “OFFICIERS DE SANT^."
The position of the French ojjicitr de santi must, we
should imagine, he sometimes an unpleasant one, as
his diploma does not give him the right to perform
operations without the presence of a doctor of medicine,
except in cases of great emergency where a doctor of
medicine cannot be found. A case has recently occurred
exemplifying this in the French courts of justice. A
certain ojficier de sant6, while attending a confinement,
found that there was an arm presentation. Of course,
he' ought to have obtained the assistance of a prac¬
titioner of higher standing than his own, but instead
of doing this he proceeded to pull upon the arm with
such effect that the limb finally came off in his hand.
Ultimately the services of a doctor of medicine were
obtained. On his arrival be promptly turned and delivered,
experiencing no difficulty in the operation. The next day
the woman died, and the ojjicier has been prosecuted for
causing her death as well as for contravention of the law,
which forbids ojficicrs to perform operations and to practise
outside the limits of the department for which their licence
holds good. The result was that several fines were in¬
flicted, and the offender was sentenced to three months’ im¬
prisonment for “ homicide by imprudence.” It is probable
that the last has not yet been heard of this affair, as the
prisoner has lodged an appeal to a higher court. It is,
however, tolerably evident that the position of ojfickr de
$a)iM is a most humiliating one, and that the present pro¬
posal to abolish that diploma has much to be said in its
favour.
VACCINATION AND PROFESSIONAL COURTESY.
De. Edmund Roihnson, the public vaccinator for Bir¬
mingham, sends us details of two cases which involve grave
want of professional courtesy. A year ago he vaccinated a
child, and not long afterwards he accidentally heard that an
inquest was to be held on the child, because its death had
been certified by another medical practitioner as duo to
syphilis from vaccination. The result was a verdict
showing that the certificate had no fodndation. Again,
Dr. Robinson this month finds a report in a local
paper as to a child whom he vaccinated some time hack,
and which, having been under the care of another medical
practitioner, is alleged to have died of erysipelas associated
with vaccination. The cause of death may, for all we know,
bo correct in this instance, and it is not this to which we
desire to draw attention. Bub we feel very strongly
tliat when a medical iwaccitioner is called in to attend
a child in connexion with its vaccination, which was
performed by another practitioner, his obvious duty is
to place himself at once in communication with his confikrc
who performed the operation; and it will be clear that no
breach of ordinary professional courtesy such as is here
indicated can possibly be justified because the case was one
of vaccination, instead of any other operation, or because
the medical practitiorrer who performed it happened to hold
a public office. It may be some satisfaction to Dr. Robinson
Digit
ized by
Google
384 ThbLancbt,]
THE FEVERS OF CHINA.
[Feb. 14,1891.
to knoiv that all euch cases as he refers to are being ioc(uired
into by the Medical Department of the Local Government
Board. ___
MR. GLADSTONE AND GROCERS’ LICENCES.
It is unsatisfactory to find, among the various devices
for abating drunkenness, so little attention by our public
men to the subject of grocers’ and confectioners’ licences.
Unfortunately, Mr. Gladstone is so occupied with other
Parliamentary matters that he has no time to undo, or
consider the undoing, of a system of licensing which does
very much indeed to favour secret drinking among women
in the better classes of society. He has excused himself of
late for this disastrous piece of legislation by saying that
he was advised in its favour by distinguished philanthropists
since deceased. This is a poor excuse. They are dead and
incapable of retrieving or conooting a great error. He has
the power, and with him lies the responsibility of doing so.
The furtive possession of drink in households should be
made, nob easier, but as difficult as possible. This is a
most binding duty at present resting on Mr. Gladstone.
THE FEVERS OF CHINA.
Dr. Coltman, writing in the China medical missionary
journal upon the fevers of China, remarks that but little
personal investigation on the subject has been made up to
the present time, owing to the comparatively recent advent
of foreign medical men, and to the want of confidence on
the part of the natives to submit for any lengthened period
to the treatment of a foreign physician, or in fact to any
one physician, their rule being to change doctors two or
three times a day if they can afford it. Again, there have
been but small hospital facilities for studying fevers, and
there is an impossibility of obtaining post-mortem examina-
tions. Dr. Coltman considers that small-pox is the most
common disease, nearly every person sulfering from it at
some period of his or her life. Vaccination, although prac¬
tised, is done very carelessly. Measles appears to be com¬
mon, but is somewhat milder than in Europe. Scarlet fever,
although it undoubtedly occurs amongst the natives, is far
less common than amongst Europeans. Erysipelas is rare.
Typhoid fever is very dilficulb to lUagnose in the short
time that a foreign medical man is allowed to attend a
cose; but Dr. Coltman thinks that when more accurate
reports are possible, this disease will be found to be more
common among the natives than is now supposed. Typhus
fever is met with all over North China, and as far south as
Shanghai. Relapsing fever is found constantly associated
with typhus. Dengue does not seem to be known amongst
natives. Cholera occurs as an epidemic every few years,
and U very fatal. Diphtheria is severe and frequently
fatal amongst the natives. Whooping-cough has occa¬
sionally been met with. Rheumatic fever is very prevalent
in some parts. Chronic muscular rheumatism is common
all over China, but is unattended by fever. Malarial
fevers appear to be common everywhere, though tlie pre¬
vailing type varies ; thus, tertian is most common in Pekin,
quartan in Foochow, Swatow, Shanghai, and Hangchow,
and remittent in Chefoo and Tientsin, In Cliinanfu Dr.
Coltman has never seen a case of quartan ague; it is all
intermittent of the tertian or quotidian type. The treat¬
ment, of course, of all malarial fever is by quinine or some
other cinchona bark alkaloid. In Hangchow the carbolic
acid and iodine treatment has been used successfully as a
prophylactic; arsenic is recognised as valuable in the chronic
form. _
FOREIGN UNIVERSITY INTELLIGENCE.
Kieff. —Dr. Heubel, Professor of Pharmacology, has been
made Emeritus Professor.
Moscow. —Dr. Babukhin^ Professor of Embryology and
Comparative Anatomy, has been made Emeritus Professor.
St. PeUrshtirg {Medical Academy). —Dr. Mendelsohn of
Warsaw is to be appointed docent iu Physiology.
Warsaio. —Dr. Dobroklonski of St. Petersburg has been
appointed Extraordinary Professor of Special Pathology
and Therapeutics. ____
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced;—
Dr. H. Cohen, of Hanover; Dr, Carl Goebel, docent in
Odontology in the University of Cracow; Dr. Bengelsdortf,
jjrivat-doeent in Medicine in the University of Greifswald.
The annual meeting of the Obstetrical Society of London
which was held on Feb. 4th was remarkable in several re¬
spects. Eighty-live persons were present, including eleven
visitors. "When the President, Dr. Galabin, began an obituary
notice of the late Dr. Matthews Duncan, in the course of his
annual address, the members present rose and remained
standing till the speaker had concluded his observations on
the life, work, and character of that eminent obstetrician.
Viscount Cranbrook, Lord President of the Council,
has consented to receive a deputation of members of the
medical profession at the Privy Council Office, Whitehall,
to-day (Friday), at 3 p.m., with a view to hearing the
expression of opinion which exists in the profession against
the Midwives’ Registration Bill. The deputation will be
introduced by the Attorney-General for Ireland.
Sir Sawyer has signified to the Council of
Queen’s College, Birmingham, his desire to resign the office
of Professor of Medicine at the College at the end of the
present session. Sir James Sawyer has held the chair since
1885, having previously occupied the post of Professor of
Pathology, _
Wii are requested to announce that the next meeting of
the Medical Society of London, on Monday, Feb. IGth, will
be a “ clinical evening ” for the demonstration of cases, and
that tlie adjourned discussion on Angina Pectoris will take
place at the following meeting on Feb. 23rd.
We learn that our announcement of the resignation of
Dr. Andrew of the post of Senior Physician to St. Bar¬
tholomew's Hospital, and consequently of the appointments
dependent thereupon, was premature.
On Wednesday, the 4th inst., Mr, Sydney Jones was
elected consulting surgeon to St. Thomas’s Hospital.
Proposed New Hospital District eor North
London. —The Local Government Board have, in pursuance
of the powers vested in them under the Public Health Act,
1875, issued a provisional order for the formation of a joint
hospital board for the districts of Edmonton, Enfield, South
Hornsey, and Tottenham. This order, which will be subject
to tlie approval of Parliament, and in opposition to which
four petitioners have lodged petitions, provides that the
joint board shall consist ot four ex-ojjicio and twelve elected
members ; the ex-ojjicio members being the chairmen of the
local boards of health for the districts named, and the elected
members being representatives from the sanitary authorities
of the sanie districts, the members assigned to each being—
five to Tottenham, three to Enfield, and two each to
Edmonton and South Hornsey. Thepurposcs forwhich this
united district is formed are stated in the order to be “ the
revision, maintenance, and management of a hospital or
ospitals for the reception of cases of infectious diseases for
the use of the inhabitant.? of the constituent districts.”
Dic::'iecl 1- LjOOglc
Tub Lancet,]
THfe lancet analytical SAillTAEY COMMlSStON.
CPbb. i4,18&1. 385
THE LANCET
^naljitiral Saiutitru Canimissw.
Results of tlie Miaroscopical and Chemical Analyses of the
Solids and Fluids consumed by all classes of the public.
BISCUITS 1 THEIR MANUFACTURE.
In reeuniing our Analytical Sanitary Commission on
Food, and especially the more common forms consumed
by the poorer classes, we may state that in the interval
which has elapsed since the last report the laboratories
have been entirely rebuilt and scientifically furnished with
every requisite,both chemically and histologically, necessary
for the elaborate investigations in which we are engaged.
We shall continue the work now from month to mon th and
as occasion may demand. We may mention, in order to
give some idea of the labour and care which this depart¬
ment entails, that the results which appear in the follow¬
ing article on Biscuits are founded on eighty-four actual
determinations successfully made by an expert staff, espe¬
cially and wholly engaged upon this important department of
The Lancet. The subject of the analysis of food has not
been neglected during the interim, as our results have been
published in a briefer form every month in our “Analytical
Records” column.
The manufacture of biscuits was at one time devoted
exclusively to the preparation of the particular kind known
as ship bread. Loaves of ordinary bread, by reason of the
fermenting principle which they contain become sooner or
later musty and unlit for food, and they are therefore ill
adapted for use on board ship, while the preparation of bread
at sea is found to be impracticable. The composition of
ship bread is of thesimplest kind. Flour is merely kneaded
into a past© with water, out into shape, docked, and then
well baked in an oven of special construction. Free from
ferment or leaven, the biscuits so prepared undergo very
little alteration during the time occupied by a more or less
extended voyage. The allowance of biscuit to each seaman
in the Royal Navy is one pound per diem, which is equal
to an average of six biscuits. The landsman can kuow
very little of the real value of this kind of biscuit, but to
the seaman it is the only form of bread which he has to rely
upon, it may be, for months together.
Of recent years an enormous industry baa developed in
the United Kingdom in connexion with the manufacture of
“fancy biscuits.” Many firms are now exclusively engaged
in this increasingly important branch, which in former times
was almost entirely managed on a necessarily small scale by
the pastry-cook and confectioner. Some idea of the extent
of til© manufacture of fancy biscuits may be gathered when
the almost innumerable varieties which are made are con-
fcideied. In the list of Messrs. Drew and Son, for example,
which is before us, we observe the names of no less than 144
different kinds.
The introduction of machinery has done more to
revolutionise the biscuit than the bread-baking trade.
There are still many bakers who make their bread in a
moat primitive and xinscientific manner. The ovens these
men employ are of the simplest construction, and, so far as
the consumption of fuel is concerned, about as wasteful as
the coal or wood merchant could well desire. The dough is
mixed by hand when it is not trodden down with the feet;
the Scotch bakers very much prefer bread made by dancing
on the dough. Formerly biscuits were also made by hand.
This explained the irregular qualities of such biscuits,
some being excellent, the others quite the reverse. Of
recent years a certain number of large breadoiiakiiig
factories have sprung into existence where machinery is
extensively used, but the whole of the biscuit trade is now
dependent on machinery. With a few rare exceptions,
biscuits made by hand could never find a market against the
machine-made 'biscuit. This is, from the public health
point of view, an important and beneficial change.
Machinery reduces the danger of contaniinabioii to a mini¬
mum, and ensures greater cleanliness and uniformity in the
quality of the a;'ticle produced. Also machinery requires
space, and could not be placed in the close, dark, un-
ventilated cellars and other unhealthy places where biscuits
used formerly to be manufactured.^ Thus the machine-made
biscuit is a much safer article of diet than the old-fashioned
biscuits that were mixed and shaped by hand. Of this our
Commissioners were able to convince themselves by a visit
to the works of Messrs. Drew and Son at Shadwell. Here
an enormous hbusiness is done, especially in supplying
hotels, public-houses, and ships with biscuits that are eaten
for hunger rather than as a sort of pastime. We therefore
determined to ascertain whether tne process of biscuit¬
making at Messrs. Drew’s factory was free from any danger
of contamination. An examination of the process from
the commencement to the end convinced our Commis¬
sioners of the great superiority over that adopted in an
ordinary bakery where the quartern loaf is produced. As
in the 'large bread factories, the ingredients—flour, lard,
butter, eggs, and milk'-are all brought to the upper
floor of the factory. Here they are mixed, and by
hoppers descend into the kneading machines, which are on
a lower floor. These machines replace the obnoxious hand
labour about which so much has been said. In large metallic
drums arms, like the propellers of a screw ship, beat
and stir the flour and the other ingredients till the dough is
thoroughly mixed. Then the door of the drum being
opened, the heaters in turning throw the dough out on to a
tray, so that it need not be touched by hand, and can be
conveyed to the next machine on the tray. This second
machine replaces the housewife’s familiar rolling-pin. It is
not unlike a mangling machine. The paste or dough passes
backwards and forwards between rollers till a smooth even
sheet of paste is produced. Now this has to be transferred
to a third machine, the cutting and panning machine which
cuts up the paste into the size and shape of the biscuits, and
stamps upon it the name of the lirm or some suitable
design. The biscuit now only requires to be baked, and as
the amount of baking necessary changes according to the
size and nature of the biscuit, no less than six different and
very large ovens are employed for this purpose. The trays
on which the paste, cut into the shape of biscuits, is placed
travel through the ovens at a rate varying from live to
twenty-five minutes. The heat registered in this journey
through the oven amounts to 400“F. By machinery the
whole works automatically. The biscuits are not touched
til! they reach the sorting and packing rooms. Here some
thirty to forty young women are actively at work neatly
placing the biscuits in boxes or tins. This packing room is
lofty, with pointed roof, and a good light streaming in frem
all sides. The lavatories were very clean and well arranged
at the time of our inspection.
The closets used by the men are well walled off from the
bakery and amply ventilated on to the stable yard; also
the bakery is abundantly supplied with fresh air. Some of
the loftier parts are not walled in, so that the open sky is
visible and the overheated air can always escape. _ Also
there is a Blackman’s air propeller, used to cool the biscuits
in summer time, but which likewise serves to stimulate
the general ventilation of the establishment. Altogether,
it may be said that the biscuits are made under very whole¬
some conditions, and the workers engaged at tins factoiy
have a plentiful supply of air and light. The water, it
should also be noted, is taken direct from the main, and is
not stored in tanks, an advantage that all sanitarians will
not fail to appreciate. Some of ihe paste used is in an almost
liquid condition, it has at most the consistence of treacle.
Even when in this condition it is dealt with by niacliinery.
A receiver is perforated on the lower side with round holes.
Pressure from above upon the receiver forces tlie paste
through these holes, from which it Hows in a thick cord¬
like stream. As it comes Ihrcmgli, a knife or divider glides
down the side of the receiver with the regularity or a clock
pendulum. With equal regularity there pass underneath
little tin pans, just in the very nick of time to receive each
piece of paste ns it oozes out from the receiver, and is cut
by the blade. The little tins now loaded travel onwards to
the oven, some perhaps receiving on the road a few currants,
which form a little black cap for the forthcoming cake. All
this works smoothly, automatically, and with marvelloua
precision. The good things that are thus made need not be
touched, they have only to be watched. Altogether, the
process demonstrated how much machinery can help to
render tbo nio.iuifD.ctviv6 of food both 6conoiuicEtI cmdclciinlyi
for, needless to say, the machine did in a few momenta
S86 The Lancet,5
THE LANCET ANALYTICAL SANITARY COMMISSION.
fpEh. 14,18D1.
what it woald take a good baker or cook, workiug with his
hands, many hours to accomplish. The rapidity of the pro¬
cess is in itself an important guarantee. Tlie quicker the
work is done, especially when the paste is in a moist condi¬
tion, the smaller becomes the risk of any accidental con¬
tamination.
The ingredients of fancy biscuits differ from those used
in the preparation of the plain ship biscuit only in that to
the flour and water are added butter, milk, eggs, and
various “flavourings," such as ginger, caraway, lemon,
orange water, cinnamon, &c.; and, though they are
characterised by difi'erences in form, appearance, and taste,
the greater number are practically made with the same
materials. The variation in the composition, either as the
result of a modified step in the process of cooking or in the
addition of other substances, is fairly indicated in the
following table of analyses which we have made of twelve
varieties of biscuits manufactured by Messrs. Drew and Son
Analyses of a sample of bread and flour have been
appended, so that any important change brought about in
the composition by the different jnethods of preparation
may be recognised at a glance. The numbers represent
parts per cent.
Albert. —The greatest amountof fat is, according to these
ansdyses, contained in the Albert biscuit, whilst the nitro¬
genous matter is, with the exception of the ginger nut,
lowest.
Arrowroot. —This biscuit is seen to contain a lower amount
of starch, and the soluble dextrin and sugar are pro¬
portionally increased. The fat approaches the common
average.
Bovril. —The chief point to be noticed in regard to the
bovril biscuit is the high amount of nitrogenous sub¬
stance (12-10 per cent.). This, like the name, implies the
presence of meat extract. The mineral matter is high from
the fact of its containing more phosphate, while the propor¬
tion of sugar is comparatively low.
Cornflour contains a large amount of cold water extrac¬
tives, dextrin and sugar. The fat is less than the average.
Microscopical examination coufirmB the presence of corn¬
flour.
Cracknel. —This excellent biscuit shows a marked dif¬
ference in composition. The amount of albuminoids, for
instance, is highest, being as much as 14-24 per cent. This
may be accounted for by the probable use of a larger
quantity of milk in its preparation. The ash is propor-
The Analyses of Vanous Kinds of Biscuits, showing the chief Variations in their Composition.
Designation.
Starch.
•Cold water extractives.
Albuminoids,
N X 0-83.
Fat.
Slhieral
matter.
Moisture,
Dextrin.
Sugar.
1. Abernathy .
CK-00
3-10
9'30
ID-OO
6-60
1-21)
2-34
2. Albeit ... .. .. „
04-81)
3-H5
38"2r.
B-20
2-60
3. Armwroot .
(1-2-11
2-'W
14 20
8'i)0
6-04
4. Uovril .
no 06
2-7-2
2-7S
la’io
0 60
1-16
4-8()
r>. Corn^our
01-76
H-.'-.'i
UI20
0 Cracknel .. , ..
12-00
2-«n
H-24
4-01)
0-()2
10--2O
'l. Digestive .
01-67
6-10
11-40
11-67
f.-rio
1-04
8-12
s. Ginger nut .
i(8-|)4
1'71
■12-70
0-0»
4-20
1-64
4-12
0. Marie.
lO'OO
11C40
8-72
0-74
I'l. Milk.
73-00
•2 80
3-00
0-44,
0-10
0'72
4-04
11. Osborne .
0:i-28
2 00
10 20
10-82
6'2I)
0'0(>
2-(U
1-L Water .
7(1-03
8'(10
2-70
11-30
1-00
1-2(1
4'()‘2
Wheat Hour .
00 00
2-76
0-71
12-01)
1-22
0-78
12-00
New bread .
twithdoxti'in /
8-1)8
7-76
0-12
0-81
42-03
„ ,, dried ... ..
78-12
0-87
1830
0-22
1-40
—
Thedifference between thecompositionof a biscuit and that
of flour consists in thegreaterquanbity of sugar and fab in the
former article and the important formation in it of soluble
dextrii^ and not improbably sugar from the heating of the
flour. The granules of starch, as indicated by the microscope
are, moreover, set free from their cellulose envelope, and some
of it is then no doubt rendered soluble by the same physical
agency. The albuminoids of flour are albumen, gluten,
mucin, fibrin, and the important substance cerealin, which
corresponds in its action upon starch to the diastase of malt.
In bread, and also in biscuits, the albumen and gluten are
coagulated, and their solubility is consequently greatly
diminished, although their value as llesh-formine substances
does not appear on this account to be affected. New bread in
its composition differs from biscuit chiefly in the large amount
of moisture it contains, and of course in the fat and sugar,
which in the biscuit are for the most part added ingredients.
The mineral matter, with one or two exceptions, where
common salt is present in small quantity, consists almost
entirely of soluble phosphate, to which is assigned bone-
forming value. Good biscuits are known by a delicate
crispness, a fresh wlieaten smell on fracture, a good flavour,
and an absence of excess of luoiabure. The biscuits examined
were in all these respects satisfactory—results which can
only be attained when the finest flour is employed in their
manufacture. This was further borne out by microscopical
and chemical examination. It may be remarked that,
although “fancy biscuits” do not enter largely into ordinary
diet, yet for many purposes they afford a convenient and
valuable form of food, containing, as appears from these
analyses, ail the elements necessary for the nutrition of
the body. The points of interest attaching to each kind of
biscuit may, in fine, be briefly indicated below.
Aberneihy. —This biscuit is characterised mainly by the
presence of caraway seeds, and probably on this account the
mineral matter is comparatively high. Fat, most likely in
the form of butter, has of course been added, flour contain¬
ing not more than 1 -22 per cent.
tionally higher from the increased quantity of phosphate,
and the moisture is well above the average—a point curious
to note, as the cracknel is commonly credited as a biscuit
which is more than ordinarily dry to the taste, and the
biscuit under examination was no exception to this rule.
The microscope showed considerable distortion of the starch
granules, and the dextrin is particularly high.
Digestive. —Microscopical examination showed the pre¬
sence of a goodly proportion of husk, and on this fact claim
to the title “digestive” is probably made. The nitrogenous
matter, it follows, is therefore high, and the amount of
mineral matter proportionately increased. This biscuit, in
particular, testifies to the general excellence of the manu¬
facture.
Ginger met. —The analysis of this popular biscuit cor¬
roborates the idea of the composition which is suggested by
the taste. Thus it contains the highest proportion of sugar
(44’50 per cent.). The ash is accordingly increased, whilst
the albuminoids and starch are diminished.
Marie.~ThQ high proportion of dextrin in this biscuit is
worthy of remark.
Milk. —Milk biscuit contains a larger proportion of
starch, and the sugar and dextrin are low.
Osborne. —Like “ Marie,” this biscuit gives figures which
may be regarded as average results.
Water. —From the fact tliat the amount of fat and sugar in
this biscuit approximates to that contained in flour, it most
probably consists of the sin)ple materials which are used in
the preparation of ship bread.
The Librauy of the Eoyai. College of
SuKOEON.s.— The library of the Royal College of Surgeons
will be closed on Friday, Saturday, and Monday, the ISth,
14th, and IGth of this month. Should a reader, however,
desire to work there on any or all of those days, he can do
so by furnishing the librarian, before the 13bh, with the
names of the books which he wishes to see.
Digitized by
Google
The Lancet,]
PHARMACOLOGY AND THERAPEUTICS.
[PEb. 14, 1891. 387
FERRIC BROMIDE.
Dr. Hecquet, formerly physician to the Abbeville Hos¬
pital, very strongly recommencla the perbromide of iron or
ferric bromide in many affections in which it is desirable to
soothe without depressing and to strengthen without
exciting. Out of twenty-five cases of spermatorrhoea
treated by this drug nineteen were completely cured, two
only being unrelieved, and in these cases complications
were present in the form of prostatic enlargement and
stricture of long standing. The perbromide was frequently
found useful in cases of chloro-anccmia, leucurrhoca,
hysteria, araenorrhoja, hydrmmia of pregnancy, chorea,
epilepsy, diabetes, and tuberculosis. In conjunction with
Dr. Vacossin a series of trials were made in the Abbeville
Hospital on its action in cases of cardiac hypertrophy,
with the result that Magendie’s observations, made
more than fifty years ago, were confirmed, the patients
being strengthened and relieved by the calming of the
palpitation and of the dyspncca. This combination is well
borne, even by irritable stomachs. It may be taken in solu¬
tion, or in lozenges, the dose being from three to five grains.
The action is more rapid than that of most iron compounds,
as its good effects begin to manifest themselves in cases of
chlorosis during the first week of administration, a com¬
plete cure being generally obtained in a month. Dr.
Hecquet has found by experience that the ferric salt
FegBr,, acts both more rapidly and gives more permanent
results than the ferrous salt FeBi'j, and hence he has latterly
confined himself to prescribing the fomier, which he does
nob hesitate to say is endowed with exceptionally valuable
properties, and deserves to be far better known and more
employed than it has hitherto been. There is a preparation
of the ferrous salt in the Pharmacopoeia of the British
Pharmaceutical Conference, which, however, is not very
largely prescribed. No preparation of the ferric salt seems
to be known in this country.
chloral as a coagulant.
Though hydrate of chloral is generally used in medicine
it is not without its advantages in surgery. According to
Dr. Marc S 60 it possess the property of coagulating blood
and serous fluids, and may be made to replace the iodine
solution generally injected into hydroceles. He himself
has treated 200 hydroceles with chloral without the occur¬
rence of any accident. He employs for this purpose a
10 per cent, solution, an ounce of which is injected all at
once, or very slowly, into the sac. Two or three days after¬
wards a large effusion of fluid into the tunica takes place,
but is soon entirely reabsorbed. Where the hydrocele wall
is much thickened injections of chloral, or, indeed, of any
kind, are useless, and recourse must be had to free in¬
cision. The chloral solution above referred to may be
repeatedly injected, with advantage, into the neighbour¬
hood of varicose veins, as it causes the blood gradually to
coagulate, and the veins to contract. Some trials have also
been made with chloral as an injection into vascular
tumours, but hardly sufficient to warrant any definite
report.
IlYl’NAL.
This now hypnotic—a compound of chloral hydrate and
antipyrin—introduced in France by Blainvillo, has had con¬
siderable trial on the Continent, and the opinion of those
who have used it is that it is an efficient sedative, that it is
less depressing and more soporific than chloral, and that it
has the advantage over both chloral and antipyi'in of being
tasteless. In the New York Medical Eecord i)r. Mattison
relates his experience of the drug in sixteen cases. The
patients had all been thesubjocts of the opium habit in some
rorm. Ten out of the sixteen cases were successfully treated
by it—i.e., each patient after his dose obtained from four to
six hours’ sleep ; in two the success was partial, sleep being
limited or delayed, while in four it completely failed to
produce sleep, and in some gave rise to increased restlessness.
It was given in doses of from fifteen to sixty minims by the
mouth, double that quantity by the bowel, while fifteen
minims were the hypodermic dose. In administering by the
mouth it is advisable to give it with twice the quantity of
alcohol, while it can be given pure by hypodermic injection.
No inconvenience was found to attend its administration.
It had apparently no effect on the heart or lungs, and it never
produced relief from pam without sleep. As has been
remarked in some cases in which it was unsuccessfully
tried, it gave rise to an increased restlessness, which, how¬
ever, was easily combated by cbloralamide.
IODIDE OP IRON IN LEAD POISONING.
It is stated by M. Lavrand in a Lille medical journal
that he has found iodide of iron in the form of pills, as
prescribed in the French Codex, very efficacious in treating
the lead poisoning which occurs amongst workmen employed
in white-lead manufactories. Sometimes he gives the iodide
of iron by itself, at others he combines with it phosphide
of zinc. Under this treatment workmen who had already
commenced to show signs of lead poisoning were enabled
to continue their occupation; their general health also
improved, and the amount of hccmoglobin increased.
INTERNATIONAL CONGRESS OF HYGIENE
AND DEMOGRAPHY.
This Congress, which is to meet in London in August
next, is assuming proportions commensurate with the im¬
portance of the subject and the great city in which it is to
be held.
The organisation of the Sections is now almost completed,
and the list of presidents and secretaries which has been
issued is calculated to enhance the success of the Congress.
Over the important section of Preventive Medicine Sir
Joseph Fayrer will preside, and doubtless his wide experi¬
ence in India and at home and his known ability as a
linguist will tend to give this section a wide and practical
basis. Dr. Seaton, Dr. Isambard Owen, and Dr. Sidney
Martin will act as secretaries to this Section.
When we say that Sir Joseph Lister is President of the.
Section of Bacteriology, and that he has for secretaries men
of such tried ability as Dr. Armand Rulfer, Dr. William
Hunter, and Mr. Sherrington, the profession may feel
assured that this important subject will meet with full
j ustice.
The Diseases of Animals in relation to those of Man is
the subject to which Section 3 is devoted. Sir Nigel Kings-
cote, one of the staunchest supporters of the Royal Agri¬
cultural Society, is to act as president, and Professor Brown
and Dr. Klein have been nominated vice-presidents; while
Dr. Sims Woodhead, Mr. Duguid, and Mr. Ernest Clarke,
the secretary of the-Royal Agricultural Society, will serve
as secretaries.
The section devoted to Infancy and Childhood will be
presided over by the Chairman of the London School Board,
Mr. J. K. Diggle; while the secretaries are Dr. Warner,
Dr. Pasteur, Dr. Wethered, and Mr. T. A. Spalding.
Naval and Military Hygiene, a subject of prime import¬
ance, will be presided over by Lord \Yantage, a nobleman
whose experience with the regular army, the volunteers,
and the St. John Ambulance Society, coupled with his
well-known philanthropic tendencies, gives him a singular
claim to such a position. The Dicectors-Ceneral of the
Medical Department of the Army and the Navy, Sir Lothian
Nicholson, Surgeon-General Marston, and Professor Notter
will act as vice-presidents. There are four secretaries to
this Section — Fleet-Surgeon Macdonnel for the Navy,
Brigade-Surgeon Hector for the Army, Dr. Colliugridge, the
medical officer of health for the Port of I^iondon, to represent
the mercantile navy, and Mr. John Furloy, to represent
the interests of ambulance work.
Lord Basing, a past President of the Local Government
Board, will preside over the Section of State Hygiene, and
associated with him are Sir Albert Rollit and Dr. Thorne
Thorne, with Mr. Lithiby, of the Local Government Board,
Dr. Louis Parkes, and Dr. Whitelegge as secretaries.
The Section of Cliemistry and Physics in relation to
Hygiene has for its President Sir 11. Roscoe, M.P.; that of
Architecture is presided over by Sir Arthur Blomlield ; and
that of Engineering by Sir John Coode, the President of
the Institute of Civil Engineers.
With such an organisation we cannot but regard the
success of the Congress as assured.
At the last meeting of the organising committee Dr. G.
V. Poore was nominated for the office of honorary secre¬
tary-general, while Professor Coriield was appointed
honorary secretary for foreign correspondence. This is as it
CoogliC
tJ'iiB. 14, l891j
§8 TiiE LAKCEl';i PllOPOSliD NEW GENEUAL MoSPtTAL IN BIRI^tiNGiiAM.
should be, for it is evident that a divided responsibility in
the organisation of a great gathering is impossible.
The Reception Committee, whioh is presided over by Sir
Spencer Wells, is making way with its arrangements for
the hospitable entertainment of the foreign and provincial
guests. The City have promised a reception at the Guild¬
hall, the medical oilicers of health are, we believe, meditat¬
ing a conversazione at South Kensington, the Zoological
Society have agreed to make members of the Congress free
of their gardens during the week of session, and Sir Spencer
Wells has, with his usual hospitality, offered to receive the
members at Hampstead on one of the afternoons. This is a
very promising beginning.
PROPOSED NEW GENERAL HOSPITAL IN
BIRMINGHAM.
A PUBLIC meeting at which most of the leading citizens
of Birmingham were present was held in the Town Hall
on tbo 29th ult., to consider the site in St. Mary’s-square
selected by the committee of the General Hospital for the
building of a new institution whudi is to replace the old
hospital in Summer-lane, now admittedly inadequate to the
requirements of the city, and unsuitable from a sanitary
point of view. The meeting was largely attended, and tlie
chair was taken by the Mayor (Alderman Clayton). They
had met, he said, to promote a noble object—the re¬
building of their old and much-loved General Hospital.
He referred bo the labours during fourteen years of Dr.
John Ash to erect a hospital for the sick and lame, and
how, in 1779, it was opened with only fourteen beds.
From this small beginning it had grown until it possessed
27.5 beds. In reference to the new hospital, he believed
the feeling in the town was this, that when the hos¬
pital was begun to be built it should be the best that
money could produce, and that £5000, £10,000, £15,000,
or £20,000 would if necessary be forthcoming to produce
that result. The Mayor pointed out that already nearly a
million and a half patients bad gone through that hospital
during the century and a quarter of its existence. He was
sure, now that this scheme was before them, Birmingham
would rise to the requirements of what was asked.
The Kiglit lion. Joseph Chamberlain then moved : “That
the present hospital is inadequate to the requirements of the
city on account of its sanitary arrangements, site, and
surroundings ; and that it is therefore desirable to rebuild
the hospital on the site in St. Mary’s-square approved of by
the governors.” He asked Birmingham to lind in the shape
of voluntary contributions a sum very little less than
£100,000. The town during the last thirty years had grown
in wealtli and population and in public spirit, and a" sense
of the duty of public munilicence, of which their ancestors
had no conception. A great sum had lieen subscribed, but
up to the present time the list of subscribers numbered only
320, out of a population of 450,000. Up to the present no
general appeal had been made, and he was quite sure that
the masses of the people would desire, when the proper time
came, to contribute their mite, although they might not
have cared to put it before the public when larger subscrip¬
tions were being announced. Tlie General Hospital has
' waited for its turn of renovation. He thought it had waited
too long. Now at last they had undertaken this task, let
them make amends for the delay by the perfection and the
thoroughness and tlie completeness of the work which they
were about to accomplish.
Dr. Wade, in seconding the resolution, pointed out the
prominent defects of the present hospital. There was no
ward for the seclusion of noisy patients, and in a ward where
there were twenty beds it was a very serious drawback to
have a patient crying or moaning night and day. The ordi¬
nary sanitary arrangements of the hospital were defective,
there was no ward for children, and there was want of
sufficient air space for the number of beds which the hos¬
pital contained. Tlie arrangements for the surgical depart¬
ment were also inadequate. It was important that the hos¬
pital should be arranged for medical study, because that had
a bearing not only on the present patient's, but on the well¬
being of patients in future years. The accommodation for
officers was insufficient, and that for the servants was worse.
Deficiencies of that kind could only be remedied by re¬
building the hospital. On the new site the hospital would
have a lung in the shape of three acres and a half of open
space in St. Mary’s-square, an advantage that would more
than outweigh many drawbacks. In was close to Corpora¬
tion-street, the great artery of the town, and from every
point of view it seemed the position in which to rebuild the
General Hospital.
Mr. Oliver Pemherton, in supporting the resolution,
maintained that tho present building was absolutely inca¬
pable of further alteration with advantage. During the
last forty years the governors must have expended some¬
thing like £50,000 in their endeavours to keep pace with
the demands of the age. The site proposed for the new
hospital seemed, in his judgment, to answer all the require¬
ments as to space and freedom from disagreeable surround¬
ings. Some true friends of the charity had pictured to
themselves rebuilding in the suburbs, but they had no right
to take the hospital from the midst of the veiy people who
required its daily and convenient use. On a well-drained
gravelly site, with the applications of science, to ensure the
healtli and comfort of the patients, it was possible to carry
on to its highest perfection a ho.spital in the midst of the
population who use it, equally as well as if it were placed
on the downs of Brighton. Mr. Pemberton next quoted
from a speech by Sir James Pagetf^ in which it was urged
that a great hospital should be in connexion with a medical
school in order best to fulfil its objects. “ Nowhere is that
union of service and charity more perfect, and nowhere does
it bear better fruit than in the combination of a thoroughly
scientific medical school with a thoroughly charitable hospi¬
tal.” Heconcluded: “Longas Ihaveaerved,! trustitniay be
my good fortune to serve yet a little longer—though the
senior member of your staff'—to aid in the accomplishment
of this great undertaking, And now let me express a hope
that the ‘New General Hospital’ that is to be shall create
the same amount of confidence, excite the same amount of
gratitude in the hearts of this great community, that the old
one has created and excited in its time and season; and that
the committee of management and the medical stall shall
be honoured and trusted in their future records as they have
ever been in the past history of their responsible and bene¬
ficent undertakings.”
Mr. J. C. Holder read a list of donations amounting to
£75,000. Of this tho Birmingham wholesale brewers had
subscribed £1.5,000. He excused himself from occupying
the audience with the whole of the list, but it was speedily
discovered that with apparently undue modesty he had
omitted to read the addendum of tho brewers’ donations, in
which he himself beaded the list with a donation of £5000.
In obedience to the command of the Mayor, Mr. Holder
completed his task amidst general plaudits.
Dr. R. ■\\'. Dale moved: “That the working classes of
Birmingham and the neighbourhood be requested to assist!
the underbaking in such manner as may seem to them most
desirable.” He said, time was when it was imagined
that the duty of supporting great charitable institutions
rested exclusively upon the more prosperous classes.
The working, classes were to receive the benefits of the
institutions; the richer people were to find the money for
maintaining them. Thirty or forty years ago, had such a
project as the present been before the town of Birmingham,
the Committee of the General Hospital would never have
dreamt of putting the resolution now moved into the pro¬
gramme of such a meeting; anyone who had predicted that
the working people of the city would raise £10,000 a year
for the support of the medical ebarities would have been
regarded as indulging in the wildest of prophecies. The
commencement of the change was evident when the new
wing was added to the Queen’s Hospital; the continued
success of the Hospital Saturday movement indicated how
far the change had extended. The great masses of the
working people had practically come forward and said,
“We have political power; on us in part depends the fate
of Ministries; our voice is potent for peace or war; we
have our share in the control of the destinies of this great
empire; we, too, are citizens, with duties and re8i)Onsibilitie9,
and we are prepared to discharge those duties.”
Councillor Ball seconded Hie resolution, and urged the
working men to do their utmost to help tho work. The
resolution was carried with enthusiasm.
The Right Hon. Lord Leigh moved: “That the General
Committee of the hospital, the Orchestral Committee, and
the visitors of the hospital, be appointed a committee to
J Tllli Lanckt, vol. ii. ISUO, p. 700.
Co ogle
Di:
Tub liANCJET,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Feb. 14,1891. 389
■caiTy out the objects of this nieetiag, with power to add to
their number, and that Mr. J. Jaffray he rec^uested to accept
the office of honorary treasurer, and Mr. W alter N. Fisher
that of honorary secretary,” which was seconded by Sir
Thomas Martineau, and carried.
The Rev. Canon Wilkinson moved a vote of thanks to
the Mayor for presiding, and expressed his deep joy that the
response to the appeal had been so generous. This was
carried, and the meeting terminated.
THE DEBATE ON KOCH’S REMEDY AT THE
BERLIN MEDICAL SOCIETY.
Tke subject of Koch’s remedy still continues to be dis-
-cussed at the Berlin Medical Society every week, the pro¬
ceedings on Feb. Tth^ being as follows:—
Professor VlBCllOW exhibited the lungs from a case
treated at the Augusta Hospital with twelve injections
from Dec. 4bh to Jan. 12ch. In each lung, especially the
^eft, were circumscribed areas of dense pigmented carnifica-
tion, intersected by whitish bands of “dissecting pneumonia”
<or spaces filled with pus and caseous material. But there
was no true caseous hepatisation. Another specimen, from a
patientwho had received thirtyinjeotions, illustrated the pas¬
sage into gangrene of acute “ smooth ” hepatisation. There
were large apical cavities, and recent as well as old pleurisy,
whilst the lower lobes showed areas of recent catarrhal
pneumonia already breaking down. There were numerous
healing ulcers in the colon. A third case was one of phthisis
complicated with syphilis and amyloid disease; only two
injections had been given. The phthisis was acute, aud
there was extensive cicatrisation of laryngeal ulceration.
Lastly, he exhibited specimens from a case of hip disease in
a child, aged three years and three-quarters. The head of
the femur had been recently excised, and prior to that
the child had had five injections. Death occurred from
acute miliary tuberculosis, tubercles being well seen in tlie
bone marrow. They also occurred in the lung, and the rare
<in child) complication of arytenoid perichonctiitis was pre¬
sent. Professor Virchow deprecated very strongly the state¬
ment that in many cases (especially the fatal ones) the
injections had been made on experimental grounds and with
no therapeutic aim.
Dr. P. Guttmann showed a case of inoculated tubercle
on the ring finger, in which tbe diagnostic reaction of
Koch’s fluid had been confirmed by microscopical examina¬
tion of excised portions. The “ wans ” were attributed to
inoculation of an abraded surface from a corpse which the
man (a hospital porter) was engaged in carrying. Under
tbe treatment they much diiDinishcd.
Dr. Grabower nad no doubt as to the supervention of
fresh miliary nodules in laryngeal cases under treatment, bub
he did nob think this serious ; it rather sbo wed that the treat¬
ment should be continued. In two cases, which he exhibited,
such nodules appeared without any pre^existing disease of
the larynx. He gave the details of these cases, both early
pulmonary phthisis with bacillary expectoration. In the
one laryngeal symptoms arose after the twenty-fourtli
injection, and examination showed swelling of the false
•cords and a profuse eruption of grey miliary tubercle.
These nodules soon became confluent;, bub entirely dis¬
appeared during the continuance of the injections. The
•other case was very similar, except that the nodules had
not been yet wholly removed. He had often noticed this
rapid subsidence of laryngeal tubercle after a few injections,
and without denying the possibility of infection by con¬
tiguity, he regarded their appearance as a direct indication
for persevering with the treatment.
Dr. Jolly, who resumed the debate on Professor B.
Praenkel’s paper, directed attention specially to the mental
disturbance excited by the fever caused by the injections in
•some cases, analogous to other febrile “psychoses.” He
mentioned two cases in Professor Leyden's wards, one a
man who bad pleurisy with effusion, and who had become
<iepresB6d mentally "by his long illness. The injections
i2 to 7‘5 mgr.) produced very notable febrile reaction (38'fl”
to 40“), during which ho always became dull and confused.
After live injections they were discontinued, and two days
later he began bo have delusions and was transferred to tiie
insane ward, where his (leliriuin continuetl to increase.
1 «ce Borliuer Klhi. Wochoiisciiv., Mo. (i.
However, these mental symptoms disappeared in a fort¬
night ; they were compared by Dr. Jolly to the delirium of
defervescence or post-febrile delirium, nob infrequently seen.
The man was predisposed by his former depression, and
by the excitement attending the hope^ of cure by the new
remedy. The other patient was in an early stage of phthisis
bub very wasted, and much enfeebled mentally as well as
physically. Although very little fever followed the injec¬
tions there was severe headache on each occasion, so that
after four had been given they were remitted for a time.
Then they were again used, and he received fifteen more,
always sufTering severely from pains in the head. He
also lost weight. He then lapsed into a state of melan¬
cholia with marked delusions. Mention was also made
of a hysterical subject who became markedly delirious
after each of three injections she received ; she had been very
delirious previously during the hectic fever of the phthisis
from which she suffered. Although such symptoms might
arise only in a minority and were seldom permanent, yet
occasionally (in predisposed subjects) they initiated an in¬
curable disorder. Hence the need to proceed very care¬
fully with injections in such subjects,
Dr. Henoch spoke unfavourably of the treatment in
pulmonary tuberculosis of children, of whom he had
treated twenty by this method. Three of these were in the
“advanced” stage, but without fever; they were all made
much wor.-e, the rever induced by the injections persisting
ashectic. Yebonly^mgr. (at first he only gave iV mgr.) waa
iveii at tbe commencement of treatment, and the largest
ose was 3 mgr. In one case there was temporary improve¬
ment, dulness disappearing, only, however, to return with
increase of obh«“r signs on continuance of the injections.
Another case illustrated Professor Virchow’s statements!
A girl eleven years old, whose mother had recently died
from phthisis, had suffered from a cough for a vear; W
there were hardly any physical signs, except slight dulness
near spine of scapula, prolonged expiration, and some
rhonehuB at apices. An injection of i mgr. gave no reaction.
One of Imgr. produced next day arise of temperature to
38‘6°, and some rJlIes appeared at the left base. Five injec¬
tions in all were given, and a few days after the last, signs
of extensive consolidation of the left lung appeared; and
even after a month’s interval they had very slightly decreased.
Obviously it was not a mere transitory hypetiemia, bub
whether caseous or catarrhal hepatisation could not be deter¬
mined. There was some suspicion of commencing excava¬
tion, for tbe breathing, whioa was intensely bronchial, had
an occasional amphoric tone, and the rfiles were metallic.
Professor Henoch attributed this change without a doubt
to the injections. He said not one of his cases had been
“cured,” nob one “improved” except the one which subse¬
quently relapsed to a worse state; and he was embarrassed
to decide if be should continue the treatment in children
any longer. It would be ludicrous in the case of a child to
follow the practice of some physicians who do nob use the
injections except at the patient’s own wish. Bearing in
mind the tendency for tubercle in children to be dispersed
in many foci throughout the body, he felt one would be
justified in only using it with the greatest reserve, and
perhaps at no distant date in discontinuing the practice
altogether.
NOTE ON
ALDEPALMITIC ACID, THE RECENTLY DIS-
COVERED CHIEF COMPONENT OF THE
BUTTER OF THE COW.
By J. Alfred Wanklyn,
COuaKSFONUINQ iHKMllEU OF TIIU ROYAL DAV.YIUAN ACAOKMT OP
SClKNCIiS.
It has long been known that the acids arising from the
saponification of butter include small proportions of butyric,
caproic, caprylic, and rutic acids. Tlie larger proportion of
the aoicls has, up to the present time, been held to consist
of palmitic, oleic, and stearic acids, which are non-volatile
and insoluble in water. In the course of investigations
with which I have beeu engaged for a nximber of years I
have arrived at the very unexpected result that the main
acid is not palmitic acid, but an acid quite distinct from
palmitic acid, both in composition and properties. On the
19lh ult. I had the honour of reading a paper on the
390 Thb Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Feb. 14, 1891.
subject before tbe Society of Chemical Industry, aud in
due time the details will doubtless be published. In the
meantime it may be of interest to mention that the new
acid, which is so abundant as to amount to about half of
the weight of the dry butter, differs from palmitic acid by
containiug less hydrogen, and that its formmais(Ci(|H 3 u 02 )n.
The melting point of tbe new acid is about 50° 0., wneieas
palmitic acid melts at 62° C. Tire new acid possesses the
extraordinary property of consolidating or gelatinising
alcohol. At temperatures below 5° C. it gelatinises more
than five times its weight of alcohol. Part of the alcohol is
held mechanically by a sponge-like action, and part is re¬
tained in chemical combination. Palmitic acid (as I have
ascertained by experiment) possesses no such property;
indeed, so far as I know, no other substance resembles my
new acid in this particular.
MEDICAL TRIAL.
■ Charge of Breach of the Infectious Diseases
(Notification) act.
At the Bolton County Police-court, on Monday, a case
of interest to the medical profession was heard, Dr. Gil¬
christ, a local practitioner, being summoned at the in¬
stance of the Bolton Rural Sanitary Authority for an
alleged breach of the provisions of tbe Infectious Diseases
Notification Act, 1889. The case for the prosecution was
in effect chat the defendant failed to notify a case of
typhoid fever in a young girl until after a knowledge that
she had so suil'ered for about a fortnight, and evidence to
this effect was given by the mother of the child and Mr.
Barr, tbe medical officer of liealth for the local autho¬
rity. The latter stated that when he received the
notification from Dr. Gilchrist he visited the house, and
found the child in a convalescent state, this being borne
out by the testing of the temperature and the pulsalion, botli
of which he found to be normal. Mr. J. M. Rutter, for the
defence, submitted that Dr. Gilchrist had always shown
himself willing to assist the local authority, and conformed
with the requirements of tbe Act as soon as he bad accu¬
rately diagnosed the case. I^urtber, he said that typhoid
fever might go on for even six weeks without a medical
man being able to certify, and he called evidence in support
of that statement. Mr. Win. Court, L F.P.S G., said it
might be possible to diagnose a case of enteric fever in four
days, or it might never be ascertained at all. He bad attended
patients for four weeks before he was able to tell whether it
was a case of enteric fever. Dr. Panton stated that cases
of typhoid fever were exceedingly difficult to diagnose. In
many cases three or four weeks elapsed before they could
form an opinion on which they could certify. It was much
more difficult in the case of children than grown-up persons.
The Beech were satisfied without further evidence, and
dismissed tbe case.
A similar case was withdrawn, but the clerk to the
Rural Sanitary Authority later on gave notioe of appeal.
VITAL STATISTICS.
health op ENGLISH TOWNS.
In twentv-eigbt of the largest English towns 6608 births
and 3803 rfeaths were registered during the week ending
Feb. 7tb. The annual rate of mortality in these towns,
which bad declined from 287 to 22-3 per 1000 in the pre¬
ceding five weeks, further fell last week to 19'8. The
rate was 19'1 in London and 20'4 in the twenty-seven pro¬
vincial towns. During the past live weeks of tbe
current quarter the death-rate in the twenty-eight towns
averaged 24'5 per 1000, and exceeded by 1-9 the mean rate
in the corresponding periods of tbe ten years 1881-90.
The lowest rates in these towns last week were 12 6
in Derby, 13'5 in Leicester, 14 7 in Hull, and 16'5 in
Salford; the highest rates were 24'5 in Portsmouth,
26‘9 in Blackburn, 30 2 in Plymouth, and 37'8 in Preston.
Tbe deaths referred to tbe principal zymotic diseases, which
had been 404 and 379 in the preceding two weeks, further
declined last week to .3-?2; they included 84 from whoop¬
ing-cough, 80 from measles, 58 from scarlet fever, 43 from
diphtheria, 37 from diarrhoea, 30 from “fever" (princi¬
pally enteric), and not one from emall-pox. No deaths
from any of these zymotic diseases were recorded in Derby,
Hull, or Cardiff, while they caused the highest rates in
Oldham, Blackburn, Preston, and Halifax. The greatest
mortality from measles occurred in Bristol, Oldham,
Preston, Halifax, and Blackburn ; from scarlet fever in
Bradford and Plymouth; and from whooping-cough in
Salford, Huddersfield, and Halifax. Tbe mortality from
“fever” showed no marked excess in any of the large
towns. The 43 deaths from diphtheria included 34 in
London and 3 in Manchester. No death from small¬
pox was registered in any of the twenty-eight towns,
and no small pox patients were under treatment eitlier
in tbe Metropolitan Asylum Hospitals or in the Highgate
Small-pox Hospital on Saturday last. The number of
scarlet fever patients in the Metropolitan Asylum
Hospitals and in tbe London Fever Hospital at the
end of the week was 1345, and showed a further decline
from recent weekly numbers; the patients admitted during
tbe week were 107, against 103 and 112 in the preceding
two weeks. The deaths referred to diseases of the re¬
spiratory organs in London, which had declined from 1018-
to 636 in the preceding three weeks, further fell last week
to 428, and were 91 below tbe corrected average. The causes
of 74, or 2 0 per cent., of the deaths in the twenty eighc
towns were not certified either by a registered medical'
practitioner or by a coroner. All the causes of death were
duly certified in Norwich, Birkenhead, Manchester, and
Cardiff. The largest proportions of uncertified deaths were
recorded in Bradford, Bolton, and Liverpool.
HEALTH OP SCOTCH TO'W'NS.
The annual rate of mortality in the eight Scotch towns,
which had been 24 9 and 26'4 per 1000 in the pre¬
ceding two weeks, declined again to 21-9 during the week
ending Feb. 7th, but exceeded by 21 the rate that pre¬
vailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns-
ranged from 97 in Greenock and 17'4 in Leith to 25 3^
in Glasgow and 25'8 in Paisley. The 574 deaths in these
eight towns showed a decline of 116 from the high number
in the preceding week, and included 17 which were referred
to whooping-cough, 12 to diphtheria, 9 to “fever,” 7 to-
diarrhoea, 6 to measles, 6 to scarlet fever, and not one to-
small-pox. In all, 57 deaths resulted from these prin¬
cipal zymotic diseases, against 76 and 65 In the pre¬
ceding two weeks. These 57 deaths were equal to
an annual rate of 2'2 per 1000, which exceeded by 0'5-
the mean rate last week from the same diseases in
the twenty-eight English towns. The fatal cases of
whooping-cough, which had increased in the previous
three weeks from 16 to 29. declined again last week
to 17, of which 9 occurred in Glasgow, 4 in Edinburgh, and
3 in Dundee. The deaths from diphtheria, which had been.
9 and 7 in the preceding two weeks, rose again to 12 last
week, and included 4 in Glasgow, 3 in Dundee, aud 2 in
Edinburgh. The 9 fatal cases of “fever” exceeded those
recorded in recent weeks ; 3 occurred in Edinburgli and 2 in.
Dundee. The deaths from scarlet fever, which had been.
18 and 10 in the preceding two weeks, further declined lasv.
week to G, all of which occurred in Glasgow. The 6 fatal-
cases of measles were within 2 of the number in the previous
week, and included 2 in Paisley. Tbe deaths refen'ed to
diseases of the respiratory organs in these towns, which
had declined from 228 to 207 in tbe preceding three weeks,
further fell last week to 161, and were slightly below
the number in the corresponding week of laat year. The
causes of 55, or nearly 10 percent., of the deaths in the
eight towns last week were not certified.
health of DUBLIN.
The death-rate in Dublin, which had been 38 4 and
32-6 Dsr 1000 in the preceding two weeks, further declined
to 2G’0 during the week ending Feb. 7th. During the-
first live weeks of the current quarter the death-rate in-
the city averaged 341 per 1000, the rate for the
same period being 25-0 in London and 21’0 in Edin¬
burgh. The 180 deaths in Dublin showed a decline of 41
from the number in the preceding week, and included
3 which resulted from different forms of “fever,” 2 from
whooping-cough, 1 from scarlet fever, 1 from diphtheria,
and not one either from small-pox or measles. Thus the
deaths referred to tbe principal zymotic diseases, which
Google
The Lancet,]
UNIVERSITY OF LONDON.
[Feb. 14, 1891. 391
liad declined in the previous four weeks from 16 to G,
were 7 last week; they wore equal to an annual rate of
1*0 per 1000, the rate from the same diseases being
1*5 in London and 2*1 in Edinburgh. The fatal cases of
“ fever,” which had been 5 and 4 in the preceding two
weeks, further declined to 3 last week. The 2 deaths
from whooping-cough exceeded those recorded in recent
weeks; and the fatal case of scarlet fever was the first
recorded in the city since the middle of December last.
The 180 deaths in Dublin last week included 33 of infants
under one year of age and 58 of persons aged upwards of
'Sixty years; the deaths both of infante and of elderly
persons showed a further decline from those recorded in
recent weeks. Three inquest cases and 3 deaths from
violence were registered ; and 41, or nearly a fourth, of
the deaths occurred in public institutions. The causes of
-26, or nearly 14 per cent., of the deaths in the city were
not certified.
UNIVERSITY OF LONDON.
REVISED SCHEME.
IN. B.— The clavaes are re-nv/inhered; to each elavxe is appended the
number of the coTrcspondin</ clause in the/oriiier draft.\
L—On.IECTS 01' INCOIU’OKATION.
1. The purposes of the incorporation of tlio University to be so deftnecl
as to include, in addition to the existing purposes, the promotion of
regular and liberal education throughout Her Majesty’.s dominions, and
.e.specially in the metropolis and its noighboitrbood. ( 1 .)
II.—CONSl'lTCTION, Ac.
2. The University tocou«ist of—(i.) Senate, (ii.) Convocation, (lit.) Con-
atitnont Colleges, (iv.) Faculties, (v.) Boards of Studies, with the Queen
as Visitor. (2.)
III.-.Sr.NATK.
Constitution of the Senate.
3. The Senate shall consist (in its final form) of the Chancellor and
fd Fellows to he appointed os follows(i.) The Cbancrllor and nine
Fellows to be nominated by the Ci'own. (ii.) The Chairman of Con¬
vocation (cx oj/iciu) and nine other Fellows to be elected by ConvociVtioii,
as follows: By the Graduates i u Arts, 2 ; by the Graduates in Science, 2 ;
By the Graduates in Medicine, 2 ; by the Graduates in l.aw, 2. In
rotation by (1) the Graduates m Art", and (2) the Graduates in Medi¬
cine, 1. Members of Convo''ation only to vote, and each member to lio
•entitled to vote in respect of each of the .said four subjects iu whicii he
holds a degree, (hi.) The President of University College, l.ondnn
(<’* oj/leio); the Principal of Iving’s College, London (ea: ojllcio) ; iiid four
•other Fellows, two to be elected by oacli of tlio.se Colleges, (iv.) The
Presidents of the Royal College of Phy.sicians of London and the Royal
College of Surgeons of linglaiid (ex offleio) ; and two other Fellows, one
to be elected by each of those Colleges, (v.) The President or Chairman
of each of tho lollowiiig bodies—viz.; Che Council of Legn.1 Education
ami the Incorporated Law Society (ex officio), (vi.) To bo elected by the
Principals or Chief Officers of the Provincial Constituent Colleges,
(vii ) To bo elected by the London Faculties as follows ; By the Faculty
of Arts, 3 ; by the Faculty of Science, 3; by the Faculty of Medicine, 6 ;
by the Faculty of Law. 1. (viii.) To be elected by the Provincial
Faculties acting conjointly.
lictirement of Hembcrs.
i. The Fellows, other than the existing Follows and Fellow.s ex o^fficin,
shall retire as follows:—In every year there sh.all retire one in each of
the following groups—(1) Fellows nominated by the Crown ; (2) Fellows
■elected by Convocation; (3) Fellows elected by University College;
(4) Fellows elected by King's College. The other elected l''uIlow3 shall
retire so a-s ultimately to give to uach of such Fellows a tliree-years’
tenure of office. The retirement of Follows shall follow iu each group
the rule of seniority, or, failing seniority, shall he determined by lot,
and any question as to the order of retirement shall be determined by
the Vice-Chancellor, whoso decision in writing shall be final. (10,11,
17,18.)
6. Any Follow, other than the existing Follows and Fellow.s ex officio,
who shall not have attended any meeting of the Senate or of a Com¬
mittee thereof during a consecutive period of two years, shall thereupon
retire. ( 10 .)
(i. Power to the Crown atid electing bodies to fill up casual vacaneioa
occurring by death, resignation, or otherwise ; but any person so
appointed shall retain his office so long only as the vacating Fellow
would have retained the same if no casual vacancy had occurred. ( 12 .)
7. Power to re-nomiuate and re-elect. (13.)
Te7nporar2i Prooisioiie.
S. The existing members of the Senate shill continue as at present,
<14.)
0. No new Fellow shall be nominated by the Crown mit’l the number
•of present Fellows appointed by the Crown not on the nomination of
Oonvocation has fallen below nine, and then only so as to bring the
number up to nine. (14.)
IO. No now Follow aliall be elected by Convocation until the number
•of present Fellows appointed by the Crown on the nomination of Con¬
vocation has fallen bolow nine, and then only so as to bring the
number up to nine. Until Convocation shall be in exevci.se of its
powers to elect tlie whole nine Convocation b’eHows, the election of
Follows shall be by the Graduates, as follow.s : -The first shall be
elected by Graduates in Arts, the second by Graduates in Laws, the
third by Graduates in .Science, and the fourth by Graduates in Medi¬
cine, and so on in .succession. (I •, Ifi.)
11. The power of all other bodies to elect Fellows and the power of
the Fellows ex officio to take their places as such ehall take effect at
once, or so soon as such bodies are constituted respectively. (1C.)
12. The Senate shall have pow^r to act, though not fully constituted.
Slandintf CoinmiUecs.
18. There shall be a Standing Committee of the Senate for the Facul¬
ties of Arts and Science in connexion with the London Constituent
Colleges in those Faculties. This Committee shall consist of the Pre¬
sident and Principal of University and King’s Colleges, of the Fellows
elected by these Colleges, of the six Fellows elected by the London
Faculties of Arts and Science, and of ten other Follows to be elected
by the Senate annually. The business of the Committee shall be to
promote the organisation, improvement, and extension of University
teaching in Arts and Science in and for London, including the esta¬
blishment of professorships and teachersliips in London, and to dis¬
charge sucli functions in relation to the said Constituent Colleges, and
the examination of students therefrom in Arts and Science, as the
Senate may from time to time delegate to them, (26.)
14. Tliero shall be a Standing Coremittee of the Senate for the
Faculties of Arts and Science in connexion with the Provincial Con-
atituont College.^, which shall discharge such functions in relation to
the Provincial Constituent Colleges and the examination of students
therefrom in Arts and Science, as the Senate may from time to time
delegate to them. (27.)
1.5. There shall be a Standing Committee of the Senate in relation to
the examinations in Arts ana Science other than the examinations
conducted under arrangements with the Constituent Colleges,
10. There shall be a Standing Committee of the Senate for the
Faculty of Medicine. Thi.s Committee shall consist of the Presidents
of the two Royal Colleges, the two Fellows elected by the saidColleges,
the five Fellows elected by the London Faculty of Medicine, and one
Fellow, holding a chair iu a Provincial Constituent College of Medi¬
cine, to be chosen by the Fellows elected by the Principals or Chief
Officers of the Provincial Constituent Colleges, and the Fellows elected
by the Provincial Faculties acting conjointly, and nine members to he
elected by the Senate. The business of the Committee shall be to dis¬
charge such functions in relation to the Medical Constituent Colleges
and the examination of students in Medicine as the Senate may from
time to time delegate to them. (27a.)
17. Tliere shall be a Standing Committee of the Senate for the
Faculty of Laws. This Comniittoe shall consist of the President or
Chairman of the Council of Legal ICilucatioii and of the Incorporated
Law Society respectively, of the Fellow elected by the London Faculty
of Laws, and of four other member.s to be elected by the Senate
annually. (27ii.)
18. The Chancellor and Vics Chancellor shall be ex officio members of
all standing Committees. (28 )
li). The Standing Committees shall in all respects be subject to the
control and direction of the Senate. (29.)
IV,— Convocation.
20. All pleidions by Convocation under this Scheme shall be con¬
ducted in such mannor as Convocation may from time to time de¬
termine. (31)
V. — Constituent Coluf-oes.
London Co}isliHie7it Colleges.
21. The Loivlon Constituent Collego.s shall he—In all the Faenlties :
University College, London ; King's Collogo, London. lathe Faculty
of Modicino: the Medical Schools of Chariiig-cross Bospitol, Guy's
Hospital, J.omlon Hospital, Middlesex Hospital, St. Bartholomew ',h
H ospital, St. George",s Hospital, St. Mary’.s Hospital, St. Thomas’s
Hospital, 'Wostniinstor Hospital, and the London School of Modicino
for Women. (33.)
22. There shall he doterminod by agreement between the Senate and
each Constituent College, or, failing agreement, by the decision of the
Lord President of the Council, the number and qualifications of the
Faculty or Faculties for the College,
23. I’ho .Smate shall have power from time to time to admit as
London Constituent Colleges such other Colleges, in or near London, as
( 1 ) give academical instniction upon a complete system and an adequate
scale iu all the Faculties, and prejiare, or are intended to prepare,
.students for degrees in the Universiiy, or (i) give instruction upon an
aduiinate scale in one or more, even though not in all, the Faculties, and
prepare, or are intenrUd to prepare, students for ilegroes in the Univer¬
sity ; but shall previously invito an expi'ossion of opinion from the
Board or Boards of Studies interosted. The Senate shall consider in
respect of every institution seeking admi.ssion the following points
(a) The character of the teaching and of the educational appliances.
(M The character of the foundation. (<0 The average ago of the
students, (if) Tile uuniher of students proceeding from the College to
the University, (e) Tlie relation of the College to any other Univer¬
sity. (32, 35.)
24. Oil the admission of a Constituent College the following matters
shall ho detenninod by the Senate—viz.: (a) The Faculty or Faculties
to which the College shall holoiig. (6) 'llie number and qualifications
of the Faculty or Faculties for the College.
25. The Senate shall have power, after consultation with the Board
or Boards of Studies interested,-(a) To increase or diminish the
nuinhorof the members of any Faculty or Fsciillies representing any
Constituent College. (5) To vemore any institution from being a Con»ti-
tuent College, subsequent to any aiipeal to Her Majesty in Council. (37.)
Prooineial Conslilvent Coi/r<7e»'.
20, The Provincial Constituent Colleges shall iu the first instance bo
such institutions .situated in ICnglaiid or \\'’alcs, but not in or near
I,nndon, as shall he determined hy the .Senate, having regard to the
conditions and matters contained in Clause 23, and the determination to
admit aiiv institution a.s a Provincial Constituent thillego shall include
the matters siiocilied in Clause 24. In the case of anv institution whose
chiim to admission as a Provincial Constituent College is not allowed
hy the Senate the detennination of the Senate shall bo subject to an
appeal to the Lord President of the Council, (37a.) - , , ,
27, The .Senate .shall have jiower lu-iviifter to admit as Provincial
C-.nstitmmt Colleges other institutions aituatod as described in
(ihiuse 2ti, and to romovo any institution from the number of Provincial
Onnstituont Colleges ; such powers to he exorcised under the like con¬
ditions and limitations as are contained in CUusss 23, 24, and 25 respec¬
tively. (37t>.)
392 The Lancet,]
“FAILURE OR CURE?”
[Feb. 14,1891.
Present affiliated Colleges.
28. The affiliation of Colleges to Che Uiiivewlty as now existing shall
ceaso. (88.)
Beeognised Medical ImtUutions.
20. Tho Institutions from which the Universify receives certifleatos
for degrees in Medicine shall vohiin their right of giving such cer-
tifleates, whether they ho or be not (Jonstituent Colleges. But the
Senate shall have power, after consxiltation with the Board of Studios
of the Faculty of Medicine, from time to lime to revise or to add to the
list of such itistitutions, and to determine in what branches of medical
education the certiScates of oach of the said institutions shall ho
received. (3D, 40.)
VI,— Facultirs.
London Factilties.
30. There shall be in connexion with the London Constituent Colleges
four Faculties—viz.: (i) Arts, (2) Science, (3) Medicine, (4) Iaws.
All dejjartmenta of knowledge in wliich examinations may he held by
the University, and which are not included in any other of the h’acultiea,
shall be included in the Faculty of Arts. (41,42.)
81. Each Faculty shail consist of the teachers of London Constituent
Colleges, as dotermined under the foregoing Clauses 22 and 24. (43.)
32. Tlve London Faculties shall elect members of the Senate, as pro¬
vided in Clause 3. (44.)
83. Each Faculty shall elect members of a Board of Studies. (44n.)
34. Tire chairman for the time being of the Board of Studies shall be
the cliairmon of the Faculty. (40.)
Protiinciai Faculties.
S.'S. There siiall be also in connexion witlr the Provincial Constituent
Colleges Faculties in all suiijecta in I'ospect of whicli sucii (^ollegos are
respectively admitted. Tho provisions of tho foregoing Clauses 30 to 31
shall apply to tho Provincial Faculties, substituting the word “Pro¬
vincial'* for the word “ London" in sucli clauses. (45a.)
VII.— Boards ok Studies.
London Boards n/ Studits.
36. There shall bo for tho London Faculties a Board of Studies in
each Faculty. (46.)
37. Each Board of Studies shall eonsiafc of—(o) Sucli a number of
members elected b^ the Faculty, being 4. 8, 12, or 16, as the Faculty
shall from time to time determine, (b) Two members of Convocation,
elected by the members of Convocation, who are Graduates in the
subject with which tho Board of Studies is conversant, (c) An examiner
in each subject in tlie Faculty in which examinations are for the time
lieing held in the Univor.Hity. (d) If the Board of Studios shall so think
fit, such person, whether members of tho University or not, eminent in
the subject of the Faculty, not exceeding two in number, as may be
from time to time elected by the Board (47.)
38. One-fourth of the members of the Board elected by the l''acuHy
shall retire each year. (48.)
3D. Any casual vacancy among tho member.s elected by tho Faculty
occurring by death, rosignation, or otherwise, shall bo .supplied by the
ineinbei's of the Board; but any person so appointed shall retain liia
office so long only as the vacating momber would have retained llie
same if no casual vacancy had occurred. (49)
40. The members of the Board elected by Convocation and the co¬
opted members shall retire every four years. ( 60 .)
41. Retiring membors of the Board rhall be to-oHgiblo. (51.)
42. The examiners in oach subject may, if more tlian ono. agree upon
one of themselves to be the member of the Board of studio.s. In case
tliey fail to agree, the oxaininor shall lie nominated by the Vice-
Chancellor in writing. {53.)
48. Each Board of Studios shall have the following powers and
duties(o) To elect a cliairman every year. (5) To con.sider and report
to the Senate upon any matter referred to it by the Senate, (c) To
represent to the Senate its opinion on any mattor connected with the
degrees and examinations and teaching of the subjects of its piiculty.
(d) To deliberate, if so requested, in conjunction with tho Senate or any
committee thereof. (54)
Provincial Boards of Studies.
44. There shall also be Boards of Studies for ths Provincial Faculties
80 far as constituted, and the provisions of the foregoing Clauses 87 to
43 shall apply to such Boards of Stuilies. But it shall bo in the power
of the Senate, if they see lit, to constitute a sepai'ate Board of Studies
for the Facilities belonging to any group of the Provincial Constituent
Colleges. (46.)
General.
45. Boards of Studies shall, if so from time to time reouested by the
Senate, and may, if they shall from time to time think it desiraide,
meet and act concurrently on particular subject-s. This provision shall
apply to meetings of the London and Provincial Boards of Studies, as
well as to tlie meetings between Boards of Studios in di/Iorent
Faculties. (56.)
VIII,— Matricui.ation and Deuuees.
MalricsUation and Degrees in Arts and Science.
40. The Senate shall have power to enter into an angements with tlie
Constituent Colleges in Arts and Science jointly, or any of them
sepaiutely, upon the following basis I. Tho approval by tho Senate
of syllabuses of courses of instruction proposeii to be given in tho
Colleges to c-andidates for Matriculation and for the Pass Examinations
for the degrees of B.A. and B.Sc. 2. Production of evidence savisfactory
to the Senate of diligent attendance at sucli (-'ollege locturcs, and for
such times as may from time to tiiiio be prescribed by the Senate.
8. Examinations of students, being candiiiates for Matriculation and
the Pa.ss lOxaiiiinatioiiB for tho degrees of B.A. and B.Sc., by a Collogo
professor or teacher in tho subject, or other person appointed by the
College, anil an examiner to be appointed by tho Senate, with power
to the Senate to make regulations or by-laws from time to time for
dealing with any cases in which the examiners may be unable to agree
upon their report. 4. The conloning of the degree on ttie foregoing
conditions. (56.)
Degrees in Medicine.
47. The Senate shall have power to enter into arrangements with tlie
Royal Colleges for conducting the examinations in Anatomy, Physio¬
logy, Medicine, Surgery, and Midwifery for the Pass M.B. degree by
a Board of Examiners, consisting of the examiners appointed by the
University, and examiners to bo appointed by the Royal Colleges, who
shall join in tho reports to the Senate on such examinations. 'J’he
examiners appointed by the University may bo called upon, if the
Senate so think Ht. to make in addition separate reports. Those
examinations iiiny, if so agreed on, be conducted in ooinbination with
examinations for the Royal Collogos. The arrangements for giving
effect to this clause shall be carried out under the direction of a com¬
mittee to bo appointed in equal numbers by the Standing Onmmitbeo-
fertile Faculty of Medicine and a committee to be appointed by the
two Royal Colleges. Such arrangements to be subject to the approvaf
of the Senate and of the two Royal Collogos. Thi? arrangBiiiont foi-
joiiib examination shall nob lessen or intertoro with tho duty of tho-
Senate to be satistlod as to the adequacy of the examinations in all
respects. (5D.)
48. Candidates for Degrees in the Faculty of Medicine to show that
they have passed through tho required courses of instruction in one oi-
more of tlie Constituent Colleges in that Faculty or of the recognised
Medical Institutions. (68.)
General.
40. With the exception of Examinations for Degrees in the Faculty of
Medicine and of Examinations to be hold under arrangements with
Colleges under the powers horoinboforo contained, candidates siiall bo
admitted to all examinations witliout regard to their place of educa¬
tion. (57.)
Honorary Degrees.
no. Power to bo given to the Senate, with the consent of the Chan¬
cellor and Vice-Chancellor, to confer Honorary Degrees. (60.)
IX.—Pnoi-'KSSOUS.
51. Power to hold real property, and to accept grants, gifts, devi.'ios,
and legacies for the purposes of tho University, including the establish¬
ment of ITofessorships and Lectureships, wiiethor attached or not to
any particular (Jollege, and tho fuvtliorance of regular and liberaH
education and of original vesoavch. (61.)
62. I'ower to the Senate in tho event of tho estalilishmont of Pro-
fossorship.s or I.ofturoships to .assign to the professors or lecturers i\
representation on the Faculties, (02.)
Cflrrtspitkitft.
“ Audi alteram partem.
“ FAILURE OR CURE ? ”
To the Editors of The Lancet.
Sms,—An important practical question is raised in a-
letter published on page 838 of your last uumber. The
profession has been led to believe that when the ovaries
and Fallopian tubes of a woman have been removed on-
account of symptoms supposed to be due to their diseased
condition, if she is not killed by the operation she will be
cured of her disease. Now we are told that hcematocele
may not improbably convert a cure into a failure. To quote-
the words in the letter I have just referred to: “ouch
hrematoceles interrupt the convalescence of such cases.
Everybody knows that who has had any experience of
them except Sir Spencer Wells.” I am free to confess that-
I never met with such an interruption to convalescence in
my own practice, and the confession of its frequency iix
Birmingham practice may, it is to be hoped, exert a salu¬
tary inlluence upon the threatened dangerous epidemic of
unnecessary mutilation. I have heard nothing from any
member of the committee appointed by the (.lymecological
Society to investigate the case which led to this correspon¬
dence ; but I shall be glad to reply to any question they may
ask, or introduce any one of them who may be selected by
his colleagues to the patient, who is still in’London. I may
also add that. I never spoke of the disease as a “neurotic ail¬
ment,” hut I do say that to call it a case of “ incurable pyo-
8alpinx”i3a8 absurd as to assert that I was answerable
for tho performance of the operation at Birmingham in;
1888 because a telegram is said to have been sent to some¬
body unnamed: “Wells has been communicated with,
and declines to advise.” I will only add that the publica¬
tion in the medical journals and in the Transactions of
the Gynaecological Society of tho supposed fact that
this lady had gonorrhoea some eighteen years before
the asserted jiyo-salpinx (although she had liad twf>
children anil one miscarriage in the interval, had enjoyed
seven years’ good health after part of her cervix uteri-
had been removed, had travelled abroad with enjoy¬
ment for several months after her second marriage in
February, 1888, and only after an accident in the
autumn in Scotland was unfortunately induced to -sub¬
mit to an operation in Birmingham, from which she has
never recovered, and for which we are told that I am
responsible because I “declined to advise”) is, in my
opinion, a disgraceful breach of professional confidence, lb
Di(.' z.cdbyC_iOOgIc
• The Lancet,]
INSURANCE ON THE LIVES OF PHYSICIANS.
[Feb. 14,1891. 393
is aggravated by the subsequent statement made at the
last meeting of the Society that the case bad been in the
law courts, and was a camo ciUbre. There is not a shadow
of truth in this cruel calumny. It never was in any law
court.
At page 294 of your current volume, it is stated in the
report of a lecture delivered at Glasgow that I, who may
be said to have been one of the earliest advocates of ex¬
ploratory incisions, discountenance them because a young
lady is said to have been brought to me in 1884 by her
medical attendant {who is not named), and that I then dis¬
couraged operation. The tumour I then found is said to
have increased afterwards, and to have been removed last
year. It is nob stated whether I saw the patient or nob
after 1884. If I knew the name of the surgeon who is said
to have brought her bo me, it is nob at all improbable that
the inaccuracy in the statements of the case brought before
the Gynmcological Society would be equalled in the state¬
ment of the case of this young lady; and that the whole
story, if not essentially fabulous, would still prove to be
exactly such a “truth which is half a truth,” as Tennyson
has stigmatised in immortal verse.
I am, Sirs, yours truly,
Upper Grosvenor-sti'oot, Fob. lOtli, 1801. T. Si’ENCEB WELLS.
*** This correspondence must now cease. We cannot
afford further space for the prolongation of this unfortunate
controversy.—E d. L.
INSURANCES ON THE LIVES OF
PHYSICIANS.
To the Editors of The Lancet.
Sirs,—S ome time ago Mr. James Chatham addressed a
letter to The Lancet, in which he showed that the mor¬
tality among medical men was far in excess of the expected
number, as calculated by the Actuaries’ Healthy Males
Table. He took hia data from the census returns’of 1861.
1871, and 1881. His conclusions I by no means desire to
call in question. They serve very pointedly to indicate in
a sufficiently telling manner the sacrifices, even of life
itself, which medical men are daily called upon to make,
and which they cheerfully make, for the welfare of their
fellow-men. But, from a life assurance point of view, it
appears to me that this method of calculating the value of
the life of a medical man is hardly a fair one ; for it must
be remembered that the mortality rate which Mr. Chatham
worked out is obtained from the deaths of all medical men
in the United Kingdom, at all ages, assured and non-assured.
Now, it is well known that many of these die quite young,
before they attain theaverage age at whichmedical men think
itnecessary to assure their lives,by reason of the peculiar risks
and hardships to which their calling subjects them. Further,
in common with all who desire to assure their lives, medical
men have to submit to a thorough medical examination,
and thus the unhealthy are excluded, and the company
assuring them has to deal with selected risks who will be
much more likely to fulfil their expectation of life than the
general body of medical men. To some extent this is
borne out by the investigation of the mortality statistics of
the Scottish Widows’ Fund and Life Assurance Society, on
which I am at present engaged. The period extends over
fourteen years, and the number of claims amounts to 5505.
Of these, 248 are made by the representatives of medical
men. (Under this heading I class physicians, surgeons, and
dentists.) The average age at which they assured their lives
■was thirty-five, and their average age at death was fifty-six
in round numbers. Their expectation, according to the
Actuaries’ Healthy'Males Table, was thirty-one years, and
of this they fulfilled, on the average, twenty-one years.
Now, the average duration of the whole 6505 -was only
20790 years, in round numbers twenty-one years ; and the
average age at death of the total number was 57'GJJ It
would thus appear that medical men are quite up to the
average of assured lives in fullilling their expectation of
life. A further examination brings out the fact that tliey
are a better class of lives than shopkeepers, engineers,
architects, teachers, artists, and much better than bakers,
butchers, masons, commercial travellers, clerks, and book¬
keepers. Mr. Chatham showed that the lives of medical
men, in the whole country, were shorter than those of coal¬
miners. But, from the example I have been able to adduce,
this does not seem to hold good for selected lives.
It may not be without interest to some of your readers to
learn what are the principal disorders by which medical
men are cut off. In common with other members of the
Society, a large percentage die of heart disease and diseasea
of the nervous system. But, as might almost have been
predicated, a large number succumb to pneumonia; nearly
double the number died of this disease as contrasted with
the other insurers. The same remark applies to enteric
fever and other zymotic diseases, while more than the
average come to an untimely end by violent or sudden
death. These causes are manifestly incidental to their
calling, and probably cannot be well guarded against. On
the other hand, it is curious to note that consumption claims
as its victims only about one-third of the. total average of
deaths from this cause, and no less than thirteen attained
the venerable average age of eighty-four, and were justifi¬
ably classed as dying of “old age.”
I am, Sire, yours faithfully,
Edinburgh, Feb. lOtli, 1301. CLAUD MUIRHEAD, M.D.
DR. KOCH’S FLUID.
To the. Editors of The Lancet.
Sirs, —In connexion with the action of Dr. Koch’s fluid
on lupus would you allow me to call attention to Dr.
Fehleisen’s experiments with pure cultivations of the micro¬
coccus of erysipelas on this disease, to which I have nob
noticed any reference in dUcuesions on the subject. The
iranslation of Dr. Fehleiaen’s paper appears in the Syden¬
ham Society’s volume, “ Micro-parasites in Disease,” pul)-
lished in 1886. On page 272 of this volume, speaking of
the curative effect of erysipelas, he says: “I shall also
omit the descriptions of its curative effect in chronic joint
affections and different forms of syphilis, although particu¬
larly in connexion with the latter many reliable accounts-
exist. The curative effects on lupus are, however, well
guaranteed by a number of trustworthy and experienced
observers, of whom I need only mention Helva.” Further
on, page 278, he gives the result of an inoculation in these
words: “ In order to exclude the objection that the cultiva¬
tion was defld, a fifth patient, a girl twenty-nine years old,
who was suffering from an extensive lupus of the face, was
at the same time inoculated with the rest of the same
cultivation. She had also recovered from erysipelas of the
face in Dec. 1881. The rigor appeared forty-seven houra
after inoculation, the temperature rose at once to39'5‘’C.
and reached the same day 40'!'’ C., and on Oct. 28th (i.e.,
four days after inoculation) it became normal. The dis-
turbance'of general health was in this case very marked.
The short duration of the attack may be accounted for by
the fact that the patient had had an attack of erysipelas of
the same place ten months previously. The lupus healed as
the result of the erysipelas with the exception of a few
nodules in the neighbourhood of the nostrils.” Dr. Febleisen’s-
paper and experiments open up many questions of deep
interest to the profession into which I shall not now enter.
In connexion with Dr. Koch’s fluid they raise the question
whether the action of this fluid on lupus (and possibly in
chronic joint affections) has any specific relation to the
tubercle bacillus from cultivations of which it is said to be
produced. I am, Sirs, yours truly,
Exeter, Fob. 3tli, ISOl. HenRY DAVY.
A PLEA FOR LIBERTY.
To the Editors o/The Lancet.
Sirs,— In the introduction to a collection of essays lately
published, and entitled “A Plea for Liberty,” Mr. Herbert-
Spencer says : “ The root of all well-ordered social action is
a sentiment of justice, which at once insists on personal free¬
dom, and is solicitous for the like freedom of others, and there¬
at present exists but a very inadequate amount of this senti¬
ment.”
In ancient Egypt, as Herodotus tells us (II. 84), the arf>
of healing was distributed into several departments, each
practitioner occupying himself with a single disorder, and no
more. This subdivision, maintained from generation to
generation, did, no doubt, for a time favour the attainment
of personal knowledge and skill, but, by persistently con¬
tracting the intellectual sympathies, and circumscribing the
range of observation, it ultimately defeated its own end.
There was, however, a more pernicious influence at
^ i Google
394 The Lancet,] TREATMENT OF DISEASE OF THE UTERINE APPENDAGES.
[Feb. 14, 1891.
work. Under the tyrannicRl sway of the priest-physicians,
every medical man was, according to Diodorus Siculus (1.82),
obliged to apply his remedies in conformity with rules laid
down in certain books deemed sacred. If his patient died he
was freed from blame, provided he had obser>'ed these rules,
but if he had not, he was tried for his life. With precept
and practice both penally prescribed, independent research
and free inquiry were impossible; and it is not surprising,
in spite of Homer’s praise of Egyptian physicians as “skilled
beyond all human kind,” that theoretic medicine made so
little progress.
Considering the temper and bearing of some of the so-
called leaders of our profession, and the tone of several of
the controversies that have of late been carried on in your
columns, can we say that the spirit which animated the
sacerdotal caste of ancient Egypt is yet extinct?
I am. Sirs, yours truly,
Feb. 7th, 1801. _ JOHN TWEEDY.
ON THE OPERATIVE TREATMENT OF DISEASE
OF THE UTERINE APPENDAGES.
To the Editors of The Lancet.
Sirs,—F ew things could be more personally distasteful
to me than to find myself differing strongly in opinion from
Dr. John Williams and Dr. Champneys. On this occasion,
however, I should be false to my convictions if I did not
express my dissent from their view. I deprecate as strongly
as they the removal of healthy ovaries, whether ill de¬
veloped or otherwise, simply for the relief of pain. The
question on which we differ is the proportion of cases of
actual disease of the appendages in which, “on ordinary
surgical principles,” operative interference is called for. 1
believe this proportion to be much larger than they seem
prepared to adntit. In a paper published five years ago' I
wrote as follows: “I have now for some time been con¬
vinced that surgical interference affords us the best, if not
the only, means at our disposal of relieving and curing a
large number of women who have hitherto drifted on from
year to year without sensible amelioration of their suffering,
and who have long been the opprobria of our gynrecological
oot-patientand consultingrooms.” This conviction,slowly
and reluctantly arrived at, increased experience has but
served to deepen. I hope before very long to bring before the
Obstetrical Society the evidence furnished by my own ca&es.
1 shall then be prepared to discuss the subject fully, and to
state the grounds on which my opinion and practice are
based. I am, Sirs, yours faithfully,
Brook-3treet, W., Feb. Oth, 1891. ChAS, J. CuLLINGWORTH.
To ike Editors o/The Lancet.
Sirs,—C ertain statements contained in the joint letter of
Drs. John Williams and Champneys in your issue of
Feb. 7th seem so widely at variance with the teaching of
other gynecologists that those who are still open to convic¬
tion, and desire to ascertain which creed is the true one,
must he excused if they venture to seek for fuller informa¬
tion than the letter gives. Is it permissible to ask the
authors of the letter to fulfil the same obligations to the
profession as tliey require from those who differ from them—
viz,, (1) to state the number of women seen during the
periods they refer to a little more exactly than by
“thousands,” and (2) the proportion of “tubal” cases
among them. Further, it would be highly valuable to
learn what proportion of cases of pyo-salpinx or suppurating
ovary, or of tubercula^ tula), or ovarian disease, has been
cured by patience? What is the average duration of such
cases when treated by patience? How longis pelvic suppu¬
ration to be left uninterfered with after diagnosis and
treated with patience? Is “patience” synonymous for
purely expectant treatment, or what is meant? “ Patience
and resignation will lighten every dilliculty,” but it is just
as true non est vivere sfd valere vita. Will the authors
formulate some more defioice and precise rules for yeneral
guidance as to when it is “imperative to operate,” when
advisable ? Such great advances have been made within the
last ten years in cerebral, renal, hepatic, and splenic surgery,
that one cannot help feeling that pelvic surgery also may
be improved by a fair and exhaustive discussion without
regara for aught but the best interests of humanity. Pluris
■est ocidatvs testis unus quam aiiriti decem. Five years ago
1 Brit. Med. Jour., Jan. 30tb, 1880.
I was prejudiced against tubal operations; since then, and
particularly within the last year or two. I have seen a con¬
siderable number of such operations. The result has been
that in practically every instance the pathological condition
has amply proved the absolute necessity for surgical
interference. I am, Sirs, yours truly,
arosvenor-streefc, W.. Fob. Oth, 1891. A. D. Leith NAPIBR.
To the Editors of The Lancet.
Sirs,—I n The Lancet of Jan. 17bh (p. 145) my own
opinions upon this subject will be found expressed in the
summary of my paper, which was read in conjunction with
Dr. William Duncan’s. The moral that I meant to draw
was more extreme than any included in the manifesto of
two distinguished London obstetricians' and in a letter
from a colleague.- Let readers of papers beware how they
advocate the removal of appendages for chronic inflamma¬
tion. Such is the warning note sounded by Drs. John
Williams and Champneys. Let readers of papers beware
how they advocate any active treatment of appendages
aftected with chronic inflammatory disease, say I. If an
experienced operator writes about “successful cases” of
oophorectomy—wliich means cases that have recovered from
the operation—only too many inexperienced men will bo
tempted to operate. We must beware, however, how we
deprecate operations, for, unless we express what we mean
very accurately, we may be misunderstood. I trust, Sirs,
that in my paper I made myself clear. In warning men
against abdominal section for the class of disease in
question we must, as a bounden duty, remind them
that unlimited “minor gynmcology” is yet more un¬
justifiable. For the inexperienced are easily dissuaded
Ji'om operating; unfortunately they are apt to think
that “minor” proceedings are safe and justifiable.
Dilatation of the cervix and scraping, valuable in pure
endometritis, are fascinating to the practitioner who
may dread to open the abdominal cavity. Nevertheless,
I know that “curettage ” may cause even worse results than
injudicious oophorectomy. In short, I fear, or rather I
know, that there is not only too much oophorectomy, but
also too much active treatment of chronic disease of the
appendages by the curette and other appliances. Not only
do I go further than the distinguished authors of the
manifesto, but I also go as far if not further than my
colleague. Mr. Meredith shows thathutfew oophorectomies
for chronic disease are performed at the Samaritan Free
Hospital, where there is much operating for the removal of
tumours. Dr. Cullingwortb, in reply to my colleague,^
remarks that at the Samaritan Hospital we receive an over¬
whelming proportion of abdominal tumours. On the other
hand, at the general hospitals “cases of pelvic inflamma¬
tion, due to or complicated by Fallopian tube disease, are ad¬
mitted (sic) in at least equal proportion with cases of ovarian
tumour.” Dr. Cullingwortb is labouring under a false im¬
pression, unless we dwell strongly on the word “admitted.”
The truth is that in the out-patient department of the Sama¬
ritan Hospital hardly a day goes by without cases of chronic
disease of the appendages applying for relief. On the other
band, many weeks often pass without a single case of true
ovarian tumour being seen. Mr. Meredith and myself have
had ample opportunities for gaining experience of chronic
disease of the appendages. We happen, however, to be in
accord with the authors of the manifesto. We might admit
many of these cases, until the number of oophorectomies
greatly exceeded the ovariotomies. We act otherwise,
however, as we find that many cases of chronic disease get
well when treated as out-patients. Some obstinate cases
recover when admitted into the physicians’ wards. There
remains a “submerged tenth,” as I may call it, where we
consider that the sufferings of the patient “call for surgical
procedures,” as the authors of the manifesto eay. My
opinion as to the conditions which justify operation is
expressed in my paper.—I am, Sire, yours faithfully,
Alban Doran.
Granville pla.ce, Portma-n-square, Fob. 9th, 1891.
To the Editors of The Lancet.
SiR.s,—Holding such strong opinions on the above subject
as apparently Drs. Williams and Champneys do, if we may
judge from their joint letter which appears in The Lancet
' The Lancet, Feb. 7th, p. 337.
2 Ibid , Jan. 31st. p. 278. » Ibid,, Fob. 7th, p. 338.
. ^ Google
Thb Lancbt,]
ERYSIPELAS AND TOTAL ABSTAINERS.
[Feb. 14, MOL 395-
of to-day, it must be a matter of surprise to the profession
generally, as well as to myself, that neither of tnem took
the trouble to attend and express those opinions either at
the debate held recently on Dr. Playfair’s paper at the
Obstetrical Society or at the Medical Society on the papers
of Mr. Doran and myself. Now, Sirs, it is clear that if
the views expressed in that letter be correct, all those who
operate, except on the rarest possible occasions, on the
diseases we are cousidering resort to a practice which is
(in your correspondents’ words) highly injurious to women
and to the profession. As these operations are performed
at several of the large London hospitals, as well as at
others throughout the United Kingdom by men who also
have thousands of patients pass through their hands, do
your correspondents mean to assert that the obstetric
physicians and the surgeons at those hospitals are less
anxious than they to promote the welfare of their patients
and to maintain the honour and dignity of the profession ?
It passes my understanding how anyone can cure or profess
to cure except by operation patients with their Fallopian
tubes full of pus or dilated with serum, or those in whom
after recurrent attacks of pelvic peritonitis the ovaries and
tubes are matted to the other pelvic organs by old adhesions,
or how the conditions just mentioned can alter (except for
the worse), even with years of rest and patience, which
most of the women sufforiDg in this manner are absolutely
unable to take. 1 feel certain that those who operate on
these cases, as well as tho^e who are witnesses of the
operations, are of the same opinion. The last sentence in
your correspondents’ letter reads thus: “In no other
department of .surgery is indammation of an organ con¬
sidered to justify its removal.” Can it be possible they are
so little cognisant of what goes on in the surgical world as
to be unaware that the hip- and knee-joints, for example,
.are being daily opened in cases of chronic inflammation in
order to remove the diseased parts, or that when, only a
few years back, Sir Joseph Lister advocated and practised
opening the latter joint anlisepticalJy a well-known
London surgeon threatened, in the event of a fatal case
occurring, that the distingaiahed operator might find
himself in the dock on a criminal charge ?
By all means hedge round these cases by some such rule
as that mentioned in my letter (which you publish to-day)
as being in force at the Middlesex Hospital, so that both
patient and operator may be thoroughly safeguarded ; but,
on the other hand, let us not be hampered in doing wbac
we conscientiously believe to be the best for our patients by
the statements of those who, on their own admission, have
practically no experience whatever of the operation in
question, and whose opinions cannot reasonably be expected
to carry greater weight than the opposite views of others
ossessing as wide—or wider—acquaintance with the
iseases of women. Doubtless, in years to come, your
correspondents and those with like views will change round,
but it is, to my mind, sad to contemplate the suflering
which must meanwhile be endured.
When I said at the Medical Society on the 17fc]i ult. that
the results in my abdominal section cases at the Waterloo-
road Hospital, before it was put in a good sanitary condition,
were so bad, I did not of course mean in any way to reflect
on the authorities, for immediately they were informed of
the condition existing they had the drainage completely
overhauled at great expense, with the result that since
1885 only five of my cases have died after abdominal section
at that hospital. Where the surroundings are insanitary,
to compare the results in cases in which the peritoneal
cavity is opened with those of ordinary surgical operations
(as your correspondents suggest), or even with ordinary
gynaicologioal operation.^, would, as every medical man
knows, bo obviously useless and misleading.
The proper place for the discussion of an important
subject is at a meeting of a learned Society, and not by
letters in the medical journals. If those who object to
operating in the treatment of chronic disease of the uterine
appendages will bring the subject forward before any of the
Societies, they may rest assured that not only I, but many
others holding views similar to mine, will take care not to
he absent. Meanwhile, I see no good likely to accrue from
continuing a controversy in your columns, and, in con¬
cluding, must ask your correspondents to carefully peruse,
not omy my paper, but also a letter from me which you
publish to-day.
I am, Sirs, faithfully vours,
Harley-street, W., Teb. Hh, l&Bl. WiLLIAM DuNCAN.
To the Editors o/The Lancet.
Sirs,—I have to request that I may supply an omission,
in Drs. Williams and Charopneys’ letter. They say that
“ this particular operation has already furnished material
for legal proceedings in a well-known case. It is conceivable
that id might form the object of ledslation.” I find it to
he generally accepted that their allusion is to an action
which was brought against me four years ago. As I am
unaware of any other case to which their remark can refer,.
I am compelled to remind these gentlemen that the jury,
convinced by the evidence before them, gave a unanimous
verdict in my favour without waiting for counsel’s summing
up, and that I won the action with costs. To omit any
indication of the conclusion of these legal proceedings is-
misleading to the profession, to whose “good sense” the
writers of the letter appeal, and is also injurious to me.
They profess to accept Bernutz’s pathological observations,
which are based uj)on many fatal cases ; yet they hold thar.
“death from diseases of the appendages is of extreme rarity.”
This was not the opinion of the late Dr. Alfred Meadows,
to whom we are all indebted for Bernutz’s memoirs, and
who bad probably more practical knowledge of the patho¬
logy of these pelvic diseases than any of his contempora¬
ries. So convinced was he of their gravity and of the need
for surgical interference that he—a busy man—spent three
days in Liverpool in order that he might add his testimony
to the evidence of the many eminent witnesses who
appeared in my behalf, and was only prevented from
entering the witness-box by the law’s delay and by urgent
telegrams recalling him at the last moment to London.
Surgical treatment of the inflammatory diseases of the
uterine appendages is now the accepted practice in Birming¬
ham, Edinburgh, Manchester, Leeds, and other towns, and
I fail to see the benefit of a reprint of ancient denuncia¬
tions. It is certainly conceivable that it might form the
subject of legislation. But Drs. Williams and Champneys
themselves remove the appendages “when life is threatened”
and “ when the health has been impaired for many months,”
and probaby they wish to be free to continue these opera¬
tions. But the threatened legislation may fail to make
suitable provision for their wishes. In The Lancet four
years ago I called upon ray criiic to publish his cases, but
they have not yet seen the light. Before ihe good sense
of the profei^sion is exercised upon Dr. William Duncan’s
cases, Drs. Williams and Champneys should publish theirs.
seriatim for comparisor.
I am, Sirs, yours obediently,
LivorpooJ, reb. lOtl), ISOI. FRANCIS ImLACII.
ERYSIPELAS AND TOTAL ABSTAINERS.
To the Editors of The Lancet.
Sirs,—I think it may be interesting to note the fact that
I have at present under treatment three (Juardsmen luffer-
ing from very severe attacks of idiopathic erysipelas of face
and scalp, contracted from exposure in the recent severe
weather, and that in each of these cases the patient is a
total abstainer. The men are strong, heulthy looking men
in the prime of life. In one case the patient suffered from
pneumonia as recently as last November, but in the other
two cases no history of previous ill health existed. These
men came from dliferent regiments, and no insanitary
conditions were observed in connexion with their cases.
Alcohol is so often blamed as a predisposing cause to this
disease, and no doubt is so when taken in excess ; birt is
the temperate drinker in a better or worse position to resist
extremes of temperature than the total abstainer? This
occurrence of the disease among total abstainers may be
only a coincidence, but it looks a significant fact that the
only three cases at present existing in the London garrison
(over 3000 strong) should come from a comparatively small
body of men, such as the total abstainers are in comparison
with the non-abstainer. Considering the value of alcohol
as a heat-producing food, and that the probability that
the disease in these instances was caused by extreme cold
acting on tissues whose vitality was lowered, there seems
some evidence of cause and effect. From my experience in
liot climates I certainly think it is a very open question
whether even there the moderate use of alcohol is not bene-
licial. 1 am inclinod to believe that the stimulating effects
of alcohol are most useful in producing digestion and
proper nutrition. I would include in the term moderate
396 The Lakcbt,] INTESTINAL IMPLANTATION AND LATERAL APPOSITION.
[Pbb. 14,1891.
drinkers only those who do not take more than two ounces
of absolute alcohol in the day, and take that either with or
just after their meals.
I am, Sire, faithfully yours,
H. li. Whitehead, P.R C.S Eag.,
Surgeon, Medical Stati'.
Coldstream Guards Hospital, Jan. 2{ith, 1891.
INTESTINAL IMPLANTATION AND LATERAL
APPOSITION.
To the Editors o/’Thb Lancet.
Sirs^—Iq your issue of Jan. 31st my old friend Mr.
Jeasett suggests that ileo-colostoroy, in the cases of cancer
of the etecura on which Mr. Bryant and I did ileostomy,
■would have been a better procedure, and his chief argument
■seems to be that the patients would then not have had fmcal
•fistuho. I presume he means “artificial anus,” as the
object of the operation is to prevent any intestinal contents
passing over the diseased surface, which, in the case of
ordinary intestinal fistulse, is not the result. But would
the patients have recovered after ileo-colostomy by implanta¬
tion or apposition? So much depends on the local condi¬
tions met with at the time of operation and on the patient’s
.general state that no hard-and-fast rule of conduct can be
formulated, and in cases of cancer where any operation
oxcept removal (which seems rarely to be indicated at the
stage we see cases) can only be of a palliative nature, the
eimpler the method the more appropriate it appears to me
to oe. Enterostomy, if done in time, is simple, of
rapid execution, and effective, and in another case I
would make a free opening low down in the ileum
/it the time of operation, so as to ensure all intes¬
tinal contents passing at once through the incision.
In these eases the sufferer baa but a few months to live, and
an opening low down in the small intestine provides for
nutritive needs, and with the use of a properly fitting
■obturator and oakum or wood-wool pads life is very bear¬
able, providing pain and irritation he abolished or much
diminished. I would remind my surgical brother now in
arms that the fault, or rather the misfortune, in the shape
of illness which hefel him prevented his accepting my
invitation to be present It is probable, had he been with
me, that the operation be suggests would have been done.
I think it our manifest duty to give our patients the benefit
of experience greater than ours in any particular branch of
surgery, and I have no personal knowledge of, or care for,
jealousy of so-called specialists in any domain. The onus
of showing the profession that the new intestinal operations
introduced by Senn, and ably continued and advocated by
Mr. Jessett, are of as easy execution and as safe in result
*3 already accepted means rests with these gentlemen, and
until this be done cautious surgeons will rely on older plans,
except in such desperate cases as that on whicli I operated
last Thursday. Boldness is not always synonymous with
wisdom, nor is carefulness the necessary autotype of
surgical cowardice or timidity. So far as is in my ken,
there are no published record.s of sufficient successes
of these new methods in human beings, but I trust
that Messrs. Senn and Jessett will soon remedy this defect.
Another argument for ileostomy is that ileo-colostomy would
take longer to execute, and in order to make the opening in
.a healthy colon one would have to go at least three inches
from the diseased part, since if the operation succeeded
the liquid or semi-solid contents of the ileum would gravi¬
tate down to the cancerous part and irritate it. This, I
fear, is another real objection ; but it may be urged the im¬
plantation or anastomosis could be made at the transverse
or descending colon, so as to avoid this backward How. I
-can only reply with the request to be shown some successes
before I adopt, in ordinary cases, new proceedings. There
is another objection which, in the present state of our ex-
erience, is to me a very substantial ore. It is that, I
elieve, no one is justified in making serious experiments
on human beings, and I cannot think bat that all surgeons
would deem a confrere more than rash who undertook these
novel proceedings without the aid of the only two men who,
so far as I know, have any experience of these operations.
I allude to Mr. Jessett and Mr. Horsley, though I believe
only the former has operated on the human subject. The
technics of these operations are rather complicated until
done or seen done, and the least slip in any detail will eer-
tainly most seriously endanger the life of the patient; so
that I would urge anyone contemplating them to practise
repeatedly on the cadaver, and if possible to secure the aid
of one or other of these gentlemen, If, now that I have had
experience of one case, my services are considered worth
asking for, I shall be most happy to render them. As stated
in my lost letter, operations and surgeons must be judged
by results, and ileo-colostomy is no exception to this whole¬
some rqle. I have recently practised what I preach, and
have availed myself of Mr. Jessett’s valuable aid, most
willingly given, in a difficult and complicated case of ileo-
sigmoidostomy, and as this is the third serious operation I
have bad to perform on the same patient, and, moreover, as
the narrative of these operations will, I am sanguine, prove
of interest and instruction to surgeons, I will, with ^ur
E ermission, publish the case, with illustrations, in THE
ANCET, whatever may be the result of the operation.
1 am. Sirs, yours obediently,
Grosvenor-sti-eefc, W., Fob. 2n(1.1891. H. A. BEEVES.
P.S.—The patient is now (eleventh day) ready to be sent
into the general ward, and complete details will be furnished
when the case is published. With regard to the case of
digital dilatation I ought to state that I beard from the
patient on Feb. 7th. He says he wrote under the influence
of morphia, and seems to be much depressed through
physical sulferiug and flnancial distress. I think it highly
probable that the relief undoubtedly afforded by the opera¬
tion has been replaced by pain caused by the growth of the
irregularities which I felt, and which are most likely epithe-
lioinatous. Taking into consideration the fact that the
bowel above tbo stricture was very much distended and
hypertrophied, it would have been very risky and difficult
to nave tried excision and enterorrhaphy or lateral anas¬
tomosis. There can be no question that life has been pro¬
longed, but whether it is worth having under such con¬
ditions is not for surgeons to decide. Their clear duty is to
prolong life if they can, and, as a matter of fact, the lar^
majoiiby of patients elect to run considerable risk and sub¬
sequent discomfort if a reasonable promise of longer
existence can be offered them. The time will come when
surgeons will see similar cases earlier, and as the technique
of intestinal surgery improves they will be enabled to deal
more radically and successfully with them. Currents
calamo I omitted to mention that, if my memory be correct,
the patient derived relief for a time from the treatment
ordered by the eminent physicians expoiiened in intestinal
diseases whose advice he sought.
Feb. 9tb, 1891. _
THE MEDICAL Dl^FENOE UNION AND THE
MIDWIVES’ BILL.
To the Editors of The Lancet.
Sirs,—I am sony to find that an attempt is being made
to drag the Medical Defence Union into “political” con¬
troversies. It is greatly to be regretted that the line upon
which the present executive have so successfully worked—
viz , defence of the individual member against outside
attacks—has been departed from by a small majority at
the general meeting. Personally I have no opinion of the
Midwives’ Registration Bill, but I voted against Dr.
Rentoul’s motion as a protest against the attempted use of
the Union by him and bis colleagues as a political agency.
Ibis perfectly true that one of bheavbicles of association of the
Union gives the company power “bo consider, originate,
promote, andsupporb legislative measures likely to benefit the
medical profession,” bub thereis no necessity to carry outevery
article in its entirety, especially when there is so much differ¬
ence of opinion about any particular subject. The Union is
young ; it has had a dangerous and almost fatal illnesssoon
after its birth; recovery was slow, bub under the treat¬
ment of its able President convalescence is now thoroughly
established, and its strength is daily increasing. It would
be a serious danger to it were it to be exposed to the risk
of infection from “politicalfever,” a disease which prevails in
some of our proviucial towns in far greater severity than
we have it in London, bub even in those places can be
successfully resisted with the usual common-sense pre¬
cautions. I do not wish to enter into any discussion
with regard to the Bill in question. All I desire is to urge
all members of the Medical Defence Union who value its
work, and who look upon it as a practical insurance
against individual attack, to protest against any attempt
to divert its power and usefulness into the uncertain
Coogle
The Lancet,]
THE OBSTETRICAL SOCIETY AND THE MIDWIVES’ BILL.
[Feb. 14,1891. 397
channela of politics. If such attempt is continued, as a
member I shall propose to the executive that the articles
of association shall oe altered, and that the power to enter
into such legislative action be taken away. A few mem¬
bers of strong political bias might resign, bub I am satished
that the loss would soon be regained by an accession of
men who look upon the Union as a personal insurance
company, and who object as strongly as I do to its being
used for any other purpose which may be lawful, bub is
not expedient. I am, Sirs, yours faithfully,
Feb. 9tb, 1891. A MEMBER OF THE UNION.
THE OBSTETRICAL SOCIETY AND THE
MIDWIVES’ BILL.
To tha Editors of The Lancet.
Sirs,—W hen the President at the annual meeting of the
Obstetrical Society excluded all discussion on the merits of
the Midwives’ Bill or its details, I determined neither to
speak nor vote on Dr. Aveling’s resolution, which was simply
a vote of confidence in the Council of the Society. Now,
the Council of the Society having, both by circular to the
Fellows and through the President in his address, disclaimed
all responsibility for the present Mid wives’ Registration Bill,
and the President having himself declared that he did not
approve of certain of its clauses, and that this Bill, as
amended by the Privy Council, does not contain the most
important of the suggestions made by the Council of the
Obstetrical Society, I saw no valid reason why I should
vote for or against the resolution in the restricted shape in
which it was put to the meeting. I went to the meeting
under the impression that it would be open to any Fellow
to give his opinion on the Amended Bill, and that we
should not be restricted to a mere vote on the ques¬
tion as to whether any kind of legislative action was
desirable. Many Fellows of the Society may approve
of legislation, but they think they see such grave blots
in the present BUI that no influential medical body,
least of all an Obstetrical Society, should hesitate to
express an opinion antagonistic to the BUI itself.
When I found tnat all criticism on the details of the BUI
was precluded by the President's ruling I merely protested
against a vote on such a resolution as that of Dr. Aveling’s
being regarded as any expression of approval of the Bill
itselh As a Fellow of the Obstetrical Society I feel, after
the statement of the President, that the Society, through
its Council, has been snubbed by the Privy Council, and
that its suggestions have been ignored. When this occurred
I am of opinion that the Council, in so important a matter,
might have taken the Fellows into its confidence, and
shown that the Bill was not constructed on lines approved
by it, and thus much misunderstanding would have been
avoided. It was widely circulated by the promoters of the
Bill that it met with the approval of the Obstetrical
Society. I was asked and pressed to add my name to
a document on which appeared the names of many of
the Council. This was an obliquely worded statement in
which the desirability ot legislative. action was urged.
When such documents, under the headings, “ Registra¬
tion of Midwives ” or the “ Midwives’ lUll,” are signed
by influential members of the medical profession, tliey
cannot be surprised if their signatures are used for the
purpose of proving that they are in favour of the Bill itself.
The Obstetrical Society by a vote has now deliberately
pledged itself, and unconditionally, to the principle of legis¬
lation for midwives; legislation on what lines? Are the
lines and limits to be those agreeable to and approved of by
the medical profession and the Obstetrical Society itself, or
on terms which will be forced on the profession and tlie
Society by the Legislature. Certainly we must be prepared
for this latter contingency if the Society, blindfolded, agrees
to the principle of legislation, and calmly sits down wliile
the safeguards it recommends are passed by and ignored. I
say nothing of the standard of education adapted by the
Obstetrical Society in granting midwives a diploma. It is
to be hoped tliat a considerable alteration for the better in
the conditions imposed for that diploma may follow should
there be legislation on the subject. Meantime, I maintain
that it is the duty of obstetricians to strive to prevent any Bill
passing through the Legislature with such glaring defects as
those existing in that one now before Parliament. Finally,
I should have wished that, no matter how strongly pledged
was the Council to the principles of legislation, the verdict
of the Fellows should have been taken on the merits of the
Bill itself. I am, Sirs, yours faithfully,
Feb. 7tli, 1801. H. MaCNAUOHTON JoNES.
EMPYEMA OF THE ANTRUM.
To the Editws of The Lancet.
Sirs,--I n The Lancet of to day you do me the honour
to report in an annotation a communication on the above
subject which I made to the Odontological Society on
Feb. 2nd. Judging from my own experience I should say
this subject must be of greater interest to the medical than
: to the dental profession; for, although I have tapped the
antrum in a considerable number of cases, in no single
instance has a patient applied to me directly in my capacity
dental surgeon. The cases have all been brought to me
by practitioners by whom a diagnosis had been made; but
many of the cases had been going on for months, some
for years, often undergoing treatment wrongly directed,
before the true nature of the malady had been made
out. Not only is our knowledge of empyema of the
antrum far from complete, but the existence of such a-
disease seems by no means sufficiently well known. The
subject, it appears to me, might therefore with advantage
be fully discussed in Tun Lancet ; and I shall be glad it
you will allow me to supplement my brief communication
by a few further observations. First, as to etiology. I am
satisfied that dental disease is by far the commonest cause.
The roots of several teeth are separated from the cavity by
merely a thin layer of bone ; sometimes the roots of molars,
extend within, covered only by a thin osseous film beneath
the mucous membrane. Periodontitis ail'ecting such roots-
may give rise to suppuration, and this extending to the
antrum may establish empyema ; or pent-up discharges from
suppurating or gangrenous pulps (“nerves”) of the teeth
may make their way tbi'ough root foramina into the cavity
and excite the disease. In the great majority of cases
which I have seen, whilst no other cause has been discover- ,
able, dental disease amply sufficient to account for empyema,
has existed ; and in other cases there has been a clear his¬
tory of dental disease. But the case narrated to the Odon¬
tological Society has left me somewhat in doubt as to what
may form etiological factors in exceptional instances. The
pathology seems simple. Pus once present in the antrum
the cavity can never be completely emptied except by art.
Pus flows out when it reaches the level of the ostium, or
when the head is inclined forwards; but a residuum is
always left on the floor of the cavity, and this becoming,
putrid, and often inspissated; the mischief is aggravated,
and the area of inflammation and suppuration is gradually
extended over greater part of the antral lining. The
symptoms, which in simple cases are almost pathognomonic,,
include discharge of fetid pus from the nostril of the affected
side only; and, be it noted, the discharge is not continuous,,
but occurs at irregular intervals, and particularly when the-
head is inclined forwards. The patient is conscious of a
noisome odour; but this is not, as a rule, perceptible to
others except at the moment when foul pus is flowing from
the nose. There is usually pain, and this may be confined
to dull local aching, or may take the form of severe frontal
heodacheand neuralgia. It is not safe to pronounce a positive
diagnosis without thorough rhinoscopical examination, as the
disease may be closely simulated by pathological conditions-
of neighbouring parts. It seems commonly believed that
distension of the antrum with bulging of the walls is a
usual accompaniment of empyema; but thig is a mistake;,
it only occurs in those rare cases in which the ostium is
completely blocked. I have met with only one instance of
the kind, and in that the patient suffered most from
presauvo on the floor of the orbit and ophthalmic troubles.
Not to enter into minutim whiob might take up too much
of your space, the treatment may be described ^as-
free drainage and antiseptic irrigation—sources of local irri¬
tation such as diseased teeth being, of course, removed or
otherwise dealt with. Effectual drainage can only be en¬
sured by tapping the cavity through the alveolar margin
or through the socket of a tooth and inserting a gold tube
extending well into the cavity, and held in position by a
plate such as is used to support an artificial tooth. Further
acoiimulatiou of pus being thus prevented, the antrum must
be thoroughly irrigated once or twice a day with an antiseptic
lotion. A syringe, such as that devised by Mr. Christopher
Di.3(Tiz3d
398 The Lancet,]
SHOULD ERYSIPELAS BE ISOLATED ?
[Feb. 14,1891.
Heath specially for these cases, must be used. It has a
long, tbia nozzle to pass well up the tube, and is capable,
without exercising too much force, of throwing a continuous
stream. The lotion should make its exit through the nose,
the head being inclined forward. Cases of empyema,
especially such as have been long neglected, often resist
treatment for lengthened periods. Whilst care should be
taken to ensure thorough irrigation, the danger of keeping
irp irritation by too much syringing and the use of unsuit¬
able lotions must not be everlooked.
I remain. Sirs, your obedient servant,
Wimpole-street, W., Feb. 7th, 189X. HENIIY SEWILL.
SHOULD ERYSIPELAS BE ISOLATED ?
To ikt Editors o/The Lancet.
Sirs,—T he above question has been brought prominently
before the medical profession in Hull owing to a recent de¬
cision of the local sanitary authority refusing to admit
erysipelas into their Infectious Hospital, and omitting to
make any suitable provision for such cases. In 1888, thirteen
•deaths occurred in Hull from erysipelas; during the fort¬
night ending Jan. 2Qd, 1891, seven cases were notified in
the borough. One of these cases (facial erysipelas) was
under my care. It was in a very populous district; several
'Confinements took place within a few doors of the case,
which was of a malignant type; neighbours and visitors
could not be prevented from passing to and fro between tine
cases; a midwife was in the infected house one day and the
next night attending a labour, though warned of the danger;
the room in which the case lay was ill ventilated, and no
skilled nursing was available. Under these circumstances
I desired the medical officer of health to remove the case at
once to the sanatorium, but to my surprise found that he was
unable to do so because the sanitary committee had decided
not to admit any eases of erysipelas. Under proper hygienic
conditions and with trained nursing the patient would, I
believe, have recovered. Under the prevailing unfavourable
conditions he died.
I brought the matter before the local sanitary committee
and was answered by one of its members (a medical man)
to the effect that he had never known erysipelas infectious
in a private house under the worst of hygienic conditions ;
that there was little to fear from it as a cause of puerperal
fever ; and that neither experience, statistics, nor humanity
would justify them in admitting erysipelatous cases into
the sanatorium. Now, seeing that erysipelas is a specific
contagious fever scheduled under the Infectious Disease
(Notification) Act, 1889 ; that it may and does prevail
epidemically; and, further,-that it may, if not isolated,
cause a series of cases of puerperal fever, I propound the
above question to the medical profession through the
medium of your columns.
The following statistics may be found in the Manual of
Public Health (Wynter lilyth), 1890During the
twenty-five years ending with 1886, 51,582 deaths in
England ana Wales are ascribed to this cause. The
maximum number of deaths was in 1874, when 3858 deaths
were registered; the minimum number was in 1886, when
1.523 deaths were caused by erysipelas, the mean number of
the whole being 2063 . If the deaths from erysipelas
and those from puerperal fever be plotted out for a sufficient
number of years in a curve, according to season, the curves
very fairly coincide.”
I shoal'd be glad to receive any communication on the
matter, privately or through your columns, from any
members of the profession who may be interested in the
subject.—I am. Sirs, yours truly,
Hull, Jan.9th, 1891. EdGAR DU CANE, B.A., M.B.
DEATH CERTIFICATION AND LIFE
ASSURANCE.
To the Editors of The Lancet.
Sirs, —I shall be glad of your comments upon the
following
A man, aged fiffy-ftve years, was admitted, without
any history, into the Criekhowell Workhouse Infirmary
on .Jan. 13th, 1891. Upon a superficial examination, he
was emaciated to a frame, pulse very feeble and inter¬
mittent, but still conscious ; a dislocation of the right knee
backwards, and two bedsores over the tuberosities of the
ischium. I ordered him brandy every hour, with a milk
and beef-tea diet. I bad known the man a year or so pre¬
viously as one of slightly feeble intellect, but otherwise
strong and in robust health. By repeated and careful
examinations I could discovernodiaease to account for his con¬
dition, but he died six days after admission. As affording a
possibleclue tobis treatment before he came under my notice,
the nurse, three days prior to his death, having fed him,
remarked that he “ had taken more then than he liad done
at all since he came in.” His reply, “Ha! they would
have grudged me it at home,” was to my mind suggestive
in dealing with a man in his condition. I refused to certify
as to the cause of death for the reason that 1 had been
unable to find one, and reported such to the police authori¬
ties. The coroner was communicated with. This officer,
however, came to the conclusion, from inquiries made, that
the deceased died from exhaustion due to natural causes,
and that an inquest was unnecessary. Now, I have never
known in my experience a man fifty-five years of age die of
“ exhaustion” without being able to find a primary disease
to account for it. Senile exhaustion would not apply in
this case. Within a few hours after the coroner had given
his certificate the friends of the deceased called upon me for
a death certificate for an assurance office, in which the de¬
ceased’s life had been insured, offering to “pay me any¬
thing” for it. I, however, declined, and referred them to
the coroner. I may add that I never refuse a death certifi¬
cate except upon what I consider strong ground, as any
medical man would who had been told—as 1 myself have
been—by a member of a Board under whom I serve that I
withheld certificates in order to obtain fees for evidence at
inquests 1 I am, Sirs, your obedient servant,
Phiup E. Hili,.
Criekhowell, Jan. 24th, 1801. Medical Ofllcer Criekhowell Workhouse.
P.S.—I may add that, as far as I was able to ascertain,
the dislocation was of nine months’ standing, and had not
been seen by a surgeon.
LIVERPOOL.
(From our own Correspondent.)
The Royal Infirmary.
The annual meeting at the Royal Infirmary was held
there on Saturday, the 31 st ult. It was hoped that there
would have been a good attendance of the trustees and
general public, who would thus have the opportunity of
seeing the splendid new pile which now occupies the former
site, and is one of the greatest improvements which the
city has had for a long time. Unfortunately the hour
chosen, 11 A.M., was not a happy choice; had it been 3 P.M.
or 4 p.m. there would in all probability have been a much
better attendance. The new infirmary has been in full
working for some time now, sufficiently long to show its
many and great advantages. The cost of maintenance will
probably require an increase to the income of £3000 a year,
which ought not to be very difficult to obtain in so large and
wealthy a city.
The Roliee-court and its Ventilation.
The ventilation of our police-court, like that of so
many law courts, is very defective, and the air at times
is so foul as to make a compulsory attendance there
for any length of time a very serious matter to persons
not used to a close atmosphere. The late Mr. Hallies, after
nine years’ experience of it, had a severe illness and was
compelled to go away for some months. He fortunately
recovered, and was enabled to discharge his duties for
many years afterwards, but frequently complained of the
state of the court, lb is pfreatly to be hoped that some
means will he found to secure a more wholesome atmosphere
for those whom necessity compels to breathe it. The great
defect is that of so many similar buildings—viz., an insuffi¬
cient egress at the top for the foul air which is always
ascending. There is no difficulty in securing the ingress of
fresh air from outside and from the lobbies.
A Temperance and Purity Crusade.
In deference to a strong expression of public opinion,
proceedings have been taken against all the keepers of
brothels known as such to the police, and within the last
few weeks nearly two hundred persons, mostly women, have
been summoned, have pleaded guilty, and been fined £5
and costs. For a second ofience one woman was fined £10,
Digitized by Google
The Lancet,]
MANCHESTER.
[Feb. 14,1891.
or one month’s imprisonment. Similar proceedings are
going on daily, the total of cases to be dealt with being
between 300 and 400. Besides these, many publicans have
been summoned for serving drunken persons, for allowing
their houses to be the habitual resort of prostitutes, and for
permitting the latter to remain longer than was necessary.
While it is gratifying to see that so much is being done to
repress intemperance and vice, the ill elFects of which are
only too well known to medical practitioners, it would be
contrary to all previous local experience to expect much
good from this raid. As was remarked in The Lancet
some time ago, the “social evil” shows a terrible persist¬
ence, and a similar remark might be made of intemperance.
The Disposal of the Dead: Burial or Cremation?
Dr. Hope, the assistant medical officer of health, will
to-morrow bring before the members of the Medical Institu¬
tion the important question of the disposal of the dead, and
will move a resolution in favour of cremation. A very
interesting discussion may be expected. Apart ffom other
considerations, it must be remembered that Liverpool con¬
tains a very large number of foreigners, who are favour¬
ably disposed towards cremation, and as Englishmen have
always been permitted to have burial grounds and
facilities for burial in foreign climes where cremation is
the mode of disposal of the dead, it is only right that in
this matter there should be reciprocity.
Liverpool, Feb. lltb._
MANCHESTER.
(From our own Cobresponeent.)
The Hospitals.
Many of our local hospitals have lately been holding their
annual meetings. At the Clinical yesterday it was reported
that additional land had been obtained adjoining the
hospital, upon which it is proposed to erect extensions
if the necessary funds (some £2000 to £30CO) can be
obtained. Increased number of patients treated and lack
of funds were reported here as elsewhere. The Mayor of
Manchester referred to the fact that hospital managers,
in their reports, always appeared to dwell with satisfaction
upon the increase in the number of patients. He was inclined
to take another view of the subject, and to submit whether
it might not be a source of satisfaction if the numbers
tlimimshed. Hospitals were not business concerns
nourishing in proportion to the amount of work they did.
The same gentleman, recently speaking at the annual
meeting of the Children’s Hospital, when the chairman took
rather a gloomy view of the increased demands upon them
and their shortness of funds, declared himself quite willing to
face the possibility of hospitals being in part subsidised
out of the rates in the same way that fever hospitals pretty
generally are now. At the Eye Hospital a satisfactory state
of the finances was reported for the year, and here, contrary
to the usual experience, there has been a little diminution
in the number of patients under treatment. At the annual
meeting of the Victoria Dental Hospital funds for pro¬
viding a new hospital at an estimated cost of £0000 were
pleaded for. The pourparlers are still going on between
the Infirmary and Owens College authorities respecting
the proposed new hospital in connexion with the College
and the; extension of the present infirmary, hut nothing
of a definite nature has yet been resolved upon. In
the face of a possible new hospital the need for any
great extension of the present infirmary has scarcely
yet been demonstrated. One very philanthropic proposal
made by the Whitworth Trustees in connexion with their
splendid gift to the College is to establish a special wing or
pavilion for cancerous diseases, with a threefold object in
view—to provide treatment for these suli'erers, to afford
opportunities for scientific study of these ailments, and to
provide a permanent home for incurable cases amongst
persons above the pauper class.
Hospital Collections.
Last Sunday was Hospital Sunday, and Saturday next is
set apart for the collections from workshops &c. iasb year
showed a slight falling off in the Sunday collections, but a
more than corresponding increase in the Saturdaylones. In
face of the almost universal cry of lack of funds, it is hoped
that this year contributions may show a considerable
augraentation.
Medico-Ethical Society.
This society, of which Dr. H. Ashby is the president for
the current jear, has mapped out for its consideration a
special subject for the coming year—i.e., the causes of the
high death-rate of Manchester. A series of papers have
been arranged for by those of its members specially qualified
to deal with such matters as infant mortality, crema¬
tion, influence of drink on the death rate, unhealthy
dwellings, &c., and it is also organising a staff of lecturers
to go out among the masses of the people and deliver
popular lectures upon sanitary matters. This is a some¬
what new departure, but possesses potentialities of great
usefulness.
Diphtheria in Salford.
Mr. Paget, the medical officer of health for Salford, has
prepared a report upon the increased prevalence of diphtheria
in that borough last year, and even at the present time it
is far from having disappeared. He speaks very cautiously
as to the actual causation, but exonerates the milk supplies
from any suspicion of being concerned in it. He thinks the
schools may have contributed to the spread of it after it was
established, and he more than hints at the possibility of a-
polluted soil by the privy-midden system «S{c. as an im¬
portant factor to be considered in connexion with it.
Hoivsing of the Poor.
An interesting scheme is being set on foot, upon philan¬
thropic-commercial principles, for providing cheap and
healthy tenement homes for the poor. A number of well-
known gentlemen interested in this social problem have
formed themselves into a limited company to raise a capital
of £20,000 for promoting the above object. They have
acquired a large disused factory in Ancoats (one of the
poorest districts of the city), and propose converting it into
about 150 separate tenements, to be let at a rental of two
shillings per week and upwards. The scheme appears to
have been well thought out, and. if the expectations of its-
promoters are realised, will yield a dividend of 4 or 5 per
cent, upon the outlay.
Fatality at the PresUoich Lxenatic Asylum.
An unfortunate and happily unusual occurrence took
place last week at this asylum. After some altercation
with an attendant one of the male patients became veiy
violent, and in the struggle which ensued a table fell upon
him and caused such injuries as to result in death. At ihe-
coronet’s inquiry the attendant was acquitted of blame.
Municipal Sanitary Work.
Our local parliament continues to direct its attention to-
insanitary districts of tlio town, and at the last council
meeting two more smaller blocks of property were con-
demnea on the certificate of the medical officer of health—
one area in Hulme, containing nearly 7000 square yards,
and another somewhat larger area in Ancoats. At the same
meeting the Bublic Health Acts Amendment Act of 1890-
and the Infectious Diseases Prevention Act, 1890, were
adopted. This latter will give increased powers in dealing
with infection-s diseases, premises, «5cc. With all our powers
and appliances, it would seem that we make but little real
progress in the diminution of scarlet fever, typhoid fever,
and diphtheria. During the last month of 1890 something
like a hundred new cases of scarlet fever, forty of diphtheria,
and nearly fifty cases of typhoid fever were reported. More
than a thousand cases have been sent into the Corporation
Fever Hospital at Moneall since June last, and this is only
a small part of the total number reported.
Manchester, Fob. 11th.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Newcastle Royal Infirmary.
The annual meeting of the Newcastle Royal Infiiinary
has been held, and the report gives evidence of a very large
amount of work having been done in this great institution
during the past year. The number of in-patients treated
was 3328, which was more by 208 than that received in the
previous year. The number of deaths had been 277, giving
a death-rate of 8•32 per cent,: of these, however, 53 died
within twenty-four hours of their admission, and may be
regarded as moribund, and beyond the reach of medical skill,
Digitiz-cd by Google
400 Thb Lancet,]
SCOTLAND.—IRELAND.
[Feb. U , 1891.
when they were admitted. Deducting these, the number of
deaths may be stated as 224, giving a death-rate of 673 per
cent. The number of casuals and out-patients bad been 13,216,
giving an amount of relief of incalculable value. The number
■of eye cases had been 1120; the dental coses were 808, In
regitfd to the recent application of the Koch treatment, it
was stated that in the lupus oases a marked improvement
took place from the very first, and it is fully expected, by a
continuation of the remedy, that health will be restored. As
regards the two cases of phthisis, no decided opinion
can at present be formed, a sufficient period not having
elapsed to say what the result may be. The Mayor,
in speaking to the adoption of the reports, said, that
one of the most gratifying things in the finances was
the large amount subscribed by working men, amount¬
ing as it did to £3201. I mentioned in former notes the
completion of the beautiful little chapel, St. Luke’s, in the
infirmary. It was stated at the meeting that a lady had
presented an organ for the chapel.
Newcastle Health Society.
The inaugural lecture of the new Society (established
on similar lines to that in Edinburgh and other large
centres) was delivered on Saturday last by Dr. William
Murray of this city, to a very large and appreciative
audience. Dr. Murray’s subject was Eating a,nd
Drinking, and he treated it in a masterly yet attractive
manner, showing the errors of various classes of the
community as to diet, the injury to health from neglect
of physiological laws, and the baneful effects of bad customs
a,8 to quality and quantity of food for the various ages. Dr.
Murray also very cleaidy showed that with proper organisa¬
tion an amount could be saved to the working man’s house¬
hold equivalent to an important rise in wages, yet this
aspect of economy is rarely taken up by reformers. The
course which has been so well commenced is to be followed
by various medical men and others distinguished in their
various departments. The Health Society supplies a want,
and supplies it well, for the north of England, with its dense
population.
2'he {children's Hospital (Fleming Memorial), Newcastle.
The annual meeting of the Fleming Memorial Children’s
Hospit^ has been held, and the report stated that the in¬
patients had been 201 and the out-patients 3.390, showing a
considerable increase in both departments. The committee
hoped that on the receipt of a munificent bequest of the late
Mr. Fleming, the founder of the hospital, wbo had also left
£25,000 to it, they would be in a position to open all the
beds in the various wards.
Alnwick.
The Duke of Northumberland has offered the local board
of health the sum of £1000 to help them in carrying out
some sewage works necessary for the town of Alnwick, also
land for purification works near the town.
Newcastle-on-Tyne, Feb. 10th.
SCOTLAND.
(Fkom our own Correspondents.)
The Prevalence of Infectious Diseases in Edinburgh,
At the Town Council meeting last week tiie Convener
of the Public Health Committee drew attention to the fact
that the City Hospital was more than fnll. There were in
the hands of the towns no fewer than 28(5 people affected
with fever—99 being cases of typhoid fever, 11 of diph¬
theria, 111 of scarlet fever, 6 of measles, 10 of whooping-
couph, 12 of erysipelas, and 13 in quarantine. Prom
this it appeared that their hospital accommodation, while
sufficient for ordinary occasions, was insivnicient for a
large epidemic. Although the intimations of infectious
disease seldom exceeded twelve daily, from Jan. 24th
the intimations had gone up considerably. So many
of the cases in hospital were typhoid fever cases, which
required very careful nursing, that they were in straits to
provide accommodation, not only for the patients but for
the nursing staff. (Questions were asked whether the
officials of the Public Health Committee had traced the
source of an outbreak of ecirlet fever in a district of the
city, and when it was intimated that they had not succeeded
in doing so it was stated there was a c<iniplaint that the
matter was not being investigated as carefully as it iniglit
be. Since the meeting, a notice has appeared that the
milk supply from adairy has been stopped. Open criticism
seems to have a stimulating effect on the official mind.
Demonstrations of Sick-room Cookery.
A short series of demonstrations of sick-room cookery
have been given during the past few weeks in the Edin¬
burgh Royal Infirmary for the instruction of medical
students, similar to those given on former occasions. The
demonstrations are given by ladies from the Edinburgh
School of Cookery, and their value to the medical student
is apparent.
Health of Edinburgh.
The mortality last week was 91, and the death-rate
17 per 1000. Diseases of the chest were accountable for 60
of these, and zymotic diseases for 9; of these, 2 were due to
typhoid fever, 2 to diphtheria, 1 to measles, and 4 to
whooping-cough. The intimations for the week comprised
19 oases of typhoid fever, 8 of diphtheria, 63 of scarlatina,
and 9 of measles. In Leith the death-rate was at the rate
of 18 per 1000.
The Edinburgh Medico-Chirurgieal Society,
At the meeting of this Society last week Dr. J. Beny
Haycraft gave an able paper with demonstrations of the
cardio-pneumatic movements. He first dealt with the views
of Voit, the discoverer of these movements, and gave a
demonstration of the method he had used ; then he con¬
sidered and demonstrated the opinions and experiments of
Ceradini and Landois, and from these went on to detail
his personal observations, and showed that the movements
are really inverted cardiograms, and due to the movements
of the heart upon the lungs; that they occur equally well
in the freely opened chest, but cease when the heart is
lifted away from the lungs. The views advanced were
illustrated by carefully planned experiments, and by pro¬
jections of tracings. This was followed by “Notes on a
Case of Hereditary Optic Atrophy,” by Dr. W. G. Sym.
Itoyal Infirmary, Perth,
The annual report for the past year shows that the work
of the institution had been efficiently carried on, and that
all the demands of the sick poor upon its resources were
fully and adequately met. The ordinary income amounted
to £2487 19.y., and the expenditure to £3125 18s. bd. During
the year £1009 had been received as legacies.
Feb. lOLh.
IRELAND.
(From our own Correspondents.)
Royal University of Ireland.
A MEETING of the Senate was held last week, when it
was decided that henceforth the examination for the
diploma for proficiency in the treatment of mental diseases
shall be held every year. His Excellency the Marquis of
Dnfferin and Ava, Chancellor of the University, having
offered for competition a gold medal for the best English
essay on a subject to be named by the Senate, they have
arranged that for 1891 the subject for the essay snail be
“Edmund Burke,” and for the loliowing year, “Colonies,
Ancient and Modern.” The following examiners have been
appointed Ciiemistry, E. A. Letts ; Biology, L. E. Klein ;
Anatomy, A. E. Birmingham; Materia Medica, F. Quinlan,
William Whitla; Medicine, Joseph O’Carroll; Surgery,
Thornley Stoker; Midwifery, J. W. Byers, A. J. Smith ;
Medical Jurisprudence, C. Pearson, M. F. Cox; Ophthalmic
Surgery, II. K. Swanzy; Sanitary Science, Sir Charles
Cameron.
Royal College of Surgeons.
An election for a member of council, in the room of the
late Mr. Corley, will be held on Monday, the 23rd inst. It
js expected that there will be two candidates, Messrs.
William Frazer and Austin Meldon, each of whom has
already served as councillor. On thh same day an election
of an examiner in law will take place to examiiie candidates
for the diploma in State medicine, granted conjointly by the
Royal College of Physicians and Royal College of Surgeons.
Royal Academy of Medicine in Ireland.
The eighth volume of the Transactions of the Academy,
that for the Session 1889-90, has been issued. There is in
the Medical Section an excellent paper by Dr. P'oot on
d . Google
The Lancet,]
IRELAND.-PAKIS.
[Feb. 14, 1891. 401
Morphinism ; and in that of Surgery the following among
others are of interest—viz., A Successful Case ot Batty’s
Operation, by Mr. J. K. Barton; Supra pubic Lithotomy in
relation to the Treatment of Encysted Calculus, by Mr.
McArdle; and One Hundred Cataract Extractions* by Mr,
Swanzy, In the Section of Obstetrics Dr. Macan describes
a case of successful Csesarean Section. In the Section of
Pathology Professor Bennett has a paper on Typical Frac¬
tures, which is of great practical value; and i4r. Franks
describes a renal cmculus where the nucleus was formed by
a foreign body, a needle which had been swallowed seven¬
teen years previously. In the same Section there is a short
note by Dr. McWeeney on Diphtheritic Micro-organisms;
and in the Section of Anatomy and Physiology there is an
elaborate paper by Mr. Alec Fraser on Operations on the
Brain. The volume is edited as usual by Mr. Thomson.
Artisans’ Dwellings in Drogheda.
The necessity for providing improved dwellings for the
working classes in this town nas engaged the attention of
Mr. J. P. Caimes, J.P., who, anxious to make some prac¬
tical effort towards supplying this want, has proposed to
place a sum of £5000 in the hands of trustees for this pur¬
pose. This offer has been made to the Corporation of
Drogheda by Mr. Cairnes, who has requested their friendly
cooperation, and that body has passed a vote of thanks to
him for his generous offer, and have appointed a committee
to wait upon him in reference to the matter.
South Dublin Union.
An election for a medical officer to Canal-street Dispen¬
sary took place last week to fill the vacancy caused by the
death of Dr. J. A. Byrne. Considerable interest was felt
in the proceedings, eighteen candidates having forwarded
applications for the post, of whom sixteen were in attend¬
ance. Dr. Herbert Byrne, son of the late medical officer,
however, distanced all competitors and obtained the
appointment by a large majority.
Midwives’ Registration Bill,
When this Bill comes on for second reading its rejection
will be moved by Mr. Macartney, M.P. The chief medical
corporations have made arrangements for their representa¬
tives to wait as a deputation on the Lord President of the
Council with reference to the proposed enactment.
Address to Mr. F. Foster Brady, L.R.C.S.l,
Mr. Brady, since bis appointment as medical officer to
Carnew Dispensary, co. Wexford, now some four years since,
has made many friends, and the occasion of his recent mar¬
riage was taken advantage of to show their esteem and
a-egard. Last week he was the recipient of an address and
presentation as a token of the kindly feelings towards him
which existed in the district in which he practises.
University of Dublin.
On Tuesday, at the spring commencements of the
University, the honorary degree of LL.D was conferred
upon the Right Hon. A. J. Balfour, M.P , Chief Secre¬
tary for Ireland. Mr. Balfour received an enthusiastic re¬
ception, and after leaving University Hall delivered a
abort speech to the undergraduates.
St. Vincent’s Hospital.
Dr. A. Smith, ex-assistant physician Rotunda Lying-in
Hospital, has been appointed gynecologist to this hospital,
an the room of the late Dr. J. A. Byrne.
Feb. 10th,
PARIS.
(From our own Correspondents.)
Dmg Treatm,cnt of Chorea.
The drug in contradistinction to the moral and dietary
treatment of chorea has up to the present given rise to a
vast amount of discussion. Id still rests on very debateable
ground, some extolling one drug, some another, n clear
proof that no one drug is ever found to bo universally
eflicient. Others, again, maintain that drugging in this
direction is quite as, if not worse than, useless. The writer
recollects being once up for an examination in medicine in
which the learned examiner, with decided views, scouted
•drugging in chorea, and informed his uncomfortable candi¬
date, in the dogmatic tone peculiar to not a few examiners,
•that when nexb questioned as to the best treatment of
chorea to reply: “Six to eight weeks, combined with
peppermint-water thrice dail^.” Judging, however, by the
recoi-ded results obtained in recent years by competent
observers in this country and elsewhere in the treatment of
chorea by antipyrin and its allies, there would appear to
be a consensus of opinion that in the therapeutics
of chorea a step has been made in advance. Amongst
the observers who have exhibited this drug with success
is Dr. Moojcorvo. He found, however,, that large doses
were necessary before any decided effect was produced
even in the case of children, and that although when
polyuria and nocturnal incontinence existed those were
appreciably diminished, they were not entirely sup¬
pressed ; these and other considerations led him to try
exalgine, and from the very first he records that the
benefit which attended its administration was decidedly
encouraging. The polyuria and nocturnal incontinence,
which the antipyrin had only served to check, were com¬
pletely arrested by exalgine. Again, while the effective
dose of antipyrin was found to bo three grammes a day
that of exalgine only amounted to thirty centigrammes.
Moreover, Dr. Moncorvo says that when treated by anti-
pyrin the average duration of the disease is one month,
while in those cases in which he has tried exalgine a cure
; has been effected under three weeks. He finds that the
drug is well borne by children, and has never observed any
unpleasant effect follow its use. Seeing how common and
distressing an affection chorea is, and the uncertainty, if
not impotence, of therapeutic efforts hitherto, the observa¬
tions of Dr. Moncorvo are worthy of note, and his prac¬
tice of more extended trial.
Intestinal Antisepsis and Drug Tolerance.
Every observer has from time to time remarked the in¬
tolerance manifested against some drugs, the administra¬
tion of which, while absolutely necessary for the ameliora¬
tion or cure of the patient’s affection, is rendered difficult
owing to this intolerant idiosyncrasy. M. F6re finds that,
by practising intestinal antisepsis by means of such sub¬
stances as naphtbo*, patients who were intolerant of small
doses of bromide ot potassium or borax in epilepsy will,
when naphthol and salicylate of bismuth are exhibited
at the same time, bear perfectly well as much as seventeen
grammes a day of bromide without any inconvenience. The
eczema and psoriasis which sometimes appear in the train
of borax will also disappear if the intestines be rendered
antiseptic. M. Ferd adds that it is quite possible that in¬
testinal antisepsis may be found to checlc intolerance of
drugs other than those directed against epilepsy.
Dogs’ Serum in Tuberculosis.
At a recent meeting of the Biological Society, M. Charles
Riches recorded the results so far obtained by the injection
of the prepared serum of dogs’ blood in cases of tuberculosis.
In one case, where the injections were practised regularly
since the beginning of last December, the patient had
gained in weight as much as four kilogrammes and a half.
In another, whose condition was so pronounced that he
suffered from bedsores, a marked amelioration was reported;
and in a case of laryngeal phthisis the progressive improve¬
ment in the ulcerations was plainly visible. M. Kicheb
does not go so far 'as to assert that these improvements
maybe permanent, but he has demonstrated at least the
main effects of the injections made with this prepared
serum. The injections are made at first every third day,
then every second, the amount injected being two centi¬
grammes a day.
The Obstetric Forceps and Faraiysis.
In the English works on obstetric medicine within my
reach I cannot find that paralysis of the upper extremities,
following the use of the forceps and the performance of
other obstetric operations, is duly insisted upon. That it
i.s by no means uncommon is evidenced by the fact that
M. Oomby reported three cases at the last meeting of the
Hosi>itals Medical Society. In the case of the forceps, the
paralysis is brought about by undue stretching of the
brachial plexus when considerable traction is used. In cases
of contracted pelvis it may also follow version or violent
traction on the shoulders with finger or crochet. In many
of the recorded cases the paralysis was permanent; in others
far.acILation and galvanism were of benefit. In two of the
three cases seen by M. Coiuby, he believed the prognosis
was g<H)d, but in the third he did not think a cure possible.
J’avis, I'cli. lotli.
Dir;- Google
402 The Lancet,]
BERLIN.—OBITUARY.
[Feb. 14,1891.
BERLIN.
{Feom our own Correspondent.)
Tht Diagnosis of Bovlm Tuberculosis.
The G'^rman Itnperial Office of Health ia testing the
value of Koch’s fluid as a means of diagnosing tuberculosis
in cattle. The result of the preliminary experiments -was
favourable.
Mikulicz on Koch's Method.
Professor Mikulicz of Breslau declares that the hope of
obtaining brilliant results by Koch’s method has not been
fulfilled. This is due, however, he adds, solely to the circum¬
stance that in their first enthusiasm people hoped too much,
for all that Koch said in his first publication is still valid.
Mikulicz admits the dangers pointed out by Virchow, but
hopes to diminish them by surgical treatment.
Virchow's Ansiver to Pro/essor Neisser.
With reference to Professor Neisser of Breslau, who wrote
that Virchow’s observations of the effect of Koch’s fluid had
been made on cases in which the injections had not been
made for therapeutic reason", “ but in order to study the
effects of the fluid at the autopsy of patients who would
have died at any rate,” Virchow repeats that he chose by
preference cases in which the bad symptoms had developed
after the injections.
The Free Association of Berlin Surgeons.
The Free Association of Berlin Surgeons discussed the
treatment of lupus by Koch’s method yesterday evening.
Professor Sonnenberg showed a female patient who had
been almost entirely cured of extensive lupus. She has been
treated by Koch’s method since October. She had been
treated without success before by other methods. Professor
Hahn said that he had found it advantageous to puncture
the parts affected by lupus during the administration of
Koch’s fluid. Dr. James Israel reported a case of indubitable
lupus, iu which there was no local reaction whatever. Dr.
Lindner of the Augusta Hospital has in most cases observed
no reaction, either local or general, or hardly any after the
injection for lupus, but has nevertheless obtained favour¬
able results. Professor Bardeleben declared it a great
mistake to pronounce a final opinion upon Koch’s method
yet. Dr. Koerte of the Hospital am Urban stated that in
most of his cases the morbid phenomena altered only a
little under Koch’s treatment, hut he too has seen isolated
cases of improvement. Dr. Bartels raised the question
whether general miliary tuberculosis had been observed in
S atients with surgical tuberculosis after Koch’s injections.
Tone of the surgeons present had seen any such effect.
Professor Bardeleben said there was no doubt that general
tuberculosis and tuberculous meningitis might set in during
the application of Koch’s method, but it was hard to
say whether they were due to the injections. The argu¬
ment ^oc ergo propter hoc might easily mislead. If,
for example, one resected a tuberculous joint in children,
the operation was sometimes followed by general miliary
tuberculosis. It was natural to suppose that tubercular
particles got into the bloodvessels during the operation. It
was found, however, that general tuberculosis sometimes
broke out in such children before the operation. If the
miliary tuberculosis had followed the operation in these
cases, it would have been erroneously attributed to it.
The Cremation Society.
The Cremation Society held a general meeting here on
the 4th instant. The number of its members is consider¬
ably above a thousand. Professor Freire of Rio Janeiro
lectured on the danger of burying persons who die of yellow
fever in South America, and declared the introduction of
cremation to be the only preventive of epidemics there.
The income of the Society last year was over 19,000 marks—
i. e., shillings; its expenditure over 17,000.
Hermann von Helmholtz.
Helmholtz will complete his seventieth year on Aug. 31sb
next, and preparations are already being made to do him
honour on that occasion. Contributions may be sent to
Mendelssohn and Co. here before the end of April.
Death-rates of the Week ending Jan. ZJfh.
Aix-la-Chapelle, 237 per 1000; Altona, 30-8; Barmen,
16'3; Berlin, 17 2; Bremen, 18-2; Breslau, 24'9 ; Chemnitz,
25‘6; Cologne, 257; Dantzic, 33; Dresden, 16; Diissel-
dorf, 16; Elberfeld, 231; Frankfort, 24'5; Hamburg,
18'4; Hanover, 20‘1; Kbaigsberg, 26 7; Krefekl, 28‘9;
Leipsic, 18‘8; Munich, 22'6; Niirnberg, 21'8; Stettin,
28-2; Strasburg, 30; Stuttgart, 15‘5.
The further application of Koch’s fluid in the Warsaw
hospitals has been officially forbidden.
Dr. Julius Lazarus has been appointed head of the medical
department of the Jewish hospital here.
Berlin, Feb. 10th. _
THE SERVICES.
Army Medical Reserve of Officers. —Surgeon Wm.
Duncan, M D., F.R.C.S. Eng., having resigned his Volun¬
teer appointment, ceases to be an Officer of the Army
I^Iedical Reserve of Officers (dated Feb. 12bh, 1891); Acting
Surgeon John Hubert Griffin, 16bh Middlesex Rifle Volun¬
teer Corps, to be Surgeon, ranking as Captain (dated
Feb. nth, 1891).
Yeomanry Cavalry. —Middlesex (Duke of Cambridge’s
Hussars): William Duncan, M.D., to be Surgeon (dated
Jan. 25bb, 1891).
Naval Medical Service. —The following appointments
have been made at the Admiralty:—Surgeons: Wm. Bett
to the (dated Feb. 11th, 1891); Octavius S. Fisher
to the Plymouth Division Koval Marines (dated Feb. llth,.
1891); George A. Waters, M.D., to the iloowerany; Walter
J. Bearblock to the Hearty; Thomas Austin to the Karra-
katta; and George M'Shane to the Seagxdl (undated).
Volunteer Corps. — Injantry: Mersey Brigade: Sur¬
geon and Surgeon Major T. M. Wills, 4bh Volunteer
Battalion, the King’s (Liverpool Regiment), to be Brigade
Surgeon, ranking as Lieutenant-Colonel (dated Feb. llth,
1891).— Rifle: 2l8t Middlesex (the Finsbury): Acting Sur¬
geon E. W. F. Stiven, M.D., to be Surgeon (dated Feb. 7bh,
1891).—Isfc Tower Hamlets (the Tower Hamlets Rifle Volun¬
teer Brigade): Geo. Gunnis Ferguson, M B., to be Acting
Surgeon (dated Feb. 7bh, 1891).
FREDERICK SIMMS, M.B. Lond., M.R.C.P.
We regret to announce the death of Dr. Simms, of
Mandeville street, Manchester-square, and Yew Cottage,
Twickenham, which occurred unexpectedly on Friday,
Feb. Gtli, at the age of fifty-six. He was seized with,
apoplexy, from which he never rallied, and passed away in
a few hours. For some time he had been in delicate health,
but nothing to make his friends in any way prepared for so
sudden a termination to the life so dear to them. Dr.
Simms was born at Greenwich, his father being a civil
engineer who had attained eminence in his profession, and
to whom his son was tenderly attached, retaining to the
last a most profound reverence for all that pertained to hie
father’s memory. He was educated at the Rochester
Grammar School, and subsequently at King’s College,
London. Everything connected with the sea possessed
a great charm for him, and shortly after graduating
he had the opportunity of indulging this taste, in con¬
junction with hia medical duties, by taking charge of
troops to India. Subsequently, Dr. Simms settled at
Twickenham, where he engaged in general practice for
eight years, when failing health induced him to relinquish
the work, to the great regret of his patients, amongst whom
he was deservedly popular. After this he commenced a
consulting practice in London, applying himself with special
interest to dermatology. He was appointed consulting
physician to the Twickenham Provident Dispensary and
John the Baptist Hospital, where he enjoyed the esteem,
and respect of his colleagues. By his generous, courteous,
and loveable disposition, Dr. Simms won the hearts of all
with whom he came in contact; his high sense of justice-
and strict adherence to professional etiquette were very
noticeable traits in his character. The good exercised by
the quiet, kindly influence of such men is deep and wide -
spreading, and in many places, especially in Twickenham,
where he lived so long, the memory of tnis true Christian
gentleman, “who wore the white flower of a blameless,
The Lancet,]
KOYAL COLLEGE OF SURGEONS OF ENGLAND.
life,” will be long cherished. Dr. Simins was twice married;
he leaves a widow and several sons and daughters. His only
published work with which we are acquainted is “ A Winter
in Paris.”
CHARLES RICHARD CROSSLEY, M.R.C.S., J.P.
Leicester and its vicinity have suffered a severe loss by
the death of this esteemed surgeon, which took place on
Jan. dth last, after a prolonged and painful illness. Mr.
Crossley occupied the post of surgeon to the Leicester In-
fiiroary for a quarter of a century, and in the discharge of
the duties of that oillce displayed remarkable dexterity,
conjoined with sound judgment. In his private practice
the confidence of his patients was secured by the firmness
and transparent honesty of bis advice, whilst his sympathy
with the suffering readily obtained for him the position of
family friend. Mr. Crossley took a great interest in
political and municipal affairs, and in the exercue of his
magisterial functions he commanded the high respect of his
colleagues on the bench. He died at the age of sixty-six,
leaving a widow, one daughter, and three sons, two of whom
were bis partners in practice. A notice in a local news¬
paper of the decease of Mr. Crossley closes with these
w’ords:—“We cannot in our sadness forget that Charles
Richard Crossley, whose name will always be uttered by
his fellow townsmen with respectful pride, was one of those
who leave behind them examples of devotion to duty, of
love for noble aims, and of manly goodness which the world
must be better for striving to follow.”
PROFESSOR GAETANO LEOPARDI.
This able consultant and estimable citizen died at
Florence on the night of Jan. 17bh, leaving a blank not
easily to be filled in the roll of Tuscan physicians.
Gaetano Leopardi was born at Jesi on Sept. 17th, 1830,
and was early marked out by intellectual giits and moral
predilection for the medical career. Like all his con¬
temporaries, with few exceptions, he took an enthusiastic
part in the struggle for national unity and independence ;
and if in his ca«e, as in that of others, academic study had
for a time to be postponed to patriotic service, the loss to
special education was made up for by the moulding of
character in the ennobling school of generous aspiration
and self'Sacriiicing discipline. He entered heart and soul
into committee work among his fellow-students for the
organisation of volunteer forces, and when that was done
he served fearlessly in the ranks against the common
enemy. He suffered exile with others of his young com-
atriots, till at length the events of 1859 and 1860 made
taly, with the exception of Venetia and the States of the
Ghurcb, mistress in her own household.
Leopardi resumed, with characteristic ardour, the studies
:so frequently interrupted, and by sedulous work at the
.schools of Pisa and Florence made ample reparation for the
time and opportunity he had lost. He graduated with dis¬
tinction in 1860, and on May 23rd of that year was nomi¬
nated assistant to the celebrated Florentine consultant and
teacher, Professor Cipriani. Florence, always the city of
his predilection, had now become his home, and he rose
rapialy in the esteem of his colleagues and in the confidence
of an ever-widening clicnUle. Once and again, however, he
*Uowed his patriotic sympathies to carry him outside the
professional pathway, and in 1866 and in lS67 he aided with
all the means at his command the movement which led in
the former year to the cession of Venetia, and in the latter
to the temporary defeat of Garibaldi at Mentana. But
when three short years thereafter the Hag of united Italy
was hoisted in the Capitol, no Italian reverted with greater
devotion to special work than Gaetano Leopardi. Aca¬
demic promotion now came to him rapidly. In 1878 he had
liaen to be clinical professor and lecturer on Pathology in
the Florentine School, and in the following year accepted
the post of Professor of Clinical and Pathological Medicine
in the University of Cagliari in the island of Sardinia. In
1882 he was transferred to a Professorship in the same
subjects in the University of Siena; but Florence once
•more asserted her old charm for him, and he returned to her
school to fill the post of “ Extraordinary Professor of
Special Pathology, Medical and I’ropmdeutic." This chair,
in his hands, became extremely attractive, and he discharged
QCs duties with progros-ively increasing acceptance, in spite
of the calls of a widely extended practice, which summoned
him in consultation to all parts of Italy, especially to Milan,
[Feb. 14,1891. 403
Rome, and Naples. His power of inspiring confidence at
the bedside was by general admission remarkable, assisted
as it was by the “light address,” the “hilarisvuUus” of
Celsus, and by the impression be conveyed of being some¬
thing more tlian a practitioner—an illustration, in fact, of
the memorable saying that “a great physician is a great
artist.” Benevolence, shown in a thousand distinctive
traits, was another note of bis character which the patient
intuitively felt, and whether in the ward of the hospital,
the dwelling of the poor, or the mansion of the grandee he
exemplified the beautiful Indian proverb: “Is a man ill?
The physician is hia father. Does he recover? The phy¬
sician is bis friend. Is he convalescent and fully restored
to health? The physician is his guardian.” In keeping
with his great popularity as a professional man and citizen,
his funeral was one of the most impressive ever witnessed
in Florence—neither Puccinotti, nor Bufalini, nor Cipriani
having been followed to the grave by a more numerous or a
more distinguished train of mourners. Though an advanced
Liberal in politics and a non-Catholie in religion, men of all
parties and creeds joined in paying the last tribute to his
memory, and, round his grave in the Protestant cemetery of
the Allori, were represented by their several spokesmen in
oraisons fundhres inspired by a common sympathy as by a
common sense of loss.
ROYAL COLLEGE OF SURGEONS OF
ENGLAND.
At an ordinary meeting of the Council held on Thursday
last the minutes of the quarterly Council on the 8th nit.
were read and confirmed. The minutes of the Museum
Committee on the 6bh inst., as the report from that Com¬
mittee, were also read and confirmed. A further report was
read from the Committee on the Extension of the College
pieniises, adopted, and entered on the minutes.
A report was read from the Laboratories Committee and
adopted. There are now fifteen Fellows or Members of
the College engaged in various researches in, the new
laboratories.
A letter of the 0th inst. from Mr. Arthur Milman, Regis¬
trar of the University of London, forwarding by direction of
the Senate copies of the Revised Scheme for the Reconsti¬
tution of the University, upon the basis of which the Senate
propose to invite Convocation to concur in applying lor a
New Charter, was read. The scheme waa approved and
entered on the minutes.
A letter was read, dated the 11th inst., from Mr. Ernest
J. Wilde, with reference to the “ meetings of Fellows,”
enclosing an opinion by the Attorney-General and Mr.
Paget, to the effect that the Council have the power to
summon meetings of the Fellows independently of the
Members. We propose to give the text of this opinion in
the next issue of The L.\ncet.
Dr. Liveingreported the proceedings of the Royal College
of Physicians with respect to affairs concerning the two
Colleges.
Mr. Hill moved and Mr. Macnamara seconded the follow¬
ing resolution, which was carried—“That members of the
Council who desire to nominate Members of the College of
twenty years’ standing for election to the Fellowship by
ballot in April shall submit such names at the meeting of
the Council in December in each year, and that such names
be circulated among the members of the Council before the
meeting in January.”
licbiral flcfos.
Examining Board in England by the Royal
Colleges of Physicians and Surgeons.— The following
gentlemen, having passed the necessary examinations, have
been admitted Diplomates in Public Ilealth :—
Brafca, Joao Francisco, L.S.A., King's College and Edinburgli.
Hrodie, Williani llnig, M.l). Eiiin., Kdinburgli University.
Ci'opley, Henry, F.H.O.S, Eng., Louiion Hospital.
Dyer, Sidney Reginald, M.l>. lirux., L.ll.C.l’. Loud., M.K.C.S., Mid¬
dlesex llospital.
Field, Oliver, M.D. Edin.. L.B.C.P. Loud., M.R,C..S., Edialiurgh
University.
Firtli, Robert Hammell, F.R.U.S. Eng., University College Hospital.
Hart, George Henry, M.R.C.S., L.R.C. F. Edin., Birmingliain.
Uaslip George Ernest, M.D, Brux., L.U.C.l*. Loud., M K.C.S., London
Hospital.
Digitized by Google
404 Thb Lancet,]
MEDICAL NEWS.
[Feb. 14,1891.
Hlchens, fYank, M.D. Land., M.U.C.S., Lonclou Hospital.
Holroyde, John, M.R.C.S., London Hospital.
Hussey, Edward, M.D. Durh.JL.E.C.P. & S. Edin., Sheffield, Edin¬
burgh, and Charing-cross Hospitals.
Kenwood, Harry Richard, M.B. Edin., L.R.C.P. Lond., London Hos¬
pital.
McOachen, Frederic 'Wm. Dobson, L.F.P.S. Glasg., London Hospital.
Mallina, Clement, M.D. Dub., Dublin.
Norton, John, M.D. Durh., M.R.C.S., Westminster Hospital.
Eoughton, Walter, L.R.C.P. Lond., M.E.C.S., St. Bartholomew’s
Hospital.
Stirling, Alexander Williamson, M.D. Edin., Edinburgh and Uni¬
versity College Hospital.
Tebb, Wra. Scott, M.D. Camb., L.E.C.P. Lond.,M.E.C.S., St.Thomas’s
Aospital and Cambridge.
Wilde, Leonard, M.D. Durh., LE.C.P. Lond., M.E.C.S., St. Thomas’s
Hospit^.
Eoyal College of Surgeons of England_
The following gentleman, having passed the necessary
examinations, and having attained the legal age (twenty-
five), was at an ordinary meeting of the Council on the
12thinst., admitted a Fellow of the College :—
Deanesly, Edward, M.D. Lond., University College Hospital. Diploma
of Member dated June 21tb, 1S87.
Society op Apothecaries of London.—T he
following candidates passed the First Examination in
January last in the subjects indicated :—
Chemistry.—1>. Berne, E. B, Greaves, B. Grange, T. L. Jolijiston.
Materia Medica, Botany, and Pharmacy.—B.. Dodds. T. H. P. Peers.
Materia Medica and Botany.—K. M. Hunter, F. K. Eider.
Pharmacy.—F. R. Rouse.
The following candidates passed the Second Examination:
Anatomy and Physiology. —W. Ashby, G. H. Baird, G. W. Brabyn,
E. S. Cbilcotb, S. A. Clarke, T. S. Collin, F. A. Cregeen, A. B.
PVaney, A. H. Grace, G. Higgin.son, H. Howells, A. S. F. Hudson,
W. A. King, A. li. Matwood, S. R. Merry, J. 0, Netherton, C. St. H.
Eobinson, J. D. Seller, J. R. Shotton, J. Stott, R. W. F. Welch.
Anatomy.—C. Bayley, O. E. Douglas.
Physiology. —A. Baldwin, H. C. Venis.
Surgery.—^. H. Adams, W. L. W. Buss, R. A. Earle, E. J. Finch, R.
A. Irvine, A, E. Mayner, B. F. Parish, G. J. Rutherford, S.C. Smith,
J. D. H. Smyth, G. R. F. Stilwell, J. F. Twist, E. B. Wrench.
Medicine, Forensic Medicine, and Uiavnjcry. —0. A. Beck, L. J. Winter,
R. B. Moms, G. Wilkinson.
Medicine and Midwifery.—G. C. W. Williams, E. H. Willock.
Medicine. —P. G. Laver.
Forensic Medicine.—^. C. Coopland.
To Messrs. Adams, Beck, Buss, Finch, Irvine, Morris, and
Wilkinson were granted the diploma of the Society, having
passed in all the subjects required for registration.
University of Dublin.— The foUowing degrees
have been conferred by the Vice-Chancellor:—
Bachelor in Surgery. —Percival Cecil Ryan.
Bachelor in Medicine, Surgery, and Obstetrics. — GeoTge Percival
Adamson, Michael Josepli Bulger, George Cole-Baker. Francis
William Dobbin, Robert Marshal Going, John George Moyles, Jolin
Ryan, Terence Woulfe-Managan.
Doctor in Medicine.—ChuTlea Kcroyd McNaught, Henry McQiiade,
William Andrews Morton, John Ryan, Perceval Cecil Hardingo
Ryan.
Conjoint Scheme of the Royal Colleges of
Physicians and Surgeons, Ireland. — The following
have passed their Final Examination :—
J. A. Burland, T. G. Dillon, A. N. Heron, A. H, Jacob, John Mackenzie,
G. H. Moorhead, G. N. D. Oakes, Joshua Pirn.
Passed in Medicine.—M. F. Cahill, Ilarry Oullin.an, J. C. Ryan.
Passed in Surgery. —H. Cullinan, Michael G, Dobbyii, W. L. Fisher,
J, C. Ryan, J. A. 'Tliompson.
Passed in Midiuifery, etc.—M. F. Cahill, M. O. Dobbyn, W. Smartt.
Royal Statistical Society.— At tho ordinary
meeting of the Society, to be held on Tuesday ne.xfc in the
lecture-theatre of the Museum of Practical Geology, .Fermyn-
street, at 7.45 P.M., Dr. Arthur Newaholme, D.P.H., will
read a paper on the Vital Statistics of Artisans’ Dwellings.
Wigan Medical Society.—T he following office¬
bearers have been elected for 1891 President: C. M.
Brady, Esq., L.R.C.S.I. Committee: Messrs. M. Benson,
G. H. Monks, jun., W. C. Barnisli, J. B Stuart, J. A.
Marsden, and I’J. Hannah. Treasurer: G. H. Monks, jun.,
L.R.C.P. & S. Ed. Secretary : Wm. Berry, F.Il.C.S.i.
Thompson Memorial Institution for In¬
curables, Lisburn.—T he annual report for 1890 shows
that at the end of the previous year there were fifty-four
patients in the home, and that eleven bad since been ad¬
mitted. Only six deaths had occurred during the twelve
months. The death of Dr. H. S. Ferguson, one of the
trustees, is recorded with regret. The general statement
of accounts shows a balance in hand of £628 5$., and the
investments (including £334 2s. , at interest at banker s)
now amounted to £54,308 16^. Id.
St. Thomas's Hospital. — We are informed hy
the authorities that at a Court of Governors of the hospital,
held on the 4th inst.. Dr. Felix Semen, Assistant Physician
forDiseases of the Throat, was granted the title of Physician.
Seamen’s Hospital Society.—A t tho meeting of
the Society to be held at the P. & 0. Company’s offices on
the 17th inst., Sir Thomas Sutherland, K C.M.G., M.P.,
Lord Brassey, the Danish Minister, and the Austrian
Consul-General are expected to be present.
Suicide of a Medical Practitioner. — Mr.
A. Braxton Hicks held an inquest on Feb. 5bh on
the body of Edmund Wollaston Parkinson, M.ll.C.S.j
L.R.C.P. Edin., aged forty-six, who committed suicide by
taking prussic acid on Jan. 31st, at the residence of
Mr. Boyd, L.S.A., of Lavender-hill. On Saturday
Mr. Boyd discovered the deceased lying on the couch,
pulseless and breathing heavily, and a bottle which had
contained prussic acid was found near the couch.
The Oldham Medical Practitioners and Dr.
Niven. —The outcome of a recent meeting of the members
of the profession in this town, who deputed Dr. Niven ta
visit Berlin for the purpose of investigating, on the spot,
Professor Koch’s discovery, is the ofleriiig by the subscribers
to the Berlin fund, for Dr. Niven’s acceptance, a cheque for
£70, to defray the expenses of his visit, at the same time
conveying to him their thanks for going to Berlin on their
behalf, as well as for the information he has given them on
the whole subject of tuberculosis, and the ready assistance
he has rendered in adopting Koch’s treatment.
Association of Public Sanitary Inspectors.—
Dr. B. W. Richardson, the president, occupied the chair at
the eighth annual dinner of this Association, held on Satur¬
day evening at the Holborn Restaurant. A large assembly
attended. The chairman, in a vigorous speech, proposed
the toast of the evening, “Success to the Association of
Public Sanitary Inspectors.” He said it was to prevent
avoidable causes of death that the Association laboured.
With them everything was from the first a question of
dealing with primary causes of disease and taking them
away. Other toasts followed, and the festival terminated.
Royal Free Hospital, Gray’s-inn-road.—T h©
sixty-third annual report, just circulated, is of a very satis¬
factory character. The work accomplished during the past
year has been attended with marked success. The re¬
building of the front, or fourth side (now the only remains
of the old building), has become a pressing necessity. The
estimated cost of the reconstruction, with other necessary
improvements, will be about £20,000. A special fund for
this purpose was opened in J anuary, 1890, and £229116s. 5rf.
has been received. It is proposed to hold a festival dinner
in the approaching spring on behalf of the hospital, and the
committee invite the cooperation of subscribers and friends
of the charity to render the festival a success. During the
year the in-patients numbered 2138, the out-patients 17,203,
and casualties 10,894.
Guy’s Hospital.—W c learn that the Court of
Governors of Guy’s Hospital have acceded to the request of
the staff for increased accommodation in the Medical
School. The existing carpenters’ shops within the hospital
grounds had fallen into such a dilapidated condition that it
was necessary either at once to undertake very costly
repairs or to rebuild them, and the latter alternative being
preferred, the Court decided to combine with it a consider¬
able extension of the hospital and school. The proposed
buildings comprise a dental department consisting of b*
conservation room llOft. long and 24ft. wide, with space
for fifty operating chairs. The room, which has a northern
aspect, will be constructed upon the model of the existing
conservation mom, which, though erected no longer ago-
than 1889, is already too small for the needs of the rapidly
increasing dental school. Beneath the conservation room
will be the dental laboratory, measuring Gaft, by 2tft.,in
which thirty students can work at one time : and beneath
the laboratory will be tlie waiting rooms for male and
female patients, with the necessary conveniences. The
total cost, inclusive of tho hospital workshops, is estimated
at £10,000, and the architects are Messrs. Woodd and
Ainslie, of 35, New Bond-street, who lately designed the
residential college.
Die: z:: t GoOglc
The Lancet,]
MEDICAL NOTES IN PARLIAMENT.
[Feb. 14, 1891. 405
Vaccination Grant. — Mr. Beaveti Kake,
M.E.C.S. Eng. andL.S.A., has, for the ninth consecutive
time, received the Government grant for efBcient vaccina¬
tion in the No. 2 District of the Fordingbridge Union.
MmwiVEs’ Eegistration Bill.—T he following
resolution has been passed by the Board of the Medical De¬
partment of the Yorkshire College :—“ The Board considers
that there is great need for improvement in the education of
mid wives, and recognises the necessity for legislation in order
to provide for their efficient training, their examination,
registration, and subsequent supervision. It does not, how¬
ever, approve of the Midwives’ Registration Bill now be¬
fore Parliament, which it believes to be imperfect in detail;
and is of opinion that it would be inexpedient to pass it in
its present form.”
Royal Meteorological SociE’nr.—At the ordi¬
nary meeting of the Society, to be held at 25, Great
George-street, Westminster, on the 18th inst., at 7 P.M.,
the following papers will be read: “The Great Frost of
1890-1891,” by Charles Harding, F.R.Met. Soc.; “ On the
Variations of the Rainfall at Cherrapoonjee in the Khasi
Hills, Assam,” by H. F. Blanford, F.R.S.; “ The Problem
of Probable Error as Applied to Meteorology,” by T. W.
Backhouse. The twelfth annual exhibition of meteorolo¬
gical instruments will be held at the same rooms from
March 3rd to 19th.
METROPOLITAN ASYLUMS BOARD.
Return of Patients remain^ in the several Fever Hospitals
of the Board at tnidnigrU on February 10th, 1891.
Beds occupied. |
6
jl.
Hospital.
Is
1
Q
S 9
li
i
t
it
Eastern Hospital .. ..
237
60
48
2
838
M8
North-Western Hospital
260
80*
9
289
448
Western „
160
24
13
T
198
224
South-Western „
168
14
5
1
178
840
Bouth-Easteni „
196
16
30
4*
246
462
Northern
276
15
23
814
480
Gore Farm „
0
-
-
-
9
800
Totals .. _ ..
1286
148
128
8
1671
2691
* Inlantfj with motheiH.
MEDICAL NOTES IN PARLIAMENT.
City of London Lying-in Hospital. — Mr.
Charles Gordon presided at the 140th annual meeting of this
hospital, which was held on Wednesday at the institu¬
tion, City-road. The report, which was adopted, showed
that 423 poor women had keen assisted in their hour of trial
during the past year. In addition, 1331 mothers bad been
«,ttended at their own homes by the medical staff. Out of
the whole number, only four women had died. In the
course of the speeches delivered by the various governors
present, gratifying reference was made to the continued
light mortality, the medical officer attributing it to
the excellence of the sanitary arrangements at the
hospital.
French Hospital and Dispensary. —The twenty-
third annual dinner in aid of the funds of this charity took
place at the Hotel M6tropole on Saturday evening last, the
chair being taken by his Excellency the French Ambassador,
supported py the Lord Mayor and the Sheriffs of London,
the Italian Ambassador, the Persian Minister, and represen¬
tatives of the diplomatic corps of a large number of foreign
countries, being present, the total number of guests being
little short of 250. The report, read by the honorary secre¬
tary, Mr. RulFer, showed that during the past year the insti¬
tution has afforded relief to 14,873 out-patients and to 490
(in-patients, belonging to no leas than twenty different
nationalities, forwthough French in name the institution
prides itself upon being essentially of a cosmopolitan cha¬
racter. Subscriptions were promised during the evening
amounting to nearly £2500. The usual toasts were
drank, musical interludes being provided under the able
direction of Cavaliere Tito Mattel, with the gratuitous
assistance of Mdlle. Trebelli, Mr. Orlando Harley, and
Mdlle. de Bono. The committee and the assistant secretary,
Mr. F. Sorel, are to be congratulated upon the success of
the evening, which surpassea all its predecessors.
St. Martin's-in-the-Fields Free Public Library.
A large and iniluential assembly met in the reference room
of the library on the 12bh inst. on the occasion of the opening
of this institution by the Right Hon. W. E. Gladstone.
Mr. Gladstone was received by the Commissioners, and after
cigning the visitors book was presented with a very hand-
come, inscribed silverkey. The Rev. John F. Kitto, the Vicar,
presented a catalogue of the library to Mr. Gladstone. In
declaring the library open, the right hon. gentleman referred
specially to Mr. Ewart, the author of the Public Libraries
Act. During the last year over seventy new libraries had
been opened, and the time was approaching when they
would be strewn over the land in cities and in villages, and
thus provide means of healthy recreation for ihe youth of
the country. A vote of thanks to Mr. Gladstone was pro¬
posed by the Right Hon. W. H. Smith, M.P., member Ifor
the borough, and seconded by the Right Hon. Lord Kin-
naird, senior church warden of the parish, and carried with
acclamation.
The Indian Hospital Corps.
In the House of Commons on Monday evening Sir W. Foster asked
the Under-Secrotary of State for India whether it was the case that the
men of the Indian Hospital Coi-pa and hearer companies in war time re¬
ceived less rations tliaii the Sepoy; were allowed only 10 lb. weight of
kit against 331b. allowed to the Sepoy; were entirely unarmed when in
the field ; and were rewarded only by a bron/.e medal, while the Sepoy
received a silver one; and whether anything could be done to remedy
these conditions.—Sir J. Gorst: The statements in the question are
substantially correct. The arrangements referred to are made by the
military authorities in India, and the Secretary of State sees no ground
for interfering with them.
New Bills.
A Bill to make better provision for tli« regulation and control of
cemeteries was brought in ny Mr. J. \V. Sidebotham, and was read a
first time.
Mr. Matthews.—A Bill to amend the law relating to factories and
workshops.
The Leeward Island/).
On Tuesday Baron H. de Worms, in answer to SirT. Esmonde, said the
medical officer of the public institutions in Dominica had been instructed
toinquire into and report upon tbe progress and treatmentofthe disease
of “ yaws " in the Loewanl and Windward Islands. During his mission
he would bo relieved of the duties of bis office. The expenses of the
inquiry would be paid out of the funds of the several islands in which it
would’bo hqld. The inquiry had not been instituted in deference to any
demand of the medical faculty or people of any of the West Indian
colonies. Notit^e was given in February, 1800, in the Federal CouncU of
the Leeward Islands of a resolution in favour of providing for a portion
of the cost of such an inquiry, but the resolution was withdrawn.
THE HOUSE OF LORDS’ COMMITTEE ON HOSPITALS.
Tire Select Committee of the House of Lords on the Metropolitaa
Hospitals resumed its inquiry on Monday, Lord Sandhurst presiding.
St. George's Hospital.
Tire first witness examined was Mr. C. L. Todd, the Secretary of
St. George’s Ho.spitai. In reply to the chaii-man he stated that his salary
amounted to £401). He had held his present office for twenty years. The
hospital was founded in 1783. It was practically a free hospital. Of
tho 440(5 pationts last year only 840 were admitted on subsenbera
letters. They had no paying beds, and no charge was made upon out-
pationts. The beds numbered SOC, and the average number daily occu¬
pied was about 335. In the early part of Hst year they had to close
.several wards because of the nurses being aifoctod with influenza. If two
c.a.ses were alike in point of urgency nnu gravity the case with the sub¬
scriber's lotterwould have itio first admission. It would only be in such
circumstances that auy distinction would be made. As matter of fact
tlie subscribers' or governors’ lottom wore of littlo use. At one time
a provision existed against receiving pationts witli an income of £1C a
year or move. It was tliouglit to be too liard a rule, and was soon with¬
drawn. Of the pationts admitted, 16 per cent, wore domestic servants,
(5 per cent., however, being out of situations. The masters of servants
never paid anything for tlie treatment of their servants, but they often
miide contributions to tlio funds of the lio.spital afterwMus. The
liospital was most frequeutod by tiio labouring classes. They drew
pationts from tlie ItatLersea, I'nlhaui, Putney. Wandswortli, and other
district Some wards liiul accommodation only for twelve beds, others
accommodated tweuty-tliree or twenty-five beds. In tho new wings
tho space was lOOi) cubic feet per patient, and in some of the other
wards (.lie space was only lOOU cubic feet per patient. Some of the
doctors would like t.« see a few bods removed from some of tho wards.
Tho matter was under the considomtion of the Board. A groat many
of tholr patients bolonged to the very de.stituto class. The? had
often to give relief to wives and families while tho husbaivda
were in tlio hospital. They did this work through tbe Saman^
.Society Only a very few of their patients could afford to pay for
medical treatment. They had often, especially in winter, to send aivay
Digiti.icd b
.Google
406 Thb Lai<cbt,]
THE HOUSE OF LORDS’ COMMITTEE ON HOSPITALS.
[Fm 14,1891.
Mople who sought admission to the hospital. Every now and then the
house physician or surgeon went round to see if there was a patient fit
to go home, in order that room might be found for a new case. He
agreed in thinking that intercommunication between the different
hospitals might be advantageous. They frequently sent patients on to
Westminster and St. Thomas’s, having no room for them at St George’s;
and it often happened that tliose two hospitsla wero filled, and the
patients came back to St. George's, when they wore sent home. The
accommodation for the sick poor was certainly dollcient in-their
district. He imagined that the same state of things existed in other
districts. No out-patient received assistance till a .satisfactory report
had been received from the Charity Organisation Society or tiie
chaplain of the hospital. The total expencliture of the hospital List
year amounted to £28,310. Tliey derived their income from subscrip¬
tions, donations, dividends, legacies, and rents. The bnildiiigs were
rated ■ at £1584. They had about 1000 governors, all of whom
might attend the Weekly Board. It was this Board whicii, with
the aid of a number of committees, managed the institution. Any
complaints with reforence to nursing were bi'ouglit before the Nursing
Committee. Complaints as to the patients’ food came before the
witness, and if they wero worth reporting ho reported them to tl»e
Board. Such complaints were very few. Their hospital being very
oentriiJly situated, they had constant visits from tlio governors. It was
therefore not difficult to get the opinion of a governor in matters of
complaint. They had four or moro governors every mouth whose
business it was to go round tiie wards day or niglit and make all
manner of inquiry and report to tho Board. Tiiby inquired with
special care as to tlie food of tho patients. This inquiry gave
patients an opportunity to make complaint if they desired. They called
their head nur.sos in fSt. George’s Hospital not sisters, but bead jmrses,
Tliere liad been great improvement i!i thoir nursing dopartmeiib during
tiie last ten years. Each nurse liad now a separate room ; at one time
two nurses occupied each Iroom. Tho iiead nurses came <jn duty at
seven o’clock in the morning, and wero relieved at ten o'clock at night.
They had breakfast, lunch, and supper in thoir own sitting-rooms, and
wont down for dinner to tlio nurses’ dining-room at four o’flock. They
liad two hours' leave every day from live to seven or from seven to
nine o'clock. Each iiead nui-so bad two rooms. Tho d.ay nurses
breakfasted at half-past six o’clock, and were on duty in the wards at
seven o'clock. They dined from half-past twelve till one, and wero
allowed half an hour for tea. They had supper at half-past nine o’clock,
and when supper was over tlieir duty for that day ceased, Tlioy wore
off duty every other day from <J,4r> till 10 o’clock. They had two weeks'
holiday and one day off every month. For a long time they had had no
nurses who died from typhoid or diplitheria. The matron liad power
to suspend, but nob to dismiss tho nurses. In tli'e event of any of tiie
nurses being taken ill, they wore placed in the nurses’ sick room, where
they were attended by the resident medical officer. They engaged a largo
number of nurses for special cases. Tlio night nurses wont on duty at
half-post nine o'clock until nine o’clock the next morning. Tlie hours
of the nurses consequently overlapped at the time of day wlieii most
work had to be done. Thoir head nurses remained a long time with
them, one nurse having been twenty years and another fourteen years.
The ward nui'ses engaged to stay three ye.ars, and often stayed longer.
The pupils in the hospital wei'o under tiie Medical Committee. Any
case of misconduct would conic before tho Board for investigation The
idea of transplanting St. Cioorge'sinthe country had never been seriously
considered, althongli it had been talked of in the neighbourhood.—By
Lord Sayo and Sole : The mortuary was beneath one of the wards.
The present dingy appearance of the hospital was due to contemplated
alterations. In all probability tlie building would bo painted tbij year.—
By Lord Cathcart: Tho surgeons could not obtain any new appliances
without the assent of the Bnard. Tliere was no undue expenditure for
novelties in the way of surgical anpliances. Naturally they got the
beat system of treatment they could for the patients. Tiie probability was
that if the surgeon.s asked for a thing they got it.—By Lord /.ouche :
They did not take cases of scarlet fever. Last year they lia<l fifty-four
cases of diphtheria.—By Lord Thring : 'J'hoy were anxiou.s to increase
their nursing staff, and only want of accommodation prevented them
doing BO. At present they were engaged in negotiations for the acejui-
sition of certain liou.se.s in which to accommodate nurses.— y>y tiie
Earl of Hiuderdalo ; Tho stock held by the hospital amoimtod to
*^41,000, and yielded an annual return of £12,042.—By tho (Jhairman ;
Some years ago, when tliey wore in low walcj', tlioy sold off stock to the
extent of .-CSilUO or £4000 yearly; they appealcil to tho public several
times. In recent years, through the receipt of laigo legacies, thoir cir¬
cumstances had imnrovod, and appeals to the public had not been
found necessary, Thoir collector received 4 per cent, on all money he
collected, and 1 per cent, on money sent tliroiigli tho bank.
Mr. H. 11. Glutton, senior assistant surgeon to St. Thomas's Hospital,
gave evidence as to tlie out-patient and particularly the siirgical out¬
patient work ill connexion with St. Thom.as’s Hospital. No surgical
cases, ho said, wui'o refused. Ho found that surgical cases were not
attended by general practitioners, and wero sent by tliem to tlie hospital.
General practitioners appealed to have loss facility in treating surgical
than medical cases. Tliey had not the appliances for the former. He
entirely dissented from tho view tliat so far as surgical cases wore con-
coined tho hospitals starved llio gonoral practitionors. The hospitals
were of advantage to the general practitioners as affording a consulting
authority. The cases sent by general practitionors for consultation
wero very often the liest cases for teaching purposes. They usually
possessed most scientific interest. Hu was strongly in favour of tliu
out-patient system from every point of view. Tlio loss of the surgical
department would bo most serious to general practitioners. Ho
beliovod there was more outcry against the out-patient system tlian the
facts justified.—By Lord Oathcart; Ho held very strongly that the
large medical schools were better with the liospitals. Ho tliouglit the
present schooling was hotter tlian could be gob at a largo contral
institution.
Dr. Whipliam, dean of the medical school of St. George’s Hospital,
said there wero about 142 students in tlio school, the fee paid for tho
whole curriculum being £120. Tho income of tlio school amounted to
something under £0UOD, and the expenses to about ’£21)00. Tlie balance
went to the lecturers and officers. ■ As to ihe general question of
education, he thought the practical part of the profession must he
taught at the liospitals. 'Tlie scientifipC part plight be better taught at
a great central institution where first m'sknppliances would bo found.
Under the .present system the medical school and nob the hospital paid
the cost of the apparatus.
Dr. Isambard Owen, senior assistant physician at St. Qeorge’»
Hospital, gave evidence as to the remuneration of the lecturers and
clinical teachers. At the present time no one in the St. George's
Hospital Medical School received more than £100 or less than £30 out
of the school. He could not describe their out-patient department a»
crowded. He did not think there were too many medical schools In.
Loudon. If it were found desirable to take awav certain subjects from
the hospitals, he thought they could be taken out of London altogether
to tho provincial colleges, .where he- believed they could be better
taught tlian In any crowded, institatiou in London. Ho thought there-
ijvoind be no difficulty in obtaining first class teachers in those pro¬
vincial colleges.
The Committee then atljoumed.
Tho Committee mot again, on Thursday.
Mr. Robert Bra.ss, receiver of St. Tliomas’s Hospital, attended for
the third time, and gave further evidence as to the finances of tbafi'
institution. ,
MidAlenex Marital.
Mr. I'. <’. Melbado;- of Middlesex Hospital, oxaminod by the-
F.arl of Kimbcrlev. said he was secretary and superintendent, with a.
salary of .£300, and hoard and residence. Tlio hospital was managed by
a weekly board, whibh met every Tuesday, and a board of governors.
The institution was founded as long ago as 1745. There were 307 beds,
and the daily average of patients was between 250 and 2C0. Only 201^
bods were devoted to medical and surgical cases ; that number included.
34 bods for cancer cases. Thoir funds did not permit of all the beda
being occupied, although they did not refii.se patients when they had
vacant beds. Lsist year the income of the hospital was derived in thia
fa.shion : Dividends, .i;03B7 ; annual subscriptions, £2851; donations,
£(1538: alni.s boxes, .£295 ; Hospital Sunday Fund, £2083 ; Hospital Satur-
dayFiind, £411 (rents, ,£1061; and incidental receipts, £100; total, £20,634.
'I'heir average income was about £1.5,000 or £10,000, last year being a-
specially good year. Their disbursements last year amounted to
£27,117, wnicli included an extraordinary expenditure of £2584. Thoir-
average expenditure was about £23,000. The apparent deficit had boei*.
mot by tlie legacies. It was their habit to cany all the legacies to-
capital account, from which they drew as they required. As matter of
fact they had no delicit last year, but a consiiferable surplus. Tlie
Middlosex was practic.ally a free hospital. Any sick person might
apply for ailmission. The applicants were seen by one of the
ailmitting cfficevs, wlio passed them on to the resident medicalt
officer, '['he cases were selected according to thoir urgency. Last
yea.r they admitted 3109 patients. I’he sisfcoi-s received £30 a year,
with board and lodging, and they wore entitled to pensions-
after twenty years’ service. Throe nurses at tlie pre.sent time received
pensions. The .stuff nurses were also entitled to pensions. In the hos¬
pital there wore lady probationers, who paid one guinea a week. Th&
sisters came on duty at 8 A.M. and left at 11 p.m. They wore actually
on duty about cloven hours daily. 'J'hoy liad passes for two hours during
four days of the week. No sisters were employed during tbe night, but-
a night superintendent was constantly going round the wards. The-
sisters had tlireo weeks’ holiday each year, and a day oft each montli.
’I’hc .staff nur.ses canic on duty at 7.30 a.m., and remained on duty till
iii-.M. The actual hours on <luty were about ten per day. They had)
passes for Cliree hours during throo days of tho weeK. Tlioy had sixteen
days’annual holiday, and one day off in each altovnale month. The-
ordinary probationers worked under tho samo conditions ivs tbe stafT
nurses, but tlio lady probationers had shortor hours. The probationers,
received no holiday until they had completed one year.
The liai'l of Kimberley { Is that reasonable '! Wa have boon told tliat-
niu'ses new to the work are less able bo liear tlie strain than ex¬
perienced nurses.— Mr. Melliado: It has not been considered neces¬
sary to give them si lioTiday.—The Earl of Kimberley; Have yois
found many probationers break down in health’f—Mr. Melh.-ulo; I can¬
not say that >ve havp. .'I’lio average number of nuvso.s off duty on account
of sickness was iv little over two, and of lady probationers, leas than one-
daily. During tlie last twenty years they had only had nine deaths
among thoir nurses.- -Tho Earl of-Kimberley ; ’What is the ground on
which you don’t employ your most responsible nurses or sister-} during;
the night'.'—Mr. Meniado: There is never so much to do during tlie-
night.—The Earl of Kimborloy ; Do you think it satisfactory to hanA
over the natients during the night to what may bo termed socond-clasa
mir.ses’'—Mr. Melhado replied that the senior mirso was respousible-
during tho night. Tlicy hiul not atiupmmodatiou for a double supply of
nurses. The sisters lived on the ".sdnio floor as thoir ward, ancf wor&:
aroiiHod during tho night if occasion domatided it. They supplied tlio-
piiblic with mirsu.s wiio liad been at least throo years in the bospital..
Since 1887 the Nursing Institute had been earriod on and liad boon
atteiiclud with the best results. 'I’ho authovitios of the hospital wore^
perfectly satisfied with the working of the institute, 'i'he profit dorived
from this department went to tho funds of the institute, not to those of
tlio hospital.-—By Lord Sandhurst: If they had more acconnnodatioin
it would be (lesirabla to have more nurses in tho hospital.—By Lord
Gathcart: Tea and sugar were not included in tho diet of the hospital
patients had to pay for tliose commodities. If tlioy could not pay tboy
were supplied gratiiiloiisly.—Lord Gatlicart: Then your position is
diffei'cnt irnm that of the London Ho.spital, where tho tea is put into-
ono lot and there is a common brew.—By tlie Earl of I,aiiderdale : Thoir-
gross capital amounted to .£252,780 oil .Tan. let of tliis year. Ten year*
ago it amounted to £172,600. Tlie inereasts had Iioen very recent. For
many years the capital was a doci-eaaing amount.—By Lord Monkswoll :
His inquiry as to tho menus of an applicant' was limited to persoiiai
intori'ogation of the applicant. They liad no. regular aystoiu of inquiry
which he could put in force.
Mr. Edward Fanloii, the resident medical officer at tho Middle.soj:
Hospital, said he received a salary of'£260, with board and lodging.
He had general medical supervision of the hospital so far as the sani¬
tary arrangemonta wore coneortied, and w.as responsible for all tlie ad-
ml.Hsiona. Within a radius of one mile of the Middlesex Hospital thoro
were eight general hospitals and a largo number of special hospitals.
In this area tliere were over 2006 .bods; in thirty-four hospitals and
seven dispensaries. Those figures did ncit include poor law iiifinnarlea
and dispensaries. 'J'he out-patient department of tho Middlesex
Hospital was inooJiveiiientlycrqwded'. Occasionally ho liad been im¬
pressed with the appearance dfi'df'^aiiefi't’as indicating his ability to
pay for medical U-eatment, attfDho -haiL-made inquiry, and in the
iniyority of instances, when ho had done so, lie found they wero
deserving cases. It rarely happened that he detected any case of groso
Thb LAMOBT,] APPOINTMENTS.-VACANCIES—births, marriages, & deaths. [Feb. 14,1891. 407
abase of the charlt? of the institution. He did not think that an
inquiry ofBcor would he worth bis pay.—By the Ifiavl of Kimberley: On
an average iiOO out-patients were examined each day. A much smaller
inumber would suffice for instruction. The treatment of the surplus
could only be defended on the ground of charity. He regarded it
as unfortunate tliat people should accept hospital relief without fooling
'that they were paupers. None of the slight cases at the Middlesex
Hospital were handed over to advanced students.
Mr. A. Pearce Gould, Dean of the Medical School at the Middlesex
Hospital, said tliat last year they had li!7 new entiios, including
’66 genertil, 7 dental, and 65 occasional students. On an average there
were between 260 and 800 students in attendance. Por the full curri-
•culum the fee was lilOO if paid in advance, illlO if paid in instalments.
The fees yielded about £5000, and the expenses of the school amounted
to over £2000.
The Committee afterwards adjourned.
%pntmtnts.
Buccet^ful applicants/or Vacancies, Seoretariea qf_ Pubtie Tnstitutiom, and
others possessing ic\formalion suitable for this column, a/re invited to
/wworS if fo The Lancet OJJlce, directed to the Sub-Editor, not later
than 9 o'clock on the Thursday morning of each week for pubmafion in
the neat number. —
Andrew, Henry, M.II.C..S., L.R.C.P., has been appointed Assistant
House Surgeon to the Devon and Exeter Hospital.
AuDUCKLE, H. W., M.D. Abortl., I..E,P..S. Glasg,, has been reappointed
Medical Officer of Health for Thorne, Doncaster.
Bandury, G. K. S., L.KC.P. Lond., M.It.O.S., has been appointed
Medical Officer for the North 'fawton District of the Okehampton
Union.
Blackledok, W. T., L.R.C.P., L.R.C.S. KUin., has been appointed
Medical Officer for the Nassington District of the Oundlo Union,
UlRUNSlCtLL, R. R., M.B|, B.Ch. Dub., has been appointed Medical
Officer at the Carlisle Dispensary, vice Graham, resignod.
■CoLLiNGRiDOE, W., M.D. Camb., M,R.C.S., has been reappointed
Medical Officer of Healtli for the Port of London.
Crawford, .James, M.D., M.R.C.P.Lond. & Ircl., L.M., has boon
appointed Honorary Physician-Acoouclieur to the bhiTingdon
^nerat Dispensary and Lying-in Charity, vice J. Tanner, M.D.,
resigned.
CritciH.EY, H. G., M.B., C.M., L.R.C.S. Edin,, has boon appointed
Senior House Surgoon at the Ipswicli and East Suffolk Hospitul.
fRASEU, P., M.D. Edin., has been appointed Medical Officer of
Health for the Llangefni Urban Sanitary Distilct of the Anglesea
Union.
•Gaiie, J. R., M.D. Brussels, M.R.C.S., has been reappointed Medical
Officer for the 'I'hird District of the Holborn Union.
■GOnther, T., M.D. Tubingen, L.B.C.P. Loud., ha.s been reappointed
Medioal Officer of Health for llampton-Wiek.
Hyatt, J. T,, L.R.C.1*. Edin., M.U.C.S., has been appointed Medical
Officer of the Workhouse, Shepton Mallet Union, vice B. N. Hyatt,
deceased.
Joy, F. W., L.R.C.P. Edin., M.R.C.S., has been reappointed Medical
Officer of Health for the Borough of Thetford and Itural District.
Madden, T. More, Obstetric Pnyslcian and Gyna'cologist to the
Mater Misericordbo Hospital, Dublin, has been appointed one of the
Masters of the National Lying-in Hospital. |
MaRRINER, W. H. L., M.B. Lond., M.R.C..S., has been appointed
Medical Officer to the Bourne Valley and Di.strict-s Dispensary.
IMH-burn, P. L., M.B.C.H., has been reappointed Medical Officer for
the Fourth District of the Holborn Union.
Milligan, William, M.B,, CM., liss been appointed Honorary
Assistant Jffiysician to the Manchester Hospital for Con.sumption.
Napier, A. D. Leith, M.D., F.B.H. Ed., M.E.C.P., has boon appointed
Physician to Out-patients, Chelsea Hospital for Women, vice II. S.
lluthorfoord, M.B., M.Il.C.P., resigned.
Pink, Tlios.. Irl.R.O.y., has been appointed Medical Officer for the
KlngsclifFe District of the Oundle Union.
Pi;gh,,J. W., M.R.C.S., has boon appointed Modic.al Officer for the
Eastern District of the Parish of Brighton.
Read, M., M.1>. Candi., M.R.O.S., has boon appointed Medical Officer
of Health for Worcester, vice Strange, doceasod.
Saunders, W. S., M.D. (U.S.), L.R.0.1’. Edin., M.R.C.S., has lieon
roappointe<l Medical Officer of Health and I’ublic Analyst for the
City of London.
Southwell, C. H., has boon appointed Public Analyst for parts of
Holland, Lincolnshiro.
Sutton, F., M.R,C.S., has been reappointed Medical Officer of the
Reynard Hospital, Willingham.
WiiiTCOMiiE. P,, M.R.C.S., has been appointed Medical Officer of the
Hospital at Gravesend.
Wbiuiit, T. P., M.R.C.S., has been reappointed Medical Officer of
Health for St. Noots, Hunts,
fatOTafs.
For further ii^fonnation regarding each vacancy r^erence should 6« made
to the advertisement.
•Cambridge.—A ssistant Medical Officer for the Camiiriclgo l•■rlemlly
Hoelotlea’Medical Association. (Apply to tho Socrotary, 20, Mawsoii-
road, Oambridgo.)
Cheltenham General irosi’iTAi,.— Junior House Surgeon. .Salary
£40 per ainnira, with boanl and apartmouts.
Doncaster (licNKiiAi, Infirmary and Dispensary.—H ouse Surgeon.
Salary .Cl00 per annum, with board and residoiice in tho liospital.
Grnkrai, Hospital, Birmingham,--Resident Medical Officer. Salary
£180 perannum, with roaidoucc, board, and washing.
Great Northern Central Hospital, HoIloway-ro%d, N.—A Oaaualty
Officer, who will bo required to act as Registrar and Assistant
Anmsthotiat. Honorarium at tho rate of 50 guineas per annum.
Great Northern Oentoal Hospital, Holloway-road, N.—Surgeon to
the Out-patients of this Hospital.
Grosvenor Hospital for Women and Children, Westminster,
S.W.—.Surgeon.
Hospital for Consumption and Diseases of the Chest. Brompton.—
House Physicians.
Hospital for Sjcic Children, Great Ormond-atreet, Bloomsbury.—
Surgical Registrar for one year. Honorarium of £40 at the end of
tho term,
Liverpool Royai, Southern Hospital.-J unior House Surgeon.
Salary 00 guineas per annum, with beard and residence.
LuiTERWORTi! UNION.—Medical Officer for No, 0 Di.strict. Salary £20
per annum, with the usual extra medical fees as allowed under the
orders of the Local Government Board. (Apply to the Clerk to the
Guardians, Lutterworth.)
National Dental Hospital, 149, Great Portland-street, W.—House
Surgeon. Salary £50 per annum.
Newcastle-on-Tyne Dispensary.—R esident Medical Officer. Salary
£250 per annum, with furnished residence.
North Staffordshire Infirmary and Fye Hospital, Hartshill,
Stoke-upon-Trent.—Assistant House Surgeon for six months. No
salary, but board, apartments, and washing provided.
Owen.s College, Mancliester,—Demonstrator in Pathology. The
stipend is £140 per annum.
Parochiai, Board of Ii'ettercairn.—M edical Officer. (Apply to Dr.
Pi'ain, F'ettercairn.)
ROYAi- Ho,spiTAL FOR SiCK CHILDREN, Olasgow.—Assistant House
Surgeon. Salary £80, with board and washing.
Royal south London Dispensari'.—S urgeon in Ordinary. (Apply to
Dr. Nundy, at tho Dispensary, St. George's-cross, S.E.)
Royal Victoria Hospital, Bournemouth.—House Surgeon and Secre¬
tary. Salary £80 per annum, with board.
Salford Union.—A Visiting Medical Officer. Salary £160 per annum.
Salford Union.—Two Resident Assistant Medical Officers for tho
Union Infirmary, Hope, near Kccles. Salary £130 per annum each,
with furnished apartmenUsin the infirmary.
St. Tiiomas'.s Hospital, Westminster.—Surgeon.
University of GLA.8ao\v.—Examiners in Medicine. Tho annual fee to
each of the Examiners is £80. Term of office in each case is four
yeai-s.
West Bromwich Di.strict Hospital.—A ssistant House Surgeon for
six months. No salary, but board, lodging, and washing in the
hospital.
^irfljs, Psm!i0fs, sn^i
BIRTHS.
Hewitt.—O n Feb. 8th, at Oakloigh, Northwich, Cheshire, tho wife of
Dr. David Basil Hewitt, of a son.
NEWBOULD.—On Feb, 6th, at Abbots Bromley, Staffs, the wife of
Nowtou J. Newhould, L.R.C.S., L.H.C.P.Edlii., of a daughter.
Stoner.—O n b'ob. Uth, at Rio Lodge, Brighton, the wife of Charles
Herrington Stoner, D.D.S,, L.D.S., of a sou.
Terry.—O n Fob. Si-d, at Hope House, Tangier, Morocco, the wife of
C. L. Terry, B.A., M.B., C.M., of a son.
MARRIAGES.
Bullivant—Butler.—O n Feb. 4th, at St. John’s, Mansfield, Samuel
Builivant, M.R.C.S., L.B.C.P., youngest son of Mr. J. T. Bulllvant,
of Ashgrove, Edwlnatowo, to Ethel Mary Godber, younger daughter
of Mr. Arthur J. Butler, Dale Close.
Morton— GOODOIIU.D.—On Feb. 7th, at St. Maik’s Church, Hamilton-
tnrrace, liy tho Rev. Canon Duckworth, D.D,, assisted by the Rev.
G. Ward Saunders, R.A., and the Rov, Edward Bate. B.A., Edwin
Morton, M.D., of Uedditch, son of tho late Vicar of Welton, Staffs,
to Amie Emily, youngest daughter of the late JohnGoodcliild, Esq.,
of Chelsea and Barwoll Court, Walton-on-Thaines.
ScilACHT—C hapman.—O n Feb. 10th, at St. Jude’s tihureh, South
singbon, Frank Frederic Schiicht, M.D., to Agatha Louisa, eldest
daughter of Robert Barclay Chapman, US.I.
DEATHS.
Daw'SON.—O n Fob. (Ith, at 9, Anindel-teiTaco, Brigliton, Richard
Dawson, M.D. Edin., L.R O.P. Lond,, M.R.O.S. Eng., aged 76.
Martyn,—O n Feb. fith. at AHhlcigh, S. Columb, Cornwall, Pliomas
Darko Martyn, M.R.O.S. Eng., Hgoil 81. o tt
Raynf.s.—O n Feh. Vth, at Chiin'li-sti-uet, South Normaiiton, S. H.
:^ynos, L.R.C.P. Lond., M.R.C.S. ^ . 17 „
Sawtell —On Feb. 4th, at I’illa ICMpcmiwe, Costobolle.IIytires,France,
Tom Henry Sasvlell, M.D, Lond., M.Il.C.P., aged 80. ,
Simms.—O n Jan. 0th, at 'J'wickenliam, suddenly, of apoplexy, Fredodok
Simms, M.B. Lond., M.H.UP-, of 0, Mandeville-place, Maachester-
Storfbu—( hf h'elL Oth, at I.owilhnin Orange, Notts, Charles Storer,
STHHUiLANiL-ihfFJb.’ 8th, at Royal Naval Sick (Quarters, Portland
Henry George Travers StriclUand, M.B., Slalf Surgeon R.N., aged 38.
TimMiR.—On Feh. Otli, at Egromont, Thicket-road, Anorloy, S.B.,
Dr, Arthur Newman Turner, agocUO.
Warren —On Jan 8lst, at Exinouth, S. Devon, Honry t liarlea Warren,
M.R.O.S. Eng , L,S.A. Lend,, aged 68.
WoTiiERSPOON —On Fell. 10th, at Brampton, Cumberland, Thomas
Allan Wothorspoon, M.D., L.R.C.S. Edin., and J.P„ aged 43.
y.B.—A fee of 6s. is barged for the Insertion of Notices <f
Marriages, arid Dtaths,
408 Ths Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Feb. 14,1891.
METEOROLOQiCAL READINGS.
(Taken daily at 8.t0 a,m. by Steteard's InetrwnenU.)
Thb Lamcst OfQce, Feb. 12tb, 1861
DaM.
Bwemstei
reduced to
Beal«vel
end 33*7.
Dlree-
tion
o(
Wind.
Wet
Bulb.
Bolat
Bsdle
in
Vaouo.
Mui-
mum
Shade.
Min.
Temp
Boln-
feU.
Bemuktat
aso AM.
Feb. 6
SO'Od
W.
41
40
68
49
39
Overcast
.. 7
30'66
H.W.
46
46
48
41
Foggy
>. 8
80-42
N.E.
42
41
46
41
Overcast
•• 9
80-40
E.
38
Xi
42
87
Overcast
„ 10
80 89
W.
35
34
69
44
34
Overcast
>• 11
80-35
s w.
85
34
76
61
34
Hazv
„ 12
80-32
N.W.
45
42
66
47
85
Cloudy
Units, Cnmmenls, ^ ^nsters In
CnrnspDnirtiils.
It is especially requested that early intelligence ^ local
events hamna a medAcal interest, or which it is (Arable
to bring under the notice of the profession, may be sent
direct to this Office.
All cornsnunications relating to the editoriai business of the
journal must be addressed “ To the Editors.”
Lectwes, origincd articles, and reports shordd he written on
one side only of the paper.
Letters, wheth^ interMed for insertion or for private in-
formation, must be authenticated by the names and
addresses of their writers, not necessartly for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
he marked and addressea “ To the Sub-Editor.*'
Letters relating to the publication, sale, and advertising
departments of The Lancet to be addressed **To the
PwUsher.”
We eamnot undertake to return MSS, not used.
Persistent Dandruff.
A CORRESPONDENT writes from the General Hospital, Madras: “ Seeing
an article on ' Persistent Dandruff,’ by Dr. Blake, in your issue of
Dec. 27th, 1890, it may interest yon to know that a perfect cure has
in my case resulted from following the direcliona given in your corre¬
spondence columns more than eleven years ago. The letter 1
allude to was signed ‘Purnell Purnell,'and dated from Strcathain-
bUl, May 6th, 1879. I have always felt most grateful for the relief
obtained.”
ifr. W. J. .Euan*.—1. A first-class Leltz microscope, with 12th oil im¬
mersion, a 7tb and a 2-8rd inch, with Abbe illuminator, nose-piece, &c.
(an excellent instrximent for bacteriological work) maybe obtained for
£17 10*.—2. Reichert's and Leitz's microscopes are good.
Dr. A. F. EfiioCf.—The Society for the Relief of Widows and Orphans of
Medical Men, 20, Hanover-square, W.; British Medical Benevolent
Fund, Secretary, Mr. E. East, 16, Upper Berkeley-street, W.
HARD TIMES IN THE PROFESSION.
To tho Editors of The LANCET.
Sirs,—I must apologise for trespassing on your valuable columns for
the purpose of dealing with so long-vexed a question as the above; but
having seen some correspondence on the matter a short time since, 1
should just like to say a few words.
That the medical profession is both an honourable and charitable
calling cannot be denied, the large numbers that are constantly
enlisted into its ranks being the sole cause of its present unhappy
state. Whilst travelling through various parts of England I have
had repeated opportunities of observing the various devices of
the so-called “penny doctor" of obtaining practice. One gentle¬
man, who holds the M.D. degree of a bcotch university and
was lately house surgeon of a provincial hospital, has a huge
signboard on the front of his house, stating that ho treats free
of charge to the poor on certain days all diseases of the lungs, blood,
liver, kidneys, and many other ailments which are too numerous to
mention. To those who are in better circumstances ho makes the
modest charge of 2d. for advice and medicine. In another district is to
be found the doctor who rents a shop with two large plate-glass
windows elaborately painted in gold letters, stating that it i.s a
“Hospital for Women and Children, free to tho deserving poor" on
certain days, flo long as we have this sort of man amongst us wo
need never hope to keep up the dignity of the profession or abolish tho
quack with his various forms of unskilled practice, and hard times will
still remain among some of us who try to work conscientiously and
with all decorum due to our learned profession.
I am, Sirs, yours obediently,
February, 1801. An Ouseuver.
Explosion of Religious Mania near Palermo.
A tragedy, uniqu© (say our Italian contemporaries) in the annals oF
criminal lunacy, has just been enacted at Mezzoinso, in the province-
of Palermo. On the night of the 2lBt ult. the family of a peasant-
named Carnesi, consisting of three young women and two boys,,
became suddenly maniacal, and left their home in a wild storm,
vociferating loudly, in quest of the nearest chxircb. The village'
authorities immediately put the unhappy creatures under restraint,,
the boys being closely guarded under their father’s roof, while the-
young women were watched by the relatives to whose charge they
were entrusted, and the preliminaries to their all being sent to the
Manicoroio of Palermo were at once proceeded with. On the evening
of the 22nd one of tho young women, a fine girl of eighteen, rose from
bed, and, having awoke her relatives, assured them that the Lord
had worked a miracle on her brother Biagio. She took oS her ear¬
rings, suspended them from a crucifix on the wall, and by dint of
entreaty prevailed on the superstitious elders to accompany her to
her father's house, where Biagio was being guarded. Arrived there,,
she got the whole household to kneel down, and then, without a note-
of warning, she seized a heavy piece of wood, and dealt a series of
violent blows on her brother's head, her strength appearing to be'
redoubled at sight of the blood that flowed freely from his wounds.
In a few minutes tlie wretched boy was a corpse, whereupon, with
the cries and gestures of an infuriated beast of prey, she set upon his-
lifeless body, and with bands and teeth emasculated him (evirt U
cadavers). The relatives and guardians of the boy, paralysed with
superstitious fear, looked on at the horrid deed without Taising a
hand to prevent it. The village authorities, on being informed of the-
occurrence, put the girl into confinement, and all those who witnessed
tho scene under arrest. Tanlum rcligio potuit suadere malorum!
Bnix. might make application to the Secretary of the Brussels Medical
Graduates’ Association—Dr. Steele, 1, Florence-terrace, Ealing.
“CONSTIPATION AND GASTRIC DISEASE.”
To tits Editors of TUB Lancet.
Sirs,—I n reply to your correspondent “Rustic L.R.C.P.,” who, in.
your last issue, asked for suggestions for treatment-, I beg to submit the
following, and shall be glad to hear if it has been of any service
As this is a chronic case and apparently due to torpidity of the-
muscular coat from over-distension &c., I think the rational indica¬
tions would be the use of nervo-muscular intestinal stimulants, preceded
by complete evacuation as by colocynth and blue pill (unless contra-indi¬
cated, or by injectio glycerini c. res. jalapa(Hocl{in), so as to thoroughly
empty the gut, and repeated every few weeks for a time. Then a mixture
of belladonna (for its action on the inhibitory intestinal nerves), strychnia
(to relieve spasm, <fec.), and If aniemia bo present fen-um tart, or ferri et
ammon. cit., with or withoutbismuth. subnit., twice aday. A pill contaVn-
iiig pepsin, sacch., gr. i. ; bismuth, subnit., gr. iss. ; strych., gr. ext.
belladonn. tr., gr, ipecac., gr. One or two of these pills at
midday. Leave out ipecac, if any special cardiac weakness exists. A
pill containing aloin, gr, I ; .strych., gr. ^ ; belladonna, gr. J ; cascara
sagrada, gr. i; every night, or one of the simplest and beat senna and
sulphur in the form of the p. glycyrrhiz® co., German Phar. Iff
aloin and cascara iji combination or senna and sulphur be unsuitable or-
fail, try the simple soda bicarb, exsic. and p. rhej, gr. iii, of each every
day before tiio midday meal. Encourage a regular habit; diet,,
digestion, and liver attended to ; and ensure sufficient muscular
exercise, mental relaxation, and other hygienic provisions, Avoid hot
fluids, tea and coffee, and stimulants, excepting, if necessary, very dry.
iced champagne. I am, Sirs, yours truly,
Fob. lOth, 1801. Von.
Diabetic Myopia.
Ophthalmologist.—Dr. Hirschberg baa recently pointed out that diabetes,,
xvhen it occurs in old persons, frequently induces changes in the lens
which, though not sufficient to cause a cloudiness, are nevetbhcloss-
capable of inducing a very perceptible degree of myopia. In some
cases where this myopia exists the commencement of lenticular
cataract may also he detected.
Cyclops.—By law the coroner is obliged to pay the fees of medisal-
witnesses as soon as the intiuest is over. In the event of his refusing,
to do so he could be .sued, or the matter might be referred to the'
Home Secretary.
‘“FUCHSINE BODIES' IN TUBERCULOSIS OP LUNG.”
I To the Editors of The Lancet.
Sirs,—I ohMcrvo a few printer's errors in my lottor on the above-
subject published in your impression of last week. The errors, though
they may appear in.signittcant, yet alter the meaning considerably.
They arc;—l. In line 13, tho misplacement of the comma, which ought
to come between tho wonts " area" and "on ” in the line above. 2. In
lino 211, the substitution of tho word “ place" forpfaceii. 3. In line 00,
omission of a comma between the words “acid ” and “ after,” and the-
placing of a period after tho word “minutes."
I am, Sirs, yours aitlifully
Feb, 9th, issil. G. Carrington PuRvia
Dig::'z3cl Coogic
Tbi Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. (Feb. 14, 1891. 400
A Question op Priority.
Under the beading “The Truth at Last” the Tintea and Begiiter
(Jan. 20bh) maintains that Dr. Dixon's discovery of the prophy¬
lactic value of sterilised cultures of the tubercle bacillus is a
clear anticipation of Prof. Koch's work. But Dr. Dixon did “ not con¬
sider his lymph an agent that could he usefully and safely employed
on man, and this is his opinion to-day.” It is concluded that
“Koch deserves great credit for his acuteness in recognising the
importance of Dixon’s work, and for his boldness in extending the
use of the lymph to the treatment of tuberculosis in man."
Ur. F. Sdnchez.—l. Any of the largo general hospitals to which medical
schools are attached.—2. Surgery—Brichsen; Operative Surgery-
Stimson, Heath; Practice of Medicine—Hilton Fagge; Therapeutics—
Ilinger, Hale White.
'•A MEDICAL HAT."
To the Editors of Thb Lancet.
Sirs,—I t seems to me that the suggestion of your correspondent in
to-day’s issue, that medical men should wear a distinguishing hat, is
one which commends itself to everybody. I would, however, sxiggest
that as conspicuousness seems to be an object of your correspondent, it
is a pity to adopt a hat with a low crown. Why not have one with a
decided leneth of cylinder—let us say three feet long? It would beso
readily discerned at a distance. Further, in order to render the doctor
still more easily recognised, I would propose to have the tile painted
sky-blue and varnished, or decorated in any other manner to suit the
taste of the wearer, after the style of the gentlemen of the ring on the
racecourse. And while on this subject, why limit oneself to a bat ? A
fancy dress or a Pickwickian costume would look picturesque, and, I
am sure, would not fall to attract the attention of strangers and others
who might be requiring the services of a medical man. The subject is
one that is capable of vast extension, and I doubt not would be readily
adopted if properly brought to tlie notice of the lending members of the
profession. I am. Sirs, yours faithfully,
London, Feb. 7th, 1891. O. W.
Self-mutilation by an Imbecile.
The Revista Uddica mentions that a short time since a poor half-witted
nan walked into the hospital of San Vicente de Paul, in Santiago
(Chili), carrying his testes wrapped up in a piece of paper. No
information could be obtained from him or from other sources as to
how be had been mutilated. On examination a smalt aperture wa.8
found in the left side of the scrotum, through which botli testes had
apparently been dragged, and separated from the cotd and vessels as
high as possible. Notwithstanding some hfcmorrhage and other
troubles the man did well.
U.B.C.S. will see that the bard times in Scotland are all a joke. If he
will alter his letter to suit tbo circumstances as explained elsewhere,
we shall be glad to insert it.
En<}uirer. — Heidenhain'a “Animal Magnetism," Charcot, Bernhoim,
Liebault, Lloyd Tuckey.
A WARNING.
To the Editors of The Lancet.
Sirs,— 1 shall bo glad if you will allow me, through your columns, to
warn otiiers against a person calling himself a medical man and
former student of St, Thomas’s, under the name of Charles Iluthwaito.
I cannot find that name in any of our book.s; and the only medical man
of that name to be found on the Register or in tlie Medical Directory
died in 1888. 1 think it right to trouble you with this letter because
the person I refer to is in possession of .a sheet of note-paper from my
waiting room, stamped with my address, on which he appears, after
leaving me, to have written ray name, and the names of some of my
colleagues previously visited, together with an exaggerated statement
of the sum given to him by each (in reality only a few shillings). Tbia
paper he has, as I have since learaod, heen using in order to extort
larger gifts from anotlior colleague.—I am, Sirs, yours faithfully,
Wimpole-stroot, W.. Feb. lUli, 1801. E. NEiTLKsiiir.
Communications not noticed in our present number will receive atten¬
tion in OUT next.
Communications, Letters, Ao., have been received from—Dr. Lauder
Brunton, London; Dr. Cullingworth ; Dr. W. Duncan; Sir Spencer
Wells, London ; Mr. Tweedy, London ; Dr. Altbaus ; Mr. Braxton
Hicks, London ; Dr. Stoavenson, London; Dr. J. H. Garrett, Stoke
Newington ; Mr. J, II. Morgan, London ; Mr, Parker ; Dr. Stopford
Taylor, Liverpool; Mr, Armstrong, Ponto.sbui y ; Dr. Macnaughton
Jones, London; Dr. Lowe, Lincoln ; Mr. Cautloy, London; Mr, Gveig
Smith, Bristol; Br. D. E. Anderson, Paris ; Dr. Lange ; Mr. Clement
Lucas, London; Dr. Scattergood, Leeds j Mr. Mugford; Mr. Reginald
Harrison, Iiondon ; Mr. Warner, SlielHeld ; Messrs. Smith, Elder, and
Co., London ; Moaars. Livingstone, Edinburgh ; Messrs. Blondoau
et Cie., London; Br, McEwan, Prostonpans; Mr. Hordley, Stoke-
upon-Trent; H. Berlhier, Paris; Mr. Horiiihrook ; Mr. Hunter,Edin¬
burgh ; Mr. Bladen, StalFordshire ; Dr. Cobbett, Beckonham ; Dr. C.
Boyd, Dontnark-hil! ; Mr. Cheesbrough, Brampton ; Dr. E. Robinson,
Birmingham ; Mr. Burdett, London; Mr. Jessett. London; Dr. Little, ,
London; Dr. Leeson, Twickenham; Dr. Andrew, London; Dr. Nias,,
London; Dr. Muirbead, Edinburgh; Mr. Coles, London; Dr. Imlach,
Liverpool; Dr. Snow, Bournemouth; Dr. Charlotte Bllerby, London;
Dr. Harrison, Lincoln; Dr. Oriln ; Mr. Truman, Beading; Dr. Mayo
Robson, Leeds; Mr. W, A. Lane, London; Messrs. Richardson and
Co., Leicester; Mr. H. Sewill, London; Dr. O. Purvis; Mr. Albam
Doran, London ; Mr. DIckiiison-Lelgh, Jarrow; Messrs. Walker and
Weller, Malvern ; Dr. J. B. Harris, Norwood; Dr. Hamilton, Easir.
Dulwich ; Mrs. Scott, Madras ; Mr. Cauty, Liverpool; Messrs. Keene
and Co., London; Mr. Sanchex, Norwood; Messrs. Greenberg anA
Co., London; Dr. T. Oliver, Newcastle-on-Tyne; Messrs. Roberts and'
Jones; Mr, Cavendish, London; Dr. Smellie, Jarrow; Messrs. Elton
and Co., London; Dr. Drummond, Newcastle-on-Tyne; Dr. Keitbi
Napier, London; Surgeon-Major Parakh, Bombay; Messrs. Roid and
Donald, Perth; Dr. R. J. Lee; Dr. H. Davy, Exeter; Messrs. Crossley
and Co., London; Mr. W. Gardner, Adelaide; Messrs, Cassell and
Co.; Dr. Bentoul, London ; Dr. Bloke, London; Dr. Paris, Sierra
Leone; Dr. Towers-Smith; Dr. Ashby, Manchester; Mr. Laban, West
Bromwich; Dr. Steele, Algeria; Mr. Hawkea, London; Dr. ZiSer,
Budtipest; Mr. Considine, Ennis; Mr. Bryant, London; Mr. Gurner,
Pall Mall; Mr. Stiff, Birmingham; Mr. Girling, Halifax; Dr. Giffard,
Brighton; Mr. Carter, Liverpool; Mrs. Shipley, Stockton; Mr. E.
Nock, London; Mr. Morillier, Rotherhithe; Mr. C. Muller; Dr. A.
Mills, Brussels; Mr Nettleship, London; Mr. F. J. Davies, Aber-
earn; Mr. Hope, London; Mr. Woodcock, Bradford; Dr. Sutherland,
Whitelrall; Dr. Favrat, Madeira; Miss Davies, Liverpool; Mr. Sell,
London ; Mr. Aveling, London ; Mr. Marsden, Hornsey ; Mr. Merck,
Darmstadt; Mr. Mungall, Glasgow; Mr. Gravatt, London; Mr. C. J.
Bond,Leicester; Mr.Peeny; Mr.C.Q.Campbell,Saddleworth; Mr.P.
Parker, Bradford; Astragalus, London; Secretary, General Hospital,
Cheltenham; M.R.C.S.; G. W. j R. H. F.; Secretary, Royal Victoria-
Hospital, Bournemouth ; En^irer; Anthracosis, London; A. R. Z.,
London; M.B., C.M. ; M.D., Hampstead; M.A., London; Assistant,
London; Secretary, Cambridge ; Delta, London ; D., London ; M.D.,
London; Astonished; Surgeon ; A.; Bachelor, London.
Letters, each with eTwlosure, are also acknowledged from—Messrs. Lee
and Nightingale, Liverpool; Dr. Marsden, London; Messrs. Sba^
and Co., Glasgow; Dr. Jennings, Manchester; Miss Rogers, Colwyn
Bay; Dr. Duke, Eastbourne; Di. Owen, Gloucester; Messrs. Slinger
and Son, York; Mr. Mitchell, Taunton; Messrs. Hazell, Watson, and
Viney, London; Dr. Giacomo, Naples; Messrs. Richardson Bros, and
Co., Liverpool; Mr Lockwood, Huddersfield; Mr. Garlike, Ealing
Dene; Dr. Pogson, Durham; Mr. Tully, Hastings; Messrs. Wyleys
and Co., Coventry ; Mr. Cross, Ormesby; Miss Montgomery, North
Wales; Mr. Bush, Beth ; Mr. Howells, Aberdare ; Messrs. Findlater
and Martin, Edgeware; Dr. Harries, Sussex; Messrs. Burroughs and
Co..London; Col.Dashwood,Longhboro’; Messrs.Woolley, Sons, and
Co., Manchester; Mr. Mackenzie, Musselburgh; Mr. Aspinall, West
Kirby ; Mr. Duncan, Aberdeen ; Mr. Cook, Totnes ; Mr. Craig, Wick,
N.B.; Mr. Cooper, Bristol; Mr. Pickett, Notting-hill; Mrs. Godfrey,
Northampton; Dr. Ritchie, Otley; Mr. Butlin, London; Mr. Tyte,
Mlnchinliampton; Mr. Chapman, Horsley; Mr. A. C. Coles, Bourne¬
mouth ; Mr. J. Carter, London ; Mr. McLay, Rothesay; Mr. Brice,
Scarboro'i Mr. Hammett, Taunton; Mr. Twyford, Hanley; Mr. R.
Davis, London; Mr.Philips,Windsor; Mr.Crisp,Nottingham ; Mr.T.
Smith, Fleet-street; Dr. E. B. Reckitt, Boston; Mr. Brown, Highgate-
hill; Mr. Griffiths, Cambridge ; Mr. Owen, Fishguard; Mr. Trimble,
Enniskillen; Mr. Atherley, Rhyl; Mr. Grote, Cardiff; Mr. Qowes,
Colchester; Dr. Windle, Halifax; Mr. Baker, London; Messrs. Mann
and Son, London; Mr. Cochrane, Wigtonshiro; Messrs. Perkins and
Co,.London; Dr. Hooper, Ripley; Mr. O’Neilly.l'uam; Dr. Fox,Child’s
Hill; Mr. Hoffmann, Swansea; Mr. Sargant, Ramsgate; Dr. Leckie,
Pontppridd; Mr. Piggott, Cambs; Dr. Gordon,Witlieridge; Mr.Tliin,
Edinburgh; Mr. Brown. Streatbam; Mr. Heywood; Mr. Kelvin,Man¬
chester ; Davies, Pontypridd; B., London; M.D., London; Hackney
Furnishing Co.; General Hospital, Birmingham; Jeyes’ Sanitary
Compounds Co., London; W. B., Fiiisbury-cirous ; Secretary, Wostorni
Medical School, Glasgow; Assistant, London; V. V. V.; St. John
Ambulance, London ; Irrigation, London ; A. C. E., Southport; Nurse
Farrington, Ireland ; Delta, London ; Vere ; Manager, Zeeds Uercur;,’’
Office; M,D., Bideford ; Graduate, London; R. A., London ; Sister
Musgrave, Bolton; C. S., Manchester; Chiswick, London; J.L.K.,.
London ; Cromwell House, Northallerton ; Country, London; E. B.,.
Southampton; J. A. B., London ; X. Y. Z, London ; C. B. 0.; A. C. G.,.
London; Secretary, Deaconesses' Institute, Tottenham ; Medicus,
Leicester ; Mr. D., Earl's-court; Malton, London ; Hon. Sec., Kenil-
worte ; Medicus, Clapton; Thane, London ; E. A., London; Index,,
London; Beta, London; B.,London; //..Manchester; A. W. H.,
Norfolk : T. H. L., Brixton.
NnwsPAPKns.— Chronicle, Birmingham Daily Post, Bristol
lUcrcunj, SooUish Leader, Yorhshire Post, Dundee Advertiser, Northern.
Whig, LUuirpool Couria', Leeds Uercury, Eastern Press (NorurichL Bath
Gazette, Sussex Adoerlisar, Sfnnircal Herald, Lincoln Mercury, Windsor
and Eton Gazette, Uertfordshire Mercury, Insurance Record, Reading
Mercury, Mining Journal, Windsor and Eton Express, West Middlesex
Advertiser, Architect, Law Journal, Spectator, Surrey Advertiser, IFesf
Middlesex Standard, Berwickshire Nx-ws, Westminster Times, Pioneer,.
Bimdiuiham Daily Gazette, Lincoln Gazetlc, Bury Post, East Anglian
Times, Ohsej-ver, Leicester Daily Post, Oldham Standard, Hastings Inde¬
pendent, Dewsbury Reporter, Essex Standard, Grantham Journal, North.
Devon Herald, Cheltenham Examiner, d:e., have been received.
zed by CjOO^IC
410 The Lancet,}
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Feb. 14, 1S91.
gisrj for % titraing ®wfe.
Honday, February 16.
Botal London Opdihalmio Hospital, Moorfislds. —Operations
dally at 10 a.h.
Botal Westhinstbb Ophthalmic Hospital.—O perations, 1.80 p.m.,
and each day at the same hour.
Chelsea Hospital Poa Women.—O perations, 2.80 p.m. ; Thursday, 2.80.
8t. Mark's Hospital.—O perations, 2.30 p.m. ; Tuesday, 2.80 p.m.
Hospital foe Women, Soho-square. —Operations, 2 p.m., and on
Thursday at the same hour.
Metropolitan Free-hospital.—O perations, 2 p.m.
Boyal OaTHOP.£Dic Hospital.— derations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.m., and
each day in the week at the same hour.
University Colleob Hospital.-E arandThroatDepartment,9A.u.;
Thursday, 0 A.M.
London post-graduate Course.—R oyal London Ophthalmic Hospital,
Moorflelds: iP.M.jMr.W. Lang: Diseases of the Iris.—London Throat
Hospital, Gt. Portland-st.; 8 P.M., Mr. W. R. H. Stewart: Otorrhcea.
Throat Hospital (Golden-sq.).—5,80 p.m. Dr. J. W. Bond: Post Nasal
Growths. (Post-Graduate Course,)
Society of Arts.—8 p.m. Mr. Gisbert Kapp: The Electric Trans¬
mission of Power, (Cantor Lecture.)
Medical Society of London.—8.30 p.m. Clinical Evening. Dr.
Herrlngham : Asthma in a Boy.—Mr. Paget: Strangulated Hernia,
Gangrene of Bowel, recovery with a fistula.—Dr. Ewart and Mr.
Bennett: Dexio Cardia (without transposition of other viscera) and
Bronchiectasis, pulmonary incision and resection of rib for tlie
latter.—Dr. Rivers (for Dr. Jackson): A case of Treadler's Cramp.—
Mr. Edmund Owen : Amputation of Both Mamma! for Scivrhus.—
Sir Hugh Beevor: (1) Malformation of Heart, Defect of Ventricular
Septum; (2) Defective Development of Abdominal Parietes, Respi¬
ration entirely Costal.—Dr. Ewart : A case of Situs Inversus
Viscerum.—Mr.Sheilcl: Loose Body in Knee-joint of unusual size.—
Mr. Allingham: CaseafterTrephining.—Dr. Campbell: Lupus cases
under Koch’s Treatment.—Dr. de Havilland Hall; (1) Raynaud’s
Disease ; (2) Addison’s Disease; (3) Bronchocele.
Tuesday, February 17.
Bing's College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
43dt’S Hospital.—O perations, 1.80 p.m., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 p.m.
St. Thomas’s Hospital.—O phthalmic operations, 4 p.m. ; raday, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
St. Mary’s Hospital.—O perations, 1.80 P.M. Consultations, Monday
2.80 P.M. Skin Department, Monday and Thursday, 9.30 A.M.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Electro¬
therapeutics, same day, 2 p.m.
IjOndon Post-graduate Course.—B ethlem Hospital: 2 p.m., Dr.
Savage: General Paralysis of the Insane, Epilepsy.
Royal Institution.—3 p.m. Prof. V. Horsley: The Structure and
Functions of the Nervous System.
Society op Arts,—4.80p.m. Commander V. Lovett Cameron: Cliartered
Companies in Airica.
Royal Colutge of Physicians. — b p.m. Dr. Thorne Thorne:
Diphtheria, its Natural History and Prevention.
ntOYAL Statistical Society (Lecture Theatre, Museum of Practical
Geology, Jermyn-st., S.W,). 7,46 p.m. Dr. Arthur Nowsholmo:
The Vital Statistics of Peabody Buildings and other Artisans’ and
Labourers' Block Dwellings.
The Sanitary Institute (Parkes Museum. Margaret-st., W.).—8 p.m.
Professor W. H. Corfleld : Sanitary Appliances.
SPatholooical Society OF LONDON.—8.80P.M. Dr. .Toh Collins: Hyper¬
trophied Kidney, with Dilated Pelvis.—Mr. S. Paget: Imperforate
Rectum.—Dr. W. Ord : Aneurysm of the Aortic Arch opening into
the Superior Cava.—Mr. Bland Sutton :• Cervical Teeth.—Mr. B.
Ktts: Colmnnar-celled Carcinoma of Humerus Secondary to Car¬
cinoma of Rectum.—Mr. J. R. Lunn : Carcinoma of Kidney.—Mr.
J. J. Clarke: Effects of Intra-utorine Pressure on the irietus.—
Mr. W. G. Spencer : Exophthalmic Goitre in a Girl, causing death
by Asphyxia. Card Specimens by Dr. W. Hadden, Mr. G. H.
Makins, and Mr. S. G. Shattock.
WedneadaFi February 18.
National Orthopedic Hospital.—O perations, lo A.K.
Middlesex Hospital.—O perations, 1 p.m. Operations by the Obstetrio
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 P.M.
Surgical (Consultations, Thursday, 1.80 p.m.
Charing-cross Hospital.—O perations, S p.m., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.80 P.M.; Saturday, same hour.
London Hospital.—O perations, 2 f.m. Thursdays Saturday, same hour.
St. Peter’s Hospital, Covent-qarden.—O perations, 2 p.m.
Samaritan Free Hospital for Women and Children.—O peratlonB,
2.30 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
Hniversi'ty College Hospital.—O perations, 1.80 p.m. ; Skin Depart*
ment, 1.46 P.M.; Saturday, 9.16 a.m.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
CHILDREN'S Hospital, Great Orhond-street.—O perations, 9.80 a.h.;
Surgical Visits on Wednesday and Saturday at 9.16 a.h.
London Post-graduate Course.—H ospital for Consumption, Bromp¬
ton : 4 P.M., Dr. R. Maguire; The Pulse, witli Demonstrations.—
Royal London Ophthalmic Hospital, Moorfielda: 8 P.M., Mr. J. B.
Lawford: Optic Atrophy.
Throat Hosimtal (Golden-sq.).—6.30 p.m. Dr. Greville MacDonald:
Neuroses of the Jrfirynx. (Post-graduate Course.)
Epidemiological Society of London.—8 p.m. Dr. Louis C. Parkes:
The Relations of Saprophytic to Parasitic Micro-organisms.
Royal Microscopical Society.-8 p.m. Dr. W. B. Benham: Kminia
Equatorialis, a New Earthworm from Equatorial Africa.—Mr. T. B.
Kosseter; Cysticercus of Tienia Coronula Duj.
Society of Arts.—8 p.m. Cok Sir Charles Wilson: Methods and Pro¬
cesses of the Ordnance Survey.
The Sanit^y Institute (Parkes Museum, Margaret-st., W.).—8 P.M.
Dr. Louis Parkes : Model Dwellings in London, and Overcrowding
on Space. The paper will be followed by a Discussion.
Thursday, February 19.
St. George’s Hospital.—O perations, 1 p.m. Surgical Consultations,
Wednesday, 1.80 p.m. Ophthalmic Operations, Friday, 1.80 p.m.
University College Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 a.m.
London Post-graduate Course.-N ational Hospital for the Paralysed
and Epileptic: 2 p.m., Dr. Buzzard: Selected Cases.—Hospital for
Sick Children, Gt. Ormond-st.: 4 p.m., Dr. M. Lubbock : Anomalies
ofSpeech in Children and their Treatment.—LondonThroat Hospital,
Ot. Portland-st.: 8 P.M., Mr. G. Stoker: Chronic Glandular Disease
of the Pharynx and Naso-pharynx.
Royal Institution.— 3P,M. ProfeasorC.HubertH.Parry: ThePosition
of Lulli, Purcell, and Scarlatti in tiie History of the Opera (with
Musical lllu.strations).
Royal College of Physicians. — B p.m. Dr. Thorne Thorne :
Diphtheria, its Natural History and Prevention.
Friday, February 20.
Royal South London Ophthalbiic Hospital.—O perations, 2 p.m.
Cancer Hostital (Fulham-rd., S.W.). —4 p.m. Dr. F. A. Purcoll:
Cancer of Tongue and its Treatment.
London Post-graduate Course.—H ospital for Consumption, Bromp¬
ton : 4 P.M., Br. R. Maguire : Pulmonary Cavities.
Society of Arts.-4.80 p.m. Capt. Abney : The Science of Colour.
The Sanitary Institute (Parkes Museum. Margaret-st., W.).—8 p.m.
Mr. J. Wright Clarke : Details of Plumbers' Work.
Royal Institution.—O p.m. Di. B. B. Klein : Infectious Diseases,
their Nature, Cause, and Mode of Spread.
Saturday, February 21.
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.16 a.m.
London Post-graduate Course,—H ospital for Diseases of the Skin,
Blackfriars: 2 p.m., Dr. Payne: 'The Different ForniB of Lupus.-
Bethlem Hospital: 11 a.m..D r.Percy Smith: Clinical Demonstration.
Royal Institution.—3 p.m. TheRigbtHon. Lord Rayleigh: The Forces
of Cohesion.
SUBSCRIPTION.
Post Free to ant part of the United Kingdom.
OneYear. 12 6 | Six Months £0 18 B
To China AND India ...One Year l 16 IB
To THE Continent, Colonies, and United
States........... ...Ditto lu l
Post OfflceOrders and Cheques should be addressed to The Publisher,
Vbb Lancet OfiSce, 423, Strand, London, and crossed ** London and
Westminster Bank St. James's-square."
ADVERTISING.
Books and PubUcatlons-faeven lines and under) .£050
Official and General Announcements ... . .060
Trade and Miscellaneous Advertisements _ 0 i 0
Every additional Line 0 0 6
Front Page per Line 010
g uarterPage . . . . . . .110 0
all a Page _ _ _ . . . _2 16 0
An Entire Page .. . . ... ... .. — 660
The Publisher cannot hold himself responsible for the return of testl*
monials <Scc. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.— Advertisers are req^ueated to observe that 16 Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
An original and novel feature of “ The Lancet General Advertiser” is a special Index to Advertisements on pages 2 and 4, which not only
affords a ready means of finding any notice, bub is in Itself an additional advertisement.
Advertisements (to ensure insertion the same week)sbould be delivered at the Office not later than Wednesday, accompamed by a remittance.
Answers ate now received at this Office, by special arrangement, to Advertisements appearing In The 1.ancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subseriptloiu should be
addressed.
Adverdsementa are now received at all Messrs. W. H. Smith and Son's Hallway Bookstalls throngbout the United Kingdom and all olbev
Advertising Agents. _
Agent ftur tbe Advertlaement Department In Franoe'-J. ABTIEB, 66. Bne Caumartln. Parlii
, Google
THE LANCET, February 21, 1891
ABSTRACT OF THE
§xixtm.
Delivered in the Theatre of the Royal College of Surgeons,
Feb. l/fth, 1891,
By JONATHAN HUTCHINSON, F.B.S, LL.D.,
EX-PRESI1)ENT OV THE COLLWiE.
[After paying a tribute to the memory of the late Dr.
Matthews Duncan and the late Professor Marshall, Mr.
Hutchinson said]: The Hunterian Oration might with pro¬
priety be given in honour of the Hunter family, rather than of
one of its members. I may go further, and say that it should
not forget the Paul family either, for Paul was the maiden
Dame of the mother of William, James, and John Hunter,
<and of the grandmother of Joanna and Dr. Matthew Baillie*
May I venture on the practical suggestion that it would be
a matter of social convenience, great help to bibliographists,
^nd at the same time a mere act of justice to the maternal
parentage which we all share, if the maiden name of the
mother were always prefixed to that of the father? Thus,
for one generation at least, we should recognise that our
■mothers have, with our fathers, an equal share in the credit
accruing tothefamily name from the deeds of their children.
Under such a plan we should have a William Arden-
Shakespeare, a John Jeffrey-Milton, a John Paul-Hunter,
and a Matthew Hunter-Baillie. John Hunter’s brother
William was exactly ten years his senior, and died ten years
■before him, each having enjoyed a life of sixty-five years.
William Hunter, when quite a youth, pledged himself to
Ms friend Cullen that he would make his home. Long
■Calderwood, famous. He nobly fulfilled his promise, but
he yet failed of the reward, simply because a brother, ten
jears his junior, of whom at the time he made no account,
outstripped him and did it first. John was the first to be
'elected into the Royal Society, yet had there been no John
Hunter, William would have been accounted a genius. His
•fame was and is deservedly very great, but bis brother has
•eclipsed it. The similarity in the tastes and endowments
of the two brothers was 'indeed remarkable. Both were
resolute to base practical knowledge upon anatomical and
physiological research. Both zealously taught anatomy.
Both were indefatigable collectors of facts, and both made
iarge museums. That got together by Dr. Hunter, and
which he bequeathed to the University of Glasgow, is
probably, as the work of an individual, second in value
•only to that which is our priceless possession here. If
William displayed, perhaps, less of concentration of aim, it
was possibly due to yet wider universality of tastes. He
•collected nob only specimens in pathology and anatomy,
bub pictures, coins, and curios of all kinds. For some
-of these John also had desires, but as compared with liis
brother his energies were much more nearly restricted to
biological objects. It must, perhaps, also be admitted
that, although of almost equal energy and industry,
William enjoyed, in somewhat less vigour, that faculty
■of insight which was the secret of much of John’s success.
It is nob enough, however, to claim that part of the
•credit which attends the manifestation of genius should be
given to the parents and predecessors of the individual con¬
cerned. Biology knows but little of hero worship, and all
departures from her fundamental truths are uuwise and
mischievous. In proportion as we lose sight of the means
hy which really great men became what they were do we
■fail to learn the full lesson of their lives. To take a great
man and treat his career not as representative but as
{phenomenal, to place him on a pedestal and claim for him
the almost exclusive plaudits of his successors, is to
Tob his life of half its usefulness. The domain of science, as
that of letters, is a republic. We crown no kings, we know
nothing of oligarchs.
It has been too much the custom of Hunter’s bio¬
graphers—not, I gladly admit, of all—to represent him as
'the uneducated and uncouth son of a Seotcli farmer, and
as having been brought up for the trade of a cabinet-maker.
Mr. Luther Holden, in his excellent Oration ten years ago,
■did much to correct these misapprehensions. Briefly,
Ms maternal grandfather was the treasurer of Glasgow,
■and his father was of an old family—the Hunters of
No. 8521.
Hunterston. Here, again, biology may come to the
aid of history. Surely it was not without its meaning,
in reference to hereditary descent, that both the
Hunter brothers sufifered in early life, and through life,
from that disease which has been named not only the
Dominus Morborum but also the Morbus Dominorum, and
of which it has been well said that it destroys more wise
men than fools. Surely we may take the inheritance of
gout thus strongly manifested as more conclusive proof of
gentle blood than any which parish genealogies could
possibly offer. ImayaSd, in support of what f have just
said as to the importance of not forgetting our mothers,
that it was perhaps as likely that the inheritance came
from the Glasgow treasurer as from the owner of Long
Calderwood.
[Mr. Hutchinson proceeded to point out the historical
events which occurred in the lifetime of William Hunter
and the personages who were his contemporaries. He said]:
Amongst those whom Hunter may have met in London
were Wesley and Wilberforce, Adam Smith, Benjamin
Franklin, Reynolds, Johnson, Grose the antiquaiy, Erasmus
Darwin, Priestley, Banks, and Benjamin "West. With the
last two there is reason to think lie was intimate. The
French naturalist, M. Buffon, was born in 1707, and died in
1788. He began the publication of his great work on Natural
History (forty-four volumes) in 1749, and the first thirty-five
volumes were accessible to Hunter before the year 1788. In
them thedissections and anatomical descriptions were chiefly
byDaubenton. Whether Hunter possessed Bufibn’s works,or
had even seen them, I do not know. Valuable as they un¬
questionably are, they do not display any material traces
of that genius for systematic observation and scientific
grouping of facts which is the special glory of Hunter’s
work. Hunter’s true competitor in these respects was un¬
doubtedly Cuvier, who visited London in 1813, and saw
Hunter’s museum after its removal to our College. He in¬
vestigated its treasures with delight, and took back with him
to Paris drawings of many of the specimens. To this list of
botanists and naturalists who were Hunter’s contemporaries
the name of Linnmus must he added. He was Hunter’s
senior by twenty years, and died fifteen years before him.
Whatever may be our conclusion as to his descent,
it is, as has been pointed out by several of my prede¬
cessors iu this function, a great mistake to class Hunter
amongst self-taught men. From the time that he came to
London, when scarcely twenty-one, he occupied a position
in his brother’s home and anatomical school, which afforded
him unequalled opportunities. It is possible, but not
certain, tnat before coming to London he bad wasted two or
three years by working as a cabinet-maker in Glasgow.
There is no doubt that In boyhood he had received a good
Scotch education in elementary matters, and that during his
Glasgow life he must have bad fair opportunities for its
further development. I find it incredible that a brain so
active, with such a thirst for knowledge and such a love of
thought, could have been guilty of any material self-ueglect
during boyhood and adolescence. The child is father of the
man ; and I cannot doubt that John Hunter, as a boy at
borne and as a youth in Glasgow, displayed similar tastes
end like aptitudes to those which attained such splendid
development in his after life. He may have earned hU
wages in his brother-in-law’s work-room, but he never was
and never could have been a carpenter only.
Hunter was, we may suspect, not a great letter-writer,
and bis correspondence was probably as nothing compared
to that which constitutes the burden of life to many of us
in these days of the penny post. If we may take as an
example his curt references to a case of fungus cerebri
respecting which Dr. Jenuer had consulted him, be did not
enter into much detail in reference to the p.atient8 concern¬
ing whom he gave advice. Three letters contained scarcely
as many lines each to the boy’s case, whilst whole pages are
devoted to questions about cuckoos, hedgeliogs, and experi¬
ments on the beat of trees.
One of Hunter’s secrets of strength was his patience.
He speaks of having listened for an hour to the complaints
of a gentleman who consulted him for impotence, and of
having spent a whole night in thinking over a case of
fractured patella. At another place we find him alluding
to the thoughts which came to him at the fireside. Ho was
not one of those who draw a strong distinction between
business and pleasure, and who regard all that relates to
the pursuit of professional knowledge as belonging to the
former. I suspect, rather, that his times of highest enjoy-
K
412 The Lancet,]
MR. JONATHAN HUTCHINSON : HUNTERIAN ORATION.
[Feb. 21,1891.
ment were those in which he was most keenly in pursuit of
surgical investigations. These were not to him merely the
means of earning money—they were matters of the most
real and deep interest, and, excepting from sheer fatigue,
they were never laid aside, whether on holiday or at work.
I hare not found any evidence that Hunter himself pos¬
sessed artistic skill. He was fond of pictures, and valued
himself on his appreciation of them. He possessed at
the time of his neath a very fair collection, one which
sold for nearly £2000. It contained works by Hogarth,
Reynolds, Louiherburg, and others, and it would—accord¬
ing to a valuation which one of Obristie’s firm gave to
Sir Janies Paget, from whom 1 take these particulars—
at the present time have been worth at least £10,000.
There are bints in some of his letters that he not only
bought pictures, but sometimes sold them again; and
he several times alludes to their price and to the state of
the art market. Those who occasionally frequent picture
auctions, and are fond of cheap bargains, have at auy rate
a right to plead that in this weakness John Hunter gave
them example. His brother William of course bought
much more expensively, being a far richer man. A point
which interests us much more deeply is to note the value
which both the brothers set upon artistic illustrations of
anatomical and pathological subjects. Dr. Hunter’s splendid
plates of the gravid uterus are well known. In the early
editions they were executed without regard to expense, and
they are but a small part of what bad been executed
under his direction of a similar kind. John Hunter never ,
published a single paper or book the subject of which ;
would admit or illustration, without accompanying his
letterpress with a liberal supply of plates. He clearly
Togaraed a drawing as coming next in value to the prepara-
Y Lon itself, and as being essential to the full instruction of
his reader. Our College possesses, in three large volumes
which are now before me, the original drawings rrom which
most of the illustrations published in his works were taken,
together with many others. Most of them were probably
from the pencil of Mr. Bell, an artist whom Hunter engaged
to live with him in the bouse, so as to be always at
hand. The original engagement was for twelve years, but
w.A.g subsequentlv prolonged to fourteen. Bell was not an
educated man, but was very skilful and painstaking in
the kind of art which Hunter wanted. He was not by any
means the only one who was employed for this purpose.
T find that not a few of Hunter’s best plates are signed by
Reemsdyck, an artist who published, on his own account,
a valuable folio illustrating some of the contents of the
British Museum. We can understand the pleasure with
which Hunter would have hailed the introduction of photo¬
graphy in aid of scientific illustration, His zeal in these
matters was caught by his nephew Baillie; and even up to
the present clay, with all our successes in coiour-printing,
no more valuable illustrations of rnnrbid anatomy exist
than the series of engravings which Ur. Matthew Baillie
f tublished during the first years of this century. I cannot
et the occasion pass without the remark that, were Hunter
with us now, he would take a foremost part in the scheme
which the Council of this College has in hand, to supple¬
ment the noble collection of anatomical and pathological
preparations, of which his museum at present constitutes
the centre, by an equally extensive collection of drawings
and casts in illustration of those departments of surgical
knowledge which cannot be displayed by other methods.
In connexion with the Medical Society, which held its
meetings in Hunter’s rooms, permit me to remark upon the |
zeal which he always displayed for the record in print or, at!
any rate, in manuscript, of all observations. He was a pro¬
lific author, and he left behind him many volumes of n<»tes. i
It is said that a cart-load were destroyed by the unfortunate j
proceedings of Sir Everard Home. ■
It may seem a bold step to seriously compare Hunter
with Aristotle. Unquestionably our countryman was far
behind the Greek in the breadth of his attainments and
sympathies. He could make no pretension to the encyclo¬
paedic range of knowledge and of insight which was the
glory of the son of the Stagira physician. The one was at
home in the study of the deepest problems of metaphysics;
the other, much the reverse. Whilst the one carried habits
of impartial investigation into all departments of know¬
ledge, the other, when he left hie own domain, sometimes
exhibited only the strength of prejudice. IVe have
recently been reminded, by a fortunate discovery, that j
Aristotle had drawn up for coropatison sketches of the I
constitutions of various cities and nations, and was bent-
upon forming his opinions on political as on other eubjecte»
by processes of careful inducHon. Hunter, on the othev
hand, expressed his vehement desire that those who were^
not satisfied with their own country would be good enough
to leave it, and vowed that be would rather his museum
and all its contents were burnt than show them to
Uemoerab. In spite, however, of these differences, it may be
reasonably alleged that, where they met on common ground,
the two showed similar habits of thought and intellectual
powers not very unequal. Both were systematic and
enthusiastic zoologists in times when the study of zoology
was the pursuit of very few. Both saw clearly that advance
in natural history knowledge could be made only by the
collection of facts, and realising that such advance waswelH
worth the effort both set themselves zealously to work. It
is probably not possible to mention a third name which can
be placed in any sort of competition with either in respect)-
to originality of effort in this direction. It has been
asserted, by one well able to form an opinion in this matter,,
that between Aristotle and the German Kant no meta¬
physician of original power has appeared. In like manner
we might say, in reference to scientific zoology, that thera-
was no one between Aristotle and John Hunter. There
were of course many who made meritorious efforts with-
more or less success, but none whose achievements can iik
the least compare with Aristotle’s account of the parts of
animals or with John Hunter’s museum. During the long
twenty centuries that were passed through between these-
two men, there did not appear anyone so capable of
applauding Aristotle’s work as Hunter—not one who-
would have contemplated Hunter’s preparations with more
true interest than Aristotle. Nor must we, in admitting
Hunter’s inferiority in scope of attainment, forget the-
great difference in their occupations. Aristotle, although
the son of a doctor, did not practise physio himself, and he
was throughout liberally provided with funds. During the
most prosperous part of his career his pupil, Alexander the
Great, noc only supplied him with money, but collected'
specimens for him in distant lands. As it bad been
remarked by Sir Alexander Grant, never before or since
was the endowment of research on so liberal a scale.
It is only justice to our own countryman to remember that
no such fortune had fallen to his lot. He had to earn every
pound that he expended in zoological science by tbo-
practice of a toilsome profession, to which also he was
compelled to devote the better half of his thoughts. He,
like many other devotees of science, was under the com¬
pulsion to earn a livelihood in other pursuits—a position
nob wholly unlike that of the Jews of old, of whom it is
recorded that they rebuilt the walls of Jerusalem with a
trowel in one hand and a sword in the other.
I have ventured to make a halting comparison between
Hunter and Aristotle, but I have omitted to mention one:
characteristic in which they greatly differed. Aristotle
earned for himself, in Plato’s school, the cognomen of the
“ Reader,” on account of his appetite for books. Hunter
acknowledges that he did not read much, and we may well
believe it. His whole library sold for only £160, and it is
stated that it consisted chieffy of presentation copies. His-
writings are all from bis own observation. He scarcely
ever makes a quotation, and rarely mentions a name. A&
to how far this neglect of professional literature was an-
advantage, and how far a loss, there may possibly be some-
difference of opinion. That to a vigorous mind like his-
the knowledge of the opinions of others may sometimes bo-
a hindrance to original thought will easily be conceded, to¬
ssy nothing of the loss of time incurred in the acquisition-
of such knowledge. It has been well remarked that a man
who does nob know the conventional explanation is more
likely to devise a new and perhaps a better one than he
who sees the whole subject already explained by others’’
minds. On the other hand, it is unquestionable that
ignorance of what others have done may lead not only to-
much waste of work, and to the rediscovery of that which
was already known, but may obviously result in a compre-
beneion of the subject less adequate than that already in
the possession of others. Were I to venture an attempt to*
estimate the value of Hunter’s work on the venereaHi
diseases—one which some of his eulogists claim as a master¬
piece,—I should be compelled in all honesty to declare that
• t was in many respects behind the knowledge of the day.
Ii abounds in sagacious thought, but yet, on not a few
matters of detail, those who bad written before himu
Hhe Lancet,]
MR JONATHAN HUTCHINSON: HUNTERIAN ORATION.
[Feb, 21,1891. 413
^ntortained opinions 'which to me seem more accurate.
It betrays too great confidence in the author’s own
opinions and a want of respect for those of others, which
could only come from want of knowledge and of facts.
In dealing with the life of a man whose whole career was
one of outspoken truthfulness, I too must use candour.
We know that praise is pleasant even to the wise, but
^ever was there a than who, less than John Hunter, could
have patiently endured the language of indiscriminating
panegyric. Exposed to such a trial, I can imagine him
breaking out with some similar rejoinder to that which be
addressed to Dr. Garthshore, who styled him “My dear
John Hunter,” and got for hia pains “My dear Tom fool.”
In his efforts to make a scientific collection, he was not
content with zoology, but took iu botany also, and finally
included fossils and mineralogy. Everyone has heard
atones of his zeal as a collector—how be begged, bought,
and bribed, in order to enrich his collection. To induce
the keepers of travelling menageries to let him have
their dead animals, be used to buy living ones, and loan
them oat, to be returnable at death. At Earl’s Court
be had a little private menagerie, and also a farmyard.
To a large extent he dissected and mounted bis prepara¬
tions with his own hands. Sir Everard Home records of him
that he excelled in the manipulative parts of his work, and
greatly enjoyed them. That his industry knew no bounds,
and that it was invariably well directed by previously
acquired knowledge, we have abundant evidence. Some of
the stories which have found their way into print are, how¬
ever, in all probability, great exaggerations—such, for
instance, as the price which he is said to have paid for
O’Rryen’sbody, and the account of his having driven tamed
buffaloes through the streets of London. Tiiese stories reach
tfaeir climax in the statement of one writer that he kept
a number of dwarfs and giants living on his establishment,
in order to make sure of ^eir skeletons.
It was for the apprenticeship with Dr. Cullen that
William Hunter derived his zeal and devotion to the
scientific aspects of medicine. It was the sight of the
museum collected by Boerhaave and his pupil Albinus that
fired Dr. Hunter with the desire to make one like it. He
returned to London and set to work. His brother John
joined him as his assistant, learned his methods, shared his
schemes, and kindled at his enthusiasm. Are we right,
then, in saying that we owe our Hunterian Museuro—one
•which, let me assert, has no equal in the world—to John
Hunter? Yea, certainly, it was his work. There is, bow-
ever, good reason for widening the basis of our gratitude,
since had it not been for Dr. Cullen and Dr. William Hunter,
for Boerhaave and Albinus, no such museum would ever
have come into existence.
It is, perhaps, not generally known that John Hunter's
Museum contained a valuable collection of fossils. There
were nine hundred specimens, and to a catalogue descrip¬
tive of them Hunter bad written, by way of introduction, a
most valuable essay on the general facts of geology. With
unconscious courage, worthy of either of the Darwins, the
fact that enormous periods of time must have elapsed in
order to permit of those changes is simply taken for granted.
The expression “many thousands of centuries ” slips from
Hunter’s pen as if tne duration of life on this planet
were as much a mere matter for research as is the life
duration of an elephant. How far be was in advance of
bis age in this matter may be gathered from a letter
which our great geographer, Major Rennell, wrote to him.
Hunter appears to have asked Rennell’s criticism of bis
essay, and the following is a paragraph from an interesting
letter which he received: “This loads me to remark that,
in page 3, you have used the term ‘many thousand
centuries.’ Now, although I Lave no quarrel with any
opinions relating to the antiquity of tJie globe, yet there
are a description of persons, very numerous, and very
respectable in every point but their pardonable supersti¬
tions, who will dislike any mention of a specific period that
ascends beyond (lOOO years. I would therefore, with sub-
niission, qualify the expression by ‘many thousand years’
instead of ‘centuries.’” What Hunter thought of this
proposal that he should deliberately sacrifice truthfulness
of expression to the prejudices of others may be easily
conceived.
The great question now lies before us. In what did
Hunter’s strength consist 'I His well-known reply to Dr.
Garthshore when saluted with “ Well, John Hunter, still
r.t work ?” was “ Yes ! and when I am gone you will not
easily find another John Hunter ! ” He was quite right.
For more than half a century no one appeared who was in
the least qualified to take up bis work.
It has been said many times that the source of Hunter’s
success lay in his combination in one person of the
qualities of thinker and observer. Undoubtedly he did
combine them in a way which few others have ever done.
He tells us that it was his delight to think, and he alludes
fondly to ideas which came to him in his armchair by the
fireside, thus proving that under conditions of ease his
mind reverted with pleasure to his pursuits. That he was
an observant man, one who not only availed himself of all
opportunities which came before him, but sought them
out and made them for himself, every page of his writing
goes to prove. “Don’t think, but try,” was one of the
now celebrated sentences in which he inculcated upon one
of bis friends the duty of experiment and observation. In
Id the word “think” must of course be understood in its
lower sense, as applied to an untested belief or supposition, a
sort of taking for granted. Never in his life did Hunter utter
one syllable in disparagement of careful thinking. Never,
perhaps, was his specieu strength in relation to others more
accurately estimated than in an exclamation of Sir James
Paget’s in this theatre nearly forty years ago. The occasion
was the production of one of our museum specimens which
Jenner had obtained, of which Cavendish had made a
chemical examination, and which finally Hunter had de¬
scribed. Well do I remember the bursts of applause which
followed the declaration: “Surely never were the elements
of an inductive process combined in such perfection—
Jenner to observe; Cavendish to analyse; Hunter to compare
and to reflect.”
There were, however, other qualities of great importance
which were elements in Hunter’s character, and to which
those who wish to train others to emulate his career will do
well to give attention. First among them I will place his
insatiable thirst for knowledge. Another of Browning’s
vigorous lines occurs to my memory which is descriptive of
Hunter’s habitual state in this respect, and as it includes
a medical—I might say a pathological—image I have the
less hesitation in quoting it here. It is from the “Gram¬
marian’s Funeral,’’ and it declares—
“ Back to his studies fresher tiian at first,
Fierce as a dvaRon,
Ho, soul-ljydroptie, with a sacred thirst,
Sucked at the flagou.”
Whence, then, in Hunter, came this “sacred thirst,” and
how shall we as parents and as teachers seek to develop it in
our children and our pupils? It was, as I have already
argued, innate. It was born with him, just as mu<m
as were the colour of his hair and the form of his
features. Let us, however, as teachers, feel no discourage¬
ment in acknowledging the truth that the John Hunters
of the future must be bred, and cannot be possibly obtained
by mere training. Rather let us take courage in the thought
that much that may for the present seem to be seed
scattered to the wind, and from which we see but little hope
of a crop, is certain in the future to produce a harvest.
If we turn now from what Hunter inherited to the in¬
fluences brought to bear upon his personal life, to the circum¬
stances which either favoured or iiindered the development
of that appetite for knowledge and aptitude in its acquisition
which he displayed, wo must cousider first his early educa¬
tion. Was it an advantage to him or a reverse that he was
brought up on a farm, and all the tuition he got was at
the parish school ? To this we may reply that probably
his country pursuits not only favoured hia physical develop¬
ment, but were useful to him in the formation of hrs
powers of observation and self-reliance. As to the school,
very much would depend upon the schoolmaster, and on this
matter I believe we liavenot tbesmallestfragmentof infoinm-
tion. That Hunter was, however, fairly well versed in the
elements of school education is, I think, unquestionable. He
mixed as an equal in London with men of high training, and
was a prominent Fellow of the Royal Society, earning for
himself the title of “ Cerberus,” given possibly in recogni¬
tion of his zeal in exposing false pretences to knowledge. He
never had any fear of taking the pen in hand, but wrote at
great length, and often with much vigour of expression. That
his orthography was not perfect, and that his style was
sometimes slipshod and obscure, may be admitted. It must
be remembered that in his day much wider liberties in these
respects were peniiitted and taken than now. It must be.
remembered also that much of what he wrote W'as composed
414 ThkLancbt,]
DR. THORNE THORNE ON DIPHTHERIA.
[Feb. 21,1891,
under very disadvantageous circumstances—when weaiied
in the evening, for instance, or at odd hoars amid the dis¬
tractions of practice; and, further, that he usually wrote by
dictation, and employed as his amanuenses his artist, Mr.
Bell, who was uneducated, and sometimes even his coach¬
man. Further, too. it must be borne in mind that several
of his publications did not receive his final corrections, but
were published with but careless revision after his death.
His obscurity is also to some extent due to the fact that he
was dealing with thoughts which went deep, and for which
as yet there was no familiar vocabulary. To these facts, as
•well as to his defective education, we must attribute the
circumstance thab he but too often permits himself the use
of vague and metaphorical expressions.
Hunter, although speaking with strong disparagement of
the definitions, saying of them, “That of all things on the
face of the earth they are the moat cursed,” could not help
recognising that they are essential to exactitude of thought
and clearness of description. He is, therefore, constantly
attempting them, and with that candour of mind which is
one of his characteristics, as constantly admitting the inade¬
quacy of his efforts. Thus he ingeniously defines the word
poison so as to excludearsenicon the one hand, and the small¬
pox virus on the other, and he calls the reader’s attention
to the fact that it does so. Hla definition of a “morbid
animal poison” takes in cancer and the itch. Respecting
the latter, and its supposed association with an animalcule
which co^d be seen oy the microscope, he suggests “ that
particles of matter may have been floating in the poison
which a lively imagination might suppose to be animalcule
and adds, “but that these animalcula are necessary to the
existence of the disease I totally deuv.”^ Definitions,
indeed, appear to have exercised a sort of fascination over
Hunter’s mind. He is much puzzled by the difficulty of so
defining the terms “shrub” and “tree,” as to distinguish
the things. Throughout his most interesting essay on
Geology he is plagued by doubts as to the legitimate use
of the word “ fossil;” and for the first and only time, so
far as I have noticed, he betrays some anxiety as to what
the critics may say.
If, however, from internal evidence, we may venture to
contend that it is certain that Hnuter's education in boy¬
hood was farfrom neglected, what shall we say as to the im¬
portant years which elapsed between school and the com¬
mencement of his London career at tlie age of twenty-one ?
We know that, some years later still, when his brother
entered him at Cambridge with a hope of repairing the
half-wasted opportunities of youth, Hunter himself peremp¬
torily put an end to the plan, and declined “ to stuff Latin
and Greek.” That he was in the right then few will doubt,
for he was advancing in years, and fiis tastes for anatomy
and zoology were in full force. It would have been a mistake
then to fall back upon the classics. This does not, however, by
any means prove that University training at tbe proper time
would not have been very useful to him. We know what
Hunter, unaided by this training, did actually accomplish ;
but we shall err, I think, very seriously if we conclude that
he would probably not have accomplished so much had his
youth been spent at a University instead of in a cabinet¬
maker’s shop. The subject is too large a one for discussion
here, but we may remember that the possession of classical
knowledge did not encumber the minds of Bacon, of Harvey,
or of Newton. I will ask your permission to record my
own conviction that, iiad Hunter obtained it at the proper
time, it would have been greatly to the advantage both of
his readers and himself.
For those of us who are placed in positions of responsi¬
bility as regards the future training of the medical profession
important lessons are ty be obtained from Hunter’s life.
In the first place, let ua impress ourselves with faith in the
power of that innate desire for knowledge which is the
inheritance, if not of all. at any rate of all in the least
fitted for our pursuits. We have seen what it effected in
Hunter’s case. Hunter was not alone in its possession.
“Who loves not knowledge?” It is not that iti posses¬
sion is not a delight to all, but that the toilsome methods
by which it is acquired, and the difficulty with which it is
retained, disgust tbe idle and sometimes dismay even (he
zealous. Let us adopt Hunter’s methods, and take our
students more directly to Nature herself. Let our education
become more objective, and concern things rather than
books. Let us renounce utterly all remnants of the methods
^ froiti PiirkinuonB Rominiscences, p. 107 .
by which the pedagogues of tbe past so often succeeded in
making the very name of education distasteful. Let uS'
trust to the intrinsic attractions of our subjects, and resort
as little as possible to compulsion in respect to methods olr
study. Let our examinations become more objective and
less merely verbal, and tbe examiner will soon be recognised
as the friend and not the torturer of the candidate. Above
all, let us avoid the error of trving to make all minds fit intO'
one and tbe same mould, and, whilst doing all we can to
encourage breadth in preliminary study, let us remember
tfcat there have, from time to time, arisen men who without
its aid have brought gain to Science and credit to them¬
selves and their profession. Lastly, in reference to our
University schemes and curricula of education, let u&
remember Hunter’s aphorism, that life precedes and causes
organisation, not organisation life; and beware lest by the'
premature imposition of a too artfully contrived organisa¬
tion we hinder the development of life.
ABSTRACT OF
®ljc lltitai); ftdnrM,
ON
DIPETHEKIA, IIB NATURE, HISTORY, AND
PREYENTION.
Delivered hefore the Jtoyal College of Physicians of
London,
By R. THORNE THOIiNE, MB., F.R.C.P.
LECTURE I.
Dr. Thorne Thorne commenced these lectures by
recalling the labours of Bretonneau, and his desire to-
attach a specific name to a specific phlegmasia which should
be anatomically distinct, as also Hirsch’s criticism, that the
identity or otherwise of two or more diseases in a group-
could only be determined by having regard to tlieir ana¬
tomical, clinical, and, above all, their etiological aspects.
He then referred, first, to the failure from the anats^-
raical point of view to differentiate between tbe severEil
membranous affections of the throat, next to clinical medi-^.
cine as not supplying the means of distinguishing between
the infective or the benign character of throat diseases; and '
whilst claiming that great advances bad in recent years,
been made as to the etiology of the disease, he admitted
that in this respect, too, we had many of the former dilfi-/
culties still to deal with. It was next shown by reference^
to statistics that during the last deceunium there had beeni.
a substantial increase of diphtheria mortality in this country]
and that a very significant portion of this increase had takerj-
place in the metropolis. This increase was the more remark]
able because whilst it had been in progress tbe zymotid
group of diseases, and notably those causes of death which^'
are amenable to sanitary administration and public health
measures, had undergone steady diminution. He next re.]
ferred in some detail to the statistical researches of Dr.\
G B. Longstaff’, and to his comparisons of tlie relative
diphtheria mortalities in districts that are divided into-
dense, medium, or sparse according to the density of their
populations, and from these statistics it was shown that-
whereas antecedent to 1860 the diphtheria rate for the sparse
districts was doable that for the dense districts, the rates-
during tbe period 1871-80 for these respective districts had
come to be nearly equal. In short, the incidence of diph¬
theria was undergoing a change, and the preference which.,
it had formerly shown for rural areas was being transferred
to dense communities. Indeed, the increasing excess whiclt
he had referred to in the case of London was found to extend;
to the large towns and cities as a whole; those urban districts
having in 1889 a diphtheria mortality of 0-26 per 1000-'
as opposed to one of only about one-half—namely, 0’14—m
1881. The circumstances detailed were, it was alleged, such
as to call for a searching inquiry into the natural history
of the disease, especially as regards its causation and
^ Turning next to the historical aspect of diphtheria, itwas-
C.oogle
Xhs Lakoet,]
DR. FLETCHER BEACH ON PSYCHOLOGICAL MEDICINE.
[Feb. 21,1891. 415
■shoviin tba/t a disease iodistinguishable from it, and this even
as :^ards its paralytic sequelae, was known before the
•Christian era, and as to this country the quaint writings of
Noah Webster were quoted in which comets, meteors, and
other phenomena were conjured up to account for epidemics
of throat disease other than scarlatina, which vividly re¬
called the several features of diphtheria prevalences in our
•own day. The first recognised prevalence of diphtheria in
England, alleged to have been imported from Boulogne, was
•discussed in connexion with the writings of Simon, Green-
how, and Burdon Sanderson ; and then the general distri¬
bution of the disease in different parts of England and
Wales was considered in some detail by the aid, in the
(main, of Dr. Longstaff’s statistics. The broad geological
features of the country were shown to have no direct influ¬
ence on diphtheria mortality, and as to attacks apart from
•death no sufficient data are available. Some areas
in the same geological formations exhibited the most
striking contrasts in this respect; but at the same
time Dr. Thorne differed from other authorities who
had declared that soil, and this even when altitude
rand dampness were also in question, had no concern in the
development or diffusion of the disease. The two areas in
•our own country where diphtheria bad caused the highest
rates of mortality were anown to lie along our exposed
(north-eastern and eastern coasts, and in the mountainous
■districts of Wales, and this especially in the damp valleys
•SO abundant in some Welsh counties. Clays, as such, were
shown not to have excess of diphtheria death ; indeed, the
great stretch of the Oolite from the borders of Lincolnshire
into Dorset, where clays abound, was the line of England’s
greatest immunity from diphtheria, a circumstance which
was largely attributed to the facilities for drainage afforded
by the flow of the great rivers which drain that area. On
the other hand, where water was upheld in clays or in
.gravels, and where to the resulting dampness was super-
added a cold, bleak air and vegetable decomposition, there
it was held that conditions favourable to diphtheria existed.
But at the same time other conditions favourable to the
•disease were shown often to outweigh all considerations of
climate and of soil. These pt^ints having been somewhat
fully discussed by the aid of charts and diagrams. Dr.
Thorne further illustrated them by somewhat detailed re-
iferences to epidemics which he and his colleagues at the
Local Government Board and various local health officers
had investigated. And as to the influence of soil-wetness,
it was suggested that whilst stagnant water, like stagnant
4).ir, was conducive of ill-health and probably of diphtheria,
the result of moving water, as in the drift along the beds of
(great rivers, was probably in no such way injurious.
The influence of season was next considered, and it
was shown generally that over a long period of years
-excess of diphtheria mortality had occurred during the
fourth quarter of the year, a circumstance that had in
■some respects been held to favour the view of a fungoid
origin of the disease. Comparison between attacks and
•deaths from this disease was not possible in the case of
the large towns where compulsory notification had been
adopted, and the records as to this, which had been com-
•piled owing to the initiative of Dr. John Tatham, were
referred to in this connexion, with the result of showing
•that a striking rise in diphtheria mortality takes place in
the month of October, that this hardly abates during
November, but that after this it shows a tendency to
diminish. But with regard to attacks it was evident that
diphtheria increased at an earlier date, the month of
September showing a marked number of attacks. And, on
the other hand, the January deaths from diphtheria were,
'in not unimportant amount, due to attacks commencing in
December, How far these urban statistics could be held
as applicable to rural areas Dr. Thorne did not feel able to
•say, but the urban experience was stated to be generally
the same as that observed in prevalences, that had been
•carefully investigated in the country, as a whole.
Coming next to the question of sex, some of Dr. Thorne’s
experiences were referred to, and this especially whore he
had expressed the opinion that the excess of diphtheria in
females over males during the first fifteen years of life was
probably duo to the fact that female children are likely to be
brought into closer contact with the infected sick than is
the case with boys. This had been generally accepted by
Or. Downes as applicable to females who had passed the
age of childhood, but the latter obser\’er had broiigbt
iforward a number of statistical and other considerations
which he thought tended to show that there was also some
physiological proclivity amongst females to take the in*
lection beyond that which attached to males. Dr. Thome,
on the other hand, gave his reasons for believing that in
girlhood, as in early womanhood, there was in females
opportunity for greater and more sustained exposure to
infection than in males.
The question of age incidence as a predisposing cause
was also fully discussed. The greatest proportion of total
diphtheria deaths was shown to fall on tne period three to
fifteen years; a still greater incidence was found on the
period three to twelve years, and a further excess on the
eriod two to five years. The comparative scarcity of
iphtheria mortality was referred as related to such cir¬
cumstances as avoidance of exposure to infection, the use
of breast milk and of milk preparations practically sterilised
in process of manufacture, as possibly also to the rudi¬
mentary character of the tonsils at a period of life asso¬
ciated with the functional obliteration of the thymus
gland. But this question of age incidence was found to
be much involved in other considerations. Thus, the age
three to twelve years is essentially the school age, and so-
called school influence here comes into operation ; it is the
age when diphtheria is a much more recognisable disease
than at some later ages, and in rightly appreciating how
far question of age may be one merely influencing the
clinical features of the local affection, much was held to
depend on the right interpretation which ought to be put
on the term “ diphtheria ” as used both in mortality and in
sickness returns.
ABSTRACT OF THE ORATION OF THE HUN¬
TERIAN SOCIETY FOR 1891,
ON PSYCEOLOGICAL MEDICINE IN JOHN
EUNTER’S TIME AND THE PROGRESS
IT HAS SINCE MADE.
Delivered, at the London Institution,
By FLETCHER BEACH, M.B., F.R.C.P.,
MEDICAL .SUl’EHINTEKDRNT, DAllENTU ASVHfM ; HONOaAllY
3ECUETA11V, MKDICO-l’SVCIIOLCKjICAL ASSOCIA'I'ION.
Mr. President and Gentlemen,— When you did me
the honour to request that I should undertake such an
important duty as the delivery of the Hunterian Oration, I
had some dilliculty at first in deciding upon what subject to
address you. The life of Hunter has so frequently been
dwelt upon by brilliant orators, such as Paget and others,
that it is impossible to bring before you any facts that are
not already perfectly well known. On reading an account
of his life, one cannot but be struck with his marvellous
power of work, his untiring energy, and his complete
devotion to science in so many departments. Lawrence
tnrly said that “ he was the greatest man in the combined
character of physiologist and surgeon that the whole annals
of medicine can furnish.” Physiology, surgery, and the
formation of his museum did nob take up the whole of his
time, for, on looking through the first volume of his “ Essays
and Observations,” arranged and revised by Sir Richard
Owen, I was surprised to find that he was also a psychologist,
llunterwas eminently a practical man, and, bad he lived long
enough, he would no doubt have applied his psychology to the
elucidation of many points in surgery and medicine. _ It
therefore occurred to me that the condition of psychological
medicine in Hunter’s time and its subsequent progress might
be a profitable subject whereon to discourse to you.
It appears that during the earlier years of Hunter’s life
the belief that the insane were possessed of the devUhad
not entirely passed away, and ignorance and superstition
guided the treatment. Ducking the lunatic was practised
in some parts of Cornwall, while in Scotland lunacy healing
wells and superstition survived as late as 179.'b In Ireland
the most important of the many stories connected with the
treatment of the insane is that concerning the Valley of the
Lunatics, in which are two wells, to which lunatics used to
resort, drink the waters, and eat the cresses growing on
the margin ; the firm belief being that the healing water,
the cresses, and the mysterious virtue of the glen would
^8
Di
416 The Lancet,] DR. FLETCHER BEACH ON PSYCHOLOGICAL MEDICINE.
[Feu. 21, 1802.
elfectually restore the madman to mental health. In
asylums at this time manacUs were applied to the arms and
legs of the patients, who were often confined in dark
chambers and lay on straw. Many others were kept in
^aols and served as sport to visitors at assizes, fairs, and
other places. The patients in private asylnms were no
better oil, and matters at length became so bad that a com¬
mittee of the House of Commons was appointed to intjuire
into the state of the private asylums of the kingdom. In
1774 an Act (14 Geo. III., c. 49) was passed, by
which five Fellows of the College of Physicians were
annually elected Commissioners in Lunacy for granting
licences in London, Westminster, and the county of
Middlesex. In the provinces, houses were licensed by the
justices of the peace. The medical treatment at this time
consisted in bleeding, purging, and giving emetics, pro¬
bably with the idea that insanity was due to excess of bile
in the blood. The views of the medical authors of that day
are interesting. Drs. Fallowes, Pargeter, Cullen, Arnold,
and Mason Cox all wrote on the subject. The latter was
the first to lay much stress on moral as accessory to medical
treatment. Management he looks upon as of the highest
importance, and he observes that it partly consists in
adaresB, but principally is displayed by making proper
impressions on the senses. Ho distinguishes between the
sthenic and asthenic forms of insanity, and sees very
clearly that, though it is usual to pursue the antiphlogistic
j ilao in the former cases, it is highly improper in the
atter, in which a generous diet, bark, and port wine
are indicated. Altogether he is much iu advance of
the treatmentof his time, though he believes that bleeding,
blistering, and the promotion of vomiting and purging are
necfssary.
In cne year 1792, a year before Hunter’s death, an import¬
ant event occurred which proved to be the beginning of the i
reform that ultimately took place in the condition of all
British asylums. It seems that there was in York at this
time an asylum which was a frightful abode for lunatic?,
and owing to the supposed ill-treatment of a patient
confined there, AVilliam Tuke, a citizen of thecity, proposed
the erection of an institution where there should be no con¬
cealment, and where patients should be humanely and
kindly treated. His proposition was adopted, funds were
provided, and in 179U the York Retreat was opened and the
experiment started. The institution was made as much as
possible a home with cheerful surrounding?, and the patients
were encouraged to work in the open air. The compassionate
treatment of the insane also commenced in France about
this time, for Pinel, in the yea- 179:1, bad freed the
lunatics at the BicOfcre from their fetters, although he
did not know until 1798 that the same humane treat¬
ment was pursued in England. It is generally understood
that he did not liberate them for medical reasons, but
chieflv from the compassion which he felt for their pitiable
condit'on.
Having given you an account of the condition of psycho¬
logical medicine during the life of Hunter, I now proceed
to point out the progress which has since been made. The
system of treatment pursued in the Retreat was not fol¬
lowed for some time. Its success excited the jealousy of
tbe superintendent of the York Asylum ; discuasiou followed,
and eventually an investigation was set on foot whicii
necessitated legislation. Various Acts of Parliament have
from time to time been passed, and tJie result has been
the humane treatment of lunatics as seen at the present
time.
In 1815 a select committee was appointed to consider
provisions for the better regulations of asylums in England.
Evidence was taken from various witnesses relative to tlie
condition of patients in the York and Bethnal-green Asylums
and Bethlem Hospital, then near Moorfields. The treat¬
ment at Bethlem was atrocious, and the case of William
Norris, who was confined there in a barbarous manner, m.ado
a great impression upon tlio jtublic mind. At the York
Asylum cells were discovered, four in number, eight feet
and a half square, perfectly dark when the door was shut,
and the stench almost intolerable; in these cells thirteen
women slept. At the Bethnal-green Asylum several of the
pauper women were chained to their bedsteads, naked, and
only covered with a hempen rug. The effect of this Parlia¬
mentary inquiry did not then bring about a new statute,
and no less than thirteen years elapsed before a radical
alteration of the law took place.
In 1829 further impulse was given to the humane treatment
of patients initiated by Mr. Tuke; for, according to Conolly
in his “Treatment of the Insane,” in that year a patient in
Lincoln Asylum had died “in consequence of being scrapped
to a bedstead during the night. This accident led to the
establishment of an important rule — that whenever re¬
straints were used in the night an attendant should con¬
tinue in the room.” In the year 1834 it was found that this
principle, which acted so well at night, was also applicable
by day, and the result was that the necessity for restraint
became less frequent. In 1835 Mr. Gardiner Hill waa
appointed house surgeon of the Lincoln Asylum, and from
this date a new era—that of non-restraint—was inaugurated
in the treatment of the insane. Although the experiment
was a success, yet the remote position of the iastitutioa
and the want of authority in its author would have pre¬
vented its acceptance for many years if Dr. Conolly, on
going to Hanwell in 1839, had not set to work to carry it
out in the then largest asylum in the kingdom.
In 1877 a feeling of uneasiness arose in the public mind>
in consequence of an impression that patients were too
easily admitted into asylums, and when there could only
with difficulty get out. A select committee was appointed
to inquire into the subject; many false charges were made,
but on strict investigation they fell to the ground. Various
proposals were suggested, which were embodied in a Bill
introduced into Parliament by Mr. Dillwyn in 1881. The
Bill never reached the stage of the third reading, but after
beinw introduced in successive Parliaments finally received
the Royal assent in 1889. A consolidation of this and
previous Acta w’as passed last year. The chief objecto
of it are to furnbh safeguards against the improper con^
finement of persons as lunatics, to secure speedy treatment,
and to protect medical practitioners and others in tbo^
performance of their dirties, to amend the law as to single'
patients, to give increased power for administeiing tne-
property of lunatics, to check the establishment of new
licensed houses, and to enable public asylums to receive
private patients. With regard to the classification of'
mental diseases various systems and principles have been
laid down. All of them, as Dr. Blandford says, “ are based
upon one or other of three principles : either they are
framed according to the mental peculiarities of the patient,
his exaltation, his depression, bis imbecility; or they point
to a disorder of one or other portions into which the human
mind is by some authors divided ; or, the mental symptoms
being put entirely aside, the malady is classified according
to its pathological cause and its relations to the bodily
organism.” I will nob weary you by recounting them, but
will simiily remark that the division into mania and melan¬
cholia adopted by the old writers is the foundation of the
whole system, and that later advances have, as time has
gone on, been due to a more scientific study of mental
disease.
Great progress lias been made in our views of the nature of
insanity. Tlie old writers were of opinion that it was due
to excess of bile in the blood, and hence the bloodletting,
purgative, and emetic treatment. It would take too much
time to study the various doctrines that have been held,
but there is no doubt that the views of Laycock, Carpenter,.
Mnnro, Anstie, Thompson Dickson, and others have all’
contributed to make more clear to ua that insanity is due to
depression of the higher centres and excessive action of
others. Dr. Hughlings .Tacloon, adopting the liypothesia-
of evolution as laid down by Herbert Spencer, thinks that)
cases of insanity may be considered as examples of dissolu¬
tion. According to this view, insanity is diseolutioa
beginning at the highest nervou.s centres, and this is the
doctrine usually held by the more advanced scientists of-
the day. The pathology of insanity has of late years mad©
great 8tride.s, and I think we have reason to hope that as
time advances we may be able to establish a relation-
between the physical appearances seen after death and the
lesion of intellectual functions observed during life. Ex¬
cluding tlie more recent cases of acute insanity, Bevan
Lewis tells me that even now he can do this in epilepsy,
alcoholism, general paralysis, idiocy (in this I agree with
him), chronic melancholia, senile dementia, and a largo
group of consecutive dementias, including “organic”'
dementia. That so much can already be accomplished is a-
result of which wo may justly be proud.
Coming now to tlie treatment pursued at the present day,
we find the wards in asylums well furnished and mad©
cheerful looking. In some parts of the country the ten¬
dency has been to do away with the hug© buildings charac-
Digur- .'i
The Lancet,]
DE. FLETCHER BEACH ON PSYCHOLOGICAL MEDICINE. [Feb. 21,1891. 417
teristic of the old asylums, and to build cottages, or, in
higher class asylums, villas upon the estate. The con¬
ditions of life more nearly resemble those of home, and it is
found that patients can be just as conveniently classified
and treated. In Scotland the most important change has
been io allow greater liberty to the patients. In some
asylums the airing courts have been abolished, locked
doors have to a great extent been disused, and many quiet
harmless cases are boarded out under medical supervision.
Industrial occupation, especially in the open air, is of great
use. Mechanical restraint, no doubt, in some cases can
never bs abolished; indeed, this is recognised by the
Lunacy Act of 1890, and the Commissioners acknowledge
that cases will occur in which it is necessary for the safety
of the patient or of others, or is beneiicial to the patient,
that resfraint should be applied. Combined with the
moral treatment, which comprises the personal influence of
the physician upon the patient, is the medical, which in¬
cludes the hygienic treatment. Diet and regimen are of
the highest importance. Fatty foods, easily digested
animal and farinaceous food, and nourishing ale and porter
are useful, and though the patient may be too weak for
out-door work, yet exercise, or even sitting out in the open
air, is now insisted upon. The state of the bowels should
be attended to, and tonics, diuretics, the use of the Turkish
bath and wet pack, and the bromides, chloral, sulphonal,
and paraldehyde, are often beneficial. For the carryingout
of this treatment, good attendants, who possess some know¬
ledge of mental disease, and are acquainted with a few
simple rules in nursing, are essential. Many such are found
in all our asylums at the present day, hut the Council of
the Medico-Paychological Association have elaborated a
scheme by which attendants, on going through a prescribed
course of lectures and instruction in the wards and on suc¬
cessfully passing an examination, may obtain a certificate,
which will not only be of use to them in passing from one
asylum to another, but will be a guarantee to tlie general
public that the possessors of these certificates have attained
proficiency in nursing and attendance on insane persons.
The Council of the same association is also now engaged in
formulating resolutions, directing attention to what is
known as tne hospital treatment of insanity. Nor should
I omit to mention in connexion with the subject of treat¬
ment that a Society for the After-care of the Insane has for
some years been at work. In summing up the difference
between the old and new treatment, i cannot do better
than quote the words of Dr. Hack Tuke, who says : “ The
old system believed in harshness and darkness; the creed
of the new is sweetness and light.”
Passing now to that department of psychological medicine
with which I have for many years been closely connected—
viz., the treatment of idiots and imbeciles,—I would remark
thattheidiot was a being not unknown to Hunter. Although
the definition he gives, in the volume of Essays and Obser¬
vations before referred to, is not quite correct with respect
to all classes of idiots and imbeciles, yet, as little was known
about their treatment at the time when he wrote, it is
sufficiently good as a general statement. The first idiot
who attracted the attention of scientific men was the
savage of Aveyron. He was a child about eleven or twelve
years of ago who had lived for some time in the woods of
Caune in France, whore he subsisted on acorns and roots.
He was eventually taken to Paris, where he arrived in the
year 1799, under the care of a poor but respectable old man,
who soon after had to leave him. t^inel, physician-in-chief
to the insane at the BieCtre, declared him to bo idiotic;
while itard, physician to the Deaf-mute In.stitution, asserted
that he was simply wild and untaught, and undertook Ins
education. At the end of iivo years, although he had
immensely improved the boy, Itard was convinced that
Pinel was right, and gave up hi.s task in disgust. His
labours were, however, not so barren as ho anticipated,
for the principles of training and treatment which he
adopted still remain, but have been further perfected hy
others, and by none more than by the late M. Seguin,
whose treatise on Idiocy and its Treatment by the Physio¬
logical Method is still a standard work on the subject.
The pathology of idiocy is still in its infancy, but progress
is being steadily made. Mierzejewaki has written an
important paper on the subject, which is also being worked
at by Dr. Wilmarth, pathologist at the PhiladelpliiaTr.aining
School for Imbecile Children. He has collected 100 brains,
and has noted tlie peculiarities met with in each. One
important conclusion has been reached—viz., that the con¬
volutions of brains of idiots and imbeciles often closely
resemble those found in the brains of criminals. There is
a tendency of the principal fissures to run into each other,
forming what Benedikt calls a “confluent fissure type.”
Those who are interested in the pathology of idiocy may he
referred to an article of my own which will appear in the
forthcoming Dictionary of Psychological Medicine, edited
by Dr. Hack Take.
Much improvement is gained by treatment. We have,
firstly, to strengthen the bodyand alleviate its defects, and,
secondly, to undertake the special training of the mind.
Having placed the patient in as good hygienic conditions
as possible, the physical training is commenced. As a
result the muscular system becomes strengthened, the
hands have less difficulty in performing any simple act,
locomotion is improved, the dribbling from tne mouth met
with in low-class cases is less evidenc, the eyes wander less
restlessly, and listlessness and inertness to a great extent
disappear. The moral training has to go on side by side
with the physical and mental treatment. Obedience must
be taught, and efforts made to impart good temper and
affection. The intellectual training in the lowest class of
idiots commences by the cultivation of the senses, and as the
tactile function is the most important, we begin by educating
the sense of touch. The senses of sight, hearing, taste, and
smell are awakened by a series of experiments, in every
case proceeding from the simple to the complex, instilling
ideas by the use of concrete forms and not by abstract
notions. Having educated the senses, we proceed to higher
branches of learning, and when some progress is made
instruction is given in tailoring, shoemaKing, &c., to the
male patients, while domestic work and sewing prove useful
for the females.
On glancing at the future, we are led to inquire whether
there is any hope that the progress which has already been
made in every branch of psychological medicine will be
maintained. T am of opinion that there is good ground for
such a hope, for as science advances more and more will be
known of the structure and functions of the brain. The
labours of Gaskell have already thrown light upon the
origin of the brain and nervous system, and those of
Betz, Bevan Lewis, and a host of others have given us
much knowledge with reference to the structure of
this important organ. Who, many years ago, would
have thought that the brain would be laid open, and
pus and tumours removed from it, as is now done from
day to day ? The labours of a noble band of workers
have enabled this to be accomplished, and science looks
forward to still greater conquests. To stimulate inquiry in
this important branch of medicine, the Medico-Psychological
Association has for some years given a prize, which is open
to all assistant medical oilicers of asylums, for the best dis¬
sertation on any clinical or pathological subjects relating to
insanity. Three essays were sent in lost year, and two of
them possessed so much merit that the examiners were
obliged to award two prizes. As long as this spirit is at
work in our younger brethren, we can with confidence look
forward to luture discoveries. The knowledge of psycho¬
logical medicine should, however, be still more extended
among all branches of the profession, so that those to
whoso lot it may fall to treat mental diseases at its
commencement, when remedial measures are most valuable,
may be able to apply their knowledge with benefit to
the patient and advantage to themselves. Inquiries into
the causation of insanity should be pushed still further,
more attention should bo paid to the laws of inheritance,
endeavours should be made to impress upon those who are
the subjects of this damnosa hareditas the utmost import¬
ance of paying attention to the laws of health, and teachers
should be warned against unduly pressing and overworking
the brains of growing children. Let us remember the old
maxim, ‘'Ars lovrja, vita brevis," and, whatever our medical
path in life may be, let us see that wo hand down the flaming
torch of knowledge pure and imdimmcd to our successors.
“ Let us then bo up and (loiitg
With a hoiu't for any fate;
Still achievintr, still piir.^iuup;,
Learn to labour ami to wait "
The Eastern Hospital.—D r. Bridges and Mr. li.
Ilodley have been appointed by the Local Government
Board' to hold an official inquiiy on oath into the complaints
against the management of the Eastern (TIomerton) Hospital
of the Metropolitan Asylums Bjard.
Google
418 Thb Lancet,]
DR. CKANSTOUN CHARLES ON PULMONARY PHTHISIS.
[Feb. 21,1891.
PULMONARY PHTHISIS;
SOME REMARKS AS TO ITS PATHOLOQY AND ITS CURABILITY
IN EARLY STAGES, PARTICULARLY BY THE USE OV
HOT AIR INHALATIONS.
By T. CRANSTOUN CHARLES, M.D.
At the,meeting of the British Medical Association in
Leeds two years ago I read a paper on tlie hot air treatment
of pulmonary phthisis, and as it so happened that all the
cases I had had under treatment were in an early stage of the
tlisease, I had only a series of very successful results to com¬
municate. Since then, however, my experience of the
method^has been greatly extended, and I have come to the
conclusion that only in very early cases can any benefit he
expected from it. A great amount of interest is now being
directed towards the cure of this disease, particularly owing
to Dr. Koch’s valuable endeavours in this direction; and
should his efforts be crowned with success, not only in early
but also in somewhat advanced cases, then a great and good
work will have been accomplished, and Dr. Koch will truly
deserve to be ranked as one of the greatest benefactors of the
human race.
The apparently essential characteristic in the pathology
of phthisis consists, it is believed, in a caseous necrosis,
the typical phenomena of the disease being produced as
the result of the influence of a special niorbid poison.
Its starting point seems to be the lodgment of a few
tubercle bacilli in the finer bronchial tubes or in the
alveoli of the lungs, leading to the development of the
miliary tubercles, and a consequent inflammation of the
bronchioles extending to the proper parenchyma of the lungs.
The caseous necrosis, therefore, depends on the growth
and development of these special tubercle bacilli; indeed,
every form of tuberculosis of the lung may be said to have
received its first impulse from the tubercle bacilli. In their
growth these bacilli evolve certain chemical products which
are highly injurious to the tissues with which they come in
contact—products also which are not of necessity confined
in their action to the surfaces and canals where they are
generated, but may extend to other parts of the orgariism,
and excite there inflammatory changes of different kinds.
The lesion, however, is not usually a penetrating one,
at least in the early stages, but rather tends to spread
superficially along the air passages and lymphatics—a
progressive infection accordingly depending upon the
multiplication of the bacilli. It is further known that the
character of the disease depends in part on the quantity and
quality or degree of virulence of these bacilli, and partly on
the Buseeptibiliby of the lungs of some individuals to their
lodgment and development, while a progressive infection is
due to their multiiflication. Where, for example, the
normal tissue resistance is too great, these organisms can
obtain no resting place, or, if they do, their development is
of short duration. In some individuals, however, the tissue
resistance is less powerful, and accordingly a morbid tuber¬
cular process is sot up, leading to the condition known as :
fibroid phthisis. In tliis variety the tissue resistance is '
greater than in tlie next, and accordingly its course is not ,
so rapid; the patients also are generally males, and their i
age more advanced. Where, again, there is still less of this j
tissue resistance, the ordinary caseous phthisis is esta- |
blished, an exceptional form occasionally occurring—the i
so-called “acute general tuberculosis,”—where the suscep¬
tibility is very great, or, in other words, the tissue resist¬
ance very feeble, and in which the bacilli develop freely,
make their way in great numbers into the blood, and by its
means effect a lodgment in many organs simultaneously,
leading to the outbreak of innumerable tubercles. Upon
the degree of virulence of these bacilli, owing chiefly as it
does to their quantity and quality, depends the type of
tubercle produced; for Baunigarten has shown that while
inoculation of animals with pure cultivations of tubercle j
bacilli induces the development of the lymphatic tubercles, j
inoculation with bacilli whose virulence has been weakened !
by the action of heat will only lead to the development of
the epithelioid tubercles—that is, an abundant impregnation !
with the active bacilli tends to the building up and rapid
degeneration of lymphatic tubercles; whilst an impregnation
with a small amount of bacilli whose vitality has been
impaired will lead to the formation of epitheliod tubercles,
with the accompanying formation of mnch connective
tissue, and its subsequent shrinking as the result of the
irritation.
As Dr. Coats puts it, in his admirable lectures on the
Pathology of Phthisis, to which I am much indebted,
pulmonary consumption is a disease of surfaces, channels,
and tubes. Beginning in the finer bronchial tubes, the
disease may extend by the air passages or by the lym¬
phatics, probably by both, but chiefly, probably by the air-
passages in the caseous form, and by the lymphaffcs in the
fibroid. A certain susceptibility, we have said, must be
present to admit of one or other of these diseased processes,
and this susceptibility, there is every reason to believe,
may be hereditary or it may be developed. The pre-existence
' of certain affections of the lungs, for example, we know
undoubtedly plays an important part in bringing about a
greater liability to the invasion of these bacilli, particularly
when the vitality of the tissues is already lowered by the
respiration of vitiated air.
Different methods have been employed to destroy these
tubercle bacilli, and it is a very fortunate thing that they
have comparatively little vitality and offer little resistance
to the action of reagents. They are easily destroyed, for
instance, by such bodies as carbolic acid, corrosive sub¬
limate, salicylic acid, acetic acid, &c., and accordingly
various attempts have been made to kill them in the lungs.
All these attempts, nevertheless, it must he confessed, have
proved more or less futile, so fai', at least, as the cure of
the patient was concerned. With the same object in view
Dr. Louis Weigert of lierlin some years ago introduced the
inhalation of hot air. Koch and other observers had shown
that tubercle bacilli are specially sensitive to the influence
of temperature. They develop best about while
their growth is weakened at 38'5°, and ceases at 42°, and at
any higher temperature than this their vitality is quite
destroyed. Dr. X. Weigert finding that it was possible to
sterilise these bacilli by means of the discontinuous periodic
action of heated air, and that a man could breathe very hot
air for prolonged periods without suffering any injury, then
convinced himself of the possibility of effecting a sterilisa¬
tion of the bacilli in the lung substance itself. This is done
by the daily inhalation of heated dry air at a temperature
of 200° to 250° C. for about two hours at a time, and for a
lengthened period extending over several months.
Without going into the question of the temperature of
tins heated air when it reaches the lungs, I shall confine
myself to saying that in early eases of pulmonary phthisis
its use certainly caused the number of bacilli in the sputum
to diminish greatly, and even in a few cases to disappear
entirely. But undoubtedly another great advantage noted
was the forced exercise of the lungs induced by it. This
lung-gymnastics proves of essential service not only to the
lungs, bub to the well-being of the body generally, for collapse
of the pulmonary lobules, with its attendant evil con¬
sequences, is thereby prevented, while, at the same time,
the inspiratory muscles undergo a marked development. I
therefore attempted to sterilise or destroy the tubercle
bacilli by the inhalation of hot air, and at the same time
made an effort to check any further invasion of the tissues
by the bacilli by improving the general tone of the tissues.
It is to bo carefully borne in mind that a susceptibility
exists, and thab every means consequentlx must be adopted
to lessen or remove tliis as far as possible, as, for example,
a good and varied diet, moderate exercise in the open air,
and change of air where possible—the more elevated and
drier the situation the better,—plenty of sunlight also,
massage, cold douches, and the like. In connexion
with the function of digestion in my phthisical patients, I
should mention thab whenever I found it impaired at all,
as the result of a catarrhal condition of the stomach—which
is so frequently the case,—I made a point of beginning the
treatment by washing out that viscus, employing in succes¬
sion for thab purpose a warm saline, a warm alkaline, and,
lastly, a warm acid solution. To this I attach some im¬
portance, as it is essential to success that the stomach be
in a condition to perform its duty in digestion. The decided
and often iraniodiate improveinent I obtained in this way
was sometimes remarkable. Some patients require this wash¬
ing process repeated several times, but others do not. And
nob only is it of importance thab the stomach should he
able to digest the food, but its activity also serves as a safe¬
guard to the intestines ; for it is the passage of the tubercle
bacilli through the sboinach that precedes the intestinal
ulcerations ; but as long as the gastric juice is possessed of
Digitized by
^8
IC
SUKGEON-MAJOR D. F. KEEGAN ON RHINOPLASTY. [Feb. 21, 1891. 419
\
Lancet,]
its noVnal acidity, the bacilli in passing through have their
vitalitj destroyed or greatly inhibited. Where, however,
there ismuch gastric catarrh, the mucous membrane being
thickly covered with mucus, and the hydrochloric acid
greatly iiminished in amount, as I have frequently observed,
then tb« bacilli in the swallowed sputum may pass safely
through ind reach the intestine, thei-e to effect lodgment in
the gut, wd bring about tubercular ulceration—a condition
of things of much too frequent occurrence, seeing that it is
present in from one-half to two-thirds of the fatal cases of
pulmonary tubercle.
As I hare already stated, the only success I have obfiained
by the useof the hot-air treatment has been in early cases
of the diseise. It is therefore of importance to begin it as
early as pcesible. By doing so we may probably prevent
any marked invasion of the blood by the bacilli, with the
acute tuberculosis consequent thereupon, as also the possi¬
bility of the stomach and intestines being affected with the
disease, as referred to above. I shall enter into no descrip¬
tion of the a])paratus employed for heating the air, but
shall limit hiybelf to stating that it has been used by healthy
men for prolonged periods without producing any bad results,
while in early cases of pulmonary phthisis I have noted the
following afuer its prolonged use : An increase in the vital
capacity of the lungs, with a considerably increased ex¬
pansion of the thorax, varying from an inch to three inches;
a gradual dfeappearance of the atrophic condition of the
external thoracic inspiratory muscles, the diaphragm also
becoming more vigorous in its action, the inspirations
accordingly being rendered deeper and more powerful; a
diminution in the bronchial catarrh, the expectoration,
though increased at first, being afterwards diminished, and
the cough finally disappearing; and a general improvement
in the appetite and health, and an increase in body weight.
The bacilli, although considerably increased at first, undergo
a marked diminution with the continuance of the inhala¬
tions—indeed, they may finally disappear entirely. This
examination for bacilli in the sputum should never bo over¬
looked, as their presence is one of the most, if nob the most,
important sign of the disease, and not one, but a series of
examinations of the same sputum should be made, of which
a considerable quantity should be collected and mixed
thoroughly. I generally direct the patient to make a
practice of spitting into a small wide-mouthed bottle con¬
taining a few drops of chloroform or a piece of menthol.
Indeed, I think the sputum of phthisical people generally
should not be distributed broadcast, as is the usual habit,
bud ought to be collected in some such way as I have
suggested, and afterwards destroyed by fire or antiseptics.
The method I pursue in the examination is generally the
following. A little of the mixed sputum is spread out be¬
tween two thin cover glasses, which are then separated care¬
fully and passed several times through the flame of a spirit
lamp, so as to coagulate the albumen and fix the sputum to
the glass. The staining fluid I prefer is Neelsen’s: magenta,
1; carbolic acid (5 per cent.), 100; absolute alcohol, 10. A
little of this fluid is heated in a small porcelain dish till
steam rises, when the cover glasses with their adherent
sputum are immersed in it, the dish covered and laid aside
for three minutes. The cover glasses are now lifted out and
placed at once in a 25 per cent, solution of sulphuric acid,
in which they are to be moved about freely for a short time
so as to decolourise all but the tubercle bacilli, when they are
to be placed finally for a couple of minutes in a dark-blue
solution of methylene blue so as to obtain a contrast stain,
and lastly washed in distilled water, dried, and mounted in
thick balsam. It quickens the process somewhat to dissolve
the methylene blue in the sulphuric acid. In cases of fibroid
hthisis there is often some difficulty in discovering the
acilli. Here, as well as in cases where bacilli are suspected
to be present but cannot readily be found, several examina¬
tions require to be made; but I find that by spreading out
a considerable quantity of the sputum between two clean
sheets of plate glass little translucent masses may often be
noticed, winch when carefully removed and examinod will
usually show the presence of bacilli.
The experience I have had with this method of treatment
disposes me to recommend its use only in the early stages
of pulmonary phthisis—cases where the pulmonary tuber-
culisation is not far advanced, and the lung substance only
slightly involved, and not at all broken down ; where, in
short, the bacilli are most recently deposited, and accord¬
ingly most superficial. Indeed, where there is a strong
suspicion of tubercle setting in, although no positive physical
signs of tubercular deposit may be capable of detection;
where, for example, there is bsemoptysis which we cannot
refer to any other source—as from the nose, mouth, gums,
throat, larynx, trachea, stomach, or from structural itera¬
tions in the terminal pulmonary bloodvessels of elderly
people with an arthritic diathesis (Clark); or during severe
attacks of acute bronchial catarrh with violent coughing,
or after severe bodily exertion or the inhalation of highfy
irritanc gases,—then, all these probable causes being
cautiously eliminated, it would be advisable to adopt its use.
That a bronchial catarrh, particularly if confined to the
apex of the lung, or spreading there and inducing a catarrhal
pneumonia—a pneumonia localised in the upper lobe, or
a catarrhal pneumonia in the lower lobe—may often be
followed by tubercle, we have unfortunately too many
examples. Now it so happens that this hot-air method
provides us with an admirable ffieans of treating many
obstinate forms of bronchitis; and I have frequently used
it in such cases with the most marked benefit. No doubt
many of the milder cases of pulmonary phthisis may
eventually recover of themselves, particularly if the con¬
ditions are at all favourable; but the course is necessarily
very slow, and liable to many accidents.
(To concluded .)
EHINOPLASTY.
By surgeon-major D. F. KEEGAN, M.D.Dub.,
RKSIUENCY SURGEON, JNDORE, CENTRAL INDIA.
The conditions under which the surgeon in India
performs rhinoplasty differ somewhat from those under
which he does the same operation in Europe. In Europe,
in the majority of cases, rhinoplasty is performed in order
to repair the ravages and disfigurement caused by lupus
or tertiary syphilis, and it is but seldom that plastic surgery
is called upon to make good the damage done to a nose by
accident or mutilation. In India, on the other band, in the
vast majority of eases, rhinoplasty is performed to hide the
ghastly disfigurement caused by mutilation, and our patients
are almost invariably young, healthy, and robust. During
my service in India I think I must have performed between
forty and fifty rhinoplastic operations, and in every single
case they were undertaken to repair the damage inflicted
by mutilation. It will be conceded by most surgeons who
have had considerable experience in rhinoplasty that the
Indian method of operation possesses many advantages
over both the Taliacotian and the French plans of pro¬
cedure. The French method I need hardly say consists in
fashioning a new nose by means of flaps taken from the
cheeks. The Indian operation, as described and figured in
English surgical text-books, is, however, susceptible of much
improvement, and it is with the object of bringing this im¬
provement to the notice of the profession in India and in
this country through the medium of The Lancet that I
write this short paper. The operation which I have per¬
formed of late years as the outcome of considerable expe¬
rience of rhinoplasty is, however, only applicable in its
fullest extent to those cases of loss of nose in which the
skin and tissues which clothe the nasal bones have been left
undamaged. All surgeons who have had much experience
in making new noses are, I think, agreed, that the principal
difficulties and drawbacks of the operation centre in the
formation of the eolurana, and in obviating the con¬
tinued tendency to contraction in the anterior nares
of the newly fashioned nose, a tendency which con¬
tinues for several months after operation. The Hap
which I raise from the forehead differs considerably in
outline from that which we see generally figured in English
surgical text-books, and although German surgeons have
to some extent adopted the same method of obviating the
contraction of the anterior nares as wo have pursuetl for
some years at Indore, still I feel I need not offer any apology
for bringing the subject to the notice of my Eoglisli readers.
This method of forming new noses has been worked out
independently by my assistant, Mr. Gunput Singh, and
myself, but we disclaim for it any title to originality, for he
would be bold indeed who would assort that he had devised
a perfectly new operation in the changeful field of plastic
Coo'?le
430 Thb LanobtJ
SUllGEON-MAJOK D. F. KEEGAN ON RHINOPLASTY.
[Feb. 21, 1891.
aurgerv. Annexed is an outline of the flap which I take
from toe forehead. It will be remarked that it differs con-
eiderably from that which we see generally figured in
English surgical text-books. Nevertheless, it is the shape
of flap which the surgeon should raise from the forehead
when ne has to deal with a case of lost nose, in which the
entire cartilage, both aim and the columna, have disap¬
peared. The size or superficial area of the flap, as dis¬
tinguished from its shape or outline, will, of course,
depend a good deal upon the make or cast of face of the
patient with whom we have to deal. If the patient’s nose
was originally a long one, then the forehead flap must be
cut proportionally longer. That the annexed outline indi¬
cates the shape of flap which should be aimed at I have proved
again and again to demonstration by mapping the outline
or several noses cut off from subjects in the dissecting room.
Should portions of the patient’s aim nasi and columna be
left intact, then, of course the shape of the forehead flap
must be modified to suit the requirements of the case. The
root or pedicle of the forehead flap should occupy the internal
angle or the eye, and care shoula be taken that the angular
artery which supplies the root be not wounded. The fore¬
head flap should ne mapped out obliquely, and not perpen¬
dicularly, to a line connecting the eyebrows. In Eastern
women, who frequently have low foreheads, I have often
•een obliged to encroach on the scalp to provide for the
columna; and, although under such circumstances hair
grows on the newly formed columna, still I think that
this is preferable to deforming the mouth by taking the
columna from the upper lip, as the hair can be kept clipped
with scissors.
Now I must describe the steps of the operation, and I
shall endeavour to make as clear as I possibly can, with¬
out the aid of a coloured drawing, the device for ob¬
viating the contractile tendency of the anterior nares of
the newly formed nose. I generally allow a fortnight or
three weeks to elapse after the mutilation before attempting
to restore a new nose. The patient having been fully
ansestbetised, the cavities on both sides of the septum nasi
are plugged with pledgets of cotton-wool, to which strings
or sutures are attached. We will suppose that we have to
deal with a case in which both alee nasi, the entire cartilage,
and the columna have been cut away. The operation is
begun by carrying two converging incisions from two points
slightly external to the roots of the alee nasi to two points
about three-quarters of an inch apart on the bridge of the
nose, where a pair of spectacles would rest. These two
points on the bridge of the nose are now joined by a
norizontal incision. This horizontal incision is bisected,
and a per^endicolar incision is drawn downwards from the
;point of bisection nearly as far as where the nasal hones
join on to the cartilage of the nose. In other words, this
perpendicular incision follows the course of the junction of
the nasal bones, but is not carried down as far as their
inferior borders. The skin and tissues are now disateted
cautiously from off the nasal bones from above downwards
in two llapSj abcd and efqh, as in the appended diagram.
The two inferior borders of the flaps—viz., c D and o H—
are not interfered with, and constitute the attachaent of
the flaps to the structures and tissues which cloibe the
inferior borders of the nasal bones, where they join on to
the cartilage of the nose. If these two flaps are reflected
downwards, so that their raw surfaces look forwards and
their cuticular surfaces look backwards, it will Ite found
that they overlap in the centre. The surgeon his there¬
fore a redundancy of flap to deal with, a redundancy
which he can utilise a little later on wher he has
raised the flap from the forehead. He now proceeds to
do so in the usual way. A piece of stout brown paper
rendered adhesive and corresponding in outline with the
flap, considered suitable to the case in hand, is stuck
firmly on to the forehead in a slanting direefion. And
then a very sharp knife is run round the border
of the paper. The paper is now removed, ani the flap
is quickly raised from the forehead. This flap shoula
embrace ' all the tissues down to the periosteum, and
should be subjected to as little handling as posiible. The
sides of the gap now left in the forehead are approximated as
quickly as possible by means of horsehair sutures, and it is
surprising now small a raw surface is left beliind on the
forehead if the approximation of the sides of the gap be
judiciously and expeditiously carried out. Attention is
now directed to preparing a nidus or bed for the reception
of the columna, and this does not require any description.
The two flaps, A BCD and efqh, which have been
ABE
already raised from off the nasal bones, are now reflected
downwards, and, as they overlap in the centre, two trian¬
gular-shaped pieces are cut away, and placed in the middle
of the gap left in the forehead, in order to expedite the
S rocesB of cicatrisation in the frontal scar. The forehead
ap is now brought down over the nasal bones, and rests
inreriorly on the two reflected flaps, A u c D and E F G n,
taken from off the nasal bones. The raw surface of the
frontal flap, inferiorly, lies on the raw surfaces of the two
reflected nasal flap.s, and the nostrils of the newly formed
nose are therefore lined inside with the skin or cuticular
sides of the reflected nasal flaps. The free inferior margins of
the forehead flap and the nasal flaps are now brought together
by horsehair sutures. The columnar portion of the forehead
flap is now fixed in the bed prepared for it by sutures, and
the two original incisions drawn from the root of the aim
nasi on either side to the bridge ofthenose are now deepened
and bevelled off for the reception of the sides or lateral
margins of the forehead flap. The sides or lateral margins
of the forehead flap are most accurately attached by means
of horsehair sutures to the bed prepared for them. Two
pieces of drainage-tubing are inserted in the newly formed
nostrils. Strips of lint on which some boracic ointment has
been smeared are placed over the junctlonoftbelateralmargins
of the new nose to the cheeks, and also on the gap left
behind on tlie forehead, and cotton-wool is applied over all.
If the root or pedicle of the new nos© is sufficiently broad,
and is not dragged upon and the angular artery has not
been wounded, then all will go well, and there need be no
fear of sloughing. Indeed, it will be generally found that,
if due antiseptic precautions have been taken during the
operation, the new nose will have adhered in a very large
extent by first intention. I allow a fortnight to elapse
before dividing the root or pedicle of the new nose, and in
Digitized by ^ooQle
The Lanoet,]
SURGEON.MAJOE D. F. KEEGAN ON RHINOPLASTY.
[Feb. 21, 1891. 42i
doing so I cot a wedge-shaped slice out of the root
so that the new nose may not be parrot i-haped.
As the inside of the nostrils are clothed with skin, the
drainage-tubes may be discarded after ten 'days, for if
the operation has been properly performed there can be no
contraction of the nostrils. I know how extremely difficult
it is to make the steps of a plastic surgical operation per¬
fectly clear and intelligible without the aid of coloured
plates; but if the reader will bear in mind that the object
of raising the flaps from off the nasal bones is to clothe the
newly formed nostrils with skin, and so counteract their
Befoeb Operation.
tendency to contraction, which is one of the great drawbacks
to success in rhinoplasty, he will, I think, be able to follow
the steps of the operation. It should also be mentioned
that the utilisation of the nasal flaps gives strength and
support to the new nose, and counteracts its tendency to
flattening. Appended are eight engravings, taken from
photographs of four patients out of a large number on whom
I operated during the past three years at Indore. They
speak for themselves, and show plainly how much plastic
surgical art can relieve the ghastly disfigurement caused by
the ruthless knife of the mutilator.
After Oferation.
422 The Lancet,]
DE. ALFEED G. BAKES ON ENLAEGED SPLEEN.
[Feb. 21, 1891.
Befobe Operation.
After Operation.
This mMi’s noso was cut off by order of Taiitia Bhil, a notorious Dacoit ov liiKhwayman and robl)ov, throe raonths before
Tantia was captured. My palieiit was a respectable Mahratta Brahmin, and was oiio of the principal witnesses in
identifying Tantia when the latter was brought into Indoro. Tmitia’s surprise, when confrontoil with the Brahmin
whose no.se had been ’'estored before he entered the witness-box, was very amusing.
NARRATIVE OF
A CASE IN WHICH AN ENLAllGED SPLEEN
ASSOCIATED WITH A LAIiGE INCREASE
OF THE WPIITE CORPUSCLES DISAP¬
PEARED UNDER TREATMENT.
By ALFRED G. BAERS, M.D., MR C.P.,
SENIOR ASSI.STANT rHYSICIAN TO THE GENF.HAI, INFiniVURY AT
LEEDS; LEI-TURICR ON MATERIA MEDICA IN THE YORKSHIRE
COl.LJCCiJC OV VICTORIA UNIVERSITY.
Mr. -, aged twenty-three years, came to me on
"Sept. 23rd, 1889. He said at once that he was suffering
from albuminuria, which had been discovered by a medical
man whom he had seen in Paris in the June previous. From
Mr.-’s age and appearance I at once suspected that he was
suffering from a functional form of albuminuria. He gave the
followinghistory of his case:—In September, 1888, two teeth
were extracted 'by his dentist and there was bleeding from
the gum for seven days after each separate extraction.
(Previous tooth extraction had not been followed by
bleeding.) He was in good health up to the date of the ex¬
traction. The bleeding pulled him down a good deal, and
he has felt more or leas feeble ever since. In Jan. 1889, eight
months before I saw him, he had been in Spain on business,
and had bad there diarrhma and a very bad cold. (No
malarial cause for this was known.) On hia return home he
looked ill, and bad lost some weight. In June, 1889, still
feeling ill but able to travel in connexion with his business,
he was seen by a medical man in Paris, who found albumen
in the urine. On one occasion the albumen was found to
be absent after exercise at 1 P.M. At this time (in Paris)
there was a copious sediment of urates. There was no
known increase in urine, no nocturnal micturition. His
general condition had improved since the beginning of 1889.
He had never passed any black urine, but he had been sub¬
ject to chilblains when a boy. I made a rapid examination
of the cheat, and found no sign of cardiac or pulmonary
change, so that the case seemed only to require the evidence
to be found in the urine to confirm my suspicion of func¬
tional albuminuria. Accordingly I asked Mr.-to send
me specimens of bis urine, taken at different times, for the
following four days, which he did. I need not detail the
results of these examioations. All the specimens examined
were loaded with urates, a fact, I need scarcely say, prac¬
tically negativing organic renal disease. All were highly
albuminous, and—a point particularly worthy of note—the
morning urine (that is, the urine passed on rising) was always
more albuminous than the urines passed before and after
dinner. In all forms of functional albuminuria the morning
urines are generally free from albumen, or at any rate are
always tnarkedly less albuminous than thosepassed after exer¬
cise and after food. In this case we had a urine loaded with
lithates, and containing more albumen in the morning than
at any other time in the day. This at once made me suspect
thatihadoverlookedsomeimportantpointiiithecasethrough
accepting too readily the statement of Mr.-’s medical
attendant in Paris. At the end of four days 1 saw Mr.-
again. On examining the abdomen I was surprised to find
an enormous enlargement of the spleen, of which I took the
following two measurements :—The lowest point of the free
edge was 6i in. below the costal margin in the nipple line,
ana its extreme right limit was easily defined at in. to the
right of the middle line. The liver could also be felt about
IJ in. below the right costal margin. There was no lym¬
phatic enlargement. On examination of the blood, the
white corpuscles constituted at least 25 per cent, of the
former elements seen in a field of the microscope. On being
questioned, Mr.-said thathehad known that his abdomen
had been increasing in girth forperhaps twelve months, bub
he had thought it was nothing more than an ordinary stout¬
ness, though healsoknewthat ho had not increased in weight.
After a careful consideration of the tacts so far as I could
ascertain then, I came to the conclusion that, in spite of the
almost absolute certainty that the patient liad at some time
been exposed to malarial inlluences, for he travelled
during the greater part of the year, and mostly in Southern
Europe, the case was a well-marked example of simple
splenic leucocythicmia. This opinion I expressed to bis
friends, and told them that the average duration of
life in such cases was about two years for persons of
Mr.-’s age. A report of the facts of the case, drawn up
by myself, was submitted to Professor Virchow, who con¬
firmed my opinion as to the nature of the disease, but gave
the patient longer to live than I had done, and suggested
some unimportant details of treatment. The urine con¬
tinued albuminous until Jan. 6th, 1890, when all the
specimens examined were found to be normal. Through
December, January, and February, the spleen gradually
retired towards the left hypoebondrium, and in March it
could no longer be felt. At the same time the increase in
the white corpuscles became less and less marked until
March 21sb, 1890, when examination showed them to be
not more numerous than normal. From the time I first
saw him till April, 1890, Mr.-had systematically taken
arsenic and iron, the former in increasing doses, until he
was able to take nine drops of the liquor arsenici hydro-
chlorieus three times daily without inconvenience.
I think anyone who had seen the case would have con¬
curred in my diagnosis of splenic leucocybbremia. Certainly,
all the cardinal signs of that disorder were abundantly mani¬
fest. A malarial induence has been always mentioned os
one of the exciting causes of splenic leucocythiemia; bub,
so far as I know, whether of malarial taint or not, such
cases as that I have narrated have always ended in death.
There could be no doubt that Mr.-had been in malarial
districts over and over again, but he had never had any
recognised malarial manifestations. The case, whatever
its intimate nature, shows that a marked leucocytosis and
Digitized by
Google
The Lancet,]
MR A. G. CREAGH ON HERNIA CEREBRI.
[Feb. 21, 1801. 423
an ©Dormoualy enlarged spleen may disappear under treat¬
ment by arsenic and iron—the only metbud of treatment,
so far as I know, which has ever achieved any reputation in
the betterment of any of the members of the group of blood
disorders to which s^denio leucocytbfomia belongs. The
occurrence of albuminuria in leucocytbaimia has been
recorded, but this case is the first example of it that I
have seen. At present, I cannot of course speak to the
permanency of the recovery, for, as is well known, at least
one member of the family of blood diseases—namely,
idiopathic anmmia, has periods of improvement, if not of
absolute recovery, followed at length by fatal relapse.
Leeds.
A CASE OF HERNIA CEREBRI ACCOMPANIED
BY MOTOR PARALYSIS; PARTIAL
RECOVERY.
By a. G. CREAGH, M.R.C.S.Eno , LS,A.Lond.
On June 20bh a Hottentot lad, aged seventeen years, was
brought to me with a compound comminuted and depressed
fracture of the left parietal. Under chloroform I removed
from the substance of the brain twelve fragments of bone,
which pieced together would correspond to an aperture in
the skull cap measuring on the inner surface 2,1 in. by
IJin. The dura mater was extensively rent and the
cortical matter protruding. Haimorrhage from a branch
of the meningeal artery was con troll od by sponge pressure, the
scalp brought over without sutures, and the wound dressed
with lint and carbolised water applications. The following
extracts from my note-book will show the progress of the
caseJune 21st, noon: Sponge removed, head dressed,
drainage-tube inserted in anterior angle of wound;
pulse 90; temperature 99’S°F.—22Qd : Considerable dis¬
charge from wound, which was dressed with carbolic lotion
{I in 40) and iodoform wool; diet, milk, and beef-tea,—
24th : There was noticed for the lirst time total abolition
of voluntary movements in the light arm and hand
and leg of the same side. The injury to brain sub¬
stance with reference to external landmarks was situated
in a perpendicular line with the right external auditory
meatus, and at a distance of 54 in. from it; distant
in a straight line from the nearest point of middle line of
head, 2^ in. The cerebral lesion would therefore correspond
to the posterior part of the superior frontal convolution,
together with the upper portion of the ascending frontal,
upper extremity of ascending parietal and part of superior
parietal convolutions—i e.,the circleof injury would, roughly
speaking, correspond to Ferrier’s centres for moveraems of
right arm, hand, and leg. The general condition of the
patient is dull and apathetic, and there is considerable dilli-
culty in expressing ideas. Pulse 84; temperature 100°.—
26th, 12.J0 A.M. : Called to patient, whom 1 found
suli'ei'ing from epileptiform convulsion. Noon: during the
night the patient passed fmces in bed; answers questions
with dilliculty, but understands easily when spoken to.—
29dh : Some sloughy brain substance was removed from the
wound. General condition brighter.—July lat: There is
considerable bulging of reddish brain substance through
the wound aperture, cerebral hernia to the size of a large
walnut being present. For the past forty-eight hours the
patient has passed urine in bed, and the bowels have acted
without his knowledge; he is unwilling to be disturbed.
Pulse 8(); temperature The hernia was treated by
bandage-pressure over the dressings.—:trd: The tongue
when protruded is drawn to the right side of the mouth.
Pulse 80; temperature 98'G°.—16th: The hernia equals .a
fowl’s egg in size and bleeds freely when touched. Paralysis of
right arm and leg still complete. Pulse 100 ; temperature
normal.—22nd: Tiie cerebral tumour has increased to the size
of a tangerine orange, and there is (odomaof both eyelids;
urine free from albumen. The accompanying engraving
from a photograph shows well the size and position of the
hernia at this date. The small diagram (Fig. 2) of the por¬
tions of the inner table of skull removed illustrates the size
and shape of the aperture in the calvaria —Aug. 26th: Under
continuous pres,‘<ure, applied daily, the tumour has become
almost level with the scalp.—Sept. 1st: 'I’here has been a
considerable gain of power in arm and leg, hernia level with
scalp and skinning over.—Oct. 3(lbh; With the aid of a
crutch the patient walks fairly well, and can approach the
right hand to within six inches of the face.
Remarks .—I think the progress of this case is wortbjr of
consideration, as illustrating several points and nving
food for reflection as to the causes of some of the
symptoms and their modus operandi. The injury was
inflicted with an iron rake during a drunken quarrel,
a corner of which caused a tripartite scalp wound of
a nob very important appearance. In the words^ of
Hippocrates, no bead injury is so trivial as to he despised
or so serious as to be despaired of. The patient was suffer¬
ing from the combined effects of concus.sion and alcohol
Fio. I.
when first seen, and had the precaution of passing the finger
into the wound been omitted, seveio encephalitis might
have supervened from irritation of the broken fragments of
bone. In two other cases of fracture of skull vault which
came under my notice at short intervals, the patients, in
whom there was reason to suspect only a slight laceration
of cerebral cortex, suffered from violent maniacal delirium,
requiring restraint. These latter were white men. Possibly
the more lowly organised brain of the Hottentot may be
more tolerant of injury; but may not its absence in this
case be due to the freedom of drainage, and impossibility of
compression and irritation, by inflammatory effusion on the
substance of the brain ? If so, is not the question of active
surgical interference bytrephinesuggested as a more frequent
Fig. 2.
Six fragment.') of iiinor table of skull renioveil.
A, Grooves of moningeal iirtorial biuuclios.
dernier rcssort in those cases of acute encephalitis and
meningitis which are tending to a fatal termination ?
Nancrede says tliat 70 per cent, of the cases of hernia cerebri
terminate fatally. May not compression and antiseptic
cleanliness hold out hopes of more satisfactory results ?
With reference to the cause of the motor paralysis, if aris¬
ing only from the destruction of the cortical centres, how
can we explain the return of muscular power ? On the
hypothesis of Exner’a theory of absolute and relative centres,
it might be suggested that the functions of the destroyed
absolute centres have been taken up by the corresponding
relative centres. On the other hand, if we suppose that a
cortaiu amount of iullainmatpry effusion took place in the
cerebral substance, intorfeiing with its functions, it is pos¬
sible that the resolution might be followed by the return of
motor power, only those centres entirely destroyed by lace¬
ration remaining useless. In any respect, as the fact stands
it has an important bearing on prognosis in similar cases.
Dii.iiized by Google
424 The Lancet,]
DR. C. E. SHEPPARD ON NITROUS OXIDE BOTTLES.
[Feb. 21,1891.
Ganglionic nerve-tissue is generally supposed to have almost
no capacity for restoration, consequently I fail to see that
the return of motor volition can be explained except by one
of the foregoing surmises. I regret that, my battery being
out of repair, 1 was unable to test the electrical reactions of
the musmes in the paralysed limbs.
Port Nollotli, S. Africa.
DIFFICULTIES CONNECTED WITH THE USE
OF NITROUS OXIDE BOTTLES IN THE
HORIZONTAL POSITION.
By C. E. SHEPPARD. M.D.,B.S.Lond.,E.R.C.S.,
iN/USTHETIST TO GUY’S HOSPITAL (DENTAL SCHOOL), AND SECOND
CULOBOFORMIST TO THE MIDDLESEX HOSPITAL.
The horizontal steel bottles now so largely used for the
storing of liquid nitrous oxide have, in respect of conveni¬
ence, many advantages over their vertical predecessors,
advantages which are so well known and appreciated that
it would be superfluous for me to specify them in detail. A
wide experience of their use has, nevertheless, demonstrated
that there are many grave objections to be overcome before
they can be pronounced perfect in their action. The objec¬
tions to which I allude may be briefly enumerated as
follows :—1. The supply of gas is fitful and irregular, neces¬
sitating the greatest care in tlie use of the foot-key.
2. There is a want of correspondence between the amount
of passage way allowed by the screw tap and the quantity of
gas liberateA 3, The screw is liable to “aet’^whilst in
use, so that the tap can be turned neither on nor off. 4. As
a consequence of this condition the flow of gas becomes
absolutely arrested, often to be re-established with sur¬
prising suddenness and violence. .'5. The metal unions and
indiarubber conducting tube after a time become frozen, so
that the latter is often found hard and frosted to a distance
of some feet from the bottle. It is needless to point out
that any one of these difficulties occurring in the course of
an administration may and does constantly give rise to the
greatest inconvenience; it therefore seemed to me of con¬
siderable importance to determine the exact conditions
upon which they depended, and if possible to devise some
remedy. Experiments conducted with the same bottle,
laced alternately in the horizontal and the vertical position,
ut under similar conditions in other respects, demonstrated
conclusively that the above-mentioned difficulties occurred
only when the bottle was horizontal. It seemed, therefore,
probable that the main cause of the trouble was associated
with the actual entrance of the liquefied gas into the
channels of exit, and for the purpose of confirming this sup¬
position, the actual position occupied by the liquid was
theoretically determined in the following manner. On
taking the inside measurement of one of Barth’s fifty
gallon bottles, the total capacity was found to be about
50‘5 cubic inches. The weight of liquid nitrous oxide with
which these bottles are supplied, and which is reputed to
yield fifty gallons of gas, amounts to fifteen ounces, so that,
taking the specific gravity of this liquid as 0'908 (at 45° F.),
the space occupied by it would be 28 ’6 cubic inches, which
is roughly three-fifths of the total capacity of the bottle.
From these data it appeared that in the horizontal position
the orifice of exit would be situated about a quarter of an
inch below the surface of the liquid, whereas in the
vertical position it would be entirely above it; and further¬
more, at a distance of some three and a half inches.
In order to test tlie iniiuence of mere proximity, an
experiment was then made with the bottle placed in an
oblique position, so that although the orifice of exit was
above the surface of the liquid, it was not more than half
an inch distant from it. On allowing ten gallons of gas
rapidly to escape, no difficulties of any kind occurred, thus
proving beyond a doubt the correctness of the original sup¬
position. Further explanation is amply yielded by the con¬
sideration of facts already well known. Nitrous oxide gas !
requires for its liquefaction a pressure of fifty atmospheres
at45°F., and this pressure being removed, the liquid at
once resumes the gaseous form, in so doing an enormous
quantity of heat is absorbed, and as a result the tempera¬
ture at the surface of the lii{uid may fall as low as -150° F.,
at which point freezing occurs and a portion becomes con¬
verted into a snow-like solid. There can be little doubt
that it is to the formation of this solid material, consequent
on the rapid conversion into gas of the liquid which has
gained access to the interior of the valve, that the complete
fixation or ‘ ‘ setting” of the screw is to be attributed; wnilst
the widespread freezing of the conducting tube &o. is to be
similarly explained, small liquid particles being in all pro¬
bability projected to some distance by the pressure of gas
within the bottle.
Having satisfactorily determined the cause of the diffi¬
culty, there remained nothing further but to devise some
simple mechanical means whereby the escape of liquid
should be prevented when the bottle was used 'in the
horizontal position. That which has been finally adopted
consists of a small piece of metal tubing, screwed firmly
into the entrance of the valve, and projecting from it into
the interior of the bottle; it is curved in such a manner that
its open end is directed upwards, and stands about one inch
above the surface of the liquid. I have had several bottles
fitted with this tube, and on subjecting them to numerous
experiments, both clinically and otherwise, find that they
fully come up to my expectations, their action in every way
being as perfect as when used in the vertical position. In
external appearance and weight, as may be gathered from
the foregoing description, they are indistinguishable from
the horizontal bottles hitherto in use.
The advantages secured by this simple contrivance will,
perhaps, be best realised if 1 relate the details of my last
two experiments, made a few weeks ago during the pre¬
valence of a keen frost, and under conditions considerably
more severe than are ever likely to occur in actual practice.
In the first experiment a fifty-gallon bottle, containing
fifteen ounces of liquid nitrous oxide, was connected by
means of five feet of rubber tubing with a gasometer capable
of holding three gallons. The screw tap being opened, gas
was allowed to escape as rapidly as possible, three
gallons passing into the gasometer in about live
seconds. This operation was then repeated at short in¬
tervals, until, in all, thirty gallons had passed over.
During the whole course of the experiment the flow of gas
was uniform and free, corresponding accurately to the
amount of passage way allowed by the screw valve; there
was not at any time the slightest trace of sticking or
“setting” of the tap, and at the conclusion the indiarubber
tube, even close to the bottle, remained quite supple and
felt barely cool to the hand. The total duration of the
experiment was seven minutes. It should he added that
after the liberation of fifteen gallons of gas a slight frost
appeared on the brass union, and that after the escape of
another ten gallons the bottle itself was slightly coated.
This occurrence was evidently due to the condensation and
freezing of ordinary atmospheric moisture and interfered
in no way with the results obtained. In the second ex¬
periment the remaining twenty gallons were allowed to
escape freely into the open air, the bottle being empty
at the end of two minutes. As before, the flow of
gas was practically continuous, and the screw tap remained
throughout perfectly free in its movements. I venture to
think that by means of this simple device the horizontal
bottles are now brought as near perfection in their action as
we can wish, and I feel sure that no excuse is needed from
me in bringing this improvement before the profession,
which numbers amongst its members many who take the
warmest interest in any means whereby the administration
of this valuable amestlietic is facilitated. In conclusion, I
would add that the new valves are made by Messrs. Barth
and Co. of Poland-street, who very kindly assisted me in
several of my experiments.
Wcibock-street, W. __
CONSERVATIVE TREATMENT OF ADHERENT
BUT FUNCTIONALLY ACTIVE OVARIES
AND FALLOPIAN TUBES.
JiY A. C. BUTLER-SMYTHE, F.R.C.S.Ed.,
SURGEON TO OUT-l'ATIF.NT.S, SAMARITAN FREE IIOSI’ITAL FOR WOMEN,
AND SURGEON TO THE QROHVKNOR HOSPITAL FOR WOMEN.
In this short paper it is not my object to discuss the
treatment of those cases in which the ovaries and Fallopian
tubes are obviously diseased, nor do I wish anyone to
imagine that I advocate attempting to save those organs
where they are completely matted together or embedded in
^8
Di
The Lancet,]
MR. A. C. BUTLEE-SMYTHE ON ADHERENT OVARIES.
[Feb. 21, 1891. 425
inflammatory tissue. Bat there are many cases where on
opening the abdomen the operator finds that the ovaries
and tubes are only partially adherent, and where no visible
or tangible signs of disease can be discovered in these
organs. Moreover, it is not always easy to decide, even
when the abdomen is opened, whether an ovary is healthy
or not. It appears to me that not infrequently it is the
presence of adhesions of the ovaries and tubes, and this
alone, that is the cause of the pain and other symptoms
which have been complained of, and which have led to
an intra-abdominal examination of the parts. Simple ad¬
hesions of these organa are not dangerous to life, nor
■do they necessarily destroy the functions of the ovaries and
tubes. Why, then, should these organs be extirpated ?
The removal of the ovaries and tubes for such adhesions
'has always seemed to me an unnecessarily severe, almost
ii.a unwarrantable, proceeding; and I feel confident that
the profession will welcome as an important improvement
any method by which the conditions under consideration
may be cured without resorting to such extreme measures.
§[ hold that in such cases the separation of the adhesions
and freeing of the ovaries and tubes can be accomplished,
and is frequently sufficient to restore the patients to health,
and, what is more to the point, the operation leaves them
with functionally active organs. This treatment seems to
me a most rational one, and 1 have operated in this way on
Three occasions, the results being most encouraging. I there¬
fore venture to lay them before the profession, in the hope
that the operation may be given a more extended trial. I
am quite aware that the results of three cases are insuf-
•licient to prove the worth of this treatment; but I am
convinced that in other hands than mine the operation will
be productive of much good. However, if it but tends to
dimit the number of “ spaying ” operations, I shall be more
than satisfied.
Cask 1.—C. N-, aged thirty-six, unmarried, came to
me in 1887, complaining of dragging pains in the lower part
of her abdomen, sickness, severe headache, and painful
menstruation. She had been ailing for some years, but of
Qate had become so ill that she had to give up her work and
'take to her bed. Bimanual examination revealed a fixed
tender swelling, situated behind the uterus. Pressure on
the swelling caused much agony and a feeling of faintness.
The uterus was somewhat enlarged and retroflexed. I
diagnosed adherent ovaries, and advised operative treat-
anent. The patient, being most anxious to obtain relief,
willingly agreed, and a few days later I opened her abdo¬
men. The organs on both sides were found to be adherent.
Without much difficulty I succeeded in freeing the left ovary
and tube, and the right ovary also, but the Fallopian tube
on that side was spread out and intimately adherent to the
•crccum, and its separation gave some trouble and occupied
much time. Sponges were packed down into the pelvis and
left there until the sutures were inserted and the wound
ready to be closed. By that time the bleeding had ceased.
The patient recovered without a bad symptom, and returned
home at the end of a month, relieved of her troubles. The
next period was almost natural, and she soon regained her
strength and resumed her work. Six months later she had
an attack of inflammation in her abdomen, followed by
'rheumatism, which confined her to bed for some weeks.
Since then she has been in poor health, and her heart is per¬
manently affected. Her uterus is movable, and the fixed
lump behind it is absent, but one could, at her last exami¬
nation, trace the remains of an old cellulitis, the result of
her attack of inflammation in 1888.
Cask 2.—K. M-, an unmarried lady, was sent to me
in 1888. Her history was as follows : Menstruation began
•at the age of ten and the periods were irregular for some
years. She suffered from pain before the How, and her
'Josses were excessive, lasting as a rule eight days. She was
'Strong and healthy up to her twenty-fifth year, but about
that age caught cold when menstruating, and her illness
•dates from that event. Between her twenty-fifth and
twenty-seventh years the periods became increasingly
.painful, and she complained of backache and dragging pains
in her abdomen when standing or walking. For close ou
two years before she came to town most of her days had
been spent in bed. Attacks of vomiting came on, rare at
'first, but increasing in frequency till they recurred at all
hours. Her appetite failed, emaciation set in, and she
rapidly got too weak to leave her bed. During her long
illness every possible treatment had been tried, but without
success. Her friends therefore advised her to come to
London for further advice. On examining bimanually I
found the uterus tilted forwards, and behind it a fixed
swelling, pressure on which caused exquisite pain and a
sensation of sickness. She was seen in consultation by two
eminent specialists and the diagnosis made was “ adherent
ovaries.’’ It was decided that the organs should
be removed, but the patient strongly objected to have
her ovaries taken away. I therefore proposed to open
her abdomen, and attempt to separate the adhesions and
free the ovaries and tubes, as I had succeeded in doing in a
former case. At the same time I reserved to myself dis¬
cretion to remove the appendages if I found them diseased.
This being agreed to, the operation was performed about a
week later in the following manner:—The abdomen was
opened in the middle line, the incision being nearly three
inches in length. Introducing two fingers of niy left hand,
I ascertained by touch the extent of the adhesions on both
sides, and having satisfied myself that the ovaries and
tubes could be freed, I proceeded to separate the adhesions
on the right side, taking care to keep my finger-nails, as
much as possible away from the ovary, so as to lessen any
chance of injury to it. There was free hmmorrhage during
this part of the operation, but the bleeding was controlled
by packing sponges down over the abraded surfaces. The
released ovaiy and tube were then brought to the abdominal
opening and inspected, both for the purpose of noting any
diseased condition, and of seeing if they had sustained any
injury during the separation of the adhesions. A small
flat sponge was then placed beneath the tube, which
was then straightened out by running it between the
fingers from the uterus towards the fimbriated extremity,
the reasons for doing so being to break down any small
adhesions between the ovary and tube, and to expel any
fluid that might be contained in the tube; also to force
open the ostium tubm, should it be closed, as is frequently
the ease under .such conditions. .The fimbriated end was
then well cleaned with a .sponge steeped in corrosive sub¬
limate solution (1-1000). The ovary and tube on the left
side were then treated in a somewhat similar manner ; but
in this instance there was troublesome bleeding from the
surface of the ovary, pressure in a hot sponge, however,
quickly controlling it. The deeply packed sponges were
left in situ till the last moment before closing the wound,
as in my former case, and when they were removed the
wound was closed, the ordinary peritoneum toilet being dis¬
pensed with in order to avoid any chance of setting up
fresh hemorrhage. No drainage was employed. The wound
was dressed with carbolic gauze, and the patient was put
back to bed within an hour. She made a good recovery,
and gave me no trouble whatever. There was a little ether
sickness, but when that passed off there was no return of
the vomiting. Tlie period came on a week later, without
pain, the flow lasting six days. At the end of four weeks
she was out of bed, and two weeks later went to the
country quite relieved of her aches and pains, and able to
take care of herself. Previously to her departure a careful
examination was made of the pelvis, and the contents were
found to be in a normal condition. Six months later the
patient reported herself “much improved in every way.
No return of sickness or pain, and able to take lots of
exercise without feeling fatigued.” In 1889 she wrote
saying, “Myliealth is excellent. I have gained 28lb. in
weight, and can walk miles without feeling overdone. The
periods are almost painless, and I have had no sickness.”
In April, 1890, 1 examined her pelvis, and found the con¬
tents in a most satisfactory condition. She was then in
excellent health and spirits, and informed me “that she
was organist at an institution, and had been playing twice
a day for months.” Two years ago she was an emaciated
creature racked with pain and confined to bed, and now
she is a robust young woman, well able to enjoy life.
Cask 3.—S. S-. aged thirty-seven, was sent to me for
operation in 1888. Sire had been married four years, but
liad no family. Her illness dated from a miscarriage in
1880, and since then she had been getting worse and worse,
the chief symptoms being sickness, backache, and dragging
pains in her audomen. The vomiting recurred at all hours,
day and night, and was always preceded by sharp pains in
the lower part of her abdomen. She was much worse
immediately before her periods, and had to lay up at those
times. For six months before I saw her she had been
unable to work or attend to her household duties, and had
been more or less confined to bed. She was much emaciated,
and looked careworn and depressd. On examining the
Co ogle
426 Thb Lancet,}
CLINICAL NOTES.
tFEB. 21,1891.
pelvis I found the ovaries prolapsed, adherent, and exqui¬
sitely tender on pressure. The uterus was somewhat
enlarged hut movable. I was requested to remove the
ovaries, but suggested that the adhesions might be sepa¬
rated and the organs released with a fair chance of relief
and possibly of cure. The patient and her husband
agreemg, I opened her abdomen and without much diffi¬
culty released the ovaries and tubes on both sides, the
only trouble throughout the operation being rather free
hremorrhage during the separation of the adhesions,
which was, however, completely controlled by sponge¬
packing. The operation lasted about an hour. The
patient did remarkably well and went to her home in
about six weeks, relieved of her sufferings and in capital
spirits. From the date of the operation the sickness stopped
entirely for two months. Her periods were almost painless
and unaccompanied by vomiting. On examining the pelvis
previously to her departure, the ovaries were found to be free,
and the uterus movable, but enlarged. She has remained
fairly well ever since. In September, 1890, she was in good
health, had grown very stout, and declared herself free
from her old troubles. Her uterus was then enlarged, and
her ovaries could be mapped out free in her pelvis.
N.B.—Since writing the above cases, I have assisted at
two operations of a similar nature, where the ovaries and
tubes on both sides were dexterously and quickly freed.
Both patients have done well so far. In one case the peri¬
toneal cavity was flushed out after the operation and a
drainage-tube inserted; in the other, drainage was employed
without any washing out of the abdomen.
Brook-street, W.
€lmml Itrfa:
MEDICAL, SXJKGICAL, OBSTETEIOAL, AND
THEEAPEUTICAL.
TRAUMATIC CEPHAL - HYDROCELE.
By R. Clement Lucas, B.S., F.R.C.S.,
SUaOEON TO OUV’S HOSPITAL.
The advantage of a term lies only in the correct grouping
of things it may indicate, and it would be a misfortune if
the interesting case reported by Mr. Burton in The Lancet
of Jan. 10th under the title of “Traumatic Encepbalo-menin¬
gocele” were to be mislaid through a title which might
divorce it from its natural associates. Traumatic cephal-
hydrocele is not a term of my invention, but it has the
advantage of implying nothing more than can be proved
clinically, and I am therefore in accord with Mr. T. Smith
in a desire to adopt it. The only difference between
Mr. Burton’s case and many others now collected rests in
the fact that the fracture was at first compound, but the
primary union of the wound left the condition of parts
precisely as if the scalp had been untorn. It is altogether
a gratuitous assertion that “absorption of a necrosed
circular portion of the bone occurred, and the meninges and
brain substance were gradually protruded through the
wound.” There is no proof whatever of the meninges
having protruded, whereas damaged brain substance is not
unfrequently met with in severe penetrating fractures. I
am afraid Mr. Burton will think me over critical if I ob^cb
also to the term “necrosis” in relation to the case. I’he
absorption of osseous tissue which takes place in these
cases 18 one of their most remarkable phenomena, and it is
not preceded by necrosis, but is comparable rather to the
pressure absorption brought about in bone ad jacent to an
aneurysm. That the aperture should close by fibrous tissue
and leave no prominent tumour is again in accordance with
the experience of the majority of cases which have recovered.
The author further volunteers the remark; “ I do not think
the fluid communicated with the ventricles,” but this is a
mere speculation; and if I were to say, judging by the
experience of other cases, that I have little doubt that the
lateral ventricle was opened, I should appear guilty of a
direct contradiction ; so I prefer, in the absence of a post¬
mortem examination, lo leave the matter open.
I'lnsbury-siiuaro, E.C.
A CASE OF SPINAL HAIMORRHAGE.
By R. Reginald Sleman, B A.Cantab., LS.A.Lond..
I WAS some time since called to see J. A. G - , age(3
twenty-eight, a clerk, single. He had been unable to pasa
his urine for twelve hours, and had sent for me to draw itt
off for him. Finding the bladder distended, I passed a full-
sized catheter and drew off a considerable quantity of urine,
noting at the time a urethral discharge due to gonorrhoca>
which at first sight might have accounted for the retention.
However, it was noticed that the patient had great difliculty
in adjusting his position for catheterisation, and on my
remarking Uiis, he said that during the day he had “ felt
his legs drag,” and although he had managed to get to
business, bad experienced great difficulty in getting borne
again. This condition of affairs culminated at night, when
I found the patient in the foJlowingcondition : Total loss of
power and sensation in both lower extremities; reflexes
absent entirely. Temperature nonnal. Loss of power
over bladder and rectum. There was also an absence cS'
pain in any situation. This condition of affairs continued
with little or no amelioration of the symptoms. Loss of
ower in the rectum was somewhat less after a time, but
edsorea developed over the buttocks, which, however, tLe-
patient did not feel much inconvenience from, as there was-
little or no sensation in the part affected. Cystitis bad
soon set in, the temperature varying from 102° to 100°; and
although the extremities were manifestly hot to the touch-,
yet coldness was felt in them—another instance of perverted
sensation. Six months later there was a slight improvemenb
in the condition of the left leg, which bad recovered some
power. This proved to be transitory, and secondary degene -
rative changes in the cord and muscles rapidly followed, and
withthemmarkedlyincreasedrellexesandppa8ticrigidity,_th©
latter condition deriving some benefit from hypodermic injec^
tions of hyoscyamine; when last seen the patient had relapsed
into his former condition. The usual remedies, such as
iodide of potassium, galvanism, &e., were tried, but withouft
any good result. I believe this to have been a case of spinal
h.'cmorrhage, the sudden invasion, the temperature (which
was normal at first), and the symptoms generally, point to
this diagnosis, especially the total loss of power ana sensa¬
tion in such a very short time. The family history showet.f
that there was phthisis in two of the jiatient’s sisters, huh.
the parents were living, and in good health ; there was also
a very doubtful history of syphilis, which disease was said
to have been contracted by the patient six mouths pie~
viously to the onset of the symptoms here recorded.
iSt. Beiict-jilace, E.C. _ _ _
CASE OF MEASLES: OESCUKE SYMPTOMS.
By J. B. Harris, M.D.
The following interesting case so baflled diagnosis for
some days that I think it worth recording.
On Feb. .Srd I was called to see a lad who had been suffering?
from diarrhuja for ten days. I found on niy arrival that the
motions were reduced in number to three in the twenty-four
hours. These were described as simply coloured water, and
were discharged with great force. The boy was in bed
looking extremely ill, but in no pain anywhere, and said ho-
felt “ all right.” The temperature was 102°, tongue covered
with a white fur ; the abdomen exceedingly distended and
tympanitic. On pressure gurgling was produced everywhere
except in the right iliac fo,s3a. The pressure did not cause
any pain. The next day he was much worse; abdomen
still more distended. The'gurgling now occurred at intervale
without pressure, and was so loud at times that it quite
startled the nurse; when this happened thechild felt pain, but
none on pressure. The temperature was 10‘P4°, and there w.ae
well-marked opisthotonos. In the evening Dr. G. F. Barnes-
saw the case with me. As we could not obtain any evidence
of the patient liaving had a proper motion for over ten
days, only what was described to us as “water,” the ques¬
tion was discussed as to whether it was a case of partial
intussusception; but there had been no vomiting, no passing
of mucus or of blood. Examination per rectum revealed
nothing. We were therefore bound to make the unsatisfac¬
tory report to the parents that the child was in a most
critical state, bub that the cause of the dangerous symptoms
Die' --n-r/ Google
The Lancet,
HOSPITAL MEDICINE AND SURGEEY.
[Feb 21,1891, 427
we were at present unable to discover. Early on the follow¬
ing morning I received a telegram, "Harold has a rash.”
I found on my arrival the patient much better. Tempera¬
ture 103“; abdomen smaller; no opisthotonos; but he un¬
doubtedly bad measles. The next day the temperature was
only 101“, and on the following normal. All catarrhal
oymptoms had been absent.
West Norwood.
% Pirm
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autem eat alia pro certo noscendl via, nisi quamplurimas et mor-
tjorum eb dissectionum hiatorias, turn aliorum turn propriaa collectas
habere, et inter se oomparare.—M orgagni J)e Se^ et Cans. Morb.,
'Ub. It. Prooemium. -
GREAT NORTHERN CENTRAL HOSPITAL.
A CASE OF ASTHMA, WITH POLYPI AND HYPERTROPHY OF
THE TURBINATED BODIES; OPERATION; CURE.
(Under the care of Dr. Cholmeli-jy and Mr. Spencer
Watson.)
In this case the relationship between disease in the nose
-and asthma, as cause and effect, appears to have been clearly
-established, the paroxysms having ceased after effectual
treatment of tjie nasal disease. 0 ther and varied treatment
had been tried ineffectually for many years. Dr. Bosworth^
•considers that in view of the results of treatment it may be
fairly claimed that of the three elements which enter into
the causation of asthma—viz , a neurotic habit, the nasal
■disease, and atmospheric conditions—the nasal disorder out¬
weighs in importance the other elements of causation. Of
•eighty cases under his care, forty-two had been cured and
thirty much benefited by nasal treatment. He- recommends
the use of cocaine in the nose during the exacerbation, and,
from the benefit which he obtained, even where no definite
disease could be found, considers that there is usually some
lesion present, though it may be obscure. Dr. Ayres^ has
.given a series of ten ; in the majority it was of old standing,
and the disease yielded only and at once to well conducted
cauterisations of diseased portions of the nasal cavities.
Cases of a similar kind are recorded by others,^ which only
recovered after treatment of some affection of the nose,
in a discussion at the Berlin Medical Society'^ in 1887, the
general opinion appeared to be that the number of these
cases benefited by cauterising the nasal mucous membrane
-was small. The view on the question held by Dr. Wes^,«
and expressed by him in a recent paper read at the Medical
"Society, will be still fresh in the memory of our readers.
Mary B-, married, aged thirty-five years, admitted in
fceptember, 1890, was a stoutisb, fair-complexioned, and
well-nourished woman, with somewhat short breath and an
■occasional livid look about the lips. Siie had suffered from
asthma for eighteen years, and at the time of her admis¬
sion the attacks came on about 12 p.m. every night. They
were very violent, and caused much distress. She had been
■under treatment at hospitals and in private, but with no
'benefit. She stated that she had twice contracted some
■disease from her husband. The nostrils were obstructed, i
hut not completely. Mucous crusts covered the turbinates,
ilie thorax was very emphysematous and hyper-resonant,
and with very limited expansion ; heart sounds regular, but
leeble. On anterior rhinoscopy a roundisli, grey, pendulous
mass was seen jn the right nostril, attached to the anterior
end of the inferior turbinate bone. In the left nostril were
several translucent polypi. The breath chani^el was not
■completely obstructed, but breathing through the nostrils
was very laboured and difficult. After treatment by various
mechcines, of which the most successful was nitrite of
^>yJ, the patient was transferred on Oct. 10th to Mr.
■w atson 8 care, and now the solution of cocaine (20 per cent.)
* Now Y^irk Mod. .Tnurn., vol. n. 1880, Sajon.s.
; Anier. Joum. of Mod. .Sciences, Sept. 1888.
i and Siirjr, .louvii,, vol. ii. 1S8S.
Modical Record, July. 1888; Rri.sto! Med. Cliir. Journ., March 1888
6 Borl. Klin. Wochon., 1887.
6 Tint Lancet, vol. ii., 1390, p, 1100.
was applied freely in both nostrils, with some temporary
relief.
On Oct. 15tb, under the influence of cocaine, some of
the masses of hypertrophied tissue were removed by the
snare, and on the 23rd further portions of the fringe and
the lower turbinate of the right side were removed by the
ring knife, the same instrument being used for the removal
of several polypi from the left nostril. This was done
under chloroform. There was a slight rise of temperature
(100‘4“) on the day of this operation, but it speedily became
normal and the asthmatic paroxysms have almost entirely
ceased.
Jan. 8th, 1891.—Though some slight threatenings of
asthma have once or twice shown themselves, they nave
always subsided under the application of cocaine. The
patient is now in perfect health and considers herself cured.
Jiemarks.—The rapid and persistent recovery after asthma
with emphysema of eighteen years’ duration is very note¬
worthy. The operation chosen—viz., by the ring knife under
the influence of chloroform—seemed to Mr. Spencer Watson
the preferable one in this case, as the clearing of the
nostrils by means of repeated operations with the snare
would have caused a less relief of the nasal breathing and
would have failed in giving a sudden blow to the morbid
habit which has so much to do with the persistence of
asthmatic seizures. Many cases of relief of asthma by
intra nasal operations have now been put on record by
recent authors, but few can compare with the above as to
the completeness of relief after the long period of eighteen
years of confirmed asthma.
NORTH RIDING INFIRMARY,
MIDDLESBROUGH.
A CASE OF OSSIFYING MYOSITIS ; OPERATION ; REMARKS.
(Under the care of Mr. F. MuNRO.)
As a result of chronic inflammation true bone formation
may take place in muscle, and this development may be
either localised or general. In the localised variety the
inflammation of the connective tissue is usually the result
of repeated slight injuries ; here there appears to have been
no such cause, for apparently the bony tumour was found
live weeks before admission in consequence of the part
having received a knock, which first attracted attention
to it. The case of a boy is given by Abernethy, in whose
muscles bony tumours developed after blows or other
injuries. These bony plates may require removal on
account of their interference with the movements of a
part, either from their size or position. Hayem considered
that there was a close relation between the generalised disease
and some nerve lesion. We have not now under considera¬
tion the occasional ossification of muscle as a consequence
of syphilitic myositis, the developments of bone found near
a joint the subject of Charcot’s disease, or that found in
close proximity to exuberant callus. Tlie condition of which
a description is given below, the formation of a large isolated
plate of bone in a muscle not subjected to pressure, in a
patient presenting in other respects no evidence of disease,
belongs to a different class. For the following account we
are indebted to the house surgeon, Mr. G. Victor Miller.
J. A-, aged twenty-four, w’as admitted into the North
Riding Infirmary on May 15bh, 1890, suffering from the
effects of a blow on the right thigh. The patient stated that
he had been playing football on Easter Wednesday, when
he came into collision with another player, whose knee
struck him on the front of the right thigh, incapacitating
him from work for three days. A week after the accident
he noticed a hard swelling an inch and a half above the
outer side of the knee-joint. It got larger, and five weeks
after the accident he sought medical advice at the above
institution. On examination, there was found what seemed
to be a lump of bone lying loose in the muscles of the outer
side of the thigh. It was about eight inches long, narrow
and projecting at its lower end and approacliing the surface,
but broadening out as it passed up the thigh and lying more
in the muscles. It was slightly movable except at its upper
end. The patient could walk about fairly well with assist¬
ance of a stick, but was able to ilex his leg only very slightly;
and his occupation—namely, that of a moulder—being
one in which there is a good deal of kneeling, the
inability to flex the leg on the thigh, along with some
DicM : : ■ CjOOgIC
428 The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[Feb. 21,1891.
pain, caused him great iocouvenience. Diagooais was
difScult, and after a fortnight’s rest in hed with the leg
on a splint it was decidea to cut down on the mass.
Accordingly, on June 1st an incision, three inches long,
was made over the projecting portion. On feeling the mass
through the wound, it was found to lie in the substance of
the vastus externus, being separated from the femur by a
sheet of fibres. The muscle covering it was raised bluntly
with the handle of the knife, and it was then seen that we
had to do with a slightly curved plate about eight inches
long, arising from the origin of the vastus and the linea
aspera. It was fully a quarter of an inch thick at its origin,
thinning out as it passed outwards and forwards. The
broadest part measured about three iuches. Nearly the
whole of it was removed with bone forceps. The wound was
sutured, two large-sized drainage-tubes inserted, then covered
with wood-wool pads. It closed without a bad symptom,
and the patient left the hospital quite well on July 6th.
liemarks. —This was without doubt a case of ossifying
myositis of very large extent. A somewhat similar case,
but not nearly so large, has been recorded by Orlow, as
cited by Virchow in his Annual for 1889, from which we
here quote :—“ Orlow bad the opportunity of examining
an osteoma of the adductor longus which had developed in a
cavalry captain. The captain, in setting bis horse to leap
a ditch, suddenly felt a severe pain in the inguinal region.
For live months after he bad constant pain, and at the end
of that time he remarked a growth of bony hardness.
About five and a half or six and a half centimetres below the
left inguinal fold there was a small elevation in the skin of
the inner side of the thigh. This was caused by the sharp
end of a bony plate fastened to the pelvis, but movable. It
was superficial, and the skin was movable over it. When
removed, it was found that the connexion between the bony
plate and the pelvis was completely movable. The fibres of
the adductor longus were attached to the whole inner margin
of the bony plate. The development of bono bad taken
place at the upper end of the muscle. The longitudinal
section of the growth showed medullated bone of a dark-
red colour without any distinct cortical substance. On
microscopic section it was seen to be composed of nests of
bone cells separated from each other by fibrous tissue.
The base of the growth was covered by a firm pale
lamina resembling cartilage. The medullary spaces were
filled with a delicate tissue consisting of irregularly
branching fibres and difierent kinds of cells (round and
spindle) of various sizes. A great part of the spaces were
occupied by bloodvessels crammed with blood-corpuscles.
The cartilaginous connective tissue layer of the tumour
was composed of a fibrous stroma containing spindle cells.
Distributed in this lamina were remnants of cartilage with
a delicate fibrous stroma, round or oval cells enclosed in a dis¬
tinct capsule. Orlow assumes that both periosteum and inter¬
muscular tissue took part in the process.” Portions of the
growth removed from our patient’s leg were sent for examina¬
tion to Professor Greenfield, of Edinburgh University, along
■with an account of the history of the case and that of Orlow.
He has very kindly sent us the following report, along with
sections for the microscope;—“The case is one of great
interest and rarity, and corresponds in almost every respect
to that of Orlow, quoted by Virchow, to which you
referred, the chief difference being the absence of such
marked vascularity and also the absence of cartilage. I
think the case is one of typical ossifying myositis.” In con¬
clusion, it may be added that the patient was seen recently
and the leg examined. It is as well as ever it was. There
is no pain, no sign of any return of the growth; he can Ilex
the leg fully, and has not lost a day’s work since leaving
the hospital. _
HORTON INFIRMARY, BANBURY.
GENEKAL EMniYSEMA AFTER FRACTURE OF THE RIBS.
Under the care of Mr. C. L. H. I’EMiiERTON.)
Emphysema of traumatic origin is very commonly met
with as a result of fracture of the ribs with wound of
the lung, and from that point of view the following case
presents nothing unusual. But if we consider the great
extent of the emphysema met with here and the serious state
induced by the distension of the subcutaneous tissue, and
that asphyxia was only prevented by the multiple punctures
made, we have an unusual condition and one alarming
both to the patient and surgeon. The risk of cellulitis
after incision for general emphysema being considerable.
resort is only had to it in extreme cases. For the account:
of this case we are indebted to Mr. Herbert Kershaw,
M.R.C.S., L.R.C.P., house surgeon.
A. G-, carpenter, aged lorty-four, was admitted on
Sept. 26th, at 5 r.M. A few minutes previously he ha<3
been working on a ladder, when he slipped and fell a dis ¬
tance of about five feet, pitching with his right side across a-
log, the blow being received over the sixth, seventh, and
eighth ribs in the mid-axillery line. He was collapsed'^
cyanosed, pulse hardly perceptible, respiration quick
and noisy, and complained or difiiculty of breathing.
A swelling extended over the whole of the right cheat
and back; the s'kin where the blow was struck wa&
slightly bruised ; the swelling rose and fell with respira¬
tion. A crackling sensation of emphysema was found
over the middle of the swelling, and occasional crepitus
from the broken ribs. A loud vesicular murmur was heard
over the swelling, as though the stethoscope was in contact'
with the lung. Hot brandy-and water was given, hot
bottles were placed around him, and he was covered witb
blankets. When he rallied he complained of dyspnoea, and
was much cyanosed. His breathing was noisy, and he
spat dark blood. Two hours after the injury the man wa&
of enormous size; very emphysematous all over. Crackling
was felt on the scalp, soles of the feet, and tips of the fingers..
His features were entirely obliterated, and he was quite
blind; neck distended, level with chin, and sluing towards-
shoulders; scrotum the size of a football. The man was-
crying out that he was suffocated. A large aspirating;
needle was thrust in over the seat of injury, the air being
expelled with great force through it. Some dozens of
punctures were made in the cellular tissue, the noise of the'
air rushing out resembling a swarm of bees. Relief was
immediate, the man holding his breath and expiring with,
great force. At 10 P.M. it was necessary to puncture the
skin again, especially around the neck, the air having
accumulated to an enormous extent; relief was as marked
as on the former occasion.
Sept. 27th,— 2 a.m.: He was fairly comfortable, but ex¬
pectorated blood freely, the exertion and pain of expectora¬
tion exhausting him somewhat. 10 A M. ; Pressure was
tried over the injured side. 1 p.m. : The emphysema again>
increasing, punctures were again resorted to, the man
urgently requesting that it might be done.
28th.—2 a.m. : He commenced to spit blood freely again.
A hypodermic injection of morphia was given. He remained
in a dozing condition all day, but became restless again at-
night; expectoration was now only slightly tinged with
blood. Temperature 10.3°.
29th.—2 A.M. : Hypodermic injection given; result good..
Oct. Ist.—Emphysema subsiding, so that he was able to-
see out of his eyes. Needle removed from chest.
2Dd.—Temperature normal; general condition good. An
extravasation of blood under the skin extending from th&
right to the left side of the chest. This was quickly absorbed.
Respiration only slightly increased. Slight pain oa
congbing. He says he is quite well. He never had any
further trouble except that of his attendants impressing
upon him the necessity of keeping still.
On Oct. 13bh he left the hospital at his own request, and'
a week later he went to work.
PATHOLOGICAL SOCIETY OF LONDON.
Hypertrophied Kidney with Dilated Pelvis.—Imperforate
Mectum.—Aneurysm of the Aortic Arch opening into
the Superior Cavd.—Cervical Teeth.—Uolumnar-cclled
Carcinoma of Humerus iecondary to Carcinoma of
Mectum. — Carcinoma of Kidney.—Ejfccts of Intra¬
uterine Pressure on the H'lchis.
An ordinary meeting of this Society was held on Feb. 17th,
the President, Dr. W. H. Dickinson, in the chair.
Dr. Job Collins read a paper on a case of Hypertrophied
Kidney with Dilated Pelvis. It was taken from the body
of a inan aged fifty, who died in the London Temperance
Hospital from malignant disease of the oesophagus. It was
situated in the usual position in the left loin, weighed
.5ioz.,waB rough on the surface, evidently hypertrophie<l
or unusually large, had greatly dilated pelvis opening into-
The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[Feb. 21, 1891. 429
ureter, which readily adinitted the fioger. The veeical orifice
of the ureter was stated to have been valvular; the bladder
was dilated, the mucous membrane injected, at the base
some dark puncta. The right kidney was noted to have
been represented only by a small dark flaccid mass, little
more than 1 in. in length”; a ureter the size of a lead
pencil, however, led from this to the bladder. There was
apparently no true renal tissue in the mass representing
tne kidney. The rapidly fatal termination of the case
appeared to have obviated any clinical examination of the
urine. The case appeared to be one of asymmetrical
hypertrophied kidney, the result of destruction of the
opposite kidney, probably from a completed hydronephrotic
atrophy, a similar earlier condition of dilated pelvis and
lureter occurring in this kidney also. It was, therefore, not
one of the exceedingly rare cases of single kidney from
congenital absence, but of the less rare, but still rare,
variety of asymmetrical kidney from atrophy of its fellow.
The important bearing of the occurrence of such cases was
sufficiently obvious in cases where nephrectomy for hydro¬
nephrosis or tubercle of kidney was contemplated.
Mr. Stephen Paget showed three specimens of Imper¬
forate Anus. The first was from a very small, feeble
infant, a thirteenth child, never at the breast. He did a
left inguinal colotomy, and ten days later he passed a
■director down the bowel, and was able to evert the cul-de¬
-sac and push it out at the anus and open it easily. But
the baby did not thrive, and died at five weeks old. The
second came from a small, feeble infant. He found the
bowel at the depth of an inch, opened it, and dragged it
^own. The child died at six days old, and was found to
iiave only one kidney, the right being undeveloped. There
was ulceration of tlie opened bowel. The third specimen
was from an infant that had gone thirteen days unrelieved.
Mr. Paget failed to open the bowel in the cul-de-sac, and
passed instead into the peritoneal cavity; he therefore
made a small median incision above the pubes, and attached
the dilated bowel here and opened it; but the infant never
rallied, and died the second day after the operation. At the
mecropsy some peritonitis was found round the wound,
but there was no extravasation or giving way of the
bowel. A Meckel’s diverticulum from the small in¬
testine was found. Mr. Paget called attention to
the coexistence of other malmrmations in these cases
and to the difficulties of operating on them.—Mr.
Bland Sutton had examined post-mortem several
•foetuses with imperforate rectum, and in five of these he
had found the kidneys abnormal. In one, the kidneys and
sireters were represented by mere fibrous tissue; in the
■others, the kidneys were sacculated. The rectum in these
cases occupied the cavity of the pelvis, and was in each
oase much distended. The pressure of this over-distended
rectum was doubtless the cause of the obstruction to the
ureters, with subsequent sacculation of the kidney.—Mr.
Bowlby understood Mr. Paget to say that he had not
•found a ureter in connexion with the kidney which he had
■described, and Mr. Paget said that this was so.—Mr.
Symonds of Oxford referred to two cases of imperforate
rectum. In one, after endeavouiihg to reach the rectum
■from the perineum—unsuccessfully, however—he had per-
•formed colotomy. After some time the rectum burst on
to the surface of the body at the proper place. In a second
case also he had been obliged to perform colotomy, after
•endeavouring to reach the rectum from the perineum. The
operation was a difficult one in many instances, and in this
ease was not successful.—Mr. W. G. Spenceu thought that
Mr. Sutton’s suggestion, that the conditions found in the
kidneys in these cases was due to over-distension of the
■closed rectum, was difficult to understand.
Dr. W. M. Ohd described a case of Aortic Aneurysm
■communicating with the superior cava, taken from a police
constable aged forty-three, admitted to St. Thomas’s
Hospital, Nov. 14th, 1890. Patient had been a constable
tfor thirteen years, and previously had led a life of very bard
work; no history of syphilis or intemperance. Five months
before admission he began to experience a pricking sensa¬
tion in thp right side of the chest, accompanied by dysphagia
And inability to lie on the left side. When first seen he
showed marked lividity of the face and ears, and the right
side of the neck and chest was mdematous, with turgid
superficial veins. No tumour of the chest was visible, but
there was marked dulnesa from the right border of the
sternum outwards between the upper border of the second
and the upper border of the fourth riba. There was pulsa¬
tion, but DO thrill over this area. On auscultation there was
a long-continuous humming murmur, never ceasing, but
varying in intensity, being more sonorous during cardiac
systole, fainter during diastole, conducted into the neck
and heard over the whole of the right side of the chest
posteriorly. The cardiac area of dulness was increased, and
there was a musical apical systolic murmur, distinct from
the continuous murmur. The radial pulses were equal,
the arteries were thickened; no ascites or anasarca. For
the first ten days in hospital patient improved decidedly,
but on Nov. 26th there was marked increase of the facial
cedema and sharp dyspncca; signs of pressure on the upper
part of the right lung developed, and the patient died
somewhat suddenly on the night between Dec. 3rd and 4th.
On post-mortem examination the right pleura contained
about eight pints of fluid and clotted blood; a small
perforation opening into it was found in the sac of the
aneurysm near the root of the lung. The aneurysm began
two iDches from the aortic valves, but the first part of the
aorta was atheromatous; the sac was about the size of an
orange, and, except for a little pale adherent clot, was empty.
In the interior a small slit in the sac, about half an inch in
length, opened directly into the superior vena cava, two
inches below the union of the innominate veins. Keference
was made to two cases occurring under Dr. Bristowe in St.
Thomas’s Hospital, which presented similar physical signs.—
Mr. Kavmond Johnson mentioned a case that bad been
described by Dr. Arkle at tlie Clinical Society, which agreed
almost exactly with Dr. Ord’s case, both clinically and
patliologically.—Dr. Seymour Taylor thought the chief
interest in the case under discussion was in connexion with
the characters of the murmur that had been present during
life. He had listened both to this and also to Dr. Bristowe’s
cases. The late Dr. Murchison had shown that there were
four signs indicative of aneurysm, and to these be thought
a fifth might be added—namely, diastolic shock, the impor-
taneeofwhicliDr. Ordbad previously pointedout. Amurmur
in the sac of an aneurysm if produced by the contraction
of the wall of the sac would be synchronous with the cardiac
diastole. A musical humming murmur would be the kind
of murmur likely to be produced by the contraction of the
sac wall, and it might be compared to that heard in cases of
congenital heart disease in which there wae an imperfect
ventricular s^tum.—Dr. Ewart referred to a specimen in
St. George’s Hospital museum in which there was a com¬
munication between an aortic aneurysm and the superior
vena cava. During life there was very great pressure on
the veins at the root of the neck. In order to try and give
relief, venesection bad been performed and the blood had
escaped from the open vein in jets as though from an artery.
Although he had not recognised the full significance of this
at the time he felt that it was a point of much importance,
and asked Dr. Ord if he had noticed any venous pulsation
in his case.~Dr._HADDEN had seen Dr. Ord’s case during
life and also the two cases of Dr. Bristowe’s that had been
mentioned. He would prefer to describe the murmur as a
continuous one with a wave of greater intensity in it. A
murmur of this character was not absolutely diagnostic of
aneurysm, as such murmurs had been known to occur in
very vascular sarcomata, and, indeed, murmurs had been
heard in sarcomata situated in the thorax and elsewhere.—
Dr. Ord, in reply, stated that no pulsation could he
detected in the veins of the neck owing to the cedematous
condition of the parts, and that there was no pulsation in
the veins of the arm. Dr. Hadden’s remarks with reference
to sarcomata were very important; he had himself
occasionally heard murmurs over sarcomata which were of
much the same quality of tone as the one in the case under
discussion, but varied in time by not being so continuous.
Mr. Bland Sutton first showed a Slieep’s Ear in con¬
nexion with which was a persistent second branchial cleft,
and attached to it was a llap of skin known as a cervical
auricle. The edge of this Hap was covered with papillae
like those found on the lip of a sheep, and in the cletb there
was a tooth somewhat similar to a sheep’s incisor. The
second specimen was a tooth which had been removed from
a persistent second branchial cleft in a horse. Teeth had
been found in connexion with the petrous bone in oxen,
and two cases had been described by Magittot, which were
meserved in the Veterinary Museuni at Alfort, near Paris.
Teeth had occasionally been found in the second branchial
cleft in man, and he mentioned one case in which a tootli
was cut behind the angle of the jaw in the neck, in the
usual position of the second branchial cleft; this had been
C
430 Thb Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[Feb. 21,189K
erroneously supposed at the time to be a wisdom tooth
which had wandered.—Dr. Okd asked whether the teeth
conformed to the mammalian type, or approached that
of some of the lower vertebrates, as some fishes had
teeth on their branchial arches.—In reply, Mr. Bland
Sutton stated that the teeth were of strictly mammalian
character. He then referred to dermoid cysts, the contents
of which also conformed to the type of the animal in which
they were found. It was, however, interesting that teeth
had only been found in dermoid cysts, which were connected
either with the ovary or the neck.
Mr. Bernard Pitts showed a specimen of Columnar-
celled Carcinoma of the Humerus secondary to Tumour of
the upper part of the Keotum, which was removed from a
woman aged thirty-two, who was admitted into St. Thomas’s
Hospital in Febtuaiy, 1890, with obstruction of the bowels,
caused by a large growth in the upper part of the rectum.
Symptoms dated from her last confinement eighteen months
previously. For the last year she had been losing flesh, and
suffered from profuse and offensive diarrbcea. The distension
of the abdomen was so great on admission, and the rectal
examination revealed such a hard and fixed growth of the
bowel, that he performed left lumbar colotomy, and opened
the bowel at once. After the abdominal distension had
subsided, a hard mass could be felt through the abdominal
wall in the left iliac region, but from its extent and its
attachments it was not thought advisable to attempt excision
of the growth ; so she left tne hospital on April Gth, having
f ained flesh greatly, and she was in fair general health.
he was able to do ordinary household work, and suffered
comparatively little inconvenience from the artificial anus.
Early in November, whilst making her bed, she felt her arm
suddenly snap, and was unable to use it afterwards. She was
admitted again into hospital, under Mr. Pitts, in December,
in an emaciated condition, aufTeriDg great pain from a large
tumour of the right humerus, with a fracture about the
middle of the bone. The rectal tumour bad increased
somewhat in size, but there was no evidence of further
g rowth within tbe abdomen or elsewhere to be detected.
'n Dec. 24tb, 1890, he amputated at the shoulder-Joint by ;
skin-liaps, having first ligatured tbe vessel in tbe axilla.
The patient made a rapid recovery, and left the hospital
on Jan. 14th, 1891, with a perfectly healed stump,
and having gained fiesh and strength in a surprising
manner. The tumour of the humerus shown was or large
size, and in appearance very like an ordinary subperiosteal
sarcoma which had infected the medullary cavity. A
microscopic examination of the tumour made by Mr.
Shattock showed it to be, as expected, a columnar-celled
/sarcinoma, so perfect in character that it would be impos¬
sible to distinguish it from a similar growth in the rectum.
Mr. Pitts in his remarks stated that he could find no
reported cases of such a growth in bone secondary to tumour
of bowel, but referred to a similar case which involved the
humerus, recorded in the Pathological Transactions for 188G
by Mr. J. Hutchinson, jun., where, however, no primary
bowel tumour had been loucd during life, and no abdominal
symptoms had been present. Unfortunately in this case a
post mortem examination had not been allowed. In the
resent case it was quite clear that the tumour could not
e described as a cylindrical sarcoma, and the specimen
showed how closely in general appearance a carcinoma of
bone might resemble a sarcoma. The life-history of
columnar carcinoma of bowel had not been satisfactorily
determined, for the growth was often present for a long
time without giving rise to any direct symptoms. It might
remain local for a year or two, not even implicating sur¬
rounding structures. So few of these tumours had been
removed at an early period that it was impossible to form
an estimate as to the prognosis in early and complete
excision, but it must be more hopeful as regarded life than in
carcinoma in most other places. —Mr. Stepiiicn Paoet read
the following statietics which he had collected Out of 40
cases of cancer of the rectum, in only one had there been
secondary deposit in bone (femur). In 291 cases of cancer of
the alimentary canal from the lip to the anus, only .3 presented
secondary deposit in bone; one (the one mentioned above),
one from the lip, and one from the cheek, both the latter
with a secondary deposit in tbe fifth rib. In cancer of the
uterus, out of 200 post mortems, no bone was secondarily
affected, whereas in cancer of the brea-st, out of 205 cases, the
humerus had been affected G times, the femur in 11, and
many other bones. Of German statistics Gussenbauer had
collected 903 cases of cancer of the stomach, and no mention
was made of any bones having been affected. Sprengel, in
131 cases of cancer of the breast, showed the femur affected
four times, and the cranium and other bones somewhat fre¬
quently. Torok, out of 336 cases of cancer of the breast;,
found tbe humerus affected in 5, the femur in 3, and many
other hones. In malignant disease of the thyroid secondary
deposits in bone were particularly liable to occur. Out of 24
cases which he had collected the bones were affected in 16. It-
did not appear to be a mere question of embolism, for par¬
ticular parts of bones, such as the upper half of the femur
and of the humerus, were especially liable to be affected.
He asked Mr. Pitts if in his case any other bones had
been affected. He said that Torok had found that in
many cases there was an unusual brittleness of bone.—Mr,
E. Williams said that fragilitas ossium in cancer wao
quite distinct from metastatic deposits. Secondary
deposits in bone were found in several cancers besides
those in the breast, and he believed sometimes with
uterine cancer. He considered secondary deposits in bone-
to be undoubtedly embolic; in Mr. Pitts’s case it wan
interesting that so large a tumour must have grown from a.
single cell, as he had no belief in any spermatic influence.—
Mr. R. Johnson mentioned a case that was in University
College Hospital about two years ago in which there was
secondary growth in the humerus. It was thought at fireti
to be a sarcoma, but on examination was found to be carci ¬
nomatous, though no primary deposit had then been found,
i but later a small ulcerating growth in the cervix uteri was
discovered. The case was interesting from the large sizo
of the secondary deposit, as compared with the small
primary growth. He mentioned another case of squamouo
epithelioma with secondary deposits in the ribs. Mr.
Snattock remarked that secondary deposits in squamoue-
cancer other than glands were alniost unknown. This-
he thought might be explained mechanically, as the
cells, owing to their large size, were filtered off in tho
glands, whereas the small cells of scirrhus not un¬
commonly had secondary deposits in hone.—Mr. Symondd-
related the case of a lady who had persistent pain in the
neighbourhood of the left shoulder. She was under the-
care of Mr. Bryant, who found the coracoid process to bo
enlarged by a cylindrical-oelled epithelioma. No primary
growth could then be detected, but she afterwards died of
carcinoma in the neighbourhood of the liver—probably of
tbe gall-bladder.—Mr. Bowlby said that bones generally
escaped unless tbe growth was widely disseminated.
Vertebrae were most commonly affected, and this wao
generally due to a local cause. He mentioned a case of
recurrent scirrhus of the breast which had directly infected
the ribs and thence tbe vertebrae In connexion with tho
commonness of tumours of bone secondary to growths in the
rectum, he mentioned two cases, one with secondary
deposits in the femur and the other in the humerus, Ali
would agree with Mr. Pitts as to tbe comparative innocence
of growths in the rectum.—Mr. Pitts, in reply, thanked
Mr. S. Paget for his statistics. It was wonderful the
way in which spontaneous fractures of the humerus would
unite. The fragility of the bones was generally due to-
secondary deposit, and he mentioned a skeleton in St.
Thomas’s Hospital museum in which nearly all the bones
had been fractured and many were reunited, the union»
being by growth. Tho primary disease was scirrhus of the-
breast,
Mr. Lunn showed a Tumour of the Eight Kidney, which
was removed from the body of a man aged fifty-seven, who
was admitted into St. Marylebone Infirmary on Sept. 18th,
1890. He stated that he had enteric fever thirty-six years
ago. Had never had syphilis, gout, or a blow in the region
ot his kidneys, and had always enjoyed good health sines
his enteric fever until six years ago, when he had an attack
of hit-maturia, the blood passing in clots, which at first waa
followed by clear urine. This lasted a few days, and then
ceased for four or five months, when a recurrence took place.
Whilst passing the clots he sullered from sharp shootin®
pains in his light side, down to his penis. No calculus was
ever passed. Some months before admission his iia-maturia.
got more frequent, and his feet began to swell three weeks
before admission. He had an attack of retention, and wasi-
ohligedtohavehisurine drawn oll'at a hospital. On admission
the patient was a strong and well built man, though pallid
from the loss of blood. He had incontinence following re¬
tention. The urine was drawn off' with a No. 10 silvei-
catheter; it was acid and contained blood, as shown
by microscopical examination. His tongue was moist-
Thb Lancet,]
CLINICAL SOCIETY OF LONDON.
[Feb. 21, 1891. 431
and furred. Bowels open; pulse nuick and small, arteries
very rigid. Temperature l6l’4‘“ F. On examiaation of
the abdomen a large tumour was found occupying the
s-ight renal region. It appeared fixed, and on deep’pressure
idoubfcful fluctuation was to be felt. An exploring needle
■was inserted into the swelling, but nothing was withdrawn.
Two days after admission the patient passedaome very large
•clots of blood by the urethra, which did not cause him
onuch pain. The urine was obliged to be drawn off twice a
day. Four days after admission the patient became very
•collapsed from loss of blood, he had several rigors, tempera¬
ture after which he gradually sank and died on the
elxtb day following admission. At the post-mortem it was
•noted after opening the abdomen the liver appeared en¬
larged and pushed forwards by some tumour behind, which
was slightly adherent. The liver was easily removed, and
alarge tumour was seen occupying the right kidney region,
■which was removed. Mr. Target had kindly examined the
humour and gave the following account: —The tumour had re¬
placed the right kidney, and in shape resembled it. The^mass
v/eighed 4^ lb., and measuredTi in- in length, 5 in. from side to
side and in. in thickness. It had a definite fibrous capsule
3ike that of a normal kidney. On longitudinal section it
v/as found that the whole of the kidney structure had nob
disappeared, for at the upper extremity a small triangular
area of normal renal tissue could be recoguised. For the rest,
the surface of the section had a spongy appearance, and was
veiy soft, yielding an abundant juice on scraping. The
pelvis of the kidney had for the most part disappeared,
except at the upper end in the neighbourhood of the normal
kidney structure, where one or two calyces remained and
were much dilated. Their outlet, however, M’as blocked
below. Examination of the hilutn showed that the renal ,
vein was completely filled with a plug of new growth,
which had extended onwards towards its opening into the
vena cava. The funnel-shaped portion of the pelvis was
ffimilarly blocked with growths and blood-clot. The
growth did not appear to have perforated the capsule
anywhere except at the hilum, and there were two bossy
projections, which seemed to have commenced as intra-
i-enous extensions. The opposite kidney (left) ■weighed
eight ounces, and contained one secondary deposit anoub
the size of a walnut. Neither kidney showed amyloid
changes. The urinary bladder -was rather thickened but
otherwise normal. The prostate enlarged. The liver
weighed four pounds and a half, soft and friable, no
•deposits. The other viscera were normal. The heart was
much dilated, and the left ventricle thickened; it weighed
twenty-six ounces four drachms. Valves healthy. The
growth appeared to be a soft form of carcinoma.—The
Phesident mentioned the rarity of primary carcinomata
of the kidney, and the specimen was then referred to the
lU'orbid Growths Committee.
Mr. J. J. Cr.AiucE brought before the Society speci¬
mens of deformities in two new born children which were
born at full time. In both cases there was good evi¬
dence of the conditions at the time of labour ; the
first cose was brought to the author by Mr. Degui.
The mother had previously attended at St. George’s
Hospital for pelvic pain, and after delivery Mr. Degui
had found four fibroid.s, the quantity of liquor amnil in
tills case was small. The second specimen was given to
the writer by Mr. H. S Collier and was a momstor. Tlte
mother had previously borne six healthy well-formed
children; the labour was slow, and no liquor amnii had
been present. The following points of interest were present
in the deformities. In the first there were membranous
tfenestrac in the cranial bones, particularly in the parietal
bones ; in the second case there was complete encephalocele,
the crania! bones being entirely absent. In the first there
was a myelocele, and in the second a spina bifida occulta,
fln the second case, owing to the thighs having been pressed
close to the groins, the descent of the testes bad been inter¬
fered with, and in this case also there was a small caudal
appendage. The deformities in these fmtuses he attributed
to excessive pressure on the developing embryo due to the
■absence of liquor amnii.
The following card specimens were shown ; —
Dr. B. W. Hadden: (I) Carcinomatous Ulceration of
Esophagus opening intoAortic Arch andTrachea; (2) Patent
Foramen Ovale in an Adult.
Mr. G. H. Makins ; Spinal Meningocele Excised after
Morton’s Injection.
Dr. H. D. ItOLLESTON : A Kuptute of the liight Bronchus
and Fracture of the First Rib.
Mr. S. G. Shatiock : Genu Recurvatum.
Dr. Wyatt AVinorave : Lungs and Larynx from a case
of Tuberculosis after Koch’s Treatment. (Recentspecimen.)
CLINICAL SOCIETY OP LONDON.
Modified Lorcta’s Operation for Stricture of the Pylorus .—
Vases of Appendicitis.
An ordinary meeting of this Society was held on Feb. 1.3th,
the President, Sir Dyce Duckworth, in the chair.
Dr. Hale White and Mr. Abbuthnot Lane related the
details of a case of Stricture of the Pylorus following upon
hydrochloric acid poisoning, in which a modified Loreta’s
operation was performed. The patient, a man aged forty-
three, seven weeks before admission into Guy’s Hospital
swallowed some hydrochloric acid, whether intentionally or
accidentally could not be made out. This was followed by
a sharp attack presenting all the symptoms of acute irritant)
poisoning, but at the end of a few days he was better and
seemed all right. At the end of a month severe hfcmateinesia
and pain sot in, for which he was admitted seven weeks
after he took the acid. He was wasted and weak, and had
hajmatemesis and meliena. He was allowed an ounce of milk
every hour, and in a few days appeared better, but a fort¬
night after admission it was obvious that the stomach was
dilated and the vomiting returned. By careful dieting and
washing out the stomach he improved considerably, bub he
again relapsed and became so weak and collapsed that death
seemed closeathaod. Three diagnoseswerepojsible: either it
was severe traumaticchronic gastritis,or there wasulceration
with cicatrisation near the pylorus, or he had some tumour of
the pylorus independent of the poisoning. On Oct. 6th Mr.
Lane, having washed out the stomach and left the tube in
as a guide, made an incision through the right rectus muscle
and exposed the .stomach, which was found to be a little
dilated and much hypertrophied. At the pylorus and the
stomach close to it was a firm, hard ina's, nob presenting
any sign of malignant growth; it was so firm that it was
thought that it would be impossible to dilate the pylorus
rapidly, and so the stomach wall was attached to the edges
of the abdominal wound, and the patient was fed with
nutrient eneniata for forty-eight hours, at the end of
which time the stomach was opened and it was found
thabthe pylorus would only admit a No. 4catheter, Through
this the patient was fed every two hours for three days; he
I seemed to be doing well, but he died suddenly seventy-
six hours after the stomach was opened. The necropsy
showed no cause for death; there was no peritonitis, no
pulmonary embolism, nor was there any ulceration of the
' stomach to account for the pyloric obstruction, which
' existed only at the pylorus, the cardiac end being normal.—
Mr. Bowueman Jjsssbtt asked what made Mr. Lane
perform the operation he did rather than do gastro-enter-
ostomy ; the latter was very easy of performance if done
with Seun's plates, and it ■was likely to lead to permanent
good in cases such as that described. He had performed
gastro-f nberostomy on five cases of cancer of the pylorus;
I three at the present time were as well as they could be, and
were going about, and one of them had been done five
months. He thought that in the case under discussion, if
' the patient had not died, there would have been great
I diiliculty in maintaining the dilatation, and when the
external wound had closed the stricture would have recurred.
In a large number of Loreta’s cases there had been recurrence
of the stricture.—Mr. Tbeves felt sure that most surgeons
would endorse the treatment which had been carried out in
the present case, and Loreta’s operation was certainly better
than the establishment of a gastro-enterostomy. With
reference to recontraebion, so far as he knew, only two
cases of Loreta’s operation had been done in this country ;
one had been performed by Mr. Hagyard of Hull, and the
other by himself. Thef‘)rmer of these, which had been done
two years ago, 'w;as still well, and in his own case, which
had also been done for two years, good liealth was like¬
wise continuing. Tiiere was therefore in this country no
evidence whatever of recontraebion after the operation. In
reading Loreta's account one could nob help being struck
with the enormous number of fibrous strictures that seemed
to occur in Italy. He referred to a case of indefinite
stomach trouble in a woman in whom that organ reached to
432 The Lancet,]
CLINICAL SOCIETY OF LONDON.
[Feb. 21,1891.
the groin. In order to diacov^er the cause he opened the
abdomen and the stomach, and hoped to hod and dilate the
pj^lorus ; but in spite of twenty minutes’ careful search he
tailed to discover the pyloric orilice. The woman appeared
tO'be much benefited by the operation, but she came back
again in nine months with a recurrence of her trouble.
Loreta in his account said that he introduced two or tliree
fingers into the pylorus in order to stretch it, but it should
be remembered that that orifice normally bad a circum¬
ference of only 16 millimetres, which was about equivalent
to that of a sixpenny-piece. He concluded by referring to
the remarkable improvement which took place in many
patients simply after the opening of the peritoneal cavity,
and he q^uoted cases of his own and one related by Mr.
Annandale in support of this, which he believed to be only
capable of explanation by an alteration of the intra-
abdomioal pressure.
Mr. Herbert W. Allingham read notes of a case of
Excision of the Vermiform Appendix. The patient, a boy
aged fifteen, walked into the Great Northern Hospital,
bending forward considerably and complaining of pain in
the abdomen, said to have been due to a fall the day before.
The previous history was that he had been quite well up to
the time of the fall, but that three months back he was ill
for a week with constipation. On admission the tempera¬
ture was 100'6®, pulse rather feeble, tongue furred and a
little dry: he complained of pain like knives catting him
in the lower part of the abdomen just below the umbilicus
in the median line. liespiration was chieily thoracic, but
the lower part of the abdomen was partly used also. The
abdomen below the umbilicus was tense and tender, but
not to any great extent. There was no marked tender¬
ness, fulness, or pain as over the region of the cjecuin.
The urine was drawn off by a catheter; it contained no blood,
and was clear. He saw him about twenty-four hours
after the accident, and, as his symptoms were obscure,
desired to make an exploratory abdominal incision.
This was made in the median line, as a careful examina¬
tion of the abdomen while under chloroform revealed
nothing. On opening the peritoneum pus welled up into
the wound, and there were evidences of commencing peri¬
tonitis. The intestines were found not to be wounded, so
he at once turned his attention to the cmcum and appendix
vermiformis. When the appendix was found he observed it
to be perforated by a ragged ulcer, and by it were two fa'cal
concretions. The appendix was closely adherent to the
cmcum. The appendix was separated from the gut and
ligatured with line silk at its base and cub away. There
were no evidences of previous inllammation about the
cmcum. Tlie abdomen was carefully washed out with warm
water and a glass drainage-tube inserted, and the abdomen
closed with silkworm-gut sutures. After a rather protracted
convalescence the boy made a complete recovery, and bad
been at work four months. The boy, a specimen of appendix,
and fajcal concretions were shown.
Mr. Bland Sutton read notes of four cases of Appen¬
dicitis, which he had successfully treated by appendectomy.
Case 1: This patient, a man aged twenty-four, was under Dr.
Sidney Coupland’s care, with unmisbalkable signs of appen¬
dicitis. The cjecum was exposed by a lateral incision, and
the appendix found lying adherent to its anterior aspect.
The middle third of the appendix had sloughed, and an ab¬
scess, containing several ounces of pus, had formed in con-
seq^uence. The appendix was removed, the stump sutured,
and the peritoneal cavity Hushed with warm water. The
patient made an uninterrupted recovery.—Case2: Agroom,
aged twenty-two, came under Mr. Sutton’s care as a case of
renal colic. The patient had had three attacks previously,
the first, two years ago, diagnosed as “typhlitis,” the
second as “ruptured niu8cle,”the third as renal colic, and the
last remained undiagnosed. On careful examination it was
clear that the disease was “ relapsing appendicitis.” Mr.
Sutton exposed the ccecum by a lateral incision and found the
appendix slightly adherent to the brim of the pelvis. Its
lumen was obstructed. The appendix was cut off, the end
carefully sutured, and the muscles drawn together by gut
sutures, and the skin closed in the usual manner. The appen¬
dix below the stricture was filled with pus. The patient left
the hospital convalescent on the fourteenth day.—Case 3 :
This patient was seen in consultation, and regarded by the
practitioner in charge as a case of renal colic. After exami¬
nation under chloroform Mr. Sutton came to the conclusion
that the patient had a post-etecal abscess, probably secondary
to infiamination of a vertical retro-cmcal appendix. The
parts were explored, and this diagnosis verified. The appen¬
dix was lying vertically behind the cmcum, and its middle?
third had sloughed. The pus was washed away, the stump-
of the appendix sutured, and a drainage tube inserted.
Convalescence was interrupted by an attack of pleurisy,
which suggested that the trouble in the tube was tubercular.
Sections of the appendix were examined for tubercle and
tubercle bacilli, but with negative results. The wound granu¬
lated andtbepatient left the hospital convalescent—Case 4 =
A shoemaker, aged nineteen, was admitted under Dr.
Finlay’s care with typical signs of typhlitis. Under medical
treatment be seemed to improve, but in the course of three'
weeks the presence of pus was clearly indicated. Mr. Suttoii
operated by a lateral Incision and evacuated a large quantity
or pus from the iliac fossa; the tip of the appendix had)
sloughed. As the rest of the appendix was dilated, it was-
cub off, its end closed by three gut sutures and the wound
stuffed with iodoform gauze. On the eighth day a smalli
fistula formed in the colon, allowing gas bo escape. This,
however, became closed as the wound cicatrised, and the
patient left convalescent. Of these four cases, three were
examples of acute and one an example of chronic relapsing;
appendicitis. The smooth andrapid convalescence in Case 2,
in which the operation was performed for chi-onic appen¬
dicitis, formed a striking contrast to the risk, danger, and*
anxiety in the acute cases. All the cases illustrated the-
importance of early operation, which was simple enough to-
surgeons acquainted with the practical details of abdominal
surgery. Case 3 suggested tliat an abscess secondary tO"
appendicitis in a vertical rebro-ctecal appendix might invade
the pevi-renal tissues and set up a peri-nepbritic abscess.
It was also curious that an abscess due to appendicitis,,
though very fetid, failed to conduct itself in an orthodox:
manner and indicate its presence by rigors. It must also
! be remembered that in many cases of typhlitis, which
presented abdominal distension, pain, and the characteristic-
symptoms of infective peritonitis of sudden onset, these-
ominous signs were due to the escape of septic material;
from a latent abscess into the general peritoneal cavity.
In such cases surgery could do little good.
Mr. Andrew Clark read notes of two cases of Typhlifcie
Abscess in which the vermiform appendix was removed.
In the first the patient had general peritonitis when he-
was first seen, and, although he improved after the opera¬
tion, be died of peritonitis on the fourth day. In the
second case, where the attack was the third, the appendix:
was found bound down by adhesions and sloughing. It wa&
removed, and the patient made a good recovery. He had
had at present no recurrence of symptoms.
The PuEcSiDENT said that these cases of appendicitis'
presented great interest for every physician. Until the^
recent triumphs of abdominal surgery the majority of
them used to die a miserable death. The more be saw
of these cases the more he was convinced that it was-
the duty of the physician to transfer then: without delay
bo the care of the surgeon; indeed, long delay wa&
positively criminal. Yet it was very important to dis¬
tinguish between cases of inflammation of the appendix
and instances of trouble in the caput coli. The latter
had a milder character and a less grave aspect, and it was
a grave error to operate on them. Though a concretion)
was not alway.s to blame, yet in the majority of cases-
one was to be found. It should, however, he remembered
in connexion with this that the appendix normally con ¬
tained some feculent material.— M>. Treves observed that
Mr. Sutton’s remark that one of the cases had “been
treated by the methods ordinarily adopted by physicians’''
had called forth what was almost a smile on the faces of
some of the audience. Yet it should be remembered tliat-
the “medical” treatment of typhlitis was successful in very
many cases, and to treat all these cases surgically would-
only lead to disaster. Tlie great majority of cases which-
had come into the London Hospital during the last ten)
years had recovered under medical measures, and there wae.
no doubt that the epidemic of removal of appendice?>
which had prevailed in some quarters had been extreme.
If mere acuteness of symptoms were a guide bo operation,
many cases would be dealt with where no disease of the-
appendix would be found ; on the other hand, he had knowrn
of cases where the patients had continued at their work till
the bursting of the appendix. A very valuable means of
distinguishing diseases of the appendix from trouble in the-
cajcum was examination per rectum, from which position it
was often easy to distinguish the outline of the appendix.
Thh Lancet,]
MEDICAL SOCIETY OF LONDON.
[Feb. 21, 1891. 43 3
Then, again, reflex pain io the testis or in the neck of the
bladder should be looked for, the frequent apposition of
the appendix to the ureter being remembered. Though
there were cases where one should clamour for early inter¬
ference, yet in many meddling would be disastrous. The
use of needles for exploration was bad practice, and
it had yet to be shown that operative interference
before the fourth or fifth day was ever called for ; it was
certain that very few had died before the third or fourth
day. Though it was only in 1887 he timidly made the
proposal (whicli was not very cordially received) that in
cases of relapsing typhlitis the appendix should be removed
in the lucid interval, yet at the present time the number of
appendices crowding the shelves of museums was enormous.
Mr. Sutton seemed to have laid stress on the fact that a
fourth attack would be fatal, but be knew of patients who
had had twelve or even twenty attacks. Again, the same
surgeon appeared to hold that tiie disease must either lead to
operation or to death, but he liad found a number of cases
where destructive inflammation of the appendix bad led to
spontaneous cure. He repeated that the greatest cere should
be exercised in the selection of cases of relapsing typhlitis
to be operated on. It }iiight be found impossible to remove
the appendix when cut down on; he himself had bad to
abandon the operation, and on one occat^ion had been more
than an hour in elfecting its removal. The ureter often lay
curved and twisted in the region of the appendix, and he
felt sure some day that a piece of that tube would be
removed in mistake. He pointed out that the normal posi¬
tion of the appendix was behind the crocum, that it
frequently lay in a vertical axis, and trouble in it was a
well-known cause of peri-nephritic abscess. He had known
the pus spread up even to perforate the diaphragm. He
observed that in Mr. Allingham’s case the abdominal
cicatrix had yielded. In spite of the greatest care and
method, yielding of the cicatrix at the seat of opera¬
tion was exceedingly common, and a method of suturing
the abdominal wall to prevent this had yet to be
demonstrated. The wisest place to make the abdominal
incision was over the adhesions and not into the peritoneal
cavity, and from there into the abscess. The former was a
little more tedious, but was decidedly the better practice.
Cases in which the appendix was found sloughing and
lying in an abscess cavity were not those in which to
attempt to carry out a plastic operation. After opening
the abscess the less tliat was done the better, beyond
putting in a drainage-tube. Certainly the results had been
best where the interference had been least, and even if a
faioal fistula resulted, it should be remembered tliat in this
region they frequently underwent a spontaneous cure. He
agreed that in many cases approximation of the serous sur¬
faces was impossible, and that where the operation was
done in the absence of pus the stump should be fixed to
the neighbouring peritoneum.—Dr. Cayi.ey, as a physician,
asked for guidance on one or two points. In the first of
the two cases of Mr. Clark’s, which had been under his
care, general peritonitis had developed; and in the
second case, in which the patient made a good recovery,
it had already sot in. Should the operation be done when
general peritonitis was present, or how long should medical
treatment be continued before operation was advised ?—
Dr. Coupland said it was quite refreshing to hear a
surgeon approving of medical methods, for physicians had
been taunted over and over again with persevering in the
medical treatment of these cases. His own observations
had led him to believe that trouble in the ciucum itself
was extremely rave. He admitted that many cases
recovered, bub in those he thought the mischief was
also in the appendix, and he knew of no sign or sym¬
ptom which would dill'erenbiabe one class from the other.
He believed that in no case which had been operated
on had the c.Ticum been found to be demonstrably
aflected, and pathologists had not met with the condition
in the post-mortem room, except in cases of obstruction
beyond the ciucum. Dr. Cayley had ])ut the question
strongly : What were the indications which justified the
calling in of the surgeon? Where young subjects were
admitted with acute peritonitis of short duration—“ ful¬
minating cases ”—with no previous history of bowel trouble,
such formerly commonly found their way to the posb-
luorteiTi room ; but now, in the probability of the case
being one of perforated appendix, one would call in the
surgeon. Such a diagnosis was made in a similar case
in his own practice a short time ago, bub on explora¬
tion the opinion proved to be an erroneous one. The
patient was a lad aged nineteen, who had strained
himself; symptoms of cmcal inflammation and of general
peritonitis developed. The abdomen was opened and peri¬
tonitis found, especially in the pelvis, bub there was no
disease of the appendix and the patient made a good
recovery. It was ailficult also to decide what bo do in cases
where suppuration was supposed to be present. In the first
case which Mr. Subton had related, which had been under
bis care, he waited because he thought at first the case
would prove a simple one ; but as soon as be could make up
his mind that suppuration was present he secured the aid of
the surgeon. It was certain that in some cases suppura¬
tion would go on round the cajcum to an extreme degree
without showing signs, and he had certainly seen cases of
extensive ahdomin^ suppuration where the source of the
mischief bad been an unsuspected infiamed appendix.
On the motion of Mr. Langton, seconded by Mr. Peabcb
Gould, the debate was adjourned till the next meeting.
MEDICAL SOCIETY OF LONDON.
Baynaud’s Disease. — Addison's Disease.—Transposition of
Viscera.—Cystic Bronchocelc.—Fistula after Strangulated
Inguinal lltrnia.—Asthma in a Boy.—Simultaneous
Amputation of both Breasts for Cancer.—Dexio-cardia
and Bronchiectasis.—Situs hivcrs^is Viscerum, — Treadler's
Cramp.—Congenital Malformation of Heart.—Deficient
Development of Abdominal Wall.—Trephining for Head
Injury.—Lupus treated with Koch's Fluid.
A “CLINICAL EVENING ” of this Society was held on Feb.
16bh, the President, Mr. Knowsley Thornton, in the chair.
Dr. DE Havilland Hall bioughb forward a case of
Raynaud’s disease in a labourer aged thirty-one, wlio was
also suffering from pulmonary phthisis. He had an attack
in December, 1889. The ears became blue, bub not painful;
the lingers and great toes were then affected. The present
attack began in December of last year. The ears were very
painful; hands and feet nob alfected. Skin of the helix
of both ears bad necrosed. No pain since the patient had
kept the ears covered up and taken five minims of tincture
of opium thrice daily.
Dr. Hall next showed an instance of Addison’s disease
in a man aged thirty-five, who was a night attendant at a
cabstand. The pigmentation was extremely well marked
in the lips, buccal mucous membrane and tongue, the colour
being bluish black. There was also increased amount of
pigment in the skin of the face about the areolie, and in
the axillfc. On the trunk and extremities there was a pig¬
mented rash. Vomiting commenced seven weeks ago, bub
had ceased the last three weeks. The patient had angular
curvature of the spine, the result of a fall in childhood.
Dr. Hall also exhibited a man, a porter, aged forty-
six, whom he had shown to the Society on Feb. 7bh, 1870,
as an example of Complete Transposition of Viscera. Since
then the heart had suffered considerably from the effects of
acute rheumatism. There was a systolic murmur, heard
loudest in second left interspace, and conducted to the
storno-clavicular articulation ; a diastolic murmur, heard
loudest over the sixth right costal cartilage, and conducted
towards apex. There was a systolic murmur at apex, con¬
ducted into axilla and faintly audible behind. The apex
was three inches below right nipple, and one inch to the
right. The liver dulness could be detected on the left side.
Dr. Hall lastly showed a woman aged fifty-three in
whom enormous masses of what appeared to be Thyroid
Gland were to be seen on both sides of the neck, with
greatly dilated veins over the chest. Twenty-one years
ago a cyst on the right side of the neck was tapped and a
seton put in ; there was great increase in the growth after¬
wards. She has had no treatment for the throat since.
Except some little difficulty in swallowing fluids, and some
dyspeptic symptoms, she complained of nothing abnormal.
Mr. Stephen F.\fa-:T exhibited a man aged twenty-four
on whom he had operated for Strangulated Left Inguinal
Hernia. Finding the gut gangrenous, he fastened it outside
the abdomen and opened it at once. The man did well,
the bowel skinning over and receding, till there remained
only a minute listnla from which a drop of mucus exuded
once or twice a week. Mr. Paget urged that it was not
justifiable in such cases to perform primary resection or to
adopt Ilelferich'a suggestion uf making an anastomosis
le
434 The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Fed. 21,1891.
above the gangrenous bowel —Mr. H. Alunoiiam had
met with a similar case in a woman ; he opened the gut
freely and fixed it at the abdominal wall. Several sloughs
came away, leaving a fistulous opening, which at the
present time had entirely closed.—Mr. Ballance, referring
no the question of the treatment of the gut in cases where
it was found gangrenous in strangulated hernia, agreed
that DO attempt at resection was justifiable at the time of
the first operation for the relief of the symptoms, and
complete resection attempted at that time was almost
invariably fatal. If it were at all desirable, it might be
done subsequently; but the less disturbance there was at
first the better, a free incision into the gat and one or two
stitches being quite enough.
Dr. Herrinoham showed a boy aged ten who was the
subject of Asthma. When he was three years of age he had
sullered from scarlatina, and after that he had pneumonia
and his feet swelled. Dyepncca also developed, which had
since become more frequent and severe, and was worse in
summer. The attacks were typical ones of a spasmodic
asthma, ending with a severe coughing fit, and bringing up
a quantity of muco-pus. There was Jio sign of bronchiec¬
tasis, though the boy was sull'ering from emphysema and
bronchitis. He had found that the compound lobelia powder,
when burnt and inhaled as the dyspnccacame on, completely
relieved the attacks.—Dr. Hall had seen great benefit
follow the use of the powder referred to.—Dr. Herrinoham
replied in the negative to Mr. Spencer Watson’s in¬
quiry if there were any obstruction in the nostrils.
Mr. Watson related a case in which a woman had had
asthma for eighteen years, who also had several nasal
polypi together with turbinated hypertrophy. These nasal
troubles being removed, siie was completely relieved and
had remained free from symptoms for more than a year.—
Mr. Ballance stated that he himself had sullered from
only two attacks of asthma in his life, and both had been
induced by the presence of cats in the house.
Mr. Edmund Owen showed a manied woman, aged
forty-nine years, who came into St. Mary’s Hospital last
October with Scirrbus of each Breast. On neither side was
the skin adherent, <ir the breast attached to the pectoralis.
She bad bad a child ten years ago, but there had been no
trouble with either breast, nor was there any history of
injury. Two years before her admission she had first
noticed a hard lump growing in the light breast, and a
year and a half later a similar growth on the left side.
The growths, though of no great size, were extremely hard
and nodular. Under an aiuosthetic, Mr. Owen removed
the right breast, whilst his house surgeon, Mr. W. J.
Foster, amputated the left; each axilla was also cleared of
enlarged glands. The patient showed no particular shock
after the operation ; the wounds healed by first intention,
and her present condition was eminently saii^factory. It
was formerly taught that operative treatment was contra¬
indicated when both breas's were the seat of maligoant
disease, and in the last edition of “Eriohsen’s Surgery’'
this statement recurred. To thi’, however, Mr. O wen took
exception. In the early stages caoctr was a local disease.
The fact of one breast only being almost invariably the
seat of the disease was evidence of its local nature. When
both breasts were aflected, the condition might be regarded
as accidental, It by no means followed that the bilateral
occurrence indicated constitutional implication ; and the
fact of both breasts being scirrhous might actually be a
double reason for advising prompt operative interference.—
Mr. Ballance had seen a woman nearly eighty years of age
suffering from cancer of both breasts and of tlie axilla, of
ten years’ duration. In spite of this she had not lost fiesli or
strength, and she illustrated the truth that in old people the
cancerous disease did not kill the patient—The Pkksiden'I’
referred to two cases on which he had operated in 18.Stl, and
in both he had removed the breast and glands. They had
both recently returned to him with recurrence in the ojjposite
breast, the recurrence in one being in tlie mammary scar,
and in the other in tlie axillary glands. In one of them he
had removed the opposite breast In the only case of
symmetrical disease of both brpnsrs which he bad seen the
patient, an old Indy, died of shock from removal of both the
organs—Mr, Owen, in reply, paid tlieie had been no
accident to the breasts and no eczema about the nipples.
He agreed that an opposite breast should be removed for
recurrence, though this, again, was against a geneial surgical
principle which had been laid down, nub which, he felt sure,
M-as wrong.
Dr Ewart and Mr. Bennett showed a ease of Dexio-
cardia without transposition of other viscera, and bron-
cluecbaais in which pulmonaiy incision and resection of the
right ninth rib had been done for the latter. The patient
was a groom aged twenty-eight, who had suffered from
cough since his infancy, and latterly had expectorated much
pus. Three years ago he suflered from brnmoptysis, and
last year from inlluenza and bronchitis. In July he had
high fever with pneumonic signs at the right base, followed
next day by the development of pneumonia on ihe left side
also. The heart on examination was found to be out of
position, and at the right base later there was pectoriloquy
and icgophony. The base of the right lung was explored,
and a drainage-tube left in for a week without evacuating
any pus- At the prepent time the pulmonary symptoms
remained the same. He was unable, from the examination
lie had made, and from the history of the ca^e, to decide
whether the displacement of the heart was congenital or
due to the traction exerted by the contracting right lung.
He referred to another case at present under his care which
presented similar symptoms
Dr. Ewart also showed a woman, aged forty-eight,
who was the subject of complete Situs Inversus'Viecerum.
The abdominal organs had been mapped out by percussion.
The patient was right-handed, and complained of nothing
but palpitation and dyspepsia. Ho bad met with another
similar case in a child, and had also seen a case of situs
inversus of the heart alone associated with malformation
of that organ.
Sir Huaii Beevor pointed out that the pleurisy and
bronchiectasis had both been of long duration, and,'as the
right side was little or no smaller than the left, the heart
had probably been dragged over by the contracting lung.
Dr. Kivers showed for Dr. Ilugblings Jackson a case of
Treadler’s Cramp occurring in a man who, after having
been a hand-loom weaver for thirly years, began to make
mistakes in bis work owing to defective treadling with the
right leg (the one principally used); later the right leg
became lame, and after using the left leg for some years
this became weak, rendering him unable to follow his
occupation. The spasm occurred at the commencement of
the flexion movement which accompanied the upward
motion of the treadle, the extension or downward move¬
ment being well periornied. The spasm was of the com¬
bined movement of the hip and knee, each joint being
moved freely by itself; the difficulty was referred by the
patient to the gluteal region, and both the gluteal and
hamstring muscles on the right side showed decided diminu¬
tion of faradaic and galvanic irritability. The right leg was
held stitlly in walking, the ca?e then agreeing with other
occupation spasms in which large movements were con¬
cerned, and in which the affected limb was more or less
generally disaliled.
Sir Hucni Beevor brought forward a case of Malforma¬
tion of the Heart for diagnosis. The patient, a man aged
thiity-three, had a loud Kystolic murmur; the point of
maximum intensity was at the left fifth cartilage close to the
sternum, whence the sound faded away in an equal degree
towards base and apex, in a less degree towards the epi¬
gastrium and across the sternum. He said he could never run
like other boys, and his lips and lingers gave evidence of
long .standing feebleness of circulation. There was no
evidence of regurgitation into the veins of the neck. These
symptoms were best explained on the presumption that
tho'^e was a small communication between the two ven¬
tricles, due to a congenital deficiency in the £ej)tum of the
wall of either ventricle.
Sir Huaii Beevor also showed a case of Defective
DeA'elopment of the Abdominal 'Wall. The diaphragm was
inactive ; there was a musical systol'ic murrriur audible
only over the sternum opposite four ribs. On throwing the
niuacloa of the abdomen into action a swelling the size of
the fist appeared high in either loin; it was tympanitic,
and the condition jiad existed since infancy. On deep
inspiration the recession of the abdominal wall was marked ;
tbe liver dulnesa iiad its upper limit, however, slightly
depressed.
Mr. tliciUiiHiT Allikoiiam sbow'ed the case of a man who
in ]8Uo had a severe accident to bis head on the loft side,
and was insensible for fen days. Since that time on and oir
he bad suffered from giddiness and head symptoms, with
loss of meiuoiy and a eeusoof pressure over tbe frontal region.
Iq February of last jear Mr. Allingham trephined the skull
over the seat of the old injury. Thebonowasgreatlyin-
The Lancet,]
OBSTETRICAL SOCIETY OF LONDON.
[Feb. 21, 1891. 435
creased la thickness, and the dura mater was also thickened,
hut the brain .appeared normal. The patient was better for
a time, but of late the sensations of giddiness had returned,
with a sense of pressure over the other side of the skull.
Mr. Sheild showed a man of stout appearance who bad
a huge Loose Body in the Right Knee-joint. It was larger
than a walnut, had so increased in size a^ to give the patient
no inconvenience, and it was therefore decided not to recom¬
mend operative treatment.
Dr. C. M. Campbell showed two cases of Lupus which
had been treated by injections with Koch’s fluid. The first
was a female aged twenty-three, in whom lupus appeared
at the age of seven on the left cheek, and had been re¬
peatedly treated locally. Fifteen injections had been given,
the dose being gradually increased up to a decigramme.
Forty-sixty days had elapsed since the commencement of
the treatment; the patient had ceased to react, but the
lupus, although somewhat attecuated, was certainly not
eradicated. The second case occurred in a married woman
aged forty-five, in whom the lupus had existed for twenty-
eight years, involving the nose, fauces, and ary-epiglottic
folds. Fourteen inoculations were given. The throat
lesions appeared to have been nearly, if not quite, eradi¬
cated; the nose was distinctly improved, bub the disease
was not e-xtirpated.
OBSTETRICAL SOCIETY OF LONDON.
Tlia President's Address.
The annual meeting of this Society was held on Feb. 4th,
Dr. A. L. Galabin, Piesidont, in the chair.
The report of the auditors of the accounts of tlie treasurer
for the year ending Dec. Slst. 1890, was read. If; was pro¬
posed by Dr. Champnejs and sec.nded by Dr. Gow, and
carried, that the report he received, adopted, and published
in the Transactions. The report of the honorary librarian
was read and adopted. The report of the chairman of the
Board for the Examination of Midwives was read and
adopted. The President laid upon the table the new
volume of the Transactions.
The PiUiSiDENT, in his address, congratulated the Society
upon a prosperous year. The most notable event had been
the removal of the Society to its new premises in Hanover-
square. The losses by death, though in one sense heavy,
had not been great in numbers. William Butler\ouDg,
M.lv.C.S , _ L.S. A , had practised in Reading; he was
a man of high principle and great uprightness of character ;
he died on March 22ad, 1890, at the age of sixty-eight.
William Pul'ard, F.R.C S. Eng., L.S.A., was a descendant
of Sir Hugh Pollard ; he had practised in Torquay, where
he was respected and beloved both socially and profes¬
sionally ; he died on March 29ili, 1890, at the age of seventy.
G. Sirignano, M.D., practised in Naples. He died sud¬
denly on Marcli 7th, 1890. Frantz Christian Faze, M. D.,
was born in 1806. In 1850 he went to Christiania,
where he became Professor of Midwifery in the University.
He wrote seveial works on obstetiic subjects. He was
physician to King Oscar I., as well as to his son Charles XV.
He was Knight of the SA'eiish North Starin Diamond?. He
was fond of ttie English, and travelled much in England, Scot¬
land, and Ireland. He was elected an Honorary Fellow of
the Obstetrical Society in 18G3. He died, at the age of
eighty-three, on May_ Oth, 1890. Montagu H. C. I^almer,
M.K.C.S., practised in Newbury. Besides being a suc¬
cessful practitioner, he was au excellent antiquarian, a
good natural historian, and a botanist He was Mayor of
the borough. He died, at the age of thirtv-ninc, on
May 22nd, 1890 James Matthews Duncan, M. 0., was
born in April, 1826. He studied in Edinburgh and on the
Continent. He was assistant to Sir James Simpson, and
was the first person ever rendered insensible by chloroform,
Simpson and Keith subjecting themselves to the same
experiment on the same night, fie rapidly fslablisbed
a reputation as a great teacher in obatetrips. His published
works soon became widely known. In 1862 he was elected
an Honorary Fellow of the Obstelrical Society. A similar
honour was conferred upon him in later years by a largo
number of societies on tlie Continent and in America Un
the death of Sir James Simpson in 1870, it was generally
^peebed that Dr. Matthews Duncan, who had already a
European reputation as one of the greatest obstetricians of
anytime, would succeed to the chair of midwifery in the
University of Edinburgh. The choice of the electors, how¬
ever, fell upon Dr. A. K. Simpson. This event had doubt¬
less much to do with the result that he accepted the post
of obstetric physician and lecturer on midwifeiy at St.
Bartholomew’s Hospital, when it was offered to him on the
retirement of Dr. Greenhalgli in 1877. The debates of our
Society gained an added interest from bis presence and
constant participation, and he occupied the chair as
Preeidentin the years 1881 and 1882. In 1860 he married
Miss Jane Hart Hotchkiss, of Castlewick, Dumfriesshire.
He had in all thirteen children. Mrs. Matthews Duncan
and five sons and four daughters survive him. In the
spring of last year his health began to fail. He suffered
from gouty eczema and from attacks of angina. He died
on Sept. Ist at Baden Baden. He was buried at East
Finchley Cemetery ; most of the leaders of the profession
who were not out of town at the time were present, and Sir
Richard Quain was deputed to represent the Queen. John
Armstrong, M.D., M.R.C.S., L.S.A., was born in 1805. At
first be practised in Sligo, and afterwards in Gravesend. In
1873 be retired from practice and went to live at Green-
atreeb-green, Hartford, Kent. He was held in great re¬
spect by his fellow-townsmen, and was highly esteemed by
his professional brethren. He died on Nov. 20th, 1890.
The President then entered upon the subject of the mid¬
wives’ education and registration, and a discussion followed
which has been already reported.—Dr. John Williams
moved a vote of thanks to the President, which was seconded
by Dr. Potter, and cai-ried unanimously. During the
meeting the oflicers for the ensuing year were elected.”
The following specimens were shown :—
Mr. Alban Doran (for Mr. Ernest Hart) : Ancient
Gold Ornament from Crete, representing a woman in labour
in the upright position.
Dr. Handeield Jones : Ovary from a case of Heemor-
rbage after an Accident.
Dr. Rutherford : Uterus removed by Vaginal Hys¬
terectomy.
Dr. WiiEATON : (1) An Ovary containing Three Dermoid
Cysts (2) Early Tubercular Disease of the Uterus.
Mr. Malcolm : The Uterine Appendages, showing small
multilocular ovarian cysts.
Dr, Herman: (1) Case of Submucous Fibroid, presenting
at os uteri ten days after deliveiy ; (2) a case of Cancer of
the Uterine- Body, illustrating the dilliculby of diagnosing
between this disease and senile endometritis.
Dr. Herbert Srencer : Congenital Diaphragmatic
Hernia.
Dr. J. Phillips : Blighted Ovum, with fleshy condition
of the decidua.
HUNTERIAN SOCIETY.
A meeting was held on Jan. 14th, Dr. Stephen Mackenzie,
President, in the chair.
Hydronephrosis.—Ttibercular Lesions in Alcoholism.
Mr, C. J. Symond.s read a paper entitled “ Three Cases of
Hydronephrosis and their Treatment ” Case I was that of
a girl aged sevtnteen, with a tumour in the right loin. She
wa^ aspirated four times within three months, nine pint?
in all being withdrawn. She remained well, but came three
years after with a very large tumour. The kidney was
laid open and drained, no calculus was found, bub the
ureter was greatly dilated. The permanent sinus was
a cause of ebstre-ss, and some months later the kidney was
removed. The operation proved very simple, the scar
tissue being readily dissected off, and the organ enucleated;
recovery was good. In Case 2 a housemaid had a recurring
renal tnmoar, filling and emptying of its own accord.
The kidney was incised, no calculus being found;
but a dilated pelvis and tbe orifice of the ureter con¬
tracted. The third case was that of a boy aged nine.
As regards the treatment of hydronephrosis, spontaneous
evacuation cures some cases, and may be assisted by posture
or manipulation. Aspiration proves curative in a few, but
need noo be repeated more than three or four times. If the
canal is contracted, and cannot be dilated, remove the
kidney. The existence of a sinus did not in these cases in¬
crease the dilliculty of performing nephrectomy. The abdo¬
minal method of operating offers advantages in some cases ;
the condition of tlie other kidney can be ascertained, and a
calculus in the ureter detected and removed. — Mr. R.
Clement Lucas having made some remarks, Dr. Newton
Dk = Coogle
436 The Lancet,]
NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY.
[Feb. 21,1891.
Pitt referred to some specimens, showing how the disposi¬
tion of vessels along the oelvis of the kidney and the ureter
may give rise to a kink in the latter, and thus cause hydro¬
nephrosis.
Dr. G. Newton Pitt read soma notes on the post-mortem
appearances in Chronic AlcoholUiu. In thirty cases in which
phthisis was present, a dense libroid pigmented change was
almost invariably present in some portion of the lung, far
more frequently than in other cases of phthisis ; grey or
yellow tubercles were less common, and caseous broncho¬
pneumonia was quite the exception. The prevalence of
these fibroids, and to a certain extent reparative changes,
appear to be associated with the taking of a large
amount of alcohol. Primd facie, the chronic dyspepsia and
irregular habits, the lack of food, and the gross impro¬
vidence and recklessness of these patients would lead us to
expect that their mortality from phthisis would be high.
The Registrar-General’s reports, however, show that the
mortality from phthisis of publicans and others whose
occupations expose them to special temptations to drink is
rather below than above the average. But acute tuber¬
culosis and pneumonia are very liable to occur in such
atients, and the tubercular nature of the disease may often
e overlooked during life. It is noteworthy that about
three-fourths of the cases of alcoholic neuritis, and about a
fifth of those of alcoholic cirrhosis of the liver, are found
post mortem to have also tubercular lesions. The associa¬
tion of such lesions with «irrh'isis is seldom innsted upon,
but is of importance. Oat of 110 cases of alcoholic cirrhosis,
in twenty-three there were tubercular lesions, phthisis most
commonly, but in some acute tuberculosis or tubercular
peritonitis. Dr. Pitt’s conclusions were that tubercular
jeaions in the lung in alcoholic subjects generally take a
fibroid form, and that tubei’cular lesions are not infrequently
associated with alct)holic neuritis and hepatic cirrhosis.—
Drs. F. J. Smith, Turner, and Gilbert, and the Pre.sident
discussed the paper, and referred to cases illustrating and
confirming the conclusions arrived at.
NOTTINGHx\M ME DICO-CHIRURGICAL
SOCIETY.
The ordinary meeting was held on Wednesday, Jan. 21st,
Mr. C. H. White, President, in the chair.
Tuberculous Meat.—Dr. Boobijyer exhibited the lungs,
heart, liver, spleen, and some lymphatic glands from
a cow which had recently been seized, slaughtered, and
destroyed by the town authorities on its exposure for
sale in the fat stock market of the borough. He pointed
out the very extensive infiltration of tuberculous matter
and comparatively small amount of necrotic action.
All the internal organs, excepting the heart, were more
or less invaded. The left lung was affected in almost
every part with miliary tubercle, and the liver was
thickly studded with deposits of various sizes, some as
large as oranges. He showed that the physical signs
and special symptoms in so pronounced a case as this
almost necessarily impliei a guilty knowledge on the
part of the vendors, although the magistrates before
whom the case was taken declined to accept this view.
The general emaciation, arched back, retracted abdo¬
men, and staring coat, together with the frequent cough,
jerky respiration from pleuritic adhesions, and continuous
diarrhcca, were indications the import of which could not
well be mistaken. Dr. Boobbyer brielly drew attention bo
the experiments of Toussaint, Bouley, Chauveau, Cornil,
Arloing, Nocard, Peuch, Gerlacli, Johul, and others, with
the flesh or juices of tuberculous animals upon others in a
previously heilthy condition, both natural ingestion and
artificial injection being used, which all went to siiow that
great risk of infection attended the use of the bodies of
tuberculous animals as food for the healthy. Dr. Boobbyer
described the attitude of the home and some Continental
Governments and local authorities with respect to the im¬
portant question of how far tuberculous disease in animals
should be considered as rendering them unfit for food, and
said that the Sheriff of Glasgow probably erred, if he erred
at all, on the right side when he gave it as his decision,
after hearing a large amount of evidence, that the simple
p esenceof the disease, ho-wever slight its development, was
in itself a disqualification.
Mr. Belcher showed a case of Erythema Iris in a man
aged forty.
Notes on Cancer of the Breast. —Mr. Hatiierly read notes
of some cases of cancer of the breast which had occurred in
bis practice. He accepted unreservedly the doctrine of a
pre-canoerous or local stage of cancer, and dwelt upon the
difficulty of recognising with any certainty the exact period
when a non-maiignant growth might become malignant.
The naicroscope even was of little assistance, as the cell
degeneration characteristic of cancer is not a sudden but a
gradual process, the same specimen often showing cells
varying within wide limits as to the degree of degeneration.
He' referred to Mr. Jonathan Hutchinson’s doctrine, that
cancer was not due to any special material introduced
from without, but that it was simply a modification of
that which occurred in chronic inflammation. Mr.
Hatherly was strongly in favour of early operation,
even in cases where there might be some doubts as to
the diagnosis; in doubtful cases the patient should have
the benefit of the doubt, otherwise the most favourable
period for operation would be allowed to slip, and an early
return of the disease would be highly probable. He
advocated free removal, and thought too much attention
was paid to union by first intention. In one case in which
he had amputated the breast in a rather advanced case,
union took place by first intention, but there was ominous
induration of the scar within a fortnight after the wound
had healed. A second operation was pei tormed, and the whole
scar was freely excised ; the edges of the wound were nearly
four inches apart; healing by granulation was rapid, and
the patient had no return of the disease for several months.
He attached the greatest importance to any brawny condi¬
tion of the skin, and thought it even of more unfavourable im¬
port than induration of the axillary glands. He gave notes
of some interesting eases in support of his view of the
necessity of free excision, and thought that in the
large majority of cases, however litrde advanced they
were, the most promising course was to remove the
whole gland. He thought that in dealing with malignant
disease conservative surgery was a mistake. — The
President directed attention to the importance of
excising cancerous growths freely, and condemned cheese¬
paring with aview to obtain rapid healing and neat cicatrix.—
Dr. Cattle quoted a case in which a tumour, after twenty
years of imperceptible growth, had assumed malignant
characters and caused the patient’s death. He thought
such changes in the character of new growths occurred at a
period of life when there was a general tendency to de¬
generative changes —Messrs. Bluuton and Wray also
spoke.
Specimen. — Dr. Cattle showed for Mr. Chicken a
Cystic Sarcoma of Testis removed by castration from a man
a"ed twenty. The diagnosis from hydrocele, hiomatocele,
and encephaloid was discussed. Dr. Cattle showed a
microscopical section of the tumour.
anil nf
National Health. Abridged from “The Health of
Nations.” A Review of the Works of Sir Edwin
Chadwick, K.C.B. By B. W. Richardson, M.D.,
F.KS. Pp. 320. London : Longmans and Co. 1890.
The author informs us in the preface that this volume
was prepared to meet the request on the part of the public
for an abridged and less expensive edition of hia original
work, and may be considered an abridgment of the most
popular and practical portions of it. Introductory to the
part relating to National Health is a biographical sketch of
Sir Edwin Chadwick. Born at Lysaght, near Manchester,
in 1800, he received his education entirely at private schools
and by private tutors. After passing some time in an
attorney’s office as a pupil, be enrolled himself as a student
of the Inner Temple, and was called to the bur in November,
1830, While carrying on his studies he supplied reports to
the Morning Herald and the London Itevicio, and contributed
to the latter two papers in 1829, one on Preventive Police
and the other on Public Charities in France. In 1828 he
Dir:' ■ L.oogIe
Thb Lancet,3
REVIEWS AND NOTICES OF BOOKS.
[Feb. 21, 1891. 437-
wrote for the Westminster Review an essay on Life
Assurance. He resided for some time with Jeremy
Bentbam, to assist him in the compilation of his Adminis¬
trative, Code. In 1832, upon the formation of the
Poor-law Commission, Mr. Chadwick became one of the
assistant commissioners, and in 18.33 was appointed a
member of the Royal Commission to inquire into the
subject of the employment of children. The Report
of this Commission, which was drafted chiefly by
Mr. Chadwick, led to the appointment of Government
inspectors, and eventually to the Ten Hours Act, and in it
he brought forward the subject of the “half-time system of
education." In 1834 Mr. Chadwick was installed as secre¬
tary to the new Poor-law Board, and continued to hold
that appointment till 1848. In 1838 the Board, on his
recommendation, instituted a Medical Commission to
inquire into the causes of a severe epidemic of fever in
Whitechapel, which brought to light the disgraceful
character of the water-supply, and the large extent to
which it contributed to the disease and death-rate of the
metropolis. He was also instrumental in inducing the
Government to introduce the Bill for the Registration
of Births, Marriages, and Deaths, which led to the forma¬
tion of the office of Registrar-General. In the same
year he was nominated one of the members of the commis¬
sion to inquire into the best means of establishing an
efficient constabulary force in the counties of England and
Wales, which reported in the following year. In 1839 (by
a misprint stated 1829) the Poor-Jaw Commissioners were
ordered to institute an inquiry into the health of the labour¬
ing classes of England and Wales, and they instructed their
assistant commissioners to report upon such parts of the
subject as came under their observation. At the request
of the commissioners, from the papers thus obtained and
from other information sent to them, Mr. Chadwick prepared
the report which was presented to Parliament in 1842. In
the following year, as a supplement to it he drew up
a report on the subject of interment in towns. In 1845,
consequent upon an inquiry into alleged abuses and illegal
practices in the administration of the Poor Law, at which
Mr. Chadwick gave important evidence, the Poor-law
Board was abolished, and his career as chief secretary
ended. In 1847 he was appointed member of a commission
to inquire into tbe sanitary condition of the metropolis,
and in 1848 a commissioner of the first Board of Health,
a post which he held till 1854, when the Board was
merged into the Local Government Board. In 1848 he
was created a Companion of the Order of the Bath
(incorrectly stated Commander), and in the same year was
appointed one of the members of the Consolidated Commis¬
sion of Sewers. The abolition of the Board of Health termi¬
nated his official public life, from which he retired with a
pension of a thousand pounds a year. After his retirement
into private life he continued to work zealously in the cause
of sanitation and of reform in the public service. In the
latter he strongly urged the adoption of competitive exami¬
nations as tests of qualification for all primary appointments
in the various Government departments. In 1877 he pre¬
sided at Stafford over the Congress of the Sanitary Institute,
and in 1881 at Brighton over the Public Health Section of
the Sanitary Congress. In 1885 he was elected President
of tho Association of Public Sanitary Inspectors, and in
1889, on attaining his ninetieth year, was entertained at a
banquet arranged by the Association. At the same time he
was promoted to the rank of Knight Commander of the
Order of the Bath.
The biography is interesting as the career of an energetic
worker in the interests of the public, hut it has the fault of
being entirely one-sided. While Dr. Richardson has given
full credit for the undoubtedly valuable service rendered by
Mr. Chadwick in liis official capacity, he has omitted all
reference to any shortcomings which may have arisen, in
a great measure, from his energetic temperament, and he
has in some instances claimed for him an undue amount of
credit. As regards the first of these points, he has over¬
looked entirely the opinion expressed by Lord John Russell
that as a member of the Board of Health he had been
an injudicious administrator. Sir John Simon, in a highly
appreciative notice of Mr. Chadwick’s rare abilities as an
original investigator in matters of social pathology, and
as one having absoluije rectitude of intention towards
the public in every line of conduct which he followed,
states that be “seems not to have been gifted with the
quality [of judicial patience] in degree sufficient for
official success. The faults which were imputed to him
in his official relations—a tendency to build overmuch on
foundation of small experience, a liability to one-sidedness
on questions of science and administration, a failure to
listen duly to dissentient voices, a deceptive trust in central
dictation as the short and ready road to success, and a too
despotic tone in affairs of local and personal interest—all
these, so far as they were Mr. Chadwick’s faults, may be
generalised as faults of over-eagerness." He subsequently
says: “ Whatever may have been Mr. Chadwick’s adminis¬
trative unsuccess, and however severely the unsuccess
may be attributed to errors of judgment on his part, nothing
therein lessens by a tittle the value of what he had pre¬
viously achieved." As regards the second point, Dr.
Richardson claims that by a paper on the “huge mortality
of our troops in India ’’ Mr. Chadwick led the way to the
formation of the Indian Sanitary Commission. We believe
this to be quite a mistake, for it was really an outcome of
the Barrack and Hospital Commission appointed in accord¬
ance with the recommendation of the Commission on the
Health of the Army, over which Mr. Sidney Herbert so
ably presided. Again Dr. Richardson says that in 1871
Mr. Chadwick suggested a plan for the drainage of
Cawnpore, but we leave it to those practically acquainted
with the subject to say how much or how little value should
be attached to such a plan drawn up by a man who had
never been in India.
The volume consists apparently of extracts from the pub¬
lished works of Sir E. Chadwick “without comment.” These
are grouped under the heads of: (1) Health in the Dwelling
House—Domestic Health; (2) Health in the School—Educa¬
tional Health; (3) the Health of the Community—Social
Health j (4) Health in the Future—Progressive Health,
Some of the views expressed in the last section, progressive
health, are very imaginative, especially his health remedies
for Irish discontent and his ventilation from cloudland. He
suggests to M. Eiffel that if he “will provide iu his high
place a shaft by means of which he can supply Paris with
breath from cloudland, bis temporary idea will become per¬
manent, and he will be known for generations to come as
the celestial ventilator, the bringer of the pure air of the
skies into the dwelling-places of men.” These extracts are
interesting as an exposition of Sir E. Chadwick’s views on
many important subjects relating to the health, comfort,
and well-being of the people, and also as showing the
gradual progress which has been made on these sub¬
jects during the last half century. Another point struck us
in our study of the book—the entire absence of any acknow¬
ledgment of assistance or cooperation in any of Sir E. Chad¬
wick’s works. That he must have received much valu¬
able assistance is undeniable, but where is the acknow¬
ledgment? The contrast in this respect with at least
as great a sanitarian. Sir John Simon, is noticeable.
Entertaining as we do a high appreciation of the services of
Sir E. Chadwick, we cannot but regret so unsatisfactory
an omission on his part.
11 3
Dinii: -d Google
438 TrfEtiAKcSt.j
OVU tlBRAHY tABLB!.-UEW INVENTION.
[Efiu. 21,1891.
OUE LIBKARY TABLE,
A System of Oral Surgery. Being a Treatise on the Dis¬
eases and Surgery of the Mouth, Jaws, Face, Teeth, and asso¬
ciate parts. By James E. Gareetson, A.M., M.D., D.D.S.,
President of the Medico-Chirurgical Hospital Ac. Illustrated
with numerous woodcuts and steel plates. Fifth Edition,
thoroughly revised, with Additions. Philadelphia: J. B.
Lippinoott Co. 1890.—As the title of this work shows, the
writer deals with a rather wide range of subjects. The
anatomy of the head is first considered, with special
reference to the muscles, vessels, nerves, and glands. The
teeth come in for a large share of attention, and their
diseases and irregularities, and the treatment required,
are discussed in detail. But, in addition to all this, not
only are diseases and injuries of the jaws and antrum
described, but also those of the tonsil, tongue, pliarynx,
larynx, nose, lips, and cheek are dealt with. The author has
managed to write more than 1300 pages of letterpress, and
this is the most noteworthy fact about the book—its size.
Our readers will appreciate the value of Dr. Garretson’s
teaching if we give them a few selections in his own words:
"Study of Cancer: We pass to the study of cancer.
Every tumour is a cancer that is not something else.”
"Ability to diagnose is proportional with knowledge.
What an eye sees it sees. With not less certainty does
judgment understand what it comprehends. Understand¬
ing is resultant of experience. Thought and experience are
one. . . . To comprehend is to be able to say exactly what a
thing is.” With extracts of this kind we might go on
almost indefinitely. As this is the fifth edition of this
work we suppose Americans appreciate it. We think we
can confidently state that Englishmen will not.
Law and Practice of Lunacy. By H. M. R. Pope, M, A.
Second Edition by J. H. Boome and V. de S. Fowke,
Barristers-at-law. London: Sweet & Maxwell, Limited.—
This hook contains in a very accessible form a large body
of matter relating to the law of lunacy, and will be found
of the greatest service to those who are entrusted, especially
in a prof^sional capacity, with the management and
custody of the property of persons mentally unsound. As
to those parts of the law which are of especial interest to
medical practitioners, it is, however, somewhat deficient.
In the first edition an appendix gave a synopsis of the law
relating to institutions for the treatment of the insane and
their management, bub this has been omitted from the
present work; and as the health rather than the property
of a lunatic forms the distinctive care of the medical practi¬
tioner, oar readers will for the most part find this book less
adapted to their purposes than some other treatises upon
this branch of law’. By readers whose interests lie within
the range of the work as now defined, the work in its present
form will he valuable.
In the Veterinarian for this month the m^t important
contribution is a correspondence, taken from the North
British Agriculturist, between Professors Williams and
McCall on the question of “Are Blisters Hurtful or Bene¬
ficial ?” Professor Williams, whose wide clinical experience
gives him the right to speak with some confidence, declares
against blisters; whilst Professor McCall gives his opinion
that blisters are useful, though he does not approve the use
of cantharidine. Thelatter promises a lecture " on the action
and beneficial effects of counter-irritation in chestaffections.”
Notes on influenza, strangles, and sand cracks, with long ex¬
tracts from the medical journals beating on Koch’s treatment
and an account of the meetings of the veterinary societies are
given. At the meeting of the Border Counties Veterinary
Medical Society, Dr. Fleming gave an interesting paper on
Influenza in Horses. The first, a catarrhal form, he says
appears to be very like the broncho-pneumonia of human
beings j the second is an intensely febrile form in which the
lungs are extensively involved, a condition which, he thinks,
might be termed "epizootic pneumonia of equinea,” in
which there appears to be infiltration of the air vessels, and
in which also a septic or gangrenous condition of the lungs
may supervene. A third, like the second, also a sporadic
form, appears to affect the skin specially, being, in fact, a
kind of erysipelas.
Ittfeitlkn.
THE R0INOMETER; A NASO-PHARYNGEAL
SOUND.
Tins simple little instrument consists of a tapering
spatula of flexible metal. Readily introduced into the
nostril, it diagnoses rapidly the various obstructive dise^es
of the naso-pharynx. Measuring about four inches in
length, and only half an inch in width, it can be carried easily
in the waistcoat pocket. In these days of countless and
cumbrous appliances, portability is in itself no mean recom¬
mendation ; besides this, the nasal sound is always at hand.
The method of use is as follows. Ten minutes after spraying
A
bo
fchoon^
j~Mau|
w—
the carefully cleansed nostrils with ten grains of boric acid,
five grains of chloride of sodium, twenty-five grains of
muriate of cocaine, to one ounce of camphor water, tlie
rough part of the sound is grasped lightly between the finger
and thumb. The smaller end is then passed very gently
along the floor of the suspected nostril, carefully preserving
the horizontal position. A rounded shoulder indicates
when the choana is reached. It is well to ke^ the sound
parallel with the vomer, but not touching it. The septum
readily bleeds, even in health, and, owing to its free nerve
supply, it is exquisitely sensitive. 'When the p^terior
Digitized by
Google
Thb Lakobt,]
THE ORIGIN OF SPECIES OF DISEASE.
[Feb. 21, 1891. 430
□ares are passed and the sound enters the pharynx its
course should be turned outwards to the Eustachian orifice.
If at this point its passage he obstructed and the tip return
stained with blood, then Eustachian adenoids are probably
present. An engraved line indicates when the posterior
pharyngeal wall ought to be reached; this point varies, of
course, with age and with sex. The smaller end of the
instrument is now raised by depressing the handle. A
doughy sense of resistance suggests the presence of adenoid
hypertrophy of the pharyngeal tonsil at the roof of the vault.
The existence of a neoplasm here is further confirmed by
blood stains on the tip of the probe. The point should
be withdrawn very slowly along the cribriform plate in
order to detect the presence of deviating septum, fibroma,
hypertrophic rhinitis, polypus, or septal bridge. Owing to the
taper edge of the sound, it serves not only to diagnose
abnormal pressureontheVidian brancheson thenaso-palatine
(nerveof Cotunnius) or on the olfactory filaments, but it gives
a rough approximation to the amount of pressure exerted.
Besides its more ostensible use, this handy probe, being
divided into small parts of an inch and of a centimetre,
provides for strict and accurate measurements, so often
needed by the surgeon ; when reversed, it makes a capital
tongue depressor, and is in addition a convenient paper
cutter. The use of this instrument, it will be quite under¬
stood, is not intended to supplant nasal illumination, but
to supplement it, and to sift out the cases that call for
visual examination.
Borkoley Man.'jions, Hyde-park, W. EdwARD BlAKE, M.D.
THE ORIGIN OF SPECIES OF DISEASE.
To the Editors o/The Lancet.
Sirs,—M any recent events have contributed to revive
interest in the old, yet ever new, question of the origin of
specific disease. Among these the addresses of Koch and
Lister at Berlin last summer on the biological and practical
aspects respectively of the bacterial hypothesis, the more
recent announcement of the “cure of consumption,” with
all the collateral questions of inoculability, immunity, vul¬
nerability, and the rest, and the brilliant display of the mor¬
phology, culture, and products of the tubercle bacillus at the
Pathological Society last week, may be reckoned as of the
first importance.
It is becoming increasingly evident that any approach to
a satisfactory solution of the enigma propounded by the
bacteriological sphinx requh’es a knowledge of the physical
and biological sciences, which it has been fashionable of
late to regard as superfluous acquisition to a medical man.
It is not less evident that, as with the sphinx of Thebes,
many reputations and lives are likely to be sacrificed in
the process of solution. Two deductions, however, ap¬
pear to be coming to the front amid the tangled skein
of researches innumerable, and a perfect maze of fanciful
theorising, based upon the slenderest substratum of fact,
or none at all, or, worse still, upon erroneous observa¬
tion, often dominated by a pre-existent idea. One of these
deductions is that bacteria are not outside the pale of evolu¬
tion, as seems to have been imagined by the specifically
minded, but that among them, even more markedly than
among higher and more fixed species, the adaptation of in¬
ternal to external relations is powerfully at work, and cor¬
respondingly that a relatively slight variation of the medium
or soil may profoundly influence their morphological charac¬
teristics. Ten years ago, in your columns,^ I ventured to
plead for a recognition of evolution of morbid species as
modifying the rigid specificity preached by Sydenham, and
later by Bretonneau and Trousseau, and urged that the
“common ancestry of specific disease once recognised would
do much to remove the hard-and-fast line so often drawn
between disease and disease in text-books and dissertations,
but of which nature knows nothing.” Your columns, as
well as the whole trend of modern pathology during the past
decade, bear fruitful witness to the truth of this view; the
doctrine of the plasticity of the germ in obedience to environ¬
ment which is now to the fore is corollary to this contention.
The other and possibly more important truth which is
1 TUE Lakcet, May 14th, 1881.
immanent in most of the best of modern work in the field of
the pathology of infective disease is that, after all, the
morphology of the micro-organism—nay, its presence—may
be but subsidiaiy to the chemico-phyaical conditions which
pre-exist, or which it may be a part cause in initiating. It
hardly needed the demonstration of the Prussian-blue test
to feel convinced that in the toxic products of the tubercle
bacillus one was dealing with derivatives of the deadly
cyano group. Here we touch the big topic of chemical con¬
stitution and physiological action, and the question arises
how far the materies morbi of so-called bacterial diseases is
not chemical after all, its modification the result of slight
variation of molecular structure, its virulence varying with
intra-molecular condensation. Beyond all this the question
irresistibly forces itself upon the mind, How far is the rdle
of the bacterium merely that of an unorganised ferment
akin to the curious contact actions of platinum and palla¬
dium, obscured rather than explained by being called cata¬
lytic ? May not the effect of the bacterium be relegated to
the relatively humble part of providing a ready initiative
for a chemical explosion which might possibly, but less
readily, have been effected without it? In this case
the relation of the bacillus to the morbid process would
be no more than, but as marked as, the relation of a
lighted lucifer to the explosion of a bairel of gunpowder.
The tendency appears to be to regard it as probable that an
alkaloid rather than an albumose is tlie effective proximate
cause in such case, and that its amount and presumably its
nature is conditioned by the pabulum at hand. In either
case we see that here, as it has been elsewhere remarked,
the atomically inert nitrogen appears to supply the deadly
pivot on which the lethal quality turns. Anyway, it
would [appear that the evolution of specific disease is a
notion consistent with either the bacterial or chemical
hypothesis. As I contended in 1884, “for panspermists to
reconcile their views with this, it is only necessary for them
to believe that organisms of an indifferent nature are
capable by cultivation on suitable soil of taking on noxious
and specifically noxious properties. For those who hold
the chemico-physical theory, it is only necessary to regard
the process of evolution of disease after the fashion of the
construction of a complex organic compound, perhaps of an
alkaloidal nature.”
The question, however, cannot long remain where it is.
The relation of bacteria to morbid processes effected by
chemical products of their activity leads inevitably to a I’e-
consideratioQ of the supposed settled question of abiogenesis.
The possibilities of environment are not exhausted by gly¬
cerine agar-agar in a test tube, nor even by alkali-peptone
broth grfatine on glass plates. The problem of the origin
of life is not solved by a reference to a remote epoch dunng
the cooling down process, which bears a suspicious resem¬
blance to the fairy tale explanation of “ Once upon a time,
in a countiy by the sea”; neither can a leaf torn from the
Mosaic cosmogony suffice any longer (apart from its “gra¬
tuitous malevolence”) to support a special creation theory
for specific disease; nor can a belief in the predestination of
bacteria to the service of man, a relic of the old anthropo¬
centric notions, excuse us from studying the lowly cocci and
bacilli in the light of their own life histories apart from
their fortuitous and most unfortunate contact with mankind.
1 am. Sirs, yours faithfully,
W. J. Collins, M.S.Lond.,,F.E.C.S. Eng.
Albert-terrace, Regent’s-park, Fob. 9th, 1891.
Hunterian Society.—T he annual general meeting
was held at the London Institution on Eeb. lltfa, when the
following officers were elected:—President (second year):
Stephen Mackenzie, M.D. Vice-Presidents : E. G. Gilbert,
M.D., E. Charlewood Turner, M.D., C. J. Symonds, M.S.,
and K. G. Tathara. Treasurer: F. Charlewood Turner,
M.D. Librarian : Arthur T. Davies, M.B. Orator for
1892 : C. J. Symonds, M.S. Secretaries : John Poland and
R. Hingston Fox, M.D. Council: S. H. Appleford, M.D.,
T. Lloyd Brown, G. A. Carpenter, M.B., J. S. E. Cotnian,
T. Rowing Fendick, J. Langton Hewer, M.D., T. Mark
Hovell, R. Clement Lucas, B.S., T. Horrocks Oppenshaw,
M.S., G. Newton Pitt, M.D., W. Percy Reynolds, and
F. J. Smith, M.B. Dr. Fletcher Beach then delivered the
annual oration, an abstract of which is published in another
part of our present impression. The Fellows and friends'
dined together at the Holborn Restaurant on Friday, the
13th inet.
L.OO*, le
O
440 The Lakokt,] ELEMENTARY SCHOOLS AND THE SPREAD OF DISEASE.
[Feb. 21, ISdl.
THE LAN^CET.
LONDON: SATUBDAY, FEBRUARY 31, 1891.
The issue by the Medical Offioer of the Local Government
Board at the close of last year of a new Memorandum^ on
the closing of elementary schools, or the exclusion there¬
from of children, with the object of preventing the spread of
infectious diseases, deserves notice by public health and
school officials from several points of view. These two sets
of officers might, in one sense, be regarded as antagonistic ;
the one has the prevention of disease mainly before him, the
other labours for the promotion of education, and he feels
that any limitation in the number of school attendances
for health purposes tends to some extent to defeat the pro¬
gress of education. It is true that, according to the Educa¬
tion Code, allowance is made, as regards the pecuniary
grant, for any properly authorised school closure; but
nothing really makes up for the failures at examinations
which such closure involve; and as regards mere exclusion
of particular scholars, it has not been found practicable to
make any corresponding arrangements as to the pecuniary
grant. For these reasons there is a natural disinclination
on the part of school authorities to be interfered with,
unless, indeed, they are made to understand the necessity
of the action contemplated. On the other hand, medical
officers of health are coming to understand more and more
the important part which is played in the diffusion of certain
of the infectious fevers hy the aggregation of children in
elementary schools, and they are naturally anxious to act
with discretion, and yet with promptitude, in respect of
school operations. Having regard to these conflicting in¬
terests, it is most important that all action taken should be
well considered, and that it should be effected strictly in
accordance with the provisions dealing with this subject.
Those provisions have in recent years undergone some
modiheations, and for this reason alone there will he
advantage in recalling the powers which sanitary authori¬
ties possess in the matter, and the principles by which they
should be guided in acting upon them.
In the first place, we would point out that the medical
officer of health has not, as is commonly supposed, the actual
power to interfere with any school processes. The sanitary
authority are alone empowered to interfere in this matter;
but at the same time it is the duty of the health officer
to advise them when to act and how to act, and he should
^ways he prepared to set out the grounds on which his
advice has been baaed. This is the more important because
school authorities have the power of appealing to the
Education Department against any interference with their
school attendances, and such appeals generally involve the
matter being referred to the Local Government Board, with
a view to a report being obtained from the health officer.
1 Memorandum prepared fn tlie Medical Department ol blie Lociil
Government Board on tlie Closuie &< 2 . of Elementary Schools. Eyre
and Spottiswoode, Id. 1800 ,
Indeed, the latter is now required, whenever a school is
closed on account of infectious disease, to report the cir¬
cumstances to the Central Board.
But perhaps the most important part of the memo¬
randum issued relates to the principles that should guide a
medical officer of health in advising whether actual closure
of a school should be resorted to, or whether mere exclusion
of scholars from infected houses or localities will suffice;
both these methods being authorised provided the order of
the sanitary authority distinctly specifies the period during
which they are to take effect. The exclusion of particular
scholars is, of course, a much less severe measure than
actual closure, and it is one that should be attempted
more often than it is, provided the early attacks of in¬
fectious diseases are heard of. The compulsory notification
system, now so largely resorted to, should materially aid
in securing such success, from the process of exclusion, as
to render complete closure unnecessary. And, even when
disease is actually epidemic, Dr. Buchanan urges that
closure, which involves a serious interference with educa¬
tional work, should nob be resorted to as a mere matter of
routine. The medical officer of health advising it should
be satisfied that minor measures will not suffice, and that
some clear prospect of good is likely to arise from the step
he advocates. During actual epidemics, for example, it
may be that children will have a greater opportunity for
mingling with infectious convalescents if they are out at
play all day in the streets and courts of crowded neighbour¬
hoods than if they were kept at school during the greater
part of the day. Besides which there are epidemics in
which school attendance plays but an unimportant part in
the distribution of the infection, and in such cases it would
be unjustifiable to impose on the school managers restric¬
tions that would gravely affect their school attendances.
On the other hand, where prompt exclusion of particular
scholars has been followed either by no lessening or by
actual increase of the epidemic, there would often appear
grounds for closing a school; and even though the period
to which the exclusion relates has not expired, a second
order may properly he issued requiring complete cessation
of school attendances. In some instances, when disease has
broken out in a single school, sanitary autliorities have been
advised to close all the schools in the district. This is a
step that can rarely he justified, and its adoption, except
on grounds that would hear strict investigation, tends to
bring this power of interference with school operations into
discredit.
On the whole, we rather gather from the tenour of the
Memorandum that school closure is not unfrequently ad¬
vised without sufficient grounds, that exclusion of scholars
from particular houses or localities is nob resorted to with
sufficient promptitude to ensure success and render closure
altogether unnecessary, and that when disease spreads in
consequence of tardiness to adopt reasonable measures
of restriction, school closure is at times resorted to
when it can do but little good. And even as to
the results, conclusions are not infrequently drawn
very hurriedly. Diphtheria, for example, is spreading in
September and October; it continues through November
into December, and the schools are suddenly closed until
Digitized by
Google
The Lakcbt,]
THE NEW UNIVERSITY OF LONDON SCHEME,
[Feb, 21, 1891. 44l
the end of January. The disease then practically ceases—
a result which is held to justify the former proceedings.
But it is forgotten that diphtheria is largely influenced by
season, and that the prevalence in question might, apart
from the school closure, have been expected to follow
the precise course which it did follow. From these
and other points of view the Memorandum deserves
the careful attention of medical officers of health, and of
others who are concerned in the control and management
of our elementary schools.
The schemes for the reconstitution of the University of
London, following on the lines of the Royal Commission,
embrace two distinct questions—the best means for the
promotion of higher education in London, and the necessity
of granting pass degrees in medicine on equitable terms to
London medical students. In the scheme of June, 1890,
the clauses dealing with the former question were pro¬
visionally accepted, with some reservations, by the Teaching
Colleges which have been agitating for a local metropolitan
University comparable to the Scotch Universities or to the
Victoria University, because a large amount of power was
given therein to a Standing Committee of the Senate for
the Faculties of Arts and Science in connexion with the
London Constituent Colleges in those faculties. On this
Committee these Colleges were largely represented, and it
was specially formed to deal with the regulations concerning
the courses of study and the examinations for pass degrees
in arts and science at those colleges, and with the exten>
sion of University teaching in London. The regulations
concerning the pass M.B. degree, however, were not
accepted by the Royal Colleges, although the Fellows o
the Royal College of Physicians were more nearly inclined to
agree with them than was the Council of the Royal College
of Surgeons. In this new scheme of February, 1891, the
position is exactly reversed. The two Royal Colleges
have now accepted the scheme because of the altera¬
tions in the clauses dealing with the medical degrees,
whilst the professors of the Teaching Colleges unanimously
decided, at full meetings held simultaneously at Univer¬
sity and King’s Colleges on Monday last, to reject it as
not meeting their requirements, and as altering the
position given to them in the former scheme ; and we
suppose the Councils of the two Colleges will, at their
respective meetings to-day (Friday) and on Friday next,
come to the same conclusion. The reasons for this double
change of front are easily seen if the clauses dealing with
the two questions are considered. The Teaching Colleges
maintain their demand for a local metropolitan Univer¬
sity as recommended in the strongest terms by the Royal
Commissioners, or for one in which they can exercise such
powers as practically will make it a Teaching University,
and they are given instead a certain, but in their opinion
inadequate, influence in a large heterogeneous body cen¬
tralised in Burlingbon-gardens. The Royal Colleges, on
the other hand, practically find themselves in the position
of being able to grant a pass M.B. degree under the tegis of
the Senate of the University of London, and over which
the Senate has reserved only a minimum of control. The
examinations, except those for matriculation and in
preliminary science, are now placed under the direc¬
tion of a committee, equally composed of nominees of the
Senate and of nominees of the Royal Colleges, and as
the first cannot but largely consist of Fellows of one or
other of the Royal Colleges, into their hands the control
of medical training and of the examination standard for
the pass M.B. degree will necessarily fall. These bodies
also arrange the curricula and define the examinations for
their combined diplomas at the Conjoint Examining
Board, so that they will exercise an almost complete
monopoly—except so far as the L.S.A. is concerned—over
every London pass medical student’s education and career.
Would the University of Edinburgh so abdicate its
functions in favour of the Scotch corporations? Have
not objections to many details in the present system of
examinations at the Conjoint Board in England been
unavailingly pointed out by independent visitors, and is not
the scale of fees charged by the Board a very excessive
one ? The new scheme of the Senate of the University will,
if adopted, take away the only means by which any effort at
reforming the examinations of these corporations could have
been effectually exerted. A fair pass M.B. degree must,
as the Royal Commissioners report, be accessible to London
medical students, but it would be preferable if it were
one really granted by a university authority, and not one
actually given by the corporations under the sanction and
label of a university.
A farther question arises as to the terms on which
this degree will be given should the scheme be passed. It
must be clearly understood that it is only the pass M.6.
degree which is under consideration. The Standing Com¬
mittee in Medicine of the Senate will fix the honours
examinations for the M.B. degree, and determine the con¬
ditions of the M.D. degree, so that the Colleges will have
no power over the M.B. (honours) or the M.D. degree.
Moreover, the difficult matriculation and preliminary
scientific examinations will (except in the case of matri¬
culated students at constituent colleges) be also under the
sole control of examiners appointed by the Senate, and we
hear of no intention to mitigate their severity. Either, then,
the Royal Colleges hope to whittle down these examinations,
or the proffered boon to the average London medical student
will prove a delusion. Let anyone examine the questions
set in experimental physics at the Preliminary Scientific
M.B. Examination for many years past, and he will soon
see that they are so high in range as to be beyond the
capacity of any average medical student without a pro¬
longed first-class mathematic training, and offer a test of
knowledge which ha is hardly likely to need in his future
medical career. Again, if the pass medical aspirant wishes
to call himself “Dr.,” against such a use of a mere M.B.
degree he is studiously admonished by the authoiities of the
University. Will tliey relax this admonition in favour of
the new graduates ? or will these be confronted anew by that
old, ever-recurring difficulty ? Will the fees be fixed on so
excessive a scale as to invite an unfavourable comparison
with the fees for degrees in the other faculties, in the
Scotch and provincial universities, and even in the other
medical corporations, as we fear will be the case
if the Royal Colleges have as much success in further
influencing the Senate as they seem already to have
obtained? The inclusion of the provincial colleges affects
the medical corporations and schools of London but little,
442 Tbb Lancet,]
THE CASE OF WILLIAM KERR.
[Feb, 21,1891.
for only one provincial Fellow out of a standing committee
of nineteen is suggested. The provincial medical schools
shonld have a fair representation or none at all. But the
arrangements for the provincial colleges in Arts and Medi¬
cine are so elaborate as to seem to us absolutely unwork¬
able. How are these to have a due representation when four
nominees of their principals or chief officers and but four
nominees of the provincial faculties, acting conjointly—
Le.,from such centres as Birmingham, Newcastle, Leeds,
SheflSeld, Manchester, Liverpool, Nottingham, Cardiff,
Bristol, Bangor, and Aberystwith, for these will all
be constituent colleges,—are allotted to them out of a
Senate of fifty-two ? How can a standing committee,
which must meet in London, regulate the courses of study
and the examinations in Arts and Science best adapted for
such different institutions? Is a peripatetic examiner in
every subject to attend at each College in turn, and act as
assessor to the professor in that subject? for the Senate
proposes to make such an arrangement with these Colleges,
jointly or separately, for such examinations. To other
examiners, or to the same, must be given the task of con¬
ducting the examinations in London on this plan, and
also those fixed for non-collegiate students. Will the
syllabuses of the courses of instruction in these different
Colleges, which have to be approved by the Senate, be
made similar or be allowed to differ ? In the one case, any
chance of local development would be destroyed, and in
the other every pass B.A. and B.Sc. degree would have a
diflbrent meaning and value. How can the provincial
faculties and provincial boards of studies from so many
centres be made fairly representative, or be assembled sufli-
ciently often to make their work of any value? These
are the practical points suggested by the new clauses in
the Charter, which those who drafted it—who surely could
have had no experience in University teaching or acquaint¬
ance with modem collegiate aims and thoughts—seem to
have overlooked.
The scheme would appear to aim at centralising all
London and provincial arts and science teaching under the
control of Burlington Gardens, and to relegate the routine
but practical work of examining for a pass medical degree
to the Examination Hall on the Embankment. j
It may be remembered that on July 2nd, 1889, William
Kerb was tried before Mr. Justice Stephen at the Carlisle
Assizes, convicted of the crime of having murdered a single
woman named Sebra Troughear, aged about fifty, and
sentenced to death. This sentence was commuted to penal
servitude for life, and subsequently to a term of fourteen
years. The offence was what is called “constructive
murder”—i. e., killing not with intent to murder, but
through the commission of an unlawful assault. The
convict was charged with having ravished the deceased,
who through his violence was caused to vomit, and was
suffocated by the impaction of food in the larynx. We
have carefully studied copies of the depositions made
before the coroner and the magistrates, together with a
report of the evidence given at the trial, and also a quantity
of correspondence derived from various sources. It has
never before been our lot, in studying the history of a trial
for the capital offence, to meet with evidence so equivocal,
such one-sided interpretation of the facts, and with a
defence so lamentably lacking in support that might and
ought to have been forthcoming.
On June 2nd, 1889, at 11.30 P.M., the dead body of Sebra
Troughear was discovered by two men lying in the supine
position, distant only 160 yards from a roadside inn. The
woman had been on a visit to some friends and was returning
to her home. Beside the body, piled in a heap, and in the
following order, were her umbrella, dress skirt, tippet,
false hair, and hat. Her handkerchief was lying near.
There had been a heavy thunderstorm the same day, which
had washed the roads, and left the gutter surface, over
which the legs of the woman lay, in a state extremely
favourable to receive impressions of objects. In fact, casts
of such marks were actually taken, which represented the
ribbed pattern of the deceased’s stockings, together with other
marks; but—and this is deserving of great weight—nothing
that corresponded with the boots worn by the accused, nor im¬
pressions of bis knees or toes as at first surmised. A quarter
of an hour previously the same men had met Kerr walking in
the direction of his home and away from the place where
the body lay. It was proved in evidence that Kerr must have
taken about forty-five minutes to traverse the distance of
657 yards from the place where he was previously seen, and
that no other person was noticed to pass by the same road.
It was further shown that the deceased would arrive at the
place where her body was found at a time when Kerr would
have met her. Here was strong presumptive evidence that
if a crime was committed Kerr was the agent of it. There
can be little doubt, however, that he was intoxicated j for
not only was he seen to be “staggering,” but one witness saw
him fall down in the road. On the police being fetched, the
corpse was removed on a ladder to a neighbouring inn,
I where on the following day Dr. Barnes and Dr. McLaren
I made an examination. They found that death had resulted
i from asphyxia. Hypostatic congestion was strongly marked.
On the front of the abdomen was a small abrasion, which
did not appear to have bled. “Blood was seen smeared
over the genitals, and fmees had escaped. Distinct marks
of bruising were seen just within the genital passage, and
these showed recent effusion of blood. A small tear was
noticed near the right side of the orifice, and a larger tear,
about three-quarters of an inch long, a little further in.
There were several small effusions of blood in the lining of
the passage beyond the tear. The uterus contained no
blood. There were no seminal stains. There was a
bruise of the scalp and temporal muscle on one
side, which might have been caused by a blow or
fall. The heart and kidneys were diseased. There
was mud on the thighs. There were slight blood-stains
on the chemise and handkerchief, and vomited matter on
several articles of dress. There was a smear resembling
blood on the face, but no wound.” It has been suggested
that the extravasations and rents in the vagina were caused
by manipulation on removing the pelvic organs, hut it
would be manifestly unfair to Drs. Barnes and McLaren
to suppose that they would commit such a blunder. On
the same day the prisoner was examined. He had
slight abrasions on both cheeks. Several spots of blood
were found on his vest and trousers, and the fly of the
latter had a blood-smear on it. His clothes were smeared
Digitized by
THU liAHCBxJ
TttE LORD PRESIDENT AND THE MiDWiVES* BILL.
[Feb. 21, 1891. 443
with mud, aud adherent to the mud on the knees were red
woollen fibres. There was vomited matter on the waistcoat,
back of the coat, and back of the coat collar. There wore
no seminal stains on the prisoner’s clothes, or blood or
marks of injury upon the genital organs.
Two questions present themselves for inquiry—(1) Had
the woman been ravished ? (2) If so, did Keku commit the
offence? In our opinion the former theory is quite unwar¬
ranted by the evidence. Assuming sexual intercourse to
have happened, there is nothing to show it was nob by con¬
sent. If it did take place it is by no means certain that it
was at the spot where the body was found, since such marks
as would be expected on the ground were absent. Against
the theory of rape, too, was (1) the orderly disposition of the
woman’s clothes by the side of the body, (2) the proximity
to a dwelling-house, (3) the fact that no one heard sounds
of alarm, (4) the absence of seminal stains, (5) the absence
of signs of rough handling of the woman’s clothes. We
cannot subscribe to the argument of the medical witnesses
that the injuries to the vagina were greater than could have
been inflicted had there been consent to intercourse with a
drunken man. In a London hospital museum is a prepara¬
tion showing complete rupture of the vaginal wall caused
by the act of intercourse with an adult. The bruise on
Troughear’s head might easily be accounted for by a
fall; moreover, there were no stones about, and Kerr was
not seen to be carrying a stick.
It is surprising to us that this, by far the most assailable
part of the case for the prosecution, should have been made
so little of by the defence. Many of the marks found upon
the body and clothes of the prisoner were certainly consistent
with his innocence. The vomit on his vest and coat was not
sufficient to prove that it came from the deceased. The
spots of blood on his vest and trousers may have been
derived from blood-spitting. Whilst in custody he remarked,
“ I have been spitting blood again,” and in the basin a
police officer noticed streaks of blood. The mud on his
clothes and the abrasions on his cheeks may be accounted
for by his falling down, which he was seen to do. The red
woollen fibres on the knees of his trousers may have got
there from another source than the petticoat of the deceased.
It was not tendered in evidence, but it has since been alleged
that on the night in question his trousers were thrown
across the same rail as his sister’s red flannel petticoat.
Besides, there are so many ways in which so common a
fabric as red flannel may have come in contact with
his trousers. Also the death took place on June 2nd,
and these woollen fibres were not detected until June 25bh,
although an examination of the mud on the trousers had
been made in the interval. It was suggested to the jury
that the little blood on the woman’s face might have come
from the abrasions on Kerr’s cheek, but surely this is very
problematical. It was said that in the mud on the knees of
his trousers wore fragments of beech leaves and scales of
beech leaves, and that the mud was different in character
from that on the ground where he was seen to fall. This may
be so. But if he fell at one place he might well have fallen
at another, so this counts for little where so grave an issue
is involved. We cannot but believe that had the prisoner
been assisted by skilled medical evidence, and had all the
facts and their possible interpretations been placed before
the judge and jury, there would have been a more favour¬
able charge and a different verdict. Exception must be
taken to Mr. Justice Stephen’s remark, that walking in
the cool of the evening would tend to dissipate the effects
of drink; the result is often just the reverse. It is better
that twenty guilty persons should escape punisfiment than
that an innocent man should suffer. We commend the
above comments to the notice of the Home Secretary, in
the hope that he may find the crime of which Kerr lies
convicted was “not proven.”
The report of the proceedings on the occasion of a depu¬
tation to the Lord President of the Council on the Mid¬
wives’ Registration Bill will be read with interest by all
parties in this controversy. They may be surprised at the
keen interest, in a Bill affecting England alone, of Irish
officials and representatives of Irish Corporations or
Societies; they may question the authority of Dr. Rentoul
to tell a high member of Her Majesty’s Government that
many medical practitioners are ready to go to a confinement
for 7s. Bcf.; they may be struck with the fact that Dr.
Gilrart Smith was able to anticipate the report of a
committee of the Royal College of Physicians, which at
that moment had scarcely met, and to convey to the Lord
President that it would content itself with opposing this
Bill; and they may be struck by some of the arguments
advanced by other members of the deputation. But,
nevertheless, they will be interested to see how differently
things that are perfectly obvious can be stated, and
bow they seem for the moment to have impressed an
able and practical statesman. The deputation received
an assurance from Lord Cranbrook— of what has been
well known to our readers for some time—that the
Government would not support the present Bill. It is
under no particular obligation to do so. It is not a
Government Bill. It is drafted with no degree of care.
It takes no precautions against admitting the unfittest
persons now posing as midwives to the Register. The
Lord President spoke of “pressure of immediate legisla¬
tion.” Of all suffering creatures lying-in women are the
most patient, and the least likely to bring any pressure
to bear on Parliament •, it is the last thing they will think
of, and the last place they will appeal to. There will
have to be a good many more verdicts against mid¬
wives by coroners’ juries before pressure on Parliament
from those immediately affected is enough to move that
body, which is so absorbed in other questions. These
facts do not seem to us a reason, however, for acquiescing
in the present state of things. Few persons of any experi¬
ence can share the perfect satisfaction which Dr. Draqe
expressed to the Lord President when be said that for bis
part he knew of no necessity for legislation,- It requires
little imagination and less experience to understand what
evils must arise for the want of a little sound training
in ordinary cases and in^he management of ordinary
labour. It remains to be seen how far the deputation,
whose speeches to the Lord President we report to-day,
represent the profession. They were not altogether har¬
monious, and the Lord President might well feel “some*
what puzzled.” Mr. Croly, representing the Royal CoUegi
Digitized by
Google
444‘ TheLancetJ
AHMY MEDICAL SeEVICE.
[Feb. 21,1801.
of Surgeons of Ireland, said that the Council of bis College
would be quite agreeable to accept the Bill if adequate
guarantees of education and competency were given. Dr.
Macnaughton Jones was in favour of legislation for
securing “ a high type of obstetric nurse,” which seems to
us very much the same thing as ” a midwife.” Dr. Jacob
properly dreaded the wholesale admission of thousands of
ignorant women to a Begister. None of these deliverances
are opposed to reasonable legislation to stop incompetent
midwives from practising. It would be strange indeed if the
chief spokesmen for Ireland, the country of Sinclair and
Haughton, who have done so much to educate midwives,
had spoken otherwise. Dr. Eentoul seemed to be the most
‘ ‘puzzling” speaker totheLord President, Whereas the other
speakers were proud of Irish examinations of midwives,
“on the other hand, Dr. Rentoul was rather for ending
the midwives than for mending them. He said that
unless they became qualified in medicine and surgery, as
well as in midwifery, they should not be taken any notice
of, and I understand from that that he would rather
things were left as they were.” It is very unlikely that
things will remain as they are. It will be a pretty
business if Dr. Rentoul succeeds in getting us a race of
inferior female practitioners, educated in medicine, surgery,
and midwifery. Such a class of persons would indeed
be a veritable blow at the medical profession. If these
are Dr. Rentoul’s views, we deny that they represent
those of the profession any more than his remark that
medical men were ready to attend midwifery for 'Is. Qd.
Neither the health of medical men nor their self-respect
can be maintained on such fees. The lowest Poor-law fee
for midwifery is 10?. 6rf. Does Dr. Rentoul mean to drag
the profession lower than this ? The Lord President will
receive the thanks of tho profession for promising not to
support the present Bill. But, in the name of the profes¬
sion, we protest without delay against a Midwives’ Bill that
contemplates creating a race of something more than
midwives for attendance on ordinary cases of labour
among the poorer classes.
The recent correspondence between Sir Andrew Clark,
President of the Royal College of Physicians, and the
Secretary of State for War, must indubitably prove of
great interest to all concerned. There is no need to enter
into any detailed history of all the occurrences out of which
has arisen the present unsatisfactory state of feeling on the
part of army medical officers in regard to their present
position and privileges. There would appear to have been
a dissatisfaction among them for years past regarding rank,
even when relative rank was believed to have some value.
Whether the abolition of the latter were the cause or not
of all that has since taken place, it certainly was the
occasion of an almost universal feeling among medical
officers that they had been deprived of any rank they had,
except departmental. There were other grievances no
doubt, some recent, some old; but the main, the corner-stone
grievance, was that of rank, without the possession of which
jiiedical officers alleged that they had neither, on the one
hand, an assured position, nor, on the other, the authority
and independence to which they were entitled, and which
they deemed essential for the satisfactory performance of
the numerous and mixed duties aud responsibilities that
have of late years been imposed upon them.
Mr. Stanhope appointed a committee of investigation,
and that being so it was naturally felt that he should carry
out its recommendations. But a good deal has happened
since then. Once started, the subject was bound to
grow and develop. Medical officers were led to study
the constitution and organisation of the medical services of
other nations, and to consider well that of their own in
relation to the army generally. In this way they came to
appreciate and understand what was really meant by army
rank as distinguished from departmental rank, and military
titles or professional ones. The [able representation of
Sir Andrew Clark to tbe War Minister embodies their
present views.
The medical officers now not unjustly contend that things
have vastly changed of late years, and that only those
who have had working experience of the service know where
the shoe pinches. In order to avert future discontent, and
to place them in a proper position, they maintain that sub¬
stantive army rank is necessary for the medical officer, and
that the Medical Staff Corps should be welded into one
body like the Royal Engineers, the officers being lieutenants,
captains, majors, &c., of that corps, with limited command.
It is obvious that so long as the medical service forms part
of the army machine, its officers should occupy a well-
defined, recognised, and assured position, and that they
should not have to be asserting themselves or be com¬
pelled from time to time to fight for precedence, rights, or
allowances. If army rank be necessary, we certainly do
not see why the principle of command it carries with it
cannot be limited in character, and restricted, as at pre¬
sent, to the sphere of the medical officer’s responsibilities
and functions. We are quite sure that no army medical
officer would desire to exercise command outside the limit
of his own duties. The terms used in a medical officer’s
commission define his position and powers in this respect.
But rank is one thing, title is another. We confess that
we have always regarded the retention of some professional
title as right and consistent with proper self-respect, to
say nothing of the practical utility of distinguishing a
medical ofiicer in some way from other officers. The sub¬
stitution of purely military titles for professional ones, so
that the latter become altogether submerged and lost, does
not appear a dignified course to be adopted by University
graduates in Medicine or Fellows of a Royal College of
Surgeons, for instance. We do nob think, however, that
Mr. Stanhope’s concessions as they stand will prove satis¬
factory to the medical service, seeing that he grants them
the composite titles recommended by Lord Camperdown’s
Commission, but does not touch the question of substantive
rank, which is, in the opinion of the medical officers, the
pivot of the whole subject.
Although it may be true that to reduce the term of
foreign service to what it was would be productive of
increased expense, it must be remembered, on tbe other
hand, that the sickness and mortality among medical
officers are already unduly large; and extended foreign
Digitized by
Google
The Lancet,]
VITAL STATISTICS OF IMPROVED DWELLINGS.
[Feb. 21. 1891. 445
«ervice means increased ineiticiency from sickness and
invaliding, with attendant monetary loss to the State.
We are glad to observe that, with respect to the conditions
<rf sick leave, Mr. Stanhope is willing to meet the medical
officers’ wishes.
^nnDtatiuns.
Ne quid nlmis.''
VITAL STATISTICS OF IMPROVED DWELLINGS.
Dr. Newsholme, the medical officer of health for
Brighton, read before the Royal Statistical Society, on
Tuesday morning last, an interesting and useful paper on
'the Vital Statistics of Peabody Buildings, and other
.Artisans and Labourers’ Block Dwellings. The paper was
inainiy based upon the careful statistics that have been
oollected in recent years by the secretary of the Peabody
Trust Fund, and which had been placed at the disposal
of Dr. Newsholme for the purposes of his paper.
The Peabody dwellings have had for some years a prac-
«tically stationary population somewhat exceeding 20,000
persons. The population and the ages of the inmates of
'these buildinga are annually enumerated by the superinten-
-dents, and the returns of deaths occurring among this popu-
ialion are specially obtained from the local registrars. Dr.
Newsholme has thus been able not only to calculate the
yeoorded rates of mortality from all causes and from certain
classes of diseases, but also to correct these rates for the dis¬
turbing influence of the abnormal age-distribution of the
R-esident population. The paper was well received by the
Society, and was very generally acknowledged to he a good
example of careful and sound statistical work. It shows
that, notwithstanding the high birth-rate, the age-distri¬
bution of the Peabody population is Jess favourable to
the rate of mortality than that of all London; that not¬
withstanding the fact that the population is a working
•class population, and that the population shows a high
proportion of density per acre, the mean death-rate during
the twelve years ending with 1885 was 2 per 1000 below the
mean London rate during the same period ; that the
mean rate in the Peabody buildings is at each age group
below the mean rate for the whole of London, excepting
only the age groups 0 to 5, and lo to fl.') years; that the
cate of infant mortality (the proportion of deaths under one
year to births) is considerably lower in the Peabody build¬
ings than in the whole of London, whereas among children
aged between one and five years the rate in the Peabody
buildings shows a marked excess; that the excess at
these ages is mainly due to the high rate of mor¬
tality from the diseases more immediately due to direct
infection, notably scarlet fever, diphtheria, whooping-
cough, and measles; and lastly, that what has been
■called Dr. Farr’s law of density—that is, the existence
of a constant relation between increasing density and in¬
creasing luortalify—receives no corroboration from the
results of Dr. Newsholme’s analysis of the mortality of the
Peabody buildings. An interesting discussion followed the
reading of the paper, in which the President (Dr. Mouat),
<Sir Rawson Rawson, Dr. Adler, Dr. Sykes, Dr. Longstail',
Mr. Lovett, Mr. Noel A. Humphreys, and others took part.
While the statistical merit of the paper was fully and freely
admitted, it was asserted by some of the speakers that the
very abnormal character of the Peabody population was
not siiiliciently recognised by Dr. Nowsholiue, and that
too much importance was attributed to the comparison
■of the Peabody rate with the rate for the whole of London.
The practical impossibility of constructing thoroughly
trustworthy statistics for groups of houses or blocks on
account of the shifting character of the popnlation and the
grave difficulty in the way of debiting to such popula¬
tion the number of deaths really belonging thereto and
occurring in workhouses was urged by many speakers.
Or. Farr’s formula for ascertaining the effect of density
upon mortality was frequently referred to, and it was
generally admitted that while the so-called “law of
density” was in force during the thirty years 1840-70,
dealt with by Dr. Farr, it is no longer strictly applicable
on account of the marked reduction of the general death-rate
of the country since the passing of the Public Health Acts of
1872 and 1875, and especially ou account of the far greater
reduction of the rate of mortality in town than in country
districts. It is quite possible that in some towns, or in
some parts of some towns, the effect of density is nearly
as fatal now as it was when Dr, Farr constructed his
formula, but one of the most marked results of sanitary
improvements has been to render possible the constant in¬
crease of density of towns without a corresponding increase
of mortality, and even coincidenbly with a continued decline
in the rate of mortality._
EPIDEMIC OF ERGOTISM.
Dr. Reformat,ski has published an account of a some¬
what serious epidemic of ergotism, or, as he calls it, “ per¬
nicious spasm,” which occurred during the latter part of
1889 and early months of 180() in the NoUnski district
of the p^^Bce of Viatka in Eastern Russia. The number
of persoaoBtacked is given as 2749, of whom 53.5, or nearly
20 per ce^Bdled. Men, women, and children all suffered,
especiall^Bne poorer classes, who, having rio store of
flour, had to use the product of the harvest of 1889
as soon as the corn was cut. Soon after eating bread made
from the diseased corn persons were affected with vomiting
and sometimes dian-hcca, and complained of pain in the
epigastrium or over the whole abdomen. This was followed
by headache and giddiness, also by great prostration or by
acondition .similar to that produced by alcohol, andby a great
desire to sleep. Sometimes vision was disordered, temporary
blindness occurring in some cases. After thesesymptoms, con¬
vulsions and tonic spasms frequently came on, and from this,
which of course was one of the most prominent features,
the name “pernicious spasm” arose. The spasm affected
different groups of muscles, especially the flexors of the
limbs, those used in mastication, and the throat muscles.
Loss of consciousness or epileptiform fits followed, and
many of the patients suffered from mental disturbance. A
good many suffered from gastric symptoms and trophic
changes, affecting the hair and nails. A table is given of
cases treated in a certain hospital, showing the number
admitted each month and the frequency of the different
forms of the disease; 55 per cent, suffered from spasms,
18 per cent, from mental disorder, 0 per cent, from fits,
8 per cent, from fibs combined with spasms, and 12 per cent,
from fits, spasms, and mental disorder. In some villages a
somewhat different form of the disease presented itself in
cases where barley or oaten sour bread had been eaten,
the symptoms being headache, prostration, and drowsiness.
These cases were all of a mild description, and the patients
recovered completely after a prolonged sleep. In one of the
post stations the thirteen ostlers belonging to it were all
affected some twelve hours after eating some hot cake.
Though they were very weak and sleepy the exigencies
of their situation compelled them to harness and start the
horses. Three of the men had os much as they could do to
attend to a single pair of horses, and one man was so over¬
come by drowsiness that he fell from the coachbox. The
next day there was less traffic and they were able
Dic::'zjd by Coogle
446 The I*ancet,]
ONE OF THE LATEST NOVELTIES.
[Feb. 21,1891.
to rest, but having eaten some more of the dele¬
terious material they suffered as before. The third day
they recovered. Or. Reformatski dbcusses the prophy¬
lactic measures which should be taken in order to
prevent a recurrence of these epidemics. Of course, in¬
struction should be given to peasants generally as to the
dangers of ergot, but Russian peasants are apt to be
obstinate. A still better and more efficacious plan is to
inform them of the great value of the diseased corn and to
take care that there are ready means open to peasants of
disposing of any that may be in their possession at, say, Qd.
per pound. Something, too, may be done by watching the
corn as it is brought to the mills to be ground.
ONE OF THE LATEST NOVELTIES.
It is not often that medical or surgical inventions are
capable of exciting amusement. Such, nevertheless, appears
to have been the effect produced by one of the latest of their
class—that suggested in our issue of Feb. 7th by a corre¬
spondent who advises the use of a distinctive “medical
hat.” In justice to the originator of this novel idea we
must recall the fact that he is evidently guided by
a more practical and a more professional motive than
the mere desire for self-advertiseinenb. The bat in
question is not of the same family as the curious robe
and wand of the ancient charlatan. It has more ailinity
with the clerical broad brim or the barrister s wig and gown,
and the chief purpose of the inventor, a practitioner in the
country, evidently is to facilitate recognition and thus
reduce the fatigues of the daily round. Viewed in this
light, the proposal is not perhaps so laughable as some have
imagined. Knowing, however, the aversion of medical
men in general, and especially of rural practitioners, to
anything like a atifUy professional fashion in dress, we are
not surprised that the proposed hat has been somewhat
battered by its contact with freely expressed opinion. The
horse and carriage, the still approved surtout, and the in¬
conveniently convenient bag may be considered to give
enough of the professional aspect without the added
bondage of a peculiar headdress. Any who may still desire
to increase the number of their accoutrements have of
course the option of adopting the newest fashion in medical
dress.
ENLARGEMENT OF THE SPLEEN IN
INFECTIOUS DISEASES.
An interesting series of researches have been carried out
by Martinetti and Barbacci (Morf/affni, September, 1890)
with reference to the enlargement of the spleen which
frequently occurs during the course of the acute infectious
diseases. Twelve guinea pigs and six rabbits were inoculated
with anthrax. In half the number of the animals the
spleen had been extirpated before inoculation. The absence
of the spleen seemed to have no effect on the course of the
disease. The temperature was taken in eleven of the cases,
and exhibited at hist a slight rise, but at a certain stage of
the disease tbe temperature fell suddenly, this corresponding
with the appearance of bacilli in the blood and a considerable
decrease of the red blood-corpuscles. This was accompinied
by an increase of white cells, most marked in those animals
in which the spleen had been rernovei. The changes which
occurred in tbe spleen were noted in those animals which
had not been previously operated on and also in thirty-six
white mice. The alteration was not apparent until the
bacilli appeared in the blood. The first changes observed
were that in various parts of the organ, and especially
around the Malpighian corpuscles, the cells became
granular and their nuclei stained more deeply ; the
spaces between the cells became wider and appeared to
be filled with a homogeneous substance. In addition
yellow pigment and red blood-cells were found in thei
interstices of the tissues. At this period, also, in
the spleens of mice and in the parts not affected by the
above changes, large cells were seen with irregularly shaped
nuclei, similar to those which occur in the marrow, spleen,
and other organs during the embryonal state. Anthrax
bacilli were also demonstrated. In the further course
of the disease the spleen substance became more and
more infiltrated with blood, and the large cells just de¬
scribed underwent a regressive metamorphosis ; so that
finally there was an appearance as if gangrene had com¬
menced. In contrast with tbe passive processes taking place
in the pulp, more active changes were occurring in tbe
Malpighian corpuscles, in spite of the almost complete
absence of bacilli. Tbe follicles * increased in size, and
there was rapid increase of nuclei. As regards the
lymphatic glands, no difference was appreciable be¬
tween the animals which had had the spleen removed
and those which had not. Changes were first observed
in the medullary substance, and these were principally
disorders of circulation — hyperremia followed by stasi&
and thrombosis. In the cells rapid cell proliferation took
place, but no bacilli could be demonstrated. In some oF
the guinea-pigs the bone marrow was examined. In those
in which the spleen had been removed there was an increase
of pigment, both free and in the cells; giant cells were also*
more numerous. In all the animals there was an increase
in number of the red and white blood-cells, and larger cells
of unknown nature were also noticed. In the giant cel]s^
contrary to what has been stated by most observers, un¬
doubted signs of karyokineais were noticed. The large cello
which were found in the spleen during the first stages of the
disease, and in the bone marrow during the whole course ot
it, were considered by the authors of the paper to stand in
some relation to the source of tbe red blood-cells, and to be
an effort on the part of the organism to make up the loss oir
these cells by fresh elements.
COTTAGE HOSPITALS.
At the recent annual meeting of the subscribers to the
cottage hospital at Mold a resolution was passed limiting,
the medical staff of the institution to two legally qualified
and registered surgeons, to take duty on alternate weeks.
An amendment to the effect that any practitioner should be
allowed to attend his own patients was not carried. Seeing
that there are about six practitioneis in tbe neighbourhood,
it seems unfortunate that the staff should be limited, since
this might make the practice of the institution too ex-
clu8lve--a most undesirable thing in our opinion, and one
not tending to the furtherance of the spirit of goodwill and
fellowship that should obtain amongst professional brethren.
The conditions under which a cottage hospital in a com¬
paratively small district is best carried on are those which
involve the mutual codperatiou of all the medical practi.
tioners in its vicinity. __
THE RESULTS OF ENTERIC FEVER AT
SOUTHEND.
Wfi have more than once commented on the doings of
Southend in connexion with the recent widespread epidemic
of enteric fever in that place. But the last news surpasses
much of the former action adopted. According to locai
statements, the medical ollicer of health, Mr. Alberb
Morris, submitted to the local board of health a state¬
ment as to the causes of the disease, which report was
strongly condemnatory of the existing sanitary administra¬
tion, and from tbe local press we learn, on Mr. Morris’a
authority, that bis statements, whatever they were, were
fully confirmed by Dr. Thresh. This report has never seen
daylight, although the authority are challenged to produce
Digitized by
Google
The Lancet,]
THE NEUROPATHIC ELEMENT IN SPASMODIC ASTHMA.
[Feb. 21,1891. 447
\b. other day, the date on which the re-election of Mr.
Morris came due, he was quietly passed over, and his prede¬
cessor in office, who resigned his office after having some years
hack “told the Board what he thought of them,” was again
elected to the office. We can only repeat that the
authorities of Southend are not going the way to restore
that confidence in the sanitary administration of their
“health resort ” on which success must necessarily depend.
Mr. Phillips, the re-elected officer, may he trusted to advise
rightly in the difficulty; bub some ratepayers would have
been more satisfied if they had seen Mr. Morris’s report
before its author was shelved. Since Mr. Morris was
doubtless under the obligation bo transmit every “ special ”
report to the Local Government Board, a copy of the
document might possibly be procurable through that
department. ____
THE DIAGNOSTIC VALUE OF FLUORESCEIN
DYE IN DISEASES OF THE EYE.
Drs. Fromm and Grovenonn, assistants in the eye
clinic at Breslau, publish in the Archiv filr Augenheilkunde
an account of some experiments with fliioresceio. They
experimented with the potash salt of fluorescei'a and the
soda salt of fluorescin, preferably with the former in a
2 per cent, solution. One drop of this liquid is dropped on
the conjunctiva; it is well afterwards to wash the con¬
junctiva with water or any indill'erent liquid. The normal
cornea is never coloured, but if it is anywhere denuded of
epithelium such spots and the whole region near them
become stained of a diffused green colour, which generally
disappears again in from two to three houre. The corneal
substance is deeply impregnated with the colour, but
the epithelium is only sliglibly tinged on each side of
the defect. Practised observers have confessed that by
no other means were they able to detect and map out
a comeal lesion so well as with fluorescein. This
chemical is most valuable for the diagnosLi of super¬
ficial injuries which are often difiicult to recognise, as if
these do not take the stain a fresh injury may certainly be
excluded. Particles of rust which often remain after the
removal of foreign bodies, and are difficult to recognise, are
plainly distinguished from their green base. Every ulcer is
of course coloured, and a green colouration is seen over
every abscess and infiltration. Opaque spots, however, do
nob stain, and so are distinguished from fresh lesions. In
•the conjunctiva the localities of any loss of substance are
coloured yellow, and injuries become visible which other¬
wise could not have been discovered. In conjunctivitis only
phlyctenulce become coloured, and by this means they are
distinguished from other nodular prominences. The deeper
parts of the eye are nob aflected.
THE NEUROPATHIC ELEMENT IN SPASMODIC
ASTHMA.
Althouoh the general explanation of the asthmatic
paroxysm is that it is due to bronchial spasm, which may
often be excited by peripheral nervous irritation—a view
■that has received much attention of late in respect to the
causal relationship of nasal polypi and asthma,—neverthe¬
less there have not been many attempts to demonstrate
the existence in the asthmatic of an underlying state of
nervous instability. This lacuna is in a measure filled by
a paper by I’rofessor E. Brisaaud [Rev. dc M6d., Dec. 1890),
in which hecollatesa considerable amount of evidence to sho w
that the (true) asthmatic may be regarded as a neurotic ;
and hence the removal of the supposed exciting cause
(e.g., nasal polypi) can hardly be expected to be curative.
Codeed in many cases, he avers, the asthma has recurred
some time or other after the patient has undergone pro¬
longed treatment at the hands of the rhinologist. The
probability of some inherent nervous defect in a disease
like asthma, the periodical recurrence of which reminds
one of the epileptic nerve-storms, seems so self-evident
that it is singular so little attention has been paid to
it, even by such a strenuous advocate of the nervous
theory of the paroxysm as Hyde Salter, for instance; but the
fact is that attention has been fastened too much on its
alleged diathetic relationships, and also to the existence of
local organic disease, of digestive, respiratory, or generative
organs as possible sources of reflex irritation. On the
other hand, the association of asthma with insanity and
alternation of attacks of the mental affection with those
of the respiratory apparatus, has been noted by several
alienists, and Professor Bdssaud quotes in this connexion
the writings of S-ivage, Kelp, and Conolly-Moore. Cases
are given of asthma associated with hypochondriasis,
melancholia, and hysteria, or combined with some
mental disturbance or other nerve disorder, as neu¬
ralgia or epilepsy. The general conclusion is that
asthma is only one manifestation of the general neuro¬
pathic tendency, and that an inheritance of nervous
disorder is a main predisposing factor in the affection.
Like migraine, which once was considered in France
to belong to the “ arthritic ” group, but which
is incontestably regarded now as “neurotic,” asthma,
too, has relationships far more close with the neuroses than
with any diathetic state. Of course, it is not implied
that in the same subject other nervous manifestations
must necessarily occur, even in their slightest form, for
this is notifissential to any single neuropathic affection. It
is only that the asthmatic belongs to the group of neuropaths,
and that his special affection may be the sole expression
of lii^ alliattce therewith. Hence it is explicable how com¬
paratively slight peripheral irritation of sensory nerves—
e.g., of the nasal mucous membrane, or odours, or even
simple mental apprehension or dread of attacks supervening
under certain circumstances—may sullice to induce the
asthmatic paroxysm in the individual of nervous constitu¬
tion. Nor, as stated, can the cure of spasmodic asthma be
reasonably expected to invariably occur after the removal
of the supposed exciting cause.
METHOD OF ADMINISTERING SULPHONAL.
Everyone who has used this drug must have noticed
how much it vayies in the rapidity with which its effects
are produced according to the method of administration.
Given in powder on the tongue its action is much delayed,
and is occasionally only produced in its greatest intensity
on the day after its administration. Given, however, with,
for example, some hot soup, an hour or two before bedtime,
its effect is not so long delayed and is more certain.
Dr. Stewart of Philadelpbia has found a simple and satis¬
factory method of using the drug, which he describes in a
recent number of the Medical Nezes. lie directs that
just before retiring the dose of aulphonal should be
p'aced in a tumbler, which is then filled two-thirds with
boiling water. This dissolves the powder. The solution
is then stirred until it is sufficiently cool for drinking,
or cold water is added to reduce ib to a suitable
temperature. Such a temperature is reached without
causing any precipitation of the drug. To insure success
the sulplional must be taken wholly dissolved, and the
hotter the solution is when taken the better. By this method
the period of so-called therapeutic incubation is done away
with. Sleep results in most cases in a very few minutes,
and is said to be sound and dreamless. Another advantage
which this method of administration is said to possess is
that it is nob followed by the annoying drowsiness so often
present on the day after the administration of the dose of
aulphonal. The taste of the solution is said to be a little
Diiidized by Google
448 Thb Lancet,]
TUMOURS OF THE BRAIN.
[Feb. 21, ISW.
unpleasant, but this is easily overcome by the addition of
some flavouring substance. Undoubtedly its insolubility is
the great objection to sulphonal, and if it can be admini¬
stered in this simple way, so as to produce its effect promptly
and efficaciously, its value will be much increased.
ALLEGED BREACH OF THE NOTIFICATION ACT
AT BOLTON.
A MEETING of the medical men of Bolton and district
was held last week to consider the recent prosecution
of Dr. Gilchrist by the Bolton Rural Sanitary Authority
for an alleged breach of the Infectious Diseases Notification
Act, 1889 (repotted in our last issue). There was a large
attendance, and Dr. Smith was voted to the chair. After
a general discussion upon the merits of the case, it was
unanimously resolved that it be a recommendation from
that meeting to the Parliamentary Committee of the British
Medical Association, local members of Parliament, rural
sanitary authorities, and other public bodies, that steps be
taken to get inserted in the Act a clause whereby the
defendant in such cases may give evidence in his own
defence. There was a general feeling expressed also that it
was undesirable for a medical officer of health to make a
clinical examination of a patient upon notilication, as in
this case. _
TUMOURS OF THE BRAIN.-
A PAPER on this subject was read a short time ago before
the Boston Society for Medical Observation by Dr. Stedman,
and several cases of so-called cerebral tumour were related.
The cases are very interesting, and, as each of the five
dealt with is completed by a necropsy, they ought to be a
valuable series. But unfortunately their value is nob so
great as might be expected, because while some of the cases
are no doubt what would be strictly described as tumours,
others are, eo far as the evidence in the paper at least
can inform us, cases of cerebral softening, the result of
embolism or of thrombosis. It is also uufortunate that
the ophthalmoscope should not oftener have been called
into requisition. We only find it mentioned as having been
used in one case, and in that case apparently but once, and
with a negative result. Considering how obscure the causa¬
tion of optic neuritis is, and how important it is to make
quite certain of its presence or absence in a given case of
suspected cerebral tumour, no apology is needed for insist¬
ing upon the importance of such an exauiination in these
cases ; and, while acknowledging the interest and value of
Dr. Stedman’s cases, we can only regret that imperfect
examination renders them less valuable than they might
have been made.
THE GERMICIDAL PROPERTIES OF BLOOD.
A GREAT deal of important information has lately been
obtained on this subject, and von Fodor, who has already
contributed some useful papers, publishes in the Cmtralhlatt
fur Bahtcriologie und Parasilenhimde, vii,, No. 21, some
further experiments which he has made, ©specially directed
to ascertain under what conditions the germicidal properties
of the blood are at their highest, and in what way the com¬
position of the blood affected these properties. Tlie first series
of researches had reference to the composition of the blood,
and proved, in the first place, that arterial blood has a more
destructive action on the bacteria than venous, and also
that fresh blood has a more powerful action than that which
has been shed for some time. Again, the germicidal power of
the blood was weakened in an atmosphere consisting entirely
of oxygen or carbolic acid ; on the other hand, the removal
of gases from the blood had no appreciable influence.
The blood of rabbits which had been poisoned by carbolic
acid gas was not fatal to the bacteria. As regards the
influence of the movement of the blood (circulation), eyeip-
ments were made by placing the blood of rabbits, which had
already been inoculated, in small globes, some of which were
kept in constant movement and others quite stationary. No-
appreciable diflerenee was observed. Some very interesting
results were obtained in reference to the temperature of the
blood. From these it would seem that the germicidal)
power of the blood increased with the rise of temperature,
reaching its maximum at 38° to 40°C. ,aud then again
gradually diminishing. The author mentions an interest¬
ing fact—i.e., that the individual predisposition of any
animal to an infectious disease seemed to stand in direct
relationship with the germicidal power of its blood.
The second series of researches was directed to the in¬
fluence of drugs on the power of the blood to destroy
germs. Hydrochloric acid had no ellect. After treat¬
ment by tartaric acid a marked decrease was noticecL
and the same result was produced by quinine. Common
salt and carbonate of ammonium caused a slight increase of
the power, the phosphate of sodium a more marked effect,
whilst the carbonates of sodium and potassium produced a
very remarkable increase. From, the experiments the
author concluded that any drugs which cause increased
alkalinity of the blood considerably raised the resisting
power of the organism against the inroad of bacteria. The
third of this series of experiments corroborated this sup¬
position. Of eight rabbits inoculated with anthrax all)
died, whilst of nineteen which had been provioirsly injected
with soda solution only three died, thns proving the
elRcacy of the alkalisation of the organism. Of the
remaining sixteen cases a few were affected at a later date,
but the majority remained perfectly free from disease.
ROYAL COLLEGE OF PHYSICIANS.
A COMITIA of the College was held on the 18th inst., the
President, Sir Andrew Claik, Barb., in the chair. It had
been specially convened to receive a communication from the
Registrar of the University of London, transmitting, by
direction of the Senate, a further revised scheme for the
reconstitution of the University. The communication wa&
read, and the President explained the tenor of the scheme
80 far as ib related to the College and the faculty of medicine*
A recommendation from the University Committee to the-
efl’eeb that the scheme be accepted by the College was read,
and its adoption moved by Sir K. Quain, and seconded by Sir
Risdon Bennett. Dr. Sansom moved an amendment to defer
action on the part of the College till the opinion of Con¬
vocation had been taken on the scheme. This was seconded
by Dr. N. Moore. Drs. Bastian, Allchin, and Sir R. Quain
having also spoken on this amendment, it was put and
lost by a large majority. After some further remarks by
Drs. Rye-Smith and Lionel Beale, the original resolution
was carried nernine conlradicentc.
NEW CLOTHES A VEHICLE OF CONTAGION.
There is probably no custom which lends itself more
readily to the propagation of infectious disease than the
household manufacture of certain goods, especially ok'
articles of clothing. Every practitioner whose duty calls
him to the homes of the working poor must have been
struck with thUfact, In many casesitcould not well be other¬
wise under existing conditions. The two or three avail¬
able apartments are occupied by a fairly numerouf^
family, and a separate workroom would be regarded
not unreasonably as a needless concession to personal
comfort. Thus ib happens that the same chamber, nay, the
same bed, often contains or bears the sufferer from scarlatina
or measles, and the jacket or gloves which to-morrow will
adorn the window of some city clothier. Disinfected?
Probably not, unless it be under pressure of some external
Dic:...ied b lOO^Ic
Thb Lancet,]
TESTIMONIAL TO ME. GANT.
[Feb. 21, 1891. 449
authority, for the class of workers to whom we have referred
too often exhibit a surprising ignorance or careleesnees with
regard to the properties of contagion. The advantages con¬
ferred by the Notification Act may not be equally apparent
among better educated and more scrupulous persons. These
are commonly a law to themselves. To the home of the
poor worker it comes as a purifying force, and ensures as
far as medical and sanitary supervision can the observance
of such rules as are needful to prevent the spread of disease.
In the present connexion these must imply the efi'octual
purification of all clothing before it leaves the infected
house, and the refusal to the inmates of any more work of
a like sort during the prevalence of the illness.
THE MECHANISM AND TREATMENT OF
IMPACTED SHOULDER PRESENTATION.
Dr. C. A. Herzi'eld of Vienna upholds, in a most in¬
teresting contribution to Holder’s Sammlung Medidnischm
SchrifUn, Dr. C. Braun’s key-hook as the gentlest, most
rational, and most successful of all instruments indicated
in impacted shoulder presentation. The author has carefully
studied the whole reference literature, and has observed
twenty-five cases in Braun’s clinic. These cases oiler
strong evidence of the simplicity, suitability, and safety of
the application, as in none of them did the decapitation of
the child lead to any injury of the mother.
TESTIMONIAL TO MR. GANT.
At a meeting of the Committee of the Eoyal Free
Hospital, held on Jan. lljth, 1891, Mr. Gant was presented
with an illuminated scroll by the committee on the occasion
of his retirement after a period of thirty-seven years’ service
on the surgical staft' of the hospital. The committee desired
“to place on record their high appreciation of his very
valuable services, which, together with his well-known works
on Surgery, have reilected the very greatest credit upon
him and the institution with which be had been so long and
so honourably connected.” Mr. Gant was also appointed a
consulting surgeon to the hospital.
ORGANIC HEART DISEASE AT DIFFERENT
ALTITUDES IN SWITZERLAND.
Taking as a basis the statistic.? of Switzerland for the
years 1876 to 1880, recording 2r>,.'")00 cases of death from
organic heart disease, Mdlle. N. IwanoIF has written an
essay on the question whether mountaineers suH’ermore fre¬
quently from that disease than the inhabitants of the plains.
The writer has constructed a table in which all the localities
of Switzerland were divided into four categories, accord¬
ing to their altitudes. In the first, situated from 200
to 400 metres above the level of the sea, there was a
mortality from organic heart disease of 102 per 100,000
inhabitants; in the second, situated from 400 to 700
metres above the level of the sea, the mortality was 92 per
100,000; in the third, from 700 to 1200 metres above the
level of tho sea, 82 per 100,000 ; the last category, com¬
prising all higher altitudes, had a mortality of only 47 per
100,000. These numbers show plainly that the mortality
of organic diseases of the heart decreases as the altitude of
the habitation increases. As a secondary result of the
inquiry, it was found that this mortality is higher in towns
than in the country. These results are all the more
interesting, as formerly all eminent physicians, excepting
perhaps Stokes, forbad their patients all unnecessary
exertion, and even now Oertel’s treatment meets with con¬
siderable hostile criticism. Professor A. Vogt of Bern adds
several statistical remarks to the essay, from which it
appears that if the population were strictly divided into
agricultural and industrial districts the law of decrease of
organic heart disease in proportion to the higher altitude
would be more marked in the agricultural districts. The
statistics of the industrial districts seem, on the other
hand, to refute the law. Considering, however, that the
mountaineers are mostly watchmakers or machinists, while
in the plains there are more builders and other artificers,
whose work requires uninterrupted motion of the body.
Professor Vogt concludes that this deviation from the rule
is only apparent. This conclusion seems justified by the
fact that, of 100,238 recruits, the proportion of heart disease
amongst those of sedentary occupation far exceeded all the
rest.
POOR-LAW MEDICAL OFFICERS AND THEIR
DEPUTIES.
A DISPUTE has been going on lately between the
Holbom Guardians and their medical officers in reference
to the appointment of deputies. The guardians have
passed a resolution forbidding their medical officers to
appoint deputies amongst themselves, though the plan is
pretty generally adopted, and also works well, both as-
regards the patient and the medical officer. It is an
arrangement, too, which is sanctioned by the Local
Government Board. Moreover, it is to be remembered
that the difficulty of finding outsiders is very great unless
the medical officers devote the greater part of their salary to
remuneration for such service. The best advice we can giv&
to the medical officers who have appointed their deputies is
to comply with the standing orders and 1st the guardians
and Local Government Board fight out the matter
amongst themselves.
THE DRINK BILL FOR 1890.
It is appalling to find that the Drink Bill of 1890
amounts to £139,495,470, an increase of £7,282,194 over the
sura of the previous year,—all common sense and medical
science notwithstanding. It is said to he equal to-
one-twelfth of the estimated income of all persons, to one-
fifth of the National Debt, and to be eight times more than
the income of all the Christian churches. It is not our
business to moralise on this expenditure. To us it meana
so much cirrhosis, Bright’s disease, gout, rheumatism, in¬
sanity, &c..—disabling employment, taking the pleasure
out of the life of families, and bread out of the mouths of
children. Tlue Drink Bill for last year is larger than for any
year but that of 1878, when it was more than 142 millions
of pounds.
OVERCROWDING AND OPEN SPACES.
In a paper on overcrowding in towns, the first part of
which has just been published, Mr. C. Koberts discusses the
density of population in the zone of parishes immediately
surrounding the City district of London. His estimate of
an ideal density is by no moans unreasonable. It is already
realised in certain parishes, notably in that of Islington,
It allows a population of 108 persons to the acre, and
eight persons to each house within this area. The death-
rate under such conditions, it is interesting to note, is in
Islington as low as 13'3 per 1000. A table of statistics,
founded on information derived from reports of medical
ollicers of health and other sources, proves that this proportion
represents the exception, and excess the rule, throughout the
circuit of the “ Greater City” above mentioned. A higher
death-rate recorded in these cases might be regarded as a
significant accompaniment, were it not that its prevalence
in other less crowded parishes asserts the active iniluence
of other causes. As regards the important subject of open
spaces, Mr. Koberts’ views may well satisfy the moat-
liberal of his readers. They are as comprehensive in scope
as wholesome in purpose, and their accomplishment cannob
Digitized by
Google
450 The Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Feb. 21,1891.
certainly be the work of a day. Among other prospective
changes he proposes that the grounds of Lincoln’s inn-fields,
the Foundling Hospital, St, Luke’s Asylum, the Artillery
Ground, and various neighbouring almshouses should be
utilised in this way, the dispossessed occupants of tlie
foundations above named being transferred to the country
near London. To do all this of course implies no trifling
cost in effort and in money. The execution of a similar
but more limited scheme might, however, be accomplished
without much difficulty, and the free enjoyment of even
one of the considerable areas mentioned would greatly
increase existing facilities for physical recreation.
FOREIGN UNIVERSITY INTELLIGENCE.
Dorpat. —Dr, Bumm of Erlangen, who was offered the
chair of Mental Diseases, has declined to leave his present
chair.
Erlangen. —Dr. F. Hermann has been promoted to an
Extraordinary Frofessorslup of Anatomy.
Heidelberg.—Dr. T. Hoffmann has been promoted to an
Extraordinary Professorship.
Leipsic ,—Professor Sattler of Prague has been offered the
chair of Ophthalmology, vacant by the death of Professor
Coccius.
Munich .—It is now stated that Professor Angerer is to
be appointed to the chair of Surgery recently left-vacant by
Professor von Nussbaum’a death (i.e., not Trendelenberg, as
in The Lancet of Jan. 3lst).
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Bousouetof Marseilles, suddenly, while bending down
to examine a patient.—Dr. Michaelis of Berlin, formerly in
fiarge practice as an ophthalmologist.
The Parliamentary Committee of the London County
Council have recommended the adoption of the following
resolution: “That a petition be presented to Parliament
by the Council in opposition to the Metropolis Water-
supply Bill; and that the Council do oppose each of the
following B Us, against which they have presented peti¬
tions : The London Water Commission Bill, the Southwark
and Vauxhall Water Bill, and the Croydon Water Bill ; and
that the costs and expenses incidental to the said petitions
and the proceedings consequent thereon be charged to and
paid out of the county fund.” It was pointed out that it
was necessary to have a majority of the Council in favour
of the resolution to make it effective, and, the show of
hands showing only sixty supporters, a division was
•demanded, when the numbers were: For the resolution,
75 ; against, 17 ; majority, 68.
Sir G. M. IIumitiuv, F.RS., has, we understand,
Accepted the invitation of the Cambridge Medical Graduates’
Club to a congratulatory dinner to be held at the
Marlborough Rooms, Regent street, on the 24bh inst,
Gir George Paget, K.C.B., is to preside. Invitations to the
<linner have been accepted by Sir Joseph Lister, Bart.,F.R S,;
the Provost of King’s College, Cambridge; Sir Alfred Garrod,
F.RS.; Mr. Bryant, President of the Royal College of
Aiurgeons; Dr. Priestley; Mr. Hutchinson, F.R.S. ; and
other leading members of the medical profession.
The death is announced at Potsdam of the well known
optician, Professor Edmund Hartnack, with whose miero-
•ecopes everyone is familiar. He commenced bis manu¬
facture of optical instruments in Berlin, but subsequently
removed to Pails. Political feeling there, however, drove
him out of France in 1870, and since that time he has been
living in Potsdam. The University of Bonn conferred an
honorary doctor’s degree on him in 1868, and the Minister
of Education granted him the title of professor in recogni¬
tion of the invaluable services be had rendered to science.
The second lecture of the course of Ingleby lectures now
being delivered by Mr. Jordan Lloyd, M.B., M.S., F.R.C.S.,
in the Examination Hall of Queen’s College, Birmingham,
will be given on the 26th inst. The course will be continued
on the following five Thursdays, the subject being “ Prac¬
tical Observations on the Surgical Diseases of Children.”
William R. Hugcard, M.A., M.D., M.R.C.P. Lond.,
Prakt. Arzt, Schweiz, has been appointed British Pro-
Consul at Davos-Platz, Switzerland.
Dr. David W. Finlay has been appointed Extern
Examiner in Medicine to the University of Durham for the
current year. _
THE DEBATE ON KOCH’S REMEDY AT THE
BERLIN MEDICAL SOCIETY.^
Tiik proceedings of the Berlin Medical Society on the
nth inst.respecting Koch’s remedy were of considerable
interest, Professor Virchow again intervening in a long
speech.
Dr. SiLicx showed a case of lupus of the face, nose, and
conjunctiva, which reacted well to the injections. After
120 niilligranitnes had been given the lupus appeared to he
healed ; bub within ten days it reappeared, and in from two
to three weeks the nodules were as large as ever. The
effect on the conjunctiva was less marked; indeed, the
whole of the Ufc cornea became covered with pannus.
He added that but few cases in the eye clinic had been
treated by the remedy.
Dr. A. Fuaenkkl reported on the .sixty-one cases of
lung disease treated at the Urban Hospital for at least four
weeks; forty-eight had been treated for more than seven
weeks, and some even for as long as eighty days. He
divided the cases into slight, moderately severe, and severe.
The “slight” comprised those of moderate infiltration of
one apex ; the “moderately severe” those with infiltration
of a whole lobe, or of both sides, orcomplicated with pleural
effusion or alight laryngeal tubercle; and the “severe”
those with indubitable signs of excavation, or complicated
with intestinal tuberculosis or advanced laryngeal affection.
Of the total eighty-three cases (including those treated for
less than four weeks) there had been two deaths. One was
a woman who, together with manifest pulmonary signs, had
paralysis of the leR sixth nerve ; and after the third injec¬
tion of O’OOi grm. she had headache and other signs of
tuberculous meningitis, from which she died in a week.
The other was a man a^ed fifty-one, with marked affection
of both lungs. He received five injections, the last being
0'005 grm , which was followed by severe dyspnoea and death
in three days. But there was no evidence of acute conges¬
tion or pneumonia—only old caseous foci and some large
cavities in the right upper lobe. In seven cases the treat¬
ment had to be suspended—in three on account of hemo¬
ptysis, in one after a week’s injections, which had reached
0-1 grm., and the bcemoptysis lasted for twenty-four days.
In iour cases an aggravation of symptoms caused the sus¬
pension of injections. In one, a case of double pleurisy,
with unilateral phthisis, severe dyspnoea; and in three,
persistent fever with increase of local signs. One of these
was especially remarkable—the changes in physical signs
being very striking, and attributable to severe catarrhal
I .See THE Lancet, vol. i. 1801, pp. 216, 271, 328, and 380.
3 ConslderationH of space compel a considerable curtailment of this
report, which occupies sixteen closely printed columns of our contem¬
porary, the Berliner Klinisebe Wocbenschrift, No. 7.
Digitized by
Google
The Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY.
paeaiooDia. One case of lupus of the soft palate, pharynx,
and larynx, together with renal tubercuioeis, was treated
with great caution; but no reaction was observed, although
as much as 0'07 grm. was reached. Still latterly there
seemed to be some melting down of the tubercular growth on
the epiglottis and false cords. As to the pulmonary cases,
he held that, whatever the value of physical signs, one could
not speak of a relative cure so lung as the sputa contained
bacilli; and, indeed, he did not think the time had yet
come to speak of absolute cures. He mentioned a case in
which bacilli h.ad been absent for nine weeks, when haemo¬
ptysis supervened, possibly from a small, not recognisable,
cavity. Of the sixty-one cases, there were three in which
bacilli were absent for from seven to nine weeks, and the
physical signs, always slight, had subsided. In no fewer
than lifteen of the slight cases no change as regards amount
of bacilli could be noted ; and yet these were cases with the
very slightest physical signs, including some which for two
months had been receiving O'l grm. twice a week. Bacilli
may spontaneously disappear from the sputum for some
time. Twenty-eight cases (thirteen alight and fifteen
moderately severe) might be described as improved;
not as regards the bacilli, but subjectively, and in
aspect, in diminution of sputum, and in increase of
weight. He had often remarked a notable increase in
weight of such patients before the introduction of Koch’s
treatment, but nevertheless the general improvement under
the influence of the injections was very striking. In twenty
cases (three slight, thirteen moderate, and four severe) no
change had been observed. Lastly, nine cases (six moderate
and three severe) had gob worse, showing that it could nob
always prevent exterision of the disease. He summed up
his experiences as:—1. A limited number, especially of slight
cases, undergo a marked change for the better, bacilli dis¬
appearing from sputa and general nutrition improving, this
being apparently due to the melting down of caseated
infiltration. Yet such a result cannot always be predicted,
even in the mildest cases. 2. In a large number (about
one-half) there is improved nutrition, which may be due to
Koch’s method or to tonic and dietetic treatment. 3. In no
small percentage the moderately severe cases grow worse,
and sometimes from conditions attributable to the treat¬
ment. i Severe cases ought to be quite excluded from the
treatment.
Dr. Julius Wolff spoke of the treatment in joint disease,
detailing two cases in which marked extension of the
tubercle took place. He did not think the original hope,
that the presence of “ dead tuberculous tissue ” would more
clearly define the parts to be excised, had been fulfilled, nor
that the general and local reactions were at all pro¬
portionate to the extent of the local process. But in nob
one case had the general condition of the patient been un¬
favourably influenced by the remedy, nor in the cases
operated upon had it had any bad effect on the course of
the wound.
Dr. Flatau referred to two laryngeal cases shown by
him a fortnight back, in which, during marked improve¬
ment, there suddenly arose a fresh outbreak of miliary
tubercle in the larynx. In the pne, where there was
nothing in the larynx at first but a small cicatrix, and
whore marked improvement took place in the pulmonary
signs, there was afurtber extension of disease in the larynx,
and appearance of tubercle in the tonsil, which had dis¬
appeared ; and no further extension occurred, alihough the
iujections were pualied as far as possible. In tlie other
patient, where weakness precluded continuance of the
injections, more nodules had appeared, the older ones
becoming more opaque.
Professor ViRUilOW spoke at considerable length upon the
question of the cure of tubercle, so variously interpreted ;
and in the first place he inquired what was precifely meant
by the term “tuberculous tissue” used by Dr. Koch. The
conception of “ tubercle ” had undergone so many changes
that it was difficult to be sure of the meaning now con¬
veyed by it; but it was clear that the tissue referred to by
Dr. Koch was nob the circumscribed granulation, but a
diffuse infiltration. It had been objected that too much
attention had been paid to anatomical facts, bub only in
that way could certain information be obtained. No one
doubts that in a tubercular inllamination—e.g., arachnitis
tuberculosa—there are two factors : inHammation, producing
an exudation ; and tuberculosis, a tissue. So in the lungs,
besides the true tubercle or tissue, there is in the course of
phthisis the occurrence of a quantity of inflammatory pro¬
[Feb. 21,1891. 451
cesses which are nob tubercle, such as the smooth, soft,,
catarrhal form, and the hard caseous form of inflammatory
change. The difference is as great as that between the exuda-
tionandthetubercleinabubercalousarachnitisorpleuritis. Iq
the lungs there are iDflammatory processes filling the alveoli,
producing hepatisation &c., and another process excited
by true tubercle, which forms a tissue. A like diversity is to-
be seen in the processes in tuberculous arthritis. In referenc&
to the action of the injections, he wished thedistinction could
always be borne in mind between (1) the tissue strictly
tubercular, (2) the tissue which arises near to or precedes
the tubercle, and (3) the mere exudation products. One
asks—Does Koch’s remedy act on all three? Possibly, but
the ostensible action is certainly not shown to an equal
extent on all three. Deferring consideration of the point
raised by Dr. Flatau as to the production of tubercle by the
injections, there is no doubt that an immediate action of
the remedy on tubercle as such is by no means uniform and
constant. This may depend in part on the site of the-
tubercle—e.g., in liver, or mucous or serous membrane, &c.,
difierences in physiological conditions. By the “cure” of
tubercle in a raucous membrane is meant its breaking down
into an ulcer, and the ultimate cicatrisation of the latter,,
all the tubercular matter having been got rid of. In
a serous membrane, such ulceration, which so rarely
occurs there, leads to fatal issues, and cannot be re¬
garded as a curative process. Laryngeal tubercle differs
from intestinal in rarely caseating (on this ground
Louis denied the existence of laryngeal tuberculosis) %
the ulcers it excites aie more superficial and earlier
formed. As to the effect of the injections, it is of
course impossible to determine whether certain tubercles
were present or not before these began ; but it is clear that
the remedy does not act on all tubercle, for often no indica¬
tions of degenerative change or of tbeir resolution are visible.
Tubercle tends rather to be encapsuled than removed by
absorption; and he had not seen any more evidence m
favour of the latter process in the present than in the past.
Dr. Koch had said the bacilli were unaffected by the
remedy, and if it were true that the tuberculous tissue
were dissolved and rendered capable of absorption, the
bacilli might be absorbed too, with considerable risk.
Professor Virchow thought rather, from tlie clinical and
anatomical facts, that ttie remedy acted upon the tissue
around the tubercle, which mighc beneficially lead to ite
extrusion, but also imperilled the patient from its extent
and intensity. In his previous statements he had only re¬
ferred to conditions wnich had occurred, and thence left
it to be inferred what were the risks involved; but
the determination of the relative frequency of these
dangers can only be made after prolonged investiga¬
tion. The severe changes excited ia the vicinity of the-
tubercle, as seen in cases of lupus and of laryngeal
tuberculosis, are probably reproduced in lungs and brain,
producing cohclitions of acute swelling, hypera'mia, cedema,.
h;emorrhagic infiltration, leucocytal emigration, and, ]ater»
new formation of tissue. Then there is the question
whether Koch's method does not hasten disintegration pro¬
cesses. It might be affirmed positively that the remedy
does not excite any process which caunut occur apart fron>j
it. Apart from cases showing extreme increase of a.
phlegmonous process, all the changes induced are those
previously known as forms of inHammation or mortification.
But their progress ia hastened, so that in a couple of day£>
as much des1 ruction is brought about as might perhaps have
otherwise taken a month ; and under certain conditions this
is a great gain, for the more rapid removal of the noxious
matteia acts prophylactically against further infection of
neighbouring or remote parts. The “clearing up” of*
all'ected parts of the lungs noted by some observers is ex¬
plicable when the characters of catarrhal inflammation with
concomitant atelectasis and bronchial occlusion are borno
in mind. Fatty metamorphosis and the melting down or
the shrinking of the hepatised areas may conceivably ex¬
plain the improvement in physical signs; not to men ¬
tion the rarer concomitant of resolving fibrinous pneu¬
monia. So that the signs of “ clearing up ” aro
attribulable to the process of catarrhal hepatisation.
H itherto we have known nothing of a spontaneous resolutioib
of caseous hepatisation. When small, these foci may become-
encapsuled; when large, softer and excavate; but neither-
of these modes of “cure” will restore the respiratory,
capacity of the affected parts. No one has affirmed thair
Koch’s remedy acts favourably on indurative and encap-
Coogle
452 Thb Lancet,]
THE MIDWIVES’ REGISTRATION BILL.
[Feb. 21,1891.
suliDg processes; its action consists in hastening the
softening of caseous material. Herein lies the danger
arising from the swallowing or aspiration of the rapidly
softened products. So far, then, there was no evidence that ;
the bacilli ate killed and dissolved; no direct facts to prove
that the remedy causes resolution of the true tubercular
tissue or the absorption of tubercle as such. Then
there was ample evidence that the tubercle as well as
the inflammation is rapidly destroyed, thereby warranting
a possibility of a relatively early cure. But there is no
iact showing that induration and the encapsuling of
caseous parts are favoured; rather is it that the remedy
liberates masses previously encapsuled, and in that way
converts an apparently harmless focus into a source
of actual danger to the patient. Professor Virchow
■expressed the nope that the facts be had adduced might
lead to more deflnite ideas as to the indications for the
remedy, and the rejection of such cases as were manifestly
unsuitable. He was far from considering these experiments
*3 closed. He recognised with pleasure that it was highly
Important that such researches as had been related by
Dr. Fiatau should be pursued to determine if a true
absorption occurs. It would be a wonderful thing if the
'tubercles evoked by Koch’s remedy should also be made to
disappear by its action. It was not impossible; but yet
when we see the thousands of miliary tubercles in the
bodies of those who had been injected (tubercles which
some thought were all present before the injections) it is
■difiicult to understand why tubercles arising in ordi¬
nary process of tuberculosis should escape, whilst those
recently arising should disintegrate. It was important to
know whether these “new tubercles” underwent any
■change spontaneously, whether, if the injectionui^e not
continuea, they would increase in size, or what wolllplhappen
to them. -S
Dr. Flatau explained that the ideas about the cure of
tubercle of mucous membrane were not bis own, aad that in
the case he related the treatment bad been susp^Bed for a
^fortnight without any change beyond further outbreak, as
related.
THE MIDWIVES’ EEGISTRATION BILL.
DEPUTATION TO THE LORD PRESIDENT OF THE
COUNCIL.
A DEPUTATION Consisting of about 100 representatives of
corporations and medical societies was introduced to Lord
■Cranbrook by the Attorney General for Ireland, for the
purpose of protesting against the Midwives’ Registration
Bill now before Parliament, and down for the second
reading on March 3rd.
Mr. Croly, representing the Royal College of Surgeons
in Ireland, pointed out that the Council of that College
would be quite willing to accept the Bill if adequate
.guarantees of education and competency were given. Tlie
training of midwives in Ireland bad always been conducted
with great care. The proposal to register all mid wives now
in practice was altogether objectionable. They ought to be
ffiiade to show that they have been properly trained ; and
this was more important, inasmuch as the limitation to
cases of “natural labour” was quite impracticable. In
Ireland no person was recognised as a midwife without six
months’ training in a lying-in hospital and a subsequent
■examination.
The Lord President. —I observe that in this Bill Scotland
And Ireland, except where expressly provided for, would not
be affected by the Act.
Mr. Croly continued that it was very important that
mid wives trained in Ireland should be put upon the English
Roister without any further testa.
The Lord President. —Yes, and that is provided for in
<flau6e 8 of the Bill.
Mr. Croly submitted that it was impracticable to entrust
to separate County Councils or boards of guardians the
■examination and registration of mid wives.
Dr. Macnaughton Jones, representing the Royal Uni¬
versity of Ireland, large numbers of the graduates of which
were practising in England, said they opposed the Bill on
the ground that it contained so many elements ^ danger
that it was incapable of being satisfactorily aOBended in
committee. It was an effort to legislate for aniDziknown
quantity, and it did not attempt at any definition saving
in one clause, where it refers to the midwife restricting
herself to cases of “natural labour” only. Scientific
obstetricians could not agree on this point. The BUI gave
the women permission to attend that form of labour
in which more than any other unskilled and uncalled-for in¬
terference imperilled the life of the offspring, and converted
a perfectly safe case into one of considerable danger
and difficulty. Legislation should take the form rather
of securing for the public a high type of obstetric nurse,
than in stereotyping and perpetuating an old and inferior
grade of midwife. Not the least dangerous part of the Bill
was that which qualified every existing “ Gamp” who chooses
to call herself a midwife to be registered without conforming
with educational regulations and examination tests. If
they could not do so, they ought to remain monthly nurses.
The Bill did not define the duties of a midwife, or her
responaibility in regard to puerperal septicrcmia or the con¬
veying of infection, and attached no penalty for neglect on
the part of a midwife to call in skilled assistance at the
proper time. The Bill contained inherent evidence of its
having been drafted for a class without due regard to the
interests or safety of the public.
Dr. Jacob, secretary to the Council of the Royal College
of Surgeons in Ireland, pointed out that it would be per¬
missible for incompetent women who were placed on the
Register to come to Ireland, where a high standard of
education bad always been maintained, and practise mid¬
wifery. They dreaded that a similar thing would happen
which occurred on the passing of the Dentists Registration
Act, in consequence of which 4700 persona were admitted
to the Register, the large majority of whom were not
dentists in any sense of the word, and there they remained
till the present day. They felt apprehensive that a similar
course would be followed in the case of midwives, and the
public for the next twenty-five or thirty years would be
preyed upon by a large number of incompetent persons who
had been annexed under this Bill simply by signing a paper
stating that tney were bond-fide practitioners of midwifery.
He was authorised by the Apothecaries’ Society of Ireland
to state that in their opinion “ no amending would make the
present Bill tolerable.”
Dr. Gilbart Smith, President of the Irish Schools and
Graduates’ Association, pointed out that, from the point of
view of an ordinary physician, labour often became com¬
plicated from obscure organic disease, such as Bright’s
disease, and ib would hardly be fair to leave the decision of
such questions in the hands of a woman qualified by only a
few months’ training. The question had been discussed at
a meeting of tlie Fellows of the Royal College of Physicians,
and a committee had been appointed to inquire into the
Bill, and there was no reason to believe that they would
report in any direction but that of opposition to the Bill.
He firmly believed that the beat interests of the public and
of the profession would be served by setting aside the present
Bill.
Dr. Rentoul said that the Medical Act of 1880 required
tho.se who practised midwifery to possess a qualification in
medicine and surgery as well. This Bill was an endeavour
to break through the spirit of that Act. The General
Medical Council had laid it down that a student must study
for at least five years, and fixes the minimum of knowledge
which ib was necessary for him to possess. This Bill wanted to
educate the midwife in a few weeks or months, and enable
her to claim fees in a court of law for all “natural labours”—
that is, 91)0 out of every 1000 cases. The Bill could not
make it penal if midwives attended abnormal cases, and it
followed that the midwife ought to be competent to
undertake cases in whicii delay threatened the life of the
mother or infant. Under these circumstances she would
require a full and complete training. In 1888 the report of
the Registrar-General stated that 4100 died from “ the
accidents of childbed,” most of whom lost their lives from
complications arising from diseases of the heart, kidneys,
or lungs. The midwife was not able to recognise these
diseased conditions. Further, 30 per cent, of total
blindness which affects persons in tnis country is due
to infantile ophthalmia. There were not at present
sufficient cases to supply both the medical student and
the pupil midwife in midwifery. At the last session of
the Council Dr. Glover moved that the minimum number of
cases for each student should be thirty. To supply this
number of cases to that number of students would require
61,990 cases. The voluntary medical charities gave relief
The Lancet,]
PUBLIC HEALTH AND THE LAND QUESTION.
[Feb. 21, 1891. 45^
to 60,790 Ivlng-in women. If both atudent and pupil mid¬
wife must W trained, then the deplorable a)i5tem which at
present exists in Liverpool, where the medical student
and the pupil midwife attend the same cose, or it would
lead to that very grave state of affairs where several
students go in a body to attend the one case. And
by repeated examinations aggravate the sufferings of the
women. He was afraid that in future the medic^ student
might have to receive his practical education in obstetrics
from a midwife. He urged, further, that it might lead
to increase in the number of stillbirths. The promoters
of the Bill urged that there were about 15,000 midwives
practising in England. He questioned if there were 1000
certificated midwives. The last census showed only 3000
who wrote “ midwife ” after their names. He submitted
that the poor did not require such treatment. The Poor
Law aids something like 10,000 lying-in women yearly; the
voluntary medical charities relieve 50,790. There were,
farther, the providentand semi-provident dispensaries, and,
lastly, over 24,000 doctors, many of whom were willing to
go out for a confiuement fee varying from 7s. Qd. to 15s. He
urged that this Bill should be opposed.
Dr. Mansell Moullin then addressed his lordship on
the statistics connected with the practice of midwives.
Mr. J. E. Dunn, representing the Preston Medico-
Ethical Society, suggested that a select committee should
be appointed to consider the whole matter, and that evi¬
dence should be taken from those persons directly con¬
versant with the wants and requirements of the people.
Dr. Lovell Drage of Hatfield took exception to the
action of the Obstetrical Society in this matter. It was
composed of 700 gentlemen more or less interested in the
science of midwifery, but the council was practically self¬
elective. This subject had never been before the Society
until last week, when the council had it forced upon them.
By postcard it had been ascertained that out of the 700
members, only 151 were actually in favour of the Bill;
while 185 had expressed themselves as against it, G were un¬
decided, 17 in favour of the principle of registration, but
objected to the Bill for various causes ; 21 considered three
months’ education insuliicient and preferred a longer period.
At the debate which had recently taken place on the
subject the council had not brought forward a single fact
or figure to show that there was any necessity for legislation
whatever, and for his own part he knew of none. He
believed, from considerable experience in the subject, that no
rules which human ingenuity could provide would ever
keep one of these uneducated women in her proper sphere.
Dr. C. Illingworth, representing the Blackburn dis¬
trict, maintained that the poor were quite able to pay the
moderate fees demanded by young practitioners. In cases
of inability the Poor-law medical officer was always ready
to attend to the mother.
Mr. Percy Dunn read letters from Mr. Braxton Hicks
and other coroners, stating that they had instructed
registrars of deaths to forward to him all midwives’ certifi¬
cates of stillbirths in order that theraatter may be inquired
into. They were of opinion that if midwives wereregistered,
stillbirths should also be registered.
The Lord President of the Council was obliged for the
fulness with which the matter had been brought before him.
They were quite aware that this was not a Government
Bill. It was a private membet’sBill, forwliichtbe Govern¬
ment was not responsible, and he presumed that in addressing
him on the subject they did so on account of his having
some connexion with the General Medical Council, and, as
siieh, he was supposed to have some interest in the matter,
and the Privy Council became an important functionary
under this Bill. At the sanie time there was no Govern¬
ment support to the Bill at present. He was a little puzzled,
he frankly owned, as to the speeches of some of the members
who had addressed him. Dilferences of opinion existed.
On the one hand, the gentleman who had addressed him
first spoke witli some pride of the examinations which take
place in Ireland, and that it was an advantage tliat such
should be tlie case. On the other hand. Dr. Rentoulwas
rather for ending the niidwives than for mending them. In
Ireland they seemed to have the idea of mending them.
Dr. Bentoui said that unless they became medical prac¬
titioners under the Medical Act, and qualified in medicine
and surgery as well as in midwifery, they should not be
taken any notice of, and he understood from that that
he would rather that things were left as they were,
and that midwives should not be recognised in anyway.
He understood that now there was no woman in the country
who could not set up a midwife’s establishment; there wa»
no restriction on the part of law or any educational qualifi¬
cation to hinder her from setting up a midwifery businesa
without any inquiry whatever. So far as the present state
of things was concerned he could quite understand that
many persons might suppose that it would be an advantage
to give some education, even a smaller education, that
would make more efficient those who could practise
now, whether they were educated or not. However,
what he gathered generally was that they entirely
condemned this BUI, and that some of them were
in favour of a general inquiry into the subject of
midwifery in this country, whether in connexion with
a Bill or not, or for a general inquiry upon the whole
question before any Bill was introduced at all. That wae
a matter for crave consideration. Parliament was nob
very fond of taKing up subjects in that sort of way without
some pressure of immediate legislation, and so far as be
was concerned there, he certainly, after heating the powerful
arguments which had been placed before him on the part
of the profession, would say that, at any rate, he should
defer offering any support to the Bill on the present occa¬
sion, and he might moreover say on the part of the Govern¬
ment that they would not support it.
After thanking his lordship the deputation then withdrew.
PUBLIC HEALTH AND THE LAND QUESTION.
A lecture delivered by Dr. George Homan, Secretary of
the Missouri State Board of Health, Professor of Hygiene
and Forensic Medicine at the St. Louis Medical College, on
Public Health and the Land Question, has been published
and circulated broadcast. It is an eloquent appeal in favour
of land nationalisation as the best means of putting an end
to the overcrowding and to the slums and rookeries that are
a danger and a disgrace to the great towns and industrial
centres of the civilised world. While leaving to political
economists and to politicians the task of meeting the claim,
pressed forward daily with more and more energy, in favour
of land nationalisation, we may at least say that medical
men, by reason of the practical experience they acquire
while ministering to the needs of the sick poor, are espe¬
cially fitted to discQss these grave social problems. Indeed,
if we study the composition of the various parliaments of
Europe, we shall find that among the most advanced and
the most energetic social reformers an exceptionally large
proportion belong to the medical profession. Dr. Homan
commences his lecture by quoting the saying of the Indian
chieftain : “ The sun is my father; the earth is my mother;
I will repose on her bosom.” And then goes on to recall
the classic legend of Antrous, son of the sea and the
earth, who, when felled in conflict, at once received new
strength each time he laid prostrate on the earth.
From these legends Dr. Homan claims for every human
being hia share of mother earth, and argues that, by the
monopolies of what natural laws intended as the property
of all, we have created the unnatural overcrowding of our
great cities, with all the attending evils that this begets.
Leaving Dr. Homan to fight out this theory as best he may,
we would cordially endorse hia strong protest against the
overcrowding of the tenement-houses in the great cities of
America. Even in the Far West, at St. Louis, the death-
rate of children under five years is equal to -10 per cent, of
the total mortality. Yet Sc. Louis boasts of being one of
the healthiest towns of its size tliat exist. If we go east
bo the larger cities, we find a mueh worse state of affairs.
This, for instance, is what the Rev. F. D. Huntington,
Bishop of New York, says about the commercial capital of
the United States :—
“A civilisation which overtasks or underpays wage¬
workers in order to add supetfluous allhienco and irre¬
sponsible power to the estates of a few; which helps a
hundredth part of the population to own half of the pro¬
perty; which exposes innumerable women bo moral ruin
for a living; which drives pale and emaciated and rickety
children daily from pestilential tenements bo factories and
mines; which countenances an owner of real estate who has
pocketed 4,000,000 dole, by the rental of four nests of misery
and dens of vice live storeys high; which lets 15,000
Google
454 The Lancet,]
PHOTOGRAPHING IN COLOURS.
[Per. 21,1891.
children die within a year after they were born in these
cellars and garrets, without uttering a sound of indigna¬
tion or alarm; which robs the citizen of his independence
and manliness, enslaving him by fear or want to a landlord
or employer; which increases the rate of suicide and in¬
sanity every year,—this, truly, is nob a civilisation for any
conscientious, thinking man to be proud of.”
Dr. Homan remarks that among these crowded and
oppressed populations a very high birth-rate prevails. This
he attributes to an effort on the part of nature to meet the
enormous waste of life so that a margin may remain to pre¬
vent complete extinction j but he protests that the vital
and moral quality of oflspring thus produced gravely en-
•danger society. Tenement districts are known to police
officials as nurseries of crime, as they are known
to sanitary authorities as breeding-places of disease.
“ Those who do not perish early in life only live to
become stunted, and crippled, and deformed in body or
in mind, or both, and usually, sooner or later, become
inmates of hospitals, reformatories, poorhouses, or
prisons.” Very truly, the lecturer goes on to complain
that some degree of alarm and spasmodic activity in the
way of arrest and prevention is occasionally manifested
when cholera seems to be marching round the world, or
Oriental plague breaks out in Russia, or some other epidemic
menaces public health. But the influence of such epidemics
on the general death-rate is really insignlBcant “when com-
ared with the eternal gnawing at the population, at the
one and sinew, b^ diseases that are domesticated in all
civilised lands mainly through the existence of conditions
contraband alike of the common health, the common safety,
common justice, and common humanity.”
Dr. Homan then repeats what has so often been demon¬
strated before—namely, that these overcrowded districts
are foci of epidemic disease which cannot be stamped out,
but which will spread from the poor to the rich. He then
eloquently urges:—
“ It is well that breaches of natural laws bring their own
(punishment, be it slow or swift, as the case may be; that
the superstition which would lean on miraculous power to
stay the march of disease flDdB scant support to-day; that
water will wet and fire will burn those who fall into them ;
that faith can stop neither bullets nor bacteria; that if we
•continually grow and sow the seeds of disease and death we
shdl j'ust as surely reap the appointed harvest, for in no
other way, perhaps, can the blind and selfish greed of man
be taught the exceeding gain of justice and fairness, the
profit of right doing to all.’’
PHOTOGRAPHING IN COLOURS.
The invention which has recently been announced from
Paris, of a method of communicating colour to a sensitive
photographic film by the action of a ray of coloured light,
will, if confirmed, awaken very widespread interest, for it
is impossible to foresee all the applications to which such
a discovery might be expected eventually to lend itself.
The idea is credited to M. Lipmann, a professor of the
Sorbonne and a physicist whose name is already widely
and favourably known in connexion with some highly in¬
genious instruments of physical research. The theory
which he is said to have successfully embodied in ex¬
periment is that the interference of two rays of light
■of the same wave length may be caused to produce a
characteristic eliectupou a sensitive film such as amounts to
dyeing the film of the particular hue in question. So far as
has at present been explained, the process appears to depend
upon the doctrine that the chemical action, like thechromatic
properties, of a ray of light is capable of being affected by
the conditions which give rise to the phenomena of inter¬
ference. In itself tins seems likely enough. It is well
known that if two rays of light having the same wave
length travel along the same path simultaneously, they
interfere with one another. It may and does happen that
at certain points along the path, depending for their position
on the wave length, the two impulses tend to counteract
and at other points to reinforce one another. A luminiferous
particle—whatever that may be—which is acted upon by
two opposing forces will remain at rest if the forces are equal
as well as opposite; while if the forces be not equal or not
directly opposed, there will be some resulting disturbance,
but still a disturbancedilferent from that which would have
been produced by either of the coincident forces acting alone.
From this cause arise all those beautiful optical effects of
interference which so strikingly illustrate the undulatory
theory of light. Now, if it be a fact that the chemical
activity of a ray of light Is subject to the same law, and
can be either exalted or depressed by causing a second ray
of the same wave length to act upon the sensitive reagent,
it is quite conceivable that a pair of . rays of light might be
so directed through a photographic film as to cause, not a
uniform, but a sporadic deposit of the precipitated element.
These minute deposits would in that case be distributed at
definite distances apart along the line of the common path
of the active rays, because they would mark the points of
cooperating and therefore exalted activity. Similarly, their
intervals would occupy the spaces in which the antagonism
of the two rays had reduced or even destroyed the actinic
effect. Now such a film would apparently be opaque to
any light not having this particular wave length, because
at some point it would necessarily be absorbed by the
opague deposit. But if a ray of the same wave length
impinged, it might be able to pick its way successfully
between the deposits. Professor Lipmann is said to have
produced such a film by the expedient of placing a
mirror at the back of his sensitive plate and causing the
focused ray to return along its own path. The mirror is
produced by making tbe plate one side of a mercury
trough, which when tilled constitutes a mirror in exactly
the desired position. The expedient, if successful, is cer¬
tainly charmingly simple, and, seeing that the healing art
would undoubtedly benefit in as high a degree as any by a
practicable system of chromatic photography, we look with
lively interest for some further information upon the theory
and practice so ingeniously originated.
VIRCHOW TESTIMONIAL FUND.
The following is the list of the committee of the above
Fund :—
Henry W. Acland (Oxford), Tb. Clifford Allbutt, John
Banks (Dublin), W. Mitchell Banka (Liverpool), H. G.
Barling (Birmingham), A. Barron, M.B. (Liverpool), H. C.
Bastian, Wm. Bowman, J. S. Briatowe, W. H. Broadbent,
Th. Lauder Brunton (treasurer), Th. Bryant, H. T. Butlin,
J. Cliiene (Edinburgh), Andrew Clark, J. Coats (Glasgow),
S. Coupland, J. Dreschfeld (Manchester), Dyce Duckworth,
John Evans, Josepli Fayrer. D. Ferrier, W. II. Flower,
M. Foster (Cambridge), W. T. Gairclner (Glasgow), Alfred
Garrod, W. S. Greenfield (Edinburgh), F, de Havillimd Hall,
D. S. Hamilton (Aberdeen), T. Holmes, O. M. Humphry
(Cambridge), J. Hutchinson, J. Hugblings Jackson, William
Jenner, George Johnson, Joseph Lister, William MacCormac,
Til. Oliver (Newcastle-on-Tyne), W. M. Ord, Richard
Quain, George Paget (Cambridge), James Paget (chairman),
F. W. Pavy, George Porter (Dublin), 11. Douglas Powell,
J. Russell Reynolds, William Roberts, Ch. S. Roy (Cam¬
bridge), T. Bnrdon Sanderson (Oxford), E. A. Schiifer,
S. G. Shattock, John Simon, A. R. Simpson (Edinburgh),
E. M. Skerritt (Clifton, Bristol), Th. Grainger Stewart
(Edinburgh), William Stokes (Dublin), Octavius Sfcurges,
Th. Pridgin Tealc (Leeds), William Turner (Edinburgh),
Hermann Weber, Spencer Wells, C. S. Wheelhouse (Leeds),
Samuel Wilks, A. H. Young (Manchester).
The following additional subscriptions have been received:
£
A.
d.
£
rf.
Sir William .Tennor, Jl.arfc.
2
2
0
. Sir .Tolin llanlcH, M.D. ..
2
2
0
•Sir Wm. ilowinan, Jlait.
2
2
0
0. (i, Wlioolliouso,
Sir William Rnliurls.M.D.
2
2
0
F.H.US.
2
2
0
Willifim Giiinlnor, M.JJ.
2
2
0
W. Broailbent, M.D. ..
2
2
0
Anirol Moiiev. M.l).
1
1
0
S. Wilka, M.D.
1
1
»
Adolf Hi'otiiior, M.D.
].
1
ri 1
C. Tlioodore Williatn.a,
Hilton 1‘oilartl. M.l). ,.
1
1
0 1
M.D.
?.
2
0
J'. E. Karkook, M.U.O.S.
0
H)
(1 :
Ro'xsrtW. Pliilip, M.D...
1
1
0
Heinrich I'ort, M.l).
2
2
0 :
K.deHaviUam! Hall,M.D.
1
1
(1
A.l!a)Ton,M.B.,M.ft.C.S.
2
2
D
Percy Hifld, M.D.
1
1
0
W. Kwart, M.D.
2
2
0
Cliarles Coatos, M.D. ..
2
2
(1
K. ClifYonl Bcalo, M.IJ...
1
1
0
Octavius SUirgea, M.B. ..
1
1
0
Southern Hospital New Nurses’ Home.— Last
Saturday afternoon the ceremony of opening the Norses’
Home attached to the Southern Hospital was performed by
Mrs. G. H. Horsfall, in the presence of a large and distin¬
guished company.
hy C lOO^Ic
Thb Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Feb. 21, 1891. 455
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6321 births
and 3818 deaths were registered during the week ending
Feb. Hbb. The annual rate of mortality in these towns,
which had steadily declined from 287 to 19'8 per 1000
in the preceding six weeks, was last week 19'9. The
rate was 19'4 in London and 20'3 in the twenty-seven pro¬
vincial towns. During the past six weeks of the
current quarter the death-rate in the twenty-eight towns
averaged 23'8 per 1000, and exceeded by 0'5 the mean rate
in the corresponding periods of the ten years 1881-90. The
lowest rates in these towns last week were 14*2 in Leicester,
15‘6 in Portsmouth, 16'1 in Wolverhampton, and 16'3 in
Halifax; the highest rates were 25‘3 in Ca»diif and in Black¬
burn, 25 8 in Derby, and 28'5 in Preston. The deaths referred
to the principal zymotic diseases, which had declined
from 404 to 332 in the preceding three weeks, rose again last
week to 340; they included 93 from whooping-cough, 77
from measles, 52 from scarlet fever, .50 from diphtheria,
36 from diarrhcca, 32 from “fever” (principally enteric),
and not one from small-pox. The lowest rates from these
zymotic diseases were recorded in Portsmouth, Cardiff,
Derby, and Oldham; and the highest in Plymouth,
Blackburn, Preston, Salford, and Huddersfield. The
S eatest mortality from measles occurred in Brighton,
aiifax, Huddersfield, Blackburn, and Bristol; from scarlet
fever in Plymouth, I’reston, and Bradford; and from
whooping-cough in Salford, Plymouth, Birkenhead, and
Huddersfield. The mortality from “fever” showed no
marked excess in any of the large towns. The 50
deaths from diphtheria included 29 in London, 4 in Shef¬
field, 3 in Manchester, and 3 in Salford. No death from
small-pox was registered in any of the twenty-eight towns,
and no small-pox patients were under treatment in the
Metropolitan Asylum Hospitals on Saturday last. The
number of scarlet fever patients in the Metropolitan
Asylum Hospitals and in the London Fever Hospital at
the end of the week was 1310, and showed a further decline
from reftent weekly numbers; the patients admitted during
the week were 97, against 112 and 107 in the preceding
two weeks. The deaths referred to diseases of the re¬
spiratory organs in London, which had declined from 1018
to 428 in the preceding four weeks, rose again last week
to 484, but were 42 belo w the corrected average. The causes
of 70, or 1'8 per cent., of the deaths in the twenty-eight
towns were not certified either by a registered medical
ractitioner or by a coroner. All the causes of death were
uly certified in Norwich, Bradford, Newcastle-upon-Tyne,
and in three smaller towns. The largest proportions of un¬
certified deaths were recorded in Shellield, Liverpool, and
Salford.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had been 26'4 and 2r9 per 1000 in the pre¬
ceding two weeks, further declined to 21’4 during the week
ending Feb. 14th, but exceeded by 1-5 the rate that pre¬
vailed during the same period in the twenty-eight large
English towns. The rates in the eight Scot^ towns
ranged from ll'O in Greenock and 12-3 in Perth to 21-I
in Edinburgh and 26'0 in Glasgow. The 561 deaths in thefo
eight towns showed a decline of 13 from the number in
the preceding week, and included 13 which were referred
to whooping-cough, 11 to diarrhcca, 10 to measles, 0 to scarlet
fever, 6 to “fever,” 4 to diphtheria, and not one to small¬
pox, In all, 50 death.s resulted from these principal
zymotic diseases, against numbers declining from 70 to 57
in the preceding three weeks. These 50 deaths were
equal to an annual rate of 1-9 per 1000, which slightly
exceeded tlie mean rate last week from tlie same diseases
in the twenty-eight English towns. The fatal coses of
whooping-cough, which had been 29 oucl 17 in the preceding
two weeks, further declined last week to 13, of which 5
occurred in Glasgow and 4 in Edinburgh. The 11 deaths
from diarrhcca exceeded those recorded in any recent week,
and included 7 in (iiasgow. The fatal cases of measles,
which had been 8 and 6 in the previous two weeks, rose
again to 10 last week, of which 6 occurred in Paisley and
4 in Glasgow. The 6 deaths from scarlet fever corresponded
with the number in the previous week, and included 3 in
Glasgow and 3 in Edinburgh. The 0 fatal cases of “ fever ”
showed a decline of 3 from the number in the preceding
week t 3 occurred in Dundee. The 4 deaths from diphtheria
were fewer thai in any previous week of this year, and in¬
cluded 3 m Glasgow. The deaths referred to diseases of
the respiratory organs in these towns, which had declineci
from 228 to 161 in the preceding four weeks, further fell
last week to 138, and were 57 below the number in the
correspejnding week of last year. The causes of 61, or
more than 9 per cent., of the deaths in the eight towns
last week were not cerciiied.
HEALTH OF DUBLIN.
The death-rate in Dublin, which had declined in the
preceding three weeks from 38‘4 to 26-6 per 1000, rose agaiik
to 26 "9 during the week ending Feb. 14th. During the first
six weeks of the current quarter the death-rate in the city
averaged 32'9 per 1000, the rate for the same period being
241 in London and 21‘0 in Edinburgh. The 182 deaths
in Dublin showed a slight increase upon the number in the
preceding week, and included 2 which resulted from “fever,
1 from diphtheria, and not one either from smallpox,
measles, scarlet fever, whooping-cough, or diarrhoea. Thus
the deaths referred to the principal zymotic diseases, which
had been 6 and 7 in the preceding two weeks, declined again
to 3 last week, a smaller number than has been registered in
any week on record; they were equal to 0‘4 per 1000, the rate
from the same diseases being 1'4 in London and 2'3 in
Edinburgh. The fatal cases of “fever,” which had been
5, 4, and 3 in the preceding three weeks, further declined
to 2 last week, and were fewer than in any week since
November last. One death resulted from diphtheria,
corveapondiag with the number in each of the previous two
weeks. The 182 deaths in Dublin last week included
28 of infants under one year of age and 68 of persons aged
upwards of sixty years; the deaths of infants showed a
further decline from those recorded in recent weeks, whil^
those of elderly persons showed an increase. Two inquest
cases and 1 death from violence were registered; and 6S,
or more than a third, of the deaths occurred in public
institutions. The causes of 12, or nearly 7 per cent., of
the deaths in the city were not certified.
THE SERVICES.
Army Medical Staff.— Brigade Surgeon Geo. Elmsiy
Will to be Deputy Surgeon-General, ranking as Colonel,
viceC. G. Irwin, M.B., placed on retired pay (dated Jan. 4tb,
1891); Surgeon-Major Robert Collins, M.B., ranking ns-
Lieutenant-Colonel, to be Brigade Surgeon, vice G. E. Will
(dated Jan. 4th. 1891); Surgeon William Parsons Feltham
to be Surgeon-Major, ranking as Major (dated Jan. 29tb,
1891).
Bengal Medical Establishment.— Surgeon George
Augustus Cones to be Surgeon-Major (dated Dec. 13th,
1890).
Indian Army.—T he Queen has approved of the restora¬
tion of the undermentioned Ollicer from the half-pay list to
the elfective list: Surgeon Major David John McCarthy,
M. D., Madras Medical Establishment (dated Dec. Otii,
1890).—The Queen has also approved of the retirement front
the Service of the undermentioned OJIicer: Surgeon-Major
John Wilson Johnston, M, D., Bengal Medical Eatablisl>-
ment (dated Feb. 4th, 1891).
Naval Medical Service.— The following appointments
have been made at the Admiralty;—Fleet Surgeon Charles
C. Godding to the Ver-non (dated Feb. 14th, 1891); Staff
Surgeon John Wilson, M.A., M.D,, to Chatham Hospitai
(dated Feb. 14th, 1891); Surgeon E. A. Spiller, M.D., to the
Excellent, additional (dated Feb. 28th, 1891); Surgeon Jas.
Menary, M.D., to Jamaica Hospital, (dated Feb. 18th, 1891);
Surgeon James M. Rogers to the Drr/etif (undated); Mr. John
Arciiibald Macquarie to be Surgeon and Agent at Peel,
Isle of Man ; Mr. Henry Bell to be Surgeon and Agent aft
Bangor (county Down), Groomsporb, and Helen’s Bay(dateiS
Feb. 17th, 1891).
Volunteer Qov.vs.—I nfantry: Western Counties: Sur¬
geon nuri Suigeon-Major F. F. Lee, M.B., Ist Wiltshire
Rille Volunteer Corps, to be Brigade Surgeon, ranking aa
Lieutenant-Colonel (dated Feb. 18th, 1891). — Artillein:
3rd Kent (Royal Arsenal); Surgeon S. Davies, M.D., from
Digitized by i^ooQle
456 'I'HB Lancet,]
ENGLISH MEDICAL PRACTICE IN PARIS.
CFeb. 21,1891.
the Volunteer Medical Staff Corps (Woolwich Division)
to he Surgeon (dated Jan. 7th, 1891).—Ist Lanarkshire:
Acting Surgeon W. J. Shaw, M B., resigns his appointment
(dated Feb. 14th, 1891)—3rd Durham (Western Division,
Royal Artillery): Acting Surgeon W. Gowans to be Captain
(dated Feb. 14th, 1891)— RiHt,; 4bh Volunteer Battalion,
the Queen’s (Royal West Surrey Regiment): Acting Sur¬
geon T. Lyndon, M.D., to be Surgeon (dated Feb. 14th,
1891).—3rd Volunteer Battalion, the Royal Fusiliers (City
of London Regiment): Acting Surgeon E. G. Younger,
M.D., to be Surgeon (dated Feb. 14th, 1891).—24th Middle¬
sex: Acting Surgeon J. D. Grant, M.D., to be Surgeon
(dated Feb. 14th, 1891).
Volunteer Medical Staff Corps.— The Woolwich
Division: Alexander Stevenson Greenway, M.D., to be
Acting Surgeon, Supernumerary (dated Feb. 14th, 1891).
ditmspnkna.
“ Audi alteram partem,”
ENGLISH MEDICAL PRACTICE IN PARIS.
To the Editors of The Lancet.
Sirs, —An article which appeared in Galignani’s Mes¬
senger of the 27th ult., and which, as will be seen, deals
with a subject that directly interests the English travelling
public, has excited much comment in both lay and profes¬
sional circles in Paris. It has further served the purpose of
arousing Eoglish practitioners established in this city to a
sense of a duty, hitherto neglected, towards themselves and
towards their compatriots who, in their thousands, throng
the Boulevards of this gay capital during la belle saison.
The article runs as follows:—
“ Several cases have been again brought before our notice of English
and American visitors to I'aris, who, upon being taken ill, in second-
rate hotels or boarding-houses, have found, on tlie part of the proprie¬
tors or managers of thoir temporary resting-places, an extraordinary
ignorance os to the residence or even existence of physicians of the same
nationality as thoir guests, Some of these cases have been of so flagrant
a character that tliey would lead to the belief that the managers recom¬
mend a certain class of French doctors ‘for a consideration.' We say
a certain class, because there are Frencli medical celebrities to consult
whom would be well wortli a long voyage. But these are not men
at all likely to lend themselves to the abuses complained of. The
misfortune, therefore, is geneiully that of the sick person, .although
the fault may be somewhat that of tlio English and American
physicians. In England, we all know it i.s coiisi<iorod infra din.
for medical men to advertise themselves. That mle does no h-artn in
England, where people have frecpient recourse to an authentic medical
directory or to the recommendation of reliable friends. But in Paris,
where the population i.s as cliangeablo as that of a largo hotel, it would
appear that the medical men would lose none of their dignity were they
lo find some means of advertising, at least, their names and addresses
with their authenticated degrees, and, when such is the case, tlie speci.al
branch of medicine to which they devote their attention. Medical men
are too often looked upon as pevsonswlio are obliged to attend anybody
who demands their care, and tho :'0 is probably no body of professional
men who render so much gratuitous service to their fellows in such an
unostentatious way. Still, they jiave to live by their profession ju-»t as
have lawyers and priests. Surely tliey might well bo allowed to ad'verti.so
in this great caravanserai, especially as the facts set before the tiavolling
public would be for the public bemeflt."
The above remarks, emanating as they do from the
recognised organ of the English colony in Paris, and from a
journal which has, moreover, repeatedly rendered yeoman
service in warning travellers against that pest, the “hotel
doctor,” merit something more than a passing consideration.
Acknowledging, with the rest of my colleague?, the truth
of the facts stated, I have felt it my duty to bring the
matter to the notice of my professional brethren, with a
view of bringing about some combined action to remedy the
evils complained of. Travellers little dream of the existence
of the occult arrangements that too often hamper them in
their choice of a medical attendant. Rightly or wrongly,
the average ailing Briton prefers to be attended by an
English practitioner, who, imbued with the traditional doc¬
trines of British schools of medicine, understands his habits,
tastes, and prejudices. But, even when the landlord con¬
sents to summon an English doctor, the independence of
the latter is too often fettered by conditions which are not
calculated to increase his self-respect, not to mention his
income. Thus, at a certaiu first-class hotel, the landlord,
to my knowledge, exacts from the unfortunate medico no
lees than 25 per cent, of the fees earned at bis establish¬
ment. Agaic, I have known of a gentleman staying at a
well-known hotel on the Boulevards, upon whom it was
unsucceEsfully attemp*'ed to foist the no doubt subsidising
hotel doctor, the practitioner whose services he had wished to
secure never having even received the message sent. Ana¬
logous instances could, doubtless, be multiplied ad infinitum.
Take, again, the chemist, on whom devolves very frequently
the choice, for a customer, of an English doctor. Of course,
the chemist cannot be debarred from exercising his right to
recommend any one practitioner. But when one of his
assistants, on being asked for the address of an English
doctor established in Paris for nearly twenty years, delibe¬
rately ignores his existence, I think it is time the public
should be made independent of such misleading information.
The facta being as above, I venture to ask you, Sirs, if
the periodical publication, in one or more respectable
journals, of a list of English doctors practising in Paris,
with their addresses and hours of consultation (the names
arranged alphabetically and no degrees or specialties men¬
tioned), would necessarily constitute a contravention of the
unwritten rule observed by all self-respecting members of
the profession forbidding advertising. Such a list would
prove of great service to English visitors to this city, and,
if made comprehensive, would not, in my opinion, come
under the head of advertising in the invidious acceptation
of the word.
I am, Sirs, your obedient servant,
Paris, Fel>. lOtli, 1801. ' J. H. BARNARD.
EMPYEMA OF THE ANTRUM.
To the Editors o/The Lancet.
Sirs, —Mr. Sewill has done good service by drawing
attention to the above subject. May I be permitted to
contribute my experience?
During the present session I have had several cases of
septic abscess of the antrum in my wards in the Edinburgh
Royal Infirmary. The following points I think are worthy
of note:—1. In every case the empyema was connected
with a diseased anterior molar. 2. In most of the cases the
anterior molars were not known to be the cause of the
empyema till they were extracted. The teeth were free
from caries, and were drawn simply in order that a free
drain might be established. When removed they were
found in every instance to have had suppuration at one or
more of their fangs, which were also protruding into the
antrum.
I consider that it is not sufficient to extract the tooth.
The opening left by the protruding fang is not large
enough for free drainage and washing out; I always
enlarge the opening considerably. This practice I learned
from Mr. G. W. Watson, dentist, of this city, and I con¬
sider it a very important part of the treatment. I make
my patients wash out the antrum themselves from their
mouths. They take a mouthful of boric lotion first and
rinse out the mouth. Then another mouthful is forced up
into the antrum and out by the nose, the process being con¬
tinued until the lotion flows clear. This manccuvre can be
learned after a little practice, and enables the patient to
wash out tlie antrum twenty times a day if necessary, with¬
out much trouble. I consider that the extraction of an
anterior molar gives a better drain than an opening above
tlie alveolar margin. The latter method I adopted on two
occasions at the request of a colleague, and in both cases
had to extract the tooth afterwards, and found it the appa¬
rent cause of the trouble. I think that no surgical treat¬
ment is required in abscess of the antrum, unless it becomes
septic or is due to a bad tooth.—I am, Sirs, yours obediently,
JCdinburgh, Feb. 14th, 1891. A. G. MiLLER,
To the Editors of The Lancet.
Sirs, —Those who have opportunities of studying the
disease which forms the subject of Mr. Sewill’a important
letter in your issue of the J4th inst. cannot but feel
indebted to him for bringing the matter before the notice
of the profession. I fully agree with him that the aifection
is often overlooked, and that not only by general prac¬
titioners, but by surgeons and specialists. I am the more
fully persuaded of this in that I question Mr. Sewill’s
statement tiiat dental disease is the commonest cause.
Not, Sirs, that I would doubt for a moment tbe recti¬
tude of his observations in his own cases. All that I
would maintain is that the large proportion of cases falling
M’itliin my own practice is associated with, and, as I
Digitized by Google
The Lanobt,]
THE CLIMATE OF GRASSE.
[Feb. 21, 1891. 457
believe, is secoDdary to, iotra-Dasal suppuration of one kind
or another. I am of opinion, moreover, that it is actually
the coexistence of nose disease, such as might be held to
account for all the symptoms, which has often prevented
any question arising as to a possible implication of the
antrum. Having diagnosed and treated upwards of forty
cases, I can affirm that of thefee only four were unassociated
with intra-nasal suppuration, the latter being generally
connected with ethmoidal disease. Many were operated
upen by my colleague, Mr. Leonard Matheson, who, I
believe, will be prepared to corroborate my statement as to
the rarity, in my cases, of tooth trouble which could be
considered responsible for the mischief. I must not
occupy more space by adducing further arguments, though
I may add that I have discussed the question fully in my
treatise on “Diseases of the Nose,” since the publication
of which I have become even more fully convinced of
the nasal origin of the larger number of cases. And in this
view I am supported by such authorities as Ziickerkandl,
Hartmann, Krause, Gougenheim, Baratoux, and others. I
most fully concur in Mr. Sewill’s remarks as to the treatment
of the affection ; yet I should like to suggest to him the
introduction of Ellis’s smallest sized spiral drainage-
tube, instead of the gold tube and supporting plate
advocated in his letter. Ellis’s tube fulfils every require-
cnent, is self-retaining, can be easily removed and replaced
by the patient, and may be prevented from slipping in too
far by uncoiling the termination of the wire. Mr. Matheson
finds this in every case efficient.
I am, Sirs, yours faithfully,
ilarloy-stieot, W., Feb. ICth, 1801. GrevilLE MacDoNALD.
THE CLIMATE OF GRASSE.
To the. Editors oj TiiE Lancet.
Sirs, —As Her Majesty the Queen is about to sojourn at
Grasse, some account of its climate and attractions may not
be uninterestiug to your readers. Towards the end of last
March, with the object of collecting information for my
freceut work, “Book of Climates,” second edition, I spent a
week exploring the country between Cannes and the moun¬
tains to the north and away to the Esterels which bound
the plain to the west, On ,tM8 plain, which for variety and
acenic beauty is not surpassed either at home or abroad,
and on the sunny slope of Mount llocavignon, at an eleva¬
tion of 1100 ft. above the sea, lies the picturesque, old-
fashioned, crooked, and crowded little city of Grasse. Rich
in historic and Napoleonic traditions, quiet and sequestered
lin situation, having great facilities for driving excursions,
and possessing lovely views, good water, and a pure and
'tonic air, Grasse has many attractions for those in need of
calm and repose. Beautiful roads lead in all directions, of
which that to Cesaire, nine miles to the west, and others
(in the neighbourhood, afford delightful views of the sea, and
is deserving of mention. The chief industry of the people,
of whom there are 12,000, is the distillation of the attar of
rose and Neroli perfumes, the llowers for which are grown
all over the district.
The climate is said to be colder than that of Cannes, which
is about 9° or 10° higher than London. It did not, however,
appear so to me, but the contrary. The heavy rain.s
sviiich generally occur in March had ceased, the trees were
bursting into leaf, and though there was a certain touch
of keenness in the air, there was no mistral, and the wind
was far lees felt than either at Cannes or Antibes. The
mistral often blows over the district in March. Having a
aunny aspect, and being well sheltered by mountains
close behind, I believe that in the daytime the climate
ils milder than that of Cannes, and the air more still. At
night, however, and when the sun goes down, the cold is
greater.
Grasse ought to have a future before it. There is a need
■for a resort differin" in many respects from the Rivierian
seaside stations, and yet possoasing all the sheltered sun¬
shine of this region. From these .stations it should afford
a pleasant change, especially when they are too exciting, or
amongst those bilious or dyspeptic folks to whose appetite
the sea-air is injurious.
Grasae should also be a good place for persons suffering from
•asthma, chronic pleurisy, chronic consumption, and heart
•disease, ■whocannotstand the winds of the coast, also for gouty
and lupoid cutaneous affections, rheumatism, and diabetes.
It is, however, such a dull place that all but the most con¬
scientious invalid would soon get tired of it. There are
two good and moderate hotels.
I am, Sira, your obedient servant,
D. H. CuLLiMORB, M.D., M.R.C.P.Lond.
WeUjeck-stveot, W., Feb. l!)tli, 1891.
“INTESTINAL IMPLANTATION AND LATERAL
APPOSITION.”
To the Editors of TuE Lancet.
Sirs,—M y thanks are due to my friend Mr. Reeves for
bis letter which appeared in last week’s issue of The
Lancet (page .396) on the above subject. It is only by
combined efforts that surgeons can hope to establish in this
country the importance of such operations as have been
taught by Professor Senn in America, the correctness of
whose conclusions I have confirmed. The difficulties of
establishing such operations as Prof. Senn and myself wish
to impress upon the profession are very great, and this must
be obvious, as the amount of material that falls to the lot
of one surgeon is comparatively small. It is only by acting
as Mr. Reeves has done that we may hope to decide if any
new operation of magnitude is worthy of the support of
the profession or not. These operations are now going
through the same stages as other great advances
in surgery have done before. It is not many years
since Sir Spencer Wells placed ovariotomy on a sound
and permanent footing. In the early days of this operation,
at a meeting of one of the societies ovariotomy was charac¬
terised as barbarous, and I believe the dire consequences
of the coroner’s inquiry were threatened to the surgeon
who should lose a patient after performing such an opera¬
tion. I am reminded by Dr. W. Duncan in last week’s
issue, page 395, that Sir Joseph Lister, when advocating
and practising opening the knee-joint in cases of chronic
inffammation in order to remove the diseased parts, a well-
known surgeon threatened, in the event of a fatal case
occurring, that the distinguished operator might find him¬
self in the dock on a criminal charge.
It was only in 1878 that the late Dr. Marion Sims
first performed cholecystotomy, and, although his case
ended fatally, yet the steps he laid down for its per¬
formance were so clear that now it is admitted to be
one of the most successful operations in surgery. The
different operations now so successfully practised upon the
kidney were, when first introduced to tlie profession,
looked upon with anything but favour, and it was
only by the enterprise of such men as Messrs. Morris and
Knowsley Thornton that they became thoroughly estab¬
lished. Mr. Reeves in bis letter says the onus of showing
the profession that the new intestinal operations are as
easily executed and safe in resul ts as already accepted means,
rests with Dr. Senn and myself. I am perfectly willing to
accept the Tesponsibiliby, but in the space of a letter it is
impossible to go further than to generalise, and difficult to
formulate evidence of the feasibility of operations on the
stomach and intestines by implantation, or lateral apposition
by means of approximation plates, t have now performed
five cases of gastro-enteroatomy by the latter method, four
for pyloric carcinoma, and one for fibrous stricture of the
pylorus. Threeof these made good recoveries, one (thefirst)
died five days after operation from exhaustion due to the
error of not feeding early enough (the operation in this case
was perfect, as shown by the pathological specimen which I
have), one case died of septic peritonitis directly the result
of the operation. Besides these, cases have been reported
by Dr. Clarke (Fluddersfield), Mr. Mayo Robson (Leeds),
Mr. Stanafield (Birkenhead), Mr. Beatson (Glasgow),
and others. Dr. Weir reports in the Medical News (N.Y.),
Dec. 14th, 1889, p. 663, eleven cases of gastro-enterostoray
with bub one death. The number of cases of ileo-colostomy
already reported are, I believe, limited to five. Two of
these are reported by Senn in the Journal of the American
Medical Association, ie.'ti. 14th, 1890. In these cases Senn
lierfornied resection of the ctecura for carcinoma, and
united the ileum to the colon below the seat of disease by
lateral apposition and bone plates ; he inverted and closed
the divided end of the colon. One of these cases recovered,
and the other died six days after the operation from peri¬
tonitis caused by deep ulcers of the excluded portion or ihe
colon. At the post-mortem examination he found the
coaptated parts 'with adjacent portion of the colon and
Coogle
453 Tab Lancet,] THE DEBATE ON TYPHLITIS AT THE CLINICAL SOCIETY.
[Fi b. 21. 189?.
ileum, tbo serous surfaces, which had been included
between the plates, firmly adherent throughout, and on
connecting a hydrant a large stream of water escaped from
the gut, showing thatthenewopeniogwas fully established,
and on closing the open end wf the colon the bowel was
forcibly distended without causing leakage, a positive proof
that union between the coaptated surfaces was perfect.
Mr. Burton (Liverpool) has communicated to me a case in
which he performed ileo-colostomy, at my suggestion, on a
atient who was suffering from a fmcal fistula opening
etween some portion of the small intestine and the vagina.
The operation was successfully performed by bringing into
api>osition a portion of the ileum with the colon by means of
bone plates. The case of ileo-colostomy reported by mo in
your last week’s issue I claim as a surgical success, and
the case which, through the courtesy of Mr. Reeves, I was
enabled to assist him in, and to which he alluded in his
letter, may also be quoted as one proving the practicability
and success attending ileo-colostomy by implantation.
I thoroughly endorse what Mr. Reeves states, “ihabopera-
tions and surgeons must be judged by results, and all opera¬
tions on the intestinal canal are no exception to this whole-
somerule”; and I ask my covfrCres to assist me in establishing
these operatioDsi which I most firmly believe will at no
distant date be acknowledged to be one of the greatest
boons to the human race, and among the most successful
operations in surgery, by giving me the opportunity of seeing
any cases of intestinal obstruction, either of an acute
form or the result of new growths, that may come under
their notice, aho any cases of f.-ecal fistula of an intractable
character. The number of successful cases of gastro¬
enterostomy, which is quite as difficult and dangerous an
operation as ileo-colostomy, or union of the small inte.stine
by lateral apposition, if not more so, should in my opinion
be sufficient to instil confidence in the minds of the pro¬
fession, and tend to justify them in advising their patients
who may be suffering from intestinal obstruction to seek
surgical aid of the description I have advocated.
I am. Sirs, yours faithfully,
Fred. Bowreman Jessett.
Upper Wimpole street, W., Fob. 14th, 1891.
THE DEBATE ON TYPHLITIS AT THE
CLINICAL SOCIETY.
To the Editors of The Lancet.
Sirs,—T he clumsiness of my remarks during the recent
discussion at the Clinical Society has, I understand, given
rise to some misconception as to my meaning, which I
should be glad if you would permit me to correct. I did
not intend to imply that I am opposed to operative inter¬
ference in the treatment of typhlitis. I have, indeed,
advocated this mode of treatment in a manner that may
have appeared to some to be even immoderate. There can
be no possible question as to the urgent need for the
surgeon’s knife in certain forms of the acute type of the
disease, and I have seen no cause to regret the
freedom with which I have employed this means. With
regard to the treatment of relapsing typhlitis by ex¬
cision of the appendix during a quiescent period, nothing
has occurred to alter the opinions I expressed upon that
point when I first introduced this method of dealing with
that affection in 1887- My list of cases is not small, nor have
the results been unsatisfactory. What, however, I wish
to protest against is the quiet’assumption that all cases of
typhlitis, and even those which are distinctly acute,
demand surgical treatment, and that in the majority of
instances at least medical measures avail little. 1 have
shown elsewhere that the majority of examples of what is
known as acute typhlitis end in recovery under simple
medical treatment, and that a surgical handling of the
trouble is only celled for in a comparatively few selected
cases, and that even in these it is possible to clamour for a too
early operation. There are cases of appendicitis and cases
of relapsing typhlitis which get well without the surgeon’s
aid, and I would urge that more discrimination'should be
exercised in selecting the cases which are suited for opera¬
tion. The almost reckless and injudicious manner in which,
to judge from published and private reports, the appendix
is being excised at the present day, is doing a great deal to
bring the operation into discredit, and to direct an adverse
criticism against wbat is in suitable cases a most valuable
and indeed indispensable measure. It would appear to be
rather among American than among English surgeons that
this epidemic is raging, and from the criticisms 1 have sub¬
mitted I would exempt the very admirable series of cases
upon which this particular debate is founded. Upon these
cases the authors of the papers are to be congratulated, and
I should be sorry if it were supposed that it is upon any of
these reports that I would found an objection to that dogma
which appears to consist of this one proposition—the patient
has typhlitis, therefore excise his appendix.
I am, Sirs, yours faithfully,
WimpoIo-.9ticet.W., Fob. 16th, 1831. FREDERICK TreveS,
“ERYSIPELAS AND TOTAL ABSTAINERS.’'
To the Editors of The Lancet.
Sirs,—I t would seem almost impossible to believe that
Staff Surgeon Whitehead can have been really serious in
inditing the letter on “Erysipelas and Total Abstainers”
in your last issue. If ever there was a case of building a
pyramid upside doum this is one. Because three abstainers
happen to have erysipelas at the same time we are asked to
conclude that their abstinence must be apredieposing cause,
and that it is detrimental both in hot and cold climates,
in the face of all the evidence which has been accumu¬
lated to the contrary. I would challenge Mr. Whitehead
to extend his observations and give us the result of the com¬
parative sickness of the abstainers and non abstainers in the
London garrison for a period of twelve months, or longer if
possible. Such comparisons liave been made in other
quarters. The days of sickness of the men in the abstain¬
ing friendly societies (Rechabite.'’ and Sons of Temperance)
is only from one-half to two-thiids of that of the Uddfellows
and Foresters (although these Include many abstainers).
Comparing 3978 abstainers and 8829 Eon-absbainers in
various regioients in the Indian Army in 1885-86, it was
found that the admissions to hospital were more than twice
as great among the non-abstainers; the proportion in.-
valided to the bills was 3-82 per cent, of the non abstainers,
and 1-88 per cent, of the abstainers; the proportion in¬
valided to England was 2-93 per cent, of the former
and 0'60.3 per cent, of the latter, the deaths per 1000
being 9'5 and 27 respectively. The results of the
insurance companies prove to demonstration that this
greater liability to disease results in a greater mortality
among the non-abstainers. Mr. Whitehead speaks of
the value of alcohol “as a heat-producing food.” Is
it possible that he is unaware that its invariable effect
is to reduce the temperature, and that practical men in cold
climates have found out that the colder it is the more in¬
jurious it is to take alcohol in any form ? It lowers the
vitality and renders the tissues more susceptible to the
hurtful effect of cold. The evidence is so overwhelming on
this point that it is superfluous to adduce it in detail. I
have been able to ffnd some explanation for this in the facs
that alcohol, even in minute proportions, depresses the
vital action of cell-protoplasm, while, on the other hand,
in the same minute quantities, it promotes the multi¬
plication and activity of bacilli. It will be found to
reduce the activity of phagocytes and increase that of their
antagonists. Its effect in promoting decomposition can be
easily proved by putting a few drops of meat-juice, bay
infusion, tartrate of ammonia, or anything which feeds
bacteria, into two bottles, one containing water only, the
other 1 part of alcohol to lOOO or oven 10,000 of water. The
latter will develop uwarms of bacteria more thickly and
more rapidly than the former. Whether or not this explains
the facts of the superior health and longevity of abstainers
(on the average, other things being the same) matters notj
the facts remain, and “winna ding.”
I am, Sirs, yours truly,
J. J. Ridge, M.D.,
lion. Soc., Brit. Mod. Tomporance Association.
Enfleltl, Feb. 16th, 1891.
THE TREATMENT OF CHRONIC DISEASE OP
THE UTERINE APPENDAGES.
To the Editors o/TiiE Lancet.
Sirs,—D uring the last two years I have watched the course
of five cases in which I was consulted because the patients had
been advised to have the uterine appendages removed, and
thought it well to have a second opinion before submitting
I Google
Tub Lancet,]
MEDICAL NOTES IN THE ISLE OF MAN.
[Feb. 21, 1891. 459
to the operation, and in which the patients got perfectly
well without any operation, two of them becoming pregnant.
This seems to me a large number to occur in the practice of
one physician, and luaKes me think that by some persons
too unfavourable a view is taken of the prospect of recovery
in cases of inflammation of the uterine appendages. I
believe that the great majority of such cases get quite well
without operation if properly treated. I do not think it
likely that ovaries will be again removed for cardiac
dyspncoa, and for this tire profession is much indebted to
.Dr. Braithwaite of Leeds for his courage and candour in
fully reporting the result of a case in which be did the
operation for this condition.—I am, Sirs, yours faithfully,
Harley-street, Feb. lOUi, 180t. G. ErNEST HERMAN.
THE PUPILAGE IN THE FIFTH YEAPv OF
MEDICAL EDUCATION.
To the Editors of The Lancet.
Sirs,—I beg to call your attention to a serious defect in
the new arrangement of the General Medical Council, under
which students may spend six months in the fifth year with
«, general practitioner. The serious defect is this, that no
provision is made for the registration of such modified
apprenticeship from the first day of its commencement.
The result of this omission will be fatal to a fair trial of the
new system, for practitioners will be found who will sign
certificates for apprenticeships never served. It is enough
■of a flaw, and one to which official attention must be called,
that an option is allowed to students to attend clinical
wards which the Medical Council’s visitors tell us are
already unable to supply adequate means for training, and
which in any case cannot supply the kind of training
contemplated by the modified apprenticeship system. I will
again appeal to the Privy Council on the whole subject.
I am, Sirs, yours truly,
Cashol, Feb. 12th, 1801. TUOMAS Laffan.
MEDICAL NOTES IN THE ISLE OF MAN.
By a Frequent Visitor.
The praises of the Isle of Man have been frequently
beard, and are both sung and said in prose and song.
Under the various names of Mona’s Isle {or more classically
Mona), Manxland, the Manx name “ Elian Vannin,” or the
cynical title of “Lilliput,” articles, chapters, songs, and even
hooks have been written. In spite of all this, it may yet
he doubted whether the island is even now as well known
as it should be as a desirable place of recreation for invalids
at all times of the year, and especially in winter. There
are, too, probably many persons who spend the winter in
some distant Continental resort, far from all the comforts
to which they have been accu.stoined, at great inconvenience
and expense to themselves, who would find all they want
in this charming island—a mild climate, beautiful coast and
aulaud scenery, all the comforts to which they have been
accustomed, and, should this bo required, skilled medical
attendance. The isolated character of this — like the
Channel or Scilly Islands, the Orkneys, Shetlands, or
Hebrides—places the reisident medical practitioners at
•a disadvantage, since they cannot meet their profes¬
sional brethren in such numbers and so frequently as those
■on the mainland, Where the whole number of medical men
only reaches that of a small provincial city, anything
like a medical society must be difficult to establish, and
still more so to maintain. But there are now nearly thirty
practitioners on the island, and if a medical society
could be established in Douglas, much valuable informa¬
tion respecting the medical history of the island, the
climate, its sanitation, the diseases most prevalent, &c.,
anight be collected and published for the benefit of the
(profession. _ The following notes are from one who during
the last thirty years has made many visits to the island,
■and has during that time—which comprises part of
the reign of Governor Hope and the whole of those of
Governors Loch and Walpole (the present governor)--seen
vast improvenrents made throughout the whole island. It
IS, indeed, difficult to identify Douglas, llamsoy, and Peel
their appearaDce.s of thirty years ago. Port Erin and
1 ort St, Mary are comparatively new places. Castletown has
not changed its appearance to the same extent, but consider¬
able improvements have been effected in it. At present it may
be well to note the more general features of medical interest
in the island at large. Its situation is too well known to
require notice here. Its proximity to Liverpool, Barrow,
Fleetwood, and Whitehaven make it the resort of “cheap
trippers ” from Lancashire, Cheshire, and all parts of the
kingdom. It has a short season, which generally includes
the months of July and August, with June or September
added, as the summer happens to be advanced or retarded.
It is this reputation of a cheap trip resort which has
deterred many persons, especially invalids, from going there.
But the great bulk of cheap trippers arrive on Saturday
and depart on Monday; those who stay during the week
limit their attention to the towns and more pronounced
show places, leaving the more rural parts quiet. But this
only applicj, as we have seen, to a very small proportion of
the year, and during the spring and autumn the island is a
most delightful and desirable place of residence, nob only
because of its climate, views, and accessibility, but also
because the cheap trippers are conspicuous by their absence.
During tlic winter, too, it may be resorted to with much
advantpge by those who require a milder climate than that
of England or Scotland at this season. Though so near to
Liverpool (seventy-two miles), and but little further north,
there is a most remarkable difference in the climate.
The climate is at once bracing and mild. Its insular
character makes all the coast as open to the sea
as the deck of a steamer or sailing vessel. Places
more inland, such as Union Mills, and Crosby near
Douglas, Kirk Andreas (near Ramsey), Ballaugh, Kirk
Michael, and Foxdale (near Peel), and the more sheltered
parts of Castletown, Peel, Douglas, Ramsey, Port Sb. Mary,
and Port Erin, enjoy a climate partly marine, partly rur^.
The coast scenery resembles that of Scotlana, all about
Kirk Michael resembles that of Derbyshire, while Glen
Helen, Sulby Glen, and other 'picturesque spots possess
beauties sui generis. The voyage from Liverpool lasts
about five hours in average weather, being shorter or longer
according as wind, tide, and sea are favourable or the
reverse.
The Noble Hospital.
A small hospital has existed in Douglas since 1839, but it
had long been found a very inadequate structure, in a
situation the reverse of healthy. It was not only the hospital
of Douglas, but of the whole island. When some years ago
the committee felt it imperative to look out for a new site
where a new and improved hospital might be erected, the
expense of the suggested land and of the hospital it was
proposed to build upon it was so great that the committee
lelt obliged bo be content with an inferior site and an
inferior building. The late Mrs. Noble (to whom the land
belonged) and her husband, when they heard of this, most
generously offered freely, nob only the site, but also to
erect the hospital. This was completed and opened on
Sept. 4th, 1888, amidst much local enthusiasm. A visit to
it will well repay anyone, and the medical visitor who wishes
to see how eflieienb a hospital can be provided at a moderate
cost w ill fi nd it a very useful model. The plan is shaped
thus: fTTi the central limb being the administrative
block, wliile rigbt-and left are those containing the male
and female wards, the hospital being on the pavilion prin¬
ciple.' The large wards contain ten patients in each, and
there are two smaller ones, each containing four beds.
There are also private ward.s and lock wards. In all forty-
five beds could be provided, but a smaller number are in
use at present. The cost of the building was £.5000, which,
considering that it has all the modern improvements, and
that the best workmanship and materials have been used,
must be regarded as a very moderate sum.
Sanitary Reforms.
Originally all the Manx towns were built with narrow
streets of small houses, mostly two-storeyed, with courts here
and there. Many of these streets are straight or at right
angles, very similar to one another in appearance. They
were originally built, it is said, for the exigencies of the
smuggling trade, and, as will be readily conceived, they
are very unfit for human habitations now. Slums, rookeries,
and courts which are a disgrace to civilisation are to be
found in Douglas, but they are gradually giving place
to more healthy .structures. The new hotels have been
fitted up with all the recent sanitary improvements in the
lavatories, waterclosets, urinals, &o., and this has had the
t Google
460 The Lancet,]
MEDICAL NOTES IN THE ISLE OF MAN.
[Feb. 21,1891.
desirable eilect of inducing the managers of the older hotels
to effect similar improvements. Modern houses also are
furnished with wash out closets, ventilating shafts, inter¬
ceptors, &c. But much still remains to be dune. The river
Douglas is a tidal one, and it is very evident from the un¬
savoury smells in the harbour at low water, especially in
hot weather, that it receives a large amount of sewage either
from town or house drains, from vessels in the harbour or
from all. It ought to be made an offence to discharge sewage
from any vessel into the harbour, and the authorities at
Douglas will act wisely if thejr follow the example of those
at Torquay, and carry all their sewage to points where it
will not be washed back by the incoming tide, but be dis¬
charged once for all into the sea. The town and harbour of
Douglas have now a very considerable extent of frontage
towards the sea, and very suitable points for the outfall
could be found—one round Douglas Head, the other between
Douglas and Onchan. The expense would at first be large,
but it would be amply repaid by the increased salubrity and
consequent popularity.
Public Mortuary,
For a long time past Douglas has greatly needed a public
mortuary for the reception of bodies found exposed, or at
dwellings in which it was not deS'irable to make a post¬
mortem examination, or to take jurors to view the body.
There is now every probability of a new mortuary being
erected, with a proper post-mortem chamber and all the
modern requisites.
Lunatic Asylum,
About three miles from Douglas is the General Lunatic
Asylum, established in 186C. It has 200 beds. The patients
average 189, which may seem a large number. It must be
remembered that the resident population of the island ranges
from 60.000 to 00,000; which number is increased very con¬
siderably in the visiting season, as many as 3000 or 4000
persons frequently arriving on a Saturday during the
summer,
T/ie Climate,
This has been thoroughly investigated by Mr- A. 'VV.
Moore, F.R.M.S,, in a most interesting paper published in
Douglas in 1889. The results of a most exhaustive research
are given at the end as follows “The results airiveil at
with regard to the climate of the Isle of Man may be sum¬
marised as follows: Its temperature is more equable than
that of the surrounding coast, being somewhat higher in
autumn and winter, similar in spring and lower in summer.
There is comparatively little frost and snow, bub a consider¬
able amount of ‘raw’ damp weather, which to certain con¬
stitutions is more trying than a lower temperature in combina¬
tion with a drier atmopphere. Us sunshine is much greater
than in any surrounding district. Us winds appear to be
much the same in strength and frequency, bub as the island
is more exposed they are felt more than on the mainland.
The question of its rainfall is a moat complex one, as the
fall in the various parts of the island varies so con¬
siderably. Generally speaking, however, the rainfall
is rather greater and moie frequent than on the adjacent
coasts, bub much less than in the mountainous districts
beyond those coasts. Its humidity, go far as can be ascer¬
tained from limited observations, is rather in excess. Wc
may say, then, that the Manx climate is equable and
sunny, and—though humid—decidedly invigorating; that
its rainfall, though never excessive, varies considerably in
its different districts ; and that it is much exposed to winds
which are, for the most part, mild and damp.” Mr. Alfred
Haviland, M.R.C.S. Eng., in a lecture delivered in Douglas
on June 13ih, 1883, spoke most favourably of the climate
of the island, as the result of “a lengthened residence,
careful investigation of its physical and climatal characters,
as well as an attentive and close inquiry, extending over
several months, into the health of the native population.”
The following- is from the concluding portion of the
lecture:—
“ The above are the principal features of the climate of
this island. They afford sufficient evidence in themselves
of its suitability as a health resort, and incontettably prove
its exceptional character, when compared with other
climates in the British Isles and the continent of Europe
lying within the same parallels of latitude. Favourable,
however, as the general climate is of this beautiful isle of
mountains and glens, a more careful study of its physical
geography has revealed numerous sites where the physical
features and the atmospheric conditions combine to produce
local climates calculated to meet the requirements of a largo
number of variously affected health and repose seekers.
In fine, the climatal resources of the Isle of Man, like many
other gifts with which Nature has endowed it, require to be
better known before they can be as fully and widely realised
as they so well deserve to be.”
The Resident Population.—Hereditary Dia&ascs.
It is only within the last few years that daily communica¬
tion has been established between the island and Liverpool
all the year round. Formerly this only existed daring the
short summer season, the service daring the remainder of the
year being only thrice weekly. Before the time of steamers
coraraumcation was even less frequent, and during the
winter seldom more frequent than once a week.' Apart
from the question of inconvenience, other much graver
evils resulted, which have a special interest for medical
readers. In such a small community as the Isle of Man
consanguineous marriages were very frequent when the
circumstance just mentioned prevented the inhabitants
from mixing with those of the neighbouring kingdoms, and
so, as it were, restricted marriages within tlie island itself.
It is to this cause that much hereditary disease is attri¬
buted. In some parts phthisis has assumed an almost
opideniic foim, scrofula in the form of ophthalmic diseases
prevails extensively, and insanity is saia bo be dispropor¬
tionately high. The increased facilities both for the resi¬
dents and visitors to reach Liverpool, Barrow, Fleetwood,
Whitehaven, and other ports has tended greatly to promote
marriages between bhe Manx and other nationalities,
much lo the advantage of the future generations. These
hereditary diseases and this deterioration of progeny
are due to no fault of the original Manx physique. The
average Manxman resembles in many respects his neigh¬
bour Scot, being tall, strong, weather beaten, and capable
of almost any amount of exposure to wind and weather.
He is, moreover, a sober, moral, well-conducted man, not¬
withstanding the many stories of an opposite character
which have been told of him. A large proportion of
Manxmen are total abstainers; they marry while still
young men, and have happy homes. It would be well if
the same could be said of the cheap trippers, many of whom
set the Manxmen a very bad example.
The Local Government Amended Act, 18S9.
This Act provides inter alio, for the removal of infected
persons from any ship or vessel, or from any house to a
hospital, unless proper isolation can be secured. Compul¬
sory notification of infectious disease is also provided for,
and the importance of these measures in such a locality
must be obvious. Otherwise disease niiglit be both ijii-
ported and exported during a busy season to a terrible extent-
BIKMINGHAM.
(From our own Correspondent.)
Students' Diversions,
Much excitement has lately been caused at Queen'^s
College by the unusual conduct of some students attending
the class of surgery. Previously to the arrival of the Pro¬
fessor tire room was filled with tobacco smoke and a broom
fastened to one side of the desk. The learned professor,
indignant at these proceedings, retired without giving his
lecture, and the authorities of the College were invoked to
maintain discipline and correct the offenders. The chief
delinquent subsequently apologised, and on the strength of
the promised absolution for doing so was surprised to find
himself suspended. The students held a meeting afterwards
to protest against this alleged breach of contract, mutual
explanations followed, and happily the affair, in itself un¬
seemly and childish, has been allowed to pass away with¬
out any further exercise of feeling on either side.
Mason College and Queen’s College,
An important tebeme affecting the medical drparfiuenfc
of the latter College has been mr some time pust under
consideration. At present the medical curriculum is con¬
ducted at both Colleges, a course which presents obvious
difficulties and much inconvenience. It bas been thought
desirable to conduct the medical teaching at one place only,
and to sever the association from the theological depart¬
ment of Queen’s College. At a meeting lately held a com¬
mittee was appointed at Queen’s, and it was resolved to
Die' ieyd 1 ■■ Coogle
The Lancet,]
NORTHERN COUNTIES NOTES.
[Feb. 21,1891. 461
invite the authorities of Mason College to appoint a similar
committee for consultative purposes. Whatever is done must
he submitted to the Charity Commissioners, and the founda¬
tion deeds carefully reviewed. The change would be pro¬
ductive of great benefit to the medical teaching of this
school, and would bo an advance towards a far higher
position than is at present held.
The- New General Hospital.
At a meeting largely and influentially attended on the
i7th inst. three subcommittees were appointed to take
charge of the questions of site, building, and finance. There
is every prospect of a large subscription list and an ultimate
realisation of the most sanguine desires of the promoters.
Death from, Swallowing a False Tooth,
The dangers attending false teeth were emphasised by
•the deputy coroner at an inquest lately held on the body
■of a woman aged twenty-eight. The tooth was found at
the bottom of the cosophagus, attached to a plate made
•of composition, which liad pierced the lungs and aorta.
The patient died of haemorrhage in consequence, and a
werdict of accidental death was returned.
•Binningham, Fob. lObh.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
The Newcastle Skin Hospital and Koch's Treatment.
At the annual meeting of the Hospital for Diseases of
the Skin, held here last week, it was stated in the report
■-that the number of coses of an aggravated nature had been
again very large, 2434 separate consultations having been
given. The senior surgeon, Mr. Anthony Bell, stated that
it was his intention to have placed three or four cases of
tlubercular lupus under Professor Koch’s treatment, but,
having watched the results of the new treatment in this
country, he had at present declined to adopt it. Mr. Bell
further stated that the treatment of lupus vulgaris con-
•stitutionally and locally adopted at tnat hospital had
proved eminently suceeesful, between thirty and forty cases
having been cured during the past twelve months.
Hartlepools Hospital.
'It was stated at the late annual meeting of the Hartlepools
Hospital that the number of patients treated in-doors and
•out-doors together was 1510, being 550 more than last year;
•and an interesting feature in the report was the fact that
the workmen’s subscriptions reached over £700, which,
together with those of the friendly societies, made up
practically half the income of the institution. The financial
position of the hospital is such that the year closed with a
4)alance in hand of £630.
Tyne Port Sanitary Authority.
At the last meeting of the Tyne Port sanitary authority
it was reported that in December last 958 visits had been
-paid to vessels, and sundry sanitary defects bad been found
in 59; in January 072 visits had been made, and
00 cases of sickness on board .were inquired into. There
had been a considerable decrease in the number of emigrants
arriving in the Tyne en route to America.
Fnendly Societies' Convalescent Home.
The first annual meeting of the Friendly Societies’ Con¬
valescent Home was held last week at Durham, and the
report presented was very satisfactory. This Society has
founded a Home at Grange-over-Sands for convalescent
-workmen, and its distinguishing features are that it is also
supported and managed by working men. It was shown
'that the average cost of a patient staying at the Home was
•under 8s. 8rf. each.
The Sanitary Condition of Mamjport.
At the last monthly meeting of the Maryport sanitary
• authority the medical oHicer presented a report showing
that the death-rate for the past year had been 27’6 per 1000
•of the 224 deaths recorded ; 106 were those of children
■under five years of age. This excessive mortality was
explained as due to scarlatina and whooping-cough.
■Scarlatina the medical oilieer reported as “prevailing during
every month of the year, and in almost every street of the
Sown.”
Whitby, Yorkshire.
This is one of our healthiest seaside resorts, and deserves.
from the natural advantages it possesses, to be better known
than it is. Dr. Tinley, the medical officer of health, has
presented his report for the last year, which shows a death-
rate of only 16-8 per 1000, while its birth-rate has been
nearly double, or 28'9 per 1000. The zymotic death-rate
for the year has only reached a decimal 4*0 per 1000, a
rate which it would be difficult to show so very low in any
town of nearly 15,000 inhabitants, with a moving population
of visitors in the summer season.
Darlington Hospital.
The annual report presented at the meeting of the Dar¬
lington Hospital showed that the number of out-patients
treated during the year was 25C0 and in-patients 173. The
treasurer’s financial statement was also fairly satisfactory.
Death of Mr. Joseph Bainbridgc Fife, M.R C.S.
Many of the older generation of practitioners connected
with the Newcastle schools of medicine will be sorry to
hear of the death of an old lecturer, Mr. Joseph Bainbridge
Fife, which took place at Croft, near Darlington, on the
12th inst. Mr. Fire, who was in his sixty-ninth year, was
the second son of the late Sir John Fife, so long the leading
operative surgeon of the north. Mr. Fife was a long time
lecturer on ophthalmic surgery at the old Newcastle
School of Medicine. He was a good general and oph¬
thalmic surgeon, and in the latter department had much
E ractice for many years as a consultant, as well as
eing one of the surgeons to the Eye Infirmary in
Newcastle. The practice of the Fifes passed into
the hands of Dr. Jeaffreson, the present surgeon to the
Eye Infirmary, many years ago, when Mr. Fife retired
to a hunting seat at Croft, where, as above mentioned, he
died. Mr. Fife was unmarried, and much resembled bis
father Sir John Fife in appearance and manners. He never
worked so hard as his father, indeed he had a dislike to the
drudgery of practice, and was always glad to escape for a
day with the hounds. I am quite sure that the mention of
“ Joe” Fife’s death will bring up many recollections to old
Newcastle students, with whom he was a great and a well-
deserved favourite.
Workington Infirmary.
This infirmary was erected four years ago, to ac¬
commodate the comparatively large number of serious
cases, the results of accidents at the neighbouring iron¬
works ; cases of all kinds, however, are admitted when
there is room. There are three wards, one of eight beds
and two of four beds eaoli. All the medical men in the
town are allowed to send in suitable cases, and each
continues to attend his own cases. This system works
smoothly and satisfactorily. The nursing staff consists of
a matron and two nurses. The main source of revenue is
the weekly subscription of the working men at the various
works—in some cases \d , in others \d., per week per man.
All the works make such contribution, the amount reaching
on an average £800 (the total population is 25,000). Almost
sufficient is collected in this way to meet the whole outlay.
Without any legacy or extraordinary item of income the
infirmary has already £400 saved for investment. The
working men of Workington are surely to be congratulated
for having shown to all others how hospitals may be sup¬
ported. That the infirmary eminently serves the purpose
for which it was built is admitted by all. As au experi¬
ment in the way of localising as opposed to centralising
hospitals, it appears to have been entirely successful.
Nowcastle-on-Tyiie, Feb. 18Ui.
SCOTLAND.
(From our own Correspondents.)
Scottish Universities Co7nmission.
Tins commission continues to have frequent meetings,
and, for the last week or two, has been taking evidence on
matters affecting the medical faculty from the representa¬
tives of the Colleges, and from other persons interested in
medical education.
Health tkc. of Edinburgh in January.
During January there were 466 deaths, giving a death-
rate of 29-30 per iOOO compared with 630 in the correspond¬
ing month of last year, and 393 in January, 1889. As to,
age, 124 were under five years, 59 between five and *
five years, 141 betweentwenty-liveandsixty years,
Dir:'
462 The Laitobt,]
lEELAND.—PABIS.
[Feb. 21,18M.
above sixty years. Diseases of the chest caused 177 [deaths,
and zymotic diseases 42. There were 648 births during
the month. Daring the same period 332 cases of infectious
disease were intimated, as compared with 1582 in the corre¬
sponding month last year, and 163 in 1889. Of the total,
114 were cases of typhoid fever, 138of scarlatina, 52 of measles,
and 28 of diphtheria. There were 167 patients admitted into
the City Fever Hospital and 113 discharged, and 12 died.
At the end of the month 257 patients remained, which com-
rised 101 cases of typhoid fever, 105 of scarlatina, 10 of
iphtheria, 10 of whooping-cough, 13 of erysipelas, and 6 of
measles.
Death-rate in Edinburgh according to Rental.
Some interesting points bearing upon the mortality of
the city during 1890 according to rental was before the
Public Health Committee last week. The mortality was
lowest in houses with a rent of £60 and upwards—namely,
11*49 per 1000; after these came the houses rented at from
£20 to £30; and in those between £5 and £10 the death-
rate was highest—namely, 23*14 per 1000. Further, the
mortality under five years of age in houses of £50 and up¬
wards was 8*57 per cent., while in bouses under £5 it was
39*65; in houses between £40 and £50 it was 6*12per cent.,
,and between £5 and £10 it amounted to 51*33.
The Disposal of the Edinburgh City Refuse.
The question of the disposal of the city refuse has been
before the Town Council for a considerable time, and it was
intimated in these pages last year that a deputation had
been appointed to visit several towns in England with a
view to ascertain the best method of disposing of the refuse.
Tbe matter has now become urgent, as it appears there are
no vacant places where the refuse can be deposited, as has
been the custom in the past. The refuse amounts to
something like 110,000 tons per annum. At one time
a large q^uantity was sold to farmers, but not only has the
demand from that quarter greatly diminished, but the price
obtained is very much lower. The committee recommend
the adoption of the destructor or burning method of dis¬
posing of city refuse, which they regard as yielding in
other places satisfaction alike as regards sanitary and
economic considerations. They farther suggest that no
attempt should be made to centralise the destructors, but
that the city should be divided into three or four districts,
each of which should have a destructor. The report on the
whole subject was brought before the Town Council at its
meeting on Tuesday, and was recommitted to the Cleaning
and Lighting Committee to bring up specific recommenda¬
tions and estimates for giving effect to the recommendations
of the report. This is certainly a good step in the right
direction, and the committee will have earned the approval
of sanitarians if they succeed in carrying out their plans
and making them all they anticipate.
Mortality of Edinburgh.
The mortality last week was 105, the death-rate being 20
per 1000. Diseases of the chest caused 45 deaths, and zymotic
diseases 9. The intimations for the week were: Typhoid
fever, 25; diphtheria, 4; scarlatina, 42; and measles, 21.
Peb, 17th.
lEELAITD.
(From oue own Corrbspondekt.s.)
DUBLIN.
Mercer's Hospital.
On Monday, in the Queen’s Bench, judgment was given
by the Lord Chief .Justice and his colleagues in the
cose of Nixon and Ward v Auchinleck, in reference to
an application to compel Mr. Auchinleck to produce the
authority by which he held the post of physician to Mercer’s
Hospital. The Lord Chief Justice, in giving judgment,
said that the governors of the hospital were left a wide
discretion as regards the application of tlie money, and no
external superintendence or control was reserved. That
was the position of Mr. Auchinleck, assuming that the
governors had power of appointing him. lie was a mere
licensee, whose licence could be revoked by the governors
at any moment, and tiierefore he iield a position in a
private hospital which could not be challenged now in the
mature of a guo warranto. Tlie other justices concurred,
conditional order for mnndamiw was accordingly
The late Dr. J. A. Byrne. *
At a recent meeting of the Obstetric Section of the Eoyal
Academy of Medicine in Ireland the following resolution
was adopted: “That the Obstetric Section of the Royal
Academy of Medicine desires to record its deep regret at the
loss it has sustained by the recent death of Prof. Byi’ne, and
to express its sincere sympathy with his widow and family.”’
Sentence on a Medical Student.
A medical student, by name Henry Harvey, was on the
14th inst., at the Commission of Oyer and Terminer,
sentenced by Mr. Justice O’Brien to one year’s imprisonment'
with hard labour for abducting a girl under eighteen yeara
of age.
Mr. Lawder T. Whelan has been appointed resident'
surgeon to the City of Dublin Hospital.
BELFAST.
The Ulster Eye, Ear, and Throat Hospital.
From the twentieth annual report presented by Dr.
W. A. McKeown at the meeting oT the friends and sup¬
porters of this hospital I learn that the operation for
cataract has been performed forty-two times, with only on©
loss. During the lust six years be has tabulated 296 opera¬
tions for cataract, and be thinks all hospitals should publish
reports of their cataract operations. Dr. McKeown urges
the need of day-rooms ana further space for the ear and
throat department. Dr. Killen has administered ansesthetica
and given much assistance. The total number of patients
treated during the year was 1613, of whom 196 were intern?
964 patients paid an entrance fee of one shilling, while the
remainder were admitted free. No one is refused admit¬
tance because of poverty, but well-to-do persons of the
working-classes are not permitted to avail themselves of
privileges to which they are not justly entitled. The com¬
mittee started the year with a debt of £78 19s. llcf.; now
the debt is £25 85 . 3a. The total receipts of the hospital
were £630 12ff. Sd.’, the total expenditure was £577 Is.
The Belfast Medical School and the Royal University.
At the last meeting of the Senate of the Royal Uni¬
versity, the following teachers in the Belfast Medical'
School were elected examiners :—Dr. Whibla, in Materia.
Medica ; Dr. Byers, in Midwifery ; and Dr. E. A. Letts, in
Chemistry. I understand that a commencement will soon
be made in the construction of the new chemical labora¬
tories which are so nece8sai*y at Queen’s College, Belfast.
Outbreak of Small-pox.
I regret to report that small-pox has again appeared in
Belfast, but fortunately the epidemic is mild, and so far no-
deaths have occurred. On Monday last, in one of the
barracks of the Royal Irish Constabulary inDonegal-street,
where there are fifty-four men of various ranks, six were
seized with the disease, and have been removed to the Union
Hospital. The barracks, after thorough fumigation, have
been closed, the men have been temporarily quartered in
other places, and every possible precaution has been taken
to prevent the disease spreading. It is stated that during
tlie past month other isolated cases of small-pox have been
met with in parts of the city, and it is thought the diseas©
has been introduced by foreign sailors.
Feb. 17fch.
PARIS.
(From our own Correspondents.)
Sanitation in Baris.
It may interest your readers to know what machinery is
employed in this great city for the carrying out of sanitary
measures. Our own Local Government Board is here re¬
presented by the Prefecture of Police, which has attached
to it divers corps of inspection, included in -which are,
besides medical men, veterinary surgeons, chemists, archi¬
tects, engineers, &c. The functions of these ollicevs consist
in the inspection of abattoirs, of the cattle market of La
Villette, of establishments which are in an,insanitary or
dangerous state, of furnished lodgings, of prisons, of lunatic
asylums, public and private, of private hospitals, and of
bureaux tliat supply wet nurses. Workshops in which
child labour is utilised are also periodically inspected. Th©
head of tliia sanitary service is tlie Prefect of Police, who
is aided by a kind of sanitary parliament, the Conseil
Dir*-- zad by Google
Thb lakobi,]
MEDICAL TRIAL.
[Feb. 21,1891. 463
d’Hygi^ue et de Salubrit6 de la Seine. A subordinate Board
of Lf^ealth exists in each arrondissement of Paris, as also in the
suburban arrondisseraents of Sceaux and St. Denis. The
supreme Board of Health meets every fortnight, its proceed¬
ings being duly reported in a volume issued annually.
Adulteration is sharply looked after by the Laboratoire
Municipal de Chimie, created some ten years ago. Here
s.rticles destined for consumption are analysed at the
instance of the authorities or of any private individual who
is willing to pay a small fee. Wine shops are visited by
inspectors every three months as a rule, and specimens of
the beverages sold are taken away for analysis. Then there
is the Laboratoire de Toxicologie, where questions affecting
public health and toxicological and medico-legal points are
studied. Lastly, the jurisdiction of the Prefecture extends
to what is euphemistically denominated the Dispensaire de
Salubritd, on the staff of which devolves the duty of
making a fortnightly examination of every registered
prostitute in Paris. Any woman found to be suffering from
venereal disease is summarily despatched to the St. Lazare
Hospital, there to be detained until she is cured. This
fortnightly examination is compulsory on every jilh sotmvise
(registered prostitute).
The Influence of Cold Weather on the Mortality of Paris.
The severe winter with which we have been visited has
provided a good opportunity for establishing the relation
that exists between the commencement and the cessation
of the low temperature and the fluctuations in the mortality
a'csulting therefrom. Commencing on Nov. 26bh, the cold
weather continued almost uninterruptedly until Jan. 21st.
The mortality did not, however, rise above the normal
until the third week after the first date above mentioned,
the increase being, of course, due to the greater frequency
of diseases of the respiratory organs. Again, from the
statistics of the week ending Jan. 31st, it is seen that the
mortality had descended to the level usual at this season of
the year, this return to the normal being only apparent
one week after the disappearance of the phenomenally cold
weather.
Paroquets as Carriers of Infection.
That domestic pets sometimes constitute a danger to the
health of their admirers is shown once more by the following
sad occurrence, reported by the Nouvelliste de Lyon. It
appears that a newly married couple went on a visit to an
aunt living in the neighbourhood of Lyons, taking with
thefn as a present to their hostess two paroquets newly
arrived at Marseilles from Oceania. A few days later, the
visitors, their aunt, and the latter’s servant fell ill. and the
disease was pronounced by two medical men to be yellow
fever. A fatal result ensued in all four cases, and the
paroquets, which are supposed to have been the unconscious
importers of the germs of the dread disease, soon died thein-
•selves of “ consumption.” The authorities have had the
•house which was the scene of this sad occurrence disinfected.
The State Uniform of French Doctors of Medicine.
It is not generally known that any Doctor of Medicine
of a French Faculty who may be desirous of availing him¬
self of the privilege is entitled to sport on solemn occasions
a costume that for gorgeousness- throws that donned by
Academicians completely into the shade. By a clause in a
law bearing the date of the 20 brumaire, an XII., otherwise
Nov. 12bh, 1803, it is enacted that a plain Doctor of Medi¬
cine is authorised to wear at public ceremonies, or .when
giving evidence before a court of justice, a costume thus
composed : a black gown of bolting-cloth {etaviine), the
back and front of which are of crimson silk bordered with
ermine ; a black coat d la Frauraise ; cambric bands, and
a cap of crimson silk with a border of gold lace. The time
is probably not far distant when that cumbrous institution,
the University of France, will be replaced by local Uni¬
versities after the English model. We shall then perhaps
see the medical graduates of the Universities of Paris,
Montpelier, Nancy, &c., cutting a conspicuous figure at
public functions attired in a costume which rivals in magni¬
ficence that seen on the professors who confront the aspirant
'to academical honours in the dingy examination rooms of
the Paris Faculty of Medicine. Its costliness would, how¬
ever,^ always militate against its universal adoption, even if
the Frenchman’s innate dread of rendering himself ridiculous
would induce him ever to appear in public in such a guise.
Voluntary Constipation.
In a recent article in the Revue de Vllypnotisme,
entitled “ Voluntary Personal UncleanliaesB,” Dr. Galippe
calls the attention of the authorities to the necessity
of reforming the sanitary arrangements obtaining in
most French educational establiehmenta. Some facts
related by him in this connexion will be read with
astonishment by those who are not familiar with the
horrible filthiness of most French closets. He says, “We
need hardly remind the reader of the disgusting filthiness
of most (school) closets, and I have known sensitive children
who refuse to repair to these places until they are absolutely
obliged to do so, such is their horror of the stench that there
assails their nostrils, and the dirt they may bring away with
them. I have kno\vn of many children who have suffered
much from this voluntary constipation, and of others who,
affected with diarrhoea, £ave for a whole week passed their
motions into their clothing.” Dr. Bourneville, in a notice
of this article {Progrts M6dical, Feb. 14th) says that he
has for years urged the necessity of endowing not only
schools but also hospitals and barracks with decent closets.
He has endeavoured to convince the French public of the
feasibility of such a stupendous feat by having constructed
for the use of hie idiot and imbecile child-patients at the
Bictltre closets, the cleanliness of which strikes the French
visitor with astonishment. M. Bourneville also demands for
each school a complete set of bath-rooms, and calls forregula-
tions rendering the use of a bath obligatory on the schtflars.
Paris, Feb. 20th. _
MEDICAL TRIAL.
Reoina versus Berry.
(Before Mr. JUSTICE Charles.)
A CASE of some interest to the medical profession was
tried at the Old Bailey on Saturday, the 14th inst., before
Mr. Justice Charles. Elizabeth Sarah Berry, an uncertificated
midwife, practising at Tooting, was charged with man¬
slaughter for causing the death of Emma Spicer by
communicating to her the disease known as puerper^
fever. Mr. Forest Fulton, assisted by Mr. Horace Avory,
appeared to prosecute, while Mr. Tickell defended. Mr.
Forest Fulton, in opening the case, stated that the prisoner
had practised as a midwife for the last twenty years, and
ointed out that the law required that midwives should
ring to bear upon the discharge of their duties, just as
medical men were required to do, a reasonable amount of
care in the management of the cases they undertook. If
that bad not been done in this instance, and if the death of
the patient was brought about by infection conveyed to
her by the prisoner, lie thought his lordship would say
that she was guilty of manslaughter. It was generally
recognised by the medical profession that a considerable
interval sliould elapse before attending lying-in women after
a case of puerperal fever had occurred. The defendant
had attended on Dec. 12bh a woman who died from puer¬
peral fever, and on Dec. 8th she had attended another
person, who bad also died from puerperal fever. On
Dec. 12bli Dr. Taylor, a gentleman practising in the
neighbourhood, tom the defendant that she ought not to
attend any other cases for a considerable period, at least
two months. The question was a twofold one, Was the
puerperal fever communicated by the prisoner, or was it,
looking at the surrounding circumstances, due to other
causes? The jury would have to say whether this attend¬
ance, under all the circumstances, with the warning of Dr.
Taylor, and the fact that there had been no leas than two
other deaths, constituted such gross and culpable negligence
as, in the opinion of the j ury, would j ustify them in coming to
the conclusion that the prisoner was criminally responsible
for the death of this woman.
At this point Mr. Justice Charles explained that, as he
understood the law, there must be such negligence as
amounted to “criminal misconduct.”
In her statement before the magistrates the witness
had stated that she had thoroughly disinfected herself, and
had refrained from attending cases for a month. How
far it was possible for persons to disinfect themselves so
as not to can-y infection to a lying-in woman was a matter
open to very great doubt. At the coroner’s inquiry into
the cause of death the prisoner stated that Dr. Taylor had
cautioned her not to attend any other cases for a month or
six weeks, and that she did not know what puerperal fever
464 Tbs Lancet,]
MEDICAL NEWS.
[Feb. 21,18M.
'waa, but noderstood it to be blood poieoniog. She bad
attended 950 midwifery cases.
Among the witnesses examined was the husband of the
deceaaed, who stated that bis occupation waa that of a
plumber, and that he bad to attend to drains and water-
closets. Dr. Bligh of Tooting was closely pressed by
Mr. Tickell to state the distinction which existed in this
disease as to its power of being communicated by con¬
tagion or by infection, and also what, in his opinion, was
the period of quarantine recognised by medical men under
such circumstances, but he refrained from expressing any
opinion on the subject. In reply to his lordship, he
explained that he was in no way concerned in the
delivery of the first woman who died, but was called in
three days after. Dr. Taylor, in his cross-examination
by Mr. Tickell, admitted that puerperal fever, coming on im¬
mediately after the birth of the child, might be due to bad
drainage, but thought that a patient might show slight
symptoms of contagion within twenty-four hours. The bus-
band was then rec^led, and stated tliat the first symptoms
of pain in the abdomen occurred just twenty-six hours after
delivery. Dr. Taylor further stated that he had advised
the prisoner to use Condy’s fluid for disinfecting purposes,
but had not gone into any details as to its use, as be
imagined the prisoner with her experience would have
known these. In reply to Mr. Justice Charles, he stated
that if he had delivered a person in whom puerperal
fever had been set up he would have abstained, after dis¬
infecting himself, froDo attending other cases for at least a
month ; and bis lordship pointed out that in this case the
risooer bad abstained for a month and had also disinfected
erself. Mr. J. li. Purdieu, Dr. Taylor’s assistant, was
then examined, and in the course of his cross-examination
by Mr. Tickell stated that he had told the woman that she
should have come to the surgery and got permission before
attending other cases. He would have given the prisoner
ermission after a month. He noticed on the occasion of
is visit to the house a “ very great stench in the room,”
bub could nob say exactly from what sources it arose.
Mr, Thomas Bond, F.II.C.S., bad made a post-mortem
examination of the deceased, and found the lungs con¬
siderably congested with purulent lymph and adherent
to the pleura. There was no evidence of bronchitis
or pnenmonia. Both ventricles of the heart were filled
with fibrinous clots, and the abdominal cavity M’as filled
with fluid of a purulent nature. The peritoneal surface of
the abdomen was also covered with putrid lymph. The
mucous membrane of the vagina was in a highly inflamed
condition, and in the uterus be found indications of recent
puerperal fever. He certified that the cause of death was
blood poisoning as the result of puerperal fever. There
was no part of the placenta or any membrane remaining in
the uterus, nor was there any evidence whatever of any
injury during parturition. There was nothing, in the
necropsy beyond the virulence of the attack to show what
bad caused the fever.
A juryman asked Mr. Bond if, in his opinion, the prisoner
was not justified in attending Mrs. Spicer, after having,
without any ill effects, attended a previous case, but his
lordship suggested that that was a question which the jury
would presently have to propose to themselves.
Dr. W. C. Grigg, physician to Queen Charlotte’s Lying-in
Hospital, in bis evidence mentioned various causes which
might give rise to this fever. Judging from the post¬
mortem examination a considerable amount of blood must
Wve been left within the cavity of the uterus, and that was
not without danger. If the surroundings were unhygienic,
it would be rapidly decomposed, and lead to this disease.
The period of the development of the disease was ratlier
against its being conveyed by the attendant. In a very
severe epidemic at (^ueen Charlotte’s Hospital (the
severest he had ever seen) sixty-two women were stricken
down with puerperal fever, of whom fifty died. He had care¬
fully gone over the records of these cases. Only ten showed
symptoms of puerperal fever within forty-eight hours, and
of these three had been in the hospital from two to three days
previously. Generally speaking, when the contagion was
due to direct infection, it showed at the end of the second
day or the beginning of the third; and where the mischief
broke out early be looked to external sources for the cause—
namely, the habitation from which the patient came—the
surroundings—and concentrated his attention upon that,
rather than upon the attendants ; but where it broke out
later be regarded the mischief as clue to something con¬
nected with the attendant.
The husband was again called, and proved that the onsab
of the abdominal pain which Dr. Grigg had stated to be
the first symptom of puerperal fever had occurred exactly
twenty-six hours after delivery, and Dr. Grigg thereupon
gave nis opinion that the disease was probably due to the
action of the patient’s surroundings.
The jury here stopped the case and returned a verdict of
“Not guilty.”
Mr. Justice Charles, while agreeing with the jury that
the case should not proceed further, thought the prosecution
had been very properly instituted, because the practice of*
attending patients after previous cases of puerperal fever
was a most dangerous one; and therefore, especially
after the verdict of the coroner’s jury and the bill of the
grand jury, he had been reluctant to interfere earlier in
the case. There was no alternative left to the prosecution
after the verdict of the coroner’s jury, which waa “ that the
said Mrs. Spicer came to her death from blood poisoning as
the result of puerperal fever, which was contracted by her
from the gross and criminal negligence of Elizabeth Berry,”'
and therefore they charged her with manslaughter. Now,
be did not agree with that finding, and he did not think any
case of “ gross and criminal negligence ” had been made outr
agairrst the defendant.
The jury expressed the opinion that the defendant lefb-
the court without a stain on her character, in which-
opinion his lordship concurred.
Sljbkal Itjfes.
University of London. — The following is a lisfe.
of candidates who passed in the respective divisions and
subjects at the Intermediate Examination in Medicine, held
in January last:—
Sntire J'!xamination.—l‘’irst Division: Henry George Felhin, J.ia.
Uylanrt Hickinbotliaiii, Charles Paine, Frodoriek John Poynton,,
Herbert Campbell Thomson, Herbert .Tatnca Walton. —
Division: Christophor AiUlison, Martin Ashley, John Aaron Bevlyn,
llamon Horace Casiollote, Robert Francis Chance, Dudley Willis-
Ceilings, Harry Guy Dain, Herbert Fox, Bertram Harold KingsfOi’d,
Robert Ciwement Kirkby, Ernest (irahain G. J.ittle, Thomas Davys
Manning, Mary Ellon Rye, Samuel Robert Schofield, Walter Scott
H. Seq,ueira, William Shears, Goo. Nathan Osevofb Slater, Kirsop>
B. Jas. Viekei H.
Excluding Physiotogy. — Firs*. Divnivn; l^-ancis.Parris Piper, Courtenay
Mansfcl Rhodes, Edwin Sly. — Second Divinnn: Evelyn Lancelot
Adams, Arthur Percy Allan, HiiKh Kennedy Birloy, Arthur James
Edge, Percy Stanhope Fives, Charles Frederick Gross. George-
Frederick Murrell.
J'hysioloyy only.—First Division: Leonard Arthur Bidwell, Alfred,,
(iooi'ge .Tones.— Second Division: Rohert Turle Bakewell, Lulluini
Wood Batlmrst, Alfred Herbert Card, William Henry Jowell,,
George Martyn, Alfred Hugli Minton, Albert Paling, William Clias.
Cunningluun Park, Reginald Smith.
The following candidates passed the Preliminary Scientific
(M.B.) Examination in January;—
Entire Exaininaiion.—First Dinision : William Dyche (B.A.), Thomas •
Hillier tirceii, Richard Jvay, Joseph Arthur Maw.son, Harold Batty
Shaw, Arthur Uerliort Spicer,—Second Diirision: Malcolm Cameron,
Claude Lionel Chevallior. Iloraco James Harris (B.A.), Thomas-
Clifford Last, Cuthlieri lleniy Jones Lockyer, William John Oakes
(li.A,), Porey Allan Palmer, George H. Wheolor (B. A.).
CheiidHtry and FxyerimnnlaC Physics. — ‘Algornon Carter Bean,.
'-.Sydney Henning Bclfrngo, ’William Marmaduke Bergin, ’Victor
John Blake, Herbert C.avdiii, ’Folix Bolton Carter.’Walter Ernest
Cross, Edward CharleH Davenport, 'Alfred Dimscy, 'Stewart
Rankcn Douglas, 'J'kiward Guy Dm Drury, Bronnan Dyball,.
■"Arthur Karnshaw, "William Dyer Frazer, FVodcrirk Ilateouvt
Gervis, Henry Norm.an Goode, Charles Hanks, ’Ch.arios John
llaniott, ’Thom.aH Hood, ’David llorwitcdi, Ednnuiil Eyre Lloyd,.
'Leonard Freeman Marks, .Jo.seiih Thomas Mar.silen, ’Sydney
Horbert Ma.son, 'Joseph Corbett Muir, “William Percy Nieol,
’.fames Jlonry i-’raneis Nunn, Arthur James Pedley, ’Norman
Howard J’iko, ’TTavid Rico, ’Edward Lionel M. Riusliy, “Josophi
Sliardlow, 'Frank Addinsell Siiiith, 'LowLs Albert Sinitli, ’James
Charles Spillane, ’Loonard Kirkby Thomas, GharlesRoliort W.atson,
Henry Cliorley Watt, ’Morris Wilks, ’Harry Mortimer Wise.
’William Boaso Bennett, “l-owis William Ihirrow, ‘.Joscplj.
JCn'iesO G. Calverloy, -Cecil Frederick Gordon, ’J. Alban Kendall
Grilllths, Tlioinas A. Ilawkesworth, Sindia ICiiidy Hickson, '’Albert
Hilton, Gwilym Prosser .Jamos, ArUiur Dickson ICetchoii, William
Maclachlaii M’Donahi, F. Arcldliald Hope Michbd, Charles Hay
Murray, ’Horbert Ainslio Scott, 'Thomas Blam-bard Scllors,
'Arthur Richard Harrio Skey, ’John Clomentscm Smellie, DanioL
Lloyd Smith, Francis .Joseph Sinitli, “Graham Udalc Smith, ’J’ercy
Montague Smitli, 'Harry .iaine.s Spon, 'John Itohert Stoinhaensor,,
“Cecil William Stickl.and, ‘Thomim Morrell 'J’liomas, ’Edward
Owen Thurston, ’Sydney Gordon Tippett, ‘Thomas lloniy Wells,.
Stanley Whicdier. . ^ ,
Two t'uMeets of Ike KxaTnination (under former Regulations), t-—
Colin C. Clarkson (C. B.), A. William R. Coclirane (P., B.), AilMe L-
Do Steiger (C,, I’.), William Henry Gray B.), Thomas lanmo-
(C., P.), Eldon j’rult (C,, P.).
Digl'izsd b'y Gc )gle
Thb Lancet,1
MEDICAL NEWS.
[Feb. 21,1891. 4&5
One Stthjeot of the Examinnatinn (under former RcfjulationB ).''\—
William Edward N. Dunn (11.), Henry Wylie Eldred (B.), Ernest
Jermyn llynoa (B.), Harry Fulham Turner (C).
'' Tliese candidates have now completed the examination,
t 'I’ho subjects taken up by those candidates are indicated by initials
after the iiaines : 0, Chemiatry ; J’, Fhysics •, IJ, Biology.
University of Cambridge.—A t a congregation
held on the 6th inet. the following degrees were conferred;—
Baohelore of Medicine and Surfer}!. — Francis Wolford, Cuthbert
Wyman, Trinity; Alfred FoaUiersUne Kellett, William Wickham
Simmons, St. John’s; Harry Edward Smith, Gonville and Cains;
Thomas Greenwood Crump, ifohn Elsdalo Molson, Emmanuel;
Eilward Spencer Blaker, Cavendish Hostel.
Proposed Infectious Diseases Hospital.—
Negotiations between the West Derby and Wavertree Local
Boards have been pending for the purpose of selecting a
suitable site for the erection of an infectious hospital for
the use of both townships, rendered necessary by the with¬
drawal of the permission to send infectious patients to the
Netherfield-road Hospital. The Derby Board has in con¬
sequence resolved to contribute two-thirds of the cost of
erecting and maintaining the proposed hospital, and the
Wavertree Board will provide one-third.
Association of Municipal Corporations.—A t
Royal College of Surgeons of England. —
Those gentlemen whose names were published in The
Lancet of Feb. 7th as having passed the examination of
the Boyal College of Physicians, also passed the necessary
examination, and, having conformed to the by-laws and
regulations, were admitted at the ordinary meeting of the
Council on the l2Dh inst. aa Members of the Royal College
of Surgeons. In addition to the list, the following gentle¬
men have also been admitted Members of the College:—
Bloomer. F, W., L.S.A., Wednosbury.
Clarke, E, A., L.S.A., Bukinlioid.
Godfrey, C. O., L.B.O.P. Kdin., Amptliill-square, N.W.
Ilutcliinson, Cyril (}., L.R.C.J’. Irel,, Birmingham.
Naval Medical Servigi':.—T he following candi¬
dates, who competed at the examination held on the
2Qd lost, and following days at Examination Hall, Victoria
Embankment, for appointment as Surgeons in the Royal
Navy, have been successful:—
Marks.
M 0 ikle,T.C.,M,A.,M.B. 2711
Senior, R.W.2022
'rindall, E. E. P. . . . 2621
Kershaw, B. E. ... 2021
Wood, J. C. 2462
Howell, A. H.2121
Marriotb, H. R. ... 2405
Lonuis, E, C., M.B. . . 2100
Marks.
Richards, N. L. ... 2304
Peiifold, E. A., M.B. . 2318
McGregor, (i.2312
Clarke, B. R. 2268
Finch, E. J. 2251
Robin.soii, J. K., M.B. . 2210
Chfl, LI.2103
Royal College op Surgeons of Edinburgh.—
The surgical essay prize of 35 guineas has been awarded
by the College to Mr. Harold Jalland Stiles, M.B.,
P.R.C.S.E., ot Edinburgh, for his essay on “Contributions
to the Development, Anatomy, Pathology, and Surgery of
the Breast.” The prize was open to all licentiates and
Fellows of the College, except Fellows who were members
of the President’s Council, and candidates had the selection
of any surgical subject.
Four Children at a Birth.—T he wife of a
forgeman, living at 14, Staniford-street, Warrington, gave
birth on Saturday to three boys and a girl. Two of the
children were stillborn, and the others lived for twelve
liouvs. The mother is doing well.
The Sanitary Assurance Association.—T he
tenth annual meeting of this Association was held on
Monday last at the offices, 5, Avgy 11-place, W., the President,
Sir Joseph Fayrcr,in the chair. Mr. Joseph Hadley, secre¬
tary, read the annual report, which referred to the work of
the Council in promoting the Sanitary Registration of
liuildinga IJill. On the motion of the President, seconded
by Mr. Henry Rutherfiird, baiiister-at-law, the report was
unanimously adopted. Surgeon-General Cornish proposed :
“That the petition to the Prime Minister requesting the
Government to make provision in their Bill for consolidat¬
ing and amending the laws relating to public health as
will secure tlie registration of buildings in some sucli
manner as proposed by the Sanitary Registration of
Buildings Bill, 1890, be approved, and that copies be for¬
warded to the governing l)()die3 of the institutions which
took part in the Sanitary Registration Conference of 1887,
with a letter requesting them to sign the petition and
take part in it.s presentation.” This was seconded by Mr.
Andrew Stirling, supported by Mr. Mark H. Judge and
Dr. Willoughby, and carried unanimously. Sir Joseph
Fayrer, having some time since announceil his intention of
retiring from the presidency, the meeting conveyed to
that gentleman its warm appreciation of and sincere
thanks for the valuable services rendered by him during
the ten years in which ho held the office of President.
Surgeon-tiencral Cornish, late Sanitary Commissioner with
the Madras Government, was elected President, and Sir
Joseph Fayrer and Professor Rogers Smith were elected
Vice-Presidents.
a meeting of the Council of this Association, on Feb. 12tb.,
at the Westminster Palace Hotel—Sir Albert Rollit, M.P.,
president, in the chair—a resolution was passed ur«ng cor¬
porations to adopt the provisions of the Infectious Diseases
(Notification) Act, 1889, and the Infectious Disease (Pre¬
vention) Act, 1890. The members of the Association also
resolved to dine together at the Hfltel Mbtropole on Thurs¬
day evening, March 12bh, and the annual meeting was fixed
for Marcli IJth.
London Fever Hospital.—I t appears from tha
annual report for the year 1890 that there had been a
considerable increase in the number of admissions. The
addition included all the various forms of fever, with the
exception of typhoid, the prevalence of which in the
metropolis during the year was much below the average.
The total number of patients under treatment was 682—
308 males and 374 females. The cash statement showed a
credit balance of £5026 17*“. 10c?., of which £3860 had
been invested, leaving in the bands of the treasurer
£1166 175. lOrf.
Presentations.'—O n the 13th inst., at the close of
the last of a course of ambulance lectures, the members of
the Rusthall branch of the Girls’ Friendly Society presented
Mr. Walter C. Aylward, M.li.C.S., L.R.C.P., with a hand¬
some Tunbridge ware inkstand, accompanied by an address
expressive of the donors’ appreciation of the services of the
lecturer.—The many friends and patients of Mr. Philip G.
Lee, L.R.C.P. &c., took the occasion of bis leaving Monks-
towD, county Cork, Ireland, on an appointment in Middleo-
boro’, to present him with an illuminated address and band-
Boiiie presentation as a testimony to the esteem and regard
in which he was held during the three years of his practice
in that locality.—Dr. C. J. Russell McLean has been pre¬
sented by the members of the Yeadon St. John Ambulance
Association with a beautiful Parisian timppieoe, as a token
of their appreciation of his “ J'irst Aid” lectures during
the past year.
Bequests and Donations to Hospitals.—T he-
late Mr. John Nuttall, of Newstead-grove, Nottingham,
bequeathed £50 to the Devonshire Hospital, Buxton,—Miss-
Margaret Chalmers, late of Broughty Perry, left by her
will .£100 each to the Dundee Royal Infirmary, and the Con¬
valescent Home, Barnhill.—Mr. John W. Dudley, late of
East Dulwich and Woodford, bequeathed £250 each to
the Brompton Consumption Hospital and the British Home
for Incurables, £150 to the Cancer Hospital, Brompton, and
£100 each to the Royal Ophthalmic Hospital, Moovfields,
and the Cancer Hospital (free), Fulham-road.—The Tallow
Chandlers’ Livery Company has made a grant of .5
guineas, the Mercers’ Livery Company a grant of .£52 1 05.,
and the Armourers’ and Braziers’ Livery Company a grant
of 10 guineas to the Great Northern Central Hospital.—
The directors of the Bank of England have voted a
donation of £100, and the Saddlera’ Livery Company
:£'20, to the Charing Cross Hospital.—The Earl of
Pembroke has sent a donation of £100 to the
Royal Hospital for Diseases of the Chest, City-road.—
Mias Tilley, formerly of Clifton, and late of Park-road,.
Gloucester, bequeathed £1600 to the Gloucester Infirmary,
.£1000 to the Bri,stol General Infirmary, £600 to toe
Gloucester Children’s Hospital, and £400 to the Gloucester
Dispensary.—Mr. George Palmer of the Acacias, Reading,
has sent a donation of ,£1000 towards the funds of the-
Royal Berkshire Hospital.--The Goldsmiths’ Livery Com¬
pany has made a grant of £20 to the Central London-
Ophthalmic Hospital.—The late Mr. Nathaniel Clayton,
J.P., of Lincoln, nequeathed £1000 to the Lincoln County
Hospital and £500 to the Lincoln General Dispensary.—
The Mercers’ Livery Company has sent a donation of 52'-'
guineas to the Surgical Aid Society.
Di(.' zed by CjOO^Ic
466 The Lancet,]
MEDICAL-NOTES IN PARLIAMENT.
[Feb. 21,1891.
Medical Magistrates.— The names of William
Henry England, M.D. St. And., M.R.C.S., and John Edwin
Scowcrofb, M.D. St. And., F.R.C.S.Edin,, have been placed
upon the Commission of the Peace for the Boroughs of
Leeds and Bolton respectively.
Portsmouth Hospital.— The forty-second annual
report, just issued, shows that no fewer than 7915 patients
had received treatment in this institution during the past
year, of whom 937 had been in-patients, and of these 658
were cured and 142 relieved. The expenditure for the
year had exceeded the income by £320 Is. 4c?. The total
investments now amounted to £19,174 6s.
The New Native Hospital at Luxor, Egypt.—
This institution will be a boon to the indigent fellaheen at
'Luxor and other natives. The opening ceremony was re¬
cently performed by the Khedive. The hospital has been
erected by contributions from English tourists, supple¬
mented by the generosity of Mr. Brunner, M. P.; whilst Mr.
■John Cook has undertaken to discharge any annual financial
deficiency. There are forty free beds, and gratuitous
medical aid will be given to the natives. The medical
officer is a native, and pursued his professional studies at
St. Thomas’s Hospital, London.
The Seamen’s Hospital Society. — Sir Thomas
Sutherland presided at the seventieth annual court, held on
'Taesday. The report submitted stated that the first
branch hospital adjacent to the docks, opened in June last,
had been almost constantly full since its opening. The
•cost of the building and furnishing amounted to £6798,
which had to be provided out of capital. During the year
i;he number of patients at the hospital at Greenwich had
been in excess of any previous year in the existence of the
Society. The dispensaries also had done good work. Ex-
-eluding the legacies, the revenue showed an increase of
U£200. The yearlj' expenditure of the Society was £13,000,
while the reliable income was less than £4000.
The Warren Triennial Prize was founded by
the late Dr. J. Mason Warren in memory of his father, and
iiis will provides that the accumulated interest of the fund
shall be awarded every three years to the best dissertation,
•considered worthy of a premium, on some subject in phy-
isiology, surgery, or pathological anatomy, the arbitrators
being the physicians and surgeons of the Massachusetts
■General Hospital. The subject for competition for the year
1892 is on some special subject in physiology, surgery, or
pathology. Dissertations must be legibly written, and
must be suitably bound so as to be easily handled. The
name of the writer must be enclosed in a sealed envelope,
on which must be written a motto corresponding with one
on the accompanying dissertation. Any clue given by the
•dissertation, or any action on the part of the writer which
reveals his name before the award of the prize, will dis-
■qualify him from receiving the same. The amount of the
prize for the year 1892 will be 500 dols. In case no disser-
'tation is considered sufficiently meritorious, no award will
•be made. A high value will be placed on original work.
METROPOLITAN ASYLUMS BOARD.
Seiwm of Patients remaining in the several Fever Hospitals
of the Board at midnight on February nth, 1S91.
Hospital.
Beds occupied.
Total accommo¬
dation.
Scarlet *
fever.
Diphtheria.
Enteric
fever.
Other
diseases.
Total J
IBastem Hospital .. . ■
67
4.6
2
80(>
442
kyorth-Westem Hospital
2:ii)
8:5'
i)
278
443
SVestem „
lt7
20
1
Oouth-WeBtern „
vn
2 :s
—
10
18(i
840
Gouth-Eastern „
190
18
?(}
8'
281
402
Northern „
28-1
14
80
828
480
Gore Farm „
5
-
5
300
Totals .. ... ..
1285
171
127
1501
2691
* Infants wibb motbeia.
MEDICAL NOTES IN PARLIAMENT.
Elementary Education (Blind and Deaf) Bill.
In ths House of Lords on Monday, thelCthinst., Viscount Cranbvook,
in moving the second reading of this Bill, said tiiat its object was to in¬
sure that blind and dsai chihivon, whenever capable of being instruoted,
should receive an education like other ciiildren in the country. Under
the provisions of the measure blind and deaf ciiildren would be sent to
institutions which already existed throughout tiio country, and which
had been established for the benefit of per.sons so afliicted, and power
was given to the school autliorities to contribute to the fiinil.s of such
existing institutions, or to establish similar institutions themselves,
which would specially be devoted to the education of blind and deaf
children. The Bill would also permit the I’avliaiiiontary grant being
extended to schools where those aftlicted litlio ones were educated, so
that blind and deaf children would receive educational advantages
similar to those enjoyed by their more fortunate companions. I^ord
Uerschell, Lord Norton, Lord Egertou, and bho Earl of Powis took part
in the debate.
Stedical Offlcere of Ilcalth.
On Tuesday, tiie I7tb, the Earl of Dunraven rose to aslc Her Majesty’s
Government as to the powers and duties of a medical officer of neaUh
appointed by a county council under section 17 of the Local Govern¬
ment Act, 1888. Ho should be glid at the same time to be informed
as to the powers of county councils in the matter. It appeared to him
to bo very difficult to gather from tho l.ocal Government Act wliat were
the powers of medical officers appointed by tiio county councils, or
what powers tho county councils themselves liad. 'They had the ap-
ointment of tiio medical officers of health, and it was provided that
y arrangement with the district councils their services could bo
rendered available ; and pending the institution of district councils
they could make, lie presumed, such arrangement with the urban or
rural sanitary autliorities. Bub wliat tlioso arrangeraonts were the
Act did not specify, and it was impo8sil)l6 to find ouc.—I^ord Henniker,
in reply, poiucoil out lliat the statute did not in any way proscribe the
duties wnicli were to bo performed by those officers; neither had ttio
Local Govormnont Board any power whatever to define their duties.
In each case the duties must bo .such as the county council iniglib lay
down when malting the appointment.
Infrinyenient of the Vaccination Acts.
On Monday, in the House of Commons, Mr. Matthews, in reply to a
question by 5lr. Chaniiing as to a sentence of seven days’ imprisonment
with hard labour, passed on B’cb. 4th on a person for non-payment of
costs incurred In connexion with an order under the Vaccination Acts,
said : I have received a report from the Justices in this case, and have
also boon furnished with a copy of the commitment. The man was
sentenced to imprisonment witliout hard labour. The occasion, there¬
fore, for such action as i-s suggo.sted in the second paragraph of tho
question has not arisen, nor have I any reason to beliovo ibat such
illegal sentences are of fretpient occurrence.
The Factory and Workshops Act(187S) Amendment Bill.
On Wednesday, Sir IL James, in moving the second reading of this
Bill, pointed out that its application was limited to those factories
where artificial humidity was mtrodiicod ; it aimed at a bettor sanitary
condition and ventilation of factories, jift'orded greater facilities for
escape from live and protection from injury fi'om clangoron.s machinery
by means of enforced fencing, and also insisted tliat workers .should
receive proper remuneration. In the discussion wliich followed Mr, Old-
royd, lilr. B. Reid, Mi-. J. A. Bright, and Mr. Jame.s McLean book part.
'J'he Home Secretary said tliat .sbmo amendment of tho li’actorii-a Acts
was requisite in tho interest of tho health ami .safety of tlio workmen,
and also for tho purpose of proventing any irregularity—he used a mild
word—in the payment of wages. G'ho ventilation of factories was nob
satisfactory, bub as regarded that it was as well not to lay down any
liard-and-fast rule to lit all circumstances. Considering the point re¬
lating to tile mean.s of esc.ape from fire, iio agreed that tlie operation
of a provision for tliat piupose (^ould not bo oonllned to future build¬
ings, ami was of opinion that a solution of the difliculty niiglit be found.
After liie debate iiml continued for some tiuie longer, tlie Bill was road
I a second time, and tbe Committeo stage w.a.s fixed for Thursday.
THE METROPOLITAN HOS3NTALS INQUIRY.
Tile Select Committee of tlio Hou.se of Lords on tho Metropolitan
lio.spitals resuraod its inijuiry on Monday. Lord Sandhurst, chairman
of the committoe, presided, and amongst other ineuibers present wove
the Arclibishop of Canterbury, tbe lilar! of Kimliorley, Lord Clilford,
Lord Saye and Selo, Lord Monkswell, I.oi'd Oatlicart, J.ord Zouoho,
and tho Earl of Lauderdale.
SI. Bariholomevi's Hospital.—The Outbreak of Diphtheria.
Ur. ’riiorne Thorne, assistant medical olHcer to tho Loc.’il Government
Board, examined by tho Chairman, said he made an Imiuiry into the
sanilarjr condition of St. Bartliolomow’s Hospital. Tho troa-surer
asked him if lie would consent to imdorlake this duty so far as the
sanitation might have afrected tho outbre;ik of dlpiitlioria among the
imrsea. Ho told him he could not do so officially, bub as an old St.
Bartholomew's man and as a por.sonal frioiid of tho troasiirer ho under¬
took to make the inquiry. The treasurer was under t!io improssion that
some of the sanitary circumsUnccs might liavo alfocted the outbreak,
ami witness naturally inquired into that first. He had nob yet
completed his inquiry, but lio liad made an investigation into the
sanitary circnmslaiico.s of tho two muses’ liomes and bho tliroe prin¬
cipal ward blocks, ami ho had sent Sir Sydnoy Watorlow a pro¬
visional report. It must l>e borno in mind tliat it was a provisional
report- Ho marked even tlie covering letter “private," in view of
the grounds on wliicli be had midortivkon the inquiry. JIo found
that the principal imrse.s’ home was so far perfect that iio thouglit
it would bo liardly possible to find aiiv ostfildisiimfinK in London tho
dr-ainage arr.angemonts of which and tlio sanitary cireum.staiicos wore
bettor. Tbo .second imr.ses'Itoaie was-an ohl biUldiiig. A groat many
attempts had boon made to put tlio drniuugo into good order, and great
expense hart been incurred, lie had found certain faults which lie
advised sliould bo remedioil. As regards botli these homos, ho thouglit
provisionall’^ tliat they had nothing whatever to <lo witli tlie outbreak
of diphtheria among the nurses, lie had two criticisms to make with
reference to the three principal ward blocka ivhicli lie exajnmod.
Coogle
The IiAhobt,]
THE METROPOLITAN HOSPITALS INQUIRY.
[Feb. 21,1891. 467
Some ttfteen years ago, at the cost of many thousands o£ pounds, the
covemora erected tho so-called sanitary bloclcB at the end of the wards,
with the object of getting the closets and lavatories aerated distinct
from the wards. He did Jtot think that this object had been properly
attained, bub a very small alteration wovrld entirely remedy tho defect.
'J'he principle of the arrangement was good, but the details were
fault^ Tho same criticism applied to certain disconnecting shafts
that were made at tho same time. It would be a small matter to put
them in order. ..... _
The Chairman: But would that not havo a very prejudicial otfoct
upon health?'-Dv. Thorne; 1 hardly think so, because all the dmins
coming down into this di.sconnecting shaft come from these sanitary
projections, which havo abundant means of cross ventilation quite in-
dependont of any air in the closets. 'J’horo was another defect con¬
nected with what was called tho nurses' scullery. In each scullery
there was a closet which had not been aerially disconnected, and which,
he thought, ought to be so. That really represented the faults he
found with the'buildings. Eocomineiidations wore embodied in his
report, and he had been informed that iustnictions had been given to
remedy all these matters forthwith.—The fjhairman : Have you been
able to form any idea how this diplitheria sliould have made such
headway ?—l>r. Thorne; I liave. I was rather anxious not to express
any opinion upon that, for this simple reason—that in order to do so
with any authority one has to know tho exact dates when nurses were
attacked, liow tho nurses were engaged, what wards they were eii-
aagod in, which home they had slept in, and especially whether they had
had to do with diphtheria patients. Tliis involvod a great deal of ivork
in a large hospital like St. Baibliolomew’s; and a inoetiug of the senior
staff was at once called with a view to gottingall these data. 1 havo not
yet received material enabling me to form any final judgment upon tho
point, but I have gone so far as to .say that I feel absolutely convinced
Miat any of the sanitary defects connected with the ward buildings
could have but only the most trivial, if any, influeiico upon tliis outbreak
of diphtheria.
By Lord (lathcart: Ho would not have advi.sod that tho nur.scs
should bo put in tho cubicle ward on tho same floor a.s tho most in¬
fectious cases. He had no doubt tiiat the spread of diphtheria led to
tho nurses being iiurried away from tho cubicle. Diplitlieria was most
rapidly increasing in England, and particularly in largo cities,—
Lord Catlicai't: You are decidedly of opinion that this diphtheria did
to some extent arise from defects in the arrangements, because you
suggested that the sanitary blocks were not in a satisfactory state, and
tiiat the nurses' scullery was nob disconnected with the main drain
Ur. Thorne ; In ray report I state “ that tho sanitary circumstances of
tho Nurses’ Homo in Little Britain are such as to forbid the belief that
they could in any way be concerned in tho production of tho disease;
tiiat wliilst I am unable to spealc with equal coiiHdont^e as to the Duke-
street Homo, I havo no ground for believing that diplitheria had
been induced by any of the sanitary conditions of that building ; tli.at
as regards the drainage of tlie ward blocks and tho internal armiigo-
nienbs of those buildings conditions do exist, and it is notable in the
ward kitcliens, which do bond to imwholosomeues.s, and which liave
been known to produce sore-throat; and that oven if this form of sore-
throat be not in its beginnings regarded as of a specific ehavactor, it is
certain that those suffering from it ars to an exceptional degree apt
to contract cliphtliovia when tlie disease is prevalent. This statement
is not intended to projmlgo tho question as to the origin and diffusion
of the infection during the recent prevalence, as to which tlie necessary
(lata are not forthcoming.’’—Lord Catlicart: Are you .satisfied that
there has boon no outburst of sewer gas into this building V—Dr.
Thorne: Iftboreh.as been at all it has been by moans of the ward
soullories.—Lord Cathcarb : And you tliiuk It probable that there was
an escape of sewer gas into those ward sculleries Dr. Tliorno : The
arrangonionts of tliose aciillorios wore about tho saino as in all I.ondoii
houses. ’.I'licy wero so far faulty. I know thoro havo been complaints
of offensive odours in that part of the ward, and liieroforo T am bound
to admit tiiat both tlio structural arrangenionls and the ovidonoo
I have received point to some such danger at that one spot.—
Lord Catheavt: Do you say tiiat the sculleribs attach to the wards?—
Dr. Thorne : Yes,—J.ord Catlicart: Would tiiat not in your opinion l>o
onoiigh to account for an outbreak of disease'i'—Dr. Tliorno ; Your torm
" disease” does not help mo, It is well known that drain effluvia cause
soro-tliroat, and sore-throat is a eoiidilion which diplitheria seeks above
all things for its attacks, tlontinuing, J)r. Tliorno said tiiat lie callod
tlie nurses and sistors together, and asked them to mako any complaints
tlioyliad to mako. They said tiiat in oortain wards thoro had lioen
offensive odours from the closets and ward .sculleries. Ho did not think
their complaints went beyond that.—I-ord Catlicart; Bub Mr. Cro.ss in
evidence s.akl that there had been no complaints about tho closets?—
Dr. Tlioriic : I can only tell you what the nurses and sisters told mo,
By tho Earl of Ixiudeislale ; Ho occasionally gave lectures on public
health at St. Bartholomew's, but ho seldom onturod the wards.
By tho Karl of Kimberley ; He considered it ii bad arrangement that
the closets should open into the sculleries, and he liad ordered its ininio-
diate disconbinuaiice. Though tlie main drain was of brick, it wa-s very
eiileieiitiy const ructed, and he was not proiaired in all tho circumstancos
to recommend its removal.
Mr, Cross, clerk of St. Bartholoinow’s Hospital, examined by_ the
Cbaiiman, said lliat tiiore was no periodical examination of the sanitary
condition of tho lio.spital. Thoyliad a surveyor as well as a Clerk of
Works. 'J'lie dork of Woiks mado an inspection of tlio drains ovoiy tliroo
iiiontlis, Ho would nob .sav whether tliab was suflioient; !io merely
"tatod tlio fact.
by J.oi'd Catli&'ui : It was the case that on Jan. 2Qtli he stated thoro
bod boon no complaints as to the closots. Ho hoard nothing of siicli
complaints until li'oh. dth or 5th. Th(M-ow:i,s no intentional Conccal-
mont of the facts on his pai-t. Jfo should bo prepared to admit that
tlioy had engaged mii’ses wlio iihysically wore not strong eiiougli for
tlio strain pul uiioti them. Alioul. two mmitlis ago the governors insli-
tiitod a inoro SHavching examination for all camiidatos as nurses, iii
oi'(lor that tlioy niiglit bo sure of their constitutional fitness for the
duties. No one could deny that tlio iioui-s of tho nurses wore very long.
His two daiiglitor.s, wiio wero iiuvsos in the hospital, told iiim tiiat they
were well and well caved for. He did not boUovo there Wiui any
ground for compliiiut a-s to the fond of tho nurses. The matron sug-
gcstoil about (.lie niiddlo of Jlocoinber that it would bo dosirablo to offer
the nurses a glass of port wine each day, and some soup at ten o’clock,
Iho suggestion was no douht due to the illness among the nurses. His
dauglitor contracted diphtheria from a ward maid.
Lord Cabheart: A ward maid would be always over the Binksj? Mr-
Cross replied that this particular ward maid had been in the hospitaB
only four days. The current balance of the hospital with the Bank of
England might amount to £40ti0 or £6000. That money lay dead. They
could not keep money on deposit receipt with the Bank of England.
By f;ovd Monkswell; It ivas not the case that they had over appliedi
for permission to take in paying patients.
Mr. I’An.sou, surveyor of the hospital, examined by tho chairman,
said he had general supervision of tho buildings. He reported anything
wrong either in sanitary or structural matters. He received reportsi
from the Clerk of Works every week, or oftener if necessary. Witneaa
was not a sanitary engineer, though ho understood drainage matters.
His salary was ;«0 guineas, and lie received 2i per cent, on new work.
He engaged in private practice. He reported annually on the .state of
the property. In consoquonce of tho onbbroak of diphtheria he on,
Dec. ‘Jth examined all the wards, Duko street nurses’ home, and the
matron's house. The report of that examination was the first report he-
hacl presented on tlie sanitary condition of the hospital since his;
appointment three years ago. He found that the sanitary arrange¬
ments of tho hospital were good, though nob up bo date. He expressed,
tlio opinion that tiievo was nothing in the sanitary aiTangements tO’
account for the outbreak of diphtheria.
By Lord (Jaihcart: He considered it one of his duties to attend to-
tlie sanitary condition of the hospital. Ho did not receive a drainage
plan from his prodecossor, although lie believed an old plan was
ill existence. Ho recommended that tho main drain, wliich was-
of brick, siiould be cut off and ventilated. He believed the drain
was executed as long ago as 182$). A largo drain passed undorneath tlie-
.surgory, ten feet below the basement. He only made this discovery
(luring Ills reient inspection If the hospital were to be brought up to
date it must be redrained. Considering that there were GOO sick persona,
in the building, it was, in his opinion, desirable that the system of
drainage siiould be begun de nooo.
Dr. Barnes, consulting piiysician in St. George's Hospital and Chelsea
Hospital for Women, submitted evidence a.s to the liospital-aupply of
London. Ho expressed liimsolf in favour of hospitals of moderate size,
and thought that some of the existing institutions might with profit be--
removod bo tlie country.
The Committee then adjourned.
The Committee mot ag.ain on Thursday, Lord Sandhurst presiding.
Middlesex Ilonpilal.
Mr.-P'. C. Melhado, secretary of the MiddlosexIIospital.attended-
andmado anunibevof alterations in thenotes of liis evidence. He also-
answered several fresh (iuo&tiona put to him by members of the Com¬
mittee.
By the Chairman : They employed a firm of public chartered
accountants to examine the accounts of the hospital twice a year, and
give a certificate to the weekly board. Tho .accounts were exainine(fe
annually by tiiroo auiiitors appointed by tho court of governors.
By Lord Oatncai t; All pationl.s were rendered itiaonsiblo before being,
taken into the operating room. In his offico tliero was a complete-
' drainage plan of the hospital. It was accessible at any moment. In.
his opinion it was absolutely noces.sary to have a drainage plan. IIO;
couhl hardly understand a largo hospital being without a drainage plan.
By Karl Spencer : When patients wero unahlo to provide themselves,
witli tea ami sugar they wero supplied from tho funds of tlio Samaritan
Society. About twenty patients oacli ii’eek were unable to provide'
themselves with those commodities.
Cliari7i!i-cros$ Hospital.
Mr. Arthur E. Iteado, .secretary of Charing-cross Hospital, examined'
by tho Cliairnmn, said tiiat the institution was founded in 1820 and tliC’
present buildings wove opened in 1834. It was an absolutely froe'hos-
pital. Letters wero issued by tlio governors, but persona bearing tliose-
lebtors enjoyed no preference. Of tlio 2105 pationte admitted Inst year,,
between 200 and 300 brought governors’ letters. The weekly board was;
open to all the governors, bub as a mlo only six or seven attended the-
mooting, and tliose wore members of council. The members of council-
were elected for tliroe years at tho annual court of governors, and were
eligible for re-election. It was tho council who dismissed the high;
officials. All raalo servante wore engaged and discharged by witness,
and mu'S(i8 and probationers were engaged and discharged by tho lady
superintendent. Sisters wore engaged by tlm council in consultation
with tho lady suporintendont. In the event of dismissal either of a male-
servant or a nurse, tho matter was always reported to the weekly board
or to the council. Thoro was always an appeal to a superior authority.
Tho annual income of tho hospit-al was about £0000. Annual subscrip¬
tions constituted their most reliablosourco of income. Their present-
income was iii.sufflcient to meet the expenses of the hospital. They
lia(i to draw from capital laid aside in uetter years. There were l75-
b(3d3 in tho hospital, of which about 105 might bo described as working
beds. Several beds wove lesorvod for accident cases, of which they had
a largo number. Tlioy had seldom to turn away patients. As a matter
of fact, he considered the hospital supply of tho district to be sufflcieiit.
They experienced no difficulty with the contractors in keeping their-
waves up to sample. He could not remember a single case of complaint-
as to the food. Thoro wore tti-e resident iihysicians and surgeons. In
the event of gross misconduct by an officer, ho would bring tho
niiibtov to tho notice of tiie treasurer. Witness had no aiitbovity
t.o suspend an officer. Witnes.s did not vosido in the hospital, and in
his aUsonce tho chaplain took his place. The nursing staff consisted of
ton sister.s, seventeen nurses, and twenty-four probationers. Six of the-
probationers wore lady probationor.s, -wiio paid one guinea a week. It-
was only rocoully that tlioy had bogiui to do their own nursing. Sistess
worked eight hours and a half per day. One Kunday tliey wero on duty
(ivo hours, and the next Sunday nine hours. Allogcthor they wore on
(iuty fifty-eight hours a week. 'The nurses wore on duty sixty-seven and
the probationers sixty-nine hours a week, Nurses did nothing bub
iiur.si'ug work. Ward maids came in to do the menial work. The
council were considering tho (jue.stionof pensions for tho nurses. Nnrses-
woro paid from £22 to £25 a year, and received uniform and 2x. (W.
per week for wasliing. I’robationoi's received no salury for the first
year, £15 for tho second, and £20 for the tliinl 'i’lioy vocoivod uni¬
form ami 2.V. lid. per week for washing. At the end of tlio third vear
they gave the nurses a certificate of ofTnaoncy. They had only very
recently begun sending out mir.sos. Ho should certainly like to see a
uniforni system of account-keeping amimg tho London hospitals. Hct/
did not think it would be possible to briiig the accounts into exactly
488 The Lancet,]
BOOKS ETC. RECEIVED.
[Feb. 21,1891.
*t;be 8a.me form. The out-patient department was not crowded, lie
<ouldglve DO estimate of the cost per patient in this department.
By Lord Cathcart; They had a sanitary plan of the hospital. Ho
regarded it as a necessity in such an institution. They had a ward for
Jewesses. The lady who gave the money for this ward was quite willing
'Uiat Christians should be admitted, although Jewesses should have a
preference. There were over 200 students in the medical school. No
complaints of overwork had been made by the nurses. Lord Cathcart in¬
formed the Committee that he had made a surprise visit to the hospital
:along with another member of the Committee. They went over the
whole establisliment, and, considering the limited nature of the site, he
regarded it as very satisfactory.
By Lord Zouche: The medical school paid all expenses, and made a
email contribution to the funds of the hospital. There ivas a post¬
mortem examination in all cases where no objection was raised.
By Lord Thring: Bighc members was a small, and fourteen a large
attendance at the monthly meeting of the council.
By Lord Clifford: Unless they received large legacies or a material
■'Increase in the way of subscriptions, they would soon be unable to carry
on the hospital as at present without a special appeal to the public.
By the Chairman: They were always appealing to the public, but
<hey hadnotmadcaapecialappeal since ISSO, when the hospital was closed
for thirty days. They did not admit scarlet fever, and only severe cases
•of diphtheria, They took typhoid fever, but not typhus fever. Sisters
received a holiday of one month, nurses of throe weeks, and probationers
‘could have a week if they cared. Any of the staff might take a day or
a half day.
By the Earl of Kimberley: Many persons used the hospital as they
would a consulting physician. They discovered few coses of abuse of
•charity. Many of the old students sent patients to the hospital both
€or admission and consultation.
Mr. Stanley Boyd, dean of the medical school at Charing-cross
Hospital, examined by the Chaiiinan, said that 228 students were at
present in attendance. Last year they had 82 new students, 81 general,
35 dental, and 16 occasional students. The school was increa.sing
slowly but steadily. The general student paid either 00 guineas
in one sum or 100 guineas in five instalments for tiio cuniculum
or the Conjoint Board diploma. The dental student paid either
64 guineas in one sum or 60 guineas in two instalments. The total
gross revenue of the school last year amounted to £4070. One-fifth
of all fees was taken off for the ho.spital, one-flfth went for school
management, three-fifths were divisible among ttie staff and lecturers.
He considered it would be a very great advantage if the hospitals were
^relieved entirely from the teaching of botany, sioology and pliysics, and
:a certain amount of the rudiments of chemistry. Those suojects could
be taught In the scliools and colleges throughout the country. A central
school would be open to considerable disadvantage.
By Lord Cathcart: They had no difficulty in maintaining discipline
-amongst students. Troubles occasionally arose.
By the Earl of Arran ; What was warned in the medical profession
was a more uniform standard of education and a standard higher than
'«the lowest now accepted.
By the Chairman: In the course of this inquiry it had been said that
they could not possibly teach such a subject as physiology at Charing-
'cross Hospital. Witliout boasting, he might safely say that their
physiological department was as good as any in London.
Mr. Frederick Willcocks, one of the out-patient physicians at the
'hospital, explained the methods of the out-patient department. Ho
expressed the opinion that, from a teaching point of view, this was the
onost valuable department of the hospital, and lie would not like to see
it abolished. Very few of their patients could pay a fee for medical or
surgical treatment. He did not think that the schools should be sepa¬
rated from the hospitals. There were .sufficient, but not too many.
- schools in existence. The physicians and surgeons received no payment
■for the work they performed in the out-patient department. The resi-
• dent appointments were the priices of the school, and were given to the
'best of their students.
The Committee then adjourned.
BOOKS ETC. RECEIVED.
'•Chdbchill, J. (b A., New Burlington-street, London.
The Barbarity of Circumcision. By Herbert Snow, M.D. Lond.
1890. pp. 67.
•Cassell & Co., London.
The Year-book of Treatment for 1891. pp. 430.
fSBOAN Paul, Thkncu, & Co., London.
Body, Parentage, and Character in History. By F. Jordan, F.R.C.S.
1890. pp. 82. Price 2*.
•Selly & Co., Great Queen-street, London.
Kelly’s London Medical Directory, 1801. pp. 380. Price to subscribers
6s.; Don-subscribors, Os. M.
iPENTLAND, YOUNG J., Edinburgh and London.
A Conipend of Oyniecology. By Henry Morris, M.D. lUu.stratod.
1891. pp. 175.
A Conipend of Diseases of Children. By Marcus P. Hatfield, A.M.,
M.D. 1891. pp. 185.
'The Elements of Ophthalmoscopic Diagnosis. By Goo. A. Berry,
M.B., K.RC.S. Edin 1891. pp. 83.
Reports from the Laboratory of the Royal College of Physicians,
Edinburgh. Edited by J. Batty Tuko, M.D., and Dr. Noel Patou,
M.D. Vol. III. 1891. pp. 804.
IPERCIVAL & Co., King-Street, Covont-garden, London.
Now Official Remedies, 1890. By Ralph Stockman, M.D.,r.R,C.P.K.
1801. pp. (15. Price
■Smith, Elder. & Co., Waterloo-placo, London.
St. Bartlioloinew’a Hospital Reports. Edited by W. H. Church,
M.D., and W. J. Walsham, F.R.C.S. Vol. XXVI. 1899.
The New Sydenham Society, London.
The New Sydenham Society’s Lexicon of Medicine and the Allied
Sciences. By H. Power, M.B., and L. 'W. Sedgwick, M.D. Part
17. Mas—Mit. 1880.
Thin, James, South-bridge, Edinburgh.
Tlifi Intra-cranial Circulation, By James Cappie, M.D. 1899
pp. 188. _
Effecte der Nervenreizung durch intermittirende Kebtenstrume; von
Dr. Br, Werigo (August Hirschwald, Berlin, 1891).—The New State,
or Unorthodox Socialism ; by J, Stirling (W. Reeves, London, 1891);
price 0(i.—The Treatment of Chronic Tubercular Consumption ; by G.
C. Smith, M.D., Austin, Texas.—Preventable Deaths in Childhood;
by W, Wynn Westcott, M.B.Loiid. (Hansard Publishing Union,
London).—Our Baby: for Mothers and Nurses; by Mrs. Langton
Hewer (J. Wright & Co., Bristol, and Slmpkin, Marshall, & Co.,
London, 1891); price Is. 6d.—Las Inyecciones de Koch ; por el Dr. D.
G. G. Lozano (Marobo y Hormano, Madrid, 1891).—Recent Reports
to the Scientific Grants Committee of tlie British Medical Asso¬
ciation ; reprint (Office of the British Medical Association, London,
1891); price 2«. 6d.—Psychologie do Tldiot et de TlmbiScile; par le
Dr. Paul Sollier (Bailliiire et Cio., Paris, 1891).—Annual Report
of the Su])ervising Surgeon-General of the Marine Hospital Service of
the United States for the Fiscal Year 1890 (Government Printing
Office, Washington, 1890).—Experiments with Drugs as a question
of Science, with a Supplement; by Wm. Sharp, M.D., P.R.S.
(G. Bell & Sons, London, 1800),—Archiv fiir Pathologische Anatomie
unci Physiologic und fiir Klinische Mediein; herauagegeben von
Rudolf Virchow; Band cxxiii.. Heft 2 (George Reimer, Berlin,
1891).—Medical Edueation, Mediral Colleges, aiicl the Regulation of
the Practice of Medicine in tlie United States and Canada, 1765-1891;
by J. H. Rauch, M.D. (II. W. Uckker, Springfield. Ill., 1891).—Inau¬
gural Address delivered before the Clinical Society of London,
Jan. 23rd, 1801, by Sir Dyce Duckworth, M.D., LL.D., President (John
Bale and Sons, London).
^pinterats.
Sueoeesful applicants/or Vacancies, Seeretaries o/PubUo Institutions, and
otk^s possessing tnformaiion suitable for this column, are invited to
forward it to ’The Lancet OJJlee, directed to the Sub-Editor, not later
than 9 o'clock on the Thwrsday morning of each week for pxiblioalion in
the neat number. - ■ —
Agnew, E. D., M.R C.S,, has been appointed Medical Officer for the
Workliouse, anti Medical Officer and Public Vaccinator for the
Ilollingbury District, of the Bishops Stortford Union, vice Cribb,
deceased.
Ballance, OiiaS. a., F.R.C.S, Eng., has been appointod Surgeon to the
National Hospital for the Paralysed and Epileptic, Bloomsbury,
vice Wm. Adams, F.R.C.S. Eng., appointed Consulting Surgeon.
Beaumont, A. W., L.E.C.S. Edin., iias been appointed Medical Officer
for the Fourth District of the West Ham llnion.
Beville, F. W., L.R.C.P,, M.R.C.S., has been appointed Clinical
Assistant for Diseases of tlie Skin to St. Thomas’s Hospital.
Bt.AVNEY, John H., L.F.P.S. Glaag, has been appointed Medical
Officer of Healtii to the Great and Little Iloatoas, Prestwich Union
Rural Sanitary Authority.
Carter, W. R,, B.A. Cantab., L.R.C.P., M.R.C.S., has been appointed
Resident Accouclioiir t o St. ’Thomas's Hospital.
Cassal, C. E., has been appointed Public Analyst for the Administra¬
tive County of Kesteven.
Collier, Horace, F.R.C.S. Eng., L.R.C.P. Lend., has been appointed
House Physician to the CIhulten's Hospital, Great Ormond-stroet,
vice James Bays, M.D. Lond., resigned.
CuESWELL, J. E., J..R.O.P. Lond., M.R.C.S., has been appointed Senior
Assi.stant Medical Superintendent for the St. Pancras Infirmary,
Dartmoiitli-park-hill.
Derry, B. G., L.R.C.P. Lond., M.R.C.S., has been appointed Medical
Officer of IleaUh for the 'J'liird District of the Bodmin Union.
Evans, Aijel, M R.C.S., lias been reappointed Medical Officer for tho
Lampeter Union.
FORDE, 'T. A. M.. L.R.C.P, M.R.C.S., has been appointed Clinical
Assistant for Diseases of the Skin to St. 'Thomas's Hospital.
GiDSON, James, M.B., C.M. Glasg.. has been reappointed Medical
Officer of Iltaith for tlie Orcetland Union District.
GODi'RKY, O. P.. L.R.C.P., L.R.C.S. Edin,, has been reappointed Hono¬
rary Con.siiHing Surgeon to the Mansfield and Mansfield Woodhousa
Di.strict Hospital.
Grij'I-ith, W. S., M.A., M.B., B.C. Cantab., L.R.C.P., M.R.C.S., has
been appointed Assistant House Surgoon to .St. Tliomas’s Hospital.
Hanson, A., L.R.C.P. Edin., M.R.C.S., has been appointed Medical
Officer for tlie Witliorn Di.strict of tho Louth Union.
Harper, J. R,, L.R.C.P., M.R.C.S., has been appointod Assistant
House Surgoon to St. 'Thomas’s Hospital.
IlAYnoN, 'T. !!.. M.B,, B.C.. Cantab., JaE.G.P., M.R.C.S., has boon
appointed Clinical Assistant for Diseases of tho Ear to St.'Thomas's
Hospital,
Hill, W. H., M.B., C.M. Edin,, has been appointed Modic.al Officer for
the Biisfiml District of the Basford Union.
Horner, C. J., L.H.C.P. Lond., M.R.C.S,, has been appointed Medical
Officer for tho 'Twelfth District of tlie West JIiuii Union.
HOUSLEY, John, M.D. St. And,, M.R.C.S., lias been reappointed
Medical Officer of Health for tlie East Rolford Rural District.
Hugo, I'l. V., L.R.C.P. Lond., M.R.C.S., has been appointed Assistant
Medical Officer of the WoiUhoiise, and Medical suporintendent at
tlio Infirmary, for tho Parisli of Paddington.
Hunter, William, M.D., M.R.C.P.. lias been appointed As.siataiit
Physician to the London Fever Hospital.
Jackson, J. L,, M.B., C.M. Edin., has boon appointod Medical Officer
for tho Uedon District, Yorkshire.
Jones, 'Tugs., M. 11.0.S., has been reappointed Honorary Medical Officer
to the Mansfield and Mansfield Woodhouso District UospitaL
c Coogle
This Lancet,3 APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, & DEATHS. [Feb. 21, 1891. 469
Kelynacic, T. N., M.B., Ch.B. (Viet ), Pathological Kegistrar to the
Manchester Royal Infirmary, has been appointed Jitnior Demon*
strator in Pathology to the Owens College.
ICiNO, A., DIl.C.P., M.R.C.S., hoa been reappointed Resklont Honae
Physician to St. Thomas’s Hoapittl.
KiRSOJH*, Thomas, M.B. Lnmi,, M.R.C.S., ha® been reappointed
Medical Officer forthe Second District of cho Horsham Union.
Eeadeu, C. R , M.B.R.U. Ire!., M.Ch., has been appointed Medical
Officer for the Worthen Di.-trict of the Foi<l<-n Union.
I/AMBERT, F. W., L.R.C.P. Efiin., M.R.C.S,, has been appointed Medical
Officer of Health to the Fatsh-y Urban Sanitary Authority.
Levick, H. D., L.R C.P., M.R.C.S , has been appointed Senior Obetotric
Clerk to St. Thoinas’a Hospital.
Lrm.ETON, P. R., M.R.C.S., has been reappointed Medical Officer for
the Ashbourne District of the Aeliboui no Union.
LOVEI.L, C. P., M.A. Oxon, 1. R.C.P., M.R.C.S., L.S.A., has been
appointed Non-resident House Physician to St. Thomas’s Hospital.
t/OW, H., M.A., M.B., B-C. Cantab., L.R.C.P., M.R.C.S., haa been
appointed Non-resident House Physician to St, Thomas’s Hospital.
Lyons, Algernon Wilson, M.B., L.R.C.P.Lond., M.R.C.S., has been
appointed Assistant Medical Officer to the City of London Lunatic
Asylum, Dartford, Kent.
Macfadyen, D., L.R.C.S. Edin., has been appointed Medical Officer
for the Parochial Board of Invernesa.
McCall, A., M.B., C.M. Qlasg., has been appointed Medical Officer for
the Conisborough District of the Doncaster Union.
Mackie, John, M.D., L.R.C.S. Edin,, has been reappointed Medical
Officer to the Brechin Infirmary.
Meadows, R. T., M.B., C.M. Edin., has been appointed Medical Officer
for the Borough of .Saltash, vice Revel.
Millar, W. IL, L.R.C.P., M.R.C.8., lias been reappointed Clinical
Assistant for Diseases of the Throat to St. Thomas’s Hospital.
Morton, C. A., F.R.C.S. Eng., has been appointed Pathologist to the
Bristol Hospital for Sick Children and women.
MUNRO, J. M., M.B., C.M. Aberd., has been imppointed Honorary
Medical Officer to the Mansfield and Mansfield Woodliouse District
Hospital.
Neii-son, H. J., M.D. Glasg., has been appointed Medical Officer to the
Workhouse, Basford Union ; also Medical Officer to the Pride of the
Village Lodge of tho Manchester Unity Independent Order of Odd
Fellows, Old Basford.
Ranson, W. E., M.R.C.S., has been appointed Medical Officer for the
Needliam District of tho Bosmere and Claytlon Union.
Riley, Rownd J., M.R.O.S., L.R.C.P. Edin., haa been appointed
Medical Officer to the Workhouse, Cannock, vice Thomas Wilson,
M.D., resigned.
Rohertson, John, M.B., C.M., B.Sc. Edin,, has been appointed
Assistant Medical Officer of Health for St. Helens, Liverpool,
Rouillari), L. a. j., M.B., B.C. Cantab., L.R.C.P., M.R.C.S., has been
appointed House Surgeon to St. Thomas’s Hospital.
Sayres, A. W. F., L.R,C.P.. M.R.CS., has been reappointed Clinical
Assistant for Diseases of tho Ear to St. Tliom.as’s Hospital.
Shearer, D. F., B.A., B.M,, B.Ch, Oxon., has been appointed House
Surgeon to St. Thomas’s Hospital.
Simmons, W. W., M.B. Cantab., has been appointed a House Physician
to tlie City of London Hospital for Diseases of the Chest, Victoria-
park.
Stokes, W. G. G.,B.A., M.B., B.C. Cantab., L.R.CP,, M.R.C.S., has
been appointed House Surgeon to St. Thomas’s Hospital.
Thomson, w. K. P., M.B., C.M. Edin,, has been appointed Resident
Medical Officer for tho Parish of Rday, Orkney.
TltOMi>aoN, W. H., M.D.Durh., L.R.C.P,, L.R.C.S, Edin., has been
reappointed Medical Officer of Healtli for tlio Quarry Bank Urban
District of the Stourbridge Union.
Toller, S. G., L.R.C.P., M.R.C.S., has been appointed House Surgeon
to St. Thomi.s’a Hospital.
Tunstall, A. E., L.R.C.P,, L.R.C.-S. F-din.,ha8 been appointed Medical
Officer of Health for the Clayton Urban Sanitary District of the
Nortli Briorley Union.
Umney, W. F,, L.R.C.P., M.R.C.S., has been reappointed Resident
House Physician to St, Thomas’s Hospital.
UsnnK,_C. H., B.A., M.B., B.C. Cantab., has been appointed Clinical
Assistant for Diseases of tiio Tliroat to St. .Thomas’s Ho.spltal.
Walker, Benjamin, M.D.Durh., M.R.C.S., has been reappointed
Medical Officer for the Ravonstonedalo District of the East Ward
Union.
Wilre, Haydock, M.D.Durh., L.R.C.P. Lond., M.R.C.S., has been
appointed MedlcnJ Officer to tho St. John’s-wood and Portland-town
Provident Dispensary.
Wilde, Leonard, M.D., D.P.H., M.R.C.S., L.R.C.P,, haa been
appointed Assistant Medical Officer of Health for Croy<lon Borough.
Wm., M.B., C.M. Edin., has been appointed Assistant Medical
Officer to the Edinburgh Provident Dispensary attached to Ihe
School of Medicine, Marshall-street, vice Andrew Messer, M.B.,
O.M., resigned.
Liverpool Infirmary for Children, Mwtle-atreet.—House Surgeon.
Salary £85 per annum, with board and lodging.
Liverpool Royal Southern Ho-spital.—J unior House Surgeom
Salary 00 guineas per annum, with board and residence.
Lutterworth Union.—M edical Officer for No. 6 District. Salary £20
per annum, with tho usual extra medical fees as allowed under thfe
orders of the Local Government Board. (Apply to the Clerk to the
Guardians, Lutterworth.)
Leeds Unkin.—A ssistant Medical Officer and Dispenser for tho Work^
house, Scliools, and Infirmary, Leeds. Sa'ary .£100 per annum,
with board, washing, apartments, and attendance.
London Temperance Hospital, Hampstead-road. N.W.—House Sur¬
geon for six months. Board and residence at tlie Hospital, and ro*-
miineration at the rate of 50 guineas per annum.
MANOHEtTER HoYAL INFIRMARY.—Resident Medical Officer for the
Convalescent Hospital at Choadle for one year. Salary £160 peir
annum, with board and residence.
North Staffordshire Infirmary and Eye Hospital, Hattshill,
Stoke-upon-Trent.—Assistant House Surgeon. No salaiy, but board,
apartments, and washing provided.
Royal South London Dispensaky.—S urgeon in Ordinary. (Apply to
Dr. Nundy, at the Dispensary, St. George’s eross. S.E.)
Salford Union.—A Visiting Medical Officer. Salary £160 per annum.
Salpord Union.—Two Resident Assistant Medical Officers for tho
Union Infirmary, Hopo, near Bccles. Salary £130 per annum each;
with furnished apartments tn the infirmary.
Skiklaugh Union.—M edical Officer and Public Vaccinator for tho
District of Sproatlcy. Salary £20 per annum, exclusive of the
authorised fees for surgical and midwifery cases, visiting lunatic
paupers, and vaccination. (Apply to the Cleric to the Guardians,
Beverley.)
St. John’s Hospital for Diseases of the Skin.—H ouse Surgeon foe
three months. Board and residence provided.
St. Thomas's Hospital, Westminster-orklge-road.—Assistant Phy--
sician.
BIRTHS.
DiCKMAN.—On Feb, 11th, at Buntingford, Herts, the wife of Heiirp-
Diclcman, M.B., of a daughter.
Dundas,—O n Fob. 12th, at Litcham, Norfolk, the wife of Mordaunt G.
Dundas, M.R.C.S., of a daughter,
Gahdineu-Hill.—O n Feb. I4th, at Middlesex County Asylum, Tooting,
the wife of If. Oardiner-Hill. Meoicol Superintendent, of a son.
ROHINSON—At New North-road, Huddersfield, the wife of F. W.
Robinson, M.B.. M.R.C.S., of a son, _ „
Welsh.—O n Feb. lOth, at Biggleswade, Beds, the wife of R. C. Welsh,.
M.B., C.M., of a son.
WORNUM.—On Feb. 13th, at Collego-torrace, Hampstead, the wife of
George Porter Woriium, M.R.C.S., of a daughter.
Wreford.—O n Feb. llt*i, at Clapham-roati, the wife of Samuel
Wreford, M.R.C.S., of a son.
UuSDF.LL.—On Fet). I2b!i. at Marldon House, Buckfastleigh, Devon, tlie
wife of Henry Ubsdell, Surgeon, of a son.
MARRIAGES.
GODLEE—SeeroHM.—O n Feb. 12th, at llitchin, Rickman John Godleo,
I''.R.C.S., of Wimpole-streot, W., second son of tho late Rickman
Gndlee, Ksq.. of Lincoln’s inn, to Juliet Mary, eldest daughter ofi
Frederic Seohnhni, of ilitchin.
IIUiilLi_ KvicuAiiD.— On Feb. I-lth, at St. Mary's. Balham. Viy the Rov.
Thos. Bai,“s, Vic.ir. George Frederick ilug'll, ot Arundel Lodge,.
Bnlham, Physician and Surgeon, thii d son of John llugill, of Ro.se-
dale, Chisloliurst, to Muriel Isabel, widow of the late Charles
Evetard, and youngest daughter of Lieut.-Colonel U. A. Vernon, of
Ilarefleld Park, Usl>ridge, late Ooldstrom Guard.s.
Jones— Sleeman.— On Fob. I2th, at Holy Trinity Church, Southwark,,
by tho Rev. W. London, Cyril Lloyii Jones, M.A., ^^.D., late of
Cains College, Cambridge, and the Middle Temple, Bavrister-at-Law,
of 2, Ashley-gardens, Victoria-street, S.W,, and Blackfriai's-road,
S.K., second surviving son of tiie late Frederick Charles Jones,
M.D., to Catherine Geitrude (Katie), youngest daughter of Dr. John
sieoman, of Southwark-bridge-roail, S-E-
SHAriCLETON— Davis.— On Feb. 10th, at Holy Trinity Church, Wey¬
mouth, Thomas lYands Shackleton, M.R.C.S , L.S.D., son of tho
late John Colyer Shackleton, Esq., of Selhurst Park House, South
Norwood, to Luiaii Terry Cockerara, youngest daughter of the late
Lieut.-Colonel Davis, Bengal Staff Corps.
i'afSTOts.
Jhr/urtAef iVomuHion regarding each vaeanoy reference Amild be made
to the advertisement.
City Asylum, Birmingham.—Clinical Assistant. No salary, butboard,
lodging and washing provided.
eastern Division of the Royal Maternity Charity.—O bstetric
Inyrician. (Apply to J. Long, Esq,, the Charity's House, 31,
Finsbury-squaro, E.C.)
Birmingham.—Resident Medical Officer. Salary
nD.ni. residence, board, and washing.
Northern Central Hospital, Holloway-road, N.—Surgeon to
<»ut-Pafcients of this Hospital.
nosi ital for Consumption and Diseases of the Chest. Brompton.—
„ House Pliysidans.
^ Children, Great Onnond-street, Bloomsbury.—
the term Honorarium of £40 at the end of
DEATHS.
BrittaN.—O n Foh lOth, suddenly, at Oxford-terrace. London, Frederick
Bribtan, M.D., F.E.C.S., of Gwynfryn, Cardiganshire, late of Clifton,
Bristol.
Emmett.— On Feb. IHli, at Winter Hey House, Uorwich, William H.
Emmett, M.R.C.S.
Olivpu,—O n Fob. 4th, at Hortford-gardens, S.W., John Ferens Oliver,
M.D., late of Durham, aged 38.
Maiisden.— On Fob. fJth, at Hastings, James Loftus Marsden, M.D.,
aged 75.
Partiudok.— On Feb. 12tli, at East-hill, Colchester, Joseph Henry
Partridge, J.P., Surgeon, in liis 74th year.
Warwick.—O n Feb. lObn, at Royal-terrace, Southend, Essex, William
Rollinson Warwick, M.D., in his 74th year.
Wotheksi'OON —On Feb. lOtn, at his residence, the Mansion House,
Brampton, Cumberland, Thos. A. Wotherspoon, M.D. Edin., aged 43.
Jf. B —A fee rf /it, is charged for the Jmerlion of Notices of DirfAs
aarriages, and Deaths.
Dir:' /ad by
Google
470 Lanost,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Feb. 21,1891.
Slfbital giarg for ensning WmIi,
Honda?, FeOruar? 2S.
Botal Lo^n)ON Opuiualhic Hospital, Mocapislos. —Opemtloiu
dailyAt 10 a.h.
BOTAL WESTMiNSTsa OPHTHALMIC HOSPITAL.—Operations, 1.80 P.H.,
and each day at the same hour,
Chelsea Hospitalkoh Women.—O perations, 2.B0P.M.; Thursday, 2.80.
8t. Mahk'9 Hospital.—O perations, 2.80 p.m. ; Tuesday, 2,80 p.m.
Hospital pob Women, Soho-squabb. — Operations, 2 p.m., and on
Thursday at the same hour.
Metropolitan Fbee Hospital.—O perations, 2 r.u.
Boyal Orthopedic Hospital.—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.m., and
each day In the week at the same hour.
University College Hospital.—E ar and Throat Department, 9 a.h.;
Thursday, 9 a.h.
London Fost-qraduate Course.—E oyal London Oi>hthalmio Hospital,
Moorflelds: 1 p.m., Mr. R. Marcus Uunn: Affections of the Orbit-—
London Throat Hospital, Gt. Portlaiid-street; 8 p.m., i)r. McNeill
Whistler: Demonstration of Cases.
Throat Hospital (Golden-sq.).-5.80 p.m. Mr. Mark I-Iovell: Chronic
Suppurative Inflammation of the Middle Ear, and its Treatment.
(Post-graduate Course.)
Medical Society of London.—8.80 p.m. The adjourned Discussion
on Dr. Douglas Powell’s paper on “Angina Pectoris” will be opened
by Sir Walter Foster, M.P.
Tuesday, February Zi.
King's College Hospital.—O perations, 2 p.h. ; Fridays and Saturdays
at the same hour.
Guy’s Hospital.—O perations, 1.80 p.m., and on Friday at same hour.
Ophtbalmio Operations on Monday at 1.80 and Thursday at 2 p.m.
St. Thomas’s Hospital.—O phthalmic operations, 4 p.m. ; lYiday, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.30 p.m.
St. Mary’s Hospital.—O perations, 1.80 p.m. Consultations, Monday
2.80 P.M. Skin Department, Mond/w and Thursday, 9.80 A.M.
'nroat Department, Tuesdays and ^days, 1.80 p.h. Electro¬
therapeutics, same day, 2 p.h.
London Post-graduate Course.—B ethlem Hospital: 2 p.m.. Dr.
Savage: Alcoholic Insanity.
Royal Institution.—8 p.m. Prof. V. Horsley: The Structure and
Functions of the Nervous System.
Royal College of Physicians. — 6 p.m. Dr. Thorne Thome:
Diphtheria, its Natural History and Prevention. (Milroy Lecture.)
The Sanitary Institute (Pai-kes Museum, Margaret-st, W.).—8 p.m.
Mr. Charles Jones : Scavenging, Dispos^ of Refuse and Sewage.
Royal medical and Ciiirurgical Society.—8.30p,m. Mr.R, Barwell:
Rachilysis, its Object and its Method.—Mr. John II. Hutchinson:
Measles as a Cause of Endocarditis, being an Account of Four Cases '
in which Organic Mitral Murmurs developed during the course of
the Disease. Wednesday, February 26.
National orthop^idic Hospital.—O perations, ioa.m.
Middlesex Hospital.—O perations, 1 p.h. Operations by the Obstetrlo
Physicians on Thursdays at 2 p.m.
6t. Bartholomew’s Hospital.—O perations, l,80 p.h, ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 p.h.
Surgical Consultations, Thursday, 1.80 P.H.
Charing-cross Hospital.-O perations, 8 p.h., and on Thursday and
Friday at tlie same hour.
St. Thomas’s Hospital.-O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.-O perationa,2p.M, Thursday ASaturday.samehour.
8t. Peter’s Hospital, Covent-oarden.—O perations, 2 p.m.
Samaritan Free Hospital for Women and Children.-O perations,
2.80 P.M,
Great Northern Central Hospital.—O perations, 2 p.m.
University College Ho.spital.—O perations, 1.80 p.m. ; Skin Depart¬
ment, 1.46 p.m. ; Saturday, 9.16 a.M.
Royal Free Hospital.—O perations, 2 P.M., and on Saturday.
Children's Hospital, Great Ormond-stheet.—O perations,9.30 a.iii. ;
Surgical Visits on Wednesday and Saturday at 9.16 a. m.
London post-graduate Course.—H ospital for Consumption, Bromp¬
ton; 4 p.M., Dr. Theodore Williams: Cases of Phthisis treated by
Koch's Method.—Royal London Ophthalmic Hospital, Moorflelds:
8 P.M., Mr. A. Quarry Silcock : Intraocular Growtl».
Throat Hospital (Golden-sq,),—n .so p.m. Dr.Non-isWolfenden: The
Treatment of Tuberculoaia of the Larynx. (Post-graduate Course,)
Hunterian Society.—8p.m. Dr. J. L. W. Thudicliuin : Urochrome, its
alleged Derivation from tbePigments of the Blood and Bile, and on
tho Bearing of tlie Alkaloids and Extractive Acids of the Urine in
Gout and Pyininia,—Mr. F. R. Humphreys; Permanganate of Potash
as a Teat for tJio Colouring Matter of the Urine.
Thursday, February 26.
St. George’s Hospital.—O perations, l p.h. Surgical Consultations,
Wednesday, 1.80 P.M. Ophthalmic Operations, Friday, 1.80 P.M.
University College Hospital.—O perations, 2 p.m. ; Bor and Throat
Department, 9 a.h.
London Post-graduate Course.—N ational Hospital for the Paralysed
and Epileptic: 2 p.m., Mr. B. Brudunoll Carter : Ocular Symptoms
in Nervous Diseases.—Hospital for Sick Childrem Gb. Ormond-st.:
4 P.M., Dr, M. Lubbock: Anomalies of Speech in Children and their
'Treatment.—London Throat Hospital, Great Portland-st.: 8 1>.M.,
Mr. O. Stoker: The more Common Forma of Disease of tho Nose.
Boyal Institution.—3p.m. ProfesaorC.HubertH.Parry; ThePosition
of Lulil, Purcell, and Scarlatti in the History of the Opera (with
Musical Illustrations).
Royal College of Physicians. — 6 p.m. Dr. Thorne Thorne:
Diphtheria, its Natural History and Prevention. (Milroy Lecture.)
British Gvn,«colooical society.—8.80 p.m. Dr. Dunbar Hooper
(Melbourne): A case of Pelvic Hmmatocele treated by Abdominal
Section. Special Meeting to consider and pass Rules and Regu¬
lations for Exauiination of Obstetric Nurses.
Friday, February 27.
Royal South London Ophthalmic Ho.spital.— Operations, 2 p.m.
Cancer Hospital (Fulham-rd., s.W.). —4 p.m. Dr. F. A. Purcell:
Cancer of Uterus and its Troatment.
London Post-graduate CouRSE.-Hoapital for Consumption, Bromp.
ton: 4 P.M., Dr. Theodore Williams : Clinical Demonatiutlona.
Clinical Society of London.—8 p.m. Living Specimens;-Mr. B.
Hurry Fenwick: Throe cases of Hydatidsof tfio Kidney.—Mr. Stanley
Boyd: A case of Thiersch’s Method of Skin-grafting.—Mr. Pearce
Gould: A case of Fracture of the Ulna.—Mr. Balmauno Smiire:
Serpiginous Rodent Ulcer of the Face of sovonteon years'duration,—
Dr. S, Mackouaia: CaseofMultiploLipoinata,—Adjourned Discussion
on cases of Reinoval of tlie Vermiform Appendix. Paper:—Mr. A.
Pearce Gould: Case of Slnmltanoous Gangrene of both Feet from
Syphilitic Disease; amputation tlirough knee-joints; recovery.
The Sanitary iNSTiTurEfParkesMuseum. Margai- 0 t-st.,W.L—8 p.m. Mr.
Shirley Murphy: Infectious Diseases and Methods of Disinfection.
Royal Institution.—D p.m. Mr. Percy Fitzgerald: The Art of Acting.
Saturday, February 28.
Middlesex Hospital,—O perations. 2 p.m.
University College Hospital.—O peration, s, 2 p.m. ; and Skin Depart¬
ment, 0.16 A.M.
London post-graduate Course.—H ospital for Disoases of the Skin,
Blackfriars: 2 p.m., Dv. Payne: Vegetable Parasitic Diseases of tho
Skin.— Bethlem Hospital: 11 a.m., Dr. Percy Smith: Clinical
Demonstration.
Royal Institution.—3 p.m. The Right Hon. Lord Rayleigh: The Forces
of Cohesion.
METEOROLOGICAL READINGS
(Taken dwUy at 8.50 a.m. by Steward's Instrvmmts.)
The Lancet 0£Bce, Feb. 19th, 1891.
Pate
Baroinobor
roducsd to
Sea Level
and 3a”P.
Direc¬
tion
of
■Wind.
Dry
Bull).
Wet
Bulb.
Solar
Radta
in
Vaouo.
Maxi¬
mum
Temp.
Shade.
Min.
Tomr
BelId-
falL
Remarku ftt
aso A.IL
Feb. 13
30-48
N.W.
38
87
74
47
37
Hazy
» 1*
80-00
S.W.
39
30
00
47
86
Overcaet
„ 16
80-01
W.
44
4-2
09
62
38
Bricht
„ 10
80-00
S.W.
38
87
79
6:{
30
Foggy
.. 17
30 (56
s,w.
37
36
03
49
30
Foggy
.. 18
80-71
K.
80
60
47
36
Foggy
„ 19
30-60
. E.
34
38
“
37
81
Foggy
Hoks, Cflmmtitts, # ^nsfers to
Coraspflitknts.
ia especially requested that early intelligence of local
events having a medical interest, or which it is desirable
to bring unaer the notice of the profession, may be sent
direct to this Office,
All communications relating to the editorial business of the
journal must be address^ “ To the Editors."
Lectwres, original articles, and reports should be written on
one side only of the paper.
Letters, whether interred for insertion or for private in¬
formation, must be authenticated by the names amd
addresses of their writers, not necessa/rily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed‘'To the Sub-Editor."
Letters relating to the publication, sale, and advertising
departments o/T hk Lanobt to be addressed “To the
Publisher. ”
We caamot vndertalce to return MSS. not used.
“ Persi.stent Dandruff.”
We reproduce, for the satisfaction of correspondents on the sub¬
ject of persistent dandruff, the receipt given by Mr. Purnell
in The Lancet of May lOth, 1879:—An ounce and a half of iron
wine, one drachm of liquor arsenicalis, throe drachms of syrup, water
to two ounces. Of this one drachm is to be taken in water after mual-s-
Thon an ointment consisting of four drachms of tho red oxhlo of
mercury ointment, an ounce and a half of bonzouted lard, and two
minims of tho essence of bergamot should be rubbed thoroughly into
tho roots of the hair, and its use coutinued for some time.
C. W. ff.—There are different rules about practice in the different
.States, In some British diplomas aro recognised ; in New York, and
probably some others, no diploma i-s rocogni.sed unlo.ss it has lioon
conferred by a University or College in that State. As tiio State
rogulationa aro increasing in strictness, it would be well for our corre¬
spondent to obtain official information as to tho actual roquiroiiieiits
in the State in wliich ho proposes to settle.
Mr. W. 5f. EUioU.—'We would refer our corrospondent to the " Manual
of Bacteriology,” by Professor Croolnsliank of King's College, who
might perhaps ho aide also to assist him to obtain what ho dosii-oa.
Coogle
Dir:' dd •
Tbb Lancet.]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. JPeb. 21, 1891. 471
DiiAi'ii Certification.AND Lite Assurance.
Mr. P. E. 2ZiK.—.TudRing from the facts stated in the letter of our
correspondont published last week, we certainly think he was justified
n refusing a death certificate. Having referred the case to the
pollco and coroner, however, Mr. Hill was freed from further responsi¬
bility. As regards the certificate for the insmunce company, the pro
priety of giving one might, we think, have been decided by the results of
the necropsy, supposing of course the foo for its performance were forth
coming. The alleged remarls of a member of the Board under whom
our correspondent servos seems pointless, since a fee could not be
recovered for making a post-mortem examination and giving evidence
at an inquest respecting a person who died in a workhouse infirmary.
Dr W. Duncan.—The dataarotoomeagro too warrant an opinion “os to
the value of the statistical statements”; indeed, the move enumera¬
tion of figures without the facts pertaining to each individual case is
liable to mislead.
Mr. Thomas Laffan.—Most of the specimens in London have, we believe,
been procured through the British Embassy.
Yavminfj should consult his medical attendant. Wo do not give
medical advice.
ASSISTANTS.
To the Editors of The Lancet.
Sirs,—I h.ad hoped to have finished with the controversy regarding
assistants, hub the .slipshod manner in which “Justus” quotes from
my letter represents me as saying what I never did say. I did not say
I had never been an as.si.stant, f only said I was not an assistant, and
did not want to bo, and this I mentioned to show that it was not the
competition of the unqualified assistant that influenced mo to write.
As a matter of fact, I was an assistant for over four years, though hoiv
tliis affects tho point I raised I cannot conceive.
A 8 to"Justu 8 ” “ Denying Ml tofo that it is the invariable rule” for
principals to palm off thoir unqu.olified assistants as doctoit). lie may
bo right, because it is possible to conceive that amongst tho numerous
employer.H of unqualified assistants there is one honest man. I said,
and still say, that “it is almost the invariable rule.” I have never known
it to be otherwise. “.Justus” misses tho only point I raised—namely, tho
fraud perpetrated on the jniblic by principals palming off unqualified
assistants as fully qualified doctors,—and goes off into tho consideration
of the comparative merits of tlio qualified and unqualified man, a point
I never intended to raise.
“ Justus” asks: “ Ouglit I to have introduced myself as unqualified
assistant?" aiimitting that he icnowingly allowed tho patient to believe
he was a fully qualified doctor, as he says he would probably have been
“ turned out ” had he not done so. Whether it is wrong or right iiniler
any circumstances to act in sucli a manner as to knowingly and pur¬
posely mislead another I have always considered to have been settled
by the Highest Authority.
I am no enomy of tlio unqualified assistant. Tho man I object to j.s
Ilia employer, who represents him as a doctor, l.'omonally, I am V 017
sorry for tho poor unqualified assistant. Ho is kicked about and looked
down upon by his employer. I should myself prefer to labour as a
“ casual ” at tho docks than to fill hia shoes. Tlie fraud he is compelled
to perpotrato by his employer must, I thinlc, in lime weaken his moral
perception of right and wrong,
It is in the interests of tho public and the honour of tho profession
that I have written. If the General Medical Council will nob prevent
tho blade sheop of the profession porpotratiiig a fraud—ospocially on
the holploss poor, whoso moans do not enable them to proaecuto the said
black sheep for obtaining money under false pretences—the general
body of the profession should, in thoir capacity as citizens, get Par¬
liament to do so. I am, yivs, yours truly,
.[''obruary, 1801. X. Y. 'A.
To the Editors of THE LANCET.
Hues,—I tru.sfc that room will bo found in TUE Lancet for a reply to
_ A Modical Practitioner,” who takes u]) tlie cudgels on behalf of
irregular practice.
“Justus" saysthat “ Iicforo tho law stops in" to stop unqualified
practico tho public should bo protected from qualified assistants, who,
ho say.s, enter the v.anks ignor.int of midwifery. Can “ Justus ” bo
sorioiw, or does tbo word “ assi.staut ” mislead him V I presume that all
quahflod men, whether tliey bo assistants or no, stand on one common
^ootmg witli regard to duly authenticated knowledge of their profession.
•Justus” relates a story to tho effect that while an unqualified assist¬
ant ho was sent for byan M.B.C.S., L.R.C.P, to remove a placenta. It
1 possibb; but I would ask, if we aro dotleiont in knowledge lot our
oxaminatioiiH and training be ronicilled, but f)h ! spare us tlio unquali-
0( .assistant as mentor. I freely admit that unqualified assistants
uond many (too many) midwifery cases. .So did tho immortal “ Sairy
V*’ 1 ’ capacity of midwife rather than in that of skilled
..Ui,* . 1 think that no one will bo found to urge thoir
<if n”” I 'h widor fields of inodicinoand surgory. As one
rcm'l? ^ •'''V’ ^'xcepting thoir patients) have most reason to
wrnr ^Dul numbers—I rofor to the junior members of tho
that tho General Medical Council .should take tho
natter in hand, and either give them a “ local liabitation and a name ”
m Uie profession or “ reform it altogether."
, I um, «irs, yours faitlifully,
I'ob. 2ml, 1801. A QuIuFiED Assistant.
The Medical Institute for Women.
We have received a communication from the chairman, treasurer, antf
hon. librarian of the Medical Institute for Women, in which they
express their desire to increase the extent and value of thoir library,,
which at present is comprised in the new buildings In Buston-road.
They acknowledge the receipt of valuable donations of books from-
members of the profession and modical publishers, and will be glad
to receive further contributions from these sources.
If. JJ. F.—l. Malaria is unknown in New Zealand, but prevails in the'
northern part of Australia-viz., to as far south as 17* latitude.—2. A
brief account of present knowledge concerning micro-organisms im
malaria is to be found in FlUgge’s work (Now Sycl. Soc. Transl., 1890),
where also full references to the literature of tho subject occur.
Cornil and Babes, “Les Bactfiries” (3rd ed., 1890, vol. ii.), and Klobs,
" Dio Allgemeine Pathologie” (1887, vol. i.), might also be consulted.
NOTIFICATION AND THE INTERFERENCE OF MEDICAL
OFFICERS OP HEALTH.
To the Editors of The Lancet.
Sirs,—W ill you be kind enough to give me your (opinion as to the-
best means of stopping the following nuisance ?
My as.sistant was called a few days ago to a child suffering from
measles. The father of tlio child being a schoolmaster, be reported the-
case to the medical officer of health. Tho latter gentleman called, saw
tho child, and said that as it had previously had measles it could nob
have them again, that the diagnosis was a mistake, and so on. He-
then wrote to me, saying that he could not tell what was the matter
with the child, and wanted my opinion as to whether it had measles or-
not. On the receipt of this letter, I went to see the child, and found it
suffering from well-marked measles, its littls sister being also in bed
with the same disease. I wrote to the medical officer of health and’
told him that after his breach of etiquette I should leave it to him to
settle as lie liked about tho closing of the school.
Can I do anytliing to put a atop to the annoyance caused to both my
assistant and myself? Is the medical officer of health allowed to see or
express an opinion on private cases reported to him? Is he justified ini
saying that a practitionor has made an error of diagnosis ? Is he in tho
right when he says (as he has done in two houses lately) that no¬
patient can have measles twice?
I may mention that my assistant is a well-qualified registered prac¬
titioner, that we have an epidemic of measles in the neighbourhood,
and that several children have been sent to thoir homes with the-
measles rash out on them during the last week from the school in
question. I am, Sirs, yours faithfully,
Jan. 10 th, 1891. M. A. S.
''s* Wo had hoped that the grievance complained of by our oorre-
.spondont had ceased to exist. It is quite unjustifiable for medicaP
officers of health to interfere with and contradict the diagnosis
of the responsible practitioner in attendance. It is a breach alike
of couvte.sy and of duty. In this ease tho sayings of the medical
officer are either miaroported, or he is ill informed as to the ways of
infectious disease. Tho occurrence of second and even third and
fourth attacks of measles is well authenticated. The symptoms in
this case, and the existence of a second in the house, seem to male©-
the doraonstration of the error of his opinion complete. Our corre¬
spondent should complain to the local sanitary authority and to tho-
chief of tho Modical Department of tho Local Government Board.—
En. L.
PURCHASE AND SALE OF PRACTICES.
To (hs Editors (ff The Lancet.
Sirs,—T lie Sfedical Defence Union is a valu.ablo guard to every-
medical man who joins it. May I suggest that there is a matter very
near homo which often needs supervision ? I refer to the sale and pur¬
chase of practices. No ono will deny that a fair price is due to a faith¬
ful practitioner who has worked up a practico and for some reason has
to velinqui.sh it. But I contend, under the circumstances now existing,
when so many mon aro ready to invest in prai^tices, there is a danger of
thoir value being over-estimated, and consequently disappointment
and loss result to the purchaser. Is there not a danger of some
mombors of our profession devoting themselves to the very unpfofe.s-
sional work of carrying on a practice simply with a view to put it in tho
market when it attains a certain supposed market value, which is often
fictitious ? I believe much advantage would ro.snlb to onr profession if
selling practices by this last class of men was under some furtliov super¬
vision l-lian now exists. I am, .'lirs, yours faithfully,
llaugiiloy, Fob. iiitli, 1891. Rorert G. White, M.R.O.S.
LEQAL OWiNERSIIIl’ OF PREaCRIFTIONS.
Dr. D. Hooper.—yfe quite agree with our correspondent. A prescription
given by a physician to a patient who consults him is the property of
the patient, and nob of the general practitioner in attendance,
jlfedtcus.—Our corre.spondont would demean himself and probably act
illegally by doing so. Midwives are not expected to have any legal
qualification. Medical sUidonts aro not midwives, and until they
have their diploma have no legal right to practise midwifery any
more than surgery and medicine.
Dig' ’sd ^
Google
472 Thb Lanobt,]
NOTES, COMMENTS, AND ANSWEKS TO CORRESPONDENTS.
[Feb. 21,1891,
The ANTI-.STRAIK COPYING PEESS.
This la a press which la intended to obviate the strain which is often¬
times required when the larger forms of the ordinary copying press
are employed. A mechanical advantage and a more rapid up-and-
down movement are gained by means of two cogwheels of different
pitch, wliich are placed at the upper ends of two screws. The
mechanical principle upon which this depends is, of course, well
known, but tlio application of it is, as far as we know, now. Tlio
inventor—Mr. P. V. Lomas, of 6, Pall Mall—states that rupture is not
unknown ns the result of using existing presses. But a more general
advantage is, we imagine, offered by its use to those whose physical
strength is not equal to applying the required amount of force with
comfort in the use of ordinary patterns.
Z>r. E. Mav is thanked for his letter. We fully recognise the value
of his suggestions, and concur with him in the opinion that if it
were possible to attack the disease at its earliest appearance its
ravages might be materbilly mitigated. We also feel certain that
this principle is a guiding one in the treatment of diphtheria, and is
more generally adhered to than he fancies; but unfortunately the
poison is so rapidly formed and absorbed that the action of local
remedies is often rendered useless, and tlie only measures remaining
are those which seek to support tlie vitality of the organism which is
being depressed by the virus.
COHHUNICATION3 not noticed In oui present number will receive atten¬
tion in out next.
Communications, Lbttehs, Ao., have been received from—Mr. Jessett,
London ; Dr. Lowers, London ; Sir B. H. Sieveicing; Mr. B. Treves,
London ; Dr. Horrocks, London ; Dr. G. Macdonald, London ; Mr. H.
Lupton, Stratford-on-Avon ; Dr. G. E. Hetman, London ; Dr. Lauder
Brunton, London ; Dr. Charteris, Glasgow ; Dr. Herschell; Dr. E. W.
White, London; Mr. T. P. Wright, St. Noots ; Mr. Q. O- Jacobson,
Huntingdon; Dr. Culliinore ; Dr. Johnson, London; Dr. Whitehead,
Pitone ; Dr. Kaye; Mr. T. H. Pounds, Derby; Mr. Warner, Sheffield;
Dr. G. Johnson, London ; Dr. Auld, Glasgow ; Messrs. Krobne and
Besemann, London; Mr. Kingdon, Nottingham; Herren Flatau nnd '
Mankiewicz, Berlin; Dr. S. 0. L. Potter, London; Messrs. Beale and
Sons. Brighton ; Mr. Tobin, Dublin ; Mr. Laflan, Cashel; Mr. Bland
Sutton, London; Dr. E. May, Eanwell; Messrs. Smith, Elder, and
Co., London; Dr. Arnison, Newcastle-on-Tyne; Messrs. Blondeau
et Cie., London; Mr. R. G. White, Eaughley; Messrs. Mitchell and
Co., London ; Mr. Boobbyer, Nottingham; Messrs. Claik, Son, and
Platt, London; Dr. Nason, Nuneaton; Dr. C. Charles; Dr. Fletcher
Beach, Dartford; Mr. W. J. Reod, Burton-on-Tront; Messrs. Keith
.and Co., London; Mr. Barling, Stoko-on-Trent; Messrs. Bates and
Co., London; Mr. W. R. Cornish ; Dr. Bampton, Ilkley ; Dr. Fletcher
Little, London; Dr. J. W. Pratt, Boston, Mass.; Messrs. Oliver and
Boyd, Edinburgh ; Mr. H. W. Street; Mr. D. Biddle ; Dr. Hingston
Fox, London ; Dr. Macclougall, Cannes; Mr. Leet; Mes.srs. Barker
and Sons, London; Mr. Cheosbrougli, Brampton; Messrs, Sliapo and
Co.,Preston; Dr.Windle; BerrBornemann ; Messrs. Richardson and
Co., Leicester; Mr. Phipman, Ottawa ; Mr. Thatcher; Dr. Hartley,
Discard; Mr.Roberts, Uxbridge; Dr. Eodsdon, Edinburgh; Mr. F. A.
Davis, London ; Mr. Seale, Peckbam ; Mr. Girling, Halifax ; Mr. T. B.
Browne, London ; Mr. Saunders, Manchester; Mr. Warburton, Tre-
herbert; Mr. Kennedy, London; Mr. Buckley, Oldham; Mr. Guthrie,
London; Mr. Walton, Highgato ; Mr Spowart, Sheffield ; Mr. G. C.
Gabriel, Cairo; Mr. Taylor, Hampstoad-road ; Dr. Moorhead, Notting¬
ham ; Mr. Delany, St. Helens ; Dr. Owen, co. Kerry ; Dr. Lawrence,
Chepstow ; Mr. Dobbin, Broinpton ; Mr. Merck, Darmstadt; Mr. J.
Steavenson, Glasgow; Dr. Hasiett, Liverpool; Mr. Boyd, Deiimatk-
hill; Mrs. Meredyth, London; Mr. Hannaford, London ; Mr. Orr,
Wanstead; Dr. Skrinishlre, Blaenavon; Messrs. W. H. Smith and
Son, London; Mr. Shaw, Worthing; Mr. Hornlbrook; Messrs. King
and Chasemore, Horsham; Mr. Thompson, Buxton; Messrs. Cooke
and Sons, Winsford; Mr. Campbell, Kensington; Messrs. Dawson
and Sons, London; Horr. G. Thieine, Leipzig; Messrs. Wright and
Co., Bristol; Mr. Odell, Torquay ; Herr Oubtmann; Messrs. Coxetet
and Co.; Mr. Macdonald, Gosport; Mr. Burgess, Walworth; Mr. Perkins,
Newport; Mrs. Gregory,Swindon; Mr. Blrchall,Liverpool; Mr,W.R.
Liston; Medicus; S. II. J.; Tenons, London ; Matron, Soutliern
Hospital, Manchester; A. B. C., London; Smedley's Hydropathiu
Establishment, Matlock; Ilos, Taunton; A. 11., Leeds; Advertising
nnd Address Co., London; X. Y. Z., London; W. M.E,; Clerk, Leeds
Union; Sister Musgrave, Bolton ; The Diroctor-Genoval of the Navy
Medical Department; Scrutator; Harvard Co., Ohio; H. F. S.
Lbtters, eaoh imth enclosure, are also acknowledged from—Mr. Tally,
Hastings ; Mr. Rynne, Ennis ; Mr. Pearson, Newry ; Mr. Lockwood,
Huddersfield; Mr. Shoen, Worcester; Mr. Dent, York; Mr. Chubb,
Devonport; Mr. Cuthboctson, Stirling, N.B.; Messrs. Paternoster
and Hales, Hitchin; Mr. Feony, StnlTordshire ; Messrs. Pownceby and
Co., London; Dr. Bailey, Staffs; Mr. Clark, Cambs; Messrs. Down
Bros., Borough; Mr. Detmold, Bournemouth; Messrs. Whitehead
and Co., London; Messrs. Richardson, Liverpool; Messrs. Gale and
Co., London; Mr. Ward, Kent; Mr. Webb, Devon ; Messrs. Sharp
and Co., Glasgow ; Mr. Thompson, Derbyshire; Messrs. Hertz and
Collingwood, London; Mr. Davenport, London; Messrs. Hewlett and
Son, London; Mr. Cross, Ormesby; Messrs. Bullock; Messrs. Back
and Co., Bishopsgate; Mr. Tyte, Minchinhampton; Messrs. Watkius
and Osmond, London ; Dr. Swayno ; Dr. Woakos: Mr. Basu, Patna
City, India; Mr. Bayliss, Slough ; Mr. Saunders, Eton; Mr. Brown,
Streatham ; Mr. Howelks, Aberdeen; Mr. Harries, Sussex; Dr. Fox,
London ; Mr. O'Meara, Leicester; Dr. Stanley, Sheffield; Mr.Blount,
Paris; Mr. Guahney, Cobhara; Mr. Watling, Hastings; Mr. Jones,
Towcester; Mr. Wells-Bladden ; Messrs. Lumleys, London; Mr. Bull,
Southampton; Miss Symons, Southport; Messrs. Giles, Schaoht, and
Co., Bristol; Mr. Shean, Northumberland ; Messrs. Robinson and
Stannard, London; Mr. Hey wood, Manchester; Messrs. Slingor and
Son, York; Mr, Flint, London; Mr. Thin, Edinburgh; Messrs. Cox
and Co..Brighton; Mr. Darke, London; Mr. Davis, Cornwall; Mr. Fox,
Child’s-hill; Mr. Howells, Aberdeen ; Dr. Davies, Bridgend ; Rev. A.
Tooth, Croydon; Mr. Lyston, Nottingham; Dr. Deane; Dr. Davies,
Longton; Dr. Allingliam, London; Dr. Sonkey, Shrewsbury; F.;
C. B. 0., London; T. F. A., Cheshire; Reliable, London; Express
Dairy Co., Bloomsbury; J.C., Dublin; Secretary, Midland Skin and
Lock Hospital, Birmingham; Sister, London; Vere, London; Bryant
Co., Toronto; C. W. C., Devonport; Newcastle, London; Midland,
London ; P. C. B., Rlckmansworth ; Gavel, London; General Medical
Councii, London ; B. S., York; Ajax, London; Matron, Stockton-on-
Tees ; Gamma, London; Cromwell House, Northallerton; A. B. C.,
Winchester; Delta, London; M.B., London ; Spos, London ; C. W,,
Southport; Dr. Medico, Bradford; E. S., Hammersmith; Medicus,
London ; A. F., I.ondon; Surgeon, Halifax; Alpha, Liverpool; Easy,
London ; A. B., Truro ; R. M. 0,, London ; Flora. London; W. K. A.,
Tewkesbury; Expertus, London.
Newspapers.— WpcMu Free Preen and Aberdeen Herald, Windsor and
Eton Express, City Press, lisadini/ Mermry, Surrey Advertiser, Local
Govemnuint Chronicle, Hertfordshire Mercury, Liverpool Daily Post,
Sunday Times, Builder, Mining Journal, Leeds Mercury, Metropolitan,
West Middlesex Standard, Broad, A rrow, Yorkshire Post, Shcjjield Daily
Telegraph, Bristol Mercury, Architect, Chemist and Druggist, Spectator,
Guy's Hospital Gazette, Liverpool Mercury/, Phannacaulieal Journal,
West Middlesex Advertiser, Law Journal, Saturday Bevieiv, Western
Mail, Army and Navy Gazette, Maidstone Jowrnal, Scotsman, Court
Journal, Vegetarian, Scarborough J 5 «Bnvn <7 News, Brighlon Gazette,
Toronto Globe, Walton Gazette, South-Eastern Gazelle, Madras Times,
Weekly Tinnes and Jicho, North British Daily Mail, Hull News, Isle of
Man Examiner, Taunton Courier, JAverpooi Courier, Cambtidge Ex¬
press, Mansfield Reporter, Waterford Standard, Sheffield and Rotherham
Independent, Border Advertiser, Fifashire J»v.rnal, Liverpool Journal
of Commerce, Dundee Advertiser, Bombay Gazette, Ac., received.
SUBSCRIPTION.
POST FitBE TO ANY PAKT OF TUB UNITED ElNODOH.
One Year..... £1 12 6 J Six Months £0 18 B
TO China AND India One Year 1 18 IB
To THE Continent, Colonies, and United
States .....Ditto lU I
Post Office Orders and Cheques should he addressed to The Publisher,
THE Lancet Office, 428, Strand, London, and crossed “London and
Westminster Bank St, James's-square."
ADVERTISING.
Books and Publications (seven lines and under) . £0 B 0
Official and General Announcements . . 0 B 0
Trade and Miscellaneous Advertlaoments _ _ 0 B 8
Every additional Line 0 0 8
Front P^e _ m •-. » por Line 0 10
Quarter Page •• « >. ~ _110 0
Half a Page — _ •. rm ..2 16 0
An Entire Page .. ... .. .. ~
The Publisher cannot hold himself responsible for the return of teaW-
menials &c. sent to the office In reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are requested to observe that lb Is contrary to
the Postal Regulations bo receive at Post Offices letters addressed to
Initials only.
An original and novel feature of “The Lancet General Advertiser" Is a special Index to Advertisements on pages 2 and 4, which nob only
aSords a ready means of finding any notice, but is in itself an additwnal advertisement.
Advertisements (to ensure insertion the same weekjshould be delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet. i.i k.
Terms lor Serial Insertions may be obtained of the Publisher, bo whom oU letters relating to Advertisements or Subaorlptions staonla DO
AdvertisemsnM'. are now received ab all Messrs. W. H. Smith and Son's Railway Bookstalls thronghoab the United Kingdom and all obbai
Advertising Agents., _
foz tb* Advsrtlsemeiit Department In Fianoe-J. ASTIBB, H, Bne Caumsrtln. Farlii
. : y .oogie
THE LANCET, Febbitary 28, 1891.
^ oeveral thousand scarlatina patients treated at the London
ABSTRACT OR Fever Hospital would be inexplicable. And, even elee-
OAtvM <«!»' i where, diphtheria was stated to have almost always occurred
%Ut itluOT as a sequel to the scarlatina, hardly ever to have been
f synchronous with it. Some recent experiences, having
ON • perhaps a somewhat contrary tendency, at the Metropolitan
DIPHTHEEIA, ITS NATURAL HISTORY AND un^er another beadFng—namely, that of the aerwl diffusion
PREVENTION.
Delivered before the Royal College oj Physicians of
London,
By B. THORNE THORNE, M.B., F.R.S., F.R.C.P.
LECTURE II.
Tub term “diphtheria,” as limited by our returns of
of the contagium of diphtheria. The relation of diphtheria
to faulty sanitary circumstances was then fully entered
into. As regards water-supply, it was held—and much
confirmatory evidence was appealed to as to this—that no
prevalence of diphtheria had ever been definitely traced to
polluted water, or even to water covered with fungoid and
other allied growths; whereas there was, on the other
hand, abundant evidence, necessarily of a negative
character, in the opposite direction. As to sewerage
and drainage, the matter was not to be so easily
disposed of. Many observers who do not, as a mere
sickness and death, was held by no means to cover all that matter of course, regard two concurrences as being related
must be included in any inquiry as to the etiology of this g^ch other as cause and eifect were decidedly of opinion
■disease, the recognised diphtheria being often involved in a that such defects as led to contamination of soil and air by
number of other less defined throat affections. A number sewage did cause and tend to diffuse diphtheiia. On the
■“‘croup” were followed first by returns of “diphtheritic been made in improving conditions of sewerage and orainage,
<‘roup,” and finally by “ diphtheria,” when at lost the true and that hand in hand with this there had been diminution
nature of the disease was recognised. And it was also of general death-rate and diminutim of rates of death from
shown that preceding any marked diphtheria cases it was sum diseases as typhoid fever. Especially had promess
■often learnt that for some considerable period there had been made in this direction in our towns and cities, and here
been prevailing a large amount of illness, to which were too the same diminution of death had taken place, whilst
applied such terms as “sore-throat,” “ tonsillitis,”&c., these diphtheria, on the contrary, was steadily laying hold of our
attacks commonly receiving but little notice until the
eeasonal activity of diphtheria showed their true meaning,
and indicated also how these mild throat attacks were often
the connecting links between successive prevalences of well-
marked diphtheria. The infectious quality of the minor
throat affections was also adverted to, and it was pointed
•out how in the same household fatal diphtheria was con¬
tracted from them. In confirmation of tliese views, and
large urban communities. Bub, notwithstanding these
general considerations, it was admitted that careful inquiry
had at times associated grave sanitary defects of the sort
referred to, with grave and sustained prevalence of diph¬
theria, and typical amongst such occurrences was the story
embodied in Mr. Spear’s report on diphtheria at Aylesbury.
This report was carefully entered into, and the main conten¬
tion of the author seemed to be that recurring localisations of
v/ibh the object of indicating the true relation of many diphtheria could only be accounted for by the localisation of
minor throat ailments to epidemic occurrences of diph¬
theria, a number of outbreaks were referred to in some
■detail, such as Mr. Power’s report on Titchmarsh diph¬
theria, I)r. Bruce Low’s report on Halstead diphtheria, and
other work by Dr. Blaxall and Dr. Parsons,
specially grave drain and filth conditions at those spots. The
story was, however, one of extreme complication, for there
had been an earlier diphtheria epidemic about eighteen
months before which was associated with school attend¬
ances, and there had been a vast number of sore-throat
Further reference was then made to the same class of | attacks in the interval that might easily be regarded
minor illness in diseuesing the origin of certain epi¬
demics, and it was suggested that beyond any interpre¬
tation which regarded -them all as distinct though mild
ettacks of true diphtheria there were a number of other con¬
siderations which called for attention. Dr. Thorne Thorne
then recalled certain experiences of his own which dated
tfrom 1878, and which had led him in that year to express
the view that in the case of diphtheria we had to do with
an unstable poison which gave evidence of a progressive
as links between the two prevalences. Bat Dr. Thorne felt
that instances of this sorb did afiord some evidence of a
relation between the conditions referred to and diphtheria,
and this went beyond mere increase of fatality owing to
unhealthy surroundings. The explanation, he believed,
lay very largely, if nob entirely, in the circumstance that
the faulty conditions in question often produced sore-throat,
apparently of a benign character, and that, just as in the
case of such diseases as scarlatina and measles, the abraded
development of the property of infectiveness, W'ffich pro- surface of the throat allorded the very soil suitable for
perty might be as easily lost as it was acquired, in much inoculation by the diphtheria organism when present in the
^hn nnmn urov no ar>«i>'ia.1 ^'hn.rn^'harlnHi'ci nm.v bn nrtificinllv air. as it uDouestionablv was at the time in Aylesbury. In
the same way as special characteristics may be artificially
developed in higher plant life, and be as easily lost again ;
end it was held that there were local conditions under
air, as it unquestionably was at the time in Aylesbury. In
such a case it would be difficult to say whether other causes
were not at Avork, leading to the development of some
which sore-throat, as it is commonly called, may at times special specificity in type, amongst the prevailing throat
thus acquire a specific and infective quality ultimately affections: but it is unquestioned that these_ attaclvs of
sesulting in true diphtheria. The views of a number of so-called tonsillitia do at times become infective, and are
observers, including certain local health olficers, such as communicable within the same household. Drains, too,
Mr. E, L. Jacob and Mr. Fosbroke, were quoted in this may possibly retain a diphtheria contagium received through
connexion ; and in a similar way it was sho wn that certain the spuba and dejecta of the sick. But the main influence of
experiences of Mr. Power tended in the same direction, drain efUuvia in relation to diphtheiia was held to be the
Bub it was admitted that this view was not universally preparation of a soil, by means of a morbid surface of the
accepted, and that some of the more recent discoveries as fauces, ready to receive and promote the development of the
accepted, and that some of the more recent discoveries as
to the causation of diphtheria tended to limit the number
of diphtheria occuironees to which it might be applied.
Coining next to r,he question of there being some sort of
identity betwoen diphtheria and scarlatina, the reports of
Dr. Bond were referred bo as those most strongly pressing
this view ; and a contribution by Dr. Parsons to the Epi¬
demiological Society on the same subject ivas dealt with at
wandering specific organism.
Much the same line of argument was applied to another
story based on a valuable report by Mr. Matthew Adam-s
of Maidstone, who Jiad pointed to the existence of a rela¬
tion between diphtheria and variations in the level of the
subsoil water. The occurrences in question were illustrated
by means of a large chart in Avhich the ainountof diphtheria
some length. It was, however, held by Dr. Thorne that if could be compared year by year, and even week by weeK,
there is any relation between the two diseases, it probably
lies in tlie circumstance that the lesion of tlie fauces in
acavlatina airords a favourable soil for the reception of the
diphtheria contagiiuii. Were it otherwise, the almost total
absence of diphtheiia a complication of scarlatina amongst
No. 3622.
with variations in the ebb and flow of tbe subsoil water,
and Mr. Adams’s main contention was that, so long as the
ordinary single autumnal rise and summer fall of subsoil
water took place, even a filth-laden soil was so far washed
clean, and the diphtheria conhogioa was so far drowned
I
1
474 The Lancet,]_MR. J. BLAND SUTTON ON TUBAL PREGNANOY. [Fbb. 28, 1891.
out that DO material mischief reeulted ; but it was explained
to be otherwise when, owing to abnormal meteorological
conditions, continual oscillations of subsoil water kept the
soil damp, favoured decomposition of its organic contents,
afforded a breeding ground for specific organisms, and at
frequently recurring intervale expelled from the soil into
the atmosphere above an air laden with these organisms.
Mr. Adams’s report wbs also specially referred to as an
example of the ^mirable and exact record of facts which
not infrequently resulted from investigations made by local
health officers, which aflbrded such excellent materia
for the elucidation of difficult problems in preventive medi¬
cine. In conclusion, Dr. Thorne discussed the influence on
the human system of drain eliluvia in their relation to
specific disease in the light of the recent researches of Klein
and Achillemonti on the concurrent inoculation of dill'erent
infections, and he referred also to those of Oertel, which go
to show that diphtheria is primarily a local disease, mani¬
festing itself solely at the point of inoculation, whether this
be effected aerially as on morbid or abraded fauces, or
rnechanically on a cornea or elsewhere, and that the general
disease is altogether a secondary one due to infection of the
system owing to changes at the seat of the primary lesion.
ABSTRACT OF THE
^ritsnras ®iI$ou ITirtea,
ON SOME POINTS IN THE PATHOLOGY OF
TUBAL PEEGNANOY.
Dtlivered at the Boyal College of SurgeoTis, February, 1891^
By J. bland SUTTON, P.R.O.S.,
ASSI8TAN1- SURGEON TO THE MIDDLESEX MOSPITaI-
Mr. President and Gentlemen,— In every female
mammal above Monotremata there is a section of the genital
tract intervening between each abdominal ostium and the
uterus in which, under normal conditions, impregnated ova
are not retained. These narrow portions are the Fallopian
tubes, and they serve to conduct the eggs from the ovary to
the uterus. Although Fallopian tubes are found in con¬
nexion with every uterus, bicornuate or median, it is a
most significant fact that I have failed to find in literature
any case of tubal gestation, except in the human female,
that will bear criticism. It is usually taught that in the
human female the tubes are the meeting place of the ova
and spermatozoa, but this is pure conjecture. The opinion
that the spermatozoa pass up the tube and disport them¬
selves among the fringes at the abdominal orifice is as un¬
supported hy facts as the fable that the Fallopian tubes
are able to grasp the ovary and secure the ovum at its
dehiscence.
It is instructive to reflect how such nonsense could ever
have gained credence among us, and it is certainly amuftin"
to watch how the members of our profession will strain at
gnats and swallow camels. Hyrtl, in his classical “Lehrbuch
der Auatomie,” writes: “The fimbrim at the abdominal
ostium appear as if they were bitten or torn away, hence
the term morsus diaboli. The devil has since live’s time
had more to do* with womenkind than with men Der
Schwabenspiegel (1273) says; “Mulier est malleus, per
quern diabolus mollit et malleat univeraiim mundum.” The
term “morsus diaboli” is borrowed from botany. The plant
Scabioaa succisa, formerly much used owing to its healing
properties, M'as called “devil’s-bit scaby” because its root
presents a premorse, or bitten-oil' appearance. The virtues
of this plant to suffering humanity rendered it an object of
dislike to the devil, and the superstitious old herbalists
believed that in his wrath he bit off the root. There is,
however, little resemblance between the root of the plant
and the fringed ostium of the Fallopian tube, but Doran
has pointed out the striking resemblance which exists
between it and the flower of the devil’s-bitacaby. It is more
reasonable to believe that impregnation occurs normally in
the uterus, and that when fecundation occurs in the tubes
it is accidental, and tubal gestation is the consequence.
Concerning the cause of tubal pregnancy we are very
ignorant, and a careful analysis of the histories of patients 1
the victims of this accident throws but little light upon the?
matter. In many instances it occurs in women who have
been married eight, ten, and even twenty years, and have^
never before been pregnant, yet the first pregnancy occurs
in the tube. In one of my cases the patient had been twice
married, and had lived in wedlock seventeen years, and then
became the victim of tubal gestation, never having beeij.
pregnant before. In other cases it follows a normal preg¬
nancy or abortion by one, two, three, or four months. It
may occur as a first pregnancy in a woman between thirty
and forty years of age, or in a girl of twenty; in the newly
married or the mother of a large family, as Parry^ has shown,
it occurs most frequently after long intervals of sterility, and
it may occur twice in the same patient, as Dr. Herman®'
has indisputablv demonstrated. The fact that this accident
ensues frequently upon a long period of sterility in a woman
who had previously borne children has given colour to the-
suggestion that the patients have been the victims of desqua¬
mative salpingitis, and the destruction of the proper ciliated
epithelium will account for the occurrence of tub m gestation,
inasmuch as it puts the mucous lining of the tubes into a.
condition exactly similar to that of the uterus. Mr. Lawson
Tait writes : “That the uterus alone is the seat of normal
conception j that as soon as the ovum is affected by the^
spermatozoa it adheres to the mucous surface of the uterus^
that the function of the ciliated lining of the Fallopian
tubes is to prevent spermatozoa entering them, and to-
facilitate the progress of the ovum into the proper nest
further, that the plications and crypts of the mucoua
membrane lodge and retain the ovum either till it is im¬
pregnated, or till it dies or is discharged.” “
The above view is entirely a speculation, and, as far as I*
am aware, no one has attempted to substantiate or disprove'
the causative relation between desquamative salpingitis-
and tubal gestation. I have made it the subject of pro¬
longed investigation, and am prepared to state that it-
contains an element of truth, but it does not hold in all
cases. In the first place, salpingitis so severe as to pro¬
duce destruction of the tubal epithelium causes such pro¬
found changes in the tubes themselves as to lead to stricture-
and complete occlusion of the abdominal ostia; it is ex ¬
ceedingly rare to meet with tubes denuded of their epithe¬
lium and the abdominal ostia patent. It is, however, well''
to bear in mind that salpingitis, even of a mild type, may
so affect the tubal mucous membrane as to retard or alto¬
gether prevent the passage of ova, and an examination of
pregnant tubes shows that salpingitis of a mild type, an(B
without even partial destruction of the epithelium, will-
lead to the detention of ova and expose them to spermatozoa-
which may wander into the tubes. On the other hand, in-
several specimens of veiy early tubal pregnancy I have failed,
even after the most careful microscopic examination, to find-
any evidence of old salpingitis or loss of epithelium. The
museum of St. Mary’s Hospital contains an InterestingT
specimen in this relation. A single woman aged twenty
yea>-8 was suddenly seized with severe abdominal pain, fol¬
lowed by symptoms indicative of internal hemorrhage.
Rupture of a pregnant tube was suggested as the cause, but:
disregartJed as the hymen was intact. Death occurred three-
days after rupture. At the necropsy a ruptured sac was
found in the left Fallopian tube. In company with the-
curator, Mr. J. J. Clarke, I examined the sac, and found it
to contain chorionic villi. Sections were prepared from the-
tube, but the epithelium was intact, and no evidence of sal¬
pingitis was detected.
Unfortuately few operators take the trouble to examine'
the tubes in such cases. Dr. Griffith reported a case of*
tubal pregnancy which terminated fatally at an early date.
Both tubes, though apparently healthy to the naked eye, were-
found on microscopic examination to exhibit marked evidence
of disease. The mucous membrane was quite denuded of
epithelium and “the conditions present appeared to indicate
a comparative recovery from a destructive inflammation of
the mucous membrane.” The woman had been married
eleven years, but had never before been pregnant.^ An-
impregnated ovum may be arrested in any part of the tube.
In the early stages the ovum becomes quickly beset with
chorionic villi, which enlarge, become vascular, and, if not
interfered with, in due course form a placenta, but in o.
manner which somewhat difi'ers from that of a uterine«
1 ISxfcrft uterino Prognaiicy.
2 Brit. Med. Jour., Sopt. 27lli, 1300, p. 722.
" Ectopic Pregnancy, p. 4.
■* Trans. Path. .Soc., vol. xxxviii., p. 227.
Google
Tbb Lancet,]
MR. J, BLAND SUTTON ON TUBAL PREGNANCY.
[Feb 28,1891. 475
(placenta. We may follow the events to be discuseed in this
lecture in the following order:—1. The changes in the tube
tind the mode of closure of the abdominal ostium. 2. Patho¬
logical changes affecting the ovum. 3. Tubal abortion.
4. Rupture of the gestation sac. The remarks in the fol¬
lowing section apply to all forms of tubal gestation except
the tubo-uterine variety.
1. Tht chcmges in the tube .—During the first month or six
weeks that portion of the tube in which the ovum is lodged
■becomes very vascular and somewhat thickened. This has
been described as hypertrophy, but it differs greatly from
the enlargement exhibited by a gravid uterus. The latter is
due to an increase in si/.e and number of the muscle cells,
whereas in a gravid tube the increase in size is simply a tur-
^gescence. This statement is the outcome of the microscopic
examination of eight specimens of gravid tubes between the
ifourth and twelfth weeks of gestation. In some the walls
Fia. 1.
I' A'fjravid Fallopian tube at the Nixth woolc. The walls are
extremely thin ; its o.stiuni is partially oloHod, 'ind th-*
^ “[^ovum was aporilectic { . i -
•of the tube in contact with the ovum seem to stretch and
thin from the beginning of the gestation. Tho rapidity of
the thinning varies in different tubes, and this is doubtless
due to the fact that under normal conditions the Fallopian
tubes not only vary in length, but in thickness. In some
individuals they scarcely exceed in thickness the vasa
deforentia of the male, or resemble tlie narrow tubes of the
mare or cow. As the tube expands from the enlargement
of the ovum within it, the mucous membrane is stretched
and its glandular folds effaced. Occasionally a few of the
pHcte will project within the tube as long straggling pro¬
cesses. Whilst these changes are in progress, curious
alterations are taking place at the abdominal ostium, which
in most cases gradually bring about its occlusion, an event
usually completed by the eighth week. During the first
four weeks tho congestion of the parts causes turges-
-cence of the fimbrioo as well as of the muscular and serous
tissues adjacent to them. When the parts are thus swollen,
the margin of peritoneum adjacent to the ostium is very
■conspicuous, and forms an irregular ring over the fimbrim.
3.° *oof>her fourteen days this ring projects beyond thd
uinbriaj, and, lastly, contracts and hermetically closes the
'Osbiuin.
2. Pathological changes which may occtcr in the ovum .—
After impregnation of an ovum the most important
change which occurs in connexion with its investing
membranes is the growth of cellular dendritic processes
known as chorionic villi. When thoroughly developed
the villi cause the exterior of the ovum to present a
shaggy appearance and serve to fix it to the adjacent
mucous membrane, whether uterine or tubal; they soon
become permeated by vessels conveyed to them from
the aorta of the embryo by the allantois. Subse¬
quently the greater number of the villi atrophy, those
which persist increase greatly in size and complexity, and
ultimately form the fcetal portion of the placenta. It
matters not whether the gealiation be tubal or uterine, the
life of an ovum is precarious until the placenta is well
formed, for the union between the ovum and the mucous
membrane is not very intimate when it depends on the
chorionic villi in their early stages. The result is that from
a variety of causes the ovum may be dislodged in part, or
entirely, from its relation to the mucous membrane; such dis-
lodgment is always accompanied with, and in very many
instances actually caused by, haemorrhage among the cho¬
rionic villi. Practitioners are familiar with rounded bodies
discharged from the uterus of pregnant women, accom¬
panied by profuse hmmorrhage. These bodies are known by
various names—“blighted ovum,” “fleshyorcarneous mole,”
“ apoplectic ovum,” &c. They are so common that a patho¬
logical museum usually contains several specimens, and few
matrons terminate their reproductive period of life without
producing one or more examples of the fleshy mole. The
clinical expression for the event is abortion. When an
apoplectic ovum is examined soon aftei' its discharge it re¬
sembles a firm blood-clot in colour and consistence. On
dividing it a cavity containing fluid, sometimes straw-
coloured, sometimes stained red from admixture with blood,
is found. The walls of this cavity are smooth and lined with
amnion, and often a misshapen fcctus is contained within,
or the stump of the umbilical cord, and frequently no trace
of an embryo can be detected. A fleshy mole is really an
early ovum with its membranes, into which blood has been
extravasated. The extent of the extravasation varies;
occasionally the blood invades the amniotic cavity and over¬
whelms the embryo. Fleshy moles similar to those arising
in the uterus occur in connexion with tubal gestation, and
they appear to be more common between the fourth and
eighth weeks than at any other period. Their formation is
in most cases attended with disastrous consequences to the
individual unfortunate enougli to become the victim of tubal
pregnancy. This fact alone should cause them to be care¬
fully studied.
In October, 1889,1 communicated to the Royal Medico-
Chiruvglcal Society two cases of fleshy moles from the
Fallopian tubes, which I had removed from patients, and
showed that they in no way differed from the apoplectic
ovum which is so, frequently discharged from the uterus.
At the time that paper was read I was able to communicate
details of a third case, which occurred in the practice of
Dr. William Walter of Manchester. Since then I have had
opportunities of dissecting and examining several specimens.
Ic is of some importance to be familiar with their chief
features, because the existence of a fleshy mole is a certain
proof of pregnancy.® When the extravasation of blood is
extensive and obliterates the amniotic cavity, it causes
doubt whether we are dealing with a lump of blood
coagulum or an apoplectic ovum ; for it must bo borne in
mind that an ovum of this character, detained for many
I days in the pelvis after its discharge from the tube, or if it
be lodged between the layers of tho broad ligament for
many weeks, becomes laminated and hard. Under such
conditions its nature can only be satisfactorily determined
by finding au embryo or its remains imprisoned in the clot,
I or by ascertaining the existence of chorionic villi. On
! several occasions I have been able to demonstrate the exist¬
ence of tubal pregnancy by the presence of villi alone.
In size fleshy moles vary greatly, depending, of course,
I on tlio date at which the hmuiorrhago occurs. My
smallest specimen equals in size the kernel of a cob-
! nut; the largest is as big as a Tangerine orange. The
size of an apoplectic ovum depends on the date at
; which the luomorrhage occurs, as well as on the amount
of blood extravasated into the membranes. In an inte-
^ A CasG of Tubal ProKiiaucy, Meilit'o-Chinirgieal TransactioHB,
vol. Ixxlii., ]>. r>5. Koller lias Mneo dosenbod tbroo and Oilhiuaiiu ton
casus (/.eitschi'ift fUr Ooburtshilfo, 1890).
Coogle
476 The Lancet,]
MR. J. BLAND SUTTON ON TUBAL PREGNANCY.
[Feb. 28,1891'.
Tsstiog Bpecimen which Dr. Horman** removed before rup-
vare, Be fouod on sUttioeopen the sac that “bfcmorrhage
had taken place into the chorion, and the coagulated
hlood made the inteiior of the sac precisely reseiuDle the
interior of the apoplectic ova so numerous in our museums.”
In this valuable specimen the blood was extravaeated into
the membranes of the ovum only; there was no free blood
in the tube. That an apoplectic ovum is not formed merely
by the immersion of its membranes in blood is demonstrated
by cases in which, after rupture of a tubal gestation sac
from violence, the ovum Las remained for several hours
soaking in blood, yet when removed from the body its
membranes and villi have been found delicate and trans¬
parent as in a normal ovum. The same condition occurs in
early ova discharged from the uterus. It would appear
that the formation of an apoplectic ovum in the tube is
a frequent means of inducing tubal abortion or rupture.
The museum of St. Bartholomew’s Hospital contains a
pai1» it was clear that the blood-clot was not between the
layers of the meso-metrium, but was entirely within the
tulw; its histology showed clearly enough tne supposed
blobd-clot to be really an apoplectic ovum, and that the
woman was the victim of a tubal pregnancy, which proved
fatal about the fourth or fifth week. My investigations
seem to show that many of these specimens are over¬
looked. A glaring example of intellectual blindness in this
direction is furnished by Goupil in his interesting account
of intra-pelvic hajmorrhages occurring in extra-uterine
pregnancies. After arranging the various causes of this
accident under five headings, he writes:—
” A sixth variety might have been made in which effusion
of blood results from simple htemorrhage of the Fallopian
tube, but it would rest on only one observation, and chat
an imperfect one. The fcctus in that case was not found,
and extra' uterine pregnancy was based only on the opinion
of M. Robin that a certain membrane presented the appear-
Fig. 2.
specimen which illustrates this. It is described thus, under
the heading Hoamatoma.of the Broad Ligament, “The
uterus and its appendages: Between the layers of the
right broad ligament is a globular cyst about as big as a
walnut, the wall of which, in the recent state, was seen
to be formed by the separated layers of the ligament-; its
cavity was filled with recent blood coagula. On the anterior
aspect of the cyst were two small, recently formed, irregular
openings. From a patient, twenty-five years of age, who,
while in the hospital for treatment of warts on the vulva, was
suddenly attacked with the symptoms of internal hjemor-
rbage, and died in twelve hours. At the post-mortem
examination the cavity of the peritoneum contained five
pints of recently effused, loosely coagulated blood ; and
dark fluid blood ooxed slowly from the openings in the cyst
above described. A very careful examination of the blood-
cyst failed to discover tbe source of the hEemorrhage. There
was no evidence of the existence of uterine pregnancy, and no
ruptured vessel was detected. It was uncertain whether the
patient was menstruating at the date of the attack.” (2940).
Thanks to the courtesy of tbe present curator, Mr. Edgar
Wiilett, an opportunity has been afforded me of examining
and sketching this interesting specimen. On opening the
0 Brit. Med. Jour., Sept. 27th, 1880, p. 722.
Fig. 3.
A graviii Fallopian lul)e. Tlie ovum hn.s hcon transfonnocl into a
fleshy molo. {Museum of St. Bartlwiomow’s Hospital,)
ances of the chorion. M. Fenerly has published the case in
bis “ Tbiise Inaugurals,” p. 46, Paris, 1855. A patient was
admitted with subacute peritonitis, which terminated fatally
in ten days. The uterine walls were thicker than normal.
The right Fallopian tube contained a clot as big as an egg,
which was hollow and lined by a membrane, yielding!
microscopically the characteristics of the choiion. The-
uterine cavity was lined with a swollen vascular mucous,
membrane.”
This case was clearly a typical example of an apoplectic-
ovum within the I'allopian tube, and is one of the earliest
examples I can find recorded, but ids true nature was-
overlooked.
It will be useful to briefly summarise the charocters by
which an apoplectic ovum found in a Fallopian tube, loos®
in the pelvis, or between the layers of tbe broad ligament,
maybe identified, (n) When recent, it resembles in external
appearance a piece of blood coagulum of a dark-red colour..
If it has been free in the peritoneal cavity or lodged between
the layers of the broad ligament for several days or weeks,
it will be of a yellowish colour externally (due to a layer of
fibrin), and quite firm and hard. (6) Large apoplectic ova.
ate usually elliptical in shape. Small ones are more or less.,
circular, (c) The average size of such ova is that of af
walnut. They rarely exceed in size a Tangerine orange.
When smaller than a cobnut they are probably lost in the
j clot, (d) The presence of a central cavity lined with a.
Digitized by i^ooQle
Thb Lancet,]
MR. J. BLAND SUTTON ON TUBAL PREGNANCY.
[Feb. 28, 1891. 41 7
smooth raembrane—the amuioo. The cavity may contain
an embryo. Very frequently the embryo is destroyed early,
or the ovum may be ruptured and allow it to escape with
the blood-clot. (<?) Sections of the clot will show under the
microscope chorionic villi. The most reliable sign of all is
the presence of an embryo. Next in value is the existence
of chorionic villi, and these may be detected in fleshy moles
even when blood has broken into, and obliterated, the
amniotic cavity.
3. Tubal abortion .—It has been already pointed out that
the presence of an impregnated ovum in the outer third of
a Fallopian tube usually leads to occlusion of the abdominal
ostium ; this event is commonly complete by the end of the
sixth week, sometimes it is delayed to the eighth week; it
is therefore a comparatively slow process. It is important
to bear this in mind, becauseitserves to explain an apparent
discrepancy, to the effect that the abdominal orifice is some¬
times open and sometimes closed. As a matter of fact, the
condition of the ostium depends upon the date at which it
la examined after the lodgment of the ovum. So long as
this orifice remains open the ovum is in constant jeopardy
of being extruded through it into the peritoneal cavity,
especially when it lies in the ampulla of the tube, and the
nearer it is situated to the ostium the greater is the chance
of its being thus discharged from the tube. To Ibis accident
the term “ tubal abortion”^ may be applied, for itis exactly
parallel to those early abortions occurring in connexion
with uterine gestation before the end of the second month ;
and it further resembles them in the fact that the
ovum is apoplectic. These cases of “tubal abortion” are
worthy of attention because specimens of Fallopian tubes
have been frequently described in which blood-clot has
been found banging from their fringes, associated with
a localised dilatation of the tubes. like gestation sacs.
Many of these cases resemble uterine abortions in which
the ovum from some cause or other becomes apoplectic
and is expelled, accompanied by a free discharge of blood
from the uterus. When it occurs early the ovum is
small, and, unless carefully sought for, frequently escapes
detection; when large, it is easily recognised. In tubal
abortions the same thing happens. The ovum is dis¬
charged with a copious h.'cmoirhage into the peritoneal
cavity, accompanied with the usual signs of internal
bleeding, and death may occur earl^ from the auiomia
thus induced or from shock. Escaping this danger the
patient falls, in many cases, a victim to peritonitis. In
such instances the ovum being very small escapes recogni¬
tion when the clot is examined, either at the operation or
oat mortem. Tubal abortion can only occur during the
rst month, when the ovum is small enough to pass
through the abdominal ostium, for we muse remember
that as the ovum enlarges the ostium is continually
narrowing, and thus diminishes the chances of the ovum
escaping through it. The large quantity of blood which
flows from the tube into the peritoneal cavity may amount
to thirty, or even fifty ounces. Tubal abortion is a subject
of much interest, inasmuch as it furnishes many of the case.s
of pelvic hmmatocele, which are ascribed to metrorrhagia,
reflux of menstrual blood from the uterus, and hnimoiTliHge
from the mucous membrane of the Fallopian tube. The
reason for associating the hicmorrhage with metrorrhagia
and menstruation is due to the fact that whilst the ovum is
crowing in tlm tube a decidua is forming in the uterus.
When tubal abortion occurs hromorrhage takes place from
the uterus, consequent on the separation and expulsion of
the decidua. If this accident happens near the time the
patient expects to menstruate the case would be regarded
as reflux of menstrual fluid into the peritoneum. If it do
not coincide with a menstrual period, it will be considered
to be metrorrhagio in origin. It will therefore be well in
searching clot removed in operations for pelvic lucmatocele,
to examine carefully any apparently organised ovoid clot,
in order to ascertain if it contain an amniotic cavity, with
or without an embryo, and also ascertain the existence or
otherwise of cliorionic villi.**
4. Itiqjturc of the srcc.—-With excessively rare exceptions,
a pregnant tube either aborts or ruptures at some period
before the twelfth week following impregnation. In tubal
abortion the blood escapes into the peritoneal cavity. When
the tube rupturos, t!io blood in most cases also finds its way
directly into this cavity ; in a certain proportion, however,
the rupture takes place in tliat portion of the tube which is
tyviu iiitroiliii'oil liyKoller. /.oitsclivift fiir Ouburtsliilfe, Hi!, xix,,
IduO
® For a typicul case of tubal aboi f ion woo Obsti-t. .Soc. 'J’rans,, ls90.
uncovered with peritoneum. Under such conditions the
blood is poured Wtween the layers of the meso-metTinm
(broad ligament), and is usually limited in amount. Gene¬
rally speaking, intra-peritoneal rupture is a fatal accident;
death may ensue in a few hours from ^hock, or may be
induced by secondary changes, such as peritonitis, a few
weeks later. The symptoms depend upon the amount of
blood which is poured out. In some cases it amounts to
three, four, or more pints, in others to only a few ounces.
When the hmmorrhage is large in amount, unless surgery
promptly affords relief, and sometimes even then, the patient
quickly dies. Museum shelves too eloquently attest this.
It is not dillicult to prove that a pregnant Fallopian tube
may rupture into the peritoneal cavity and the hsemorrhage
be so slight as to give rise to no marked symptoms, in
August, 18SG, 1 removed by abdominal section the tubes and
ovaries from a woman aged twenty-five years. She had been
treated for many weeks by rest and medicine for what was
.supposed to be chronic inflammation of the Fallopian tubes,
and a bard rounded swelling was easily detected on the left
side of the uterus. The symptoms bad come on insidionsly;
there bad never been any sucfden pain or arrest of menstma-
tion. On drawing up the left uterine appendages they
were found adherent to a large fold of omentum, containing
blood-clot and an ounce of fluid blood. The omentum, tube
and ovary, with the adjacent portion of the meso-metvium,
were removed. The ovary contained some enlarged follicles,
and it was thought that one of these had ruptured and fur¬
nished the hmmoirhage. The specimen puzzled me at the
time, and was carefully preserved. Two yeais later I re¬
examined the parts, an^ found a rupture in the Fallopian
tube near the abdominal ostium. Lying snugly in the fold
of omentum adherent to the tubs was a rounded mass of
laminated clot, and in this an apoplectic ovum as big as a
cobnut. One part of its circumference looked ragged,
and on teasing some of the fragments in glycerine and
examining them microscopically they were found to be
typical chorioni villi. The parts are shown of nearly
natural size in Fig. 4 It then became clear that the tube
had been gravid. The ovum had been converted into a
lleshy mole, and led to rupture of the gestation sac at about
the third week. The date of the rupture could not be fixed
with cei'tainty, but I knew from physical signs that this
Fig. 4.
clot had occupied the omentum for many weeks preceding
the operation. The fact that this ovum and the surrounding
clot were for so many weeks tolerateil by the peritoneum
assists us in comprehending that when an apoplectic ovum
is discharged from the Fallopian tube and lodged between
the layers of the meso-metrium, it becomes sequestrated,
and in many cases causes no further trouble- Whtn a living
ovum is thus dislocated, it frequently continues to grow,
and its subsequent history will afford a theme for a future
occasion.
478* TBk Lancet,] DR. H. BADCLIFFE CROCKER ON ALOPECIA AREATA. [Feb. 28, 1891.
ALOPECIA AEEATA, ITS PATHOLOGY AND
TREATMENT.!
By H. RADCLTFFE CROCKER, M.D., F.R.C.P.,
IHTSICUN TO TUV; SKIN DEPABTMl^NT, UNIVERSITY COLLEGE HOSPITAL ;
PHYSICIAN TO THE EAST LONDON HOSPITAL FOR CHILDREN.
Fbw diseases of the skin have been so long recognised as
alopeciaaroata, as itssynonym areaCelsiclearlyindicates, yet
we know but little more of its true origin than Celsus himself.
Without being in any way a physically painful disease, it
is an important one to the sufferer on account of the
censpicuous disligorement it produces; while it is interesting
to ftie practitioner on account of its frequency, its rebellious'
ness to treatment, and the mystery which hangs round its
pathology in spite of many attempts to explain it. I hope
that by the interchange of oar experience, and the ideas
suggested by that experience^ some advance may be made in
clearing up these moot points ; and even if we are not so
successful as we could wish, by arriving at a deGnite under¬
standing as to what points attention should be directed we
may perform the more humble oilice of paving the way for
future scientists to solve the problems which await solution.
Time would fail if I were to try to do justice to the labours
of the numerous workers in this Geld, and I propose, therefore,
to base my remarks chiefly npou my own experience; and
for this purpose I have carefully analysed 207 consecutive
cases of alopecia areata which occurred in nearly 10,000
cases of skin disease, indicating a frequency of 2 per cent.,
while from private practice I have taken the first 50 cases
which occurred in 1500 cases of all sorts—i. e., per cent.
In the hospital cases, there were 112 males to 95 females,
and in private, 28 males to 22 females. The ages of the
hospital cases ranged from two to fifty-six years, the private
cases from tliree to Gfty-five years. In the hospital cases
the greater number—viz., 125—were under twenty. There
were 70 cases between twenty and forty, and only 12 above
that age. On the other liand, in private there were only 6
under twenty years, 29 between twenty and forty years,
and 15 above that age. This discrepancy between public
and private practice is, I think, chiefly to be ascribed to the
peculiarities of consulting practice in a special branch. In
this adults largely predominate, and there is also always
as undue proportion of obstinate and rare diseases. Statis¬
tics as to frequency therefore are unreliable. Speaking
generally, we may safely say that it is most common
under twenty, frequent between twenty and forty, un¬
common after forty, and rare after fifty; it is probably
also rather more common in males than in females. I
will not adduce further statistics, but I must remark that,
though I have grouped all these cases together, I do not wish
it to D 0 inferred that I consider them all identical in their
pathology. And this leads me to allude briefly to the
current theories of the pathology of the disease, the ex¬
ponents of which are practically divided into two hostile
camps. In one dwell those who hold that alopecia areata
ia due to a vegetable parasite; in the other those who
regard it as a tropho-neurosis. The tropho-neurotics, sup¬
ported by the authority of the great Hebra, have out¬
numbered their more ancient opponents, and, adopting a
Fabian policy, calmly await the onslaughts of the parasitics,
who from the time of Gruby have never been wanting in
defence of their theory. From time to time they sally forth—
usually as single champions, wearing their own newly dis¬
covered parasite, like a lady’s favour, on their breasts,—and
challenge the tropho-neurotics to fresh inquiry; but the
latter’s motto is a “Non po8sainu8,”and they only watch and
wait until a new champion with a new parasite appears,
and, slaying the old parasitic, tramples his parasite to the
dost, and has a short-lived triumph, until be himself
and his parasite perish in their turn. I am going to try
to bring peace between these old opponents, and to uphold,
as the French have already done, that there are parasitic
and non-parasitic cases of so-called “alopecia areata,” and I
shall endeavour to prove my proposition by appealing not so
much to the microscope—with which it is very difficult to
make a man see what he does not wish to see—as to clinical
facts, which make, I believe, a parasitic basis an absolute
An Atlclress, introilucfcory to thedlscuaaion on the siihject, delivered
at tke meeting of tlie Britisli Medical Association on .luly 3i)th, 1S90.
necessity for a large proportion of cases. A careful exami¬
nation of the cases I have alluded to leads me to believe
that under the generic term “alopecia areata” there are at
least four classes of cases which should be separated from
each other. Possibly further experience may lead to still
further difterentiation.
‘ In Class 1 I would jplace those cases in which the alopecia
is universal, and in which the hair does not necessarily cotne
i out in patches, but there is general falling off, often very
rapid, and accompanied in some cases by changes in or even
falling off of some or all the nails, as in the following in-
. stance. A boy, aged eight years, without any apparignt cause
or preceding Ul health except a poor appetite, within ten days
lost the whole of the hair all over the body, together with
all the finger and toe nails. Three years later, when I saw
him, there was not a hair or nail present, and the nail-bed
was rough and irregular, as if the nail bad been torn off,
leaving a little horny matter behind. In a secofld case, a
boy of fourteen, the whole of the hair had come off some
time previously, soon after a fall from a tree on to his
head. In a third, a girl aged two years fell nine feet from
a window. She did not recover complete consciousness for
three weeks, and a week after regaining her senses the hair
began to come out on the left side of tliehead, and she became
quite bald in a week, with the exception of a small tuft at
the left occipito-parietal suture; the nails were unaffected.
A year and a half later the hair Avas returning, leaving cir¬
cular bare patches like a commencing alopecia areata.
Rapidly universal cases after worry, fright, and injuries to
the head have been recorded by Tyson, Duckworth, Cooper,
Todd, Holmes, Collier, and others in this country and
abroad. In some the hair began to fall out in patches; in
others it came out indiscriminately, or even in masses. In
a captain whose ship was struck- by lightning, and who
sustained scalp wounds, it began the very next day on the
beard, and then the scalp and the rest of the body were
denuded; two months later the nails scaled off from the
fingers, hut not from the toes. In several other of the
above cases some or all of the nails were lost. In one of
Tyson’s cases the big toe and thumb nails alone escaped.
In a veiy large proportion of these loss of hair is permanent,
and the course ia for the most part rapid. In the following
instance it was more gradual. A woman aged thirty-three
began to lose her hair during pregnancy, nine months before
I saw her, hut it was several months .before the alopecia
was complete on the scalp, with the exception of a few
straggling hairs on the back. The eyebrows and lashes
were partially lost; some of the nails were deeply furrowed,
others were half separated from the matrix, while others
again were flattened with slight pitting. The universal
cases of this typo are really very rare, although, owing to
their striking character, a considerable number are recorded
in dermatological literature.
In Class 2 1 would place baldness occurring in one or
more patches at the site of the injury, or in the course
of a rocoguisabl© nerve. These are very few in number
comparatively, bub there are many on record. In a woman
with melancholia, aged thirty-four, whom I saw Avith
Dr. Savage at Bethlem Hospital, there were white patches
of hair in the course of the left supra-orbibal, and one
between two or three inches in diameter was almost bare ;
there was no history of them obtainable. In Pontoppidan’s
case a girl, aged ten, had some glands removed in the left
carotid region, Avhich was followed by ocular paralysis,
indicating injury to the sympathetic nerve, while loss of
hair in areas on the hack of the head took place, and six
Aveeks later the Avhole hack of the head became denuded in
the region corresponding to the domain of the major and
minor occipital nerves, and the posterior branch of the
auricularis inagnus. Within three months the hair began
to grow again. Josepli excised the second cervical ganglion
in the cab and rabbit, and this operation was followed by
alopecia patches in the territory of the second cervical, the
occipital, and the great auricular nerves; but the remits
were not uniform, and hia experiments, though partially
confirmed by Mibelli, are not accepted as conclusive; for
Behrend and otiiers have not been able to get the same
effects. Two instances of local baldness on the site of a
blow are related by J. Collier in Tiik LanoiC'I' of June 11th,
1881. Similar cases are scattered through the literature of
the subject.
Class 3 is the form originally described by Neumann as
alopecia circumscripta seu orbicularis. In this the patchy
are circular and always small, from a lentil to a pea in
... ..og
TBS LANOST,]
[FSB. 28, 1891. w
DR. H. RADCLIPFE CROCKER ON AL07>ECIA AREATA.
diameter, much depressed below the surface, with often a I
marked decrease of the sensibility. It is, in my experience,
a rare form, and the prognosis is very unfavourable. The |
following instances from my own practice. A gentle- |
man aged ^rty-five, in robust health, and with no history ;
of antecedent worry, syphilis, or other serious illness, had a
large number of bare, depressed, pea-sized spots on the
scalp, chiefly at the vertex ; the hair round them was loose,
and came out with the sheaths attached, and there were
no (!) hairs. All the nails of the Angers and toes underwent
the following changes: they first separated from their bed,
then became of a dirty yellow colour, and finally thickened
without splitting ; the surface remained smooth on the
finger and big toe nails, but in those of the smaller toes the
free end was thick, yellow, and everted, while the proximal
part was thinned, rough, and striated, but not discoloured,
a deep furrow separating the thin from the thick part. In
a second case, the patient was an unmarried lady, aged
forty-six years. The alopecia began fifteen years pre¬
viously in small patches, on which the hair has never
grown again, but the baldness had increased rapidly
xn the last two years from the multiplication of the
patches. On the vertex were several irregular areas of
perfectly bald skin, atrophically and deeply depressed
below the surface, and there was no trace of a hair-follicle
left on them. There were one or two stumps adjacent
which drew out without requiring any force. There were also
small patches of baldness, not sharply defined or round, but
very atrophically depressed. Her general health had been
bad for several years; she is subject to vomiting two or
three hours after taking food, bringing up mucus only, but
this has been better lately; her sight has been failing, espe-
ci^ly in the left eye, for the last two years, and she is
very subject to chalazion; she is also dyspeptic. Sangster
relates two cases of this form—his own and a case of
Pringle’s—in the February number of the British Journal
of Dermatology.
These cases are distinguished by the very marked depres¬
sion of the bald area below the surrounding skin, and must
not be confused with the pea-sized bald smooth white spots
on which the area is not depressed, and which are to be
referred to the fourth class. Few would dispute, I believe,
that all three of these classes are essentially of a tropho¬
neurotic nature. The prognosis of the first and third classes
is for the most part unfavourable. Taken collectively they
form a very small proportion of cases classed as alopecia
areata—certainly not 10 per cent., and I believe not more
than 5 per cent.,—and it was for that reason that in my pre¬
liminary statistical statement I did not attempt to separate
numerically the diflerent classes, as the general conclusions
would not be Ihereby affected. It might be convenient to
place them all under the head of “alopecia neurotica,” with
varieties universalis, localis, and circumscripta.
The fourth class is not only numerically the largest by far,
but the one most open to discussion as to the origin of the
affection, and on tnis point the conclusion has been gradu¬
ally forced upon me by clinical facts that it is due to a
vegetable parasite, and that if wo reverted to the old term
“ tinea decalvana,” we should not really be taking a retro-
E ,de step. Before I bring forward the faefs whicli have
me to this conclusion I must state in a few words the
clinical features of the class. (Fig. 1.) In it, the cases occur
chiefly in patches from half to two inches in diameter, and
of round shape primarily, but they may be larger and irre¬
gular, in outline from the coalescence of neighbouring
patches They commence more frequently at the back of
the head than elsewhere, but may come on any part of the
scalp. (Fig. 2.) A less frequent form is a broad band of
baldness which may go ail round the head. (Fig. 3 )
This band or serpiginous form is much less common than
the round patch form and often extends much more rapidly,
and its prognosis is less favourable. In one of my cases the
hair came off in zigzag channels until the whole scalp be¬
came denuded. This variety is the ophiasis of Celsus, who
considered it the more favourable form. The bare areas
are smooth and whiter, and tlie tissue is lax and thinner
than normal skin. In all recent and active cases there are
short hairs about one-eighth of an inch long, thicker at the
free than at the tapering point of insertion, so that these
stumps resemble a note of admiration sign (I). They pull
out almost with a touch and very soon fall out spontane¬
ously, so that their presence betokens recent extension;
and they are, in my opinion, quite characteristic of this form
of the disease, as I believe they are absent in the other three
classes. They are seldom present in great numbers, though
Fig. 1.
CoiDinoii form ot Urn fuiirth d.-vss.
Fig 2.
Coiiiinon fonn of tho fourth chiss.
Fig, 3.
liiintl form of itlopoi'in. iire.sta.
Digitized by
Google
[FiiiJ. 28, 1891.
480 Thk Lamcet,! MR. MAYO COLLIER ON TAPPING THE MASTOID GLANDS.
I have once seen them.coTering the whole of a new patch,
and as the disease ceases to extend disappear altogether
(Fig. 4.)
Ic must be admitted that in a large number of cases tbe
origin of the affection cannot be traced. As already stated,
tbe eruption occurs mainly in youth and the prime of life,
no less than 188 of 207 were under forty ;year» of age,
and in private practice 35 out of 50. Except in a very small
Fia, 4.
lUuabrating LIbo ciisoaMfl alfectinc tho face. lire lialii ai'ca.i
on the chin, eliooK, and moustaclie.
proportion of cases there is no departure from health ; most
cases are perfectly healthy in every way. In tbe hospital
cases 14 women and 7 men showed some departure from
health ■, O had headaches and neuralgia, the others were of !
trivial importance; but this point is brought out best in the '
private cases, because in them this point is always inquired
into most thoroughly, while in hospital practice, owing to
the high pressure at which the work is done, inquiry in this
direction is less systematic. In 10, 5 males and 5 females,
there was or had been some departure from health ; 3 were
subject to headaches, 1 man was overworked and run
down, 1 bad bad a railway accident which had left him
nervous, 2 were notably neurotic women, 1 was subject to
asthma, 1 had hud syphilis some years before, but had
never exhibited any recurring symptoms ; 1, a girl, had had
sciatica. All the rest, equivalent to 80 per cent., afUrmed
that they were,and appeared to be, in perfect health. Surely,
if this was always a neurosis, ami that, too, of a degenerative
kind, it would be unparalleled among all other neuroses that
it should be—first, a very common disease; secondly, most
common in the prime of life; and tbiidly, that four-fifths
of its victims should be otherwise in perfect health, while
those who were not quite well should f»r the most part
suffer from merely functional disorders of the most common
kind, probably io about the same proportion as would
generally be found in a large number of people taken
indiscriminately. Very few exhibited any other lesion
of the skin, and they cannot but be regarded as acci¬
dental complication!?. Among the whole 250 were noted
one exairrple of eacti of scabies, seborrhma capitis, come¬
dones, pityriasis circinata, lupus vulgaris, ec/ema, lichen
lanus. One had tinea versicolor; and in one, the gfrl who
ad bad Bcia*ica, her mother thought that her skin was
dry and powdery, and that there was a persistent redness
of the cheeks wbieli had not existed before the alopecia
areata. This was one of 7 patientsof tbe 60 private cases in
which there was some fair grounds for considering them
neurotic. Of the other six, 2 were universal, 2 were
Neumann’s atrophic forma, 1 (already referred to) had had
his nervous system shaken by a railway accident some years
before the attack, and the sixth was classed as possibly
neurotic, but the evidence was not very strong. Of the .50
private cases not less than 11 had had previous attacks,
and of the 200 hospital cases ^2 had had previous attacks,
some of them having been attacked several times. U
began in a lady of thiity-two years wiien she was seven
years old, and she had often been nearly well—i.e., with
only a single small patch; but she had never been quite
free. This patient was a strong, healthy woman.
(To be concluded.)
TAPPING THE MASTOID CELLS.
By MAYO COLLIER, M.S.LOND., F.RC.S.Eng.,
LATi: SUHOIJON TO THE TIIIIOAT AND EAR DEPARTMENT, NORTIt-
WEST LO.NDON IIOSPITAI., ETC.
In recording this not unusual case of chronic discharge
from the ear, due to caries of the temporal bone and treated
by tapping tbe mastoid cells, I do so not in the least wish¬
ing to arrogate to myself any particular credit for an
ordinary simple surgical procedure, but rather with a desire
to induce others to whoso lot the treatment of such affections
may fall to remember the old adage, “ Prevention is better
than cure,” and whilst not rushing needlessly into operations
accompanied with more or less danger to remember that a
patient sufleriog from a chronic offensive discharge from the
ear is one whose life may practically not be worth a week’s
purchase, and one whose discharge, unless checked, will
most certainly lead sooner or later co very grave troubles.
The recent death of the great archaeologist. Dr.
Scbliemann, from abscess of the brain consequent on
a chronic discharge from tbe ear, may possibly bring this
matter borne to us. The brilliant feats lately recorded in
The Lancet of opening the skull and plungiog trocars into
the brain in search of cerebral abscesses would, I maintain,
be uncalled for io most instances were one of the first prin¬
ciples of surgery applied by surgeons to tbe treatment of
obstinate discharges from the ear. Compared to ligaturing
the lateral sinus and trephining the skull in various places
in search of pus, tlip simple procedure of tapping the mastoid
cells to ensure efficient cleansing and drainage of the middle
ear is, as it were, a fleabite. On referring to the best known
authors in this country and America, I find no definite
advice or authority given for such procedure, unless pain
or symptoms of retention of pus be present in the mastoid
process. I would urge that, although there be no pain or
tenderness and no evidence of the retention of pus, if the
discharge be obstinate, offensive, and of some years’ stand¬
ing, a cure may be effected, and death averted, by a timely
vent in tbe mastoid process. The mastoid cells may be opened
with rapidity, certainty, and safety, by working from the
posterior wall of the auditory canal backwards, upwards, and
inwards. To effect this, a curved incision should be made
parallel to tbe antibelix close to the pinna, and well out of
sight, severing all the tissues, periosteum included, down to
the bone. The pinna being displaced forwards, the
posterior segment of the auditory canal is exposed. If the
operator now works in the angle formed by tbe posterior
root of the zygoma and posterior wall of the auditory canal,
working in a direction at first inwards and backwards, the
posterior portion of the tympanic cavity and cells of the
antrum are reached with certainty and a minimum of risk
incurred. The chisel and mallet I have found more handy
than the trephine, drill, or other appliances. In operating
on this case I had the advantage of the assistance of roy
colleague, Mr. James Black, aural surgeon to Westminster
Hospital.
A. S-, aged twenty, a tall, delicate-looking girl, came
as an out patient to the North-West London Hospital
in the spring of 1885, complaining of deafness and an
offensive chronic discharge Irom the right ear of twelve
months’ standing. Watch heard on contact; left side
hearing good ; never had scarlet fever or measles. Throat
and post-nasal space normal, with the exception of pallor
amhome relaxation of mucous membrane. Both Eustachian
tubes were patent. On examination, left membrane normal,
right obscured by pink lleshy mass bathed in pus. On
cleansing, a polypus was discovered springing from the
edge of a large perforation in the upper and posterior
segment of the membrane. The polypus being re¬
moved with the snare, the middle ear was cleansed with
warm boracic lotion and dusted with diluted iodoform.
The patient attended twice weekly after this, with
some periods of improvement, but never with entire
disappearance of tbe discharge. Tbe diligent use of
Politzer’s bag, associated with antiseptic and astringent
Google
Digit'/ed
Thb Lancet,] DR. CRANSTOUN CHARLES ON PULMONARY PHTHISIS. [Feb. 28, 1891. 481
lotions and powders, for a period of five years, was nob
sufficient to bring about a cure, the discharge persisting and
causing much annoyance by passing occasionally into the
mouth during sleep. After consulting with colleagues,
I opened the mastoid cells in the manner above indicated, re¬
placing the auricle and draining from an opening made in the
pinna immediately over the mastoid opening. During the
operation carious bone could be felt with the probe on the
posterior and inner wall of the tympanum. The case did
remarkably well, and in ten weeks the patient left the hos¬
pital free of discharge, and with partially restored hearing.
New Cavondish-street, W.
PULMONAEY PHTHISIS;
SOME REMARKS AS TO ITS PATIIOLOGV AND ITS CURABILITY
IN EARLY STAGES, PARTICULARLY BY THE USE OF
HOT-AIR INHALATIONS.'
By T. CRANSTOUN CHARLES, M.D.
{Condud.tA from. p. 1,19.)
Of the twenty-five cases of pulmonary phthisis in which
I have adopted the hot-air treatment six recovered, fourteen
died, and five passed from under my observation, three of
them having gone to live abroad. The fatal cases were all
in an advanced stage, with one exception—thab of a girl
aged seventeen, who apparently recovered after the use of
the hot-air apparatus for four months, but in whom a year
subsequently the disease returned and carried her off in
seven months, although the hot-air inhalations were re¬
sumed. Only brief histories of the cases in which a cure
resulted will here be given; bub whether the sole credit is
duo to the hot-air inhalation or nob I shall leave my readers
to judge.
S. J-, a young lady aged twenty, whose parents were
healthy, but one of whose maternal aunts died at the age
of twenty-four of phthisis, had been liable to frequent
catarrhs of the air-passages. She had had an attack of
catarrhal pneumonia of the upper lobe of the left lung three
years ago, since which time she has never recovered her
strength. Six months ago she had a slight attack of
pleurisy in the loft side, lasting a month, and following this
a frequent and troublesome cough. The patient is very
delicate-looking, having a long slender neck, with promi¬
nent claviclesand badly-developed thoracic muscles. When
first examined by me (Nov. 1888) there was loss of resonance
on the left side from the apex of the lung to the lower
border of the third rib, with prolonged harsh expiration
and crackling rales. The pulse was quick, and the tem¬
perature 102 6° (6 P.M ). Emaciation was marked, and
there was some hoarseness of the voice. The expectoration
was blood-streaked, purulent, and nuramulated, and was
found to contain tubercle bacilli and elastic bundles. Night
sweats were of frequent occurreuce, and the patient was in
a very exhausted condition. The bob-air inhalations were at
once commenced, and continued regularly for five months.
The cough became less frequent, and by degrees the bacilli
disappeared. The breathing over the upper part of the
left lung was ultimately very slightly harsher than on the
right side, all iHles having disappeared. I saw this patient
again in August last, after she had returned from a trip to
Australia, and I could detect no positive abnormal signs in
the chest; indeed, she had increased greatly in weight, and
appeared in robust health.
B--—, a young lady aged nineteen, no family history
of phthisis. In 1883 she had an attack of bronchitis passing
into pneumonia, and was subject to occasional coughs from
time to time till the spring of 1880, when she had conges¬
tion (?) of the left lung attended with much pain in the side,
violent cough, and bloody expectoration. This luemorrhage
increased and continued for three weeks, bub the cough
lasted till the summer of thesameyear. In each of the three
lollowing winters she suffered from a severe eougii, but
about the Christmas of 1888 the cough became very fre¬
quent and severe. On examination there was dulness ex¬
tending from three-quarters of an inch above the left
clavicle to the lower border of the second rib on the same
side anteriorly, and the expiration was markedly prolonged,
narsh, and blowing, with abundant crackling rdles. The
patient suffered from pain on the left side, frequent
cough, and abundant hasmoptysis; there was a great wane
of appetite and energy, she slept badly, and perspired freely
bothdayand night, and wasrapidlylosingweight. Thehpjmo-
ptysis continued for some time, and therilles became coarser,
thebronchialbreathingand bronchophony alsobeoomiug more
ronounced. Towards the end of January, 1889, she began.the
ot-air treatment, and for the first three days after beginning
its use the cough and hcemoptysis increased somewhat, after
which they both began bo decrease, and in two weeks the
bsemoptvsis ceased entirely, the cough also becoming easier
and less frequent. After two months the cough likewise
ceased. Some weeks subsequently she left off the inhaling
entirely. The expectoration was frequently examined, and
at first tubercle bacilli were very abundant; but they
quickly diminished in number, and they are now completely
absent, although for a considerable time one or two could
be found in a preparation of the sputum. The patient is at
reseat most active in her habits, and her health has never
een so good.
J. S-, clerk, aged twenty-seven. No family history of
phthisis. In 1887 was in Brontpbon Consumption Hospital,
under the care of Dr. R. Thompson, and Dr. Theodore
Acland has kindly found out for me that he was then suffer¬
ing from chronic tubercular disease of the lung, with no
active mischief, bub with a contracted cavity in the left
upper lobe. He left the hospital somewhat improved, but
since then he has had repeated attacks of hemoptysis,
having had three of these, lasting a few days each, in
November, 1888, and showed evidence of cavities in the
upper lobe of the left lung. There was great dyspnoea and
a sharp pain in the chest, shooting back from the right apex
towards the lower angle of the scapula; the coughing was
almost continuous at night, with profuse expectoration con¬
taining bacilli in abundance, and the night sweats were
most profuse and exhausting. He began the hot-air inhala¬
tions in February, 1889, for some hours daily. The inhaling,
however, owing to circumstances, was done very irregularly
at first, and could not be continued for any length of tiipe,
bub later it was done for an hour in the morning and two hours
in the evening. The cough gradually ceased, and all the sym¬
ptoms improved. In July, 1889, he was still inhaling, but
when the chest was examined it was found clear and reso¬
nant on both sides, slightly higher pitched in tone, however,
in the right infra-clavicular region ; the respiration also was
normal, although after coughing dry clicking or a dry
mucous r^le could occasionally be heard during inspiration.
But on examining the chest again a short time subsequently
there were no rales to be beard of any kind, and the patient
had increased seven pounds in weight. His digestion as
well as his strength generally had so much improved that
he was able to attend to his daily work, which is noth heavy
and of long duration.
G. G-, aged thirty. Phthisis not hereditary. General
health good until two years ago, when she had an attack of
pleurisy in the right side, lasting seven weeks, followed five
months later by pneumonia in the opposite lung. For the
last four months she has had a very troublesome, dry,
hacking cough. When examined (January, 1888) she was
suffering from a frequent and distressing cough, with a
slight amount of expectoration, in which tubercle bacilli,
bub no elastic fibres, were detected. Elevation and expansion
movements were evident in both infra-clavicular regions,
and there was no loss of resonance perceptible anywhere
except posteriorly inside the spine of the left scapula, at a
spot corresponding to the apex of the lower lobe oi the lung.
Here the expiration was prolonged, with bronchial breathing
and crackling rales audible on deep inspiration. The patient
improved rapidly under the hot-air ti'eatment, and all signs
of dulness and rales entirely disappeared (July, 1889). The
cough and expectoration had likewise ceased.
T. W-, aged twenty-seven, a hard-working curate of
the Church of England. Health has never been very robust,
and has occasionally been subject to slight catarrhal
bronchial .attacks in the winter, but has never had to give
up work buT his present illness. This began three months
before I saw him in April, 1889, with hoarseness and frequent
tickling cough. The hoarseness varied from time to time,
bub gradually developed into aphonia. On examination I
found the ary-epiglottic folds both swollen, their surface
ale, and with a few scattered small ulcers ; the vocal cords
ad lost their w hiteness posteiiorly where slight thickening
was perceiJbible, and one small ulcer was visible on the
right side. The epiglottis was likew'ise thickened and
o
Coogle
482 Tqe Lancet,]
DB. CKANSTOUN CHARLES ON PULMONARY PHTHISIS.
[Feb. 28, 1801.
ulcerated. Tbe patient had suffered from sore-throat and
slight djsphagia for some time, hut these symptoms gradu¬
ally decreased in severity. The cough was very frequent
and tbe expectoration abundant, tubercle bacilli being
present in great numbers. No evidence of tubercular
deposit in the lungs could be discovered, although over the
left apex tbe resonance was slightly high pitched ; but no
abnormal sounds could be detected with the stethoscope
either on deep inspiration or after frequent coughing. When
the patient bad been under the hot-air inhalation for six
weeKs he recovered bis voice completely, and on examining
him in July, 1889, I could detect no swelling or ulceration
of the larynx, nor could I discover any abnormal appear¬
ances there when I saw him in the October following, or
any signs of tubercular deposit in the lungs. Ulceration
of the larynx, we know, is very common in pulmonary
hthisU, occurring in an average of one-third of the cases ;
ut it is generally regarded as always being secondary.
Ur. Byrom Bramwell and Dr. Coats, however, have recorded
cases in which the disease appeared, like tbe above, to com¬
mence in tbe larynx. It is possible, of course, nay, even
probable, that a slight tubercular deposit may have pre¬
viously occurred in tlie lung in this case, for it is sometimes
very ditficult, if not almost impossible, always to detect it
in its veiy early stages.
S. W-, aged twenty-five, governess. Motlier died of
pulmonary phthisis. The patient suEFered from scrofulous
glands in the neck in early childhood, and has never been
strong or robust. She has been xeiy liable to bronchitic
attacks, but has never spat blood before tbe present illness,
which began three months previously, with great debility,
loss of appetite, frequent dry cough, and great feeling of
feverishness and prostration at night Two months prior to
seeing me the cough was attended with expectoration, and
it was noticed to be tinged with blood. Night sweats also
became frequent and troublesome. On examination in
February, 1889, the patient was much emaciated, her face
pale with flushed cheeks, the left cheek particularly ; the
chest was lean and narrow, and above and below tbe
clavicles there were deep hollows, but better marked on the
left side. Expansion was absent below the left clavicle, and
there was lo6« of resonance over the same area, bronchial
breathing and bronchophony also being audible; at one
point a cavernous r.lle was to be beard on inspiration and
expiration, occasionally attended by an amphoric echo ; and
at the lower limit of dulnesa in (he third intercostal space
crackling rfiles with occasional dry clicking were to be heard.
Some hoarseness of the voice was noticeaole, and there was
slight hypera^mia with swelling of tbe ary-epiglottic folds.
Bacilli were abundant in the sputum. Under tbe use of
the hot-air apparatus the patient underwent great improve¬
ment, and after four months her weight had increased by
2(> lb., tbe cough had almost ceased, and only a few bacilli
were to be discovered in the sputum. She slept well, her
appetite was good, and she possessed plenty of physical
vigour.
In all these cases tbe signs and symptoms were of a
positive kind and tubercle bacilli were abundantly present;
and in them all the results were most satisfactory. The
treatment combined not only the sterilisation and destruc¬
tion of the bacilli by means of tbe hot air, but also the
general employment of remedies and methods tending to
improve the general health of the patient, and raise the
tone of the tissues, assisted, of course, by such therapeutic
agents as were indicated to allay symptoms or treat any
accidents or complications that might arise in the course of
the disease. In cases of bronchitis also, attended with
profuse expectoration, the hot-air treatment may, I believe,
be employed -with very great advantage. In seven such cases
where there was much effusion into the bronchial tubes,
attended witli dyspnoea and great general debility, and in
two cases of localised catarrhal bronciiitis following pneu¬
monia, the hot-air inhalations soon brought about rapid and
complete recovery.
I shall now refer briefly to some of the diflVrent thera¬
peutic agents that have been strongly recommended of
recent years in tbe treatment of phthisis, and state the
results I have obtained with them. 1. Breathing the vapour
of burning sulphur has afforded only very slight benefit, but
has caused much bronchial irritation. The fitronger tannin
wine-s, as St. Raphael claret, proved liighly serviceable as
an adjuvant in many cases. In one patient a marked increose
in weight occurred under the administration of forty grains
of tannic acid daily, but the iroproven-eni/only lasted during
three months. One phthisical patient, who also suffered
from marked cardiac debility, with a very rapid, feeble,
and irregular pulse, and whose digestion was being impaired
by tbe long-continued use of digitalis, benefited greatly in
every respect underthe administration of tinctureofstrophan-
thus in three-drop doses; but how long the improvement
losted I cannot say. The use of anilin and eucalyptus oil by
inhalation, the administration of acetanilide, and the appli¬
cation of an ointment of iodoform and eucalyptus oil to the
chest, the internal administration also of iodoform, were
all of only temporary advantage, and tbe same mav be
said for inhalations and sprays of oil of peppermint. 2. Fure
wood creasote proved very often of some service. It was
useful in allaying irritable cough dependent on congestion
of thelarynx, as it appears to exercise a tonic action on the
mucous membrane. It may be given iDternally with cod-
liver oil, inhaled, or employed as a spray when ailuted with
spirit of chloroform. One of its constituents, however,
guaiacol, the methyl ether of pyrocatechin, is an advance
on creasote in every respect. Its taste is not so un¬
pleasant, it rarely disagrees, and it appears more effective,
particularly in the early stages. It can be given
in drop doses in cod-liver oil or sherry. I employed
it last year in three cases over eeveral months; a slight
hub decided improvement showed itself, the cough and
expectoration diminished, and the weight, as well as the
bodily strength, increased. This amelioration lasted for a
month in one of the cases, for six weeks in the second, and
for eleven wejks in the third, .‘k Lactic acid and lactate of
soda, besides improving the digestion in some of the cases
in which they were given, tended also to diminish the
sweating. About ten drops, every twoor tliree hours daily, of
the lactic acid allayed tbe cough and quenched tbe thirst.
Under their administration, also, tlie sleep was rendered
deeper and more refreshing. By increasing the acidity of
the system by tbe use of tincture of the percblovide of iron
and niiro-hydrochloi'ic acid, alternately wilh lactic acid in
large doses, an atliempt mav he made to lessen the activity
of growth of the bacilli. Much benefit seemed to result
in two cases in which the experiment was tried, the
number of bacilli in the expectoration undergoing marked
diminution. 4. For the profuse sweating 1 have found
atropin most useful, particularly where there was ex¬
cessive formation of mucus in the stomach, and much ten¬
dency to haemoptysis; though for the latter I have had
to resort on several occasions to the inhalation of amyl
nitrite, or to the subcutaneous injectionsof ergotin, ergotinin,
and hyoscin. Snlphonal and hydrate of butyl chloride aho
proved serviceable, if there were likewise sleeplessness and
much night cough. On a few occasions pilocarpin (t,’^ gr.)
injections afforded relief, as it also tended to diminish tbe
dyspnma. Camphoric acid gave but little eatiefaelion.
High temperatures were reduced by antipyrin and phe-
nacetin in small and repeated doses. These bodies also
relieved the cough and induced sleep. Hypnon, likewise,
when inhaled in five-drop doses every four hours, lessened
the frequency of the cough, slightly lowered the temperature,
and gave a quiet sleep; but it proved somewhat variable in
its action. In a few of tbe cases after taking antipyrin a
troublesome skin eruption showed itself, accompanied by
elevation of temperature. In these cases quinine proved most
useful, and did not appear to manifest any liurcful action,
such asDaiemberg states is sometimes the case. Daremberg’s
plan of administering antipyrin I have, however, followed
with advantage : Fifteen grains when the temperature is
rising, but before it has reached 99'7 ^; then fifteen grains
every hour if it rises more than 0T)°, or even for a less rise
than this should the patient be asleep. Cold baths
proved of great service in two cases; but in another
case in which the temperature rose to 105 8® it was
rapidly reduced by the application of llannel cloths
wrung out of iced water to the chest and frequently
changed, any tendency to collapse in either method
being carefully watched for and overcome by stimulants.
G. In the case of a phthisical girl of healthy parents but of
hysterical tendency, whose right apex was aull down to the
lower margin of the second rib, and where the emaciation
and loss of strength were very rapid, and there was groat
disinclination for food, after several methods of treatment
bad failed, I tried, with marked success, the following plan
of excessive feeding. The stomach was well washed out,
and then, by means of the stomach tube, 2 oz. of powdered
beef with 18 oz. of sweet milk and three raw eggs were
introduced into it morning and evening. After three days
Thb Lancet,] MR. CARDEW : ELECTRICAL RESISTANCE OP THE HUMAN BODY. [Feb. 28, 483
the powdered flesh in each meal was increased by ;]! 0 / ,
until 4 oz. were reached. Some brandy was also given with
each meal. This treatment was continued with the best
results for fifteen days, when suddenly great irritability of
the stomach with persistent vomiting set in. Rectal
feeding was then had recourse to fora few days. The bowel
was washed out as high as possible, and twice daily the
following mixture was injectedFinely divided beef, .'5 oz.;
finely divided fresh pancreas, 2oz. ; and lukewarm water,
4oz. ; a little carbonate of soda being added. The patient
had in addition a quart of milk daily, both with the gastric
as well as with the rectal feeding. Well-marked increase in
weightoccurred under both methodsof nutrition. Accordingly,
the latter method was had resort to occasionally, but some¬
times .S^oz. of flesh peptones were injected instead of tbebeef,
varied occasionally with 4 oz. of pea-meal that had been
artificially digested in water, to which glycerine extract of
pancreas had been added, together with a little salicylic
acid. Under this purely dietetic treatment, which extended
overfournioQths,and was combined with the use of hypophos-
phites, cod-liver oil, and maltine, this young lady increased
greatly in weight, the bacilli disappeared entirely from her
sputum, all hiemoptysis ceased, and when I saw her a year
and a half subsequently, shortly after she had returned
from a long sea voyage, she appeared to be in peifect
health, all dulnesa at the right apex having disappeared,
and the respiration become normal. This case is, 1 think,
interesting, as the treatment was almost purely dietetic.
Hypophosphites undoubtedly tend to raise the nerve power
and to improve the character of the secretions, and ac¬
cordingly are most valuable tonics in phthisis. I have
noticed under their administration an increased expansion
of the chest, an improvement in the appetite, and a diminu¬
tion in the night sweats. Combined with the malt extracts,
cod-liver oil, Valentin’s extract of beef, and Kemraerich’s
peptones of beef, they are often of great value. In early
cases, also, arsenic may likewise be given with advantage.
7. In some cases in which dianhcca was very troublesome,
good results followed the use of small raw meat balls,
alternately with meat peptones and Valentin’s extract of
meat, opium and bismuth being given at the same time.
8. In three cases I have tried Potain’s treatment—that
is : sodic chloride, 10 ; podic bromide, 5 ; potassic iodide, 1 ;
•water, 100, 2oz. every morning in a cup of milk. In two
cases of caseous phthisis it was of no service, but a case of
fibroid phthisis appeared to benefit greatly under its
administration. 9. In aflections of the throat in connexion
with phthisis, 1 have repeatedly seen great improvement
follow the injection into the larynx of 10 to 20 pei- cent,
solutions of menthol in olive oil. la one case, however, it
failed completely; but in another, a man aged twenty-four,
in whom there were tubercular ulcers in the larynx pos¬
teriorly, with tubercle bacilli in the sputum, and some slight
alteration in the normal physical signs at the left apex, the
ulcers completely healed under the inlluenee of the menthol
injections, menthol also being given internally. Having
lost eight of this patient, I, however, can say nothing as to
how he has progressed.
Albert Mansions, S.W.
THE VALUE OF DIMINISHED ELECTRICAL
RESISTANCE OF THE HUMAN BODY AS
A SYMPTOM IN GRAVES’ DISEASE. .
By H. W. D. CARDEW, M.K.C.S. Eno.
It is, perhaps, advisable to recall a few well-known
■physical and physiological facts bearing on this subject
before proceeding to discuss it. Regarded from an electrical
point of view all bodies are classified as conductors or non¬
conductors. Bodies which allow the free passage of elec¬
tricity through their substance are called conductors, the
term bodies being used in a general sense. Those which do
not allow the free pa.s8age of electricity through their sub¬
stance are called non-conductors, it being an accepted fact
that every substance permits of some movement of elec¬
tricity in itself. Electrical resistance is the reciprocal of
electrical conductivity — thus: if X has a resistance of
1 ohm and Y a resistance of 10 ohms, we may say that the
resistance of Y is ten times that of X; or, that the conduc¬
tivity of Y is one-tenth that of X. It is customary, however,
and more eonvenient, to apeak of the resistance of-substances
when wishing to compare that property in definite terms
of measurement. The unit of resistance is called an ohm,
and is arbitrarily taken to be that offered by a column
of mercury at 0“ C., 106 centimetres in length, -with a
section of i square millimetre. In order to create a readily
comparable standard of resistances for various substances,
a definite quantity (one cubic centimetre) is taken of each
substance at a definite temperature, and its resistance
measured from face to face. Such resistance is known as
the specific resistance of each substance, and a glance at a
table of such specific resistances enables us to see the
relative conductivity of the various substances. The specific
resistance of solid conductors is easily found, but in
attempting to calculate that of a liquid we are confronted
with certain difficulties. We take the same amount at the
same temperature of the vaiious liquids, but it is not easy
to be so sure of its definite composition and strength if a
solution, as in the case of a solid, such as a metal. Further,
a fluid conducts by convection, being electrolysed by the
passage of a current through it, and this electrolysis sets up
a counter electro-motive force, which opposes the current,
and is yet not true resistance. Many methods have been
introduced for minimieing these difficulties.
The following table of specific resistances will be of use,
as bearing on the subject:—
Copperannealed, 1‘598 microhms (one millionth of an ohm).
Silver annealed, 1-504 ,,
Graphite, 41800 ,,
Sulphate of zinc solution with density, 1-2891 = 28-3 ohms.
Sulphate of copper solution ,, 1-2051 = 29-3 „
Water (pure) • 9320 „
Taken from Jenkin on Electricity and Magnetism. The
temperature of the first two was 0° C.;of graphite, 22“ C.; of
solution, 10“ C.; of water not stated.
This table demonstrates the fact that though a saline
solution has not the high conductivity of copper and silver,
it may yet be regarded as a fairly good conductor. It is a
recognised fact, and one easily proved, that the human body
conducts solely by virtue of the fluid contained in its tissues,
the conductivity of each tissue being in direct proportion to
the quantity and conducting quality of the contained fluid.
This resembles the manner in which a silken thread, itself a
non-conductor, after being moistened with a conducting fluid,
conducts by virtue of the conducting fluid contained in its
interstices. Any one tissue of the human body U, when freed
from fluid, a non-conductor ; but it can be converted into a
conductor by soaking it in a hot saline solution, provided
that it allows the lluid to occupy its minute instertices.
Through the kindly courtesy and with the assistance of
Professor Stewart, I e.xamined two muintnies in the Museum
of the College of Surgeons, with a view to see if they*acted
as conductors. These mummies were prepared in 1779, and
may reasonably be looked upon as human bodies free from
their fluid constituents. I used an electro-motive force of
60 volts; the galvanometer used would show 0-00001
ampbre. Bare ductile metal electrodes, connected with the
battery and galvanometer, were placed in various portions
of the mummy examined, but there was no deflection of
the galvanometer. A simple calculation shows, therefore,
that the resi.stance of each mummy must have been over
6,000,000 ohms. Other dried tissues have acted in a similar
manner. Wo are, therefore, justified in accepting as a
recognised fact that the human body conducts solely by
virtue of the fluids contained in it. These different fluids
are, to all intents and purposes, saline solutions containing a
variable amount of different salts. They may be regarded
from our point of viewas fairly good conductors, remembering
the conductivity of those solutions enumerated in the table
of specific resistances. Regarding the human body as con¬
ducting solely by virtue of these different solutions con¬
tained in the various tissues, we should expect to find it a
good and not a bad conductor. How comes it then that
riiere is such an enormous difference between their con¬
ductivity, when contained in the various tissues of the
body, and what we are led to believe by analogy would bo
their conductivity if examined external to ami separate
from the body. • The dill'erence is not due to tliem, but to-
the different conditions of the two experiments. When
examined separate from the body, they would be in¬
direct contact with the electrodes; when examined as
part of the body there is placed between the electrodes
and the fluid a layer of non-conducting material which
Di:
Coogle
484 Thb Lancet,] MR. CARDEW : ELECTRICAL RESISTANCE OF THE HUMAN BODY. [Feb. 28, 1891.
■would be a complete non-conductor were it not for minute
orifices and interstices contained in it, which perfora¬
tions contain a variable quantity of fluid. This non¬
conductor is the stratum corneum of the epidermis, con¬
sisting of cells which, as they approach the surface from the
deeper portion of the skin, become dry from evaporation
and horny from conversion of their protoplasm into keratin.
When we recall the statement that the human body free
from fluids is a non-conductor and apply it to this tissue,
we see at once why it is a bad conductor, and why it is that
were it not for the minute interstices between the cells, the
openings of the sweat glands, sebaceous glands, and hair
follicles, containing a conducting medium naturally or arti¬
ficially placed there, it would be a complete non-conductor.
We may assume that it is to this layer the body owes
its high resistance, this being borne out by the fact
that the resistance of the body is different according as
to thickness and the number of orifices in the portion
of this structure covered by the electrodes. It has
also been demonstrated that the resistance of a definite
portion of the human body is enormously diminished by re¬
moving the epidermis. A simple way of demonstrating this
theory to be correct is the manner adopted by us in the per¬
cutaneous method of applying electricity. We reduce the
resistance of the stratum corneum byeither sponging the skin
with hot water (the resistance of fluids is diminished by
heating them), or a hot saline solution, or by soaking the
coverings of the electrodes in the same fluids; or better still
by doing both. In either case the fluid enters the inter¬
cellular interstices and the other perforations of the stratum
corneum by capillary attraction, thus forming a conducting
medium between the moist structures immediately beneath
it and the electrodes placed on it. The further reduction of
its resistance depends on the electro-motive force of the
battery, and the duration of the application up to a certain
oint. I examined one patient, and with all conditions of
oth examinations the same, bare metal electrodes being
used, I found the resistance 60,000 ohms before and only
3764 ohms after moistening the skin with a hot saline
solution.
In applying the various physical facts to the study of the
human body as a conductor, we see at once that it is not
possible to assign a specific resistance to it. Theconditions
affecting its conductivity are so diverse that enormous
variations in the resistance are found in the same body.
We cannot take any definite portion of a body for a
type of the whole of the body as regards its structure
and composition. Since it conducts by virtue of the fluid
contained in it, we meet with all the difficulties enumerated
when speaking of the specific resistance of a fluid, this being
further complicated by the fact that the electrodes are not
placed so that their whole superficial area is in contact with
a corresponding superficial area of fluid ; and, further,
that the sectional area and length of the column
of fluid vary. But in examining the resistance of
human bodies, for the sake of comparison, there are
certain conditions we can control, and then our results
are of some importance. Such conditions are to use
electrodes, made of some ductile metal, having a definite
superficial area, to apply them bare to definite portions
of the bodies, to ensure as much as possible that the
number of orifices in the stratum corneum beneath them
are approximately the same. This is important, for we
must regard these orifices as containing threads of the
conducting medium, and therefore the greater the number
of these threads beneath the electrodes, the less the resist¬
ance will be, since resistance diminishes with increasing
sectional area and increases with the length of a conductor.
The electro-motive force of the battery used should be the
same in all cases. Other conditions vary with the method
adopted of estimating the resistance.
The first to call attention to the fact that the bodies of
those suffering from Graves’ disease offered a very diminished
electrical resistance was Dr. Charcot. He did not say that
it was present in all, but only in the majority of such cases.
He states in a lecture on this disease^ that in it we have a
symptom of great value, and likely to be of great import¬
ance in the diagnosis of atypical cases (formes frustes).
That it is present in the majority of cases I believe to
be certain. I found it present in fifteen out of twenty
cases. That it is a sypoptom of great or even any value, I
would venture, with all respect for such a distinguished
. * Gazette des Hopitaux, Jan 31st, 1885.
observer, to deny. My attention was called to this condition
when I first had the opportunity of carrying out the electrical
treatment for Dr. Sansom in some cases of Graves’ disease.
One noticed that in the majority of these cases the electro¬
motive force necessary to produce at once the desired current
strength was very much less, all other conditions of the
application being the same, than in patients suftering from
ocher diseases, such as facial paralysis—that is to say, the
resistance offered at the commencement of the application
was very much less than usual. Thus, with all conditions
of the examinations the same, I found in the majority
of patients suffering from Graves’ disease an average resist¬
ance of about 3000 ohms, as against from 30,000 ohms and
upwards, according to circumstances, related further on, in
other cases. This being the case, on recalling the condi¬
tions by which the human body conducts, one naturally
attributes this enormous difference to some change in the
resistance of that portion of the body (the stratum corneum)
which offers the greatest part of the whole resistance. This
was the condition found. Most patients suffering from
Graves’ disease perspire more or less profusely, and as
evaporation does not take place at a rate equal to that of
the secretion, the stratum corneum is covered with sensible
perspiration, and its intercellular interstices and the orifices
piercing it are filled with this saline solution, which forms
an excellent conducting medium between the internal
fluid of the body and the electrodes placed on it. This
deduction I found confirmed in my own cases, as pronounesd
diminished electrical resistance such as described occurred
only in those patients in whom the perspiration was
sensible. I thought, however, that, incontrovertible as this
explanation of the diminished electrical resistance was to
me, it would be advisable to examine a number of other
cases. By the kindness of Dr. Sansom, and with the assist-
ance of his house physician Mr. Reynolds, I examined a
number of suitable cases in his wards at the London
Hospital. In addition to these I examined in the out¬
patient department of the London Hospital, by the kind
permission of Dr. Ralfe and Dr. James Anderson, a large
number of out-patients. I take this opportunity of thanking
these gentlemen for so kindly affording me the necessary
facilities for obtaining the information I desired.
I found it practically impossible to estimate the resistance
in all these cases by the Wheatstone Bridge method for
obvious reasons, and therefore adopted the plan of estimating
it by means of Ohm's law. This is usually written as an
E
equation C = (C being the current strength in amperes,
E the electro-motive force in volts, R the resistance in
ohms); II being the quantity I wished to find out, the
equation for this purpose being written R= The electro¬
motive force I estimated with a voltmeter, and the current
strength with a galvanometer. These two factors being
known, a simple calculation gave the required R. My method
of procedure was as follows:—I used a 4 cell (chloride of
silver, Schall) battery, having an electro-motive force, of
6‘4 volts and an internal resistance of 1'2 ohms ; a gal¬
vanometer, which was graduated in ten-thoqsandths of an
ampbre, having a resistance of 200 ohms. A deflection signi¬
fying 0*0001 arapbre, with the electro-motive force 6‘4 volts,
therefore showed the resistance in circuit to be 64,000 ohms.
This, less the 200 ohms resistance of the galvanometer, and
the 1 '2 ohms resistance of the battery, would represent the
resistance of the portion of the human body being exa¬
mined, the equation being R (64,000) =
In describing the eases below, when I say that the re8i.st-
ance was more than 64,000 ohtns, 1 mean that with such an
electro-motive force and such galvanometer pub in circuit
with a patient, the deflection was not equal to 0 ’0001 ampbre,
my object nob having been to ascertain the exact resistance
when high, but merely to establish the difference between
the two extremes, high and low. I further ignore the
other resistance in circuit—namely, that of the battery and
galvanometer—in stating the resistance to be over 64,000
ohms. The electrodes used were of ductile metal, to allow of
their adaptability to the body surface, and circular in shape,
having respectively a diameter of three and one and a half
inches. The large one was placed on the nape of the neck
BO that the centre of its lower border corresponded bo the
centre of the seventh cervical spinous process ; the smaller
one on the rqanubrium, so that the centre of its upper
O
Thb Lancet,]
DR. E. N. NASON ON MEGRIM.
[Feb. 28, 1891. 485
'border corresponded to the centre of the sternal notch. The
electrodes were applied bare and dry, care being used to
keep their surfaces clean and bright. The current was
allowed to flow for ten seconds. Thus I venture to think
that the conditions of the examinations were the same in
.all cases, so far as those under ray control were concerned.
The site of the electrodes igi convenient of access, and has
constant landmarks for accuracy of position. The actual
.examination consisted of five steps : (I) applying the elec¬
trodes ; (2) switching in a voltmeter and noting the electro¬
motive force; (3) withdrawing the voltmeter and switching
'the patient with galvanometer simultaneously; (4) switching
the patient with galvanometer out of circuii at the expira¬
tion of ten seconds, and switching in the voltmeter again
tfco note the electro-motive force ; (5} calculating the resist¬
ance of the portion of the body examined by the equation
The following are notes of some of the cases examined by
sue:—
Healthy adult male, examined three times in' the twenty-
^ou^ hours; the first time, immediately after undressing at
night (he wore flannel next the skin), perspiration sensible to
'touchaDd8ight,R=2438'8ohm8; the second time, ten minutes
later, the subject having remained with chest and back bare
to allow evaporation, previously interfered with by his
clothing, to take place freely, R = 4713ohm8; the third ,
time, the following morning, the subject slept in a cotton
oiight-shirt, perspiration insensible, R = 32,798 ohms. This
great difference would be due to diminished perspiration
with increased evaporation during the night. These three
examinations were made in moist warm weather. I there¬
fore examined the subject again during dry, cold weather,
and found, all conditions of the examination being the same,
that the resistance at similar periods was respectively
3167’2ohms, 8941-6obm8, and over 64,000 ohms. This
was due to diminution of perspiration and increase of
evaporation being influenced by atmospheric conditions.
A large number of out-patients were examined, some
before being exposed for the purpose of physical examina¬
tion, and some after their cli ests aud backs had been exposed
for this purpose. The resulting resistances found varied in
all degrees from 3000 ohms to over 64,000 ohms, the recently
'.stripped patients oll'ering the lowest, and those examined
some minutes later the highest resistance; whilst, on re¬
examining those offering low resistance immediately their
chests and backs were exposed, some minutes later, the re-
distance had increased according to the time they had been
■exposed for physical examination, and in proportion to the
.amount of original perspiration and tlie rate of evapora¬
tion. These cases were all of them suffering from the various
■chronic disorders such as are usually met with in out¬
patient departments. In every case where the resistance
was markedly low, the portion of skin to which the electrodes
were applied was covered with perspiration sensible to the
touch andsight. Of acute cases I examined in the wards of
!Dr. Sansom at the London Hospital, the followingtwo will he
'sullicient to quote. One, a young woman suffering from
‘Subacute rheumatism, was perspiring moderately when I
■first examined Iier on the night of her admission ; li found to
be 2899'8 ohms ; ten days later perspiration insensible, over
64,000 ohms. Another case, that of a man, was 3.')63‘5 ohms
when perspiration was sensible but moderate in amount,
and 31,798'8 ohms when perspiration was insensible. In
the case of a healthy male adult examined by thellridge
method, I reduced his resistance from 80,000 ohms to
MOO ohms by administering hot spirituous drink to him,
then putting him in a hob room and covering him with
thick clothes until he perspired excessively. In this case the
■electrodes were the same ns regards size, position, and all
•other conditions as in the experiments described above. It
'is nob necessary for me bo enumerate the results of other
examinations, as 1 venture to think that those described
aboye are sullicient to support my contention that markedly
■mminished electrical resiscance of a definite portion of
the human body signilies merely that the portion of
«Kin covered with the examining electrodes is moist
;^ith sensible perspiration. Such being the case, I leave
for_ those who read this statement to assign that
■condition ib3_ proper value. If the existence of sensible
perspiration is regarded as a diagnostic symptom of any
value, then, as it is sensible to our touch and sight, any
•orroborabion by means of special apparatus is unnecessary,
‘b on the other hind, the question of perspiration being
sensible or insensible depending on such a great number of
circumstances, it is not to be regarded as a symptom of value.
This being my opinion, such evidence for or against the
presence of sensible perspiration is absolutely unnecessary.
Ilarley-sbreet, W. _
CASE OF
MEGRIM, ACCOMPANIED WITH PARALYSIS
OF THE THIRD NERVE, AT FIRST TRAN¬
SIENT, BUT SUBSEQUENTLY BECOMING
PERMANENT.
Bye. N. NASON, M.B.Cantad., M.R.C.S.
That megrim is sometimes accompanied by paralysis of
the third nerve is w’ell known, but that this transient and
generally called functional paralysis should become per¬
manent is extremely unusual. This, with some other
points of interest in the following case, is I think sufficient
reason for its publication.
George C-, aged twelve years and a half, the child of
healthy parents, was brought to me last September, having
suffered for the last five years from recurrent attacks of the
following nature. An attack begins with a feeling of lan¬
guor and general weariness. The child is at the same time
extremely restless, wandering about unable to settle to any¬
thing, or to attend school. This prodromal stage often lasts
from one to even three days, and is accompanied towards
the end of this time by continued slight but increasing pain
in the left frontal region. Then suddenly there supervenes
a period of from twelve to twenty-four hours characterised
by intense nausea and vomiting, associated with pallor;
irregular, slow, and feeble pulse, and great prostration.
The pain now rapidly increases, and soon becomes
agonising. This pain is referred to the course of the supra¬
orbital nerve of the left side, but is also felt over the occi¬
pital protuberance, but much less severely. There is at the
same time increased lacrymation and a discharge of watery
mucus from the left nostril, great intolerance of light, pro¬
minence of left eyeball and increase of intra-ocular tension,
wrinkling of left side of forehead, with fibrillar twitchings
of the frontalis, *.'cc. Gradually increasing paralysis of tlie
third nerve then follows, the various branches of that nerve
being affected in the following order of severity: the
levator palpebrie superioris, rectus superior, and obliquus
inferior are completely paralysed. The rectus inferior is
almost completely paralysed, and the rectus internus is
partially paralysed. The pupil remains midway between
.contraction and dilatation, and reacts but slightly to light
or accommodation, the reactions being anomalous. To
light there is a momentary, almost imperceptible, contrac¬
tion, followed by a slight permanent dilatation. The pupil
dilates, too, slightly when ^e patient looks from a distant to
a near object. There is also marked double vision over
the whole field visible to both eyes. During the height
of the attack the child seems extremely ill. His face
is pallid and the expression anxious; tongue furred;
bowels confined I the urine scanty and high-coloured.
There is complete anorexia. After a variable time
the pain leaves liiiu almost suddenly, the sickness
abates, the appetite at once returns, and within a
few hours he feels quite himself again. The paralysis
however, remains for a day or so, but gradually passes off.
Lately these attacks have become more frequent and more
severe, and have left more and more residual paralysis,
till at the present time there is almost as much paralysis
between the attacks as during one. There is no optic
neuritis or atrophy or other appreciable change in either
I fundus, but vision, especially in the left eye, is much im¬
paired, enabling him to do little more than count fingers at
three feet with that eye. There is no family history of
epilepsy, niegrin, or other kindred neurosis, or of syphilis
in either parent. The mother gives the following history :
The child was quite healthy up to four years of age, when he
had scarlet fever rather badly, but this was not followed by
any discharge from the ears. Since then he has suffered ati
frequent intervals from severe “colds in the head,” and
from what the mother calls “ sick headache,” also from
occasional nocturnal incontinence of urine. She dates his
present attacks from his seventh year, and says they have
continued at intervals of from three to four weeks ever
. Coogle
486 The Lancet,]
HOSPITAL MEDICINE AND SUEGERY.
[Feb. 28,18&>.
since. If he goes beyond four weeks without an attack, the
next is proportionately severe. Between the attacks he
appears to be in good health, and is an intelligent though
rather ill-developed boy. He is also the subject of dou^o
undescended testicle.
This case is probably a variety of megrim, and certainly
should be classed among the paroxysmal neuroses. The
nuclei of the third and fifth nerves of the left side are probably
first affected, the “storm” spreading also to the nucleus of
of the vagus, as evidenced oy the vomiting and irregular
cardiac action. If we regard these storms as of vaso-motor
origin and consisting of spasms of the arterioles supplying
these nuclei, an explanation of the permanence of the
paralysis suggests itself. If the nucleus of the third nerve
were repeatedly deprived for some length of time of its
proper nutritive supply, what was at first a mere functional
derangement might ultimately become an organic change,
and partial atrophy of the nervous elements might result,
having for its visible effect permanent paralysis of the
muscles supplied from that centre.
Nuneaton. __
% llirror
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autem eat alia pro certo noscendl via, nlal quamplurimas et mor.
borum et diasectionum historias, turn aliorum turn proprias coUectaa
habere, et inter se comparare,— Mokqaoni i>e Sea. et Caiu. Morb.,
lib. iv. Prooemium. -
LONDON LOCK HOSPITAL.
INCONTINENCE OF Fv-ECES, FOLLOWING PlIAGED^ICNA,
TEEATEll BY INGUINAL COLOTOMY; RELIEF; REMARKS.
(Under the care of Mr. J. Ernest Lane.)
The history of this patient helps to confirm the statement
that “the occurrence of phagedeena is almost invariably a
concomitant of the infecting sore”; for at the time when the
patient suffered from the ulceration there was evidence of con¬
stitutional infection. We rarely meet with the phagedajnic
sore, with its rapid destruction of tissue, at the present day;
and although cases similar to the one described are recorded,
still such an extensive cicatricial deformity is luckily most
uncommon. The unusual position of the intestine with
regard to the artificial anus is of importance in view of such
a procedure as that referred to by Mr. Lane.
M. B., aged twenty-eight, single, was admitted as an in¬
patient to the Female Lock Hospital on I’eb. 4bh, 1890.
The history was that nine years previously she had
contracted a syphilitic sore of the labium, which subse¬
quently took on phagedicnic action, the destructive ulcera¬
tion spreading to the rectum and nates, destroying com¬
pletely the labia and nynipha}, and spreading thence
forwards to the pubes and outwards on to the thighs. She
was under treatment at one of the metropolitan hospitals,
and subsequently at an infirmary. The sore was followed
by a severely ulcerated throat.
The condition of the patient on admission was as follows.
She was a spare woman, of good family history, with an
anxious expression of face; she had not menstruated for
eight years. The vaginal and anal orifices had been com¬
pletely destroyed by a severe ulcerative process, which had
in some places become cicatrised over, while in other parts
the scar tissue had broken down, leaving extensive and un¬
healthy ulcerated surfaces. Examination under an anes¬
thetic revealed the following condition: An oval opening
with tough indurated edges existed in the perineum and ad¬
mitted the finger into a species of cloaca, for the recto-vaginal
septum had been destroyed for some distance; with the ex¬
tremity of the finger it was possible to make out two circular
apertures—one, the larger, leading backwards presumably
towards the rectum, while the other led forwards towards the
vagina; both these openings were surrounded by dense cica¬
tricial tissue, and barely admitted the tip of the index
finger. No urethral aperture could be discovered, but
it was ascertained by the nurse that the urine was voided
partly through the cloacal orifice, and partly through two
minute fistufio on either side of this. From tlie perineum
ulceration had spread upwards to the groins ; cicat^sation
had taken place, the result being that the thighs were
maintained in a slightly fiexed position, while, owing to th&
contraction of the scar tissue between the thighs and peri¬
neum, abduction was only permitted to a very limited
extent. The result of this exammation was a severe rigor,
and a rise of temperature to 105°; the hyperpyrexia disap¬
peared on the following day. The most distressing feature-
of the case was complete incontipence of faeces, which pre¬
vented the patient from moving about or undertaking any
duties. Whenever she rose from the sitting posture there
was an escape of liquid fajces, in consequence of which she
was shunned by her fellow-patients, and her life was one of
abject misery and enforced solitude.
As she was willing to submit to any operative procedure,,
it M'as decided to have recourse to inguinal colotomy, and'
accordingly on March 14th, assisted by Mr. Cotes, that
operation was performed in the usual manner, and with tb&
strictest antiseptic precautions. To lessen the tendency to
prolapse of the mucous membrane through the artificial
opening, the sigmoid flexure was drawn downwards as far
as possible, and with a view to creating an eilicient spur the.
bowel was drawn forwards so that quite two-thirds of its
circumference were placed in front or the sutures attaching
it to the abdominal wall. On March 20bh, the patient,
having felt no inconvenience from the operation, and the
temperature not having once risen above the normal, tbe^
bowel was opened and some flatus escaped ; three days after¬
wards there was a copious evacuation of the bowel, and
within three weeks from the time of the operation the'
patient had recovered from its effects.
The condition of the patient in August, five months after
the operation, was as follows:—Her general appearance had
greatly improved, and |he was in the best ot spirits. She
was wearing an abdominal belt with a plug projecting into
the artificial anus ; the bowels were opened regularly once a
day ; there was scarcely any prolapse of the mucous mem¬
brane, and no passage of fcecea by the aperture in the
perineum. On a close examipation it was found that the
fjoces escaped from the lower extremity of the artificial
anus, and on passing tlie finger downwards into the lower
of the two portions of bowel attached to the abdominal
wall, this was found to contain moist fmces, while the mucous-
membrane of the upper segment was dry and its cavity was
empty. .The signiucance of this unusual circumstance is-
explained below. Since the patient was discharged from
the hospital she has been menstruating regularly through
the cloacal opening in the perineum, though before tlto
operation the menses had been absent for eight years. Tl;8
cicatrix in the perineum was contracting, and the aperture
into the cloaca was smaller.
EemarJes by Mr. Lane.—H itherto inguinal colotomy has
seldom been performed except for the relief of those aufl'er-
ing from stricture of the rectum, such stricture being in the;
majority of cases malignant in nature. Mr. Harrison,
Cripps records a case in which the operation was done for-
the relief of a recto-vesical fistula in my case, as in
Mr. Ciipps’, the operation was one of expediency. The con¬
dition of the patient was a very distressing one, still it was-
not one which would endanger or shorten life, and the only
object of the operation was to enable her to resume her
I household avocation, by ridding her of the intolerable-
I annoyance to which she was subjected by the constant-
escape of feeces. It was with a feeling of considerable
responsibility that I undertook an operation which can
hardly be said to be devoid of danger, and it is a matter of
congratulation to me that the proceeding has been fully
justified by the result. It was not till a considerable time
had elapsed after the operation that it was discovered,
the f.TJCes escaped from the lower part of the artifical anus,
and not, as one would naturally expect, from the upper
end of that opening. The reason of this condition of tilings
I pre.sume to be as follows:—^Ab the time of the operation
tlie sigmoid llexure, owing probably bo the existence of a
long and loosely attached meso-colon, was twisted upon
itself somewhat as in a volvulus. If this condition exists
it must be difficult, or even impossible, to discover it at the
time of operation, and it will only be ascertained _hy close
examination of the artificial anus; after a time the distal end
of the bowel becomes dry and empty, the proximal end being
naturally moist and containing fieees. This occurrence is or
course well known to surgeonswho have had much experience'
in abdominal surgery, but hardly sulficienb stress has been
pla^d upon it in the published accounts of the operation ;
lb has been mentioned m discussions at the societies, hut him
1 Tub Lancet, Sept. 20th, 1888.
Dig ;;..ad GoOgIc
The Lancet,]
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
[Fee. 28, 1891. 487
not, I believe, obbained any prominence in print. It does
■nob in any way militate against the success of the operation ;
on the other hand, there can be no passage of fiuces into
the distal end of the bowel, as such passage would be
against the laws of gravity. At the same time this com¬
plication must be borne in mind should the surgeon adopt
the operation recommended by Mr. Jesaett; here the bowel
Is divided, its upper end is attached to the abdominal wall,
while the lower is invaginated, stitched up, and returned
into the abdominal cavity. For this procedure it is essential
vthat the operator should recognise which is the upper and
■which the lower end of the portion of bowel exposed ; any
•misconception on this point would he attended by disastrous
results, and the possibility of making such a mistake is a
feature upon which I would lay special emphasis.
SALFORD ROYAL HOSPITAL.
A CASE OF COMPOUND DEPRESSED FRACTURE OF THE
RIGHT PARIETAL RONE OVER THE MOTOR AREA
TREPHINED, AND BONE REPLACED.
(Under the care of Mr. Andrew Boutflower.)
The indications for operative treatment in this case were
•very clearly marked, there being a compound fracture of
the skull, with symptoms of injury to the motor region.
The success of the operation adds further proof {if that
were needed) of the value of the method of treatment em-
ploj’’ed in the present day. A recognition of the feet that
it is possible in some cases to replace the bone removed by
the trephine at once, and so secure complete restoration of
the vault of the skull, has only obbained during recent years.
Dr. Hopkins has found that when sterilised dead bone is
placed in contact with living bone, under favourable circum¬
stances it undergoes absorption; when placed in contact
with periosteum it undergoes organisation. These processes
are not associated with inliaminatory action. For the
following account of this case we are indebted to Mr. W. P.
Stocks, bouse surgeon.
The patient, a healthy looking lad of fourteen, on the
evening of Aug. 8bh, 1890, jumped from a train in motion,
alighting on his head upon the platform. With the
assistance of a porter he walked to the hospital, a distance
of about half a mile. When in the accident room he
appeared muddled, but perfectly conscious, and was able to
give an account of himself. There -was a contused wound,
two inches in length, running horizontally forwards,
between two and three inches above the right ear, and a
finger introduced into the wound detected a depressed
fracture. On being put to bed he exhibited symptoms of
cerebral irritation ; he speedily was seized with an epilepfi-
•form convulsion, with the following sequence of events.
Both pupils, previously normal, became suddenly dilated ;
•clonic spasm of the left orbicularis palpebrarum, accom¬
panied by twitchings of the mouth and cheek supervened,
next the left arm, then the knee, and lastly the left side of
the trunk were affected with similar spasms. The entire fit
•lasted some three minutes, and the spasms died away in the
reverse order of their appearance. Tliere were no spasms of
the right side; a comatose condition remained. An hour and
a half_ after the accident Mr. Boutfiower trephined. On
•enlarging the wound the fracture was found to run forwards
and then upwards, linear anteriorly, somewhat comminuted
behind, and the upper fragment was depressed beneath the
lower. The disc of bone removed was placed in warm
•carbolic lotion. The dura mater was intact. When
elevation was complete the bone disc was replaced entire,
and the pericranium drawn over it and stitched witli fine
•catgut. The wound was sutured with silk and a small
drainage-tube introduced posteriorly. A dry dressing of
'Corrosive sublimate gauze and sal-alembroth •wool was
applied. The carbolic spray was used throughout. On
recovery from the chloroform the lad was quite conscious
and free from pain. . His restoration to health was uninter-
■‘■upted. Thetemperatureneverrosebeyond99‘G°. Tbewound
was dressed on the third day, owing toaslight haimorrhage ;
n the seventh day the sutures and drainage-tube were
emoved, and a few days later the wound was quite healed,
n Uct. (ith he presented himself at the out patient room,
perfectly well; the disc of bone was firm and appn-
united, the seat of injury only presenting a small
’ the bony structure was perfectly even, showing no
wgM of ever having been disturbed.
ROYAL MEDICAL & CHIRURGICAL SOCIETY.
EacMym.
An ordinary meeting of this Society was held on
Feb 24bh, the President, Mr. Timothy Holmes, in the chair.
Mr. Bar WELL read a paper on Rachilysis, its Object and
Method. He stated that the first commencement of lateral
curvature was merely a faulty position, produced either by
unequal length of the lower limbs, by bad habits in sitting
while writing &c., by muscular debility and excessively
rapid growth, or by other like causes. If this position were
maintained for a certain period with considerable per¬
sistency, both muscles and ligaments underwent certain
changes; he laid more particular stress on the latter, showing
that theintervertebraldiscsbecame wedge-shaped, thethinner
end lying in the concavity of the curve. Bat the changes
undergone by the anterior common ligament were even
more important. In 1881 he observed, at a post-mortem
examination, made under restrictions and very great
difficulties, that this structure had a very tight,
sharp edge, which lay quite in the concavity of the
curve, the whole structure having become apparently
moved in that direction. Since that date Nicoladoni
had shown, and his observations have been amply con¬
firmed, that in lateral curvature this ligature shifted its
place towards the concavity. Mr. Barwell accounted for
this nhenomenon by the fact that most fibres of this liga¬
ment passed from one vertebra over several others to be
inserted into a more distant one, the more superficial over
five or six bones, the deeper over a less number. Therefore,
when the column assumed a sidew’ays curve these fibres
must tend to be straigliter than the deviated spine; sub-
I sequently as they thickened and contracted they pound the
bones into their abnormal position, acting as did the string
which kept a tense bow bent. Considering that this con¬
dition could hardly be overcome by mere gradual pressure,
or by what was erroneously termed support, Mr. Barwell
devised some years ago a potent means of straightening the
curves—in other words, of stretching the contraebured liga¬
ments. This, which he therefore named “ rachilysis,” he de¬
monstrated to the Society. In describing it he supposed an
S-shaped curvature, dorsal to the right, lumbar to the left.
To two walls or beams facing each other certain hooks were
fixed. Between these, on an ordinary chair, the patient
was seated in a three-quarter aide-back position. A pro¬
perly padded loop-like belt was placed on the side of the
Join opposite the most pronounced part of the curve and
fixed oy a hook on the right. A similar appliance was
placed, loosely for the present, on the dorsal prominence.
A loop with a lanyard attached was passed under the left
axilla, the body was inclined to that side so as to unfold
somewhat the lumbar curve, and the cord of the lanyard
was secured immovably, acting as counter-extension on the
patient’s right. Now the dorsal belt was hitched on
to the hook of a system of dislocation pulleys, an
eighteen-inch board or strut was placed between the laps
of each belt, preventing compression of the abdominal
organs or of the ribs, and traction was made. This,
though considerable, produced no pain, and after two or
three times not even discomfort. Measures were taken on two
lads markedly curved, which showed that by this force the
column was lengthened in one case one inch, in the other
one and three-quarter inches, an effect which could only
be due to rectification of the morbid bends. In practice
Mr. Barwell applied this method with a frequency com¬
mensurate to the severity of the cose and tho ago of the
patient. The amount of traction used by the hand varied
according to the same condition, from 8ib. to 161b.—i.e.,
the force exercised by the belt is from 40 lb. to 801b., mimis
unavoidable friction. Immediately after its use he applied
that one of his bandages moat adapted to the sort of curve.
An appendix to the paper consisted of histories of cases
which justified the following conclusions:—That in young
persons even badly deformed spines were curable witli
patience and sufficient perseverance within a moderate
period. That older patients, even considerably deformed,
might be greatly benefited—i.e., the form improved, and
persistent aching of the back cured. That deformation of
the bones—certainly of the ribs, therefore presumably of
the vertebree—might be to a considerable extent rectified.
488 The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Feb. 28, 1891.
Mr. Golding-Bird found that the subject waa one very
difficult to discuss, and probably the best way in which to
approach it was to endeavour to measure the treatment
proposed by ordinary surcical standards. Under the head
of “causation” he found that the author bad placed unequal
length of leg side by side with other more important etio¬
logical factors. He had carefully watched cases of spinal
curvature develop in which this condition was present, but
it was remarkable how many years elapsed before any
deformity was produced, and even then it could be cured
by a high boot. So far as he had seen of these cases there
was something more than mere stretching necessary in order
to render a cure complete. There was a limpness and want
of stability about the muscular system, the patients being
usually either flabby and indolent girls, or thin and wiry
ones who were neurotic and quickly exhausted. It was
essentially the lack of muscular power which caused the
disorder or tended to its permanence, and treatment must
be directed to a restoration of the muscular tone. As to
faulty position, the posture of standing at ease was a good
one physiologically; it was, injact, a physiological luxury,
but if it were carried too far it would bring about disease.
The pain in the back which was complained of was really
an augmentation of muscular sense. He disputed the
office which the author would give to the anterior common
ligament when he compared it to the string of a bow ; if
this ligament were really the cause of the curve, how
came it about that one could completely straighten
the curve at one sitting by merely pressing on the curves or
suspending the spine ? for the ligament was quite inelastic,
and must rupture if it were taut in the concavity of the
curve. Any treatment to be successful in permanently
strengthening these spinal cases should relieve the spine of
the weight of the head and shoulders, should periodically
straighten the curves, should strengthen the muscles, and
the treatment as much as possible should be placed in the
patient’s own hands. In all chronic diseases this latter was
an important practical point, "for it was very difficult to
persuade the patient or the public of the necessity of very
frequent visits to the doctor in these cases. He considered
that the old support treatment received its death-blow from
Sayre when he demonstrated his extension method, bub
Mr. Barwell’s apparatus appeared to act very much on the
old principle. Sayre thought that by means of his jacket
giving the patient a hard exterior crustacean-like shell he
would be able to keep the spine straight after extension ;
but in practice it was found that an accurate fit could nob
as a rule be obtained, and the patient telescoped again as
before. He knew as yet of no means by which the
elongation of the spine could be maintained, but it
was certain that girls improved very much when con¬
stantly told by their friends to sit up. He believed in
recumbency, which kept the spine straight and took off
the weight of thehead andshoulders. The passive straighten¬
ing of the spine which had been recommended he believed
was ineffectual because it did not do all that was required ;
whereas the well-known active method of Sayre not only
bad all the advantages of the passive method, but also caused
the patient to use her muscles. The ordinary suspensions
from a trapeze in bad cases he had seen relieve the pain,
the oppressed breathing, and the irritable heart, though
they did not cure the curvature. Finally, he thought that
the machinery to be used was somewhat formidable and
might frighten the patient.
Mr. Warrington Haward, while thanking the author
for his paper, was unable to agree with the pathology and
treatment be had put forth. He held that the faulty
position was produced by the muscles themselves. The
ligaments were passive, and it was the muscles which held
the spine upright; if these contracted unequally on the two
sides, then a curvature was produced. It v/as remarkable
that if a lateral curvature were produced by putting a block
under one foot a alight degree of rotation only was produced,
and nob neatly so much as would be present in a curve of
corresponding extent from disease. The ligaments did not
prevent or limit this rotation, for they were relaxed and
weak, and allowed the muscles to pull the spine into a false
osition. The frequent accompaniments of flat-foot and
nock-knee bore out this idea of ligamentous weakness.
Though the spine could be pulled straight in this way it
was a question how long it would remain so; when the
pressure was taken off the spine went back, and it appeared
to him that this would always happen. The rational treat¬
ment appeared to be exercising the weak muscles and
alternating that with reasonable rest.
Dr. Little referred to the case of a girl with threatening
phthisis who was wearing a heavy apjiaratus for lateral
curvature. On removing this and applying massage to the
muscles of the back great improvement had taken place,,
both in the curvature and in the chest trouble.
Mr. Noble Smith, referring bo the subject of causation,,
said that it was common to hear of all weakness spoken
of as muscular weakness, but he had thought that there
was often a general weakness of the body, the bones being
unnaturally soft and the ligamentn unnaturally lax. The
treatment, therefore, should not be confined to exercise of
the muscles alone, and he found himself unable to accept-
any one method of treatment for all cases. Mechanical
means in some cases were useful, and it was absurd to
abuse mechanical apparatus on the one hand, and yet on
the other to advocate the use of poroplastic felt jackets,,
which were one of the most barbarous measures of treat¬
ment ever proposed. He was a strong advocate of muscular-
e.xercise, especially massage and an occasional resort to-
recumbency on a prone couch, this position being a ranch
better one in which to exercise the muscles of the back
than the supine one. He thought certainly that the treat¬
ment advocated by the author ought not to be ignored
simply because it required attention from the surgeon; if
so, on that ground cancer and many other chronic diseases
would be d^arred advice.
Mr. Barwell, in reply, said that he had not stated that
the ligamentous condition described was the cause of the
lateral curve, but rather that it was the result, and he sup¬
posed that when once the curve existed the ligament might-
aid in increasing it. Many writers had found that in lateral
curvature beyond the first degree—that was, the stage of
mere malposture—the ligament shifted itself towards the
concavity of the spine. It was one of the results of a com¬
mencing curve, and it aided in keeping it up. He called a
case a severe one in which a rotation existed of twenty de-
rees; he had seen a case where the rotation was twenty-five
egrees, and under rachilysis for three months it was now
only five degrees. As the paper was not upon the treatment
of lateral curvature, but upon rachilysis alone, he had not
referred to the other measures of treatmeut he was in the
habit of adopting, such as the lateral sling and the prone-
position for short periods. The weight of the head and
shoulders certainly did not produce the curve, and he knew
of no support which would lift the head, and the best of-
them only partially bore the weight of the shoulders. Sus¬
pension had not in his hands straightened the spine in the-
way Sayre said it would. He admitted that the spine in
some cases could be straightened by the hands, but
it was only possible in the very commencement of the-
affection. Constantly carrying a weight in one hand and a
faulty position in writing were great causative factors in
producing lateral curves. Though a lumbar curve could be-
corrected by putting a piece of wood under the affected side,
yet if a compensatory dorsal curve were present this could
hot be straightened by this means. He failed to see in what
way muscular action could produce rotation of the spine.
MEDICAL SOCIETY OP LONDON.
Adjourned Discicssion on Angina Pectoris.
An ordinary meeting of this Society was held on Feb. 2.‘hd,.,
the President, Mr. Knowsley Thornton, in the chair.
Sir Walter Fo.ster of Birmingham reopened the dis¬
cussion on Angina Pectoris. He agreed with Dr. Powell*
that a broad basis should be taken for consideration of this
subject, for under this title could be grouped a series of
conditions from trivial remediable disorder to severe
attacks of terrible heart pangs, ending in sudden death,
and, if they were considered as a whole, some ideas might
be built up as to their pathology and treatment. He first
desired to refer briefly to four cases. The first was that of
a doctor aged sixty-four, who complained of angina pec¬
toris, which came on in the course of the night. The
symptoms were described as those of intense pain, which
developed in the region of the nipples and radiated down
the left arm, and he was seized with terror and a sense of
impending dissolution. Under sinapisms and free stimula¬
tion be was relieved. It was in this patient the beginning
of a gouty condition, and attacks were afterwards induced
by walking up hill. The patient died of a dilated heart
eight years afterwards. He saw another case in the year
1863, when he was in charge of afriend’spracticein the south
^8
Thb Lancet,]
MEDICAL SOCIETY OF LONDON.
Feb. 28, 1891. 489
of London. It was that of a youne man who was a good
runner, and who one evening ran thelengtli of the street for a
wager. When near the end of the street he uttered a sudden
<!i-y and died in afew minutes. A careful necropsy revealed
the left cavities empty, the right ventricle almost so, while
ibe right auricle was enormously distended. In his death
agony he complained of intense cutting pain in the chest.
In another case a prematurely old man aged about fifty-
eix complained of intense pain across the diest; the pulse
was slow, not more than 60 to the minute, and was of
^igh tension. During the attacks the pulse fell to 36 and
became intermittent; there was pain between the nipples,
•down one or both arms, together with much anxiety,
general clammy sweats, and pallor of the face. Against
advice he married a young wife, and though he survived
■very well the earlier weeks of matrimony, he died eleven
months later, and at the necropsy 'no valve lesion was
found, and there was no aortic atheroma. In another case,
which occurred in a medical man, he graphically described
the attack. The pulse fell to 20 at the wrist, though the
heart was beating more frequently, and it was small,
irregular, and hard; the face was pale, there was no pain
in the chest, but he felt that be was dying. Siuapisms
were applied to the chest and hot bottles to the feet, while
■strophanthus, with ether and ammonia, were given in¬
ternally. Under this treatment he recovered; he put it
down to n neurotic attack induced by influenza, and in-
ifluencing the pneumogastric nerve. Later he had a second
.attack, slighter in degree, but he died in the midst of a
third, which came on at night, and was associated
with well-marked heart pang. No necropsy was made,
but‘there was no indication during life of organic
disease of the heart or arteries. These cases illustrated
certain features of the aflection, and he wanted to
compare them with other cases—cases in which there
was agonising pain accompanied by grave organic
•disease. In one man, who committed suicide on account
•of the anguish, there was double aortic valve mischief,
with an aneurysm springing from one of the sinuses of
Valsalva, and pressing ou the root of the aorta and on the
•cardiac nerves. In the cases of valve disease which
suflered the most pain there was considerable dilatation of
'the left ventricle of the heart, with, later, degeneration of
the cardiac muscle. As this dilatation was usually
associated with aortic disease, it confirmed Dr. Walshe’s
■remark that tlie cases of disease of the basal valves were those
associated with angina. He had once witnessed a case of
rapidly developing insufiiciency of the aortic valves produced i
by a sudden strain. The patient had severe cheat pang,
and was collapsed and insensible. He was bled from the
arm and rallied, and was then found to have aortic re¬
gurgitation, although he was known before the strain to
have sound valves. For days he comidained of stretching
pain under the sternum, due to dilatation of the ventricle.
The same kind of stretching pain was met with when further
•dilatation was in progress in an already diseased heart, as
when the hypertrophied muscle underwent degeneration
'late in Bright’s disease; and such cases were relieved by
the establi^ment of mitral regurgitation. In all these
cases ho had related he believed the immediate cause of the
heart pang to be distension of the cavities of the heart,
•either right or left. In the case of the patient who got
his attacks when walking up hill, the right was
'involved, while in the gouty patient, in whom the
attack came on at night, it was the left ventricle
which could not overcome an increased vascular pres¬
sure, brought about, perhaps, by the circulation in
the blood of some excess of uric acid. He held that
stretching and not spasm was meant by the “ distensio ” of
dieberden. He thought that in all or nearly all the cases
there was a degeneration of the myocardium, with distension
•of the_ cardiac cavities. This view was counter to that of
neurosis, but he knew of no direct evidence to support the
idea of spasm of the coronary arteries. In Sir Richard Quain’s
■revised article on Angina he referred to Dr. McWilliams’s
recent researches as to the nature of “delirium cordis” in
in which there was a quick irregular cardiac action,
with fall of blood pressure due to a distended ventricle
remaining in a state of diastole and excited by trivial
•causes, such as distension of the gut. He preferred to
regard angina, not ns a disease, but as a mode of death and
u term under which might be grouped a number of allied
•conditions having a common pathological basis. In the treat-
rirent a scientific step had been made when drugs like nitrite
of amyl and nitroglycerine were introduced, which counter¬
acted the vascular condition which was the starting-point of
the malady. If the pain were prolonged, morphia sub¬
cutaneously was indicated, while in the intervals no drug
was more valuable than arsenic, with ether, iron, bromides,
or alone. Iodide of potassium, in doses of five, ten, or
fifteen grains three times a day, had wonderful power of
lessening the pain and improving the patient’s condition.
The female sex were not troubled with angina because they
were less exposed to strain of the heart than men.
Professor Gkainqer Stewart of Edinburgh found that
his line of thought diverged considerably from that of the
previous speaker, and he referred to the interesting com¬
parisons that had been made between glycosuria and asthma
and the afi'ection under discussion. Cases of angina grouped
themselves into four categories: 1. Simple neuralgia of the
heart, seen in women at the climacteric, and in men of
gouty constitution, in which pain was referred to the heart
itself, and was very amenable to treatment. 2, A condition
of angina.dependent upon and associated with acute or sub¬
acute inflammation of the aorta. He had more than once
seen a patient describe a curve on his chest like that of the
aorta to indicate the site of his pain, and he described a
case in which pain was referred to the lower part of the
thoracic aorta which recurred in paroxysms and travelled
gradually higher up. Later a marked double aortic murmur
developed, and death occurred. There was no post-mortem,
but aneurysm, pleurisy, and new growth had been ex¬
cluded, and he considered that the case bad been one in
which an aortitis had commenced low down and had spread
upwards, damaging the valves and producing dilatation of
the heart. Though this latter had only developed at the last,
pain had been present from the first, and had fceen of true
anginous character. 3. A common group of cases in which
angina pectoris was associated with fatty, fibrous, or other
degeneration of the cardiac walls, or with changes in the
coronary arteries. 4. Angina pectoris associated with spasm
of the arteries and increased tension. There was very
little change in the heart, but it was overmastered by the
arterial spasm without the coronaries or substance of the
heart being necessarily involved. As to the determining
causes of anginal attacks, manyr of them would ap[)ly to all
four groups. They were exertion, emotional excitement,
such as anger or grief, dyspepsia, constipation, the various
toxines absorbed into the system from the intestines, or
from failure of the kidneys or other eliminants, and certain
changes in the nervous system, such as, for instance,
occurred when sleep was setting in; each or all might
sulllce to bring on an attack. Bub in any of the last three
pathological groups the same lesions might exist without
pain; so that one had to ask one’s self what was the
explanation of the pain when it occurred. Was it of mus¬
cular or of nervous origin? Sir Walter Foster had said that
it was a muscular pain, but he did not know what spasm
of the liearb muscle meant; he doubted very much if it were
like cramp, though a vague idea to that elfect still fioated
in the minds of some. What seemed against this was that
the heart and pulse might remain steady all through an
attack, and if aortitis could of itself be a cause of angina,
that vessel did not contain enough muscle to produce a
painful cramp. He therefore looked upon it as a pain of
nervous rather than of muscular origin. Inquiring whether
any purely nervous diseases resembled angina, be pointed
out that epileptiform neuralgia was wonderfully like it,
coming on in sudden paroxysms, and often ceasing as sud¬
denly, leaving the patient well, but subject to a new attack,
being more common in men, and at or after the middle
period of life. Certain slight peripheral influences would
provoke intense pain, which was relieved by cutting or
stretching the affected nerve. So also in angina, explosions
of pain occurred from time to time in connexion with irrita¬
tion in the aorta or heart, the cardiac nerves being capable
of afferent as well as efferent function. In short, he sug¬
gested the essence of the process to be a change of organic
or functional nature in the nerves or nerve-endings which
controlled the heart, and he added that distension of the
heart did not necessarily produce pain. For treatment, he
agreed that the general health should be improved, excite¬
ment and effort being avoided, and nitrite of amyl adminis¬
tered to relieve spasm. The latter drug he believed had
also a direct effect on nervous structures, for it relieved other
neuralgias Arsenic and iodide of potassium were invaluable,
and occasionally direct cardiac tonics, such as digitalis and
strophanthus, might be given with benefit.
490 The Lancet,]
MIDLAND MEDICAL SOCIETY.
[Fer 98, 1891.
ProfesBor MacVail of Glasgow agreed that the basis of
the whole subject should be broadened, so that any con¬
dition of pain about the heart should be alluded to as
angina. As regarded the pain, it might be general or partial.
He had seen Wo cases in which it was likened to a knife
plunged into the apex of the heart; in another it was as if
needles had been driven in; in another as if crushed or
grasped; and in yet another as if greatly dilated, the
atient actually feeling to ascertain if his chest was not
ulged out. In some the pain was radiating, in others it
was distinctly local. The question of radiation depended on
two circumstances : on the amount of the pain and on the
ability of the nerves to conduct. People differed from
one another, and the same people differed at different
times with regard to their power of conductivity. In
one of the cases above mentioned, in which the pain
was knife-like, there was no radiation; but in the second
case of knife-like pain it passed from the cardiac apex
to the left shoulder. In the case in which the pain was
like needles it passed from the apex of the heart to the
scapular angle, thence to the top of the left shoulder and
down to the bend of the arm. In the case in which the
heart felt to be dilating the patient either became faint or
was confused mentally; this might he due either to an
insufficient blood-supply to the brain, or it might W really
an instance of radiation, and thus resemble some of the
mild forms of epilepsy. Not only did pain radiate from
the cardiac seat, but before the attack began a sensation'
might also travel towards tbe cardiac area. It was a kind
of aura. In one case, that with the crushing sensation,
the patient described a sensation as of burning or of boiling
water poured on a small area of skin near the umbilicus ;
thence it travelled towards the heart, and then the
attack of angina commenced. In the case where the pain
was like needles it commenced at the inner end of the left
seventh interspace; thence it travelled to the apex of
the heart, which took five minutes; from there the pain
went to an inch below the scapular angle, taking ten
minutes, and it was now no longer like needles, but like
a knife; thence to the left shoulder in five minutes,
and finally to the bend of the arm in two minutes. The
connexion between angina and epilepsy was worth more
attention than had been paid to it, and in every case
an antecedent secsory condition should be inquired
for. He had found the organic conditions present to
vary much; in one of the cases of knife-like pain there
was a double mitral murmur, while in the other there was
mitral regurgitation alone. In the instance where the
sensation was of a crushing character there was a double
mitral murmur ; in that in which a sense of dilatation was
complained of the condition was one of double aortic
trounle. In the case where tbe pain was like needles no
organic abnormality could he made out. What was tbe
actual condition of the heart when the pain was present?
Sir Walter Foster and Professor Stewart bad contended
that it was not cramp. Was it possible to separate cramp
from a neurotic condition ? Though it might be done in
laboratory work, it was quite impossible to separate them
in practice. He himself was quite unable to separate the
nerve condition from the muscular condition of the heart
as regarded pain. An ordinary muscular contraction was a
pleaaurahle sensation, as in exercise ; but if the contraction
were much increased in intensity, as under strong faradaism,
it then became painful and was a condition of cramp. The
muscular condition in the living body was always one
of tonus ; there was no such thing as complete relaxation
during life. It had long been taught that the cardiac con¬
traction was not one of physiological tetanus, but this idea
had been proved beyond all dispute to be false. If
over-contraction were present, it was simply a ques¬
tion of degree whether pain would be present or
not. Dr. Walshe had objected to angina being due to
spasm, because he held that if it were due to spasm
the heart would necessarily remain continuously con¬
tracted during the spasm. But this by no means followed,
for if the upper extremities were thrown into a condition
of tetanus by means of the faradaic current, it would he
still found possible to move the hands, unless, indeed, the
current were extremely strong; so in moderate cases of
angina tbe tetanic spasm was not strong enough to inter¬
fere with the impulse. Dr. Walshe likewise stated that
as in diastole the ventricle was flaccid, the angina, if due to
spasm, should he intermittent. But there was no evidence
to show that the ventricular wall ever became flaccid even
in diastole. The presence of a murmur in aortic regurgita-
tion was fatal to the idea of the ventricle ever giving up>
its grip of the blood. The idea of this murmur being caused
by valve vibration was of course absurd, and Baliour bad
shown that it was caused by a thin stream of regurgitant
blood forcing its way back into a mass of blood remaining
in the ventricle under considerable tension. If the ventricle-
were thus never quite flaccid even in diastole, it removed
the great objection to the theory of spasm. He thus upheld
the old idea of Heberden, as supported by Latham, that the^
condition of angina was immediately dependent- upon
spasm of the heart. The excessive irritability of nerve
and muscle caused by overwork induced instability of the-
nerve centres, and if the explosions from the unstable,
centres became sufficiently frequent, then a condition of
cramp would result. He asked^, in conclusion, that each
individual case should be examined in reference to the
order in which the parts were attacked by pain and the
directions into which it radiated.
On the motion of Dr. Seymour Taylor, seconded by
Dr. Little, tbe debate was adjourned to a future meotingt..
due notice of the date to be given by the secretaries.
MIDLAND MEDICAL SOCIETY.
An ordinary meeting was held on Jan. 14th, Mr. A,
Messiter, President; in the chair.
Subconjunctival Dislocation oj the Lens. — Mr. Wood-
White showed a man who some weeks before had received
a violent blow from a fish on his only eye, resulting in
almost complete blindness. The iris was torn from its
ciliary border for about one-third of its circumfeience; the
vitreous was so opaque that no details of the fundus could
be seen, and the lens was lying between the conjunctiva
and the sclerotic near the upper and outer corneal margin.
Lupus of Palate and Larynx. —Mr. Barling showed a
patient aged twenty-five with lupus of these parts without
the skin being affected. The disease commenced in the-
pharynx five years ago, and then extended upwards and
downwards. The condition at present is as follows In
the oro-pharynx and in the soft palate complete cicatrisa¬
tion ; on the hard palate ulceration involving the mucous
membrane of the anterior third, the ulceration (having no
tendency to perforate its area) having extended but little
during the last two years, and its base being covered with
coarse granulations; the upper gums of the incisors and
canines are red, swollen, papillary, and in places slightly
ulcerated. The epiglottis is extensively destroyed, the
upper margin presenting an irregularly excavated condition
with some thickening, whilst the colour is for the most
part a curious glistening white ; over the inter-arytenoid
fold is an ill-detined, somewhat warty thickening, hut no
ulceration can be seen. The patient is married and has^
a healthy child. There is no evidence of acquked
or of congenital syphilis, and the administration of
mercury and iodide of potassium has had no effect on the
lupus. Locally lactic acid has been applied up to a strength
of 75 per cent., hut without effecting improvement, so it is-
proposed to try the effect of injecting Koch’s ffuid. Mr.
Barling pointed out the advisability of being prepared to
intubate such a case instead of doing tracheotomy shouldr
injection produce much stenosis of the larynx.
Fibroids. —Dr. Malins showed (1) a Fibroid Tumour
of the Broad Ligament weighing 9^oz., with microscopic
sections made by Dr. Ratcliff establishing its structure.
The patient was a widow aged forty, multipara. The
tumour was enucleated by abdominal section, the edges
of the capsule being sewn to the wound. She recovered
without an untoward symptom. (2) A Fibroid Tumour
weighing two pounds and abalf, enucleated per vaginam from
a woman aged lifty-one, presenting in the anterior part of
the utenis into the vagina. The tumour was delivered by
midwifery forceps from the vagina; the perineum torn and
stitched up again. The patient did remarkably well.
A Series of Calculi removed from one Patient. —Mr.
Thomas showed a number of calculi which he bad removed
from the same patient by four operations. The first was in
January, 1887, when apbosphatic stone, weighing 604 grains^
was removed. In the following April three small calculi,
weighing thirty grains, were removed by nephro-lithotomy
from the right kidney ; in May, 1887, a calculus, weighing
423 grains; and in December, 1890, three more, having an
r Coogle
TflK Lancet,]
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
[Feb. 28, 1891. 491
^aggregate weight of 500 grains. The first was almost a
pure phosphatic stone, but in the others were layers of uric
acid. The supra-pubic operation was done three times, and
it was interesting to observe that the condition of the bladder
Tvas not affected by the numerous operations.
Modifications in the Treatment of Cluh-foot. —Mr. THOMAS
read a paper on the above subject. The paper was illustrated
by the exhibition of a number of cases, including a tarsectomy
^four years and a half after operation, a case in which Syine’s
amputation had been performed on one foot and tarsectomy
on the other for severe talipes, and other cases showing the
improvement according to the mode of treatment and
length of time.
Exhibition of Specimens —At a meeting held on Feb. 4th
(John W. Taylor, F. R.C.S., in the chair), Mr. Haslam
showed a small Branched Exostosis that be had removed
irom a woman aged thirty four. It was growing from the
upper and inner’ aspect of the humerus, and was causing
pain by its pressure on the branches of the brachitu
plexus. Mr. Haslam also showed some Phosphatic
■Calculi that he had successfully removed by the
supra-pubic operation from a man aged seventy.—Mr. John
■yv. Taylor, in showing a specimen of Ovarian Cyst with
Twisted Pedicle, which had been diagnosed previously
to operation, pointed out the main elements which goto
form a rational and successful diagnosis—(1) The previous
'knowledge of a cystic tumour of moderate size (presumably
ovarian) situated fairly high in the abdomen, and there¬
fore possessing a long pedicle; (2) the sudden occurrence
•of abdominal pain and other local peritonitic symptoms,
together with rapid and marked increase in the size
of the tumour. When these conditions are satisfied,
strangulation of the cyst with hromorrhage into its cavity
may be inferred, with every prospect of the diagnosis
being correct, which leads to early and usually suc¬
cessful treatment. The patient made a rapid recovery.—
Mr. David Walsh showed a Heart which, with its great
■vessels, had been ruptured by indirect violence. The patient,
who suffered from advanced phthisis, jumped from the
4op storey of the workhouse infirmary. The necropsy
showed several bone fractures. The heart showed the fol¬
lowing lesions : An irregular rent opened into the cavity of
the right ventricle ; the tip of the auricular appendix was
torn away, and was found in the pericardium. The left
ventricle showed a small non-penetrating laceration, and a
ragged rent at the apex communicating freely with the
cavity. Tlie aorta was almost completely severed from
its cardiac origin, and the^ pulmonary artery was rent
longitudinally.
Dr. Malins read a paper on Rudimentary Organs of
Generation in the Female, which was illustrated by six
cases.
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
An ordinary meeting was held on Feb. 12bh, Mr. W.
Dales James, M.li C.S., Fresident, in the chair.
Dog-bite. —Dr. Hunt read the notes of a case which had
been admitted into the Fir Vale Union Infirmary suiTering
from the effects of a dog-bite. The symptoms wore exten¬
sive cedema of the face and bead, epistaxis, delirium, and
fever. Post-mortem examination revealed meningitis, and
on the membranes were found a large number of tuber¬
cular-like tumours, which from their pressure had produced
indentations on the inner surface of the skull. There was
no pus or fluid in the ventricles. The wound where the
man had been bitten was discharging pus. There was
nothing of importance found in the other organs. Dr.
Hunt could not say how far the condition of the brain,
which was the cause of death, was attributable to the bite
which had been received a month before.
Multiple Cystic Bronchocelc. — Dr. Sidney Roiierts
showed a woman aged sixty-seven with Multiple Cystic
•Bronchocele of forty-seven years’ duration. The swelling
had been tapped twenty-seven yearsago.but speedily refilled.
In the last eleven years the patient had been subject to
attacks of sudden dyspncca, and had to be propped up in
bed. Except for this the tumour caused no pressure sym¬
ptoms whatever, and very little discomfort. The greatest
circumference of the neck was twenty-four inches. The
goitre measured seventeen inches across and nine inches
from above downwards. The walls of the thyroid between
the cysts were extremely hard and cartilaginous to the
touch.
Xanthoma Multiplex —Dr. Gwynne showed a boy aged
nine years suffering from this affection. The disease bad
commenced when no was about four years old, anpearing
first on the elbows and next over the tendo Achiilis, just
above its insertion, where it formed an oval mass one inch
long by three-quarters of an inch broad, and raised one-
third of an inch above the surface. It next appeared on
the webs of the fingers and on the posterior aspect of the
pinote of the ears. The patches on the elbows were about
an inch in diameter, and had the usual nodulated appear¬
ance and wash-leather colour. There was no family history
of any special diathesis. The boy had suffered from the
usual complaints incident to childhood. He had never had
jaundice. He was delicate, of sallow complexion, with
pigmentation of the skin under the eyes.
Mr. J. Jeeves showed three Hearts, all taken from the
bodies of men between fifty and sixty years of age, in
which the pericardium was very thick and adherent, pre¬
senting in nearly the same situation in each case, on the
posterior aspect of the heart, a calcareous plate from three
to four inches in diameter. '
Dr. Arthur Hall showed a series of Micro-photo¬
graphic slides with the oxy-hydrogen lantern. They in¬
cluded physiological and pathological specimens which had
been very kindly taken by Mr. G. T. W. Newsholme from
sections by Dr. Hall. Dr. Hall stated that his chief object
in showing the specimens was to endorse what had been
said and done by others lately on the great teaching value
of micro-photography. The photographs, which had been
taken with an ordinary camera, without its lens, a Beck’s
microscope, and an ordinary paraffin damp, included speci¬
mens of human retina, intestine of frog, showing the ab¬
sorption of fat by the epithelium, rodent ulcer, pneumonic
lung, anthrax bacilli, &c. A discussion followed, in which
Dr. Burgess, Dr. Rhodes, Mr, Boynton Lee, Dr. Ruxton,
Dr. Lyth, Dr. Martin, and Dr. Sinclair White took part.
Lymphangioma Cavemosum. —Mr. James read the notes
of acase of this disease, which be had shown to the Society
previously as a doubtful tumour which he then believed to
be cystic. It occurred in a boy aged five, was situated near
the angle of the left scapula, was a smooth, slightly
lobulated tumour, bluish in colour, not greatly involving
the skin, but rather subcutaneous. It had been noticed for
six months, and was painful when struck gainst any¬
thing, which not infrequently happened. 'The tumour
was removed on Dec. 6th, peeling readily from its
bed. To the naked eye it presented a large num¬
ber of cysts, of various sizes, from a millet seed
to a marble, some containing clear lymph, others venous
blood. The cyst walls were well defined and very tense,
the contents being jerked several feet on puncture; Micro¬
scopical examination showed a structure characteristic of
this form of tumour. The surface of the epithelium was
quite normal, and the dermis as far down as the level of
the sudoriparous glands. Here, amongst and between the
lobules of adipose tissue, were large and small irregular
spaces, some containing granular shrunken lymph cor¬
puscles. These were surrounded by very definite cyst walls,
some of them showing faint indications of endothelial
lining. The fibrous structures were presented in two very
different conditions—those which remained were evidently
hypertrophied, w’hile others had undergone atrophy, and
appeared as partially destroyed septa between lymph
spaces. The etiology and histology of the disease were dis¬
cussed, nothing being found to lead further back than
Torok’s suggestion, that it was a congenital disease
analogous to the earlier stages of congenital elephantiasis.
aitb ButwM of j^oofes.
A Contnbvtion to the Natural History of Scarlatina By
D. Astley Gbk.s.swell, M.A., M.D. Oxon. Oxford:
Clarendon Press. 1890.
The author of this monograph, which was presented as a
dissertation for the M.D. degree, merits much commenda¬
tion for the good use to which he has put his experience at
the South-'Westem Metropolitan Fever Asylum during the
epidemic of scarlatina of 1887-88. He made a series of obser*
492 Thb Lakcet,]
EEVIEWS AND NOTICES OF BOOKS.
[Feb. 28, 1891.
vations upon individual cases, which have brought to light
many new facts, whilst his generalisations are based upon
a very thorough and exhaustive study of the subject. The
book opens with a brief historical sketch of the prevalence
of scarlet fever in England, and then proceeds with a
general statement concerning the cases which are so minutely
analysed in the subsequent chapters. Here we find a
study of the cause and symptoms of the disease in rela¬
tion to season, and also in regard to the incidence of
albuminuria Indeed, no inconsiderable portion of the
monograph is devoted to the important subject of renal
complications, and many curious and interesting facts are
recorded. For instance, it was found that of the patients
admitted during the months of October and November as
many as 93'1 per cent, had albuminuria ; of those admitted
in December and January there were 13'8 and 26'8 per cent,
respectively which did not have albuminuria before getting
up; whilst this condition was but slightly marked in no
fewer, than 31’9 per cent, and 19'5 per cent, respectively of
this series. Indeed, it may be said that albuminuria was
nearly twice as prevalent in the latter as in the former
series. Dr. Greaswell shows that this albuminuria was
mainly of renal origin, and he associates it with glomerular
lesions. Leucocytes were found in the deposits, hut
epithelial casts only scantily. Ho is inclined to believe
that in those cases (no small proportion) in which the
albumen did not appear until after the patient “got up,”
the kidneys were already diseased. The incidence of
albuminuria varied also with the ages of the patients and
the stage of the illness. A full discussion of the nature of
early and late albuminuria is given, and the question of
“cyclical” albuminuria receives full attention. Some
instances of this symptom arising along with recurrence
of sore-throat are quoted. The general inference to be
gained from the study of the facts so carefully gathered is
that in albuminuria we, have an index of the severity
of the disease, not so much with regard to pyrexia, as
to the amount of scarlatinal poison circulating in the
blood.
Dr. Gresswell notes that as the hospital scarlatina in-
reased in its prevalence, and as the mortality from scar¬
latina rose for the whole of London, so did most of the
symptoms increase in frequency and severity; bub that as
prevalence and mortality subsided, so also did the relative
frequency and severity of the symptoms. The differences
exhibited at various periods between individuals comparable
as to age, sex, and surroundings, can only be explained by
modifications in the action of the scarlatinal virus, or dilTer-
ences in mode of infection, and also perhaps to individual
proclivity. It clearly appears, however, that there is a very
decided weakening of the virus as the epidemic inffuence
extends and declines. The subject is one of great difiiculty,
and allows of much theoretical speculation; but it is of
wide range, and requires profound study. The con¬
tribution made by Dr. Gresswell will aid in the determina¬
tion of some of the problems of epidemic disease, whilst in
scarlatina especially it will long be a standard of reference.
"We regret, however, that many of the diagrams and charts
illustrative of statistical points are so intricate as to
be of comparatively small service.
Les Microbes de la Boiiche. Par le Dr. Tn. David,
Directeur de I’lilcole dentaire, Ghirurgien Dentiste des
HOpitaux. Pt6c6d6 d’une Lettre-Preface de M. L.
Pasteur. Avec llSfiguresennoir et en couleurs dans le
texte. Paris : Fdlix Alcan. 1890.
In the work before us, Dr. David has collected in a well-
arranged and clearly written form a description of the
various micro-organisms that have been found in the
mouth, not only in connexion with diseases of the teeth.
but also with such other diseases as tuberculosis, gangrene,
diphtheria, pneumonia, and the like.
The work is arranged specially for the use of dental?
students, but it should also prove useful to those who wish
to acquire a general knowledge of micro-organisms. Otf
course, as one would expect in a text-book of this nature, a
part is devoted to general considerations of the subject.
The historical section carries us* back to Leeuwenhoek’s
earlier investigations which were made on micro-organisms
taken from the material covering the teeth. A short sketch
of the general form and classification of micro-organisms,
their structure, biology, mode of reproduction, and the
substances that they secrete, is followed by a description,
of the more important methods of cultivation and exami¬
nation. The common non - pathogenic microbes are-
then sketched, special attention being paid to the organ¬
isms that give rise to the mannite and lactic and butyric-
acid fermentations. A chapter is devoted to the organisms
of salivary septicicmia, first described by Pasteur; the
microbe of pneumonia, described by Friedliinder, and the
pyogenic streptococci and staphylococci are all in turn
spoken of as occurring in the mouth. The next chapter
treats of the organisms of the disease conditions already
mentioned, whilst the last chapter deals with what should'
be the practical outcome of the study of bacteriology to
dentists—the destruction of injurious organisms that occur
in the mouth, a note being given on the antiseptic treat¬
ment of caries. This part concludes by a list of formulas-
of liquids and antiseptic powders adapted to the prophy¬
lactic and curative treatment of affections of the mouth and
teeth. The bacillus of influenza is described in an appendix,
its claim to notice being that it finds its way by the moutk
into the lungs and intestine.
In a book that goes over so much ground it is difficult,
no doubt, to give any great amount of detail, but we-
cannot help feeling that a somewhat fuller description of
particular methods and of the special organisms connected)
with the study of dental surgery might have been more
appropriately given than such a collection of pathogenic
organisms, that, after all, have to be studied more by,
and are of more interest to, the general physician, tliaih
the dental surgeon; whilst to the laryngologist and
rhinologist some parts of the work would be specially
interesting, though they can only have a very general)
interest to students of dentistry. The subject of phagocy¬
tosis, we think, from the short reference made to it in the-
hook, can scarcely be fully understood, as the author speaks-
of phagocytes as certain microbes which can destroy others,
by devouring them, although he certainly assigns to the
white blood-corpuscles and the tonsils the r6lc of phago¬
cytes, but in a secondary degree. In the chapter on actino¬
mycosis the author follows Cornil and Babes very closely,
and here, as in the former work, we find no reference to-
M'Fadyean’s important contribution to the subject, and
Delepine’s and Crookshank’s work is nob alluded to.
Some of the illustrations are exceedingly good, and, as a
whole, the book may he highly recommended to those who-
take something more than a general interest in bacteriology,
especially in its relations to dental surgery. It is pleasantly
written, and the paper and print are really excellent.
OUR LIBRARY TABLE.
Casuistisch - Statistische Beitrdf/e zur Pathologic und!
Chirurgie dcr Gallenmge. Von Dr. L. G. Couiivoi.siicR, Pro¬
fessor in Basel. Leipzig ; F. C. W. Vogel. 1890.—During
the last ten years the gall-bladder and bile-ducts have been,
submitted to surgical treatment, and with a large measure-
of success. This has given a great impetus to the careful
pathological and clinical study of the diseases of these parts,
.oogle
Dir:' '3d ’
The Lancet,]
OUR LIBRARY TABLE-NEW INVENTIONS.
[Fed. 21. J891. 493
and many valuable addltiouB have been made to the litera-
ture of the subject. At a cost of great labour Dr.
Cuurvoisier has studied the literature of the gall-bladder
and the ducts, and in the -work before us he gives the
results of his labour. He discusses the various parts
of his subject in an orderly and methodical manner,
and, as the title of his book tells, he largely deals
with statistics. He first of* all reviews what is
known of the pathology of the gall-bladder and ducts,
taking in order gall-stones, fistulous openings into the
biliary tract, inflammation, congenital malformation, and
then injury. The second part is surgical and therapeutical,
dealing with descriptions of the various operations that have
been performed for the previously named diseases and
injuries, their results, and a discussion of their value. The
book closes with a very full and carefully prepared biblio¬
graphy. Altogether it is an excellent piece of work, and
will be of great service to surgeons who are anxious to
ac(iuire a complete knowledge of what has been effected in
the investigation of this important group of diseases.
The Law relating to Medictil Practitioners. By Joseph
Craven .and Theodore Coppock, Barriaters-at-Law.
London: Shaw and Son.—The object of the authors of this
book has been, as explained in their preface, to collect within
a reasonable compass the law relating to medical practi¬
tioners in England, and to embody it in concise and
ordinary language. So far as the size of the volume is con¬
cerned they have succeeded, for it extends to no greater bulk
than some two hundred and fifty small octavo pages, printed
in very legible type. The writers have, however, adopted too
slavishly the practice of extracting the language of reported
cases for the material of their text to have attained either to
conciseness or the perspicuity that lies in freedom from
technical expression. Thus, for example, we find on
page 41 a definition of gross negligence extracted from the
report of Rex v. Markuss, and on page 46 we have the
same definition in the same terms—indeed, the identical
extract repeated. In other passages considerable laxity,
and even inaccuracy, of expression is permitted, as, for in¬
stance, where it is said, “If any person cause the death of
another intentionally, it is murder,” as if justifiable
homicide were unknown to the law. Again, many
passages might be cited in -which the loose language
employed is apt to be even misleading. One example
may suffice. On page 23 we read : “ Speaking generally,
the patient is the person who is liable to pay the charges
of the medical man who attends him. In some cases
it is another person who has promised payment.” Why
the patient instead of the person who employs the medical
man to attend should be designated as paymaster is hard to
perceive. A parent calling in a medical man to attend his
child, a husband to attend his wife, or a master to attend
his servant becomes liable to^pay the fee incurred, and
when these numerous instances are excluded from the
operation of the rule given above its scope will be seen to
be so very restricted that it will be difficult to see why it
should be introduced with “speaking generally.” But
though the book is in some respects open to criticism, it is
very handy, and calculated to be useful if certain imper¬
fections which characterise it are borne in mind.
A Zoological Pocket-hook, or Synopsis of Animal Classifi¬
cation, By Dr. Emil Selenka, Professor of Zoology in the
University of Erlangen. Translated by J. K. Ainsworth
Davis, B. A. Trinity College, Cambridge. Pp. 238. London:
Charles Griffin and Co. 1890.—This is a little volume that
will prove very serviceable to those who are attending
biological lectures, and to those also who are about to present
themselves for examination in biology at any of our univer¬
sities. It contains a brief description of the essential
characters of tJie several classes and genera of the animal
creation on the most recent taxonomic arrangement. Space
is left for the student to append notes of lectures. We can best
give an idea of the manner in which the subjects are treated by
a quotation. Selecting theMolluscai-we find thefollowing:—
“Phylum V. Mollusca : unsegmented animals with a soft
body, mantle, and dorsal shell (usually), muscular ventral
foot, large digestive gland (liver), and open vascular
system. Enteroccele represented by pericardiac cavity
which typically communicates with exterior by a pair of
nephridia. Cerebral, pleural, and pedal ganglia. Larva
(veliger), usually with a velum. Subphylum A. Lipo-
cephala (acephala): bead region rudimentary and devoid of
eyes; no odontophore. Class I., Lamellibranchiata, with
bilobed mantle and shell (valves equal, but uasymmetrical),
large gill-plates (in most), two pairs of labial palps, paired
nephridia (organs of Bojanus), auricles, digestive gland,
and gonads; sexes generally separate. Order 1, Asipbonlda;
no siphons; with one adductor muscle: Pecten jacobeeus
clam, Ostrea edulis, oyster, both hermaphrodite, with two
adductors. Meleagrio a roargaritifera, pearl mussel. Mytllua
edulis, edible mussel. Lithodomus dactylus, Trigonia, Unio-
pictorum, anodoota cygneea, freshwater mussels (the free
larva, ‘glochidium’ parasitic on fishes). Order 2, Siphonida
siphons, two adductor mussels. Cardium edule, cockle.
Cyclas cornea, in freshwater. Venus. Solen aspergillum,
with tubular shell. Teredo navalis, shipworm.” The trans¬
lation is accurately and clearly done.
Dissection of a Symelian Monster. By R. C. Benington,
M.B., Newcastle-on-Tyne.—This pamphlet, which is a
reprint of a paper contributed to the twenty-fifth volume of
VoQ Journal of Anatomy and Physiology, gives the results
of a careful dissection made by Dr. Benington of a monster
in which there was complete union of the lower limbs, the
combined limbs being terminated by two feet, with the
soles turned to the front. There were nine toes, the second
toe of the left foot being absent. An excellent plate accom¬
panies the description.
The Quarterly Journal of Microscopical Science. Edited
by E. Ray LANKESTERand Professors Klein, Sedgwick,
and Milnes Marshall. New Series, No. CXXV. London:
J. & A. Churchill. ‘1891.—The memoirs contained in this
part are: 1. Studies on the Comparative Anatomy of
Sponges, Part 3, devoted to the anatomy of Grantia laby-
rinthica and the so-called family Trichonidm, with one
plate; and 4, on the Flagellated Chambers and Ova of
Halichondria panicea, by Arthur Dendy, M, Sc., F. L. S,, with
one plate. 2. On Megaloseolex cmruleus from Ceylon, with
a Theory of the Course of Blood in Earthworms, by Alfred
Gibbs Bourne, D.Sc., with two plates. 3. On a little
known Sense Organ in Salpa, by Arthur Bolles Lee, with
one plate. 4. Immunity against Microbes, by M. Armand
Rutfer, M.D.
Infentiuns.
NEW FORM OF UTERINE DOUBLE TENACULUM,
The principal objections to the use of the ordinary form
of uterine tenaculum ate, first, its liability to tear its way
out of the tissue when the necessary traction is made on
the hook, and, secondly, the difficulty of disengaging the
point, more especially in cases where the speculum has to
be dispensed with while examining by touch the posterior
fornix or wall of the uterus. By using the form of double
tenaculum illustrated these objections will vanish, and I
can safely recommend it as an improvement on either the
tenaculum or vulsellum, from which it differs by having the
points set at rightangles,and so holding a larger surface. The
instrument will be found easy of introduction, and there can
Digitized by
Google
494 The Lancet,]
A NEW DANGER TO LONDON.
[Feb. 28, 1891.
be DO fear of the poini s tesriog their way out, unless a force
uDsecessary and unjustifiable is used. The points can be
disengaged in a moment, without using the speculum, by
simply pressing on the side of the handle approximated
by the cross-action spring. The convenience of possessing
an instrument that will hold firmly and can be disengaged
at once will, I think, commend itself to the gynce^ologist,^
of whose armamentarium it should form an essential part.
Messrs. Arnold and Sons, London, are the makers.
Alexandek Duke. F.R.C PI.,
E.'C-Asaistanb Master Rotunda Hospital, Oynascologist
at Stoeveiis's Ho.spital, Dublin.
AN OVUM CURETTE.
It has always appeared to me that the treatment of
early miscarriages has been unsatisfactory and incomplete
in the majority of cases, and this opinion has been con¬
firmed since practising in New Zealand, where patients may
be fifteen or twenty miles from skilled assistance. If the
patient is within easy reach, the ordinary method of plugging
and administering ergot may be satisfactory enough, and
direct interference not called for; but there are many cases,
as I have instanced, to which a medical man is called, and
on arrival he finds the fcetus escaped, a mass of
placental tissue remainlog, and more or less severe
iifcmorrhage taking place. The distance and the
urgency of the case render it imperative that every¬
thing should be removed at one sitting, and the
choice hitherto has laid between removal by the
fingers or forceps. In the former case a consider¬
able amount of unnecessary force is apt to be used,
and in addition the operator is f>equently tanta¬
lised by feeling the placental mass, end yet is not
able to remove it without considerable difficulty,
owing to insufficient dJatation. IVitb regard to
the ovum forceps, I consider it requires a some¬
what callous operator to use them with any con.
fidence, owing to the impossibility of forming any
idea of the substance held by them. It was this
unsatisfactory choice which suggested to me the
advisability of trying the curette, and in wj next
cases I used a Sims’ improved one with considerable
success and much greater satisfaction than here¬
tofore, the result being that I left my patient
feeling satisfied that the whole of the embryonic
tissue was removed. As I consider there is still
room for improvement in the instrument, I offer
to my medical brethren what I have christened
“ an ovum curette.” As will be seen from the en¬
graving, in general appearance it resembles an
ordinary curette, but tne raspatory portion, as it
may he termed, is of steel, and on section is
comma-shaped, with an edge sufficiently sharp to
remove the tissue and yet not to injure the under¬
lying structure By means of the flexible stem
this edge may be directed upwards, forwards, or
downwards, according fo the placental site, which
is first ascertained by digital examination. After
the operation the cavity is gently washed out with
a warm antiseptic fluid. I think with such an instrument
the whole uterine cavity may be successfully searched and
cleared of placental tissue without difficulty or injury to
the uterus, and also it w'ill have the advantage over the
forceps of communicating to the operating hand the nature
of the particular part with which it is in contact.
Since sending my first description and sketch to Messrs.
Arnold and Sons, I notice in the Australasian Medical
Gazette of October, 1890, that the subject of curetting in
miscarriages has been advocated in a disciusion before the
South Australian Branch of the British Medical Associa¬
tion, and that an instrument was suggested by Dr. A. A.
Hamilton.
Pitotic, N.z. A, Meredith Whitehead, M B , C M.
A NEW DANGER TO LONDON.
To the Editors of The Lancet.
Sirs,—T hree weeks ago I discovered that the wharf
known as Bingley’s Slate Wharf, situated next to end
south of the Millbank pier, opposite to the south-east angle
of the now disused prison, had been bought by the united
vestries of St. John’s and St. Margaret’s, Westminster,—
sanitary authorities, he it remembered—and that they were
quietly and rapidly having it altered to fib it for a wharf
for storing and dealing with the dustbin and other
scavenger’s refuse, and shipping it into barges on the river,
“and for other parish purposes”—a very elastic description,
which, considering that there is nothing to prevent their
accommodatingthegreatneighbouringvestriesof St. James’s,
St. George’s, Chelsea, and the Strand for an adequate
money consideration, is by no means reassuring, as, in
addition to the contents of the many thousand masses of
corrupting animal and vegetable matter from the bins of
these two large parishes which will be concentrated here
day by day and week by week, we should have four or five
times that amount from those which border on us. As they
are putting up a high wall, which I understand is to be
roofed in, and the electric light is to be introduced, I
think it may fairly be inferred that it is intended to
“screen,” or sift, all this filth, and that the work will be
carried on almost continuously. I do not think that it is
contemplated to set up “destructors”—at present at all
events—as these, though comparatively harmless to life and
health, emit much noisome stench, and this would speedily
lead to legal suppression, as in Kensington and Paddington,
thanks to the eneigy of Sir Algernon Borthwick. The hot
fumes pass up tlie shaft, and, after they have been carried
a certain distance by the wind, are condensed and fall to
the lower levels. The nuisance proposed to be created
is of a far more subtle and dangerous description, as the
gases and germs most inimical to life, which cannot fail to
be generated and multiplied, will spread laterally from
this plague centre like a huge fan, travelling according to
the direction and force of the winds. A more ingenious
plan of spreading the germs of malaria, diphtheria, scarlet,
and other fevers, cholera, and the host of other infectious
diseases, far and wide over the wealthiest portion of the
greatest cif.y the world has ever seen could not have been
devised by its most malignant enemy. You will therefore,
Sirs, be still more astonished when I inform you that
another and greater sanitary body, the London County
Council, has actually voted a loan for these purposes.
The statements I make have already been hrouaht to tlie
notice of the Government by me, and duly verified as exact.
No blame whatever attaches to the medical authorities of
the Local Government Board, Dr. Buchanan not having
heaid of the matter till I told him. and I should not have
found it out had I not been resident close to the place, for
the outrage in contemplation was kept as quiet as possible.
This spot is at the southern extremity oi the great river
reach which extends thenc§ to Waterloo almost in a straight
line, and a southerly wind will bring infection to the Houses
of Parliament, Westminster Abbey, all the great public
offices up to and including Somerset House, the Strand, and
Fleet-street. An east wind carries it to the palaces, clubs,
and the line of Piccadilly and Hyde-park, while northerly
winds would rake all CheUea. But the Houses of Pai-
lianient and St. 'rhornas’s Hospital would be the greatest
sufferers. I trust, Sirs, therefore that the profession will as
usual come to the rescue and show Parliament the grave
danger of permitting such accumulation within the metro¬
politan district. That the parishes are puzzled what to do
with their refuse is some slight excuse, but the remedy they
propose is infinitely worse than tlie evil. It is not, however,
beyond the resources of modem physical and mechanical
science, and with your permission I will in a future com¬
munication indicate a safe and cheap way of removing
decaying refuse from our midst. Meanwhile it behoves us
to urge the necessity of forbidding the creation-of such a
dangerous nuisance on Parliament
I am, Sirs, your obedient servant,
Gr JMVonor road, 8.W., Fell. 25tli, ISQl KENNETH CORNISH,
Dir:
Aioogle
Thb Lancet,]
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.
[Feb. 28, 1891. 4&5
THE LAT^CET.
LONDON: SATURDAY, FEBRUARY 2S, 1891.
It will be in the recolleclion of our readers that lost
October a deputation from the Association of Fellows of the
College of Surgeons of England had an interview with a
committee of the Council of the College for the purpose of
obtaining an increase of privileges for the Fellows of the
College. Of the three points urged the first and most im¬
portant was that meetings of the Fellows should be
summoned by the Council separately from the Members to
consider all matters of interest to the Fellows, and that the
Fellows should have a common room in the College^ The
position taken up was this, whether the Council under the
Charters and by-laws possessed the power of calling
together the Fellows apart from the Members was
not certainly known. If they had, the Association
desired the Council to exercise it; and if they bad not,
they wished them to obtain it. After some discus¬
sion, in the course of which some of the members of the
Council present expressed themselves as favourable to the
concessions asked for, a half promise was given that the
question should bo submitted to counsel, and on Nov. 13th
it was resolved by the Council that Mr. Wn.DE be in¬
structed to prepare a case for submission to the Attorney-
General and Mr. Paget for their opinion whether the
Council possesses the power to summon a meeting of the
Fellows of the College separately from the Members. The
opinion asked for was drawn up on Dec. 22Qd, 1890, and
submitted to the Council at the ordinary meeting on the
12bh inst. It would have been more satisfactory if the case
submitted by Mr, Wilde to counsel had been published
with the opinion to which it was a reply; for, judging by the^
latter part of the opinion, it would seem that it was not a
simple question to whfch a direct alfirmative or negative
only was required; but that the advice of counsel
was sought as to the expediency of exercising the
power of calling meetings of sections of the corporate
body, presuming that such power was possessed by the
Council. In substance the opinion states—(1) that there is
no legal objection to meetings either of the Fellows or
Members in the College premises, whether such nieetings
were summoned by the Council for consultation purposes or
permitted by the Council to be held therein; (2) meetings
of sections of the corporate body could not possess any cor¬
porate efficacy, and any proposals to affect the interests of
the corporation or any of its members could only be dis¬
cussed so as to have effect at a regularly assembled meeting
of the whole corporate body; (3) neither the Charters
nor By-law 17 give or imply any inherent power to
summon or countenance any .effectual meeting of Fellows
only or of Members as distinguished fronj Fellows;
(4) if separate meetings of Fellows are summoned or
permitted, it would neither be consistent nor reasonable to
refuse similar facilities for meetings of Members if such
meetings were requested by a substantial number of the
Members; (5) it would be inexpedient and unwise to permit
a meeting of any section of the College whilst litigation is
pending, as it would be ground for comment and prejudice
in the course of it. At the end of the opinion the remark is
volunteered that it is for the Council to consider whether
the end they have in view—namely, to take the sense of the
body of Fellows—cannot as well be attained by some less
formal method, either by private meeting elsewhere than
in the College, or by circular, neither of which courses
seems to counsel open to the same objections as the one
suggested. This opinion shows that there are absolutely no
obstacles to regular consultative meetings of the Fellows
of the College hut the good pleasure of the Council and
pending litigation. The Members of the College are better off
already than the Fellows, for the annual meeting of Fellows
and Members is virtually a meeting of Members, and only
such questions as afiect the interests of the Members can
possibly be discussed. Questions affecting the interests of
the Fellows, chiefly or exclusively, have no chance of
engaging the attention or interest of a mixed meeting of
Fellows and Members in which the latter may largely pre¬
ponderate. This is one of the grounds on which the
Fellows’ Association have asked for the concession of
separate meetings ; and doubtless if more meetings of
Fellows than one in the year were likely to lead to incon¬
venient demands for more meetings of Members, the Fellows
of the College would be satisfied if they were called
together separately once in the year. The other ground
for asking for meetings of Fellows is that they may he placed
on an equality with the Fellows of the other medical
and surgical Colleges, all of which possess a more liberal
constitution than the College of Surgeons of England.
Undoubtedly it would be desirable to get rid of all litiga¬
tion in the first instance, and it is to be hoped that the
long-pending action Steele v . Savory will come to a speedy
termination, satisfactory if possible to both parties. The
request of the Association of Fellows for separate meetings
of Fellows, which is areasonahle request, would not he likely
to excite the opposition of the Members of the College, pro¬
vided those fair concessions were made to the Members
which the justice of the case and the interests of the
College and profession have so long demanded. , It would
be the most satisfactory solution of the existing con¬
troversies if the contending parties could arrive at a
mutual agreement, but the basis of such agreement must
necessarily be the grant of representation on the Council,
in some form or other, to the Members of the College. If
this were done, as it might be done, gracefully by the
Council at the present time, a new Charter might be
obtained embodying the provision's for such representation,
and for separate nieetings of Fellows as well as for meet¬
ings of Members for consultative purposes. We fear, how¬
ever, that the millennial period of universal peace and good
will is too far distant to justify the Fellows of the College
in resting on their oars and allowing their craft to glide
gently down with the favourable current in which Col¬
legiate politics are running. The Association of Fellows
of the College has undoubtedly scored a point in pressing
the question of separate meetings of Fellows on the atten¬
tion of the Council of the College, and securing from
Digitized by
Google
496 Thb Lancet,]
ANTISEPTIC MIDWIFERY.
[Feb. 28, 1891.
counsel an opinion which, with all its gnalihcations, is
distinctly affirmative of the power of the Conncil to consult
the Fellows as a body in the College whenever they should
be so minded, and that which now remains to be done is to
follow up the success without delay. In the circular which
the Association issued last year a memorial to the Council
from the general body of Fellows was proposed, and if the
majority of the Fellows have any e^rit de corps or any desire
toimprove their status, there ought not to be much diffienlty
in obtainiog a large number of signatures to a memorial
asking for at least one meeting of the Fellows for con¬
sultative purposes in the course of the year. The Council
of the College have a happy method of minimising the force of
any recommendation, or proposal, or suggestion in the cause
of progress which may be brought before them by assuming
that the persons who make it represent no one but them¬
selves, and it is absolutely necessary for success that there
should be evidence of substantial support to the present
movement. When a sufficient number of Fellows asked
for voting papers, voting papers were conceded; if a suffi¬
cient number ask for meetings of Fellows, meetings of
Fellows will be summoned in due time. The Association
of Fellows has been strictly moderate in its programme.
It has not asked that the decision of meetings of Fellows
should necessarily be binding on the Council, but that
opportunity should be given to the Fellows assembled
within the walls of the College to make known their views
to the Council. If such opportunity should he affiorded, all
other desirable changes will follow in due course, and the
Fellows of the College will do well to adhere with perti¬
nacity to this cardinal measure of reform.
Everyone acquainted with the literature of “puerperal
fever” knows the numerous theories and hypotheses which
have been suggested to explain its nature, etiology, and
pathological relations, and the consequent unsatis¬
factory methods of treatment employed to abate
the evil in wbat was regarded as its epidemic course.
For long it was looked upon as a specific fever, and
this idea even yet dominates the minds of some ob¬
stetricians and modifies their methods of treatment. As
our knowledge, however, of traumatic diseases in general
has increased, so the investigation of the febrile sequelse
of labour has become more exact, and in accordance
with the principles of modem pathology. The result of this
investigation and the application of purely scientific
methods to practical midwifery have proved that puerperal
fever is of a septic infective nature, and that the lesions of
the parturient canal are the chief points of entrance
into the system of the poison-generating germs. It
has been thought by some that clinical experience renders
it probable that the germs may enter by other channels—
as through the respiratory organs—hut the results of most
of such experiences have not been submitted to the
judgment of those who are well qualified by pathological
education and bacteriological experiment to arrive at a
generalisation. Such conclusioos are certainly open to dis¬
cussion, and, indeed, many of them are probably capable of
refutation. The theory of antisepsis is based upon a long
series of well-attested clinical and experimental facts, and i
is now almost universally accepted as a true explanation of
the excellent results of modern surgery and practical mid¬
wifery as seen in nearly all our maternity hospitals. Even
in the practice of those surgeons and obstetricians who do not
admit this theory it is found that their methods are not in¬
compatible with the teachingof Lister, to whom the elabora¬
tion of this great theory is due, as based upon the brilliant
labours of Pasteur.
The early history of the evolution of antiseptic
methods in midwifery is very interesting, and a glance
at its development emphasises the immense improve¬
ment that has taken place in the conduct of lying-in
cases from the application of the principles involved. To
Semmei.WEISS is due the credit of having in 1847 recognised,
though dimly, what has in recent years developed into the
antiseptic system. The mortality in the lying-in wards in the
General Hospital of Vienna had been excessive—about 12 per
cent. With a true scientific spirit, he set about to discover
the cause of this high death-rate. “Telluric conditions”
bad for long been regarded in Vienna, in London, and other
places as a mighty factor, but Semmelweiss found that the
fatal fever was not “epidemic” in other parts of the city,
and, as a result of his investigations and careful reasoning
thereon, it became to him a self-evident fact that the
cause or causes must be within the clinique itself. At
that time anatomical students were allowed to go
direct from their practical studies to attend midwifery
cases, the only precaution taken being the ordinary
washing of the hands with soap and water He, how¬
ever, ordered all students previous to examining par¬
turient women to wash their hands in a solution of
chloride of lime. In the course of a few months the mor¬
tality in the lying-in wards under his charge was reduced
to about 3 per cent., and within a year it further diminished
to between 1 and 2 per cent. Like all pioneers, Semmel¬
weiss was subjected to opposition, and even received the
abuse and ridicule of bis rivals, who endeavoured to upset
his methods. Many of the higher minds in the pro¬
fession in Vienna at that day supported him. Among
these were Rokitansky, Skoda, Hebra, and Haller. The
last-named observer saw with prophetic eye the grand anti¬
septic system now developed by Lister, and, in a paper
read in Februaiy 1819, remarked that the importance of
Semmelweiss’ “experiences for the welfare of the maternity
department and for the hospitals in general, but particularly
for the surgical wards, is beyond calculation.” In 1850,
SiMRSON of Edinburgh published a short paper on the
“Analogy between Puerperal and Surgical Fevers,” and
with a remarkable foresight heralded many of the
truths with which we are now thoroughly conversant,
as brought to light by the investigations of modern
pathology and bacteriology. What we think is required
by surgeons, obstetricians, and gynaicologists is to apply
the truths of pathology and the more recent teaching
of bacteriology to their respective practices. Cleanliness,
it has been averred by those who do not adopt the antiseptic
theory as a working hypothesis—and this is the important
point practically, — is sufficient for them, and they
point out their results as comparable with or superior to
those who work on antiseptic lines. Those who arc
“satisfied with cleanliness” forget that this is the very
Digitized by
Google
The Lancet,]
AKISTOTLE AS A NATURALIST.
[Feb. 28, 1891. 497
esseoce of aDtiseptic methods, the aim of which, in fact, is
microscopic cleanliDess or asepsis—that is, the absence of
septic germs or decomposing material. Some reproachfully
refer to the laying aside of many of the complicated means
formerly employed to maintain asepsis, such as the spray pro¬
ducer, which in some maternity hospitals was employed to
form an antiseptic cloud into which the child was ushered at
birth. Thisisonlypartof thesimplifyingof themeansadopted
to secure aseptic conditions, and the greatest and most
recent successes of the system have been the perfecting and
making more simple the means employed to attain them.
What we wish to impress upon every practitioner is that in
order fully to appreciate the full scope and responsibility
of antiseptic midwifery cases of childbirth must be
guided as faithfully in every minute detail as any serious
surgical operation. It is needful, we think, for all practical
obstetricians to profit by the most recent advances in
pathology and bacteriology, and to receive the teaching of
these in a scientific spiiit. The experiments and ob-
rervationa of Mktcunikoff, which attempt to prove the
anti-bacteiial action of normal leucocytes —a process of
phagocytosis,— may assist in explaining some of the
anomalous or milder cases of febrile disturbanoe seen in
puerperal cases. Whether this be the case or not, it is
well to keep our minds open for all the help that pathology
and bacteriology may give us in establishing correct prin¬
ciples for the regulation of the conduct of lying-in cases in
our every-day practical antiseptic midwifery.
In the February number of the Contemporary Review
Mr. Romanes discirsses the position of Aristotle as a
naturalist, and it is worthy of notice that in the Hunterian
Oration which has just been delivered by Mr. Hutchin.son,
the orator remarked that in the long interval between
Aristotle’s death and the birth of our groat English
surgeon, few, if any, men can be mentioned whose
owners would have been so capable of estimating the
value of the accpiisitions made to science by Hunter
as the Greek philosopher. Aristotle was born n.u. 384
at Scageira, and died at the age of sixty-three at
Cbalois. He was the son of Nicomachu.s, physician
and friend of Amyntas, King of Macedonia. His
father died early, and after running through the fortune
that was left him Aristotle is said to have become a
S' Idier, and, satisfied with a brief experience of that life, to
have exchanged it for philosophy, and to have maintained
himself for a time by practising pharmacy. Settling in
Athens, then the centre of the intellectual life of Greece,
I e became the pupil of Plato, who, soon recognising his
ability, remarked that he did not need the spur but the
bridle. For twenty years he continued a disciple of Plato,
but at length, probably as the result of pursuing a different
and more objective method of research, he separated from
the school to which he had so long been attached with the
notable apophthegm—“ Amicus Plato, amicus Socrates
He,d major veritas,” Departing from Athens, he went
to Atarneus in Mycia, married, and lived in Mytiiene,
wlience, in his forty-second year, being summoned by
Philip of Macedon to educate Alexander the Great,
then a lad, be devoted nearly twelve years of his life
to this important vocation. Returning to Athens when
Alexander had gone to the East, he founded the peri¬
patetic school, and his lessons were doubtless illustrated by
the numerous specimens of plants and animals that were
collected by the orders of Alexander and forwarded to
his old teacher. The personal qualifications of Aristotle
were not attractive. Small of stature, with bald head,
wrinkled cheeks, little eyes, a stammering pronounciation
and generally feeble health, it required, indeed, the fire of
genius to make him the most successful teacher of his own
time and to render him one of the greatest—some think
him the greatest—thinker and writer the world has seen.
The subjects on which he wrote were numerous, and in¬
cluded physics, astronomy, meteorology, zoology, compara¬
tive anatomy, physiology and psychology, poetry, ethics,
rhetoric, logic, politics, and metaphysics—a goodly array;
and whilst all were done well for hie time, the second
group, it may be confessed, was more satisfactorily treated
than the first. A careful examination of his works enables
Mr. Romanes to say that he mentions at least seventy
species of mammals, one hundred and fifty of birds, twenty
of reptiles, one hundred and sixteen of fish, eighty-four of
articulata, and about forty of the lower forms—making
about five hundred in all.
Mr. Romanes justly expresses surprise at the inequality
and curious imperfection of Aristotle’s knowledge; for
whilst he to some extent understood the structure and
functions of the heart, experimented on the coagulation of
the blood, and had certainly observed the development of
the embryo of the fish, he exhibits absolute ignorance of a
nervous system, and an inability to comprehend the functions
of the muscles, which is extraordinary, since he never asso¬
ciates them with movement. He seems to have confused
the arteries and veins with the nerves, since he thought
the nerves sprang from the heart. The breadth of the
studies of Aristotle enabled hini to perceive the import¬
ance of the inductive method of inquiry, and to recognise
the value of generalisations founded on a sulficient number
of well-observed facts; and in most instances, when he
states what he believes to be a fact, he gives an illustration
by which he may be better understood. It is in the value
he sets upon observation, though many of the observations
he records were certainly erroneous, and in the vast number
that he has collected, that the high esteem in which he is
held by those best qualified to judge mainly rests, and
amongst them we may mention Buefon, Cuvier, Flourens,
Claus, and Owen. The plan and method of his work
were his own. The facts were perhaps supplied by others,
and on this point Mr. Romanes makes a remark that we
think requires correction. Looking, he says, to the
“ enormous range of his work in biology alone, remembering
that in this work he had had no predecessors ; considering
that at the same time he was thus a single-handed collector
of facts, and a single-minded thinker upon their import, it
becomes evident that Arlstotle would have been some¬
thing more than human if either his observations or his
reasonings could everywhere be justly compared with
those of the scientific genius when more favourably
circumstanced.” We are inclined to doubt that Aristotle
had no predecessors. In the first place, the growth
of a subject like biology is slow; words have to be
Digitized by Google
498 The Lancet,] PROFESSOR LEIBREICH’S REMEDY FOR TUBERCULOSIS.
[Feb. 28, 1891.
coined, expresBions forged, and it is incredible that any
one man could have performed the dissection and established
the phraseology of a science; and, secondly, he himself
directly refers to the labours of others, as, for example,
when he refutes those who believe the lungs are void of
blood, and of those who have established the existence of
mammae in the dolphin. The errors and inconsistencies
are so remarkable that it is almost impossible to believe
that we are really in possession of the original work of
Aristotle. His writings were buried for more than a
century, and when they were eventually brought to light,
Apellicon, into whose bands they fell, Mr. Grote informs
us, felt no scruples in correcting what had been worm-eaten
and supplying what was defective or illegible. In con¬
cluding, we would remark that we are indebted to
Mr. Romanes for a very readable article.
'* Ne quid nlmla."
THE COUNCIL OF THE ROYAL COLLEGE OF
SURGEONS OF ENGLAND AND THE
UNIVERSITY OF LONDON.
Our report of the proceedings at the meeting of the
Council of the Royal College of Surgeons of England, held
on the 12bh insb., which appeared in The Lancet of
Feb. 14th, contained two announcements of the highest
possible interest to the body corporate of the College. One of
these, which related to the power of the Council to summon
meetings of Fellows separately from the Members, we have
discussed in another column. The other had reference to
the revised scheme for the reconstitution of the University
of London, which the Senate are about to submit to Con¬
vocation for discussion and approval, or otherwise, and
which the Senate liad adopted after conference with the
two Royal Colleges. This scheme, be it noted, was approved
by the Council of the College of Surgeons then and there,
and ordered to be entered on the minutes. Not a word
appears to have been said about submitting the scheme to the
body corporate, the Fellows and Members of the College, for
considerationand approval. If anythiDgwassaidyifanyvoice
was raised against the summary determination of a very im¬
portant question, it was plainly in vain ; neither was it in
any way operative, for it was not backed up by the proposal
of any resolution in favour of the obvious and desirable
course, consultation of the Fellows and Members of the
College before the Corporation was committed to a scheme
with far-reaching consequences. Surely it is a great anomaly
that a scheme which vitally concerns the interests of the
Fellows and Members of the College should be considered
and approved in secret conclave by twenty-four individuab
only out of the thousands who belong to the Corpora¬
tion, and are interested in its well-being and relations to
the Universities and the other medical and surgical
Colleges. Whilst the Fellows of the College of Physicians
and the graduates of the University of London will enjoy
opportunities for thorough discussion and consideration of
the scheme, the Fellows of the College of Surgeons, to
say nothing of the Members, are absolutely excluded from
any voice in, a measure which would increase the power of
the Council of the College and profoundly modify for good
or evil the existing conditions of medical education and
examination. That ignoring the views of the constituency
is not advantageous either to the public or to professional
interests was clearly shown when the Society of Apothecaries
was excluded from the Conjoint Scheme of the Colleges in
the hope that this exclusion would lead to its extinction as
a medical authority and licensing body. It only resulted in
kicking the Society upstairs and enhancing its power by
enabling it to confer a complete double quallBcation at a
price far below the costly exactions of the Royal Colleges.
If the voice of tlie constituency had been heard and obeyed,
the fatal mistake of neglecting the opportunity of absorbing
the Apothecaries’ Society, and securing the boon of a single
examining board for the ordinary professional licences,
would not have been committed ; and it may be that a
similar neglect of the constituency or body corporate in the
present instance may lead to disadvantages which might
have been avoided by encouraging open discussion of the
scheme. Why are the Fellows and Members of the College
to be treated like ciphers or children, and how long will
they submit to their degraded position ? It is time that
they should “ awake, arise, or be for ever fallen.”
PROFESSOR LIEBREICH’S REMEDY FOR
TUBERCULOSIS.
We have received by telegram from our Berlin corre¬
spondent an account of the remedy which Professor Liebreich
has introduced as a means of combating tubercular disease,
and the good effects of which were vouched for by Professor
B. Fraenkel in his speech at the Berlin Medical Society on the
18th Inst, to be found on another page. It was at the meeting
of this Societyon the25th Inst, that Professor Liebreich gave
an account of his remedy, which consists of cantharidate
of potash, a combination of 0-2 grm. pure cantharidin and
0 ‘4 grin, of potassic hydrate, in 20 cubic centimetres of water.
In his opening remarks Professor Liebreich regretted that the
older methods of treating disease had been so much lost
sight of; and he said that he had been led to think of
cantharidin in the present connexion, by the good
effects observed from the prescription of canbharides in skin
diseases. The specific property of cantharidin is to excite
serous exudation from capillary vessels, and he argued that
this effect would more readily occur if those vessels were
already irritated. In applying the drug to cases of
tuberculosis he proceeded very cautiously, commencing
with injections of l-60th of a decimilligramme of the
solution of the cantharidate of potash, and gradually in¬
creasing the dose. It was found that the expectora¬
tion was thereby increased, and that the ordinaiy dose
required to produce substantial effect was one to two
decimilligrammes. It is likely that six decimilligrammes
would be the maximum amount that could be safely used.
No cures have yet been effecjied, but, as already said, Pro¬
fessor B. Fraenkel and Dr. Heymann have been struck with
the remarkable amelioration of cases so treated, and with the
absence of any untoward symptoms. The drug probably
only affects the diseased tissues, and it may be applicable
to other affections than tubercle. The address was followed
by great applause. _
CHOLERA INTELLIGENCE.
According to intelligence up to the end of January last,
cholera had undergone a great diminution in Syria, no new
cases having been recorded for several weeks in the
villayets of Aleppo, Adana, and Damascus. On the other
hand, it was reported that two cholera deaths had occurred
in the villayeb of Diarbekir and five i that of Beyrout.
The total cholera mortality in Syria up the week ending
Jan. 24th had been 4170. Of these, the villayet of Aleppo
waa responsible for 2361, that of Damascus for 1189, of
Beyrout for 421, of Adana for 97, of Memouret-ul-Azia for
85, and of Diarbekir for 15. Later intelligence is to the
effect that cholera bad ceased in Syria by Jan. 22nd, and
Dici-.^ed t Coogle
The Lancet,]
THE JUBILEE OF THE CHEMICAL SOCIETY.
[Feb. 28,1891. 499
we have information from a correspondent who is able to
speak with considerable authority, to the effect that so far
as the towns, at least, of Beyrout and Damascus are con¬
cerned no case of cholera has as yet appeared. It may also
be added that quarantine restrictions imposed at Constanti¬
nople on arrivals from Syrian ports between Alexandretta
and Beyrout have been removed, and that the Syrian ports
generally are regarded as free from the disease. There
is, however, reason to believe that, es regards Tripoli,
cases are being hushed up, and that the disease has not yet
quite ceased there. The serious epidemic in Japan, to
which we have from time to time adverted, also seems to
have come to an end.
THE JUBILEE OF THE CHEMICAL SOCIETY.
A MEETING in celebration of the jubilee of this Society
was held at Burlington House on Tuesday, the 24th inst,
when a large assemblage of representatives of various
chemical societies, both home and foreign, attended. On
Wednesday, the 25bh inst., the members of the Society dined
at the Hotel Mdbropole, on the occasion of the Society’s
jubilee. The President (Dr. W. J. Russell) occupied the
chair, and there were present the Marquis of Salisbury, the
Attorney -General, Sir Lyon Play fair, M. P., the Prime Warden
of the Goldsmiths’ Company, Professor Prankland, Professor
Odling, Dr. Will (representing the Deutsche Chemische
Gesellschaft), Dr. J. H. Gladstone, M. A. (iautier, M. A.
Combes, M. de Clermont, M. A. Haller (representing the
Socidtd Chimique de Paris), Sir F. Abel, Sir fl. Eoacoe, M.P.,
Professor Victor Meyer, Dr. Hugo Muller, Dr. J. F. Holtz,
Professor T. M. Thompson, Dr, H. E. Armstrong, Profes-or
T. E. Thorpe, Sir Douglas Galton, the Presidents of the
Physical Society, the Pharmaceutical Society, the Institu¬
tion of Electrical Engineers, the Institute of Chemistry, the
Society of Chemical Industry, and some 200 other gentle¬
men. The President proposed a toast in honour of the
Jubilee, and the Marquis of Salisbury proposed “Pros¬
perity to the Chemical Society,” on behalf of which Sir
Lyon Playfair replied. The Attorney-General gave the
toast of “ Science and Industry,” which was responded to
by Sir H. Roscoe. Other toasts followed, including “ The
Delegates of Foreign Chemical Societies,” to which M.
Gautier and Dr. Will responded; “Our Foreign Members
and out Visitors,” to which Professor Victor Meyer and the
Prime Warden of the Goldsmiths’ Company replied; and
“The Presidents Past and Present.”
HEART SOUNDS AT A GREAT DISTANCE.
Dr. Guido Bell, who had previously reported in the
Mamorabilien a case in which, after coabusion of the thorax,
the heart sounds were plainly audible the whole length of the
room, and even further, now publishes a second case of a
similar kind. A large and heavy but healthy man had, in
the presence of the author, fallen backward from an open
vehicle bo the street, and in a state of unconsciousness was
carried the short distance to his house. He had fallen on
his right shoulder and had fractured several ribs, bub with¬
out injuring the pleura. His breath was short and
superficial; the pulse frequent and very small; the pupils
of moderate size, bub insensible to light; the eyes
open and expressionless; the skin cool and pale. When
the patient was placed in bed, the heart sounds were very
loud at the distance of a foot. This abnormal loudness
lasted half an hour. The patient recovered after a serious
attack of pleurisy, and both he and the patient previously
referred to are now strong and well. Both patients had
been under the influence of shock while these peculiar
symptoms lasted, and these are in Dr. Bell’s opinion merely
symptoms of shock. Assuming that in low vitality of the
vagus and sympathetic the ganglia of the heart may have
increased activity, he considers that we may look upon the
increased action of the heart as simply a symptom of shock.
The author considers his theory proven by the fact that each
nerve system, besides being under the control of the brain,
also has an independence of its own, with ganglia for
centres. The spinal cord, and still more the sympathetic,
certainly have this independence, and probably also every
other ganglion in a corresponding manner. When the in¬
fluence of the brain as nerve centre has ceased to be felt in
any organ—the heart for instance—this may still exercise
its independent activity, and especially so when its
antagonist has become inactive. Even the apparent con¬
tradiction of a small pulse with increased action of the
heart could be explained by assuming a certain inde¬
pendency of the ganglia. This independent action is
further increased by the narrowing of all bloodvessels
through paralysis and consequent increased resistance.
LIFE INSURANCE OMITTING THE INVESTMENT
ELEMENT.
Carrying into effect a suggestion contained recently
in our Insurance Supplement, the Directors of the
Caledonian Insurance Company liave formulated a scheme
of long term temporary life insurance, under which
they are able to give, in the form of immediate
insurance benefits, a return greatly in excess of that
which is secured by an ordinary insurance policy. The
contingent nature of risk undertaken by the office,
which will make no payment whatever in the case of a life
insured which survives the stipulated period, compensates
for the enhancement of the benefit in amount during the
period over which the contract extends. The result is
aptly described, in the language of the prospectus, os
securing to the policyholder “ during the time that he really
needs it an insurance of about double the amount which he
could obtain for the same premium under the cheapest
ordinary policies.” _
TREPHINING FOR SUBDURAL H/EMORRHAGE.
An interesting and valuable case is recorded by Drs.
Homans and Walton in the Boston Medical and Surgical
Journal. The patient was a man aged twenty-eight, who
was thrown from a horse, and struck his liead against some
stones. He was immediately sent to the hospital, where he
was found to be unconscious and to have a large heematoma
over the right side of the scalp at a point corresponding to
the middle of the suture between the right parietal and the
occipital bone. The riglit pupil was at first dilated, but in
a few minutes tlie pupils became equal, and consciousness
began to return. The pulse was slow and full, and there
was no bleeding from the nose or ears. The htematoma was
incised, but no fracture could be felt. Consciousness
returned to .all appearance perfectly, and there was
no paralysis. Two days later the patient, who had
been going on well, became delirious, with a high
temperature, and soon after sank into a state of semi¬
consciousness with aphasia. On the ninth day after the
injury he bad twitching of the right angle of the mouth;
during the next day or two he had numerous epileptiform
attacks, all apparently starting in the right side of the face,
but at times extending to the limbs and trunk; and finally,
before operation, the entire body was in a state of almost
continuous tonic rigidity. On trephining over a point
corresponding to the lower end of the fissure of Rolando
and incising the dura mater a large clot was found, and
after the opening had been enlarged it was turned out. At
one point a small htemorrhage was seen under the pia mater,
and this also was removed and the wound closed. Eveiy-
thing went on well, and a rapid improvement took place in
the aphasia, so that at the end of a month the patient
Diu . _
500 ThsLanobt,]
THE DKA.INAGE OF OVERSTRAND.
[Feb. 28,1891.
could talk without difficulty, although he still occasionally
used a wrong word. Except for an attack of headache and
fevenshness a month later—an attack associated with the
formation of an abscess over the left ear—the progress was
excellent, and the patient is now pursuing his calling as a
waiter. The diagnosis of hromorrhage from contrecoup
which was made in this case, and the localisation of the
lesion, were amply confirmed by the subsequent progress,
and the success of the measures taken to relieve the
condition has added one more to the already brilliant results
of cerebral surgery. __
THE LEPROSY COMMISSION.
The latest intelligence to hand respecting the labours of
the Leprosy Commission now engaged in India fs to the
effect that Dr. Rake and Surgeon-Major Thomson have
returned to Calcutta from Burmah, and, after conferring
with their colleagues, Dr, Buokmaster, Mr. Kantback, and
Surgeon-Major Barclay, they will probably next pursue
their inquiries in the North-west Provinces and thePunjaub.
The laboratory work is reserved for the hot season, and it
is not expected that the inquiry will be completed until the
end of the year. _
THE DRAINAGE OF OVERSTRAND
A GOOD deal of discussion has been going on concerning
the need of a scheme of drainage for Overstrand, which is
becoming a bathing resort on our eastern coast; aod in the
end it has been decided that the cesspool system is for the
present to be retained, on the understanding that “ the
cesspools shall be properly looked after.” What this means
it is difficult to say, for, unless the cesspools are watertight
and periodically emptied, it is perfectly obvious that their
contents must soak into the Surrounding soil—a condition of
things that is hardly calculated to attract those who seek
recreation and health. The decision seems to have been
come to because of some doubt as to whether the flow of the
tide would not bring back the sewage from the proposed
outfall to the spot where bathing is resorted to. It Is by
no means clear that this would have been so, but it ought
to be possible to devise a scheme wbicn should be free from
any snch risk. _
PATHOLOGY OF GLAUCOMA.
In an exhaustive review of recent contributions to the
subject of glaucoma {abstract in Fortschr. d. Med , No. 4)
Knies formulates as essential to the affection changes at
the corneo-scleral margin and its vicinity and those in the
optic nerve. The earliest changes in the corneo scleral
margin are those arising around the canal of Suhlemin,
which give rise to no clinical signs, not even an increase in
tension. At this stage there is a considerable accumulation
of round cells in the corneo-scleral region. Subsequently
there occur more obvious inflammatory lesions with
adhesion of iris to cornea aod obliteration of Fontana’s
space. The optic nerve changes likewise appear early, com¬
mencing as bypericmia and mdema of the papilla, often
associated with cellular infiltration, this neuriDis invariably
preceding excavation; then follows optic atrophy. (Jlau-
coma thus characterised may begin very acutely or have a
much more chronic course from the commencement, with
round cell infiltration of the corneo • scleral margin
and optic neuritis, increase in globe tension and ex¬
cavation of the nerve following later. This being
so, the condition might perhaps be better termed
“iridocyclitis anterior adhesiva.” It is nob easy to diller-
entiate from it those cases in which there is excava¬
tion, but without increased tension or the above pathological
lesions, especially the neuritis; for that class von Graefe’s
term, “ amaurosis with excavation of the optic nerve,” is
still the best. Iridectomy is indicated in tnle glaucoma;
it is useless in excavation without increase of tension.
Knies concludes by attributing the lesions to the presence
of irritant substances formed within the eye, and not circu¬
lating in the general blood-stream ; and that it is owing to
their passage outwards that inflainmatory changes are
excited in optic nerves and around the sinus, which form
the.chief outlets from the organ. The obstruction to the
outflow of lymph thereby occasioned produces the phenomena
of glaucoma. _
SENTRY DUTY.
We are glad to have Mr. Stanhope’s assurances, in reply
to Viscount Wolmet, that the matter of sentry duty
at St. James’s, Buckingham, and Kensington Palaces, the
War Office, and Home and Foreign Offices, had recently been
under consideration, and that material alterations had been
effected in the arrangements for that duty. The number
of sentries at these various places in the metropolis
ba£ not unfroquently been remarked upon, and the
necessity for such a provision is not very apparent to
the non-military mind. No doubt sentry duty is an
integral part of the soldier’s training; it is indispensable
in war, and some practice of it in peace is therefore
requisite. But as the exposure and lose of rest incidental
to that duty are frequent sources of ill-health, and it is
naturally irksome and unpopular, it is right that its amount
should be reduced within reasonable limits. Apart from
sanitary considerations, the waste of physical energy and
power and loss of sleep involved by the posting of a number
of sentries, as a matter of form or routine, within short
distances of one another, to guard unoccupied places, must
be very unpopular with soldiers, who are constituted like
other men in their dislike to performing labour that must
seem to them purposeless._
LECTURES AT THE COLLEGE OF SURGEONS
DURING MARCH.
The following lectures will be given during the month of
March in the lecture theatre of the Royal College of Surgeons
at 6 pm. on the dates mentioned below:—Professor
Benjamin Thompson Lowne will give three lectures on the
Anatomy and Development of Insects in Relation to Recent'
Views on the Origin of Vertebrates, on Monday, Wednesday,
and Friday, March 2ad, 4th, and 6bh. Professor Charles
Stewart will give six lectures on Secondary Sexual
Characters, and Some New Additions to the Museum, on
Mondays, Wednesdays, and Fridays, March 9oh, llth,
13th, 16th, 18th, and 20bh._
CYSTS OF THE PANCREAS.
In the DetUiche M'edictnuche WochenschHft, 1890, No. 46,
Dr. Karewski publishes an exhaustive paper on the Diagnosis
and Treatment of Cysts of the Pancreas. Ho describes two
cases of this affection, in each of which an early diagnosis
was made and operative treatment successfully carried out.
In both cases some injury was given as the exciting cause,
the cysts developing four weeks after the accident. The
subjective symptoms accompanying the formation of the
cysts were continuous feeling of pressure in the stomach
and frequent vomiting after meals. The objective signs
were not so dillicult to make out as usual, and the
diagnosis could be made fairly easily. In each case
there was a slightly movable tumour corresponding
precisely with the position of the pancreas, and which
could be distinguished by a tympanitic percussion
note from the spleen and liver. In the first case Dr.
Karewski attempted to substantiate the diagnosis by means
of an exploratory puncture, This was not altogether satis¬
factory, but was productive of a useful warning, as a later
Dig—ed t OOglC
Thd Lancet,]
THE FACTORY BILLS.
[Feb. 28, 1891. 501
operation showed that there were extensive adhesions
between the wall of the cyst and the stomach, so that the
needle had penetrated the stomach before reaching the
tumour. Dr. Karewski therefore advises that an exploratory
incision should be made rather than merely a puncture,
and an additional reason for this is that the amount of
fluid contained in the cyst is too small to offer any
very great aid to diagnosis by its examination. The
supposition of Kuster.'that the contents of a pancreatic
cyst are always haemorrhagic and consist of small round
granules, is not correct, as in many cases the fluid from
the cyst has been perfectly clear, as in transudations.
Dr. Karewski maintains that an early diagnosis of these
pancreatic cysts is all the more important, as the prognosis
is then much more favourable than when they have existed
for some time before the operation has been performed.
Up to the present time three principal methods of operation
have been adopted. The first is total extirpation of the
organ. The author has collected five cases of this kind, of
which three proved fatal. In one of the two successful
cases the cyst was pedunculated, and in the other the wall
of the cyst was extremely thick, so that it was possible to
shell out its contents. The other two methods consist in
single or double puncture of the tumour with subsequent
drainage. The double puncture is only possible when the
wall of the cyst is thick, and the tumour itself large. As
a rule the tension is so great that two punctures could
hardly be made. _
THE FACTORY BILLS.
Thk ponderous and voluminous report of the Lords’
Committee on Sweating is at last bearing fruit. For a
while not a few persons despaired of seeing any practical
result arise from so many disclosures and so much disserta¬
tion. The evils of the sweating system, which The Lancet
was the first to bring to public notice, were admitted on all
sides, but doubts were expressed as to the possibility of
dealing with such questions by legislative enactment.
We sketched out what improvements to the existing
laws would beneficently affect the condition of the
workers who toil in sweating dens. Parliament, how¬
ever, adjourned, and it seemed as if nothing was to be
done. But our hopes were not abandoned, they were only
deferred, and now at last we are rewarded with a
deluge of Bills on the ,quest!on w'hich, in a great measure,
we have made our own. The principal difficulty to-day is
to sort and to select the best suggestions from these many
projects. In the House of Lords we have the Sanitation of
Factories Bill, introduced by Lord Thring, who was an
active member of the Sweating Committee; and the Fac¬
tories and Workshops Bill, presented by Lord Dunraven,
who was the chairman of that Committee. In the
House of Commons Sir Henry James and Mr. Sydney
Buxton have each Bills dealing with the same question; while
Mr. Matthews, on behalf of the Government, has introduced
a fifth Bill, on which should be grafted, it is suggested, the
best clauses of all the other Bills. It will, however, we
fear, be necessary not merely to add new clauses to the
.Government Bill, but also to extract some of the pro¬
posals it contains. For instance, on all sides there is a
consensus of opinion that it is the application rather
than the law itself which is most at fault. If inspectors
were more numerous and more active, if the authorities
entrusted with the duty of applying the law were not
themselves interested in evading its provisions, the
grievances which have been so loudly denounced would
not have arisen — at least in their present aggra¬
vated fiinn. The greatest of all necessities is the
creation of an army of inspectors who will he per¬
fectly free from local influences and local corruption.
But the Government Bill proposes practically to do away
with certifying factory surgeons, who number in all about
twelve hundred. An increase of inspectorships in other
directions will not compensate this very severe loss.
We trust, however, this clause (No. 19) in the Bill will
he excised. In this respect, as on all other points, advan¬
tage should he takeu of the present favourable disposition
of Parliament to arrange matters in as broad and liberal
a spirit as possible._
QUEEN’S COLLEGE, BELFAST.
As a means of reunidng and strengthening the corporate
feeling of old members of Queen’s College, Belfast, it has
been decided, if possible, to arrange a dinner, to be held at
Belfast. A circular has been addressed to many of the
graduates of this College, many of whom now hold important
positions in every department of public life. Those who
are resident within a convenient distance are requested to
sign the slip accompanjiing the circular and return it as
early as possible to the hon. secretaries : John Park, M. A.,
D.Lit., Queen’s College; James Alex. Lindsay, M.A.,
M.D., 37, Victoria-pi ace, Belfast; RobertT. Martin, B.A.,
4, Holbom-terrace, Belfast.
PROTRUSION OF THE UPPER MAXILLA AND
TEETH.
Dr. Eugene Talbot of Chicago, in a paper read at the
International Medical Congress at Berlin, subdivided this
particular form of irregularity into six classes. 1. Anterior
protrusions due to constitutional causes. In these cases,
which are generally hereditary, the upper maxilla is too
large for the lower, and stands out beyond it; the incisors,
however, are not inclined forwards, hut are vertical or
turned inwards; the lower incisors bite considerably inside
the upper, whilst the bite of the molars is normal.
2. Anterior protrusion of the alveolar process and teeth
from excessive deposition of osteoblasts. The facial angle
' in these cases is less than normal, as the alveolar process
and teeth protrude. The lower maxilla may he normal or
the chin may recede. The partial eruption of the first
molars makes the bite too close, thus causing the
lower incisors to strike against the palatal surface of
the uppei’; often they glide hack and find a vesting
place in the alveolar process. The irritation which
results from the pressure against the mucous membrane
produces excessive deposit of bone-cells in the inner
plate of the alveolar process, which causes the superior
central incisors to be carried forward. Finally, the cutting
edges of the teeth appear below the upper lip, and the lower
lip is caught beneath, increasing the tendency to stand out.
3. Anterior protrusion found in the V-shaped arch. When,
from a want of harmony between the size of the teeth and
that of the upper maxilla, their combined diameters form an
arch larger than that of the maxilla, the teeth are neces¬
sarily crowded, and when the cuspid erupts it pushes the
anterior column forward. This leads to a flexion in the
alveolar process at its weakest point, which is at or near
the mesial line. The local causes producing the same con¬
dition are the forward movement of the first molars of the
upper jaw, due to the premature extraction of the deciduous
teeth or the arrested growth of theramira of the lowermaxilla.
4. Anterior protrusion due to thumb-sucking. The location
of this deformity is not uniform, as it depends upon the hand
used, and the habitual position of the finger or thumb.
The teeth usually flare out fan-shaped, or one or more teeth
may be pressed sideways. This form of irregularity differs
from the V-shaped arch in that the central incisors in a
thumb-sucking deformity diverge, whereas in the V-shaped
arch they converge. 5. Anterior protrusion due to extrao-
^ Digiiized' tOO^IC
502 The Lancet,]
MEDICAL MEN AND LITERATURE.
[Feb 28, 1891.
tion of posterior teeth. When all the teeth of the upper
and lower maxUlse have been lost for some time, and not
replaced by artificial substitutes, there occurs in many cases
a straggling arrangement and Haring out of the upper teeth,
while some or all the bicuspids migrate backward. This is
due to several causes. More work in mastication is thrown
upon the anterior teeth, which have to perform the double
function of cutting and grinding. This introduces a new
form of antero-posterior motion exerted by the cutting edges
of the lower incisors against the basillar ridge of the upper,
which forces them forward. Moreover, the two wedge¬
like cusps of the bicuspids ate forced between the crowns
of their antagonists, which cannot now resist this action
when not fortified by adjoining molars, and the resulting
shortening of the bite forces out the incisors more and
more. 6. Anterior protrusion from Rigg’s disease. In
Rigg’s disease the teeth are forced out of their sockets very
gradually, .so that the change in the contour of the
mouth takes place imperceptibly. The front teeth become
prominent, the angle at which they strike each other being
more acute than normal. The distinctive feature of this
form of protrusion is the diseased state of the gums.
THE AMBULANCE IN THE MERCANTILE MARINE,
The Mercantile Marine Service Association has decided
upon forming a class for instruction of ships’ officers in the
elementary treatment of urgent illness and injury. There
would seem to be in some quarters no very clear idea of what
is likely in the circumstances contemplated by its promoters
to be included in the course of study provided for the class,
and this is perhaps hardly to be wondered at when we reflect
on the utter isolation of some ships at sea and the perils to
which they are exposed. It should be clearly understood
and taught, however, that first aid in such cases, though
necessarily a term of wider meaning than it usually is on
land, implies essentially such a degree of assistance as can
safely be rendered by one intelligent man to another on a
basis of quite elementary medical knowledge. Continuous
and systematic treatment could neither be learnt nor
applied without risk under this system. Some knowledge
of the home remedies contained in the medicine chest,
some ready surgery, as, for example, the posturing and
provisional setting of a broken limb, the arrest of
bleeding from a divided vessel, the resuscitation of persons
apparently drowned, the use of the catheter, the relief of
bums and scalds, these and matters of like simplicity,
details of cleanliness, ventilation, wholesome cookery, and
ordinary hygienic rules in general, come within the scope of
a legitimate course. Any attempt to go further and to
teach with greater fulness the methods of medical proce¬
dure would only place in hands unskilled in the work, and
otherwise fully engaged, the duties and responsibilities
without the powers of practical treatment. In conclusion,
let us express a hope that such a measure of ambulance
training may be provided for seamen as will fit them to co¬
operate with the useful efforts f'f their officers
MEDICAL MEN AND LITERATURE.
Literary production in other than professional fields has
in all ages divided with more purely technical studies the
power of attracting the mental energies of medical men.
Such names as those of Roger Bacon, Sir Thomas Browne,
Locke, Gartht^and others have indeed so shone in the
fame of letters that in their case an original connexion
with medicine has almost been forgotten. In these days
the zeal for learning follows a more exclusively practical
and scientific tendency. As if in harmony with the laws of
the circulation, the cravings of the medical mind commonly
find satisfaction within the round of its most familiar occupa¬
tions. There are, however, not a few exceptions to this rule.
We have not yet lost the medical poet or philosopher, nor
have the efforts of romance in prose been unassisted by
practitioners of our art. To employ thus the precarious
leisure of routine in practice cannot but refresh the mind of
those most nearly interested, while recent experience might
also be shown to prove that efforts thus applied have not
been fruitless in refreshing the intellect of the reading
community. Some faults might naturally be expected in
the productions of a medical writer. Among the chief
obstacles to his success may be numbered a too didactic
style, a philosophic heaviness, above all, a tendency to excess
in realism, particularly if engaged upon that now all-
popular and most profitable form of composition, the novel.
An error of discretion, indeed, may sometimes lead to
serious embarrassment. Take, for example, the case of a
medical novelist in France, who was lately called upon to
answer the allegations of an indignant husband that his
wife’s morbid state was exactly reproduced in the heroine
described by her doctor, who was therefore liable for a
breach of professional secrecy. The case might well have
been one in which the cap of the proverb was found to fit
a head for which it was not made, but it may serve, never¬
theless, to accentuate the dislike to an exact description of
morbid states and symptoms in which we must admit a
share with many general readers. A high professional
standard alike in literary taste and in true medical pro¬
priety is, we take it, best maintained by those who can
discreetly separate what are in them related faculties, and
be medical in their medicine but scholarly in letters.
THE BRITISH INSTITUTE OF PREVENTIVE
MEDICINE.
The initial steps in the foundation of the British Institute
of Preventive Medicine at Cambridge have advanced so far
as the selection of a site near to the museum and medical
laboratories, where the new buildings are to be erected.
The Council of the Institute contains representatives of all
the British Universities and several scientific and medical
corporations. Sir Joseph Lister is the chairman of the
executive committee, and in Cambridge the local com-
luitteeconsists of Sir George Paget, Sir George M. Humphry,
Professor Liveing, the Master of Downing, Dr. Gaskell,
Dr. Lea, Dr. D. Macalister, Professor Roy, and Messrs.
J. W. Clark, Shipley, Shore, Adami, and Hankin.
THE MICROBES OF PNEUMONIA.
In a bacteriological study of acute pneumonia,
Dr. Guido Banti (abstract in Cmtralhl. f. Bahteriol., ix., 5)
found that the diplococcus lanceolatus was present in the
lungs and pleural exudation of eveiy one of the forty-seven
cases of fibrinous pneumonia examined. Once only was it
associated with the staphylococcus pyogenes aureus and
albus, and in four cases other non-pathogenic microbes were
present also. But in no case did be meet with Friedliinder’s
bacillus or the streptococcus pyogenes. Dr. Banti has,
however, rendered the subject more complicated by his
discovery that the diplococcus pneumonia' occurs in four
varieties (of which one is the well-known Fraenkel-
Weichselbaum form), differing in their pathogenic properties
and degree of virulence when inoculated on animals.
Without entering into details, it must suffice to say that he
attributes the varying severity of cases of this disease to
the special variety of microbe witli which it is associated,
and he points out that during the years 1886, 1887, and
1890, when the type of pneumonia was relatively mild,
only the Fraenkel-Weichselbaum form of diplococcus
occurred; but that in 1888 and 1889 the cases were far more
severe, and the other three varieties of this micro-organism
were far more constantly met with. His investigations
also comprise eight cases of secondary broncho-pneumonia,
oogic
Dig . /ed b.
Thb Lancet,]
THE RECONSTITUTION OF THE UNIVERSITY OF LONDON. [Feb. 28, 1891. 503
which yielded the diplococcus lanceolatus alone or asso¬
ciated with staphylococcus pyogenes aureus, or the latter
alone or in association with the streptococcus pyogenes.
In exceptional cases other microbes, such as the bacillus
pneumoniae of Friedliinder, occurred. The main point of
his research seems to be the well-nigh invariable presence
of the diplococcus lanceolatus in lobar pneumonia, not only
in the exudation in lung and pleura, but often, and pro¬
bably always, also in the blood ) and that variations in the
intensity of the disease depend on differences in the
virulence of the microbe ; and lastly, that complications are
as a rule excited by the same agency.
THE RECONSTITUTION OF THE UNIVERSITY
OF LONDON.
The objections raised to the new scheme by the pro¬
fessorial stafifs of the London teaching colleges have been
followed by other objections from the provincial colleges.
The professors of the Birmingham colleges have met and
adopted resolutions demanding an increase of four provincial
representatives on the Senate and of four on the standing
committee of Medicine, and they add that without these
additions they decline to enter on any further considera¬
tion of the scheme. The other provincial colleges will
probably soon follow the lead of Birmingham in the demand
for increased provincial representation, and this, if granted,
will necessitate another recasting of the Senate and of the
standing committees. We may direct attention to the
remarks of Mr. Erichsen, addressed to the members of
University College at their annual meeting, and which will
be found reported in another page. At a meeting of
graduates of the University of London, held on Wednes¬
day, the I8th inst., it was decided to take steps to
oppose the latest revised scheme. A provisional com¬
mittee, consisting of Dr. J. B Napier, M.D. (chair¬
man), Dr. W. E. Grigsby, LL.D., L.C.C., Dr. Baines,
M.D., Dr. W. J. Collins, M.D., M.S., B.Sc., Dr. J. W.
Carr, M.D., B.S., Mr. H. Austen, M.B., B.S., was ap¬
pointed, and the following, to whom communications may
be addressed, are the hon. secretaries: Mr. J. G. Joseph,
LL.B., B. A., 3,Harcourt-buildings, Temple, E.C.; Mr. H. J.
Waring, M.B., B.Sc., St. Bartholomew’s Hospital, E.C.
TUBERCULOSIS IN CHILDREN.
An analysis of the relative frequency of tubercular (and
scrofulous) lesions in children has been made by Miiller,’
based on 500 post-mortem examinations made at the Munich
Pathological Institute from 1881 to 1888. Of this number,
in 150 tuberculosis was the cause of death; in 59 it accom¬
panied other disease. The majority (76j of the deaths due
to tubercle occurred at less than five years of age. The latency
and limitation of the process to certain parts—viz., glands
or joints—are pointed out as characteristic of this period of
life. The lungs wore involved in 173 cases, but not so much
with regard to the apical as the middle and lower parts,
those nearest to the bronchial glands, which were generally
caseous. The condition in the lung was one of caseous
pneumonia, and it is inferred that the bacilli may pass
through the lung without settling there, but, arrived at the
glands, remain in them. Of other lymphatic glands, the
cervical were most often diseased, and the inspection of these
after death is recommended. Miiller regards the tendency
of such glands to oaseate to be a leading feature of tuber¬
culosis in children. Tubercular meningitis occurred in
forty cases; and the general statistical result of implication
of other organs is given as follows: Lymphatic glands, 170j
pleura. 111; spleen, 10; kidney, 68; intestine,58 ; liver, 61;
bones, 36 ; peritoneum, 27 ; brain, 12 ; heart, 8 ; stomach,
6; pericardium, larynx, each 4; tonsils and submaxillary
gland, each 3; spinal cord, adrenals, each 2; (esophagus,
J AbsUuut in Oontralbl. f. liakteriol., No. 5, iSOl.
parotid, thymus, Fallopian tube and ovary, epididymis and
testicle, each one. Dealing with a part of the same subject
in a paper read before the New York Academy of Medicine
on Jan. 20th, Dr. Northrup^ analysed 125 post-mortems in
cases of general tuberculosis recorded at the New York
Foundling Hospital. His investigation also went to show
the comparative frequency of primary tubercular infection
of bronchial glands. In thirty-four cases the lesions were
so disseminated as to forbid any positive determination
of the primary focus. In twenty where these glands
were infected, there were cheesy masses in the lungs
and general tuberculosis ; in forty-two such caseation
was limited to the bronchial glands, but there was
general tuberculosis; in thirteen, caseous bronchial glands,
miliary tubercle in lungs; in thirteen the bronchial glands
alone were tnberculous; in three the primary infection
was obviously in the mesenteric glands. Inoculation ex¬
periments were related to prove the latency of the tuber¬
cular virus in the bronchial glands of apparently healthy
subjects. Arnold’s experiments, proving the path of trans¬
mission of inhaled dust from the lungs to the glands, were
claimed in support of the probable course taken by the
bacilli. Dr. Roosevelt considered primary infection of the
bronchial glands to be equally frequent in the adult, and
suggested that the lungs were attacked subsequently by
material from the glands entering the circulation through
the medium of the thoracic duct.
LIFE INSURANCE AND PROFESSIONAL SECRECY.
The French Court of Appeal has just delivered judg¬
ment in a case in which a widow had brought an action
against a life assurance company for the amount of her
husband’s policy, which the company declined to pay because
the medical man who had attended him refused to fill up the
usual form with the name of the disease and its duration,
declaring himself bound by the law of professional secrecy
not to reveal the nature of his patient’s disease. The court
has decided against the company, holding that the medical
man himself is the sole judge as to whether facts revealed
to him by a patient were confided to him under the seal of
professional secrecy._
THE PREVENTION OF STREET ACCIDENTS
Whether it be due to reckless driving, to the hurry of
pedestrians, the mere excess of traffic, or the carelessness of
parents who allow their younger children the run of crowded
streets, the number of accidents in the London thorough¬
fares is alarmingly great. It has recently been stated that
during the year 1889 5000 persons were run over, in
the majority of cases by covered vans or carts. The
obvious inference need hardly be insisted on. A driver
seated aloft, under the shadow of a canvas awning, is with
regardito vision clearly under conditions not unlike those of
his own horses. He is practically between blinkers, the sides
of his van, and his observation of wayfarers is correspond¬
ingly limited. Some alteration for the better is certainly
not impossible. As a step in the right direction we would
suggest the adoption of a driving-seat projected much more
forward than is now usual, combined with the use of a
covering, where this is needful, more cut away at the sides.
Exact lateral observation could not thus, indeed, be assured,
for the simple reason that a driver’s horses are his chief
concern; but it would be rendered much less difficult, and
the danger of accident would be decidedly lessened. For
other safeguards we must look to the better regulation of
traffic, and to greater personal care on the part of foot
passengers. It is further most important that police
authorities should oblige parents whenever possible to pro¬
vide for the proper control of the numerous children who
“ Boston Mo<J. and Surg. Journ., No- 1801. -
Digi'zed i:. rOOQlC
504 The Lancet,]
PRODUCTION OF EXOPHTHALMOS.
[Feb. 28, 1891.
now throng some thoroughfares literally among the horses’
feet. The more we contemplate the matter the more are we
surprised that children so recklessly exposed aie compeira-
tively so seldom injured._
PRODUCTION OF EXOPHTHALMOS.
At a recent meeting of the Acad^mie des Sciences,
Dr. Stilling made a communication with reference to the pro¬
duction experimentally of exophthalmos. He carried out
hk observations on rabbits, and his method was to tie both
external jugulars, and to cut through the sympathetic on
one side. The result was the production of cedema of the
face, of the nasal mucous membrane, a how of tears from
both eyes, exophthalmos on both sides, prominenceof the lids,
and slight upward deviation of the eyes. All thesymptoms
disappeared on the day after the operation, with the exception
of the exophthalmos, which lasted from six to ten days.
It was found that simple ligature of the veins produced
slighter exophthalmos than was produced by this procedure
together with the section of the sympathetic. No alteration
was found in the orbital tissue or glands; but in the ocular
muscles, in a case in which exophthalmos had been present
ten days, there were found changes consisting chiefly in a
loss of striation and a granular change in the fibres. This
change, as well as the exophthalmos. Dr. Stilling considers to
be due to engorgement of the veins of the orbit; but he is
unable to ofier a satisfactory explanation of the increase of
the exophthalmos through section of the sympathetic on
one side.
A CASE OF MELANCHOLIA.
Dr. Frank Churchill relates a case in the New York
Medical Record which is of some interest. The patient was
a young married woman, who, after weaning her child,
began to suffer from sleeplessness and gradually increasing
loss of health and strength. In a few months she had become
absent-minded, moody, and despondent. Her condition
was rendered more serious at this juncture by receiving
a telegram announcing the death of a friend by suicide.
When seen by Dr. Churchill, she was manifestly a victim of
melancholia. She had delusions of sight and liearing, and
she “felt something urging her to do this or that, like
killing her baby.” On physical examination, the only
lesion found was a bilateral laceration of the cervix uteri.
General treatment by good feeding and hypnotics was tried
first, and in seven weeks her condition physically was much
improved. Her mental condition, however, was unaltered,
and an operation on the cervix was then performed. On
the third day after the operation it was evident that a
mental change was taking place, and at the end of a week
she was quite sane. Her recovery was uninterrupted. The
rapid improvement after the operation is certainly
significant, but it is not easy to be quite sure that any
profound mental impression, such as that produced by any
operation, migiit not have produced the same effect.
INTRODUCTION OF OXYGEN INTO THE
STOMACH.
Du. Landi mentions, in the Revinta Gcnerale Italkina di
Clinica Medica, some observations on the effect of oxygen
on the interior of the stomach, which he has recently con¬
ducted under the advice of Professor Grocco. The method
adopted was to introduce an oesophageal tube into the
stomach, which was then partially filled with water;
oxygen was passed into the tube and made to bubble up
through the water, and the patient was desired to eructate
the gas, which was accomplished without difficulty, either
by making gentle pressure on the abdomen or without any
external assistance at all. The stomach was again filled
with oxygen once or twice, so that the interior should be
acted upon by it throughout. Dr. Landi found, as the
result of his observations on patients, that this treatment
has the effect of improving gastric digestion, and that it
could be employed as a therapeutic measure in cases of
atonic dyspepsia. Amongst the results of the observations
on the gastric juice, Dr. Landi came to the conclusion that
the free hydrochloric acid in it has less effect on digestion
than has generally been ascribed to it.
CONGRATULATORY DINNER TO SIR GEORGE
MURRAY HUMPHRY, M.D,, F.R.S.
A congratulatory dinner was given by the Cambridge
Medical Graduates’Club to Sir George Murray Humphry on
Tuesday evening, Feb. 24th. A large and representative
gathering assembled to do honour to the guest of the even-
ing. In proposing his health, Sir George Paget said the
members of the club and their guests had met to offer their
congratulations to Sir George Humphry on account of the
honour of knighthood which had been bestowed upon him
by Her Majesty the Queen. Sir G. M. Humphry responded
bo the toast at some length, and gave an amusing account of
the difficulties under which the study of anatomy had been
prosecuted at Cambridge. At the conclusion of his speech the
company rose and gave the guest of the evening three times
three with musical honours. Dr. Dickinson, the Senior Phy¬
sician to St. George’s Hospital, proposed the toast of “The
Guests,” coupling with it the names of Mr. Bryant, the
President of the Royal College of Surgeons, and Dr. Austin
Leigh, the Provost of King’s College, Cambridge, as the
heads of the two Colleges of which Sir George Humphry is
a Fellow. Dr. Hare, Consulting Physician to University
College Hospital, proposed the health of the Chairman,
which was drunk with enthusiasm. Sir George Paget re¬
turned thanks, and also proposed the health of the hon.
secretaries of the club, to whose exertions he said they were
indebted for a very successful evening.
Her Majesty the Queen has been graciously pleased to
command that in future the British Nurses’ Association
shall bear the style and title of “ Royal.” The Association
has been in existence three years, and its first and primary
object has been the publication of a register of traine<l
nurses. The first annual register is now in course of issue,
and in time will undoubtedly prove of much value to medical
men and the public. The Association has already been
joined by a large number of well-known medical men, and
by about 3000 trained nurses, working in every part of the
Queen’s dominions. It carries out various important
benevolent schemes for the good of its members. The offices
are in Oxford Circus Avenue, W.
It is announced that Dr. von Gossler, Minister of Public
Worship, has issued an order containing instructions as to
the regulabioua to be observed in connexion with the sale
by apothecaries of “Tuberculinum Kochii,” This order
requires all apothecaries engaged in the sale of the fluid to
return to Dr. Libbertz at Berlin whatever quantities of the
remedy still remain unsold within six months of the time
of purchase, when a fresh supply will be given in exchange
without further cost. The price of the remedy has been
fixed at six marks per cubic centimetre, or five cubic centi¬
metres for 25 marks. _
This year the Council of the Royal Medical and
Cliirurgical Society have fixed the hour of five o’clock for
the annual meeting- We understand that the address of
the President (Mr. Timothy Holmes) will be somewhat of a
departure from the old lines, and that the meeting will, to
a great extent, be spared the details of the annual obituary,
which has for many years furnished the material for the
presidential address. Several important changes in the
by-laws have been proposed, and we understand that more
are in contemplation, _
Digitized by iOOQIC
Tub Lancet,]
"REVISED SCHEME” OF THE UNIVERSITY OF LONDON.
[Feb. 28, 1891. 505
Rv permission of the Senate, a lecture on certain points
in the Physiology of Diabetes will be given in the theatre
of the University of London on Tuesday, March 4th, at
7) o’clock, by Dr. A. E. Wright, late "Grocers’ Student”
in Sanitary Science._
Mr. Victor Horsley asks us to allow him to state that
<be is not and never has been a candidate for the Chair of
Anatomy now vacant at the Royal Academy.
«EEVISED SCHEME” OF THE UNIVERSITY
OF LONDON: ADDRESS BY MR. ERICHSEN.
At the annual general meeting of the members of
University College, on Wednesday, Feb. 25bh, Mr. Erichsen,
ithe President of the College, in moving the adoption of the
report, dealt inUr alia with the subject of the new "revised
■echeme” for the reconstitution of the London University in
Qts relation to the medical profession. In directing attention
to the question he said: At the last annual meeting we were
iStill in negotiation with the University of London with
regard to its reconstitution, and in the month of June or
July these negotiations appeared to have been brought to a
tfairly satisfactory termination. Wp had agreed upon the
principal points in connexion with that reconstitution,
leaving certain questions of detail—although some of these
•questions of detail were of very high importance—still un¬
settled ; and there was a general consensus of opinion between
the delegates of the two Colleges and the University that
■some of these points might perhaps be left for settlement by
the Lord President of the Council. Since that period a
complete change has come over the scene. The kaleidoscope
of the University of London has been again shaken, and a
mew and most startling hgure has mide its appearance.
Since the commencement of this session a scheme called
the “revised scheme”- of the University has been pro-
(pounded. That "revised scheme” differs most essentially
from any of its predecessors on two particular points.
9a the lirst place, it provides for admission into the
(reconstituted University of provincial colleges to be
•constituent colleges of that University, a provision
which necessarily altera the face of things entirely.
That reconstituted University would no longer be a
University, as originally contemplated, in and for London
with an open side, but one quite as much for the whole of
England as for London, and having constituent colleges
Qcactered all over the country. And, further, it is a provision
which is in direct contravention of the recommendation in
the report of the Royal Commission upon this very point.
I will not say more upon this particular subject, because it
as a matter that is perhaps a little outside our province, and
we must look upon it as unfait accovipli which certainly now
-cannot be undone. But there is another point to which I wish
■to direct your attention. It is also a novel one in the
'"revised scheme,” and which touches the medical faculty of
this College, medical schools, and the profession in London
.generally very closely. It is the provision in the new
scheme by which the University of London has associated
itself with the two Royal Colleges of Physicians and of
■■Sargeons. Now, most of you are aware that for some years
£ a8t there has been a general demand in the profession in
ondon for the establishment of a medical degree in the
metropolis, readily accessible to students at a moderate
-cost, and on not too high a level—a degree, in fact, that
would be on tlie same level as that of the best Scotch
funiversities like that of Edinburgli, and that demand
was very much and very closely pressed, up to three
years ago. The two Royal Colleges proposed a scheme in
virtue of which their licentiates and members could under
•certain terms obtain this degree. That Hchcme was sub¬
mitted to and condemned by the Royal Commission, and
since then the matter has dropped. Rat those who were
anxious for the institution of an M.D. degree upon the
terms I have mentioned necessarily turned towards the
reconstitution of the University of London or the foundation
of a new "Albert” University in Loudon in the hope
that one or other of these bodies, whichever might come to
the fore, would be enabled to grant the degree that was
desired. Still the University of London has sent in its
"revised scheme” which is generally understood to be its
ultimatum. And now what does that scheme propose
in reference to the medical degree ? The demand has been
for a doctor’s degree—an M.D. degree—equal to that which
is given by the University of Edinburgh. Instead of that
the reconstituted University leaves the old M.D. degree of
the London University exactly where it was, as difficult of
access as it ever 'was before, hedged in by the same
difficulties of matriculation and preliminary scientific
examinations — such obstacles to its attainment by
the average student in former days ; and now so
great are these obstacles, and so difficult of attain¬
ment is this degree, that in all probability less than
5 per cent, of the medical students of London are able to
tatce it. The rest must go elsewhere in search of a doctor’s
degree. All this is left exactly where it stood—and perhaps
very properly left, for I should have been sorry to see a
degree of such high standing as this, to which so many
emineub men in the profession owe their doctorate, in any
way lowered. I think it is of great importance that
such a degree should continue intact and be obtained only
after a long and serious course of study. But the demand
has been for an M.D. degree of a different kind. What
has the University of London done? The profession asks
for bread, and the University of London gives it a stone,
and that stone is the M.B. degree. The M.B, degree is a
perfectly valueless thing. It is neither a man nor a boy,
but a sorb of hobbledehoy degree. Nobody uses it, it does
not confer the title "doctor,” and it is rarely pub on any brass
plate. It is a stepping-stone to the other degree, but as a
finality—as a final degree—it is comparatively worthless to
the profession, and that is the kind of degree which is now
proposed to be given by an examination " in com¬
bination ” (that is the 'word) with the two Royal Colleges.
What "in combination” means it is difficult to say, except
that the examinations would in all probability be con¬
ducted chiefly by the two Royal Colleges with some kind of
assessors appointed by the University of London. But if
we look into the constitution of the body which will finally
determine the kind of examination that is to lead to this
degree, I think it is impossible to be altogether satisfied.
That body is called the standing committee of the
Senate. It is composed of nineteen persons—viz , the
Presidents of the two Royal Colleges, together with a Fellow
from each of them; five members of the Faculty of
Medicine of the University, and one provincial Fellow.
Added to these ten there are to be nine members of
the Senate of the University of London. I think
it would be difficult to find a body more unworkable
or more difficult to bring together or to manage. The two
Colleges could easily send their delegates, so could the
Senate. The provincial Fellow would always have to come
from a distance. But where are the five faculty fellows
to come from, .and how are they to be elected ? Under
the new scheme they are to be the representatives of
the constituent Medical Colleges—twelve in all—in¬
cluding University and King’s Colleges and the nine
schools, which are generally looked upon as registered,
and finally, the London School of Medicine for Women.
Now that is the prdnt to which I wish particularly to direct
the attention of the members of the medical faculty in this
College—the admission of the London Medical School for
Women into the medical faculty of the University.
Personally, I have not the slightest objection to women
entering the medical profession, or to their studying law
or divinity, riding to hounds, shooting grouse, or throwing a
fly over aaaltnon. Theymaydoanythiogtiiev like, according
as their instincts or their abilities direcD. But this is intro¬
ducing a new element into the constitu Hon of the examining
bodies and the governing bodies of the University of London,
because five faculty members of this standing committee
will be elected by the faculties of the constituent colleges,
of which the London School for Women would constitute
apart. The faculties of the constituent colleges, accord¬
ing to the revised scheme, are composed of teachers of these
constituent colleges, and they are all put upon a line; there
is no distinction made, so far as appears on the scheme,
between the best and most important schools in the metro-
nolis, such as our own College, St. Bartholomew’s or Guy’s
Hospital, and the smaller schools. I cannot conceiveanything
that is more likely to lead to disunion, disagreement, and
trouble of all kinds between the medical schools in London
than for the twelve schools, including the London School
Coogle
506 Thb Lancet,] DEBATE ON KOCH’S REMEDY AT THE BERLIN MEDICAL SOCIETY. [Feb. 28, im.
of Medicine for Women, to elect somehow’ or another the
five faculty members. I am only thankful that T am no
longer connected with a medical school to have to take part
in this kind of election. Medical schools in>London are not
particularly harmonious amongst themselves, and how this
election of five faculty members out of twelve schools is to be
managed the scheme does not say, and 1 cannot form any
conception. It seems to me to be an utterly unworkable
and certainly a most undesirable arrangement. These are
the chief points to which I wish to direct your attention in
connexion with the medical department of this scheme; and
BO far as I am enabled to understand it—and I have giveQ
the best attention that I could to the subject—that is the
portion of the scheme that I, as a medical man of some
experience in London in teaching, and as having eat for a
long time upon the Council of the Royal College of Sur¬
geons, and served the office of president in that College,
should most emphatically condemn. The scheme does not
give the profession in London the M.D. degreethatit urgfently
needs and has repeatedly demanded. It practically throws
the whole of the medical education of the metropolis into
the bands of the corporations, and it admits women for the
first time as exercising a control over the management of
that education.
In reply to the llev. Henry Solly, who asked whether
the scheme did not require Parliamentary sanction before
being really an accomplished fact, Mr. Erichsen explained
that he merely meant that the union between the provincial
colleges and the University of London was unfait accompli,
and not that it was a legalised proceeding.
THE DEBATE ON KOCH’S REMEDY AT THE
BERLIN MEDICAL SOCIETY.^
The debate arising out of Professor B. Fraenkel’s paper
read before the Berlin Medical Society on December 17th,
has at length concluded. The chief speech on the 18th inst."
was that in which Professor Fraenkel replied, and his refer¬
ence at the close of his remarks to Dr. Liebreich’s new
remedy foreshadows continued discussion on the subject of
tuberculosis at this Society, of which Professor Virchow is
the president.
The proceedings on Feb. 18th commenced by Dr.
Grabower reporting further concerning the two patients of
the Moabib Hospital which he had suown to the Society
(p. 389). Under farther treatment the fresh miliary nodules
in the larynx bad disappeared. The tubercular character
of these nodules bad been proved by microscopic examina¬
tion of excised portions; so that there was indubitable
evidence of the occurrence (during this treatment) of grey
tubercles in previously healthy parts, and its later subsi¬
dence, without leaving any defect or scar in the mucous
membrane.
Professor Virchow showed specimens from a case which
had received thirty-six injection^from Nov. 27th to Feb. 2Dd,
death occurring on the 8th. He remarked that the case bad
been sent from another instil ution, and incidentally com¬
mented on the paucity of fatol cases reported elsewhere as
compared with those at the Charitc, where they amounted
to twenty-one last year, twenty in January, and ten in
February. The specimens showed a recerit ulcer at the
posterior extremity of the vocal cord ; a large mass of
recently caseated bronchial glands ; slight old disease of one
apex, with recent caseous and ulcerative changes that must
have arisen during the period of injection. Miliary nodules,
mingled with recent catarrhal hepatUation, were scattered
throughout the lung.
Dr. Leo Jacorsohn, in resuming the debate, asked
whether the disappointing results noted in many cases were
nob due to a disregard of Koch’s statement that the
“initial stage of phthisis should be tbe sole object for treat¬
mentand that his remedy can only “influence living
tuberculous tissue, not acting on the dead tissue.” Evident]}^
Koch only had in view cases of such recent infection that
all the specific tissue was still active, and would nob consider
as in the “initial stage” any case in which tbe process had
become arrested and dead masses encapsuled. I’hthisis in
r See THE Lancet, vo). i. I89i, pp. 21.% 271, .m, 38i), and 460.
2 Berliner Kliniadie Wochenschiift, No. 8,18yl.
that very early stage might not be revealed by any
physical signs or febrile movement, so that one might say
we never do detect com7nen(iing phthisis, but only that
which is more or less advanced'. That must be borne in
mind in attempting bo test the truth of Koch’s prophecy
that he hopes to certainly cure commencing phthisis.
Still, his remark does not apply to florid and hectic oases,
which are not favourable for treatment. In attempting to
dilTerentiatean initial phthisis “in Koch’s sense” all such
cases must be diacardea as show an improvement in general
symptoms, since such abatement indicates cessation of
absorption of the morbid products, because of their
encapsulation. In such cases a cure in the fullest sense of
the word is impossible. On the other hand, that very urn-
usual improvement takes place under Koch’s treatment
even in the second stage of phthisis, and in those of exten -
'sive infiltration, is indubitable.
Dr. B. Fraenkel, in his reply, said that he could not-
traverse all the ground taken by tbe various speakers in.
this debate, but would content himself with some generaji'
remarks. The original statement that Koch’s remedy
destroys tuberculous tissue had been borne out in many of
the specimens shown by Professor Virchow, which showed
destruction of parts admittedly tuberculous. This had aho-
been observed in the living subject; but Professor Virchow
had said the destruction involved the surrounding tissue
rather than the tubercle itself, and in that way explained
the apparent effect on the latter. Nevertheless, it seemed
to the speaker that “tuberculin,” as it is now officially
termed, acts like a powerful caustic on parts where tubercle'
bacilli ffourisb and excites therein an inllammatory change
leading to necrosis. He said “injiarts,” because in speci¬
mens brought before them they had seen that by no meane-
ali the tubercle is acted on. Miliary tuberculosis, foci of
caseous pneumonia, and tuberculous ulcers were met with
in injected cases. In using tbe term “ tuberculous tissue
he only meant to imply tnat the changes excited by the
remedy took place in parts where tubercle bacilli areseated,
and are producing changes. If this be so, be must still bold
tuberculin to be a specific for tuberculosis, and thence
arises the question how it is that so many objections!
have been raised to its efficacy. The answer, he thought,,
depends on the fact that tuberculin (1) leaves the tubercle^
bacilli undisturbed, and that (2) it develops some injurioue-
bye effects (Nebcnwwkungen). In veiy many cases the
“tuberculous tissue” is so destrojed as to allow of the'
bacilli being directly removed from the body. This is-
especially the case in cutaneous tuberculosis, in that of
the pharynx and larjnx, in some cases of tuberculosis of
the lung, and in intestinal tuberculosis. Here the condi¬
tions are most favourable. When ulcers are formed which
still contain bacilli, and yet heal, the healing process is due-
to the granulations that aie formed resisticg the further
inroads of the bacilli. This may explain the variations-
observed with respect to the characters of the ulcers and
their tendency to heal. Professor Virchow had shown
specimens of partially cicatrised intestinal ulcers, and similar
specimens had been elsewhere shown by Dr. Guttniann and
Professor Rindlleisch. Thus in the living as well as in th&
dead subject it had been shown that under certain condi¬
tions the cure of tuberculous processes could be effected by tbe
action of tuberculin. When the bacilli are not to favourably
placed, but are seated within closed cavities, or in caseous-
nodules, or with peribronchitis, or even below the epidermis
or deeply beneath the surface of mucous membranes,
then either the materials must be absorbed or the bacilli
become encapsuled. The description given by Schimmelbuscb
of partially cured lupus cases renders it probable that,
tubercle nodules and bacilli may still be found beneath an
apparently healed skin. Dr. Fraenkel did not know whether
this was also the case in those instances observed by himself
end others, where tuberculous infiltration of mucous mem¬
brane gradually subsided wiihout ulceration. He bad not-
yet had the opportunity of examining such cases micro¬
scopically. As to closed cavities, or where a peribronchitis
undergoes such a change as is seen in superficial mucous
membranes, then there occurs that permanent fever of which
he had spoken, and which bad been very often observed.
This fever, which excites much anxiety, is owing to the con¬
tinued absorption of the breaking-down tissue. Of much-
more importance is the possibility, suggested by Professor
Virchow, of the superveni ion of general miliary tuberculosis.
In his opening address he (the speaker) had pointed out
that sometimes in the vicinity of existing foci an erup-
Google
The Lancet,]
LUNAC'^ INQUIRY.
[Feb. 28, 1891. 507
tion of tubercle will appear at the early period of the
iojectioDs; but often bo early ae to suggest rather that
the tubercles had been present before, and otfly brought
into view by the changes exerted by the tuberculin in their
vicinity. But Ur. A. Fraenkel showed a case in which a
previously healthy part (the tongue) became the seat of
tubercle whilst undergoing a long course of treatment.
Turning from these local extensions of tubercle to the more
important question whether general tuberculosis can be
excited by itoch’s remedy, be pointed out that the liability
to miliary tuberculosis was not limited to those who are
being injected with tuberculin. The possibility of miliary
tuberculosis being evoked by the remedy must be admitted,
especially if the tubercular process involve the walls of
veins or lymphatics ; for then tbebacilli would, through the
breakiag down of the deposit, gain an easy entrance into the
circulation, and be disseminated throughout the body. But
this bypothesiscanonlybesustained when atleast threeM'eeka
have elapsed between the appearance of the miliary tuber¬
culosis and the injections, since inoculations in animals show
that this period is required for th% development of tubercle
•after the entrance of bacilli into the body. Respecting the
age of tubercle, be remarked that he had formerly de8cribe4
at that Society a case in which tubercles had been
■observed in the choroid from May 22nd until Oct. Ist.
Specimens showing the presence or tubercle had been ex¬
hibited in which more than three weeks had elapsed after the
injections, and it must therefore be deemed probable that
in certain caeee a miliary tuberculosis may arise under the
influence of Koch’s remedy. The cases brought forward by
the President showed nothing special; the most unusual one
was that of tuberculosis of the epicardium. The anatomical
•conditions did not*prove the alleged cause; it must be
shown that in the bodies of the injected general miliary
tuberculosis is more frequently met with than in cases of
phthisis not treated in this manner. However,in viewof the
theoretical possibility of the supervention of miliaiy tuber-
<ulo8i8, physicians must attribute its occurrence in some
cases to the action of the tuberculin until the contrary
is proved. Just as a general fever may be excited by reten¬
tion of the bacilli withiu the body, so do we see “the pos¬
sibility, indeed the probability, of miliary tuberculosis being
■generated,” As regards harmful bye effects, these, too, must
be admitted as probable. Among them is the occurrence
■of inflammatory changes in the lungs, the four varieties
■described by the President. He would only remark that
the invasion of caseous pneumonia in phthisis had previ¬
ously been discussed—viz., as to whether it arose out of
■catarrhal pneumonia excited by pulmonary htomorrhage.
Professor Virchow now suggests that material filled with
bacilli taken into the lung Is able to excite caseous changes,
and there is no ground for disputing this provided that a
■sufficient time is allowed for the development of the
bacilli, but not if such inflammatory changes arise on the
day after the injection. If a pneumonia occur a few days
■after injection, it must be catarrhal; and so long as the
contrary is unproved, this must be considered one of the
‘risks of the treatment. So, too, as regards perforation of
the serous membrane under the influence of tuberculin. Ho
had reported such an event in the infCstine, and I)r.
Lazarus had seen one in the pleura. Such events might
■arise apart from the Ireatment, but tliis might hasten them,
eo that here was another danger to be reckoned with.
Then tuberculin is a remedy which is dangerous per se,
imposing responsibility on him who employs it. Whenever
the slightest unusuat change occurs, he asked himself
whether that might not be of ill omen ; or, if fever arise,
was it due to general tuberculosis ? If patients complained
•of lieadache, or if any intestinal symptoms occurred, he
always felt the need of great caution, and considered a
great responsibility rested on the physician using the
remedy. But the risks must be taken into the bargain.
With the creasote treatment he had never seen anything
like the effect of that produced by Koch’s treatment. So
that on the one hand we have a remedy involving risks,
which cannot be disregarded ; and on the other a remedy
which offers prospect of cure to many hitherto incurable
cases. The physician must act on the same lines as the
.surgeon in risking something in prospect of saving life.
The attempt must be made to separate clinically the
cases in which dangers may arise and those in which
there is prospect of cure. Care in dosage alone does
not suilice, for the dangers have been observed in some
which bad only received a few milligrammes. Rather must
one seek by improved diagnosis to separate the unsuitable
from the suitable cases. In conclusion, Ur. Fraenkel said
that since the last sittipg he bad, through Ur. Liehreich,
been made acquainted wiwi a remedy whi^, without excit¬
ing fever or local inflammation, has given astonishing results
in six cases of laryngeal phthisis in his policlinic. A similar
excellent result has been observed by Ur. Paul Heymann;
and as soon as permitted Ur. Liebreioh proposed to lay the
details of bis remedy before the Society.
LUNACY INQUIRY.
In pursuance of a petition to the Lord Chancellor, and an
order consequent thereon, an inquiry has been held in
Queen’s Bench Court V., before Sir Alexander Miller, one of
the Masters in Lunacy, and a special jury, as to the alleged
lunacy of Mr. Francis Henry Paget, a gentleman formerly
residing at Birstall, in Leicestershire, the petitioner being
his daughter, Mrs. Walker, of Maunby Hall, Thirsk, York¬
shire. The case on behalf of the petitioner was that Mr.
Paget was neither dangerous to himself nor to others, but
that, owing to an illness which bad come upon him in 1889,
bis brain had become affected, and that consequently he
was unable to manage his own affairs. He was now fifty
years of age, and had an income of about £1400 a year.
He had been married, having a daughter, now Mrs. Walker,
the petitioner. In 1883 he was separated from his wife and
left Birstall, where he had resided, selling the property,
and went to live at the County Club at Leicester, where it
was suggested he led a somewhat irregular life. In Sep¬
tember, 1889, he was out shooting on a farm which belonged
to him in Uorset, and was seized with a severe illness,
attributed to a complaint from which he had previously
suffered, and which resulted in a state of diseased brain.
Evidence was given that Mr. Paget suffered from loss of
memory and from delusions. Mr. Francis Joshua, who
attended him after the seizure, formed the opinion that he
was of unsound mind, and gave evidence to that effect.
Ur. Fielding Blandford and Ur. Maudsley had also
examined him, and they were likewise of opinion that be
was of unsound mind and incapable of managing his
property or affairs. Ur. Marriott of Leicester gave
evidence that Mr. Paget was improving in his mental con¬
dition, that be had no delusions, was able to read and do
simple sums in arithmetic. On cross-examination Ur.
Marriott said there could be no doubt that Mr. Paget had
suffered from severe disease of the brain, but he regarded it
as an ordinary seizure. In July last there had been a
wonderful improvement. Uespite the experts and the
evidence called for the petitioner, he did not regard Mr.
Paget as a lunatic. He was not a man of sound mind, but
there was a marked distinction between the two. Mr.
Berkeley Hill deposed that in conjunction with the lost
witness he had examined Mr. Paget in July in regard to his
mental powers. To several simple questions he answered
satisfactorily. His difficulty was in remembering matters,
and witness formed the conclusion that he had suffered from
syphilitic disease of the brain, but had tolerably improved.
Some further evidence having been given, Mr. Bucknill,
Q C., addressed the jury on behalf of the alleged lunatic.
Having pointed out that the evidence in sup^iort of the
petition was contradictory, he severely aniniaciverted upon
the conduct of the petitioner, and contended that the pro¬
ceedings were not the outcome of pure filial piety. He
appealed to the jury to say that Mr. Paget was improving,
and that, although his memory was impaired, he was stul
quite capable of managing bis own affairs, and that he was
not a lunatic.—Mr. Crump, Q C., then addressed the jury,
urging that the proceedings were approved by the chief
members of the Pagetfamily, and that the opposition arose
entirely from Mr. Miles, the deceased solicitor, of Leicester,
wlio died by his own hand. He urged that this case was
on “all fours” with the celebrated Wyndham case, where,
as the result of the jury finding that the gentleman was
not insane, he was allowed to do as he chose without any
control, and with the result that he dissipated a splendid
fortune. This, he contended, would be the result unless
some control was placed upon Mr. Paget by the appoint¬
ment of a Committee in Lunacy for the administration of
his affairs under the court. On the conclusion of thelearned
counsel’s address the court was cleared in order that the
~ ^8'
508 The Lancet,] THE GERMAN CONGRESS OF INTERNAL MEDICINE. [Ficb. 28, 1891.
alleged lunatic might be examined before the master and
the jury in private. The jury retired at a quarter to
three o’clock. They were absent only ten minutes, and
unanimously found that Mr. Paget was of unsound mind,
but that he was not dangerous, though incapable of taking
care of himself or of managing his afTairs.
Upon the evidence, and after personal inquiry and exami¬
nation, the jury arrived at the only, conclusion open to
them; for even Dr. Marriott admitted that Mr. Paget was
not of sound mind. All who have experience of paralytic
seizures from cerebral lesion, especially if there is a syphilitic
taint, know how very frequently the consequences show
themselves in mental enfeemement and loss of business-like
qualifications which the individual may have previously
possessed. The loss of memory which almost invariably
accompanies this condition may be a not unlikely means
of causing the individual to do an unintentional injustice
in one direction or another when writing out his will or
making some similar business effort. Again, this enfeebled
condition of mind is apt to cause the individual to take such
likes or dislikes to those about him as he would never have
done had be been in full possession of his faculties. So
long as a lunatic or person of uusoimd mind is not a source
of danger to himself or to the community, we think that a
reasonable latitude should be given to him in spending
his money or indulging in innocent foibles. But we are
strongly of opinion, on the other band, that no unreasonable
obstruction ought to be placed in the way of the afifairs of a
lunatic who is himself unable to manage them being handed
over in a legal and proper manner to the control of such a
committee as may be approved by the Chancery authorities.
THE GERMAN CONGRESS OF INTERNAL
MEDICINE.
The tenth annual meeting of the above Congress will
take place at Wiesbaden from April 6bh to 9th, under the
presidency of Professor Leyden of Berlin. The subjects for
general debate are; 1. Biliary Calculous Disorders, to be
opened by Dr. Naunyn (Strasburg) and Dr. Fiirbiinger
(Berlin). 2. Koch’s Remedy in Pulmonary Tuberculosis
and other Internal Tuberculous Diseases. 3 Angina
Pectoris, to be opened by Dr. A. Fraenkel (Berlin) and Dr. O.
Vierordt (Heidelberg). The following is a list of the papers
promised /or the meeting:—Dr. Kaliler (Vienna): Inter¬
mittent Albuminuria. Dr. Mosler (Greifswald): the Treat¬
ment of Leukfomia. Dr. T. Schott (Nauheim): the
Differential Diagnosis of Pericardial Exudation and Cardiac
Dilatation. Di*. Knoll (Prague): (1) Disorders of Circu¬
lation; (2) Morbid Changes of Striped Muscle. Dr.
Brieger (Berlin): Chemical Changes in Infectious Dis¬
eases, Dr. Rosenstein (Leyden): the Diagnosis of Hyper¬
trophic Cirrhosis of the Liver. Dr. Quincke (Kiel): Hydro¬
cephalus. Dr. Eichhorst (Zurich): Observations on the
Patellar-tendon Rellex in Tabes Dorsalis. Dr. Edelfsen
(Kiel): (1) the Origin of the Vesicular Murmur; (2) Varicella
Statistics. Dr. Tappeiner (Munich); the Diuretic Action
of Phenylmethylpyrazolcarbonic Acid. Dr. Friedliinder
(Leipsic); (1) the Method of Mathematical Diagnosis of
Acute Articular Rheumatism and of all forms of Central
Rheumatism; (2) Etiology of Bright’s Disease. Dr.
Leubuscher (Jena): Clinical Researches on Acid Excretion
in Mental and Nervous Diseases. Dr. Schmaltz (Dresden):
Examination of the Specific Gravity of Human Blood, and
its hehavionr in Anaemic Conditions. Dr. Mordhorst
(Wiesbaden): Diagnosis and Treatment of Gout.
The secretary of the Congress is Dr. Emil Pfeiffer of
Wiesbaden.
HOSPITAL ABUSES AND GENERAL
PRACTITIONERS.
On Monday last a meeting of medical men in general
practice was held at 29, Tbreadneedle-street, E.C., to
consider the question of hospital abuses and the advisability
of taking collective action to make the views of general
practitioners as regards hospital reform known to the
Special Committee of the House of Lords now sitting to
inquire into ho^ital management. Among those presenb
were: Messrs. George Brown, M.R.C.8. (cbtiirman), T. R.
Atkinson, M.R.C.S., F. H. Alderson, M.D.. J. B. Cook,
L.R.C.P. Ed., James Dawson, M.D , W. Piercey Fox,
L. R.C.P.Ed., T. C. Winn, M.R.C.S., A. C. Dove,
M. D., F. H. Corbyn, LRC.P. Ed, and Hugh Woods,
M.D. After considerable discussion the following reeo-
tion, proposed by Dr. Corbyn and seconded by Dr. Cook,,
was carried ncm. con.: “That a provisional committee
be formed with a view to organise general practitioners to
protect their mutual interests, especi^ally in regard to the'
abuses of medical charities.” All the above-named gentle¬
men having consented to join the committee. Dr. A. C. Dove
was elected hon. secretary pro Um., and the meeting;
terminated with a vote of thanks to Mr. Brown for presiding.
VIRCHOW TESTIMONIAL FUND.
Professor Huxley, F.R.S., Professor Strubhers (Aber¬
deen), and C. Theodore Williams, M.D:, have joined the>
committee.
The following additional subscriptions to the above fund
have been received since the last list was published :
T. H. Huxlev, F.E.S. ..
& s.
2 2
d.
li
T. Grainger Stewart,
.€
8.
(L.
Sir Joseph Lister, Bart...
P. Frank, M.D.
2 2
0
M.D.
2
2
O'
2 2
0
T. Bi-yant. P.R.C.S.
2
O'
■T. Althaua.M.D.
t 1
0
w. Pj'iestlov, M.D.
2
2
0
Professor A. R. Simpson
2 2
0
Julius Dresohfeld. M.D.
2
2
O'
Walter K. Sibley, M.D...
0 10
(1
Henry Simon, Esfi.
2
2
O
John Moorheail, M.D. ..
1 1
0
Professor Struthera.. ..
1
1
0>
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 59G4 births
and 4139 deaths were registered during the week ending
Feb. 2l3t. The annual rate of mortality in these towns,
which had been 19‘8 and 19‘9 per 1000 in the preceding
two weeks, was last week 21‘(). The rate was 20'4 in
London and 22 5 in the twenty-seven provincial towns.
Daring the past seven weeks of the current quarter tho
death-rate in the twenty-eight towns averaged 23'4 pe?
1000, and exceeded by P'3 the mean rate in the correspond¬
ing periods of the ten years 1881-90. The lowest rates ins
these towns last week were 14'5 in Nottingham, 14'8 in
Wolverhampton, 14'9 in Hull, and 15'4 in Brighton; the high¬
est rates -were 28'6 in Blackburn, 30'9 in Manchester, M'Oiiii
Huddersfield, and 37'7 in Halifax. The deaths referred to>
the principal zymotic diseases, which had been 332 and
340 in the preceding two weeks, further rose to 381 last'
week; they included 126 from whooping-cough, 113 from
measles, 49 from diphtheria, 44 from scarlet fever, 27 from
diarrbcea, 22 from “fever” (principally enteric), and not
one from emall-pox. Th« lowest rates from these zymotic
diseases were recorded in Norwich, Hull, and Nottingham
and the highest in Salford, Blackburn, Halifax, and
Oldham. The greatest mortality from measles occurred
in Leeds, Huddersfield, Halifax, Bristol, Blackburn, and'
Oldham; from scarlet fever in Bradford; and from
whooping-cough in Oldham, Birmingham, Halifax, Salford,
and Birkenhead. The mortality from “fever” siiowed no
marked excess in any of the large towns. The 49 deaths
from diphtheria included 34 in London, 7 in Manchester,,
and 2 in Derby. No death from small-pox was registered
in any of the twenty-eight towns, and no small-pox
patiehts were under treatment in the Metropolitan
Asylum Hospitals on Saturday last. The numner of
scarlet fever patients in the Metropolitan Asylum Hos¬
pitals and in the London Fever Hospital at the end of
the week was 1287, and showed a further decline from
recent weekly numbers; the patients admitted during
the week were 113, against 107 and 97 in the preceding
two weeks. The deaths referred to diseases of the re¬
spiratory organs in London, which had been 428 and 484
in the preceding two weeks, further rose last week to
524, and were 27 above the corrected average. The causes
of 90, or 2*2 per cent., of the deaths in the twenty-eighb
towns were not certified either by a registered medical
practitioner or by a coroner. All the causes of death were
Dir: OOgeC
The IjAkcet,]
HEALTH OF SCOTCH TOWNS.-HEALTH OF DUBLIN.
[Feb 28,1891. .'",09
duly certified io Leioeeter, Nottingham, Hull, Sunderland,
and in four other smaller towns. The largest proportions
of uncertified deaths were recorded in Liverpool, Bristol,
Hull, and Halifax. _
HEALTH OP SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had declined from 26'4 to 21*4 per 1000 in the pre*
ceding three weelcs, rose again to 22'6 during the week
ending Fob. 21st, and exceeded by I’O the rate that pre¬
vailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns
ranged from 14*3 in Greenock and IC'l in Leith to 28'6
in Glasgow and 29'9 in'Paisley. The 591 deaths in these
eight towns showed an increase of .30 upon the number in
the preceding week, and included 20 which were referred
to whooping-cough, 9 to scarlet fever, 8 to measles, 7 to diph¬
theria, 7 to “fever,” 5 to diarrhoea, and not one to small¬
pox. In all, 62 deaths resulted from these principal
zymotic diseases, against numbers declining from 76 to 50
in the preceding four weeks. These 62 deaths were
equal to an annual rate of 2'4 per 1000, which exceeded
by 0'4 the mean rate last week from the same diseases in the
twenty-eight English towns. The fatal cases of whooping-
cough, which had declined from 29 to 13 in the previous
three weeks, rose again last week to 26, of which 16
occurred in Glasgow and 3 in Leith. The deaths referred
to scarlet fever, which had been 6 in each of the pre¬
ceding two weeks, rose to 9 last week, of which 5 occurred
in Glasgow and 4 in Edinburgh. The 8 fatal cases of
measles were within 2 of the number in the previous week,
and included 4 in Paisley and 3 in Glasgow, The deaths
from diphtheria, which had been 12 and 4 in the preceding
two weeks, rose again to 7 last week, of which 3 occurred
in Glasgow and 2 in Leith. Of the 7 fatal cases of “ fever,”
3 were recorded in Edinburgh and 2 in Dundee. The deaths
referred to diseases of tue respiratory organs in these
towns, which had declined from 228 to 138 in the preceding
five weeks, were lost week 140, and were 65 below the number
in the corresponding week of last year, The causes of
41, or 7 per cent., of the deaths in the eight towns last
week were not certified.
HEALTH OP DUBLIN.
The death-rata ia Dublin, which had been 20'6 and 26'9
per 1000 in the preceding two weeks, further rose to 27 3
during the week ending Feb. 2l8t. During the first seven
weeks of the current quarter the death-rate in the city
averaged 32 T per 1000, the rate for the same period being
23‘6 in London and 20‘4 in Edinburgh. The 185 deaths
in Dublin showed a flight increase upon the number in the
preceding week, and included 2 which resulted from whoop¬
ing-cough, 1 from diphtheria, but, not one either from
small-pox, measles, scarlet fever, “fever,”or diarrhcca. Thus
the deaths referred to the principal zymotic diseases, which
had been 7 and 3 in the preceding two weeks, were again only
3 last week; they were equal to an annual rate of 0'4 per 1000,
the rate from the same diseases being 1 -5 in London and 1‘7 in
Edinburgh. The fatal cases of whooping-cough, which had
been 2 and 0 in the preceding two weeks, rose again to 2
last week. One death resulted from diphtheria, corre¬
sponding with the number in each of the previous three
weeks. The 185 deaths in Dublin last week included
30 of infants aged under one year and 58 of persons aged
upwards of sixty years; the deaths of infants showed a
slight increase, while those of elderly persons exhibited a
<lecline of 10 from the number recorded in the preceding
week. Three inquest cases and 2 deaths from violence
were registered; and 71, or more than a third, of the
deaths occuned in public institutions. The causes of 18,
or nearly 10 per cent., of the deaths in the city were not
certified.
THE SERVICES.
The Army Estimates.
There are no important changes to chronicle regarding
the Army Medical Service in the Army Estimates for the
year ending March 31st, 1892. Vote 2 shows a net decrease
of £1400 for the coming year. The estimated cost of the
Medical Establishment, pay, medicines, &c., amounts to
£292,800, as against £294.200 in 1890-91. There is an in¬
crease of £700 over 1890-91 under the head of Pay, &c., of
the Medical Stafi’, but a saving of £1000 in the cost of
medicines, as well as one in the estimated amount for pay
of Militia Surgeons and civilian medical practitioners and
that of the Medical Staff Corps, nurses, clerks, and other
subordinates. In addition to the foregoingvote for Medical’
Services provision for similar expenditure is made in other
votes, and among these we notice that the cost of the staff of
the Army Medical School is estimated at £7910, and that-
of the Director-Genotal and Medical Officets at headquarters
at £4850.
Armt Medical Staff.— Brigade Surgeon Jas. Wilson,
M.B., F.F.P.S. Glasgow, is placed on retired pay (dated
Feb. 14th, 1891 ); Surgeon Robert Hippisley Cox, from the
Coldstream Guards, to ne Surgeon (dated Feb. 25tb, 1891).—
The undermentioned Surgeons on probation to be Surgeons,
ranking as Captains (dated Jan. 31st, 1891):—Tbos. Buswall
Beach, Edgar Elkins Powell, Coryndon W. R. Healey,
James Willes Jennings, Edgar McKenzie Williams, Henry
Esmonde Dowse, John Colpoys Connor, M.B., J'ames
Edward Carter, M.B., Frederick Wynne Hardy, John
Thurlow Clapham, Walter Ap Samuel James Graham,
Daniel Davis Shanahan, Charles Wm. Henry Whitestone,
M.B., Albert Pearse, Hubert Dempster Mason, and Cbas.
Dalton.
Army Medical Reserve of Officers. —Surgeon C. E.
Douglas, M.B., resigns his commission (dated Feb. 25th,
1891).
Naval Medical Service. —The following appointments
have been made at the Admiralty:—Surgeons John L.
Thomas to Jamaica Hospital, and Anthony Kidd to tbe-
Bellerophon (both dated Feb. 19tb, 1891); Surgeon Henry
G. Jacob to the WiLdjire.y additional (dated March Sth,
1891).—The following qualified candidates for the Naval
Medical Service have been appointed Surgeons in Her
Majesty’s Fleet:—Tbos. Christopher Meikle, M.A., M B.,
Robt. Wilks Senior, Ernest Edwd. Partridge Tindall, Erio
Edwd. Kershaw, Jos. Cudlip Wood, Arthur Henry Howell,
Horace Bruce Marriott, Ernest Courtney Lomas, MB,
Norman Lloyd Richards, Ernest Alfred Penfold, M.B.„
George McGregor, Basil Roberton Clarke, Ernest Jamea
Finch, John Kirkup Robinson, M.B., and Hugh Clift'
(all dated Feb. 11th, 1891).
Volunteer Corps.— 2Qd Volunteer Battalion, the
Royal Warwickshire Regiment: Acting Surgeon R. Bullock
to be Surgeon (dated Feb. 2l8t, 1891).—Sth Volunteer Bat¬
talion, the Cheshire Regiment: Surgeon and Surgeon-Major
(ranking as Lieutenant-Colonel) S. H. Milinro, M. D., resigns
his commission ; also is permitted to retain his rank, and to-
continue to wear the uniform of the Battalion on his retire¬
ment (dated Feb. 2l8t, 1891).—2nd Volunteer Battalion,,
the Hampshire Regiment: Acting Surgeon H. W. R.
Bencraft resigns his appointment (dated Feb. 21st, 1891) —
3rd Volunteer Battalion, the South Staffordshire Regiment:
Surgeon and Surgeon-Major F. E. Manby is seconded whilst
holding the appointment of Brigade Surgeon in the Stafford ¬
shire Infantry Volunteer Brigade (dated Feb. 2l8t, 1891).—
3rd London: William Maurice Abbot-Anderson, M.B., to-
be Acting Surgeon (dated Feb. 21st, 1891).
Volunteer Medical Staff Corps.— The Edinburgh-
Division : Acting Surgeon D. Wallace, M B., to he Surgeoa
(dated Feb. 2l8t, 1891).
PiUiSENTATiONS.—Oil the SOtli ult., at the Norfolk
and Norwich Hospital, a handsome dressing-bag, excellently
fitted with silver mounts was presented by Mr. Cadge,
on behalf of the nursing staff, to Mr. H. 0. Nance, upon bi&
leaving the hospital, having held the post of house-surgeon
for six years.-On the 11th inet., a handsome silver
salver, bearing the inscription, “ Presented to Brigadier-
Surgeon Sandford Moore, on his marriage, by his brotber
ollicera of the Army Medical Staff, 1890,” was forwarded to
him by Surgeon-tleneral Sinclair, P.M.O. in Ireland.-Mr.
Edward Pope, M.R.C.S., of Tring, has been presented by
the mombers of Court Albion, No. 4423, of the Ancient
Order of Foresters, on hia retirement from the post ofr
medical officer to the lodge, after a service of nearly
twenty-five years, with a handsome cruet set, os a token off
esteem and regard.
- Google
510 The Lancet,] THE “REVISED SCHEME” OF THE UNIVERSITY OF LONDON. [Feb. 28, 1891.
dffmspnkiiff.
" Audi alteram partem."
THE “REVISED SCHEME” OF THE
UNIVERSITY OF LONDON.
To the Editors of The Lancet.
Sirs, —I have elsewhere expressed the opinion t^bat the
■“revised scheme'’ is very unsatisfactory, seeing that it
is not calculated to satisfy the wants which afforded the
principal occasion for it and other recent attempts to
reconstitute the University of London. I have ventured
‘further to express my own belief that this scheme will fail
to prove acceptable to Convocation. I should like, with
.your permission, to be allowed, as briefly as i)ossible, to
explain to your readers my reasons for entertaining these
views.
This last attempt at the reconstitution of the University
has, like those which have preceded it, beep undertaken
in consequence of the report of a Royal Commission.
The appointment of this lioyal Commission grew out of
:a loud but in part twofold cry. The first element of
this cry was of a general character, urging the pressing
need of a real “Teaching University in and for London,”
which should comprise within itself all the faculties
' of a university. The second element was a cry of a narrower
nature {partly included within the former), and having
special reference to the need existing in London for an
anility to obtain the degree of M.D. by medical students
■after curricula and examinations less stringent than chose
necessary for the acquiring of such a degree from the Uni¬
versity of London. This latter element of the cry assumed
A separate and more or Uss isolated character mainly on
account of the efforts made by the two Royal Colleges to be
themselves allowed to grant degrees after appropriate exami¬
nations. Some of us have felt all along that the University
of London has, in its own way, as au imperial examining
and degree-giving body, bad a career of distinguished use-
iulnesB in the past, and one which in this respect is likely
to grow in the future. And, not to speak of its influence
in raising the standard of education and of examination in
Arts and Science (possibl.v also in Law), we believe that it
has bad an admirable effect in elevating the standard of
medical education and examination—and that too even
-elsewhere than within its own walls. The standard of
the University of London in Medicine is ‘so high that
its degrees are only sought after and obtained by some
•of the best men; they constitute, in fact, a species of
“ Honours Degree,” obtained, however, only by about 8 per
-cent, or less of the total number of medical students in
London. In the face of tbui state of things we may ask, in
the first place, How does the “revised scheme” propose to
meet the acknowledged wont so far as the great majority of
medical students are concerned? That tliis scheme meets
with the approval of the two Royal Colleges is not difficult
to understand, for reasons which you have sufficiently ex¬
plained in your very able article in last week’s issue. If
the Royal Cfolleges do not acquire the right to grant medical
degrees, they obtain the nearest approximation to it that
seems possible. But if we look at the scheme proposed,
apart from corporate interests of this or that kind, we may
easily see that, so far as students are concerned, it must
entail one or other of two results—either (a) it will lead to
a lowering of the standard in the case of the medical part
of the M.B. examination which is to be conducted con¬
jointly by the two Royal Colleges and the University—any
■certain prospect of which would, as I believe, sureHy lead
to the rejection of the “revised scheme” by Con¬
vocation; or [b) it will not lower the standard, aud
in that case it will not meet the acknowledged want
-{for which a cry has been so widely raised), and
make M.B. and M.D. degrees distinctly more accessible
to the great majority of London medical students. It
seems delusive to me to say, as some of the advocates of
the present scheme in the Royal Colleges do say, that the
proposed arrangement “will tend to raise the standard of
meaical education in London.” Why should it do so?
The University of London has all along tended to foster a
high standard of medical education, and the result is that
-about 8 per cent, or lees of London students obtain its
medical degrees. Do the Royal Colleges think that the
new conjoint degree of M.B. will be more sought after than
that of the University of London alone has been ? Yes,
possibly, if they lower the standard, but surely not other¬
wise. But, touching this possibility, other considerations
remain. If the new scheme is not to result in a lowering
of the standard, and if (as I bear it whispered) the standard
for those who are to obtain the pass M.B. is to be distinctly
higher than that now enforced by the Conjoint Board for
the obtaining of medical diplomas, then my experience as
an examiner in Medicine under that Board leads me to
believe that the result would be an obtaining of M.B.
degrees by a percentage of students only a little if at all
higher than the 8 per cent, above cited. And even should
1 b^e mistaken in this estimate of the effect of any distinct
elevation of the standard in the conjoint examination
for men seeking the M.B., I would still ask, Where
are we to find the distinctly increased facilities for the
acquiring of an M.D. degree by average students under
the provisions of the revised scheme,—with the difficult
matriculation and preliminary scientific examinations re¬
maining to bar the way precisely as before, with a pro¬
fessional examination for tlie M.B degree not appreciably
lowered (and, be it remembered, this degree of itself gives
the holder no right to assume the coveted style of
“Doctor”), and, finally, with all the difficulties of the
M.D. • examination remaining exactly as they were?
Surely the belief is utterly delusive. I do nob say that
those who are in favour di the scheme do not think the
facilities will be much greater; I merely say that I see no
real grounds for entertaining any such belief.
After what has been so ably said in your two leading
articles I need not occupy further space in pointing out
some of the more general demerits of the scheme. It is,
io my opinion, an inadequate attempt to meet the general
demand for a “Teaching University in and for London.”
Let the University of London go along its own previous
lines of growing usefulness as an imperial degree-giving
body, and let us have a real Teaching University for
London rather than something of a nondescript character
which does nob profess'to be more a University for London
than one for all England. And seeing that the Royal Com¬
mission pronounced strongly against the inclusion, which
has now been made, of provincial colleges in any new
scheme, there is much room for doubt as to the view which
the Privy Council will take of the means now proposed by
the University of London for meeting the general wants as
to which the Commission reported. This doubt seems to
me to be all the greater by reason of the way in which the
new scheme proposes to meet the more specif cry in regard
to increased facilities for the obtaining of medical degrees
by London students. The Commission reported strongly
against conferring the power of granting degrees upon the
Royal Colleges. Bub they might wso condemn the
approximation to this course which is now proposed. “What
I wish, however, particularly to enforce is this, that even
if the standard of the conjoint M.B. were to be distinctly
lowered, the facilities offered to London medical students by
the “revised scheme” for obtaining an M.D. degree would
be scarcely appreciably greater than they are at present,
so long as all the well-known difficulties offered by the
earlier and the later exanrinations remain (as it is proposed
they should) precisely wbat they have hitherto been in the
hands of the University of London. .
I am, Sire, yours truly,
Manchu.ster-,sfi., Fob. 23rcl, 1891. H. ChaIiltON BASTIAN.
THE FACTORY ACT AND CERTIFYING
SURGEONS.
To the Editors o/The Lancet.
Sirs, —The text of the Factory Act Amendment Bill is
out, and in it we can see that the same cavalier treatment
of the military medical service by the Horse Guards is
meted out to their civilian brethren by the Government.
Sir Andrew Clark, as head of the profession, who has so
ably and vigorously taken up the cudgels on behalf of army
doctors, will perhaps assist us civilians t.oo with his
inlluence.
Clause 19 of the new Bill abolishes.the chief functions of
certifying factory surgeons, and thus deprives them of nine-
tenbha of their income from such anpoinbments. 'Thesecond
section of the same clause certainly reserves their services
for the purpose of reporting accidents; but, as every cer-
Thb Lanobt,]
ENGLISH MEDICAL PRACTICE IN PARIS.
[Feb. 28, 1801. all
tifj'ing surgeon knows, accidents, especially slighter ones, are
often never notified to them for report—in any case are few
and far between, are paid for at about the rate of a cab
fare, and, in fact, as in my own case, yield less than one-tenth
of whatever the total emoluments of the appointment may
be. Therefore at one stroke I may say we are practically
abolished, with a few months’ notice to quit, so to speak,
^r the Bill is to take effect from Jan. Ist, 1892. To many
certifying surgeons, in large towns and manufacturing dis¬
tricts especially, these changes are a serious matter. A
number of years have elapsed since these surgeons were
appointed. The income they derive for this woi^ forms an
appreciable amount of their total income, to which they
have been accustomed to look to meet tho daily neces¬
sities of life. Being a public appointment they have
often felt bound to attend to its requirements first at
the possible sacrifice of private interests. So that
in respect to their position they have come to feel that
Tihey have acquired so far a vested interest, as
great indeed as that of any Government official. It seems
to me a rank injustice that a body of men who are doing
and have done useful work all over the United Kingdom,
in helping to render the working of the Factory Acts
efficient, should be summarily deposed and their means of
living straitened, not through any fault of their own, but
because a body of manufacturers, having egged on their
operatives to join them, bring political pressure to bear
on Ministers to rescind a portion of these Acts, which,
though distasteful to them, are undoubtedly for the public
benefit.
Clause 20 of the amending Bill obliges employers to keep
copies of certificates of births of “young persons” em¬
ployed in the factory, to be produced when required by the
inspector. Sirs, from my knowledge of the past working of
the Factory Act, I do not hesitate to say that such a pro¬
vision against the employment of children under the legal
age will be a farce; or, worse still, it will be a dead letter.
Inspectors have quite enough w&rk to do as it is, and can¬
not attend at the innumerable factories in large towns often
enough to keep a check on this point over employers. Many
factories they will not be able to visit more than once in
several months, where factory surgeons now call once a week
or fortnight, and where it is quite necessary they should
call, unless the old evils of infant employment are to he
gradually and insidiously revived. I am surprised at such
a retrogressive step on the part of a Conservative Govern¬
ment. Under present conditions, with factory surgeons
living in the various manufacturing localities where they
have been appointed, with all their intimate knowledge of
their factories, they repeatedly find attempts made to evade
‘the law on the question of age, either wilfully or through
ignorance. To appoint a large number of extra inspectors—
for a small number will not do—may counteract the evil.
But at what an expense, compared to the present method !
Dispensers of patronage may find it very delightful to have
the gift of numerous additional inspectorships in their
hands. But the country will 'have to pay for them, and
our Civil Service estimates are liigh enough already, in all
conscience. As matters stand, the country pays nothing,
for the manufacturer pays the certifying surgeon. And,
after all, what does each manufacturer pay in the
course of a year ? The sum is so trifling, such a
miserable pittance, that I am astonished that there could
have been any agitation capable of evolution from such a
microscopic origin. But the Bill is not yet law. To amend
the clauses alluded to above I would urge on every certify¬
ing surgeon to bring what influence he has, directly or in¬
directly, to bear on the M.P. for his constituency. Politics
being an organised hypocrisy, where good is sometimes done
by chance, not for its own sake, but because it is expedient,
the medical profession will find their feelings and interests
eternally ignored by Government unless they can prove
their political power. If they Avill not take the trouble
they must suffer in the future as they have suffered in the
past. The importance of this subject, I trust, will stand as
my apology for occupying so much of your valuable space,
which is so generously and so often devoted to the welfare
of the profession.—I remain. Sirs, yours faithfully,
T<’eb. 26th. 1801. MALLEUS InJUSTITU-L
*** The impolicy and injustice of the proposal to practi
cally abolish the oilice of certifying factory surgeon are
referred to in another column, but will receive further
consideration in our next issue.—E d. L.
ENGLISH MEDICAL PRACTICE IN PARIS.
To the Editors of The Lancet.
Sirs,—I n his letter of last Saturday Dr. Barnard baa
asked you a question which is of the most vital importance
to all of us here in Paris, and which I venture to think will
not be without interest to many other members of the pro¬
fession, more particularly those who reside in continental
towns or other places where a floating hotel population vo-
one of the chief sources of practice. When the suggestion
made by Galignani first appeared, it naturally caused a-
great difference of opinion, and two opposite camps were^
formed, one consisting of the few men who are the favourites
of the chemists and ^^proUgis of the hotel keepers, who-
censured in the most scatrhing terms this proposal of medical
adeortising; the other comprising the'balance of the pro¬
fession who have never managed to ingratiate themselves-
witli the hotel clerks and chemists’ assistants who dispense
medical favours, and who naturally thought any way of
bringing their names without impropriety before the publie
worth consideration.
The question you are asked to answer is practically this.
Whether those men who have persistently been kept oui
of the most lucrative practice obtainable, and who have-:
found that no length of waiting avails anything against the
prevailing system, should consent to accept an undignified
and subordinate position? or whether it is more fair to-
publish in the English organ of this city a simple list of
names and addresses? 1 dare say that some of your'
readers would be inclined to advise Dr. Barnard to wait,,
to practise his profession with dignity and propriety, in
the certainty that such an attitude will be rewarded in the
long run; and possibly Dr. Barnard, who is comparatively st-
newcomer, would find it hard to make a suitable reply.
I, however, who have been here for fifteen years, can,
vouch for it that unless a doctor can manage to-
become persona grata with hotel keepers or chemists,
he will never % any.chance see an hotel patient,
except, perhaps, the one out of every live of those recom¬
mended to consult him by their friends or professional,
advisers at home, who has sense enough to refuse to b&
“ choked off” seeing the man he wants by interesting inter¬
mediaries. I believe that it Avas to me that Dr. Barnard
alluded when he spoke of a physician who had been,
practising here for twenty years, and who was unknown to
a chemist in the Rue de la Paix. If iiot, with the slight-
exception that I have only been here fifteen years, the
anecdote might have applied perfectly. A lady, sent to me-
for the treatment of the morphia habit by her doctor in.
San Francisco, was advised independently to consult me by
the physician who attended her in London. She very
naturally thought that I must be a well-known person, but
on inquiring for my address at the office of the hotel
•where she’was staying—one of the most important,—
she was assured that no such doctor was known, nor could-'
his name be /oicnd in the directory. This is an arrant false¬
hood. Determined, however, to find meif possible, she refused
the kind offer of the booking clerk to recommend her “ tbe-
best doctor in Paris,” and started for the Rue de la Paix.
There, again, I had never been heard of, and the assistant-
had no idea as to how I could be found. It was by the^
merest accident that another person in the shop desired
the cashier to show him the Medical Directory, where my
name was of course found at once
Some time back an American confrere, then starting in
this town, but since gone elsewheri*, determined to bring;
about, if possible, a change in the existing state of affairs,
and, in order to ascertain exactly how the land lay, he sent,
round somefiiends to the chemists who pretended to be in
want of the address of a first-rate English or American
physician. The result was that the same two or three
names were almost invariably given, and, these, curiously
enough, were the saiho as were recommended in the hotels^
and in many cases the persons designated were not British
practitioners at all.
Let anyone who reads this, and who knows of a patient-
now or recently under the care of an English physician re-
cnmnieud by the hotel keeper, consult the English Medicaid
Directory or Register, and I will engage to say that in,
three cases out of four, whatever may be the qualifications
of the person guaranteed as an English physician, his name,
will not be found in either of these volumes, a clear proof
that he has no right to bear any such title. It would be.'
easy enough to multiply cases of imposition on the part of
: r Coor'Ie
O
512 The Lancet,]
THE CASE OF WILLIAM KERR.
[Feb. 28, 1891.
hotel keepers and chemists. 1 also know of the case men¬
tioned by Dr. Barnard where 25 per cent, was regularly
deducted from the gross total; and it is not long since 1
was offered the patronage of a leading courier on the same
terms.
Some years ago Dr. W. Chancellor, writing to a Baltimore
paper from the Continent, expressed himself as follows :—
“ 1 feel that I would be but ill acquitting myself of a duty
were I to fail to administer an admonition to those of my
•compatriots who may one day ;journey into this land, and I
hope that they will take heed to what I say, for it is whole-
<3ome. I would strongly advise Americans who contemplate
•travelling upon the Continent to be very chary of patronis¬
ing physicians recommended by hotel or boarding-house
keepers, concierges, porters, &c., without first having in-
•quired of their consul, or their banker, or some friend, as
to the standing of the party recommended ; for it not un-
frequently happens that these parties plot together exclu-
48ively as a matter of personal gain, and without any regard
whatever for the well-being or interest of those whom they
Advise. It would be well for persons visiting Europe either
to obtain the addresses of competent medical men in the
various cities they propose visiting before leaving home, or
on their arrival to get advice from some reputable person
•out of husintss and above taltinq a comminsiony otherwise
they may have a tenth-rate doctor introduced as the
■‘former physician of the Emperor,’ ‘the chief of the hos¬
pitals,’ ‘the doctor to the American Legation,’ or some
other high-sounding but fictitious title, and they may be
left in his hands to be robbed, maltreated, perhaps
murdered. Travellers, in fact, should make it a rule
io take any other physician than the one proposed
>by a lanalord, or concierge, or courier, unless the
medical man thus recommended be a compatriot or
as endorsed by some disinterested person, and they should
■insist upon having the doctor of their choice, if they have
a choice, really sent for, taking no excuse for any delay or
neglect in regard to the matter.” As regards the danger of
being murdered, that is perhaps ^ing a little too far, but
there certainly is danger to the patient that the hotel
keeper’s physician may not have independence enough to
insist upon sanitary matters distasteful to the proprietor,
and so oblige him to run a greater risk thau he need do.
I Tnfi ,in tA.in that this practice of the exclusive recommenda-
<tion of an hotel favourite has degenerated into an
ainjust monopoly, against which those who have been
persistently left out in the cold have a right to protest.
A.8 I live within a hundred yards of an English chemist in
’the Champs Elya^es, I am generally supposed to derive
a number of patients from this source. I may state that
it was on iny encouragement, if not at my suggestion,
'that the proprietor substituted the practice of giving a
printed list of English and American practitioners to
■every English speaking person inquiring for a doctor,
instead of recommending any one man. I am glad to
see that Dr. Barnard has had the courage to commence
the attack upon this abusive monopoly. I cordially hope
that now it is under investigation the subject will be
•carefully considered by the profession in England, and
that it will lead to proper advice being given to patients
about to travel on the Continent. If no better advice can
be found for a given case, remember Dr. Chancellor’s recom-
tmendation, “ to take any other physician than the one
proposed by the'landlord or concierge,” and, let me add,
•the chemist. This will always be timely counsel.
In conclusion, let me add, that to a certain extent the
public can judge of a man by his fees. There is no English
physician here who asks more than a guinea a visit,
most of us charge the more convenient price of a Louis. If,
then, a medical account exceeds these charges the patient
anay suspect that he is being victimised, and that his
amiable landlord is also having a finger in the pie.
I am, Sirs, yours faithfully,
Oscar .Jennings,
Paris, Feb. 23rd, 1801. M.D. Pari.s, M.R.C.S. England, &c.
THE CASE OF WILLIAM KEUR.
To the Editors of The Lancet.
Sirs,—W e have read your leading article on the case of
William Kerr, and we trust to your sense of fairness to
insert the following reply.
It is a singular circumstance that the theory of consent
should he put forward a year and eight months after the
trial. It is well known here tbat the prisoner had the
advantage of skilled medical assistance at the trial ; that
two medical witnesses were in court prepared to support by
their evidence the theory of consent, but they were not
called. The prisoner’s counsel, confessedly one of the ablest
barristers on the circuit, after hearing the evidence for
the Crown, declined to call tliom. One of these wit¬
nesses subsequently took an active part in obtaining
a remission of the sentence: he abandoned the consent
theory, and in a memorial which was presented to the
Home Secretai'y in May of last year, and which was infiuen-
tlally signed, he has put forward an entirely new theory,
quite inconsistent with the theory of consent. It is in this
memorial that the suggestion is made that we probably
caused the injuries, and we are glad to see that you say it
would manifestly he unfair to us to suppose that we would
commit such a blander. With regard to this memorial, as
we may have to refer to it at some future period, we need
only say at present that there is absolutely no foundation
for such a charge, and that the statements upon which the
theory is founded are purely fictitious. With regard to our
evidence we are not conscious that we gave any which can
he called equivocal, and we do nob think that we gave any
one-sided interpretations of facts. The investigation which
we undertook in the public interest was a laborious
one, we felt its difficulties and its responsibilities,
and we were determined to make it as exhaustive and
impartial as possible. We can point out with satisfaction
that no new fact, so far as we can learn, either for or
against the piisoner, has been discovered since the trial. In
your report of the ease^ you say, “ It must be admitted
the evidence against him [the prisoner] was very strong,”
and you are good enough to conclude an excellent summary
of the trial in these words: “It is only just to add
that the reports of Drs. Henry Barnes and Maclaren
Avere admirable, showing that all their various examina¬
tions of the body of the deceased, of her clothing and
the prisoner’s, and of the various localities had been
of a most exhaustive character, leaving nothing to he
desired.”
We accept your two questions, and shall proceed to deal
with them in their order.
I. Had the woman been ravished? We think we can
satisfy you that this question must he answered in
the affirmative. As to the evidence of sexual intercourse,
it should be stated that this was not questioned at
the trial, or probably a fuller statement of the grounds
upon which our opinion was founded would have appeared
in the depositions. The woman was found on her back,
with her clothes down behind and up in front, the chemise
only covering the thighs nearly to the knees ; the legs were
separated, about eighteen inches between the feet; the
front of both thighs were smeared with mud, which she
could not have done herself, but which might have readily
been caused by a man with muddy trousers ; and then,
finally, there was the smearing of the blood on the external
genitals, the bruises at the orifice and the tears mentioned
ia our report. It is certain that these injuries must
have been inflicted very shortly before death, as there
was no great amount of blood cn her underclothing, it
was mostly on her person. You mention five points against
the theory of rape. 1. The orderly disposition of the
woman’s clothing by the side of the body. The term
orderly is not a correct statement. The clothes are
described as all thrown down together on the hard road
about a foot from the body. With the clothes was
a wisp of false hair, which a consenting woman would
have no object in removing and placing there her¬
self. 2. The proximity to a dwelling - house. The
distance was 102 yards. It was late at night, and the
witness who saw the prisoner pass the house afterwards
went to bed. 3. The fact that no one heard sounds of
alarm. There is strong presumptive evidence that the
first act of the tragedy was a knock down blow which
rendered the woman unconscious. 4. The absence of
seminal stains. Taylor says the non-discovery of sperma¬
tozoa does nob prove that stains have not been caused by
seminal fluid, a fact established by Casper. Emission,
however, is not necessary to establish the crime of
rape. 5. The absence of rough handling of the woman’s
clothes. If the woman was insensible, or even semi-
1 The l.iVNCET, July 20th, 1889.
Google
The Lancet,]
TREATMENT OF DISEASE OF THE UTERINE APPENDAGES. [Feb. 28, 1891 51^
conscious, there is no reason why the clothing should
be roughly handled. There was one tear in the outer
skirt. ,
We have never used the argument which you attribute to
us—that the injuries to the vagina were greater than could
have been inflicted had there been consent to intercourse
with a drunken man, and there is no foundation for such a
statement in the depositions. What we did say was that if
the woman had been conscious the injuries must have caused
great pain, and there would have been evidence of a struggle,
even if she had been a consenting party. Apart from the
utter improbability of asober, respectable woman consenting
to lie down on a muddy, miry bank, we may just allude
to some other evidence against the consent theory. There
was the smearing of blood on the cheek. She had not
placed that there uerself, as her hands were clean. There
was the bruise on the head already alluded to. A severe
blow or fall would cause such a bruise. In our opinion it
was caused by a blow, as there was no evidence on the
clothing or bonnet of a fall. The actual mode of death
might be cited as evidence against consent, inasmuch as a
woman, conscious and unrestrained, would instinctively
make some effort to save herself from suffocation by turning
on her face or side. Kerr himself said, when arrested, “I
saw no woman, and know nothing about her.” He adhered to
this denial after his conviction.
II. Did Kerr commit the crime? The jury have
already answered this in the afBrmative, and no material
facts have come out since the trial. You have already
mentioned some of the presumptive evidence against
Kerr. We do not propose to enter into detail as to
the general evidence, but shall coniine ourselves mainly to
that for which we are responsible. It has been suggested
that the vomit on his coat came from himself. We
made our first examination of his clothing eight hours
after his arrest, when the vomit was still fresh and moist,
and it had no smell of beer, of which he had been par¬
taking freely. Some of it was on the back of his coat,
where he could not have put it himself. As to the blood¬
stains on the vest, we do not think he can have caused
them by blood-spitting; they probably came from his
face; but the smears of blood, epithelial scales, and
mud on the fly of his trousers clearly came from
another source. They resembled closely the stains on the
woman’s thighs and person. As to the red woollen hairs
found in the mud on the trousers, it has been suggested
they may have come from his sister’s flannel petticoat. It is
important to remember the hairs were not simply adherent,
but were found embedded in the mud. Probably the
explanation of their being overlooked in the first examina¬
tion is due to the fact that only a minute portion of mud
was placed under the microscope, and it was in conse¬
quence of the discovery of hairs on the plaster cast that a
further examination was made. There is one other point
which has been commented upon, and that is the absence of
any distinct impression of the prisoner’s knees or toes at
the place where the body was found. It should be stated
that there was a good deal of water in the muddy ditch
across which the woman’s legs were stretched, and there
were many depressions in the ditch filled with water at the
time of our visit. There were several footmarks about.
Only two casts of impressions near the edge of the ditch
were taken by direction of the police, but it is a mistake to
say there were no other impressions.
In conclusion, it must be remembered that the evidence
in a case of this kind must be treated as a whole. Nothing
is more easy than to pick out sundry details from their sur¬
roundings, and to show that these may possibly be ex¬
plained on some other theory (or even on contradictory
theories) than that of the commission of a crime, or of the
guilt of a prisoner. But we think that few will read the
story as a whole without coming to the conclusion which
we hold, that in no other way can the whole facts be ex¬
plained than that the poor old woman was grossly out¬
raged, that in consequence she died, and that Kerr was the
man who did it. The deed was done in darkness, no wit¬
ness can testify to what actually occurred, and on some small
points inferences may be wrong. But even if this is so, the
main facts on which the verdict was given remain unalter¬
able evidences of guilt.
We are, Sirs, yours faithfully,
Henry Barnes, M.D.
Carluk, Feb. 24tli. 1801. RODERICK MACLARBN, M.D.
ON THE OPERATIVE TREATMENT OF DISEASE
OF THE UTERINE APPENDAGES.
To the Editors o/The Lancet.
Sirs,—I am really grateful to Dr. Herman for the way in
which he refers to the “ courage and candour ” with which
I reported the result of a case of removal of the “ovaries ”■
for cardiac dyspnoea—meaning, I suppose, that the result-
was so bad that no one would again attempt the like. 1
feel, however, that I hardly merit his praises, as the case,
instead of being a miserable fiasco, was a brilliant success.
Moreover, only one ovary was removed. I read this case
before the Obstetrical Society of London on April 5bh, 1882.
The chairman, the late Dr. Matthews Duncan, completely
extinguished me. The drift of his denunciatory speech was
to the effect that it is better for a woman to have pain or any
amount of suffering, such as my patient had, rather than have
one diseased ovary removed, xhis was echoed by most of
the members, with the noteworthy exception of Dr. Barnes.
They declined to publish my case in the Transactions,
and it never was published. It is so unique and interesting:
that I venture now to give a brief account of it.
L. R-, aged thirty years, multipara, applied as an
out-patient at the Women and Children’s Hospital, to-
which I was then one of the surgeons in April, 1881. She
stated that she bad been under the care of numerous
medical men, of whom she could give the names of eight or
nine, but she bad never succeeded in getting relief front
attacks of dyspneea. These attacks came on from any
ordinary work or exertion, and had for five years rendered
her unable to do her own housework except to a very
liiuited extent. On admission I observed one of these
attacks, and it was clearly cardiac, the heart being excited
and beating violently. The patient could lie upon her
stomach or on either side in bed, but not upon her back, as
the “ shortness of breath ” was at once induced. During
the day she found out that she could relieve the attack by
sitting upon a stool and bending the body forward so that
the forehead rested upon another stool; also by lying down
“curled up” on one side. There was a marked mitral
murmur. The lungs were sound. Behind the uterus, and
almost in Douglas’s pouch, was a prolapsed ovary, exqui¬
sitely sensitive to pressure, and pain and discomfort con¬
tinued for some time afterwards. My colleague, Mr.
Scattergood, agreed with.me that it was worth while trying
whether removal of this ovary would relieve her, and we
thought ourselves justified in doing this by the great length
of the case, and the absence of any hope of relief by any
other mode of treatment. The curious effect of certain
positions in relieving her and in bringing on the attacks-
also led us to this opinion.
I removed this one ovary through a small incision in the
roof of the vagina, the other ovary being left. It was
examined, and found to the touch normal. The first result
of the operation was spontaneously mentioned by the
patient—namely, that she could lie upon her back with
comfort. The result was to nearly, but not absolutely, cure
the dyspneea. On Sept. 27bh her husband reported that she-
had up to then been able to io her own housework, and
especially to knead the dough, which she never could do
before. It had not been necessary for her to resort to the
peculiar positions again. Of course I could come to no-
other conclusion than that the dyspneea, although cardiac,
was excited in some way by the state and position of the-
ovary. Dr. Galabin kindly made a microscopic examina¬
tion of the ovary, which was cystic. He says ■■ “ The tissue-
near the cysts was in parts greatly infiltrated with inilara-
matory nuclei, especially between the cysts, and the surface
of the ovary and dilated! vessels containing blood were here
seen.” I am content to leave this case to the judg¬
ment of the profession, and to ask if they see any
reason why this removal of a diseased and useless ovary
should not have been done, and if, as the result showed,
great relief was given, why I should have been “ put down ”
and “ sat upon ” by the President, who called the treatment
a “wild proceeding.” Dr, Barnes, however, said he
“ regretted that the attitude assumed by London surgeons
seriously obstructed the progress of this branch of surgery.
All great improvements in surgery were largely due to a spirit
of enterprise, it might be said of experimental research.” I
think I have shown that Dr. Herman’s memory has played
him falsely in his reference to this case; perhaps it also lias
in reference to the five cases he mentions in which the
Co ogle
4)14 The Lancet,]
MIDWIVES’ llEGISTKATION BILL.
[Feb. 28,1891.
patients bad been advised to have the uterine appendages
removed, and got ultimately perfectly well without the
operation. We all know how much patients’ accounts of
opinions of their cases may be trusted. Probably in
several the operation had been merely mentioned as
possibly required at some time. I am mvself not in s^-
pathy with the manifesto of Dr. John Williams and Dr.
'Champoeys; it breathes too much the same spirit with
which I was met. The real secret of this matter is that the
London obstetric physicians are as a body not surgeons,
whereas gynmcology has been becoming more and more sur¬
gical ; and it is a question whether the appointments should
sot be surgical ones, rather than medical.
I am, Sirs, yours faithfully,
James Braithwaite,
Presifleut of the North of England
Leeds, Feb. 21st, 1891. Gynacological Society.
MID WIVES’ REGISTRATION BILL.
To the Editors of TiiE Lancet.
Sirs,— I had hoped that I had made my position quite
clear in connexion with the Bill. It is evident from your
leading article that 1 have not. My contention has been
from the first that it is for the promoters of the Bill to
justify its introduction. This they have not done. Neither
during the debate at the Obstetrical Society nor in their
circular did the Council furnish, or attempt to furnish, any
facts to demonstrate the basis on which they rest their
position. All that is said in the circular is : “From year
to year successive Councils since 1872 carefully discussed
every aspect of the question, and through a system of exa¬
minations gained practical experience as to the value of
examination.” Surely after nearly twenty years’ labour they
might have incontestably proved the justness of their views
by facts, if facts existed. In the next place, I have taken
my stand against the present Bill on the grouixl that
it reverses the principle of all recent medical legislation,
and that it creates a new race of inferior female practitioners
in midwifery. You, Sirs, protest against the same class, if
educated in medicine and surgery as well, so I do not
think there is much between us on that point. You talk
of reasonable legislation to stop incompetent midwives
from practising. I haveironi the first stated that I believe
that IS exactly what is required. But before such legis¬
lation could be passed, surely the grounds for its necessity
must be clearly stated, and the sufficiency of the means
adopted to secure the end demonstrated. With regard to
the satisfaction you say I expressed to the Lord President,
I must remind you that you have omitted a very material
part of my statement—I mean that relating to the paucity
of women attended by any but doctors in my own district,
and also the inquiry as to how it was that of all the women
who receive the diplomas year after year from different
bodies so few of them were found attending the poor and
destitute. It is a tolerably well known fact that these
trained women as a rule prefer monthly nursing at high fees,
and small blame to them. I very much regret the tone
that some have introduced into the discussion—5)r. Holman’s
accusation, for instance, that an appeal has been made to the
cupidity of the profession j and Dr. Grigg’s charges against
his own profession, contained in bis address to the British
Gymccological Society. It seems a pity that he did not
make them during bis speech in the debate on the liiil,
when there were present those who could answer him.
Verily, discretion is the better part of valour. In answer
to him I will ask him who is responsible if doctors are
burned out with insufficient knowledge of their subject?
Surely, I say, those men in the position of Dr. Grigg whose
establishments are advertised as training medical students
and monthly nursing. What has (iueen Charlotte’s Hos¬
pital done in the cause of education in midwifery ? In my
time in London the men who went there, as a rule, were
those who were not anxious to do more than the indispens'
able minimum, and that comfortably.
I am. Sirs, yours faithfully,
Hatflekl, Feb, 21st, 1891. XoVELL DrAGE.
To the Editors of The Lanoe'i’.
Sirs, —I trust, as you have made some very grave state¬
ments regarding my action in opposing the Midwives’
li^istration Bill, that yon will give me room for reply.
In The Lancet of i’eb. 2l8t, p. 444, the writer of the
editorial article suggests that I wish to form a low order of
ractitionera educated in medicine, surgery, and midwifery.
shall only answer this by calling attention to the notice of
motion pub down by me for the last meeting of the British
Medical Association, which, I trust, shows that I am as
opposed to the recognition of midwives as to the recognition
of a barber surgeon, or any itinerant bone-setter, herbalist,
and quack specialist, holding, as I do, that the midwife
must give place to the woman doctor, just as the barber
surgeon bas been displaced by the modern surgeon. The
following is the notice of motion :—
The Refjistration cif Midwiaes. —Dv. Reutoul also gives notice that he
will move : “ It is the opinion of thin meeting that no new order or class
of midwifery practitioners is required, and that any Act passed by Par¬
liament which provided that any man or woman may practise midwifery,
either as a registered midwife or registered medical practitioner, unless
such have undergone a period of four years’ study at a recognised school
of medicine, and possess a degree or diploma recognised at present by
the General Medical Council, would be injurious to the lives of lying-in
women and infants, and prejudicial to tho best interests of the medical
profession. Also, that tho Local Government Board bo requested to put
into force in oacli Union the Oenoral Order of the Poor-law Commis¬
sioners of 1817, Acts 1S2 and 1S3, empowering guardians to pay certain
fees to their medical officers, in cases of childbirth amt puerperal
maladies. That a copy of this resolution be forwarded by the General
Secretary of the Association to the (leneral Medical Council, both
Houses of Parliament, tho President of tlie Local Government Board,
to the daily press, and to tho medical journals.'’
Secondly, you question my statement-regarding Is. 6cf.
midwifery fees. In a late number of The Lancet
the Derby Friendly Societies’ Medical Aseociation adver¬
tised for a doctor,' offering 5s. 3rf. per confinement. Is
it not a fact that some Poor-law medical officers get leas
than 10s. ? Personally, I may say that the fee paid to
me lor attendance on the confinement itself frequently
does not exceed Od Take a case of a 30.?. confinement fee.
The woman comes to engage me and is certain to want
twenty minutes’ consultation and a prescription. Then I
have to go out at night to her confinement perhaps twice.
Next I have to visit her again on the night of the
confinement. She will expect to be visited during the
fourteen days following the labour. It is 50 to 1 she
will also ask that her baby be vaccinated free—i.e.,
included in the confinement fee. That latter means for
me—writing to London for calf lymph and paying Is. 2d.
for it, seeing the child to see that it is fit, vaccinating it,
inspoebing the arm, and filling up the certificate. I do
not think any reader will consider the above an exaggerated
picture of general practice. I regret the above conditions ;
bub the competition of medical charities, midwives, doctors
who keep unqualified assistants, State vaccinators, and
younger practitioners all tend, by an unhealthy competi¬
tion, to keep the fees down. I know very well that those
who pay roe my lowest confinement fee of 30s. can readily
pay me 50s , but thus they can get Dr. So-and-So to attend
for 20s., 25s, or .30.?. ! I do not in the above estimate
include bad debts. Now, Sirs, taking the above 30s. con¬
finement fee, and counting that I must give at least
ten visits, this gives me 3s. Crf. per visit, and practically
nothing for the confinement. I do nob include the
vaccination and its usual three visits. Indeed, most
general practitioners own that the fee paid nominally for
the confinement gives them on an average 2s. ijd., 3s, (id., to
5s. per visit, and leaves nobbing for attendance on the
connnement itself. I wish that general practitioners would
honestly speak out, and let you know the real state of
affairs. At present I know good men who are going out
for a fee of Is., and to confinements for less than 10s. I
have no ends to gain by exaggeration, and no one has yet
shown my statements to be wrong.
I am, Sire, yours faithfully,
llOllICRT BeIU llENTOUL, M.D.
Livorpodl, Feb. 2;5vd, 1891.
*,* We gladly give Dr. Kenboul, as we have freely given
before, room to expound his views—in our opinion extreme
views, which do not place the profession in a good light
before the public and Parliament. His statement before
Lord Cranbrook that “many medical men were willing bo
attend midwifery for 7s. M." still appears to us one of
the most astounding assertions which any medical man
assuming to represent the profession could have made,
especially when considered in connexion with a proposal
of his to ask Parliament to prohibit midwives attend¬
ing a case under 15s. And, in our judgment, hia attempt
to justify it fails' completely. The offer of a Friendly
The Lancbi,]
THE MICROBE OF MALARIAL FEVER.
[Feb. 28, 1891. 515-
Society of 5^. Zd. per conSnement is surely not a proof
that “many medical men are willing” to accept such
terms. Ho tells us. that the fee paid to him for a confine-
ment does not exceed sixpence. To reach this conclusion
he has to spread the fee of 305., which is his lowest, orer a
daily attendance for fourteen days, to regard the interview
withhim for making the engagement as a visit, and to include
one or two possible night visits. This seems to us very
far-fetched. Wo all know that many of the cases of a busy
obstetrician take only a short time, and require very few
subsequent visits. But if Dr. Rentoul’s own fee of 30s. is
so inadequate, why did he represent to Lord Cranbrook that
many men were willing to go for less than the»fourth of that
sum ? Again, referring to Dr. Itentoul’s attempt to answer
our remark that the tendency of his arguments or of his
agitatibn is to create a new class of medical women, “ I do
bold,” he says, “that the midwife must give place to the
woman doctor, just as the barber surgeon has been displaced
by the modern surgeon,” bub he does nob tell us how the
10,000 midwives are to be gob rid of. The midwife has
survived the barber surgeon, and is recognised as a fact,
to the number of 10,000, by law, by the profession, and
by the public. We approve legislation that would provide
a respectable woman with some training for ordinary cases ;
hut we object to more than this. We do not want medical
women imported into this business, and the’proposal is un¬
fortunate and uncalled for. Midwifery is laborious work
for men, a fortiori for women. In the simplest cases the
midwife may act. It is not conceivable that any legislation
would absolutely forbid her acting. But it might do two
things. Indeed tLe necessity for its doing two things is
urgent—viz., to stop the practice of midwifery by the in¬
competent, and to insure an amount of training that will
enable a midwife to know when a case is abnormal, and
impose a solemn obligation on her in such circumstances
to send for a medical man.—E d. L.
THE MICROBE OF MALARIAL FEVER.
To the Editors of The Lancet.
Sirs,—I t was only a few days ago that my attention was
drawn to the annotation in your issue of Dec. Cth, 1890, in
which you refer to a statement from a Monsieur Daruty,
who stylos himself Director of the Microbiological Labora¬
tory of the Royal Academy of Arts and Sciences of
Mauritius, contradicting the assertion I made in my article
on the discovery of the malarial parasite in Mauritius (The
Lancet, Aug. ^.Ird, 1890). I beg strongly to protest against
any criticism upon my researches coming Irom Monsieur
Daruty’s pen, for the simple reason that that gentleman,
who has never left his native isle, is not a competent person
to form an opinion on the subject which my paper treats.
Monsieur Davuby is the Curator of a small museum in
Port Louis, and as such he is responsible to the Govern¬
ment for the microscope which belongs to that institu¬
tion. I am astonished at his assertion that I showed him
my specimens, whereas only one out of the sixty that
I took from the fifteen patients I examined actually came
under his observation, and that by a mere accident, whilst,
together with a fellow-graduate of the London University,
I was examining that specimen undec the microscope of the
museum. I remember bis remarking that the solid, small
round body, seen in profile, adherent to the disc of a red
corpuscle, was a vacuole, but we treated the remark as it
deserved, and I never again had occasion to use the museum
microscope. Several of the specimens revealed this sessile
pearl-like body (distinctly seen to bo solid when caught' in
profile), and also the non-nucleated pigmented spheroids
which are a further development of the former, bub I was
not positively certain at the time that these were the
parasites I was looking for; it was only after my return to
France, after seeing Professor Laveran’s specimens, that I
became convinced of their identity with these.
In conclusion, I beg to state that Dr. Chevreau, who was
not in the Mauritius when I was there, and who never saw
my specimens, speake sans conncUssance de cause in his-
criticism on my researches. Begging you to insert this-
letter in The Lancet,
I remain. Sire, yours faithfully,
Daniel E. Anderson, M.B., B.A., B.Sc.Lond., &c.
Paris, Feb. lOtb, 1801.
AMBULANCE CLASSES FOR THE MERCANTILE
MARINE.
To the Editors of The Lancet.
Sirs,—S ome influential nautical men have inaugurated
this work in Liverpool, so that at no distant date it may
fairly be expected few vessels will leave this port without
at least one mate or seaman holding the certifiate of the
St. John Ambulance Association. This movement,
initiated as it has been by employers and not by seamen
themselves, marking the commencement of a new era in
marine sanitation, induced me on the 9tb Inst, to address
a respectful letter to the manager of the Shipping Federa¬
tion, pointing out that, as these classes were to be
“specially adapted for sea service,” the medical instructors
should iuclude in the course the subjects of ship sanitation
a'nd personal hygiene, and that the practical result would
be that iusanitary conditions on shipboard could in future
be respectfully reported to the owners and the Board of
Trade by these men who were trained in the ambulance
course. But one practical difficulty I have submitted in a
letter to the leading Liverpool shipping paper—viz,, “'Will
not masters, mates, engineers, and seamen holding Ambu¬
lance eertifleabes hesitate bo use their knowledge by sub¬
mitting to their employers anything like a report upon
insanitary matters lest their personal interests should
suffer thereby? In fact, somewhat like the ship’s surgeons
of to-day, who, possessing no locus standi on shipboard, are
tempted to shut their ears to seamen’s complaints of faulty
ventilation. I feel so strongly the vital importance of this-
subjeet that I have solicited the opinion of the profession
through The Lancet and British Medical Journed." With¬
out further encroaching upon your valuable space,
I am, Sirs, yours faithfully,
Charles Henry Leet, F.R.C,S.,
I.atB Surgoon-Major Royal Engineers..
Heafovth, Liverpool, Feb, 23i'd, 1891.
LIVERPOOL.
(From our own Correspondent.)
Discussion on Cremation at the Medical Institution.
There was a well-attended meeting. at the Medicat
Institution on the 12th inst., a large number of
members being present, to hear Dr. Hope’s paper on
the subject of cremation, and to vote for or against,
the following resolution: — “That this Society reco¬
gnises the sanitary advantages of cremation as a means
of disposal of the dead, and considers the establishment of
a crematorium in Liverpool, under suitable regulations, as
free from objection.” Dr.- Hope’s paper was studiously
moderate, showing the advantages of cremation' as
a means of disposal of the dead and meeting the
various arguments against it. While admitting all the
advantages of our present reformed burial system,
he contended that there must be great dilficulty before long
in acquiring the large quantity of land which will be
necessary for burial purposes, it being requisite to provide
for the d^isposal of the bodies of the 15,000 who die annually
within the city of Liverpool and its suburbs. The discus¬
sion, in which many members and two lay visitors—Mr.
Alfred Holt, ex-chairman of the Dock Board, and Mr.
Boulnois, City Engineer—took part, was very interesting.
The general feeling was in favour of cremation as a
voluntary principle, and the resolution was carried by an
overwhelming majority.
Royal Southern Hospital Nurses’ Home.
The new nurses’ home in connexion with the Royal-
Southern Hospital, which has just been completed, was
opened on Feo. Mth. The new home* which adjoins the
hospital, has accommodation of a very complete character
for forty nurses, each nurse having a separate bedroom,
while the bath and sanitary arrangements are in the best
style. The nursing institution in connexion with this
Digitized by ^ooQle
516 ThbLanckt,]
BIRMINGHAM.—NORTHERN COUNTIES NOTES,
[Feb. 28, 1891.
hospital was first established ia 1880, and has been so
successful as to require this new and enlarged building. In
the course of the proceedings Dr, Cameron, the senior
physician to the hospital ana chairman of the building
committee of the new home, stated the reasons which had
induced them to build the new home, adding that it was
their desire to provide in close proximity to the hospital
the means of leisure and recreation necessary to the health
of the nursing staff; and whilst teaching the details of
medical and surgical nursing, in order to tit the nurses for
the useful and honourable career they had chosen, to protect
them from unhealthy infiuences, and enable them to renew
their duties with vigour and usefulness. He hoped that
ceremony would ename the hospital to take a place among
the most valued philanthropic institutions of the city.
Coroners' Juries and Vieioing Bodies.
Some months ago Mr. Brighouse, the county coroner,
dispensed with the viewing of a body on the grounds that,
as it was in a very advanced state of decomposition,
such viewing might be attended with danger to the health
of the jurors. More recently the deputy coroner for Leigh
has left it to the jury to decide whether such a duty is
necessary, and in an evening local paper it is stated that if
the body is identified by a relative, its inspection by the*
coroner, by one juryman, or by a police-constable would
sutlice. Until, however, this is settled authoritatively, an
inquest without a view must remain null and void.
Swing-boat Fatalities.
Several accidents have recently occurred from the swing-
boats which are to he found on vacant pieces of land in
different parts of the city. In two the result was fatal.
A hoy aged fourteen died in the Northern Hospital on
the 12th inst. from injury to the head received from being
struck by a swing-boat two days previously. A fireman,
twenty-one years of age, died on the 11th inst. in the
Royal Southern Hospital from the effects of an injury to
the head caused by his falling out of a swing-boat. A
boy bad a wound on his head dressed at the same hos¬
pital, he having received it in a similar manner. Nothing
should be easier than to prevent by the most ordinary care
most, if not all, of these accidents. Swing-boats could be
so constructed that it would be next to impossible for any
one inside to fall out of them; while the fact that it is
possible for a boy to go so near one while it is in
motion shows great carelessness.
Liverpool, Feb. 2itb.
BIRMINGHAM.
(From our own Correspondent.)
Hospital Befonn.
It will he remembered that some months ago, acting upon
the suggestion of the mayor, a special representative com¬
mittee was appointed to inquire into the subject of hospital
abuse in Birmingham. The report has just been issued,
and will be presented at an adjourned conference of repre¬
sentatives of the charities and of the medical profession to
be held on March 9bh. At the close of the inquiry the
committee passed a hearty vote of thanks to his Honour
Judge Chalmers, and eulogised the valuable services he had
rendered in bis capacity of chairman during the proceedings.
The report is an exhaustive one, and gives evidence of
careful consideration of the subject at issue. A form of
questions of a close kind was sent out to fourteen of the
medical charities of the city and district; seventeen wit¬
nesses were examined, nine of whom were medical men,
acquainted with the working of the respective charities and
the grounds of complaints generally. The alleged abuses
oft reiterated were discussed, and are well known to the
profession. The work of the hospitals, the committee
rightly say, fundamentally consists in the treatment of in¬
patients, to which the expenditure is largely devoted. I’rac-
tically no complaints were made against this management.
The report adds that no subscriber to the hospital should
think that bis money has been wasted, and no friend of
the hospitals should relax his efforts to promote their elii-
ciency and welfare. The number of patients treated is
very large According to the returns furnished there were in
voluntary hospitals in 1889 patients—namely, 8611
in-patients and 141,830 out-patients. The list of hospitals
includes the West Bromwich Hospital, with 6485 patients,
but does not include the General Dispensary, with 20,899
f atients; nor does it include the patients in the Workhouse
nfirmary, or the 8351 who received out door relief from
the guardians. The suggested reforms form an important
pawt of the report. They are as follows: The first essen¬
tial ia to devise some means by which the hospitals can
take collective action, and the committee suggest the
formation of a general council, on which all the hospitals
should be represented, as well as the Hospital Saturday
and Sunday Funds; also the City Council and the guardians
should be represented. The functions of such a council
would be almost purely consultative. It would have no
power of enforcing its opinions on individual institutions,
except so far as it could bring public opinion to bear on
them. Secondly, it has been suggested that an inquiry
agency should pe formed in connexion with hospitals, for
the purpose of investigating the financial means and position
of applicants for hospital treatment. It has been suggested
that the Charity Organisation Society could best supply
the necessary machinery. But whether it would be better
to work in connexion with or independently of that Society
appears to be one of those matters which is proper for the
determination of the proposed General Council. Thirdly,
it has been suggested that the committee should recom¬
mend the formation of a self-supporting provident dis¬
pensary. In concluding the report the committee recom¬
mend : 1. The formation of a General Council representative
of all the public medical institutions of the city. 2. The
formation of an inquiry agency to investigate the cir¬
cumstances of applicants for treatment at the hospitals.
3. That, apart from first aid and urgent cases, regulations
should be framed by the hospitals to exclude trivial cases
and cases where either the patients are in a position to pay
for.such treatment as they may require, or which could be
more properly dealt with under the Poor Law. 4. That
facilities should be given for cases so excluded being dealt
with by dispensaries or provident associations. 5. That
any person recommended by an approved provident associa¬
tion, or by a qualified medical practitioner, should, as a
rule, be admitted to the out-patient department of the
hospitals without further formality. Some minor expres¬
sions of difference of opinion amongst members of the com¬
mittee are noted ; but, taken as a whole, the subject of the
inquiry has been dealt with in an exhaustive manner.
What the practical outcome will be is difficult at present
to determine, but the exertions of the committee will at
least have had the effect of bringing into prominence the
widespread feeling that something should be done towards
remedying the defects and grievances attending the present
system of working out patient departments.
Feb. 2Dth.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Northern Counties Hospital for Consumption and Diseases
of the Chest, Newcastle.
The annual meeting of this charity has been held,
and the report stated that 1020 out-patients had been
treated. Of this number, 244 were cured, 744 relieved,
and 0 died. There had been 12 in-patients, 3 of whom were
cured, 8 were relieved, and 1 died. The financial state¬
ment was satisfactory. It having been resolved to try the
Koch treatm'enj in some cases, a supply has been obtained
from Dr. George Murray, who has recently been to Berlin,
and has presented the fluid to the institution, and it is
being tried in three cases, which seem to bo deriving
benefit, but it is too soon to speak decidedly on this point.
The Shidy of Bacteriology in Newcastle.
At the last meeting of the North of England Veterinary
Medical Association Dr. G. Murray showed, on the invitation
of Mr. Clement Stephenson, some hearts of pigs which had
died of endocarditis ; the cavities of these heaj'ts abounded
with valvular vegetations, and the microscopic slides of
these growths were distinguished by bacilli, the exact
nature of which, however, it v^as irapos-siblo to define. The
College of Physical Science has afforded Dr. Murray facili¬
ties for pursuing the study of bacteriology, and we look
in Newcastle for some important results from this new
laboratory.
The Newcastle Health Society's Lectures.
The Newcastle Health Society’s lectures, so successfully
inaugurated by Dr. Wm. Murray, are creating a good deal
Di(.' zodfc/" lOOglc
The Lanoet,]
SCOTLAND.
[Feb. 28, >1891; 517
of iQkerest, which has been fully maintained by the able
and popular lectures of Professor Oliver on “ The Air we
Bieathe and the Clothes we Wear.” Both at these lectures
and at the lecture given by Dr. Howden on “The Human
Body” the attendance has been very large and the auflience
appreciative.
Annual Meetings of Medical Charities.
The annual meeting of the Gateshead Dispensary has
been held, and from the report it appears thac the
number of letter patients treated was for the past year
,‘3404, and the number of casual and accident cases 12,222.
The total number treated by the institution was 15,626.
Scarlet fever had proved fatal in many cases, and was con¬
stantly present in the borough. With a view of diminishing
■this and other infectious diseases the report is in favour of
the compulsory notification of diseases being adopted and
enforced. The financial condition of the dispensary was
shown to be satisfactory. The annual meeting of the Gates¬
head Children’s Hospital has also been held, at which the
Bishopof Durham spoke strongly in favour of the institution.
The total number treated during the year had been 863,
consisting of 789 out-patients and 74 in-patients. The
financial condition of the hospital was satisfactory.
Death of Dr. G. S. Dixon.
I regret to note the death of Dr. George Seymour
Dixon, long the oldest practitioner in Gateshead, where
he had resided for fifty-two years. He died on the
&.5thinst,, and was interred on the 19bh. His remains
were followed to the grave by the members of the Gateshead
Medical Society and numerous friends and former patients.
Dr. Dixon, who was in his eighty-first year, was noted
during his long career for his strict attention to the rules
■of professional etiquette and for his courtesy and kindness
to his brethren. lie held that in a brother’s unavoidable
absence it was only a duty to fill his place and do the best
for him until his return, when, the patient’s wishes being
regarded, he was to be honourably handed back to his
'family attendant. He was sometimes considered severe
on those who did not sufficiently regard this rule, but
it worked well in Gateshead for all who adopted it, and
may be said to have given a high tone to medical practice
in the town. Dr Dixon has left two sons in the profession.
Another son, in the legal profession, is honorary secretary
to the dispensary,
Darlington Hospital.
The annual report just issued refers to the completion of
the increased accommodation in the domestic department
which had been provided by Mrs. Pearse. The statement
of income and expenditure is fairly satisfactory. The
total receipts amounted to £1171, against £1.351 in the pre
vious year. The committee solicit the aid of the sub¬
scribers in preventing persons able to pay for medical
attendance from obtaining the benefits of the hospital; 160
in-patients had been admitted during the year, the largest
(number of any previous year; 3377 out-patients’tickets
were received at the dispensary. Of these, 877 were double
tickets—that is, requiring attendance at their own homes.
It is stated that Mr. H. B. Brady (son of the late Mr. H.
Brady, surgeon, of Gateshead), the eminent chemist and
naturalist, whose death I noted lately in this corre¬
spondence, has left the sum of £1000 to the Natural History
Society of Newcastle for the promotion of its objects.
Dn-atum —In my communication last week, referring to
the zymotic death-rate of Whitby, by a printer’s error I
am made to give that rate as 4-0 per 1000. It should, of
course, have been 0'4 per 1000.
Nswcasfcle-on-Iyne, Feb. 25tb.
SCOTLAND.
(From our own Correspondents.)
EDINBURGH.
Royal Edinburgh Asylum.
The annual meeting of the Corporation of the Royal
^dinbuvgh Asylum for the Insane was held on Monday.
After the treasurer’s report was read and adopted, Dr.
vlouston submitted his report for the past year. The total
number of patients under treatment was 1156. There had
been 322 admissions and 226 discharges, and 109 deaths.
Ihe number of rate-paid admissions was 225. It was a fact
that did not tend to bear out the popular ideas as to the
rapid increase of mental diseases in recent years that the
yearly production of pauper lunacy in the district had
scarcely risen appreciably during the past fifteen years,
The production of pauper insanity was with them
not keeping pace with the growth of the population.
They seemed to be a saner people in Bdinburgh
than they were fifteen years ago, for in that time the
population had increased SO per cent,, while the annual
production of pauper insanity was only 37 per cent, more
at the end of that time than at the beginning. There was,
however, a steady increase in the total number from the
accumulation of uncured cases. This continuous increase
or silting up must, however, stop in time if the new pro¬
duction did nob^ncrease year by year, for a chronic lunatic
must die sometime; and this process of diminishing
accumulations of incurable cases had clearly begun. There
were two marked facts in connexion with the cases
admitted. The one was that the average general health and
condition of the patients were lower toan usual; the other
was that in the two chief divisions made of the mental
condition of patients—namely, melancholia and mania—
the cases of mania commonly greatly predominated. During
the past five years the cases of mania exceeded those of
melancholia by 37 per cent., while during last year they
had 140 cases of melancholia and only 134 of mania
admitted—quite an unprecedented experience. He had
come to the conclusion that there must be causes for this,
and from his observations generally he believed that the
year 1890 was. one depressing in its conditions to the nervous
tone and lowering generally to human vitality. Whether
it was the influenza in the early part of the year that had
perceptibly lowered human vitality, or whether the pre¬
valence of the influenza merely showed that European
humanity was in a lowered state of vitality, so being a
fit nidus for the influenza germs to propagate in, or whether
it was the sunless, aummerless general character of the year,
he could not say. He distinctly connected, however, the
influenza in some way with the unprecedented number of
melancholic patients sent to them. He believed the epi¬
demic of influenza of 1889-90 left the Euroi)ean world’s
nerves and spirits in a far worse state than it found them,
ami that they scarcely yet had recovered < their normal
bone. The poison seemed to burn up the nervous energy
and leave the brain in some cases unable to recuperate. He
next dwelt upon the dangers attending the period of
adolescence, and thereafter considered the causes of death,
and referred to the observations made in the asylum during
the influenza epidemic.
Scottish Microscopical Society.
The fifth meeting of this Society was held on the 20th
inst., Professor Rutherford, F.R.S., in the chair. Dr.
Joseph Coats of Glasgow was elected by the Council a vice-
president of the Society, in place of tne late Mr. Schulze.
Dr. G. Carrington Purvis, B.Sc., gave a communication
on the Microscopic Structure of the Electric Organ of
Raia Fullonica. He traced the development of electric
organs from muscle as originally described by Babuchin,
and showed that in Raia Fullonica the “cup” type of
electric organs is highly developed. Each cup has a thin
nucleated mass of protoplasm, the electric layer lining its
concavity, in which the nerves end. The existence of an
electric organ in the skate was discovered by the late Dr.
Stark of Edinburgh; and Dr. Burden Sanderson has shown
that it produces feeble electric currents. Dr. Robert Muir,
junior assistant to the Professor of Pathology in Edinburgh
'University, read a paper on Blood Plates, and gave reasons
for regarding them as distinct elements of the blood. He
described their characters as seen in fresh blood, in various
preservative fluids, and in films prepared by Ehrlich's
method. He discussed Hayem’s theory of their being
hiematoblasts about to become red corpuscles, and regarded
it as untenable. He detailed the results of elaborate
enumerations of blood plates, leucocytes, and red corpuscles
in artificial anmmia and in various diseases. He showed
that blood plates are found only in blood, and not in lymph
from tlie thoracic duct; that the theory of their being the
nuclei of broken-down multi-nucleated leucocytes had some
facts in its support, bat was still unproved. Both papers
were illustrated by numerous diagrams and preparations,
and excited much interest. Mr. Frazer, optician, explained
a new metliod of adjusting a double nose-piece to give a
miniuium of trouble to the microscopist.
518 The Lancet,]
•IRELAND.
[Feb. 28, 1891.
Health of Edinburgh. ^
Tbe mortality laet week was 82, making the death-rate
15 per 1000. Diseases of the chest accounted for 23 deaths,
and zymotic causes for 7. The intimations for the week
included 22 cases of typhoid fever, 9 of diphtheria, 33 of
scarlatina, and 37 of measles.
Royal Physical Society.
At the meeting of this Society last week Dr. William
Russell read a paper on Robertson’s Prevertebrai Haemo-
lymph Glands, _
ABERDEEN.
The Aberdeen Dispensary. •
In the report of the dispensary for tbe past year it is
stated that the total numoer of cases treated during tbe
year was 10,769, being an increase on the previous year of
226. The number of ordinary and zymotic diseases was
8666, being an increase on the previous year of 137 ; there
were 212 midwifery cases—a decrease of 32 ; vaccinations,
482—a decrease of 115 ; dental operations, 893—an increase
of 15. In addition to these, special attendance is given on
the afternoons of Tuesdays and Fridays for diseases of the
ear and throat and diseases of women. Of the former class,
305 cases were treated, and of the latter 211. There are
eight qualified midwives attached to the institution, and
during the year sixty-two medical students paid for
admission to the practice of the institution. Medicines cost
£243 19s. ^d., as compared with £261 for .1889. With
regard to the work done by the medical otRcers, tbe com¬
mittee of management state that they have again to thank
those gentlemen for the excellent way in which they have
performed their duties during the past year. The com¬
mittee regret that Dr. Gibson, one of the medical officers,
has by severe illness been prevented for a considerable
period of the year from undertalcing his work ; bub the
same has been efficiently performed by his substitute. Dr.
Beveridge. Dr. Gibson has sent in bis resignation, and the
committee recommend the appointment of Dr, Beveridge at
the coming general meeting of managers. Soon after the
annual meeting of managers in March, 1890, the committee of
management had before them a communication from Pro¬
fessor Stephenson on the subject of providing a maternity
hospital. At present the students and nurses attend mid¬
wifery cases at the patients’ homes. Owing to impending
changes in medical education and contemplated public
improvements in the neighbourhood of the dispensary, the
committee resolved to delay consideration of this question
and other matters referred to by the medical olficers in
their report. The financial statement shows a balance of
£135 3s. 5c?. to the credit of the institution.
Health of the City.
Daring the past week the following cases of zymotic
diseases were notified to the medical ofiicer of health :
Scarlet fever, 12 ; typhoid fever, 1; diphtheria, 1; whoop¬
ing-cough, 3—a decrease of 17 as compared with the total
for the previous week, and of 14 in the oases of scarlet fever.
Feb. 25th.
IRELAND.
(From our own Correspondents.)
DUBLIN.
Royal College of Surgeons.
A MEETING of the College was held on Monday, the 23rd
inst., to witness the election of a member of Council in the
room of Mr. A. H. Corley, deceased. As already stated,
there were two candidates—Messrs. Austin Meldon and
William Frazer,^—the former gentleman being duly elected
by a large majority. It is stated that Ilis Excellency the
Lord Lieutenant has accepted the invitation of Mr. Croly,
the President, to a banquet at the College, which will take
place on March 7th.
Dublin Hospital Sunday.
The committee of the Dublin Hospital Sunday Fund
held their annual meeting last week. The report was a
satisfactory one, the total sum collected and available for
distribution being £4332. It is believed that the two
ophthalmic hospitals will shortly be amalgamated—a result
>^ich must conduce not alone to efficiency, but also to
economy^
Patliamentary Grants to Dublin Hospitals.
Tbe annual grant for the coming year for those nine
hospitals which receive assistance from Parliament will be
the sEMue as for previous years—viz,, £15,722 15s. 9c?. Gf
this sum the lion’s share goes to the House of Industry
Hospitals, which obtain £7472 15s 9c?.; while Cork-street
Fever Hospital gets £2500, and St. Mark’s Ophthalmic
Hospital only £100.
Factories and Workshops Act Amendment Rill.
This is a Government measure, and the second reading
takes place this week. It is to be hoped that the 19th
clause will be opposed in the interests of the community.
Under tbe arrangement which exists at present an ap¬
prentice before being admitted to a workshop or factory
requires to undergo a medical examination, showing that
he is not sufiering from any organic malady or con¬
tagious disease, and that he is a fit subject for the
employment he seeks. The l!)th clause of the Bill
rescinds this arrangement. Why it has been admitted by
the Government is inexplicable; it cannot be on the score
of economy, inasmuch as the fee for medical inspection
is paid by the employers, and does not come out -of tbe
Treasury.
Poor-law Out-door Relief.
By the tenth section of the Act passed in 1817 no person
who occupied land more than a quarter of an acre in extent
could be regarded as a poor person and entitled to relief.
This clause was repealed some years since so far as it i'elate<^
to relief inside the workhouse ; and Sir J. Pope Hennea&yis
now promoting a Bill to repeal the quarter-acre clause so-
far as it relates to out-door relief.
Sir George B. Owens, M.D., J.P., has been elected a.
honorary life governor to the Royal Hospital for Incurables.
BELFAST.
Queen's College.
For some time it has been felt that an attempt should b&
made to strengthen tbe corporate feeling of the old membera
of Queen’s College, Belfast. Many men who now hold
important positions in every department of public life were
educated there. It has, therefore, been decided to hold a-
reunion of the Belfast graduates in March in the form of
a dinner, and the President, wbo, since his appointment,,
has been unceasing in bis efforts to advance the interests of
the College, is using every endeavour to make it a success.
Prof. Park, Dr. J. A. I^-indsay, and Mr. R. T. Martin are
the secretaries of the movement.
Death of John Laird Gaussen, M.D., F.R.C.S.Eng.
I have with sincere regret to announce the death of one
of tbe oldest medical men of Belfast, Dr. J. L. Gaussen,
who died on Feb. 22nd, At his residence, Wellington-place,
at the advanced age of eighty years. Dr. Gaussen,
graduated M.D. of Edinburgh in 1831, and in 1859 he
obtained the Fellowship of the English College of Surgeons.
For some time he was Surgeon-Major of the Antrim
Militia, but in later years he had quite given up practice of
any kind.
The Small-pox Epidemic.
I am glad to be able to report that there have been no
new cases since Wednesday, Feb. 18th, and it is hoped the
epidemic will not spread. At a meeting of the Belfast
Dispensary Committee, held on Feb. 23rd, full reports were
handed in by tbe various medical officers us to their districts,
and the propriety of revaccination was strongly urged. On
Saturday night it was reported that three cases had occurred,
in Ballymena, but as the sailor wbo introduced the disease
into Belfast had visited this town, it is probable it was be
who carried the infection. Dr. Staflbrd, Local Government
Board Inspector, along with Dr. Whitaker, is making every
eflforD to localise and to stamp out the disease. One of the
greatest disadvantages that Belfast labours under at present
is that it contains no infectious diseases hospital for non -
pauper patients. The better class of people will not go-
into the Union Hospital, and consequently they must be
nursed at home. If the Town Council adopt the Notifica¬
tion of Infectious Diseases Act, it will be absolutely neces ¬
sary for them to erect a hospital for contagious maladies.
The Ulster Medical Society.
At a largely attended special meeting of the Ulster
Medical Society, held on Wednesday, Feb. 18th, Dr. McCaw,
the secretary, presented a report from the Council contain¬
ing the following resolution passed by them : “That the
Digit d Google
The Lakcbt,]
PARIS.
[Feb. 28,1891. 519
CouQcii of the Ulster Medical Society has with pain recently
Been lepoi’ts from time to time in the daily press of purely
rofessional subjects, which, no matter with wbat’object or
y whom inserted, must be regarded as of the nature of
advertisements for those concerned, and that this Council
considers such publications inj urious to the best interests of
the public, degrading to the honour and dignity of the pro¬
fession, and deserving of our strongest and most earnest
disapproval." On the motion of the President (Dr. Alex.
Dempsey), seconded by Professor Dill, and supported by
Professor Cuming, this report of the Council was unani-
cnously and cordially approved of and passed.
The Boyal Hospital.
The quarterly meeting was held on Monday, and from
<the report I gather that 655 intern patients were treated
during the past three months, while there were 5077 extern
cases. The large deficit existing at the end of last quarter
had been reduced by nearly £500. At the commencement
of the last Buancial year the debt had been £1607, but
during tbe Arst six months of that year it increased to
£1964. The receipts from donations this year are below the
average, and there have been no bequests. In September
the Royal Hospital enters its hundredth year of existence,
and in commemoration of this it has been decided to bold
a fancy fair and bazaar in November. The one favourable
point in the Anancial statement is that the subscriptions
flrom the working classes have increased.
Feb. 24th.
PAEIS.
(From our own Correspondenis.)
Report q/ the St. Louis Committee on Koch's Treatment
of Cutaneous I'tcbcrculosis.
In the latter part of November, 1890, there was con¬
stituted at St. Louis Hospital, as I have already informed
•your readers, a committee composed of Drs. Vidal, Besnier,
Fournier, Hallopeau, Quinquand, and Lailler, deputed to
study and report on the effects of Koch’s liquid on the
cutaneous forms of tuberculosis, more especially lupus. A
male and a female ward were set apart for the purpose, and
a special staff of students detailed for taking and registering
clinical observations. All the patients, numbering fifty,
were first carefully examined seriatim by the assembled
committee, and, the diagnosis verified, the programme of
inoculations for each case (date of repetition and dose) was
made out, subject to modification. Each patientwas, more¬
over, kept under observation for several weeks after the
termination of the treatment (the end of January). All
necessary antiseptic precautions were taken, and the whole
-inquiry rendered as precise as possible. I have already
communicated to your readers the gist of the preliminary
report furnished by M. Vidal {vide The Lancet, Jan. 24th).
'On the 13th inst. MM. Besnier and Hallopeau presented in
their turn to the Sooibtd de Dermatologie et de Syphili-
.graphie a very full report of the proceedings of the com¬
mittee, illustrating it by a table giving the following lieads
of information:—Age and sex of patient; diagnosis ;
number and date of inoculations, with doses ; principal
phenomena of the inoculatory fever; characters of the
local reaction; date when tolerance was established;
other phenomena and complications observed; result of
the treatment ; name of the physician treating the
case. The table contains the history of thirty-eight
•cases, the remaining twelve not being included because
certain of them were eases of leprosy, whilst in the rest
the treatment had either been interrupted or bad been
undertaken too recently to merit a place in the list. After
a few introductory remarks, M. Besnier said: “There is
•one feature attending the application of the method which
the appended table cannot bring home to your minds—no
mere reading will enable you to adequately appreciate its
importance, and I am surprised that, in so many published
accounts of the inoculations, this aspect of the question is
glossed over with such a light heart—refer to the suffering
indicted on many of the patients experimented upon,
whoever has visited our wards six or eight hours after a
series of inoculations of patients who bad not yet reached
wie period of tolerance will never forget tbe speotacle.’’
The above remark fiirnisbes the keynote to the criticisms
“that follow. The speaker added that, although no fatal
result had occurred in their practice, several of their
patients had, despite precautions as to dosage, frequency of
Inoculation, &c., been in danger of falling victims to the
action of the toxise. Two points dominate thehlstory of these
experiments—viz , (1) local reaction: its insufficiency, its pro-
gressive diminution in spite of the increased dosage, and its
ultimate cessation; (2) general reaction: its noxious effects in
certain cases, the serious localisation of its action on tbe
viscera in general, and on the circulatory system in par¬
ticular, and finally the risks of a fatal result even with
feeble doses, and even after a single injection. The com¬
mittee deny the germicidal properties ot the liquid, as also
its power of sterilising the UsBues invaded by the bacillus.
When a patch of lupus is vaccinated with tbe liquid its
local effects do not exceed those excited in healthy skin,
cellular tissue, or muscle into which it is injected. Nay,
there is reason to believe that, thus employed, it tends to
favour the tuberculous process. In a little boy affected
with lupus of tbe lower extremities a patch was vaccinated
with the liquid, and that patch is now, several weeks after
the operation, considerably more florid than its neighbours.
The inoculations provoke local irritation of an exudative
nature, with a tendency to consecutive cicatricial atrophy;
but this tendency is followed by a revival of the tuber¬
culous nodules, which appear to be endowed with greater
vitality than ever. In the cases expeiimented on not only
have all the nodules reappeared, but fresh ones have also
sprung up. As to tbe wleged affinity of the liquid for,
tuberculous tissues, the committee need only call to mind
the following phenomena noted before, coincidently with,
or independently of, the irritation of the lupus patch,
viz , hyperpyrexia, leucocytoeis, diminution of red blood-
corpuacles, cutaneous eruptions, endocarditis, pulmona^,
splenic, and renal congestion, hjematuria, albuminuria,
arthropathies, and many another neurodynia affecting
viscera certainly free from tuberculosis, or which are simply
in a state of physiological, congestion—e.g., the ovaries in
menstruating women. The ephemeral fever of Koch
generally reveals itself locally in cicatricial or “closed”
lupus by tbe provocation of inilammation of an erythe¬
matous, erythemato aquamous, or erysipelatous type, bear¬
ing a great resemblance to the recurrent attacks of I^ympho-
dermatitis so common in cutaneous tuberculosis. In
“open” lupus the reaction is more manifest, being
characterised by a serous discharge, cedema, and the for¬
mation of scabs—a rare occurrence in “closed” lupus. In
all forms of lupus the local reaction may be intense, but at
St. Louis it has never been seen of such violence as to
cause loss of substance. In every case the reaction is only
a passing storm, which subsides in a few days, excepting
when the operation has excited phtegmonous inflammation
in glands, or in the neighbourhood of joints. The storm
over, a more or less marked reduction in volume w
noted in the pathological mass, together with a diminu¬
tion of vascularity of the adjacent tissues, followed
by a certain levelling of the surfaces affected. Some¬
times there is also noted an obvious tendency to cicatrisa¬
tion, which appears extraordinary only ’to observers
imperfectly acquainted with the normal lupic process.
This curative effort is sometimes very remarkable; but even
when it is very marked the tubercle is never destroyed. A
striking case was cited in support of this statement. This
partial or general reduction in volume is not always pro¬
portionate to the intensity of the apparent reaction. It is
observed more particularly in the upper lip or other parts
where the lesion is complicated ny the chronic lymph
ccdema which is so pronounced a feature in certain cases of
lupus. Should this constrictive process occur in lupus of a
cavity, such as the nose, much relief is experienced from
the restoration of the patency of the passage. In buccal,
pharyngeal, and laryngeal tuberculosis the same relief may
be conferred. But even after reiterated inoculations the
previous condition is not only re-established, but it becomes
sometimes aggravated. Of tbe lupic patients who have
benefited the most from the treatment not one has been
cured, the improvement having been only temporary.
In not one of the cases of lupus of the parts
situated behind the nostrils has cicatrisation of the
ulcers been obtained. In the majority of tbe cases
tolerance has been established, and the experiments have
thus necessarily been brought to a premature conclusion.
Even should the susceptibility to tbe action of the liquid
reappear at a future time, .no advantage will have been
gained, for fresh tubercles will have developed in the
meantime.. Ibis a case of “No thoroughfare!” Several
writers have compared the action of Koch’s liquid to that
of the (now rare) intercurrent attacks of erysipelas aome-
D
O
520 Thk Lakcet,]
BERLIN.—CANADA.
[Feb 28, 1891.
times seen. Bat eren in its most intense form the local
reaction excited by tubercnlia never attains the propor¬
tions, nor does it present the same characteristics of form
and duration, of true erysipelas. A single attack of this
latter disease effects a cure apparently more complete than
has been noted in any one of the fifty patients of the
committee. It should be remembered, however, that
even erysipelas never cures lupus. In none of the patients
of the committee has there been obtained a result
superior, or even equal, to that realised in the same
time by ordinary methods of treatment. Painful as these
latter are, they occasion less suffering than is entailed by
the fever consecutive to inoculation. M. Besnier thus sums
up:—" 1. In cutaneous tuberculosis in general, and more
particularly in all the divers forms of lupus, the inoculation
of Koch’s liquid is productive of a local reaction, the
earliest effect of which is the temporary reduction of the
morbid mass. Very appreciable in all the ‘ open ’ varieties
of the lupus of Willan, this atrophic process becomes less
marked in the ‘closed’ varieties, and is still lees in the
dry, sclerotic, fibrous forms. The minimum result is seen
in the lupus of Cazenove, all the varieties of which are dry
and ‘ closed.’ In all these forms the beneficial effect may be
considerably increased by the simultaneous employment of
any therapeutical measures which excite deep irritation of
the lupus, or which convert it into the ‘ open ’ variety. In
the immense majority of cases the treatment, even when
pushed to tolerance, is incapable of curing; it is not
superior, indeed it is nut equal, to methods of treatment in
actual use. 2. In every case without exception, how¬
ever feeble the dose injected, the local reaction cannot be
evoked without the ephemeral fever, the intensity of which
cannot be predicted, but which, even with small doses,
and with a single inocuHtion, may kill the patient.
Even when the patient does not succumb, the toxine
may occasion grave persistent symptoms in relation
more particularly with the circulatory system, the brain, or
the kidneys, not to mention the awakening up into renewed
activity of tuberculous deposits which had hitherto lain
dormant. 3. Such being the case, I do not consider myself,
nor do I deem any other physician, authorised to continue
these experiments with Koch’s liquid. In refusing to per¬
severe with the application of the method, I believe I am
only acting in conformity with the dictates of humanity,
and with that respect for human life which is one of the
noblest characteristics of French medicine. ” M. Hallopeau
continued in the same strain, and gave it as his opinion
that, the therapeutical value of the liquid being at best
extreroeljr limited, itS employment is for the present
contraindicated.
A Simple Treatment of Corneal Ulcers,
M. Valude, one of the ophthalmic surgeons of the (^uinze-
Vingta Eye Hospital, communicated to the Acad6mie de
Mcdecine on Feb. lObh a new method of treating those
troublesome cases—ulcers of the cornea—so simple in its
application, and, according to its inventor, so successful in
its results that it cannot fail to be generally adopted.
Hitherto corneal ulcers complicated with hypopion have been
treated by puncture either by the knife or thermo-cautery,
this operation having frequently to be repeated, and too
often leaving behind it opacities, if not actual staphyloma.
For this unsatisfactory method M. Valude substitutes a
simple dressing, consistingof a pad of salol gauze, which, with
a moistened gauze bandage, elTectually seals the eye and
maintains a certain amount of compression. Before being
applied the eye is carefully disinfected. The dressing is
not renewed until after three or four days have elapsed,
when the ulcer is found to be already healing, and the
collection of pus in the anterior chamber much diminished.
M. Valude states that the cornea tends to regain its original
transparency without any opacities. In corneal ulcers un-
conipucated by hypopion M. Valude, relying on bis ex¬
perience of fifteen successful oases, asserts that this new
treatment is the treatment excellence.
Paris, Feb. 24tJi. _
BERLIN.
(From our ov/n Correspondent.)
Koch’s Method.
At a meeting of the Society for Internal Medicine on the
16th insb., Dr. Thorner, who has used Koch’s remedy since
Nov. 20tb, gave a full account of his observations. He is
of opinion that there is no reason for trying to prevent its*
use in private practice, and that, on the contrary, it
highly and even urgently desirable that it should be made
accessible to all practitioners. He declared the entering of
tubercle bacilli during the application of Koch’s method
into the bloodvessels, and consequent general miliary tuber¬
culosis, to be an extremely rare occurrence. With reference
to experiments on animals, he made the new statemenp
that already existing miliary tuberculosis in animals can be
cured by Koch’s remedy, and that, during the injection
period, certain animals are immune against new inocula¬
tions with tubercle bacillL The bead of the medical)
department of the Prussian army and the Prussian Home
Minister have issued special regulations for the treatment-
of tubercular soldiers and prisoners by Koch’s method.
The former social democratic deputy Viereck has petitioned
the Beichstag to prohibit the use of Koch’s fiuid as dan¬
gerous to the public welfare.,
Professor Angerer.
Professor Angerer of Munich has been appointed Nuss-
baum’s successor as professor of surgery there. He was*
born at Geisfeld in Bavaria in 1850, and studied surgery
under Linhart at Wurzburg. He was assistant, first ta
Linhart and then to Liobart’s successor, Bergmann. As a-
special province he chose the study of coagulation of th&
blood. He has been a university lecturer since 1879, first at
Wurzburg and then in Munich. In 1872 Bergmann and he
together wrote on the relation of ferment intoxication to*
septiccemia. His other writings are reports on the Wiirzburg,
and Munich surgical hospitals, studies on the application of
sublimate, on the excision of joints, &c.
Professor von Helmholtz,
The President of the French Republic has conferred the
Grand Officer’s Cross of the Legion of Honour on Professoi-
von Helmholtz.
German Death-rates for the week ending the 7th inst.
Aix-la ChapelIe,25'4perl000; Altona,30‘8; Barmen, 15-5;;.
Berlin, 17'5 ; Bremen, 10'3; Breslau, 25 4; Chemnitz, 26 .3;.
Cologne, 23 6; Dantzic, 24 4;Dresden, 15’3; Diisseldorf, 20;
Elberfield,22-8; Frankfort, 14'2; Hamburg, with its suburbs,
2r4; Hanover, 166; Konigsberg, 217; Krefeld, 22‘3;
Leipsic, 19-5; Magdeburg, 21 6 ; Munich, 24'S; Niirnberg,
19 ; Stettin, 28'G ; Strasburg, 237; Stuttgart, 19'9.
Berlin, Feb. 22nil. _
CANADA.
(From our own Correspondent.)
Cattle Transport.
The evidence given before the Deputy Minister of Matin©
at the inquiry held last month in Montreal disproved the
various charges of heavy losses during transit, great suffering
of the cattle from cruelty, want of fresh air, and sufficient-
room to permit of their lying down. A statement sub-
' niitted by the steamship companies showed the losses-
during the past ten years to he small indeed—in one line
being only 1 in 2C0. It was generally considered advisable
to prohibit the shipping of deck loads after Nov. Ist of each
year, while some of the exporters were of opinion that
shipment in any manner might cease after that date. The-
exporters, shippers, and employers were unanimous in
disclaiming the acts of cruelty; the cattle were as well
treated on the steamers as at the farms. An exporter-
who has crossed some sixty times with the cattle had
never witnessed an act of cruelty, but considered tli©
men worse off than the cattle—a fact which receivc(6
testimony from several witnesses, the food being poor,
and in some cases supplied in a pail which was used)
for watering the cattle; the sleeping accommodation
also was bad. Mr. Baker, V.S , assistant to the chief
Government inspector, explained how the cattle were
inspected. First being seen at the stock yard, and if in good
health a permit was given to load ; after being shipped an
inspection was made cliiefly with the view to ascertain that
Bullicient space was allowed each animal, it being generally
agreed they should have thirty-two inches in warm and
thirty inches in cold weather. The space permitted cattle
to lie down and rise at will. The steamers on most of the lines-
are now provided with steam fans and condensers, the
latter supplying twelve gallons per head of cold water every
I twenty-four hours. The shipments last year were given-
I as 123,136 head of cattle and 43,372 sheep. The commis-
Coogle
Di:
The Lancet,!
MEDICAL NEWS.
[Fan 28, 1891. rj2l
4)ioner, in concludinc the inquiry, expreased the hope that
it would have the enect of stopping legislation hostile to
C'anada, and in his opinion it would.
Examination for Personal Injuries.
In an action to recover damages for personal injuries—
lleily V. City of London-caused by the alleged negligence
of the defendants, a motion by the defendant corporation
for an order directing the plaintiff to attend and submit to
an exandnation of her person by medical experts chosen by
the defendants was decided recently by the Master-in-
Ordinary sitting for the Master in-Chanibers, as follows :—
*' The ap(>lication of the defendants in this case is to compel
the plaintiff to submit her person to an inspection and exami¬
nation by surgeons chosen by this Corporation, and subject
her to the contingency of being committed for contempt in
■case of her refusal. By the cummou law, any unlawful
setting upon or interference with another’s person is an
assault {itisultus), and therefore what the court is asked to
do by the order desired by these defendants is to authorise
the surgeons nominated by the corporation to do what the
common law forbids; for compelling the plaintiff to submit to
their tactual examination of her person against her will
would come within the definition of an assault. And if
surgeons can be authorised—for there is no magic in the
title of ‘ surgeon’—so may other persons, or even officers of
the corporation. And if these defendants are entitled to
this compulsory exhibition and examination of the person
of this plaintiff in such a way as these surgeons may deter¬
mine, it must follow that they have also the right to have
a similar exhibition and examinatioh made before a jury,
for a jury are entitled to see as well as bear for themselves.
And if one part of the person may be subjected to such an
examination, so may every part, and this judicial sanction
might be given to an act trenching upon another rule of
law governing exposure of the person. On no principle of
law can acts which involve that which is forbidden by the
criminal law be authorised by the court. The motion must
therefore be refused, with costs to the plaintiff in any
■event.”
Death-rates of Canadian Cities.
The mortality returns of the principal cities of the
Dominion for the month of December are as follows:
<5uebec, 2'37; Halifax, 2-11; Montreal, 1-84; Toronto,
1’35 ; Ottawa, 1 '31; St. John (N.B.), 1'26 ; Victoria (B.C.),
0'71 ; Winnipeg, 0'66. Referring to the medical health
offieer’.s report of the city of Ottawa for 1890, a leading
daily says the report records the fact that in one foundling
institution, out of 191 children 110 died, and adds ; “This
seems to be a wholesale baby farm.” That something is
radically wrong with the sanitary condition of Toronto is
evidenced by the great increase in the totality of cases of
p^ymotic di.seases. Quoting from the acting health officer’s
report, the figures are ;—■
1S8P. isoo.
Enteric fever . 273 947
Diphtheria . 290 441
Scarlet fever . 250 353
The reported cases during August, September, and October
of enteric fever were 500^, while during the last quarter of
the year diphtheria was more prevalent, and in .July the
record showed scarlet fever as then most prevalent. The
report further speaks of an “immense number” of privy
pits in use, and suggests their abolition in the more densely
populated parts, substituting dry-earth closets therefor in
reference to waterclosets, as the latter plan “ involves the
anger of cont-iminating our water-supply,” and yet large
quantities of excrement are poured daily into the bay from
thousands of waterclosets, and no voice is raised against
the ever-increasing evil.
Koch’s Eemedy.
Several of the medical men who went to Berlin to study
the treatment of tuberculosis by Dr. Koch’s liquid, have
returned ami given most interesting accounts of their
clinical experience. Dr. J. D. Thorburn reading a paper
thereon before the Toronto Medical Society. Through
.Professor Ramsay Wright, who is still in Berlin, a supply
of the liquid has been received and distributed to the
hospitals of the province.
Training of Nurses.
The commencement exorcises of the Training School for
Nurses of the Toronto General Hospital were held on Jan.
lOtb. The report of the lady superintemlent stated that since
its establishment in 1881 111 had qualified after a two
■years’ course of training; and at present there were fifty-
two pupil nurses during the year. Over 400 applications for
admission were received. The excellent training received
and high standard attained by the pupils are generally
recognised, and many are filling important positions in the
United States and Canada.
Death of Dr. John Stewart.
The death is announced at Kingston of Dr. John Stewart,
for many years dean of the Royal College of Physicians and
Surgeons, Kingston, in the founding of which he took an
active part. Deceased was a native of Perthshire, Scotland,
receiving his medical education in Edinburgh.
Cana<la, t'otj. __ , _
Ptbiral Ittfas.
University of Cambridge.—A t a congregation
held on Feb. 19th the following degrees were conferred:—
BackeloTH o/ Medicine, and Sur^eni.—AlUed Waugh Metcalfe, Trinity ;
Arthur Henry Bindloss, John Croesley Wright, St. .John’s; Victor
Grey Moiteno, Charles Rolfe, Clai'e ; Thomas Horace Uaydon,
Charles Howard I.'sher, Gonvdle and Caius; Henry Sharland Pope,
Cavendish Hostel,
RoYAii Colleges of Physicians and Surgeons,
iREi.ANU : Conjoint Examination —The following have
passed the February Supplemental Examination in Physics:
'r. Cairns, 11. Coffey, T. Conion, J. Connack, B. Coyle, W. Croiy,
O. Davidge, .T. Davis, K. Dolany, M. Delany, .1. Dwyer, G. Fisher,
.7. Foley, M. Goodwin, II. Herrick, K. Hogan, T. Jordan. E.
L'Estraiige, H. Martin,.). Martin, E.Moore, C. OTiorman, T. Palmer
Qleclianics), J. Shera, J. Walsh, W. Whitla, F. Woods.
Army Medical Staff.—T he following is the list
of the successful candidates at the recent competitive
examination for commissions in the Medical Staff of Her
Majesty’s Army:—
Marks. Marks.
Porter, F. .1. Hardy, W. H. 2781 )
Robinson, O. L, ... 302ri Hegbie, F. W. 2770
Brown, F. J.200(1 Burtchaell, C. H. . . . 2700
Hoaly, C. .7.2000 Loiielian, T. J.27(50
Stalkart, C. E. G. . . . 20S() McDowell, F.2'730
Gibbavd, T. W.2025 Faiclmie, N.2755
Buist, H. J. M.25)05 MauCartliy, J. A. <). . . 200.5
Duggan, C. W.2880 (ierrard, J. J.2(500
Brogden, J. K.2815 .StanUtieet, 0. B. . . . 2030
Au.stin, J. H. li. ... 2780 Ja(ne.son, J. C. 2070
Indian Medical Service.—T he following is a list
of the candidates for Her Majesty’s Indian Medical Service
who were successful at the competitive examination held at
Burlington House on Feb. 9bh, 1891, when 5J) candidates
competed for 21 appointments, and 57 were reported qualilied:
Markn. Marks.
Burton-Brown, F. 11. '. ;5fi25 l-'rost, G. II.3035
Lunisden, J. S. S. . . . 3340 Smith, S. B.:{030
Dcare, B. H. 3330 Graves, D. H. McD. . . :5020
Brown, A. T.3215 Pennv, .7.3020
Bird, tt,,M.D.:5180 Kwwis, G. F. W,, M.D. , 301(1
Oldham, B, 0.:5I«5 Hlmivov, W.3010
W)lkhisoii, E.3U)0 I'ridHiore, W. G. . . . :1010
Ducr, U.3155 Irvine, J. W. 3005
Wood, H. S.3125 Dallas, S. A. G. ... 2005
Kiitvican, .7., M.D. . . 3ono Pallc, G. II. L. 2075
l)onovan, C., .M.D. . . 3000
Society of Apothecaries of London.—T he
following candidates passed the Examination in Surgery
during February -
A. Allen, Ghariiig-crosM Hospital; II. Cidlior, I.iverpnol University
Gollego and Middle.sox Hospital; G, E. Gor:nvan, .St. Bartlioloiucw’.s
Hospital; R. S. Freeland, J„R,G,1’,, M.lt.C.S,, Guy’s Hospital;
A. <i, Hnydon, .St, Bartholomew’s Hospital; G, G. Hutchinson,
L. K.tJ.G.lM., Birmingliaiii Queen's Oollego u»id Dublin ; G. Jonos,
M. A , Oxioril and I.ondon Hospital; W. F. II. New'iery, M.I),,
Trinity Medical Gollego, Toronto : J. H. llobovts, (iuy'.s Hospital ;
G. B.'P. Sporn'or, Giiy'.s Hospital; R. 1). Wagtiorn, Westminster
Hospital; F. G. Wood, L.8.A., Loudon lln.spitid.
The following candidates passed in the subjects indicated :—
Medici, w, J'orciixlr iMnliciiie, and !ll!diri/c.r}i — T. S. llyass, Universily
Collosc; H. Fairfax, Gharing-cross Hospit-al; jr. Lewis, St. Mary’s
Hospital; F. II. Lowe, St. Bartholomew's Ho.spital ; II. F. S.
Nuiies, St. Miu'j's Hospital; G. B. 1“. Spencer, Guy’s Hospitsl ;
J. F. Twist, Queon's Gollogo, Birmiughani.
Medicine and /•'(ircnxic Medicine. — \V. R. Thomas, M.D., McGill,
Montreal, ami Loii'^oii Ho.spital.
ami Sdidwil'rrji.—W. U, Willey, St. Mary's Hospital.
h'orensic Medie.ine. —W. U. Nicol, M.D., McGill, Moidix-al: W. K.
Toyiio, ShcJIicld ami Kdinlmrgli.
The following received the Diploma of tho Society, having
passed in all the subjects retiuired for reglstvatlnn ;—
A- Allen, T. S. Byiiss, G. F., Goniwall, II. Fairfax, F. Lewis, F, H.
Lowe, 11. J''. 8. Nunes, C. B. 1’. Sponcer, J. F. Twist.
Di^ibzecJ by Google
522 Th£ Lanobt,]
MEDICAL NOTES IN PARLIAMENT.
[Feb. 2S 1391.
Medical Magistrate. — Mr. John Walter Yoat-
man, M.RC.S., of Auburn, South Australia, has been
appointed a Justice of the Peace for the colony.
Bequests —Mrs. Emily Fitzgerald left £500 to
the Mater Misericoi'dite Hospital, and £100 to the Royal
Hospital for Incurables.
Warneford Hospital, Leamington. — Lord
Leigh, the Right Worshipful Master of the Province of
Warwick, has appointed March 18th for laying, with
Masonic honours, the new wing of this hospital.
Superannuation Grant.— Mr. Charles M. Frost,
F.B.C.S. Eng., L.R.C.P. Edin., lately medical officer for
the second district of the parish of St. Mary Abbots,
Kensington, has been granted an allowance of £83 Gs. 8(f.
per annum.
Aberystwyth Infirmary and Cardiganshire
General Hospital. — The report for the year 1890
shows the growing usefulness of this charily. During the
year the in- and out-patients numbered 1375, an increase of
87 on 1889. The cash account showed a balance in hand of
£388 9«. 3d.
New Mortuary.—T ho formal opening of a public
mortnary for Hampstead took place on the 21st inst. It
is situated in New-end, near the workhouse, and is a red¬
brick building of one storey, containing chambers for the
reception of ordinary and infectious cases, a dissecting room,
and accompanying offices.
Irish Medical Schools’ and Giuduates’ Asso¬
ciation. —The annual general meeting of the Association
will take place at 11, Cuandus-street, Gavendisiv square, at
6 P.M. on Tuesday, March 17th. ' On the same evening the
members will dine at the Holborn Restaurant at 7.30 1 ’.M.,
Dr. Gilbart Smith, President, in the chair.
The College of State Medicine.— Professor
W. R. Smith, M.D., D.Sc., has resigned the office of Pro¬
fessor of Hygiene and Public Health in this institution, and
the council have selected Mr. A. Wynter Blyth, medical
officer of health d,nd public analyst, St. Marylobone, to
fill the vacant office. Professor Blyth will commence his
classes early in April.
Derbyshire Infirmary. — At a meeting of
the governors of the [Derbyshire Infirmary, held on the
23rd inst., it was unanimously decided to pull down the pre¬
sent building, which has been proved to be deficient from a
sanitary point of view, and to erect new premises at a cost
of £74,000. The Duke of Devonshire, as mrd-lieutenant of
the county, has promised to call a county meeting for the
purpose of raising the necessary funds.
Lincolnshire County Hospital.—A t a special
meeting of the governors of the Lincoln County Hospital
held at Lincoln on Monday last, it was resolved to accept
the offer of Mr. Joseph Ruston, ex-M.P. for Lincoln, to pro¬
vide a children’s ward for the hospital, and to tender their
cordial thanks for his noble gift. Plans for the new build¬
ing and the alterations have been approved, and the work
wul be commenced as soon as possible.
Hospital for Women, Nottingham.— The pro¬
minent feature in the past year’s report of this institution
is the completion of the purchase of the premises occupied by
the Inland Revenue and the prospective removal of the work
of the hospital to more commodious and suitable premises.
The year has also been marked by a special increase in the
operative work. During the twelve months seventy-five
patients were admitted, forty of whom had undergone
operations of a more or less serious nature, with satisfactory
results. The beds were continuously occupied, and the
capacity of the hospital had been taxed to the utmost.
Charing-cross Hospital.—T ho seventieth annual
report of this hospital states that during the past year the
number of in-patients had been 217 more than in any pre¬
vious single year, and the out-patients numbered 21,540.
The statement of receipts and expenditure was again
unsatisfactory. A decrease is shown lu the donations, and
the amount of legacies was the smallest in the history of
the hospital since it had attained its present proportions.
These ueficienciee had necessitated the disposal of stock
amounting to £.3662, and a liability of £3000 had b(ea
incurred with the bankers.
The Sanitary Institute.—T ho Duchess of Albany
has consented to present the certificates aw^arded at the
close of the course of lectures on Domestic Hygiene to be
given at the Sanitary Institute.
Fox V. Whitehead.—I n tho case of Mr. Richard
Dacre Fox, F.R.C.S. Edin., M.RC.S., of Leeds, against
Messrs. Whitehead, Limited, proprietors and vendors of a
patent medicine known os Mother Seigel’s Curative Sytup^
an application to tho Court of Appeal for a new trial was-
refusem
Kidderminster Infirmary and Children's-
Hospital.—T his institution has accomplished very satis¬
factory work during the past year. The invested funds
now amount to £8794 15^. 1^. A former encumbrance
had been discharged, and there was a balance on tbe-
ourrent account of £196 12.v. Id.
Suicide of a Medical Practitioner.—M r. T,.
Hoyle, the coroner for the Borough of Newcastle, held an
inquest last week on the body of Mr. W. C. Wicks, M.B.,
L.R.C.P. Edin., aged forty years. The evidence adduced
was to the effect that the deceased had suffered greab
mental depression during the last two years, and that deathr
was caused by taking prussic acid while in a desponding
state of mind.
The Proposed New Fever Hospital at Bir-
KiiNiiEAD.— A meeting was held on Tuesday of ratepayers
of this town, convened for the purpose of considering the
proposal of the Heatbh Committee of the Corporation to'
erect a fever hospital to accommodate seventy-two patients,^
after considerable discussion a resolution was adopted
strongly opposing the proposed hospital, and urging that
it was desirable the ratepayers should have the opportunity
of petitioning the Town Council to reconsider their decision
on the question. A committee was formed to prepare a
memorial for presentation to tho Town Council.
Weston-super-Mare Hospital and Dispensary.
The yearly demand upon the good work of this institution
well attests its value and importance to the town andi
neighbourhood. During the past year 248 in-patients had
been treated. There was a diminution in tho number of
those residents in the town who attended as out-patients,,
due to the establishment of the provident dispensary, but-
the country parishes supplied their usual quota. Voluntary
efforts were being made to permanently augment the income
by £250 a year, which is required to put the institution on
an efficient footing. The Provident Dispensary still main¬
tained its ground, about 2300 members being entitled
to its benefi ts.
MEDICAL NOTES IN PARLIAMENT.
Klentenlarti Education (Blind and Deaf) Bill.
In the IIoiiso of Lords on Monday, Feb, Sard, this Bill passed thi'oughi
Committee, and was reported with aineiidment.s.
Faclorji mtd Woi-kslinpii Sanitation Bill.
In the House oC Lords on Friday, tho 20tlj lust.. Lord Thring morod
the second reading of thia Bill, and explained that the object of the-
measure was to extend to worlislioim the regulatiouH now applied to
factories. It proposed to provide that every workshop should he kept-
in a state of cfeanlinasa. The inspector might enter at .all reasonable
times anti take with him a medical officer or other person experienced'
in sanitary matters. It gave power to the inspector to enforcesanita-
tion,instead of taking proceedings to enforce a fine. The Bill did not-
doal with ilio hours of labour, as the cjnestion had not boon suifieiently
invostigatod. Ho believed tho Bill would bring light and healthiness--
into dark .spots, and brighten and make healthy what must be admitted
to be the unlovely existence of many a humble artisan and many a
hard-working woman.—The Karl of Ininr.aven supported, and hoped-
the Bill would become law.—Lord do Ramsey asked their lonlaliipa to
read tho Bill a second time only on tho undor.standing that tlio noble
Lord would proceed no further with it until tlioro had been an oppor¬
tunity of diacn.s.sing the Cloverninent measure. Tho Bill was road a
second time. .
Eaclury and WotkihopK Bill.
The Harl of Dunmven moved tho second reading of this Bill. He
said it was founded principally, if not onlirely, upon the report of thc'
Sweating Commission, and was designed to meet some of tho graver
evils and sc.andal.i which had hooii proved before tho Commission. Tliv
Bill was reail a second tirno.
CnnHoildation 0 / the I’uhlic Health Lawx.
In tho House of Commons on Saturday, in reply to Sir H, Tyler, Mr.
.Matthews stated that tho [’resident of tho Local Government Board
would bring in a Hill to amend and consoUdate the law as to public
health in the metropolis. He muutionud that in 1887 a Committee of
the House of Lords had investigated the subject of smoke in the
metropolis, and did not think any now light would be thrown on the-
subject by the establishment of another similar inquiry.
Dir: -ed-'y Google
Thb Lancet,]
THE METROPOLITAN HOSPITALS INQUIRY.
[Feb. 28, 1891. 523
Sentry Duty.
In the House of Commons on Monday, Fob. 23rd, in reply to Viscount
Wolmor, Mr. E. Stanhope said that the number of senti ios stationed at
■St. James's Palace, Kensington Palace, the War Office, the Home Office,
.•and the Foreign Office was fourteen, supplied by a guard of forty-two
men. Since 138R the medical officers of the Guards have not reported
against sentry duty. On the contrary, in 1880 and 1888 thoy reported
that tho duties were not too severe. Too heavy sentry duty is un¬
popular. and probably has an unfavourable effect on recruiting, but
.every effort has been made to reduce it to a reasonable extent in
jiondon.
The Windsor Courts and Alleys.
Ill 'answer to Mr. Loveson-Oower, Mr. K.itehio said : Inquiries have
l)een held by inapeotorw of the Hoard with regD.rd to the .saiiitivry eon-
■dition of courts and alleys in Windsor. I am infoiined tliat since
January, 1387, considerable Improvoinents have been made in South-
place. On the north side six houses have been provided with additional
-sculleries and back door.s, and with windows at tlie back. 'J'en now
waterclosets have been erected, and six old ones recnnstructod. An
.additional water-supply has been provided, and also now dustbiii-s and
the paving of the yards and the drainage have been improved. As
regards tho houses on tho south side, nine have been improved by
mafioh-boarding and tho undor-ventilabion of tho floors, and through
-ventUatlon has been secured by moans of grid ventilators on tho stair-
•cases whore back windows have not boen provided, Tlio eleven houses
on the south side are now occupied by only forty-six persons, and as
tho medical officer of health is of opinion that tlio watorcinset accoiu-
anodation cannot now be declared Inaderiuato, he does not adviKO tliat
.some of the houses should ho demolished for the purpose of making
-Mucli provision.
The Sale of lilher in Ireland.
In answer to Dr. Tanner, Mr. A. Balfour said ether had i>o 0 ii
••Hchoduled, and it can only now be sold by qualitlod chemists or
slruggists as a poison.
The Foij Playue.
Viscount Wolmer has intimated to the First Lord of tlio 'J'i'ea.siiry
that on Monday ho will ask whether, considering the serious injury t»
lioaltli, tlte disturbance of business and the haidsliips inllictod cm many
sif tho poorest wage earnevs of the metropolis by the curtailment of,
their working hours, caused by tho increasing prevalence of fogs, the
Ooveminent will consider the advlsa\>ility of appointing a Royal Com-
iinission to exauiine and report how far the 'evil i.s one which (;an ho
mitigated by legislation.
Injlammablo LhfwUls Bill.
Mr. James Rowlands and Mr. Cobb have given notice of tliuir
iintontiou to move tiio rejection of the Infiaminable Liquids Bill.
THE METROPOLITAN IIOSPITAI.S INCiUIR’S'.
Tlie Select Committee of the House of Lords on tho Metropolitan
(Hospitals rosutned its inquiry on Monday, Lord Sandhurst presiding.
SC. Mary's Uuspital.
Mr. Thomas Ryan, secretary of .St. Mary’s Hospital, Parldliigton,
.stave evidence as to the affairs of that institution. In roply to the
■chairman^ ho stated that the hospital was founded in 18-15. Althougli
the building had tho advantage of youth, it could not be said to have
all tho advantages of modern sanitary science. I'lio medical staff were
inclined to tho view that tho building did not possess those ailvantago.s.
It was practically a free hospital, althougli they liad a latter system.
They had no paying patients. Tlioy had 281 bods, and a working
anaximuTu of aliout 2.55 bods. Tho numbor of patients tliey took in per
Sied per annum was about fourteen, which was more than most other
liospilals. The hospital-was continually full. They wore very careful
to sift the patients, with a i-iow to taking tlio gravest cases.
The Chairman: It has iieeii said by one witness that in this <listrict
*hore is an oiionnoiis amount of medical relief in tlio way of iiospitala
-and diapensanes. Wo have boon told that there ate 2000 bods.—Mr.
Ryan ; I sliould have thouglit tliat tliat was hardly so. Thevois only ono
hospital in our district. Tlio whole district to tho west of Kdg'vare-road
••andthe north of the Park is supplied by 8b. Mary's Hospital. Continuing
his evidence, witness said tiiat St. Mary's Hospital was inador(uato at tlie
present moment to meet tho neces.sibies of tho district. In iiis opinion
medical relief for the poor in tlio I’aildiiigton district was covtaiiily
■deflcleiib. His salary amounted to T400. Ho diti not rosido in tlio hosjiital.
Ho was responsible to tho weekly board, 'i'he quarterly and u'eokly
•boards appointed tho two standing coinmitteGs - tho hoiiso and iinaiioe
•and tlio medical conmiitteos. Complaints, if serious, wore laitl before
the coniuiitteo; if triiiing ho dealt with them, and afterwards niado a
n'eporb to tho comniittoe. If complaint as to tlie food roacliod him, ho
would not report to the committee in the first instance, but deal
■I'liroctly witli tho contractor. The circuui.staiico would bo recillod
when tho tenders wero considorod. When moat or coal was bad
he sent it back to tho contractor. Tho medical comniittoe mot
•:mce a month, on tlie iir.st Monday of each month. They ex¬
amined the modii?ai suporintondont’s report, whicli would refer to
anything of the nature of the sanitary condition of tho hospital,
the behaviour of clerks and drossors, ami mattors of that class. In tho
standing orders witness was .spoken of as being the governing head of
the establishment, and ho presumed, althougli it haa' never boon nocos-
i-sary, that ho should susjioiid an otRcor in curtain civcumstancos. He was
.'hi apositlon to dismiss subordinate servants, imt he should have to give a
good reason to the weekly board for what ho had done. Tho medical
BUperiiitondoiit rocoived a salary of £150, with board and lodging. Ho
was not a moinber of tho niodlcal couimitboe. Ho acted as head of the
■oatablishinent in tho ahsonco of witness. Ho suporviaed tho resident
'medical ofllcors, the olorlis, and iho dressers. Ho would bo expected to
woport any sanitary defects in tho building to tho medical comiiiitteo.
"hey ailraitted all classes of cases except infectious eases. When tlioy
Admitted cases of iliphthoria they wore only c;iacs wliicli it would not
be safe to Hoiid away. Tho cases wore rigidly isolated. 'I'hoy had not
found their charity abused. Tlioy mado strict inquiry as to their
•iiut-patieiits. They had a form re<iuiving particulars as to name,
•HddroBS,' occupation, wage, <Sc. If any feature of an excep¬
tional cliaractor was brought out by tho elork, then tlie ciuto
’■®PO*'tod to witness, who made furtlier investigation. The clerk,
rtitor ills long experience, was practically an inciuiry oflicor, and
was vory capable of judging the merits of cases. The number of cases
In which witness had to make Inquiry outside the building was very
email. Last year tlieir income from subscriptions amounted to 1^227.
'That sum more than covered tho amount of annual salaries aJid
wages of all classes. The total expenditure last year was £28,808.
The halani'e against tho hospital last year amounted to .£1068, which
had to be mot out of capital. Among their items of income lost year
were : Donations, £3177 ; dividends and rents, £2521; legacies, £8270;
Hospital Hunday Fund, £2083 ; Hospital Saturday Fund, .£368; alms
boxes, £47; and payments by probationers, £412. During the past
ten yeara tho average income from legacies amounted to £7354. The
statement of tho Cliarifcy Organisation .Society was absolutely in¬
accurate as regards 8t. Mary’s Hospital in respect that legacies
were left out of the ordinary income, lie included tho legacies
ill tlio ordinary income, and they spent every farthing of it. Their
beds va{ie(l in annual cost from .£72 to about £84. He questioned
entirely the correctness of endeavouring to form a criterion of
either tho excellence or the economy of a hospital by a com¬
parison nf the cost per bed. It was a fallacious comparison and
exti'omely misleading, and bo considered it was open to considerable
mischief. Nothing would please him more than to have a uniform
system of hospital accounts. (Such a system would render comparison
easy and roliablo. 'J'liere were many citcumatances which made com¬
parisons a", present unreliable. , For instance, a hospital with a
medical sciiool attu.ched to it was more expensive than a hospital
withouta medical school. A medical school was undoubtedly a source
of increased expenditure. On the other hand, it increased the number
of persons interested in the inebitution. 'J'he comparison was disturbed
!>y tho expensive cliaracter of certain cases. There was the proportion
of children also to consider; children wero much less expensive than
adults. In the case of tlie out-patient department much depended on
tho extent of tlie maternity work. Homo hospitals were rated at their full
value, while others paid upon a very small sum. St. Mary’.s Hospititl bad
paid upon a rateable valuoof £ 260 , bub the otiior day tho sum was raised to
£1000, the difference representing £1 4>i. per bod. Another point was
theexistenceortliea bsenceofnecessity for expense in collecting the funds.
In some hospitals such articles as tea and sugar were not included in the
dietary. Tho matron was head of the nursing department at 8b. Mary’s
Hospital. Her salary was £125, with board and lodging. She was respon¬
sible to the house and finance committee and tlie weekly board. The
nursing staff consixted of ono matron, one night supermtendont, ten
sisters, twenty-six staff nurses, and twenty-three probationers. Occasion-
aiiy they were at a loss for a nurse, and in such an event they applied to
:Bvomplon Consumption Hospital, where there was an institute. There
were twenty-three wards. At night it happened that two nursps had
tho charge of fovty-tlireo beds. Special arrangeriients were made for
special cases. ’Die sisters came on duty at eight o'l-lock each morning,
and loft at ten o’clock each evening. They wero off duty twice weekly
from llvo till iialf-nast ton o'clock, once weekly from seven till
half-past ten o’cloclc, every other Sunday from throe till half-past
ten o'clock, and every Sunday from two till half-past four o’clock.
’J'lieir holiday.s wore ono day iier month, and one calendar month per
ivimuni. Tlie st-ilf nurse.s’ hoiim were from seven o’clock in the morning
till nine o’clock in tho evening. They wore off duty twice weekly from five
o’clock, once weekly from seven o’clock, and every other Sunday from three
o'clock. Their holidays were ono day per month, and one <'alerdar month
per atiiiuni. The lioiiin of probationers wero from seven o’cloi^k in the
morning till half-past eight in the evening. They wore off duty two
liours daily. Tliey treateii tlio proliationers bettor tlian tho staff nurses
in this respect, 'The prob.ationers wore less accustomed to the work
than the staff nurses, and required more leisure. The niglit suporinten-
donb came on fluty at ton o’clock, and loft at sovtin. ’The neb worldng
hours of sistor.s were 101. of staff nurses Oil. and probationers 94 hours per
day. 'file sisters' wages ranged from £30 to £41). and staff nurses from
,C2i) to £25. and pvobaticuovs wero paid £10 per annum. Tlie pro¬
bationers began to get full nurses’ wages in the second year <if their
apprenticeship- Tlie hospital was affiliated with tlie National I'ension
Fluid for Nur.sos. Every nurse iiiu.st contribute to tlie fund, and the
liONiiital paid ono-lialf of tlie contribution.
By Loid.8ayo and Sole: The hospital was in possession of investments
of the value of £72,000.
By Lord Catlicart; J.ast year tho nnmher ill among the nursing staff
was fifty, wliich included tweiity-ono cases of infiubnza. Tlie number
of days they wore ill was -150, and the average daily iimnbor of nurses
on tlio sick list was i'2ri. They tiad a drainage plan. Tlio quarterly
mootings of tlie board wove open to reporters. They kept a tempemture
book. On tho whole, he vegardoil a medical school as lulvaiiUigeous
to a hospital.
By tho Chairman : Ho certainly would prefer to see the reorganisa¬
tion of hospitals come from within rather t'lian from some out.sido body.
A contval authority niiglit do some good. If it put a chock on tho
spread of small spocial hospitals it would do a valuable work imlood.
Personally, however, ho did not tliink that much good to hospitals
would come from placing tliom under a coiilral autliovity. Ills impres¬
sion was tliat till) result of central authority was rather towards harm
Ihivn good. Thoy had before them tho experiGuco of tho Metropolitan
Asylums Board. Ho thought it well that tuo hospitals should presovvo
tiieir individuality. No distinction was made in tlio treatment of the
ii obationors and tlio lady probationers. They dinoil at ono table. Tho
ady probationers paid .£:t0 a year for board and lodging.
Colonel liird, chairman of the house and finance committee, stated
that the duties of his committee wero to eliock extravagance. The
iiisLitution was governed by an open lioartl which, in his opinion,
was very ilisadvantageoiis to it. Governors who took little interest
ordinarily in the affairs of tlio hospital came upon occasion to the
meetings' and overruled tlioso governors who devoted themselves
systematically to tho institution. Ho did not object to tho iiiiarterly
Ixiarii being open to all governors. His objection applied to the
weekly hoard.
Mr. Herbert W. Pago, late donn of tlie niedical school and one of
tho surgeons of tho hospital, stated th at tho numbor of .students was
.about '31)0. Until last year the number had been on the iiicioiise. The
fall last year lie attributed to tho successful rivalry of otlior scliools.
Tho attendance had nioro than doubled in tlio last four or five
years. The average inconio amounted to about £451)0, and tho
expenses to about £33ui). Tho balani-o was distvilmted amongst the
lectnrei'.s. Tho largest sum i-ecoived by any lecturer was about £10IK).
It might 1)0 desiiablo to have some of the subjects dealt with in a
central school. Ho would not advocate any Interference with the
£21 The Lancet,]
THE METROPOLITAN HOSPITALS INQUIRY.
[Feb. 28, 1891.
present Individuality of the hospital schools as to the teachii^g of
medicine and surgery, but he thought there was great waste of energy
in keeping up eleven medical schools in London, all of which taught what
he might call preliminary subjects. They had a residential college in
connexion with St. Mary’s Hospital Medical School. It was a com¬
mercial undertaking quite apart from the hospital. It began well, but
bad since fallen oif on account of the high fees charged. A reduced
scale of fees had been framed. As to the question of hospital manage¬
ment, be thought there should be ne Government interference. Some
means, however, might be devised to regulate the erecbioa of new
hospitals.
Mr. Malcolm Morris, physician-in-charge of the skin department of
the hospital, stated that during his nine years’ experience he ha<l not
found on instance in which a person applied for assistance who did not
deserve to receive it. He thought Poor-law infirmaries should be
utilised for teaching purposes. Patients in these infirmaries took it as
a compliment to be lectured upon. The objection came irom the
managers, not tlie patients. He thought that before s.anotioii was
given for the erection of a hospital public necessity should bo proved.
Mr. Pearce Gould, dean of the Medical School of the Mkldlesex Hos-
{ lital, said that in London there was great need of improved facilities
nr teaching practical anatomy, subjects for dissection were becoming
scarcer every year. The general medical schools were without proper
facilities for teaching their students ^Yith regard to infectious disease.
With few exceptions, the hospitals excluded infectious diseases from
their wards. He would not like to see the old apprenticeship system
revived, but he thought it might be desirable to Jiave some system of
apprenticeship after the close of the curriculum. This would tend to
diminish the number of unqualified assistants. The experience of
London was not strongly in favour of residential colleges.
The Committee then adjourned.
The Committee met again on Thursday, Lord Sandhurst presiding.
Westminster Hospital,
Mr. Quehnell, secretary of the Westminster Hospital, was examined.
In answer to the Chairman, he said that the hospital was founded as
long ago as 1719. Thepresent buildings were orectedin 1884, and had since
then been extensively altered. It was practically afroe hospital, although
they had governors' letters. Out of 2600 or 2000 patients admitted last
year only about 100 brought governors’ letters. Ther6 were 200 beds in
the hospital. Sometimes the beds were all occupied. They were not
very careful about keeping a margin. The average number of patients
last year was 184. Witness was responsible to the bouse committee, who
met once a week. They bad a professional auditor. At the end of
the quarter the bills were all checked by witness and scheduled, and
when that was done the professional auditor was called in and checked
them. The professional auditor made a report to the finance committee.
The petty cash was checked once a fortnight. The bank accounts
were checked once a quarter, but the bank book was exhibited and
examined at the weekly meeting of the committee. Witness received
a salary of £400 without residence. Last year they derived £2700
from dividends and rents, £1401 from annual subscriptions, £1800
fr)ra donations, £6610 from legacies, £1146 from the Hospital Sunday
Fund, and £800 from the Hospital Saturday Fund—total, £14,109.
The expenditure amounted to £13,331. In addition to the income
he had stated they had transferred to them during the year £24,000
in Consols. They had also received £1000 for tlie endowment of a bed.
In the way of capital they had £10,000 for the endowment of a ward,
£17,353 for the endowment of what was called the incurable establish¬
ment, £1324 for the endowment of a lithotriptic ward, and £4400 for the
endowment of beds and cots. At present they had £50,800 to the credit
of the General Purposes h’und, and about £34,000 of those endowments.
They could spend the former but not the latter. The patients were
practically all .admitted by tho senior house physician and the senior
house surgeon. Patients arrived at all hours of the day and night.
They had notaresldentraedicalofficer. They had two house physicians,
two house .suigoons, and the officers of the obstetrical department.
In the event of a grave case arriving a messenger would be sent in a cab
for the surgeon or piiysician. They excluded smill-pox, typhus fever,
and sc.arlet fever. They admittedcliplitheria. They hadnoregularsystein
of isolation. In the out-patient department the resident physicians were
not obliged to see more tlian twenty new cases each per day. It was
reckoned that each patientattended four times, and that the total attend¬
ances in the course of a year numbered about 100.000. They did not
make any inquiry into the circumstances of the out-patients. It was pro-
E osed and carried fourteen or fifteen years ago, at tlie JIou.se Committee,
) employ a Chaiity Organisation Society officer to make inquiries, but
the decision was overruled by the governors at their general court. In his
opinion, he did not consider tliat upon tho whole tho charity was alnised.
Although occasionally they had to turn away applicants, ho <iid not
consider that the medical relief for the poorin the dustrict was insiifficiont.
Complaints as to food would come to him in the first instance. He
presumed that he was responsible fpr the sanitary corn! ition of the hos¬
pital—at any rate during the daytime. He was not an expert in sanitary
matters. They liad an architect, and if witness came to the conclusion
that there was anything wri-ngin tho sanitary arrangements ho would
send for him. They paid the architect no salary or commission, hut
simply forwork done. Tlie matron received no salaryfrom the hospital.
She was not only tlieirmatron, hut the superintendent of tlio Westminster
Training ScJiool and llomefor Nurses, Tliis institute trained thenursosin
the hospital. The Home was independeutof the hospital, but the two in¬
stitutions were very much involved one with the otlicr. 'I'ho nurses
wore paid by the institute, nob by the ho.spital. They found this
arrangomenb work admirably, 'j'he nurses were controlled by the
matron. He supposed that cases of raiseoiuluct would Ire reported by
tho inatrou to the managers of the institute. Tiie nurses who worked
in the hospital—to the number of about thirty-three—iiad their food in
the hospital. Many of the probationor.s had theirfood in the institute,
which was only about 1.60 yards distant from the liospiial.
By Lord Monk.sweil; They liad several lady governors, but lie liad
never summoned them to the meotings. Tlie'govcniors iiuniberuil
about 800 , and at the quarterly meetings last year tile attendances were
27, 26, 21, and 22. It was felt tliat the governors, having supplied tiio
hospital with funds, should review the work of tlio House Committoc.
In his opinion the establishineiit of a centra! board to control the
hospitals of London might do a great deal of harm, and lio wa.s not pre¬
pared to advocate it.
By lord Cathcart: Tliey had a drainage plan which wa.s always
accessible. If reporters a.sfeed admittance to tnoir general muotings bo
would submit the qiiestlon to the Board. He admitted that when an
institution received its means and support from the public reporters;
should be allowed to attend those meetings.
By the Earl of Kimberley: They had no periodical inspection of
the drainage system. The last inspection took place in 1883, when large
alterations were effected. The drains were regularly flushed and the-
work was well done owing to the force of water tliey had. It might bo
desirable to have a yearly inspection by an outside authority. Such an
arrangement would be attended with somedlfficulty.—By the Chairman:
He wished to explain that they employed a man whose duty it was to
examine the waterclosots and drains every Monday.
Miss Pyne, matron of the hospital, and superintendent of the Nurses’’
Training School and Home, examined by the chairman, said that the
nursing arrangements of the hospital were very satisfactory. The build¬
ing (lid not afford accommodation for the nursing staff. They had eight-
ward sisters, thirty-two nurses, and twenty-three probationers. They had
no payingprobationers. Tho Home did not nurse any hospital besides tho
Westminster, but they sent out nurse.s to private houses. The aister.s
went on duty at 8 o’clock In the morning, and were relieved at 9 o’clock
in the evening. They had two hours for dressing and meals, and they
were off duty three evenings a week from 6 to 0, and four hours on-
Sunday. Tho staff nurses went on duty at 7 o’clock in the morning and
wererelievedat 9 o’clock in tbo evening. They had two hours for dressing,
and meals, and they had two hours off duty three times a week and
four hours on Sunday. The niglit nurses went on duty at 9 o’clock, and
were relieved at 9 o'clock in the morning. They bad a meal in the
middle of the night, and came down from the wards for breakfast at
7 o’clock in the morning. There were eighteen wards. As a rule they
had two or throe nurses off duty thron^i sickness. Tlie sisters and
nurses had an annual holiday of one month. The private nurses-
received no percentage on their eaniings. Tlie surplus derived,
from the working of the Home was devoted to the Simerannuation
Fund, which at presented amounted to over £3000. 'They did not
keep ward maids in the hospital. Tlie nurses did all the work of the
wards save that in connexion with the floors and the beds. They
employed a certain number of scrubbers. She did not think the nursev
were overworked. The presence of the nurses gave a good tone to the
wards, and the work was better done by them than by ward maids.—
By Lord Monkswell : She had full power to dismiss probationers, but
she could not dismiss a trained nurse without reforence to the Com¬
mittee.
Mr. Allchin, dean of the medical school in connexion with West¬
minster Hospital, examined by tho cbaimian, said that there were about
100 student.-) in attendance at the school, They had accommodation for
about fifty more. The average receipts for the past five years had been
£1800 and tbe average expenses £913. He thought there might be an
amalgamation of some of the smaller schools for the purpose of teach¬
ing certain of the preliminary subjects in medical education.
By the Earl of Arrsn : All their physicians and surgeons must hold'
the London qualifications. He did not think they lost good men by
this arrangement. The London Colleges exercised a disciplinary
control over their Members and Fellows with far more certainty than the
colleges in .Scotland and Ireland. The position of an individual attached
to a London hospital was a powerful one for influencing medical opinion,
and it was highly desirable tliat tho.se who held the position should be
of the highest possible character and should be subject to disciplinary
control. The greater number of the London students went to the
London qualifying bodies for examination.
Lord 'I'hriiig : Do not you think London is showing a bad example-
to Dublin and'Jfidinbu- gh in restricting its hospitol appointments to its*
own degrees?—Mr. Allchin : It is nob a question of restriction to Ixindon
degrees. Tho degrees are not in question. It is a question of control’
other than that on a purely professional standard.—Lord Thring : Do
you not think it woiihl be a great disadvantage to Dublin tliat nobody
should be allowed to bean officer of agreat Dublin hospital unless he had;
a Dublin qualification?—Mr. Allchin ; I really do not know how to
answer that question, because if I say “ yes ” it would imply that tlitf
London qualification is so much better than the Dublin qualification.—
Lord Thring : Quite so, you surely think so V—Mr. AUchin ; It is not on
the ground of tlie professional (jualiflcation that I speak, it is on thti-
ground of the control exennsed by the London bodies.
'J'lic Committee afterwards adjourned.
^poinlmcitts.
Sueoes^lappUcanteyor Vacancies, Secretaries o/Public Imtitutlons, a/nt\
others possessing information suitable for this colunm. are invited to
forward it to TiiK Lancet Office, directed to the Sub-Editor, not later
than 9 o'clock on the Thursday morning cf each week for publication in
the rieat mi/niber. - ■
Adam, G. R. W., M.B., C.M. Bdin., has been appointed Honorary
Medic.al Officer to tiie Austin Hospital, Melbourne.
Ai.coitN, Roup, O., L.U.C.P. Hdin,, L.R.C.H. Irel,, has been appointed
Visiting Surgeon and Dispenser to the Gaol, Maitland, New South-
Wales.
BOAKI-;, W., L.R.C.S., L.K.Q.C.P. Irel., has been appointed Public
Vaccinator for MalEra, Victoria, Australia, vice Brown.
Brkwis, R. a., W.D. Fdiii., has been appointed Medical Offic-e?
of Health for the District of Waratali, Tasmania.
Bky.vnt, J. II., M.B., B.S. Bond., has boon appointed Assistant llouso-
Physician to Guy’s Hospital.
Bvr.n’e, Huch J., L.R.O. P., L.K.C.S. Irel., has beon appointed Medical
Officer of Health for tho Di-strict of Uampbell Town, Tasmania.
Ca.sson, 'J'., L.R.C.P. Kdin,, M.H.C.S., lias boon appointed Medical
Officer to tlie Hearts of Oak Benefit Society, Caiii.stjrjiough,
Cai.tiiroi’, L. G. JtVKRAHn, L.R.C.P., M.I.I.O.S., has been appointeii-
Itesidoiit Accoucheiiv to tho London Hospital.
GliARNi.EY, William, M.D., M.C. Cantab,, M,R.O..S.. lias boon appointeiJ
Honorary Oculist to the Briilgnortli and Soiitli sSiropshire Infirmary.
Creasy. Roi.i-', L.II.C. P, J.ond., M.It.C.S., has been appointed Medical
Officer for tlie First District of the Winslow Union.
Ki.i.i.MAN, Artiidr U., JI.R.O.S,, L.R.C.P. Loud., has boon appoiutedl
Assistant House iSurgoon to the Kent and Ciuitorbiiry Ho.spital,
vice W. F. A. Clowes, resigned.
\
Th® Lancet,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, & DEATHS. [Feb. 28, 1891. 525
l-l’miERSTON, Gebald II., M.D. Slelb., L.E.C.P. EcHn.,L,F.P,S. GImr ,
has been appoh)ted an Official Visitor of the Lunatic Asylums at
Yarra Bond and Kew, Victoria, Australia.
Grii'I'ith, J. De Buiiaii, M.B., M,Ch. Dub., has been appointed, pro
tmi.. Assistant Medical Officer at the Quarantine Station, Victoria,
Australia.
Haurison, RKQINAI.D, F.R.C.S., has been appointed Consulting
Sui'geoii to tlie Braintree and Booking Cottage Ilospital.
llARTi'ORD, H. W., L.R.C.P., L.ll.C.S, Ire!., has been appointed Medical
Officer for the WorJchouso, Christchurch, Hants.
IIawkins-Amui.eii, Geo. A., M.R.C.S., L.ILO.P. <fe L.M. Irel., has been
appointed Medical Officer for the Whitley Upper Saiiitary District.
Hugo, Epwin V., M.B., B.S., L.R.C.P. bond., M.R.C..S., has been
appointed Assistant Medical Officer of the Workhouse, and Assistant
to tho Medical Superintendent at the Infirmary for the Parish of
Paddinaton.
Jackson, C. Oranvili.e, L,R.C.P. Irel., has been appointed Medical
Officer of Health for the District of Ringarooma, ’rasmania.
Kennish, T. L,, M.B., C.M. Edin. has been appointed Medical Officer
for the Second District of tho Winslow Union.
Lll’SCOMiJ, E. H., M.B., L.R.C.P. Lond., M.R.C.S., lia-s been appointed
riono’ary Medical Officer of the St. Albans Hospital, Herts.
LLOYD, H. Sanderson, M.B., C.M. Edin., M,R.C.S., has been appointed
Government Medical Officer and N'accinator for the District of
Bydo. New South Woles.
LOVEGBOVH, James F,, M.B.C.S., has been appointed an additional
Public Vaccinator for the District of Timarii, New Zealand.
Maxwell, Kenneth, M.B., C.M. Edin., has been appointed Assistant
House Surgeon to the Hobart General Ilospital, Tasmania.
MiLE8 , Geo. iC, L.R.C.P. Lond., M.R.C.S., has been appointed Public
Vaccinator for tho District of Leichhardt, New Soiitn Wales.
MUDGE, T. H. T., L.R.C.P, Lond., M.R.C.S., has been reappointed
MenicoJ Officer for the Paignton District of the Totnes Union.
It08.s, J. M., M.B., C.M., B.Sc., F.R.C.S. Edin., has been appointed
Medical Officer of Health for the County of Dumfries.
Bowse, E. L., L.R.C.P., M.R.C.S.,, has been appointed House Phy¬
sician to the Hospital for Consumpiion and Diseases of the Chest,
, Brompton.
SLOOOETT. H. Payateh, L. & L.M.K.Q.C.P. Irel., M.R.C.S., Dipl..State
Med., has been appointed Resident Surgeon to tlie Victorian Eye
and Ear Hospital, Melbourne.
Smith, Alkred, ex-Assistant Master to the Rotunda Hospital, Dublin,
has been appointed Examiner in Midwifery to tho Royal University,
Ireland,
Stevens, T. G., M.B., B.S. Lond., has been .appointed Assistant House
Surgeon to Guy’s Hospital.
SWEETNAM, F. A., L.R.C.P,,L,R.C.S. Edin., has been appointed Medical
Officer for the Shire of Mount Bouse, \’ictori9, Australia, vice
Woodford.
Turner, Alfred J.,M.D. Lond., M.R.C.S., has hoen appointed House
Surgeon to tlie Hobart General Hospital, Tasmania.
Vaisey, T. F., M.R.C.S., has been appointed Medical Officer for the
Third District of the WiiiKlow Union.
Watson, John, M.B. Durh., F,ll.C..S. Edin., has been appointed Senior
House Surgeon to tlio Royal Portsmoutli, Portsca, and Gosport
Hospital.
WOOD. Wm. D.. L.R.C.P., L.R.C.S. Edin., has been reappointed Medical
Officer of llealtli for Witney.
Wellford, F., M.B., B.C. Cantab., has been appointed Assistant
House Surgeon to Guy’s Hospital.
fittanrits.
Porjwther information regwrding each vacancy reference should be made
to the advertUement.
liiRMiNGHAM PROVIDENT DISPENSARY.—Medical Practitioner on the
staff of the Balsall-heatli Hrancli. (Apply to Rev. W. 0. 'I'lioinas,
lion. Sec , Moseley, Bivminghaui.l
CUEI.SEA IIosPiTAi, for WOMEN, Fulliam-road, S.W.—Medical Officer
for one year. Salary £80 per annum, with lioHrd and ixisidence.
Df.ntal Hosi’ITal of London and School of Dental Suhoerv.—
Four i.leiiionstrators. Honorarium £00 per annum.
Hospital for women (Lo.ndon School of Gynaecology,, Soho-
squary, W.—Clinical Assis,aiits.
Hull Royal Infhimaky,—F our Honorary Assistant Surgeons to take
charge of fheout-pationts.
Hull Royal Infirmary.—O piithalinic Surgeon.
Manches.ter Hoval Infirmary.—R esident Medical Officer for tlie
Convalescent Hospital at ClieacUe for one year. Salary £160 per
annum, with board and rasiilonce.
Miller Hospital and Royal Kent D! 81 ’f.ns,vrv, Gvoeiiwidi, S.E.—
Physician.
National Hospital for Consumption, ventnor.—Dispenser. Com-
menciiig salary £0U, with board and residence.
Noirm.itASTKRN Hospital for thiii.iiiiEN, llackncy-road, N.E.—
Junior House Surgeon for nine months at a salary of .C5 per
iniinih.
ItOTiiEiiiiAM Hospital.—A ssistant House Surgeou. In lieu of salary,
rooms, commons, and washing provided in the hospilal.
RoyalBath HospitalakdRawsonConvai.esckntHome, Harrogate.—
House Surgeou and Secretary. Salary .£80 per annum, with boanl,
lodging, and WHshing.
OT, JheVER’S lIOHPITAl. HIR .STONE AND UlUNAHV DLSEA.SES, Heilrietta-
struet, Ooveut garden.—House Surgeon for six months. Ilono-
rariuiii 26 guineas, bo.ard, hKlging, and washing.
Turner's Hospital, Kirkloattuiin.—Surgoen. Unfiiniiahed house,
rout free, and no other reinuiieration.
West Ham Union.—A fslstant (Resilient) Medical Officiw for the Wovk-
liniiso. Salary .£100 per .annum, with the usual resident allowance.s.
(Apply to the Clerk, Clerk's Office, Union Workhouse, Ciiion-road,
JAsytonstoiie, E )
||lEraa:s:e0, ani gtat^s.
BIRTHS.
Beville.—O n Feb. 23rd, at the Firs, Palace-road, East Molesey, the-
wife of Fredk. W. Beville, L.R.C.P. Lond,, M.R.C.S., of a daughter.
Brownpteld.—O n Feb. 22nd, at Petei-sffeW, Hants, the wife of H.
Mmiyard Brownlleld, M.R.C.S., L.R.C.P., of a son.
Dons.—On Feb. 18th, at Bugbrooke, Weedon, Northamptonshire, tho ,
wife of Louis F. Dods, Surgeon, of a son.
Farrar.—O n Feb. IVbh, at the Vale House, Stamford, Mary, the wife of
Dr. BeginaM Farrar, of a daughter.
Lane.— On Feb. 2lst, at Burford, Oxon., the wife of Fi-ederick H. Lane.
M.B.C.S., of a son.
Lyster.—O n Feb. IStli, at Long Eaton, Nottingham, the wife of Arthur
E. Lyster, M.B.C.S., of a daughter.
Prout.—O n Fob. lObh, at 0, Montone-terrace, EdinburgJi, the wife of
William T. Prout, M.B. Edin., Government Medical Officer, OolcT
Coast,, of a daughter.
Pritchard.— On Feb. iflth, at Combehurst, Nutley-terrace, Hampstead^
the wife of Urban Pritchard, M.D., F.R.C.S., of a daughter.
Rushworth.— On Fob. 20th, at Langdale, GoJdhurst-terrace, Hamp¬
stead, the wife of Frank Rushworth. M.D., of a daughter.
pStivun.— On Feb. 21st, at the Manor Lodge, Harrow-on-the-HiU, the.
wife of E. W. Flemyng Stiven, M.D., of a daughter.
MARRIAGES.
BrCKERTON—B urton.— On Feb. 21st, at St. James’s Church, Birkdale^.
by the Rev. R. Stephenson, Thomas H. Bickorton, of Rodney-street,
lAverpool, to Mary Jessie, daughter of the late James Burton, of
Hilton House, Prestwich.
Fish— Hall.— On Jan. 28th, at Georgiana, Brevard County, Florida,
U.S.A., Henry Clay Fish, M.D., to Alicia Maria, elder daughter
of the late John Charles Hall, Esq., J.P., late of Letterfrack, county
Gnlway.
Irvine—DURY.—O n Fob. 19th, at St. Nicholas Church, Strood, Kent,
D. L. Irvine, Army Medical Staff, son of the late Rev. Walter Irvine,
M.A., Rector of All Saints, Newcastle-on-Tyiie, to Diana Lucy
Elizabeth, daughter of 'f. H. Dury, Esq., D.L., of Bonsoll Ley8»
Derby.shire.
vSi’ENCER—C harlton.— On Feb. 21st, at St. BarthoIomew-the-Less,
Siuithfleld, by the Rev. W. Ostle, Vicar, Walter George Spencer, of
36, Brook-street, son of tho late Walter Spencer, Esq., of Little
Chalfleld, Wilts, to Elizabeth, daughter of the late William Charlton,
Esij., of Madras. _
DEATHS.
Barnard.—O n Feb. 23rd, at Uppingham, John Wyatt Barnard, M.D.„
aged 74.
Carmichael.— On Fob. 21st, at Walmer-crescont, Paisley-road, Glasgow,,
James Carmichael, M.D., Fleet Surgeon Royal Navy, retired List,,
in his 89th year.
Elliott.—O n Feb. 20th, after a sliort illness, F. U. Elliott, M.D.,
aged 38.
Lestouhoeon.—O n Feb. 22nd, at Tho Close, Cambridge, Charles-
Lestoiirgeon, M.B., aged 83.
Massey.—O n Feb. 21at, at his residence, Park-row, Nottingham, Isaac
Massey, M.D., Surgeon-Major South Notts Yeomanry, in his 82adi
year.
Ogilvy.—O n Feb. 20th, at Clovedon, George Livingston Ogilvy, M.D.,.
late of Newton Mill, Forfarshire, aged 77.
TONGE.— On Feb. 19th, at Harrow, Morris Tongo, M.D., aged 64.
Tucker.—O n Feb. 19th, at Start House, Slapton, Richard Paige Tucker,.
M.R.C.S., aged 80. _
N.S —A fee of 5 b. is charged for the Insertion of Notices of Bis-lha
Carriages, and Deaths.
METROPOLITAN ASYLUMS BOARD.
Betwm of Patients remainmg in t/ie several Fever ffospitala
oftJie Board at tnidmght on Fehriiary 1891.
Beds occupied.
i
'
HospitaL
s
1
Is
Is
.33
t
® as
02
1 .
A
d
s’-
H
S'”
o
H
Eastern Hospital .. -■
258
62
1
37
2
860
448
North-Western Hospital
224
se*
8
268
Western
163
18
161
20
12
18S
840
187
16
20
3*
226
462
Northern „
264
10
-
26
-
290
480
Totals .. „
1227
168
1
112
8
1603
2861
* Infants with motheia.
Digitized hy L^ooQle
S26 Tbb Lakoxt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Feb. 28, 1891.
METEOROLOGICAL READINGS.
(Taihen daUy at 8.90 a.m. Stetoard’e InstrwjtmtB.J
TBB Lahcbt Office, Feb. 2etb, 1891.
Barometer
roduood to
Sm Level
end n’t.
LirM-
tdon
of
Wind.
Pet
Bulb.
Wet
Bulb.
BoUr
Bedla
Id
Veouo.
Maxi¬
mum
Temp.
Bhaae.
Min.
Temp
Rain¬
fall.
Bemorksat
S.80 A.M.
e’eb.so
80-41
B.
85
84
47
40
31
Overcast
„ -21
80-68
E.
84
33
89
32
Foggy
„ 22
80-40
S.E.
34
31
43
82
Hazy
28
80-80
£.
80
46
41
29
Foggy
„ 24
80-66
K.
83
38
45 '
41
80
Foggy
.! 26
80-84
K.
81
68
61
81
,,
Foggy
„ 20
80-00
E.
84
34
70
68
81
-
Foggy
Sj)m1 Cmitmtnts, ^ ^itsfotrs to
Jt is especially requested that early inteUiaence of local
events haviny a medical interest, or mhich it is desirable
to brmg 'imacr the notice of the profession, may be sent
direct to this Office.
.All comm.'unications relating to the editorial business of the
journal nmst he addressed .'‘To the F.ditors.'’
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private informa¬
tion, muJit he authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot pirescribc or recommend practitioners.
Local papers containing reports or 7tews paragraphs should
be marked and addressed ‘‘'To the Sub-Editor.”
Letters 7'clating to the publication, sale, and adeertising
departmcJits of The Lancet to be udd^-essed “To the
Publisher.”
We cannot undertake to return MSS. not used.
The MiDwivES’ Bill.
Ubr.C.M. Campbell.—ytBiKgtei thitwe bave not room for Dr. Campbell’s
letter, our space being given to replies b? two gentlemen who reason¬
ably claim to answer our criticisms of last week. Dr. Campbell thinks
it would be manifestly unfair and absurd to bestow upon an unedu-
K^ated woman a legal recognition and right to practise one of the
•three great branches of the profession apart from the other two,
•while forbidding men to do so. The answer is, that midwives in
'thousands have already a quasi-legal position without the slightest
education or guarantee of fitness, and that it is not proposed to give
4;bem a right to do more tlian attend a normal labour. He further
rargues that the Bill is meant to soothe the consciences of guilty and
shabby guardians, who employ midwives instead of medical men.
But thousands of women employ mid wives who are not paupers, and
whom there would be very grave objections to making into ])aupors by
'denying them the right to employ a midwife. It must not be forgotten
■that 10,000 women practise as midwives now, not only without lot or
hindrance, but with a certain legal standingand title. Happily, there
is now almost universal agreement on this one point, which is all we
•contend for—that legislation is needed to prevent incompetent and
ignorant women from practising as and calling themselves midwives.
Sfr.JoK. S. Gatizia, B.A .—We fear our correspondent is without redress,
unless lie could come to England and take proceedings.
ASSISTANTS.
To Ike Jidilors of The L.vNXEt.
Sins,—Will you permit me to say a few words on behalf of the much-
."abused class of unqualified assistants, to which I have tlie misfortune
•io belong ?
Your correspondent, O.P., is especially severe when ho puts us on a
level with travelling quacks &e. The majority of assistants liave spent
:some time at a hospital and passed one or two oKaminatiaus. I never
-met a pharmaceutical srudent who was employed as one. The fact
•seems to be completely ignored, that if the employment of assistants
ifeine diploma) were to be forbidden, as some of your correspondents
.seem to wish, a great number of men would bo thrown out of employ¬
ment. Take my own case, by no means an isolated one. I am
married and liave tliree young children, have passed first college and
failed once for final, have never had the money to go up again. I do not
•write well enough for a clerk, and am not fitted for any other occupa¬
tion. l am, Sirs, yours faithfully,
February, 1891. H. L.
The Climatb op the Isle of Man.
On this subject Dr. D. JT.C-iiffiiflwewriteslii effect aafollowsPhysicians
in their appreciation of the value of therapeutic measures lu the
treatment of disease may be broadly divided into two classes—the
constitutionally enthusiastic, who see in every drug a panacea; and
the constitutionally incredulous, who rely on the m^nedicatriz natura.
The safest course is to follow the old adage, in medio tutis/iiTtms
ibu. Those who recommend this sea-girt isle as a winter resort in
comparison with the many admirable stations in this and other
countries assuredly belong to the former class. The dampness of the
climate must be to certain constitutions more trying than a lower
temperature in combination with a drier atmosphere. If the sani¬
tation of Douglas, the chief place of resort, “leaves much to be
desired,” it is difficult to see for what class of invalids the island is
suited. Our correspondent alludes also to the dangerous character
of the voyage, and states that the soil, being a stiff clay and marl
underlying sand, is unfavourable to invalids. The mountain chain
which passes over the north-east and south-west of the island helps
to increase the rainfall, without affording any protection from the
rainy winds which oven in summer are apt to blow over its timberless
fields. The element of great equability between the day and the
night temperature is not so important as is generally imagined. The
island is, liowever, an admirable resort in summer, and may perhaps
be advantageously visited even in tho spring ami aubump.
Jfors.—Full details of tho art of embalming will be found in articles by
Dr. B. W. Richardson in the Asclepiad for 1888 (vol. v.).
AN 1NSJ>KCT0R OF PRAi^lTCAh MEDICINK AND SURGiCRY.
'To the JSdilors of The LANOEr.
sms,—'J'lieimportance of a fair apportionment of “subjects'' for the
practical study of anatomy in tlio dissecting rooms according to the
rociuiremonb of each medical school has long been recognisod by tho
institution of an inspector of anatomy. Is it not necessary to liave a
somewhat similar official to .see that oiwh modical school receives
students only in proportion to the amount of clinical material available
at the hospital connected therewith, especially fifth-year students ? A
knowledge of medicine Ac. gained only from books, lectures, and
malting one of a crowd going round the wards with tho phy¬
sicians and surgeons may avail tho passing of examinations,
oven with distinction, but they are nob snOicient to equip a
man for tho responsibilities of practice. It is iinporativo tbat
every effort should bo made to secure for this fifth year a real oppor¬
tunity for educating the senses of sight, hoariiig, and touch, together*
with the practical use of instruments required for diagnosis and treat¬
ment. It should ho arranged that each .student has sole charge of a
certain nnnilior of beds (of course under tho physician or surgeon) for a
definite period in addition to ins other clinical work, tlie number of '
“ clinical” students permissible at anyone hospital to bo determined
by the numljer of beds in general occupation, attiliation with hospitals
or infirmaries not having medical .schools being allowed if required.
Tlii.s would bo the principal duty of the propo.sed inspector.
I am, Sirs, yours truly,
CnAs. vv. Chapman, M.D.
Fitejolm's-.avenuo, N.W., Fob. 20th, 1801.
Vaccination and its Results.
Dll. CitKqiiY has had charge of the cmploip-s of tho Chomins do Fer do
I'Est in the matter of vaccination, and ho has just given hia experi¬
ences in an interesting paper. From 1870 to 1888 the mean number
of days lost to tlie Company by the prevalence of small-pox among
the personw.l was 400 per annum. For tiie last two years, from 1888
to 1890, after vaccination and revaccination rigidly and carefully
practised, tho figures fell to 20 per annum—a sufficiently eloquent
Iiroof (if the value of the propliylactic measure.
J. McC. will find tho required information in tlie quite recent work of
Dr. Th. David on tho Microbes of the Mouth.
Mr. IK. Purnies. —Tlie paper has been roceivod and marked for
insertion.
Medieus has not enclosed his card.
THE METROPOLITAN HOSPITALS INQUIRY.
To tho Editors of The Lancet.
Sirs,—I n your condensed notice of my ovidoiico before the Lords’
Committee on the Kith inst. I am reported to have said that "some of
the existing institutions might with profit be removed to the country."
In labouring to be brief you attribute to me a statement which a fair
reading of my argument will not support. The tenour of ray evidence
went to explain how tho rise of tho special hospitals is .accounted for
by tho inado(iuato accommodation afforded by the general hospitals,
and by the close government of these hospitals, which drives men
impelled by the spirit of scientific research to .seek unfettered oppor¬
tunities elsewhere. • I am, Sirs, yoiir.s faithfully,
Harley-streot, February, 1391. Rouert Barnks.
Digitized by
Google
TaS IiANOBT,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS, [Feb. 28, 1891. 527
Xhi5 Mattei Treatment and. the Ebiqhley Cottage Hospital.
At the annual meebing oi this hospital, the governors dealring informa'
tlon as to Dr. Boberts's resignation, a letter from that gentleman was
read, from which it appeared that he had used Count Mattel’s
romedios for cancer, and that his live colleagues on this ground
declined to co-operate with him. He expressed regret for anything
be had said which iiad hurt the feelings of his con/rires, but vindi-
. cated ills right to use any remedies he found to be of value. We can¬
not agree that tho use of secret remedies in public institutions can in
tlie long run be beneficial. The tradition of the profession in favour
of openness is unmistahably sound, and should be adhered to. Let
Count Mattei make full disclosures as to his remedies, and they will
receive fair trial. The matter was not pursued.
G. S. if’.—Thore is no infiexiblo rule. The custom of the district should
be followed.
X)i‘. Kendal PVanAs.—We shall bo pleased to receive the paper.
HOSPITAL ABUSE.
^ To the Editors of The Lancet.
SlR!^,—I shall be glad if some of your readers will advise me as to
what should be done in the following instance.
Some weeks ago I sent a patient with a letter to Dr, Edmunds, ask¬
ing that he might be admitted into one of the pay wards of St. Thomas's
Hospital; but, as far as I can muko out, instead of handing in my letter
he managed to got taken into one of the general wards as a non-
paying patient. When I told him on Ills return home I under¬
stood he had been an inmate of one of the free wards, he said,
“Well, I have not to thank you for that.” I have written to the
hospital authoritie.s, and told them he was in a position to pay for
his board and attendance, as ho was for many years in a good business
and had a regular banking account. It appears to me that tho amount
which he would have been charged had he been admitted into the pay
wards should be demanded of him, as he had no right to live at the
expense of a charity which at the present time has to clo.so some of its
wards on account of its income being insufficient to keep them open.
I am. Sirs, your obedient servant,
Surbiton, Feb. 2r)th, 1801. F. 1’. Atkinson.
Residence and Poor-law Appointments.
Dr. D. A. i'raser .—We think that, cceteris paribus, tho resident In a
parish should be preferred by guardians to one for whom the poor
would have to send four or oven seven miles. But the present
incumbent certainly has strong claims in being in possession and in
there being no complaint to make of inattention. Responsibility |
would be considerable if the distance which the poor have to send
were found to be too great in urgent cases.
SPONGE SUBSTITUTES.
To the Editors of The Lancet.
Sirs,—H aving been hitherto dissatisfied witli the artificial sponges in
general use, I have for some time past been experimenting with
different sponge substitutes, with the aim in view of getting a cheap
aatisepbic and absorbent sponge. I find that Hartmann’s wood wool
enclosed in a layer of sublimate gauze to be decidedly tlio best sub¬
stance whicli I have tried. I may mention tliat wool and gauze are
impregnated with ^ per cent, of corrosive sublimate. 1 liave suggested
to tlio .Sanitary Wood Wool Company, 11, Uatton-gardon, that tiiey
should make an<i bring out these sponges in three sizes, and have also
a larger and flatter fourth size, which I think will bo found of great
use in abdominal operations.
I am, Sirs, yours faithfully,
Derby, Fob. 13th, 1301. T. Henderson I-'ocnds, F.R.C.S. J'liig.
Communications not noticed in our present number will receive atten¬
tion in out next.
COMJiuNiCATloNs, LETTERS, &c., ha VO been received from—Dr. Bastian,
London; Dr. Broadbent, London ; Mr. 8. Snell, Sheffield ; Dr. W. S.
Playfair,London; Dr. Cullimoro, London; Dr.Barnes,London; Dr. J.
Braithwaito, Leeds; Dr. Peregrine, London; Dr. Mason; Mr. Victor
Hor.sley, London; Dr. Linn, Paris ; Mr. Green, Derby; Dr. Theodore
Williams, London; Mr. Lund, Manchester; Dr. Heracholl; Mr. Stuart
Low, London; Dr. Stoaveiiaon, London ; Mr. W. L. Dickinson; Dr. J.
Idttle, Maryi>ort; Mr. Mackintosh, Harpurley; Dr. Campbell Black,
Qla-sgow ; Mr. Cardew; Dr. J. W. Martin, Leith; Messrs. Margrave
Bros., Llanelly ; Prof. A. Stuart ; Dr. Groiintl, Maidstone; Mr. Mayo
Robson, Leeds ; Dr. C. W. Cliapman, Hampstead ; Messrs. Mann and
Son, London ; Mr. 0. Russell; Dr. Charles, London ; Messrs. Oliver
and Boyd, Edinburgh; Mr. Kendal Franks, Dublin; Messrs. Perlcins
and Co., London; Mr. Trubahaw, Mold ; Mr. A. S. Pandny, Qo^vallia
Tank; Dr. S. Stephenson, Hanwell; Mr. Creagh; Messrs. Tliorp and
Co., GlosBop; Dr. Lovoll Drago, Hatfield ; Dr. Rentoul; Dr. Glover
Lyon, London ; Dr. G. H. Mackonzio, Edinburgh; Messrs. Mayer and
Meltz.er, Liiiidon ; Mr. Briscoe, Esher; Mr. P. Edgolow; Dr, Leslie
Phillips, London ; Br. C. M. Catiipboll; Mr. F. A. Rogers; Dr. Oscar
Jennings, Paris; Dr. F. P. Atkinson, Surbiton; Surgeon-Major Deane,
Croydon; Mr. j. S. Gallzla, Malta; Mr. Flggott, Clare; Dr. Barnes,
Carlisle; Dr. Fergusson, Banff; Dr. Goldmann, Frieburg; Mr.^Watt,
London; Dr. Mackinnon, Damascus; Mr. Davie, London; Dr. Jones,
Ruabon; Mr. Cranston Charles, London; Messrs. Hopkinson and
Co., Notts; Mr. Blount, Paris; Mr. Harries, Sussex ; Messrs. Giddy
and Giddy, Pall Malt; Me.ssrs. Richardson, Leicester; Messrs. Griffin
and Co., London; Mr. Dunscombe, Westminster; Messrs. Keene and
Ashwell, London; Miss Pemie, Macclesfield; Messrs. Bailli^ie and!
Co.; Mr. Perkins, Newport; Mr. Mackiewicz, Berlin; Dr. Lediard,.
Carlisle ; Mr. Bramwell, Edinburgh; Mrs. Morice, Agra; Mr. Gumer,.
Pall Mall; Mr. Whitney, Liverpool; Mr. Ramage, Larga; Mr. Diack,.
.Suffolk; Mr. Cornish, London; Mr. O’Meara, Carlow; Mr. Roberts,
Sheffield ; Mr. Ackrill, Harrogate; Dr. Rouw, London; Mr. Smith,.
Bromsgrove ; Mrs. Matthews, Birmingham; Mr. Horne, Bradford ;
Miss Campbell, Glasgow; Mr. Johnson, Leicester; Mr. Hornibrook,
Bloomsbury; Mr. Rutherford, Redcar; Miss Hooper, London; Dr. A.H.-
Robinson, London; Mora; M. O. S., London; Maltlne Manufacturing
Co., Bloomsbury; G. W. S., Leeds; Geoffrey, London; Rotherham-
Hospital; M.D., London; Urbanua, London; Z,, London ; Children’s-
Hospital, Bradford; Medicus, London; Evans, Beckenham; Indian
Engineering, Calcutta; Doctor, London ; L.R.C.P.; Audi Alteram-
Partem; Clentha, London; Beta, London; A Ruined Lodgfing-house-
Keeper; Veritas; The Clerk, County Borough ofSheffield.
Letters, each with enclosure, are also acknowledged from—Mr. Tally,.
Hastings; Mr. Norman, Bayswator; Mr. Sheen, Worcester; Mr. Tyfo,
Minohinbampton; Mr. Fitzgerald, Queenstown; Mr. Istance, New¬
port ; Mr. Buckley, Oldham; Mr. Pearson, Newry; Mr. Rushwortb,.
Halifax ; Mr. O’Meara, Leicester; Mr. Burns, Carlisle; Dr. Thomas,
Pontypridd; Mr. Macdonald, Manchester; Mr. Jones, Glamorgan^
shire; Mr. Williams, Oswestry; Mr. Proub, Edinburgh; Dr. Huide,
Banbury; Mr. Blatchley, London; Mr. Evored, Atblone; Dr. Jones,.
Ruabon; Mr. Davies, Newport;. Mr. Thomas, Liverpool; Mr. Hogg,.
Huddersfield; Mr. Cheosbrough, Brampton; Mr. Cochrane, Wigtown¬
shire ; Dr. Henderson, co. Derry; Mr. Crosskey, Kent; Mr. Brooks,,
Hull; Mr. Hepburn, Bournemouth; Mr. Spencer, Wilts; Dr. Lloyd,.
Llanarthney; Dr. Chawner, Chesterfield; Messrs. Coule and Son, New
York; Mr. Trestrail, Glasgow; Miss Walker, London; Messrs. J. and
H. Grace, Bristol; Mr. Yorke-Davies, Sherborne; Messrs. Blondeaa
et Cle., London ; Mr. Whitehead, Brentford ; Mr. Thomas, Wickhami
Market; Mr. Flint, London; Dr. Pope, Dublin; Messrs. Cassell and
Co.; Mr. Moore, Welshpool; Mr. Jerome, Camelford ; Messrs. Smith,
and Son, Manchester; Mrs. Campbell, Kensington; Messrs. Beal and
Sons ; Mr. Jessop, London; Mr. Tidswell, Cornwall; Messrs. Mertens.
and C.; Mr. Thomas, Leeds; Mr. I'inloy, Longford; Messrs. Cooke
and Sons, Winsford; Mr. Heywood, Manchester; Messrs. Shape and,
Co., Preston; Rev. Mr. Thomas, Birmingham ; Mr. Thomas, Ystrad
Rhondda; Mr. Owen, London; Mr. Howard, Norfolk; Messrs. lies.
and Stradling, Watford ; Mr. West, Stamford; Mr. Whiteley, Uver-
pool; Mr. Walsh, Glasgow; Mr. Essex, Pontypool; Dr. Hector, Brad¬
ford ; Dr. Fraser, Manchester; Mr. Thin, Edinburgh; Mr. Rhodew,
Manchester; Mr. Plm, Dublin; Dr. Briscoe, Wilts; Mr. Eaton, Shef¬
field; Mr. Baird, Walsall; Mr. Ryley, Loudon; Dr. Saul; Dr. Orr,
Hanover; Dr. Hooper, Ripley ; Mr. Smith, Oldham; Mr. Reynolds,.
Cambs; F.H.,London; Fiorence, Yorkshire ; Nessler; Kenilworth
Convalescent Homo; D. G,, London; Secretary, Bamwood County
Asylum, Dorset; Delta, London; Scot, London; Vere, London ; Vade-
Mecum, London; Medicus, Glasgow; Deltoid, London; West Riding
Lunatic Asylum, Wakefield ; Christian, London; Secretary, County
Asylum, Dorset; M. 0. S., Manchester; Iodine, London; Stamfords
Infirmary, Rutland; A. F., London; M.B., Loughborough; latros,
London ; B,, Manchester; Oxon, London; M.A., London; Ferndale,
Torquay ; Carter, London ; K. L., London; Success, London; M.D.,.
Bristol: Medicus, London ; Crown, Roxburghshire; Stafford County
Asylum; P. A., Hatcham; Gamma, London; Secretary, Hospital for-
Women, Leeds; A. R., Halifax; Omega, Manchester; A. W.H.,Nor¬
folk ; Country, London ; Princeps, London ; Surgeon, Cardiff; G. W.,.
Leeds; Alpha, London; Genuine, London; C.D., London; Omega,
Cardiff; Secretary, Royal Hospital, Portsmouth; F. W. H., Barking-
road ; .Spea, London; Surgeon, London; A. M. H., London.
Newspapers. — ScoUman, Mo-niing Post, North British Mail, Mining'
Journal, Local Oovernment Chronicle, City Press, Windsor and Eton
Gazette, OlcuujowUcraUl, Hertfordshire Mercury, Weekly Free Press and'
Aberdeen Herald, SuiuUiy Times, Builder, Beading Mercury, Chemist
and Drugg'ist, West Middlesex Advertiser, Windsor and Eton Express,.
Architect, Broad Arroio, Metropolitan, Spectator, Law Journal, West
Middlesex Standard, Guy’s Hospital Gazette, The Schoolmaster, Eastern
Daily Press, Saturday Review, Pharmaceutical Journal, Yorkshire
Post, SuTi-ey Advertiser, Leeds Mercury, Scottish Leader, Newcastle
Journal, Oldham Evening Chronicle, Bristol Mercury, Rangoon Times,.
Health, Statist, North Star, Western Mercury, Invention, Waterford
Chronicle, Observer, Hastings Chronicle, Walton Gazette, Manchester-
E-.mminer, Worcester Herald, Sidmouth Observer, Belfast News Letter,.
Worthing Gazelle, Alliance News, Galiynani's He.sse'nger, West Hertjf
Post, Durham Chronicle, Isle of Ely Advertiser, Braintree and Bockinff
Adver er, Glossop Times, Daetven Post, Ac., havo been received,
Digiii/i-'i ij,' vjOOgit
1528 Thb Lancbt,]
NOTES, COMMENTS. AND ANSWERS TO CORRESPONDENTS. [Feb. 28, 1891.
Hfbwal Jisr? l&t tusditg ®tek,
Monday, March 2.
.ROTAl XiONOON Oputhajluio HOSPITAL, MooRFiELDS. — Operations
daHy at 10 A.H.
HoYAi Westminster Ophthalmic Hospital.—O perations, 1.80 p.m.,
and each day at the same hour.
Chelsea Hospitalfoa women.—O perations, 2.80 p.h. ; Thursday, s.80.
8 t . Mark's Hospital.—O perations, 2.80 p.k. ; Tuesday, 2.80 p.m.
Hospital for Women, SOHO-3<ii;ARE. — Operations, 2 p.u., and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 8 p.m.
Royal Orthopedic Hospital.—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 8 p.m., and
each day In the week at the same hour.
University Colleqb Hospital.—B ar and Throat Department, 9 a.h.;
Thursday, 9 a.m.
London Fost-oraduate Course.—R oyal London Ophthalmic Hospital,
Moorflelds: 1 P.M., Mr. Win. Lang; Strabismus.—London Throat
Hospital, Gt.Portland-st.: 8 P.M.,Dr.Woakes: Tinnitus and Vertigo.
Royal institution.—S p.m. General Monthly Meeting.
Royal Medical and ciiiRunaiCAL Society .—6 p.m. Annual General
Meeting.
Throat Ho.spital (Gr>lilen-Hq.).—5.30 p.m. Dr. J. W. Bond: Oziuna.
(Post-graduate Course.)
Odontological Society of Great Britain (40, Leicester-sq., W.O.).—
8 P.M. Paper:—Dr. W..lobCollins; Related and As.soclated Ocular
' and Dent^ Diseases, Casual Communications:—Mr. Storer Bennett:
A case of Alveolar Abscess of three years' duration caused by the
f erforation of the side of a root.—Mr. Ackery ; Some cases of Erup-
ion of Teeth in Abnormal Positions.—Dr. Scanea Spicer : Opacity
of the Antrum in Disease (ademonstration with the electric light).—
Dr. David Hepburn : A New Dental Dre.asing Stand.
Medical Society of London. — General Meeting at 8 p.m. for the
Election of Officers and Council. Ordinary Meeting at 8 . 8 i) p.m.
Mr, Knowsley Thornton (President); Further Observations on
cases illustrating Hepatic Surgery.
Society op arts .-8 p.m. Mr. Glsbert Kapp : The Electric Trans¬
mission of Power. (Cantor Lecture.)
’ Tuesday, March S.
King's College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
-OUY’s Hospital.—O perations, 1.80 p.m., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 p.m.
St. Thomas’s Hospital.—O phthalmic operations, 4 p.m. ; Friday, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.m. 5 Saturday, 2 P.M.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
.Si. Mary's Hospital.—O perations, 1.80 p.m. Consultations, Monday
2.80 P.M. Skin Department, Mondt^ and Thursday, 9.80 A.M.
Throat Department, Tuesdays and ^days, 1.80 P.M. Electro¬
therapeutics, same day, 2 P.H.
London postgraduate Course.—B ethlem Hospital: 2 p.m., Dr.
Savage: Legal Relations of Insanity.
Royal Institution.—3 p.m. Prof. V. Horsley: The Structure and
Functions of tlie Nervous System.
Royal College op Physicians .—6 p.m. Dr. T. Oliver: Lead Poisoning
in its Acute and Chronic Manifestations. (Goulstonian Lecture.)
The Sanitary Institute (Parkos Museum, Margaret-st.. W .).—8 p.m
M r. J. P. J. Sykes: General Powers and Duties of Inspectors of
Nuisances.
Pathological Society of London.— 8.30 p.m. Mr. w. G. Spencer:
Exophthalmic Goitre.—Mr. H. B. Robinson: (1) Cystic Disease of
Breast (two cases); (2) Duct Carcinoma.-Dr. W. Colliei': Throm¬
bosis of Cerebral Veins.—Mr. Howard Marsh: Loose Bodies from a
Tubercular Knee-joint.—Mr. E, Willett; Loose Body from tlie Knee.
Mr. B, Clarke : Loose Body from the Knee, consisting of portion of
the Articular Cartilage of the Patella.—Dr. II, D. Rolleston: Patella
with Dislocated Internal Semilunar Cartilage fixed to it.—Mr. L.
Shaw: Sarcoma opeiiingTrachoa. Card Specimens:—Mr. K. Solly:
Melanotic Sarcoma of Conjunctiva.—Dr. W. B. Iladtlon ; Pancreas
in Diabetes.—Me.s.srs. S. Q. Shattock and C. A. Ballaiiee; Fiichsin
Bodies in Carcinoma, Tuberculosis, Diphtheria. — Dr, Rolle.ston
(for Mr. A. A. Kanthack): Piiohsin Bodies in Various Condition.s.
Wednesday, March 4.
National Orthopadio Hospital.—O perations, 10 a.h.
Middlesex Hospital.—O perations, 1 p.m. Operations by the Ohstetrlo
Phy^ciana on Thursdays at 2 p.m,
St. Bartholomew’s Hospital.—O perations, l.so p.m. ; Saturday, same
hour. Ophtbalmio Operations, Tuesday and Thursday, 1.80 P.H.
Surgical Consultations, Thursday, 1.80 P.M.
CHARiNQ-caoss HOSPITAL.—Operations, 8 P.H., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 p.m. Thursday (&Saturday,samehour.
St. Peter’s Hospital, Covent-oarden.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Children.—O perations.
2.30 P.M.
University Coi,legr Hospital.—O perations, 1.80 p.m. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 9.16 a.h.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
CHILDREN'S Hospital, Great Ormond-strekt.—O perations, 9.80 a.m. 5
Surgical Visits on Wednesday and Saturdav at 9.16 a.m.
London Post-graduate Course.—H ospital for Consumption, Bromp¬
ton : 4 P.M., Dr. Aclaml: Some Affections of Ihe Bronchi.—Royal
London Ophtlialmic Hospital; 8 I’.M., Mr. Lawford: Ocular Palsy.
Throat HO-spital (Golden-sq.).—6.80 p.m. Dr. MacDonald: Stenosis
of the Larynx. Intubation, Tracheotomy. (Post-graduate Course.)
Obstetrical society op London ( 20, Hanover-square, W.).—8 p.m.
Specimens will be shoxvn by Mr. J. B. Sutton, Dr. Hayes, Dr. Craw-’
ford, and others. The President will doliver the Inaugural Address.
Dr. Dakin: Tetany in Preenancy.—Dr. JoVin Phillips: On a case of
Death following Vaginal Injection of Acid Nitrate of Mercury.
Society of Arts .—8 p.m. Mr. J. H. Carter: Modern Flour Milling.
Thursday, March 6.
St. George's Hospital.—O perations, 1 p.m. Surgical Consultations,
Wednesday, 1.80 P.M. Ophthalmic Operations, Friday, 1.80 p.m.
University College Hospital.-^O perations, 2 p.h. ; Bar and Throat
Department, 9 a.m.
London Post-graduate Course.—N ational Hospital for the Paralysed
and Epileptic: 2 P.M., Dr. Ormorod : Electrical Testing.—Hospital
for Sick Children, Great Ormond-st.: 4 p.m.. Dr. O. Sturses: Cases
illustrating the Simulation of Tubovcnio.sis in Young Children.—
London Throat Hospital, Great Portland-at.: 8 p.m., Dr, E. Iaw :
Demonstration of Cases.
Royal Institution .—8 p.m. Professor C. Meymott Tidy : Modern
Chemistry in relation to Sanitation.
Royal College of physicians .—6 p.m. Dr. T. Oliver: Lead Poisoning
in its Acute and Chronic Manifestations. (Goulstonian Lecture.)
Friday, March 6.
Royal South London Ophthalmic Hospital.—O perations, 2 p.m.
Cancer Hospital (k'ulham-rd., S.W.). —4 p.m. Mr. F. Bowreman
Jessett: Cancer of the Stoinacli and its Troatment.
London Post-graduate Course.—H ospital for Consumption, Bromp¬
ton: 4 p.m.. Dr. Aciand: A Demonstration illustrating both by
living and other Specimens the Lecture on “ Some AflectionH of tbo
Bronchi" delivered on March 4Lh.
Society of Arts.—4,30 p.m. Capt. Abnoy ; The Scienco of Colour.
The Sanitary Institute (Parkes Museum. Margarot-8t.,W.).—8P.M. Mr.
J. F. J. Sykes ; Objects and Methods of Inspection.
West London Medico-Oiiiuurgical Society (Board-room, West
London Hospital).—8 P.M. Mr. Percy Dunn will show some Patho¬
logical Specimens. Mi. Bruce Clarke : A case of extensive Skin
Grafting.—Mr. Edwards : Two cases which have undergone Opera¬
tive Treatment subsequent to Inoculation with Koch’s Lymph,—
Mr. Keotley : A Boy witli Healed Tubercular Fingor,—Dr. Ball: A
case of Lupus of the Nose treated by Scraping.—Mr, Pickering Pick:
Notes of a case of 'Trephining for Epileptic Fits, the result of a
Depressed Fracture.— Dr. Horringbaui ; A case of Multiple Neuritis
in a Man.—Dr. McAdam.s Eccles ; A Uliild with Multiple Epiphysitis
of Syphilitic Nature.
Royal institution.—9 p.m. Professor J. A. Fleming; Electromagnotio
Repulsion. Saturday, March 7.
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p. m. ; and Skin Depart¬
ment, 0.16 A.M.
London Post-oraduate Course.—H ospital for Skin Di.seases, Black-
friars : 2 P.M., Dr. Payne : The Treatment of Cutaneous Inflamma¬
tions.—Bethlem I-loapitahll A.M., Dr,Smith;CliuicalDemonstration.
Royal Institution.—3 p.m. TheRightHon, Lordltayleigh: The Forces
of Cohesion.
SUBSCRIPTION.
Post Free to any part of the United Kingdok.
One Year..— £112 61 Six Months ^ £0 10 I
To China AND India .....One Year 110 11
To the Continent, Colonies, and United
States ..... Ditto 1 14 I
Post Office Orders and Cheques should bo addressed to The Publisher,
The Lancet Office, 423 , Strand, London, and crossed "London and
Westminster Bank St. James's-squaro."
ADVERTISING.
Books and Publications (seven lines and under) .£060
Official and General Announcements .. . .060
Trade and Miscellaneous Advertisements .. .060
Every additional Line 0 0 6
Front P^e ..... per Line 010
Quarter Page . - . . - . -110 0
Half a Page _ . . . . . .2 16 0
An Entire Page .. . . .. .. . .660
The Publisher cannot hold himself responsible for the return of tesM-
monials &c. sent to the office iu reply to advertisements; copies only
should be forwarded,
Notice.—A dvertisers are requested to observe that It Is contrary to
the Postal Regulations to receive at Post Otlicos letters addressed to
Initiab only.
An original and novel feature of " The Lancet General Advertiser” Is a special Index to Advertisements on pages 2 and 4, which not only
aBoids a ready means of finding any notice, but is in itself an additional advertisement.
Advertisements (to ensure insertion the same week)8hould be delivered al the Office not later than Wednesday, acoompamed by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should be
.addressed.
Advertisements are now received at all Messrs. W. H. Smith and Son’s BaUway Bookstalls throughoub the United Kingdom and all otbet
Advertising Agents. __
A««it tor ttM AdTertUeaient Department in Franoe--J. ABTIBB, M, Rue Caumnrtln. Vaxlii
THE LANCET, Maech 7, 1891.
ABSTEACT OF
ON
DIPHTHERIA, ITS NATURAL HISTORY AND
PREVENTION.
Delivered before the Boyal College oj Physicians of
London,
By R. THORNE THORNE, M,B., F.R.S., F.R.O.P.
LECTURE III.
The third lecture was largely devoted hy Dr. Thome
■'Thorae to the subject of “school influence ” in relation to
•diphtheria. That some such influence obtained had been
•one of the earliest observations following on inquiry
into this disease, and it was at first ^sumed that the
•question ivas simply one of personal infection under
epecialiy favourable circumstances. Beyond this the
«arlier investigations did not go. Dr. Thorne cited as
an example of further progress the story of the Cogges-
hall epidemic in 1877, from which it was seen that under
three years of age school attendance did not materially
affect the number of attacks, that between three and
twelve years the incidence was 50 per cent, greater on
those attending school than on those who did not, and that
from twelve to fifteen years the school attendants suffered
three times as much as those not known to attend school.
An outbreak at liadwinter was next adverted to, from
which it appeared that school attendance had clearly
afforded to healthy children at a particular age the special
opportunity of coming in contact with others capable of
transmitting throat infection. There was also a marked
'difference in the incidence of the disease at different ages,
on school attendants, and on others, and it was noticed
that from three to twelve years, 70 per cent, of school
attendants were the first attacked in households; whereas,
including all subsequent attacks at those ages, they only |
•amounted to 48 per cent. There was also some evidence to |
show that attack and death were more common in the same
■locality in the case of scliools that were overcrowded and
dll-ventilated than in others.
Bub in 1883 an outbreak at Pirbright, which was iu-
■veatigated by Mr. Power, revealed other features of school
influence. It was here distinctly shown that the child of from
•three to twelve years of age had, for a reason other than its
age, a susceptibility to contract the disease and to convey
iib home, school-going being the reason in question. Then,
again, each time the school was closed the diphtheria
practically came to an end; each time it was reopened the
disease recommenced, and this without any source of
‘infection that was obvious, although much care was taken
to detect any such cause. And although it became quite
•clear that school attendance had played an important part in
the speciality of the diphtheria amongst children at the ages
of three to twelve years, it seemed clear that faulty sanitary
circumstances had had no concern that could be detected in
bringiBgabouttliis result, But a further point was illustrated
by reference to the facts observed. Not only did diphtheria
'break out each time school operations were recommenced, bub
•the disease appeared on each occasion with startling sudden¬
ness and with fatal gravity, and this without any known
'intermediate cases which could have admitted of a process
-of progressive infectiveness; and it seemed that the mere
bringing together of the children was responsible for im-
‘PartiDg to the throat affection the serious specific quality in
■question. Otlier cases were also cited in which the com¬
mencement of school operations bad led, after apparent
•cessation of diphtheria, to sudden “explosions” of the dis-
•'ease, and one instance was quoted to show that other
•aggregationa of children than those actually in school
houses operated much in the same way. The case in
■question was one recorded by Dr. Bruce Low, in which
•a schoijl tieat was held on a damp day in a tent after a
prevalence of throat disease, the result being that the dis-
«Me brolce out again within twenty-four hours, with a
virulence and fatality quite in excess of anything that had
No. 8623.
gone before; and ic was held that such aggregations had,
under certain circumstances, the peculiarity of manufac¬
turing, as it were, an infection or a special potency and
virulence.
Another point bad also been observed in connexion with
school attendance—namely, the recrudescence of the infec¬
tive quality attaching to throat affections, the observations
as to this having been mainly recorded by Dr. Astley
Gresswell. It had been noticed that a number of
persons in different parts of the country, who had years
before been attacked with diphtheria, were constantly
suffering from throat affections, any change of weather
or trifling cold sufficing to produce an acute inflam¬
matory condition about the tonsils. And it having been
observed on a number of occasions that amongst those
associating with such persons there had occurred cases of
diphtheria the origin of which could nob be accounted for,
the question arose whether the chronic tonsillar affection
left in certain persons after diphtheria might not be due to
the continued sojourn in them of the material cause of diph¬
theria. A series of instances were quoted in connexion
with these occurrences, and it was especially pointed out
that in schools diphtheria attacks had occurred immediately
subsequently to the recurrence in monitresses, who had pre¬
viously had diphtheria, of any symptoms of renewed throat
mischief such as was assumed only to have resulted from
taking cold. These cases have suggested dormancy
and recrudescence in an infectious form of the mate¬
rial cause of diphtheria in an individual. The obscurity
Involved in such occurrences was also pointed out to
be the gi'eater because convalescents from diphtheria,
who have returned to their work with healthy looxing
tonsils, may be found shortly afterwards with creamy
patches on the tonsils and pharynx, or even with genuine
diphtheria membrane on the fauces, and this apparently
without the general symptoms usually affecting the system
when such results ensue on a primary attack of the disease.
Diphtheria appeared, according to the views expressed,
to become at times a chronic malady in certain individuals
with liability to recrudescence ; and glanders in the horse,
contagious ophthalmia in children, as also gleet in its
relation to gonorrhoja, were referred to os analogous to
diphtheria in this respect. A somewhat parallel experience
bad also been noticed in the case of certain parasitic
organisms, which exhibited periods of renewed vitality, to
which the term “ rejuvenescence” had been given. And, as
regards diphtheria, U was stated that such recrudescences
had mostly been associated with uuwbok some circumstances
and surroundings much of the same sort as those conditions
which had before been sho wn to induce a form of sore-throat
which rendered the individual especially liable to receive the
diobtheiia contagium, the tonsils under such circumstances
afl'ording exceptionally suitable hosts for sustained main¬
tenance of the virus of the disease. Such experiences, also,
may possibly afford one explanation of the circumstance
that an attack of diphtheria does not, as is the case with
moat of the specific fevers, afford immunity from a second
or even a third attack.
Dr. Thorne then summed up, under a number of headings,
the various methods in which school influence would appear
to be operative iu favouring diphtheria, and he laid especial
stress on the conditions of school life that tended to com¬
munication of the disease from person to person by reason
of the closeness of the mouth and nares of the recipient
individual to the faucial mucous membrane of the individual
by whom the infection is imparted. And reverting again to
the excess of diphtheria in females at school ages over males,
he pointed out how a number of practices which tended to
danger, such as the collective singing and intoning of lessons,
kissing, and the sharing of sweetmeats, were more commonly
sources of mischief amongst girls than amongst boys. And this
led him to speak of one possible cause of excess of diphtheria
amongst females who bad reached more adult years. Pre¬
mising that age susceptibility had by that time largely passed
away, be was inclined to think that a much closer contact
with diseased fauces was necessary in the case of adults than
in children, and he pointed out that whereas in diphtheria
wards, where nurses wero in the habit of carrying the sick
children about; the spread of the disease to those nurses was
not uncommon, there were instances whore no such spread
had been known for a series of years, this result being
associated with a prohibition to lift or carry about a
diphtheria patient. The danger to adults of close contact
with diphtheria was exemplified by the terrible risks
530 The Lancet,]
DR. THOMAS OLIVER ON LEAD POISONING.
[March 7,189K
iocurred by Burgeons and dresaeifi in endeavouring to save
life by suction of blocked tracheotomy tubes; but whilst
such action must be regarded as akin to a deed of lieroism,
the needless actions of parents, nurses, and others who
could not be prevented from embracing and fondling the
diphtheria sick amounted only to a wanton carelessuesB of
life. And when, as is not uncommon, especially in some
northern counties, children were deliberately brought by
echool teachers to see and even kiss their dying or dead
schoolmates, the practice became one bordering on criminal
culpability. The varioua aspects of school aggregation,
involving a steadily increasing stringency in hiinging
together children to the elementary schools under our
present Education Acts and regulations, were next con¬
sidered, in so far as the success in attaining those edu¬
cational results may have had a bearing in the increasing
incidence and fatality of diphtheria both in the country
generally, and especially in our large towns and cities.
Aqd in this connexion Dr. Thorne explained that again and
. again bad suggestions to exclude from school children
residing in infected houses and localities been resented,
because the step tended to diminish the average attendance
on which the financial status of the school, and at times of
the teachers also, was dependent. Indeed, when children
stayed away from causes such as “ sore-throat,” amongst
. others, there was at times a “ whip-up ” of this dangerous
absentee residuuna; and it bad become notorious that the
suspicious form of sore-throat previously adverted to could
most easily be found in schools. Then often followed
“explosions” of diphtheria. “And if,” said Dr.
Thorne, “as I have suggested, the specific organism
of diphtheria tends to behave as do certain low forms of
vegetable life, may it not be that, just as special charac¬
teristics tend to be developed by the gathering together
into a hothouse of selected forms of plant life that have
hitherto been struggling towards a tardy and imperfect
development in the open, so the increased virulence and
greater reproductiveness of the diphtheria contogium,
which would appear in point of time to have been associated
with the steady growth of a system by which the young
are gathered together for educational purposes may turn
out to be dependent on the aggregation, forced or other¬
wise, within school premises, of children suffering from sucli
throat ailments as I have indicated
ABSTRACT OF THE
6mdstoniiiii fcriiti'ts
ON
LEAD POISONING IN ITS ACUTE AND
CHRONIC MANIEESTATIONS.
Delivered at the Royal Collegeof Physicians, March, 1801,
By THOMAS OLIVER, M.A., M.D., RR.C.P,
I-IIYSICUN TO TllK IlOYAI. INlOaMAriY, NEWCASU.K-CPON-TYNI.;,
ANo i>n(»iT;ssoR or i’iiysiolouv, UNivEnaiTY ov Durham.
LECTURE I.
Mu. President and Gentlemen,— Let me thank you
for the very great honour which you have conferred upon
me in inviting me to become the Goulstonian lecturer for
the year. Having accepted the office, I am deeply sensible
of the responsibility it involves. Weighty as I feel the duty
imposed upon me, it is only equalled by my desire to make
these lectures acceptable and instructive. In searching for
a subject, I considered there was one upon which, with the
time at iny disposal for its preparation and delivery, I
might be able, from the opportunities afforded me for its
study, to say something that might prove of interest to you
and of service to the profession. Lead poisoning is not only
of local but of national importance. The last two years
have shown how truly necessary it is for u.s to realise the
dangers that lurk in the supply of drinking water and of
food. The wholesale poisoning that occurred a short while
ago in Sheffield and in Keighley bear witness to this
Btateroent. Apart from epidemics of lead poisoning due
to the contamination of Ch/* drinking-water, it is true
that the diseeise only affected a small proportion of the
working classes, but that is one reason why we, who are
the guardians of the public health, should help those-
who cannot help themselves. It was in the College of
Physicians that in 17(37 Sir George Baker, a scientist of
celebrity, first drew the attention of the medical professioa
at once to the production of colica pictonum by the use of
cider, and successfully taught how to remedy the evil.
There is a general consensus of opinion that the insidious
introduction of lead into the human system in very minute-
quantities is followed by symptoms of a more serious nature-
^an when taken in large quantities and for a short period.
In the latter case we have the symptoms of irritant
poisoning, but in the former the symptoms are sometimee
so remote that their relationship may escape our attention.
' In the cumulative action of the poison lies tlie danger. /
Whilst recognising food, water, and fermented liquors as.
media whereby lead may be introduced into the system, my
experience has been gained mostly from workers in lead
factories. I shall therefore deal with the subject more from
the industrial than the accidental side. Lead poisoning,
has long been known. Galen condemned the use of lead \
pipes. Nicandre described acute lead poisoning, and thb
Roman architect Vitruvius forbade the use of lead for con¬
ducting water owing to the ceruse which it formed being
hurtful to the human body. Lead is introduced into the
system through many channels. Those who are engaged
in lead mining never suffer. The danger begins with-
the smelting of the metal. This is a hazardous occupa¬
tion. The fumes which escape from the molten metab
frequently poison cattle gmzing in the vicinity of the
smelting furnaces—a circumstance which has frequently
been a cause of litigation. Cattle have died from-
eating the grass thus impregnated with lead dust, and the
dogs that have lapped the water trickling from lead works,
have also exhibited signs of lead poisoning. Some interest¬
ing points bearing upon this point have been shown by
Schroeder and Reuss. In their paper, on the “Influence
of Forge Smoke upon the Animals of the Forest,” they states
that the birds which eat the berries of the mountain-ash
trees which are in close proximity to the forges are fre¬
quently found lying at the foot of the trees paralysed or
dead; 'but that the wild animals, particularly the stags,,
which r^am about in the woods, whilst not sufSering from-
paralysis of the extremities, exhibit peculiar monstrosities
of their horns. Their antlers are short and stunted; the
radioles are small, sometimes they are absent, the rosettes
in these cases being flat and almost touching the cranium..
I Double crowns sometimes appear. These monstrosities.
^ are most apt to occur amongst stags whose sexual organa
have been injured, for stags, like men, have their reproduc¬
tive organs aiFected in lean poisoning. Gam^e, in his work,
on the “Domestic Animals in Health and DiBease,” draws
attention to the fact that cattle have frequently died from
drinking water contaminated by lead, and from eating
grass impregnated with the oxide of lead, and ho has shown
that the deposition upon land of town rr^nure which con¬
tains the refuse of paint, sheet lead from tea-chests, and
pieces of p&mted oilcloth, has been followed by an attack o^
what is known as “staggers” in the animals allowed to graze
in the fields. Thackrali, in his book on the “Effects of
Trades on Health and Longevity,” gives no place to lead -
making as a dangerous employment. He introduces the
subject in his remarks upon plumbers and painters.
Plumbers suffer, ho says, from the inhalation of tlie vola
tilised oxide of lead arising during the process of casting.
They are short-lived. /
It is amongst lead workers that the worst types oS
plumbisin are met with. So far as the working of lead ie-
concerned we have seen that the producer of the raw mate¬
rial never suffers; it is the smelter. The next danger arisec.
during the process of the conversion of the metal into white
lead or carbonate. There is no process of preparation of
white lead, so far as is known, that is equal to the old Dutch-
method. It is a simple but a dangerous procedure. It was-
introduced into thi.s country about the year 1780. [Dr.
Oliver briefly described the process, and showed t)>at the
greatest danger arose in what is known as the “white beds'"
and “stoves.^’] It was the opinion of Sir Janies Aldersop,
when be delivered the Lumleian Lectures in this College in
1852, that women were less frequently affected by lead!
than men. Such is not my opinion. It is known that
when the two sexes are exposed equally, or in epidemics of
plumbism from the use of contaminated waters, the fair sea
: r AjOOgle
The LANcetJ
DR. THOMAS OLIVER ON LEAD POISONING.
[March 7, 1891. 531
is^weaker, and their nerve centres are more readily under-
onined.
[Drinking water as a source of accidental lead poisoning
■was discussed, and the following case reported :]
Last year I saw, in consultation with Dr. Sniith of Ryton, a
,gentleman, aged hfty, who a few months previously had been
suddenly seized witia unconsciousness in a hay field. The
.attack was regarded as syncopal. From that day he was
never well. He complained of severe pain in the abdomen,
just above the umbilicus, and became extremely depressed
in spirits. When I saw him a few months afterwards he
had aJl the symptoms of general paralysis. In addition to
^^olic and constipation he bad delusions and fibrillary tremor
of lips and tongue ; the right pupil was dilated compared to
the left; he was extremely cachectic. He complained of a
disagreeable taste in his mouth and a blue line was noticed
•on his gums. His heart and lungs were healthy. There
was no albumen in the urine, but a trace of lead wai preseut
in it. He was sent to the seaside, where he improved.
The drinking water was analysed, and found to contain
•0‘0028 grain per gallon. This patient, died of an iuter-
current disease, but retained many of his symptoms of lead
poisoning. At the necropsy there were found thickening of
the pia mater and arachnoid over the fronto-parietal region,
'with accumulation of fluid in the subarachnoid space,
•extreme pallor and hydrjomia of the brain, fluid in the
lateral ventricles. His wife had also a blue line on her
^ums, but none of the children. The water from the well
passed through several feet of lead piping into the house.
As an illustration of lead poisoning from the use
■of fermented liq^uors I would draw attention to the
■following case. It occurred in the practice of Dr. Cromie
•of Blyth, Northumberland. In September of last year
he was called to see a botanic beer manufacturer,
aged forty-four, who had been a healthy man until
two years previously, when he suffered from constipa¬
tion and dyspepsia. In February, 1890, he had “wrist
■drop.” In August of last year he had a convulsion whilst
standing in liis shop, but he soon recovered conscious¬
ness. The convulsions kept recurring, and in one of them
he passed into a state of coma, in which he died. The case
was one with all the physical signs of plumbiam. The
history of his household is interesting. His wife, who is
twenty-eight years of age, bad formerly a good deal of
•colour. She is now very an.'uinio. She has two children,
one aged five and the other three years and a half. Since
’the birth of the younger child she has had one miscarriage.
Her menses are profuse. At her husband’s instigation she
has taken botanic beer for the last two years. She was
seized with colic twelve months ago, had vomiting, head-
■ache, and constipation, but soon recovered. When I saw
'her she had just recovered from an attack of colic, which
had come on soon after her husband’s death. She was pale ;
had well-marked blue line on her gums ; no albuminuria.
Living in the house with her two children was a domestic
servant. The maid, though frequently pressed to take the
botanic beer, refused on the ground that she did not like
the taste of it. She has remained quite well, and has no
blue line on her gums, nor is she ancemic. The elder child
has been living most of the time away from home with liis
gi'andmother, and has therefore not had many opportunities
of taking the botanic beer. He is not distinctly anmmic,
and lias only the faintest trace of a blue line on his gums.
His sister, a child of over three years of ago, has lived
always at home, and since early in infancy has received
■daily a small quantity of the botanic beer. She is very
•anaemic, and has a blue line on the upper gum. This child
wlion I saw her could not talk, nor even walk well. There
was a good deal of staggering ; her knee-jerks were absent.
Three months afterwards she died in a convulsion, There
'had bean several convulsions. The urine contained albumen.
The use of hair dyes is a source of lead poisoning. A
■short time ago one of the ballet girls from the Tyne Theatre
was admitted into the infirmary under my care suffering
from colic headache and amaurosis; there were retinal
‘hemorrhages. She had been using a cosmetic containing
'lead. She recovered. A more striking illustration of tlio
serious effects of the indiscriminate use of lead hair dye
•<i_ccurred in the practice of my friend Mr. C. B. Morgan of
'■Sunderland.^ It was that of a maiden lady who sought
adv'ioe because her left eyelid drooped, that she saw objects
■double, and that for some weeks post she had been gradually
' Ti'anNautions of the Northnmliovlajul anil Duiliaiii Medical Society,
^prll, lli77. ■
losing the power in her arms. There was obstinate con¬
stipation. Her mind was perfectly clear. A week after¬
wards, as she had notimproved, Mr. Morgan added iodide of
potassium to her mixture Next morning she was found
dead in bed. At the necropsy, Mr. Morgan naturally
expected to find some brain lesion, but the most careful
examination, conducted by himself and Dr. Ransom, failed
to reveal anything abnormal either there or anywhere else.
Both these gentlemen were struck by the luxuriant
black hair of the corpse. A few weeks after this the
niece of the old lady, who had also bean struck by the
beauty of her aunt’s hair, ventured the suggestion that the
illness might have been due to the use of a hair dye which
the aunt made by mixing sugar of lead and sulphur
with another liquid which was unknown to the niece.
By its use, Mr. Morgan suggests, may be explained the
paresis of the upper limbs, then of the third nerve, and then
rapid death following the administration of iodide of potas¬
sium, on the theory of Melsens, that a soluble iodide had
been formed which is highly injurious. Dr. Macdowell of
the Northumberland County Asylum has related to me two
cases of lead poisoning arising from the wearing of false
teeth the plates of which contained lead; both patients
became insane. Lead poisoning due to the contamination
of articles of food was alluded to, and the colique s&clie of
the French navy was shown to be nothing else than lead
colic. Dr. Stephen Mackenzie alleges that in the autumn
a larger number of cases of lead poisoning is mot with than
at any other season of the year. The months of June,
July, and August have supplied the largest number of cases
in the north of England.
As regards the age at which plumbism is most apt to occur
it is dilliculb to say. Children are not exempt. Adults are
niostexposed to theinfluenceof lead, and therefore sutt'er most.
Whatever doubt surrounds the question of age, there is no
doubt as regards the greater susceptibility of the female to
be contaminated with lead compared to the male. This is
an opinion so totally dt variance with that given by several
authors tliat I must explain myself. My experience, drawn
from hundreds of cases, is that, both as regards acute and
chronic forms of lead poisoning, women are much more
! quickly brought under, its influence than men, and this not
I simply from the fact that women are more exposed in the
j factory to greater dangers. It is shown by the statistics of
epidemics. In Yorkshire, where, out of 1000 coses of lead
' poisoning, it was noted to bo due to the drinking of water con-
' taminated by lead, the proportion of females to males was
! as four to one. Brown of Bacup also noticed a preponder¬
ance of females affected. Not only is there a sexual, there
is also an individual idiosyncrasy to plumbism. There is a
class of women very easily affected, but what that type is
it is impossible to say. It is the ill-clad and the poorly-fed
women who suffer most. They soon break down when
exposed to the influence of lead.
Lead as a poison strikes early at the functions of blood-
making and reproduction, producing sterility, liability to
abortion, and araenorrhosa or menorrhagia. From her
constitutional idiosyncrasy, woman is, therefore, more
liable to be impressed by lead. Whatever may be the
power of sex, of family and individual predisposition, how¬
ever potent may be the effects of inadequate food and
clothing, if there is one thing wliich most greatly increases
the infliienco of one or other of these a.s factors in deter¬
mining lead poisoning, it is alcohol.
Once the individual has suffered from an attack of lead
colic or any symptomof lead poisoning, he is launched upon
a morbid stream of life where, under tbe influence of meta¬
bolism which is making for health, he may recover ; on the
other hand, if he is inattentive or uDwilliog to regulate the
requirements of his constitution by abstinence from alcohol,
and again exposes himself, preferring thus to be wafted by
the breeze that placed him on that stream, be floats the
more rapidly down, heedless of the gulf in which he is so
soon to be submerged. Between the first and subsequent
attacks thoro are periods of quiescence; the first attack
predisposes to the second, and the second to the third ; or a
first attack is experieuced, and, witboutany fresh exposure,
there is—long affor, it may be—another outburst. What
is the meaning of this? Is it that during the period of
apparent health load has been deposited in some of the
organs in an insoluble state, and that as the result of some
particular diet, drink, or medicine it has again been
rendered soluble, circulates afresh in the system, and for
the time being the person is poisoned with lead absorbed
from his own tissues?
c5
le
S32 Thb Lancet,] MR. W. H. BENNETT ON THE VITALITY Of THE TESTICLE.
[Makcii 7,1891.
ON THE EFFECT OF THE DIVISION OF
CERTAIN CONSTITUENTS OF THE SPER¬
MATIC CORD IN THE RADICAL CURE OF
VARICOCELE AND OTHER OPERATIONS
UPON THE VITALITY OF THE TESTICLE.
By WILLIAM H. BENNETT. E.R.C.S ,
SURGEON TO ST. GEOROE'S HOSPITAL.
In Thb Lancet of Feb. 9bh, 1889, page 261, I called
abtentiop to an operation for the relief of varicocele difTer-
ing in important respects from any method previously
described. I then stated that in my opinion this proceeding
was by far the best means available for dealing with the
class of afFection for which it was devised. This belief has
been strengthened by a considerable additional experience,
obtained since the publication of my paper on the subject.
An essential detail in the operation, after the vas deferens
has been isolated in the customary way, is the applica¬
tion through an incision in the scrotal tissues of two
ligatures ^aced at a distance from each other round
the sheath of fascia which contains the spermatic plexus
of veins. The portion of the cord lying between these
ligatures is then excised. The remaining points in the
technique of the proceeding need not be recapitulated,
as they have no special relation to my present purpose.
The whole of the spermatic plexus of veins, with the
exception occasionally of a small vessel lying remotely at
the back, are contained within the sheath fG'‘med by this
fascia, and one object of including it in the ligature is to
ensure tbe obliteration of the whole of the veins ; for it is
clear that if the ligatures are passed round tbe connective
tissue sheath before the vessels are exposed none of these
can escape. Further, if the ligatures are passed in tiie
manner described, not only are the veins with certainty
included, but also the main trunk of the spermatic artery,
in evidence of which it is niy custom, when operating in
hospital practice, to demonstrate the existence of a section
of this artery in the excised portion of the cord.
Two points of interest here arise: First, it is obvious
that if the spermatic artery is included in tbe liga¬
ture, as it certainly is under these circumstances,
the traditional teaching of the schools that the vas
deferens when pushed aside carries the spermatic artery with
it is wrong. Practically this is so, for the artery does not go
with the vas deferens when it is displaced, but remains either
quite close to the spermatic veins, or, as commonly happens
iu varicocele, is actually surrounded by them. So intimate-
indeed, is this relation of the artery to tbe veins that I
believe it to be almost impossible to include the whole of
the latter vessels in a ligature in a case of varicocele without
also including the artery, unless an elaborate and tedious
dissection be undertaken for the purpose. I have therefore
little doubt that in the vast majority of operations for
varicocele in which the spermatic plexus of veins is divided
that the main trunk of the artery is also involved in the
section. To this fact no reference exists in the literature of
the subject so far as I can ascertain. It is dillicult to see
upon what anatomical basis, if such exist, this traditional
view as to the associated displacement of the vas deferens
and spermatic artery rests. It is, however, possible that the
belief commonly held that the nutrition of the testicle is de¬
pendent almost entirely upon the integrity of the spermatic
artery led to tlie conclusion that in operations in which the
spermatic veins were freely divided the artery had escaped
injury because no ill t llect was necessarily produced upon
the testicle. It was then easy to assume tiiab the apparent
safety of the vessel was due to its having been pushed aside
with tbe vas deferens. The second point of interest is the
effect of this division of the spermatic artery, together with
the veins, upon the nutrition of the testicle. The isolated
position of this organ, coupled with tho accepted view just
referred to that its blood-supply depends almost entirely
upon the long and slender spermatic artery, lias given rise
to the impreesion that its vitality is endangered by the
division of this vessel, together with the spermatic plexus
of veins, and that section of the spermatic artery, veins,
and vas deferens—i.e., virtually the whole cord—is certain
to be followed by sloughing of the testis. So strongly is
this view held by some practitioners that it is, I believe,
not uncommonly taught, in the event of the cord including'
the vas deferens being divided during an operation, that it
is proper to remove the testis at once, not only on account ofi
its having been rendered functionally useless, but especially
because if it is left sloughing will surely follow.
Now, with regard to division of the spermatic artery with-
the veins no harm whatever need result, for the artery of
the vas deferens which is certain to have escaped injury is-
by DO means always an insignificant vessel, and generally
sufficient by its anastomoses with the spermatic to pre-
vent not only immediate necrosis of the testicle, but also
immediate wasting, as it often receives assistance fronv
other vessels which will be indicated presently. In sup¬
port of this contention I can state without any hesita¬
tion that in almost every case of varicocele upon which'
I have operated a portion of the spermatic artery could
be demonstrated in the excised part of the eord, an^
that in none of these instances has there been tbe least
suspicion of wasting. On the contrary, the testicle when-
soft or small has invariably become more natural in size
and consistence, and certainly in one instance more perfect
in a physiological sense. The immediate result of division of
the vas deferens with the spermatic veins and artery, whether-
by accident or of necessity, is naturally to render the testicle
functionally useless, as its duct has been severed; but the-
idea that sloughing of the organ necessarily ensues is cer¬
tainly not correct, as will be seen from the three examples
which follow, (a) Some years ago, whilst performing one'
of my earliest operations for the radical cure of a congenital'
hernia, I divided apparently the whole cord, including with ¬
out doubt the vas deferens, the spermatic artery, and veins.
My first impulse was to remove the testicle, buti, for reasons'
which I need not enter into, I did not do so. The case pro¬
gressed rapidly without any sign of inflammatory action ;;
moreover, to my surprise, no appreciable change had taken
place in the testis four months after the operation, when
the patient was seen for tbe last time, (b) In the course of
an operation for the radical cure of hernia, I saw a surgeon
of repute and experience divide apparently the whole cord.
In this case again the testicle did not slough, and two-
months after tbe operation was indistinguishable in general'
characteristics from the opposite healthy gland, (c) I have
recently examined a youth in whom I know that the vas-
deferens and apparently the remainder of the spermatic cord
was divided about four months previously in an operation
for the cure of a congenital hernia. The testicles remain-
precisely alike in natural consistence and size. These are
remarkable cases and will, I venture to think, repay a brief
consideration as to their practical bearing, for I can liad no
record of any similar instances.
In the pre-antiseptic period of surgery there is little doubt
that such an extensive injury to the cord as occurred in-
each of the above cases would generally have been followed
by sloughing of the testicle. Hence the traditional teach¬
ing to that effect. The only possible explanation of the-
survival of the organ after such a serious interfereuce with-
its vascular arrangement must lie in the fact that there
exists a considerable arterial supply over and above that
which need be involved in a section of the cord itself. The-
only available sources of this additional blood-supply are
(1) some outlying branches of the spermatic artery, one of
which sometimes comes off' high up, and so may easily escape
division ; (2) the artery of the vas deferens, which may not
be injured, even though the duct itself be divided; and’
(8) some small bub important anastomotic vessels passing-
from the subvaginal tissue, which, in cases of congenital
liernia, are more than usually large and numerous, in con¬
sequence of the modified relation of the tunica vaginalis
and the hernial sac. This additional supply, albliough'
sufficient under favourable circumstances to maintain
adequate nutrition of the testicle, is, liowever, derived
from vessels which are as a rule small and delicate ; any
inflammation therefore about the part would be sufficient to-
choke them, sloughing of the organ following as a necessary
result. If, however, no inJlamination occurs—i e-, if the-
wound remains aseptic,—the supply of blood is enough to
prevent sloughing and subsequent atrophy. The imme¬
diate cause, then, of the death of tho testicle, which
happened in these cases in the days prior to the practice
of surgical cleanliness, as the term is now into'preted,.
appears to me to have been nob the mere division of
the cord, but rather the inJlamination and suppuration,
one or both of which almost constantly followed upon-
it. For iny own part, I hold very strongly tbe view?
-Og
The Lancet,]
DR. H. RADCLIFFE CROCKER ON ALOPECIA AREATA. [March 7, 189]. 533
that the fact of the testicle haviag been rendered phy-
Biologically useless by the division of its duct is no suf¬
ficient reason for its immediate removal. On the contrary,
there is ample cause for its preservation if there be a
reasonable chance, as the instances I have mentioned
clearly show there is, of the organ retaining its vitality;
for, quite apart from its functional purpose, the testicle
should be if possible preserved, not only on msthetic
grounds and in consequence of the esteem in which its
existence is held by the majority of subjects, but also in
order to prevent the feeling of mutilation suggested by its
loss, which in highly sensitive people may be produc¬
tive of serious mental depression. Again, in the “radical
cure” of hernia in candidates proposing to enter the public
services, the saving of the testicle, under any conditions, is
of special importance, since its sacrifice may raise the
question of iueligibility on account of “physical defect,”
and entirely defeat the object for which the operation on
the hernia was performed. Personally, therefore, I should
never think of the immediate removal of the testicle under
the circumstances now being discussed; indeed, I should
go a step further and, if the patient were an adult, or in
any other subject with parts sufficiently large, certainly
attempt to restore the continuity of the vas deferens by
uniting the cut ends with sutures, whicti is not difficult, as
may he demonstrated in the cadaver.
'I'he principal points to which I wish to call attention in
this communication may be conveniently summed up in the
following conclusions, which, although in several respects
opposed to what is commonly taught, I believe from ex-
erience to be perfectly sound:—1. That the vas deferens
aving been displaced in the manner usually adopted in
operations for varicocele the spermatic artery does not
accompany it, but remains with the spermatic veins.
2. That in cases of varicocele the division of the main trunk
of the spermatic artery, together with the veins, if the
ordinary principles of surgical cleanliuess be observed, is
not only harmless to the testicle, but probably aids in the
ultimate relief of the affection by diminishing the pressure
of blood going to the testis at the time when almost all the
returning veins are suddenly obliterated. 3. That the
division of the vas deferens, spermatic artery, and sper¬
matic veins, which entails a section of apparently the
whole cord, is not necessarily followed by sloughing, or
even subsequent wasting of the testicle, provided that a
perfectly aseptic condition of the wound is maintained.
ALOPECIA AREATA, ITS PATHOLOGY AND
TREATMENT.
By H. RADCLIFFE CROCKER, M D, F.R.C.P.,
PUYSICrAN TO TIIK SKIN ril’!>AUTMr;NT, UNIVERSITY OOU.KUE IIO-SPITAI.;
PHYSICIAN TO THU EAST UONDON HOSPITAL POR CIlILDllEK.
{Concluded from pane /iSO.)
Hitherto I have discussed the negative evidence of a
universal neurotic theory, and I hope I have shown that it
is inapplicable to a large proportion, perhaps as much as
nine-tenths, of the cases. I propose now to examine the
positive evidence of the only other possible hypothesis—viz.,
the parasitic theory. This I must admit in limine has
many weak links in the chain of evidence; had it not been
so, the matter would have ceased to be one of controversy
long ago.
First, let us examine as to the evidence of contagion.
Here, again, much of it rests on the patient’s statements oi
opinions, but while individually many of the instances I am
going to relate are nob very conclusive, cumulatively they
have, I think, some value. Isltall talco first the private cases
where inquiry was most thorough ;—A man aged twenty-
seven stated that it came on eight dajs after wearing a
theatrical wig. A lady ascribed it to the servant using her
brushes. A man aged fifty-live stated that it came on soon
after having had his liair cut by a country barber. A man
aged twenty-three worked alongside of a man who also had
it. A lady aged fifty stated that hers began soon after
sleeping for three weeks with a married daughter who was
sull'ering from it, who ascribed it to sleeping with a lady
who had been quite bald from childhood. A man aged
thirty had a brotuer who also lost all his hair, which has
now regrown. In a man aged nineteen; his father has also
had it for twelve years. In a girl aged seven; her brother
has a small bald patch; the patient has the characteristic
I hairs. A woman aged forty dates the disease from
having her hair cut by a barber. A man aged twenty-eight
said that bis brother had it when he was eight years
old, and he himself^ bad a single patch about the same
time; when I saw him the face and scalp were almost bare.
A man aged twenty-nine said that the disease was of four¬
teen years’ duration altogether, though hie hair bad regrown
several times, The mother, who has dark hair, first had it,
then the patient, who also has dark hair, and then his
younger brother, also with dark hair. The father and
sister, who have fair hair, have not had it. This is not a
solitary instance with regard to dark-haired people ; it has
even been asserted that it occurs exclusively among dark¬
haired people. This, however, is certainly not true. 1 have
repeatedly seen it among fair-haired persons of both sexes,
but 1 am inclined to believe that it is more common in dark¬
haired persons. There is, however, a close relationship
between alopecia areata and tinea tonsurans. One of the
first patieuta who apprised me of this fact was a medical
man who came to me with a bald smooth spot on the
side of the chin. He stated that he bad been treating
some cases of ringworm, and had a habit pf rubbing bis own
chin with his finger at the spot which bad become bald. On
pulling out some of the hairs round the patch, in one,
unmistakable fungous elements like those of tinea ton¬
surans were observed. Many cases corresponding with this
have since come under my notice. In a schowmaster, a
perfectly healthy man, who bad been personally treating
ringworm in some of the boys of his school, smooth bald
spots appeared in his whiskers, in some of the hairs of
which I found fungous spores. In spite of treatment
other patches formed in the scalp, and gradually denuded
nearly the whole scalp, eyebrows, and lashes. Recovery was
very incomplete, and after a long course of treatment he
deserted me for other advice. Two years and a half after
her father had been affected, his little daughter, aged three
years, came under my care with two perfectly bald patches
with some I hairs. Sbehad, however, been also with a little
boy who had bad ringworm, but was said to be cured. I
did not succeed in finding any fungus in this case, but I only
made one examination. Another little girl of three, who
had played with another patient of mine who had ring¬
worm, was brought to me with smooth bald patches and
! hairs. But I will defer relating any more such cases
in children, as it will be said that these are the cases we
all recognise as the bald form of tinea tonsurans. Without
denying this I will only remark that they are often abso¬
lutely indistinguishable from alopecia areata, possessing
the straight ! hairs of that affection, and not the bent and
twisted ones of ordinary tinea tonsurans. A lady nurse
aged thirty-five had tinea tonsurans at the nape just where
the hair commences. I got her apparently well with some
difficulty, and a month or two later she came with a patch
of alopecia areata on the temple. Another lady about,
thirty came with a single patch of alopecia areata, which
she bad noticed two days. She wanted to know if it was
ringworm, as she had recently been in confact, though
not very closely, with a child affected with ringworm.
Quite recently a medical man practising in the West Indies
came to me with alopecia areaca of the beard and whiskers
of nine months’duration. He was physiologically bald to
a considerable extent on the scalp, and he stated that three
years previously he had had his hair cut by a negvo barber,
and within a few days distinct rings of tinea circinata
appeared on the bald part of the scalp ; and, although with
mercurial applications he had removed it apparently, it had
recurred again and again. All these were in pi ivate practice,
but for some of the cases I have gone outside the first fifty
cases of alopecia which I took for comparison with the
hospital cases.
Among hospital cases one was a woman who was bringing
her son to the hospital for ringworm, and who, after attending
for some time, showed me a bald smooth patch on the side
of her head. Another was a girl of seventeen, who had
disease on tlie right temple. She stated that she had been
working with a girl who had ringworm of the face, and the
bald patch on her head appeared soon after. A man aged
twenty-two, who had some occipital patches, stated that his
brother’s child, with whom he had been in contact, had bad
ringworm, though it was supposed to have been cured for
more than a year. I could relate many instances of smooth
534. The Lancet,]
DE. H. EADCLIFFE CROCKER ON ALOPECIA AREATA.
tMAKCH.7, 1891.
bald patches in childi-ea with ! hairs who had been in contact
with ringworm; but I know it will be said of tliem that these
are merely iastancee of bald tinea tonsurans, and 1 will only
mention one family of eight children who, while at seaside
lodgings, developed small bald patches; they then heard
that in the previous season several children with ringworm
had been in the same lodgings. 1 do not wish to lay any
stress upon this, but after a time the governess, aged twenty-
four, observed three pea-sized bald spots on her own head.
She went to her home, and the doctor there told her that it
was alopecia areata, and not contagious; she therefore slept
with her adult sister, who soon after showed similar spots
on her head. The mother of the children, when she came to
me, had a bare spot half an inch In diameter in the occipital
region; it had been noticed three weeks; there were no
! hairs, hut the hairs round were loose, and on one of them
from the border of the bald patch were spores of the appear¬
ance and size of those of tinea tonsurans. Hillier’s cases
are well known. In a parochial school of 1100 of both sexes
the outbreak occurred suddenly in forty-three girls of one
block in which one girl had had it for some time. To com¬
plete the chain of evidencel must allude to certain instances
of tinea tonsurans, with regard to which I will only make
statements. First, briefly, then, I have repeatedly
seen cases of ordinary ringworm of the head with
characteristic bent* hairs, which after being treated for
some time change into smooth bald spots with the
straight ! hairs of alopecia areata. That smooth bald
spots occur ah initio which it is acknowledged are of the
nature of ringworm, even by ardent advocates of the
universal application of the neurotic theory, is an acknow¬
ledged fact. In one family in which several were attacked
there was a strong reason to believe it was originally con¬
tracted from a horse with ringworm. In some of this class
of cases the patches are very small, from a hempseed to a
large pea in size, while in others they are of the ordinary
size and aspect of alopecia areata. These small spot cases
usually remain small to the end, recover very slowly as a
rule, and are not depressed like Neumann’s neurotic form. I
have, I trust, shown that this fourth class of alopecia areata
is to a limited extent contagious under favourable conditions,
tliougli far less so, of course, than tinea tonsurans, as its
clinical symptoms would lead one to infer ones grounds.
Secondly, that cases with all the signs of ordinary alopecia
areata arise not in children only, hut in adults from contact
with ordinary tinea tonsurans. Thirdly, that not only may
tinea tonsurans commeuce in a bald form, but that cases
which have begun in the ordinary way may be converted
into alopecia areata in children.
It follows, then, from all this, that the two forms of
disease may be interchangeable in childhood, while in adults
practically we see only the one, or bald form, and the
question forces itself upon us, therefore, Is not alopecia
areata in the majority of cases not only non-neurotic but
parasitic, and is not the parasite tliat of trichophyton
tonsurans ' This would account for the otherwise curious
fact that, while ringworm of the head is so common in
children, it disappear after puberty, and may this not be
because the hair alters in its consistence, and the fungus is
no longer able to penetrate into its substance, but passing
down between the root-sheaths separates the hair from its
nutritive supply and so leads to its atrophy and gradual
extrusion Y It may naturally be asked. Why, then, cannot
the fungus be found, except by a very favoured few who do
not agree as to its characters ? I believe that it can be so
demonstrated in recent cases, if rightly looked for. It is no
use looking on the bald places themselves, it is no use
looking in atrophied ! hairs; the fungus is never in the
shaft, but on it or the attached epithelium. The best way
is to pull out a good many of the loose hairs at the border
of the bald area, then to examine these with a lens, and
select those hairs which have most root-sheath attached,
rejecting those with smooth atrophied toots, and then,
taking the selected hairs, cut off the greater part of the
superfluous shaft, soak theso root ends in liquor potassse or
a saturated solution of caustic potash in glycerine, and
examine the portions of epidermis attached to the shaft;
it should not be manipulated too much, or the affected
part may get detached from the shaft and he lost.
The fungus is always in small foci, and perhaps only
in one of several selected hairs; sometimes it may be
seen at the very extremity of the root, as if it had worked
round and separated the liair from its papilla. In moat
recent cases, in my opinion, its presence can oe conclusively
shown with a sufficiently careful search, but I have found
it more easily in hairs from the beard than those from
the scalp. It is worthy of notice that alopecia areata
is most common where tinea tonsurans is most common,
and it is also instructive to , observe that the
neurotic theory is most strongly held in those countries,
such as Germany and America, in which both ringworm
and alopecia areata are compft,ratively rare. The old-
fashioned tinea decalvans was an acknowledged entity until
the great Hebra, who did so much to sweep away the myths
of dermatology, swept poor tinea decalvans away with the
rest and placed it along with other forms of alopecia areata
among the tropho-neuroses; but while alopecia areata con¬
stitutes less than 1 per cent, in Vienna, ringworm of the
head is infinitely rare. In answer to an inquiry, his
son, Dr. Hans Hebra, kindly informed me that of 15,000
cases in his policlinique only 196 were cases of ringwoiTu,
and in only 14 of these was it in the head—not 1 in
1000, therefore; while in my hospital practice it con¬
stitutes fully 10 per cent. Clearly there is something in
Vienna scalps unfavourable to trichophyton tonsurans
fungus, and alopecia areata exists in only 0 ‘6 to 0 7 per cent,
in the same clinique. In Franco, on the other hand, where
alopecia areata is commoner even than with us, a parasitic
origin and a limited capacity for propagation are generally
acknowledged, and had I not been obliged by the limited
time at my disposal to confine myself to cases in my own
experience, I could have strengthened my argument much
from the interesting cases related in the excellent recent
monographs on Pelade by Besnier, Leloir, and Dubreuilh,
who relate extensive outbreaks amongst soldiers and firemen.
The percentage of alopecia areata in different countries is
approximately as follows : France, 3 per cent.; England, 2 ;
Scotland, 1‘6; Vienna, 075 ; North Germany, 075 to 1;
America, 0’5.
With regard to the treatment, I rely most on blistering
the early patches, painting on tlie liquor epispasticus in
three coats, allowiiig each to dry before the other is applied.
At a later stage those parasiticides, which are also powerful
stimulants, give the best results in ray hands. It is true
that such applications fit either theoi-y, but they are none
the worse for that. The loose hair round tiie patclies should
first be pulled out, and, where practicable, from lialf a
drachm to one drachm of chrysarobin to one ounce of
lanoline and oil is one of the best applications ; but owing
to the erythema it is liable to excite, the indelible staining
of linen and the discolouration of the hair, ic can only be
used in a small proportion of cases. A cleaner and universally
applicable remedy, even for the face, is two to five grains
of percbloride of mercury, one drachm of rectified spirit of
wine, to seven drachms of oil of turpentine. The smaller pro¬
portion of pcrchloride of mercury should first be tried, and
the strength increased as the patient can bear it. Of course it
produces some burning and stinging of the skin, but this is
inevitable in all really efficacious remedies. It should be
rubbed in with the finger, not only on, but round the patch,
night and morning. Internal medication is not of any use,
except in the late stage when the disease is not spreading,
but only the dormant vitality of the injured hair follicles
requires awakening, then I think pilocarpine may be given
with advantage internally in the proportion of one-sixth to a
quarter of a grain at bedtime, and I find it acts most surely
when given in solution. Where circumstances permit,
hypodermic injection of pilocarpine is still more efficacious.
One-tenth to one-sixth of a grain may bo given. It is not
wise, however, to administer it except at the patient’s
house, 08 in some subjects it produces vomiting and faint¬
ness. Of course, if I find any defect in the patient’s health,
I endeavour to rectify it, but I do not think it exercises
any ialluence on the course of the affection.
Let me, in conclusion, sum up what I have said in the
following propositions:—At least four classes of cases are
recognisable under the term “alopecia areata.” In the first
are universal cases, usually of rapid development, and not
necessarily in patches. In the second are those cases with
one or more patches in the course of a nerve, or on the site
of an injury. In the third are cases witli small atrophically
depressed patches, which Neumann called “alopecia circum¬
scripta.” In the fourth are cases of the common type in
patches or bands of irregular distribution, and with charac¬
teristic ! hairs at the border of spreading patches. The
first three classes are undoubtedly of tropho-ncuiotic origin,
and the fourth is parasitic, and forms the largest pro¬
portion of the coses. With regard to the fourth class
og
The Lancet,] DR. RICHARD LEA MACDONNELL ON THORACIC ANEURYSM. [March 7,1891. S35
the preceding facts show1. That this form is to a
limited extent contagions, and that from time to time
limited outbreaks have occurred in .small communities.
2. That not only children, but adults who have been in con¬
tact with tinea tonsurans sometimes develop bald patches
indistinguishable from alopecia areata. 3. That in tinea
tonsurans commencing in the typical way the typical
crooked stumps may both spontaneously and under treat¬
ment disappear, and the patches deveIo]r into an alopecia
areata condition with ! hairs. 4. That in those countries
where tinea tonsurans is most common alopecia areata is
also most frequent. 5. Hence we must conclude that a large
proportion of cases in adults which are termed alopecia
areata are cases of bald tinea tonsurans which is acknow¬
ledged to exist amongst children, and tliat the old authors,
from Bateman onwards, were .iustihed in calling it porrigo or
tineadecalvans. G Finally, 1 believe that a parasite indis¬
tinguishable from the trichophyton tonsurans fungus may be
demonstrated in recent cases, and the treatment most elli-
caoious is inunction of powerful and stimulating parasiticides.
THK
DIAGNOSTIC VALUE OF THE PHYSICAL
SIGN “TRACHEAL TUGGING” IN
THORACIC ANEURYSM.
By RICHARD LEA MACDONNELL, M.D.,
PROl'ESSOIl or OI.IMCAL MEDICINS, MACOIT.L UMVEHSITY, MONTREAI.,
PHYSICIAN TO THE MONTllEAI, (iENERAL HOSPITAI..
In 1878 the following remarks, by Surgeon-Major W. S.
Oliver, M,D., appeared in The Lancet
“As the diagnosis of thoracic aneurysm of the aorta is
often difficult and obscure, notwithstanding the various
physical means we have now at our disposal for detecting
it, I am desirous of mentioning a method of examination
which has afforded me material assistance in diagnosing
this disease (or ovon simple dilatation of the vessel) when it
occurs, as is moat generally the case, either in the ascending
or first part of the transveise portion of the arch. The
process is as follows:—Place the patient in the erect posi-
Uon, and direct him to close his mouth and elevate his chin
to the fullest extent, then grasp the cricoid cartilage between
the finger and thumb, and use gentle upward pressure on it,
when, if dilatation or aneuiysm exist, the pulsation of the
aorta will be distinctly felt transmitted through the trachea
to the hand. The act of examination will increase laryngeal
distress should this accompany the disease.”
Since the publication of the above remarks this physical
sign, which came to be known as “ tracheal tugging,” has
been sought for in the medical wards of the Montreal
General Hospital, and its great importance was early
recognised by my teacher and predecessor in the chair of
clinical medicine, Dr. George Ross. Tracheal tugging was
always found to be a reliable sign of aneurysm of the
transverse arch, and in one case it was the only positive
sign present of an aneurysm whose existence was sub¬
sequently made evident by well-marked signs and symptoms
of the disease. In all the cases of aneurysm of the aorta
published in journals or in society proceedings either by
Dr. Ross or by myself, the presence or absence of tracheal
tugwas carefully noted. Ou several occasions, too. Dr. Ross
has drawn attention to its value, notably in his article on
Thoracic Aneurysm in Wood's “ Reference Handbook of
the Medical Sciences”;—
“Another physical sign of very great diagnostic import¬
ance, and whicli is also to be obtained by the educated
sense of touch, is what is now known' under the term
‘tracheal tugging.’ It ia but quite lately that attention
has been directed to this method of examination, and it ia
only now that its value has been realised.If a deep-
seated aneurysm be present which impinges at all upon the
trachea or one of its principal divisions, then a very distinct
and unmistakable Uigqinxf downward will be felt with each
systole of the heart. When Che heart is acting strongly, or
when aortic incompetence is present, considerable rhythmical
pulsation may be communicated to the fingers from the
adjacent carotids, but with a little care this cannot be mis¬
taken for the tugging directly downward above described.
I have observed a number of cases of thoracic aneurysm,
cardiac and other thoracic diseases, with reference to this
sign, and [ have never observed it produced by any other
condition but aneurysm.”
The author of the article Thoracic Aneurysm, in Pepper’s
“System of Medicine,” refers to Dr. Oliver’s directions as to
the mode of examination for “tracheal tugging,” but be does
not mention his own opinion of its value. Beyond these two
references I am unaware of there being any mention of this
physical sign in any treatise on thoracic disease, British or
foreign. Nor have I found that the sign was looked for in
any hospital I have visited cither in England or the United
States, except in the medical wards of the Johns Hopkins
Hospital, where Drs. Osier and Lafleur, old pupils of the
Montreal (General Hospital, have carried some of the results
of their clinical teaching with them. In the discussion on
the diagnosis and treatment of aneurysm of the aorta at the
Medical Society of London on Dec. Dch, 1889, “tracheal
tugging” was not mentioned—in fact, it appeared to be
uiCe unknown.-As to the mode of eliciting this physical sigDj
have nothing to add to the directions given by Dr. Oliver.
In some cases the movement of the box of the larynx is so
distinct that the pulse can be counted simply by placing
the tip of the forefinger upon the pomuin Adarni, and
making a slight upward pressure.
With the object of forming a just estimate of the value of
the tracheal tug, I have collected tlie histories of all the
cases of thoracic aneurysm recorded in the case-books of the
Montreal General Hospital since 1878, omitting those in
which the absence or presence of tugging was not definitely
noted. This period embraces the service in the medical
wards of Drs. Osier, Rosa, Wilkins, Molson, and myself.
Twenty-three such cases are upon our records, and to this
series X have added the histories of two cases observed in
private practice. With these twenty-five cases I shall
attempt to prove a series of statements regarding the signL
ficance of tracheal tugging as observed in the light of our
clinical experience at tlie Montreal General Hospital.
1. Tracheal tugging is never present-cxccpt in aneurysm .—
Though I have repeatedly examined patients who were
sufiering from other diseases, as well as those who were
suspected of having aneurysm, witV. a view to testing the
truth of this statement, I have never found the tug per¬
ceptible. In a case of Hodgkin’s disease, where there were
enlarged glands in the thorax causing a pressure upon the
trachea, which could plainly be seen with the laryngoscope,
and in which there were other signs of pressure—dilated
pupil, unilateral sweating of the face, unilateral episbaxis,
and accelerated pulse-rate, all pointing to pres.sure upon
the sympathetic in the root of the neck,—1 could detect
no tug.
2. \Vhe7i tracheal txigging is present the aneurysm is so
situated as to press Jram above doionwards on the lejt
bronchus, or upon that poi'tion of the trachea immediately
adjacent to 'it .—To understand thoroughly the mechanism
of tracheal tugging a careful study of the relations of the
transverse aorta in a cross section of the frozen chest should
be made. The plates of Braune or of Dwight are also very
instructive. The length of the transverse arch is not great,
and the direction of its course is almost directly backwards
from the upper border of the second right costal cartilage to
the upper part of the left side of the body of the fifth dorsal
vertebra. The transverse aorta rides on top of the root of
the left lung, lying between the left bronchiig and the
trachea. An enlargement of the bloodvessel, be it ever so
small, will press upon the bronchus or upon the trachea at
the root of the bronchus, and impart its pulsation to the air
tube. At each beat it would push the bronchus down, and
this downward push would necessarily be felt by the trachea
and the larynx.
In seventeen out of twenty-five cases tracheal tugging
was noted. What part of the aorta was involved in these
seventeen cases, and on what part of the trachea did the
aneurysm press'/ A necropsy was obtained in eight of
these cases. Seven were hospital patients, and one was a
private patient. In six there was distinct jiressure upon
the left bronchus from above. The most convincing case is
one of Dr, Molson’s (Case 1), in which the aneurysm, after
ressing upon the left bronchus, caused a fatal huniioptysis
y opening into it. In Case 2, which I closely watched
myself, the tumour as seen in situ distinctly pressed down
upon the left bronchus. In Case 4 there was no pressure at
all on the trachea, but only upon the left bronchus. The
main features of these cases arc as follows :—
Case 1 (Dr. Molaon’s patient),—James G-. Tugging
present. Other evidences of anourysm of the transverse
arch, including paralysis of the muscles of the left side_ of
the larynx .—Necropsy : A ruptuvo of an aneurysm the size
of a small orange into the left bronchus.
536 Thb Lancet,] DR. H. SNOW; THE BONE LESIONS OF MAMMARY CARCINOMA. [March 7,1891.
Casb 2* (Dr. MacDonnell’spatient).—H, G -. Tugging
well marked. Other evidences of aneurysm of the trans¬
verse arcli, including paralysis of the muscles of the left
side of the larynx, contraction of the left pupil, weak
breathing in the left lung, almost complete obliteration of
the left radial pulse.— I^ecropsy: An aneurysm the size of
a small orange pressed directly upon the left bronchus into
the angle between it and the trachea.
Case 3 (Dr. Rosa’s patient).—William H-. Tracheal
tug present. Evidences of aneurysm of ascending arch,
including perforation of sternum. The patient left the
hospital, and died two years later at ms liome in the
country.— Necropsy A large aneurysm occupied the whole
of the transverse arch extending from the sternum to the
vertebral column, and pressed upon the last inch of the
trachea and left bronchus.
Case 4^ (Dr. Ross’s patient).—Tracheal tugging present.
Cough, dyspneea on exertion, pain in chest and left arm,
slight dulness and loss of vocal resonance on npper left
front. Marked weak breathing at left base. No inequality
of pupils.—Aecropsi/.' A saccular aneurysm between the
trachea and ascending aorta. " Immediately behind the
right half of the sac is the bifurcation of the trachea, and
the left bronchus passes along the posterior wall just
^posite to the mouth.” The trachea was not compressed.
The condition of the larynx not noted. Here tracheal tugging
is associated with downward pressure on the left bronchus.
Case 5* (Dr. Ross's patient).—Tracheal tugging present.
All the other symptoois pointed to innominate aneurysm.
Fain in the top of the right shoulder, extending up the
neck to behind the right ear. Voice husky; respiratory
stridor. Pulsating tumour above the right sterno-clavicular
notch. Pupils unaffected. Paralysis of right vocal cord.
The presence of the tug clearly indicated that the trans¬
verse arch was involved, for tracheal tugging is never found
when the innominate is above the seat of aneurysm. At the
necropsy, the aortic arch uniformly dilated and of large
size; projecting from it, just before the innominate is given
oil', is an aneu^smal dilatation about the size of a walnut,
somewhat conical in shape, which passed by the side of the
innominate and occupied a position immediately behind
the sterno-clavicular articulation. The lower lobe of the
left lung was bepatiaed.
Case 6 (Dr. MacDonnell’s patient).—Hugh M-,
tracheal tug present. Aneurysm was thought to involve
the innominate artery. The symptoms began with pain on
the riglit side of the head and neck extending to the back of
the right ear. Extreme varicosity of the thoracic and abdo-
itiinal veins. Brassy cough. Pulse on right side is weaker
than on the left. Pupils equal; paralysis o the muscles
of the right side of the larynx. Here the only symptom |
which indicated an extension of the disease to the aorta i
was the tracheal tug. Had I valued it properly, I might
have made a better diagnosis. At the necropsy a large
aneurysm was found to nave involved the whole arch ex¬
tending from the sternum to the vertebral column and
pressing up on the innominate artery, thereby shutting
off the olood-supply to the upper extremity. The superior
vena cava was mso pressed upon.
Case 7 (Dr. Molson’e patient) —Anthony G-, a negro.
Tracheal tugging. Pains in back and right arm. Trachea
evidently obstructed. Pupils unaffected. Right radial
pulse somewhat weaker than the lefc. Strong pulsation in
episternal notch and a heaving impulse limited to a small
area under the right sterno-clavicular articulation. The
breathing generally impeded, but there was no difference
perceptible at the bases of the lungs. Condition of larynx
not noted. Death from dyspneea — Necropsy ■. The sac
compressed the trachea and eroded the fourth and fifth
dorsal vertebrae, being formed entirely upon the transverse
aorta, the ascending portion being tolerably normal.
The following case is not so conclusive as those which
f recede it. The notes of the necropsy are not to be found.
t is stated in the clinical case-book that the aneurysiii was
situated upon the ascending arch, but no mention is made
of the condition of the transverse arch, or of the relations
of the trachea to the tumour. The particulars are as follows.
Case 8 (Dr. Molson’s patient)—Andrew J-. Tracheal
tugging. Burning pain in the middle of the sternum. Stridor.
No evidence of tumour, except rather well-marked visible
J Reported fully in the Medical Now.s, Feb. 15th, 1890.
I am iodebtud to my former pupil, Dr. J, E, Orr, of Cookahire, P.Q.,
for the detailed report of the necropsy.
Canada Medical and Surgical Journal, vol. vill., 1878, p. 241.
* Ibid.. voL vili., p. 461, and vol. ix., p. 20.
pulsation at the right of the sternum at the junction of the
third costal cartilage wtth the sternum. A brassy cough,
relieved by lying upon the face. Death occurred by rupture
into the trachea and consequent hmmoptysis.
In the remaining ten cases no necropsy was obtained.
The clinical evidence in favour of the existence of aneurysm
of the transverse arch is very strong, particularly in
Cases 7 and 8, where there was pain in the left shoulder and
arm, together with tumour to the left of the sternum and
paralysis of the muscles of the left side of the larynx ; and
in Case 8 additional evidence was afforded by the weakened
breath sounds in the base of the left lung.
Case 9 (Dr. Ross’s patient).—James McG-. Marked
tagging. Pupils unaltected. Pain in left shoulder, back
of the neck, and left axilla. Dull area to left of sternum
under the inner end of the clavicle. Paralysis of the muscles
of the left side of the larynx.
Case 10 (Dr. Ross’s patient).—Patrick T-. Tugging
present. Pupils unaffected. Pain in left shoulder. Evi¬
dences of tumour to left of sternum. Weak breathing in
the base of the left lung. Paralysis of muscles of the loft
side of the larynx.
In the following series the evidences of aneurysm of the
transverse arch are not so clear as in the preceding cases.
Case 11 (Dr. MacDonnell’s patient).—James G-. The
tracheal tugging is very distinct, and has a direction down¬
wards and to the right. Pupils unaffected. Tumour behind
right sterno-clavicular articulation, which can be felt pul¬
sating at the sternal end of the subclavian triangle. The
tumour can be felt to move with the act of swallowing.
The larynx is unaffected. The lumen of the trachea is not
pressed upon. The physical signs observed in connexion
with this case show that tugging may be present without
any pressure upon the trachea. The movement of the
tumour with swallowing is due to the lifting up of the
tumour by the left bronchus, and is an additional proof
that tugging depends on pressure on the left bronchus from
above. I shall attempt to explain later on how a tumour
may give rise to tug, and yet leave the recurrent laryngeal
nerve unaffected.
Case 12 (Dr. Ross’s patient).—Frank G—-. Tracheal
tugging. The evidences of transverse arch disease were
pain in left side of the chest and enlargement of the cervical
and thoracic veins on the left side. This patient died in a
paroxysm of dyspneea. No necropsy.
Case 13 (Dr, Ross’s patient).—J. B-. Tracheal tugging.
The evidoiicea of an aneurysm of the transverse arch were
contraction of the left pupil, and pain in back of the neck.
Tumour in centre of chest; dulness and bulging behind
the upper piece of the sternum.
Case 14 (Dr, Molson’s patient) —G-. Tracheal tugging.
Pupils unaffected. Pain in back of neck and down the right
arm. Tumour in centre of chest, behind manubrium. No
diilerence in the breath sounds of the two lungs. Distension
of cervical and upper thoracic veins.
Case 15 (Dr. Ross’s patient).—McD-. Tracheal
tugging. Pupils unaffected. Pulsating tumour to right
of sternum under the clavicle. No difference in the breath
sounds of the two lungs.
Ca.se 10 (Dr. Rosa’s patient).—Elizabeth 0-. Tracheal
tugging. Pupils unalfectecl. Pain in the middle of the
I sternum, between shoulders and down the arms. Tumour
in the centre of the chest. Weak hreatbiog at the base of
the left lung.
{To be co7icluded.)
A NOTK ON THE NONE LESIONS (USUALLY
INSIDIOUS) OF MAMMARY CARCINOMA.^
By HERBERT SNOW, M.D. Lond., &c.,
SUIIO’EON TO THE CANCER IIO.Sl'ITAl,,
I THINK it will be generally admitted tiiat the clinical
course of carcinoma in the female mamma is frequently ob-
scureandmysterious. Thattbetwophenomena,in particular,
of an occasional long interval of seeming immunity after
operative measures, followed by renewed manifestations of
disease,—of a similar growth in the opposite breast, after a
more or less prolonged period of health, and often pur¬
porting to be an independently developed tumour,—raakp
^ A paper read in tlie Keotion of Pathology at the Birmingham
meeting of the British Medical Aeeociatioii.
Di
: CoogL
The lancet,] DR. H. SNOW; THE BONE LESIONS OF MAMMARY CAECINOMA- [March 7, 1891. 537
this particular variety of maliguant neoplasm a crux in the
path of those who, like myself, are convinced—from the
analogy of all the other species, as well as from clinical
observation—that the developments of cancer are consecu¬
tive and infective. In this paper I attempt an elucidation
of the mystery, although my investigations are far from
complete, and I have to ask the indulgence of the Section
for tneir fragmentary character.
1 need hardly remark that carcinoma of the mamma is
the result of abnormal proliferation of the acinar epithe¬
lium—a process ordinarily cJuronio and insidious, and giving
birth to the familiar “scirrhous cancer.” When, however,
as happens in a substantial minority of cases, the malady
runs an acute course, the resulting tumour formation may
aptly be termed “ soft, encephaloid,” or “medullary carci¬
noma.” The two, however, are practically identical; every
radation of acuteness or of chronicity is observable in in-
ividual examples; and both the clinical and histological
differences between specimens at opposite extremities of
the scale are plausibly explicable by the variations, which
we are daily called on to notice, in the consistence
of the fibrous tissues of respective individuals. However
this may be, the point here in question is of some conse¬
quence in the present connexion, because, if 1 am not
greatly mistaken, there is a tendency to classify soft,
rapidly advancing growths of this region as sarcomata;
partly by reason of the inconspicuous gland infection often
manifest undersuchcircumstances, partly because very careful i
examination of their sections taken from several portions
of the periphery is often needed in order to demonstrate
the acinar arrangement and epithelioid origin of the cells.
I have not noticed any bone symptoms in a true sarcoma
whose connective tissue origin could be definitely traced.
Every surgeon must be familiar with the so-called
“rheumatic” pains which torment the latter days of most
or all scirrhous patients. The upper arm on the same
side as the disease, the corresponding scapula, and the
lumbar region are their moat usual seats specially re¬
ferred to by the sufferer, but hardly any portion of the
body in the neighbourhood of bone may not be com¬
plained of. A certain amount of subjective localisa¬
tion thus takes place. The patient often speaks of
universal and overwhelming sensations of painful weari¬
ness and lassitude out of all proportion to the objective
manifestations of disease in the shape of tumour or of
palpable secondary deposit, and often present when the
latter is entirely wanting. The local pains are described
as gnawing and as deep-seated, as being felt in the bones
rather than in the soft parts. Like those of true rheu¬
matism, they are often worse at night, and are also greatly
relieved by the administration of salicylates—a point I am
disposed to attribute to their origin in irritative conditions of
the periosteum. They are nob, however, specially confined to
the neighbourhood of articulations ; they are referred to the
bone; avelixed,nobinetastaticandtransibory. Byfarbhomost
conspicuous point of distinction from true rheumatism lies
in the concurrent and progressive muscular weakness.
Except in so far as it may be propped up by medicinal
measures of treatment, the general health steadily and
rapidly breaks down; the patient becomes wan, pinched,
and sallow, and her physical condition may be nob inaptly
designated by the almost obsolete term “cachexia.” In
rheumatism all the symptoms are usually subjective. In
the state here described we have the most unmistakable
objective evidence that grave organic lesions exist some¬
where, and are surely sapping the springs of life ; although,
as nob seldom happens, we find few outward manifestations
of cancer growth during life, and after death an amount of
visceral deposit entirely inadequate to account for the
phenomena.
Now, so far as my opportunities of investigation have
extended, the concrete basis underlying these syniptoius is an
infection of the bone marrow by malignant cells derived
from the primary growth, or from some of its secondary
tumour formations. With perhaps greater respect for the
clinical acumen of our forefathers than is universally current
nowadays, I take it that the “cancerous cachexia,” on which
they were wont to dwell in this connexion, actually denoted
the fact of such infection, mingled, it is true, with the result
of the ulcerative and septic processes commonly, but not in¬
variably, met with in cancer. Ji’rom the analogy of similar
tisanes elsewhere it is primA. facie obvious that the marrow,
richly cellular and abundantly supplied with lymphatics
and bloodvessels, must almost of necessity form a particu¬
larly favourable soil for the development of cancer cells,
should these once gain access to it, as also for their diffusion
by means of the general circulation. The phenomena of
extensive diffusion seen in cases of primary malignant
growths on bone may be pointed to as countenancing the
latter statement. And, in the second place, in the light of
current views of this structure as the great red-corptiscle
Jactory of the organism, we can readily comprehend the
marked physical weakness and steady progress down hill
obvious whenever the “ rheumatic” pains of mammary car¬
cinoma—I am not aware that they are commonly associated
with any other variety—are felt in any great degree.
The recorded symptoms and morbid appearances of many
cases of “ osteo-malacia” seem to indicate that this should
rank as a truly malignant disease of the bone marrow. Pro¬
fessor Huxley makes the following remarks upon an allied
topic. The italics are the'writer’s own: “This circum¬
stance enables us to understand that which one would
hardly suspect from the appearanceof a bone—namely, that
throughout life, or at all events in early life, its tissue is
the seat of an extremely active vital process. The perma¬
nence and apparent passivity of the bone are merely the
algebraical summation of the contrary processes of destruc¬
tion and reproduction which are going on in it.”'
If we examine the shoulder-j oint and its vicinity in a person
dead from breast scirrhus, in whom “ brawny ccdema”of the
adjoining arm is a conspicuous feature, we commonly find
it difficult or impossible to disarticulate the bead of the
humerus from the glenoid cavity in the ordinary manner.
Hardly any calcareous salts seem to be left in the bone
matrix; and the knife passes through the upper epiphysis,
where the condition is most marked, with little or no more
resistance than through the soft parts. It might be sup¬
posed that this phenomenon is due to the general absorption
of lime-aalta occasionally met with in other chronic wasting
diseases, particularly in connexion with insanity. In my
experience, however, it is associated with an actual deposit
of malignant cells in the marrow. Individually, these are
! distinguishable from osteo-clasts by the relatively huge
nuclei; collectively they, if degenerative processes have not
proceeded too far, present tlie acinar distribution specially
characterising mammary carcinoma. The fine adipose tissue
reticulum seen in sections of healthy marrow is absent;
everywhere we find indications of absorption and of erosion
of the bone matrix (such as myelo-plaxea and How.sbip’s
lacunae), seemingly by the proliferating cells of the
new growth; the cancelli are occupied by masses of
parenchyma, apparently malignant, but often more or
less degenerate, and breaking down into granular ddbris,
This state of soft decalcification is only apparent as a rule
in the humerus, sternum, and ribs adjoining the primary
growth — parts where the cell growth is presumably
most abumlant. It is but relatively very exceptional to
encounter a distinct tumour in the bones, the result of
secondary deposit in the course of breast scirrhus; and the
cases in which fracture takes place are also comparatively
rare. Yet I believe I may assume that failing the one or
the other of these two occurrences, the state of the bones
does not ordinarily receive attention at a necropsy ; is cer¬
tainly not tested' by the microscope. Thus to take the
specimens of such deposit in the long bones contained in
the Museum of the Royal College of tiurgeons, which are
derived from four patients. No. 1U70, vol. ii., part 4, is a
preparation of the condyles of a femur, filled “ mthout any
change of form,” by the malignant parenchyma. Here
there had been no tumour or fracture; but attention had
been called to the part by local pain, swelling, and knee-
joint eff'asion. No. KjTl: Head and upper part of femur
in like condition. Fractm-c bad taken place. '‘Form of
bone scarcely altered.” No. lG7d: Humerus, filled with
secondary scirrhous deposit, frnciured. “Shape of hone
scarcely altered.” No. 11175: Humerus, similar to last,
tioice fractured. No tumour.
I beg to exhibit drawings of the appearances in several
of these cases, and also the slides themselves. Most are
from the upper epiphysis of the adjacent Imiuerua after
death from breast scirrhus; in one, which I regard as a
specially tost case, seeing that not only were objective bone
symptoms absent during life, but that death took place
from cerebral and pulmonary complications long before it
might have been expected from the malignant growth
alone, deposits of scirrhous cells, arranged in acini, were
^ lilomentavy Pliysi.i!o;;y. ISSC, p. 331
K -1
538 Thb Lancet,] DR. H. SNOW : THE BONE LESIONS OF MAMMARY CARCINOMA. tMARCH 7,1891.
found in both humeri and in one of the lumbar vertebra?.
There are two sectione of marrow taken from the shaft of
the femur in a case some years ago under the care of my
colleague (Dr. Purcell), to whom I am indebted for kind
permission to quote particulars. Here multiple tumours on
the bones, secondary to an encephaloid carcinoma of the
left breast, existed, but, as may readily be seen by the
outlines of the section, no tumour formation was present at
the spot. The section was taken, in fact (as I did nob then
suspect this infection phenomenon), as a specimen of normal
marrow, and the binall groups cf scirrhous cells discovered
by accident oily. Theie's a slide of secondary deposit,
buhsequentlv to excieion of the left mamma for scirrhus,
in the bodies of the sixth and seventh cervical vertebrm ;
but as here, although no distinct tumour was produced,
marked objective phenomena, and death from paraplegia,
ultimately resulted, the case is, to some extent, foreign
to the main purport of ray paper. Particulars of these are
given in the appendix. The recognition of this actual deposit
of malignant cells in the bone marrow is useful in enabling
us to comprehend the cachexia and general mal-nutrition,
out of proportion to the palpable amount of disease present,
the infection of the opposite breast which takes place in a
certain percentage of instances, and the renewed manifesta¬
tions of tumour development after several years of seeming
immunity procured by operation,
i It remains briefly to glance at two of the early objective
\ indications of the occurrence, which are not without im¬
portance to the practical surgeon. These are:—1. Asen-
' sation of fulness and enlargement, sometimes accompanied
by tenderness on pressure, aflbrdod by the upper epiphysis
of the humerus nearest to the diseased mamma. 2. A
marked thickening and prominence of the sterti/um, affecting
especially the part between the articulabions of the lirsb and
third ribs. Tue first of these was described by myself in
The Lancet, vol. i. 1880, p. 912. I am not aware that it
had been pointed out by any previous observer. At a com¬
paratively early stage in the course of breast scirrhus (long
anterior to any oedema of the soft parts) the humerus on
the side of the disease becomes slightly thickened and
seemingly flatter and less rounded than in health. Occa¬
sionally the bone is tender to the touch ; bub more fre¬
quently hyperaasthesia is absent, at least in any marked de¬
gree; and occasionally again the part may be sore on pressure
without manifest enlargement. Sometimes, but very seldom,
the woman complains of aching “rheumatic” pains about the
shoulder and down the limb; as a rule, at the early stage
to which I refer, no subjective symptoms direct attention to
the part in question ; and the condition is discemible only
by the medical attendant on a careful comparison of the
corresponding bones on each side. Tne apparent hypertrophy
is at the best but slight and inconspicuous; and several
cases in succession may be examined before a well-marked
instancfi is found. I need hardly say that in a stout patient
it is diflicuit or impossible to satisfy oneself as to the
presence of the condition. At a still later stage the
phenomenon, moreover, becomes obscured by “brawny
cedema” of the soft tissues on the one hand, and on the other
by the supervention of a similar physical sign in the
humerus on the opposite side.
Opporbunitiesofexatniningmicroscopieally or otherwise the
state of the bones at the early period indicated are necessarily
rare. I have, however, in ray possession thin sections taken
post mortem from a woman who lately died in the Cancer
Hospital insane, and with very advanced tubercular disease
of the left lung in addition to a right breast scirrhus of
tliree years and a half s duration—death thus resulting from
the complications long before the period when it would
apparently have been caused by the malignant disease
alone. In this patient no mdeina of the arm anywhere
existed, and no symptom (objective or subjective) was
present to direct attention to the bones. Vet typical
scirrhous cells, arranged in acini, were present in both
humeri, and in one of the lumbar vertebne in proportion
to the proximity of these to the initial lesion, being
most abundant in the head of the right humerus, less so in
that of the left, and least in the vertebra. The degree of
tenderness on pressure varies considerably, and this symptom
is often entirely absent; or, fairly marked at one time, may
be wanting at another. Being entirely subjective, not
much stress can be laid upon it; it is probably due to
irritative conditions of the periosteum, not sufliciently
acute to be called periostitis.
As above remarked, this humerus symptom is at the best
but inconspicuous; beyond some “aching” or “gnawing”
pain down the upper arm, complaint of which is as a rule
elicited only upon direct inquiry, and which, therefore, is
probably not very severe, attention is not drawn to the
part, in a marked degree, and in such form as to be
readily demonstrable at the first examination to anyone
unfamiliar with it, it occurs about once in five or six cases,
being most readily recognisable in stout fleshy women a
little before the supervention of cedema in the soft parts,
and being usually absent in cases of “atrophic” scirrhus
after the lapse even of several years. In most examples of
mammary carcinoma, however, minor degrees of the affec¬
tion are commonly present, when the patient has boon thus
diseased for more than a twelvemonth.
Digitized by
The Lancet,] MR. C. J. BOND ON THE TREATMENT OF TRACHEAL STENOSIS. [March 7,• 1891. 539
Thus of twenfcy-on^ cases recently examined the sign is
recorded as specially marked in four only ; in twelve
instances the upper epiphysis of one humerus appeared, on
careful comparison of the two sides, to be fuller and thicker
than the normal; in seven, both, although the basis of
inference was then necessarily unreliable; in two only—both
atrophic—were the results of examination purely negative.
I am aware of the categorical contradiction, by no less an
authority than Dr. Samuel Gross,^ to my report of the above
symptom. I have, however, been in the habit of demon¬
strating it in the out-patient room since 1880, and am well
satisfied of its existence in a large proportion of the cases.
{To be concluded.)
the posterior wall of the trachea was very hard, almost
cartilaginous, and bad to be smoothed oif with cutting
forceps. The problem now remained how to keep the
reopened channel patent and prevent reobstruction. For
the first few days a piece of indiarubber tubing was worn
entirely in the trachea, with a lateral opening oppo¬
site the tracheal opening, and secured by two threads.
This, however, soon clogged with mucus; and as the outer
opening contracted, its introduction became more and more
dilficult. After many trials and several disappointments
I had the metal tube made in two halves, with a removable
collar and screw. (See engraving ) This the patient now
T-SUAPED TRACHEOTOMY TUDI3.
NOTE ON TUB
TREATMENT OF TRACHEAL STENOSIS BY A
NEW T-SHAPED TRACHEOTOMY TUBE.
By C. J. bond, F.R.C.S.,
SURGEON TO THE LEICESTER INITRMARY'.
The good results obtained by intubation in the cases of
tracheal obstruction following tracheotomy recorded by
Messrs. Pitts and Brook in The Lancf:t of Jan. 10th show
the value of that method of treatment in such cases. There
is, however, another class of cases—viz., suicidal wounds of the
trachea occurring in adults—in which the wound of the air-
tube is always a transverse one; such cases are often only
seen late in their history, and after cicatrisation and con¬
striction have advanced to a considerable degree, and are
correspondingly difficult to treat. In such a cass I have
found the T-shaped tube'described below very useful, not
indeed affording complete cure, for the tube has still to be
worn, bub rendering the patient’s condition very comfort¬
able, enabling him to talk and earn his living. The patient,
a man aged fifty-two, “cut his throat” six months ago; the
transverse wound completely divided the trachea below
the cricoid; suppuration occurred, and dyspnoea came on
three days afterwards; this was relieved by the introduction
through the wound of an ordinary bivalve tracheotomy
tube, and this he has never been able to leave out for any
length of time since. Oa examination six months later,
respiration was carried on entirely through the tracheal
opening, the larynx being entirely shut off by a tough
skin-like septum, which completely blocked the trachea at
the upper level of the opening. 'JThe voice was of course
absent. It was evident that free removal of the obstruction
must be the first step, and this was done by first enlarging
the opening downwards, and plugging the trachea with a
Trendelenberg’a cannula. The cricoid was then divided
in the middle line, and the larynx laid open above the
obstruction. (See engraving.) In this way the limits
Vhr'itcai- Section ok faRVNX.
and attachments of the membrane were made out, and
it was cut away with scissors. The part attached to
^ IiibeniationalJournal of the MeUicol Sciences. March and April, 1888.
introduces easily himself one half at a time, and these,
when held together by the collar and screw, form one rigid
T-shaped tube, of which the long or tracheal portion passes
through the cicatrising portion of trachea and keeps it
patent; by blocking the outer opening with a plug of cork
or the linger respiration is ^uite natural, and the voice clear
and distinct. The patient has now worn the tube some
months without any discomfort or sign of tracheal irrita¬
tion. In this ease the tendency to cicatricial encroachment
was so great that I think it Avould have recurred whenever
any tube was discontinued, even an intubation tube—
in fact, he wore at one time a tracheotomy tube with
the curve upwards, passing through the constricting ring ;
but in a short time, while wearing this, constriction began
at the lower angle of the opening, by an encroachment
all round of granulation tissue, leading to urgent dyspneea.
until relieved by the downward tube. The T-tube combin¬
ing the dilating advantages of an upward and downward
tube was introduced in two halves, to get over the dilli-
culty of introduction. If compelled, at any rate for some
time, to wear some sort of tracheal dilator, the T-tube has
I the advantage over the intubation tube of allowing
' phonation. In these cases, then, of obstruction after trans-
'• verse suicidal wound the T-tube will, I think, prove useful,
and if not necessarily permanently, perhaps as a commence¬
ment before beginning intubation. It may be also that
when healing is complete—that is, when skin and mucous
membrane have joined all round and left no granulating
and encroaching edge,—the T-tube might be discontinued,
when the outer opening would soon comparatively close,
though leaving a small aerial fistula. The tube was made
for me by Wood of Leicester.
Leicester.
Thk North of England Surgical Aid Society:
The annual report, in reviewing the work of this Society
for the year 1890 (the second year of its existence), points
with satisfaction to its augmented usefulness. In the nine
months of 1889 forty-nine appliances were supplied ; in th©
same proportion last year the number would have been
sixty-six—the actual number was 121. The work has
hitherto been carried on free of cost in rooms in the in¬
firmary, but the committee have been compelled to begin
the year by appointing (with the consent of the governors)
one of the house surgeons of the infirmary to do the work
previously performed by a subcommittee. The financial
position renders necessary an appeal for funds to meet the'
increasing demands upon the Society,^
Digitized by VjOOQ IC
510 The Lancet,]
CLINICAL NOTES.
[March 7,1891.
CMtal llotts:
MEDIOAIi, SUEGIOAIi. OBSTETEIOAX, ATO
THERAPEUTICAL.
SURFACE AND SUBSURFACE NODULAR
RHEUMATISM.
By Angel Money, M.D., F.R.C.P.
In the recorded bUtory of nodular rheumatism mention
■will be found of pericardial nodules and nodular pericarditis.
I believe there is a radical distinction between the two, as
there is between surface lesions and subsurface lesions
generally. At a recent necropsy on a woman aged twenty
fairly recent adhesions obliterated the whole pericardial
sac, and nothing very nodular about the pericarditis could
be detected ; but, on peeling oil'all the pericardial lymph, at
least three subpericardial nodules were found, each of
the size of a small hempseed ; the pericardial endothelium
appeared to be intact over them, and they had made a place
for themselves in the surface myocardium. These are, I
suggest, the true homologues of subcutaneous nodules, and
ought to be called subpericardial. The nodular endo¬
carditis is to be compared to nodular pericarditis, pleurisy,
and perihepatitis. Further information is required about
this surface infiamraation. In the nodular perihepatitis
which I have seen several times one observes line granula¬
tions not much larger than grains of white sand, and the
spaces between them are wide; but there is a regularity
about the arrangement of the granulations which does not
obtain in nodular perisplenitis. The appearance hardly
reminds one of tlie true granular pneumonias, and yet the
sizing and regularity are points in common. As a suggestion
it may be put forth that all rheumatic manifestations ore
locally circumscribed, but that at the surface of organs this
feature is masked by attendant phenomena, such as the
effusion of lymph and the coalescence of locally circum¬
scribed areas! Beneath the surface there is less chance for
the masking, possibly owing to the less anastomosis between
vessels and other anatomical and physiological arrange-
nr,ents.
Subcutaneous nodules and acute rheumatic polyarthritis
are seldom found together. Generally the rheumatism is
of subacute and subchronic intensity and duration when
nodules appear. The more smouldering the lesion the
more liability is there to subcutaneous and subcapsular and
subserous nodules to form. Is this true? It is rather rare
iu ray experience to find crops of nodules coming and going
with rapidity—i.e., in the course of a few days. A nodule
now and then behaves thus, but not often. Their relation
tO' chronicity is further testified by the usual absence of
tcoderness, of pain, and of fever. Diseases that are
chronic in adults are leas chronic in their histological deve-
litpment in children, any irritation giving rise to more
interstitial sprouting in children, as would indeed be
expected from their nearness to or less distance from the
embryonic multiplication which is, or which characterises, the
growing. Dr. Cheadle observes: “ This very acute inflam-
ination (pericarditis) appears to be less identified with the
de\'eloj)menb of nodules than the more chronic form.” In
iiiost acute diseases there is a tendency to surface inllam-
luations, and, in proportion as chronicity obtains, lesions
appear in the deeper interstitial parts. The subserous,
cutaneous, and capsular nodules then are a measure not
only of the gravity of the prognosis, but also of the dura¬
tion and insidiousness of the disease.
A contrast io suggested between surface and subsurface
rujJular rheumatisni. That the rheumatic foci are more
numerous, smaller, more closely aggregated, more transient,
mo-e painful, the more superficial they are; and, con¬
versely, the deeper seated, the less numerous, the less
closely packed, more permanent and less painful.
3i i.rlcy-sti'sct, VV.
HYPERPYREXIA FOLLOWING CURETTING.
By J. E. H. Kelso, M.B., U.M. '
The following case is interesting as showing the care
necessary after curetting, and also one of the difficulties
practitioners often have with patients in the country.
Mrs. F- came under my care in August, 1889. Her
case was as follows. She commenced menstruating at fifteen
years of age. At eighteen she had hard out-door work on a
farm, and at this time she noticed that her menstniatiou
was excessive in amount. She married at twenty ; had no
children; no history of abortion, and her family history
was good. The menorrhagia increased as years went on,
and at twenty-seven—viz., three years previous to her appli¬
cation to me—she was attacked with severe pain in the back,
and at this time had an almost continuous discharge. She had
derived little benefit from treatment previously adopted.
When she consulted me she was pale and somewhat emaci¬
ated. On examination 1 found her uterus to be enlarged, retro-
llexed, and immovable ; there was no pain on passing the
sound. I ordered rest, hot water injections, and ergot
internally. No improvement resultingfrom this treatment,
on Oct. 9th I determined to curette, the discharge being
little. With strictly antiseptic precautions I performed
the operation, dilating the cervix with Hegar’s dilators.
The scrapings were set aside for microscopic examination,
but were acidentally thrown away by one of the patient’s
friends. After curetting, pure carbolic acid was applied to
the endometrium, and I left the patient with strict orders
to keep her bed for a week. I subsequently learned that,
feeling perfectly well, the patient got up an hour after the
operation, went to her garden to take in some clotheswliich
were drying as it had commenced to rain, and got wot during
the process. In the morning of Oct. 11th her temperature
was 103°; pulse 110, hard, bounding; no tenderness on
abdominal pressure. I prescribed hot vaginal injections
of carbolic acid. The next day the temperature was
lOoT®; pulse 120. I ordered drop doses of aconite every
quarter of an hour, as there were pain and symptoms of
pelvic peritonitis. In the evening she became delirious;
temperature 107°; pulse 100. Owing to the extreme gravity
of lier symptoms I ordered her to be placed in a warm bath,
cold water added, and afterwards wet packing. Four hours
after this was done the temperature was 101 ‘2°, and she was
now conscious ; she now had a morphia suppository (^; gr.)
and a tablespoonful of brandy every three hours; also,
small doses of quinine; milk diet. From the 12th to the
21st there were a morning fall and evening rise of
temperatirre, but it did not exceed 102°. Her bowels
were regulated by enemata and an occasional gentle
aperient. Abdominal pain was slight. On Oct. 2l9t the
temperature reached 105T°; and quinine failing to reduce
it, I gave twenty grains of antipyrin every three hours. On
the following day the temperature fell to 100°; antipyrin
was stopped, and quinine substituted. There was little
variation of temperature until Nov. 1st, when it rose to 103°
with vomiting and retention of urine. I ordered ice to be
sucked, relieved the retention of urine with the catheter,
and gave fifteen grains of quinine per rectum every
four hours. In the evening of Nov. 2nd no nourish¬
ment could bo taken by the mouth, the patient bein"
supported by beef-tea and brandy enemata, also rectw
suppositories. Temperature now fell to 99'8°. On Nov.
6th she passed urine without the aid of the catheter,
and took some milk by the mouth, which she retained.
On the lObh the temperature was 99°. She now had a
simple febrifuge. There was no pain or abdominal tender¬
ness. The next day the temperature was normal. Men¬
struation occurred on Dec. 1st, lasted three days, and was of
small amount. The patient was now allowed to get up daily,
the temperature remaining normal. She recovered strength,
although she was under treatment for anceraia for four
luonthe. I saw her at the end of June, 1890. She had men¬
struated regularly, had gained llesh, was not anauiiic, and
said she had nob enjoyed such good health for ten years.
KInca]''Uno-on-Foi't)i.
HERPES ZOSTER OF THE LEG.
By ClaeencI'; Bbesley, L.R.C.P., L.R.C.S.
The following brief notes of a case of herpes may be of
intereat as showing the apparent nervous origin of the com¬
plaint, and its distribution over the cutaneous area supplied
by a given nerve—in this case the anterior crural. The
patient, a male aged sixty, had suffered very severe pain
in the right thigh ten daysbefore the eruption showed itself.
When seen, a very copious characteristic herpetic rash
covered the anterior aspect of the thigh as far as the upper
border of the patella, and there was also a small patch just
.oogje
Thb Lancet,
HOSPITAL MEDICINE AND SURGERY.
[March 7, 1891. 541
Above the gluteal fold. The eartorius appeared to divide
the eruption into two distinct parts, and there were no
vesicles in the skin over this muscle. The following diagram
Cutaneous Nerves oe Lower Extremity.
Posterior view. Autevior view.
{After Flomr.)
ehows the extent of the rash at a glance, and it is seen to
be exactly limited to the external {e c), middle (M c), and
internal (i c) cutaneous branches of the anterior crural.
Under appropriate remedies the patient made a somewhat
4ardy but complete recovery.
Wan'iiiKtoii.
THE EFFECTS OF OVERDOSES OF EXALGTNE
{METHYL-ACETANILIDE).
By Arthur Conning Hartley, M.B., C.M.
While having many satisfactory results from the use' of
•exalgine, I think it would be of some interest to give an
account of two cases of overdose.
Case 1.—Mrs. C-, aged twenty-seven, married, had
been subject to severe periodic attacks of neuralgia over
the right orbito-temporal region for the last five years, and,
as nothing had done her any good, exalgine was tried. The
-attack began at 11 a.m., and increased in severity. At
1 P.M. she took a three-grain dose of the French preparation
((MM. Brigonnet and Naville), and the same dose was repeated
•at 2, 3,4, and (i r. iw., without giving any relief or discomfort.
At 9 P.M. she took three grains more, and almost irame-
•diately afterwards felt absolutely powerless. This lasted
'for five minutes, the patient remaining quite conscious.
She compared the sensation to that of taking chloroform
before she was quite “ under.” At 12.45 A M. the pain still
being very severe, she took a seventh dose, and in fifteen
minutes felt a feeling of impending death, could not speak,
gasped for breath, pallor intense, dilated pupils ; the limbs
became quite rigid, heart palpitated, felt utterly powerless,
•and liroke out into a profuse perspiration. By the aid of
fresh air, stimulants, &c., the attack passed dlT in fifteen
minutes, leaving her very prostrate, with ringing sounds in
the ears. The pain, which frequently lasted only this
^length of time, now left her. Other functions remained
normal, and no rash developed. This happened between
her menstrual periods.
Cask 2.—Mrs. C-had been taking two-grain doses
at intervals for a neuralgic headache, obtaining relief,
though sometimes feeling slightly faint, but by mistake an
'undetermined overdose was taken. She soon experienced
a feeling of complete prostration, her limbs became power-
though not rigid, felt as if she was sinking through
'the bed, slight perspiration, and thought she was dying;
'breathing faint and shallow, and nearly pulseless at the
•wrist. Mustard, hot bottles, and stimulants, brought her
round, but she felt very weak for many days afterwards.
Liscartl.
% Itirm
OF
HOSPITAL PKACTICE,
BRITISH AND FOREIGN.
Nulla, autem est alia pro certo noacendl via, nia! quampIuTimasetmor.
borum at diasectionum blatoriaa, turn aliorum turn proprias coUaotaa
habere, et inter ee comparaie.— Moroaoni De Sea. et Cam. Jdorb,,
lib. iv. Proosmium. ■ • -
ST. GEORGE’S HOSPITAL.
TWO CASES OF PERFORATING ULCER OF THE STOMACH,
WITH MISLEADING PHYSICAL SIGNS.
(Under the care of Drs. Dickinson and Ewart.)
In these cases the peritonitis which followed the perfora¬
tion of the ulcers did not pursue the more usual course and
spread throughout the peritoneal cavity, but remained more
or less localised, though most intense and purulent. The
purulent collections secondary to perforations of the stomach
may attain large size and produce swellings in parts of
the abdomen where such would not be suspected. They
present great difficulty in diagnosis on account of the
gaseous contents which are not infrequently present
and mask the evidence of fluid. Sometimes, in consequence
of adhesions between the base of the ulcer and the
diaphragm, perforation may take place into the pleura, and
empyema, with pneumothorax, result. The symptoms in
Case 2 made it probable that such a complication had
arisen. The occasional coexistence of certain heart murmurs,
indicative of pericarditis and endocarditis, with symptoms
pointing to gastric ulcer in chlorotic girls, has been observed
by Dr. Ord in a few instances, and formed the subject of an
interesting paper read by him before the Medical Society.^
For the account of these cases we are indebted to Dr.
Charles Salter and Mr. W. L. Dickinson, formerly medical
registrars to f.he hospital.
CASE 1. Perforation with supposed pericarditis. —In
December, 1887, a chlorotic gijl aged twenty-four was
admitted under Dr. Dickinson with symptoms of peri¬
tonitis, which from the histoiy was considered to be due to
perforation of the stomach. Besides the peritonitis there
was considerable disturbance of respiration and circulation.
The heart’s action was forcible, and friction sounds, having
all the characters of those present in pericarditis, were
plainly audible along the right border of the sternum from
the third to the fifth costal cartilage. Moreover, there
was tenderness over the whole precordium. Pleural
friction was heard in the left axilla. These signs, taken in
connexion with the fact that there was a great liability to
syncopal attacks, seemed to indicate that in addition to
peritonitis and pleurisy there was pericarditis. When
the patient had been in the hospital about ten days
she was attacked with diphtheiia and rapidly died.
At the necropsy there was found a perforation of the
posterior wall of the stomach, which had caused peri¬
tonitis, almost restricted to the left half of the diaphragm
and the upper surface of the left lobe of the liver, the
under surface of the liver being also coated by recent
lymph. A layer of soft lymph coated the lower part of the
left pleura. There was no trace of pericarditis. Between
the liver and the diaphragm was an abscess pushing up the
left leaflet some distance; and it is probable that this altera¬
tion of the usual relations, together with the pleurisy on
the left upper surface of the diaphragm, gave rise to the
friction synchronous with the heart’s action which was mis¬
taken for pericarditis.
Case 2. Perforation xoith supposed pneumothorax. —In
November, 1890, a very chlorotic girl, aged eighteen, was
admitted under Dr. Ewart with signs of pneumonia at the
base of the left lung and a histo^ of gastric ulcer. Three
days later there was consolidation at the bases of both
lungs. This condition of double pneumonia underwent
very slow resolution, but a gradual subsidence of fever
suggestive of an irregular pneumonic lysis took place
in the coume of three weeks. There was now a
return of fever and serious symptoms. A careful
examination of the chest showed that the right lung
had returned to its normal state, but that on the
1 Trans. Motl. Soc,, 1S88, March.
Dig!. _3(j by ^.wjOO^Ic
542 Tee Lancet,]
HOSPITAL MEDICINE AND SUKGERY.
[March 7,18&1,
left side just above the spleen pure amphoric breathing
was audible, and a perfect “bell-note” could be obtained
by percussion with a couple of coins. At the posterior base
there was evidence of some effusion of fluid. The^e physical
signs varied a little from day to day, but those especially
characteristic of oneumothorax were always present.
Many rigors occurred, and the patient died six weeks
after admission, ordinary gastric symptoms having been
in abeyance throughout. At the necropsy there was no
pneumothorax. The lower lobe of the left lung was
partially compressed by a small eilusion of turbid fluid
into the left pleura. An abscess cavity was found contain¬
ing air and pus between the diaphragm, the spleen, and the
upper surface of the left lobe of the liver. Opening into
this abscess was a small perforating ulcer on the anterior
wall of the stomach near the cardiac end. There was also
a ragged abscess in the substance of the spleen, which com¬
municated with that beneath the diaphragm.
TOTTENHAM HOSPITAL.
FOREIGN BODY IN THE FEMALE BLADDER ; REMOVAL.
(Under the care of Dr. Hooper May.)
The surgeon is much more frequently called upon to
remove foreign bodies from the bladder of the female than
from the bladder of the male, and such bodies are very
commonly found forming the nucleus of a stone when
removed from the former. Although they are usually
introduced from the urethra by the patient, there is a
specimen in the museum of Guy’s Hospital, a piece of slate
pencil, which was removed from the bladder, having found
its way there from a neighbouring viscus. Sometimes the
shape of the body prevents its ready extraction, but removal
can usually be effected, as in this case, after dilatation
of the urethra.
E. A-, aged twenty, was admitted to the hospital
in June, 1889. She was a delicate-looking girl. The right
hip-joint was stiff, with scars in the thigh from old
abscesses. She says “she sat on her pocket, and a pencil
slipped into her bladder a week ago.” She complains of
constant pain at the ^‘bottom of the stomach” and pain
during micturition, whicii has not been more frequent than
usual. There has been no incontinence, and the urine is
neutral, with pliosphates and mucus.
June 27th,—Patient being under chloroform a sound was
introduced, but gave no certain'sign. The urethra was
dilated with forceps and the finger, and on introducing the
finger it immediately came in contact with a pencil lying
across the bladder. Difficulty u’as found in turning it so
as to get hold of the end. After partly filling the bladder
with 'boracic lotion it was turned so that the end could be
seized with email lithotomy forceps, and then it was
removed through the urethra without difficulty. The
urethra was slightly torn upwards for about half an inch.
The night afterthe operaticnshe had incontinence of urine;
none in the day,' and none in the night following. Since
that there has been incontinence occasionally. The bladder
was washed out daily with boracic lotion until July 7th.
Before the operation the temperature had been irregular,
ranging as high as 102'’. The day after it was 100 4°; then
it became normal.
July 10th.—The urine continues neutral in reaction.
The loreign body, which the patient called a pencil-case,
was a thin tin cylinder, about 3^ in. long, partly encrusted
with phosphates.
13ta.—ror the last two or three days the urine has been
acid, and there has been no incontinence.
14th.—Discharged well.
LINCOLN COUNTY HOSPITAL.
CASE OF TRAUMATIC EPILEPSY; TREPniNING; RECOVERY;
remarks.
(Under the care of Mr. Cant.)
EoR the account of this case we are indebted to Dr.
Brook, late house surgeon.
C. C-, a carter aged thirty-four, came to the surgery
on the afternoon of Sept. 25bh sulfering from the elfects of
a kick from a horse on the right temple and cheek. He
walked to the hospital and wae perfectly sensible, but said'
that he remembered nothing for some minutes after the'
receipt of the injury. There was an abrasion of the skini
over the right malar bone, with ecchymosis of the con¬
junctiva on the outer side, and there was a bruise on the
temporal ridge, where the caulking of the shoe had struck
him. No fracture could be made out, and the eye had
escaped injury. Ha complained of pain over the right-
malar bone and temple, buc absolutely refused to be treated
as an in patient, coming to the surgery every morning to-
have the wound dressed. The wound healed up, and ha
was apparently almost well when he came on Oct. 1st, six.
days alter the accident, and asked to be admitted as an
in-patient, as be had had two fits that morning for the-
first time in his life.
On admission the patient was a thickset, short, very
muscular, and in every way healthy man. He complained
of pain over the right temple, but was perfectly con¬
scious. No paralysis; superficial and deep reflexes anti
electrical reactions appeared healthy. Pupils, moderately
dilated and equal, reacted to light. Ophthalmoscope
showed nothing abnormal, except old high myopia of
right eye. Temperature norma). Urine: sp. gr. 1015;.
no albumen. He had always enjoyed excellent health
never bad any epileptic fits. Total abstainer for the laeU
six years. On Oct. Ist three epileptiform attacks after-
admission.
Oct. 2nd.—Eight attacks between 5 a.m. and 11 a.m, ;
they were all similar in nature ; immediately before one of
these the patient was lying on his right side and perfectly
conscious. The attack began with twitching of the left
side of the mouth, which was drawn upwards and to the
left, followed after a few seconds by twitching of the left/
band and protrusion of the tongue to the right. During"
this time the right side and both legs were unaffected ; buu
he now turned over on his back, clenching his hands and
drawing them up, while the legs were extended stifHy, the
eyes closed and teeth clenched, and back arched so that he
was resting on his heels and back of his head. This
condition of opisthotonos lasted for a few seconds and then
suddenly relaxed ; at the same time he gave a loud cry and
struck the bed violently several times, not rapidly, but at
intervals of about live seconds, drawing up his arms and
arching his back, and then, after a pause, violently extend¬
ing the arms, while the back relaxed. This attack lasted
four minutes. Immediately before he recovered he sighed,
deeply, turned on bis right side, and put his right hand to
the right temple. He regained con.sciousness perfectly in
the course of a minute. Pupils widely dilated. He did
not pass urine during the attack. He said that before
an attack comes on he has pain at the seat of injury,,
which passes right round his head, and then he loses
consciousness.
During the next fortnight he had from seven to twelve
j such attacks daily, although he had been taking twenty
grains of bromide of potassium, five grains of iodide of
potassium, one drachm of liquor hydiargyri percbloridi;
to be taken three times a day. During this time he rapidly
lost llesh, becoming very weak, so that the attacks appeared
to be less violent; they, however, were of longer duration,
and had altered in character, the patient often biting hie
tongue.
Oct. 29bh.—Unconscious for two hours; no movement,
except quivering of the eyelids, but when touched ho
sprang into a sitting position and tried to bite, snarling like
a dog. On coming round, he remembered nothing of what
had happened. He was out of bed when one of these
attacks began, walking across the ward, and was seen
to drag the left leg for some seconds before he lost
consciousness and had time to get back to bed. On
percussing over the right temple there was a very tendesi
area the size of a shilling two inches behind and above the
external angular process of the frontal bone. This was
exactly the place over which he put his hand before regain¬
ing consciousness, and he said that he had always pain
there after a tit was over. As the symptoms indicated a
localised cortical lesion, and as they were not relieved by
medicinal treatment, it was decided to trephine over the
seat of the lesion in the hope of relieving the patient.
Every attack began with twitching of the left zygoiiiatici,
so that there was evidently a discharging cortical lesion
situated in the facial centre on the right side—i.e.,in the
ascending frontal and ascending parietal convolutions and
point opposite to tlie sulcus between the second at a
Coogle
The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
- [MARcn 7,1891. 543
third frontal convolutions. The patient’s head was
shaved and the motor area mapped out according to
Beid’s rules, and at the point indicated a circle one
inch in diameter, having its centre two inches and a
.(quarter behind and two inches and a half above the
external angular process, was marked out with nitrate of
silver. The following day, Nov. lOth, the patient was
anajsthetiaed by the A.C.E. mixture, and the operation
performed by Mr. Cant. The strictest antiseptic pre¬
cautions were adopted. The scalp was shaved and
thoroughly washed, a wet pad of sal aletnbroth wool and
perchlotide of mercury lotion being applied for six hours
.before the operation, which was performed in one of the
small wards. All the instruments were kept in carbolic
Motion, and the operator’s bands dipped in perchloride of
■mercurylotion (1 in 2000 ), sponges of sal alembrothwool being
.used. The scalp was reflected downwards from the right
temple by a semilunar flap. There were no signs of any
fracture of the skull. The pin of an inch trephine was
applied at a point corresponding to the centre of the circle
cnarked out (.fin,) behind the coronol suture just over the
temporal ridge. The circle of bone was removed without
difficulty, and appeared quite natural. The dura mater
bulged very much at the posterior part of the opening.
The dura mater was divided and reflected, a considerable
-quantity of serous fluid escaping from the bulging portion,
which was found to be situated over the ascending parietal
convolution, the fissure of Kolando crossing the posterior
half of the opening. The fluid (which was of a yellowish
colour) was beneath the arachnoid, lying entirely behind
the Assure of Kolando, and at this spot a black substance
could be seen through the pia mater, which on exposure
proved to be two small blood-clots in the grey matter, and
which were removed. An aspirator needle was pushed into
•the cortex for three-quarters of an inch in case there should
be any collection of pus, but nothing was found. The
trephine opening was extended backwards for another
•three-quarters of inch, but nothing further was discovered.
The wound was washed with perchloride solution (1 in 2000),
•and the dura mater brought together with fine chromic gut
sutures, the scalp replaced, and sutured with carbolised
silk. A pad of wet sal alembroth wool covered with tissue
was applied. The bone was not replaced owing to the brain
bulging. During the operation, whenever the cortex was
touched, the left side of thu mouth and left hand twitched.
The patient soon came round from the anaesthetic, and was
perfectly conscious.
Nov. 11th.—Very excitable and restless. The wound
was dressed under the spray and a suture removed. Ordered
'bromide and chloral if restless.
12th —No epileptic attack since the operation. Tempera¬
ture 98-8°.
13bh.—Had a slight twitching of the left side of the
mouth lasting half a minute.
J5th.—Scalp wound united; sutures removed. There has
not been any recurrence of the convulsions since the l.'lbh,
and the patient is in very good spirits.
Dec. 22Qd.—Discharged from the hospital in perfect
health and spirits, having had no return of the fibs in any
wav whatever.
Remarks by Mr. CANT.—The above case seems to clearly
prove the advisability of operating in cases of traumatic
epilepsy, especially when the convulsions and the pain both
so clearly indicate the seat of the lesion. This patient com¬
menced having fits about one week after the receipt of the
injury, and continued having them very frequently and
very severely for six weeks, with commencing loss of power
of left leg. After the operation was performed they entiroly
ceased, and up to the present time, several weeks after, he
has had no return of them, but has gained in flesh, and
’iis now apparently in perfect health.
Blackburn and East Lancashire Infirmary.—
^rhis infirmary was satisfactorily and successfully conducted
during the past year. There were 7889 in- and ou b-patients.
Of the out-patients, 915 were treated in the eye and ear
department. The continuous increase of in-patienks fore¬
warns the Board that additional wards will soon be required.
The total income was £6728 195. 3rf., and tlie expenditure
(including £441 I 65 . Grf., the previous year’s deficit),
amounted to £6916 . 55 . Id. Bat that liability Lad been re¬
duced to £187 5s. iOrf. During the year fair progress was
made with the building fund for the “ Nurses’ Horae.”
PATHOLOGICAL SOCIETY OF LONDON.
Exophthalmic Goitre.—Duct Carcinoma of Breast.—Cystic
Disease of Breast.—Thrombosis of Cerebral Veins .—
Loose Bodies from the Knee-joint,—Dislocated Internal
Semilunar Fibro-cartilage fixed to the Patella.
An ordinary meeting of the Pathological Society was
held on March 3rd, the President, Dr. W. H. Dickinson,
in the chair.
Mr. W. G. Spencrr showed a specimen taken from a
fatal case of Exophthalmic Goitre, consisting of a large
broDchocele, and attached to which at the lower border was
a persistent thymus gland. The bronchocele had been pro¬
duced by uniform enlargement of both lateral lobes and of
the isthmus, and surrounded tbe trachea so as to meet
behind that tube, compressing it laterally from tbe larynx
above to one inch from the bifurcation below. Thecarotids,
vagi, and internal jugulars had been pushed outwards, and
lay separated from one another in ileep grooves on the back
of the tumour, whilst the recurrent nerves, after their re¬
flection, were buried in the mass. The inferior thyroid
arteries Avere much enlarged, that on the right 8 id 6 being a
branch of the subclavian; on the left it arose from the aorta
between the left carotid and subclavian. The tumour had
the structure of a cystic colloid hypertrophy of the thyroid
gland. There were no changes in the central nervous
system. A persistent thymus larger than the head of the
pancreas Avas attached to the goitre at the lower part, having
the characteristic microscopic structure. The specimen avos
taken from a girl aged twenty, Avho had been under the care
of Drs. Ferris and Davidson of Uxbridge for a year suffering
from exophthalmic goitre. The goitre slowly increased in
spite of treatment, until the patient had attacks of dyspnoja.
After admission to tbe Westminster Hospital asphyxia
became imminent, and Mr. Spencer opened the trachea
through the upper part of the tumour. There was much
hasmorrhage, and the gland substance bulged greatly when
the capsule was divided, showing the tension which existed
within the capsule. The operation could not have been
performed except with the aid of several assistants. No
relief was afforded when the trachea was opened, nor when
an ordinary tracheotomy tube was inserted. However, air
entered freely through a vulcanite tube passed for four
inches down the trachea. The dyspnoea Avaa quite relieved
for a time, but during the same, evening mucus collected
below the tube which the patient could not cough up, and
she died in, asphyxia. Mr. Spencer further remarked that
this termination of a case of exophthalmic goitre was rare,
and that some recent operations by Avhich a cure had resulted
after the removal of a great portion of the gland connected the
pathology of the disease closely with the thyroid body.—The
President asked what part of the trachea was constricted,
and whether the tube was passed in aboA'e the constriction
or below it.—Mr. Spencer replied that the compression
was exerted from the larynx to Avithin an inch of the bifur¬
cation of the trachea, and that the rubber tube was passed
down the trachea to below the area of compression.
Mr. H. B. Kouinson showed a specimen of Duct Carci¬
noma ’of the Breast, taken from a Avoman aged fifty-one.
Five years before she had had a knock on the breast, and
there was no family history of cancer. The tumour
involved the left breast, and was external to the nipple,
which was not retracted, and there was no discharge from
it. The growth had for soipe time increased steadily in
size, and there was no enlargement of the axillary glands.
On removal, it was found to be partly hard and partly
cystic, the cysts containing greenish-brown fluid, and the
cut surface of the hard part cupping distinctly. Under tbe
microscope the larger cysts were found to be lined with two
rows of cells, which Avere flattened from pressure, while in
some there was marked proliferation of the epithelium,
which was swollen and of spheroidal type. The solid
part showed typical columnar-celled carcinoma. There
was ver^ little round-celled infiltration of the con¬
nective tissue. Clinically it appeared to bo a typical
scirrhus, only there was no retraction of the nipple
and no involvement of the glands. This low degree of
malignancy suggested that early removal would lead to per¬
manent cure. 'The growth might either begin in the large
544 The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[March 7,1891.
ducts, aod thus resemble papUloma, or it might begin in
the acinous dilatations.—Mr. R. Williams said that a
great many of these growths were not cancers at all, but
were either villous growths or sarcomas. They were classed
by Billroth as soft tubular adenomas.—Mr. BovvDiV said
that these tumours did not generally run the ordinary
course of cancers of the breast; they grew more slowly, did
not affect the ^ands, were less likely to recur, and did not
disseminate. They were not simple papillomas, because
they infiltrated both the skin above and the adjacent tissues
below; they often broke down to form ulcers. The specimen
shown differed from the ordinary duct cancer of the breast,
with its branching processes, in presenting these distinct
tubular structures. He doubted if this case would fall
clinically under the same category as the majority of duct
cancers.—Mr. Robinson, in reply, said that the operation
was done in November, 1889; the whole breast was
removed, and the patient was at present free from recurrence.
Mr. Robinson then described two cases of Cystic Disease
of the Breast. The first was a single girl aged twenty, who
was admitted in July, 1890. A lump in the left breast had
existed for two years, and bad slowly increased in size.
There bad been no discharge from the nipple, and no en¬
largement of the glands. There was no limiting capsule to
the growth. Its centre was found to be composed of an
aggregation of small tense cysts ; at the margin the cysts
were further apart, and radiated towards the periphery of
the gland. The cysts were surrounded by condensea fibrous
tissue. The second case occurred in a girl aged nineteen,
who was admitted in the same month. Eleven months
before a growth had been noticed in the upper part of the
left breast of about the size of a filbert, and it caused some
shooting pain, which strapping failed to relieve. It was
freely movable, there was no retraction of the nipple, no
enlarged glands, and it was devoid of limiting capsule. Its
appearance on section and under the microscope was similar
to the first case related. The cause of both was obscure.—
Mr. R. Williams regarded them as instances of chronic
interstitial mastitis, and to a question as to the presence of
intracystic growths he received an aihrmative reply.
Dr. W. Collier exhibited a Brain which was the seat of
Thrombosis of the Veins. The patient was a woman aged
twenty-three, who was prematurely confined of a stillboni
child on Jan. 4th, 1891, and on the 20th she complained of
headache, and became hysterical and aphasic. In a few
hours general convulsions affected the right side, vomiting
supervened, and the urine contained a trace of albumen. In
a week the patient became comatose and died, the tempera¬
ture rising before death to 107" F. At the necropsy the upper
surface of the left hemisphere was found ecchymosed and
covered with a thin layer of lymph. There was extensive
thrombosis of the veins on the left side, while the arteries
at the base were normal and empty. The cerebral substance
was softened, and there was no evidence of ear disease or
septic trouble.—Dr. Dickinson remembered seeing a young
woman who after confinement Jiad plugging of the veins
of the leg, and later hemiplegia supervened.—Dr. Hadden
referred to the case of a young woman aged twenty-three,
in whom hemiplegia developed after an attack of convul¬
sions. She died, and cerebral thrombosis was found. There
had been a suspicion of miscarriage some time before.
Mr. Howard Marsh showed several Loose Bodies re¬
moved from the Knee-joint during the operation of excision.
The patient from whom the specimens were removed was a
female aged seventeen, whose left knee-joint had been the
seat of tuberculous disease for three or four years. The
synovial membrane was considerably thickened, and the
head of the tibia was displaced .backwards and outwards
towards the popliteal apace. When the joint was opened,
five loose bodies escaped. They were about the size of
almonds, glistening and perfectly smooth on the surface, of
a pale-yellow colour, and apparently consisted of masses of
fat. The joint was extensively diseased. The synovial
membrane was thickened and overlapped the articular
cartilage. There was no suppuration, and the joint con¬
tained no fluid. Two other similar loose bodies were found
attached to the synovial membrane investing the lower
end of the femur. On examination, these loose bodies wore
found to consist of a shell, or capsule, enclosing a central mass,
with an intervening space. The capsule was firm and of
the consistence of coagulated fibrine. The central portion
resembled, in general appearance, those shaggy maeses of
fibrine, which are often found in the cavities oi burste. Mr.
Edgar Willett, curator of the museum, ha<l furnished the
following report: “Under the microscope the difference
between the outer layer and the central portion was very
distinct. The outer layer was about iJ^th of an inch thicks
and was composed of a uniform collection of granular cella
without stroma or definite structure. The transition to the
inner part, or kernel, was veiy marked. This kernel had an
imperfect and irregular structure, presenting a number of
well-defined collections of small cells, either circular or
oval in shape, and resembling the giant cells found
in tubercular deposits. No tubercle bacilli were found.”'
Mr. Marsh remarked that ho had not met with this
kind of loose body before; but, after Mr. Willett’s
report, he was inclined to regard them as tuber¬
cular formations in the fringes of the synovial mem¬
brane, to which some were still connected, while some had
become detached. The view which some might be in¬
clined to hold, that these ma.s8eswere similar to the melon-
seed-liko bodies often found in the sheaths of tendons, ap ¬
peared to be negatived by the fact that the two dillered
from each other in structure, the melon-seed-like bodies
being quite amorphous—evidently nothing more than
masses of coagulated fibrine,—while the bodies which he-
had shown presented the microscopic structure of tubercle'
in, as he thought, an unmistakable form. Mr. Alexis
Thomson of Edinburgh bad described, in a chapter on
nodular tubercle of the synovial membrane, the occurrence
of polypoid masses apparently precisely similar to those-
described in the paper, and Mr. Watson Cheyne had also-
alluded to loose bodies of the sarhe kind.
Mr, Edgar Willett showed for Mr. Harrison Cripps
two Loose Bodies which had been removed separately, with
an interval of four weeks, from the left knee-joint of a-
healthy young man. There was a history of an injury.
The bodies were fiat, roughly about one inch square, and
had a layer of smooth cartilage on one surface, and were-
calcareous if not bony on the other. On comparing them,
it was found that they fitted together. The question was
raised as to whether they had originally been attached to-
the femur and had become separated by the injury.
Mr. Bruce Clarke showed a piece of a I’atellar
Cartilage which had been knocked off and formed a loose
body in the knee-joint. The patient was a man aged
twenty-eight, who slipped on getting into a ’bus in the
Hamraersmith-road, and was taken to the West London
Hospital. He was operated on for a dislocated internal-
semilunar cartilage, and in the course of the operation an
abrasion was found on the under surface of the patella, from
which a piece of cartilage had been knocked out. ThC'
cartilage (about half an inch by three-quarters of an inch) was
extracted from the joint, and was shown to the meeting,
A good recovery with perfect movement of knee-joint
ensued, and the patient had since been under his care for a-
loose body in the opposite joint. A loose body had been
removed from this joint seven years ago by Mr, Baker of
Birmingham. It was worthy of note that; this joint, which
had been twice operated on, was now the seat of rheu¬
matoid thickening of the edges of the condylar cartilages on
the femur.
Dr, Rolleston showed the Patella from a Left
Knee-joint which bad been partially dislocated outwards
for years. The articular surface of the patella had regularly
adherent to its periphery a cartilage resembling the semi¬
lunar cartilages of the knee-joint. The internal semilunar-
cartilage was absent from its position on the tibia. What
appeared to be the femoral surface of the internal semi¬
lunar cartilage looked into the joint, the tibial surface
being adherent to the margin of the patella by what greatly"
resembled a coronary ligament of the nornial knee-joint.
There was a synovial pouch between the cartilage-clad
surface of the patella and the tibial surface of the displaced
cartilage, just as in the knee between the tibia and semi¬
lunar cartilages. At the upper border of the patella, how¬
ever, the whole cartilage was for a small area adherent to
the patella. The two extremities of what appeared to be
the internal semilunar cartilage were not separated, bub
united by a firm plate of cartilage the size of a shilling.
This additional piece Jay to the inner side of the patella,
so that bhesupposed internal semilunar cartilage had rotated
round before becoming adherent to the patella, the ex¬
ternal condyle of the femur only articulating with the
tibia. There was chronic rheumatoid arthritis of the
joint. The external condyle was eburnated, and the-
external semilunar cartilage was partially eroded. The
internal condyle was clad with cartilage. Cartilages
Thb Lancet,]
CLINICAL SOCIETY OF LONDON.
[March 7,1891. 545
lipped around both condyles, especially the external.—Mr.
SiiEiLD referred to a loose cartilage which he had exhibited
laonie time ago, and which he believed had been separated
by violence. His ideas as to its causation were subjected to
much criticism at the time, but two of the cases now shown
conhrtned the view he then :put forward. Another of the
specimens looked much like quiet necrosis of the cartilage,
.and a microscopical examination should be made to see if it
■were so. The idea that loose bodies in joints might be
tubercular was new to him, although he knew that bacilli
■had been found in the-melon-seed bodies of compound
palmar ganglion. These bodies were common in chronic
(rheumatoid arthritis, and tbio affection was often found in
joints which clinically had exhibited no symptoms of that
affection.—Mr. J. Hutoiiin.son, jun., thought that the
eartilage in Dr. liolleston’s case was semilunar, and he
wondered if ever a semilunar cartilage had been found free
in a joint. Ho referred to a specimen in which a complete
■septum existed between the femur and the tibia, which he
believed to be due to an error in development, and he
opined that the displacement might be developmental in
the case shown. He related a case in which melon-seed
bodies were removed from the front of the ankle-joint of a
boy who a few months later returned with tubercular dis-
■ease of the joint itself.—Mr. Glutton said that it was a
pity that in the discussion many distinct varieties of dis¬
ease jvere being confounded. On two occasions be had
■removed loose bodies from chronic tubercular joints, and
■less than a week ago he' bad found one of these bodies
■attached to the pulpy synovial membrane. They were
never found in olden days, because the joints were
not opened until the loose bodies had caseated, softened
•down, and dissolved, coming away disintegrated in the
•discharges from the sinuses. He had removed a loose
body which was rough on one side and smooth on the other
■from a case in which there was no history of injury.—
Mr. Shkild said there was a specimen in the museum of
St. George’s Hospital where the semilunar castilage was
practically free, being held only by a thread. He thought
that Dr. Kolleston’s specimen was too small to be a semi¬
lunar cartilage.—Mr. Brodiis called attention to the fact
that the cartilage was only attached to the patella on the
outer side,—Mr. lloniN.sON said that three cases of nodular
tubercular disease bad been in St. Thomas’s Hospital
recently. In all the bodies were attached by long peduncles
■and were jn-oved to be tubercular.—Mr. Wingkave said it
was carious that the cartilage should be of the precise size of
the patella.—Mr. Marsh, in reply, thought that loose
bodies might be tubercular in a larger number of cases than
had hitherto been suspected.—Dr. Kolleston, in reply,
said that as there bad been a history of severe injury to
the join't, he. was loth to believe that the aflection was. of
•congenital origin. The smallness of the cartilage was
no doubt due to the fact that it probably did not develop
■after being displaced.—ThePRESiDENTreferred the specimen
tfor further report to a special committee.
The following card specimens were shown
Mr. E. Solly : Melanotic Sarcoma of Conjunctiva.
Dr. W. B. Hadden : Pancreas in Diabetes.
Messrs. S. G. Shat’I’Ock and C. A. Ballance : Fuohsin
Bodies in Carcinoma, Tuberculosis of Glands, and Diph¬
theria of Tonsil.
Dr. Rollk.ston (for Mr. A. A. Kantiiacic) : Fuchsin
Bodies in Rhinoscleroma and Madura Foot.
Recent specimens:—
, Mr. Wyatt Wingravb : Lungs and Larynx of a patient
treated by Koch’s method.
Dr. A.’F. Voelcker : Scurvy Rickets.
Dr. N. Pitt : Gumma of Heart.
Living specimen :—
Mr. Roger Williams : Man with Median Siiper-
aiumerary Nipple.
CLINICAL SOCIETY OP LONDON.
Jlydatids of Kidney. — Thiersch's Method of Shin-grafting. —
Fracture of Vina.—Lipoma of Nose.-—Multiple Lipo-
mata.-—Serpiginous Ttodent Ulcer of Face.— Stricture of
(Esophagus, loiih Laryngeal Paralysis. — Adjourned
discussion on Removal of the Vermiform Appendix.
A CLINICAL EVENiNGof this Society took place on Feb. 27 th,
'the President, Sir Dyce Duckworth, in the chair.
Mr. Hurry Fenwicic showed the case of a man aged
forty-six, who had a large Renal Tumour of thirty years’
standing, and had passed hydatids by ,tbe urethra for
the last five years. He also showed a second case of Renal
Hydatid in a man aged fifty-seven. In this instance the
cyst appeared to have been suppurating, as the urine at one
time contained pus, together with bacteria, phosphates, urio
acid, and small cysts. Gradually, however, the pain com¬
plained of had become less, the loin tumour began to con¬
tract, and the urine to clear. When the man was going to
pass cysts he had definite indicative symptoms. There
was first numbness of the testicle, which gradually in¬
creased to pain; the pain then travelled to the kidney, and
the testicle became better; later, when the hydatid entered
the urethra, there was tingling at the end of the penis.
After from eight to ten hours the renal pain would cease,
and the patient would pass about eight ounces of hydatid
cysts. He had had a third cose of renal hydatid under
his care, in which drainage had been followed by a good
result.
Mr. Stanley Boyd showed a man aged sixty-five, from
whose leg he had removed an Epitheliomatous Growth,
leaving a large ulcerating surface. In order to cover this
he adopted Thiersch’s method of skin-grafting, sawing off
with a razor large pieces of epidermis from the forearm, and
covering the whole of the raw surface. An antiseptic
dressing was placed over it, and the whole left for ten days,
when it was found that it had healed by first intention.
Success with the method depended upon stopping. the
hemorrhage before applying the grafts.
Mr. Peaecic Gould showed a case in which the Ulna
was Fractured obliquely through the base of the Olecranon
Process. The accident was one which had escaped the
notice of most English writers, thoiighit had been described
by French and American authors. He himself had seen
four cases. The patient he showed was aged twenty-eight,
and he fell whilst skating. The fracture started from the
base of the sigmoid notch, and passed obliquely downwards
and backwards, the fragments being held in place by the
aponeurosis. lu the first case be had seen non-union had
occurred, and the bone was wired. In the second and third
cases bony union occurred. In the case he showed there
was no bony union, and the triceps had wasted con^
siderably. The injury was one liable to be overlooked,
and if put up with tbe elbow bent at a right angle the
lower end of the upper fragment was likely to come
through the skin. It was better to put it up with the arm
nearly straight. .
Mr. Balmanno SciUiRE showed a case of Lipoma Nasi
after operation. The patient was a man aged sixty-five.
The end of the nose bad been carved off at four successive
operations, and the parts had granulated up, giving a very
good result. . •
Dr. Stephen Mackenzie showed a man with Multiple
Lipomata of twelve years’ standing. They were. first
noticed after an attack of acute rheumatism, and were very
painful at times. They were most plentiful on the ex¬
tremities, being more abundant on the forearms and legs
than on the arms and thighs.
Mr. Squire showed a woman aged fifty-four with a
Serpiginous Rodent Ulcer of the Face of seventeen years’
duration, commencing on the lower lip. He referred to the
points of diagnosis from syphilis and lupus.
Mr. Charters Symonds showed two cases of Epithelio-
matous Stricture of the Qisophagus, situated respectively
twelve inches and eleven inches from tbe teeth. There was
complete paraly-sis of the left side of the larynx, producing
a high-pitched voice.
In reopening the discussion on the cases of Removal of
the Vermiform Appendix, the President said that it was
a question of moment for the physicians to decide when to
transfer these cases to the surgeons, and for the latter to
determine how best to conduct tbe operation. It was
evident, from the large measure of success that attended the
medical treatment of these cases, that operation was not
needed in every instance, and there was a dilliculty in
deciding which should be transferred and when tiiat step
should be taken.—Mr. Langton said that the good results
which had been brought forward bore evidence of the fact
that removal of the appendix did not necessarily involve
any serious risk to life, and this may have led to too hasty
interference in some cases. A fuller experience, however,
would indicate more accurately the proper time for trans¬
ference for the iuirposes of operation. Though he had seen
a large number of cases recover completely under the care
of the physicians, there being in some no recurrence of the
disease for many years, yet he was sure that surgeiy was
546 Thb Lancet,]
CLINICAL SOCIETY OF LONDON.
[March 7,1891’.
far in advance of medicine in the treatment of this afTection.
The anatomy of the parte was accurately known, and sur¬
geons were at one as to the necessity of making the incision
either just above Poupart’s ligament or in the right linea
semilunaris. Mr. Allinghani'a incision in the middle
line had yielded, and it would be well to fit a support.
It was no doubt more difficult to wash out from a
lateral incision, but the tendency to hernia was less.
There could be no universal way of dealing with the
stump of the appendix. He (Mr. Langton) then referred
to the time at which the operation should be performed.
In the cases of acute perforative appendicitis, especially if
associated with general peritonitis, operation was clearly
called for at once. In recurrent cases with a periodic rise
of temperature, indicating probably the formation of a small
amount of pus, interference was also justifiable, but there
remained a considerable number of cases in which it was
difficult to decide. It was certainly bad practice to thrust
in a needle to search for pus ; it a^ded considerably to the
patient’s danger. It was remarkable that the great majority
of these cases occurred in young people and in males. The
large amount of adenoid tissue in the appendix explained
its liability to give way, and for the same reason the emcum
itself gave way before the rest of the large intestine in cases
where the gut ruptured from obstruction a fronte. A great
secret in the treatment was to provide free drainage. The
operative measures constituted a marked advance over the
old method of allowing the cases to drift on unrelieved, and
if there bad been such an epidemic of removal of appendices
as had been referred to, they had been taken rather from
the operating theatre, where lives had been saved, than
from the post-mortem room, where lives bad been sacrificed.—
Mr. Pearce Gould said that the subject matter of the
paper had been much discussed abroad, especially in Berlin
and in America. He could not agree that surgeons were at
one with regard to methods of treatment. The cases which
bad been described in the papers were fair examples of the
three forms of the affection, and they also represented about
the proportion in which they occurred. Ttie relapsing or
recurrent cases formed about 10 or 11 percent, of theAvhole,
and those with general peritonitis about a similar ratio.
Bub by far the largest number of cases were instances of
inllammation of the appendix associated with circumscribed
suppuration. Mr. Sutton had seemed to imply that abscess
had existed some time before the acute symptoms were
set up, bub he himself (Mr. Gould) regarded the abscess as
the result of the local disease. The inflammation which
occurred round the appendix very often not only shut off
and localised the disease, but set up an inflammation in the
appendix itself, which led to its obliteration, and the patient
might then remain free from attacks afterwards. He bad
never known a relapse after a case of suppurating appendi¬
citis. As to the treatment of these cases, the aWess should
be opened, washed out, and drained, but the appendyc need
not be removed. It was better to wait in order to see where
the abscess was forming, and then evacuate the pus by a
small incision not more than an inch or an inch and a quarter
long. This nob only weakened the abdominal wall less,
but one could never be sure of tho extent of the adhesions,
and it was certainly desirable to avoid opening the general
peritoneal cavity. All the pouches of the abscess should be
evacuated, taking care to avoid breaking down the limiting
adhesions. He referred to a case in which under palpation
the latter accident happened, and in spite of speedy opera¬
tion the patient, a child, died of acute peritonitis. He
advocated leaving the appendix, because its removal
rendered the operation more dangerous, while leaving it did
not increase the danger; also the incision must be larger,
and the risk of breaking down adhesions was greater.
There was more probability of the occurrence of ventral
hernia, and it did not of necessity remove the whole of
the disease, as gangrene recurred in the stump in one of
the coses related. In tho second class, represented by
Mr. Allingham’s case, an early laparotomy was clearly the
only treatment. He preferred a median incision, with
another over the semilunar line, which best provided for tlie
speedy exit of pus from the appendix and allowed cleansing
of the peritoneal cavity. With regard to relapsing typhlitis,
theattacks occurred very frequently; hehadknownacaaewith
as many as fourteen, and then tho patient got well; they were
therefore nob necessarily fatal if nob operated on. Nothing
could be better than the result of Mr. Sutton’s operation,
which removed a distinct source of danger, though the latter
might have been deferred for weeks or months. He was
glad to hear that the opinion which Mr. Treves had recently
expressed with regard to these cases was different from that
which he propounded at the Iloyal Medical and ChirurgicalJ
Society three years ago; for it should nob be forgotten that
there was a distinct mortality to this operation. Error in
diagnosis was frequent, and he himself bad seen one case in
which a perfectly healthy appendix was found on explora¬
tion. It probably might be safely asserted that the danger
of local suppuration if a case were left would not be greater
than the danger of the operation if the removal of the
appendix were undertaken.—Dr. J. K. Fowlee referred to*
the pathology of the affection. Mr. Treves was apparently
now of opinion that in the majority of the cases which
recovered the symptoms were due to fascal accumulation in
the caecum, followed by stercoral ulcer and inllammation of
the overlying peritoneum. Stercoral ulcer was a rare con¬
dition, generally absent in fmcal accumulation, far in excess
of that met with in typhlitis, and when present, as in
chronic ob.struclion of the large bowel, often the cause,
of perforative peritonitis, whereas in fatal cases of typhlitis
no such changes were found in the ciccum. All post¬
mortem evidence and that derived from operations was in.
favour of the appendix being the seat of the affection. That
the “ coniplete clearing up of the local signs ” could nob be
trusted to prove that the mild cases were of csecal origin
was shown by Mr. Treves’ case,^ which proved to be one of
appendicitis, although before the operation there was “no
trace of the iliac swelling,” and “the abdominal signs bad:
entirely disappeared.” He agreed with the statement that
“it could not be denied” that inllammation of the caicum
might in some cases be the cause of the symptoms, but he-
knew of no evidence pointing to that conclusion. He had
analysed the medical and pathological reports of the
Middlesex Hospital for the ten years 1880-89. During that,
period eighty-five cases had been admitted with the diagnosia
of typhlitis or perityphlitis, of which eighty-four had re¬
covered (in three fatal cases included in 1889 the diagnosis
was altered post mortem) and one had been “ discharged at
own request.” Apparently only two of the cases had been-
submitted to incision (1889). These figures showed that
“the measures generally employed by physicians’'
were not without success, and they to some extent
indicated tho degree ot need for surgical interference.
During the same period, in fourteen cases in which
the appendix was found on necropsy to be perforated
the diagnosis on admission had been (generally) peritonitis
(? typhlitis) or (?) enteric fever (one case), pyo-pneumo-
tborax, &c. In none were the signs sulliciently definite to.
allow of a positive diagnosis of typhlitis. Twelve of these
cases were fatal from acute peritonitis, in three of which-
there were old lesions about the appendix. A concretion
was found in nine cases; in six cases ib was still in the
appendix. With regard to operation, he agreed with Mi-.
Pearce Gould’s views : where the diagnosis was acute peri¬
tonitis (? typhlitis) laparotomy was indicated; and in all'
otlier cases the early treatment should be that at present-
adopted. No absolute rules could be given as to the time
for incision, but the persistence of a high temperature after
the fifth day suggested suppuration. Medical treatment in
the early stage could not be said to have failed, even should
incision ultimately become necessary, as by localising the
pus ib saved the patient from general peritonitis. He
was opposed to the removal of the appendix. Re¬
lapsing perityphlitis in a labouring man who could
not afford to rest might be treated by operation,
but other cases he thought had better be left alone.—
Mr. Charters Symonus referred to a case wliich he had
published in 1885, the patient being a young man aged
twenty-tbree, who. was subject to repeated attacks of'
abdominal pain. He bad six attacks of acute pain in the five
weeks previous to admission, and there was a rise of tempera¬
ture, with a swelling in the right iliac fossa. This swelling
subbided, leaving a lump the size of a marble, and he
was discharged. He speedily returned with another attack,
so an incision was made like that for tying the external
iliac artery, and a calculus was found in tho appendix.
The concretion was removed, the appendixstltched up, and,
though a sinus remained open for some time, the patient
ultimately got quite well, and had had no attack since. This,
he thought, was a case of relapsing typhlitis of a kind in
which operation was quite justifiable. He agreed with
Mr. Gould that it was usually not necessary to remove the
1 Mod. Cljir. Trans., vol. Ixxi., p. 171.
Tan Lancet,]
MEDICAL SOCIETY OF LONDON.
[March 7,1891. 547
vermiform appeodix, and he referred to three cases in which
43 ,fter simple opening of the abscess the patients recovered.
The abscess should be thoroughly irrigated out and a
concretion sought for, due care being taken not to
disturb the adhesions.—Mr. Jjhssett considered that the
coses which the authors had related showed that early
operation must be a proper procedure; the risk to
life was certainly not so great as if the diseased appendix
was left behind. If an abscess formed which was sliut off
from the peritoneal cavity, then the appendix might be left.
In dealing with the stump of the appendix, he suggested
that it should be invaginatod into the crecum and held there
by stitches.—Mr. Allingham, in reply, said that in both
the cases he had dealt with it was impossible to tell at the
time of the operation precisely what the condition was, and
.therefore the median incision was adopted. As a matter of
•fact, he bad found that to deal with the appendix from the
middle line was just as easy as to deal with it from the
.side. The boy ho showed had worn an abdominal belt since
the operation, and the yielding of the cicatrix was to be
explained in bis case by the special circumstances detailed
in nis paper connected with the healing of the wound. In
neither of his cases was there any localised abscess. He sug¬
gested that these cases might be divided into three classes ;
first, the very acute cases, like the two he had related,
which were severe from the beginning; secondly, the acute
cases supervening on chronic attacks ; and thirdly, the very
chronic cases. In those of the first class the sooner
•operative interference was adopted the better. In the second
class operation was also surely advisable, for he was
quite unable to understand why a man should be left with
an abscess to burst where it wished; it would be sounder
surgery to cut down over the indurated part, and let the
pus out as soon as it had formed. He bad been look¬
ing through the necropsy records at St. George’s Hos¬
pital, and had found that the fatal cases were all due
to trouble in the appendix, and not in the cmcuni,—
Mr. Sutton, in reply, regretted that his references to
the treatment adopted by physicians bad been misunder¬
stood. There hod certainly been no epidemic of removal
of the appendices at the Middlesex Hospital, and the six
cases he had related represented the whole of bis practice.
-Mr. Treves seemed to fear that the result of wholesale
removal of the appendix might lead to its suppression, but
there was overwhelming evidence against the transmission of
mutilations, consequently surgeons need not be apprehensive
that their art would sutler in that direction. Speaking as a
•demonstrator of anatomy of many years’ experience, he had
never once failed to find the appendix, though it frequently
lay out of position. The only instance of abnormality of
the appendix he had met with was in a fmtus, in which it
was represented by a dimple. Mr. Treves’ observations bore
on far too small a number of cases, and he illustrated this by
his conclusions with regard to Meckel’s diverticulum. The
appendix might be regarded as an abdominal tonsil pos¬
sessing adenoid tissue and glands, and pathologically this
.resemblance explained the morbid phenomena met with in
respect of the appendix. Many people suflered from simple
toDsillibis, and this condition in the appendix would account
-for the cases of appendicitis, which recovered under medical
treatment. Others, however, resembled tonsillar abscess in
running on to suppuration, and the very acute quinsies corre¬
sponded to sloughing appendices. He explained the greater
frequency of appendix troubles in young people by the fact
that allections of adenoid tissue generally were more
common in early life. As to the greater frequency in males
.as compared with females, he suggested that part of the
■excess might be accounted for by the fact that the sym¬
ptoms, when occurting in females, were usually put down
to perimetritis. He admitted that notwithstanding this
there would remain an unexplained preponderance of male
atients. He never opened the pentoueum intentionally,
ut made his incision over where he believed the adhesions
to exist. If he opened the abdomen, found a sloughing
appendix and failed to remove it, be believed he would be
as guilty as if he, in operating for hernia, returned a piece
of gangrenous omentum into the abdominal cavity. The
removal of the necrotic appendix shortened the con¬
valescence, did away with a source of danger, and obviated
the formation of a sinus. On the other hand, to carry out
the plan he had adopted was simply to follow ordinary
surgical axioms.—Mr. Andrew Clark, in reply, could not
feel sure that if the appendix had been left in the second
.case the result would have been any better for the patient.
MEDICAL SOCIETY OF LONDON.
General Meeting.—Cases Illustrating -Hepatic Surgery.
A GENERAL MEETING of thisSooiety washeld onMarch2nd,
Dr. Gilbart-Smith, Vice-President, in the chair.
The report of the Council for the past year was read and
adopted. The total number of Fellows had reached 744,
there being thirty-five accessions during the year. The
Society regretted the loss of thirteen Fellows by death, in¬
cluding Dr. Henry Bigelow (of Boston, U.S. A.), Mr. C. H.
Kogers-Harrison, Dr. Matthews Duncan, Dr. Gulliver,
Dr. Pearce, and Mr. Bellamy. A new scheme for the
administration of the FothergillianFund had been practically
sanctioned by the Charity Commissioners by which the
Fobhergillian medal will be awarded triennially instead of
annually, together with the sum of sixty guineas, for
original work done during the previous five years, the first
award taking place in 1893. It was announced with regret
that Mr. Poole, who had faithfully served the Society as
librarian for a period of twenty-five years, would resign on
account of bis health in the autumn. The reports of the
hon. treasurer and hon. librarian having been received and
adopted, the business of the ordinary meeting was proceeded
with.
In the absence of Mr. Knowsley Thornton through illness
his paper on Observations on Some Additional Cases illus¬
trating Hepatic Surgery was read by Mr. Marmaduke
Sheild. After recalling his two previous papers on the
same subject read before this Society in 1887 and 1888, the
author stated that the present series completed the wboleof
his practice in this branch of surgery to the end of January,
1891. He gave full notes of nine cases in which he bw
diagnosed gall-stones, had found and removed tliem in
seven with complete cure, had failed to find a stone which
was present in one, the patient dying, and the stone being
found after death in the peritoneum ; and in the remaining
case found hydatids to be the cause of obstruction instead
of gall-stones, the patient making a smooth recovery. He
then referred more briefly to seven other cases in which he
had operated and found pathological conditions having a
more or less important bearing upon hepatic surgery.
One of these was a large hyaatia cyst of the liver,
which had been diagnosed by several physicians as
disease of a much more serious character. The patient
recovered. Two were coses of malignant disease, one
a case of doubtful nature, and one of chronic pain, and
adhesion after the passage of large gall-stones. In none of
these did he consider before operation that the indications
pointed to the presence of gall-stones. In one other case he
operated, expecting to find gall-stones, hut found nothing
definite to account for the attacks of pain, and though tem¬
porary relief followed the exploration, there had been
recently fresh attacks of pain. The last case was one of
very large tropical abscess of the liver in a gentleman aged
sixty-three, in which unusually rapid recovery followed
free incision and drainage. Commenting on the whole
aeries, he claimed the results as good, and amply justifying
the operative procedures. At the same time there was suffi¬
cient uncertainty and failure to show that it was to more per¬
fect diagnosis that ourattention must bedireeted. This would
be greatly aided by more frequent exploration in doubtful
cases. He dwelt upon the important points in the diagnosis
of gall-stones while still in the bladder, in the cystic duet,
and in the common duct, and emphasised from two pf the
cases recorded the danger of attempting to force the stones
through by massage ; and also nointed out that adhesion of
the gall-bladder to the right kidney was a potent source of
error in diagnosis, both from the position of the swelling and
the sympathetic renal symptoms induced. He claimed three
entirely new departures in this branch of surgery: 1. Direct
incision of the common duct and removal of the stone, with
complete suture of the opening without opening the gall¬
bladder. 2 Incision into the common duct, needling the
stone into fragments, and closing the duct over the frag¬
ments, leaving them to find their own way into the
duodenum. 3. Leaving the gall-bladder open in the peri¬
toneum with efficient provision for drainage through the
abdominal incision in cases in which it is impossible to
suture it into the abdominal wound, and not advisable to
attempt complete intra-peritoneal suture. In the' latter
cases, and in all cases where fouling of the.peritoneuni was
possible, he strongly advised a counter opening above the
548 The Lancet,]
SOCIETY OF MEDICAL OFFICERS OF HEALTH.
[March 7, ISOT.
pubes, and additional drainage by means of a glass tube in
tbe pouch of Douglas.
Sir Joseph Fayreb congratulated the author on includ¬
ing the unfavourable as well as tbe favourable data with
regard to his cases. He himself had seen practically
nothing of the surgery of the gall-bladder, but he had had
a very large experience of hepatic abscess. He quoted two
cases of calculus of the gall-bladder in which nature had
relieved herself; one patient came to him with a history of
long trouble in the hepatic region and a sinus at the
umbilicuB. He recovered completely without operation,
passing twelve gall stones by way of the umbilical opening.
Another case was that of a lady, the wife of a medical
man, who was very D1 and suffering from severe hepatic
colic and jaundice. On deep palpation an enlarged gall¬
bladder was felt, the outline of the stones being distinctly
perceptible. He advised waiting a day or two before opera¬
tion, and during this time all the gall-stones were passed
by the bowel, the manipulation for the purpose of diagnosis
having probably dislodged them.
Dr. Gilbart-Smith, speaking of massage, w’as reminded
of a case which he had seen seven years ago. An old
gentleman was at the point of death and complained of
abdominal pain, and presented a hard lump in the neigh-
bonrbood of the gall-bladder. Malignant disease had been
diagnosed by others, hut after examination he himself, in¬
clining to the belief that it was gall-stone, ordered gentle
massage over the neighbourhood of the swelling, with the
local application of hot fomentations and tbe administra¬
tion hypodermically of strychnine and digitaline every two
hours to stimulate the failing heart. Two days later he
p^assed a large gall-stone, and had since remained well.
The frequency with which patients, after abdominal pal¬
pation, passed gall stones which had previously given
trouble suggested that massage in many cases might be
rightly and beneficially employed. To illustrate the value
of exploration in abdominal disease he related two
cases. A patient with pyloric obstiuction died within
a week of his first seeing him ; malignant disease had
been diagnosed and operation advised against. At the
necropsy a duodenal ulcer was found caused by an impacted
gall-stone. Some years later this patient’s brother came to
consult him, suffering from a condition which had been
diagnosed as cirrhosis and ascites. But absence of alcoholic
history and the peculiar character of the abdomen on per¬
cussion were against this idea. Fluid of an inflammatory
character being withdrawn, a tumour in the epigastrium
presented itself, which was variously diagnosed as abscess,
malignant disease, and enlarged spleen. A week later,
under exploration, eleven pints of dark-green fluid were
evacuated, which proved on examination to be decompo.sed
blood. The patient recovered, a result which could hardly
have been hoped for had it not been for the exploration.
He referred to one other case where a cyst was opened
which was thought to be hydatid. It was really connected
with the kidney, and it unfortunately drained into the
peritoneal cavity, leading to a fatal result.
Dr. Althaus said that one of the syphilitic cases referred
to had since come under his care, and was progressing
favourably under antisyphilitic remedies.
Mr. John Taylor of Birmingham said that his expe¬
rience of hepatic surgery was mainly confined to the opera¬
tion of cholecystotomy,'which, though not needed in quite
so many cases as he had at one time thought, was useful in
obstinate instances of biliary colic, in cases of distension
due to obstruction of the cystic duct, and in suppurative
cholecystitis. Phosphate of soda be had foimd to relieve most
cases of hepatic colic arising from biliaiy calculi. In cases
of_ calculus impacted in the cystic duct, when all efforts to
seize it or break it from within had failed, three resources
remained: either to crush it from outside the duct, or to
extract it through an incision in the duct, or after chole-
cystotoray to inject fluids which were either solvent or
helpful towards spontaneous cleavage or removal. The two
former methods he looked upon as dangerous, whereas the
third in his hands bad proved ellicienfc. He injected a solu¬
tion or emulsion of the tauro-cholate of soda twice a day
into the gall-bladder, and this speedily produced separation,
breakage, and evacuation of the impacted stone. The
removal of the obstruction was indicated by the discharge
of bile from the wound, and the incision, as a rule, healed a
few days later.
Mr. M. SHJilLD referred to Murchison’s remarks on the
similarity between hepatic gummatous projections and
cancer formations. In a young man presenting hepatic
nodules the thought of syphilis should ever he present, and
mercurials with iodide administered for the purpose of
diagnosis. He related a case which he had seen two years-
ago whicli had been pronounced to he of a cancerous
nature, but in which the adoption of this method of treat¬
ment led to a favourable issue.
Dr. Sidney Coupland had had no personal experience-
of the treatment of gall-stone in the ways suggested by the
author. Evidently a considerable advance had been made,
when not only were dilated gall-bladders attacked, but the
bile duct itself had been successfully dealt with surgically.
It was a question how long patients should be allowed to
suffer with hepatic colic before being submitted to surgical
treatment.
The following officers were elected to serve during the-
ensuing year:—PresidentDr. Richard Douglas Powell.
Vice-Presidents : Drs. Stephen Mackenzie and W. H.
Allchin, and Messrs. Reginald Harrison and \Y. Rose.
Treasurer: Mr. A. E. Durham. Librarian : Dr. W. H.
Allchin. Honorary Secretaries: Dr. T. Colcott Fox and Mr.
A. Matmaduke Sheild. Honorary Secretary for P’oreign Cor ¬
respondence: Dr. Jean S. Keser. Council : Drs. Frederic
Bradshawe (St. Leonards), T. Churton (Leeds), C. J.
Cullingworth, A. E. W. Fox (Bath), G. Allan Heron,
Donald W. C. Hood, Percy Kidd, Isambard Owen, C. E.
Sheppard, and Messrs. H. W. Allingbam, C. A. Ballanre,
J. Astley Bloxara, W. Watson Cheyne, Alban Doran, D.
H. Goodsall, W. F. Haslam (Birmingham), C. Bell Keetley,
Stephen Paget, Bernard Pitts, and J. Knowsley Thornton.
SOCIETY OF MEDICAL OFFICERS OF HEALTH.
The Preseni Position of Disinfection.
A MEETING of this Society was held on Feb. 13th, Mr.
H. E. Armstrong, President, in the chair.
Mr. Wynter Blyth, in introducing this question,
wished to confine his remarks to one important change that
our ideas on the subject had undergone within the last few
years. When Professor Koch, in 1881, gave to the world
the first results of his inquiries into the relation of micro¬
organisms to disease, it was the general inference that-
athogenic microbes, or those concerned in the propagation of
iseases of the infectious kind, were exclusively or nearly
so of the spore-hearing class, and that, since the sporea
of all such organisms possessed great inherent vitality,
no so-cailed method of disinfection could be deemed tho¬
roughly efficient which did nob succeed in destroying the-
vitality of the spores of bacillus anthracis, the most
resistant of all. Now, however, that the nature of patho¬
genic microbes was no longer a matter of conjecture, those-
of most specific diseases having been identified, it was found
that the bacillus 'anthracis could not be looked on a&
typical of the whole class, since the greater number, in¬
cluding such well-known forms as those of cholera, enteric
fever, epidemic diarrhoea, septicoamia, and erysipelas,,
were not sporiferous, but occurred as micrococci, strep¬
tococci, or bacilli; very feebly resistant to heat , or che¬
mical agents. It was therefore unnecessary to liave re¬
course to powerful chemical substances, the use of which was
attended by obvious practical difficulties. In a paper read
before the Royal Society he had pointed out the importance
of temperature, time, and space as factors, and had shown
that under appropriate conditions such simple measures as>
limewashing and aeration were in moat cases amply suffi¬
cient for disinfection. Recent experiments, as those of
Behring and of Pfuhl, published in tbe Zcitsch. f Byg.,.
had proved the remarkable efficacy of lime. Boer had
observed that while the addition of very small quantibien
of lime to culture fluids greatly favoured the develop¬
ment of the bacteria, larger quantities or the equivalents-
of potash or soda, producing an alkaline reaction equal
to what was known as 50° of normal acidity, were
speedily fatal to ail pathogenic organisms in any form othei-
than the spore. Thus the strongly alkaline soft soaps were
far better germicides than the much vaunted carbolic,
thymol, or terebene soaps, and stripping off the wall paper,
limewashing of walls and ceiling, with scrubbing of the
floors and woodwork.of a room with soft soap, were gene¬
rally sufficient for all the purposes of disinfection. Lime^
from its power of absorbing sulphur compounds and other
offensive gases, while it was itself inodorous, was speci-
Diy..-■ >g
The Lancet,]
NOTIINGHAM MEDICO-CHIRUEGICAL SOCIETY.
[March 7,1801. 549
ally suited as an application to the contents of street
guileys, in the removal of disinterred corpses, i-n mortu¬
aries, and in nearly all cases in which it would not cause
the evolution of ammonia. For deodorising stable manure
and excreta he thought that the acid sulphates, which
would fi-x the ammonia, and not detract from the
value of the manure, would be found preferable to carbolic
powders, In the disinfection of rooms he now believed that
sulphur fumigation was a useful addition to limewashing
*&o., though at one time he was very doubtful as to its
eificacy ; but he held that all disinfection should he com¬
posite. He was inclined to the belief that the danger of
infection being carried by the clothing of persons visiting
the sick had been exaggerated. He did not deny that it
might be conveyed by attendants who had been, so to say,
“soaking” all night in the poisoned atmosphere, but it
was quite a different matter with medical men and in¬
spectors, whose exposure to the infection was of short
duration.—Dr. SwBTB called attention to sec. 5, subs. 3
oLtbe Infectious Diseases Prevention Act, and described his
practice of fumigation with sulphur and hob limewashing,
not whitewashing. He considered that the state of the'
atmosphere, especially as regards humidity, had an impor¬
tant influence in the conveyance of infection on the
person.—Dr. Sykes narrated his experience of the immense
value of quicklime in the removal of 2000 bodies and 4000
tons of the most horribly offensive earth from Sb. James’s
churchyard, in the parish of St. Pancras, to the extras
muial cemetery. As the ground was opened quick¬
lime was thrown in, and the stench at once ceased.
The eol'fins were placed in wooden cases with lime,
and at first lime was spread over the loads of earth;
but complaints being made by the residents in the streets
through which the carts passed, he substituted clean earth,
when no more complaints were raised. The graveyard had
been closed for twenty years, and the condition of the
bodies was awful; indeed, without the lime the operation
would have been impossible. He objected, however, to the
use of lime in mortuaries, preferring to irrigate the place
with a 50 per cent, dilution of Burnett’s fluid, which was a
4 per cent, solution of zinc chloride, a powerful disinfectant
and quite inodorous. He called attention to a description
in the first number of the HygieniscIiG Bundschau of
the admirable arrangements of the refuges recently opened
in Berlin, where the persons admitted were treated to a
bath while their clothing was being disinfected in a steam
chamber. Recent German researches appeared to establish
the superiority of current to pressure steam, the steam
being admitted above, and its temperature observed at its
exit below.—A gentleman suggested that the advantages
of current and high-presaure steam might bo combined by
making the aperture of exit smaller than the inlet, or by
fitting the two pipes with safety valves of unequal power.—
Dr. Willoughby supported this suggestion, fearing that
current steam might otherwise tend to follow the lines of
least resistance without penetrating the entire mass of
bedding &c.— Mr. Hollinshead said that in the midlands
the removal of midden refuse and the contents of
pails was a serious question. He used a mixture of
powdered .sulphate of iron and sulphate of lime, which he
found both clieap and eil’ective.—Dr. Caiger, as medical
officer to two large fever hospitals, had frequently had to
disinfect wards, the walls of which had been saturated for
months with the poison of one or other fever. He used soft
soap and limewashing, followed by free aeration, and had
never found the patients subsequently admitted contract the
fever that had been treated in the same ward previously.
He did not use .sulphur fumigation. There were regulations
as to bathing and change of clothing by nurses going out
of the hospital; but, looking to the fact that at certain
times one could not expect a woman to take a bath before
going out of doors, the regulations in respect of bathing
were in some cases a dead letter. Yet though ho had
given 12,000 passes in one year, he was not aware of
any infection by their means. In the laundry clothes were
exposed to steam for twenty ininirtes before soaping.—
Dr. Gibbon, when in the countiy, had often known
scarlatina carried out by nurses to the neighbouring villages.
He objected to odorous disinfectants as likely to conceal
instead of destroying other odours, and he was surprised
that no mention had been made of corrosive sublimate, the
most powerful and inexpensive of all disinfectants.—
Dr. WooDFOORU observed that he alway.s employed it.—
Dr. Newsholm recommended it for the disinfection of
enteric stools.—Dr. Caiger believed that persons who had
for weeks breathed an infected atmosphere continued to
exhale the poison for some days afterwards, and that thus
the frequent experience of fevers being propagated by
discharged patients, notwithstanding the thorough disin¬
fection of their persons and clothing, might be ex^ained.—
Dr. Verdon invited inspection of the disinfecting chamber
at Lambeth, where steam was injected into a Neville’s
baking oven, the temperature of which had been previously
raised to SGO^F., the iron trays &c. being covered with
asbestos to avoid the scorching of clothing &c.—The
President deprecated any hasty expressions of opinion
such as might be calculated to put the public off their
guard. It was also a question whether lime might not
occasionally act as a preservative of infection.—Mr.
Blyth, in replying, insisted that all recent research
tended to show that time was a most important factor.
Given unlimited time, comparatively low temperaiures
were effective, and intermittent heating below 100° C. might
be well employed in the disinfection of such articles as kid
gloves, which would be damaged by higher temperatures.
In connexion with Dr. Caiger’s last remarks, he referred to
Oertel’s discovery of the bacillus of diphtheria in the throats
of convalescents three weeks after apparently complete
recovery, and suggested that juch might be the case also
with scarlatina. Puerperal septiemmia was, he believed,
mostly communicated through the finger-nails of the
medical attendant, a source of danger not obviated by any
change of clothes or ordinary bathing.
NOTTINGHAM MEDICO-CHIRTJRGICAL
SOCIETY.
A MEETING of this Society was held on Wednesday,
Feb. 4bh, Mr. C. H. White, President, in the chair.
Abdominal Section for Inflammatory Diseases of the Pelvis.
Mr. Miciiib read a paper on this subject, and gave among
other statistics particulars of twenty-nine recent cases in his
own practice, with but one death. He laid stress upon the
necessity of avoiding as far as possible manipulation of the
intestines, of providing free drainage, and of evacuating the
bowels after operation by the careful use of enemata. He
was opposed to the use of saline purgatives for this purpose.
In his practice the results obtained by such treatment had
not been nearly so favourable as those attending the former
method. Having described the various forms of pelvic in-
llammation, he stated that te omitted pelvic cellulitis from
the list because he had never met with a case.
Fibrinous Casts. —Mr. F. M. Wright exhibited Fibrinous
Casts expectorated by a male patient aged twenty, still
under his care, with plastic bronchitis. The first attack
had occurred two years before, and between this and the
last there had been occasional slight recurrences. The
symptoms were never very serious or acute, but the material
expectorated was always more or less fibrinous in character.
One curious physical sign was a shrill whistling sound to be
occasionally heard over .affected patches of lung.
Aspirationfor ChronicSanguineousPcricardiallCffusion —
Dr. Handford related this case, which occurred in a miner
aged twenty, who was admitted conjplaining of vomiting
and pain at the stomach. There was never any precordial
pain or difficulty in swallowing. He had nob had rheu¬
matism or other serious disease. His illness began four
months previously and kept him in bed nine days, After
that he worked a fortnight. Subsemiently he kept
his bed more or less till admission. The sickness was
soon relieved, but he continued to complain of pain
and distension at the epigastrium. The liver was
greatly enlarged, but not tender ; vertical dulness six inches
and a half. He had slight cough. The pulse was very
small and irregular. There was an area of dulness extend¬
ing from the first left intercostal space to tlie sixth rib, and
from a variable distance to the right of the sternum to the
mid-axillary line. Over this area the breath sounds were
audible in varying degrees of intensity, and the heart
sounds were feeble and distant. There was no impulse, and
the apex could nob be localised. The left back was hyper-
resonant and the breathing bronchial. The urine was free
from albumen. The temperature continued normal. Peri¬
cardial effusion was diagnosed, and he was treated by rest
and iodide of potassium After a inonlb general tedema of
DIg: zod i./
650 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[March 7,1891.
the extremities and aseites came on. Aspiratinn of the
pericttrdium was contemplated, but it was decided to wait.
The abdomen was tapped, oigitalis was added to his
raedicioe, and in ten days all his rodema was gone. For
some time he improved in general condition, but the
physical signs did not alter. On Jan. 10th he rapidly
oecame faint and pulseless without known cause. In
two days, by the assiduous use of warmth and stimulants,
he had considerablv improved, and it was decided to
aspirate the pericardium. A fine needle was entered in
tile fourth space about one inch outside the nipple and on
the same level. Eleven ounces of coffee-coloured fluid were
removed, when the pulse began to llnttsr, and it was
thought wise to withdraw the needle. He was much re¬
lieved for two days, but became collapsed again, and died
three days and a half after the tapping. At the necropsy
the pericardium occupied almost the whole of the left chest,
the lung being invisible from the front, collapsed, and
pushed to the back. The pericardium was much thickened
and the sac contained over forty ounces of fluid as described,
making more than fifty ounces in all. The heart was small
amd covered with shaggy lymph. The mark of the punc¬
ture could not be traced, and there bad been no leakage of
pericardial fluid into the pleura. There was extensive
perihepatitis. As the peri^rdium was evidently quite in¬
capable of absorbing, Dr. Handfurd's chief regret was that
he bad not aspirated much earlier and removed more
fluid.
Thrombosis of the Vertebral and Basilar Arteries —Dr.
Handfokd showed this apeeimeo, which was taken from a
man aged sixty, who had had syphilis many years ago. J
Failure of sight had been coming on for ten years. There*^
was some atrophy of both discs, remains of syphilitic
choroiditis, slight retinitis pigmentosa, and a few bright
spots, probably cholesterin. There were no hicmorrhagea,
no hemiahopia, and no ocular paralysis. The pupils
were equal, and reacted to light and accommodation. Six
weeks before admission he had what ho thought was a
bilious attack, accompanied by severe occipital headache,
which had continued ever since. Within forty-eight hours
right hemiplegia became complete There was no loss of
consciousness. The face appears not to have been allecbed,
and there was centainly no aphasia-or breathlessness. But
for several days difficulty of swallowing was gi-eaf. This
afterwards completely passed off. Ou admission tire leg
had improved so that he could stand and walk with
assistance, and the arm was gaining power. The
radial and temporal arteries were not much thickened.
There was no paralysis of the Ups or tongue, but the
soft palate and larynx were unfortunately not examined.
The very gradual onset pointed to thrombosis rather than
embolism or hmmorrhage. .The difliculty of swallowing
localised the lesion to the pons and medulla. The history of
syphilis and the choroiditis suggested syphilitic arteniis as
the cause. He was treated with iodide of potassium and
saline aperients. The paralysis continued to improve, and the
headache greatly diminished. But after a fortnight he had
a sudden attack of uneonsciousneFS, and died in twenty
minutes. At the necropsy the left vertebral, which was in
the same straight line with and formed the main supply of
the basilar, was blocked by an old-standing, adherent,
partially decolourised clot. The right vertebral showed a
quite recent thrombus, and the upper end of the basilar
was also occluded. There was some opacity of tho mem¬
branes, subarachnoid effusion, and a small quantiiy of fluid
blood under the arachnoid on the upper and posterior part
of the cerebellum. No softening could be detected by the
naked eye. All the vessels at the base of the brain were
more or less thickened by syphilitic arteritis. The kidneys
were somewhat granular. The cause of his sudden death
was apparently tho blocking of the second vertebral and of
the basilar, causing aommia of the respiratory centre.
A special meeting was held on Feb. 20L]i, Mr. C. H.
White, President, in the chair.
Dr. W. S. Playfair delivered an address upon the
Neurotic Complications of Uterine DiseaFO, in which he
uttered a warning against the irrational treatment of
more or less imaginary physical ailments of the female
generative apparatus, followed by a description of neuras¬
thenia arising from a combination of conditions especially
common in partarient women. In conclusion, be described
bis own trea'/ment for the latter conditions especially
following principal headings—viz, altered surroundings,
rest, nursing, massage, electricity, feedirg. Daring the
delivery of the address photographs were exhibited illus¬
trating the remarkable impruveiiients brought about by
this system of treatment in suitable cases,
A vote of thanks to Dr. Playfair, proposed by Mr. Joseph
White and seconded by Dr. Ransom, was carried with
acclamation.
MANCHESTER CLINICAL SOCIETY.
At the meeting held on Feb. 17bh, Dr. Braddon, President,
in the chair, the following communicatious were made :—
General Cystic Degeneration of the Kidneys. —Dr. Bucklby
reported a case of this kind in a woman aged forty-two.
The patient when admitted into the Clinical Hospital was
suffering from symptoms simulating bowel obstruction,
the colon being greatly distended with solid fmcal accumu¬
lation, which obscured the recognition of renal enlargement
until emptied. At first there was a complete absence of
symptoms pointing to kidney mischief, the urine being free
from albumen, blood, or pus. Three days before death
albumen was present, the appearance of which was quickly
followed by uricmic convulsions in one of which she died.
The intellect remained clear between the attacks, uncmic
coma never supervening. Both kidneys were found to have
undergone complete cystic degeneration, the cysts varying
in size from a pea to a walnut. Tlie cysts contained a
serous-like fluid varying in colour from light yellow to deep
purple. The fluid contained B.lbumen, bub showed an
absence of urea and uric acid. The left kidney weighed
23 cz. and tho right 22 oz. Similar cysts were also found in
the liver. No trace of hydatids could be found. Tliere
was also disease of the aortic and mitral valves, with left
cardiac hypertrophy.
Treatment of Prostatic Itetention of Urine. —Mr. SOUTIIAM
made some remarks on tliis subject, and mentioned two
cases where, ordinary palliative measures having failed
to give relief and self catheteriam being impracticable, riie
patients had regained the power of voluntary micturition,
in one instance after division, in the other after removal of
the obstructing portion of the prostate gland through a
supra-pubic opening.
Peritonitis. —Dr. Hutton read notes of a case of perito¬
nitis occurring in the course of an attack of tuberculosis,
treated by incision and free drainage, with very satisfactory
results In commenting upon this case, Dr. Hutton
mentioned others in support of his contention that it is by
no means uncommon for all the symptoms of tuberculosis
to subside and for health to be restored in cases where the
peritoneum, the luncs, and even the meninges of the brain
have been the seat of di.sease.
Dr. OWRN made some remarks upon the treatment of
Spasmodic Aflections in Childhood, and showed several
cases—Dr. Hill Griffith showed a case of Vascular!?)
Protrusion of the Eyeball.
|{ri)id«s iiiilr lloticcs of fioolis.
Studies of Old Case Books. By Sir James Paget, Bar^
London : Longmans, Green, & Co., and New York.
1891.
It was good reading for the profession when the Messrs.
Longman intimated a few weeks ago that they were about
to publibh some results of Sir James Paget’.s dip into hisold
case books. Medical practice is a mine of experience, and
the case book of any ordinary observant and intelligent
practitioner, whose term of practice has extended over
forty years, would repay examination-. How much more
the records of the cases seen by such a student of nature
and of disease, or perhaps of disease as a part of
nature, as Sir James Paget. He, it is true, in tho
preface—tbat most important part of a book, in which the
author most reveals his mind—makes light of the value
of old case books, his own amongst others. He
argues that the reports of the daily progress of his cases
forty years before the introduction of the antiseptic system
Dir'
The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
March 7,1801. 551
would be well-nigh useless and uninteresting. But m’c
scarcely subscribe to this conclusion—which is partly qual tiled
indeed by Sir James Paget’s own remark that "they would
give evidence of considerable success under treatment which
would now be justly deemed utterly negligent.” Whether
they supply evidence in this happy direction, or only show
that the success in any given class of cases was less then than
now, they would still he full of instruction and interest. It
may, indeed, be confidently (aid that in the literature of
our profession we have too few “case-books.” We might
in this gather a lesson from the lawyers, who so quickly
and patly refer one to “cases.” Our “ Practice of Physio ”
is boo much systematised, too mechanical, too much cut-
aod-dried. Hence our disappointment in actual practice to
find descriptiou that does nob ht living and actual cases.
It is the genius of men like Sir James Paget which gives life
and nature to our notions of disease, which reproduces cases
in their flesh-and-blood form and connexions, and in their
details. In this view we hail the Studies from the “Old
Ca’e Books,” which, for want of leisure, ceased to be
written much after 1870.
The mere enumeration of the heads of the chapters of
the “ Studies ” will be the best indication to our readers of
the varied nature of the contents of this book, with the
remark that the chapters consist not so much of the history
of cases as of comments suggested to the thoughtful mind
of the author by tlie chief facts of them. The chapters are
seventeen, and are thus headed : I. Periostitis following
Strains. 11. Diseases of the MebabarsO'phalangeal Barsfe.
III. On Some Diseases of the Corpora Cavernosa Penis.
IV. On Spines Suspected of Deformity. V. Obscure Cases
of Caries of the Spins. V f. Perforating Ulcer of the Septum
of the Nose. Vfl. The Detection of Abscess. VIH. Errors
in the Chronomebry of Life. IX. Ilesidual Diseases.
X. Diseases of Structure due to Disturbance of Nerve Force.
XI. Diabetic Gangrene. XII. Subentaneous Ulceration.
XIII. Ununited Fractures in Children. XIV. Swellings
abovetheClavicle. XV, An Irregular Pulse. XVI. Single
Rare Cases. XVH. Use of tlie Will for Health. Such is
the rich store of redcction and experience provided for the
readers of this volume. We are far from believing, how¬
ever, that it exhausts the interest or the lessons of Sir
James Paget’s “Old Case Books.” It may be that bis
own leisure or diepoaibion for working at the mine may be
limited ; but it would be well if lie would think seriously of
further dips into the treasury, either personal or vicarious,
with the view of bringing out of it things new and old.
No advance in either pathology or treatment much aflects
the value of the experience and observation of such
minds as Sir James Pageb’.s. llebcrden’s commen¬
taries are as valuable to-day as if Bright and Addison
had never lived, and all the triumplis of antiseptic
surgery do nob lessen the value of the worlc.s of John
Hunter. We will nob attempt to discuss in detail the
above chapters, or bo bake from the freshness of them by
any analysis of their coubenbs. The study of them will
make every man more likely to achieve accuracy of diagnosis
and wisdom of treatment and forecast, not only in regard
to the particular groups of disease under discussion, but in
the very habit and attitude of his mind in the daily practice
of his profession. If wo may single out individual chapters
that have most interested ns, we should specify the first on
Periostitis following Strains; the fifth, on Obscure Cases
of Caries of the Spine; the eighth, on Errors in the
Chronomebry of Life; and the ninth, on Residual Diseases.
The fundamental virtue of Sir Janres Paget’s description
of cases is in his quick and strong sense of what we may
call the physiology of disease and the relation of facts
and cases which to common or careless observation .seem
altogether unrelated.
Studies in Statistics: Social, Political, and Medical. By
Georqe Blundell Lonostaef, M. A., M.B., Cert. Pre¬
ventive Medicine, Oxon., F.RC.P. With Maps and
Diagrams. London: Edward Stanford. 1891.
[First Notice.]
The true and sufficient reply to the oft-quoted allegation
that one can prove anything by statistics is that without
them one can prove nothing. This book might not in¬
appropriately have been styled Studies in Demography, for
it deals with the vast problems affecting or arising out of
the life conditions of peoples as deduced from a study of
statistical data.
Tlie nature, scope, variety, and thoroughness of this
volume make a notice of it an emharraesing task to the
reviewer. To afford anything like an adequate idea of the
book presupposes the possession on his part of considerable
analytical power and painstaking. But we fear that even
then the result would, after all, prove inadequate, save by
the absorption of an amount of space altogether beyond the
limits at our disposal. “Studies in Statistics” might be
thdught abstruse and uninteresting ; but these studies
raise so many points, are so suggestive of thought,
and the facta are sot forth with such perspicuity
that many readers will feel that they are taking part,
as it were, in a personally conducted tour through new
countries, and prospecting the future from the appearances
of the present. The author wisely decided not to overload
his work with long arrays of figures and tables. Foi these
he has substituted maps and diagrams for the most part,
and by a free use of the graphic method he has rendered his
treatment of the subjects in hand clear, purposive, and
attractive. The care and labour bestowed in their produc¬
tion and in that of the work itself must have been very
great. As the author says in his preface, the numerous
and voluminous reports on the very dusty shelves of the
library of the Statistical Depoi-tmenb of the General Register
Ollice form a vast reservoir, into which a ceaseless stream
of facts has been llowing for more than half a century. To
disturb the dust upon those shelves; to sort out facts; to
group, arrange, compare, and ponder over them, has long
been his hobby. Nor have his labours been circumscribed
within these limits. They have been extended into con¬
siderations- of the phenomena of human life as these are
unfolding themselves in other countries, communities, and
races—the growth, fluctuations, mlgi-ations, and food sup¬
plies of populations, the admixture of races, and, by a legiti¬
mate exorcise of the scientific imagination, the potentialities
and probable political influences of these factors on the
future history of the race.
The fust three chapters are introductory in character'.
Chapters IV. to XII. consist of an exposition of the more
striking facts and results of the growth of population in
Europe, America, and the British colonies within the lost half
century; Chapters XIIL to XXI. are mainly technical and
medical; and a short concluding chapter closes with the
following paragraph: “ My hope throughout has been that
increased knowledge of facts, alike in matters political and
matters medical, may tend to make legislative and ad¬
ministrative efforts more reasonable, and lets empirical.
Some progress is more likely to be attained by the diligent
and patient study of details than by the more showy and
more attractive method of a priori speculation, which is
but too apt to lead to rash and possibly disastrous experi-
mon ts.”
A careful perusal of this book would no doubt he profit¬
able as a preparatory course of study to many a would-be
philanthropist provided with some brand new scheme for
ameliorating the social condition of the masses. It would
serve to indicate, at any rate, the complex nature and vast
scope of the problems that have to be solved.
Dig::'=Jd by LjOOglC
562 The Lancet,]
ANALYTICAL EECOEDS.
[March 7,1891.
In the first essay on Death-rates, the author, speaking of
the difference between the sexes in this respect at certain
periods of their lives, remarks that the well-known greater
length of life attained by women to a large extent accounts for
their numerical excess in this country, and that their occupa¬
tions, habits, and probably some constitutional differences,
account for this superior longevity ; but he does not see his
way to explain satisfactorily the great excess of mortality
.of male infants in the first year of life (which almost
disappears during the second), unless it depends upon
some constitutional difference. The author points out
and explains the sources of fallacy underlying the vulgar
notion that a high death-rate is no proof of sanitary defects,
but is attributable to, and can be accounted for by, the
high birth-rate, since the mortality of young infants is
well known, and large towns giving high death-rates have
also commonly excessive birth-rates. And as regards the
assertion that epidemics do not, on the whole, materially
affect the general death-rate, since their action is to kill off
those who would have died from some other cause had there
been no epidemic and those who were already in bad or
feeble health, with the result of lowering the death-rate for
the years immediately following. Dr. Longstaff properly
remarks that, while there may be some truth in these
assertions, the permanent injury to the constitution of those
attacked by the epidemic has to be borne to mind. We have,
in short, to deal not only with the killed, but with the
wounded. He then proceeds to illustrate this and the effect
of epidemics on the general death-rate. The cholera epi¬
demic of 1849, and the terrible sufferings of our troops before
Sebastopol in the w'inter of 1854-.5, were the main causes of
that movement in public opinion in favour of sanitary legis¬
lation and improved sanitary practice which has resulted in
our remarkable freedom from serious epidemics and a
striking fall in the death-rate in the last fourteen years.
Chapter IV. deals with the growth of population in
■England, Chapter V. with the migrations of the people in
the nineteenth century, and Chapter Xf. with the popula¬
tion of London and its migrations. The facts and figures
contained in these sections will essentially concern the
members of the proposed Koyal Commission on Labour,
The recent increase of population is absolutely enormous ;
such an increase has taken place during the last fifty years
in Europe and in the new worlds of the west and south as
has never been seen before. The opening up of new land
and new countries afforded unlimited employment and
supplies of food, and the great expansion of the nineteenth
century is not only exceptional, but absolutely unique.
Dr. Longstaif aum.s up the causes that have led to the
remarkable developments of the past fifty years in a
sentence. The application of novel mechanical appliances
has rendered possible an unparalleled increase of population
by bringing within reach unlimited supplies of food.
As regards births, England and Wales alone add 1000 a
day to the population of the world. It is shown in a table
that the natural growth of population in London is 133 a
day, reinforced by thirty-two daily immigrants, mostly
from the country districts. Assuming this rapid produc¬
tion of human beings to continue unchecked to the be¬
ginning of the next century, accommodation will have to
be found in England and Wales by a.d. 1901 for some seven
millions more persons than were enumerated at the last
census, and more than half of this addition will be given
to our already teeming cities and towns, the balance
going to make up what may be conveniently, rather than
accurately, styled our rural population—painfully sugges¬
tive, as Dr. Longstaff remarks, for the future of the people
of England, if a comparison be made between the aspect
and physique of our country and town-enlisted military
and militia recruits.
On page 29 an estimate is given of the new public build¬
ings that will be required by 1901 for the vastly increased
population. And on the same page the earnest attention of
economists is called to one of the results of modern legisla¬
tion, with its increasing tendencies to State socialism and a
“progressive” policy. Between 1875 and 1887 the National
Debt was reduced by some 32J millions sterling—a very
satisfactory result for twelve years. But during the same
period the indebtedness of the local authorities of England
and Wales alone increased by no less a sum than 94 millions
sterling. During the eight financial years 1880-88 the
amount levied in rates has been increased by nearly 23 per
cent.
MILK STERILiaSD BY THE PROCES.S OF NBUHAUSS,
GRONWALD, AND OEHLMANN.
(ACKNT IN London: F. H. Goti-lieh, Yeddo Guanoe,
Lewisham Pahk.)
The increasingly important subject of the su'pfily of
milk free from infection has received considerable atten¬
tion on the part of the patentees of this process. They
have made a praiseworthy attempt to deal with the diffi¬
culties which have hitherto baffled earlier experimenters,
and much of the success achieved depends upon their correct
interpretation of the cause of previous failures. The
sterilising agent employed in this process is purely and
simply steam, and the milk is submitted to its action in
open bottles, and the stoppering of the bottles is accom¬
plished during the exposure. A preliminary warming
of the milk is, however, a fundamental part of the method,
as while this brings about a temporary preservation of
the milk, it also incites the germs of bacteria, especially
those of a tenacious character, as the potato bacillus or the
hay fungus, to development, thus ensuring their destruction
in the condition of organism by subsequent treatment with
steam. As regards the quality of the milk, better could not
be desired, as a glance at our analysis will show, while the
flavour can scarcely be distinguished from that of fresh
cow’s milk but for a very slight boiled taste. The milk was
kept in a warm corner of our laboratory for a month without
undergoing any apparent change as long as the stopper was
not removed. Even after this the milk kept perfectly sweet
for several days. The only drawback we find is the diffi¬
culty of getting the cream, which separates into clots, to
mix satisfactorily again with the rest of the milk. The entire
absence of antiseptics was confirmed. Analysis: Non-fatty
solids, 9‘49 per cent.; fat, 3‘‘J0 per cent.; mineral matter,
0'88 per cent.
ANGEL WHITE TOILET POWDER.
(Geo. C. Blackwel!,, Liveiu'Ooi..)
According to the results of our examination of this
powder, it may justly be regarded as a specially refined
species of fullers’ earth. The powder, which is beautifully
white and free from harmful ingredients, is composed of
very finely divided silicate of magnesium and possibly
aluminium. Fullers’ earth is of similar composition, con¬
taining 63 per cent, silica, 10 per cent, alumina, and 9 per
cent, of oxide of iron. This powder may therefore claim
to have the healing and cooling properties which are attri¬
buted to fullers’ earth, while the special purity of colour
contributes to its value,
VICHY LIQUEUR.
(Agents, Ingham and Rovi.e, r > 2 , ji'AiuuNGDON-.s'niErT, B.C.)
Tfio special claim made for tliis liqueur is that it is
prepared with the natural salts of Vichy water, and on this
account it is esteemed a valuable digestive. Acting on this
statemen b, we were prepared to find by analysis an appreciable
Dig ^ .oogle
The Lancet,]
THE GENERAL PRACTITIONERS’ UNION.
[Mabch 7,18dl. 553
amount of the well-known salts which occur in natural Vichy
water, as, for instance, the bicarbonates of soda, potass
magnesia and lime, and the sulphate and chloride of sodium,
which, with traces of iron'and manganese, are present accord-
ingto published analyses to the extent of 7'914gramme8 per
litre. An analysis of the lic[ueur, however, which we have
purposely repeated, gives the following figures Absolute
alcohol by volume, 3974 per cent.; extract in 100 cc., dried
at 100° C. (chiefly sugar), 35'62 grammes; mimrat matter,
0'13 gramme per 100 cc. Neither chloride of barium or
silver nitrate in an acid solution gave any positive result;
the former reagent of course is used to indicate sulphates
and the latter chlorides. The small amount of mineral
salt, chiefly carbonate of soda, is, it cannot be contested,
probably derived from natural Vichy water; but the pro¬
portion is so small that the liqueur can hardly claim to be an
aid to digestion any more than are other concoctions of the
same class. The flavour is decidedly pleasant, and is
certain to be liked by those who are wont to indulge in this
so-called “digestive.”
CALVEET’S ORESO-CARBOLIC DISINFECTING .SALTS.
(F. C. Calvisui’ & Co., Manchester,)
Manufacturers of disinfectant compounds are recognising
the desirability of employing a soluble rather than an
insoluble substance to act as the vehicle for the distribution
of disinfectants. Hitherto, insoluble substances like
gypsum, kieselguhr, and various silicates were extensively
used for this purpose, with the result that in not a few
cases drain-pipes have been choked and stopped. The
well-known firm of Calvert & Co. now manufacture under
the name of “creso-carbolic disinfecting salts” a brick-dust
coloured powder, perfectly soluble in water, which contains
a high proportion of phenols. The base, from our experi¬
ments, is soluble sulphate of soda. On the application of
beat the phenols are readily expelled, and can easily be
recognised by the crystalline appearance of the tri-bi'omo-
derivative produced on adding bromine water to the
distillate. Another advantage attaching to a soluble dis¬
infectant powder of this kind is that it may be used for the
disinfection of cuts, wounds, and insect bites.
GRANULAR EFFERVESCENT PREPARATIONS.
(Alfred Bishop and Sons, Specks-fields, 48, Spelman-strekt, E.)
Granular effervescent preparations, as every practitioner
knows, afford in many instances a convenient and acceptable
form of administering drugs. Children, for example, will
often take a preparation that “ fizzes,” although the medica¬
ment contained therein may happen to be nauseous to the
taste. Messrs. Bishop were amongst the first to prepare
compounds of this kind, and we have more than once had
occasion to report upon their general excellence. Of recent
effervescent preparations examined we have on record the
following:—(1) Sulphur compound (Dr. Garrod’s formula);
(2) caacara sagrada, two grains in each drachm; (3) citrate
of caffeine, three grains in each drachm; and (4) salicylate of
soda, ten grains in each drachm. The results of our analysis
are interesting, inasmuch as in the cases where the drug per¬
mitted of quantitative determination the presence of the
proper quantities was confirmed. Thus the citrate of caffeine
preparation, when treated with slaked lime and hot cliloro-
form for the purpose of extracting the caffeine, yielded for
every drachm of the powder 1 ‘80 gr. caffeine, which calcu¬
lates into 3-50 grs. of the citrate. Similarly the salicylic
acid extracted from the salicylate preparation with ether
when calculated into sodium salt amounted to exactly
10'30grs. The sulphur compound readily gave up its
sulphur to what is the best sulphur solvent, carbon disul¬
phide. The preparations are readily soluble in water;
whilst the excellent granulation indicates the care which is
bestowed upon them in the course of manufacture.
COOMBS- EUREKA AERATED PASTRY FLOUR.
(W. A. CooMiiS, Nottingham.)
Carbonic acid gas, tliough deadly poisonous to inspire, is
probably one of the most useful agents which serve to pro¬
duce a wholesome form of food, an agreeable form of
beverage, and frequently a palatable form of medicament
as in effervescent preparations. Carbonic acid, for instance,
is generated by the action of yeast on sugar in the produc¬
tion of sparkling wines, and it is by the disengagement of
this gas that bread is made light and porous. It is well
known that carbonic acid is obtained from chalk and vitriol
for the purpose of manufacturingartificial mineral waters, and
ingredients which interact to produce this gas are frequently
substituted for yeast in the production of a light dough. The
action of yeast, however, is known to be uncertain, and
it has occasionally been accounted the cause of the sourness
in bread, which may not unreasonably be supposed to render
it less wholesome. The microscopical as well as the chemi¬
cal examination of Coombs’ flour shows it to consist of pure
wheaten flour, with the addition of a small quantity of a
mixture of two substances like tartaric acid and carbonate
of soda, which when moist of course evolve carbonic acid
gas. The logwood test sliowed the entire absence of alum.
IMPROVED Eli-FERVESCENT CARLSBAD POWDER.
(S. KUTNOW & Co., 00, HOLliORN VIADUCT, E.C.)
The medicinal virtues of the well-known waters of
Carlsbad depend on the presence of mineral salts, which
analysis has shown to consist largely of the sulphates of
soda and potash, in addition, to small quantities of car¬
bonate of lime, with which occur traces of the rarer salts
of lithium and strontia. The water is accordingly reputed
to be useful in rheumatism, gout, and kidney disorders.
Kuthow’s Carlsbad Powder is stated to contain, amongst
other ingredients, the active principle of the Sprudel salt
obtained direct from the mineral water. However this
may be, our analysis confirmed the presence of the chief
constituents referred to. The powder is beautifully clean and
white, and is evidently prepared witli care, while the taste
of the ellervescing solution is by no means disagreeable.
THE GENERAL PRACTITIONERS’ UNION.
At a meeting held at 29, Threadneedle-street, E.C., on
Wednesday, March 4th, it was decided that the name of the
Society be the “General Practitioners’ Union,” and that
the objects of the Association be as follow To consider
the question of the abuse of medical charities, to obtain
evidence thereon, and to take such steps as may be neces¬
sary to safeguard the interests of general practitioners ; to
obtain increased and more efficient representation on the
General Medical Council, especially for the purpose^ of
forcing that body to exercise its powers in suppressing
illegal medical practice; to supervise all legislative pro¬
posals calculated to allect the interests of general prac¬
titioners ; to deal with all matters atlecbing medical men
in general practice. It was resolved that every registered
general practitioner should be eligible for membership and
riiat the subscription sliould be 6*'.
The following members were elected as a subcommittee'
to confer with the Charity Organisation Society on the
subject of hospital aWses—viz., P. H. Alderson, P, H.
Corbyn, J. Dawson, Hugh Woods, Geo. Brown.
Windsor Infirmary and Dispensary. — The
annual report for 1890 presents a favourable financial posi¬
tion compared with the previous year, but the income is
still less tlian the expenditure. During the year 203 patients
were admitted to the sick and convalescent wards; of
these sixteen died—an increase in the mortality attri¬
buted to several cases being sent for admission in a hopeless
condition. The committee had been enabled to reduce the
balance due to the treasurer from £470 to £137*
Dir iOOQIC
554 The Lancet,) PROPOSED ABOLITION OF CERTIFYING FACTORY SURGEONS. [March 7,1891.
THE LAJfCET.
LONDON: SATURDAY, MARGB 7, mi.
The factory surgeons have much reason to he satished with
the debate on the Factories and Workshops Bill. Neverthe¬
less, it is necessary that they should lose no time in organising
themselves for the vindication of their ofhce. Not a day
is to he lost in preparing statements of their work. We
would urge upon them to use every diligence in this
matter. The masters and employers have evidently been
sowing tares and bringing strong pressure to bear on the
Government. Very likely, too, they have been assisted
and supported in this matter by parents who are apt to
think that children who should be at school might with
profit be at work. For once masters and employers seem
to have acted in agreement. It is high time, therefore,
that the factory surgeons take counsel among themselves
OB to the best way of meeting this plausible attack on their
office, which has so far overcome the Home Secretary, who
is generally a sensible and a Wise statesman. But the debate
mimt have somewhat opened his eyes. It seems to us not
only to have triumphantly vindicated the existence of
factory surgeons, but to have shown that, so far from being
disestablished, they should be strengthened in their appoint¬
ments, and that the range of tlieir duties should be extended.
We very much misjudge Mr. Matthews if he does not
now see that the certifying surgeons are an indispensable
if not a prime element in factory legislation. They repre¬
sent the very humanity of the State. Unless Sir U. K.
Shuttleworth, Mr. Lbng, Mr. Mundella, and others
were all misinformed, they reject a considerable number of
children. Mr. Mundella said he had abundant evidence
that they had not only frequently rejected children, but that
their work had acted as a great deterrent in the matter of
the employment of sickly, weakly, and diseased children.
Their efficiency is not, however, to be judged by the number
they reject; though, as Sir Lyon Playi'Air showed, in one
district alone (Dublin) in one year (1888--89) there were fifty-
six refusals on account of age, eighty-four on account of
infections disease and debility, and thirteen on account of
heart disease. As Dr. Farquharson argued in his admir-
able speech, the very fact that children have to be examined
by a factory surgeon has the effect of keeping back those
who are unfit—either from age, or infirmity, or infectious
complaint. Such influence is of the very kind that is needed—
impartial, kindly, and, for the purpose, judicial. Well might
Sir Lyon Playfair say that the proposal to abolish the
protection of the children by the examination of the factory
surgeons was a most unreasonable retrogression in this
kind of legislation, in regard to which the Conservative
party has a reputation to lose. It may be that the pay¬
ments should be made in part or altogether by the Govern¬
ment, as Mr. Shaw Lefevre argued. The State in this
matter stands, as it were, in loco parentis, and in that view
should perhaps pay for the protection of the children. But,
at any rate, it will abdicate one of its most honoured and
binding functions if it does not continue its protection to
them in respect of ascertaining the facts as to age and
physical fitness. And it can delegate this duty to none but
to members of the medical profession. We agree entirely
with Mr. Mundella in this matter that the action of the
factory surgeons should be extended. Their services should
be utilised more freely in the way of occasional inspection of
half-timers as well as for the purpose of giving an initial
certificate. It is of enormous importance to this country,
and to the credit of it, that it should show regard
for the sanctity of young life. How else is the
physical welfare of the people to be secured ? We
know what reckless waste of life has obtained in former
days, and how slowly we have advanced in attempts to stop
it. The factory surgeon is one of the safeguards most
prized by no less an authority than Lord Cross. It is
inconceivable to us, after the discussion of Feb. 26tb, that
Mr. Matthews will at a stroke and in the mere wanton¬
ness of a majority abolish what has worked so well. He
may well ask to be excused inilicting such a blow, not
only on factory surgeons, but on factory legislation. The
opinions of Mr. BuRTand.Mr. Beoadhurst, bo temperately
and yet so forcibly expressed, may well convince him that
the best section of the working classes appreciate the pro¬
vision of factory surgeons, and see in it no real enemy to
these classes. By rejecting children who are too young or
physically unfit for work, it not only preserves them, but
by so mu(A abates this—a most undesirable—competition
with adult labour.
Let us emphasise, in conclusion, the practical advice we
offer to the factory surgeons at the beginning of this article.
They will make a great mistake if they allow the favourable
tone of the debate as a whole to lull them into a sense of
security. They must organise themselves so as to convince
every member of the House, and especially those on the
Government side, of the importance of the work they have to
do. They must undeceive Mr. Matthews in his amazing
delusion that for years not a child has been rejected by
the examining surgeon. The debate shows that the spirit
of reasonableness and humanity which gave rise to the
Factory Acts is nob dead yet, but it needs to be carefully
cherished and kept well up to date.”
We have on more than one occasion adverted to the
serious prevalence of enteric fever which occurred in the
Tees Valley towards the close of September last, and to
certain attempts which were made to dispute or to minimise
the conclusion arrived at with respect to its cause being the
drinking of the water supplied by certain companies
deriving their supply from the river Tees. It would appear
that some of the more interesting features of the epidemic
involve the consideration of a number of complex facts, and
that the full report on the subject may, in consequence,
have to be delayed. Under these circumstances Dr. Barry
has submitted bo the Local Government Board an interim
report, the character of which can leave no doubt in the
minds of unbiased readers that his original contention as
to the cause of the outbreak is confirmed in the most con¬
vincing manner.
The Tees Valley contains a population roughly estimated
gii'.'
The Lancet,]
ENTERIC FEVER AND THE TEES WATER.
[Mabch 7, 1891. 555
at 520,090, and it includes the towns of Darlington,
Middlesbrough, and Stockton, besides a number of smaller
towns and villages. In a tabular form Dr. Barrv sets out
the number of attacks of enteric fever fortnight by fortnight
from January to October, 1890, and whilst the fortnightly
average from January to September 6th was about 33, there
occurred in the fortnight ending September 20bh no less than
243, and in the fortnight ending October 4th no less than
334 attacks—or 577 cases of' enteric fever in four weeks.
And taking certain towns, such as the three just named, it
was further found that the distribution of the disease had
been fairly uniform throughout their whole area. In the
villages lying in the Tees Valley the same uniformity was
not observed, the special incidence of the fever being con¬
fined to certain townships and localities, others escaping.
Seeking the cause for this sudden and widespread out¬
burst of fever. Dr, Barry found himself enabled to elimi¬
nate all ordinary conditions which are held to be capable of
leading to enteric fever, except one, and this was the
water service. The three towns named, with other places
and villages in the Tees district, get their water through
two bodies—namely, the Stockton and Middlesbrough
Water Board and the Darlington Corporation, and both
these bodies draw their supply from the‘Tees at nearly the '
same point in the river; and it is shown that, with one
single exception, and this in the latter part of the four
weeks referred to, the heavy incidence of the disease was
practically limited to the areas so supplied.
In the Tees Valley district some 41,000 houses receive
Tees river water, and they were invaded by enteric fever at
the rate of 12 per 1000; in the same district are some 56,000
houses obtaining water from other sources, and these were
invaded only at a rate amounting to rather less than 1 per
1000. So also in localities receiving no other supply than
the Tecs water the rate of attack on houses varied from
11‘5 to 13 per 1000; and much higher rates of attack were
observed in such portions only of localities which received
this water, whereas other portions had a dillerent supply.
In short, the exceptional incidence of the disease was found
to have been almost entirely confined to the users of the
Tees water; and the suggestion that one cause only was
the essential one at work is shown by the uniformity in tlie
rate of incidence in the larger communities receiving Tees
water only.
But how did the Tees water come to have the faculty of
disttibuting disease ? The answer to this reveals a state
of affairs hardly to be credited. The drainage area of the
Tees covers some three hundred square miles, and within
this area the river receives, either directly or indirectly,
the drainage of some fifteen to twenty villages, as well
as that of the town of Barnard Castle and of many
graveyards and farmsteads. Dr. Barry's report carries
the reader up and down from Barnard Castle to the
intakes of the two water-distributing bodies, telling in
detail of the filth discharged into it, and of the filth
deposited on the foreshore, which only awaits a sudden
Hush of water to he swept on towards the intakes. As
to Barnard Castle, the sewage of some six thousand people,
to say nothing of large bodies of summer visitors and
the militia, has its outfall through a main sewer “directly
Into the Tees.” Besides other local sources of contamina¬
tion there are the contents of the waterclosets from
nearly four hundred houses. We need not follow Dr.
Barry in all his details as ta the pollution of the river.
His conclusion, “that a considerable amount of exore*
mental filth and house refuse is being continually poured
into and conveyed down the river,” can admit of no
denial; and it seems equally clear that the pollution
of the liver must he enormously increased during periods of
heavy rainfall, when the river is in flood. Having this
latter point in view, he inquires next if, by reason of any
exceptional circumstances, any- wholesale discharge of
sewage into the Tees could have taken place shortly before
the prevalence of fever. It soon transpired that in the
fortnight ending Aug. 23rd no less than 3’6 inches of rain
fell, this being one of the heaviest records of rainfall known
in the Tees Valley. This circumstance, too, came into play
just when it should have done to allow of the period of
incubation generally exhibited by enteric fever as an ante¬
cedent to the explosion beginning on Sept. 4tb.
Enteric fever is rightly regarded as typical of the class of
“ flith diseases,” and its occurrence is very commonly asso¬
ciated with the excremental pollution of potable water.
In the instance under consideration we And that the people
attacked are drinking a water habitually fouled by sewage
and excreta, and that a special flush of filth was swept into
I the source whence the supply is derived just antecedent to
I a special outburst of disease.
j But why, it may be asked, is not enteric fever more
common in the Tees Valley, and why were only some
10 per 1000 of the households drinking this water
attacked last autumn? We have abundant evidence
that the contagium of enteric fever must be a par¬
ticulate one, and that it is not uniformly distributed
through such a vehicle as water in the same sense that
any substance in solution would be. It also seems clear
that the extent of risk to infection from water depends,
in the case of this disease, in the number of opportunities
which occur for receiving the particles of infection. In
the case of the Tees, often a rapidly flowing river, the
amount of risk may perhaps be roughly estimated by the
average amount of enteric fever occurring amongst the
inhabitants of the Tees Valley, although we would not
presume that the river water is the only cause of that
disease. On the other hand, the special risk, such as was
incurred in a particular fortnight last year, may to some
extent be measured by the tenfold increase in the amount
of the disease which took place in September last. That
much matter potent to produce enteric fever was washed
past tho intakes of the water companies during the rapid
flush in August last must be obvious, and that a good deal
of water free from the particulate infection could have been
drawn up into the town must be equally obvious. Herein,
doubtless, lies the answer to the questions put. But the
danger remains, and must remain so long as the people in
the Toes district are supplied with water from a stream
charged with the excreta and sewage of their neighbours
above.
Whatever may be said of total abstainers from alcohol,
it can never be alleged truthfully against them that their
peculiar habit interferes with their industry, their energy,
DiniTized b. ^
556 The Lancet,]
ALCOHOL AND THE PROFESSION OF MEDICINE.
[March 7,1891.
or their perseverance. When an aspiring member of Parlia¬
ment is about to contest a district, one of the first things he
considers is the strength of the teetotal element. If there
be many teetotal organisations, he m sure from the first
that he must reckon with them ; they will have their own
ideas, they are likely to combine in many ideas, and
perfectly certain it is that, should they set to work, their
physical powers will fully compensate for any shortcomings
of an argumentative kind. They will be aggressive, patient,
vigilant, and of long endurance. Last week there was an
illustration of some of these faculties in those abstaining
members of the profession of medicine who are the repre-
sentacives of the British Medical Temperance Association,
a medical body now numbering close upon five hundred,
and, we believe, overnumbering that figure if they who are
learning tlieir “rndimans,” as Dr. Cophagus called it, may
be considered medical. This Society, like its fellows, meets
ordinarily in its own central rooms in the west end of
London, or in the central rooms of its branches in other
parts of the kingdom, and there carries on its work of
papers and discussions. But now, on the suggestion of its
indefatigable honorary secretary, Dr. Kidge, the members
of the Society, with characteristic pertinacity, are moving
into new pastures and holding meetings in different dis¬
tricts in order to invite the busy practitioners of the dis¬
trict visited to meet them in the most convenient way and
discuss with them the great argument for and against
alcohol. On Wednesday week last, Feb. 25th, the first
meeting of this kind was held at Northampton House, St.
Paul’s-road, Highbury, and for numbers present, as well as
for the matter of debate, it must be accepted as a most
successful first attempt. Dr. B. W. Richardson, the
President of the Association, occupied the chair, and in an
opening address led the way simply towards discussion.
Every word that was extreme was avoided as unnecessary.
The apathy of the profession as compared with the energy
of the clergy was first touched upon, and then the sanitary
side of the matter was made a special point for considera- |
tion. Alcohol produces a certain large and calculable mor- i
tality} the mortality means a large bill of sickness, and
the sickness means an enormous loss of labour and the
rewards of labour. But we as a profession of health, said the
chairman, are the custodians of health, and ought, therefore,
specially to concern ourselves in the wholesale rempval of
the preventable cause of so much disease and misery. If
an epidemic from some more obscure cause destroyed a
tithe of people so systematically and regularly as alcohol
does, we should be ambitious to vie with each other in dis¬
covering the mode of reaching and removing the root of the
evil. It is our duty to do the same thing in regard to this
great plague which is always before our eyes. Another
point dwelt on was the recognisable pathology of alcohol,
and the lesson it supplies, in respect to the employment of
it as a medicinal remedy. Touching this last subject,
the speaker repeated his often stated opinion that
alcohol, whenever it is prescribed in disease, should be
prescribed as “a weapon of precision"—that is to say,
diluted with water in measured doses, without the least
complication. This plan, he urged, answers perfectly,
and after fifteen years’ employment of it he had found
it eiual to every requirement. Finally, the require¬
ment itself wsis, he thought, in truth, very much Curtailed
when all the facts of the necessity were fully disclosed. The
masters of physic who recognised the force of the experientia
fallax were most sound when they exposed that kind of
experience, and never more was that soundness verified
than in the practice of alcohol administration. Let a
practitioner, said the speaker, who has been accustomed to
use alcohol once have the courage to look at the other side
of the shield, and see what remarkable results follow
treatment without it—as, for example, in cases of hcemor-
rhage, pneumonia, and asthenia, and the rapidity with
which the mode of treatment without alcohol would
advance would lead to quite a revolution in the practice
of using alcohol as a remedial instrument. Dr. Ridge,
Dr. Norman Kerr, and Mr. Moift followed on the same
side. The most tiencbant opponent was Dr. King, who
dwelt more particularly on the social influence of alcohol'
for good when perfect moderation tempered appetite. He
was of opinion that wine judiciously taken aided the
worker and sustained the enfeebled. Altogether, this new
experiment of local discussion on the alcohol topic from its
medical aspects, by medical men amongst themselves, was
so friendly, hopeful, and instructive that we trust it v’ill be
repeated. It is good for brethren to dwell together in unity.
The Report of the Hospital Reform Inquiry Committee
of Birmingham has recently been published^ and should he
procured and read by all who are interested in the great
and urgent question of Hospital Reform. Our Birmingham
correspondent gave last week a summary of its principal
points. It is to be presented on the 9bh instant to an
adjourned conference of representatives of the medical
charities of Birmingham and other organisations allied to
them, and of representatives of the medical profession as
convened by the Mayor of Birmingham in January of 1890.
The chairman of the committee was his Honour Judge
Chalmers (of the County Court). Three members repre¬
sented the medical profession, two the General Hospital, one
the Queen’s Hospital, two the General Dispensary, one the
Hospital Saturday Committee, one the Children’s Hospital,
the Eye Hospital, and the “Women’s Hospital collectively.
It may be remembered that medical men are largely
responsible for the initiation of this inquiry. In Novem¬
ber, 1889, the profession in Birmingham met to consider
a report on the question by a committee of medical
mhn, prepared in October of that year, and passed resolu¬
tions suggesting a conference of all parties interested. The
conference was held, and recommended a committee the
constitution of which should be left to the Mayor, and was
composed as we have described above. It is gratifying to
think that the medical profession has been so honourably
associated with this inquiry.* Of the seventeen witnesses
examined nine were members of the profession. They
were, of course, in a minority on the committee. But it
will be seen from the report that the results of inquiry and
the remedies suggested accord closely with the views long
held by the medical profession. The report is an admirable
one in its arrangement, in its lucidity, and in its brevity.
It does not include a copy of the evidence taken, but we may
I Messrs. Osborne and Son, New-atreet, Birmingham.
DiuuizeO by
The Lancet,] THE BIRMINGHAM REPORT ON HOSPITAL REFORM.
[March 7,1891. 557
bopethatthiswillbepubliahediaaseparateform. Thegeneral
result of the inquiry is to show that there is an enormous
abuse of hospital charity in the out-patient department
of hospitals by the almost reckless admission of all comers.
In some hospitals there is no pretence of inquiry; in others,
and almost in all, it is formal and ineffective. The result,
of course, is that the people prefer the gratuitous advice of
consulting and hospital physicians and surgeons to paying,
however reasonably, for the services of the ordinary prac¬
titioners. They would undoubtedly prefer to get their food
and other necessaries of life on the same terms. Under
this demoralising system the out-patients of hospitals in
Birmingham have advanced in twenty years—1867 as com¬
pared with 1887—from 67,000 to 166,000. The evils of this
monstrous excrescence of charity are well pointed out:
unfair pressure on the hospital staff; hurried examination
of patients; and the long detention of those who are
seriously ill. The framers of the report seem appalled
at this rapid growtii. They become prophetic, and say if
it is not stopped an utter breakdown of the present arrange¬
ments must be the result. This is what we have long
prognosticated. The benevolent will give any reasonable
amount for the relief of really urgent cases, hut for those
who can insure themselves against sickness, in the clubs of
private practitioners or in provident dispensary or sick funds,
they will not subscribe, and are already becoming critical.
The main conclusions of the Coiikmittee are to recom¬
mend : 1. The formation of a general Council to secure
common and joint action of all hospitals and dispensaries.
2. The formatioh of an inquiry agency to investigate the
circumstances of patients. 3. The exclusion of all but
serious cases, and of all who can either pay or who could
more properly be dealt with by the Poor law. 4. Provision
for cates so excluded in dispensaries or provident associa¬
tions. 6. The admission to the out-patient department of
any person recommended by a provident association or a
qualified medical practitioner.
These are admirable suggestions. Only one thing re¬
mains—to carry them into practice. It must be remem¬
bered that the gratuitous treatment in hospitals of those
who can pay is only one shade less demoralising than down¬
right pauperism. We shall look anxiously for the con¬
tinued action of the profession in assisting the Mayor and
other leading men of Birmingham in this great refoini. We
must be practical. We must give help to social reformers.
It will be another feather in the cap of Birmingham if,
even before the Lords’ Committee shall have time to
report, it shall have shown the way of effective reform of
the hospital out-patient system.
“Ne quid Dlmb.''
THE RECONSTITUTION OF THE UNIVERSITY
OF LONDON.
Since our last issue the Councils of University and
King’s Colleges have held special meetings for the con¬
sideration of the latest “ revised scheme ” of the Univer-sity
of Loudon. As was anticipated, neither body has accepted
it. The Council of University College pMsed a' resolution
to send a letter to the Senate (1) Recognising that in the
course of the discussion of successive draft schemes the views
on behalf of the London Colleges on some important points
have been fairly met, hut at the same time regretting that
in the revised scheme there are other important points which
in their present form are not satisfactory to the Council.”
We understand that a stronger resolution was only defeated
by the narrowest majority, so that the new scheme meets
with little favour at University College. The resolution
passed by the Council of King’s College was more pro¬
nounced in its opposition, and was carried with scarcely a
dissentient voice: (1) “Recognising that in the course of the
discussion of successive draft schemes the views urged on
behalf of the London Colleges on some important points
have been carefully considered; but the Council regret that
in the revised scheme submitted to them changes have been
introduced which are inconsistent with an important
principle laid down by the Royal Commission, and which
render the scheme materially different from that to which the
Council assented last July.” The July scheme made some
provision towards a local university or its equivalent in
London; the latest scheme, by engrafting on it the recogni¬
tion of provincial colleges as constituent colleges, and by
enlarging the Senate to carry out this new work, has altered
materially the position of the London Teaching Colleges,
and these could hardly be expected to agree to a new scheme
in which they were placed at a relative disadvantage,
and which was in direct opposition to the recommenda¬
tion of the Royal Commission. The divergence of views
on educational questions to be expected on such a large
Senate was emphasised by a proposition placed before it on
Jan. 28th, to enlarge its proposed number of fifty-two still
further by adding ten more non-collegiate members. The
other resolutions, which were passed in identical terms at
both Colleges, would seem to intimate that conferences with
the Senate of the University were at an end, and that
they were anxious to refer the question at once to Lord
Cranhrook. In this manner a solution of the problems will
possibly he most readily found. “ (2) Expressing the opinion
that on these it will probably be best that the views of the
University and of the Colleges should be heard by the
Lord President or the Privy Council; (3) and reserving
full liberty to the Council to express to the Lord Pre¬
sident or the Privy Council their objections to any features
of the Scheme which , may remain in a form unsatis¬
factory to the Council, or may fail to secure for London
the advantages of a Teaching University.” A memo¬
randum published this week by the Senate of the
University of London is most interesting in relation to
medical degrees. It is distinctly stated that “no altera¬
tion is now made in the degree of M.D.” In regard to the
M.B. pass degree arrangements are suggested which will,
while keeping the preliminary scientific M.B. examination
under its own Standing Committee in Medicine, transfer all
the other subjects for the pass degree to the supervision of
a joint committee of the Senate and the Royal Colleges.
This arrangement is, strangely enough, described as one
“ which will not lower the standard or lessen the value of
the medical degrees of the University, or impair their
scientific character.” If this means that the examinations
to he controlled by the newly suggested Board are to be
kept at the existing standard, then the boon of medical
degrees to London students on reasonable terms will be
as far off as ever; if such conditions are granted under these
new arrangements, how is the standard—declared by the
Royal Commission to be an Honours one—to he maintained
at its present level? The two positions are clearly in¬
compatible.
Di:;' ’ed by
Google
558 The Lancet,]
THE MIDWIVES’ REGISTRATION BILL.
[March?, 1891.
THE MAIN DRAINAGE OF LONDON.
The immediate necessities of London in respect of main
drainage have been placed before the London County
Council in a carefully prepared report by Sir Benjamin
Baker and Mr. A. K. Binnie, the chief engineer of the
Council. These necessities are twofold. The one, the pro¬
vision of suthcient sewers for the effectual drainage of the
metropolitan area; the other, the proper treatment of the
sewage before its 6nal discharge. London north of the
Thames is provided with three main sewers—the high level
draining Hampstead, Kentish Town, and Hackney, and
being joined at Old Ford by the middle level sewer, which
runs nearly in a straight line to this point from Bayswator;
while the northern low level sewer extends from Pimlico
to Abbey Mills, where the sewage from the northern part
of London is raised by pumping into the northern outfall
sewer, to be discharged at Barking. The southern part of
London is drained by two main sewers, the high and low
level, joined by the Effra branch, eventually discharging,
after pumping, at Crossness. The insufficiency of these
sewers has long been recognised, and the fioodings of the
low-lying parts of London, especially in times of heavy
rainfall, have been frequently the subject of public comment,
There has been, therefore,’ much necessity for this in¬
sufficiency to be considered by competent engineers, and for
the necessary steps to be taken to make provision which
will relieve these districts from the disadvantage from
which they suffer. The proper method of dealing with
the sewage, whether by chemical treatment or by irriga¬
tion, has been matter of so much investigation that it
cannot be expected any further light will be thrown upon
it for some time to come. At the present time the arrange¬
ments for chemical treatment are incomplete, and par¬
ticularly at Crossness, where the necessary works for
precipitation are in progress; but the experience gained at
Barking warrants a more hopeful view of this method than
might have been anticipated. No one, therefore, with any
sense of responsibility would be prepared to recommend a
new departure until it was known that there was necessity
for further change. This is evidently the outcome of the
inquiry, the details of which we propose to discuss shortly.
THE INFLUENZA OF 1890 AND A DEPRESSED
TONE OF HUMAN VITALITY,
In our Edinburgh correspondent’s notes last week some
interesting extracts were given from the report sub¬
mitted by Dr. Clouston upon the Royal Edinburgh Asylum
for the past year. They had reference more especially to
some evidence produced by Dr. Clouston as to the existence
of an exceptionally low tone of human vitality during the
year 1890 in relation to the epidemic of influenza. Whether
it was the influenza in the early part of the year that had
perceptibly lowered human vitality, or whether the pre¬
valence of the influenza merely showed that European
humanity was in a lowered state of vitality, so being
a fit nidus for the influenza germs to propagate in, or
whether it was the sunless, summerless general character
of the year, Dr. Clouston could not say. He distinctly
connected, however, the influenza in some way with
the unprecedented number of melancholic patients sent to
Morningside Asylum. He goes on to say, and we think
with truth, that he believes the epidemic of influenza left
the European world’s nerves and spirits in a far worse state
than it found them, and that they scarcely yet had recovered
their normal tone. Many others have expressed themselves
in the same sense, and we look upon the subject as one
of deep interest. An excellent opportunity will be given
to asylum superintendents at this season of preparation of
their annual reports to confirm or otherwise this expression
of opinion on the part of Dr. Clouston. With regard to
the vexed question of the alleged increase of insanity, Dr.
Clouston stated that the number of rate-paid admissione
into the Edinburgh Asylum did not tend to hear out
the popular ideas as to the rapid increase of mental diseases
in recent years, for the yearly production of pauper lunacy
in the district bad scarcely risen appreciably during the
past fifteen years. The production of pauper insanity was
with them not keeping pace with the growth of the popula¬
tion. The cases of melancholia admitted during the year
were in excess of those of mania, and this was quite an
unprecedented experience, as during the past five years the
cases of mania exceeded those of melancholia by 37 per cent.
The relationship existing between insanity and other
diseases and epidemics, on the one hand, an,d with disturb¬
ing social influences of a general character on the other,
is yet far from being worked out, and we welcome such
observations as those of Dr. Clouston as being not only
interesting and instructive in themselves, but as suggestive
and useful to other workers in this complicated region of
scientific thought and medical experience.
THE MIDWIVES’ REGISTRATION BILL.
We are glad to be able to give a report of the proceedings
of a deputation on the Registration of Midwives’ Bill to
the Lord President. The Lord President’s answer is impor¬
tant, and shovi’s that he is considering the subject carefully.
He takes for granted that there is an almost universal desire
to improve the education of midwivea so far as that can be
done by legislation. We are not the less satisfied with
Lord Cranbrook’s position that he sees clearly the diffi¬
culties to be overcome. He is a very likely man to over¬
come them. There seems no prospect of legislation this
year, so that plenty of opportunity will be given for the
consideration and removal of all reasonable objections.
THE CANTHARIDIN TREATMENT OF
TUBERCULOSIS.
We may refer those who are interested in the newly
found substitute for Koch’s liquid to the pages of our
esteemed contemporary, the Berliner KUnische Wochen-
ficAn/if/which devotes many pages to the textual report of
the proceedings of the Berlin Medical Society on the 26th
ulfc., when Dr. Oscar Liebreich discussed the pharmaco¬
logical and therapeutical properties of salts of cantharidinio
acid. Drs. Paul Heymann, G. Guttmann, and B. Fraenkel
related cases in proof of the efficacy of the minimal doses
(averaging two decimilligrammes) of the drug used as sub¬
cutaneous injections in cases of tubercular disease. The
evidence adduced by these experienced observers is all the
more valuable since they have been for the past few months
carefully following up the results of Koch’s injections, in
casesof laryngealphthisisparticularly. Thelocal changes and
the general improvement ensuing upon the cantharidin injec¬
tions appear, in the few ca«es that have been so far treated,
to have been very marked, and, what is more to the point, to
have been unattended by any of the drawbacks with which
the use of “ tuberculin ” is so often associated. Unless the
“ enthusiasm ” has outrun even that which was displayed
in the early days of Koch’s remedy—and we can hardly
suppose that the lesson then taught has been given in
vain,—it does really seem as if Dr. Liebreich’s pharmaco¬
logical speculations are likely to be fruitful in many ways.
We may remind our readers that he selected this substance
because of its known remarkable property of exciting
exudation from the capillaries. That property, which is
patent to all when the skin is subjected to the action of a
blister, is doubtless likewise exerted upon internal organs,
notably the kidneys and sexual organs, when cantharides
is taken internally. Nay, it has been found to produce
pulmonary oedema, and Dr. Liebreich said t^at he had
The Lancet,]
CAPACITY OF THE SPINAL CANAL.
[March 7,1891. 559
found it recoiumended (in English literature too) in certain
pulmonary diseases. He reasoned then that, since it has
some selective property—e.g., a much greater affinity for
the renal glomerular capillaries than for the vessels in
other parts — it wm not unlikely that, in the case of
capillaries in a morbidly irritable state, its effects might be
exerted by doses quite inadequate to excite transudation
in the normal body. As to its applicability to tubercle, he
ventured on the farther surmise that its action might be
an indirectly specific one, since the researches of Buchner
and Stem have shown that blood serum has a bactericidal
action. Commencingwith the greatest caution, and finding
that a dose of six decimilligrammes excited hmmaturia
in one case, he recommended that no more than one or
two decimilligrammes of cantharidin in alkaline solu¬
tion (one cubic centimetre of which contained two deci¬
milligrammes) should be injected, and that an interval of
one day might elapse between the injections. Benal disease
is of course a contraindication. Strangury, hmmaturia,
and other symptoms were observed by Dr. Heymann in
some of his cases, symptoms which soon disappeared on
suspending the injections for a short time. It is clear that
in Berlin professional interest will be centred for some
time upon the relative value of “ tuberculin ” and “can¬
tharidin ” in tuberculosis.__
BURIAL REFORM AND THE STATE OF
ST. ASAPH CHURCHYARD.
In spite of all that has been done in the cause of burial
refoim cases crop up now and then which show how much
still remains to be done. An instance has occurred lately.
Dr. Hoffman, the medical officer of the Burial Acta Depart¬
ment of the Home Oflice, has been holding an inquiry into
the insanitary condition of St. Asaph Churchyard, which
has been in use for four centuries, and is so crowded that
new graves cannot be dug without bringing up the contents
of old ones, while human bones are to be seen frequently
strewn on the surf^ioe. Dr. Hoffman inspected the church¬
yard in company with Dr. Lloyd Roberta, the medical officer
of health, who informed him that owing to the impregnated
condition of the soil it was dangerous to health. Dr, Hoff-
mann intimated that be should recommend increased
restrictions, limiting burial to existing vaults and walled
graves, and to earth graves for widows and widowers of
those already interred there. It is, however, greatly to be
hoped that public opinion and the good sense of the
St. Asaph citizens will efiect even a greater reform, and
close entirely this already too full churchyard. The Church
Congress will meet this year at Rhyl, under the presidency
of the Bishop of St. Asaph. We trust that burial reform will
receive the early attention of the “subjects committee.”
Welsh people have always been very conspicuous for their
conservatism of language and of ancient traditions. Their
churchyards have been condemned before in no measured
anguage, and the description just given of St. Asaph
churchyard is one which could hardly have been expected
so near to the close of the nineteenth century.
CAPACITY OF THE SPINAL CANAL.
The results of certain experiments undertaken by Pro¬
fessor Reid and Dr. Sherrington, with a view to determin¬
ing the result of position on the capacity of the spinal canal,
are related in the lost number of Brain. The plan of
experiment was as follows. After trepanning over the
vertex close to the longitudinal sinus, the dura mater was
removed to an extent corresponding with the trepan hole.
Water was then poured into the subdural space until it
filled it, and a glass tube was next secured in the hole in a
perfectly watertight fashion, a thin membrane which floated
on the water filling the subdural space having been pre¬
viously drawn over the end of the tube. A piece of glass
tubing was connected with the other tube by flexible water¬
tight joints, the farther end of this tube being on a level
with the trepan hole in the skull. Finally, this tube and
its connexions were filled with water and its free end pro¬
jected over the scale pan of a sensitive balance, the other
arm of which had a recording apparatus marking a re¬
volving cylinder attached to it. The cadaver was suspended
by means of an iron coronet, and variations in position
were produced with the aid of a horizontal bar from the
vertical stand on which the body was hung. The con¬
clusions arrived at are that the capacity of the cranio¬
vertebral canal is at its maximum when the body is hanging
freely and vertically, that there is diminution in this
capacity when the ■\\'oight of the trunk and limbs is taken
oil', and also when the vertebral column is bent backward
or forward. In other words, it is found by this method ot
investigation that the alterations in the curvatures of the
spinal canal by various movements do influence the capacity
of the canal, but not to any great extent. This variation
is found to be greater in the child than in the adult. The
authors conclude by remarking that this increase is so
small that it becomes difficult to conceive how in the sus¬
pension treatment for cases of tabes there can, as has some¬
times been claimed, be any actual stretching of the spinal
cord. _
MILITARY MEDICINE IN ARGENTINA.
We have received the first number of the Boletin de
Sanidad Militar, a monthly journal dealing with subjects
of interest to the naval and military medical services of the
Argentine Republic, and edited by the inspectors-general
of each service and a number of other officers. A good deal
of space is devoted to Koch’s treatment in Europe, the
observations which were being made in Buenos Ayres
being in too incomplete a state to warrant any report.
Dr. Cabezo contributes an article on first dressings, in
which he does not give any information as to what were
used in the Paraguay and Entre-Rios campaigns, though
he mentions these operations as showing the great import¬
ance of efficient field dressings. A description of a simple
apparatus for estimating the carbonic acid in the air is
contributed by Seuor Bosque y Reyes, pharmacist, and a
complete list of the military and naval, medical, and phar¬
maceutical officers is appended.
THE ROYAL MEDICAL AND CHIRURGICAL
SOCIETY.
The presidential address of Mr. Timothy Holmes at the
annual meeting of the Royal Medical and Chirurgical
Society was full of satisfaction with the present position of
the Society and of hope for its future. The Society hM
embarked on a considerable financial undertaking, but there
is reason to believe that it is fully equal to its responsi¬
bilities, although during the past year it has had to curtail
considerably its outlay on the library. Still, those who are
best acquainted with its position are confident that it will
be able to keep up its invaluable library on a scale equal to
all requirements. Mr. Holmes, whilst omitting the full
biographical details of deceased Fellows, intimated, however,
that he had prepared these for publication, and his brief
references to the departed were marked by good feeling and
judgnrent. We would suggest that the compilation of full
obituary notices—which certainly should be retained—
might be entrusted to personal friends of the deceased
Fellows, and that they might form an appendix to the
published address by the President. Mr. Holmes referred
to the idea initiated thirty years ago, and more than once
revived (the last occasion, we believe, being in Mr,
Erichsen’a presidency), of the combination of the leading
Dig':z3dby lOO^ C
560 The Lancet,]
HYSTEEICAL DEAFNESS.
[March 7,1891,
medical societies of the metropolis into one Academy of
Medicine, but he did not think the time yet ripe for the
initiation of such a scheme; whilst Mr. T. Smith, when
seconding the vote of thanks to the President for his
address, was wholly opposed to it. Mr. Holmes alluded to
the increased facilities to be offered to country Fellows ; and
amongst other suggestions he made one which was received
with some favour. It was that an attempt should be
made to cultivate the social aide of the Society by having
riunions of a less formal character than the ordinary meet¬
ings. Another matter on which the Society is to be con¬
gratulated is the foundation of a permanent endowment
fund, initiated last year by Sir R. Quain, and augmented
by benefactions from other gentlemen. The utility of
such a fund iS unquestionable, and it affords an admir¬
able opportunity for the Fellows to prove their practical
interest in and attachment to the aims and objects of the
Society. _
HYSTERICAL DEAFNESS.
A CASE of so-called hysterical deafness is related by Dr,
Wiirdemann in the Philadelphia Medical News. It occurred
in a girl whose age is not given, and who was the subject of
interstitial keratitis and middle ear disease. The hysterical
symptoms consisted in inability to hear and understand
what was said by members of her own family, with retained
ability to hear what was said by others, and the abolition of
peroBseous conduction of the tuning-fork sound, although
she was able to hear it through the ear. There were areas
of ansesthesia about the ear, and sensibility on her bands,
feet, and knees seems to have been lessened, although the
patient’s stupidity was great, rendering the examination
unsatisfactory. Vigorous treatment by galvanism, blister¬
ing, and hot baths was used with good effect. The hearing
improved, but the areas of diminished sensibility persisted
on both sides.
DIPHTHERIA AND ITS CAUSATION IN
SALFORD.
Salford is one of the large towns in England which has
within recent years exhibited a large increase in diphtheria,
and the subject has been dealt with in an exhaustive report
by Mr. Charles Paget, the medical olficer of health for the
borough. During the five years 1883-87 the mean annual
number of notified attacks from diphtheria was 72; in 3888
the numbers rose to 176; and in the next two years they
reached 691 and 694 respectively. The increase in the in¬
cidence of diphtheria commenced before Mr. Paget’s tenure
of office; and, apart from this, there are obviously great
difficulties in tracing the beginnings of such a disease as
this three years after its commencing prevalence. Indeed,
it is admitted that the origin of the epidemic cannot
now be determined; bub there is a strong presump¬
tion that there was a considerable prevalence, in the
last quarter of 1887, of that form of sore-throat which
goes unnotified, but which has some definite connexion
with diphtheria prevalences. With regard to origin, Mr.
Paget farther states that he is able to exclude botli
milk and disease among domestic animals from any
obvious share in the occurrence; but he is convinced
that the elementary schools tended largely to the dis¬
tribution of the malady, and this mainly by means of
the aggregation of children sulfering from the mild attaclcs
of so-called “sore throat" already referred to. Much
pains were evidently devoted to ascertaining whether,
and if so how far, soil pollution could have had any
influence on the disease, and a special effort was made to
ascertain how far “ tips ’’ and the erection of buildings on
soil polluted by accumulations of refuse had a share in
locating the prevalence. In the end Mr. Paget is
obliged to come to the conclusion that between such
conditions and the diphtheria in Salford no direct con¬
nexion could be made out. Still, he by no means
exonerates the midden privy system and the practice of
levelling up building laud with refuse containing organic
matter from a share in aggravating the circumstances of
the epidemic and from enhancing the virulence of the
infection in regard of individual attacks in persons exposed
to such influences. The general effect of such influences in
lowering vitality can hardly fail to be operative for evil, in the
sense indicated, in the case of such a disease as diphtheria.
All clue to adirect infectionseems, however, to have been over¬
whelmed in-the one prevailing circumstance that, whether at
school or elsewhere, there was ample room for the operation
of direct personal infection from person to person. But a
predisposing cause beyond that already suggested is believed
to have existed in the condition of the drains and sewers,
and this especially where these admitted of the retention
in them of offensive and infectious matters. By this latter
statement we assume that Mr. Paget is inclined to regard
sewers and drains as capable of acting directly by giving
out the diphtheria contagium which has been received into
them. The point is one of considerable interest; it is one
as to which it is impossible to speak with certainty, and
this especially where personal infection by means of un¬
recognised, as well as by recognised attacks, was so widely
in operation. One thing is certain—namely, that immense
pains have been devoted by Mr. Paget to the inquiry, and
to the preparation of the well-illustrat^d report which he
has submitted. If he and others before him have failed in
clearing up the obscurities attaching to the causation of
diphtheria, we may well concur with him that mere local
investigations can no longer be expected to solve the
difficulty, and that “the necessity for an exhaustive inquiiy
as to the origin and maintenance of diphtheria in this
country” is growing daily, and has “already become a
matter of national concern."
THE VIRCHOW TESTIMONIAL FUND.
An official letter has been received by the honorary
secretaries to the above fund from the German Committee,
in which the latter express their pleasure at seeing the
thoroughly representative character of the British Com¬
mittee and their warmest thanks for tlie readiness with
which the British profession are responding to the invitation
to do honour to the great pathologist. They further inform
the honorary secretaries that it- is the intention of the
German Committee to present, as far as means will permit,
replicas of the medal which is to be struck in Virchow’s
honour to some of the representative British institutions.
Finally, they state in reply to a question raised by several
British admirers of Virchow, who wish to possess a lasting
memento of his jubilee, that the artist to whom the
execution of the large medal will be confided will also
produce a replica on asraaller scale,whichmay be purchased
from him, Particulars on this point will be given in due
time.
THE SERUM OF GOATS’ BLOOD IN PHTHISIS.
Dr. LRpine of Lyons, who, starting from the fact that
goats are refractory to phthisis, has been experimenting on
patients by injecting goats’ blood or its sernm subcutaneously
for some little time past, has just described in La Semaine
M6dicale tlie method which his experience has taught him
is the best to employ. He finds that subcutaneous injections
of serum cause so large a surface to become painful that it
is impossible to repeat such injections frequently. When,
however, they are intravenous, they maybe repeated every
two or three days, 80 or 100 cubic centimetres being intro¬
duced each time. ’ There is, too, practically no danger, and
Dir; /edt;. .GO e
The LANCsr,]
A NEW SUBSTITUTE FOR SANTONINS.
[MABCii7,1891. 561
scarcely ary pain, if the serum and all the apparatus are
properly sterilised, and if the operation is conducted slowly.
A goat in good condition will give 400 grammes of blood.
This is drawn through a cannula inserted into the jugular
vein, and is caught in a vessel half immersed in cold water.
It is dchbiinated, filtered through steriliised muslin, and
then put into tubes attached to the circumference of a
revolving disc, which is made to revolve by steam power
•2000 times per minute for about forty minutes; after which,
the separation of the corpuscles from the serum being
complete, the latter is transferred to a sterilised vessel
provided with an indiarubber tube issuing from the bottom
•and closed above with cotton-wool. The patient’s arm
having been disinfected and tied as for phlebotomy, a
prominent vein is selected, and a very line silver trocar
inserted without dissection,-which is by no means a difficult
operation. This is cautiously connected with the indiarubber
tube and the serum allowed to flow into the vein very slowly.
3f the patient should feel malaise, the flow must be stopped
by lowering the reservoir. The highest amount that Dr.
Lepine has transfused at one sitting, has been 100 cubic
■centimetres'. When the blopd itself was transfused not
snore than 40 grammes could be borne, the patients com-
plaining—for some not very evident reason—of extreme
pain in the loins. Dr. Lepiue does not as yet profess to be
•able to. say how far this method of treating diseases
by injecting blood or serum from an animal refractory
•to such diseases is likely, to be successful; but it is, be
considers, a promising idea, and he thinks it has the best
chance of succeeding if the serum only is used, as the cor¬
puscles appear to him, if anything, to hinder the good
•effect.
A NEW SUBSTITUTE FOR SANTONINE.
According to Dr. Coppola santonine is not a true vermi¬
cide, its action on threadworms being that of a convulsant
only, causing movements very similar to those due to epi-
*Jepsy. In this state the worms are unable to coordinate
their movements, and are easily expelled from the intestine
by a purgative. Santonine also labours under other disad¬
vantages ; it is very easily absorbed by the mucous mem¬
brane of the gut, and it sometimes produces toxic efl'eets.
A much better vermicide is to be found in a compound of
santonine, santoninoxyme, which he has recently prepared.
This actually kills the worms, and is well borne in much
■larger doses than can be given of santonine. The best plan
is to give for two or three days three times as large a quantity
as is ordinarily prescribed of santonine, each dose being
•followed by a purgative. _
THE SPREAD OF SANITATION.
The amount of' good which may result from a diffusion
of a kno wledge of the simplest sanitary laws has long been
recognised. The difficulty is that, in spite of legislation
and inspection, little can be done unless these are aided by
'individual appreciation and intelligent coiiperatioc. In
many places lectures'upon the laws of health have been
delivered with the view of rousing interest and supplying
useful facts. But the lecture, when addressed to the
relatively uneducated classes, stands a poor chance of
doing lasting good. If notes are taken, they are frequently
confused, and more frequently still they are incorrect.
Almost a special training is necessary for the task of
jiidiaiously selecting the wheat from the chaff, which so
often forms a large part of a popular lecture. To overcome
this difficulty the Manchester health lecture.s for the people
have been for some time past most usefully supplemented
by their publication in cheap form, but in addition to these ^
the Manchester and Salford Sanitary Association has i
'recently issued a series of tracts prepared for distribution I
at a merely nominal price (2s. per 100). These touch upon
a great variety of topics connected with health—e.g!,-ttie
care of children, the prevention of' blindness in infanoyi
school attendance and infectious disease, how to avoid
scarlet fever and to prevent its spread, the influence of alcohol
upon the system, &c., while in one tract we find grouped
most usefully together the early symptoms of t^e commoner
infectious diseases of childhood. These tracts are-in
simple, straightforward language, and should go fdf-to
accomplish the end in view.
THE SHELTON-STREET IMPROVEMENT
SCHEME.
The St. Giles’s Board of Works are endeavouring to
prevent confirmation by Parliament of the provisional order
relating to the Shelton-street scheme. The main objection
of the Board is to the proposal of the London County
Council to erect a model common lodging-house upon th6
vacant land. The London County Council inherited from
the Metropolitan Board of Works an unfortunate legacy.
The scheme, it will be recollected, was forced upon the Board
by the St. Giles’s authorities, and the Board neglected to
acquire sufficient of the trade premises with which the ared
was interspersed to enable it to be dealt with in a satisfac¬
tory manner. The Council’s diflSculbies are therefore con¬
siderable, and it may be anticipated that when the subject
is discussed in the House of Commons a satisfactory
answer will be given to the objection of the Sb. Giles's
authority. One of the allegations of the Sb. Giles’s Board is
that the vacant land is not sufficiently devoted to the pro¬
vision of artisans’ dwellings, which it is stated are much
needed in that neighbourhood. The area is, however, not
well adapted for buildings of this kind, and, indeed,
it is not obvious how the Council would meet their
statutory obligation to rehouse one half the number of
inhabitants displaced by the clearance were they to adopb
any other course. No doubt the proposal to erect a
common lodging-house will not be looked upon with
favour in the distriefc, especially by the owners of build¬
ings of a similar kind, who may fear that the accommoda¬
tion which they provide will be in less demand than that
of the London County Council. There is not much
probability that the House of Commons, when all the -oir-
cumstances of the case are explained, will refuse to endorse
the decision of the Home Secretary. The chief lesson to
bo learnt from what has taken place is that it is false
economy to carry out an improvement scheme in any but a
liberal manner.
BACTERIA PROTEINS AND THEIR RELATION TO
INFLAMMATION AND PUS FORMATION.
Db. H. B'QCHNKE gave last year tliree lectures on the
relation of bacteria proteins to the inflammatory and pyo¬
genic process, in which he said that it is generally sup¬
posed the proximate chemical cause of inflammation and
formation of pus is the presence of decomposing substances,
the chemical produce of bacterial cells; but that ptomaines
and toxins, and even toxalbumena, are pre-eminently nerve
poisons, and in only a few of them, as in cadaverin and
putrescin, can a pyogenic effeeb be traced as well. These
substances do not, therefore, explain the inflammatory and
pyrexial character of moat infectious irrocesses, including
suppuration, especially as Lange and lloemer have proved
by their experiments that no decomposing substances have
any considerable affinity for leucocytes. Substances having
such affinity, however, do exist, according to the author*,
and he has already referred to them in a previous publica¬
tion. They' are parts of the bacillary body, that is, of
its plasma- namely, the so called bacteria proteins, which
Nencki had already studied in 1880 without imagining their
Dig(tizei,i’r. -^lOO^Ic
563 ThbLanobt,]
THE HOUSING OF THE WORKING CLASSES.
[March 7,1891.
great pathological importance. Dr. Buchner has shown by
his experiments that bacteria proteins have the strongest
affinity for leucocytes, and that in man they also have an
intensely inliammatory effect. A hypodermic injection of
a few milligrammes of the protein of bacillus pyocyaneus
caused an inflammation which, though non-infectious and
free from bacilli, and almost deservingtbename of chemical
inflammation, presented all the clinical symptoms of ery¬
sipelas with lymphangitis ; the course of this inflammation
is, however, more rapid and more benign, and the general
state of health is little disturbed. The author considers
that the proteins can exercise their activity only when they
have been secreted from the bacterial cell, and that this
secretion takes place exclusively when the cell is in
“involution”—that is, dying, or at any rate morbidly
affected. This also explains why in anthrax of rodents,
when virulent bacilli are indefinitely increased in the blood
and never die, there is no sign of inflammatory leucocytosis,
while a hypodermic injection of very weak or even com¬
pletely sterilised anthrax culture has a strong pyogenic
effect in the same rodents. Of seven different bacilli which
the author has been able to experiment upon the proteins
of the typhus bacillus seem particularly effective. It is
very easy to obtain the protein of Friedliinder’s pneumonia
bacillus, and still more so that of the bacillus pyocyaneus.
The protein has the same chemical reaction as all albu¬
minoids, and most nearly approaches in that respect vege¬
table caseins. The author subsequently experimented
on vegetable caseins, especially on the gluten casein
of wheat, and the result was remarkably similar to that
of experiments with bacilli.
THE HOUSING OF THE WORKING CLASSES.
The Paddington Vestry, not satisfied with the results of
the conference held at the offices of the London County
Council on the Housing of the Working Classes Act, in¬
vited to a Conference at the Paddington Vestry Hall repre¬
sentatives of those local authorities who were prepared to
further discuss the matter, aud the first meeting was held
on Feb. 20th. This conference endorsed the resolution
passed at the County Hall, that the Council should con¬
tribute one moiety of the expenses of carrying into effect
all schemes comprising an area of five dwelling-houses aud
upwards, and appointed a committee to further define the
conditions which constitute a house so dangerous or in¬
jurious to health as to he unfit for human habitation.
Certain suggestions on this point were referred to this
committee for consideration. We have already expressed the
opinion that every house must be taken on its own merits,
and that it is impossible to define what is really a question
of degree, and we fail to see that the suggestions are any
nsaterial advance upon the report of the medical officers of
health presented to the meeting at Spring-gardens. Other
proposals were also referred to the committee which enter
into more detail, and among them we note one to the
effect that a bouse is to be deemed so dangerous or
injurious to health as to be unfit for human habita¬
tion if it be without a dustbin.
TRIGEMINAL NEURALGIA.
In the Medical News, Professor Andrews of Chicago
draws attention to a means of relief aflbrded in those
distressing cases where there is a recurrence of the pain
after resection of the nerve. A patient of his, on whom
he had operated by removing a portion of the inferior
division of the nerve, returned after eighteen months again
suffering from pain, and begging for an operation. He
incised the old cicatrix, and, judging that the end of the
nerve was probably attached to the cicatricial tissue, he
got hold of that as deep down as he could, and forcibly
drew upon it and twisted it until it came away. Although
no nervous tissue was discovered in the removed matter,
there is no doubt that even if no part of the stump of the
nerve was removed very considerable traction was exerted
upon It, and to this nerve-stretching the author is inclined
to ascribe the relief from pain which followed the opera¬
tion. This, no doubt, in part at least, explains the result,
but it is also iu some degree to be ascribed probably to
freeing the stump of the nerve from the cicatricial tissue in
which it had become involved.
THE PATHOLOGY AND SURGERY OF THE
APPENDIX C/ECI.
Although the Clinical Society departed from its usua?
course and devoted its meeting on Friday last to an
adjourned discussion on the above subject, yet it must have
been felt at its close that the question had been by no¬
means exhausted. It is one that bas of late years come
promineatly to the front—one, too, in which both physiclane
and surgeons have an interest. It deals, moreover, with n
class of disease of singular frequency, and of varying
fatality. To discuss it adequately would require a debate
much more prolonged than that which has just been
assigned to it. We will therefore content ourselves here
with noting some of the points raised in the course of
that discussion. In the first place is to be remarked
the want of unauimity upon the true nature of so-called
typhlitis—a term which is, in the opinion of some, mis¬
applied to the larger proportion of cases that are at
present included under it. Although Mr. Treves has-
apparently gone back from his former belief as to the-
frequency with which the appendix shares in the production-
of the symptoms of typhlitis, and although, as Mr. Pearce-
Gould showed, the diagnosis of “appendicitis” had in
some quarters been often very erroneously made, still
there is no question that the pathological evidence
of an independent inflammation of the body of the
ccecum is as rare as the verification of an inflamed
and ulcerated appendix in cases of “ typhlitis” is common.
Dfs. Coupland and Kingston Fowler expressed this view
strongly, the latter dealing with definite post-mortem facts.
Mr. Treves laid some stress upon the palpation of an
enlarged appendix through the rectum as serving to dis¬
tinguish the cases; but he did not state whether this plan
had been adopted in the ordinary cases, which recover
under the guiding principles of “rest”; and it is certain
that “relapsing” cases form no very large proportion
of all those in which there is appendix mischief, nor,
indeed, that there is more danger in a relapse than in.
a primary attack. On the whole it will conduce to
lucidity if we regard the appendix as the seat of
the trouble in all classes of cases—those which resolve and
those which lead to more or leas extensive perityphlitic
suppuration. Mr. Bland Sutton’s comparison of the
appendix to the tonsil was suggestive, but hardly essential
to the argument. For although, as he showed, this structure
is richly provided with lymphatic tissue, yet it is by no
means certain that its inflammatory lesions are primarily
evolved and not excited by fmcal or other impacted con--
tents. As to the results of inflammation and ulceration
of this structure, the cases may be grouped under the
following heads 1. Cases where perforation occurs
suddenly leading to general peritonitis. 2. Cases
where the surrounding inflammation is limited, owing
to the formation of adhesions. This class may be further
subdivided into (a) those where there is resolution of the
inflamed products, with or without a liability to relapse -,
Digitized Google
Thb Lancet,]
THE LATE ME. JOHN MAKSHALL.
[March 7, 1891. 563
and (&) those where suppuration takes place, the ultimate
issue beiog uncertain, the pus sometimes burrowing into
the tissues outside the peritoneum in various directions,
sometimes being more or less confined within a peritoneal
abscess, the existence of which is a constant element of
danger to life. There can be no hesitation as to the pro¬
priety of surgical intervention in these latter cases ; but the
fact that the progress of the suppurative inflammation is often
very insidious emphasises the need for a prompt recourse to
surgery whenever possible. A highly interesting point was
raised by Mr. Pearce Gould—namely, whether the diseased
appendix should be removed or not. He advocated the
latter course, trusting to free incision and drainage, and he
was supported by Mr. Charters Symonds; whilst Mr. Sutton,
in bis able reply, contended that this would hardly be an
advance upon the old practice, and that it would be wrong
to leave behind the source of irritation. The final decision
in this matter must be left to the teachings of experience.
One thing at any rate may be hoped for as the result of
this debate, and that is a prompter resort to surgical inter¬
ference when the indications point to extension of the
inflammatory process to the general peritoneum, or Che
flupervention of suppuration.
THE LATE MR. JOHN MARSHALL.
We would call the particular attention of those among
our readers who were friends, pupils, or admirers of the
'late Professor Marshall to a letter which appears in another
column inviting subscriptions to a fund which is being
raised to establish a roemoiial to him in the shape of a bust
und prize in connexion with University College, London.
While it is becoming that the memorial should be attached
to the institution with which Professor Marshall was himself
so intimately associated for half a century, it should not be
.forgotten that the influence of bis thought and activiiies
extended over a wider range. Professor Marshall’s work
was indeed useful and many-sided. He was not only dis¬
tinguished as an anatomist, a physiologist, a pathologist,
and a surgeon ; but as President of the Koyal • College of
Surgeons and of the General Medical Council be took an
active and important part in shaping recent medical polity,
and in botli these offices exhibited administrative powers and
political insight of a rare and very high order. Indeed,
there are not a few who think that, eminent as were his
labours in the more scientific and technical departments of
professional work, his peculiar and special excellences were
most conspicuous in the domain of medical politics and
statesmanship. _
EPILEPTIC DELIRIUM.
In the CentralblaCt fur Klimschc Medicin, 1891, No, 0,
an abstract is given of an interesting paper by H. A.
Wildermuth on Epileptic Delirium. The author first treats
of the chronic psychical degeneration occurring in epi¬
leptics, which has been long recognised and studied, and is
characterised by steadily progressing weakness of intellect,
wliich is easily detected, and needs no special description
or comment. The transitory delirium or incoherency is more
interesting, and demands more attention. It may be divided
into two large classes :—1. The p'lychosee, which are com¬
bined with more or less complete loss of consciousness.
The psychical alterations, which are not so accompanied.
To the first division belongs the epileptic stupor which
often occurs in connexion with severe attacks, and which
may roach any stage, from total loss of consciousness to the
capabiUty of performing simple conscious acts. When eon-
nciousnesa has returned, or partially so, hallucinations are
frecpient, generally having a grotesque purport, and driving
the patients almost to the verge of death from flight, or
putting them in a delirium of joy. These forms generally
follow an epileptic seizure, seldom replacing it and never
preceding it. The second group is far more often
met with. In the less marked eases there is only
a change of “natural inclination.” According to the
relation of time which the mental defects bear to
the epileptic fib, four forma may be distinguished1. The
psychical changes are equally distributed over a aeries of
attacks. 2. The morbid condition of mind is entirely
different before and after the fits; before it is depression,
after exaltation; or this order may be reversed; in the
same patient the same sequence is nearly always followed.
3. The delirium is only apparent after the attack has com¬
pletely passed, and usually takes the form of querulous
mania. 4. The psychical phenomena may take the place of
a fib. The mental complications are very different when
occurring with purely cortical epilepsy; the disturbances of
the intellectual balance appear late, and seldom reach an
extreme grade, and recovery usually occurs.
NOTTINGHAM METEOROLOGICAL AND .
MORTALITY RETURNS.
For some years past it has been the custom to issue
from the municipal buildings at Nottingham a record of
the meteorological conditions observed in the preceding
year, the records being prepared under the direction of the
borough engineer aud the medical officer of health. Those
issued this year by Mr. A. Drown, C E , and Dr. P.
Coobbyer- are, if anything, of even greater value than
formerly ; and it is especially noticeable that much trouble
has been taken in setting out the materials collected,
both as to climatic conditions and mortality, in diagram¬
matic form. Such returns are of great value. Their true
worth cannot 1)9 judged by single reports, but wlien the
causes of a given disease come to be studied it is important
in Ihe extreme to have at hand a trustworthy record of all
the complex circumstances which constitute for a given
locality that which is known as its “climate.” It is
because of the paucity of returns compiled with similar
exactness and care that our knowledge remains so deficient
with regard to the true influence of climate and meteoro¬
logy in the etiology of disease. With increase in accuracy
of notification of disease we may hope to see comparison
made between local meteorological conditions and attacks
from dlil'erent diseases. Hitherto fatal attacks have alone
been dealt with. _
CIRRHOSIS OF THE LIVER AND NERVOUS
SYMPTOMS.
In the St. Bartholomew’s Hospital Reports, vol. xxvi.,
Dr. Onnerod directs attention to a curious and important
class of cases in which extreme cirrhosis of the liver is pre¬
sent, and in which the symptoms are mainly nervous. He
relates the particulars of one which was under the care of
Dr. Gee. The patient was a boy of ten, who had three or
four months before admissiou developed weakness with
cramped position of right hand and arm and difficulty in
speaking. This condition became more pronounced, and was
accompanied by gradual mental impairment, difficulty in
swallowing, and finally some atfection of the left arm and
hand. Daring the time he was ia hospital his condition
was characterised by severe attacks of pain, extreme noisi¬
ness, and idiotic appearance. The electrical condition of
the muscles femained unchanged in spite of the contractures
and weakness. During the last three months of life he bad
occasional attacks of pyrexia, sometimes with profuse
sweatingbe developed bedsores; the urine became alka¬
line and pbospbatic, and mental hebetude became extreme.
The optic discs and fundi underwent no change. At the
necropsy the liver was found to be in a state of extreme
cirrhosis, aud the only lesions found in the nervous
Digitized hy
564 ThbLancbt,]
THE INFLUENCE OF EXERCISE ON DIGESTION.
[March 7,1891.
system were two smal], almost symmetrical patches of
Boftenisg in each lenticular nucleus, and two minute points
apparently also of softening in the pons. Dr. Ormerod, in
his comments on this case, mentions one or two similar
cases, of which, however, he is unable to give full notes;
but reference is particularly made to a set of cases recently
published by Professor Homen in the Neurologinchcs Central-
hlatt. These cases were three in number, and the patient^
were all members of the same family. Their symptoms
were giddiness, headache, mental failure, unsteady gait,
and difficulty of speech, together with contractures of the
limbs, and in two of them there were found, in addition to
slight changes in the cortex cerebri, softening in both
lenticular nuclei and well-marked cirrhosis of the liver.
These cases offer a new problem in symptomatology, for,
whatever may be the relation of the slight changes found in
the nervous system to the symptoms produced during life,
there seems to be little room for doubt that the funda¬
mental morbid condition is the cirrhosis of the liver.
THE INFLUENCE OF EXERCISE ON DIGESTION.
Dr. STRENCi, in a lecture before the Medical Society of
Giessen on the Influence of Exercise on Digestion, which
has been published in the Deutsche Medicinische Wochen-
schrift, states that he concludes from his own experiments
that this influence is of a retarding nature. His experi¬
ments, however, suffer from the fact thatbealways injected
.300 cubic centimetres of water before obtaining the con¬
tents of the stomach, so that the proportion between gastric
juice and w’ater continually varied. The first experiments
in the clinic at Giessen were made on two dogs. Twenty-
five grammes of meat, suspended in 300 cubic centi¬
metres of warm water, were twice injected into the fasting
stomach, and after one feeding the dogs were compelled
to remain for three hours in absolute bodily rest, while after
the other feeding they were made to take active exercise.
After the three hourg the contents of the stomach were
obtained and analy.sed. The quantity did not essentially differ
in the two cases ; the experiments consequently tended to
prove that exercise does not influence the time required for
digestion. The chemical analysis also detected no difference.
The same results were obtained by substituting the white
of an egg for the meat. The experiments were then
repeated twenty-five times on three men with healthy
stomachs. Two of these suffered from sycosis, and the
third from incipient muscular atrophy. Tliey were fed
each time with 200 grammes of minced meat, a bun, a
plate of bouillon, and three spoonfuls of mashed potatoes,
and the contents of their stomachs were obtained four hours
and a half afterwards. The exercise after meals consisted
partly in gymnastics, partly in walking; absolute rest was
obtained in bed. These experiments gave the same results
as those on the dogs, the difference resulting from the
chemical analysis being especially imperceptible. The
author therefore concludes that the gastric function is in
no way influenced either by muscular action or by absolute
rest. __
TUBERCLE OF THE LARYNX.
The article in Virchow's Archiv, Bd. cxxi,, by E. Fraenkel,
on the Etiology of Tubercle of the Larynx, will well repay
perusal. The task the author set himself was to answer
two questions: 1. Whether all ulcerations of the larynx in
phthisical subjects were to be considered as specific, or
whether ulceration may sometimes be due to other causes
than the tubercle bacillus? 2. Is tubercle of the larynx
the product exclusively of tubercle bacilli in the tissues of
the part, or are other organisms also concerned in intensify¬
ing the effects and supporting, as it were, the action of the
true pathogenic organism ? By careful microscopic examina¬
tion, and also by means of cnltivation experiments, the fol ¬
lowing results were arrived at. The presence of tubercle
bacilli in the tissues is the most important factor in the pro¬
duction and further development of the characteristic
changes in the larynx; but in a considerable number off
cases a secondary infection may take place in the affected
tissues by other micro-organisms, such as the staphylococcus
and streptococcus. In thirteen out of eighteen case.s these
organisms were found in addition to tubercle bacilli. It
appeared, however, that deep ulceration producing exfolia¬
tion of the cartilage is purely the result of the action off
the tubercle bacilli. Again, in the ulceration usually
designated as “ aphthous,” or “ lenticular,” tho bacilli were
always found. Fraenkel is very strongly of opinion that,,
according to his researches, the bacilli reach thedeepev tissues
through the epithelium, although this may be little, if at
all, diseased. The number of bacilli present seems to stand
in no relation to the intensity of the destructive process. In,
general, the axiom propounded by Baumgarten and Weigert
holds good—namely, the more numerous the giant cells, the
less in number are the bacilli. The entry of the strepto¬
coccus and staphylococcus is always secondary, the tubercle
bacilli invariably lying deeper in the tissues. The phleg¬
monous process that sometimes occurs may, indeed, be caused
by micrococci. In one case in which there was an ulcer in the
trachea from which an abscess had spread into the front-
part of the neck only micrococci could be discovered, and)
no tubercle bacilli. In reference to the second question
quoted above, the author states as his opinion that any
marked disease of the larynx in consumptive patients-
must be considered as the product of the tubercle bacillus;,
but the results are commonly intensified by the engrafting
of pyogenic organisms. Fraenkel only twice found disease
of the larynx in tubercular subjects from which tubercle
bacilli were absent. In one of the coses there was a shallow
ulcer on the inner surface of the arytenoid cartilage above-
the processus vocalis, this being the only lesion to bo seem
in the larynx and trachea. In the second case the trachea
was the subject of disease, this being undoubtedly of a tuber¬
cular nature; but over the processus vocalis was an ulcer
in which no bacilli could be found, and which Fraenkel-
thought was not specific. These non-tubercular ulcers are-
to be considered as mycotic necrosis of the epithelium, being
a similar process to that which occurs in enteric fever.
THE REGISTRATION OF BRITISH NURSES.
The opponents of the Royal British Nurses’ Association-
held a meeting on the 27th ulb. at St. Thomas’s Hospital for
the purpose of concerting measures to oppose the licence to-
register the Society without the word “ limited ” as a part-
of its title, for which application has been made to the-
Board of Trade. To say that objections can he urged'
against the proposed register of nurses is to say no more-
than that it is like everything else that is human, whether
good, bad, or indifferent. It was proved with much energy
of conviction that no register could exhibit, and no registra¬
tion test could determine, all the qualities of a good nurse.
All this may be freely admitted, and yet it may prove in,
the end desirable that a register should be established for
the purpose of recording and publishing such facts concerning
the qualilications of nurses as are capable of being scheduled.
The present is, however, hardly an occasion that calls for
a discussion of these general questions. Whether the Royal-
British Nurses’ Association shall be registered by that titles
or by the title of the Royal British Nurses’ Association-
(Limited) is nob an issue which naturally or properly leads to
ageneral discussion of its merits. Its promoters are entitled-
to registration under the Companies Acta if they satisfy
certain atatutabJo conditions concerning the raising and
holding of their capital and other property, and they are
Diyiiiztt-.J -jy ^ooglc
Thb Lancet,]
WEATHEK CHANGES AND THEIK WORK.
[March?, 1891. 565
entitled to i-egistration in the way desired if they satisfy
the Board of Trade that their Association is formed, not for
profit, but for the purpose of promoting “ art, science,
charity, or any other useful object,” and that the intention
is to apply the profits, if any, or other income of the Asso¬
ciation, in promoting its objects, and to prohibit the pay¬
ment of any dividend to the members of the Association.
We cannot imagine that they will find any difficulty in
furnishing this proof, and if so the present opposition will
be futile. Under the circumstances it seems to us to be
singularly ill timed, for although the considerations agitated
at the St. Thomas’s Hospital meeting would be very proper
to be laid before the Privy Council on an application for a
charter, they ought not to affect the decision of the President
of the Board of Trade. _
EXPERIMENTS TO DETERMINE THE CENTRE
OF RESPIRATION,
De. Labordb communicates to the “ComptesRendus de la
Soci6te de Biologie” the results of experiments made by him
to ascertain the nerve centre for respiration, promising a
larger work at some future time. He found that superficial
mechanical injury to the region of the aim cinerem does not
accelerate respiration ; a deep puncture decreases, or even
temporarily arrests, respiration ; if the injury penetrates at
least to the middle of the substance, respiration may cease
altogether. This result is always obtained if a certain
circumscribed portion of the substance is cauterised with
the hot iron. This portion need in the rabbit be only half a
millimetre in diameter, in the dog from one to two milli¬
metres. The iron must, however, enter immediately above
the apex calami, and must penetrate at least half the sub¬
stance from the raphe. If the injury is unilateral, respira¬
tion may continue for some little time on the opposite side.
Total separation of the medulla below the apex calami
always arrests respiration of the trunk, while that of the
head continues for some time. Spinal reflexes continue, and
even increase; irregular superficial contractions of the
respiratory muscles, leading to no results, may be observed.
The increase of the reflex action is especially remarkable in
new born animals. No parts of the brain above the medulla
oblongata, including the cortex, the corpora quadrigemina,
and thalami optici, have any specific influence whatever on
the respiratory muscles. __
WEATHER CHANGES AND THEIR WORK,
Every winter as it passes leaves behind, in evident
marks of disease and death, proofs of the close relation at
all times existing between man and his constant environ¬
ment of atmospheric tenipej-ature. We iiave already had
occasion to notice the consequence in certain cases of ex¬
posure to the mere cold of the recent severe winter, and to
trace in.them the somewhat unfamiliar evidences of frost
bite, systemic and local. We have still more recently had
to do with related iniluencea, which, however, belong to
another class, and though apparently less violent in
their action, are even move dangerous on account of
their more insidious and uncertain operation. No sooner
has the thaw set in, and a promise of coming spring
breathes now and then through the lengthening days, than
there come also the petty chills, obscurely localised, of
unaccountable origin, prone to be overlooked by the
sufferer and those about him, yot full of mischievous
possibility. These are the natural accompaniments of the
breaking season, the morbid counterpart of those per¬
petually changing movements of temperature, moisture,
and air density, which by degrees and with some amount
of bodily illness and discomfort will bring us forward to
more equable conditions. To find these latter will be
Nature’s fee to hied and enduring organs, but some will
have perished in the trial. Perhaps not a few even of the
stronger constitutions, endowed with much elastic vitality,
will not have met without grave change and peril the swift
variations of weather which we have lately had to face.
Certainly we may say that when spring is reached many of
the feeble young and the time-stiffened aged will not have
safely passed through the daily alternations of frost and
balmy sunshine, with sudden gales and chill overburdening
fogs, hut will have found among them the end of their
earthly way. For all, but especially for such as these,
avoidance is the truest caution. But this is not always
possible, and careful management of the person therefore-
becomes an imperative and somewhat anxious duty. In-
parcicuiar, let us urge the necessity of warm woollen
clothing. No form of clothingisequally protective. Further,
it is to be hoped that the public may be wise enough to-
aummon their trusted medical advisers to treat at the out¬
set the beginnings of illness, or to follow out by consecutive-
measures the morbid changes immediately following. By
the time that a mere chill has developed into pneumonia^
for example, the fittest opportunity for treatment is already
passing away, for in this class of diseases we must sow
betimes our remedies if we would reap success.
MEDICAL REPORTS AND THE PROOF OF
INSURANCE CLAIMS.
We receive from time to time complaints from so many
medical practitioners of the demands which are made upon
them in connexion with the proof of claims upon insurance
offices arising upon the death of patients that we have-
thought it desirable to inquire fully into the subject, and
to state for the benefit of the profession generally the resnlfr
of our inquiries. The practice which gives rise to this disr-
cussion is this: When a claim is made upon an office two-
things have necessarily in every case to be proved—namely,,
the death of the person whose life was assured, and the-
title of the person claiming to receive the proceeds of the
policy. Most offices, however, stipulate for something,-
more than this—that is to say, for a report by the medical
attendant upon the fatal illness. Such a report is in¬
teresting to the paying office in many ways. It adds-
statistical nraterials to the records of the case. It serves in
some cases of long-standing illness to detect a concealment-
or deception that may have been practised upon the ofiice-
at the time of effecting the insurance, and it affords very
valuable evidence of the identity of the deceased person.
All these are points upon which the directors of the com¬
pany may reasonably enough desire to be satisfied ; and if'
they have stipulated with their policy holder that such evi¬
dence shall be given, they may reasonably enough ask to-
be satisfied at his expense. It appears probable, however,
that the demand is made in behalf of some companies which
have no right to insist upon it, having undertaken, os the-
phraso runs, to pay on proof of death and title. When-
that is the case the demand ought to bo resisted by
claimants, but the practice is now so general that a-
claimant seldom knows whether be is liable to satisfy it,
but always assumes that he is. He therefore asks the-
medical attendant to fill up the form, and becomes liable-
to pay him the fee for so doing. Bub he commonly
expects bo get it done gratuitously, and we believe that-
the custom of many practitioners is to acquiesce in this-
course. In the circumstances it must no doubt be left to-
roedical men to deal as they think proper with every
particular case. We entertain no doubt that the legal
right is what we have indicated above. If the offices
became liable in these circumstances to pay the fee, there-
could be no difficulty or delicacy about exacting it. Un¬
fortunately, however, that is not the case, for the practice,
and we believe invariable practice, is to ask not the medicaS
Dig!...:ed by _lOO^Ic
566 Thb Lancet,]
THE DISFIGUREMENT OF KENSINGTON GARDENS.
[March 7,1891
afctesdaQt, but the clalmaut, to provide such a report.
This interposition of his patient’s representatives at such a
time betvi'een him and the oflice is undoubtedly a hardship
to the medical attendant. The ditficulty in the vray of its
^removal is, hotvever, so far as we can see, insuperable. The
claimant must necessarily be the paymaster, and as, the
office stands in a more or less hostile attitude to him, it is
not likely to take any part of the burden off his shoulders.
THE DISFIGUREMENT OF KENSINGTON
GARDENS.
In order to justify, if that be possible, such an evident
barbarity as is contemplated by the Paddington and Ken¬
sington Subway Bill, there must at least be the prospect of
.great public advantage or the proof of a great public neces¬
sity. Neither of these conditions has up to the present
time been shown to exist. On the contrary, there is already
very free communication by road and rail between the
parishes already mentioned. Yet it is proposed, with little or
no reason beyond that afforded by themereenterpriseof specu¬
lation, to deface one of the most tastefully planted and most
popular of the larger parks with which London is favoured,
It is not therefore surprising that under the circumstances
Mr. Plunket was recently questioned at some length in the
House of Commons as to the scope of the proposed measure,
and it is evident that so important a matter as the
preservation of this beautiful area has been far too little
■considered. Among other matters, we learn that a number
of trees will be permanently destroyed. This is hardly sug¬
gestive of subterranean transit under ordinary conditions,
but is rather indicative of an overground route, which,
whatever its advantage from a commercial standpoint,
could not fail to disfigure the park, and, in our opinion,
•quite needlessly. The Bill has already passed a second
reading, but we have it on record, by way of consola¬
tion, that the Select Committee, the subscribing public,
and, lastly, Her Majesty, who is the final custodian of this
Royal gift to the metropolis, may refuse to sanction the
proposed very material alterations in its character. There
•can be no doubt that the scheme in its present form is
impossible, and it clearly behoves the committee, to whom
its future course is now for a time entrusted, either to
refuse it altogether as a needless and vandalic undertaking,
or to ensure for the subway a passage which will be unde-
•structive, underground, and unobtrusive.
SURGICAL TREATMENT OF PULMONARY
CAVITIES.
The bold endeavour to radically attack phthisical
•cavities and drain them, although introduced some years
ago, has been lately receiving fresh advocacy, especially
■in relation to the treatment of phthisis by Koch’s “ tuber¬
culin.” Many of the dangers of this remedy in advanced
cases of phthisis rest upon the retention of necrotic
material within the lung, and the liability to its being
■■inhaled into previously unaffected areas. Dr. Sonnenberg
recently operated upon four cases undergoing this treatment,
and Dr. E. Leser of Halle reports two more.^ One of these
was a female aged forty-three, •who bad had symptoms
for four years, and presented physical signs of excavation
at the left apex. The operation consisted in making an
incision in the first intercostal space, seven centimetres
long, and, after dividing the muscles and securing blood¬
vessels, introducing a trocar in the direction of the cavity.
Although no fluid could he obtained, it was evident that
'the point of the trocar was in the cavity, and the pleurro
1 MOncheiier Med. VVoch., Fob. S-fth.
being firmly adherent, an aperture was bored through the
layer of tissue overlying the cavity by means of a Paquelin’s
cautery, the trocar being taken as a guide. The cavity
was the size of an apple, bad somewhat irregular walls, and
was coated with flakes of inspissated pus and caseous matter;
these were removed, and the cavity stuffed with antiseptic
gauze. Subsequently the patient was injected with Koch’s
“tuberculin,” which always caused increased discharge
from the cavity; and later still some of the fluid was
directly introduced into the cavity itself. At the last report
the patient had improved much in general health, and the
cavity bad dwindled to one-half its former size. The second
case, a man aged forty-two, was similar, except that in him
the cavity was no larger than a chestnut, and was situated
at the right apex. Here, too, the use of tuberculin produced
increased discharge, and on one occasion its direct injection
into the cavity was followed by severe vomiting, dyspncea,
and other alarming symptoms. Dr. Leser, however,
thinks this mode of treatment has a future before
it. At present he would make it a ivm guA non
that the costal and pulmonary pleurce should bo firmly
united, as they usually are when cavities are of some
standing; and he enters fully into the technique of the
operation, laying stress upon having a fairly large incision
through the thoracic wall, but not a very large aperture
made in the lung, since this will be sure to increase by
sloughing. The notable feature of these cases seems to be
the immediate relief to cough and expectoration given by
the external opening, although, when the injections are
resorted to, the secretion becomes so much more abundant.
LENTEN FASTING.
A TENDENCY to ascoticism is not a distinguishing feature
of the British character, and it naturally follows that the
austerities of Lent have no very wide prevalence among us.
Systematic fasting still is observed indeed, hut it is at
best the custom of a considerable minority. Yet it cannot
be said that the practice in itself is necessarily an unwhole¬
some one. In some cases and in due measure it is probably
advantageous in a physiological sense. In others it is,
judged by the same standard, but little to be recom¬
mended. The habitual and full flesh-eater, for ex¬
ample, may well intermit his daily round of two
or three meat meals by allowing an occasional fast
day, and the rest thus afi'orded his overdriven digestive
organs will be repaid in his present comfort and their
subsequent healthy action. We might even go so far
as to say that few persons in robust health would not rather
benefit than otherwise if the more stimulating elements
in their food were at stated intervale, say, once a week,
omitted or reduced in favour-of the more bland. There
are, however, other persons whose condition is at any time
under par, and these may nevertheless, nay often do,
exhibit an almost abnormal zeal for abstinence.* Here,
again, physiological rule is in danger of infringement. In
such cases fasting in any strict sense, whatever its moral re¬
lation to the soul of man, amounts to a sin against his body,
A clerical writer, on fasting in Lent, sees tit to rally the
medical profession on its as.sumed reluctance to control
those excesses in diet which provide it with occupation.
We will not mistake fur earnest a jest so trite and so
manifest. The above remarks, however, will servo to show
that medical practitioners are careful above all to inculcate
moderation as the rule of life, and to impress its import¬
ance upon the too eager and aelf-aillicting spirit no less
than on the unbridled appetite. Since it is, after all, the
physical condition which must qualify or disqualify in a
matter of this kind, it is obviously advisable that anyone
desirous of fasting should consult his medical adviser
j before so doing.
Digiti,:^8d by i^ooQle
The Lancet,]
PROFESSOR KOCH’S TREATMENT OF TUBERCULOSIS.
[March 7, 1891. 567
FOREIGN UNIVERSITY INTELLIGENCE.
Buda-Pesth.—'DT. Laufenaur has been 'promoted to the
lull rank of Professor of Mental Diseases,
Erlangen. —Professor Leo Gerlach has been promoted to
the chair of Anatomy, Dr. Friederich Hermann taking his
place as Prosector, with the rank of Extraordinary Pro¬
fessor.
Florence. —Dr. A. Lustig has been appointed Extraordi¬
nary Professor of General Pathology.
Giessen. —Dr. Hoingman has been re'cognised as privai-
docent in medicine.
Seidelherq, —Dr. Hofmann has been promoted to the
chair of Nervous Diseases. He was a pupil of Erb, and has
l^een his first assistant for several years.
Eome. —Dr. Conasanti has been appointed Extraordinary
Professor of General Pathology.
Vienna. —Dr. A. Edler von Rosthorn has been approved
as privat docent in Midwifery and Gynajcology.
At the meeting of the Royal Medical and Chirurgical
Society next Tuesday, March 10th, Dr. Hale White and Mr.
Golding-Bird will, between 8 and 8.30 P.M., before they read
their paper, demonstrate by means of the phonograph the
peculiarity of speech to which the term “ Idioglossia ” has
been applied. The children as improved by treatment will
also be shown. Dr. F. Taylor and Dr. Hadden will also
show cases.
At the next meeting of the Hunterian Society on
March 11th Dr. Hughlings Jackson will exhibit Phono¬
gram-talking of a Patient the subject of Disseminated
Sclerosis.
At the meeting of the Medical Society of London on
Monday next, the adjourned discussion on Angina Pectoris
will be opened by Dr. Lauder Brunton.
Mr. HjiRBERT F. Waterhouse, M.D,, C.M. Edin.,
F.R.C.S. Eng., has been appointed Assistant Surgeon to
Charing-cross Hospital.
Dr. H. P. Hawkins has been appointed assistant phy¬
sician to St. Thomas’s Hospital.
PROFESSOR KOCH’S TREATMENT OF
TUBERCULOSIS.
Professor Virchow, at the meeting of the Berlin
Medical Society on the 25th nit., again referred to Koch’s
treatment, and showed some specimens in illustration of
his remarks. He doubted whether the statement by Dr.
B. Fraenkel, as to the duration of miliary tubercle, based on
inoculation experiments, was correct—namely, that a period
of three weeks is required for its development. The ques¬
tion was one to be decided by clinical observers, for it could
not be determined by pathologists. If one were to admit’
that in all those cases in whicii miliary tubercle is
found this has been present before the injections were
practised, then a much longer extension must be given to
the duration of miliary tubercle than has hitherto been
assigned to it. A distinction in this respect must be made
between local tuberculosis and the general acute disease
which creates such marked, constitutional disturbance. He
detailed a case of pleuritic effusion under the care of Pro¬
fessor Leyden, in which phthisical signs, with laryngitis
and fever, developed whilst under treatment by Koch’s
injections, death supervening four weeks after the first
injection. In this case there was very marked general
miliary tuberculosis,—suhmiliary granulations occurring
in liver, kidneys, thyroid, larynx, and in parts of the
peritoneum, including the recto-vesical pouch, as well
as in the lungs, which were also tho seats of old apical
mischief. Here was a case which certainly did not come
under the class referred to by Dr. Fraenkel, for.it had been
long under observation and bad been injected before the
supervention of the acute tuberculosis. Professor Virchow
also showed a lung from a patient who had received eighb
injections which presented a large caseous mass in procesa
of separation, and an intestine exhibiting a very marked
eruption of tubercles and implication of the lacteals in the
vicinity of ulcers.
Professor Cantani of Naples, in giving the results of his
experience with Koch’s remedy {Beri. IPocA.No. 9),
points out that the important part of the method is the
production of local reaction, which in eome cases occurs-
without any general febrile disturbance. This local reaction,
he said, is nothing else than a quickening of the natural
processes whereby the organism seeks to get rid of the
materies morbi. He found more marked improvement in
cases where there was no fever and only slighj; local
reaction—cases in which the commencing doses were very
small, and their repetition with slight increase in quantity
made at some intervals. He further explained that many
of the alleged dangerous results of the treatment are prone
to occur in the spontaneous course of tubercular disease,but-
may occur more readily and rapidly from the hastening of
the necrotic process by the injections. Nor should the
result of every case that is fatal whilst undergoing this
treatment be assigned to the latter; and he did nob
doubt that when the time came for a full survey it
would be found that the favourable results would counter¬
balance the unfavourable. As to the prospect of Koch’a
fluid curing tuberculosis, Professor Cantani remarked that
the changes observed in lupus were very hopeful. In th&
lungs the physical signs denote the occurrence of similar
changes to those observed in lupus, and the increased
bacillary expectoration was evidence of the focus being
destroyed. But the impediment to the free removal of the
necrosed area in the case of the lungs was against marked'
progress, although this was noted in eome cases. The
laryngeal cases showed more obviously the local improve¬
ment. Professor Cantani points out that phthisis embracea
not only tuberculosis, but other septic processes due to tho
presence of pyogenic organisms ; so that in advanced cases
little can be expected from tho treatment, which in such
must be followed with the greatest caution, if at all. He
did not think the time had arrived for a definite conclu8ion>
to be formed as to the efficacy of the method in phthisis,
and deprecated too great enthusiasm on tbe one -hand and
depreciation on the other as contraiy to the interests of
truth. The remedy was new and its eflects striking, but it
must be farther studied before its practical value is^
appraised. At any rate, Koch had shown the paoh to be
taken by bacteriology in the future, and tbe progress of
knowledge would cause its further e.Ktension.
At the Aerzte Verein in Prague last week Professor Cbiari
gave an account of seventeen further necropsies on casea
of tuberculosis treated with Koch’s fluid. He divided them,
into two main groups. In seven, mostly in children, the
doses had been small and the results were mostly negative-
In one case—a woman—temporary extension of the dul-
ness was noted clinically, but nothing was noticeable post
mortem. la tbe second main group distinctive reactive:
changes were always present. He placed them in three
clasBQs: 1. Cases of severe tuberculosis. 2. Surgical
tuberculosis. 3. Miliary tuberculosis apparently contem¬
poraneous with the injections. Tbe first class all showed
the hypermniic exudation to which he drew attention in his
first eases. In one case where there was laryngeal ulcera¬
tion the appearance of the tuberculous tissue was much
more necrotic than usual. In another, where two distinct
ulcerations could be seen with the laryngoscope some time
before death, (he aid of the microscope was necessary to-
show its existence post mortem, when one very small
(healing ?} ulcer was detected. The other seemed,
quite healed. In another case, where the tuberculosis
was extensive, almost the whole lung was in a condition of
hepatisatioD, and there was hardly any air-containing tissue^
left. In the bronchial glands in this case the miliary
tubercles appeared almost like sequestra. The second class.
seem to promise most for the success of tbe treatment, as.
some ulcerations appeared to be almost healed. In one
Diy.J by GiOOglc
S68 Thb Lancet,] EMERGENCY RELIEF DURING THE GREAT FROST IN PAItlS. [March 7,1891.
«ase, where there was also a tuberculous nodule iu the luug,
it was surrounded by a species of colloid matter. The third
group compels the most serious consideration. Two cases
•of not T6ry severe tuberculosis after the second injection
developed milmry tuberculosis. In conclusion, he dwelt on
the power of tne injection in causing inOammatory hyper-
jemia, and re-enunciated the caution u-bout using the fluid
where there is extensive disease, as the reaction may practi¬
cally obliterate the patient’s already diminished breathing
•space. Curative processes weresometimes distinctly present.
The cases of miliary tubercle, though demanding most
serious consideration, were too few to draw any delinite
•conclusion from, In answer to Prof. Jaksch, he said that
he had not examined the blood, as the process was so \id-
iieliable post-mortem.
ROYAL SOCIETY.
The following are abstracts of three papers read on
Feb. 3th by Dr. Anderson Stuart, Professor of Physio¬
logy, Sydney University:—
On the connexion between the Suspensory Ligament of the
•Crystalline Lens and the Lens Capsule. — The common
teaching is that there is a direct continuity of substance
between the suspensory ligament and the capsule of the
^ens, but an observation % the author of the paper seems
to indicate that the ligament is only cemented to the
•capsule. On opening eyeballs in an advanced state of de¬
composition (putrid), he found the lens in its capsule per-
■fectly free, and no indication of any rupture of tissue along
the line of attachment of the suspensory ligament. This
ligament was found intact, projecting from the collapsed
■vitreous body as a sort of frilled ring with a free edge.
These points are best seen after the Gross staining of the
•structures, as described by the author ia the Journal of
Anatomy and Physiology.' The observation bears upon the
•still unsettled question of the development of the lens
capsule, and upon cases of detachment of theligament from
the capsule, of atrophy and solution of the ligament, and of
(luxation of the lens.
A Simple Mode of demonstrating how the Form of the
Fhorax is partly determined by Gravitation —Remembering
how poteut and how constant is the action of gravitation,
and arguing that the segments of the thorax were so many
rings of more or less elastic mutter, the author concluded
■that if similar rings of any other elastic material were
•suspended in the same way, the form of the thoracic seg¬
ments should be reproduced, provided there intervened no
•other condition strong enough to counteract the action of
•gravitation. The author finds crinoline steel most con¬
venient, though bands of paper do very well. The forms
cf the thoracic segment of the quadruped, of the human
'f(ctu8, and of the human adult are necessarily reproduced
if the hoop be held between the finger and thumb and
gradually turned from lying in the vertical to lie in the
horizontal plane. The complete reproduction of thefeatures
of the human adult thorax at its most characteristic level
•is most striking ; this is when the steel as usually sold is
some six feet long and half an inch wide. As the hoop is
made smaller the forms of the higher segments appear in
succession. The points that are thus reproduced are so
numerous and simultaneous that the author cannot believe
them to be mere coincidences, and concludes, therefore, that
•gravitation has had a greater influence in determining the
typical form of the chest than would generally be ad¬
mitted. This is supported by the shapes assumed-by the
•steel rings when the mode of snspension is varied from the
normal, as in deformities of the vertebra;; here the par¬
ticular form in the individual—the tlioracic deformity—ia
more or less accurately reproduced.
On a Membrane Lining tht Fossa Patellaru of the Corpus
Vitreum. —The existence of a membrane hero had been the
subject of discussion «ro and co«. till 188f)-87, when the
matter was considered by some to have been finally set at
rest by Schwalbe, who decided against it in very clear and
explicit terms. According to his description the vitreous
jelly itself lies against thelens capsule andforms the posterior
boundary of the canal of Petit, if such it could be called, for
•the canal, he says, is merely to be compared with the other
clefts in the vitreus. Any membrane that had been seen he
declares to be an artificial product the result of the action
of reagents. The author, however, finds that in the
perfectly fresh, unaltered eye, after the removal of the lens
and its capsule the membrane may be raised olF the jelly,
and that when stained and mounted it does not disclose any
structure. Isolated and tied over the mouth of a test-tube,
the membrane from a four year old ox sustained a column of
forty inches of water, and a somewhat smaller column than
this may be sustained for days. Isolated and dried it forms
a delicate membrane. It is thinner in the centre where it
lies against the lens capsule, thicker peripherally where it
forms the posterior wall of the canal of Petit, which is thus
a true canal. The line of separation of the two parts is
fairly sharp, and when the entire vitreus is squeezed the
middle of the anterior face may be seen to bulge more than
the periphery does. The sun’s rays concentrated upon it
show fluorescence as marked as in the case of the hyaloid,'
and at a puncture the fluorescent sharp edge of the mem¬
brane U strikingly distinct from the glassy appearance of
the jelly showing through the hole. Treated with picro-
carmine by the Gross method of staining (described by the
author in the Journal of Anatomy Physiology), the
membrane is red, the jelly is yellow, and now its wrinkles,
as the vitreous floats in the water, are seen just as in the
case of the hyaloid- In successful meridional sections of
the eyeball the membrane is seen in situ. For ophthalmo-
logical practice a knowledge of the existence of this
membrane is most important, and the observations of
ophthalmologists strongly support the author’s observations.
EMERGENCY RELIEF DURING THE GREAT
FROST IN PARIS.
Considerable surprise and admiration have been ex¬
pressed throughout Europe at the prompt and wholesale
character of the relief given to the homeless in Paris
during the recent severe weather. Casual wards had
already been established ia Paris, where applicants may
receive hospitality for three nights. They are given a good
douche, a bowl of soup in the evening, a piece of bread in
the morning, and their clothes are stoved and disinfected
during the nights. The accommodation thus afforded in
normal times by the municipality amounts to 244 beds at
the Quai Valmy refuge, 22.'j beds at the Hue Cbflteaux des
Rentiers, and 200 bods for women at the Rue Fessart.
There are also night refuges organised by private charity
in the Rue St. Jacques for 130 women and fifty children,
and in the Rue Labatt for forty more women. For men there
are 140 beds in the Rue de Tocqueville, 250 in the Rue
Charonne, and 210 in the Boulevart Vaugirard. Thus in
normabtimes the Municipality provides 609 beds, and private
charity 820. The help thus given contrasts favourably with
our English workhouses and casual wards in the sense that
nothing is done to humiliate the recipients of the i-elief. It
is considered that they are entitled to the hospitality given,
at least in the municipal refuges, as a sort of return for the
taxes they have paid in more prosperous days.
When the great winter set in the 1489 beds men¬
tioned above were rapidly filled, and the doors of the
Municipal Councillors, who consent to receive applica¬
tions from inhabitants in distress, were besieged • by
starving crowds. Dr. Paul Brousse, Vice-President of
,the Municipal Council, received in one single morning
280, all from his own district, which consists of but one-
eightieth part of Paris. A great number of these applicants
had been driven from their homes through inability to pay
the rent, and therefore could not receive relief from the
Assistance Publique, as inquiries must first be made at the
domicile of the applicant. Dr. Paul Brous.se—and we are
glad to note that what was done was due to the initiative
of a member of the medical profession—called in M.
Thuillier, a fellow Municipal Councillor, as a witness of
this distress, and together they applied to M. Alphand,
Prefect of the Seine, insisting on immediate action. M.
Alphand responded by at once establishing eighty braseros,
or open fire-gratos, in the streets, so as to revive those
who were weakened by the cold. Half an hour later
Dr. Brousse and his companion called on M. Peyron,
the Director of the Public Assistance, who declared that
stretchers were blocking the space between the beds in the
hospitals, so great was the crush of the sick poor. Pro¬
ceeding to M, M enant, Director of Municipal Affairs, who
: c L-oo^le
The Lancet,]
NOTIFICATION OF DISEASES ACTS.
[Makch 7,1891. 56^
bas in bis charge the night refuges, it was at once agreed
that supplementarv night refuges must be opened. The
bureau of the IlOtel de Ville was convoked by urgency, and
with the greatest promptitude it organised relief in a
wholesale manner. What is most remarkable is the
readiness with which Dr. Brousse's efforts were supported
by the authorities concerned, the absence of red tapeism,
and the rapidity of the action taken. Abroad wo have
heard principally of the night refuge, which held some
2000 persons, organised in the art galleries in the exhibition
palace of the Champ de Mars, and the pavilion where 100
women received shelter. But other supplementary refuges
were opened in the Gymnasium Voltaire for 800 persons,
in the gymnasium of the Rue d’Allemagne for 330, in the
Rue C16raut for 180, in the Rue Paj'ol for 200, in the Rue
St. Maur for 190, and in the Rue Jenner for 30 women.
Altogether an average population of 3900 to 4000 was
provided in these supplementary refuges with food and
sleeping accommodation. The maximum reached on any
One day was 4500. The beds consisted of a straw mattress
and a military rug provided by the War Department, and
the Municipality provided the management, the premises,
and soup morning, noon, and evening. Soup was also
f iven to those who did nob sleep at the night refuges,
ub who declared they were in want. Altogetiier as many
as 24,000 servings of soup were given out in a day. This
soup was made of dry vegetables, such as haricot beans,
peas, lentils, salt, and lard. Bones could not be obtained
at a sufficiently low price or in large enough quantities, and
of course all green vegetables were exorbitantly dear during
the frost. It is calctilated that the soup cost about seven
centimes per portion; a little more than a halfpenny, and
a little less than three farthings. At this rate two persons
would be fed for three halfpence; and the lard was found
a fair substitute for meat. Soup of this description
still contimies to be distributed at all the refuges through¬
out Paris to the poor in the neighbourhood. Though the
weather is now much milder, 17,000 portions of soup per
day were given out last week.
Of course, it will be objected that such widespread charity,
distributed without question or check, must tend to
pauperise a number of people. This is not the view the
Parisians take of the matter. They argue that it must
tend to maintain the vitality of the race and to prevent
illness and death. Undoubtedly many of the recipients
were unworthy objects ; but it was practically impossible
to separate the chaff from the corn. The oljject in view
was to save life and not to inquire into the moral character
of those who were evidently suffering. Tlie dilliculfcy that
does cause some anxiety, and even alarm, is the necessity
of closing the temporary refuges opened during the
exceptional stress of the weather. Of course, a considerable
numoer of the occupants of the refuges have obtained
work and have left, but some 2500 still remain, and among
these are the individuals who are the least worthy of sym¬
pathy. They were naturally the first to come, and will be
the last to go. As the weather is now milder, and there i?
no longer the same excuse for the distress, questions are
put to those who remain in the refuges. Of the 2000 at the
Champ de Mai's it was found that 1200 had their papers in
order, and could give satisfactory explanations of them¬
selves. No less than 600 had Hocked into Paris from the
outside rural districts as soon ns they heard that relief was
so freely given in the capital. Arrangements will be made
to send them back to their native districts. Of the
thousands helped only some 500 persons seemed re¬
luctant to give explanations about themselves or allow
inquiries to be made. Setting down the number of persons
received in the night refuges established to meet the ex¬
ceptional distress at an average of 4000, the advisability of
helping some 500 of these is open to question. Admitting
that it is not right or expedient to give relief to a criminal
or an incorrigible idler—and it is questionable whether even
the 500 con be thus defined,—is it not better to commit this
mistake with regard to the .500 dubious cases rather than
neglect the 3500 other and more worthy persons ? If one in
every eight is undeserving, public health would be gravely
compromised by the abandonment of the seven because some
doubts are entertained about the eighth. Such neglect
IS all the more inexcusable when we consider how
very small is the cost of relief like that given in
1 ans. There was, of course, no rent to pay, as the
edihces used belonged to the Municipality, The bedding,
provided by the Ministry, was certainly not worth
more than eight shillings, or ten francs at the very
outside. The 4500 to 5000 beds of this description cost, let-
us say, £1800. The bedding has nob been destroyed, no-
attempt was made to steal any of the rugs, the wear aod
tear has nob done more than deteriorate this property to tbe-
extenb of a few hundred pounds. The management of the
refuges and the distribution and the making of the soup
cost, in all, £60 a day. P’or this very small sum,
thousands of persons have been saved from the
intense rigour of the winter, and all the horrors-
of starvation. It is not often our pleasure bo record
that it has been possible to accomplish with so small a.
sum so great a good. The braziers, on the contrary, cost
£80 a day, and the heat they gave out, lost in the space of
the streets, was of comparatively small service, though the
expense was considerable. These fires were consequently
not maintained for long.
In conclusion, we would urge that the Paris Municipality
has shown us how relief can be organised very promptly, on
a very lai-ge scale and for an extraordinarily small outlay-
When the winter is as rigorous and the distress as exceptional)
as they were during January, such wholesome relief, given
without hesitation, stint, or question, must have materially
helped to preserve life and prevent illness.
NOTIFICATION OP DISEASES ACTS.
On Tuesday, March 3rd, at the Clerkenwell Police-court,,
before Mr. Bros,Mr. FrederickLefevre Milburn, M.R.C. S. Sec .,
appeared in answer to a summons taken out at the instance of
the vestry of Clerkenwell, charging him, under the Notifi¬
cation of Diseases Amendment Act, with having neglected
to report for five days a case of typhoid fever which had
come under his care. The case was instituted in order to
ascertain the meaning of the words of the Act which require
that notification shall be made “ forthwith.”
The first witness called was the mother of the child, who
stated that in February last her child suffered from typhoid
fever, and was attended by Mr. Milburn, who informed her
of the nature of the disease on Feb. 12bh, having mentioned
to her on Monday, the 9bh, that there were symptoms of
typhoid fever in the case. At this point the prosecutor
intimated tliat he could not carry the case further, as the-
evidence of the witness was at variance with what he had
been informed had happened.
Mr. M. A. David, Barrister-at-law, instructed by
Messrs. Rookes and Co., who defended the case at the-
instance of the Medical Defence Union, stated that
as a matter of fact very serious reflections had been thrown
upon the defendant on account of a total misapprehen.sion
of the circumstances. As he understood the facts from
Mr. Milburn, they were exactly as the witness bad stated.
It was perfectly true that on Feb. 8bh the doctor had been
consulted, and it was most important to see what was the-
nature of the disease. Cn Feb. 9bh there were certain
symptoms much more developed, but it was nob until the
evening of the 12bh that the medical man was able to deter¬
mine by the general symptoms that the case was one of
typhoid fever. Having done so, Mr. Milburn did not
even trust the post, but on the morning of the 13bh he
actually delivered personally the notice that is required by
the statute. It was perfectly clear that this was giving
notice forthwith in accordance with the provision,? of the-
stabute. Typhoid fever was very difficult to determine
until many clays after the incipient symptoms had appeared,
and he had come prepared with six medical gentlemen to
give scientific evidence in support of that contention. He
hoped his Worship would at least say that there waa no-
reflection on Mr. Milburn, and that tiie whole matter had
evidently arisen from some misconstruction placed upon
something that the witness had told the inspector.—The
Ih-osecutor: It may have been that some error has been
committed, but the witness told both the medical officer of
health and the inspector that live days had elapsed before
notification, and they were quite willing to enter the box,
and swear to that fact.
Mr. Bros thought the case very important; and under
the circumstances, although the case could not go on, he had
allowed the counsel for the defendant to make a public
statement. The case ought never to have been brought
there at all; and to mark his sense of the gravity of the
mistake he would, although no application had been made,
allow one guinea costs.
570 Tm Lancet,]
PROPOSED REGISTRATION OF MIDWIVES.
[March 7,1891.
PROPOSED REGISTRATION OF MIDWIVES.
DEPUTATION TO TUB LORD PRESIDENT.
A DEPUTATION from various medical bodies had an
interview with Viscount Cranbrook, the Lord President,
at the Privy Council Office, on the 27th ult., in support
of the Bill introduced by Mr. H. Fell Pease, M.P., for the
educational examination and registration of midwives.
Dr. Farquharson, M.P., introduced the deputation.
Dr. FARQUHAR.SON said they came less in support of a
particular Bill than in the interests of general legislation
irequired by the community. It would be an advantage if
the Government could grant a select committee, before
which the subject could be thrashed out, and evidence
taken.
Mr. SiDLEY said that in all other countries midwives
were more or less nnder State control, but in England
any woman, although ignorant and unqualified, might call
herself a midwife, and practise as sued. The Obstetrical
Society and two or three other bodies now granted certifi¬
cates, but it was most needful that all professing midwives
should have to pass through a definite course of study and
examination.
Mr. Fell Pease, M.P., said he would be ready to with¬
draw the present Bill if the Government would appoint a
select committee on the subject.
Dr. Grigg said it had been found that of the number of
women delivered in Edinburgh, for instance, 1 in 120 died
within a month after delivery ; and in other places he had
found the proportion to be at least 1 in 100. It was often
not until the last gasp that the medical man was called in.
Dr. James Aveling said the services of midwives were
indispensable to many of the poor who could not afford to
employ medical men, and, moreover, the midwife combined
the functions of the medical man and the monthly nurse.
Public safety demanded legislation. There were in this
country 900,000 births per annum, and of' this number mid-
wives attended about 500,000. The average’’mortality in
childbirth was about 1 in 200; but it was found tliat in the
cases undertaken by such trained midwives as were
employed in lying-in hospitals the mortality waa only 1 in
fiOO. If this reduced rate of mortality could be extended
generally, it would mean an annual saving of the lives of
3000 mothers. As midwives had at childbirth the care of
two lives, it followed that the midwives of this country
had annually under their care no fewer than one million
lives. Surely this was a sufficient reason for legislation,
it had been said that the medical profession was divided on
this subject, but he believed the opposition to be an ener¬
getic minority, which did nob include eminentobstetricians.
Dr. Barnes said he also thought it was most desirable
that mid wives should he made responsible to society through
recognised bodies, so as to check illegal practices.
Dr. Playfair said he was quite satisfied that most of the
objections which had been urged against the Bill were
fictitious and untenable or capable of being easily overcome.
It was clear that, as such a Bill could not be retrospective,
existing interests must be recognised and protected.
Lord Cranbrook, in reply, said he thought it might be
taken for granted that there was an almost unanimous
•desire to improve the qualifications of midwives so far as it
was possible to do so by legislation. More than twelve
years ago there was an attempt in a Government 13111 to
deal with the subject, but that provision had to be taken
out because of the opposition it encountered. He found
there were now considerable objections taken to tlie County
Gouncils having anything to do with the matter, nor was
favour extended to the idea that the Privy Council as a lay
body should decide the difficult question as to what was a
iond-fido midwife. He would nob himself like to venture
upon a definition, and he did not know where he could get
responsible medical advice which would enable hini to
lay down rules under which midwives could come upon
the Register. Difficulties also arose in connexion with
the protection of the interests of existing midwives,
and from the fear that the legislation proposed might
deprive many country districts of any mid wives at
all. Many of them might nob bo able to go to
the expense of the prescribed education without making
such increased charges as would disqualify them from
getting such employment as they now obtained. Was
it to be laid down that the mere fact of practising as a
midwife after a prescribed date should be of itself con¬
sidered an offence ? Hitherto in this country there had been
no such exclusion, and' he could not help thinking that in
a number of country districts the women who now under¬
took these duties would still be called in by the poor and
would still occupy the position that they do now, even
without the registration, on account of the cheapness and
under a genertu belief that, after all, there were few cases
in which serious difficulty arose. He had great difficulty in
making out who was to lay down the proposed rules of
education for midwives, who was bo keep the Register, and
who was bo be responsible for it. Medical men were divided
in opinion, and the Medical Council was understood to a
certain extent to reject the position which would naturally
be assigned to it. It would be impossible for the Privy
Council to act satisfactorily in this matter unless it was
supported in an official and responsible manner by the
medical profession, which support at present was nob forth¬
coming. With regard to the suggestion of a select com¬
mittee, be could not at present give an answer to it, for he
had nob yet had an opportunity of laying the suggestion
before his colleagues, and he would have to consult them.
Speaking for the Government, ho could not this year support
the Bill which Mr. Pease had brought forward ; nor did be
think there would be a chance of amending it this year in a
manner satisfactory to the medical profession, the public,
or the midwives already in practice. With regard bo the
whole question, be would give it his careful consideration,
and would be glad if he could meet the wishes of this and
otlier bodies in a way which might be calculated to give
the satisfaction which, he was afraid, they could nob get by
attempting to pass a Bill this year.
The deputation then withdrew after Dr. Farquharson
had thanked the Lord President for receiving them. Earlier
in the afternoon a large deputation of ladies from various
nursing associations «!vc., introduced by the Countess of
Aberdeen, had an interview with Lord Cranbrook for the
purpose of urging reasons in favour of the same Bill.
THE LONDON HOSPITAL.
Mr. J. H. Buxton presided at the quarterly Court of
Governors of this hospital on Wednesday last, and, in
moving the adoption of the report, took occasion to correct
an error he made at the last meeting in reference to the
number of nurses who had been dismissed by the matron.
What he should have said was that eight engagements had
been terminated by the matron during the last two years.
On the subject of nursing he had nothing to say except tliat
it had been very much in the minds of the committee, who
were always glad of advice and criticism, to do what they
could to perfect that branch of the hospital. At the present
time they were in the middle of a scheme for an alteration
in that department. Nothing definite had yet been adopted
with the exception of appointing two men to do certain
work which had hitherto been done by the nurses.
Mrs. Hunter said that the chainnan’s correction was an
important one, and if anything had been wanted to confirm
her convictions .respecting the nursing department, it had
been furnished by the report. Undue responsibility had
been laid on the nurses, who did not receive the pay, bub
had to do the work of the staff nurses, and the anxiety so
occasioned tended to produce the collapse which finally
occurred. The question relative to the sending of nurses to
private patients had not been met by the report. She
pointed out tliat one-fourth of the nurses, after having been
selected by the matron, were afterwards rejected. She
suggested that a subcommittee connected with the nursing
department should be appointed to consider the questions
relating to the nurses of that institution.
VITAL STATISTICS.
health op ENGLISH TOWNS.
In twenty-eight of the largest English towns 0210 births
and 4020 deaths were registered during the week ending
Feb. 28th. The annual rate of mortality in these towns,
which had increased in the preceding three weeks from
19'8 to 21‘6 per 1000, farther rose to 24T last week. The
rate was 23-7 in London and 24-4 in the twenty-seven
Coogic
Dir:
The Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Maucii 7, 1891.
provincial towns. During the past eight weeksof the current
quarter the death-rate in the twenty-eight towns averaged
23’5 per 1000, and exceeded by 0’5 the mean rate In theeor-
reaponding periods of the ten years 1881-90. The lowest rates
in these towns last week were 13-8 in Plymouth, 14-6 in
Derby, 18 .3 in Hull, and 18'4 in Portsmouth; the highest
were 28'G in Bristol, 30‘4 in Huddersfield, 33‘9 in
Halifax, and 38’9 in Blackburn. The deaths referred to
the principal zymotic diseases, which had increased from
.382 to 381 in the preceding three weeks, farther rose to
431 last week; they included 150 from measles, 139 from
whooping-cough, 52 from diphtheria, 37 from diarrhoea, 30
from scarlet fever, 23 from “fever” (principally enteric),
and not one from small-pox. No deaths from these diseases
were recorded in Brighton, Norwich, Plymouth, Wolver¬
hampton, and Cardiff; while they caused the highest
death-rates in Leicester, Bristol, Huddersfield, and Black¬
burn. The greatest mortality from measles occurred in
Leicester, Huddersfield, Bristol, and Blackburn; from
scarlet fever in Derby and Preston; from whooping-cough
in Leicester, Huddersfield, and Halifax ; and from “fever”
in Birkenhead. The 52 deaths from diphtheria included 32 in
London, 4 in Birmingham, 4 in Manchester, 3 in Liver¬
pool, and 3 in Sheffield. No death from small-pox was regis¬
tered in any of the twenty-eight towns, and one case of
small-pox was under treatment in the Metropolitan
Asylum Hospitals on Saturday lost. The numoer of
scarlet fever patients in the Metropolitan Asylum Hos¬
pitals and in the London Fever Hospital at the end of
the week was 1242, and showed a further decline from
recent weekly numbers; the patients admitted during
the week were 80, against 97 and 113 in the preceding
two weeks. The deaths referred to diseases of the re¬
spiratory organs in London, which had increased in the
preceding three weeks from 428 to 524, further rose last
week to 685, and exceeded the corrected average by 202. The
causes of 102, or 2'2 per cent., of the deaths in the twenty-
eight towns were not certified either by a registered
medical practitioner or by a coroner. All the causes of death
were duly certified in Portsmouth, Norwich, Bristol,
Sunderland, and in three other smaller towns. The largest
a ortions of uncertified deaths were recorded in Livor-
, Preston, Huddersfield, and Sheffield.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had been 21'4 and 22-6 per 1000 in the preceding
two weeks, further rose to 23'S during the weekending
Feb. 28th, but was slightly below the rate that pre¬
vailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns
ranged from 17'0 in Perth and 18'2 in Dundee to 2G'6 in
Paisley and 27’8 in Glasgow. The G20 deaths in tlie-'c
eight towns showed an increase of 29 upon the number in
the preceding week, and included 27 which were referred
to wliooping-cough, 18 to measles, 11 to “fever,” 10 to cUar-
rhma, 7 to scarlet fever, 7 to diphtheria, and not one to small¬
pox. In ail, 80 deaths resulted from these principal
zymotic diseases, against 50 and G2 in the preceding
two weeks. These 80 deaths were equal to an
annual rate of 3T per 1000, which exceeded by 0 7
the mean rate last week from the same diseases in the
twenty-eight English towns. The fatal cases of whooping-
cough, which had been 13 and 20 in the preceding two
weeks, were 27 lost week, of which 9 occurred in Edin¬
burgh, 7 in Glasgow, and 5 in Leith. The deaths from
measles, which had been 8 and 10 in the previous two
weeks, further rose last week to 18, and included 9 in
Glasgow and 8 in Paisley. The 11 fatal cases of “ fever "
also showed a further increase upon recent weekly numbers ;
4 occurred in Edinburgh and 3 in Glasgow. The 7 deaths
from diphtheria corresponded with the number in the pre¬
ceding week, and included 2 in Greenock and 2 in Glasgow.
Of the 7 fatal cases of scarlet fever, 4 occurred in Glasgow
and _2 in Aberdeen. The deaths referred to diseases of the
respiratory organs in these towns, which had been 138 and
140 in the preceding two weeks, further rose to 146 last
.week, but wore .55 below the number in the corresponding
•week of last year. The causes of 49, or nearly 8 per
^^nt., of the deaths in the eight towns lost week were
nwt certified.
It HEALTH OF DUBLIN.
Thexdeath-rate la Dublin, which had increased in the
preceding three weeks from 26 6 to 27’3 per 1000, further
rose to 29 4 during the week ending Feb. 28th. During the
first eight weeks of the current quarter the death-rate in the
city averaged 31‘8 per 1000, the rate for the same period
being 23'6 in London and 20'9 in Edinburgh. The 109 dea^a
in Dublin showed an increase of 14 upon the number in the
preceding week, and included 4 which resulted from dian-hcca»
3 from “fever,” 1 from diphtheria, 1 from whooping-cough,
and not one either from small-pox, measles, or scarlet fever.
Thus the deaths referred to the principal zymotic diseases,
which had been 3 in each of the preceding two weeks, rose to
9 last week; they were equal to an annual rate of 1'3 per
1000, the rate from the same diseases being 1*8 in London
and 3'2 in Edinburgh. The 4 fatal cases of diarrhoja ex¬
ceeded the number recorded in any week since November
last. The deaths referred to different forma of “ fever,”
which had declined from 4 to 0 in the previous four weeks,
rose again to 3 last week. One fatal case of diphtheria was
registered, corresponding with the number in each of the
previous four weeks. The 199 deaths in Dublin included
42 of infants under one year of age and 57 of persons
aged upwards of sixty years; the deaths of infants showed
a further increase upon recently weekly numbers, while
those of elderly persons showed a slight farther decline.
Four inquest cases and 6 deaths from violence were re¬
gistered ; and 53, or nearly a fourth, of the deaths occurred
m public institutions. The causes of 20, or nearly 10 per
cent., of the deaths in the city were not certified.
THE SERVICES.
A TfiiANGULAii Bandage.
Surgeon R. R. Sleman, M.A., of the 20th Middlesex
(Artists) Rille Volunteers, has recently brought out a
Triangular Bandage with a printed key to it, in connexion
with the Volunteer Ambulance School of Instruction. The
various figures on the bandage clearly depict the methods'
of using it. The bandage can be obtained of Messrs. Savory
and Moore.
Tub Afghan Campaigns.
The Jourml of the United Service Institution of India has
a paper by Surgeon-Major (h J. H. Evatt, M.D., of the
Medical Staff, describing that officer’s personal recollec¬
tions of the Afghan campaigns of 1878-79-80. The present
is the first part of the report, and Dr. Evatt proposes in
a subsequent paper to deal with the occurrences of the
second campaign, where much progress was made, and
apparently required, aud the lessons learned in 1878-79-
were largely made use of. The record is interesting as it
sets forth what occurred when the medical service, mobilised
in a hurry and with little cohesion or defined method of
work, had suddenly changed over from our old system to
an entirely novel one.
Ahmy Medical Reserve of Officers.— Surgeon-Major
Geo. Paddock Bate, M.D., 5th Battalion, the Rifle Brigade
(the Prince Consort’s Own), to be Surgeon-Major, ranking
as Major (dated March 4th, 1891).—The notification in the-
Gazette oi Feb. lOth, 1891, that Surgeon'William Duncan,
M.D., F.II.O.S. Eng., ceased to be an Officer of the Army
Medical Reserve of Officers, is cancelled.
India Office. —The Queen has approved of the follow¬
ing appolutuxents to Her Majesty’s Indian Medical Services
Surgeons on probation to be Surgeons, ranking as Captains
(dated Jan. 31st, 1891)Bengal: dames Muir Crawford,
John William Wolfe, Bawa Jiwan Singh, Hugh Koberc
Campbell Barber, Charles Henry James, Fredk. O’Kinealy,
Christopher Clemons Cassidy, and Arthur Wm. Treminhere
Buist-Sparks. Bombay: Ernest Gerald Robt. Whitcombe,
Frank Erskine Murray, Henry James Younger, and Banian
Das Bosu.
Naval Medical Service.— The following appointments
have been made at the Admiralty:~Staff Surgeons: Wm.
B. Drew to the Trafaltjnr, Richd. D. White to the Colling-
wood, and Ileniy C. Walsh to tlie Neptune (all dated
March 2Qd, 1891); William Bennett to the Alexandra,
(dated March 8th, 1891). Surgeons: John P. J. Coolican to
the Vioid, for tlie Royal Naved Barracks (dated March 7th,
1891); Alfred E. Weightman to the Wildfire, additional
(dated March 7th, 1891); and William O’Meara to the
Alexandra (dated March 8th, 1891); Mr. Joseph William
Gallagher to be Surgeon and Agent at Kellybegs, and Mr.
Die Google
572 The Lancet,] THE “ REVISED SCHEME OF THE UNIVERSITY OP LONDON. [March 7,1891.
Thomas M. Pollard to he Surgeon and Agent at Trihane
[both dated March 3rd, 1891).
Royal Naval Artillery Volunteers. — (Clyde
Brigade): Surgeon John MacIntyre, M.B., to be Stall
Surgeon (dated Feb. 21&t, 1891).
Volunteer {^< yRVS .— Artillery: lat Cornwall (Duke of
Cornwall’s), Western Division, Royal Artillery: Acting
Surgeon J. Quick resigns his appointment (dated Feb. 28tb,
1891).— Rifle: 2ad (Prince of Wales’s) Volunteer Battalion,
the Devonshire Regiment: William Square, Gent., to be
Acting Surgeon (dated Feb. 28th, 1891).—Ist Volunteer
Battalion, the Cheshire Regiment: Surgeon A. Craigmile,
M.D.. resigns bis commission (dated Peb. 28th, 1891).—
3rd Volunteer Battalion, the Cheshire Regiment: Acting
Surgeon T. Fennell to be Surgeon (dated Peb. 28th, 1891).—
4bh Volunteer Battalion, the Cheshire Regiment: Acting
Surgeon E. Chamberlayne, M.B,, resigns his appointment
[dated PeK 28bb, 1891).—Isb Roxburgh and Selkirk (the
Border): William Turnbull Barry, M.B,, to be Acting
Surgeon (dated Peb. 28bh, 1891).—3rd (the Blybhswood)
Volunteer Battalion, the Highland Light Infantry: Acting
Surgeon A. D. Moffat to be Surgeon (dated Peb. 28th, 1891).
Volunteer Medical Staff Corps.— The Edinburgh
Division: William Henry Barratt, M.B., to be Acting
Surgeon (dated Feb. 28bh, 1891).
Corrjsfonknte.
"Audi alteram partem,"
THE LATE MR. JOHN MARSHALL, E.R.S.
To the Editors of TnE Lancet.
Sirs, —The former colleagues and'many of the friends of
the late Professor John Marshall wish bo establish a memorial
of him in connexion with his alma mater. University
College, London. It is proposed that, primarily, the
memorial should take the form of a bust, to be placed
within the College. In the event of the contributions to
the fund which is being raised for this purpose being more
than enough, the surplus will be set aside for the foundation
•of a mize in the medical faculty of the College, to be called
the Marshall Prize. As there are doubtless among your
readers many of Mr. Marshall’s friends and old pupils who
will be glad to cooperate in this attempt to perpetuate the
memory of his useful and many-sided labours, both within
the profession and without, we beg to be allowed to state
that subscriptions may be sent on or before April 11th next
to the Treasurer of the fund, Mr. John Tweedy. 100.
Hailey-street, W.
Wo are, Sirs, yours truly,
Thomas Barlow, M.D., \
10, Wimpole-street, W., I Honorary
Victor Horsley, f Secretaries.
80, Park-street, W., j
THE “REVISED SCHEME” OF THE
UNIVERSITY OF LONDON.
To the Editors o/ The Lancet.
Sirs,— Having served many years on the committees of
Convocation and having given evidence before the Royal
Commission on its behalf, may I again appeal to your
readers on the most recent phase of the University
question? The latest revised scheme of reconstitution
which you have published in your columns has nob yot been
officially communicated to Convocation, and members of
that house have been refused copies of it. This appears to
be a suicidal policy upon the part of the promoters of the
scheme directed towards a body which possesses, and no
doubt will not hesitate to use if it see fib, the right
of veto. It may, however, be consistent with tlie in¬
tention of first squaring all outside claimants, and
then having thus cornered Convocation endeavour to
compel its reluctant submission. Meanwhile opposi¬
tion to the wholesale dissolution of the University
is growing apace; arts and science and law graduates, who
have no interest to serve save that of “the promotion of
regular and liberal education throughout Her Majesty’s
dominions,” are not slow to recognise the tendency of the
new scheme to destroy the unity and high standard and in¬
dependent character of our pass examinations. I ask per¬
mission to add a few criticisms upon the medical aspect of
the scheme.
The Fellows of the Royal College of Physicians and the
Council of the Royal College of Surgeons have approved
the scheme. The lormer body, not, however, wichout the
defection of a minority, appear to have swallowed their
objection of last year to the delegation of the control of ex¬
aminations by the Senate to a body partly outside itself.
The Council of the College of Surgeons, without consulting
the Fellows, in accordance with the newly recognised
power, and the expressed desire of some of its number,
appear to have approved without division the new scheme,
with wliich, according to the chairman of their committee
on the subject, his colleagues were very imperfectly ac¬
quainted.
Let us follow a hypothetical medical student’s career
through the curriculum which the new scheme implies, up
to the coveted M.D. London. First of all, if procession to
the preliminary scientific is to be conditional on matricula¬
tion, or what is to serve as ica substitute, his paterfamilias
will be wise in sending him to University, or King’s, or
some other constituent college in arts and science, with
which an arrangement has been come to under Clause 46
for a modified matriculation. If he go to one of the other
medical conatibuent^colleges, or, if a woman, to the School
of Medicine for Women, then the ordinary matriculation must
be encountered. Now either the matriculation is to remain
what it is, or it is to be lowered probably to the level of the
College of Preceptors examination in arts. If it is to remain
what it is, medical students will remain where they are,
with the first gate remaining shut except to a better few,
or they will drift into constituent colleges with an arts
faculty and a modified matriculation; if the matriculation is
to bo lowered for medical students, and presumably then for
all, it would save a great deal of misconception and mistrust
by candidly saying so. Next, an undergraduate will come
up for the preliminary scientific with its 50 per cent, of
rejections. If he be a University or King’s man he may
take their collegiate intermediate B.Sc., perhaps, in lieu of
this; if not, then under pressure from the corporations and
medical colleges, anxious to prevent an exodus to Scotland,
down will come the standard of the preliminary scientific.
The intermediate and pass M.B. examinations, as conducted
under Clause 47, must tend bo simulate the ordinary exa¬
mination for the M.R.C.S. and L.R.C.P., and will present
little difficulty.
Even then the new “M.B. London” will find his heart’s
desire of the doctorate unsatisfied. The admonition of the
University against M.B.’s assuming thabtible will disturb his
conscience. TheM.D.istoremain“under theabsolutecontrol
of the University,” for which may be read, under the control
of the Standing (^lommittee in Medicine, with its ten out of
nineteen members representing the two London medical
Colleges and English teaching bodies. Now, it is common
knowledge that the demand for the title of “ Dr.” has filled
the sails of the agitation for the Teaching University and
carried it along. Will those teachers who have urged this
popular demand rest content with this stoppage just short of
the promised land ? Of course they will not; they would
be foolisli if they did. Logic and psychology and mental
physiology will be thrown to the winds, and the M.D.
London of the future will exhibit only slight histological
difl'erences from the M.R.C.S. and L.R.C.I‘. All this is
very sad, and comes of attempting tho impossible—of incor¬
porating metropolitan teaching colleges into a cosmopolitan
examining university. Even the Vice-Chancellor, Sir James
Paget, would appear not to have foreseen this inevitable
result when in May, 1886, he assured the assembled
graduates and undergraduates that “he was not one of
those who advocated the lowering of the standard of
excellence of the University ; it was not proposed bo inter¬
fere with the working of the University; it was proposed to add
something better rather than create aomctiiing different, and
it would certainly not tend to lower the standard in any one
dec/ree"; nor the Chancellor, Lord Granville, when in .
1887, anlid loud cheers, ho declared “ the high character of :
our degrees will he maintained." Bir Philip Magnus not) s',o
very long ago waxed eloquent over the “undue and pre¬
ponderating influence” of the teachers, and
sequently imperilled standard of examination, as well as
The Lancet,]
INFLAMMATORY DISEASE OF THE UTERINE APPENDAGES. [Mauch 7, 1891. 573
over the rights of Convocation as distinguished from out¬
side bodies. Surely be cannot give a tacit assent to this
scheme. Anyway, a committee of Convocation is organising
opposition to the scheme, and either the honorary secre¬
taries or myself will be glad to hear from any medical
graduate who will join this committee.
I am, Sirs, yours faithfully,
W. J. Collins, M,S., M.D., B.Sc.
1, Albert-terrace, Regent'a Parle, March let, 1891.
P.S.—Since writing the above I have received from the
University a “memorandum in explanation of the scheme
for the reorganisation of the University,” which, unlike the
scheme itself, is not “ conlidential.” Tti^jpi^cejnsiicaiive
is presumably intended to anticipate objections on the part
of Convocation. As, in dealing with the medical degrees,
it states that the Royal Colleges and medical schools are
solicitous of maintaining the standard and scientific cha¬
racter of these degrees, one can only conclude that the
author of the document is a guileless innocent or a lawyer
expert in compromise and totally ignorant of “ the medical
grievance.” __
TREATMENT OF CPIRONIC INFLAMMATORY
DISEASE OF THE UTERINE APPENDAGES.
To tha Editors o/Thb Lancbt.
Sms,—The statements made by Dr. Herman and others
on the one hand, and Dr. Cullingworth, Dr. Bantock, and
myself and others to the contrary, are so widely discrepant
that it will be the wisest plan for all concerned, particularly
for the sake of suffering women, that someinquiry be made
as to what is the cause of the misunderstanding. By strict
logical analysis of the statements, it becomes perfectly
ovident that one factor has not been properly estimated—
that is, what may be called the personal equation. The one
statement is to the effect that chronic inflammatory diseases
of the uterine appendages in the majority of instances get
well, and without any kind of surgical treatment. The
statement, on the other hand, is that they rarely do get
well, and my own conviction is that the exception is so
remarkable that it may almost be discounted entirely.
From these diverse statements of the case it must be
perfectly evident that we are not speaking of the same
•thing, and that what Dr. Herman calls chronic inflamma¬
tion of the uterine appendages, I certainly should not
■dignify by that term. Those of us engaged in the surgical
treatment of these cases verify our diagnosis and justify
•our treatment of these cases by the display of the prepara¬
tions, and these preparations indicate conditions of the
disease which put the matter of diagnosis, at any rate,
altogether beyond the question, whatever may bo thought
■concerning the treatment, It is not so with Dr. Herman
and his school, for they have so far presented no confirma¬
tion whatever of their assertions. The personal equation
■element then of the difficulty is that Dt. Herman does not
diagnose as cases of chronic inflammatory disease of the
uterine appendages those cases which we do; whereas we,
on the contrary, disregard as altogether too trifling the
class of cases which Dr. Herman considers to be deserving
•of that name. Such is my own explanation.
Personally, I see a very large number of cases which
belong to the same group entirely as those of whicli I
believe Dr. Herman is speaking, and they uniformly get
well; but I never speak of these cases as coming within tlie
categoryof chronic inflammatory diseaseof theuterineappen-
•dages. It rests with Dr. Herman to let us see some of the
cases, as he understands them, in their initial stage, so that
we may discover if possible where the misunderstanding lies.
5n fact, I do not think it would be at nil a difficult matter
to place a real value upon this personal equation. An ex-
jperiment of a somewhat rough, but quite satisfactory, kind
would settle the point. Let tlie two diverseschoolsof opinions '
be represented oy two such persons as Dr. Herman and
wyself. Lot Dr. Herman or anyone else of his school select
a number of cases, say, twelve or twenty, or even a hundred,
■of what they call “chronic inflammatory disease of the
uterine appendages.” Let them be examined by the other
representative person, say, by myself, and concerning each
case on a partieulardate written opinions giving diagnosis and
prognosis by Dr. Herman and myself shall be placed together
in a sealed envelope, neither knowing what the otlier has
written. This envelope shall he placed in the custody of a
chird person to be selected by the two. After an interval of
six months or twelve months, or any time which may he
agreed upon in any particular case, a second examination
of the patient is to be made and similar written opinions
concerning the diagnosis and prognosis shall be made
by each of the observers, unknown in every instance
to the other. An analysis shall then be made by the
third person of each group of cases, and these shall be con¬
trasted by the results to be ascertained by the person in
whose custody the envelopes have been placed. The cases
would always fall inevitably into two groups : those that
had got well and those that bad not, and the value of
the personal equation will be determined, by one factor
alone, upon which side the prognosis of recovery or the
prognosis of non-recovery falls with the greater certainty.
So far as my opinion goes, the treatment of either case is a
matter of relative indifference so long as rest in bed during
the menstrual period is made obligatory.
A personal equation of another kind seems inevitably to
step in the moment the operation of removal of the uterine
appendages comes to be discussed, and that has been very
well illustrated in the case of Dr. William Duncan, whose
critics have desired to show that he has had an improper
because disproportionate number of cases of removal of the
uterine appendages not affected by large cystic disease, as
compared with those in which this large cystic disease had
occurred, as if the two classes of cases had a constant relation
to one another. Such an assumption is perfectly preposterous.
The MiddlesexHospital has had for averylong time a number
of beds devoted to cancerous diseases, and therefore can¬
cerous cases have been attracted to that institution for very
manyyears. Itismoretlianlikely,therefore, that fh^clienUie
of the Middlesex Hospital will have a larger proportion of
cases of malignant disease in it than will have the London
Hospital, where there is no such special provision, and
where the population is, on the other hand, subject to a
disproportionate number of accidents. Any institution
which had existed for nearly a generation, such as the
Samaritan Hospital, with a large reputation for dealing
with ovarian tumours, will have a disproportionate number
of tumour cases, and so on indefinitely. A number of
qualifying incidents can be exposed which would render a
constant relation of any two classes of cases in any one ex¬
perience, either hospital or individual, equally improbable.
Such relation must depend largely upon reputation and
upon other surrounding circumstances, many of which are
quite inscrutable. I am, Sirs, yours truly,
Bii-mingham, Feb, 26tli, 1891. LaWSON TAIT.
TI-IE FACTORY ACT AND CERTIFYING
SURGEONS.
To the Editors of TlIE LANCET.
Sirs,—K indly permit me briefly to supplement my letter
of last week. The position of certifying factory surgeons
was admirably defended by Sir Lyon Playfair, Sir F.
Milner, and by many other members who followed, in the
late debate in the House of Commons, and our thanks are
due to them for their advocacy of our cause. But none of
the speakers insisted sufficiently on one important point.
It was argued that there was no reason for the existence of
certifying surgeons, because there was little or nothing for
them to do and their occupation was gone. It was stated
that unhealthy “ young persons” seldom or never presented
themselves for examination or employment. This statement
was by no means conclusively proved ; but if true, why do
the unfit decline to offer themselves ? That is a crucial
point, and one to which I wish to draw especial attention:
plainly and clearly because employers and employed knew
and know that it would be useless to do so in face of a law
which requires a certificate not only of age but of health
and fitness from a medical man. Abolish that deterrent
inlluenec, and as sureJy as night follows day you will
behold a recurrence of the evils which that influence over¬
came and which it keeps so efficiently in check.
I am, Sirs, yours faitlifully,
Man-li 1891. MALLEUS iNJUSTITI.r:.
NOTIFICATION OF INFECTIOUS DISEASES.
To the Editors of Tim Lancet.
Sirs, —Would you allow me to endeavour to elicit through
your columns the opinion of the profession on the following:
The general adoption of the Notification of Infectious
"^8
574 The Lakcet,]
INFLUENZA IN THE HINDU KHUSH.
[March 7,1891.
Diseases Act is briaging promineatly forward in many
localities the questioo of the provisioQ of isolation hospitals.
Practically the three diseases with which such liospitala
everywhere will be expected to be prepared to deal at
all tiDies are scarlet fever, diphtheria, and typhoid fever,
with possible outbreaks of small-pox and,typhus. Without
further reference to the two latter diseases, which could
be regarded as exceptional emergencies to be dealt with
accordingly, and admitting that typhoid fever may be
safely treated in the same building with scarlet fever and
vice versd (although within the last few days I have seen a
patient with typhoid fever, exposed very slightly to the
infection of scarlet fever, contract that disease in a typical
form), I would ask, Is it prudent and in accordance with
what we would wish to have done in the case of our
own children that scarlet fever patients should be received
in the same building with diphtheria patients? 1 am
assuming the case, not of a large hospital with detached
blocks, but of a small hospital with an administrative
staff necessarily more or less in coinmon, and where
precise and scientific isolation of one disease from the other
could not be depended upon. It has long been a matter of
observation with myself, and doubtless with others, that,
given the presence of infection, however slight, nothing
predisposes so much to the incidence of diphtheria as an
inilatned and congested condition of the mucous membrane
of the throat, and this fact has been demonstrated in France
by experiments on the lower animals. Sach a condition of
throat is almost invariable in cases of scarlet fever, and as
no one would think of introducing a case of erysipelas into
a lying-in hospital, the question arises. Is there not a
somewhat analogous connexion between diphtheria and
scarlet fever? I am, Sirs, yours truly,
Shrewsbury, Feb. 25th, 1891. W. N. THUUSFIELD, M.D.
EMPYEMA OF THE ANTRUM.
To tliA Editors of The Lancet.
Sirs,— My experience agrees with those who have found
dental disease the most frequent cause of this complaint.
It is rare to detect it without caries of the corresponding
teeth, whilst it is not unusual to have it developed without
intra-nasal disease other than what may fairly bo attributed
to irritation of the nasal mucous membrane by the septic
discharge from the antrum. In treating this disease it is a
mistake to suppose that extraction of teeth and perforation
and washings out of the antrum, with or without the inser¬
tion of a tube, are likely to lead to a speedy cure. These
steps may suffice in very recent instances ; but in the long¬
standing cases, which constitute the majority, other mea¬
sures are necessary. The mucous membrane of the antrum
ought to he thoroughly curetted,^ and, after the sloughs and
ddbris have been washed away, should beached on by dry boric
acid, applied byinsuffiation. Let anyone who has opened an
antrum and finds the discharge of pas continue try the effects
of these measures, and he will be surprised and delighted at
the immediate result. After perforation, and in spite of fre¬
quent washings out, these cases frequently drag on for pro¬
longed periods, and become sources of disappointment both
to the patient and the practitioner. The application of the
curette, which may be repeated if necessary, is rapidly
followed by a healthy action and loss of pyogenic functions
of the antral lining membrane. To admit of the carrying
out of these procedures the tube inserted ought to have a
wider bore than is usually the ease. Some German surgeons
say that it ought to be able to admit the little finger, but
I think this is nob necessary. The tube I am in the habit
of using is about half tliat calibre. I may add that my
dental colleague, Mr. G. W. Watson, who has rendered me
valuable aid in tlie treatment of many cases of antral
empyema, shares the above views.
I am, Sirs, yours obediently,
Edloburgh, Fab. 24bh, 1801. G. HUNTliu MACKENZIE.
INFLUENZA IN THE HINDU KHUSH.
To the Editors of The Lancet.
Sirs,— You may be interested in hearing of the prevalence
of this disease among the valleys of these mountains at the
present time. Here, at Gilgit (4800 ft. above the sea),
which is in the extreme north-w^st of Kashmir territory,
1 For this purpose I have used an antral curette, made at my sugges¬
tion by Mr. Watson, dental surgeon.
the epidemic first made its appearance about Dec. 1st,
having been brought by a party of Mussulman priesta
corning from Chitral, a country twenty marches Ul>oub
200 miles) west of this, where we have news of its prevalence.
I cannot obtain information of its more remote origin,
though the inference is that it is the dregs of the epidemic
which appeared in India in tiie early part of this year, and
did not at the time spread to these remote districts. The
probability of its spreading to Kashmir and India is small,
owing to communication with these being almost cut off by
snow on the passes. The symptoms are pretty typical;
the bronchial catarrh is well-marked and the coryza often
absent, while pain over the frontal sinuses, with or without
coryza, is pretty common. The temperature is high, often
over 103°, and the course of the disease apt to be prolonged
owing to the resuscitation of dormant malaria; tlie latter
prevailing in these valleys even up, to 7000 ft. above the sea.
The winter season of these parts is characterised by cold,
bright weather, frost at night, a slight snowfall in the
valleys, where it lies above 5000 ft., and a great deal of
snow on the peaks above. Ikying beyond the influence of
the monsoon, the Hindu Khush valleys are practically
rainless, and dependent on the melting snows for their
water-supply. The streams derived from this source are>
utilised for irrigation purposes; hence, in autumn, after
the burning heat of June, July, and August {maximum.
96°), the soil is laden with mafaria, and fever is very pre¬
valent. I am, Sirs, yours truly,
J. R. Rouerts, F.R.C.S, Eng.>
GiJgit, Kashmir, Dec. 2Sth, 1800. Ind. Med. Service.
THE BORIC ACID TREATMENT OF
GRANULAR LIDS.
To the Editors o/The Lancet.
Sirs, —Although I liad sotne years ago given a trial to (and
abandoned as useless) powdered boric acid in the treatment
of granular lids, it was nob until I read Mr. Beaumont’s
paper in The Lancet of October 18th, 1890, that I tried
what effect boric acid in conjunction with “massage” would
produce in cases of this class. Mr. Beaumont, it may be
remembered, advised that the boric acid powder should be
dusted over the conjunctiva of the everted lids, and them
well rubbed into the membrane (the so-called “massage”) by
the pulp of the forefinger for five or ten seconds. In support-
of this treatment, he cited three cases of trachoma which
had received benefit; two of these cases were under treat¬
ment for a fortnight, the third for a month. I can corro¬
borate Mr. Beaumont’s statement that after one or two-
applications a tolerance on the part of the patient becomes
established, and the boric powder certainly causes less
pain than that which results from the employment of the
usual remedies (cupric sulphate, silver nitrate, carbolic acid,
&c.) to the conjunctiva. FrimiXfacie this treatment (and its
theory of action) appeared to be so reasonable as to justify
me in adopting it; and, with a view to test for myself its
value, I selected eight cases of granular lids for experiment.
In the selected cases the powder was applied in the manner
recommended by Mr. Beaumont, the application being made
once daily. The treatment was continued for four months
in two cases, for tliree months in four cases, and for ten
weeks and one month respectively in the last two cases. The
changes present in the selected cases may be epitomised by
saying that the palpebral conjunctiva was thickened and
unduly red, and that small vesicular grains were present in
the outer part of the lower lids, in the superior fornices,
and along the foraical borders of the upper lids; the
discharge amounted only to a little “gvimming” together
of the eyelids first thing in the mornings. They were, in
fact, examples of what many surgeons call “ follicular
conjunctivitis.” These cases were selected as appearing to
me peculiarly appropriate for the use of a comparatively
mild agent likeboric acid, more especially, perhaps, since they
seemed hardly serious enough to call for the use of stronger
remedies. What was the result of the experiment? Five
cases remained in statu quo, neither the anatomical appear¬
ance of the lids nor the amount of discharge being altered in
any way. One child (after treatment for four months) had
the discharge lessened; in another child the redness of the
lids was somewhat reduced. In the eighth case, which
deserves special mention since, together with the boric acid,
hydronaph'/hol ointment was bring used, some of the grains
disappeared, the lids, however, remaining thickened and
T«n Lancet,]
ENGLISH MEDICAL PRACTICE IN FRANCE.
[March 7, 1891. 575
cangested. And I may a6 once say that this was the only
case in which the grains were iDiliienced in any way. IC
will be seen, therefore, that in my hands at least this
treatment has given what amounts practically to a negative
result.—I am, Sirs, yours truly,
Sydney Stei-henson, M.B , F.R.C.S.Edin.
Central London School, HanwoJl, Fob. 23i'il, 1891.
.ENGLISI-I MEDICAL PRACTICE IN FRANCE.
To the Editors of The Lancet.
Sirs,—T he facta shown in my friend’s (Dr. Barnard)
letter, in your issue of Feb. 2lat, deserve consideration, as
the interests of practitioners abroad are not so much at
ebake as those of the great mass of travelling Eoglieh and
Americans on the Continent. It would be well for all persons
visiting Europe to obtain first the address of competent pro¬
fessional men before leaving home, as it can be stated as a fact
that local advice is not always disinterested. Indeed, it is
positive that most of the professional people recommended by
«evvants, couriers, concierges, hotel-keepers, and chemists
have to pay a commission to these people for the clients
obtained, and, like the well-known 5 per cent., or sou per
franc, given by commercial people in France to our servants,
we can be sure it comes on our bills and not out of their
pockets. These abuses are so well known now that people
who settle in France put up with them like the pnurhoire,
as a necessary evil, but they limit it as much as they cau.
It would be well if all persons who need a doctor abroad
could first of all inquire as to the standing of anyone recoin-
,Kiended of their consul or clergyman, and others, but many
(indeed most hotel patients) are those who are taken suddenly
ill, and who perforce must accept the hotel doctor, for the
moment. If we were to put into print the really outrageous
things that have happened and the charges made it would
take too much of your space, but to hasten on the remedy
proposed by Dr. Barnard it ought to be accepted for the
special reasons given. It might be possible also to in-
duca hotel-keepers and chemists to keep a framed list of
the members of the Anglo-American Continental Medical
Society, which includes most of the English and American
doctors who are legally entitled to practise abroad.
Hoping that some practical solution may be found to stop
the present abuse, '
I am, Sirs, your obedient servant,
Nice, Fob. 23rcl. 1891. ' TlIOMAS LiNN.
THE USE OF NITROUS OXIDE BOTTLES IN
THE HORIZONTAL POSITION.
To the Editors o/TiiE Lancet.
Sirs,—D r. Sheppard has called attention in The Lancet
of Feb. 2lsb to some very practical points of embarrassment
that are liable to occur at times with the supply of gas from
horizontally placed bobbles. My experience with the improved
pedal attachment loads me to assert that it is unaccompanied
by such objections. As the valve ends of the bottles are on
a slightly higher level than the opposite ends, it is possible
the aperture of exit of the gas is j ust above the level of the
liquid nitrous oxide. The supply of gas is never fitful and
irregular with it, but, on the contrary, can be regulated
with the utmost facility. The screw is certainly liable to
“set” in any bottle, bub this can never be a source of incon¬
venience during the administration when the improved
pedal attachment is used, for the reason that it is turned on
at the commencement of the operation, the escape of gas
being then controlled by the pedal screw valve.
I am, Sirs, yours truly,
Percy Edoelow,
Anraathetisb fco the National Dental Hospital.
<0111 Burliiigton-atroot, W., Fob. 21st, 1891.
MANCHESTER.
(From our own Correspondent.)
The Infirmary and Owens College.
The negotiations which have for some time been going on
between these two bodies respecting the provision of in¬
creased hospital accoinmodabion appear bo make but little
progress, and at present matters are almost at a deadlock.
A conference held on the 17th ult. between the Infirmary
and College authorities ended without anything definite
beinp' done, and the matter is further adjourned to consider
certain suggestions made by Dr. Renaud. To all who hare
any intimate knowledge of either institution it is an open
secret that there is a feeling of rivalry between certain
sections of the two bodies which, unless some more cordial
relations be established, augurs rather badly for an amic¬
able settlement of the questions now in dispute. Shortly
pub, the position of affans at present is this : The College
wishes to have a more direct share in the control of the
clinical instruction which must be given to the medical
students, and they are desirous of having a new hospital
erected on the site they now have for the purpose, whilst
the infirmary authorities are unwilling to enter-into any
arrangements to forward such a scheme, bub prefer to
extend the present building in Piccadilly. It is admitted
that some additional hospital accommodation is wanted,
and will be still more wanted in a few years. The question
in dispute is how and where it shall be provided. So far
the public at large has scarcely been approached in the
matter, but it is nob unlikely that public opinion, as
expressed through the general body of subscribers to the
infirmary, will be averse to any further extension of the
{ )resent building or the covering of any more of what is
eft of the open space around the infirmary.
Licensing Reform.
Important public meetings have recently been held “ to
unite in immediate practical efforts all those who are
interested in the moral and social well-being of the
people,” with a view bo obtain some speedy reform in our
licensing system. The conferences were presided over by
the Bishop of Manchester, and, as usual when the “drink
question” is discussed, a wide divergence of opinion was
found to exist as to the best practical steps to be taken to
forward the ends which all had at heart. So keen was this
divergence that at one time it seemed as though the present
elTorbs would end in nothing, bub at the last meeting (held
on the 26th ult.) a series of resolutions were arrived at
which may be briefly put as providing (I) for the extinction
of all licences within seven years from the passing of a Bill;
(2) licences to be granted only according to a fixed ratio of
the population ; (.3) three-fourths of the inhabitants of a
licensing district to have the power to veto all licences, and
the licences to be granted only by representative bodies. A
Bill upon these lines is to be promoted in Parliament.
Provident Dispensaries.
At the annual meeting of the Provident Dispensaries it
was stated that there are at present 24,000 members. The
receipts froiii members amounted to £4107, and the sum
total paid to the medical staff, exclusive of confinement
fees, was £2372. Eight of the nine branches are now self-
supporting. The only disquieting reflection upon this report
is whether any, and, if so, how many, of the above 24,000
members are in such position as to pay the ordinary fees of
the general practitioner?—for complaints are still at times
heard that persons are allowed to become members without
sufficient inquiry as to their means and income.
The Workhouse Infirmaries.
It was recently noted in these columns that Dr. Reynolds
had been appointed visiting physician to the Crumpsall
Inlirmary. This week another old infirmary “resident,”
Mr. Milner, has been appointed to a similar appointment
at the Hope Hospital, bmonging to the Salford guardians.
Another vacancy has been caused at Crumpsall by the
resignation of Mr. Havdie, who for many years has been
visiting medical officer there. A singular item is down on the
agenda for the next meeting of the City Council—i.e., the
infirmary is to be bold that in the opinion of the Council
patients are nob to be taken into the fever hospital from dis¬
tricts outside tlie city. As well might the districtsoutside the
city who use the hospital in common with the corporation
tell the infirmary that they consider the city authorities
should no longer use the hospital, but provide one for
itself and leave the present one for their exclusive benefit.
A very fitting reply from the infirmary would be that if
the corporation is not satisfied with the manner in
which the hospital has hitherto been conducted and
managed, they had better enter into negotiations for
having it tran.sferred to them, as at present the infirmary
burdens itself with the care of a large infectious hospital—
Diyiii/-u ' i-J Google
576 The Lancet,]
NORTHERN COUNTIES NOTES.—SCOTLAND.
[March 7,1891.
a business which is rightly none of theirs, but of the health
authority of the district.
It is with much satisfaction one has to record that at lest
the corporation has provided a proper and more decent
coroner’s court than tue stuffy, dingy room in John-street
that has done duty, to the discomfort of all who have had
to attend there for many years past.
The amounts collected on Hospital Sunday at present
received are £4700, a alight increase over last year, when it
reached only £46.36, The Saturday collections are £3095, a
falling off compared with last year’s £3536. It is hoped,
however, when all the collections have been sent in, the
total may not be below the preceding year.
Manchester, March 3rd.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Pauperism in the North.
At a late meeting of the Newcastle guardians, Mr.
Knollys, Local Government inspector, brought forward
some interesting statistics as to pauperism in the northern
district, which included forty-four unions, practically
Northumberland, Durham, the North Riding of Yorkshire,
and two unions in Cumberland. At the end of 1884, when
trade depression was about at its deepest, there were in the
district 47,217 paupers, and at the end of 1888 there were
39,549, which was satisfactory, considering the severe
winter which ended the year. The number of vagrants
too had been reduced from 129,219 in 1888 to 86,000 in
1890. Mr. Knollys seemed to think that this redaction had
resulted from improved administration, as the vagrants
knew that they could not now get a good night’s lodging
without a good day’s work being required from them in
return.
Newcastle Surgical Aid Society.
The annual meeting of this young but useful Society
has been held, and from its annual report, read by Dr.
Arnison, it appeared to have supplied invalids of the poor
and deserving classes with appliances of a most useful
character. The Society, however, deserves better support
from the general public, for it was shown in the report that
but for the considerable suras contributed by the patients
the funds would have been entirely absorbed.
The Sanitary State of Middleshrotigh.
The medical officer of Middlesbrough reported to the
sanitary committee that the total deaths were 215, giving a
mortality for the month at the rate of 33-50 per 1000 per
annum. The high death-rate was attributable to two causes—
viz., first, all the deaths arising from the unprecedented
severity of the weather at the beginning of the year fell
within this month. This was shown, he said, by the deaths
from diseases of the respiratory organs, and also by the
number of deaths among infants and very old persons from
extreme cold. The second cause of death was typhoid
fever. The renewed outbreak of this disease, wliilst not
giving so many cases, was of a rather more fatal character.
He also stated that the typhoid fever epidemic was
gradually diminishing.
St. John Ambulance Work at Durham.
The ambulance class whicii was commenced at the
Durham Railway Station towards the beginning of tlie year
has been examined by Surgeon-Major Hutton, and forty-
two received certificates of proficiency. The class was
instructed by Dr. Jepson, who was complimented by
Surgeon-Major Hutton on its knowledge of ambulance work.
The late Mr. John Fleming's Di'/ucsls.
It is stated that the whole of the charitable legacies left
by the late Mr. John Fleming, solicitor, of this city, have
now been paid over. Mr. Fleming, it may be remembered,
died in February last year, and I noted the various charities
benefited by his will in a former letter. The legacies
amounted in the aggregate to £60,500, and this very large
sum has been paid free of duty.
Newcastle-on-Tyne, March 4tb.
SCOTLAND.
(From our own Correspondents.)
EDINBURGH.
Edinburgh Public Health Committee.
At a meeting of this committee last week it was reported
that there were 274 patients in the city hospitals under
treatment for infectious diseases, of whom 130 were cases of
scarlet fever and 80 of typhoid fever. Arrangements have,,
it was stated, been made for giving a course of lectures to
the nursing staff of the hospital. The drains in the vicinity
of St. Bernard’s Well are also being overhauled to settle the
question, which from official statements were regarded as
settled some time ago, whether the well is being con¬
taminated or not by sewage.
Disposal of Edinburgh Refuse,
It has been intimated here that it was proposed to erect
destructors in different districts of the city, and it is under¬
stood that these proposals are assuming practical shape»
and that steps are being taken to acquire ground on which
to erect them.
Royal Society of Edinburgh.
At the meeting of this Society on Monday, under the
presidency of SirJDouglas Maclagan, Dr. A. Bruce made a
communication on a case of Human Cyclopia, and Dr.
Byrom Bramwell gave particulars of several cases illus¬
trating the position of the visual centre in man.
Health of Edinb urgh.
The mortality last week was 118, making the death-rate
22 per 1000. Diseases of the chest accounted for 50 deaths,
and zymotic diseases for 15, of which 0 were due to-
whooping-cough and 3 to typhoid fever. The intimations-
for the week comprised—typhoid fever 29, diphtheria 6>
scarlatina 27, and measles 40.
GLASGOW.
University Court.
At a meeting of this court held last week the following
examiners in medicine were appointed, the appointment
being in each case for four years :—In Materia Medica, Mr.
Ralph Stockman, M.D., F.K C.P.Edin., &c., Edinburgh >
ia Chemistry, Mr. John Millar Thomson, F.K.S.Edin.,
&c.^ Professor of Chemistry, King’s College, London; in
Zoology, Mr. D’Arcy W. Thomson, B.A., Professor of
Zoology, University College, Dundee ; in Botany, Mr.
George Murray, B Sc., presently Examiner in Botany in.
the University; in Clinical Medicine, Dr. Ebenezer Duncan,
M.D., Crossbill Professor in Anderson’s College Medical
School : in Clinical Surgery, Dr. A. Ernest Maylard,
B.S., M.B. Glasgow. It is worthy of note that only one of
these six gentlemen is a graduate of Glasgow University.
Dr. E. Duncan has resigned his professorship in Anderson’s-
College.
Loch Katrine Water and Tapeworm.
There have been at various times serious scares regarding
the use of the matchless water-supply of Glasgow from
Loch Katrine. At first it was said that the water was too
soft and would give rise to rickets, but the fear of this has-
evaporated. Then it was the risk of contamination of the
water by the inevitable discharges from the small steamers
which ply on the loch in summer, but that, so far as io
known, has led to no evil results. The most recent scare
has arisen over ttio statement that the trout in Loch
Katrine suffer very much from tapeworm, but the very-
unsavoury suggestion which this implies has been shown to
be groundless by an investigation made by Professor Young
and Dr. J. B. liussell, who find that, though the trout do-
undoubtedly suffer as stated, there is no risk so far as the
propagation of tapeworm is concerned. Cases of tape¬
worm are certainly not more common in Glasgow than else¬
where ; in fact, there is reason to believe they are rarer in
Glasgow than in the country.
Marc!i OHi,
Disj'OSAL of Refuse in Eiiussicus.—Tbo speciul
commission appointed to report on the disposal of the refuse
of Brussels has recommended the adoption of the Leeds
system of destruction by lire. The furnaces will be situated
in the vicinity of the city, but, except in times of epidemic
disease, it is nob proposed to burn the whole of the refuse.
Digitized by ^OOQlC
Tbs Lancet,]
IRELAND.-PARIS.
[March 7, 1891. 677
IRELAND.
(From our own Correspondents.)
DUBLIN.
Address to Mr. W. J. Wheeler, F.B.C.S.
Mr. Wheeler waa last week presented wUh anillnminated
nddress by the nurses of the City of Dublin Nursing losti-
tutiott on his resigning the position of honorary secretary to
tliat institution, expressing regret at his retirement, and
gratitude for the impartial and kindly care and energy he
had bestowed upon all that concerned their welfare. Mr.
Wheeler, in replving, expressed his appreciation of the in¬
telligence and efliciency with which the lady manager and
nurses had carried on their arduous and useful work, and
said that be would always take a keen interest in their
welfare and individual prosperity.
National Eye and Ear Infirmary.
The committee, in their annual report, state that about
a year since it was intended reflooring some of the wards
and ejecting other improvements, but, as it was found
that more extensive changes were demanded, they were nob
carried out. The institution at present contains thirty
beds, and the committee wish to enlarge it so as to provide
at least double that number, and it is estimated that a
eum of £7000 will be required. The union of St. Mark’s
Ophthalmic Hospital ana the Eye Infirmary nnder con¬
templation means an outlay of a very considerable sum for
the Duilding of a proper hospital to contain 120 beds, and
if it is to be carried out the public must contribute
liberally.
Strange Freak of a Lunatic.
Insane people, it is well known, occasionally swallow
foreign bodies, and a case in point occurred last week in the
Cork Asylum, where an inmate of that institution bad
impacted in his tbi'oat several pieces of wood and a large
atone. An operation removed the obstruction, but the
patient died shortly afterwards during an attack of acute
mania.
Fever in Coik.
The small number—thirty-three—of adiuissione last year
'to the Cork Fever Hospital is a fact worthy of special
notice. During the last quarter there were only four cases
of typhus admitted, a period of the year which usually
shows the largest amount of sickness. There were fifty-
4ihree admissions during the year of enteric fever cases.
A pure supply of water would undoubtedly greatly
dimioieh the prevalence of this fever, as the river which
supplies the city at present is contaminated along its banks,
and cannot properly be supervised. It is satisfactory to
learn that a registration of ^umbers has been started in the
city, and that domestic drainage will be carefully attended to.
Several cases of small-pox are reported to have occurred
in the Magherafelt Union.
BELFAST.
7he Sanitation of Belfast.
On Monday last a deputation from the Ulster Medical
Gociety, consisting of the President (Dr. Dempsey),
Dr. O’Neill, and Dr. Lewers, appeared before the corporation
of Belfast, at the usual monthly meeting, to lay their
views before the members in reference to the necessity of
increased sanitary precautions. Dr. Dempsey, in his state¬
ment, said they were of opinion the deatn-rate of Belfast
was too high. He thought, when the new drainage scheme
■came into operation, it would have a good eflect, but they
believed this effect would be much increased by the more
'frequent removal of accumulations of lilth from the rear of
their buildings. He thought the by-laws recently enacted
were excellent, but one of them, lie pointed out, had no
'Scientilic basis—that was the one which provided for the
covering of aslipits. The death-rate of Belfast was 25-5 per
QOOO; that of Birmingham was 19 per 1000. If the mor¬
tality in Belfast could be reduced to that of Birniingliam,
the saving of human life would be 1500 persons annually.
Dr. O’Neill pointed out how thesystem of the frequent re¬
moval of filth had in Edinburgh, Rochdale, and Birming¬
ham led to a distinct lowering of the death-rate. After
Dr. Lewers had spoken, the Mayor, in very courteous
terms, thanked the deputation, and said he was sure
their visit would prove profitable to the corporation. In
reply, Dr. Dempsey urged the necessity of providing a
steam steriliser for disinfecting the clothes of persons
suffering fiooi infectious diseases.
Public Health Committee.
In the report presented to the Citv Council attention was
drawn to a memorandum drawn up oy Dr. Torrens (Dispen¬
sary Medical Officer) in reference to the insanitary state of
oeicain streets iu his district, and it was stated rules had
been made to obviate this in the future. Every precaution
had been taken to prevent the spread of small-pox.
Proposed Hospital for Infectious Diseases.
In connexion with the recent outbreak of small-pox in
Belfast, tbenecessity for an infectious hospital for non-pauper
patients has been much felt. The Public Health Committee
of the Corporation approached tbeBelfast Board of Guardians,
suggesting that a joint committee should be appointed by
the two bodies to confer on the matter, and this was strongly
supported at the last meeting of the latter by Dr. Stafford,
Local Government Board inspector. The guardians declined
to comply with this request, on the ground that in their
fever hospital there was ample accommodation for the
pauper classes, there being at present 400 vacant beds there
for cases of infectious disease. In reply to this it may be
stated that this hospital does not meet the case of those
who are not paupers and who would be willing to pay for
treatment, but who would not enter a pauper ward. Further,
it is urged that it is against modern scientific ideas that a
fever hospital should be placed in the midst of a populous
district, Co tbe inhabitants of which, owing to their
proximity to the hospital, the germs of disease might easily
be spread. It was stated that when small pox prevailed in
Belfast before, it occurred to a larger extent in streets near
this fever hospital than in other portions of the city.
The guardians think they have to do only with the paupers,
and that if an infectious hospital is to be erected for a
class above the poor, the corporation have the right to do it.
March 3rd.
PARIS.
(From our own Correspondents.)
The Danger of Unboiled Milk.
In my own practice I have for some years been in the
habit of recommending the boiling of milk as a matter of
routine, epidemics of typhoid fever having been sufficiently
often traced to a contaminated milk supjuy to warrant the
adoption of this simple and efficacious precautionary mea¬
sure. About a year ago the Acad6mie de Mddecine pro¬
nounced itself formally in favour of this practice. Many
people, however, have a rooted objection to the taste of
boiled milk, and, as a matter of fact, that liquid is generally
drunk unboiled. The public will perhaps be more inclined
to depart from the beaten track they read of the fol¬
lowing case brought to the notice of the Academie de M6de-
cine by M, Ollivier, one of the physicians of the HOpital
des Enfants Malades. Clinicians are “moving heaven and
earth” to exorcise the ogre tuberculosis, and, in our
anxiety to discover an antidote for the ravages of the terrible
bacillus, we are apt to forget the old adage. “Prevention is
better than cure.” The case related by M. Ollivier was that
of a young lady aged twenty, whose family and personal
health antecedents were excellent, bub who had the mis¬
fortune of being brought up in a school where, in the space
of a few years, six out of thirteen girls had fallen
victims to tuberculosis, two being cases of tabes mesen-
terica. The young lady succumbed rapidly to tuberculous
meningitis. An examination of the udder of the cow
which had for nine years supplied the school with milk
was, after death, found to be the seat of extensive tuber¬
culous lesions. M. Nocard emphasised tbe contention of
M. Ollivier that unboiled milk should be banned, however
healthy the cow yielding it may appear, by relating how
the lymphatic glands of a calf in seemingly excellent con¬
dition, which, to the great disappointment of its owner,
bad died after a few days’ illness had been found stulled
with bacilli. A short time afterwards the mother of this
calf—a fine beast, to which had been allotted numerous
prizes—died in her turn, and the udders, lunge, and
lymphatic glands were discovered to be tuberculous. The
lesson taught by these two interesting comiimnicatious is
plain : avoid unboiled milk.
Coogle
Dir:'
578 The Lancet,]
BERLIN.—EGYPT.
[Makch 7,1891.
Chloride of Ethyl a Local Anassthetic.
Chloride of methyl, iDtroduced into the domain of thera¬
peutics as a local ansesthetising agent by Debove, has the
inconvenience of being costly and cumbrous, of producing a
temperature unnecessarily and sometimes hurtfully low
(-40° C.), and, finally, of being explosible. Ethyl chloride,
on the other hand, possesses the advantage of being a liquid
whose boiling point is 10° C., the mere heat of the hand
sufficing to volatilise it, thus doing away with the necessity
of the expensive apparatus in which its rival is supplied.
M. Monnet of Lyons has had the happy idea of utilising this
easy volatility of the ethyl chloride oy keeping it for use in
glass capsules similar to those in which amyl nitrite is
supplied. Each capsule contains ten grammes, and
the breaking of the capillary tube in which it ter¬
minates allows of the escape of the vapour generated
by the heat of the hand. The vapour, directed at a
distance of twenty centimetres on to the part it is
desired to anm-sthetise, determines a fall of tem¬
perature of - 30° C. This new agent will be found useful
in such small operations as the opening of abscesses, tooth
extraction, avulsion of ingrowing toe-nails, «itc. It will
also, it is said, allay instantaneously the pain of facial and
intercostal neuralgia.
The Bill of Mortality at the Pasteur Institute.
The statistics of the years 1886-87-88-80 show that of
7893 persons bitten by rabid animals and treated at the
above establishment, fifty-threedied—a mortality of 0'67 per
cent. If patients in whom hydrophobia declared itself after
the cessation of the treatment by inoculation be counted,
the mortality rises to only 1 per cent. M. Leblanc tells us
that of 336 bitten persons (years 1880 to 1880) treated by
cauterisations or on the old expectant plan, thirty-nine
succumbed—a mortality of 12 per cent.
The Action of Koch's Liqriid on the Monkey.
The effects of Koch’s liquid on a quadrumanous animal
BO vulnerable to the invasion of the bacillus as the monkey
have been investigated recently by MM. Hcnocque and
Capitan at the College de France and the Hotel Dien
respectively. M. Hcnocque informs us that when his
monkey entered the laboratory (Dec. 2l8t, 1890) ausculta¬
tion yielded no physical signs denoting phthisis. Two
days after the Crst injection a few rfiles and impaired
resonance were noted at the right apex. The third injec¬
tion determined duloess still more marked, and, in addition,
slight dulness at the left apex. From this moment all the
symptoms of acute phthisis manifested themselves (cough,
anorexia, debility, intense fever), and eight days later the
animal died, having lost a tenth of his weight. At the
necropsy four tubercular masses of the size of a big pea
were discovered in the right lung, the left organ in two-
thirds of its extent being the seat of caseous pneu¬
monia. Surrounding the lesions there were zones of
red hepatisation, with marked exudation of red blood-
corpuscles. Two guinea-pigs have been inoculated with
poisons of the pneumonic tissue, and both animals
now present signs of cutaneous and glandular infection.
The total quantity of fluid received by the monkey
was six milligrammes — a quantity apparently quite
capable of determining the onset of acute phthisis.
M. Capitan’s results differ somewhat from those obtained
by M. Hcnocque. One tuberculous monkey received in
ten days three inoculations of one milligramme each.
Death ensued on the tenth day, no reaction having been
evoked. Tubercles were discovered in the mesenteric
lands, the liver, and the spleen, all containing colonies of
acilli. The only pulmonary lesion was a small mass of
grey granulations surrounded by an inflamed zone, and
containing a few bacilli in the anterior edge of the left
lung. Another monkey, supposed to be tuberculous, has
up to the present time received four milligrammes of fluid,
and seems none the worse for it. No reaction whatever
was excited ; indeed, the temperature has been noticed to
descend 0*5° C. from four to five hours after an inoculation.
Paris, Mar<;h 4th. _
BERLIN.
(From our own Correspondent.)
Professor Oscar Ziebreich.
Professor Oscar Liebreicii, whose speech at the
Berlin Medical Society is justly attracting so much atten¬
tion at present, is one of the most eminent of the German
pharmacologists. It was by Hoppe-Seyler, a well-known
master of the subject, that he was initiated into the
mysteries of medical chemistry. His first publication io
1864 announced his discovery of protagon, and was a highly
important contribution to the ^emistry of the brain. In
1869 he showed that chloral hydrate, which Liebig had
discovered thirty-six years before, ■was an excellent
soporific. He was led to this highly important dis¬
covery by studies of the connexion between the effect
of chemical substances and their chemical constitution^
Under certain ^conditions chloral separates into chloroform
and formic acid, and Liebreich showed that this separation
can take place in the bodies of human beings and animals.
This pregnant observation afterwards enabled Liebreich to
restore ethylene chloride, trichloride of acetic acid, and
butylio chloral to the pharmacopccia ; it also led Kolbs to
the discovery of the therapeutic value of salicylic acid.
One of Liebreich’s later contributions to practical medicine
was the application of lanoline as a basis for oint¬
ment. He is now engaged in very important investiga¬
tions. He has observed that the chemical reactions in
mixtures are not equally rapid in all parts, and he deems
this observation significant in connexion with the biologioai
processes in the cells. He was born at Kdnigsberg in 1839,;
and educated there and in Berlin. He left school before
finishing the full curriculum, studied chemistry, travelled
for two years as a sailor, studied chemistry and medicine,
and graduated in 1865. In 1868 he was appointed chemical
assistant in the pathological institute here, established
himself as a private lecturer in 1869, and was appointed
professor in 1871.
Virchow on Koch and Liebreich,
At a meeting of the city deputies of Berlin last Thursday,
at which the project o^ erecting a convalescent home-
near Berlin for patients treated by Koch’s method was-
discussed, Professor Virchow, one of whose multifarious
functions is that of a city deputy, said: “Everybody
knows that public opinion as regards the success of Koch’s
method, which had somewhat fluctuated of late, has risen
again within the last few days. This is due to the presen¬
tation of Liebreich’s new medicament which was published
yesterday, and which has been brought forward with such an
abundance of good proofs that one may safely say it is
likely to do at least as much for laryngeal phthisis as
Koch’s medicament, perhaps somewhat more ” In the
same debate Dr. Straasman stated that, of the 623 patients
treated in the hospitals belonging to the city of Berlin, 3ft
had been cured, while 306 had improved in a greater or less
degree.
German Death-rates in the Week ending Feb. l^th.
Aix-la-Chapelle 23'4, Altona 31'8, Barmen 26'0, Berlin
25 4, Bremen 17'4, Breslau 25 7, Chemnitz 29 3, Cologne-
24'9, Dantzic24'9, Dresden 17T, Duaseldorf 24-6, Elbevfeld
2;l-6, Frankforb-on-the-Main 20-5, Hamburg (with its-
suburbs) 22-7, Hanover 18-5, Kdnigsberg 24-0, Krefeld
23'8, Leipsic 16'9, Magdeburg 18'3, Munich 27'-t, Nurnberg
26’4, Stettin 28'0, and Stuttgart 2*2'8.
Prostitution in Berlin.
The number of women under police control (including
medical supervision) in Berlin in 1875 was 2140; at the
end of 1890 it had risen to 4068.
Professor Koch is expected back in Berlin at Easter, and
•will probably travel home -old Italy.
Professor von Helmholtz has received the distinction of
honorary citizenship from his native town of Potsdam.
Borliii, Mivrch Ist.
EGYPT.
(From our own Correspondent.)
Visit of Professor Koch.
Du. Ko(jii landed at Alexandria on February llth at
8 A.M., and an hour later was at the Arab hospital looking
at the cases on which the tuberculin fluid has been used.
J)r. Koch reached Cairo on the evening of Feb. 12th, looking,
very thin and ill after live days’ sea-sickness and all its
attendant evils, but the following morning be felt so much
better that he insisted on going to Kasr-el-Aiui Hospital^
where he very good-naturedly devoted an liour and a half
to seeing and talking about the cases shown to him by
Messrs. Milton and Sandwith. Among some twenty casea
Di; by CjOOgIc
Thb Lancet,]
OBITUARY.—MEDICAL NEWS.
[March 7, 1891. 579
of lupus glands, bone disease, and phthisis there was
matevial enough for him to teach about the manner and
method of using the fluid, the increased quantities, the
times for injection and for repose, and the continuance
of the ordinary surgical and medical aids to recovery.
He was much interested in the cases of tubercular glands of
the neck, groin, axillai, and pelvis, and was astonished to
’^nd so great a number of these cases in hospital. He
warmly congratulated Mr. Milton upon the improvements
in the hospital since his last visit in 1883, and was interested
to find the kitchen and the pharmacy under competent
German management. Later in the day he visited also the
German Hospital in Cairo and saw the cases undergoing the
Koch treatment. His chief criticism here, as elsewhere,
was that the operators were a little too cautious and did
not use sufficiently large doses of the tubercnlin. Dr. Koch
avoided all visits that were not absolutely necessary, and
left Cairo on Feb. 14bh for a fortnight’s rest on the Nile. He
has courteously declined to accept a dinner offered to him by
the English military and civil doctors of Cairo, and only
intends to spend three days here upon his return to Italy
and Berlin, where he is due at the end of March to take up
his new work.
Egyptian Immunity from the Exceptional Cold of January.
It is unnecessary here to refer to the cold weather lately
suffered in Europe, but it may be worth while to note that
the climate of Egypt has not been affected by the glacial
period elsewhere. The newspapers and private accounts
tell us of exceptional snow in Algiers and of six inches of
snow at Tunis between Jan. ISth and 2Ist, occasioning
the greatest misery among the Arabs, and snow clouds
seem to have strayed as far as Bagdad. The December
temperatures, as reckoned for invalids in Cairo, ranged
from a minimum bedroom heat of 60° F. to a maximum out¬
door temperature in the shade of 70°. In January the
average minimum in a north bedroom without artificial
heat was 58°, and twice fell as low as 56°; while the
maximum temperature by day in the shade varied from
59° on two days to 74° on Jan. 17th. The absolute
minimum out of doors in January was 36°, and the weather
for two weeks seemed as cold as it has ever been in Cairo ;
but this was chiefly due to the clouds obscuring the sun
by day. The heat at Assouan (south of Luxor) varied
in January from about 60° by night to 80° by day, with
an average heat of 71°, and at Wady Haifa, which
is the furthest point on the Nile to which invalids travel,
the January temperature has varied from 55° at night to
90° by day.
The Tourint Season.
In spite of the opening of fresh hotels and of a new
line of Nile steamers, Cairo has never seemed so crowded
as it is this winter. During four days last week no fewer
than 600 people left the capital—250 to ascend the Nile, and
•of course return here later, and 250 others for Alexandria,
to indulge their love of travelling, to Athens, Constanti¬
nople, and the Holy Land.
Cairo, Fol>. 23r(l. _
RICIIAUD MIDDLEMOllE, F.llC.S.
On Marcli Ist, at Birmingham, llichard Middlemore, in
his eighty-seventh year, broke the long chain connecting
him with the past and peacefully went to his rest, full of
all that should accompany age—honour, love, obedience,
troops of friends. He was born on Oct. I2tb, 1'504, of an
ancient family, whose records extend back to the time of
Henry IL At the age of sixteen he was articled to a
•surgeon at Lichfield, subsequently becoming a dresser at
St. Bartholomew’s Hospital, where he also formed a friend¬
ship of a life-long character with Sir Itichard Owen.
Settling in Binnin^iam, he resolved, after mature delibera¬
tion and with the advice of his friend Joseph Hodgson, to
-devote himself to ophthalmic work exclusively ; afterwards
be^was appointed assistant surgeon to the Birmingham and
Midland Eye Hospital, and in 1836 honorai-y surgeon,
which post ho held until 1849, when he joined the
■oonsulting staff. Ho obtained the Jacksonian prize for
bis essay entitled “A Dissertation on the Diseases of
'the Eye and its Appendages, and the treatment of them,”
which was embodied subsequently into his well-known
work, a “Treatise upon Diseases of the Eye.” His
enthusiasm and energy in all matters relating to the branch
of which be was such an able exponent gave an impulse to
his philanthropy, and stimulated others in the cause of
which he was so interested. Thus the Asylum for the
Blind at Edgbaston came to be founded, and received the
benefits of his fostering care and services. In 1889 his
undiminished zeal for this institution led him to give £2000
for the purpose of founding a trust fund for assisting poor
deserving blind persons who shall have been inmates of the
said institution by making grants to them on leaving, so
as to enable them to earn their living by honest industry.
In 1877 he also founded a prize to be awarded by the
Council of the British Memcal Association triennially
“for the best essay on the scientihc and practical
value of improvements in ophthalmic medicine and surgery
made or published during the previous three years.” In
1888 he made a gift of £1000 to the Birmingham and Mid¬
land Eye Hospital to pay for the delivery of an annual
lecture or a short course of post graduate lectures, to be
open to all recognised practitioners, on some subject or
subjects connected with ophthalmic science and practice.
Thus for fifty years he displayed a keen and devoteti loyalty
to his calling, and enriched its records with assiduity and
experience of an unusual career. High-minded and honour-
able in character, with instincts true and unselfish, be
gathered during bis long life friends around him who now
lament his death and look back with satisfaction upon his
friendship with peculiar gratification. His memory remains
as an unsullied example of an honest and useful life, and
as a type of a Christian and a gentleman.
Guy's Hospital.— Mr. Edward Cock, senior consult¬
ing surgeon to this hospital, has sent a donation of £59 to
the College library.
Bath Eye Inpirmaky.— The an?uial report (the
79th), just circulated, gives a favourable record of the con¬
dition and working of this institution during the year 1890,
the first year, since entering on its new premises. There
has been a marked increase of applications for treatment
compared with the previous twelve months. The number
of in- and out-patients shows an increase of 62 and of 120
respectively. The receipts from all sources (including a
balance of £288 Is. brought forward from 1889) amounted
to £999 Os. &d., and the disbursements to £470 12s. 1«!.
The London Conference on the Housing op
THE WoiuciNG, Classes Act.—T he Special Committee on
Defects in Houses appointed to prepare for the consideration
of the conference a list or schedule of the conditions or
defects which may be considered to render a house “so
dangerous or injurious to health as to be unfit for human
habitation” within the meaning of the Housing of the
Working Classes Act hold their first meeting at the
Paddington Vestry Hall on Tuesday last. On the motion
of Mr. Judge, Dr. T. Orme Dudfield was elected chairman
of the committee. The committee sat for nearly three
hoars, and almost completed their draft report, which will
be finally revised at a meeting to be held on Monday next,
so as to be ready for the meeting of the conference fixed
for Friday, March Kith.
Diploma of Public Health.— The University
of Cambridge has instituted a course of practical instruction
in connexion with the requirements of the medical officers
of health diploma. It includes the sanitary examination of
water, air, and foods chemically and microscopically, the
laws of heat, pneumatics, hydrostatics, and hydraulics. It
further includes the preparation of different media used in
the cultivation of micro-organisms, yhovt lectures will be
given in explanation of the above subjects, and of analytical
reports in general relating to water, air, and foods, and the
interpretations to be put upon them. In addition to the
six monthis' course, there will be a shorter one, beginning on
July 8bh, 1891, and ending in the last week of August. In
the long vacation Professor Uoy will lecture on Bacteriology
thrice weekly, beginning on July 8tb, for a period of six
weeks.
Dir:' ed-'V' Google
580 The Lancet,]
MEDICAL NEWS.
[March 7,1891.
Yellow Fever in West Africa.—A report from
St. Louis anuounces that yellow fever is rafriog in the
CamerooDS and at the mouth of the Niger, and that grave
fears are eutertaiued of an outbreak at St. Louis.
The Animals’ Institute.—A t the Congress which
was announced to take place at the Animals’ Institute with
relation to horse traffic, the committee decided to offer prizes
for the best essay on draught (accompanied with models), and
also for any improvements in appliances used for horse
traction on the London streets.
Centenarians.—M rs. Kilham, of Mexborough,
near Sheffield, celebrated her 103rd birthday on Monday.—
Captain A. C. Littleton, R.N., of Cross Hayes, Hoar Cross,
Burton-on-Trent, writes to a contemporary that there still
lives at Armitage village, near Kugeley, an old man who
entered his 104th year on Jan. otb.—William Adam, a
gardener by trade, died on the 22nd ult., at Taunton, in his
107th year. His age, it is stated, is well authenticated. He
was born atDunhead,in Wiltshire, on March 3rd, 1784, and
removed to Taunton in 1820.
Essex and Colchester General Hospital,—
The report for the past year shows an excellent record of
work done. The in-patients numbered 585 and the out¬
patients 1814. The total income for the year was adequate
to discharge the expenditure, to clear off a small deficiency
existing at the beginning of the year, and to leave a small
balance in hand. The experiment initiated in January,
1888, of giving a salary (£200) to the physician in charge of
the whole medical work of the hospital does not seem,
judging from the report of 1890, to have injured either the
finances of the hospital or its popularity, as the income
of the institution has already exceeded that of 1887 by a
sum slightly in excess of that accorded to the pbysiciau.
Great Northern Central Hospital. — The
annual report for the past year of this hospital, which is
situated in the Holloway-road, states that for want of
adequate accommodation a great many serious cases seeking
admission bad been sent to other hospitals, or obliged tu
wait a long time before they could be received. The com¬
pletion of the buildings had become urgent, and public
assistance is solicited to enable the governors to carry out
the work. The estimated cost is £20,000, and there is only
about £1000 of this sum in baud. During the year there
had been a large additional number of new cases admitted,
equal, as compared with the previous year, to nearly one-
sixth.
Cottage Hospitals. — Bourton - on - the - Water
Hospital: Since the foundation, in 1861, of this hospital,
1107 patients have received treatment. At that period no
similar institution existed in the county, but now, within a
radius of about ten miles, there are four other cottage hos¬
pitals. Notwithstanding this addition, the average yearly
number of cases has been maintained—namely, thirty five
in-patienta. The financial position is .satisfactory, a
balanceof£67135. Qd. remaining in hand.— Hospital:
The first annual meeting of the subscribers’ was held
recently. The annual report seated that since the opening of
the hospital in September last thirteen patients had been
admitted. The ordinary account showed a balance in hand
of £137, and there was a credit balance of £384 on the
building account. Promises of annual subscriptions had
been received amounting to £100.
Presentations.—O n the 21st ult., at the distri¬
bution of the certificates of first aid in connexion with tJie
St. John Ambulance Association, the nieiubers of the
Duffield branch of the Derby centre gave a supper, and pre¬
sented Mr. Robert Morrison, L.R.C.P. and L.R.C.S., with
a handsome pollard oak writing case, bearing a silver plate
with an inscription expressive of the pupils’ appreciation of
the services of the lecturer.—At a well-attended meeting of
members of the committee and of the medical staff of the
Royal South London Dispensary, held on the 3rd iust, a
handsome clock bearing the following inscription was pre¬
sented to Dr. C. Corbett Blades, late senior surgeon, and
who has now been appointed consulting surgeon to the
institution “Presented toC. Corbett Blade.s, Esq., M.D.,
by members of the committee and of the medical staff'of the
Royal South London Dispensary, in recognition of the
assiduous and valuable services rendered by him during a
period of thirty years as one of the honorary medical officers
of the institution.”
Metropolitan Police Surgeons’Association.—
A general meeting of the Association will be held ab‘
Cannon-street Hotel on Thursday, March 12th. The chair
will be taken by Mr. Alex. 0. Mackellar, F.R.C.S., at^
eight o’clock, when a paper on some cases of medico-legal
interest will be read by Mr. H. Nelson Hardy, F,R,C.S.Edin.
International Congress of Hygiene anD'
Demography. — A meeting of the general committee of
the International Congress of Hygiene (of which the Queen-
has consented to become patron) will be held at 20, Hanover-
square, on Monday, March 16th. His Royal Highness the
Prince of Wales will preside, and will take the chair at-
3.30 o'clock precisely.
The Sanitary Institute.—A sessional meeting of
the institute will be held at the Farkes Museum on
Wednesday, March 11th, at 8 p.m., when a paper will be read
on “The Prevention of Infectious Diseases” by Professor
A. Wynter Blyth, M.R.C.S., medical officer of health for
Marylebone. The paper will be followed by a discussion.
Sir Douglas Galton, K.C.B., F.R S., will occupy the chair.
Southport Infirmary.—D uring the year 1890,
351 in-patienta were treated, of whom 79 were cases of
accidents. The out-patients numbered 2366. The total
income on the general account was £2202 175. 8d., and the-
expenditure £2075 05. id., leaving a balance of £127 11s. id.,
which had been transferred to the extension building-
account. This account now showed a debit of only
£31 19s. Id During the year legacies and doDations>
amounting to £399 2s. Id. had been added to the investment-
fund, which now stands at £9379 8s. lid
East London Hospital for Children.—T he
twelfth annual dinner in aid of the funds of this hospital
was held on Monday evening at the HObel M6bropole. The
Duke of Portland presided. His lordship, in proposing
“Success to the Bast London Hospital for Children,”’
referred to the ever-increasing benefits it brought to the very
poor of the district in which it was situated. He urged
the public not to desert old and well-tried iustitutious for-
unfledged schemes, which might or might not be of great-
utility. The Secretary, Mr. Whitford, announced aona-
tions to the amount oi £4500, including one of £200 from,
the chairman, through whom no less tnan £1600 had been-
given to the institution.
Eastern Hospital Inquiry.—T he inquiry into-
the alleged maladministration of the Eastern Hospital
has resulted in the production of very important evidence.
Mr. Eldridge appeared for the complainants, and Mr. Gye-
for the Metropolitan Asylums Board. Evidence has been-
given by patients and former nurses, to the effect that the-
food supplied was inferior; occasionally the bread was-
mouldy or mouse-eaten. Cocoa was seldom supplied, and
the fish was stated to be unlit for human food. Complaint&
relative to the bad quality of the food were made to the-
medical officer from time to time,, but produced, oe alleged,
no definite reply except that patients could not expect to-
be supplied with food of the first quality. It was also
alleged that bedsteads were removed without disinfection'
from one ward to another for the use of patients, and
tJie result was in many cases outbreaks of infectious disease.
King’s College Hospital. — The fifty-second
annual meeting of the supporters of this hospital took place
on the 25bh ult., Mr. RicUard Twining occupying the chair.
The report, which was of a satisfactory character, showed
that the hospital was now maintaining on the average more-
than 200 beds. The total number of cases under treatment
in the hospital during 1890 was 2518, as compared with 2185^-
in the previous year. This increase, it may be explained,
is due to the Cheere Ward having been opened, consequent
on a gift (the fourth of its kind) of £1000 by Mr. Matthew
Whiting, one of the vice-presidents of the’hospital. The
number of cases which had been under treatment was-
larger than in any previous year by about 250. The total'
increase of expenditure during 1890 was only £733 Ils., and
in return for this the fifteen beds in tlio Todd Ward had
been open during tlie whole year, and the fifteen in the
Cheere Ward for the last two months. As regarded the-
nurses, under the new rules their hours would be reduced
from Hi to 9;(:. The report was unanimously agreed tov
and the rest of the business, which was of a formal ciiaracter,,
having been gone through, the proceedings terminated.
The Lancet,3
MEDICAL NOTES IN PARLIAMENT.
[March 7, l«9]. 58i
Tub London Sanitary Protection Associa¬
tion.—T he report of the Council for the year 1890 shows
a further increase of membership in the tenth year of the
Association’s existence. The total number of members
was 1588—an increase (after deducting withdrawals} of 81
on the previous year. There were 400 houses inspected for
the first time during the twelve months. The special in¬
spections numbered 467, against 439 in 1889. The cash
statement showed a balance in hand of £680 6;. 7d.
British Medical Temperance Association.—
A meeting of several medical men practising in the
neighbourhood of Highbury and Canonbury was held on
Wednesday, Feb. 25bh, at Northampton House, St. Paul’s-
road, convened by the council of the British Medical Tem¬
perance Association. The President, Dr. B. W. Richardson,
gave an address, and an interesting discussion followed on
the practice of total abstinence, in which several medical
practitioners took part. Dr. Westcott stated that one fifth
of all the inquests held by him were on cases in which
death was more or less due to drink. It is proposed to
hold similar meetings in other districts of the metropolis.
Yorkshcrk CollectB, Medical Department.—
The Dean, Mr. Scattergood, presided at the twelfth annual
dinner of the past and present students of the medical
department of this College, which took place at the Queen’s
Hotel, Leeds, on the 27tb ult. A large and infiaential
company attended. The toast of “The Queen” having
been honoured, Dr. Churton proposed “ The Victoria
University,” which was responded to by Principal Bnding-
ton. Dr. Chadwick gave “ The General Infirmary,” and
Dr. Eddison replied. Other toasts followed. Daring the
evening, songs and musical selections were given, and the
occasion was a complete success.
MEDICAL NOTES IN PARLIAMENT.
Local Qovcmment Proirisional Order (Poor Law) Pill.
In the House of Lords on Monday, March 2nd, this Bill was read a
third time and passed.
Smoke Jfuismoe Abatement (iKetropoUx) Bill.
Lord Rtratheileu and Camphell moved the second reading of this Bill,
which differed from its predecessors in that tlie intervention of the
Home Office was dispensed witii. The Earl of Kimberley thought tlie
Bill should not be accepted. He explained that the Bill imposed a
penalty on all houaeholdovH who allowed opaque smoke to issue from
their chimneys. He supposed all smoke was more or less opaque, and
80 the Bill contained a deflnitiou iWheroby “opaque smoke” was taken
to moan “ anioke of such volume and density as unnecessarily to impair
the atmosphere." The Courts would (ind that definition somewhat
amusing. He did not think it was much use ti> pass legislation which
could not be carried out in practice. Ho nndor.stood tlio difficulty was
that no fireplace had hoen invented which could consume Us own
smoko. The Marciuis of Salislmry criticised the expression “ opaque
smoke ” and the dctlnilion of the term in tlio Bill. There might bo
.smoke with no density at all—it miglit be absolutely translucent. Was
it to bo said that such smoke, if it were omitted in volume, was to be
considerod opa(|uo smoko ? What wa.s meant by impairing tlio atmo¬
sphere .and doing so “ uiniGcessarily ” V The Bill omitted all rofevonce to
furnaces. Its provisimis would require very careful reconstruction.
Tito Bill was road a second time.
Puipcflvrfi o/ Factories anil Workshops.
On Thursday, Fob. 2(itli, in the House of Oommon.s, in reply to
Mr. I/eiig, Mr. Mai thews said that the existing Act gave him powor to
appoint ieinalo inspectors in factories and workshops, hut tliovo were
strong oh.jcctioiw to its exercise in that direction. In the Bill now
hefore the House the auiitavy supervision would be made over to tlio
loral authorities.
Filler as an Intoxicinl in Irela^ui.
The Chancellor of tiio ICxchoiiuer, replying to Sir L. Playfair, .said
there would ho no olt.iectiou to the Select Conimittoo on British and
Fovoigu rtpirit-s being put in posse.ssiou of the report inadu to the
Govurnmciit uu the use of utlicr as an intoxicant in Iruland.
Coinpvlsori/ Vacciiutiio^i Acts.
Mr, Ritchie, in answer to Mr, Hu Lisle, said that ho li.ad been in
cniiimunicatioti with the Royal Commission appointed to impiiro into
the working of those Acts, hut thero was no ho]>o that their report
woulci bo piesontcd to Parliament this session.
Lo7idiin Overhead Wires Bill.
On till) occasion of the .second reading of tins Bill on Friday, 27th
ult., .Sir H. I.otlihviilgc movod: “ That it bo an instruction to tiie com-
mittoo to which tlio Bill is roforred to consider tho advisability of
amending the Bill, so that its provisiona may ho in accoriianco with
Part I t, of tho Public Health Acts Amondmeut Act, Ho .said
thatiui tile Bill was adniittod to be a compromise, the oonipnmiise
Would bo more >atisf.actory, more eomploto, and more fair if the Com-
miUce were to ho instructoii to a.ssimilate tho provisions of the Bill as
it alloctod tho inoLi-opolis to tlio provisions of tlso law as it aiVeetod tlie
pi'oviucoH generally. Tho Public lloalth Acts Amendment Act was
iissod after a good deni of careful coiisidoration, and its provisions had
eon found to work satisfactorily in various largo towns, He there¬
fore thought it would be well if they wore extended to London, After-
Home discussion tho proposed instruction was carried hy a majority
of W,
The Foij Nuisance.
In the House of Commons on Monday, in i-eply to a question hy
Viscount Wolinor and Sir H. 'J'yler, Mr. w. H. Smith stated that Her-
Ma,iesty’s Government were sceptical as to the value of a Royal
Commission for the Investimtion of the Fog Question. The evil arose-
mainly from smoke emittoiTby domestic fires, and the problem to bo-
solved was whether ttwa.s possible by legislation to prohibit and prevent
the production of smoke in this way. The Committee of 1887 showed
that smoke could bo prevented by the use of non-hituininous coal for-
heating purposes, or by the use of coke or gas, or l>y the use of an im¬
proved gi'ate.
New Bills.
Mr. Ritchie has obtained leave to bring in the following Bills re¬
lating to tho public health law, vix. : A Bill to Amend the J.aws Relating
to Public Health in London and the Public Health Law Consolidation
Bill, a Bill to Consolidate the Laws Relating to Health in London.
Both Bills were read for the first time.
Notices of Motions.
Mr. Atkinson's Bill to regulate the income of dowagers has given riae-
to considerable amusement among member.s of Parliament. Although
tlie measure is not regarded in a serious light, Mr. Esslemont has givon
notice of a motion to the effect “ that as dowagers have had no addition-
to fixed allowances from agriculture in pi-osporous times, it is unjust,
unmanly, and unfair to compel them by legislation to accept a reduced
allowance during the present depression."
Sir Walter Foster and Dr. Cameron have been peculiarly unfortunate
in their efforts to obtain suitable places in tlie order list of the House-
of Commons for the motions in which they are interested. It is the
wish of the former to call attention to the losses sustained by charities,
through tho non-payment of rent charges, and of the latter to call
attention to the state of our laws respecting the disposal of the-
dead. The ballot has been unkind to both gentlemen. It has given.
Sir Walter Foster fourth place on Tuesday, the 17th inst., and Hr.
Cameron sixth place on the same day. The character of the motions,
having precedence makes it highly improbable that either Sir Walter-
Foster or Dr. Cameron will he lieard then.
Mr. Gray will ask tlie Secretary of State for War on Tuesday next-
whetlier there is any foundation for the report that frozen meat, badly
preserved or of inferior quality, supplied to soldiers at Colchester and-
otlier gari'isons, has given considerable dissatisfaction, and .vhethor he
will consider the advisability of supplying the army with “ fresh killed,
meat, wliich is obtainable In Groat Britain and Ireland at from Jourpence
to sixpence per pound,” _
THE METROPOLITAN HOSPITALS INQUIRY.
Tlio Select Committee of the House of Lords on tlie MetroiioHtan.
Hospitals resumed its inquiry on Monday. Earl Handlnirst occupied
the chair, and tho other members of tho Committee who ati ended were
the Archblahop of Canterbury, the Earl of Kimberley, Loiil iMoiikswell,.
Lord Siiye and Sole, Lord Clifford, Lord Gathcnrt, Lord /.oucho. Lord
Thring, the Karl of Lauderdale, and tho liarl of Erne.
University College Hospilal.
Mr. N. II. Nixon, secretary of the University College Ho.spitnl,
examined by the chairman, said that the ii.stitution was practically a.
free hospital, Tho qualification for admission was disease, althougli
they had a .system of governors' letters. The institution was started as.
a di.spensary in 1828, and founded as a hospital in 183;i. Thore wore-
207 bods in tho hospital, the working number being 181. The o wore
only two dispensaries in the iimnediato district, and tho Middlesex was
tho neavost liospitnl. His salary aiiiountod to ii(>l)0. They had often
to semi away patients through want of room. In the i-ourso of last
year they treated 41,782 new cases. As to tho organisation of the
liospital, there was an annual meeting of donors and .subscribers. Tlien
theru was a fortnightly meeting of the Hospital Cnmmitteo, which waa
compo.sed of fourteen donors or subscribois, seventeen nominees of the-
Council of tho University College, and three delegates from the
Medical ConimitteG. The Hospital Committee were practically the
executiveof tho hospital. In the way of sub-committous, they liad the
House and Finance Comraitteo and tho Samaritan I'lind Coiiimittco.
The Sister Superior was summoned oneo a month to tho House and
Finance Committee. In the absence of witness the clerk and .steward
povfonued hia duties. The total income of tho ho.spitai last year
amounted to £19,834 and tlie expenditure to £il),f)()9. J.pgarics had
yielded about .£1300 per annum during tin* post ton yeais. They
found itprofitablo to bo always iwlvertisiiig and applying for lunds. Tho
capital invested amomitod to £112,042, only a smsil part of wliieh could
ho used. They had not had to Iceep any boils empty tliroiiph lack of
funds. Tlie resident medical officer adniittod tlio i>alieiits, bolli medical
and surgical. Ho received a salary of .tioo, with boaid and lodging.
Tho officer of tlie staff who happened to ho on dutyadmitted patients to
the lint department. If a ease of scarlet fever iireseiuod itself, it was at
once iselatwi, and .a tclogi-aiii was .sent to tlie Metvepolitau Asylums
Board. They admitted cirsea of diphtlieria when bliore was danger to
life. Tlioy liad .sepiuate wards for sucli c-nsas, Tlio contraels for food
wont before tlie House ;uul Fimuico Committee, who made recoiii-
moinlaiions to tlio Hospital Cominitloo. 'J'lio fond, as a rule, wu,s taken
in hy the .steward, lie liad never heard ooniplaiiits from patients as to the
food,—The Karl of Kimberley : TheuyouaroquitoporfectMr, Nixon
I do not .say .so. but that I have iiovor heard oomplaiiits. Tin* question
of the rpiality of food is dealt willi before it reaches tho pal-ienls. If
thoro is anv fault, tho food goes b.-ick to the coiiti-aebor.— Furl her exiv
ininod by (lie Cbaivman, witness said that tho surveyor of tho hospital
would hii called in if any compliiint were made as to the ilrains. They
had a i>lan of tho drains which was kept up to ilato. 'J'he hospital was
nursed by a sistorliood associated with the Church of J'iiif'land. They
found this arrangement to work oxcollently. No iliffieultics had arisen
as to tho division of authority. They !ia<l a Cliurch of J'higlaml'
chapluiii, hut they admitted mim.stor.s of .all denomination.s at any time.
They had a separate ward for ehililren. Witness preferi-ed to see
cliildi'ou in a separate ward. Cliildren disturbed adults to a consider¬
able extent.—By the Earl of Kimberley: In 187!*, and again in 1888 .
Dr
582 The Lancet,]
THE METROPOLITAN HOSPITALS INQUIRY.
[March 7.1891.
considerable alterations were made in the drainage system of the
taosplt^. In the latter year the drains weia examined by an
•expert sanitary engineer. No doubt it would be a good tiling to have
a yearly inspection by an expert sanitary engineer wholly uncon¬
nected with the hospital.—The Earl of Kimberlev: Has there been no
dissatisfaction on the part of rhe authorities witli the buildings being
•old?—Mr. Nixon: Yes, but the buildings are as good as wo can expect.
The Earl of Kimberley: The buildings have been improved?—Mr. Nixon:
Not structUTOdly, but the drains have been put in thorough repair.—
The Ear) of Kimberley : But the buildings are structurally inconvenient?
—Mr. Nixon: Yes, and it la coniemplated to rebuild the hospital.—In
tfurther examination by Lord Kimberley witness said that the hospital
was originally founded as the medical school of the University College,
The Hospital Committee reported its proceedings to the Council of the
College. The finances of the two boclies were kept entirely separate,
the College merely acting as trustees of the hospital,—By the Archbishop
•of Canterbury: No difficulties arose in the relations between the
College and the hospital.—By Lord Cathcart: On one sido the
iiospit^ buildings abutted on some houses which ho might say wore
being purchased by the hospital in view of the reconstruction
.scheme. The midwifery cases which they treated were not of tiro
•class that general practitioners cared for. Tire people were very
poor. The wife of a man receiving £2 a week in wages would not be
treated. They did not limit tiro cases to tlie teaching requirements.—
The Earl of Ivimberlej': Is not that a directly pauperising arrange¬
ment?—Mr. Nixon : It is difficult to define tlie term pauper.—The Earl
•of Kimberley : Do you tliink it is a desirable thing to provide a system
by which people shall know beforehand that they liave not to provide
for the expenses of confinement?—Mr. Nixon: Ido not think that that
•enters into the consideration at all.—The ICaii of Kimberley: So I
observe ; but don’t you think it ought?—Mr. Nixon ; Yes, jjovhaps it
ought.—The Earl of Kimberley: Do you not think it is a very undesir¬
able thing that in any ho.spital in London more cases of this kind should
be taken than are necessary for the purpo.ses of instruction ?—Mr.
Nixon : I find it difficult to answer that question, beeiusc I think tlio
•cases are really so poor.—By Lord Thring ; He should like very much to
aee the floors renewed. No religious tests were applied to the nurses,
Mr. Nixon hero volunteered a suggestion. It occasionally occurred, he
said, that patients became affected with mania, and wore very noi.sy.
Before they could be romoveil the whole machinery of the relieving
■office had to be invoked. All lie wished to sugge.st was tliat it would
be a great convenionce to hospital staffs generally if the certilicato of
the officer under whom the patient had been in the ward were
accepted as sufficient to send the patient in an ambulance to the
infirmary or the workhouse.
Sister Cecilia, of the community of All Saints, exaaniiied by the
Chairman, said that the sisterhood nursed tlie Uuivej.sity Oolloge Hg.s-
f 'itaJ. Under the contract the sisterhood received .£192 fi.v. por.month
or the work. There were nine ward sister.s, fifty-six niirse.s, and
thirteen probationers. They had one w.ard sister between two largo
"wards. They did not employ weud maids, but had scrubbers. Tlie
sisters were practically on duty from six o'clock in tlio morning nntil
10 o’clock in the evening. In the sisterliood they had suflicient'nuvsoM
for all thebeods of the hospital, Apart from private nutsos they had
112 nurses in the sisterhood.—By the liarl of Kimberley: Any complaint
as to the conduct of nur.ses would be dealt witli by witness.—)iy the
Archbishop of Cantorbuiy : Tho qualit;*' of tlie food in tlio liospital was
■excellent. If anything went wrong ii, was at onco remedied. The
-.sisterhood engaged nurses from all denomitiacions,—By Lord Thring;
She did not thinlc the nurses wore overworked. During the pirst nine
years there had been only five deaths among tho nurses. Tliu average
length of service of the nurses on duty was betweeTi six and eight
years. Sire could not suggest any means by which tho lives of the
nurse.s could be leiigtheneil.
Dr. Barlow, for ten years on the staff of tlie liospital, stated that tho
.acenmmodation of the out-patient department was very satisfactory.
Tho space available was by;no means crowded. There was no syste¬
matic inquiry as to the circumstances of the patients. If ho found a
man in better circumstances he would treat him on tiio first applica¬
tion, but infonn him not to return to the JioapitaJ. It might be desir¬
able to liave an inquiry officer, but lie M'ould reepiivo Lo bo a superior
person and not a mere mercenary individual. Ho was decidedly in
favour of out-patient departments. He did not tliink they starved out¬
side practitioners. He should certainly like to see a new hospital,
although he considered the present building to be quite s.anitary, lie
would not say that there were no cases of abuse of the charity which
the hospital oifered, but be would .say that sui.h cases were rare, Ho
did not think that the poor suffered in the hospitals througli the
resence of students. On tiie other hand, lie considered that I ho poor
eneflted by the presence of the students. Tlioso hospitals which
had medical schools attached were tlie most pojiular among ttio poor.—
By Lord Cathcart: Ho considered that nui’ses were bad lives to
in.Hurance companies in the same way as wen; doctov.s. lie did not
think that as regards the Univei'sity College iJo.spitai Ihevo was any
^special wear and tear among nurses.
Mr. A. B. Barker, a surgeon on the staff of tho hospital, expressed
himself strongly in favour of oiit-p.aUont dop.aitmcnts. The complaint
against out-patient departments came from a very undesirable fringe of
the profession. He believed they interfered with this fringe, and ho
thought it proper that they .sliould intorfei-e. In his opinion the public
had great confidence in the general hospitals of London.
Mr. Berkeley Hill, at one time dean of the medical school, gave evidence
4 is to that institution.
The Committee afterwards adjourned.
Tiieir lordships met again on Thursday, Earl .S.iiidliurst presiding.
The Royal Free IIo.ipilaL
Mr. C. W. Thies, secretary of the Itoyal Free Hospital in Cray’s-inn-
road, examineil by the Chairman, stated that their institution was a
■general liospital. The students who attended for clinical instruction
were attached to the London School of Medicine for Women, It was
entirely a free hospital. The governors had no privileges wliatever in
respect to the admission of pallent.s. No letters were issued, all cases
being adrriibted on the discretion of the medical ofllcor. 'fhoy had a
weekly board, at the meetings of whicli six or seven governors usually
Attended. Tills board was practically tlio executive of tlio liospital.
He called special meetings when necessary. In a case of insubordi¬
nation he would undoubtedly suspend tho oflicor, and immediately
report the matter eltiier to the weekly board or its chairman.
There were 160 beds in the hospital, tho working average being about
185. They admitted all diseases save infectious diseases. They had
no special accommodation for special diseases. At the time of the last
cholera epidemic in London the committee threw tho hospital open en¬
tirely to cholera patients. In 1S;12 they admitted 700 cholera cases, in
1S40 about 8000 cases, and in 1854 about 6000 cases. He could not ex¬
plain how accommodation had been found for so large an influx of
patients. They had not been compelled to keep beds vacant through
want of funds. They kept things going by “eating the capital.’’
The ordinary income last year amounted to £6048, and tlio legacies to
£6865. I'Yom 1881 to 1890 the ordinary income averaged £6028, and the
legacies .£7870. The expenditure last year amounted to ,£10,071; the
invested funds of the iiospital amounted to £20,081. They were about
to issue an appeal for funds upon a largo scale. The hospital was
founded in 1828. In 1842 the hospital was removed from Hatton-gai'den
to Gray’s-inn-road, where it occupied some old barracks formerly used
by the Light Horse Volunteers. Owing to the receipt of legacies tlie
committee were able to rebuild three sides of the quadrangle without
appealing to the public. Tlie remaining side was the present front, which
was in such a dilapidated condition that unless they spent a very large
sum of money upon it they would probably have the roof coming down.
The committee now wished to rebuild this front. A staff nurse complain¬
ing of food wouldspeak to tlie lady superintendent, who would report to
witness or tho weekly board. Minor complaints were received from time
to time, but none of a serious character. Tho architect was responsible
for the sanitary condition of tho building, He would not describe that
gentleman as a sanitary expert, but he had a thoi ougli knowledge of all
sanitary matters. They had a drainage plan wliich was kept up
to date. The .steward was re.siionsiblo for the drains being flushed
every week, and was required to report to witness in tho event of
finding anything ami.ss. The drains were tested about once a year. In
connexion with their building sclieiue they contemplated a complete
revision of the drainage system. He liad never had any suspicion as to
anything being wrong witli tho dr.ains. He did not think that a bad
odour could bo detected in any part of the building. They had a lady
superintendent and forty nur.sos. Tliey had a system of training which
extended over three years. At the end of that period, and after
examination, nurses received a certificate. The question of pensions
for nurses was being coiisidorad by the committee. Tho nurses on day
duty worked from 7 in the morning until 8.80 in the evening. Every
nurse was off duty for two hours per day, and had an allowance of two
hours and a quarter per day for uieal.s. Tho time .spent in the wards,
therefore, amounted to nine liours and a quarter per day. Every nurse
had besides one whole day per iiionffi and four hours and six hours per
month. Tho annual holiday extended to about three wooks. During
the four years they had clone their own nursing tlievo had been only
four cases of illness in the nursing .staff and no deatlis, They did not
employ ward maids. The Earl of Kimberley : Why does tho lady
suporiiitondent dine in wliat I may call tliis solitary grandeur?—Mr.
Thies : It is merely a personal matter,—Tlie lOavl of Kimberley : Does
slio consider the nurses below hei V—Mr. Tliios ; Oh, no, but, ,slie has
to carve for tlie genor.al body of the nurses, and it i.s liarilly likely that
siio would care to eat her own dinner at the same time. Sho attends
and carves at tliree dinners per day. By tlie Cliairnian ; They did not
.supply patients with tea, sugar, or butter. It was a mere question of
expense, and was now being considered by the board. By Lord (Jatii-
cavt; lie .sliould like to see toloplionic communication between the
liospitala in London. Tliey did not-keep a ward toniporaturo book.
By the Earl of Lauderdale: Tnove were 17,208 out-patients last year,
and in addition 10,894 casualty cases. By tlie Karl of Kimberley : lie
estimated that tho hospital saved the parish about £2009 a year, and
oil tiiat ground ho considered it would be free for parochial assessment.
By tlie Chairman ; Ho estimated tlie coat per occupied bed last year
to have lieeii .£(10 11s. Each out-patient, it was ciJculated, cost lx. 3d.
He should like to see fpeater uniformity in the accounts of tlio London
ho-spitals. Comparisons at present were altogether fallacious, lie hail
been in tlie out-patient clepartraent of every hospital in London, and lie
believed that tliero was very little abuse of charity. They were making
a special appeal for as.sistance to the Groat Northern Railway Company,
whose evijdo)F« were brouglit in large miinbers to the hospital. He
calculated that the patients from the Ureat Northern Rtvil way Company
cost the hospital about £590 a year,
Mrs. (larrottAndor.son. Dean of tlio Medical School for Women, who.se
students receive their clliiica! instruction in the Royal Free Ho.spital,
gave evidence as to tho work of the school. There were, she ssiiX 107
students, the number lieing on the increase. This year they had tliirty-
foiiv new students, which was liio largest number on record. Tho
students paid £li0 for tlio course of study, and of that sum £70
went to she school and tho remaindur to tho hospital. Tliore were
forty-three students studying for tlio London ijualiflcations.—By
tlio J''.arl of Kimberley ; Two ladie.s harl pa.ssed the M.l). examina¬
tions, and a very large number the M. 11. examinations. Tho course of
instruction in tho hospital was nearly tlio same as that in force in
hospitals where male students were taught. Tlioir students had a good
deal of trouble in getting thoir out door midwifery instruction.—8y
tlio E.arl of Arran ; There were about 129 qualified women on tho
Register, and they were nearly a.ll in practice. A great number were
abroad, but they wore gradually scattering over the largo towns of
England. She thought that, as ivomon went, tho medical profession
was a very good profession for womon. Women wore not so ambitious
as men in tlio matter of making J.arge incomes, and sho thoiigiit they
had evory reason to bo satisflod with the medical profession.
Mr. Calbort, assistant physician at tlio Royaf Free Hospital, gave
evidoiico as to the working of the oiit-patlontdepartmont. Heexpressed
liiinself as strongly in favour of tho retention of out patient liopart-
inents. General pmetitionovs could lo.so only very little through thoir
existonco, for tlie patients wore oxtrouiely poor. Tho pri’-sBiico of the
lady students in no way liamnered the work of the out-patient depart¬
ment, As a matter of fact, tlie lady students were very useful.
Mr. .iamo.s lierry. surgeon of tho hospital, .said lie was <niite satisfied
with tlie sanitary eoiirlition of tlio liospital. As a riile, lliei'e was suffi¬
cient material for teaching purposes. He considered that it would bo
very advantageous to send tlio students round the iiiHrmarios,—By
Lord Monlcswcll; Ho approved of the ajipointnients to the .stall’
being limited to lioliluvs of Lontbm qualifications. It would be in¬
advisable to admit otiior qualifications.
The Comiiiitteo then adjourned,
Thb I.ANOBT,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, & DEATHS. [March 7, 1891. 58S
Svoeestful applica/nln for Vacancies, Sfitretarien 0 /Public Institutions, and
oUurs posaesitin!/ inforitiaiion milahlc /or this column, are invited to
forward it to 'I,'mi Lancict Office, directed to the Sub-J3ditor, not later
than 9 o’clock on (he Thnraduy snomisiy of each week/or publication in
the next number. • . .
Adams, W., F.E.C.S., has beon appointed Consulting Surgeon to the
Great Northern Central Hospital, llolloway-road.
Beruy, F. C., M.D., M.H., B.Cli., ha.s been reappointed Medical Officer
of Health, Lyntpn.
BOGDEN, P. Hamilton, M.B., C.M. F.iiin.. haa been appointed Medical
Assistant to the Dundee Iloyal Lunatic Asylum.
COOKE, R. T. E. B., L.H.C.P., F.R.C.S. Kdin., M.B.C.S., haa been
reappointed Honorary Consulting Medical Officer to the Royal
Novt'horn Sea-Bsthing Infirmary, Scarborough.
DIXEY, AUTHUR Orosree, M.D. Mass., M.R.O.P., L.R.C.S. Bdin.,
L.S.A. Lond., has been appoinfed Medical Officer for the Caldicot
District of the Chepstow Union, Surgeon to the vSevern Tunnel,
Great Western Railway, and Tin l-'late Company’,s Works ; Certify¬
ing Factory Surgeon, Medical Referee to the Prudential Assurance
Company, and Surgeon to Oddfellows, Foresters, and otlier Clubs,
vice O. X. Slatter, resigned.
EVANS, M. G;, M.D.Aberd., L.R.C.P. Lond., M.RC.S., has boon
appointed Consulting Physician to the Brecon County and Borough
Infirmary.
Grace, henry, L.R.C.P. Lond., M.R.C..S., Inus lieen appointed Medical
Officer of Health fi>r the Kingswood Urban Sanitary District of the
Keynsham Union.
Hickman, HerueutV., M.R.C.S., L.R.C.P. Lond., late House Physician,
has bean appointed Ophtlialinic Assistant to Guy's Hospital,
LOVK, Dr. .Tames Keru, has been appointed Aurist to the Deaf and
Dumb Institution, Longsidc, Glasgow.
MAR.SHALL, Charles Devereux, M.R.C.S., L.R.C.P. Lond., has been
appointed House Surgeon to University College Hospital.
•MiLlA, JosEi’H, M.R.C.S., &c., has been appointed Anicsthetist to St.
Mark's Hospital, City-road.
Read, SiDLEy\V.,L,D.S.B-C.S.Kng., has been appointed Dental Surgeon
to the Metropolitan Hospital.
Saunderson, Rout., Jim., M.D., L.K.Q.C.P. Irel., has boon appointed
Medical Officer to the Edoaderry Dispensary, Jfidenderry Union.
Simmons, E. Walvoeb, M.B. Durh., M.R.O.S., has lieen appointed
Honorary Physician to the Worcester Infirmary, vice Strange.
Smith, E. M., M.B., C.M. Eilin., has beon appointed Assistant Medical
Officer to the York Friendly Societies’ Medical Association, vice O.
Scarr, resigned.
SVKHS, J. n., L.R.C.P. Lond., M.R.C.K., lias beon appointed Assistant
Medical Officer of the Cvumpsall Workliouse, and also Assistant
Medical Officer of the Workhouse and Receiving Wards, Bridge-
street, in the township of Manchester.
TaxlOR, .f. W., M.l). St. And., M.R.C.S., has been reappointed
Honorary Consulting Meiiical OlHcer to the Royal Northern Sea-
Batliing Infirmary, Scarborough.
Vernon, A, IL,L.R.C.P, Lond., F.R.C.S., has beon appointed Honor.ary
Surgeon to the Boscombe Hospititl and Provident Dispensary, vice
Nunn, resigned.
Wehii, F., L.R.C.P. Lond,, M.R.C.S., has been appointed House Surgeon
to the Doncaster Infirmary, vice i.niul.
Wheaton, S. W., M.D. Lend., M.R.C.P., D.P.H., ha.s been appointed
Pliy.sician to the Royal Hospital for Children and Women, Watorloo-
briiige-roail, vice Dr. Dakin, resigned.
Wood, W. D., L.R.C.P., L.R.C.S. Edin,, has boon reappointed Medical
Officer of Health for the Combined Districts, Thame.
^mmus.
Fur further information regarding each vacaney reference should be made
to the adoertisemcsil.
Belghave Hositj'al eor Chu.drkn, 79, Gloucostor-street, S.W.~
House Surgeon. No salary, but board, lodging, fuel, and light pro-
vikted.
Birmingham Provident Dispensary.—M edical Practitioner on the
statu tif tlie Balsall-lieatli Brandi. (Apply to Rev. W. 0. Tlioinas,
Hem. Sec , Moseley, Binningliain.)
Chelsea HosPiTAi. FOR Women, Fulham-road, S.W.—Medical Officer
for one year. Salary £80 per annum, with board and residence.
Forest-hill Provident Dispen.sauy.—M edical Officer. (Apply to
the Hon, Secretary, the Ridge, West-hill, Sydonbam.)
Hull Royal Infirmary.—F our Honorary Assistant Surgeons to take
charge of the out-patients.
Hull Royal Infirmary.—O plithalmic Surgeon.
Kino’s College, London.—Demonsti atov of Physiology.
Leith Hospital.—U ou.Ho Physician for the Out-door Department for
six montlis. Salary at the rate of £90 a year, with l>oai\i in the
IloxpiUil.
Leith Hospital.—H ouse Surgeon for the Out-door Department for six
montlis. Salary at the rate of ,£90 a year, with board in the Hos¬
pital,
Leith Hospital.—S m-goon for the Out-door Dopartinent for six
montiis. Salary at the rate of .CSO.a year, witli board in tlio Hos¬
pital.
Liverpool Northern Hospital.—A asistant House Surgeon. Salary
£70 per annum, with residence and maintenance in tiio house.
Norfolk and Norwich Hospital.—P hysician on the Honorary
Medical Staff. (Apply to the Secretary, NorwiCli.)
North-Eastern Hospital for Children, Uackiicy-road. N.E.—
Junior House Surgeon for nine months, at a sowy 01 £6 per'
month.
Royal Free Hospital, Oray’s-inn-road.—Junior Resident Medical
Officer for six months. Board and residence provided in the iius-.
pital.
ROYAL Bath Hospitaland Rawson Convalescent Home, Harrogate.—
House Surgeon and Secretary. Salary £80 per annum, with boards
lodging, and washing.
St. Peter’s Hospital for Stone and Urinary Diseases, Henrietta-
street, Covent-garden.—House Surgeon for six months. Hono¬
rarium 26 guineas, board, lod^ng, and washing.
St. Pancras and Northern Dispensary, 120, Buaton-road.—Honorary
Pliysiciau.
Sussex County Asylum, Hayward’s Heath.—Junior Assistant Medica’l
Officer, Salary £100 a year, witti board, lodging, and washing.
Teionmouth, Dawlish, and Newton Infirmary and Convalescent
Home.—H ouse Surgeon (to act also as Secretary). Salary £40,.
with board and lodging.
West Bromwich District Hospital.—A ssistant House Surgeon for
six months. No salary, but board, lodging, and washing in the-
Hospital.
West Ham Union.—A ssistant (Resident) Medical Officer for the Work¬
house. Salary £100 per annum, with the usual resident allowances.
(Apply to the Clerk, Clerk’s Office, Union Workhouse, Uniou-road,
Leytonstone, E.)
West London Hospital, Hammorsmith-road, W.—House Physician
for six months. Board ami lodging provided. No salary.
West London Hospital, Hammersmith-road, W.—House Surgeon for
six months. Board and lodging provided. No salai-y,
West Loni^n Hospital, Hammersmith-road, W.—Assistant Surgeon.
X. N P., The Lancet Office, 423, Strand, W.C.—Medical Officer to tak&.
fullchirgoof a Dispensary in the Fast of Loudon. Salary £l(Xt*
with pariially furnisliod rooms, fuel, and gas.
Hlamagfs, anli
BIKTHS.
BOYTON.—On March 1st, at 65, Seymour-streot, Hyde-park, the wife of
Ivan H. Boytoii, L.D.S. R.C.S. Kng., of a daughter.
Burke.—O n Feb. lath, at Civil Lines, Poona, the wife of W. H. Burke,
M.B., ludian Medical Service, of a son.
Clark.—O n March 2nd, at Raliore, Brunswick-road, Gloucestor, Mrs.
Oscar Clark of a daughter.
Gould.—O n March 4th, at 10, t^uecn Anne-street, the wife of A. Pearce-.
Gould of a dauglitor.
Gunn.—O n March 3rd, at 94, Queen Anne-street, Cavendish-square, W.,.
tho wife of R. Marcus Gunn, F.R.C.S., of a daughter.
Huntington.-O n X<'eb. 28th, at 43, Soutli-street, St. Andrews, the wife
of William lluniiiiglon, M.U.C.S., L.R.C.P. Lend., of a daughter.
Venn.—O n Sunday, March 1st, at 122, Harley-street, W., the wife o£
Albert J. Venn, M.D., M.R.C.P., of a son.
WiLLiAMSON.—On Feb. 20th, at Eldoii-squaro, Newcastle-upon-Tyne,
the wife o£ 0. E. Williamson, F.R.C.S., of a son.
MARRIAGES.
Power—Ci.utterhuck.—O n Fob. 20th, nt St. Andrew’s Church, Ply¬
mouth, K. R. Power, Surgeon-Major Army Medical Staff, only son.
of tho Rev. E. R. Power, I'lie Naut, Balbriggan, county Dublin, to
Catherino Annie, on)y child of Surgeon-General J. E. Clutterbuck,.
M.D., Army Medical Staff (retired), of Newark Park, Wotton-under-
Edge, Ulouce-stershire.
Savage—B ousFiELD.—On Feb. 9th, at St. Paul’s, Capetown, S. Radford
Savage, M.H., of JIaseru, Basutoland, to Mary Isabel Boustield,
second daugliter of the Bishop of Pretoria.
Simpson—Macnauohton.—O n Feb. 28th, at St. Peter’s Church, Pad¬
dington, John Pollock Simpson, M.B., to Annie Jolianua Stuart
(Bennett), dauglitor of the late Alexander Macnaughton, J.P.,
‘ Banker, Scotland. _
DEATHS.
Allan,—O n March dud, at 23, Milner-squaro, John Allan, M.D.,
M.B.C.P., in his 7dth year.
Archer,—O n Fob. 26tli, alBnyne-terrace, Notting-liill, William Archer,
F.R.C.S., in his 83rd year.
Middlemore.—O n March ist.at his residence, TheLimos, Biistol-road»
Birmingham, Richard Middlemore, F.Il.C.S., in his 87th year.
Pierson.—O n Jan. 20th, at Shelabagh, Khojak Pass, Baluchistan, o£
typhod fever and pneumonia, Alfred Henry Pierson, Suigeon Indian
Medical Service, eldest Son of tho late Henry 0. Pierson, of the.
India Office.
Wakefdoli).—O n Feb. 29th, at Alwyno-placo, Canonbury, N., Thomas-
Wakollelil, M.R.C.S., in tho 82nd year of liis age.
WOLi-'iL—On March 1st, at tlie vesidonco of his neijhew, North Audley-
stroet, Grosvenor-scfiiare, Dr. Julius Wolff, in his OOth year.
WORTiuNGTON.—On Fel). 20th, at Pattensweir, Enfield, Frederick.
Worthington, M.R.C.S., formerly of l.iverpool, aged SI.
fee of Os. is charoed for the Insertion of Notices o/Birthe,
Marriages, and Deaths.
Dir:' /e(j by
Google
£84 Ths Lancet,] NOTES, COMMENTS, AND ANSWEBS TO COBBESPONDENTS. [March 7,1891.
Htbital gisrg for t|e maiitg
Honday, Maxell. 9.
RetAi. London Opiiihaluio Hospital, Moo&fields. —Operations
dally at 10 a.h.
BOTAL WBSTMiNSTEa OPHTHALMIC HOSPITAL.—Operations, 1.80 P.U.,
and each day at the same hour.
Ceslsea Hospital for Women.—O perations, 2.S0P.H.; Thursday, 2.80.
Hospital for Women, Souo-s^uarb. —Operations, 8 p.h., and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.h,
KOYAL ORTHOP.fiDlc HOSPITAL.—^eratlons, 2 P.M.
Central London Ophthalmic Hospital.—O perations, 2 p.h., and
each day In the week at the same hour.
Vniversity Colleoe Hospital.—B ar and Throat Department, 9 A.H.;
Tburs(h<.y. 9 A.H.
Throat Hospital (Golden-sq.).—6.80 p.m. Mr. Mark Hovelt; Chronic
Suppurative InRammation of the Middle Bar, and its Treatment.
(Post-graduate Course.)
Society op arts.—8 p.m. Prof. R. Meldola: Photographic Chemistry.
(Cantor Lecture.)
Medical Society of London.—8.S0 p.m. The Adjourned Discussion
on Dr. Dongias Powell’s paper on Angina Pectoris will be reopened
by Dr. Lauder Brunton.
Tuesday, March 10.
'Kino's College Hospital.—O perations, 2 p.h. ; Fridays and Saturdays
at the same hour.
Out'S Hospital.—O perations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 P.H.
St. Thomas’s Hospital.—O phthalmic operations,4 p.h. ; Friday, 2 p.h.
St. Mark's Hospital.—O perations, 2 p.h.
Cancer Hospital, Brompton.—O perations, 2 p.x.; Saturday, 2 p.h.
Westminster hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.h.
Si. Mary's Hospital.—O perations, 1.80 p.h. Consultations, Monday
2.80 P.H. Skin Department, Mond^ and Thursday, 9.80 a.h.
Throat Department, Tuesdays and Imdays, 1.80 P.u. Electro¬
therapeutics. same day. 2 P.M.
BOYAL Institution.—8 p.h. Prof. V. Horsley; The Structure and
Functions of the Nervous System.
Boyal College op Physicians.-6 p.h. Dr.T.Oliver: LeadPoisoning
in its Acute and Chronic Manifestations. (Ooulstoiiian Lecture.)
Society of arts.-8 p.m. Mr. J. Starkie Gardner: Enamelling and
Damascening.
The Sanitary institute (Parkes Museum. Margaret-st., W.).—8 P.M.
Mr. J. F. J. Sykes; Nature of Nuisances, including Nuisances the
Abatement of which is Difficult.
'BOYAL Medical and Ciiiruroical Society.—8.30 p.m. Dr. W. Halo.
White and Mr. C. H. Oolding-Bird: Two cases of Idioglossia.—
Dr. Frederick Taylor: A case of Defective Articulation.
Wednesday, March 11.
National Orthopedic Hospital.—O perations, 10 a.h.
Middlesex Hospital.— Operations, 1 p.u. Operations by the Obstetric
Physicians on Thursdays at 2 P.u.
.St. Bartholomew’s Hospital.—O perations,1.80 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 P.u.
Surgical Consultations, Thursday, 1.80 p.h.
Charino-cross Hospital.—O perations, S P.H., and on Thursday and
Friday at the same hour.
St. Thomas’s Hospital.-O perations, 1.80 p.h. ; Saturday, same hour.
London Hospital.—O perations, 2 p.m. Thursday <bSaturday,samehour.
St. Peter’s Hospital, Covent-garden.—O perations, 2 p.m.
Great Northern central Hospital.—O perations, 2 p.m.
University college Hospital.—O perations, 1.80 p.m. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 9.16 A.H.
Boyal free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations,9.80 a.m. ;
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
Throat Hospital (Ooldon-aq.).—6.80 p.m. Dr. Norris Wolfenden: The
Use of Electricity in Diseases of the Throat. (Post-graduate Courao )
Hunterian Society.—8 p.m. Dr. Hughlings-Jackson will exhibit a
Phonogram—talking of a patient the subject of Dis-neminated
Sclerosis, Dr. J. Langton Hewer: A case of Chronic Osteo¬
myelitis of Tibia, with'Specimen.-Dr. P. C. Turner: A Specimen
of Ulcerative Aortitis. And other Specimens.
Society op Arts.—8 p.m. Mr. H. Newman Lawrence and Dr, Attliur
Harries: Electricity in rolalion to the Human Body.
Thursday, March 12.
Bt. Oboroe’s Hospital.-O perations, l p.u. Surgical Consultations,
Wednesday, 1.80 p.m. Ophthalmic Operations, ftiday, 1.80 p.h.
University Collf.oe Hospital.—O perations, 2 p.u. ; Bar and Throat
Department, 9 a.h.
Boyal Institution.—3 p.m. Professor C. Meymott Tidy : Modem
Chemistry in relation to Sanitation.
Boyal College OP Physicians.— 5 P.M. Dr. Broadbent: Structural
Diseases of the Heart, from tJie point of view of Prognosis.
(Lumleian Lecture,)
British GvNiECOi.oGiCAL Society. — 8.30 p.m. Mr. Lawson Tait:
Further Observations on the Methods of Restoring the Perineum.
Oputhalmolooical Society op the United Kingdom.—8.30 p.m.
Patients and Card Specimens at 81’.M. Mr. Treacher Collins : On tiio
Glands of the Ciliary Body,—Dr. Benson (Dublin): On a case of
Neuro-retinitis with High Tension simulating Intra-ocular Tumour.
Mr. Cross(Clifton);0:ica8esofHydroplithaImos —Mr.G.lX.fohnston
(Vancouver): Penetration of Eyelasli into Anterior Chamber, removal
by operation,—Mr. J. 11. Lunn : Case of Coredialysis and .Secondary
Cataract. lOl’.M., Special General Meeting, to consider (1) Alteration
of tile date of the Bowman Lecture ; (2) an address to Professor von
Helmholtz on ids seventieth birthday; (3) a motion by Mr. Tweedy
(with the concurrence of the Council)—" That, ih view of the course
of medical study extending over a period of five years, it is expedient
that the Ophtlialmological Society of tlie United Kingdom urge
'Upon the General Medical Council the desirability of making tiia
subject of ophthalmic medicine and surgery a compulsory part of
4be ordinary curriculum.”
Friday, March 18.
Royal South London Ophthalmic Hospital.—O peiatloiis. 2 p.h.
Cancer Hospital (Fulham-rd., S.W.). —4 p.m. Mr. F. Bowremaa
Jessett; Surgery of the Intestines, with Demonstrations.
Society of Arts.—4.80 p.h. Capt. Abney: The Science of Colour.
Clinical Society of London.—8 p.m. Dr. Gowers: Acase of Atrophic
Spinal Paralysis and Multiple Neuritis.—Mr. A. Pearce Gould; A
case of Simultaneous Ganjivonoof both Feet from Syphilitic Disease,
amputation through knee-joints, recovery.—Mr. C. Mansell Moullln;
Three cases of Septicosmia due to Sewer Gas.—Mr. A. T. Norton;
A case of Popliteal Aneurysm in a Youth aged seventeen.
The Sanitary lNSTn'UTE(Parke8 Museum, Margaret-st., W.).—8 p.m. Mr.
A. Wynter Dlytb: Diseases of Animals in relation to Meat Supply ;
Characteristics of Vegetables, Fish, &c., unfit for Food.
Royal Institution.—9 p.m. Dr. Felix Semon: The Culture of the
Singing Voice. Saturday, March 14.
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.16 A.M.
Royal Institution.—3 p.m. TheBightHon. Lord Rayleigh: The Forces
of Colieslon.
METEOROLOGICAL READINGS.
(Taken daily at 8.30 a.m. by Steward's Instruments.)
The Lancet Office, March 6th, 1891.
Dato.
li.ironietur
rciiucacl to
.Sou Level
and aS'F.
Diroc-
tlon
of
Wind.
Dry
bulb.
Solar
; Wot Hiidia
bulb, iu
Vacuo,
Maxi-
iniiiii
Toiiiii.
Slmdo.
Mill.
|Tuiiii>
Rain¬
fall.
Remarks at
8.JU A.U.
Feb. 27
80 20
S.B.
' 40
88
81
60
31
„ 28
30-80
S.K.
86
86
76
01
86
Mar. 1
80-20
S.W.
i 48
46
81
66
80
CloilcCV
» 2
80 T 1
8 .W.
61
60
69
68
47
Overcast
„ 8
80 25
S.W.
40
87
87
61
87
Bright
>• 4
80-89
w.
40
37
67
63
87
Overcast
„ 6
80-31
w.
GO
47
86
67
40
Cloudy
Ilfftfs, Comments, # ^nsfoers to
ferespitkents.
It is especially requested that early intelUyenee of local
evods having a viedicul interest, or irhich it is desirable
to brmg ■under the notice of the, profession,, may be sent
direct to this Office.
All commnnications relating to the editorial business dfthe
journal must be addressed the Editors."
Lectures, original articles, and 'nports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private informa¬
tion; ■ninst be authenticated by the na-nies and addresses
of their writers, not necessarily for publication.
We cannot qwescribe or recommend practitioners.
Local papers containing reports or 7ie7i’s paragraphs should
be ■marked and addressed ''To the Bub-Eclitor."
Letters relating to the publication, sale, and advertising
drpartme7its of The Lancet to bo addressed "To th,e
Publisher."
We cannot sindertake to 7'eturn MSS. 7iot 'used.
Dental Practice in Australia.
Mediaus.—ThQ Australian Dontists Act of 1887 provides that the fol
lowing persona ate entitled to registration as dentists : — 1. All
medical men or persons in the actual practice of dentistry at the
date of the passing of the Act. 2. All persons over twenty-one years
of ago who have studied dentistry for four yoar.s, and passed the
examination instituted by the Board. 3. AH persons who for six
months previously to tho passing of the Act iiavo been dentists or
apprenticed bo a dentist, and who shall continue in that capacity for
a further term of three years. 4. Any person not domiciled in
Victoria on showing that he has practised for ben years, and holds a
foreign diploma.
Dr. A. Oyier Ward will see that the subject of Ids letter is fully dealt
wiLli ill an annotation on p. 606 .
Pauper sliould obtain a copy of tlie by-laws of tho hospital.
Mr. J. B. liaW.—The paper will appear very sliortly.
EXTREME HYPERPYREXIA.
To the JidiUrrs of The Lancet.
Sirs,—T he following may prove of interest to readers of THE Lancet.
A. B-, aged twenty-two years, died on the sixth day of an attack
of rheumatic fever. The temperature, taken a quarter of an liour
before death in tiio axilla, was 100'2’. Taken again five minutes after
death with a second thermometer it was found to he at exactly tho
same point. Both thermomotors aro perfectly reliable. Thero was no
heart affection. I am. Sirs, yours faithfully,
Workington, March, 1801. C. McKenow, M.B., C.M.
Di(:
oogie
Thb Lancbt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Mabch 7, 1891. 585-
TUDEBCULINB.
I > r . Wtn . Fer !; ug 8 on has favoured us with a copy of the following lines
and charade, which were written by one of the “cases'' recently
nnder treatment by Professor Koch’s mothod at ttie Chalmers
Hospital, Ban!!.
1 feel this mundane sphere's a fraud—
A gift not worth the giving;
That things are going to the bad,
And lifers not worth the living.
It is not that the world is false,
Thongti false It is and vain :
That makes no riot in my pulse;
2'hat brings my head no pain.
It is not that my love's unkind,
Though that Is also true;
I bear that now with equal mind.
For it is nothing new.
It Is not that I am in debt—
None ever gave me credit—
Nor am I turning crusty yet,
Though unkind folks have said it.
You ask : “ Whence then this clouded brow ?
This world dissatisfaction?'’
I am inoculated now,
And this is ttie “ Reaction ” I
Charade.
I.
My ArH lies at llie root of things.
With homely earth is soiled, I
Yet at the festive boarri of kings ;
Is always welcome—boiled. I
II. !
My second o’er the level green
Impels (ho polished ball;
Where “ cannons” rattle it is seen,
Yet loves the peaceful “stall.”
in.
My third around the p'een earth lies,
No angel over saw it;
’Twas never viewed by mortal eyes,
Yet men must somewhere draw it.
IV.
When wasting sickness crowns tlie ills
By hapless men endured,
My whole fresh strengtii and hope instils,
And whispers '• Be thou cured I”
Mr. Reynolds (Leeds).-Dr. Liebreicli’s formula of his cantliaridin solu¬
tion is as follows:—Cantharldin, 0'2grm.; potassic hydrate, 0’4grm.;
water, 20 cub centimetres. Add water up to 1 litre (lOOOcc.). One
cub. centimetre contains 0'00l)2 gramme, or 2 decimilligramines.
Dr. Rentoul return* characteristically to a defence of his statement that
many medical men arawilling to take 7«. ed. fees. We mustloave
the matter now to liio judgment of the profession.
L.R.C.P. would do more good by bringing such facta under the notice
of the Registrar-General or the Secretaries of the Defence Onion.
Enquirer. —We cannot approve of such an alliance, or recommend It to
our correspondent.
INSOMNIA.
To the Editors o/TiiE Lancet.
Sms,—Permit mo through your pages to state a few particulars in
reference to a case of above which has been exceedingly unyielding to
treatment. I have prescribed in this case various preparations of
opium, also chloroform, Indian hemp, tlie bromides, chloral, and
hyoscyamus with only partial success. The opiates in full doses
induced n moderate amount of sleep but required constantly increasing
and wore omitted subscquontly in consequence of interference with
secretions. Tlie best results or liypnotic effects were obtained from the
tliree last named in combination, but the doses re((uire<l were very
large, and some doprossiou followed. A wariir bath at a temperature
of 00“ F. just before going to bed, the uso of a hot.water bottle to feet,
and cold applied to head relieved headaclie and Induced some sleep,
but the effect was not maintained. These remedius were tried at com-
moncomonb of attack with laxatives and alte atives before resorting to
narcotics. Patient was formerly addicted to tlie uso of alcoholic stimu¬
lants in excess, but this habit has boon given up for some time, and the
present attack is attributed to mental exertion in close application to
scientific study (now probibited) prolonged into tlie early hours of the
morning for sovoral montlis. Thoro are no symptoms of organic cerebral
disease, the headaclie being apparently functional, accompanied with
dyspepsia, and relieved iiy remedies. Alkaloidal stimulants were freely
taken by patient to relieve tliia symptom (chiefly sti'o.ng tea), but now
reduced in strength and quantity. Tobacco has been smoked largely,
but the amount was reduced concurrently with that of alcohol.
Although muscular and nervous debility exist, the present physical con¬
dition does not preclude out door exercise to a limited extent. I have
had no experience of the therapeutic effects of sulphonal, hypnol,
paraldehyde, or any of the recently introduced hypnotics. Perhaps
one of your numerous readers would kindly suggest a remedy.
1 am, Sirs, yours truly,
Feb. 20th, 1801. M.R.C.S. 1868 AND L.S.A, 1869.
The Health of Florence.
Dr. Alexander R. Coldstream writes to us from ^Oronce to the effect
that an epidemic of enteric fover, lasting from Dec, lat, 1800, to
Feb. 25th, 1801, attacked 1477 persons, of whom 282 died from tho
disease out of a population of 181,000. The infection was derive*
from Che contaminated water of an aqueduct supplied from an open-
stream In a mountain valley, about three miles from the dty. Tbe-
munldpal authorities acted with decision and promptitude. As soon
as the cause of the outburst became apparent the Infected water wa»-
eompletely cut off from the city, and printed “ hygienic precautions "
were freely circulated throughout the town. A public furnace wac-
erected in tlie outskirts of the city for disinfection of clothes and'
infected bed-linen at the municipal expense. The municipality has-
done its utmost in every way to mitigate the evil, and for some
weeks boiled water baa been gratuitously distributed to the poor.
The reports of "typhus” which have appeared are erroneous, and were
probably due to an error of translating the Italian tifo abdmninate-
into “ typhus.” In other respects the condition of the public health
is satisfactory. During the last month Florence has enjoyed glorious
sunshine and blue skies, and the severity of the north wind has
much diminished, the weather resembling. It is said, a Juno day lit<
London.
RECIPROCITY BETWEEN MEDICAL PRACTITIONERS AND-
CHEMISTS.
To the Editors of THE Lancet.
Sirs,—I f there were more reciprocity between medical men and'
chemists there would be fewer “ medical and consulting chemists." A
man must live, and if a chemist does business in a district where alL
the doctors dispense, and scarcely one writes a prescription in a year,
he soon finds that it is but a poor livirg can be made out of penny¬
worths of salts and castor oil, and turns to counter proscribing or even
visiting to increase the sale of his medicines and specialities. If alh
the medical men in a district would agree together to give up the (tO'
them) usually distasteful’work of dispensing, and either prescribe oi"
employ the nearest trustworthy qualified chemist to make up all theii "
medicines at a fixed rate per mixture, and thereafter to boycott any
chemist wito continued to entrench upon their legitimate sphere off
work, 1 believe that it would prove beneficial to both parties. I know
a practitioner in London wlio sends all bis presciptions to a chemist
and pays him quarterly at the rate of S^d. per prescription; and I am ot''
opinion tliat where there are tliree or four doctors to one chemist, it
would pay the latter to do tho dispensing at yj. per proscription,
bottles included, provided that the number of dose.s in each mixture be
limited to six or eight, and that where twelve or si.xteen doses are-
given the charge be doubled; expensive and unusual dnigs to be
charged at a special rate or paid for by tho patients tlienisulves.
Dispensing is degrading to the profession. Tiie patient does not think,
when he hands you his fee, that he is paying you for skilful advieo-
and for the thoughtful consideration of his case. No, tie is simply,
buying a bottle of medicine from you as he might buy a pound of
butter from his grocer, and frequently seeks tho “ doctor's shop ” where
ho will get it tho clieapest. It is time tliat tho public were edueateif
into regardingmembeis of the medical profession as something morn
than mere tradesmen ; but that time will never como until we eliminate
the spirit of the shopkeeper from our midst.—I'oura truly,
Harpurhey, Feb, 26th, 1801. G. D. M.vckintosii, L.R.C.P., Ac.
L.R.C.P. (Reading).-The foe should depend partly on the means of the-
patient anil the foe of the ordinary practitioner. It sliuuld not be less-
than one guinea, and as much more as is consiitent with tlie above:
principles.
THE AMMONIO-CUPRIC TEST.
To the Editors of THE I.aNcet.
Sirs,—I should feel obliged if some of your readers, who haveuse(l<
Pavy’s ammonio-cupric solution for tho quantitative estimate of sugar,
would assist mo in the following difficulty. 1 find that the solution,
after it is boiled and decolourised with the diabetic urine and i»
allowed to cool, again acquires a blue or bluish-green colour, accom¬
panied with a fiocculent deposit, whicli often lias a roddisb-yellow-
tinge. Is tills as it ought to be 7 And if so, what is tlie re-colouration
due to ? I should add that I have applied the test not in a flask, as-
Dr. I’avy recommends, but in a large open test-tube.—Yours truly,
March 2nd. R. R.
DISINFECTANT DISTRIBCTOR.
To the Editors of The Lancet.
Sirs,—W ith reference to the disinfectant distrilmtor described in
The Lancet of Fob, 7th ns a new invention, I beg to say I have had a.
similar apparatus in use for the last two years without requiring any
attention except refilling with permanganate about every three months.
My apparatus appears to differ in one or two particulars only. Firstly,
that it is formed of non-corroding metal, and is therefore not porous,,
which it is quite unnecessary it should be, as its action is by the syptiois
tube. [Secondly, it has a conical tube lu the lid (which acts as both
inlet and outlet for air) instead of the two holes, which appear to bo
much more likely to admit dust and dirt. Thirdly, it has a screw clip,
by which it is attached to the side of the cistern,—Yours truly,
Baling, Feb. 27th, 1801. B. Potter.
Digitized by' lOO^Ic
5S6 Thb Lanobt,] notes, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Maech 7,1891.
A Perpetual Calendar.
The Aotuaiy of the flock Life Office baa inflicted a most iogeiiioua
perpetual calendar upon his day and generation, and kindly intimates
tbat a copy will be furnished to any medical man on application to
liitn. For those whose business in life it is to ascertain how the
weeks pieced into the years in bygone ages, and how posterity will
'Solve this problem in the next millennium, it is simply invaluable,
while its ingenuity and neatness will make it an object of interest
.even to those of us whose good fortune it is to esc<ape such invo.sti-
gations. For ourselves we confess that perpetuity, so far as this
calendar is concerned, begins with the somewhat uncertain date of
the new style—an uncertainty which our instructions do not dispel;
and while referring to the instructions we cannot refrain from
observing that Mr. Crisford's rule for flnding the golden number does
not always work, and might be improved by adding tlte unit to the
remainder, instead of to the dividend as he directs.
Pairjtlay ,—Parties in this case were placed at a disadvaDt.age by want
of candour in the patient or bis friends. Dr. A., we think, should
accept the explanation of Dr. C., who acted bond fide, in urgent
circumstances.
Dr. Santini (Rome).—The copy has been received.
ISrratuh. —Tlie second name in the first line of our annotation on the
Diagnostic Value of Fluorescein Dye in Diseases of the Eye, p. HI
ante, should have been printed Groenouw, not “Grovenoiin."
<10MMWMCATI0NS not noticed In our present number will receive atten¬
tion in our next.
Cokmunications, Letters, Ac., have been received from—Dr. Skene
Keith, London; Dr. Boobbyer, Nottingham ; Mr. J. Furley; Mr. 11.
Leigh, Liverpool; Mr. H. C. .Tones, London ; Mr. C. K. Bond, Liver¬
pool ; Mr. B. G. Byrne, Colon ; Mr. Harcourt, Essex; Mr. Spowart;
Dr. McKenow, Workington; Dr. Digby, Stafford; Messrs. Shelley
-and Co., London; Dr. Alex. Wallace, Colchester; Messrs. Eichardaon
Bros., Liverpool; Dr. T. Oliver, Newcastle-on-Tyne ; Dr. E. Warren
Bey, Paris; Dr. Holden, Birmingham; Mr. B. Potter; Sir Walter
Foster, Edgbaston; Mr. B. S. Bingev, Amoy ; Messrs, Burroughs and
Wellcome, London ; Mr. A. T. Hunter, Edinburgh ; Mr. Cleary, New
Tork; Dr. H. Snow, London; Mr. J. Tweedy, London; Mr. D’Arcy
Power, London; Mr. J. R. Roberts, Gilgit; Messrs. Richardson and
Co,, Leicester; Mr. Sleman; Dr. Atkinson, Surbiton; Messrs. Bush
and Co., London ; Dr. Collins, London; Dr. Ridge, London ; Dr. Hale
White, London ; Mr. C. Cotton, Ramsgate ; Messrs. G. Street and
<30., London; Mr. Cropley, Northampton; Messrs. Smith, Elder, and
Co., London ; Mr. Haviland, Douglas ; Messrs. Rock, Hawkins, and
Thorpe, Hastings; Mr. H. H. Taylor, London; Dr. Gacldcs, Palmer
Lake; Dr. Coldstream, Florence ; Mr. Shaw, Worthing; Dr, Ogier
Ward, Tottenham ; Dr. Sellers, Radcliffe ; Messrs. Mitchell and
Co., London; Mr. W. E. H. Stewart, London ; Messrs. Carnrick and
Co., London; Mr. James, Highfleld; Mr. V. Horsley; Messrs. Ash
and Sons, Golden-square; Mr. Beck, Melbourne; Mr. Laban, West
Bromwich ; Mr. Drewett, Paris; Mr. Duke, Dublin ; Messrs. Kilner
Bros., London; Mr. Matthews, Birmingham ; Messr.s. Blondeau
«t Cie., London ; Mr. Ackrill, Harrogate ; Mr. A. Frost; Messrs. Cox
and Co., Brighton ; Mr. Marshall, Uttoxeter; Messrs. Heilgers and
Co,, London; Dr. Favrat, Madeira; Mr. Obert, London; Messrs. Watkins
and Osmond, London ; Mr. Horner, Scarborough ; Mr. Vissor, South
Africa; Mr. Cranny, Dublin ; Dr. Williams, London; Messrs. Koene
andAshwell, London; Mr. Lloyd, Ventnor.l.W.; Messrs. Palmer and
Sons, London ; Mr. Sharpe, Matlock ; Messrs. Mackey, Mackey, and
Co., London; Mr. Gurnor, London ; Mr. Webb, Bury ; Messrs. Flatau
and Mankiewicz, Berlin ; Dr. Wlndlo, Halifax ; Mossrs. Coupland
and Co., Burnley; Mrs. Theobald, Leisester; Messrs. W. H. Smith
and Son, London; Mr. Thomas, Liverpool; Messrs. Paternoster and
Hales, Hitchin; Dr. Newman, Capri; Mr. Nance; Messrs. Pimms and
Co,; M. Battistinl, Bologna; Mr. Bullivaut; Messrs. J. Wright and
Co., Bristol; Mr. Fox, Manchester; Matron, Portsmouth; Pauper;
M.R.C.S., L.S.A.; Bspec; Medicus; R. R,; Royal Albert Edward
Infirmary, Wigan; M.D., M.B,, C.M,; B.; Secretary, Norfolk and
Norwich Hospital; A. C. G., Southsea; Alpha, London ; A Qualified
Assistant; M.B., Forest Gate; M.D., Newcastlo-on-Tyne; Malleus
Iixjitstitio!; Inquirer.
Letters, each with encloxure, are also acknowledged from—Mr. Ross,
Belfast; Mr. Wheeler, Manchester ; Mr. Tally, Hastings : Mr. Evans,
Llanerchymedd; Dr. Peacock, Klngawinfovd; Messra. Burgoyne and
Co.,London; Mr.Forgitt,Lincoln; Messrs.Swan Sonnenscheinand
Co.; Dr. Johnson, Swindon; Mr, Orchard, Dublin ; Dr. Baker, Forest
Hill; Mr. Feeny, Bilston; Mr. Shannan, co. Durham ; Messrs. King
and Co., Horsham; Mr. Lockwood, Huddersfield; Messrs. Margrave
Bros., Llanelly; Mr. Brown, Weatgate-on-Sea; Messrs. Murray and
Co., Paris; Dr. Bower, BedfordMr. Cowan, Glasgow; Messrs. lies
and Stradling, Watford ; Miss Cotton. Bridgwater; Mr. Lowe, Upper
Norwood; Mr.Walsh,Ireland; Mr.Perkins,Newport; Messrs.Rocke
and Co., Hastings; Mr. Ramage, Largo, N.B.; Mr. Aspinall, West
Kirby; Dr. Rentoul, Liverpool; Mr. J. Keegan; Messrs. Walker and
Weller, Malvern; Mr. Tyte, Minchinhampton ; Messrs. Fannin aud
Co., Dublin; Mr. Huntingdon, St. Andrews, N.B.; Messrs. Smith
and Son, Birmingham; M. di Giacomo, Naples; Mr. Collier, West
Kirby; Mr. Vect, Edinburgh; Mr. Boyton, London ; Messrs. Eason
and Sou, Dublin; Dr. Leckie, Glamorganshiie; Dr. Galbraith, Great
Barmouth ; Mr. George, Preston; Mr. Burcombe; Messrs, Hooper
aud Co., Pall Mall; Mr. Cochrane, Wigtownshire; Dr. Oibbea, Ann
Arbor, Michigan; Mr. Forjitt, Lincolnshire ; Messrs. Mann and
Son, London; Mr. O’Meara, Loughborough; Mr. Young, Birming¬
ham ; Mr. Birehall, Liverpool; Mr. Griffith, Carnforth; Dr. Mygene,
Denmarlc; Mr. Smith, Fleet-street; Mr. Dinck; Mr. Heywood, Man-
clie.ster; Mr. Thin, Edinburgh ; Mr; Hornibrook, London; S. Pomfret;
Country, London ; Gavel, London ; Bristol Infirmary; Birmingham
City Asylum ; Nurses’ Institute, Leicester; Secretary, James Murray
Royal Asylum, Perth ; Beta, London; 'A., London ; Secretary, Devon
Hospital, Buxton; Cicero, London ; Ulna, London; Secretary, North
Biding Infirmary, Middlesbro’-on-Teos; Oxon, London; Corporation
of Birkenhead; Secretary, General Apothecaries’Co,, London; Gordon
Hotel Co., London; Hon. Secretary, Teignmouth; Secretary, Sheffield
Public Hospital; M.D., Leeds; Alpha, Surrey; Secretary, Royal Eye
Hospital, Manchester; Vere, London ; Iota, London; Sigma, South
Wales; M. M. 6., London; C.antab, London; Delta, London ; County
Asylum, Rainhill; Alpha, Manchester; A. V. M., Loudon; Doncastor
General Infirmary ; Muspratt, Brighton ; Fostiiio, London; Helix,
London ; Secretary, Portland-place ; Iota, Folkestone; Ferndale,
Torquay; Medicus, Holborn : Omega, London ; M.D., London ; Spes,
London; Medicus, London; F. S. D., Leeds; A. B., London ; Smilax,
London ; B. A. O,, London.
NEW.spAPE.ns.—iVnfioJiaf (Juardian, Newcastle Daily Leader, SheMeld
Teleyraph, fdanchester llxaininer, 'Jhe Nejva, Liverpoul Daily Post,
Yorkshire Dost, Scottish Leader, Insurance. Kecord, liining Journal,
Hertfiordshire. Mercury, Surrey Adaertiser, Leeds Mercury, Weekly Free
Press and Aberdeen Herald, Heading Mercury, Sunday Times, West
Middlesex Standard, Bristol Mercury, Builder, Broad Arrow, Chemist
and Druyyist, MutropolHan, Pharmaceutical Journal, Guy’s Uospital
Gazette, A rchitect, Spcelalor, Law Journal, City Press, Local Gomim-
nient Chronicle, Dundco Advertiser, Saturday Jieview, West Rliddiesex
Advertiser, Manchester Coxwier, Lancaster Observer, Western 'Times,
'Taunton Courier, Army and. Nary Gazette, West Breton Advertiser,
Bury Standard, Hull 'Times, BuUand Post, 'Teesdale Mercn-iy, Rochdale
Observer, Antytua Standard, Royal CommiU Gazette, Wolverhampton
Chronicle, Nuneaton Chronicle,, UcaUh Sanitary Record, Melbounic.
A ryus, Helper Chronicle, Pnlul Sleiriny, liedioorlh Guardian, Jiuckiny-
ham Rxpress, Shields Daily Gazette, Water/ord Mirror, SlaJforUshire
Sentinel, Ac., ha\'o been received.
SUBSCRIPTION.
Post Free to any part op the United Kingdom;.
One Year.... - £1 12 8 1 Six Months ___ £0 19 B
To China AND India ....One Year lien
To the Continent, Colonies, and United
States .. _ Ditto l li i
Post Office Orders and Cheques should be addressed to The Publisher,
She Lancet Office, 423, Strand, l.ondon, an<l crossed “ Ix>ndon and
Westminster Bank St. James’s-square."
ADVERTISING.
Books and Publications (seven linos aud under) .. <30 B 0
Official and General Aiinuunceuients .. ... .. 0 fi 0
TVade and Miscellaneous Advertisuments ~ ..046
Every additional Lino 0 0 9
Front Page per Line 0 10
g uarter Page .. .. .. .. - ... .>110 0
alf a Page >. .. .. >.2 1fi0
An Entire Page .. ~ _ .. ..560
The Publisher cannot bold himself reaponolblo for the return of testi*
nioniais &c. sent to the office in reply to advortiseuieiiie ; copies only
should be forwarded.
NOTICJ-;.—Advertisers are requested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addi-essed to
Initials only.
An original and novel feature of “ The Lancet General Advertiser" Is a special Index to Adverti.Mements on pages 2 and 4, which not only
aSordsaready means of finding any notice, but is in it.self an adflikjojiaf advertisement.
Advertisements (to ensure insertion the same week) should be delivered at the OBice not later than Wednesday, accompanied by a remittance.
Answers are now receive at this Office, by special arrangement, to Advertiaeiiients appearing in The JjANCIct.
Terms for Serial Insertions may be obtained of Che Publisher, to whom all letters relating to Advertisements or SubacrlpMone should bo
addressed.
Advertisements are now received at all Messrs. W. H. Smith and Son’s Railway Bookstalls throughout the United Kliigduin and all other
Advertising Agents.
igvax toi tut AaTertisemeat DepiutmeBt in Fraiioe- -J. ASTISR, M, &u« Caumartln, Pariiii,
Dir--- zed byCjOO^Ic
THE LANCET, Mabch 14, 1891
ABSTRACT OF
fates,
ON
©IPHTHEKIA, ITS NATURAL HISTORY AND
PRETENTION.
Delivered before the Royal College of Physicians of
London,
By R. THORNE THORNE, M.B., F.R.S., F.R.O.P.
LECTURE IV.
Milk in connexion with the causation and diffusion of
vliphtheria was next discussed, Dr. Michael Taylor’s and
Dr. Ballard’s experiences being referred to as the first in
which any such cause was suggested as having to do with
the specific fevers. Mr. Power has the credit of having
first definitely shown a relation between occurrences of
•diphtheria and the use of particular milk services, and his
investigations as to this in North London in 1878 were
recorded in some detail, it being shown that the incidence
of the disease on households taking the special milk and
those having another service was at the rate of 60 and
-5 per 1000 respectively. And when the various circumstances
by which milk could at that date be regarded as liable to
become infective had been discovered, the suggestion had
•even then been made that there had probably been some con¬
tamination of the milk by particular cows suffering, whether
’recognised or not, from some specific disease. The idea as
to the existence of some relation between disease in the
'lower animals and man was, indeed, not altogether new.
There was the analogy of foot-and-mouth disease, and
oorne early experiences of Dr. Thorne were referred to, in
which he had found that young pigs fed on the milk
■of cows suffering from the latter disease were killed by it,
whilst children using it suffered from certain affections of
the mouth and fauces. Other diphtheria outbreaks having
-somewhat similar histories were quoted, but no sub¬
stantial advance was made until the occasion of an outbreak
at Hendon in 1882, which, having first been investigated by
Dr. Cameron, was afterwards also inquired into by Mr.
(Power. Hero again nine-tenths of the houses invaded re-
•ceived their milk from one dairy, the houses being those
which were best circumstanced from a sanitary point of
■view. And here it was further noticed that there had been
a special incidence of the disease on people, whether children
or adults, who habitually consumed uncooked milk in large
•quantities. The source from which the milk had received
its infection was again involved in much obscurity, but there
were circumstances which led to the surmise that the infec-
tivoness had possibly been brought about by causes operating
■through the cow herself, and enabling her to furnish a milk
•capable of inducing diphtheria and the allied sore’throat in
the human subject; and the milk itself gave some physical
’indications of this. But no disease in the cow other than
some possible trivial ailment, which, according to veterinary
Judgment, did not prevent the cow from being regarded as
healthy, had as yet been made out.
So matters remained until 188G, when a very severe
diphtheria epidemic appeared amongst the better classes
living at York Town and Cambeney. The onset was
sudden, 88 marked attacks and 52 of lesser severity
taking place in three weeks and a half. Of those attacked,
8‘t'2 per cent, received their milk from one dairy, which
thus came under suspicion, and during ten day? of especial
aeverity every one of the forty-eight houses invaded took
the supply in question ; and this speciality of incidence qua
milk was quite different from any other incidence that could
'be made out. Here, again, the amount of milk consumed
was seen to have to do with the risk of diphtheria. In
-some previous milk epidemics, where other infectious diseases
had been concerned. Dr. Thorne had been led to believe that
there was a special infectivity attaching to cream, which he
thought had in its formation probably entangled the specific
•particles of disease, and so carried them to the surface. But
this view could not account for all the circumstances noted
at Camberley. Indeed, if any additional risk was incurred
by mere cream-drinking, it was altogether overwhelmed
iby the danger attaching to the storage of milk, the skim
No. 8624.
milk resulting from the storage being as infective as the
cream, and it seemed as if this storing gave opportunity for
the cultivation of the specific organisms of disease which
did not otherwise occur. Subsequent experiences of Dr.
Klein have gone far to confirm this view.
In the meantime, diphtheria prevalences which could
unmistakably be attributed to milk were increasing, and
suspicion bad arisen that a number of the lower animals
might be concerned in it. The early experiences of the
Medical Department of the Local Government Board having
! been referred to as to this, the observations of Dr. George
i Turner, Dr. Robinson, and others were quoted. The exist¬
ence of a disease- akin to diphtheria was found amongst
fowls which had pecked at diphtheria sputa; amongst
turkeys, from which the disease had apparently spread to
the human subject; and also amongst other animals, notaMy
cats. With regard to cats, the disease had appeared to be
transmissible both from them to children, andirom the latter
back to cats, and a number of occurrences of diphtheria
were quoted in this connexion. Noah Webster’s writings
in 1800 were also recalled as to the occurrence of fatal
“ angina” in man synchronously with a “pestilence amongst
cats,” and the more recent labours of tbeMledical Department
of the Local Goverment Board, in so far as the special patho¬
logy of the disease was concerned, were then entered into in
some detail. Latterly Dr. Klein had been experiment¬
ing on certain animals with the membrane of diphtheria,
and though he had failed as regards birds, it was other¬
wise with cats, 00 the cornea and conjunctiva of which
animals a disease, infective amongst cats, could bo produced,
by inoculation from human diphtheria membrane; and from
this induced disease bacilli could be isolated resembling the
Ktebs-LoHler diphtheria bacilli. From this, Dr. Klein was
led to study this bacillus more in detail, and he succeeded not
only in confirming Lbffler’s view that the organisms hitherto
regarded as one, included abacillus potent to induce diphtheria
and a pseudo-diphtheria bacillus, Wt he also showed that
whilst the two forms of organisms were so far alike as to be in¬
distinguishable microscopically and otherwise, they differed
in their power of mutiplication when cultivated at different
temperatures; the true diphtheria bacillus multiplying, in
milk, for example, at the ordinary temperature of the air.
This discovery had, it was pointed out, important bearings
on the special virulence of diphtheria induced as the result
of drinking an infective milk which had been stored for pur¬
poses of securing cream or otherwise. At this stage Dr.
Thorne recalled the fact that in nearly all the care¬
fully recorded cases of milk diphtheria there had been
evidence either of some “trivial” ailment in the
milch cows, showing itself, for example, on their udders
and teats by means of vesicles, “ebaps,” &c., or some story
of a physical alteration in the quality of the milk, such as
was shown by a condition of “ ropinees,” which dairy
farmers admitted to be due to some condition affecting the
cow herself. And he then gave an account of Dr. Klein’s
most recent researches as to milch cows, researches which
are to be fully recorded in Dr. Buchanan’s forthcoming
report on the proceedings of the medical department of the
Local Government Board. Brielly told, they amount to
this: Milch cows inoculated with human diphtheria mem¬
brane acquire a definite specific disease, which may or may
not in the end be fatal. The milk apparatus of the animals
continue to furnish abundant milk, but the udders and
teats exhibit vesicles, “chaps,” sores, &c., almost exactly
like those found by Mr. Power and otliers in the milk
diphtheria epidemics; and in the lymph of these udder
vesicles the true bacillus diphtherko could be found. So,
also, from the milk itself abundant colonies of the bacillus
could be cultivated, whilst no other organisms could be de¬
tected. Thencameacuriousaccidentalexperiment. Contrary
to orders, two cats had been supplied with some of the
cow’s milk, and in these cats the disease called by Dr. Klein
“ cat diphtheria’’ resulted. This latter experiment is stated
to be referred to by Dr. Buchanan as lacking scientific pre¬
cision owing to its accidental character, but it is of much
interest in connexion with the subject discussed, and it
will doubtless be repeated. Reviewing the information
resulting from these experiments on cows, “ we are able,”
said Dr. Thorne, “ to appreciate the import of those appa¬
rently trivial ailments in milch cows, to which so little
importance has hitherto been attached by veterinarians and
dairymen, but which have so commonly been discovered in
association with epidemics of milk diphtheria.’
At this stage of the lecture Dr. Thorne laid down a aeries
L
588 Thb Lakcet,}
DE. THOMAS OLIVER ON LEAD POISONING.
[Makch 14,1891.
of propositions embodying the points which he had brought
. forward, and he explained that time ^ad not permitted him
to deal with all the matters which were properly included
in the somewhat comprehensive title which he had originally
. attached to this course. Prevention of diphtheria had not
been touched upon, and he had desired to deal with a
number of other points, such as the stability of the con-
tagium, the vehicles by which it could be communicated,
its possible diffusion aerially, the incubation period of the
disease, and its relation to croup. And finally he announced
his intention of publishing the course of lectures, in such
form as would include these and otlVer points which he bad
been compelled, by reason of time, to pass over without
comment. _
• ABSTRACT OF THE
imisWait ftrlims,
ox
LEAD POISONING JN ITS ACUTE AND
CHRONIC MANIEESTATIONS.
Delivered at the Royal College of Physicians, March, 1891,
Py THOMAS OLIVER, M.A., M.D.. F.R.aP.,
rnVSICIAN TO the royal INI'-IRMARY, NEWCASTLE-UPON-TYNE,
AND PHOEESSOR OF PHVSIOLOOV, UNIVERSITY OK DURHAM.
LECTURE II.
At the close of the last lecture Dr. Oliver dealt with the
peculiar susceptibility of women to the influence of lead,
and he said that under any circumstances, once saturnine
poisoning was induced, it was particularly apt to recur on
exposure. Indeed, sometimes the symptoms reappear
without exposure, the explanation being that lead which
had been deposited as an inert compound had by some
changes either in the blood or in the fluids become con¬
verted into a soluble lead compound, and in this form was
reabsorbed. He said it was sufficient to state here that either
in a state of solution, of fine subdivision, or dissolved in some
volatilised agent, such as turpentine, lead is taken into the
system. Of all the symptoms and physical signs of lead
poisoning, the one physical sign above all others which
indicates that the system is becoming impregnated with
lead, and is suffering in consequence, is the development of
anaemia, which becomes gradually confirmed, and is spoken
of as saturnine cachexia. Almost from the first day of ex¬
posure to lead, hinmatosis is interfered with. He had never
found in a lead worker the normal number of red blood cells.
They vary from 2,500,060 to 4,000,000 per cmm. There
is no marked increase in the number of white cells, but
the colouring matter falls as low as 45 or 50 par cent, of the
normal. The bones have in some cases contained lead, and
to this fact the aniemia may be partially attributed. The
physical sign of plumbism which is most looked for and
generally met with is the presence of a blue line on the
gums, noticed by Burton, but previously described by
lancquerel. When present it is a valuable sign. But it
maybe absent; it generally is when the teeth and gums
are perfectly sound and the mouth is kept cleansed. And
yet there may be colic and no blue line, or a girl may die
from acute encephalopathy with no blue line present from
first to last characteristic of the poison. There are two
blue lines. One is a delicate line just at the margin of the
gum, It is a deposit of sulphide of lead on, and not in, the
gum. It is easily removed by cleansing the teeth and
rinsing the mouth. I'lie other, the characteristic line, is
bluish black, and occurs also at the margin of the gum,
where it is not in complefe apposition with the teeth.
There the gum is frequently ulcerated and irregular in
outline. The lecturer had seen a blue line deveIoi> the day
after a large ddse of acetate of lead liad been taken. It
persisted for a few days, and then disappeared. It is diffi¬
cult to say how long tlie blue line of plumbism will remain
after removal of the individual from the influence of lead.
In some of Dr. Oliver’s cases it had disappeared very
quickly—the earliest eight days, but in the severe forms
three to six months. He had never succeeded in developing
the blue line in plumbism by iodide of potassium whenr
absent, as some authors are said to have done. He alluded
to the line on the gums noticed in other forms of poisoning—
bismuth and copper,—and showed a drawing in which a
black or carbon line bad been noticed on the teeth and gums>
of a coal miner admitted into the Newcastle Infirmary under
the care of his colleague, I’rof. Philipson.
One of the earlier symptoms complained of by patients-
suffering from plumbism is sudden and severe pain in the
abdomen. Generally it is preceded by such prodromata as-
a metallic taste in the mouth in the morning and by
vomiting, or only by a feeling of sickness and loss of appetite
and constipation, and occasionally by diarrbeea. Colic
occurs early after exposure to lead ; in one of the lecturer^is
cases twelve days after. Pressure is said by most writers to
relieve it, but sometimes the patient cannot bear to have'
the abdomen touched. There are two kinds of pain : the-
paroxysmal or acute pain, which is the true lead colic, and
which is generally relieved bypresssure; and the other is
the dull, continuous pain, which follows it in the intervals.
It is this pain which is usually aggravated by pressure. It
is difficult to say what produces the acute pain in lead
colic. A spasmodic constriction of the small intestine
occurring at irregular intervals appears to be the cause-
of the pain in lead colic by pressure upon the nervee>
and this is aggravated by the efforts made by the distended
portions of the intestine to propel their contents into the-
contracted tube below. The lecturer gave his reasons
for regarding the action of lead upon nerve ganglia ae-
primary, and upon muscular fibre as secondary, and
showed that the colic whilst aggravated by constipation-
that might be present was not caused by it, there being in
not a few cases diarrbcca. The question of colic was, how¬
ever, part of a much larger problem. During the attack of’
colic the pulse is known to become hard and resistant, and
is very decidedly retarded. Slowing of the heart’s action
being part of thus process, and explained by refiex inhibition
through the cceliac and mesenteric plexuses, sphygmograms
were shown in support of the opinions expressed. They
showed the heightening of arterial tension that arises in the
course of exposure to lead, the increase of the tension
during colic, and in addition a peculiar difference in the
pulses of the radial arteries whenever severe colic had been
experienced—a difference far in advance of anything observed!
in health or in other diseases save aneurysm, and which (as
it persisted in spite of concurrent heart disease) Dr. Oliver
regarded as characteristic of lead poison, and dependent
upon some alteration in the structure of the abdominal'
sympathetic ganglia. He also alluded to the almost com ¬
plete suspension of the renal function during the attacks of
colic, and drew attention to the difference in the pupils met
with in lead poisoning.
An early symptom in lead poisoning is an alteration of
the menstrual function, Them is frequently menorrhagia,
even in young girls. Others suffer from amenorrhcca. Leat^
workers miscurry in a far larger percentage than other
women. Dr. Barnes^ alludes to the subject, and quote©
the experience of M. I’aul as to fifteen pregnancies of four
women whohad worked in a typo foundry. Ten of tbese^
ended in abortion, two in premature labour, one in still -
hirth, and the child died within twenty-four hours.
Dr. Oliver gave details of several cases, showing how fre¬
quently exposure to load indviced abortion or the early
death of the offspring from convulsions. He alluded to the
po,sb-mortem appearances met with in the liver and kidney
of an infant whose parents were lead workers, drawing
attention to the atrophied condition of the secreting;
structures of liver and kidneys.
The various forms of lead paralysis were subsequently
di.scussed,_from the classical wrist-drop to the generalised
paralysis in which muscles of legs, back, shoulders, and
arms were affected; and the lecturer showed a good illus¬
tration of the latter, which had occurred in the cliniqu©-
of Prof. Philipson. The predilection of the extensor
niupcles to be affected was also discussed, birt he showed
that whilst the ffexors and supinator longus, as a ruloj,,
escaped, the latter muscle occasionally became involved.
Jlis colleague Dr. Drummond had observed paralysis of the
flexors. The muscles were affected in groujis. Dr, Oliver
discussed the primary seat of the lesion in lead paralysis
and whilst he regarded the probability of the lesion being,
in many instances a peripheral neuritis, he favoured tlie^
J Obstetric Medicine and Surgery, vol. i., p, 49(1.,
Dig;;,zed by Google
ThbLanoet,] me. J. W. HULKE on disorders of the frontal sinuses. [March 14,1891. 589
view of it beins a central lesion. The relation of optic
neuritis and lead poisoning was discussed, and it was shown
that long before albumen is detected in the urine there
may be neuro-retinitis. Cases were detailed. One case, a
female aged twenty-three, after having been blind for twenty-
one weeks, gradually regained her eyesight. Optic atrophy
is a frequent consequence of lead neuro-retinitis. There were
many circumstances in operation at one and the same time
in lead poisoning to cause neuro-retinitis; such as, for
example, contracted cerebral arteries, imperfect emunction,
disordered menstruation, and a peculiar influence of lead
itself upon disc and retina that it was difficult to assign to
each its proper share in the production of the neuritis.
Attacks of acute lead encephalopathy were frequently pre¬
preceded by hysteria. This the lecturer had often seen.
Baumgartner of Newcastle had met with it. The symptoms
gradually increase in severity and differ from those associated
with functional derangement, becoming ultimately signs of
some deep impression made upon the biain by leaa. These
cases frequently end in death within a few days of their
first appearance. The lecturer then alluded to the question
of toxic hysteria in general and of the sensory disturbances
met with in lead poisoning, and concluded the lecture by
drawing attention to the relation of lead poisoning with
acute delirium and insanity; and in one case in particular
to a peculiar loss of memory for names of places.
FIVE CASES OF DISORDERS OF THE
FRONTAL SINUSES.
By J. W. HULKE, F.R.C.S.Eng.
Disorders of the frontal sinuse^, if we except the fleeting
congestions of their mucous membrane, which are a part of
“nasal catarrh,” are of infrequent occurrence. They occur,
indeed, so infrequently that many surgeons in large prac¬
tices have never met with them, and few can claim much
familiarity with them. Some of these disorders are un¬
attended with symptoms sufficiently distinct to denote
their presence, in others the local condition is merged in
one of wider extent, and so escapes recognition. As an
example of the former class may be cited the slight degree
of hyperostosis which imparts to the normally smooth walls
of the sinus a finely tuberculated roughness resembling
that of shagreen, comparable to that whicli in ana¬
tomical preparations is better known in the antrum,
where attention was called to it by Professor Hyrtl.
Such, also, are the examples of excessive irregular bone
growtir in the walls of the sinus in certain instances of
cranial hyperostosis—e.g., that characterising the condition
known as “ leontiasis ossea.” In these and in allied condi¬
tions, whilst the cavity of the sinus is encroached on
by the adventitious tissue and its capacity lessened, the
walls of the sinus are thickened, and so the circum¬
stances are completely different from those attend¬
ing the presence of an exostosis within the sinus; for
this latter, whether it originates within the sinus spring¬
ing from its walls, or whether it intrudes into the sinus, its
origin lying outside it in some neighbouring part, expands
the cavity of the sinus as it fills it, and wastes its walls,
even to making perforations in them. The clinical recogni¬
tion of these two forms of inordinate bone growth in the
sinuses is important, since the diffuse is beyond the reach of
surgery, whereas “ exostosis,” even when of large enough
size to attract attention, is removable by operation, in some
instances at least, its relation to the wails of the sinus being
througliout^the greater part of its extent only one of close
approximation of surfaces, organic connexion, when present,
being usually very limited. The enlargement due to diffuse
hyperostoses is usually not so extremely slow as that
caused by exostosis, and the surface of the awelling, whilst
uneven, lia8_ not that hoasinces whicli is so characteristic
of exostosis in this region. The excessive hardness of these
exostases has been a chief operative dillienlty. Here the
American dental engine is a valuable aid, “ roses” and
other forms of cutters larger than those employed by dental
surgeon.s prove here extremely useful. Perluipa the com-
nionest disorder of the frontal sinuses for which surgical aid
isBoughtare the distension and expansion of the sinus by the
accumulation of glairy mucus within it, occasioning the cbn*
dition known as ‘' mucocele. ” In this the orbital is commdniy
more displaced than the external wall. The encroachment
on the cavity of the orbit thus cansed occasions a cor*
responding displacement of the eyeball from its normal
position. This, before externally evidenton inspection, may
early discover itself by diplopia—a symptom which, in con¬
junction with frontal headaches, has occasionally in these
cases led to an uniounded impression of the presence of
cerebral disease.
The etiology of (uncomplicated) mucocele of the sinus is
frequently far from clear. In not a few instances a history
is given of an antecedent mechanical injury—e.g., a blow
OD the forehead or upper border of the orbital ouening, yet
seldom sufficiently severe as to render probable a direct
lesion to the infundibulum. In other cases, a chronic inflam¬
mation of the nasal mucous membrane has been regarded as
a causal antecedent. Of both these circumstances closure
of the lumen of the infundibulum must be regarded as a
possible consequence. It is, however, certain that obstruc¬
tion of the infundibulum is not a necessary antecedent, since
after a free passage has been made from the most dependent
part of the sinus into the nasal chamber mucus may continue
to accumulate in the sinus, as may be shown by syringing
out this cavity. In such cases, however, the mucus is very
glairy and tenacious ; and this affords a useful therapeutic
hint, for it is not until the secretion of the mucous
membrane of the siuus has regained a normal tenuity that
the cavity can be efficiently drained. Hence injections of
astringent solutions, and in particular of zinc chloride,
may often be usefully employed. Although in probably a
majority of instances manifestingitself by external signs on
one side only—possibly even in some of these instances both
sinuses form a common cavity owing to imperfection of the
septum between them,—yet instances do occur in which
each sinus is the seat of a separate mucocele, as in the
following case, where the completeness of the septum was
certainly verified:—
A lady, aged fifty years, was seen by me, in consulta¬
tion with Mr. Sibley, in June, 1889. She had at the
upper and nasal angle of the right orbit, beneath the inner
end of the eyebrow, an obvious swelling. It was smooth,
of a subglobular figure, not distinctly fluctuating, yet so
elastic as to suggest the presence of fluid. At its margin
could be felt a hard edge, suggesting that it had perforated
the bone. The left upper eyelid was osdematously swollen,
red, and tender, and beneath the middle of the upper
orbital border was a fixed, deeply placed swelling, in which
an obscure fluctuation was discoverable. The known dura¬
tion of the right swelling was about two years, and
that of tbe left about three weeks. She had long bad
more or less severe frontal headache, which very recently
had been more severe on the left side. The symptoms
appearing to denote a double frontal mucocele, the right
swelling was incised, giving escape to much very thick
glairy mucus. An opening in tbe bone forming the external
wall of the sinus was verified, and when this was enlarged
so as to admit the linger, the cavity of the sinus was
found much expanded and the septum complete. The
swelling in the roof of the left orbit was then explored through
an incision in the upper eyelid. It also proved to be a
mucocele, which had made a considerable perforation in the
orbital wall of the siima. A perforation was next made
through the most dependent spot in the floor of each sinus
into the corresponding nasal chamber, and a rubber drainage-
tube was passed from the external wound through
the sinus into the nose, the lower end of (lie tube being
brought out through tbe anterior nostril. The mucus was
so viscid that syringing several times daily was required
for its expulsion. When this was omitted, accumulation
always occurred, notwithstanding the free communication
between the sinuses and the nose. The progress was very
alow. The rubber tubes were replaced by short vulcanite
tubes suitably curved, but tliese were found less com¬
fortable by the patient than the flexible rubber. After
trial of several astringents, the use of a zinc chloride
solution in water (one grain,to tbe ounce) twice daily was
quickly followed by improvement, but it did not appear
prudent to lay aside the tubes until several montbs had
elapsed. After they were discontinued the openings soon
closed.
The above was a case of simple mucocele. In another
class of cases tbe mucocele is complicated by the presence
of a solid neoplasm, autochthonous or intrusive; of these,
Digitized by ^ooQle
690 The Lancet,] ME, J. W. HULKE ON DISOEDEBS OF THE FRONTAL SINUSES. [March 14,1891.
polypi resembling the raucous form of nasal polypus appear
to oe not very infrequent; whilst less frequently complex
forms of tumours, combining cartilaginous, osseous, and
myxomatous tissue, and also sarcoma, have been met with.
That frontal, although frequently concurrent with nasal
polypi may occur independently of the latter is certain.
This may be seen in tne first of the following cases, in
which the nasal passages were perfectly free. This is
probable, seeing that the mucosa in the two cavities is con¬
tinuous, so that even when frontal and nasal polypi happen
to be concurrent, the former are not thereby shown to be
intrusive and not autochthonous; since the two “terrains”
being essentially identical, the causes which lead to their
evolution in the one may not be denied efficiency in the
other. The following three cases illustrate the above
affection of the sinuses.
Case 1. Mucous polypi in frontal sinus. —A shoeblack
aged eighteen years applied at the Moorfields Eye Hospital
on April 18th, 1888, for a painful tender sweiling of the
roof of the left orbit attended with proptosia. No history
of mechanical injury. The case was regarded as one of
periostitis with suppuration. An incision was made into
the swelling, some pus escaped, and the wound soon closed.
The proptosis, however, remained. He continued under
observation through the summer, and in October, the
swelling having slowly increased, he was readmitted into the
hospital, and the swelling w'as explored through a free
incision. A large defect in the orbital roof was discovered,
leading into the frontal sinus. Much viscid mucus escaped,
and When the lips of the wound were separated with re¬
tractors a gelatinous polypus of the size of a grape was
seen filling the opening in the bone. This and another were
removed. A drainage-tube was inserted and the cavity
syringed. Antiseptic precautions Avere observed, but the
operation was followed by diffuse phlegmonous inflammation
and pytemia, from which he slowly recovered, and went to a
convalescent hospital. In October, 1889, although a free
passage into the nose from the sinus existed, and an
examination of the sinus made it nearly certain that no
polypi were present in it, the free secretion of viscid mucus
still persisted, necessitating the continued employment of
syringing and tube. The further history of the case is not
known.
Cask 2. Mucous polypi in frontal sinus. —A gentleman
aged seventy, by the advice of his family medical attendant.
Dr. W. Bell of "West Brighton, consulted me for a
diplopia of six weeks’ duration. On taking up his news-
f iaper one morning he was alarmed by a “ doubling” of the
ines of type, and this continued up to the dat^e of bis
coming to London. Its explanation was found in an evident
proptosis of the right eyeball, the outward an<l also upward
movements of which were restricted. The cause of the dis¬
placement of the eyeball was a fixed, circumscribed, elastic
swelling, projecting downwards from the roof of the orbit
within nearly the whole extent of the upper margin of this
cavity, and bulging most at its inner or nasal end. At the
inner and upper angle of the left orbit was a similar
but smaller swelling. The nasal tone of the patient’s
voice led to an examination of his nasal passages; they
were found plugged with mucous polypi. The objective
characters of the orbital swellings taken in concurrence
with the presence of nasal polypi favoured the idea that
they were due to expansion of the frontal sinuses, with
absorption of their orbital wall, by similar polypi within
thenp The patient mentioned that in 1852 (twenty-six years
previously) ho had bad polypi taken from the nose by
Erofeasor .Syme of Edinburgh, and he was afterwards
advised not to allow any other surgeon to interfere with
them, though they recurred. To this advice he obstinately
adhered, notwithstanding Mr. Synie’s death, and he could
not be brought to entertain the 'iilea of having the orbital
swellings explored, but he promptly returned home.
Shortly after this he was attacxed by what was regarded
as phlegmoDou.s cellulitis over the left swelling. The skin
sloughed, and necrosed masses of polypi were thrown off
from the sinuses. His state was for some time very
critical, but he recovered, and in March, 1879, Dr. Bell
wrote that tlie undue prominence of the eyeball was
less, and the opening between the sinus and the external
surface had become fi.stulous. The farther history is
unknown.
Case li. Mucous polypi in frontal sinus. —A bakeresa
aged sixty was received into the Middlesex Hospital on
Jan. 1.5th, 1889, on the recommendation of Mr. E. ISnell of
Ketton. Her right eyeball was distinctly advanced; its
mobility was unimpaired, its vision good. There was
troublesome epiphora. At the upper and nasal angle of
the orbit w^ a bard, fixed swelling, circumscribed, ex¬
tending outwards to beyond the supra orbital notch, at its
outer end elastic. The space between this and the upper
and outer angle to half the height of the outer orbital
border was occupied by a movable swelling, the figure,
size, and consistence of which suggested it to he the dis¬
placed lacrymal gland. The left nasal passage was com¬
pletely, and the right almost completely, obstructed by
mucous polypi. She said that the prominence of the eye¬
ball had oeen first noticed three years previously. She had
attributed it to a strain through coughing violently. Two
years later (March, 1888) finding her “ nose stuffed” so that
she could not breathe through it, she consulted Mr. Snell, who
took severalpolypifrom both nostrils. On the hypothesis that
the orbital swelling was the cause of the proptosis, against
which view there were not any apparent grounds, and that
the woman’s statement as to its duration (three years) was
trustworthy, thepresentsizeoftbeswellingindicated avery
slow rate of increase. This was unfavourable to the idea of
a sarcoma, which in the orbit has usually a rapid course.
The objective characters of the swelling harmonised with
the idea that it was the expanded frontal sinus, and the con¬
currence of nasal polypi suggested that mucous polypi might
be the cause of its expansion. The nasal polypi having
been removed on Jan. 16tb, the orbital swelling was
exposed through an incision parallel to the eyebrow; a
smooth, dark-bluish body came into view. On slitting this
open a small quantity of glairy mucus escaped, and a
mucous polypus of the size of a small grape protruded itself
through the opening. It was removed, and the opening
enlarged by cutting away its bony margin until the finger¬
tip could be passed; it entered the greatly expanded frontal
sinus, which enclosed other polypoid masses. These also
were removed, and the cavity was thoroughly cleared.
At this moment the patient’s respiration and heart failed
so much that the exhibition of the anu:;sthetic bad to be
stopped and measures taken to restore her. Her critical
condition made it prudent to at once terminate the opera¬
tion, and the establiaUment of a free opening between the
sinus and the nose which had been intended Avas deferred.
She rallied and quickly recovered fri>m the immediate effects
of the operation, and a fortnight later returned and placed
herself under Mr. Snell’s care. For a few months it was
hoped that no further inconvenience Avoiild remain than the
presence of a small fistula under the eyebrow, discharging
a little mucus ; but in the spring of 1890 she re-entered the
hospital, Avith renewed distension of the upper eyelid and
greater protrusion of the eyeball, AA'hich had become in-
llanied and was then disorganised. The eyeball was
enucleated and the sinus thoroughly explored through the
wound. The orbital plate of the sinus was found largely
defective, and the cavity packed with mucous polypi.
These Avere removed, and the walls were thoroughly
scraped with a sharp scoop. Some thickening of the
postero-superior border of the opening into the sinus
gave a probability to the idea of sarcoma, as originally
suspected by Mr. Snell. She recovered, and soon went
home. Mr. Snell writes on Dec. 28th, 1890: “On
March 29th I removed through the unclosed wound three
polypi of the size of large currants, and again on April 7th
three or four others. 1 also re-establislied the opening
between the sinus and nose Avhich had closed. Carbolic
acid injections appeared to be useful in diminishing the
quantity of mucus secreted. Glandular swellings, which in
the spring had appeared in the neck, have disappeared.
There is now not the slightest sign Avhateverof any abnormal
growth in the sinus or orbit. She is now in better health
than for the past throe or four years.”
These cases show how much more grave is the occurrence
of mucous polypi in the frontal sinuses than in the nose ;
that in these they have a similar obstinate tendency to
recrudescence which they exhibit in the latter ; and that,
owing to their more strict coiilinement in the sinuses, they
more quickly expand and waste the bony Avails than they
do those of the nose, Avhere their restriction is less. Their
diii'erential diagnosis from simple nuicoecle of the sinus,
except in very advanced stages, is probably impracticable,
but the presence of nasal polypi affords a useful clue. For
their efficient treatment, free access must be gained to the
sinus by an incision along the upper orbital margin.
Old Burlington-strcot, W.
Digitized by
The Lancet,] SURGEON-MAJOK E. LAWRIE : THE HYDERABAD COMMISSION. [March 14, 1891. 591
THE
HYDERABAD CHLOEOEOEM COMMISSION.
By SURGEON-MAJOR EDWARD LAWRIE,
PRESIDENT or THE COMMISSION.
SiNCR the publication of my clinical lecture in Tub
Lancet of Nov. 29bh, 1890, I have received numerous
letters from Europe and from different parts of India re¬
questing me to draw up authoritative rules showing briefly
the method of chloroform administration which experience,
based upon Syme’s principles and upheld by the Hyderabad
Commissions, has shown to be uniformly safe:—
1. The chloroform should be given on absorbent cotton
stitchedintoanopenconeorcap. 2. To ensure regular breath¬
ing the patient, lying down, with eveiything loose about the
neck, chest, and abdomen, should be made to blow into the
cone held at a little distance from the face. The right distance
throughout the inhalation is the nearest which does not
cause struggling, or choking, or holding of the breath.
Provided no choking or holding of the breath occurs, the
cap should gradually be brought nearer to, and eventually
may be held close over, the mouth and nose as insensibility
deepens. 3. The administrator’s sole object while producing
anscstbesia is to keep the breathing regular. As long as the
breathing is regular, and the patient is not compelled to
gasp in chloroform at an abnormal rate, there is ab.solutely
no danger whatever, in pushing the anmsthetic till full
amesbhesia is produced. 4. Irregularity of the breathing is
generally caused by insuflicient air, which makes the patient
struggle, or choke, or hold his breath. There is little or no
tendency to either of these untoward events if sulHcient air
is given with the chloroform. If they do occur the cap must
be removed, and the patient must be allowed to take a
breath of fresh air before the administration is proceeded
with. 6. Full ancesthesia is estimated by insensibility of
the cornea. It is also indicated by stertorous breathing, or
by complete relaxation of the muscles. Directly the cornea
becomes insensitive, or the breathing becomes stertorous,
the inhalation should be stopped. The breathing may
become stertorous while the cornea is still sensitive. The
rule to stop the inhalation should, notwithstanding, be
rigidly enforced, and it will be found that the cornea always
becomes insensitive within a few seconds afterwards. It is
only necessary to add that the patient should be so dressed
for an operation that his respiratory movements can be seen
easily by the chloroformist. In the climate of India this is
not diilicult to manage, but it is diflicult to manage in the
climate of Europe ; so that in this respect, and in this respect
alone, the chloroformist in England is placed at a distinct
disadvantage compared with the chloroformist in India.
Proceeding in the above way, chloroform never produces
any bad enects, and its administration, in any case which is
fit for an operation, is entirely free from danger.
I have drawn attention to the danger of tEdcing the circu¬
lation as a guide as to the effect of chloroform,^ and
should not further allude to it but for an article on chloro¬
form administration by Dr. Dudley Buxton in The Lancet
of Deo. 13th, 1890. Tins article is by far the cleverest that
has yet appeared from our adversaries, but Dr. Dudley
Buxton’s teaching condemns itself. His plan of giving
chloroform is—“ (1) To use Lister’s open method or Krohne
and Sesemann’s recent and useful modification of Junker’s
inhaler ; (2) to test the vigour of respiration by placing my
hand over the mouth; (3) to watch the colour of the patient’s
face and ears ; (-1) to keep a finger upon an artery—always
testing the initial rate and force of tiie pulse in that artery
at the commenceraont of the operation.’'
The first remarkable point in these rules is that no fixed
principle of chloroform administration is laid down. The
chloroformist may employ indiscriminately the open method
or an inhaler, according to bis fancy. In the second place,
if the chloroformist places one hand over the mouth to test
respiration, and keeps the linger of the other upon an artery,
as Dr. Buxton recommends, it is difficult to understand how
the anrusthetic is to bo administered, unless the patient is
to do it himself. The severest condemnation of the method,
however, is to be found in Dr. Dudley Buxton’s own words.
He says : “ Proceeding in this way I have sometimes found
that the heart flags even when the respiration, judged by
1 TiiH J.ANCET, Nov. 2!)th, 1800.
the eye and the plan above mentioned, shows no alteration;
that not only is there evidence of general feebleness of
circulation, but that distinct' and unmistakable cardiac
enfeeblement occurs. Further, this is progressive, and
likely, it has appeared to me in more than one case, to end
in.cardiac syncope, unless prompt and vigorous nieaeures
were used.” This shows plainly that the plan is faulty,.if
not impracticable ; infact, itstands self-condemned. There
is never any dangerous enfeeblement of the general circnla-
tion or of the heart in the method of giving chloroform
recommended by the Hyderabad Commission. Dr. Dudley
Buxton can readily satisfy himself of the truth of this state¬
ment by giving our method a thorough and impartial trial.
None of our critics have done this yet, but if one fair-minded,
man of Dr. Buxton’s calibre were to do so, be would infallibly
convert himself to our views, and the conversion of the rest of
Loudon would follow in time as a matter of course. Dr. Bux¬
ton states that ‘ ‘ having once seen the heart relax and dilate
under chloroform, as in Professor McWilliam’s experiments,
one recognises the anatomical counterpart of the procession
of events which one has encountered again and again in the
operating theatre.” This statement goes far to prove that
there must he some fallacy about Professor McWilliam’s
experiments. As a surgeon I care very little whet happens
to the heart when it is subjected to such abnormal treat¬
ment as is involved in laying open the thorax and pumping
chloroform into the lungs in order to prove that it is
directly affected by chloroform. We might just as well
pump in boiling water, and then tell old women they are
not to inhale steam when they get bronchitis. But it is
interesting to be told by such an authority as Dr. Dudley
Buxton that Professor McWilliam’s results form the ana¬
tomical counterpart of a method of chloroform administra¬
tion which causes general feebleness of the circulation and
of the heart, and there is very little doubt that they do.
Professor McWilliam’s premiss that heart failure is not
necessarily accompanied by a fall of blood pressure is
manifestly unsound, and his description of rhythmic cardiac
relaxation and dilatation, under chloroform, is open to the
fatal objection that he has not shown that the movements
of his base line, by which they were estimated, were not
produced by relaxation of the diaphragm, pushing up the
heart through his artificial opening. If his heart dilatation
can really occur without fall of pressure, or when chloro¬
form is properly given, it must bo a natural condition and
free from risk.
The Hyderabad Commission has proved that there is no
such thing as chloroform syncope, and that in death from
an overdose of chloroform the respiration always fails before
the circulation. What the harmless fall of blood pressure in
normal chloroform administration ia due to, as well as what
happens to the heart after the respiration failed from over¬
dosing, which are the only two points left open tO’ discussion
by the Hyderabad Commission, must be entrusted to physio¬
logists to determine. In the telling words of Dr. Boraford,
“ it is sufficient for us as practical men to know (1) that the
heart is the very last organ to give in under ^be action of
chloroform, and (2) that there is no more danger of per¬
manently paralysing it in chloroform administration, than
there is of paralysing the legs and giving the patient para¬
plegia.”
PRACTICAL NOTES ON THE ADMINISTRA¬
TION OF ETHER AND CIILOROFORM.i
By RICKARD W. LLOYD, M.R.C.S. &o.,
AN.I'ISTHKTIST, WKST LONDON IIOSHTAI. AND (iOY’S IHiNTAI, SCHOOL.
It is my intention to make some remarks upon the con¬
siderations which guide us in cases about to be operated
upon under general ancesthesia by ether or chloroform, and
then to proceed to describe briefly some details of their
administration. Ether and chloroform are nob free from
danger; but any patient upon whom it ia determined to
operate is suitable for ancesthesia, or, at any rate, a trial of
it. One is guided in selecting the onmsthetic by the state
of the patient’s health as to chronic disease, lung and heart
mischief, alcoholism, and the nature of the operation, as
well as the age of the patient. The chief danger in patients
1 A paper read before tlie West London Medico-Cliirurfiical Society,
Fob. 0th, 1891,
• Google
592 ThbLancbt,] MR. LLOYD : ADMINISTRATION OF ETHER AND CHLOROFORM. [March 14,1891.
sufiering from chronic disease and wasting disease is in
prolonged operations, especially when they involve any
considerable loss of blood, as these patients have not the
same rallying power, and special precautions against their
collapse should be taken. They generally take the ances-
thetic well, however, and require less of it than stronger
persons. Patients suffering from acute disease, attended by
shock or collapse, require all the attention of the ances-
thetist, as their failure is often sudden. Operations under¬
taken in such cases are to give the patient the best hope
of life, and probably could not be accomplished without
ancBstbesia, which is sufficient justification for the risk
entailed. Euher is ns a rule preferable in these cases, and
often seems to improve the condition of the patient. Heart
disease should not preclude the administration of an anes¬
thetic. In such a case the circulatory and respiratory
symptoms may become alarming, so that the observation
and confidence of the aomsthetist will be fully exercised,
and sometimes, although rarely, it may be prudent to dis¬
continue the administration altogether. Ether is to be
preferred. In chronic or acute lung disease chloroform
would he much more suitable than ether, and, especially in
the latter class of cases, should be given cautiously, care
being also taken nut to administer move than is requisite.
This remark applies also to cases of empyema, in which it
is advisable to give only so much as is absolutely necessary.
Another class of cases in which it is important to give as
little as will suffice is that of brain surgery, and chloroform
here has the advantage over ether in lessening congestion
and biumorrhage. It is remarkable how small a quantity
of chloroform is sufficient for these patients, especially if a
small dose of morphia has been previously given. In chronic
renal disease chloroform has caused coma, and ether is there¬
fore to be preferred. It is true that in abdominal surgery
reater muscular relaxation and less tendency to cough will
e obtained with chloroform. Bat I prefer ether. In many
of these cases in which I have given it I have been quite
satisfied, but I have often commenced with ether and found
it necessary to change to chloroform.
In operations about the mouth and throat, as for removal
of the tongue or extirpation of the larynx, if the surgeon
considers it expedient to perform tracheotomy as a pre¬
liminary, and a. sponge be lightly placed in the pharynx or
a Hahn's tube be placed in the trachea, the diiliculties and
dangers of aclmioistering the ancesthetic in such cases are
very much lessened, as blood is thereby prevented from
getting into the air passages, and the effect of spasm of the
glottis is removed. In all such cases, whether tracheotomy
he performed or not, chloroform is the preferable ancesthetic,
and when the patient has been an.mstbetised in the ordinary
way the supply of chloroform may be kept up from a
Junker’s inhaler through a tube without the face-piece.
Take care that the bottle of the Junker’s apparatus is only
one-third filled with chloroform, and that the indiarubber
tubes are properly applied to the metal tubes each to each,
or liquid chloroform instead of vapour will be administered.
The danger of the accident does not require to be pointed
out here by me. Ether is scaicely available, as the
apparatus would be too often in the operator’s way,
and when the actual cautery is in use its iuilammable nature
makes it very dangerous. Alcoholic patients present diffi¬
culties on account of their becoming more congested, often
struggling greatly, being more liable to spasmodic actions,
and on account of the far larger quantity of ancesthetic they
require, but once under generally give little further trouble.
Ether suits them better than chloroform. The ago of the
patient also influences the selection of the ancesthetic. For
infante and young children chloroform is always used. In
older children and adults ether is also available, and in old
age chloroform again has greater favour. For fairly healthy
aged patients chloroform is best, but when there is evidence
ot considerable circulatory failure ether sliould be used; and
in the absence of bronchitis an old man with an extremely
weak, very irregular and intermittent pulse, with much
anaemia, may even be improved by the ether, as happened in
such a gentleman, nearly seventy, weighing Kist., who had
a leg amputated for gangrene, and to whom 1 gave ether.
In that case I believe chloroform would have caused
alarming, if not fatal, symptoms, whereas I had no cause
for anxiety during the administration of ether. Anicmic
patients are generally quieter than others in taking an
ansesthetic, but they have the disadvantage of failing more
rapidly and suddenly. Whenever possible patients should
always he properly prepared for anmathesia. In cases that
are not urgent it may even be thought advisable to improve
the patient’s general health before operating, and it would
be well if all patients were rested in bed for a day or two
before any major operation.
For the immediate preparation, care should he taken that
only a light meal of beef-tea and dry toast, or the like, at
least three hours previously to, and exceptionally a little
stimulant shortly before, the operation, be given. In some
extreme cas^s an enema of brandy and beef-tea adminis-
tered previously to operation is serviceable. There should be
nothing tight or constricting in the garments of the patient
to interfere with thoracic or abdominal respiration, and the
administrator should satisfy himself that there are no
foreign bodies in the mouth, such as food or false teeth.
Have at hand a pair of tougue forceps, and, as sickness is
generally sudden, a basin, soap-dish, or bowl of some kind,
before commencing. The temperature of the operating
chamber should be G0° to 66° F., and loss of body heat be
prevented, as far as possible, by avoiding undue exposure
of the patient and tne use of blankets. My experience
of anicstbetisiog patients who have recently received
morphia does not encourage me in the practice, except
perhaps in brain cases. All physical examinations should
be made before the patient is en the table, when it is
well not to delay the administration, and any conversa¬
tion in the patient’s hearing then often seems to give
rise to trouble by unnerving him. The an.'csthetic may
be administered to the patient in the several positions of
the horizontal, supine, lateral, or prone, and in the oblique
or sitting posture. The horizontal supine position with the
head slightly raised is the most convenient and best. It
may be useful to raise the shoulders when the lungs are
omWrrassed; but the great point is to see that the
patient is lying comfortably, otherwise resistance and
struggling will be encouraged. When it is necessary for
the operation that the patient he in one of the other
positions, except the oblique, I prefer to change the
position after administering in the horizontal supine. If
the head be kept on one side the escape of saliva and mucus
from the mouth is facilitated, and falling back of the tongue
less likely to occur; but unless there is necessity for turning
the bead on one side, I think it better not to do so.
liaising the patient during or soon after anmsthesia from a
recumbent to a sitting or upright position is likely to give
rise to syncope, and should be avoided. 1 have seen this
occur after the administration of ether for only ten minutes.
In the removal of post-nasal growths I am accustomed to
let the patient’s head hang over the end of the table, that
the considerable haemorrhage which takes place may escape
from the nostrils, and not have the opportunity that it
might otherwise have of flowing into the larynx and trachea.
In these cases I do not deeply amesthetise the patients, and
have always used chloroform for them.
For the administration of ether I use Clover’s small appa¬
ratus, and as a rule sprinkle chloroform on a piece of folded
lint about the size of a closed sheet of note-paper. The
actual rate of administration of ether or chloroform depends
greatly upon the depth and frequency of the respira¬
tions and the inlluence of temperature, the volatility of
ether being especially increased by warmth. Anaesthetics
affect individuals in different degrees from causes some
of whicli have already been referred to. The approxi¬
mate effect of these factors should be closely observed,
and the administration conducted accordingly. The com¬
plications that arise in administering etlier or chloro¬
form are numerous. The patient may be nervous and
afraid of the anesthetic, and resist the presence of the ap¬
paratus, especially when physical examinations are matie
upon the patient while still conscious, or if conversation is
going on around, or should the administrator appear at all
diffklent. Confidence can be given by a word or two of
encouragement, firmly expressed. If the breath be held at
this stage, ask the patient to bre.athe deeply, or appear to
take no notice, whichever seems best; and in either case the
patient will soon commence to breathe or proceed to give
forcible resistance, when it is better to remove the apparatus
and after a little encouragement make another attempt,
which is generally successful. When ether is employed it
is well to allow the patient to respire several times the air
contained in the bag before turning on the ether, whicliahould
be gradually increased as the patient becomes accustomed to
it. When the patient has lost consciousness there may be
spasm, involuntary resistance, and more or less arrest^ of
respiration, in which case the jaw should be raised, whicli
^8
The Lancet,]
DR. ARTHUR R. CUSHNY ON CHLOROFORM AND ETHER. [Maecii 14, 1891. 593
often has the effect of causing respiration, and the anass-
thetic pressed. So long as the pulse is good the supply of
fresh air may be limited, notwithstanding considerable
cyanosis. In regard to chloroform any cyanosis calls at
once for more air. Should any doubt arise in the mind of
the administrator while the respiration is arrested or
irregular, the pulse and pupil will guide him as to inter¬
ference. Coughing may be , stopped by diminishing the
supply of ether or, if necessary, allowing a breath or two of
fresh air. When anmstheaia is complete, the corneal reflex
is abolished; and, if extreme, the pupil, which has been
variable during the administration, becomes dilated and
fixed, and under chloroform the pulse is slowed. Cyanosis
should bo avoided by removing the apparatus during
two or three respirations when it appears necessary.
More excitement, spasm, cyanosis, and arrest of respira¬
tion occur when the patient receives during administra¬
tion a larger admixture of air than is perhaps intended.
When chloroform is used, fifteen drops to a drachm may be
sprinkled on the lint, which is then held several inches
from the face during several respirations, and gradually
brought nearer until it forms a dome over the mouth and
nose, the edges falling lightly upon tlie face, more chlo¬
roform being sprinkled on the lint from time to time pre¬
viously to its being turned over. The respiration should be
carefully watched, and any cyanosis, as before stated, calls
at once for a greater supply of air. The patient often
rambles in speech, and more or leas spasm of the muscular
system occurs, the patient struggling to get up, while at
the same time respiration is often arrested. Soon this stage
is succeeded by deep respiration, passing ofl' of the spasm,
and the completion of the amesthesia, when the pulse will
be found to be slow, the corneal reflex abolished, and the
pupil fixed, though not necessarily dilated. Should the
chloroform bo suddenly discontinued or unduly diminished
up to this time or now, what is known as primary chloro¬
form syncope is likely to occur, and is to be carefully
avoided.
The influence of anesthesia upon respiration and circu¬
lation is so great and important that I need offer no apology
for introducing here one or two physiological deductions.
Experiments show that dyspncoa occurs when there is no
obstruction to the exit of carbonic acid, and that, if plenty
of oxygen be supplied, dyspnoea does not occur, although
the carbonic acid may be in excess. The respiratory centre
in the medulla oblongata governs respiration independently
of consciousness, and is evidently stimulated by deficiency
of oxygen in the blood; it may also be influenced by im¬
pressions made on the nerves of the skin. The organism after
a time adapts itself to vitiated air, but this can only take place
at the expense of a depression of all the vital functions; and
when therefore the respiration is shallow during’the induc¬
tion of chloroform aniusthesia, the administrator must be
on the look out for cessation of respiration and syncope.
It may be well, also, to recall briefly the effects of the
quantity and quality of the blood upon the vaso-motor centre.
It has been found by experiment that, although the blood
pressure sinks whilst large abstractions of blood are taking
place, as soon as the .bleeding ceases it rises rapidly, and
speedily becomes normal, due to the regulation of the
peripheral resistance of vaso-motor nerves. The small
arteries contract—due to the stimulation of the vaso-motor
centre—from diminution of the supply of blood, and there¬
fore of oxygen. Failure of the blood pressure to return to
normal in the case of too great abstraction of Mood must be
taken to indicate exhaustion of the centre and consequent
want of regulation of the peripheral resistance.
The quality of the blood supplied to the heart has a
distinct effect upon its contraction, as too watery or too
little oxygenated blood must interfere with its action. The
agents during an operation influencing the general condi¬
tion of the patient are therefore in part attributable to the
an.'xisthetic and in part to the operation, the deprivation
of oxygen from the respiratory and vaso-motorcentres being
brought about by the administration of the aneesthetic and
loss of blood combined, both tending in this way to the
exiiaustion of these centres. The anjosthetist has some
control over the amount of deprivation of oxygen in his
method of administration, and so over the respiratory and
vaso-motor centres; but tlie loss of blood, over which he
has no control, may exhaust them.
Daring the administration of an ansesthetic untoward
symptoms may at any moment arise. For undue cyanoBis or
airestof respiration, whether on account of spasm of the
glottis or falling back of the tongue, the aozestbetic should
be wholly or partly temporarily withdrawn and the jaw
raised, which manccuvre is often followed by a deep inspira¬
tion. If necessary the tongue should be drawn forward,
and if matters are not now improving—i.e., if respiration
is not re-established—artificial respiration must be at once
resorted to, care being taken to perform it slowly; this
latter precaution is most important, as is also that of
keeping the tongue drawn forward during its performance.
When the failure is primarily from syncope, the inversion
of the patient, the taking up of a small child by the legs,
for instance, and holding it head downwards, is easily done,
and in several instances I have found this most effective.
Should it appear to have no good effect after half a minute
I would resort to artificial respiration, or this may be
applied at the same time. I have heard medical men say they
would not practise inversion, and understood their reason
to be that the sending of blood to the btain charged more
or less with chloroform cannot improve matters. 1 believe
the increased supply of blood to the vaso-motor centre,
although this blood be charged with chloroform, has
made the difference between life and death. Where the.
recovery from failure of the heart or respiration is
rapid, it may not be necessary to administer brandy ;
but when it is not, it should be given by the mouth
or rectum, or both, and where the failure is supervening
gradually the anaesthetist must estimate whether it Is
necessary to administer brandy or not. An injection of
brandy per rectum has a marked effect upon patients who
are collapsed from the length of an operation, shock, or loss
of blood. On one occasion, some three years ago, when in¬
version and artificial respiration in the ordinary way had
failed, I restored the child, two years of age, by closing its
nostrils, holding the tongue forward and blowing through
the mouth of the patient, so expanding the lungs, then
pressing the air out and repeating this until respiration
was re-established. It was an hour and a half before
the collapse was sulliciently recovered from for me to
leave the patient. Wood of Philadelphia, in his paper on
Ether and Chloroform read at the Berlin Congress last
summer, showed an apparatus for this purpose. Of elec¬
tricity in restoring patients I have no experience. Nitrite
of amyl stimulates the respiratory and cardiac centres and
causes dilatation of the peripheral vessels, thus also reliev¬
ing the heart. I have occasionally used it with apparent
benefit.
SOME EXPERIMENTS ON CHLOROFORM
AND ETHER.
By ARTHUR R. CUSHNY, A.M., M.B.Aberd.
(FROM THE 1‘IIVSIOI.OGICAL LAllORATORV OF UBRN ONIVEHSITV).
The report of the Hyderabad Chloroform Commission
has been read with interest not only in England and
America, but also in Germany and Switzerland, where it
has aroused widespread discussion and comment. In the
latter country especially, which is at present in the throes of
a discussion as to the respective merits of tlie rival anies-
thetics, the report of the second Commission was awaited
with anxiety and received with much approbation by the
numerous advocates of chloroform. On the decision ot the
Commission becoming known. Professor Kronecker of Bern,
whoso pupils, Ratimoff and Schmey, had already shown the
poisonous action of chloroform on the heart, suggested that
I should make a few experiments on the subject. The
details of those will be published elsewhere, and I will here
state merely the.general results.
By the Hyderabad Commission no experiments seem to
have been made with chloroform vapour of ascertained
concentration, and, as this factor seems to be of consider¬
able weight, I have used an apparatus^ in which it
could be exactly regulated. This consists of two wash-
bottles, one-third filled, the one with chloroform, the other
with water. Part of the air inspired by the animal passes
through one, part through the other, and becomes saturated
with chloroform fumes or water vapour accordingly. The
proportion of tlie chloroform saturated to the moisture satu-
1 Itiitiiuolf and Schmiioy used the same apparatus in tlioir experiments.
h
Google
594 The Lancet,] DR. ARTHUR R. CUSHNY ON CHLOROFORM AND ETHER.
[March 14,1891.
rated air is regulated by two graduated stopcocks (Kroneck-
net’s ScMehhahn). The two currents unite, and are led by a
short tube to the tracheal canuula. Expiration is proviaed
for by a small hole in the sheath of the latter, which is
covered by a dap of moist goldbeater’s skin, to prevent the
inspiration of air which has not first passed through the
apparatus. In order to exclude all chance of aspbyxial
complications, and to allow a regular amount of chloroform
to be absorbed in a given time, the air was driven through
the apparatus by a machine for nvlihcial respiration.
The animals used were dogs and rabbits, and the experi¬
ments were carried out at ordinary room temperature
(15° to 17° C.}. The movements of the heart and respira¬
tion were recorded by a heart needle and diaphragm lever,
and tracings were taken in almost all the experiments.
Iq the respiratory tracing tbe curves formed by spon¬
taneous respiration were combined with those caused
by the arti&cial inflation of the lungs, but could be easily
distinguished, and the moment of cessation of the former
ascertained. When this occurred artificial respiration was
generally stopped for a few seconds, to see if any spontaneous
movements occurred. I may here state that the heart
needle was not found to be an accurate index of tbe heart
beat, as in some cases it continued to vibrate after paralysis
of the ventricles, owing to the continued pulsation of the
auricles communicating a motion to the ventricles through
which the needle passed. In all cases, therefore, in which
there was any doubt as to the condition of tbe heart, arti¬
ficial respiration with air was resumed, and the heart
observed directly by opening the thorax. As soon as
chloroform was applied to a rabbit (except when the
vapour was greatly diluted with air), the animal began
to struggle and the respiration became irregular with expi¬
ratory gasps, or almost ceased for a few seconds, Veiy soon
the stage of rapid respiration described by Knoll set in.
In those cases in which tbe air was saturated with chloro¬
form (i.e., in which all the air inspired passed through the
chloroform bottle), this stage only lasted from twenty to sixty
seconds. In cases i-i which a lower concentration was used
it lasted much longer, sometimes for two hours, but in all
the spontaneous respiration gradually got shallower without
getting slower, till it ceased entirely. The condition of the
heart at this moment varied with the concentration in
which the vapour had been blown into the lungs. Of seven¬
teen rabbits chloroformed with saturated air, in live the
whole heart continued to beat, in nine one or both auricles
were in rapid motion while tbe ventricles were still, in one
the left auricle alone was paralysed, while in one the
whole heart was in diastolic standstill. In rabbits which
were aniesthetised with a mixture of chloroform vapour and
air—i c., in experiments in which the stopcock on the water-
bottle was partially open—the whole heart was invariably
found beating, but the more chloroform the mixture con¬
tained the weaker was the heart beat. Even when only
four parts chloroform-bearing air were mixed with ninety-six
parts pure air the respiration ceased, though only after
from two hours to two hours and a half’s exhibition of the
drug. With lower concentrations than this I could not
obtain narcosis, and did not attempt to find bow long an
animal could be exposed to the vapour. Ratimoff found
that rabbits could be kept narcotised for six hours without
tbe respiration ceasing. Paul Bert, on the contrary, found
that dogs died after two hours and a half’s constant inhala¬
tion if the narcosis was complete. Beveral dogs were chloro¬
formed by the same method, and in all of these, however
concentrated the chloroform vapour, the respiration ceased,
Svhile the heart could still be felt pulsating. A rather
higher concentration was required to keep dogs narcotised
than was necessary for rabbits.
In regard to the restoration of spontaneous respiration,
in both dogs and rabbits, I found that success depended not
so much on the length of the interval between the cessation
of the spontaneous and the recommencement of the artificial
respiration as on the c incentration in which chloroform had
been given. In dogs inllation of the lungs was successful
in all cases. In rabbits, on tbe contrary, it was impossible
to restore life when chloroform-saturated air iiad been used,
however soon after paralvsis of tbe respiration restorative
measures were taken. When a half-and-half mixture was
used, three out of eleven animals could be resuscitated, and
with lower concentrations the proportion of recoveries in¬
creased till below per cent, all animals could be restored.
In one case, in which a 4 per cent, mixture was used, an
interval of three minutes elapsed before artificial respiration
was begun, and the animal still recovered. The chances of
recovery after paralysis of the respiration, in fact, depend
entirely upon the condition of the heart, and therefore on
the concentration in which the drug has been used. If, as is
the case in rabbits, tbe heart is very much weakened by very
concentrated administration, it is impossible to restore tbe
respiration. If, on the other hand, the heart is comparatively
unafTected, as in dogs, or in rabbits in which the drug has been
administered in amoro diluted form, the animal can always
be revived provided the necessary measures are taken within
a reasonable time. Tbe essential point is that the drug be
given in siilficient dilution to avoid its action on the heart,
and if this dilution can be sulliciently provided for, observa¬
tion of the pulse is not absolutely necessary. Although I
cannot agree with the Hyderabad OommUsion that the
heart always continues to beat after respiration ceases, yet
the ditliculty in maintaining the concentration necessary to
paralyse the heart siraultaneously with the respiration is
extremely great, and I should think that in ordinaiy chloro¬
form administration such a simultaneous paralysis can never
occur.
As, in the great majority of my experiments, death was
due to the respiration alone, some experiments were made
to find the condition of the medulla oblongata during
chloroform narcosis. This question was approached by an
examination of the reflexes connected with it. I found
that these all ceased before tbe respiration, and returned
(incases where tbe animal was revived) some time after
spontaneous respiration had set in. ’I'be move concentrated
the mixture, tbe shorter the interval between their dis¬
appearance and that of respiration. The first to cease to
act was the corneal reflex, then that on the respiration from
the nasal branch of the trigeminus, then the swallowing
reflex from irritation of the soft palate or of the superior
laryngeal nerve; and, last of all, Traube’s active expiratory
reflex from expansion of the lungs. The reflexes in dogs
were not so carefully noted as in rabbits, but in general
presented no marked diflerences.
The respiratory centre, a.s Knoll has pointed out, is afleefced
differently in different stages of chloroform narcosis. At
first it is acted on by the reflexes first from the nose then
from the trachea and lungs Then the rapid stage of respira¬
tion sets in. This occurs after division of the vagi, and is
due to stimulation of the vagus roots in the medulla, and
not to stimulation of the respiratory centre itself ; for, if the
latter were the case, the result would be, as Marckwald has
pointed out, respiratory spasms; whereas, after section of
the medulla above the centre and division of both vagi,
chloroform breaks up the resulting spasms into regular
respirations exactly as weak tetanisation of the vagi does.
Last of all, the centre is paralysed by chloroform, and
fails to respond to electrical stimulation of the medulla.
The blood pressure was registered in several experiments in
which the drug was administered in weak concentration,
and I found that there occurred a slight rise and then a
very gradual uninterrupted fall. Iq very weak form
(4 per cent.) chloroform caused no preliminary rise, but a
slow fall from tbe very first, though so gradual was the
change in pressure that it could only be seen by comparing
the curves at intervals of ten minutes. No such sudden
falls of pressure were seen as have been noted by some
critics of the Commission, wliich is perhaps to be explained
by the abundant and uninterrupted supply of air to the
lungs. I may remark that in those experiments in which
the movements of the heart were registered directly,
they never showed any sudden change, but a gradually
increasing weakness, whicli culminated in paralysis or
passed off, according as chloroform was continued or
shut off.
For the sake of comparison a few experiments were made
with ether, and the same stages were observed as with
chloroform, death occurring equally rapidly if undiluted
ether vapour was used, and being due to paralysis of the
respiration plone or with accompanying heart paralysis. In
one case delirium cordis was observed after a minute and a
quarter’s inhalation. Rabbits anmatlietisod with pure ether
vapour could not be revived by artificial respiration. Dogs
always ceased to respire while the heart continued to beat,
as also did rabbits to which diluted vapour had been given,
and the majority of these could be revived. The reflexes
appear to behave in the same way as in chloroform
narcosis. Ether was borne in higher concentration than
chloroform, 4nd the respiration could be more certainly
restored. For example, in one case 8 per cent, was
The lancet,] DR. H. SNOW: THE BONE LESIONS OF MAMMARY CARCINOMA. [March 14, 1891. 595
given for two hours without killing the animal, while
with chloroform 6 per cent, was fatal after one hour
and a half. This fact is the more striking because a
very much larger quantity of ether than of chloroform is
given in a concentration of 8 per cent. Theoretically,
2'7 times as much ether as chloroform should be carried to
the lungs by a given quantity of air, and by actual experi¬
ment I found a proportion of 2 61:1. In both an.Tjsthetics
the action on heart and respiration seems the same, a
difference in degree only being perceptible. Ether can be
given in greater qxiantity with safety ; but so long as the
proportion of drug to air is kept low enough either can be
used with safety. The concentration necessary to keep
rabbits and dogs “under” chloroform is respectively four
and eight parts chloroform vapour (at from 15“ to IV'C.) to
ninety-six and ninety-two parts pure air. Since, how¬
ever, the concentration necessary to maintain narcosis
varied in different species of animals, no inference could
be made as to that necessary for men, and my results
would have been incomplete had I not been enabled
through the kindness of Professor Girard and Dr. Niehans
to carry out some'experiments in their operating' theatre
in Bern Inselspital. In these experiments the anaesthetic
was given in the same way as in rny experiments on animals,
with the exception that, instead of a tracheal cannula, a
Y-shaped glass tube was used, the two ends htting tightly
into the patient’s nostrils. Expiration was allowed through
the mouth, but inspiration through it was prevented by a
valved respirator. The patients in general did not object
to the method, and one who had to be anaesthetised again
some days .subsequently begged that the apparatus might
be used again instead of the mask. Narcosis was attained in
from five to twelve minutes by a mixture of 16 to 20 per «ent.
of chloroform, and could be kept up by continued inhalation
of 5 to 7 per cent, in children and of 7 to 10 per cent, in adults.
Almost no excitement occurred. Throughout the narcosis
the face and conjunctiva remained red, and in several cases
the concentration necessary t) keep up insensibility with
retention of the corneal i eflex was mainbaiDed. With ether
adults were narcotised with dilliculty, and only after pro¬
longed inhalation. Anrosthesia was afterwards kept up by
a concentration of 10 to 15 per cent. Children presented
less difficulty, requiring 25 to 30 per cent, to induce in¬
sensibility, which continued uninterrupted with a con¬
centration of 10 to 15 per cent. In all cases the usual
increased secretion of tears, saliva, and mucus was mani¬
fested. The difficulty in inducing narcosis with ether seems
to confirm the theory of many observers that ether alone is
in,sufficient for this purpose, and must be aided by a
partial asphyxia.
The results of these narcoses may be summed up
shortly hy saying that, to maintain narcosis with chloro¬
form, a concentration of live to seven and seven to
ten parts of chloroform saturated to ninety and ninety-
five parts pure air must be adopted for children and
adults respectively; while, if ether be used, a con¬
centration of ten to fifteen parts saturated to ninety and
eighty-live parts pure air is suitable for all ages. The drug
may be inhaled in a slightly higher concentration to induce
narcosis, hut, as soon as the eyelid reflex disappears,
the above proportions should be given. The use of the
above apparatus (which will be more fully described in the
Zeitschrift far Biologie) offers an easy method of
regulating the strength of the inhalation, bub, if the usual
method is adopted, the ana'sthetic should be poured on fre¬
quently and in .small quantities rather than at longer in¬
tervals and in larger doses. By the latter method of
administration the narcosis is rendered unnece-ssarily, and
often dangerously, deep for a short time, and then quickly
passes off’; while by the former it is kept at approximately
the same depth throughout.
SuKjiDB OF A WuiiCikON.—All iiKfuest was held on
the 2nd insb. at Berkeley-square, Clifton, on the body of
Mr. Walter K. Thomas Hawkins, M.R.C.k, aged twenty-
nine years, wlio committed suicide on the previous clay. lie
had been in practice at North Tawton, Devon, biit had
lately relinquished it, and on the previous Saturday returned
to his mother’s residence in Jierkeloy-square, apparently in
good health. On Sunday morning he was found lying on
the floor of his bedroom with his throat cut, a razor being
by his side. The deceased had no pecuniary dillicultieH,
and it appeared he had committed suicide whilst suffering
from a ut of tomporaiy insanity.
A NOTE ON THE BONE LESIONS (USUALLY
INSIDIOUS) OF MAMMAEY CARCINOMA.
By HERBERT SNOW, M.D.Lond., &c.,
SURGEON TO THE CANCER IIOSl’ITAL.
(Concluded Sroin p. C30.)
TiiEsecondphysicalsign—" the sternal symptom”—which
indicates marrow infection in an early stage is not usually
noticeable until a period of many months subsequently to the
preceding, hut is far more conspicuous. A portion of the
sternum for about two inches downwards (in the first instance)
from the upper margin of the second costo-sternal articula¬
tion becomes prominent and seemingly hypertrophied. The
condition slowly bub progressively increases, so that the
upper and lower portions of the bone being unaffected,
a marked prominence and curvature result. The deformity
is most conspicuous in a broad and well-developed thorax,
and can hardly, in a 'nell-marked instance, escape ob¬
servation on exposure of the chest. I beg to exhibit
photographs (for which I am indebted to Dr. T. Johnston
English, an able amateur photographer) of five typical
cases. The condition 1 am describing occurs long anterior
to fixation of the mamma to the thoracic wall, and when
there can be no suspicion of infiltration by contiguity
of tissue. (See figure in previous number, p. 638.)
When the mamma has become fixed to the thoracic wall,
the appearances may be at first accentuated, but are eventu¬
ally masked by general infiltration of the parietes. The
patients seldom complain of tenderness on pressure or of pain
in the part affected ; and, indeed, do not appear usually to
notice the deformity unless this becomes extreme, the altera¬
tion taking place very slowly and gradually. I have known
actual tumour formation take place only in four instances;
one of the photographs exhibited displays, in addition to
the regional curvature above described, a small, irregular,
bossy growth from the right lower half of the gladiolus,
the primary lesion being situated in the left breast. We
sometimes find non-cancerous women with exceptionally
prominent sterna; in these, however, the manubrium is
also commonly implicated, the prominence commencing at
the very top of tbe bone. In malignant cases its upper
border, as aoove stated, is on a level with the upper edge
of the second costo-sternal articulations—i.e., a little above
the junction of the manubrium and gladiolus. The gradual
development of the physical sign in patients kept under
observation for a year or two differentiates it from any
natural condition of the parts; and it is often seen after
an operation, when all the other tissues (excepting perhaps,
the humerus) seem perfectly healthy. Though not in¬
compatible with several years of life, it usually contra¬
indicates, I consider, any operative procedure of gravity.
Marked physical weakness, lassitude, and inability to.
perform ordinary daily tasks are always concurrent, even
when DO palpable emaciation lias taken place. Unless,
physical signs of intra-thoracic deposit or of pleural
effusion coexist, there is no attendant dyspnoea. In ex¬
planation of the exemption of the manubrium I need
hardly remind you that this is, to all intents and purposes,
a distinct bone until very advanced age. Of the twenty-
one cases referred to nine exhibited this sternal prominence.
The most typical illustration of bone disease secondary
to mammary carcinoma with which I am acquainted is to
be found in the museum of St. Thoma.s’s Hospital. No. 673.
is the plaster cast of the body of a woman who died in
that institution subsequently to excision of the right;
breast for scirrhus. No tumour formation is apparent,
but the bones of the trunk have become frightfully dis¬
torted. The right humerus and both femora have under¬
gone fracture—the broken ends having subsequently united
almost at right angles. The sternum and libs have sunk
until the former appears almost in contact with the ver¬
tebral column, the whole thorax being llattened out trans¬
versely. The pelvis seems similarly widened and llattened.
From the position of the cast, the state of the vertebral
column cannot bo ascertained ; and I liave been unable to
discover the history of the case. The position of the right
breast is occupied by a seemingly healthy scar. The half
section of one femur had fortunately been preserved in
spirit; and Mr. Shattock has been kind enough to have this
d:.
596 The Lancet,] DR. H. SNOW; THE BONE LESIONS OF MAMMARY CARCINOMA. [March 14,1891.
mioroscoped for me. He finds the growth to be a “typical
spheroidal-celled carcinoma of the firm kind, a growth
similar to an ordinary carcinoma of the breast.” The re¬
maining half of the same bone, the other femur, right
humerus, and one patella are mounted as dry specimens,
and constitute excellent examples of the so-called
“fragilitas ossium,” supposed to be the result of carcinoma.
The custom of mounting such examples of malignant
bone lesion as dry specimens necessarily prevents their
being subsequently available for microscopic investigation.
Most pathological museums appear to contain one or more,
but the instance alluded to is the only case I have met with
in which a portion of the affected bone has been preserved
in spirit alongside of the white, spongy, skeleton frame¬
work with which you are familiar. The so-called “ rheu¬
matic ” pains of cancerous disease appear to be a charac¬
teristic feature of mammary carcinmna, and restricted to
cases of the latter neoplasm. So, also, secondary deposits
in distant bones would seem to he almost peculiar to the
same, instances of malignant new growths arising primarily
from bone or periosteum being of course excluded. I have
not myself encountered any examples of the phenomenon,
except in connexion with breast cancer. The museum of
the Royal College of Surgeons contains specimens taken
from two cases. No. 1687^ is a tumour in the parietal bone
of a child, secondary to medullary carcinoma of the testis.
Nos. 1G87A and ld87B are deposits in tbe skull and left
femur of a man, considered to be secondary to primary
carcinoma of the prostate. According to the record, how-
over, the fact seems a little doubtful. Three or four other
museums a,t which I have made inquiries do not appear to
possess any example of secondary bone deposit, except in
connexion with mammary carciaoiiia. On the other hand, the
museum of St. Thomas’s Hospital contains twelve specimens
of “ carcinoma of bone,” taken from seven coses. In six of
the cases the deposit is secondary to breast carcinoma. That
of the College of Surgeons has eleven specimens (Nos. 1C70,
cf seq.) also from seven eases of secondary deposit of carci¬
noma in bone. Two of the latter have just been alluded
to; the remaining five are sequential to primary growtlis
in the mamma. Again, of six specimens in connexion
with the breast, two are of deposit in the femur, two in the
humerus, one of malignant cells infiltrating the dorsal and
lumbar vertebrm, and one of nodules attached to the
posterior surface of the sternum, but nob seemingly grow¬
ing from the bone itself. In advanced cases of mammary
carcinoma, bone symptoms are rarely absent, though, like
all the other phenomena of malignant disease, subject to
material variations of degree in individual examples.
The conclusions which I beg to submit are — (1) that
bone lesions in connexion with breast carcinoma are not
exceptional, but an ordinary phenomenon of the later
stages of this disease; (2) that the condition depends
not solely upon absorption of calcareous salts, but is the
result of actual deposit of malignant cells in the marrow;
<•3) that the marrow, when thus infected, forms a species of
“ nidus for the resting spores” of the neoplasm, in which
the cancer cells insidiously nourish, it may be for several
years, without any conspicuous indications of tb eir presence.
APPENDIX OF CASES REFERRED TO.
Case 1. Photograph of anterior ehest toall exhibited .—
Mary E- (living), a woman aged sixty, married, cook ;
no family history of cancer. A scirrhous tumour of the
left breast, as large as an orange, of a year’s duration,
following a blow, was excised in October, 1888; it waa
freely movable. There was a lymph gland in axilla, of the
size of a hazel-nut; the axillary contents were removed at
the same time, and the patient was discharged well to all
appearance on Dec. 27th, 1888. To the present time (July,
1890), the cicatrix, left axilla, and external tissues of the
left chest wall have remained perfectly he.altby. The
woman is rather stout, has a broad chest, and the mamnim
are large and pendulous. In December, 1»88, the patient
began to complain of aching pains in the left shoulder
(shooting down the arm) and across the loins. On Jan. 14th,
1889, thickening about the upper epiphysis of the left
humerus and sternal prominence in the site above described
were both very marked. On May (itli, 1880, a tumour was
found in the right breast. This now (July 2nd, 1890) im-
licates the whole gland tissue of the mamma, tbe skin
eing adherent, bub still retains perfect mobility on the
^ P.alholofrical Catalogue, vol. ii., part i.
chest wall, so that no question of infiltration by contiguity
of tissue can arise. There is deposit in tbe lymph glands of
the right axilla. The patient is invalidish, and is unable
to follow her occupation, but has no very marked objective
indications of failing general health or of visceral con¬
tamination. There is a general feeling of lassitude and
weakness, for which the obvious tumour formation seems in¬
sufficient to account.
Case 2. Photograph, of anterior chest wall. —Elizabetli
G-(living) aged fifty-seven, was admitted into the Cancer
Hospital on June 24bh, 1890. She is a spare woman, with
small atrophic mammm and advanced scirrhous disease of the
left breast, noticed one year, but evidently of much longer
duration. The whole mamma is infiltrated and becoming
adherent to the parietes; a large mass of lymph glands
completely blocking up the left axilla and firmly fixed.
No ulceration, but considerable cedema of left arm and
forearm. Prominence of the sternum, but not so marked
as in tbe preceding case; tbe epiphyses of both humeri
seem fuller than normal, the left slightly more so than
the right. No infiltration or codema of tissues between the
mamma, and sternum apparent. “Rheumatic” pains in
arm ; not in loins.
Case 3. Photograph of anterior chest wall. —Susan D-
(living) aged fifty-three; very short woman, with broad
chest; married; nine children, six living; no family
history of cancer. The right breast with contents of
axilla excised by Dr. Purcell, in March, 1890, for scirrhus,
noticed seven months; probably of much longer duration.
On July 7th, 1890, marked prominence of sternum at second
costo-sternal articulation, over this three smell reddish
nodules in skin, freely movable, apparently composed of
kelbid tissue (not of scirrhous); near these two small while
scars. The right humerus showed very marked fulness and
thickening of tbe upper epiphysis. The cicatrix healthy,
and no palpable malignantdeposit in soft parts. No cedema
of arm or forearm ; no lumbar pain, but continuous gnawing
pain like that of rheumatism—worse at night, and then pre¬
venting sleep—felt “ in the hone” of the right arm as far as
tbe elbow.
Case 4. Photograph of anterior chest wall. —Jane R--
(living), aged fifty-three, single; a spare, much emaciated
woman. Atrophic scirrhus of the left breast, of six years’
duration, not operated on. No family history of cancer.
No injury, mucli mental distress, and hard work as seam¬
stress. Small mamnim; the left completely infiltrated,
shrivelled looking, and adherent to the chest wall. Skin
and axillary glands also diseased; the latter small, but
firmly fixed. A large goitre, present from childhood. The
sternum presents (July 7bh, 1890) general curvature and pro¬
minence from the second costo-sternal articulation to the
attachment of the ensiform cartilage. Close to the latter,
on the right of the middle line, is a prominent irregular
hard boss growing from the bone ; noticed one year and a
half; slightly tender. Deposit of scirrhus at base of left
lung; just above the crista ilii, on each side, a small sub¬
cutaneous nodule of the same, movable. Marked thickening
and prominence of right sacro-iliac articulation. N o tender¬
ness ; this not previously noticed by the patient. Marked
lumbar rheumatic pains, complained of for previous
twelve months ; no pain in the shoulder and no “ humerus
symptom.” (An out-patient at the Cancer Hospital, under
the care of Mr. Bowreman Jessett.)
Cask 5. Photograph of anterior chest wall. —Mrs. 0-
(living), age fifty-three. No cancerous family history;
great domestic trouble for several years previously ; no
injury. In February, 1889, the left breast was excised for
advanced scirrhous disease, which had been noticed two
years. The whole of the mammary parenchyma was then
infiltrated, bub the gland was still movable; the axillary
lymph glands were considerably enlarged, and were removed
at the same time. They were then found to be softened
and breaking down, were implicated as high as tlie clavicle,
above which was a slight suspicious fulness. There had
been discharge from tbe nipple of a purulent character (nob
hmmorrhagic) for four months, and a small cyst was found
near the root of the nipple. Examination of bumenis
negative and no sternal prominence noticeable. A rapid
recovery from the somewhat severe operation. On
Oct. 2.5th, 1889, the cicatricial tissue healthy, but three
small subcutaneous secondary nodules above and below the
scar wore destroyed with pobassa fusa. The sternum
showed marked prominence over tlie .second costo-sternal
articulation. On June 7bb, 1890, the upper epiphysis of
Coogle
The Lancet,!
ME. EEGINALD HAERISON ON PETEESEN’S EECTAL BAG. [March 14, 1891. 597
the lefb humerus was found to be much thicker in appear¬
ance than the right. On July 19bh, 1890, the photograph
was kindly taken by Dr. T. Johnston English. The sternal
rominence and condition of the left humerus remained as
efore; the upper epiphysis of the right humerus seemed to
be also slightly fuller than the normal. The sternal
prominence was tender on pressure and the patient also
complained of aching down the left upper arm. A fulness
'just below the left clavicle, evidently due to deposit in the
lymph glands upon the axillary bloodvessels ; this was the
sole manifestation of malignant deposit in the soft parts.
General lassitude, but little or no pain; the patient able to
et about well, being kept under the influence of small
OSes of opium.
Case 6. Microscopic sections from cancellous tissue of head
and shaft of right humerus, ditto of left, from marrow in
both boms, from cancellous tissue of lumbar vertebra; the
portions of bone from which the sections had been taken also
■exhibited. —Sarah J-, a woman aged lifty-one, with no
(family history of malignant diseaise, was admitted into the
Cnnoer Hospital on May 2ad, 1890. On examination she
was found to have an ulcerated scirrhous tumour of the
right breast, about two inches in diameter (including
surrounding area of livid skin), becoming fixed to the
•chest wall. Several glands in the axilla as large as
hazel-nuts. Extensive tubercular disease of the left lung
was also present, and after admission the patient was
■found to 00 iuaane. No cedema of the arm existed ; the
disease had been present three years and a half and had been
ulcerated two months. The patient had led a bard life,
and had received several blows. She was much emaciated.
After causing considerable trouble, the patient died on
May 2‘tth. The rapid termination was largely brought
about by the coexisting cerebral and pulmonary conditions.
The amount of malignant disease present should, under
ordinary circumstances, have permitted a much longer lease
of life (as evidenced by the total absence of arm cedema).
No bone symptoms existed during life. The acute mania
present precluded complaint of rheumatic pains, and no
■outward and visible physical sign existed to draw attention to
the bones.— Necropsy: An emaciated slightly builtwoman,
with small rnammtu. In the right breast an ulcerateil
scirrhous tumour, not very large or prominent, and still re¬
taining some degree of mobility on the thoracic parietes.
In the right axilla a cluster of 'lymph glands, movable, fis
large as hazel-nuts; in the left one such, the size of a
horsebean. Seven or eight small nodules in the sub-
•entaneous tissue of the trunk; several, also of small size, in
the liver. No other visceral malignant deposit. The left
lung extensively excavated by tubercular disease; the right
healthy. Examination of the brain gave negative results.
On incision over the upper epiphysis of each Immerus an
alteration in colour was apparent, the grey epiphysis con¬
trasting with the white shaft of the bone. The point of the
-scalpel passed readily into the former, which was evidently
in great measure decalcified. No change in the consistence
•of the shaft was noticeable. Under the microscope scir¬
rhous cells (arranged in the typical acini) were found
in the above sites, being most abundant in the right
Immerus, less so in the left, and least in the vertebra
<Iumbar).
Case 7. Section of marrow taken from femur exhibited,
showing small group of scirrhous cells ; also section of rib. —
Mildred W-was admitted into the Cancer Hospital on
Jan. 15th, 1883, under the care of Dr. Purcell. Malignant
tumour of the left mamma as large as a cocoa-nut noticed
•one year; deposit in axillary lymph glands. Two soft
■elastic bossy masses grew from the left half of the sternum.
In the course of a few months similar tumours appeared on
left parietal bone, at the angle of the left scapula, and on
■the shaft of the right femur. The latter bone underwent
spontaneous fracture below the trochanters about a fort¬
night before the patient’s death in Nov. 1883. The micro-
•acopic appearances of the primary tumour were those of
•encephaloid carcinoma—i.e., exuberant proliferation of
epithelioid cells, with scanty residual fibrous tisane, a
larger proportion of the cells being, however, small
and nuclear in appearance than is usually the case. Beside
the bone tumours alluded to extensive deposits were found
in the lungs and kidneys, the liver and other viscera being
healthy. No tumour existed at the spot where the marrow
-section was taken; a portion of the shaft seen by theaeebion
to be of normal calibre. It w.as obtained and mounted as a
specimen of presumably healthy marrow; infection was
not then suspected, and the malignant cells were discovered
only incidentally. No enlargement of the rib existed,
the fragmentary state of the specimen indicates the fragile
condition of the bone, reduced to a thin shell of periosteum
and bone matrix, enclosing a few loose masses of paren¬
chyma, stained red by picro-carmine. (It is not certain in
the case of this last specimen that infiltration by contiguity
tissue may not have taken place.)
Cases, Microscopic sections of cancellous tissue in head
of left humerus, stained by picro-carmine, also by picro-
carmine and logwood. —Emma B-. Scirrhus of the lefb
breast, with brawny cedema of lefb arm. Extensive visceral
deposits. Bone,decalcified; the head of the bone divided
by the knife as readily as the soft parts, so disarticulation
from the glenoid cavity effected only with difficulty. Micro¬
scopically tlie cancellous tissue eroded by what appears
to be cancerous parenchyma, the normal marrow stroma
absent.
Case 9. Sections of head and upper part of shaft of left
humerus ; stained by picro-carmine. —Mary F-. Scirrhus
of lefb breast, with brawny ojdema of arm. Same appear¬
ances as in the preceding.
Case 10. Thin sections of seventh cervical vertebra, infil¬
trated by schrhus of mamma; logwood stain. —Martha
S-, aged forty-one. In April, 1888, the lefb breast was
excised for a scirrhous growth, noticed for preceding ten
months. In September, 1889, readmission into hospital
with a mass of glands above the left clavicle, infiltrated
and fixed; some axillary reappearance and an ill-defined
fulness over the sixth and seventh cervical vertebra). The
symptoms mainly consisted in progressive weakness and
paraplegia. For several weeks before death (in October,
1889) there were incontinence of urine and fmces and also
marked cerebral derangement (dementia). The vertebrae
in question were found decalcified and infiltrated, with
scirrhous cells of typical acinar distribution. No distinct
tumour was produced. (No. 1684 in the Pathological Cata¬
logue of the College of Surgeons’ Museum, vol. ii.,
part 4, is a somewhat similar specimen of secondary
vertebral deposit with mammary carcinoma, also without
tumour formation. The Museum of St. Thomas’s Hospital
contains an example of the same occurrence.)
ON THE
USE OF PETERSEN’S EECTAL BAG AS AN
AID IN SOUNDING FOR STONE AND IN
LITI-IOTEITY WHERE THE BLADDER IS
POUCHED OR SACCULATED.
By EEdINALD HAERISON, F.R.C.S.,
.SUIIGISON TO S'f. I’ETEU’S HOSPITAL, LONDON.
Where the prostate is large and the posterior wall of the
bladder considerably pouched or sacculated, as is often the
case, it is not always easy to bring the point of a metal
sound in contact with a stone which may thus be concealed.
In this way a stone often escapes detection, whilst the
searching for it, by r( 2 B 8 on of tlie elevation of the floor of
the prostate, is nob only thus rendered futile, but at the
same ,timo is frequently an extremely painful process. In
the same way during lithotrity fragments of stone may
become trapped in^hese spaces, and lead to the persistence
of cystitis and tlie formation of another calculus. I have
found the use of Petersen’s rectal bag distended after
its introduction into tlie bowel with two or three ounces
of water extremely useful in turning out sacculated
stones into the larger cavity of the bladder, and in pre¬
venting the lodgment of fragments during a lithotrity.
By this means the depressed posterior wall of the bladder
is brought up almost on a level with the prostatic
urethra, thus facilitating the movement of sounds and
other rigid instruments, and at the same time tending
to turn any sacculation that may exist in this part with its
contents, so to speak, inside out. I have tested these
points now on several occasions. About the time I was
making some observations bearing upon this point I was
seeing a patient from whose bladder on two occasions, at
short recent intervals, I had removed phosphatic calculi
of small size. The prostate was large, there was a con-
Di zodbv''- fcOO^lC
598 The Lancet,]
DR. JAMES B. BALL ON NASA.L IRRIGATION.
[March 14, 189L
siderable amount of residual urine requiring the use of the
catheter, and the posterior 'wall of the bladder was pouched
and irregular. As the relief,following each of these
operations was only very temporary, and the urine was
most offensive by the large amount of blood and muco-pus
it contained, it seemed probable that there was more
calculus in the bladder than could be got at in the ordinary
way, and I thought it likely that some form of cystotomy
which would admit exploration of the bladder with the
finger with subsequent drainage might yield more per¬
manent results. Wishing to avoid this, and considering it
possible that a stone might be lodged in a sacculus, I
introduced Petersen’s bag, as used in supra-pubic cystotomy,
and turned out into the general cavity of the bladder a
phospbatic stone, having a diameter of an inch and a half,
which was readily crushed and evacuated in the ordinary
way. The ease with which the manipulations both with
the lithotrite and the evacuating catheters were carried on
compared most favourably with the two previous occasions.
It is now nearly four months since the last operation; the
patient remains quite well, and the urine is normal.
Previously to this last operation the patient could not
sit down with any comforc, by reason, I presume,
of the pressure of the fixed stone on the prostate.
He can now dispense with the catheter, and as the
amount of residual urine does not exceed an ounce,
I conclude the sacculation, having once been properly
emptied, is becoming less. However, he takes the precau¬
tion of washing out his bladder every day with an anti¬
septic. I do not see how I could otherwise have removed
this stone without opening the bladder, or without the use
of the lithotrite in a manner which I should deprecate.
Lower Berkeley-street, W.
A NEW METHOD OF NASAL IRRIGATION.
By JAMES B. BALL, M.D., &c.
Whatever difference of opinion there may be as to the
amount of direct benefit which medicated fluids are capable
of producing, by being brought in contact with the mucous
membrane of the nasal passages, there is no room for
questioning the importance of cleansing the passages of
secretions in every disease in which these tend to accumu¬
late, and more especially if there be decomposition and
fetor. For the purpose of cleansing the nasal passages
and the naso-pharynx a tepid alkaline lotion is generally
preferred, with or without some antiseptic ingredient.
Various modes of applying such iluid are in use, such as
the spray apparatus, some form of syringe, and the nasal
douche. There is no doubt that a band-ball spray apparatus,
throwing a powerful coarse spray, is, when properly used,
an elhcient means of cleansing the nasal passages in many
cases, and it is free from some disadvantages attending
other methods of irrigation. Where, however, there is
much viscid or inspissated secretion to remove, it is de¬
sirable to pass a stream of the lotion through the nasal
passages, so that it may enter at one nostril and,
passing round the naso-pharynx, il6w out at the other.
The method in general use for this purpose is the
ordinary nasal douche, and with certain precautions it
is a sate and eOicient method. Unless these precautions
be observed, there is some danger of forcing the lluid into
the Eustachian tube, or into one of the accessory sinuses,
and thereby setting up trouble in these regions. We
also find that in many people the contraction of the soft
palate, whereby the naso-pharynx is cut off from the lower
pharynx during the passage of a stream through the nose,
is by no means so continuous and complete as is necessary
to prevent some of the fluid from passing downwards, leading
to fits of coughing and choking. I have met with persons
who, even after much practice, were unable to use the nasal
douche with comfort and efficiency.
I was impressed with a description of a simple and
ingenious method of nasal irrigation, devised by Ur. IMns
of Vienna, which appeared in the Wiener Medicinisehe
Wochemchrift of April 19th, 1890, and I determined to
ive it a trial. Dr. Pins describes his method as one
y which a stream may be passed through the nose and
raso-pharynx, with not too great force, and by which
the naso-pharynx is easily and effectually shut off from
the throat below. The apparatus consists of a bottle
of suitable size, fitted with an indiarubber cork, through,
which pass two glass tubes of unequal length. The longer
tube reaches to the bottom of the bottle, and is furnished ah
its upper end with an olive-shaped nozzle to fit the nostril.
The shorter tube does not quite reach the upper surface of
the lluid, and its upper end is bent to form a mouth-piece.
The patient takes the mouth-piece between bis lips, while
the olive-shaped nozzle is filled into one nostril. He then
blows into the bottle, with cheeks distended, and the fluid in
forced up into the nose, and fiows out at the other nostril.
With short pauses for respiration, in which he takes in a
full inspiration, a pint or more of iluid can be passed through
the nose in a few minutes.
It is known that when one expires forcibly, with the
mouth closed and the cheeks blown out, the soft palate ia
firmly contracted and shuts off the naso-pharynx. In using
this apparatus tlie expiratory force meets the resistance of
the fluid in the bottle, and is sufficient to force it through
the nose. At the same time the force with which the fluid
enters is not excessive, and not likely to cause trouble.
The shutting off of the upper pharynx is very effectual, the
soft palate being strongly contracted and its under margin
firmly applied to the posterior wall. The Eustachian is
also thereby kept closed, and fluid is prevented from
entering it.
I have for some time past used an apparatus (see engrav¬
ing) constructed at my suggestion on Dr. Pina’s principle by
Mr. Basdon (Carr and Co,, 171, High Holbovn). I hava
uniformly found that patients use the apparatus with great
ease from the first. There is none or tbe choking and
coughing which I have so often found with the ordinary
douche. I can confirm Dr. Pine’s statement that children
very readily learn to use it. Obviously if either nasal
passage is completely obstructed the apparatus cannot be
used, and if one passage be much less free than the other it is
well to observe the same rule as with the ordinary douche,
and to use the narrower passage for the in-How. The
apparatus can be fitted with a bottle of any size. Hitherto
I have used a IG-oz. bottle, which nearly always contains
a sufficient quantity for any one application. In many
cases this quantity is sufficient for several applications,
and the lluid is wanned by standing the bottle in hot
water each time before use.
Wimpole-street, W.
Leeds General Infirmary.—A highly satisfac¬
tory report was submitted to the annual meeting, held on
tfaefibhinst. The receipts amounted to £19,094, and the
expenditure to £20,458. The in-patients treated were .5200;
and the out-patients 26,585; 784 in-patients were trans¬
ferred to the Ida Hospital during the year. The average
daily number of beds occupied was forty. With reference
to the extension of the hospital, for which nearly £81,000
had been promised by the public, the estimates for the work
exceeded the amount originally calculated, but tenders,
amounting altogether to £32,000, had been accepted. To
complete, however, the cost of building and furnishing, a
further sum of £7000 will have to be provided. The build¬
ing is making rapid progress, and it is expected some
portion at least may be ready for occupation within the
next twelve montbp.
Digitized by Google
Tub Lancbt,]
HOSPITAL MEDICINE AND SURGERY.
[March 14, 1891. 599
% llirrflr
OF
HOSPITAL pkactice;
BRITISH AND FOREIGN.
Nulla auteiQ oat alia pro certo noacendi via, nlal quamplurlmasetmor.
borutn et diaaecMonum hiatoriaa, turn alionim turn propriaa coUeotaa
loabere, et inter ao comparare.—M oroaoni De Sea. et Cam. Morb.,
Siib. iv. Procemium. • ■ ■■
SOUTH DEVON AND EAST CORNWALL
HOSPITAL, PLYMOUTH.
3'’RACTUEB OF STERNUM, LEFT CLAVICLE, AND SEVERAL
RIBS, DISLOCATION OF SCAPULA ; RECOVERY.
(Under the care of Mr. W. Square.}
The occurrence of multiple fractures such as those de¬
scribed in this case is very rare, even as a consequence of
severe and rapidly fatal injury. Generally a hopeless
j>rognosi8 would be given, for fracture of the upper ribs is
dangerous on account of the important structures adjacent;
and fracture also of the clavicle and of the sternum in the
same patient implies an amount of shock from which few
could rally. Por the following notes we are indebted to
Mr. W. Gifford Nash, house surgeon.
W. C-, aged forty-five, a navvy, was admitted on
Jan. 7fch, 1891, with a history that whilst at work about an
hour previously a ton of frozen earth fell on him, crushing
liis chest. Half an hour was occupied in extricating him.
When admitted he was very collapsed, the pulse only
just being perceptible. There was great duliculty of
Breathing. The upper half of the left side of the
chest was much damaged, it felt like a bag of bones,
and Happed in and out with respiration. Tliere was a
slight amount of surgical emphysema in the left
clavicular region, and a large effusion of blood. The
sternum was broken transversely about the junction of the
manubrium and gladiolus. The left clavicle was broken
■one inch from its sternal end, and at its outer end the liga¬
ments were torn, so that the scapula was dislocated below
it. The four upper left riba were broken near their junction
with the sternum, and also near the anterior axillary border.
The chest was at once firmly strapped horizontally and ob-
iliqnely over each shoulder, so as to fix the clavicles. The left
arm was bandaged to the side. For the first few days there
were great dyspnoia and collection of mucus in the air tubes.
Carbonate of ammonia and twelve ounces of brandy daily
were given, and morphia occasionally to relieve pain and
produce sleep. The effect of the morphia was very bene¬
ficial, as during the day there was great dyspncca, but, as
eoon as morphia produced sleep, the breathing became quite
tranquil. A catheter was required for a fortnight. At the
end of three weeks the strapping was changed, and at the
■end of five weeks omitted. There was then firm union of
all the fractures, the acroinio-clavicular joint was in perfect
position, and the movements of the left-arm perfect. The
patient i.s now quite well.
Remarks .—This case at first seemed quite hopeless, and a
•very bad prognosis was given. The firm strapping gave
great relief and kept the very movable fragments at rest.
The beneficial effect of the morphia in relieving the dyspncca
was a marked feature of tlie case. The perfect position of
the acroraio-clavicnlar joint after dislocation is also a satis¬
factory result.
CHALMERS HOSPITAL, BANFF, N.B.
REPORT OF CASES UNDER DR. KOCH’S TREATMENT.
(Under the care of Drs. Fergusson and Dingwall )
The following series of seven coses in which tubercular
disease was present gives the result of treatment by the
method of Dr. Koch, and forms an interesting addition to
the evidence as to the value of the treatment. In each the
effect of the injections was marked, and in some the ulti¬
mate result was most satisfactory. Wo hope to be able to
report later that the improvement was permanent.
CASli 1 . Hip joint disease. —W. S-, aged seventeen, a
boatbuilder, was admitted on April 2nd, 1890. The disease
bad lasted since childhood. On admission there were nume¬
rous sinuses over the region of the left hip-joint, from which
there was a profuse discharge. The femur was dislocated
upon the dorsum ilii, and aukylosed. The patient was treated
with complete rest and generous diet, but little improve¬
ment resulted. On May Ist the sinuses were thoroughly
laid open, and scraped with Volkmann’s spoon. They did
well for a time, but gradually returned to the old condition.
They were again operated on on Oct. 3rd, and for a time
I promised to do well, but when the first injection was made
I (Dec. 28bli) the discharge was profuse, and there were as
many as eight sinuses. Between these lay raw patches
■ with the characteristic tint of tubercular wounds. Tem¬
perature before first injection had been normal for several
weeks. The patient was in fairly good health. He suffered a
considerable amount of pain when the affected limb w'as
moved.
Treatment .—From Dec. 28 bh to Feb. 20th he received
thirty-one injections. The first was 0'0025 gramme, and
the last OT gramme, the latter injection being repeated
several times. The reactions have been very variable,
the highest being after the second injection (0‘0045),
when the temperature rose to lor, and the pulse to 108.
There have been reactions with all the injections except
the fourth, sixth, tenth, and the last four. There have
been few general symptoms. After the first injection the
patient had slight frontal headache, and nine hours after he
was sick and vomited. He has felt somewhat dull and heavy
after several of the injections, but suffered no further incon¬
venience. Locally there was a marked reaction after the
earlier injections. For about two inehesaround the wounds th^
skin took on an erysipelatous look, and the discharge from the'
sinuses became more profuse. Here and there at the edges
of the wounds appeared gelatinous-looking nodules, which
gradually broke down and disappeared, leaving a healthy,
raw surface. He felt the parts hot and burning during the
reaction, hut afterwards the parts felt easier than before.
After tho later injections there has been very little local
reaction, and the discharge has now almost ceased. The
wounds are now reduced to about one-fourth their original
extent, and there is but one sinus an inch in depth. The
w'ounds have not made the same progress lately as they did
atfirsb, but they continue to improve. Patient expresses
himself as feeling inuclr better and stronger. He has now
no pain at the hip, and can lie on the affected side and
move the leg, which he could not do before. He has
gained fiesh considerably, and has lost the careworn ex¬
pression he had before the treatment was begun.
Cask 2.—M. C-, female teacher, aged thirty-two,
single. Admitted to hospital on Dec. 27bh, complaining of
cough, expectoration, general debility, and slight night
sweats. Disease of six years’duration. Sputum muco-puru-
lent, and containing numerous tuberclebacilli. Sputum three
ounces daring twenty-four hours. Cough at times severe.
No hasmoptysis. Her sisterdied of phthbis. On the anterior
aspect of left infra-clavieular region there was much flatten¬
ing, diminished expansion, little or no vesicular murmur to
be heard for the numerous moist sounds present during the
whole respiratory act, the crepitations being largest betsveen
the first and second ribs. Same condition, but not so pro¬
nounced, in supra spinous region. Breath sounds fairly
normal in lower parts of lung. Breathing at right apex
slightly harsh, but no moist sounds. Temperature for two
days before treatment normal.
Treatment .—From Dec. 30th to Feb. 20th .she has had
thirty-five injections. Marked reactions have followed the
third, sixth, seventh, and ninth, the temperature rising to
101 '2“ after the sixth, and the pulse to 101, but latterly
the symptoms were less marked. There have been but
slight reactions following the tenth and remaining injec¬
tions. After the first injection patient felt veiy dull and
heavy, and inclined to sleep. She had also headache.
There were a few streaks of blood in tlio sputum on the
second day after the first injection, but none have appeared
since. The first injection waa O'OOl gramme, and the last
0‘1 gramme. Although after several of the injections the
general reaction was slight, still, as far as one could j^udge by
auscultation, a local reaction had taken place. This was
evinced by diminished respiratory sounds and increase of the
moist rillea, although not to nearly such an extent as
previously to treatment. On the day following the injection
the sounds were again dry and harsh. The natural respi¬
ratory murmur extends higher up than it did before treat¬
ment. She can now lie with esse on the affected side,
which she could not do for several years before treatment
G lo^ie
600 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Maeoh 14,1891.
was commenced. The sputum is now reduced to three
drachms, and bacilli con only be detected with diiliculty.
Very few moist sounds of any kind are to be heard, but
.there is loud, harsh, bronchial breathing, along with a
creaking noise which seems to be superficial. Dulness less
marked, not so extensive. Patient thinks herself much
stronger than on admission, and is now gaining flesh. She
is up and moving about the hospital, but not out, owing to
coldness of weather.
Case 3. Lupus of face. —W. R-, female, aged thirty-
nine, was admitted to hospital on Deo. 29th. Tlie disease has
lasted for twenty years. Began as a small patch on right
cheek, and has gradually spread over the whole of both
cheeks, nose, lips, and left side of chin. Parts of tiie
cartilages of the nose are eaten away; they have been
scraped several times with little or no permanent benefit.
General health fairly good. No chest symptoms.
Treatment. — The patient has received eleven injec¬
tions : beginning with 0*003 gramme, and the last injection
0-07 gramme. The first reaction was well marked; the
temperature of the fifth reached 101'4®. Pour hours after
the injection the patient complained of oppression in the
chest, with slight cough, and a little later she was sick
and vomited. The local reaction was very marked, pre¬
senting the usual well-known appearances. On each cheek
is a large, thick, yellow scab; that on the left cheek is
of considerable thickness, and is beginning to separate.
From below the scabs there is a considerable muco¬
purulent discharge. March 7bh: Scabs removed ten days
ago, leaving raw surfaces, which have now entirely healed
under boracic acid ointment. This patient is much im¬
proved, hut there are still tubercles studded about.
Case 4. Lupus of face and leg .—C. G-, aged twenty-
two, female. Disease of thirteen years’ duration, and
began as a small, hard nodule on the right cheek. Face
has been blistered repeatedly, hut never scraped. Admitted
Dec. 31st. Patient in very good health. Chesi) normal.
Both cheeks, nose, and chin are affected. There is also
a large quiescent patch on the posterior aspect of the right
ankle and a small patch on the back of the left shoulder.
Towards the centre of the alTected parts the disease seemed
quiescent, while towards the edges tubercular nodules
could be seen and felt. The disease also affected the
gums, roof of mouth, uvula, and tonsils, these being
red and granular. Part of the uvula had been eaten
away.
Treatment. —On Jan. 2Dd she received a first injection of
O’OOSgramme. An hour after the injection the temperature
fell to 96'4%and then began to rise. In eleven hours it reached
a maximum of 102‘2“, with pulse 108. It kept as high as
102 ® for fourteen hours, when it gradually fell to normal.
On the day after the injection a measly rash appeared over
her chest and back. It lasted for about twelve hours. Tlie
local reaction was very marked. The gums were veiy red
and swollen, and the patient complained of feeling her
teeth “loose.” The nodules have disappeared considerably,
but are still present, and the diseased parts are, with the
exception of the nose, now quite on a level with the
surrounding healthy skin. The last injection, given on
March 4th, was 0'4 gramme, the largest dose by far yet
given at this hospital. In this case no raw surface lias
been caused, but a great deal of whitish scaly debris has
been thrown off. The affected mucous membrane now
appears quite normal, and shows no reaction after injection.
The patch on the ankle has several times become slightly red,
but lately has shown no change, and looks quite cured ; no
tubercles whatever discernible.
Case 5. Pulmonary phthisis .—J. W - ■, female teacher
aged thirty-eight; no family history of phthisis. Ad¬
mitted Jan. 3rd, complaining of cough and expectora¬
tion. She has also been much troubled with dyspnma.
She has been under Dr. Fergusson’s observation for
five years, during which time the physical signs liave
shown very gradual though intermittent extension of
the disease. On admission she was much thinner than
she had ever been before. The temperature has never
been high, even at night. She was most anxious to try the i
treatment, as she felt herself gradually becoming weaker.
Bacilli were found in the sputum. On examination flatten¬
ing and diminished expansion of left side in infra-clavicular
region were found, dulness well marked down to fouvbli
rib, and in supra-spinous fossa behind. Tubular breathing
over infra-clavicular region, with cavernous breathing
between first and second ribs. Large and small moist
sounds over the whole of the same area. Harsh breathing
at right apex, with occasional moist rales in supra-spinous*
fossa. Diminished respiratory murmur in lower lobe behind
on left side. Otherwise the chest sounds were fairly normal.
Treatment. —She has received thirty-three injections,,
ranging from O’OOl gramme to 01 gramme, the last being
repeated ten times. The highest reaction has been after
the fourth injection, when the temperature rose to 100'6®.
She has shown no general symptoms beyond feeling some¬
what dull and heavy after the injections. Sputum on
admission was four ounces and is now six drachms. No-
marked change lias taken place in the pliysical signs, but
the dyspncca lias been entirely relieved, the patient herself
saying that it is now a pleasure to breathe compared with
what it was before admission. The cough is also much
relieved.. This patient still reacts to 0-1 gramme, her
temperature being normal the intervening two days, and
rising to about 100® on the day of injection. She is up and
v’alking about the corridors.
Case (5. Lupus of hack and nose .—A. M-, single, aged
forty, fishwoman. Disease of fourteen years’duration. First
appeared as small nodule on the hack of the left shoulder, and
has gradually spread since. It has never been quite whole-
on the back. About five months ago a small nodule appeared
on the right ala of the nose. This shortly after broke*
down, forming a small ulcer. Admitted Jan. 17th, in good'
health; chest normal. On centre of right ala was a roundish-
deep, ulcer with pouting edges. At the edge of the right-
nostril was a slight erosion not so deep as the former.
Around these were several small bard nodules, and the-
surface around them had a red appearance. The redness-
also extended for about an inch and a half upon the right
cheek. Over the whole of the back of the left chest were-
seen old scars, white and seamed, and over the supra¬
spinous region of the same side was a reddish surface about-
the size of the palm of the hand, with a small active patch
towards its outer edge. Over the right shoulder and extend¬
ing downwards upon the deltoid region was seen a similar
scarred appearance with two active patches.
Treatment.—T \\q patient has received thirteen injections,,
the first being 0'003 gramme and the last 0-07 gramme.
Little reaction followed the first three, but marked reactions
were got with the fourth, fifth, and sixth. There wa&
slight local reaction after the first three injections, but
after the fourth the affected parts on the nose became much
swollen, and the surrounding redness more intense. The-
ulcer became quite filled up with a brown scar. The active
patches on the back and shoulder also became red and con¬
gested, but have now ceased to react. The nose is much-
improved, and shows but slight reaction.
Case 7. Pulmonary phthisis.—V. L-, aged twenty-
five, admitted Jan. 22nd. No family history of phthisis.
His first illness was in the spring of 1887, when he had a bad'
cold, and spat up a little blood in the morning for a few
days. In Sept. .1887, he had severe haemoptysis, and con¬
sulted a medical man, when perceptible signs of disease in
the right apex were found. On the doctor’s advice he went
to South Africa, but returned in June, lvS90. He had no-
bad symptoms whilst in Africa. On admission the physical
examination showed dulness in the tight infrn-claviculai
region, but no difference could be seen on inspection. The
breathing in the same region was bronchial, but there were-
no moist sounds. Bacilli were found in the sputum.
Treatment .—Patient has received nineteen injections,
the first being O'OOl gramme, on Jan. 2.3rd, and the last,
O'l gramme, on Feb. 20th. Hohos never felt any dillerence-
from the injections, except that after the eighth
(O'Ol gramme) he had slight difficulty in breathing with
inclination to ait up for relief. On auscultation after this
injection fine moist sounds were heard for the first time,,
but these could not be detected three days later. After
the tentli injection he had slight cough but no expectora¬
tion. The temperature has never been high ; after the
tenth injection it rose to 100'2°, then fell to normal, and
next day rose to 100'6“, which has been the highest
reached. Since the fourteenth injection there has been no
reaction at all. On physical examination it is now im-
ossible to detect any difference between the two sides
eyond a slight difference in the percussion note. _No
bacilli can now be detected in his sputum. This patient
left as “cured” on March 7th.
Besides these coses, there are at present six cases of
phthisis, three of lupus, and two of tubercular disease of
femur under treatment, but they have not been sufficiently
long under treatment to render a report on their progress-
of sufficient interest for publication.
v_jv>Ogiv_
The Lancet,]
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
[March I4, 1891. 601
ROYAL MEDICAL & CHIRURGICAL SOCIETY.
Aiinual General Meeting.
TiiJC annual general meeting of this Society was held on
Mai'ch2nd, therresident, Mr. Timothy Holmes, inthechair.
The minutes of the last annual meeting having been read
and approved, the report of the President and Council,
•together with the financial statement, were presented.
The latter had been duly audited, and showed that th#
giecuniary position of the Society was satisfactory. The
jiermanent endowment fund, which had been established
only a little ovet twelve months, had received some sub¬
stantial additions. The President then moved that the
alterations in the by-laws proposed by the Council be
adopted. They were, for the most part, purely technical,
and had become necessary owing to the altered circum¬
stances in which the Society found itself. On the ballot
being taken, they were declared duly carried. He then
delivered his annual address, to which allusion will be
found in our last week’s number. A vote of thanks for this
was proposed by Sir Edwin Saunders, and seconded by Mr.
Thomas Smith, who alluded to the desirability of de¬
veloping the Society in a social direction. The President
having been thanked for his gift of a magnificent table for
•the meeting room, and the usual votes of thanks having
been accorded to the retiring ollicers of the Society, the
meeting adjourned. The following were elected to serve as
■officers during the ensuing year president: Mr. Timothy
Holmes. Vice-presidents : Drs. J. Langdon Down, George
Harley, and Messrs. Howard F. Marsh and Alfred Willett.
I Treasurers : Dr. Charles John Hare and Mr. John Ashton
Bostock. Honorary secretaries : Dr. Frederick Taylor and
Mr. J. Warrington Haward. Honorary librarians: Dr.
Samuel Jones Gee and Mr. John Whitaker Hulke. Mem¬
bers of Council : Drs. Walter Butler Cheadle, W. R. Gowers,
Norman Moore, John Williams, George Vivian Poore, and
Messrs. William Harrison Cripps, Charles N. Macnamara,
Henry Walter Kiallmark, Herbert William Page, and
Knowaley Thornton.
as it is in heaven. Give us this
ah eet tee ea ahyah. Yee abtsee deesee
clay our daily bread,
dali ah dahdl bahdi.
Forgive us our tvespasaes, as we
Dosoyoe (os as in hero) ahaee aliee sahpeedee, ah yee
forgive those who
dosoyee (os as in hero) do (hero) u (as in frugality)
trespass against ' us. Lead us
sahpeo ahdalithd (hero) alisee. Leedt ahsee
not into temptation; but deliver
out (ou as in loud) eeto (hero) taliptahsi; baht deeSdl
us from evil:
ahsoe soum (on as in soul) oeew (ew as in Matthew):
For ' Thine is the kingdom, the
Soud (ou as in soul) Dabdl ee dee teedo (liero), dee
power, and the glory, for
pardi, ahd dee doudi (ou as in loud), so (hero)
ever and ever. Amen,
ahyah alidl ahyah. Ahyah.
Robert J. P. P-.
(а) The alphabet. Unless otherwise stated the letters
have their usual value.
a bedef g h
ahsee b c gee o f dzee aisee (a as aye, i as eye)
i j klinnopq
oee (a as aye) zaee (a as aye) kee 1 m n o p q
r 8 t u v w
ah eos koe ?i (u as in frugality) wee dalibeeyew
X y z.
us y z.
(б) The Lord’s Prayer. (The words are spelt the same
when he pronounced them as ordinary persons do.)
Our Father, which art in heaven,
Ah Fahweo, wis aht eo eewee,
hallowed he Thy name. Thy
halidoe be Di (i as eye) nahlin. Di (eye)
kingdom come. Thy will be
keedOm (o as in got) come. Di (eye) wiSII bo
done ii« earth, as it is in
Igahd ee of, ahsee eot ees ee
Idioglossia.
An ordinary meeting of the Society was held on March
SOth, the President, Mr. Timothy Holjnes, in the chair.
Dr. Hale White and Mr. Golding- Bum described two
cases of Idioglossia. The patients, who were brothers, were
thought by their parents to be sufl'ering from deaf-mutisui.
This was not So. They heard well, and expressed them¬
selves in articulate sounds. The sounds were unlike those
of any known language, but the same sound was always
used by the same child to express the same word. Each
•child bad thus a language of its own, and consequently the
:authors had (at Dr. Perry’s suggestion) named the condition
■“idioglossia.” The elder sister of these boys was slightly
affected. All the children were remarkably intelligent,
and could read any book, understanding what they read,
■and writing English correctly. There was no observable
physical defect; one of them was left-handed. There wore
'traces of insanity in the family. The treatment adopted
had been careful training, and the boy who had been
longest under treatment showed marked improvement.
•Owing to the kindness of the Edison Phonograph Company
the authors were able to show the phonograms of the
children, taken before any treatment was adopted. These
•exactly reproduced the original speech. The following
tables show the speech recorded phonetically :—
Alfred I'-.
(a) The alphabet. When not otherwise indicated the
fietters have choir usual value :—
a b c il e f g h i j Ic 1 in
ah b (5 il 0 ahth yeo alwoo ah eeyah tali alU ahni
no p q r B t u
•ahill u (as in frugality) p t« ah ahsoo t u (a.s in few)
V w X y z.
.yoe dahbuyew aJit eoynh yahdill.
'((>) The Lord’s Prayer :—
hoaven. Give us this day
eewoe. ZwivI (first i as eyo) ahsoo dls gaoo (a as aye)
our daily liread. Forgive us our
alieo gayeo (a as aye) bCd. Forgive ahsee ahee
trespasses, as wo forgive tlioae who
salipoesees, alisoe we forgive dosoe (o as in iiero) who
trespass against us. Lead
sahpis agaoosee (botli a’s as aye) ahsee. Eedee
us not into temptation;
ah.soe not oekew (ew as in Maltliew) keekasOm (a as aye);
but
doliviii'
us from
evil:
For
baht
geewue
aliseo vuiu
eewH
For
Tliiiio is
the
kingdom,
tire
power.
Dalteo is
dee
keadou (on as in loud),
deo
pahdl,
aud tho
glory,
for
over
and
aiul dee
gori (or as in aiiclior),
for
oewoo
ahd
over.
Amen.
eewee. Ahuiou.
Dr. Frederick Taylor reported a case of Defective
Articulation similar to those communicated by Dr, Hale
White and Mr. Golding-Bird. The patient was eight years
and a half old, and had no physical defect beyond a very
slight arching of the palate. Ho bad three fits at the age
of eight months, and had measles and scarlatina at four
years. He had never talked properly, and when he came
first under observation was almost unintelligible. He,
however, understood what was said to him. could read little
words, and could write in a child's round hand. When he
first came under notice his pronunciation of many con¬
sonants, especially p, t, k, s, was defective, and he added
the syllables “Ida ” and “ odd” to nearly every word that
he spoke. He had been submitted to a modified oral in¬
struction, and was after some months much better. His
E rominciation, of two kinds, of the Lord’s Prayer, on
loc. 20th and Feb. 3rd, was shown
Our Ifatlior,
whicli
art
in
Iieaven,
Our
Father,
wbicii
art
in
heaven
Ah .Siihyeo,
yeo
aliLeo
00
aiiyah,
Doc. 20th.—Oiiarda
Favada,
id
ai'da
a
balda,
fiallowed bu
Thy
name.
Tliy
Icingdom
Feb. 3rd.— Oner
Faanla,
wo
ad
a
evven,
f.iaiiiK, (o as in horo) 1)l'o
Dah
all.
Dah
tclO (o as ill hero)
Hallowod
bo
Thy
name.
rome. Tliy
will
lie
done
in eiirtli.
Doc. 20!.li,—riowimla
boda
Adavda
iloiio.
torn (o as ill son). Dali
yoo
boo
dali
ee aiilseo,
L Fob. 3i'(l.— Alloi'da
bo
Tliy
namo.
w
Digitized by
Google
602 The Lancet,]
MEDICAL SOCIETY OF LONDON.
[Maech 14,1891.
The author re^rarded this as mainly a defect of articulation,
the centres for which might he regarded as less apt for
education than those of average individuals. The patients
wore shown and made to spealc out loud, and hy means of
the phonograph their speech both before and after treat¬
ment was demonstrated for comparison.
Dr. Pye-Smith agreed with Dr. Taylor in doubting if
idioglossia was the best term to employ in describing this
affection. It was not a peculiar language, but only a per¬
version of one which was-no'> peculiar. It was only
English imperfectly pronounced. The recognition of the
peculiarities of pronunciation would have been easier if the
authors had adopted a more consistent method of notation.
The vowels were difficult to be sure of, but the method or
pronunciation of the consonants was not widely diiferenb
from the imperfect English spoken by children. The pre¬
fixing of an initial vowel was peculiar, but it was common
in the language of the South Sea Islands, and it also
occurred in old French. As to the curious suffixes, these
S eculiar terminations of words were to be found in the
iexican and even in the Italian languages. If the initial
and terminal syllables were omitted wiat was left was
practically English “baby language.” He thought that
the explanation bore on the question of general develop¬
ment and philology rather than on peculiarity of organs.
It was not a wane of power in the instruments of speech or
in the central organs, but was connected rather with the
imperfect speech of children learning to talk, of idiots, and
of foreigners, and it perhaps bore some relation to
“ aglossia,” a term he applied to the condition of foreigners
who came to England, did not properly learn English, and
forgot their native pronunciation. The interest in them
therefore was physiological rather than pathological, and
as to therapeutics, the efforts of those who had tried to
instruct these cases were to be admired.
Dr. Hadden had met with three cases of this affection
during the last eighteen months ; they were all of the same
kind, all intelligent, with no defect of the palate and with
normal hearing. He showed one of them, a boy eiglit years
of age, who spoke before the meeting. He was slovenly in
ending bis words, and would sometimes transpose letters at
the end. Another boy was much worse and made but little
attempt to form words. He agreed with Dr. Pye-Smith
that tne alphabet was not a good teat; there were in all
about fifty elementary sounds, and an endeavour should be
made to find out which of these were impossible of
pronunciation. It was noteworthy that in one of the cases
he had published, when the boy was asked to write to
dictation, he would begin all right, and then would go on
to write up and down strokes with no meaning, or would
write words which would suggest the language be usually
spoke. Some of these patients if speaking deliberately
would pronounce well, out if they attempted to speak
quicker they would get confused. 'He thought that much
of the language that children learnt was acquired by the
oral system, the mother deliberately pronouncing the words so
that the child could see the mechanism. Some letters, such
as g, j, q, and w, were difficult, and were acquired later,
because the mechanism of their pronunciation was con¬
cealed. He doubted if these cases were simply instances of
persistency of infantile blundering, but they were very like
it. In none of bis cases could the patients trill the r. The
association of left-handedness was worthy of being borne in
mind. There was probably no gross change in the brain,
and the chief success of the treatment was due to the
corapletenees of the isolation.
Mr. Spencer Watson said that though deaf-mutiem
had been excluded in these cases, yet there might be some
defect of the sense of hearing short of deafness, and in this
condition certain labials and dentals would be difiicult to
distinguish. The condition, therefore, would be somewhat
analogous to errors of refraction and would bo diminished
by education. He suggested that imitation might account
for part of the peculiarity, and that in one case, at least, the
obstruction in the naso pharynx by adenoid vegetations
acted as a causative factor.
Dr. Wilks considered the condition a defect rather of
speech than of language; to suppose that children could
invent a language of their own was diHicult to believe; it was
merely a modification of an ordinary known language. Hut
now and then the defect might be deeper; he had seen four
cases of children who had never spoken at all, though they
were otherwise intelligent. He referred to the case of a
boy, the child of French parents, who went to an English
school and spoke English well; though he thoroughly
understood French he could not speak a single word o?
it. When a man was drunk, though his expressions,
were indistinct, he believed that he still followed a rule
of speech.
Dr. Langdon Down had had a great deal to do Avith
non-speaking children, but they were mostly of feeble in¬
tellect. The cause he thought in the present cases was a.
defect of hearing, and the eftect of the therapeutics pointed
in the same direction. He bad known of one case to which
the term “idioglossia” could perfectly correctly be given; it
was that of a girl who spoke a gibberish language of her-
own, though her sisters could translate it for her to other
people.
Dr. Matiieson, as the result of examination of a large-
number of cases of defective articulation,, came to the con¬
clusion that there were usually two elements present: a
neurosis, such as insanity or hysteria, with some nasal or-
pharyngeal obstruction as the exciting cause. Very slight-
causes such as acute or chronic rhinitis were efficient.
Dr. Hale White, in reply, said that the name proposed-
had been recommended to him by Dr. Perry as the most
suitable. Whether the peculiarity constituted a language-
or not was merely a question of degree, for many languages-
were only slightly diflerentiated from one another. Tli-e
point was that each of these children had its own languagCi
which was peculiar to each of them. The condition was
distinct from defects of speech, such as that in general
paralysis, where patients who were once correct were now
defective. The view he put forward was strongly supported!
by Romanes, who had pointed out that occasionally one got
“ sports ” in language. No deficiency of hearing could be-
detected, and if it were due to this the condition should
certainly be commoner. The curious association with left -
handedness took it out of the category of mere defects of
speech; it was something deeper. His patients were-
unable to trill the r. He could not make out that it could
be explained by imitation. There was no condition of nose-
or naso-pharynx which could account for the defect.
Dr. Taylor, in re^ly, said that there was no evidence of
physical defect in his case. It might perhaps be a con¬
genital failure on the part of the individual to make the-
most of bis opportunities of learning the language ; he had
not the same cerebral capacity as bis fellows for articulating
ideas, and in this way proficiency in speaking might
perhaps be compared to the varying proficiency amongst,
diirerent performers on the piano.
MEDICAL SOCIETY OF LONDON.
Adjmrnzd Disctission on Angina Pectoris.
An ordinary meeting of this Society was held oq
M arch 9bh, the chair being taken by the new President,
Dr. Douglas Powel).
Sir JoSEi’ii Fayrer proposed, and Dr. De Havillani>
Hall seconded, a vote of thanks to Mr. Knowsley
Thornton, the retiring President.
Dr. Lauder Hrunton proposed a vote of thanks to tl;e
retiring officers of the Council. This wan seconded by Dr.
Mitchell Bruce, and Dr. Giijjart Smith replied.
Dr. Douglas Powell, in a few well-chosen words,,
thanked the Fellows of the Society for the honour they had-
done him in electing him President.
Dr. Lauder Brun'JON reopened the discussion on
Angina Pectoris. He observed that it was very rare for a
third night to be devoted to discussion in any society, and
the fact that the Medical Society had done so on this
occasion showed its indebtedness to Dr. Douglas Powell
for the admirable paper by which ho had introduced the
subject. He agreed wii.h Dr. Powell and with the otlur
speakers that the subject of angina pectoris should bo
treated on a wide basis. In discussing the subject much
help might be obtained from the analogy pointed out by
Professor Grainger Stewart between the heart and the
bladder. Both were hollow, muscular organs, contracting
and dilating at fairly regular intervals, and expelling liquid
contents. In both slight distension formed a stirnulus to
contraction, but if the distension became excessive it might
cause pain varying in amount from slight discomfort to
extreme agony. The sensation of pain was al ways central, for
it depended on a condition of the brain which might be ex-
Coogle
THK LANtJET,]
MEDICAL SOCIETY OF LONDON.
[March 14, 1891. 603
cited by a peripheral irritation likeadiseaaed joint, but might
exist quite apart from any peripheral disease, as in hysteria.
A mixed condition might exist which was both central and
peripheral, as in the vesical crises of locomotor ataxia, and
possibly a similar condition might occur in the heart.
CJsually distension either of the bladder or the heart not
only caused contraction in them, but through the nervous
system lessened the resistance of the sphincter in the case
of the bladder or of the arterioles in the case of the heart.
Disturbance of this nervous relationship might cause
excessive distension or pain in either organ, apart from
organic disease, giving rise to spasmodic retention or vaso¬
motor angina. 13ut while the spasmodic character of angina
pectoris indicated its nervous origin, it was so frequently
associated with diseased coronary arteries and fatty heart
that these evidently played a great part in its causation.
A.Dglna pectoris might be said to be due neither to high
tension alone nor weak heart alone, but to weakness of the
heart in relation to the resistance it had to overcome, and it
might be brought on either by weakening the heart or in-
creasing the resistance, or both together. In tracing
cut its pathology the analogy with the bladder was
useful. The resistance which the heart had to over-
coQie depended upon the contraction of the systemic
arterioles. Of these there were three subdivisions—
cutaneous, visceral, and muscular,—and the latter was
the most important in relation to tbe attacks of angina.
■One of the most striking symptoms of angina was tbe ease
with which it was brought on by muscular action. The first
effect of this was to prevent the passage of blood through
the muscles and to raise the tension, although afterwards
the vessels of the muscles dilated and tbe tension fell. To
this primary rise Dr. Brunton attributed the occurrence of
anginal attacks on exertion, and their passingolTif exertion
could be continued was, he considered, due to the subsequent
dilatation of the vessels of the muscles with consequent fall
of blood-pressure and lessened resistance. He thought that
‘dtheroma of the coronary arteries was so powerful in causing
angina because it prevented the supply or blood to tbe heart
being increased on exertion as it ought to be in muscles
■generally. The pain of angina he considered to be due to
distension of the heart, and its more common occurrence
in the left than the right side of the heart to be due
to the greater ease with which the tricuspid valves became
incompetent than the mitral when the ventricles became
dilated. Angina pectoris was very rare in children, tub
one case was recorded of a boy of murteen in which there
were aortic regurgitation and mitral stenosis, and another in
a boy of eleven, where there was ossification of the aurieulo-
ventricular groove, conditions which would prevent dilata¬
tion of the mitral orifice and insufficiency of the valves. He
agreed with the previous speakers in regard to the necessity
for the elimination of waste products, and also for restricted
diet in gout, and for the use of iron and arsenic in feeble
heart; but he regarded the nitrites as the most efficient
remedy during a paroxysm, and, on the whole, iodide of
potassium as the most useful in the interval. He showed
a tracing which appeared to indicate that it lessoned tbe
rise of blood-pressure on exertion, and mentioned a case
sllustrativo of its remedial action.
Dr. MiTCHiiLL Bhuch said that he intended to confine
ids remarks to some practical clinical points. He deal,
first with the cases of vaeo-motor angina pectoris. Ho bad
seen some instances of this character, but he thought that
the majority were associated with cardiac lesion. He did not
gather from Dr. Powell what proportion ho considered these
two groups boro'to one another, but in his own experience
oases of simple vaso-motor angina were excessively rare.
The term “ vaso-motor angina pectoris” he ventured to con¬
sider an unfortunate one, and it was apt to be misleading.
An attack of angina was determined not so much by the
vaso-motor condition as by the relation of the state of the
pulse tension to the state of the heart behind it. It was
really a matter of relation between the pressure ahead and
the driving power, and in the great majority of instances it
was the fault of the heart and not of the periphery. If the
term “vaso-motor angina pectoris” were used to express this
condition, it was obvious that it overlooked the most im¬
portant factor in regard to both the pathology and the
treatment. He had not found the pulse particularly tense
in patients with vaso-motor angina; they possessed usually
rather a soft and poor pulse. In aortic cases with angina
the pulse was, as a rule, anything but tense, and in Bright’s
disease the angina only came on when the heart began to
fail. If the heart were carefully examined in most gouty
people there would he found physical signs of some organic
change, not necessarily valvular disease, hut enlargement
with weakness. The typical gouty people who suffered with
angina were men between forty and fifty years of age, who
had led an anxious but not active life, and who, having been
successful, found themselves now entitled to ease wim free
living. Such people soon broke down, and presented signs
of irregular gout, complaining of diarrhoea, insomnia, eczema,
and flying pains. They likewise had palpitation, some¬
times actual angina, and were despondent and nervous, with
a feeble pulse. It was worthy of remark that the first
attack of angina was often associated with a definite act of
over-exertion. In many cases they were stout men who, in
order to counteract their obesity, took to exercise in an ill-
judged way, such as excessive rowing, tricycling, &c., and
in this way strained themselves, and afterwards became
the subjects of gouty heart. It had often been noted that
before an attack of acute gout there was increased pulse
tension, but during this period of increased tension the
patient was better of bis angina. Lastly, the effect of
treatment bore out tbe importance of keeping the cardiac
element well to the front. Under certain circumstances
iodide of potassium was more valuable than nitro-glycerine,
and between the attacks regular gentle muscular exercise
was good, the patient attending strictly to his diet. As to
purges, be agreed with Dr. Ord as to their value, and if in
the treatment of this affection he wore limited to one drug,
he would select blue pill, which acted wonderfully in
irregular gout with angina, though he was unable to
explain its method of action. In massical angina he hod
been struck with the frequency of the small attacks and
with the comparative rarity of the large and severe ones.
The occasional appearance of gastro-intcstinal phenomena
in both gouty ana organic angina should he borne in mind.
He referred to the case of a man aged fifty-six with a weak
heart and an intermittent mitral murmur, who suffered
from attacks of angina both of slight and uf violent degree.
One evening, when walking home on a level road, he was
suddenly seized with increased pain in the chest and in the
left arm. He passed a large motion, became unconscious,
and this was followed by vomiting. The temperature rose,
cough developed, and moist sounds were present over the
base of one lung. He had known of a similarly sudden
development of gastric disturbance in three other cases.
He considered that instances of pseudo-angina pectoris were
deserving of some attention in a debate on the subject.
Dr. Db Havili-and Hall, in speaking of gout of the
stomach, said that Dr. Brinton, in his classical work on
“Diseases of the Stomach,” had pointed out that there was
really no such thing, but that a certain proportion of cases
so called were instances of angina pectoris, while others
were cases of gall-stone colic, and that these two affec¬
tions were often confounded. He himself had collected a
□umber of cases of angina pectoris, and found that two of
them gave a distinct history of gall-stone colic. He had
known of several attacks which had been directly induced
by exposure to cold, and in these cases nitroglycerine
answered particularly well.
Dr. Seymour Taylor said he had been working at this
subject for years past, and he had found that these cases
grouped themselves under three headings: the first class
were those in whom the symptoms were referable mainly to
the cardio-vasculoT system, the second formed a neurotic
group, while the third owned a reflex origin. The majority
of the coses commenced between the ages of fifty and sixty,
at a time when tissue expenditure overbalanced tissue
income ; they were of the male sex, and in the better class of
life. He agreed that the affection was rare in association
with mitral disease, and common in connexion with aortic
lesion. In some instances he thought that the cause might
be a local degeneration of the vessels of the heart wall. He
had seen angina develop in patients the subjects of epilepsy
and assume a form akin to tic; in other cases it was asso¬
ciated with glycosuria, or bowel trouble. As to treatment,
rest he considered the most important thing; nitrite of
amyl should he used with great care and not indiscrimi¬
nately, and he had seen groat relief follow bleeding and
calomel purges. With regard to diet, the patient should he
treated as if he were being trained for an athletic per¬
formance.
Dr. F. Little quoted three cases which illustrated from
a practical point of view some of the points mentioned by
previous speakers.
604 The Lancet,]
WEST LONDON MEDICO-CHIEUKGICAL SOCIETY.
[Matiot 14,1891.
Dr. Douglas Powell, in reply, said that two opinions
seemed to be current as to the nature of the pain—one that
it was due to spasm or distension, and the other that it was
of the nature of a neuralgia. He confessed that to his own
idea the theory of spasm or distension presented the most
attractire features, and the more he thought over it the
more difficult he found it to conceive of the pain as being
of neuralgic origin. The majority of the arguments
eloquently used hy Professor Grainger Stewart against
tension or spasm could with little difficulty be applied with
equal force against the neuralgic theory. He admitted,
however, the difficulty of the objection that the heart some¬
times preserved its equability of action during angina,
though Dr. MacVail’s observations as to the condition of
striped muscle under faradaic contraction to some extent
disposed of this difficulty. He was unable to agree with
Dr. Broadbent and others as to the rarity of mitral regur¬
gitation in angina. He could recall instances of angina in
which mitral lesion alone existed, and he thought that in
the degeneration commencing in elderly gouty people the
mitral valve was usually the first to give way. With
regard to treatment, he gave preference to nitroglycerine
over nitrite of amyl in most instances, and it might be
pushed, with great caution and strict watching, to very large
doses with great benefit. In one instance under these con¬
ditions in the intervals between the attacks seven minims
were given three times daily, and during tlie attack as
much as thirty-five drops repeated at a short interval. As
to the eliminative treatment, all would be agreed, and, on
the question of exercise in purely vaso-motor cases, regulated
exercise according to the constitution of the patient was
often of great value ; but where there was definite disease
of the heart or a definite rise of peripheral pressure, then
the greatest caution should be observed in this respect.
Professor Gairdner of Glasgow, who was unable to be
present at the debate, wrote to say that in the article
he contributed some years ago to “Reynolds’s System of
Medicine” he stated bis reasons for not accepting Noth-
nagel’s angina pectoris vaso-motoria as a true clinical de¬
scription of facts running parallel with Heberden’s angina.
He was at the present time of the same opinion, and thought
the name given a most misleading one. In Heberden’s
angina there was, no doubt, a vaso-motor element super¬
induced as a rule upon organic or structural change.
Perhaps the most curious point about angina pectoris which
bad become known to him since writing his article was in
reference to the claim so generally maintained in France in
almost all dictionaries and mono^apbs, on behalf of a
certain M. Rougnon to have anticipated Heberden in the
description of the disease as a cause of sudden death. He
had dealt with this claim in a note at the end of his article,
and had shown it, he thought, to be quite untenable even
on the secondhand data then known to him, not having
found it possible at that time to obtain access to the original
of Rougnon’s letter to M. Lorry, dated 1768. The letter,
indeed, was rather difficult to procure even in France, as
there were only one or two copies of it known to be in
existence. But in a conversation be had in Paris with ids
friend Dr. Lereboullet be managed to interest him in the
subject so far that he was kind enough not only to consult
the original for him, but to have an extract made of all
that was important in it as bearing on this question. Pro¬
fessor Gairdner added that, according to Dr. Lereboullet’s
judgment, as well as his own, there was no trace of any¬
thing like a clinical description of angina pectoris in
M. Rougnon’s letter, and that the one case of unexpected
death he referred to gave no evidence of its being due to
that cause. It was impossible to suppose that of the very
numerous authorities that had affirmed this claim on behalf
of M. Rougnon even one could have intelligibly read the
single document on which the claim had been represented
as resting. It was quite certain, as was shown long ago by
Parry, that Morgagni in 1761 did describe an individual
case of angina pectoris, and it was equally certain, he
thought, that M. Rougnon in 1768 did not; and yet both in
France and Germany the latter had been generally accredited
with being the first to make the discovery.
Dr. James Ross of Mancliester likewise wrote regretting
his inability to take part personally in the discussion, as he
desired to present a theory to account for the distribution
of the pains in angina and in other visceral diseases. He
stated that his theory was that when a viacus was diseased
there was local pain which might be regarded as of splanch¬
nic origin (pro^cordial pain in the case of the heart). In
addition the irritation was conducted to the portion of the
spinal cord from which the visous derived its splanchnie
nerve, and thence spread in the grey matter of the posterior
horns, whence by the law of excentric projection it was
referred to the termination of the somatic nerves derived
from the segment of the cord—the second and first dorsa)
in the case of the heart. This explained the pain shoot¬
ing between the shoulders and down the inner side of the
arm (second dorsal) to the elbow and the ulnar border
of the forearm and band and ulnar fingers (first dorsal).
The left was the one moat usually attacked, because the'
left ventricle was the diseased one in angina. Besides-
these pains, the irritation was conducted inwards along the-
afferent fibres of the pneumogastric and reflected outwards
to branches of the fifth cranial nerve as vertical headache.
The close association of the function of the pneumogastric
and phrenic might give rise to other disorders. Some cases-
of angina were, he thought, attended with spasm of the
diaphragm, a muscle which derived its nerves from the
second and third cervical segments of the cord. Whenever
the diaphragm was affected, whether it were by spasm or
by inflammation, as in pleurisy, pericarditis, or abscess of
the liver, the chief pain was referred to the shoulder and
back of the neck, in the region of distribution of the second
and third cervical nerves (sensory branches). He thought
that this shoulder pain was present in some cases of angina.
He followed Gaskell in believing that the splanchnic nerves
(visceral) were derived from the cells of Clarke’s vesicular
column, and whenever these columns were absent in the-
cord there were no reflected pains.
WEST LONDON MEDICO-CHIRURGICAL
SOCIETY.
An ordinary meeting was held on Feb. 6bh, Mr. T. GuntoD
Alderton, President, in the chair.
Observations on certain Cases of Fatty Heart. —Dr.
Clemow read a paper on this subject in which details'
were given of a case of fatty heart associated with obesity
and hepatic enlargement and severe dyspneoa. The treat¬
ment adopted and recommeded by Dr. Clemow was resr. at'
first, followed by exercise, Oertel's diet, restricted lliiid,.
digitalis, and strychnia. The patient lost weight and girth
and gained strength, being able to take long walks without
breathlessness or other untoward result.—Dr. TraveuS'-
agreed with Dr. Clemow, but where there was high specific
gravity of urine fluids must not be restricted.—Drs. Campbell'
Pope and Batten took part in the discussion, and Dr.
Clemow replied.
Notes on the Administration of Chloroform and Ether .—
Mr. It. Lloyd in his paper (which is printed in full
another column) laid down the axiom that anyone on
whom it was desirable to operate was at least fit for-
attempted induction of anmsthesia. The choice between
ether and chloroform depended on the nature of the disease'
or injury calling for operation, the presence or absence of
complications—e.g., heart, lung, or renal malady,—and on
the site of the operation. Posture, method of administration,,
and the eftects on the respiratory and vaso-motor centres of
anmsthetics were alluded to, and it was urged that morphia-
should not be given before administration of anmstheticS'
save in certain traumatic cases of brain surgery.—The'
paper elicited a prolonged and animated discussion, in
which the President, Drs. Orr, Hewitt, C. Pope, Batten,
and Silk, and Messrs. Keetley, Edwards, and Benham took
part.—Mr. Lloyd replied.
Pathological specimens were shown by Mr. Percy Dunn.
The meeting on March Gbh was a clinical evening, Mr. T.
Gunton Alderton, President, in the chair.
Mr. Startin showed a case of Morphoia.—Dr. CAMPnEU...
Poi’E: A case of Skin Disease in a woman exhibiting
Scorbutic Symptoms.—Mr. Bruce Clarke: A case of Ex¬
tensive Skin Grafting on the Leg of a Child, who had been;
run over by a tramcar and denuded of two-thirds the cir¬
cumference of the skin of the leg, which was subsequently
reproduced by grafting strips of epidermis shaved off from
another part'by a razor, and closely applied to the granula¬
ting surface of the wound. Large grafts, as opposed to
minute particles of skin, were advocated by Mr. Bruc©
Coogle
The Lancet,
ROYAL ACADEMY OF MEDICINE IN IRELAND.
[March 14, 1891. 605
Clarke in all cases of skin denudation.—Mr. Edwards
showed two patients on whom be bad operated after in¬
oculation with Koch’s tuberculin for Strumous Joint
Disease,—Dr. Abraham showed a boy tbe subject of
Extensive Lupus of the Face treatea by injection of
tuberculin with the best results hitherto obtained by
Koch’s method. The patient, who was subjected to
the most careful scrutiny by many of those present at the
meeting, exhibited no trace of the disease, and was an
object of great interest to the members of the Society
present at the meeting.-*-Mr. Keetley showed a case of
Healed Tubercular Index linger of the Left Hand in a boy
where there had been ulceration for six years. The finger
healed after tbe sixth injection. The case was cited, with
another, by Mr. Keetley as an example of the value
•tuberculin injection should prove to surgeons in modifying
the tuberculous tissue, and thus aiding the removal of
diseased matter. An animated discussion followed the
exhibition of this and the previous case, in which Drs.
Travers and Alderson and Messrs. Startin, Bruce Clarke,
and Lloyd took part.—Dr. Ball showed a patient in whom
scraping once only for Lupus of the Tip and Septum of the
Nose had removed the disease. No deformity was re¬
cognisable in the patient, whose appearance before opera¬
tion was illustrated by a coloured sketch,—Mr. Pickering
Pick exhibited a patient, whose history he related, on
whom he had operated for traumatic epilepsy in 1884, No
fibs had occurred since fourteen weeks after operation,—
Dr. Herringham showed a case of Multiple Neuritis,
probably of alcoholic origin. Drs. Campbell Pope,
Symons Eccles, and Mr. Keetley took part in the discus¬
sion.—Dr. McA.dam Eccles showed a case of Multiple
Epiphysitis, of syphilitic origin, in a child.—Dr. Batten
showed a case of Disseminated Sclerosis.
ROYAL ACADEMY OF MEDICINE IN IRELAND.
A MEETING of the Medical Section was held on Doc. 19th.
Case of Left Hemiplegia with Aphasia. —Dr. Beatty
exhibited a young girl, an example of left hemiplegia with
aphasia. There was complete loss of taste and smell on
the left side, and left hemianopsia was present and sym¬
metrical.
A Case of Scleroderma. —Dr. Nixon read the notes of a
case of unilateral scleroderma, in which there was hemi-
atrophia facialis, atrophy of one side of the body, and
alopecia confiued to the side of the head corresponding to
that of the body implicated. The patient was exhibited,
and the existing features of the ease dwelt upon. Large
patches of morphcca were engrafted upon the sclero¬
dermatous skin. Dr. Nixon gave the reasons why the
affection should be regarded as a trophoneurosis, and men¬
tioned the evidences which lent .support to the view that
trophic nerves existed. He thought it probable that the
distribution of trophic nerves was closely related to that of
the sympathetic. In his case the treatment adopted was
the administration of cod-liver oil and a mixture containing
muriate of quinine, tincture of the perchloride of iron, and
the liquor ot the hydrochlorate of arsenic. The local treat¬
ment consisted in Jhe use of warm baths, with shampooing,
and rubbing the indurated skin with lanolin. The patient
was kept warmly covered, and warned to avoid wet or cold.—
Dr. Tweedy said it was well known that if those cases did
not proceed to atrophy they underwent spontaneous evolu¬
tion, and the thickness of the skin eventually disappeared.—
The President said ho had never seen a case similar to
that of the boy exhibited, but he had seen one of general
scleroderma of the whole body, and, beyond interfering with
the free movement of tbe joints and the action of the
muscles, tliere were no contractions or deformities.—Dr.
C. J. Nixon, in reply, said no doubt the history of eases of
scleroderma showed a tendency to spontaneous evolution.
The scleroderma became gradually absorbed by a natural
process independently or in spite of the u.se of drugs, which
were of little avail in it.s tre.atment.
Cystinuria. —Dr. Walter ({. Smith read a paper on
Cysiinuria. The condition is a rare one, and scarcely
seventy cases are upon record. A boy aged eight years was
reported by his mother to have passed urine of a fragrant
orris-root odour, and depositing a greenish .sediment. The
boy’s health was excellent in all respects, and there were
no symptoms of urinary irritation. Out of six occasions
upon which the child’s urine was examined, once only was
cystin found. The c^stals were identified by their form,
solubility in ammonia, and insolubility in acetic acid.
Dr. Smith disenssed in some detail our present knowledge
of the physiology and pathology of cystin. He maintained
that—(1) Cystin, or a cystin-like body, occurs in small
amount in human urine as a normal product of proteid
metabolism ; (2) no relationship exists between uric acid
and cystin; (3) associated with cystinuria, pathologically,
is the occurrence, in the urine and fmees, of certain
ptomaines belonging to the class of diamines — viz.,
(a) penta-methylene diamine (caclaverin), ; (6),
tetra-methylene-diamine (putrescin), CiHijNo; (4) normal
urine and fasces never contain diamines, nor do they occur
in cystin calculi; (5) the formation of diamines is due to,
the agency of specific bacteria in tbe intestine ; (6) the.
exact nature of the correlation between cystinuria and
diaminuria has not yet been determined; (7) cystinuria
may persist for years without apparent injury to the health
of the patient; {8) the therapeutical indication is to dis¬
infect the contents of the bowel.—Dr. Smith exhibited
some microscopic slides showing the characteristic crystals
of cystin. _
A meeting of the Obstetrical Section was held on
Feb. 6tb.
Ihe late Dr. J. A. Byrne. —The following resolution of
sympathy with the family of the late Dr. J. A. Byrne was
passed sub silentio: —“That the Obstetric Section of the
lioyal Academy of Medicine desires to record its deep
regret at the loss it has sustained by the recent death of
Professor Byrne, and to express its sincere sympathy with
his widow and family.”
Parovarian Dermoid Cyst. —Dr. More Madden exhi¬
bited a Dermoid Cyst which he had removed seven days
previously from a young unmarried woman at the Mater
Misericordi.'© Hospital. The patient, a very stout country
woman, had been in fair health until a year before admis¬
sion, when she first noticed a small swelling in left hypo¬
gastric region. This increased in size rapidly, its develop¬
ment being accompanied by a continual, dull, weary¬
ing, abdominal pain, which subsequently became more
and more troublesome, and was then frequently in¬
tensified by paroxysms of acute suffering, uhtil she
was thus compelled to seek admission into the hospital.
On examination, a firm globular intra-peiitoneal tumour,
then apparently as large as the hnbal head, and freely
movable in every direction, was discovered. On laying
open the abdominal walls, which were coated by about
three inches of fat, the tumour came at once into view,
and was punctured with a Wells’ trocar, giving exit to
about four pints of thin, dark-coloured fluid, and thus
enabling the withdrawal of the solid portion of the cyst
through a very small abdominal wound. Tbe pedicle was
then ligatured, divided from its attachment, the peritoneal
cavity washed out, and the wound closed in the ordinary
way. Some hours subsequently obstinate and uncontrollable
vomiting set in, her pulse rose to 150, and never fell below
140 to the time of her death, three days after the
operation. On post-mortem examination, the wound was
found fairly united, the peritoneal walls and intestines
somewhat congested, but; not sufficiently to account for
tbe result, which was probably largely attributable to the
fact of the heart and kidneys being found very ex¬
tensively affected by fatty degeneration. The solid
portion of the tumour, on examination by Dr. M'Weeney,
proved to be a dermoid cyst, containing hair, a_ plate
of hone, and fatty matter, for the investigation of
which ho was indebted to his colleague, Dr. M'Weeney.—
Dr. W. J. Smyly showed a Uterus extirpated per vaginam
for Carcinoma of the Cervix.—Dr. Bagot exhibited an
Ovarian Cyst which he had removed at the Rotunda Hos¬
pital from a young woman aged twenty-two years. She
had made a perfect recovery.—Dr. Baoot also read a paper
on “ Massage as applied to the Treatment of Incontinence of
Urine in Females.” He had cured three cases by the iise^
of Brandt’s system, omitting some of the steps which he’
considered useless. He related particulars of these cases
which had been treated by Brandt’s method, and after¬
wards directed attention to Dr. Sanger’s method. In
all eases in which the treatment luul been performed
by him a cure was stated to have been the result,—
Dr. Mt)iiE Madden felt bound, as a gynaecological prac¬
titioner and teacher, to express in the most distinct terms
Di:: : zBd bv GoOglc
606 The Lan(?et,]
EEVIEWS AND NOTICES OF BOOKS.
CMarcii 14,1891.
that he conld employ without giviDSf any offence to those
from whose oploions he ventured to differ hie roost emphatic
dissent from Dr. Bagot’s views with respect to the use of
massage in the treatroent of incontinence of urine in
females, as described iu the paper. Apart from the many
serious, and by no means merely medical, objections to
which the speaker referred at some length as being, in his
opinion, almost inseparable from any procedure involving
any frequent or prolonged manipulation, whether within or
even in the immediate vicinity of the female genital tract.
Dr. More Madden believed that ihe great majority of cases
of incontinence of urine in females, when not resulting from
parturient injuries or causes, resulted from cystitis ; and he
was strongly of opinion, from clinical experience, that such
cases {as be bad elsewhere shown) might generally be more
effectually and better treated by other and rapidly curative
methods of treatment.
|iri)idi)s nitlr llotias ai §o:oli'i.
Studies in Statistics: Social, Political, and Medical. By
George Blundell Longstake, M. A., M.B., Cert. I’re-
ventive Medicine, Oxon., F, RC.P. With Maps and
Diagrams. London: Edward Stanford. 1891.
[Second Notice.]
The chapters on the Growth of Nations form, when
taken together, a really remarkable narrative. A table,
setting forth the different order of precedence of the Cheat
Powers by population in 1850 and 1880, shows in the former
year Russia at the top and the United States at the bottom
of the list; whereas in 1880 the Tlnited States stands
second among the Great Powers. France in 18.50 occu¬
pied the second place on this list, and the United Kingdom
the fifth. In 1880 France occupies the fifth place. The
political significance, as Dr. Longsbaft' remarks, of this
table is evident. It is intensified by the fact that Germany
and Italy, two congeries of petty States in 1850, are now
solid nations, while the Austro-Hungarian Monarchy is
much more consolidated than it was. At the next census
the population of the United Kingdom will be very nearly
equal to that of France.
As regards the United States, the author calls attention
to the very rapid increase of the coloured population, and
its concentration in certain States, as constituting a grave
social and political danger to the future of the Republic;
“ in more than one sense a black cloud may be said to hang
over it.” And Dr. Longstaff points, by way of illustration,
to the abortive experiments in self government by negroes
in recent history. We can only briefly touch upon the
history, statistical, social, and political, of the French,
German, Irish, Scandinavian, and other races in the
United States, and in Canada, South Africa, and Australasia,
hut readers will find much in this history to interest and
ponder over. One consideration, at any rate, will occur to
them, that as the leopard cannot change his spots, so
neither does a race change its I'eal character, temperament,
or those habits of generations that have become specific and
distinctive, as it were, by being transplanted into a new
environment. What does change is not the real but the
apparent and factitious; the pretended aspiration or the
assumed motive and political grievance soon disappears in
a new soil, but the qualities of character remain. The
“staying power,” the enterprise, persevering energy, and
thrift that characterise some races are much the same in the :
’newcounbj-ythatthey werein the old. The regiet is, however,
that it is not the more robust in intellect and character,
bub the weaker races in these respects, that are the
most prolific. Looking at this migration question from
the British Empire point of view, it is important to bear
in mind that the political centre of gravity is slowly
shifting. The populations of our great self-governing
colonies in North America and Australasia increase much
more rapidly than that of the mother country, so that if
the population of the United Kingdom at each census be
taken' as 100, it will be seen that the united popula¬
tions of British North America and Australasia, which in
1841 corresponded to 7, in 1881 corresponded to 21. A
large proportion of Irisli emigrants go to the United
States, of English to Australasia, and of Scotch to
Canada. The facts, figures, and deductions contained in
this section of Dr. Longstaff a book have a direct bearing
on the question of Imperial federation.
But we must pass on to other portions of the volume
more directly connected with sanitary, medical, and social
subjects, and these are all present in the chapter on the
Growth of Modern Cilies. The same movement appears to
be almost universally in active operation. Dr. LongstafFa
explanation of the remarkable growth of cities in recent
times is that, under modern conditions, with improved
culture, better means, and increased facilities of communica¬
tion, a much smaller fraction of the people is able to provide
tbe food required by the whole body. Then, again, those
sot free from agriculture apply themselves to supplying
the innumerable new requirements of a people living up to
a far higher standard of comfort than that which contented
their fathers. We have already called attention to the
chapter on the Population of London, in connexion with
which the author has a word to say as to the health of this
mass of bumauiby. The metropolitan area extends over
some twelve miles from north to south, and some seventeen
miles from east to west ; within this space thirty-nine
governments so rule the houses, roads, and drains of their
three millions and three-quarters of subjects that for the
last ten years the death-rate has been only 22^ per 1000. or
bub 1 per 1000 in excess of that of the whole country.
In the seventeenth century it is believed that the deaths
exceeded the births in London, and the death-rate was then
about 49 per 1000, or more than double what it is now, and
higher by far than the mortality rates of the unhealbhiesb
cities of Europe of to-day. This is a marvellous and credit¬
able stride, and “by patient continuance in well-doing” on
similar lines there is every reasonable hope of accomplithing
still more. Dr. Longstaff does not take an altogether
optimistic view in regard bo the enormous scale on which
social problems present themselves to the London philan¬
thropist. He would wish that something could be done to
prevent tbe increase in the number of the inhabitants, so as
, to render it possible to deal with the vast mass of arrears that
neglect has allowed to accumulate. Hisown ideas incline to
emigration as the only practicable remedy, onlyhe cautions us
to beware of aiding emigration from London itself, as in that
case, for every family sent from Wbiteebapol or Poplar two
families will rush in from Norfolk, Devon, or Ireland. It
would be far better to stop some of the eighty people daily
coming into London from the country, and ship them off to
the Antipodes.
As regards Food ^Supply and MaUhus’ famous essay,
which appeared nearly a century ago, the author evidently
considers that tbe time will come, and that before the end
of the next century, when men will once more think
seriously of Malthus and his warnings. The growth of
population proceeds in a geometrical progression, like com¬
pound interest. During the past century the population
of the United States has doubled itself in every twenty-five
years. The area and resources of the country are very great,
bub they are nob without limit. The demand for food in¬
creases every year, nob njerely in Europe, but even more
rapidly in those countries which we are too apt to look
upon merely as the granaries of Europe.
We pass over the chapter—and an excellent one it is—on
Suggestions for the Census. Chapter XIV., on the Recent
Digitized by ^ooQle
The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
Declino ia the English Death-rate, considered in connexion
•with the CauBOs of Death, was read before the Royal Statis¬
tical Society in 1884, to which Dr. Longstalf has added a
postscript in 1890. At page 252 et se.q. he reduces the chief
inferences to be drawn from the facts under review into
^r&ds form. The decline is mainly to be attributed to the
diminished mortality from fever (chielly enteric) and phthisis,
and in a less degree to scarlet fever, diarrhccal diseases,
small-pox, diphtheria, and measles. On the other hand,
deaths from diseases of the lungs, heart, kidneys, and cancer
have increased, the number of deaths now attributed to the
last-named disease being double that of forty years ago.
Chapter XV. is on the Causation of Summer Diarrhcca,
and the subject is well and lucidly discussed in connexion
with three questions : Where, when, and whom does it
kill ? The opinion is definitely expressed that summer diar¬
rhcca is caused by the pollution of air, water, and food with
some product or other of the decomposition of organic
matter during very hot weather, and is not simply due to
the ellecb of heat on the nervous system.
Omitting all notice of the chapter on some Statistical
Indications of a Relationslsip between Scarlatina, Erysipelas,
Puerperal Fever, and certain other Diseases, except to remark
that it is admirably illustrated by coloured diagrams, we
come to Chap. XVII, on the Geographical Distribution of
Diphtheria in England and Wales, being a repiint of the
author’s studious and exhaustive supplementary paper to
the seventeenth annual report of the Local Government
Board. The subject has been so much discussed of late
years that our readers are familiar with its general history,
embracing as it does some very interesting and curious facts.
The distribution of diphtheria is altogether peculiar, and its
mortality is not apparently regulated by the same causes that
inlluence tlie general mortality. Density of population is
not a factor of primary importance in the production of
fatal diphtheria. On the contrary, its predilection for
scattered rural populations and for exceptionally healthy
districts, and the striking tendency which the disease has
shown of late to invade cities and towns, are well-known
and remarkable facts. These are well set forth and illus¬
trated by Dr. Longstaif. The centripetal How of population
from country to cities, the growing aggregation of children
in connexion with the Public Education Acta, the long
periods over which tlie poison possibly retains its activity,
its increased potency and active evolution under ceitain un
determined favouring coeditioDS, and the increasiog facili¬
ties for its spread, are all subjects of extreme interest at the
present tin.e. Chapter XVIII. treats of Plithisia, Bron¬
chitis, and Pneumonia: are they Epidemic Diseases ?
Chapter XIX. deals with the Communicability of PhtJiisis
from a mathematical and actu.arial point of view : Chapter
XX. with the Seasonal Prevalence of Continued Fevers in
London; XXI. with Hydrophobia Statistics, and XXII.
forms the concluding chapter of a \ ery laborious, useful,
and really remarkable book.
Lthrhnvli dcr AUgcmeinen. vncl spcdcUen rathologUdiCAi
Amitomie. Von. Dr. Ern.st Z(fc(;Lici{. Sechste Aullage.
ZweiterBand. Jena: G. Fischer. 189t).
This bulky volume comprises special pathological
anatomy, and its appearance completes the sixth edition of
a work that must be regarded as the foremost text-book of
pathology of the present day. By j udicioms editing and revision
there is not much increase in the number of pages, although
one cannot fail to be struck with the numerous additions to
the text and the more systematic arrangement employed in
several sections. The number of illustrations, all of which
are original, has been considerably iucreased. The author
states that several of the chapters have been entirely re¬
written, whilst the bibliographical refe
value to workers) are more clearly indi
It would obviously be impossible to
a work which covers so wide a field
a useful purpose if, for the sake
thoroughly the author treats his subje
inn through one of its sections—that, name]
logical anatomy of the lungs. It opens with'
tion of the normal structure of the lungs^
congenital defects, special stress being laid
plasia” or “agenesis”of the respiratory pareiicl
may be the foundation of a diffuse or cystic biM
In rare cases, says the author, the development
may remain rudimentary or in portions—the
little if at all developed. Then follows a descrl
atelectasis, congenital and acquired, and after that^
sema receives a full share of attention. Then co^
changes due to disorder of the circulation. Conj
byperiumia is shown to depend upon diminished resisi
in the pulmonary circuit, or to the presence of irritant
the inspired air or in the blood itself ; and it is a condi^
which is generally fatal. Hyperoemia from stasis, on
other hand, is not so transitory; it is due to enfeeble
cardiac action or to dilliculty in the venous outllowl
(Edema may result from such stasis, but oedema may als<^
be caused by septic agencies (probably through increasing
the permeability of the bloodvessels), or to inflammation,
as seen around pyromic foci. Hmraorrhagic conditions,
infarction and brown induration are naturally next con¬
sidered. 1‘neumonokoniosis is treated, together with focal
bronclio- paeumonie processes, the alliance of those diseases,
due to dust inhalation, with those of other forms of more
acute broncho-pneumonia from inhalation of septic and
inflammatory (e.g., bronchitic) products being clearly
brought out. it is sliown, too, how the type of lung
inllanimation and its subsequent progress is modified
according to the nxture of the inhaled material. The
.whole deacripti( n of broncho-pneuinonia is thus made more
intelligible when its etiological relationships are studied
side by side with its anatomy and distribution. Lobar
croupous pneamouia.U defined as “an infective lung
disease, which is in the majority of cases caused by the
diploooccus pneumoni;c (Weichselbaum, Fraonkel), but may
aLo be excited by other bacteria,” notably the bacillus
pneumoniio (Friedliinder), as well as streptococcus and
staphylococcus pyogenes. How these micro-organisms
act has still to be determined ; but their occurrence in the
gpnta, the inlluminatory exudation, and in other organs
suggest that they may enter by the air passages, and per¬
haps also by the blood-stream. The rave terminations in
suppuration and gangrene are ascribed to special infection ;
whilst caseation is held not to occur except in tubercular
infection. The outcome in induration is evidently regarded
as not being so very exceptional. Other forms of pneu¬
monia, septic and metastatic, are next described, and then the
pleurogenic interlobular conditions. Tuberculosis heads
the list of infective graiiulomata, and is very carefully and
thoroughly dealt with. It is shown how variations in
anatomical features are impressed by the mode of entrance
of bacilli—whether by bloodvessels, lymphatics, or through
the ordinary channels of respiration; and how the tubercular
products are mingled with secondary broncho-pneumonic
foci; and how, again, in chronic phthisis the occurrence of
caseation, excavation, and induration disguises the primary
and essential tubercular characters. Syphilitic disease,
actinomycosis, tumours, and animal parasites are discussed
in turn, the whole section being admirably complete, as
well as beautifully illustrated.
This systematic and thorough method obtains through
the whole volume, and w’e cannot avoid expressing the hope
Digitl/ed by
Google
REVIEWS AND NOTICES OF BOOKS.
[March 14,1891.
arrivea for a new edition of the English
ar, Dr. Macalister M’ill be enabled to
5 whole text of this publication, which has
editions) undergonesuch extensive revision
'a words, to constitute it almost a new book.
^nourablc Arthur MacMurrotigh Kavanagh:
;i/. By his Cousin, Sarah L. STEELii. With
London and New York: Macmillan & Co.
?n, unpretending narrative is fraught with in-
'the medical educationist, to the student of
K to the country gentleman, and to the statesman.
0 ct was one of the most striking personalities of
keenth century. Bj'' an intra-uterine complication,
J^h unique in the annals of gyn.%“cology,—the umbili-
frd constricting and amputating legs and arms alike,
jelow their upper third,—he was brought into the world
all the disadvantages incident to defective means of
Fomotion and prehension. On the other hand, by the
Fmpensatioa which nature seldom fails to give in such cases,
had a nobly proportioned head and trunk, and intellectual
Ind moral powers specially adapted, it would seem, to over-
^comeeveryphysicalimperfection. Thebestsurgicalandortho¬
pedic resources of the day were invoked, but inell'ectually,
to provide artificial substitutes for the missing extremities,
and nothing remained but to make the best of what was
given. “ By sheer principle and pluck,” as his biographer
puts it, young Kavanagh trained himself to do nearly
everything of which his more favoured fellows were
capable—aided, it also appears, by the judicious upbringing
vouchsafed him by his singularly gifted mother. In sensory
and motor power his muscles acquired a development equal
to the most various uses, and while little more than a boy
he could write, draw, guide a horse from the saddle or
from the box of a carriage, shoot, fish, work a ship, and, in
short, perform all the functions and take part in all the
sports congenial to bis class. An active, open-air life, it
will be readily understood, was essential to the maintenance
of his health, and this was provided him not only in the
extensive and beautiful demesne of his birthplace, but on
frequent and prolonged visits to the country seats of his
■relatives, and, above all, by foreign travel under the eye of
his sagacious and accomplished mother.
Mrs. Steele touches lightly on these details, not so mucli
describing to us, as leaving us to infer how he proved
equal to the life of travel and adventuie to which he was
thus early inured. We think the interest of the book
A-ould have been increased if the authoress had given a few
particulars of the methods employed to overcome as far as
p()3sibie the physical defects which characterised the hero
of the narrative. His letters from Egypt, the Syrian
Desert, and the Holy Land, and, better still, his diary of
exploration and sport, while still in his teens, from llussia
to Northern l^wsia, from Koiirdistan, down the Tigris and
Persian Gulf, to the Bombay presidency, teem with
evidence of the skill and self reliance to which his per¬
severance and energy liad trained him, ashore or alloat, on
the mountain or in the jungle, facing a gang of Kourdish
robbers or a tiger at ten paces. This part of the biograpliy,
indeed, in which Mrs. Steele wisely lets him tell his own
tale, abounds in di'amatic incidents, rare in any book of
travel, and absolutely unprecedented in the history of one
to whom Nature liad denied, and, at the same time, vouch¬
safed, so mucli.
His moral development went passu with his jihy-
sical. As Mrs. Steele points out, his head and heart were
ennobled and refined by the discipline to which lie put
him-self. Instead of the jealous, suspicious, often morose
disposition characteristic of those whom nature has visited
witJi corporeal defects, his cheerfulness, bonne camaraderie.
sense of fun, and benevolence to all, were equally remark¬
able with his bodily prowe.?s and versatility. Here, again,
the iniluence of his mother is made manifest—in the re¬
ligious training which culminated in the simplest, manliest,
most self-sacrificing piety of which the human soul is
susceptible. His entries in his diary, where he seems to
hold communion with his “ Great Taskmaster,” are among
the most touching passages in literature, one especially,
when, on the eve of completing his thirtieth year, he
reviews his past life and owns his indebtedness to God
with a resignation and a thankfulness which goes to the
reader’s heart as it came straight from his own.
We have dealt with the points in which the medical educa¬
tionist and the sbudentof character will find special interest.
The details which address themselves more particularly to the
country gentleraan and the statesman are less within our
province. Even here, however, illustration is not wanting
of the salutary self-discipline he underwent to retrieve his
disqualifications. When still a mere youth, a younger son
without immediate command of money—earning his liveli¬
hood, in fact, as a carrier of Government despatches over
vast solitudes in India,—he made a remarkable vow, which
seems to imply a foreknowledge of what his career was to
become. And when that position in life to which he aspired
was fulfilled to the letter, he set himself late and early, in
leisure moments as in active hours, to discharge its duties
aright. He became not only what Sir Charles Kussell, in his
famous speech before the Parnell Commission, designated
him, “ a landlord of landlords,” but also a statesman, in and
out of Parliament, of whom Mr. Gladstone declared publicly
that he always spoke with the highest re.spect. While
on the one hand he entered into the vie inlimc of his very
numerous tenantry, guarding their interests, advising them
in perplexity, visiting and relieving them in sickness, con¬
stituting himself, in a word what they fondly called him,
“ the father confessor,” he vindicated them in I’arliament,
and promoted or averted legislation according as it seemed
calculated to do them good or harm. So little of a party
man was he that, though nominally a Conservative and
generally voting on tliat side, he was often found support¬
ing liberal measures, and exercising an independence in the
debates and the divisions not very agreeable to the ollicial
whip. Again, when excluded from Parliament in the
general election of 1880, his public activity continued the
same, though exerted througli other channels, such as the
press and the platform; while in critical moments in the
government or administration of Ireland he was consulted,
as his correspondence amply reveals, by those high in
authority to whatever party they belonged.
The biography—in whicti Mrs. Steele has wisely resisted
all temptation to book-making—reads like a romance, and
ought, as she hints in the preface, to yield a salutary lesson
to young men. Rare, indeed, are the examples in which
disadvantages seemingly so hopeless were more successfully
overcome—in which physical imperfection became ao
triumphantly “the crown of moral completeness.” An
Irisliman pur sang, Artliur MacMnrrough Kavanagh was
an honour to his country and his compatriots, and as such
will long be remembered after the passions and polemics of
the day have receded into oblivion.
KOYAL iSEA-i'.ATIHNO INFIRMARY, MaKOATK.—O il
the 9th instant the annual meeting of this eh.arity was held
at the oilices, Chariug-cross. The secretary road the report,
whicii expressed regret tliafc, owing to lack of funds, two
wards had been closed. This year, however, it is proposeit
to fonrjd a special endowment fund of £i30,0()(), to celebrate
the centenary of the in.stitutioii. Towards this sum Mr._ ^.
Jlarbori of Guillford lias promised £1000, on the condition
that sixteen donors of £2.')0 each are fiirthcoming. The
number of patients treated during the year was (i.54. Tlie
percentage of cases cured annually increases, it liaving risen
from 23'5 per cent, in 18G0 to 52’3r) per cent, last year.
Digitized by
e
The Lanobt,]
CASE OF ALLEGED POISONING BY ARSENIC.
(March 14, 1891. 609
Ittto Infeittkn.
AN IMPROVED BINAURAL STETHOSCOPE.
The weak point of the binaural stethoscope, as usually
constructed, is the spring. If strong enough to keep the in¬
strument in position, its constant pressure hurts the ear, and
if made weak enough to be harmless to the user, it fails to
keep the stethoscope properly applied to the auditory meatus.
These remarks apply equally to the common elastic loop
and to the metal spring which is
DOW in more gener^ use; besides
which, the former has the fault of
always slipping out of position,
while the latter invariably causes
loud musical sounds, which materi¬
ally hinder accurate diagnosis. I
venture to think that I have suc¬
ceeded in overcoming these draw¬
backs to the use of the binaural
stethoscope by doing away with
the spring and substituting a clamp
at the joint. This is actuated by
a hanging tail-piece or lever, moved
hy the second finger of the right
hand, the arm being held between
the first finger and thumb; the
other arm is held between the
corresponding fingers of the left
hand. When the lever is in the
position A, the hinge is loose, and
the instrument can be applied to
ibe ears and adjusted to press as
lightly or as heavily as desired.
The lever being then moved into
the position R, the instrument is
fixed, and remains in position.
It can then be easily removed
from the ears and closed without
touching the lever. A minor im¬
provement consists in enlarging
the orifices in the ivory ear-pieces,
so that the bore of the instrument
may remain in continuity with
the axis of the auditory meatus
during the rotatory movements
round the said axis made in
altering the position of the stethoscope.
Messrs. Down Brothers, of St. Thomas’s-street, have
carried out my idea completely to my satisfaction, and
produced an instrument which does everything that I
anticipated.
West-stroot, E.c. George Herschell, M.D. Lond.
CASE OF ALLEGED POISONING BY
ARSENIC.
After a short interval following the many cases of
poisoning which occurred in 1889 and the previous yeare
comes the report of another trial for murder by arsenic, this
time from Scotland. The trial took place at the High
Court of Justiciary, Edinburgh, extending over Feb. 17th,
18th, and 19fch, the presiding judge being the Lord Justice
Clerk (Lord Kingsburgh). The accused was John Webster,
tenant of the Newton Hotel, Southmuir of Kirriemuir, and
the following is a brief recapitulation of the principal facts
revealed in the evidence. The household consisted of tlie
prisoner, his wife (the deceased), two children, one female
servant, and the barman. Neither of the two latter
slept in the house. The prisoner and the deceased
effected in October, 1889, a joint policy of insurance for
£1000 in tbe Prudential Insurance Company, the amount of
the policy being payable to the survivor on the decease of
the first. Two premiums of £24 14s. 2rf. were paid, one
before the policy was issued—on Oct. 31st, 1889—and the
second six montos after. Tbe deceased and her husband
had a serious quarrel in the following April (1890), which
led to a temporary estrangement, but subsequently the
prisoner returned to her, and she was in her usual health
on Thursday, July Slat. On the following day the servant,
Helen Grant, on first seeing her mistress, thought her
looking pale. Later on Mrs. Webster, saying she felt sick,
lay down on the children’s bed and vomited. »he ate very
little dinner, and in tbe afternoon vomited again, the vomited
matters being, according to the witness Grant’s description,
“grey and white mixed stuff.” The vomiting continued
the following day, though potash and milk were taken to
allay it, and tbe deceased also complained of thirst. She
bad some “brandy toddy” that night, hut next day (Sun¬
day) the vomiting continued in spite of repeated doses of
E otash and milk. That evening about 7 p.m. she was seen
y Dr. Clark of Kirriemuir, who had not attended her pre¬
viously, she and her husband being perfectscrangers to him.
He found her very pale, weak, and exhausted, complaining
of vomiting and retching which she said had commenced on
the morning or forenoon of the previous day. She com¬
plained of uneasiness and pain in the stomach, which was
slightly intensified on pressure. The thirst was very great,
and there were no indications of intemperance. Dr. Clark
ordered six powders of subnitrate of bismuth, one to be
taken every three hours in milk. When he saw her the
next day (Monday), between 10 and 11 a.m , the vomiting
and retching were slightly relieved, but she was weaker.
The powders had been all taken, and Dr. Clark now
prescribed oxalate of cerium in doses of one or two grains, to
be given every three hours on jelly or buttered bread.
When he next saw her, between 1 and 2 p. M. the same day,
she was in a state of complete collapse, but conscious. She
was veiy feeble, cold, and pallid. He ordered stimulants
to be given and hot applications to the feet and hands, but
she died soon after. Dr. Clark certified tbe death as
from gastritis of four days’ duration, and tbe body was
buried. But subsequently, in consequence of some
suspicions as to the real cause of death and other
circumstances, it was exhumed on Nov. 27th and examined
by Dr H. D. Littlejohn of Edinburgh and Dr. Clark.
It was found remarkably fresh and free from putrefactive
odour, this being partly due to the wet condition of the
grave, partly also to the presence of arsenic which was sub¬
sequently found by Dr Littlejohn and Mr, Falconer King,
analyst to the city of Edinburgh. As the necropsy had
revealed no appearances of death from any natural disease,
Dr. Littlejohn removed the stomach, intestines, liver,
kidneys, spleen, one lung, and the uterus for chemical
inspection and more minute examination. The stomach
was empty; there was externally a yellow patch the
size of a florin, internally some dark mucus. l)r. Little¬
john found tbe presence of arsenic in the stomach,
and, on communicating with tbe Crown Office, was
associated with Mr. Falconer King. They found arsenic
in all the abdominal viscera and in the lungs. Unfor¬
tunately they made at first an erroneous calculation
as to the quantity, making tliat found in tbe stomach as
three-fourths of a grain, whereas upon verification it was
found to be less than half a grain. A further examination
was made by Professor Crum Brown of the Edinburgh
University, with the result that he also found arsenic in all
the viscera, and he estimated that, calculating from what
he found, the total would be 1704 grain of arsenic for the
whole stomach. Marked quantities were also found in the
duodenum and intestines. It was therefore clearly proved
that death resulted from arsenical poisoning, the symptoms
observed during life, the appearances seen after deatu and
four months' burial, and the chemical examination all
bearing out this conclusion. The possibility of accident was
apparently excluded, and that of suicide almost equally so.
Tbe barman, Peacock, who would have- been an important
Crown witness, committed suicide by drowning a few days
before the trial was first fixed, and bis depositions (or
precognitions) do not appear to have been tendered in
evidence. The prisoner was ably defended, and there were
points in bis favour, especially the entire absence of any
proof of the purchase or possession of arsenic by him.
The verdict of “ Nob guilty ” was therefore justified.
Seeing that Dr. Clark had only seen tbe deceased for
the first time the day before her deatli, and only three
times altogether, and bearing in mind how often gastritis
has been caused by poison, it would have been more satis¬
factory had a post-mortem examination been asked for
before a certificate of death was given.
L 3
dimiil- t;
610 The L\ncbt,]
THE FACTORY BILLS.
[March 14, ISBI.
THE LAJVCET.
LONDON: SATURDAY, MARCS U, 1891.
The five Bills before Parliament, all dealing with our
factory legislation, will, we fear, not suffice to do away
with the evils of the sweating system. Even if the best
clauses of each Bill are grafted on to the Government Bill
we shall still have an imperfect measure. No one has
studied the question of sweating without realising that,
from every point of view, the greatest evils are to be
found in the domestic workshops or among the home
workers. Even the disciples of the extreme individualistic
Bohoel are on this point at one with those who, on
the contrary, rely principally on the interference of
the State. Both sides are aware that the sweater’s
victim cannot alone free himself from his economic
thraldom ; but the one party urges that the State should
help him, and the other side argues that he should help
himself by forming a strong organisation such as a trade
union. While, however, the workers are separated one
from another, liid away in the noisome dens of the sweater
or toiling in their garret or cellar dwellings, they cannot be
brought together into an organisation. From the sanitary
point of view, it is the working at home in bedrooms and
in private dwellings which most offends against the laws of
decency and of health. The first object, then, of any measure
dealing with sweating should be to reform the present dan¬
gerous condition of domestic workshops. Yet Mr. Matthews
deliberately exempts domestic workshops from the opera¬
tion of his Bill. Clause 29 of the Government measure does
contain an important alteration exempting from the future
Act “a room solely used for the purpose of sleeping therein,’’
whereas the existing law exempts “a place solely used as a
dwelling.” The sweater can now, on the approach of the
inspector, Iiide his workwomen and “young persons” in any
part of his private dwelling adjoining his workshop. In
future he will have to hide the women and children he is
employing after regulation houi-s, not in his dwelling gene¬
rally, but only in his bedroom. There, by Mr. Mattiiew.'s’
considerate clause, the inspector will not be able to follow
them. But, says Mr. Matthews, “ the Bill does not
deal with what is commonly called domestic workshops,”
and it would seem that he agrees with Lord Dun-
RAVEN’s definition that a domestic workshop is a place,
perhaps merely a bedroom, where only members of the
same famDy work together. Places sufficiently good for a
family to live in are, according to the Home Secretary’s
opinion, sufficiently good for a family to work in. This,
we maintain, is not at all the case. First of all, it does
not in the least matter whether the workers are of the same
family or not. Their relationship to each other does not in
any way lessen the amount of oxygen they consume in
breathing. We never heard that less ventilation was
required for a family gathering than for a gathering of
strangers. Nor are the germs of disease less infectious
because they emanate from the same family. Also, what
are the limits of family relationship? How many times
“removed” may cousins he who work together? and
does Mr. Matthews seriously imagine that a British
magistrate will ever be able to unravel the intricacies
of family relationship betweeen the Polish Russian Jews,
who, to the number of several thousand, have taken refuge
in the East-end of London ? It will be found quite im¬
practicable to make distinctions between members of the
same family and strangers; and as the dangers to health
are the same in both cases such distinctions should not be
attempted.
Some of the suggestions which we pressed forward during
^ our campaign against sweating have, we are glad to note,
I been adopted. On many occasions we have urged that the
j local authorities are the principal offenders. Mr. Matthews
: now proposes that where the local authorities do not fulfil
their duty the central Government may send down any
number of inspectors to “ sweep the Augean stables clean.”
This, too, is to be done quickly and without the interference
of local magistrates. Mr. Matthews is further to be
congratulated on abolishing the distinctions formerly made
j between factories and workshops, and between the fac¬
tories and workshops where adult males alone were
employed, where women were employed, and, finally, where
“young persons” worked. All are now to be placed on
the same level with regard to ventilation, overcrowding,
cleanliness, limewasbing, &c. Where alterations are
necessary, the inspector may cause these to be made and
recover the cost by summary procedure. But we miss in
the Government Bill a clause which is to be found in other
projects of law—to the effect that where men and women
are employed there shall be separate sanitary accommoda¬
tion for each sex. Again, the Bill, though it provides for
ventilation in a vague manner, does not lay down any
rule as to the minimum cubic space that should be allowed
to each worker.
In dealing with the work of women, the Government Bill
proposes to do away with the existing difference made
between the factories where only women work and those
where young persons also work. In both cases the hours of
work shall be twelve, with one hour and a half for meals.
This will simplify matters, for formerly, where only women
worked, the hours were fifteen, with four and a half for
meals, and it was no easy matter to ascertain whether the
women really did enjoy to the full the four hours aud a half
of relaxation, as stipulated by the law. These are, how¬
ever, all very small advantages compared with what we
had a right to expect. For instance, no promise is made as
to the increase in the number of inspectors; though, on the
other hand, the certifying factory surgeons are to be
abolished. This very unfortunate proposal was the subject
of special criticism in our lasts issue. There are actually
134,000 factories and workshops registered, and the visits
made by the inspectors last year were in all 114,000. Thus
the average is less than one visit a year, though a visit
every three mouths would not be too much. Nor is it easy
to understand why the Government did not follow the
recommendation unanimously given by the Berlin Labour
Conference, that children should not be allowed to work
before they had reached the age of twelve. Mr. Matthews
Digitized by
Google
The Lancet,]
ANGINA PECTOKIS.
allows half-timers to commence work when they are only
ten years old. Mr, Matthews also showed himself far
too tender towards “season pressure,” which is generally
a mere question of fashion, of ignorance, and indifference
on the part of purchaser and tradesman as to the suffering
this pressure entails. If dresses during the season had to
be ordered a few days sooner, this would be no great hard¬
ship, and it would save many a workwoman from over¬
pressure, with its inevitable and mischievous consequences
on health.
The Government Bill is, in a word, wanting in gra^'p and
scope. It altogether fails to deal with the worst grievance—
i.e., the domestic workshops,—though the registration of
outworkers and of ordinary workshops is imposed. But if
lists of places that should be visited will thus be forth¬
coming, there is no provision made for appointing inspectors
to pay these visits. Finally, if these inspectors are
appointed, what is to replace the unwholesome workshops
which will be condemned ? As we pointed out when the
Lords’ Committee was appointed, a constructive as well as
a destructive policy is necessary. Workshops, like rookeries,
must when destroyed be replaced by better accommodation,
and no hint whatsoever as to how this phase of the subject
will be treated is to be found in the measures before us.
Perhaps the discussion in Committee will help to impart
greater strength and a wider scope to the Factory Bills now
before the House of Commons.
The debate which has occupied three meetings of the
Medical Society, and has just been concluded, deserves
attention, not only from the intrinsic interest of the
subject—angina pectoris,—but in no small degree from the
remarkable breadth of view taken of it by most of the
speakers. For it is singular how restricted have been the
opinions held in past time concerning angina pectoris, and
how, in this respect, medicine has been apparently influenced
by that feature which so strikes the popular imagination—
we mean the liability to sudden death. No one, however,
who has followed this debate can aver tbac English
physicians adhere to any such narrow conception, and many
doubtless would agree with Dr. Mitchem. Bruce in the
desire that the term “ angina pectoris ” could be got rid of.
That being impossible, the next best thing is to deprive it
of its application to any single morbid state, and, if not
adopting Sir Walter Foster’s notion of its being
a “ mode of death,” to at least employ the phrase in
a merely clinical sense, as expressive of paroxysmal pre¬
cordial pain. Obviously, then, the sufferer does not die
from the symptom itself; but from the cardiac conditions
that underlie it—conditions that may be of organic origin,
or of hardly less serious functional derangement. The
mechanism of the circulation is suddenly disturbed, and
the expression of the heart’s dUliculty is to be found in
the anguish experienced by the patient. With one notable
exception the speakers at this debate agreed with the
opener of the debate, Dr. Douglas Powell, in attributing
angina pectoris to some defect in the harmonious coopera¬
tion of heart and vessels in the work of the circulation.
At the same time there were certain divergencies of view
as to the precise form of this derangement, All, however,
concurred in including under th(
of the most varied kind, having
in common. The chief points of
the question whether the cardiac,
attack was one of muscular spasr
distension of the cavities; as to
taken by the state of arterial blood
ing the seizure, and as regards the
muscular substance. Dr. Douglas Powe^
attributed many cases to a condition of un^
irritability, whereby under comparatively
the arterial blood pressure, previously in most'
high, is increased, leading therefore to a
increased effort on the part of the heart. Suc|
maintained, were numerous, and though al^
symptoms, were seldom fatal. In them the heaJ
was healthy, and they contrasted with the gra^
associated with cardiac degenerative changes. Dr.:
Brunton’s comparison of the heart with the b*!
went further, in explaining the rationale of the
produced by over-distension, bub he admitted a
disposing state of heart) weakness owing to which
increased arterial resistance, such as is produced
the first stages of muscular contraction, is sufficient bl|
cause undue distension of the cavities. Sir Walt
Foster lucidly and simply referred the immediate cause of
the attack to over-distension of one or other of the cavities,
although in many cases he recognised that the heart
was degenerate. Dr. Broadbent did nob allow that
heightened arterial tension was at all a oonstanb feature;
he laid stress on the dangers of a weakened heart, and
candidly confessed that some cases afforded no reasonable
explanation. Dr. Ord seemed willing to admit all factors,
vascular and cardiac, as piovocative of attacks, but distin¬
guished two main groups, dependent upon whether exertion
was or was not the exciting cause. Dr. Mitchell Bruce
contended for an undeilj ing weakness of ohe heart, which
was generally enlarged, and declared that symptoms
of vaso-motor disturbance and of increased arterial tension
were generally wanting. Indeed, it was manifest bhai
no single theory could explain the varied conditions under
which an anginal seizure may arise. The “gouty heart
seemed to Dr. Bruce to best describe the condition most
often present.
Professor Grainger Stewart was almost alone in
pleading the neuralgic theory, and he would even extend
angina to include pain ascribed to aortitis apart from bean
disease. The distinction he drew between muscle pain
and nerve pain does nob seem a very tenable one, and
since all the conditions named by him as exciting attacks
arc equally well explained on the muscular hypothesis,
it is somewhat difliculb to see the reason for retaining
the notion of cardiac neuralgia. The question whether
the pain be due, as Dr. McVail argued, to excessive
coutraction, or, as Dr. Seymour Taylor held, to spasni
of the heart, or to the mechanical effect of over-distension,
like that experienced iu the bladder on Dr. Brunton’s ana¬
logy, is to a certain extent immaterial, except that it empha¬
sises the notion that the condition of the muscular wol
rather than that of the cardiac nerves is the primary fact
Digitized by
Google
EMOTIONAL EXPRESSION.
[March 14,1891.
to contrast the attacks of pain with
epsy, and urged that the mode of
of the pain should be more care-
central fact of the whole discussion
upon the character of the pain than upon
ie heart and bloodvessels; and we believe
the majority of speakers as to angina
Tan index of cardio-muscular dilliculty are
' harmony with facts. The only ground for
the neuralgic doctrine advanced by Pro-
ifGBR Stewart is that it forms, as it were, a
[escape from the difficulty .which other theories
fin the fact that each of the several cardio-vascular
described may exist apart from angina. Thus
sctoris does not occur as a result of the heightened
tension of Bright’s disease, nor usually from the
of cavities due to valve defects, notably the
^1 valve; whilst cardiac degeneration with or with-
lisease of coronary arteries may most certainly exist,
to a fatal issue without ever being characterised
anginal seizures. Obviously there is much to learn
concerning the nature and immediate causation of
ingina pectoris, but its association in fatal cases with
'manifest organic lesion of heart or bloodvessel and, in non-
fatal attacks, with clinical evidence of defective circulation
and heart enfeeblement, and the rarer event of breast
pang—sometimes with fatal result—from sudden and violent
exertion, seems to point conclusively to its origin in dis-
^ ordered mechanical conditions of tlie circulation, with conse¬
quent strain on the cardiac power.
Therapeutically, there is general agreement as to the
lines to be adopted in dealing with these cases, and the
utility of the nitrites is admitted by all as usually affording
the most speedy and sure relief from the anginal pain. The
prescription of iodide of potassium and of eliminant
measures, the due regulation of diet and exercise, pro¬
portioned, of course, to the degree of iutegrity of the
heart, were also spoken of with more or less approval and
unanimity.
There are few more curious or more obscure departments
in the wide field of anthropology than the subject of the
physical expression of the emotions. Why tears should
express grief, laughter joy, a blush shame, pallor fear, are
questions which we hardly ask, thinking, very incorrectly,
that we have sufficiently explained such facts when we have
said that they are “natural.” Jiut the further question
obviously arises, Why are they natural? Why should an
emotion of one kind cause an overllovv from the lacrymol
gland, while an emotion of another kind causes dilatation of
the bloodvessels of the face or a certain definite contraction
or relaxation of the facial muscles ? Such facts can hardly be
regarded as ultimate and final, needing no explanation, and
admitting of none. Jlatiier, inasmuch as all analogy teaches
us that nothing is arbitrary or purposeless, we are inclined
to suspect that there mustbosomelink between an emotion
and its physical embodiment, some purposive relation
between the outward expression and the inward feeling.
And the further we go the more light do we find in tracing
such a relation. The labours of Sir CriAitLES JIkll and
Charles Darwjn have shed a flood of illumination over
this obscure subject, and have not only explained many
things which seemed at one time impenetrable mysteries,
but have indicated sure and fruitful lines for farther
advances.
Darwin has laid down three broad principles under
which he believes may be included the explanation of most
cases of emotional expression. The first of these is that
“ certain complex actions are of direct or indirect service
under certain states of the mind, in order to relieve or
gratify certain sensations, desires, &c.; and whenever the
same state of mind is induced, however feebly, there is a
tendency through the force of habit and association for the
same movements to be performed, though they may not
then be of the slightest use. Some actions ordinarily asso¬
ciated through habit with certain states of the mind may
he partially repressed through the will, and in such cases
the muscles which are least under the control of the will
are tlie most liable still to act, causing movements which we
recognise as expressive.” Two of the clearest illustrations of
this lavv may be quoted from the lower animals. A horse
paws the ground when about to be fed in his stall, an ap¬
parently meaningless proceeding. But the explanation in all
probability is that the horse learnt to paw the ground as a
sign of eagerness to start upon a journey, the pawing being
an obvious anticipation of the muscular acts necessary for
rapid movement. Hence pawing becomes associated in the
equine mind with the idea of eagerness in general, and the
act is performed under circumstances in which it serves no
purpose. The other instance is from the cat. This animal
dislikes having its feet wet, and will shake its paws violently
if water be thrown upon them. But if water be poured
into a glass close to a cat with the characteristic noise, it
will shake its paws, although the act has in this case no
meaning or utility. The explanation is that the associa¬
tion in the mind of the cat between the pouring of water
and shaking its paws is so strong that the act is instinctively
performed even when' it serves no purpose. Examples of
the same law are found in the case of man. If a person
has forgotten a name and is vainly endeavouring to recall
it, he frequently looks upward and rolls his eyes about,
probably an unconscious effort to increase his field of vision,
experience having shown him that in other matters this is
one means of discovering some desired information. A
young child when enraged shuts its eyes tightly in the act
of crying. This is probably to protect the eyeballs against
the increased pressure in the bloodvessels, which results
from the violent expirations in crying. The same child, if
only slightly annoyed, will wrinkle the skin about the eyes,
a ])arbial performance of the act performed in violent
crying, but under circumstances in which it serves no
useful purpose.
Darwin’s second principle is that of antithesis: “Certain
states of the mind lead to certain habitual actions, which
are of service according to the first principle. When a
directly opposite state of mind is induced, there is a strong
and involuntary tendency to the performance of movements
of a directly opposite nature, though these are of no use.”
He gives as an illustration of this law the fawning move¬
ments of a dog when caressing liis master, which may he
explained as the antithesis of the movements of the same
dog when approaching another dog in a threatening and
Digitized by
Google
Thb Lanobt,]
THE ETHICS OF GYNAECOLOGY.
[March 14,1891. 613
hostile manner. In the latter case back and tail are erect,
the body is stiff, and the hairs stand up ; while in the former
ease the movements are supple and Ilexuous, and the hair is
smooth. This principle is a very ingenious one, and would
fairly explain the facts, but it does not seem to rest upon
the same solid foundation as the former principle. We
should be inclined to suspect that the fawning movements
of the dog have some purpose and utility se rather than
believe that they are a sort of designed antithesis to other
movements. This latter idea seems to us too artificial and
hardly in accordance with the laws of evolution.
The third principle enunciated by Darwin is that “ when
the sensorium is strongly excited, nerve force is generated
in excess, and is transmitted in certain definite directions,
depending on the connexion of nerve cells and partly on
habit.Effects are thus produced which we recognise
os expressive.” This is undoubtedly a sound principle, of
which the illustrations are many. Trembling from fear is
a case in point, or the violent action of the heart under any
powerful emotion. Neither of these is serviceable—rather
the reverse,—and they are most probably explained as the
result of the overflow of nervous force along various channels.
The effect of fear or joy upon the various secretions is another
instance of the same principle. It would seem that if
under the influence of a powerful emotion, a large amount
of nerve force is generated, it must “find vent" in some
outward and physical manifestation, whether tears, cries,
laughter, muscular movements, or the like. This principle
readily accounts for such facts as “crying for joy," laugh¬
ing as the result of nervousness or embarrassment, the
twitching of the muscles under strong excitement, the pass¬
ing of large quantities of urine in hysterical attacks, the
relaxation of the bowels as the result of terror, and a host
of kindred phenomena.
The acute divisions of the gyngecological world are a
subject of anxiety and regret to the rest of the profession.
Schism is schism, whether in the Church or in science;
and, if anything, it is more unseemly and unpardonable in
the region of science than elsewhere. Here we are supposed
to be all philosophers, men in humble personal search after
truth and wisdom, too painfully conscious of the difficulties
of the quest for anyone to be impatient or intolerant of
another. Such a rent as we now see in the gynecological
branch of medicine—or shall we say surgery—seems to us
schism in the worst form in which it can affect or afflict a
profession. In every department of medicine unity and
harmony are virtues so essential as to have been insisted on
by every authority in the science. It is not always pos¬
sible for medical men not to differ, but it is always
possible for them to agree to differ, and to use all
diligence to abate the cleavage of disputes. This mutual
attitude of members of the profession who differ is bind¬
ing, as we have said, in all branches of medicine. Bab
if there be one section of medical work more than
another in regard to which it is most binding, it is the
gynecological section, and this for very obvious reasons.
It concerns parts deeply situated, of extreme delicacy and
interest, and in regard to which diagnosis is obviously
diflieulb. And, finally, the operative proceedings arising
out of such diagnosis often are mutilatlve and defunc-
tionising to an extent comparable to few other opera¬
tions in surgery. The responsibility of the operator is
extreme. The most distinguished gynecologists differ
among themselves as to points that would seem not to
be so abstruse. One authority says it is quite easy to
define an ovary—another not so. One says serious disease
of the appendages is attended with menorrhagia, another
with amenorrhcca. One sees danger in flushing the peri¬
toneum, another does it almost daily; one says drainage
should be abolished, another that it is most valuable.
More thau this, the teaching of experts to errors in the
organs of reproduction has undergone a wholesale change
within a very few years, and the incidence of blame has been
transferred largely from the uterus to its appendages.
There is yet no guarantee that we shall not have other
equally great changes announced. Our point here is
this: if there be all this difference of practice, as we
know there is difference of diagnosis and prognosis among
gynaecologists themselves, what slight control can the
general practitioner have over the fate of a patient sup¬
posed to be affected with disease of the appendages ? In
most other cases his opinion as a man of large experience
will enable him powerfully to guide his patient. Here the
sufferer is much more dependent upon expert opinion. For
all these reasons it is important that those who devote
themselves to this branch of the healing art should be
controlled by the strictest ethical^ traditions of the profes¬
sion. They should be extremely reluctant to remove parts
which they cannot restore, or to act without giving most
respectful and careful consideration to the opinion of those
who hold different views from theirs, either as to the possi¬
bilities of medical cure, or the right of the profession to
remove organs whose function is only less precious than life
itself, and in the absence of which the whole outlook of life
is changed. We shall be told here that it is no worse for
the operator to remove appendages than for nature to dis¬
organise them. The case is very different, and nature can
bear a much heavier responsibility than any poor human
being. Besides, is it not true that many of these cases undergo
remarkable changes within a reasonable time ? and is it not
often the case that women for years sterile lose their
sterility and become the happy mothers of children ? For
all these reasons we hold that at tins juncture in gynmoo-
logy it is the duty of experts themselves and of their
colleagues to surround these operations with precautions
and hindrances over and above those of other operations.
The exact nature of these need not be defined, but they
should include due consultations concerning any projected
operation, a full statement of the history of the case and
the diagnosis of each case before operation, an exhaustive
pathological report by the pathologist of the particular
hospital of every specimen removed, and an equally careful
report of the progress of the case immediately afterwards,
and for as long a time as it can possibly be traced.
We are not unmindful of the easy-going conservatism of
older minds, which are apt to lose faith in the progress
of our art, especially when their own fame and ease are
assured. This conservatism has to be fought against,
and we are prepared to fight against it, and to join all
careful workers who advance the medical art on sound lines.
What is more, we are prepared to believe that in this very
Digitized by
Google
SU ThbZ4Akoet,^
THE CERTIFICATION OF FITNESS FOR CHILD LABOUR.
[March 14,1891.
controversy this conservative spirit does count for some¬
thing. But we believe that it does not count for much, and
for the following reasons. First, the natural objections to
the operation under discussion are strong enough to explain
the antipathy that exists in most minds to them. Secondly,
many of the chief objectors are young men who have a keen
love of surgical procedure when entirely justifiable.
Thirdly, mere blind conservatism and satisfaction with the
actual are not the force now that they were, say, in the days
when ovariotomy first came to be practised. Great revolu¬
tions in surgery have happened since then. The greatest
revolution of all is in the growing conservatism of surgery
itself, that spares so much that it used to sweep away, and
saves what it used to amputate. We take up no extreme
position. We admit that there are eases which justify the
mutilation in question. But we submit that the whole effort
of gynmcologists and of the profession should be to reduce
them to a minimum, and that these operations should not be
undertaken without such precautions as we have indicated.
^niurtatkns.
•• Ne quid nimls."
THE CERTIFICATION OF FITNESS FOR
CHILD LABOUR.
It is only uttering a truism to say that fitness alone can
qualify for work, yet this very obvious truth appears to be
doubted by the authorities concerned in the regulation of
child labour. Up till the present time the employment of
children under the Factory and Worlcshop Act has been
subject to their certification in respect of sufficient school
education, age, and physical fitness. It has recently been
proposed to reduce even the modest compass of this in¬
quiry. This will be accomplished by limiting it to the two
conditions first mentioned, the mutual interest of parent and
employer being relied upon to protect a weak or unhealthy
child against the consequences of overpressure. Experience,
we fear, will not justify this reliance. The evident assump¬
tion is, nevertheless, that the child in his teens must be able
to work, and no longer requires to be certified or inspected.
He will do for what he has to do. This argument, however,
though plausible in its general aspect, does not adapt itself
to the case before us. It must be remembered that the whole
structure of State regulation as applied to labour is founded
on the necessity of maintaining due adaptation between the
worker and his work. Fitness is its very key-note. What¬
ever is omitted, therefore, we cannot agree that official super¬
vision with regard to this primary consideration can be dis¬
pensed with, but would rather witness its closer application.
As matters now stand, indeed, cases might be quoted which
will amply suffice to prove that many parents are quite
unable to gauge the working power of their children, and that
a real necessity exists for the services of the certifying
surgeon.
Messrs. Rickards, Hall, Nunneley, and Wright, the
certifying surgeons under the Factory Acts of the Leeds
district, have set an example which may well be followed
by the factory surgeons of other districts. After intimating
that if time be given them they will be able to tabulate the
number of rejections they have felt it their duty to make,
they mention various cases in which they pass persons with
qualifications, or stop them in some trades, as the llax and
ready-made clothing, for short periods to clear them of
itch, ringworm, sore eyes, &c. For this work the public, if not
the employers, ought to he thankful to them. They stop con¬
valescents from scarlet fever and other infectious diseases
from returning prematurely to work. Among recent cases
they specify the following, which ought to open the eyes of
the Government. Six cases of syphilitic sores of the mouth
have been detected in glass blowers. Men and boys
alternately use the same blowpipe. A cose of scarlet fever
fully developed has been prevented working amongst a large
number of women and children. A convalescent from
small-pox still infective. A girl who had previously lost
one eye has been prevented working among dust. Her
other eye was found unhealthy by the surgeons, not by her
friends or the foreman. A girl in an early stage of con¬
sumption has been prevented working in a dusty flax mill.
Two epileptics have been prevented working among
machinery, in spite of the urgent solicitations of the parents
and foreman. It is by such instances as these rather than
by great array of figures that the function and uses of the
factory surgeons are to be demonstrated. The time between
now and Easter should be used to accumulate such informa¬
tion for the benefit of the committee to which the Factory
and Workshop Bill has been referred.
THE COLD BATH TREATMENT IN TYPHOID
FEVER.
Mr. F. F. Hare, M.B., resident medical officer of
Brisbane Hospital, Queensland, contributes to the Prac¬
titioner (March) a very well ordered study of the effects of
cold baths in the treatment of typhoid fever. The number
of cases dealt with is surprisingly large, and affords every
opportunity for arriving at reliable statistical results.
Thus a contrast is made between the cases treated during
the sixteen months, August Ist, 1888, to Dec. 3lst, 1886,
on the “ expectant plan,’’ and those from Jan. 1st, 1887, to
Dec. Slst, 1889, when the bath treatment was thoroughly
carried out according to Brand’s directions. The gross
result was an improvement in mortality amounting nearly
to 50 per cent. Thus on the expectant plan there were
treated 586 cases, deaths 85, mortality 14'50; under the hath
treatment 1173 cases, deaths 92, mortality 7'84. Dr. Hare
points out certain fallacies which are likely to arise in
every such inquiry, particularly those due to a too liberal
extension of the term “typhoid,” and those to the varying
severity of the disease at different periods; and then dis¬
cusses the special value of the treatment, the success of
which is proportionate to its. commencement early in the
disease. He shows that the liability to intestinal per¬
foration and hjemorrhage is unaffected, so that no reduc¬
tion in the general mortality below 5 per cent, (the rate
due to these accideute) can he expected. The greater
liability of males to these complications gives a vastly
better prognosis under the bath treatment to female
cases; but at the same time he points out that in
moderating the diarrhoea and in sustaining the vital
powers the patient is better enabled to resist the
ellects of hemorrhage and “other not necessarily fatal
intestinal conditions.” Lastly, he reaffirms the position
assumed by former advocates of the measure as to its
chief efi'ect in reducing mortality, for he says : “The vast
bulk of the reduction in mortality is due to the prevention
of those complications and modes of death which, being
more or less common to the febrile state, however induced,
have been termed pyrexial. Thus (a) fatal pneumonia has
been less than one-fourth as frequent, this being chiefly
due to the rarity of the bronchial form; {b) brain complica¬
tions have been leas fatal and brain symptoms (delirium,
stupor, &c.) enormously reduced in frequency; while (c) it
is no exaggeration to say that simple cardiac failure would
have been practically expunged from the list had all the
oases admitted come under treatment during the first week
of the disease.”
Dic::'zjd by Google
The Lanobt,]
THE LINCOLN WATER-SUPPLY.
[March U , 1801. 615
THE CIRCULATION OF THE BLOOD IN
THE BRAIN.
Db. B. Levy has published in Virchow's Archiv an ex¬
tensive series of careful mathematical researches, the result
of which entirely contradicts that previously obtained by
Geigel, who contended that constriction of the arteries pro¬
duces an increased blood-supply, and that their dilatation
causes the supply to decrease. Dr. Levy insists that physio¬
logical supply of blood to the brain is regulated in the same
way as in all other organs—that is, the dilatation of arteries
produces an increase, and their constriction A decrease, in
the current of blood. Venous congestion leads to arterial
ansemia. Acute compression of the brain, caused, for
instance, by a foreign body penetrating the skull, causes
arterial anromia. Dilatation of arteries beyond certain
limits—caused, for instance, by inflammation—produces
arterial anmmia. Extensive depletion of the capillaries
leads to a perversion of the blood-supply ; so that dilata¬
tion of the arteries then produces aneemia, while contraction
leads to hypermmia. The supply is consequently not in¬
fluenced physiologically by the fact of the enclosure of the
brain in a firm unyielding case. The opening of the cranium
likewise does not alter the supply.
THE LINCOLN WATER-SUPPLY.
The attitude of the Lincoln Corporation towards the
subject of their water-supply must be judged of from
two points of view. The first is that of widespread
publicity such as is involved in a letter which has
been carefully drafted in committee, and which is to be
sent to the Local Government Board. This letter prac¬
tically says that the diarrhoea complained of in the city
cannot be proved to have been caused by the water-
supply; that all the water does not come from the river
Witham; that the sewage effluent received into this
river does not affect the water to an extent that would
secure its condemnation by the chemist; that even if the
complaint were just the circumstances of the past season
were exceptional; that the power of the central authority
to compel the city to get a supply from other and less sus¬
picious sources is limited by certain statutory restrictions;
but that, notwithstanding all this, a special committee
shall inquire further into the matter. It is, we fear, not
difficult to read between the lines of this letter. It prac¬
tically means that the majority of the committee prefer
running a risk such as that involved in the meteorological
conditions of the past season, to spending money on pro¬
viding a supply that shall not, in part, consist of sewage
eillaent, which on occasion has been found to be chemi¬
cally altered before consumption. But the debate which
followed, and which will not accompany the official
document, opens up another phase of the question. The
want of unanimity in the compilation of the letter became
evident, one councillor stating that he had opposed it
in committee, and that he still objected to it. Another
said that although no “ very disastrous results ” had ensued
from the use of the water, they ought to have a “purer”
supply; and Dr. Lowe, who in his speech evinced the
utmost desire to save Lincoln from the effect of any exaggera¬
tion of the facts, could dolittlemore than explain that so far os
mere results, as shown by actualdeath rates,were concerned,
the habit of using a water “ drawn from a source which might
at any time become dangerous ” had not yet done the mischief
which such supplies have often done before and such as has
recently been done so disastrously in the valley of the Tees.
It is admitted that owing to the attitude of The Lancet,
amongst other papers, Lincoln stands medically condemned.
It can only remain so until its water-supply is such as to
make it impossible for any medical man to refer to this
necessary of life and health in terms so significant of risk
and of danger ae those which are embodied in the sentence
which, according to the local press, emanated the other day
from one of Lincoln’s town councillors, who spoke with the
authority of one who has had medical training and ex¬
perience.
THE EPSOM COLLEGE NATURAL HISTORY
SOCIETY.
An interesting appanage to the Epsom College is the
Natural History Society, the report of which for 1890 is
now before us. Under the fostering care of Mr. J. S.
Jackson, the President, in conjunction with the Head Master
of the school and other gentlemen, the Society has acquired
a very useful position, and must prove a valuable adjunct
to the educational advantages of the College. The report
contains epitomes of instructive lectures on various topics
germane to the scope of the Society, such as one on
Luminous Animals, by Mr. F. A. Heron; another on the Iden¬
tification of Birds, by Mr. Macpherson ; and a third on the
Flight of a Bird, by Mr. W. Hubert; whilst Sir E. H.
Sieveking has contributed a paper on Epsom Salts, in
which paper, after premising that “Epsom” is a Cockney
corruption of “St. Ebbisham,” he pleasantly recalls the
history of the place with its famous sulphate of magnesia
well. A summary of meteorological observations during
the past year concludes a report which is as satisfactory in
ite contents as it is indicative of the healthy activity of the
College. _
HEAT CENTRES IN THE NERVOUS SYSTEM.
At a meeting of the Cambridge Philosophical Society, on
Monday the 9th inst.. Dr. J. G. Adami read a preliminary
communication upon certain points in regard to the func¬
tions of the cerebral heat centres. After indicating how
uncertain is our knowledge concerning not only the position
and exact nature, but also the very existence of, definite
cerebral beat-regulating or heat-producing centres, he
described certain experiments made by him in M.
Metschnikoff’s laboratory at the Institut Pasteur, Paris, to
determine whether substances inducing typical fever
in the intact animal lead to any rise of temperature
when injected into the animal deprived of its hemispheres.
Employing for this purpose the hen, he found that for the
first few days after the removal of the cerebrum, when
evidently the shock caused to the system is still persisting,
the temperature-regulating mechanism is thoroughly dis¬
organised. Place the hen in a chamber warmed to 22® C.
(71 ^“F.) and the rectal temperature rapidly rises in the
course of a few hours to, it may be, several degrees above
the normal; remove it to a room at 16® to 18® C. (60-66° F.),
and for some hours the temperature as rapidly falls, though
there is a tendency for it to eventually rise again. No
corresponding temperature changes, it is needless to say,
occur in normal hens when exposed to such slight variations
of external warmth. Give the animal 1.5 ccm. (two drachms)
of cold water by the mouth and the temperature os measured
in the rectum falls through 1° F. or more in the course of
forty minutes. Again, feeding with warmed egg—a rich
proteid diet—induced a rapid rise of body temperature.
The temperature being so liable to variation it was diffi¬
cult to determine the suitable moment at which to
inject substances which, in the ordinary hen, cause a
ti-ansient experimental fever—as, for example, sterilised
cultures of the vibrio Metschnikovi. Yet Dr, Adami
managed to gain clear indications that these substances,
when injected under proper conditions into the hen
deprived of its hemispheres, do lead to a marked rise
of temperature—a rise of as much as 2® C. (3'6° F.)
in the course of six hours, continuing afterwards at a slower
rate for some considerable period. Whether such rise is
Dic::'iecl by LjOOglC
B16 The Lancet,]
THE VOLUNTEER MEDICAL STAFF.
[March 14, l'89l.
truly febrile or not (which can only be determined rightly
by calorimetric observations), and whether it can be pro¬
duced in fowls minus their hemispheres at a later period,
when the system is in a more stable condition, are matters
which have yet to be investigated, and which Dr. Adam!
hopes to determine in due time. In the discussion which
followed Sir George Humphry, Professor Roy, and Dr. Lea
took part.
THE VOLUNTEER MEDICAL STAFF.
It is only natural that a feeling of disappointment should
possess the members of the Volunteer Medical Stafi Corps,
who have this year been excluded by an order from the War
Office from their usual share in the Easter manceuvres. The
reason assigned—namely, that it is desirable to test by
actual practice in the held the efficiency of the trained men
ordinarily included in the brigades—carries at best a sort of
unsatisfactory conviction. It is doubtless well that the
field ambulance men should have their due share of practical
training, but need this imply the enforced idleness of
the Staff Corps? For the purpose of training, which,
we take it, is the primary object of manoeuvres,
the attachment of a few additional members to the
strict numerical strength of the regiments engaged could
not fail to promote the efficiency of all concerned in
rendering aid to the wounded. If, on the other hand, the
field operations are intended to gauge the proficiency at¬
tained by the ambulance men when thrown on their own
resources, what are we to understand as the function allotted
by authority to the medical staff in a general mobilisation ?
Are the latter intended as reserves for the field service ?
Then in that case they should surely be afforded an oppor¬
tunity of seeing actual field work with a force, and
arrangements might have been made to provide the required
hospital accommodation. An omission of this kind is a
conspicuous want in the system of training by means of
manoeuvres, and, in our opinion, the War Office would do well
to reconsider the matter.
THE SEWAGE OF GUILDFORD.
The urban sanitary authority of Guildford have taken a
substantial step in a direction that has long been needed,
both in the interests of the town and of those who dwell on
the river Wey. They have unanimously passed a resolution to
purchase from the Earl of Onslow a definite plot of land for
the purposes of dealing with their sewage. As yet they do
not tie themselves to any special process of dealing with the
contents of the sewers when they reach the site in question,
but it is understood that the scheme will involve some
chemical process.
THE GENERAL MEDICAL COUNCIL.
The minutes of the recent meeting of the Executive Com¬
mittee of the Medical Council contain references to several
subjects which must shortly engage the attention of the
Council itself, and which meantime have interest for the
profession. A severe rebuke on the subject of defective
preliminary education comes from an unexpected quarter.
The Secretary of War intimates to the Council that he has had
before him a reportfrom the Director-General of the Medical
Staff on the “ manifest deficiency in orthography prevalent
amongst the young medical officers of the army.” This
fault has of late so obtruded itself on the notice of the
military medical authorities that a special clause has been
introduced into the regulations for admission to the Army
Medical Staff, to the effect that the Secretary of State re¬
serves to himself the power of making bad spelling a cause
of rejection. The defect in question has long been re¬
cognised by the Medical Council. It is often very apparent
in the examination papers. But it must now be brought
home to the bodies whose carelessness in the preliminary
examinations allows of this scandal.
The Local Government Boards of England and Ireland and
the Board of Supervision in Scotland have given very favour¬
able replies to letters from the late President of the Medical
Council, seeking to gain permission for the sanitary officers
under their control to give instruction in the practical details
of sanitary work. The Registrar laid on the table stitched
copies of the Medical Register, the Dentists’ Register, and
the Medical Students’ Register, which, he stated, he had
got into type much sooner than had ever before been accom¬
plished. We defer, however, any notice of these works until
they are completed. _
THE PORT OF LONDON.
In the report on the Port Sanitary District of London for
the second half of 1890 we learn that 7914 vessels were
inspected, and that, amongst other results which were
brought about, 103 structural alterations were effected,
besides 84 which were not completed and approved at the
date of the report. The admissions into the Port Hospital
for Infectious Diseases were 22 in number; and the system
of compulsory notification of disease which is carried out
led to the adoption of numerous precautionary measures
which benefited the port, the crews, and other persons afloat,
and also the population of the metropolis, which would
otherwise have been largely at the mercy of imported
infection. In short, the sanitary administration of the
Port of London, which is carried out under the imme¬
diate supervision of Dr. Collingridge, is steadily effecting
improvements which are far-reaching in their influence. As
to the Thames, Dr. Collingridge has nothing good to say.
I If the attempts to deal with a portion of the huge mass of
sewage coming from the metropolis have been of any benefit,
such benefit is counterbalanced by the increasing flow of
■sewage which goes on year by year; and the sewage is
I reported to be, for any practical purposes, unaffected by
the chemical processes carried out. In dealing with the
' canal boats, Dr. Collingridge points out the measures taken
; to effect the improvements permissible under statute, but
! he still maintains that such craft cannot possibly, by reason
of the size of the cabins, ever be made fit places for young
women and children to live in.
SYRINGOMYELIA.
In a recent number of the Progrds Medical there is
reproduced a lecture by Charcot on 'this obscure and
interesting condition. This lecture, however, has more
than a passing Interest, for it directs attention to a series
of signs and symptoms not formerly described, so far as we
are aware, in association with the condition known as
syringomyelia. The patient who was the subject of the
lecture was first seen in 1875. He was at this time
twenty-five years of age, an officer, presenting weakness of
the whole of the left side of the body. The leg was much
weaker than the arm, there was marked rigidity, difficulty
in directing the foot in a given direction, and a great
tendency to inversion of the foot. The knee-jerk was
exaggerated, and the whole condition, Charcot says, was
suggestive of infantile hemiplegia, with a certain amount
of athetosis. In the previous history of the patient there
was nothing to throw any light on the present state. He
had always been strong, and came of a healthy stock. He
was very fond of horses, and had had several accidents in
connexion with them, but apparently nothing of any moment.
He had first noticed slight weakness of the left side when
he was of the age of ten, but this had not been marked;
and although it had increased, it was nob sufficient to pre¬
vent him from serving with his regiment in the Franco-
Prussian War. While on service, however, he had one day
Dig.:.jed _jOO^IC
Thb Lancet,]
THE PHONOGRAPH IN MEDICINE.
[March 14,1891. 617
^reat weakness of the left side of the body, and although
this passed off to a great extent in the course of the day the
weakness had again increased until he came under observa¬
tion in 1875. He was nob seen again until last year, and
♦during the fifteen years that had elapsed considerable
■changes had taken place. He now had a well-established
condition of left hemiplegia with rigidity and contracture,
^greater in the leg than in the arm, exaggerated reflexes,
a.nd naturally almost complete loss of power in both leg and
arm. The limbs on the right side were quite normal.
'There was no muscular atrophy, but there was almost com¬
plete loss on the left side of the sense of temperature, and
«uuch impaired sensibility to painful impressions. There was
<al 80 a peculiar condition of the left hand. It was broad and
olumsy-looking, there was enlargement of the fioger-joints,
«,nd the hand, in short, closely resembled that of a patient
suffering from acromegaly. There was also some trophic
•change in the cicatrices in the lumbar region where the
cautery had been applied in 1884 or 1885, audit is note¬
worthy that this application had been unaccompanied by
^anything more than very slight pain. It is evident that
this case presents many points of difference from what is
(regarded as the type of syringomyelia. In the latter, while
’the impairment of temperature sensibility and of sensibility
to pain are present, they are usually accompanied by
muscular atrophy. In this case the absence of this
cardinal sign is noteworthy,^and so is the oae-sidedness
■of the lesion. Of course, there is no absolute proof
'that the diagnosis is correct, hut if the further progress
of the case should confirm it a good deal of light
will probably be thrown on the considerable class
•of cases of lateral sclerosis of alow and gradual onset; for
■the patient under consideration, when seen fifteen years
ago, showed nothing more than well-marked symptoms of
•such a condition. As the changes in sensibility and in the
trophic functions are, however, the only signs which are
(relied upon for the diagnosis, it is evident that in the
^)re3ent state of our knowledge of the tract by which such
impressions are conveyed an absolute conclusion can scarcely
be arrived at.
THE MEDICAL SERVICES.
Among the latest items of intelligence from India we are
mot surprised to learn, according to The Times’ correspon-
•dent that the medical ollicera in India are not at all satis¬
fied with Mr. Stanhope’s concessions, which they regard as
valueless. A feeling of disappointment and irritation, it is
alleged, pervades botii the British and Indian medical
services, and it is understood that a defence fund is to be
raised in order to promulgate and support the views enter¬
tained by the medical oliicers on this subject.
DAMAGES AGAINST PRINCIPAL AND
ASSISTANT.
At the Manchester Assi/es a very painful case was tried
^n an action for damages by Mr. Moses Brlerley for the
-death of his daughter, caused by her taking prussic acid,
which had been given her negligently and in mistake
■for medicine by Mr. Myles, the assistant of Dr. Clegg.
•Dr. Clegg was called to see the deceased and used the
stomach pump, but witliout avail. Tlie lamentable mistake
^lappened in tlie most casual way. The deceased was bar¬
maid at an hotel where Mr. Myles called for refreshment.
<5ut finding the barmaid ill, Mr. Myles volunteered to
'fetch some medicine for her. Ho made some up at
the surgery, and at the same time filled a bottle witJi
iprussic acid for use at another branch, He left the
wrong bottle with Miss Brierley, without any label on
nt. Before he had time to correct the mistake she had
taken the dose he had instructed her to take, with of
course a rapidly fatal result. The father claimed damages
for the loss of her services. The jury awarded him
£100—£75 against Dr. Clegg, whoso assistant Mr. Myles
was, and £25 against Mr. Myles. The judge had laid
down that Dr. Clegg was liable for the acts of bis
assistant. We deeply lament the accident, and, with
all respect to the judge, venture to doubt the absolute
accuracy of his ruling. It is a striking proof of respect for
Mr. Myles that in connexion with this incident he was pre*
sented by the inhabitants with a sum of thirty guineas.
THE PHONOGRAPH IN MEDICINE.
The applicability of the phonograph to the record and
demonstration of defects in speech has been well illustrated
during the past week at the Royal Medical and Chirurgical
Society and at the Hunterian Society. At the first-named
Dr. Hale White and Mr. Golding-Bird were enabled by
means of this instrument to allow the Fellows present to
bear the curiously defective speech of two children, and to
contrast this with the improvement effected by treat¬
ment, for the subjects were present, and after
the phonograph had given theii* past utterances,
their present speech was demonstrated vivd voce. The
papei-s read by the above gentlemen and that by Dr. F.
Taylor led to an instructive debate, which was further
illustrated by some marked cases introduced by Dr
Hadden. The outcome seemed to he that these defects in
articulation are probably of central origin, and not due to
any mechanical interference with the organa of speech.
Whether, as suggested by Dr. Langdon Down and Mr.
Spencer Watson, the defect was primarily one of audition is
a question certainly worthy of consideration. Another
point raised was whether the defect should he considered
one of speech or language, and some exception was
taken by Dra. Taylor, Pye-Smith, and others, to
the use of the term “idioglossia," which, however, was
ably defended by Dr. Hale White. The other phonographic
demonstration at the Hunterian Society was by Dr.
Uughlings Jackson, who thus reproduced the characteristic
speech of a subject of cerebro-spinal sclerosis. There can
be littla question that the phonograph will ultimately
prove very useful, especially in the preservation of certain
anomalies of articulation, and its further extension to
other sound phenomena in the range of clinical medicine
may be justifiably hoped for.
HEMIOPIC HALLUCINATIONS.
I’l' is several months since Dr. Peterson of New York
published a case of delusional insanity in which the visual
hallucinations always appeared in the right fields of vision,
and in a recent number of the ^cto York Medical Journal
he takes occasion to refer to the occurrence of this condi¬
tion in association with symptoms other than those of mental
disturbance. Although in the case which Dr. Peterson pxib-
lished hicmianopsia was not present, it is only natural that
the two conditions should as a rule be associated. Thus iu
,l)r. Ssguin’s case, that of a woman who after the birth of
a child experienced a sudden “ snap ” in the left temple,
and who subsequently had right hiotnianopsia, there were
at first in the blind fields visual images of a few simple
objects, such as a chair, a chicken, &c. In another case,
which appears for the first time in the paper under
notice, a woman soon after the birth of a child
experienced pain in the head and began to have trouble
with her vision, everything appearing blurred and
indlslinct. When this had lasted some time sfie observed
that to the left of the middle line all was dark, and a
month after she noticed that visual images appeared in the
blind region. The images were those of cats and dogs and
Digitized by
Google
618 Thb Lancet,]
THE NOTIFICATION OF MEASLES.
[March H, 1891.
children, who arranged themselves in rows and formed pro¬
cessions, the children moving in circles, the animals remain¬
ing still. This continued, except of course during sleep,
for four weeks, the vividness of the scenes and the dis¬
tinctness of the images being increased by fatigue and
during attacks of headache. Beference is also made to
the occurrence of similar phenomena in epilepsy and
migraine; and, in conclusion, four cases of hemiplegia
with hemianopfia, in which visual images appeared in
the blind fields, are quoted from the recent work of
Henscben. In two of those cases there were necropsies, and
although in both there was found a diseased condition of
the occipital lobe, other lesions were present. In his re¬
marks on the cases Dr. Peterson offers the explanation that
those hemiopic hallucinations are the result of irritation of
the cortex, such irritation in organic disease being pro¬
duced at the seat of the lesion, while in a disorder like
migraine vascular spasm and consequent anmmia are
regarded as the cause of the irritation. To explain the
occurrence of the phenomena in his case of delusional
insanity, Dr. Peterson supposes that some mild nutritive
disturbance of the occipital cortex took place—a disturbance
similar to what may account for the hallucinations of
ordinary delirium, not widespread as in the latter condition,
but limited to one part of the cortex.
THE NOTIFICATION OF MEASLES.
The health officer for Newcastle-upon-Tyne has brought
under the notice of his town council the subject of the
notification of measles, with a view to the prevention of
this disease, and at their request he has sought information
on the subject from a number of other boroughs. We
cannot say that the main body of this information is par¬
ticularly helpful, for it amounts to bub little more than
statements from towns where the system lias not been tried,
and where, in consequence, no experience on the subject
was available. There seems, however, a pretty general
consensus of opinion that school attendance diffuses the
disease on a wide scale, and that, in order to prevent this,
children who come from infected houses must be kept away
from school. It is difficult to see how such a scheme
can ha successful unless notification is carried out, for it is,
above all, the early attacks that it is so needful to control,
school closing at the height of an epidemic being a much
more clumsy and doubtful remedy. Seven large towns
with no notification of measles are dissatisfied with
their existing method of dealing with the disease, and
although there is no such expression of dissatisfaction
from towns where notification is carried on, yet the infor¬
mation supplied rather tends, by reason of its paucity,
to imply that systematic effort to deal with the information
when it is acquired is by no means so general as it should
be. On the whole, we think that a good case is made out
by Mr. Armstrong for notification of measles, but if it is
adopted it should be pub to a thorough test by the strict
application of exclusion from school of all children having
any signs of measles or coming from infected houses, and
this should be maintained for a sufficient period of time to
enable a proper judgment of its value to be come to.
Where this is not intended it will probably be of Utile use
to adopt the system, and the difficulties attendant on the
needed organisation have probably induced a number of
health officers to say that they hardly advocate the system
at the present moment. A very common reason alleged
against it is the expense that would be involved. As to
this, we. would observe that expenditure incurred in the
prevention of infectious disease is by no means an altogether
unremuoerative one, and it must also be remembered that
the annual average of some 13,000 deaths from measles in
this country, besides involving a great waste of human life.
must also necessitate a great and a useless expenditure.
When this number is multiplied by ten, so as to give a
total of 1.30,000 cases—which is probably a low estimate—
the waste of money in connexion with a preventable
sickness is seen to be enormous.
MEDICAL SOCIETY OF LONDON.
The annual dinner of this Society, which took place af>
the Whitehall Rooms of the Hotel MdbropOle on Saturday
last, was certainly the most successful in its annals. The
Fellows of the Society and their guests were present to the
number of over 150, a pleasing innovation being introduced',
that of inviting as guests distinguished members of pro¬
fessions other than the medical. Mr. Knowsley Thornton
occupied the chair, and amongst those present were Sk-
Jaraes Paget, Sir George Humphry, Sir Andrew Clark,.
Sir William Savory, Sir Joseph Lister, Sir William Roberta,
Sir Joseph Fayrer, Sir J. Crichton Browne, Sir Dye©
Duckworth, Dr. Douglas Powell, the President-elect, and
the Presidents of the sister societies. Sir H. Selwyn-
IbbetsoD, M.P., Sir John Bridge, the Master of the>
Merchant Taylors’ Company, Mr. H. A. GifFard, Q.C,, and
Colonel Melville, R.E., were also present. In proposing
the Medical Society of London, the President made feeling
allusion to the loss the Society was sustaining in the retire¬
ment through ill-health of the registrar, Mr, Poole, who;
had performed his duties most ably for a great many years.
A long toast list was successfully disposed of, many of tho
speeches being of a high order of merit, and an excellent
musical programme, arranged by Dr. Charles Boevor and
Dr. Charles Sheppard, added greatly to the enjoyment oS
those present. _
THE CANTHARIDiN TREATMENT OF
TUBERCULOSIS.
At the meeting of the Berlin Medical Society on the 4bb
inst. some members related their experiences with Professor
Liebreich’s new remedy for tuberculosis, the cantharidinat©
of potash ; and one cannot fail to be struck not only by th©
caution displayed by the speakers, but by the manifestly
slighter disturbance produced by this remedy as compared
with Koch’s tuberculin Dr. Saalfeld showed the case of
a child with lupus of the cheek; there had been live injec¬
tions, commencing with half a decimilligramme, and the
only effect so far had been some flattening of the elevations,
some shrinking of the affected area, and a paler colour.
Dr. Landgraf gave his experience of the remedy in laryngeal
cases, and summed up bis results in the declaration that-
the remedy in repeated doses produces (odemaof the mucous
membrane when this is chronically inflamed; that evens
small doses cause increased expectoration, and that tl:©
signs of cedema rapidly disappear. His evidence confirraa
Professor Liebreich's statement that the action of the drug
is to promote exudation of serum from bloodvessels, but Dr.
Landgraf considered that the curative effect of this wa&
still an open question. Dr. Lublinski, who liad injected
sixteen cases, alluded to the fact that there was some pain
excited by the method, and he had seen headache, diarrhcca,
strangury, and slight haemoptysis follow it, although he
had never exceeded two decimilligrammes. Ho, too, had
noted increased expectoration in laryngeal and pulmonary
cases, and had seen ulcers in the larynx rapidly heal,
and a diminution take place in the size of lupus patches.
Dr. B. Fmenkel had noted improvement in cough and
diminution of rJlles in a case of pulmonary phthisis, and iu
two others a notable subsidence of the hectic fever. He
had met with strangury and albuminuria as a consequence
of the treatment, which, in view of the renal troubles, he
urged should be employed with the greatest caution.
Professor Liebreich referred to a case of lupus which wp*
lOogle
Diaiuzed l
Thb Lanobt,]
A NEW DANGER TO LONDON.
[March u, 1891. 619
showing marked improvement, and dwelt upon the fact
that no rise of temperature is caused by the injections. As
to the cantharidinate being a specific, he said that it was
80 in the Sense of its acting upon the locus a^ectus, but not
in the sense of its powers being limited to one special form
of disease; and he hinted that serum therapeutics ” might
be found applicable to many other diseases besides tuber¬
culosis. _____
ENGLISH MEDICAL PRACTICE IN PARIS.
The editor of the Anglo-American “Annual” (248,
Kue de Kivoli, Paris) writes us to say that the “ Annual ”
contains a list, supplied by Dr Bull, the bon. secretary of
(the Continental Anglo-American Society, of all the English
and American practitioners. The “Annual ” has been sent
gratis to all the principal hotels of the city. The list, revised
and corrected, may be seen on page 65 of the “Annual.” It
as a matter of importance that, if such a list must be pub-
iished, it should be as destitute of mere advertising qualities
as possible. The bare name, qualifications, and address
should be given, without pretences of specialism. We
think the diplomas and their sources should be stated. We
regret that such an expedient should be called for, but the
recent revelations as to the interested and haphazard way
un which Anglo-Americans are informed as to available
medical help renders this course almost justifiable. We
should advise all our compatriots to seek disinterested
advice in the selection of a medical man from respon¬
sible and respectable residents. But failing this, and in
•emergencies, the list given in the “Annual” should be asked
tfor and consulted. -_
“A NEW DANGER TO LONDON.”
Under the above heading we have recently published a
tetter protesting against the creation of a depftt for dust¬
bin and other refuse on the ground left vacant by the de¬
molition of Millbank Prison. Further correspondence on
this subject has now reached us, which, however, is too
voluminous to publish. One correspondent, we are pleased
to note, withdraws the title of a “ new ” danger to London.
The danger, in point of fast, is about as old as vestrydom,
£q the autumn of 1883 we published a Special Commission
Report on the Dustyards of London, and therein denounced
grievances even worse than that which now seems to alarm
some inhabitants of the Pimlico district. Not far ofl’, on the
cfther side of the river, there are huge refuse deposits close
by filtering beds of the Southwark and Lambeth water-
aupply. The dust blowing over into the drinking water-
eupply is a more serious danger than anything our corre¬
spondent mentimed. Also the positions occupied by many
dustyards in various parts of the metropolis are worse and
more dangerous than the site of Millbank Prison. Indeed,
this new site is likely to prove less objectionable than the
wharf formerly used by the same sanitary authorities, and
v/hich is situated within a stone’s throw of the Houses
of Parliament, and is surrounded by a dense popu¬
lation of very poor people. Such causes of in-
aalubrifcy are likely to prove more mischievous in very
poor and crowded districts than in the broader and com¬
paratively well-to-do streets such as are to be found
near the site of Millbank Prison, Wo do not by this mean
•that our correspondent has no cause of complaint. The
pity of it is that his grievance, though quite genuine, is
apparently not so great as that which previously existed.
This brings us to the conclusion we have so often urged
before—namely, that there should be no dustyards what¬
soever in any part of the metropolis. Dust sorting and
stfbing is an unwholesome industry, and as such should
be classified and not tolerated in any great city. By
water or by rail the refuse can be sent off to a safe
distance, or there are destructors by which it can be
burnt on the spot and thus rendered innocuous. To wage
war against one particular dustyard can only result in
transferring a danger from one district to another, and we
should not care to assume the responsibility of deciding
which neighbourhood is best able to bear such a cause of
contamination. We aim at a higher purpose—that of
altogether removing the danger, not from one district, but
from the entire metropolis and from all large towns.
INTUBATION AT ZURICH.
At a meeting of the Medico-Chirurgical Society of Zurich,
on the 3lst ult., Dr. W. von Muralt, consulting surgeon to
the Children’s Hospital, read an interesting paper on
Intubation. A demonstration of O’Dwyer’s.case of instru¬
ments was followed by a short historical account of the
development of this system of treatment of acute laryngeal
stenosis, and the results obtained in various hospitals on
the Continent and in America were mentioned. He said
that it was not without some apprehension that iu February,
1888, he had introduced intubation at the Children’s Hos¬
pital in lieu of tracheotomy, but he was glad to be able to
report that his fears had not been realised. It had now
been tried in a series of 56 cases, and 21 of the patients,
or 37i per cent., had recovered. In 18 of the above cases
intubation failed to afford any relief, and was followed by
tracheotomy ; only one of the cases recovered. He had
means of a fair comparison of the results obtained by
tracheotomy and intubatlou, both being performed at the
same hospital by the same operator and on the same prin¬
ciple. From 1874 to 1883 there had been 318 tracheotomies
performed at the Childron’s Hospital, and 113 patients, or
35^ per cent., recovered. Dr. von Muralt also treated a
few cases of chronic laryngeal stenosis'with success. In
the ensuing discussion, Professor Kronlcin said that although
in some suitable cases he had bad recourse to intubation,
he still considered tracheotomy the sovereign method, and
did rot think it would be superseded by intubation. His
operative results were relatively favourable, there being
about 40 per cent, of recoveries in the lest 300 or 400 cases
of tracheotomy performed ex indicationc vitali. He had
been rather discouraged by unfavourable results of intu¬
bation reported from surgical departments of German hos¬
pitals, and mentioned that some of the statistics collected
from dozens of different hospitals in different countries were
inaccurate, and had not the same value in his eyes as those
cases which had been reported by Dr. von Muralt.
THE TREATMENT OF UNCONVICTED PRISONERS.
The English law holds that, however strong the evidence
may be against him, a man must be considered as innocent
till such time as the verdict and sentence are pronounced.
This being the case, it is surprising that better care is not
taken to provide suitable accommoda'.ion for unconvicted
persons awaiting their trial. The rough treatment of
prisoners in police cells is a constant subject of complaint,
while the cells under the Central Criminal Court, which
have just been officially visited by Mr. Justice Grantham
and Mr. Sheriff' Harris, consist of solitary boxes about
7 ft. high and 4 ft. square, witli only a little hole to admit
fresh air. So impressed were both judge and sheriff
that they have brought the matter to the notice of the Lord
Mayor, and the Court of Aldermen discussed the subject.
Surely Newgate is large enough to supply convenient
rooms for prisoners awaiting their trial. With the tele¬
phone at hand there is no need to keep the prisoners cooped
up just under or close to the court. They can be brought
from the prison cells rapidly enough for all practical
purposes. It is not fair, it is not humane, to torture a
prisoner just before his trial by such close and cruel con-
Digiti^ed by LjOOQle
620 ThbLakoet,]
DANGERS OF DOMESTIC REMEDIES.
[Mabcii 14, 1891.
finement. At such a moment the prisoner should be
spared from all disturbing influences, so that he may
collect his thoughts and be in a frame of mind to make
the best defence possible. But if the prisoner is to be
subjected to prolonged suspense and confinement, not in
a cell, but in a sort of box, it can scarcely be said that
he has a fair trial. Nor does an unconvicted prisoner
deserve such treatment. We are glad, therefore, to note
that this grievance has attracted the attention of the Court
of Aldermen, and that they have summoned the governor
of Newgate and the chairman of the City Lands Committee
to attend their next meeting, to discuss the matter.
Much has been said of late in the lay press concerning the
barbarous treatment of prisoners in Russia; perhaps it would
be well if we pijt our own house in a little better order.
EXPERIMENTS ON THE ORIGIN OF PERISTALTIC
MOVEMENTS OF THE INTESTINES.
Dr. C. Luderitz publishes in Virchoxo's Archiv the result
of experiments on rabbits, to elucidate the nature of those
spontaneous movements of the intestines which carry their
contents downwards, and to decide if there is also a con¬
traction of the annular muscles, which, though tending
downwards, does not depend on the intestinal contents, but
is entirely automatic. The author finds that the excito-motor
nerve apparatus, situated in the intestinal wall, whenever
acted on by any kind of exciting cause, is affected not merely
in the place directly acted upon, but, according to the in^
tensity of the exciting cause and the existing irritability, also
in a more or less extended sphere between the original seat of
stimulus and the pylorus. This tendency of the stimulus
to travel upwards can be plainly observed only with exciting
causes, which lead to a contraction of the annular muscles.
The nerve apparatus experiences is affected by irritation,
like the grey substance of brain and medulla, the excitation
gradually accumulating until it produces muscular contrac¬
tion. A nerve-exciting cause, applied to a circumscribed
spot of the intestine, leads consequently, if sufficiently
strong, to contraction of the canal for some distance towards
the pylorus. When, however, the exciting cause acts upon
a larger portion of the nerve apparatus and in the whole
circumference of the intestinal canal, as in congestion of a
segment, the sum of the exciting causes becomes greater at
the proximal end of the segment, and contraction of the
annular muscles begins here, and takes a downward peri¬
staltic direction. This drives the contents of the intestines
to the lower end of the segment. The peristaltic move¬
ments are visible in the full intestinal coils, not in those
which are empty. The author accepts llie conclusion
Nothnagel arrived at from bis experiments in reference to
antiperistaltic movements aa correct.
DANGERS OF DOMESTIC REMEDIES.
Popular delusions, although frequently possessing
farcical characteristics, mostly end in producing disastrous
results. The craze for economy is widespread, and
perhaps inevitable when the income is small and ex¬
penses are j great. The general practitioner protests
against the prescribing chemist, and the chemist in
turn is never-ending in his denunciations of “stores.”
According to their means and opportunities, members of
the public glide down the scale from the top to the
bottom, ever seeking a cheaper market. Necessarily a
certain amount of danger attends the downward path, but
the danger is greatest when the individual essays both
diagnosis and treatment, especially if be attempts to pre¬
pare his own remedies. Doubtless there are some simple
modes of treatment which may he safely carried out; but
in the oral transmission of the details of domestic medica¬
tion the risk of a missing link has always to be reckoned
with, and, to the experienced onlooker, the problematic
nature of the sequel is intensely interesting. Happily,
it is not often that ignorance is so fatal as in the
recent instances in Cheshire. Two men have died»
and a third lies in a precarious state, as the result
of attempted self-medication. Imagining that they were
suffering from itch, the advice of a fellow workman wa&
taken, and some nitric acid and quicksilver Vere procured^
mixed and applied to the skin. The druggist had labeled
the bottles “Poison,” but he does not appear to have
made any inquiry as to the purpose for which the
substances were to be used. A verdict of “Death
from misadventure” w’as passed, and strong comments
on the ignorance displayed were made by the coroner.
To attempt to fathom the stages by which such ignorance
has been reached may seem futile, and yet it appears within
the bounds of possibility that this sad accident is really the
result of confusion. Ammoniated mercury ointment and
nitrate of mercury ointment have widespread uses. It-
seems just possible that with lapse of time simple directions-
for the preparation of the former have been muddled into-
the latter, and that in place of a precipitate a highly
corrosive and poisonous liquor has been made. The
substitution of nitric acid for ammonia, both being in
common use, seems a fairly natural error, although the
selection of liquid mercury for the solution of the per-
chloride of mercury is more difficult to follow. As it stands,
the case sufficiently demonstrates the dangers and folly of
attempting to compound remedies in complete ignorance off
the properties they possess._
WHAT IS “CHEWING GUM”?
The fine distinctions required by legal definitions fre¬
quently threaten confusion, even when the facts appear to-
be perfectly clear. There is no room for doubting the in¬
convenience and danger which may arise from the accumu¬
lation of a mass of paraffin wax in the intestines; and yet-
when any legal interference with the sale of chewing gum„
containing 50 per cent, of this substance, is attempted,
the charming uncertainties and quibbles which arise are-
more amusing than edifying. In a recent prosecution at-
the Haoley Borough rolice-court it was livsb contended
that the 1 ibh section of the Food and Drugs Act, which re¬
lates to the division of the substance in the presence of the-
seller at the time of purchase, had not been complied with.
Then it was submitted that the article was not one of food,,
since ib'was sold simply forchewing. Then it was suggested
that, as sweets are so utterly indeliaibe in their composition,,
it was impossible to deal with them as ordinary articles of
food. And the climax was reached in the contention that-
ib was not sold to the prejudice of the purchaser, as the com¬
plainant said he did nob intend bo eat it. This was
extremely ingenious, bub the purchaser happened bo be the-
inspector of nuisances, who was merely collecting evidence.
The case ended for the present with the imposition of a
fine, on the ground that the substance was sold to the pre¬
judice of the purchaser, inasmuch as it was not in the--
nature of the substance and quality of the article demanded
by the purchaser, who asked for gum and got paraffin wax,..
If the case is ever taken to a higher court, it is quite possible
that it may be argued that the complainant did nob ask-
for “gum,” bub for “chewing gum;” that he did nob geb-
“paraffin wax,” but only .50 per cent, of “paraffin wax,” aniB
the remaining 50 per cent, of unknown ingredients which
suiliciently bring the substance within the legal meaning
of “chewing gum.” But what is “chewing gum”^
The following definition might be suggested: A substance
of very variable composition, ignorantly employed by
children, which, when containing paraffin wax, may lead
to very grave dangers, and the sale of which should b&
prohibited.
Digitized by ^ooQle
THB Lancet,]
PHARMACOLOGY AND THERAPEUTICS.
[March 14, 1891. 621
FOREIGN UNIVERSITY INTELLIGENCE.
Giessen. —Dr. Philipp Sfcohr of Zurich has accepted an
invitation to the chair of. Anatomy.
Vienna. —Dr. Eugen von Bamberger, son of the late
Clinical Professor, has been appointed Primararzt in the
Rudolf Hospital. «___
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Wilhelm Strieker, the well-known medical writer, at
Frankfort, at the age of seventy-six, suddenly.—Dr. E. T.
Schurry, physician to the Saxon Court, at the age of sixty-
one.—Dr. N. Toloki, Professor of Midwifery in the Uni¬
versity of Moscow. _
In his report on the chemical and bacteriological
examination of the waters supplied to the inner and por¬
tions of the outer circle of the metropolis during the month
of January, Dr. E. Frankland, F.R.S., states that the
water taken from the Thames by the Southwark and
Lambeth Companies was inferior in quality to that de¬
livered in December; while that supplied by other com¬
panies was of a superior quality. The water of the New
River maintained a high degree of chemical purity, and
compared favourably with the deep well waters. The
results of the bacteriological examination by the method of
gelatine-plate culture devised by Dr. Koch showed that one
cubic centimetre of the water developed the following
numbers of colonies of microbes Kent, 27 ; New River,
68 ; East London (river supply), 95; West Middlesex, 180;
Chelsea, 204; Lambeth, 595; Grand Junction, 1029; and
Southwark, 2088. This process is an exceedingly delicate
teat of the efhciency of filtration, both natural and artificial,
and the elliciency may, cceteris paribus, be taken as in¬
versely proportional to the number of microbe colonies.
We have been asked to state that the first volume of the
Transactions of the Tenth International Medical Congress is
nowready for distribution among the members and associates.
Personal application may be made at the office, Jerusalem-
strasse 38, Berlin, S.W., or those who desire that their
copy should be forwarded by post are requested to intimate
this to A. Hirschwald, publisher, Berlin, transmitting the
postage for the volume, which for the Germau kingdom and
Austria-Hungary amounts to .30 pfennigs, and for foreign
countries 90 pfennigs (about lO^cf.). Due notice will be
given of the publication of the sectional proceedings.
Dr. C. S. Sherrinoxon, Lecturer on Physiology at
St. Thomas’s Hospital, has been appointed Superintendent
of the Brown Institution, vice Mr. Victor Horsley, F.R.S.,
who has resigned.
THE aUHER MINERAL WATER.
Dr. H. Pasciikis publishes in the Wiener Klinische
Wochenschrift an analysis of the Guber water of Srebrenica
in Bosnia. It is clear, colourless, without odour, and has
an acid and astringent taste. Tlie latter is so slight that
the water is taken undiluted, and even children like it; it
may, however, be taken with wine. The absence of all un¬
pleasant taste is due to the comparatively small quantity
of iron. This is a great advantage, as small quantities of
iron may be absorbed, while larger quantities interfere with
the digestion and cavise constipation. Four tahlespoonfuls
contain a third of a grain of iron and about yKth of a grain
of arsenic. Those small quantities make it immaterial at
what time of day the water is taken. The author
calls attention to the fact that when the efieeb
is to ]>e a local one, on the stomach or intestine,
the water must generally he taken fasting. If tb©'
effect aimed at is a general one, it should be taken
with food. According to bis experience, nervous dyspepsia-
and any kind of dyspepsia in neurasthenic people are tbe
most appropriate cases for treatment by Guber water. In
four cases—one man and three women—improved appetite,
a more healthy appearance, and increase of weight wer©
observed after treatment of from four to six weeks. Most-
remarkable was the effect of the water on a young woman
of twenty-eight, with neurasthenic troubles, insomnia, and
entire absence of appetite. All the symptoms had twice
entirely disappeared, but reappeared when she ceaeed to-
take the water, and again disappeared on the resumption
of the treatment. Three cases of simple chlorosis wer©
cured in eight weeks. The success in struma is doubtful.
Brilliant results were obtained by systematic treatment by
tbe water in two cases of oxaluria with slight traces of
sugar, the cure, according to the author, clearly not being;
due to any effect of arsenic on diabetes. Good results were
also obtained in furunculosis. No results, however, were
obtained in two cases of slight psoriasis ; the author
considers this want of success entirely due to the smalt
quantity of arsenic contained in three or four glasses
of tbe water, the largest quantity taken in a day. Alto¬
gether, the Guber water is a valuable addition to the-
materia medica. It is generally at the beginning of tbe
treatment taken in doses of from two to four tahlespoonfuls-
by adults or teaspoonfuls by children, undiluted or with
water or wine. The best time to drink it is just before or
soon after meals, or it may be taken early in the morning.
A favourable result is generally obtained in from six t©
eight weeks. As in the administration of all preparations-
of arsenic, the dose may gradually he trebled and them
decreased again.
ALCOHOL IN ALBUMINURIA.
Dr. Guvich has examined very minutely the effects of
giving alcohol in a number of cases of both chronic and
acute forms of nephritis in the wards of the Obukhoff Hos¬
pital in St. Petersburg, and comes to the conclusion that in
both classes of cases moderate quantities—that is to say,
from three to six ounces of spirit containing 40 or 50 per¬
cent. of alcohol—may be given daily for a fortnight without
in any way acting injuriously on the kidneys, and without-
increasing the amount of albumen in the urine. It does-
nob, he finds, exert any effect upon the quantity of urine-
secreted.
deodorisation of iodoform cv creolin.
Dr. Ludwig Vaezi, a practitioner in Nagy-Karoly, com¬
municates to tbe Mcdicinish-chirtirguiche Rundschau his
discovery of the power of creolin to deodorise iodoform,
lie had prescribed an ointment consisting of one part of’
creolin, two of iodoform, and twenty-five parts of vaseline.
On the following day he was surprised that not only was
the usual colour of iodoform ointment changed, hut that
there was no smell of iodoform and only a slight smell of
creolin. He points out how important it is in many cases
that the presence of iodoform should not be known by its-
odour, and considers creolin the very best of all deodorising
drugs for the same. It not only does not irritate, but it iS'
also itself a good disinfectant.
OLYCERINE FREE FROM ARSENIC.
It is said that arsenic may be removed from glycerine by-
adding a certain amount of recently precipitated ferric^
oxide, and allowing the mixture to stand for several hours
in a warm place. The product is then filtered, and the-
filtrate, which is now free from arsenic, is evaporated till
it has the ordinary specific gravity of glycerine, or rather
the water derived from the hydrated iron oxide is driven off
at a moderate heat until the desired specific gravity is-
obtained.
TE.5T FOR COC.MNE.
According to a pharmaceutical contemporary cocaine may
be found even in small quantities in any substance which
contains ib by the following method. The substance or-
residue supposed to contain cocaine is first purified or con¬
centrated by any of the ordinary methods until a dry or
nearly dry residue is obtained likely to be pretty rich in.
cocaine if the latter is really present. A few minims of
fuming nitrate acid (sp.gr. 1500) having been added, th©
magma is cautiously evaporated to dryness.^ The residue-
(in a small te.st-tube, capsule, or watch-glass) is then stirred
with two or three drops of a very strong alcoholic solutioi>
Dir:' 'ed by Google
622 The Lancet,]
THE ORIGIN OF THE VERTEBRATES.
[Maucii 14,1891.
of potassa, and slightly warmed. If any trace of cocaine
be present a very characteristic odour will be observed, which
greatly resembles that of oil of pepperment.
THE TREATMENT OF TYPHOID FEVER BY CHLOROFORM.
Dr. Stepp of Nurenberg gave some time ago a lecture on
the internal administration of chloroform, which in his
hands had not only proved a most useful ingredient in
lotions for the mouth and in gargles, but was also most
successfully administered in acute diseases of the digestive
organs, in chronic ulceration of the stomach, in croupous
pneumonia, and in typhoid fever. Of the latter he had
experience of six cases when he gave his lecture, which a
year later, when be made a communication to the Munich
Medicinische Wocltenschrift, had increased to eighteen. In
most of these cases he gave about six drops of chloroform
in two ounces of water thrice daily, but occasionally he
made a slight change by the addition of a scruple of
quinine. The result of this treatment, even in the severest
'cases, was that in a few days drowsiness and delirium dis¬
appeared, the dry-coated tongue became moist, and the
general state considerably improved. The temperature
fell considerably in from eight to ten days, the stage of
B'emissions was cut short, aud convalescence accelerated.
Relapses were unimportant. One case, that of a girl of
thirteen, was fatal, Go the average the fever lasted
nineteen days in severe cases, and eight days in alight
attacks. The longest continuance of the fever was thirty
'da'ys, the shortest eight days. Dr. Stepp inclines to the
belief that chloroform passes through the system without
decomposition, and so exercises an anti bacterial effect.
He never saw any ill effects from its administration, and
^considers it a useful stimulant. It is, he thinks, impossible
that the daily administration of one scruple of chloroform
could have a deleterious effect on the blood by dissolving the
corpuscles, which might very well result from the inhalation
of enormous quantities of the anfcsthetlc.
APPLICATION FOR ACNE ROSACEA.
Dr. Unna of Hamburg has produced what he believes to
be an ideal preparation of ichthyol for application in cases
of acne rosacea. It is prepared by combining it witli
starch in the following manner:—Forty parts of starch
are moistened with twenty parts of water, and this is well
rubbed up with forty parts of ichthyol, and finally, one or
one and a half parts of a strong solution of albumen inter¬
mixed with it. This is applied to the skiu at night; it
dries in about two minutes, and can be easily washed off
in the morning. As tliere is no fatty matter in this varnish
it is eminently suited as an application in lupus erythema¬
tosus, or, as XFnna calls it, “ulerythema centrifugum,” in
which fatty matter is to be avoided.
THE STRUCTURE OF INSECTS IN RELATION
TO RECENT VIEWS ON THE ORIGIN
OF THE VERTEBRATES.
Professor Benjamin Thompson Lowne, F.R.C.S.,
delivered last week ab the Royal College of Surgeons three
lectures on the Structure and Dsvelopment of the Skeleton
of the Head, the Nervous System, and Sensory Organs of
Insects in relation to Recent Views on the Origin of
Vertebrates, giving the results of work in which he has
been engaged for at least fifteen or twenty years. His views
are that the vertebrate and the arthropod stand in a
genetic connexion with each other. He said : “ If we seek
for links uniting these two great subkingdoms, we must look
for them amongst the most generalised groups iu each: in
the vertehrata amongst the amphibia, and especially the
perennibranchiate forma ; in the arthropods and in the king
crab “ Limulus,” which hold a zoological position between the
arachnids and the Crustacea.” The lecturer compared the
embryos of the axolotl, as figured by Professor Parker wRh
arthropod embryos, and showed many points of similarity.
He then adverted to the fact that both Drs. Gaakell and
Patten had independently arrived at theconciusion that the
^ing crab stands in a genetic relation to the vertehrata.
The existence of a notochord in the chordata has been
Hooked upon as of primary import in the question of the
■descent of vertebrates from an invertebrate type. Adopt¬
ing, however, Gaskell’s views, and holding that the central
canal of the spinal cord represents the arthropod alimen- '
tary canal, the lecturer showed at some length that the
proctodeum of the insect embryo corresponds with the
mesenteron of the vertebrate; aud he held that a notochord
should rather be regarded as a secondary character, result¬
ing from an invagination of theepiblast, than asastructure
of high morphological significance ; and ho showed that a
rod of cartilage, similar to a notochord, is actually de¬
veloped on the dorsal surface of the invaginated head
capsule of the blowfly larva, whilst those structures in
invertebrates which have been supposed to represent a
notochord have a similar origin. He pointed out that the
structure which supported the nerve centres in Limulus,
is composed of cartilage very like the cartilage of the
vertehrata, and it could only, with great difficulty, be dis¬
tinguished from it. Professor Ray Lankester was the first
who made out this peculiar form of cartilage, which he
said was developed from the n^esoblast; while the lecturer,
judging from the relation the structure bears to the same
arts in insects, believed it to be an epiblastic structure,
his led him to accept the view put forward by Dr. Patten in
America and by Dr, Gaskell in this country, that the ventral
surface of the anterior somites of the arthropods repre¬
sents the basis cranii of the vqrtebrata. The relationship
between the nervous system in the vertebrates and the
arthropods led him to adopt Dr. Gaskell’a hypothesis, inas¬
much as it harmonised many things which had formerly
uzzled biologists. For many years it had never occurred to
im to compare any parts of tfie arthropods with the func¬
tional corresponding parts in the vertehrata. As soon as
Dr. Oaslcell showed that there were strong reasons for he-
llevlng that the central canal of the spinal cord corresponds
with the primary intestinal canal, thedifficulty considerably
diminished, and many parts of the insect were found to
correspond so closely to parts of the vertebrate, that it was
no longer possible to ignore the correspondences between
the structures, both in development and in relation to
their anatomical parts. Having given a description of the
insect brain, Professor Lowne referred to the idea that
the antennai of insects were horaologues of the ventral
appendages. The evidence against that idea was becoming
stronger and stronger every day. They were not lateral
appendages, in the usual sense—a fact long since recognised
by Professor Balfour,—bub olfactory organs, corresponding
point by point, more especially in relation to the nerve
anglia, to the olfactory organs of the vertehrata. Neither
id the eyes of the insect represent ventral appendages;
they bore no relation whatever to them.
The lecturer entered at great length into the details of the
structure and development of the arthropod brain, and
showed that it possesses many points of similarity with the
cephalic nerve centres of vertebrates ; that it is developed
from three vesicles; and that median, pineal, eyes are
developed in the wall of the middle vesicle. That there is
actually a third ventricle from which the nerve of the
median eyes, ocelli, arises.
The lecturer finally dealt with the development of
the eye. The sensory organs of arthropods were usually
developed by the process of invagination of the epiblast,
just in the same way as the sense capsules of ver¬
tebrates were developed. The eyes first appeared as
a single layer of cells in a kind of cup-shaped cavity, '
divided into at least two layers; from the surface layer
a series of lenses was developed about 4000 to 6000 in
number, instead of one great lens. In some insects there
were as many as 24,000 to 30,000 separate lenses. These
form the compound cornea. The lenses were very
remarkable in their structure, and appeared to consist
of a stroma very much like the stroma of the red blood-
corpuscle of a vertebrate, and a substance which has
a very highly refractive power, and which is fluid and
soluble in ether. This substance gradually passes out
through the stroma after the insect dies, and impregnates
the other tissues, but in a living insect the cornea has the
same kind of brilliancy as in the vertebrate; but as soon
as the insect dies the brilliancy rapidly fades, and in a quarter
of an hour it lias become quite dull. The stroma con¬
sists of profceid substances, but as development progresses
the albuminous material gives place to tltis highly refractive,
probably oily material, and then the lenticular portion of
the cornea becomes reticular after having been treated with
such reagents as will dissolve out this interlibrillar sub¬
stance. About twelve years ago, when examining the
Coogle
TBB IzANCET,]
KEPORTS OF MEDICAL INSPECTORS.
[March 14,1891. 623
lateral povtians of the compound eye of the lobster, he
continually found thickenings beneath the rod-like bodies
which united the corneal portion of the eye with the nerve
centres beneath, and ho became convinced that no nerve
structure passed through this membrane, and then it struck
him that, in trying to make out that this structure was
retinal, he was doing veiy much the same thing as examin¬
ing the minute structure of the crystalline lens of the
vertebrafca, and coming to the conclusion that the rod¬
like fibres of that lens were in themselves not merely a
portion of the refractive structure, but were actually the
terminals of the optic nerve. He regards the whole of
the structure developed from the supetficial epiblast as a
refracting organ, and with that view he had termed it the
dioptron, or the refractive portion of the, compound eye.
In some insects which do not undergo metamorphosis the
great compound eye is at first small, and consists only of
a few facets, but a new portion of the eye is developed at
each shedding of the integument. The nerve also gradually
passes to the surface, encircles the old nerve, and forms a
new retina. This goes on until at the last the optic nerve
is found very much spread out. During the last shedding
of the skin the whole of the retina undergoes degeneration,
and a new one takes its place ; so that new sets of facets
are developed at each skin shedding, and a new retina is
developed from the nerve centres beneath the dioptron.
In expounding the various theories of insect vision, the
lecturer explained that Muller’s theory of “ mosaic vision ”
was not in itself tenable, because, in the first place, the
images produced would bo blurred, and surfaces of eight or
ten inches square, would only be visible as points at very
moderate distances—say, ten or twenty feet. The theory
which the lecturer propounded was that an inverted sub¬
corneal image was foruied beneath each corneal facet, and
the great rods of the dioptron produced a magnified erect
image of that portion of the subcorneal image which lies
in the axis of each. The integration of these images pro¬
duces the retinal image upon what he had described as the
neuron.” This image had actually been demonstrated
by Sigismund Exner of Vienna, who first showed it at the
Cologne Congress of Naturalist. The “mosaic view,” or
Muller’s theory, announced about 1826, assumed that the
tubes of thedioptrononly permitted axial lightto pass through
them; so that each tube of the dioptron produces one distinct
stimulation of the nerve, and there could only be as many
separate sensations of light as there are tubes to the
dioptron, a supposition which is quite incapable of explain¬
ing vision in an insect which has perhaps only fifteen or
twenty lenticules of the eye, some only having five or six,
although others have as many as 24,000 to 30,000. Even in
those which have the largest number, the acuity of vision
is not sufficiently explained by Muller’s theory.
VIRCHOW TESTIMONIAL FUND.
The following additional subscriptions to the above fund
have been received ;—
Robert Munro, M.D.. ..
■\V. Collier, M.fl.
Sir Geoi'Ko Pagef^ K.C.B.
Thomas Oliver, M.l).
SiUnoy Martin, M.D.
A. 0. Maolaren, E.ll.C.S.
H, Charlton Hastiaii, M.D.
Thomas Harlow, M.D. ..
Thom.as Oliver, M.D.
Sidney Martin, M.l).
iC
f.
(?.
1
&
s.
d.
1
1
i)
A. C. Maclarop, L.KC.S.
2
0
1
1
0
II. (.Tmi'lLoii Bastiaii, M.D.
1
1
0
1
1
(1
Tiir)iii;vs Barlow, M.D. ,.
1
1
0
1
1
0
R. l-’elkin, M.l).
1
1
0
1
1
0
E, Klciin, M.D.
1
1
0
2
2
()
P. W. Latliain, M.D.
1
1
0
1
1
0
Sir John Simon, K.C.B.,
1
1
(1
li’.R.S.
1
1
0
1
1
0
T. Sympson, l’'.R.C.S.
0 10
U
1
1
0
The Committee has been joined by Dr. Priestley and
Dr. Samuel West.
anil f ak
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF INSPECTORS OP THE MEDICAL DEPARTMENT
OF THE LOCAL GOVERNMENT BOARD.
On iha Sanitary Condition of Wells, hy Mr. Si'EAR.— This
report deals exclusively with the sanitary circumstances of
this little Norfolk town, which is a small fishing and
shipping centre. The sewerage cannot be commended,
especiaily in such matters as lack of ventilation and Hushing,
but the authority has secured the abolition of the majority
of thecesspoolsand privy pits which wereformerly so general.
The latter have unfortunately been replaced by tank closets,
which cannot be regarded as a wholesome arrangement;
but the object in contriving these, as also in remedying
many of the old leaky drains, appears to have been the pro¬
tection of the water-supply, which is exclusively derivedi
from local wells. As to these, Mr. Spear points out that
pure water is hardly to be expected from shallow wells sunk
in a soil that has been occupied by human beings for ages,
and which has until a comparatively recent time had its
surface perforated by cesspools, privy pits, and faulty
drain-pipes. Some samples of water were, it appears,
sent to Dr. Frankland for analysis, and he was
obliged to class them as “dangerous.” And even
as regards wells that are not so obviously fouled in so*
far as their chemical constituents are concerned, it ie-
assumed that they only escape similar condemnation!
because the soil in which they are sunk is kept fairly cleaa
by reason of an ebb and flow induced by tidal action. It is
to be feared that locally no especial dissatisfaction prevails
as to this water-supply, acquiescence in which would seem,
Mr. Spear judges, to express the popular sense of the
general wholesomeness and sufficiency of a water-service.
No special outbreak of disease has recently occurred in
Wells, but in 1884-85 a prevalence of enteric fever wa&
found to have its focus in a well that was ascertained to he
contaminated. It is stated that during the summer there
is some influx of visitors into Wells. For this reason alone
the local board of health should provide the town with &
water that is above the suspicion of unwholesomeness ; and
such action on their part would certainly confer benefit om
the resident population to an even greater extent than on.
occasional visitors.
VITAL STATISTICS.
HEALTH OP ENGLISH TOWNS.
In twenty-eight of the largest English towns 6149 births
and 4547 deaths were registered during the week ending
March 7 th. The annual rate of mortality in these towns,
which had risen in the preceding four weeks from 19-8;
to 24T per 1000, declined again to 23 7 last week. The
rate was 23'4 in London and 23'9 in the twenty-seven
provincial towns. During the past nine weeks of the currenb
quarter the death-rate in the twenty-eight towns averaged
23'5 per 1000, and exceeded hy 0'5 the mean rate in the cor¬
responding periods of the ten years 1881-90. The lowest rates
in these towns last week were IG'6 in Brighton, 17'3 in
Wolverhampton, 17'4 in Nottingham, and 17‘6 in Hull; th&
highest were 31'6 in Newcastle-on-Tyne, 32'5 in Huddero-
fielii, 33 T in Cardiff, and 33 9 in Halifax. The deaths referred
to the principal zymotic diseases, which had increased in the;
preceding four weeks from 332 to 431, further rose lost
week to 470; they included 161 from whooping-cough,
100 from measles, 55 from diphtheria, 36 from scarlet fever,
32 from diarrheea, 25 from “ fever ” (principally enteric),
and one from small-pox. The lowest death-rates from these
diseases were recorded in Wolverhampton, Norwich, Derby;,,
and Birkenhead ; the highest rates in Halifax, Salford,
Blackburn, and Huddersfield. The greatest mortality from
measles occurred in Sheffield, Portsmouth, Salford, Bristol,
Blackburn, and Huddersfield; from whooping-cough ii>
Halifax, Huddersfield, Birmingham, and Salford ; and froni^
“fever” in Halifax. The mortality from scarlet fever show^
nomaikedexcessinanyof thelargetowns. The SSdeaths from
diphtheria included 31 in London, 7 in Liverpool, 4in Manches¬
ter, and 3 in Birmingham. One death from small-pox was
registered in London, but no small-pox patients wereundoi"
treatment in the Metropolitan Asylum Hospitals or in the
Highgate Small-pox Hospital on Saturday lost. The number
of scarlet fever patients in the Metropolitan Asylum Hos ¬
pitals and in the London Fever Hospital at the end of
the week was 1184, and showed a further decline from
recent weekly numbers; the patients admitted during
the week were 87, against 113 and 80 in the preceding
two weeks. The deaths referred to diseases of the re¬
spiratory organs in London, which had increased in the
preceding four weeks from 428 to 685, were 673 last-
week, and exceeded the corrected average by 181. The
causes of 70, or 1 -7 per cent., of the deaths in the twenty-
eight towns were not certified either by a registered*
medical practitioner or by a coroner. All the causes of death'
were duly certified in’Brighton, Portsmouth, Leicester,,
Coogle
«24 Thb Lancbt,] the FACTORY ACT AND CERTIFYING SURGEONS. [March 14,1801.
Sunderland, and in four other smaller towns. The largest
proportions of uncertified deaths were recorded in Black¬
burn, Sheffield, and Liverpool.
HEALTH OP SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which bad increased in the preceding three weelcs from 21*4
'to 23'8 per 1000, further rose to 24'1 during the week
ending March 7lh, and was 0‘4 above the rate that pre-
■vailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns
ranged from 12 3 in Perth and 13‘5 in Leith to 28-3 in
Glasgow and 37’1 in Paisley. The 028 deaths in these
eight towns showed an increase of 8 upon the number in
the preceding week, and included 34 which were referr^
to whooping-cough, 10 to measles, 10 to scarlet fever, 8 to
-diarrbma, 6 to "fever,” 5 to diphtheria, and not one to small¬
pox. In all, 70 deaths resulted from these principal
zymotic diseases, against 50, 62, and 80 in the preceding
tnree weeks. These 79 deaths were equal to an
.€inntval rate of 3'0 per 1000, which exceeded by 0 6
the mean rate last week from the same diseases in the
twenty-eight English towns. The fatal oases of wbooping-
■cough, which bad increased from 13 to 27 in the pre-
-ceding three weeks, further rose last week to 34, of which 16
occurred in Glasgow, 7 in Edinburgh, 4 in Dundee, and 4 in
(Leith. The deaths from measles, which had been 8 and 18 in
the previous two weeks, declined last week to 16, and
included 10 in Paisley and 4 in Glasgow. The 10 fatal
cases of scarlet fever exceeded by 3 the number recorded in
the preceding week, and included 7 in Glasgow and 2 in
Paisley. The deaths referred to "fever,” which bad risen
in the previous three weeks from C to 11, declined again last
week to 6, of which 3 occurred in Edinburgh, where 3 of
■the 5 fatal cases of diphtheria were also recorded. The
•deaths referred to diseases of the respiratory organs in
these towns, which had risen in the previous three weeks
'from 138 to 146, were again 140 last week, and were 3.'>
below the number in the corresponding week of last year.
The causes of 53, or more than 8 percent., of the deaths
in the eight towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate in Dublin, which had increased in the
{)receding four M’eeks from 26 6 to 29 4 per 1000, declined
to28’2 during the week ending March 7th. During the
ffirst nine weelcs of the current quarter the death-rate in the
city averaged 31’4 per 1000, the rate for the same period
being 23*6 in London and 2L'0 in Edinburgh. The 191 deaths
in Dublin showed a decline of 8 from the number in the
.preceding week, and included 2 which resulted from diph-
tiieria, 1 measles, 1 from diarrhcca, and not one from small¬
pox, scarlet fever, whooping-cough, or "fever.” Thus the
deaths referred to the principal zymotic diseases, which
had been 3 ami 9 in the preceding two weeks, declined to
4 lost week; they were equal to an annual rate of O’G per
1000, the rate from the same diseases being 1-8 in London
and 2-8 in Edinburgh. The 2 fatal cases of diphtheria ex-
•ceeded the number recorded in any of tlie preceding six
weeks. The death from measles was the first recorded in
any week since the end of January. The 191 deaths in
Dublin last week included 32 of infants under one year of
age and 46 of persons aged upwards of sixty years; the
deaths both of infants and of elderly persons showed a
decline from those returned in the preceding week. Three
inquest cases and 2 deaths from violence were registered ;
and 05, or more than a third, of the deaths occurred in public
'institutions. The causes of 23, or more than 12 per cent.,
of the deaths in the city were nob certified.
THE SERVICES.
Army Medical Staff. — Surgeon Robert Hippisley
Gox resigns his commission (dated March 11th, 1891).
Army Medical Reserve of Officers.— Surgeon Philip
Barnett Bentlif, Royal Jersey Artillery Militia, to be Sur-
■geou, ranking as Captain (dated March 11th, 1801).
Naval Medical Service. — The following appoint¬
ments have been made at the Admiralty:—Fleet Surgeons;
Walter Reid, M.D., to the Royal Artillery Barracks,
•Eastney, and James Trimble to the Camperdown (dated
March 10th, 1891). Staff Surgeon Alexander R. Joyce to
theTAmrfcrcr (datedMarch 17th, 1891). Surgeons: Robert
H. J. Brown to the Thunderer (dated March 17th, 1891);
Horatio S. R. Sparrow to the Rapid, for the Mildura; Henry
G. Jacob to the Cura^oa, for the Wallaroo; Thomas Austen
to the Guraroa; and Henry S. Jackson to the Katoomha
(undated); Herbert P. Shubtleworth to the Royal Marine
Artillery, Eastney (undated); Edward B. Hazleton, M.D.,
to be Surgeon and Agent at Clovelly (dated March 6th,
1891).
Volunteer Go^vs.—R ifle: 6th Volunteer Battalion,
the King’s (Liverpool Regiment): Acting Surgeon E. W.
Barnes to be Surgeon (dated March 7th, 1891).—2od Volun¬
teer Battalion, the Lincolnshire Regiment: Acting Surgeon
T. P. Greenwood resigns his M)pointment (dated March 7th,
1891)—1st (Hertfordshire) Volunteer Battalion, the Bed¬
fordshire Regiment: Acting Surgeon H. 0. F. Butcher
resigns his appointment (dated March 7th, 1891). —
4th Volunteer Battalion, the Hampshire Regiment: Sur¬
geon H. G. Dyer, M.D., is ’granted the rank of Surgeon-
Major, ranking as Major (dated March 7bh, 1891). —
5dh Volunteer Battalion, Princess Louise’s (Argyll and
Sutherland Highlanders): Acting Surgeon D. McMillan,
M.B., to be Surgeon (dated March 7th, 1891).—Ist London
(City of London Rifle Volunteer Brigade): Edgar Alfred
Hughes, Gent., to be Acting Surgeon (dated March 7th,
Cffrrjspnkita.
" Audi alteram partem.”
THE FACTORY ACT AND CERTIFYING
SURGEONS.
To the Editors o/The Lancet.
Sirs, —Much misrepresentation of the duties of certifying
surgeons has been laid before the public in letters ana
reports of the proceedings of chambers of commerce by men
who would be the first to cry out for impartial arbitration,
should any question touching their own duties and incomes
arise. In the first place, these writers state that the duties
of the surgeons consist merely in making certain clerical
entries, which work they consider can be fully as well done
by a clerk; they either are ignorant, in which case they
should be silent, or they deliberately ignore for their own
purposes the fact, that in each separate certificate the sur¬
geon states by his signature tliat he has personally examined
each child or young person, and is of opinion that such
child or young person is nob incapacitated by disease or
bodily inlirmity from working the time allowed by law in
that particular factory. This no member of any'chamber
of commerce in the kingdom can truthfully contradict.
With a well-grounded fear those statements may be insuffi¬
cient, these same men proceed to tell us that the certifying
surgeons never or hardly ever refuse for disease or bodily
infirmity to pass a child, and should they liave done so,
that it is merely by reason of recent agitation. In
answer to this I would mention some few cases out of
many in my own practice as certifying surgeon. In the
month of July, 1881, nearly ten years ago, I was obliged to
write to H.M. inspector in a case where an employer defied
my refusal, and insisted on working a boy with heart
disease and serious eye di.sease (bad case of mitral incom¬
petence, with double coloboma anterior and posterior and
nystagmus), for which I am happy to say he was fined. On
another occasion a bad case of heart disease and chorea, or
Sb. Vitus’s dance, was refused, and very soon ended fatally.
On one occasion I have been threatened with legal pro¬
ceedings by the father of a girl, who had an epileptic fit in
the mill office, while I was there for purposes of certifying;
in another with a boy who was totally unfit for factory em¬
ployment who had been throe times presented to me for cer¬
tificate, in the hopes he might pass by a "fluke”; in another
case the parents offered to indemnify the employer against
consequences if accident or death from machinery should
ensue to a girl suffering from deaf-mutism and debility.
Had I passed any of these the cry might well have been,
“_Wliat is the good of these surgeons?” Cases of heart
disease, consumption, rheumatism, spinal disease, epilepsy,
eye disease, and skin disease, of undergrowth, and under-
Google
The Lancet,]
THE TREATMENT OF PHTHISIS.
[March 14, 1891. 625'
develo^ent repeatedly ate under notice and obeerva-
tioD. For rather more than ten yeara 1 have been engaged
on factory work, and during the whole of that period I have
been in the habit of refusing or keeping under observation
all children or young persons whom I have thought unfit,
with, I consider, distinct advantage to all concerned. I
always give the child the benefit of the doubt, as every
small addition of wages to a house means more food, and by
inquiry from time to time ascertain how its health pro¬
gresses.
Another objection has been raised to the office; we are
asked, “What good are these surgeons? They see a child
at ten, and again at thirteen. What can they say as to its
fitness between these ages ? ” This may be a point against
the imperfection of existing legislation, but the answer
under the circumstances is decisive—the surgeon if he sees
a child at ten unlit for work, refuses it, and refuses it until
he sees that it is lit for work, and similarly again at thirteen,
should the health unfortuuately have failed between the
two ages. And, again, to this objection, among the
better cared-for children of the more provident operatives,
who are not in the habit of migrating from mill to mill in a
district, there is, as a rule, a better condition of health;
they are frequently only seen twice, because they seldom
change their employment, and are less in need of re¬
examination than the worse cared-for children of the slums,
who migrate from mill to mill in a district, and therefore,
fortunately for themselves, come ofbener under observation.
Other causes and influences at work to keep up a constant
circulation of children do not come under the surgeon’s
scope, and are more connected with the social and moral
questions of divided authority and small premiums or com¬
missions on employment. Lancashire and Yorkshire employ
137,000 half-time children, as against 41,800 for all the
remainder of England and Wales, and it is certain that
they employ young persons under sixteen years of age in
like or probably larger proportion, with constant circulating
changes taking place in these important, smoky, crowded
districts. I often examine as many as 100 in a week,
occasionally as many as 200. It is obvious that the cer¬
tifying surgeon must inspect these children as a whole more
frequently than twice, and when it is remembered that
from ten to seventeen is probably the most critical period
of youthful development the importance of this can hardly
be over-estimated as a matter of State hygiene. Then the
question of payment of the surgeon’s charges by the parent
has been raised. The Act says that the employer may
deduct .3rf, from the wages of such child as its share towards
the payment of the surgeon’s fee. This is frequently
evaded, and the full fee or its proportionate part demanded
from the parent as a condition of employment, dividing
the whole cost among one or more parents. In some
cases the employer makes a very fair profit on the
surgeon’s visits, as he takes the full fee from each
child or young person. I have known the employer take
half a-crown eaA from the parents of live children and pay
me the half-crown fee (sixpence each), putting ten shillings
into his own pocket, and on some occasions I have been
personally upbraided by the parents as the perpetrator of
this atrocity. I am glad to say that, though too frequently
adopted, this plan is only carried out by a minority of
employers in this district; but this last fact has naturally
strongly influenced the operatives themselves, who are
unaware that the maximum cost to themselves is, or ought
to be, threepence for the surgical certificate, and that they
are overcharged by the employer on a mere pretext. The
question of expense to the employer has been mentioned. In
the above cases he is shown to profit; but mills are hinted
at, not named, which pay the surgeons sums varying from
£20 to £40 a year for certifying. I cannot doubt that
any surgeon in whose district this has occurred will be glad
of the opportunity of confirming and explaining or denying
it. Personally, I will believe the statement after it has
been proved. The charges are laid down in Section 74 of
the Act, and I have frequently, when asked, pointed out
this and other details of the Act in my own copy to men
who do nob possess one, and whose knowledge even of the
short abstract is very limited, and it cannot be doubted that
our visits are a valuable aid to H.M. inspectors, whose
duties are so extensive that they could not without us be
kept in such close and continual touch with all parts of their
district as is now the case.
I write as a representative factory surgeon, living in a
manufacturing centre, and well aware employers and ,
employed are as a rule alike ignorant of elementary sani¬
tary matters and consequently incompetent to form opiniona
of any value upon them. Otherwise the one class would
not create, nor either tolerate, our smoke-defiled atmosphere,
polluted streams, and other unwholesome conditions of
existence. They may confer with advantage on work and
wages, but where tlieir personal health is in question
they do not consult self-created chambers of commerce or
mutually prescribe for each other. Yet according to the
speech of an Under-Secretary of State, numbers and not
knowledge arc sufficient to constitute “the most influ¬
ential” deputations on important public questions wbichr
lie behind their intelligence and experience, and involve in
our case the sudden sacriflee of efficient public servants npot&
the altar of, shall we say, a general election ?
I am, Sirs, yours faithfully,
Rochdale, March 7th, 1801. WILLIAM StANWELL.
THE TREATMENT OF CHRONIC DISEASE OF
THE UTERINE APPENDAGES.
To the Editors of The Lancet.
Sirs,—I t is impossible from the nature of the ease for on©
who thinks that a disease has been present and ended in
recovery to bring evidence of the fact convincing to the in¬
credulous. By Inflammation of the uterine appendages I
mean what I think most medical men understand by it. It
has long been known that the commonest cause of peri¬
metritis is inflammation of the Fallopian tube; that matting
together of tube, ovary, and adjacent parts is very com¬
monly seen on tbe post-mortem table; and that tender
fixed lumps by the side of and behind the uterus, with-
symptoms such as Mr. Taib has described as those of dis¬
tension of the tubes, are very often met with during life.
Mr. Taib has himself admitted that it is often impossible
until the abdomen has been opened to say what these lumps
are—whether they contain blood, pus, or serum; whether
this is in the tube, the ovary, or in a cavity bounded by
adhesions in their neighbourhood, and sometimes this latter
point cannot be determined even after the parts have been
removed. Those lumps are what I mean by inflammation of
the uterine appendages. Tbe great majority of them, if
sufficient time and re-st be given, end in diminution in size
or even practical disappearance of the lumps and .cessation
of symptoms. I do not doubt that there are some case©
which can only be cured by operation ; but I believe that
the more patient the trial allowed to the vis medicatrix
natxira',, the fewer will these cases be found to be.
I am, Sirs, yours faithfully,
Harley-strsot, March 10th, 1891. G. ERNBST HERMAN.
THE TREATMENT OF PHTHISIS.
To the Editors of The Lancet.
Sirs,—I am a constant reader of The Lancet, and hav©
been following -with marked interest the controversies upon
Koch’s cure and the various theories as to its mode of
action. I beg to record a case in which the cure was
elfected, not by strong measures like those of Koch, or by
the empirical methods from Paris by dog’s serum and goat’s-
blood, but recovery has been brought about by what I must
call an accident of Nature in the course of the disease.
The case is shortly as follows:—J. W-, aged twenty
years, male, came under my care towards the end of October-
last year, when I recognised he was sufleringfrom phthisis of
the lunge, and his illness shortly after took an acute form,
manifesting all the symptoms of that terrible disease. I
need not indicate his symptoms more than to refer to the
temperature, which ranged from 103° to 101° F. night and
morning the first month, and afterwards from 102° to 100°
and 99° after that. The patient was going steadily down
hill and -was markedly weak, and to show the extent of
his disease the trophic centres became affected, as illustrated
in paresis of the bladder, and ere long a large bedsore
formed over the sacrum. There were tubercle bacilli in tbe
sputum, bat afterwards many other kinds of bacteria -were
to be seen in the expectoration. The bedsore became a large
slough about Nov. 29fch, and from that day it very much
engaged my attention, requiring all manner of dressings
Ikc. On the Kith, 24th, and 29bh the temperature rose to
103‘8° and 103°, and was brought down by antipyrin. On
r Google
6-26 Thb Lancbt,]
EMPYEMA OF THE ANTEUM.
[March 14,1891.
thelasfe occasion it did not come down to a satisfactory
point till Dec. 9Dh. On Thursday, Dec. llth, I found the
patient changed. By this time the slough was removed.
His face was livid and suffused, the veins standing out on
his temples, and the temperature registered 104 0°. There
were moist crepitant sounds in the lungs. I administered
a full dose of antipyrin, and by evening I bad the
satisfaction to see the temperature down to normal, and the
patient looked bis usual again. From that day the tern-
peratnre has remained at normal or below it, and ere long
the symptoms began to disappear—the cough, spit, sweating,
&c.—and in two weeks the bedsore was a large healing
wound. The patient began to get back his appetite, and
though stimulants were administered there was a return to
strength. The patient seemed to pass through a stage of
hypermsthesia until he got fairly on the road to recovery.
To bring the case to a conclusion, the wound has gone on
slowly but steadily healing up, and with return of appetite
the patient has gained strength and weight, so that
now be is able to walk about the house. There has
been no cough, and the patient has not been so well
for many months. It has been pointed out that small-
ox &o. have been known to cure phthisis, and erysipelas
as driven away lupus. I beg to place this case on
record as a case cured by incipient septicmmia, for I
can regard as so other these rises of temperature when
the bedsore was covered in greater part with a black slough,
and such was my diagnosis at the time when I skw the
state of the wound. It would seem that some principle
like sepsine was formed and circulated in the blood, and,
reaching the tuberculous areas, acted as an antagonist to
the disease and killed the tubercle bacilli. Hence the dis¬
appearance of the symptoms. Is it not possible that Koch’s
liquid may not be a genuine specific for phthisis, but
merely one of the numerous fever agencies which bring
about phenomena when they find a proper nidus in the
organism? Whatever may he said, it is not the only agency
which kills the tubercle bacilli and cures phthisis. It may
be that this case I record will be of interest to those deeply
versed in the etiology and cure of tuberculosis.
I am, Sirs, your obedient servant,
LoiUi, N.B., Feb. 10th, 1891. JAMES W. MARTIN, M D.
THE TREATMENT OF PHTHISIS BY THE
INHALATION OF SUPERHEATED AIR.
To the Editors o/'Thb Lancet.
Sirs,—D r. J. Cranstoun Charles in his article in The
Lancet on the above treatment of phthisis, after ex¬
plaining the rationale of the method, proceeds to say :
“ Without going into the question of the temperature of
this heated air when it reaches the lungs &c.” It is some¬
what surprising that Dr, Charles did not remind your
readers that there is very good evidence that air, at what¬
ever temperature inhaled, reaches the lungs very slightly,
if at all, above the temperature of the blood. By some
experiments carried on at the Consumption Hospital,
Brompton, the result of which I read before the Clinical
Society last session, this aJI-important point was pretty
definitely settled.
“Thevo was a patient under the care of Dr. Mitchell Bruco'with
well-marked bronchiectatic excavation of tlio base of the left lung.
Mr. Godleo had successfully tapped it after removing a piece of rib.
On illuminating the ifiterinr of the cavity two openings could be
distinctly seen, and a probe could be passed up them, and appeared
to reach somewhere near the trachea, and caused coughing. Air
passed very freely in an<l out of the cavity. When the patient
Inhaled peppennint it could be smelt at the wound, and when it
was blowji through the opening he almost instantirnoously tasted it.
This showed that there was a very free communication between
the mouth and the cavity. Inspection of tlie lung, whicii was re¬
moved after deatli, clearly shows how very free tliis communication
was. This patient was set to inhale hot air, which lie did at about a
temperature of 300° h'. A tliermometer was placed free in tlie cavity,
and carefully plugged in. At the end of one hour tho thermometer
only rose 1°, The patient thought it was a form of treatmoiit which
Huibed him, so wo had no difficulty in repeating tliis experiment sovorai
times, and always with the same result. Anotlicr case soon occurred
wbicli gave us further opportunities of trying experiments. A patient
was admitted under tho care of Dr. 'I'atham, also with a cavity at the
base of the left lung, Ils ox.act nature was never dotoriniiied, as he
fortunately made a complete recovery. It was tapped by Mr. Cndlee
after resecting a piece of rib. In thi.s case also there was a
free communication with the mouth, hut not cpiito so free as
ill the preceding case, as he did not taste tlie peppennint
<iuite so iiisbantahRously. A probe could be passed up towards the
trachea, which he said he felt, and it caused much coughing. The
* Clinical yociety’s Transactions, vol, xxiii.
same experiments were repeated on him, but in bis case the thermo¬
meter never rose at all. I think that these experiments show what
most of us would have expected—viz., that the temperature of super¬
heated air is rapidly dissipated in tho mouth, plmrynx, and larger air-
tubes. These struotnros are extremely vascular, and tlie ro.pidity with
which the blood circulates appears quite able to carry off any super-
ilunus heat, and reduce the air to tlie normal temperature of the blond
befoi-e it reaches tlie smaller bronchi and pulmonary tissue. It follows,
then, that the inhalation of superheated air can have no influence over
the course of phthisis.’’
Home experiments have also been made by Dr. Ernest
Schowald of Jena on dogs, and the conclusions he came to
were the same as my own. 1 should not have troubled you
with this communication but an inventor of one of these
hot-air machines is actively advertising it.
I am. Sirs, faithfully yours,
Brighton, March 9bb, 1801. H. H. TAYLOR.
EMPYEMA OF THE ANTRUM.
To the Editors o/TllE LANCET.
Sirs,— Dr. Hunter Mackenzie, in his interesting letter
in your issue of the 7iih inst., tells us that, from his ex¬
perience, it is rare to detect pus in the antrum without
caries of the corresponding teeth. It is always instructive
to have the (minion of so careful and trustworthy au
observer ; but 1 think his statements would prove of even
more value if he would give us some idea of the number of
cases of empyema of the antrum he has observed and
treated. Such a statement appears to me to be essential
to the great question among rhinologists—viz., whether
disease of the teeth or some gross inflammatory aflection of
the nose is to be considered the commoner cause of sup¬
puration in the antrum. In my forty cases I have never held
a simple coexistent rhinitis to be responsible for tho mischief,
although, as Dr. Mackenzie suggests, such is often apparently
caused by the irritation of the septic discharge through the
ostium maxillare. Nor do I consider it fair to assume that
a coexistent carious tooth is necessarily the cause of the
suppuration. We ought at least to have a periostitis of
the fang, with suppuration around it, or penetration of the
fang into the cavity above, before we can, on pathological
grounds, assume that dental disease is responsible for the
mischief. Unfilled carious teeth are so common among
hospital patients that it is unusual to find no carious teeth
in either a case of empyema of the antrum or any other dis¬
ease. In fact. Sirs, I do not hesitate to aflirm that the
large majority of cases of nasal polypus, associated with a
purulent discharge from the nose (I do not say muco¬
purulent), will be found to be associated with pus in the
antrum ; and, as I have remarked before, I believe it is the
frequent coexistence of nose disease, which might in itself
be considered sufficient to aceounc for the suppuration with¬
out supposing the antrum to be involved, that explains why
so many cases of empyema of that cavity are overlooked.
I am. Sirs, yours truly,
Harley-sti-eet, March 9th, 1801. , Greville MacDoNALD.
ETIOLOGY OF ENTERIC FEVER.
To the Editors of TlIE LANCET.
Sirs,—I n December I was sent for to see a boy whose
symptoms turned out to be those of typhoid fever. He is
recovering, but a younger brother is now ill with the same
complaint. Notice was given to the urban sanitary
authority, and the medico officer of health visited the
house where these patients live and found nothing amiss
with its drainage or water-supply. For years there has not
been a case of this fever in the town, and there is none
existing in the neighbourhood. The boys have not
been outside the town for many months. About tho
time when the boy first attacked was taken ill there
had been occasional most unpleasant smells in the parish
church, where he is a choir boy. Home thought the
stench came from the sewer leading from the schools, and
into which the church tower drain pours ; others maintained
the smell was not sewer smell at all, but was due to
mouldering Christians buried in and closely around the
church. But as these two boys are the only individuals
who have contracted typhoid fever, it would seem im¬
probable that the church smells were causative. No other
guess has been hazarded as to the origin. The drinking
water they used is that common to Trowbridge and many
neigbbounng villages, as well as this town. There is, and
r Coogle
The Lancet,]
AMBULANCE CLASSES FOR THE MERCANTILE MARINE. [Maech 14, 1801. 627
has been, no typhoid fever at the farm from which their
milk ie supplied. It would seem, then, as if the first of
these cases had originated de novo; the second contracted
from the first.—1 am, Sirs, yours obediently,
Melkaliam, Wilts, Jan. 27bb, 1801. SahUEL GeOSB.
AMBULANCE CLASSES FOR THE MERCANTILE
MARINE.
To the Editors o/The Lancet.
Sirs, —I read with much interest the letter of Mr. C. H.
Leet in Tub Lancet of Feb. 28th, and I should be very glad
to learn that the efibrts of himself and those who are work¬
ing with him meet with the encouragement they deserve, as
there is no class to whom first-aid instruction is more neces¬
sary than the ollicers and men of the mercantile marine,
especially those on board vessels which do not carry a doctor.
Some years ago I assisted, on behalf of the St. John Ambu
lance Association, in the inauguration of this work at
Liverpool and other ports, but there was a very great diffi¬
culty in finding officers who could give sufficient time to
attend the lectures, although the syllabus was altered and
compressed to meet their special requirements. With regard
to this subject, I received in 1882 a letter from the Marine
Department of the Board of Trade, which contains the
following paragraph:—“ With reference to the corre¬
spondence, and to your recent interview, with officers of this
department on the subject of the instructions of masters and
mates in the mercantile marine, I am directed by the Board
of Trade to acquaint you, for the information of the com¬
mittee of the St. John Ambulance Association, that the
Board of Trade, after careful consideration of the subject,
are disposed so far to assist the Association in this matter
as to authorise the placing by the Registrar-General of Sea¬
men of an endorsement upon the certificates of such officers
as are reputed by tbo Association examiners to have passed
successfully in this subject. I am, at the same time, to state
that before conveying such authority to the Registrar-
General of Seamen they will require to have before them
some farther information as to the character of the instruc¬
tion, and of the examination Avhich will be employed, and
of the arrangements generally, bearing in mind the limited
time at the disposal of officers of the mercantile marine for
acquiring knowledge of this kind.”
This is such a valuable concession that I am sure it will
strengthen the hands of those who are now taking up this
important matter.—I am, Sira, yours faithfully,
March 4th, 1801. JOHN FuELEY.
MEDICAL MEN AND THE NOTIFICATION OF
DISEASES ACT, 1885).
To the Edito7's of The Lancet.
Sirs, —The receutvexatious prosecution instituted against
me by the vestry of Olerkenwell, which is fully reported in
The Lancet of the 7th inst, shows the necessity and
great advantage derived from belonging to such an institu¬
tion as the Medical Defence Union. On my informing one
of the hon. secretaries (Dr. Bateman, of 64, Longridge-
road, S. W.) that a summons was about to bo issued against
me, he immediately took steps for my defence, and
neither trouble nor expense was spared to make the case a
winning one. It frequently happens tliat medical men are
saddled with heavy costs in defending their professional
reputation and private character against unjust prosecu¬
tions, necessitating their appealing to their professional
brethren for assistance ; whereas, by belonging to this ex¬
cellent Society, they would be saved much of the anxiety
attending such prosecutions and the humiliating position
of having to appeal under such circumstances.
I am, Sirs, your obedient servant,
March 9th, 1801 . F. L. Milburn.
ERYSIPELAS AND TOTAL ABSTAINERS.
To the Editors of The Lancet.
Sirs, —My absence from England has prevented my
taking notice before now of Dr. Ridge’s letter in your issue
of the 2lst ulb. He seems to have “run amuck” on the
subject of alcohol generally. I do not see the point of bis
letter, and did not advocate the immoderate use of alcohol.
I am quite aware that alcohol in large doses, especially ia
the high temperature produced by disease, lowers the
temperature of the body, but unaware that small doses of
alcoWl, well diluted, in health do so; in fact, the evidence
goes to prove the contrary. The statistics he quotes on the
rate of invaliding in India do not, 1 imagine, separate the
moderate from ^e immoderate drinkers, and. if not, are
worthless as far as the present question goes. Reference to
any of the standard works on the subject will probably tell
him why alcohol in small doses is classed as a heat-pro¬
ducing agent. Dr. Parkes, who experimented largely on
the subject of alcohol, found that a man in health could
take about 2oz. of pure alcohol daily without any dele¬
terious effect, and the question I asked was whether, under
certain conditions, it was not beneficial. I should recom¬
mend Dr. Ridge, instead of instituting frosh experiments,
to study what is already known on the subject; his know¬
ledge on this particular point seems to require, to say ther
least of it, revision. I regret that my absence abroad will
for the present prevent my continuing this discussion, which
promises to be both amusing and instructive.
I am, Sirs, yours faithfully,
Monti'eux, March yrd, 1891. H- R* WHITEHEAD.
LIVERPOOL.
(From our own Correspondent.)
Society for the Prevention of Cruelty to Children.
During the mouth of February the local Society for the
Prevention of Cruelty to Children, which is the first of its
kind, took up 62 new and 61 old cases, the former involving
the welfare of 92 and the latter that of 72 children. Among
the complaints were—4 of assault, 58 of general neglect, 1 of
begging by night, 49 of selling at night, 40 of exposure,
8 of sleeping out, 4 of dangerous surroundings. Great
efforts are being made to prevent children trading by night,
a form of cruelty practised by many idle and vicious parents,
who, instead of providing for their children, expect the latter
to provide for them.
Legislation for Midwives.
There is a phase of the present controversy respecting
mid wives which appears to have escaped notice. Not many
years ago the average hospital and workhouse nurse was a
drunken, ignorant old hag. Without any legislation all
that has been changed, hospitals and workhouses being now
supplied with well-educated, thoroughly trained young
women, many, indeed, being ladies in the strictest sense of
• the word. Moreover, private nursing has been developed to
a most extraordinary extent, quite as greatly to the advan¬
tage of the rich as the improved hospital and workhouse
nursing are to the poor. In Liverpool an attempt was
made almost a century ago to improve the status of
midwives by the aid of the Ladies’ Charity, the
midwives of which were previously trained and examined
by the surgeons before being appointed to office. Later
on the Lying-in Hospital carried on this educational pro¬
cess, extending it also to monthly nurses, whose position
has greatly improved in recent years. But in this, as in
other cities and towns, many women little, if any, better
than the midwife of old, still practise among the poor, and
among those who, not being poor, are still foolish enough
to employ them. The records of our coroner’s court within
the last twenty years would furnish material enough to
fill many columns of The Lancet with sad illustrations of
I the fatal results caused by the ignorance and, what is worse,
! by the persistent recklessness of these women in refusing
I to send for medical aid when it is imperative. It is
' bad enough in large towns and cities, but what must it be
' iu remote villages and hamlets far away from medical aid?
Legislation is absolutely necessary to prevent ignorant and
incompetent women from practising for gain to the danger
of those women who employ them. A drunken old hag
could not obtain a situation as nurse to a hospital or work-
house, but there is nothing to prevent her putting a brass
plate with “ Midwife” under her name on her door. In this
simple fact lies the whole question to be solved.
The laic Assistant Recorder of Liverpool.
Mr. Leofric Temple, (i-C., whose death occurred on the
6 th inst., was well known to the medical profession here, in
London, and elsewhere. Formerly he was engaged as
Dib Google
628 The Lancet,]
NORTHERN COUNTIES NOTES.—SCOTLAND.
[March 14,1891.
counsel in many remarkable trials. As Assistant Recorder
here he was most courteous and considerate to medical
witnesses, doing his utmost to save them from loss of time
and the many other annoyances to which medical witnesses
are liable. ■
The Spring Assizes.
In charging the grand juiy, Mr. Justice Day complained
of the accommodation provided for prisoners before trial
at the Assize Courts. Though much better than that of
other assize cities, it is not worthy of such a city as this,
or consistent with the other parts of the magnincent hall
<St. George’s) in which the courts are situated. It is to be
hoped that bis lordship’s attention will next be called to
the inadequate provision made for witnesses, even pro¬
fessional ones, which is most miserable. Medical practi¬
tioners have to wait for hours on a landing at the top of a
flight of stairs amid a crowd of other witnesses, and in a
most polluted atmo^liere, waiting their turn to go before
the Grand Jury. The room for witnesses near the Crown
Court is a comfortless and unhealthy apartment, and medical
witnesses have to choose between sitting in court on a seat
generally overcrowded, or walking about the passages.
The Anatomical Jlooms oj the Medical Factdty,
Liverpool TJniversity.
During the winter session now approaching its close the
anatomy class of the 'School of Medicine has been well
attended. Professor Mitchell Banks continues to lecture
on this very important branch of medical education, and
he is ably supported by Mr. Thelwall Thomas. The rooms
are furnished with every requisite for the teaching of
anatomy. Altogether, the anatomical department of the
Liverpool School of Medicine will compare not unfavourably
with those of metropolitan schools.
Liverpool, Mavcli 10th.
NORTHEEN COUNTIES NOTES.
(From our own Correspondent.)
that few towns have notification of measles is do argument
against the principle.” The same, he says, was said only
eight or ten years ago of notification of infectious diseases
of every kind. In conclusion, he gives several very strong
and forcible reasons for the notification of measles, and
recommends his committee to give it a trial in Newcastle
for a period of, say, five years.
The Newcastle Health Society’s Lectures.
The lectures given under the auspices of the Newcastle
Health Society have now concluded. Two lectures have
been given since I wrote last on the subject. The first by
Mr. 11. Clark Newton, on “Exercise and Athletism: Use
and Abuse,” at which Dr. Aruison presided. The con¬
cluding lecture of the series was given on Saturday last,
on “Dangers to Health from Defective Drainage,” by
Mr. R. Laing Hay, architect, North-Eastern Sanitary In¬
spection Society, and Dr. Hume presided. The course has
been highly successful; the lecturers are men of acknow¬
ledged ability, and their selection of subjects was judicious;
while the public throughout have shown appreciation by a
crowded attendance.
Hypnotism in Newcastle.
We have lately had some public exhibitions of “ hypno¬
tism,” so called, in Newcastle, but to any middle-aged
person these exhibitions differ little from the mesmeric per¬
formances of several years ago. Tlie performer is most
successful, or, as he says, has most power over his own
travelling company. Several medical students went on the
platform, but he could do nothing with them,—a sign that
they were, I suppose, a very “ hardened” set as regards
nervous impressions. The Rev. Dr. Ross, one of our lead¬
ing ministers, takes the matter up very seriously, and writes
a condemnatory letter on the subject to the Newcastle
Journal, He does not discuss the scientific aspect of the
question, but concludes that all public exhibitions of
hypnotism should be legally prohibited; that the medi¬
cal use of it should be strictly limited to properly qualified
members of the profession, and to certain districts or insti¬
tutions ; and that there are strong reasons against the public
practice of hypnosis as a source of entertainment.
Gateshead.
Only a fortnight ago I noted the death of the oldest
practitioner in Gateshead, Dr. Dixon. I now have to men¬
tion the death of a very promising young physician, who
might be said to be on the threshold of professional practice,
Mr. Charles Wilson, M.B. Lond., son of Dr. R. H. Wilson,
Gateshead, and a leading practitioner there. Dr. C. Wilson
acted as house physiciau to the London Hospital, in which
capacity he unfortunately contracted a post-mortem wound
which led to empyema and ultimately to fibroid phthisis,
causing his death on the dth inst. at his father’s house.
Koch's Treatment of Tuhcrcidosis.
With regard to Koch’s treatment of tuberculosis in
Newcastle, 1 have spoken to a leading physician here, and
he assures mo that he knows of one undoubted cure of pul¬
monary consumption from the treatment. The case, he said,
had progressed so far as to have cavities, and these appeared
to heal up under tlie treatment, and all symptoms of phthisis
have also disappeared.
Dr. William Robertson, who had a serious accident from
a corrosive acid some time ago, has now quite recovered.
Neweastle-on-Tyne, March lOth.
SCOTLAND.
(From our own Correspondents.)
Edinburgh, Medieo-Chirxirgical Society.
At the meeting of this Society last week a number of
interesting specimens and cases were shown, including a
case of Friedreich’s ataxia in a boy; two cases of brain
tumour, the position of one of which was diagnosed by the
area of the field of vision alfected and the position of the
unaffected area, and the other a cerebellar tumonr witli a
distinct history of live years’ duration; and photographs of
a case of facial hemiatrophy. Those were shown by
Dr. Bramwell. Dr. Allieck showed a patient with vaso¬
motor disturbance of the hands and lividiby, due probably
to injury, and wliich he regarded as being probably allied to
Raynaud’s disease. Dr. W. Russell showed a lung with raul-
□is, Google
Barber S'urgeons.
At the last meeting of the Newcastle Society of Anti¬
quaries Dr. Embleton read an interesting and amusing
paper on the Incorporated Society of Barber Surgeons &c.
of Newcastle. It described the customs and rules of this
ancient Society, and their practice as to bloodletting *Scc.
The records show that tlie barbers were fined for trimming
their customers on the Sabbath day, and fines were also
imposed when members used “ill words” to each other.
For “giving” members the “lie” fines respectively of
from Zct. to (jd. had been made. Dr. Embleton has pro¬
mised to read a second paper on the subject.
The Health of Tynemouth.
The medical officer of health for Tynemouth writes to
the Newcastle Daily Chronicle to explain a misapprehension
which has taken place from confusing the borough of Tyne¬
mouth with Tynemouth Village as to sanitary reports.
The borough of Tynemouth, he explains, includes the whole
of North Shields and several adjacent villages, and con¬
tains a population of 50,000 people. In Tynemouth Village
itself there were only two deaths in the year from any of
the chief zymotic diseases, and during the last months only
two cases of infectious diseases have been reported in the
borough, one of scarlet fever and one of typhoid fever, the
latter imported. The Village of Tynemoutli stands high,
and deserves to do so as a watering-place and health-resort.
The Not lficaiion of Measles in Newcastle.
It is a considerable period now since the medical officer
of health for the city of Newcastle (Mr. H. E. Armstrong)
was requested by the Sanitary Committee of the Corpora¬
tion to obtain particulars os to the extent to which the
notification of measles was in force elsewhere, and
on other points bearing on the general question. This
he has done by addressing a series of questions to
the principal large towns in England and Scotland.
These replies, together with opinions given in the annual
reports of several health officers, lie has collected and sum¬
marised in a very careful, fair, and painstaking manner,
and presented as a report to the Sanitary Committee. Mr.
Armstrong, in some appended remarks as to the general
question of the notification of measles, says that “ the fact
The Lakckt,]
SCOTLAND. —DUBLIN.
[March U, 1891. 62^
tiple sarcomatous tumours secondary to sarcoma of the thi^b,
wliich had been removed by Mr. Duncan, the lunw being
the only organs affected. A paper was read by Mr. Duncan
•on Stricture of the (Esophagus and Gastrostomy. He
reviewed the various causes of stricture, and dwelt mainly
on the differential diagnosis of malignant stricture. As
uegarded operative interference, he preferred gastrostomy
to any other procedure. He considered it a mistake to
make two operations— a preliminary one and a second for
the purpose of opening the stomach. He completed the
operation at once, and only made a small opening in the
-stomach, into which he put a tightly fitting tube. Out of
seven cases on which he had operated five had lived for
{months, had put on flesh, and had their symptoms greatly
ameliorated, although they had ultimately died from
■extension of the disease or from some intercurrent affection.
The two that had died were in a very prostrate condition,
and he thought that the had result in them was in part due
to the double operation, instead of making it a single one.
The second paper was by Dr. Byrom Bramwell, on the
Symptoms of Mjlxcodema and of Exophthalmic Goitre
contrasted. After reviewing the symptoms in the two con¬
ditions he regarded them as antithetic. Professor Greenfield
regarded exophthalmic goitre as due to disease of the
thyroid gland, but this view did not find favour with the
other speakers or with Dr. Bramwell. Mr. Duncan gave
his experience of electrolysis of the thyroid, and thought it
might bo of benefit in exophthalmic goitre, for he had had
one case in which it had been.
Tli,c Edinburgh Sanitary Protection Association.
The annual meeting of this Association was held at the
•end of last week, Professor Sir Douglas Maclagan presiding.
The Council’s report was of a very gratifying kind, and
alluded to the remarkable success which bad attended the
efforts made to establish an institution which had been of
so much hene.IiD to the community. It and its various
ifiranches had done much to educate public opinion and to
arouse the attention of oflicials to tW means of resisting
disease and of increasing comfort and security in their
•dwelling-houses.
Health of Edinburgh, ♦
The mortality last week was 109 and the death-rate 21
per 1000. Diseases of the chest caused 35 deaths and
Kymotic diseases 10, of which 8 were due to whooping-
cougli. The intimations comprised 20 cases of typhoid
fever, 6 of diphtheria, 33 of scarlatina, and 68 of measles.
Paisley Infirmary.
Dr. Fraser, senior physician to the infirmary, has for¬
warded a letter to the president of that institution, stating
■that a gentleman, who wished to remain unknown, had
intimated his intention of giving £1000 towards the ex-
itension of the institution.
{Ciliiilmrgli, March 10th.
DUBLIN.
(From our own Correspondent.)
Iloyal College of Surgeons in Ireland.
On Saturday last the President, Mr. H. GrayCroly, J.P,,
eatertained at a banquet his Excellency the Lord Lieu¬
tenant and a largo number of distinguished guests. The
entertainment was a very brilliant one, and his Excellency’s
Mpeech in response to the toast of his health was well
received by those present. An interesting feature in con¬
nexion with the table decorations was a valuable collection
of silver cups I'ic. won by Mr. Croly’s horses at various
•exhibitions. General Viscount Wolseley, speaking on
behalf of the Army, said that the president, m proposing
the toast, had drawn some distinction in his remarks
ll>atween the combatants and non-combatants of the army.
That was a distinction unknown in the army, for they
looked upon the doctors as the most valuable members of
'tlieir profession. The members of the army owed a deep
debt of gratitude to the members of the medical and sur-
igical profession, nob merely because some of them owed
to them the fact that they were alive that day—he hiin-
.self was one of these,—bub because they had done so
Buuch for the army in times of peace. It was a well-known
fact that it was owing bo the members of the medical pro-
iloasion tlie question of the housing of the soldiers had come
to be considered. The barracks in the United Kingdom
had been a disgrace to civilisation and to the British
Government, and he was glad that this reform had been
brought about, not by coercing or bringing great pressure to
bear upon the Government, bub by the outspoken manner
in which the question had been treated by the medical officers
of the army. When the soldiers were better housed than
they are now, and in a manner that becomes the great nation
which has the privilege of paying for those houses, it would
be a great satisfaction to men like himself that in bringing
about this state of things they were largely indebted to the
! profession which was so well represented. He thanked
them most cordially for the army, and he begged to include
in his thanks the medical officers of the profession to
which he had the honour to belong. •
Death of Mr. Henry J. Gogarty, F.H.C.S.I.
This gentleman died on Saturday last at his residence,
6 , Ilutland-square, Dublin, after a few hours’ illness. He
had been attending patients on the day he died, and on
his return home in the evening was seized with the attack
which resulted fatally very shortly afterwards. Mr. Gogarty
was about fifty-four years of age, and leaves a widow and
four children to mourn his untimely decease.
Rotunda Lying-in Hospital.
A considerable amount of money being urgently required
for the purpose of carrying out certain necessary alterations
and improvements in this institution, it has been arranged
by a committee to hold a bazaar and kuklos this week,
which will last four days. As almost all the counties will
be represented, and as substantial help has been promised
from many influential friends, it is expected that a very large
amount will be obtained for a thoroughly deserving charity.
Mollusctim Contagiosum,
At a meeting of the Medical Section of the Iloyal
Academy of Medicine last week Dr. Joseph O’Carroll ex¬
hibited a patient sulFering from a rather rare malady—
viz., molluscum contagiosum, the mycosis fungoides of
M. Aliherb. The patient, a young man about twenty, a
hairdresser’s assistant, showed an eruption of small tubercles
on the pubes and scrotum. Each elevated spot was slightly
urabilicated, and on pressure exuded a whitish fluid from
the apex. 'The disease was of three months’ duration, and
has not spread.
An Irish Journal of Sanitary Science.
The first number of a new monthly journal, the Health
Record, is published to-day, and the publication has been
undertaken to assist in promoting the all-important ques¬
tions relating to sanitation. The present number contains
articles by Sir Charles Cameron, Dr. Cosgrave and Mr.
Edgar FJinn, and others, notably one by Mr. W. Kaye
Parry, on a very important subject—viz., “On Sanitary
Defects in Tenement Dwellings.” The editor is Mr. Edgar
M.II.C.S.I., &c., Flinn of Kingstown, who has had con¬
siderable experience in sanitary subjects.
Dublin Sanitary Association.
The annual general meeting of this Association will be
held on Thursday, the 12fch iiisb., when the report for the
past year will bo presented, and the President, Mr. F. W.
Pim, will read an address entitled “ A Sketch of Sanitary
Progress in Dubliu.”
Norik Infirmary, Cork,
A debt of £900 has been incurred, and the committee
have issued an appeal for funds; if this is nob responded to,
a reduction of tlie number of beds by one-half will be
necessitated. As the hospital is an excellent one and
managed with clue economy, it is to be hoped that the
necessary funds may be forthcoming, and that the committee
may be speedily relieved from their financial embarrassment.
Watcnoorlcs fo>' Mitchclstown.
A scheme has been proposed for the introduction of a
proper water-supply for Mitchelstown, county Cork. Tho
water can be obtained two miles outside the town at an
estimated cost of £i849, which will include the erection of
twelve public fountains and twenty hydrants; and as the
inspector of the Local Government Board has reported
favourably of the scheme, the matter will be accomplished
without much delay.
Control of Lunatic Aciilums.
The grand jury of county Sligo have adopted a resolution,
Dir:'
Google
630 Thb Lancet,]
PABIS.—BERLIN.
[MARcn 14, 1891.
to the effect that as they learn that the governors of lunatic
asylums as representatives of ceespayers have nob only no
voice in preparing the plans for any addition to or alteration
of the structure of their asylum, but that they are not
entrusted 'with the duty of even appointing a clerk of works
to superintend the execution of the work, they are strongly
of opinion that the law, as it at present exists, requires to
be amended. Copies of the resolution have been forwarded
to the Chief Secretary and the Lord Lieutenant.
March 10th.
PAEIS.
(From our own Correspondents.)
The B6l6 of the Optician.
The legal status of the optician is in France, as else¬
where, a somewhat anomalous one. In this country, so
long as the functions of this craftsman are limited to deter¬
mining for a customer the kind of glasses necessary to
correct errors of refraction, no charge of illegally prac¬
tising the healing art can be preferred against him. But a
recent judgment delivered by the Correctional Tribunal of
Havre declares illegal the giving by an optician patho¬
logical information on the state of the eyesight, and the
prescribing for any visual trouble a combination of lenses.
In other words, the optician is free to pose as a physio¬
logist, but he is debarred from correcting any deviations
from normal vision which he may discover in a given case.
This is rehning with a veugeanee, and I do not envy the
judge who may be called upon to settle a controversy of
this kind.
Fro^nosi$ of Syphilitic Pseitdo-paralysvs.
The late M. Parrot, whose little patients were drawn
from a class in which la misire physiologique was the rule,
appears probably for this very reason to have taken too
gloomy a view of the prospects of cure in the disease which
he christened as above. At the last meeting of the Soci<it6
M6dicale des HOpibaux three authorities on pediatrics
enunciated the opinion that, provided the hygienic surround¬
ings of the little sufferer be favourable, the chances of com¬
plete recovery are great. M. Comby related the case of an
infant of six weeks who was brought bo him with his body
covered with characteristic syphilitic stigmata, and whose
right arm was completely powerless, the upper extremity of
the radius being swollen and painful. The mother, who
enjoyed good health, had been enceinte ten times, the Arsb
child, born free from syphilitic taint, together with the
subject of this communication, being the only sur¬
vivors, all the other children having been stillborn before
term. The father is syphilitic. The infant in question was
treated by daily inunctions and by sublimate baths
(lifteen grains to each bath), with the result that im¬
provement was clearly manifested from the sixth day, and
recovery was complete on the fifteenth. M. Cadet de
Gassicourt, physician to the Hupital Trousseau (for children),
opines that one reason for the greater frequency of cures
nowadays lies in the earlier recognition of the nature of the
affection. He has, moreover, seen the disease undergo in
one instance a spontaneous cure, the paresis transferring
itself, however, from one member to its fellow. M. Sevestre,
also of the HOpital Trousseau, while concurring with the
views of the previous speakers, warns against reliance being
placed, for diagnostic purposes, on the presence of syphilides,
which are more commonly conspicuous by their absence. He
also protests against the employment of the word “paralysis”
to designate the affection, the loss of power being analogous
to the weakness found in ordinary fractures. M. de Gassi¬
court further criticised the treatment applied by M. Comby,
and stated that be had always found inunctions sufficient,
without mercurial baths, which were useful only when
cutaneous excoriations were present.
Thoracoplasty: a New Method
At the last meeting of the Acaddmie de Mddecine,
M. (Judnu described a new proceeding for closing a pleural
fistula, the relic of empyema. The principle of the opera¬
tion consists in the resection of small fragments of each
extremity of several ribs, so that the intervening segment,
thus rendered mobile, may recede, and so determine the
filling up of the suppurating cavity. In the case upon which
the communication of M. Qu6nu was based the operation
was thus conducted The patient being antesthet'sed, a
vertical incision 15 ceotimetres in length was made bebint}
the posterior axillary fold, against the axillary border of
the scapula. The incision was then carried between, with¬
out greatly involving, the fibres of the latissimus dorsi,
and the eerratus magnus was incised transversely.
The ribs exposed were approximated, and about two cen¬
timetres of seven (the fourth to the tenth inclusive)
excised by means of Farabeul’s costotomo, thus lajiiog
bare the thickened pleura. Anteriorly, a corresponding
vertical incision was made posterior to the nipple line.
Some fibres of the pectoral mirscles being drawn aside, the
ribs, with three digitatioos of the serratus magnus, were
exposed, and a width of from one centimetre ana a half to
two centimetres was resected from six ribs. The mobility
of the bony parietes sepavating the two vertical incisions
having been proved by the effects of pressure with the hand,
the fistula was united to the anterior Incision by a transverse
out, the corresponding rib was excised in its entirety, an(2
the pleural cavity opened. This cavity was then scraped
with a curette and swabbed with a solution of zinc chloride.
The edges of the two vertical wounds were accurately
brought together with sutures, a large drainage-tube being
inserted into the most dependent part of the posterior one.
The transverse incision was likewise sutured, a large
drainage-tube being passed through it into the pleura)
cavity. A dry iodoform dressing completed this ingeniously
contrived operation. The patient recovered completely in
forty days.
Hypnotic Experimenia and the Law.
Does the speculative or speciilating layman who indulges
in experiments in hypnotism expose himself to the risk of a
prosecution for illegallypractisiog medicine ? This question
was discussed in solemn conclave by the Paris Bar on
Monday last, and the answer was in the affirmative. These
psychological exhibitions are very popular at the numerous
fairs held in the neighbourhood of this capital. It remains
to be seen if the authorities, armed by the collective opinion
of Messieurs les Avocats, will make an attempt to put a
stop to a practice not devoid of social dangers.
Life Assurance and the “ Secret Professioiincl."
Autre pays, autres mccurs! In France the medical mac
cannot be compelled to divulge, even in a court of law,
the nature of the disease for which he has treated a
patient, Should he do so withoiit the consent of hie
patient (or his representatives after death) he incurs the
risk of being prosecuted for damages. The following legal
pronouncement will give your readers some idea of tlie pro ¬
tection extended to French practitioners in this respect. Our
French confr&re is a real father confessor. On Fet). 4th the
I’aris Court of Appeal confirmed a verdict pronounced by the
Tribunal of Commerce against an assurance company which
had refused to pay the insurance money due to the widow
of a policy-holder on the ground of the non-production of a
medical certificate stating the nature and duration of the
malady to which the deceased had succumbed. The widow
could not produce the document in question for the simple
reason that tho medical attendant had, for reasons best
known to himself, declined to indite it. The Tribunal of
Commerce ruled that the doctor, bound by tho rules of
professional secrecy, is not compelled to furnish a death
certificate, it being left to his sole judgment to decide if
information revealed to him by his patient comes witltio
the limits of le secret professionnel.
Paris, Marcli 10th.
BERLIN.
(From our own Correspondent.)
A Collection of Clinical and Pathological Reports 07i
Koch's Method.
Dr. von Gossr.ER, Prussian Minister of Religion, Educa¬
tion, and Medical Affairs, ordered last Decenibor that the
heads of the Prussian university clinics and policlinics in
which Koch’s remedy for tuberculosis had been used shoulc)
report their experience to him. Tho heads of the patho¬
logical institutes were also requested to report every-
, thing of importance observed by them at necropsies, or
otherwise bearing upon Koch’s method. Besides th©
heads of the university clinics, Jh'ofessor Fraentzel, of
the Charitd, who was the first to try Koch’s method
in consumptive cases, and Dr. Paul Guttmann and
Dit i:;= Google
The Lancet,]
VIENNA.—NEW ZEALAND.
tMARCH 14, 1891. 631
Profeseor Soonenberg of tbe Moablt Hospital, who
has practised tbe method under Koch’s supenuteodeDce,
were requested to report their experience. Fifty-live
reports were sent in, and have been edited by Proiessor
Guttstadb and published by Springer of Berlin in a volume
entitled, “The Efficacy of Koch’s Remedy for Tuber¬
culosis.” With very few exceptions the reports coniioo
themselves to the time before Jan. 1st, but tbe results of
the first half of that month are once or twice alluded to.
Dr. Guttstadt has extracted the most important items
from the reports, and summarises them in an appendix. In
the hospitals to which the reports refer 2172 persons were
treated with tuberculin during the time in question, and
they received more than 17,500 injections in all. The
greatest number of injections received by any one patient
was 64; the greatest total quantity 3'826 grammes. Tbe
diseases treated were tuberculosis of the lungs, tbe larynx,
the peritoneum, the intestine, tbe cerebral meninges, the
kidneys, the bladder, the lymphatic glands, the sof^t parts,
and the bones, lupus, leprosy, pernicious anojnoia, pleurisy,
and corneitis. ’j?he pulmonary patients are divided into
three groups—those with incipient phthisis, those with
moderately advanced phthisis, and those with very far
advanced phthisis with cavities. Of those of the first class,
242 were treated with tuberculin; 9 were cured, 72 con¬
siderably improved, and 59 improved. Of the second class,
444 were treated; 1 was cured, and 68 more or less im-
{iroved. Of the third, 230 were treated ; 7 were considerably
limproved, 31 improved, and 30 died. Many of those patients
had laryngeal phthisis too. Of 18 patients who had
laryngeal phthisis alone, 1 was cured, 2 were considerably
improved, and 10 in a less degree. The number of lupus
patients treated was 188, of whom 5 were cured, 78 con¬
siderably and 84 less decidedly improved. The book con¬
tains reports of necropsies from the pathological institutes
of Berlin, Bonn, Breslau, Gottingen, Halle, Konigsberg, and
Marburg.
Dr. Wilhelm Strieker,
Dr. Wilhelm Strieker of Frankfort-on-the-Maine, a
literary physiciap of mark, died last week. The themes of
his numerous writings are the History of Medicine in
Frankfort; the lives of Soemmering, Neef, and Stiebel,
Itaar, and other miracle doctors ; Ettner’s medical novels ;
the Care of the Sick in the Wars of the Past ; Taylor,
Ludwig Hoeruigk, Burggrave, Haller, Zimmermann ; the
mortality of children, suicide, marriages between blood
relations, medical statistics, hermaphroditism, hairy men,
emall-pox, vaccination, labial cancer, the effieebs of lightning
on the human organism, the history of his native city of
Frankfort, the life of its greatest son, Goethe, &;c. He
was born in 1816, studied at Dresden, Gottingen, and Berlin,
travelled for several years in Italy, established himself as a
medical practitioner in Frankfort in 1844, and spent the
rest of bis life there.
Uorliii, March 10th.
VIENNA.
(From our own Correspondent.)
Koch's Treatment.
The trials of Koch’s liquid in the treatment of tuber¬
culosis have been brought to an end here in the course of the
last two or three weeks, and “ Kochin ” is now only rarely
administered at the Vienna hospitals, and the official report
wi the treatment will shortly be published. At the last
meeting of tbe Vienna Society of Physicians, Professor
Billroth presented his case of actinomycosis, which had
been treated with Koch’s liquid and which has been
mentioned in previous letters to The Lancet. It was
the case of a labourer twenty-six years old, who had
been at first admitted to the wards of Professor Notlinagel
on account of some abdominal disease, combined with
vesical and rectal symptoms. By the examination of the
imne the presence of actinomycosis could be detected, and
the patient was sent to the wards of Professor Billroth.
As there was an extensive infiltration of the abdominal
walls, an incision was made on August 2nd, and the actino¬
mycotic tissues were scraped out; by the infiltration ex¬
tending deeply throughout the abdominal muscles and
fascia, a perforation of the bladder was produced. The
wound, as well as the vesical fistula, in a short time began
to heal; bub after some weeks the abdominal walls became
infiltrated again, so that a tumour of the dimensions of
16cra. by I2cm. by 2icm. was found on the left side
of the abdomen. Then on Dec. 5th the first injection of
Koch’s fluid was made, tbe initial dose being 10 milli¬
grammes, and a considerable local and general reaction
resulted from it. The tumour, at first exceedingly bard,
became softer and decreased in size after repeated injec¬
tions of the fluid, so that after fifteen injections the
infiltration had perfectly disappeared in the first day;a
of February. The dose had been increased to 260 milli¬
grammes. At the present time, the patient having been
under observation for four weeks in tbe wards, no relapse
has occurred, and he seems to he healed. At tbe last
meeting of the Vienna Dermatological Society Dr. von
Hebra demonstrated three of his cases of lupus treated
by Koch’s fluid. One of them was a young man in
whom the first injection had been made in Vienna on
Nov. 2l8b. He then showed a very remarkable reaction,
both local and general, after the application of 3 milli¬
grammes. This reaction diminished with each later injec¬
tion, and from the time when 10 milligrammes were in¬
jected no reaction at all could be observed. At present a
dose of 80 milligrammes was used without any effect. The
lupus efflorescences themselves have scarcely diminished
under the treatment. Before the treatment both hands
were affected ; there was along the dorsum of the fingers
a lupus infiltration raised a quarter of an inch above
the healthy skin ; that bad not disappeared. The second
patient, a boy of seventeen years, with a lupus vulgaris
occupying the entire right cheek, suffered very much
in the course of tbe treatment from pains in his bowels,
dyspepsia, and diarrhoea, so that several times the treatment
had to be stopped for a couple of days. The lupus had
decreased in size, but a considerable part of it remained un¬
changed, and at the same time new lupus nodules made
their appearance on the previous healthy chin, and the
enlargement of them could not be checked by tbe injections;
in this patient also a dose of 80 milligrammes had been used
after twenty-seven injections. The tfiird patient, a very pale
lad twelve years old, with a lupus patch of the size of the
bowl of a tablespoon on tbe plantar surface of his left foot,
and one on the inner side of his left knee, was also suffering
very much from affections of the bowels in consequence of
the injections. After the first injections in this patient bis
lymphatic glands (axillary, inguinal) became tumefied to
the size of walnuts, and very painful, bub never suppurated.
With every increase of the dose he suffered from asthmatic
fits lasting from three to seven hours. It was impossible to
increase tlie dose as quickly as in the other patients, the
highest dose used till now being 25 milligrammes. The
reaction was very slight, and the lupus of the plantar pedis
increased in size, and new nodules appeared in the neigh¬
bourhood of the lupous patch of the knee. Dr. Hebra also
mentioned a case in private pvactice—thab of a young
lady with multilocular lupus vulgaris, in whom the doses
could be rapidly increased up to 70 milligrammes after ten
injections without any effect whatever. In opposition to
Koch’s statement, that the diminishing of the reaction is
not due to accommodation but to the diminishing of the
quantity of tuberculous tissues in the body, Dr. Hebra
found that, although this diminution had been compara¬
tively small, the reaction was nevertheless less marked even
when eighty times larger doses had been used.
The Caniharidin Treatment.
Experiments are now made here with the injections of
cantharidin in cases of laryngeal tuberculosis, and other
tuberculous affections, at the General Hospital, as well as
at some private institutions, and, as I am informed, the
results obtained till now seem to be favourable. On the
other side a series of other irritant substances obtained,
including even jequiiity, have been also experimented with
for the treatment of tuberculosis since November last, butt
the results obtained are nob yet published.
Vienna., March lltli.
NEW ZEALAND.
(From our own Correspondent.)
The late Sir William Filzherhert, K.C.M.G., M.D.
There are few of the early pioneers of the colony now left
to us, and of these sparse survivors the most distinguished
has passed away. It is not generally known-^at any rate
Dig-j t, Google
632 The Lancet,]
AUSTRALIA.
[March 14,1891..
in the colony, for he never practised his profession—that
the late Sir William Fitzherbert was a member of the medical
profession, having graduated in Medicine and Surgery in
1840. It is therefore not as a medical man that Sir AVilliam
Fitzherberb’s name will be handed down in the pages of the
history of New Zealand. He, nevertheless, took a deep
interest in the advancement of science generally. He w’as
a staunch supporter of all movements pertaining to the
efficient management of local medical and sanitary offices.
Bom in England and educated at the University of Cam¬
bridge, where he obtained a Fellowship at Queen^s College,
the deceased had for a great many years been identified
with the interests of the colony from a political and social
point of view. Mr. Fitzherbert emigrated to New Zealand
in 1842. He soon gathered round him men of light and
leading. Bishop Selwyn, although by no means always
agreeing with Sir William Fitzherberb’s conduct of native
auairs, had the highest opinion of his capacity. The
Maoris, in the early days, had great confidence in him, and
often undertook long journeys to seek his advice. During
the Maori war—a cntieal time in the history of the colony—
Mr. Fitzherbert was Sir George Grey’s ablest counsellor,
and, together with the late Dr. Featherstone and Sir
William Fox, constituted the celebrated “ three F.’s.” The
early settlers had few of the advantages which w’e now
possess. The chief event in those days was the arrival of
the English mail, and greedily indeed the news it
brought was devoured by all, and by none perhaps more
so than by a gentleman of culture and refinement like Sir
William Fitzherbert. How different is it now when events
occurring in Europe are flashed to the Britain of the South in
a few hours. In 1864 Sir William Fitzherbert was appointed
colonial treasurer, but resigned that office the following
year. In 1866, however, be was reappointed to the same
office. He came to England as Agent-General in 1867, and
right well were his duties undertaken. But it is in the
cmony that bis power of work and versatile genius are
best known; for his life has been devoted to the develop¬
ment of her interests. After his return to the colony from
England in 1876 he became Speaker of the House of Repre¬
sentatives, and in 1879 he was advanced to the position of
Speaker of the Legislative Council. In 1877 he was made
a Knight Commander of St. Michael and St. George, having
been previously, in 1872, created a Commander of the same
order. Sir William Fitzherbert in 1887 represented New
Zealand as delegate at the Colonial Conference held
in that year in London. This was his last visit
to the old country. In politics he favoured the Whig party.
Few colonial politicians have done more to advance the
mutual interests of the Maori and English races, and it is
to men of the intellectual calibre of Sir William Fitzherbert
that all the credit is due of making the colony what it now
is. No natives of any colony have ever been better con¬
sidered by the English-speaking race than the Maoris have
been. Their interests from the first have always been fairly
weighed. It was the knowledge of this fact that really
saved the early English settler.? at the Hutt, Wellington,
when the celebrated chief “ Te Puni ” stayed the hands of
the natives under him and prevented the contemplated
massacre. The deceased “roughed it ” in these early days,,
and he paved the way nobly and well for his successor.?. 5tle
has clearly shown that he was a staunch friend, a genial
companion, and a most able adviser. Few young men
arriving from home and armed with a letter of introduction
to Sir William Fitzherbert failed to be received with the
greatest hospitality and to get the best of advice for their
future career in the colony.
AUSTRALIA.
(From our own Correspondent.)
Climate and Temperature.
The climatic conditions of the world appear to be topsy¬
turvy. While you in Europe are being scourged by weather
so severe that even the “oldest inhabitant” remembers
not such another winter, we here are passing through (juite
a cold summer. Last year at thus time a heat wave was
passing across this continent, and for weeks the tem¬
perature was between 90'and 110° F. in the shade; this
year the weather is wintry, and up to the present there
nave been only three or four hot days.
Typhoid Fever in Melbourne.
In consequence of this cool weather, the annual typhoid
fever outbreak which usually occurs in Melbourne about
this time has not been so virulent. What may happen if a-
heat wave similar to that of last year visits the colony it
is impossible to forecast. All the elements for the genera¬
tion and spread of typhoid fever are present in Melbourne
and its suburbs. “Melbourne,” its inhabitants boast,
“is a marvellous city,” and so it is in many respects.
Outwardly it has put on fine raiment, but this fine-
raiment covers a multitude of impurities. Here is a city
picturesquely situated—having fine wide streets, splendid
public buildings, spaciotrs parks, a most complete cable
tramway system, and no beggars, yet under all this a.
system of sanitation that even a Kalmuck Tartar would
blush at. The river Yarra, on which the city is built, is
from Melbourne to the sea one huge cesspool. In comparison
with it the Liffey at Dublin is a crystal stream. When
stirred by the screws of the numerous steamers that throng
itBbanks,iti3 said to emitnoless than sixteen distinct odours ^
In his address to the Victorian Branch of the British Medical
Association the retiring president, Dr. Le Fevre, touched on>
this matter, and his words are worth quoting :—“ A matter-
requiring immediate consideration, and one to which he had'
frequently called attention in Parliament, was that of pro¬
viding for the prevention of the pollution of our rivers.
The present condition of our streams was simply disgraceful,,
as well as disgusting. There was probably no other country
in the world where such a state of things was allowed to-
prevail as that to be witnessed in and about Melbourne.
The Government was spending thousands of pounds on our
defences, while at the same time no adequate machinery wa&
provided for coping with an insidious enemy, which was-
continually lurking in our midst. Typhoid fever had beem
extending year by year, and would continue to extend
until they adopted some measures of sanitary reform which
would bring about better results than any we have yet'
achieved. In fact, unless this were done, we feel quite-
certain there would be such an epidemic one of these-
days as will arouse us to a sense of our duty.” Open-
pan earth closets are generally in use, and it not
infrequently happens that the nightmen deposit their-
loads of night-soil surreptitiously on or near the main
thoroughfares, and thereby save themselves the journey to>
the proper depots some miles out of town. Moreover, at-
the last meeting of the Central Board of Health for Victoria
Dr. Gresawell, the Board’s medical expert, reported that
during bis investigations into an outbreak of typhoid fever
at one of the suburbs he was astounded to find that the
excreta of the typhoid fever patients, instead of being
destroyed, were superficially buried in the back yards..
Your readers will thus readily understand why typhoid fever
and other intestinal diseases are so very rife and so very
fatal in the capital of Victoria.
The Melbourne Hospital.
The staff of the Melbourne Hospital have been taken
to task very severely quite recently by the city coroner,
apropos of a death from chloroform in that institu¬
tion. The patient was an elderly woman seventy years of
age, and ohloroform was administered by one of the bouse
surgeons for the purpose of incising a carbuncle at the nape
of the neck. The doctor averred that “ the woman took tne
anuisthetic well, but that just after taking it she died of
suffocation, and the post-mortem examination showed that
the glottis was diseased.” It seems that another death
under chloroform occurred at the same institution a little
while ago, and although no one wa.s held to blame, the
coroner suggested to the staff the advisability of appoint¬
ing a teacher of anicsthetics. This the staff have not done,
for, in reply to a question asked hy the coroner, one of the
number stared that the staff, having talked the matter
over, had decided that such an addition was quite unneces-
sai-y. Tlie coroner thereon intimated to the hospital!
authorities that they were neglecting their duties to the
public and to the students themselves in omitting to leach
in a practical manner a most important part of medlcaA
practice.
Professor Koch's Remedy.
Dr. Koch and his remedy, after monopolising the cable¬
grams for many weeks, have been dropped entirely by the
newspapers, but the interest is certain to be revived when
the doctors who are hurrying out from Berlin with suppUea
of “parataloid ” arrive and give demonstrations.
. Melbounio, Jan. 27tli
-Google
The Lancet,]
ROYAL COLLEGE OF SURGEONS OF ENGLAND.
[March 14,1891. 633
JOHN ALLAN, M.D., M.R.C.P. LOND.
By the death of Dr. Allan, of Milner-square, Islington,
the profession loses a type of a class of practitioner the leaven
of whose influence is always working for our good, and it
behoves ns to note such men with reverence and honour as
•one by one they pass away. A line specimen of a true Scot,
Dr. Allan was nevertheless born in the West Indies, and he
passed little of his lifetime in Scotland. His parents and an
uncle, who was a medical man, were residing in Antigua
during the early part of the century, and there on Oct. 10th,
1815, the subject of our memoir was born. He lost both
father and uncle during his early childhood, and was then
brought by his mother to Europe ; his school days were passed
chiefly in France. He commenced his medical education in
Paris, and was wont to relate many interesting anecdotes
of the medical and surgical worthies of that day. After a
time he went to Edinburgh, where, in 1830, he passed the
College of Surgeons. In 1837 he graduated at St. Andrews,
and subsequently, in 18G0, he became a Member of the
Royal College of Physicians of London. About fifty-two
years ago he commenced practice in Islington, and his
sterling character, kind-heartedness, and unsparing self-
•denial soon won for him a wide circle of attached patients
and friends. During his early days he held the post of
/physician to the Islington Dispensary. He had also been
^or many years physician to the Church Missionary Children’s
Horae and to the Church Missionary College. One of his
marked characteristics was his stern sense of professional
right and wrong, but his uncompromising mode of de¬
nouncing any deviation from his ideal was sometimes mis¬
understood. Among his friends, however, who knew him
well, apart from his nobler qualities, his ready humour, his
'tfund of anecdote, and tbatcneery eye of his will not soon be
-forgotten. His health had been failing for some time,
although he continued to practise to witbin a few weeks of
•the end. He died of disease of the heart on the morning
•of March 2nd, at his residence in Milner-square, leaving a
widow and three daughters.
FREDERICK WORTHINGTON, M.R.C.S.ENG.
Although it is more than eleven years since Mr. Frederick
Worthington loft Liverpool and retired, after upwards of
tfifby years’practice, the tidings of his •death were received
there with much sorrow by liia professional brethren and bis
cnumerous friends. The son of a local surgeon, he became a
student of the infirmary long before it acquired its royal
title, and before the first local School of Medicine was
founded, though lectures on anatomy and other medical
-subjects were given. He subsequently studied in Paris, at
■& time when the late Philip Ricord was beginning to acquire
fame, and learned what must have been of much value to
him subsequently. Returning to Liverpool, he was in
•1832 elected surgeon to the newly completed lock
'hospital in conjunction with the late Mr. Simon, and
held that office until his resignation in 1873, when he
was elected consulting surgeon, and continued in private
practice until towards the close of 1879, when he left
Liverpool for Enfield. He had very fair health until re¬
cently, and at the time of his death was in his eighty-
•second year. Many former students will remember his
•quaint anecdotes of the old treatment of venereal diseases
which be used to detail—mercury given for gonorrhcca,
even to the most profuse salivation; and the inoculation
experiments of Ricord, which were also practised at Liver¬
pool Lock Hospital. He also gave vivid descriptions of the
•aursing of his student days, which amply confirmed the
descriptions of the immortal Sarey Gamp and Betsy Prig.
Mn Worthington had a very large practice, both special
and general, for many years, among his patients being
many leading citizens. He leaves a widow, three
-daughters, and one son, who is a member of the medical
j>rofes8ion.
KOYAL COLLEGE OF SURGEONS OF
ENGLAND.
At an ordinary meeting of the Council held on Thursday,
the 12th inst., the minutes of the meeting of the 12 th'of
February were road and confirmed.
The report of the Committee on the Extension of the
College Premises was approved, adopted, and entered on the
minutes. The report sec out that, plans having been pre¬
pared by Mr. Salcer for altering and enlarging the College
forecourt, and estimates for carrying out such plans having
been obtained, the committee recommend the Council to
sanction an expenditure of £1894 for this purpose.
A report was read from the committee on the form of
the report of the Council to the annual meeting of the
Fellows and Members of the College. The committee
are of opinion that it is desirable that the report should
be written in narrative form and should record the work
done by the College in its various departments during the
past Collegiate year; that it should contain contributions
from the chief officrrs of the various departments on the
following subjects—viz.: Museum, Library, Laboratories
(at the College and at the Examination Hall), Examina¬
tions, Finance, Lectures, Obituary Notices, College Prizes
and Honorary Elections, and other subjects of in¬
terest contained in the minutes of Council; and that
the report be edited by a committee to be appointed by
the Council.
Mr. T. Bryant, President of the College, was elected a
representative of the College on the General Medical
Council in the vacancy occasioned by the death of Mr. John
Marshall.
The report from the Committee of Management, with
regard to the arrangement of studies and of examinations
during the extended curriculum of five years, was referred
to a committee of ten members of the Council, including
the President and Vice-Presidents, to report thereon to an
extraordinary meeting of the Council.
A letter of the I 81 -I 1 ult. from Dr. Liveing was read re¬
porting the adoption by the Royal College of Physicians on
that date of the revised scheme for the reconstitution of the
University of London.
A letter of the 17th ult. was read, addressed to the
President, from Mr. Hutchinson, offering to present to the
College his collection of clinical and pathological drawings,
on condition that the College will maxe them useful by dis¬
playing them in well-arranged classification in such a
manner that they may form the nucleus of a far more
nearly complete series. This letter was referred to the
Committee on the Extension of the College Premises to
report thereon to the Council.
The President reported a correspondence between himself
and the President of the Royal College of Physicians in
reference to the grievances of Army Medical Officers.
In pursuance of his notice on the 12ch ult., Mr. T. Smith
proposed that the proceedings of the Council in relation to
the scheme for the reconstitution of the University of
London be placed before a meeting of the Fellows and
Members summoned for the purpose, and that the date of
the meeting he determined by the President and Vice-
Presidents. This was seconded by Sir W. S. Savory, and
carried by a majority of 16 to 5. It was also agreed, on the
motion of the Vice-Presidents, that, prior to the meeting, as
soon as the date of the meeting has been fixed, a copy of
the scheme for the reconstitution of the University of
London be sent to each Fellow of the College, and to any
Member who may apply for the same.
Slelriral
Royal College of Surgeons of England.—
The following gentleman, having previously passed the
necessary examinations, and having now attained the legal
age (twenty-live years), was, at the ordinary meeting of the
Council on the 12bh inst., admitted a Fellow of the College :
Ciuldy, Aruolil, L.R.C.P. Lond., of St. Goovgo's Uospitiil. Diploma of
Mombev dated Aui:i.ist •Itli, liisT.
Medical Magistrate. — Dr. Alfred Sutton,
Government medical officer and medical officer of health
at Bornleigh, Queensland, has been appointed a Justice of
the Peace for the colony of Queensland.
Fire at a Hospital.—O n Sunday last a fire
broke out in the Bowdou branch of the Manchester
Hospital for Consumption. Fortunately, two only of the
seventeen beds were at the time occupied, the remainder of
the patients being in the day-room. Though much damage
was done to the building, the flames were eventually
subdued without loss of life.
Di(.' zed by
Google
634 The Lancet,]
MEDICAL NEWS.-MEDICAL NOTES IN PARLIAMENT.
[March U, 1891.
Epsom College.—A. C. Knight, of this school
(sixth form), has just been elected to an open classical
scholarship of £80 at Queen’s College, Oxford.
St. Bartholomew’s Hospital.—A t a meeting of
the Commissioners of Sewers on Tuesday a monon catling
attention to the alleged insanitary condition of this hospital,
and recommending that the matter be referred to the
Sanitary Committee for immediate consideration and report,
was rejected.
Koyal Hospital for Children and Women,
Waterloo-road. —The annual meeting of this institution
was held at the Mansion House last week, the Lord Mayor
presiding. The annual report stated that the income had
exceeded that of the previous year by £604, and of that
amount £300 had been added to the extension fond. The
in-patients numbered 509 and the out-patients 6710; there
were 27,164 attendances and 310 dental cases. His lordship,
in reviewing the history of the hospital, said it had a great
claim upon the City of London, as it was founded within the
City boundary in 1816 by Dr. Bunnell Davis, and it well de¬
served liberal financial support. Annual subscriptions
were announced amounting to ten guineas, and donations
to £270.
The Dental Hospital of London.—T he twenty-
third annual meeting of this institution was hold this week
at the hospital, Leicester-square, under the presidency of
Sir Edwin Saunders. In the report, which was unanimously
adopted, the mauaging committee congratulated the
governors on the continued success of the institution ; also
on the great benefits which the hospital continues to afford
to the suffering poor, 48,764 cases having been treated
during the year 1890, a large number of them painlessly
(under anccstbebics); being 26,770 in excess of the number
treated in 1874, when the hospital was removed to its pre¬
sent site. Unfortunately, there was £2500 remaining of
the mortgage debt on the hospital incurred for the neces¬
sary extension of the hospital. The managing committee
had pleasure in announcing the continned increase in annual
subscription.
Presentations.— Mr. J. Hay Caird, L.RC.P.,
L.B.C.S. Edin., parochial medical olficer for Loeligoilhead
district, received on the 28th ult., at the close of the second
course of Ambulance Lectures under the St. George’s Kales,
Glasgow, a handsome presentation from the memWs of his
class in recognition of bis zeal and success as a lecturer.—
The members (6mploy6s at the Lincoln Railway station) of
the Great Northern Railway Ambulance Class have pre¬
sented Dr. Lowe with a silver card salver, in acknowledg¬
ment and appreciation of his lectures to them on “ First
Aid.”—Mr. Arthur Cox, M.R.C.S , of Long Buckby, Rugby,
has been presented with a cheque for twency guineas, a copy
of Fagge^s “Principles of Medicine,” and an illuminated
address (framed), by the inhabitants of that town and
neighbourhood, in testimony of his unvarying kindness and
attention in the discharge of his professional duties to all
classes during his practice in the district, covering a period
of thirty-two years.
Outbreak op Small-Pox at Sea.—T he four-
masted barque Kelton, 1770 tons, was detained in Mel¬
bourne by tbe authorities on account of an outbreak of
small-pox on board. The Melbourne Argus gives a circum¬
stantial account of the “ terrible experiences,” which have
been undergone on board that unfortunate vessel. The
vessel sailed from Glasgow for Rio Janeiro with a cargo of
sewage pipes. Six weeks after leaving Rio a man named
Duncan McColl, twenty-seven years of ago, was taken ill of
small-pox. No epidemic had existed at Rio, and tbe crew
had been ashore at that port only a few hours. Some days
after McColl’s death others were attacked, and ultimately
the whole of the crew were seized. Captain Young himself
caught the disease, and was unconscious for about twenty
days. Tbe ship was well supplied with medicines, spirits,
and all requisites fur the sick. All on board had been
vaccinated in early childhood, the captain amongst the
number. At the quarantine stations tbe patients were
attended by Dr. De Burgh Grifiith and two nurses,
sent from Melbourne, with the greatest possible kindness.
Tbe chief officer and one of the crew were not suffi¬
ciently recovered to join the ship on its departure from
Heibournc.
Superannuation Grants. — Mr. T. J. Cottle,
M.R.C.S,, lately district medical officer of the Cheltenham
Union, and Mr. H. V. Ellis, M.B., C.M. Aberd., lately
medical officer for the westera district and workhouse of the
Gower Union, have been granted allowances of £100 and
£23 3^. per annum respectively.
METROPOLITAN ASYLUMS BOARD.
Beturn of Pat ients remaming in the several Fever Hospitals:
of the Board at midnight on March lOth, 1891.
Beds occupied.
i
Hospital.
S 9
GQ
Diphtheria.
Typhus
fever.
Enteric
fever.
Other
diseases.
Total
9
s
Eastern Hospital .. ..
240
54
42
2
838
442
North-Western Hospital
393
87
8
238
448
Western
164
19
33
2
188
22 d
South-Western
147
23
11
181
840
South-Eastern „
108
2 U
24
3*
216
462
Northern „
223
19
—
16
-
267
480
Totals.
1126
172
—
113
7
1417
2891
* lolaDt and mother.
MEDICAL NOTES IN PARLIAMENT.
Lodning-home-keeperK' Ref/istration.
On March Oth, in tlie House of Commons, the Chancellor of the-
Exchequer, in reply to Lord 11. Bruce, said that it would be impossible-
to make any concession now in favour of tliose who, under these cir-
ciinistance.s, failed to comply with the conditions dotnanded by the law.
But, of course, tliey will be able to secure the benoiit.s of the lower
charge in future by registering themselves each yoar within tlio proper-
time.
The Royal Cuintnixsion 07i Vaccination.
Mr. Ritchio will proiio.se the appointment of a member of the Royal
Commission to take the place of Mr Bracllaugh.—In reply to Mr.
Clianning. Mr. Ritchie stated that lie was aware that Mr. Bradlauglt
was accepted as a representative of those wlio were opposed to vaccina¬
tion, and felt bound in making the selection to give weight to that
consideration. •
Feoer in India.
On Monday, the 9th, in reply to I'll-. Conybearo, Mir James Fevgusson
aaid the sUvtistics of fleaths in India, whicii will bo found in thc-
statistical abstract, do not aliow a progres.sive increase in each year in
the total number of deaths nor in the number of deaths from fever, and
the latter depend in great measure upon tiro season,
Leprosy and the I’rke of Salt in India.
In answer to Mr. Conybenre, Sir J. Fergiisson .said: In the Presidency
of Ma(lr;Ls the price of salt has risen from 9 annas and 8 annas per maund
in 1800 to 2 r. II a. in 1890. The Secretary of State cannot give informa¬
tion for tiro earlier years of the cantui-y, but if tlio lion, member wishos-
it, he can place at his disposal statistics going back to 1841. There is no¬
certain information as to the increase of leprosy. Lepers were counted
at the census of 1881, but tire results of the census taken last month are
not known. The Commission now .sitting will <ioul)tloss consider the
question of the connexion which has been stated to exist between in¬
sufficient salt and the prevalence of leprosy.
Kxcegsive Drinkiny at Publk-hoxms.
In answer to Mr. Kowntree, Mr. Matthews sjiid ; TTio Commissioner
of J’oiico asHuros me tliat every effort was made for tlio offidont enforce¬
ment of the law, and tlio figures quoted .sliow that the police are not in¬
active. But the lion, member is doubtlfss aware that there aro great
difficulties of jiroof in cases whore publicans aro cliarged witli per¬
mitting drinikeniie.s.s, and I do not think those difficiiltie.s will bo re¬
moved by alteration of tlio law.
Interment of StUlhirtlis.
On Thursday, the 12th inst, Br. Cameron asked the President of the-
Local Oovermnent Board whether his attention liad boon called to the
statement of Dr. Rentoul to the effect that lin the yoar 1889 0821 still¬
born children wore interred in seventy-one burial board comotorios
that there are llfit) board cemeteries in J'ingland ; and that the larger
number of such interments take place in parish churchyards, and asked
for returns on the suljject.—Mr. Ritchie ; My attention had not
pruviiiusly been called to the statements whidi have been published by
Dr. Rentoul. Tiio births of stillborn children aro not rogisLorod by the
registrars of hirtlis and doath.s, and con.serjueiitly no returns of tiie.so
hirllis ate made to tlie Registrar-General. I am therefore not in a
position to give a return of tho number of infants interreil as stillborn
In 18 !)(), nor to state what proportion of tlieso iitfanls wore boi-ii respec¬
tively in and out i>f weillock.
Vaccination.
Mr. Channing asked the I’resident of the Local Government Board
whothor his attention h:i<i been called to the case of Mr. I’uiishon, of 37.,
Davwin-street, Old Kent road, S.l-i,, whose infant cliild is inouically
Digitized by <^ooQle
The Lancet,]
THE METKOPOLITAN HOSPITALS INQUIRY.
[March 14,1891. 635
tiertifled to have died on Feb. 26th from blood poisoning, from vaccina¬
tion performed by a public vaccinator; and whether he had directed an
inquiry to bo made into this case; if so, with what result; if not,
whether it was his Intention to direct that sucli inquiry bo held by hie
department.—Mr. Ritchie: I have received a copy of the entry in the
Register of Deaths in the case of the child referred to. The cause of
death as certified by the medical man was vaccinia and pycemia. The
case has been brought under ttio attention of the Royal Commission on
Vaccination; and it is, I understand, to he investigated by one of the
medical men employed by the Commission for such inquiries.
Food and Drugs AefJ
In repW to Mr. Herbert Gladstone in reference to the case of
Police u. Cannon, ia wliich the defendant was charged with adulteration
under the Food and Drugs Act, and which wa.s dismissed by the magis¬
trates, Mr. Ritchie recapitulated tiie facts of the case, and said: As
regards the question of legislation, I am not prepared to propose that
any legal proceedings should be taken under inaction 20 of the Sale of
Food and Drugs Act, 1875, upon a single unsupported analysis. Sec¬
tion 22 already gives power to tlie justices before whom any complaint
IS made under the Act upon the request of either party to cause an
analysis to be made by the chemical oiticers of the Inland Revenue
Department of the article of food alleged to be sold In contravention of
-Che Act, and to obtain a certificate as to the result. This power was
•conferred upon the justices to enable them to obtain .an Independent
analysis whenever the circumstances appear to require it.
THE METROPOLITAN HOSPITALS INQUIRY.
THE Committee of the House of Lords on the Metropolitan Hospitals
resumed their inquiry on Monday. Earl Sandhurst presided.
Tkc Admissio7t of Nurses to University College Hospital.
Mrs. Alison appeared before tire Committee to give evidence bearing
•on tbe statement of Sister Cecilia, that in admitting nurses to the staff
•of Univor.sity College Hospital no preference was given on account of
religious profession. In October. 1883, she applied to be taken as a pro¬
bationer, and she was objected to on the ground of being a Noncoii-
a'ormiat.—By the Earl of Kimberley; Sho saw the head of the nursing
<lepartment, and she had been told tliat the lady was Sister Cecilia. She
received no answer iu writing. Ail that occurred was a personal inter-
•view. The lady told her that she, being a Nonconformist, was ineligible.
No other question was discussed- She did not make any representation
'to the authorities of the hospital.—By Lord Cathcart: The lady aho
jaw was dressed in the uniform of the All Saints’ community. Witness
wius accompanied by her aunt, Miss Body, who was at tluat time a
Sister of All Saints’ Community.—By Lord Thring : She did not think
she could identify the lady,—By the Chairman: According to her ex-
iperlenco the .statement made to the Committee by Sister Cecilia was a
misreproseutation. She expressed no opinion as to the justice of the
rule. She merely wished to contradict the statement which had been
smade to the Committee.
At a later stage in the pi'oceedings, tho Chairman read the following
(letter which the Olcvk of tho Comnutteo had received from the Sister
Cecilia~viz.: “ Dear Sir,—In reply to youi' letter, I beg to state that on
-April 6th, 1881), the Mother Superior of AH Saints decided that it would
be well to admit imr.sos of all creeds to the paid stall' of the hospitaJ.
Mw. Alison, of whom I have no recollection, must have applied pre-
wiously to this decision, Prior to April (1th, 1889. we trained nurses of
-ail creeds, but did not take them on our paid stall.”
The llfelro 2 H>Utan Hospital.
Mv.C. II. Byers, o.xaminod by tho Chairman, said he was secretary to the
Metropolitan Hospital. Ha liad beou four years in that position, having
jn-eviously been engaged in busine.ss. Until recently tho institution was
•c^led the Metropolitan Froo Hospital. It was started in 1836, originally
as a df.spensary.by tho present chairman, Mr. .Joseph Fry. The present
buildings were completed in 1886. T’heycost somotliing like .-fise.OOn. and
•accommodated 160 beds. 'J'he aauitary arrangomoiits were thoroughly
good. Each ward was isolated. There were two lire hydrants on oacli floor,
> ind a fire drill w.as conducted by Messrs. .Shand, Mason, and Company,
in which all the nui-sos as well as the porters took part. At tho
•governors' meeting at which tlie name of the hospital was changod
'there was only ono dissentient. Every accident ami urgent case was
token in on its morit-s irrespective of the social status of tlie patient,
•and at the same time every person who came to the hospital was .seen
for tho first time by the doctor on duty, prescribed for and received
seven days’ medicine. After that certain questions were asked, and it
was optional on the part of tho patients to answer tlieni. T'hey had a
provident department intended for persons living in tlie hospital dis¬
trict who were unable to pay the usual feos of inoiiical men. Inquiries
were made, if iiecossHry, as to the circumstaucss of tlioso who took
•advantage of tho achomo. It was generally understood that no single
person earning more tlian 21». per week, and no man, wife, and family
•earning more than would bo allowed to become a member of the
provident department. There were ninety medical men in the district,
and when the scheme was being ariaugod tliey were invited to meet
and discuss it. Only seven of tlie ninety attoiulod the mooting.
'Undoubtedly the medical men of the district objected at fli-.st to the
schema as likely to intorforo with thoir practices, but lately ho had
heard no complaints from thorn. 'L’ho position tho committee took up was
'that while the hos))ital was coniluoted on the ohl linos abuses certainly
occurred, luid they wished to pub a stop to thoin. The oxporionco they
bad already obtained had demonstrated lliat their provident department
was tho right thing for the hospital, and ho thought that tho medical men
(in the district wore boginning to see that tlioy had no desire to take
money out of Ihoirpockots. Members of tho provident dep.artmoiit were
treated as out-pntieiits, or at their own homes, or iu tho hospital, us tho
•circumstances of thoir ailmoiits roquiveil. Tho great difficulty under
which the scheino lahourod was tho sliifting of the population, but lio
■thought a proper sysioni of coUectiou would overcome that dilHculty.
Ho saw no reason why tho scheme shouhl not be a groat success. Tlie
amount received in providoul donartnioiit payments last year was .CdTl),'
and the previous year .dU53. 'I'lie total oxpendituro of tho liospilal
amouiit.ed to .£7500 last year, .Jews Irail been very good to tlie
fiospital, and when tlie now Iniildiiigs woi-e orccteil they ro.sevvod
forty of the 160 beds for people of the Jewish faith, and mads
special arrangements for cooking the food of Jewish patients. Of
the seventy-eight beds now in occupation twelve were occupied by Jewe.
Witness received a salary of £800. His assistant,’ who acted In his
absence, had a salary of £60, with board and lodging. Witness could
not suspend a nurse, but could recommend the matron to do so. Un¬
doubtedly complaints had been made by patients as to the food they
received, but they had never been of a serious character. Their build¬
ing being new they had no drainage plan. It seemed desirable to have
one, and' the matter would be attended to immediately. Three members
of the committee of the hospital accompanied the surveyor in his
inspection of tlie drains last autumn. He admitted the desirability of
having an inspection by some outside and expert officer. The system
‘of nursing was similar to that in force at University College Hospital.
Tbe work was undertaken by contract by the All Saints' Com¬
munity, Sister Dorothea being the Sister Superior. At present the
nursing staff consisted of tlilrty two persona—ono sister superior, one
night superintendent, three ward sisters, twelve nurses, tliirteen pro¬
bationers, and two lady pupils. They actually paid for sixteen nurses,
and received an allowance from the board of the other sixteen in the
hospital. 'J'he net payment for nursing lost year amouted to £185.
Tliey were quite satisfied with the nursing arrangements, which had
been in force for two years. There had been nn deaths among tho
nurses during that period, and no epidemic. — Lord Cathcart: Tho
weak part of your system seems to be tliat for fourteen hours per day
you have in charge only your clerk, with a salary of £00 a year.—
Mr. Byers: £60, with board and lodging. Continuing, witness said
that from his own knowledge he could say that their nurses were of
mixed religions. They were by no means all extreme persons holding
very extreme views. They had no students at the hospital. — By
tho Cliairman: They had a deficit last year of £1300, which they
hoped to wipe off by appealing to the public. As a matter of fact, they
hoped to get rid of it by the usual and inevitable festival dinnor. How¬
ever much members of the committee might object to the festival
dinnor, they could not do without it. As a rule they derived about
£20u0 from the festival dinner,
Mr. J). H. Qoodsall, for seventeen years on tho staff of the hospital,
said, in answer to the Chairman, that he regarded the buildings as
admirably suited for the purposes of a hospital. They received all
serious cases without comment. When a patient had been seven
days in the hospital he was told ho must either go elsewhere or
join the provident scheme. As a rule tho member of the provident
department paid 2.''. annually. This income paid the salaries of the
medical officers who attended tbe department and the drug bill. Tbe
out-patient department was not so crowded now as when no provident
scheme oxistod. Ha thoroughly approved of out-patient departments
combined, as in the case of the Metropolitan Hospital, with provident
.schemes.—By Lord Cathcart: Practically all objection to the provident
department on tbe part of the local medical practitioners had dis¬
appeared. He agreed with the view that modic.al praclitioneis were
the most sensitive people in the world with I'egard to any trespass
upon their practices.—By Lord Monkswell; He tlioiiglit it desirable to
maintain the London qualification in the aiipointmont of tho staff, The
attendance of students at thoir hospital was not recognised by tbe
licensing bodios.—By tho Chairman ; The accomniodatioii for the sick
in the district was, in his opinion, very deficient.
'die Lock Hospital.
Mr. Algernon Coote, secretary of tlio Lock Hospitals in Dean-street
and Harrow-road, gave ovidonco as to that instituiion. The hospital,
he said, was founded in 1740. They had 140 beds for females and 20 for
males, their working average being al)out 100. 'I’he funds did not admit
of all the beds beiiig oecupiocl, although at the present moment they
wore not refusing cases. In the past it had been their habit to hold a
quarterly meeting, open only to governors, but tlii.s year for the first
tinio they would hold an annual meeting, open to reporters. The
average annual cost per bod for females was between .£40 and £45, and
for males was about .£60. The comparative lowness of cost was due to
the fact that 75 par cent, of thoir pationtiwere aide to assist the nurses,
and they liad to employ only seven nurses. They liad neither invest¬
ments nor endowments, and since the repeal of the Contagious Diseases
Acta they had received no Government support. They had a debt of
£4000 duo to their bankers .and tradesmen, Their out-patient depart-
niont was almost self-supporting.
'J'lioir lordships then ntijournod.
Their lordships met .again on Thursday, Lord Samlhuriit presiding.
Brompton Conxui/i;^)£ioa
Mr. H. Dobbin, seevotavy of tho Brompton Consumption Hospital in
Fnlliam-road, oxauiiiied by tlie Cliairman, said that ho was in receipt of
a salary of £560 a year. The hospital w;is founded in 1841. They admitted
casus of consumption and nil diseases of the chest, including heart
disease. Tlioy ailmitted the disoase.s in every form and every stage.
Tho Iniihliiigs wore regarded by tlie staff as tlioroiighly satisfactory.
They liad 184 beds in the old building and 137 in the new building.
When tho hospital was full their ilaily average of beds occupied was
about 30(1. They had four mootings each year of governors, open to all
tho govornoi'.s and ropvesentativos of tho pros.s. The committee of
managomeiifc, which might be regarded as the executive of tbe
liospital, consisted of twenty-live eloclod members, the whole of
the Hiodlcal stall's niiinbei'ing sixteen, tho prosidont, tho treasurer,
and the chanlain. Five or six was a common attendance of the
committee, '.t'lie average would bo hardly as niKiiy as a dozen.
They generally found that tho hu-goi- the comiuitteo the loss
satisfactorily was tho work got tUi-oiigh. Tho cominittee met once a
week. The treasurer was an honorary officer. He did not take the
aamo position as tlio treasurers of such large hospitals as St. Bartholo¬
mew’s or Guy's, lie was merely tho custodian of the hospital funds
ami the porson who signod receipts for legiicie.s Ac. 't'liey had live
auditors elected by the annual court of governors. The anditor.s were
men of business, with a kmnvledgo of accounts. The audit took place
every tlireo months. 'I’hero was no iirofossional audit. The patients
were all free patients wlio woro not suppoeeil to be ivble to pay for
modical advice. Tlioy had a very largo out patient department.
Pal.ients woro admittud on governors' letters. The governor made a
statement to tho off'ect that the patient was unable to pay for medical
ailvico. Sonio patients were adiuittod as acute oises without a
686 The Lancet,] THE MBTEOPOLIT 4 .N HOSPITALS INQUIRY.-APPOINTMENTS. [March 14,18M.
governor’a letter. In snch cases they reg,uirecl the signature of three of
t^lie medical officers. Patients were questioned ns to tlieir religious belief
in order that they might have the benefit of the ministrations of priesis or
minlstere of their own religious persuasion. The committee of manage¬
ment made the contracts for food. The contracts were not advertised
but sent round to a number of respectable tradesmen in the neiglibour-
hood—usually to live or six of each trade. The cost of the liospitiU last
year was .£24,495. Their income included ground rents £932, rents £198.
dividends £8590, annual subscriptions ^^060, donations £5208, and
legacies £9604. Tho legacies for the last ten years averaged in cash and
stock £14,000. The collector had a percentage of 5 per cent, upon all
old subscriptions, and nothing upon new subscriptions unless they came
through Ills hands, which was very rare. Ho received nothing more
than five shillinos upon any one subscription. Their outlay for salaries
and wages r^vesented about two-tiiirda of the return from annual sub¬
scriptions. The hospital was .situated in two parishes—namely, Ken¬
sington and Chelsea. In the former parish they paid on a rateable value
of £884, the amount being .£212 18s. Formerly they were assessed at
only £40. In the Chelsea parish they paid .£887 10s. on a rateable value
of £1680. In this way .£800 of hard-got subscriptions went in rates.
They did their own nursing. The lady superintendent resided in the
hospital. She had a salary of £150, and everything found. She had
a special fee of twenty guineas for lectures to the nurses, snd in
recent years, in raspeet of extra duties in connexion witli the private
nursing department, tlie committee had given her a special gratuity of
fifty guineas, The lady superintendent had just left llie service of the
hospital in order to get married. They employed .seven sisters for day
duty and two for night duty, sixty-one staff nurses and probationers,
and nine extra numos. Tho oay nurses were on duty from seven in tho
inoi-ning till nine at night. Th«y wore off duty three times a week from
six to eight o’clock in the evening, once a niontli from two to ton
o’clock, once a month from twelve to ten o’clock, and one Sunday in tlie
month from six to nine o’clock. They enjoyed an annual holiday of
sixteen days. The lady superintendent had told iiim that she hoped to
be able to allow tho nurses off duty every day of the week. Tiiey
found it an advantage to have children among the adults. The children
amused the adults, and were themselves as hapoy as they could possibly
he in tho circumstances.—Ijord Sandhurst: Supposing that you con-
.sidered a certain medical officer in the establishment to have committed
a very serious broach of ’discipline, have you power to suspend him
pending tlie meeting of the committee’i’—Mr. Dobbin; 1 do not re¬
member such a case. I remember a gentleman who did not conduct
himself satisfactorily, and he was told to go. I do not think the matter
came before the committee.—Lord Sandhuivit: Supposing that a cer¬
tain officer committed a serious breach of discipline, would ho go on
with bis duty until the committee met?—Mr. Dobbin : No, I don’t think i
he would. We really have never had such an instance.—’fho Karl of '
Kimberley: If one of the medical officers were found to be drunk
while in the discharge of his duty, would you allow him to remain ?—Mr.
Dobbin: No, I don't think so. We have never had a case of the sort.—
The Bari of Kimberley : But it might happen 7—Mr. Dobbin : If it ilkl
tliomatterwouldbetreatedby the immediate suspension of the officer.—
By Lord Haye and 8elo : Tlie only case of trouble which he remombered
was that of a young physician who was inclined to flirt withanur.se.
He was packed off at once. The young medical officers did not
have latch-keys. The hospital gates were closed at ten o’clock, and
any‘one arriving after that iiour had to ring the bell. Tho door was
opened by the night sister, and consequently t!ie condition of all persons
entering was observed. They got a superior class of people. 'They were
different from what were termed ordinary medical students,—By Lord
Monk.swell: They did not employ an inquiry officer for tho in-patients.
He dill not think that their chanty was abused. It was ho who sent
the conli'acts out among the tradesmen in the neighbourhood.—By Imnl
Cathoart: Ue felt certain that no servant of the hospital had ever
attempted to get reward or fee from any of tlie tradesmen who sup¬
plied the food. Tho drainage of the hospital was in a thoroughly
satisfactory condition. He did not see that any advantage could be
derived from having a professional audit. Nothing coubl bo more
searciiing than their system of conducting the audit. Ho had not
heard of any servant who contracted consumpfion through attending
the patients,—Lord Thring ; Your hill of faro is rather monoto¬
nous. Do you use nothing save log of mutton?—Mr. Dobbin; Leg
of mutton is what is called ordinary full diet.—Lord Tliring: Is it
supposed to be particularly ,good for consumptive patients? — Mr.
Dobbin; It is considered to be very digostible.—By the Chairman;
The cliaplain received a salary of £800 and a house. J’atients came to
tho hospital from a great distp,nce—from the extreme noibli of .Scotland,
from Spain, and Germany. A patient arrived some time ago from tlui
post office in Vienna. Last year they admitted 1628 in-patients ami
treated 13,768 persons in the out-patient doii.irtment. The co.st per
bed amounted to £80 D. 3(1.
Dr. Theodore Williams, senior physician to tho hospital, .said that
these was no ehance of infection in tlio hospital owing to tho construc¬
tion of the building and tlie system of vontilation. Tlie patients had
good food ami tonics, and tho temperature was always kept up to a
certain degree. 'I’iiey made .a point of keeping the patients as iniioli
as possible iri tho cUning and other rooms ratlier than in tho wards.
Tho throe great essentials for consiiraptivo patients wore, dryne.ss of
temperature, efficient vontilation, and good food. In all those respects
the Broinpton Hospital was ipiito satisfactory.—By Lord GlilCovd ; tic
would not say that consumption could bo curod, but the condition
of tho patients was often greatly improved, uiifl they were enaliled
to live long enough to die of Homething else. Darwin had attacked
hospitals on the gronml that tliey kept living a lot of people who ought
not to bo alloweil (o incroas© and multiply.—Tlio Karl of Kimberley;
His not tho same argument been used against llni medical profession?—
Dr. Williams : l h ive beard sonic of your lord.sliips say that they aro
benellcial in the opposite w.ay.~liy Lord Mauk.swoll; Ho defended tho
arrangisinent limiting the sfall' appointnioiits to men lioldiiig Ivonilon
ipmiificati'ins. He thought no injustice was caused to licentiates of
Dublin or Edinburgh.
The Committee, after examining Dr. Fowler, .adjourned.
ERiUTliM.—In our report last week of tlio evidence of Mr. Nixon,
weretary to Univer.sity College I/ospiul. tho witness is represeiilod as
stating that tho fortnightly mooting of tlio Hospital Gonimittco was
composed in p.'irt of ‘■suvemteon” noininues of tho Omincil of University
College. The number should have been stated as Mven.
BOOKS ETC. RECEIVED.
Amkiucan 0llTH0i>3inic AssociA'i'iON, Philadelphia.
Ti'anaactiona of the American Orthopedic Association. Fourth)
Session, 1890. Vol. III. pp. 242.
Baillii5:re, Tinpall, & Cox, King Wllllam-.streot, Sti-and.
The Pocket Phamacoptnia. By C. 15. A. Semple, M.B. Cantab.,,
M.K..O.P.Lond. pp. 102.
CiiORCKlLL, J. & A., New Burlington-etreet, London.
Surgery. By C. W. Mansell Monllin, M.D. Oxon., F.E.O.S. 1891.
pp. 1413.
CBOsiiY LOCKWOOn & Son, Stationora’-liall-eourt, London.
Ventilation j a Text-book to tho Ih-actlce of the Art of Ventilating:
Buildings. By W. P. B. Buchan, U.P. Illustrated, pp. 228. 1891.
DORNAN, W. J., Philadelphia.
Transaefious of tlie American Gyn«?coIogical Society. Vol. XV_
For tho year 1890. pp. 411.
HiciQiNnoTHAM & Co., Madras.
Clinical Manual for India. Compiled for tho use of the Students of
tlie Madras Medical College. By )>epnty Surgeon-General C..
Sibbhorpe, F.K.Q.C.P. Third Edition. 1800. pp. 420.
Lewis, H. K., Gower-atreet, London.
Tho Middlesex Hospital Reports for tho year 1889. pp. 271..
Price 2 k. Cd.
Macmillan &, Co., London.
A Biography; The Right Honourable Arthur M. Kavanagh. Com¬
piled by lii.s Cousin, Sarah I.. Stoele. With Portrait. 1801.
pp. 340. Price 14k. nett.
SVRINGER, Julius, Berlin.
Die Wirlcsamkeit des Koch’sehen Heilmittolsgogen Tuborkulose;.
1891. pp. 006.
VOSS, Leopold, Hamburg and Leipzig.
Bakteriologiaohe Diagno;4tik. Von Jas. Eisenherg. 1801. pp. 60l?i
Wright, .f,, & Co., Bristol; Simpkin, Marshall, <fc Co., London.
Lectures on Diabetes. By Robert Sauiidby, M.D. 15din., F.R.C.P’
Lend. With Illustrations. 1891. pp. 232.
The Medical Annual and Practitioner a Index. 1891. Ninth year;
pp. 887. _
Tho Baths of Balnoovillc; by A. II, Idyot, M.R.C.S. (Simpkin, Marshall,,
and Co., London, 1801). —Igieno doll’ Urecchlo ; per il Prof. C. V.
Cozzolino (Fiiinto Cosmi, Napoli, 1801).—Social Reform in the North ;.
by Lala Baij Nath, B.A. ; second edition (Printed at the “ Voice of
India" Printing Press, Bombay, 1800). — Index Medicus, Authors and
Subjects, Vol. XIII.; No. 1, January, 1801 (Tnibner A Co., and Lewis,
J,ondon).—Catochi.sm Series; Materia Medica, Part II.,Anatomy r
Head and Nock, Part III. (E. and S. Livingstone, Edinburgh, 1891);.
price lx. each. — After Four Centuries, the World's Fair. The Dis¬
covery of America. To bo commemorated by an International Expo¬
sition, Chicago, Ill., U.S.A., 1803 (J. M. W. .Tones, Chicago).—The
Anglo-American Annual; a Directory and Handbook for Residents in.
Paris, 181)0-01 (Neal’s Library, Paris),—New South Wales ; its History
and RB.sour('es (.Special edition of the Year-book of Now South Wales,
prepared for the Now South Wales Oovorninent, 1801).—Polytechnics,
or Technical and Recreative Institutes ; by Howard Seth-Sniith (B. T.
Batsford, London, 1891); price lx. Off.—Bourne’s Handy Assuranco
Manual, 1801; by W. Bouvno, F.S.S. (A. Trongovo, London); price lx.—
],’6tlior. ost-il picfcrjible an Cliloroforinc ? par M. lo Dr. Julliai-d, de
0(5ni,v6. — Dio Peptone; von Dr. Med. V. Gerlach (L. Voss, Hamburg
Hiid l,eipzlg, 1801).—Journal of the Leprosy Investigation Committee
edited iiy P. S. Abraham, M.D., B.Sc., F.R.C.S.I. No. 2, February,
1891 (Macmillan & Co., London); price 2x. Od.—Magazines for March:.
Good Words, Sunday at Homo, Leisure Hour, Sunday Magaziner
(Isbister), iBoys' Own Paper, Girls’ Own Paper (Rollgious Tract
Socioty). Scribner s.
irrMxfiU appUMiiis for VacanentK, Srcre.iartes of Public 1 Miilnticns,^
olharn Tjomiioiimi infonnalMm juiUahk for l.hu oo/unm arc inviled to
fiirwuni it to 'J’liE LANUicr OI/Ick, iHrecled lo the Siib-Jiihtor, not latc}'
'than :i o'clock im the Thunddyvutrninn o/eachweokfor publioaliomn'
the next nuiiiJ/cr. — -
1 EXANDEII P L H C.P., L.R.C.S. Kdim, has boon appointed Modical
’ Officer of iicaitli for the Whitley and Moiilcsoaton Urban .Sanitary
District of the Tynemouth Union, vice P'rasor, rosigiush , „ ,
LIEN JAMi'ts J). G., M.B.. O.M. Kdiiu, has been appomled Houae
Surgeon to the WirralOhildreii’s Hospital, Birkenhead.
ITE II II L It 0 I’ r..H.G.S, ICdin., has boon appmiilod Medical
Officer for Urn Biddondcn District of tho Tentorden Union.
l•'V^;all)<)K A. T. G., M.B., O M. Aherd., has been aiipomtod Meeinal
Officer to the Aberdeen General eF
AH'orr L B. M.R.O.S., has boon roappomted Medical OlHcor of
Health for tlio Oinullo Rural and Urban DistrieU nm,.nr nf
LAKE .lOiiN, L.ll.(;.S. Kdiii., lias been appomlud Medical Officer ot
Hcaltii for tho GoHiity Borough of llaiiloy. M-n,Hcn.rj
Ui.i.iN, il. B., L.ll.G.1’., I..U.C.S. Kdm., has been reappointed Moiiicau
Officer of Health for Tiverton.
The Lancet,] APPOINTMENTS.-VACANCIES.—BIBTHS, MARRIAGES, & DEATHS. [Maech 14,1891. 637“
Dbndi.e, Frank, M.B., C.M. Edin., has been appointed Medical Officer
to the Bosewell Coal Company, Lochgelly, Fife, vice J. Stioll, M.D.,
reslgnod.
: East, 0. II.. M.D. Ditrh., M.R.C.S., has been appointed Medical Officer
of Healtli for the Rural Sanitary District ot the Doro Union, vice
Walker, resigned.
Eli.iott, E,, L.B C.P. lirlin., M.R.C.S., has been appointed Medical
Officer for the Bromsgvove Union.
QAOunct,, Auratoon, 1..R.C.P., L.R.C.S. Bdin., has been appointed
Medical Officer for the Borough of Donoily, Victoria, Australia,
vice Maneon, resigned.
llAiU'icii, J. Maukicic, M.E.C.S., has been appointed Honorary Medical
Olflcer to the Eastern Dispensary, Batli, vice II. Q. Terry, I'Mt.C.S.
Edin.,resigned.
IlAiiKis, J. H,, M.D. Brussels, L.R.C.P. Bdin., M.R.C.S., has boon
appointed Medical Officor of the Bear-yard Workliouso, Strand
Union.
HiLi,, T. EOSTACK, M.B,, C.M. Edin., has been appointed Medical Officer
of Health for tlio County Borough of South Snielcls.
IIODOSON, Victor, L,R.C.P.Dond., M.R.O.S., has been appointed House
Surgeon bo tlio Scarborough Hospital and Dispensary.
IIUOHKH, Samuki., M.B. Edin , M.ll.C.S,, has been appointed Medical
Officer of Health for the City of Coalville, Utah, United States of
America.
^AMES, F, P. B., L.K.Q.C.P. Irel., has been appointed Medical Officer
for the Fourbli District of the Hunsleb Union.
Johnson, Raymond, M.B., B.S. Lend., IMt.C.S. Eng., has been
appointed Surgeon to tlie Groat Northern Central Hospital.
Kempe, A., M.D. Brussels, M.R.C.P. Edin., M.R.C.S., has been reap¬
pointed Medical Officer of Health to the Budleigh Saltorton (Ex¬
mouth) Local Board,
Knox, A. w., M.B., C.M. Aberd., has been appointed Medical Officer
for the Smallburgh District of the Smallburgh Union.
Lansdown, F. PooM';, has been reappointed Surgeon to the Bristol
General Hospital.
Lindsay, 1). Moore, L.R.C.P., L,R.C.S. Irel., has been appointed
Medical Officer of Healtb for Wasatch County, Utah, United States
of America.
MacLachlan, S. F., M.B., C.M. Glasg., has been reappointed Medical
Officer of Health for the Longtown Rural District of the Loiigtown
Union.
MoiiT'ON, Edwin, M.D. Edin., has been appointed Medical Officer of
Health for tlie Reddish Url>au Sanitary bistrict of tlio Bromsgrove
Union, vice Smith, reeignod.
Palmer, H. L., M.B.C.S., has been reappointed Medical Officer of
Ho.alth for tlie Nowton tlrban District of tho Newton and Llanidloes
Union.
Pearce, ARTimii, M.R.C.S., has been reappointed Medical Officer of
Healtli for tlie .Salcoiiibo Urban District of the Kingsbridge Union.
Prichard, IIoht, David, L.B.C.S., L.H.C.P. Ed,, L. F.P.S.Glasg., has
been appoiiite<l Surgeon to the Reaolvon and Ynisarwon Colllorios.
Reynoi.d.s, K S., M.D. bond., M.R.C.P., M.B.C.S., has been appointed
Snperintoiulont Medical Officor at tlie Royal Inlintiary, Mancliester.
Russici-i., James W., M.B,, B.C. Camb,, has been appointed Resident
Medical Officer to tlie Binniiigham General Hospital.
Sawyer, Jas. A. F., L.K.Q.C.P., L.R.C.S. Irel,, has been reappointed
Medical Officor of Healtli for Clovodon.
Spackman, Coniston, M.R.C.S,, L.R.O.P. Eilin., has boon appointed
Medical Officer to tho Union land No. 1 District of Faringdon, vice
F. G. Spackman, resigned.
STiiWART, W., M.D.Glasg., L.R.C.P. Loncl,, has boon appointed Medical
Superintendent to the Oamaroo Hospital, Now Zealand.
Styi.e. F. W., L.R C. lb Loud., M.B.C.S., has been reappointed Medical
Officer of Ilo.alth for Hiiclciiall-Huthwaite.
SUNDEiiLAND, OLIVER. L.R.iMb Edin,, M.R.C.S., has beon reappointed
Medical Officer of Healtli for tho Boxloy Urban District of tlio
Hartford Union.
Thom, Jas. M., M.B., O.M. Edin,, lias boen appointed Medical Officer
and JJursar of Trinity Coliogo, Glenalmoiid, vice Lowo.
Thomson, Theodouio, M.B. Loud,, L.R.C.P. Edin., has boen reappointed
Modica! Officor of HoalUi for Sheffield.
Tyndai.e, W. B., M.B. Alievd , L.R.O.I*. Loud., M.R.C.S., has been
reappointed Medical Officer of Health for the Hampton Urban
Sanitary District of the ICingston-on-Thantos Union.
Warren, Wm., M.R.C.P., L.R.C.S, Irel., has beon appointed Medical
O)li(;oi' for tho Borough of Kow, Victoria, Australia, vice Walsh,
rcHigiied.
Wkhh. O. F., M.D. Durh., F.U.O.S. Edin., has liaoii reappointod Medical
Officer for the First District of tlio Basingstoke Union.
Wei,(' ll, J. R., M.B. Loud., M.R.C.S., has been reappointed Modic.al
Officer of Uealtii for the Ilaudsworth Urban Sanitary District.
Wii.Ev, A. O., I,.U-C.P. Edin., L.U.O.S. Iro!., has liceii appointed
Meiiical Officer for tho Rural Saiiilary District of the Kiiaros-
borougli Union, vice Oautley, rosigued.
Wise, N. V., I,,K,(i.O.I'., I,.B.('.S, Iiel,, has boen appointed .Medical
Officer of Healtli for Trowbridge.
IJitraiinci
Fur/tirlher in/ornialioit rfnariliiui each vacaiiry re/e.rcncc should bo made
III Uio adiirrtinttliuint.
Ani)KNiiiH) 0 HK’s IIosi’itm,, Caniin'idgo.—Rosident House PliyHiciaii,
S.ilai'V i-dC) per aiiuuiii, with Iioanl, lodging, and wasldtig in the
Hospital.
ItEl.liUAVE tllWClTAL I'DR (blll.llREN, 7i), < JloUCOstor.stl'Oet, S.W.—
lloiiHU Siu'goon. No salary, but board, lodging, fuel, and iiglit pro.
vidod.
Betiii.em IIosi’lTAf..- • Two Resident Utinical A-ssisbants.
Bra Di'iiiti) I.M.'iRM.iRY AM) 1 >isi‘EN,SARV. •-Dispoiisary Surgeon. Salary
.ClilO por anniuii, witli board.
CiiEi.HEA llosi'lTAi.EDR WiiMEN, Kulham-road. .S, W. -Resident Medical
OllU'or for Olio year. Salary .tbO por annuni, with beard and rest-
deiico.
CUBLSEA Hospital for Women, Pulham-road, S W.—Clinical Assist-
ants. The fee is 8 guineas for a period of thi-ee montlis.
County Asylum, J^restwlcli, Manchester —Dispenser.
County Asylum, Bainhill, near Liverpool.—Assistant Medical Officers..
Salary commences at £100 a year, with prospect of an increase of
£26 at the end of the first year and £26 at the end of tlie second,
witli further increase according to promotion, together with fur^
nished apartments, board, washing, and attendance.
District Infirmary, Ashton.under-Lyno.—HouaeSurgeon. Salary £90-
per annum, and board and lodgini^
Great Northern Central Hospital, HoUoway-road, N.—Obstetric-
Physician to Out-patients.
Guy's Hospital Medical School.—T wo additional Anaesthetists for
tlie Dental Department.
Hospital, King’.s Lynn,—House Surgeon and Secretary. Salary £89
? ier annum, rising to £ 100 , with board, lodging, and washing in tho
lospltal.
JAFFRAY SUnURBAN BRANCH OF THE GENERAL HOSPITAL, Gravolly'
hill, near Birmingliam.—Resident Medical Officor. Salai'y £150 per
annum, with board, residence, and washing.
King’s College, London.—Demonstrator of Pliysiology.
LivisRPOOL Northern Hospital.—A ssistant House Surgeon. Salary
£70 per annum, with residence and maintenance in the house.
Liverpool Dispensaries.—A ssistant Surgeon. Salary £80 per annum,
witli apartments, board, and attendance. (Apply to tho Secretary,
Leith Offices, 24, Moorflelds, Liverpool.)
M.R C.P., THE Lancet Office, 42S, Strand, W.C.—Assistant Medical
Officer in a Metropolitan Private Asylum.
Metropolitan asylums Board.—C linical Assistant at the Soutlir
Eastern Fever Hospital, Neu'-cross-road, S.E. Board, lodging-,
and washing
Newcastle-on-Tyne Dispensary.—V isiting Medical Assistant. Salary
£120a year,
Norfolk and Norwich IIospitai..—P hysician on the Honorary-
Medical Staff'. (Apply to the Secretary. Norwich.)
Queen Charlotte’s Lying-in Hospital, Maryiebone, N.W.—Be.sidenb
* Medical Officer for four months. Salai'y at the rate of £60 pet-
annum, with board and residence in the Hospital.
BoYAi. South London Dispensary.—H onorary Surgeon,
Royal Hospital for Children and Women, Waterloo-bridge-road,
S.B.—Resident Medical Officer. Salary £70 per annum, with
board and residence.
Royal Hospital for Children and Women, Waterloo-bridge-roai?.
S.E.—Anresthetist and Registrar for one year, honorarium of)'
70 guineas being voterl at tlie end of that tonn.
St. George’s and St. .James’s Dispensary, oo, King-street, Regent*
street, W.—Surgeon.
St. Tiioma.s’3 Hospital.—R esident Assistant Pliysician.
Township op Manchester.—R esident Assistant Medical Officer at
tho Worldiouse at Crumpsall. Salary £100 par annum, with fur¬
nished apartments, fire, light, washing, and attendance.
West IjONDOS Hospital, Hammersmith-road, W.—Assistant Surgeon.
an!» Jtdljs.
BIRTHS.
Brown.—O n Marcli Urd, at I.aucaster House, Ooole. the wife of Dr..
Macdonald Brown, of a daughter (pveuiaturely).
Fi.ETCHER.—On March Gih, at Ilyde-park-mansions, the wife of H. Morley
Fletcher, M.A., M.B., ot a daugnter.
Fox.—On March 10th, at BrisUngton House, near Bristol, tho wife of
Dr. Bonville Fox. ot a son.
G RAY.—On Ma-rch 9tli, at l-lolsworthy, Nortli Devon, the wife of Walter
O. Gray, M.B.C.S., L.R.C.P. K., of a dauglitor,
Hargreaves,—O n March 0th, at Melrose, Merton Park, Surrey, tho-
wite of M. K. Hargreaves, M.D., of a daughter.
BuSHiiiiooiCK.—On March 0th, at Dresden Houso, Stamford-hill, N., tho
wife of Thomas Rushbrooko, M.A. Cantab., M.R.C.S., L.ll.O.P., Ac.,
of a son.
Stein.—O n March 0th, at Beckenham, tho wife of Dr. C. Giitlirie Sfcein,
of a .son. _
M A R 111 A a E S
Daniei.l—W ooKEY.—On March Dtli, at .St. Mary's, Hornsea, Henry.
Pywell Daniell, Iv.H.C.P., fourth sou of tlie late Alfred Horatio
Daiiiell, M.B.C..S.. of Kegwortii, lieicostorsliiro, to Klinor Mary,,
only daiigntor of James VVookoy, of Potter's Bar, Middlesex.
Deacon—P oiiK.—On March -Ith, at West Croydon Cliurcli, John.
Gillespie Deacon, M.D,, Army Medical Staff, to Carrie, eldest
daughter of Fred. Pook, of Idsburii, Thornton Heath.
DEATHS.
Hawkins.- On March ist, at Heikoluy-siiuaro, Clifton, Walter R. T.
Hawkins, M.U C.S., agod '2i).
lIoi.i.iNwoivm.—On March 'iiid, at Iligh-stroec, I,cos, Oldham, John
I-lolliiiworib, M.R.U..S.
Morris. -On March •Itli, at Hereford, David Fj. Morris, M.B.C.S.
OsiiORN.—On Marc'll llth, at 2, Angle.sori-placo, Southaniptcm, Henry.
O.sbmn, i'il.U.C.I-’., for tweiily year-s Medical Officer of Health for
till) Borough of Southampton, aged 78. No llowers.
BODKimoN.—On March r>lli, at 'I'lie Birlilaiids, llilsea, Coslmni, Hants,
Frotiorii'k From' Leslie Itoboi'Uso)!, M.B , M.B.C.S.. aged 4il.
TiiKWiM.AN.- -On March 8tb, at < iroville Villa, Bxmoutn, George Kobert
Trewiiian, M,Il.C..S. and L.S, A., in the SJtii year of ids ago.
Wii.i.KT'i'.- -On Marcii (lUi, lately residing at WancbosLer-sti'cct, Mary-
lebono, Oharles VerraJl Willett, M.B.C.S.
Wii.sD.N.—On Mai'cli r>t.h, at Walker-toirace, Galo.sbead, Charles Wilson,
M. B. Loud., agod 'Z'l. _
F.B.—A fee- of Us. is charged fin- the InsertUm of Polices of Birlha,
Marriages, and Deaths.
Digitized by L^ooQle
638 Thb Lanobt,] N0T£S» COMMENTS, AND ANSWEBS TO COBBESFONDENTS. [March 14, 1891,
HeMtal giarj for t||« mning Malt.
Holiday, March 16.
BOTAL London Ophthaluio Bospitai,, Moorpieios. —Operations
(laily at 10 A.H.
BOTAL WBSTHiNsrzB OPHTHALMIC HOSPITAL.—Operations, 1.80 P.M.,
and each day at the same hour.
Chelsea Hospital for Women.—O perations, 2.80P.H.; Thursday, 8.80.
Hospital for Women, Soho-s<)uars. — Operations, 8 P.K., and on
Thursday at the same hour.
Mbtropoutan Free Hospital.—O perations, 2 p.h.
BOYAL ORTHOF.fiDlc HOSPITAL.—Operations, 2 P.H.
Central London ophthalmic Hospital.—O perations, 8 F.M., and
each day In the week at the same hour.
Cniyersity Colleob Hospital.-E ar and Throat Department, 9 a.m. ;
Thursday, 9 A.H.
Throat Hospital (Goldon-siL).—5.30 p.m. Dr. J. W. Bond: Hoarse¬
ness and Loss of Voice. (Post-graduate Course.)
Society of Arts.—8p.m. Prof. R. Meldola; Photographic Chemistry.
(Cantor Lecture.)
Medical Society op London.—8.80 p.m. Mr. Edmund Owen: A fatal
case of Litholapaxy in a Child.—Surgeon-Major Keegan (Indore):
litholapaxy in Children, illustrated by Specimens of Calculi and
by various Instruments.
Tuesday, March 17.
CiNO'S College hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
OiTY'S Hospital.— Operations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 p.h.
St. Thomas’s Hospital.—O phthalmicoperations,4P.H.; Friday,2 p.u.
St. Mark’s Hospital.—O perations, 2 p.m.
Cancer Hospital, Brohpton.—O perations, 2 p.h. ; Saturday, 2 p.h.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.- Operations, 2.80 p.m.
'Si. Mary's Hospital.—O perations, l.SO P.H. Consultations, Monday
3.80 P.M. Skin Department, Monday and Thursday, 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Electro-
tberapeutica, same day, 2 p.m-
Boyal Institution.—3 p.m. Prof. V. Horsley: The Structure and
Functions of the Nervoua System.
Royal College of Physicians.—6 p.h. Dr. Broadbent; Structural
Diseases of the Heart, from the point of view of Prognosis.
(Lumleian Lecture.)
BOYAL Statistical Society (Lecture Theatre, Museum^ of Practical
Geology, Jertnyn-st., S.W.).—7.46 P.M. Dr. Frederic J. Mouat;
Prison Ethics and Prison Labour.
The Sanitary Institute (Parkes Museum, Margaret-st., W.).—8 p.m.
Professor A. Bostock Hill: Trade Nuisances.
Pathological Society op London.—8.30 p.m. Dr. Lauriston Shaw:
Malignant Disease of the (Esophagus.—Mr. A. A. Bowlby; Sym¬
metrical Periostitis with peculiar fonnation of New Bone.—Dr. A.F.
Vorfcker: Scurvy Rickets.—Dr. S. West: Liver with two Hydatids,
the Sacs communicating, but not the Cysts.—Mr. A. E. Barker:
Malignant Polypus of Nose.—Dr. Galloway: Syringomyelia.—Mr.
E. Solly : Myeloid 'funiour of Tibia, with Secondary Growths.—Mr.
J. Hutchinson, jun. : Syphilitic Disease of Occipital Lobe with
Perforation of Cranium.— Mr. Roger Williams; Median Super¬
numerary Nipple in Male. Card Specimens Dr. S. West: Plastic
Bronchitis.—Mr. Edgar Willett: Secondary .Scirrhu.s of Bono.—Dr.
A. F. Voelcker: General Peritonitis after Perforation of Vermiform
Appendix. Wednesday, March 18.
National Orthopjidic Hospital.—O perations, lo a.m.
Middlesex Hospital.—O perations, l p.m. Operations by the Obstetrlo
Physicians on Thursdays at 2 P.M.
6 t. Bartholomew's Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday. 1.80 P.M.
Surreal (jonsultations, Thursday, 1.80 P.M.
-Charino-cross Hospital.—O perations, 8 f.m., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.30 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 P.M. Thursday dtSaturday, same hour.
St. Peter’s Hospital, Covent-gardbn.—O perations, 2 p.m.
Samaritan Free Hospital for Women and Children.—O perations,
2.80 P.M.
Oreat Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.80 p.m. ; Skin Depart¬
ment, 1.45 p.m. ; Saturday, 9.16 a.m.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations, 0.80 a.m. ;
Surgical Visits on Wednesday and Saturday at 0.16 a.m.
Throat Hospital (Golden-sq.).—6.30 p.m. Dr. Grevillo MacDonald :
Hay Fever and Paroxysmal Sneezing. (Post-graduate Course.)
Epidemiological society of London.—8 p.m. Dr. E. F. Willoughby:
A Retrospect of the successive Epidemics of Cholera in Europe and
America from 1820 to 1880.
BOYAL Microscopical Socif,ty.—8 p.m. Mr.T. Clrartevs White: New
Method of Demonstrating Cavities in Dental and Osseous ’lissuos.
Thursday, March 19.
■St. George's Hospital.—O perations, l p.m. Surgical Consultations,
Wedneady, 1.80 P.M. Ophthalmic Operations, Friday, 1.80 p.m.
University College Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 a.m.
Royal institution.—3 p.m. Professor C. Meymott Tidy : Modem
Chemistry in relation to Sanitation.
Royal college ok Physicians.—6 p.m. Dr. Broadbent: Structural
Diseases of the Heart, from the point of view of Prognosis.
(Lumleian Lecture.)
fr*u. vi.uAN Society of London.—8.30 P.m. Clinical Evening. Dr.Rayner
Batten: (1) A ease for Diagnosis ('/Disseminated Sclerosis); (2) A
case of Tracheitis with Dry Crust Formatirrn in a Laryngoscopic
case.—Dr. Ewart: (1) Friedrich's Disease, with increased Knee-
jerk ; (2) The Symptoms of Paralysis Allans in a Hysterical
Subject. Cases will also be shown by Drs. Cagney, Quarry Silcock,
Maguire, Sidney Phillips, and Mr. Keetloy.
Friday, March 20.
Royal South London Ophthalmic Hospital,—O perations. 2 p.m.
Cancer Hospital (Fulham-rd., S.W.). —4 p.m. Mr. W. H. Elamj
Malignant Disease of Breast.
The Sanitary iNSTiTUTEfParkes Museum. Margaret-st. ,^W.).—8 p.m. Mr.
A.WynterBlyth: SanitaryLaw,English,Scotch,andltish; General
Enactments; Public Health Act, 1876 ; Model Bye-Laws, &c.
Royal Institution.—9 p.m. Professor Victor Horsley: Hydrophobia.
Saturday, March 2L
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p.h. ; and Skin Depart¬
ment, 9.16 A.M.
Royal Institution.—8 p.m. TheRightBon. Lord Rayleigh: The Forces
of Cohesion.
METEOROLOGICAL READINGS.
(Taken daily at 8.30 a.m. by Steward's Instruments.)
The Lancet Office, March 12th, 1891.
Duto.
Baromotor
reduced to
SoaLuvel
aud eri'.
Diroc.
tion
or
Wind.
Dry
Bulb.
Wot
Bulb.
.Solar
liadia
in
Vacuo.
Maxi¬
mum
'I'onijK
Nlintlo.
Min.
Touip
Rain¬
fall.
Remark! at
a.S0A.H.
Mar
6
30-09
W.
42
40
88
66
40
Cloudy
y i
7
29-73
w.
47
44
69
63
42
Cloudy
8
29-01
N.E.
41
40
42
40
•46
Raining
t >
0
29 78
N.E.
37
36
49
40
36
■08
Overcasti
))
10
29-39
E.
3-2
69
86
80
■22
Snowing
»»
11
29-29
E.
34
33
81
40
81
■30
Snowing
»»
12
29-73
N.E.
31
70
40
29
Foggy
Iftrtts, Sljort Cflinineiits, f to
dtffrHsjjmiiitnts.
It is especially requested that early intelligence of local
events having a medical interest, or which it is desirable
to brmg under the notice of the profession, may be sent
direct to this- Office.
All communications relating to the editorial business of the
journal must be addressed ''To the Editors."
Lectures, original articles, and reports should he written on
one side oidy of the paper.
Letters, whether intended for insertion oi'for private informa-
tion, imtst be authenticated by the names and addresses
of their -writers, not necessarily for publication.
We cannot pirescribe or recommend practitioners.
Load papers containing reports or news paragraphs should
be marked and addressed ''To the Siib-Editor."
Letters relating to the publication, sale, and advertising
departments of THE LANCET to be addressed "To the
Tublishcr.”
We cannot undertake to return MSS. not used.
Si’EciMEN.s OF Medical Advertising.
The following card is stated to have been widely circulated at Balhara.
It is said to be a new thing at Balhara, ami we trust the specimen will
remain a unique one
“Endlesli.am-road Surgery, No. 103, Endlesh.am-road (Balliain end).
A resident physician always in attendance. Hours of consultation:
Morning. 0 to II a.m. ; evening, 7 to 9 I’.M.; Sunday evening, 7 to
0 P.M. Usual small fees. Vacciiiatiou eacli Wednesday at 11 a.m.
Advice and medicine one shilling."
Wo would also direct attention to tlie following advertisement :—
“Consulting Rooms for Cancer and Diseases of the Skin, Kon-
siugton-chambevs, Simmons-.stroet, Blackburn. Physician, Dr.
IJindle, I/ic. Royal College of Pliysiciaiis, Edin. Hours, 2 to 6 p.m.
daily ’’
A yet bolder departure from professional usage is a long circular pur¬
porting to be written by Mr. Charles Oakes, M.B., C.M., L.N.A., and
L.M., 38 and 40, Millinan-street, Bedford-row, W.C. It sets forth
the author’s unusual opportunitie.s of studying all sorts of diseases.
But the specialty on wliich ho obviously most iJi'idos Iihnself is ulcers
of the legs, of wliich ho ha.s permanently cured 600 cases, and never
yet met one to fail him.
Tlio following is from a Hobart (Tasmanialnewspaper
“ fA card] Dr. Charlc“s Watson, Surgeon (General, with Speciality
for Cancer, TuinoiU's, Ac.), begs to announce that having recently
arrived from London, he has taken 41, Davey-.street, Iloiiart, where
lie may be consulted from 0.30 to 11 a. si.,or by appointment, daily.”
Wo can only ask the attonlion of the bodies whoso qu.'iliilcations are
held by thi.s gi'oup of advertisers to the above spocimoiis.
e lyGOOgle
Thb L&ncbt,}
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS, [Mauch 14, 1891. 639
TUBAL PREGNANCY IN A BITCH.
To (As EditwB qf THE LANCET.
Sirs,—S eeing in Mr. Bland Sutton's Erasmus Wilson lecture that
tubal pregnancies in the lower animals are unrecorded, I think it may
be worth while to note a case wlilch I have always hitherto regarded as
tubal, and which occurred in a bitch. It was a valuable little black*
and-tan bitch, the property of a friend at whose house I was for a
time staying. This was to be the third litter; the second had consisted
of one puppy only. She had been now in great pain for some hours,
and was forcing out some brownish fetid fluid from the vagina. As
the animal was so valued, I advised a veterinary opinion, which was
obtained, the gentleman declining, however, to interfere. With a
button-hook and a small sequestrum forceps I got away three puppies
that apparently had been dead about a week. Much gas and fluid
escaped with them from the uterus. In the night tlie bitch died.
Next morning I found on opening the abdomen that a pulpy mass
covered with very thin membrane lay toward the right side among the
intestines, and attached at its lower part by a small peduncle to the
uterus, which was flmly contracted and apparently normal. I opened
up the mass, and found it contained much of the same sort of fluid that
bad escaped, and also a puppy, wliich was macerated and had all its
hair and cuticle quite loose. It was bigger and had been more de¬
veloped than the ones I removed, and evidently, from these facts and
being so much more decomposed, had belonged to a previous litter.
My reasons for believing it to be tubal were that the uterus soejned
normal, and that it would have long before sot up peritonitis if intva-
peritoneal, besides which it was almost free in the cavity, except by
the uterine peduncle and a small adhesion at the back. My investiga¬
tion caused disgust in the house, and all the parts were surreptitiously
conveyed away and buried, so that unfortunately I am unable to pro¬
duce the specimen.—I am, SirsJ yours faithfully
GuSTAVUS G. Gim-EY, M.R.C.S., L.B.C.P.
Honiton, March 4th, 1891.
Mr. C. M. J<'e< 7 cn.—Our correspondent has no claim upon the guardians
in the case mentioned by him. It is only when the knife is used in
the operation that an extra fee is granted.
J>r. John W. Oyle.—The paper has been received.
“THB AMMONIO-CUPEIC TEST.”
To the Editors of THE Lancet.
Sirs,—Y our correspondent “ B. B.” in last week's issue asks for an
explanation of the gradual reacquisition of a blue colour by Pavy’s
ammoniated cupric test solution after the liquid has l>een decolouri.sed
by boiling with diabetic urine. The explanation is simple. The cupric
oxide originally present in the blue liquid becomes reduced, on boiling
with a saccharine fluid, to the lower or cuprous oxide, which is held in
solution by ammonia, yielding a colourless liquid. The cuprous oxide,
however, in contact witli air rapidly passes by reoxidisation into the
cupric oxide, and in so doing reacquires a blue colour. For this reason,
as'also for the purpose of preventing the rapid dissipation of the
ammonia, the solvent, the operation should be performed in a small
flask fitted with delivery and escape tu'jos, and not in an open vessel.
If the ammonia is too rapidly driven off, the red cuprous oxide is pre¬
cipitated, interfering with the perception of the terminal point of
decolouration. Obviously the veoxidation and voappeaintice of blue
colour occurring only after the determination is completed arc of no
account. Your correspondent will find a full description of the
process, with a sketch of the appai-atus employed, in The Lancet of
March Ist, 1884. I am, Sirs, yours faithfully,
W. S. Bowntree.
The Laboratories, Examination Hall, March 10th, 1801.
To the Editors of The Lancet.
Sirs,—I n amswer to the inquiry of your correspondent “R. R..” 1
write to say that having some time ago been in doubt as to the
meaning of the recolouration after cooling of the solution, I wrote to
Dr. Pavy, who very kindly replied as follows;—“The blue colour may
reappear aUer cooling, and is thus explained: Decolourisation takes
place as the result of the reduction of the oxide of copper to the state
of suboxide. This reduced suboxido ia very ready to take oxygen
again. ludoed, an ammoniacal solution of suboxido of copper is used
by chemists as a test for oxygen. As the oxide is re-formed by the
absorption of oxygon the blue colour is restored.”
I am. Sits, yours truly,
March 0th, 1891- H. C. H.
jlf.O.H.—Unless the district has at the census procedipg the election a
population of at least 90,000, no diplom.a of Public Health ia neces.sary,
although sanitary authoritioa for districts of smaller populations
often give preference to candidates holding such diplomas, 'J'he
diploma is also not needed if for three eonsocutivo years before 1892,
when the requirement comes into operation, the candidate has hold
the post of medical officer of health for a population of not loss
than 25,900.
A Westminstei' Student.—The method suggested has been in use for
many years.
Dr. llelm's piper is marked for insertion.
Jlf.i?.C,.r.—Yes, shortly.
Medicat. Ot'PiCERS OF Health and Medical Practittonem.
An interesting correspondence has been sent to us—too long for inset'
tion —betwoen a medical practitioner who had notified and the
medical officer of health, in which the practitioner complains that-
the medical officer of health visited his caaes and criticised, and
sometimes questioned, his diagnosis in cases of diphtheria, saying in
one case just after Dr.-had cleared patches off with sulpburoav
acid : “ Dr.-has diagnosed diphtheria, but I can see no patches.’'’
In another case be took a gentleman with him, and they reported
“that they could not see anything.” In another case he said his eyea
were weak, and the “match” gave a very bad light. “The other
gentleman felt her neck about, but did not look in the throat, and
said ho did not think it was that.” The next day, however, the-
patch was still there. In another case, in a house where one had
died of the disease, the medical officer of health examined a child
and said there was nothing the matter. The next day the case-
proved a very severe one of diphtheria, and the parents said they
would have sent sooner for the medical man but for the opinion of
the medical officer of health. Such interference as this Is intolerable,
and should be sternly condemned by the medical authorities of th&
Local Government Board. The correspondence discloses a series of
cases in a small place with several deaths. The practitioner was
right in regarding every case, in sucli a place, with membranous
patches as one of diphtheria. The correspondence is a very striking
illustration of the inconvenience of divided responsibility in diagnosis.
If medical officers of health wish to visit notified cases, they should
put themselves in communication with the practitioner in attend-
ance. The smaller fee in pauper cases is according to law.
Messrs. Wright and Mackenzie .—The case being one of infectious disease
rather than of blood-poisoning, we are of opinion that a claim would
not stand.
INSOMNIA.
To the Editors of THE Lancet.
SlJis,—Having seen in your last issue the letter of a correspondent
requiring some advice in a case of insomnia, I would advise what I
found of great benefit in a case in which I did not care to administer
narcotics or sedatives. I simply prescribed liq.strychniffi.TTli.; aquie, jii.
This dose every two hours. Also ext. ergotw liq., iqi. ; aqum, 3 ii. This
dose every two hours also, alternately with the former. It may have
been a little extta trouble for the patient having to take medicine every
hour, but the re.sult was most satisfactory. In less than twenty-four
hours natural sleep ensued. Iji the case given by your correspondent E
would advise substituting for tobacco cubeb cigarettes. If possible
recommend the patient a hot sea-water bath for ten minutes, followed
immediately by a cold sea-water plunge, or a couple of gallons poured
over the patient will do instead. The patient should then be rubbed
with a rough bath towel for half an hour or more. This bath to be
taken every morning about two hours after breakfast, the temperature
of the water commencing at lOd', and rising one degree every two day&
up to 106". For diet as much milk as possible; fish three times a day,
and as little meat as possible. No stimulants, and as much out-door
exercise as possible without fatigue. I understand that if sulphonal
be given it must be taken in hot water to be effective. It leaves no ill
effects. I am. Sirs, yours faithfully,
Ealing, Marcli 9tli, 1891. • T. H. FORD.
A CONCESSION TO INFIRM SIGHT.
To the Editors of The Lancet.
SIRS,—Please allow me to diaw attention in your columns to a new
penny monthly paper, published by Messrs. Simpkin, Marshall, & Co.,
called “ The Old Folks’ Monthly Chit-Chat.” It is printed with
special large type (great primer), to suit the eyes of those whose sight
is impaired from old age or other cause. To mo there seems to be
ample need ami room for such a publication. Doubtless some will
think it might with advantage bo conducted on somewhat broader
linos, so as to he acceptable to others besides members of the Church
of England. I enclose for your inspection copies of the three numbers
already published, aiul havo only to add that I have no personal
interest in the success of the paper.
1 am, Sirs, your truly,
Oeo. AuiiOTT,
Surgeon to llio Tunbridge tVolls Eye and Ear Hospital.
March, 1891.
SURGICAL TREATMENT OF GRANULAR LIDS.
To the Editors of THE LANCET.
Sirs,—I have treated several cases of gr.anular lids, principally with
the “ lapis divinm.” and although a cure resulted in most, the time-
occupied was vovy long. During the last two months I have ti-eated
three cases in the following way. After eversion of the lids, I make a
number of short deep incisions pamllol witli the edge of the eyelids,
and then thoroughly scrape away the granulations with as little
damage as possible to tlio conjunctiva. A cure I'osulted in oacli ease
under the fortniglit. I think tliis metliodwill compare favourably with
any other. 1 am, Sirs, your.s ti'uiy,
Nowhaven, March 7th, 1891. Arthur G. MOSSOP.
Di . t ree) bv Google
■610 "Thk Lancet,J NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [March 14, 1891.
itr. T. &. Bari-ison.—Thfi heat-diffusing fireplace mentioned in our
issue* of Jan. 3rd can be had of Mr. Binnie of Wokingham. Or a
grate of Jslniilar construction suggested by Mr. Tealo of Leeds can be
bad through the manufacturers of these grates at Leeds. There
la also another form of heat-diffusing fireplace manufactured by
Messrs. Bishop and Barnard of Norwich.
Dr. Sfac/arlam'n paper will appear very shortly.
<3. 0. P.—No, not on general subjects.
•Communications not noticed in our present number will receive atten-
tion.in'our next.
Communications, Lextbrs, Ac., have been received from—Dr. Lauder
Btunton,\London; Dt. J. W. Ogle, London ; Mr. Hulke; Dr. Gordon
Holme, London ; Dr. McCall Anderson, Glasgow; Dr. Hingaton
Fox, London; Mr. B, Sutton, London; Dr. C. Steele; Mr. Colcotc
JFox, London; Mr. Barrow, London ; Dr. Herman, London; Sir James
■Sawyer, Birmingliam ; Dr. M. Cohn, Berlin ; Dr. Ilerschell; Dr. G.
Macdonald, London; Sir O. M. Humphry, Cambridge; Dr. Brondbenb,
London: Dr. Dimmock, Harrogate; Mr. P.Edgelow, London; Mr. 1C.
Glavo, Abadob; Mr.H. J. Collins, Norwich; Dr, W. B. llaward, Cali-
•fornla; Mr, Pugin Thornton, Canterbury; Dr. S, Dixon, Philadelphia ;
Mr. J. B. Pike, Loughborough; Mr. Newnes, London; Mr. Bopwojth
Collins, Manchester; Mr. A. C. Hartley, Liscard ; Messrs. Clarke and
Hodgson, Leicester; Dr. G. Doan, Vienna; Messrs. Haaaonstein and
Vogler, Frankfort; Dr. Gemmol, Lanca.ster; Messrs. C. Mitchell and
Co., London; Dr. J. G. Border, Cavdilf; Messrs. Walter, Thorp and
Co.,01osHop; Dr. T. Oliver, Nowcastle-on-Tyne ; Messrs. Langridge
and Freeman, London; Mr. K. Thornton, London; Dr. Oourley, West
Hartlepool; Mr. Ford, Ealing; Mr. Evans, Akyab; Mes.srs. Isaacs
and ;Co., London; Dr. Bowlan, Newcastlo-on-Tyno ; Messrs. J. and
H. Grace, Bristol; Mr. J. E. Cornish, Manchester; Messrs. John
Wright and Co., Bristol; Mr. F. A. Davis, London; Messrs. Wright and
Mackenzie, Eotnford; Dr. Brett, Watford; Messrs. J. Richardson
and Ce., Leicester; Surgeon-Major A. Duncan; Dr. Williamson, Man¬
chester ; Dr. Altomeyan, Aleppo; Mr. Milburn, London; Mr. Gidloy,
Honiton; Mr. Eminson, Scotter; Mr. Stanwell, Rochdale; Dr. De
Henzy, Dublin; Mr. W. II. Brown, Leeds; Mr. Whitehouso, Birming¬
ham ; .Mr. Haviland, Douglas; Mr. Cardew, London ; Mr. Rowntree,
London; Mr. Tubby, London; Dr. R. Favell, Sheffield; Mr. Southam,
Manchester; Mr. Ball, London; Dr. Walmsley; Mr. Edwards, Bir¬
mingham : Dr. Crowther, Hobart; Mr. Birchall, Liverpool; Mr. C. H.
Leet Liverpool; Dr. Gramshaw, Easingwold ; Messrs. Darnton and
Bottomley, Ashton-under-Lyne; Mr. Ryan, London; Messrs. Cooke
•and Sons Winsford; Mr. H. Green, London; Dr. J. MacMnnn, Crouch
'End' Mr. Gurner, London ; Mr. Thomas, Leeds; Messrs. Barker and
;Son8, London; Mr. Hiine, -Bradford; Mr. Glover, Tyrol; Dr. A. S.
Taylor, Surbiton; Mr. Hornibrook, London; Miss Fernie, Maccles-
"fieid; Mr. Macfarlane, London; Mr. Griffltli, Caniforth; Mr. Osborn,
Southampton; Dr. Evans, Bradford ; Mr. Gates, London ; Mr. Smith,
Gldham; Mr. Kelly, London; Dr. Carman, Kondal; Mr. O'Gorman,
Kilkenny; Mr. Lewis, Rainhill; Mr. Kosho, Manchester; Mr. T. B.
Browne, London; Mr. Macdonald, Manchester; Dr. Bogliill, Bir¬
mingham ; Miss Hooper, London; Mr. Weller, Colchester; Mr. .1. C,
Neill, Hasllngden; Mr. Sheine, Pniladelpliia; Mr, Soli, London;
Mr.Evorard,Athlone; Mr.Bullivant; Mrs.Harvey,London; Mr.Fox,
Manchester; Bristol Drug Co., Ansonia, U.S.A.; Notification Act;
T. H. J. P-; Ubique; C. F.; H. C. II.; M.O.H.; Secretary, Norfolk
and Norwich Hospital; R. D., London ; Attendant, London; Sick
of Dispensing; II.; F.R.C.S.; Peno, London; Oxon, London; Bedford
Infirmary ; The Author of “Flomieh Interiors”; Secretary, West-end
Hospital, Wolbock-street; A. V. M., London; Anglo-Swiss Condensed
Milk Co., Loudon i Bradford, London ; House Surgeon, Kidderminsor
infirmary; F. F., London; Dunelm, London ; One who Subscrihes to
■Charities; Alpiiabot, London.
- ■' — — ..u
Letters, each unth enclosure, are also acknowledged from—Mr. Tyte,
Minchinhampton; Mr. Norman, Bayswator; Messrs. McQeachy and
Go., Glasgow; Dr. Lloyd, Llanarthney; Messrs. White, Druce, and
Brown, London; Mr. Stranaghan, Pontypridd; Mr. Boyd, Denmark
Hill; Dr. Stanley, Hereford : Mr. Tully, Hastings; Messrs. Fenwick
and Cliinery, London; Mr. Blacko, Teignmouth; Messrs. Paternoster
and Hales, Bitchiii; Mr. Thomas, Manchester; Messrs. Potter and
Sacker, London; Dr. Henderson, Bournemouth; Messrs. Rowntree
and Co., York; Mr. Luff, London ; Mr, B. Edwards; Messrs. Watkins
and Osmond, London; Mr. Huish, London; Messrs. Hewlett and
Son, London; Mr. Evelyn, York; Dr. Windle, Halifax ; Dr. Francis,
Wandsworth; Mr. Pirn, Lincoln; Mr. Ward, Anerley ; Mrs. Belcher,
Hampstead; Mr. Wavdo, Yalding; Mr. Jenkins, Salford; M. Menier,
Southwark; Mr. Caird, Glasgow; Dr. Deane, Salop; Mr. Atkinson,
Stockwell; Mr. Elliott, Devon; Mr. Mackay, co. Cork; Dr. Halket,
Glasgow; Dr.McCarbhy,Worcester; Mr.Boulton,Bri.stol; Mr.Clarke,
Newbury; Mr, Rushbrooke; Dr. Whltham, Adlhigton; Mr. Sisson,
Newcastle-on-Tyne ; Miss Bamsden, Brighton; Miss Carson, Folke¬
stone : Dr. Lambert, Bradford; Mr. Ellams, Liverpool; Dr. Mackay,
Darlington ; Mr. Nioliolls, Bury St. Edmunds; Mr. Brownlow, Bolton-
le-Moors; Mr. Glover, Innsbruck ; Mr. Pearson, Nowry ; Mr. Freer,
Llandudno ; Mr. Forjett, Lines; Mr. Kemble, Dorset; Mr. Cochrane,
Wigtonshire ; Messrs. Ueywood, Manchester; Mr. Faithful!, Wimble¬
don ; Mr. Harrison, Bristol; Dr. Leatliam, co. Tyrone ; Mr. O’Meara,
Loughboro’; Mr. Ir'vine, Liverpool; Mr. Mannsell, Cardiff; Mr. Thin,
Edinburgh; .Styloid, London; X. Y., London; Scotia, London;
Miss X., Manchertor; A. G. 0. E., London ; Secretary, Kent County
Asylum, Maidstone; Bistowey, London; Modicue, London; Clayton
Hospital; Deiiia, London; C. F. K., Cardiff; Groat Towor-sbroeb Tea
Co.,London; F. S. D., Leeds; Oxon,London; Secretary, East Suffolk
Hospital; Aberdeen, London; M.D.Berlin, Lond 9 n; The Clerk, South
Shields Union; Ulna, Manchester; Secretary, Victoria Hospital for
Cliildren, Chelsea; Moa, London; Modicus, Horwich, Lancs; City
Newspaper Office, London ; M.B,, Birmingham ; Hackney Furnishing
Co.; Vere, London; B.A., London; W. J. R., London; Children's
Hospital, Pentllobury; Delta, London; Adoption, London; Beech
Hurst, Hanley; Delta, Nowcastle-on-Tyne ; County Borough South
Shields: A. M., Sydenham; Alpha, Dorking; S. L., London ; Suffolk
General Hospital; Medicus, Ramsgate; Micros, London; University
College Medical School, Bristol; Genuine, London; Secretary, Bolton
Infirmary ; M.D., London ; K. J., London ; Lymph, London ; Ruhery
Hill Asylum, Worcester ; C. N. J., Manchester squaro; Labor Omnia
Vincit, London; Security, London; H. W. J., Bradford; Nottingham
Borough Asylum; Surgeon, London ; Dr. K., London; J, S. R., Sand¬
wich ; Chiton, London; Smilax; Spes, London; M.D,, Kilburn.
Newspaper.^.— jWrdfrwKf Boenimj News, tfewaaalle Chronicle, Liverpool
Mercury, North Briliah Daily Mail, Jliriidnyham Post, L'oeniny News,
Galii/netni'a Mesaenyer, Admiralty Horse Guards’ Gazette, Dundee
Advertiser, Wiyuhor and Eton Gazette, Leeds Me-rcmy, Livopool Daily
Post, Minin'/ Jot/mal, SeotHsh Leader, Weekly J^ee Press <t Aherdeen
Uerald, Bristol Mercury, InSisrancc llecord. Local Government Chronicle,
Yorkshire Post, Windsor and Eton Express, Headhiq Mercury, Leinster
Chronicle, N ewsman and Publication Jlegiater, Ueri/ordshire Mercury,
City Press, Sunday Times, Builder, West Middlesex Advertiser,
Spectator, Broad Arrow, Chemist and Dniyyist, Met7-opolitan Law
Journal, Salm-day Jteview, West Middlesex Slmulard, Pharmaceutical
Joui-nal, Gnj/s Hospital Gazette, Surrey Adoertiser, Architect, }yeste7-n
Morniny News, Kirkintilloch Jlcrald, Li/zroln Gazette, Wkitehaue7i
News, L'Eclio Sttlo/iais, Aryus (Melboi/rne), Perthshire Constitutional,
Bury Post, Scots7nan, Poole Herald, Jia7iyoo7i Times, Bosse/idalc Pree
Press, Ar77vy a/id Kaey Gazelle, No/ih Deeo/i Joicr/ial, Sca7-borowjk
Post, Ac., have been received.
SUBSCRIPTION.
Post Free to any part op the United Einodom.
One Year_12 6 | Six Mouths £0 10 B
To China AND India Year 110 11
To the Continent, Colonies, and United
States ...— —Ditto 1 14 I
post OfficeOrders and Cheques should be addressed to The Publisher,
fTHB Lancet Office, 428, Strand, London, and crossed “London and
Westminster Bank St. James’s-square."
ADVERTISING.
Books and Publications (seven lines and under) ..£0 4 0
Official and General Announcements .. » m 0 B 0
ikade and Miscellaneous Advertisements _ _ 0 4 0
Every additional Line 0 0 0
Front Page per Una 0 10
g uarter Page » «. •• _110 0
alf a Page _ « _ ^ ^ _2 16 0
An Entire Page .. — « .. _ _660
The Publisher cannot bold himself responsible for the return of testf.
monials &c, sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are requested to observe that lb Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
Ao original and novel feature of "The Lancet General Advertiser" is a special Index to Advertisements on pages 2 and 4, which not only
aBords a ready means of finding any notice, but is in itself an additional advertisement.
Advertisements (to ensure insertion the same woek)should be delivered a( the Office not later than Wednesday, accompamed by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Berial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subsoriptlona sbonld bo
Ad^^tlsements ate now received at all Messrs. W. H. Smith and Son’s Railway Bookstalls throughout the United Klngdoin aid all otbet
Advertising Agonto. ____
Agent (or t&e IdTerUflement Department In Franoe>-J, ASTIBB, 06. Bne Caumartln. FarlSi
Db .Google
THE LANCET, March 21, 1891,
ABRIDGED REPORT OF
fumleian fettms
STRUCTURAL DISEASES OF THE HEART
CONSIDERED FROM THE POINT OF
VIEW OF PROGNOSIS.
By W. H. BROADBENT, M.D., F.R.C.P. Lond.
After introducing the subject matter of the lecture, Dr.
Broadbent said: The muscular walls of the heart are
liable to changes of various kinds, some of which constitute
■diseases which shorten life and give rise to much sufferiDg.
Of these structural alterations, some are extremely coni m on—
hypertrophy, dilatation, fatty degeneration; others rare—
■cancer, syphilitic gumma, abscess, aneurysm, and localised
'fibrotic induration. We shall concern ourselves only with
those which arecomparativelyfrequent; the others, obscure
as well as uncommon, are very seldom recognised during
life, and a diagnosis is only made when an exceptionally
■clear case comes under the notice of an exceptionally
acute observer. Even when the common and familiar
affections — hypertrophy, dilatation, and degeneration
■only—are taken into consideration, we find ourselves
■on far less secure ground than when dealing with
lesions of the valves. The latter we can localise with
reat confidence; and knowing partly by experience, partly
y the application of mechanical principles, their effects and
tendencies, we can, by making out how far such effects are
manifest, form an opinion as to the probable course of the
:symptoms and as to the future of the patient. On exami¬
nation after death, again, we can understand the connexion
between the lesion and the symptoms, and can follow the
sequence of secondary changes in the heart and vessels
which are set up by the origiual valvular defect. In the
•case of structural changes, on the contrary, we are often
left in some degree in the dark even by a post-mortem
■examination. In one patient fatty degeneration has
apparently proved fatal at so early a stage that the
naked-eye characters of the condition are scarcely per-
■ceptible, and it is only by the microscope that its exist¬
ence is definitely established; in another the change has
proceeded so far that the fingers sink into the pale
greasy walls, and the muscular fibres have almost dlsap-
eared, so that it is scarcely conceivable how the heart
as been able to impress any movement whatever on the
blood or bow life has been sustained through the inter-
.mediate stages of disintegration. So with regard to dila¬
tation: there is no fixtd relation between cho degree of
•enlargement of the cavities and thinning of the walls found
.after death and the interference with the circulation
observed during life. One man will live for years with a
'heart which has reached the extreme limits of dilatation,
while another succumbs when it is bub moderately advanced.
If, therefore, we could make out with great exactness the
•dimensions of the heart, the size of its separate chambers,
o.nd the thickness of their respective walls, which is no easy
task, we could not, on these grounds alone, compare one case
with another and decide upon the relative danger.
Many other considerations of extreme inipoitance will
•come into the estimate — the functional vigour of the
muscular walls as well as their thickness, the liability to
palpitation, the state of the vessels, the degree of peripheral
'resistance, the presence or absence of reilex irritation of the
heart from gastric or other derangement. Ib is of the
•utmost consequence that such approximation to a forecast
•of the prospects of life as is possible should be an object of
serious endeavour. Tlie cases are numerous, far more
numerous at and after middle age than of valvular disease,
■and everything which has been said as to the importance of
prognosis in general applies here. An early recognition of
these changes, indeed, is often of greater service to the
•subject of them than in the case of valvular affections, since
it reveals also the tendencies which are in operation, and
often at a time when they can be successfully combated by
treatment. Too commonly, however, no attempt is made
to recognise the existence and extent of degeneration or
No. 862C’
dilatation. The symptoms due to derangement of the circa-
lation force themselves upon the attention of the medical
man, but no murmur being detected, the only diagnosia
ventured upon is that of weak heart,” a vagoe term which
covers the entire ground, from temporary functional debility
to disease inevitably and imminently fatal. Such a
diagnosis reacts unfavourably upon the mind of the ob¬
server who rests upon it, and makes him less exact and
trustworthy, while it may be full of danger to the patient.
A further justification of the prominence given to prognosis
is that the grasp of all the facts of the disease and of the in¬
dividual case, which is necessary to the formation of a just
forecast of the result, is tbe best guide for treatment,
whether this may demand chiefly patience and caution or
must be energetic and prompt. Prognosis is not merely a
well-instructed conjecture as to the ultimate issue, it is a
deliberate judgment as to the processes and tendencies of
the disease and as to the constitutional soundness and
strength of the patient; the foresight which relates to tbe
dangers which attend tbe attack, to the course which it
will run, and to the iniinences and contingencies which
make for or against the sufferer.
Hypertrophy .—The progno'^is of cardiac hypertrophy is
that of its cause. The character and degree of hypertrophy
are important as indicating tbe existence of some condition
which ha" given rise to the hypertrophy. The canses
which bring about hypertrophy of the left ventricle ate:
(1) Valvular diseases: (2) stenosis or insufficiency of the
aortic valves; (.S) mitral insufficiency; next in frequency
will be (4) protracted high arterial tension, the evidence of
which is manifested by large, thickened, tortuous radial and
temporal arteries or a dilated ascending aorta, the causes of
which may be renal disease, incipient and confirmed gout, and
tbe prognosis and treatment depend on the identification of
tbe underlying condition ; (5) adherent pericardium, which
is difficult to diagnose, may be a factor in the causation of
sudden death, ana its recognition therefore is a matter of
interest. Hypertrophy of the right ventricle arises from
(1) valvular disease, cbiefiy mitral stenosis, or insufficiency;
and from (2) conditions which give rise to obstruction in the
pulmonary circulation, such as emphysema or bronchitis.
The hypertrophy is rarely dissociated from dilatation, which
is the primary effect of the obstructioa in the pulmonary
capillaries. Collapse of a portion of tbe lungs, contraction
of a lung from pleural adhesions, fibroid pUtbuis, or any
condition which throws considerable area of lung surface
out of gear, will in a certain degree give rise to overwork
and consequent hypertrophy of the right ventricle.
The diagnosis between dilatation and hypprtrophy requires
notice. In hypertrophy the pulse will be of that condition
which has given rise to the hypertrophy. If it has arisen
from arterio-capillavy obstruction, from renal disease, gout,
lead poisoning, or pregnancy, tbe pulse will be one of high
tension. The artery will be full between the beats, not
easily compressed, and has a cordlike feel. The pulse will
not have a violent ictus, but will rise gradually and subside
slowly, so much so that it is frequently desciibed as weak.
Regarding the physical signs, bulging is sometimes reco¬
gnisable over the cardiac area. Tbe apex beat is depressed
to the sixth or seventh space, and may be displaced out¬
wards. It is a circumscribed gentle heave. Palpation is
always an extremely important patt of the physical exami¬
nation, by meins of which the apex beat can be further
defined and felt as a powerful but deliberate thrust iu the
space. When the Hat of the baud is laid over tbe cardiac
region a general bearing impulse can usually be felt. When
the left ventricle is alone or mainly affected, the impulse is
not very cimspicuous. When tbe aorta is dilated pulsation
may be felt in the second and third spaces near the sternum.
Occasionally when the hypertrophy is considerable neither
apex beat nor impulse can be seen or felt. The results of
percussion must be correlated with all tlie other evidence
as to the size of the heart. Auscultation, besides teaching
tlie character and intensity of the sounds, must be made to
contribute to the information by careful noting of the seat
of maximum intensity of the sounds in the apex region.
The first sound of the left ventricle, as heard at the apex,
is less distinct than in a normal state of the heart; either
the mass of muscle enters into contraction less simultane¬
ously, and, tbe muscular tension being less sudden, yields a
duller sound, or the thicknees of the walls masks the sound
produced by the sudden tension of the valves and tendinous
cords The second sound, whicli at the apex is aortic only,
is, on the contraiy, usually louder than normal, and is often
M C
642 The Lancet,] DR. W. H. BROADBENT ON DISEASES OF THE HEART. [Makch 21,189J.
heard at and near the apex more diatinctly than in the right
second space- When the first sound is prolonged and mufiled,
and especially when it can be described as “impure’’
(a very objectionable term) or murmurisb, careful ex¬
amination will usually reveal that it is reduplicated, the
first two sounds of the right and left ventricle not
coinciding. This indicates that the left ventiicle is no
longer quite equal to the extra work imposed upon it and
niacks the supervention of a tendency to dilatation. At
the base of the heart the left ventricle first sound is still less
distinct than at the apex, and is, indeed, frequently quite
inaudible, while the accentuation of the second is rendered
more evident by the absence of a first sound. As has
already been said, however, the aortic second sound may be
even toore distinct at the apex than in the aortic area
When this sound is not only accentuated but low pitched
and ringing, the root of the aorta is more or lees ailated,
and the sound will be heard for some distance to the right
of the edge of the sternum, perhaps over a great part of the
chest and along the spine.
The sounds of the right ventricle undergo no modification
of sufficient importance to require notice. Various symptoms
are described as resulting from hypertrophy of the heart.
Discomfort in the region of the heart, tenderness, throbbing
sensations in the bead and neck, pulsatile noises in the ears,
audible pulsation of the carotid and other arteries, undue
frequency, abrupt, irritable, and irregular action, and
proueness to palpitation: some of the symptoms bting
the result of tue size of the organ and of the vehemence
of the heart beat, others being due to the cause of the
hypertrophy, and others to various affections of the heart.
Toe question of prognosis in relation to hypertrophy mostly I
resolves itself into thU: whether the compensation which it
establishes is adequate and efficient, and now far it promises
to be durable. Compensation is efficient wben there are no
symptoms of embarrassment of the circulation, and when
the heart responds to all ordinary calls upon it without
undue shortness of breath or respiratory distress. The
effects of exertion are an important criterion, due allowance
being made for the greater liability to breathlessness which
is natural to some individuals, or is produced by bodily
confoignation or results from a sedentary mode of life.
The sounds of the heart usually give notice when it is
overtaken by the redstaoce to the onward movement of the
blood. The interval between the first and second sound
may be prolonged, the systole requiring more time than
under ordinary circumstances to complete itself. So long as
the normal proportion between the systolic and diastolic
pauses is not disturbed, there is no indication that the
heart is unequal to its work, or is suffering from the stress
put upon it; but when the systolic pause is lengthened at
the expense of the diastolic, so that the sounds are equi-
(lUtant, the period of repose and reconstitution of the mus¬
cular fibres of the ventricle is shortened, and their nutrition
must in time sufl'er. During systole the blood is squeezed
out of the walls of the heart, and it is during the diastolic
relaxation that it obtains free access to the cardiac fibres.
Another evidence that the heart is yielding to the strain of
<iverwork is reduplication of the first sound. The prognosis
becomes serious when the first sound is. broken up in any
very considerable degree. But when the cardiac hyper¬
trophy has been brought about by high arterial tension,
whether associated with renal disease or gout, or other
cause, there must be taken into consideration the possi-
bili'y that the powerful heart may rupture diseased vessels
in the brain.
Treatment for hypertrophy as such has always ap¬
peared to me to be out of place. The functional
vigour and energy of the overgrown and over-strong'heart
could no doubt be reduced by various means—low diet,
euforced rest, and such drugs as aconite; but, unless it is
clear that tlie hypertrophy has gone beyond the require-
meuts of the condition which has given rise to it, theaiivan-
tage of this procedure would be more than doubtful. Even
in the attempt to relieve the incidents of hypertrophy—
psl()ibatioD, throbbing sensations in the chest or heuil,
in liable or irregular action of the fieart, pnocordial
oppression—the employment of direct cardiac depressants
is rarely of service, and is at times attended with danger.
In aortic stenosis, for example, I have known aconite, given
with a view of quieting tumultuous action of tire heart, si»
far to reduce the contractile energy of the left ventricle thar,
it was no longer able to cope with the obstruction, and
death quickly followed from cardiac asthenia, the pulse
becoming imperceptible, the extremities livid, and the snr-^
face of the body cold and damp. This would be less likely
to occur wheie the cause of the hypertrophy was obstruction
in the peripheral circulation, as the arteries and capillaries-
are relaxed by such agents as depress the action of th&
heart.
We have really tc consider, not the treatment of hyper¬
trophy or its cause, but the treatment suggested by tike
hypertrophy. We shall recognise, for example, the neces¬
sity of diminishing the volume and improving the quality
of the blood by appropriate diet and hygiene, and, if neces¬
sary, by tonics. We shall recognise also the desirability of
diminishing the resistance to the onward movement ofi
the blood in the arterio-capillary network by care in
diet, again by aperients and by eliminants of various
kinds. In some cases the resistance in the peripheral cir¬
culation may be further lessened with advantage by the'
physiological relaxants of the arterioles and capillaries, suclv
as nitro-glycerine and the nitrites. By these means the
work thrown upon the heart is reduced, and, if necessary^
the heart may then be strengthened by such remedies as-
Btrycbnine and digitalis.
All tlteee measures are specially required wben the hyper¬
trophy is no longer equal to the task which it had originally'
been developed to perform, and the reduplication and other
modifications of the sounds are present.
Dilatation .—When spoken of as a form of heart disease^
this usually means dilatation of the ventricle with or with¬
out dilatation of the right. There may be an attempt at-
hypertropby of the walls, compensatory of the dilatationi
itself, and not infrequently the hypertrophy has produced
the dilatation. More important than the anatomical con--
dition is tbe physiological or functional condition, the
special characteristic of which is that the ventricle does nob
complecp its systole, but only expels a portion of its con¬
tents. la well-marked cases the chambers of tbe heart are'
always full, and, little blood being received and expelled,,
there is a stagnation in tbe auricles and ventricles wbich>
may allow of the deposition of fibrin among tbe fleshy'
columns and pectinate muscles. It baa seemed to me that-
the imperfect emptying of the ventricles has not always-
been fully realised as the special feature of dilatation, but
it will be seen that if a dilated ventricle launched the whole''
of its contents into the arterial circulation, the amount
being much larger, the rate of movement of blood would bc'
greatly accelerated, whereas the contrary is the case. The
dilatation attending aortic regurgitation belongs to a-
different category, and, instead of aggravaliig the diffi¬
culties of the circulation, it is a part of the compensatory*
arrangement. It is clear that if a certain proportion of the
blood projected into the aorta at each systole retnrns to the
ventricle during diastole, it is an advantage, and indeed a-
necessity, that tbe capacity of the ventricle should be.
increased, so that, in spite of the reflux, a normal amount
of blood may remain in the arteries and be distributed to-'
the tissues. The dilatation, however, in aortic regurgita¬
tion is accompanied by hypertrophy, which enables the^
ventricle to contract perfectly, so that the characteristic of
dilatation—the partial and imperfect emptying of the
ventricle—is not present.
Dilatation is, I think, usually understood to be the-
result of a gradual yielding of tlie walla of the ventricles,
eibhsr from their own inherent weakness or from undue-
resistance to the onward career of the blood. It is often-
supposed also, when dilatation exists, that it is an esta--
blished and more or less unvarying or progressive condition.
Both these ideas require modilication. But the circum¬
stances which are capable of producing a temporary disten¬
sion of the ventricles in a sound and vigorous state of tbe
organ are those which will be competent to give rise to-
dilatation when it is weak and flabby and other conditions
are present which tend to dilatation, and it is more likely
that the weakly ventricles give way from time to time under
stress, and fail to recover perfectly than that tbe yielding
is gradual and continuous. Arterial tension, dilatation at
an early period, is comparatively rare, wliich would scarcely
be the case were continuous resistance to the emptying of
the ventricle the most efficient cause.
In violent exercise the pulse, in becoming extremely
frequent, also becomes extremely soft; the arterioles and'
('»).,)'lUries are relaxed in order to facilitate the rapid
n.civemeut of the blood, whicli is necessary to supply fuel'
tiii'i "xygen to the muscles during exertion and the arterial*
ten ion is lowered. Tbe resistance to be overcome by the-
The Lancet,]
DR. W. H. BROADBENT ON DISEASES OF
HEART. [March 21, 1891. 643
ventricles is thus reduced to a minimum, which diminishes
'<the liability to over-dietension.
In the production of dilatation a common and important,
•af not a constant, factor is habitual high arterial tension.
A second factor, less constant, perhaps, but more impor-
'tant, is inherent weakness in the ventricular walls. With
these proximate causes, to use an old-fasbioned term, will
■cooperate very varied influences — exertion, excitement,
■chills, imprudence in eating and drinking, constipation,
augmenting the stress on the heart; anaemia, anxiety, and
depressing emotions diminishing its power of resistance.
Acute dilatation of the heart is more common than is
generally supposed. There are grounds for supposing that
dilatation has been induced at once in a heart not pre¬
viously affected.
A certain degree of dilatation of the left ventricle usually
occurs at the onset of acute renal disease, under the com¬
bined influence of the resistance in the peripheral circula¬
tion and of the enfeehlement of the heart. In other acute
diseases this may happen.
A common cause of dilatation of the heart is anxiety.
Nothing is more certain than the influence of prolonged
mental depression upon the heart, and the sensation of
aching, oppression, and weight which attends griefs and
anxiety, and which was considered to point to the heart as
the seat of emotion generally, is indicative of an injurious
•effect upon this organ; it is almost literally true that people
'die of a broken heart. The combination of overwork, ex¬
citement, worry, and trouble often met wifcli in city life,
especially on the Stock Exchange or in the mercantile or
financial circles during a commercial or financial crisis,
brings us many cases of cardiac dilatation among men, and
it is needless to say that domestic anxieties, grief on account
of children who have died or given trouble, have the same
■effect among women. Among the special causes of dilata-
>uion of the heart, acting no doubt on pre-existing tendencies,
which have come under my notice are injudicious hydro¬
pathic treatment, the so-called “Banting”raethod of reducing
■obesity, and inhalation of the fumes of Hirorod’s powder for
the relief of astiima. In one case a gentleman suffering
'from dyspeptic symptoms, probably due to cardiac weak-
iiess and consequent sluggish circulation in the abdominal
viscera, underwent a routine treatment by baths, wet cold
packs, and compresses, under which attacks of dyspnoea
came on and cedema set in. He had previously been under
the care of competent observers who had not found any
oerious degree of dilatation. The dropsy advanced in spite
■of treatment, and when I saw the patient was considerable,
o,nd the physical signs gave evidence of extreme dilatation
and thinning of the left ventricle. Death occurred suddenly
during a paroxysm of dyspnoea.
One of the most extreme cases of dilatation I have ever met
with was in the case of a lady who had undergone an amateur
course of “Banting” treatment for obesity. Apparently
iiabitual high arterial tension had been exaggerated by an
■exclusively nitrogenous diet, and under it the ventricle bad
(given way. It may perhaps be well to add that in the
treatment of obesity by beefsteak and copious draughts of
hot water there has not been, according to niy experience,
increase of arterial tension, bub the reverse.
Dilatation of the heart .—The diagnosis of dilatation of
•'the heart is comparatively easy to anyone who has had a
■fair amount of experience and who is prepared to exercise
•sullicient care in making the requisite physical exaniina-
'tion. Certain precautions are necessary, which will be
pointed out later. When, however, the diinensinns of the
heart have been made out, and an estimate has been made
of the relative degree of dilatation and hypertrophy, and of
'the comparative condition of the two ventricles, a small
step only has been taken towards the attainment of the
knowledge which is necessary in order to forecast the course
and issue of the case and to direct the treatment. There
may bo hereditary tendency to weakness of the heart, or
ithe heart may be worn out by an unhealthy mode of life or
by protracted emotional strain, of the patient’s tissues
‘generally may lose their nutritional value early. Facts of
this class are not revealed by physical signs ; some of them
may be known to the family medical man, but otherwise
they are ascertained only by persevering and careful
inquiry. It is obvious, then, that many other considera¬
tions enter into a true and thorough diagnosis of dilatation
of the heart besides its anatomical condition.
The pulse in advanced dilatation of the heart is usually
irregular in rhythm and unequal in force of beat, and is
sudden, short, u^^ptained, and usually easily compressed.
The arterv at may be large or small; it will be
specially largethere has been antecedent high tension
which has dila^^Bbe arteries. The significance of a pulse
of this charac^^p not absolute, as all these characters may
be present wj^Hthere is no recognisable change in the
walls, cavitie^V valves of the heart, apparently from dis¬
ordered nervi^Hniluence only. The pulse, again, need not
he irregular j^Hvanced dilatation of the heart, so long as
the patient repose and the breathing is tranquil and
easy. Th^WguIarity, however, is easily diatuibed by
exertion or^Bort, or by bronchitis, or merely by deep
breathing, moderate and slight dilatation the pulse may
be reguIar^Kt while irregularity is the rule, tuere is no
such cons^Brelation between the degrees of regularity or
irreguIarij^Bf the pulse and the amount of dilatation of
the bearl^Ko make one diagnostic of the other.
Palpa^Bin moat cases of dilatation furnishes informa-
tioD whi^Bontributes more to precision of idea as to the
actual of the heart than any other branch of physical
expIora^Pp. The right hand should be applied closely over
the ent^p^cardiac region, the palm over the right ventiicle,
the linfll, spread out and close together alternately, over
the arBpdix region. Distinct impulse over the right ven-
triclejHhile it indicates more or less obstruction in the
pulmBiry circulation, indicates also some degree of vigour
in bl^Bentricle available for compensatory work. A mere
vibrBon has a converse sigaificance. The first object of
att^BioD, however, will be the identification of the point
of Aximum impulse in the apex region, and a careful
estjHation of the area over which the apex beat extends,
antfof its force and character; whether, for example, it is
a Are concussion of the chest wall or a more or less disticct
tliAsb at any point. According as the apex is capable of
gBng a distinct thrust or of communicating only a diffuse
sAk, and according as the heat is 'n’ell defined or steady,
oAaguely felt over a considerable area, will be the esbiipate
oBhe degree of dilatation, and of the thickness or thinness
oBthe heart wall. Not unfrequently neither impulse nor
aP^x beat can be detected, or the' impulse is so vague that
iMcannot be localised; unless this is due to overlapping
jfcg, it indicates great weakness of the muscular walls of
Ae heart.
P By percussion the outline of the heartcan be mapped out.
■t is more rounded in the apex region than normal, and the
Iirea of dulness is greatly extended to the left. When no
impulse of any kind can be felt, we may have to depend en¬
tirely on percussloQ for information as to the size of the
heart. I have found continuous deep dulness outwards as
far as the raid-axillary line, and downwards to the seventh
space, shown to be cardiac by the intensity of the sounds at
the extreme limits, and, when the heart had gained strength,
by an apex beat recognisable by palpation at the furthest
point. The characteristic modification of the sounds of
the heart produced by dilatation is that the left ven¬
tricle first sound becomes short. Usually it is also
louder than normal. Probably from this change in the
character of the left ventricle first sound it is almost
always audible in the aortic area, contrasting iu this
with hypertrophy. It is audible also to the left of
the apex beat. When no impulse or apex beat can be
felt, the sounds, and especially the first, must be made
use of to ascertain how far bo the left the left border and
apex of the heart have been carried by the dilatation, and
in what degree the enlargement is due to dilatation or
hypertrophy. Percussion, of course, maps out the deep
dulness and shows approximately the limit of the heart and
its extension to the left, but the pointof maximum intensity
of the sounds and the area over which they are audible will
corroborate or correct the idea formed as to the size of the
heart from percussion, and percussion yields no information
whatever as to the kind of enlargement, but leaves it to be
supplied by the character of the sounds on auscultation.
Not uncommonly dilatation of the left ventricle is accom¬
panied, and gives rise to a systolic apex murmur obviously
due to mitral incompetence. This is induced by imperfecu
accomplishment of the constriction of the orifice which is
part of the normal contraction of the ventricle and which
cooperates with the curtains of the valves in preventing re¬
gurgitation into the auricle. Now, mitral valvular disease
18 attended with precisely the same combination of condi¬
tions—incompetence of the valve and dilatation of the
ventricle—and of piiysical signs—a systolic apex murranr
and displacement of the apex beat with increased catdiao
O
644 The Lancet,]
DR.
[MAS OLIVER ON LEAD POISONING.
[March 21,1891.
dulnesB. The prognoais is very dilfer^^Kt the two cases,
and it is therefore extremely import^^Ato distioguish
between them. This cannot be done^^^ any degree of
confidence by means of physical sig^^ftlone, and the
discnssioD of the diagnosis must be^^vved; but it
may be eaid that the presence of t^^Heft ventricle
first sound in primary dilatation absence in
primary valve lesion will sometimes b^^u great ser¬
vice as a factor. There is nothing in d^ntion of the
cavities of the heart to affect spcciall^^Kpd directly
the second sound ; but in proportion as this^Bition of the
ventricles impairs the propulsive energy of ^Bjystole, the
second sound will be enfeebled; and tte aorti^Hcood sound
is usually weak as compared with the left^fctricle first
sound. The relative loudness of the soun^B therefore,
enters into the considerations from which may^Balculated
the efficiency of the ventricle.
Very important information is often suppIied^Bobserva-
tion of the intervals between the first and seco^&ind the
second and the first sounds—the short and ij^B pauses
respectively. When with dilatation of the lei^Kntricle
there is resistance in the arterioles and capilla^B which
is very commonly the case, the interval between^Be first
and second sound may be prolonged ; and, as this nHks the
duration of the systole, it shows that the ven^Ble is
endeavouring to cope with the difficulty and to comflbe its
contraction. The short or systolic pause may be^Bpro-
longed as to equal the diastolic or long pause, a^fttbe
sounds thus become equidistant; the first also hwing
become short and sharp, the only difference betweeiBthe
sounds is one of emphasis or of pitch, and It is often difimlt
to say which is which. The sounds may be compared, vBen
the heart is acting slowly, to the ticking of a clBk,
when rapidly, to the puffing of a distant locomot».
On the other hand, the first and second sounds mayBe
approximated, and as we cannot suppose that a dilated Bd
enfeebled ventricle completes its systole in a shorter tBe
than normal, the only possible explanation is that ifls
quickly brought up short by the resistance in the arteiBl
system and expels but a small proportion of its c(fl-
tents. This abbreviation of the systolic pause is theB
fore a serious indication of failure of the ventricleB
and when carried to an extreme, so that the second sounB
follows the first immediately and almost seems to overtaki
it, is significant of immediate danger. In two successivil
attacks of symptoms due to dilatation of the heart, when!
the degree of dilatation appears to be exactly the same, a
difference in the length of the systolic pause is sometimes
the chief if not the only point which makes a difference
in the prognosis. The first and second sounds are spaced
in the first attack, which is survived, and approximated in
the second, which proves fatal.
To what extent dilatation may go without giving rise to
symptoms, provided the heart wall retains sufficient vigour
to give a distinctimpulse and apex push, maybe illustrated
by a case seen within the last fortnight. A gentleman of
seventy-two consulted me on account of irregular pulse and
action of the he<art, with breathlessness on slight exertion.
The pulse was extremely irregular and small, but rather
tense ; the rate about J 20 per minute. The action of the
heart was also hurried and irregular both in time and
force, many beats not reaching the wrist. The impulse,
however, could be felt and the apex boat could be
defined. It seemed to me that peripheral resistance
and imperfect action of the liver and bowels were con¬
tributing to the embarrassment of the heart, and a
mild pii. bydrarg. and colocynth pill was ordered.
The patient has taken this twice a week ever since,
has continued to follow his profession, and presented
himself at the age of seventy-five simply to show
how well he was. The pulse was still frequent and
irregular.
National Health Society.— At the annual meet¬
ing of the Society recently held, Mr. Frederick Treves being
in the chair, the report showed a most satisfactory increase
of work. During the past year lectures had been given to
educated audiences in drawing-rooms and elsewhere, on sub-
J 'ects relating to the care of the health, first aid to injured,
lome nursing, &c., as well as many hundreds of homely talks
and simple practical addresses to the poor throughout London
on the care and management of children, the value of fresh
air, food and cookery, &c..
ABSTRACT OF THE
' ftrfMKS,
ON
LEAD POISONING IN ITS ACUTE AND'
CHRONIC MANIEESTATIONS.
Delivered at the Royal College of Physicians, March, 1891^
By THOMAS OLIVER, M.A., M,D., F.E.C.P.,.
I’lIYSICIAN TO THE HOYAI. INl-TUMARY, NKWCA.STLK-UPON-TYNi!,
AND rHOSICSSOll OK I'lIYSIOI.OGY, UNlVlillSlTY OK DVliJIAM.
LECTURE III.
Dn OLiVERdealtsomewbatexhaustivelywiththesympto-
matology of lead poisoning; he said it now d evolved upon him
to draw attention to the channels by which lead in its varioue*
forms is introduced into the system. It gains entrance into-
the human body by the skin, by the lungs, or by the diges¬
tive organa. Tancquerel does not admit that any absorp¬
tion of lead occurs through the skin, He says that colic:
has never been known in the practice of the surgeona
of the Paris hospitals to follow the local application of
lead. The experience of the lecturer was the opposite of
this. He regarded lhe skin as a very suitable surface-
for the absorption of lead. In two of his patients, lead*
was found by Professor Bedson in the perspiration. If
lead is capable of being eliminated by the skin it must be-
capable of entering the system by the same whannel. As*
regards the entrance of lead by the respiratory organs there
is no doubt. People who have slept a few nights in newly
painted rooms have suffered from colic. It was thus he
sought to explain the colique sHche noticed on board French
men-of-war. Lead dust disseminated through the atmo¬
sphere whilst enteringby the digestive organs »iay also pass-
into the system by the respiratory mucous membrane. The
insoluble lead carbonate is carried into the’tracbea and
bronchi and probably into the air-cells of the lungs
but, in whatever part of the respiratory passages it is
deposited, it comes under the influence of heat and moisture;;
it is moistened by alkaline fluids rich in carbonic acid
coming from the lungs, and the lead carbonate is converted'
into a bicarbonate which is fairly soluble. A similar change-
in all probability occurs with the fumes of the molten
metal. It has been stated that absorption by respira¬
tion is more productive of deleterious consequences than
any other method of receiving the metal into the system.
On this point the lecturer offered no opinion. Sir
Joseph Fayrer, remarking on Dr. Oliver’s paper om
Lead Poisoning read two years ago at the Royal Medico-
Chirurgical Society, alluded to the case of a gentleman
who was anmmic, and who was supposed to be suflering;
from the effects of malarial fever or climatic disturbance.
Some time afterwards, when seen by Garrod, the symptoms-
were found bo be those of plumbism; and, as the patient
was an inveterate snufl'baker, the source of the poison was*
found to lie in the leaden envelope in which the snuff wae
encaseA When this was remedied the patient soon,
recovered The channel par excellence by which lead is
passed into the system is the digestive canal. _ Under any
circumstances the amount of lead absorbed is small, and
when absorbed it is freely eliminated by the kidneys...
Lead is generally present in the urine of leadworkers.
With the object of determining the chemical conditions
under which lead enters the system through the-
digestive canal Dr. Oliver had a series of experiments car¬
ried out for him by Mr. Beet, under the direction of
Professor Bedson, of the College of Science, Newcastle.
How, for example, do lead compounds behave in contact
with the various secretions which are poured out during
digestion ? In the experiments which follow lead carbonate-
was employed, and as nearly as possible in all of them the
same quantities of lead carbonate and animal juices were-
employed. It was found that human saliva bad a aligiit
solvent action upon white lead. Its inlluence is greater
when no other ingredient is present. During the digestion
of starch by saliva in the presence of lend carbonate, it was-
found that less of the metal was dissolved than where saliva
operated upon lead alone. Two double sets of experiments*
Coogle
The Lancet, DR. THOMAS OLIVER ON LEAD POISONING. [March 21,1891.
frere performed with gastric jaice, artificial and natural.
The experiments were performed in test tubes and in parch*
meat tubes, as recommended for digestion experiments by
Sheridan Lea of Cambridge. When lead carbonate was
digested with gastric iuice for three hours at blood heat
more or less of the lead was always dissolved.
Digestion Experiments : Carbonate of Lead.
iA) Gastric Juice—{a) Natural, obtained from Fistula in
Stomach of Dog, One part of filtered gastric secretion mixed
with two parts of water. Digestion in test tubes.
Amount of carbonate
of load.
Conditions of
digestion.
Grains of diluted
gastric juice.
Amount of lead
dissolved.
Grains per oz. of
gastric juice.
<«)
It'4 grains
1
154
0-00312
•(6)
16-4 „
164 '
0-00200
<c) 1
ie-4 „
154
0-00298
(ft.) Gastric Juice {Artificial: Merck’s).
Amount of carbonate
of lead.
Amount of artiflciol
juice.
Amount of lead
dissolved.
Grains per oz.
.(a)
15-4 grains
164 grains
0-001010
<P) To show that the Active Agent in effecting the Solution of
Lead Carbonate in GastricDigestionisHydrochloric Acid."^
Amount
Amount
Amount
of HOI
(in terms of
solution).
Lead, in grains, per oz.
Total
dissolved.
of lead
curb.
of
pepsine.
Dttrused.
Non-
ditfused.
Grains
per oz. of
solution.
16-4
15-4
|0'3 percent.
4-22
1-25
6-47
15-4
1-7
0-.3 „
3-28
2-05
5-33
16-4
3-85
0-3 „
8-32
2-10
6-48
16-4
Nil.
0-S „
3-50 j
2-31 j
6-87
15-4
15-4
Nil.
1
Nil. j
Nil. 1
1
Nil.
These experiments were repeated with varying amounts
•of pepsine, but with the same percentage of hydrochloric acid 5
•and the results indicate that the active agent throughout is
'the hydrochloric acid contained in the gastric juice, convert*
"ing the lead carbonate into lead chloride. They also illus¬
trate the easy diffusibility of lead chloride. When pepsine
is alone present with lead carbonate, none of the metal is
•dissolved. The active agent therefore is the acid, and the
Influence of pepsine is rather to diminish than increase the
•amount of lead dissolved. The next question was to deter¬
mine the influence of the digestion of proteids upon the
•amount of lead carbonate acted upon. The presence of
proteid in gastric digestion was found to reduce considerably
the amount of lead dissolved. It is in the form of lead
•chloride that lead chiefly passes into the system from the
stomach, and neither as albuminate or peptonate, both of
which are insoluble.
Dr. Oliver then alluded to the form in which lead passes
•into the system in drinking water contaminated with lead.
•He thought it was generally in the form of bicarbonate.
The solvent influence of bile and pancreatic juice was dealt |
with. Digested with bile, a relatively large quantity of lead
carbonate was dissolved. Bodson and Best found that three !
timesmore lead wasdissolvedwithbile than with gastric juice. '
A purely duodenal digestion was then dealt with, in which ^
gastric juice, pancreatic juice, and bile acted upon lead car¬
bonate, albumen, and fat. Dr. Oliver then alluded to the
'xesults obtained by experimental investigation. Animals
were fed upon carbonate of lead. Erom the first nutrition was
interfered with. The animals (rabbits and rats) rapidly ema-i
dated ; one rabbit became paralysed in all its limbs. N early
all of them lost theirappetiteatanearly stage, and theanimals
drank water greedily. TheygeuerallydiedinconviilsioDs Dr.
Oliver then gave the details of the post-mortem conditions
met with, and showed microscopical drawings of sections of
r The remiltH obtained aro not intended to bo compared with the
•experimenba made with artihcial and natural gastric juico.
the liver and kidneys in s^port of bis views aa to the infla*
ence of lead as a poison. There was, generally speaking, to
be observed in the liver of animals that had cTied of lead
poisoning and in lead workers an atrophy of the cells—
sometimes a fatty degeneration of the hepatic cells and an
increase of the connective tissue, the appearances being not
unlike those seen in cirrhosis of the liver. The kidneys
presented appearances that are most interesting. Dr. Oliver
thought that interstitial nephritis was too much regarded I
as the renal lesion met with in plumbism. Both in anin^ f
and in women he had found that the earliest pathological.
changes occurred in the renal cells. Theepitheliaof the con* i
voluted tubules exhibited cloudy swelling, fatty granular \
degeneration, slight shedding and disintegration of the
cells, and, as time went on, Bowman’s capsule became
thickened and laminated. The cells lining Bowman’s cap*
sule underwent proliferation, as also those within the cous
of the Malpighian glomeruli. In nearly every instance
the lecturer had observed a considerable accumulation of
leucocytes around the afferent arteriole of the glomerulus,
so that he could not but regard it as in a sense more or less
characteristic of saturnine poisoning. It is upon the liver
and kidneys that the brunt of the effects of le^ must
primarily fall. Lead is being constantly eliminated by
the urine of those who work with the metal. The
strain upon the kidney from the first is great, and the
cells in consequence soon degenerate. So long as the
kidneys are eliminating lead, the patient runs little risk
from lead poisoning. Potter, of tne College of Science,
Newcastle, has demonstrated the pernicious effects of lead
upon plants. He iniected 1 cc. of a 1 per cent, solution
of lead nitrate into datura stramonium, and he noticed
that the flowers on the branches thus injected fell off,
whereas the flowers on the other branches which had not
been touched continued to bloom and reached maturity.
The relationship- of lead to deranged metabolism was dealt
with, and particularly the association of lead and gout.
Sir Alfred Garrod’s observations in regard to the deficient
elimination of uric acid in plumbism bad been confirmed
by numerous observers, but particularly by Haig, and also
i by Ralfe, who bad shown that the alkalinity of the blood
I is diminished in lead poisoning. Dr. Oliver laid consider¬
able stress upon the' fact that gout in lead poisoning was
not a frequent symptom in the north of England ; but gout
itself, he remarked, was not so frequently metwitb there as
it is in London. He questioned whether, after all, it was a
true gout that occurred in lead poisoning. He rather sup¬
ported the view recently put forward by Sir Wm. Roberts—
viz., that tbo gouty diathesis and lead poisoning have a
tendency or vice in common — a tendency to uratosis or
precipitation of crystalline urates in the tissues or fluids
of the body. A saturnine uratosia, therefore, would be
simply saturnine poisoning reinforced by a previously
existing gouty tendency. The daily amount of urea passed
in plumbism was deficient, generally speaking; and Mr.
Wm. Turnbull, who bad carried out an extended series of
observations on Dr. Oliver’s patients in the Newcastle
Infirmary, had noticed how much iucreased in severity
headache became when urea was intermittently discharged
in abnormally small cmantities.
In the first lecture t)r. Oliver alluded to the relation of in¬
temperance and plumbism. Comhemale and Francois have
shown howvery susceptible dogs are to the influence of lead,
and howveryrapidlynervoussymptorasaredevelopedin them.
They become the subjects of hallucinations and illusions of
sight, and are extremely liable to become epileptiform or
choreiform. The interesting point brought out by these
observer.? is the influence shown by alcohol in precipitat¬
ing epileptiform seizures. In a guinea-pig Dr. Oliver
had noticed that the administration of small quantities
with the food, which contained lead, precipitated a
fatal termination. If there is one class, therefore, to
whom the results of clinical experience and expetimentaJ
research apply it is to lead workers. To them alcohol is a
poison : it must in many instances have determined epilepti¬
form seizures terminating fatally which complete abstinence
would either have postponed or altogether prevented.
The lecturer, in bringing his subject to a close, drew the
attention of his hearers to what he regarded as the explana¬
tion of acute lead encephalopathy. He admitted that lead
was found in the brain and in tlie various organs of the
body. The charts exhibited showed till this; but he did
not think that the epileptiform seizures and death which
took place in these cases were due to the presence of lead in
oogle
Die'
TMarch 21, 1891.
€46 Thb Lancet,) MK. J. GREIG SMITH ON INTESTINAL OBSTRUCTION.
irhe braio. Id ooe of his mostreceot cases, where a girl had
only worked for forty days in a lead factory, no lead was
found in the brain on the most careful chemical analysis.
Ic appeared to him that lead deranged the functions
of the liver and kidney; their cower as emunctories
failed; the secretion of urine gradually lessened—some*
times even it ceased altogether; and the eclampsia—
even whilst up to the commencement of the attack
the urine was found to be free of albumen—could only
be explained by the circulation of animal noisons that
bad been retained. Cerebral ansemia or hyarsemia was
invariably present after death, the surface of the brain
appeared compressed, and the arteries contracted. These
were circumstances which doubtless aided in bringing about
a fatal termination.
To the use of preventive measures be had little to add, nr
to the treatment of saturnine paralysis by electricity. He
bad noticed that opiates, with castor oil, iodide of potas¬
sium, and sulphate of magnesia, gave satisfactory results in
colic. Alum was not a successful remedy for colic in his cases.
Lithia had increased the amount of urinary secretion, but
bad had no effect upon paralytic conditions. In the cases
of acute lead encephalopathy nothing gave such satisfactory
results as the inhalation of nitrite of ara^l. Convulsions
were frequently warded off by it. Pilocarpine had been suc¬
cessful where convulsions with complete suppression of
urine had occurred.
INTESTINAL OBSTRUCTION CAUSED BY
TUMOUR; ILEOSTOMY; DISAI^PEAEANCE
OF TUMOUR; SUBSEQUENT ENTEROE-
lUPHY; RECOVERY.
By J. GREIG SMITH, M A., F.RS.E.,
iVRQEON TO TIIIC llUISTOf. IIOYAI, INh'SHMAUV : I.KCTUMEH ON SOlUJUttY,
UJUSTOL MICDJCAL SCJIOOI..
The following case is remarkable as an example of the
spontaneous disappearance of a solid abdominal tumour of
considerable size after abdominal section. A few such
cases have been recorded, but they have been received
either with open incredulity or great hesitation. It is
necessary, therefore, in this instance to supply a full
clinical account of the case which has been throughout
under the observation and treatment of my colleagues and
myself at the Bristol Royal Infirmary.
Lionel L-, aged twenty-five, shop assistant, was ad¬
mitted to the Bristol Royal Infirmary on June 1st, 1889,
complaining of piin in the abdomen, with frequent vomiting.
Seven weeks previously the patient first felt pain in the
hypogastric region ; this gradually increised till, a month
ago, he had to give up his work in London and go home to
Wells. The day after his return home the pains became
very severe, and in the evening he vomited a good deal of
brown fluid. Dr. Fairbanks of Wells saw and prescribed
for him, and he impiovei for a few hours. The pain and
vomiting returned the next afternoon, but under treatment
again abated, and he continued fairly well, though confined
to bed for a week. At the commencement of the following
week—that is, three weeks prior to admission—pain and
vomiting recurred, and continued daily at intervals, chiefly
in the afternoon and evening, up to the time of his admission.
The bowels had been acting regularly but not satisfactorily.
A fortnight previously he had on two occasions noticed that
some whitish glairy fluid passed before the motion. Fandly
history unimportant. The patient was a thin, pale man,
with an anxious, pinched countenance Pulse about 100 ;
temperature 99'’ F. Abdomen distended to the utmost,
measuring 31 in. ; muscles very tense, almost brawny.
Exaggerated resonance all over the abdomen, except over
an area measiiiing 2 in. in diameter a little above the left
anterior superior iliac spine. In this dull area a hard mass
could be distinctly felt, but, on account of the abdominal
distension and the muscular rigidity, could nob be fully
palpated. The tumour could just be felt by the finger in
the rectum.
Progress of the ctwe.—June 2nd: Temperature 98 5°.
Urine, sp. gr. 1032; neutral; no albumen; trace of sugar..
No action of bowels since admission. A seidlitz powder
was administered and an unsatisfactory action followed.
Sickness and pain at .8 p.m , for which morphia was-
administered. Another severe attack of pain at 8 p.m ,
with vomiting, for which morphia was given. The vomited
matter was light-brown in colour and odourless, Diet to
consist of peptonieed liquid foods.—3rd : Temperature 98‘8°.
Bowels acted once slightly after seidlitz powder. No sick¬
ness. Chloral draught at night.—4tb : Temperature 98 2°.
Urine, sp. gr. 1020; no albumen; trace of sugar. Pulse 76.
Seidlitz powder followed by severe pain. Cliloral draught
was immediately vomited. Severe pain and vomiting at-
7 P. M. The pain continuing, and getting worse, an injection)
hypodermically of I gr. of morphia was administered at
8 p,M. ; relief of pain, but no sleep —5th : The abdominal
distension is, if possible, more marked; violent peri¬
stalsis, with loud gurgling noises, the intestinal contrac¬
tions being visible through the parietes. As the patient-
was evidently losing ground, and would soon he in
a condition when operation would be impossible, it
was decided after consultation of the surgical staffi
to operate, with the view of relieving the obstruc¬
tion, which, although not absolute, was evidently becom¬
ing so.
At 1 P M. on June 5th, the patient being under the influ¬
ence of chloroform, the following operation was performed :•
An abdominal incision, beginning l^in. below umbilicus,
2 in. long, was made; the parietal peritoneum was thick¬
ened and vascular, chiefly towards the left side. Occupy¬
ing the left side of the abdomen and extending from ihe-
pelvis upwards towards the umbilicus was a hard, rounded
tumour as large as a cocoa-nut, to which seyeral coils of
small intestine were firmly adherent. The growth was lixedi
below, and could not be moved from its pofcition. The ab¬
dominal opening being dragged to the left the growth was
exposed to view, and was seen to be covered with thickened
peritoneum of a dusky hue, and with large vessels coursing,
over it. An aspirator needle inserted into its 8 ub 8 banc.e-
showed it to be solid ; the puncture bled rather freely. A
piece of distended ileum as close to the tumour as possible-
was pulled to the surface and fixed to the abdominal wound,
with a view to subsequent opening. Fixation was made by
two sutures passing through the parietes and outer coats of
the bowel at the top and the bottom of the wound ; and by
two Halsted sutures passed through the outer coats of the-
bowel, and fixed to strapping at the sides of the wound.
There was no suturing of parietal peritoneum to skin,
and no sutures were placed in the incision beyond the
two, which also passed through the outer coat of the.
bowel. Dressing of boracic lint and absorbent wool,—
June 6 bh: Temperature normal; pulse 102 . Vomited twice.
Hot water rectal injection at 2 30 a.m. to relieve thirst;:
restless night—7th: Temperature normal; pulse 70; no
vomiting; a good night— 8 th: Temperature 97 5°; pulse 69:
Passed a good night. Intestine opened and a No. 8 cellu ¬
loid catheter bent in hot water to a sigmoid curve was
passed into its lumen. An indiarubber tube was attached'
to the outer end of the catheter and conveyed the intestinaJ
contents into a bottle placed by his side. The intestine-
was firmly glue<l to the parietes, and there was no fouling
of the wound by escaping fluids during the opening of the
bowel. Bowels opened twice naturally after the intestine
was opened.—9t.h : Temperature 98°; passed a fair night.
Free escape of intestinal gases and fluids into the bottle._
lObh : Temperature subnormal: pulse 74. Wound dressed,,
quite healthy and free from inflammation. A large piece of
rubber tubing placed in the intestinal opening instead of
the small catheter. Free discharge of brown feecab
matter; abdomen nearly flat. Bowels acted naturally
twice. — 11 th: Temperature subnormal. Not much dis¬
charge through the tube till the evening, when a pint
of brown stercoraceous matter was rapidly ejected. This
matter on being tested showed the presenceof bile pigment.
Bowels acted sliglitly after a simple enema.—12th ; Tern.-
perature 97". Patient improving in every way. Distension
nearly gone. — 13th : Temperature 97-5°. Conlinuod im-
provement. Tube acting satisfactorily ; discharge distinctly
stercoraceous. — 14th to lObli: Steady progress. About a
pint of stercoraceous matter discharged daily through the
tube into the bottle. No action of the bowels for five day&-
till the 19tb, when there ivas a slight action.—2;trd : Free
action of the bowels after soap enema continued daily tilt
the 29bh, when he was discharged with a small fistulo,.
Dir Google
The Lancet,]
DR. DAVID DRUMMOND ON CROUPOUS PNEUMONIA.
[March 21.1891. 647
through which a little yellow foeoal matter escaped at in¬
tervals during the day. The bowels acted normally and
regularly, _ All abdominal distension was gone, and there
was no pain or nausea at any time. The tumour, now that
all distension was gone, caused a quite visible bulging in
the left lower abdomen, and was easily palpable. It
had apparently increased in size, certainly it had not
decreased.
Front time to time the patient came to the infirmary for
inspection, when we were surprised to find the growth
gradually diminish in size, till in August, 1890, no trace of
it could be felt. The patient himself had greatly improved
in health, being then quite robust, well nourished, and,
with the exception of the intestinal fistula, in perfect health.
Daring this month he stayed in the infirmary for a week,
when an attempt Nvas made to close the fistula by Mitchell
Ranks’method, which failed.—Dec. 2ad: He returned with
a view to having the fistula closed. Not more than a
drachm of fluid came through it daily; but this had ceased
to diminish in amount, and his work could not be satis¬
factorily performed while it existed. For a few days a diet
was administered which left little residue, the bowels were
kept acting freely, and enberorraphy was performed on the
8 bh. Chloroform auiesthesia ; thorough scrubbing with soft
soap all around fistula, and washing with 1-20 carbolic lotion.
A small sponge with string attached passed into the fistula
Md pulled outwards, so as to keep it plugged. Abdominal
incision an inch below fistula, and extending downwards for
two inches more. Numerous adhesions between bowel and
parietescar 6 fQlly 8 eparate(l,workingupward 8 towards fistula,
where adhesions were so dense that they bad to be divided
by cutting. Incision carried an inch above fistula ; bowel
freed, brought througli the wound, and closed above and
below the fistula by Makin’s clamps. Opening in intestine
closed by Lembert’s sutures arranged along axis of bowel.
Farts well irrigated with warm boracic lotion. Bowel
returned, and parietal wound closed with silkworm gut
sutures.—lOth : Progress entirely satisfactory, except that
he complained of pain in the penis in passing urine and for
a short time afterwards. Temperature 98°. Urine acid ;
sp. gr. 1033; no albumen ; urates. —13tih: Progress con¬
tinues satisfactory, with normal pulse and temperature.
Still pain on micturition. Urine smoky and acid; sp. gr.
1028 ; contains some albumen and blood. Wound dressed ;
stitches removed. Perfect union, except at seat of fistula,
where a minute orifice exists, which is granulating.—
16bh : All pain on’micturltion now gone. Urine norm^._
Jan. 3rd, 1891: Patient getting up and having ordinary
diet.—13bh : Patient disehargeci well; wound quite firm
and dry.
Bemarks .—What the nature of the tumour was I cannot
say. It was perfectly solid, globular in shape, nearly as
large as a child’s head at birth, and had naked eye cha¬
racters such as we associate w'ibh sarcoma. In the opinion
of my colleagues who saw it and myself, it was malignant,
and this opinion was conveyed bo the relatives of the patient.
The result proves that it was not malignant, however. It
was certainly not fixical, and there were no evidences that
it had an infiammabory origin, either simple or specific—
indeed, all the signs were against this. Believing that the
tumour was sarcomatous, and finding the bowels closely
adherent to it, and therefore probably infected with the
growth, I did not attempt removal. Ileostomy seemed to be
most likely to relieve the patient of the great distension from
which ho suffered and from the recurring storms of intestinal
contraction which caused so much pain. The operation per¬
formed in the manner described above was of the simplest
character, and added little risk to tho patient’s condition.
I am convinced that the elaborate methods of suturing
usually recommended in this operation are quite unneces¬
sary, even when the bowel is to be opened at once; and I
have with perfect success still further simplided the mode
of operation which I employed in this case eighteen months
ago. The subsequent operation of euterorraphy was de¬
layed until it seemed certain that the furtlier maintenance
of the fistula was unnecessary. Indeed, the fistula would
probably have closed spontaneously at tho end of three or
four months had it been permitted to do so ; at the end of a
year tho tissues around had become very hard and dense,
and after failure of a simple method had been proved,
entororraphy was performed. It may be added that at this
Operation, with the lingers inside the abdomen, there was
no trace of tumour to be felt.
Clifton
REMARKS UPON THE PROGNOSIS IN
CROUPOUS PNEUMONIA.
By DAVID DRUMMOND, M.A , M.D.,
PHYSICIAN TO THE ROYAL INFIRMARY, NEWCASTLK-ON-TYNE.
The opinions advanced in this short paper are the
outcome of a series of observations made in hospital and
private practice over a considerable number of yean.
The prognosis of pneumonia is a subject of the deepest
interest, and the fact that the disease is both short
iand acute—one in which the hopes and fears are crowded
nto a very few days, gives it a fascination that belongs to
but few other medical topics. I am not concerned now with
the statistical question of the mortality in pneumonia, bat
rather with the clinical grounds upon which a prognosis
may be attempted. This much 1 may say, that in my
opinion the rate of mortality in pneumonia is generally
placed too low. Some statistics give a loss of bat 8 per cent.,
others as low as SJ per cent., whilst Hughes Bennett re¬
corded 105 cases without a death. Of course it will be
recognised that the mortality varies very much in different
years and at different seasons, but my experience bas led
me to look upon pneumonia as one of the most fatal of aente
diseases. At the outset I wish it to be understood that my
remarks refer to what I may call fairly typical croupous
pneumonia. I would rather not involve the subject by in¬
cluding complicated cases—as, for example, pneumonia
arising in the course of Bright’s disease, or after traumatism
i or surgical operations, or that complicated by ulcerative
^ endocarditis. Nor do 1 propose to include that interesting
group of cases in which empyema follows an attack <u
I pneumonia.
, It will, I think, be conceded that we all undertake the
management of a case of uncomplicated pneumonia in the
' most hopeful spirit, and that our reply to questions raised
I by anxious friends, during the first tew days, as to the risk
is almost invariably reassuring, except in the case of the
\ drunken, the aged, and the otherwise enfeebled. Yet few
i there are who have not bad their minds rudely disabused, and
their predictions falsified, by the appallingly sudden, because
unexpected, termination to what promisea to be a favour¬
able case in a robust person. It would undoubtedly be a
great gain if we could recognise indications of approaching
danger some little time before the end is upon us, and thus
diminish the number of so-called sudden and unexpected
deaths in pneumonia, and so lessen the reproach that
prognosis is one of the weakest phases of our art.
Naturally, the first point to be considered is the general
condition of the patient—his ability to resist so serious an
illness. Here, of course, the gross abuse of alcoholic
stimulants plays a most important part, and for the special
reason that in the great majority of fatal cases the result is
due to cardiac failure, to which necessarily previous alcoholic
excesses largely contribute. Then weak and elderly people
are always insecure, though it must be admitted tlnat, like
the drunkard, the old and feeble will sometimes battle
successfully with the storm in a manner that surprises the
doctor and friends alike. These must therefore be prognosed
with the utmost care, for assuredly no general rule founded
on shattered constitution will apply. The same may be
said of those liable to bronchitis, particularly if the subjects
of emphysema to auy extent, for although tho risk is
decidedly increased, few would think of condemning the
patient on this ground alone. In this connexion it should
be borne in mind that most of the expectoration in pneu¬
monia is from the bronchial mucous membrane, which is
stimulated to secrete in nearly every case, more or less, but
particularly in cases of old-standing bronchorrhcca; and
that this excessive secretion bas a most damaging effect
upon the portions of lung that are carrying on respiration.
Further, old-standing cases of emphysema have associated
with a general change in the vessels of the lung a condition
of heart by no means favourable for withstanding au attack
of pueumonia.
In venturing to offer an opinion as to the result in a case
of pneumonia it is most important to detorinine the day of
the disease, as symptoms of little or no prognostic moinent
at one time prove to be of the greatest value at anotheT.
It is not always an easy matter to sny what day of_ disease
the case has reached, for although tiie initial rigor will prove
a useful guide in the majority of cases, it not unfre*
CIS ThkLamobt,
DR DAVID DRUMMOND ON CROUPOUS PNEUMONIA.
[March 21,1891.
^uentJy happens that there is no distinct rigor at all, and
again in some instances the rigor is postponed for a day
or two after the beginning of the illness. It must be
freely admitted that at times it is absolutely impos¬
sible to fix the commencement of the attack. So many
eases are preceded by catarrhal complaints, particularly
brondiitis, 'with a general feeling of illness, that we are
often informed that the patient has been ill for eight
Of ten days when the pneumonia has probably just developed.
We are, therefore, compelled, in the absence of a conclusive
statement, to determine the day of the disease as accurately
as fWBsible by a careful consideration of all the main
ieatares of the case, attaching due weight to the history of
a rigor. The occurrence of an antecedent or prodromal
illness does not appear to influence the prognosis to any
extent, except in so far as it serves to lower the patient’s
vigour. Nor is much importance to be attached to the
period of incidence of the consolidation, though it is not
without some significance. In the majority of cases the
ttird day is reached before consolidation can be clearly
demonstrated, whilst it is not unfrequently the fourth. In
Biy experience dulness on percussion, with tabular
bathing, is to be regarded as unfavourable when It occurs
very early in the course of the disease. And it will be
found occasionally that the cases in which the dulness is
decidedly postponed run an unsatisfactory course; these,
however, are not reliable prognostic factors.
I am not satisfied that the situation of the consolidation
is a guide of any practical value in prognosis. As is well
known, some attach great importance to the apex lesion,
in which case it is the custom to shake the nead with
ominous gravity. In my own practice, however, apex con¬
solidations have not proved especially fatal. 1 refer, of
course, to cases in which the upper portion of the lung is
affected in the first Instance, for I admit at once that exten¬
sion of the disease upwards in basic pneumonia is a very
serious event. We all watch the expectoration with interest,
and it will, I think, be conceded that lessons of importance
are often to be learnt from its nature. A total absence of
expectoration is both rare and significant. It is rare, for as
a rule in cases in which we are shown an empty spitcup or
stainless handkerchief the patient has swallowed the expec¬
toration. This he may do as the result of impaired vigour,
or it may arise from inattention due to mental hebetude;
in either case it is important. But some patients appear to
bare no free secretion to expectorate, and they seldom do
well. On the other hand, a large quantity of frothy bronchial
secretion is to be regarded with suspicion; for although
some have strength enough to carry them through, not¬
withstanding this and other obstacles to their recovery,
many are so hampered by the incessant coughing, sleepless-
nesB, cardiac diflicuity, and increased respiratory effort, all
of which are the usual accompaniments of copious secretion
in pneumonia, that the balance is turned against them.
The superabundant expectoration in these cases is shown
noisy rile and almost constant cough. The patient is
f >ale and haggard, with increasing cyanosis, and is worn out
or want of rest. My own observations have led me to favour
in the main the view that the prognosis is unfavourable in
eases in which the expectoration is of a dark prune-juice
character; hut I have so frequently seen this indication
falsihed that I am not disposed to rely upon it in the
absence of other grave signs. A thin watery fluid, especially
when ii is heavily charged with blood-colouring matter and
profuse, is a serious omen, indicating as it does an extensive
«5flema of the lung. The cases that run the most satis¬
factory course to convalescence are those with a moderate
amount of arrowroot-like expectoration, stained a rusty or
yellowish-fawn or orange-juice colour. It should always be
recollected that a falliug off in the expectoration when the
r&les are on the increase, especially towards the sixth day,
is mo?t unfavourable.
Although not of so much importance as some other indi¬
cations, the temperature is not to be despised in prognosing
a case of pneumonia. A continued high temperature from
the first (at or about ].04-°) is suspicious, and if it reach l.OS"
en two consecutive days without any material decline it is
highly dangerous. So also is a fall about the sixth or
seventh day, if associated with an increased respiratory rate.
Marked acceleration in the respiration is no doubt a sym¬
ptom of danger, and in the adult the outlook is 8eriou.s
when a rats above r>0 is maintained. But it is the pulse
that furnishes us with the most reliable information, and
were I restricted to one sign I would unhesitatingly select
She indication aff''»-dod by the pulse in venturing on a pro¬
gnosis. It yields no uncertain sound. Bv it we recognise
the heart failure that is so much to Be dreaded, and
is so often the cause of death from the sixth to the eighth
day. In considering the pulse it is most important
to keep ourselves informed as accurately as possible as
to the day of disease. Eor a good steady pulse of 100 or 110
may mean nothing on the third or fourth day, whereas on
the seventh or eighth it seldom fails to indicate recovery.
On the other band, a rising pulse at this time is a warning
not to be mistaken, while the same phenomenon on the thirl
or fourth day may have no real significance. Few who have
watched with anxiety the course of a severe attack of pneu¬
monia—say, in a valued friend, when perhaps frequent ob¬
servations are made—can have overlooked the rise in the
pulse-rate that almost invariably ushers in unfavourable
symptoms about the sixth, seventh, or eighth day. This
rise is essentially progressive, as shown by the addition of
a few beats in the minute as hour succeeds hour. A pulse
of 120 in the morning of the sixth day is 130 in the evening,
or perhaps more, rising to 140 during the succeeding twelve
hours, and as it rises becoming smaller, with the running
character, or perhaps intermitting, or it may he full ana
bounding, though compressible. "W^hateverparticularquality
indicative of failure it may possess one is almost constant—
viz , increasing rapidity. Now, as already remarked, this
sign to be of prognostic value should be a feature of that
articular period of the illness when the pneumonic consoli-
ation is at or is approaching its height—usually from the
sixth to the eighth day. And It should be observed that
the unfavourable indication lies in the fact that the rate is
constantlv rising. I have repeatedly, for example, known
of cases that made an excellent recovery with a rapid and
very empty pulse, maintained at about 130 to 135 on the
seventh day. The observation that the pulse is not rising
is particularly valuable in cases marked by extending con¬
solidation at the time of an expected crisis, for these not
unfrequently do well, which is seldom the case when the
pulse-rate rises rapidly pari passu with the pneumonic ex¬
tension. A very rapid pulse from the beginning is disquiet¬
ing, as the heart is apt to fail at the critical moment- The
urine should be examined often for albumen, and due
weight attached to its presence if in any quantity.
It is essential to watch closely the progress of the pul¬
monary lesion, as a constantly extending area of dulness
after the sixth day is decidedly ominous. It is no doubt
difficult in many cases bo determine whether or not the dis¬
ease is extending, partly owing to the medical attendant’s
dislike to making frequent examinations, and partly because
the consolidation often sets in rapidly, for a little harsh
breathing in the area subsequently affected may be the sole
premonitory sign even a few hours before the exudation
solidifies. Notwithstanding the difficulties, it will amply
repay the practitioner to give special attention to this
point. The later the period in the attack the extension
takes place, the greater the importance to be attached to it.
Thus, for example, an extension from the lower to the
upper lobe on the eighth day is a prognostic sign of much
greater moment than on the sixth. It is most important in
weighing the significance of extension as a prognostic
criterion to determine accurately the condition of the portion
of lung primarily affected. If we find that the tubular
breathing at the base has been replaced by a feeble respira¬
tory sound accompanied by medium crackling rhlos, and
that the dulness, though still pronounced, is diminishing—
in other words, that the process of repair has set in satisfac¬
torily in the part of the lung first consolidated (say, on the
seventh or eighth day), notwith.standing the extension of
the lesion,—the prognosis is by no means so bad as when
the consolidation is still active, as shown by a continuation
of the tubular breathing and pectoriloquy.
Much valuable aid is derived from the nervous symptoms
of pneiinionia. Delirium is unfavourable in the main, bub
particularly when it is constant throughout day and night
and occurs early in the course of the atciick—say, on the
second or third day. It is generally recognised with truth
that quiet delirium confined to the night time is a symptom
of little importance; bub, on the other hand, all practical
men dread the advent of wild, noisy delirium with constant
restlessness. Sleeplessness, a very common symptom, is
usually associated with delirium when it presages a fatal
termination ; bub in any case it decidedly adds to the
gravity of the illness, and has its weight in the prognostic
scales. The pupils are frequently altered in cases with an
unfavourable bias. They may be contracted—a condition
often associated witli cyanosis, a small rapid and empty
The Lancet,] DR. J. W. B. HODSDON ON BLOOD PRESSURE UPON THE LUNG. [March 21, 189L 649
pulse, and quiet delirium. Or they may be dilated and
sluggish, when the delirium is generally noisy and irrepres¬
sible, with much excitement. As the end approaches there
is not unfrequently rigidity of the limbs, whicn seldom lasts
long and may be associated with spasm of the -abdominal
muscles and involuntary fiscal discharge.
To recapitulate. A prognosis can only be attempted,
save on general grounds, when the lung mischief is
approaching its acme—after the fifth day. The principal
factors are the patient’s general condition, the pulse, and
the amount of albumen, as the indices of the circula¬
tion, and the limits of the lesion. But every symptom
is no doubt of value, and requires to be carefully con¬
sidered ; for it is unfortunately only too true that with the
utmost attention to every point we are often taken un¬
awares. Patients will succumb, passing into a state of
rapid collapse with little or no warning, even after they have
passed through what appears to he a satisfactory crisis.
It is noteworthy that in some cases the disease is protracted
much beyond the usual limits, the pulse and temperature
declining about the tenth day and the general symptoms
improving to a certain extent, but with a continuation of
the dulness on percussion and a degree of illness that still
excites uneasiness. In the great majority of instances
these cases turn out to be purulent effusion (empyema)
following on the attack of meuro-pneuinonia. This is a
point of the greatest practical importance, for if not reco¬
gnised and dealt with, the patient may sink exhausted in a
few weeks. I have expressed my opinion elsewhere that
the ordinary cases of empyema that come under treatment
as chronic or subacute chest affections are the outcome of
pleuro-pneumonia, and my later observations have con¬
vinced me of the truth of this statement, and if such be the
case, the prognosis of pneumonia embraces the prognosis of
empyema—an exceedingly difficult task.
Nowca«blo-on-Tyn 0 ._
AN EXPERIMENTAL INQUIRY INTO THE
INFLUENCE OF THE PULMONARY BLOOD
PRESSURE UPON THE COLLAPSED LUNG.
By JAS. W. B. HODSDON, M.D,, F.R.C.S. Ed ,
ASSISTANT aUIlGEON, EDINllUKGH UOYAl. INl■IUMARV; LECTURER ON
SURflERV, SCHOOL 01' MEDICINE, EDlNBUIUill.
(From the Physiological Laboratory, Surgeons' Hall,
Edinburgh.)
In a lecture which I published on the “Method of Cure in
Empyema”^ it was pointed out that a satisfactory termination
can only be brought about in that affection by the combined
action of several factors. It is not necessary to discuss
these factors in detail; all of them are well known and
more or less understood. Their mere mention will suffice.
Normal expiration aids to a certain extent; forced expira¬
tion and coughing are of special importance ; while possibly
a valvular action at the wound, and the absorption of a
certain quantity of air between the intervals of dressing, if
these intervals be suIBciently long, may also be of service.
As further adjuvants we have the formation of pleural ad¬
hesions, and in some cases the falling in of the chest wall,
and the return of the heart to its normal position, should
that organ have been displaced by the pleural effusion. All
these factors are of importance; but there is, I believe,
another which plays a considerable part in the expansion of
a lung when we make a thoracic fistula—namely, the action
of blood pressure in the pulmonary artery and its branches.
I have arrived at this conclusion as a result of an experi¬
mental inquiry made into the subject.
Method.—'th'd apparatus employed resembled in many
respects the oncometer of Roy (Fig. 1). It consisted of a
bottle filled with olive oil in which the lungs wore suspended
while blood was circulated through them. The increase in
the volume of the lungs was measured by the amount of oil
displacedduringthecxperiment. Tholungsof rabbitsrecently
killed were used, and both lungs were employed, because it
was found inconvenient to work with one lung only. The con¬
tents of the thorax were removed. The heart was then cut
across at about one-third from its base, and two caunulio were
introduced—one into the pulmonary artery, and the other
into the left auricle towards the pulmonary veins. A third
cannula was introduced into the trachea. Before com-
1 Edinburg;!! Modinal Journp.l, December, 1888.
mencing the experiment the volume of the lungs was first
ascertained by measuring the quantity of water they
displaced. The three cannulsewereconnected by indiambber
tubing to glass tubes fitted into the cork of a large bottle.
The tube (a) in connexion with the pnlmonaiy artery was
fitted into a piece of tubing leading to a vessel (A) contain¬
ing a mixture of equal parts of defibrinated blood and
normal saline solution, and also connected by means of a>
T-tube with a mercurial manometer (1)- The pressure ia
the pulmonary arteiy could be varied by lifting the vessel
containing the blood and salt solution to any desired height.*
The tube in connexion with the pulmonary vein (&) was
fitted with a piece of tubing, and the blood as it flowed out
of the lungs collected in a vessel. The third (c) tube was
tied in the trachea, and a fourth (d) served to conduct the
oil displaced during the experiment into a graduated
ceased dropping from the outflow tube the experiment was
begun by removing a clamp which had been placed on the
tubing in connexion with the pulmonary artery. The
experiments were commenced with the pressure at 12 mm.
of mercury. The actual blood pressure in the pulmonaiy
artery of the rabbit is, according to Knoll, 12*07 mm.
mercuiy.- When oil ceased to be displaced by a pressure
of 12mm., the vessel cuntaining the blood was gradually
raised until in some experiments it reached SOmni. After
the experiment was completed the volume of the lungs was
again taken with the trachea tied. The quantity of oil
displaced was added to the initial volume of the lung. This
should correspond to the volume of the lung after the ex¬
periment, and the difference between the iwo gives the
limit of experimental error. This on an average was
4*1 per cent., and it is mainly due to the occurrence of a
leak in Experiments 3 and
Experiment 1 .—Large rabbit. Lungs displaced 10 ca—
12.18: Experiment begun; pressure 12mra. Hg. —12.20;
Circulation established and oil displaced simultaneousiy.—
12.23: 3cc. oil displaced.—12.25: 3cc. ; pressure raiserl to
15mm.—12.28: 3cc. ; pressure raised to 30mtxi.—12.2S):
30 mm.; 4 cc. oil displaced ; volume of lungs after experi¬
ment 14-5 cc. Leak occurred ; experiment stopped.
The lungs were ecchymosed, and the circulation was nob
established until twoinimites after theexperiment was begun.
Ciuantityof oil displaced by normal pressure 3 cc., indicating
an increase in volume of lung of 33 cc. Total displacement
of oil with increased pressure 4cc. ; added to lOcc. initial
volume of lungs gives 14cc. Actual volume of lungs at end
of experiment 14*5 cc.; an error of 3*400.
Experiment 2 .—Large rabbit. Lungs displaced 14 co.—
6 I’.M.: Experiment begun; pressure 12 mm. Hg.—3.0.5:
Circulation established; pressure 12 mm. Hg.—0.1: 5 cc.
displaced; pressure 12mm. Hg.—6.3: 5 cc. displaced ; pres¬
sure 12 mm. Hg.“6.5: 5 cc. displaced; pressure 15 mui.
Hg.—6.10 : 0 cc. ; pressure 20 mm. Hg.—6,12 : 9cc. ; pres¬
sure 25mm. Hg.—6.14: 19 ce. ; pressure 25 mui. fl^—
0.15 ; 20 cc. ; experiment stopped ; pressure 25 mm. Hg.
Lungs displaced 35 cc.
Circulat-ion became established in half a minute, and
6 cc. of oil were displaced in one minute. No further dis¬
placement took place until the piossuie was increased.
Quantity of oil displaced by normal pressures cc., indi-
* Sitzpsb. <1. 'Wiener A. math. med. Wiasorsch., Bil. xrril., Abt. S, 188S.' •
Dir :v: ■ CjiOOgIC
660 Thb Lancet,] DR. RICHARD LEA MACDONNELL ON THORACIC ANEURYSM, [March 21,1891.
cabins an increase in volume of lung of 28 per cent. Total
dieplaoement of nil with increased pressure 20 cc.; added
to 14 cc. initial volume of lungs gives 34 cc. Actual volume
of lungs at end of experiment 35 cc.; an error of 2*8 cc.
Experiment S .—Large rabbit. Lungs displaced 18 cc.—
6.12: Experiment begun ; pressure 12 mm. Hg.—6.17:4cc.
displaced; pressure 12 mm. Hg.—6.18: 4 cc. displaced;
pressure 12mm. Hg.—6.20: 6cc. displaced; pressure 15 mm.
Hg.—6.25 : 9 cc. displayed ; pressure 20 mm. Hg.—6 30 :
12cc. displaced; experiment stopped; 20mm. Hg. A leak
occurred. Lungs displaced 32 cc.
Quantity of ou displaced by normal pressure 5cc.,indicat¬
ing an increase in tbe volume of lung of 36 cc. Total dis¬
placement of oil with increased pressure 12 cc.; added to
18 CO. initial volume of lungs gives 30 cc. Actual volume
of lung at end of experiment 32cc.; an error of 6 cc.
Experiment 4.— Large rabbit. Lungs displaced 17co. —
5.13: Experiment begun; pressure 12mm. Hg. — 5.15:
6 cc.; circulation established ; pressure 12 mm. Hg.— 5.15:
5 cc. displaced; pressure 12 mm. Hg —5.17: 6 cc. displaced;
pressure 13mm. Hg.—5.19: 6-75cc, displaced; pressure
13 mm. Hg.—5.20: 6'75 cc. displaced; pressure 17 mm.
Hg.—5.23: 7'5cc. displaced; pressure 17 mm. Hg.—5.25:
7'5 cc. displaced; pressure 20mm. Hg.—5.26: 10cc. dis-
placed; pressure 20 mm. Hg. —6.27: 10 cc. displaced;
pressure 30mm, Hg.—5.30: ll'Scc. displaced; pressure
30 mil). Hg. — 5.34: 15‘5 cc, displaced ; pressure lowered to
10 mm. Hg.—5.40: 16 cc. displaced ; experiment stopped.
Lungs displaced 34 cc. Quantity of oil displaced by normal
pressure 6 cc., indicating an increase in volume oif lung of
28 per cent. Total displacement of oil with increased
pressure 16 cc.; added to 17 cc. initial volume of lung gives
.33 cc. Actual volume of lung at end of experiment 34 cc.;
an error of 2'9cc.
Experiment 5 .—Large rabbit. Lungs displaced 13 cc.—
5.28 : Experiment becun ; pressure 12 mm. Hg.—5 28.6cc.;
circulation established, flow, in drops only, 12 mm. Hg.—
5.30: 3cc. displaced; 12 mm, Hg.—5.35 : 3'5 cc. displaced ;
12mm. Hg.—5 36: 5cc. displaced; 15 mm. Hg —.5.40: 6cc.
displaced ; 18 mm. Hg.—5.45: 7 cc, displaced ; 20 min. Hg.—
•5.48: lOcc. displaced; 25mm.Hg.—551: 12cc. displaced ;
30mm. Hg.—5 64: 15cc.displaced; 30mm. Hg.—5.58: 18cc
displaced; 36mm. Hg.—6.0: 22cc.; experiment stopped,
A leak occurred.
Lungs displaced 37 cc. Quantity of oil displaced by
normal pressure 5 cc., indicating an increase in volume of
lung of 26 per cent. Total displacement of oil with
increased pressure 22 cc. ; added to 13 cc. initial volume
of lungs gives 35 c.c. Actual volume of lung at end of
experiment 37cc.; an error of 5'4cc.
The following table gives a summary of the results of the
experiments:—
With Pressure of 12 mm. Hg. [Normal).
Expet-i-
inout.
Duration of j
experiment
in minute!).
Initial vol. of i
lung ill com. j
i
Oil displaoeil
in cum.
Per cent, in-
crea.'Ho in vol.
of lllllg.
1
7
10
:{
IIO'O
2
G
14
f)
35'7
8
18
r,
! 27'2
4
17
6
2
6
8
J3 !
1 38'1
-
32
72
1 24
' 10r)'2
Avorage
C'4 ininutOH.
14T)CC.
4-8 Cf.
33'2 por cent,
With Increased Prc'sure.
Experi¬
ment.
Duration
of expe¬
riment in
miniitex.
Maximum
pressure.
Total V'.l.
ct lungs.
Total oil
displaced.
Error
in cc.
1
4
30
14-G
0-4
0-G
2
10
2G
3G'0
20
1
3
10
20
32-0
12
2
4
23
30
34-0
10
1
5
24
36
37-0
22
2
-
71
140
1G2-&
74
(J'G
Average
142 minutes.
28 cc.
30-6
14-8
1-3
The question next arises, Was the increase in the volume
of tbe lung due to a true expansion of tbe alveoli or to the
development of an codema ? To determine this a series of
experiments were performed similar to the foregoing, but in
addition tbe glass tube in the trachea was connected by
means of indiaiubber tubing with a water manometer (2).
A T-tube was placed in tbe connecting tube so as to allow
of an adjustment to tbe level of the fluid in the limbs. Tbe
results of these experiments corroborated in every respect
those of the first series, and at tbe same time it was found
that when tbe blood circulated through the lungs at tbe
normal pressure (12 mm. Hg.) tbe water in the arm of the
manometer next to the trachea rose, on an average, three
centimetres, indicating clearly that an expansion of the air
vesicles was occurring.
We thus have under tbe influence of the normal pul¬
monary pressure an expansion of the lungs of the rabbit to
the extent of 33 per cent, of their volume in the collapsed
state. We can only have the full benefit of the action of
blood pressure when the thorax is opened, for until the
pleural effusion is evacuated, the lung is surrounded by a
medium which is incompressible, and which renders expan¬
sion impossible.
My thanks are due to my friend Dr. Nool Patou for the
use of his laboratoi-y, and for much valuable assistance
in carrying out this research.
Kclinburgh.
TIIIC
DIAGNOSTIC VALUE OF THE PHYSICAL
SIGN “TRACHEAL TUGGING” IN
THORACIC ANEURYSM.
By RICHARD LEA MACDONNELL, M.D.,
PROl'KSSOR OV Ct.lNICAI, MICDICINE, MACOII.T. UMVERSITY, MONTREAL,
IMIYSICIAN TO THE MONTRIUI. (iENERAL llOSPn'AL.
[Cojicludcd/rom page S:J0.)
3. Tracheal tugging may he present when many other
physical signs and symptoms are absent. — Examples to
prove the truth of this statement ate afforded by the
following cases:—
C.\SE 17 .—J. T-{Dr. Molson’s patienf).—This was a
Norwegian sailor, aged thirty-one, admitted on Dec. 24th,
1889, complaining of chills, pain in tbe left side of the chest,
and cough. lie was in good health and doing hard work
up to six months ago, when he began to cough, and this
was soon followed by persistent and severe pain in the left
side of the chest. No night sweats or other evidence of
phthisis. There was a history of chills and headache, and
on admission his temperature was 100'2'"; pulse 90 ; respira¬
tion 30. A frothy expectoration, at no time viscid or
rusty, accompanieu the cough ; a few streaks of blood were
seen in the sputum on one occasion. This feverish attack
lasted a few days, and he recovered from all the symptoms
but tlie cough and the pain in the side.^ Physical examina¬
tion of the chest was entirely negative, but tracheal tugging
was well marked. On Jan. 29th the left vocal cord was
found to be fixed in the middle line and devoid of move¬
ment. He remained in tlie Montreal General Hospital
until the spring without the development of any further
evidences of aneurysm. A few days ago (Deo. Ist, 1890)
Dr. Molson was hind enough to inform me that he had
found this man living in the city, and that well-marked
physical signs of transverse arch disease were present.
in Case 4, already cited, the only physical signs were
slight dulness and loss of vocal resonance at tbe left front,
together with weak breathing at the base of the left lung.
Tracheal tugging alfoided strong additional evidence of
pressure on the left bronchus.
4. Tracheal fugging does not occur in aneurysms which do
not involve the transverse arch .—In eight coses tracheal
tugging was never found. In but one was there evidence
of disease of the transverse arch. Two necropsies were
obtained, hut in neither was there pressure upon the left
bronchus.
Case 18 (Dr. MacDonnell's patient).—J. K-. This
case has already been reported in detail.^ There was no
tugging. Tbe aneurysm was on the transverse arch, but
1 Tnfluonm rvaa epidemic at the time.
* New York Medical Journal, Oct. 18th, 1800.
Digitized by
Google
The Lancet,]
DR. McCALL ANDERSON. ON KOCH’S TREATMENT.
[March 21, 1891. 651
situated quite beblud the point where the arch croasos the
bronchus. Dr. Johnston, who made the necropsy, was able
to demonstrate the left bronchus moving quite freely under
the aorta. The aneurysm involved the third part of the
arch, and caused death by rupturing into the posterior
mediastinum, causing pressure on the left vagus. Both
vocal cords were paralysed.^
Case 19 (Dr. Wilkins’ patient).— L -. No tracheal
tugging. Symptoms and physical signs point to aneurysm
low down the thoracic aorta. Vomiting, epigastric pain.
Visible pulsation in upper epigastrium.— Necropsy: Eusi-
form aneurysm of aorta above and below the diaphragm.
Hmmorrhage into both pleurro.
In the next series of four cases the patients were lost sight
of after leaving hospital. In these, however, the symptoms
and physical signs pointed to aneurysm elsewhere than the
transverse arch.
Case 20 (Dr. MacDonnell’s patient).—James S-, No
tracheal tugging. Distinct evidences of aneurysm of the
innominate. Dislocation of the sternal end of the clavicle
preceded by attacks of the moat sevei'e pain in the shoulder,
right side of the neck and head, and behind ear. No evi¬
dence of pressure on left bronchus, the breathing specially
noted as being quite free. Right pupil smaller than left.
Case 21 (Dr. MacDonnell’s case).—R-. No tracheal
tugging, innominate aneurysm. A prominent area to
right of mid-line under the sterno-clavicular articulation;
dull on percussion. Partial dislocation of the sternal end of
the clavicle. Wasting of the right arm. Began with pain
in the right arm, shoulder, neck, and behind right ear. No
difference in radial pulses. The superficial veins on the
right side of the chest become varicosed whenever coughing
occurs.
Case 22 (Dr. MacDonnell’s patient).—David J-. This
case has been already reported in detail,'* The aneurysm
was evidently in the descending aorta. There were never
any symptoms specially pointing to the transverse arch.
The airless condition of the left lung was probably due to
direct pressure of the third part of the aorta or of the
thoracic aorta, both of which were probably enormously
enlarged.
Case 23 (Dr. MacDonnell’s patient).—W. H. B-.
Aneurysm of the innominate. Pulsating prominence under
the inner end of the right clavicle. Pain in the right side of
the head, behind the ear, and down the arm. Complete
obliteration of the subclavian and carotid arteries of the
right side. No laryngeal paralysis.
The next two cases afford negative evidence. Case 24 is
probably an aneurysm of the first part of the arch. No
laryngeal examination was made. In Case 18 we have
laryngeal paralysis without tracheal tugging.
Case 24 (Dr. MacDonnell’s patient).—Joseph C-.
Probably an anenrvsin of the first part of the arch. Radials
unaffected. Visible pulsation ; dull area; systolic murmur
and thrill at the junction of the second right costal cartilage
with the sternum. The dull area extends an inch to the
left and two inches to the right of the mid-line of the chest.
No laryngeal symptoms, but brassy cough. This patient
had been sent from the country for consultation, and his
career after leaving the hospital is unknown to me.
Case 2.'> (Dr. MacDonnell’s patient).—John A-. A
case of aneurysm of the innominate or of the first part of
the aorta. The pain was in the right side of the chest.
Inability to lie upon the left side owing to cough and
dyspnoea. Enlargement of veins of upper chest and left
side of abdomen. Pupils unaffected. Local bulging at
second rib and right siae next the sternum. Paralysis of
left vocal cord. No evidence of interference with the left
bronchus.
5. Direct pressure on the trachea does not cause tracheal
tugging. —A clinical observation above mentioned affords
evidence upon this point. The patient was the subject of
Hodgkin’s disease. A large thoracic gland behind the
sternum pressed upon the trachea so as to cause stridor of
the breathing, and to give rise to danger from suffocation.
The projection of the tumour into the lumen of the trachea
could be distinctly seen with the laryngoscope.** If aneu¬
rysms pressing directly against the trachea could produce
Vido TransdctioHs of the PaUiological Sooioty of I.oinlou, vol. xxiii.,
p. 0 ( 1 , vol. xxiv., p. 4‘i. Cases aro horo roconled by BaimiloL' and liy
fieoi'fio John.'’ou wlioro prossuro on tho vaRus ami roeurront on ono sido
produced paralysis on botli sides.
4 American Journal of tho Medical Sciences, March, 1888; also June,
1800.
0 Montreal Medical Journal, Nov. 1890, p, 049.
tugging, then it would become an accompaniment of aneu¬
rysm of the innominate, which we can readily understand
when we consider the relations of that artery to the trachea.
In all cases I have seen in which aneurysm of the innominate
could fairly be diagnosed tugging was absent. Tagging
would therefore prove a valuable assistance in arriving at a
decision as to the locality of an aneurysm. Those affect¬
ing the inuorainate artery are sometimes treated sur¬
gically, but such measures as ligature would hardly
bo adopted in full knowledge of the fact that the arch
was involved. Here is a case in point, the particu¬
lars of which I take from one of the journals. A man
entered hospital with symptoms of innominate aneurysm.
Ligature of the carotid and subclavian was advised by tlie
members of the surgical staff. The patient declined to
submit to any operation. A few months later he died
suddenly. It was found after death that not only did the
aneurysm involve the innominate, but also the transverse
arch. Tracheal tugging might here have pointed out the
inutility of surgical interference.
These are the proofs which the clinical experience of our
hospital enables me to bring forwardin support of the state¬
ments I have made as to the great value of this physical
sign in the diagnosis of aneurysm. A few more points
require consideration. Tracheal tugging is a very early
sign in the history of the case. In all the cases in which it
was present it was detected on admission. I can find no
history of its gradually appearing after admission. And as
compared with laryngeal manifestations, it appears still
more valuable, since the tug can be detected by any¬
one accustomed to practise physical examinations; while
a reliable opinion as to paralysis of the cords can be
given by a specialist or a person thoroughly skilled in the
use of the laryngoscope. The two symptoms exist togetW
in most instances. One case cited affords an explanation of
how there may be laryngeal paralysis without tugging.
Here (Case 18) the tumour was situated beyond the leit
bronchus and pressed it from behind instead of from above,
thereby causing the weak breathing at the left base. The
vagus was not subjected to pressure until the sac burst into
the posterior mediastinum, pressed upon the nerve, and
caused the adductor spasm which nearly proved fatal. In
another case (25) there was absent tugging and laryngeal
paralysis ; but here, as there was no post-mortem examina¬
tion, it would be useless to guess at an explanation. In
another case there was tugging and no laryngeal paralysis.
Here, again, there was no necropsy.
In conclusion, I trust that those who read this imperfect
attempt at establishing the value of a new physical sign will
search for its presence amongst the cases within their ob¬
servation and bring forward their results, whether thej'
support the views 1 have expressed or not.
Montreal.
ON KOCH’S TREATMENT.!
By dr. McCALL ANDERSON,
I’KOl'ESSOH OV CLINICAL MEOICINE IN TUB UNIVERSITY OV GLASGOW.
The extravagant laudation with which the treatment of
tubercular diseases by means of Koch’s fluid was ushered in
has given place in many quarters to an equally absurd
depreciation of its merits. Considerable practical expe¬
rience of its results having been gained in the hospitals of
Glasgow, it is right that we should take stock of our know¬
ledge and compare notes with one another, in the hope that
we may arrive at just conclusions. But as our experience
is necessarily a short one, it follows that whatever
views may be expressed must be taken as provisional,
and liable to modification when a larger number of cases
has been dealt with, ami when they have been under
observation for a longer period of time. Before bringing
any cases under notice, it may be well to indicate, in
a general way, some of the conclusions which, I think,
may be derived from them. AVhen a patient is inocu¬
lated for tho first time with an appropriate dose of the
fluid, there result, in typical cases—(1) elevation of tem¬
perature, (2) a series of other constitutional symptoms,
and (3) local reaction. But, in a considerable number of
' lioiiig fin abstract of rowarks at tlio opciiiiiK of a iliscussion at
the (.ihvsgow Moilk'O-Chicuvgical Society, Maidi i:lth, isoi.
Google
652 The Lakcet,]
DR. J. DIXON MANN ON ADDISON’S DISEASE.
[March 21,1891.
instances, one or more of these sets of symptoms may be
absent, or onlv present in a minor degree. Thus it is not
uncommon to nnd decided reaction at the diseased part with
little, if anv, constitutional reaction and fever. Or there
maybe an aosence of fever, but other well-marked constitu¬
tional symptoms ; or local reaction may be alone observed.
But, as a rule, the more pronounced the fever and other
.general symptoms the more decided is the local reaction,
and vice versa.
With regard to the body heat, tlie first effect of the
inoculation in many cases is to produce a temporary
lowering of the temperature, but this soon gives place
to a rise, which reaches its maximum generally within
twelve hours—sometimes not until the following day; or
there may be a primary rise of temperature the day after
the inoculation, and a secondary one the following day,
which may even be greater than the first. First inoculations
are likely to lead to a slower rise and one of longer duration
than subsequent ones, in which the tendency is towards
a rapid rise and an equally rapid fail of temperature. It is
not, in my opinion, desirable to encourage an elevation
which exceeds 104° F., and in this connexion it must be
borne in mind that au inoculation frequently produces a
greater rise than the preceding one, although the dose is
not increased. The other constitutional symptoms observed
varied in different cases, but the most common were chilliness
or rigors, headache, pains in the back and throughout the
body, sickness, vomiting, and prostration. In two cases what
has been described as a measly, but which is really a roseolous,
rash made its appearance, but in no instance was a scar-
latiniform eruption induced. As regards the local reaction,
we can best ooservo it when the lesion is on the surface,
although the symptoms arising when internal organs—such
as the lungs—are affected, leave little room for doubt that
similar changes take place in them. The first result—in a
case of lupus, for example—is the occurrence of redness and
swelling which are not limited to the affected 2 >art, but spread
to the skin in the vicinity, which often assumes an erysipe-
latoid appearance, an'i a serous exudation take’s place from
the diseased surface which dries into crusts. Each succeed¬
ing inoculation is followed by less inflammation, and when
serum ceases to exude, the crusts become very dry, contract,
and finally fall off, leaving a dry, scaly, rosy surface,
the cicatrix being smooth, and less pronounced than after
any other local treatment with which I am acquainted.
When any isolated lupous nodules lie embedded in cicatricial
tissue, the inoculations may fail to destroy them, the poison
being apparently unable to get at them ; and what may be
done under these circumstances is to penetrate them with
a pointed stick of caustic, and then to inoculate again, when
a certain amount of reaction ensues, generally making short
work of them.
From what I have said it may be inferred that, when
the lupous nodules are confluent, the result is better
than when they are discrete, and the best cases of all
are those in wliich the whole patch is in a state of
ulceration; that is to say, the worse the case the more
brilliant is likely to be the result. .But, while tuberculin is
often in a position entirely to destroy the existing disease,
it seems to have little influence in the way of preventing
relapses, which must be warded off by endeavouring to im¬
prove the general health, especially by giving anti-strumous
remedies—above all, cod-liver oil—ust as we have been in the
habit of doing formerly in connexion with the use of local
applications. A patient who cannot take cpd-liver oil in full
doses—say, to the extent of 3 oz, daily—has a poor chance of
being permanently cured. As regards phthisis, the time is
much too short to entitle one to formulate very positive
conclusions, but I am quite sure that it is undesirable to
treat advanced cases in this way. Indeed, I have no doubt
that such treatment is dangerous; or, at any rate, it is
very apt to leave the patient in a worse plight than before.
But there is equally little doubt that if we get a case at
the very commencement, before excavation, with a veiy
limited amount of lung tissue involved and the general
health not being undermined, the best results may
often be obtained. In considering the propriety of carry¬
ing out this treatment in a given case of phthisis
it must never be forgotten that the extent of the
disease is almost invariably considerably greater than
the physical signs would seem to imply. Indeed, in
most of the patients treated, moist rflles, with or without
evidences of consolidation, have made their appearance at
parts where, previous to the commencement of the inocula¬
tions, there were no traces of pulmonary mischief. These
new physical signs cannot certainly always be attributed
to the development of new centres of disease, the result
of setting free tubercle bacilli to work mischief else¬
where, because they sometimes appear immediately after
the first inoculation.
With regard to diagnosis, there can be no doubt that
Koch’s discovery is a most valuable one, because, although
it cannot be asserted that the fluid exclusively attacks tuber¬
culous tissue, it is certain to inflame parts which are
tuberculous when the appropriate dose is reached, and
it undoubtedly often ferrets out quite unsuspected foci of
disease.
As to the dose, I think it may be laid down as a good
rule that not more than one or two cubic millimetres of the
I in 100 dilution should be given as a first injection, espe¬
cially if internal organs are involved, or if the patient is
weakly; but the appiopriate dose varies in different persons,
just as we find in connexion with the administration of
medicinal substances. It is much better to start with a
dose which may fail to yield any result than with a large
one which produces violent local and constitutional reaction,
it being always safer to feel one’s way at the outset. We are
all cognisant of the fact that the system soon becomes
habituated to the use of certain drugs, so that after a while
doses may be taken with impunity which might have
poisoned the patient at the outset. And there can be no
doubt, with reference to tuberculin, that a remarkable
tolerance is speedily established ; so much so, that we can
often ultimately give an inoculation without any result one
hundred times stronger than that which at first produced
well-marked local and general reaction.
When I commenced to inoculate patients I made use of
the syringes recommended by Koch, and with which we
are all familiar; but I found that they were somewhat
ti'oublesome and uncertain in their manipulation, ^specially
when not manufactured with the greatest care. So that
most of my inoculations have been made with an ordinary
subcutaneous syringe, graduated for the purpose, which has
none of the drawbacks of the other, and from the use of
which I have experienced no inconvenience, while inflam¬
mation at the seat of puncture has never occurred.
In conclusion, I may be permitted to say this much, at
least, with regard to tuberculin, that, whatever the ulti¬
mate verdict of the profession may be with regard to the
scope of its utility in diagnosis and treatment, it is
possessed of most remarkable and unique properties; and
no one who has had much practical experience of it, can
grudge the encomiums and the honours which have been
showered upon its discoverer.
[Dr. Anderson concluded by showing a series of cases,
upon the treatment of which the above remarks were based.]
ON ADDISON’S DISEASE.
By J. DIXON MANN, M.D., F.RC.P.,
l-liySICIAN TO TIIF. SAI,l-'OHn UOVAI, liOSl’lTAI., I-ECTUIIKH ON VORE.NSIC
MEDICINE AND I'llACTIOAC TOXICOI.OUV IN OWENS COU.EUE.
The following cases came under my care in the Salfdrd
Royal Hospital:—
Case 1. —William A-, aged nineteen, was admitted on
July 2.3rd, 1889. Family history good, no phthisis. The
patient had sullered from no previous illness. In December,
1888, he noticed his face becoming darker in colour; the
hands next became discoloured, and subsequently the dark
hue spread over the whole body. The abdomen has been
darker than the rest of the body as long as the patient can
remember. About a month ago he noticed that he was
getting thinner, and for the last three weeks he has vomited
every day. He has had pain in the abdomen from time to
time —Present condition: The patient looks fairly healthy,
weighs 1012 lb. The colour of the whole skin is a dark
yellowish-brown, like that of a mulatto ; the scrotum and
penis are of a peculiarly dark-slate or indigo tint. Tlie
nipples also are darker than the rest of the skin. With
these exceptions the colour is fairly uniform over all the
body. The inner margins of the lips are bluish, and
there are small scattered patches of pigmentation on the
palate. On each side tlie buccal mucous membrane
shows a horizontal band of pigmentation corresponding
Die-
oog.
Thb Lancet,]
DR. J, DIXON MANN ON ADDISON’S DISEASE.
[March 21, 1891. 653
to the meeting line of the teeth. The cervical and
submental glands are slightly enlarged. The pupils are
rather large. The superficial reflexes are normal; the knee-
jerk is absent. The pulse (76) is small. The temperature is
normal. There are no physical signs of phthisis. Whilst
in the hospital the patient had repeated attacks of vomiting,
and occasionally of diarrhcca, the bowels being constipated
in the intervals. Enr a time he felt much better, and was
free from sickness. He gradually lost weight, however (being
now lb.), and looked emaciated. On several occasions he
had severe pain in the abdomen. The urine was of normal
appearance and amount, sp. gr. 1012, acid, no albumen, no
excess of chromogens; urea averaged 280 grains in the
twenty-four hours. The vomiting returned, and occurred
at frequent intervals, the patient becoming much weaker.
Death from asthenia took place on Oct. 16bh, 1889. Two
days before death the blood was examined ; the proportion
of white corpuscles to red was not increased ; the red were
numerically decreased 72 per cent., otherwise there was
no abnormality. The patient was moderately anmmic
towards the last, bub not to any great extent. — Necropsy:
The external appearances were as already described. In¬
ternal appearances: Heart normal. The pleura showed
signs of old adhesions. The lungs were free from tuber¬
cular deposit. The anterior mediastinum contained several
small glands, undergoing calcification, situated at the bifur¬
cation of the trachea. The liver and kidneys were normal.
The glands of the intestines were prominent. There were
no pigmentary patches in the alimentary tract. The right
adrenal was nearly double the normal si/e ; it was irregular
in shape, and the surface was nodulated. The left adrenal
was as lar"e as a kidney bean; it was caseous, and con¬
tained pus in a broken-down cavity at the lower part. The
solar plexus and semilunar ganglia sliowed no macroscopic
changes. In the upper part of the abdomen the retro¬
peritoneal glands showed signs of incipient caseation. The
spleen was friable, but otherwise healthy. The membranes
of the brain were hyperiomic; they showed no pigmented
areas. The brain substance was normal. The adrenals and
semilunar ganglia were removed for microscopic examina¬
tion.
Case 2.—Annie B-, aged eighteen, unmarried, a
tailoress, was admitted on Sept. 2l3t, 1889, Family history:
Father healthy; motlier delicate ; two sisters both weakly;
one has lupus of the face, and the other has had convulsions
(epilepsy ?); only one brother, an infant, who is healthy.
Fersonal history: Patient has never been strong; she had
bronchitis and convulsions when a child. Has been subject
to attacks of vomiting as long as she can remember, for
which she has stayed at home from time to time for a week
or more at once. In June last she had a sick headache of
unusual violence, after which she felt excessively prostrate,
and for a time was unable to work. At this date a change
in her complexion was first noticed. She continued to work
until the middle of August, when she went away for a
change of air; on her return, being still poorly, she was
admitted into hospital. Present condition: The patient is a
.small-made girl of childi.sh appearance, fairly well nourished,
but says she bus gone thinner lately. She weighs 871b. The
skin is uniformly dark without patches, except round the
eyes and nipples, on the temples, and over several of the
vertebral spines, where it is darker; in the last-named position
evidently from friction against the clothing. There is no
pigmentation of the tongue or of the lips; but there is a
line corresponding to the meeting of the teeth along both
sides of the buccal mucous membrane, as in the last case.
The appetite is good, but the patient feels weak. Pulse
72, very small; temperature normal. She has no pain. The
bowels are regular. She has not menstruated since June
last. The lungs and heart are normal. Superficial re¬
flexes normal; knee-jerk absent. For a time the patient
improved. The vomiting ceased for five weeks, and
she gained in weight, being now 89.1 lb. The urine was
of medium colour, sp. gr. 1018, acid, no albumen, no
excess of chromogens. Average amount forty-eight ounces,
and average excretion of urea 21:8 grains, in the twenty-
four hours. On Nov. 4th she complained of severe frontal
headache, and felt very sickly, the pulse being exces¬
sively small and feeble. The patient was now decidedly
anmmic. The anoemia was not only perceptible in the
palpebral conjunctivic, but at the folds of the skin at
the base of the fingers when interposed between a bright
light and the eye of the observer. From this time she
rapidly got worse; she vomited at frequent intervals, and
was very cold to the touch. She also became much darker
in colour, and complained of extreme exhaustion. The
respiration was slow, and the radial pulse was imper¬
ceptible. Death from asthenia took place on Nov. 2l8t,
1889. For a few days before death the breath had a
strong “ethereal” odour. Two days before death an ab¬
normal amount of indican appeared in the urine; 880 c.e.
were treated after Jafie’s method, and yielded 0'0047 grm.
of indigo. Continuous observations enable me to state
that the amountof indican in the urine before this date was
never above normal. On Oct. 15th the blood was examined
with the LEcmocybometer. The red discs were in normal
percentage; the white corpuscles were relatively increased,
being 1 to 250. (I am indebted in both oases to Mr. Percy
Stocks, late house surgeon to the hospital, for the examina¬
tion of the blood with the bfcmacytometer.)— Necropsy: The
external appearances corresponded with those observed during
life. Internal appearances: The heart showed no patho¬
logical changes. In the apex of the right lung were two
small caseous nodules, otherwise the lungs were healthy.
The intestines were normal, with the exception of some
small brownish patches of pigmentation on the peritoneal
coat. The liver was small and pale, otherwise healthy.
The spleen was small and firm. The kidneys were pale.
The adrenals were much enlarged, especially the left, which
showed signs of breaking down. No niacroscopical changes
were observed in the semilunar ganglia and solar plexus.
The uterus was of the infantile type. On the upper part of
the posterior wall of the vagina, behind the cervix uteri,
were small patches of pigmented mucous membrane. The
external genitals were like those of a young child. The
ovaries were small and showed one or two cicatrices, but
not of recent formation. The adrenals and the semilunar
ganglia with some of the adjacent nerves were removed for
microscopical examination.
I am indebted to the kindness of my friend, Dr. Arthur
Robinson, of Owens College, for his valuable assistance in
preparing and examining sections from the semilunar
ganglia from the above cases, together with the ganglia
from a case of about the same age, not of Addison’s disease,
for control observations. The exhaustive investigations
made by Dr. Robinson establish beyond question the accu¬
racy of the conclusion he has arrived at. He was also good
enough to prepare a number of sections of skin and mucous,
membrane from the same cases.
Dr. Itobinson's report .—At Dr. Dixon Mann’s reqirest I;
prepared and examined three pairs of semilunar ganglia. ,
The first pair was from a man who had died from Addison’s
disease. These ganglia had been placed in raethylatedi
spirit. I transferred them to Muller’s fluid and afterwards,
back again to spirit, but evidently the first spirit in which
they were immersed had produced such an effect that the
sections made from them did not stain properly when sub¬
jected to Weigeft’s htomatoxylin method. The second pair
of ganglia was from a girl who died from Addison’s disease,
and the third pair from a man affected with phthisis. Both
the latter pairs of ganglia were placed first in Miillei’s fluid,
and afterwards in methylated spirit. When the hardening,
process had beerf completed in the spirit all tbe ganglia were,
transferred first to absolute alcohol, thence to turpentine,
and finally to paraffin melted at The embedded
ganglia were cut into sections by means of the rocking
microtome, and the paraffin was removed from the sections
by passing them through warm turpentine into absolute
aicoliol, thence into methylated spirit, and afterwards into
70 per cent, spirit. The sections were transferred from the
70 per cent, spirit to tbe various staining solutions that
were used, sections from each case being passed through
exactly the same solutions. The sections were stained in
six different ways: (1) By Weigert’s method ; (2) in aniline
blue black; (3) in a 4 per cent, solution of methyl blue,
after which they were washed in a saturated solution of
picrate of ammonia; (4) in borax carmine; (5) in borax
carmine, and after dehydration cleared in oil of cloves con;
taining picric acid in solution; (6) in hiumatoxylin. When
the staining was completed it was found that all tbe ganglia
presented exactly the same microscopical appeamnees,
There was no excess of fibrous tissue either in their cap¬
sules or in their interiors. There was no excessive pigmen¬
tation of the ganglion cells. The ganglion cells were not
shrunken. The nuclei and the processes of the ganglion
cells were distinct. The nerve fibres passing through the
ganglia showed no traces of degeneration. The capsules of
the ganglion cells presented all their usual features. In
„..ogie
(54 The Lancet,]
DK. J. DIXON MANN ON ADDISON’S DISEASE.
[Maech 21, 1891.
short, so far as the implication of the semilunar ganglia in
the production of Addison’s disease is concerned these cases
presented negative evidence only, nothing abnormal was
sound in the ganglia. The adrenals from the two cases of
Addison’s disease were examined with the following result:
The normal tissue was almost entirely replaced by tuber¬
cular deposit partially broken down. Tubercle bacilli were
sought for, but none were found.
It will be seen from the description given that these two
eases are typical examples of Addisoirs disease, uncompli¬
cated by other derangement. They may, therefore, serve
as a basis for the discussion of the morbid physiology of the
disease. Whilst desirous of avoiding as far as possible
ground already covered, it is necessary to formulate con¬
cisely the views held with regard to the pathology of the
disease. They are three. First, that the symptoms are
immediately due to disease of the adrenals. Second, that
they are caused by certain changes in the semilunar ganglia
or in the abdominal sympathetic nerves, which may be
primary or may be caused by mechanical pressure from a
neighbouring morbid growth, but are more frequently
referred to extension of slow inflammatory processes from
the adjacent adrenals. In the latter case the adrenals are
still to be regarded as the initial seat of the disease. Third,
that tliey arise from the presence of a toxic agent or agents
in the blood. According to this view, also, disease of the
adrenals would probably be the first link in the morbid
chain. Some pathologists consider that the specific cha-
Tacter of the morbid processes which take place in the
adrenals is the true determinative of the symptoms. Wilks^
holds that infiltration of the adrenals vdth an albuminous
material, which subsequently may undergo caseation or
cretification, is the only pathological change in them which
can occasion Addison’s disease. It is supposed by some
that slow inflammatory processes thus set up spread to the
neighbouring semilunar ganglia. Greenhow- supports this
view, by which he accounts for the absence, for the most pail;,
of the symptoms of Addison’s disease when the adrenals are
the seat of haemorrhage or of malignant deposit, these
processes being non inflammatory.
In the two cases narrated, the changes in the adrenals
were of tbekindusually met with after death from Addison’s
disease. The semilunar ganglia, however, presented no
abnormality. Microscopic sections from the ganglia of these
two cases could not be distinguished by expert observers
from sections of normal ganglia. Many pathologists at the
present time refer the symptoms of Addison’s disease
exclusively to morbid changes in the semilunar ganglia.
Xahlden,^ after critically reviewing the reported cases,
and substantiating his deductions by results ootained from
two cases of his own, has no hesitation in localising the
disease in the semilunar ganglia. He very properly dedines
to accept any hut skilled examination of the ganglia as
evidence, and further suggests, to make the evidence valid,
that it should be founded on direct comparison of the
ganglia under examination with normal ganglia from
individuals of like age. In my two cases these precautions
were fully carried out. I emphasise this as it is obvious
that some alteration of nerve function' offers the only
reasonable explanation of the symptoms under discussion,
and the semilunar ganglia, from their anatomical relations,
are naturally the organs on which suspicion rests. In many
instances this suspicion has been verified : the ganglia have
been found both macroscopipally and microscopically
changed. Disease of the semilunar ganglia would account
fairly well for most, if not all, of the symptoms, although
the exact mode in which interruption of their functions
could occasion some of the symptoms is not quite clear.
Still the assumption of a causal relation is justifiable, and
if the nerve cells of the semilunar ganglia were atrophied
m every case of Addison’s disease, its pathology would
be simplified. When we find, however, in a number
®f cases of Addison’s disease, in which all the cardinal
symptoms wore present, that the semilunar ganglia are
intact, it is obvious that structural changes in these organs
do not constitute the essential factor of the disease. It is
not to be forgotten, moreover, that more or less pigmentation,
atrophy, and other morbid appearances in the semilunar
ganglia are seen under many pathogical conditions apart
from Addison’s disease. Hale White’s^ observations on this
subject are very remarkable. Of thirty-three semilunar
1 Guy's Hospital Reports, 1802. * On Addison's Disease.
Virchow’s Arcliiv, vol. cxiv., 1888.
4 Journal of Physiology, 1M9.
ganglia, taken indiscriminately from persons dying from
various diseases, three were from children and were quite
normal. Of the remaining thirty, the nerve cells were
normal in six; all the rest showed more or less degeneration
of the cells, which in many cases were reduced to minute
masses of non-nucleated granular pigment, Ijing free in the
middle of the capsules. A few of the sections were crowded
with leucocytes, for the presence of which no cause could be
ascertained ; the appearance of the section bad no relation
to the cause of death. The inference drawn is that tlie
semilunar ganglia in the lower animals and in the young
human subject are functionally active. In the human adult
the nerve cells degenerate and are functionally inactive,
but the nerve fibres always retain their structure and
function. As the evidence afforded by the semilunar
ganglia in my cases was negative, it becomes necessary to
discuss the claims of the adrenals to the position of causal
agents. These bodies are pathologically changed in such
an overwhelming majority of cases of Addison’s disease
that it is impossible to regard the conjunction as a mere
coincidence. There is evidently a close relation ; whether
one of cause and effect is an open question. Many modern
pathologists have ceased to regard disease of the adrenals
as a possible immediate cause ot the symptoms of Addison’s
disease. The very ambiguity of the physiological func¬
tions, and even of the anatomical structure of the ad¬
renals, makes it so much the easier to eliminate them
from consideration. They are regarded as ductless glands,
as organs belonging to the nervous system, as partaking
of both characters—the medullary substance being a net¬
work of nerves and the cortex a vascular and glandular
structure,—and, finally, as having solely embryonic func¬
tions. The most recent investigations tend to show that
the adrenals are functionally active in adult life, at least in
some of the lower animals. Tizzoni” observed a tendency
to redevelopment in injured adrenals, and .even after they
had been removed. In some more recent experiments'* on
rabbits he removed one adrenal only in each animal, some
of the animals living upwards of a year. After death he
found infiltration of the pia with small round cells, especially
in the neighbourhood of the vessels. There was also a
fibrinous exudation in the subarachnoid space, and im¬
portant changes in the floor of the fourth ventricle, the
grey substance of which was in some places replaced by
these small cells. He further found degeneration in the
peripheral nerves. Tizzoni attributes these changes to
alteration in the bloodvessels. Stilling^ divides the adrenals
into glomerular and fascicular zones. In animals the
glomerular zone contains cells charged with pigment,
which are very like the pigment cells of the choroid.
In man the pigment is found between the cortical and
medullary substances. The pigment cells are star-like
in appearance, and they lie outside the walls of the
capillaries. The pigment is limited to these cells ;
the gland cells themselves contain no pigment. The
deepest pigmentation of the adrenals occurs in those
animals which are piebald ; in such animals there are often
spots of pigment in the throat, but all the internal organs,
except the adrenals, are free from pigmentation. Another
series of experiments made by Stilling® tend to disprove the
view that the adrenals are only active during embryonic
life. In a number of young rabbits one adrenal respectively
was removed, and the animals were allowed to live for
several months after the operation. On examination after
death, the remaining adrenal was found considerably hyper¬
trophied, due, as Stilling considers, to compensatory hyper¬
trophy, one gland having to perform the duties of two.
When one of the adrenals was incompletely destroyed, the
fragment that remained had a tendency to develop, some¬
times to the size of the normal adrenal. After removal of an
adrenal, accessory adrenals frequently develop on the cava
or in the neighbourhood of the kidneys.
Chemical examination of the adrenals reveals in them the
presence of certain colouring matters, the nature of which
18 not yet determined. Vulpian,® Arnold,’® and others ob¬
served peculiar colour reactions with solutions obtained
from the adrenals, indicating the presence of a substance,
or substances, not found in the other tissues of the body.
Mac Munn” detected ha;mo-chromogen, which be regards as
an effete blood product, the inference being that the adrenals
6 Gazz. depli Ospitali, 1884. “ Arch, per le Seienza Med., vol. x.
7 Virchow’s Arcliiv, Bd. oix. ** Ibid., Bd. cxviii.
0 Comptes Rendus, 1800. J® Virchow’s Archiv, Bd. xxxv.
n British Medical Journal, 1883.
The Lancet,]
DR. GEORGE F. HELM ON ANTERIOR SYNECHLE.
[March 21^ 1891.
are employed in its elimination. According to this view, if
the adrenals are diseased there oughttobeevidence of incom-
4 >letely metabolised pigment in the excretions. In two cases
of Addison’s disease Mac Munn found in the urine a deriva¬
tive of hasmatin, which he names “urohsematoporphyrin.”
This substance may be found in the urine under two con-
^Utions: (1) when excess of effete htemoglobin or of histo-
hrematin is present in the circulation, the blood-metabolising
glands being healthy but incapable of dealing with the excess
of pigment; (2) when the pigment is not in excess, but the
blood-metabolising glands are diseased, as is assumed to
be the case in Addison’s disease In this case other effete
or abnormal products are assumed to be present in the
blood, and to exercise a toxic effect on the organism, and so
produce the asthenia and other symptoms. Krukenberg,’®
^imongst other products, extracted from the adrenals a
■chromogen which possesses many properties in common
with pyrocateclnn. The coloured derivatives of this
ohromogen, with one exception, are of a very fugitive
character, much more so than the pigment deposited in the
skin in Addison’s disease. Krukenberg considers that the
identity between the above-mentioned chromogen and
pyrocatecbin completely excludes the possibility of any
•chemical relation existing between the pigment obtained
ifrom the adrenals'and that deposited in the rete cells in
Addison’s disease.
(To be continued.)
CASES ILLUSTRATING THE UTILITY OF
LANG’S KNIVES IN EFFECTING DIVISION
OF ANTERIOR SYNECHIA.
Bv GEORGE F. HELM, M.D., F.R.C.S.,
■OPimiALWIC SURGEON TO THE ROVAL CORNWALL INITRMARY.
A FEW months ago Mr. Lang of Moorfields introduced to
the profession, through the Ophthalmic Hospital Reports,
some knives which he had found useful in his practice.
Their special design was to assist In dividing the adhesions
which produce an anterior synechia in the eye. They do
this by allowing the division to be made whilst the aqueous
is still retained in the anterior chamber. One knife has a
ssharp point, with which an incision is made in the cornea;
n,nd on its being withdrawn a second knife with a blunt
point is inserted through the hole made by the first sharp-
pointed knife. The two knives being of exactly the same
size, one fits well into the opening which has been made by
its predecessor. This admits of almost any adhesion being
■divided by the blunt-pointed knife, the aqueous being re¬
tained by it. I have recently had under my care in the
Royal Cornwall Infirmary two cases which well illustrate
'the usefulness of these knives.
Case 1.—A. B-, a girl aged fourteen. About a year
ago she ran the prong of a fork into her right eye. The
fork wounded the lens and cataract ensued. When she
came under my care the larger portion of the cataract had
been absorbed. In the end, however, a large piece of opaque
capsule and some ddbris of the lens remained behind. This
completely blocked up the pupil, and was, moreover,
adherent (1) to the back of the cornea, just where the
'wound was originally made by the entering prong of the
ifork; (2) it was also adherent to the iris at its upper part
•and at the sides, the lower portion of the iris being quite
‘free from adhesions. All vision was of course obstructed
by this capsule, and even in October, 1890, the eye was
•commencing to diverge. She is a good-looking girl; there¬
fore it was necessary that something should be done to clear
away the opacity and so, in all probability, remove the di-
■vergent strabismus. Theiirst thing to do evidently was to free
tlie capsule from the back of the cornea. This I attempted
with the ordinary appliances, but failed’ to accomplish it in
consequence of the escape of the aqueous. The tension of
the eye ^nd of the cicatricial band became so altered that I
could noc get the band to present any resistance to the
knife. I had also to remember that if I used too much force
I might easily have an escape of vitreous. Subsequently,
however, on using Lang’s knives and retaining the aqueous
'there was not the slightest difficulty in freeing this band
12 Virchow’s Arcliiv, Bil, ci.
from the back of the cornea. After allowing the eye to rest
fqr a week or ten days I made an incision into the cornea as
for iridectomy, and with the iris forceps withdrew the cap¬
sule from the'anterior of the eye. It was, however, so firmly
adherent to the iris that I was compelled to withdraw the
iris through the wound and then to snip a portion of it off.
The ultimate result is very good, and 1 discharged her from
the infirmary on Nov. i2bh. Probably now that light is
admitted to the eye, it -will no longer diverge.—Feb., 1891:
I have just seen this patient, who has an excellent eye;
but the divergence continues. This of course can be
rectified.
Case 2.—C. D-a worker at a tin smelting works, was
hit in the left eye twelve months ago by a splutter of molten
tin on the lower segment of the cornea. The bum was of
course very slow to heal, and ultimately the resulting ulcer
opened the anterior chamber, and the iris became adherent
to the back part of the scar. On Oct. 26th, 1890, it was
impossible to see the exact positiou of the synechia, as it
was obscured byvan opacity of the cornea, which extended
over a larger area than was originally represented by the
scar of the ulcer. The pupil was excentric and oval, and
displaced downwards. The upper portion of the iris was
seemingly much stretched. He had constant circumorbital
pain on each side of the head and face. The right eye
was on several occasions inflamed, and he described it
as having watered very much. No doubt it was the sub¬
ject of sympathetic irritation. Ophthalmoscopic appear¬
ances of it were natural. Right eye, left eye,
V=-ijV R® admitted into the Cornwall Infirmary
on Oct. 26th, 1890, with the object of having the anterior
synechia detached from the back of the cornea of the
left eye. This I was fortunately able to do by the aid
of Lang’s knives, though it was haphazard work, as I could
not see the exact position of the synechia on account
of the opacity of the lower segment of the cornea. No
aqueous escaped, and on Oct. 28th he expressed himself
as being quite free from pain. Indeed, be described the
pain as having entirely ceased immediately after the opera¬
tion.—Oct. 30th : On testing I now found the vision of the
right eye -g-, as contrasted with on the day before the
operation. Atropine has been instilled into the left eye
morning and night, which resulted in the pupil becoming
perfectly sound and well dilated in all parts of its circum¬
ference. The opacity of the cornea is also largely clearing
away, so as to allow a sight of the lower portion of the iris.
Nov. 2ad : He insisted on being discharged. He has since
called upon me, and the improvement continues. This ease
ft interesting as showing the injurious effect on the sound
eye of an anterior synechia. For here is a case in which
vision was only yet after the division of the synechia it
almost at once becomes improved to g-. I do not say that
the division of the synechia could not have been done with¬
out using Lang’s knives; yet they undoubtedly rendered it
much more easy of accomplishment, and they have more¬
over allowed me in the second case to restore to its owner
an unmutilated eye—for the only alternative, had I failed,
would have been an iridectomy. As it is now, the patient
has a perfect pupil, and this, with perhaps a gradual improve¬
ment of the corneal opacity. Will give him a fairly uaefiu eye.
ON A METHOD OF APPLYING WEIGHT
EXTENSION IN THE TREATMENT OF
OBLIQUE FRACTURES OF TPIE TIBIA.
Bv G. H. R. HOLDEN, M.A., M.B., B.C. Cantab,,
RESIDENT SURGICAL OFEICER AT THE GENERAL IIOSTITAL, RIRMINGUAM.
That oblique fractures of the tibia often present great
difficulties in treatment is, I think, a proposition which no
one will deny; and few will maintain that the methods of
treatment in ordinary use are satisfactory in bad cases. To
prevent tbe upper fragment of the tibia riding over the
lower extension is necessary in some cases, and three forms
have been used;—(1) Extension by means of a screw
attached to a movable foot-piece ; (2) extension by means of
elastic bands ; (3) weight extension. Undoubtedlyof these
the equable steady traction of a weight lias the greatest
advantage, both mechanically and physiologically. Hitherto
the great difficulty in using weight extension has been the
Dig- ed ■ CjOO^IC
656 The Lancet,]
CLINICAL NOTES.
tMARCH 21,1891.
absence of a satisfactory method of applying it to the leg.
Messrs. Arnold and Sons have made, at my request,, a
splint which, 1 think, meets all requirements, and 1 have
used it in several difficult oblique fractures 'd'ith excellent
results—results which are as good as those obtained
in ordinary transverse fractures. The splint, as shown
in the engraving, is similar to a Neville’s back splint, but
has a sliding foot-piece. The “ purchase ” for the extension
is got from a padded leathern " spat,” which is laced on to
the foot. In applying the splint the spat is placed behind
the heel, and the mot and leg are fixed in the usual manner,
care, however, being taken that the bandage does not
interfere with the free play of the foot-piece. The spat
is then laced up, the splint swung from a cradle, and side-
splints applied. Next, a weight of from 4 lb. to 8 lb. is
m
attached to the spat by means of a cord and pulley. In
the engraving the cord is seen to be attached to two pairs of
rings, but in practice it will be found better to attach it
only to the lower or posterior pair, as then the line of
traction is directly in the line of the long axis of the limb,
and so the heel is kept well down against the foot-piece and
the fragments are made to drop into good position.
To illustrate the above I will quote one case in which I
used this method while senior house surgeon at St.
Bartholomew’s Hospital.
W. B-, aged forty-two, was admitted into the Harley
ward, under the care of Mr. Willett, on Aug. 11th, 1890,
suffering from compound fracture of the left leg. The tibia
was very obliquely fractured about its middle third, and
the sharp end of the upper fragment was protruding about
14 in. through the skin. Attempts at reduction under an
anmstbetic failed until the tip of the upper fragment had
been sawn off. The wound was irrigated with corrosive
sublimate lotion (1 in 2000) and dressed with sal alembroth
gauze and wool, and the leg put up on a Neville’s splint
and side splints, and swung from a cradle. No consti¬
tutional disturbance followed, and the leg was not inter¬
fered with for fourteen days, when on the removal of the
dressings the wound was found to have nearly healed, but
the position of the fragments was far from good ; in fact,
the upper overlapped the lo^ye^ by an inch, and it was not
found possible to keep them in good position without exten¬
sion. The splint above described was then applied with a
weight of 8 Ib., and the fragments came into good position
within twenty-four hours. The weiglit was reduced to 4 lb.
twelve days later. On Sept. 11th the fracture was found to
be united in excellent position, and the wound healed, so a
Croft’s plaster splint was applied. The patient left the
ho^ital three days later.
From the above and several subsetjuent cases of simple
oblique fracture treated in this way I have every confidence
that weight extension used with a splint such as I have de¬
scribed may be found useful in cases where other splints fail
Birmingham.
Koyal Hospital foe Diseases op the Chest,
City-road.— The work done by this charity is daily in¬
creasing, but the income is inadequate to meet the constant
addition to the expenditure. The annual report (the seventy-
seventh) states that during 1890 569G out-patients were
admitted, and the total attendance was 23,666. The in¬
patients numbered 623, of whom 50 had died. The debt
which last year existed upon the new wing had been liqui¬
dated by the generous efforts of Mr. Hope Morley and
Mr. T. Andros De La Kue. The hospital is now the pro¬
perty of the governors. There are still two wards closed for
want of funds. The financial condition is a source of anxiety
to the council of management, there being a large deficit.
The funded capital of the charity does not exceed £3200
from bequests.
atEDIOAL, SUEGICAL, OBSTETRICAL. AKD
THERAPEUTICAL.
BANDIA DUMETORUM.
By Sir James Sawyer, M.D., r.R.C,P., F.R.S.E „
CONSULTING I'lIYSlCIAN TO THE QUEEN’S HOSPITAL,
BIUMINOHAM.
In Messrs. Southall’s exhibit at the meeting of the BritisSi
Medical Association in Birmingham last summer there were
some interesting Indian drugs, comparatively or quite un¬
used or unknown in England, which had been collected by
Mr. David Hooper, the eminent Oriental pharmacologist,
who has been for some time engaged in India in the ollice
of quinologist to the Madras Government. I examined these
drags, and considered the information I could gather about)
them, and one of them—namely, randia dumetorum—ap¬
peared to me to be worthy of further investigation and
trial. Under my directions, Messrs. Southall prepared a
series of tinctures of the drug, and one of these, a tinc¬
ture made with the spirit of ether, B.P., I have been
using in practice as a nervine calmative and antispasmodin
in cases in which the vegetable antispasmodics, such as
valerian or assafcctida, appeared to be indicated. I now
desire to invite my brethren to examine this drug for them¬
selves, and to say my experience of its employment points
to its proving a useful addition to our repertory of nervine
antispasmodics and cardiac excitants. The fruit of randia
duroetorum has an ancient repute as a popular medicine in
India, being given in large doses as an emetic. The
pericarp, especially when fresh, has a powerful and
penetrating odour, due to valerianic acid. The active
principle of the drug is said to be allied to saponin, which
is a giucoside found in soap bark, and aJso contained in
senega and sarsaparilla. We may remember that saponin
has been shown to possess some very marked physiological
potencies, of a kind which point to valuable and numerous
therapeutic applications. For example. Dr. Lauder Brunton
describes saponin in various places in his well-known text¬
book of therapeutics as a respiratory excitant and depressant',
as a sternutatory, as a stimulating expectorant, as a
depressant of the cardiac inhibitory ganglia and of the
vagus ends in the heart, and as a cardiac antagonist
of digitalin. In the official pharmacopoeia of India,
prepared under the direction of Dr. Waring, of the India
Office, 1868, I find randia dumetorum described as a non-
officinal drug. Randia appears to be a common shrub in
most parts of India, growing, as its second name states, in
thickets. The fruit is held in high esteem by the natives
on account of its emetic properties. The following note
upon its use was communicated to Dr. Waring’s phanna-
copccial committee by Dr. George Bidie“The fruit is
about the size of a crab apple, round, two-celled, many-
seeded, and crowned with the rim of the calyx. It has a
eculiar sweetish sickly smell, which increases after the fruit
as been kept for a few days. It is very commonly used
as an emetic by the poorer classes in Mysore, and is
said to be safe and speedy in its action. 1 have myself
seen it used several limes, when ib produced emesis in
about fifteen minutes The dose is one ripe fruD,
well bruised, which may he repeated if necessary. Ic
is apparently an irritant emetic.” Dr. Waring also
adds;—“According to Ainslie, an infusion of the bark
of the root is used by the natives to nauseate in bowel
complaints. Roxburgh mentions that the bruised Luib
thrown into the water intoxicates and even kills fish^
which, however, are not considered less wholesome in con¬
sequence.” I have had four tinctures of randia made—
namely, with spirit of ether, rectified spirit .of wine,
aromatic spirit of ammonia, and proof spirit respectively,
and of the strength of one part of the drug in five parts of*
the tincture. When any one of these tinctures is diluted
with water and acidulated with acetic acid, the odour of
valerian is very apparent ; and it is most apparent in the
tincture made with spirit of ether, and this is the tincture
I have selected for therapeuticuse. The dose of tinctura
randire dumetorum mtherealis is from fifteen to sixty
.OOg|!
Diflni.
The Lancet,]
CLINICAL NOTES.
[March 21, 1891. 657
icninims diluted with water, with which it makes a milky-
looking mixture. The tincture has a strong and character¬
istic odour and taste, and is of a bright maize colour. It may
be given with iron, if a greenish colouration be permissible.
Birmingham. _ '
A SINGULAR CASE OF AURAL GROWTH.
By Gordon Holmes, M.D.,
PHYSICIAN TO THE MUNICIPAL TilUOAT AND KAR INPIRMAIiy, LONDON;
CONSULTING I’HYSICIAN TO THE SIIEPITELD EAR AND
THROAT HOSPITAL.
The following case is probably unique in the published
asnals of ear disease, and therefore deserves to be placed
on record.
In the latter end of 1889 T. A. H-, a healthy-looking
and well-grown boy of fifteen, was brought to me on
account of deafness of one ear, which bad only just been
•discovered. On examining the right meatus I found the
•entrance veiled by a film of purulent discharge. When this
was cleared away a growth came into view, having the
appearance of an ordinary polypus and filling np the meatus
to within a couple of lines of its external outlet. To the
probe this growth evinced an unusual firmness, and I con¬
cluded that I had to deal with a polypus of remarkable
toughness. I applied Wilde’s snare, however, in the ordi¬
nary way, but brought away only about a quarter of an
inch of the growth. Again I essayed, but the second time
removed only a thin slice, leas than a line in thickness.
Exploration with a probe now revealed the fact that the
iueatus was blocked at about a third of its length from the
outside by a solid body, presenting all the characteristics of
an exostosis, from the external face of which the soft growth
had arisen. Under suitable treatment with astringents &c.
the raw surface healed up, and as soon as the parts
were clear of all discharge it was found that hearing was as
perfect, or nearly, as with the sound ear. Nevertheless by
ocular inspection it was scarcely possible to detect a crevice
through which the sound waves could reach the tympanum.
No doubt there is a cavity behind the projecting bone, and,
on the principle of hydraulics, a very small aperture is suf-
ilicient to inlluence fully from outside the body of air con¬
tiguous to the tympanic membrane. Whether the stenotic
•condition of the meatus is due to some congenital deformity
w to an ordinary exostosis it seems not easy to determine,
‘but I incline to believe tliat there is a morbid growth from
the bone. I have recently heard of the case, more than a
year having elapsed, and it appears that the boy has suffered
mo inconvenience since the local treatment was finished, so
that up to date the ear remains practically as useful as if
lanaflected. An operation is therefore deferred sine die,
unless further symptoms arise which may demand it.
Cases of exostosis of the auditory meatus are extremely
rare—from my own experience,—not more than one in
3000 ordinary instances of ear disease. In two previous
cases I have seen there was a purulent discharge) appa¬
rently from behind the growth. In such instances I have
'read that a soft polypus has been discovered posterior to
tlie exostosis after its removal. Ordinary polypus of the
•ear is decidedly frequent—fully 2 or 3 per cent, of all ear
■cases. They occur at all ages up to about forty, and I have
seen at least one in an infant of a few months old. I do not
remember seeing a case after forty, nor do I think they often
Lave their origin much beyond the period of adolescence.
Finaljurj-square, K.C.
A CASE OF MONSTROSITY.
By W. Armstrong, L.R.C.P., L.R.C.S. &c.
On Feb. 7th I was called to attend on Mrs. C- at
2 1 '.M. in her second confinement. She did not expect the
birth till the end of March. About 11 A.M. the membranes
had ruptured, and a large amount of fluid escaped; from
'that time until my arrival there had been regular though
slight hiomorrhage. On examination the rectum was found
to be loaded^ with fifces, the os being about the size of a
threepenny piece. An enema of soap and warm water was
admlnisterea, and the bowels were freely opened. As there
were no pains for an hour and a half I left, promising to call
later on. I returned at 7 I’.M. The patient had had strong
pains since four o’clock. On vaginal examination I felt in
the vagina a rounded mass, which I took to be a shoulder,
and on pushing the finger onwards I felt four or five sharp
bony prominences, above which was a soft mass. I then
uUed on the arm, and brought down a very small hand,
then introduced three fingers, and booked on to the foetus
and pulled it down. The placenta was dislodged in a
similar way. In this casa there was no history of shock or
fright during pregnancy. The previous (first) confinement
was characterised by complete inertia, and the child was
stillborn. Patient is always very aniBiuic. The foetus pre¬
sented the following appearance:—Sex, male. Length
between seven and eight inches. The head was continuous
with the body, back, and front, the neck being absent. The
limbs were long, and feet and hands relatively large; the
abdomen much swollen. With these exceptions the body
was normal in appearance. The face resembled that of a
frog, the eyes very protuberant, and the tongue protroding
from the mouth. Immediately above the eyes the head
presented a flattened surface at right angles with the face.
The skin of the face was continued over this surface to
about the level of the ears, from which line backwards
extended a thin red membrane, which had evidently con¬
tained fluid, and formed aaac, and this membrane continued
backwards down the spine, forming the roof of the open
vertebral canal. Just behind a linedrawn between the two
ears were two bony prominences on each side, projecting
vertically considerably above the flat upper surface of the
head. Immediately behind the remains of the sac, in
the occipital region, was a deep depression, and thence
down the spine extended a broad open groove, bounded on
either side by six bony prominences, and terminating just
above the sacrum. The sketch conveys a very good idea of
the appearance of the monster.
Pontesbury, Salop.
CASE OF PUERPERAL FEVER COMMENCING
NINE DAYS AFTER DELIVERY.
By Geo. H. Salter, L.R.C.P.Ed., M.R.C.S.Eng.
I THINK a few notes on this case may be of sufficient in¬
terest to find a place in the columns of The Lancet.
On Aug. 30bh at 7.30 A.M. Mrs. D- gave birth to a
male child, this being her fifth confinement. She was
attended by a midwife. On Sept. 8bh ab 11 a.m. by request
I first saw Mrs. D-. The woman in attendance told me
“ the labour had been easy, the afterbirth coming away
half an hour after the child, and that until 9 o’clock that
morning the mother had been doing splendidly. At that
time she began to shiver, looked strange about the eyes,
and talked queerly. She had had plenty of milk, had
suckled the infant several times through the previous night»
Dic:...ied by Google
658 Thb Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[March 21, 1893.
and there had been no bad smell about the discharge.” On
examination I found the patient looking terribly iu, dorsal
decubitns, knees not being drawn up; she wae more or leas
delirious. Skin moist, tongue thickly furred. Temperature
104°; pulse 140; respiration‘40 per minute. Abdomen was
not swollen, and there was not the least tenderness on
ressure above the pubes. The lochia were not offensive,
at the condition of the bedclothes was not so clean as one
could wish. This I saw remedied, oi-dered her the usual
diet (milk and meat broth), and ordered a mixture containing
ten grains of salicylate of soda with two minims of tincture of
aconite every two hours, promising to call again in the
evening. At 7.30 p.m. 1 found her in much the same condi¬
tion. She had been delirious through the day. but had taken
freely of nourishment without vomiting. Had passed two
copious andofiensive motions. Temperature 105°; pulse 160 ;
tongue dry. I syringed her with dilated Condy and ordered
an ounce of brandy every four hours. On the 9tn I visited her
twice. The temperature at 11 a.m. was 105°; at 8 p.m. 104°.
Her general condition was much the same. The breasts were
soft and contained very little milk. The lochia had ceased.
There was no swelling of the abdomen or tenderness. She
had taken nourishment freely, and the bowels bad not been
moved. She bad not vomited. Had dozed at times, and
been less delirious during the later part of the day. She was
syringed morning and evening. On the 10th, at 11 A.M.,
she expressed herself as feeling much better, and certainly
looked so. She had taken plenty of nourishment without
vomiting, and had slept fairly well during the night.
Temperature 102°; pulse 108. I syringed her as before, and
gave a mixture containing five grains of quinine every
three hours, and promised to call the following morning.
On the nth I was sent for at 8 A.M., and found her condi¬
tion as follows : Face anxious ; slightly jaundiced tint;
lips bluish ; skin moist; dry tongue, with sordes about the
teeth. She was quite conscious, and complained of cough
and of pain about the wrists, elbows, and knees, which
were slightly swollen. The abdomen was much swollen.
There had been some diarrhcca, but no vomiting, through
the night. The nourishment had been taken freely.
Temperature 102°; pulse 130; respiration 40 per minute.
The sputa were brownish, and on percussion and ausculta¬
tion there were well-marked signs of pneumonia in both
lungs. From this time onward she went from bad to worse,
and died on Sept. 14th at 11,30 a.m.
1 have seen manjr cases of puerperal fever during the time
I have been practising, and in all previous to this my ex¬
perience has accorded with what is stated in the works I
possess on Midwifery. That the initial rigor in this case
did not take place until the ninth day I cannot doubt, as
the patient told me she had never felt better than she did
until the niorning of Sept. 8th. Information gained from
those who had seen her on the 6th and 7th tended to cor¬
roborate this. No doubt the exciting cause of the disease
was lack of cleanliness; and 1 imagine, as the woman was
very stout and flabby, the reparative process was more
slowly accomplished, and thereby the susceptibility to septic
influences unduly prolonged. So good an authority as Lusk^
writes :—“The third day is the one upon which ordinarily
the beginning of the fever is to be anticipated. After the
fifth day an attack is rare, and at the end of a week patients
maybe regarded as having reached the point of safety.”
Other authors I have at hand take much the sanoe view,
and although they agree in saying that the disease may
occur later, I fancy a case in which it commenced on the
ninth day is sufliciently rare to make it worthy of record.
Learmontb, Victoiia, Australia.
’ The Science and Art of Midwifery, by Wm. Thompson Lusk, M.A.,
M.B.; Ist edition, p. 020.
The Royal Slreey County Hospital.—T he
annual report for 1890 is satisfactory, The continued
generous support received has relieved the committee from
present financialanxiety. The receipts on current account—
£4204 17^.—have been adequate to discharge the disburse¬
ments and leave a balance of £84 8s. \d. in hand. The house
surgeon’s report showed that the in-patisnts numbered 774.
The home patients on the books were 409 and visits made
1395. The total of out-patients was -1640 and attendances
11,006. The proposal to abolish the attendance of the house
surgeon on home patients residing within a mile of the
Town Hall, Guildford, has been referred to a committee to
consider and report to a special meeting of the governors.
% Pirm
ov
HOSPITAL PRACTICE,
BRITISH AJfD FOREIGN.
NuUa autera eat alia pro certo noscendl via, niai quamplurimaa et mor -
borum et diasectionum bistorias, turn aliorum turn proprlaa collectan
babere, et inter ae oomparare.-~MoaoAONl De Sea. et Catie. Jforb.,
Hb. iv. Procemium. i
EASTERN FEVER HOSPITAL, HOMERTON.
A CASE OE rURPURA EULMINANS ; NECROPSY; REMARKS.
(Under the care of Dr. Colliis.)
Purpura of the severity exhibited in the case of this
patient is fortunately of very rare occurrence in thiS'
country, and the resemblance which it bears to the cases
described by Dr. Henoch is pointed out by Dr. Collie iii>
his remarks. A more recent contribution to the literature^
of the disease will he found in the A rc/uves of jPedmiricS'
for December of last year by Dr. Jackson, of Boston, U, S. A.
His communication was founded on the observations of the
case of a boy aged five, who had died under his care on the
fifth day of the disease. The patient bad suiTered from
severe hemorrhages from the mucous membranes (epistaxis,
hemabemesis, m^ena, and hiematuria), as well as from large
subcutaneous extravasations of blood. The following account
is from notes by Miss Fleury, assistant medical officer.
F. B. D-was admitted into the hospital about 9 p.m.
on Nov. 11th last. About Oct. 20bh he had an attack of
scarlet fever, which he appeared to be passing safely through
when the “ eruption” which is about to be described was
observed on Nov. 10th, about three weeks from the com¬
mencement of the scarlet fever. On admission the patient
was a pale, thin boy, nine years of age. His expression was
placid, and his intelligence remarkably acute. Over the
extensor aspect of the left elbow a large ecchymosis extended
some way down the forearm. There was an extensive*
ecchymosis over the right hip, and one on the calf of
each leg. The ecchymoses appeared to be recent, and
at their margins the extravasated blood was of a bright-
red colour. There was extreme tenderness of the skin, out-
otherwise the patient made no complaint of pain. The
tongue was fairly clean, and the gums sound. There was-
no hcemorrhage into the conjunctiva, and there was none-
from the mucous membranes. The pulse was fairly good,,
and the temperature 98'6° 1''. There was a little branny
desquamation on the face. Mind clear. He passed a rest¬
less night, but took his nourishment readily, apparently
being very thirsty. He complained of “pins'and needles’”'
sensation all over, but at 7 A.M. he was reported to
have been bright and cheerful. He passed two ounces ol
urine free of blood during the night, and there was no
motion from the bowels. About 8 a.m. violent vomiting
came on. He cried much when moved in bed, and complained-
of pain in the abdomen. At 11 A.M. a new ecchymosis wa&
observed behind the left ear. His face was now very pule,
pinched, and drawn, and generally he appeared to be in
great distress. It was clear that "he was sinking, but his
mind continued clear. He died about noon ; that is, about
sixteen hours after admission, and about forty-eight after
the appearance of the “ eruption.”
liecropsy, forty-eight hours after death .—Rigor mortis
was very marked. There was a large ecchymosis on the
back extending downwards from the right shoulder ; also
one over the left hip. The patches were somewhat sym¬
metrical. There was some fluid in each pleural cavity, but
more in the right than in the left. Lungs were anrcmic,
but otherwise normal. The heart contained no clots, but
the walls were somewhat thin and flabby. The liver and
kidneys were anscmic. Spleen not enlarged. Intestines
were very anemic, containing a little feculent matter,
walla very thin. There were a few drops of urine in the
bladder, no fluid in the peritoneal cavity. Patchy con¬
gestion of the tonsils. On examination of the brain, the
arachnoid was found to be milky, the convolutions some¬
what flattened, and a small quantity of serum in the
ventricles. There was no extravasation of blood in any of
the internal organs.
Remarks hy Dr. COLLIB.—The interest of this case is-
The Lancet,]
HOSPITAL MEDICINE AND SURGEEY,
EMarch 21,1891. 659
'that it appears to he one of a class of rare cases which have
’been descnbed ^ Dr. Henoch of Berlin. (For this reference I
am indebted to !6r. Donkin.) Henochsays: “In recent years
I have seen two cases of extensive ha3morrhage into the
skin, both of which were rapidly fatal. I have termed
them ‘purpura fulminans.’ A third case was communi¬
cated to me by Dr. Michaelis, and a fourth has been pub¬
lished by Charron. All these cases had this in common—
that bmmorrhage from the mucous membranes was want-
"Ing, and that extensive ecchynioees, from which within a
few hours all the extremities became of a blue-black-red
•colour and the skin tolerably bard from infiltration of
blood, occurred with great rapidity. In two cases there
were sero-sanguineous blisters on the skin, which blisters
aaever became gangrenous, or even stank. The course of
these cases is very rapid, scarcely twenty-four hours elapsing
between the first appearance of the blood spots and death.
The longest case lasted four days. There were no compli-
■catioDs, and post-mortem examination, with the exception
of general anccmia, gave negative results; in particular
there was no trace of embolism or thrombosis. The etiology
is as obscure. One of ray cases showed itself two days after
the complete crisis of a pneumonia, the other a week
and a half after a very mild scarlatina. For the two other
•cases no etiology could be suggested.” ^ Henoch adds in a
footnote that two similar cases have been observed by Strom
and Arctander, one of which followed a scarlatina, and
according to Hero6 three quite similar cases have been pub¬
lished by Guelliot._
ROYAL INFIRMARY, NEWCASTLE-ON-TYNE.
OROSS-LBOCED DEPORMITV; OPERATION j GOOD RESULT..
(Under the care of Mr. Frederick Page. )
Recorded examples of the cross- or scissor-legged
•deformity resulting from ankylosis of the hips in the
adducted position are few. The better recognition of the
^principles of treatment and the increased facilities for
obtaining treatment in cases of disease of both bip-joints
cuake it improbable that the deformity will ever be other¬
wise than rare, disease affecting both hips being of itself a
rarity. Most of our readers will remember the account of
tiie deformity in the patients under the care of Mr. Lucas,
who brought the condition to the notice of tlie profession in
1880,'* and the description of Dr. Tuson’s’* case published in
I KInderkraiikhoiten, funfte Auflage, p. 810, Berlin, 1800.
2 TUK LANCE'f, vol. ii. 1880, pp. OOC, 1000.
y Ibid., vol. i. 1831, p. 700.
the following year. The eversion of the limhs, which was
such a marked feature in those cases, does not appear to
have been present in the patient whose history is here given.
For the notes of this case we are indebted to Mr. J.
Hindhaugh, house surgeon.
J. B-, a schoolgin aged thirteen years, was admitted
in August, 1890, suftering from cross-legged deformity due
to ankylosis of both hip-ioints. Six years ago she was
confined to bed for eight monchs by an attack of acute
inflammation of both Inp-jointe, and during the illness the
deformity arose. The engraving fairly represents her con¬
dition on admission. The legs could not be separated, and
in consequence the child was much inconvenienced. She
was in good health. On Aug. 21st the neck of the right
femur was subcutaneousW divided with Adams’ saw, and
the leg straightened. The neck of the left femur was
similany divided, but the limb could not be straightened
until the origin of the adductor longus was severed. The
legs were then secured in a box splint with starched
bandages. The wounds healed at once, without any consti¬
tutional disturbance. In six weeks the splint was removed
for the first time, and the result, as shown by the following
engraving, leaves little to be desired.
Rcmarlcs ly Mr. PAGE. — Cross-legged deformity, from
ankylosis of both hip-joints, is fortunately rarely met
with, and its treatment is not always satisfactory. In this
case the patient’s condition has been materially improved.
She walks less awkwardly and much more readily than she
did before the legs were straightened, and in other respects
she is in a more satisfactory condition, though the hips are
still ankylosed, and there is slight genu valgum on the
right side. _ _
LONDON COUNTY LUNATIC ASYLUM,
HAN WELL.
A CASE OF SUICIDAL EPILEPSY.
(Under the care of J. Peeke Richards, M.R.C.S.,
Medical Superintendent, Female Department.)
TirEpresenceofcertaindefmitecoordinatemovementswhioh
arise while the patient is in a state of epileptic unconscious¬
ness is a point of peculiar interest in this case. She does not
continue what she may happen to be doing before the onset
of the petit mal, as is usual in such cases, hut commences
an entirely new act, the whole end and object of which has
always been self-injury or destruction. Moreover, thwe
movements are always preceded by a state of muscular
relaxation (which sometimes commences with very slight
spasm) which invariably renders the patient helpless and
Digitized b', ’OO^ C
660 Thb Lanobt,]
PATHOLOGICAL SOCIETY OF LONDON.
[March 21,18M.
canees her to fall if going about, this again dHTering from
the common forms of epilepsia mitior. It is, perhaps,
fortunate that up to the present her unconscious impulses
have always been directed towards suicide. Had they been
homicidal, it seems not impossible that a serious medico-legal
question might have arisen in regard to them. As she often
makes very dehnite plans for self-destruction there is no
reason to doubt that, had she been homicidally inclined,
she would have done the same thing, and in such a case,
although totally ignorant of, and therefore irresponsible for,
her actions, there would have appeared so much method in
her madness as to render the proof of her innocence a very
difficult, if not impossible, ta^ in a court of law and before
the public. It is also interesting to note the unusually
prolonged duration of a state of quiet, calm, unconsciousness
which IS nearly always a marked feature of the attacks of
petit mal in this patient. During the intervals between
Iier fits, and at sucn periods as they are few in number, she
shows not the slightest indication of a suicidal intent.
She is occasionally low-spirited and depressed, but this is
exceptional at such times, and her normal state seems to
he bright and cheerful. For the notes of the following case
we are indebted to Dr. Percy J. Baily, under whose imme¬
diate cha^e the case is.
Clara H-, a female aged twenty-eight years, was
admitted into the London County Lunatic Asylum at
Hanwell on Aug. 7th, 1890. Tl^e following are the notes
of her condition on admission: Body well nourished;
weight Sst. 121b. Her general appearance gives one the
impression of a rather low type of development. Com¬
plexion dark; temperament hervous, with an admixture
of the bilious and sanguine. Tongue dirty j pupils
normal; irides dark brown. Pulse regular, soft, out
full; 84 beats per minute. There is a mitral systolic
bruit, and on the left side of the cbest a little
pleuritic friction. Temperature nearly 99° F. Skin
moist; urine free from albumen. Mentally she seemed
bright and cheerful, said she did not feel ill, and for some
time spoke in a rational manner. Before long, however,
her attention commenced to wander, and her talk became a
little disconnected. She was evidently able to exert for a
short time an efiort of will over herself sufficient to concen¬
trate her attention upon the- matter under discussion, but
her power of inhibition was so small that it soon became
exhausted, and she began to express delusions about her
husband and children. She is one of a family of eighteen,
and siie inherits insanity. Her education ia plain. She
has always been a little imbecile. Her sleep has been good,
and her habits temperate. Bodily health always indifierent.
Menstruation irregular. She has been subject to fits since
she was fourteen years old. Her father and eleven sisters
died of phthisis. Since her admission she has had several
slight attacks of hfcmoptysU. Her epileptic fits have been
very frequent, amounting on one occasion to as raanyas 171
in twenty-four hours. During the first three months of her
residence here she had over 3500. She seldom, however,
shows any very great exhaustion, a few hours’ sleep
restoring her wonderfully. For some time after her admis¬
sion the majority of her attacks affected chiefly the con¬
sciousness—in otner words, they were attacks of epilepsia
mitior or petit mal. They lasted from five to ten minutes,
and were generally accompanied by some slight convulsive
movement of the arms and neck. She rarely made a faint
cry at the commencement of an attack, hut never called
loudly; if going about she would fall down. It was
thought that she never had an aura, as she gave no warning
before the actual onset of the first stage of the fit. If she
happened to be spoken to shortly before the approach of an
attack, it was sometimes possible to notice a slight altera¬
tion in her manner, her cerebration appeared to be slowed,
she did not seem to comprehend what was said to her, and,
either from this reason or because she was nob able to frame
her words, she would not answer when addressed. This
condition of semi-consciousness usually lasted only a very
short time (two or three minutes), but passed into a state
almost resembling coma, either with or without the
slight convulsion above mentioned. She would then lie
back in the bed entirely free from spasm; her respira¬
tion wae calm and easy, but a little deeper than usual;
her pulse was slightly increased in frequency, and was
fall, soft, and regular; her pupils were moderately con¬
tracted and did nob react to light; her corneas were quite
insensible to touch ; her skin remained cool, and there
was no tendency to any marked increase in the secretion of
sweat; the smaller vessels of the face were contracted,
giving rise to a marked pallor. After remaining in thi»
state for two or three minutes the patient sab up, opened
her eyes, and began gazing about her as if lookingfor some¬
thing. There is every reason to suppose, however, thatj
during this stage of the attack she had entirely lost
the sense of sight, as all her actions appeared to
be led by that of touch. It was now that the mostr
peculiar features of the case revealed themselves. While
still remaining in a state of complete unconsciousneso
she would go through a series of perfectly coordinated
movements, all of which were of a suicidal kind. Taking
one of her sheets by one corner in one hand (alv’ays the
left), she felt about with the other in order to find itsv
borders, and, having discovered these and arranged thent
satisfactorily, suddenly, by drawing the sheet through the
right hand, converted it into the semblance of a rope, and„
throwing it rapidly over her head, pulled so vigorous^ upon
the two extremities as most effectually to prevent aD
I possibility of respiration. So determined was she in thus
attempting to strangle herself that it was almost im¬
possible for two people to overcome her muscular action
and disentangle the sheet from her neck until by partial
asphyxiation she became weakened and exhausted. Then
followed a slight spasm of the muscles of the gullet, giving
rise to a peculiar gulping sound, after which the patienc
rapidly regained consciousness, waking up as if from a pro¬
longed sleep. She remained for a short time much confused
mentally, was entirely ignorant of all that she had been
doing, mistook the identity of persona, forgot the names oi‘
the nurses by whom she was constantly attended, had no
idea of what time of day or night it might happen to be,
and could not tell where she was or bow long she bad been
in the asylum. Occasionally she had hallucinations either
of sight or hearing or both. She would talk to and
about her husband and children as if she both saw and
heard them. After her admission the character of the fibs
gradually changed; she gave up attempting to strangle
herself, and instead would end these attacks of epilepsia
mitior by jumping out of bed and rushing with all her
might against a brick wall or other obstacle. In this
way her head had received some rather severe contusions,
and she has lately varied their termination by attempting
to swallow anything within her reach. Being under con¬
stant supervision she has not been able to do herself any
harm in this way. At the present time most of her fits
are of the more usual kind o! epil^sy, passing through the
stages of tonic and clonic spasm. The former stage is, how¬
ever, of very short duration, and in the latter the
movements are more rapid, as well as being more regular-
and of less amplitude, than is usually the case in typical
cases of epilepsy. After these attacks of haut raal she
shows no manilestatioDS of the suicidal impulse. Occasionally
she is a little restless, but, as a rule, she gives no trouble,
and the post-epileptic state presents no peculiarity.
Thecase remains under treatment. All the usual remedies
have been tried without effect. Bromideof potassium made a
sensible reduction in the number of attacks, but produced so-
much depression that its use had to be discontinued.
Tincture of cannabis indica, commencing with ten-minim
doses, appeared to relieve her for some little time; bub
she so rapidly became inured to the effects of the drug that
it was thouglit unwise to increase the dose to the extent
which seemed necessary to maintain its effect.
PtMal SflAtits.
PATHOLOGICAL SOCIETY OF LONDON.
Malignant Disease of the Oisophngus.—Symmetrical Ferio9-
titis.—Hydatids of Liver.—Malignant Nasal Polypus .—
Szjringomyelia. — Cerebral Syphilis. — Sxipcmumerarx}
ifipple.
An ordinary meeting of this Society was held on
March 17th, the President, Dr. Dickinson, in the chair.
Dr. Lauriston Shaw showed two cases of Malignant
Disease of the (Esophagus. The first was a sarcoma which
appeared as an ulcer with well-delined margins, destroying
an extensive area of the mucous membrane of the gullet,
and perforating the posterior wall of the trachea just above
The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[March 21, 1891. 661
ibB bifarcatioD. There were secondary deposits in the
neighbouring mediastinal lymphatic glands, and in the
lungs and kidneys. The patient from whom the specimen
%va8 taken was a female aged thirty-eight years who had
euffered from dysphagia for six months, and died two days
after her admission to Guy’s Hospital in 1855 The
histological characters of the growth were those of a
earooma with round and oval cells, and as such was a rare
condition, only one other primary sarcoma of the ccsophagus
liaving been shown at the Pathological Society. The
second specimen shown was an ordinary sciuamous-celled
epithelioma, which was worthy of notice on account of the
existence of a large mass of growth protruding Into the
Juraen of the gullet, and thus producing cosopbageal
obstruction. The growth, which was cylindrical in shape,
measuredin. from above downwards, and liin. across,
and completely filled the tube, so that a small tube could
barely be passed by its side. The tumour was attached to
the hinder wall of the ccaophagus by its lower and-posterior
surface, and for the rest was free, aiod presented a nodular,
i?loughy appearance. There was a ring of ulceration around
the ccsophagus below the attachment of the tumour. The
patient was a male aged fifty-live who was admitted under
Mr. Charters Symonds in 1890 for dysphagia of live months’
duration. When admitted be was extremely emaciated
ami quite unable to swallow, and it was found impossible
to pass a bougie into the stomach. He died fourteen days
after admUsion, and at the necropsy the lungs were found
partially consolidated by broncho-pneumonia There were
DO secondary deposits. 'The specimen illustrated an unusual
iform of obstruction of the cesophagua by malignant disease,
and one which would be particularly difficult to overcome
by intubation — Dr. Galloway said he had been investi¬
gating the. way in which malignant disease of the viscera
spread. The growth sometimes, though rarely, inorusted
the viscera without invading them, or at other times the
tt\uscular structure alone might be involved, He referred
to a case of sarcoma in which the growth spread over the
v/hole of tile peritoneum without penetrating the muscular
substance; and in two cases—one of sarcoma and one of
carcinoma—the muscular coats of the stomach had been
invaded ; the carcinoma, however, appeared to destroy the
muscle fibres to a far greater extent than the sarcoma did,—
Mr. Shattock said that most sarcomas springing from the
submucous tissue belonged to the small round-celled
class.—The specimen was referred to the Morbid Growths
Committee.
Mr. Bowlisv showed specimens of Symmetrical Periostitis
with Peculiar Formation of New Bone. The patient was a
male infant aged one year, and had been ill for about a
week prior to admission into the Metropolitan Hospital.
There was slight pyrexia, and the legs were swollen from
03dema. The lower part of each thigh was greatly swollen,
the right being the larger. On this side there was fluctua¬
tion, on the other there was none, and an incision liberated
pus from the former. The child suffered from bronchitis,
and died eighteen days after admission. A post-mortem
examination showed a complete ring of new bone on the
right side separated by a large interv^ from the shaft of the
femur, to which, on transverse section, it bore the same sort
of relation that the tyre of a wheel did to the axle. On
the left side was a similar but smaller formation. The
oomplete ring of bone was evidently due to a separation of
the periosteum in an intact state from the shaft of the
femur, and was of great thickness. It was apparently
formed with great rapidity, as the whole duration of the
illness did not exceed four or five weeks. There was no
evidence of any constitutional disorder.—Mr. Jonathan
Hutcuin.son, jim., asked if the pus evacuated bad been
examined for micro-organisms. He referred to the case of
a young infant suffering from pyromia whoso clavicular
joints at both ends were full of pus, and yet there was a
considerable wall of new bone round the affected joints
which must have been formed with extreme rapidity.—Mr.
Shattock said that if the case had been one of acute peri¬
ostitis the central bone ought to have undergone necrosis.
He suggested that the periosteum had been primarily
separated by an effusion of blood which had softened, and
tlien, perhaps, an infective inllammation had been set up.—
Mr. Bowluy, in reply, said he had not examined the pus.
There was absence of any sign of scurvy tickets, no clot
being evacuated and the pus remaining uncoloured. He
thought that the periosteum liad been raised by a passive
serous effusion, and for that reason the bone did not die, as
it was not inflamed.
Dr. S. West showed a Liver with two Hydatids, in which
the sacs communicated but not the cysts, taken from a girl
aged sixteen, who had been in good health until two years
before she came under treatment. At her first admission
to hospital she was tapped and much relieved, but she
returned seven months later with an enormous abdominal
swelling, there being a prominence in the epigastrium
which was soft, boggy, and fluctuating. The girl, who
suffered much respiratory embarrassment, was tapped in
one of the right intercostal spaces and a large quantity of
fluid removed, which was clear and of hydatid character ;
then something appeared to burst and the fluid became
bile-stained. At three successive tappings large quantities
of fluid were evacuated, but as it reappeared an incision
was made and a cyst connected with the liver emptied of
decoraposiug membrane. There were found to be two
cysts, one in the liver and one above it. Drainage proved
to be a very difficult matter, and a fortnight after the
operation the patient sank and died. At the necropsy
there were found two sacs, one in the substance of the
liver and one beneath its capsule below the diaphragm.
There was a communication between the two large
enough to admit a finger, but the cyst in the upper sac
was quite separate. The pleura was not obliterated,
and hence the upper cyst could not have been opened
through the intercostal spaces.— Mr. Williams had seen
a case of hepatic hydatid so large that it filled the
abdomen and pelvis, and was operated on iu mistake
for an ovarian tumour.—Dr. Openshaw had seen hydatids
between the liver and diaphragm. He suggested injection
of iodine into the pleura, so as to obliterate the lower part
of the sac and thus allow the cyst to be drained from a
intercostal space.—Dr. Stephen Mackenzie remarked
that the removal of a small quantity of ilaid from an
hydatid cyst usually led to its death. If one withdrew a
Quantity of fluid from a liver cyst whose walls were so
placed that they could not collajise, something must take
the place of the removed fluid; in some cases not merely
serum would transude into the sac, but also a number of
corpuscular elements, causing the formation of abscess.
He asked Dr. West what was the basis of his assumption
that the cyst was alive after the tapping. True multilocular
hydatids were rare in this country, though they were
commonly met with abroad.—Dr. Voelcker said that at
the Children’s Hospital last year Mr. Pitts excised a portion
of rib, stitched off the pleura, and then drained a hepatic
hydatid through the opening; the patient recovered.—
The President referred to a case of hydatid of the liver
Nvhich occurred in a child of six. It was tapped with an
aspirator and a large quantity of fluid drawn off; the child
died three day.s later of what was thought to be acute
peritonitis, but at the necropsy the cause of the fever was
found to be, not peritonitis, but suppuration of the cyst.—
Dr. West, in reply, said that on the second tapping the
fluid was serous, and therefore probably the cyst was still
living, but at the third tapping the fluid was albuminous.
He had never seen a mulcilocular hydatid in this country.
He knew of cases in which hepatic hydatids had been
drained through tlie healthy pleura.
Mr. A. E. Barker gave an account of a peculiar Polypus
of the Nose which he had met with in a lady aged forty, in
the autumn of 1888. The polyp had been present for aoout
a year, according to the history of the symptoms. The
tumour, wlien seen in situ, appeared to be an ordinary
polyp of the nose, except for some small hromorrhagic
spots on the surface. At the operation for removal it was
found to be friable and inelastic, and came away in little
pieces. It could not be torn away en masse. There was
very profuse hmmorrhage, thirteen ounces of blood being
lost altogether. After the operation the patient had
remained well for six or eight weeks. In November, 1888,
the nose was again completely blocked, and death occurred
in February, 1889, when there were secondary growths in
the cheek and throat. The growth had not penetrated
through the ethmoid bone. The tumour possessed wi-
thelium both on the surface and in the interior. The
whole was supported and mounted on a stroma. There
was no limiting membrane. The epithelial elements were
irregular, but not columnar. In parts tbe epithelial
cells had undergone degeneration, especially where they
were packed most closely together. The stroma was
fibrous and myxomatous. The specimen w-as a very un¬
common one, and he thought that it most likely belonged
to the class of tumours known as “carcinoma myxoma-
. toides.”—Mr. Bowlby had seen two similar cases, one m a
c
662 Xhb Lancet,]
CLINICAL SOCIETY OP LONDON.
[March 21 ,1891
lad aged nineteen, who was admitted with exceedingly
vaacnlar polypi, which were removed. Thirteen months
later he came hack with a large growth blocking the nose,
and he died of meningitis, the growth, a myxosarcoma,
having fungated through the ethmoid bone. In the second
case a man of twenty-two had suffered from polypi for
years, and presented himself with a sarcomatous mass in
the nose. The growths, as far as possible, were removed,
but the patient became comatose and died. This also
roved to be sarcoma, which had perforated the ethmoid
one and set up meningitis. A third case had come under
the care of Mr. Butlin, while others bad been mentioned in
a clinical lecture by Sir William Savory published some
• time ago.—Mr. R. thought the growth should
he called adeno myxosarcoma.—Mr. Barker, in reply,
said the only other case known to him had been under Mr,
Erichsen’s carp, end the ethmoid bone was perforated.—The
specimen was referred to the Morbid Growths Committee.
Dr. Galloway showed a specimen of Syringomyelia.
The patient from whom it was taken, a male aged forty-
three, suffeied during life from general jjaralysis of the
insane, and died on account of exhaustion from acnte
mania complicating this condition. He suffered also from
alteration of sensation, which, being probably exaggerated
on account of his mental condition, caused him to tear his
skin in various places and to inflict severe injuries on him¬
self, his complaints being that he had been placed in
Cayenne-pepper bottles, or thav the devil was inside him
and wanted to get out. Post mortem it was found that
the brain showed the ordinary appearances associated with
general paralysis of the insane, and in addition showed
dilatation of the lateral ventricles. The spinal cord, to
naked-eye appearance, seemed almost normal, except in
the dorsal region, where it appeared flattened antero-
posteriorly. On making transverse sections, however, it
was founa that a central cavity extended along the cord
from the upper cervical to the upper lumbar region. In the
dorsal region the cavity was moat extensive, and on this
account allowed of the flattening of the cord like a collapsed
tube. In the cervical, lower dorsal and upper lumbar
regions the cavity was small, and did not affect materially
the shape of the cord. The cavity was surrounded by a
ring of tissue, firmer and whiter than the surrounding
cord substance, and which on microscopical examination
proved to be composed of characteristically branched
neuroglia cells. The neuroglia ring varied inversely with
the size of the cavity, being almost inappreciable in the
mid-dorsal region, where the cavity extended into and
replaced most of the grey substance of the cornua. The
rod of morbid neuroglia, with its cavity, was situated
posterior to the central canal of the cord, which was
normal, except in the dorsal region, where it was ab¬
sorbed in iho widely extended cavity. The primary lesion
seemed to be the formation of the rod of neuroglia at the
base of the posterior median fissure of the cord behind the
central canal, probably as a relic of the embryonic filling
^ of the posterior extension of the original central canal.
The usual explanation, that the cavity was formed by the
subsequent li(piefaction and absorption of the central parts
of the column of neuroglia, was difficult to accept in this
case, as the cells of the neuroglia showed no signs of
degeneration at any point, and the growth was well sup¬
plied with bloodvessels. The spreading of the cavity into
the grey matter of the cornua to such an extent in the
dorsal region was probably due to a secondary myelitis
followed by absorption of the inflamed grey matter. A
characteristic feature of the neuroglia tissue surrounding
the abnormal cavity was that its inner layers seemed con¬
densed, and formed a sort of the lining membrane, which
showed a very contorted outline, and which somewhat
resembled the elastic coat of an artery.—The President
had seen dilatation of the cord in two or three cases of
nervous disease, notably in one instance of chorea.
Mr. J. Hutchinson, jun., showed the Skull-cap and
Brain from a case of Inherited Syphilis, the right occipital
lobe being almost entirely replaced by a huge gumma which
was adherent to the dura mater. Thinning liad occurred
as a result of this through the parietal bone, and a large
oval aperture one inch and a half in long diameter had been
formed, through which the membrane and subarachnoid
fluid had protruded. There had never been any ulceration
over this, though the scalp was extremely thinned; daring
life the swelling had pulsated. The ventricles were much
dilated, and the left lateral one was continued hack into
the perforation of the skull. The left lobe of the cerebellum
was implicated by extension of the gummatous proceed
through the tentorium. There was no general meningitis,
and the process had been a very slow one, the aperture in
the skull having formed five years before the patient’s-
death, when she was sixteen years old. The symptoms
during life were, besides this peculiar form of meningocele,
(1) paraplegia varying from time to time and incomplete, no-
doubt due to intra-ventricular pressure of fluid ; (2) doable
optic neuritis leading tp atrophy and blindness ; (3) albu¬
minuria and anremia. Sections showed that the left
occipital cortex was in large part replaced by fibrous ancit
characteristic gummatous material with considerable cal¬
careous degeneration. The patient was under the care of
Dr. Buncombe in the City of London Infirmary, and the
case had been diagnosed as syphilitic, although the teeth
and eyes presented no characteristic features of inherited
syphilis. She had some years before suffered from (?) gum¬
matous ukers on the back and neck, which had healed with.'
extensive scarring. Allusion was made to the rarity of
extensive perfoiation of the skull from syphilis apart from-
actual necrosis and from cranio-tabes in infantile periods,
and a somewhat similar specimen referred to in the London
Hospital museum, in which an aperture had formed in on&
frontal bone over a gumma in the cortex. In this case-
(under Dr. Hugblings Jackson) a similar pulsating swelling,
bad been present during life.
Mr. R. Williams read an account of a Supernumerary
Median Nipple and Areola, the patient being exhibited at
the last meeting. He was a man aged sixty-seven, who-
presented not only this median nipple and areola as large a&
a shilling over the lower part of the sternum, two inches
below the level of the normal nipples, but also a small'
rudimentary nipple, devoid of areola, four inches below the
left nipple, and rather internal to it. The normal pectoral
pair of nipples were of great size, p,s large as a woman’s,
and there was a recurrent epithelioma of the lower lip and
glands of the neck. Median mammm were of very rare
occurrence in human beings, only three other casesliavingboen-
recorded. In each of these the supernumerary structures
were rudimentary, and occupied the same position as itt
this case—namely, over the lower part of the sternum. In
the animal world median mammte were almost unknowa
except among the marsupials. According to Darwin, nipples,
were first acquired by marsupials after they had diverged
from and risen above the monotremes, and were by them
transmitted to the placental mammals. The occasional
appearance of supernumerary median mamma; in human.-
beings was regarded as due to reversion to this ancient-
ancestral arrangement. There was no evidence that
redundant mammary structures could arise just anywhere
as mere “sports” from ordinary sebaceous follicles; but-
they were met with only in certain definite situations,
which corresponded with those normally occupied by the
glands of polymastio animals.—Mr. Jonathan Hutchin¬
son, jun., felt sure that the case was one of pigmented
mole, and hoped that the diagnosis would be verified with
the microscope.—The President suggested that if possible
this course should be pursued, and the result reported later
to the Society.
The following card specimens were shown:—
Dr. S. West: Casts from Plastic Bronchitis.
Mr. Edc.AeWillett: Microscopical specimens of Secon¬
dary Scirrhus of Bone.
Dr. A. F. Voelcker: (1) Rickets with General Tubercu¬
losis ; (2) General Peritonitis after Perforation of the Vermi¬
form Appendix.
Dr. Newton Pitt: (1) Anthrax (Kdema of Stomach j.
(2) Gangrene of Lung Secondary to Bronchiectasis.
CLINICAL SOCIETY OF LONDON.
AiropJdc Spinal Paralysis and Multiple 'Neuritis. — Sym¬
metrical Gangrene of Feet.—Septictvniia due to Seiecr Air.
An ordinary meeting of this Society was held on
March 13th, Sir Dyce Duckworth, President, in the chair.
Dr. Gowers read an account of a case of Acute Atrophic
Paralysis (acute anterior poliomyelitis), in which there was
also a primary multiple neuritis. The patient was a boy
aged seven, in whom the paralysis developed after several
days of constitutional disturbance. The first symptoms ofi
The Lancet,]
CLINICAL SOCIETY OF LONDON.
[Makch 21, 1891. 66S
thia commesced within twenfcy-four hours of a quite cold
bath, to which he was unaccustomed. The weather at the
time was very hot. The atrophic paralysis involved the
wiiole left arm and shoulder muscles and the right deltoid,
triceps and biceps. At the end of a fortnight these muscles
and all those of the left arm presented the reaction of
degeneration, and their paralysis and wasting proved per¬
manent. Simultaneously with their palsy the legs became
weak, although d.11 movements could be performed. The
knee-jerks were preserved throughout, and when the palsy
had existed for a week they had become excessive, and a foot
clonus had developed on each side. This continued for some
months, although the legs gradually regained power 5 so
that the child was able to walk in two months from the
onset, and the legs ultimately became quite strong. The
symptoms thus showed cervical anterior poliomyelitis
extensive and severe on the left side, and on both sides
involving slightly the adjacent white substance, so as even
to cause some secondary descending degeneration in the
pyramidal libres, transient, and due to damage that passed
away. The interest of the case, however, rested in the
indications of neuritis. Even before the palsy was dis¬
covered the arms and legs became extremely tender,
chiefly in the neighbourhood of the elbow-joints and knee-
joints, and thought to be in them because every movement
and manipulation of the joints caused great pam. Careful
examination showed, however, that it was entirely in the
nerves—in the sciatic and popliteal nerves of the legs, and
the ulnar and median especially in the arms. The tender¬
ness lessened upwards and downwards, and was much
slighter at the brachial plexus. The nerves of the left arm
were more tender than those of the right. There was no
anesthesia or other evidence of damage to the conducting
fibres of the nerves. These symptoms lessened in the
course of a few weeks and passed away entirely, although
the atrophic palsy persisted in almost its initial degree.
They were certainly due to a multiple perineuritis, affect¬
ing the nerves in- the middle of their course, primary, and
developing simultaneously with the spinal lesion in con¬
sequence of the same cause. In commenting on the case.
Dr. Gowers remarked on the probability that the pain and
tenderness met with in other cases of poliomyelitis, and
usually referred to the joints, was really seated in the nerves,
which suffer mechanical disturbance at every movement
of the joints. Although poliomyelitis was probably pro¬
duced through the agency of a blood state, the latter was
certainly often generated by exposure to cold, and effective
chiefly in the hot season of the year, which in some way
predispose either to the susceptibility of the individual or
to the production of a toxic influence. Exposure to cold was
capable also of causing the other and more common form of
multiple neuritis, the parenchymatous variety, in which the
nerve libres suffered primarily, the sheaths scarcely or not at
all, except in their nerves, and the incidence of the effect was
peripheral and more perfectly symmetrical. A difference
must exist in the blood state due to cold in the two classes
of neuritis, and it was important to note the associations of
the two forms thus produced. In this connexion the
author referred to the leading features of the two forms of
neuritis, the parenchymatous and the adventitial, using the
latter term as a designation for the variety in M’hioli the
connective tissue elements were primarily alfected. Recent
researches were referred to which suggested that there were
two varieties of poliomyelitis, the primary affection in one
being of the nerve cells, in the other the basis substance of the
grey matter, the former being analogous to the parenchy¬
matous, the latter to the adventitial forms of neuritis, and
reasons were given for regarding the poliomyelitis in the case
described as of the second class. The paper concluded with an
allusion to the probability that an actual organised virus
sometimes produced the adventitial form of neuritis by the
direct influence of the organisms on the connective tissue
elements, and especially on the sheath, as was seen in
leprosy, and might bo the case in syphilis ; wliile, on the
other band, the parenchymatous form was certainly often due
to a product which biie organisms produced by their growth
in the body, as one active agent, alcohol, was produced out of
the body. The question was suggested, as deserving study
in this connexion, whether diphtlieritic neuritis eommenj-
ing during the primary disease was not chiefly adven¬
titial, and that which began when the disease was over in
greater degree parenchymatous, and the contrast was
noted between the adventitial neuritis of the active
'stage of syphilis and the parenchymatous later form
which often constituted part of the lesion of tabes.—
The President said that he would be glad to have known
more about the treatment adopted in this case.—Dr. Beevos
said be bad never seen a similar case. He asked whether
there was any ana3sthesia in the affected limbs, and whether
Dr. Gowers looked upon the neuritis as secondary to inflam¬
mation of the anterior horns or as something quite separate.
He wished to know also whether the supinator loogus was
affected, remarking that it was a very useful muscle in de¬
termining whether the lesion was central or not. He pointed
out that if the deltoid and biceps were paralysed the supi¬
nator longus nearly always followed suit when the lesion
was central, whereas if not central it was usually not
afiected.—The President asked whether Dr. Gowers sup¬
posed that the pain so commonly associated with the early
stage of atrophic spinal paralysis was dependent upon neu¬
ritis.—In reply. Dr. Gowers mentioned one point in treat¬
ment often neglected—the importance of not permitting the
spinal cord, when the seat of acute inflammation, to be the
lowest part of the body. The evidence was conclusive that
the neuritis was primary and not secondary to the spinal
lesion, and also that the conducting fibres of the nerve were
not involved. In regard to the grouping of the muscles
affected, as bearing on the central or peripheral nature of
the lesion, he stated that the rule of association according
to function in poliomyelitis was one to which exceptions
were met with, in which the distribution of the palsy was
more or less random, and indicated an irregular position of
the lesion in the grey matter, by which groups of cells were
partially and irregularly damaged.
Mr. Pearce Gould read a paper on a case of Symmetrical
Gangrene of the Feet from Obliterating Disease and Throm¬
bosis of the Arteries and Veins. The patient was a draper’s
traveller, forty-three years of age, who, with the exception
of an attack,of mania some years ago, enjoyed good health
until Christmas, 1889, when he suflered from influenza.
This was folloived by mental depression, and on June 22ad
ho was admitted into the Newington Infirmary, suffering
from hallucinatioDB and mania. Two days later he was
transferred to Grove Hall Asylum under the care of Dr.
Mickle. On Jan. 29bh he complained of severe pain in the
right knee, down the leg, and into the foot. Two days later
the right foot was found to be cold and blue, and no pulsa¬
tion could be felt in either tibial artery. He now com¬
plained of pain in the left foot. On Feb. 2nd the right foot
was gangrenous, and the left foot was cold and blue, and
quickly became gangrenous. On Feb. 22nd the patient was
transferred to Mr. Pearce Gould’s care in Middlesex Hos¬
pital. Both feet were black and gangrenous to above'the
malleoli; the tips of the toes were mummified, the rest of
the part being soft, but without much swelling, vesication,
or crackling; the left leg up to the knee pitted on pressure.
On the right side pulsation was felt along the whole length
of the femoral artery, and the popliteal trunk was a hard
pulseless cord. On the left side pulsation was felt as low
as the level of the knee-joint, and there abruptly ceased.
The other arteries of the body, the heart, and the urine were
found to be healthy. The patient was febrile, the tempera¬
ture ranging from 100° to 101°. The mania and hallucinatioDB
had disappeared with the onset of the acute pain in the feet.
The legs were amputated through the knee-joint by Stephen
Smith’s method, at a week’s interval, and the patient made
a complete butt slow recovery. (He was shown at the
meeting.) Dr. Sidney Martin examined the vessels of the
diseased limbs, and exhibited microscopical specimens of
several of the vessels which showed a widespread endarte¬
ritis andendophlebitisaffectingbothlar^eand small vessels,
the change being more marked in the veins than the arteries.
Many of the diseased vessels were plugged with organieiog
thrombi. Commenting on the nature of this case of spon¬
taneous gangrene, Mr. I’earce Gould said that many causes,
such as atheroma, calcareous degeneration, ergotism, and
diabetes, could be at once excluded. Although the sym¬
metry suggested Raynaud’s disease, there was nothing else
to support that view’. No previous attacks of ischminia;
no biomoglobinuria. There was also no history or evidence
of constitutional syphilis. Although but little was known
of the disease called “ primary arteritis obliterans’’—coses
of which had been reported by Dr. Hadden and Miuself te
this Society, and by Burow, Jaescli, and Winiwarter in
Germany,—he felt that at any rate provisionally it must
be placed in this category, in spite of the symmetry and
ncute onset of the gangrene, in winch it differed markedly
from the above-meuiioned cases. The pathological evident*
664 The Lancet,]
CLINICAL SOCIETY OF LONDON.
[March 21,1891.
of a primary eadarterltis aod endophiebitis was tbe maia
argument in support o! this view. The treatment pursued
—amputation well above the gangrene — was opposed to
tbe general rule of surgery in cases of spontaneous gangrene.
It was held to be justified by the relief it alTorded from tbe
blood poisoning from tbe gangrenous parts, by the distinct
indications of the limitation of tbe vascular disease, and
also by the special merits of Stephen Smith’s amputation.—
Dr. Mickle said the case bad oeen under bis care before
passing under that of tbe author. The patient was evidently
predisposed to insanity, having had previous attacks lasting
lor a month. With regard to the case being produced by
syphilitic disease of the arteries, he remarked that there
was apparently no connexion between the medical and the
emgical aspects of the case. Tbe case was not like those
he had seen of syphilitic disease of the arteries giving rise
to secondary diseases of the brain with nervous and mental
symptoms and gangrene of tbe lower extremities. Tbe only
case of this kind which be had seen was one in which, in
addition to brain lesion attributable to syphilitic disease of
the cerebral arteries, there was syphilis of tbe heart. Mr.
Gould’s pitient had Buffered severely from influenza, and
the attack was followed by great depression, to which was
superadded a good deal of worry in consequence of his
having lost his place. This worry led to a second severe
attack of insanity. When admitted he had a number of
bruises on the limbs and also on tbe trunk, but he incurred
none afterwards, every care having been taken by placing
him in a padded room &c.—Dr. CiiURTON of Leeds said he
had at the present moment, in the Leeds Infirmary, under
bis care, a case which had given him a good deal of
anxiety. It somewhat resembled that related by Mr.
Gould. The patient was a woman of forty-two, married,
exceedingly scout, full-blooded, and strong. She was
brought in complaining of loss of piwer and sensation
In the left leg, which was dark and discoloured. Tbe
limb WES cold and insensitive, and sensation in the back of
the limb extended three inches lower than in the front.
There were patches like blisters and superficial ulceration,
hut she had nad some turpentine applied before admisdon,
and be was uncertain how far this local irritation had been
caused thereby. She had bad one child twenty years sgo,
and none since. No miscarriage and no signs of syphilis.
Tbe arteries could not be examined on account of her obese
condition, but there was distinct thickening in the line of
the femoral. The heart was enlarged, and there was a
systolic brnit at the apex ; at the base there was a slight
aortic clank. No ccdema or disease of the veins, hut there
was a little albumen in the urine. The attack began on
Feb. 1st, with pain in the right foot, numbness and tingling.
The limb was rubbed and the sensation disappeared. The
same day the left foot began in a similar manner and could
not be got rid of by rubbing ; on the contrary, in a very
short time it began to be discoloured. It was thought that
she was about to have gangrene, and be was urged to con¬
sent to amputation, but he waited for eight days. He sup¬
posed that it was an endoarteritis of the femoral artery
above the profunda. It was not until Feb. 12Gh, when the
skin was becoming mummified and the foot was shrinking,
that he consented, and the leg was amputated by Mr. Mayo
liobson. A soft clot was found in the artery, but it itself
was healthy. A few days later the right foot began to
show symptoms of gangrene, but this gradually passed
off. The patient bad been given blue pill, and this seemed
to have some effect in causing it to clear up ; she was
otherwise in a very good condition.—Mr. Lunn said tliat
he had shown a case at this Society eome time ago for
purposes of diagnosis. It was a man with cold, black
feet associated with agonising pain, requiring large doses
of opium for its relief. Tbe general opinion was in
favour of its being due to liajnaud’s disease. The man
was quite unable to get about. One foot got very black
and enlarged up to tne ankle-joint. He amputated tbe
foot, and the man gob so much better that he amputated
the other. The last few months he had begun to get his
old pain again, and tbe stump was still extremely cold, a
fact which inspired him with some apprehension. His legs
were perfectly sound at present, bub were very cold. This
case was far more chronic than the one related. He asked
what was the cause of the delirium in Mr. Gould’s case;
the man had told him that he was liable to get very wet
feet.—Mr. Lonqhurst suggested that it might be due to a
dyscrasia of the blood associated with gout, diabetes, or
syphilis. He thought the symptoms pointed to a complaint
having a nervous origin.—Mr. Gould, in reply, observed
that it must be always a matter of doubt as to what was
the precise cause. His own opinion was that there was a
blood state giving rise to an inflammation of the arteries in
the lower limbs, and then that the blood state plus the
state of the arteries led to thrombosis. There was no
evidence of trophic change or anything to indicate a nervous
origin. He was glad Dr. Mickle had given his experience
of tbe case, for when the man was admitted to the nospital
his memory was markedly imperfect, and he could give no
dotoils of his past history—so that lie was unaware of his
having suffered from influenza, a very important detail.
Dr. Churton’s case was one of extreme interest, and was a
parallel to his own. As to the coldness of stumps, he
would not be inclined to lay much stress on this, it being
very common and not necessarily inspiring any apprehension.
Mr. C. Mansell Moullin read the notes of ttiree cases
of yeptieicmia due to Sewer Air. Tlie first was a com¬
pound comminuted fracture into the ankle-joint in a
healthy hoy aged twelve; the second, a large, cold, sub-
gluteal abscess (probably originating in the bursa) in a man
aged fifty-two; the third, a compound dislocation of the
metacarpus in a boy aged seventeen. The three cases were
admitted, the first on Oct. Ooh, the second on Nov. Oth,
and the third on Dec. 2nd, 1879- They occurred in the same
bed in tbe same ward, and there was no other case in the
ward either then or since, although at the same time, and in
beds immediately opposite (but on the windward side), were
such injuries as compound fractures of both legs and
primary amputation of the leg, trephining for injury to the
frontal bone, and fractured jaw. The first and the lost
case (those in which llie injury was confined to the limb^)
were treated by prolonged iiiiinersion in baths of perchloride
of mercury (1 part in 10,000), the first for two hours twice a
day, tbe last continuously. The abscess was drained
thoroughly and inigated with carbolic lotion- In all three
the symptoms presented a striking resemblance. In the
first (treated by baths twice a day) the temperature rose at
once and rapidly assumed a severe remittent character.
In the second it rose, not when tbe abscess was opened, but
two days later, when the wound was exposed, and followed
the same type In the third it remained normal so
long as the limb was immersed, but each time an attempt
was made to leave off the bath it rose at once. The first
recovered after amputation ; tetanus set in on the twelfth
day after tbe injury, and the symptoms rapidly increased
in severity until tbe limb was removed ; then they began
to fall at once, although it was nearly a fortnight before they
disappeared. The second and the third died, the latter of
the two suffering for the last week before death from rigors,
which recurred twice a day with the regularity of ague.
The cause was found out by Dr. Parkos in the course of
an independent investigation ordered by the Hospital
Committee. Underneath the flooring close by the bed was
a cistern with an overflow pipe runningstraight down, with¬
out trap or bend, into an old sewer. This had formed part
of some long since forgotten system of drainage, and had
many years before been (very inefficiently) adapted to the
wants of the hospital. The pipe acted as the ventilating
shaft, and under the flooring there was a strong current of
air setting in tbe direction of the bed. Tbe pipe was
sealed and no case had occurred since. Mr. Mansell MouHin
pointed out that the poison must have been absorbed
through the wound without causing any local inflanmiaiion ;
there was no cellulitis, lymphangitis, or phlebitis; there
wos no sign of any tecondary abscess or of any visceral
inflammation (although one patient suffered from diarrhuiv),
and no gross lesions oi any kind (other than slight granular
disease of the kidneys) was found in the post-mortem
examination of the second case. Unfortunately permission
could not be obtained for the third,—Mr. Bruce Clarke
said that about six or seven years ago there had been an
extraordinary number of cases at the West London
Hospital, and never since. He observed that all the casc.s
had occurred in two or three beds at one corner of the ward,
and on attention being directed to the sanitary conditions it
was noticed that there was outside the window in that
corner a dustheap upon which a number of bones had been
llqiig, and on to which drained a pipe from the post-mortem
room ; the air from it passed into the window. This was
rectified, and there had not been a ease since.—Dr. Donald
Hood narrated a series of rases showing tlio deleterious
effects of sewer air. iS.mietiiiios it produced simple, unex-
p'a'nahle oscillations of temperatur^ the morning teiu-
The Lancet,]
MEDICAL SOCIETY OF LONDON.
[March 21, 1891. 665
perature generally being the hiaher. In other cases he
showed that it hew a very marked effect in prolonging and
aggravating diseases, such as measles, normally of a mild
character. In one family in which measles lingered for a
considerable time one member of it died from a malignant
form of the disease, but they all rapidly recovered on being
removed to the country. He thought it was most impor¬
tant to recognise the effect of sewer air upon the natural
course of any disease.—Mr. Man.skll Moullin, in reply,
said be had seen several outbreaks of tetanus, in each of
which only one of three or four persons was attacked in the
same ward. He had been unable to trace any connexion in
the matter of contagion or infection. He presumed that
there was no doubt at the present time that tetanus was a
disease which was caused by external agents acting upon
wounds.
MEDICAL SOCIETY OP LONDON.
Litholapaxy in Children.
An ordinary meeting of this Society was held on
March 16th, Dr. Douglas Powell, President, in the chair,
Mr. Edmund Owen reported a fatol case of rupture of a
boy’s bladder, which accident occurred during the perform¬
ance of the operation of Litholapaxy. The patient was an
unhealthy child of something less than five years, who for
two months had been troubled with frequent and painful
micturition, the urine being thick and offensive. He had
been taken to a large hospital, where, the mother said, cir¬
cumcision had been advised; but it was also suggested that
the boy was nob at that time in a Qt state to be operated on.
He then came under Mr. Owen’s care, and, on sounding
him, a euiall stone was discovered. Slight bleeding followed
this examination. The boy was put to bed and fed up for
twelve days in order that his strength might be so much
improved that be could the better stand the operation of
litholapa.xy after the manner of Surgeon-Major Keegan.
At the end of this time chloroform was administered, a
No. 0 libhotiite was introduced, and the stone was effectually
and efhciently dealt with. The bladder was then washed
out, and the fragments were removed by a No. 1) evacuation
tube. The operation was thus practically at an end. A
final washing was being performed, however, when an
ominous gurgling was heard, and'an unmistakable wave
ascended nehind the anterior abdominal wall. All resist¬
ance, moreover, to the flow from the evacuator had ceased ;
and on detaching the wash-bottle, only a trifling amount of
water escaped by the tube. There could be no doubt, that
the bladder had given way, and that the best chance of the
boy’s recovery probably lay in opening the abdomen and
sewing up the rent. Accordingly, a three-inch incision was
made in the linea alba above the pubes. The peritoneum
was opened, and a search was made for the collapsed
bladder in the depths of the pelvis, nothing beingeeen of the
bladder until the peritoneum had been traversed. The rent,
however, was eventually discovered in front of the peri¬
toneum, and at the root of tlie urachus. It was also made
out that the irrigation-lluid which had escaped from the
bladder had infiltrated itself along the subperitoneal connec¬
tive tissue, none of it having entered tJie peritoneal cavity.
The rent in the bladder—which was about one-eighth of an
inch long—was sutured, and the abdominal wound was
closed. It was deemed expedient to secure absolute rest
for the bladder by a perineal drain. A lateral incision was
therefore made through the prostate, and on passing the
linger through it into the bladder a few insignificant frag¬
ments of stone, which were to have been removed by the
final washing, were detected. The boy died of collopse in
about eight hours. Mr. Owen attributed the calamity to the
fact that in the temporary absence of a wash-bottle of a size
appropriate to childhood he was using one designed for the
adult. He had no extenuating circumstances to urge. The
case had been a great grief to him, and he had come to the
conclusion that the only way in which lie could atone for
the misadventure, in however slight a degree, was by openly
reporting it. Perchance his experience, thus being placed
on record, might be the means of averting a similar cata¬
strophe at the hands of others.
Surgeon-Major Keegan of Indore then read a paper on
Litholapaxy in Children, which he illustrated by specimens
of calculi and various instruments. We give here an
abstract of the communication. The collection which he
showed consisted of 117 out of 12.'5 litholapaxies which he
had performed in males below fifteen years of age. They
varied from one 3 >car and nine months to fourteen years,
the average being 6 .38 years. The average weight of the
calculi removed was 89'15 grains. The average number of
days spent in hospital after operation was 4'6, and the per¬
centage cf mortality was 3'2. The four deaths were not
the result of any accident during the operation, but were
duo in each case to organic disease of the kidneys. There
was but one recurrence of stone in the series, and this was
not more likely to happen than in lateral lithotomy, pro¬
vided no detritus was left behind. This absence of recur¬
rence in children was due to the fact that their bladders
weie seldom hypertrophied, sacculated, or fasciculated, and
they did not, of course, labour under enlargement of the
prostate, which were the main causes of recurrence in the
aged. Ho gave preference to this procedure over the lateral,
median, and supra pubic operations for two reaeons: the
rapidity of cure ana the freedom from the objections and
dangers inherent in all surgical operations in which the
knife was used. But though be thus advocated crushing in
preference to cutting, he could not recommend surgeons
who had had no experience of the former operation to
attempt it on a young male child the subject of a calculus
of considerable size and hardness. Such a surgeon would
act more wisely if he adhered to the lateral or supra-pubic
methods of procedure. He also showed a collection of
lithotiites and evacuating catheters, and one or two aspira¬
tors. He held that no surgeon should set about attempting
to perform litholapaxy on a child trusting to one lithotrite
and one evacuating catheter; for a lithotrite which would
pass readily enough into a boy’s bladder at the beginning of
an operation might not do so towards its termination, when
the urethra had perchance become swollen and congested
by the frequent passage of instruments. He showed five
lithotrites. Nos. 4^, .5, 6, 7, and 8, and five evacuating
catheters, Nos. 5, 6, 7, 8, and 10; also two aspirators. For
most canes two or three lithotrites and three cannuim would
probably suffice. Fully fenestrated lithotrites should be
used, and cannulm fitted with large stylets to prevent
clogging with dibris. He had found by experience that the
narrowest part of a child’s urethra, except the meatus,
was at the junction of the penile with tlie scrotal portions,
about two and a half to three inches from the meatus. His
manner of procedure ivas as follows. The child’s bladder
should be emptied of urine and two or three ounces of water
at blood heat should be thrown in. Wlien the lithotrite
)iad been withdrawn after the crushing, the cannula fitted
with a stylet was introduced. The styles being withdrawn,
nearly all the water in the bladder was allowed to drain off.
The aspirator, filled with water at blood heat, was then
attached to the cannula, and an assistant pressing gently
over the bladder, the aspirator was steadily and gently
woiked. The stylet should be run home before the cannula
was removed, the last particles of stone being first well
searched for. A finger introduced into the rectum would
frequently be found to dislodge some small fragments
resting near the neck of the viscu". The height of the
operating table should be such that the surgeon should not
be compelled to stoop. A light hand was essential, and
anything approaching to forcible introduction of lithotrites
or cannula) into the bladder was fraught with danger. To
illustrate what had been stated be briefly sketched the
salient points connected with the operation of crushing a
few out of the large number of stones be exhibited. (Par¬
ticulars of these cases will be found in The Lancet, vol. ii.
1890, pp. 716-717.) He likewise showed the debris of calculi
from girls aged respectively three and seven, and a few large
ones from his collection of stones from the adult male bladder.
In conclusion, he emphasised the necessity of attention to
the details of structure of the instruments employed already
mentioned above, and added that four or five ounces of
water should be the maximum quantity in the bladder at
any given moment, injection never being practised while
the patient was straining, that extreme gentleness and
care should be taken in practising all manipulations in the
bladder and urethra, and that it should be ascertained that
not a grain of ddbris was left behind in the bladder. Upon
attention to all these conditions would depend the measure
of success obtained.
The President asked if these cases came from a large or
from a restricted area, and if stone was particularly pre¬
valent in Central India. Was its formation connected with
the diet, and was he in the habit of prescribing to prevent
recurrence of the calculus.
Mr. Marshall of Nottingham said he had been very
Coogle
1866 The Lancet,]
OBSTETRICAL SOCIETY OF LONDON.
[March 21,1891.
pleased 'A'ith the result of his lateral lithotomies, having had
twenty-six without a death. He bad performed one supra¬
pubic operation, which proved fatal. But an increasing
experience of litholapaxy in children made him feel that it
must be the operation of the future; the rapid way in which
they recovered in three days instead of an average of three
weeks, as with lithotomy, being a great point in its favour.
He had only had one untoward circumstance with litho¬
tomy: his lithotrite bent when he was crushing a white
oxalate stone. He therefore removed the instrument, accl
performed a lithotomy instead. He could not see the
advantages of the supra-pubic over the old lateral method.
With tM exception of one case of hccmorrhage, one of
jistula, and three or four of incontinence, he bad had no
trouble at all from his cases of lateral lithotomy. As to
the question of emasculation hy the lateral operation, he
knew of no data bearing on that point, but amongst the
fathers of the boya he had cut were two who had also been cut
for stone. The supra-pubic was said to be an easier method,
but he did nod admit that it was freer from danger, and so
few of tbe cases that had been operated on had been pub¬
lished. With regard to recurrence, be bad had only one,
and that was amongst his earlier cases, where tbe stone bad
been crushed imperfectly. He aske(\ Mr. Keegan if he re¬
garded chloride of sodium as a preventive of stone, and if
the abuse of the farinacea and abstention from water were
causative agents.
Mr. Morgan said that in children a cutting operation
should if possible be avoided, and though the lateral
operation M'as successful, nevertheless certain calamities
resulted from it. Haemorrhage, for instance, to a serious
extent had happened, and ne recollected five or six
cases of fistula between tbe bladder and the rectum.
As to emasculation, tangible proof had been given of
its occurrence. The supra-pubic operation was not to
be advised save under exceptional circumstances, such
as where the stone was too large or constantly avoided
the lithotrite. The objections to litholapaxy were none
where the stone was suitable. Practically no force was
accessary to bring out the fragments with the aspirator,
the slightest pinch causing extensive movement of the frag¬
ments. The only objection to the procedure that had been
made was that small fragments might remain and form a
nucleus for a fresh calculus. In London but very few cases
resented themselves, the average at Great Ormond-street
eing only four and a half per annum.
Mr. Buckston Browne held that all honour was due
to Mr. Owen for his surgical honesty in publishing his
case. He did nob expect to hear that the rupture was
extra^eritoneal. As the incision was being made he asked
Mr. Owen if be noticed water in the tissues, and he
inquired also the reason of making the perineal opening.
The proper performance of lithotrity depended upon coin-
? lete aneesthesia, so that tbe patient could not strain.
'his was especially important when washing out was being
done. Witn regard to the evacuating catheters shown, he
thought that for children they might be shortened one half,
and thus get the stone over in lees time. It was useful to
have a clean spare aspira^’ing bottle to use for the last
washing, and thus make absolutely sure of emptying the
bladder of fragments.
Mr. Reginald Harrwon said that he was sceptical as
bo the application of lithotrity to such young subjects
until Mr. Keegan s paper was ipublished. He had performed
the lateral operation thirty-five times on children with a
mortality of only one, and be had no complication or
after consequence which had been cause of regret. The
facts, however, which had been brought forward were of
such a cogent nature that he was induced to take to '
lithotrity, and the more he bad seen of it the more he
could recommend it. He bad performed it thirteen or
fourteen times, and the results as to rapidity of recovery
compared most favourably with tbe lateral operation. He
had, however, only used it at present for comparatively
small stones.
Mr. Owen, in reply, asked Surgeon-Major Keegan if he
had ever met with a medinni-si^ed stone in a child which
ie had been quite unable to crush, and for which lithotomy
had to be done. He himself bad met with such a case; the
calculus being of tbe mulberry variety. It had been said
that the supra-pubic operation bad no statistics, but more
appalling results than those published from Russia could
not be imagined. He would put tbe operation altogether
sn one side, and use the lateral operation for children
where litholapaxy could not succeed. He noticed water in
the extra-peritoneal tissue as be cut down. The incision in
the perineum was perhaps a mistake, but it should be re¬
membered that he bad already opened the peritoneum, and
that therefore a very efficient drain was desirable.
Surgeon-Major KEEOAN,;in reply,said that stonein Central
India was common, and that a number of dispensaries fed
tbe hospital of which he had charge in Indore. The number
of cases of calculus in the whole of Madras probably did
nob amount to more than 24 a year, while in Scinde and
Hyderabad there were as many as 180 or 200. In Lower
Bengal stone was not common, but it was very prevalent
in the North-West Provinces, in the Punjaub, and along
the Bombay coast. He was unprepared to state the cause
of stone, though no doubt food, geological formation, cloth¬
ing, and meteorological conditions all played a part in its
production. On one or two occasions he had seized a stone
which he had failed to crush, and so he had resorted to
lateral lithotomy. His first fatal case of litholapaxy he
published in the Indian Medical Gazette in 1888, the death
being due to disease of tbe kidneys, but no post-mortem
examination was allowed. He hoped that those who had
performed the supra-pubic operation for cases of small stones
would also place their cases fully on record.
OBSTETRICAL SOCIETY OF LONDON.
Presidential Address.
A MEETING of this Society was held on March 4th.
The following specimens were exhibited:—
Mr. Bland Sutton: A case of Tubal Pregnancy.—Dr.
Hayes: (1) An Inbra-uterine Sessile Polypus; (2) Sub-
peritoneal Pediculated Fibroid Tumour of the Uterus.—
Dr. Crawford: Ovarian Tumour, with a Polypus in the
Uterus, and a Small Tumour and a Fibroid 'Tumour.—
Dr. Grigg: (1) Cyst (Tubo-ovarian?); (2) Pyo-salpinx com¬
plicating Pregnancy; {.8} Double Pyo-s^pinx, with Tubo-
ovarian Cysts; (4) Matted Appendages.
The President (Dr. Watt Black) then delivered his
address. He thanked the Society for the honour con¬
ferred upon him. He congratulated them upon the
prosperous condition of the Society. He then dealt with
the subject of puerperal fever and septic poisoning.
In ancient times puerperal fever had been described as
suppression or retention of locbia. ' It had been referred
to in tbe seventeenth century. According to Copland,
the first satisfactory account of it was contained in Halle’s
“ Dissertatio de Febre Puerparum” published at Leyden
in 1689. The first writer who had given an adjectival
name to puerperal fever was Richard Morton. Edward
S brother was the first writer who used the name ‘ ‘ puerperal
fever.” The numerous outbreaks of puerperal fever which
had occurred in the second half of the last century had led
to the production of a considerable number of monographs
on the subject, especially in this country. The chief of the
writers were John Hall, 1755; Thomas Denman, 1768;
Nathaniel Hulme, 1772 ; Charles White, 1773; John
Leake, 1773 ; Thomas Kirkland, 1774 ; William Butler,
1775 ; Philip Pitt Walsh, 1787; John Clarke, 1793; and
Alexander Gordon, 1795. In these writings puerperal
fever was referred to as erysipelas, putrid fever, putrefac¬
tive fever, pituitous fever, bilious fever, gastrobilious
fever, typhus fever, typhoid fever, nervous fever, inflam¬
matory fever, peritoneal fever, bysteritip, uterine phlebitis,
lymphangitis, and many different diseases such as existed
under other circumstances, but modified by tbe puer¬
peral state. References were them made to the writings
of Dr. Nathaniel Hulme and Dr. William Butler.
Puerperal fever had been attributed to many causes.
Amongst them might be mentioned suppression, retention,
and putrefaction of the lochia, retention of secundines,
retention or metastasis of milk, severe labour, tight binder,
rising too soon after delivery, mental emotions, errors of
diet, use of stimulants, exposure to cold, epidemic in¬
fluence, miasms, and hospital air. Veson attributed the
mortality at tbe HOtel Dieu to tbe fact that the lying-in
ward was over the ward for the wounded; also that the
number attacked with puerperal fever was greater when
the air was moist. Dr. Kirkland had recommended that
the patient should sit up two or three times a day in order
to facilitate discharge of the lochia, clots, &c. Charles
^ 8 -
The Lancet,]
ROYAL ACADEMY OP MEDICIJJE IN IRELAND.
[MaiicJi 21,1891. 657
Whife, P.R.S., surgeon to the Manchester Infirmary, was
the lii'st to assert the infeetiousness of puerperal fever (1773).
Other writers had previously discussed it, but only to discard
it. Some supported the view, but it was Dr. Alexander
G-ordon of Aberdeen who brought facts to prove iis infeccious-
ness. He also had given an admirable account of the
relation of erysipelas to peurperal fever. In 1851, when
forty-five cases of puerperal fever occurred in the practice
of one man, while none of the patients of the other prac¬
titioner in the same place had been attacked, no other ex¬
planation had been required than that itwasa dispensation
of God’s providence. A belief in its infeetiousness had led
to precautions being taken, and thus outbreaks had been
frequently arrested or checked. The next moat important
advance was the tracing by Semmelweis of the infection
to the introduction of decomposing animal matter into the
enital passages by the attendant. The revelations of
acteriology and the proved prophylactic efficacy of anti¬
septics have set the q'JSstioD at rest. Many interesting
facts in bacteriology were then given. The experiments of
Ahlfeld were related, in which he showed that the inner
surface of the uterus possessed its greatest absorbent
power on the third, fourth, fifth, and sixth days after
labour. Edmund Ealk had also shown that the endo¬
metrium possessed remarkable absorbent poweis, while
the vagina had very little and the mucous membrane of the
cervix scarcely any. It had not yet been ascertained to
what cau-se wa.s due the groat diversity in the anatomical
changes produced by puerperal fever iri difi'erent cases. In
all cases of puerperal fever microbes of the coccus order were
to be found, and most frequently of all the streptococcus
pyogenes. As the microbes came from outside, the auto¬
genetic origin had been virtually abandoned, Of late, how¬
ever, it had been revived in a modified form. Czerniowski
had examined the uterine lochia of eighty-seven perfectly
healthy women, and had found no microbes of any sort,
except in one case in which there were streptococci, and in
two cases in which there were the bacillus subtilis and
sarcinju. Ho had examined the uterine lociiia of seventy-
seven women suffering from slight illness, and had found
streptococci in forty-nine, staphylococci in two, and non-
pathogenic forms in a few others. He had examined the
uterine lochia in ten women who were sufferinar from severe
illness, and had found streptococci in all. Homen found
the number of bacteria much greater in the first day of
menstruation than before menstruation bad begun. Dr.
William Taylor of Edinburgh believed that ho could trace
certain cases of puerperal fever to the want of proper
cleanliness on the part of nurses who happened to be
menstruating at the time. The results of experiments by
several observers were then given. Hauamann had found
that serum from the body of a person who had not died
of sepbiciomia did not produce fatal results when introduced
into the vagina of gravid rabbits, while pua from the
abdomen of a woman who had died of puerperal fever had
roved rapidly fatal when similarly injected in the second
alf of pregnancy. It had no effect w’hen injected into the
vagina of rabbits only two weeks pregnant. Tlie con¬
version of non pathogenic into pathogenic microliEs, under
altered conditions, was then referred Jo ; also the relative
resistances of healthy and diseased or injured tissues to
the inlluence of microbes. The influence of microbes in
the production of mastitis and of various infantile diseases
was fully described. Natural immunity was next discussed,
as well as acquired immunity, or the exhaustion theory.
A vote of thanks was given to Dr. Watt Black, on the
motion of Dr. I'laj fair, seconded by Dr. Chanipneys.
ROYAL ACADEMY OF MEDICINE IN IRELAND.
A MEETING of the State Mediolue Section was held cn
Feb. 13bb.
_ The Midtoives' Registration Bill.—In the absence of Dr.
Atthill through illness his paper, on the Education of Mid¬
wives considered in connexion with the Midwives’ Kegis-
tration Bill, was read by Dr. Cosgrave, hon. sec. of the Sec¬
tion.—Dr, Foot thought it would be the duty of the Medical
Council to lay down regulations for the education of
midwivea. The chief interest of the discussion would lie in
the direction of the points of contact between the proposed
educated niidwives and the general practitioneis.—Dr.
Quinlan said that as the Bill did nob extend to Ireland it
appeared to him that the principal point was to protect the
right of practising in England and Scotland, now
belonging to the diplomated midwives and nursetenders
who bad hseu lleunsed by the two chartered Dublin
hospitals, and also by ilie Royal College of Physicians of
Ireland. At present these Irish diplomates were legally
authorised to assume the title of midwife in any part of
England and Scotland. If this Bill were passed, the rights
of these diplomates would be swept away in the two sister
kingdoms. He thought that the institutions referred to
ought to see to this either by petition or some other way.—
Dr. J. W. Moore severely criticised the Midwives’ Regis¬
tration Bill, more particularly in reference to the uneatis-
factory provisions contained in it for the framing of rules
respecting the examination of midwives, the appointment
of examiners by county councils, and the wholesale registra¬
tion of existing midwives for a fee not exceeding 2s. (id.
The Royal College of Physicians of Ireland had taken
active steps against the present Bill on public grounds,
and had urged the necessity of referring the whole sub¬
ject of the education and registration ot niidwives to a
Select Committee of the House of Commons before legis¬
lation on so momentous a matter is undertaken. 'The
speaker considered that this was the wise and proper
course to pursue.
Note on Illness caused apparently by Aniline Coloured
Sweetmeats. —Sir Charles Cameron, after' pointing out
tliab numerous cases of illness had been attributed to
aniline colours used in clothing and for colouring food, ex¬
plained that the toxic action of the dyes was generally
attributed to the arsenic used in the preparation. The
author had investigated three distinct cases of illness in
which the symptoms were attributed to the use of coloured
confections. The children in three distinct families were
taken ill with voaiitingand purging after eating coloured
comfits apd sugar balls. Some of the cases were treated in
Mercer’s Hospital. Analysis revealed in the confections no
mineral poison ; but it was noted that the colouring matter
was veiy large in quantity. It proved to be fuchsine. The
author thought that these cases rendered it not improbable
that fuchsine might be toxic even when free from arsenic.—
Dr. Foot said he thought the injurious effects of aniline
dyes, especially fuchsine, might be due to the affinity for
this colouring matter on the part of the protoplasmic
matter of cells, which imbi’oition and staining might
reasonably be expected to interfere with their physio¬
logical or biological action, and therefore be detrimental
to various bodily functions,—Dr. Quinlan said that the
colouring of confectionery was a very interesting subject.
One of his earliest recollections was the banquet given in
Dublin to the soldiers coming from the Crimea. On that
occasion the tables were decorated with confectioned
edifices, which, perhaps, contained as much plaster-of-Paris
us sugar ; in compliment to this country, they wore mostly
coloured green, that colour being due to Scheele’a green.
Through a window left open for ventilation the boys of
the locality got in after the banquet, feasted on the con¬
fectionery, and as a result there was extensive arsenical
poisoning. Fortunately, none of these cases proved fatal,
but they gave great anxiety. He thought that the use of
nniline colours in confectionery was much to be deprecated.
Aniline colours were very powerful, and very small quan¬
tities were required for colouring confectionery; still, we
have available vegetable and animal colours which are
absolutely safe ; and with these resources he thought that
aniline colours ought to be let alone until, at all events, we
knew more accurately the details of their toxic effects. Of
course, it was unnecessary to add that the use of metallic
pigments by the confeclioner was simply a crime which
ought to be severely punished in all cases where it was
detected.—Dr. Falkiner and Dr. Lentaigne also spoke.
Civil Service Insurance Scheme. — Dr. MacDowel Cos-
ORAVB read a paper on the recently instituted Civil Service
Insurance Scheme. The committee of the Civil Service
Insurance Fund have arranged with the North British
and Mercantile Insurance Company to insure, up to
£1000, the lives of all civil servants applying within
two years, without any medical examination, without
any declaration of health, and without any re^eretice
to friends. After the two years have expired all joining
the Civil Service will be insured on the same terms any
time within five years of having passed the medical exami¬
nation made on entering the service- In both oases a ro-
duction of 15 per cent on the first premium and on renewaU
is given. The author pointed out the probable resultj
B68 The Lancet,!
REVIEWS AND NOTICES OF BOOKS.
tMARCIl21, 1891.
thaC whilst bad lives—i.e., those rejected or required to pay
higher premiums by other oflices—would be certain to take
advantage of this chance, first-class lives would probably
prefer offices taking only healthy lives, and so more likely to
pay good bonuses. Several lives rejected or loaded by the
author, which had since entered under the new scheme,
were cited. If the scheme succeeded, it would cause other
companies to relax their medical examinations, and would
tend to place insurance in the hazardous condition it occu-
f ded early in the century. It would also injure first-class
Lves by putting them m the same category with the in¬
different and bad lives.— Dr. Lbntaigne was greatly
interested in Dr. Cosgrave’s paper; he would add that he
felt very uneasy at what seemed to him a very reckless and
dangerous policy.
iralt llotkes d ^iwrlis.
New Official Remedies, containing all the Drugs and Pre¬
parations contained in the Addendum (1890) to the
Rrilish Pharmacopeia of 1885, with Pharmacological
and Therapeutical Notes adapted for the Use of Students
and Practitioners. By KaH’II StockmaN, M.D ,
F.K.C.P.Edin. Pp. 67. London: Percival and Co. 1891.
The above title, expressed in every possible variety of
type, appears almost suHiciently cumbersome to weigh
down a book of such small size, and yet has apparently
only been decided upon as an afterthought, since it differs
from tlie title given on the iirst page of the text. Here we
find “ New Official Remedies contained in Pharmacological
and Therapeutical Notes on the Addendum (1890) to the
British Pharmacopoiia of 188-5.” Both titles seem rather
unhappily chosen. The remedies are scarcely “contained
in ” the Notes any more than the drugs and preparations are
“ contained in ” the Addendum. Under any other name the
rose would smell as sweet, so perhaps the definition attempted
is scarcely worth troubling about. The book is apparently in¬
tended to supply a guide to those Jo whom the Addendum to
the Pharmacopceia has come with a shock of novelty. The
pharmacological notes seem to have been compiled with a
certain degree of care from numerous well-known authori¬
ties. Although the prefatory note says nothing of the
indebtedness of the author, it is easy to trace the source of
Ifiie various quotations. The therapeutical notes are less
satisfactory. It is difficult to determine whether the author
thinks that the time is hardly ripe for dogmatic state¬
ments, or whether he feels that the pharmacological action
is of such importance that the question of therapeutics may
be comparatively neglected. Certain it is that in too many
instances the account of the therapeutic uses, as given
here, fails to afford sufficient justification or explanation of
the need of the Addendum. The Pharmacopceia was never
intended merely as a collection of substances possessing
interesting pharmacological actions, and yet the impression
left by this book is that the author regards the Pharma¬
copoeia as a pioneer, opening up new districts for further
investigation.
The alpliabetical arrangement of the Addendum is closely
followed; the only deviation being the grouping of the
official preparations under the heading of the various sub¬
stances from which they are obtained. An interesting
account of acetanilide gives in some detail the explanation
of the term “phenylacetamide”; in the description of the
tests, however, it is left doubtful whether the perchlovide of
iron test is to be applied to a hot or a cold solution. In this
the first issue of the Addendum is followed, although the
error was indicated in Squire’s Supplement and corrected
in the subsequent reissue of tlie Addendum. The account
of the pharoiacological action of acetanilide is very full,
though, perhaps, greater space might have been found for
the interesting discussions which have been raised upon the
reduction of temperature in fever. The possibility of “ in-
I creased heat-dissipation” appears to merit moic than the
bare mention. Its therapeutical uses are considered under
two headings: as an antipyretic, and as an analgesic, but
I no mention is made of its employment as a hmraostatic.
In the consideration of the treatment of poisoning by
this substance a serious warning is given against tbe
administration of alcohol by the mouth, “as it dissolves
up the antifebrin and hastens its absorption.” This is
curious, as immediately above directions are given for
emptying the stomach and bowel, after which, if efii-
eiently performed, there should be no such risk as that
indicated. With regard to lanoline, although the account
is very full, even going back to the “ancient Greeks and
Romans,” there is an uncertainty of expression which is
disappointing. “ It mixes well with most drugs, either in
solution or powder, and the mixtures are readily absorbed
by the skin. It is doubtful, however, whether absorption
takes place more readily with it than with lard.” And yet
a little further on it is stated that “in those cases of
cutaneous disease where rapid absorption is a disadvantage,
wool fat is, of course, contraindicated.” The activity
of eucalyptus gum is attributed solely to the tannin it
contains, and ite utility as a local astringent and
styptic is properly indicated. On the other hand, the value
of euonymus bark, and the dry extract of euonymus
scarcely receive due attention; the beneficial effects de¬
serve more note than the remark “any purgative will
relieve the condition, and hence the value of euonymin in
these cases.” Nor is it quite clear why, after having just
stated that “the name ‘euonymin’ is inappropriate for this
preparation,” the author should proceed to employ an “ in¬
appropriate ” term. Of gluside or saccharin the description is
short, and not well arranged; the statement that its prolonged
use is very apt to cause gastric irritation and dyspepsia is cer¬
tainly not in harmony with the experience of those who have
employed this substance largely and judiciously. The
pharmacological ajid therapeutical notes upon hamamelis
are also very brief, and although the properties of hazeline
(which u obtained by distillation) are adduced to combat
the assertion of Bartholow that the action is due to tannin,
this does not advance matters materially, as no single
volatile substance is mentioned under the heading of
“chemical composition.” Hydrastis is dealt with in
greater detail, the contrast of the effects of berberine
and bydrastine affording greater scope; but amongst the
therapeutic uses, it is stated that “ Marfori has shown that
the frequent administration of small doses keeps the
spleen in a condition of constant contraction.” Surely it
would have been better to indicate in this place in what
diseases, if any, it is desirable to keep the spleen in such
I a condition. Dr. Stockman agrees with most pharmaceu-
, tical authorities in disapproving of the composition of the
castor-oil mixture. Of phenazone the accounts given are
unusually full and satisfactory, but strophanbhus is dealt
with in a disappointing way. The composition upon which
so much work has been done is dismissed with five lines ;
while about the same space is devoted to its therapeutical
uses. Throughout the book signs of undue haste are only
too frequently apparent. Perhaps, however, these are
sufficiently to be indicated from the change in tlio title and
•from the curious misprint on p. 17, where the “ alimentary
cancel" is mentioned. To those unacquainted with recent
literature, no doubt the book will bo of service.
Studies from the Physiological Laboratory of Owens
College, Manchester. Vol. 1. Published by the Council of
the College, and edited by Professor Wm. Stirling.
Manchester : J. E. Cornish. 1891.
We should have been disposed to name this book vol. ii.,
since a work with a similar title from the same College was
Dr >og^e
Thb Lancet,]
REVIEWS AND NOTICES OF BOOKS.
tMAUUJi2I, 1891. 669
published in 1877 by Professor Arthur Gamgee. Many
of the articles have appeared in other scientific journals,
but some are original, and it is very convenient to
have all the memoirs that have issued from the Man¬
chester school in a collected form. One of the original
papers is by Dr. G. N. Stewart, in which he treats of
the conditions which ail’ecb the loss of heat by radiation
from the animal body. Dr. Stewart shows that the tem¬
perature of the surface of the clothes in man and of
the hair in animals is a very important element in deter¬
mining the amount of radiation, and this depends chiefly
upon the temperature of the epidermis, the conductivity of
the coverings, and the temperature of the air. In small
animals, he says, such as rabbits and guinea-pigs, it is
astonishing how little an increased heat production can
supply the loss of a considerable part of the protective cover¬
ing, or make up for an alteration in it which increases
the outflow of heat. It has long been known that a rabbit
dies when its skin is varnished. The superstition still
lingers in some text-books that this is duo to interference
with the excretory functions of the skin. This explanation
may perhaps hold good in the case of animals like the horse.
It is not necessary in the case of the rabbit and the guinea-
pig. For without varnishing at all, if the hair be removed
from the greater part of the body of either of these animals
by rather close clipping, or still better by shaving, and the
animal be kept in an empty box so that it cannot cover
itself, it dies in summer weather with an air temperature
of 15° to 18° C., and that sometimes in from twenty to thirty
hours. Such an animal can be restored to health if before
the cooling process has gone too far it is placed in a
warm atmosphere. The paper contains much informa¬
tion of a practical character. Dr. Stewart also contributes
an article on Electrolysis of Animal Tissues, and shows how
and wliy the process is likely to prove serviceable in various
forms of disease—as, for example, in uterine fibroidsand
supplies another important article on Polarised Nerves. Pro¬
fessor Stirling himself contributes a memoir on Red and Pale
Muscles in FisHes, which, having been published in. the
reports of the Scottish Fishery Board, has not probably
come under the notice of many readers, though it oilers
many points of interest. Mr. Cooke, the Platt phy¬
siological scholar, describes “ the action of various stimuli
on non-striped muscle.” Mr. Marshall presents areprint of
bis observations on the Histology of Striped Muscle, and
Mr. J. Edkins describes a Fat-extraction Apparatus. The
book is altogether a very good contribution to physiological
science, and a creditable result of the work in the
physiological laboratory of Owens College.
The Year-hook of Treatment for 2S91: a Critical Review for
Practitioners of Medicine and S-argery. Pp. 480. London:
Cassell & Co.
Tins year the bulk of Cassell’s well-known Year-book of
Treatment is the first thing to strike attention. Hitherto
the si /0 of the book has varied slightly, ranging from 300 to
320 pages ; but this year a sudden bound has been made,
and the book is half as large again as it has ever been. In
view of such a change, the prefatory explanatory note that
the original plan of the book has not been altered is some¬
what reassuring, although it was scarcely necessary to
add that it is not intended to be either a dictionary or a
text-book on medicine. Four names have dropped from
the list of contributors—viz., those of SirDyco Duckworth,
Dr. Goodhart, Dr. McBride, and Mr. Frederick Treves; and
three new names appear—Mr. Barclay Baron, M.B., Mr.
Stanley Boyd, and Dr. Archibald Garrod. While many of
the sections have an increased space allotted to them, the
most noteworthy increases occur in the sections devoted to
General Surgery and to Midwifery, Jmst year these respec¬
tively occupied nineteen and twenty-three pages; this year
the section on General Surgery is swollen to fifty-six pages,
and that on Midwifery to fifty-two—an amount of space
which is scarcely consistent with the idea of a concise
epitome which has hitherto ruled the production of the
Year-book of Treatment,
In dealing with Diseases of the Heart and Circulation,
Dr. Mitchell Bruce now adopts a very simple and useful
classification. The most valuable portion of this section la
that which treats of the selection and employment of
cardiac tonics and diuretics; in this a very lucidly written
account appears of the work of H. C. Wood, of Nothnagel
and of Fhrbringer, together with several valuable annota¬
tions on Sbrophanthus by Bucquoy, Moncorvo, and
Roth/legel. The question of exercise as a therapeutic
agent in cases of chronic cardiac disease had been much
advanced by the writings of Loomis, Sonsom, and
Nothnagel, although Oerfcel now advocates massage of the
heart as a safe method whereby the same nutritive and
circulatory benefits are obtainable as from hill-climbing.
Dr. Markham Skerritb writes the epitome upon Diseases
of the Lungs and Organs of Respiration, and summarises
several American views of the value of cocillana as an
expectorant. The ice bag treatment of pneumonia, the
open-air treatment of phthisis, and the employment of
creasote and guaiacol receive due notice. Necessarily,
a great deal is said of Koch’s treatment of tuber¬
culosis, but of this the reporter concludes: “It is
evident that a long period must elapse before any definite
conclusions can be drawn as to the ultimate value of this
method of treatment.” Tillmanns’ very striking case of
the surgical treatment of tuberculosis of the lung and
pleura is described, but without comment. Dr. James
Ross and Dr. Septimus Reynolds are responsible for the
section on Diseases of the Nervous System, and at the
outset they indicate how largely the published literature
has been directed to the treatment of locomotor ataxia
and of insomnia. On the whole they speak favour¬
ably of suspension for the relief of certain symptoms
of tabes, even though it is not to bo regarded as a cure.
Chloralamide, cliloralimide, sulphonal, hyoscine, uralium,
somnal, hypnal, and urethane are the more important
remedies which have been suggested for the treatment of
insomnia. The opinions of Gaudineau and Fraser upon
exalgine are followed by a somewhat lengthy list of cases
in which this drug is considered to have produced toxic
eirecfcs. Dr. Maguire’s account of Diseases of the Stomach,
Intestines, Liver, <fcc., is usefully critical, and the
same applies to the work of Dr. Ralfe, Dr. Archibald
Garrod, and Dr. Sidney Phillips. The section on
(.General Surgery, as above indicated, appears rather
lengthy, but a large amount of space is devoted
to the discussions which resulted from the publication
of the report of the second Hyderabad Chloroform Commis¬
sion. Amongst the very numerous important advances
which may be mentioned here are those connected with
abdominal surgery, more particularly those dealing with
intestinal obstruction and perityphlitis. Pressure of space
compels us to pass over the sections by Mr. Walsham, Mr.
Edmund Owen, Mr. Reginald Harrison, Mr. Alfred Cooper,
Dr. Berry Hart, Dr. Herman, Mr. Malcolm Morris, Mr.
Henry Power, Mr. George Field, and Mr. Barclay Baron,
M.B. These writers are in most instances sulliciently well
known for their names to ensure tliorougli and careful
work. The volume concludes as usual with a summary of
recent therapeutics, chielly in reference to new remedies,
compiled by Dr. W. G. Smith.
Viewed as a whole this book forms a very worthy suc¬
cessor to those which have preceded it, and it will doubtless
be received by the medical profession with the favour
extended to the volumes of previous years.
Toogle
Di'
670 The Lancet,)
LITERARY ETHICS.
[March 21,1801.
Diahates: its Games, Sym 2 itoms, and Treatment. By
Charles W. Purdy, M.U., Queeu’s University. Witli
Clinical IllastratioDS, Philadelphia and London: P. A.
Davia. No. 8 in tbe Pliyaiciatfs ami Student’s Ready
Reference Series.
Though we know very little about the immediate or
remote causes of diabetes or of the true remedial methods to
be employed for its cure, the literature connected with the
subject is very extensive, and the views advanced by many
workers in different countries are numerous and varied.
The subject is one, moreover, which is specially fitted for
investigation by physiological experiment and by wide
observations amongst different races and in various climates.
Added to these features is the fact that cases of diabetes
are nob of everyday occurrence, though they are met with
often enough to excite the interest of every practitioner, and
the manifestations of thecondition areoften more remote and
indirect than arethesymptoms of many better delined diseases.
All these things tend to render the study of diabetes v<»ry
difficulb to those who have not the advantages of leisure and
literary opportunities, and, to such, a volume of this kind is
of inestimable value. The work has been well sifted, so
that the mind is not .confused by too many or too trivial
statements, but the attention is concentrated upon the
main facts and currents of opinion which are given in a very
lucid style without the sacritice of conciseness. The various
observations and opinions are so marshaled that it is easy
to see bow far they support or are consistent with one
another, and the gaps in our knowledge, where they exist,
are sufficiently distinct, though sometimes filled in with
conjecture.
A statistical report shows that during forty years the
naortaliby from diabetes in the United States has increased
from 72 to 191 per 100,000 deaths, and tlie statistics on
which this statement is based afford a very valuable com¬
parison between the death-rates in the different States
whose climates vary widely in temperature, humidity,
and elevation. The States offer another advantage in
the several races which occupy their territories, and a
consideration of the subject shows that the incidence
and severity of diabetes vary greatly among the different
races.
The chapters into which the subject naturally divides
itself are well written, and Dr. Purdy, besides supplying a
comprehensive epitome of diabetes in its various forms,
writes of the disease from points of view that are both novel
and suggestive. The notes of cases appended furnish excel¬
lent illustrations of tbe features recorded in tbe text, and
the publishers of the “Physician’s and Student’s Ready
Reference Series” are to be congratulated on the addition
of this volume to their list.
LITERARY ETHICS
To the Editm-s of The Lancet.
Sirs,—I forward you some correspondenoe upon a subject
of great importance to authors, which I trust you will
insert in an eaily number of your journal.
I am, Sirs, yours faithfully,
Grosvenor-street, March lOth, 1801. ThOMAS BrYANT.
Dear Mr Moullin,—M v attention having been drawn
to your work on “Surgeiy,” I have been looking over it,
and find that jou liHve utilised in a very free way the
drawings I had made for my own work on “ The Practice
of Surgery,” all of which were copied from either original
drawings or from those at Guy’s Hospital. As I read in
your preface that you had Messrs. Courchill’s permission
to use the blocks made from my drawings and which
belong to them, I can probably find no fault with
your having done so; but I must venture to ex¬
press my supreme surprise that you should not have
recognised the necessity of acknowledging the source from
which you drew them, and so of guarding against tbe im¬
putation to which you have exposed yourself of passing off
upon the uninitiated my drawings as your own. You may
possibly have been led into this error by the fact that of
late years this kind of acknowledgment of other men’s work
has oiten been forgotten; but surely the sins of obWs in a
small way can in no sense justify such a wholesale appro¬
priation of my work as you have been guilty of without
acknowledgment. I regret much to have been obliged bo
call your attention to this blot upon a book which in other
respects may be worthy of commendation, and shall be glad
to hear from you on the subject.
Yours faithfully,
C, W, M, Moullin, Rs<i. ' THOMAS BrYANT.
Wimpoio-sti'oet, W., March lltli, 1891.
Dear Mr. Bryant,—I am exceedingly sorry you should
think I liave been guilty of discourtesy or of any intention of
appropriating to myself work done by others. 1 had under¬
stood from the publishens that, provided I made an acknow¬
ledgment in the preface, I was at libeity to make use of
the blocks illustrating your book, in the some way as those
of Fergusson and Astley Cooper. I can only express to you
my deep regret that I should have misunderstood them to
such an extent. Immediately on the receipt of your letter
f went to consult them, and I have arranged that the preface
shall be cancelled at once, and that a new one shall be
written specifying the illustrations that I have appropriated.
May I ask you, therefore, kindly to look over the list of
illustrations in the copy of my work that I am sending
with this? I have marked either with “Life ” or “Bryant”
all those of the origin of which I am certain ; but would
you lot me know whether the others I have marked in
pencil, which were printed from blocks in the publisher’s
possession, were all of them made from originals of yours?
I cannot tell you how deeply I regret the occurrence, and I
trust you will think that I am doing my best to amend it.
With kind regards, Yours faithfully,
C. W. Mansell Moullin.
Grosvenor-stvent, March 12th, 1891.
Dear Mr Moullin,—T have done what you asked and
marked with my initials one hundred and forty-one (141) of
the illustrations in your book which have been printed from
blocks made and used for my “Practice of Surgery.” In doing
this I have found that I am the only living author from
whom you have borrowed (?) woodcuts without acknow¬
ledgment. Can you explain bow this came to pass? Was
it by accident or design ? You say in your note of yester¬
day that you have been misled by your publishers, but I
can hardly accept such an excuse as valid, although you
might fairly have expected them to have saved you from
such an error as you have committed. You have, however,
made good use of my woodcuts, for many chapters of your
book would have been poorly illustrated without them.
What you propose to do with your preface in future
numbers may be of some service, but it cannot undo the
evil you have done, for any student of your book will as he
reads take my woodcuts for your own, as there is nothing
to distinguish them. If you have any further remarks to
make upon this wholesale piracy of my work I shall be glad
to have them. Yours faithfully,
Thomas Bryant.
Wimpolo-sti'sct, March ISth, 1891.
Dear Mr Bryant,—T he list of illustrations is being
printed again with your name attached to all those that
you marked. The number of copies issued at present is
under one hundred. The new list shall ha inserted in all
the rest in place of tlie old one.
I am, yours faithfully,
C. Mansell Moullin.
Any comments upon these letters are unnecessary ; they
speak for themselves. T. Bryant.
Clevkdon.—T he work of the Convalescent Home
is to be extended by a third house, Montpellier, Highdale-
road, being added as a home for men; Belmont and Ella-
combe, the two former homes, being reserved for women
and children. This will afford considerable extra accom¬
modation, but will also entail at least £150 per annum
more expense, besides alterations and furnishing, i
Die: edb. ‘QIC
Thb Lancet,] THE DIAGNOSTIC AND'TIIERAPEUTIC VALUE OF TUBERCULIN. [March 21,1891. 671
THE LANCET.
LONDON: SATURDAY, MARCH 21, 1891.
The voluminous reports^ which have just been issued, at
the request of the Prussian Government, from the University
clinics and pathological institutes of that country, afford an
opportunity for reviewing the situation with regard to the
efficacy of the remedy for tuberculosis introduced by Pro¬
fessor Koch. It must, however, be noted that these reports
for the most part deal only with cases injected up to the
close of the year, and therefore do not embrace much more
than a period of observation extendingover six or eight weeks.
It says much for the eagerness with which the remedy was
adopted that the total number of patients injected in the
fifty-live clinics amounted to no less than 2172, of which
number about 1700 may be regarded as having been under
treatment sufficiently long to afford some indication
as to the efficacy of the plan. At the same time this
xinique testing of a new remedy, and this remarkable
example of collective investigation, cannot be considered
as embodying a conclusive judgment. For the reports,
which bear names of men of well-tiied capacity and expe¬
rience, are mostly cautious and guarded in their conclu¬
sions—all admitting the impossibility after so brief a trial
of arriving at a positive result; added to which is the fact
that in many instances there has been no selection of cases.
Thus, as regards phthisis, it is clear that the essential con¬
dition imposed by Professor Koch to obtain a curative
result—namely, that the cases treated should be quite in
the initial stage—has been far more honoured in the breach
than in the observance.
It would be a difficult and wearisome task to analyse the
contents of this bulky volume in any detail, even if our
space afforded it. The book is within the reach of
all interested, and it will doubtless receive careful study
at their hands. Nor shall we attempt to reproduce
any of the elaborate statistics which give in striking
form the number of cases treated, their nature, and
the extent to which they were influenced for good or ill
by the use of the new method. All we can do here is
to avail ourselves of the admirable summary of the reports
compiled by the editor, Dr. Albert Guttstadt, and to
extract therefrom some of the chief opinions expressed by
eminent authorities as to the value of tuberculin in the
diagnosis and treatment of tubercular diseases. For
this purpose it will he convenient to follow Dr. GurrsT act’s
plan, and deal in turn with cases of internal tuberculosis,
and then with those of tuberclar disease of external parts.
The importance of a new aid to the diagnosis of tuber¬
cular disease within the body is obvious, not only as
enabling one to difierenfiate it from allied conditions, but
as a guide to the early adoption of therapeutical measures.
1 Pie Wirksainkait (lea Kooh'sclien Hoilmittels p;ogen Tuberculoae.
Ambliohe Bei'ichto rtov Klinikeii, Poliklliiikeu und Patlioloj^iscli-
amitoiniachen Insbitnto dev l^veussisolieii UnivoMitiCten. Borliii; \'evlag
von Julius Sprlngor. 1801.
In Koch’s “tuberculin” it was hoped that we should
possess a divining-rod which would reveal the hidden foci
of an insidious malady; and there were many who
declared that therein would lie its chief value. Ex¬
perience, however, as embodied in these reports, com¬
pels but a guarded acceptance of this opinion. A
few observers, such as Professors Lichtheim and
SCHRBIBBR of Konigsberg, and Dr. P. GUTTMANN of
Berlin regard it as an efficient test, but Professor Leyden
(Berlin) thinks it cannot he solely relied upon, and
Professor Gerhardt says that no reaction was observed in
some cases when bacilli were present. Professor Ebstein
(Gottingen), who appears to have been the least impressed
of all with the value of the remedy, does not think there is
any absolute certainty in its use for diagnostic purposes.
Professor Biermer (Breslau) is also very cautious; he had
two cases of undoubted tuberculosis with bacillary
expectoration which gave no reaction, either local or
general; whilst in another case, of alcoholic tabes, with no
suspicion of tubercle, there was a marked general reaction.
Professor Quincke (Kiel) thought it gave more certain
indications in cases of slight lung disease, but could not
admit that there was latent tubercle in every case in which a
general reaction followed the injections. The Greifswald pro-
fessors- Mosler, Strubino, and Peiper,— speak with some¬
what more confidence, whilst Professor Schultze of Bonn
thinks it a test “within limits,” and Professor Weber of Halle
that it is far less certain diagnostically in internal than in
external tubercle. Professor Finkler of Bonn met with
hut few exceptions to the rule of reaction among cases of
commencing phthisis, and did not regard the absence of
reaction in chronic phthisis as diminishing its value in dia¬
gnosis. Lastly, Professor Rumpf (Marburg) believed it was
a test which should always lead to greater care in physical
exploration of the chest and in the search for bacilli. On
the whole, then, it would seem as if the position taken
by Professor Leyden was the correct one. There is general
agreement as to the fact of reaction (local or general, or
both) whenever tubercle is present, thus bearing out the
singular selective property of the substance; but cases have
undoubtedly occurred in which in the presence of tubercle
there has been no reaction, or in which the converse has
obtained. The reaction therefore is not pathognomonic,
and the test cannot be absolutely relied upon.
The experiences gained of the value of tuberculin as a
therapeutic agent will be eagerly scanned. The unreason¬
able hopes excited on the first announcement of the dis¬
covery have in many minds given way to almost as un¬
reasoning a rejection of its utility j and it must be admitted
tiiat these reports, on grounds above stated, are inadequate
to determine the question one way or the other. Still,
when every allowance is made for the duration of the
treatment, for the elimination of cases which were wholly
unsuitable for trial, or of those in which improvement
might well have taken place without any other than dietetic
treatment and good nursing, there is no gainsaying the fact
that the results here given are on the whole favourable to
the cautious use of tuberculin in phthisis. Professor
Leyden abstains from giving any definite judgment, and
notes that, although cases of early phthisis improved, jet
tho change was not striking, and bacilli were still being
Q72 Thb Lanobt,
THE PUBLIC HEAXTH (LONDON) BILLS.
[March 21,1891.
expectorated. Professor Senator, on the other hand, is
more hopeful, especially if a longer period be allowed for
the treatment. Indeed, the cases of “cure” in the
records are so few as to hardly enter into the reckon¬
ing ; whereas the cases of marked benefit were consider¬
able, and those of “improvement” without such quali¬
fication still more numerous. Professor Eustein, to be
sure, is sceptical even as to the latter, but he stands almost
alone in this respect. Professor Biermer cites a case of
tubercular pleurisy with effusion, which rapidly got better
under the treatment. Dr. P. Guttmann, of the Moabit
Hospital, who worked in conjunction with Professor KOCii,
is the one who gives the most striking results of improve¬
ment in these pulmonary cases; and others, as Professor
Liciitheim, regard the results as remarkable. One cannot
fail to be struck by the fact that the improvement was
often more manifested in the general condition of the
patient, and especially in his subjective sensations, than
in the local signs as derived from physical examination.
The indications derived from auscultation and percussion
have been variable. Some report a frequent diminution in
the dulness and rA.les; others note an increase in these signs,
but often independently of the more constitutional effects,
There is a preponderance of testimony to the influence the
treatment had in diminishing or wholly arresting night
sweats; whilst the observations on the sputum fairly agree
in the fact that after the first increase in its amount and its
bacillary constituents, it generally diminished in both re¬
spects. Somelaystress onthedegenerativechangesundergone
by the bacilli, but others (more correctly) think such changes
of no special significance. There is a not inconsiderablediffer-
ence as regards the question of the weight of the patients
under treatment, for whereas some state that a certain pro¬
portion gained in weight, others note that this never in¬
creased, and that it either remained stationary or there
was a loss (Mosler). Dr. Feaent;^el says that as a
rule there is loss in weight so long as reaction occurs,
and after that a gain. Dr. Guttmann notes that many
patients increased in weight, some notably so; and Pro¬
fessor Geriiardt, dealing with sixty-one cases, gives
twenty-two as gaining, seventeen as stationary, and
twenty-two as losing, in weight. These are only a few
of the conclusions arrived at with respect to the
most interesting question of the applicability of the
remedy in pulmonary phthisis. It must be remembered
that the most favourable results occurred in those in whom
the disease was least advanced; but that the proportion of
cases in which “no improvement” took place was not strictly
in harmony with the extent of the disease may be gathered
from the following record: of 242 coses of commencing
phthisis, 93 were not improved; of 444 cases of moderately
advanced phthisis, 278 were in this category, together with
11 deaths; and of 246 very advanced cases, with cavities,
there were 162 unimproved, and 30 deaths. It will be seen
that there is very little difference, except in respect,to
mortality, between the two latter series. It must also be
remembered in estimating the degree of improvement in
the early stages—and, indeed, in all classes—that the hopes
excited by the new treatment may in some cases have led to a
temporary rally of the forces of the patient without any real
material advance towards the cure of his malady. When all
is said, however, it would seem that tuberculin has a place
in the treatment of pulmonary tubercle, but one which is
much more limited than was at first thought likely ; and
if the catalogue of cases which do not improve under it is to
be in any way diminished, it will have to be by a most
careful discrinrination in the selection of suitable oases.
The problem is whether the advantages derived from its use
are sufficient to counterbalance the possibility, so strikingly
brought forward by I’rofessor VlRCilOW, of harm arising
from the use of an agent that exerts a disintegrating action
upon tubercular deposits. The opinions expressed in the
late prolonged debate at the Berlin Medical Society repre¬
sent, we imagine, fnore clearly the standpoint at which
the remedy is regarded at present than do the reports con¬
tained in the volume before us, which were the first fruits
of the discovery.
So far we have confined our survey of this interesting
work almost solely to pulmonary phthisis, perhaps the
most difficult class of tubercular disease of all upon which
to obtain a definite judgment. Next week we propose to
deal more especially with the other forms of tuberculosis
in which the remedy was employed, and in some of which
the results have been more satisfactory.
Two Bills relating to the public health administration of
London have now been published, the one consolidating the
many London Acts, the other an amendment Bill which
gives bo the metropolis nob only most of the advantages now
possessed by urban authorities in England and Wales, but
in some respects places it in advance of all other districts
in the kingdom. The powers for dealing with nuisances
are very comprehensive, and in future the fact that a con¬
dition is “ dangerous to health ” is to warrant proceedings
for its removal. The County Council is, moreover, em¬
powered, for the prevention of nuisances of various kinds,
to make by-laws which are to be enforced by the sanitary
authorities, and if these duties be honestly performed,
London will be free from many of the unwholesome con¬
ditions which are to be found in some of its localities.
The provisions of the Infectious Diseases Prevention Act
of last year replace those which sanitary authorities pre¬
viously administered, and the County Council is permitted
to extend these powers as respects London to any infectious
disease not specified in that Act. An important amend¬
ment is made in the sections relating to unsound food, by
which it is made penal to offer for sale any article intended
for the food of man which is unfit for human consumption ;
and further, the retail vendor is protected against the
wholesale dealer if it can be shown that the food when
purchased from the latter was in the same condition as
when it was seized. The limitation imposed by the existing
law has hitherto prevented proceedings being instituted
against the sale of much unwholesome food.
The apathy of sanitary authorities in respect to mortuary
provision will not be allowed longer to prevent any district
in London being provided with proper accommodation for
the temporary deposit of the dead, and sanitary authorities
may also be required by the County Council to provide a
suitable building in which post-mortem examinntioDS can
be made.
A motor power has at length been
Digitized by
atpd by which
The Lancet,1
EPIDEMIC DANCING.
[Makcii 21,1891. 673
saoikary aul-lioriLies wliicli are lax in theper/ormaDce of their
duties can be stimulated. The County Council, if satisbed
that any sanitary authority has neglected to discharge any
ty under the Act, may institute any proceeding and do
ny act which the authority might have instituted or done
for that purpose, and is entitled to recovery from the sani¬
tary authority all the expenses thus incurred ; and, where
this power is found to be insufficient, the Council may
make representation to the Local Government Board, and
the Board may make an order to be enforced by writ
of mandamus limiting a time for the performance of the
duty by the Sanitary Authority, or may appoint the |
County Council to perform it. It need not be doubted
tliat the creation of this power by X’arliaraent will go far
to remedy many of the faults of London administration,
and it may be anticipated that the County Council will
not hesitate to perform its part should the necessity arise.
The City of London is not subject to all these provisions,
nor indeed has it ever been shown that the Commissioners
of Sowers have dealt ungenerously with the question of
sanitary administration, but there would have been advan¬
tages in dealing uniformly with all London districts in a
measure relating to the public health.
In future medical officers of health and sanitary inspectors
are not to be appointed for a limited period only, and will
be removable only with the consent of the Local Govern¬
ment Board, if appointed or reappointed after the passing
of the Act; thus there will therefore be greater security of
tenure of office.
No one will study these measures without being im¬
pressed by the sincere eflort which has been made to give
all the powers that are needed for improving the health con¬
ditions of London. If there should he failure in the future, it
will be the fault of Londoners in neglecting to return
proper representatives to constitute the sanitary boards
and the County Council. London owes a debt of gratitude
to Mr. KiTCHiE for the benefits he has conferred by his
efforts to improve the sanitary law, and this debt will be
further increased if at an early date he decides to give to
the County Council the same powers as to open space about
houses which are now enjoyed by every urban authority
throughout England and Wales. This is, perhaps, the most
pressing of metropolitan wants, for it is the absence of such
provision that has in the past and will in the future impose
heavy expense on the ratepayers by necessitating improve¬
ment schemes. The work Mr. Ritchie has already per¬
formed has raised the hope of all interested in the public
health that he will not deal less generously with this ques¬
tion than he has with the general sanitary law.
In an annotation in our issue of Jan. Crd reference was
made to an epidemic of chorea which occurred some
months previously among the children attending a school
at Wildbad. Twenty-six children in all were affected
(eighteen girls and eight boys), the majority slightly, hut
some cases were severe. Many of the patients continued
their attendance at school, and there is little doubt that
imitation, unconscious perhaps in the first instance, had
considerable influence in evoking the manifestations of
the disorder, a view which receives confirmation from
the fact that those who were kept away from school
rapidly improved, and were soon completely restored to
health.
The outbreak of such an epidemic as this naturally
carries the mind back to long bygone days when the dance
of St. ViTi/.s was a disorder very different from that to
which the terra is now applied. In those days the term
mania was not at all inapt as applied to the dance of
St. Vitus and the similar dance of St. John, and we may
congratulate ourselves on the fact that nowadays our
civilisation has advanced so far and our power of self-
control has become so strong and so well developed that
such outbreaks as occurred in those earlier times are, so to
speak, impossible. Yet the occasional occurrence of such
a mild epidemic as that just referred to in the school at
Wildbad, and the not uncommon association in those
latter days of extravagant gestures and loud cries with
religious observances, show that deep down in our organisa¬
tion there still lurk the remnants of that nerve instability
in which the dancing epidemics of the Middle Ages bad
their origin.
Although there wore doubtless outbreaks more or less
severe of this dancing mania in earlier times, it was only
in the year 1374 that the dance of St. John assumed that
severe and epidemic character which has made it memor¬
able. In this year hands of men and women from different
parts of Germany appeared at Aix-la-Cbapelle. They
paraded the streets, and besieged the churches. They
joined hands, and, regardles.s of observers, indulged in the
wildest gestures and the maddest dancing until they fell
down in a state of exhaustion. They rolled upon the
ground foaming at the mouth and gnashing their
teeth. They groaned as if in the agonies of death,
and relief could only be obtained by tying a band
tightly round the waist of the sufferer. The object
I of this was to relieve the tympanites, which was a
prominent symptom, but other and more forcible methods,
such as thumping and trampling upon the parts affected,
were nob uncommonly resorted to for the relief of this con¬
dition. While the dancing continued its votaries were in a
state of ecstasy, They were oblivious of their surroundings,
they saw signs and visions; to them the heavens were
opened, and the Saviour enthroned with the Virgin became
visible. From Aix-la Chapelle the epidemic quickly spread
over the Netherlands, and all the arts and rites of the
Church were invoked against it. Orders were promulgated
against the wearing of various things to which the fanatics
showed aversion, such as red garments or pointed shoes, and,
whether by reason of Church exorcisms and secular regula¬
tions or by natural exhaustion, the epidemic gradually
subsided.
It was forty years later that a similar epidemic broke
out at Strasburg, and to this the name of the dance of
St. Vrms was first applied. The name had reference to
the fact that this saint was supposed to have special power
in overcoming the disease, and his sliiines in various
places became the resort of the alHicted. The association
of this saint with the affection was no doubt due to
a legend, in all probability invented for the occasion.
St. Vitus was a Sicilian who had suffered martyrdom in
the fourth century, and, according to the legend which now
Digitized by
Google
B74 Thb Lancet,]
THE INTERNATIONAL CONGRESS OP HYGIENE.
tMAUCH 21,189]
became current, just as he bent his neck to the sword he
prayed that be might protect from the dancing mania all who
kept his commemoration day and fasted upon its eve. In
answer to this a voice was heard to say, " Vitus, thy prayer
is answered,” and henceforth St. Vitus became the refuge
and protector of all who suffered from this dancing
mania.
Italy had an epidemic of its own, almost contemporaneous
with the dance of St. Vitus, and it has had, perhaps, more
lasting efl'ects than either of the others. This was the
epidemic of tarantism. It was supposed to be the result of
the bite of a ground spider, the tarantula; but, as has been
suggested, it is more likely that the fears of the conse¬
quences of the bite—fears arising easily in the gloomy and
despondent temper of the time—hod more to do with thecausa-
tion of the malady than the bite itself. Those bitten became
stupid, dull, and lethargic, or they became excited and went
about laughing and dancing. All were keenly sensitive to
music of a certain kind, became wildly excited when it was
played, danced and sang, shouted and screamed until they
were exhausted. Music was the only remedy, and it was sup¬
posed that the poison was expelled in the perspiration
produced by the violent exercise. It soon became customary
for bands of musicians to traverse the country at the proper
season, and the “women’s little carnival”—for women
made all the arrangements—was eagerly looked forward
to, and became quite an institution. It thus died out as
an epidemic, and became almost a recognised popular
festival. That, too, in process of time was dropped, but
the merry notes of the “ tarantella” still survive in more
forms than one, fortunately now deprived of the unpleasant
associations of earlier times.
Such were the great dancing epidemics of the past, and
their origin is lost amid the myths and superstitions of those
remote ages. When we remember, however, that they first
assumed their important and striking characters at a time
when the Black Death had devastated Europe and left it in
a condition of extreme nervous exhaustion and consequent
susceptibility to all disturbing influences, at a time, too, when
the Church was doing its best to substitute sacramental rites
and saints’ days for the rude barbarian observances which
had up till that time been the festivals of the people, we
probably recognise the two great factors in their causation.
Thus the ancient heathen custom of the “ kindling of the
Dodfyr,” forbidden by the Church, had been engrafted in
some modified way on the festival of St. John’s Day. To
him who bad leaped through the llames and smoke of the
“ nodfyr ” was granted immunity for a year from fever and
pestilence, and it may be, as Heckkr suggests, that the
dance of St. John was really this leaping run mad.
The dance of St. Vitu.s does not seem to have diil’ered
materially from that of St. John ; in both there was much
that was objectionable. But when we reflect how prominent
a place in all ancient festivals dancings and processions
occupied, how the wild bacchantic dances and the rude
phallic rites were really a part of the ritual in the heathen
worship of nature, we can understand how the dancing
epidemics came to have associated with them much that
was sensuous and coarse. It is interesting to trace the
gradual decline of those epidemics, and how, as they
declined, the name still adhered to the changed malady; so
that we have now in the usually mild disease chorea the
lineal descendant, at least in name, of the wild and
turbulent S’r. Vitus’s dance.
I1.K.H. the Prince of Wales, in presiding over a meeting
of the General Committee of the International Congress of
Hygiene and Demography on Monday, the IGth inst., at
20, Hauover-square, justly remarked that a good start had
been made. The meeting was certainly well attended. A
very strong organising committee has been constituted, and
the committees managing the various sections are now well
in harness. They have held numerous meetings, carefully
drawn up and printed programmes for debate, and have
already accomplished a very considerable amount of
work. This labour comprised, among other things, the
writing of 480 letters to various town councils and local
authorities asking for their support. Replies have already
been received announcing the appointment of 168 delegates
from these local bodies. Some local authorities have
coupled the nomination of delegates with invitations
to the Congress to visit anything of sanitary interest
in their respective districts. This is an important matter,
and should be carefully considered. We must show our
numerous foreign guests things that are really remark¬
able and new in this country. Fur instance, in the all-
important question of drainage, all the newer experiments
as well as the old systems should be visited. An invitation
to view the sewer farm at Croydon has already been re¬
ceived. There are numerous, extensive, and successful sower
farms on the Continent; but nowhere on the Continent will
a town be found draining up a bill instead of down a hill,
and this of course not by the force of gravitation but by the
strength of pneumatic propulsion. Oar continental guests
will want to see not that which they already know, but
rather those innovations which have not yet become
notorious throughout the world.
The Congress bos two divisions and ten sections. This
subdivision of the work to be done is on the whole wisely
contrived, with one exception. We cannot bub think that
a mistake has been committed in classing together in¬
dustrial hygiene and demography. This is altogether
without precedent. There is no more connexion between
statistics and industrial hygiene than there is between
statistics and any other form of hygiene. Architects, in
building artisans’ dwellings, will quote statistics to show
that their model dwellings are more healthy than the
old rookeries. Why nob say, therefore, that architec¬
ture is a section of demography ? Engineers, who prove
that after draining a town the death-rate is reduced,
might put in the same claim. At the previous Congresses
industrial hygiene has been a section by itself, and we
should have thought that in England, the greatest indnsbrial
country of the world, this subject, which interests and
personally concerns the masses more than any other topic,
would have held one of the first places. Now, howe^■6r,
the discussion of problems relating to industrial hygiene is
to be handicapped by the necessity of treating them from a
statistical point of view. Wehavefive Factory Bills before
Parliament at the present moment. Similar projects of
law are before the Legislatures of almost every country in the
Digitized by
Google
Thb Lancbt,]
BURIAL OF SO-CALLED STILLBORN CHILDREN.
[MAECH21, 1891. 675
■world, and yet the dUcussion of these most urgent and
'practical questions is ,to be obscured under the mantle
of demography. We hope it is not yet too late to
correct this error. Also 'we would remark, while it is still
time to make some modifications, that we fail to dis¬
cover in the programme any provision for sittings of the
Uongress as a whole. Sectional sittings are useful for the
'Study of special subjects, but when it is a question of
enlightening, influencing, and, in fact, guiding the Legis-
natures of the civilised world, a discussion, and, above
-•all, a vote of the Congress as a whole, are needed.
This is what the previous international congresses
of hygiene have given us, and the effect on various
Legislatures has been most marked and beneficent. Con¬
sidering that this Congress, if properly managed, and if it
has a due sense of its importance and influence, will un-
■cloubtedly bring about in various countries the enactment
<of laws bearing on sanitation, no trouble or expense should
be spared to render it a thorough success. The cost of the
■Congress is roughly estimated at £GOOO, and towards the
•completion of this sum £2500 are still wanting. This, then,
is the moment for the friends of hygiene to prove their
•devotion to the cause by substantial donations.
*' Ne quid nlmls."
THE ROYAL COLLEGE OF PHYSICIANS.
The office of President of the Royal College of Physicians
is an annual one, but the Fellows have long since recognised
<1116 importance of retaining for a much longer period the
services of the physician whom they once select. The duties
•of the office are not only important, but are decidedly
arduous, and there is general agreement as to the assiduity
with which they have been pursued by its present bolder. Sir
Andrew Clark now completes his third term, and if it be in
accordance with his own feelings, he fully merits a con¬
tinuance of the confidence reposed in him. This, there is no
■doubt, he will receive next Monday, when we feel sure the
vote of the Fellows will be endorsed by the profession at
largo. _
BURIAL OF SO-CALLED STILLBORN CHILDREN.
The question recently asked by Dr. Cameron in the
House of Commons respecting the interment of stillborn
children, and the reply of the President of the Local
•tfovernmenb Board, calls for more serious attention than
it is likely to receive. Dr. R. Kentoul has just issued
a pamphlet in support of his active opposition to the
Midwives’ Registration Bill, in which he states that bo
flias ascertained by personal inquiry that during the
year i8S9 there were interred in seventy-one burial board
cemeteries, as stillborn, the bodies of 6321 infants ; and that
there are no fewer than 1100 such board cemeteries
ill England, in addition to the parish churchyards, in
which the proportional number of this class of burials
'is supposed to be larger than in cemeteries under
the control of burial boards. Dr. Cameron, knowing
the very loose and unsatisfactory system under which still¬
births are certified for burial purposes under the Births
And Deaths Registration Act, 1S74, asked the President of
the Local government Board for a return of the total
cumber of infants interred as stillborn during 1890 in
England and Wales. The answer to this question obviouBly
suggested by the facte of the case was that, as there is no
system of registration of stillbirths in England and Wales,
it would be impossible to furnish the return asked for. It
is seriously to be regretted, however, that the importance
of this subject, from many points of view of deep public
interest, did not suggest the possibility of providing some
remedy for an evil which amounts to a grave public scandal,
rather than suggest the assertion of a simple non fossumust
a position too readily assumed by Government departments
as a foil to suggested reforms. It is needless now to
enumerate the many evils that arise from the present loose
ystem of certification of stillbirth j but we may point to
one which is but too likely to be overlooked—its effect
upon vital statistics, which constitute one of the most
powerful and stimulating factors of health progress.
Vital statisticians have in recent years been startled by the
constantly rapid decline of birth-rates and of death-rates.
It is obvious that so-called stillborn children are not re¬
corded in the birth or death registers, and in the interests
of trustworthy statistics, it is therefore of real importance
to know what truth tlieie is in the assertion of the amount
of interment of so-called stillborn infants that is going
on around us, practically unknown and unchecked. The
results of Dr. Rentoul’s private inquiries are striking
enough to call for Government inquiry; and there seems
to be only one real difficulty in the way of such an
inquiry. This difficulty is the apathy of the Government
in the matter. All burial grounds and all burial authorities
are, it is supposed, under some kind of control exercised by
the Home Office. Why then should not the inquiry, so
urgently needed and called for, be undertaken by the
Homo Office? and why should not all burial authorities be
required to furnish annua), or more frequent, returns, show¬
ing the number of burials of so-called stillborn infants,
accompanied by the actual cerbificates which the Births and
Deaths Registration Act, J874, requires, as authority for
the burial of any child as stillborn ? Such a course would
supply the means for a kind of registration of stillbirths,
and would also prove a real check upon the gross abases of the
present system, which are very generally known to exist.
PETITIONS AGAINST THE MIDWIVES’ BILL.
It is difficult to judge accurately of the amount of feeling
for and against such a measure as the Mid wives’ Bill. The
number of petitions or of meetings does not show much
unless we know the number who signed the petitions,
or the number who attended the meetings, and the
kind of representation made to them of the probable or
pos-sible effects of the Bill. In the last list of petitions
against the BUI published by the House of Commons is one
from medical practitioners in and about South X^ondon,
signed by 111; also one petition from members of tlie
Women’s Franchise League of Great Britain “ in public
meeting assembled.” We are nob told the size of the public
meeting, but the number of signatures is two. The number
of medical practitioners in Portsmoutii is over 100, bub tlie
petition from bliem is signed by 14. Up to the 9bh inst. the
total number of petitions was thirty-eight, and the total
number of signatures 773. The Medical Register for 1891 con¬
tains 29,103 names. When we remember the prodigious efforts
that have been made to urge these petitions, and that many
of the petitioners, and probably most of them, only peti¬
tion against the present Bill, it would not seem that there
is any serious opinion in the great bulk of the profession
adverse to a reasonable measure for abating the scandal of
untrained midwives. It would not be right to assume that
the 28,300 members of the profession over and above these
773 accept the present Bill; but we shall not be far wrong
iu assuming that they realise the responsibility of not
DiijiLized by (jOO^Ic
676 Ths Lancet,]
HOSPITAL SATURDAY FUND.
[March 21,1891.
attempting to grapple with the question. This will have
to he done, and credit will be due to those who can devise
a Bill that shall save women from the risks of the moat
Ignorant midwives, and yet draw wide the line between
midwives and medical practitioners. Here is a call for
a medical statesman. Where shall he be found?
HOSPITAL SATURDAY FUND,
We heartily congratulate the working men of London
on their annual meeting and on the greatly improved
account they were able to give of their stewardship. The
increase in the workshop collection of £7000 — from
£8001 in 1889 to £15,000 in 1890—is a veritable credit
to the executive. It is still far below what it might be,
and what it should be; hut a few leaps and bounds like
those of last year will bring it up to a worthy figure. We
are glad also that a satisfactory arrangement has been
reached by which the Motley House Convalescent Home
will be more intimately associated with the Hoipital
Saturday Fund, and the accommodation for working men
increased. Another good piece of work announced at the
meeting was an arrangement with the Invalid Transport
Corps of the St. John Anabulance Association for the
removal of invalids to hospital, by application of col¬
lectors of the fund at its offices. Sir John Colomb
and the Bishop of London both spoke with natural
satisfaction at the growth of every indication of inde¬
pendence in the working classes. We share the feeling,
but we must remember that these contributions to hospitals
are in no proper sense provisions for the attendance on the
working classes in ordinary sicknefs, bub charitable contri¬
butions on their part to institutions whicli exist for the
treatment of grave cases of accident or sickness,
THE BLOOD IN PNEUMONIA.
Dr. Kikodze has published in the Bolnichnaya Gaztta
of Dr. Botkin some interesting observations on the blood
during pneumonia. He found that during the course of
this disease the white corpuscles increase in number to as
much as double, or even treble, what they are in healthy
persons. The increase is observed in the fully mature and
over-mature corpuscles rather than in the young ones. It
is worthy of note that in fatal and very severe cases no
increase in the white corpuscles is found. As a rule, how¬
ever, the increase begins even before the physical signs of
pneumonia are detected. It persists from that time onward
without any great variations to the crisis, immediately after
which it suddenly falls. It appears bo he due to there entry
into the circulation of the corpuscles which have passed out
into the alveolar spaces ; hence probably the preponderance
of over-mature corpuscles. After the crisis this preponder¬
ance ceases. _
CHOLERA NOSTRAS.
In a paper read before the Socicte M6(lica]e des HOpibaux
on Feb. Gth, Drs. Gilbert and Girode describe the reaearches
they have made in regard to some cases of cholera nostras.
The chief interest lies in the bacteriological work. The
stools in some of the cases yielded almost pure cultivations
of Escheiich’s bacillus. Cultivations were also made from
the fmces on different media, and numerous colonies were
also obtained from the cerebro-epinal fluid, but not so many
were yielded by the blood of the liver and spleen. The
fluid squeezed from the lungs produced, in addition to the
pathogenic bacteria, organisms morphologically similar to
the pneumococcus. Although cercain organic disturbances,
such as high temperature, favoured the development of the
bacillus, as shown by the fact that when such occurred pure
cultivations could be easily obtained from the stools, the
authors would not imply the reverse order of things—that
the high temperature &e. was caused by rapid multiplica¬
tion of the organism; they considered that cholera nostras
is not always a symptom of a local lesion of the intestine,
and that the germs were able to pass through the walls of
the intestine, invading the body, and so bringing-about a
new morbid type—the infectious form of the disease. They
were also of opinion that the bacillus of Escberich was not
the only choleraic microbe in this climate. Finkler and Prior
have also found a bacillus in the alvine evacuations of
patients suffering from cholera nostras, very similar to the
cholera bacillus of Koch. There are two suppositions which
may be considered as regards the connexion of Escherich’e
bacillus with cholera nostras. In one the microbe may be
concluded to be harmless before it enters the body, and
may there develop its special pathogenic properties. The
second idea supposes that the germs are widely distributed,
and .acquire their poisonous properties before entering the
body, most probably doing so by means of drinking water.
In the guinea-pig, if a pure culture of this bacillus be
injected, it is followed by all the symptoms of a typicaa
attack of cholera nostras. _
MEDICAL CHARGES.
On Friday, the 13th insb., according to the Tmes report,
Judge Stonor, at the Marylebone County Court, tried a
case in which a medical man claimed a sum of about £45
from a gentleman residing in Bayswater. The jury returned
a verdict for £41 19s. 3cf. The lady, described as delicate
and nervous, was not the regular patient of the medical
man, whose name is not given. She was led to consult hitn
from fear concerning a draught given her by a chemist,
tasted but not taken, which was said to contain aconite by
mistake. The regular medical adviser called on the plain¬
tiff, and offered him what appeared the usual fees for his
services, bub he declined. Thereafter the patient and her
husband soright the plaintiff’s advice, chiefly, it is said,
influenced by the promise of a complete cure. On various
days she went to the plaintiff’s bouse and remained a con¬
siderable time, being submitted to examinations and treat¬
ment and provided with medicines and tins of Brand’s essence
of beef, milk, and eggs. The charges for these were higher
than usual, but he said be did not generally supply them.
The chief questions were as to the character of the consul¬
tations, and whether the plaintiff gave personal supervision
during the whole of the time, which he averaged at three or
four hours daily, and for which he charged three guineas a
day. The jury seem to have been satisfied on this point,
and, though a jury of medical men might have something
more to say on the case, we are nob disposed to quarrel
with an ordinary jury for supporting higher fees than
medical men generally charge.
A NEW METHOD OF INDUCING PREMATURE
LABOUR.
Dr. Scbkader of Hamburg publishes in the Ctntra^-
blatt fur Gyniicologie a method of inducing pTeraabur©
labour based on his observation that cold is a greater
excitant of the nervous, and consequently also of the
muscular, system than warmth. Continuous irrigation at-
the temperature of 45'' F. is impracticable on accouno of the
pain it causes, bub a cold douche alternating with a warm
one can be borne. Dr. Schrader connects a vaginal glass
tube by means of a T-shaped piece and the necessary india-
rubber tubes to two irrigators, one of which contains the
cold and the other the warm water. By allowing now one
instrument and now the other to work, cold or warm water
may be sent through the vaginal tube into the vagina.
Two people are required—-the one to fill the irrigators, tha
other to work the douche. For each sitting about twenty-
Digitized by ^ooQle
The Lancet,]
THE PREPARATION OF CANTHARIDINATES.
[Maech 21,1891. 677
four litres of cold and half the quantity of warm water at
112 ° are required, and the douche has a-fall of about one
metre and a half. The irrigation begins with the warm
current, and before the cold water is turned on pressure is
made on the perineum with the vaginal tube, so as to allow
a>U the warm water to run away from the vagina. The
same plan is observed before the change from cold to warm,
by which means the alteration in the temperature as felt
by the patient is always sudden. Each time about two
litres of cold and half the quantity of warm water are used.
The douche is generally repeated about every hour and a
half until labour is active enough to make its continuance
probable. Of eighteen women treated by this method
exclusively, and four others who were partly so treated,
one died of eclampsia twelve hours after delivery, but all
the others made a good recovery. The eighteen women
who were treated by the douche exclusively had twenty
children, of whom fifteen, that is 75 per cent., were alive.
These cases required on the average ten douches and a
half; in half the number three douches and a half were
sufficient. _
CERTIFYING FACTORY SURGEONS.
The Royal College of Physicians of Ireland have peti¬
tioned Parliament on the subject of the Bills relating to
Factories and Workshops at present before Parliament,
pointing out objections to the clause providing for the
abolition of certificates of fitness for the employment of
children and young persons in factories. The petitioners
think that public health will he seriously menaced by
iramoval of the safeguard of medical examination of those
persona seeking employment in factories and workshops.
T-he National Society for the Prevention of Cruelty to
Children have also petitioned the House of Commons
against the proposal now before it to abolish the require¬
ment of certificates of bodily fitness for employment of
children and young persons in factories and workshops.
There seem some signs that the Government perceive the
force of the wide opposition to the 19Ch Clause of this Bill.
ST. BOTOLPH’S CHURCH, ALDGATE.
An application was made on the 2nd inst. before Dr.
Tristram, Q.C., Chancellor of the Diocese of London, for
an order varying the terms of a faculty granted by the
Consistory Court of Loudon authorising certain alterations
in St. Botolph’s Churchyard, Aldgate. A decision to enlarge
an adjoining street by acquiring a portion of the churchyard
necessitated the removal of the remains interred therein,
and the Court, by the faculty granted, had ordered that
any remains which it should be found necessary to remove
should be placed in a vault to be erected in the churchyard
at the cost of the Commissioners of Sewers. Since the
faculty was granted it liad been found that a vault suffi¬
ciently large could not be erected without endangering the
foundations of the church, and application was now made
to authorise the remains being placed in the crypt. In
granting the order the Chancellor remarked that in pre¬
paring for the enlargement of the street it was found that
there was a very largo number of remains in the ground
that was to be appropriated for the street, filling sixty or
-seventy boxes and forty-two coffins. The space left would
)t>ot be large enough to enable a vault sufficiently large
to be erected. Since the matter had been before
him he had inspected the church, churchyard, and
crypt. He now varied the faculty so as to order
that the remains be placed in two parts of the crypt
wndorneabh the church, that they should be walled
</fffrom other portions of the crypt, and so cemented as to
prevent any effiuvia whatever from coming into the church.
That (he observed) could be done without any difficulty.
Further, be ordered that the flooring of the crypt should be
also covered with concrete by the Commissioners of Sewers.
After what has so recently occurred in St. Mary’s Woolnotli
and in another City church we must confess our surprise
that Dr. Tristram should have jpade such an order. It
would have been unwise fifty years ago; in these days of
burialreform and cremation it is withoutdefenoe. Many, if not
all, of the forty-two coffins are probably leaden ones, the re¬
moval of which will give rise to noxious emanations, and Dr.
Tristram is mistaken in assuming that any cementing, how¬
ever good, will prevent any effluvia from entering the church.
Had he made an order at first that the remains must be
removed to some suburban cemetery and re-interred there,
he would have shown himself in touch with the times, and
in harmony with modern sanitary views as to the proper
disposal of the dead. Whether the congregation of St.
Botolph will continue to worship in the church after the
completion of the two proposed charnel-houses beneath is a
question which, we trust, will be anticipated by the inter¬
vention of the Home Secretary. The removaJ of human
remains from a city churchyard to the crypts under the
church is a retrograde movement, which will not admit of
any arguments in its defence.
THE PREPARATION OF CANTHARIDINATES.
I^rofessouOscarLiebreich gives the following directions
for the preparation of cantharidinate of potash or soda. The
cantharidinate of soda as well as the other salts of canthari-
dinic acid described by Dragendorff andMasingare not purely
chemical bodies, owing probably to the variable quantity of
cantharidin mingled with them, so that they have not
hitherto been capable of being used for exact dosage. To
obtain a constant solution weighed quantities of cantharidin
were dissolved by prolonged heating with alkali, and then
carefully diluted to the required degree of concentration.
It results from this that the quautity of alkali theoretically
needed for the conversion into cantharidinate was not
exceeded, so as to keep the cantharidinate in solution.
A large number of experiments showed that to obtain
a solution which would remain clear on dilution and
cooling, it was necessary to use twice as much potassio
hydrate and half as much again of sodic hydrate as of the
amount of cantharidin employed. The alkali must be pure,
dry, and free from carbonic acid. Solutions were therefore
prepared as followsCantharidin, 0'2 grm.; potaasic
hydrate, 0 4 grm. most carefully weighed, and heated over a
water bath in a 1000 ccm. flask, with about 20 ccm. of water,
until a clear solution resulted ; then water was very gra¬
dually added, whilst still heating, to about the full quantity,
which was quite completed after cooling. Or: Cantharidin,
0'2 grm.; sodic hydrate, 0'3 grm., were dissolved in the same
way up to a litre.^ _
THE WORK OF THE DALRYMPLE HOME.
By the kindness of Dr. Norman Kerr we have been
favoured with an advance proof of the annual report of the
work of the Dalrymple Home for Inebriates. The ad¬
missions during the year were : Under the Inebriates Act,
18 ; as private patients, 23; with 18 under treatment on
Jan. 31st, 1890, the cases for the year were 59, of which
1 was discharged by order of a magistrate, 40 by the effiux
of time, and 18 remained under treatment on Jan. 31st, 1891.
The number of cases discharged since the opening is 224, and
some of the particulars are interesting. More (124) have
entered as private than as under the Act. The average length
of period of treatment of all patients discharged is about
six months and a half. Whisky was the inebriant used in
84 cases. The prevailing temperament was nervous. The
> Therapeutische Monatsliefte, Mtircli, 1891.
Die:: zed Google
678 ThbLancbt,]
THE UVEAL GLAND.
[March 2!, 1891.
drinking hafcit in 148 was regular, in 76 cases periodical. As
to after history, 94 are reported as doing well, 10 as im¬
proved, 74 as not improved, 10 as insane, 1 as dead, and 35
as not heard from.
THE LATE SURGEON-GENERAL BALFOUR.
We understand that it is proposed to erect a memorial
brass to the late Snrgeon-General Balfour, E.R.S., in the
chapel of the Royal Victoria Hospital, Netley. It is con¬
sidered that a donation of half-a-guinea from twenty or
thirty subscribers will sulHce for the purpose, and we have
no doubt that Sir Thomas Longmore, who has kindly in¬
terested himeelf in the matter, would gladly receive sub¬
scriptions. Dr. Balfour's real memorial is the admirable
statistical work he performed; but it may not be so
generally known that the late Surgeon-General was one of
the ablest and most popular principal medical ollicers that
ever presided at Netley, and it is fitting, therefore, that
the memorial of him should find a place there.
THE UVEAL GLAND.
An important addition to our knowledge of the structure
of the ciliary region of the eye has lately been made by
Dr. W. Nicati of Marseilles, whose researches demonstrate
the existence of a glandular apparatus by which the
aqueous humour is secreted. Dr. Nicati names it the “uveal
gland,” or gland of the ciliary processes, which suificiently
indicates its position. The escape of the aqueous humour
was formerly considered to entail the loss of the eye, and,
indeed, when it escapes as the result of serious wounds
loss of the eye is not of infrequent occurrence ; but in later
times it was perceived that escape of the aqueous was not
in itself serious, and that the fluid was soon reproduced,
the eye recovering its normal fulness and aspect. Chirac, a
distinguished French physician, at the close of the seven¬
teenth century attributed the secretion of the aqueous to
glands which he described as situated at the margin of the
iris. Nuck wrote a special treatise on the subject in 1685,
in which, whilst denying the existence of the glands, he
gave a detailed account of the ducts which Chrovet subse¬
quently found to be filled with blood, and which Haller
demonstrated to be the ciliary arteries and their branches.
In still more recent times the aqueous humour has been
regarded as an exudation from the vessels of the iris and
the walls of the anterior chamber, and in the present day
is held, as by Leber, to proceed from the posterior surface of
the iris and from the ciliary processes. The parts specially
described by Nicati as closely associated with or forming
part of bis uveal gland are, first, an epithelium, continuous
at the ora serrata with the retina, and prolonged over the
whole surface of the ciliary processes to the attachment of
the iris. This represents the gland, and he estimates it.s
surface to amount to at least 6 centimetres square. The
cells constitute a single layer, with large oval or spheroidal
nuclei, and rest on a layer of pigment cells continuous with
that external to the rods and cones of the retina. Internal
to the epithelium is the suspensory ligament, a special
structure which extends from the tips of the ciliary pro¬
cesses to the lens, and is composed of delicate connective
tissue, and of the rigid friable fibres of Heule, amongst
which some free blood-corpuscles are found. These lie
believes to be the remains of the vascular organ which
occupied this position before birth, the tunica vasculosa
lentis, of which the pupillary membrane of the fmtus is a
part, receiving its vascular supply from the hyaloid artery.
External to the secreting epithelium is a close network of
capillaries, which is a continuation of the chorio-capillaris
and ministers to the nutrition of the gland. The larger
arteries supplying the plexus are the short ciliaries, and the
veins retnrning the blood are the venm vorticosiu. The
nerves proceed from the plexus formed by the ciliary nerves
given off by the nasal nerve and by the lacrymal ganglion.
The ducts of the gland are represented by the canal of
Petit, the circular marginal slit of the posterior chamber
which separates the iris in front from the ciystaUine lens
and the ciliary processes behind, and tlie slits connecting:
these spaces with each other ; whilst the channels by which
the aqueous humour is absorbed and carried away are
lacuna) in the epithelial layer covering the crypts on the
anterior surface of the iris, sometimes named the lymphatic'
lacuna? of Fuchs or the stomata of Nuck and Cornil, which
open into a system of lymphatic channels that are agains
continuous with the lymphatic sheaths of the anterior and
posterior ciliary veins and of the venm vorticosse.
THE FRENCH SURGICAL CONGRESS.
Tub fifth session of this congress will hold meetings'
from March 30th to April 4th in Paris, in the great amphi¬
theatre of the Medical Faculty, under the presidency of Pro¬
fessor Guyon. The inaugural meeting will take place on
Monday, March SOfcb, at two o’clock. Communications
will be read on the question of “ surgical intervention ” in
all'ections of nerve centres, trepanning of the skull excepted.
Drs. Reclus, Bazy, Doyen of Rheima, Vaslin, Jeanlen, Pro¬
fessor Oilier, Dr. Picqu6, Professor Victor Horsley of
London, and others. The subject of the results of removal
of the uterine appendages in afiections which are not
neoplastic in their nature will be discussed by severa)
gynecologists of eminence. The discussion will be opened
by Mr. Lawson Tait on April 2nd, and Sir Spencer Wells-
will take part in the proceedings. The question of the
different kinds of suppuration examined from a clinicaS
and bacteriological point of view will form a subject off
discussion.
LEGAL CRUELTY.
Tub abduction of Mrs. Jackson, which has been the talk
of Lancashire for some days past, has given occasioD
for one of those exhibitions of the tenacity with which
legal doctrines survive their date which fairly take away
the breath of a layman. On Monday last an applica¬
tion was made by Mr. E. Forbes Lankester to the-
Divisional Court of Queen’s Bench for a writ of habeas--
corpus, directing her husband, who was at that tim©'
holding her a close prisoner, to bring her into Court-
and assign the cause of her detention. The main facts-
of the case have become well known through the daily
press. Mr. and Mrs. Jackson were married in 1887,.
but on the day of the marriage the hus)>and brought-
the wife hack to the house in which she had been
previously living, and himself departed in the evening,,
and shortly after left the country for New Zealand. The
parties corresponded and quarrelled by letter, and upon the
husband’s return to England his wife declined to live with
him, and refused to obey an order for restitution of con ¬
jugal rights which the husband obtained from the High
Court of Justice. The husband in these circumstances-
found an opportunity of forcibly seizing his wife on Sunday,,
the 8th iust., as she was leaving church, and carrying her
oil'to Blackburn, where he kept her in close confinement.
The evidence by which the application was supported showed
that the lady was ellectively prevented from communi¬
cating with her friends, and unable, therefore, to bring her
own case before the Court, and it comprised an allulavit by
Mr. Masson, her medical attendant, who deposed that he-,
bad attended her for thirty years, that she had suil'ered on
three occasions from rheumatic fever, which on the first-
occasion was complicated with severe inflammation of the
heart; and that, although there has since then been no
objective evidence of heart disease, it is highly probable that
DigitizeO by
Google
The Lancet,]
PATHOLOGY OF GRIEF.
[March 21, 1891. 679
there exists a delicacy which in unfavourable circumstances
might produce serious results. He further stated that he
considered a large amount of out-door exercise of essential
importance to her health, and that, in his opinion, continued
confinement to the house, and particularly when accom¬
panied by mental disturbance, would be very detrimental.
Upon these materials the Divisional Court came to the
conclusion that no case for inquiry had been made out.
Mr. Justice Cave iustified the husband’s proceedings upon
the ground that he had been led to adopt them, first, by
his wife’s obduracy in refusing to live with him; and,
after the abduction, by the conduct of her relatives, who,
as he expressed it, had “picketed” the house. He con¬
sidered the facts to determine whether in carrying out his
blameless purpose the husband had used any unnecessary
violence or cruelty, and came to the conclusion that the
evidence did not go to this. It is some satisfaction to
reflect that the Lord Chancellor and the Court of Appeal
did not sanction the very antique doctrine which found
favour with the Judges of the Queen’s Bench Division, but
it is at least startling to learn that at the present time
any tribunal can be found which will entertain a doubt
as to whether a'husband is entitled to drag a delicate woman,
if she be his wife, by main force to his house, and to detain
her there a close prisoner under unremitting surveillance.
THE HOUSE OF LORDS AND THE MEDICAL
PROFESSION.
Colonel Fitzgerald in the Morning Post comments
on the conspicuous absence from the Upper House of repre¬
sentatives of the medical profession. The defect is an
absurd one, and the Minister who has the courage to remove
it will deserve well of the public, and of the House of Lords.
BIOLOGICAL ACTION OF IRON AND
MANGANESE.
Dr. Fausto Faggioli has published in a recent issue of
La Itiforma Medica some notes of a research upon the
physiological behaviour of iron which he has carried out,
with Professor Pellacani’s assistance, in the Bologna labora¬
tory of Forensic Medicine. From these it would appear
that iron enjoys the property of setting up mitosis or
nuclear change and cellular increase, especially in cultures
of unicellular organisms such as protococci. Under some
circumstances manganese will act in the same way, but
Dr. Faggioli was unable to find that any other metal
could do so.
PATHOLOGY OF GRIEF.
That severe mental distress or fright sometimes produces
physical disease, and occasionally even death, is an ad¬
mitted fact, although the way in which it acts has hitherto
been but little studied. In order in some measure to supply
the deficiency in our knowledge regarding this matter.
Dr. G. Bassi has recently made a number of observations
on animals which apparently died in consequence of capture.
Birds, moles, and a dog which had succumbed to conditions
believed by Dr. Bassi to resemble those known amongst
human beings as acute nostalgia and “a broken heart”
were examined post mortem. Generally there was hyper-
mmia, sometimes associated with capillary hiemorrhages of
the abdominal organs, more especially of the liver, also
fatty and granular degeneration of their elements, and
sometimes bile was found in the stomach with or
without a catarrhal condition. The clinical symptoms
were at first those of excitement, especially in the
birds, these being followed by depression and per¬
sistent anorexia. The theory suggested by Dr. Bassi is
that the nervous disturbance interferes with the due
nutrition of the tissues in such a way as to give rise to the
formation of toxic substances—probably ptomaines,—which
then set up acute degeneration of the parenchymatous
elements similar to that which occurs in consequence of the
action of certain poisonous substances such as phosphorus^
or to that met with in some infectious diseases. In support
of this view, he points out that Schule has found parenchy¬
matous degeneration in persons dead from acute delirium^
and that 2^enkor found hemorrhages in the paucreas in
persons who had died suddenly; he refers also to some
well-known facts concerning negroes in a state of slavery
and to the occasional occurrence of jaundice after fright.
He hopes that these hints may induce medical officers of
prisons and others to study both cliuically and anatomi¬
cally this by no means uninteresting or unimportant
subject. _
THE POLLUTION OF THE AIRE.
DiFFioULTV is already raised as to the formation of a
Conservancy Board for the river Aire, and at a public
meeting inaugurated by the Keighley Corporation opinions
were expressed that the two boroughs of Leeds and Brad¬
ford, which were moving in the matter, were the worst
oftenders; entire disapproval was also expressed at the
action taken. But it seems njore than likely that the real!
grievance lies in the question of representation, and that a-
number of urban and other areas in the West Riding find
that their influence will be overridden by an overwhelming
majority. A request is to be made to the President of the
Local Government Board to receive a deputation on the'
subject, and if this is assented to, the matter will probably
be soon settled one way or the other. Anyhow, we hop&
that the pollution of the Aire, and of the Calder also, will
before long be a thing of the past, for the present state of
affairs is a disgrace to the localities through which the rivers*
flow. _
GLANDERS IN HAVANA.
Glanders is unfortunately of frequent occurrence in Cuba^
more especially in Havana. The reason of i.hia is said by
Dr. Davalos, in a paper read before the Cuban Medical
Congress, to be that the bacillus mallei in cultures of
nutrient material increases in virulenoy in the ordinary
spring temperature—that is to say, at 28° to 30° C., con¬
trary to what occurs in the case of cultures of bacillus-
anthraois, and, indeed, of most other microbes. When^
therefore, clothes and other things have become contaminated'
from contact with a patient suffering from glanders, whether
human or equine, the liability of the disease to spread under
the conditions which exist in Havana—a thickly populated
aud not over-clean town—is very great; indeed, Dr. Davalos*
ventures an opinion that, with the amount of infectioa
already existing in Havana stables, it would take twenty
years of scrupulous antisepsis to destroy it.
DEATH UNDER CHLOROFORM AT KING’S
COLLEGE HOSPITAL.
We have been favoured by Mr. A. Whitfield, L R.C.P.»
M.UCS, with tlie following particulars :—D. W., agecJ
twenty-eight, admitted Dec. 14th, 1890, with Pott’s fracture^
of right fibula, was put up in plaster-of-Pavis bandages, and
sent out some days later. He was afterwards treated as ai>
out-patient at King’s College Hospital. The patient came
on Friday, March 13th, 1891, when the plaster splint^ had
been removed some time, complaining of stiff ankle, painful
on walking, and was told to come the following morn¬
ing, having had no previous meal, in order that hi»
ankle might be forcibly moved under an aniusthetic.
He came to the hospital as ilirected. He seemed ia
good health and tlie circulatory organa gave no sign of
Digitized bv
Google
680 The Lancet,]
THE PREVENTION OF BABY-FARMING.
[March 21, 1891.
disease. Chloroform was used as fche ancesbhetic, and was
given from a drop bottle on a folded towel. The patient took
the anaesthetic well, and struggled little during the pro¬
duction of aniusthesia. When sufficiently under, the ankle
was forcibly moved, and the adhesions broken down, by Mr.
Hewlett, house surgeon. The patient was then in a state
of fairly complete ansesthesia, his pupils were moderately
contracted, and there was still slight corneal reflex;
breathing normal and quiet, pulse fairly quick} no mus¬
cular resistance was felt in breaking down adhesions.
After the operation no more chloroform was given, and the
patient seemed quite well for about three minutes. He
then stopped breathing suddenly. Artificial respiration
was commenced and he started breathing again, which he
continued for about ten good breaths; he then stopped
again. The pulse was then very quick and small. Arti¬
ficial respiration was kept up, and fifteen minims of ether
injected subcutaneously. The patient was inverted and
galvanism and flicking the chest with wet towels were tried.
Nothing, however, was of any avail, and after about three-
quarters of an hour, during which time artificial respiration
was continuously applied, the circulation also failed. Not
more than three drachms of chloroform were administered,
and the patient was not under its influence more than a
minute. There was no cyanosis.or other alarming symptoms
till the cessation of breathing occurred. At the necropsy
all the organs were found healthy. The heart was empty,
with no sign of organic disease or fatty degeneration.
DIPHTHERIA AT ESHER.
The neighbourhood of Esher has from time to time
been troubled with diphtheria. Some have thought that
the modem system of drainage should have put an end to
(that disease ; others have thought that the connecting of
houses with the drains had brought it about. We are told
that the last occurrence has takenplace where no connexions
with the sewers have as yet been made, hut where nuisances
of an ordinary type and others due to the keeping of fowls
end rabbits prevail. The truth is that this endless seeking
for some nuisance to explain diphtheria Is very misleading.
In nine cases out of ten the mischief lies in infection from
antecedent cases of a trivial sort which escape detection,
and the centre often lies in the school. If, when a case of
diphtheria occurs, examination were made of all the throats
of children and pupil teachers at school, with a view to the
•exclusion of any who present symptoms, however slight, of
throat disease, much more would be done to stay the sick-
mess than is at present the case. The only advantage of
the other course is that remediable evils are dealt with
by the sanitary officers, and to that extent preventable
disease is diminished. But the hunt for some fault in
■sanitation and its acceptance as cause, whether it be pre¬
sence or absence of drainage, privy nuisance, or eflluvia
from chickens and rabbits, U not altogether scientific.
THE PREVENTION OF BABY-FARMING.
The recent baby-farming revelations exhibit in ghastly
■seality the whole ordinary plan and circumstance of this
•detestable form of crime. Its usual causes, inducements,
■evasions, methods, and eti'ects have been clearly exposed, and
•it is hardly needful for us to discuss in full detail the now
familiar history. Some study of the method adopted by the
would-be farmer will not, however, be without advantage,
eince it is only by way of prevention thatthe evil can be cured.
On examination the first point that strikes us is that this
business rests, like every other, upon a foundation of demand.
Legally fatherless, practically motherless, many thousands
of children annually born in this country are from birth
intended for other than parental keeping. In many cases
they are parted with in order that they may be forgotten.
The “ nurse ” understands this, and she will, for a suitable
remuneration, supplemented, it may be, by the prospect of
a sum payable through an insurance agent, guarantee their
disappearance. Advertisement is the medium of com¬
munication, and frequent changes of name and residence
enable the gttasi-parent, for a time at least, to baflle
suspicion, and thus the inconvenient infant is transferred
and absorbed into obscurity. Then follows the well-
known process of neglect, starvation, and death. The
case of Reeves, which has lately resulted in a verdict
of manslaughter, conforms in all essential particulars to
the description above given. In the light of such over¬
whelming proof of wanton mismanagement as was here
brought forward, the finding of the jury was a foregone con¬
clusion. Disease had indeed helped forward the slow pro¬
cess of dissolution, but the medical evidence tendered left
no doubt as to the fact that starvation and squalor were
acting powerfully as preparatory and concurrent causes.
Their swift and deadly influence may be judged from the
fact announced by the judge in summing up—namely, that
in the short apace of six months eight children out of twelve
in this woman’s care bad died. We may naturally ask
whether nothing can be done to arrest at its beginning this
indiscriminate transfer of infants, about which nothing
appears to he so certain as its fatal issue. Why not, for
example, arrange that every advertisement relating to the
custody of nurse children and every case of infant insurance
be liable to official registration, this latter to be supported
by vigilant after inspection ? The work of supervision
might be entrusted to the sanitary oHiciala or to persons
deputed by them, such, for instance, as the officers of
the Cruelcy Prevention Society, whose elforbs have been
deservedly commended. _
THE QUESTION OF NOTIFICATION AT
BARNSTAPLE.
The Barnstaple Town Council are somewhat afraid of
compulsory notification; indeed some of their number argue
that the Act conferring this power is a useless piece of legis¬
lation. Since the Councillors resorting to such an argument
have never put the Act to the teat, their opinion naturally
does not go for much ; and we may hence pass on to another
objection that has been raised—namely, that such a power
is useless in the absence of an isolation hospital. To a con¬
siderable extent we sympathise with this class of objectors,
but if their objection be a genuine one we may console them
by informing them that the adoption of the Infectious Dis¬
eases (Notification) Act is doing more towards securing the
provision of means of isolation than anything else; forwhen
sanitary authorities learn how many are the instances in
which they could have stayed the spread of infection bad
they only bad means at hand for the prompt isolation of
. first attacks of sickness, they feel it their bounden duty
towards their constituents to make the needed provision.
And pending such provision, a good deal may, according
to the experience of other places, be done, for there
are a number of instances in which control can be exer¬
cised, and this successfully, where hospital isolation is not
called for. We refer, for example, to the value of excluding
from school all children coming from houses where cases of
such diseases as diphtheria, measles, and whooping-cough
have existed. _
THE CORONER AS INTERPRETER,
Without prejudice to the capacity for office displayed
by lawyers in other spheres of usefulness, we have always
maintained that the functious of the coroner can best be
exercued by a medical man. The subject matter comes
naturally within his proper sphere of thought. Provided*
Dioiuzttij ijv
i00g[e
The Lancet,]
TROPHIC DISrUBBANCES IN HYSTERIA.
[March 21, 1891. 681
in addition, as he must be, with an appropriate knowledge
of law, his position is. really that of an expert, and his
judicial opinion of necessity reliable in a corresponding
degree. Moreover, his very familiarity with medictd
technicalities is in his favour. A somewhat amusing
illustration of this latter point occurred a few daj)s ago at
an inquest in Chelsea, where the descriptive terms employed
by a medical witness were as Greek to a jury of workmen
until they were properly translated into good coroner’s
English. We do not for a moment pretend that it is ex¬
pedient or necessary for medical men in giving evidence to
confine themselves to a technical nomenclature. In this
matter, if in anything, simplicity is the essence of gjod
expression. It is obvious, however, that whatever care is
taken to observe this desirable clearness of speech, the need
of explanation must arise from time to time, and with it
the medical coroner’s opportunity.
MODE OF ENTRY OF THE TUBERCULAR POISON
INTO THE BODY.
A VERY good summary of the various paths of in¬
fection adopted by the tubercle bacillus is given by
C. Bollinger in the Munchemr Med. Wochcnschrift, 1890,
No. 43. He considers that the frequency of infection
through the skin has been under-estimated. Several cases
have been recorded of direct inoculation by wounds received
from broken spittoons &c., by bites, after circumcision, by
morphia syringes, and earrings. Eczema and impetigo
increase the susceptibility of the skin. No case has as
yet been attributed to vaccination, and it would appear
that the tubercle bacilli are unable to live in the vaccine
lymph. They also appear unable to pierce the pores of the
skin as do some of the pyogenic organisms. The suscepti¬
bility of the mucous membranes is increased by inflam¬
matory processes, such as otitis, rhinitis, conjunctivitis,
pharyngitis, &c.; from thence the poison travels to the
submaxillary glands and those of the neck, and gene¬
rally causes local tuberculosis of the glands. The chief
point of infection is of course the lungs. Local pre¬
disposition is best exhibited by apices which have been
before diseased, but have undergone a healing process.
The movement is deficient both in expiration and inspira¬
tion, and the liability to reinfection is increased by ancemia,
irritants (such as coal and metallic dust), constitutional
influences, such as diabetes, disturbances of digestion, and
unhealthy surroundings. The poison may pass through the
lungs and attack the bronchial glands, under which circum¬
stances the disease may be very insidious. The predisposi¬
tion of the lungs again exhibits itself in metastasis; not
every tubercular disease of these organs is due to inhala¬
tion of the bacilli or their spores. As regards primary
tuberculosis of the testicles, joints, and bones. Bob
linger considers that a latent hmmatogenic infection
must be understood, which leaves as little trace
of its point of entry as does a primary septic endo¬
carditis or an osteomyelitis. Tubercular disease of the
larynx depends upon an autoinfection through the sputum.
The rarity of this disease In children is explained by the
infrequency of pulmonary cavities in the rapid forms of
phthisis. Primary tuberculosis of the intestine generally,
combined with an affection of the mesenteric and retro¬
peritoneal glands, is usually occasioned by means of
vitiated food and contaminated feeding utensils. Secondary
tuberculosis of the intestine depends upon an autoinfection.
The tubercular poison passes through to the intestine
unaltered by the juices of the stomach and attacks
the Peyer’s patches and solitary follicles. Tubercu¬
losis of the peritoneum, which is three or four times
as common in men as in women, can arise directly
from ulcers of the intestine, from tubercular abdominal
glands, or, especially in women, from the urogenital tract %
further, through contagion from the lungs and pleura, and
finally in the course of miliary tuberculosis, or from caseous
bronchial glands. Primary tuberculosis of the peritoneum is-
rare (3 to 4 per cent, of all cases). As regards the infectioa
from milk, this is, in Bollinger’s opinion, undoubtedly d\i&
to the udder of the cow being affected with the disease-
infection through the milk of tuberculous women has noa
yet been proved. In tabular form the organs of the bodyr
are thus affected, beginning with those most frequently
diseased:—(1) lungs, (2) the lymphatic glands, (3) intes¬
tine, (4) serous membranes, (5) larynx, (6) spleen, (7) joints^
(8) bones, (9) liver, (10) kidneys, (11) the genital tract;,
(12) the skin, (13) brain and spinal cord, (14) muscles.
UNQUALIFIED ASSISTANTS AND INQUESTS.
The coroner for West Bromwich, in a case of a child'
dying twelve hours after birth, where a death certificates
was alleged to have been given by the unqualified assistant;
of a medical man, expressed his surprise that medical men>
did nob generallyemploy qualified assistants, and announced
his intention of holding an inquest on every case where a>
certificate of death was given by an unqualified assistant.
TROPHIC DISTURBANCES IN HYSTERIA.
Under tliis title a lecture by Pitres appears in the-
Progrds Medical, and the cases dealt with are five in>
number. The first is that of a young woman who, after an
disappointment, suffered from some hysterical manifesta¬
tions, and when she came under observation was suffering
from oedema, confined to the left leg. The swelling was.
hard and resistant, and did not pit on pressure. There
were contraction of the visual fields and bemianoosthesia.
The knee-jerk on the affected side was diminished. A cure-
resulted after magnetisation. The next cose referred to i&
one of paralysis of both legs, with complete flaccidiby,.
which had come on suddenly after a miscarriage. There
was anesthesia of the legs, with loss of sense of posibion,.
and sinapisms on being applied provoked neither pain nor
redness. There was notable lowering of the temperature
of the affected limbs. The visual fields were contracted,
and a complete cure was effected by brisk faradisation^
The third case is one of wasting of the left hand and
arm, which had commenced apparently some months-
after a wound inflicted in the pectoral region, so-
long ago as 1882, There was a characteristic main en-
gri-ffe, wasting of thenar and hypotlienar eminences, bub
the electrical reactions are said to have been absolutely
normal. There was anaesthesia over the left arm and over¬
parts of both sides of the chest and back. There wer&
also anmsthetic areas on the head, and marked but almost-
equal contraction of the visuaP fields. This cose was.
diagnosed as one of hysterical atrophy consequent on trau¬
matism, bub the subsequent progress is not reported. The
fourth case was one of facial paralysis of the right side-
with diminished electrical excitability, which recovered'
completely in a month; while the last one is thab
of a girl who had several attacks of paralysis, supposed to-
be hysterical, and who was said to have developed a
bedsore in those attacks, and on one occasion to have had
suddenly and painlessly several teeth drop out without-
apparent cause. It is evident that all these cases present,
anomalies, and to the English mind at least the acceptanoe-
of the diagnosis of hysteria in several is difliculb. We are
prepared to grant that all the patients were what we under¬
stand by hysterical, but we are nob prepared bo say that there
was no underlying organic affection. A patient in whom»
there is codema of the leg below the knee, with diminished
knee-jerk, even if the visual fields are contracted, and there
Digitized by
Google
^82 Thb Lancet,]
PERFECT COMBUSTION AND SMOKE PREVENTION.
[March 21,1891.
i8 hemiana5sth<>8ia, is nob necessarily tbe victim of hys¬
teria alone. We should say that the probabilities were all
the other way.. Nor can we at all uuderaband why facial
.paralysis with diminished electrical irritability of the
muscles, and with all the classical appearances, should be
•called hysterical. The only apparent reason is that it
•occurred in a girl. The last case of all is related as one of
’trophic disturbance occurring in hysteria; but as the patient
was not seen when she was paralysed, and as moreover the
-existence of tbe bedsore—the trophic disturbance referred
to—was taken entirely on hearsay and had left no cicatrix,
we cannot see any sufficient reason for including it in the
.group of hysteria, far less for. citing it as an example of
trophic disturbance in that affection.
SIR HENRY THOMPSON.
We are enabled bo qualify a statement which has
appeared in the newspapers with respect to the health of
tSir Henry Thompson. Sir Henry has nob visited Monte
Carlo, and has no intention of going there. On Sunday
last he was the subject of a slight surg'cal operation,
'from which be is, we are glad to say, fast recovering,
and which will probably keep him in bed not more than
ten days. _
FOREIGN UNIVERSITY INTELLIGENCE.
Buda-Pesth .—Professor Klug of Clausenburg has been
tselected as successor to the late Dr. Jendrassik in the chair
•of Physiology.
Freihurff. —Dr. Katelden has been promoted to the rank
•of Extraordinary Professor.
Giessm .—Professor Stbhr of Zurich has declined an in¬
vitation to this University.
itfoscow). —Dr. Filatoff has been appointed Professor of
■Children’s Diseases. _
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
Thb deaths of the following distinguished members of
the medical profession abroad have been announced:—
5)r. Eugen Jendrassik, Professor of Physiology in the
University of Buda-Pesth, after a short illness (erysipelas),
in his sixty-eighth year.—Dr. Hermann Kugler, of Stettin.
—Dr. Blodig, formerly Professor of Oplithalmology in the
■University of Gratz.—Professor Regeezy-Nagy, of Buda-
Pesth.,
The Irisii Medical Schools’ and Graduates’ Association
.celebrated St. Patrick’s Day with due honours. The
Association numbers about 700 members. The dinner,
j)re8ided over by Dr. Gilbarb Smith, was numerously
.attended and much enjoyed.
Surgeon T. H. Parke, of the Army Medical Staff,
hag, we leain, been appointed a Vice-Consul in tbe Oil
Rivers Protectorate. Surgeon Parke has lately been doing
•duty with the 2Qd Life Guards in London.
The University of Aberdeen has paid Dr. Bruce the eom-
(pliment of conferring on him the degree of LL.D. in con¬
sideration of bis being the Direct Representative for
Scotland in the General Medical Council.
The corporation of South Shields have adopted the Noti¬
fication Act, but only by a majority of one. The adoption
of the Act was moved by a member of the medical
profession, Mr. T. M. Young, M.R.C.S , L.S.A
Intelligence has been received of a death in conse¬
quence of the injection of cantharidin in the Moahit Hos¬
pital in Berlin. The fatal result is said to have been
caused by tbe action of tbe drug on the kidneys.
THE LANCET
Analytical Sraitacjj Ccimnrasimi.
REPORT ON
PERFECT COMBUSTION AND
SMOKE PREVENTION.
The increasing prevalence of fogs, the unlimited growth
of this immense metropolis, the rise in the price of coals,
and the exceptional severity of the winter have naturally
revived the old and vexed problem of smoke abatement.
It is very widely felt that there must be a limit to the
reckless waste of fuel, with its consequent poisoning of the
atmosphere by smoke &c. With the prevalence of fogs the
death-rate rises, and of course those who are suffering from
diseases of the respiratory organs find their complaints
greatly, sometimes fatally, aggravated when they have to
breathe the soot and the sulphurous gases which, when
mixed with aqueous vapour, constitute the special charac¬
teristics of a London fog. This is, of course, entirely due
bo the hundreds of thousands of chimneys that daily throw
off black smoke, and the number of these chimneys is in¬
creasing to an appalling extent. Nofv, what is generally
termed smoke—that is to say, dark visible smoke—is
simply UDConsumed or wasted coal. The coal has been
partly decomposed by the heat of the fire, but under the
influence of the cold air it condenses anew and re-forms
itself into carbon in the shape of soot. To prevent
black smoke we must, therefore, thoroughly burn
or consume the fuel used. We should then secure
the double advantage of obviating smoke and of prevent¬
ing a great and disastrous waste of fuel. For years,
liowever, we have sought in vain such a consummation.
Improvements—many improvements—on the ordinary fire¬
grate have been suggested. Some had considerable merit,
and did contribute to abate the nuisance from which we all
suffer, but none offered a complete and practical solution of
the entire problem. A Russian civil engineer, M. 0. de
Clausen, recently exhibited in Paris a stove illustrating the
theories he has advanced with regard to the laws of com¬
bustion. His invention had passed comparatively un¬
perceived in the French capital. Technical juries awarded
him gold medals, but the public at large and even the world
of science cared little and knew less about his innovations.
Yet coming beneath our notice they seemed to us likely to
render such great service nob only in the world of indust^
and manufacture, bub, above all, to the cause of public
health and social economy, that we invited M. de Clausen
to submit his theories to the severest tests we could devise,
so as to check his assertions and claims.
The formation of soot and of the highly injurious and
poisonous carbon monoxide gas have always been attributed
to the insufficiency of the supply of oxygen reaching the
fire. But though combustion in an ordinary fire is incom¬
plete, and therefore produces soot and carbon monoxide
(CO), M. de Clausen found by analysing the smoke that it
also contained a large proportion of free oxygen. How,
then, could it be said that tbe supply of oxygen was in¬
sufficient when such oxygen as did exist was nob all con¬
sumed ? M. de Clausen concluded that imperfect combustion
must be due to another cause, and not to the want of a
stronger draught or of more air. The reason of failui'e is due,
he declares, nob to the want of air, but to the absence of a
suffieienbly elevated temperature to ensure perfect combus¬
tion. The combination of the right quantity of oxygen
with carbon in a sufficiently elevated temperature can only
produce carbonic acid (COj). In an ordinary fire C(X is
formed in tbe lower layer ot fuel resting on the grate. This
gas, M. de Clausen explains, travels upwards through the
Digitized by Google
The Lancet,
PERFECT COMBUSTION AND SMOKE PREVENTION.
[March 21,1891. 683
superior layers of incandescent coal which take from it one
atom of oxygen, tbas bringing into existence the carbon
monoxide CO, and continues combustion by means of this
atom of freed oxygen, and not by means of the large quantity
of free oxygen contained in the air of the draught passing
through the stove. The oxygen of the incoming air does
not possess a suiGciently high temperature, and therefore
presents far less affinity for the chemical combination
than the heated oxygen derived from the decompo¬
sition of COj. This explains why the chemical analysis
of the products of combustion in ordinary fires or stoves
shows us simultaneously COj, CO, and 0. But if
the carbon monoxide produced by the decomposition of
CO 2 could meet at the place where it is formed a new
current of air of a temperature sufficiently elevated, it
would burn and combine once more with an atom of
oxygen and reconstitute carbonic acid COj. M. de
Clausen therefore concludes that it is not the want of
oxygen which determines the production of CO, but the
unsuitable distribution and temperature of the free oxygen
of the air amid the layers of burning fuel.
This is the first or theoretical side of M. de Clausen’s dis¬
covery ; it now became necessary to find its practical appli¬
cation. Basing his researches on Pacl6 and Dulong’s
theories—that a spherical surface t^-kes up and surrenders a
larger quantity of heat than a fiat surface of the same size,
and that the coefficient of the transmission of heat for
spherical surfaces augments in the ratio of their curve,—
M. de Clausen sought to produce a fire clay of extremely
porous character, and composed of innumerable spherical
particles infinitely small in diameter. For this purpose he
mixed powdered magnesia with the clay, and M. de Clausen’s
invention rests in the special mechanical process by which he
is able to mix a large proportion of magnesia with the clay
without deteriorating the quality of the brick made.
By referring to the accompanying illustrations, it will
be more easily understood how these theories are realised.
The first gives the external appearance of the portable
stove, which of course can be modified to suit the artistic
fancies of the public. The second drawing represents the
side section. The fuel, it will be seen, is introduced
at the top by the aperture li, an operation which
need be performed but once in twelve hours. MM are
the iron bars of the grate where the coal rests, and
J is the regulator by which air is admitted through
the very small openings, about the size of an ordinary
encil, and discharged just where the fuel is in an incan-
eacent state. The amount of air admitted by these minute
openings is so small that it cannot lower the temperature of
the burning c^al to the extent of destroying the chemical
affinity of the oxygen to the carbon, k is the ash tray. This
can be drawn out so as to throw away the ash, which falls
through the iron bars. The dotted lines represent a Hue, by
which fresh air from tbeoutside of thedwellingcan be-intro¬
duced,and warmed by passing up tbeback of the stove, along
the passage, p, and discharged at the top over the pans, F.
These maybe charged with plain, scented or medicated water.
The third figure will give us a still clearer understanding of
the system, o is the interior space charged with fuel,
p represents the incandescent or burning part of the stove.
There is a very slight downward current of air, so that any
smoke or inflammable gases produced by the distillation of
the black coal in the upper part of the stove passes down¬
wards into the incandescent part of the fire, and is here
consumed. The central walls, as shown by the shading of
the drawing, dip into the incandescent part of the fire, just
as the dip of a drain trap plunges into water. Thus, on
the same principle as the hydraulic syphon drain trap,
M. de Clausen has constructed a smoke trap. The smoke
from the black coal that has not yet been ignited is con¬
sumed by passing through the smoke trap in the incan¬
descent part of the fire. The products of combustion travel
from the smoke trap up the passage a. Here, on both
sides, they are surrounded by walls made of the porous mag¬
nesian fireclay. These walls, by reason of their special absorb¬
ing character, take up nearly all the heat contained in the
gases that are the product of the combustion. This utilisa¬
tion of heat is facilitated hy the fact that the gases have to
ascend to the top of the stove, and then descend to the
bottom, before they can escape into the chimney by the
Hue placed on a level with the ash tray, k.
In order to determine how completely and economically
combustion is effected in this stove, a large number of ex¬
periments were carried out. It is well, in deciding questions
of this kind, to consider, first, what ought to be the products
of the complete combustion of coal in air; and secondly,
what should be the percentage amount of these products
in the f ftluent gasrs. The first question can only be answered!
when the composition of the coal employed is known. In
the experiments about to be described three varieties of coa5
Fia. 1.
Fig. 2. Fig. 3.
were used—namely, (1) Welsh anthracite, (2) Lancashire
coal {ordinary house coal), and (3) Welsh sceam coal (a
very hard coal). The chief variations in their composition
are seen intbe following analyses:—
Anthracite. Lancashire coal. Hard steam coU.
Percent. Per com. Pov cent.
Carbon ... 9C0() 79'95 SIW
Hydrogen... 3'30 . .’>•4.1 . 4’75
Oxygen ... 2-50 . 7 73 . 4 78
Sulphur ... 1-00 2-00 I'SH
Nitrogen ... 0 80 1 ' 8 () 1'40
Ash . 1-40 . .3-07 . '
Carbon U of course the chief combustible constituent, but-
along with it are h.vdrogen to the extent of from 3 to 0 per
cent., and aulpliur from 1 to 2 per cent. The perfect com¬
bustion of coal in air should give nothing but the oxides of
Digitized by Google
^4 The Lancet,]
PERFECT COMBUSTION AND SMOKE PREVENTION.
[March 21,1891.
carbon, hydrogen, and sulphur—namely, carbonic acid,
water, and probably sulphuric acid, and accompanying these
«,Te the unchanged nitrogen of the air and the small
-quantity of nitrogen which occurs in the coal. Since the
composition of the coal is known, and therefore the amount
of oxygen necessary for its complete combustion, the second
question as to what should be the composition of the gaseous
products (assuming complete combustion to have taken place)
can be decided. For example, 100 grammes of the anthra¬
cite coal such as the specimen analysed would require 920
litres of air (in addition to the oxygen the coal contains) in
order to be completely burnt into carbonic acid, v/ater, sul¬
phurous or sulphuric acids, and regarding that the steam
condenses into water along with^the sulphur acids, the gases
passing out of the chimney would consist merely of carbonic
acid and nitrogen. The amount of nitrogen in the air and
also the amount of carbon in the coal being known, the
composition of the exit gases is only a matter of calculation.
The three varieties of coal analysed, if perfectly oxidised,
would give theoretically exit gases of the following per¬
centage composition:
Anthracite. LancasJiire coal. Hard steam coal.
Per cent. Per cent. Per cent.
N. 81-41 . 82-50 . 82-20
CO. . 18-59 . 17-50 . 17-80
It follows that if the exit gases or invisible smoke given
off by a stove are found on analysis to approximate to the
above composition which theory demands, then not only
perfect combustion but complete utilisation of the oxygen
of the air may practically be regarded as having taken place.
Passing from these theories to the practical experiments
made in our laboratory, we ascertained, by means of
(numerous and careful analyses, that the products of com¬
bustion derived from M. de Clausen’s stove yielded for the
three kinds of coal used gases of the following composition
Coal con¬
sumed.
Nitrogen.
Carbonic
acid.
Anthracite ... 81-65 . 18 .35
,, 82-29 15-21
Lancashire coal 81-08 . 17 00
Hard steam coal 81-45 . 18-55
Oxygen.
2-50
1-92
Amount of coal
consumed in
2 1 hours.
...4 kilos.
Unused oxygen to the slight extent of about 2 per cent,
appears in the gases only when the combustion is permitted
to proceed with comparative slowness. In the above results,
for instance, it will be seen that in the case of anthracite in
the second experiment the coal consumed amounted to three
kilogrammes per twenty-four hours, while in the first, four
kilogrammes were consumed in the same time. Again, in
the ease of the Lancashire coal, where three kilogrammes
and a half were consumed in twenty-four hours, 1-92 per
cent, of oxygen was obtained. The rate of consumption
can be regulated with remarkable exactness by the adjust¬
ment of the air valves with which the stove is provided.
Nevertheless, it was felt desirable to ascertain the minimum
rate of consumption which would permit the perfect com¬
bustion of the coal and the utilisation of all the oxygen of
the air. These experiments show that the minimum rate
of consumption in this stove is four kilogrammes of coal in
twenty-four hours; theoxygen of the air is then entirely used.
The following results are amongst upwards of a thousand
experiments made with the Orzat gas analysis apparatus by
M. de Clausen himself. The analyses were conducted under
our supervision, and their accuracy was confirmed by a dupli¬
cate analysis, for which we employed the most delicate and
approved apparatus used in this kind of investigation:—
1. 2. 3 4. 5.
Por cent. Per cent., Per cent. Per cent. Per cent.
COa. 13 .., 17 ... 17 ... 18 ... 20
0. 5 ... 2 ... 2 ... 0 ... 0
CO. — ... — ... — ... — _
N. 82 ... 81 ... 81 ... 82 ... 80
SO 2 . — ... ~ ... — ... — ... —
The gases (1) containing 5 per cent, oxygen were taken
eoon after lighting, and the others were collected at intervals
of from thirty to forty minutes. The results of No. 4 (three
•or four hours after lighting) show the stove to be in full
working order as regards combustion of fuel and utilisation
of air; while the high amount of carbonic acid in No. 5 is
probably due to a higher proportion of carbon in the par¬
ticular parcel of anthracite coal used on that occasion.
From the public health point of view, it is essential to
observe that when the stove was not thoroughly ignited,
but was burning at a low.heat, and the experiments demon¬
strated that the highest ascertained percentage of unutilised
oxygen was making its escape, still even at this, the most
unfavourable moment, no products of incomplete combus¬
tion, such as carbon monoxide, acetylene or opaque smoke,
were present. Thus it was shown, visually as well as by
analysis, that the whole of the carbon being converted into
carbonic acid gas, there was no possibility of its escaping in
any other and injurious form.
it is worthy of mention, however, that in one experi¬
ment sulphuretted hydrogen and smoke were produced;
but, singularly enough, this served as an excellent illus¬
tration of the theory held by M. de Clausen that air
must not be forced rapidly through the burning coal if
perfect combustion is desired. The presence of sulphuretted
hydrogen &c. was due to the method by which the
gases were collected. A large bottle of water provided
with a tap was connected by means of rubber tubing
with the flue of the stove. About half-way u^ the
rubW pipe a test tube fitted like a wash bottle was inter¬
connected. On allowing the water to run out of the bottle
the gases from the stove were drawn through. After a
time the sample tube was disconnected, and placed over
mercury. When the water was allowed to flow out of the
bottle rapidly smoke was seen to fill the tuba, and lead
paper showed the presence of sulphuretted hydrogen.
M. de Clausen soon suggested the cause of this unfavour¬
able result. In subsequent experiments the gases were
drawn over slowly. The entire absence of sulphuretted
hydrogen was then manifested. No better evidence can
surely be given in favour of the hypothesis that only
air in suitable quantity must approach the burning fuel.
If the air is too quickly or too abundantly drawn
through the fire imperfect products of combustion that
are prejudicial to health, like sulphuretted hydrogen,
I carbon monoxide, and smoke, will be produced. No
smoke could be perceived issuing from the chimney
during the course of this investigation, and it may be
added that the glass wool used in tlie Orzat apparatus to
filter the gases remained perfectly white, even although
upwards of 1000 samples of gases had been drawn through
it. The sulphur does not, according to our tests, appear in
the gases as dioxide (S O 2 ); but it is probably oxidised com¬
pletely to sulphuric acid, for in the water used in the Orzat
apparatus this acid, in notable quantity, was found. It is
well known that the sulphur in coal gas burns completely
into sulphuric acid, Our experiments demonstrate further
that the stove is competent to deal with all kinds of coal,
whether they contain a high or low proportion of sulphur
or ash, or differ in physical properties, such as brittleness
and hardness. The ashes produced from the burning of the
three kinds of coal were perfectly white.
The current views which are very generally held on the
subject of the supply of air to fires and furnaces may be
opportunely and briefly mentioned here. As a practical
rule 12 lb. of air per pound of coal are generally considered to
be sufficiently approximate. An additional supply of air
is required for dilution, but the smaller the pieces of fuel
the less air is needed for this purpose. Insufficient air
causes smoke or the production of carbon monoxide accord¬
ing to the nature of the fuel, and too much air represents
loss through the excess weight of air raised in temperature.
An eminent authority on this subject argues that if the
oxygen of the air is in contact with every particle of fuel
during ignition in a furnace it is evident that the deside¬
ratum required in combustion would be attained; no
escape of combustible gas would then ensue, nor of the
carbonaceous particles wnich give to the gases passing up
the chimney the character of smoke, and the greatest
possible heat arising from the burning of the substance in
air would be developed. Indeed, nothing would be wanting
to extract from the fuel the benefit of its total theoretical
heating power but such an arrangement of the furnace as
would perfectly utilise the heat so produced. “No one,
however, who has any experience as to the manner in
which the fire is managed in ordinary kinds of furnaces will
hesitate to assert that the above conditions are never sup¬
plied.” And, again, “several modifications of furnaces
have been patented of late years for the prevention of
smoke, while it is alleged at the same time that the heat
of the fire is increased ; but it is to be feared that many of
these arrangements, while ostensibly obviating one evil,
produce others quite as injurious. This arises, for the most
Thb Lakget,]
THE UNIVERSITY OF LONDON.
[March 21, 1891. 6&5
part, from the iojudicioiis introduction of cold air at a part
'where the temperature is too low to cause combustion of
the inflammable vapours and portions of carbon.” On the
other hand, the fact that in M. de Clausen’s stove perfect
combustion is accomplished seems to be established by
actual experiment.
The next point of importance to consider is the quantity
of heat produced and the extent to which it is utilised or
made available for any given purpose. M. de Clausen states
that a temperature of 2700° C. may be obtained in this stove,
and has been actually shown to exist just in that thin plane of
heat where the combustion is most active—that is, where
the glowing fuel is in direct contact with the air. Here it
may be pointed out that any disturbing influence—like an
excess of air, containing as it does a large proportion of
inert nitrogen—would tend to lower the temperature. We
had DO means of ascertaining whether this high temperature
was attained or not until it occurred to us that thin^atinum
wire, which melts at 2000° C., might possibly showit. Accord¬
ingly, about a foot of thin wire was pushed up into the stove
ana left there lor a time. The gases in the chimney then
showed 18 5 per cent. CO 2 and 81'5 per cent. N. On with¬
drawing the wire it was fcmnd that abont three inches from
the top end it had been severed by melting. The melted
part of the wire no doubt coincided with tbe thin plane, at
which place the most intense heat existed. In ordinary
furnaces or fires, supposing that no more air than is abso¬
lutely necessary passes through, it will be easily under¬
stood that a ^reat anmunt 01 heat is rendered useless by
the draught, in the chimney. But if, as is the general
rule, the supply of air is greater than the amount
assigned by theory as sufRcient, an enormous quantity
of heat is lost. The temperature of the exit gases
in the flue of M. de Clausen’s stove averaged during twelve
hours 64° C. At this time the analyses showed the
maximum amount of CO^. The temperature of the room
was 20° C.; the loss of heat through the chimney amounted
to 34° C. Assuming the stove to be working under the
best possible conditions, this means a loss of 1’3 per cent, of
the total heat. But even regarding the temperature of the
fire to be as low as 1000° C,, then the loss by way of
the chimney does not exceed 3'4 per cent. Thus at least,
and probalily more than 97 per cent, of the total quantity
of heat, is steadily radiated into the surrounding atmo¬
sphere. This extraordinary result depends upon the very
remarkable property which the magnesian brick has of
absorbing heat. The porous brick appears to act, in fact,
as a kind of calorific accumulator, so that when the tem-
erature reaches a certain point radiation proceeds with a
eautiful regularity; it acta as would a mass of metal
which is kept permanently incandescent by some hidden
source of energy.
The magneiianbrick stands in a surprising manner theheab
of the oxyhydrogen blowpipe, and like the lime cylinder used
for the limelight it seems to yield but obstinately to the influ¬
ence of so high a temperature. It is reasonable to expect
that in the highe.st temperature which is ever attained in
the combustion of coal m air this porosity, upon which so
much appears to depend, would not be likely to undergo
destruction. The inventor states that tbe part which the
porous brick plays in the utilisation of heat and in tbe
perfect combustion of coal resembles that of spongy platinum
m bringing together into intimate contact the distillation
product's of coal with the oxygen of the air.
M. de Clausen maintains that ail these principles
can be applied to furnaces for factory engines, loco¬
motives, steamships, and even to blast furnaces. How
largely factories are responsible for defiling tbe atmo¬
sphere anyone can judge for himself who travels in, for
instance, Lancashire; and, to take but one detail, how
much more pleasant life in London would become if the
\inderground railway could be run without producing any
smoke. In Bussia there is a small factory where M. de
Clausen’s stoves are made. Here a powerful furnace is
necessary for the manufacture of the fireclay. Though
we have only seen M. de Clausen’s system applied to
portable domestic stoves, he informs us that in his
own factory the principle works well when applied to
a large furnace. We know that a kilogramme of coal, if
the combustion is complete and it is converted into CO 2 ,
produces heat estimated at 8080 calorics; but if, as is
almost invariably the case in ordinary fires and furnaces,
the combustion is incomplete and the coal gives off carbon
monoxide, then the heat produced is regarded as only
2470 calorics. For a commercial and manufacturing
country like England, the immense economy in fuel repre¬
sented by the difference between the figures 8080 and
2470 is of great importance; while, the absence of carbon
monoxide will be of great benefit in tbe preservation of
health. Considering that the maintenance of an equable
temperature, both day and night, is essential for the proper
treatment of many diseases, this stove may render great
service. The poor often cannot afford to keep up a suffi¬
cient fire in tbe sick room; and tbe rich often fail to
maintain a regular temperature because they cannot control
the heat given off by an ordinary fire-grate. By using M. de
Clausen’s stove it would seem that the temperature can be
regulated with great precision. With such facts before us
we have thouehc it right to give prominence to this dis¬
covery, since from the results of our investigations we con¬
sider it is calculated to confer great benefits on the com¬
munity at large. _
THE PEOPOSED EECONSTITUTION OF THE
UNIVERSITY OF LONDON.-
The following letter to Members of Convocation on the
proposed Reconstitution of the University of London has
been forwarded to us for publication :—
The Senate of the University of London, after-numerous revisions and
variations, lias at Iciigtli produced a sclieme for the reconstitution of
the University which it ha-s considered sufficiently complete to submit,
to the governing bodies of University and King’s Uolieges and the Royai
Colleges of Physicians and Surgeons, and to other external institutions.
Before any application is made to the Crown for the grant of a new
charter, embodying the proposals contained in the Senate's last sclieme,
it will be necessary for Convocation to express its approval tliereof.
In anticipation of the immediate distribution of the scheme to
mombei's of Convocation in accordance witli the request by that liouse
to the Senate, we invite your attention to the considerations set forth
below. We may state that the full text of tlie sclieme appeared in
Tun Unckt of Peb. 14th, the Bntieh Sledicrtl Jourjial of Feb. 21st,
and was fully commented upon in The Timex of Fob. iTtli.
1. The scheme in question differs very materially alike from tha'd
suggested by the Eoyal Commission, and from the one to which Convo¬
cation gave its sanction in the year 1880.
2. The new Senate is to consist of the unwieldy number of flfty-two
Fellows, of whom ten only will bo elected by Convocation, thus
reducing the representation of Convocation from one in four (as is now
the case, and as the Commissioners advised) to less than one in five.
8. Sixteen Members of the Senate will directly represent various col¬
legiate and corporate bodies hitherto not represented on the Senate-,
and sixteen more will be electorl by Metropolitan and Provincial teach¬
ing bodies. It i.s understood that tlie proportionate representation of
University and King’s Colleges on the one hand, and of the Provincial
Colleges on tho otlier, is regarded as equally unsatisfactory by those
bodies.
4. Five separate standing committees of the Senate are provided
for—viz., one for tho London Colleges in Aits and Science, one for the-.
Provincial Colleges in Arts and Science, one for Arts and Science Ex-
iiiiiinations of candidates not from constituent colleges, one for
medicine, and one for law. Tlieso standing committees, nlthouph
nominally under the control of the Senate, will evidently be influential
in effecting such avrargements for examination in the matters with
which they are conversant as will open the way for considerable varia.-
tions in standards of graduation.
r>. Convocation has not in this, as it had under former schemes, any
share in the selection or revision of constituent colleges ; tlie first list
contains schools of very different efficiency, some of which have unsuc-
oe.ssfully claimed admission ns constituent colleges in more than ono-
faculty. while others exhibit little justification for admission in any.
(I, ’r'he representation of Convocation on the Boards of Stiuiiea in
each faculty is to be two members out of a possible total of twenty-
four or more, instead of one-fourth of the combined Boards of Studies.
(Council of Education), as recommended by its special committee and
carried by Convoc.ation.
7. Power is given to tlie Senate to enter into arrangements with each-
constituent college in arts and scie'ce separately for conducting exa¬
minations for the Matriculation and Pass B.A. and B.Sc., by a College
professor and a university examiner conjointly, and consequently oppor¬
tunity is given for as many varieties of standard in such examinations-
as there shall becoiistitiumt colleges.
8. 'Tlie Pass M.B. lixaminatioiis are to be conducted by examiners-
appointed by tho Royal Medical Colleges conjointly with University ex¬
aminers, under a committee elected in equal numbers by tlie CoUeges-
and the Standing Medic.al Committee of tho Senate. As this latter
cannot fail to consist largely, and must consist in part, of nominees and
Fellows of the two Royal Colleges, tlie University thus practically
abandons the contral of its Pass M.15. to tho corporations, in direct,
opposition to the recommendation of the Royal Coiiimi.ssioii.
0. The Preliminary Scientific I'lxamiuat iou, which has hitlierto offered-
the most serious check to medical canciiclates, and the M.D. Exainina'
tioii, which confers the coveted title of Doctor,” are still to be con¬
ducted by tho Unlveraity. If they continue as tliey are, the so-calledi
medical grievance will remain uiiredresaed; tliere is, however, reason,
to believe that tliey will bo moditled or lowered in standard under
pressure from tho Corporations until the M.D. Liind. is the equivalent of
thoM,R,C.S. and L.R.C.P. How powerful such pressure may becon e
is indicatud by the enormous departure from Che decision iif the Royal
Commission which the two Colleges liave already succeeded in effecting,
10. Hitherto the examinations in all faculties, save the medical, na\ e
been equally accessible to, and of tlie same seventy for, private
686 Thb Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[Maroii 21, 1891.
And collegiate students. Our examinations have won the confldonco of
the private student and their public repute on account of tbelrimpartial,
because Impersonal, character. The facilities afforded to collegiate
atudenta, under the scheme, cannot fail to place private students at a
relative disadvantage.
11. Lastli;, the power of confenlng honorary degrees, which Convoca¬
tion has uniforiuly opposed, is again introduced.
SALE OF PROFESSOR KOCH’S LYMPH.
Tub following official rescript appeared in the German
Medical Ga/:ette of March 13tb, and a translation has been
transmitted to us for publication from the Foreign Office.
Ih-ofessor Dr. Koch has published in the German Medical Gazette
•of .Ian. 15th last a description of the maimer in which the lymph, dis¬
covered by him for the euro of tuberculosis, Is prepared, and according
to this description it appears tlrnt this remedy comes within the pro¬
visions of Section 1 of the Imperial Ordinance of Jan, 27th of last year,
and can thoroiore, with the exception of wholesale trade, only be sold
by licensed ehemi.sts (apothecaries).
Chemists can at present obtain the lymph, prepared under the per¬
sona! supervision of the inventor, only through his authorised repre¬
sentative, Dr. Libbertz, 28, Liinoburgerstrasse, Berlin, N.W. It is
supplied to them in special bottles of a capacity of 1 or 5 cubic centini.
These bottles have glass stoppers covered with bladder and secured by
a leaden seal, bearing the letter “ L.” On one side they bear the nanie
^‘Tuberculinuin Ifocliii" in white letters on a black ground, on the other
iiide a white label with the signature of Dr. l.ibbertz, and a note giving
the date on which the lymph was prepared. Each bottle is accompanied
by a printed paper containing instructions for its use.
With regard to the preservation and sale of the remedy in chemists’
ishops, the following regulations must be observed :—
1. The “ Tuberciuinuni Kochii" must be kept in the poison cupboard,
and in the division I’eserved for alkaloid.s.
2. It can only be sold in the original bottles, and only upon the
■written order of an approved physician, and delivered to sucli physician
himself or to a person authorised by him.
3. A record of the purchase and sale of the remedy must bo kept in a
special book, in which each bottle must be entered. The contents of
the bottle, the date of preparation, of purchase and of sale, the name
of the physician to whom it has been sold, or eventually the removal of
the unsold bottle from the shop, must all be noted.
4. If a bottle has not been sold within six months of the date of pre¬
paration marked upon it, it can no longer be sold or otherwise disposed
of, but must be removed from the sliop. Such bottles will bo exchanged
by Dr. Libbertz for others containing freshly prepared lymph free of
charge.
6. The price of the “Tuberculinum Kochii” is hereby fixed (ex¬
clusive of the cost of packing) at C jnarks for a bottle containing 1 cubic
centim., and at 26 marks for one containing 6 cubic centini.
I have the honour to request you to cause the above Regulations to
lie communicated to the chemists in your district for their guidance,
and also to take steps to insure their due observance.
(.Signed) Dr. VON GOSSLBR.
Berlin, March 1, 1801.
T'o the Governors of Provinces and the President of Police in Berlin.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 5818 births
and 4238 deaths were registered during the week ending
March 14th. The annual rate of mortality in these towns,
which had been 24-1 and 23'7 per lOOO in the preceding two
weeks, further declined to 22-1 last week. The rate was
20'7 in London and 23‘2 in the twenty-seven provincial
towns. During the past ten weeks of the current quarter the
death-rate in the twenty-eight towns averaged 23-4 per
1000, and exceeded by 0’3 the mean rate in the correspond¬
ing periods of the ten years 1881-90. The lowest rates in these
towns last week were 16-7 in Norwich, 177 in Derby, 19'2
in Wolverhampton, and 19-3 in Bradford; the highest
were 27’C in Oldham, 28'1 in Manchester, 29-9 in Hudders¬
field, and 31 •! in Blackburn. The deaths referred to
the principal zymotic diseases, which had increased in the
preceding five weeks from 332 to 470, declined last
week to 413; tliey included 137 from measles, 130 from
whooping-cough, 42 from scarlet fever, 42 from diarrhoea,
32 from diphtheria, 20 from “fever” (principally enteric),
and not one from small-pox. These diseases caused the
lowest death-rates in Wolverhampton, Derby, Hull, and
Brighton, and the highest rates in Bristol, Halifax,
Huddersfield, and Blackburn. The greatest mortality from
measles occurred in Leeds, Fortsmoubli, Bristol, Hudders¬
field and Blackburn; from scarlet fever in Sunderland,
Bolton, and Halifax ; and from whooping-cough in Salford,
Huddersfield, and Halifax. The morWity from “fever”
showed no marked excess in any of the twenty-eight
towns. The 32 deaths from diphtheria included 18
in London, and 2 each in Norwich, Manchester,
Salford, and Newcastle-upon-Tyne. No death from
small-pox was registered in any of the twenty-eight
towns; one small-pox patient was under treatment in
the Highgate Small-pox Hospital, and not one in
the Metropolitan Asylum Hospitals, on Saturday lost. The
number of scarlet fever patients in the Metropolitan Asylum
Hospitals and in the London Fever Hospital at the end of
the week was 1143, and showed a further decline from
recent weekly numbers; the patients admitted during
the week were 64, against 80 and 87 in the preceding
two weeks. The deaths referred to diseases of the respira¬
tory organs in London, which had been 685 and 677 in the
preceding two weeks, further declined last week to 581,
bub exceeded the corrected average by 58. The causes of
88, or 2-1 per cent., of the deaths in the twenty-eight
towns were not i certified either by a regbtered medical
practitioner or by a coroner. All the causes of death
were duly certified in Plymouth, Nottingham, and Birken¬
head ; the largest proportions of uncertified deaths were
recorded in Brighton, Bristol, Huddersfield, and Liverpool.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality In the eight Scotch towns,
which had increased in the preceding four weeks from 21-4
to 24 •! per 1000, further rose to 26 2 during the week
ending March 14th, and exceeded by 4'1 the rate that pre¬
vailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns
ranged from 15'4 in Perth and 17'4 in Aberdeen bo 31’4 in
Glasgow and 477 in Paisley. The 684 deaths in these
eight towns showed an increase of 56 upon the number in
the preceding week, and included 31 which were referred
bo whooping-cough, 23 bo measles, 10 to diarrhoea, 6 to diph¬
theria, 5 to scarlet fever, 4 to “fever,” and nob one to small¬
pox. In all, 79 deaths resulted from these principal
zymotic diseases, against 80 and 79 in the preceding
two weeks. These 79 deaths were equal to an
annual rate of 3'0 per 1000, which exceeded by 0’8
the mean rate last week from the same diseases in the
twenty-eight English towns. The fatal cases of whooping-
cough, which had increased in the preceding three weeks
from 13 to 34, were 31 last week, of which 20 occurred in
Glasgow, 4 in Edinburgh, and 3 in Dundee. The deaths
from measles, which had been 18 and 16 in the previous two
weeks, rose again last week to 23, and included 13 in
Paisley and 8 in Glasgow. The 6 fatal cases of diphtheria
exceeded by 1 the number recorded in the preceding week,
and included 4 in Glasgow. The deaths from scarlet fever,
which had been 7 and 1() in the previous two weeks, declined
to 5 last week, of which 3 occurred in Glasgow. The 4 fatal
cases of “fever” showed a further decline from recent
weekly numbers, and included 3 in Glasgow. The deaths
referred to diseases of the respiratory organs in these
towns, which had been 146 in each of the preceding two
weeks, rose last week to 201, and exceeded by 47 the
number in the corresponding week of last year, 'fhe causes
of 72, or more than 10 per cent., of the deaths in the eight
towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate la Dublin, which had been 29’4 and
28'2 per 1000 in the preceding two weeks, further declined
to28'l during the week ending March 14th. During the
first ten weeks of the current quarter the death-rate in the
cib^ averaged 3l’l per 1000, the rate for the same period
being 23-3 in London and 21-1 in Edinburgh. The 190
deaths in Dublin were within one of the number in the pre¬
ceding week, and included 4 which resulted from “fever,” 3
from whooping-cough, 1 from diphtheria, and not one either
from small-pox, measles, scarlet fever, or diarrhma. Thus
the deaths referred to the principal zymotic diseases, which
bad been 9 and 4 in the preceding two weeks, rose again
last week to 8; they were equal to an annual rate of 1 ‘2 per
1000, the rate from the same diseases being 1 -6 in London
and 17 in Edinburgh. The deaths referred to “fever,”
which had been 3 and 0 in the previous two weeks, were 4
last week. The 3 fatal cases of whooping-cough exceeded
the number recorded in any week since January last. The
190 deaths in Dublin last week included .30 of infants
under one year of age and 56 of persons aged upwards of
sixty years; the deaths of infants showed a further decline
from recent weekly numbers, while those of elderly persons
showed an increase. Four inquest cases and 2 deaths from
o^ie
The Lancet,! TRICHLORACETIC ACID AS A TEST FOR ALBUMEN IN URINE. [March 21, 1891. 687
violence were registered; and 53, or nearly a third, of the
deaths occurred in public institutions. The causesof 20, or
more than 10 per cent., of the deaths in the city were not
certified.
THE SERVICES.
Army Medical Staff. —Surgeon-Major (ranking as
Lieutenant-Colonel) Thoe. O'FarreiJ, M.D., to be Brigade
Surgeon, vice J. Wilson, M.B., F.F.P.S. Glasgow, retired
<dated Feb. 14bh, 1891); Surgeon John Lees Hall is placed
on temporary half pay on account of ill-health (dated
March 3rd, 1891).
Army Medical Reserve op OFPICERS.—Surgeon-Major
Walter Caret Aubin, M.B., Ist or West Regiment Royal
Jersey Militia, to be Surgeon-Major, ranking as Major
(dated March 18th, 1891); Acting Surgeon Tbos. Lyndon,
M.D., 4th Volunteer Battalion, the Queen’s (Royal West
(Surrey Regiment), to be Surgeon, ranking as Captain (dated
March 18th, 1891).
Bombay Medical Establishment. — The Queen has
approved of the retirement from the Service of the under¬
mentioned Officers: Surgeon-Major Bernard Callan Keelan
(dated March 15bb, 1891), and Surgeon-Major Septimus
Jesse Goldsmith (dated March 4th, 1891).
Naval Medical Service. —Staff Surgeon James Long
Sweetnam, M.D., has been promoted to the rank of Fleet
Surgeon in Her Majesty’s Fleet (dated Feb. 27th, 1891).
Volunteer Corps. — Bifle: 2nd Volunteer Battalion,
the Suffolk Regiment: The undermentioned Acting Sur¬
geons resign their appointments:—H- P. Leech and A. W.
Aldrich (both dated March I4th, 1891),—5th Volunteer
Battalion, the Cheshire Regiment: Surgeon P. M. Davidson
is granted the rank of Surgeon-Majoi-, ranking as Major
(dated March 14tb, 1891). —Ist (Inverness-shire Highland)
Volunteer Battalion, the Queen’s Own Cameron High-
Handers: John Dewar, M.B., to be Acting Surgeon (dated
March Uth, 1891).
" Audi altoram partem.”
TRICHLORACETIC ACID AS A TEST FOR
ALBUMEN IN THE URINE.
To the Editors of The Lancet.
Sif?s,—The practical value of trichloracetic acid as a test
Jor albumen in the urine is .so great that any sources of
■error in its employment should he carefully noted. In a
Setter from Dr. C. F. Heywood of New York, which appears
in the February number of Merck's Bulletin, the writer,
after speaking in very laudatory terms of the value of the
test, says: “I have yet to find that it declares Q.-ay other
elements of suspected urine than albumen,” and he recom-
iuiends that a saturated solution should be carried about in
the pocket. I have long been employing this test, both in
private and in insurance examinations, and can speak very
highly of its results. I have been in the habit of comparing
its reactions with those given by nitric acid and picric acid,
■and while I have never found it fail to react in specimens in
which albumen has been discovered by other tests, it has
given a line of opacity in numerous samples which have
'been unaffected by nitric acid or picric acid. In some of
these the trichloracetic acid appeared to be a more delicate
'test, since in cases with a history of an acute attack of
(■nephritis the urine has often given a line of opacity after
it might have been declared free from albumen when the
•customary tests were employed. On the other hand, the
need of the warning originally given by Boymond
•de T’/i.arjn.) has been very strongly impressed upon me by
•several cases—viz., that when the urine is rich in urates the
reaction may appear without any albumen being present,
.and this possible source of error can only be avoided by free
•dilution of the urine before making the test.
With regard to the desirability of carrying tins reagent
in the pocket the effects of a crystal on a piece of blue
paper or on the blade of a knife have been suificient
fio deter me from making the experiment. Although
trichloracetic acid may be used either in a solid or liquid
form, it gives the most striking results when a good-sized
crystal is dropped into the test tube containing the urine.
The crystal speedily liquefies, and, if albumen is present,
produces a zone of turbidity in the urine just above it,
otherwise a sharply defined line marks the junction of the
white acid with the yellow urine. The zone of turbidity
appears immediately when due to albumen, but when due
to urates it forms more slowly, and is not so wide.
I am, Sirs, yours truly,
Nestor Tirard, M.D. Bond., F.R.C.P,,
Henior Assist. Physician, King's Coll. Hosp.
M’oymoutii-Btreet, W., March 17th, 1891.
RECONSTITUTION OF THE UNIVERSITY OP
LONDON.
To the Editors o/The Lancet.
Sirs, —It is very important that the latest revised scheme
of the Senate in reference to the reconstitution of the
University of London should be well considered in all its
bearings, and not only in those connected with the Faculty
of Medicine, especially as many of the medical graduates
possess degrees other than those of medicine. For this
purpose I beg to offer these few remarks in supplement to
those furnished lately by Dr. Collins. By the present
scheme, which M’ill be presented to Convocation for accept¬
ance, there will be at least three different standards
of arts and science degrees according to the “arrange¬
ments” made with the various colleges in London and
the provinces; and in accordance with the powers reserved
by the Senate, these schemes for these degrees may be, if
required, multiplied to any extent to meet the demands of
the colleges individually. If such be the case, how can we
hope for any uniformity of standard, the syllabus of each
college or of each combination of colleges necessarily varying
and being of unequal value? Let such arrangements be
carried out as desired by the London and provincial colleges,
and the University also carry on as of old its own examina¬
tions in Arts and Science on its present lines,in all common
reason the question may be asked. Of what value can such
varying degrees be deemed, or how can they be designated
for the comprehension of the world at large, and what pro-
. bability will there be of their ever remaining at any proposed
standard ? Since such multifarious degrees cannot be
accepted as equivalent to each other, some fanciful distinction
must be made, and, taking the University examination,
as the degree par excellence, we can suppose that some
B A
fractional designation must be devised, such as
or B.A., with some London or provincial College as the de¬
nominator, before the public can value their relative merits.
The same observations equally ajmly to the Matriculation
and that for the Preliminary Scientific Examinations.
Hence it behoves Convocation to realise the probable future
of the University which submits to such arrangements as
ultimately must destroy itself as a degree-giving centre.
"With respect to the medical aspect of the scheme, the
Senate has gone further out of its way than in the
matters of Arts and Science, and actually proposes to
give to the two Royal Colleges great, if not absolute,
control over the M.B. Examination. This seems inconsistent
on the part of the Senate which now seeks to form a Teaching
University, for neither of these two Colleges has any pre¬
tensions whatever to being considered as teaching bodies
except so far as their few endowments for speciallectures
can be considered as partaking of a teaching quality. To
these bodies it really will delegate its powers, subject to
“ arrangements ” which, knowing the desire of those two
Colleges, must ultimately by pressure of time and influence
not only entirely control the Pass M.B., but will consider¬
ably modify the Honours Examination for the same degree,
and in the end absorb the M.D. degree also. Indeed, it is
reported that the teachers at one of the proposed Constituent
CollegesinMedicinehavealreadyexpressedademandforsuch
privileges. Another point in connexion with these degrees
is the price at which they are to be obtained. As matters
are, it is impossible to believe that they will be granted for
the moderate fees which the University now receives. Any
one knowing the fees exacted for passing the Conjoint
Examination will readily doubt if the present scale will be
adopted, especially if they are to be shared between the
corporations and the University. These doubts are equally
Die,;.,-...: by -lOOglC
688 The Lancet,] CHRONIC INFLAMMATION OF THE UTERINE APPENDAGES. [March 21, ISM.
applicable to the Arts and Science side of the question at
issue.
The function of a University is to grant degrees distinct
from any qualification given by colleges, and to relegate
that power under any circumstances to teaching and non-
teaching colleges is an innovation in the cause of education
■which cannot in the future bear good fruit to the University
■which so deserts the reason for its existence, and so
annihilates itself. Such a course will be detrimental to the
cause of that higher education which the University of
London first established, and will finally, under the pressure
of competing colleges, encourage a depreciation of the value
of our degrees, ■which, though not backed as in the older
Universities by the social standing of residence, have
their mark in the world at large and command respect as
an evidence of that higher education, which, under
threatened arrangements (a most elastic word), will bid fair
to be a phantom m the future history of our University.
I am, Sirs, yours faithfully.
Junior Athenteum Club, March 18th, 1801. M. BAINliS, M.D.
THE TREATMENT OF CHRONIC INFLAMMA¬
TION OF THE UTERINE APPENDAGES.
To the Editors of Tub Lancet.
Sirs,—L et me say that your leading article of this date
will be the initiation of a calmer form of discussion of this
question, and of a happier time for those like myself who
have held to their opinions on this question through much
misrepresentation and no little persecution.
I trust my friend Dr. Herman will forgive me saying
that his letter is logically jorinctpti. “Byinllam-
matioQ of the uterine appendages I mean what I think
most medical men understand by it” is no answer to my
suggestion that the two schools of thought on this subject
cannot by any possibility be speaking of the same thing.
He quotes my own description of the diseases I have
diagnosed and verified by production of the specimens, and
then says that the great majority of them, if sufficient time
and rest be given, end in diminution in size, or even prac¬
tical disappearance of the lumps and cessation of symptoms.
But this is precisely the opposite of my experience, and the
literature of the subject abounds with cases which I have
pul)lisbed in detail where the “ time and rest,” together
with other appropriate treatment, has been given at the
hands of competent practitioners, and no such happy ending
has been arrived at. Dr. Herman does not doubt that there
are some cases which can only be cured by operation—an
admission I am glad to get from such an authority,—but
there remains the very grave question as to which teaching
is the correct one, that the niejoriby of the cases get well
without surgical treatment, or that very few get well
without it.
I must urge on Dr. Herman that this comes now to be the
pressing question for settlement, alike for the practice of
medicine, the interest of the patients, and the credit of all
classes of practitioners. My constant experience is that it
is in the delayed cases that the danger and the discredit alike
lie. Dr. Herman may say that as an operating surgeon
my interests lie in operations. But to this I may just
as well answer that to the non-operating (or rarely
operating) physician undue delays have equally strong,
perhaps even stronger, inducements. It must be clear,
therefore, to every judicial mind that it is to the interests
of all concerned that the question should be settled
by logical research, and that the question should not
be begged. The first step towards settlement, there¬
fore, is to decide this question—Are Dr. Herman and I, as
representatives of the different schools, really speaking of
the same pathological conditions? I do not for a moment
believe that we are. Why should not, therefore, Dr. Herman
accept my challenge proposal ? I am quite prepared to take
on myself the hulk of the trouble, for there are very few
weeks in which I do not spend a day in London, and the
tax of passing an hour occasionally at the London Hospital
would he, I am sure, amply repaid by the results of the
experiment. Either Dr. Herman must accept this challenge
or he must desist in future from stating that the “ great
majority ” of these cases get well, seeing that, in his own
words, *‘it is impossible, from the nature of the case, for
one who thinks that a disease has been present and ended
in recovery, to bring evidence of the fact convincing to the
incredulous.” If he acoepts neither of these alternatives,
be must not be surprised if we continue to express our
incredulity forcibly.—I am. Sirs, yours faithfully,
Lawson Tait.
ON
THE EFFECT OF THE DIVISION OF CERTAIN
CONSTITUENTS OF THE SPERMATIC CORD
IN THE RADICAL CURE OF VARICOCELE.
To tliA Editors of The Lancet.
Sirs,—I have read Mr. Bennett’s paper on the above
subject in the issue of The Lancet for March 7th with
considerable interest, and can fully bear out what he states
with regard to the effect on the testicle of the division of the
spermatic artery and veins. In I8t<61 published a series of ten
cases of varicocele treated by excision,^ the operation differ¬
ing very slightly from that recommended by Mr. Bennett
in his paper published in The Lancet of Feb. 9th, 1889.
I have had the opportunity of seeing many of these cases
since, and find that there has been absolutely no atrophic
change or other apparent alteration in the testicle, and yet
in all of them not only was the bundle of veins bub a
portion of the spermatic artery removed, for it is quite
easy, as Mr. Bennett says, to see the open mouth of the
artery in the mass of tissue removed, leaving no doubt
about its division. In all my cases an aseptic course
was pursued, and in none was there any trouble from
orchitis.
With regard to the third conclusion on the division of the
vas deferens I have had no experience, but it is very in¬
teresting to know that the division of the duct should also
not bo followed by atrophy of the organ.
I am, Sirs, yours faithfully,
Leeds, March 12tli, 1891. A. W. MAYO RoDSON.
To the Editors o/The Lancet.
Sirs,—A fter reading in The Lancet of March 7bh Mr.
William Bennett’s remarks upon his treatment of varicocele,
I think it well to draw attention to the tenth volume of the
Medical Society’s Proceedings (1886), in which the operation
I then advised for the radical cure of varicocele will be
found with the discussion which took place upon it. Mr.
Bennett will there see the remarks of Mr, Hutchinson,
jun., upon the course of the spermatic artery as de¬
duced from thirty dissections; and he will notice my
remarks upon a method of operating which does nob
subject the spermatic artery or other important structures
of the cord to the risk of being injured or included in the
ligature. Since making this communication to the Medical
Society in 1886 I have simplified the operation slightly,
by making the incision over the external abdominal ring
only, and not extending it into the scrotal tissues at all, as
I found that it was quite easy to pull up the veins into this
limited opening and ligature them ; and in this situation
there is no li^ility to injure the vas deferens, so I have
discontinued the use of the pins I then recommended. But
I attach the same importance to that point in which IS
advocated the clearing and ligaturing the veins first at the
external abdominal ring, where it is easily donej and,
having cut them through, to pick up the distal ends of the
veins, and lifting them up to strip off the surrounding
tissues of the cord as low as the upper part of the testicle ?
then apply the lower ligature, cut the veins through again,
and allow the testicle, which has been drawn up to the
wound, to slip back into the scrotum. In this way I have
operated upon a large number of cases, in a few instances-
removing the veins of both sides at the same operation,
and often doing the operation in association with the radical
cure of hernia, and I have had unvarying success both a&
regards the rapidity of healing of the wound, the cure of
the affection, and the ratisfactory condition of tho testicle.
Several cases have been afterwards admitted into th&
services.
I have not found the testicle diminish in si/e in any case,
but, on the contrary, it usually increases. In some cases S
have observed that there is a tendency for the tunica
vaginalis to become slightly distended with fluid when the
} Evit. Med. Jour., Feb. 27tli, 1880.
Dt- uzed by Google
Thb Lancbt,]
FACTORV SURGEONS.—BIRMINGHAW.
[March 21, 1891. 689
patient first begins to walk about, but this condition dis¬
appears duriog the night when the patient is lying down.
I am, Sirs, yours truly,
A. Bovoe Barrow,
. Senior Surgeon, Royal Free Hospital, Assistant Surgeon, King's
College Hospital.
Wolbeok-Htreet, W., March 18th, 1881.
THE NATURE OF ANGINA PECTORIS.
To the Editors o/'The Lancet.
Sirs,—W ith reference to the recent discussion on angina
pectoris and the interesting leading article in the last
number of The Lancet (March 14bh) may I suggest that
sufficient stress is not laid on the statement that during an
attack of angina the pulse may be unaltered in character?
'This statement seems to be definitively accepted, and I need
only mention as guarantors thereof the names of Walshe,
Balfour, Broadbent, and Gairdner. But if we accept this
statement, how can we escape the conclusion that angina
pectoris may be independent of heart failure? If the heart’s
action is embarrassed, if there is lack of ventricular power
or excess of peripheral resistance, or, in fact, mechanical
failure of any kind, and however brought about, how can
the pulse remain unaffected ? The pulse gauges the
efficiency of the heart better than any thoracic examina¬
tion, and if the pulse do not fail the heart does not fail,
i cannot hope to add to the cogency of Professor Grainger
Stewart’s words in the recent discussion, for so long as the
above statement remains undisputed they possess the
cogency of logical necessity.
I am, Sirs, yours faithfully,
Welbock'St., March 17lh, 1891. HARRINGTON SAINSBURY.
FACTORY SURGEONS. I
To the Editors of The Lancet. |
Sirs,—T here are many factory surgeons who have i
given up a portion of their practice in order to perform
a public duty, and these Mr. Matthews would cast adrift
al^ough there was nothing in the appointment that!
their services would be dispensed with in a summary i
manner without compensation. Health officers who have
given up their practices and taken up public health j
appointments are liable to the same treatment, but still j
they are only appointed for a period. They are as sure !
«of a permanency as we were, but their life is as uncertain,
and may be cast off as “unnecessary and costly,” quite
as untrue as in our case, who have rejected scores of |
boys and young people on account of age and incapacity. :
The Government has been asked to release “ Barabbas ” to j
the mob, and they in their turn must release him or fear j
themselves that they will be dismissed as “unnecessary,
and costly.” When zymotic diseases decrease, will the
Government discharge medical officers of health and public
vaccinators as ‘ ‘ unnecessary and costly,” and call in the ser¬
vices of a private practitioner, or keep them to preserve the
present condition? Cheap labour can always be obtained from
crippled and scrofulous children, and would be plentifully
supplied by drunken parents, and they could work for
months together without fear of an inspector’s arrival, for
at the present time the demand on bis tinie is far greater
than the supply. Instead of dismissing men who have
done good service and are willing to be more useful, they ,
shoula be made answerable for all sanitary work in factories
and should pay periodical visits to see that the health of the I
employed is in no way damaged by their occupation. The |
factory surgeons are considered to be “unnecessary and |
costly” in the eyes of Mr. Matthews; would he explain |
that costliness ? Does it consist in receiving six warm
coppers fished up out of the trousers pocket of a |
factory lad, or the payment of a fee of 4s. for |
a two-mile journey and report on an accident^ and
seeing that machinery is properly guarded. This is
■tiio only fee which comes out of the Treasury. Costly
indeed as regards leather—but these small fees are accept¬
able to men who have relied on them for years, and framed
'their practice in order to do their public duty to unpro¬
tected children. Far better to attend to the health of the
rising generation than to spend money on books for them
wlien their we<akly frames aro too attenuated to study in
reading-rooms. The matter should he plainly put before
illie public, and let them have a voice in it.
I am, Sirs, your obedient servant,
March ISth, ISOI. UbIQUE.
RESPONSIBILITY IN ANAESTHETISING.
To the Editors of The Lancet.
Sirs,—I have read your remarks on the above subject and
the moral you draw—“Let no one underbake the respon¬
sibility of giving chloroform unless in the presence of another
medical man ”—with much interest, and I wonder what
advice you will give to the many isolated medical men in
the country districts of this colony, who are often compelled
to undertake the double rdle of ansesthetist and operators.
Like many of oar profession at the Cape, I am livine about
fifty miles distant from any other medical man, ana many
of my patients cannot afford the fee charged by a second
doctor, who* must travel most of the way in a C^ecart;
hence 1 am obliged in nine out of ten cases to give chloroform
and operate alone. Daring eight years I have performed
nearly one hundred and forty operations necessitating chloro¬
form, and, although alone, have not had one fatal case, and
only once alarming symptoms, amongst patients whose ^es
have varied from a few months to seventy-two years. The
mortality from amesthetlcs during operations is, as far as
I can learn, in this colony extremely low, due, no doubt, in
a large measure to great care in administration, and also to
our.glorious climate. Sole responsibility in operative prac¬
tice carries with it increased anxiety for the doctor, and
who of us does not feel it ?
I am, Sirs, yours faithfully,
J. Herbert Mearns, M.D.
Prince Albert, Cape of Good Hope, Feb. 23rd, 1891.
THE PHONOGRAPH IN MEDICINE.
To the Editors of Tim Lancet.
Sirs,— In your annotation on this subject in your last
issue you express a hope that the phonograph will prove of
use in medicine. I agree with you it will be useful in
recording defects of speech ; but it may save the time of
some of your readers to know that at present it is useless
for recording cardiac or pulmonary sounds, for if the
vibrating membrane (usually glass) is sufficiently delicate
to take up these sounds, it also records all faint extraneous
sounds, such, for example, as those very slight ones pro¬
duced by the machine; hence all that the phonogram emits
is a confused noise, in which the cardiac or pulmonary
sounds are quite indistinguishable.
I am. Sirs, yours faithfully,
Harloy-street, March 14tb, 1891. W. HaLE Wiiite.
BIRMINGHAM.
(From our own Correspondent.)
The General Hospital.
The annual meeting of the governors of this hospital was
held on the 18 th inst., under thepresidency of the Hon. A. C. G.
Calthorpe. The report noted that there was a decrease in
the cost of maintenance from £2 lls. Qd. in the previous year
to £2 10s, Crf. in the year just ended ; the other details also
were satisfactory. With regard to the subscription list for
the new hospital, it was stated that over £84,000 was the
present amount. As affecting the professional staff, two
important alterations in the laws were made at this meet¬
ing—viz , that no medical officer should retain office aher
he is sixty-five years of age, and that no surgical officer
should retain office after he is sixty years of age. The next
alteration was that these officers should be appointed in the
first instance for fifteen years, and that a general meeting
should have the opportunity of further appointing them for
a period nob exceeding ten years, subject to reference to a
subcommittee. It is believed that these amended laws will
have a good effect in the interests of the hospital and of
the profession.
The Women's Hospital.
The annual meeting of this hospital was held on the 18bh
inst. The Mayor, Alderman Clayton, presided. The report
stated that there had been a uecrease in the out-patient
numbers of 192, and in the in-patient department a decrease
of 57. ^ The total number of patients treated during the
year was 15.067. The balance-sheet showed that the total
expenditure for the year was £1869 6i’. 5d., which was
. £14 9i-. 2d. in excess of the income. It was resolved to pull
Dir;., -ed b, ^-OO^IC
690 The Lancet,] LIVERPOOL -NORTHERN COUNTIES NOTES.—EDINBURGH. [March 21,1891.
down a present ward and build a new one in its place
at an expense of £1500.
Quern’s and Mason Colleges. ,
The proposed scheme to transfer the medioal department
of Queen’s to Mason College is progressing satisfactorily.
The outcome of the meeting held on ^e 19th inst. will have
a material influence in settling the matter if the sanction of
the Court of Chancery can be obtained. The Government
grant now obtained by Mason College is £1400, and this
would be much increased by the amalgamation. The
Mason College funds would be considerably augmented for
teaching purposes, and a substantial benefit accrue to the
medical school.
LIVERPOOL.
(From our own Correspondent.)
The Assizes: Trials Jot Murder.
A PORTER named Penfold, aged thirty-one, was tried
before Mr. Justice Day on the 13th inst. for what was locally
termed “The Murder in a Cab.” The deceased was a young
woman of the unfortunate class, and both she and the
prisoner had been drinking heavily for some days before
December 17th last, the date of the fatal event. The two
were seen to enter a cab, and when it stopped at the
desired destination the prisoner informed the cabman that
be had stabbed the girl because she asked him to do it.
The prisoner made no attempt to escape, and was at once
taken into custody. The deceased was taken to the
Royal Infirmary, and attended to by the house surgeon,
but she died in twenty minutes after her arrival there.
On post-mortem examination six punctured wounds on
the left side of the chest were found. One penetrated
the heart and another went through the heart to the
liver. The absence of any motive suggested a doubt
as to the prisoner’s sanity, and evidence was given that
his mother and other members of the family sufi'ered from
nervous diseases. But there was no evidence to show that
the prisoner was insane when he committed the act, that be
was insane now, or that be ever had been so, and the
jury, without leaving the box, returned a verdict of
“Guilty.”—On the same day a married woman aged
twenty-nine was indicted for' the wilful murder of her
infant child. On being called upon to plead she burst
into a hysterical fit of crying. It was proved by the evi¬
dence of Dr. Joseph Wiglesworth, medical superintendent
of Rainhill County Asylum, and of Mr. George Beamish,
nieiical officer of Her Majesty’s Prison, Walton, that she
was suffering from melancholia and delusion. She was
therefore acquitted, and ordered to bo detained during Her
Majesty’s pleasure. She cut the child’s throat, and
then gave herself up to the police. — A third trial
for murder took place on the 16th inst. The crime
having been committed on board the British ship Bucldvg-
ham 'while she was on the high seas on Oct. llth last, the
prisoner being the cook of the vessel, a Hindoo named
Jassiwarra, and the deceased, Peter Lyall, the captain.
Though contrary to his nationality, the prisoner appears
to have volunteered to act as cook; he latterly took a
dislike to the work, and neglected his duty. This led to
words from the captain, who, according to the prisoner’s
statement, struck him twice, but this was not seen by any
of the crew. The captain was found dead soon afterwards,
with two wounds, one over the right eye and another over
the left temple. A knife was found, on which Dr. Barron
observed blood ; he was of opinion that the wounds were
the cause of death. The prisoner was seen to be sliarpening
the knife previously to committing the murder, and he had
also been beard to threaten the captain if the latter struck
him. He was found guilty, with a strong recommendation
to mercy on the grounds of the provocation be had received.
Liveipool, March 17^1^_
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
The late Weather in the North.
It is computed that 300,000 tons of snow fell in
the city of Newcastle on the night of March ^th and
the morning of the 8th. This is exclusive of parks,
cemeteries, and large open spaces. Nearly one-third of
this fell on streets, and, together with the snow falling
from and cast from the roofs of houses, will give a total
quantity of at least 120,000 tons to be dealt with. Much
of this had to be twice removed—first, to the sides of the,
streets, and, secondly, carted away—'SO that it may be
estimated that altogether 200,000 tons have been dealt-
with, the Corporation employing for the purpose 700 men.
White-lead Poisoning in Newcastle.
Another of those poisoning cases so common in Newcastle
among female workers in white-lead factories occurred last
week. It was shown that the girl, aged eighteen, had been
in good health when she went to the factory nine months
ago, but since then she had suffered from pains in the head
and stomach and vomiting of green matter. At last
she was brought home in a convulsive attack, from
which she never rallied. The jury found that the
deceased died from the effects of lead poisoning. These
verdicts are returned with sad regularity, but it is really
strange that this work is allowed to go on.
Conversazione in Newcastle.
One of the most successful gatherings of the season was
held last Friday, in the museum of the Natural History
Society, under the auspices of the associated artistic,,
literary, and scientific clubs and societies of the city. The
proceedings were opened by the mayor, and there was a
very large audience. Microscopical research was well re¬
presented, and the company ranged freely through the-
corridors and galleries of the very fine building, viewing;
such objects as Bewick’s original drawings, Hancock’s-
drawings and Collection of British Birds, and the Athey
Collection of Fossil Fishi &c.
Cumberland.
A motion of some consequence to the general practitioner,,
unless he prefers to submit to a process of extinction
without demur, was carried in the Carlisle School Boartl
last week. It is to the effect that the certificates of health
required by pupil teachers and monitors be given by the
medical officer of health. It was in vain that a member
(Canon Waterton) showed and argued that the family
medical man, who was likely to have a far more competent-
knowledge of the constitution &c. of the candidate, should
be paid by the Board, and employed to certify; and he
moved an amendment, which was lost, to that effect.
There has been an outbreak of scarlet fever at Isel, in the
Cockermouth Union, and the medical officer has obtained
authority to close the school at once.
Phthisis in Sigh Altitudes in England.
The medical officer of liealth for Alston, noted as the
highest market town in England, reports a death-rate of
13'9 per lOOO for the past year on the current census, but he
believes that the new census will show a decrease in the
population, which would of course show a corresponding:
increase in the death-rate. Influent bad caused two-
deaths, and he believes it had sown the seeds of consumption
in many cases. The medical officer for Nenthead, in the
same district, says that phthisis was far more prevalent-
than might have been expected, considering the high situa¬
tion and the pufe rarefied air. Something of this he also-
believed was due to consanguineous marriages. I may
remark in reference to this that the large numbar of patients
(comparatively for a sparsely populated district like that of
Alston) presenting themselves at the institutions of New-
castle-with defects and diseases of sight and hearing has
often been noted.
Nowcast!e-«pon-Tyne, March 18tlj.
EDINBURGH.
(From our own Correspondent.)
Soyal College of Physicians, Edinhiirgh.
In terms of the bequest made to this College by the late
Dr. John Parkin, a Fellow of the College, a prize is ofrere(3
for the best essay on the “Curative Eifects of Carbonic
Acid Gas or other forms of Carbon in Cholera, the different
forme of Fever, and other Diseases.” The prize is £100,,
and is open to competitors of all nations. Essays must b®-
received by the secretary not later than Dec. Slat, 1892.
Digitized by <^ooQle
The Lancet],
DUBLIN.—PARIS.
[March 21, 1891. 691
Edinburgh Maternity Hosf.ital.
The aDQual meetiog of this boepibal was held at the eod
of last week, Professor Grainger Stewart presiding. In the
report it was stated that 293 patients had been treated, as
compared with 2136 in the previous }>ear : and the out-door
patients numbered respectively 661 and 707. Three of the
patients died, but these suffered from a complication of
troubles when admitted. Forty-eight nurses passed through
the hospital curriculum. The financial position showed a
balance to the credit of the institution.
Odonto-Chvrurgical Society.
At the annual meeting of this Society, held last week,
after the business report was submitted, Dr. Clouston read
a paper on the Bard Palate in its relation to Brain Develop¬
ment, in which he went over ground dealt with in the
Morison lectures. His reason for the communication was
to stimulate investigation and collect additional facts.
Medical Appointments.
The directors of the Sick Children’s Hospital have
eppointed Mr. R. D. Rudolf, M.B , C.M., and Mr. Henry
Greville Huie, M.B., C.M , to be resident physicians in the
hospital for six months from May 1st. Dr. Alexander
Black has been appointed a surgeon to the Ear and Throat
Dispensary, in place of Dr. Maxwell Rose, who has been
eppointed medical officer of health for the county of
Dumfries.
Close of the Winter Session.
The winter session of the medical classes in the Uni¬
versity, and the School of Medicine, Edinburgh, terminates
-on Friday. The first professional examinations begin next
v^’eek, and the second professional the week after.
Health of Edinburgh.
The mortality last week was 114, and the death rate 22
per 1000. Diseases of the chest caused .'50 deaths, and
zymotic diseases 8, of which 4 were from whooping-cough.
The intimations for the week were typhoid fever, 16 ; diph¬
theria, 3 ; scarlatina, 22 ; and measles, 53.
The Victor ia Dispensary for Consumpt ion.
A meeting in connexion with this institution was held on
Monday. Professor Grainger Stewart, in speaking about
the work done by the dispensary, said with regard to the
future treatment of disease in Edinburgh it would be neces¬
sary to double the size of the Royal Infirmary and build a
new wing to the Maternity. He said it was deplorable
that their young students should have to pay £5000 a year
to the infirmary and get nothing like what they ought to
get in the way of clinical experience in return. In addition
he moved that every effort be made to extend the useful¬
ness of the Victoria Dispensary and to provide hospital
accommodation, where suitable cases recommended from
the dispensary might be treated in-doors. A committee
was appointed to carry out the objects of the resolution.
March 17th.
DUBLIN.
{From our own Correspondent.)
Stewart Institution for Imbecile Children.
This institution, the only one of the kind in this country,
Idas accommodation for eighty beds—a very small number
when contrasted with the fact that the last census showed
that there were between 7000 and 8000 imbecile children in
Ireland. The accommodation being inadequate for the
Applications for admittance, the commitree have determined
'to enlarge the present building. Dr. Kidd, who has taken
a very active part in the institution since its formation,
recently pointed out that the outlook for support is
■encouraging, and subscriptions have not fallen off. There
is a sum of about £3000 available for the required purpose.
Dublin Sanitary Association.
The committee in their annual report regret that the
Act for the Notification of Infectious Diseases has been
adopted in only one out of seven townships adjoining Dublin.
The Act has been made operative by almost every sanitary
authority in England, and ought to be adopted by all Irish
authorities ; for if outbreaks of infectious disease are to be
successfully coped with, provisions such as chose contained
in the Act must be complied with universally. The Infec¬
tious Disease (Prevention) Act was passed last year, but
is an Act which requires adoption by the local authority in
order to make it operative in any particular district, and as
a result of this, it has not been adopted by any authority
in Ireland. As is well known, the sanitary anrangeraente
of a large number of houses in the city and suburbs are still
in an unsatisfactory state, and the unenviable notoriety
which Dublin has acquired on account of its high death-
rate will not disappear until the defective system of drainage
which so largely exists is rectified. Mr. Pirn, the President,
in an excellent address, in which he referred to the sanitary
work accomplished in Dublin of late years, alluded, among
other topics, Co the condition of the tenement houses, which
he regarded as one of the greatest sources of the high death-
rate. The Corporation have erected blocks of buildings
for workpeople, but so foul was the Augean stable which
had to be cleansed, so enormous is the mass which still re¬
mains to be moved, that all that has been done seems as
yet but a drop in the bucket. Yet it has already appreciably
affected the general death-rate, and as the working classes
are better housed and more attention is paid to domestic
drainage year by year, the good results must sooner or
later appear in the improvement, gradual though it may
be, of the health of the citizens of Dublin.
Memorial Tablet to George Tate, M. D., Surgeon A M.D.
A tablet in memory of the late Surgeon Tate has recently
been placed in Downpatrick Church. The deceased, when
only twenty-six years of age, died at Kasauli, India, in
July, 1889, and the tablet has been erected by his brother
olficers who mourn bis untimely death.
At a meeting of the Macroom (co. Cork) Dispensary Com¬
mittee last week, Mr. O’Donoghue was elected medical
ollicer in the room of Mr. White, resigned.
A fancy hall in aid of the Dublin Orthop.'edic Hospital
will be held on April 8th.
Dublin. Much 17th.
PARIS.
(From our own Correspondents.)
French Pharmacy and its Future.
Most of your readers are doubtless aware that as there
are in France two grades of medical practitioners—viz.,
doctors of medicine and ofjiciers de sanU —so there exist two
orders of chemists, pharmaciens de premitre and pharmaciens
de scconde classc, A movement has been initiated of late
years tending towards the suppression of the inferior grade
in both branches of the healing art. A Bill regulating the
practice of pharmapy, and drawn up by the ex-Minister,
M. Lockroy, has been reported on by a parliamentary
committee, which approves of the reforms indicated above,
and in addition pronounces against the plan of allowing
hospital and infirmary dispensers to deposit at dispen¬
saries and relieving offices medicaments specially prepared
by them for distribution to the sick poor bypersonsdesignated
by the said dispensers. The conclusions of the committee
have been adversely criticised by the Comild Consultatif
d’flygicne Publique, who allege as reasons for the rejection
of these two provisions the fact that the second grade phar¬
macists constitute two-thirds of the 7100 chemists who ply
their calling in France, and, further, that one-fourth of the
cantoD-s have no resident chemist at all. The Comitd
d’Hygibne recommend the abolition of the trade of herbalist
on the ground of that hybrid relic of a darker epoch being
dc trap, and also because of the considerable amount of
illegal advice given at these botanic depots. While on
the subject of pharmacy I may mention that the
Progrts Midical has for some years advocated the taking
up of this branch of industry by women. I myself
have often speculated on the reasons which induce women,
who so loudly complain of the limited scope allowed them
in the choice of a career, to prefer the more anxious and
arduous, if more dignified, functions of a medical practitioner
to the obviously more appropriate calling of a chemist. At
the dispensing counter tlie special genius of women for
detail and delicate manipulation would find a fitting field
Din-ized by V_iOO^lC
692 The Lancet,]
PAEIS.-NEW YORK.
[March 21,189L
■without exercising an undue strain on their physical powers,
and undermining their health by the anxieties inseparable
from the carrying on of a medical practice. The true
reason is, probably, that the one calling ranks as a.
trade, while the other—the favoured one—is a pro¬
fession. In France there are a few pharmaciennes, the
best known of them being olBcially attached to the
lycie of Toulouse. Should the second-grade chemist, whose
existence is menaced by legislation, be allowed to survive,
the examination tests required of him should not prove
too heavy a tax on the intelligence of the average
educated Frenchwoman.
A Novel Mode of contracting Syphilis.
At the last meeting of the Socidtd de Derniatoloaie
et de Syphiligraphie, M. Feulard reported the case of a
man who, having been treated at St. Louis Hospital for
post-scabious eczema, principally of the arms, sought re-
admission for syphilitic roseola. Researches made as to
the seat of inoculation of the virus revealed an enlarge¬
ment of the epitrochlear gland, and hard chancres of the
posterior surface of the right forearm, of the elbow of the
same side, and of the left elbow, the genital organs being
free from all sores. It was remarked that the chancres
corresponded with the points which would touch a table
when, the arms being folded, it served as a poiiit d'appui
for those members. It is consequently surmised that the
raw eczematous surfaces on the backs of the arms became
inoculated by contact with an infected table in the ward.
M. Besnier remarked that instances of the contraction of
syphilis in the wards of a hospital were extremely rare, it
being probable that the activity of the virus deposited on
instruments, furniture, &c., is only of limited duration.
The only exception is the frequent transmission of the
disease oy means of the Eustachian catheter. M. Lailler
cited a ease where syphiliticinfection occurred at ahospital
through a vaginal cannula in indiscriminate use for all
the patients. M. Verchbre had noted a similar case.
Salol as an Antiseptic in Cancer of the Uterus.
Of the symptoms characterising cancer of the uterus in
its later stages, more especially when it is complicated by a
vesico-vaginal fistula, none is more trying to the poor
sufferer than the repulsive odour proceeding from the
diseased surface. The palliative means in ordinary use,
such as injections of caroolic lotion, sublimate and iodised
solutions, vaginal suppositories of iodoform, &c., are only
partially successful in mitigating the fetor which renders
the last days of the patient a veritable martyrdom to herself
and to her entourage. In salol administered internally in
daily doses of from two to four grammes (increased if need
be to six or eight grammes, and continued uninterruptedly
for a long time) Dr. Marty of Toulouse claims to have dis¬
covered a sovereign remedy for this state of things, pro¬
vided there be a communication between the vagina and
the bladder. The urine, flowing constantly over the
diseased tissues and impregnated with the products of the
decomposition of the salol—viz., a phenylsulphate and
salicylic acid—keeps the parts sweet, and its action adds
greatly to the comfort of the patient.
Le M6decin Militaire MalgH Lni.
An incident reported in the Temps of the 9bh inst. has
excited some expostulatory comments in several medical
organs. I refer to the refusal of the Minister of War to
accept the resignation of his commission by an army surgeon.
M. de Freycineb bases his action in this matter on the dis¬
cretionary powers vested in him by the law of 183-1. Re¬
ferred to the judgment of the Council of State, the
controversy has been decided in favour of the Minister of
War. It is certainly difficult to discover wherein the un¬
lucky mtdecin aide-major erred in expecting bis application
to be acceded to, seeing that a provision of a decree pro¬
mulgated on the 16th of June, 1880, renders obligatory the
reir^urseraent of sums expended by the State for the
education and maintenance of those officers who quit
voluntarily the Army Medical Service before the expira¬
tion of their term of engagement (ten years). This
condition the officer in question was, it appears, quite
willing to fulfil. The Bulletin Medical states that the
reason for Ministerial refusal is not far to seek. Govern¬
ment dreads the possibility of resignations becoming con¬
tagious in the eorps de sanU irdlitaire.
Paris. Mi-rh I7tli
NEW YORK.
(From our own Correspondent.)
Medical Education in the United States.
The annual report of the Illinois State Board of Health
contains the elaborate report of its secretary, Dr. John H.
Rauch, on medical education, medical colleges, and the
regulation of the practice of medicine in the United States
and (Canada. The present report is far more complete than
any of its predecessors. It is, in fact, an exhaustive review
and exhibit of all of the medical teaching and licensing
bodies in this country. As this is the tenth annual report
it affords a favourable opportunity of showing the progress
of medical education during this period. In 1882 there
were 135 medical colleges, and in 1891 148. The
number of colleges requiring certain educational quali¬
fications for matriculation in 1882 was 45-; in 1886>
114; in 1889, 117 ; in 1890, 124; in 1891, 129. In
1882 the number of colleges that required attendance on
three or more courses of lectures before graduation was 22 j
in 1886, 41 ; in 1889, 47 ; in 1890, 64; in 1891, 85. Of the
148 colleges, all have chairs of hygiene but 14. The dura¬
tion of lecture terms has increased from an average of 23 •&
weeks in 1882-83 to 26-3 weeks in 1890-91. The number of
colleges having berms of six months or more is now 111, as
against 42 in 1882-83. There are now 32 examining and
licensing bodies which do not give instruction. There are
34 colleges that now or soon will require four years’ study
and three courses of lectures; 11 chat now or soon wilJ
require four years’ study ; 4 that have or soon will have
four courses of lectures. The total number of matriculants
in all of the colleges in 1889-90 was 14,884, and the total
number of graduates was 4492. We may form some estimate
of the present status of homccopathy from the fact that the
number of matriculants in its schools was 1128, and that
of its graduates 391. It appears that there are 6 medical
colleges for women in the United States and 2 in Canada.
There are 5 medical colleges for coloured students.
A Medical College for Women.
An effort is being made to establish a Women’s Medical
College connected with the Johns Hopkins University, Balti¬
more. Several wealthy ladies have combined to raise the
requisite amount of money. This College will be organised
on a very broad basis, and the course of instruction will, I
hear, be most thorough.
The American Public Health Association.
Tliis body held its annual meeting recently at Charleston,
South Carolina. Among the delegates in attendance were
two representing the Superior Board of Health of Mexico^
and several from Canada. A large number of interesting
papers were read and discussed. The prophylaxis of tuber¬
culosis excited much interest, and a committee was ap¬
pointed to formulate practical prophylactic measures
against that disease.' One of (he Mexican delegates read
an elaborate paper on the Federal District in the Republic
of Mexico as a Suitable Residence for Persons predisposed
to Tubercular Affections and, for the Relief of Pulmonary
Consumption. Another paper on the Prevention of Tuber¬
culosis reviewed a century’s supervision in Italy under the
influence of the preventive laws of the kingdom of Naples
enacted in 1782. The incoming President is Dr. Frederic
Montizamberb, of Quebec, Canada.
Death by Neuritis after Dissection of a Babic Subject.
The assistant pathologist at the New York Hospital,
Dr. H. W. Stevens, made a necropsy on -Ian. 23rd on the
body of a man who had died of hydrophobia. He had pre¬
viously injured his forefinger while dissecting, and the
sore was not healed at the time. To miard against danger,
he applied to Dr. Paul Gibier, of tne Pasteur Institute,
and had a series of injections made to protect his system
against the possible presence of rabic poison received
at the necropsy. These were made from .Ian. 26 bh to
Feb. 9bh, when ho was seized with severe nerve pains
and paralysis of the lower limbs. His disease assumed
the form of multiple neuritis and rapidly proved fatal.
Horsley and Brisbowe have described a form of paralytic
rabies, but this case is nob believed to be due to the injec¬
tions. There is much speculation as to the exact nature of
the exciting cause of the disease. Dr. Stevens was himself
much alarmed after the exposure, and apprehended troubles.
Ne'v York, March 2i)d
'C; le
Thb Lancet,]
MEDICAL NEWS.
[March 21, 1891. 69'3
University of Oxford.— The Final Examination
for the degree of Bachelor of Medicine will commence on
Monday, Jane 1st, and the examination for the degree of
Master in Surgery will take place on Thursday, June llth.
Names, with the statutable certificates and fees, may be
«ent to the Secretary of the Boards of Faculties at anytime
before May 30th.
New Fever Hospital at Cleckheaton:—O n the
14th inst. the memorial stone was formally laid of a new
fever hospital for the North Bierley District. The site
comprises upwards of four acres, and cost £837. 11 is central
and midwav between the Cleckheaton and Low Moor
Stations. The buildings will contain an administrative
block, a pavilion of two wards and twelve beds, an
isolation block, with four wards and ten beds, and neces¬
sary offices.
Hospital for Consumption and Diseases of
THE Throat, Manchester.— The sixteenth annual report
states that during the year 1890 the number of out-patients
attending had been 5880, and the total attendance was
31,140. At the hospital at Bowden 231 in-patients were
treated. The enlargement of the in- and out-patient de¬
partments at Bowden was in progress, which would provide
the extra accommodation required. The financial state¬
ment shows a deficit of over £300.
Loughborough Hospital and Dispensary.—
The work of this institution during the past year maintains
its claims for a continuance of the liberal support hitherto
^accorded to it. There has been an increase in the numbers
both of out- and in-patients, the excess in the latter depart¬
ment being twenty-three more than the previous year. The
'expenditure for the year had exceeded the income by
upwards of £60. It has been decided that the title of the
hospital shall be altered to “The Loughborough District
Hospital and Dispensary.
East London Nursing Society.— The Princess
</hristian, the president, was present at the annual meeting
held on the 12ba inst. at Lowther Lodge, Kensington Gore.
Viscount Cranbrook, who presided, gave an interesting
jkccount of the work and objects of the Society. It aimed
at getting nursing possession of the whole east end of
Lonaon, consisting of 100 parishes. It bad twenty-seven
on its hands, and its work was conducted on strictly non-
sectarian principles. The Society had existed for twenty-
one years, and, according to Sir Henry Acland, required
£6000 a year.
Bequests and Donations to Hospitals.— The
late Dean I'lutnptre beqdeabhed £2000 to the Wells Cottage
Hospital.—The Leabbersellers’ Livery Company has granted
donations for the present year to the metropolitan hospitals
and charitable associations amounting to £1653 15i'.—The
''Queen has made a further donation of twenty guineas to
the East London Hospital for Children, Shadwell.—The
late Miss Mary Baird, of Camelon, left £1000 to the
Edinburgh Itoy^ Infirmary ; her sister Mrs. Eliza Beatson,
also of Camelon, also left the Royal Infirmary £1000.—
By the will of the late Mr. Nathaniel Clayton of Lincoln
£1000 has been left to the Lincoln County Hospital and
£600 to the Lincoln Dispensary.—Mr. Samuel Burdge,
late of Bristol, bequeathed £300 to the General Hos¬
pital, Bristol, — A legacy of £600, bequeathed by the
late Mr. Donald Cooper (Dundee) to the Dundee Royal
'Infirmary, has become payable to that institution by the
death of his sister.—The Grocers’ Livery Company has
made a grant of £50 to the Greut Northern Central
Hospital.—The late Mr. Andrew Pickard, of Ossett,
S ueathed £1000 to the Dewsbury and District General
rmary.—Mr. Charles W. Lea, of Parkfield Hallow,
Worcester, has forwarded a donation of £1000 to the
Worcester Infirmary.—By the will of Mr. George Thomas
Sionnett, of Kilburn, £100 each is bequeathed to the
Middlesex Hospital, University College Hospital, and the
teamen’s Hospital, Greenwich.—The Hon. Algernon Tolle-
mache, of Montrose House, Petersbaiii, Surrey, has sent a
donation of £100 to the Royal Hospital for Diseases of the
Chest, City-road.
Football CASUALTY.-i-Ori thh’ 5th inst., a youth,
whilst playing at football hb Clev^ddn, fractured his arm,
which was also dislocated at the elbow.
Presentation.—A t the cloae of the .first aid course
of lectures (St. John Ambulance Association) given at
Ballymena, co. Antrim, a presentation was made to Dr.
Alexander D’Evelyn by the members of the ladies' class, as
a testimony that they appreciated his kindness and patience
as their lecturer.
Death through Tight Lacing.—O n Saturday an
inquest was held at Kingston on Ellen Mary Lewis,
twenty-two, a single woman, residing at 8, Down Hall
Villas, Lower Ham, Kingston, who died suddenly at the
Steam Laundry, Oil Mill-lane, Kingston. Dr. Reginald
Bayley, of London-road, Kingston, said he found traces of
pneumonia, but in his opinion the immediate cause of death
was sudden failure of the heart’s action, brought about by
tight lacing. A verdict in accordance with the medical
testimony was returned.
Chesterfield and North Derbyshire Hospital.
The annual report states that 300 patients were admitted
during the past year, an excess of 55 on the previous
twelve months, and the number treated was 63 more, being
the highest on record. The total number of out-patiento
was 1643. There was an increase of £167 in the expenditure,
for necessary miscellaneous requirements, and the income
amounted to £2071 11s. 3cf., the highest yet recorded.
Plana for additions to the hospital bad been prepared, and
the outlay will exceed £5000, which it is proposed to
defray out of invested funds, together with subscriptions
given specially for that object.
Hull Royal Infirmary.—T he annual meeting of
the governors was held at the hospital on the 12th inst.
Mr. W. R. King, J.P.,chairman of the board, presided. In
moving the adoption of the accounts, which was unanimously
carried, the chairman congratulated the governors on the
satisfactory state of the balance sheet. The annual report
showed that during the year 1890 11,588 patients received
the benefits of the institution. By the liberality of special
donors during 1889-90 the charity had been entirely relieved
of the embarrassment which bad existed during the last two.
years, and the accounts of the twelvemonth under review
closed with a balance at the bankers. The ordinary receipts
amounted to £7994,
Wolverhampton and Staffordshire General
Hospital. —The annual meeting of the governors was held
at the hospital on March 10th. Lieut.-Col. Thomeycroft
presided. The chairman opened the proceedings by moving
the adoption of the report, which had already been cir¬
culated. He refeiTed to arrangements which had been
made for the treatment of women subject to diseases
peculiar to their sex. There was a separate building set
apart for them. The report was adopted. A letter was
read from Miss Lonsdale, matron of the Sister Dora Con¬
valescent Home, Milford, near Stafford, offering a free cob
in that institution for children of both sexes. There would
be no expense to the hospital in connexion with it. It was
remarked that Miss Lonsdale’s offer was practically a free
gift to the hospital.
Royal Statistical Society. —Dr. Mouat read a
paper before this Society on March 17th on Prison Ethics
and Prison Labour, in which questions relating to the regu¬
lation of gaol industry, its bearing on free labour, and the
encouragements which may be allowed to a convict in the
disposal of the portion of his earnings sanctioned, without
prejudice to good discipline, were categorically answered
by the lecturer. He concurred in Howard’s principle of
treating prisoners—“ Make them diligent and they will be
honest,”—and quoted an inscription in the room of the
prison of San Micliel in Rome: “It is of Hole advantage
to restrain the bad by punishment, unless you render them
good by discipline.” ' Principles such as these Howard con¬
sidered to be “an expression of the grand (mrpose of all
civil policy in relation to criminals.” Prison labour, as
the best of all instruments for the punishment of crime,
was then considered in its disciplinary aspect, in the action
of courts of justice, and of the laws in relation to labour
sentences, and in the economic objections to prison work,
one branch of which was the subject of a recent repre¬
sentation to the Home Secretary.
, Coogle
691 ThbLancbt,]
MEDICAL NEWS.
[March 21,1801'.
■ University op Cambridge.—A t a meeting of the
Masber and Fellows of Jesus Collee:e. held on the 12bhinst.,
Mr. John George Adami, M.A, M B , formerly scholar of
Christ’s College, was elected to a fellowship Mr. Adami
is University Demonstrator of Pathology and John Lucas
Walker student of pathology.
Kent County Ophthalmic Hospital. — The
annual report just issued is a satisfactory record of the
work done during the past year. 332 in-patieuts had been
treated, which was the largest number in any year since
1869, the average for the last twenty-one years being 268.
The balance sheet showed that the sum of £362 6s. 3^.
was in hand. It is proposed to erect a commodious room
to be set apart for a chapel, a want which has been long
felt.
Insanitary Casual Wards.—A t the meeting of
the Lambeth board of guardians on Wednesday, Mr. John
Smith presiding, the Rev. C. E. Brooke, reporting upon his
visit to the casual wards, said their sanitary condition was
simply disgraceful. There was an open drain, from which
there came a most filthy stench, and which should not be
allowed to remain open. Mr. SCockbridge explained that
the drain had been opened for the purpose of carrying out a
scheme for perfecting the drainage.
York County Hospital.— The report for 1890
(the 150th) shows that the financial position was highly
satisfactory. Although £2792 10$. iiad been invested during
the year there was still on Dec. 3t8t a balance in hand of
£80 14.5. lOcf. The expenditure was well within the income,
a result partly attributable to the smaller number of
patients. During the year 1074 in-patients were treated
and 8198 out-patients. A house-to-house collection pro¬
duced £371 3s. 2d. Several improvements and alterations
are contemplated in order to render the institution more
efficient.
Oldham Infirmary.— The medical statistics of
this institution for the past year record that 640 in-patients
and 3904 out-patients had been treated daring the year.
Of the former 130 were medical, and 512 surgical cases. Of
the latter, 276 were accidents, 364 patients had been dis¬
charged cured, 160 relieved, 33 left at their own request,
and only 13 were incurable. The Convalescent Hospitals
have been utilised for promoting the recovery of 33
patients, in each case with evident advantage. The balance
sheet showed a deficiency of £781 2s. lid., including the
deficit of £566 2s. 5c?., brought forward from the previous
year.
The Factories Bill. — At the sitting of tho
Standing Committee on Trade, at the House of Commons,
on Thursday, to consider the Factory and Workshops Bill,
it was decided to iuclnde laundries in the provisions of the
Act. The clause providing that all factories constructed
after Jan. Ist, 1892, shall be provided on every floor with
a means of escape in case of fire was met with an
amendment by Sir Henry James, providing that spin¬
ning mills already existing should be provided with
outside means of escape. The Home Secretary maintained
that the machinery of the Bill was sufficient, and in
the event of a building not having sufficient means of
escape the proprietors would be prosecuted before a
magistrate.
The Hospital for Sick Children.— The Duke
of Fife, presiding on Wednesday at the dinner of the Hos¬
pital for Sick Children, Great Orraond-street, held at tbe
Hotel MObropole, said that in days gone by, when the sick
poor were huddled together in the poor-houses, tbe
position of the sick child was sad indeed. It was only
forty years ago that this hospital was established, and to
show tbe way in which it was appreciated he might mention
that tbe average number of patients annuwly treated
within its walls was now about 60,000. Of these, the
in-patients numbered about 1060, and the average number
of new out-patients was 6371; while the grand total of
patients treated during the existence of the hospital was
620,000. He had now to appeal to the public for funds to
enable them to complete the new wing, which would enable
them to carry on the good work upon a more extended
scale. Later in tlie evening subscriptions amounting to
£4360 were announced.
Fire at the Nashville (U.S. A.) Luna'IIC Abylum).
A diaastrous fire occurred last week at this Central Lunatio
Asylum, and resulted in the death of six inmates; 400
lunatics were in the asylum. Only twenty-eight were con¬
fined in the wing where the fire broke out, and twenty-two
of these were rescued, the remaining six perished in the
flames. Tbe inmates became beyond the control of the
guards, and twenty-five escaped, but the most dangerous
were in safety in another wing. The firemen succeeded in
confining the conflagration to the wing in which the fire
broke out.
Newsvendors’ Benevolent and Provident
Institution. —The festival dinner of this institution took
placelast weekat the Hotel M6tropole,Mr. G. Newne8,M.P.,
? residing. Tbe chairman, in proposing “Prosperity to tbe
ustitution,” referred to the great interest the late Charles
Dickens took in the charity, and stated that they
were met on the anniversary of the publication of tho
first daily newspaper in London, which took place on
March 11th, 1702. He urged the claims of the institu¬
tion upon their liberal support. During the evening the
secretary announced donations and subscriptions amount¬
ing to about £800, which included 100 guineas from the
chairman.
The Gordon Hospital for Fistula and other.
Diseases of the Rectum, London.— During the past
year 147 patients were admiDted. The outjpatienbs
numbered 513, and the attendances were 2642. The com¬
mittee in their annual report refer to the Committee of the.
House of Lords on the London Hospitals, and state that
tho figures given by the Charity Organisation Society were
for the year 1887, and do not fairly represent the work of
the hospital at the present time. They hope to have an
opportunity of explainit^ this and other matters referred
to in the evidence. The report of the medical com¬
mittee shows satisfactory results of the work done,
bearing in mind that nearly all the patients are ad¬
mitted for operation. Financially a small balance remains-
in hand.
The Alexander Memorial Prize.—T his triennial
pri/.e, which is open for competition to executive officers of
the Medical Staff, and consists of £60 and a gold medal of
the value of £10, has just been awarded for the second time-
to Surgeon R. H. Firth, Medical Staff. The prize was
founded as a memorial of the late Mr. Thomas Alexander, a
former Director-General of the Army Medical Department^
but, by a clerical error in an advertisement which appeared
in our last issue, it was described as tbe “Alexandra” in¬
stead of the “Alexander Memorial.” Essays for the next-
competition must be despatched so as to reach the Director-
General on or before Dec. Slst, 1893, and the particulars as-
to tbe conditions of the competition will be found in the
advertisement referred to. This information is also fully
given in the annual “ Reports of the Army Medical Depart¬
ment.”
METROPOLITAN ASYLUMS BOARD.
Return of Patients remaining in the several Fever HospitcU$
of the Board at midnight on March I7th, 1801.
Beds occupied.
1
Hospital.
Scarlet
feyer.
1
ji
.fi-
Enteric
feyer.
si
fli
Total
h
P
Eastern Hospital .. ..
23(1
67
61
840
442
North-Western Hospital
172
46
10
232
44S
Western
143
22
13
180
224-
South-Western
145
27
12
184
840
South-Eastern
173
14
21
2»
210
468
Northern „
222
14
-
16
-
251
480
Totals ..
1001
170
-
122
11
1403
2801
Smali,-1’OX.— AUoh hoNpitaJ ship, 2.
* Infiuit and mother.
.OOgle
Dir'
Thb Lancet,] _ THE METROPO LITAN HOSPITALS INQUIRY. [March 21, 1891. 695
MEDICAL NOTES IN PAPLIAMENT.
The General hf/'dlr.al Council.
Tug accounts for isno of tlie Oeneiul Medical (’oniicll and Its brancli
councils Bml of tlio Dental Rogistration Fund were presented to the
House of OomraoBB on Friday, tlio 13th inst., and were ordered to lie
upon the table.
fVaCer-Buppli/ from the Thames.
In the House of Commons on Monday, March lOtli, Mr. Leng directed
attention to the condition of tlie liOudon water supply ns represented
in Professor FranMand's report, in respect of the organic impurity
found in the various samples.—Mr. llitchfo ; My attention has been
drawn to the report to which the hon. member alludes. With regard to
the analysis of the water supplied by the Grand Junction Water
Company on Fob, (itli, I recently stated tlie facts very fully in reply to
a question of the hon. member for the Kmitsford Division of Cheshire.
As to the analysis of the water supplied at a later date in the same
month by other metropolitan water companies, I have no doubt that
the abnormal amount of vegetable matter, although much le.s.s than was
the case willi the water from tho Grand Junction Water Company on
Fob. Oth, was occasioned liy similar causos. Dr. Frankland informs
me that tho exceptionally impure condition of tho idver-tlorivcd waters
supplied to the metropolis in li'obruary has now pas.soil away, and that
these waters have appiiroutly returned to a condition approaching the
normal at tins soasim. I have communicated with Dr. Frankland
with regard to his statomouts as to Iho existence of ruicrobos. He
states that tho ruuiibor was not large for liltcred river wafer, and that,
as no pathogenic organism was observed among the microbe.s, their
presenco docs not aiforu any ground for alann.
The Fanlorics and Workshops liUl.
Many important amendments to tlie Factories and Workshop.s Bill
have been drafted by niomliors of the House of Commons. Mr. Hoyle
has pveparedsoveiul with roferenco to tho sanitary clauses of the Bill.
He has propai'ocl a now clau.so to tlio effect that it shall bo the duty of
every inspector to soud to the proprietors of factories and workshops in
his district full information as to new methods of ventilating and im¬
proving the sanitary concUtion of factories and workshops whiclr he has
mot with in liia district. Another clause prepared by Mr. Hoyle pre¬
scribes that the inspector shall send round reports of all accidents and
injuries to life or limb, with details of tho machinery and appliances
which have caused them, .Sir Henry James has di-awn up a most for¬
midable list of amendments. A few of them deal with the sanitary clauses;
others relate to holiday.s. A large group have reference ^ the work
of the inspectors. Sir Henry James proposes that, where an inspector
is obstructed in the cx-eciition of his duties, the person obstructing him
shall he liable to a lino not loss than one nor exceeding ten pounds
sterling. In a now clause ho proposes that where it appears to an in¬
spector that dust is generated in any factory and Is inhaled by the
workers 10 an injurious extent, and thntsucli inhalation could be pre¬
vented by the uao of mechanical or other means, he shall serve on
tho occupier of tho factory a roquireiuont that means be provided
witliin a reasonable time. Mr, .Sydney Buxton lias given notice of an
amendment prohibiting the employment of ehililren under twelve years
of age. He excepts those children for whom special provision is made
under tho Prevention of Cruelty to Children Aetj issa In relation to
this Bill wo may add that Mr. Matthews has intimated his hope tliat
he may bo able to effect some coiupromiso with regard to the aDolition
of the oflico of certifying factory surgoous.
THB MBTROPOLITAN HOSPITALS INQUIRY.
Tine Sele,;t Committee of the House of Lord.s on the Metropolitan
HoBjiitals resumed its inquiry on Monday. Karl Sandhurst presided.
Oreenwich Seamen's UoapUal.
Mr. Mtclielli, secretary of the {Jreenwicli Hospital for four years,
said tlmt for the last thirteen years lie had been connected with
hospitals. Tills hospital was for seaiiieu, and was managed by the
Keamcn's Ho.spital Society. They admittod seamen suffering from
all diseases, and, in cases of urgency, other people. Their main
hospital was at (Ireenwich, with 22r) beds. 'I'here was a branch
liospital witii fourteen beds, and disponsurios at tfie London Docks and
Oravosond. Tliero was an income of tSOdO from laud and funded
property—.C700 of tliat sum coming from laud. Ilia salary was
iilOO a year, with a houso, and he had coinmission.s which averaged
lietwetu &iO and ,£6fl a year. They wore governed by their own
Act.s of Parliament. He tlicnght llicir method of checking small
cxpeiidituro was good, but really tho chief responsibility lay with
him. The working luuuber of bods was 1!)7, and they adinlUod
all di.seasos, except small-pox and typhus. Tlioir legacies last year
amounted to .11701)4, which was an oxcepUoiially good year, tlie average
being t;i7(K) for ton years. Tlio total rcceipis last year wore,CIS,U(i().
and the ordinary expoiulituie .212,70'', They had a professional
auditor. Tlioro ought m bo a unifoniiit-y of hospital accounts all over
tho country. IIo liuniglit it pos.slhlo to liavo a central body to
audit all the accounts. Tlio oxpriutituro should be put under heads,
so as to find out tlio cost of foods aiul drugs, He thought it a pity
that sni.all hospitals slHuiId bo slji.rUal under tho windows of largo
hospitals, ami tliove should be a liceiwiiig body to exaiiiiiiB mid
report us to the uece.ssity for any new hos]>ital. Ho did not
liko to see tho general hospitals increased in -si/.o; he would rather
see hospital oxloiisjou (ako the form of erection of hospitals outside
London, Two-thirds of the patients might witli safety he reuiovod to tho
cfiuuti'v, only sutlicient patients being kept in London for instruction
inirposea. Tho licensing body miglit be elective and in connexinn with
the (Charity Gcmimissioiiers. It slumld audit accounts and inspect tho
liospitals, but liavu no control. It might also liccu.so tho now liosjiitals,—
By Lord Kimberley; liispoctioii diil nob necessarily moan control, bo-
cause the inspucbiiig bodiu.s in the Goloiiics and in Dublin did not
exercise control.- kiiglit not tlio general body of J.ondon hospitals
appoiiitaii auditor wiilioiit bniigiiig in public control? 1 think there
is such a rivalry that it would bo dillicult —You propose to invest your
funds in tho Cliiirity Comiiiissioiiers. Do you think the public have
confirtoMCo in the Charity Commissioners? 1 think they have.—
Have you found thorn an agreoabio body to deal witli? Yes,—
Do you get an answer to your letters In a reasonable time, or have yon t9>
wait for six months? In a reasonable time.—By Lord Thrlng: In rega^
to this licensing body, why should you prevent any man from doing any¬
thing which Is not injurious to the State? Well, if there was this liceneioe
body, you might have a hospital at Camberwell Instead of a hospitd
at Paddington, where it was not wanted.—By the Chairman: The
patients were admitted by the principal medical officer. The food)
was supplied by open tender through advertisement. There were-
not inany complaints as to food. When there was any complaint,
the food was brought to him, and he along with the medical officer
decided whether the complaint was well founded. The atewardi
and matron had a salary of £100 a year each. There was a staff of
thirt^y. Deducting meal hours, a sister or probationer was on duty for
ten hours forty minutes, Night nurses were on duty eleven hours fifty-
four minutes. The nurses did no menial work, and had a very easy
_ time during the day. ^ They had no students, but the principal medical
officer took a certain number of students. There was a Samaritan
Ilrnd, out of which they relieved the patients who were Incapable of
going back to sea. There was a principal medical officer (£8C0 and a
house), a house pliysician (£70), and a house surgeon (£60). The two-
latter were nominally appointed for a year, but usually retained offico-
much longer. He was the head of the institution, but he had no power
to suspend a medical officer for a grave irregularity. In such a
case he could call tho committee together witliin twenty-four houifl.
As a matter of fact, such an emergency had never occurred. During
tile last yeai' they had liad 85.62 out-patients.—By the Chairman: It woo
a pity that at nearly all the London hospitals out-patients were kept
.standing in the street.s, sometimes in the wet, until the doors opened.
The Lock Hospital.
Mr. Sliillitoe. surgeon of the Lock Hospital examined by Lorik
Catlicart, said he had some statistics as to venereal disease, but they
were very mitleading. It was not possible to give statistics as to
the prevalence of the disease, because when people got the diseasu
surreptitiously they did not like to publish tho fact. The hospital
accommodation was not nearly sufficient. It was a horrible thing that
the women should be allowed to leave hospital uncured. He could
not speak in strong enough tonns on such a subject. The disease pre¬
vailed all over the country to a much larger extent than was suRpoaod.
The typo of the disease was very much the same as it had been for
many years- It was quite as virulent as it used to be. There were
accessions in the strengtli of tho disease occasionally, and he noticed
tliat, especially after the Paris Exhibition, that was through importa¬
tion, I’he aggravated forms of disease were not so common, but thati
was tlirough the spread of education. Tlie mercurial treatment was the
only one of any avail. The chief objection to the female out-patieut
system was that lliey only got partially cured and then continued
their evil courses. 'The same objection applied bo female in-patients,
who left before they were quite cured.—But public opinion will not let
you keep the women in? I hope that public opinion will veer. 1 hope
to see the day when wo shall be able to keep the women till cured. I
think the present law is a great miafoitune to the nation at large.—
Were you always in favour of the Contagious Diseases Acts? Yes; and
my opinion has become intensified since my connexion with the Lock:
Hospital.—Do you find that the women leave the ho.spital uncured
before fair.s, or, say, tho Derby clay ? Yes, that is the case.—Examina¬
tion continued ; Ho had known many cases of surgeons aiicl nurae.s
taking the disease. He had known cases where infection was coni-
municirted by towels. liven in travelling people might meet tlio
microbes of tlie disease. The public were not sufficiently alive to tho
danger they ran from this terrible disease.
Mr. A. 0. Coole, secretary of the Lock Ho.spital, recalled, said that if/
the present apueal for assistance was not re.spondod to adequately the-
hospital would have to be shut up, or another appeal issued. They
were in debt £3000 to their tradesmen, but. of 781 cases treated in tho-
hospital, they only lost sight of 177 caves. They were able to follow
many of the women after leaving the asylum altached to their hospital,,
and the rosulis wore most encouraging. They had 1200 men out¬
patients and 150 women. Thoyalwavs made inquiry as to the circum¬
stances of patients before giving advice.
Mr. Khillitoe, recalled, examined by Lord Catlicart. said that a great
deal of quackery rxi.sted in tho treatment of this disease. In the-
beginning of the disease much of the treatment was by chemists.
The committee then adjourned.
'J'lieir lordships met again on Thursday.
Bromplon Cojisuwptum Hospital.
Mrs. Taylor said slio was formerly matron of the Brompton Con¬
sumption Hospital. The staff consisted of about seventy. They sent
out many nurses to private cases. It was not tho usual thing to take
out nurses from the wards and send them to piivate c.vses. Quite
half of the private nurses came to them adequately trainod, and ihe-
nurses they thcmsclvus trained had three months’in a general hos¬
pital. They liad voluntary helpers, but no unpaid probationers. Ii»
her nine years’experience at Brompton she bad never heard a com-
])laintfi-om a nurse as to the food. If there had been anv complain!*
slie would liavo boon sure to hoar of the matter. The resident medical)
officer had two courses of lectures in tho course of tlie year. She also-
held classes, and found it bettor to keep the classes down to four or six.
at a time.
King s College Hospital.
Dr. Waco, D.D., cbairiiiau of the committeo of management of King's-
College Hospital, said they bad practically no endoivmoiiis. I,.ast year
thoir receipts wore £11,288, and their expoiuiituro £l7,12(i. 'J'liis showed ai
largo doiicit. Tlie deficit was mot by some legacies and tlio sale of some
stock. This was the largest deficit they had had for many years. 'I'liey
had kept tlio hospital constantly before tlie public, and they found thai;
tho more tlioy appealed tho more money they got. .li^ve years ago they
Iiad to close two wards and reduce tho nuinbdr of beds, but since that
time they had been able to reopen the wards and fill all tlio bods. They
had 220 beds, and 216 beds were occupied last week. More patients,
ciimo to tho hospital than they could accomnuulate. Thoir deficit did)
not cause them great anxiety, because they could always catch it up.
They liad a large body ef friends who were ready to respoiul to any
special appeal. The number of iu-patlents admitted during tho yeai-
was 2H8L and this added to the number remaining in the hospital made
till) total number treated 2018. Tho out-patients numbered 0060, butt
there W!ia also a casual department, where 10,337 persons wore timted.
'Ogi.
, S6 The Lancet,] THE'METROPOLITAN HOSPITALS INQUIRY.—APPOINTMENTS. CMarch 21,189L
In addition, 607 poor women were treated during confinement. Their
nurses bad all to attend the services of the Churclx of England. They
admitted all kinds o( disease except smali-pox, with chU reserva¬
tion : that there should not be more tnan ten cases of infectious disease
atone time.—By Lord Cathcart; Bo you think it fair, in a hospital
wliich takes money from all rell^ous denominations, to make a religious
test in regard to the nurses? Perfectly fair, if we make the bargain
beforehand.—Bo you think it judicious? We find it works well, and
there has never been any objection made to it.—By Lord Clifford: We
thought it better that there should be some, liospltals managed on the
prindple of religious tests for the nurses.. Thov found it advantageous
for the general dlsolpline and good workint;; of the whole institution that
there should be this tost.
iilster Munk, matron of the hospital and lady superintendent of the
nursing department of King’s College Hospital, said they had nurses for
private work, hut this did not at all interfere with the regular staff in
the wards. Their nurses were probationers for two years, and took'
<their certificates at the end of three vears. If the nurses did private
work they received a commission on their .earnings; the maximum was
16 per cent. The nurses were on the National Pension Fund. No nurse
lhad left the hospital except to fill a better position.' She always dined
with the nurses, as did also the sisters. ' She would therefore bo able
to know if there was any cause of complaint, but she had not known of
.any complaints as to food. She was opposed to any British nurses’regis-
tmtion society, as every hospital had its own registry of trained
nurses.
Br. Gurnow, dean of King's College Medical School, physician to the
Itospital, and professor of anatomy, said that since 1601 he had been
'Connected with King's College with the exception of one year. He
proceeded to give evidence regarding the arrangements in the out¬
patients' department, dividing the cases for this purpose into
•casual patients and out.patients proper. It was only very special
<ases wnich continued under treatment for over three weeks. The
arrangements for the treatment of casual patients were detailed, and
the duties of the resident medical officers subtnitted to their lord-
ships. The visiting staff wore compelled to obtain the membership of
itho Royal College of Physicians or a Fellowsliip of the Royal College
■of ijurgeons within a year of their appointment to the staff. This was
on account of the disciplinary powers exercised by these bodies in
>regard to questions of etiquette. The examination of the Royal
College of Surgeons was acknowledged to be the best surgical examina¬
tion in the kingdom, with almost no exceptions. He might say that the
^legree of Master of Surgery of the University of London was quite as
liigh as that of the Royal College of Physicians, tlie examination being
quite different, and separate from that for the M.B. degree, an
arrangement which did nob hold in the case of other Universities. If
tlie Universities exercised such disciplinary powers over their graduates
he saw no reason why a man belonging to those Universities
^ahouid not become a member of the hospital staff. — By Lord
.Zouche : They had standing rules in the hospital whereby ten
<ases of infectious diseases were achnitted, so that the students in
King’s College bad a better chance of seeing such diseases than
students had in any other hospital in London, King's College Hospital
^elng in q^te an exceptional position in regard to those diseases.—
By Lord Spencer: These patients were in the same wards as the
oidlnary patients, unless there was anything special in tlieir case. Tliere
•were two Isolation wards in the hospital, In regard to the utili- '
sabion of the Metropolitan Asylum Bonds hospitals for teach¬
ing purposes, Br. Curnow said it would be extremely imprac-
■ticable for a teacher of one of the ‘general iiospitals to take a
■class to an Asylums Board hospital where the management was
under a different superintendent, and wlieretbe patients were under a
different physician, and over which hospital the teacher had no control.—
By Lord Monkswell; The question of special ho.spitals depended upon
stho class of the hospital. Hospitals like the Bronipton Hospital for
Consumption were essential because the eases they treated were ex-
■trernely numerous. Then there were hospitals for incurables and those
which, like Moorfleld.s, were founded before optithalmic <lep;u’tmonts
were common in general hospitals. In general hospitals now they
ha<l separate departments for the oye, ear, noso, tlivoit, skin, &c.,
:and he saw no longer any necessity tor special hospitals dealing
with those special diseases, but they could not do away with an old
institution. Most of the recent special hospitals certainly were useless.
It was simply parcelling the body out into pieces, and treating tlie one
part as if it fiad nothing to do ivitli the other. Regarding hospitals
for diseases of children, also, it simply amounted to a miestion as
to how the accommodation could beat bo distributed.—By the
■Chairman: The medical school was not an independent .school. All
accounts were paid in to the secretary of King’s College. Since 1866,
whon he was appointed dean, the receipts averaged from .£2600 to
£6500, the highest total receipts being nearly £6700. That meant an
average of tiiirty or forty students entering for tiie year. During the
bust year or two the numbers had been increasing. The medical men bad
no control over the institution at all. They had a medical committee
which rocommonded to the Council of the College candidates for the
-appointments.—Lord Spencer : Your school differs from other .schools
in this, that there is a large element of lay management, wlioreas in
other hospitals it is alroo.st entirely managed by the hospitivl staff.—
The Witness: Ours is the medical department of a college, managed
1)y the council of a college, but other medical school.savo simply associa¬
tions made by ho.spilal surgeons for teaching purpu.ses. 1 prefer it
infinitely to the private system.—Lord .Spencer: Would you like to
•develop this system stiil furtlier. ami have a largo board for the manage¬
ment of medical schools in London ?—The Witno.ss: I tliink it would l»n
most disastrous. Tlio cliief objection I should have is tlutt all scientific
studie.H are ho practical that I could not understand how a teacher
•could teach practical science to more than IDO students at once. The
teaching would be left mainly in the hands of inferiors or assistant de¬
monstrators. lb is nob so much to the lecture system that oiijoction
can be urgoil as that tlie practical work would bo neglected. I aui
very strongly of opinion that tliero is a groat waste of teaching power
in science subjectM in London, which could be improved by combination.
In fact, the great advantage of King’s College mid University College is
that pupils can be sent to study, for instance, physical Huionco in
one of tlie finest physical laboratories in the kingdom. It is almost
umpossible fur a medical department to keep up tliese things unless it
IS extremely rich.
The Committee then adjourned until after the Raster recess.
^puintments.
Suecesuful applxcantBfor Vacancies, Secretaries o/Pultio TnBtitutionB,and
others possesHng i7^for7nation suitable for this column, are invited te
forward it to The Lancet Ojflce, directed to the Sub-Jiditor, not later
than 9 o'clock on the Thursday morning of each week for publication tn
the next number. . . ■ -
Allen. W. C.. L.R.C.P. Kdin., M.R.C.S., has been reappointed Medical
Officer of Health for the WlUtngton Urban Sanitary District.
Armstro.vo, James, L.R.O.P., L.R.C.S. Edtn., has bsen appointed
Medical Officer for the Workhouse, and District Medical Officer to
the Brampton Union, vice Wothorspoon, deceased.
BERRy, Edmund, L.R.C.P. Irel., L.F.P.S. Qlasg.jhas been reappointed
Medical Officer of Health, Leyland.
Berrv, H. P., M.B. Lond., M.E.C.S., has been reappointed Medical
Officer of Health for the Grantham Urban District.
Black, Alex., M.B., F.R.O.P. Udin., has been appointed Surgeon to
. the Eye, Ear, and Throat Infirmary, Edinburgh, vice Rosa, resigned.
Chambers, E., M.B. Aberd., M.R.C.S., has been appointed Bistriot
Medical Officer and Public Vaccinator, Holborn Union.
Cheesewrigh^ J. F., L.R.C.P. Edin., M.R.C.S., has been reappointed
Medical Officer of Healbb for the Greasborougb Urban Sanitary
District.
Clarke, A., L.R.C.P. Lond., M.R.C.S., has been reappointed Medical
Officer of Health for the Street Urban Sanitary District of the Wells
Union.
Clark, W. F., L.R C.P., L.R.O.S., has been reappointed Medical Officer
of Health for Clieshunt.
Clibborn, Wm., B.A.. M.D. Dub., L.R.C.S. Irel., has been appointed
Medical Officer of Health for the Borough of Bridport; also Cer¬
tifying Surgeon under the Factory Act for Bridport ond tho
surrounding districts.
Collins, J. T., L.R.C.1’., L.R.C.8. Edin., has been appointed Medical
Officer for the Roscommon District of the Ballinasloe Union.
CoNOLLY, C. H., M.R.C.S,,. has bean reappointed Medical Officer for
tho Wood Green Urban Sanitary District,
Corner, Harry, M.B., L.R.C.P.Lond., M.R.C.S., has been appointed
Second’ Assistant Medical Officer at Bethlom Royal Hospital.
CrOSSFIeld, A. K., L.R.C.P., L.R.C.S. Edin., has been reappointed
Medical Officer for the Dittisham District of tlie Totnes Union.
De la Hunt, J. J., L.R.C.P., L.R.C.S, Edin., has been appointed Medical
Officer for the Galway l)i8trIot of tlio Ballinasloe Union.
Eady,' G. j., M.D. Brussels, M.R.C.P. Edin., M.R.C.S., has been
appointed Medical Officer for the Kilburn District of the Hampstead
Union, vice Hill, resigned.
Emerson, D. N. B., B.A., M.B.,B.Ch.,B.A.O. Dub., has been appointed
Senior Resident Medical Officer to the Victoria Dock District Dis¬
pensary, vice C. H. Burtchaell, M.B., resigned.
Evans, C. H., L.B.C.P.. M.R.C.S., has been appointed House Surgeon
to St. John's Hospital for Diseases of tho Skin, vice Q. W. Damioan.
Faicunie, Fred,, M.R.C.S., L.R.C.P. Lend,, has been appointed
Clinical Assistfint to the St. Marylebone Infirmary, Nottiiig-hill,
vice Bornean, resigned.
Gartley, T. a., L.D.S.B.C.S. Eng., has been appointed Honorary
Dontal Surgeon to the Frenoli Bonovolenb Society.
GiLiiERT, H. P.. L.R.C.P. Edin,, M.R.C.S., li.as been appointed Medical
Offleor for the Twelfth District of the Wisbech Union.
Grant, Ogilvie, M.B., D.P.H. R.C.P. Edin., has boon appointed
County Medical Officer for Inverness-shire.
Gratte, C. Brooke, M.R.C.S,, L.R.C.P.Lond., has been appointed
Medical Inspector of Seamen for the Board of Trade, Newport,
Monmouthshire.
Hall, George, M.D. Edin., has been appointed District Medical
Officer and Public Vaccinator for tho Witlo District of tlie llamblo-
doii Union.
Hamilton, A. A., L.R.C.P., L.R.C.S. Edin,, has been reappointed
Medical Officer of Health for Crowle, Thorne Union.
Harris, H., M,R.C.S., has boon reappointed Medicid Officer for the
Ugborougli District of the Totnes Union.
Hartford, H. W., L.R.C.I’., L.R.C.S. Irel, has been appointed Medical
Officer for the Workhouse of tho Christchurch Union,
IIICIIKNS, F., M.D. Loud., M.R.C.S., has boon appointed Medical Officer
for tho Workliouso of tho Redruth Union, vice Carlyon, resigned.
IIODSON. Tfios., M.R.C..S., has been appointed Modioal Officer and
Public Vaccinator for the Sixth District of the Chelmsford Union,
vice Wiustanloy, deceased.
HuiJ’^ U. G.| M.B., C.M, Edin., haw been appointed Resident Physician
of tho lioyiil Edinburgh Ilo.spital.
Johnson, II. 8., 1,.R,C.P. Irel., L.F.P.8. Glasg., has boon reappointed
Medical Officer of Health for tho Totnes Rural Sanitary Distriot.
Kkmfe, Arthur VV., M,D. Briix., M.R.C.P. Edin,, M.R.C 8,, lias been
appointed Medical Officer of^ lloaith to tlio Exeter Port Sanitary
Authority.
Leks, E. Leonard, M.D., C.M., M.R.C.S., has been appointed Medical
Registrar to tho Bristol Hospital for Sick Children anil Women.
Lucas, Herbert, M.R.C.S., has been reappointed Medical Offleor of
Health to tho Huntingdon Town Council
Lund. T., M.B., B.S. Diivh., lias beau appointed Resident Medical
Officer and Secretary to the Royal Victoria Hospital, Bournemouth.
MaCKAy, P.B., L.R.C.P. Loml, M.R.C.S.,has been appointed Honorary
Surgeon to the Doncaster Infirmary, vice Robinson, resigned.
MacLeod, John Norman, M.A., M.B,, C.M.fllasg., has been appointed
House Surgeon to tho Royal Infirmary, Dundee.
McOscAR, John, M.R.C.S., has boon appointed Medical Officer for the
Cliinnor District of tho Wycombe Union.
Malcolm, W. A., M.B., C.M., has been appointed Oasiialty Officer.
Registrar, and Assistant Aiuvstholist to tlie Great Norllmrn Central
Hospital,
Nevin, Rodeht j., M.B,, C.M. Glasg., has boon appointed Medical
Officer and Public Vaccinator for the Wast Anuklaml District of the
Auclcland Union ; also Surgeon to tlio West Auckland, TIndule, and
St. Ilelons Collieries.
Thb Lancet,]
VACANCIES.-BIRTHS, MARKIAGES, AND DEATHS.
[March 21,1891. 697
POWBLL, L. L.^^L.R.C.P. EdIn.,M,R.C.S., has been appointed a District;
Medical Officer for the Melton Mowbray Union.
PuitVEs, A. S., M.D. Edin., has been appointed Medical Officer for the
Losbiiry District of tlic Alnwick Union.
PRE3TON, H. T., M.D. Abev(l„ M.R.C.S., has been reappointed Medical
Officer for the Wolverley District of the Kiddorminater Union.
Rawlings, H. K., L.R.C.P. Irel., M.R.(; S., hits been appointed Medical
Officer of Health for the Rural Sanitary District of the Gower Union,
vice Jones.
Ross, Jas. M., M.B., C.M. Edin,, has been appointed County Medical
Officer for Dumfriesuhire,
RuDOLi'-, R. D., M.B., C.M. Edin., has been appointed Resident Phy¬
sician of the Royal Itdinbui-Rh Hospital.
SUAiiMAN, M., M.B. Olasg., M.RC.S., has boon appointed Medical
Officer for the Rickmanswortii District of the Watford Union.
Shore, Hkrbt. G., M,R,C.S., has been appointed Medical Officer for
the Cropredy Districtj of tlio Banbury Union, vice Hodgson, resigned.
Smith, K. R,, M.D. Lond., M.R.C.S., has been reappointed Medical
Officer of the Harbtonford and Halwell Districts of the Totues
Union.
STOCiciUPGE, T. G., M.D. McGill, Montreal, M.C.P.S. Ont., M.R.C.S.,
has been appointed District Medical Officer and Public Vaccinator,
Holborn Union.
Symington, W. D., M.D. Edin., has lieen appointed Medical Officer of
Health for the Brampton Union Rural Sanitary District, vice
Wotherspoon, deceased.
Temple, T. C., M.R.O.S., has been appointed Medical Officer for
Shillington, Gravenhurst, and Haynes, Ainpthill Union.
UnSDELL, ll., M.R.O.S., has been reappointed Medical Officer for the
Staverton and Ratterv Ilistricb of the Totnes Union.
WlIiTAKEH, G. H., L.R.C.P., L.R,C.S. Edin., has boon appointed Certi¬
fying .Surgeon of Factories and Workshops for the Horwich District,
Bolton-le-Moors, vice Einmott.
WiLLAN, G, T., M.R.C.S.. has been appointed a District Medical Officer
of the Melton Mowbray Union.
Fo further iij^ormation reiiu-iinij each vacancy rcferencenhould fie mode
^ tj the advertimruint.
BetHLEM Ho.SPITAi,,—Two Resident Clinical Assistants.
Bradpord INPIRMARY AND DISPENSARY.—Dispousary Surgeon. Salary
£100 poi' annum, with boivd.
Burton-on-Trent Friendly Societies' Medical Association.—
Junior Medical Officer. (Apply to the Saevotary, Shobnall-road,
Burton-on-Trent.J
Borough Lunatic asylum, Portsmouth,—Clinical Assistirnt for si.Y
months. Board, rooms, lodging, washing, and attendance pro¬
vided.
Bridgwater Ineirmarv.—H ouse Surgeon. Salary £80 per annum.
Cancer Hospital (eree), Fnlham-road, S.W.—Assistant Surgeon.
Counties op Midlothian, West Lothian, and Pkerles, and Dw-
tricts within the same.—M edical Officer. Salary £600. besides
travelling expenses. (Apply to the County Clerk, County Build¬
ings, Edinburgh.)
ClIARiNG-CROSS hospital. — Surgical Registrar. Salary ,£10 per
annum.
County Asylum, Shrewsbury.—Junior Assistant Medical Orticcr.
Salary .£100 per aiumm, and £8 in lieu of beer, with board, lodging,
and washing.
CilARiN(i-CROSS Hospital Medical School.—D emonstratorship of
Physiology, ilouorariuni £100 per annum.
CiiEl^EA Hospital por Women, Fulham-road, S.W.—Resident Medical
Officer for one year. Salary £80 per annum, with board and resi¬
dence.
County A.sylum, Rainhill, near Liverpool.—As.sistant Medical Omcovs.
Salary commences at £100 a year, with prospect of an increase of
£2batthe cud of the first year and £20 at thoondof the second,
with further inci'oaso according to promotion, togetlior with fur¬
nished .apartments, board, washing, and atteiuianco.
Deacones.srs’ Institution and Uo.spital, Tottenham.-;-Re.sid6nt
House Siu'goon for one year. Salary £90 per annum, with board
and residence.
District Inpirmauv, Ashton-under-lvyne.—HouseSurgeon. Salary £00
per annum, with board and lodging.
East Sui-t'OLIC and Ipswich Hospital.—H ouse Surgeon. Salary
£ 10(1 per annum, with bo»rd, lodging, and washing.
Great Northern central Hospital, Holloway-roid, N.—Obstetric
J.’liysician to Out-pationts.
Hospital, King'.s Lynn.—House Surgeon and Seerotai^, Salary £80
S er annum, rising to £ 100 , with board, lodging, and washing in the
uLspitid.
Hospital eor Women (London School of Gynuicology;, soho-
squaro, W.—Clinical Assistants.
Japfuay SunuRiiAN Branch of the General Ho.8pital, Gravelly-
iiill, near Birmingham,—Resident MedicalOlticer. Salary £i.')0 per
annum, with board, residence, and washing.
Kent County Asylum, Charbluun, near Canterbury.—Junior Assis'iint
Medical Officer. Salary £125 per annum, witlifurni.shodapartments,
board, and attendance. (Apply to Mr. Alien Fielding, Solicitor,
Canterbury.)
Liverpool Dispensaries.—A ssistant Surgeon. Salary £80 per annum,
with apartments, board, and attendance. (Apply to the Secrotary,
Leith Offices, 21, Moorllelds, Liverpool.) .
Me'thopoi.itan Hospital, Kingsland-road, N.K.—House Physician for
one year. Salary at the rate of £00 per annum for the first six
months, and at tlio rate of £70 per anmnu for the second six
Metropolitan Hospital, Kingslaiid-road, N.K.—House Surgeon for
one year. Salary at the rate of .£00 per annum for the first six
montliH, iuid nt the rate of £70 per annum tor the second six
mouths
Metropolitan Hospital, Kingland-road, N.F..—Assistant House
Surgeon for six months.
Newcastle-on-Tvne Dispensary.—V isiting Medical Assistant. Salary
£120ayear.
Royal South London Dispensary.—H onorary Surgeon.
Royal Hospital for Children and Women, Waterloo-bridge-road,
S.B.—Resident Medical Officer. Salary £70 per annum, with
board and residence.
Royal Hospital for Children and Women, Waterloo-bridge-road,
S.E.—Anresthetist and Registrar for one year, honorarium of
20 guineas being voted at the end of that tei-m.
RoyalbathHospitalandRawson Convalescent Home, Harrogate.—
Resident Secretary and Dispenser. Salary £80 per annum, with
board, lodging, and washing.
St. Mary’s Hospital, Paddington, W.—Surgeon in chkrge of Out-
S atleuts for five years.
lARYLEUONE GENERAL DISPENSARY, 77, Welbeck-street, W.—Resi¬
dent Medical Officer. Salary £106 per annum, with furnished apart¬
ments, attendance, coal, and gas.
Stockport Infirmary.—A ssistant to tlie House Surgeon for six
months. Board and residence.
Windsor Royal Infirmary.—H ouse Surgeon. Salary £100, withi
apartments, but no board.
WORCESTER County and City Lunatic Asylum.—T hird Assistant-
Medical Olfictr. Salary £100 per annum, with board, lodging, and
washing.
Slsraages, anli
BIRTHS.
AvARNE.—On March 15th, at Crossfteld House, Blaenavon, Mon., the-
wife of Arthur Blair Avarne, M.R.C.S., L.S A., of a son.
Caldwell.—O n March 14th, at Bri.xton, the wife of W. T. D. Caldwell,.
M.D., of a daughter.
Critchett,— On Mivreh 16th, at 21. Uarley-streeb, W., the wife of
O. Anderson Critchett, of a daughter.
Duke.—O n March 9th, at Locksley, St. Leonards-on-Sea, the wife of
Edward Duke, M.R.C.S., of a daughter.
I'lMsiETT.—On March 12th, at Woodville, Kingston-road, Portsmouth,,
the wife of Richard Emmett, M.R.C.S., L.R.O.P. Lond., of a
(laugliter.
IIEARNDEN.— On March mil, nt Rose Cottage, Leatherhcad, the wife of
Walter C. llcavnden, M.R.C.S., of a son.
Jones,—O n March IStli, at Southgate, Kckington, the wife of G. H.
West Jones, of a daughter.
SyMPSON.—O n March 14tli, at 3. James-street, Lincoln, tho wife of
E. Mansel Sympson, M.A,, M.D., B.C. Cantab., M.R.C.S., of a son.
Troup.—O n March 10th, at Pembroke-square, Konsingloii, the wife of
Surgeon-Major It. W. Troup, Army Medical Staff (retired), of a son.
MARRIAGES.
Clarke—Hector.— On March I2th, at St. Peter's, Morley, by the
Rev. Vavasour F. Hainmond, M.A., Vicar of Drighlington, assisted
by the Rev. O. Pedley, Curate of St. Peter’s, Morley, Arthur Clarke,
B.A„ L.R.C.P. LomJ., M.R.C.S. Eng., of Street, Somerset, to-
Ooorgina, fourth daughter of the late Alexander Hector, of
Montrose, Forfarshire, N.B.
UoDGKiNSON—W hitnai.l.— On March 5th, at St. Philip's Church,
Alderloy Edge, Alexander Hodgkinaon, M.B., C-M-, B.Sc., of Disley
and Manchester, to Eliza Francos Whitnall, of Southport.
Mani.ey—Dundas,— On March 12th, at St. Simon’s, West Kensington
Park, Herbert Manley, M. A., M.B. Cantab., only son of John Manley,
of West Bromwich, to Alice C. M. Dundas, eldest dauglitov of the
late Robert Thomas Dundas, Commander in the P. and 0. Com-
pany'.s service.
Martin—CRO.SS. — On March 12th, at St. Stephen's, Hampstead,
Charles Js-mes Martin, M.B., B.Sc., to Edith Harriett, second
daughter of tho late Alfred Cross, of Kilmartli, Hastings.
RODEN— Join*.—On March 4th, at St. Andrew's Church, Aberdeen,
Percy Austin Rodon, M.B., second son of S. S. Roden, M.D.,
Droitwicli, Worcostershiro, to Minnie Abercrombie, youngest
daughter of Keith Jopp, M.D,, Aberdeen.
Taylor—A iiiiOTT.— On March lird, ;vt St. Paul’s, Onslow-aquaro. Henry
nerbovb Taylor, li'.R.C.S., of Rnmswick-place, Brighton, to Florence-
Mario, daughter of the late William Abbott, of Tasmania.
DEATHS.
Bull.—O n March I7th, suddenly, William Bull, F.R.C.S., of Shepherd's
bush-road, W., aged 41.
Carter.— On March 14th, Albert Carter, M,D., of Bexhill, Sussex.
Gordon.— On March 13Ui, at Muir House, Juniper-green, Midlotliian,
Patrick Gordon, M.D.
SVMiis.—On March 7th, at tho County AHvliim, Rainhill, George
Dickinson Symes, Assistant Medical Officer, socond son of J.
Gustavus Symes, of Southfield, Weymouth, late Medictil Supor-
intondoiit of the Dor.iet County Asylums, aged 30. Greatly loved ;
deeply lamented. Au.stvalian and Indian paper.s please copy.
Erratum.— Wo regret that in our obituary column last week a serious
error was sulfercil to pass uiicorrocted. The paragraph
“ Hawkins" was intended to announce the death of Mr. I'mnU byoney
Hawkins, not of Mr. Walter U, T. Uawkiiis, who wo are glad to know
is still in tho possession of his wonted health.
S.B.—A. fee of J«. is charned for the Insertion of Noticct of Births,
jUttn-iotfes, and Deaths.
Dig ; t, ^OOglc
698 Thb Lancet, J NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [March 21,1891.
V , ■=
METEOROLOGICAL READINGS.
(Taken daily at 8.30 a.m. by Steward's Inetrwnents.)
Tub Lancet Office, March mh, 1801.
Date.
Barometer
reduced to
Sen I/evel
and S 2 F.
Direo-
tiou
of
Wind.
Dry
Bulb.
Wot
Bulb.
Solar
Itacliu
in
Vacuo.
Maxi-
ruutn
Temp.
SlULOU.
Min,
Tump
Rain¬
fall.
Itcniarks at
S.SO A.M.
Mar. 13
•29 77
B.
37
85
81
47
31
Hazy
.. u
29-83
N.B.
41
88
61
46
37
■02
Overcast
„ 16
29-72
S.W.
40
S7
72
40
35
02
Cloudy
» 16
29-87
S.W.
40
88
68
47
88
■21
Overcast
17
29’57
N.E.
43
42
63
48
40
■01
Raining
„ 18
29-80
N.H.
44
48
58
49
42
■12
Overcast
„ 19
29 85
N.B.
41
88
69
40
87
Cloudy
Sljbital Jiarg for ensaing ®etfe.
Monday, March 23.
ClOTAL London Ofutualuic Hospital, Uooefields. — OperaOioDs
dally at 10 a.h.
Royal Westminster Ophthalmic Hospital.—O perations, l.80 p.h.,
and each day at the same hour.
Chelsea Hospital for Women.—O perations, 2.80 p.h. ; Thursday, 2.80
Hospital for Women, Soho-squarb. — Operations, S p.h., and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.m.
moYAL Orthopjidic HOSPITAL.—Operations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.h., and
‘ each day in the week at the same hour.
(Unitersity College Hospital.—E ar and Throat Department, 9 a.h. ;
Thursday. 9 a.m.
Society of Arts.— 8P.M. Prof. R. Meldola: Photographic Chemistry.
(Cantor Lecture.)
Medical Society of London.—8.80 p.m. Dr. b. Ward Richardson:
Peroxide of Hydrogen, and Various Methods for its Aclminisbration
and Use.—Mr. Alban Ooian : Fibro-Sarcoma, oj‘ Desmoid Growth
of the Abdominal Wall.
Tuesday, March 2i.
Kino’s Collsoe Hospital.—O perations, 2 p.h. ; Fridays and Saturdays
at the same hour.
QUY's Hospital.—O perations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 p.m.
St. Thomas’s Hospital.—O phthalmic operations, i p.m. ; Friday, 2 p.m,
St. Mark’s Hospital.—O perations, 2 p.m.
Cancer hospital, Brompton.—O perations, 2 p.m.; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
Sr. Mary’s Hospital.—O perations, 1.30 p.m. Consultations, Monday
2.80 P.H. Skin Department, Mond!^ and Thursday, 9.80 a.m
T hroat Department, Tuesdays and Imdays, 1.80 P.M. Electro
therapeutics, same day, 2 r.H.
Society op Arts.—8 p.m. Mr. Clement Heaton : Uses of Cloisoniiij
for Decoration in Ancient and Modern Times.
The Sanitary Institute (Parkes Museum. Margaret-st., W.).—8 p.m.
Mr. A, WynterBlyth: Sanitary Laws and Regulations governing the
Metropolis.
iRoYAL Medical and Chiruroical Society.—8.30 p.m. Mr. C. B.
Lockwood: The Treatment of Strangulated Hernia when the In¬
testine is Gangrenous or Ulcerated. — Mr. W. Arbuthiiot Lane :
Chronic Traumatic Arthritis.
Wednesday, March 25.
National ORTHOP.fiDic Hospital.—O perations, 10 A.H.
Middlesex Hospital.—O perations, 1 p.m. Operations by the Obstetric
Physicians on Thursdays at 2 P.M.
•St. Bartholomew’s Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 p.h,
Surgical Consultations, Thursday, 1.80 P.M.
Charinq-cross Hospital.—O perations, 8 p.m., and on Thursday and
Friday at the same hour.
6t. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same hour,
London Hospital.—O perations, 2 p.m. Thursday ASaturiry, same hour.
St. Peter's Hospital, Covbnt-garden.—O perations, 2 p.m.
<3aharitan Free Hospital for Women and Children.—O perations,
2.30 P.M.
OftEAT Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, lsop.h. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 9.15 a.m.
Royal Free Hospital.—O perations, 2 p.h., and on Saturday.
CHILDREN'S Hospital, Great Ormond-street.—O pei-abiona,9.80 a.m.|
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
eiUNTERiAN Society.—8 p.m. Dr. Galabin; Modern Methods of
Ctesarean Section.
Thursday, March 26.
St. George's Hospital,—O perations, l p.m. SurMcal Consultations,
Wednesd^, 1.80 P.M. Ophthalmic Operations, IViday, 1.80 p.m.
University college Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 a.m.
British gynecological Society.—8.30 p.m. Specimens of Uterine
Polypi will be shown by Dr, Kdis. Dr. Robt. Bell: The Treatment
of Chronic Disease of the Uterine Adnexa.
Friday, March 27.
Boyal Sooth London Ophthalmic Hospital.—O perations, 2 p.m.
Batiuday, March 28.
ailDDLBBEZ HOSPITAI_Operations, 2 p.h.
lUNtvBRsiTV COLLEGE HOSPITAL.—Operations, 2 p.m. ; and Skin Depart¬
ment, 9.15 A.M.
Itotes, Sljrot ComiKent^, # to
Cffittsptotnti
li J.S espcciall)/ rerpiicstcd that early intdligance of local
events having a medical interest, or which it is desirable
to br ng under the notice of the professiout may be sent
direct to this Office.
All communications relating to the editorial business of the
journal must be addressed ''To the Editors.”
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private informa¬
tion, must be authenticated by the names and a^resses
of their writers, not necessarily for publication,
Wc cannot pi-escribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed "'To the Sub-Editor.”
Letters relating to the publication, sale, and advertising
departments of THE Lancet to be addressed "To the
Publisher ”
We cannot undertake to return MSS. not used.
Diarriuea due to Balantidii.
J. The Balantidium coli is an infusorium which was discovered by
Malmsten of Stockholm as long ago as 1858, and has since been studied
by Lenckardt and otlieis, being found frequently in the emeum and
colon of tho p'g, and occasionally in the human colon, in wliich case
it is, .sometimes at all events, associated with obstinate diarrhoea and
intestinal ulcers. It is probable that it may bo conveyed from the
pig to the human subject in food. Little is known about the treat¬
ment, and no examples of this parasite seem to have been found in
the human subject in this country, or in France or Germany.
In Sweden and Russia, however, It is probably not a very uncom¬
mon cause of diarriima. A case is reported by a Russian medical
woman in which a female patient of seventy years of age, who suffered
from cliroiiic interstitial nephritis, was attacked by profuse diarrheea,
there being as many as twenty stools daily containing balantidii.
Eneinata of salicylic acid and of naphthalin and also of salol were tried,
the last being given in (inanbities of a quarter of an ounce twice a
day; all these, howeve>-, without effect. When the aalol enema •was
given thiue times a day, and increased to a third of an ounce each
time, the pjirasites disappeared. 'Tiioy returned, though in diminished
numbors, a.s soon ns tlie .salol enomata were left off.
hiexperliis should refer to Whitaker's Almanack, or other authority on
tho point.
“RECIPROCITY BETWEEN MEDICAL PRACTITIONERS AND
CHEMISTS."
To the Editors of The Lancet.
Sirs,—I beg to support your eorrosponrtont, Mr. G. D. Mackintosh,
whose letter on the above subject appeared in your issue of the 7th iiist.,
in his denunciation of dispensing by general practitioners. There can
bo no doubt that this stupid practice is at the root of the custom of
prescribing by cliemista ; and is not this latter from many points of
view an unmitigaied ovil? And certainly dispensing is degrading to
the profession itself, and is, moreover, exceedingly jrk.some and incon¬
venient. The dispensing every clay at fixed hours comes in the way of
the visiting, the midwifery, and even of the desirable and necessary
rest. People, who may be very ill, have often to wait for hours before
the busy practitioner can be back at his surgery to make up tlie medi¬
cine; and. in order to be at his surgory as soon as possible, he has to
hurry over his viriis; hence imperfect diagnosis and meagre advice.
He has also to subject himself to all the discomforts and risks of violent
exertion in hastening about, and of postponed and irregular meals; has
to .shorten his con'iiltatii.ns by doing the manual work of making up a
bottle of physic, for wliicli he has time only to slop in hurriedly two or
throe Ihiiig.s, piobably nut infrequently incompatibles; has to deprive
himself of much well earned leisure, of lime for his hobby (“Every
sen-ible man who wisbes to preserve his soul and his senses lias his
hobby"), for general and medical reading, for study of his obscure
case.s, and for doing more in thought and in deed for some of his patients
who may need all the deliberate scienbiftc attention possible, Fiirlhar-
mote, the custom involves the habit of visiting and consulting merely
to get to know as quickly as possible for wliab crudely to prescribe;
and hence there much leas true, careful sdentifle observation and
good to humanity than might be. And do not patients now go to a
“doctor" to get physic, and expuct to get physic which must be Id
nothing less than a bottle, and as cheap as possible? No advice or
attention is recognised minus phy.sic. Hence grows the enormous
popular evil of everlasting drugging and physic-taking, as evinced in
the vast extent of the patent medicine trade. Your correspondent’s
Diyiiized by
Google
Thb Lanobt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. IMarch 21, 1891. 699
remark is andeniable—that the present general practitioner is con¬
sidered by the public little more than a mere tradesman and a shop¬
keeper; so the cheapest doctor is sought for, and he is the one who
does the “ roaring business.” To eliminate this popular 'delusion ; to
raise the tone of a practitioner’s status, habits, and vocation ; to rid him¬
self of an inconvenient and fatiguing “extra” to his legitimate calling—
is surely not a very difiBcult matter. Give the dispensing over to the
chemists, by reciprocal arrangement or otherwise, as seems most con¬
venient. But to give up the present malpractice only needs united ac'ion
on the part of all truly professional men, and then even general boycotting,
if necessary, of all private practitioners who persist in underbidding their
brethren by keeping up the shop system at cheap charges. Could not
your correspondent or some other supporter read a practical paper on
the subject at the next British Medical Association meeting, when
the matter could be discussed, proposals made, general universal
action taken, and a special committee and subassociation formed, if
necessary ? For a practitioner to decline to join surh an effort, would
it not seem suspicious that he Intended to keep out so as to trade in
drugs and water, and, like the dog in the manger, rob of their legiti¬
mate and whole business well-trained, well-educated men. indnitely
better able to dispense neatly, properly, safely, and effectively than the
best dispensing medical practitioner who ever “fagged” through his
dispensing? Or is he afraid of a chemist’s criticism of his prescriptions?
I am, Sirs, yours truly,
York, March 10th, 1891. Sick op Dispensing.
HERPES //OSTER.
To the Editors of The Lancet.
Sms,—It is an interesting fact that one case of herpo.s r.oster is gene¬
rally the herald of others, but those attacked need not necessarily live
in the same immediate locality, nor yet have been in contact with each
other. This tends to prove that the neuritis originates in some common
cause, either atmospheric or otherwise. Tlie disease, as far as my
experience goes, is not at all infectious, although some cases have been
reported in which infection appears to have been at work in their pro-
pa^!;ation. The following cases which recently occurred in my practice,
none of them nearer than a mile of each other, bear out these state¬
ments. On Dec. 6th, T. H-, male, aged forty-five, applied at my
surgery with a well-marked crop of herpes following the course of an
intercostal nerve. On Dec. Kith, R. M-, male, aged sixty, sent for
me. He complained of intense paiii in his gluteal region and lower
part of the abdomen of the left side. On examination I found him
suffering from herpes, tire vesicles in this case being over the distribu¬
tion of the gluteal branch of the external museulo-cutaneous and
middle musculo-cutaneous nerves. On Jan. 10th, N. C-, female, aged
ten, appeared with the herpetic eruption on one side of her face, map¬
ping out the course of the facial nerve. Jan. Uth: VV. B-, male,
aged forty-seven. Herpes over tiie course of an intercostal nerve.
All these cases did well under the treatment except the second, in
whicli tho neuralgia has nob yet disappeared, and at one time was so
severe as to make liia friends apprehensive of liis sanity.
I remain. Sirs, your obedient servant,
Geo. Tandy Wilkinson, L.R.C.S.I.,&c.
Cloughton, Scarboro’, March ICtli, 1801.
“A NEW METHOD OP NASAL IRRIGATION.”
To the Editors <if The Lancet.
SiKS,—Without douiit the profession is indebted to Dr, Ball for
ringing under notice the simple and ingenious method of nasal irriga¬
tion devised by Dr. Pins of Vienna. To obtain its maximum of useful¬
ness there are three points in which the instrument and its mode of use
are capable of improvement1. The nozxle should be oval, so as to fit
the nostril without undue distension. 2. It should be made of hard
rubber and perforated in five or six places, as is the cose with tlie
nasal syringe which goes by my name ; for by this means a combination
of a coarse spray and of a full stream is obtained; and in this connexion
it has to bo noted that whatever method of irrigation is employed the
fluid is bound to return by the opposite nostril, provided the nostril of
entrance is thorouglily blocked by tho nozzle of the irrigator. 3. The
nozzle should not be inserted up the nostril, as in the engraved (igure,
bnt along tlu! floor: for while a stream in the former direction is not
necessary for efficient nasal irrigation, it is very liable to produce head¬
ache and other symptoms of discomfort.
I am. Sirs, yours faithfully,
Weymouth-streot, W., March 16th, IS'Jl. Lennox Bkowne.
THE SURGICAL TREATMENT OF PHTHISICAL CAVITIES.
To the Editors of The Lanc-i-t.
Sm.s,—When the Koch treatment wa.s flr=t introdiu'cd, I remarked to
my partner that it pub me in mind of tho .surgicaUreiif input of phllii.sical
cavitie.s, which was mooted ami written about, ami, if I mi-stake not, put
into practice so long ago as tho end df 1851. Tbi.s identical method of
tveatineut is ropovteil in The Lancet of March 7tli tins year, and cases
given from the practice of Drs. Sonnonbevg and Luser. Tho date is
fixed in my mind, as I l omomber reading tho accounts on my first voyage
to the Australian gold fleUls. If reference were made to TiIE Lancets
at the end of that year accounts of this treatment would bo found.
I am, Hir.s, yours obediently,
Brierley-bill, March IGth, 1801. Sainthii.i. Peakse.
A FOREIGN BODY LODGED FOR BIGHT MONTHS IN
THE BRONCHUS.
To the Editors of The Lancet.
Sms,—A case was lately reported in one of the French medlcail
journals of a cigarette having remained in one of the bronchial tubes of
an individual for seven months. A similar case came under my notice
lately, in which a bone was lodged in one of the bronchial tubes for
over eight months. Ihe circumetances are these. A lady, while par¬
taking of s'omesoup at lunch, turned quickly to speak to one of her
children, when she felt the bone pass into the larynx, which caused a
fit of coughing with nausea and vomiting. In the afternoon she wentA
foradiive, having a seDsatimof “tightness in the chest and wheezing.”
About midnight or the early hours of the following morning sbehadj
another prolonged fib of coughing, followed during the day by feverish¬
ness at intervals, a troublesome cough, and all the symptoms of sub¬
acute bronchitis. With the aid of sedatives, such as chloric ether,
bromide of ammonium, and compound tincture of camphor, the tight¬
ness in the chest was alleviated. The cough of the early hours of the
morning still continued, but was at length allayed by a mixture con¬
taining sulpbonal. Although greatly relieved by the medicine, she did
not regain her usual bealtu, dnd was very subject to exacerbations of
cough and tightness in the chest on exposure to cold, so that for tw»>
months she was confined to her room. The bone was at length ejected
in the following manner. The patient had been away on a visit, and
on her return, after a journey of two days, she was coughing more than
usual and could get no sleep, which she ascribed partly to having
caught cold during tlie journey and partly to having been disturbed by
her children, who were suffering from whooping-cough. Twenty-five
drops of chlorodyne were accordingly given along with the usual dose
of sulphonal mixture, which had the effect of giving her a good night'a-
rest. This was repeated the next night, and on the following morning
1 was informed that she had rested well till 4 a m., when a severe fit of
coughing came on and lasted for over two hours, during which sha
several times nearly fainted, and that at length the bone was coughed
up. Beyond a few streaks of blood in the sputum, there was nothing
to indicate any injury it had caused in its passage out.
I am, Sirs, yours faithfully,
John W. Weib, M.D ,
March, 1891. District Surgeon, Bnjeobo, Transkei.
THB PROFESSIONAL STATUS OF QUALIFIED ASSISTANTS;
To the Editors of The Lancet.
Sirs,—W ill you give me your assistance on tho following case in your
next issue?
I am qualified assistant to Dr. A., am twenty-seven years of age,,
was registered in December, 1888, am a member of the local medical
chirurgical society, have been with Dr. A. a year and eight months,
and hold more the position of a salaried partner than an assistant..
Dr. A. is sent for to a case one night. Be is ill, and sends me in his
place. 1 treat the patient, and he takes two doses of my medicine,,
getting some relief. For some reason or other he has no confidence in'
me, and so, two hours perhaps afterwards, sends for another medical'
man—Dr. B. In the course of a conversation with my principal-
afterwards, Dr. B. says that he does not recognise me—ignores me—irr
the case. Dr. B. knew that I was qualified, and he also knows me-
personally. 1. Can Dr. B. thus ignore me? 2. Generally speaking,,
what is the position of a qualified assi.stant in relation to other
qualified men? 3, Ouglit I to take up the matter, and request ais
explanation from Dr. B. ? I am, Sira, yours faithfully,
March 10th, 1891. C. A. L.
Dr. B. undoubtedly was within Ids right in ignoring the qualifiecii
assistant of a principal ill, but we think he vfouid have acted a higher
and more neighbourly part in reg.arding the illness of tho principal aj*-
a reason for coiisnlting with the 'lualified assistant or attending the
patient till his own adviser was alilo to resume the care of the case-
Wo assume that the relations of the two principals 5i’ere of a friendly -
character, and that the patient would have acquiesced in such an
arrangement.—E d. h.
JtaiAer. —1. We do not see that our correspondent has any remedy for
the action of hi.s board of guardians.—2. “Rapier's” friend c.ur.
certainly claim his fee.
CoAservdtioe has forgotten to enclose his card.
THE USE OF THE RECTAL BAG IN LITHOTRITY.
To the Editors of The IancET.
Sirs,—W ith reference to Mr. Reginald Harrison's remarks in your
last issue on the use of the rectal bag In certain cases of sounding for
stone and of lithotrity, I am quite sure that a paper I read before the
Havveian Society of London, and which was afterwards published at
length in the Provincial Medical Journal of April, 1890, “On some
Sources of Error in Sounding for Stone when the I’rostate is Enlarged,
with a description of a New Form of Sound,” has entirely escaped his-
iiotice. I there described the use of the rectal bag in a case in which I
performed lithotrity, a very deep post-prostatic pouch being present, in-
order “ to prevent, as far as possible, debris from falling into the
pocket behind the prostate.” I am. Sirs, yours truly,
Wimpole-streel, W., March lOtb, 1891. G, BuCKSTON BROWNE.
Lioogle
Di,
700 Ths Lakobt.S notes, COMMENTS, AND ANSWEKS TO CORRESPONDENTS. [March 21,1891,
It has been taught by some authorities, especially in France,
that there is a period of agenesia in the inter-menstruum; but it is
not an established fact. No doubt there is not so great a probability
insemination being fruitful at the time stated by our correspondent.
As a matter of experience, conception does take place during any
part of the month, but perhaps rrith greater certainty after or before
the menstrual period.
A Coitntry Person.—Our correspondent should communicate with the
Medical Defence Union.
Dr. W. if. Thursfield will find the case commented on in our last issue.
Communications not noticed in our present number will receire atten¬
tion in our next.
Communications, Letters, (fee., have been received from—Dr. Hale
White, London ; Mr. L. Browne, London; Dr. Wyllie; Dr. Gordon
Holmes, London; Mr. towers-Smitb, London ; Mr. Pearse, Brierley
Hill; SirE. Saunders, London ; Dr. Horrocks, London ; Mr, Lawson
Tait, Birmingham; Dr. Gowers; Dr. Oainsbury, London ; Dr. More
Madden, Dublin; Dr. Collins, London; Dr. Althaus, London; Dr. W.
Hime, Bradford: Sir W. Dalby, London; Dr. Rutherford, Glasgow ;
Dr. D. James, Sheffield; Mr. White, Guildford; Messrs. Langridge
Aud Freeman, Cheapside; Mr. Ainley, Halifax; Messrs. Richardson
and Co., Leicester; Dr. H. Barnes, Carlisle; Messrs. Biirgoyne and
Co., London; Mr. Deuebar, Edinburgh; Messrs. Keith and Co., New
York; Dr. Syer, London; Dr. M. Baines, London ; Messrs. Krohne
and Sesemann, London; Dr. Thursdeld, Shrewsbury ; Mr. Buckston
Browne, London; Mr. T. Christy, London; Messrs. Farmer, Lane, and
Co., London; Dr. J. B. Ball, London; Dr. J. H. Mearns, Cape of Good
Hope; Dr. Steele, Clifton; Dr. Stalcatt, London; Messrs. Ingram
and Boyle, Battersea; Mr. G. T. Wilkinson, Scarborough; Mr. Mayo
Robson, Leeds; Mr. J. H. Caird, Lochgoilhead ; Messrs. Blondeau
Cie., London; Dr. Ridge, Enfield; Dr. Eicbberg; Messrs. Bishop
and Sons, London ; Dr. Churton, Leeds; Dr. Walmsley; Mr. Gifford
Hash,Plymouth; Mr. Reeves, London; Dr. G. Johnson; Dr. Oscar
Liebreicb, London; Dr. Rentoul, Liverpool; Messrs. Mitchell and
Co., London; Mr. Bampton, Ilkley; Dr. J. Adam; Messrs. Orridge
and Co., London; Mr. R. Lloyd, London; Messrs. W. H. Smith and
Son, London; Dr. E. B. Edwards, Constantinople; Messrs. Uoyd and
Co., Leicester; Mr. Michelli, London; Mr. Piggott; Messrs. Bush
and Son, Sheffield; Dr. R. Neale, Hampstead; Messrs. Hoywood and
Co., Manchester; Mr. E. Roberts, Manchester; Messrs. Perkins and
Co.,London; Mr.Whitefoord,London; Dr. J.E.Squire; Dr.Hingston
Fox, London ; Col. Fitzgerald ; Mr. H. Herbert; Messrs. Hawkins
and Thorpe, London; Mr. McClelland, Glasgow ; Messrs. Price and
Co., Battersea; Mr. Moullin; Dr. Black, Glasgow; Messrs. Cassell and
Co., London ; Dr. Holden,Edinburgh ; Mr. Singleton, Jarrow ; Mr. F.
Grange, London; Dr. Fitzgerald, Folkestone; Mr, Ackrill, Harro¬
gate ; Dr. Hodsdon, Edinburgh; Dr. Fletcher, Ormskirk; Mr. T. P.
Lowe, Bath; Mr. Yeoman, Morpeth ; Dr. Potter, London; Mr. Evans,
Shrewsbury; Mr. Sharpe, Matlock ; Mr. Huish, London; Mr. Freer,
Llandudno; Mr. George, Preston; Mr. Mitchell, Hepburn ; Mr. Tats,
Manchester; Mr. Coombs, Bridgwater ; Mr. Barling, London ; Mr. M.
Wheeler, London; Mr. C. Heath, London; Mr. Tresise, Burton-on-
Ti'ont; Dr. Fletcher, Highgate; Mr. Mayhew, Ipswich; Mr. S. E.
Atkins, London; Dr. Skrimahire, Holt; Mr. Smith, London ; Mr. A.
Mackay, Aberdeen; Mr. Woodeson, Milton; Mr. Meadows, Hastings;
Messrs. Squire, London; Rapier; C. A. L.; Maltine Manufacturing
Co , Bloomsbury ; Francis ; R. B,, London; M.D,, F.R.C.S.; County
Asylum, Shrewsbury; Surgery, London; M. M., London; A Counti^
Person; Sister-in-Obarge, Hitchin; General Practitioner; Kent and
Canterbury Hospital; Inexpertus; Secretary, Worcester County
Asylum ; Prescriber; Stockport Infirmary; Secretary, Chichester
Infltmary; Public Hospital, Sheffield; F.R.C.S.
Letters, each with enclosure, are also acknowledged from—Dr. Buck,.
Boston, U.S.A.; Dr. Hoffman, Swansea ; Mr. Tully, Eastings; Mr. B.
KUhn, London; Mr. Lockwood, Huddersfield; Messrs. Maclean and.
Sons, Edinburgh; Mr. Tyte, Mlnchinhampton ; Messrs. Scratoherd
and Hopkins, Leeds; Mr. Stranagban, Pontypridd; Messrs. Seabury
and Johnson, London; Mr. Jones, Llangollen; Mr. Harries, South
Wales; Mr. Wylie, Dorking; Dr. Garman, Kendal; Messrs. Cooke
and Sons, Winsford; Mr. Weller, Finsbury-clrcus; Messrs. Resson
and Robbins, New York; Mr. Neill, Haslingden; Messrs. King and
Co., London; Dr. Jessett, London; Mr. Ruck, London; Messrs. Caine
and Co., Sontbsea; Mr. Armstrong, Cumberland ; Messrs. Baelz and
Co.,London': Dr. Davies, Newport; Mr. Buller,Worcester; Mr. Clark,
Somerset; Mr. Tasker, Sheffield; Mr. Pirio, Wakefield ;”Mr. Morton,
Norfolk: Mr. Wilkes, London; Dr. Mannsell, Cardiff; Dr. Osborn^
Southampton; Mr. C. W. Price, Cardiff; Mr. Kay; Mr. Richardsy^
London ^ Dr. Newman, Paris; Dr. Stanley, Hereford ; Mr. Mopp^al,
Bangalore; Mr. Memble, Dorset; Mr. Considine, Ennis ; Dr^r^ack,
London; Mr. James, City-road; Mr. Ladd, Canterbury; Dri Davies,
Maesteg; Mr. Ronw, London; Mr. O’Meara, Wisbech ; Mr. Jones,
Glamorganshire ; Mr. Watt, London; Mr. Pearson, New'ry ; Mr. Thin,
Edinburgh; Dr.Williams,London ; Mr.Simpson,Lincoln; Mr. Jones,
Eckington; Mr. Cochrane, Wigtownshire; Mr. ^orjett, Lincolnshire;
Miss Symons, Southport; Dr. Flndlater, Edgware; Mr. Adams, Bom¬
bay; Mrs, O'Connor, Hampstead ; Mr. Thorpe, Bradford ; Latakia;-
M.R.C.S., London; Alpha, London; Ulna, London; Grove House
Private Asylum; Ludovicus, London; Forceps, London; Nottingham-
General Hospital; Adoption, London; B. H., London ; Anderson’s-
College Medical School, Glasgow; B,, Leeds; Smodloy's Hydropathic
Establishment, Matlock; Medicua, Suffolk; Delta, London; Staffs
General Infirmary ; K., London ; W.S.,London; Secretary, Carlisle
Dispensary; Oxon, London ; Spes, London ; A. B., Truro; Farringdon
General Dispensary, London; M.O.H., London; Medicus, Birming¬
ham; M.B., Loughboro'; Lancet, Nottingham ; K., London ; Iota,
Folkestone; B. J. R., London; Undergraduate, London; Cardamoms,
Bury; Feirum, London; Cantab, London;' H M. S., London; Vicar,
London; L. P. C., London; Veritas, London; Smilax, London ; Brad¬
ford, London ; P. W. H., Barking; Lymph, London ; J. F. B., Peck-
ham ; M.R.C.S., London ; Surgeon, Dulwich.
Newspapers.— Natinnal Press (DuhUn), hJdinhurgh Evening DisixUch,
North British Mail, Islinjjton Gazette, Leeds Mercui-y, L'Independence
(Brussels), Birmingham Post, Scottish Leader, The Newspaper, Citu
Press, Wvndser and Eton Gazette, Mining Jowmat, Liverpool Daily
Post, Manchester Guardian, Bristol Mercury, Weekly Free Press and
Aberdeen Herald, Reading Mercury, Hertfordshire Mercury, Windsor
and Eton Express, Local Government Chronicle, Sunday Times, Broad
Arrow, Builder, Metropolitan, West Middlesex Standard, Chemist and
D’l'uggist, Spectator, Saturday Beview, Law Journal, Pharmaceutical
Joiirnal, Architect, Guy's Hospital Gazette, Surrey Advertiser, Labour
World, West Middlesex Advertiser, Times of India, Melbourne Argus,
Bradford Observer, New York Herald, Hastings Neivs, Eastbourne
Qazet'.e, Worcester Chronicle, Luton Times, Stajj'ordshire Chronicle,
Southampto'n Times, Shields Daily Gazette, Norfolk Daily Standard,
Sidmoxilh Observer, Cape Times, Evening Mail (Portsmouth), Chester
Courant, Dartmouth Chronicle, Andover Standard, Birmingham Daily
Gazette, Corriere D’ltalia (Rio de Janeiro), The Schoolmaster, <t‘c.,
have been received.
SUBSCRIPTION.
Post Free to ant part of the United Einqdoii.
One Year £1 12 6 | Six Months £0 10 fl
To China AND India .One Year 1 10 ll
To the Continent, Colonies, and United
states.... ..... Ditto 1 14 I
Post Office Orders and Cheques should be addressed to The Publisher,
The Lancet Office, 420, Strand, London, and crossed London and
Westminster Bank St. James’s-square.”
.£0
» 0
0
0
0
1
ADVERTISING
Books and Publications (seven lines and under)
Official and General Announcements .. ^ m
Trade and Miscellaneous Advertisements _ _
Every additional Lloe
Front PMe «. . » _ per Lise
Quarter Page ^ ~ —
Half a Page ^
An Entire Page .. .. » .. .. .. _ . . _
The Publisher cannot hold himself responsible for the return of testl.
cionlals (fee. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.-A dvertisers are re(^nested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
•
s
4
0
1
10
2 16
6 6
An original and novel future of " The Lancet General Advertiser" la a special Index to Advertisements on pages 2 and 4. which not onlv
affords a ready means of finding any notice, but is in itself an additional advertisement.
Advertisements (to ensure insertion the same week) should be delivered al the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing In The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or SubscrlptlouB abonid be
addressed.
Advertlsemento ate now received at all Messrs, W. H. Smith and Son's Railway Bookstalls tbronghont the United mti g iio n ) and 01 other
Advertising Agent*.
Aitat for tbo AdTortlMmont Dopartmwt ia ASXIBRr M. Bat Oanmutla. P«rl«
Google
THE LANCET,
' ABRIDGED REPORT OF
fumlrisn futims
ON THE
■STEUOXURAL DISEASES OF THE HEART
CONSIDERED FROM THE POINT OF
. VIEW OF PROGNOSIS.
By W. H. BROADBENT, M.D., F.K.C.P. Lond.
LECTURE II.
Dilatation {Symptoms ).—The symptoms which attend the
■earlier stages of dilatation are extremely varied and very
vague. An imperfect and fluctuating supply of blood to the
brain will give rise to impairment of bodily and mental
•energy and to irresolution and vacillation of purpose ; the
memory is li able to fail, especially in regard to recent events
^nd the power of sustained attention and consecutive thought
is diminished. The frame of mind will often be despondent
4 iDd the temper may be irritable ; there may be attacks of
giddiness or faintness; sleep is usually disturbed and some¬
times almost absent, aud, whether the nights are good or
bad, there may be sopor at any period of the day, the
patient dropping off to sleep even over his morning news,
paper. For the same reason, the irregular and imperfect
blood-supply and the back pressure in the veins, digestion-
and the action of the liver will be deranged. The appetite
is usually bad, and food is followed by discomfort and by
riatulent distension, which latter, again, reacts on the heart
and gives rise to oppression, or palpitation, or irregular
action. The bowels are generally torpid. The urine is
usually deficient in amount and high coloured, and there is
trfben an habitual deposit of urates. Turbidity of the urine
‘day after day, whatever the food and drink, or weather, or
mode of life, should direct attention to the state of the
•circulation. There is no one, and scarcely any combination,
of the symptoms enumerated, however, which may not
occur independently of weakness and dilatation of the
heart, especially in states of system attended with high ;
tension, and it would be waste of time to attempt to die- \
•entangle those directly due to the state of the heart from I
those which are merely accidentally associated with it. ;
The special symptom which calls attention to the heart ■
AS the probable starting-point of a number of ailments is .
breathlessness on slight exertion; but even this may be.i
.produced by other causes—by anmmia, for example. After ■
middle life pernicious anremia may often give rise to ex- ;
treme breathlessness, which may excite a suspicion of heart,
•^lisease. High arterial tension alone whion has not yet
given rise to dilatation, simple debility, very sedentary
habits, may also cause great shortness of breath. These
facts are mentioned in order to warn against a too-ready
inference that heart disease exists simply because the
breath is short. A sense of breathlessness coming on during
repose, and inciting the patient to make freq;ueut deep
inspirations, is usually a symptom of nervous depression,
And has no necessary relation to heart disease. For the
most part, as the disease advances symptoms arise which
•are indicative of hack pressure in the systemic veins—a
gradually advancing mdema, and the like. But the problems
which come before us in the prognosis of dilatation of the
heart will best be elucidated by discussing them as they
present themselves at different stages of the disease, and
■we may first take the fully developed eli'ects. The patient
is dropsical, cedema invading the thighs, loins, and ab¬
dominal pavietes, as well as the legs, and there may be
fluid in the abdomen, and perhaps in one or both pleural
■cavities. The feet and legs will be cold and pale, or purjfle
And livid, especially if hanging down. 'J’he hands also will
be cold, and are often crimson or jmrplisli, and the nails of
a deep or dusky instead of a bright pink. A white
patch on the hand pro>iuced by pressure is very slowly
invaded by returning colour. Tlie urine will be scanty, of
A deep colour, and probably high specific gravity. It most
•commonly throws down a copious deposit of biickdust
lithates, and it may contain alhuraep. The appetite will
bo veiy bad, and frequently there are intolerable nausea and
No. 3520.
March 28, 1891.
disgust for food; the tongue will probably be furred and
flabby; the bowels constipated or irregular.
One of the most distressing symptoms is sleeplessness,
and when, after hours of weary shifting of position, the
sufferer is overcome by fatigue and drops off, he has painful
dreams, and wakes suddenly in a fright with a dreadful
sense of suffocation for lack of voluntaiy help to his respira¬
tion. The longest and best sleep will be obtained while
sitting in a chair, and sometimes oy day rather than in the
night. The patient is probably unable to lie down in bed,
; and is propped up by pillows, or he must have bis legs
' down, and thereforespends day and night seated in his chair.
' Remarkable exceptions, however, are met with in this
respect, some sufferers, while extremely ill, being able to
lie down without distress. The face is pale, and perhaps
puffy, with injected capillaries over the cheeks, and wears
an expression of distress, and the eyes are watery. The Ups
are pale or bluish. The breathiog is more or less laboured,
even in repose, and the sufferer constantly supplements his
reflex respiration by voluntary deep breaths. When he
' speaks it is in fragmentary sentences, and with evident
effort and aggravation of the respiratory distress. The least
movement brings on shortness of breath, which is often
painful even to witness. The pulse is frequent, irregular,
and probably greatly deficient in tension, but not always.
Pursuing the examination, the jugulars will be found full,
bub not as a rule greatly distended or pulsating fordbly.
The liver will be enlarge^ coming down sometimes as low
as the umbilicus, and extending across the epigastrium
into the left hypochondrium. lb will often be jogged by
the right ventricle, but does not usually exhibit the true
expansile pulsation. There may be fluid in the peritoned
or pleural cavities, more commonly not, and there may be
physical signs of cedema and congestion of the lungs, or the
percussion note may be good and the entry of air free and
unattended with adventitious sounds of any kind to the
very base of both lungs. The physical signs of dilatation,
as already described, show that this is the condition under¬
lying the symptoms of embarrassment of the circulation.
We are called upon to answer the question, Has the patient
a chance of recovering from the condition described, or will
he die ?
The first element in the judgment to be formed will be
the urgency of the symptoms, and special importance will
attach to two of the series—the nausea and loss of appetite
and the sleeplessness—from the effects which they have on
the patient’s strength. Frequent vomiting of food is of
very grave import, nob only because the patient does not
get the benefit of the nourishment, but because it shows
that the stasis in the abdominal circulation has reached a
point which interferes seriously with the digestive .secretions.
Attacks of faintness and extreme exhaustion, or of severe
dyspncca, are also very serious. An observation is here neces¬
sary. It U not always when the dropsy is excessive that the
patient's condition is worst. From the late appearance or
entire absence of dropsy in fatty degeneration of the
heart in aortic disease and mitral stenosis it would
appear that a certain degree of pressure in the arterial
system is required to cooperate with the back pressure in
the venous system for the full development of dropsical
effusion; and when the cedema remains moderate in amount,
while other symptoms, such as breathlessness, faintness,
and great muscular weakness, the latter especially, indicate
great cardiac ineflicieney, it may be because the left ven¬
tricle propels the blood with very little force. A frequent,
short, and unsustained pulse and heart beat without much
cedema may thus indicate a more grave condition than ex¬
treme dropsy; long-continued great frequency of the pulse
is an unfavourable sign. The urgency of the symptoms
being about the same, a greater degree of dilatation, as
indicated by a more extended area of dulness, displacement,
and especially greater diffuseness aud weakness of the apex
beat and impulse, and greater shortness of the first and
weakness of the second sound, will add gravity to the pro¬
gnosis, and it will be borne in mind that approximation of
the first and second sounds is always a very serious indica¬
tion. A favourable point in the p^sical examination will
be a good right ventricle impulse, and it has appeared tome
that there is a greater margin for treatment when the liver
is considerably enlarged.
AVhen the symptoms and physical signs have been well
weighed, the first question to be asked in view of prognosis
is whether there has been any adequate exciting cause
of the symptonn. If there has been recognisabie over-
N
Coogle
702 The Lancet,]
DR. W. H. BROADBENT ON DISEASES OF THE HEART.
[March 28, 1893. •
exerbion or excitement or grave anxiety—any mental or
bodily strain—or if there has been a chill, giving rise to
bronchitis or other aiTection of the lungs, or deranging
seriously the liver and digestive organs, it may be hoped by
means of rest and treatment to undo the ill effects and restore
the balance. If, on the other hand, the symptoms have
crept on gradually without traceable cause of the kind
mentioned, and especially when due care has been exercised,
aud there has been no habitual error in regimen or neglect
«if bowels, the probabilities are that the symptoms are the
outcome of conaltions which cannot be reversed, of radical
inherent weakness of the heart. The previous mode of life,
active or sedentary, careful or imprudent, and especially
the patient’s habits with regard to alcoholic stimulants,
will have a very important bearing on the probable issue of
the attack, as will also bis general soundness, and the
abtenje or existence of disease of any othrr important
organs, especially the kidneys and liver. The patient’s
cbeetfulness, hopefulness, and courage under his sufferings,
or his despondency, will make powerfully fur or against
him, not only as direct iniluences, but because the state of
mind is often an index of the state of the system.
Another inquiry of great prognostic weight will be as to
the patient’s family history. It is through this that we
obtain an idea of his vital tenacity and of the trust-
worthiness of bis tissue^, and sometimes of the special
liabilities of his heart. There are few tendencies which run
more strongly in families than those which are manifested
in the heart and vascular system, whether to high arterial
tension with the effects on the vessels and beait which
follow from this, or to dilatation and weaknefs, or to
degeneration ; and a prognosis, otherwise not unfavourable,
might have to be instantly revised on learning that the
father and an uncle or two, or a broiher, bad died at about
the patient’s age from heart disease Finally, the response
to treatment will speedily afford an indication of the utmost
value, and this may be described at once.
Treatment .—We have to deal at the same time with de¬
fective propulsive power on the part of the ventricle and
damming back of biood in the venous system, and the iudi-
citions are to relieve the ventricles of work and increase the
vigour of their action, and at the same time to deplete the
venous engorgement. Now when the he^rt is weak, as it
is here, it is much more important to relieve it of work than
to try to lend it vigour. We can do much more in one
direction than in the other, and we are more sure of our
result. Without first diminishing the resistance in the cir¬
culation, to stimulate the heart to more energetic contraction
may only caus. it to give way and dila'e furtter. This last
object must indeed be taken first. We must undo the
effects as a means of reaching the cause, a course we are
often compelled to take in therapeutics.
Venesection, the most effectual means of relieving the
light side of the heart, is very rarely applicable in dilata¬
tion. It is conceivable that under some pulmonary compli¬
cation, resulting from chill, the engorgement of the right
auricle and ventricle might be such as to make bloodletting
the less of two dangers; but the initial fault being weakness
«>f one or both ventricles, we cannot trust the heart to adjust
iiself to a rapid change of any kind, and the right ventricle
may nob be in a condition to take advantage of the relief
afforded it. Usually, however, the venous engorgement is
developed slowly, and the indications for venesecuondonot
arise. The application of six or eight leeches over the liver
is safer, and it will usually effect all that can be done by
direct abstraction of blood. The indication for this local
bletding is enlargement of the liver, and when this is con¬
siderable it rarely fails to afford striking relief. Very fre¬
quently, for example, the patient who has previously been
tortured by sleeplessness will sleep at once, and sometimes
for a night or two afterwards. The reason for selecting the
) epatic region for the application of the leeches is simply
taab pain and tendeiness felt there are relieved; it is not
supposed that blood is drawn from the liver, or that the
same amount abstracted elsewhere would not be equally
efficacious. The leeches will be followed by a hob poultice,
which, besides encouraging the bleeding, will bring blood to
the surface. When the liver is nob enlarged, and especially
if the right ventricle sounds and impulse are weak, there is
no advantage to be gained by leeching.
Concurrently with the application of leeches a purgative
will be given, which will deplete the portal system at the
same time with the systemic veins. Afterwards this will
be the principal means of keeping down the venons engorge-
I ment. In a large majority of oases, indeed, we have to>
! depend entirely upon purgatives for these purposes, a&>
abstraction of blood by any method is inadmissible. It i&
nob a matter of indifference wbat purgatives are employed.
The object of a purgative is not simply to carry off as much
fluid as possible, and so drain the tissues. This may bei
the case, perhaps, in ascites from cirrhosis of the liver, but
in heart disease of any kind, and especially in dilatation^
much more is to be gaioed by rectifying the balance of tbea
circulation, when the kidneys will resume their function
and remove the excess of liquid. Purgatives, then, may be-
made to contribute to this; and before considering tnem
further we must refer to the first ol>ject of treatment—the
relief of the heart from work and the increase of its vigour.
Of these, we can be much more sure of the first than of the
second ; we can more easily and certainly diminish the
resistance in the arterioles and capillaries than we cai>
lend strength and efficiency to the action of the hearty
and, without removing the obstruction in the peripberah
circulation, it might only do harm to incite the heart—
weakened as its structures are—to greater effort to*
overcome it. Now, mercurial purgatives have this effect
of diminishing arterio-capillary resistance and of lower¬
ing arterial tension, and therefore of relieving the heart.
The hypothesis by which, as it seems to me, this observed
fact is best explained is that mercury iniluences the liver
chemistry and promotes the elimination of impurities which-
when retained in the blood give rise to resistance in the-
capillaries. Bub, whatever the explanation, the fact that-
the arterial tension is notably lowered mercuiial aperients'
is confirmed by daily experience, and it is remaikanle how
frequently the statement recurs in works on heart disease-
tbat other remedies often fail to act until a dose of calomel'
or other mercurial preparation has been given.
Mercurial purgatives, then, have the double effect o&
depleting the portal system, which relieves the engorgement
of the liver and the distension of the right side of the beart>.
and of dimioisbing the resistance in the peripheral circula¬
tion, and so relieving the left ventricle of stress. Very
commonly the best of testimony as to the beneficial cha¬
racter of the result is given by refreshing sleep. The dis¬
advantage, if such it be, that less fluid is carried off than by
hydragogue cathartics is often compensated by an increased-
flow or urine ; and elaterium, gamboge, jalap powder, and.
tbe like, when repeated give rise to great exhaustion.
Calomel, then, or blue pill, or grey powder should be given-
in doses of from one to five grams, according to the urgency
of the case, with colocynbh and hyoscyamus, or rhubarb,
followed by some mild saline. After one or more full doses
at the outset a moderate dose may bo given every second
or third night. The acid tartrate of potash will often
cooperate beneficially both by its action on the bowels.
and on tbe kidneys. The heart being relieved of work^
may be urged to more vigorous contraction by digitali8».
strophanthus, spartein, squills, caffeine, convallaria, apo-
cynum—the special heart tonics,—with which strychnine-
may usually be combined with advantage. In a case of’
extreme suffering digitalis may be given with ammonia^
ether, andnux vomica; in the more chronic stages with iron,,
and perhaps strychnine. Sometimes an effect can be ob¬
tained by giving citrate of caffeine in a pill at the same
time with digitalis in a mixture when singly neither seems
to be efficacious. Squills, again, may be given with
digitalis, as in the well -known pill with mercury, or in some-
liquid combination. Next to digitalis stands strophanthus,.
which is a most valuable alternative when digitalis seems to
produce sickness, as is sometimes tbe case, or when it fails
to exercise a favourable influence on the heart. Sulphate
of spartein I have seen to be of great service when digitalis
and strophanthus appeared to have exhausted theirinlluence;;
of convallaria I have little to say. Apocynum has in one or
two coses seemed to carry off dropsy in a remarkable way,
but one patient died suddenly when apparently just well.
It is not necessary to go into greater detail with regard to-
these remedies. Throughout a case of the kind the
medical man has to light, so to speak, with both bands, and
continuous watchfulness will be necessary lo meet the.
vicissitudes which occur, and many changes in method may
be required while the same principles are held in view.
The prognosis, as has been said, will be greatly influenced
by ihe response to treatment. This will be energetic,
etpecialiy in the matter of purgatives, in proportion
as the symptoms are urgent, and if no favourable
effect is produced the prospect of recovery is very poor..
The Lancet,]
DE. W. H. BROADBENT ON DISEASES OF THE HEART. [March 28.1891. 703
Wery commonly improTemenfc takes place up to a certain
{joint and then progress seems to stop, to come to an
‘end. This is a trying stage both to the patient and
to the medical man. Changes of remedies and new com¬
binations must be tried both in regard of the aperient and
•of the tonic, not frequently and capriciously, but with
•careful study of the results and due allowance of time for
■obtaining them. Sometimes it does good to suspend all
•medicines for a few days and start atresb. Under these
•circumstances, again, it may be of the greatest service to
■drain away the fluid from the legs, even when the extent of
<the cedema is not such as actually to call for it. The
(good result of removing an ascitic accumulation, should
this he present, may be still more striking. Even a moderate
amount of effusion in the pleural cavity, such as we should
mot think of dealing with under ordinary circumstances,
•should be aspirated. A straw may turn the balance either
way, and a very slight obstacle may prevent the heart from
•regaining control over the circulation. It is not always
'desirable to postpone the removal of fluid till the particular
•conjuncture described arrives ; it may be an urgent necessity
•at a very early period. Usually, however, it is prudent to
give remedies a chance before resorting to puncture or
lOaracentesis. As regards the method of drainage to be
Employed, whether for codemaor ascites, but particularly in
•case of ascites, Southey’s tubes are in niy opinion much
•the best.
The feeding of the patient through the long course of
*fereatment will be a task of extreme difficulty. We have to
•contend with nausea and distaste for food amounting to
•disgust; sometimes the sufferer positively cannot swallow
anything requiring mastication. The object to be held in
view is to keep down the volume of the blood while main-
taining its quality. A small amount of solid or semi-solid
(food should be taken about every tliree hours. When the
{jatient is not too ill to take his meals at the accustomed
time, it is a great encouragement to him to be allowed to
•do so, and he may then eat what he can of fish, fowl,
tender meat, game, milk pudding, &c. When the amount is
amall, the regular meals may be supplemented by inter-
•mediate nourishment, such as beaten-up egg, a little milk,
•or perhaps a small cup of strong soup or beef-tea, or a little
beef or chicken jelly or meat extract. Soups and jellies
Slave the disadvantage of containing little proteid and much
(liquid, but they are stimulants to the flagging heart.
iPotted meat sandwiches are a great resource, and the pulp
■of raw beef-steak can be given in this form, disguised by
cooked meat or concentrated gravy. A German physician
•of my acquaintance tells me that he frequently feeds his
{latients suffering from cardiac drcpsy of the kind under
•consideration entirely upon raw ham, and baa great
success. The amount of lluid must be restricted as far as
.possible, especially that taken witli food. Stimulants are
usually imperatively nece«savy, but should be kept within
•(limits known and dellnod by the medical man. The patient
•is under a great temptation to resort to them for the relief
of faintness, exhaustion, and nausea. Cream of tartar
'drink may be taken to quench thirst between meals, and in
•some cases a copious draught of hot water once or twice a
day will run through the system rapidly and wash out the
^tissues without augmenting permanently the volume of
blood or adding to the dropsy. When this is tried, it must
be ascertainea definitely that the amount of urine is
correspondingly increased.
A question which arises in almost every severe case is
whebner the patient must be urged to remain in bed or
allowed to get up. Bed is undoubtedly the best place for
‘him at first, during what may be called the crisis of the
•attack, for many reasons ; the rest and warmth protect the
■heart from the strain of exertion and changes of tempera-
■bure. On the other hand, the dyspnoea is usually worse in
the recumbent position, even with the shoulders raised,
and may be intolerable unless the legs are allowed to hang
■down; iiot unfrequently it is simply impossible for the
patient to remain in bed. A suitable chair, therefore, is
always necessary, with .support for the elbows, shoulders,
and head, which can be taken advantage of in turn in the
'frequent changes of position to which the patient has
recourse to ease his breatliing or elude di.scomforb, and the
•quickness and ingenuity of the nurse or medical man in
devising expedients may greatly alleviate his sufferings. A
Ibed table or other form of support upon which the patient
may rest his arms or elbows and head when leaning forward
will often be very useful. A patient will frequently sleep
better in this position than in any other. Perhaps the most
common state of things is that toe patient is up during the
day, and tries to spend more or less of the night in bed.
When he cannot at once bear to go to bed at night be may
undress and sit in his chair wrapped in blankets near the
bed for a time, when he will often, after a nap or two, be
able to lie down and sleep.
We come DOW to tbeproraosis and treatment of dilatation
of the heart at a period when' it has not given rise to the
serious consequences justdescribed, and an enormous degree
of dilatation may be arrived at before such effects are de¬
veloped. As regards physical signs, the most important
evidence will be, not as to the actual size of the heart, but
as to the strength of its walls. A greatly dilated heart
which is capable of giving a recogoisable apex beat and
fair impulse of right or lefc ventricle is more to be trusted
than one which has apparently undergone less change, but
the movement of which can scarcely be felt at all. There
is always a possibility that degeneration may enter into the
caueationof the symptoms. I b is better, again, that the sounds
should be strong than weak, spaced than approximated;
and it is important that the second sound of bcth ventricles
should be well markefi. Irregularity of action is, according
to my experience, of less consequence than frequency, and
1 have learnt not to attach serious importance to the regular
alternation of a strong and weak beat so long as there is no
great frequency with it. The pulse is important chiefly as
an iudicatioD of the vigour with which the blood is pro¬
pelled into the arterial systero. Dilatation of the heart
presupposes high arterial tension at the time of its pro¬
duction, and it is a favourable sign that a certain degree
of this tension persists. When we find a low tension pmse,
unless this is the result of treatment, it mei^ns that the
heart has not sufficient strength to maintain the pressure
in the arteries.
The probability of improvement or of prolonged immunity
from ulterior consequences will next depend on the generw
condition of the patient, on the soundness and nutritional
vigour of bis tissues and organs, and especially of his blood¬
vessels; if he is weak and anmmic, on the cause and
character of the impairment of health, whether it is inherent
or accidental—whether, in effect, it is remediable or not;
when the state of tbe heart and of the general health is
attributable to alcoholic or other excesses, including the
abuse of tobacco, to habits or mode of life or external con¬
ditions adverse to heaUli ; whether or not the patient is
willing and able to renounce his self-indulgence, and relin¬
quish his vices or alter his ways and surroundings.
When we come to consider the treatment of cardiac
dilatation in this stage, t.be first question to be asked is,
what object may we venture to set before ourselves ? What
assurance can we give our patients? Can we ever
reduce existing dilacation ? Can we even arrest the
tendency to increase and avert or postpone the evil con¬
sequences ? To no question can we return a more confident
answer. Every day we see dilatation reduced in some
degree in favourable cases, and at the worst much can be
done to prevent the development of its ill effects. It has
already been stated that in tbe acute aggravation of dilata¬
tion which gives rise to symptoms the apex and extreme
limit of dulness may be seen to return towards tbe normal
position day by day, and the well-named “curable mitral
regurgitation” of Dr. George Balfour is only a form of dila-
tacioQ incident to anmmia. The means to be taken are, in
the first place, the removal of any recognised cause in the
habits and mode of life and surroundings so far as this
is practicable. Next to improve the general health by
favourable hygienic influences and by suitable remedies.
The amount of exercise to be taken will be a most important
question, but no rule can be laid down applicable to all cases,
ypeaking generally, exercise is good, and whatever amount
of walking can be done without breathlessness or exhaus¬
tion, and especially with enjoyment, that will be safe and
beneficial, and, piovided due prudence is exercised, walking
uphill need not be forbidden. The exercise, however,
should be regular and daily, not spasmodic with intervals
of inaction. A walk may be taken day by day with advan¬
tage which taken only once a week would be iniurious.
The exercise, again, should not come immediately after
food, and it is better taken early in tbe day than in the
afternoon or evening. A walk into the City, for instance,
might do good when a walk back after tbe day’s work
would do harm. In some cases the treatment may have to
be begun by actual rest in bed for two or three weeks,
704 Thb Lancbt,] mb. a. MARMADUKE SHEILD ON NOSE AFFECTIONS.
[March 28,1891.
^hajis with massage, and the patient mav have to resume
exercise with just the same caution as fooa is resumed after
heematemesis from gastric ulper.
The question will now come before us whether we should
recommend the graduated walking uphill at considerable
elevations, known as the Oertel’s treatment, for heart
disease. In my judgment the idea is good, inasmuch as
many people will submit to carry out strict regulations to
which a certain amount of mysterious virtue is attached
who will not obey common-sense instructions. I doubt
very much whether any good will be done in fatty degenera¬
tion of the heart; some cases of early dilatation will be
benefited, and an enormous number of imaginary cases of
heart disease will be cured; the class of patients who come
to us saying that they have heart disease will be attracted
by the treatment as carried out; a few patients will he
lolled. But it is not always possible either to modify the
patient’s life in such a way as to put an end to the
conditions which tend to produce and aggravate dilatation
of the heart, or to secure for him all the desirably
hygienic influence. It would be useless, for example, to
recommend a City clerk to relinquish the sedentary ocpupa-
tion which is his only possible livelihood, and iittie less
vain to order a lady who has never walked in her life to
take regular exercise. We can, however, do much to keep
down tne arterio-capillary resistance or high arterial tension,
which plays such a fatal part in the production of dilata¬
tion of the heart. We can regulate the diet and warn
against habite and occasions which are injurious, and by
securing efficient and continuous elimination from the liver
and bowels we can often make just that difference which is
required for the safety and comfort of the patient. This
can usually be effected by an operient pill containing a
small dose of one or other of the appropriate mercurial pre¬
parations taken twice a week, and we must not be afraid to
order patients whose hearts have given way under pro¬
tracted tension to go on with such a pill for years. Tonics
of various kinds may be given with advantage from time to
time with acids or alkalies. It is not often that digitalis or
remedies of the same kind will be required continuously,
though they may render service occasionally.
ON
THE REIATKm BETWEEN NOSE AFFECTIONS
AND DISEASES OE THE EAE.
Delivered at the Charing-cross Medical S<*hool,
By a. MARMADUKE SHEILD, F.E.C.S. Eng.,
ASSISTANT SUilGEON AND ADUAI, SUROICON TO THU IIOSl’ITAI..
(lleportedjrom Shorthand Notes.)
Gentlemen,—T he subject of my lecture to-day is the
relation between nose affections and diseases of the ear. I
shall discuss the matter as plainly and practically as I can,
without entering into the consideration of ob.scure affec¬
tions. I hope that what I say may prove useful to you
^ your future professional life. The connexion between
inflammatory affections of the middle ear and like affec¬
tions of the nose and pharynx was very early recognised
by writers on aural surgery; especially was it recognised
^d dwelt upon about the year 1887. It was in that year
j connexion between obstructive diseases of the nose
diseases of the ear was especially treated of by Meier,
lie may be looked upon as a pioneer in bringing into pro¬
fessional notice this all-important juatter. Since that time
it has become more and more recognised, until now it is
well known to all those who deal with affections of the
nose, throat, or ear. The first point I would strongly
attention to is this, that the mucous membrane
of the tympanum and the mucous membrane of the
naso-pharynx are directly continuous, and therefore it
IB very obvious that inflammatoiy affections of the
naso-pharynx may spread by direct continuity of tissue
into the tympanum. Almost all inflammatoiy affec¬
tions of the tympanic cavity have their prototype in the
inflammatoiy , affections of the naao-pha,rynx. ^ ,<Marlf,'
then, that if we have an unhealthy 'condition of the;,
nose and throat with constant attacks of inflanima-'
tipn, we shall also meet with an unh^eaJthy tympanuiH’
with recurrent inflammation, and^ tlie type, of inflan^^.
mation of the tympanum will originate or “talce its-,
cue” from the inflammation of the naso-pharynx. To-
illustrate this in as commonplace a way as I can wa will
consider on^ or two ordinary types of inflammation
of the tympanic cavity, and first consider that wellf.
known “ear trouble” which is called cafarrh ,o| the
.middle ear. The disagreeable symptoms of the gttack a.i&
very likely familiar to some of you in your own persons...
You get an ordinary catarrhal cold, accompanied w)th dry¬
ness of the nose and fever. Soon afterwards proftise. dls,-
charge from the nose occurs, with perhaps pain shqotlpg nip.
the Eustachian tube. You next find that you are a httle
deaf, that you have a sense of “stuffiness” and “giddiness’’
in the bead. What has happened is merely th^t
catarrhal process in the nose and throat has spread up, the
Eustachiau tube, and has caused swelliog and hyperisni.iai oi*
the limngmembrane of the tympanum, and h^s probably ajsp-
narrowed or occluded the lumen of the tube by catarrhal swell¬
ing. The ordinary result of an attack like this is recovery.,
Patients are commonly content to let the affection take itS'
own course, and the swelling of the mucous lining of the
tympanum and tube gradually subsides, and these parts are'
restored to their normal condition. In many instanoes^
however, a very slight degree of permanent deafness is often
left behind, and recurrent attacks of this nature more often
lay the foundation for chronic inflammatory changes than
is usually believed. Next let us take a typical case of a.
more severe catarrhal condition of the throat and .noee. In
such the inflammation of the tympanic cavity may be asso¬
ciated with exudation of mucus, varjiing in quantity and
quality, within the cavity of the tympanum. The result¬
ing deafness and “stuffiness” are marked and serious.
Though the patient cannot hear the voice of others, his-
own voice is distressingly loud, and tinnitus is marked. He
is usually also cognisant of “bubbling” or “cracking”"
sounds. Unless such a case is treated, the sufferer may
remain with his hearing seriously impaired. The exuda¬
tive material poured out into the tympanic cavity will
become organised, causing fibroid changes which are oftem
irremediable. A third type, which is so familiar to-
all practitioners, consists of suppurative affections within
the tympanum, complicated with the ulcerated sore-throat
of scarlet fever, measles, diphtheria, and the like. Tn scar¬
latinal sore-throat the mucous membrane of the naso¬
pharynx is enormously swollen and hyperremic, laden with
micro-organisms of all kinds, and not uncommonly ulcerated.
The type of inflammation is septic and virulent. Like
pathological processes are induced within the tympanic-
cavity, and the unfortunate results which ensue are a
matter of daily observation—destruction and discharge of
the ossicles, perforation or destruction of the drum, and not
infrequently complete loss of hearing. What I have put
before you so briefly will, I hope, serve to illustrate the-
clinical fact first stated, that inflammatory processes in the
nose and naso-pharynx are the great originators of inflam ¬
mations of the tympanic cavity.
The practical lesson that we learn is this—that whenever
we are treating any chronic inflammatory affection of the-
middle ear we must remember that it is our duty to treat
morbid conditions of the nose and naso-pharynx also. This-
general consideration applies to all varieties of middle
ear inflammations. A large number of these cases occur
in young children, and it is of the greatest importance to-
remember that suppuration of the middle ear in children can
be often entirely prevented, or much lessened in violence,
if the naso-pharynx be kept clean and free from accumulated
and inspissated discharge. This is a detail of treatment whicb
is too often entirely neglected in cases of sore-throat and
colds in the head. The measures by which you will best
carry out cleanliness will be by gently syringing through
the naros every four hours a very dilute alkaline and anti¬
septic fluid, pleasantly warm. We may employ a warm
and dilute lotion of boracic acid, chlorinated soda, or the
like. Such remedies do a great deal to “clear out" the
back of the naso-pharynx. In a tolerant child or an adult
you should invariably with a soft curved brush remove the
inspissated secretion from the back of the nose wilb
antiseptic and astringent applications. These indica¬
tions in young and fractious children are very diffi-
Thb Lancet,]
MR. A. MAEMADUKE SHEILD ON NOSE AFFECTIONS.
[March 28, 1891. 705
«alt to carry out, but a great deal may be done
with patience and perseverance. You will find that
lihough they will often resist brushing out the throat, they
■will permit you to clean out the naso-pharynx with a
'Spray containing such drugs as iodine, benzoin, chlorate of
ipotasb, chlorine, or other moderately dilute and antiseptic
.applications. In the ulcerated throat of measles or scarlet
fever, the importance of the above measures cannot be ex¬
aggerated. What I have already said must have its bearing
and application on the great and complicated question of
obstructive affections of the nose. For the worst cases of
aiaso-pharyngeal inflammation are found in those patients
who suffer beforehand from naso-pharyngeal obstruction. If |
you take the case of a perfectly healthy child having ,
« perfectly healthy naso-pharynx, with no enlarged tonsils j
.and no adenoid growths obstructing his nose, you will
rarely find that such will suffer from destructive sup-
jiuration of the middle ear; but, on the other hand, if
you have a patient who before the onset of severe inflarn-
mation has these complications, you will find that it is in
■such cases especially that dire results, as far as the ear is
■concerned, will ensue. The more important varieties of
oasal or naso pharyngeal obstruction to which I would
•draw your attention to-day are: (1) Adenoid growths
And enlarged tonsils—I put these together because they are
frequently clinically associated j (2) that so-called hyper-
•trophic condition of the spongy bones of the nose in
which these structures are enlarged and covered with
awollen, hypermmic, almost erectile, mucous membrane;
<3) polypi of all kinds ; (4) deviation of the septum of the
nose and bony growths, so-called exostosis ; and, finally,
•cicatricial contraction of the nares from old ulcerations of
sypiiilis, necrosis, or the result of operative procedures.
These, you will remember, are only some of the causes of
obstruction of the nose and naso-pharynx that you are
ilikely to meet with in practice, butt tney will suffice for our
purpose to-day.
Let us, then, consider why these conditions may
cause or complicate' deafness. First of all, you will have
■to consider that in many of these conditions—and I want
to be particularly explicit about this—the orifices of the
HEustachian tubes are mechanically closed by swelling,
adenoid growths, or especially inspissated mucus. This is
found to be the case in greatly enlarged tonsils, adenoid
.growths, and great nas^ obstruction. When there is
nasal obstruction, it must be obvious that we cannot
•get proper ventilation of the naso-pharynx. The patient
may not be able to “blow his nose” properly, and the
result is that Inspissated mucus and foul discharges collect
in enormous quantities at the back of the naso pharynx,
"forming a veritable plug of nasal excrement. We must
•also consider the possibility of mechanical interference
with the normal acts of the opening and closing of the
Eustachian tube. It is not at all clear to me how the
(Eustachian tube opens and shuts, but there are certain
muscular fibres inserted into it, and it is supposed by
some that the action of these fibres is interfered with
by swelling or accumulated secretion, and that con¬
sequently Wie normal patency or closure is interfered
with in the acts of deglutition and respiration. In the
vast majority of cases of nasal obstruction if inspissated
•discharge hangs about the back of the naso-pharynx an
(unhealthy catarrhal condition of the mucous membrane is
caused by it. This eventually leads to inflammation of the
ffcympaimm.
Having thus briefly considered some of the explana¬
tions of the association of obstructive diseases of the
•aose and deafness, we will next consider what are
the leading symptoms of nasal obstruction. They are
•quite familiar to many of you. The patient is, in the
first place, a mouth breather, invariably goes about with
'his mouth open. This gives rise to a vacuous expression of
countenance, which often finds a corresponding condition in
the intellectual powers. Sacli patients uauallysnore loudly
at night, and very often are more or less deaf, the deafness
'(being bilateral and varying in severity. These symptoms
are common to many forms of obstruction of the nose, and are
especially marked in young individuals who are the subjects
• of enlarged tonsils and adenoid growths, lu the latter class
-of cases the voice is altered, and the patient pronounces his
words badly, especially tbeir terminations, speaking with a
I,peculiar nasal intonation.
To make the diagnosis complete in the examination of
iA case of supposed nasal obstruction, you would first Inspect
the anterior nares by well dilating them with one or other
of the specula I now show you, a good bright light must
be thrown into the nose. You may nee the electric light,
good daylight, or a strong lamp and reflector. Yon can
then definitely see and touch polypoid growths, great
swellings or hypertrophy of the mucons membranes, or
deviations of the septum nasi. If you next illuminate the
back of the throat you may discover enlarged tonsils or
adenoid growths. The latter usually show very charac¬
teristic signs of their presence. The tonsUs are mote or
less enlarged, and the soft palate is frequently depressed by
the bulk of the growth above. In bad cases portions of the
growth may actually be seen. The appearance of the
pharynx is more or less granular. If you detect these
symptoms in a child or young adult who is a mouth
breather, you need not put the patient to the inconvenience
of passing your finger behind the soft palate. Such
a patient is practically certain to be the subject of
adenoid growths. Next comes tbe question bow to best
examine the back of the nose. First consider posterior
rhinoscopy. This is exceedingly useful in adults, but
children and nervous individuals who cannot bear tbe sight
or contact of instruments seldom tolerate it sufficiently for
you to profit by its adoption. In order to employ it the
soft palate is well cocainised with a 5 per cent, solution of
cocaine, and the mirror is then inserted behind tbe soft
palate and turned into whatever position is best for getting
a view of the posterior nares. Often it is needful to draw
I the palate forwards with a small sharp hook. I show you
a useful form of this instrument, and also the self-retaining
palate hook of Mr. C. Baber. Posterior rhinoscopy requires
time, skill, aod tolerance, with repeated examinations.
Some of you have seen the method I commonly
employ in the out-patient room, which has much to
recommend it. After cocainisation the index finger, well
protected with lint at its root, is rapidly passed behind
the soft palate and swept over the posterior nares.
This manipulation, well executed, gives much explicit in¬
formation. By posterior rhinoscopy or manipulation, then,
you may obtain a clear idea of the condition of the back of
the nose in cases of obstructed breathing. Adenoid growths
are perhaps tbe most important of all causes of nasal
obstruction, and the idea is rapidly gaining ground in mv
own mind that a certain amount of these growths, with
swollen mucous membranes and lodgment of secretion, are tbe
great cause of deafness in many cases of apparent anterior
nasal obstruction. What I mean is, that in cases of deviat¬
ing septum and hypertrophy of the spongy bones the con¬
dition of the naso-pharynx is often the true cause of the
associated deafness. Cases of nasal obstruction, espe¬
cially adenoid growths, are not only important because
they cause and complicate deafness, but from an educational
point of view. I do not hesitate to express my belief that
inanv of the failures that occur in tbe education of boys are
due to a certain amount of deafness from these conditions.
You all know the stupid boy at school, who generally bos
his mouth slightly open, who snores in the dormitory at
night, who fails to learn his les'sons. He is often the “ butt ”
of his comrades, and sometimes has his “ears boxed ” by
the masters. The unhappy lad probably does not hear
properly. His deafness varies according to the state of the
weather, or whether he has a “ cold iu the head.” But
he may fail in the educational race, and have to end his
career in some rural occupation. This is not an exag¬
gerated picture of a considerable number of these cases.
Sufferers from adenoid growths are worse in damp and cold
localities, and the varying amount of deafness is one of the
great characteristics of the affection. When we have the
question of the treatment of these adenoid growths under
con.‘5ideration we shall find that of all affections of this kind
which complicate and cause deafness the treatment of
adenoids is perhaps the most satisfactory, because you may
take an individual who is really seriously deaf, and by care
and pains bring him to a condition in which he can
hear perfectly well. Before operating for adenoid growths,
or indeed any form of nasal obstruction, you should be
quite clear that the condition of the auditory nerve appa¬
ratus is healthy, and that the patient has not had prolonged
and chronic iuilammatiou of the middle ear previously. To
this 1 will again refer.
The treatment of adenoid growths, w'ben they really
exist, consists in their removal. I think one of the first
points to bear in mind in connexion with operatic^ upon
them is the comparative risk from ana'Bthesia. This u
706 Tub Lancet,] MR. A. MARMADUKE SHEILD ON NOSE AFFECTIONS.
[March 28, 1891.
not) as well known as it ought'to be. When I tell you
that I am cognisant of several fatalities having occurred
oa will see how urgent this consideration becomes,
always prefer in young adults to remove adenoids by the
help of cocaine applied through the nose and to the
naso-pharynx. In cnildren and nervous individuals it is
necessary, however, to give an anaesthetic. The patient
should never be put so deeply under the influence of the
ansesthetic as to deaden the insensibility of the larynx. Any
material which flnda its way into the air passages is then
coughed up. When these gro>vths are removed by scraping,
cutting, or avulsion, sudden profuse bleeding takes place, the
blood mixed with a marvellous quantity of inspissated secre¬
tion, and fragments of growth will often half nil a very con¬
siderable bowl. If a patient is deeply unconscious and in a
bad position, the danger of bis choking is sufflciently obvious.
The operation usually performed by myself is scraping
these growths away with the steel nail, strongly advocated
by Sir William Dalby, which I now show you. This most
useful instrument must not be used timidly. Your own
fingernail is sufficient, if you have a strong one, for the
cases of young children. [The lecturer here exhibited and
described the principal instruments used in operations con¬
nected with the removal of adenoids of the nose, and con¬
tinued:] You must not imagine that when you have
removed the adenoid growths the treatment is at an end.
It must be continued for at least three weeks or a month
after the operation by swabbing out the naso-pharynx
with astringent and antiseptic solutions, by syringing the
nose and throat with the same remedies, and especially carry¬
ing out Politzer’s treatment every day so as to render the
Eustachian tube thoroughly permeable. If this be done the
results are very gratifying both in improving the hearing and
the intelligence of the patient. Profeesor Guye has written a
most interesting paper on the connexion between iotellec-
tual torpor and nasal obstruction, pointing out the bad,
effects of nasal diseases on the cerebral circulation by
lymphatic obstruction. My own idea is that thereason why
these people are stupid and unintelligent is tha,t they do not
hear properly. At all events, on the removal of the obstruc¬
tions you will generally find the parents telling you that
the child has improved in intelligence, has moved up a class
at school, and so on. You will next ask me whether there
are any other risks in the operation for adenoid growths
utisides the matter of amosthesia. There is one point
which should be always inquired into before proceeding
to remove either tonsils or adenoid growths—viz , whether
the patient is the subject of the Inemorrhagic diathesis.
Children are sometimes brought to us who are “bleeders,”
and if you perform operations on the nose or pharynx in
these cases, you will place yourself in great difficulties, and
may perhaps lose the patient. Another very important
matter is, that In a certain proportion of cases of nasal
obstruction there may be old-standing perforative otorrlicea,
with a foul and septic condition of tie tympaniini. There
is then some rUk of an operation setting up brain mischief,
or even leading to general sepsis.
Time will only allow me to speak briefly of the so-called i
hypertrophy of the spongy bones as a cause or complication
of deafness. I have stated my belief that it is in the
naso-pharynx we should especially seek the conditions
which complicate or cau^c hardness of hearing, and it is my
candid opinion that the influence of anterior nasal obstruc¬
tion has been much exaegerated in this connexion. I am
aware that I am speaking in direct opposition to many
recognised authorities on this subject, but everyone,
hovvever humble, has a right to his own opinion, and I
believe that many operations are now done upon the
spongy bones and feptum of the nose which further time
and experience will consign to a well-deserved oblivion.
Occasionally the spongy bones, or rather the mucous mem¬
brane over them, become so swollen and enlarged as
actually to ooclude the passage, and then there is a need
of treatment. The common procedure consists, first, of
cauterising the surface with the galvano-cautery, or by the
use of chromic acid, and the resulting cicatrisation will
usually sufficiently pucker up the surface of the bones to
admit a sufficiently free draught of air to pass through the
nose. More rarely it is needful to remove portions of the
bone, either in front or posteriorly, with a small wire
coraseur. Deviations of the septum nasi are only occa-
Hionally associated with deafness. To s.ay that all devia¬
tions of the septum cause deafness is not correct. I have
notes of cases of marked deviation of the septum where
there was no deafness whatsoever, although the patients,
had been the subjects of this malformation all their lives.
If I were to examine a case of unilateral deafness with cor¬
responding extreme deviation of the septum nasi, I should
long suspect and examine for some otner condition than
that of the nose as the cause or complication of the hard¬
ness of hearing.
The same remark applies to cicatricial contraction of the
nostrils. You have the opportunity of seeing complete
occlusion of the nostrils after lupus or syphilitic ulceration,
and no deafness coexists. When cicatricial processes go oo-
at the posterior nares, the result is different. Deafness is
common in these cases, for the tube may be involved in#
the morbid processes. The instruments used for deviated
septum and removal of the ^ongy bones are various knives,
forceps, and snares, which 1 now show you. [After men¬
tioning the various forceps and instruments used in these
operations the lecturer proceeded:] Bub whatever operation
you perform on the septum of the nose, you must re¬
member that the septum will very readily recur to its
former position, and therefore it requires to be kept
straight. Ivory plugs form tbe best things the patient
can wear as a septum splint, and these require to be worn by
the patient for a certain number of hours every day for a.
considerable time before the septum can be got to retain its-
position permanently.
We have now to consider what conditions require to be
revolved in our minds before recommending to a patient-
the performance of anv operation on his nose for the relief
or cure of deafness. The first thing we must consider is the
period of time during which the deafness has lasted; in
other words, the degree of chronicity of tbe deafness. A
gentlemen twenty-two years of age was brought to me
some n\onths ago who was stone deat—that is to say, if yon
bawled into his ear on either side he could nob hear. Tuning
forks applied to the head could be plainly beard by bolb
pars, indicating that the auditory nerves were quite healthy..
His friends informed me that all his life he had been sub¬
ject to colds in the head and to sore-throat. The deafness
was gradual in onset, and was of at least ten years’ dura ¬
tion. Tbe examination of his drums showed them to be
opaque, shrunken, and lustreless, denoting that chronic^
inflammation had been going on in them and in th&
tympanic cavity for a long period of time. He bad marked
hypertrophy of the spongy bones, and was a mouth breather.
My opinion was that in such a case dilatation of tbe nose
and removal of the bones would be quite futile so far as>
relief of the deafness was concerned, because pathologicav>
processes had been going on for so long as to produce
irremediable conditions,
Next we must inquire into the condition of the auditory
nerve apparatus by careful examination through means of
tuning forks. In such conditions as congenital syphiliS;,.
the sudden deafness following mumps, the specific fevers,
and marriages of consanguinity, evidence may be found
of labyrinthine mischief. Time merely allows me to-
mention these cases, and they are comparatively rare^
but if you find nasal obstruction in such you will not
markedly benefit them by operating on the nose. Suppose,
in the next place, that the patient has had violent and
severe suppurative inflammation of the tympanic cavity,
and the drums and ossicles are almost entirely destroyed,,
you would in that case recommend removal of the adenoids
or other nasal obstructions merely as an assistance in the
treatment of the suppurative affection of the ear, and you-
would not promise that it would in any way improve thC'
hearing.
Lastly, you must always in these cases, if you are honest-
as a medical man, be rationally certain that there is a-
definite disease of the nose to be operated upon, and should-
have a reasonable idea that the deafness may be dependent
upon it. It is so easy to look upon the cavities of the
body and see disease which does not really exist; and there¬
fore before you say a patient is the subject of polypi,
adenoid growths, hypertrophy of the mucous membrane,
or tbe like, you must be quite sure that they exist to-
such a marked degree as to justify their removal by opera¬
tion. Operations undertaken for conditions themselves-
not fraught with grave suffering or danger to life should bo-
looked upon with a peculiarly jealous eye by judicious
surgeons. Disaster in such is very lamentable. I pleaik
for the cavities of the nose the same privileges as are
accorded by careful surgery to other parts of the body
accuracy in diagnosis, care in selection, and a distinct
rational belief that the patient will receive benefit from
the operative procedures adopted.
Di.3iT:z5d b/
The Lancet,]
DR. B. W. ■RICHARDSON ON PEllOXIDE OF HYDROGEN. [March 28, 1891. 707
ON PEROXIDE OF HYDROGEN, OR OZONE
WATER, AS A REMEDY.
CONTINUED FROM A RESEARCH COMMENCED IN THE
YEAR 1858 1
By B. W. RICHARDSON, M.D., F.R.S.
Introductory and Historical.
In the year 1858 I commenced a study on peroxide of
hydrogen with the view of introducing it into medicine as
an addition to our treasury of remedies. The history of
this singular chemical body, discovered in the year 1818 by
the illustrious French chemist Baron Th(^oard, had in
1858 almost become forgotten, and no one, as far as I could
learn, had ever taken it up in respect to medical research ;
although, as I afterwards ascertained, a seat of learning at
Haarlem did for some years offer a prize for a medical
research upon it, which prize was withdrawn not very
long before my work was entered upon, simply because
there had never been a competitor. The peroxide when I
commenced my investigations was so rare a chemical
curiosity that I could not obtain it in quantity, and was
therefore obliged to set up the necessary apparatus for its
manufacture in my own laboratory. In the manufac¬
ture I followed in every particular the instructions left by
Thenard, and continued the manufacture until I could
assign good reasons for advancing thelluid into the position of
a valuable remedy in the treatment of disease. The great
novelty of the peroxide solution—for the substance must be
considered a solution, although it can be made to take
the gaseous form—rendered the study of its physical pro¬
perties alone of extreme interest, and, as it still remains a
novelty to many, I may with advantage devote a few
moments to a description of one or two of the special
qualities of the solution ; otherwise I might be talking an
unknown language to some who are not conversant with
certain primary facts, themselves unique in the history of
chemical substances. This solution, then, is water contain¬
ing, according to strength, so many atmospheres of oxygen.
It is an oxygen atmosphere in solution. It is not, how¬
ever, a mere mixture, but a peculiar chemical compound.
The oxygen can be made to accumulate, volume by volume,
until the volume of water, say as much as would hll a pint
measure, can rise to ten, twenty, thirty, and some say even
over a hundred volumes of oxygen, before complete saturation
is reached and a volatile body is formed. In the specimens
on the table before us, prepared by Mr. Robbins, we
have solutions of three strengths—viz, of ten, twenty,
and thirty volumes. We hold, therefore, in a specimen
of the peroxide condensed oxygen chemically combined
either with the hydrogen of the water, or with the oxygen
of the water, or with the two elements acting as a radical.
There is here not much difference at first sight from wh.at is
common in combinations where there is accumulation of one
element on another; as, for example, in the case of carbon
with one equivalent of oxygen as in carbonic oxide,
and carbon with two equivalents of oxygen as in carbonic
dioxide. But now comes a distinction. The combination
of the added oxygen in hydrogen peroxide is stable in the
presence of some substances, unstable and easily evolved
in the presence of others. Some substances, inorganic or
organic, when added to the solution are neutral; other
substances, inorganic or organic, evolve the oxygen and are
themselves unchanged; a third kind evolve the oxygen, and
with that some of their own contained oxygen; a fourth
kind absorb the oxygen into themselves.
I will illustrate this by experiment. Here are llasks
equally charged with a ten-volume solution of the peroxide.
To liask one I add a portion of oxide of iron : the action is
neutral. To flask two 1 add black oxide of platinum : there
is brisk action, so that I can light a taper from the oxygen
thrown off. To flask three I add solution of permanganate:
there is very brisk action, and, with the action, evolution of
oxygen from the permanganate as well as from the solution.
To flask four I add arsenions acid : there is absorption
of the oxygen by the arsenious compound. These are in¬
organic bodies ; let roe compare them with organic. Into
flask jive I put albumen: the action is neutral. Into llask
six I put^brin: there is brisk evolution. Tlidnard, in a
generaM^Hbad a wonderful knowledge of these distinc-
tho Mmlioal 8oduty of London, on ‘MondHy,
tions, but he did not live to follow them out or apply them.
They are all important to onr medicinal labours, in pointing
the way to success by the experimental instead of by the
empirical mode of questioning nature.
These observations led me very early in my research to
form an original view as to the constitution of the flnid.
When I liberated the oxygen from the solution, by one or
other of the means described above, 1 found that the
oxygen was neutral—that is to say, it presented neither
ozonic nor antozonio qualities, but was like the oxygen of
the common atmosphere in its natural state. When, how¬
ever, it existed in solution in the form of peroxide, it re¬
sponded to ozone tests, rendering the ozone test-papers of
deep, dark colour, as I now demonstrate. These facts led me
to conceive that the extra oxygen exists as ozonised oxygen,
ozone, in combination with water, so long as it is in solu¬
tion ; but that, as it comes off from tho solution, it escapes
as atmospheric oxygen. This theory has met with opposition,
for which I have much respect, but I still bold by it; and
I call special attention to it betebecause,from a medical point
of view, it is of primary importance. As I shall show, we
use the oxygen of the solution in two forma: sometimes as
a solution, when it is ozonic; and sometimes as a gas
liberated from thesolution.when it is neutral. The difference
is great; it is the difference between ozone and oxygen, and
until the profession understands that difference the utmost
confusion must prevail in regard to therapeutical action.
It may gratify a new generation of Fellows of the Medical
Society ot London if I briefly relate what led me to use this
solution in the first instance. It was in this way : I was
working at ozone, and bad been studying, with the late
Dr. Moffat of Hawarden, the changes of disease in what he
called “ atmospheric ozone periods.” I made peroxide, and
found that the oxygen condensed in it coloured Moffat’s ozone
test-papers of starch and potassium iodide, a fact which
showed that this oxygen was more active than the
oxygen of common air. It then occurred to me that the
peroxidfe might be of service as a medicine if its action
on the animal body and on the tissues were well investi¬
gated and defined. In those days we were inclined to
believe that diabetes was due to the deficient oxidation
of organic material,—a theory which an original ob¬
servation of mine, namely, that dogs could be made to
eliminate urine containing glucose by subjecting them to
an atmosphere of carbonic oxide, seemed to confirm.
As a result of this line of thought 1 made an original
investigation, the results of which I reported at length
in a paper read to the Medical Society in the session of
1860, describing the chemical, physiological, and therapeutic
action of the peroxide. I also fixed in this paper tho best
form of the peroxide of hydrogen for medical use, sug¬
gesting ten-volume strength as the most certain and cun-
venient for ordinary use- At the meeting of the Society
on March 3rd, 18G2, under the presidency of the late Mr.
William Coulson, I made a second report on the medicinal
use of the peroxide. I had by this time used ib in 223
cases of disease, including cases of phthisis, diabetes,
anmmia, subacute and chronic rheumatism, strumoas
enlargement of the cervical glands, mesenteric disease,
pertussis, chronic bronchitis, chronic laryngitis, mitral
disease, and some forms of dyspepsia. On referring
back to these two communications to the Society, I
find in them a good deal of new physiological inquiry.
I find that I bad tested all the free tissues of the body
to learu which of them did and which of them did not
eliminate the oxygen by contact. I found that fibrin of
blood and cellular tissue liberated the oxygen, that albumen
and gelatine did not liberate It, that blood entirely deprived
of fibrin absorbed the oxygen; and that common water
deprived of all its gases so efficiently that fish could not live
in it could be reoxygenated and revitalised by addition of
the peroxide solution, but not to the same perfection as
obtains in water that has not been deprived of its
natural air. It was also in these researches that
I observed for the first time the remarkable in¬
fluence of temperature on the .action of the oxygen on the
body; that heat caused oxygen to lose its power of sus¬
taining muscular contractility, and that by it oxygen could
be made a relaxant even of tetanic spasmodic rigidity.
What, however, will interest luost a practical body of men
like the members of the Medical Society of London will be
the rHiim,6 of the therapeutical properties of the peroxide
from those earliest papers. The n'iumi wss as follows
In the paper of 1860 it was advanced (a) that the
708 The Lancet,) DR. B. W. RICHARDSON ON PEROXIDE OF HYDROGEN.
[March 28, 1891.
peroxide quickens oxidation, increases secretion, arte-
rialiaea blood, and hastens the decomposition of decom¬
posing animal tissues; (h) that in combination with
blood it restores the power of muscles Just dead to
contract, and yet calms musonlAr'irritabihty; (c) that
it promises valuable aid in a large number of cases of
disease; (c^) that in instances of poisoning by narcotics and
1 ^ the alkaloids it might with advantage be introduced
into the blood by transfusion or injection; (e) that in tetanus
it affords a most rational treatment, since tetanic rigidity
is relaxed by its presence in muscle; (/) that in typhus, in
which death occurs from what I designated asphyxia
commencing in the blood, it might be employed with
good elFecti as an oxygenator; (^) that it ought to
prove useful both as an internal and external remedy
in the treatment of cancer. In epitome of results in
1862 1 drew the conclusions: (a) That in diabetes the
peroxide reduces the specific gravity of the urine, whilst it
rather increases quantity; (&) that in chronic and subacute
rheumatism it afi'ords relief; (c) that in valvular disease of
the heart with pulmonary congestion it gives relief to
the dyspnoea; (a) that in mesenteric disease and in
jaundice it causes an improvement in the digestion;
(a) that in pertussis its effect for good is very re¬
markable, since it cuts short the paroxysms of cough,
and seems decidedly to shorten the period of the
disease; (/) that in chronic bronchitis it lessens the dys-
pneea, and renders the expectorated matter less tenacious ;
(. 9 ) that in chronic la^ngitis it gives pain on being
swallowed, and does not appear to be useful; (A) that in
anmmia it does not of itself render a service, but favours
the good effect of iron ; (^) that in the first stage of phthisis
it causes improvement in the digestion, and in the later
stages gives unquestionable and even wonderful relief to
breathlessness and oppression, acting, in fact, like an
opiate without producing narcotism, and assisting oxi¬
dation.
But the most important new observation I had, to com¬
municate to the Society in 1862 was that in free and fre¬
quently repeated doses the peroxide could be made to pro¬
duce a modified salivation, a fact which led to two sugges¬
tions : one, that in the use of the mercurial and iodide pre¬
parations it might be the chlorine or iodine in them which
caused the ptyalism; secondly, that the peroxide would
be a good substitute for mercury and the iodides in the
treatment of syphilis. In the discussion which followed
upon the reading of this paper I was warmly supported on
several points by Drs. Septimus Gibbon, Symes Thompson,
and Gibb, all of whom had been prescribing the peroxide on
the suggestions made in the previous paper of 1860. Dr.
Gibb bore special testimony to its value in affording relief
during the last stage of phthisis, for which f had prescribed
it in the case of a member of his own family.
Such in the briefest terms is the history of the intro¬
duction of the peroxide of hydrogen, as it is commonly
called, or ozone water, as I should call it, into medicine.
Soon after it was thus introduced it created a great deal of
discussion, but owing to dilliculties in its manufacture and
some instability of the earlier specimens of it, it fell out of
favour; except in two unexpected directions. An inci¬
dental observation of mine that the solution gave a golden
colour to feathers led to the employment of it as a golden
bair dye; while a similar reference to its effective
action as a deodorant and disinfectant led, I believe,
bo its use in that very excellent compound called
“sanitas.” Occasionally also it was employed in medi¬
cine, and now and then I was consulted in regard to its
employment. Matters remained in this state until about
five years ago, when by some sudden and inexplicable
impulse the peroxide began to become popular in medical
f ractice, especially in America, and from that time onwards
have had communication with practitioners, both at home
and abvoa<i, who were anxious to be informed on points of
a practical kind relating to it. It was this circumstance
that led me three years ago to propose to revive the subject
in the Medical Society of London, and finally to bring for¬
ward the present paper. This was the more necessary
because, although practitioners who are now largely pre¬
scribing the remedy have often, in the most handsome
manner, assigned to me the credit of originating the
practice, they do not seem to have seized on the principles
which led me to introduce it, nor to see the compound
nature of the fluid and the different lines of practice which
spring from that recognition. Meantime, in the twenty-
nine years that have elapsed I have continued to work
at this research; practically in the steadiest manner,
theoretically by fits and starto, as the opportunities of my
overcrowded life have permitted. Now, as a kind of con¬
tinued report, I propose to give a further account of my
stewardship during the gap of time that has supervened
since I last spoke on this topic from this place.
New Methods of Application.
In cariying out this idea let me notice in the first place a
few new facts bearing on modes of administration which did
not in any way belong to the previous communications to
the Society. Some time about 1863 I made an observation
regarding the behaviour of the peroxide with ether. In
agitating a thirty-volume solution of the peroxide with
anhydrous ether I found that the ether became ozonised,
and that it was in this way possible to make a new and
useful medicinal preparation. To the preparation so formed
I gave the name of ozonic ether, and from the time when it
was first announced to the present it has been utilised. The
late Dr. Day of Geelong, in Australia, sent to me early for
the mode of preparation, and having learned to use it in
his own practice, devoted to it much study up to the end
of his valuable life. He warmly supported roy application
of the fluid in the treatment of whooping-cough and ite use
as an inunction after scarlet fever. He it was who first em¬
ployed this compound with guaiacum as a blood test. The
admixture of the peroxide with a volatile compound like ether
led mo to anothermodification—namely, the administration
by inhalation of the oxygen evolved either as oxygen,
ethereal oxygen, or ozone, for I soon learned that it could
be administered, as I shall show presently, in all these
states This was a distinct advantage, as it enabled me to
move from the mode of adniinistration by the mouth to a
larger and, in cases of lung disease, a more direct method.
Taking farther advantage of the ozonic properties of the
peroxide in solutions, I introduced it in 1865 at the meeting
of the British Medical Association at Chester for the
deodorisation and disinfection of rooms in which patients
suffering from infectious diseases are under treatment, and
also for application as spray to fetid or ulcerated surfaces,
as in diphtheria, syphilitic ulceration of the throat, and
gangrene. For this purpose it may be used either as
ozonic ether or simply as the aqueous solution. In addition
to the above new progressions I have made others of a
physiological and practical kind, bearing on other possible
methods of administration. Some of the facts disclosed in
this direction are published in the last Asclepiad, and I
may therefore be content by stating of them in summary,
that it is practical to inject the peroxide solution sub¬
cutaneously; also, under some circumstances, into mucous
and serous cavities, and even into the pulmonic structures.
Lastly, I would report in this place that I have tested the
effects of morbid substances like purulent matter on the
peroxide, as I had previously tested it on normal structures.
Oi.D AND New Exi*1';riences in Practick.
Let me now proceed to compare the practical experiences
I have gained in the use of the peroxide since 1802. In the
previous reports I dealt with many cases of disease in which
I had applied this remedy ; and in respect to all the forms of
diseases specified I may say that in the long experience which
has succeeded I have nothing of moment to retract, little to
modify, much to emphasise and support.
Diabetes —I have many times prescribed the peroxide solu¬
tion in this disease since 1802 . lufour cases, specially notice¬
able because occurring in members of our own profession, the
patients were all satisfied of benefit from it, one of them
taking it during a period of eleven years. The results have
always been that it reduced the quantity of sugar, but did
not reduce the quantity of water eliminated, unless it were
combined with codeine, with the use of which Dr. Pavy
has made us so familiar. Codeine three grains, alcohol
{sp. gr. 0'830) two iluid drachms, solution of peroxide of
hydrogen (10 volume strength) two iluid ounces, distilled
water to make twelve ounces, makes a mixture of which
half a Huid ounce may betaken three times a day in a wine-
glassful of water, and forms the most useful prescription I
have ever used in diabetes.
Phthisispulmonalis .—In the treatment of phthisis pulmo-
nalis the solution has been constantly in use, and in it I have
found the greatest service. In some cases o f, tjii s disease,
in which the solution has i)een borne doses
during the early stages, it has led to
able r6sult8 towards recovery that I mig.
The Lancet,]
DR. W. E. STEAVENSbN DN THE ELECTRIC BATH.
been pardoned if in younger and enthusiastic days I bad
declared in it the discovery of a specific. Happily a natural
fear of the experientia fallax held jne back from such a
course; but the fact ought not to prevent me from stating
that in the first stages of phthisis it is of all medicinal
remedies I know the most valuable, and that in the later
stages, when dyspncca is the distressing symptom, it is, espe-
ciafly in combination with ozonic ether, the remedy that
gives most relief. It soothes, and it seems to supply
oxygen to the blood, and so act vicariously, to a small
extent, for the purpose of respiration.
Pertussis.—1 repeat all I previously said about the
value of the peroxide in the treatment of whooping-cough.
I am sure there is nothing so near to a specific for this
affection. The only difference I have instituted in the
employment of it in this disease consists in prescribing it in
the form of ozonic ether. 1 prescribe it for children in this
form, in doses of from ten to sixty minims, diluted with
half a fluid drachm of spiritus tenuoris and four drachms of
water, to be taken four times a day, with a little more
water if that be preferred. But I also proscribe the ozonic
ether in this disease by inhalation from the Siegel
spray inhaler. In one instance, where the paroxysms
were as severe as I have ever seen them, they were
arrested at once by this inhalation, and wore held
in such control by continued inhalations that what
may be called a “cure” was the immediate result. As
to the power of the oxygen to control muscular spasm,
I repeat with still more insistance its value. In practice I
have availed myself of the peroxide with ether, not only in
whooping-cough, but also in asthma and in angina pectoris.
Here the ethereal solution can be used by inhalation in
its simple form, or combined with amyl nitrite, or other
body ot the antispasmodic class that will admix with ether
and diffuse with it. Id these affections I administer by
inhalation in a manner that will be demonstrated in the
lost section of this essay.
Local me for ulceration and purulent exudation .—In the
paper of 18(12 I recommended the use of the peroxide for
external application in cases of surface decomposition,
ulceration, and purulent exudation. I have to emphasise
this use. I will name one case alone in illustration. I was
called to see a gentleman advanced in life who was suffering
from moist senile gangrene of the foot. The extremity was so
offensive and the separation so slow, although there was a
fair line of separation, that the management was most
distressing. I had the foot wrapped in cotton-wool holding
peroxide solution slightly acidulated with dilute hydro¬
chloric acid. The offensive odour was at once removed,
and the process of separation went on rapidly; the foot
soon fell off, leaving an excellent healing surface. The
patient lived many ydavs afterwards in fair health, and
died at last of mere old ago.
Syphilis.—I restate the value of the peroxide in syphiHe,
and especially in all the chronic stages and eonditions of
syphilis in which mercury or potassium iodide would,
usually, be resorted to. It seems to me, in these cases, to :
have an intermediate action between mercury and potassium
iodide. It is also useful in indolent syphilitic eruptions,
and it has the great advantage over both niercuiy and the
, iodide that it leaves no after-effects of an injurious character.
Salivation from large and frequently repeated doses is soon
recovered from when the Iluid is withdrawn, as if theptyalism
had been induced by a volatile substance. It also aids the
action of mercury, rendering much smaller doses of that
remedy effective. The property exemplifled in this action is
that of elimination by excitement of glandular function, an
excitement probably always sustained by the oxygen of the
tissues in normal states of health, and only accelerated
by the active oxygen. I have of late years become
80 confldent of the value of the peroxide in the treatment
of syphilis under the conditions in which mercury or iodide
come ordinarily into use that I have employed it as a matter
of course. I use it in the primary as well as the secondary
form of the disease, and for those cachectic lesions in the
syphilitic constitution to which the term “ tertiary”ia applied
tnere is, I think, no remedy equal to it. In obstinate cases
of ulcer and cutaneous eruption it goes admirably with the
mercurial bath, and may be prescribed in doses or from two
to four drachms three times a day with full doses of fresh
ciuehona infusion. The solution also has its local use. It
makes.an excellent injoclion into the nasal cavity when there
is syphilitic ulceration of the cartilage and spongy bones.
(To be conchided.)
[March 28, isM.'
THE ELECTRIC BATH. ^ ' ■
By W. E. STEAVENSON, M.D.Cantab.,. M.'r.C.P.,
IN CHAHCa OK TIIK ELHCTRICAt DEPAn'rMBNT, ST. RARTUOLOUBW'S
nOSm-At; PHYSICIAN TO TUB oaOSVENOtt lio&pmn KOa
W0.M1CN AND ClUr.nnEN,
The electric bath is used iu the treatment of morbid
affections that influence the whole constitution, especially
in some having their origin in the central nervous system.
It is an easy way of applying general faradisation, but not
so efficacious as when the interrupted current is applied
successively to the nervous centres by means of a dry
electrode or one moistened with solt-and-water. It is ah
extravagant and wasteful way of applying the continuous
current, except in such conditions as those alluded to, in,
which the general system suffers, and when there is no local
manifestation of the disease on which the effects of the
current can be concentrated. Both currents may he com¬
bined and used through a bath, and perhaps this combina¬
tion is more easily accomplished by the use of a bath than
in any other way. It has yet to be proved t hat the com¬
bined current possesses any increased therapeutic value; it
is certainly not so useful as the continuous current in
rheumatoid arthritis, lead poisoning, lateral sclerosis, and
gout. The interrupted current may be used singly to the
extensor muscles of the wrist in lead palsy after the galvanic
bath has been administered.
The bath itself, which bolds the water, may be made of
metal, porcelain, or wood. "When made of metal the bath
forms one of the electrodes by having the rheophore from
one pole of the battery attached to it. Such baths are
usually made of copper, and are kept quite bright. A
japanned metal bath is not suitable for any form of
electric bath. When the copper bath is used provision has
to be made so that the patient may not touch the metal.
The bottom of the bath is covered by wooden lattice work
on which the patient lies, a rest is also provided for the
back, and protecting pieces of wood are placed at the sides, ,•
at the position about where the hips would come, so as to
prevent the body of the patient touching the sides of the
path. This form of hath cannot he so advantageously used ,■
for inffuencing the general system, as the second electrode
has to be used locally on different parts of the body, and ,
the part that it is applied to has, for the time being, to be ,
out of the water. On this account such strong currents
cannot be borne as when the whole of the body is immersed :
and although moat probably the current is widely diffused,
and enters the body at many points, it U more or less con¬
centrated at the part to which the second electrode is
applied, and as the resistance is greatly reduced by the
warm water a strong current cannot be tolerated. With
this form of bath, or this mode of administering the bath—
that is, with the second electrode applied to a part out
of the water,—the conducting power of the water may be
increased by the addition of salt, soda, or acid. Any
addition of the sort is inapplicable in the usual and more
useful modes of administering an electric bath, as will
presently be explained. The best bath to employ is one
made of a non-conducting material such as porcelain or
wood. A porcelain bath is the cleanest and best, but it is ,
also the most expensive and is very heavy. Each por<»lain _^
bath is made in a separate mould, and many are rejected
when turned out on account of some flaw; this difficulty ex¬
perienced in their manufacture is compensated for by an in¬
creased price being placed upon the perfect ones. A
wooden tub is therefore the cheapest. The best wood of
which it can be made is oak, similar to that employed for
ordinary household tubs. The appearance can be improved
by the outside of the bath being polished and the hoops of
iron which support it being painted black. The inside of
all wooden baths used for electrical purposes should be care¬
fully painted with non-metallic paint. White non inetallic
enamel is the best for this purpose. If the inside of the
b 0 ,th is not thus protected the wood becomes waterlogged,
and is then a conductor of electricity. The water in the
bath should be of the temperature of 100® F. , if the patient
can bear it, as tiie conductivity of the water is increased in
proportion to its temperature ; but it is often advisable to
give the first bath of a series at a temperature of 98®. Many
atients cannot at any time bear a higher temperature. Ijie
ath should be well filled with water, so that when the
Di::iiz;jCvA^-C
710 The Lancet,]
DR. W. E. STEAVENSON ON’THE ELECTRIC BATH.
[March 28,1891.
patient lies down his whole body and shoulders may be
covered. A bath thermometer should always be used to
ascertain and regulate the temperature.
In the ordinary and more efficacious electric bath a metal
plate is placed at the head and foot, and always kept bright.
These metal plates form the electrodes, and each is provided
with a binding screw, to which the rbeophores from the
Fio. 1.
and is altogether lost to the patient. This makes the employ¬
ment of electricity in the form of agalvanio bath such a waste¬
ful one. It has been calculated that a fifth part only of the
current traverses the patient. Thus with a current strength of
200 milliampbres passing through the bath the patient gets
forty milliamp^res only. It can easily be shown that part
of the current traverses the human bo(]y when immersed in
Wooden bafcli and Stdhrer’s hattevy.
battery can be attached. The best metal is copper. It is no
use having these metal sheets plated, as is sometimes done
for appearance sake, for the plating is always decomposed
on the one attached to the positive pole. The electrode
placed at the bead of the bath is usually the larger, and
may measure a foot and a half by a foot, that at the lower
end of the bath being eleven inches by nine. Smaller plates
are used for the hips and knees when it is wished to localise
the current more or less to those parts. Tlie water should
always be deep enough in the bath to cover the plates.
Metal plate electrodes.
The shoulders and back of the patient are prevented
touching the plate at the head of the bath by a rest made of
wood, something like a picture frame across which is
stretched pieces of webbing. A depression is made in tlie
upper bar of the frame to support the back of the patient’s
head. The feet may be allowed to touch the electrode at
the opposite end of the bath because the epidermis on the
soles is so thick that it is not likely to become blistered.
H a patient prefers she need not place her feet against the
lower electrode, but may keep them in close proximity. A
galvanic current will always prefer to traverse the human
body when immersed in ordinary water, as the body is the
better conductor; but not so greatly superior as to insure
all the current passing through it. The water in the bath
oflei's a broad conducting medium with a large transverse
sectional area, several times larger than the patient, and
therefore a large portion of the current traverses the water
Beat for back.
a hath even if the feet do not touch the
bottom electrode, fur if one of the legs is held
up out of the water the current strength, as
registered by the galvanometer, is immedi¬
ately reduced. “ That the body conducts
better than the water is proved by this ex-
E eriraent, which we have often made. Place
oth hands, at some distance apart, in a
bath through which a current ol consider¬
able strength is running, and a sensation
will be distinctly felt in them. Bring the hands still
immersed very close to each other and the sensation
will be much diminished. When the hands are far apart
a considerable portion of the current passes through the
body from one hand to the other. It prefers this much
longer and round-about road to the direct path through the
water.^ When a faradaic current is passing the efl'ect is such
that the wrists are quite doubled up by tbe contraction of
the muscles when the hands are held far apart. If salt or
acid is added to tbe water, the water becomes a far better con¬
ductor than the human body and the whole of the current
passes through it. A metal bath is also inappropriate for this
lorm of treatment, when it is wished influence the general
system ; for if two electrodes were placed one at the head
and the other at the foot of a metal bath, tlie current would
run round tbe bath and not enter either the water or the
patient. This is also almost invariably found to be the
case with japanned metal baths. The japanning is seldom
80 perfect that the current cannot in some way or other find
its way to the metal and escape tbe comparatively badly
conducting water and patient. In the treatment ot a case
the current should be allowed to flow through the patient
for from ten to fifteen minutes. It is often not possible to
detect much improvement in a patient’s condition until
after the sixth or eighth batb. The first five or six baths
may be given on consecutive days, and then every other
day until the end of the course. A course may consist of
thirteen or fourteen baths. A patient may have more If be
wishes, and if the improvement continues; but often, after
a course is concluded, a patient’s condition is so improved
that the restoration to health will proceed although tbe
baths have been discontinued, and the improvement be
maiQtained until some fresh cause arises to produce a
relapse.
The current strength employed in a galvanic bath maybe
raised so that the galvanometer registers 200 inilliamphres,
but it is best for the first bath or two to pass a current of
60 or 100 milliampbres only through the water. A good
cell to employ is the large No. 1 LeolaDch6. A Stdhrer’s
battery may also be used as represented in I'ig. 1. The
cells are here added' to the circuit by a travelling com¬
mutator, two cells being added at a time. There is more
' Heard and Rockwell: Modical and Hurglcal Uses of Electricity,
third edition, p. 30U.
Digitized by
Google
The Lancet,]
DR. J. DIXON MANN ON ADDISON’S DISEASE.
[March 28, 1891. ?I1
risk in the employment of these batteries of giving a
patient a shock from some imperfection in the contact'
makers under the commutator; Wt Stobrer’s batteries are
the best both for electrolysis and baths, and, in fact, for all
purposes where a fairly large external resistance has to be
overcome, as the description of cell conmoeing a Slbbrer’s
battery does not so easily polarise as Leclanchc cells do.
When Leclanchc cells are used, the No. 1 size are preferable
for baths on account of their producing a more constant
and sustained current than the smaller sizes. Leclancb6
cells have the advantage of not so frequently requiring
attention. The galvanometer that is included in the circuit
should be a highly graduated one, such as Gaiife’s, which is
used for the electrolysis of fibroid tumours. These galvano¬
meters are graduated up to 250 milliampbres. Two hundred
milliamp6res is a suthcient strength to employ in a bath.
The patient, after entering the bath, should be allowed a
few minutes to recover from the reaction produced by the
warm water before the current is turned on. The current
should be increased slowly and the galvanometer watched,
and the current strength reduced as slowly at the termina¬
tion of the bath. A medical man should always be present
to regulate, increase, or diminish the strength of the
current. The patient can be provided with a bathing-
dress, and of course with female patients a nurse would
always be in the room. The medical man’s attendance
is only required while the current is flowing. An arrange¬
ment exists on the switch-board or on the battery for com¬
pleting the circuit, and for gradually increasing the strength
of the current without any interruptions taking place, so
that all chance of giving a patient a shock is avoided. As
the current is slowly augmented the only sensation experi¬
enced by the patient is usually a slight pricking at the
ankles from their proximity to the negative pole. A galvanic
taste is produced in the mouth as the current becomes
stronger. Should the patient’s bead feel full or throbbing
during the administration of the bath, a cold wet towel
may he placed on the bop of the head; and if any faintness
is caused the current should be reduced. An electric bath
should not be taken too soon after a full meal. During the
bath the pulse-rate is said to be diminished, as is also that
of the respiration. After the bath the skin of the back which
was opposite the upper electrode will be found of a bright-
red colour; this will remain for about two hours. After
dressing the patient should rest for fifteen or twenty minutes
before going out into the open air, and should not imme¬
diately engage in exhausting exercise. There appears to be
no tendency to catch cold after an electric bath, as is often
the case after an ordinary bath. The patient generally feels
exhilarated and better. Should the patient feel languid
and depressed after each bath the treatment should not be
persevered in. (ToUomtinucd.)
ON ADDISON’S DISEASE.
By J. DIXON MANN, M.D., F.R C.P.,
PHYSICIAN TO THE SALEOUD KOVAf. HOSPITAL, I.ECTOIIHH ON POIIENSIC
MJJIHCINE AND PRACTICAL TOXICOLOGY IN OWENS COLLEGE.
(Continued fro7iip. 055.)
In discussing the possible influence of disease of the
adrenals as the primary link in the chain of symptoms we
call Addison’s disease, these bodies may be regarded from
two standpoints—(1) as ductless glands, and (2) as nerve
structures. As glands, any pathological changes in them
could only cause Addison’s disease by allowing abnormal
pigment, or pigment-forming substance, and some toxic
product which it is their function to excrete or to destroy, to
be present in the blood, the pigment being responsible for
the skin discolouration and thetoxine for the more obviously
nervous symptoms. Whatever pigment-yielding substances
may be present in the blood as a consequence of arrest of
function of the adrenals, such substances do not exist in
the blood qna pigment. No trace has ever been found in
the blood in Addison’s disease either of free pigment
granules or of any pigmented appearance of the white
corpuscles. The assumption of a soluble chromogen in the
blood, which under normal conditions would be removed by
the adrenals, is not so easily negatived by direct evidence.
The tendency of the above-mentioned experiments on
animals is to prove that in them the adrenals are func¬
tionally active in adult life. How far this is the case in
the human adult is doubtful. The compensatory hyper¬
trophy which is found to take place in the lower animals is
a strong proof that in them the adrenals partake largely of
the nature of glands—it is characteristic of glandular struc¬
tures to hypertrophy when there is an excessive call on the
functional activity of the gland. In the early period of de¬
velopment the adrenals in the human subject are relatively
large, and they probably exercise important glandular
functions. After the commencement of extra-uterine life
they are relatively insignificant in volume. If the adrenals
in the human adult act solely as glands, one would
expect iu those cases in which one adrenal only has been
destroyed hy disease that the other would be found hyper¬
trophied. The post-mortem records of such cases do not
bear this out. Allowing, however, that the adrenals do to
a certain extent act as blood-depurating glands, there are
dilflculties in the way of accepting cessation of their func¬
tion as the cause of Addison’s disease. The skin pigmenta¬
tion in Addison’s disease, except in degree, differs in no
respect from the normal pigmentation in the white races,
found in the scrotum and round the nipples of the two
sexes respectively, on the exposed parts of the body after
being subjected to powerful sunlignt, and in the skin of
the negro. The identity refers both to the histologic^
position and, as far as is known, to the chemical composition
of the pigment. The inference is that the pigmentation of
Addison’s disease, like many other pathological conditions,
is nothing more than an exaggerated and widely spread
form of a physiological process. The common genesis of
physiological skin pigmentation and that of Addison’s dis¬
ease has a most important bearing. The question baa been
exhaustively discussed by Nothnegel,^ and the conclusion
he arrives at is that there is a complete anatomical and
histological agreement between the two kinds of pigmenta¬
tion indicative of their common origin. Further considera*
tioD of the subject is reserved until pigmentation of the
skin is specially dealt with. Admitting that normal skin
pigment and that of Addison’s disease are derived from a
common source, it follows that if the adrenals excrete effete
blood-colouring matter, and if cessation of this function is.
the cause of skin pigmentation in Addison’s disease, one of
two conditions must be conceded to account for physiological
skin pigmentation : 1. That the adrenals habitually perform,
tbeir function imperfectly, and leave a percentage of the
pigment-forming material in the blood at the disposal of
certain of the rete cells, in order to provide for physiological
requirements. If this were so effete colouring matter would
always be present in the blood, and the question naturally
arises, What is to prevent the whole of the lower layer of
the rete cells becoming charged with it under normal con¬
ditions? 2. If the adrenals remove all effete colouring
matter, that there is a perpetual struggle for it between
them and the lower layer of the rete Malpigbii through the
intervention of the carrier cells of the corium. This would
be a necessary corollary to the entire removal of the effete
colouring matter in order to provide for skin pigmentation
known to bo independent of disease of the adrenals, as, for
example, that which comes on after prolonged exposure to
the ra;ys of the sun or other exceptional mode of skin stimu¬
lation. Such stimulation might be supposed to act by tem¬
porarily giving the carrier cells in the regions subjected to
its influence a greater affinity for the effete colouring matter
than the adrenals. On this hypothesis the normal pigmen¬
tation of the aieolce round the nipples and elsewhere would
be provided for by the aasunaption that the rete cells iu
these parts are supplied by carrier cells permanently en¬
dowed with a greater capacity of abstracting effete pigment
from the blood than that of the adrenals. Under these
conditions any disturbance of the adjustment between the
pigment cells and the adrenals (in favour of the pigment
cells) would determine general skin pigmentation. Such
disturbance of the adjustment, to the advantage of the pig¬
ment cells, would bo caused by any destructive lesion of
the adrenals, and would be inevitably followed by skin pig¬
mentation. This is contrary to experience. The occurrence of
skin pigmentation from disease of the adrenals is almost en¬
tirely limited tooneforniofmorbidchangeinthem; theymay
be completely destroyed by other morbid processes without a
vestige of skin pigmentation. The fugitive character of tho
coloured products obtained from the adrenals, and the utter
i Zoitscl’.r, f. Klin. Meil., 18ii5,
N 2
712 The Lancet,!
DR. J. DIXON MANN ON ADDISON S DISEASE.
[March'28,1891.
want of resemblance in chemical reactions between such
f roducts and the pigment contained in the rete cells, afford
urbber evidence against the view that the skin pigment is
derived from effete blood-colouring matter, in the elimina¬
tion of which the adrenals are concerned. The length of
time that elapses between destruction of the adrenals and
the appearance of pigmentation looks more like the result
of intermediate action than of interference with the
excretory functions of a gland. It might be expected, if it
were solely a question of non-removal of an abnormal
pigment from the blood, that the skin would speedily afford
evidence of its unwonted presence. Cases occur, however,
in which pigmentation appears only during the last few
months of life, and yet the adrenals are found to be the
seat of cretaceous degeneration, obviously indicative of
prolonged disease, which in its early stage would as com¬
pletely interfere with the functions of a gland as at the
period when the pigmentation took place. MeckeF and
IClebs’ state that in negroes the adrenals are very much
larger than in the white races. This hardly bears out
the view that the adrenals are the excretory glands of
effete blood-colouring matter whence the skin' pigment is
derived. If the skin of the negro were supplied with
pigment from this source, it would probably require all the
effete bmmoglobin products to maintain its hue. Why,
then, should glands which have only to excrete a possible
small residuum of effete pigment be developed to twice the
size they are in the white races, in whom they have to
remove all, or nearly all, of it? Another peculiarity
observed in the adrenals of the negro is that the cortical
portion is deeply pigmented. This, in conjunction with the
fact previously mentioned, that StilllDg found excess of
pigment in the adrenals of piebald animals, undoubt¬
edly points to some relation between the adrenals and
skin pigmentation. Without denying that the adrenals
may exercise glandular functions, it is possible that they
may act rather as receptacles for pigment than as purely
excretory bodies. The description given by Stilling of the
pigment-containin? cells in the adrenals as star-lHce cells
laying outside the walls of the capillaries, the pigment
being limited to these cells, none being found in the gland
cells, fits very closely with the description presently to be
given of the pigment-carrying cells of the corium of the
skin. The abstraction of pigment by such cells from the
bloodvessels is probably distinct from any glandular func¬
tion of the adrenals, and is more nearly allied to a general
excessive activity of the pigment cells throughout the body.
The deeply pigmented adrenals of the negro may be thus
accounted for. In relation to the question of excretion of
effete haemoglobin products by the adrenals, repeated
examinations of the urine were made in both my cases,
with the view of ascertaining the presence of MarMunn’s
urohrematoporpbyrin. The urine was treated with neutral
and basic lead acetates, and the precipitate was extracted
with alcohol acidulated with sulphuric acid. In no instance
were any absorption bands observed in the filtrate. It may
therefore be inferred that no exceptional effete product of
hffimoglobin is necessarily present in the urine of cases of
Addison’s disease. The accidental presence of such de¬
rivative is valueless as evidence oi suppressed adrenal
function.
Against the assumed presence in the blood of a toxic
proteid (also the result of arrested function of the adrenals
regarded solely as glands), which would occasion the
asthenia, vomiting, and other symptoms, is the steadily
progressive and prolonged character of the disease, lasting
in many cases for years. There is no analogous condition
of chronic auto-intoxication, the result of suppressed
glandular function, which slowly depresses the vital energy
and, as is usually the case in Addison’s disease, causes
death from asthenia. It is further to be remembered that
the presence of a toxine or special proteid poison resulting
from suppressed adrenal function is purely hypothetical;
DO satisiactory evidence of its existence has yet been given.
The foregoing objections are equally applicable against the
glandular theory of the adrenals as the cause of Addison’s
disease, whether these bodies are regarded solely as glands
or as a combination of gland and nerve structure. We
therefore pass on to the second standpoint from which, .so
far as the present discussion is concerned, the adrenals are
considered solely as organs richly supplied with nerve
structures.
* Handbuch der Path, Anatomies. “ Ibid.
On developmental grounds the adrenals are classed
amongst the ductless glands. Their intimate r elation with
both-sympatbetlc and cerebro-spinal systems of nerves,
however, justifies the position from which I am about to
regard them. In addition to fibres in direct communication
with the abdominal sympathetica and pneumogastrics, the
adrenals contain tnuUipoIar nerve cells. Although there
are ample anatomical grounds for explaining the causation
of Addison’s disease, on the assumption that certain morbid
processes in the adrenals derange the functions of both
systems of nerves, there is great difficulty in indicating even
in an indefinite manner the modus operandi. The nerves
with which the adrenals are in immediate relation are com¬
posite strands containing fibres from various sources, the
functions of which are equally varied. Consequently the
effects of irritation, or of paralysis, of these nerves cannot
be estimated with the same precision that is possible in the
case of the cerebro-spinal nerves. It is well known that the
splanchnics command the largest vascular area of any of the
vaso-motor nerves. Lewin* suggests that these nerves
undergo such changes as to impair their function, and that
in consequence the visceral bloodvessels would be dilated,
and that form of intra-vascular hmmorrhage induced which
depletes the rest of the system. The tissues specially affected
by this withdrawal of blood are thebrain and cord. Permanent
depletion of these centres would account for the excessive
loweringof energy, and inparfc for thefeeble pulse, both charac¬
teristic of the disease. Irritation of the splanchnics, the
sensory nerves of the intestines, causes severe local pain, such
as frequently occurs in Addison’s disease. Itis to be observed,
however, that in Addison’s disease structural change in the
splanchnics is by no means the rule; in many cases, in¬
cluding the two recorded by me, no microscopic change was
found. Is it possible that persistent irritation of the nerve
could induce permanent exhaustion without structural
change? The remissions that occur from time to time
during the progress of the disease in the pain, vomiting,
prostration, and other symptoms—not necessarily simul¬
taneously—probably have some relation to the morbid pro¬
cesses in the adrenals: in other words, are expressions of
varying nerve irritation. To such variations may be re¬
ferred the not unfrequently observed alternations of consti¬
pation with diarthcci. Irritation of the pneumogastrics
through their adrenal filaments is a probable cause of the
attacks of vomiting. It is to be confessed, however, that
much has to be granted in the building up of a hypothesis
founded on conditions so little understood. The pigmenta¬
tion of the skin in relation to abnormal nerve inlluenee will
be discussed separately.
The chief obstacles in the way of accepting morbid
changes in the adrenals as the primary link in the causa¬
tion of Addison’s disease are that skin pigmentation occurs
without disease of t)ie adrenals, and that destructive lesions
of the adrenals are not invariably followed by skin pigmen¬
tation. It is not to be inferred from this way of stating the
question that skin pigmentation is regarded aa the most
important symptom of Addison’s disease, but that the com¬
bination of symptoms thus named is not complete without
skin pigmentation. As long as morbid changes in the
adrenals are regarded only as antecedent factors in the
causation of Addison’s disease, the real causal agent being
held to be structural changes in theseinilunar ganglia,asatis-
factory explanation is to hand. It is that Addison’s disease
results if the adrenal mischief sets up secondary changes in
the semilunar ganglia, but not if the morbid processes are
limited to the adrenals themselves. According to the view
advocated in this paper the difficulty is more apparent than
real. I hold that Addison’s disease is due to abnormal nerve
influence, and, in the great majority of cases, that struc¬
tural changes in the adrenals is the initial cause; such
changes may or may not be followed by secondary changes
in the semilunar ganglia. The primary lesion, it’is true, is
a morbid process affeeling the adrenals. The after-effects,
however, are not due to damage sustained by the adrenals
as glands, but to implication of the nerve elements they
contain, and consequent, alteration of function of ceitain
portions of the nervous system with which they are inti¬
mately related. The first of the objections to this hypo¬
thesis—skin pigmentation without adrenal disease—is dis¬
posed of by allowing tbat exceptionally the nerve structures
concerned may be implicated on the central side of the
adrenals in morbid processes which do not affect those
* Cliaritd Aimalen, 1885.
ThbLahobt,) dr. J. WALTER CARR on ulceration of the trachea. [March 28, 1891. 713
bodies. la this way skin pigmentation without disease of
the adrenals can be accounted for. Illustrative of this
cause of skin pigmentation is Paget’s case,'^ in which the
adrenals were healthy; but the semilunar ganglia and
solar plexus were embedded in a masb of enlarged glands, '
the skin being characteristically pigmented. It is not to
be assumed, however, that pressure on the abdominal sym-.
pathetic or its ganglia will, as a matter of course, produce
skin pigmentation. Merkel” states that he has seen the
semilunar ganglia embedded in a slowly growing cancerous
mass without a trace of skin pigmentation. Other cases of
interference with the abdominal sympathetic by pressure of
contiguous growths without skin pigmentation have been
recorded. On the other hand, apart from Addison’s disease,
malignant abdominal disease not unfrequently gives rise to
some degree of skin pigmentation. The second of the two
objections—adrenal disease without skin pigmentation—is
not so easily met. It might be reasonably expected that
destructive lesions of the adrenals, of whatever type, would be
followed by uniform results. Such is not the case. Sarcoma
and cancer of the adrenals frequently occur without pro¬
ducing skin pigmentation. It has been suggested that when
cancer attacks the adrenals it is frequently unilateral, hence
the absence of pigmentation. Fenwick^ has tabulated a
number of cases of malignant disease of the adrenals without
skin pigmentation, and states that one capsule only was
attacKed in a considerable proportion of them. On referring
to Averbeck’s” tables, however, I lind that of nine cases of
carcinoma of the adrenals in which the skin was pigmented
five were unilateral, and of twenty-five cases in which the
skin was not pigmented eighteen were bilateral; in three
out of the twenty-five no statement is made as to whether
they were double or single. A more satisfactory explana¬
tion appears to me that on which Wilks lays stress—
cbronicity. It is probable that the akin does not become
pigmented until the adrenals have been diseased for a
considerable time. The changes in the adrenals which
are usually associated with skin pigmentation are of
a chronic inflammatory type. It is highly probable that the
two factors—time and the inflammatory nature of the
morbid process—have much to do with the after-effects.
When malignant disease attacks the adrenals, in the great
majority of cases they are the seat of secondary deposits.
It is probable in such cases that the patients are far
advanced towards the lethal issue before the adrenals are
attacked, and consequently the time factor would be wanting
for the after-effects to develop. Of forty-two cases of
malignant disease of the adrenals taken from Averbeck’s
tables, three are not specified as to whether they were
primary or secondary, and in two other cases the patients
died from interourrenb disease: this leaves thirty-seven
cases, in thirty-three of which the disease was secondary.
Whilst advancing this explanation, however, it is to be
admitted that a few cases are on record which do not
coincide with the data on which it is founded. Brinton,®
Collier,^” and Cagiati‘‘ record cases in which the adrenals
were the seat of cretaceous degeneration without the skin
being pigmented. The inconsistent behaviour of the adrenals
when subjected to pathological changes has its parallel in
that of another ductless gland. Extirpation of the thyroid
gland has often been observed to be followed by myxmdema,
so frequently that the name strumipriva has been given
to this disease. Yet Billroth (quoted by Moslet^-) states
that of the many cases in wliich he has removed the thyroid
he has seen none in which the operation was followed by
myxeedema. (To be concluded.)
5 Tiiu Lanckt, vol, i, 187f>.
<5 Von Wamssen'a Oycloptedia, vol. viii.
7 Patli. Trans., vol. xxxiii.
8 Die Addison'sche ICvankhoit, ISGl).
" Path. Trans,, vot. ix.
>0 Ibid., vol. xx-xlx. Itlforma Med., ISOO.
*- Virchow’s Arcli., lid. cxiv.
New Dueferin Hospital, Allahabad. — The
Lieutenant'Governor formally opened this hospital on
the 16bh ulb. In the main building the accommodation
consists of the necessary' administrative oflices and wards
for twenty-two patients. The subsidiary buildings con¬
tain four Zenana wards, suitable provision for female hos¬
pital assistant and four better class pupil nurses, and also
for six pupils; dais and domestic ollices. To guarantee
the permanent maintenance of the hospital, additional funds
are required.
i
A CASE OF ULCERATION OF THE TRACHEA
PRODUCED BY INTUBATION.
By J. WALTER CARR, M.D.Lond , M.B.C.P.,
ASSISTANT I’HYSICIAN AND PATHOLOGIST TO THE VICTORIA HOSPITAL
I'OU CHILDREN, CHELSEA.
At the present time, when intubation is on its trial in
this country, it is of importance to note any evil results
which it may produce, particularly any which experience
may enable us to prevent in the future. From this point of
view the following case may be instructive.
Herbert N-, a well-developed child two years and
eight months old, was admitted to the Victoria Hospital
for Children, Chelsea, on Nov. 22ad, 1890, with a history of
illness since Nov. 18tb. On admission the temperature was
100 8° F.; there was distinct diphtheritic membrane on the
right tonsil, with considerable swelling of glands in the
neck; no albumen in the urine. On Nov. 23rd the tem¬
perature rose to 102°, but was afterwards normal or sub¬
normal until Dec. 3rd. On Nov. 27th membrane appeared
on the left tonsil and on the posterior wall of the pharynx;
still no albumen in the urine. On Dec. 2ad laryngeal sym¬
ptoms (aphonia and stridulous cough and cry) appeared for
the first time, and on Deo. 3rd the temperature again began
to rise, varying from this time between 101° and 104’2%
which latter was reached shortly before death. On ac¬
count of increasing dyspnoea, stridor, and recession of
chest wall the child was intubated at 4.20 P.M. on
Dec. 3rd with a tube for a child of two years, according
to O’Dwyer’s scale. This gave complete relief. It was
coughed up two hours later, and the dyspnoea returning in
about twenty minutes a tube for a child of three to four
years was inserted with some difficulty, being noticed to fit
tightly in the larynx. The dyspnoea was again quite
relieved, and the tube was retamea till Dec. 76h, when it
was coughed out. Whilst it was being washed the child
made violent hut ineffectual efforfs to clear the larynx, and
became livid, but was at once relieved when the tube was
replaced. It was then kept in until death, on Deo. 9bh, six
days altogether. The child gradually sank with increasine.
lung signs and symptoms; food was taken fairly well
throughout, but occasionally caused some coughing. During;;
the last few days albumen appeared in the urine, and at.
last amounted to one-half. At the necropsy extensive,
broncho-pneumonic changes were found in both lungs. The
diphtheritic membrane had disappeared from the throat
some days before death, but on the right tonsil was a large,
adherent slough, and in the left one a central cavity, from,
which a similar slough had evidently separated. There was.
no membrane in the larynx or trachea, but the entire
mucous membrane presented a dirty greyish-white appear¬
ance, and in the larynx could be very readily peeled off-
from the cartilages. There was slight swelling over the
arytenoid cartilages. In the centre and exactly on the top.,
of the left aryteno epiglottic fold was a narrow ulcer
about one-third of an inch long. At the upper end of the
trachea, in the middle line in front, was a small circular
ulcer, about a quarter of an inch in diameter, exposing
the first ring. About half way down the front of the
trachea, also in the middle line, was a larger ulcer, fully
half an inch long by one-third broad, which bad actually
ulcerated through three of the cartilaginous rings, the
ragged ends of which projected freely on each side into ^e
lumen of the tube. The base of this ulcer was covered with
an adherent slough. The other organs were healthy.
The case is of interest in the late commencement of the
laryngeal symptoms, probably fourteen days alter the
onset of the disease. In Fagge’s Medicine it is stated that
“ Jenner, in 1801, had never known the onset of laryngeal
diphtheria delayed beyond the end of the first week ; but,
Oertel says it is not infrequent on the eighth or tenth day,
and may be as late as the thirteenth.” The small ulcer on
the left aryteno-epiglottic fold was probably clue to the
string attached to the intubation tube, which was kepl’ lU
throughout, and fastened to the left side of the child s bead.
Ulcers similarly situated, and probably attributable to this
cause, were described by Mr. Turney at the discussion on
intubation at the Medical Society on Dec. Ist, 1890. inere-.
fore, although the string is often a great convenience m
withdrawing the tube, it is probably better not to leave it
attached when the tube is worn for mote than a day or two,
L-oogle
714 The Lancet,] DR. JULIUS ALTHAUS ON BILATERAL FACIAL PARALYSIS. [March 28,1891.
although in this case the resulting ulcer was so slight that
it would probably have readily healed without causing any
trouble. Mr. Pitts and Mr. Brook, in their paper read at
the Medical Society,^ 8 a 3 [ that “in all cases where the tube
was expected to remain in for more than twelve hours the
string was removed.” The chief interest of the case, however,
lies in the tracheal ulceration. Tlie large lower ulcer exactly
corresponded in position with the end of the intubation tube
when in situ, and had evidently been produced by this,
although the end was quite smooth and thoroughly well
bevelled off. The cause of the small upper ulcer is less ob¬
vious, as although there is some lateral bulging of the tube
in this situation, its anterior aspect is perfectly straight and
smooth. Perhaps it is that the lumen of the trachea is
narrowest here, as it is said to gradually increase in calibre
from above downwards (Quain’s Anatomy), so that a tube
might just press against the firstring and escape those below.
The ulceration did not cause any symptoms during life, and
bad probably nothing to do with the fatal issue, which
seemed to be owing simply to the extension to the lungs of
the infiammation started by the diphtheria in the large
tubes; but, had the child escaped this danger, such exten¬
sive ulceration of the trachea might have proved a very
serious complication later, as in the specimen from St.
Thomas’s Hospital, shown by Mr. Pitts at the Medical
Society, in which a tube worn for four days produced
tracheal ulceration, which probably led to gangrene of the
lungs and death. The practical points to determine are—
assuming that there is no defect in the shape of the
tubes at present in use—how far was the ulceration
due to the time the tube was retained, and how far to
its size?
To take the former point first. Undoubtedly it is desirable
to remove the tube as soon as possible, but the range and
utility of intubation would be very seriously curtailed if a
tube could only be retained with safety for a day or two.
In the cases of laryngeal stenosis recorded by Mr. Pitts and
Mr. Brook, a large tube was often worn continuously for
many days, by one of the children frequently for a fortnight
at a time, without any harm resulting; but then, as they
point out, not only can a much larger tube be tolerated,
and is desirable, than is laid down for the treatment of
acute cases, but also in these chronic conditions the larynx
and trachea are very tolerant of interference and pressure,
which might have most serious results when applied to
parts damaged by local acute inflammatory and diphtheritic
processes, and with the general vitality greatly impaired by
the constitutional disease. * Nevertheless, there are now
many cases on record of a tube being retained many days
in laryngeal diphtheria without injurious results. Thus
Dr. Wm. Hailes of Albany, U.S.A., has recorded successful
cases in which the tube was worn for seven, ten, and tw'elve
days respectively, and also mentions a cose in which it was
nece-ssary to keep the tube in the larynx for twenty-three
days without any ill effect, the patient recovering.^ Dr.
O’Dwyer mentions two cases in which the tube was in for
ten days, and Dr. Waxham one iR which it was retained
for fourteen days without harm resulting. Moreover, in
none of the children at the Victoria Hospital (some twelve
in number), on whom a necropsy has been obtained in
case of death after intubation has any trace of ulceration
of the larynx or trachea been found, though it is true that
in none was the tube worn nearly so long as in the case
under consideration, though, j udging from its size and depth,
the ulcer in this case would in all probability have been
well marked, even had death occurred some days earlier.
In one case in which the tube was retained for five days and
a half the necropsy was unfortunately refused. How¬
ever, in the series of cases from the hospital recorded
by Mr. Btaveley,^ there was one of diphtneria (No. 7),
ending in recovery, in which the tube was worn for
nine days, and the voice completely regained ten days
later.
The one feature which, so far as I can ascertain, distin¬
guishes the present case from all the others intubated at
the hospital is the fact that for the age of the child a tube
relatively too large was used. It has always been the
custom to adhere strictly to the scale given by O’Dwyer;
in this instance, when the first tube was coughed out, with
rapid return of dyspnoea, a larger one was inserted, so as to
1 The Lavcet, ./an. iOth ami 17th,
'i Brit. Med. Jour., vnl. i. 18!)0, p. llSIi.
» The Lanci:t, Nov, f)th and lOlli 1380.
prevent a repetition of this if possible, and so far with
success, as it was only expelled once in the six days, but it
was noted at the time of insertion to fit very tightly. It
would be interesting to know if, in any other case where
ulceration has been found—and I believe that at some hos¬
pitals it has been more frequent than at the Victoria,—any
tube beyond the regulation size has been used. At any
rate, for the present the practical lesson of the case seems
to be that whilst it is always well to withdraw an intubation
tube as early as possible, it is still more Important, even at
the risk of its being frequently coughed up, not to use too
large a tube, especially it it is likely to be wanted for more
than a few hours. Although in hospital practice this ex¬
pulsion of the tube is of no great moment, in private prac¬
tice, when the child would have to be left entirely in charge
of a nurse, it might possibly be an important point, in
considering the expediency of the operation, to remember
that a tube so large as to be likely to be retained for a
considerable time may very probably cause serious tracheal
ulceration, whilst a smaller tube may be frequently ex¬
pelled, and should this occur within the first few hours,
urgent dyspnoea may probably return when there is no one
at hand to replace it.
I have to thank my colleagiie Dr.Jlidge Jones for per¬
mission to use the notes of the case during life.
ON BILATERAL FACIAL PARALYSIS AS A
FORM OF POLYNEURITIS.
By JULIUS ALTHAUS, M.D., M.R.C.P. Lond.,
SENIOJI PIIVSICIAN TO THE I'OR El’ILEI'SV AND I’AIUr.VSIS,
KEOliNT’S-l'AHK.
Bilateral facial paralysis is an uncommon affection,
of which only few cases are recorded in medical literature ;
and having recently met with two well-marked instances of
it, I am induced to offer some remarks on the pathology
and treatment of the disease. 1 shall not speak here of the
surgical form of the malady which is seen after injury to
the head, and on which Dr. Bristowe has written an able
paper in The Lancet for Jan. pth, 1883, but shall confine
myself to that form which arises from damage to the nerves
by disease. In the two cases which I shall relate the
affection was owing to neuritis of the portio dura in the
lower portion of the Fallopian canal, and appeared to be
part and parcel of a somewhat generalised polyneuritis. In
the first case the illness was attributed to the sting of a
poisonous insect; while the second case occurred during the
influenza epidemic of last winter, and probably arose from
infection with that virus.
The subject of tlie first case was a merchant, aged
twenty-six, single, who was sent tome by Professor Striimpell
of Erlangen; and the case has been described by that gentle¬
man in the Neurologische Centralhlatt for Nov. Ist, 1889.
On comparing the notes of the historj' of the case, which I
took at my first interview with the patient on May let, 1888,.
with the account given by Professor Striimpell, tiiey are
found to differ in a good many particulars, which shows once
again that statements of patients cannot be always im¬
plicitly relied upon. Thus, the patient informed me that
he was, white sitting in a garden, stung by an insect on
Aug. 28th, 1887, while the Professor gives the date of this
accident as October, 1887. As the first symptoms of
paralysis appeared at the end of December of the same year
this would give an interval of four^months for my version
and less than three mouths for the Professor’s. I believe
that in this instance the version given to me was the
correct one, because more circumstantial; and the same
applies probably to the locality of the sting, which, accord¬
ing to the Professor was, in the right hand, and according
to my notes in tlie middle finger of the left hand. The
patient also told me that the inflammation which super¬
vened extended not only to the left arm and axilla, out
spread to the right axilla, where the lymphatic glands were
painful and swollen. Anyhow, it is certain that tho
patient, who had been in excellent health previously to that
occurrence, and having neither syphilitic nor alcoholic
antecedents, bad a smart attack of lymphangitis, attended
with feverish symptoms and loss of appetite. After a
few weeks the inflammation subsided, ana he felt better;
Coogle
Thb Lanobt,} dr. JULIUS ALTHAUS ON BILATERAL FACIAL PARALYSIS. [Mabch28, 1891. 715
yet hie health was not as good as it had been before, and
^glycosuria was found to exist, for which an anti-diabetic
Tegiraen was prescribed. On Dec. 29th, 1887, while abroad,
the patient was suddenly, and without any apparent cause,
'taken with pain in both temples, giddiness, oppression on
•Che cheat, unsteadiness in walking, and difficulty in speak¬
ing. On Jan. 2nd, 1888, the pain had become much worse,
had spread to the ears, arras, and legs. The patient could
not sleep, and took to his bed on the following day. There
was no fever, and the pulse was not accelerated. When
Professor Strumpell saw him he noticed the symptoms of
double facial paralysis and ataxy of the lower extremities.
It appears from my notes that the left side of the face was
first ailecbed, and the right aide soon afterwards. Although
the patient had great difficulty in standing and walking,
■there was no actual paralysis of the limbs, bub diminution
of sensibility and ataxy of movements in the legs. The
'knee-jerk was found to be lost in both sides. The muscles
of the legs responded well to electricity, but in the face the
■electric tests showed the signs of the reaction of degenera¬
tion. The patient was treated with mercurial inunction,
.galvanism, and saline baths. He was three weeks in bed.
After a week there was some improvement, and in about
six weeks the ataxy of the lower extremities had dis-
'Appoared. In March the voluntary power began to return
'in the face, and the knee-jerk came back. I first saw him
on May 1st, _ 1888, and found the signs of double facial
ppesis, affecting chiefly the eyelids and lips, with greatly
-aiminished faradaic contractility, and increased galvano-
muscular excitability milliampfere). In addition to this
there was loss of taste in both sides of the tongue, but no
tinnitus aurium or hyperacusis. The soft palate was not
affected. The knee-jerk was normal, the urine contained a
-small quantity of sugar, and the patient had during his
illness lost S5 lb. in weight. I treated him by a carefully
regulated diet and systematic applications of the constant
current, and in July of the same year he had almost
■entirely recovered. The urine contained then not a trace
of sugar, and the only muscle which had not fully regained
its strength was the orbicularis oris. The patient could
“ laugh and kiss,” but could not whistle quite so well as
before.
Professor Striimpell has not expressed any opinion as to
'the precise seat of the paralysing lesion in this case, but it
seems to me quite clear that the paralytic symptoms, the
•electric tests, and the loss of taste on the one hand, and
the absence of tinnitus and hyperacusis on the other hand,
•pointed to the lower portion of the Fallopian canal as the
■seat of the disease. The chorda tympani was evidently
involved, while the sbapeclian nerve, higher up in the
Fallopian canal, which supplies the laxator tympani muscle,
had escaped tlie pathological influence. The question
whether the sting of the insect really led to all the troubles
which this patient experienced is difficult to answer
•definitely, but there is no inherent improbability in such a
supposition. I have seen a cose of epilepsy in a farmer,
•aged thirty, who had been in perfect health until he was
one day stung by bees, which caused inflammation of the
hand. He never recovered his health thoroughly after this,
And nine months after the occurrence had his first epileptic
fit,^without any assignable cause. The occurrence of para¬
lysis together with ataxy is not uncommon, and is seen in
Alcoholic and post-diphtheritic affections. The same cause
may affect one set of nerves more than another, and the
portio dura in the Fallopian canal may, for anatomical
reasons, be more thoroughly compressed and squeezed
by the effusion, and therefore suffer more severely in
.its functions, than the nerves of the lower extremities.
That the ataxy was not owing to spinal disease, but
•to peripheral neuritis, would seem to be proved by the
impfd recovery which the patient made both from the
•ataxy and, although in a less degree, likewise from the
paralysis.
, The second ease was that of a clerk aged forty-five, single,
■'vhom I exhibited at the Clinical Society on May 23rd, 1800.
He had never iiad syphilis, always been temperate, and had
'®»joyed excellent health. About the middle of March last
he began to be troubled, without any apparent cause, and
without any particular exposure to wet or cold, with severe
pain all over the body and limbs, and more particularly in
the arms and the lower portion of the back. The pain was
■constant, and prevented him from sleeping. There was no
£evar, but a considerable degree of prostration. After this
iiad gone on for about three weeks he noticed one morning
that his speech was becoming affected, that he had a
difficulty in eating, that his food seemed to have lost all
flavour, and that his face felt “fixed.” His face
indeed changed to such an extent that his friends hardly
recognised him, and told him that he looked as if he bad
been turned into stone. When I first saw him, on April 18th
last, his expression was statuesque: the features were com¬
pletely immovable, while the eyes and muscles of mastica¬
tion had retained their power, and there was no aniesthesia
in the face. The forehead was as smooth as if it had been
ironed out, illustrating Romberg’s remark that facial palsy
is the best cosmetic, by making all the wrinkles disappear.
The eyes were widely open, and he had lost the power to
blink, while epiphora K^as marked, and led to dimness of
sight; indeed, the patient complained of being unable to
read for any length of time, although the structures of the
eye were in their normal condition. Otherspecial functions
suffered likewise indirectly through the facial paralysis.
Although the olfactory nerve was unaffected, yet the
patient had lost the power of smelling through being unable
to sniff, and the food had lost all its flavour, which made
him say thatfor the taste ofit he might justas well be eating
sticlvs. This also deprived him of the enjoyment of his
pipe, for, having been very fond of smoking for many years
past, he had lately given it up, partly because he could
not smell the smoke and partV because be experienced
extreme difficulty in drawing ic out of the pipe with his
lips. The simple tastes, apart from flavours, Were likewise
affected. I tested the tongue with glycerine, quassia,
table salt, and citric acid, and found that the taste of the
acid was entirely lost, while it took him about six
seconds before he realised the sweet, bitter, and salt.
While the action of the temporal and masseter muscles had
remained normal, yet there was such difficulty in eating,
from paralysis of the buccinators, that he had to work bard
for a quarter of an hour before he could dispose of a small
piece of flsh or bread-crumb. The morsel kept constantly
falling out of bis mouth, aud the attempts to eat caused
such fatigue that the patient eventually took nothing but
slops ; yet even drinking was difficult, as part of the liquid
taken used to run out of the mouth. In consequence of
these difficulties he lost greatly in weight, or, as he gra¬
phically expressed it, he had “from a waggon-load become
a cart-load,” and lost four inches round the waist. One of
the most striking symptoms of the case, however, was the
alteration in the speech. The patient could really not arti¬
culate at all, but seemed by great efforts to forcibly expel
his words from the throat, and his speech was therefore so
indistinct that it was hardly possible to make out what he
meant. He had chief difficulty with the vowels a, e, u, and
the labials. He could neither blow his nose nor spit; if
attempting the latter, a tenacious mucus flowed slowly out
of his mouth. He could blow out a lighted candle, but not,
as one usually does, by puffing with the lips, but by a
forcible expiration. The mouth was generally half open.
The soft palate was not affected, and the sense of hearing
normal. The electric tests showed complete loss of faradaic
excitability of the nerves and muscles, loss of galvanic
excitability of the nerves, and greatly increased galvanic
excitability of the muscles (0'25 milliamp6re). There were
no other symptoms of importance. The urine was of low
density, 1010, the excretmn of urea being diminished; it
was fairly acid, and showed no trace of albumen or sugar
or excess of phosphates. The knee-jerk was normal. I
treated the patient first with salicylate of soda, and after¬
wards with antipyrin, which relieved the pain in the body
and the limbs considerably, although it took some weeks
before he was entirely free from pain. As bis suffering had
entailed considerable loss of strength I put him presently
on quinine. The paralysis was treated by the constant
current, of which more presently. The patient was about
three months under my care, when he had so far recovered
that the treatment could be discontinued. He called on me
on Nov. 27th last, when the condition of the face was perfect
and his health excellent.
As in the former case, it is difficult to speak with
certainty about the cause of the neuritis in this patient.
The severe pain in the body and limbs from which he
suffered at the beginning of the illness and for some
time afterwards looked at first sight like an attack of
subacute rheumatism, and the facial palsy as owing to
rheumatic neuritis of the portio dura. Since then, how¬
ever, I have seen and read of a number of cases of
acute nervous affections which bad come on after, and
Lioogle
716 ThbLANOKt,] MR. T. B. FRAUKLIN EMINSON on PLEURO-PNEUMONIC FEVEE. [March 28,18M.
19660; clearly owing to, eevere attacks of influenza, and
it seems to me. ther^ore, much more likely, oonsider-
ins that the illness commenced during that epidemic,
an^ that no exposure to wet or cold could be made out,
that it was owing to infection with that virus. Severe pain
in different parts of the body, probably owing to acute
neuritu, has been the characteristic feature of many cases
of induenza. From this point of view the pain about the
body and limbs in the present case would have been owing
to polyneuritis, which, although it affected the afferent
nerves severely enongh, did not lead to any trouble in the
motor sphere, except in the case of the portio dura, where,
for anatomical reasons, the pressure of the effusion on the
nerve was greater than in the bther parts which were
affected. The localisation of the lesion in the present case
appeared to be the same as in the first. It was clearly not
central—that is to say, situated at any point between the
pons and the cortex, because in central palsy only the
muscles about the mouth are much affected. Nor could the
disease be seated at the base of the brain, for where this
occurs there is also deafness from affection of the portio
mollis, but no loss of taste, as in the present case, since
the portio dura carries gustatory fibres only during its
course in the Fallopian canal. This symptom also showed
that the affection was not seated in the external branches
of the nerve, after this has emerged from the stylo-mastoid
foramen, nor in the nucleus of the nerve in the meclulla
oblongata. 'Vybere this latter portion suffers the paralysis is
confined to the lower branches of the nerve, for patients who
are on the point of dying from bulbar paralysis can still
express their feelings to some degree by movements of the
upper portions of the face. As there was no hyperacusis,
the stapedian nerve had evidently escaped injury; and
the lesion could therefore be traced to the nerve in the
lower portion of the Fallopian canal, involving the chorda
tympaoh
The prognosis is favourable in most forms of neuritis,
except where it attacks highly specialised structures, such
as the expansions of the optic and auditory nerves, which
easily succumb to pressure by the effusion. The recupera¬
tive power of the ordinary peripheral nerves is indeed very
great, especiellv when compared with the nerve cells of the
grey matter. The natural tendency of the disease is there¬
fore towards recovery, and this may be much aided by
treatment. In the treatment of polyneuritis I should not
resort to mercurial inunction, which was used in the first
case, except if a specific cause could be clearly shown.
Iodide of potassium, which is often prescribed, I believe to
be quite useless in the treatment of such eases, but
salicylate of soda and antipyrin (in ten grain doses) act
beneficially in the first stage. After the inflammation has
subsided, quinine should be given in hydrobromic acid.
The most important part of the treatment of the palsy,
however, is the cautiou.s use of the constant galvanic
current. It has been often stated that this agent should be
reserved for the later stages of the complaint; but my
experience is to the effect that it is most useful when
resorted to in the beginning. We may then call into
play the so-called catalytic effects of the current; and by
doing so I have seen habitually a more perfect recovery at
the end than where the electricity liad oruy been used some
months after the occurrence of the paralysis. The principal
thing here is the mode of application, in which it is so easy
to go astray. A powerful current is sure to do harm by
aggravating the existing inflammation; while an exceed¬
ingly gentle force, such as we can measure with the greatest
nicety with Edelmann’s absolute galvanometer, appears at
once to ease the circulations and to reduce the pressure of
the effusion. I am in the habit of using about i to 1 mill!-
ampere with the anode resting on the mastoid process, and the
cathode below the stylo-mastoid foramen, so as to embrace
the diseased portion of the nerve for five minutes; after
which a few cathodal passes, with the same current-strength,
are made over the paralysed muscles. There can be no
question that this is useful, because the patient at
once expresses himself as relieved of the unpleasant
feeling of stiffness about the face, and because the muscles
that have been acted upon are seen to do their work
much better after the application. This latter result is
more especially seen in the muscles of the eyelids, where
the immediate beneficial effect is often very striking.
Perseverance with this treatment for two or three months
is, however, generally necessary for securing a permanent
result.
PLEUEO-PNEUMONIC FEVER AT SCOTTER,
m 1890 .
THE SUPPOSED METHOD OF EXTENSION OF THE
DISEASE TO NEIGHCOURINC PLACES.
ByT. B. FRANKLIN EMINSON, M.R.C.S., L,S.A.^
MEDICAL Oia-ICEtt 01' THE SCOTTER DISTRICT 01' THli
GAINSDOROUOH UNION.
It is a fact well known amongst farmers that certaia
seasons independently of climatic variations are especially
prone to the production of mildews, blights, smuts, &c.,
while other seasons with similar weather are less liable to
such pests. The bay harvest of 1889 was unusually fine in
this neighbourhood, most of the hay being gathered with¬
out any rainfall, and the farmers looked forward to having?
good sweet fodder for winter use. In December, however,
when the stacks were cut, a foot of outside was found full’
of mould, so that when disturbed the hay gave out clouds ofr
whitish spore dust, enveloping the men so completely that-
they were sometimes invisible to each other. This mouldy
condition extended, as I have said, about a foot into the
stack all round—that is, wherever the outside air could
readily penetrate, the inside of each stack being perfectly
sweet and free from mould. Dampness is a common
cause of mouldy hay after a wet hay harvest, but in that
case the mould is found interspersed throughout the stack
this, however, was of a different nature, and gave
rise to special remark as something out of the ordi¬
nary, the mould having attacked each stack after it
was built. This was general in the neighbourhood of
Scotter, and I tried vainly to meet with sound hay for niy
running horses, but I cannot say whether the same thing
was observed in other districts.
The winter of 1889-90 was particularly open, and was
followed by a spring of very unusual dryness, there
being ninety-seven consecutive days during which the
rainfall was considerably less than half the average
amount, and forty-seven days, extending from March 24th
to May 9bh, during which the rainfall was just about
one-lifth the average amount. It was in this latter
period that the epidemic of pneumonia began and accom¬
plished most of its task in Scotter. But what connexion is
there between the pneumonia and mouldy hay ? No direct,
yet possibly some indirect, relation. The same seasonal
peculiarity which favoured the production of this special
mould in the dry, sweet, and well-gathered hay may
perhaps have favoured the propagation and activity of the
still more lowly life form—the pneumonia bacillus. It was-
evident that the mould spores were conveyed to the hay
by the atmosphere, for the disease attacked only the
outside, not the inside, as is usual when dampness is
the cause, showing that the parent spores were filtered
from the air as it penetrated into the substance of the
stack, and then grew. May not this process suggest an
explanation of how the pneumonia bacillus travelled from
Scotter to Scotton, Messingham, and Laughton"' During
the forty-seven days of drought just mentioned, the south
sewer must have contained much stagnant and semi-solid
sewage, with dry islands standing up here and there. Sewer
air is known to have been evolved freely, and in its passage
over the dried sewage it would cany the specific germ into
the outside atmosphere. May it not be possible that germs
so given off, perhaps in great abundance, travel short dis-
tancestlirougli the atmosphere, reaching other scenes of opers'-
tioDS, not perhaps in a condition to effect an entrance into
the human system, but sufficiently active to escape extinc;-
tioD, provided they meet with suitable surface or sewer lUtl
in which to thrive?
I venture to suggest that in some such way as thi
the pneumonia may have established itself in the villages
immediately surrounding Scotter, and, if this be so
it would indicate some little- relationship to that pere¬
grinating disease, inlluenza—a relationship which the
known like characters of the two diseases naturally coh
to mind.
Scotter, Lincolnshire.
Dig;- -ed •■•/
e
TiiE Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[March 28, 1891. 71T
% Pirrrtr
OF
HOSPITAL PKACTICE,
BRITISH AND FOREIGN.
Nulla autem esb alia pro certo noscendl via, nlal quamplurimas etmor-
borum et disaoctionum hiatoriaa, turn alionim turn propriaa collectaa
babere, ©t Inter se comparare.—M oroaoni De Sea. et Cotu.
lib. It. Procemium.
ROYAL FREE HOSPITAL.
JAUNDICE ACCOMPANYING SPECIFIC DISEASE ; TYPHOID
SYMPTOMS ; DEATH ; NECROPSY : ACUTE YELLOW-
ATROPHY OF LIVER.
(Under the care of Dr.. Sainsbury.)
Acute yellow atrophy of the liver or malignant jaundice
is a disease which is rarely met with in the wards of our
London hospitals, from whatever cause arising.^ Cases
seem to be much more common in Cuba and other tropical
countries, as well as more frequently idiopathic in nature,
than in more northern climates, for while only one case in
27,000 was met with at the London Pever Hospital,
fifty-eight have been received in the Civil Hospital
■of Havana during a period of ten years. Dr. Martinez,
from whose dissertation this statement is taken, finds the
•disease much more common in men, whereas in Europe the
■reverse appears to be the rule. It is a very interesting
ipoint in this case that the disease developed while the
patient was undergoing mercurial treatment for the
syphilitic state. Dr. Frua® has published two cases of very
einiilar character. Jaundice came on three months after
infection, and both patients died within a fortnight after¬
wards. Both patients had undergone mercurial inunction
for the syphilis.
Ellen H-, aged thirty-four, widow, charwoman by
occupation, was admitted into the Royal Free Hospital on
Sept. 10th, 1890. On admission she was jaundiced, and
complained of the presence of a rash on the body, of abdo¬
minal pain, loss of appetite, and weakness. Born in Devon¬
shire, she came to London fourteen y^ars ago. Nine years
i^go she went to Canada for a year as lady’s maid ; since
(this time she has lived in London. As a child she bad
measles, scarlet fever, and typhoid fever. At the age of
nineteen slie was laid up for three months with pain in the
(head and down the spine, and during a portion of this time
there was palpitation of the heart. At twenty-three and
again at twenty-four she suffered from bronchitis. In
January, 1890, she had influenza, and has not been really
well since. She has had three children, all born before
full term. Two are delicate, and are said to be con¬
sumptive. Her husband died of conouraption. The pre¬
sent illness began on July 22Qd, with the appearance of
a very red rash over the whole body. She accounted for
tJiis rash as being caused by drinking cold water when she
was hot; this occurred on the day the rash appeared.
During tlie next fourteen days she complained of vertical
headache, of loss ot appetite, and of being unlit for work ;
■she kept lier bed two days. Next (five weeks subsequently)
her legs began to swell, and she found standing difficult; the
•swelling went down on resting. She then took to her bed (four
weeks ago) and kept it for ten days. At the end of this time
jshe felt stronger, and resumed lier work, at which she con¬
tinued till live days ago. On Monday, Sept. Ist (eleven days
since) she was sick, and had diarrhoea. The vomiting con¬
tinued till two days before admission, when it seems to '
have been cured by eating an apple. The vomit resembled
whatever she had been eating. The diarrhoea lasted from ,
three to four days ; for the last four or live days the motions
have been formed, and have resembled white clay. Jaundice
set ill on Sept. 3id. On Sept. 8th she began to have pain
across the upper part of the abdomen. There has been
much thirst since the jaundice appeared. The urine has
been much yellower since the jaundice. The “ present
state” showed a well-marked jaundice of somewhat
brownish hue. On the nock and arms there were dark-
reddish-brown patches running into one another here and
* The Lancet, vol. i. 18S0, p. 284. ^ Sojoua, vol. i,, n, 84, 1890.
there; the patches were desquamating slightly, they were
not raised. On the chest were numerous coppery stains.
On the abdomen scattered spots of a similar colour, but of
a darker shade. There were anorexia, thirst, and a furred
tongue, with unpleasant taste; the stools clay coloured;
the abdomen tender all over, but not to any great degree;
the liver enlarged, its lower margin reaching two inches
below the costal margin (tip of ninth rib cartilage). The
^leen could not bn felt. Thoracic organs nothing abnormal.
Pulse 68; respiration 25; temperature 99°. Urine brownish
yellow, sp. gr. 1018, acid, no sugar, no albumen; gives bile
reactions. The patient is much thinner now than before
the influenza in January. She was put on milk and soda-
water, and a bismuth mixture was prescribed. On Sept. 12th
one grain of pulv. hydrarg. cum creta was ordered thrice
daily. During the next few days there was much trouble
with the bowels and abdominal pain, but by saline
aperients the constipation wa^ overcome and the abdominal
pain then became much better. The rash meanwhile bad
improved. Then for a few days vomiting became trouble¬
some, and nausea was almost constant. On Sept. 26th the
vomiting had ceased. Patient now complained of the great
irritability of the rash. Then there was a return of the
sickness and nausea, with flatulent distension of abdomen ;
and again the patient complained of ahominal pain and of
pain in the back; next a remission of these symptoms, and
in this way the case proceeded. Theahdominal pain was at
times very severe, and on more than one occasion required the
use of hypodermic injections of morphia and fomentations.
On Oct. 3rd she complained of swelling of the hands and
feet. This symptom, an actual oedema, lasted a few days,
but is not mentioned after the 7th. On the 22ud a dultiess
in the flanks and hypogastrium, obviously due to fluid in
the peritoneal sac, is recorded. This ascites was, however,
noticed a few days previously. On the 27th there was
much swelling of the left side of the face; it was accom¬
panied by an aching pain. On the 30th the face was still
swollen and the ascites had apparently increased. On this
day the tongue waa brown and dry and this symptom was
yet more marked on the Slat. On Nov. Ist there was
epistaxis, and this was repeated on the 3rd and 4th. During
these days the condition became distinctly typhoid. On
the 5th the patient was semi-conscious during the night
and part of the morning. Death occurred at 11.30 A.M.
The jaundice varied very little throughout the progress of
the case; at one time it is noted as being of somewhat
lighter colour, at another time as being darker. The
stools on Oct. 3rd are said to have contained bile for
the first time, and on the 6th to be more deeply; tinged, but
practically there was but little change in this symptom.
The urine on admission contained no albumen, but on
Oct. 10th, 14tb, and doubtfully on the 17th it contained
albumen. Subsequently the albumen again disappeared.
Throughout it gave Gmelin’a test for bile. In general it
was thick. On one occasion a dense greenish sediment was
observed; the urine on this occasion was examined for
leucin and tyrosin, but with negative results. The re¬
action was acid throughout. The vomit on Sept. 24th was
greenish with a coffee-ground admixture. On Oct. 10th the
vomit was colourless.
Necropsy .—The body was emaciated and uniformly
stained a dull brownish-yellow. The abdomen was pro¬
minent. The peritoneal sac contained a considerable
quantity of brownish-yellow serum, and this filled the
pelvis and the right hypochondrium. The left hypo-
chondrium was occupied by the distended stomach, and
the rest of the abdomen, front and flanks, was occupied bv
moderately distended intestines. The diaphragm stood high
on the right side. The liver was small and lay against the
spine; it was separated by a considerable interval from the
chest wall. The stomach contained a considerable quantity of
fluid, consisting in part of tarry matter. The walls were dotted
with black spots (hteniorrhag’ic). There was no ulceration.
In the duodenum was a similar fluid. The intestines (large)
contained pale greyish-white fmees. The mucous membrane
of the large gut was injected; its walls somewhat thickened.
■The liver weighed 31 oz, ; it presented (by gaslight) a dark-
brown mottled appearance, and on section the normal
lobulated structure was absent. Seen next day a fresh
section through the posterior parts of the right lobe showed
a mottled brownish-yellow appearance, whilst anteriorly
the right lobe and section through the left lobe showed a
reddish colour and a dense but to some extent lobulated
structure. The liver substance was very firm. Scrapings
718 Thk Lancet,] HOSPITAL MEDICINE AND SURGERY. [Mabch 28, 1891.
from tbe surface showed under the microscope much fatty
debris, with numerous cells in an advanced stage of fatty
degeneration. No crystals were seen. The portal fissure
was quite free from mucus. Tbe common bile-duct was
quite patent, a director passing easily into the bowel. Tbe
pancreas was extremely firm, almost cartilaginous in hard¬
ness,but otherwise quite normal in ^pearance. Kidneys (7 oz.
each) and spleen (ll oz.) were very firm. Thorax: There was
slight excess of fluid in the pleural sacs, with some collapse
of ^ngs posteriorly. Lungs emphysematous. Heart normal.
The microscope showed the almost complete replacement, in
portions of the liver, of the normal structure by a close
fibrous texture, which suggests a collapsed and thickened
meshwork, very rich in small nucleated cells. Here and
there in this fibrous texture were foci of round cells more
closely congregated. In other portions of the liver the
lobules of hepatic cells could still be seen, but the cells
showed an advanced fatty degeneration, and the lobules
were in many places much encroached upon by a dense round-
celled infiltration. Tbe pancreas was fibrous in appearance,
but there was no suggestion of new growth. The kidneys
showed nothing of note under tbe microscope.
Remarks by Dr. Sainsbury. —The points which call for
notice in this case are—1. The occurrence of jaundice in the
presence of a skin eruption, which in its characters was
strongly suggestive of specific disease, though no history of
infection was obtained. The relation between syphilis and
jaundice is admitted, and now and then what appears
to be at first a slight catarrhal jaundice becomes
rapidly developed into the symptoms of acute atrophy”
in time.'* 2. The presence of ascites without the dis¬
covery of any pressure on the trunk or main branches
of tbe portal vein. Query, was the acute round-celled in-
lilbration of the liver sufficiently widesmead and suffi¬
ciently acute to determine this dropsy ? Clinically it is of
interest to note that the accumulation of fluid in the right
hypochondrium noted at the time of the necropsy would
and did mark the diminution of the liver. 1 have not found
mention of ascites ss a complication of acute yellow atrophy,
and desire to lay farther stress upon it, because it raised
doubts as to the possibility of acute yellow atrophy, which
had been considered, and because for this reason the ex¬
amination of tbe urine for leucin and tyrosin was not made
systematically. .3. The enlargement of the liver on admis¬
sion. This was undoubted. 4. The absence of bile from
the stools, except in one or two instances. 5. Tbe appear¬
ance of albumen in the urine daring the progress of
the case, and then its disappearance. The other features
were the usual ones. The htemorrhagic tendency, how¬
ever, did not become marked till the last three days.
On Sept. 24th, soon after the patient’s admission, tliere
was some coilee-ground vomiting. The swelling of the
hands and feet and of tbe face I am unable to account for.
That of the hands and feet was not marked, and not
ermanent. The swelling of the face was painful in the
rst instance; it subsided subsequently.
GENERAL HOSPITAL, NOTTINGHAM.
A CASE OF CANCER OF THE PYLORUS ; GASTRO¬
ENTEROSTOMY; RECOVERY.
(Under the care of Dr. Brookhouse and Mr. Owen
Taylor.)
Evidence as to the amount of benefit to be expected by
a patient suffering from cancerous disease of the pylorus
who submits to the operation of gastro-enterostomy is
accumulating month by month. Although it is probable
that all the operations which have been performed have not
been brought before the profession, enough has been written
to prove the value of gastro-enterostomy in selected cases
for the relief of some of the symptoms wJiich cause most
distress. Mr. Page,’- in a paper read before the Medico-
Chirurgical Society, gave a series of thirty-six cases of the
operation j of tliese, fifteen were fatal directly or indirectly
from the operation; deatii -was usually from collapse.
In the first eighteen cases tliere were ten deaths, and
in the second eighteen only live deaths. We have pub-
Murchiaon, second edition, p. 2CU. Kco also J''aKgo (Principl of
Medicine) and Hutciiinson (Syphilis, p. 14r., caao of Dr. Wilks)
» The Lancet, vol. ii, 1689, p. 080.
lisbed accounts of six cases since the date of that paper.2-’
Of these, two recovered and four died. In the two suc¬
cessful oases Senn’s bone plates were used, and the opera¬
tion thus rendered of as short duration as possible j
further, in both feeding by the mouth was commenced at
very early date—on the second day. In this patient
success was also attained by means of a rapid aseptic opera ¬
tion and early feeding by the mouth, and the importance of
these factors in a successful operation must be fully reco¬
gnised. We need statistics showing the duration of life
Mter the operation. The account of the following case is
from notes by Mr. J. P. Gray, resident surgical ollicer
jr. G-, aged fifty-six, a miner, was admitted into*
hospital on Sept. 26th, under Dr. Brookhouse. For six.
months before admission he had suffered from digestive
troubles, pain after food, and occasional vomiting, which
gradually got worse. He was losing weight steadily. Nine
months before, he had been weighed and scaled 9st. 101b.,
and six weeks before admission he had only weighed
8 st, 10 lb. On admission he weighed 8 st. 5 lb. He is tu
small man, of sallow complexion, with a miner’s stoop, very-
thin. He takes food readily and with relish, but lias a.
dull pain all over tbe abdomen, and vomits about once a.
day, occasionally missing one day, and sometimes vomiting,
more than once a day. He generally brings up several
pints of frothy fluid, found to contain sarcinse. On examina¬
tion of his abdomen, a sausage-shaped tumour, the size of a.
hen’s egg, was found in the right hypochondriac and
umbilical regions, movable within small limits. The
greater part of tbe left side of the abdomen was prominent^
the bulging reaching as low down as midway between the
umbilicus and pubes, and extending across the middle line
with a lower curved edge leading up to the above-describedi
tumour. This area on percussion gave a stomach note, and
a succussion splash could also be obtained over it. The
diagnosis made from these signs was cancer of the pylorus^
with a greatly dilated stomach. His stomach was emptied'
and washed out with warm water once a day, with con¬
siderable relief to his uneasiness; but he steadily grew
worse in condition, and during one week lost close upon a.
stone in weight. Accordingly, on Oct. 26bb, the operation of
gastro-enterostomy with Seun’a plates was performed by
Mr. Owen Taylor. The patient then weighed only 7sb, 2ilb.
Before the operation his stomach was washed out with
warm water, and an enema of 1 oz. of brandy with 3 oz. of
water administered. There was nothing particularly worth
noting in the operation. The fingers of an assistant were-
found better than Makin’s clamps for holding the emptied
gut. Some little difficulty was experienced in tying the
two lower lateral sutures. Several Czerny-Lembert suturea
were also put in at the end. The patient took the A.C.E.
mixture badly, and had several hypodermic injections of
brandy during the operation, which lasted thirty-five
minutes. He was in a very critical condition after the
operation, and during the next day vomited three times,
the vomit consisting of dark blood with a strong fmcal
odour. For two days he was fed by enemata of pancrea-
tised milk with brandy and egg, with an enema of tepid
-water every morning. He retained them very well. On
tbe second day he had milk-and-water in teaspoonfuls, the
enemata being continued. On the third day Brand’s essence
was given in small quantities. By the ninth day he took,
everything by mouth, and the enemata were discontinued.
The stitches were taken out on tbe sixth day, and he made
a continuous recovery—interrupted, however, by the abdo¬
minal wound giving way and gaping for about two inches,
though it had been apparently healed in the sixth day.
This, however, gave rise to no serious symptoms. The
edges were refreshed and sewn up again. On the thir¬
teenth day he was put on meat and rice pudding. He gob
up three weeks after the operation, and was found to have
gained DUb. in weight. He was very constipated, but hie
f.-nces contained bile. The stomach reaches now to the level
of the umbilicus. He continued to gain in weight, and was
discharged in six weeks’ time, taking ordinary diet.
S Till-; Lancet, vol, ii. 1800. Mr. .lossott, p. 08; Mr. noatson, p. 70*2;
Mr. Oarko, p, TZlIi; The Lancet, vol. i. 18M, Mr. Ban-ow.
Guy’s Hospital.— Mr. Fred. Gowland Hopkins,
B Sc. Lond., has been appointed to the studentship in
pathology lately established at Guy’s Hospital by Sir
Cameron Gull in memory of his distinguished father, the late
Sir WilliaTn Gull.
Digiiized b/GoOglC
The Lancet,]
MEDICAL SOCIETY OF LONDON.
[March 28,1891. 719
MEDICAL SOCIETY OF LONDON.
The Administration and Use of Peroxide of Hydrogen.
An ordinary meeting of thisSociefcywasheld on March 23rd,
Mr. Keginald Harrison, Vice-President, in the chair.
Dr. B. W. Richardson read a paper on Peroxide of
Hydrogen and the Various Methods for its Administration
-■and Use, the first portion of which we publish in another
part of our present issue.
Mr. llicGiNALD Harrison, referring to the composition
and use of “sanitas,” which contained peroxide of hydrogen
in combination with turpentine, said that he bad found it
of much use as a bladder wash in cases of chronic cystitis,
especially after lithotrity and in instances where the walls
of the bladder were encrusted with phosphates. He usually
prescribed it diluted with from six to twelve times its
volume of water.
Mr. Bryant had had experience of the use of peroxide of
5iydrogen rather as a local application than as a medicine.
He had used it largely in ten-volume solution for the last
three years. The first case in which he applied it was
'one of suppuration about the scrotum in association with
tubercular testis. There were a great many sinuses, and
'the patient was old and refused operation. He repeatedly
injected a solution of five-volume strength into the sinuses,
■and a material came out which was at first like yeast, but
was afterwards quite clear. After using it three or four
times the sinuses closed and the patient got quite well.
The second case in which he tried it wag one of
isuppurating tracts in the gluteal region, following a
.^luteal abscess, in a middle-aged man who had no
rectal, vesical, or bone disease. The sinuses were long,
and led into the pelvis ; they were treated by the
ten-volume solution, and, after about half a dozen syring-
ings, in the course of four weeks the patient was quite wefi.
The third case was one of extensive sinuses running up
behind the rectum, and it was doubtful whether they com-
anunicated with the gut; this patient also made a good
recovery after injection. A fourth case was one of very
muraerous sinuses about the breast, which, being treated in
the same way, led to a similarly favourable result. Six weeks
ago he saw a young woman of twenty-four, who, after a
■chill, complained of pelvic pain, and was very ill with typhoid
■symptoms for a month. He found a large tumour springing
from the pelvis, approaching the umbilicus and causing
obstruction of the bowels. Under chloroform he made an
opening through the posterior cul-de-sac of the vagina, and
■evacuated more than a quart of fetid pus. He then thoroughly
lirrigated the cavity with the peroxide solution, and this
was continued regularly for some time afterwards. The
'temperature at once fell to normal; at the end of a week
'the drainage-tube was pushed ovit and she was at the present
ttime quite well. Such a result surpassed his greatest expecta¬
tions. He had found it also of great use in large spinal
■abscesses: it reduced the fluid which exuded from these to
■a condition almost like that of serum-—a result which he
had not found to be brought about by any other antiseptic.
Its especial value would certainly be found in the treatment
■of suppurating tracts and abscess cavities.
Dr. Little asked if the author believed the remedy acted
in angina pectoris by reducing spasm.
Mr. Stencer Wat.son said that it had been used in
America for the purpose of diagnosing suppuration within
'the antrum, a white foam filling the nostrUs if pus were
fliresent when the peroxide was introduced.
Mr. SitBiLD said that he lately used it with the best
iresults in a number of cases of putrid and ofi'ensive otorrhcca.
'lu one case of mastoid abscess it controlled the odour and
■reduced the discharge in a remarkable way.
Dr. Koutii had employed it in phthisis, in which disease
llie thought that it was as beneficial as cod-liver oil. He
had likewise given it in pneumonia where cyanosis was
■present, and had found it of much value in cases of exhaus-
'tion from chronic discharges or over-work.
Dr. KicirAinisoN, in reply, said that he thought Mr.
Bryant had alluded to the class of cases in which the per¬
oxide would be found most useful. Tliere could be no harm
in extending its application to cases of typhoid fever where
■there was persistent discboi'ge and much llatulence. .It
would likewise be safe to inject it into pulmonary cavities.
He administered it by inhalation in angina, which he
thought was perhaps a neuralgia rather than a spasm. It
was interesting to watch under the microscope the way in
which the peroxide produced disintegration of pus-corpuscles.
OPHTHALMOLOGICAL SOCIETY.
Tl\a Glands of the Ciliary Body in the Human Eye —
Hydrophthalmos.—Hunterian Chancre on the Oculcvr
Conjunctiva.—Operation for Ectropion.
An ordinary meeting of the above Society was held on
March 12th, the President, Mr. Henry Power, F.E.C.S.,
in the chair.
Mr. Treacher Collins read a paper on the Glands of
the Ciliary Body in the Human Eye. He first briefly
referred to the experiments of Deutschmann, Schccler,
UhthoiF, Leplat, and Nicati, as proving that the aqueous
humour and the nutrient fluid of the vitreous were secreted
in the ciliary region. He then described a method of
bleaching sections of the eye with chlorine. From the
examination of sections thus treated, he found that the
uveal pigment layer from the root of the iris to the ora
serrata was composed of a single row of somewhat flattened
cells, projecting from the outer surface of which were
numerous processes, each composed of a group of cells.
These were largest and most numerous at the junction
of the plicated and non-plicated parts of the ciliary
body, where they were pear-shaped. Examination of
sections of them cut transversely showed them to be
tubular, with a small central lumen. These tubular
processes, he thought, could be nothing else than
secreting glands concerned in the elaboration of the
aqueous humour and nutrient fluids of the vitreous.
So-called serous iritis be regarded as primarily a catar¬
rhal inflammation of these glands. The whole course
of the disease, he thought, pointed in this direction, and
the histological appearances of eyes lost from it were quite
in keeping with this view—there being some increase in the
size of the glands, some irregularity and proliferation of
their epithelium, enlargement of the bloodvessels in their
vicinity, and a variable amount of round-celled infiltration
about them. When inflammation of the ciliary body had
been of a more plastic character, there was considerable over¬
growth of its uveal pigment layer, in which overgrowth the
cells were arranged in the form of cylindrical tubes just like
tubular glands. He mentioned a case of tumour of theciliary
body described by Alt, which he regarded as an adenoma,
and another growing in the same region which he considered
to be a glandular carcinoma. The histological points referred
to in his paper were afterwards illustrated by lantern
slides made from photographs of microscopical sections.—
The President considered Mr. Collins’ paper was one of
very great interest, and proved that there were still parts of
the eye which would repay careful examination ; he thought
such an investigation as that described might lead to an in¬
crease in our knowledge of glaucoma.—Mr. Priestley
Smith referred to the early descriptions of the ciliary body,
and stated that Mackenzie as long ago os 1835 attributed to
it the function of secreting fluid into the vitreous and
aqueous chambers, which had since been confirmed by experi¬
ment. He suggested the advisability of using the term
“serous cyclitis” instead of serous iritis, as had been done
already in modern German works.— Mr. Jessov drew atten¬
tion to the difference in the character of the fluid obtained
from the anterior chamber by a first and subsequent tapping,
that obtained by the second tapping containing more proteid
material. —Mr., Coi.UNS, in reply, said that he had examined
a large number of glaucomatous eyes in reference to ciliary
body changes, andnad found no obvious alteration in the
glands described, except that in cases of long standing they
shared in the general atrophy.
Mr. F. R. 0UO.S.S (Bristol) read a paper on Hydroph¬
thalmos, in which he first made reference to recorded
cases and descriptions by writers of fifty years ago, and
commented upon the gradual development of knowledge of
the subject. In recent text-books but little space is given
to any variety of hydrophthalmos. Some authors deal with
the condition as only congenital, others as though its con¬
sideration could be adeqixately completed by treating it
under the head of “ secondary glaucoma.” Excess of intra-
Din T ze ' Goodie
720 ThbLanobt,]
MIDLAND MEDICAL SOCIETY.
[Maech 2&, 1893.
ocolar preeaure produces some expauaion in any healthy
Bclerotic coat, but the maximum of expansion is soon
reached. During the growth of the eyeball, and to some
extent up to early adult life, continuous high intra-ocular
pressure is accompanied by distension and thinning of the
nbrous coats, with stretching and modification of the uveal
tract and retina; while in later years, after senile and
retrogressive changes have occurred, the sclera resists
a high degree of intraocular pressure for months with¬
out progressive distension (P. E$mith). Glaucoma before
the age of thirty is rare, and before the age of twenty
extremely so. A few cases have been published, several in
eyes distinctly microphthalmic, and in others the corneal
measurement has been found below the normal standard
(11 to 12 millimetres, P. Smith). On the other hand,
hydrophthalmos almost always commences, whatever be its
cause, in childhood. It may begin in early adult life, while
the tissues of the eye are still extensile. It never com¬
mences in middle life, but when it is protracted to this
period the symptoms tend towards the glaucomatous type.
Anything which causes excess of blood in the eye, venous or
arterial, or imperfect lymphatic outflow, tends to raise the
intra-ocular pressure, and such conditions produce in the
adult eye glaucoma, in the youthful eye hydrophthalmos.
Dufour regards the condition as one of primary glau¬
coma, and he accounts for the open filtration angle and
deep anterior chamber by weakening of the zonule of
Zinn, and yielding of the corneo-scleral ring, thus allowing
of easy passage of the intra-ocular fluids, and an egutu
pressure in both aqueous and vitreous chambers. The
author considers that the cases apparently congenital
in origin may depend upon error m development, or
upon intra-uterlne inflammation, but thinks that in some
the morbid condition really commences after birth, or may
be a true primary glaucoma during childhood, and that
undoubtedly many which can only be classed as hydroph¬
thalmos are true cases of secondary glaucoma, traumatic or
otherwise. Several observers have described the micro¬
scopical characters found in bupbtbalmos, but the patho¬
logical changes are probably as much the result of intra-ocular
pressure as its cause. The primary seat of inflammation
seems to be in the ciliary body, at the base of the iris, with
implication of the limbus cornece and the flltration channels.
Weakness of the zonule, distension of the lens capsule, and
lenticular trouble might also easily arise, with modification
of the intra ocular fluids, and interference with their proper
transudation. Diirer and Schligtendal, in a recent account
of the microscopical examination of five eyes affected
with congenital (so-called) hydrophthalmos, draw special
attention to the condition of ^e uveal tract. In all
these cases both choroid and ciliary bodies were found
markedly atrophied ; the vence vorticosae were extremely
narrowed in their passage through the sclerotic, while their
tributaries in the supra choroidea were dilated and varicose.
In some of the cases dilatation of the large veins and atrophy
of the tissues alone existed, whilst in th^e others there was
distinct evidence of inflammation, especially in the region of
the posterior aqueous chamber. Increased vascularity and
round-celled infiltration were found in the corneo-scleral
margin. Schlemm’s canal, Fontana’s spaces, and the anterior
ciliary veins were usually narrowed or obliterated. The term
“ buphthalmoB ” should only be applied to cases in which the
prominent cornea is surrounded by a thinned blue-tinged
sclera, while the term “megalophtbalmos” might be retained
for cases in which the hypertrophied staring eye is otherwise
normal. The history of the case will determine when it
should properly be called congenital. Mr. Cross read his¬
tories ot two cases of hydrophthalmos, one associated with
a high degree of myopia, the other dependent on blockage of
the filtration angle by a dislocated lens ; and of five cases of
buphthalmos (the exaggerated form of hydrophthalmos), one
probably congenital, one commencing in early life, and
three secondary to iris bomh6, or perforating wounds of the
cornea.—Dr. Argyll Kobertson remarked that under the
heading of ‘ ‘ hy dropb thalmos,” Mr. Cross included cases which
differed in some particulars, although they had in common
the distension of the anterior parts of the eyeball. He
mentioned a family under his care in whom the mother and
three children were affected with this disease ; in one child
the condition was unilateral.
The following living cases were shown :—
Mr. Lang : Hunterian Chancre on Ocular Conjunctiva.
Mr. Tweedy : Eesulfe of Operation for Ectropion of
Lower Lid following hum.
At the general meeting held subsequently it was resolved
that the date of the Bowman lecture be altered from
November to the first Thursday in July, subject to the dis¬
cretion of the Council. Also that an illuminated address
be presented to Professor Helmholtz congratulating him oo
the attainment of his eightieth birthday, and acknowledging
the value of his services to ophthalmic science. Mr.
Tweedy moved a resolution, wnich was carried, to the'
effect that, in view of the extension of the curriculum to five'
years, the subject of ophthalmic surgery should be made
compulsory, and a committee was nominated composed of
aat-presidents of the Society and representatives of thes
cotch and Irish Universities to urge the matter on tb.«t
Medical Council.
MIDLAND MEDICAL SOCIETY.
A MEETING of this Society was held on Wednesdayij
Feb. 18bh, W. Ross Jordan, MR.C.S., in the chair.
Aphemia. —Dr. T. Stacby Wilson showed a man aged
fifty-one who was Buffering from a third attack of Aphemia.
The first attack, which occurred in 1885, was accompanied
by a slight degree of word blindness, and he remained abso¬
lutely dumb for eleven months. He then suddenly and
completely recovered his speech, and remained perfectly
well till January, 1890, when he again lost his speech. On
this occasion there was, just as during the first attack,
much headache and some fever. He regained his speech in
thirteen weeks, however, thanks to a sudden fright that he
bad. He lost his speech for the third time last August in
just the same way as on previous occasions, and his present
condition is one of absolute mutism, although in the posses ¬
sion of all his other faculties. Dr. Stacey Wilson pointed
out that the case at the present time might be considered
to be practically one of hysterical mutism, and that some
sufficiently powerful and correctly directed external stimulus
was all that was necessary to put the patient’s motor speech
centre once more under his control.
Rodent Ulcer of Eyelids. —Mr. WOOD White exhibited a
man aged fifty-three who, five years before, had been struck
on the upper eyelid by a piece of wood. The wound never
healed, but, according to the patient’s statement, “ seemed
to ulcerate and go on wasting.” It continued thus fox
two years before it spread to neighbouring parts. All
previous wounds healed readily. Nine months ago the
man was first seen by Mr. Wood White. The eyelids wer®
then much thickened and infiltrated, especially near their
margins. The palprebal aperture was reduced in size and
the eyeball pushed backward, but there was no sign ofi
ulceration. The patient was again seen a week ago, when
the appearances were much altered. The infiltration had
spreaa upwards as far as the eyebrow, and downwards fo7
some distance over the cheek. Its margin was well defined,
and it left the skin in an atrophied and scarred state, bui
there was still a remarkable absence of ulceration.
Foreign Body in the Eyeball. —Mr. Wood White showed
a patient who had received a penetrating wound of the eye¬
ball from a piece of bell metal. The vitreous was perfectly
clear, and the details of the fundus could be well seen. The
foreign body was adherent to the retina on the inner side a
short distance behind the ciliary processes, and was project¬
ing into the vitreous; the reflex from it was bright and
glistening. It had been in the eye for several days, but
there was no sign of redness or inflammation. Bell metaJ
being a composition of iron, brass, and glass, and the piece
being firmly fixed in the globe, the electro-magnet had not
been used.
Deformity of Pelvis. —Dr. PuRSLOW showed a patient
with Rickety Deformity of Pelvis, for whom he had per¬
formed craniotomy in the out-door maternity of the Queen’s
Hospital. She had been in labour twenty-four hours.
Version had been performed by the obstetric house-surgeon
who had been called to the case two hours previously, and
when seen by Dr. Purslow the feet of the child were pro¬
truding and the cord pulseless, hut the bead was not engaged
in brim ; the occiput was lying to the left side. The head
was perforated behind the right ear and delivered by th®
aid of the crochet, though not without difficulty, after
evacuating the brain. The patient made a rapid recovery
without a single bad symptom. The diagonal conjugate
measured by the hand while the patient was under chloro ¬
form = 35 in. True conjugate, allowing for shape of pubes,
nob more than 2^ in.
Paper. —Dr. FoxwELL read a paper on the Ilear.t
Murmurs in Anremia.
O
The Lancet,]
REVIEWS AND NOTICES OP BOOKS.
[March 28, 1891. 721
Itc&itfos flfltias of “^oob.
Hypnotism. By Dr. Alrert Moll (Berlio). Contemporary
Science Series. London : Walter Scott.
Hypnotism, or Psycho-Therapeutics. By R. W. Felkin,
M.D., F,R.S.E. Edinburgh and London: Young J.
Pentland.
Should Hypnotism have a Recognised Place in Ordinary
Therapeutics? By Norman Kerr, M.D., P.L.S.
H. K. Lewis.
• [First Notice,]
The literature of hypnotism grows apace. We have here
three brochures upon the subject, and, whatever reserves
nay remain in our mind, there can be no doubt that their
perusal is calculated to elucidate many obscure problems,
to enlarge our conceptions of the action of mind upon
physical function, and to place forcibly before us the claims
which hypnotism is now loudly making for recognition both
in the domain of psychology and of therapeutics. The
impartial reader will probably rise from their perusal feeling
that the time has gone by when the facts of hypnotism
<50uld be legitimately questioned, and that what now
remains is rather the interpretation of those facts and the
•determination of their due relation to the science of mind
and the art of healing.
Dr. Moll’s'work, which is much the most thorough and
•elaborate of the three, is the production of a thoroughgoing
adherent and enthusiastic exponent of the doctrine and
practice. Dr. Felkin’s shorter and slighter work is also
almost wholly favourable in tone; while Dr. Norman Kerr’s
pamphlet, which is a reprint of the address delivered by
him at the last meeting of the British Medical Association
fin Birmingham, is an emphatic protest against the admission
of hypnotism within the recognised domain of therapeutics,
We shall notice the three in turn, and shall aim at present¬
ing a fair risumi of the facta and deductions of their
authors, rather than at assuming any dogmatic position of
our own. While the subject of hypnotism cannot be called
oew, it nevertheless presents many and peculiar difficulties,
and we see nothing to regret in the attitude of reserve
which has hitherto been maintained towards it by the
medical profession in this country. If we could say what
mind is and what body is, and what are their relations
the one to the other, then the phenomena of hypnotism
might admit of a ready explanation; bub these ques¬
tions are really insoluble in the present state of our
knowledge, and the solutions which are offered are verbal
only. Hence if hypnotism often bailies us and defies
our attempts at a thorough analysis, this is only what,
from the nature of the case, might have been fairly
expected.
Dr. Moll opens with a historical review of the subject,
and points out that while traces of hypnotism can be found
among the ancient Egyptians and other Oriental rations,
and while it and kindred phenomena were studied by
Paracelsus and Van Helmont in the Middle Ages, universal
attention was first drawn to the subject by Mesmer
(1734—1815). The career of Mesmer is characterised by a
curious medley of science and chicane, and into its merits
and demerits, successes and failures, we have not space to
enter. Mesmer believed in animal magnetism and in
metallo-therapeutics. His well-known haquet at Paris (a
sort of oak chest or tub, with appendages of iron) was sup¬
posed to be magnetised by him, and to be able to give forth
virtue of itself. Several commissions sat to consider the
doctrines of Mesmer, and their reports were in the main
hostile, most authorities attributing the alleged phenomena
solely bo the operation of the imagination. In Germany
"animal magnetism" was studied by Lavaber, Wienholt,
Heineken, Bockmann, Gmelin, and others. Selle of Berlin
admitted the genuineness of some of the alleged pheno¬
mena, bub excluded all that was supernormal (clairvoyance).
Two currents of thought on the subject were perceptible,
one critical and scientific, the other mystical. Early
in the present century the Abb6 Faria, in his teaching
in Paris, practically anticipated the modern doctrine of
hypnotism when he showed that no unknown force was
necessary for the production of the phenomena; that the
cause of the hypnotic sleep was in the person who was to be
sent to sleep; that everything was subjective. In England
the chief name is that of Braid of Manchester, who about
the year 1841 induced cataleptic conditions by making the
patient fix his eyes steadily upon some object, and who first
gave to these phenomena the term "hypnotism.” Braid
was inclined to draw a distinction between hypnotism and
mesmerism. A little later Grimes in America expounded
similar doctrines, and gave to the states produced the
term "electro-biological.” Modern hypnotism, with its
doctrine of the influence of "suggestion,” dates from
Licbeault, who became the founder of the Nancy school,
and whose work, entitled "Du Sommeil,” published in
1866, contains the germs of all recent theories upon the
subject. In 1878 Charcot began his public classes, in which
he directed attention to the physical states of hystero-
epileptics during hypnosis. Since that time Bernheim,
Beaunis, and Li6geois in France, Van Reuberghem in
Holland, Webtersbrand in Stockholm, Forel in Switzerland,
and Heidenhain, Berger, Weinhold, Opitz, and many others
in Germany have occupied themselves with the subject.
Recent investigations have taken one of two directions—
viz , the determination of the place and value of hypnotism
in therapeutics, and the utilising of it for the founding of
experimental psychology.
The general phenomena of hypnotism and the various
methods of inducing the hypnotic sleep are passed in review
by Dr. Moll, bub are probably sufficiently familiar to our
readers. We may draw attention to the fact that the
school of Nancy proceed by the method of "suggestion”
rather than by the procedure of Mesmer or Braid—i.e.,
the various hypnotic phenomena are "suggested” to
the patient by verbal descriptions, and no attempt is
made to fatigue the senses by fixed attention, revolving
mirrors, or the like. It is important to distinguish
these two methods, which are fundamentally distinct.
The former attains its end by physical, the latter by
psychical means. The latter, or the method of Lidbeaulb,
is said bo be free from some of the unpleasant after
phenomena which sometimes accompany the method of
Braid. When the latter plan is adopted, certain stimuli
are applied to the senses of sight, hearing, and touch.
Taste and smell have been rarely tried, and have generally
given negative results. A revolving mirror, the ticking
of a watch, the sudden ray of the Drummond light, the
loud noise of a gong, contact with hob plates of metal,
are among the means that have been adopted. It is
always a question, when these physical agents are em¬
ployed, whether the effects are due to the agents them¬
selves or to the patient’s belief in them. Dr. Moll states
that “he knows of no well-authenticated case in which
sense stimulation has produced hypnosis by a purely phy¬
siological action. Most people upon whom such experi¬
ments are made know that an attempt is being made to
hypnotise them ; they have been already hypnotised, and
the stimuli arouse conscious or unconscious mental images
of the hypnosis; or they have seen the same experiments
with others, or they have heard of them.” This remark
touches the crucial point of hypnotism, and indicates the
adhesion of Dr. Moll to the doctrine'of the Nancy school,—
Digitized by ^ lOOQle
722 Thb Lancet,]
ROYAL COMMISSION ON TUBERCULOSIS.
[March 28, MSI.
viz., that “ suggestion ” is at the bottom of all hypnotic
phenomena.
Dr. Moll in his third chapter gives the Symptomatology
of Hypnotism with great minuteness, but we cannot follow
him into all the interesting physiological and psychological
questions which he raises. Among the most striking
features of hypnosis are the subjection of the voluntary
muscles to external suggestion, the loss of the power of
voluntary motion, rigidity of the whole body on the one
hand, or on the other that peculiar condition to which the
term “ flexibilitas cerea ” has been applied, various contrac¬
tures ; the phenomena of imitative speech (ecbolatic), the
patient repeating what is said to him like a phonograph;
sense delusions of various kinds, hypnotics being made to
drink ink for wine, to eat onions for pears, to smell ammonia
for eau de Cologne, &c. The senses of touch and taste are
said to be those most easily iniluenced. The mucous mem¬
branes can be made ancesthetic by suggestion in hypnosis to
such an extent that the fumes of ammonia in the nose and
tickling of the throat are not felt; even the conjunctiva
can be touched without producing the corresponding reflex.
The muscular sense can also be inhibited in hypnotism, the
patient resembling a sufferer from locomotor ataxia. Com¬
plete analgesia is exceedingly rare in hypnotism accord¬
ing to Dr. Moll, although it has often been regarded as
common.
The influence of hypnotic suggestion upon the various
physiological functions is a very curious subject, and some
of the alleged facta are novel and startling. Krafft-Ebing
claim to be able to prodnee any temperature he pleases
in his patients by suggestion. Heidenbain and Preyer
claim to have succeeded in controlling the secretion of
urine. The perspiration and the saliva are also said to
be under the influence of suggestion. Local reddening
of the skin, slowing of the action of the heart, &c., have
been said to be similarly affected. Startling as are such
assertions, it can hardly be said that they present any a priori
impossibility. It is quite impossible to assign any limit to the
influence of mind upon body, which is probably much more
potent and far-reaching than we are usually prepared to admit.
Even more startling statements follow. We are informed
that under the influence of hypnotic suggestion blisters can
be made to rise upon a patient if be can be made to believe
that a blister has been applied to him. Marks like burns
are said to have been produced by pressing such objects as
a snuff-box or a pair of scissors to the akin, the patient
being told that the skin was being burned. Various
bleedings are said to be capable of being produced by
suggestion. Wheals, redness, and swellings are said to
have followed the slightest pricks to the skin when the
patient had been led to expect them.
NoUs on the Examination of the Sputum, Vomit, Fmces,
and Urine. By Sidney Coupeand, M.D., F.K.C.P.
London : H. K. Lewis.
It has been aptly remarked that time is short and
practical medicine is long, only a very small portion of the
art being acquired even in a lifetime. It is all the more
essential therefore that “Note8’'purporting to give informa,
ticn on that subject should be at once for the most part com¬
prehensive, concise, accurate, and arranged in such a form
as will aid the student to retain them in his memory. Tliese
characteristics will be found in the “Notes ” contained in
the present little volume, for which the autlior modestly
“lays no claim to any originality either in the subject
matter or»in the form in which it i,s presented.” We think,
however, that the work shows great originality, and more
particularly in avoiding the practice so usual in students’
note-books of condensing the print and not the matter.
The work deals with everything connected with the sputum,
vomit, fmces, and urine which a student or practitioner
ought to know, and will form an excellent book of directions'
for those who are about to be examined on the subject of
practical medicine. _
ROYAL COMMISSION ON TUBERCULOSIS.
To the Editors of The Lancet,
7, Whitehall-place, London, S.W., March 16th, 18W.
Sirs,—W ill you be good enough to find a place in your
columns for the enclosed copies of letters and questiont
papers which have been forwarded at the request of thie
Commission by tbe Local Government Board to the medical)
ofilcers of health ?
1 am. Sirs, your obedient servant,
Leopold Hudson, Secretary.
7, Wbitehall-pUce, London, S.W., February, 1891.
Sir,—I am requested by the Commission to state that
they will feel very much indebted if the President of the'
Local Government Board will cause the enclosed question
papers to be forwarded to the medical officers of health of
the United Kingdom, together with a note commending;
them to their consideration.
The Commission was appointed on the 2l8t July, 1890,
“ to inquire and report what is the effect, if any, of food
derived from tuberculous animals on human health ; and,
if prejudicial, what are the circumstances and conditions
with regard to tbe tuberculosis in the animal which produce^
that effect upon man.”
The Commission have pursued this investigation up to a.
certain point and are engaging in certain experiments.
They also desire to ascertain by inquiry through the medicali
officers of health of the United Kingdom whether any ex¬
perience has been obtained by local medical observers that,
may throw light on the subject referred to the Commission.
Any experiences of the medical officers will be particularly
valued, if they will be good enough to reply to the questions,
on the enclosed form. The Commission will also be obliged
if they will kindly forward a copy of these questions to any
practitioner in their neighbourhood who they think may
be able to furnish information of the kind needed.
I am, Sir, your obedient servant,
Leopold Hudson, Secretary.
To tJie Secretary, tho Local Coveniment Board.
Local Government Board', Whitehall, S.W., March ICth, 1801.
Sir,—I am directed by the Local Government Board to»
forward to you the accompanying copy of a letter from the^
Royal Commissioners on Tuberculosis, expressing th eir desire
to enlist the cooperation of medical oflicevs of health in
collecting information on the particular points specified in
the memorandum of which copies are also enclosed ; and li
am to state that the Board will be obliged by your affording
any assistance in your power to tbe Royal Commissioners iit
the important inquiry which they have undertaken.
Information on the subject, furnished by yourself or by
any medical practitioner in whose hands you may think it.
useful to place a copy of the memorandum, should be com-
municatea to the Secretary of the Commission, 7, White-
hall-place, London, S.W.
I am, Sir, your obedient servant,
Hugh Owen, Secretary.
To Medical Ofliccr of IlealUi.
7, Whitehall-place, London, S.W.
Medical practitioners are invited to record for the in¬
formation of tho Commission any observations that they’
may have made on the apparent communication of tubercle*
from animal to man or from man to animal.
Information is asked for under the following heads
1. —A history, with particulars, of any case of tuber¬
culosis in man which has appeared to the observer to-
be caused by the use of tuberculous food (meat or
milk) or by attendance on tuberculous animals.
2 . —A history, with particulars, of any case of tuber¬
culous infection of animals which has appeared to
tbe observer to have been contracted from human,
subjects suffering from tuberculosis.
3. —A history, with particulars, of habitual use ol'
animal food believed by the observer to be tuber¬
culous in cases whore individuals or communities-
have kept free from tuberculous disease.
Replies to this inquiry will be received by Mr. Leopold
Hudson, secretary of the Commission, at the above address.
February, 1891.
Dici.lzed by CjOO^Ic
The Lancet,]
THE ROLL OF THE PROFESSION
[March 28, 1891. 723
THE LANCET.
LONDON: SATURDAY, MARGE SS, 1891.
The Registers of the profession have made their appear¬
ance a little earlier than usual. Last year they were not
issued till April 17th. This year we received them on
March 18th. In 1887 they were as late as April 29th.
We must be thankful for the improvement in respect
of time. But there is room for more. It is probably
less the fault of the registrars than of the publishers;
but it is clearly somebody’s fault that public docu¬
ments of great importance do not appear till nearly a
quarter of the year is over. There are great lessons to the
profession to be derived from a study of these Registers,
which we may briefly indicate. First,- they constitute the
great and official roll of the profession. There are other
compilations of great interest and with a value of their
own, but for official and legal purposes, unless a practitioner
finds his name here be is a private and non-medical person.
Our first inquiry is as to the numbers of the profession.
In the Medical Register itself there is no falling off.
Perhaps when we come to the Register of Medical
Students we may see indications of a recognition of the fact
that the profession is overstocked and that young men are
perceiving the fact. But in the Medical Register of the
31st December, 1890, there were no less than 29,163 names.
This exceeds the number registered on the same day in the
previous year by no less than 815 !—a startling addition to
an already excessive quantity. When we come to inquire
into the details of the explanation it may seem a little
less startling. But still the fact remains that 29,163 are on
the Register for this year, against 28,3-18 in the previous year.
They are not all pure additions—that is, names added for
the first time to the Register. Of such fresh names there
is a little falling off in the last year. In the three divisions
of the kingdom—England, Scotland, and Ireland,—there
were respectively 637, 462, and 107 added by registration,
or 1266 in all, as against 657, 444, and 204, or a total of
1305 in the previous year—a dilFerence of diminution of
thirty-nine new registrations. There is a clause (14)
in the Medical Act which empowers the Registrar,
after certain fruitless inquiries, to remove names; and
in some years hundreds of names are removed, in others
hundreds are restored under' this clause. In 1889 no less
than 407 were so removed; last year the number was
only 82. PrsLctitionets so removed often apply for restora¬
tion, and in last year 105 names were restored, against 82
in the previous year. Clause 14 gives oscillation to the
numbers on the Register, which must be considered in
estimating the real additions by registration for the first
time. We have seen these werelesstlian in the year before
by 39, and less than the average of the last five years by
78. So the additions, as compared with the previous year,
are nob quite so alarming, when they come to be analysed,
as at first sight they appear to be. But as a matter of fact,
there is a greater number of names on the Register for
1891 than there had been in any previous year, and
doubtless represent an excess of the actual wants of the
empire.
There are three or four ways by which men disappear
from this roll of the profession which demand a few sen¬
tences. Happily those erased for evil behaviour only
average two a year. Hundreds, as we have said, may be
removed by carelessness in intimating changes in address.
Some men cease to practise. It will surprise men of more
lucrative and lemurely callings to learn that seven prac¬
titioners a year on an average so withdraw from the Medical
Register. There remain the removals by death. And here
we find the Registrar’s figures most satisfactory and most
unsatisfactory. Satisfactory as showing so healthy a state
of the members of the profession; unsatisfactory as show¬
ing that the Registrar and Dr. Ogle are at serious
variance as to the mortality of medical men. The
removals from the Register by death have been only
467, which for the numbers in the previous Register
(28,348) give a mortality of something over 15 per 1000.
Dr. Ogle, a few years ago, gave the mortality of medical
men as 25 in the 1000. We can scarcely doubt that the
actual mortality of the profession exceeds 467, in spite of
the Registrar’s great pains to be accurate; but we are
disposed to believe that it is not nearly so high as
Dr. Ogle’s statistics seemed to prove.
A novelty in the Medical Register is the Colonial
Register. But our readers need not be unduly alarmed.
It contains only two names—viz., those of two graduates of
the University of Melbourne, one resident in Melbourne
and one in London. Coming to the Register of Medical
Students, it contains much material of interest, but we have
only space to notice the supply of medical students, and the
principal sources whence it comes. We find a falling off
in each division. In England there were 974 registra¬
tions, in Scotland 613, in Ireland 229, in all 1846; as
against 1039, 702, and 286, in all 2027, in the previous year.
The number is less than in any of the previous twelve years,
except 1883, when it was 1783. We must not too hastily
conclude that the rush into the profession of late years
has'been really stayed. The commencement of medical
study may either be at a medical school, or a hospital or
infirmary, or by pupilage with a medical practitioner.
It is interesting to note with regard to this latter method
that it is followed by 140 of our new students. Cam¬
bridge, in England, has the largest number of registered
students, 104. Edinburgh, in Scotland, has 244, the largest
number of any school. In Ireland the largest number is in
Queen’s College, Cork.
The Dentists’ Register contains 4802 names of dentists
who hold diplomas from bodies in the United Kingdom,
and fifteen from foreign sources, of which six are from
Harvard University and nine from Michigan.
The next meeting of Convocation, on May 12th—when
the Draft Charter, prepared on the basis of the latest revised
scheme, will be laid before the members for their acceptance
or rejection—will be one of the most important in the history
of the University of London. The Draft Charter, as well
Digitized by LjOOQle
724 Thb Lancet,] : THE LATEST SCHEME OF THE UNIVERSITY OF LONDON.
[March 2S, 1891.
as the scheme, will be circulated amosf'et them before
the meeting, so that every member may become acquainted
with the latest proposals. It will simply embody the details
of the scheme which we published on Feb. I4th, and on it a
vote of yea or nay will be taken. It must be understood
that it will be impossible to alter the proposed Charter by
rejBcting any of its clauses or by the introduction of any
others; it must be accepted or rejected en bloc. The
question, then, which Convocation most decide, in the
first Instance—for, if accepted, it will still be contested
by University and King’s Colleges before the Privy
Council,—is whether the graduates are willing to com¬
pletely transform the character of the University in a
manner at once at absolute variance with the traditions of
the existing University and with the proposals for its
reform which were suggested in the report of the Royal
Commission. In that report the necessity of a local metro¬
politan University was specially insisted on, whilst the latest
scheme is really an attempt to federate all the University
Colleges of arts and science throughout England and 'Wales
under the control of Burlington Gardens. Even in so doing
it offers these Colleges a very insudicient representation
on the Senate, and an unworkable set of regulations for
their faculties and boards of studies. Eight representatives
on a Senate of fifty-two meeting in London will be quite
unable to give effect to any special action affecting the pro¬
vincial interests, and, if not sufficient to do this, the repre¬
sentation of provincial Colleges, except through Convocation,
is useless, and only seems to give a power which is really
not possessed. The proportionate representation of Convo¬
cation is greatly reduced in the new scheme. But of much
more importance to the medical profession and to our readers
are theclauses dealingwithfuture medicaldegrees in London.
For the past seven or eight years we have urged the neces¬
sity for the removal of the disadvantages under which the
London medical student labonrs in regard to the ohtaln-
menb of a medical degree as compared with the oppor- '
tunities enjoyed by students at other centres of medical
education, and we had hoped that the report of the
Royal Commissioners, pointing out that the present pass
degree of the University of London was really an
“honours” degree, would form the basis of some satis¬
factory plan for bis relief. Bat the present scheme
simply lowers the existing standard for the Pass M.B.
degree by accepting the professional examinations of
the Royal Colleges in lieu of the Intermediate and
Pass M.B. Examinations, which are not really the
barriers to the degree. Ib still maintains the Matri¬
culation and Preliminary Scientific M.B. Examinations
on the old footing. So far back as 1881 it was
pointed out to the Senate of the University that the
two preliminary examinations were those which required
modification, hue since then these have been allowed to
become even more difficult, and it is further intimated
that this standard will undergo no change. Where, then,
is the relief? And if no relief, why should the existing
status of the degree be disturbed ? The new scheme only
divides the responsibility for pass degrees by admitting the
Royal Colleges to an equal share, so far as professional
subjects are concerned, and quite fails to amend the
unfair position in which London medical students are
placed. It gives the Royal Colleges a position to which the
Royal Commission would nob assent, and it practically
preserves the present conditions at the expense of the
students. It is stated in an explanatory memorandum
published by the Senate that the opinion was unanimously
expressed by the representatives of the Royal Colleges
and of the medical schools, “ that nothing should .be
done which should lower the standard or lessen the
value of the medical degrees of the University, or impair
their scientific character;” but this scheme lowers the
standard of the degrees without increasing the facilities
for obtaining them. We also hear that the medical schools,
except those of University and King’s Colleges, have
given in their adhesion to the scheme, although “no
alteration is now made in the degree of M.D.,” which there¬
fore remaius an “ honours” degree. We cannot believe that
the various committees of the medical schools, of whose
members many were especially concerned in the promotion
of the movement for obtaining degrees for London medical
students on equitable terms, have really passed resolutions
in support of such an unreasonable scheme, which, if the
application for the Charter be successful, will prolong
for another gen'eration the present disparity between the
terms on which London and the Scotch and provincial
students respectively can obtain degrees. The advan¬
tages of studying at the largest clinical schools in the
world will not compensate for many of the disadvantages
under which the students will labour in after-life; no fair
chance ot obtaining a degree is afforded to them.
It will probably take some time to settle in a satisfac¬
tory manner the various points of difference enumerated by
Sir Andrew Clark in his recent letters to the War
Minister on the present condition of the Army Medical
Staff and the reforms by which it would be benefited.
The medical officers are never likely to have their case put
, forward more fully and forcibly than Sir Andrew Clark
has done; and we probably cannot do better than point
out, as brieily as we can, how the matter stands at present
between him and the War Minister.
The grievances of which the medical officers complain, not¬
withstanding their connexion with questions of social and
professional position, are by no means of a purely sen¬
timental character. A principal cause of complaint, the
duration of continuous foreign service, is eminently prac'
tical in its bearings. Ib will be remembered that the period
of five years was in 1888 extended to six. What is asked
for is a return to the five years’ system—a reform already
advised by Lord Camperdown’s [Committee. The medical
officers, says Sir Andrew Clark, ask for the shorter term
of continuous foreign service. Mr. StanhoI’E promises he
will consider what he can do to meet their wishes in this
respect, but is doubtful whether such a concession will be
considered a boon, as the shortened periods of foreign
service would mean more frequent changes, and, as a con¬
sequence, some additional expense to the ollicers concerned.
As regards conditions of sick leave for medical officers,
Mr. Stanhope also makes the necessary concessions. Bub
from this point there is considerable divergence in the
views expressed on either side. Take, for instance, the
Digitized by
Google
The Lancet,]
SIR ANDREW CLARK ON THE ARMY MEDICAL STAFF. [Maecii 28. 1891. 725
question of the allotment of honours. On the one hand,
we find H.R.H. the Comraander-in-Chief, supported by a
group of distinguished olKeers, declaiming against the excess
of honours lavished upon medical men. On the other, we
have the official statements in which the rewards reaped by
medical officers for service in the field appear bub as a fraction
of those enjoyed by other members of the same force. Thus
in the Egyptian campaign of 1882, while the percentage of
decorations to the regimental strength in the Ordnance and
Commissariat Departments combined was 84, that in the
Medical Staff was 7. In connexion with the Nile Expedi¬
tion two years later the value of services rendered was
acknowledged by promotions in the proportion of 44 in the
case of chaplains, 41 in that of pay officers, 30 of Ordnance,
and 13'8of Commissariat officers, while the medical depart¬
ment added but a lean total of 7 9. The higher decorations
—namely, those of the Bath, the Star of India, the Order of
Sb. Michael and St. George—have strayed at times to the
breast of the military surgeon j but their presence has
been of conspicuous rarity. Sir Andrew Clark gives an
effective table, comparing fhe honours bestowed upon the
Royal Engineers with those conferred upon the Medical
Staff. Sir Ralph Thompson’s Committee in 1878 noticed
the marked inequality between the medical and the
combatant officers in this particular, and advised that the
former should be treated as virtually combatant. It is
needless to add that the recommendation was forgotten.
In view of such facts and opinions as these we fail to
understand what is meant by the term “excess” as
applied to the rewards of the Army Medical Department.
Mr. Stanhope alleges that honours cannot be made a
matter of proportion, and urges that the fact of the
Engineer honours being “ for the moment in excess of those
enjoyed by the Medical Staff,” in no way lessens the force
of his statement; and he adds that if the rewards con¬
ferred upon Engineers in civil and colonial employ and in
high command be eliminated, the two lists, of Engineers
and Medical Staff, are not disproportionate. But, even so,
Mr. Stanhope does not touch upon the other illustrations
cited by Sir Andrew Clark.
We come now to deal with the question of substantive
rank. This subject has been treated with much vigour
by Sir Andrew Clark, who maintains the position
already ‘ ‘ supported by the experience of the armies of Italy,
Switzerland, Holland, Turkey, the United States, and of
several other countries, by the opinion of all the medical
corporations of the United Kingdom, by the conclusions of
almost all bodies of men who have judicially investigated
the question, and even by the approval of a rapidly
growing number of combatant oilicers ”—namely, that
the army medical officer, having to discharge every military
duty except actual fighting, must be confirmed in his posi¬
tion by some fitting rank and title. Mr. Stanhope, on
the other hand, declares that the claims put forward
and the parallel instituted between the Corps of Royal
Engineers and the Medical Staff are based upon mis¬
apprehension; that a Royal Medical Staff Corps with
definite rank and title to all its officers, and its organic
incorporation into the general army on the lines followed
in the case of the Royal Engineers, can only carry one
meaning to his mind (that of military command whenever a
medical officer happened to be senior in the field); and that
medical officers already possess the requisite limited
command by virtue of the substantive rank conferred on
them by their commissions. If this be so, it is to be
regretted that it was not made plain. Instead of the
words “ with ” or “ as,” the medical officer’s position might
have been described and defined at the time of relative rank
‘being abolished by the use of the words “with the rank of”
so and so—captain, major, colonel, as the case might be.
Officers of the medical branch of the service have in¬
dubitably the same claims to consideration as have those of
any other branch of Her Majesty’s service, and it Is an
anachronism in the present day, to say the least of it, to
make any of those distinctions which Sir Andrew Clark
emphatically says are made between the treatment accorded
to them and other officers. Sir Andrew Clark cites in
illustration, the cases of Surgeon-General Sir Anthony
Home and Surgeon Reynolds, both of whom won Victoria
Crosses for conspicuous bravery.
We have never had any doubt that the Army Medical
Staff could be welded together into a corps, and that,
if necessary, its officers could he endowed with army
or substantive rank equivalent to and conterminous
with their sphere of duties. What we have contended
for, however, is that so long as these officers are members
of the medical profession and in the pursuit of their
calling—and we hope proud of their professional status
—they should retain some distinctive title expressive of
the profession to which they belong. We would protest
against the assumption that the profession of medicine is
in need of any reflected dignity. It has every bit as much
title to respect as the profession of arms.
We referred last week to the experiences gained up to
the close of last year in the use of Koch’s tuberculin by
the leading physicians of Northern Germany, as embodied
in the lately issued official reports. In completing that
account of the medical use of the remedy, a brief reference
may be made to what is especially said concerning its
employment in tuberculosis of the larynx and other internal
organs. Respecting laryngeal tubercle, Professor Senator
reports good results, and notes in one case the marked relief
given to painful deglutition during the use of the remedy,
but the difficulty returned when, owing to cardiac weakness
and extension of lung disease, the injections had to be
discontinued. Professor Schultze (Bonn) observed in
some cases that the first injections produced a hoarseness of
voice not previously noticeable, whilst ulcers became
covered with exudation and their bases cleansed. He
could report no cure—a statement repeated by many
others, as Biermer (Breslau), Mosler (Greifswald), Weber
(Halle), and Lichtheim (Kfinigsberg). Still most, if
not all, admit marked signs of improvement in the
character of the ulceration, and Professor Fraenkel
(Berlin) is of opinion that the action of tuberculin on the
larynx is more rapid than it is upon the lungs. Dr. P.
Guttmann, who treated upwards of thirty cases of all
kinds, varying “from simple infiltration to extensive
ulceration and perichondritis,” observed favourable effects in
i all, especially in the slighter cases. But he noted actual
Digitized by uooQle
726 The lancet,] THE DIAGNOSTIC AND THERAPEUTIC VALUE OF TUBERCULIN. [March 28,1891.
eicatriaatlon of ulcers. It is noteworthy that he expresses
an opinion that the fearii of exciting a dangerous cederna
globtidis by the action of tuberculin are groundless. Pro¬
fessor Fraenkel thinks the laryngeal ulcers improve more
rapidly than they do under local applications; and Professor
Barth (Marburg) observes that pain and cough abate after
a few injections. As regards other organs there is little to
be said. The remedy has been applied in comparatively*
few cases, and of the majority of these it is reported that
they are still under treatment. Dr. Olshausen thought the
ascitic effusion of abdominal tuberculosis became rapidly
absorbed under the remedy. Yetthelistof “cures” embraces
only one case of pleurisy and one of abdominal tuberculosis.
Four casds of renal tuberculosis are all returned as “unim¬
proved.”
Passing from the medical to the surgical clinics, it is at
once patent that there is not quite so much diversity of
opinion respecting the value of the remedy among the latter
ae in the former. Thus, as to its use as an aid to diagnosis,
M'e find Professor voN Bergmann considering that it is of
much value in discriminating a tuberculous from a syphilitic
or cancerous affection ; Professor voN Braman (Halle)
alleging that it is apparently a certain test of the presence
of tubercle ; and Professor VON Esmarch (Kiel) expressing
an opinion that it is of great service in the diagnosis
of lupus and bone and joint disease—especially because
of the fact that cases of early disease react the
best. In a similar sense speaks Professor Braun
(Konigsberg), who thinks the remedy has extended the
powers of diagnosis, as establishing the tubercular
nature of affections not hitherto recognised as such,
and as determining whether a tuberculous process is cured
or not. Professor Ki/STER (Marburg) holds it to he a marked
aid in diagnosis, although he failed togetreaction in certain
cases of fistula, and yet observed reaction in a case of
lupus erythematodes. Professors II. Kohler andWESTPiiAR
think it surpasses all other measures, and that its specific
powers are indubitable. Professor Lewin (Berlin) and
Professor Doutrelepont (Bonn) also express their high
appreciation of its value. Exceptions to the production of
reaction in undoubted cases of tubercular disease are, how¬
ever, noted by several—e.g., Professors Bardelehen and
A. Kohler, —who think that such occasional failures may
be explained by variations in individual susceptibility or in
the preparation of the remedy. Professor Trendelenburg
(Bonn), whilst admitting its practical value in the detection
of tubercular foci, notes that it is especially uncertain in
tubercular disease of the testis. Still, he has used it with
advantage in the differential diagnosis of vertebral caries
and effusion into the knee-joint, as well as in the early detec¬
tion of renal tubercle. Professor Mikulicz (Breslau) notes
the various degrees of reaction that may be observed, some¬
times a general reaction being present without any local
effect ; in such eases the diagnosis of tubercle rests mainly
on the intensity of the febrile reaction. He has no
doubt tubercle may be excluded if neither general nor
local reaction develops. Professors Konig and Hildebrand
(Gottingen) consider that, in view of some undoubted
cases of tuberculosis not showing any reaction, one ought
not to estimate its diagnostic powers too highly. Pro¬
fessor Helfericii (Ureifswald) seems to be in doubt
whether itis an absolute test. ProfessorNEissER (Breslau),
who believes in its diagnostic value—negatively as
well as positively—thinks that general reaction without
local effect may imply the presence of concealed internal
tubercle.
The surgical cases in which tuberculin has been used for
its therapeutic effect comprise mainly lupus, bone and joint
disease, disease of lymphatic glands, and a few cases of
tubercular ulceration of soft parts or of cicatrices. There
is practical unanimity regarding the striking effects pro¬
duced in lupus, more than one observer recording what
ho considers a complete cure (there are five such out
of a total of forty cases discharged from hospitals, but
148 remained under treatment), although, as Professor
Doutrelepont remarks, sufficient time has not elapsed
to exclude the possibility of a recurrence. Opinion is
less unanimous regarding the value of the injections in
tuberculous bone and joint disease. Professor v. Bergmann
stands alone, however, in the assertion that they seem to be
wholly without effect (wir/cung'slos) in such conditions.
Professor Trendelenburg found no clear result from the
use of the remedy, and noted that cases of suppurating
joints were made worse. But both he and most of the
other surgeons seem to have had cases of more or less
marked improvement, especially when it was employed as an
adjuvant to more radical surgical measures. The truth is
that comparatively few opportunities seem to have occurred
for testing its efficiency in the earliest stages, and just as
in phthisis, so in joint and bone affection, the disease was
already complicated when it had been subjected to the
treatment. Professor v. Braman thinks that the super¬
vention of suppuration is a clear indication for surgical
intervention.
The general impression resulting from the perusal of these
surgical experiences is that sufficient has been shown to
justify the further careful trial of the remedy ; hut that in
justice to its powers the cases should he selected with dis¬
crimination. The volume contains also reports from various
pathological institutes giving the post-mortem appearances
in fatal cases. This aspect of the question has, since these
reports were drawn up, been so fully gone into by Professor
Virchow that we do not propose to enter upon it now. It
will, however, have to be maturely weighed and considered
in connexion with the question of the indications and con¬
traindications for the use of so powerful a remedy as
tuberculin. These are questions which may well be left
over for a space, and the debate which will shortly take
place at the German Congress of Internal Medicine will
doubtless throw more light upon them than can be gained
from the brief experiences recorded in these official reports.
The following notice has been issued from the Foreign
Office:—“With reference to the notice which was com¬
municated by the Foreign Office to the newspapers on
Jan. 16bh respecting an outbreak of typhoid fever at
Florence, Her Majesty’s Consul.General in that city reports
that the epidemic is now declared to be at an end. A few
isolated cases may still occur, but nothing more than is
usual in a population of 200,000 inhabitants. The condi¬
tion of the water-supply is occupying the urgent attention
of the local authorities, and there is evoiy reason to believe
that a satisfactory solution will shortly be arrived at.”
Digitized by LyOOQle
Trb Lancet,]
THE ROYAL COLLEGE OF PHYSICIANS
[March 28, 1891. 727
“ Ne quid nluti."
THE ROYAL COLLEGE OF PHYSICIANS.
The Extraordinary Comitia held on the 23td inst,, to “elect
President, pursuant to Act of Parliament 23 & 24 Vic.,
cap. IxvL,” was very well attended. The preparation of a
mew edition of the By-laws and Regulations of the College
was entrusted to a committee consisting of Dr. Church, Sir
Dyce Duckworth, SirH. Pitman, Dr. E, Liveing, Dr. Marsii,
4 ind Dr. Allcbin. The report of the Committee on the
Midwives’ Registration Bill was presented, and on the
nnotion of Sir R. Quain, seconded by Dr. Barnes, it was
received and entered on the minutes. The report, which
w’as favourable to State registration, suggested that the
<Jeaeral Medical Council might be entrusted with the task
of framing regulations. On the motion of Dr. Champneys,
seconded by Dr. Barnes, it was resolved to have the report
printed and circulated among the Fellows, with a view to its
iurther consideration. .A communication was read from the
Association of Certifying Factory Surgeons, asking the
College to take immediate action to prevent the passage of
dause 19 of the Factory Acts Amendment Bill now before
Parliament, which clause abolishes the granting of medical
■certificates for children and young persons engaged in work-
abopa. It was decided to leave the matter in the hands of
'the President to take such action as he might think fib. On
the motion of Sir Joseph Fayrer it was resolved to give a
reception to the members of the International Congress of
‘Hygiene, which will meet in London in August next. Sir
Andrew Clark then delivered the annual Presidential
address. He said that during the past year 11 Fellows and
@ Members had died, and that on January Isb of the current
year the College comprised 299 Fellows, 466 Members 8
Licentiates (prior to Dec. 1860), 30 extra-Licentiates, 4832
Licentiates, and SODiplomatesia Public Health. He referred
to the baronetcies conferred on Sir H. Acland and Sir R.
4iuain, and the Court appointments of Sir A. Garrod and Sir
Dyce Duckworth. He stated that the total outlay incurred
by the College for the new buildings and laboratories on
the Embankment amounted to £31,044, that the labora¬
tories were now fully etjuipped and in working order, and
that it was estimated the annual working expenses of
the institute would be about £1000. He paid a warm
tribute to the admirable work of Dr. E. Liveing, who “ has
f>roved himself a worthy successor of our revered Emeritus
Registrar, Sir H. Pitman”; and next proceeded to sketch
in felicitous language and with much discrimination and
Reeling the careers of the folio ving deceased Fellows : Dr.
A. Lochee of Canterbury, Dr. A. J. Pollock, Dr. Fincham,
Dr. Matthews Duncan, Dr. C. Handheld Jones, Dr. Graham
Balfour, Dr. G. Gulliver, and Dr. Markham. A review of the
•affairs of the College during the past year, including especial
Teference to the reconstitution of the University of London,
<5oncluded an address characterised throughout by much
eloquence and clear thinking. It was received with much
applause, and the motion of the Senior Censor (Dr. Russell
Reynolds), according thethanksof the College to Sir Andrew
Glark, coupled with the request that ho would allow his
address to be printed, was carried by acclamation. The
election for President then took place. Sir Andrew Clark
received 96 votes out of the 103 Fellows present, the
R-emaindcr being divided betw’eon Sir B. tjuain, Dr. Wilks,
Dr. Bristowe, Dr. G. Johnson, and Sir A. Garrod.
ACCIDENTS UNDER AN/ESTHETICS.
TitKRE are various contingencies against which no amount
of forethought or care can guard, and perhaps this is more
emphatically true of the use of anesthetics than of almost
any other domain of the healing art. Although the most
careful thought has been given in the choice of the agent to
be used, and all the preparations of the patient and the
operating-room have been properly made, yet what, for
want of a better name, we call an accident talces place,
I and all calculabiona are thtown out. We do not here
j include accidents which can be referred to any given
ancesthetic, since no authoritative decision can be yet
quoted as settling the vexed question, Which is the best
and safest anaesthetic ? Opinions differ, and so each
medical man has to decide for himself. But when epileptic
seizures, vomiting of hard masses of food, «&c., occur, it
matters little what agent has been employed — the
results are the same. , These remarks are illustrated
by some cases the reports of which have been recently
placed before us. At Chelmsford a blacksmith, who
was an epileptic, fell while in a fit, and burnt his
arm so severely as to necessitate amputation. Chloroform
was administered and the operation commenced, but an
epileptic seizure took place and the man died, the “cause
of death being epilepsy and syncope.” The occurrence of
epileptic fits tinder anaesthetics—nitrous oxide, chloroform,
ether—is not uncommon, but as a rule is not followed
by a fatal result. The knowledge of the existence of
epilepsy in a patient, while it emphasises the necessity
for caution, does nob contraindicate the employment of
an anaesthetic. In the case of the death which occurred
at University College Hospital, the patient, a young man,
had been seen in the early pait of the day and carefully
instructed to abstain from food, as he was to present him¬
self for a trilling operation in the evening of the same day.
He was asked, before the house physician administered
ether, whether he had obeyed his directions and replied in
the affirmative. It appears, however, this was nob true, as
he had just before going to the hospital partaken of a hearty
meal. Theoperationov6r,vomibingcameon, and as the patient
became cyanosed the finger was passed to the back of the
pharynx and dislodged a mass of meat. The symptoms
were nob relieved, and suffocation appearing imminent,
laryngotoiny was performed, bub without success. The
necropsy showed that another wedge of meat had been
drawn into the trachea and become fixed, occluding both
bronchi. Here only to the victim could blame be imputed.
A METHOD FOR RETAINING ARTIFICIAL
DENTURES.
One of the great discomforts of artificial dentures where
all the teeth have been lost and much absorption of the
gums has taken place is the constant tendency for them to
slip forwards. To overcome this difficulty Mr. Wm. Dali
of Glasgow has developed a method of fixing dentures by
means of two or more gold pins attached to the under¬
surface, which enter holes either made by drilling the jaw¬
bone or left after the extraction of a tooth. In the former
case the gum is first painted with a 50 per cent, solution
of cocaine, and the holes are drilled by means of the
dental engine. In the lower jaw any place may he chosen
between the symphysis and the mental foramen, and in the
upper almost anywhere, care, however, being taken nob to
pierce the floor of the antrum. Koch’s solution is used
as an antiseptic at the time of operation, and also
prescribed as a mouth-wash during healing. The den¬
ture is applied a few days later, and is of course
to be regularly removed for the purpose of cleaning.
He believes that the bone forming the walls of the socket
becomes sclerosed, and that there is little danger of necrosis.
Where the holes or sockets result from the extraction of
teeth the gold pins have simply to be fixed to the denture,
and in all cases it is important that they should be parallel.
During the last three years Mr. Dali has drilled ten cases
Dig::'zjd by Cooglc
728 The Lancet,
THE SANITARY STATE OF SOUTHEND.
[Mabch 28', 1891.
in all, seven in the upper and three in the lower jaw, and
in only one indammaiion followed by suppuration occurred,
and this quickly subsided. In fifteen cases dentures were
inserted with pins entering the sockets of extracted teeth.
Two cases were shown at the Odonto-Chirurgical Society of
Scotland exemplifying this method of treatment. This
operation can hardly be considered analogous to wiring
bones together, as was suggested during the discussion of
Mr. Dali’s paper, for this is done under antiseptic conditions
impossible in the mouth, and, moreover, every effort is
mside to keep the wound aseptic afterwards, whereas in
drilling the sockets are left open. Some objections to the
operations are the risk of opening up the antrum or the
inferior dental canal, and the difficulty of keeping the
sockets clean. _
THE SANITARY STATE OF SOUTHEND.
The Local Board of Health of Southend seem in no
hurry to take the steps necessary to the removal of the
reproach which now attaches to their town. Since the
serious epidemic of enteric fever of last autumn we have
had reports from one and another, and also the exhaustive
account of the circumstances associated with the fever
which Dr. Thresh issued after his special commission to
inquire into the causes of the outbreak. Then came the
failure to re-elect the past medical officer of health, and
now, at the moment of the Easter holidays and within
about four months of the next summer season, we find
Mr. £. Phillips, the new medical officer of health, making the
old suggestion over again—namely, thatit is of the greatest
importance that the sewage of the lower town should be
dealt with. Twice a day the tide enters the sewer, and the
resulting reflux of sewage must be prevented if healthiness
is to be maintained. The view held by tbe health officer
may be judged of from his evidence in a recent trial which
was tbe outcome of an attack of enteric fever, due to un-
wholesome conditions in a sublet house, and in which he
laid stress on the “especial ” need in even distant parts of
Southend of preventing the sewer air forced in by the tide
from getting into houses. But with all this before the
Local Board, the latest recommendation is still the first one
that was made—namely, “ the sooner a skilled engineer was
employed . the better it would be for the place.”
DIABETIC RETINITIS.
In the Deutsche Medicinische Wochenschrift, Nos. 51 and
52, 1890, Dr. J. Hirscbberg publishes the results of his in¬
vestigations on the affections of the retina which occur in
connexion with diabetes mellitus. There are three chief
forms : (1) A peculiarly characteristic infiammation attack¬
ing the central region of tbe retina, accompanied by small
bright spots, and generally also by minute bjemorrhages;
(2) bfcmorrhagea into the retina, followed by inflammatory
and degenerative changes ; (3) a rarer form of inflammation
with degenerative changes. The connexion of this condition
with diabetes baa yet further to be investigated. Inflam¬
mation of the retina occurs in patients of middle age,
or in those more advanced in life who have had sugar
in the urine for some considerable period. It gene¬
rally affects both eyes, and the earliest symptoms are
bright specks appearing before the eyes, difficulty in
reading, and general indistinctness in viewing small objects.
Tbe acuity of vision is therefore diminished, but the field of
vision is normal, although dark spots often occur in the centre
of it. When the fundus is examined by the ophthalmoscope
groups of small white shining spots are seen between the
superior and inferior branches of the central artery, and
others are seen close to the optic disc, being most numerous
on its inner side. These spots gradually grow larger and
form narrow streaks or curves, but star-shaped collections
are never seen. No pigmentation occurs. Minute heemor*
thagic points and streaks are observed surrounding the
bright spots j ust referred to. The complete escape of tbe
optic disc is remarkable, as is also the absence of any consider¬
able cloudiness of the retina, or any very marked changes in
the vessels. In this respect diabetic retinitis differs from the
albuminuric form. The former is an exceedingly serious con¬
dition, as there is little probability that the disturbances of
vision will disappear, and it also denotes that the primary
disease (diabetes) is severe and deeply rooted. Spon¬
taneous bremorrhages in the retina occur, being due to
changes in the vessels, as atheroma is a frequent conse¬
quence of diabetes. Small round patches of hemorrhage
are then seen, if attainiug any size, beingaccompaniedwitlli
cloudiness of the vitreous, hemorrhagic glaucoma, and
hemorrhagic infarcts in the retina. These hemorrhagic
affections of the retina are less characteristic of those
occurring exclusively with diabetes as those described above,
but the prognosis is even more grave, not only as regards
tbe length for which sight may be prolonged, but also in
reference to the time the patient will probably live.
DEATH FROM SWALLOWING CHLOROFORM.
A SAD case is reported from Abingdon. According to a
local paper, a youth aged twenty was tempted, while sufi'er-
ing from ill-health and under the dread of a forthcoming
examination, to take chloroform, and, it would appear,
actually swallowed some three ounces. Although emetics
were given and vomiting induced, the unfortunate
young man died. Tbe drug seems to have been taken
soon after 7 A,M., and death took place at 9.15 a.m,,
in spite of the assiduous efforts of his medical attendants.
The effects of chloroform taken into the stomach are now
well known ; the symptoms ate similar whether the vapous
is inhaled or the liquid swallowed, save that in the latter
case there is an irritant action superadded to the narcotic
and anaesthetic effects occurring in the former.
INTERNATIONAL MEDICAL CONGRESS IN
BERLIN.
We have been asked to announce that it has been foun<I
more convenient that copies of the Transactions of tho
International Medical Congress should be distributed by an
English firm instead of being obtained direct from Berlin.
Arrangements have been made with Mr. Kolckmann, of 2,
Langham-place, for their sale, and for free distribution to
members on payment of a nominal sum for carriage.
Country members can have them forwarded on application.
Non-members can obtain them at the net price at which
they are published in Berlin. Volume 1. only is at present
published ; the rest will follow at short intervals.
EPSOM COLLEGE.
As an indication of the good work being done in Epsomi
College the following facts may be mentioned. Last year
the school passed six boys through the preliminary scientific
examination for the degree of MB. of the University of
London; sixteen passed through the London matriculation
examination, and eight passed last January. In July, 1890^
seven boys (all who entered) obtained higher certificates in
tbe examination of the Oxford and Cambridge Board, and
since Jan. Ist three open scholarships have been gained,
two directly from the school—one at Cambridge of £30 fo?r
natural science, and one of £80 at Oxford for classics. It ha»
become necessary for tbe Council to consider the question of
extending the school accommodation. Those interested in
this important charity should not forget the proposal made
by Dr. Holman, the treaanrer, at the last festival to enable
the pensioners to have augmented incomes, with residence
Digitized by Google
The Lancet,]
THE FAVEKSHAM POISONING CASE.
[Maech 28, 1891. 729
tLtBODgst their friends. This should not be lost sight of,
and fresh endeavours should be made at this time to meet
the appeal of the treasurer to secure fresh donors and fresh
eubscribers to the institution as a whole, so as to enable
the Council to undertake these pressing responsibilities
and to extend the advantages offered by the school.
THE FAVERSHAM POISONING CASE.
After a trial which lasted four days, Charles Lyddon,
aged twenty-eight, was ac(iuitted on the 21et inst. of the
charge of murdering his stepbrother, William Keeks
Lyddon. The case had been removed from the Kent
Assizes to the Central Criminal Court by writ of certiorari.
The deceased had practised as a surgeon at Faversham for
twelve years. For two years be had been assisted by the
accused, who was to receive £50 a year for his services. It
appears that the salary was not paid. Partly to cover this
debt and partly to secure some creditors of the deceased’s
estate, a covenant was executed in April, 1889. By this
instrument the deceased became indebted to his brother in
a sum of £550, secured by the goodwill of the practice and the
household furniture, but it did not contain the usual restrict¬
ing clause preventing the deceased from practising in the
vicinity of Faversham. It was contended hy the prosecution
that the desire to possess himself of the amount guaranteed
fey the deed was the motive of the accused for taking the
life of the deceased. The evidence revealed a most painful
history of intemperance, for It established that not only the
•deceased but his mother and the accused were addicted to
drink. The deceased seems to have been a confirmed
drunkard, and from the testimony of several witnesses there
could be little doubt that he also indulged in narcotics:
From June to August, 1889, the deceased was an inmate of
St. Thomas’s Hospital, where he was treated for fistula.
In October, 1890, at the suggestion of Dr. Boswell, he went
to the Cottage Hospital at Faversham, where he remained
for about three weeks. Subsequently he went to Herne Bay,
and from there he returned home on Nov. 24th. The fol¬
lowing day he was dead. From the evidence of a boy named
Naylor, employed as a page by the Lyddon^, it appeared
that there were frequent quarrels between the deceased and
his brother, when either or both of them were under the
Influence of liquor, but that at other times they lived on
mutually affectionate terms. On the night precedingbisdeath
the deceased was made by the accused to sleep in a lumber
room, a circumstance which had not previously occurred.
In this room he was locked by the accused, who slept with
the boy Naylor. At 7.30 the following morning the deceased
was found in a state of coma, partly dressed, on the floor
•of the room. When discovered neither the accused nor
iris mother appears to have assisted Naylor in removing
•deceaeed to Mrs. Lyddon s bedroom, but this may be
accounted for by their thinking him helplessly drunk, a
condition not hy any means unusual. Two local medical
men were called in, and from their previous knowledge of
the life led by the family, and also from the circumstances
surrounding the death of Mr. Lyddon, very properly refused
to give a death certificate. The accused sent for the police,
and offered them every facility in searching the house. In
the room occupied by the deceased overnight a bottle,
tightly corked, containing some morphia, was found. From
an analysis of the contents of the stomach and the liver,
Dr. Stevenson was of opinion that death was due to morphia,
and that from seven to eight grains of the drug had been
administered. Although on thenightpreviouslytohisdeath
•deceased was very drunk from whisky-drinking, none was
detected in the stomach, but there was a quantity of fluid.
From the latter fact the prosecution suggested that some
liquid had been given to the deceased hy another person
It was not proved, however, that he could not have obtained
it himself. Moreover, it u by no means certain that during
the process of osmosis the spirit may not have entered the
circulation, leaving the watery constibnent in the stomach;
or the latter may possibly have transuded from the gastric
vessels into the viscus. At any rate, the physiological pro¬
blem was too complicated to afford grounds for rendering
the guilt of the accused even probable. In due course an
inquest was held at which the accused was examined and
cross-examined on oath. During the lifetime of the deceased
the accused had on various occasions and to different people
complained of the former giving way to the abuse of drugs;
and Dr. Hill of Colchester and Dr. Boswell of Faver¬
sham had both seen deceased in a condition consistent
with the theory that he was under the influence of narcotics.
Then, too, no attempt at secrecy was made by the accused
either on the night before the death or subsequently. His
conduct was not that of a person about to perpetrate the
crime of administering a fatal dose of morphia to the
deceased. The coroner's jury returned a verdict making
the brother chargeable with causing the death. Consider¬
ing that an inquest is a court of first instance equivalent to
a grand jury, no fault can be found with the event of the
inquiry; bub it was manifest to most who studied the
evidence that it would fail to bring to the minds of the
jury at the Criminal Court the conviction that the accused
was guilty “beyond reasonable doubt.” To the verdict
we unhesitatingly subscribe.
LEPROSY IN NEW SOUTH WALES,
The Government of New South Wales have placed on
the statute book an Act providing for the notification of
cases of leprosy, for the detention and isolation of lepers, the
appointment of lazarets, &e. The Act (54bh Viet. No. 20)
re quires that the immediate notification of any case of leprosy
be made in writing to the proper authorities by the house¬
holder and medical practitioner in attendance on the case,
under a penalty of not less than £10 or more than £50.
Power is given to the governor to direct the formation of a
lazaret for the reception and treatment of lepers, to the
board of health to investigate reported cases, and to order
the removal and detention of the leper. Kegulations may
be made and issued by the governor, on the recommenda¬
tion of the board of health, to carry the Act into effect, and
penalties are imposed upon any person who wilfully dis¬
obeys or obstructs the enforcement of such regulations.
THE RELATION OF BACTERIOLOGY TO NOSE
AND THROAT DISEASES.
At a meeting of the British Laryngological and Rhino-
logical Society held on Friday evening, the 20bh inst.. Dr.
John Macintyre of Glasgow gave an interesting lecture,
introductory to the discussion on the relation of bacterio¬
logy to the diseases of the throat and nose. In the course of
his lecture Dr. Macintyre discussed the general facts con¬
cerning bacteriology, such as classification, vital pheno¬
mena, &c., and stated the arguments for and against the
vitalistic theory of disease. He demonstrated a large number
of specimens of well-known forms of micro-organisms under
fhe microscope, as well as numerous micro-photographs on
the screen, and made special reference to those of interest
in throat and nose work. He showed several found in the
mouth and nose of healthy people, which ate apparently
harmless, and others found in diseases where there is decom¬
posing material such as in ozmaa. He referred to the
specific forms found in diseases of the lower part of the
respiratory tract, as tubercle, lupus, diphtheria, pneu¬
monia, and suppurative diseases. Lastly, he discussed the
question how protection was to be gob from the diseases asso¬
ciated with micro-organisms, noting the result of inoculation,
and criticised the theory of phagocytosis. He explained some
.oogle
Dig:.,.:ed L
730 The Lancet,]
TREATMENT OF DIPHTHERIA.
(March 28, 1891.
inteiesting experiments now being made in Glasgow with
reference to the hypodermic injection of chemically pure
carbolic acid, which bid fair to demonstrate the possibility
of rendering the elTects of certain pathogenetic micro¬
organisms inoperative within the body. In considering the
possibility of rendering the tissues unsuitable for the growth
of organisms after their entrance into the system, he cau¬
tioned his audience not to be carried away too hastily by
Koch’s or Liebreicb’s methods of treatment for tuberculosis.
TREATMENT OF DIPHTHERIA.
Db. Guntz of Dresden has had great success in the
treatment of diphtheria with bichromate of potash in water
containing carbonic acid, which he has found by numerous
experiments on animals, as well as in the course of extensive
clinical observation, to be entirely harmless. For an adult
600 grammes (about a pint) are ordered per diem, in which
are dissolved three centigrammes (about half a grain) of
potassium bichromate. The whole quantity is directed to
be taken in about half a dozen doses, regarding which it is
important to observe that they must not be taken on an
empty stomach ; a little milk or gruel should therefore be
swallowed before each dose. Children, of course, take
smaller quantities, according to age. They can be given
the medicine in a tumbler mixed with some fruit syrup,
and they do not generally object to it. At the commence¬
ment of the disease Dr. Guntz washes the mouth out with
a 1 per cent, solution of permanganate of potash containing
OT per cent, of thymol, or with a corrosive sublimate
solution of the strength of 1 in 3000, taking care, in
the latter case, that none is swallowed, and that the mouth
is well rinsed with water afterwards. In the case of young
children the pharynx must be brushed out with the solution.
Sometimes iodoform is employed, being applied on the tip of
the finger to the affected spots. Dr. Guntzspecially remarks
that potassium bichromate, though harmless in the way
described, is by no means so when in pills, powders, or in
solution in non-carbonated water.
STRUCK BY LIGHTNING.
A MOST curious and interesting case is recorded in the
Boston Medical and Surgical Journal by Dr. L. M. Palmer.
It is that of a man who, while mowing with a two-horse
mowing machine, was apparently struck by lightning, while
the off horse of the team he was driving was instantly killed.
The men who were working near him said that he did not
fall from his seat, but that bis head simply tipped backward.
When first seen by Dr. Palmer his pulse was 100; respira¬
tion 40 per minute and stertorous; the pupils were dilated;
eyes fixed and staring; conjunctiva insensible to touch ;
and there was general muscular rigidity. He was treated
by hypodermic injections of brandy and ammonia, and at
the same time was briskly rubbed, and his condition soon
changed to that of constant restlessness. He had some
bromide of potassium, and in an hour and a half was able
to be moved in an ambulance waggon. On arriving home
he vomited, and during the next few days he had several
similar attacks. He passed a restless night, but became
quieter in the early morning, when he for the first time re¬
cognised his friends and surroundings. On careful examina¬
tion on the day after the accident there was found a gash in
the occipital region an inch and a half long down to tlie bone;
the hair between the cut and the neck had been destroyed,
and he had a burn in the left scapular region 7 in. by 9 in.
There was a blister along the under part of the right arm
and a deep burn below the elbow over the fleshy part of the
forearm. No mark could be seen beyond this. The crown
of his straw hat was completely destroyed. He made a
slow recovery, being troubled with noises in the head, deaf¬
ness, a feeling of confusion, loss of memory, and general
prostration. The right hand and arm were almost power¬
less, and be suffered from pain in the lumbar region and
genitals. In eleven days be was able to sit up; in ten weeka
he could once more drive a team, but even so long as fourteen*
weeks after the accident he was weak, walked as if he had
lumbago, his right hand and arm were weak, and he had
tenderness over the nerves of the right arm and forearm,
and in the lumbar and gluteal regions; he also had great-
loss of memory. Looking at the serious and unusual nature
of the accident, it is not surprising that his recovery haa
been slow, but as improvement seems still to be taking place.
Dr. Palmer hoped that it would be complete.
TRANSITORY BLINDNESS IN WHOOPING-COUGH,
In the New York Medical Journal Dr. Jacoby has
recently drawn attention to the occurrence of this condition
in two cases which he has observed. In the first case there
was inaction of the pupils to light, and they were widely
dilated; there was also optic neuritis. In the second
case the reaction to light was retained, the media were
clear, and the fundi normal. As the blindness was
gradually recovered from, a condition of right hemianopsia
was present in one case. The author regards the condition
as due to codema of the brain, but it is well to remombqr
that in children this disease is not uncommonly accompanied
by convulsion, a condition probably analogous to the
sudden temporary loss of consciousness which occurs in the
adult, and it may be that all those conditions are associated
with some toxic blood state, a result of the morbid process.
Both cases recovered. _
DEFORMITY OF THE HEAD IN MYOPATHY.
M. Marie has recently described the case of a child who»
was suffering from progressive myopathy, and in whom there
was considerable bead deformity. The antero-posterior
diameter was IGGmm., the transverse 168mm., giving a
cephalic index of 101. As the usual cephalic index is about
80, the limit in negroes being 88’5, it will be recognised
that the departure from the normal was considerable.
Another case was referred to with a cephalic index of 89-7.
The explanation offered is that there is some osseous con¬
dition associated with the muscular one, and that the
position which the patient has to assume accounts for the
deformity in the bones. _
THE HOUSING OF THE WORKING CLASSES.
The delegates from some of the London vestries and
district boards have held another meeting at the Paddington
Vestry Hall, and have adopted a report as to the conditions-
which render a house so dangerous or injurious to health as>
to be unfit for human habitation. This report divides
houses into two classes—those which can he repaired, and
those which are incapable of repair; and, furthei', it states
that the housing of the working class contemplates this
distinction. We do not, we roust confess, know upon what-
evidence this last statement rests. Undoubtedly, the Act
provides for repair and demolition, but for both the house
must be closed. The statement in the report, however,
appears to indicate that this is not all. The attempt to
specify particular structural defects is a mistake. The Act
does not deal with houses technically unfit for habitation,
but with houses actually in such a condition as to be-
dangerous in a degree which renders them unfit for such-
habitation, a point which can only be decided after the localJ
cireumstancea of the premises have been taken into account.
The only two resolutions of any practical importance which
were adopted were one by which it is claimed that where*
an improvement scheme under Part II. of the Act is carriedl
out, to which both County Council and district authority
Dic!...ied by ' ■ lOO^Ic
The Lancet,]
THE TUBERCULOSIS INQUIRr.
[March 28, 1891. 731
have contributed, the land acquired shall be vested in
the district authority; the other that the owner of a house
should be informed, at the time of service of the first
notice, if it is the opinion of the local authority that the
house cannot be made fit for habitation.
THE POPULATION AND BIRTH-RATE OF
FRANCE.
The diminishing birth-rate of France is attracting atten¬
tion from more points of view than one. In a remarkably
interesting paper by Mons. Monod, Director of the Public
Health Department in the Ministry of the Interior at Paris,
entitled “Les Mesures Sanitaires en Angleterre depuis
1875 et leurs K6^ultats,” the late Lord Beaconsfield is first
quoted in a passage M'here he refers to the decadence of
nations in connexion with causes such as the population
remaining stationary in point of numbers, and it is then
pointed out that if France were saving life to the extent to
which England has done since our modern sanitary
administration took general effect 130,000 lives would be
annually spared to our neighbours. Another document has
recently been issued from the same Government Depart¬
ment, and in the opening address by Mons. Brouardel to
the Minister of the Interior, France is reminded that whilst
the population of neighbouring nations is doubling itself
every forty to fifty years, that of France is hardly increasing
at all, and that unless the amount of death is diminished
the death-rate of the country will in two or three years
exceed the birth- rate. Whatever influences may be held
to affect the birth-rate. Dr. Brouardel regards them as
beyond the scope of the Government, but he urges that an
imperative duty is imposed upon the State and on local
communities to prevent such children as are born from
succumbing to preventable epidemic diseases. The cautions
thus issued are weighty ones.
THE TUBERCULOSIS INQUIRY.
As will be seen from some correspondence published in
another column, the Royal Commission on Tuberculosis,
having completed one stage of their inquiry, and having
also initiated an experimental investigation into the com¬
municability of that disease, have now addressed a series of
questions on the subject to the medical officers of health
and practitioners throughout the country. The object is,
in the first place, to obtain some definite information
regarding the transmissibility of tubercular disease to man
through the consumption of the Ileah or milk of tuberculous
animals. It is well that such an attempt should be made
to put the question to the test of actual experience; for
hitherto, it must be freely confessed, the evidence in sup¬
port of such transmission has been less direct. It has been
based upon such inferences as can be derived from the simi¬
larity in anatomical lesions between human and bovine
tuberculosis, or those furnished by the prevalence of
mesenteric tubercular disease amongst the milk-fed por¬
tion of the community, and chiefly perhaps upon the fact
that the bacillus is common to all forms of tuberculosis, both
in the lower animals and in human beings, together with the
results of inoculation experiments. That there are great
difficulties in the way of proving such direct transmis¬
sion of tubercle by means of the ingesta must be admitted,
not the least being the proof that the food consumed really
proceeded from an infected animal. Still, here and there,
it would seem, if there be such direct transniisaibiliby,
cases iiinst have occurred under circumstances which can
hardly admit of any other explanation. If any such are
known to any medical practitioner in the United Kingdom,
he will confer a great benefit on the community by placing
the Commission in possession of the facts. Secondly,
information is sought upon the question of the transmission
of tubercular disease from man to animals. Here, again,
the determination of positive facts must be very difficult,
owing to the comparative frequency of the disewe both
amongst cattle and mankind. It is, however, not un¬
likely that some examples of local (inoculated) tubercle
may be thus shown to occur ; and there have, we believe,
been recorded instances of tuberculosis in fowls traced tcv
infection of their food by phthisical sputa. The Commis¬
sion do not propose to limit their inquiry to the positive
side of the subject, for they ask, in the third place, to be>
informed of instances of the habitual use of animal food
believed to be tuberculous “in cases where individuals or
communities have kept free from tuberculous disease.”*
Such negative evidence w'ould, doubtless, be of value if it
could possibly be obtained; but judging from the prevalence
of tuberculosis amongst animals used for human consump¬
tion and the comparative laxity which, until the last few
years, permitted the meat from such sources to go on the
market, and the ubiquity of the human disease, the non-
tuberculouamust be limited tea very small area of the earth’s
surface. Moreover, the fact that several persons exposed to
the same source of infection escaped whilst others contracted
the disease might only show that a certain proclivity was
needed to ensure direct transmission. The assertion that
the Jewish community, when living strictly according tcfr
the Mosaic code, are remarkably immune from tuberculosis
has been made to meet the converse case—namely, that,
rigid rules as to dietetics may greatly diminish the
liability to infection through diseased flesh. But in this
case one must not lose sight of other, and perhaps equally
important, sanitary rules which were enforced as part
of a religious observance. We congratulate the RoyaB
Commission on its bold attempt to grapple with this im¬
portant question at close quarters; but we are not very
sanguine, from the complex conditions of modern social
existence, that they will succeed in procuring such reliable
evidence as may determine the question one way or another.
We can hardly conceive of a matter more difficult of demon¬
stration, and yet one in which there appears to be suclii
fairly reasonable prim&fadc ground for acceptance, than w
that of the transmissibility of tuberculosis between maa
and the lower animals.
THE AUSTRALASIAN HEALTH OFFICER.
Wij have received for comment an advanced proof of aa
article in the Australasian Medical Gazette, under the
above heading, the main burden of the article being a.
criticism of the action of the quarantining staff and of the
health officer for t)ie colony of Victoria. It is always
difficult, without knowing what has to be said by bothi
sides, to express a definite opinion as to any line of action
taken in regard of infectious disease ; but when the circum¬
stances involve the question of judging between a ease of
chicken-pox or of small-pox modified bypreviousvaccinabion,.
we should justly be deemed hasty if, in the absence of the
most detailed facts, we ventured to decide a point which
is admitted by experts to be one of the least easily
solved in connexion with the infectious fevers. So.
far as we can gather from the few facts included
in the editorial comment, a vessel had arrived at Melbourne
having on board a man who, according to the ship’s surgeon,,
had recently had chicken-pox. The Victorian health officer
seems to have had doubts as to whether it might not have-
been small-pox modified by vaccination i indeed, he would
appear to have called it “ varioloid.” Was it right, under
these circumstances, that a whole ship—crew, passengers,
&c.—should be quarantined or not? The patient had since-
recovery been about bis ordinary duties for twelve days,
and no one was ailing. Experience has enabled us to draw
Digitiied by Google
782 The Lancet,]
SANITATION AMONG THE EAST-END JEWS.
[March 28, 1891.
a Hoc between the risk of infection from small-pox during
the acute stage, and in either the scabbing and after-
scabbing period; and if during the most dangerous period
of the illness, and for even twelve days afterwards, no
spread had taken place, a skilled official well informed as to
the natural history of small-pox might well take the respon¬
sibility of deciding that the period of danger bad so far elapsed
tirat it would not be justifiable to carry out wholesale
restrictions. This was done, and, apart from certain pre¬
cautionary measures of revaccination, the vessel and her
inmates were left unhindered, and, no harm resulting, she
arrived afterwards at Sydney, where the case was regarded
as one of chicken-pox. The article in question lays it down
that a health officer must decide prudently, quickly, and
decisively, and it adds that “if he practise long without
error, he may be called blessed.” We hope that mere
rapidity and that sort of decision which comes of hastiness
will never be allowed to outweigh an attitude of prudence
which generally comes with sound knowledge of the subject
to be dealt with. In this case the end justified the means.
But, had it been otherwise, we could hardly have held that
the circumstauces, so far as we can gather them, would
have justified wholesale hindrances and restrictions rather
than a determination to take responsibility in acting on the
basis of information, to the acquirement of which many
years and exceptional attainments had been devoted.
SANITATION AMONG THE EAST-END JEWS.
It may be remembered that when our first special
report on Sweating was published, in May, 1884,
the revelations we then made bad, among other good
effects, considerable influence with the Jewish Board of
Guardians. They realised that the Jewish refugees coming
from foreign countries, but more especially from Poland
and Russia, where no knowledge of sanitation exists, were
likely to degrade the houses in which they lived. A sani¬
tary subcommittee was therefore appointed by the Jewish
guardiaus, and,they nominated a special inspector, who
was to visit the homes of the Jews in the East-end;
end, where necessary, this inspector was to call upon
the local authorities to take steps for the abatement
of nuisances. Unfortunately the local authorities did nob
manifest any particular desire to support these voluntary
efforts organised by the Jewish Board of Guardians. In the
seven months from May to December, 1884—we mentioned
the fact at the time,—the inspector visited 1747 houses
inhabited by Jews, and found that 1621 of these houses
were unprovided with any arrangement for flushing the
drains. It required some years to make the authorities
realise this fact. But, in the course of time, they took
ftction, and between Jan. Ist and July 1st, 1890, the Jewish
inspector visited 880 houses, and found only twenty houses
where the drains had no flushing apparatus. In 1884 no less’
•than 93 per cent, of the closets were without flush, in 1890
only 2 per cent, were in this insanitary condition. These
figures show what can he done by private initiative when
perseverance and tact ate combined, The Jewish Board of
Guardians and their inspector, Mr. Goodwyn, are to be
congratulated on liaving so largely contributed to wipe
away the reproach which, nob without reason, was addressed
to their coreligionists, who from various parts of the
Gontinent flocked to the East-end of London. Though
most of the closets of the houses inhabited by Jews are
now provided with water with which they can he
tHushed, there remain many other defects that should be
promptly remedied. Mr. David F. Schloss, the hon. sec. of
ithe Sanitary Committee of the Jewish Board of Guardians,
states that the proportion of the housesvisibedhy the Jewish
inspector in which the character of the defects existing are
such as the local authorities admit they have full power to
remedy is still very large. - Of the few houses situated in
the City, and inspected during the course of last year, one-
half were up to the sanitary standard established by the
local authorities. In Whitechapel the proportion of satis¬
factory houses was only 32 per cent.; in Bethnal-green,
25 per cent.; in St. George’s, 22 per cent. ; and in Mile-
end only 16 per cent. Therefore the sanitary condition of
the districts in which the Jewish poor reside remains, not-
withstanding all tliese eflbrts, in a very unsatisfactory state.
The report of the year’s work gives some description of the
sort of defects detected. We are told of closets that have
had their drains blocked up for weeks, notably in some
“model dwellings,” where two inhabited cellars are
flooded with sewage. There is another place which for
several years had earned an unenviable reputation in con¬
sequence of its noxious odours. Here the committee
succeeded in causiug to be removed from a basement room
a great accumnlation of refuse, which contained among its
varied component parts the bodies of five cats, a dog, and
a rabbit. In St. George’s-in-the-East three boob finishers
were found at work in a front basement room, while the
adjoiniog back basement room was flooded with sewage,
which forced its way up a gully supposed to he protected by
a bell trap. In connexion with the boot trade, the report
notes with satisfaction that a strike of four weeks of the
operatives resulted in induciogtbe manufacturers to abolish
home work for “lasting” and “finishing,” and this
phase of bootmaking will now be done in factories
and workshops, and not in the miserable, and often
unhealthy, houses where the bootmakers live. Wlien such
defects are discovered by their inspector the Jewish sani¬
tary committee first seek to persuade the owners of the
insanitary property to put matters right. It is only when
the owners fail to act that the committee appeals to the
local authority, sending such appeal, according to the
nature of the case, either to the sanitary inspector, the
factory inspector, the street inspector, the vestry surveyor,
or to the water company. Thus the Jewish Board of
Guardians does voluntarily and at its own expense a large
share of useful pioneering work, which should be accom¬
plished by the local authorities. This is certainly most
creditable, and shows a very worthy ambition to do
away with the evil repute in respect to sanitation of the
Jewish refugees. While congratulating heartily the Jewish
Board of Guardians on their initiative and their energy, we
would suggest that it does not suffice to inspect houses. It
is, above all things, necessary to educate their inhabitants,
so that they may understand their duty to themselves and
bo their neighbours in respect of the requirements of modern
sanitation. The influence of the rabbis might he useful
in spreading such a knowledge of the importance of cleanli¬
ness, and leaflets might ho distributed by the inspector
which would explain the dangers arising from unwholesome
surroundings. _
REFORM IN CHARITY VOTING.
The many persons who have at one time or another
laboured to secure the admission of candidates to any public
charity must know something of the expense, effort, delay,
and frequent disappointment which attend this process.
They will not, therefore, feel surprise that the murmurs of
discontent have at last found voice in a protest. This pro¬
ceeds from the Charity Voting Reform Association, and
aims at nothing less than the ultimate abolition of the
present system of election by votes. Though conscious,
however, of possessing some hold upon public sympathy,
the reformers have not forgotten that many old customs die
hard. They have accordingly tabulated a series of sugges¬
tions to form an interim plan of procedure for employment
in those institutions the governors of which cannot or
Digitized by ^ooQle
The Lancet,]
THE INDIAN MARRIAGE LAW.
[March 28, 1891. 733
will not as yet forego the use of the present method.
By these it is proposed to reduce considerably the
number of eligible candidates in any given case, to
empower the committees of benevolent associations to
select at each election the most deserving applicants,
whose names, moreover, should occupy a prominent
place in the voting list, and also to enable them to assume
and employ the votes of subscribers not themselves desirous
of using them. Such modifications would, of course, imply
a radical change in existing arrangements. They would,
no doubt, greatly facilitate the admission of approved
applicants; and if this alone were considered, they could
not fail of acceptance. It is very doubtful, however,
whether any electorate of subscribers would be willing to
surrender the privilege of recommending cases without re¬
ceiving some guarantee of influence in exchange. Whether
any other pledge of such practical utility as the vote can
be found the promoters of any philanthropic venture can best
determine. In the meantime, it is possible to obtain, without
resorting to drastic alterations, some relief of pressure by
reducing as proposed the number of allowed candidates, and
by granting to committees a controlling voice in the
admission of the more obviously necessitous cases.
THE SANITARY STATE OF HASLEMERE.
The Haslemere Parochial Committee decide to retain
impervious cesspools and local wells because of the great
expense which, it is alleged, sewerage and water-supply
would involve. And the County Council of Surrey have
through their Sanitary Committee deferred further action
pending the appointment of a county health officer. Dr.
Edward Seaton, lecturer on public health to St. Thomas’s
Hospital, having now been elected to that office, the case of
Haslemere will, we assume, soon come forward again.
THE INDIAN MARRIAGE LAW.
Much has been said and written respecting the opposition
to be encountered by the Age of Consent Bill recently under
the consideration of the Indian Government. It has now
been successfully shown that this was much overrated.
Now there remains only another and a lesser fear, which
has probably no very solid foundation—namely, the dread
lest the measure, when applied, should lead to police
tyranny and to irritating interference with the sensitive
tissues of social and religious life. We may rest assured,
however, that the Indian Legislature have not so far com¬
mitted themselves without substantial proof that this reform
has wider aud stronger sanctioua than the mere countenance
of a minority schooled in Western ideas. The recent can¬
vass of opinion in the Presidencies brought out the fact that
approval of the measure was all but coextensive with the
Queen’s rule in India. Simiiar evidence is to be gathered
from the pages of a little pamphlet lately published by
Babu Baij Nath, B.A., which describes an almost triumphal
progress undertaken through the North-West Provinces
in 1886 by that well-known advocate of marriage reform,
Mr. Behramji Halabari. In aseries of gathering.?, attended
by representative Hindus and convened in some of the
most important cities of this wide area, Mr. Malabari was
able to prove the existence of a strong popular sentiment
in accord with his own views. He also showed that this
feeling was in harmony with the doctrines of the primitive
religious teachers, and he trained it to recognise the
advantage of supporting their authority by modern legisla¬
tion such as that which has just been carried out. The
raising of the age of consent to twelve years of course
comes far short of our own ideas of preparedness for under¬
taking the duties of marriage and motherhood. Still, it is
a step in the right direction. As such we welcome it. A
later day perhaps will witness yet sounder views respecting
the necessity of postponing all concern in these importanfr-
duties till the term of puberty is well over. This matter,
as well as the amendment of existing rules relating to
child widowhood, possesses an indisputable claim to early
consideration. _
THE FACTORY AND WORKSHOP ACTS.
Mr. Matthews could not be expected to say much less
to the deputation of employers and operatives on the great
questions of half-time and factory surgeons than he did.
The deputation did cheir best to show that factory eurgeona
were an obsolete institution, and that half-time work wa»
beneficial to children as well as to the parents, who in York¬
shire and Lancashire alone received £1,274,000 from sneb
work. Mr. Matthews did not admit his conversion on either
of those subjects; hut he observed that be felt that the
general sense of the House was against him. We are glad
he has perceived this undoubted fact. We cannot doubt
that the Committee of the House will represent the pre¬
valent feeling on both these points, and we are not without-
hope that the Home Secretary himself will how to the general
opposition. The party which haa the credit of the Factory
Acts should not be the party to discharge factory surgeons.
The numerous communications which have been published
in the medical papers show the high uses of factory surgeons*
in the matter of child labour.
FOREIGN UNIVERSITY INTELLIGENCE.
Buda. Pesih. —Dr. Feuer has been recognised as privaS-
docent in Ophthalmology, Dr. Salg6 as privat docent in
Mental Diseases, Dr. tfdraniezky as privat docent in.
Chemistry, and Dr. Onodi es privat docent in Laryngology.
The Physiological Lectures are being delivered by Prof. Paul)
Plosz in consequence of the death of Prof. Jendrdssik.
Giessen. —Prof. Eckbard is about to resign the chair of
Anatomy, retaining that of Physiology, which he hoa
hitherto held concurrently. Dr. Honigman, First Clinical
Assistant in the Medical Clinic, has qualified as private
docent.
Madrid. —Dr. Don Amalio Gimeno, Professor of Hygiene,
has been appointed after an open competition to the Chair
of Medical Pathology.
Santiago -{Spain). —Dr. Don J. Farreras y Framis of
Barcelona has been appointed to the Chair of Histology.
Strasburg. —Dr. Sedderhaus has been promoted to the*
rank of Extraordinary Professor.
Tomsk. —Dr. Fortunatoff of St. Peterehurg has heett
appointed Extraordinary Professor of Pharmacology.
Vienna. —Dr. Herzfeid has been recognised as privaP
docent in Midwifery and Gynaecology. He is assistant to
Professor K. Braun.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Seuor Andrade of Aleu, formerly Professor in the Medical
Faculty of Valladolid.—Dr. Emerich Regdezy Nagy, Pro¬
fessor of Physiology in the Veterinary School of Buda*
Pesth._
Pyoktanin or anilin dye has been employed by Professor
Eggeling of Teltower in the foot-and-mouth disease of cattle-
with, it is said, surprisingly good results, the affected
parts being syringed out with a solution of the strength of
1 per cent. _
We regret to learn that the condition of Professor Brana
von Fernwald has become much worse, there being extreme
weakness of the heart’s action.
Digitized by LjOOQle
734 Thb Lakckt,] local GOVEKNMENT BOARD : MEDICAL OFFICER’S REPORT. [March 28, 1891.
An outbreak of typhoid fever of a very virulent type,
which has caured great alarm, is reported to have taken
place at Nant-y-Filint, a country hamlet situate between
{Flint and Halkyn. The corporation of Flint have taken
very stringent measures to isolate the cases and stamp out
the epidemic, and they have also engaged trained hospital
mursea to attend to the sufferers.
Mr. William Anderson, F,R.C.S., has been elected
S’rofessor of Anatomy at the Royal Academy, in succession
to the late Professor John Marshall, F.R.S. We con-
,gratulate Mr. Anderson on his appointment, which cannot
(fail to give general satisfaction.
His Highness Syed Ali, G.C.S.L, Sultan of Zanzibar,
has been graciously pleased to confer a decoration (medal)
of Kakob-al-Dari (Brilliant Star of Zanzibar) upon Dr. P. B.
Nariman, physician and surgeon to bis Highness, in reco-
ignition of his eminent services to the State.
Dr, Jablokofp has been appointed to the senior phy-
siciancy of the pediatric department in the Moscow Foundling
Hospital. _
The recent Congress of Russian medical men decided that
the long-talked-of memorial to Professor Pirogoff shall he
•erected in Moscow.
REPORT OF THE MEDICAL OFFICER OF
THE LOCAL GOVERNMENT BOARD.
The report of the medical officer of the Local Government
Board for the year 1889 has only just been issued, and a not
unimportant portion of the volume is taken up with reports
■of the medical inspectors on certain occurrences of infectious
■disease, such as enteric fever, diphtheria, scarlet fever, &e.,
which we have already noticed at the date of their original
tissue. They embody certain points typical of tlie circum¬
stances under which prevalences of the specified diseases
•occur, and hence there is distinct value in thus placing
•them on permanent record. Dealing with the question of
vaccination. Dr. Buchanan again refers to the misuse of
the term “ insusceptibility.” If certificates as to this were
'to be regarded as trustworthy, we should have to face the
4 iwkward fact that insusceptibility to vaccination is twice
ns frequent in London as elsewhere in the country, we
ishould require to know why in Fulham one child out of
•137 is insusceptible, whilst no insusceptibility at all occurs
in Shoreditch, and we should have to explain how it is that
when the Local Government Board have inquired into this
.alleged excess of insusceptibility in certain places, no certi¬
ficate of the kind was found to have been given by a public
vaccinator. The vaccination returns for 1887 are those as
to which the last complete account is given, and from these
'it appears that of children born in England and Wales
during that year, 7'1 percent, still remained unaccounted
•for on Jan. Ist, 1889, and, whether the metropolis or the rest
of England be considered, this indicates a growing increase
in the number of such default.
The auxiliary scientific investigations were of exceptional
•interest during 1889, and this especially in so far as diph-
theriais concerned. Thevolumenownndevconsiderabiongives
the detailed report of the discoveries made by Dr. Klein, and
of which the principal outcome was at the time submitted
to the Royal Society in a paper on the Etiology of Diph¬
theria. That two forms of bacilli had been confounded under
the term “Klebs-Lbfller bacilli” has been made clear, and
Dr. Klein has succeeded in showing that whilst the two
sets of organisms present hardly any morphological differ¬
ences, yet that they can be differentiated, and this essen¬
tially in their conditions of growth. One form of bacillus
appears to be benign ; it certainly fails to produce any of
the typical symptoms and results which follow on the inocu¬
lation of certain animalswith diphtheria membrane; whereas
the other, which Dr. Klein regards as the true diphtheria
bacillus, produces amongst cats, for example, the same con¬
ditions as have been ascertained to exist in the case of cats
suffering from disease contracted in households 'where diph¬
theria has prevailed. One of the most interesting differ¬
ences between the two forms of bacilli is that whereas the
pseudo-bacillus fails to multiply on milk at comparatively
low temperatures, the true diphtheria bacillus does so
multiply, and in milk at the ordinary temperature of the
atmosphere—a point of extreme importance in connexion
with those occurrences of diphtheria which have taken
place as the result of drinking milk from special dairies,
and in which the potency of the disease has appeared to
be enhanced as the result of the storage of milk in
dwelling-houses and elsewhere.
Recalling his experience as to the inoculation of cats with
diphtheria membrane, and the resulting production of the
diphtheria bacillus in connexion with a disease communi¬
cable by cat to cat within the same cage, experiments were
then instituted as to the behaviour of milch cows under
similar inoculation, and it was ascertained that following on
this process cows were found to be suffering from a disease
accompanied by vesicular and allied affections of the udder
that at once recalled those symptoms whicii bad on several
occasions been found to attach to cows the milk from which
bad been regarded as causative of diphtheria. And, when the
contents of the vesicles in question came to be examined,
the bacillus diphtberim could be demonstrated unmis¬
takably both in cover-glass specimens and in cultures. The
disease induced in cows was a mild one, but it was one which
was inoculable into calves, and when milk was taken from a
cow suffering from the udder affection referred to, bacterial
colonies formed within a few days, and in all such there
appeared “ unmistakably coloniesof the bacillus diphtheriae.”
Thus astage is now reached which renders it imperative that
this question of the relation of diseases such as diphtheria
in the human subject to disease, whether of an apparently
trivial sort or not, in cows should be definitely determined,
and it seems a pity that the department of State which
deals primarily with the health of man should be working
alone in this matter.
The volume also contains a suggestive report by Dr.
Klein on concurrent inoculation of different infections in
the same animal body; a paper by Dr. V. D. Harris on
Bacteria in their observed relation with Digestive Processes ;
and a preliminary contribution by Dr. Sidney Martin on the
Chemical Products of. the Life Processes of Bacillus
Antbracis.
Incidentally, a point is adverted to in this report which is
not raised a day too snon. In referring to the illustrations
appended to Dr. Klein’s contributions on diphtheria, Dr.
Buchanan says: “Many of these drawings and photo¬
graphs .are practically worthless for their purpose. Yet
they are second attempts made by the lithographers; and
upwards of four months have been spent in the production
and reproduction of the professing illustrations to Dr.
Klein’s essay.” And Dr. Klein himself is obliged to brand
, certain of the individual drawings with such words as, “ The
I representationshere madefail in reproducing the points of the
I original photographs.” Herewehavesomeexplanationof the
great delay in the issue of the report. But more, it has long
j been obvious thatthedepartmentof Covernment responsible
for illustrations to these and kindred reports utterly fails in
! itsobject. Theso-oalled“illu8tration8”whichhaveapp6ared
' in some recent official volunjos, and notably in this one and
in one nob long issued by the Agricultural Department, are
such as this country ought to be ashamed of when they
are compared with the drawings issued by private indi¬
viduals or by foreign Governments. Besides which, when
diagrams no longer illustrate the points which they
' were intended to indicate, the expenditure bestowed on
them—small as it obviously must be—is thrown away.
We trust that some member of Farliament who is alive
to the value of scientific research in the promotion of
public health will ascertain in the House of Commons to
whom the country is indebted for the present state of affairs
in this respect.
Digiiized by
Coogle
The Lancet,]
THE ARMY MEDICAL STAFF.
[March 28, 1891. 7 35*
THE ARMY MEDICAL STAFF.
We have been favoured by Sir Andrew Clark with a
copy of the following correspondence between the Secretary
of State for War and himself:—
Royal College of PhysicianH, London,
March 7th, 1891.
Dear Mr. Stanhope,—
Immediately on receiving the letter which you did
me the honour to address to me as leader of the deputation
from the medical corporations of the United Kingdom, on
behalf of the grievances of the army medical officers, I
placed myself in communication with those bodies for the
purpose of ascertaining their views of the replies which you
had made through me to their representations. Having
now received answers from all of them, and their views
being in complete accord with my own, I venture again to
address you in this letter, with the desire to promote such
an issue to these'negotiations as will prove at once just and
satisfactory to the medical officers of the army, and of real
and lasting advantage to the State.
Although I am w^l assured of your unaffected desire to
deal generously with the army medical officers, and to grant
to their just grievances every just and practicable remedy,
although I fully recognise the difficulties of your position
as a Minister of State, standing between the army, the
Government, and the House of Commons, and can under¬
stand somewhat of the obstacles in the way of reconciling
them to such a reform as we seek, I am constrained to
acquaint you with the unanimous judgment at which we
have arrived—that the concessions made to our representa¬
tions are, with one exception, unsatisfactory, and that they
fall far short, nob merely of what is claimed by the medical
officers, but also of what has been recommended by Parlia¬
mentary and War Office Committees, and of what has been
regarded as just by men experienced in public affairs.
For my own part, I regard this unhappy result as due to
the strange misapprehensions and the inaccurate state¬
ments of those who have supplied you with technical
information upon the subject; and 1 cannot understand
how our arguments should have been met by replies which
could be immediately refuted by reference to official regu¬
lations. This is a grave statement to make, and did I not
know that in dealing one by one with the paragraphs of
your letter I should be able to make the statement good, it
would not assuredly have been made.
Here, in order to illustrate this allegation, and to prove
its accuracy, I must anticipate what I shall have to say at
the close ot this letter.
It is averred that “ to incorporate, the medical staff
into the general army, and to give its officers substantive
rank ana military titles . would have the effect of
placing a medical officer in military command over
troops in the field whenever one might happen to be the
senior officer present," Now this is the supreme objec¬
tion mode to conceding the claims of the medical officers,
and, strange to say, it is absolutely without foundation,
for in various places in the books of oflioial regulations
express provision is made for the granting of rank and
title without command in the field, and for the granting
of rank and title either with no command at all, or with
such a limited command as may be defined on appoint¬
ment. In the Royal Warrant of 1890, paragraph 69 a, we
read as follows “An officer permanently transferred from
the commissariat and transport staff to the supernumerary
list of our Army Service Corps shall nob hold any military
cominand outside our Army Service Corps, except over such
officers and men as may be specially placed under his
command.” “ An officer of our Army Service Corps
detailed for barrack duties shall not hold any military com¬
mand, except over such officers and men as may be specially
placed under his cominaud.” And again, even more ex¬
plicitly, we read in paragraph 70 that “ an officer of our
army employed in auy of the cases specified in Article o.»
(/i) or (i) shall not be entitled by virtue of his military rank
to assume any military command in oiir regular army,
unless called 'out for military .duty by our Secretary of
State.” Surely neither the claims of reason nor the neces¬
sities of experience coulil require more conclusive proof that
the granting of military rank and title does not necessarily
imply 01 -involve the granting of military command in the
field.
With your permission I will now proceed to deal with
those paragraphs of your letter which have a crucial bearing:
upon tire questions under discussion.
Paragraph 10.—You state that the only way of lengthen¬
ing the home service of medical officers is to increase th©
□umbers employed-at home; that this could be done only
by employing them upon duties which would OQpupy bub
a small portion of their time; that they would thereby
lose experience and deteriorate in professional knowledge?,
that an increase of establishment necessary to lengthen the
period of home service would cost £27,000 a year ; and that
therefore you are unable to grant this request. Now I
must be permitted to point out that this subject has nob
been brouglit fairly before you, and that this answer is-
entirely irrelevant to the relief sought for by the army
medicEu officers. They do nob ask for a shorter term of
foreign service, and they do not ask for a longer term-
of home service. They only ask for a shorter term
of continuoiis foreign service; they ask only to be
restored to the rule which was in operation before 1888 ?
they ask only that, unless in cases of State emergency, the
term of continuous foreign service should be .limited to five
years instead of six years ; and they allege—justly, I
think—that the granting of this relief would not only nob
lengthen, but discinctly shorten, the duration of continuous
service at home. This relief is asked by the army medical’
officers on grounds not less important to the State than to
themselves. It bas been found that the additional year of
foreign service imposed in 1888 upon the army medicab
officers, more exposed than any others to the active causes
of disease, bas notably increased bbe rates of their sickness-
and mortality, and has, without compensating advantage
to the State, added to its burden a growing list of non-
effective medical officers. Furthermore, it was declared by
your own committee, the Camperdown Committee', that-
the grounds upon which this relief was sought were just-
grounds, and they recommended that the new rule
should be abrogated and the old rule restored. _ Finally,
having regard to the conduct of medical affairs before
1888, when bbe term of continuous foreign service, which
acted well, was enlarged from five to six years, to the fact
that the number of medical officers is about the same now
as it was then, and to the circumstance that facilities for
drafting are greater at present than at any former period,
and that the services of medical officers may be utilised in-
bhe troopships so employed, there does not appear to exisb-
any valid reason why, if this request were granted, the
somewhat more frequent transport of medical officers, in-,
volved in the grant, should necessitate the introduction of'
new machinery, the enlargement of some existing establish¬
ment, or any material addition to present expenditure.
Paragraph 2.—Your concessions as to the conditions for
the granting of sick leave to medical olficers have been-
received with uniform and grateful satisfaction, not only by
the Army Medical Staff, bub also by the whole body of tbe-
niedical profession which bakes an active interest) in the-
just settlement of the questions considered in this corre¬
spondence.
Paragraph .’I.—In reply to the complaint that the army
medical olficers do nob receive a fair share of the honours
and rewards conferred upon officers generally for exceptional'
services to the State in warlike and other expeditions, you
observe that such rewards can hardly be made a matter of-
proportion, and that the granting of them must necessarily
depend on the opportunities which officers, whether com¬
batant or medical, have of distinguishing themselves. The
force of these general remarks need not be denied ; but the
contention of the army medical officers and the contention,
and recommendations of Sir Ralph Thompson’s Committee
do not lie within their limits. The contention of the army
medical officers is that, in like circumstances of perils
encountered, hardships endured, and services rendered in
successful expeditions, they -should obtain a fair sbare_ of
the honours bestowed upon such occasions. The contention-
of Sir Ralph Thompson’s Committee of 1878 is that, judged
by the standard about to be mentioned, the medical ollicers-
are tar below the combatant ranks in tlieir enjoyment of
the honours of the Bath, the Star of India, and the Star of
St. Michael and St. George ; and the committee recommends-
that in regard to honours, rewards, and good service pensiona-
the medical department should be judged rather by the-
standard for combatants than by that for non-combatMts.
I am aware that it is contended by the combatant oflicers-
of the army that the medical department receives more than
Di-giiized by Google
T36 The Lancet,]
THE ARMY MEDICAL SERVICE.
[March 28, 1891.
its fair share of honoars and rewards. His Royal Highness
the Commander-in-Chief asserts that the army medical
ofhcers bavf absolutely got such an excess of honours aud
rewards at the present time that we cannot give them any
DOW,” and he adds that the '‘honours and rewards are all
a pp ortioned most carefully,” Sir Archibald Alison, Lord
Wolseley,' General Harman, and other distinguished com¬
batant officers follow in a similar strain. As a matter of
fact, however, these statements are incapable of sustaining
any critical examination, and a reference to olhcial returns
brings immediately to light the conclusive evidence of their
complete inaccuracy.
In illustration of the gravely inaccurate information
with which you have been supplied on this subject, let me
compare the honours bestowed upon the Engineers with
honours bestowed upon the Army Medical Staff.
strength of the Royal
Engineers.
Sti-ength of the Army
Medical Staff.
707
G.C.B. ...
... 2
K.C.B. ...
... 5
C.B.
... 7
C.C.M.G.
... 2
K.C.M.G.
... 1
€M.G. ...
... 10
C.I.E. ...
2
D.S.O. ...
... 10
39
Percentage of honours to strength, R,E.,S'6 A.M.S., 1-7.
Furthermore, of the Egyptian decorations conferred in
,4882 the percentage to stren^h was:—
For tne Ordnance Store Department. 57
For the Commissariat Department . 27
For the Medical Department . 7
Finally, in respect of the Nile Expedition of 1884, the
percentage to strength of promotions among departmental
officers was as follows:—
Chaplains. 44
Pay Department . 41
Ordnance. 30
Commissariat. 13-8
Medical Staff'. 7'9
Such illustrations could be largely added to ; bub I have
adduced already a number sufficient to show that whilst the
contentions of the medical officers of Sir Ralph Thompson’s
Committee and of Director-General Crawford are grounded
on official records and are accurate, the contention of the
combatant officers is grounded on merely emotional im¬
pressions and is inaccurate.
In view of these facts, and especially in view of this
further fact, that more than one "War Office Commission has
recognised the existence and acknowledged the justice of
this ground of complaint, we have received with disappoint¬
ment your decision on this subject.
The matters alluded to in paragraphs 4, 5, 6, and 7 are
not of serious importance to the settlement of the main
•question at issue, and, having been mentioned more by way
of illustration of the chronic attitude of mind preserved by
combatant officers and high officials towards the medical
officers than for the purpose of making any present claim
for their reform, are herewith set aside. Nevertheless such
matters have some importance, and men of the u-orld
acquainted with military organisation, the drift of social
opinion, and the general tendencies of the ago will think it
neither wise nor safe entirely to ignore them.
Permit me to give two illustrations of the matters referred
to in the paragraphs specified. When Surgeon-General Sir
Anthony Home received the Victoria Cross for his heroic
defence of the wounded in a sbteeb at Lucknow, he was the
only officer decorated on the occasion wlio was not after¬
wards invited to the Palace. He felt the slight so keenly
that for years afterwards he refused to wear the decoration
w/hich he bad so honourably won. Again, and in like
manner, wlien Surgeon Reynolds received the Victoria
Cross for his gallant conduct at Korke’a Drift, his companion,
a,n officer of Engineers, was afterwards invited to the Palace,
bub Surgeon Reynolds was passed over unnoticed. He did
not belong, one might infer, to the same caste, and he was
therefore unfit to sit with any combatant officer above the
salt. To those who do not understand the ways of the world
of military life these may seem to he email things unworthy
of consideration, hub to those who enter into the constitution
of military society, and to most persons who understand it
aright, they are symbols of things which in the aggregate
become serious, inasmuch as they tend to foster discord,
disaffection, and distrust, and to man with growingly
inferior persons a department upon which the nation
depends for the safety of its army in peace aud for the
conditions essential to its success in war.
Paragraph 8.—-In this paragraph you are pleased to
concede to the army medical officers the composite titles
recommended by the Camperdown Commission, and you
“ trust that this concession will put an end to the regrettable
agitation which has obscured the true hearings of this
important matter.” Unfortunately, however, this is the
concession of title alone and of nothing else. But it is
not title by itself for which the meaical officers con¬
tend : it is for some sucli title as will carry with it
the guarantee of substantive rank ; since they declare
that without such rank they are unable to discharge
in the prompt, thorough, and acceptable manner which
they desire the military duties and responsibilities now
imposed upon them ; and they earnestly maintain that title
without an accompanying guarantee oiaubsbantivemilitary
rank is absolutely worthless for the remedy of any grievance
of which they have just cause of complaint. This conten¬
tion of the army medical officers has received a kind and
measure of support perhaps never before accorded to any
like demand for class reform. It is supported by the ex¬
perience of the armies of Italy, Switzerland, Holland,
Turkey, the United States, and of several other countries;
by the opinion of all the medical corporations of the United
Kingdom; by the conclusions of almost all bodies of men
who have judicially investigated the question ; and even by
the approval of a rapidly, growing number of combatant
officers. Furthermore, this plan of incorporating the
medical officers into the general army and giving them sub¬
stantive rank therein has never hitherto failed, where it has
been tried, to allay dissatisfaction, to promote unity and
efficiency of action, and to secure for the medical service
higher men and better work.
Rut there lies in this question still another fact, which,
although it is at the root of the whole discussion and of the
I first importance in its just settleraenb, has been either over¬
looked or ignored by your military advisers. Array medical
officers are nob merely doctors; they are doctors whom the
I progress of ideas and the march of modern warfare have
I made of necessity soldiers also; and the further they ad-
I vance in the service the more important and the more
purely military their duties become. As surgeon, the
army medical officer has to discharge all military duties
and responsibilities except the one of actual fighting in the
field. Chief among them I m^ mention the command and
discipline of the Medical Staff Corps and of all persons either
attached to the corps or else on duty in the military hos¬
pitals, the instruction of the corps in infantry and stretcher
drill, the management of the pay, clothing, and general
equipment of tlie Medical Staff' Corps, the accounting of
officers for hospital buildings, general supplies, and neces¬
sary stores, the study of military law and its administra¬
tion in minor offences. Furthermore, in charge of a
field hospital and responsible for a hundred sick, he has
military command of four officers and a hundred and seventy-
one non-commissioned officers and men ; whilst in charge of
a bearer company in action, and possibly under fire, he has
military command of three officers and one hundred and one
non-commissioned officers and men, and ho may himself have
to fight in defence of his sick. As a surgeon-general, the
army medical officer has the military command of nearly
three hundred officers and of fifteen hundred non-coni-
miasioned officers and men of the medical staff and the
Medical Staff Corps; he has the control of probably two
thousand sick, and he has to settle in all its complexity of
details the medical organisation which may become necessary
for the injuries and diseases of forty thousand men.
It seems to me that to deal with an official having
responsibilities of such moment as if he were merely a
doctor, as if he were nob a real officer, as if he were not
entitled to rank as combatants rank, and as if ho wore not
worthy of being incorporated into the general army, ia at
once a serious anomaly, a tactical mistake, and a grave
injustice. For if this surgeon-general were not acquainted
with military organisation, it he bad not studied the
economy of armies, if he did not understand military
Coogle
The Lancet,]
THE ARMY MEDICAL SERVICE.
[Maech 28,18OT. 7^7
strategy, if he were not capable of makiag adequate pro¬
vision for transport and of establishing secure bases for
supplies, if he were not experienced in the command of
men, and if he were not in heart as true a soldier as any
on .the field, he would be utterly incapable of making
those preparations for action without which, in the present
day, it is probable that no great battle could be fought
and won.
And now, in the last place, as respects the supreme
objection to the granting of substantive militaiy rank to
medical officers—the objection that it implies and involves !
the granting of military command in the field,—1 venture to
remind you that in the beginning of this letter I have con¬
clusively proved from the Koyal Warrant of 1890 that this
objection has no valid existence, and that definite provision
has been made for the granting of rank and title in special
circumstances without command. And I may be permitted
further to remind you that at this time there are to be
found in the army numerous officers of almost all ranks
who have no combatant command. The granting of sub¬
stantive rank to medical officers, therefore, would and could
do DO more than confirm them in the command with which
they ate already invested over the Army Medical Corps,
and enable them to discharge their duties unencumbered by
the trials and difficulties with which they are now sur¬
rounded.
The more widely I have considered this subject of the
grievances of the army medical officers, and the more criti¬
cally 1 have weighed what has been said on both sides of
the iliscussioD, the more deeply have I become convinced
that those grievances are just, that they require but one
remedy for their cure, that no other but this one remedy
will succeed in curing, and that to the adoption of it no
sound and substantial objection can be taken and main¬
tained. In the presence of this conviction I pursue no
further the exposure of the misapprehension and in¬
accuracies which have crept into the “combatant” side
of the discussion. I set aside as covered and satisfied
by the main issue all collateral questions of loss of pay,
place on courts-martial, comparison with Engineers, and
others referred to in your letter, and I content myself
with declaring on the part of the medical corporations of
the United Kingdom, wliom on this occasion I have the
honour to represent, their unanimous judgment that the
only remedy for the full and just relief of the grievances
of the army medical oificers is the conversion of the
whole Army Medical Department into a Royal Army
Medical Corps, and the granting of substantive military
rank and title to all its officers.
We firmly believe that if this conversion were effected
agitation and disaifection would cease, frequently recurving
discords and difficulties would disappear, unity and concord
would be restored, the best order of men would seek the
medical service, and tlie naturally high and generous
instincts of the combatant officers would soon reconcile
themselves to a change which could not fail to bring about
increasing advantages to the soldier and higher service to
the State,—I am, dear Mr. Stanhope, yours faithfully.
The Right lion. Kdwanl Stanhope, M.P., ANDREW OLAUIC.
Secretary of State for \\'ar.
War Office, Pall Mall. S.W.
March 17th, 1S1)1.
Sir,—I have the honour to acknowledge your letter of
the 7th inst. You refer to the concessions made in my
letter of Feb. 2nd as unsatisfactory, and again impute that
condition of things to the “strange misapprehension and
inaccurate statements” of those who have supplied me with
the information which you say can be immediately refuted
by reference to olficial regulations.
In proof of this most serious allegation, you c^uote
paragrapli 8 of my letter, and you then show, from mihtaiy
regulations, that military rank does not necessarily carry
more than a limited command, and can be, and often is,
limited in its scope j and you therefore characterise my
objection to incorporate the Medical Staff into the general
army as absolutely without foundation. These are strong
statements, and they are as wrong as they are strong.
In your letter of Jan. 17th you asked for “ the transforma¬
tion of the whole department into a Royal Army Medical
Corps with, definite rank and title to all its officers and its
orfjanic incorporation into the general aimiy on the Imcs
follotoed in the case of the Royal Engineers." These words
cany but one meaning to my mind, and to that meaning
there must be the fatal objection described in my lettw,
and I can only conceive that you labour under a total mis¬
apprehension of the powers of officers of the Royal
Engineers.
I am quite aware that the function of command can be
limited, and in the same paragraph I pointed out th^
medical officers actually have this limited command, which
they derive from the substantive rank given them by their
commissions.
As regards the length of foreign service of medical officers,
you say that my answer is “ entirely irrelevant to the relief
sought for.” I should be very sorry if I had consciously of
unconsciously misrepresented what these officers wish for,
but I would point out to you that your mention of the
subject was of the baldest possible aescription, and from
your reference to the Camperdown Committee I was led to
suppose that your proposal was identical with the recom¬
mendation of that Committee. That recommendatioa
i was that continuous service abroad should not exceed
five years, and that more home service should be givea
to army medical officers by employing them in posts
now filled by retired medical officers {vide paragraph 6 of
report).
It was to this that my remark as to the great expense of
the change applied. If, however, what is asked for is merely
a slight rearrangement of the periods of foreign service not
involving longer home service, I will consider what I can do
to meet their wishes. I should, however, say that such a
concession would be a doubtful boon, and might possibly
not be appreciated by many of the officers concerned. Such
shortened periods of foreign service would mean more fre ¬
quent changes, and each cuange of station means some cost
to the officer.
As regards the grant of honours, I can only repeat what
seems to me to be a self-evident proposition—viz., that it-
cannot be made a matter of proportion, but must depend on
the opportunities which officers have of distinguishing them¬
selves. The fact that the Engineer honours are for the
moment in excess of those enjoyed by the Medical Staff in
no way lessens the force of my statement.
The Engineers obtain rewards for services not only in the-
army but in innumerable civil positions, and they have that
very qualification of command which you admit should not-
be given to officers of the Medical Department. If you will
eliminate from the list you give of Engineer rewards tho8&
gained in civil and colonial employ and in high command,
you will find the two lists are not disproportionate.
On the question of Court privileges, I have already said
that I would consult with the proper authorities.
The concluding portion of your letter rejects the conces¬
sion which I made in accordance with your own suggestion.
You say that medical officers “ contend for some such title
as will carry with it the guarantee of substantive rank to
enable them to discharge the military duties and responsi¬
bilities now imposed on them.” On this ijoint there i»
evidently some misunderstanding on your part. Substantive
rank Army Medical officers already have by virtue of their
commissions to the full extent you ask for, and no grant
of military titles of any description will change or in¬
crease it.
I regret very much to be at variance on this point with-
the distinguished profession which you so ably represent,
but I am satisfied that it is not desirable to give medical-
oificers the power to assume the active command of troops
in the field or in quartei-s, and that were I to allow their
formation into the corps you propose, and their “organic
incorporation into the general Army on the lines follows
in the case of the Royal Engineers,” this command could
not be denied them. I am not therefore prepared to do
more than give the composite titles which, as I have
already remarked, was your own proposal, and which was
also tile recommendation of Lord Camperdown s Com¬
mittee, of which representatives of the prof^sicm nomi¬
nated by the Royal Colleges of Physicians and Surgeons
were members.
Having therefore adopted one of the alternatives which
you have yourself put forward, I do not think that any
object would be gained by any further correspondence on
the subject.
I have the honour to be, Sir, your obedient servant,
Edward STANHors.
Sir Andrew Clark, Rart, M.D., F.R.S., &c.
Die zcdbyGoO^Ic
738 The Lanckt,]
REPORTS OF MEDICAL OFFICERS OF HEALTH.
[Mabch 28, 1891.
IRISH MEDICAL SCHOOLS’ AND GRADUATES’
ASSOCIATION.
The annual general meeting of the Irish Medical Schools’
Q.Qd Graduates’ Association took place at 11, Chandos-
etreet, on March 17th (St. Patrick’s Day).
In the absence of the retiring President, Dr. Kidd,
F.R.S., of Dublin, the chair was taken by Sir Thomas
Crawford, K.C.B., who presently vacated it for Dr. GLlbart-
Smith, the President for the coming year. A vote of
thanks was passed to the retiring president. Dr. Kidd.
In the annual report of the Council, which was adopted
unanimously, mention was made, amongst other matters,
of the action of the Association in respect of the Mid¬
wives’ Registration Bill, and of the disabilities of Irish
diplomates in regard to appointments on the honorary stall'
of certain hospitals. It was announced that the Association
now numbered more than 660 members, most of whom
reside in England.
The following oflicers were elected :—President-elect:
Director-Generw Dick, C.B,, R.N. Vice-Presidents : Pro¬
fessor Gerald Yeo and Sir Thomas Crawford, K.C.B.
Fifteen gentlemen were also chosen to serve on the Council
for the ensuing year.
The annual dinner took place the same evening at the
Holborn Restaurant, where Dr, Gilbart-Smith presided
over a large and representative company. The guests of the
evening were Sir G. Murray Humphry and Canon Teign-
raouth Shore. A congratulatory message was read from Sir
Andrew Clark, expressing also his regret that he was irnable
to he present, The toasts were “ Our Sovereign,” “ Our
Defenders,” “ Our Guests,” and “ Ourselves.” These were
handled in a lively and entertaining manner by the Pre¬
sident, Dr. Macnaughton Jones, Director-General Dick,
Surgeon Parke, Professor Macalister, Sir George Hum¬
phry, Canon Shore, and the President of the Royal College
of Surgeons in Ireland. Between the speeches a selection
of Irish songs was admirably rendered by Messrs. Groome
and Clive. The Association may be congratulated on a
very enjoyable and successful entertainment.
anb fafa.
LOCAL GOVERNMENT DEPARTMENT.
KEPORTS OF MEDICAL OFFICERS OF HEALTH.
WakefieldEuralDistrict. —The corrected death-rate for this
district during 1890 is given by Mr. John W. Walker as 17'2per
1000; and in view of the fact that amongst the attacks of
infectious diseases notified there were 168 cases of scarlet
fever, 34 of typhoid, and 38 of diphtheria—240 in all—Mr.
Walker urges that efforts should be made to induce people
to use the isolation liospital at Carr Gate more than they
do. Re finds occasion to point to the advantages of free
admission to the hospital; and we may therefore assume
that herein lies the difficulty experienced. Why people
should pay to go into a hospital erected at the cost of the
rates for the purposes of protecting the health of the public
must be, to all, an enigma. If it is preferred that cases of
infection should be left scattered about, for the sake of a
pecuniary trifle, it seems a pity to spend money on hospital
construction and maintenance. An interesting portion of
the rei)ort deals with lead poisoning, and it is stated, on the
authority of a chemical expert, that “the Wakefield water
after prolonged contact with lead—e.g., twelve hours—
should not be used for drinking purposes.” But a table
appended shows, amongst other things, that whereas water
after standing in a lead pipe has 0'6gr. of lead per gallon, and
a lead dissolving power estimated at 14, water merely passed
through a lead pipe without standing in it has the same
amount of lead in it, and has a lead dissolving power of 17.
The one sample is, to say the least, as bad as the other in
this respect.
Scmdal Magna Urban District. —This district also receives
the Wakefield water, and Mr. Walker supplies the same
information as to the lead-dissolving character of the water
drawn from the pipes after standing and otherwise. The
general death-rate was 15’71 for 1890, and the compulsory
notification of infectious diseases seems to work satis¬
factorily. The general current sanitary work was evi¬
dently well maintained throughout the year.
Hova Urban District —Estimating the population at
27,000, Mr. Ernest Medcalf gives the death-rate for Hove
as 12 ^7 per 1000 living during 1890, the zymotic rate being
1'4. The notification of infectious diseases is stated to
have been of great utility in securing early isolation, and
the number of patients having substantially increased at
the isolation hospital, it has been decided to erect another
ward pavilion.
Exeter Urban District. —Dr. J. Woodman and his col¬
leagues report, as to the Exeter Sanatorium, that 107 cases
were admitted during 1890, 88 of these being scarlatina
patients. In all, 673 cases have been isolated since 1882,
and in a number of instances disease has been prevented
from spreading. The Diseases Notification Act, which ha»
now been in working over a year, has materially aided in
the results obtained last year, and has facilitated the
isolation of infectious cases which called for removal from
their homes at an early date; indeed, in some cases imme¬
diately on their becoming known. The patients arerefen-ed
to as appreciating the care bestowed upon them. The ad¬
missions in 1890 exceed those for any previous year, and
this goes to confirm the view that the auvantagea of early
isolation are increasingly appreciated.
Melton Mowbray Burod District. —Mr. William Tibbies
records a death-rate of 15‘3 per 1000 during 1890, This
represents an excess on the rate for 1889; the causes of the
excess being the severity of the inliuenza epidemic, and to a
lesser degree a prevalence of scarlet fevei\ But it is also
recorded that enteric fever and diphtheria were at their
lowest ebb. In a number of villages systematic house-to-
house inspection was carried out, and such conditions
found as were deemed to call for amendment in the
interests of public health were dealt with. Some addition
was also made to the system of public drainage.
Wirksworth Urban District. —In this district, with a
population considerably under 4000, the death-rate for 1890
was 2T3 per 1000, and even the mean for the past
ten years—namely, 18'6—is needlessly high. Mr. A. E.
Broster, indeed, calls for a house-to-house inspection, and
be indicates certain general causes of excessive mortality,
such as sewer emanations, elHuvia from foul closets, and in¬
sufficient house ventilation. These are typical causes of an
increase of sickness and death, and are such as ofcen do
mischief without actual death being easily identifiable with
them. There appears to be a system of removal of privy
contents at fixed charges. Hardly anything conduces more
to nuisance; the people generally like, in view of the fixed
charge, to have what they call a good-sized privy which
does not often need emptying. Hence lar^e accumu¬
lations occur, and attempts to reduce the privy pits so
as to prevent these accumulations fail. The authority
should undertake the work themselves in the proper
way. If they do it at all, they have no legal right to
oharjie for it.
Liverpool Port Sanitary District. — Daring 1890 the
number of vessels entering the port of Liverpool was 23,086,
and of these 3372 were inspected, with the result that 270
were found defective. According to Dr. Stopford Taylor,
the condition of the British vessels is on the whole very
satisfactory, and it is quite clear that labours such as are
carried out in the pork of Liverpool constitute an important
agency in bringing about that result. Amongst the cases
of sickness met with was one of leprosy, the patient being
a Swedish emigrant, who was detained and returned to her
own country. Such emigrants as are found to he ill are
removed to hospital, and the two infectious hospitals
belonging to Liverpool have proved useful in this respect.
Disinfection and other precautionary measures are also
adopted.
Whitechapel. —Mr. Loano estimates the deatii-rate for
Whitechapel during the past year at 24 per lOOO, and he
discusses the causes of tins mortality in some detail. He
also gives separately the deaths from certain specified
causes in the model dwellings. In view of the work of
improvement as regards dwellings which is going on in
Whitechapel, a detailed account is given in the report of
the conditions which, according to the general consent
of the metropolitan medical officers of health, are to be
egarded as constituting a “ condition dangerous or injurious
ogle
Dir:' 'ed :
The Lancet,]
HEALTH .OF ENGLISH AND SCOTCH TOWNS.
[March 28,1891. 739
to health” under the Act of 1890, as to the housing of the
\roTking classes. They relate to site, construction, age, and
want of repair, and nuisances ; and though no general code
can serve for application to every individual case, the rules
Said down will doubtless be of some service.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenly-eight of the largest English towns 6343 births
and 4196 deaths were registered during the week ending
March 21st. The annual rate of mortality in these towns,
which had declined from 24T to 22'1 per 1000 in the preced¬
ing three weeks, further fell to 21 9 last week. The rate was
20’3 in London and 23'I in the twenty-seven provincial
towns. During the past eleven weeks of the current quarter
the death-rate in the twenty-eight towns averaged 23 3 per
1000, and exceeded by 0‘4 the mean rate in tlie correspond¬
ing periods of the ten years 1881-90. The lowest rates in these
towns last week were 12'C in Derby, 16'5 in Birkenhead,
J7‘0 in Brighton, and 17'4 in Nottingham; the highest
were 2!)'2 in Portsmouth, 29‘5 in Preston, 33‘5 in Hudders-
dielii, and 30'0 in Blackburn. The deaths referred to the
principal zymotic diseases, which had been 470 and 413 in
ibe preceding two weeks, rose again last week to 449; they
included 181 from measles, 117 from whooping-cough, 52
from diphtheria, 39 from “fever” (principally enteric),
38 from diarrhcca, 22 from scarlet fever, and not one from
small-pox. These diseases caused the lowest death-rates
in Derby, Hull, and Wolverhampton, and the highest
Q'ates in Huddersfield, Salford, Portsmouth, and Blackburn.
The greatest mortality from measles occurred in Bristol,
E^lymoubh, Leeds, Huddersfield, Portsmouth, and Blackburn;
and from whooping-cough in Huddersfield, Leicester, Liver¬
pool, and Salford. The mortality from scarlet fever and
from “fever” showed no marked excess in any of the
twenty-eight towns. The 52 deaths from diphtheria
included 33 in London, 5 in Manchester, 3 in Salford,
2 in Liverpool, and 2 in Newcastle-upon-Tyne. No
death from small-pox was registered in any of the
twenty-eight towns; two small - pox patients were
under treatment in the Metropolitan Asylum Hospitals,
and one in the Higligate Small-pox Hospital, on Saturday
last. The number of scarlet fever patients in the Metro¬
politan Asylum Hospitals and in the London Fever Hospital
at the end of the week was 1126, and showed a further
decline from recent weekly numbers; the patients admitted
during the week were 91, against 87 and 64 in the preceding
two weeks. The deaths referred to diseases of the respira¬
tory organa in London, which had declined from 685 to 581
in the preceding three weeks, further fell last week to 656,
but exceeded the corrected average by 27. The causes of
Ql, or 1-9 per cent., of the deaths in the twenty-eight
towns were not certified either by a registered medical
practitioner or by a coroner. All the causes of death
were duly certified in Brighton, Portsmouth, Norwich,
ll’lymouth, Derby, and Bolton ; the largest proportions of
uncertified deaths were recorded in Liverpool, Halifax, and
JShellield. _
HEALTH OP SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had increased in the preceding five weeks from 21‘4
>10 26-2 per 1000, declined to 25'9 during the week ending
March 2l8t, bub exceeded by 4 0 the rate that prevailed
•during the same period in the twenty-eight large English
towns. The rates in the eight Scotch towns ranged from
S5’5 in Leith and 18'6in Aberdeen to 31'5 in Paisley and
in Glasgow. The 676 deaths in these eight towns
show a slight decline from the number in the preceding
week, and included 32 which were referred to whooping-
cough, 24 to measles, 5 to scarlet fever, 5 to diarrhcca,
■4 to “fever,” 3 to diphtheria, and not one to small-pox.
In all, 73 deaths resulted from these prmcipal zymotic
diseases, against 79 in each of the preceding two weeks.
These 73 deaths were equal to an aunnal rate of 2 8 per
SOOO, which exceeded by 0'5 the mean rate last week
Ifrom the same diseases in the twenty-eight English
towns. The fatal cases of whooping-cough, which had
been 34 and 31 in the previous two weeks, were 32 last
week, of which 19 occurred in Glasgow, 5 in Edinburgh,
and 4 in Leith. The deaths from measles, which bad in¬
creased from 18 to 23 in the preceding three weeks, were
24 last week, and included 13 in Paisley and 10 in Glasgow.
The 5 fatal cases of scarlet fever corresponded with the
number in the previous week, and included 3 in Glas¬
gow. The deaths from diphtheria, which had been 5 and 6
m the preceding two weeks, declined to 3 last week, all
of which occurred in Glasgow. The 4 fatal cases of “ fever ”
corresponded with the number in the previous week. The
deaths referred to diseases of the respiratory organa in
these towns, which had been 146 and 201 in the preceding
two weeks, declined last week to 194, but exceeded by 65
the number in the corresponding week of last year. The
causes of 61, or more than 9 per cent., of the deaths in the
eight towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate In Dublin, which had declined from 29'4
to 28T per lOtiO in the preceding three weeks, rose again to
28*4 during the week ending March 2l8t. During the
first eleven weeks of the current quarter the death-rate in
the city averaged 30'8 per 1000, the rate for the same period
being 23'0 in London and 21-3 in Edinburgh. The 192
deaths in Dublin slightly exceeded the number in the pre¬
ceding week, and included 5 which were referred to whoop¬
ing-cough, 4 to “fever,” 2 to diphtheria, and not one either
to small-pox, measles, scarlet fever, or diarrhcca. Thus
the deaths referred to the principal zymotic diseases, which
had been 4 and 8 in the preceding two weeks, further rose
last week to 11; they were equal to an annual rate of 1-6 per
1000, the rate from the same diseases being 1’8 in London
and 1 ’3 in Edinburgh. The deaths referred to whooping-
cough showed an increase of 2 upon the number in the
previous week; while the 4 fatal cases of “fever” corre¬
sponded with those recorded in the preceding week. The
deaths from diphtheria, which had been 2 and 1 in the pre¬
vious two weeks, were 2 last week. The 102 deaths in
Dublin last week included 31 of infants under one year
of age and 50 of persons aged upwards of sixtv years; the
deaths of infants showed a slignb increase, wliile those of
elderly persons were below those recorded in the previous
week. Tour inquest cases and 3 deaths from violence were
registered ; and 63, or nearly a third, of the deaths occurred
in public institutions. The causes of 20, or more than 10 per
cent., of the deaths in the city were not certified.
THE SERVICES.
Army Medical Staff.—S urgeon John George Stephen
Lewis is placed upon temporaiy half pay on account of
ill-health (dated March 6th, 1891).
Army Medical Reserve of Officers.— Surgeon Chas.
Stewart Young, having resigned bis Volunteer appoint¬
ment, ceases to be an Officer or the Army Medical Reserve
of Officers (dated March 25th, 1891).
Naval Medical Service. — The following appoint¬
ments hr-ve been made at the Admiralty:—Staff Surgeon
W, 11. White, M.B., to the Hotspur (dated April 26bh, 1891).
Surgeons: Edward H. M ‘Sherry to the Duke oj Wellington,
additional, temporarily (dated March 20th, 1891); Robert
Hill to the Research and Thomas Rowland to the Triton
(both dated April Ist, 1891); Wm. Tait to the Partridge,
Alexander G. Andrews to Bermuda Hospital, William M.
Craig, M.B., to the Sfivem, and Hamilton E. L. Earle to
Hongkong Hospital (undated); Joseph H. Whelan to the
Racoon (dated April 2nd, 1891).
Volunteer CoRvs.—Ariillerg: 1st Edinburgh (City):
Surgeon J. M. Ross, M.B., resigns his commission
(dated March 25tb, 1891).—2nd East Riding of Yorkshire
(Western Division, Royal Artillery): Surgeon W. Barter,
M.D., resigns his commission (dated March 2l8t, 1891).—
3rd (Dumfries) Volunteer Battalion, the King’s Own
Scottish Borderers: Acting Surgeon W. D. Grieve, M.B.,
resigns his appointment (dated March 25bh, 1891).
3rd Middlesex: Acting Surgeon, H. Cooper resigns his
appointment (dated March 2l8t, 1891).—2nd Cadet Bat¬
talion, the Queen’s (Royal West SurrOT Regiment):
Charles Swaby-Smith, Gent., to be Acting Surgeon (dated
March 21st, 1891).
Digiti/Rd by Google
740 -The Lancet,] THE REVISED SCHEME OF THE UNIVERSITY OF LONDON. [March 28, 1891.
" Audi alteram partem."
THE REVISED SCHEME OP THE UNIVERSITY
OF LONDON.
To the EdUors of The Lancet.
Sirs, —Without goiug into the many other questions
which might well be discussed in connexion with the above
scheme, one very obvious objection, it seems to me, exists
to it froin the point of view of the graduates of the Univer¬
sity—viz., the very inadequate representation of Convocation
upon the new SenaXe, which the new scheme proposes.
According to the scheme, Convocation is to be allowed to
elect only ten (10) Fellows of the University out of fifty-
two (52); or less than one-fifth of the tot^al number of
Fellows of which the new Senate is to be made up. The
medical graduates are to be allowed only two (2) represen¬
tatives (or, alternately with the Faculty of Arts, 3)—in
other words, the medical graduates will have a twenty-sixth
to one-seventeenth part of the voting power in the governing
body. It will be generally conceded that one of the chief
obstacles which has existed in the ftast in the way of
making graduates of the London University take a due
interest in the affairs of what, after all, is their university
(in spite of the opinion which appears to prevail in some
quarters that they should be allowed no voice in its recon¬
struction) has been the fact that the Senate practically
ignores the expressed wishes of Convocation in nearly every
case, and that it is quite out of touch with the graduates
of the University of which it is the governing body. The
constitution of the Senate was, perhaps, necessary when the
University was first founded, but now, when there are
thousands of graduates from which to select a governing
body, to continue even the present arrangement is an
anachronism ; but the new Senate is to be formed in a way
which, from the point of view of the legitimate representa¬
tion of the graduates, is worse than the original. The
graduates will have less voice than ever in the government
of the University. It will be said, no doubt, that, although
the CTaduates will have less direct representation, they
will nave more indirect representation, since most of the
medical graduates, for instance, belong to one or other of
the Royal Colleges or to one or other of the medical
schools. In reply to this, however, we may venture to ask
what guarantee is there that all or any of the representatives
elected by these bodies will be graduates of our own
university ? As a matter of fact, excepting certain
members of the Senate, who are, as it were, almost
bound officially to support it, the chief part of the
advocacy of the scheme has been carried on by gentle¬
men who are not graduates of the University. These pro¬
minent advocates will certainly be as likely, and probably
will be more likely, to be sent as representatives of various
bodies upon the Senate. They would not be likely,
nor would they be expected, to make the interests of the
graduates their first consideration. It follows, therefore,
that the interests of the graduates, as graduates, will be in
the hands of a mere fraction of the Fellows of the Senate.
Is nob this, Sirs, obviously unfair ? It seems to me that
Convocation would be unwise to accept so inadequate a
representation. Yours veiy truly,
Wiinpole-streot, W., March 20th, 1801. V.'l). HARRIS, M.D.
THE PULSE IN ANGINA PECTORIS.
To the EdUors of The Lancet.
Sirs,—A letter by Dr. Sainsbury in your number of
to-day represents me as having, along with some others,
“definitely accepted ” the statement “that during an
attack of angina the pulse may be unaltered in character.”
I could indeed, without much sense of individual responsi¬
bility, have accepted (in such good company, too) a tradi¬
tion that has come down to us apparently from Ileberden
himself, were it not that in the article published in 1877 by
Dr. Reynolds these words occur, p. 540 : “ But it is difficult
to accept without hesitation the statement of some autho¬
rities that, throughout the attack, the pulse maybe entirely
undisturbed, either as to its rate of frequency or as to its
characters, ” Dr. Sainsbury will himself see that this posi¬
tion la as nearly as possible the opposite of that which be
assigns to me; and I will add that I have not as yet
encountered anyone of authority who, giving accurately the.
results of personal observation, or with modern means and
appliances, has confirmed the statement in question, sup-
E osed to be now “definitely accepted.” The question
eing of some importance in tne pathology of angina, I >yill
venture to occupy your space for a few lines more in order to
show how, according to the view 1 bold of it, the traditional
statement has arisen. In Heberden’s first memoir the
statement is in these words: “ The pulse is, at leasff
sometimes, not disturbed by this pain ” (Medical
Transactions, 1768). In his Commentaries (1796) the
statement is made in less qualified terms, but also
in terms that betray more distinctly a theoretical
bias, as follows: “ Arteri® eorum, qui in hoc dolore sunt,
naturaliter prorsus moventur . in ipsa accepione pulsus
non condtatur." Now, in quoting these phrases, I pointed
out that “several authors have followed Heberden here
without observing that his real meaning is not that
there is no alteration of the pulse {in ipsa accepione),.
but that there is no excitement of it—i.e., that the
pulse is not quickened (non conoitatur) as in infiamma-
tion.” The Kernel of Heberden’s pathology was that-
angina pectoris is not an infiammation, but a spasm, or,
as we should now say, a neurosis (distensio nervorum)’,
and accordingly the pulse, be virtually affirms, does not-
obey the rule of alteration observed in inflammations. But-
it is a long stride from this to the assumption that in a-
severe, still more in a fatal, paroxysm of angina there may’
be no alteration at all, and no evidence of heart failure.
This conclusion was, in fact, distinctly disputed by Dr. Parry
(1799) within a few years of Dr. Heberden’s last publication
on the subject; and in referring to this in the article in
question I add: “Such personal experience as I have oi>
the point leads me to agree with Dr. Parry.” But it is nob
easy, of course, to get evidence that is beyond question on this-
subject. In many cases of sudden death from angina pectoris
there is practically no evidence at all as to the facts imme¬
diately preceding the fatal event. In others (as in the
famous case of Dr. Arnold, recorded in Dr. Latham’s book)*
the evidence, so far as it goes, is entirely adverse to
Heberden’a assumption or apparent conclusion. Everyone-
of course admits that in the intervals of the severe
paroxysms the pulse may be apparently that of health •,
but if this conclusion is to hold as regards the whole courser
of the paroxysm, it must be on the strength of observations
as yet unknown to me, and which it would be very desirable
even now to have set forth in exact language and froni
personal observation.—I am, Sirs, yours faithfully,
Glasgow University, March 21st, 1891. W. T. GaiRDNER.
THE HYDERABAD COMMISSION AND THE
aSE OF CHLOROFORM.
To the Editors of The Lancet.
Sirs, —Surgeon-Major Lawrie’s pei-sonal reference to m&
calls for a brief reply. My paper was not intended to-
instruct in the elementary methods of administering chloro¬
form, so I omitted details which I thought were familiar to-
all who had mastered the subject of chloroform administra¬
tion, and were not so wedded to one method as to allow them¬
selves to remain ignorant of all others. The open method,,
or that of Syme and Simpson, is so well and fully set forth in
Sir Joseph Lister’s article in “Holmes’s System of Surgery,”'
written in 1861, that it appeared to me to be superfluous
to describe it in the columns of a journal like The lancet ^
but since Surgeon-Major Lawrie has received numerous
letters from Europe concerning it, and has gone to the pains-
of describing it, I suppose I am wrong in supposing that
the A. BO of the chloroformist’s duties are pretty generally
understood.
With regard to the second method to which I alluded, that
in which Junker’s inhaler is employed, I must say that
your correspondent is clearly wholly unacquainted with the
method, or he w5uld nob have permitted himself to
indulge in such playful criticism. His humour loses
none of its point when read by a person who is
familiar with Junker’s apparatus. I may just say that,,
with average intelligence and common-sense, the inhaler
can be used without necessitating Surgeon-Major Lawrio’s
suggestion being caiTied into effect, and the patient^
Digiti -d 'ly' Google
The Lancet,]
ERYSIPELAS AND TOTAL ABSTAINERS.
[March 28,1891. 741
compelled "to do it himself.” Further, the argument
-which he adduces — viz., that because 1 had seen
various degrees of heart failure and circulatory trouble,
therefore my methods are erroneous—is an instance of
what logicians call a ■petitio prmcipvi, and proves
too much. In the first place, the open method, to
which my remarks mainly referred, is precisely the
method which the Hyderabad Commission,following Syme,
advocates. I, as well as many others in Europe, learnt
the method before the session of the Commission. That
Surgeon-Major Lawrie has never seen the heart fail and
that 1 have is not surprising, because he has never felt the
pulse or examined the action of the heart during chloro-
lormisation, and 1 have. That Surgeon-Major Lawrie has
had many cases I do not for a moment doubt, only he has
overlooked them, and as, fortunately, in most cases re¬
spiratory rhythm is ailected pari passu with cardiac
enfeeblement, he has seen the danger-signal gnd the
tespiratioD, and has taken measures accordingly.
1 am further stated to give no fixed principle of chloroform
administration, and in my paper, to which reference bos been
made, I admit such is the case, and for the reason above
-stated, that my object was argumentative rather than
didactic. In iny lectures and practical demonstrations I
believe I am dogmatic enough, but personally I regard
dogmatism in discussions upon scientific subjects in a scien¬
tific periodical as unseemly and valueless. In conclusion,
tnay I draw attention to a sentence against which 1 am
bound to enter a protest? It runs: "The Hyderabad Com¬
mission has proved that there is no such thing as chloroform
syncope, and that in death from an overdose of chloroform
the respiration always fails before the circulation.” I sub-
tmit the Hyderabad Commission has done nothing of the
kind; its conclusions were based upon purely negative
evidence, and were not warranted by the facts before the
profession, and I am strongly of opinion that any teaching
which tells chloroformists to ignore the pulse is fraught
with danger. I am greatly obliged to Surgeon-Major
Lawrie for his courteous reference to myself, and can
assure him that I constantly employ the open method and
obey the rules he, following Syme, advocates; but I also
watch the pulse.—I am. Sirs, your obedient servant,
Dudley W. Buxton.
Moi'timer-street, Cavoiulisli-square, W.
INFLUENZA COMMUNICATED TO CATS AND
HUMAN BEINGS BY HORSES.
To the Editors of The Lancet.
Sirs,—A t Cairndow, Loch Fyne, on Dec. 24'ih, 1889, two
.yearling coUs in Mr. J-’a stables were seized with
" strangles,” or what was believed to be that disease. On
Jan. 2nd, 1890, two horses, aged respectively five and six
years, were seized with iollaenza; the symptoms were
as follows: short cough, profuse nasal discharge, nauseous
breath, marked stiffnes of joints, disinclination for food or
•drink; no lung complications; duration of illness about three
weeks. I had nob the opportunity of seeing these horses,
but gob the above facts from the owner, a gentleman skilled
in the treatment of horses. I had, however, the opportunity
of seeing and treating a horse infected in Mr. J-’s stables;
this horse was in the infected stables for four hours on
Jan. 17bh, 1890, and was not in any other infected stables
or near any other infected animal. The incubation period
was six days and the period of illness sixteen days.
This horse suffered from the following symptoms while
‘Under my treatment: short coughj witli nasal discharge,
at first watery and latterly thick, with a yellowish tint and
ofibnaive smo'll; no glandular swelling of the throat or jaws;
he had a weak appearance, staring dry coat, drooping head,
dal], sunken eyes, and suffered from loss of appetite, dilfi-
culty in urinating, and constipation. For a few days this
horse had not lain down in his stall at night. The stetho¬
scope revealed no lung complications. Temperature per
rectum 102°; pulse 60 per minute. Mr. J-, the owner of
the liorses at Cairndow, had three young cats which fre¬
quented a hay loft over the stables where the horses were
kept while suiraiing from influenza. These cabs were often
seen in the stables or about the stables where the horses
fed. They were soon seized with sneezing, cough, discharge
from eyes and nose, were disinclined to take solid or liquid
nourishment, and suffered from severe purging. One died,
the others recovered.
From Jan. 9th, 1890, to Feb. lObh, a dancing class was
taught in the hey loft above the stables. This loft was low
in the roof, with deficient ventilation, and the infected
stables below were in a most insanitary condition. There
was direct communication between the mangers out of which
the affected horses fed and the hayloft through which a
current of air passed into the loft and contaminated the
atmosphere. There were forty pupils at this school, mostly
the children of shepherds isolated from each other over an
area of about four or five miles from the hay loft where this
class was held. There are only about a dozen families in
the district, and owing to their pursuits in life and primi¬
tive habits they have little communication with the outside
world. There was no case of infiuenza in the district or
anywhere near it as far as I know before Jan. 1st, 1890. On
that date a person, who was in continual contact with
the horses, was seized with the disease. On Feb. 2od his
BOD and a neighbouring lad were attacked with influenza,
complicated with pleuro-pneumonia. The son described bis
symptoms as follows. General malaise for about a week.
reat depression, sickness and nausea, foul breath, hot and
ry skin, alternately with cold sweats, severe pain in loins,
frontal headache, deep-seated pain behind the eyeballs,
followed by cough and prune-juiceexpeeborabion. All these
cases were convalescent before I had the opportunity of see¬
ing them, and cannot describe the symptoms more minutely.
All the forty pupils in the dancing class suffered from well-
marked influenza except seven. Some had the disease in a
mild form, others haa the gastro-intestinal type of this
disease, one bad severe otitis, with foul discharge from the
ears. An occasional onlooker at the dancing class, a young
lad, took ill on Feb. 7th, and his father the following day,
both died on the 15th of the same month. They were ailing
more or less for a week before being confined to bed. These
were the only two fatal cases. At Loebgoilbead, about
nine miles from Cairndow, there were five or six mild
sporadic cases after the epidemic at Cairndow, but there
were no other cases to my knowledge within ten miles of
Cairndow. I think it fair to infer that a type of this disease
was communicated from the horses to the cats and all the
pemons who suffered from it.—I am, Sirs, yours truly,
J. H. Caird,
Lochgoilhead, Matdi IGU\, 1801. Medical Officer of Health.
ERYSIPELAS AND TOTAL ABSTAINERS.
To the Editors of The Lancet.
Sirs,— I should be sorry if any of your readers should, by
my silence, imagine that I admit the truth of Mr. White¬
head’s Parthian shot. I can atl'ira to be amused at his
reference to ray supposed want o ■ knowledge on the subject
of alcohol. Mr. Whitehead is mistaken as to Dr. Parkes’
dictum with regard to the quantity of alcohol which an adult
man might possibly take. It was the late Dr. Anstie who,
at one time, pub the limit at two ounces (not "about two
ounces,” Mr. Whitehead). Dr. Parkes put the limit as
between an ounce and an ounce and a half in the twenty-
four hours, the maximum amount for a powerful man
accustomed to the use of alcohol. And what he said
about this was that this amount was nob followed by any
immediate and obvious deleterious effects. I think it can
be shown that Dr. Parkes was mistaken on this point;
but even if he were not, it by no means follows that such a
dose could be taken day after day, month after month, and
ear after year with similar freedom from obviously
ad consequences. As a matter of fact, the returns of
some insurance companies show that in the long run these
constantly repeated small doses of alcohol cause earlier
average death by five or si.x years than would otherwise
have been the case. Bub more accurate tests than
Dr. Parkes applied have shown that all the senses are
rendered less, acute than before by moderate doses of
alcohol, and that perception, discrimination, and decision
are all rendered slower. As Dr. Lauder Briinton has said,
it produces progressive paralysis of the judgment, and, I
may add, of the will likewise. Mr. Whitehead says he is
unaware that alcohol in small doses, well diluted, lowers
the temperature in health, and says there is evidence to
the contrary. Some observei-s have noted a very
small temporary rise of half a degree or so, fol¬
lowed by a fall; others deuy any alteration, espe¬
cially in those accustomed to it. I have noted in myself,
an abstainer, a fall of from half to one depee F. some
time after two drachms of alcohol well diluted. It is
742 The Lancet,]
AEKEST IN GENERAL PARALYSIS.
[March 28, 1891.
an experiment which aiwone can make, taking ordinary
care to avoid fallacies. These and many other considera¬
tions show that alcohol lowers vital action, though it may
apparently stimulate indirectly through relaxation of
bloodvessels. We come back to the point that in such a
condition the body is less fortified against the attacks of
erysipelas or any other disease. The returns of the London
Grand Division of the Sons of Temperance for 1890, not¬
withstanding the influenza epidemic, show an average sick¬
ness of seven days per member. The most temperate users
of alcohol cannot beat that. I trust that Mr. Whitehead
will further investigate the subject, and see what the
standard works on alcohol really say.
I am, Sirs, yours truly,
J. J. Ridge,
Enfield, March 10th, 1801. Hon. Sec., Brit. Med. Temp. Assoc.
*** The correspondence on this subject must now cease._
Ed. L.
ARREST IN GENERAL PARALYSIS.
To the Editors o/Thb Lancet.
Sirs,—R ecently there have been under my observation
three successive cases of general paralysis, in each of which
“arrest” has taken place; all were strong men and in the
prime of life. The symptoms were unmistakable; indeed,
they were typical of the disease. I need hardly give them
in detail, they are well known. The first patient believed
himself King of Heaven and Earth, and made princes and
dukes of those around him; he made millions of money
daily, and invited the Prince of Wales and the Duke of Cam-
bridge to dine with him. The second was violent, fought and
resisted at first; he made two hundred thousand pounds
a day, and offered to make the fortune of all indiscrimi¬
nately at once; he squandered his money and wrote cheques
recklessly.^ The third was maniacal; be shouted incessantly
and was violent, he had thrown knives about, he was King
of the World, he had inherited millions under successive
wills, and spent most of his time, from his lofty elevation,
in watching and controlling the revolutions of the earth.
In each of these cases there were pin-point, unequal, or
irregular pupils, the usual great excitement of the first stage,
the filthy habite, the restlessness, the sleeplessness, the loss
of flesh, the tremulous movements of lips and tongue, and
the defective and drawling articulation. They each went
through a longer or shorter first stage, and, finally, each in
turn gradually lost the excitement, the exaltation, the
delusions, the filthy habits, the restlessness, the sleepless¬
ness, and made flesh. Coherence returned perfectly in the
first two cases, tlie third is gradually regaining it. The
mental powers, considering the strain they had gone through,
were wonderfully little impaired. Each became able to
transact business, to settle, manage, and put in order his
own affairs. It is not improbable—indeed, it is likely_
that each of these cases will again break down physically,
and lose mind, but my object in seeking to draw attention
to such ceaes is to show that it may prove of immense
advantage to a patient suddenly struck down with so for¬
midable a disease as general paralysis to practically recover,
although the recovery may be only temporary, and thus
have time given him to put bis house in order. That such
remission, arrest, or temporary recovery from the disease as
I have here described may be favoured by early treatment
and careful conduct of the patient through the first stage
my later experience of general paralysis leads me strongly
to believe.—I am, Sirs, your obedient servant,
James Adam, M.D.
West Mailing’, Kent, March 14th, 1891.
ST. BOTOLPH'S CHURCH, ALDGATE.
To the Editors of Try. Lancet.
Sirs,-—A s upper warden of the church of St. Botolph,
Aldgate, I cannot allow to pass without comment the con¬
demnatory remarks you have thought lit to make upon the
conduct of those concerned in the removal of the bones in
the churchyard surrounding this church. The original
order was varied because it was found that, in order to con¬
struct a vault as originally ordered to receive the displaced
bones, other bones, probably in equal quantity, would have
fo be displaced. During tlie erection of a new beating
apparatus three months ago numerous vaults containing
reinains were found in the floor of the crypt, and it was
decided that this should be leveled and concreted. Before
this could be accomplished the difliculfcy occurred with
regard to the disposal of the bones found in the churchyard.
Dr. Tristram came down and carefully inspected the pre¬
mises, and ordered that the bones should be deposited in
the crypt. This order has been reverently and decently?
carriea out. The bones so collected have been sprinkled
with lime and put in boxes, and each box has been covered
with an inch of vegetable charcoal before being fastened
down, and this has been done, not because there has beem
the least perceptible effluvium, but simply as a matter of
precaution. The leaden coffins are placea each in a separate
box in the crypt under the tower of the church, and there
walled in and cemented. The bones are all dry and clean
there has not been at any time during the progress of the
work any odour detected. You probably are not aware
that no law exists which would permit the removal of the
bones as you suggest. In order to obtain such removal
nothing short of a special Act of Parliament would have
been required. I think it desirable that before making
public comment on such an undertaking you should make
yourself personally acquainted with the circumstances. I
shall be happy to show you or your representative over the
church and c^pb at any time by appointment. Meanwhile
I shall be gla^ if you will cause the insertion of this letter
in The Lancet of this week.
I am, Sirs, yours faithfully,
Jno. Cotman, M.R.C.P. Edin., &c. ,
Minories, Cifcy, March 28rd, 1801.
A NOZZLE FOR NASAL DOUCHE.
To the Editors of The Lancet.
Sirs,—H aving had some difficulty in arranging a nasaf
douche for a lad^y, I had a nozzle made for me, which I
think presents some advantages. It consists of a hollow
indiarubber nose piece, which can be blown out just so as te
be comfortable to the nostril. It has a central tube, into
which a glass tube (connected with a syphon douche) fits.
By its softness and its accurate adaptability to the nostril,
it prevents escape of any lotion used, and at the same tim&
gives the patient no discomfort.
I am, Sirs, yours obediently,
Russell Coomee, M.A,, F.ll.C.S.
West Southemhay, Exetor.
P.S.—It was manufactured by Messrs. C. Wright & Co.,
of New Bond-street.
THE “REST CURE” IN THE SAHARA.
(From a Holiday Correspondent.)
Tins islet, or rather group of islets, in the great sand aea'
has all the makings of an admirable health resort,
particularly for the sufferer from brain fag or the con¬
valescent from neurasthenia. Its stillness, its estrangement-
from “ the fever and the fret” of the populous European
centres, its pure exhilarating atmosphere, its varied
Digit'zed by Google
The Lancet,]
THE “REST CURE” IN THE SAHARA.
[March 28,1891. 743
iodnceroents to opea-air life, are all in the invalid’s favour,
while its natural and historical interest is sullicient to
keep the intellect in gentle activity, to say nothing of the
moral fascination it owes to the work of Cardinal Lavieerie,
that exemplary pioneer in the cause of negro disenthr^dom
and enlightenment.
For six months of the year the climate of Biskra is all that
<000 be desired. Its salubrity and general attractiveness
were familiar to imperial Rome, which made it one of the
outposts of the Third Legion, which was quartered in the
province. Ad Piscinam was the name it then bore,
whence, by phonetic decay, we get “Biskra.” Its mean
temperature on an average of ten years is 73° F., the
maximum during the same period being 124° (in summer)
and the minimum 36° (in winter). Rain seldom or never
dalls, and its only objectionable feature is the occa-
aonal prevalence or high winds more or less charged with
sand.
Its w’ater-supply from the Oued Biskra (“ Oued” corre- ,
spending to the “Wady” of Upper Egypt, and meaning
nver or river valley) is aWndant in winter and spring, and
never fails except in phenomenally dry summers. Even in
such droughts the boring of artesian wells has made the
'inhabitants independent of the Oued, the enterprise of the !
French having provided it, as well as the oases in the
Sahara, with such means of maintaining water enough for
drinking as well as for agricultural requirements. Thanks
«to this addition to its resources the vegetation of the town I
and neighbourhood is wonderfully fresh and luxuriant, fur- I
nisbing not only pleasant shade in the public garden, but
affording in the private retreat of M. Landon an assortment
of successfully acclimatised trees, tropical and subtropical,
which form a source of perennial delight to the public, to
whom they are made liberally accessible.
Again, the sulphur baths (with a temperature of about
!112°F ) are another resource of Biskra not to be overlooked
by the visitor. Rising in the Djebel-bon-Ghazal, a low
limestone range about six kilometres from the town, they
burst forth in great volume to the amount of forty litres a
second, and have been greatly utilised by the oflicers of the
French garrison, as they doubtless were by the Romans of
the Empire. Unlike their Imperial predecessors, however,
the French have done but little to make tlieir virtues
•enjoyable by the general population. Where Rome, as
the remains of ruined structure testify, must have had a
thermal establishment on the system, if not to the extent,
•of those yet visible at Pompeii and other provincial
towns, I’rance has only produced an assortment of cabins,
but one of which—that reserved for the officers-—is fit for
•decent use. True, there is a talk of extending the accom¬
modation at these baths, and there is even a project of
•carrying the water by pipes into Biskra itself. But as this
'latter enterprise is to be associated with the construction
of a casino and the establishment of a gambling table on
■the model of Monte Carlo, its realisation seems fraught
with very doubtful advantage to the hitherto tranquil and
■unspoiled health resort in the Sahara Whatever “ busi¬
ness” of the fashionable kind it would bring to Biskra, it
would be fatal to the chief attraction the place now pos¬
sesses as a seat of the “ rest cure. ”
While the natural recommendations of Biskra are so
^tronounced, and, in some respects, so unique, there are
•drawbacks connected with it which have made the former
accessible to comparatively few. The Algerian railways are
<a discredit to French civilisation. Their rate of travel is so
alow—top speed barelyfifteen miles an hour—that to getfrom
one considerable town in the colony to another the pas-
•aenger has to start at an hour far too early for all but the
robust. The conveniences of the railway service are, more-
•over, quite inadequate to modern requirements. No means
of retirement in the railway carriages such as the traveller
■on the English or European lines is universally accustomed
'to ; no foot-warmers, even in the dead of winter, except on
•one or two favoured routes; no intermediate stations
where the passenger can, if necessary, spend the night
with safety to health or without oifence to decency; no
buffet or restaurant where food lib to eat may be counted
on • and (most objectionable feature of all) no lie.u
-rf’a’mnce which the average Briton, a fortiori the deli¬
cate lady, can enter or even approach. Out of Algiers
it is dUlicult to find a hotel where cleanliness and comfort
are provided for on a civilised scale; indeed, but for Swiss
enterprise and management, Biskra itself would be quite
inferior, in point of hotel accommodation and appointments,
to a second-rate Italian town. Improvements in this direc¬
tion, and nob in that of multiplying casinos and gambling-
tables, are wbat is needed for the development of Algeria
as a health resort. After sixty years’ occupation of the
colony—a colony, moreover, little more than a day and
night’s voyage from her Mediterranean ports—France has
done marvellously little for the introduction of civilised
institutions. The “rest cure ” is an excellent addition to
therapeutics, for which Southern Algena is admirably well
adapted. It is a pity that those in high office ehoula have
practised it in their own case, and made their posts little
better than the dormitories of officialism.
Biskra, Marcli IStli.
NORTHEEIT COUNTIES NOTES.
(From our own Correspondent.)
Prudhoe Memorial Convalescent Home.
At the late meeting of the Convalescent Socie^ of New¬
castle, held in the library of the Royal Infirmary, Dr. Philip-
son read the report, which was the thirty-first of the
Society’s existence; but the Prudhoe Memorial Home at
Whitley was only opened in September, 1869, and, as will
be shown from the report, has done an immense amount of
good work since. The number admitted during the twelve
months ending Dec. 3Ist last has been 1513. This number
is tbir^.six less than that of 1889, but the year 1889 was
exceptional as compared with all preceding ones. The total
number of patients received since the inscitution was
opened has been 21,722. Dr. Bramwell read the medical
report, which stated of those cases treated during the year
1094 were cured, 378 were greatly benefited, 39 weremsiafw
<luo, and 2 died.
The Health of Middlesbrough and Stockton.
The medical officer of health for Middlesbrough (Dr.
Malcomson) reports that the death-rate had greatly im¬
proved, having fallen from 33 in January to 22 in February,
which was owing to the favourable weather and the dimi¬
nution of fatal cases of typhoid fever. At Stockton, too, it
appears that typhoid fever is decreasing, but there was still
some continuance of scarlet fever.
Ambulance Work in the North.
An examination of members instructed under the rules of
the St. John Ambulance Association was held at North
Ormesby last week, the men being from the large works in
the neighbourhood. Surgeon-Major Hatton was the exa¬
miner, and he said the examination reilected great credit
on Mr. Smith of North Ormesby, the instructor of the
class. Upwards of 5000 persons have passed the Asso¬
ciation examinations, which numerically is now the largest
district engaged in this work, w'ith the exception of
Londonat Darlington, too, classes have been examined,
and Mr. Jackson has been complimented for their proficiency,
likewise Drs. Smeddle and Fieiden at Shildon ; the last has
received a presentation from his class. Dr. Lambie of
Lowick has received a presentation of ahandsome stationery
cabinet, together with a purse of sixty-seven sovereigns, in
grateful recognition of his valuable services as medical
adviser and the lively interest he has taken during his resi¬
dence of twenty years in the village in the well-being of the
neighbourhood.
Hexham.
Dr. D. Jackson, the medical officer of health for Hexham,
in his annual report says that the death-rate, 15'52 per 1000,
was the lowest it had ever been his privilege to record.
The year’s working of the notification of diseases had been
satisfactory. He is strongly against having a hospital
conjointly with other authorities for infectious diseases, as
the chief attraction of Hexham, and a future source of its
prosperity, would be its public health, and to concentrate
the infectious diseases of a wide area in their midst would,
in bis judgment, be most detrimental to the best interests
of the district.
Recovemi of Sulphur from a Waste Product on the Tyne.
The Newcastle Chronicle, referring to the opening of
works on a large scale some time ago for the manufacture
of sulphur by Chance’s process, notes that it has been a com¬
plete success; that so large a market has been found for the
sulphur recovered from the “tank waste ” in the alkali manu-
Google
744 The Lancet,} SCOTLAND.—IRELAND. [March 28, 1891.
factare that the article commands a price 50 per cent, above
that formerly realised. But there is another aavantage in the
utilisation of this tank waste—namely, the removal of a
nuisance which was at once unsightly and offensive. If the
carbon and sulphurous acid which are so freely suspended
in our Tyne atmosphere could be recovered in some similar
way it would be indeed a blessing- For this, I suppose, we
must wait until it can be shown to be acommercialsuccess.
Newcastle-upon-Tyne, March 24tb.
SCOTLAND.
(From our own Correspondents.)
Edinburgh Public Health Committee.
At the meeting of the Public Health Committee last
week it was reported that the total number of deaths regis¬
tered in the city during February was 396, making the
death-rate 17'25 per 1000, as compared with 490 in the
corresponding month of last year, and 367 in 1889. The
rate was below the average of the preceding five years by
a fraction of a unit per lOOO. As regards age, 29*29 per
cent, were under five years, 12'12 per cent, between five and
twenty-live years, 29'79 per cent, between twenty-five and
sixty years, and 28*78 above sixty years. As regaixis the
causes of death, diseases of the chest accounted for 35*85
per cent., debility and old age for 12*12 per cent. zymotic
diseases for 10*10 per cent. During the month 393 cases
of infectious disease were intimatedf, compared with 1037
iu the corresponding month of last year, 161 in February,
1889. Of these, 165 were oases of scarlatina, 107 of
measles, 94 of typhoid fever, and 27 of diphtheria. Into
the Cit^ Hospital 139 patients had been admitted, 123
discharged, and 10 died. At the end of the month there
remained 262 patients in the hospital, 129 being cases of
scarlatina and 82 of typhoid fever. The birth-rate for the
city was at the rate of 24*04 per 1000; the males num¬
bered 290 aud the females 262. During the month
29,714 lb. of unsound meat were seized or delivered.
There were 16 cases of tuberculosis, in 10 of which the
animals were destroyed by order of the Board of Agricul¬
ture.
Royal Physical Society.
At the meeting of this Society last week Dr. G. Carring¬
ton Pnrvis read a paper on the biological examination of
water and milk, with special reference to typhoid fever, and
another on the pineal eye of the porbeagle shark.
Health of Edinburgh.
The mortality last week was 114, making the death-
rate 22 per lOOU. Diseases of the chest caused 60 deaths,
and zymotic diseases 7, of which 5 were due to whooping-
cough. The intimations for the week were—typhoid fever,
4; diphtheria, 5 ; scarlatina, 15; measles, 88.
Hospital for Sick Children, Aberdeen.
Daring the past year 484 patients were treated in the
hospital, of whom 387 had been resident in Aberdeen, and
97 came from the country. The expenditure amounted to
£1717 8s., while the income, including a balance of £23 4.v. id.
brought forward from the previous year, amounted to only
£1637 Os. 5d., showing a deficit of £80 7s. Id. During the
year £730 17s. 9rf. had been received on capital account,
consisting of legacies and special donations, which had been
applied towards clearing off the hospital debt, which has
now been reduced to £1670 5s. Id.
Factories and Workshops Bill.
The Senatus Academicus of the UniversiWof Glasgow
have forwarded to Mr. James A. Campbell, M.P., for pre¬
sentation to Parliament, a petition with reference to the above
Bill, setting forth that the certificate of fitnessforemployment
of children and young persons in factories and workshops is a
valuable safeguard, that the requirement of it is in accord¬
ance with other legislative enactments for the protection of
the young, and that its abolition (as proposed by the nine¬
teenth clause in the present Bill) would be a retrograde step.
A resolution has also been adopted by the Medical Faculty
of Aberdeen University viewing with apprehension the pro¬
posal to abolish the certificate at present required of fitness
for the employment of children and young persons in
factories and workshops.
March 24tli.
IRELAND.
(From our own Correspondents.)
DUBLIN.
The late Mr. R. O, H. Butcher.
The late Mr. Butcher [a notice of whose life and work
appears in another column] was a brother of the late Bishop
01 Meath, and as a memorial to him and his father, Admire
Butcher, he at bis sole cost fitted up a lifeboat station on<
the west coast of Ireland, at a large expenditure, the boat-
alone costing £1000. During his last illness he was attended
by an old pupil, Mr. W. J . Wheeler.
Health ofBuhlin during ISOO.
. In th» Dublin registration district the births registered
last year numbered 9629, being equal to 27 per 1000, and the
deaths 9454, or 26*8 per 1000, or, allowing for the inter¬
calary week, to 26*3, being 0*7 over the rate for 188(^.
Deaths from zymotic diseases were 1019, or 418 below the
average for the previous ten years. Of these, measles-
caused 106 deaths; scarlatina, 8. . There were 25 deaths
from typhus, 185 from enteric fever, and 9 from simple
continued fever. Whooping-cough caused 187 deaths
diarrhcea and dysentery 184; while inftuenza, which pre¬
vailed in the early part of the year, caused 78 deaths, of
which 61 occurred in the first quarter from pulmonary and
other complications. The mortality among children was
considerably below the average, the death-rate under live
years being 69*6 per 1000 of the estimated number of the-
living at that age, against an average of 88*1 for the'
previous ten years. The deaths of infants under one year-
were equal to 163 per 1000 births registered ; in 1889 the-
infant mortality rate was 180.
Monkstown Hospital.
During the pash year important and, extensive improve¬
ments have been made, and at present the institution is in
a thoroughly efficient condition. It is satisfactory to learn
that the new wing, comprising two wards, a nurses’ room,
and kitchen, has been furnished and equipped without,
trenching upon the funds of the hospital. There is, how¬
ever, a balance due on the building account of about £300„
and a debt of about £100 on the ordinary maintenance of
the hospital; but as every item which may be regarded as-
permanent income increased last year, the outlook for the
future is encouraging.
Poisoning by Paraldehyde.
In August last a patient in the Cork Workhouse dieri
from an overdose of paraldehyde administered to her by the
nurse. Miss Catherine Horgan. particulars of which have
already been fully reported in these columns. At the Cork
Spring Assizes last week the grand jury found a true bill
for manslaughter against Horgan.
A Centenarian.
A lady named Sullivan died in the Kanturk district,.
CO. Cork, last week, aged 109 years. Her sister died about-
twelve months since, also at a very advanced age—viz., 106.
Queen's College, Cork.
The following lecturers have been appointed by the
CouncilOscar Woods, M.D., L.K.C.S.I, to be lecturer
in Psychological Medicine; J. Cotter, M,D.,M.Ch.. to b&
lecturer in Pathology ; Arthur W. Sandford, M.D., M.Ch,»
to be lecturer in Ophthalmology and Otology; and Denis
D. Donovan, L.ll.C.P. and S. Edin., to be lecturer in
Hygiene.
A grand ball, under infiuential patronage, will take place
at the Assembly Rooms, Cork, on April lOtb, in aid of
the Nile-street Hospital. _
BELFAST,
Queen's College, Belfast.—The Graduates' Reunion.
One of the most interesting events in the history ,of
Queen’s College, Belfast, took place on Thursday evening,
^'^aroh 19bb, when the old graduates assembled at d banquet
ip the Great Hall of the College. There was a very large
attendance. The President (Dr. Hamilton) occupied the
ebair, having on his right Lord Justice Fitzgibbon and
on bis left Mr. Justice Gibson. The Mayor . (Mr.
Connor, M.A.), an old Belfast student. Lord Bangor, -th^
Moderator of the General Assembly, the 'Prerideiit off
DiaitiZCC: hy Google
The Lakcbt,]
IRELAND.—PAMS.
[Mabcq 28. 1891. 745
the Harbour Commissioners, the City Recorder, Rev.
A. H. Pakenham, the President of the North of Ireland
Branch of the British Medical Association (Dr. W. A.
Keown), the President of the Ulster Medical Society
(Dr. Dempsey), the professors of the College, and a large
number of the leading representatives of the clerical,
medical, legal, and scholastic professions in the north of
Ireland were mesent. After the usual loyal toasts had been
proposed the President gave “ The Health of the Judges,”
which was responded to by Lord Justice Fitzgibbon and
Mr. Justice Gibson, The toast of the evening was then
proposed by Lord Justice Fitzgibbon—“ Floreat Collegium
neginale Belfastiense,” to which the President replied, and
in a very happy way pointed out the distinguished positions
that old graduates of Queen’s College, Belfast, now occupied
in all parts of the world. He gave the following interesting
statistics. The College has now been in operation for four
complete decades. In the first of these the average number
of students each year was 189; in the second this figure
was nearly doubled, rising to 368; in the third it rose to 400;
in the fourth, the last which has been completed, it mounted
to 473. Professor liedfern, M.D., then proposed the toast,
“ The Benefactors of the College,” to which the Rev. A. H.
Pakenham replied. “ The City and Trade'of Belfast ” was
given by Mr. Shaw, Q.C., and the Mayor, the President of
the Harbour Commissioners, and the President of the
Chamber of Commerce replied. TbeModerator of the General
Assembly (Rev. W. Park, M.A.) proposed in very felicitous
and complimentary terms, “ The Medical Schools of Ireland,”
to which Professor Cuming, M.D., re^onded. Mr. Dodd,
<i.C,,gave “ The Press,” to which Mr. Henderson, M.A.,and
Mr. M'Knight replied. Professsor Purser, D.Sc., proposed
“Long Life and Happiness to our President and Mrs.
Hamilton,” which was received with great enthusiasm.
The President having replied, the proceedings terminated
shortly after midnignt. In addition to the band of the
Rilie Brigade, the following gentlemen contributed an
excellent programme of vocal music, under the direction of
Dr. J. A. Lindsay: Dr. MacKenzie, Dr. Leslie, Dr. McCaw,
Dr. M‘Kissack, and Mr. W. N. Watts, B.L , LL.D. The
Hunion was a very great success, and the proceedings
throughout were most interesting and enthusiastic. The
President has won golden opinions by the admirable tact,
good sense, and sound judgment which he displayed
throughout the proceedings of the evening.
March 28r<l. _
PAKIS.
(Fkom oub own Correspondents.)
The New Law Regulating the Practice of Medicine in France.
The great event of the week here is the passing by the
Chamber of Deputies, on the first reading, of this much-
talked-of Bill. Having been declared d'urgence, a second
reading of the Bill is unnecessary, and it passes at once,
after the Easter recess, to the Senate, where it is unlikely
that its clauses will undergo material modification. The
Bill derives its claims to importance principally from the
•clauses affecting indigenous and foreign doctors and
dentists, and also from the fact that it renders compulsory
the notification of certain infectious diseases (the list to be
made out by the Minister of the Interior after consultation
witli the Acadcmie de Miidecine and the Comitd Consultatif
d’Hygifene Publique), and the participation of medical
practitioners in medico-legal inquiries, whenever a requisi¬
tion to that effect is made by the authorities. With
regard to the compulsoiy notification of infectious dis¬
eases, it seems to mo that its working will be diffi¬
cult, seeing that the words et n-engagcant pa.? le
.secret professionnelf qualifying the words maladks 6pi-
demigues, leave apparently a considerable loophole for its
non-observance. The clause providing for the compulsory
participation of doctors in medico-legal investigations is
doubtless meant as a reply to the strike of the profession,
the members of which naturally object to give and prepare
evidence in such cases for the miserable pittance now offered
to them. The present Bill is designed to revise the rigime.
under wliich, since the year 11 of the first Republic,
followers of the healing art have existed. As long ago as
1883 Dr. Chevaudier, a medical deputy, laid on the table
of the Chamber a similar Bill, but it is curious that the
measure just passed by the Lower House should be almost
identical with one that was voted by the Chamber
of Peers in 1847. The officier de sanU dates from
the year 11 above-mentioned. In no other European
State, excepting Portugal, does there exist a similar
inferior grade of practitioners. In France, he differs from
the M.D. in that (1) he has never passed his haecalawr6ate
bs Sciences et ^s Lettres (in student slang, backo) ; (2) he is
forbidden to perfonn major surgical and obstetrical opera¬
tions ; (3) he does not enjoy the prestige of his bierarchiMl
superior, the M.D. The new law provides fur the extinction
of this second-class practitioner, while reserving to existing
ojftciers de scvnti their right to practise under the same
restrictions, and allowing such of them as desire to do so
to graduate as M-.D., under conditions to be hereafter de¬
termined by the Conseil Sup6rieur de I’lnstruction Pub-
lique. In future, no one will be allowed to practise
medicine on French territory who is unprovided with
tbe diploma of Doctor of Medicine delivered by the
French Government. Foreigners desirous of practising
in France will have to pass the examinations (and write
the thesis) qualifying for the degree at whichever faculty
they may choose; but if they can produce tbe pass
certificate of a preliminary examination undergone in their
own country, and deemed by the French Minister of Public
Instruction of sufficient value as a mafrieulafcion test, they
will be excused the baccalauriate. Tbe Minister shall also
have the power to excuse the foreign aspirant not more than
three professional examination tests (trois 6preuves). A
novel feature of the Bill is tbe recognition of tbe legal status
of the dentist. While at present anybody may practise that
art, in future no person unprovided with the diploma of
M.D. or that of ofjieier or with the licence (iirewei) of
dentist delivered by the French Government, may do so.
It was originally proposed to create a diploma in
Dentistry, but an amendment was carried declaring a
simple licence sufficient. The nature of the examinations
qualifying for the brevet de dentistc will he hereafter
determined by the Conseil Sup6rieur de I’lnstruotion
Publique. Vested interests are respected as in the case
of offtcicrs de santd. Any native or foreign dentist who, by
the production of bis "patcnte (nearly all callings pay a
patente in France), can prove having pracli^efl in France
for one year previously to tbe promulgation t)f the new law
will be allowed to ply his art unmolested. But an import¬
ant distinction is made between him and the licensed
dentist of the future, in that the latter alone may,
without the collaboration of an M.D., adntiuiater anma-
thetics, both general and local, the presence of a
doctor being compulsory in the case of the unlicensed
dental practitioner of the ancien rdgimv Doctors of
medicine, officiers de santd, dentists,' and mgesfemmes
must register their diplomas and brevets within one month
of their having made a choice of a domicile for business
purposes. Sagesfemmes (midwives) have their actual
privileges, including that of vaccinating and revaccinating,
confirmed, and will be, as at present, of tbe first and
second class, according to the examinations passed qualify¬
ing for tbe diploma delivered by the French Government,
which diploma alone confers the right to practise midwifery
(M.D.’s and oficiers de sanU have, of course, that right).
Sagesfemmes are forbidden to employ instruments or to
administer drugs, certain rare exceptions being made as
regards the latter. No doctor, dentist, or sage-femme may
act as a pharmacist, even though he or she possesses the
latter title. The right of doctors to dispense their own
prescriptions in certain districts deprived of a pharmacy has
still to be taken into consideration, and the question
is deferred until the Pharmacy Act is discussed.
A person who employs as a prefix or an affix to his name
the title of doctor in medicine without indicating the
source of the degree is considered guilty of usurping the
title of a French doctor in medicine, unless Mie said title
emanate from tbe French Government Various penalties
for the illegal practice of medicine, denti>r,ry, and mid¬
wifery are specified in the law, and the said vienalties are
increased if to illicit practice be superadded the offence of
usurping titles. Doctors, ojjicicrs de santd, dentists, or
sages-fcjnmes, who cover with their names irregular practice
by unqualified persons, may be prosecuted themselves for
illegal practice. The above clauses comprise all that
can interest your readers. The law modifies consider¬
ably the position of any of our compatriots who may
wish to settle in F'rance with a view of practising. There
are, I believe, several English doctors established in France
Goo^:
O
746 The Lancet,]
BERLIN.
[March 28,1891.
who practise in virtue- of a special permiseion, without
having qualified even as an officer de santi. The Bill is less
favourable to them than to dentists already established,
and 1 take it that they will either have to cease practice
or graduate at a French Faculty. A deliberate attempt
was made by three Boulangkt deputies, one of whom was
M. Deroulbde, to exclude foreigners entirely, and to make
French nationality a sine gud non for doctors and dentists.
Happily the good sense of the majority soon disposed of
this piece of Chauvinism. Throughout the entire discussion
Professor Brouardel, Dean of the Paris Faculty, acted in
the capacity of Commissary for the Government.
Fluoride of Sodium as a Remedy for Tuberculosis.
Having observed the similaiity of the beneficial effects in
tuberculosis of dog and goat serum and fluoride of sodium,
M. Bourgeois was led to analyse the serum of the blood of
these animals, which, as is well known, are refractory to the
disease in question. M. Bourgeois has, be inforiua us
(Socidtd de Thdrapeutique, March 11th), succeeded in en¬
graving letters on glass by means of the blood of the dog
and goat; and he believes that, employed as a therapeutic
agent, it is the fluoride of sodium, which he designates the
natural preventive of tuberculosis, which endows the vital
fluid of these animals with its antibacillary powers. M.
Bourgeois was led to give the fluoride a trial in conaemience
of the happy results obtained by inhalations of hj'dronuoric
acid. The results were good in the pulmonary, intestinal,
and osseous forms of tuberculosis, the patients gaining in
weight, and the sweats disappearing.
Paris, March 24th.
BERLIN.
(From our own Correspondent.)
Dr, von Gossler.
Dr. von Gossler’s resignation of his post as Prussian
Minister of Religion, Education, and Medical Allairs afl'ords
a fit opportunity for drawing attention to the important
services rendered by him to medical science. One of the
most memorable of these was his speech on vivisection in
1883. Another was his energetic defence of vaccination
against repeated Parliamentary attacks. He was also a
most liberal promoter of tbe new sciences of hygiene and
bacteriology, and the enthusiasm with which he welcomed
and promoted Koch’s last discovery is still in lively remem¬
brance. The success of the Berlin Congress of Naturalists
and Physicians in 1886 and of the tenth International Medical
Congress last August was largely due to him, and it was in
recognition of tbe latter of these services that the Berlin
Medical Society created him “honorary member.” He was
the founder of the “Klinische Jahrbuoh” {Clinical Annual),
in which tbe heads of the university clinics have to render
annual account of their stewardship, and to discuss medical
questions of general importance.
Professor Koch.
The following telegram was sent from Cairo on the 16bh
instant: “Professor Dr. Robert Koch, who arrived here
yesterday, has expressed his opinion in favour of the erec¬
tion of a barrack hospital for pulmonary patients in Thebes,
as he considers the climate there especially favourable.”
The Thirteenth Annual Congress of the Balneological Society.
The proceedings of the thirteenth congress of the Balneo¬
logical Society began with the inspection of the new Berlin
Hospital am Urban in the forenoon of the 6th instant. The
first meeting took place in tbe evening of that day in
the lecture-ball of the Pharmacological Institute, and was
opened by the president, Professor Liebreich. The next
speaker was Dr. Roempler of Goerbersdorf, who spoke on
the prophylaxis of consumption. He did not agree with
those who thought the destruction of tubercle bacilli the
one thing needful in the battle with consumption, because
it was, in his opinion, impossible to exterminate tbe bacilli.
Care must rather he taken that they should find no good
nutritive medium in the body. The best way was to in¬
crease the resisting power of tbe predisposed organa. Good
nutrition and plenty of fresh air were the main means to
this end. Even in tbe case of intelligent and well-to-do
people it was difficult to cany out the precautions for
tbe destruction of the bacilli. If, on the other hand,
one considered the extraordinary decrease in the con¬
sumption death-rate in English cities in consequence
of hygienic institutions on a grand scale, there could
be no doubt that hygienic prevention was the only
way to obtain really tangible results. Koch himself bad
said that the inheritance of consumption was due to the
inheritance not of the bacilli, but of the predisposition.
Dr. Roempler gave instructive statistical proofs of his
opinion. As to tbe promotion of consumption by cold,
light had also begun to be thrown on this, as it had beet»
observed that fission fungi increased much more rapidly in
the blood of living rabbits in the refrigerator than under
ordinary conditions of temperature. Thanks to fresh air
and the vigorous circulation caused by their work, rural
labourers seldom fell victims to consumption, whereas
young gentlemen learning agriculture, whose food an<J
sleep were often scanty, and who bad to superintend the
work in all weathers without working themselves, very
often did. The once prevalent opinion that there was
a consuraptionless zone, dependent on height above
the level of the sea, had long yielded to the truer
view that the eonsumptionless zone began everywhere
for everybody with the conditions of life which secured
him a sufficient quantity of normal blood and vigoroue-
circulation. Professor Winternitz of Vienna then spoke
on the importance of hydro-therapeutics in clinics. He
complained of the neglect of hydropathy in hospitals, in¬
consequence of which it had become the chosen domain of
quacks, who obtained as many indisputable successes by it
as they did harm. He had gained excellent results himself
by the hydropathic treatment of neuralgia, rheumatism^
and consumption.—Dr. Groedel of Nauhexm proposed that
the Congress should take steps towards having the centi'
grade theiinometer introduced everywhere in indicating the-
temperature of baths both in practice and in scientific work.
This proposal was accepted.
The Treatment of Tuberculosis by Combined Methods.
A Bulgarian army doctor named Tranjen is making
experiments in the Augusta Hospital here, with a view to-
curiDg tuberculosis by an original combination of the
remedies hitherto known.
School Hygiene.
The School Board of the province of Brandenburg has
ordered that the teachers and pupils of the schools under
its care shall expectorate in the buildings exclusively
into spittoons of proper construction or into bottles con¬
structed on Dettweiler’s system; that dust shall be removed
from the rooms as completely as possible, but only by wet
methods; that the teachers shall especially insist on the-
observance of the first of these orders by pupils who cough
much; and that leave of absence with a view to treatment
shall be granted with special readiness to pupils suffering
from pulmonary disease. The head masters are to take
care that the schools be sufficiently provided with suitable
spittoons.
A Medical Exhibition.
There will be an exhibition of medical instruments and-
preparations in the new Medical Institute in the Johannis
Strasse here in tbe beginning of April. Its purpose is to-
afford the members of the Surgeons’ Congress and the
hearers of the holiday courses of lectures for practitioners-
an opportunity of estimating the progress made here in the
manufacture of iustruments &c.
Professor Virchoio.
A week or two ago Prof. Virchow measured some micro¬
cephalous Mexican aborigines on show here. He opposed
the theory that such persons are to be regarded as specimens
of transitional stages between the ape and man, and main¬
tained that tbe forms in question are merely morbid, nob
atavistic.
Professor Rindfleisch.
Professor Edward Rindlleisch of Wurzburg has been-
elected a member of tbe Academie de M^decine in Paris.
Except the recent bestowal of tbe Grand Cross of the-
Leglon of Honour on Helmholtz, this is the first distinction
of the kind bestowed on a German scientist by the French
since 1870. There are only three other German members of
the Academie—viz , Virchow, Bunsen, and Helmholtz.
Rindfleisch is director of the Pathological Institute of
the University of Wurzburg. In his scientific views he
differs considerably from his teacher Virchow. His chief
works are his Text-book of Pathological Histology and
his Elements of Pathology.
Professor Renk, Director of the Hygienic Institute in the
University of Halle, has been appointed extraordinary
member of the Imperial Office of Health.
Borlis, March 22nd.
Di(. by
The Lancet,]
CANADA. -OBITUAKY.
[March 28, 1891. 747
CANADA.
(From o.ue own Correspondent.)
McGill University.
This UDiversity haa received from Mr. W. C. McDonald,
Montreal, a furtner handsome donation of 40,000 dollars
towards endowing a chair in electrical engineering. This
gentleman’s various gifts to McGill amount to nearly one
million dollars.
Board of Health for Ontario.
The quarterly meeting of the Board was held in this city
on Feb. 25bh and 26th. An interesting discussion took place
regarding the placing of actinomycosis among contagious
diseases, a case having been reported where diseased
animals were slaughtered and offered for sole, convictions
having been obtained; but an appeal is pending, the defend¬
ant claiming that the meat was not offered for sale. The
Board allowed the matter to stand pending the appeal. The
important matter of the quality of ice cut by the leading
railway companies for summer use for drinking purposes was
shown to be one in which local boards had power to adopt
such regulations as they deemed best to secure a pure ice.
The Committee on Epidemics reported the correspondence
between the Grand Trunk Railway with reference to the
transportation of dead bodies. The committee had reiterated
the views expressed by the Board in May, 1889, in a series
of resolutions, the gist of which is that the practice of
transporting the bodies of persons dead from dangerous
communicable diseases be discontinued, owing to the impos¬
sibility of at all times preventing persons wbo may have
received infection from contact with the corpse, or in any
other way, from afterwards communicating the infection to
others. Dr. P. H. Bryce, secretary to the Board, was
appointed delegate to the annual meeting of the American
State Medical Health Officers, to be held in Washington
this month.
Toronto Medical Socictu.
At the meeting held on Feb. lObh, being a pathological
evening, a number of interesting specimens were exhibited,
among which was a Tumour of the Bladder and Uterus,
accompanied by Ascites, in a seven months’ fcctus,
obstructing labour, by Dr. Gordon, and Dermoid Cyst of
the Ovary in a child twelve years of age, by Dr. Atherton.
Serious and Fatal Explosions.
During the month two accidents, attended with great loss
of life, have occurred, The first accident was the explosion
of a boiler whereby twenty-one persons were killed and
thirty wounded. According to the finding of the jury it was
caused by overpressure of steam due to the stop-valve
being closed. The other accident occurred at the Spring
Hill Coal Mines, Nova Scotia, an explosion resulting in
the loss of 123 lives. The day preceding the accident an
inspection of the mine had been made by the deputy
inspector, as also by a committee of the miners, and found
to be in good condition. Inspector Maddin.s, testing for
fire damp, showed only in one instance the presence
of one and two-fifths per cent., wliile other examinations
showed its absence. The committee of miners reported the
ventilation a? all that could be desired, both in distribution
and quantity; they, however, mention the fact of Nos. 6
and 7 balances, where the explosion occurred, as “ very dry
and dusty, and the air in a condition, from the quantity
of dust floating about, to make it a source of danger.”
They reported this to be almost nil by “a sjstem of
waterworks with hose attached for sprinkling.” The
adjournment of the inquest until March lOtb prevents the
record of the finding of the jury—indeed, as yet no satis¬
factory reason has been advanced for this the most fatal
accident in the history of our mining industry. The
sympathy for the bereaved has been widespread, and found
expression in contributions from private as well as public
purses.
Leprosy in British Columbia.
Word has been received at Ottawa that this disease
has been found among the Chinese in tliat province, and
has been communicated to the Indians.
I notice with regret the death, in a western town of
the piovince, of a medical practitioner while using chloro¬
form, which at times he administered to himself. He was
found with the chloroformed handkerchief over.his face, no
doubt having become aniusthotised.
March 12th.
- RICHARD G. H. BUTCHER, M.D., F.R.C.S.I.,
OF DUBLIN.
An able exponent of Irish surgery has passed away, Mr.
Butcher, a most distinguished surgeon, having died onr
Saturday last at his suburban residence, Towerville, Sandy-
mount, aged seventy-two. Owing to failing health he had
for some years withdrawn from the practice of his profession,
and had led a very retired life. The deceased was born ah
Killarney in April, 1819, being the third son of the late-
Admiral Butcher, and was educated at Cork and at the
Peter-street School of Medicine, Dublin, and Guy’s Hos¬
pital. He obtained the membership of the London College
of Surgeons in 1838, and the licence of the Irish College
three years afterwards, being coopted a Fellow of the latter
institution in 1844 The subject of this notice shortly after-
being qualified became a demonstrator of, and afterwards a
lecturer on, anatomy in Peter-street School, and was
elected surgeon to Mercer’s Hospital; he was a membep
of the Council of the Royal College of Surgeons of
Ireland, Examiner, and finally, in 1866, he obtained
the Presidency. Upon his leaving Mercer’s Hospital he?
joined Sir P. Dun’s Hospital as lecturer on operative
surgery. His practice was now a very large one, his.
reputation deservedly great, and honours and distinctions
were showered upon him. The University of Dubliin
conferred the M.D. degree, honoris causd ; he was a>
honorary Fellow of the Philadelphia College of Physicians,
and a member of the Royal Irish Academy, while hi&
fame as a brilliant and successful surgeon went far beyond
the limits of his own country. He was the inventor of the
well-known Butcher’s saw, which he first described in 1851,
and of a splint for fractures of the femur. Mr. Butcher
was a bold and skilful operator, and attracted large crowds
to the hospital to which he was attached. In 1885, at the-
request of Sir Charles Cameron, he presented his valuable,
museum of surgical specimens to the Royal College of
Surgeons of Ireland, a room having been constructed for
the purpose by the late Mr. O’Reilly Dease, D.L.
published in 1865, in a large volume of 933 pages, his work
on operative and conservative surgery, which was mainly
composed of papers published at various periods in the
Dublin Journal of Medical Science. A man of great muscular
strength and striking physique, dark complexion, handsome
features, and long curling black hair, he presented quite a
foreign appearance, and some years since his face was one-
of the most familiar in the Irish capital.
Sltliiral Itttos.
University of Oxford.—I n a congregatiun held*
on the 2l8t inst. the degree of M.D. was conferred on
Fi-edevick J. .Sinitli,
Victoria UNivifiRsiTY: Faculty of Medicine.—
The following candidates have sati.stied the Examiners in'
the examinations indicated:—
Second ]ixninination.—Firnt Diinaion: 'HuKh Aiti8>vorth, K. L.
Compston, R. S. Hardman, Percy McDongall, and "'Peter Thompson,.
Owens College; Douglas Seaton and W. W. Stoney, Yorksblre-
College,—Second Division.: Reginald Alcock, II. C. Cadmiin, D. H.
Clioetbam, E. A. Goublen, Ertinuiicl Han-isou, Joseph Jones,.
Arthur Leigh, and O. M. Y. 'VVliittlngham, Owens College; S.
H. House, E. S Miller, J. P. Nixon, and R. L. Wood, University
College. !■" Distinguished in Anatomy.)
Final Fxanmialion {Part i ). — G. F. Ohmlwick, J. G. Clegg, Sftuiueli
Crawshaw, A. J. Edwards, B. W. Marsdon, Gruner Stowell, .1. H.
Taylor, J. H. 1.. Tylecote, W. II, Waddington, and W. B. Warrington,.
Owens Collogo; Alfred Harris and S. R. KniglR, University College.
Final Fxanunation {Part 21.). — First JHoinon: H. A. Beiver,
University College ; William Griffith. Owens College.--6Vc(>/kf
Disision: J. H. Bailey, W. .1, Howurth, C. K. Rawes, and Frank,
Robinson, Owens College; S. H. Fairrie, University College.
University of Cambridge.—A t Gonvillo and
Oaius College a Shuttleworth Scholarship open to medical
students of the U niversity of not less than eight terms’ stand¬
ing has been awarded to Francis Carr Bottomley, scholar ofi
the college. The value of the scholarship is about ii56 per
annum, and it is tenable for three years, being given for pro¬
ficiency in botany and comparative anatomy.
LiOOgle
748 ThbLanokt,]
MEDICAL NEWS,
[Mabch 2S, 1891.
SUPBEANNUATION Grant. — Mr. Thos. Odell,'
M.R.C.S., lately medical officer of the second and third
-districts of the Hertford Union, has been granted a super¬
annuation allowance of £50 per annum.
Donations.—M r. David Drummond, J.P., haa given
£200 to the building fund of the Royal Hospital for Incur-'
ables. Lord Iveagh has given £100 to the Coombe Lying-in
Hospital, Dublin.
Leamington Hospital Extension.—U nder the
■auspices of the provincial Grand Lodge of Ancient, Free,
and Accepted Masons of Warwickshire, Lord Leigh,
Lord-Lieutenant of the county, performed the ceremony,
■on the 18th inst., of laying the foundation stone of a new
wing to the Wameford Hospital, Leamington. The esti¬
mated cost of this extension is £13,000.
Vbntnor Consumption Hospital.— The anriual
meeting of the governors was held on the 21st inst., at
•■ 34 , Craven-street, Charing-cross. The report presented
stated that the whole of the 132 beds were constantly occu-
j)ied during the past year, and 80 applicants were usually
waiting for admission; 763 patients were treated. The
income amounted to £10,383, and the expenditure, in-
■cluding£1769 for heating and ventilation works, to £ll,3i4.
Bolton Infirmary and Dispensary.—-T he work¬
ing of this institution continues satisfactory. The number
-of new cases admitted during the past year -was 3783 The
allotment of beds at convalescent hospitals by the Cotton
Districts Convalescent Fund had been taken advantage of
for patients requiring change of air, and 114 patients,
-against 97 last year, had been sent to the:°e institutions,
The total receipts amounted to £4514 175. id., and the dis¬
bursements to £5341 16.$. 6cf., leaving a cle/iciency. to bo
taken from the donations, of £826 19s. 3rf. Mr. William
ISlater, J.P. (Holmes, Dunscar), bad presented to the insti¬
tution a completely equipped horse ambulance.
Children’s Hospital, Bristol.—T he annual
meeting (the twenty-eighth) was held on the 21st instant,
^ir Charles Wathen, the Mayor, presided. The report,
which was read, stated that the year commenced with an
adverse balance of £445 10s. lOc^., and the income and ex-
enditure in the year under review closed with a debit
alance of £936 11s. Zd. The committee had sold out a
portion of their investments, which realised £657 10s. Zd.,
and had reduced the actual deficit to £279 Is. No less
than 30,000 patients, or nearly 4000 more than last year,
■had been treated. Four cots bad been added to the list of
those which are either supported by annual subscriptions of
.-£25 or by special contributions. The beds had been well
occupied throughout the year, and the attendance of out-
,patients had been large.
The Victoria Hospital for Children, Chelsea.
"The annual report (the twenty-fourth) is a gratifying record
of tJie ^ood work effected during the past year. The
=St. Gabriel’s Hospital for Infants had been amalgamated
with this institution, and twelve cots are specially set apart
for infants under two years of age. 978 patients were
■treated in the course of the year, of whom 734 were dis-
-charged either cured or relieved, and the remainder sent out
for specific reasons; 15,451 children were treated in the out¬
patients’ department, and 209 cases were sent to the con-
•valescent branch at Margate. The committee hope the new
convalescent home at Broadstairs will be ready for occupa-
'tion in the autumn. There was a balance at the banker’s
of £123 18^. 4c?. A deficit of £141 15$. Zd. on the Margate
Convalescent Horae had been made up from the capital
^iccouut.
The National Association of Sanitary In-
iSPECTORS (Yorkshxrk CENTRE), — A general meeting was
held at Wakefield on the 21st inst. There was a large and
fully representative attendance. Assembling at the Town
’Hall, the visitors proceeded to the West Riding Asylum,
which they inspected, and expressed high satisfaction with
•all they bad seen. On returniDg to the Town Hall, the
chair was taken by Mr. D. Travis, Chief Sanitary Inspector,
Halifax. A paper on “Modern Sanitary I,egislation” was
read by Mr. J. Maguire, Chief Sanitary Inspector, Hud-
■dersfield, and an interesting discussion followed; bub the
.paper was considered so exceptionally important that its
luller discussion was reserved for the next quarterly meet¬
ing, A p^er was afterwards read on the “Duties and
Position 01 an Assistant Sanitary Inspector,” and the
meeting terminated.
The Urban Sanitary Authority for Wokingham has
decided to adopt the Infectious Diseases (Prevention) Act,
1890, and Part III. of the Public Health A*ctB (Amendment)
Act, 1890. These Acts will come into operation on April 9tbk.
Diseased Meat.—A jobbing butcher, of Ringwood,
Hampshire, was last week fined £30 and costs for sending
two quarters of diseased beef to the London Central
Market, intending it for sale as human food.
The Animals’ Institute.—T he council of this
institute have decided to hold during the season a series of
exhibitions of appliances used in the working of horses, with
the object of leeseniog suffering amongst animals employed
in traffic. Prizes will be given for the best collection of bits
and of horse-shoes and o^er inventions coming under the
head of harness. Those collections will be considered the
best which are found to be the most humane and practical.
The first exhibition will open on April 6th.
Fire at a Lunatic Asylum, Montreal.— On
Saturday a fire was discovered on the first floor of the
extensive temporary buildings at Longue Pointe Lunatic
Asylum, Montreal, which were erected to replace in some
measure the loss of accommodation sustained by the terrible
conflagration of a year ago. The flames spread rapidly,
and four workmen on the fourth flat made a demerate
leap to escape. They were all seriously injured. During
the raging of the fire the lunatics in the adjoining buildings
made frantic efforts to escape, and with difficulty the
keepers kept them under restraint. The damage, which is
estimated at 12,000 dols,, is covered by insurance.
Presentations.—O n the 20th inst.,at Westminster
Medical School, Mr. James Black, lecturer on anatomy,
was presented with a handsome marble clock, bearing an
exquisitely worked plate, with the following inscription:
“Presented to James Black, Esq., B.A , M.B., F.B.C.S.,
&c., as a token of esteem and gratitude from his anatomy
class, Westminster Hospital, 1889-91.”—At the close of a
St. .lohn Ambulance class at Huntingdon Mr. Oscar
Jacobsen, M.B.C-S., L.B.C.P., was presented by the mem¬
bers with a handsome liq^ueur frame as a token of their
appreciation of the trouble he had taken. All the candidates
were successful in obtaining certificates.
St. MARii’s Hospital.—T he general efficiency of
this institution is maintained. Satisfactory progress has
been made for extending the building and giving it a
frontage in Praod-street. The work of the past year had
been exceptionally heavy, the number of patients being in
excess of any previous year. The Board direct special
attention to the high encomiums recently passed upon the
management by the Select Committee of the House of Lords.
The expenditure amounted to £23,608, and but for the
receipt of upwards of £8200 in legacies the resources of the
charity would have been insufficient to meet the demands
upon it. The total income only amounted to £22,344.
Norfolk and Norwich Hospital.—T he annual
report for tlie past year just issued shows that the number
of in-patients (including those remaining in the hospital
Jan. Ist last) was 1323. The number of out-patients
(including 288 admitted originally as out-patients) was
4105. The total receipts (exclusive of legacies) was
£7570 1.5.Y,, while the ordinary expenditure (exclusive of
special items) was £7662 12.?. 8rf. The amount derived
from legacies was £1453. The fees received from nurses’
services in private nursing was £429 10s. Crf, or £105
more than the previous year. An additional ward had
been furnished, at an outlay of £177 17s. A sum of £500
had been invested in the public funds, and the balance to
be carried forward amounted to £248 6.v. 9rf.
Worcester Infirmary.—T he annual report for
1890 shows the increased usefulness of the charity. The
number of in-patients admitted during the year was the
highest recorded. The out-patients treated show a large
addition on the previous year. In the course of the twelve
months forty-nine patients had been sent to the St. John’s
Convalescent Home, Malvern, where beds had been pro¬
vided by Mrs. Perrins. A Hospital Saturday collection had
been made for the first time in the city, and £90 19$. l£?.
was allotted to this infirmary. The cash stafcoiient shows
a deficiency on the income of £805 5s. lie?. , The invested
property amounted to £48,583 16s. 4e?. The committee
contemplated selling out of the capital £1000 to meet the
deficiency, but that was averted by Mr, Wheeley generously
giving a cheque for that amount.
'^EtE LANOXT,]
MEDICAL NOTES IN PARLIAMENT.—APPOINTMENTS. [Mabch 28, 1891. 74&
UOJOtfllTAL OF AN ILLEGAL PrACTITIONEE AT BIR¬
MINGHAM—JeBse Key,'having failed to pay the penalties
inflicted upon him for practising as an apothecary without
beihg registered, was on the 12bh inst. committed for forty
days each on two summooses. This will doubtless give him
time for reflection, and, though stating that his earnings
were limited, and that he bad a wife and eight children to
support, he will probably think over some more profitable
method of keeping them on his release from his present
incarceration.
London Temperance Hospital. — The annual
report for 1890 (which by altered arrangements only covers
a period of nine months) shows that the in-patients were
753 during the year, of whom .390 were cured, 268 relieved,
60 unrelieved, and 45 died. The general statistical
summary states that of the in-patients admitted since the
opening of the hospital 3628 were abstainers and 3268 non-
abstainers. The total expenditure for the nine months was
£4415, and it had been necessary to transfer £1300 from the
endowment fund, of which a balance still remained in hand
of £6540.
MEDICAL NOTES IN PARLIAMENT.
The Cojmimption of Chtorodync.
In the House! of Oomnions on the 21st inst. Mr. S. Smith asked the
Secretary of state for tlie Home Department whether Jiia attention had
been drawn to the large conauinption of clilorodyno, especially among
women, and the grave evils which resulted from the practice; whether
the fact of ehlorodyne being a patent medicine and protected by a
stamp exempted it from the operation of the Sale of Poisons
Act; and wlieUier the Government would take into considera¬
tion the expediency of classing ehlorodyne with other narcotics,
and only allow It to be sold under the same restrictions.—
Mr. Matthews; I received last year a representation from a
coroner’s jury that some restriction should be placed on the sale of
ehlorodyne. 1 forwarded this representation to tlie Privy Council Office,
which is the department concerned. The answer to the second parn-
grapli depends upon the proper construction of sections Hi and 17 of the
Act, to which I beg to refer the lion, member. Section 2 of the Phar¬
macy Act, 18tl8, prescribes the manner by which any article nmy be
added to Schedule A of that Act—namely, by a resolution of the
Council of the Pharmaceutical Society. The bon. member sboxdd
address any representation to that Society in the flrsb instance.
Baby Faryning.
Hab’t F. J. Louimer, M.B., C.M., L.M. Bdin., has been appointed
Honorary Assistant Medical Officer to the Home and Infirmary for-
Sick Children and South London Dispensary for Women, Lower
•Sydonbam, 8.K., vice R. H, Qwynn, resigned.
Haydon, W. R., M.D. Glasg., has been reappointed Medical Officer for-
the Cruwye Morchard District of the Tiverton Union.
Hockiudge, T. Granville, M.D., M.B.C.N., L.S.A., has been,
appointed Medical Officer for the No. 0 District of the Holbona
Union.
Hodge, W. T., M.R.C.S., has been appointed Medical Officer for the-
Bllosmere Union.
HoepmeisI'ER, W., M.D. Heldelb., L.R.C.P. Lond.. M.R.C.S., has been,
reappointed Medical Officer for West Cowes, Isle of Wight Union.
Macdonald, C. R., M.D. Aberd., D.P.H. Camb., has been appointed
Medical Officer of Health for the Comity of Ayrshire.
MACKINNON, NiCOL. M.D. Aberii., has been appointed Medical Officer-
to the Parochial Board of South Uist, vice Moclachlan, resigned.
McLaren, Alice J., M.D. Lond., has been appointed House Physician,
to the Leith Hospital.
Murdoch, Andrew, M.B., C.M. Glasg., has been reappointed Medicali
Officer for the Rainford District of the Ihescot Union.
Nasmyth, T. G., M.D. Edin., D.Sc., has been appointed Medical Officer-
of Health for tlie County of Fife,
Platt, John Edward, M.D, Lond., M.R,C,K,, L.B.C.P.. has -been-
appointed Resident Medical Officer of the Barnes Convalescent-
Hospital, Cheadle, vice E. C. Lonisia. M. H., resigned.
Rickards, J. S., M.B., B.S. Lend., has been appointed Assistant House.
Physician to Guy’s Hospital.
Scott, Patrick Cumin, B.A.. M.B. Cantab., M.R.C.S., has been-
appointed Physician to the Miller Hospital.
Shepherd, R. F., M.B. Edin,, has been appointed Medical Officer and
Public Vaccinator for the Haintoii District of the Boston Union.
.SWAYNE, F. G., M.B., B.C. Cantab., has been appointed House Surgeoia
to Guy's Hospital.
Wbudur, H. W., M.B., B.S. Lond., has been appointed House Physician,
to Qny’.s Hospital.
Welsi-'ORD, a. (i., M.B., B.C. Camb., has been appointed Assistant-
Medical Officer for the Central London Sick Asylum District.
Wilson, Helen M., M.B. Lond., has been appointed Resident Medical.
Officer to the Temperance Hospital, Hainpstead-road.
WiN.siiiP, W. A., M.R.C.S., has been appointed Medical Officer for the-
Wetheral District of the Carlisle Union.
WORDOYS, T. S., L.R.C.P. Lond.. M.R.C.S., Imsbeon appointed Medicali
Officer and Dispen.ser to the Union Infirmary, Leeds, vice Buck.
WORGER, T. H., M.R.C.S., lios been reappointed Medical Officer ofc'
Health for Badstock.
fararats.
For /urtker wybnnafion regarding each vacancy refacnce shoxUd be made'
ta the adoercisement.
Mr. Ohanning asked the Home Secretary whether his attention had
been called to the evidence in several recent baby-fanning cases in
which convictions had been obtained for manslaughter; whether it
appeared that the children were largely obtained by means of adverti.so-
raents in daily and weekly newspapers published in Loudon and the
provinces.; and whether he would take into consideration the ad¬
visability of legislating with a view to control or prevent the in¬
sertion of such advertisements. — Mr. Matthow.s; I observe that the
evidence in these cases shows that children are obtained by moans
of advevtiseniont. I do not see tny way to legislative interference with
these advertisements, which do not invite toanytliingnocessarily illegal.
Neither the Infant Life Act of 1872 nor the amending Bill of last year,
which was considered by a Select Committee of this House, proposed to
control or prevent the insertion of such advertisements, which are.
moreover, found by tlie police to be a useful clue to the wliereabonts of
the baby.fiu-ming e.Htabhshmouts.
^pointments.
Suceeiiff iU apjdicantit .for Vacancies, Secretaries of Public Tnstilulioyu!, and
others possessing in/onnalioyy suitable for this cohiinn. are invited to
fanoard it to Tiiio 1/ANCKT Office, directed to the Sub-Fdilor, not later
than y o'clock on the Thursday morning of each week for publication in
the next number. -
Bailey II 11 M.D. Brux., M.R.C.S., has been reappointed ModirnI
Officer for the Spittlogate District of the Grantham Union.
Barwise, Sydney. M.B. Lond., M.li.O.S., D.P.H. Camb., has boen
appointod Medical Officer of Health for the County of Derbyshire.
COLLINGWOOD, E., L.ll.O.IM'klin., M.R.C.S., has been reappointed
Jledical oilicer for Lho Buvtoii-Cogglos District of the Grantham
COLMAN, Wai.'I'eh Tawell, M.R.G.S., L.S.A., has been appointed one
of the Surgeons on the Staff <if tho Slierbourne-road Dispensary,
' Blrminghiim, vice F. VV. Stokos, resigned.
DaNiki.l (i. 11. S., M.B., B.C. Cantab., has been appointed House
Surgeon to Guy’s llo.splUl, • , , t • r,
Dunn K A M.E.C.S., J-.ll.C.P., has boon appointed Junior House
Surgeon to tho North-lCastorn Hospital for Cliildron.
■’ /CEl”r, .L, M.B., B-iS. Lend., has boon appointod House Physician to
Guy’s Hospital.
TUM P w , M.D. ICclin., M.R.C.S., has boen reappointed Medical
Officer of Health for the Baslow Urban District.
: W. t>iKUi!y, L.R.C.P., L.E.C.S., has been appointod Medical Officer
to No. 12 District (New District), in udciilion to No. 0 District, in
Fawcect, .L, M.B., B-iS. Lend., has boon appointod House Physician to
Guy’s Hospital.
Fenthm, P. w., M.D. Edin., M.R.C.S.,Jias been reappointed Medical
Fox
the piuTsli of Lamb'oth. ,
Gordon, H. J-ving. M.B., Mast. burg. Edin., has been appointod
Medical Officer for the No. U District of the South Molton Union,
Haj5eii"'o'!'L.R.C.P. Edin., M.R.C.S.. has been reappointed Medical
Officer of Health for the Bath Rural District.
Birmingham City Asylum, llnbery-hill, neat- Bromsgrove.—Clinical.
Assistant. Board, lodging, and washing will be provided.
Bradi-ord Children's Hosimtal.—H ouse Surgeon. Salaiy £80 per
annum, with board, residence, and washing.
Burton-on-Trent Friendly societies' Medical association.—
Junior Medical Officer. (Apply to tlie Secretary, ShobnaJl-road,.
Burton-on-Tieiit.)
Bridgwater Inrirmary.—H ouse Surgeon. Salary £80 per annum.
Cancer Hospital (Free), Fulluvin-road, S.W.—Assistant Surgeon.
Counties or Midlothian, West Lothian, and Peebles, and Dis¬
tricts within THE SAME.—Medical Officer. Salary £000, besides,
travelling expenses. (Apply to the County Clerk, County Build¬
ings, Hdinbui'gli.)
CilAHiNu-cuoss Hospital. — Sutgical Registrar. Salary £10 per-
annum.
Charino-cross Hospital Medical School.—D emonstratorship ot
Physiology. Honorarium £100 per annum.
County Asylum, Shrewsbury.—Junior Assistant Medical Officer-
Salary £100 per annum, and £8 in lieu of beer, with board, lodging,
and wasliing.
DtiACONivssiis' Institution and Hospitai., Tottenham.—Resident.
Hunso Surgoim for one year. Salary £90 per annum, witli boarii
and residence.
Fast Suffolk and Ipswich Hospital.—H ouse Surgeon. Salary
.£100 per annum, with boerd, lodging, anti washing.
Guy’s Hospital Medical School.—T wo additioMal Annwthetista for
the Dental Doparl.ment.
General Hospital, Birininghain.—Honorary Physician.
Holloway Sanatorium (Hospital for -niic Insane).—C linical Assist¬
ant. Board, lodging, washing, and small lioiiorarium. (Apply to-
Dr. Rees Philipps, Virginia Water.)
Kent County Asylum, Ohartham, near ('antorbury.—Junior Assistant.
Medical Officer. Salary £126 per annum, with furnished apartments,
board, and attendance. (Apply to Mr. Allen Fielding, Solicitor,.
Canterbury.)
London Lock Hospital, Harrow-road, and Ol, Dean-street, W.—
Registrar.
Metropolitan Hospitai., Kingsland-road, N. H.—House Physician for-
one year. Salary at the rate of £00 per annum fur the first six.
months, and at tho rate of .£70 per annum for the second si*
months.
Paddino'I'ON Infirmary.—R esident Clinical Assistant. Board, resi¬
dence, and an lioiiorarium of 12 guineas on completion of si*:
months’ satisfactory service. (Apply to tho Medical Suporintoudeut,
286, Uarrow-i-oad, W.)
Queen’s College, Birmingham.—Co-professor of Medicine.
Royal Victoria Patriotic Asylum for Girls, Waiulsworth-oomraon,.
S.W.—Medical Officer (non-resident). Salary .CWO per annum.
(Apply to the Secretary, Royal CommiMsioii I’atriolie l''und, 62„
Chariiig-cross, S.W.)
royal College of Physicians, Pall Mall Fast, S.W.—Milroy Lec¬
turer.
STOCKPORT Infirmary.—A ssistant to tho Hmise Surgeou for si*,
mouths. Board and residence.
750 The Lancet,]
BIRTHS, MARRIAGES, AND DEATHS.—BOOKS RECEIVED. [Makch 28, 1891.
S^LKORD Union.—A ssistant Medical Officer for the Union Infirmary,
Hope, nearKccles. f-alaTy £130 per annum, with furnished apart¬
ments In the Infirmary. (Apply to the Clerk to the Guardians,
Union Offices, l'>.clea-new-roaa, Salford.)
South Devon and East Cornwadl Hospital, Plymouth.—Assistiut
House SurKeon for six months.
Worcester County .and City Lunatic Asylum,—T hird Assistant
Medical Offictr. Salary £100 per annum, with board, lodging, and
washing.
Slamagts, anli
BIRTHS.
©RUSTON.—On March 22nd, at Oatlands Park Hotel, Weyhridge, the
wife of T. Jjauder Bmnton, M.D.,P.B.S., of 10, Stratford-place,, W.,
of a son.
■CuTi'TELD.—On March 21st, at Merton House, Ross, Herefordshire, the
wife of Arthur Outfield, B.A., B.Sc., M.B.O.S., of a daughter.
B)nKE.—On March Ifith, at The Olen, Lewisham, S.K., the wife of John
Challen Duke, M.R.C.S., of twin daughters.
Freer.—O n March isrh, at Ormeside, Llandudno, the wife of K. Luke
Freer, M.R.C.S , of a son.
Xake.—O n March 23rd, at Barnes, S.W., the wife of R. Lake, F.R.C.S.,
. of a daughter.
Cegoatt.—O n March 10th, nt Elm-avenue, Nottingham, the wife of
Gerard S. Leggatt, M.R.C.S,, of a son.
flOHERTS.—On Marcli 2(>th. at 261, Qlossop-rnad, Sheffield, the wife of
Sidney Roberts, M.A., .M.IJ., B.C. Cantab., M.R.C.S,, of a son.
MARRIAGE
■Dunlop—Duncan.—O n March lOth, in St. Oile.s’ Cathecliul, Kdin-
bnrgli, James Craiifurd Dunlop, M.lh, M.R.C.P.K., to Mary Isabella,
elder daughter of J. M. Duncan, Advocato.
DEATHS.
Brunton.—O n March 2-tth, at Oatlands J'ark Hotel, Weyhridge, the
infant son of T. Lauder Bruutnn., Ml)., F.R.S., of 10, Stratford-
place, W.
De Li.sLU. — On March 20th, at Hiilouan, Cairo, Albert De Lisle,
M.R.C.S., L.R.C.l’., son of the late Albert De Lisle, of Teignmouth,
aged 20.
Fowler.—O n M.arch 15th, suddenly, George Fowler, F.R.C.P. Edin.,
of Ciapham-road and Kennington-park-road, In his r>7th year.
.Kershaw.—O n March 31.st, James B. Kershaw, M.A. and M.B. Oxon.,
Resident Medical Officer at Brompton Hospital for Consumption,
only surviving son of the late James Kershaw, Esq., of Bowdoii,
Cheshire, aged 3.'). _
y.B.—A /ee a/ />s. w chargad for the Innertion of Nolicea (if liirlha,
JUai-riagea, and Leatha.
BOOKS ETC RECEIVED.
iBLAKiSTON, Son, & Co., Pliiladelpliia; and H. K. Lewis, Gowet-streot,
London.
Text-book of Medical Jurispj'udence and Toxicology. By John-I.
Reese, M.D. Third Edition, revised. 1801. pp, OijG,
Fannin & Co., Dublin ; and Baili.ikhe, Tindall, & Cox, London.
Transactions of the Royal Academy of Medicine in Ireland.
Vol. VIII. 1800, pp. 035.
-Jenkins, W. r., New Vork.
The Microbe has his Rights, By G. T. Cii.apmaii. 1801. pp. 80.
Pentland, Youno J., Edinburgh and London.
Botany : A Concise Manual for .Students of Medicine and Science
By Alex. Johnstone, F.G.S. Illustrated. 1801. pp. 200.
.'Swan Sonnenschein i£ Co., Paternoster-square, London.
Crime and its Canaos. By Win. Douglas Morrison. 1801. pp 230.
The New York .State Reformatory in Elmira.' By Alex. Winter,
F.S.S. 1891. pp. X72.
An Introduction to the Study of Botany. By Edward Avoling,
D.Sc. Loud. With Illustrations. 1801, pp. 303.
Che Amrric'an Ophtiialmolouical Society, Hartford.
Transactions of the American Ophthalmological Society. Vol V.
1888-1890.
■<rhe Thermometer in Olistotrics and Gyniccology ; byA. D. Leith Napier,
M.D., F.R.S. (A. K. Lewis, London, I 8 O 0 ); price 1*. Od.—Klinischo
Beifcriige zur Konntniss der Acuton Miliartuberculose und Tuber-
culci.sen Meningitis ; vorgolost von Dr. H. Reiniiold (J, B, Hirschfold,
Leipzig, 1891). — The Strand Magazine, March, 1801 ; edited by Geo.
Newnes (360, Burloigh-street, W.C.). — Tlie Treatment of Clironic
’Tubercular Consumption; by G. C. Smith, M.D. (Austin, Texas),—
New Method for tlie Analysis of Peptones ; by A, Donaeyer (S. Strakor
.and Sons. London, 1801).—La Neurasthiinie ; Malailie de Board ; paiTo
Or. Fernand Lovillain (A. Maloine, Paris, 1801). — Index Modicus,
Authors and .Subjects, Vol. XIIL, No. 2, February, 1801 (TtUbnor
land Co., and Lewis, London). — Die Totanie ; von Dr. Med. Lothar v.
Frankl-IIochwart (August Hirschwald, Berlin, 1891). — Magazines for
April: Ijeisure Hour, Sunday at Home, Good Words, .Sunday Maga-
.•zlne, Boys’ Own Paper, Girls’ Own Paper.
METEOROLOGICAL READINGS.
(Taken daily at 8.30 a.m. by Steward'a Inatrumenta.)
The Lancet Office, March 2r)th, J801.
Date.
Biirotuotor
niiluuud te
Still LuvqI
ikiitl
Diroc.
llmi
of
Wind.
Dry
Bulb.
Wot
Bulb.
Solar
Kail la
ill
Vaouo.
Maxi-
imiin
Toinjj.
81iiiao.
Min.
Toiup
Ralu-
fuU.
Ilemarks at
y.eoA.u.
Mar. 10
20-86
N.E.
41
88
60
46
87
,. 20
20 80
N.W.
88
88
rs
47
35
„ 21
20-83
N.E.
88
88
73
44
31
Oloudv
„ 22
80-05
N.W.
88
71
46
20
•04
Bright
„ 23
8i)-07
8.W.
35
33
06
44
88
•01
Snowing
.. 2»
29-91
S.W.
42
40
88
62
86
.. 26
29-72
S.W.
40
47
9-2
64
41
•01
Cloudy
Peliiial for mning
Holiday, March so.
Royal London Ophthalmic Hospital, Moorfields. — Opemtlona
dally at 10 a.u.
Royal Westminster Ophthalmic Hospital.—O perations, 1.80 p.m.,
and each day at the same hour.
Chelsea Hospital fob Women,—O perations, 2.80 p.k. ; Thursday, 2 . 8 O.
Hospital fob Women, Soiio-squabb. —Operations, 2 p.h., and on
Thursday at the same hour.
Metropolitan Fbee Hospital.—O perations, 2 p.k.
Royal Obthopaidic Hospital,—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.m., and
each day in the week at the same hour.
University College Hospital.—E ar and Throat Department ,9 a.m.:
Thursday, 9 A.M.
Tuesday, March si.
KiNO’8 College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
Guy’s Hospital.—O perations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1,80 and Thursday at 2 p.m.
St. Thomas's Hospital.—O phthalmic operations,4 p.m.F riday, 2 p.m.
St. Mark's Hospital.—O perations, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.h.; Saturday, 2 p.m.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
Sr. Mary’s Hospital.—O perations, 1.80 p.m. Consultations, Monday
' 2.80 P.M. Skin Department, Mondi^ and Thursday, 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Blet^ro-
tberapeutics, same day, 2 p.m.
Wednesday, April 1.
National Orthopaidic Hospital.—O perations, 10 a.m.
Middlesex Hospital,—O perations, 1 p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.-O perations, 1.80 p.h. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 P.M.
Surgical Consultations, Thursday, 1.30 p.m.
Charino-cross H 0 .SPITAL.—Operations, 8 p.m., and on Thursday and
Friday at the same hour.
St. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 p.m. Thursday ASaturday, same hour.
8t. Peter's Hospital, Covent-hardbn.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Children.—O perations.
2.80 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
University Colleqic Hospital.—O perations, 1.80 f.m. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 9.16 a.m.
Royal Free Hospital.—O perations, 2 p.m., and on Saturday.
Children’s Hospital, Great Ohmond-strbkt.—O perations, 9.80 a.h. j
S urgical Visits on Wednesday and -Saturday at 9.16 a.m.
Obstetrical Sociicty ok London (20, Ilanover-sqiiare, W.).—8 p.m.
Specimens by Mr. Targett, Mr. Alban Doran, Dr. W. Duncan, and
others. Mr. John W. 'raylor; Case of Extra-uterine Pregnancy at
full term ; removal of child and placenta by abdominal section;
recovery.—Dr. W. S. A. Griffith ; (1) Case of Obstructed Labour in
which a large li'lbroiua was miataUen for the Head of an Extra-
uterine Fiutus ; (2) Case of Extra-uterine Gestation, the Sac being
situated in the Right Broad Lig.amont; Pregnancy advanced to the
early part of the fourth month.—Mr. Mavmaduke Slieild : Case of
Extra-uterine Gestation associated with Sloughing of the Abdominal
Wall, and attempted Extrusion of a matured and putrid Fojtu.s near
the Umbilicus.
Thursday, April 2.
Bt. George's Hospital.—O perations, 1 p.m. Surgical Consultations,
Wednead^, 1.80 p.m. Ophthalmic Operations, Friday, 1.89 P.H.
University Colleoe Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 A.H.
Harveian .society op London.— 8.30 p.m. Dr. Guthrie: A ca.so of
Post-hemiplegic Spasm.—Dr. Seymour Taylor: On Bradycardia,
the Slow Heart.
Friday, April 3.
Royal South London Ophthalmic Hospital.—O perations. 2 p.m.
Cancer Ho.8i>ital (Fulha.m-road, S.W.).—4 p.m. Mr. W. H. Elam:
Malignant Disease of Breast.
West London Medico-Cmihuruical SoniExv (Board-room, West
London Hospital).—3 p.m. Mr. Percy Diiiiii will .show sonic Patho¬
logical Spocliiiens. Dr. AldorMon : A case of Atteinnl.od Buiciile by
Chloroform.—Mr. S. Edwards : Observations on Lithotrity, with a
series of forty cases.
Saturday, April 4.
Middlesex Hospital.—O perations. 2 p.m.
Uhivbbsity College Hospital.—O perations, 2 p, m. ; and Skin Depart¬
ment, 9.16 A.M.
Digitized by
lOOglC
TBl Lancbt,] notes, comments, AND ANSWERS TO COBBESFONDENT8, [Mabcii 28, 1891. 751
Hfltes, S|flrt Comments, ^itsters to
Corresponkttts.
It is especially requested that early intelligence of local
events having a medical interest, or which it is desirable
to hr'.ng unker the notice of the profession, may be sent
direct to this Office.
All communications relating to the editorial business of the
journal must be addressed ''To the Editors ”
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private informa¬
tion, must he authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs shoidd
be marked and addressed "'To the S^ub-Editor.”
Letters relating to the publication, sale, and advertising
departynents of TUE Lancet to be addressed "To the
Publisher.’’
We cannot undertake to return MSS. not used.
Mft, MANSEI.t.-MOUI.I.I.N'S “SUUOEKr."
Wio have received from Messrs. J. & A. Churchill a copy of a fresh
list of iliustratlons to the above work, vritb the intimation lliat it is
intended to replace the list included in the copy which has been sent
out for review. Wo observe that to each of the borrowed illustrations
the name of tlie author is now attached.
.?a&ae might apply to the Editor of the Niwsing Itecord, published at
St. Bunstan's House, Fettor-lane, London, K.C.
Eye Btseasc.—We have no knowledge of the gentleman mentioned.
CIVIL SERVICE INSURANCE SCHEME.
To the Edilon of THE Lancet.
Sirs,—I n your is.sue of the 21at inst. is reported a meeting of the
Royal Academy of Medicine in Ireland, at which a paper was read by
Dr. MacDowel CosgiAve in reference to the above scheme. The above
reported meeting was held on Feb, lath, 1891. I have before me a
prospectus, dated Dec. 13th, 1890, which enacts as follows;—“On and
after 1st January, 1891, every proposer for life insurance aliall be
required to sign the following declaration: ‘1,-, of-, being
desirous to become a member of the Civil Service In.surance Society,
do hereby declare that I am nt the present time occupied upon my
usual official duties, and that I am, to the best of my knowledge and
V)elief, at the present time in a good state of health.' In addition, a
certificate appended to the declaration must be signed by two civil
servants serving in the same department as tlie declarant, to tlie effect
tliat he is at present engaged upon his usual duties, and is believed by
them to be in a good state of healtli.” In Dr. Cosgrave’s paper, as
reported, he states that the insurance is elfected “without any declara¬
tion of health, and without any reference to friends.” Perhaps the
above extracts will induce him to correct his statement, and will
also tend to modify Mr. Lontaigne's expressed opinion of uneasiness at
what seemed to him (with Dr. Cosgrave’s spectacles) "a very reckless
and dangerous policy.”
Perhaps the following facts may also conduce to the formation of a
more accurate judgment on the mei'its of this special case. 1. All civil
servants prior to appointment are subjected to a very extended medical
examination; and the medical examiner is specially asked to give the
benefit of any doubt he may liave In regard to fitness for tlie service not
to the Individual, but to the State, and ns a result only tho best men
are passed. 2. They enter the servic.e young. 3. Tlieir lives are in the
main not devoted to laborious callings, mentally or physically. 4. Only
five years must elapse between date of joining the service and date of
insurance.
After taking into consideration all Ihe above facts, 1 think it will be
at once acknowledged that tho conditions present in the lives of civil
servants collectively will distinctly outweigh in their prospects of
longevity those present in any first-class insurance office. While
strongly defending the Civil Service Insurance Scheme-safeguarded as
I believe it to be,—I would equally sttongly deprecate wliat Dr. Coagravo
believes will follow its succoas—viz,, tho indiscriminate admission of
lives witliout medical examination.
1 am. Sirs, yours faithfully,
March 2Srd, 1891, A Medical Civil Servant.
Cl.ADSEN’.S STOVE.
Mr. Camyholl Uyslop and several otlrer correspondents are referred to
the inventor, M. de Clausen, 87, Fitz-roy-square, W.
ProfesHor WindU (Birmingham).—The matter will bo treated fully in
our next Issue.
The Medical Department op the Peruvian Army.
The Crinioa M<>.dicii complains bitterly of the wretched condition of
the medical department of the Peruvian army, and considers that
much of the suffering endured by the latter during the late war wltb
Chili is to be attributed to the want of proper organisation of th&
department. One serious defect Is that of a medical school wherer
military surgeons may be adequately trained for the important andi
special work they have to do.
Dr. Jno. Wyllie,-—!. No.—2. The older qualification is perhaps the more
esteemed, though the possession of a university degiee Is generally
supposed to be accompanied by supenor culture.
M./i.C.S.—T he Lancet of Nov. 20th, 1886.
THE GENERAL PRACTITIONERS’ UNION.
To the Editors of THE Lancet.
Sirs,—I was very pleased to read in The Lancet of March 7th that
a Society has been formed under the above title for the protection of
general practitioners. Now, the great evil that general practitioners
have had to suffer from is the fact tliat they are only represented on
the General Medical Council by three members, who, of course, are-
elected by a majority of medical men as being those roost likely to-
press forward matters in which general practitioners are Interested.
But I beg to state that even these three gentlemen are not conversant
with the trials and troubles of a general practitioner in a country
practice in the northern counties.
Scattered thickly over the county of Durham are numerous villages
owned by the various collieiy proprietors, who each appoint a certain*
medical man as “colliery doctor” at a certain salary per annum, for
wiiich he has to attend all cases of accident which may happen to-
miners working in their pits. In addition to this, nt most coUleries the
oi'dlnnry attendance upon tho miners and their families, together wltb
any medicines that may be required, is covered by the large sum of
6 (t. per fortnight for each family, no matter how many “workers” there
may be, or how many persons may be ill at the same time, or over how
long a period the illness may necessitate attendance and medicine. The
only extra is a fee of lOx 6d. for confinements, whicli does not vary
whether the case is simple or if forceps or an operation may be needed.
Tliis fee includes attendance until the mother is well again, and usually
vaccination of the child as well. 1 might mention here that the
average pay of a miner in this county is £6 6«. per fortnight of eleven
working days of six hours each. He also has house and coals free, and
no rates or taxes. In my own case I have about 280 families to attend,
which means a population of about 1400. This number at Od. per fort--
night for each family should bring in £182 per annum -, but from this is
deducted 10 per cent, for collector’s commission (tlie custom of the
district), wlilch leaves .£103 ICs. net. Then there are about fifty con
finements, bringing in £20 6s.—a total of £190 !«., to cover an average
of twenty-five visits per diem and medicine, wliich, excluding ttie con¬
finements, means supplying persons with attendance at a rate of 4.Jrf. per
visit, and giving them the medicine gratis. If one speaks of raising the-
fees, one is met by the reply that Dr. So-and-so will attend for the old
fee, and miners are so migratory a population that it matters little to-
tliem what doctor attends them so long as he can give the necessary
certificate in case of death, and thus save an inquest. They may
become pretty well altaclied to a man If ho looks after them well and*
is possessed of a fair amount of skill; but even should the most popular
man raise his foes, they would leave him almost cnmanw for the neai-est
man who is content with things as they stand.
There is also an element of unqualified practice to contend with..
There are two iinquaJified practitioners in iny district; but when I
asked my qualified neighbours to unite with me in prosecuting them, B
was told as regards one of them: “Let the poor old man go on in peace..
He has been in practice here lor over thirty years—before any quoUfied
mail was in the neighbourhood.” I was also told that I should do
myself more harm tlian good by interfering with him, which I really
believe. This man puts “M.R.S." after his name, and thus deludes
persons into believing he is qualified, and registrars accept his cer¬
tificates.
The formation of a General Practitioners’ Union which would put
down unqualified practice, and also help a general practitioner towards-
raising tho low standat d of fees quoted above, so that he may have a
fair recompense for hia work, will be hailed with joy by the great mass
of general practitioners, a large number of whom have their lines-
certainly not cast in pleasant places.
I am, Sirs, yours truly,
March 16th, 1891. General Practitioner..
MacMunn'8 Case Sheets.
Anv plan which facilitates the record of cases seen by the busy prac-
titionev is sure to be appreciated. The “Case Sheets” devised by
])r. MacMunn, and issued by Mr. Silverlock, seem to ua to answer
well all the requirements for tho noceasurily condensed form of note-
taking tliat is alone possible under tire conditions of private practice.
Many will doubtless be glad of so convenient a method of beeping
records of their patients.
F,li.C.S.~Ov.\ correspondent’s letter on the risk of dispensary abuse
shall be published next week.
Digitized by ^ooQle
752 ThbLai^ost,] notes, COMM3&NTS, and answers to COBBESPONDENTS. CMarcr 28, 1861,
Vbrbuoa Pbruviama.
'Do. Paoaza recently brougbt before the Lima Medical Society, " Union
Femandina,” a caee of the peculiar Peruvian wart disease in which
gangrene of the right leg occurred, which caused an embolus, resulting
fatally.
i>. 2>. H .—Our correspondent does not appear to have tried subnltrate
of bismuth (ten-grain doses) every two or three hours. The liquor
ferti pemltratls is often of some service.
Mr. J. Lawrence Newton (Sydney).—We regret we cannot answer the
question.
CORONERS AND POST-MORTEM INSPECTORS.
To the Editors ef The Lancet.
Silts,—Certain occurrences happened here a week ago wbiclirendered
it necessary that 1 should question the coroner's selection of a post¬
mortem Inspector. A friendly and courteous correspondence ensued,
which much impressed me with the gentlemanly demeanour of the
coroner. During that correspondence, however, the coroner em*
pbatlcally declared that the selection of a post-mortem inspector was,
under every and any circumstance, at his unquestionable discretion—
that is to say, any medical man in charge of a case eventually ending in
a post-mortem examination and inquest may be quite ignored, passed
over, slighted, and made give place to the coroner’s nominee, the latter
having no earthly connexion with the previous history of the case.
Further, the coroner, as in the above Instance, may be a lawyer, unable
to judge of the fitness of his especial nominee for the work in band.
In fact, the said nominee may be practically and truly the inferior of
the medical man whose place he takes. If this he law, it is a law con¬
structed by an idiot. 'The discretion of any coroner in this matter
should be open to revision. It is a discretion liable to grave abuse,
and fraught with many annoyances to the medical man slighted. It is
open to strong censure; for an ignorant public will judge that the
doctor who supersedes is more intelligent than the one superseded.
Cannot this law—if it be law—be abrogated, annulled, reinstated in the
Simbo of oblivion which probably liolds its constructor f
I place the matter before my professional bretbren, and await the
«nunc!ation of their opinions.—I am, Sirs, yours faithfully.
Moses Gate, March 2;jr(l, 1891. W. B. Brodie.
Communications not noticed In our present number will receive atten¬
tion in our next.
Communications, Letters, &c., have been received from—Mr. Bruce
Clarke, London; Dr. Steavenson; Dr. Ed. Seaton; Dr. Theodore
Williams, London; Dr. Herman, London; Mr. Kitkham; Mr. Hay
Forbes, London; ProfessorCharteris, Glasgow; Mr. Erodie, Moses
Cate; Mr. Lawton, Poole; Dr. W. White. Birmingham; Dr. Mortimer
■Granville,London; Dr. J.Barr; Mr.IIowlett,Hull;Messrs.Keeneand
Ashwell, London ; Dr. Vidal Solares, Barcelona; Messrs. Richardson
and Co., Leicester; Prof. Windle, Birmingham ; Mr. Hyslop, Chiu'ch
Stretton; Dr. Hekimian ; Dr. G. Johnson, London; Messrs. Burgoyne
and Co., London; Dr. W. T. Gairdner, Glasgow; Mr. Behnlce, Karl’s
Court; Dr. V. D. Harris, London; Mr. Hawkes ; Mr. Mann, Milo
End; Mr. Pocock, Bangor ; Dr. Kelso, Soutiiaoa; Dr. P. C. Lai'.son-
Utke, Copenhagen ; Mr. Low, London; Dr. Currie, Madras; Mr. A.
Duke, Dublin; Mr. Tweedy, London; Dr. Grove, Wilts; Mr. H. M.
’Milton, Cairo; Mr. Bag.shaw, Salford; Mr. Pearson, Cork; Dr. E. F.
Neve, Kashmir; Mr. Mendelsohns, London ; Mr. Mitchell, Washing-
iton, U.S.A.; Dr. Santini, Rome ; Dr. Appiab, Bangalore ; Mr, Giirner,
Pall Mall; Dr. Wareman, ZanKlbar; Messrs. Oppenhoimer Bros, and
Co., London; Mr. Gibson, Newcastle-on-Tyne ; Messrs. Hortz and
Collingwood, London ; Dr. Moorhead, Notts; Messrs. Orridgo and
Co., London ; Mr. McDonald, Gosport; Messrs. Wright, Dain, and
Co.,Birmingham; Messrs.Southall,Birmingham; Mr.Ma^rader.Now
Orleans; Mr. Freeman, Lpndon; Mr. Donelan; Dr. Phillips, Virginia
Water; Mr. Mackenzie, London; Mr. Heatsn, London; Messrs. Ross
and Co., Belfast; Mrs. Learmontb, Canterbury; Messrs. McMillan
and Co., London; Mr. Stranaghan, Pontypridd; Messrs. Mottorshead
and Co , Manchester ; Mr. Ilornibrook, London; Dr. Roberts, Shef¬
field ; Mr. Little, London; Mr. Foskott, Dulwich ; Dr. Coghill, Bir¬
mingham ; Dr. Maunsell, Cardiff; Mr. Woodcock, Bradford; Mr. Le
Fevre, Bedford; Mr. Vickers, London; Mr. Clifford, London ; Mr. W.
Rayner, Uxbridge; Dr. Stephenson, Aberdeen; Mr. Mahony, Liver¬
pool ; Mr. Emlnson, Scotter; Mr. Cotman, London; Mr. Edwards,
London; Mr. Maugan, London; Surgery, London ; Prescrlber; Thor;
Sigma; Micros, London; Dispatch, London; Maltlne Manufacturing
Co., Bloomsbury; J. W. F.; M., London; Pulsometer Engineering
Co., London; Medical Superintendent, Harrow-road; Sanitary Wood
Wool Co., London; Owner, Lancs; Sabac; A Medical Civil Servant.
Lettehs, each with enclosure, are also acknowledged from—Mr. Leoch,
Bristol; Mr. Tully, Bastings; Mr. Moore, London; Messr.s. Coxoter
and Son, London; Mr. Heywopd, Manchester; Mr. Dale, Market
Drayton; Dr. Murrell, London; Mr. Ward, London; Messrs. Battle
and Co., Paris; Mr. Cba;^mo>n. Falmouth; Messrs. Brown, Gould, and
Co,, London; Mr. Tresise, Burton-on-Trent; Messrs. Blondeau et
Cie., London; Dr. Diver, University College Hospital; Messrs. Bush
and Son, Sheffield; Mr. Lockwood, Huddersfield; Messrs. Brady and
Martin, Newcastle-on-Tyne; Dr. Scriven, Duffleld; Messrs. Allen and
Wilson, Indianapolis; Mr. Hutchinson, Belfast; Mr. Roberts, Shef¬
field ; Dr. Deane, Ellesmere; Mr. Coombes, Bridgwater; Mr. Biasett,
Aberdeen; Dr. Fletcher, Highbury; Dr. Hinde, Banbury; Mr. Tyte,
Minchiniiampton; Mr. Heywood, Nottingham; Mr. Huisli, Lordship-
land ; Mr. Taylor, Ventnor ; Mr. Russell, Liverpool; Mr. Shavaksha
Horabji, Hydembad; Dr. Cbeeaewright, Eawnarsli; Messrs. Godfrey
and Cooke, London; Mr. Rowortb, Grays, Essex; Dr. Adams, West
Mailing; Mr. Lee, Bath; Mr. Arkle, Teignmouth; Me.ssvs. Cooper
and Morris. Rosa ; Mr. Edwards, Bridgend ; Messrs. Ponsford and
Co., Taunton ; Mr. Meehan, Kritli; Mr. Evans, Bradford; CblchesteE
Infirmary; Alphabet; Alpha, Brighton; Pheenix, London; Devon and
Exeter Hospital; O. W. C, Loudon; Sussex, London; Portsmouth
Lunatic Asylum ; Wanderer, London; Cliurchman, London; County
Asylum, Prestwich; P. A., London; Hercules; Seci-otavy, Southern
Hospital, Manchester; F. J. D., liOndon ; Lupus, London ; Cantab,
London; Lake, London ; Superintendent, Newcastle-on-Tyne ; M.,
Birmingham; Smilax, London; Mercury, London; Medicus, Scar¬
borough; Genuine, London; Student, London; M.D.,Loncl 0 D: M.A.,
Croydon; B. M,, Sidmouih; Miss X., Manchester; Forceps, Accring¬
ton ; DTtnolin. London ; Nurse, Sheffield.
Nkwsi’AI’ER.s.—J fonfreal Star,New Vork Herald, Loni/ Eaton Adoertlser
Lhierpool Daihi Post, Scottish Leader, Bnilder, Leeds Mereuri/, Smiday
Times, Bristol Mercunj, Yorkshire Post, Broad Arrow, West Middlesex
Gazette,, Chemist and Drsigyist, Army and Eavy Gazette, MeiropolUan,
Jaiw ■! oiimal, Spectator, Pharmaceutical Journal, City Press, Surrey
Admrtiser, Guy’s JJospit.al Gazette, IVesI Middlesex Advertiser, Saturday
JieBie^v, Mininy Journal, Birminyham Daily Gazette, Insurance Jlecord,
Ilerl/nrdshire Mervuin, Windsornnd Eton Exjtress, Beadiny Blanniry,
Weekly /'Vee Press and Alierdeen Herald, Local Government Chronicle,
The. Ecwspape.r, Klextriaal Knyincer, Enyllshman (CalctiHa), Windsor
and Eton Gazette, CorkCoiistituium, Pionae.cl^&Uahatjad), Morniny Pos’.,
Le.Temm(_Paris),Scotsman, Banlmry (iutirdian, Manchester Exammer,
North llritish Daily Mail, Shejjleld Indepcmlent, Western Mail, Man¬
chester City News, ISssex County Chronicle, Erith Times, jVorf/jampfon
Mercury, Bath Gazette., Lowestoft Journal, Devizes Gazelle, Doncaster
Chronicle, Labour World, Eenlish Gazette, Cor^fectioners' Union, etc.,
have been received.
SUBSCRIPTION.
Post Free to any part op the United Einodom.
One Year..... £l 12 6 | Six Months £0 1# 8
TO China AND India .._..-..One Year 1 Ifl li
TO TUB Continent, Colonies, and United
States.. ... Ditto l 14 8
Post OfficeOrdevs and Cheques ehould be addressed to The Publisher,
The Lancet Office, 428, Strand, London, and crossed “London and
Westminster Bank St. Jauies's-square."
ADVERTISING
Books and Publications (seven lines and under) .. 80 B D
Official and General Announcements .0 4 0
Trade and Miscellaneous Advertisements .. ..046
Every additlotkal Lliic 0 0 6
Front Page . per Line 0 1 0
Quarter Page. .1 10 0
Half a Page .2 15 0
An Entire Page.660
The Publisher cannot boju hlniself resporuublo tor the i-etum of testi¬
monials &c. sent to the office in reply to advertisements ; copies only
shnulcl be forwarded.
Notice.—A dvertisers are requested to observe that it la contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
^ Special Iiidex to AdvertJaonieiits on pages 2 and 4. which not only
affords a ready means of finding any notice, but is in itself an additional advertisement.
Advertisements (to ensure insertion the same week)should be delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
addKss^ Serial Insertiona may bo obtained of the Publisher, to whom all letters relating to Advertisements or Subsorlptioiu should bo
Adv«Urii«^entIs *** Moel^ed at all Messrs. W. H. Smith and Son’s RaUway Bookstalls throughouti the United Hlngdom Md ail other
Agent for the AdvertiBement Department in France~J, ASTIER, 66, Rue Camuaitln, Paiia
THE LANCET, April 4, 1891
®;|e fataws
ON TUB
STRUCTURAL DISEASES OF THE HEART
CONSIDERED FROM THE POINT OF
VIEW OF PROGNOSIS.
By W. H. BEOADBENT, M.D., F.E.C.P. Lond.
LECTURE III. I
Fatty degeneration .—No form of heart disease is regarded .
with BO much apprehension as fatty degeneration. More
(than any other, it carries with it the danger of sudden death
<and the liability to angina pectoris, and, although happily
<the disease is not very common, it would be a most important
jncquisition to be able to make the diagnosis with certainty
4 it an early period. The important point in its cansation is
■that the primary change is atrophy of the muscle substance,
Gthe invasion of the fibres by fatty matter being secondary
•to this and consequent upon it. Disease of the coronary
•arteries being thus a cause of degeneration of the heart, the
•existence of conditions which may lead to the implication
•of the coronary arteries or their orifices in morbid processes
will warrant a suspicion that cardiac weakness, which may
%)e recognised, is the result of degeneration, l^or example,
•an aortic murmur coming on after middle age may not
indicate serious valvular lesion ; but, as it is probably the
•result of atheromatous changes in the valves or arterial
walls in close proximity to the orifices of the coronary
•arteries, there is reason to apprehend that the disease may
cause obstruction here or may have extended to the vessels
-themselves, and progressive weakness of the heart, were this
■to supervene, would be attributable to degenerative change
un its walls. Acute aortitis is recognised mainly by a train
of eflecbs on the heart produced in the same way—i.e., by
(blocking of the mouth of the coronary arteries.
Rub there may be fatty degeneration of the heart when
the coronary arteries are healthy. It is usually present,
•sometimes in a very advanced degree, in pernicious anmmia,
-and granular degeneration, which is an acute form of the
•disease, is a constant effect of severe typhoid fever and of
•fatal phosphorus poisoning. Cases occur from time to time in
which apatient convalescing from typhoid fever dies suddenly
•on sitting up in bed. Here, again, in fatal aniomia and
enteric fever, the process must be the resultant of a balance
•on the wrong side as between the catabolic and anabolic
operations, disintegration and repair; but it is now the
■quality of the blood which is at fault, nob the supply, and
in typhoid fever there is also the injurious effect on the
•Qutrlbionai processes of long-continued high temperature.
It is not to be wondered at that in pernicious apmmia and
'fever the heart suffers more than the voluntary muscles,
•since these are at rest and there is no functional wear and
tear, whereas in the heart this is continuous and excessive.
Ci''rom what takes place in typhoid fever, again, it is seen
■howrapid degeneration maybe. Diabetes, alcoholic excels,
tippling rather than drunkenness, a sedentary mode of life,
may conduce to fatty degeneration of the heart, probably
•through deterioration of the blood, or it may be secondary
60 myocarditis. Cases are met with for which no explana-
■tion can be found, and we are almost compelled bo assume
that there may be a defective assimilative action in the
muscle cells of the heart, or possibly some unrecognised
t)lood condition.
There is very little that is characteristic in the sym¬
ptoms. In a large proportion of cases the subject of this
affection has had no ailment which has led him to consult a
medical man, when he is overtaken by sudden death during
oxerbion or excitement, or the administration of chloroform,
or after a full meal. Or the excitement or exertion may be
passed through safely and death follow some hours later,
next day even. Rupture of the heart is one mode of termi-
matioD, and this may take place on very slight provocation.
Sometimes the patient has been engaged in his usual avoca¬
tion up to the moment of its occurrence. In one case, which
■aame under my observation, an old gentleman of quiet re¬
tired habits, with nothing beyond the weakness incident to
age, was heard to knock at the wall against which his bed
No. 3627.
was placed, and was found dead, the bedclothes scarcely
being disturbed. A neat slit was found in the left ventricle
near the apex, close to and parallel with the septum.
When the course of the disease has been sufficiently
chronic to permit of the recognition of symptoms (which, in
my experience, is chiefly when the degeneration is secon¬
dary to change in the coronary arteries, or to old-standing
hypertrophy, with or without dilatation) they will he such
as are produced by a slackening circulation, and they are
not so different from those attending dilatation as to permit
of any distinction being drawn between the two conditions
in an early stage witnout physical examination. There
may perhaps be greater fluctuations in dilatation, though
even in degeneration there may be great temporary improve¬
ment under care and treatment. In advanced st^es
characteristic differences make their appearance. The
symptoms of advanced dilatation have already been de¬
scribed ; those attending degeneration are evidences of
heart failure of another kind. A noteworthy point is
that well-marked dropsy is rare, and probably never
occurs in uncomplicated degeneration. The significance of
this is that the special efl'ecb of the disease is defective
pressure in the venous system, and it is to this are due the
syncopal, apoplectic, and epileptiform attacks, which,
together with angina pectoris, are the most characteristic
later effects of fatty degeneration. The syncopal attacks
Vary greatly in intensity. So far as they have come under
my obsei'vabion, they have been marked rather by duration
than intensity, and have rarely been so complete as to be
attended with absence of consciousness; they have usually
been accompanied by prolonged coldness 0 ! the extremities
and of the surface. I have not met witli instances of sudden
and complete loss of consciousness and immediate recovery
as in dilatation. These syncopal attacks are very signi¬
ficant, and are often premonitory of fatal syncope. The
apoplectiform seizures are very remarkable, and in the
absence of history and without examination they are not
distinguishable from the apoplectic condition resulting from
cerebral hicmovrhage. The epileptiform attacks are not
often violent, but resemble petit mal rather than a typical
epileptic fit. While, however, the convulsion may not
be severe, there is profound unconsciousness, not like
epileptic coma, but of a syncopal character, and the pulse
maybe extremely infrequent, sometimes less than 20 in the
minute. In my judgment the heart failure manifested by
the slow pulse and the consequent arrest of the cerebral cir¬
culation are the cause of the fits, and it is not the epilepti¬
form attack that affects the action of the heart. By the time
any of these forms of attack occur the diagnosis of fatty
heart is usually sufficiently clear; but 1 have had under
observation a case of very alow pulse with petit mal, in which
the strength and volume of the pulse and the degree of im¬
pulse of which the heart was capable precluded the idea of
advanced degeneration. Is there anything characteristic in
the appearance of a patient suffering from fatty degene¬
ration of the heart? A greasy state of the skin Avith a
sallow pallor of the face has been described, but nothing of
the kind is present in a large majority of the cases. Many
of the subjects of the disease retain the look of health for a
long time, and even up to the moment when the heart ceases
to beat.
Fulse and physiecd signs .—The most constant and signili-
I cant feature of the pulse is that it is short and uusustained.
The size of the artery at the wrist and the condition of its
walls may vary greatly. When the arterial coats are liealtby
they are apt to feel extremely thin. The jjulse rate may be
regular and about normal, or extremely irregular both in
force and time, and it may be frequent or slow. A very
slow pulse with extreme low tension is most characteristic,
but then it is the most rare. The physical signs may be
described as negative. Unless degeneration has attacked
a heart already enlarged the size will be normal. If the
fatty change is at all advanced impulse can neither be seen
nor felt, or if perceptible it is only as a faint vibration. A
heart in this condition is incapable either of giving a distinct
push or maintaining continuous pressure in the arteries.
The sounds are weak, sometimes so weak as to be almost
inaudible, but except that the first is short there is
' nothing about them; the intervals, again, are usually
' normal. The very absence of murmur, or of consuicuous
modification of the sounds or intervals, and of disturb¬
ance of the relation between the two sides of the heart
or of increase of dimensions, when symptoms of serious
slackening of the circulation are present, and especially
o
754 The Lancet,]
DR. W. H. BROADBENT ON DISEASES OF THE HEART.
[ArEiL'4,1891,
when there have been anginal, syncopal, or apoplectic study of the symptoms whi^- attend affections of thi&
attacks, adds gravity to the case. But a weak, short, un-, ventricle secondary to disease of the left ventricle or its
sustained pulse is common as a constitutional peculiarity, | valves, which therefore are really attributable to the originals'
or may at any period of life be simply a result of general disease. Undoubtedly the s:dpervention of dilatation of the-
debility, and impulse and apex beat may be entirely absent, right ventricle and of reflux through the tricuspid orifice’
and the sounds may be short and weak. In young'people allows back pressure to be brought to bear upon the
there is no danger of such weakness being taken as an veins, but this o^ intensifies pre-existing symptoms
indication of degeneration of the heart, but it may arouse and makes no change in their character. We are
anxiety after middle age, especially if there is also irregn- perhaps justified in assuming that the venous back pres-
latity. It is important to be able to distinguish between sure, to which insufficiency of the tricuspid valve will
functional weakness of this kind and weakness arising from give rise, will in some de'gi'ee produce the same results,
organic disease. Usually this is accomplished by making whatever the state of the left side of the heart, and.whether
the patient walk briskly. A few steps will often be sufli- or not the tricuspid regurgitation has been caused by
cient. If the heart is sound, it rises to the occasion ; the obstruction in the pulmonary circulation, but theconditione-
pulse beat and sounds are all more distinct and strong are fundamentally dilleient when the tricuspid reflux is-
and regular, whereas the fatty heart “ goes to pieces,” and primary. It is not impossible, for example, tuat a sound
the pulse becomes irregular and shorter than ever, or may and strong left ventrime may come to the aid of the right
even disappear. ventricle, just as the right ventricle so constantly comes tO'
Until the disease is far advanced the diagnosis of fatty the aid of the left, notwithstanding the great length of the--
degeneration of the heart is not easy, and is scarcely to be systemic as compared with the pulmonic circuit and the weak
m^e without more than one opportunity of examination, blood pressure in the systemic veins. The pressure whicb
"When the diagnosis has once been made, the prognosis for will cause the blood to spurt for two or three feet in vene •
the most pa.rt can contemplate only one result : a fatal section might carry a current through the capillaries of the
termination is merely a question of time and circumstance, lungs, aided by the respiratory movement of the valves of
Excluding cases in whicli death has been sudden without pulmonary artery. It has, moreover, seemed to mo that
warning, the shortest period in my experience over which weakness of the right ventricle, the left ventricle being,
characteristic symptoms have extended, together with in a normal condition, in some cases have given rise
recognised physical signs, has been about six weeks; to symptoms due rather to inadequate supply of'
several _ patients have survived the diagnosis two years blood to the left side of the heart than to damming
before justifying it by dying suddenly. But circumstance back of blood in the veins. I have, for example, met-
as well as time enters into the question. A slight eflbrt or with several instances of primary tricuspid regurgitation,
a fall, a little hurry or excitement, too hearty a meal, an either as a constant condition or coming on under very
attack of flatulent indigestion or constipation, a chill, may slight provocation. 'When any effect of this has beeni
hurry on the fatal termination; and, on the other hand, traceable it has not been breathlessness on exertion, but
judicious care may postpone it till the heart is completely tendency to syncope. Perhaps this is what we ought to-
worn out and conies to a standstill. expect, since the occurrence of tricuspid regurgitation on
The question must be asked. Is fatty degeneration of the the breathlessness of violent exertion has been regarded as
heart ever cured or arrested? If the granular disintegration a safety-^valve action, since, also, shortness of breath re-
which is produced by typhoid fever is to be included under suits from mitral regurgitation. A difference of symptoms
the term, the answer must undoubtedly be, Yes. The heart ought to attend mitrw and tricuspid insufficiency, one
may ultimately regain structural soundness and functional giving rise to turgescence and high pressure in the pul-
vigour when during the fever the first sound has been com- monary circulation, the other to deficient supply of bloods
pletely lost, and the impulse has been scarcely perceptible; and low pressure. If mitral disease produces pulmonary
and when degeneration has been the result of other forms symptoms tricuspid disease may well produce systemic-
of blood poisoning or deterioration, it ought to be possible, symptoms. In a few cases which have come under niy
and now and then does occur, that recovery of the heart notice, in which the right ventricle has appeared to be pre -
should follow a return to a healthy state of the blood. dominantly or almost exclusively aft'ected by asthenia or-
More than ten years ago I came to the conclusion that a degeneration, the effects have been similar to those of
gentleman still living, aged at that time about fifty-five, tricuspid regurgitation.
was suffering from fatty degeneration of the heart. Spare A patient aged seventy-two, who had never had a day’s
in habit, strictly moderate in eating and drinking, regular illness in his life, consulted me in 1879, complaining oi'
in taking exercise and a great pedestrian, he rapidly lost failing vigour, giddiness on running to catch a ’bus, and
strength without recognisable cause, became breathless tendency to fall asleep iu the day. He was constipated
on very slight exertion, so that he could scarcely walk the pulse was not more than 60, was sometimes tense, some-
100 yards without actually stopping, either to get his times soft. The heart sounds generally were weak, the
breath, or on account of anginoid pain. On one occasion at aortic second accentuated. In April, 1881, symptoms,
least, while sitting in his chair, he became suddenly pale and which had previously been relieved, returned, and it wa&-
unconscious ; his head fell on his chest, and the jaw dropped, now found that over all parts of the right ventricle, and
With this change in his health, the pulse and heart were even over the pulmonary area, there was absolute silence,
extremely weak, lie never would relinquish exercise, but No impulse or apex beat could be detected, but at the apex
continued to walk, however slowly, and at whatever cost the sounds were normal; the aortic second sound was
of pain and distress, every day, exercising great self- accentuated. The pulse was 72, a little irregular, but fair
command and measuring his strength very exactly. Little in force and length. A month later he was much
by little he gained ground, and he is now in fair health, but better. The pulse was 60, fair in strength and length,
capable of very little in the way of work. It should be added The left ventricle sounds were good, the right ventricle
that never at any time were his intellectual faculties at all sounds faintly audible. From this time neither the
affected. This case may have been an instance of arrest and right ventriclWlrst sound nor the pulmonary second sound-
partial recovery. _ -was ever at any time audible. The pulse varied con-
There is not much to be said on the subject of treatment, siderably both in frequency and in tension, but it -was-
Life should be made as easy as possible for the sufferer. He usually well sustained, indicating considerable vigour of
should have as much sun and iresh air as his strength and the left ventricle, and the left ventricle sounds were good,
the weather will permit, but on no account must he be He had from time to time severe fainting attacks, whicli
exposed to severe cold. Such exercise as he is capable of sometimes threatened to prove fatal. He was always worse
is good for him, but he should never incur angina or extreme when the bowels were not kept freely open. In June, 1883,
breathlessness. His food should be simple and his meals the pulse is described as large, full, and tense ; the aortic-
strictly regular, and the bowels should be kept well open, second sound was accentuated at the apex in the right
The rectification of functional derangements will be of second apace; there were no right ventricle sounds,
service, and tonics may do good. Towards the end of 1884, when not under my care, the-
Bight ventricle .—Little has been said about the right bowels were allowed to get confined, and he fell into a
ventricle in the discussion of the different structural condition of stupor, with incontinence of urine and fmces.
diseases of the heart, for the reason that affections of this He recovered from this condition after free aperients, and'
ventricle have been reserved for special consideration. It was again able to go about, though bis mental facultiea
has seemed to me that our ideas of the effects of the disease were impaired and he was childish, but in November, 1885^
of the right ventricle have been to much based upon a thrombosis of the left middle cerebral artery took place.
Thb Lancet,]
DR. W. H. BROADBENT ON DISEASES OF THE HEART.
[April 4,1891. 755
giving rise to hemiplegia and aphasia, of which he died.
The entire absence of right ventricle sounds in this case
was very remarkable, and I cannot doubt that there
was really no action of this ventricle. As it seemed
to me impossible that the pulmonary circulation could
fee maintained without its aid, I formed a very un¬
favourable prognosis, and when this was belied I watched
'the case with extreme care—first to make sure that
my observation was not at fault, and next in order that
’I might arrive at some comprehension of the problem
5 )resented by the facts. The conclusion appeared to be un¬
avoidable that the left ventricle was carrying on the circu¬
lation through the lungs; it was throughout capable of
maintaining high tension in the arteries. The amount of
blood passing through the pulmonary vessels under these
•conditions and reaching the left auricle would be easily in-
duenced and would vary greatly, and the fluctuating supply
of blood to the left ventricle would account for the varying
•character of the pulse.
One of the most serious effects of weakness of the right
ventricle is met with in disease of the mitral valve. When
■the mitral valve from thickening and shrinking of the cur¬
tains and tendinous cords becomes ineflicient, the right ven¬
tricle is for a time the rampart by which the reflux of blood is
arrested and is a reinforcement to the crippled left ventricle.
When we hear a systolic apex murmur telling of mitral re¬
gurgitation, the murmur itself gives no trustworthy infor¬
mation as to the amount of blood which is carried, back
into the auricle. We gather this mainly from the efl'ecbs
upon the right venbricl* The first of these is accentuation
-of the pulmonary second sound, indicating increased pressure
in the pulmonary circulation, and following on this hyper¬
trophy of the tight ven ti-icle, by means of which the obstruc¬
tion to the passage of blood through the lungs is overcome.
'It is hy the augmented strength of the right ventricle that
the mitral leaKage is neutralised and aworking equilibrium
-established. The greater the regurgitation the greater the
^amount of hypertrophy required to compensate for it. The
•change in the right ventricle thus becomes, together
with the accompanying dilatation of the left ventricle, a
■measure of the regurgitation. When, therefore, we detect
•a mitral systolic murmur, we at once examine the right
ventricle in order to gather from its condition information
as to the amount of reflux which is not yieldetl by the
•murmur itself. This is specially the case when symptoms
-of failing compensation have set in. But if the right
ventricle is in a state of degeneration or great weakness,
'these indications fail us altogether, while dropsy and
other evidence of serious stasis and back pressure in the
■venous system are rapidly developed for lack of hypertrophy
■or compensatory effort on the part of the right ventricle,
^nder these circumstances the prognosis is extremely grave.
The right ventricle is unable to come to the aid of the left,
the mechanism of compensation makes default, and the
back pressure bears at once upon the venous system. The
fulcrum for some of our most eflicacious therapeutic
measures is missing—we dare not open a vein, however
.great the respiratory embarrassment and cyanosis, the
•effect of leeching over the liver is less certainly good, and a
dose of calomel is not well borne. Recovery is rare, and
twice it has happened in my experience that during apparent
convalescence, when an unfavourable prognosis seemed to
have been belied, the patient has died suddenly when
'beginning to walk about. Similar conditions result from
time to time from adhesion of the pericardium. The right
ventricle suffers much more than the left from peri¬
carditis. During the attack the muscular fibres imme-
■diately subjacent to the serous membrane, which are
^)aralysed by the inflammation, form an appreciable
proportion of the thin wall of this ventricle, which is thus
weakoning and prone to dilate, whereas, although the
superficial layer of the muscular fibres of the left ventricle
'is similarly paralyse<l, they constitute a relatively unimpor¬
tant part of the mass of the ventricular muscle. Again,
'the right ventricle is much more hampered by adhesion of
the pericardium than the left, partly because its superficial
•area is relativel.y large, bub chiefly because of the thinness
of its walls ; and when the adhesii)ns are general, and especi¬
ally if there is also adherence of the pericardium to the
chest wall and diaphragm, ettioienb contraction of this
ventricle must be impossible. Cases of this kind, then, are
not uncommon. There is valvular disease, mitral or aortic;
from the size of the heart, the position and character of the
apex beat and impulse the persistence of sounds in spite of
the murmurs, there are gounds for concluding that the
valvular lesion is not very great, bub there is a premature
development of symptoms. Under such circumstances we
may often confidently infer adhesion of the pericardium
when it cannot be demonstrated by physical signs. The
right ventricle may he obviously labouring and the pul-'
monary second sound may be lees definite and pronounced,
which will tend to corroborate the conclnsion arrived at.
The right ventricle is undoubtedly sometimes the cause of
sudden death; and when the heart i's embarrassed or stopped
by pressure upwards of the diaphragm by a distended
stomach or colon, it must be on the right ventricle that the
pressure takes effect. This part of the heart rests upon the
diaphragm, and will be directly compressed when it is
pushed up. Probably it is the diastole which is mostly
interfered with, and it would seem that the proper expan¬
sion and filling of the ventricle must be impossible when
the pressure upon it is such that the heart is carried up
bodily by the diaphragm, especially when the ventricle is
dilated and over-disturbed.
A melancholy instance of this occurred in my experience
in the ca^e of an eminent artist. He was suffering from
mitral stenosis and regurgitation and had an extreme degree
of distension of the right side of the heart with tricuspid
regurgitation, and suffered especially from sleeplessness
and dyspncca so that his misery was insupportable
and life was despaired of. The application of leeches
over the liver, which was enormously swollen, and the
administration of calomel at once gave him sleep, and by a
repetition of the leeches and regular employment of mer¬
curial aperients, with the usual heart tonics, he so far
recovered as to be able to leave his room, and his con¬
valescence seemed to be assured. One morning after a
hearty breakfast in bed the nurse was about to wash his
face and hands as usual, but he impatiently bade her give
him the basin and stand aside. He sat up in bed with the
basin between his knees, and when the time came for wash¬
ing bis face bent forwards over it. The pleasure upwards of
a full stomach caused by this movement brought the weak
right ventricle to a standstill, and the patient fell back
dead. One cannot help being reminded in relating this in¬
cident of the rough-and-ready but effectual way in which a
man is brought to who faints after the frightful exertion of
a boat race. He is seated on the ground, and his body is
bent forcibly forwards so that his head almost comes to the
ground between his knees, or if he has fallen forwards over
his oar, it is done while he is in the boat. The models
operandi of the remedy is pressure on the distended right
heart; and when emetics are resorted to in bronchitis
which has gone on to the ])roduction of cyanosis, the good
effect is due not only to the emptying of the bronchial
tubes, but to unloading of the right auricle and ventricle by
the act of vomiting.
Angina pectoris .—While heart disease generally of what¬
ever kind IS remarkable for the almost entire freedom from
pain, so that, when patients come complaining of pain in
the cardiac region, ib is a presumption against the existence
of any serious organic affection of the heart rather than an
indication of any such charge, there is one form of pain in
and around the heart, angina pectoris, which is very definite
and constant in its significance of disease and or danger.
In a characteristic attack of angina there is intense pain in
some part of the cardiac region in the left breast, or behind
the sternum or across the chest, at its upper part usually,
but occasionally lower down, with radiation down the left
arm. Accompanying the pain is a sense of utter powerless¬
ness and extreme fear and dread. The patient stands still,
not daring to move or breathe, and feels as if he were in the
act of dying; he will say afterwards that if the pain had
lasted another moment he must have died. In no other con¬
dition is the physical agony of dying realised in anything like
the same degree. The two elements of pain and sense of
dying coexist in a true paroxysm of angina, and are almost
equally characteristic. The pain differs in character and
sicuation and in intensity in diilerent cases. Some sulFerers
will say it is indescribable : nothing in their previous
experience suggests even a comparison. Otliers speak of
the pain as severe cramp in the heart, or as if the heart
were gripped by an iron claw, while pain of a shooting
neuralgic character, sometimes intermittent, sometimes
persi.sbent, seems to radiate from the chest to the left
shoulder, the inner side of the arm, the forearm, and the
ring and little fingers. Occasionally there la a sensation as
of the wrist being grasped so tightly as to cause great pain.
756 Thb Lancet,]
DE. W. H. BKOADBENT ON DISEASES OF THE HEAKT.
[April 4,1891.
With the pain in the heart there may be pain down both
arms or- shooting up into the left side of the neck, very
rarely in the rjgbb arm only. Occasionally the pain may
be felt first in the arm and seem to travel up to the chest,
or may come in the inner side of the arm as a kind
of warning of an attack. Another description of the pain
is that it feels as if the sternum were being crushed back
to the spine, or, again, os if the whole cheat were being
held in a vice. In other cases the pain is compared to a
bar of iron across the upper part of the chest; in others,
^ain, to a ton weight upon the lower part of the chest,
'^e ramifications of the cardiac plexus and its communica¬
tions with other nerves make comprehensible the radiation
of pain in all the various directions enumerated, and the
nerve of Wrisberg has been specially instanced as explain¬
ing the pain in the left arm; but no explanation can be
given why in one case the pain is felt in one part of the
cardiac region, and has some particular character and takes
a given direction down one arm or both, or through to the
back, while in another case the seat, character, and exten¬
sion of the pain are quite different. It is not a pressure
effect on the plexus outside the heart, neither heart nor
aorta being necessarily enlarged, and extreme fusiform
dilatation of the arch of the aorta being common with¬
out anginoid pain, and there can be no stretching or
mechanical irritation of the ramifications beneath the endo¬
cardium at all comparable to that which takes place in
acute dilatation of the heart. It seems to me probable
that the pain is really central and that the radiation of
irritation giving rise to its extension takes place in the
epinal cord. An interesting point is that at the end of a
paroxysm there is usually flatulent eructation from the
stomach. The attacks are therefore very commonly attri¬
buted to flatulence. Distension of the stomach by food or
gases may undoubtedly be, and often actually is, an exciting
cause ; but )iic»re frequently the sensation as of wind on the
stomach is only a part of the general commotion, and is
due to communicated or sympathetic irritation of the gastric
distribution of the vagus, the cardiac brandies of which
are primarily implicated. The escape of gas from the
stomach is often a signal that the paroxysm is over
rather than the means of bringing it to an end. Occa¬
sionally there is a vehement necessity to pass urine,
although the bladder may at the time be empty. The
duration of the attacks is very varied. Sometimes it can
•be reckoned in seconds, most frequently, perliaps, a
paroxysm will last a few niinute.s ; but I have known a
patient sit in tlie same position almost through an entire
uigbt, nob venturing to make the slightest movement, and
scarcely seeming to breathe, while tne perspiration rolled
off his forehead and came through iiis clothes. According
to my experience it is when the attack comes on in the
night wibUonb provocation by exertion or exposure that it
is protracted. When it is started by exertion it generally
ceases soon after the exertion is left off. While it would
not be justifiable to say that a patient was the subject of
angina jiectoris unless he had had one or more paroxysms of
intense radiating pain, associated with a sense of irnme-
<Uatel,y impending death, it must bo admitted that attacks
of true angina occur which fall short of the typical develop¬
ment. For example, when a patient has been taught
prudence by one or more bad attacks, he may, by stand¬
ing still on the first warning, or by taking remedies,
cut short the paroxysm, which will then have been repre¬
sented only by the initial pain in the breast or arm without
the mortal dread. It is possible, therefore, that before any
characteristic attack has occurred, pains of a similar kind
*nd intensity, disregarded by the patient or relieved by
rubbing the chest or arm, may have the same significance as
a fully developed paroxysm. Again, the patient who has
liad attacks of true angina may cease to suffer pain, but
may have attacks of what he cails faintness, in one of which
he ultimately dies. These, which have lo.st their title to tlie
name angina, have an equally serious significance. The
aspect of the patient is one of extreme anxiety or alarm.
He is usually pale and often livid round the mouth, but it
is said that sometimes the colour does not change. A cold
perspiration usually bursts out on the forehead, and may be
80 copious as to diip off the face. The pulse, in the rare
instances in which I have had the opportunity of examining
it during a paroxysm, has been irregular, small, and weak.
In some cases it has been reported to be very small from
contraction or spasm of the arteries. In oliiers, again, it
has scarcely been affected at all.
I Great importance attaches to the exciting cause of thei
j paroxvsms. In the first instance, they are almost alwaya
brought on by exertion. The patient while walking*
perhaps more sharply than usual, or uphill, or against o/
wind, is more or less suddenly arrested by pain in the chest,
with a feeling as if the heart were about to stop and he tc>
fall down dead. On standing still the pain gradually
passes off, and he is able to resume his walk, but only
feebly and gently. For a while the attacks only occun
when provoked by exertion, but more and more easily ao
time goes on, and they tend to become more severe. They
are more readily induced when a walk is taken, or any
imprudent exertion, such as stooping, pulling open a>
drawer, pushing up a window, is made soon after a meal—•
especially after breakfast. External cold, again, pre¬
disposes to an attack ; and exercise, which can be takea
with impunity in mild weather, brings on a paroxysm if
the air is cold and damp. Attacks, again, may be brought
on by indigestion or constipation, apparently througb.
reflex disturbance of the heart, or as a result of pres¬
sure from the distended stomach or colon carrying tho
diaphragm upwards and obstructing mechanically the
action of tho heart and the expansion of the lungs..
They are also liable to occur during the night, and maybe
induced in various ways. The contact of cold sheets ma 3 ’<
have this effect by causing contraction of the peripheral’
arterioles, and thus throwing increased work on the heart.
Or the upward pressure of the abdominal viscera on
assuming the horizontal position may embarrass the heart.
Nut unfrequently an attack comes On after sleep when tho
vigour of the circulation has run down. It is clear that tho
great exciting cause is a demand for increased effort on tho
part of the heart, to which it is not equal, or, what is
equivalent to this, interference with the movements of tho
heart by a dilated stomach and colon.
The conditions of the heart associated with angina pectorio
are varied, but perhaps the most remarkable and significant,
point in the relations between heart disease and angina in
that angina does not attend the chain of events through
which stenosis or incompetence of the mitral valve proves^.
fatal, and is not among the symptoms which arise out
of the valve lesion and its effects upon the heart.
This fact was duly emphasised by Dr. Walshe in hio
classical work on the heart, and no exception to it
has occurred in my experience. I have, indeed, knowii
instances in which, after attacks of angina had occurred
at intervals for many months, mitral regurgitatioii
has supervened with dilatation of the left ventricle,
and concurrently with the establishment of so-oalleA
mitral symptoms — pressure in the pulmonary circula¬
tion, dilatation of the right side of the nearb, and dropsy—
the angina has censed. In these particular circumstancep.'
Dr. George Balfour’s view, that the giving way of the mitrat
valve may be an advantage to the sufferer from aortic
disease, is justified. Aortic stenosis may be attended with
true angina, as may also, but less frequently, aortic in¬
competence and a combination of the two conditions of the
aortic valve. In association with aortic valvular disease
angina may be met with in early adult life, and may con¬
tinue for many years without proving fatal. The sense of
impending death is, however, not fully pronounced in many
aortic cases. Adherent pericardium appears in some ensen
to be a factor iu the liability to anginoid attacks wlien it-
coexists with aortic valvular disease, but in my experience
it bus not given rise to angina when no other lesion waf»
present. Injury to the root of the aorta has been known to
give rise to angina. In aortitis there is usually angina, tho
attacks, at (irat slight, increasing in intensity and duration^
and coming on more frequently as the disease advances.
A perfectly characteristic attack of angina has been de¬
scribed to me as having occurred in intermittent fever, and
serious weakness of tho heart was left behind for some time.
Angine, again, has sometimes been an incident of diabetes,
possibly from high arterial tension, wliicli is commonly
present in this disease late in life. Attacks of pain in tho-
region of the heart of various kinds, some being true
angina, are spoken of as gouty, sometimes no doubt iu ordei
to disguise the real nature of the paroxysms from a nervous
f iatient, to whom the knowledge might be dangerous or
atal. In a very large proportion of tho eases in which
angina has proved fatal the heart lias been found whet>
examined after death to he in a more a less advanced stogo
of fatty degeneration. The condition of tho lieart during
the attacks of angina has been generally supposed to bo
; r CoO'Me
D
The Lancet,] DR. GEORGB JOHNSON ON THE PHYSIOLOGY OF ASPHYXIA. IAteil 4, 1891. 757
one of apaam, bub there are great dillicultiea in accepting
this view, and probably ideas as to what is meant by spasm
of the heart in the anginal paroxysm by those who nave
employed the term have been diverse and very often vague.
If by spasm of the heart is understood tonic contraction or
an unrelaxing systole, this is certainly not the condition
present. The heart has never been found in this state
after death, and in most cases is absolutely incapable of
such contraction from the state of its walls. No pulse would
be possible were the heart in a spasm of this kind, and the
ulse, though small and often irregular, can usually be felt,
t has, indeed, in some cases been apparently unali'ected by
the paroxysm. But by spasm may be meant an irregular
and partial contraction like cramp in voluntary muscles,
or a librillar contraction such as is sometimes induced by
faraclaio currents in muscle under experiment. The late Dr.
Matthews Duncan, in the last conversation I bad the honour
to hold with him, suggested that the state of the heartrin
angina pectoris might be like hour-glass contraction of the
uterus; be had probably at that time experienced the pain.
Views of this kind cannot be proved bo be wrong, bub
objections might be raised, and for my parb*I have to admit
that I have no clear and dellnite idea of the state of the
heart during the paroxysm. The central fact and essential
Bignilicance of angina is that stress is pub upon the heart,
to which for the moment it is unequal. One of the
main causes of such stress is persistent resistance
in the peripheral circulation—or, in other words, habitual
high arterial tension; and we owe to Dr. Lauder Brunton
the knowledge that in many attacks of angina there
is an aggravation of habitual high tension by a general con¬
traction of the arterioles. But the habitual state of the
arterial circulation may possibly be one of relaxed arterioles
and capillaries and low tension, so that the heart has no
abnormal resistance to overcome. Here sudden general
arterial spasm would put the heart to greater stress than if
the habitual tension were high, since Uie contrast between
the work demanded would be greater.
When the paroxysms of angina can be distinctly traced
to arberio-capillary resistance, or, when in the case of a
patient subject to angina the usual condition of the circula¬
tion is one of high tension, the term “ angina vaso-moboria”
may, perhaps, be appropriately employed. It is easy to
imagine that stretching of the muscular fibres of the heart
in the endeavour to overcome the resistance in the arteries
might cause pain. But even when the vasomotor element
is moat potent another factor must enter into the causation.
Nothing is more common than high arterial tension, and it
is met with in an extreme degree and produces fatal results
without angina by ruiningheartorarteriesorboth in hundreds
of cases for one in which angina is present. Acute dilatation
of one or both ventricles, again, in which stretching of
the muscular fibres is obvious, frequently occurs without
angina. The importance, and even dominance, of this
second factor becomes clear when the cases of advanced
fatty degeneration are borne in mind, when the fibres must
be incapable of producing anything like actual mechanical
tension. It has been assumed that tlie other element is
neuralgic, and in a sense this is true, but not in the sense of
a predisposing neurotic tendency. It must be remembered
that angina is much more common in the male, which is the
least neurotic sex. Mechanical stretching and neuralgic
predisposition being put out of the question, there remains
the fact tiiat the existence of the patient is threatened at
the moment of the attack by arrest of the heart’s action,
and, where it not for the warniiig given by the pain and
for i/ho ceaaabioD of exertion enforced by it, tiie subject of
the particular condition of the heart would die. We must,
it seems to me, assume that angina is one of the defensive
arrangements by which the adjustment of internal reactions
to external conditions is securod.
The prognosis of angina is beset with uncertainty.
Wo can never tell when the next attack will come or
whether it may not be the last. We are not, however,
altogether without guidance, the elements of which will bo
an estimate of the relative predominance of the two chief
factors in the production of the attack—whether inherent
weakness of the heart wall or obstruction in the circulation
or other cause of ciubarrassiuent of the heart’s action.
While the attacks only come on when provoked by exertion
or excitement or by flatulent indigestion (not of course
taking the patient’s word for the last-named cause), the hope
may be entertained that by care in avoiding all known
occasions they may bo postponed indefinitely. The patient,
for example, must not take exercise immediately after food,
must never hurry or walk against a wind, and even on level
ground must adapt his pace to his condition, and, if com*
polled to go uphill, must do so very gently and circum¬
spectly. If, further, there is habitual high tension in the
pulse, this is at the same time evidence of obstruction in
the arterioles and capillaries, which may be capable of
mitigation, and of some degree of vigour in the heart. So
also will be the accentuation of the aortic second sound,
and still more any recognisable impnlse or apex beat.
Angina, again, in connexion with aortic valvular disease
may run a very protracted coarse. It is when the pulse is
soft and the heart is normal in dimensions with imper¬
ceptible impulse and weak sounds—when, in fact, the
results of careful examination are negative—that the greatest
uncertainty and danger exist. The occurrence of unpro¬
voked attacks and of nocturnal angina will emphasise this
conclusion.
Treatmont .—The hygienic and general treatment for
angina is that which has already been described in speaking
of dilatation and degeneration—which, indeed, mostly
underlie the angina—and the special precautions against
the provocation of attacks have been sufficiently indicated.
Arsenic has long been held to exercise some influence
preventive of tlie paroxysms, and my experience leads me
to agree with this view. Phosphorus, which belongs to tho
same chemical and therapeutical series as arsenic, has a
similar inlluence, which has in some instances seemed to be
superior. The great means of cutting short the attack is
that placed in our bands by Dr. Lauder Brunton—nitrite of
amyl, or nitro-glycerine,—and a patient subject to angina
should never be without one or other of these remedies.
Tiiey are no doubt greatly abused, and many persons,
feeling secure of obtaining relief, neglect the important
precautions by which tlie real disease, of which angina is
only a symptom, may be held in check, and so, if they
escape sufiTeriDg, hasten on a fatal termination.
ON THE PHYSIOLOGY OP ASPHYXIA AND
ON THE ANAESTHETIC ACTION OP
PUEE NITEOGEN.
By GEORGE JOHNSON, MD,, F.R.S.,
COXSlIi.TINC I’lIYSICIAN TO KIMi'S OOM.BCil': lIOSI’ITAf., KMEKITOS
I’KOFlISSOa OI' CI.INIC’AI. I’lIVStCIAN EXTIU-
OaiUNAKV TO II..M. THE (iUBEN.
PllOLOaUB.
TitK following paper was read (in abstract) and disouspe V
at a meeting of the Royal Society on Feb. 5tb, 1891. lu
now submitting it to the readers of The Lancet, I have
interpolated a few short paragraphs and notes which are
distinguished from the rest of the paper by being included
within brackets. The subjects here discussed are such as
should excite the interest not only of physiologists, but of
all who are engaged in tho practice of medicine and surgery.
It is impossible to correctly interpret the character of the
pulse in various morbid conditions without a clear under¬
standing of the inlluence of the arterioles, both pulmonary
and systemic, upon the circulation of the blood. The
phenomena of asphyxia from exclusion of atmospheric air,
and the results of tfic^iuhalation of pure nitrogen and other
azotic gases, ofibrd most instructive illustrations of the
regulating and controlling influence of the arterioles upon
thecirculation. These intereslingandinstructive phenomena
it is the main object of this communication to describe And
explain, in accordance with the established facts and
pvincijiles of physiology.
Ill a recently published Essay on Asphyxia (Apnuia) I
have endeavoured to prove that those physiologists who
accepted the doctrine of Alison, Reid, and Erichsen—that
the immediate cause of death from what is commonly
called asphyxia is the arrest of the pulmonary circulation—
were right; and that the more modern doctrine, which
assumes that the circulation is finally arrested in conse¬
quence of the muscular walls of the heart being paralysed
by the circulation of unaerated blood through the tissues,
is erroneous. Since the publication of the essay in question
I have thought it desirable to obtain additional evidence in
Di-:-
758 ThbLanokt,] DR. GEORGE JOHNSON ON THE PHYSIOLOGY OF ASPHYXIA. [April 4,1891.
sapport of the theory which I first published twenty-two
years ago—viz., that the arrest of the circulation in the
final stage of asphyxia (apncoa) is caused by the contraction
of the muscular-walled pulmonary arterioles.'
I have to express my obligation to my friend Mr. Charles
James Martin, M.B., B.Sc., Demonstrator of I’hysiology,
King’s College, London, for the time and labour which ne
has Stowed upon the skilful performance of numerous and |
varied experiments, the results of which will, I venture to i
say, throw much light upon the complex phenomena of'
asphyxia. It is tight to mention that Mr. Martin is not
responsible for my interpretation of the results of his ex¬
periments.
And here it may he w'ell to state that all these experi¬
ments were performed on animals under the inlluence of
anmsthetioe—usually morphia, suboutaneouslyinjected, and
in some cases with the addition of chloroform—anrcsthetics
which, while they entirely prevented suiFering on the part
of the animals, did not interfere with the physiological
results of the experiments. Every animal was finally killed
by deprivation of air. Animals—rabbits, cats, and in a few
cases dogs—were asphyxiated either by ligature of the
trachea, by the paralysing infiuence, of curare, or by
causing them to inhale a gas contaioing no free oxygen—
viz., nitrous oxide, pure nitrogen, hydrogen, and car¬
bonic acid gas. In all these experiments reinspir ation
of the gases was avoided by allowing the expired gases
to escape through a T tube fixed in the trachea. During
the performance of the experiments in most cases the
chest and pericardium of the animals were opened, so
that the relative degree of fulness of the heart’s cavities
might be readily observed. In all these experiments the
results as regards the distension of the heart’s cavities were
essentially the same, no matter whether the air was simply
excluded, or whether an azotic gas (i e., a gas not in itself
poisonous, yet unable to support life) was substituted for
atmospheric air, the only dillerence being that in the case
of inhalation of an azotic gas the phenomena are more rapid
in their occurrence, in consequence of the more speedy dis¬
placement of oxygen from the lunge.
The principal changes in the heart’s cavities were as
follows:—1. Distension of the left cavities of the heflrt.
2. Enormous distension of the right cavities, with
diminished distension of the left; the distension of the right
cavities being so great that the enlarged heart actually
bulged out between the split sternum of the animal; the
longs at the same time being pale, bloodless, and collapsed
to an extreme degree. The circulation was apparently
brought to a standstill by the inability of the right cavities
to empty themselves in consequence of opposition in front.
That the arrest of the circulation could not be due to
paralysis of the heart’s walls by the circulation of venous
blood through its tissue is, I think, conclusively proved
by the following experiment amongst others.
Into the trachea of a small dog, prepared with the chest
and pericardium opened, and kept alive by artificial
respiration, as above described, a glass T-tube was intro¬
duced, through which pure nitrous oxide gas was passed into
the lungs, whilst the expired gases escaped into the air.
As usual, first the left, then the right cavities became dis¬
tended, and in one minute the heart’s action had nearly
ceased, with over-distension of the right side. Then,
without loss of time, inhalation of nitrous oxide, imprcfj-
noted with the vapour of nitrite of amyl, was substituted
for the pure N.jO, oy means of a two-way stopcock, and the
result was that almost immediately the distension of the
right cavities began to subside, and in two minutes they
had nearly regained their normal size.
It was found that after the inhalation of the nitrite of
amyl the lungs harl assumed a peculiar dirty yellowish
tinge, and artificial respiration of air failed to restore life.
It is well known tliat nitrites convert Inemoglobin into
methamoglobin, as a result of which the oxidation of the
tusues is hindered. It appears to me that the only possible
explanation of these phenomena is that the circulation
Laving been arrested by contraction of the arterioles, was
for a time restored by the paralysing influence of tlie nitrite
of amyl upon those vessels, atmospheric air being all the
time strictly excluded.^
1 Metl. Uhir. Trans., vol. li., isiis, i>. (i§.
^ rpurin*? the rliscussion of iny paper at- the Uoyal Sooiety .in omiiienb
phy.Hiologint sairl, truly enougli, tliat nitrite of amyl n-ia\c*s Llio
systemic as well as tlie pnlraonary ai twiolcs : but that the ilispro-
portionalo distension of the right <Mvitios in this experiment was the
result of contraction of tho xni.hivjit.ary arterioles tan, I think, scarcely
be doubted
Additional evidence of the influence of the arterioles in
arresting the circulation during the progress of asphyxia is
derived from the fact that a sufficient dose of such agents
as are known to paralyse the arterioles—e.g., curare and
atropine—prevents over-distension of the heart’s cavities,
and considerably prolongs the life of the animal.
The following experiment was performed upon a rabbit
previously narcotised by morphia. The chest and peri¬
cardium being opened and the animal kept alive by arti¬
ficial respiration, nitrous oxide was then substituted for air.
In half a minute there was distension of the left cavities,
followed in one minute by distension of the right. In one
minute and a half enormous distension of the right cavities
was observed, with convulsions. In two minutes and a
half the heart stopped. Artificial respiration Avith air was.
now resumed. 'The heart immediately recommenced to
beat, and its distension was removed. The heart’s cavities
were of the normal size and fulness in seventy seconds after
the readmlssion of air into the lungs. Then a decigramme
of curare was slowly introduced into the jugular vein, the
introduction occupying live minutes. Three minutes after
the completion t>f the curare injection inhalation of NjO
was resumed and continvied. The result was that the heart
continued to beat slowly and feebly, that there was no dis¬
tension of its cavities, that there were occasional slow con¬
tractions ten minutes after the commencement of the NjO
inhalation, and even fifteen minutes afterwards the heart
was still flickering. In this experiment tlie dose of curare
had been sufficient to paralyse tho arterioles.
Into the peritoneal cavity of a cat a decigramme of curare
was injected, the animal being kept aUve by artificial
respiration. When the respiration was suspended, the
blood pressure in the carotid immediately began to fall,
and artificial respiration had to be resumed to prevent the,
complete arrest of the circulation by cardiac paralysis.
The same phenomena occurred more than once after the
respiration had been suspended. At length, after an in¬
terval of nearly an hour, suspension of respiration was fol¬
lowed by a rise of blood pressure in the carotid; and the
heart having been exposed, there was seen to occur the
usual distension, first of the left cavities, then of the right.
In this experiment the excessive dose of curare had para¬
lysed the arterioles and weakened the heart. The suspen¬
sion of respiration still farther weakened the heart, and
caused an immediate fall of blood pressure. After a time a
ortion of the curare was eliminated, probably by the
iilneys, a considerable amount of urine having been passed
upon the operating table, and then the usual results of a
moderate dose of curare were observed.
The following experiment was performed upon a cat, pre¬
viously narcotised by morphia and chloroform. A dose of
curare was injected, sufficient to paralyse the voluntary
muscles but not the arterioles. A manometer tube, con¬
nected with the kymograph, was introduced intoonecarotid.
Suspension of the respiration was followed by the usual rise
and subsequent fall of systemic arterial pressure. The cir¬
culation having been restored by artificial respiration,
sulphate of atropine was injected into the jugular vein;
after which the arrest of the breathing produced no rise of
pressure in the carotid, and when the sternum was split
and the heart exposed, no distension of its cavities was
observed.
The three experiments above described suffice to prove
that the distension of the heart’s cavities and the arrest of
the circulation during the progress of asphyxia are the
result of arterial contraction, and not of paralysis of the
heart's walls by the circulation of venous blood through its
tissues.
It has been suggested that the distension first of the left,
then of the right side of the heart, is the result solely of
systemic arterial contraction, the impediment acting back¬
wards from the loft side of the heart through the lungs to
the right cavities and the systemic veins. One main objection
to this theory is the fact, I think generally admitted, that
when the chest is opened immediately after death from
asphyxia, the lungs are found extremely pale, from an.'umia
of their minute vessels, and in a corresponding degree
collapsed. Surely a backward pressure from the left side
of tlie heart, sufficient to greatly distend tlie right cavities,
must of necessity involve engorgement of the pulmonary
capillaries. That there is a certain amount of backward
pressure from the primary distension of the left .side,
extending as far as the pulmonary veins, would seem to be
proved by observations made by Mr. Martin, to the efFecb
that a manometer in a branch of a pulmonary vein indicates
Thb Lancet,] DR. GEORGE JOHNSON ON THE PHYSIOLOGY OF ASPHYXIA. [Apeil 4,1891. 759
an early and continuous increase of pressure during the
progress of asphyxia. But that this backward pressure
does not cause the distension of the right side of the heart
is shown by the fact that in the last stage of asphyxia,
while the right cavities are in a state of extreme distension,
the left are, as a rule, flaccid and comparatively empty, the
lungs, as before mentioned,beingveryancomicandcollapsed
to an extreme degree.
[Moreover, if the distension of the light cavities of the
heart were a result of backward pressure from the left, not
only would the pulmonary capillaries be engorged, but the
pressure in the pulmonary veins would be greater than that
in the pulmonary artery, the fact being that the venous
pressure is so much less than the arterial, that it can be
measured only by a water manometer. ]
A most complete demonstration of the condition of the
heart’s cavities in the difTerent stages of asphyxia was
afl'orded by some experiments performed by Dr. Ruther¬
ford, now Professor of the Institutes of Medicine at the
University of Edinburgh, which I had the privilege of
witnessing when he was my colleague at King’s College
in the year 1873. The following is a brief description of
Dr. Rutherford’s experiments.
Into the trachea of a large dog, previously anrcsthetised
by chloroform, a tube was tied, and connected with a
bellows for the performance of artilicial respiration. The
voluntary muscles were then paralysed by the injection
of a moderate dose of curare, and the animal was
kept alive by artificial respiration. The sternum and
portions of the ribs were removed, and the pericardium
was opened, so as to expose the anterior surface of the
heart. One common cai-otid artery was divided, and a
dynamometer tube connected with a mercurial kymograph
was introduced into the proximal end. Artificial respira¬
tion was now suspended, and immediately the colour of the
left auricle changed from crimson to purple, the dark venous
blood showing through the thin walls of the auricle, while
the kymograph indicated a continuous rise of pressure in the
systemic arteries, the variations of arterial pressure being
registered by a pen on a revolving cylinder. After the in¬
crease of pressure had continued for about a minute the Uft
cavities of the heart were much distended, the auricle in
particular becoming expanded into a tense globular ball
with a smooth surface. (See Fig. 1 .) In the next period
Fig. 1.
llepresents the distension of the loft cavities of the heart and aorta in
the lirst staffo of apiueiv (aspliyxiii). l.a., Loft aurielo ; f.v., left
ventricle. Uotli greatly distended, the foniier like a smootli indiiv-
nibber ball, a., Aorta distended ; p.«., puhnoniu-y .artery ; p.u., pul¬
monary vein ; r.a., right anriclc; /'.w,, right ventricle; e.c.d., descending
vena cava; •('.(•.a., ascending vena cava, ’i’lio riglit cavities of the
heart, tlio pulmonary artery, and tbo .systemic voin.s arc in a .state of
normal fulness. Tlie right vontriclo is pai tly overlapped by tlie dis¬
tended loft.
the pressure in the systemic arteries began to fall, and
about the same time the right cavities of the heart,
which had hitherto remained of the normal size and form,
became distended, while the distension of the left rapidly
subsided. Meanwhile the right cavities became more and
more distended, and now the rit/ht auricle assumed the
K earance of a tense globular ball, while the left auricle
become flaccid and nearly empty. The right ventricle
also became so distended that it projected above the level
of the left. (See Fig. 2.) This was the condition of the
heart s cavities when the animal died by the final arrest of
the circulation through the lungs; but more than once,
when the circulation was nearly at a standstill, artificial,
respiration was resumed, and’ then all the phenomena
rapidly changed. The blood, which had accumulated in
the pulmonary artery and in the right side of the heart, at
once passed freely through the Inngs, the distension of the
right cavities subsided, and the systemic arterial pressure
became first excessive, while the blood was partly venoos,
and then normal, when the blood became thoroughly
oxygenisod, and its passage through the terminal syst^nic
arterioles was therefore no longer abnormally resisted.
[The following is the explanation of the facts revealed b,
Dr. Rutherford’s most instructive experiment;—Artificial
respiration being suspended, unaerated dark blood at first
passed freely to the left side of the heart and to the systemic
arteries. Arrived there, either by its direct stimulation of
the muscular arterioles, or by a reflex influence through
the vaso-motor nerves and centre, the muscular arterioles*
Fig. 2.
Kepresents the rtistonsion of tho right cavities of the heart, of the
puhiioiiavy artery, and the large .systemic veins in the final stage of
apiKoa (asphyxia). The letters have the s.amo signiflcanceas in Hg. 3.
In Acklitioii, iKC. indicates the aninnio condition of the pulmonary
capillaries; ?)., loft bronchus. The right auricle and ventricle and tii«
piilmojiary artery arc fully distended, the auricle having the form
and smoothness of a distended ball, ^vhilo the left cavities of tbo
heart and the aorUr are collapsed and nearly empty.
are excited to contract, and by this action of the vaso¬
constrictors the blood pressure in the arterial trunks is
ipcreased, while the left cavities of the heart become dis¬
tended and dilated, as seen in Fig. 1. The circulation
through the systemic arterioles is impeded and lessened,
but not entirely arrested ; some black blood passes through
the capillaries, and this venous blood, becoming more and
more entirely deoxidised, reaches the right side of the heart,
and the pulmonary vessels, and coming in contact with the
pulmonary arterioles, it excites in them the same contraction
aud resistance as had before occurred in the systemic vessels.
The resistance offered by the 7 )ulmonary vaso-conatrictors,
while on the one hand it tends to empty the left side of the
heart and to lessen the blood pressure in the systemic
arteries, on the other it causes that great distension of the
right cavities and of the systemic veins which is invariably
found when the chest is opened immediately after death
from asphyxia, and which in such experiments as Dr.
Rutherford’s are plainly seen to occur during the lifetime
of the animal. (See Fig. 2)] The relative amount
of blood on the two sides of the heart is not an exact
measure of the degree of pulmonary obstruction which
has existed during the last moments of life, for the
reason that the impairment of the contractile power of
the left heart by an.'crnia and venous blood appears to vaiy
in diflerent cases; but I may here mention tlie results of
the simple experiment of ligaturing the trachea of a dog
which has been twice performed in my presence ; the chest
having been opened and the amount of blood in the two
sides of the heart measured immediately after the animal
had ceased to struggle.
In one dog, weighing 19;]-lb., 2 oz. of blood gushed from
the distended right cavities, while 2[, drachms of blood
^ It li;is lioen sliiiwn in LiulwiK'n J.i.iioratoi’y that tln> arteries of mi
oriiati which has licon withdrawn from all iiervoii.s iiiHuoiieo contract
wlien bhiod ovtirloadud witli cariionic acid Hows them. Sea
Conbeim’s S-octiuv.s on General Pathology: NewiSydenliaiii^iociety’s
Tmnsaclions, p. llT
Google
Die:' I
760 ThkLancbt,] DB. B. W. RICHARDSON ON PEROXIDE OF HYDROGEN.
[Apbil 4, 1801.
.Howed alowly from the compwatiTely empty and flaccid left
aide. In a dog half the size of the above, the experiment
having been performed by Mr. Martin, the right auricle
waafoond diatended, the left empty; the right aide of the
heart contained 5^ drachma of blood, the left a quarter of
4 drachm.*
(To be oontinved.)
ON] PEROXIDE OF HYDROGEN, OR OZONE
WATER, AS A REMEDY.
CONTINUED FROM A RESEARCH COMMENCED IN THE
YEAR 1858.
By B. W. RICHARDSON, M.D., F.R.S.
(Concluded frompaffc 709.)
From these references to practice based on the old
observatione I pass to some observations of a practical
nature which have not before been recorded. I might have
dealt longer on old experiences in respect to mesenteric
disease, epilepsy, and aosemia ; but as my mind is not so
satisfied in regard to any advance in these directions, I let
what I have already said remain in its original form, in
order to give room for what is new. I also allow to stand
over for future comment some notes on the action of the
peroxide on digestion and in dyspepsia.
I7s« in diphtheria.—Oving to the observation made on
the effect of the peroxide solution in causing sexraration of
dead from living structures, I have several times used it
since 1864 as a local application of diphtheria, in the treat¬
ment of which hitherto inscrutable disease I have had the
most painful of human experiences. Applied to the throat in
diphtheritic patients, the solution of peroxide, either alone
or in combination with glycerine, causes, without any doubt,
a rapid separation of the false membrane, and produces a
favourable condition of the local surface. Bab here, I regret
to say, the benefit—and it is a benefit—epds. On the general
or constitutional conditions it has not as yet, according to
present modes of using it, been efficient. It does nob touch
the collapse. I name this because I see that some writers,
observing the good local effect in cases that have, for some
other reason, recovered, have, post hoc et propter hoc,
proclaimed the peroxide as a specific in diphtheria. It has
as yet not won that position. At the same time I invariably
prescribe it locally in diphtheria, not onlyto the throat, bub
as a wash for ihe nostrils when there is ichorous and offensive
discharge. The twent^y-volume solution can be applied
freely to the fauces, with borax or with glycerine, and to
adults it can be administered in the form of spray.
Use in intestinal cases .—The administration of the
.peroxide solution os an injection per anum was a line of
practice that occurred to me about 1870 in a case of cancer
of the rectum, accompanied with a free and very offensive
discharge. The action of the solution in destroying the
odour, and, combined with tannin, in limiting the discharge,
was most useful. Soon after that I was summoned to a
patient suffering from what I may designate as strumous
caries of the sacrum, with adhesion and ulceration of the
lower intestine, and copious escape of pus into the rectum.
A more painful case, or one more difficult to manage, I do
nob remember to have seen. Here I prescribed the ten-
volume solution, with tannin and dilute hydrochloric acid,
by injection, with the best results. The disease proved'
fatal, for the whole of the sacrum was involved before the
use of the oxygen solution wae commenced, and after
paralysis of the lower extremities had supeivened. But
the solution exerted such a controlling iolluenee, and
rendered the discharge so healthy, I could hut regret that
the treatment by it had not been brought into action at an
earlier stage.
In a case of what was called chronic dysentery, with
frequent motions of a fluid and offensive character, I pre¬
scribed the ten-volume solution, with tannin, in ounce doses
diluted with a pint of tepid water. The injection was thrown
into the bowel once daily through along O’Beirne tube, and as
Che oxygen was liberated freely in the intestine soon after
♦ The roeults of these experiments suffice to prove the error of llioso
physiologists who maintain that the corapai'af fve emptinesR of the Ic-ft
cavities after death from asphyxia is the result of rigor mortis.
the injection was thrown in, the evidence was supplied of
the excretion of purulent fluid, or of some excreted matter
from blood. The result was very satisfactory,'and led to
such a rapid and sound recovery that I can recommend the
repetition of the practice with the utmost confidence.
Use by inunctioh .—From ,a similar line of thought and
practice 1 have for many years used the peroxide as an
inunction for the surface of the body of patients affe6ted
with cutaneous exfoliation, as in scarlet fever and measles.
In these instances the ozonic ether is used instead of the
aqueous solution, because of the facility with which it
mixes with the oil or iard required to make an ointment.
The body is rubbed from head to foot with the ointment,
the spaces between the fingers, toes, and flexures of joints
being included. The application is very agreeable to the
patient, and the effect in removing obnoxious odour is most
marked. But the grand advantage lies in the circumstance
that the process seems co remove all danger of infection
from the convalescent after three or four applications.
Use in eczema .—As a general rule, oily ana fatty dressings
do nob agree well in chronic eczema. But I once gained
considerable advantage by treating a chronic eczema,
which had previously and for a long time been most
intractable, with an ointment of spermaceti saturated
with ozonic ether. In other eczematous cases, with exuda¬
tion of blood, I have employed the aqueous solution with
tannin with great advantage. In cases of this nature,
where there is great irritation, the solution goes well with
an anodyne.
Use in diagnosis .—I have found the peroxide of hydrogen
of great seivice in diagnosis. It diagnoses pus from
mucus. In cases where J am in doubt whether matter
expectorated by the lung is or is not purulent 1 perform
the following teat. I place the expectorated matter in a
test-tube containing the solution. If the matter causes no
evolution of oxygen, there is no purulent matter present.
If the expectoration produces liberation of oxygen, the
evidence of pus is strong ; and if the same event occurs after
all carbonic acid is removed, the presence of either pus or
of some plastic element of blood or cellular tissue element
may be affirmed of a certainty. In the first test-tube which
I now take up there is secretion I do not suspect, and on
adding to it some of the twenty-volume solution there is,
as you will see, no action wliatever. In the second tube
there is some doubtful secretion; but again we see tliere
is no action. The third tube holds a few minims of
secretion strongly suspected to be purulent, and on
addition of the tolution the vehement action confirms
the suspicion. In the large majority of instances it
will be pus that is present, but the diagnosis extends
to cellular tissue. Injected into a closed mucous cavity,
like the bladder, the surface being in a healthy state,
and the viscus having been emptied of urine and washed
out with warm distilled water, there is no liberation
of oxygen from a neutral solution of peroxide. But if
there be any ulceration, by which a surface of cellular
tissue is laid bare, or if there be pus present, then the
escape of oxygen will be so free from two or three ounces of
a ten-volume solution injected into the bladder, that the gas
maybe detected as it escapes from the free end of the catheter
by its effect in relighting a partly extinguished taper. The
same test might bo applied for the diagnosis of ulcerated
mucous surface, or presence of pus in the uterine cavity,
and possibly also the stomach, but no opportunity has been
offered me of testing in these last-named cases. I may,
however, add that no more mischief could follow from the
test than would follow from the injection of common water
or common atmospheric air, if the solution made be chemi¬
cally pure ; on the contrary, the ozonic quality of the oxygon
in the solution would tend to have a good effect. It might be
sound practice, indeed, to sustain in some forms of ulcera¬
tion a gentle continuous current of the Iluid through a
mucous cavity. In extensive ulceration of the bladder or
uterus, accompanied with offensive discharge, this treatment
offers promising results.
SUGGESTED NEW PRACTICES FROM PAST
EXPERIENCES.
In the course of original research it often happens that
a number of side suggestions and thoughts occur to the
mind which were not dreamed of when the research com¬
menced. In this way theory is brought out which, being
an induction from experiment, may easily become practice,
and that, too, of a valuable chaiacter. As a rule, it is
^8
Dk;
The Lancet,]
DK. B. W. RICHARDSON ON PEROXIDE OF HYDROGEN.
[April 4, 1891. 761
good for the investigator not to advance theory even of
this order until he himself has put it to the test. Bat
there are exceptions to every rale, and here seems to me
to be one. Some suggestions leading to important lines of
practice have forced wemselves oq my attention, which
call for proofs I can hardly hope to make in my own life¬
time, but which younger men may have the opportunity
of making, and which I, therefore, proceed to state with¬
out reserve; and the more readily because really in some
instances the way towards practice has been opened for a
considerable distance with perfect safety. Let me take
as a first illustration of this kind an extension of the
practice of injecting the peroxide solution into mucous
canals. I have indicated, as a practical fact, that
the solution can be injected into the alimentary canal,
and that in more than one example it deodorised and
neutralised an o^eneive discharge in a most effective
manner.
Typhoid .—I would venture further. I would recommend
thepracticeinthetreatmentof typhoidfever. In typhoid fever
it would be possible to throw into the canal by this means
twenty pints of ozonised oxygen per day by using only one
pint of the ten-volume solution. The gas when liberated
would diifuse through the whole of the canal, and would
decompose and oxidise the decomposing exuded products,
which uy secondary absorption are the cause of the relapsing
febrile seizures, with an efficiency possessed by no other
remedy. It would be like exposing the decomposing ulce¬
rated surface to ozonised sea air.
Hypodermic and subpulmonary injection .—As in phy¬
siological research I found no danger from injecting
the neutral solution of the peroxide into the cellular
tissue. I would venture the same on the human subject,
and I fully expect that the practice will in time be
largely adopted. In asphyxia, as after drowning and
after suspended animation from chloroform and other
narcotics, a hundred pints of oxygen might easily be
transfused, hypodermically, by using the thirty-volume
solution ; and, with the temperature of the solution raised
to blood heat, the diffusion of the gas through the cellular
tissue would oxidise the blood ra^dly, and tend to give a
new force to the circulation. I should even go one step
further in extremesb cases. In sudden cofiapse from
chloroform, if the natural respiracion had actually ceased,
and death seemed to have occurred, I should, to save
time, whilst sustaining artificial respiration, ’ inject the
lung cavity directly on both sides of the chest with
the solution. The diffusion of the gas through the lung
structure would arterialise the blood remaining in the lung,
and the mechanical pressure exerted within the pleura
against the elastic structure would be a motor to the
circulation, compressing the blood towards the left side of
the heart, and producing a current of blood from the right
aide. For these subcutaneous and subpulmonary injections
of the peroxide I have invented a new automatic syringe,
which can be used without withdrawing the needle, the
piston movement being suflicient for filling as well as for
emptying the syringe. There would be no danger of in¬
jecting four ounces of the thirty-volume solution, rendered
neutral and warmed to the normal blood temperature, into
each thoracic cavity by needle i puncture through an inter¬
costal space high up in the forepart of the thorax. The water
might produce a little codema, but it would soon be picked
up, and carried into the circulation by the capillary vessels.
Bearing also on this subject of subpuluionavy injection there
is anotlier use of the solution which has often occurred to
my mind, and which would be perfectly legitimate as a
practice, when the powerful action of the peroxide in
destroying decomposing and purulent matter is taken into
account. I suggest that in cases of cavus of the lung in
phthisis, where the cavity can be clearly defined, there
would be no risk of injecting the cavity, through a fine
needle, with the solution, and of oxidising all the lliiid that
it might contain. Again, in dangerous huuuoptysis it would
be most legitimate practice to inject into the pulmonary
structure the oxygen solution saturated with tannin. The
oxygen could do no harm, and the tannin, which would be
(|uiekly transformed into soluble glucose, would merely
charge the blood with a useful saccharine food, with the
advantage of making the lung, in a small degree, a
kind of second stomach. Still more, it is quite worthy
of serious 'Consideration whether it would not be good
practice to inject the solution in small quantities by the
subpulmonary method in the early stages of phthisis. The
oxygen would destroy the tuberculous exudation more
uickly than any other agent, and 1 can see no danger of
iffasing oxygen through an organ that is made for the sole
purpose of receiving and condensing oxygen. The one
danger would be haemorrhage, and that could be met by
combining tannin with the solution. I name this new
mode of treating the lung substance “the subpulmonary.”
In a word, my contention is that we may learn to
transfuse the peroxide solution without risk and with
benefit into the lung, and indeed into any organ of
the body, not excluding the brain and nervous centres
themselves. The only danger that could follow would
arise from delivering into the tissues so much oxygen
at once that the blood would- not absorb it with sufficient
rapidity to allow afterwards a free course through the
minute circulation.
I will show you an experiment on this point in order to
illustrate w’hat I mean. Here is a two-necked flask charged
with six ounces of defibrinated blood from an ox. The
blood has been deprived of all free carbonic acid by being
washed with oxygen. It is of bright arterial colour, and if
a current of air free of carbonic acid be driven through it
into lime-water, there is no trace uf carbonic acid. Bat
when to this blood I add neutral peroxide solution, there is,
even though it is already arterialised to some extent, brisk
action. There is more oxidation, there is a alight elevation
of temperature, and there is free escape of gaseous matter
from the free tube and by the flask through the lime-water.
The gaseous matter escaping consists partly of liberated
oxygen, but, as shown by the precipitate in the lime-water,
there is also carbonic acid; and had the blood been venous
the amount of carbonic acid would have been very con¬
siderable. Thus it is clear that liberation of carbonic acid
in the venous circuit from the use of peroxide may occur;
and as there is no escape within the circuit for the gas or
gases, there is the same danger as there would be from blowing
air into a vein. I observed this fact in an experiment recorded
in the last number of the Asclepiad, in which 1 restarted re¬
spiration in a lower animal, after death from chloroform, by
injecting peroxide solution into the peritoneal cavity. The
respiration was so good that life seemed to be returning until
the vital functions were arrested from some other cause
telling upon the circulation. After death it was found that
the right side of the heart and large veins were filled with a
bright arterialised blood richly cliarged with oxygen gas
that had been absorbed from the large veins, and with which
carbonic acid gas was also admixed. The prevention of this
source of danger has to be worked out. Id may be done by
using a weak peroxide solution, or by using an alkaline
solution. Meantime the danger ought to be known and the
nature of it understood, since its existence without being
understood might interfere materially with the proper appli¬
cation of the peroxide in its most useful and innocent
administrations.
Vse in tetamis and hydrophobia .—I have spoken of the
effect of the peroxide in relaxing muscular contraction, and
the facts I have observed in this direction lead me to suggest
its use in two particular diseases of the spasmodic type,
hitherto so intractable—I mean tetanus and hydrophobia.
Anyone whe has watched the course of one at least of these
diseases (tetanus) will feel that the treatment the most of
all hopeful, if it could be realised, is a means for preventing
the muscular tetany, for producing free glandular elimina¬
tion, and free oxidation uf the septic blood. In the peroxide
solution we have all these requisites, and in the next case
uf tetanus that comes under my care it is my intention to
put the remedy to the completest trial. I shall inject the
muscles in groups with the neutral ten-volume solution,
heated to blood temperature, adding, if the oxygen be not
alone elficieut in reducing the tetanus, a weak alcoholic solu¬
tion of amyl nitrite.
Mechanical use .—One other purpose for the peroxide must
be named—a purpose purely mechanical, and yet not to be
slighted. In the process of being liberated from its solution
the gas exerts an expansion, which in ipany instances may
prove of great service. In this mechanical mode of applica¬
tion it could be used in obstruction of the bowels from intes¬
tinal involution. It could be used for causing distension of
the bladder when the sound was being employed, and perhaps
in stricture for producing dilatation oi the passage pos¬
teriorly to the stricture. In the same manner it could be
brought into play for dilating the uterine cavity; while for
bringing on premature labour, in instances of contracted
pelvis, the effect of the equal distension by the gas liberated
752 The Lancet,] DR. B. W. RICHARDSON ON PEROXIDE OF HYDROGEN.
[April 4,1891.
from three or four ounces of the ten-volume solution would,
I suspect, be as rapid as it would be safe and effective.
NEW PHARMACOLOGICAL RESEARCH.
Let me describe in the last part of this essay some
pharmacological outlines. Peroxide of hydrogen U still
made, as Tbbnard first made it, by the action of an aqueous
acid solution on peroxide of barium, the number of volumes
in each specimen turning on the number of precipitations.
I originally proposed a ten-volume solution for medical
purposes, and that has been well adhered to; hut for
special purposes a solution of twenty and even thirty
volumes may be employed. In order to keep the oxygen
in the solution it is necessary to have it slightly acidified,
either by dilute nitric, hydrochloric, or pho8i)horic acid ; and,
for my part, I prefer the dilute phosphoric acid. In this form
the solution can he administered internally in doses varying
from a fluid drachm to a fluid ounce; but two or four drachms,
dilated in ten fluid ounces of water, may be considered
an average dose. The taste is peculiar, being identical with
that of ozone when inhaled b;^ the mouth, and not at all
dissimilar to the taste of chlorine in a weak solution. For
injection purposes the solution should be rendered neutral
^ the cautious addition to it of caustic soda or potafsa.
The soda I think is the beet; but it should not be neutralised
until the time it is wanted. In ten volumes it may be
injected either into the cavities or into the cellular tissue
without being further dilated. The solution of the per¬
oxide is incompatible with many substances; but it is com¬
patible with the following : the mineral acids, tannin,
alcohol, glycerine, alcoholic solutions of the a’kaloids, and
alcohol combined either with ether, amyl hydrate, amyl
nitrite, or iso-butyl.
Administration by Inhalation.
The oxygen from the peroxide can also be administered
by inhalation by means of a simple apparatus which I have
constructed for general use, and in working which I have
taken advantage of another oxygenated body that liberates
the oxygen and at the same time yields up a portion of its
own oxygen. Into a glass vessel having two necks, like
the ordinary Wolffs bottle, a few ounces of the peroxide
solution are placed. A tube from a funnel, the tube
having a stopcock, runs through the stopper of the bottle
to the bottom of the contained solution. From the second
neck of the bottle there springs another tube for in¬
halation, at the free end of vmich is a double-valved
mouthpiece, like the oldest and best of the chloroform
inhalers. The apparatus is now ready for use. When
it is wanted the funnel is charged with a solution of
permanganate of potassa in the proportion of ten grains
of the permanganate to a fluid ounce of water. The tap
is then turned, the permanganate solution flows into the
eroxide solution, and, immediately, oxygen derived from
oth bodies is briskly evolved. This, if necessary, can be
caught in a flexible balloon, or bag, from which it can be
inhaled in measured doses, but this is not a requisite.
Should the practitioner desire to combine the oxygen with
ether, or with any other volatile body, soluble in ether but
not in water, be can allow the etlier, or ethereal solution, to
float on the top of the peroxide solution. Then, as the
oxygen escapes, the ether, or the ether with its other volatile
comrade, passes over in combination with the oxygen. A
patient can help himself to a dose at any time, as may be
directed, by merely adding a measured quantity of the per¬
manganate solution. Nitrite of amyl can be inhaled in
this manner with ether, and, in short, there is here a means
f administering most of the active volatile medicaments
y j(hbalation, and in a form most ready for combination
V A'with the blood, as it passes in its course over the pulmonic
cireiiit. How easily the apparatus can be brought
into use will be seen by the demonstration here made.
Under the form of ozonic ether the administration can be
carried out either as a medicine to be taken in water, or as
spirit solution by the mouth, in doses of half a fluid drachm
to two fluid drachms, or as fine spray from the Siegle steam
inhaler. For a styptic and deodorant spray for the throat
the following form is useful: alcohol, pure {sp. gr. 830),
half a fluid ounce; tannin, pure, twenty grains. Dissolve
the tannin in the alcohol with an ounce of distilled water,
and then add solution of peroxide of hydrogen (ten-volume
strength) to six fluid ounces. To make a solution for spray.
Of this solution, one or two fluid drachms can be used with
Siegle’s steam spray inhaler, a mode especially applicable
in cases of throat affection. When the peroxide spray is
brought into use for the throat, it is good practice, in some
instances, to make the spray the means of administration, in
small doses, of medicinal agents which may act internally.
Quinine may be administered in this manner, and ako
soluble preparations of opium, and many other substances
that are soluble in alcohol, and are, at the same time, com¬
patible with the oxygen solution.
Spr^y for the Sick Room.
Reference was made in the first part of this paper to
ozonic or sea spray for the sick room—a solution diffused
in the air as spray from a spray producer. The solution is
composed of the solution of peroxide of hydrogen (ten-
volume strength), ten ounces; common salt, two drachms.
If a pleasant and pine-tree odour be desired, a few drops of
ethereal tincture of Kaurie gum can be added, and the eft'ect
can easily be produced. In sick rooms and in the wards of
hospitals such sprays could be arranged to work automatic¬
ally so as to deliver and diffuse the solution at regular
intervals. For this purpose Messrs. Kroline and Sesemann
have constructed for me an apparatus which will distribute
spray for several hours at a time.
Other Modes of Application.
The peroxide solution can be prescribed as a gargle,
antiseptic and astringent. A good form for this purpose
is : Tannin, pure, ten grains; glycerine, pure, one ounce ;
distilled water, four fluid ounces; diluted hydrochloric acid,
ten minims; solution of peroxide of hydrogen, sufiieient for
eight fluid ounces. To make an eight ounce gargle. An
evaporating lotion can be made with the peroxide in the
following form: Alcohol, pure (si), gr. 830), two fluid
ounces ; anhydrous ether, one fluid ounce ; distilled water,
four fluid ounces; solution of peroxide of hydrogen (of
neutral reaction and ten-volume strength), to twelve fluid
ounces. To make a twelve fluid ounce lotion.
Another simple yet useful preparation of the peroxide is
as the unguent, for inunction over llie surface of the skin
after scarlet fever, and other affections where there is free
shedding of dead cuticle. The ungirent is made by rubbing
up ozonic ether with spermaceti ointment, so as to form a
thin paste, which may, if desired, be rendered thick by
the addition of a little more spermaceti, or thin by addi¬
tion of olive oil.
Administration by Injection : an Automatic
Injection Syringe.
In order to inject the peroxide solution into the cavities
or beneath the skin, I have invented a syringe which I call
the “automatic syringe,” and which Messrs. Krohne and
Sesemann have very neatly constructed. It is, as will he
seen, a ginall graduated instrument, having a feeding-tube
for charging it on one side, and an exit tube fordischarging
it on the other aide. The syringe is automatic in the sense
that when both tubes are in place the mere act of working
its piston up and down fills it and empties it. The quantities
of fluid received and delivered by it vary from ten minims
to four fluid drachms, and at the end of the exit tube it
can be fitted with injecting needles of different sizes or
with a nozzle, according to requirement. With this syringe
the peroxide solution can be injected through a needle
subcutaneously, as into a carbuncle or into deeper struc¬
tures. By attaching the delivery end to an enema tube it
can be used also for theinte-stinal injection, and by attaching
the same end to a catheter, it can be employed for injecting
the bladder. The advantage in every case is that the
current can be kept up when once it is started, either for
a small or large injection, and that the admission of air is
impossible. The syringe might be used without any com¬
plication for the transfusion of blood and for aspiration, as
well as for transfusion ; but it has been specially adapted for
the oxygen solution.
CONCLUSION.
In closing these pharmacological notes it is well to recall
the important fact that the remedy we have had before us
has about it the peculiarity that it is a purely natural remedy,
that it is not toxic, and that with the exception of the
danger of producing by it gaseous accumulation in the blood,
under some circumstances of its.use—a danger which admits
of being avoided—it is free of all risk. In its remedial
application, too, there is no complexity as to ite modus
operandi. In every instance that which it effects is oxida¬
tion. For asphyxia it is oxidation ; for spasm it is oxida¬
tion ; for breaking up pus and exudations it is oxidation ;
zed by CjOO^Ic
The Lancet,]
MR. J. KNOWSLEY THORNTON ON HEPATIC SURGERY.
[Afbil 4, 1891. 763
for destroying infectious and fetid organic secretions, or
excretions, it is oxidation; for producing eliminative action
it is oxidation.
At the close of the paper on Peroxide of Hydrogen, read
before the Medical Society of London in 1860, I said:—
“ Sir, in placing this memoir on the annals of the Society
I guard myself, once and for all, from any exaggerated
suggestions as to the value of this new medicinal
agent. The subject is so novel, even to me after many
months’ learning and knowledge of it, I have feared to use
a sentence that has not been measured and recast over
and over again. I am not offering this medicine as an
clixi/r vitae. I do not pretend to know all its properties.
I do not bind myself, irrevocably, to that which, at the
present meeting, has been offered ; on the contrary, I remain
open tp all new observation and knowledge for correction
and guidance I believe we have here within our grasp a
powerful medicine, the full value of which it may take
ears'to develop, and the useful application of which may
e developed in directions different from those now advanced.
My purpose will be served if I call forth investigation and
elicit fact, let the course of the events bend as they may.”
A generation has passed since these words. Sir, were
spoken, and twenty-nine Presidents have filled the place
you occupy to-night. But to you and my fellow-students I
re-echo these words; and although I have spoken with
more knowledge, experience, and confidence in a remedy
which forms the most active and preponderating element of
the healthy living body, I wish still to express the same
earnest hopes with the same candour and the same respect-
fnl confidence in the voice of the future.
OBSERVATIONS ON ADDITIONAL CASES
ILLUSTRATING- HEPATIC SURGERY.i
By J. KNOWSLEY THORNTON, M.C.,
I'KKSIDENT 01' THE MEDICAL SOCIETY.
In November, 1887, and again in December, 1888, 1 bad
the honour to read before the Medical Society papers
containing my experience up to date in hepatic surgery.
On March 2nd, 1891,1 communicated to the same Society my
further experience in this very important branch of
abdominal surgery. The work is so comparatively new,
and so interesting both to the physician and surgeon, and
the individual cases differ so much in detail, that I venture,
as in my previous papers, to record them a little more fully
than I should do if dealing with some of the commoner
operations performed on abdominal organs. I will take,
first, nine cases in which I diagnosed gall-stones as the
cause of illness, and in seven I found and removed them,
with complete cure of the patients. In the eighth case I
missed the stone, the patient died, and the stone and much
effused bile were found in the peritoneum after death. In
the fifth case the obstruction proved to be hydatids, and
they were successfully removed. I will, then, refer more
briefly to seven other cases, which have a more or less
important bearing upon the diagnosis of pathological
conditions of the liver.
Case 1.—A young lady of thirty-two, much crippled with
chronic rheumatic arthritis, had lived in early life on
marshy land in Roumania. There had been several ill¬
nesses, occurring at intervals during several years, which
had been diagnosed as due to gall-stones. Prom the
description given by the patient, and from the marked
renal and bladder symptoms which accompanied the attacks,
I was very doubtful whether they were gall-stone or right
renal colics, and when I came to examine the abdomen I
was still more inclined to think the illness renal, for there
was a_ rounded tender swelling projecting from under the
false ribs on the right side in front, and giving an impulse
right back into the Join; and though there was some crepitus
over the usual site of the gall-bladder, there was no swell¬
ing there and no very marked tenderness. On Feb. 28th,
1889, Mr. Murray gave chloroform, and, assisted by Mr.
Malcolm and in the presence of Mr. Heath, I made a small
incision over the swelling, but rather to its inner side, in case
it should turn out to be the gall-bladder, and found it was
that organ completely enclosed in matted omentum and
intestines; having aspirated and drawn off a little bile-
1 A papor communicatecl to the Medical Society, March 2ncl, 1891.
stained mucus, I packed it carefully round with carhdlised
sponges, and opened it by a small vertical incision, and
extracted two large stones with my sponge forceps and some
debris with a lithotomy scoop. The adhesions made the
examination of the right kidney very difficult, but it was
certainly large and hard, and 1 greatly feared she might
have renal trouble as well. I sutured the edges of the gall¬
bladder into the abdominal incision in the usual way and
drained it, and she made a perfect recovery, all discharge
ceasing on the fifteenth day. She has been in much bettor
health in every way since the operation, and the kidney
has given no further trouble; so I hope the renal symptoms
were due to its adhesion to the inflamed mass formed by
gall-bladder, iutestiDes, &c. She has recently had a slight
attack of pain, but I think from the description it was
merely an ordinary “ bilious attack.”
Case 2.—Hospital patient, single, thirty-seven. Opera¬
tion, March 16tn, 1889. Symptoms for a year, two severe
attacks of colic. After tne second she was seen by Dr.
Goodhart, who diagnosed gall-stones. She had never been
jaundiced, but the stools had been pale ever since the first
attack. Usual incision; healthy gall-bladder, with no
adhesions; two good-sized stones in common duct. After
aspirating and opening the gall-bladder, I found it impos¬
sible to dilate the cystic duct, which had closed behind the
stones. 1 therefore needled them into pieces by passing a
line needle through the wall of the duct, and then further
crashed the fragments with a pair of nasal polypus forceps,
the blades being protected by red rubber tubing drawn over
them. The gall-bladder had been so much injured in the
attempts at dilatation that I decided to remove it. The
liver was large and congested, and much in the way, and I
found the operation much more difficult than in the case
described to the Society in my last communication. After
the operation she was distinctly jaundiced, and for eight or
nine days there was a good deal of bile in the urine, but
the first motion passed was brown, and the fragments of
stone began to pass on the eleventh day. She made a good
recovery, and went home well in a month.
Case 3.-*Single lady aged forty. Attacks of f»ain and
indigestion every three or four months for the last six years,
For the last two years pain has been much more severe and
prolonged in the region of the gall-bladder, with eructa¬
tions, sense of constriction round the cfiest, nausea and
vomiting. On March 24th, 1889, very severe attack;
jaundice on 29bh. April 24tb, very severe pain for three
days. June 2nd, succession of four attacks of severe pain,
jaundice persisting since it first appeared. I saw her in
consultation with Mr. Propert, and found her deeply
jaundiced; small, quick pulse; temperature over 102°^
great pain over the common duct. I diagnosed stone im¬
pacted in the common duct, and, looking to her very serious
condition, urged immediate operation, and operated the
same afternoon, Mr. Murray giving chloroform, Mr. Mal¬
colm assisting, and Mr. Propert being present. I removed
a large angular stone from the cystic duct after breaking it
up, and found another impacted in the common duct just
below the entrance of the cystic duct. Failing either to reach
it through the cystic duct or to break it up, as in the last case,
I incised the common duct, and needled the stone into frag¬
ments, which, however, I was unable to extract through any
reasonable opening in the duct wall. I therefore left most of
the fragments in the duct, carefully suturing the opening
over them. I then sowed the edges of the open gall-bladder
into the external wound, and drained it in the usual way,
passing a glass tube also into the peritoneal pouch below
the liver. The highest temperature after the operation was
100-2®, pulse 72, and after thisnormal. All discharge ceased
on the sixteenth day, and she was up on the nineteenth ; all
jaundice gone and urine and ficces normal, and she rapidly
recovered perfect health.
Case 4.—Married lady aged thirty-five, mother of five
children. Lump just below liver and pain noticed six years
ago, just after birch of last child. Several attacks of pain
after this; no jaundice. Came to me in July, 1889, during
attack; the last previous attack had occurred a year before.
I could distinctly feel a number of stones in the gall-bladder,
and advised their removal. Operation July Slst, 1889. A
simple cbolecystotomy, gall-bladder sewn into abdominal
incision and drained; bile-stained mucus discharged very
freely at first; entirely ceased in a fortnight. Temperature
once rose to 101®; was normal on the seventh day. Excel¬
lent recovei-y, and remains well.
Case 5.—Hospital patient, single woman, aged thirty-two,
sent to me by Dr. Jack of Emperor’s Gate, was seized with
Coi-n le
O ■
764 The Lancet,] DR. J. DIXON MANN ON ADDISON’S DISEASE. [April 4,1891.
laddbn severe pain in the region of the gall-bladder during
sleep, in May, 1889. The pain continued all next day,
recurring in severe paroxysms; two da^s later she was
jaundiced and the nnne was yellow. This attack entirely
passed off with a simple purge. On Oct. 11th a similar
attack, in which she was attended by Dr. Jack, who found
a tumour in the region of the gall-bladder and sent her to
me, having first aspirated the tumour and drawn off two
pints of mle-stained fluid. The tumour refilled rapidly.
On Nov. 11th, 1889, 1 cut down upon the tumour and
having removed two pints and a half of bilious fluid with the
aspirator, opened it and removed a quantity of hydatids,
and found that it was the gall-bladder. There were many
adbesioDs all round it, and I removed a separate hydatid
cyst from the omentum. As there was fluid in the pelvis I
made a counter opening over the pubes and drained the
peritoneum through it by a glass tube. The gall¬
bladder was sutured into the abdominal wound and
drained. The temperature rose to 102® on the first
two evening, but was normal on the fifth day. The
pelvic tube was removed in thirty-six hours. The gall¬
bladder discharged for twenty-two days. Perfect recovery.
Case 6 —Married woman, aged forty-three, mother of
twelve children, youngest four, was sent to me in same month
as above by Dr. Maurice of Marlborough. She was mucli
emaciated and deeply jaundiced, with that peculiar earthy
bluish tinge which so often accompanies malignant disease.
Indefinite swelling and dulness in region of gall-bladder,
but more to left than usual. Liver large and hard, and
obvious matting of parts below it; no ascites. Pirst attack
nine months before. Severe pain, which continued off and
on for two weeks; did not notice her stools or urine. At end
of two weeks violent vomiting, complete anorexia, and
green jaundice. On admission, colour as above, tongue
clean and moist, fair pulse, small hard glands in both
groins, pelvic organs normal. I diagnosed impacted gall¬
stone and advised operation, but could not help being a
little anxious, lest it should prove to be associated
with malignant disease. I operated on Nov. 2$th,
1889, in presence of Dr. Maurice, Sir Spencer Wells,
and many other visitors. I found the liver so large
that the gall-bladder and ducts were quite covered,
much adhesion of omentum and intestines, a large
oval stone impacted in common duct, and, failing to define
the gall bladder accurately, and feeling sure that it would
bo impossible to get at the stone through a contracted
eystic duct, I decided to incise the common duct at once
and BO remove it. I was mucii hampered by the large
liver, and had to work entirely by toucn deep in the abdo¬
men, guiding the knife on the leit index finger. The first
incision was followed by such a rush of dark venous
blood that I feared for the vena cava, but, having
introduced a small Ferguson’s glass speculum, 1 saw
that it proceeded from a vein in the adherent omentum,
and this I easily secured. I had great dilUcuIty in
loosening the stone, which was firmly adherent to the
lining membrane of the duct over a great part of its
surface. After removing it I could see the termination
of the duct in the duodenum quite distinctly through the
speculum. 1 closed the opening in the duct by six fine
interrupted points of silk suture, and a continuous one over
all, using the omentum to strengthen the closure as I had
done in the previous case of duct incision. I drained the
peritoneum by a glass tube. Slie suffered very seriously
from shock, and the first urine was half albumen ; there
was none before the operation. She quickly rallied, however.
The temperature never rose above 100‘6°, with a pulse of 100,
and both were normal on the fifth day. All drainage was over
on the sixth day; there was a natural action of the bowels
«n the fifth day; the urine began to improve in colour on
the third day. but the stools were clay-coloured till the
eighth day. The wound was healed in a fortnight, and she
left the hospital in three weeks quite well, but still slightly
jaundiced. Dr. Williamson of Ludgershall writes that the
jaundice lasted about five weeks after her return home, that
she has grown stout, and is quite well and able to do all
her house work.
Case 7 was that of a single lady aged thirty-six, whom
I saw in consultation with my friend Mr. Hewer at High¬
bury. The patient had long suffered fronj inactive liver,
with sallow complexion, and attacks of pain in the right
hypochondrium, suggesting the presence of gall-stones.
For the last six months the attacks had clearly been due to
attempted passage of gall-stones; the pain became very
violent, and M'as accompanied by vomiting, jaundice, and
rapid emaciation. Sir Andrew Clark, and afterwards
Dr. George Harley, saw her, and the latter made a pro¬
longed attempt to massage the stones into the intestine, nut
without effecting any amelioration of the symptoms. When
I saw her with Mr. Hewer she was deeply jaundiced, with
raised temperature and quick pulse, and we agreed that if
relief was to be given there was no time to lose, and I
operated on the next day. May 3rd, 1889. I found two
stones impacced one above the other in the common duct.
The gall-bladder was so shrunken that it was difficult to
recognise it, and I at once decided to open the common
duct, remove the stones, and suture the opening. This
procedure I carried out with much difficulty, owing to the
matting of parts by adhesions; and not being very well
satisfied with the security of the sutuiing of the duct, 1
passed a rubber tube into the pouch, at the bottom of which
it lay, and brought it out through the upper part of the
abdominal incision, and I also passed a glass tube into the
pouch of Douglas through a counter opening above the
pubes. The latter was hardly required, but a very heavy
discharge of bile-stained serum flowed from the rubber tube
for many days after the operation, showing that my fears
as to the security of the duct sutures wore well founded.
She recovered rapidly, without a single bad symptom, and
Mr. Hewer reports on Feb. 13th, 1891: “ Perfectly well,
good complexion, and takes her food without any incon¬
venience.”
Case 8 was that of a young married woman aged thirty-
four. She had suffered for a long time with attacks of pain
round the back and in neighbourhood of liver, which lasted
a ^w days, and then entirely passed off. In January of
last year she noticed a lump in the situation of the gall¬
bladder which varied in size. In February she had a severe
attack of pain, with tympanites and severe vomiting. The
lump was said at this time to be irregular in outline, ami
so mobile that it was thought to be in the omentum, and of
a malignant nature. This diagnosis was strengthened by
gradual emaciation with constant pain, and by her mother
having died of internal cancer. When I first saw her I
found a smooth oval tumour about as large as a turkey’s
egg, and with all the characters of a distended gall¬
bladder. She went away for a time, and when I saw
her again I found a much smaller, harder, and more
sensitive swelling, and this confirmed my diagnosis;
but I feared it might be a case of malignant obstruc¬
tion rather than stone. I operated on May 20bh, 1890, and
found a very hard and thickened gall-bladder, and laid it
open and hunted carefully, but could find no stone. The
adhesions round it were so firm that it was difficult pro¬
perly to explore the ducts from their peritoneal surface, and
the thick wall of the gall-bladder cut so easily with the
sutures that I determined not to attempt to fasten it into
the incision, but to suture it carefully and drop it in, this,
as it proved, most unfortunate decision being aided by the
unusually small amount of bile or mucus which escaped
from the bladder during the necessary manipulations of the
operation. The patient did badly from the first, and died
on the third day with septic symptoms. An examination
after death showed that a large quantity of bilious fluid had
escaped into the peritoneum through the giving way of the
sutures in the gall-bladder wall, and close to the opening
lay a small gall-stone free in the peritoneal cavity—a
remarkably small one to have caused so much trouble and
such great thickening of the gall-bladder; but no other
disease could be found to account for the mischief.
{To be coticluded.)
ON ADDISON’S DISEASE.
By J. DIXON MANN, M.D., F.R.C.P.,
PHYSICIAN TO THE SALI-'OUD HOYAI, IIOSIMTAI., I.ECTUIlEll ON TORENSIC
MliUIClNIi AND PUACTICAI. TOXICOLOGY IN OWENS COLLEGE.
(Concluded from page 71S.)
The discolouration of the skin in Addison’s disease has
been the subject of much investigation. Various explana¬
tions have been offered as to the constitution, source, and
mode of deposition of the pigment. The two principal
views are: (1) That the pigment is a proteid substance
which undergoes colour changes within the refce colls in which
it is found; (2) that it is an bicmatogenous product, and is
transferred to the cells pre-formed. It will be convenient
Coogle
The Lancet,]
DR. J. DIXON MA.NN ON ADDISONS DISEASE.
[April 4,1801. 765
to discuss together the questions relating to the constitu¬
tion and the source of the pigment. The chemical com-
{position of other pathological pigments has been appealed
TWO with a view of obtaining a clue. A point specially
aimed at has been to ascertain whether iron is present or
mot. If present it affords presumptive proof that the pig¬
ment is derived from blood-colouring matter. Berdez and
Nencki^ found that the pigment of a melanotic tumour
'Contained no iron, but a considerable amount of sulphur.
An analogous pigment is that of the choroid, which, accord-
'ingto Sieber,- contains neither iron nor sulphur. Bsrdezand
Nencki, foundingtheir opinion on the results of their analysis,
(hold that melanotic pigments are in no way related to
the colouring matter of blood. Tlie absence of iron and
the presence of sulphur contradict the assumption of any
derivation of melanine from bmmatin, which contains iron
but not sulphur. Morner® attributes the absence of iron in
the results obtained by Berdez and Nencki to the mode of
research, as he found that melanotic pigment is nearly half
as rich in iron as is hmmoglobin. He regards the pigment
as a derivative of hiemoglobin, and declines to accept a
decomposition product of haimoglobin-—hmmatin—as repre-
eenting blood colouring matter, Klebs'* holds that the pre¬
sence of sulphur in melafline proves that it is not derived
from hasmoglobin but from the decomposition of some sul¬
phur containing albuminoid, remarking that to this class of
substances htemoglobin, being sulphur free, does not belong.
This applies to htematin but not to hsemoglobin. Hremo-
iglobin contains sulphur, but hosmatin does not. Schmidt®
regards pathological pigments which do not contain iron as
simply two states of a colouring matter derived from hmmo-
•globin. In the early stage iron is present, later on it is
absent. In some instances portions of the pigment afford
evidence of the presence of iron, whilst other portions do
not, the difference being due to the relative age of the re¬
spective deposits.
With so much diversity of both results and opinions as to
the composition of morbid pigments, it may seem useless to
try to determine the presence or absence of iron in the
pigment of Addison’s disease as a means of tracing its
derivation. If the result is negative, it is true that no
inference can be drawn, as a pigment undoubtedly derived
■from hfcmoglobin may contain no iron. On the other
band, if iron is found, the assumption of the pigment being
a product of hicmoglobin receives material corroboration.
Peris," Nothnagel, and other observers failed to obtain any
reaction with the Prussian-blue test w'hen applied to
sections of pigmented skin from Addison’s disease. I made
a series of experiments in this direction with potassium
ferrocyanide, potassium sulpboeyanide, ammonium sulphide,
and sodium salicylate, the result in all cases being negative.
To sections of the skin a few drops of a .’1 per cent, solution
of potassium ferrocyanide or sulpboeyanide were added,
and then a drop of hydrochloric acid. With ammonium
Qulplude the sections were simply covered with a drop
or two of the reagent in various dilutions. In some
instances a drop of glycerine was added after the re¬
agents, and the section covered with thin glass and
allowed to stand for several hours. No colour change in
the pigmented cells was produced even after prolonged
■exposure. As remarked by Nothnagel,’’ these negative
(results by no means prove the absence of iron, as the
(metal may be present in some combination which the
reagents will not touch. If iron is present in the pigment,
it is probably in some form which cannot be unlocked except
by destruction of the organic elements of the combination.
Incineration would free the iron, but there are practical
•^difficulties in the way of direct demonstration by this pro¬
cess. After trying many methods with sections of tbe skin
’to liberate anv iron present in the pigment, so as to enable
it to yield colour reactions in situ, all of which were un-
■successful, I adopted the following procedure. The pigment
from a portion of skin from the scrotum (as being moat
deeply pigmented) was carefully scraped away and trans¬
ferred to a test tube and well washed with water, and sub¬
sequently with alcohol acidulated with hydrochloric acid,
in which it was allowed to remain for some hours with
frequent agitation. The mass containing the pigment was
then dried, weighed, placed on a slip of clean platinum foil,
/ Arthiv flir Experiment. Path., lid. xx,
- Ibid. (' ;.Coitscli. f. PhyNiol. Chemie, Bd. ix.
Pio Allgemoiiio Pathologie, 1889.
5 Virchoiv'.H Arch,, 3id. exv. « Il>id., Bd. xxxix.
^ Zoitacli. f. Klin. Mod.. 1880.
and cautiously incinerated. The residue was treated with
two drops of 10 per cent, hydrochloric acid in water, and
one drop of a 3 per cent, solution of potassium ferrocyanide.
Two short pieces of glass tube were previously prepared by
grinding their ends nat, and cementing on to the one of
each a circle of thin microscopic cover-glass. The tubes
were coated on the outside with lampblack, so that tbe
whole layer of any contained fluid should be traversed by
the rays of light directed through them. The tubes were
clamped vertically side by side, and a piece of white paper
was placed below them at such an angle as to reflect the
light through tbe tubes to tbe eye. The mixed fluitl
obtained from the pigmented skin was transferred to oi|e
tube, and to tbe other the fluid obtained from an equal¬
sized piece of normal (non-pigmented) skin treated in pre¬
cisely the same way, the washed product when dry corre¬
sponding in weight with that yielded by the pigmented
skin. In order that tbe quantities of the reagents should
always be equal, the same solutions and tbe same pipettes
respectively were used throughout the experiments. A
number of experiments were made in precisely the same
way, the result in all eases being the same. There was
no perceptible difference in depth of colour between the
solutions obtained from the pigmented and from the non-
pigmented skin. Tbe colour was always a light blue, and
was due to a minute quantity of iron diffused in the cell walls
and cement substance that was scraped away. The cells
containing pigment were no richer in iron than those which
were free from pigment. Some of these experiments were
made with potassium sulpboeyanide in the place of the
ferrocyanide. Tbe result was the same except for the
difference in colour of the reaction ; the depth of colour was
equal in the fluids from pigmented and from non-pigmented
skin. Zaleski® found minute quantities of iron in various
tissues after careful removal of all traces of htemoglobin.
The iron probably exists in more than one combination. As
a simple albuminate of the oxide (judging from tbe behaviour
of the artiflcially prepared albuminate) it would be separated
by acidulated alcohol, which is not tbe case. The result of
these experiments tends to support the view that the
pigment deposited in the skin of patients suffering
from Addison’s disease does not contain iron. After
what has been already said it is superfluous to observe
that it by no means follows that the pigment is not
of hosmatogenous origin. Spectrum analysis also yielded
negative information. The pigmented layers of several
sections of skin were arranged in apposition on a micro¬
scope slide, and then examined witli the micro-spectro¬
scope. A high-power objective was used, so that all
the light received by the spectroscope should pass
through the pigmented cells. Not the least trace of an
absorption band could be detected. The violet end of tbe
spectrum was damped, without any (iecided cutting-off.
This corresponds with the spectroscopic observations ma<ie
on solutions of the pigment from melanotic tumours by
Berdez and Nencki, and by Morner.
Chemical evidence as to the source of the pigment being
negative, the subject has to be discussed from other stand¬
points. In favour of the hmmatogenous hypothesis, it is to
be observed that there is good reason for believing, broadly
speakiog, that all pigments, normal and pathological, of the
human body are derivatives of bicmoglobin. This statement,
however, is by no means universally accepteti, and moreover
it proves nothing; but convincing evidence to the contrary is
required before it can be rejected in any special instance of
pigmentation. It is accepted on all sides that the pigment
I in Addision’s disease is deposited in tbe lowest layers of the
rete Malpigbii, precisely where normal pigment is found—
for example, in tbe dark-skinned races, and iu those parts
of the body in whites where pigment abounds, as the
areolie of the nipples in women and the scrotum in
men. Further, the deposit of pigment seen in some cases
of phthisis, and in puerperal women, occupies tbe same
anatomical site. As Nothnagel puts it: it is impossible to
distinguish microscopically between sections of tbe skin in
Addison’s disease and those derived from a negro; if there
is any difference it is solely in degree. This resemblance
applies not only to the site but to the colour and character
of the pigment. Recklinghausen" lays great stress on the
reddish-brown and gold-yellow tint of thepigmentgranulea,
as indications of hromatogenoua origin. Further evidence
8 VirchoTv’s Arch., Bd. civ.
« llandbuch dor Allgcmoino Pathol., 1883.
766 Thx Lancet,]
DR. J. DIXON MANN ON ADDISON’S DISEASE.
[Apkil 4,1891.
of biematogeDous origin is alibrded by the observation of
RiehP° in the transport of pigment from the blood to the
hair, by cells which carry the pigment from the bloodvessels
through the corium to the hair. Kblliker^^ explains the
mode of physiological pigmentation in exactly the same
way, and is of opinion that it differs in no respect from
pigmentation of pathological causation. It has been urged
against the heematogenous derivation of the pigment in
Addison’s disease that the part where the pigment is de¬
posited is removed from the immediate neighbourhood of
bloodvessels, and consequently cut off from them as a source
of supply. The explanation just given removes this diffi¬
culty. Pigment cells have been found attached to the sheath
of the bloodvessels in the corium, and others on their way to
the epithelial layer surrounding the papillre. When they
reach the lowest cells of the epiderm they yield up to them
their pigment. According to Ehrmann,the basal cells of
the epiderm send short, thin pigment-carrying processes
into the corium, which play an important r6U in the
transport of the pigment. These finger-like processes act
as bridges between the lower cells of the rete Malpighii and
the corium, and along them the pigment is propelled as fine
granules into the protoplasm of the lower rete cells. Under
physiological conditions in the more pigmented parts—as,
lor example, the skin of the scrotum—the corium is found
to contain pigment-carrying cells. By far the greatest
amount of pigment exists in the rete cells, because its
presence in the corium is only transitory; it is being con¬
tinuously passed on to the rete cells, where it is stored up.
In physiologically deeply pigmented parts the supply is so
abundant that a considerable amount is always to be met
with in transit. This was beautifully illustrsted in a
specimen of skin taken from my second case. Some weeks
before the patient died a mustard-plaster was applied to
the surface of the abdomen. The skin underlying the
plaster remained permanently more deeply pigmented than
the surrounding skin. At the necropsy a small piece of
the skin of the abdomen was i^moved, so as to include
some that showed the pigmentation solely due to the
disease and some in which it was intensified by the counter
irritant. On microscopic examination it was seen that not
only did the lower layer of the rete cells, corresponding to
the more deeply pigmented part, contain a larger amount
of pigment than those of the neighbouring skin, but that in
the underlying corium, below as well as in the papillee,
were a large number of carrier cells charged with pigment.
In the conum of the surrounding skin there was a marked
difference—the carrier cells were sparsely scattered.
The oft-repeated observation that the pigment in the
rete cells is almost entirely limited to the lowest layers,
the upper cells of the epiderm being free, suggests the
inquiry as to what becomes of it. Ehrmann’^ stages that it
is rubbed oil' with the epiderm as it reaches the surface.
In the sections of the skin from the cases I examined there
was a layer of cells free fvotu pigment, of considerable
thickness, above the cells which contained pigment, and con¬
sequently the latter could not be rubbed off without causing
an abrasion. The squamous cells which are shed in the
ordinary course of events contained no pigment. In very
deeply pigmented skin the pigmented layer is much thicker,
and may extend to the surface, as is the case with negros,
in whom the pigment may be parted with, as described by
Ehrmann. In the skin from my cases it appeared as
though the pigment cells of the rete lost colour as they
f iassed up further from the papillto. This would indicate
ading of the pigment, the hue being maintained in the
lowest layer of the rete cells by a continuous supply from
the corium. The loss of pigment either by fading or by
rubbing off from the surface explains the variations in
colour frequently observed in cases of Addison’s disease.
At times the patient appears darker, at times lighter. If
the supply equals the loss the colour reraain.s unchanged—
if it is more, the colour is deepened; if less, it is diminished.
In the case of the mustard-plaster alluded to, an increased
activity was occasioned in the transference of pigment from
the bloodvessels to the rete cells, which remained in force
long after application of tlie stimulus. As time went on,
however, there were indications of diminution. The more
deeply pigmented patch, which at first was very distinct
both in hue and outline from the surrounding skin, lost
some of its colour, and the margin its sharp contour.
10 ViertBljalirschr, f. DeriDatologie, 1884.
Zoitschr. f. Winsonsch, Zoolojrio, 1887.
12 Vi«jrt*lja,lir8schr. f. Jlcrmatologie, 188&-(1. Loc. cit.
There was an evident tendency to return to the general
condition.
It is a striking fact that mucous membrane is noli
pigmented in Addison’s disease. With the exceptions
about to be mentioned, there is an entire absence of
pigmentation of both mucous and serous membranes,
as well as of the internal organs throughout the body.
The exceptions appear to be limited to those portions
of mucous membrane where localised inflammatory pro¬
cesses have taken place, and to those which have been
subjected to intermittent pressure, or to friction—cbielly
the buccal mucous membrane along the meeting line of
the teeth, within the lips, and on the tongue. In aevera]i
coses small spots of pigmentation have been observed on
the peritoneum ; my second case presented this peculiarity.
In one of the cases recorded by Greenhow, small tubercular
granules were scattered over the mesentery and peritoneum,
and around each was a deposit of black pigment. In my
second case the posterior vaginal wall was pigmented at the
upper part, evidently due to pressure produced by an
elongated cervix uteri. It appears that the same condition—
local hyperromia—which determines pigmentation in mucous
membrane intensifies it in the skin. When mucouo
membrane is pigmented the discolouration is not so
pronounced as it is in the skin. On microscopic
examination a notable diff'erence is seen in the posi¬
tion of the pigment; instead of being deposited in the
lower layer of the rete cells, it is found in cells within the
papillm of the corium, the cells of the rete being free. This
distribution of the pigment in mucous membrane has been
noticed by Greenhow,^'* Hadden,^® Kablden,’® and others.
The cells in the papillae have all the appearance of carrier
cells. They are irregularly grouped so that some of the
a illm are free from pigment,'others contain one or two
9, and others again are filled with them. To this
sparing and irregular distribution of the pigment, together
with the fact that it is below instead of in the epiderm, the
lighter shade of pigmented mucous membrane as compared
with the skin is due. In Addison’s disease it will be seen
that mucous membrane presents three characteristics ia
reference to pigmentation which distinguish it from skin:
it does not undergo general pigmentation; certain local con¬
ditions are necessaiy to develop it; the pigment occupies
a different histological site. As regards the second
characteristic, it is to be noted that the pigmentation is
strictly limited to the areas acted on by the local conditions.
In the portions of mucous membrane that are the seat of pig¬
mentation the same process takes place, up to a certain stage,
as in the skin. The carrier cells charged with pigment
make their way from the vessels through the corium to wards
the rete. Here the resemblance ceases ; for instead of tbo
pigment being transferred to the lower rete cells and stored
up in them, it remains in the carrier cells within the papilljE;
I noticed tliat when, exceptionally, any of the pigment did
find its way beyond the limit of the corium, it was not de¬
posited within the cells of the rete, as ia distinctly the case
with tiie skin, but was diffused in minute granules amongst
the rete cells in such a way as to obscure their outline. In
the rete of the skin the pigment granules are mostly
within the cells, and Jielp to differentiate their contour.
Sometimes the pigment granules which penetrate the
lower rete layer of mucous membrane run in between
the cells, and appear as fine dotted lines. It is evident from
all this that the cells of the rete Malphighii of mucous,
membrane are incapable of receiving the pigment, hence its
retention in the carrier cells of the corium. It is probable-
that the rete cells of mucous membrane are devoid of the
finger-like processes described by Ehrmann, which bridgeovoi*
the space between them and the carrier cells in the curium.
This behaviour of mucous membrane towards pigmen-O
strengthensthecarriercell hypothesis. Byshowingtheproceso
of pigmentation transport in an incomplete stage, it demon¬
strates that in pigmented skin the pigment is nob formed
within the rete cells from colourless albuminoid material or
chromogen, bub that it is conveyed to them preformed. The
argument is corroborated by the analogy which exists between
the pigmentation of mucous membrane and two pathological
conditions affecting the skin. In leucoderma and in the
tufts of white hair prematurely formed in some individuals
the papillm of the underlying corium are as abundantly
supplied with pigment carrier cells as is the rest of the
skin, but in consequence of the absence of means of com-
n Lac. dt. Path. Trans., vol. xxxvi. J" Loc. cit.
Google
The Lancet,]
DR. J. DIXON MANN ON ADDISON’S DISEASE.
[Apeil 4,1891. 767
tTiiuDicatioD between fche rete cells and the pigment cells—
the linger-like processes of the former—no pigment is
transferred. This absence of receiving filaments is the
pathological condition which constitutes the cause of the
abnormality^ in pigmentation in the cases cited; in mucous
membrane it is probably a normal histological condition.
From the observations I have made in the pigmented
mucous membrane of Addison’s disease, it appears that
exceptionally some of the pigment granules find their way
'from the carrier cells of the corium into the rete, not, how¬
ever, into the cells, but between them. The pigment cells
of the corium are not capable of retaining toeir pigment
for as indefinite time—they are vehicles, not stores,—and
it is probable, when the pigment is not removed from them
in the usual way, that the granules after a time escape
from the cells and are carried with the lymph into the rete,
where they are distributed around the cells.
It has been assumed that light is the agent by which the
depth in tint of skin pigmentation is increased. The fact'
that the exposed parts of the body—the face, neck, and ;
hands—are usually of a deeper hue than the parts which
are covered by the clothing is regarded as proof of this
statement. I am disposed to think that light does not in¬
crease the pigmentauon by virtue of its actinic powers,
but that in conjunction with the air, and with heat—from
the sun and from artificial sources—it increases the amount
of blood in the parts acted on, and in this way develops
^greater pigmentation. My reasons for thinking so are
that portions of skin which are subjected to friction—the
shoulders of men from the rubbing and pressure of the
braces, and the waist in women from the pressure and
■fi'iclion of the bands of their underclothing—have often
been found in cases of Addison’s disease to be more deeply
pigmented than the neighbouring skin. The deeper hue of
the skin produced by a mustard plaster, and the deposit of
pigment in raucous membrane being limited to those places
where either mechanical or pathological irritation has been
set up all point to local hypercemia as the cause of increased
pigmentation.
As to the condition in which the colouring matter exists
when received from the bloodvessels by the carrier cells
there is room for doubt. Whether the blood discs pass
■chrough the walls of the vessels and are directly received
by the carrier cells clinging to them, or only the hcemo-
giobin transudes, is not known. In either case it is remark¬
able how soon the hcemoglobin loses its iron. The activity
of cells in splitting up proximate constituents may possibly
account for it. NotlinageP’’ strongly insists that the pig-
2 uentation in Addison’s disease is entirely due to nerve
inlluence {affecting not so much the receiving cells of the
corium as the bloodvessels of the skin. He denies that the
•pigmentation is due to any primary alteration in the blood
.’taelf. The hypothesis of nerve influence being the cause
of akin pigmentation accounts more rationally for its
occurrence under various conditions, physiological and
pathological, than does the presence of effete or ab¬
normal colouring matter in the blood. It is conceiv¬
able that the necessary nerve influence may be occa¬
sioned in a variety of ways from central and from peripheral
causes. Addison's disease and some other systemic diseases'—
phthisis and malignant disease, for exarriple—are so many
conditions which may cause permanent skin-pigmentation
by acting on some segment of the central nervous system.
Tile word “central” is here used in a relative sense, as
apposed to peripheral. Temporary pigmentation from
central causation is illustrated by that which frequently
accompanies pregnancy. ’ Peripheral stimulation causes
pigmentation of the skin when the surface is exposed for
some time the action of powerful sunlight, especially if
accompanied by the presence of saline particles in the air
as from sea breezes. These conditions have a mode of action
in common, and do not require special morbid processes to
suit each case. The presence of effete or of abnormal
colouring matter in the blood requires a much more com¬
plicated hypothesis in order to embrace all forms of skin
pigmentation. It is much simpler to suppose that undue
•stimulation of the skin nerves by the powerful rays of the
sun determines a change in the relation between the walls
•of the bloodvessels of the skin and the adhering pigment
cells, which results in excessive abstraction of pigment from
normal blood, than that the blood itself is altered to furnish
the pigment.
Loc. clt.
Two additional points in my second case merit attention.
The external genital organs resembled those of a young
child, the uterus was of the infantile type, and the ovaries
were very small. Kleinwachter^® relates the case of a
woman twenty-nine years of age, who died from Addison’s
disease, wliose generative organs presented the following
appearances. The mons veneris was devoid of fat and hair,
the labia were flaccid, and the uterus, ovaries, and mammm
atrophic. The patient had not menstruated for nine
months. The effects of deranged nutrition on special
organs is well illustrated by these cases; in the one there
was retarded, or rather arrested, development, and in the
other the atrophic changes resembling those of advanced
old age. It is to be remembered that general wasting
does not take place to any great extent in uncom¬
plicated Addison’s disease, the inference therefore is that
the trophic nerves of the organs named are liable
to share in the abdominal nerve changes. The uterine
vaso-motor nerves are in close relation with the splanchnic,
whence the abnormal influence is probably derived.
The second point is that the patient’s breath for the last
two or three days of her life gave off a peculiar odour which
has been described as “ ethereal.” NothnageP® observed a
similar odour in one of bis cases of Addison’s disease in
which von Jaksch found marked aeetonuria. The tenspera-
ture in my patient was subnormal previous to the occurrence
of the odour, but afterwards the breath and the surface of
the body felt exceptionally cold to the hand. The respira¬
tion was slow but not of the sighing type observed in
diabetic coma; the patient was exhausteci to the verge
of dissolution but was not comatose. The urine did
not contain sugar, nor did it give any reaction with
ferric chloride, or with sodium nitro-prusside and
ammonia. About 90 cc. of the blood obtained at
the necropsy were placed in a flask connected with a
condenser leading to a closed receiver surrounded with ice.
■The flask was placed on a <frater bath at about 60“ C. After
a time the receiver was changed, and the temperature was
increased to 100“ C. In neither case was any product ob¬
tained which responded to the tests for acetone, or the sub¬
stance which gives the so-called acetone reactions. I am
disposed to refer the “ethereal” odour in my ease to some
aromatic product, probably of the phenol group, derived
from the splitting up of the proteids of the tissues. It was
about the period of the occurrence of this odour, as recorded
in the history of the case, that there was for the first time a
marked increase in the amount of indican in the urine.
Some of the urine at this period was acidulated with
sulphuric acid and distilled. The distillate yielded a
much more abundant precipitate with bromine water than
the distillate from an equal amount of normal urine. The
quantity of urine at my disposal was too small to
admit of a reliable quantitative estimation of the phenol
from the amount of tribromo-phenol formed, and the
death of the patient prevented further investigations.
It is known that under many pathological conditions
aromatic products are found in the urine greatly in excess
of the amount met with in the urine of healthy individuals.
For the most part they arise from putrefactive changes in
the contents of the intestines, and in the course of certain
putrefactive diseases. Exceptionally they may bo formed
from the tissues of tlie organism itself by abnormal rr-eta-
bolism apparently apart from the influence of micro¬
organisms. It is not uncommon for aromatic products to
replace each other in the urine from time to time in the
progress of a disease. Phenol and indoxyl have been
observed to alternate, and also to be present in excess at
the same time. Indoxyl may bo replaced by acetone, or a
substance giving the acetone reaction. I should be disposed
to regard the products encountered in my case as evidences of
auto-intoxication, presumably referable to abnormal tissue
change the result of perverted or perhaps of arrested trophic
influence. Increase in the amount of indican in the urine of
atients suffering from Addison’s disease has been observed
y Koaonstern^'' to the extent of 64'5 milligrammes of indigo
in one case, and 75'3 milligrammes in another (being eleven
or twelve times greater than the normal amount), and also
by other observers. The increase here spoken of occurred
during the progress of the disease ; it was not limited, as in
my case, to a short period immediately pi-eceding death.
As far as the evidence of my two cases goes, the excretion
'8 Deutscb© Med. Zoitimg, 1889.
m Loc. clt. 28 Vlrcliow's Arch., Bd. Ivl.
c
768 The Lancet,] DE. GEOKGE DEAN ON THE MICRO ORGANISM OF CANCER.
[Afrtl 4,1891.
of excess of indoxyl aud of ether^sulpbonates bas no direct
relation to Addison’s disease per sc. The instance in
which it occurred can only be regarded as one of far-
adranced disordered metabolism, such as may determine
the formation of like derivatires towards the end of any
disease in which the tissues are profoundly affected.
Manchester.
DE. RUSSELL’S CHARACTERISTIC MICRO¬
ORGANISM OF CANCER.
By GEORGE DEAN, A.M., M.B., C.M.
In an address read before the Pathological Society of
London on Dec. 2nd, 1890, and published in the medical
journals of Dec. 13th, Dr. William Russell of Edinburgh
described what he called a “Characteristic Organism of
Cancer.” Since that time I have had the opportunity, in
the Pathological Institute, Berlin, through the kindness of
Professor Virchow and his assistants, of carrying out some
control observations on this subject. At the outset a
number of cases of cancer were examined by the methods
described by Dr. Russell. In these the fucbsin bodies
could be found, being in some cases numerous, in others
rare. Some of the appearances described by Dr. Russell
were not observed—e.g., the appearance of a row of two or
three bodies united by rods. It was also found that the
most characteristic groups of bodies always occurred in the
connective tissue, in capillaries, or in lymph spaces. The diffi¬
culty referred to by Dr. Russell was encountered—viz., that
in certain cases the nuclei and nucleoli of the cells gave the
same colour. Sometimes this was found to be a loc^ change
occurring over small areas. This in itself was sufficient to
excite suspicion as to the organismal character of the fuchsin
bodies, pointing rather to the action of some chemical agent
affecting the cells, or to a degeneration due to some change
of nutrition. In some instances the bodies were very closely
associated with irregularly shaped masses of hyaline-like
substance, giving the same colour—red by Dr. Russell’s,
purple by Gram’s—and glossy appearance as the fuchsin
bodies. In Fig. 1, from a case of carcinoma of the liver,
Fig. 1.
From a case of carcinoma of the liver, secondary to cardnoma of
the mamma. (Zeias, j'j, oil immersion, oc. No. 2.)
secondary to carcinoma of the mamma, stained by Gram’s
method, such an appearance is presented, and the nucleoli
in the neighbourhood are also shown to have taken on the
colour.
In other cases the bodies were found in intimate relation
with hyaline degeneration occurring in and around blood¬
vessels. In Fig. 2, from « case of ovarian carcinoma, this
appearance is seen. Inside the wall of the vessel masses of
hyaline substance are to be seen, and among these are one
or two bodies very similar in appearance to the fuchsin
bodies. In the connective tissue around the vessel some of
the bodies are to be seen, and in the alveolus, near the
vessel, the altered nuclei of the cells give the red colour and
glossy appearance of the bodies, and are practically indis¬
tinguishable from them.
These appearances seem to indicate that the bodies are
really due to a degeneration, and of the degenerations
“hyaline” degeneration is remarkable in giving the same
colour with eosin and fuchsin in acid solutions, and in its
tendency to form spherical bodies. The term “hyaline” is
used in its widest sense, and with the view that the appear-
aneo may originate from a number of different sources—
e.g., from blood plasma, blood plates, blood corpuscles,
epithelium.^ The position in which the fucbsin bodies occur
points in some instances to a post-mortem change taking-
place in the blood under conditions of which at present we-
are ignorant. That the bodies are due to the action of
reagents 1 think cannot be entertained; for I believe they
can be seen in fresh sections, though here it is much more-
difficult to be certain one is looking at the same thing. In
a rfresh section the bodies may be seen lying in charac¬
teristic groups, resembling fatty globules, but with thes-
contour not so dark as in the case of fat. A section con ¬
taining such a group of bodies was treated with acid
and afterwards with alcohol and ether, and after this-
treatment the bodies still retained their characteristics,
thus excluding calcareous and fatty deposits. From the
same tissue beautiful specimens of the fuchsin bodies were
afterwards obtained. The exact nature of these bodies
is a question about which it is possible for much discussion
Fig. 2.
Vessel showing hyaline thrombus, with transition to th©
uchsin bodies. In the neighbouring alveolus the altered
nuclei are stained red. (Zeiss, oil immersion, oc. No. 2.)
to arise. A much more important question, however, and
fortunately one much easier to decide, is whether these-
bodies occur in cancer only. For if they are found in other
pathological or in normal tissues, with any degree^ of'
frequency, it is impossible to bold that they have anything,
to do with the etiology of cancer. A number of other
pathological and also of normal tissues was therefore
examined by the same methods. The results certainly do
not tend to establish the appearance as one peculiar to-
cancer. From a comparatively small number of tissues the
fuchsin bodies were found in six separate cases. Two were
typical cases of uterine myoma without a suspicion of
cancer. In a case of syphilis of the lungs the bodies were-
found in tlie connective tissue around the bronchial glands.
The fourth was a case of phthisis. The other two ca^es
were normal tissues. The one was a case of non-lactating.
mamma from a woman who had borne children ; the other
was from a lactating mamma.
The conclusions, therefore, to which this paper leads are :
1. That the bodies are not to be regarded as micro-organisms.
2. Even admitting that they were of vegetable origin, they
cannot be regarded as pathogenic—i.e., they cannot be
regarded as a “ characteristic micro-organism of cancer.”
* Zioglev'H Pathology, vol. i., p. 118.
North London Hospital for Consumption.—
The annual report of this charity states that £2000, out
of £6000 required, had been collected for the purpose of-
erecting a central block to the hospital, which will afford
room for thirty extra patients. Dr. J. Edward Squire was
deputed to go to Berlin to study Professor Koch’s system-
for the treatment of tuberculosis. The result of the inocu¬
lation of several patients with the fluid was satisfactory. The
in- and out-patients for the year were 396 and 2840 respec¬
tively. The cash statement shows a balance in hand of
£274.
Digitized by ^ooQle
The Lancet,]
CLINICAL NOTES.
[April 4,1891. 769
dlittital Itttte:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
A CASIO 01''
A BROKEN CATHETER IN A MALE BLADDER AT
SEVENTY YEARS OF AGE, ILLUSTRATING THE
VALUE OF INTERNAL URETHROTOMY.
By G. Buckston Browne.
The operation of internal urethrotomy is not yet fully
-accepted by many surgeons whose opinion is worthy of
respect ; indeed, it is only two years ago that at one of the
most important gatherings of the medical profession a well-
iknown surgeon of many years’ experience publicly stated
that in the whole course of his experience he had never
known a case where this operation was called for. The
operation, however, is so useful and important a one, that
when very striking illustrations of its advantages occur they
should be published, in order that those who have found
fault with the procedure may reconsider their decision. It
•may also be mentioned as an interesting fact that those
-surgeons most prone to entertain the newest proposals in
the way of stricture treatment have been obliged publicly to
■confess that for all practical purposes internal urethrotomy
us the best mode of treating tough undilatable strictures.
The following case illustrates a condition of things in
which internal urethrotomy was of the greatest service
ipossible, and whore no other means, save an operation of
•magnitude, could have relieved the patient.
General B-, seventy years of age, had long suffered
■from urethral stricture. This had induced some vesical
debility, and he was in the habit every day of introducing
unto the bladder a small gum elastic catheter, in order to
■draw the residual urine, which on the average amounted to
three ounces. The stricture was situated three inches from
'the external meatus, and admitted, but very closely, a
No. 4 catheter. One day in Augus^ last he introduced the
■catheter as usual, but on withdrawing it found he had left
about an inch of it in the bladder. He was naturally
■alarmed, and sought advice, but was assured that if
he waited the catheter would decay, and come away
an pieces naturally. But as time went on the patient
became uncomfortable, and he experienced great irrita¬
bility of the bladder and pain on sitting down. I first
aaw him on October 30bh, when be had all the sym¬
ptoms of stone in the bladder. I sounded him with a
■small sound, and felt what was practically a stone in
the bladder. A week after he was anmsbhetiaed, and an
attempt to dilate the stricture was made, but in vain.
Nothing larger than No. G would pass. Internal urethro¬
tomy was therefore at once resorted to; the stricture was
incised by means of Civiale’s urethrotome, and immediately
a No. 14 sound (English scale) passed with ease into the
bladder. A lithotrite was now introduced, and the offend¬
ing body seized and lightly crushed; it was seized and
released again and again, care being taken every time it
was seized to nip it only lightly. By these manceuvres the
stony crust was efiectually removed from the foreign body,
and it was considered ready for evacuation. It was there¬
fore again seized and drawn into the neck of the bladder,
whore it was felt to meet with a resistance, and was evi¬
dently held crossways between the jaws of the lithotrite.
The body was therefore seized again, and this time it came
"through the neck of the bladder, without trouble, between
the jaws of the lithotrite. Upon inspection it proved to be
more than an inch of a black gum catheter, evidently once
■entirely coated with calculous matter, but now almost
entirely denuded of its phosphatic covering. By means of a
libhotriby tube and aspirator all the calculous deposit was
evacuated from the bladder. The patient made a good
recovery, and now, five months after the operation, his
-urethra easily admits a No. 14 sound, and it is important to
note that the bladder has regained its contractility, and
empties itself completely by its own efforts. This case
could nob be managed by dilatation; the prolonged and
trying treatment by electrolysis was entirwy out of the
question, and either the supra-pubic or a perineal cysto¬
tomy would have exposed the life of such a patient to very
serious risk. On the other band, treated by internal ure¬
throtomy, the patient had no pain, lost no blood, and was
out of bed and about in ten days.
Wimpole-stroot, W. _
CASE OF CHLORAL POISONING.
By John L. Welch, M.A., M.B., C.M. Edin.,
niSTHICT SURGEON, SELANGOR, STRAITS SETTLEMENTS.
The following case appears interesting on account of the
size of the dose administered, the violence of the symptoms,
and the presence at the same Jime of malarial fever.
On March 17th at 8 A.M., I was called from the pauper
hospital to my house, to see the wife of the Chinese cook,
who had been taken suddenly ill, and was now “ aa if
dead.” During the previous davit appeared the woman
had been suffering from an attack of ordinary jungle fever,
and had asked my “boy” to get her a dose of salts. Under
the impression that it contained salts, he had adminis¬
tered a dose of chloral hydrate from a bottle which he
found in my midwifery bag. As nearly as I could judge,
360 grains had been abstracted from the bottle, which before
had been nearly full. A few minutes after the drug had
been given the patient complained of giddiness. She
wandered a little In balk and then fell down insensible.
When I first saw her, about twenty minutes after the adminis¬
tration of the drug, the patient was lying deeply comatose,
face flushed, conjunctivao injected, pupils contracted and
insensible; respiration about thirty to the minute, quick
and shallow, box of larynx moving with every respiration ;
pulse 152, and very weak ; reflex absent from conjunctiva
and patellar tendon. I passed an ordinary syphon stomach-
tube, and washed out the stomach four times, The fluid at
first evacuated was strongly fragrant of the drug. On the
fourth washing the odour could not be detected. Before
the tube was removed half a glass of pure whisky was thrown
into the stomach as a cardiac stimulant pending the arrival
of other means of treatment.-—8.25: Pulse could hardly be
counted. Epiglottis began to foil back on the larynx.
This was seized in a pair of forceps and kept forward. A
hypodermic injection of five minims of liquor strychnia? was
thrown into the biceps, and mustard poultices were applied
to the chest and the calves of the legs.—8.45: Pulse could
not he counted. ReBjiiration 25, gasping, with occasional
pauses. Strong ammonia applied to nostrils without effect.—
9 : Pulse could nob be felt at wrist; breathing shallower ;
cheeks blown out on expiration. A pint of very strong
hot coffee with half an ounce of sal volatile were injected
into the rectum, and shampooing commenced over arms
and legs.—9.20: Pulse still imperceptible. Respiration
stopped twice, bub was restored by the application of hob
water to the chest. Injected live minims of liquor strychnia?
as before, and continued massage to the arms and legs.—
10.30 : Pulse could be detected at wrist. Shampooing con¬
tinued. Hot and cold water applied alternately to precordial
region.—11: Pulse counted at heart about 160. Tem¬
perature taken for the first time OS'S^F. in axilla.— 2p.m.:
Puls^ 145; much stronger; respiration fairly full, 22 per
minute. Face congested ; conjunctiva: injected, but sensible
to touch ; pupils still contracted. Gave a large cupful of
strong coffee.—6: Temperature in axilla lOO'S"; pulse
98. Patient wandering and delirious.—9 : Patient still
under the effects of the drug. Pupils contracted; tempera¬
ture 10l“. When disturbea she raves slightly. At 6 A.M.
on the following morning the patient was very weak and
S , sweating profusely, slightly wandering at times;
1 normal. I gave her eight grains of sulphate of quinine
aucl half an ounce of sulphate of magnesia. She fell asleep,
and woke in about five hours, refreshed and perfectly
sensible. Conjunctiva?, still injected. Although every other
symptom of chloral poisoning was present in a marked
degree, there was never any fall of temperature. This seems
bo nave been due to the occurrence of an attack of inber-
mitbenb fever, which was itself delayed for about two hours.
Salaiiffov, Sfcniits Sottloinoiits.
HYDATID OF UTERUS; LAPAROTOMY
ItECOVERY.
By A. A. Altobmyan, M.D.
A PEMALE, aged thirty-five, was married at the age of
fifteen. Seven years afterwards she bore a child. Five years
ago she married a second time, and soon after noticed a
Coogle
Di:
770 The Lancet,]
HOSPITAL MEDICINE AND SUEGERY.
[April 4,189-1.
swelling in the left iliac region, about the size of a small
orange. It grew slowly, but continually, without causing
pain or discomfort. Menstruation was regular, both before
and after the appearance of the swelling. She was first
examined by me in September, 1890, when I found a
tumour of round contour, the size of a head, with apparently
soft contents; it was pretty freely movable, and perfectly
dull on percussion. Digital examination per rectum and
vagina revealed nothing abnormal. Bimanual examination
did not show any intimate connexion with the uterus. I
diagnosed ovarian tumour, and advised operation. The
patient did not return till Jan. 10th, when I found the
tumour twice as large as in September ; it was painful, had
lost mobility, and taken a more central position. The
patient had lost strength, and had developed the “facies
ovarian.” She consented to operation, and laparotomy was
performed. On incision, peritoneal adhesions of the tumour
to the parietal wall were found, which were easily sepa¬
rated. The trocar was introduced, and a light straw-
coloured fluid ran out. The pedicle was found to originate
in the substance of the uterus; it was treated extra-
peritoneally, after passing an elastic ligature round it. On
examining the tumour it was found that the thick investing
capsule was driven out of the fandus of the uterus, just
above the attachment of the left Fallopian tube. Within
this uterine capsule was found a thick, laminated, homo¬
geneous elastic membrane, the “ectocyst” displaying a
eculiar tremulous motion ; within this was a thinner
elicate membrane, the “endocvst,” within which were found
about a dozen walnut- and filbert-sized cysts, with a few
granular particles. Under the microscope pieces of the cysts
showed the characteristic laminated homogeneous strata:
free hooks and new bud.s from the germinal membrane.
There was no fever, and the patient made a rapid recovery.
Aleppo, North Sytia.
% llirm
OP
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autem est alia pro certo noscendl via, nisi quamplurlmas et mor-
borum et dissectionum bistorias, turn allorum turn proprias coUectas
habere, et inter se comparare,—MonOAOKl De Sea. et Cans. Morb.,
lib, iv. nodemium. ■ ■ -
ST. MARY’S HOSPITAL.
EXCISION OF THE THYROID FOR MALIGNANT DISEASE;
RECOVERY ; REMARKS.
(Under the care of Mr, Pepper )
Tins case presents several features which render it of
unusual importance and interest. It is not often that
malignant disease of the thyroid is submitted to surgical
treatment in the early stage before local signs of malig¬
nancy are such as to render complete removal very uncertain.
There were difficulty in swallowing and recent enlargement
in size, but no marked fixity or irregularity of outline, no
enlargement of the lymphatic glands, or evidence of secon.
dary growth. The proof of the malignancy was alForded by
the microscopical examination. Removal of the whole of
the thyroid gland is an operation of considerable magni¬
tude, and baa hitherto been attended by considerable mor¬
tality in this country, the amount of which cannot be
ascertained. The performance of the operation in two
stages in this cose undoubtedly diminished the risk of
a fatal result by lessening the shock and limmorrbage. Mr.
Butlin^ gives it as bis opinion that “at present the number
of instances in which a cure of the disease (malignant of the
^yroid) can be claimed is so small that the operation is
scarcely justified.” Dr. Rotter^ gives an account of fifty
cases of operation for cancer of the thyroid. Eight of these
died withm twenty-four hours of the operation, five at the
end of the first week, and eight at the end of the second
week. Only four remained free from recurrence at the end
of six months, but one of them continued well for at least
four years after the operation. The operation in this patient
1 Operative Treatment of Malignant Disease, p. 204.
Arch, fiir OUn. Cbir., I3d. xx.\i., 18t6,
comes more under the heading of that for removal of hyper¬
trophied thyroids; for although malignant disease was
present, the removal vf the two parts of the gland presented
few of the dilficulties usually met with in the excision oS
malignant growths of this part. The operator is justifiedi
in anticipating a cure of the disease. It will be noted that
in this, as in most recorded cases of cancer of the thyroid,
the patient was the subject of long-standing enlargement of
the gland.
G. E-, a married man, aged fifty, by occu)i)atiou a
blacksmith, was admitted on March 26bh, 1890, with an
enlarged thyroid. He is a native of Buckinghamshire,
where he has lived all his life, and he has always been
strong and well. One of his daughters died at the age of
sixteen from cystic bronchocele, which had been treated hy
injection. His tumour was first noticed about ten years ago.
He was then told that it was enlarged glands, and it wan
painted with iodine. It, however, slowly continued to-
increase in size, causing little discomfort. About three
months previous to admission hehad an attack of influenza,
and since then the tumour has grown much more rapidly.
For a similar period he has been unable to swallow solid
food.
Condition on admission .—The man is strong and well
nourished. His intellect is not impaired, and ^ere is no>
myxcodema. There is a huge lobulated tumour in the front
of the neck. It is larger on the right than the left aide, and
extends upwards behind the angle of the jaw on either side,
downwards as low as the sternum and clavicles, and back¬
wards to the level of the ears. The tumour moves with the
trachea on swallowing, and the lobes on either side of th«'
neck are connected by a central enlargement passing ovoir
the front A the windpipe. All the lobes are lobolated,
simulating errlarged lymphatic glands, and somewhat
elastic; the right is rather tender. The neck measures
20;^ in. round the moat prominent portion of the tumour*
and the right lobe is 9 in. broad and 7 in. long. The voice
is impaired, and there is difficulty in swallowing anything
except liquids. When be lies on his left side there is ster¬
torous breathing, owing to pressure of the growth on the
trachea. He complains of radiating pains in the neck, giving
rise to headache. Urine: sp. gr. 1022, faintly acid, no
albumen. As the symptoms were nob urgent he was givem
arsenic. Three weeks later the tumour was apparently in¬
creasing in size, so it was decided to remove it, the rieht
lobe first.
On April 18bh, the neck having been shaved and ren¬
dered aseptic, the man was antcsthetised (chloroform)
and a_ longitudinal incision, about five inches in length,
mado in the middle line of the neck. The tissues were
divided until the gland was reached, and, as it wao
thought impossible to remove the right lobe through tho
existing wound, a further incision was made about three
inches in length, starting from the upper extremity of the
first incision and in a diref^tion parallel to the ramus of the
jaw on the right side. This flap of skin, with platysma,
fascia, &c., was dissected from the gland, and turned out-
Digitized by ^ooQle
Tks Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[April 4,1891. 77I
wards. The steroo byoid muacle was pulled over to the
left, but the sterno-thyroid and omohyoid, which were
thinned out over the tumour, were divided, and the .right
lobe fully exposed. It was then slowly dissected out in
its capsule, bleeding vessels being ligatured as they were
divided. The chief difficulty in the removal of the tumour
lay in the number and immense size of the bloodvessels
supplying the gland. Of these the superior thyroid artery
and vein—the latter being quite the size of the finger, and
the former proportionately large—the middle thyroid vein,
and the inferior thyroid vessels were the largest, and were
all ligatured in two places, and divided between the liga¬
tures. After they had been divided, and the gland freed of
all its connexions except the enlarged isthmus, this structure
was also ligatured and divided, and the right lobe then
removed. A huge cavity remained, bounded posteriorly
by the carotid sheath throughout its whole length, while
below the pleura could be seen rising with each inspiration.
The larynx and trachea were flattened out and twisted
over to the right side. The wound was washed out with
boracic acid lotion and its edges brought into accurate
apposition by sutures of silkworm gut, a drainage-tube
inserted, and a dressing of iodoform gauze and absorbent
wool applied. The operation lasted nearly three hours.
There was very little bicmorrhage considering the ma^ni-
Cude of the operation, and the amount of shock was email.
On April 19th the temperature was 100’F., and on the
noth 101°, but it was never above normal afterwards. The
wound healed by first intention, and the cavity had entirely
closed on the seventh day after the operation, when he was
allowed to get up for the first time. He went home a week
Sater, with instructions to return in three weeks’ time, it
having been thought, from the microscopy of the portion
removed, that there was evidence of malignancy.
He returned again on May 27th. He had been in capital
health since the previous operation, and had had little if
rny difficulty in swallowing, even solid food, or of breathing.
On May .31st the left half was removed in precisely the
same rnanner as the right half had already been dealt with.
On this side, however, the superior thyroid vessels were
much smaller and the inferior larger. The recurrent laryn¬
geal nerve was seen underneath the tumour and avoided.
The wound was treated in the same way as before. On
June 6th all the sutures were removed, and on the 7bh the
drainage-tube, which had been shortened half an inch daily.
The man went home on June 14th quite recovered, the cir¬
cumference of the neck being then fourteen inches and a
iialf.
Pathology .—Section of the right lobe showed it to be an
ordinary bronchocele, with colloid degeneration; there
were, however, two masses, each the size of a walnut,
which showed a different structure. They were rounded,
distinctly marked off from the neighbouring tissue, soft,
And more highly vascular. In one a small cyst was found.
Microscopically, they showed an alveolar stricture, the
fibrous tissue bounding the spaces being small in amount,
with numerous bloodvessels. The smaller alveoli were
■filled with small cubical cells, whilst the larger showed
colloid degeneration in the centre, with similar cells
around. These masses were evidently of a carcinomatous
nature. The left lobe was similar to the right in structure,
but showed no evidence of malignant change.
Remarks by Mr. TiDPrER.— This is an interesting example
•of a tumour remaining stationary or only increasing slowly
in size for many years, and then suddenry taking on a more
active growth, as the result of its undergoing malignant
change,, which is the more likely if the patient has reached
adult life. The rapid increase in size and the pressure
■effects rendered operative interference necessary. The larger
lobe of the tumour was first removed in the hope that the
symptoms would disappear, and that the enlargement would
.prove to be due to simple hypertrophy ; but microscopical
examination showing its malignant nature, it was resolved
to cornplete the extirpation. Although total excision of the
thyroid for simple hypertrophy may not be defensible (save
for relief from pressure) on account of the possible develop¬
ment of myxcodema, there can be no doubt that in cases of
malignant disease the more immediate danger from the
nature of the growth renders the operation aavisable. At
tlie present time the patient is in excellent health, and no
aigns of myxcodema have appeared. As the areas of malig¬
nant growth were circumscribed, and the lymphatic glands
.free from infection, there are grounds for hope of immunity
from recurrence. For the clinical notes of the case I am
indebted to Mr. Knox, house-surgeon, and for the patho¬
logical report and photograph from which the drawing was
made to Mr. Crowle, surgical registrar to the hospital.
LONGFORD INFIRMARY.
THREE CASES OF ABDOMINAL SECTION ? RECOVERY.
(Under the care of Dr. Maynb.)
We publish below the notes of three cases of successful
operation on the abdomen for conditions of varying
character: in one the patient suffered from tubercular peri¬
tonitis ; in another the peritonitis was secondary to an
ovarian tumour ; and in a third there were many and firm
adhesions remaining from a peritonitis, the result of tapping
a cyst some time before. Of these, the effect of the opera¬
tion in the case of the patient suffering from tubercle of the
peritoneum is the most interesting. We have already
drawn attention to the fact that this condition has often
simulated ovarian tumour, and many operations have been
undertaken for the relief of patients supposed to have
been suffering from the latter when the symptoms were
caused by tubercle. The evidence as w the value of
operative treatment in tubercle of the peritoneum is
so very conclusive of improvement (if nob of cure) in the
majority of patients submitted to it, that it is not possible
to agree with the unfavourable opinion of Spaeth.^ Kdnig
gave at the recent congress at Berlin a series of 131 cases in
which operation had been done for tubercular peritonitis;
of these, no less than 107 were left in a satisfactory condition
when they were last reported, 84 were said to be quite cured,
and 30 were well two years after the operation. We would
refer our readers to our remarks on cases of this nature, and
their treatment, as exemplified by patients under the care
of Mr. Keetley.^
Cask l. —E. H-, aged twenty, was admitted on
March 3td, 1889, suffering from an attack of tubercular
peritonitis, which commenced several weeks before. The
abdomen was greatly enlarged and distended with fluid,
very painful, and on the left side between the ribs and the
crest of the ilium, and about five inches in breadth, there
was dulness, which might have been mistaken for a tumour;
but careful examination left no doubt of its being caused
by disease of the peritoneum. Her features were pinched,
and there was a well-marked hectic flush. Severe diarrhcca
and night sweats were very troublesome and distressing to
her. Temperature 103'2°; pulse 140, very weak. She was
ordered daily eight ounces of port wine, egg-flip, beef-
tea, jelly, milk and lime-water; for medicine she had
quinine, pepsine, and bismuth, and when necessary hypo*
dermic injections of atropine and morphine in combina¬
tion ; applied over the abdomen cod-liver oil and belladonna.
This treatment was continued for some days, but without
any satisfactory result, the temperature varying from 103*
to’l04-2° during the time. The patient having been told
that an operation would afford her tneonly chance of recovery,
she replied, “ I came to hospital believing I must die and
lace myself entirely in your hands,” On the 13Cb, having
een put under the influence of chloroform, an incision about
five inches long in the usual site was made. The abdomen
having been opened, a large quantity of fluid escaped.
The intestines were bound down to the posterior wall of the
abdominal cavity, and they occupied a very small space,
several bands of lymph spearing to tie them down; these
were carefully broken. The dull space referred to was next
carefully examined, the peritoneum found greatly thickened
and studded with tubercles, several patwies having com¬
menced to suppurate. While Dr. Mayne’s hand was in the
abdominal cavity, about six gallons of water, which had been
boiled and allowed to cool to a temperature of 105° F., were
poured into it, and during the OTocess some more of the
adhesions carefully broken down. Thehand was then removed
and all the water that would was allowed to flow away, but
no attempt was made to empty the cavity. The wound was
now closed and the patient put to bed and given a hypodermic
injection of ether ; as she seemed very weak, some brandy
was also given. About two hours afterwards vomiting
occurred, and continued during the night. At ten o’clock the
temperature was 104'2°; pulse 140, weak and compressible.
1 Deutsche Med. Wooh., No. 20, 1890.
2 The Lancet, vol. ii. 1890, p. 1028.
Coogle
772 Thb Lancet,]
KOYAL MEDICAL AND CHIKURGICAL SOCIETY.
[April 4 , 1891 .
She vaa given morphme and atropine hypodermically, and
each alternate hour two tableapoonfula ot beef-tea with two
teaspoonfnls of brandy, and a ^erry glassful of champagne.
The following morning she expressed herself as better, but
extremely weak and sore where the wound was; tempera¬
ture 103°. She steadily improved, the temperature on the
morning of the 22nd being only 99°. She left the hospital
on April 2nd, and has since been ;for several months at
service as bouse and parlour-maid, and is now a strong
healthy-lookine girl.
Case 2. —K. W-, aged fifty, was admitted into hospital
on July 6bb, 1889, suffering from an attack of peritonitis.
On examination an ovarian tumour, which occupied the
right side, was found. Having been kept quiet and under
the influence of opium she speedily recovered from the
symptoms of peritonitis. On the 14th, chloroform having
been administered, Dr. Mayne operated, and removed a
large polycystic tumour of the right ovary, which was
very adherent to the peritoneum (left ovary healthy).
Having washed the cavity of the abdomen out with
water, which had been boiled and allowed to cool
to a temperature of 106° F., the wound was closed and
dressed, and the patient placed in bed. Temperature 99°.
Hypodermic injection of morphia and atropine was given.
Next morning the temperature was normal, and never rose.
The only complaint she had was that the surgeon would not
open the dressing and look at the wound, which was done on
the 21st, when it was found perfectly healed and the stitches
removed. She left the hospital on Aug. 2Dd, nineteen days
after the operation, and has since been in good health.
Case 3,—M. C , aged eighteen, of strumous appear¬
ance, was admitted on July 11th, 1889. On the 14bh,
chloroform having been administered, a tumour (which
was monocystic, and sprang from the left ovary, had a short
pedicle, and was very adherent) having been removed, and
the abdomen washed out with water, as in the previous
case, the wound was closed and dressed, and the patient put
to bed. The pulse being weak, she was given some brandy
and a hypodermic injection of morphine and atropine.
Temperature 99'3°. There was slight vomiting during the
evening. She was given another nypodermic injection of
morphine and atropine. At ten o’clock next morning the
temperature was 09°, and continued at this until she went
home on Aug. 3rd. This patient had been tapped before
coming to hospital. With the exception of having had a
slight cold she has been in good health since the operation.
Pdiital Sffmtks.
ROYAL MEDICAL & CHIKURGICAL SOCIETY.
The Treatment of Strangulated Hernia when the Intestine
is Gangrenous or Ulcerated.
An ordinary meeting of this Society was held on March
24th, tlie President, Mr. Timothy Holmes, in the chair.
Mr. C. B. Lockwood read a paper on the Treatment of
Strangulated Hernia when the Intestine is Gangrenous or
Ulcerated, of which the following is an abstract. The
communication was based on the analysis of cases of hernia
in which the intestine was gangrenous or ulcerated, collected
from the records of St. Bartholomew’s Hospital, and upon
the details of two others in the author’s own practice. The
St. Bartholomew’s Hospital cases were treateci in the manner
laid down by Sir'William Lawrence—namely, “by a free
incision of the mortified part, in order to unload the
distended intestinal canal, or, if the gut should have
already given way, to divide freely the integument and
sac, and to leave the subsequent process of cure entirely
to nature,” the stricture being also divided, if necessary,
for the proper flow of ftcces. Four of the thirty-five
St. Bartholomew’s Hospital cases recovered, three of them
completely} one had a fistula eight months after the
operation. These patients only recovered after repeated
operations, and the details of their cases were given.
Thirty-one (88'57 per cent.) of the St. Bartholomew’s Hos-
f )ital cases died and both of the author’s cases. One of tlie
atter had no proper relief from the opened bowel, although
there was a free passage, and the other fatal cases showed
that this was not at all unusual. The causation of the
absence of relief was discussed and illustrated with
cases, and the conclusion was arrived at that the usualP
operation could not be depended upon to give relief.
Next the other causes of death were examined into, and it
was shown that intra-peritoneal or subperitoneal fmcal
extravasation might occur, or that tbe gangrene or ulcera¬
tion might continue to spread to the bowel within the
abdomen, or septic peritonitis might spread from tbe sac tO'
the rest of the peritoneum. Should these dangers be
escaped, the patient incurred the risk of dying of inanition.
All of these accidents were illustrated from the list of fatal!
cases. The alternatives to performing the usual operations
were next given, and the statistics or treatment by clamp,
secondary suture, and of primary resection and suture were
mentioned. The conclusion was in favour of primary resec¬
tion and suture, and the rationale of the procedure was
briefly described.
Mr. Mayo Robson sent a communication from Leeds
bearing on the subject of the paper. He agreed that-
primary resection was the best treatment to puisue in these
cases, and be bad twice carried out this method successfully
within the last two years. The first case was that of a.
middle-aged woman, who had a small hernia which had
been strangulated for eleven days. The gut became gan¬
grenous, and be resected tbe dead portion and brought the
intestine together with Lembert’s suture. The second case,
in a woman aged sixty, was one of strangulated femoral
hernia. A large portion of gangrenous omentum was
removed, and the necrotic bowel was resected as in the
other case. The bowels were open on the third day, and
there was no abdominal trouble. He held that this treat¬
ment M'8s far more satisfactory than the old method, and)
the conditions were different from those existing in cases of
resection after fistula, for there was no difficulty in getting
tbe two tubes of gut to fit.
Mr. Bryant was surprised to find that the mortality of
this affection was so terrible; he certainly thought that
there was a larger percentage of recoveries; at least ho
could recall a good many cases which got well. In con¬
sidering the question of resection it should be remembered
that the bulk of the cases of gangrene occurred in femoral'
rather than inguinal,hernia. He nad looked up thirty-on©
cases from the records of Guy’s Hospital, and twenty-six.
were femoral, four were inguinal, and one umbilical. Ih
followed that tbe operation would have to be done on small
hernia' with narrow necks, and it would bo difliciilt t©
enlarge the incision freely. The majority of cases which
presented themselves were almost moribund before they
were operated on, and the surgeon as a rule felt himself
justified in doing only that which would preserve life, and
was not able to resort to a grave operation. It might
perhaps be done where there seemed to be a reasonable
chance of recovery, in those instances where the bowel waa
almost but not quite gangrenous. He held that in these
cases the gangrene did not extend upwards, but was a.
gangrene se following on the long blood stasis. In the
cases he bad collected there was not one instance of f.t'cal
extravasation, and in only one was there peritonitis other
than local. All the patients died collapsed from want of
power. It should be remembered that there was often firm
union between the neck of the sac and the injured intestine,
and hence, if an attempt were made to draw down the gut,
the result might be only to tear away the gangrenous por ¬
tion. In order to draw down the intestine it would be
necessary to incise very freely the neck of the sac, and this
would be difficult in femoral hernia. The incision in some
cases would have to be so free that the result would be
literally to perform a laparotomy. In young patients with
a hernia in the inguinal region of congenital character and
with acute gangrene, the plan suggested by the author would
be the best course to pursue. In conclusion, he held that
the treatment could only be applied to a very small number
of cases, and for the majority the old form of treatment
would be adhered to. Sir 'William Lawrence had recom¬
mended that as much as possible of the gut should be re¬
turned towards the neck of the sac, so as to leave as small
a spur as possible after the gut had sloughed awny. He
could recall two of Mr, Cock’s cases which were treated in
this way, and which got well. That these patients did not
die from obstruction was evident from the fact that in ordi¬
nary cases of strangulated hernia seven, fourteen, or twenty-
one days might elapse before the bowels were open, and yet
no symptoms of obstruction ensue.
Mr. Bennett said that (he treatment described was no
doubt the ideal one, but it was not always easy to adapt an
L.OO*, le
O
The Lancet,]
EPIDEMIOLOGICAL SOCIETY.
[April 4,1891. 77S
ideal treatment to ordinary practice. In many patients the
condition was such that the question of resection could not
he considered. In many cases when the bowel was laid
open no relief to the obstruction ensued, no passage of fmces
took place, owing to the paralysis of the gut; but if under
these circumstances resection were done the patient would
be no better ofF. In those cases where opening of the gut
was not followed by evacuation relief could be easily
obtained by introducing a tube, and drawing off the con¬
tents of the bowels. He had done this twice successfully,
and thus the opening in the abdominal wall might be the
means of saving the patient’s life. The method he had
advocated of returning the gut within the nock of the sac
gave the patient a chance, and no more could be said of the,
plan recommended by the author. In one of his cases the
bowel had given way after being so returned, but the
drainage-tube inserted at the time carried off the fmces.
Even it there were an aperture in the bowel he would tie it
up, and return the gut towards the abdomen, providing a
drain, and this resembled the method of Mr. Cock. In
young people in good condition the operation might perhaps
be performed, but at the best its application was limited,
and be held that it was to be especially avoided in cases of
paralysis of the gut.
Mr. Hulke felt able to endorse most of Mr. Bryant’s
remarks, but where resection was not contemplated he
would reject alike both drawing down or thrusting up the
gut. He was surprised at the heavy mortality of these
cases. He advocated clipping away the gangrenous in¬
testine and soaking thoroughly what remained with zinc
chloride solution. He thought the combination of resection
with radical cure was dangerous, for if union did not take
place there would be a mechanical bar to the outflow of
faeces, and thus a purulent peritonitis might result.
Mr. Treves said that wlien this subject was brought
before the Medical Society of London in 1885 by Mr. Banks
it was surprising what great differences of opinion existed
with regard to treatment. These cases were rare in
the individual experience of any surgeon. He pointed
out that the author was dealing with a fallacy when
comparing the statistics of the old method as illus¬
trated by the history of St. Bartholomew’s Hospital cases
with the cases of primary resection tabulated by McCosh,
for the cases in the latter table wore all selected. The
author had likewise failed to draw attention to the
mortality after the operation for ordinaiy strangulated
hernia. Taking all cases at the London Hospital as
they came, he found that the mortality was nearly 50 per .
cent. It was curious that surgical instinct had almost,
always been opposed to resection of the bowel, notwitli- !
standing that the iirst two cases recorded by Raradorh '
in 1727 and by Arnaiid in 1732 were successful. When he
was the surgeon on duty for the emergency cases at the
London Hospital he found that he had operated on seventy-
three cases of strangulated hernia, in six of which there
was gangrene of the gut; tlie latter all died. In two of
these'he left the bowel as it was, in one be cut it open and ,
stitched it to the parietes, and in three he resected the
gangrenous portion and united the cut ends. The patients
were most of them desperately ill, and were not suitable j
subjects for an elaborate plastic operation, which might j
take three or four hours to perform, and the average from
McCosh’s table was one and half to two liouvs. The opera¬
tion was usually done in an atmosphere of putrid pus. As
in acute intestinal obstruction the less that was done the
better, and as the patients died of the obstruction and not
the gangrene, the removal of the gangrenous portion was
not essential. If the bowel were cut into and nothing |
escaped from it, it might be relieved by a tube, or better by
an aperient; but if tlie gut wore resected and united, the
patient would not bo one whit the better as far as this was
concerned. No one could speak with precision upon this
matter j but it seemed to be the simplest method to open
the sac and relieve the obstruction of the bowel, associating
this with division of the stricture. The gut might either be
opened or left to open of itself, but no attempt should be
made to pull it down without first nicking the neck of the
sac. The gangrene was not a spreading gangrene, for it
only extended in the proximal portion of the gut where it
ensued from the excessive distension.
Mr. Lane was inclined to differ entirely from previous
speakers. The operation of resection could be done easily
and rapidly by Senn’s method. He himself bad operated
on two cases in this way; one got well, and the other, w Inch
was almost moribund at the time of operation, went on well
for live days, when the proximal bowl became gangrenous;
this might have been prevented if he had excised more gut
at the time of operation,
Mr. Lockwood, in reply, said that the difficulty of resec¬
tion was not what it used to be, and the newer methods
promwed a better result. His paper was only intended to
make out a case for a trial of resection on patients who
bad a reasonable prospect of recovery. He agreed that it
would be wiser to put a drainage-tube in, though he could
conceive that the tube might in some cases do harm. In
performing the operation of resection the proximal portion
of gut should always be emptied before proceeding to suture.
EPIDEMIOLOGICAL SOCIETY.
The relations of Saprophytic to Parasitio Micro-orqanisms.
A meeting of this Society was held on Feb. 18fch, Joseph
Ewart. M.D., President, in the chair.
Dr. Louis Parkes, in his paper on this subject, said:
These micro-organisms, microbes, or bacteria were low
forma of life, consisting of protoplasm enclosed in a mem¬
brane of cellulose, without chlorophyll, and multiplying^by
fission, whence they were also termed schizomycetes. The
saprophytes were those bacilli, micrococci, &c., which, sub¬
sisting on dead matter only, swarmed in the air, earth, and
water, and to which, in conjunction with yeasts and moulds,
all fermentative and putrefactive processes in organic
matter were due. The parasitic micro organisms, on the
other hand, preyed on living matter alone, or equally
with dead, splitting up the albumens into other organic
bodies or bases. This power of attacking non-living matter,
evidence of a certain degree of saprophytism, enabled us to
cultivate many pathogenic organisms in artificial media, as
peptone gelatine, milk, broth, serum, and agar-agar, and
by inoculating animals with the pure cultures to study
their action on the living body. These, which included
the microbes of tubercle, diphtheria, anthrax, erysipelas,
tetanus, and many others, were called “facultative” para¬
sites, while those which were not hitherto known to
develop out of the living body were termed “ obligate ”
parasites. To this class belonged the micro-organisms of
8mall-i)ox, vaccinia, measles, whooping-cough, &c., and of
them we necessarily knew but little. The division, moreover,
was only provisional, since improved methods of culture might
enable us to transfer some or even all of them to the facul¬
tative class. Another subdivision of the parasites had been
proposed—viz., that into (1) toxic and (2) infective micro¬
organisms. The latter, including those of the exanthema¬
tous fevers, were found to pervade the blood and every organ
of the body; the former, of which those of tetanus and
diphtheria were typical examples, acted on the organism
through the toxines or ptomaines which they produced.
Those chemical substances could be isolated, and in a state
of chemical purity, inoculated into an animal, gave rise in
the absence of the bacilli themselves to all the phenomena of
the disease. In the case of man the bacillus of diphtheria
was confined to the throat or seat of inoculation, though
the phenomena of the disease, owing to the diffusion of
the poison, were general. Closely corresponding with the
division of parasitic micro-organisms into obligate and facul¬
tative was that of the respective diseases into epidemic and
endemic on etiological considerations. By the former was
to be understood those which, as small-pox, scarlatina, and
measles, were propagated by personal intercourse only, the
eriods intervening netween the so-called epidemics being
etermined by the time required for the accumulation of a
new and susceptible population. By endemic diseases was
meant those in which personal infection played either no
part or a secondary one only, the principal factors
being local and climatic—in other words, conditions con¬
nected with the presence and propagation of the micro¬
organisms in the outside world, with the degree of
susceptibility of the individual to invasion by them. Such,
in the strictest sense, were malaria and tetanus, tubercle
for the most part, and in a wider sense cholera, enteric
fever, diphtheria, and all other diseases, which, though
propagated more or lets by human intercourse, were
amenable to sanitary improvement. Their recurrence as
so-called epidemics depended on the existence of conditions
favouring the development of the microbes in a locality,
and it was highly probable that their entrance into the
’8
774 The Lancet,]
MANCHESTEK PATHOLOGICAL SOCIETY.
[April 4,1891.
body was a mere accideot and but a small point in their
life bistoiy. Whatever the explanation of immunity con¬
ferred by one attack against subsequent infection, it was
peculiar to the epidemic class, the endemic diseases, as a
rule, conferring little or no such protection, though it
would aeem that some degree of insusceptibility was
acquired by long residence in infected localities, and that
persons recently arrived were most liable to infection. It
was an interesting question whether such pathogenic
organisms might nob be developed by a long process of
evolution from indifferent saprophytes, and that the com¬
parative insusceptibility of the native populations might
nob be attributable to the previous influence of transitional
and less virulent microbes, incapable of giving rise to the
disease, but giving an immunity like that following inocula¬
tions with attenuated culcures. Such was the opinion
of Professor Hueppe and Dr. Cartwright Wood, who found
in earth and water a bacillus morphologically indistinguish¬
able from that of anthrax, but without any pathogenic
action. White mice, however, when inoculated with it,
were in most cases rendered absolutely refractory to sub¬
sequent inoculations with the B. antbracis, though control
animals, as usual, invariably succumbed. In the few that
did take the disease it ran a chronic course, as seen after
inoculations with the attenuated virus. These researches
seemed to show that some saprophytes possessed the power
of splitting up living albumens, as otherwise they could not
have any such action on the living organism, and to offer a
scientiflc explanation of the genesis of pathogenic micro¬
organisms. The relation between septic di-^eases and the
roducts of putrefaction was a very close one. The febrile
isturbance and metastatic abscesses following the inocu¬
lation of torulm and aspergilli were interesting in this con¬
nexion. On the other band, the attenuation of pathogenic
micro-organisms by cultivation under unfavourable con¬
ditions, and the fact that these degenerated microbes grew
more luxuriantly in arbiflcial—i.e., in non-living—media
than their original forms, seemed to point to a reversion to
the saprophytic character. If such evolution were still going
on, we could well understand the striking contrast between
the uniformity of the phenomena of diseases depending on
obligate parasites, and the anomalous cases and variety of
symptoms exhibited by those caused by the facultative, as
enteric fever and diphtheria; and we might yet expect
new forms of disease to appear in the world as the result
not of a rfe novo origination, but of a long previous evolu¬
tion. Such a theory was in harmony wich the now almost
universally accepted ideas of the origin of species associated
with the name of Darwin.
Dr. WiLLOUGHBy said that he had listened with the
deepest interest to Dr. I'arkes’ paper, having been him¬
self the flrst to put forward a rational classiflcation of
specific diseases in which he had used the terms intra-
and extra-corporeal contagia in almost th« same sense
as the obligace and facultative parasites of Dr. Parkes,
and had also, in a paper read before this Society, and after¬
wards in bis work on the “Natural History of Specific
Diseases,” advanced identical theories of evolution and
degeneration, and the same explanation of immunity, as
w^l as of the greater variety of symptoms and absence
of subsequent immunity in diseases of bis extra-corporeal
class of contagia, which he held to be less differentiated or
specialised than the intra-corporeal or obligate parasites.
The staphylococcus pyogenes aureus was certainly a parasitic
saprophyte unable to attack heal thy living tissues, but he was
inclined to consider the results of inoculations with the asper-
gilluB and torula as rather akin to actinomycosis, or perhaps
simply as the effects of embolism. With regard to the toxic
or infective character of diphtheria, be would observe that
Dr. Klein had found the bacilli not only as Dr. Parkes
stated, in the organs of the cow after death, but in the
milk, even before the appearance of the eruption, as well as
in the contents of the vesicles afterwards. Dr. Parkes had
spoken of influenza as an epidemic sui not appa¬
rently propagated by human intercourse. He was, on the
contrary, convinced that the progress of the late epidemic
left no doubt as to its being spread by that means alone, its
course having been independent of, or opposed to, the pre¬
vailing winds, slow in Siberia and Kiissia, but rapid so soon
as it reached the network of railways in Central and
Western Europe, diverted by the mountain ranges of Scan¬
dinavia, invading Norway, not from Sweden, but later
from Holland and England, and deflected in like manner by
the Carpathians, reversing its couise down the valley of the
Danube, and following in direction and time the ocean
routes to America, Africa, India, and Australia; and in
India showing the same relation to railways and other
facilities for travel that it had in Europe. He referred to
Dr. Salmpn’s experiments on the absolute immunity to swine
plague imparted to pigeons by inoculations with the products
of the culture of the bacilli, contrasting with these those of
Eoux and Yersin on diphtheria, in which the products set
up all the phenomena of the disease, apparently precluding
all hope of the prophylactic inoculations against this disease
so often promised by the school of Pasteur. Dr. Willoughby
was inclined to give the fullest adhesion to Metschnikoff’s
doctrine of phagocj bosis, but was very incredulous as to
Ilueppe’s and Cartwright Wood’s alleged discoveries.
Buchner long ago believed that he had effected the trans¬
formations of the hay and anthrax bacilli into one another,
but bad since fully recanted.
Dr. CoPEMAN, as a working bacteriologist, was equally
sceptical on this point, and said that Dr Klein too had now
admitted that his assumed evolution of tbeB. antbracis was
an error of observation, the air of the laboratory having
been charged with anthrax spores. He did not doubt the
evolution of pathogenic from saprophytic micro-organisms,
but was convinced that the process had been a work
of centuries, or longer, and was not to be achieved
in the laboratory. The nature of the albumoses, ptomaines,
toxines, &o., called for minuter examination, since they
seemed to include bodies of the most diverse and even
antagonistic properties. He referred to the extremely
poisonous character of some of the transitional products of
the digestion of albumen as bearing on these problems.
Sir Joseph FAYitrsii, though asserting his disbelief in the
communicability of cholera by human agency or material
means, urged bacteriologists to pursue their investigations
in the calm, temperate, and judicial spirit shown by the
lecturer. He differed from many of their conclusions,
although unacquainted with their methods, but, provided
they did not ignore other causes of disease, their labours
could not fail to lead us nearer to the truth.
MANCHESTER PATHOLOGICAL SOCIETY.
A MEETING of this Society was held on March 11th,
Mr. G. A. Wright, President, in the chair.
Sx>ontane,om Combustion. —Dr. E. S. Reynolds read a
paper on so-called soontaneous combustion, with details
of a recent case. All the reported cases of so-called spon¬
taneous combustion might be divided into five classes:
(a) Hysterical, (6) spurious, (c) true spontaneous com¬
bustion, (rf) increased combustibility, (e) homicidal. Pro¬
bably no such thing as true spontaneous combustion ha.s
ever occurred, and almost every case is merely one of in¬
creased combustibility, the body being first set on fire and
then going on burning independently like a candle. Tim
presence of fat in the body is a great aid, although some
cases have been thin. Alcohol seems to play a more im¬
portant part, but bow it acts is unknown. In a recent case
the woman, aged forty, was thin, an old alcoholic, had
while drunk fallen near a hearth, where she was found next
morning with the flesh still burning. The femora were
carbonised, the knee joints open, but the stockings entire,
the abdominal wail burnt away, and the intestines and
stomach protruding, the latter being burnt through. The
hands, head, and hair had escaped. The surrounding
furniture was merely scorched.
Papilloma of Kidney —Mr T. JoNES showed sections of
a papilloma removed from the pelvis of the kidney. The
patient, aged fifty-five, had suffered for eighteen months
from almost constant hamiaturia without any pain. He,
however, complained of a throbbing sensation confined to
the region of the right kidney. This led to exploration of
this organ and the removal of the growth. Three days later
the lirematuria completely ceased, and the man madeagood
recovery.
Cerebral Heem-orrhage and Arterial Degenerationin Early
Life. —Dr. T. Harris showed preparations from a case of
cerebral htemorrhage which had occurred in a lady twenty
years of age. The bfemorrhage was a profuse meningeal
one, which had arisen from the rupture of an aneurysm,
the size of a small pea, of the left middle cerebral artery.
At exactly the corresponding poeitioa of the right middle
cerebral artery was another aneurysm, somewhat larger than
Di;:iiz;HbvC-(_
The Lancet,]
NORTH OF ENGLAND OBSTETRICAL SOCIETY.
[April 4, 1891. 775
the one oq the other eide, aod which had not ruptured. There
was DO sign of degeneration in the vessels at the base of
the brain evident to the naked eye, bub microscopically
they were found to present the changes of endarteritis.
The kidneys presented very few changes to the naked eye,
the most notable one being that on separating the capsules
small portions of kidney substance were torn away at
various parts, but between these torn-out portions the
kidney surface was qitite smooth and different to an
ordinary granular kidney. Microscopically there was found
to be no general interstitial nephritis, but marked changes
in connexion with the arteries. The arterioles presented
marked perivascular fibrosis and decided hyaline changes
in the intima. Some of the glomerular capsules were
slightly thickened. The aorta presented small patches of
atheroma, and the small vessels in the loose tissue round
the aorta showed both periarterial and endarterial
changes. The endarteritis in some of these vessels had
led to nearly complete obliteration of the lumen. The
left ventricle of the heart was much hypertrophied. There
was no valvular disease. Other organs healthy. There was
no trace of syphilitic history in the family, and the girl had
DO idea that there was anything seriously the matter with
her before the fatal attack came on. For the last few years
she had complained of headache, which would last only
a few hours, but during the last four months she had not
complained at all. During the recent frost she had been
taking a great deal of violent exercise, walking and skating.
In the evening of the fatal termination she was at a dance,
hut the attack commenced before any dancing had been in¬
dulged in. Dr. Harris regarded the case as probably one
which, if life had been prolonged, would have gone on to
the development of a cirrhotic kidney, and which probably
corresponded clinically to the pre-albuminuric stage of
Bright’s disease._
NORTH OF ENGLAND OBSTETRICAL AND
GYNAECOLOGICAL SOCIETY.
The annual meeting was held in Manchester on Jan.
16bh, and the office-bearers for the year 1891 were elected.
The retiiiog president, Dr. Wallace (Liverpool), made a few
remarks, coi^ratulating the Society on the work of the
past year. The President, Dr. Braithwaite (Leeds), then
took the cbair.
Uterine Cancer.—T)r. KEELING (Sheffield) showed two
specimens of Uterine Cancer, removed by vaginal hysterec¬
tomy, and read notes of the cases. The first case was one
of cancer of the cervix, which occurred in a widow aged
forty. The body of the ut-enis was freely movable and un-
alfected by the disease. The operation was performed in
the usual manner in July, 1890. Tlie patient lost blood by
the bladder for forty-eight hours after the operation, but
otherwise her convalescence was uninterrupted, and she
left the hospital bix weeks after operation. Fifteen weeks
afterwards she was again examined, and a ring-like swell¬
ing was found in the vaginal roof. There was a yellow
discharge, but the patient’s general condition was very
good, A month after this the recurrent growth was very
marked. The second case was one of malignant ulceration
of the cervix, with enlargement of the body of the uterus.
The whole uterus was removed in November, 1890, only three
ligatures being used for each broad ligament. There was
profuse b.'emorrhage during the operation. The case ended
fatally some weeks after from congestion of the lungs and
meningitis. At the necropsy there was' no evidence of
cancerous infiltration. In the discussion on these cases Dr.
Wallace, Dr. Sinclair, Dr. Donald, Dr. O’Hagan, and Dr.
Braithwaite took part.
Ectopic Gestation. —Dr. EobeutsoN (Oldham) read notes
of a Case of Ectopic Gestation, and exhibited the specimen.
The patient, who had previously borne two children, com¬
menced to have uterine hjcmorrhage nine weeks after a
menstrual period. Ten days afterwards she commenced to
have attacks of pain in the lower part of the abdomen,
accompanied by vomiting. Sbe was admitted to the
Oldham Inlirmary. At that time she was blanched and
her abdomen was distended, but no definite tumour could
be made out. The case was diagnosed as one of intva-
peritoneal bleeding, and as she became more pallid and the
abdominal distension increased, it was decided to make an
exploratory incision. On opening the peritoneum liquid
and coagulated blood escaped freely. On the left eide of
the pelv» a round tumour was felt, with a mass protruding
from it, and on traction being made a small foetus was
brought into view. As bleeding was still going on freely,
the pedicle of the tumour, which appeared to be composed
of uterine tissue, was transfixed, tied with silk, and divided.
The fluid and coagulated blood were then washed out of the
abdomen by a stream of hot water, a drainage-tube was
inserted, and the wound stitched up. The patient was dis¬
charged cured about a month after the operation. Some
remarlcs were made on this case by Dr. Sinclair and Dr.
Braithwaite.
Sickness of Pregnancy. —Dr. LAUDER (Manobester) read •
notes of a case of Incoercible Sickness of Pregnancy re¬
sulting from a Hydatidiform Mole. The patient, a multi-
para, aged twenty-eight, was admitted into the Maternity
Hospital on Nov. 4tb, 1890, She had missed three menstrual
periods, and was sufl'ering from obstinate vomiting. After
trying small quantities of milk by the mouth for some days
nutritive enemata and suppositories were administered.
Some days after this nourishment by the mouth was again
tried, a teaspoonful of peptonised milk being given every
hour, but the sickness returned in a few days, and rectal
alimentation was resumed. On Nov. 10th uterine hrnmor-
rbage occurred, and it was decided to induce abortion. It
was found, however, that the uterine cavity was occupied
by a hydatidiform mole. On this being scraped out, tbe
patient rapidly improved, and soon after was discharged
cured. Tbe case was discussed by Dr. Donald, Dr. Edge,
and Dr. Braithwaite.
At a meeting held at Sheffield on Feb. 20th, Dr. James
Braithwaite, President, in the chair, specimens were shown
by Drs. Sinclair and Keeling, and Mr. Laver (Sheffield).
Pelvic Abscess and Abdominal Section. —Dr. Hellier
(Leeds) read a paper on three cases of Pelvic Abscess, and
treated by abdominal section, in the Hospital for Women
and Children at Leeds. One case originated In a pyo-
salpinx, and formed a large abscess on the left side of the
uterus, surrounded by matted tissues on all sides, into
which the abscess extended. A second case was an abscess
of the broad ligament of uncertain origin. The third was
apparently a pelvic cellulitis. In each case tbe condition of
the patient made prompt treatment urgent, but the abscess
was not pointing in the pelvic or abdominal wall. In each
case abdominal section was performed with a small median
incision ; the exact position of the pus was determined with
the aspiiator,tbe abscess was opened ami thoroughly drained,
and finally the cyst wall was stitched to the edge of the
paiiebal peritoneum. The patients bad all done well; the
most recent case, which was on the 27th ult. operated on,
is still under treatment. Dr. Hellier said that this treat¬
ment seemed to be applicable to those cases where suppura¬
tion is present in the pelvis, and yet there is no pointing
obvious in rectum, vegina, or groin. He did not think that)
abdominal section would supersede pelvic incision and
drainage, but be said that it provided a means of dealing
with cases not amenable to treatment from below. In
one of the cases cited vaginal incision and drainage
had been thoroughly tried, and in spite of this the abscess
had nob only not healed, but bad opened into tbe bladder,
while after the abdominal incision tbe whole was quickly
cured. In such cases it is often ioipossible to say before
operating exactly where the pus is, and he had hesi¬
tated before opening the abdomen lest be should not
be able bo approximate the cyst wall to the edge of the
parietal peritoneum. This, indeed, proved a difficult thing
to do with an abscess lying deep and having friable wails.
He was now inclined to the opinion tliat often all this is not
so vital a point as it seems at first, provided only that good
drainage be secured and that the fear of being unable to
secure the cyst wall in this way should not deter an
operator from opening the abdomen if there were strong
reasons for doing so on other grounds. These cases need
much care in nursing, and the rule that cases of abdo¬
minal section should be kept on very short commons for a day
or two after operation must not be enforced in the case of
patients worn down by previous hectic fever. In conclusion.
Dr. Hellier said that as in general surgery abscesses did not
always heal when incised and drained, so probably a resi¬
duum of these cases would fail to recover; yet, having bad an
opportunity of watching such cases treated on the ^d lines
in other hospitals in years gone by, he felt convinced that
abdominal section for pelvic abscess is a gain to gynnsco-
logical surgery, and that certainly these three lives had been
saved by this mode of treatment.
Electrical Treatment of Uterine Tumoxirs. —Dr, Burton
Coogle
Di:
776 Thb Lancet,]
ROYAL ACADEMY OF MEDICINE IN IRELAND.
[Apkil 4,1891.
(Liverpool) opened a discussion on this subject. He
said his experience had not been ve^ lar^, but such as it
was he would lay it before the meeting. He had treated a
total of nineteen cases of uterine fibromata by the electrical
method introduced by Dr. Apostoli. He was able to divide
them into six classes: (1) Where temporary improvement
had been efiected—two cases; (2) where he believed
permanent improvement had resulted—seven cases; (3)
where no improvement had been obtained—three cases ; (4)
where the treatment had not been sufficiently tried—three
cases ; (5) cases unfit for treatment—two cases ; (6) where
the result was doubtful—two cases. Details of the cases
were then given. In Case 1 in the second group the tumour,
which was of moderate size and accompanied by bmmor-
ihage, was much reduced in size after nine applications.
After this the patient became pregnant for the first time in
her life, but miscarried about the third month. When last
seen, eighteen months after the cessation of treatment, the
patient was in good health. In the second case the tumour
was so much reduced in size by six applications that the
patient’s clothes showed that her girth was less by
one inch and a half. In July, 1890, eighteen months
after treatment, the tumour gave her no trouble.
About the diminution in size there conld be no doubt,
lu the third case the tumour was of moderate size, but
the chief feature was the btemorrhage. The patient had
eight applications between Feb. IsC and April 30th, 1888;
although not by any means well she was very much
improved by the treatment. Case 4 was a small myoma
in the anterior uterine wall with hcemorrhage. After
eight applications the tumour was scarcely perceptible.
Two years later there was no return of the symptoms.
Case 5 was a tumour reaching to the umbilicus ; after
twenty-eight applications the tumour was much smaller
(by at least one-balf), and the patient felt well; eighteen
months after the last application she continued so.
Case 6 was a small tumour in the anterior wall of the
uterus with pains and hasmorrhage. Applications were
made at varying intervals for about three months, when
treatment was discontinued, as there appeared no further
need of it. Case 7 was a large fibro-cystic tumour reaching to
the ribs, and was of many years’ standing; at the patient’s
wish applications were made and were given about three
times a week for four weeks. Diminution in size was con¬
siderable and relief to symptoms marked. She considered
herself sufficiently well to do without further treatment,
bub expressed herself as perfectly satisfied with the progress
that had been made Further details were given, and the
speaker then summed up his conclusions as follows : 1. In
small fibroids almost entire, if not complete, disappearance
of tumour may be effected. 2. In large ones, considerable
diminution in size with relief of symptoms may be expected
in a fair proportion of oases. 3. When relief has been
obtained there may be a return of the symptoms sooner or
later, which may again call for treatment. 4. In a propor¬
tion of cases (probably from one-third to one-half)
little or no effect will be produced without puncture. r>. The
speaker knew of no case where the tumour had become
larger under treatment than it was before it was
commenced ; so that be claimed that the growth is at least
checked in all cases, 6. In the words of Dr. Brose of Berlin
at the International Congress, “ Electricity will not take
the place of or exclude niyomobomy, bub it will save many
eases from it.” He claimed, therefore, that it ought to have a
patient trial in every case, before recourse is had to dan¬
gerous methods of treatmeut. 7. If ten or twelve applica¬
tions made in the course of three or four weeks do not give
any result, nothing need be expected from a continuance of
the treatment unless punctures be made.
510YAL ACADEMY OF MEDICINE IN IRELAND.
A MEETING of the I’athological Section was held on
Feb. 20th.
Specimeyc o_f Cystic Kidney. —Mr. Kendal Franks
showed a sfiecimen of a large kidney, weighing over two
pounds, which was in a condition of advanced cystic de-
eneration. The kidney was removed by operation on
an. 13th, through a median abdominal incision, from the
left side of a married woman aged twenty-five ; and it was
specially remarkable in this : Uiat the right kidney, which
was examined through the abdominal wound at the time of
operation, was apparently healthy. This is a rare condi¬
tion, The diagnosis of renal tumour was made previous to
operation, bub its exact nature was not determined. The
patient made an uninterrupted recovery. Mr. Franks dis¬
cussed at some length the differences between isolated,
though sometimes multiple, cysts of the kidney and the
congfomerate cysts of cystic degeneration.—Dr. M'Kee
thought, there was no essential difference between
what Mr. Franks had called “ isolated ” cysts of
the kidney and the “ conglomerate " cysts of the specimen
shown that evening. Both were equally congenital, and
the latter was formed by the conlluence of single cysts.
The cysts resulting from chronic nephritis were mostly
microscopic in size, and never larger than a pea.—Dr.
Alfred Smith reminded Mr Kendal Franks that two
cases of cystic degeneration of the kidneys were reported in
this section during the past three years as having occurred
in the fcctus at the Rotunda Hospital, and were fully re¬
ported in the Transactions. One was a large cystic variety
due to a congenital stricture of the urethra; the other,
shown by Dr. Bagot, was of the fine cystoid variety.—Mr.
Patteson wished to ask Mr. Franks if any microscopical
examination had been made of the case before the section.
Judging from the microscopical appearances, the tumour
clearly belonged to the congenital cystic variety. The
condition of the urinary tract was nob stated, and
those cases which Virchow more especially described
were conditions of dilatation of the uriniferous tubules
due to congenital absence of the pelvis of the kidney
or other analogous causes. The importance of careful
microscopical examination was shown by a consideration of
the views recently put forward by Mr. Shabtock and con¬
firmed by Mr. Bland Sutton.—Mr. Kendal Franks, in
reply, said that it was generally admitted that in cases of
cystic degeneration of the kidney the urinary passages are
patent, and the condition could in no way be attributed to
an obstructive cause. Virchow’s view was that the con¬
dition originated in utero as an interstitial nephritis. The
first case alluded to by Dr. Smith was evidently not an
example of conglomerate cystic disease, but was a hydro-
nephritic kidney, the result of congenital atresia of the
urethra. He could not agree with Dr. M'Kee that isolated
cystic disease and the conglomerate cysts were not dis¬
tinct conditions. The isolated cysts were not congenital,
but frequently may be traced to an injury, and one
kidney is alone affected. Other differences might also be
mentioned.
Exhibition of Cerebral Tumour. —Dr. E. H. Bennktt
exhibited a cerebral tumour occupying a large part of the
motor area of the right cerebral^ hemisphere, including
almost the entire arm centre, which had proved fatal by
intracranial pressure, but without at any time paralysis of
the left arm. The sections showed the size of the tumour
to be about that of half a Tangerine orange, the base of
the hemisphere being directed against the dura mater. The
tumour lay enveloped in the cortical convoluted surface
directly over the fissure of Sylvius. The microscopic exa¬
mination was reserved until the more important facts
relating to the site of the tumour liad been demonstrated.—
Mr. Story had examined the eyes of the patient when in
hospital and found neither optic neuritis nor hemianopsia.
Proptosis (or rather retraction of lids) was present on both
sides, winking was infrequent, and the upper lids did nob
follow the downward movement of the globes. There was
partial ana-.sthpsia of cornem and conjunctivic, and loss of
conjunctival reflex. It was an interesting fact to observe these
well-known signs of that remarkable disease, exophthalmic
goitre, in an undoubtedly cerebral case, and it strengthened
the modern view that this disease is of central origin. — Dr.
M'Wbeney gave the result of his experience of cerebral
tumours examined post mortem during his tenure of office
as pathologist to the Mater Misericordim Hospital, —
Dr. M. A. Boyd said a case of cerebral tumour under
his care was, like the president’s case, areniarkablo example
of a considerable motor area of the brain being involved in
a tumour without any motor symptoms whatever being
present.—Dr. R. G. Patteson was not quite certain
whether Dr. Bennett had spoken of aphasia in the case he
brought forward. Undoubtedly, in certain cases trans¬
position of the speech centre occurred, and in such cases
observation had established the presence of an exaggerated
development of the more complex muscular movements
on the left side. As regards the non-occurrence of motor
phenomena in connexion with the presence of a tumour in-
: r L.30(^le
The Lancet,]
REVIEWS AND NOTICES OP BOOKS.
[April 4, 1891. 777
volving most of the motor area, it was possible to conceive,
in the case at least of slowly developing tumours, that a
certain amount of accommodation could take place, either
through already establlsbed or newly formed channels, in
the opposite side; and it was not, he thought, an exaggerated
view to attribute to centres of the higher level a power of
associated action which was daily exempliiied in the
subsidiary centres of the spinal cord after separation from
those of a higher order. In the case of more rapidly
developing tumours the explanation was of course more
difficult.
Hydatid Cyst of the Phwra. —Dr. Duffby made a com¬
munication on this subject, and exhibited a large cyst
(ttenia echinococcus), with numerous daughter cysts, re¬
moved from the right pleural cavity of a man aged thirty-
one, together with the lungs, portion of the diaphragm, and
the cyst wall; as well as numerous microscopic sections
made by Dr. W. R. Graves, pathologist to the City of
Dublin Hospital. The subject or the case had been a soldier,
and had seen five years’ service in India. He had been
under Dr. Duffey’s care for four months in June, 1890,
six weeks previous to his last admission, for attacks of
hremoptysis, and was then found to have tubercular deposit
in the left apex. His cough persisted after leaving hospital.
About Christmas he became much worse, but continued at
his work as a wine porter until compelled, by pain in the
right side of the chest, violent hard dry cough, dyspncea,
and weakness, to seek admission on Jan. 21st, 1891. On
examination he presented all the usual physical signs of a
large pleural effusion on the right side. The liver was
pushed down and the heart displaced to the left side.
There was also clear evidence of the existence of vomica in
the left apex and of softening in the right- There were
great respiratory distress, constant hard dry cough, quick
pulse, cyanotic appearance of face, but no fever. Forty-
seven ounces of a clear straw-coloured serous fluid were
removed by paracentesis. Alarming dyspnoea, and intense
cyanosis of head, face, and neck, with burning heat of
the hands, set in while the fluid was being removed.
He rallied slightly, but subsequently the dyspnoea re¬
curred, the pulse and temperature rose, and be died thirteen
hours after the operation. On post-mor'em exami¬
nation it was found there was no pleural effusion. The
pleura on the right side was most intimately adherent. In
trying to detach it the band ruptured a large tumour,
which forcibly ejected a quantity of clear fluid, immediately
followed by the extrusion of a large hydatid mother cyst,
with a number of small daughter cysts. This cyst was
situate between the diaphragmatic and pulmonary pleura.
It lay within a dense fibrous capsule, intimately adherent
by its external surface to the lung, pericardium, and dia¬
phragm. The left lung was pushed upwards, forwards, and
to the left by the tumour, and its lower and middle lobe
greatly compressed. Its upper lobe contained numerous
miliary and caseating tubercles, and in the apex one
large and three small vomicai. A similar condition,
but more advanced, existed in the upper lobe of the
left lung, and its lower lobe was much congested.
The cyst was sterile, but the laminar construction of
its delicate wall was sufficiently distinctive. Dr. Duffey
referred to the remarkably few cases of hydatids that had
been reported in Ireland, and to the extreme rarity, in any
part of the world, of the primary development of the
echinococcus cyst in the pleura. Some of the cases reported
as hydatids of the pleura might have had their origin in the
lung, or have forced their way into the pleura from the
abdomen, especially from the liver. The author of the
communication, in an extended search through the literatpre
of the subject, could only find eight cases in which evidence
existed of the primitive development of the hydatid in the
cavity of the pleura. One of these was given by Davaine,
two by Heller, two by Vigla, two by Cobbold, being speci¬
mens in the miisenin of Guy’s Hospital, and one in the Army
Medical Museum atNetloy.
Gift of a Nkw Convalescent Home. — On
Monday the foundation stone was laid at Perranporth of
the Convalescent Home which Mr. Passmore Edwards is
presenting to hia native county, Cornwall The ceremony
was performed, in the presence of a large assembly, by tlio
donor’s son, Mr. 11. Passmore Edwards. The Home will
be a memorial to Mr. Eclwarda’ niother. The estimated
cost is between £2000 an<l ,£.3000, and towards an endow¬
ment fund Mr. Edwards has contributed £2000.
rail Itfltms rf ^Dflks.
Hypnotism. By Dr. Albert Moll (Berlin). Contemporary
Science Series. London : Walter Scott. 1890.
Hypnotism, or Ps^fcho-TherapeuUcs. By R. W. Belkin,
M.D., F.R.SE. Edinburgh and London: Young J.
Pentland. 1890.
Should Hypnotism have a Recogndsed Place in Ordinao'y
Therapeutics? By Norman Kerr, M.D., F.L.S.
H. K. Lewis. 1890.
[Second Notice.]
Many theories have been put forward to explain the
phenomena of hypnotism. One of the most influential of
these is the doctrine of Heidenhain and Mendel, that the
phenomena are due to inhibition of the cerebral cortex.
Hughes Bennett supposed that the explanation was to be
found in a functional disturbance of the nerve fibres con¬
necting the ganglion cells of the cerebrum; Braid thought
that the essential condition was some alteration in the
circulation in the brain and spinal cord; Carpenter sup¬
posed cerebral an®mia; while Rumpf and Hack Tuke have
conjectured a partial spasm of the vessels. An adequate
discussion of these and other theories upon the subject would
lead us far beyond our present limits, so we must con¬
tent ourselves with a mere enumeration of the various views.
We must pass over many other aspects of hypnotism to
consider its hearings upon medical practice and therapeutics.
This part of the subject is handled calmly and dispassion¬
ately by Dr. Moll, and no attempt is made to paint in
roseate colours the advantages likely to accrue to our
art from hypnotism. He believes those advantages to
be considerable, but he is careful to observe the attitude of
a scientific inquirer rather than of a prejudiced partisan.
Dr. Moll is convinced that from the therapeutic point of
view “suggestion” is the really important factor in
hypnotism—i.e., there is generated in the patient’s mind a
high degree of preparedness or expectancy, the potent in¬
fluence of psychical upon physical conditions follows, and
thus the desired result is often obtained. “ The idea of a
cure should be instilled into the patient during hypnosis.
If it is allowed that the idea of a cure effects a cure in many
cases, there can be no doubt that suggestion is an integral
part of therapeutics.” This remark touches the core of the
question. There are some, especially in this country, who
will regard such measures as pure charlatanism, while others
will retort that if the required benefit to the patient follows
: it matters not whether we attain that end by the administra¬
tion of a drug or by “suggestion.” As regards the conditions
I amenable to “suggestion,” the following are enumerated :
I “ All kinds of pains which have no anatomical cause (head¬
aches, stomacli-aches, ovarian pain, rheumatic and neuralgic
pains, &c.)—sleeplessness, hysterical disturbances (particu¬
larly paralyses of the extremities and aphonia), disturbances
of menstruation, spontaneous somnambulism, uneasydreams,
loss of appetite, alcoholism and morphinism, neurasthenic
ailments, stammering, nocturnal incontinence of urine,
pruritus, writer’s cramp.” Dr. Moll demurs to Charcot’s
view that only hysteria can be treated by hypnosis, and
apparently regards pronounced hysteria as comparatively
rebellious to suggestion. He quotes with approval Forel’s
remark that “ a sound brain is above all things necessary
for hypnosis,” and adds that “ in hysterical patients the
Lrain is of ten by no means sound. ” It is well known that
Ziemssen, Mendel, Ewald, and others regard the treatment
of hysteria by hypnosis as only likely to result in mischief,
and altogether deprecate the practice. Insanity, according
to Dr. Moll, is difficult to treat by hypnosis. He affirms
that benefit has been obtained in the lighter forms of
mental disease (some varieties of melancholia and mania),
o 3
; ; Google
Dir--:
778 ThbLancbt,]
REVIEWS AND NOTICES OF BOOKS.
[April 4,1891.
but that “ generally the effect la leas than in the neuroses,”
the reason being that insane persons are not good subjects
for hypnosis. Improvement is alleged to attend the use
of hypnotism even in organic affections, and cases are
given by Bernheim, Tuckey, and the writer where benefit
has been obtained in tabes dorsalis, hemiplegia, and
articular rheumatism. The benefit obtained in cases of
hemiplegia is explained by the view that while hypnosis
cannot restore the function of the necrosed portion of brain,
it does restore the functions of neighbouring parts, which
functions are sometimes inhibited by the existing lesion.
Dr. Moll discusses with considerable candour the objec¬
tions usually urged against hypnotism. He first notices
Ewald’s protest that “ suggestion ” is not, properly speaking,
medical treatment at all, since it requires for its practice
neither medical art nor medical knowledge, but only self-
confidence. To this Dr. Moll replies that “ medical science
and psychological knowledge, the ability to diagnose and
practise, are all necessary for using hypnotism.” He protests
that if hypnotism has been practised hy quacks and charlatans
there is the more need for it being taken out of their hands
and properly regulated by men trained in scientific methods.
The second objection to hypnotism is the danger that
may attend its practice, and this Dr. Moll recognises as
a point of real gravity. He retorts, however, that the
recognised dangers of such agents as chloroform, strychnine,
and antipyrin are not valid grounds against the cautious
and legitimate use of such remedies. In reply to the charge
that hypnotism induces nervousness, he says: “I agree
that fixed attention too long continued may have un¬
pleasant effects. It may he followed hy nervous debility
or nervous excitement. But I have never seen anyone
become nervous whom I hypnotised verbally, and to whom
I made no exciting suggestions.” He gives the following
rules for obviating any unpleasant after-effects from hyp¬
nosis ;— 1. To avoid continuous stimulation of the senses
as much as possible. 2. To avoid all mentally exciting
suggestions as much as possible. 3. To do away with
the suggestion carefully before the awakening. The real
dangers of hypnotism, according to Dr. Moll, are not those
usually imagined, but the following—viz., the increased
tendency to hypnosis and heightened susceptibility to sug¬
gestion in the waking state—i. e., the possibility of a new
hypnosis against the subject’s will, perhaps without his
suspecting it, and the danger of his accepting external sug¬
gestions even without hypnosis. We have contented our¬
selves mainly with an exposition of Dr. Moll’s views, as a
fall discussion of them would lead us beyond our present
limits.
Dr. Felkin’s short work goes over in briefer compass
much the same ground as Dr. Moll’s volume, and does not .
call for detailed notice from us. It is in the main a plea
for further inquiry, advanced by one who has given the
question considerable attention, and who doubts if the
attitude of reserve hitherto maintained towards hypnotism
by the profession in this country can be any longer safely
or justly preserved.
Dr. Norman Kerr’s pamphlet is a thoroughgoing con¬
demnation of hypnotism root and branch. He passes in
brief review the objections to hypnotism, and gives his
opinion that, “in view of all these possible abuses and
dangers, it passes my comprehension how it could ever have
been contended that family medical practitioners should
practise hypnotism on patients of both sexes and all ages as
part of their regular daily work. Surely the perverted
actions of hysteric patients and the existing cliances of
groundless and serious charges to which we are already
exposed are more than enough, without the addition of
hysteria-cum-hypnosis complications.” We are heartily in
accord with what follows, when Dr. Kerr says: “I cannot
find language strong enough to express my abhorrence of
the disgusting and degrading exhibitions to be seen in
many public places of amusement, as well as in the select
circles of fashion—sometimes for mere amusement, some¬
times in philanthropic guise, sometimes for pure gain
honestly enough professed—at which men, women, and
young people are made to perform ridiculous antics, and
to unconsciously play the fool, to the detriment of their
mental health and to the depraving of the public taste.”
We have also received “ Der Hypnotismus,” by Dr. Otto
Wetterstrand of Stockholm, and a small work on Hypnotism
(lienshaw) by Dr. Augustus Niooll, but our space is ex¬
hausted, and we cannot review them at length. Wetter-
strand’s work is an able and exhaustive treatise on hypnotism
from the point of view of a leading authority and ardent
supporter of the system. Dr. Nicoll also writes on the same
side, and is of opinion that “not only disease, hut some of
our most crying sobiol evils, may be alleviated by a careful
and expert application of hypnotism.” He is an adherent
of the Nancy school, and believes that sooner or later
“ benefits will most surely accrue to all humanity from that
great boon which is waiting, nay, crying aloud for reco¬
gnition—modern hypnotism.” To this and all similar
confident prophecies we must content ourselves for the
present with saying, Qui vivra verra.
Errata. —In the former portion of the above review,
published last week, two corrections require to he made.
Onp. 721, second column, line 28, for “lleuterghem” read
Benterghen; on the following page, line 12, for “eebolatic”
read icJiolalie.
OUR LIBRARY TABLE.
CEuvres Computes de J. M. Charcot. Tome IX. Paris:
Aux Bureaux du Progris Medical. Lecrosnier et Babd.
1890.—This, the ninth volume of Professor Charcot’s
writings, which are being so faithfully collected under the
careful editorship of his former pupil, M. Bourneville, con¬
tains some of his earliest as well as his most recent
contributions to neurology. For side hy side with the
memoir upon cerebral hceraorrhage, written in conjunction
with M. Ch. Bouchard, in which the invariable presence
and the etiological importance of miliary aneurysm in such
cases were first pointed out, we find papers upon hypnotism
and hysteria, to which Professor Charcot has devoted so
much thought and attention of late years. The volume,
too, contains a reproduction of his observations upon
metalloscopy and metallotherapy made in 1877. We arc
not quite so much inclined as is the able editor to
regard these curious records as of the first importance,
and it is certainly remarkable how transient was the
interest—keen enough at the time—taken in the subject.
However, as a matter of history, and as exemplify¬
ing the manner in which Professor Charcot investigated
this by-path of neurology, the republication of these papers
is welcome. Hypnotism is treated at considerable length,
and we are glad to find in an appendix the excellent paper
of Babinski, which sets forth clearly the views of the Paris
school on this subject, as opposed to that of Nancy. The
reader should peruse M. Babineki’s essay first, before com¬
mitting himself to the study of the experiments detailed in
M. Charcot’s memoir. The place of static electricity in
therapeutics, and its application especially to the treatment
of hysteria, form the final part of the volume.
Preventable Deaths in Childhood. By W. WvNN West-
COTT, M.B., Deputy Coroner for Central Middlesex. The
Hansard Publishing Union, Limited, London and Redhill.—
From time to time the teaching.? of caution deduced hy
coroners and jurymen from the cases which come under
their observation find expression in the daily press. We are
apt to think that here the matter ends. The verdict has
been given, a rider perhaps appended by way of reproof or
warning, and the subject will soon be forgotten, Such i^
Dic::'zed h Coogle
The LanoetJ
OUR LIBRARY TABLE.
CApril 4, 1891. 77$
doubtless the natural tendency in the great majority of
inquest cases, and it is to be feared that the othcial camat
so timely issued must often exercise but a passing and very
limited influence. We therefore welcome as the herald of
better things a little pamphlet just published by Ur.
Wynn Westcott, Deputy Coroner for Central Middlesex,
which treats, in a brief but effective, statement, of the
causes of preventable deaths among children, and the re¬
sponsibility of those entrusted with their care. The circum¬
stances commonly attending accidental deaths from over¬
laying and from physical injury or poison, the danger of
domestic {medical treatment, and the duty of obtaining
skilled professional attendance in illness are discussed in
considerable detail. A chapter devoted to the subject of
death certification, and the conditions under which this
primary duty should not be exercised by the practitioner,
deserves attentive scrutiny. The paper closes with an in¬
structive examination of the uses and abuses of child life
insurance, of the practice of baby farming, and of their
connexion with what may appear to be ignorant mismanage¬
ment. The paper is not a long one. In its present shape it
should admirably serve the purpose for which it has been
published—namely, the instruction of parents and others as
to the risks of childhood, and the means of their avoid¬
ance. If somewhat amplified it would constitute a most
useful little handbook for the practical guidance of prac¬
titioners.
Th& Asclepiad. First Quarter, 1891. No. 29, Vol. VIII.
By Benjamin Ward Richardson, M.D., F.R.S. London:
Longmans, Green, & Co.—The opening article in this
issue of Dr. Richardson’s quarterly deals with the physical
properties and physiological application of peroxide of
hydrogen in continuation of a “ research commenced in the
year 1856.” The readiness with which oxygen is liberated
from this substance suggested many interesting experiments
to the author’s fertile mind, and one of the most important
of his discoveries was that it acted in decomposing pus.
This article is followed by one on “ Cold and Mortality,” a
scientific exposition of the effects of lowered temperature
upon the vital forces, leading to useful practical conclusions
as to the means whereby the influence of cold may be best
warded off. Amongst the “Opnscula Practica” are several
dealing with the question of hcemorrhage and its arrest.
The memoir of the quarter is that of John Hunter, a plea¬
sant sketch of the personality, character, and work of the
great anatomist, written with much discrimination and in
the felicitous style of narrative which stamps all these
memoirs. The autotype of Sir Joshua Reynolds’ famous
portrait of Hunter does not, however, appear to be quite so
successful a reproduction of this work as the engraving
which is so familiar to us. Dr. Koch’s remedy for tuber¬
culosis is dealt with by Dr. Richardson in a very outspoken
manner, and his strictures on the furore excited in the
medical world by the announcement of this new treatment
are not altogether unmerited.
The Doctor's Holiday, or a Mediterranean Trip in
Search of Health. Liverpool: Turner and Dunnett.—This
is a brief account, in a sort of diary form, of one of
those coasting trips in the Mediterranean which have
now become so popular. The writer visited Gibraltar,
Genoa, Naples, went thence to Rome, then by land
to Ancona, where he rejoined his steamer, thence to
Venice, Trieste, Bari, Zante, Patras, Valencia, and
home. The author, who writes in a somev/hat blunt
style, and carefully eschews all heroics, evidently en¬
joyed his trip, but was nob overwhelmed with admira¬
tion for anything ho saw. He found even Rome dis¬
appointing. “The Tiber looks like a big gutter, its
water being the colour and consistence of pea-soup. The
Coliseum is a fraud, the Forum a diiapulatioii.” The
cherubs by Michael Angelo in St. Peter’s “ look like
inflated babies.” As for the Laocoon and the Apollo
Belvedere, “the former is just what one expected to see,
and the latter is nob imposing.” He is roused into a little
enthusiasm by Venice, where he found it “ quite refreshing
that the images conjured up in the past by both poetry and
prose still existed, and that every thing—cathedral, churches,
canals, bridges, prisons, and gondolas—all came up to
expectations.” He did not warm, however, to the picture
galleries, and the neighbourhood of the Bridge of Sighs
suggests to him chiefly “ what a lot of sooundrels the Doges
must have been to consign any fellow-creatures to such
dungeons.” At Patras he saw “the pure, unadul¬
terated Greeks, and scarcely found them so romantic in
appearance as Byronic lays had led one to antici¬
pate.” Evidently the writer has nob steeped him¬
self very deeply in classical lore, and hence the
memories of Italy and Greece appeal only feebly bo him.
As regards the advantages of the sea voyage, he believes
that its peculiarities—viz., perfect rest, pure air, out-door
life, and absolute change—are, conjoined, a very potent
force, whilst the astringent quality of sea breezM is in
addition a strong tonic, the best remedy for some well-
defined diseases, and the most agreeable for that deviation
from health commonly called “seediness.”
The Midwives' Begistration Bill, or the Proposed Repeal
of the Medical Act. By ROBERT Reid Rentoul, M.D.,
L.R.C.P., M.R.C.S,, Fellow of the Obstetrical Society.
Liverpool: F. & E. Gibbons, Ranelagh-streef.—Those who
wish to have in a compact form all that Dr. Rentoul has to
say against the Mid wives’ Bill now before Parliament, and
against those who differ from him, will find it in the above
pamphlet. His objections are—(1) that the Bill will repeal
the Act of 1886 by registering a class of practitioners nob
educated either in medicine or surgery ; (2) that there are
nob cases enough by which bo train and teach both medical
students and pupil midwives ; (3) that in certain even¬
tualities, and if the Bill becomes law, medical students will
have to study under midwives; (4) that it will lead to a
great increase in criminal practices, especially in the way of
stillbirth; (6) thabthe Medical Council will have nothing to do
with the administration of such a Bill; and {6) that the poor
are already fully provided for. Without sharing Dr. Rentoul’s
fear of all the dire consequences which he considers involved
in this Bill, we should like to see any measure that is to
pass so drawn as to obviate all reasonable objections.
In an appendix to the pamphlet Dr. Rentoul gives an
abstract of the views of various bodies on this question.
The abstract shows that there is much variety of opinion.
The Nottingham Medieo-Chirurgical Society is explicit in
saying “ that it is not expedient to give any legal recogni¬
tion to persons practising midwifery unless they are duly
qualified practitioners.” The Committee of the Birmingham
Branch of the British Medical Association, on the other
band, “cordially approves the principle of the Bill—viz.,
the compulsory registration of mid wives after due examina¬
tion,” but suggests various useful amendments. Other
branches support the Parliamentary Bills Committee. Dr.
Rentoul quotes a resolution of the Medical Council in such
a way as to make it appear that this body is opposed to
such legislation. This is a mistake. The Council has on
all occasions recommended legislation. In the resolution
referred bo it only expressed its inability to undertake
the necessary duties under a Registration of Midwives'
Bill. We feel sure that Dr. Rentoul will see that, no
doubt unintentionally, he misrepresents the position of
the Council in this matter. Judging from another com¬
munication he sends us, he seems to think that the present
Bill is still not dead. Bub it is certainly moribund, and
he will have plenty of time to devise a better one. Mean¬
time he advises all opponents to continue to petition
against it.
Di< Google
Y 80 TssLancxt,]
OUR LIBRARY TABLE.—ANALYTICAL RECORDS.
[April 4,1891.
Supplement to the Companion to the Latest Edition of the
British Phei/rmacopceia, including the Additions of 1890, By
T. W. Squire, F.L.S., F.C.S , and A. H. Squire. Pp. 23.
London: J. & A. Churchill. 1891.—The enterprlBing
authors of the Companion to the British Pharmacopceia are
to be congratulated. In issuing this little supplement
they can proudly say, “The greater portion of what is now
made official by the publication of the Additions to the
British Pharmacopceia is described in our current edition as
nof official; it therefore becomes necessary to issue a supple¬
ment to the ‘ Companion,’ making this alteration. ” The Com¬
panion clearly got thestart of the moreyouthful “Additions,”
and the authors have now to show how far their forecast has
been justified, and also gently to correct the “ Additions ”
when the latter has left itself open to reproof. The in¬
sertion of Fehling’s solution instead of Pavy’s is regarded
as a matter for regret, and the omission of a small quantity
of sulphuric acid in the copper solution is also noted. The
physical properties of acetanilide, of paraldehyde, of
phenacetin, of picrotoxin, of gluside, and of sulphonal are
criticised, and in various points corrections are suggested.
This very unpretentious little book has evidently been the
outcome of much careful work, and its utility in relation to
the Additions will be as great as that of the Companion to
the British Pharmacopceia.
Ophthalmological Transactions, Vol. X., Session 1889-90.
London: J. & A. Churchill.—The last issued volume of
Transactions of the Ophthalmological Society of the United
Kingdom fully maintains the standard attained by its pre¬
decessors. It commences with the presidential address
delivered by Dr. Hughlings Jackson, in which he insists
upon the necessity for ophthalmic knowledge, and a
familiarity with normal conditions and variations, before
drawing conclusions from ophthalmic appearances in the
diagnosis of morbid conditions; and proceeds to review
modern observations in connexion specially with nervous
disease. In the Bowman lecture Professor Grut of Copen¬
hagen gives an elaborate analysis of strabismus, in which
he maintains the nervous as opposed to the anatomical
theory of squint. Mr. Priestley Smith contributes a
suggestive paper, based on measurements in 1000 cases,
on the relation between glaucoma and smallness of the
cornea, which he finds associated with a small globe
without corresponding diminution in the size of the lens,
so that the latter is large relatively to the eye. A valuable
paper on Secondary Glaucoma after Extraction of Cataract
is furnished by Mr. E. Treacher Collins, baaed on careful
pathological examination of ten eyes, in all of which there
was obliteration of the filtration angle and adhesion of iris
or lens capsule to the cicatrix. The paper is illustrated by
some beautifully finished reproductions from photographic
enlargements of actual sections, Other noteworthy papers
are contributed by Professor Snellen of Utrecht, on New
Methods for treating Symblepharon, Ptosis, and Epi¬
scleritis; by Mr. Simeon Snell, on the Artificial Maturation
of Cataract; and by Dr. James Anderson and Mr. Doyne,
on Recovery from Hemianopsia with subsequent necropsies.
Many remarkable and interesting cases are recorded, such
as Pysemic Panophthalmitis and Spontaneous Purulent
Hyalitis, by Drs. liocklilfe and Berry respectively ; a case
of Embolism of a Branch of the Arteria Centralis Retinae,
by Dr. Lawford ; and of Cystic Detachment of the Retina,
by Dr. Tatham Thompson, all illustrated by lithographic
plates.
TheRoyalLondonOphthalmicffospitallleports. Vol. XIII,,
Parti,December, 1890. EditedbyR. Marcus Gunn,M,A.,
F.R.C.S. London: J. & A. Churchill.—This part contains
a memoir by Dr, George A. Berry, in which he discusses the
theories of fundamental colour sensation, and points out
the difficulties of their application to cases of colour-blind¬
ness, He goes so far as to ask, Is there any good reason
for assuming that there are any fundamental colour sensa¬
tions at all? and thinks the colour sensations run into one
another continuously. Practically, he believes the ordinary
test for colour-blindness by making the subject match
colours is completely satisfactory for the detection of
colour-blindness. Dr. Lawford and Mr. Collins publish
some notes on Glio'ma Retinse, with a report of sixty cases ;
and Mr. Collins adds two valuable memoirs on the
Pathology of Intra-ocular Cysts, illustrated by several
woodcuts; and a second on the Development and Abnor¬
malities of the Zone of Zinn. Dr. Tatham Thompson
gives 0 note on Forster’s Artificial Ripening of Cataract;
and lastly, Mr. Lang advocates the division of anterior
synechisB, which he thinks would prevent the occurrence
of many cases of secondary glaucoma.
The March number of the Veterinarian contains papers of
more than usual interest. They comprise an interesting ad¬
dress by Prof. McCall on ‘ ‘ Are Blisters Hurtful or Beneficial
in Acute Diseases of the Chest ?” which, with the discus¬
sion that follows, gives some idea of the stages through
which the blister and counter-irritation theory has passed
in arriving at its present modified stage; a note on Texas
Fever; a paper reprinted from the Philadelphia Medical
News on the Production of Immunity with the Chemical
Substances formed during the Growth of the Bacillus of
Hog Cholera, by E. A. v, Schweinitz; and a number of
notes on the disease of animals reprinted from other
journals. The number also contains reports of the
National Veterinary Association, the Royal Agricultural
Society of England, and the Lancashire Veterinary
Medical Association, at the first of which a paper on
Soundness and Unsoundness in Horses was read, which
will be of interest to more than members of the veterinary
profession, although, as might be expected, veterinary
surgeons, even amongst themselves, cannot agree as to the
meaning of the term “soundness.” Perhaps it should
be said rather that there seems to be no concurrence of
opinion as to what a sound horse really is, and bow far
slight malformations or other abnormalities really interfere
with the working value of an animal.
THJi LOCH NESS BLEND WHISKY (EXTRA OLD).
(A, GllITTBN & Co., E.C.)
This is a whisky which is soft and mellow to the taste,
and evidently a well-matured spirit. Our analysis yielded:
absolute alcohol 41-5.5 per cent, by weight, 49 02 per cent,
by volume, equal to proof spirit 85'90 per cent.; extractives
0'26 per cent.; mineral matter 0’09 per cent. The black
reaction with perchloride of iron would serve to iudicate
further the “ extra ago ” of this evidently choice blend.
COCOA EXTRACT.
(AidtoTT it liARHErr, Nbp’I'unh Works, J,o\vi';s’i'oi-T, and
47, MINORIHS, K.)
Petroleum ether extracted from this preparation 25 per
cent, fat, so that probably more than half of tire original
fat in the raw product has been carefully removed. This
treatment, while it increases the proportion of nourishing
as well as the stimulating constituents, theine and theo¬
bromine, renders the cocoa more agreeable and more
digestible. The flavour of the decoction is excellent.
Mineral matter 4*24 per cent.
fSAUMUR CHAMPAGNE “BRUT ROYAL" OOZKN).
(ACKERMAN-LAORANCK, 41, CrUTCHED FRIAflS, E.C.)
A good, wholesome, and exhilarating wine, with taste
somewhat sweet, hut equal to many champagnes at twice
the cost. Alcohol by weight 10'77 per cent., by volume
.oogle
Di ’.ed
The Lakcbt,]
ajjjalytical records.
[April 4,1891. 781
13'34 per cent.; extractives 3'13 per cent.; mineral
matter O’lO per cent. (The mineral matter was tinged a
light brown, from the presence of oxide of iron.)
UNO. EMOLLIENS AND UNG. EMOLLIBNS ANTISEPTICUM.
(ELTON & Co., 28 , KNDSLEiaH-QARDENS, EUSTON-ROAD, N.W.)
We are able to confirm, as far as can be judged from a
chemical examination, the statement that ung. emolliens is
a neutral, pure, and well-prepared fatty cream, and there¬
fore well adapted as a basis for ointments. Ung. emolliens
antisepticum is delicately scented, and contains a well-known
antiseptic in conjunction with a preparation of zinc. The
many applications to which preparations of this character
may be advantageously put wUl suggest themselves to every
practitioner.
PAPAIN PEPTONE.
(B. KUHN, 38, St. Mary-at-Hill, Eastcheap.)
This preparation is very interesting from a ohemico-
physiological point of view. It is the body obtained on
peptonising beef albumen with papain, the vegetable pepsin.
Papain peptone is a brown spongy mass, soluble in water,
the solution possessing a somewhat insipid taste, which, how¬
ever, is improved considerably by the addition of salt.
According to our experiments nitrogen is present to the
extent of 14'67 per cent., which, adopting the factor 6‘3,
represents so high a proportion of albumins as 92’42 per
cent., of which, as we have verified hy actual tests, the
greater proportion are uncoagulable and soluble; that is
to say, in the form of peptone and albumose. Glue
peptone occurs only to a traceable extent. Papain peptone
seems likely to prove a valuable adjuvant to food for the
debilitated, and it may obviously be employed to increase
the nourishing value of many kinds of ordinary food.
HORLICK’S MALTED MILK : A SUBSTITUTE FOR MOTHER'S
MILK.
(Tub Malted Milk Co., Racine, Wis., U.S.A., and 39,
Snow-iull, E.C.)
The action of diastase, whether it be that derived from
barley or other cereals, is by no means limited to starch,
which under its influence undergoes transformation into
dextrin and sugar. It is well known that in trustworthy
preparations of cod-liver oil and malt the oil does not exist
in the free state, hut in the condition at present regarded as
an emulsion, and, as is shown by the microscope, immediately
on the addition of water oily globules are seen to separate.
The precise nature of this action of diastase does not appear
to have received much attention. From recent experiments
it would also seem that diastase acts in such a manner upon
the casein and albumen of milk as to reader these bodies
uncoagulable by acids. Surely this is a subject which
recommends itself to the attention of investigating chemists.
Advantage has already been taken of this property of
diastase by the Malted Milk Company. They are intro¬
ducing a preparation of dry malted milk. During the
process of manufacture they regard the casein of milk to
be so acted upon by the diastase as to become partially pre¬
digested, for experiments show that on mixing active malt
with milk and maintaining the mixture at blood heat for a
few hours the casein is rendered uncoagulable by acids. The
company’s own account of the composition of the dry
powder which they prepare is given in the following table:—
The analysis made in our laboratory substantially con¬
firms this, and it will be seen that chemically the composi¬
tion of malted milk resembleB that of human milk (for
which it is offered as a substitute), supposing all but 4 per
cent, of water had been removed. Important differences,
however, consist in the presence in the prepared milk of a
leas quantity of fat; while, of course, the dextrin owes
its origin entirely to the malt. The Ilavour malted milk
is excellent, and it will he interesting to watch the results
accruing from the practical use of this product, which is
likely enough to prove an important contribution to food-
supply.
LIQUOR CABNIS.
(The Li<iUOH Carnis Company, Limited, 60, Holhorn Viaduct, E.C.
We have already had occasion to examine this excellent
preparation. Liquor carnis is now flavoured with a “dash”
of celery, which gives it a very pleasant taste. That
this in no way interferes with the admirable condition in
which the meat juice is preserved in the cold is evident from
the fact that the simple experiment of boiling resulted in
the coagulation of the fluid.
KOLA WINE AND KOLA BITTERS.
(T. Christy & Co., 26, Lime-street, E.C.)
Messrs. Christy, who we think were the first to intro¬
duce the kola nut to this country, have recently suc¬
ceeded in preparing a wine and a “ bitters,” which contain
in a wineglassful the equivalent of thirty grains of kola.
The port used in the preparation of the former is, judging
from the taste, of no inferior kind; while the “bitters,”
which does not require to be'mixed with anything else,
possesses a pleasing flavour, that of orange predominating.
The alkaloid caffeine was readily extracted with chloro¬
form. Further analytical results are as follows:—Kola
wine: Alcohol, 17'00 per cent, hy weight; 20 89 per cent,
hy volume; extractives, 8'72 per cent.; mineral matter,
0'32 per cent. Kola bitters: Alcohol, 20 68 per cent, by
weight; 25'17 per cent, by volume; extractives, 9'90 per
cent.; mineral matter, 0'20 per cent.
PEPSALIA.
(G. &G. STERN, 62, GRAY'S-INN-ROAD, W.C.)
This preparation, which has been examined previously,
has also undergone improvement in manufacture. It is
evident that the colour is a purer white, the salt is more
uniformly grained, and the digestive agent more active than
before. Glycerine we find readily extracts the digestive
agent from the salt, and the extract so obtained quickly
transforms hard white of egg into soluble albumins.
NATURAL MINERAL AND AERA'TBD WATERS.
(Richard Davis, 20, Maddox-street, Regent-street, W.)
All the samples submitted to us indicated careful pre¬
paration and the employment of good materials. There
was a remarkable absence of organic matter, and no
trace of injurious metals, as lead, tin, or copper. Analysis
gave the following results:—Soda water, 17^ gr. of the
bicarbonate to the pint; lithia water, 9 gr. of the carbonate
to the pint. Taraap water: Total solids, 1165 gr. per gallon;
chlorine, 158'6gr. per gallon; magnesium and sodium pre¬
sent in large proportion, with smaller quantities of calcium,
potassium, and lithium, combined with chlorine, bromine,
sulphuric, and carbonic acids. Tarasp is pleasant to taste,
and it contains its own volume of free carbonic acid gas.
Water.
Sugar.
Dextrin.
Fat.
Albuminoids.
Ash.
Malted Milk (Company Analysis).
3'27%
40'63%
17-10 X
0-78 X
22-20%
8-00%
Malted Milk (The Lancet Analysis).
2-21 %
(33-60 %
(and dextrin)
—
8-40%
21-86 %
3-06 %
4'00%
40-78 X
28-80%
28-S9 %
2'44%
Dir;;;ized by Google
782 Ths Lanobt,]
VACCINATION AND SMALL-POX.
[April 4,1891.
The lithiam M'as readily defected by the spectroscope, but it
may possibly be of interest to those who drink lithia water
to mention that the presence of the metal is easily made
manifest by merely dipping the wire of the bottle into the
water and then holding it in the transparent part of a
common gas flame. Lithium m indicated by tlie carmine
colour imparted to the flame as the liquid vaporises.
VACCINATION AND SMALLPOX.
To tht Editors o/Thb Lancet.
Sirs,—D uring a voyage on the South-west Coast of Africa
an outbreak of confluent small-pox occurred on board among
the black passengers, resulting in some deaths. Owing to
native prejudice some difficulty was experienced in persuad-
Ittto Intmlwn.
CONVERTIBLE VAGINAL SPECULUM.
This speculum is a modification of the bivalve variety,
and can be used either as an expanding instrument, or
as a retractor after the manner of
Sims’s “Duckbill.” The joint is of
a simple character and is very easily
disconnected, so that it can be tho¬
roughly cleaned — a very important
point in gynecological instruments,
and one not always kept in view.
We have used the instrument and
find it very efficient. The figures
show how one blade of the in¬
strument is placed at right angles
to the other and fixed with a
small catch, when it may be used
to draw back the posterior vagi¬
nal wall. It is made by Messrs.
Mayer and Meltzer, Great Portland-
street, W.
VIECHOW TESTIMONIAL FUND.
The following additional
ceived :—
& e. (1.
P. W. Latham, M.D. .. 2 2 O'
George Johnson, M.D. ..110
W. L. Eeid, M.D.110
Charles Workman, M.D... 2 2 0
James Finlayaon, M.D. .. 2 2 0
Alex. Robertson, M.D. .. l I 0
Joshua Paterson, M.D. ..220
J. K. Kelly, M.D. 110
James Jvawrenco, M.D. .. 1 1 o
James C. IIowden.M.D... 110
William Frew, M.D. 110
Sir G. H. B. Macleod,
M.D. ..,2 2 0
George Heron, M.D...... 1 1 0
Joseph Coats, M.D. .... 2 2 0
subscriptions have been re-
£ n. d.
Johnstone Macfle, M.D. .. 110
JohnIjindaaySteven,M.D. 0 16 0
John Cleland, M.D.,L1;.D,,
F.It.S.110
■T. Kingston Fowler, M.D. 110
J. Langdon Down, M.D. 110
B. Farquharson, M.D..
M.P. ..110
G. H. Savage, M.D. 110
H. ltadcIiifeCrocker.M.D. 110
F. Itoberts, M.D.110
B. Thorne Thorne,
F.E.C.P..F.B,S. . 110
Thomas Bold, M.D. .... 1 1 0
ing them all to undergo vaccination. However, after one
death had occurred, the few who had rejected vaccination
presented themselves for it. Among these was a well-made
muscular negro, a native of Monrovia. He complained of
vague pains in the back and limbs, slight headache, and
chilliness; his pulse was 100 per minute, and his tempera¬
ture 100'5°. The bowels were confined; no papules
could be felt in the skin. Fearing that he was about
to develop an attack of small-pox, he was vaccinated in four
places in the upper arm, and given ten grains of calomel,
together with a diaphoretic mixture, containing five grains
of quinine, which was given every four hours. In addition to
this he was isolated. For the two following days he remained
in much the same condition, and on the third day the
site of vaccination presented three well-defined papules.
During the day the patient became much worse; he
vomited twice, complained of great frontal headache, and
lumbar pain. In spite of the administration of ten grains of
calomel the previous evening, the bowels were confined.
The temperature was slightly raised (to 101"), and the pulse
, full and bounding, the tongue being thickly furred.
He was given a mixture containing hyoscyamus and bromide
of potassium every three hours. The next day the patient
was better; the headache bad diminished, the pains in the
back were less, and the bowels had been moved freely. In
the meanwhile the vaccination was steadily advancing, the
papules having increased in size, and the upper arm being
slightly swollen. The medicine was continued every four
hours, and the patient slept most of that day and passed a
good night. On the following morning he complained still
of some headache and vague pain, but his temperature was
normal, the pulse natural, and the patient apparently well.
He complained of some pain in the right axilla, which was
due to enlarged glands in that situation caused by the
vaccination. He was practically well on tbeday follotving,
complaining of nothing but his arm, which was slightly
inflamed, .swollen, and painful on movement. In a
few days he was allowed to go back to his work; he
kept in good health and the arm matured well, vaccina¬
tion being successful in three out of the four situations
operated on.
I have given the above details in order to point out what
seems to me the efficacy of vaccination in arresting the
development of small-pox. The severe symptoms which
appeared on the third day were, to my mind, those of the
onset of variola, as they exactly resembled those presented
by the cases which developed the disease. I may add
that, although we had more than 100 black passengers, the
majority of whom had never been previously vaccinated, the
disease did not attack any who bad undergone the opera¬
tion. Of course, such cases of small-pox as did arise were
rigorously isolated, and due antiseptic precautions were
taken. As this, however, was not done until they were
taken ill, some risk of Infection must have been run by their
fellow-passengers; and, as everyone knows who has been in
countries inhabited by black races, small-pox is the most
terrible scourge that can well be imagined, decimating
whole tribes, and sparing neither young nor old. There¬
fore no immunity on the score of race can be pleaded
on behalf of negroes. Owing to the rare occurrence
of the disease in a severe form in England, we do not,
I think, often realise the fearful ravages which this
disease can effect both in loss of life and in the appear¬
ance of individuals. On this account we are, perhaps,
inclined at times to undervalue the immense importance
of vaccination, the benefits derived from which were
vividly brought before both myself and my white com¬
panions during the voyage I mention.
I remain. Sirs, yours truly,
F. M. Mangan, M.R.C.S., L.R.C.P.
Fairholmo-roail, West Kensington, W., March Jlst, 1801.
Digitized by i^ooQle
Thb Lancet,]
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.
[April 4,1891. 783
THE LANCET.
LONDON: SATURDAY, APRIL 4, 1^91.
Readers of the reports of the proceedings of the Council
of the Royal College of Surgeons of England can rarely find
therein any indications of progress in the direction of a
reform of the peculiarly close constitution of that important
and influential corporation. The rays of light which are
occasionally emitted from the Council chamber are often
intercepted by an official diaphragm before they can reach
the outer world, and Fellows of the College are left to infer
that the Council as a whole are a united body unanimously
in favour of upholding the best of all possible constitutions
at the best of all possible colleges. It is not practicable,
however, to shut out every gleam, for the most careful
revision of the proceedings of the Council could scarcely be
so stretched as to exclude the report of important motions
carried by a majority of the Council. Such a motion was
that which was made on March 12th by Mr. Thomas Smith
in pursuance of notice given a month previously, “that the
proceedings of the Council in relation to the scheme for
the reconstitution of the University of London be placed
before a meeting of the Fellows and Members summoned
for the purpose, and that the date of the meeting be deter¬
mined by the President and Vice-Presidents.” This motion
was seconded by Sir W. S. Savory, and carried by a
majority of 16 to 6. Considering that the scheme to be
submitted for the consideration of the Fellows and
Members has already been virtually settled, and is not
likely to be materially modified by anything said or done
at the general meeting, the adoption of this motion does
not appear at first sight to be any considerable step in
advance, but that it is of some importance may be inferred
from the facts that five members of the Council opposed it,
and that the Association of Fellows had urged upon the
Council the desirability of calling the Fellows together
to consider any scheme of reconstitution of the University
before its final ratification. When it‘was pointed out by
the Attorney-General and Mr. Paget that at the present
moment, when an aci/ion by the Members of the College is
pending, it would be undesirable to call together the
Fellows separately, the Committee of the Association
passed a resolution in favour of convening a general meet¬
ing of Fellows and Members. This step, therefore, is in
harmony with the opinions of those who are recognised
advocates for a reform of the constitution of the College,
and is emphatically a step in the right direction. One of
the fundamental articles of the Association was “that it
is desirable that no alteration in the constitution or
relations of the College shall be elfectod without the
consent . of the Fellows and Members convened to
discuss such alteration,” and this was rejected ,by
the Council of the College in the spring of 1884—a
rejection which led to the formation of the Association of
Fellows and the Asaooiabion of Members, Had the resolu¬
tion been accepted it is extremely doubtful whether either
Association would have come into existence, for it was the
most important of the four resolutions proposed by
Mr. Paul Swain on March 24th, 1884, and adopted
at the general meeting then held in the theatre of the
College. We are, therefore, inclined to regard the success
of Mr. Thomas Smith’s motion as indicative of a gradual
approach on the part of the Council to an agreement
with the very moderate and rational programme which
the Association of Fellows is engaged in supporting. It
would have been better to have called the meeting sooner,
but it is better now than not at all, for the scheme of recon¬
stitution of the University of London has not yet been before
Convocation, and when it is discussed by that body it is
most likely to be rejected. A farther approach to an agree¬
ment with the reforming section of the Fellows does not
appear upon the face of the official record, for the ray of
light was intercepted in its passage! The deputation from
the Association of Fellows which waited on a committee of
the Council last November pressed for a simplification of
the method of voting by voting papers, and their proposals
were referred to a special committee of the Council, with
the ultimate result that no change was made. An
ordinary reader of the published minutes would probably
imagine that the Council were unanimously of opinion
that the present plan was the best that could be
devised, but it is an open secret that the Council were
divided in opinion, and that the determination not to
comply with the reasonable re(iue8ts of the deputationfrom
the Aesociation of Fellows was only ratified by the smallest
possible majority. Mr. Mitchell Ranks strongly sup¬
ported the proposals of the Association of Fellows, and
urged the Council to accede to them, thus showing that his
adhesion to the programme of the Association as set forth
in their recently issued report was substantial and sincere.
This is in the highest degree satisfactory, for it shows that
his return by a large majority at the head of the poll last
year and the failure of the candidates supported by the
Association of Fellows did not signify any reactionary
movement or any opposition to reform on the part of the
constituency, and that this return can be claimed as a
victory for the reforming party among the Fellows.
Looking at the political situation as a whole, we
are satisfied that it is distinctly favourable to steady
constitutional development. By the persistent action
of the Association of Fellows, to whose steadfast¬
ness in a good cause the Fellows of the College
generally are indebted for the progress that has been made,
it has been conclusively settled that the Council has the
legal power to call separate meetings of Fellows if they
are so minded, and we feel sure the change must come
shortly. The simplification of the method of voting
by voting papers advocated by the Association, and
lost by a bare majority, will be carried the next time
that it is proposed in the Council. Consultation of the
constituency as to changes in the constitution and relations
of the College is in the ascendant, and will not he neglected
hereafter. The reforming element of the Council is being
strengthened, and so soon ns it receives the smallest re¬
inforcement tlse whole fabric of obstruction to moderate
Digitized by
Google
784 Thb Lanoet,]
PROVIDENT DISPENSARIES AND HOSPITAL REFORM.
[APBlii 4,1891.
and necessary measnres for investing the Fellows and
Members with a larger share in the management of the
CoUage will ** dissolve, and, like an insubstantial pageant
faded, leave not a wreck behind.”
The subject of Provident Dispensaries is coming power¬
fully to the front in connexion with the acute criticism
which is being brought to bear on the out-patient depart¬
ment of hospitals. The result of all investigations of a
searching character into the out-patient department is to
show that it is greatly abused by persons who are not
ill enough or poor enough to need the paraphernalia and
the gratuitor^ aid of a great charity. These persons will
have to be excluded if medical charities are to continue to
receive the support of the benevolent. And if they are to be
excluded means must be provided for their treatment
on independent, though at the same time practical,
terms elsewhere. This is the problem before the public,
and especially before the profession. Those who crowd the
out-patient department cannot do without medical aid.
It is perhaps natural that they should go to the out¬
patient department, where they expect to get for nothing
the advice of consulting surgeons and physicians. But
this is a use of medical charities that was never con¬
templated, which has become demoralising to the people
and highly injurious to the profession. The problem
is to devise an alternative that shall preserve the in¬
dependence of the people and have some regard to
the interests of the medical profession. For, after all,
it is the private members of the profession in general
practice on wbom the burden of all onerous sickness
of the working classes falls. They have to be on duty
night and day, to face infection in the close apartments of
the poor, and to be their neighbours and friends in every
emergency.
The general remedy suggested for hospital abuse is the
Provident Dispensary. Whether in London, Birmingham,
Manchester, or elsewhere, these institutions are not only
lauded, but they seem to answer—to meet in a certain degree
the wants of the case of those who are pronounced by general
consent to be unfit for hospital relief. We have before us the
annual reports of two or three of these dispensaries, and some
of them betray obvious expectations that these institutions
are destined to fulhi a great function in connexion with the
movement for hospital reform, in the way of affording
facilities for the working classes being attended on inde¬
pendent principles. However this may be, some of these
institutions seem to thrive well. In Manchester there are
nine dispensaries in connexion with the Manchester and Sal¬
ford Provident Dispensaries Association, with a membership
of 24,000. The subscriptions of members amount to £4107,
and they pay their medical officers £2372. Only one of the
branches is not self-supporting. The rest show a profit of
£482. The chairman put forth a very just suggestion that
the time was coming—we should say had come—when the
medical staff should share more largely in the profit
of the dispensary. It is claimed that in Manchester
hospital abuse has been almost abolished by a system
of investigation and by the provision of these dispen¬
saries. The report of the Northampton Royal Victoria
Dispensary is also before us. The members number 20,000,
or one-third of the population. The increase in member¬
ship in the last year was 981 and that of free payments
£315. The total receipts, including a balance in the
treasurer’s hands at the beginning of the year of £1792,
were £5270 12$. 9cf. The amount paid to the medical
men for the year 1890 was £2481 16$. \d. The largest
sum paid to one medical officer was £1048 19$. 4cf.
This seems a large sum, hut it represents 20,000 visits
at the houses of patients, 10,150 interviews with
patients at the doctor’s house, and 642 at the dis¬
pensary—in all, 31,142 attendances I There are fire
medical officers in all. It Is claimed in the report that
only eligible persons are admitted and that a large
number anxious to join are excluded. Another report
before us is that of the Hockley Provident Dispensary.
Mr. Lawson Tait presided over the annual meeting and
expressed his conviction that the only effective method of
dealing with the sick poor was by provident dispensaries. The
establishment of such institutions was the only practical
solution of the difficulty. In the last year 670 new
members had been admitted. The total membership was
1800; the income £614 16$. 3^rf.
Such are favourable specimens of the provident dispen¬
saries, and such are the favourable accounts of them by their
promoters. We heartily recognise the good they do, and
we cannot fail to see that such institutions are looked to
for much service in the immediate future. It is well, how¬
ever, to remember that they have their critics. Their
friends will do well to consider the criticism for what it is
worth, and to meet obvious objections in a friendly spirit.
A letter before us complains that in Northampton trades¬
men are admitted, and others in good circumstances.
Moreover, that dispensary patients are seen by qualified
assistants, and not by the gentleman nominally doing the
largest dispensary work, who, by the way, is said also to do
the largest private practice in the town. Our correspondent
characterises the appointments as a monopoly, enjoyed by
“the favoured, subsidised few,” and that the enormous
amount of work done for a small sum borders closely on
“the sweating system.” A correspondent at Greenwich
complains with much reason of the wholesale distribution
of handbills advertising the Greenwich Provident Dis¬
pensary and the names of the medical staff. In the Man¬
chester dispensaries we believe there is no wage limit, and,
if we mistake nob, it was abolished at the instigation of the
Manchester Medico-Ethical Society. Surely here we have
a proof of the want of some thorough understanding and
agreement in the profession at this juncture. The great
body of the profession is complaining, and justly, of the
competition of the out-patient department. But there
is no agreement of opinion to be found as to the
substitutes for it, which must be organised and ready.
If the Lords’ Committee come to conclusions similar
to those of the Birmingham Committee, and the profession
is unprepared and divided on the question of substitutes,
the result will be an indefinite lease to the out-patient
department. We think there should be a wage limit and a
strict inquiry into the circumstances of patients. More¬
over, there should be a determined effort on the part of the
promoters of provident dispensaries to make the remunera-
Digitized by i^ooQle
The Lancet,]
THE BACILLUS PYOCYANEUS.
[Apbil 4, 1891. 785
tion of medical men more proportionate to the nature and
amount of their work, and to include in their scheme the
largest number of the practitioners of the town. With these
precautions—and these are absolutely imperative—the pro¬
vident system should have the hearty support of all who
are battling for the reform of hospital abuses. It is easy
to find fault with such a scheme as the Northampton Dis¬
pensary. But it is more ditlioult to imitate it or to excel
it. We would ask those who oppose such institutions to
consider the miserable substitutes for them in the shape
of cheap dispensaries and coopetative medical associations,
in which a young and impecunious medical man is induced
■to undertake a herculean task of work for a pittance that
would not pay a respectable mechanic.
Within recent years the bacillus pyocyaneua has
attracted considerable attention both in Prance and in
•this country; first, because of the beautiful colour to which
it gives rise and its characteristic appearance and manner
■of growth under certain conditions; secondly, because of
its action on certain animals ; and thirdly, because when
either the bacillus (Charrin) or merely its products
<WooDHEAD and Wood) are introduced into the body, it
seems to interfere in a most remarkable manner with the
ilevelopment of the anthrax bacillus when simultaneously
inoculated. M, C. Gessard^ has again concentrated our
■interest on the bacillus itself, and in a series of experiments
has been able to show that the surroundings of the micro¬
organism, or the conditions under which it is developed,
may so far modify the manifestations of its activity that it
actually seems to become developed into a distinct organism,
and that we have in such cases not merely a varietal
•difference, but even a species or race difference. He gives
a definition of race, based on that given by Pasteur in
his studies on beer, wbo takes as the basis of his classifi¬
cation not outward form resemblances, which can often
•obscure marked differences, but the physiological functions,
which are far more important in distinguishing the races
than are most morphological characters.
M. Gkssard finds that by growing the pyocyaneus bacillus
•on bouillon he is able to obtain both pyocyanin and green
Guorescence; and that if the growth is continued on this
nutrient medium, both of these functions may become-so
•strongly developed that, even when removed from the
uuedium, the organism still retains these functions in a
most remarkable degree. If, however, it be cultivated for a
'number of generations on egg albumen, the green fluorescence
■is lost, and it takes some little time to regain the power of
•giving rise to this appearance when again grown in broth.
On the other hand, gelatinised peptone meat infusions allow
■of the production of the pyocyanin and not of the lluorescence,
although another greenish pigment is always formed.
On the addition of glucose to this latter medium even the
.pyocyanin ceases to be developed, and we have then only
the greenish pigment above mentioned. On passing this
•organistn through a rabbit it is found that thepyocyanic
function is lost, and even on cultivation in broth outside
1 Dea Races du Bacille ryocyani<iuo : Annalea do I’lnstitut Pastour,
tome V., No. 2,1891.
the body a considerable number of cultures have to be made
before it again obtains this power of forming pyocyanin,
although the fluorescent function may still remain. The
importance of such facts as these is very great, as we have
gross optical demonstration of the modifications of the
functions of the bacillus due to its cultivation on various
media, to the action of heat, and to the passage of the
organism through the animal body. There are a number
of other organisms which, treated in the same way, become
similarly modified. It is always difficult by mere chemical
processes to determine how far the products and functions
of such organisms have become altered, whilst in the case
of passage through animals so many sources of fallacy may
creep in that it is extremely difficult to avoid doubt
that the results obtained exist in the mind of the ex¬
perimenter rather than in actual fact. Where, however,
the changes can be followed with the eye, and where in
consequence a large number of experiments may be carried
on and observed in a very short time, we are able to
secure much more satisfactory and convincing proof of
function modifications ; and we feel emboldened to accept
more freely the results obtained by the more delicate
methods, especially when these can be confirmed by the
coarser ones resorted to by M. Gessard. It is easier to
understand how pathogenic organisms—at first compara¬
tively benign—may on passage through several individuals
attain a virulence so great that almost every patient
attacked by a disease succumbs; whilst in the same way
the passage through successive human or animal bodies
may so modify the activity of another organism that the
attacks of the disease become gradually less and less severe.
The passage of anthrax or hydrophobia, for example, through
one series of animals gives rise to an attenuation; whilst the
passage through another series increases the activity of the
virus to such a degree that it almost invariably proves fatal.
Similariy,we know that organisms growing on different media
give rise to diilerent products; for instance, the bacillus
prodigiosus forms a beautiful pigment when growing at
certain temperatures on protoid substances, whilst growing
on sugar it gives rises to the formation of lactic acid. From
this it may be readily understood how other organisms,
ordinarily not specially dangerous, when placed in favourable
nutrient media outside the body, may develop powers and
activities that render them most dangerous to the public
health. Further, however, it must be remembered that
these organisms act and react one upon another. Of this we
have an admirable example in the growth of an innocuous
pseudo-diphtheria bacillus within the cavity of the mouth.
We find that it may attain certain degrees of virulence,
but tiiat the virulence is developed to the highest degree
only in those cases where there is present also a micro¬
coccus or streptococcus similar to that of erysipelas, which
by its presence appears to prepare the ground, and perhaps
even the food, for the development of special toxic sub¬
stances by the diphtheria bacillus itself. A number of
facts bearing on these points will gradually be accu¬
mulated, and eventually we may arrive at some
general conclusions or obtain some reliable guide as
to the means by which these modifications are brought
about or determined. For the present we must accept
Digitized by
786 The Lancet,]
THE UNION OF QUEEN’S AND MASON COLLEGES.
[Apbii 4t, 18^1.
M. Gessakd’s moab remarkable facte as an indication
of the lines along which future work will have to be
carried on.
The most important step in the history of the Birmingham
School of Medicine since the conferring on it of the title of
Queen’s College by Royal Charter in 1845 was taken on the
20th ult.,when the amalgamation of Queen’s and Mason
Colleges was agreed to with only one dissentient—viz., Sir
James Sawyer. Mason College has for the past ten years
supplied the necessary scientiiic teaching for the medical
students of Birmingham which could not be so efficiently
rendered by the older college, and now the disadvantages of
a dual control and an attendance on two institutions for a
proper curriculum will be removed. There can be no doubt
as to the wisdom of this decision, and, with characteristic
vigour and determination, the requisite steps for presenting
a petition to the Chancery Division praying for the approval
of the new scheme have been already taken, whilst the plans
for a new building behind Mason College, which is to accom¬
modate the medical students with class-rooms for the medical
lectures &c., have also been prepared. The amalgamation
will remove from the authorities of Mason College all
temptation to become a complete school of medicine in
itself, and will secure for the students of Birmingham a
security of scientific education which might at any time
previously to this union have been taken from them if the
professors at Mason College had wished to exclude Queen’s
College students from their class-rooms. Sir James
Sawyer opposes the destruction of an old foundation, but
the progress of the scientific element in recent medical
education, especially in the curricula of universities, makes
it incamhent on all medical schools to form a thoroughly
scientific side among their professors, or to enter into an
alliance with a college of university standing for the pro¬
vision of this scientific instruction. The closer the
union the better for the student and the teacher. Such an
amalgamation, far from being a destruction, is really but
a further development, especially if the union is to the
advantage of both Colleges. We look upon this fusion as
the first great step towards the formation, at no very
distant date, of a university in the Midlands, which will
emulate in good work the Victoria University, if not some
of the older foundations. Local universities are among the
most potent forces at work in the elevation of the higher
education throughout the country, and we have no doubt
that a fully equipped teaching university will soon be
desired by the citizens of the Midlands, and be secured for
their children. Whether the department of Theology, which
will remain to Queen’s College after the removal of its
Faculty of Medicine, should be continued at Birmingham
or removed to Worcester must be decided by the support
afforded to it by the Churchmen and inhabitants of Birming¬
ham. This is a local question. The future of the Bir¬
mingham Medical School, of the Medical Department of
Queen’s College, and of Mason College is of importance to
everyone throughout the kingdom who is interested in the
due development of medical and scientific education,
and in the adjustment of their proper relations to each
other.
^nnDla&ns.
“ Ne quid nlmls."
HER MAJESTY’S VISIT TO GRASSE.
The eagerness of competition extends, it would seem, t«>
localities and towns, and a knowledge of this fact will cause
some hesitation before accepting absolutely all that hae
been said about the town of Grasse, which is now being
honoured by a visit from the Queen. The question which
has been asked, with a purpose as it would seem, “ Is Grasse
healthy?” admits of a ready answer. The situation of
the hotel which the Queen occupies at Grasse is perfect.
It is well protected from the north, is llOOfc. above sea
level, and has a view of plain and sea and mountain suclr
as can scarcely be excelled in Europe. The air io such a
place must be pure, and it goes without saying that Her
Majesty’s advisere are satisfied as to the purity of th©
water which the Queen will drink, and the soundness of
the sanitation of the house which Her Majesty inhabits.
That the old town of Grasse is nob calculated to impress
the traveller as a place the construction and sanitary
arrangements of which are in any degree perfect is of
course true; but the Queeu will incur as little risk
from the old town as Her Majesty does from the slums
of Westminster whan inhabiting Buckingham Palace.
It must be admitted that the old towns along the
Riviera are none of them luvibing, and must be re¬
garded as a menace to the health of visitors. The
old towns of Hj^res, Frejus, Cannes, Nice, Eza,
Rocca Brunna, San Remo are all pretty much alike—
crowded, ill-paved, malodorous; but as the new towns
where the visitors congregate are more or less removed from
the old ones, those who visit these spots for health or
pleasure take no harm. In one respect Grasse is better
than its neighbours, inasmuch as the custom has long pre¬
vailed there of applying all organic refuse to agricultural
purposes, instead of allowing it to foul the foreshore, as is
done at all the so-called “ health resorts ” upon the coast.
The argument has been used that inasmuch as Grasse is
a place of great antiquity, the soil must have become
impure; but such an argument shows a great want of
knowledge of elementary biological principles. The ground
round Grasse is highly cultivated, so that the impurities of
Grasse become in due time violets, roses, jasmine, and
orange blossoms ; and it is a well-known fact that the more
highly land is cultivated the more readily will it eat up, as
it were, the impurities which are applied to it. With regard
to the earth, the Shakesperian saying, that “ appetite doth
grow by what it feeds on,” is strictly true ; and it may bo
hoped that those who visit Grasse may not be too prejudiced
to bring away maybe a useful and thrifty lesson in sanita¬
tion from this old city of Provence.
THE MEDICAL MORTALITY RATE.
In our correspondence column to-day will be found an
interesting letter from Dr, Glover Lyon on this subject, ii^,
which the attempt is made anew to elucidate the question
of mortality in the medical profession. The results so-
brought out conform much more nearly to what we conceive
to be the facts of the case than did Mr. Chatham’s figure.?,
which we recently criticised. But Dr. Glover Lyon’s>
method seems to us open to objection, and from two opposittj
points of view. The method is bo bake the claim register of
an insurance office and search through it until a medical
man’s claim is found, then to note the age at entry of tire
life assured, and, as we understand, to continue, the search
until a non-medical claim is discovered arising upon a life
Digitized by ^ooQle
The Lancet,]
PREHISTORIC TREPHINING IN PERU.
[April 4,18M. 787
which wag entered in the company’s books in the
same quinquenninm of age and approximately at the
same date as the medical case already discovered.
The result is that the non-medical policies are found to
last slightly longer than the medical ones. Now it is
clear that the method of selection precluded the possi¬
bility of any great divergence between the two classes
of policies because the date of death and date of entry
are taken approximately the same, and the ages are
tiaken within the same quinquennial groups. It might
happen that these precautions should prevent the true dis¬
parity from becoming apparent. Bat, on the other hand, if,
as we understand, the medical case were fir^t Jov,nd, and
then a non-medical companion case was looked for Jurther
en in the register, it would follow that the non-medical
oases would have had a process of—perhaps unconscious—
selection applied to them the tendency of which would he
to give them au a 'priori advantage over the medical cases,
since, other things being equal, the later entries must repre¬
sent policies of longer duration than the earlier. We should
be interested to know what would happen to Dr. Glover
Lyon's ligates if instead of looJdrg forward for his non¬
medical claims he looked back for them in his registers, and
so gave to the medical policies the advantage which the
suethod as it stands ap pears to give against them.
PREHISTORIC TREPHINING IN PERU.
The antiquity of trephining has formed a frequent topic
for the medical historian, and many skulls have been pro¬
duced from caves in I'rance, the Canaries, Algeria, Mexico,
and Peru, which hear evidences of having undergone the
operation during life. M. Broca Isas written a good deal
on the subject,^ also Dr. Prunibres of Toulouse,^ who dis¬
covered soine of the specimens. There does not seem to
be any doubt that the European specimens really represent
a. rude surgical operation, for in many of the cases the
edges of the bone are rounded as if the individual had
lived for some considerable time after the operation. Less,
however, would appear to be known about the Peru¬
vian trephining, as the accounts existing in medical
literature are apparently limited to a description of a
tsiugle specimen by Broca and Nott. A very interesting
;.nper hai, however, now been published in La Cronica
Medica of Peru, by Dr. A. Lorena of Lima, with drawings
of four skulls, which, however, are only intended to
carve as specimens of several hundred similar ones in
the old tombs of Calca and Pomancanchi in Silque.
Although Dr. Lorena does not seem to hold any strong
views on the origin of the trephine holes, he thinks it very
■doubtfnl whether they were made hy a surgical operation,
though the beveling and notching may have been done by
some rude instruments—perhaps with some reference to the
fitting of an obturator plate of lead, silver, gourd, or other
substance, such as is not uncommon at the present day in
Homepartsof South America. It is suggested that syphilitic
disease, which is known to have been very common in the
time of the Incas, notwithstanding their severe moral laws,
may have caused the perforati ons, or some of them. It would
appear that the venereal origin of some kinds of disease was
pretty well known, forasmall statue has been preserved repre-
Henting a m m covered with tumours and deformities, the sup¬
posed nature of which is sufGeiently indicated by the figure of
i/he phallus engraved on the surface. Another explanation
possible is that the skulls were injured by weapons. A
Clilrd may also occur to those who are acquainted with the
<iiaboUcal cruelty of Indians—viz,, that the holes in the
fikulls may have been chiselled or burnt out as a species
^ Sao TIIK Lanckt, vol, ii. I8S7, p. 213.
- ,Soo n, leltor from Mr. Jilakor of Burgoss-liill, in THK Laxcf.t, vol. ii.
X333, p. 881.
of torture. The objections to the theory of surgical
trephining is that the Incas seem to have had no knowledge
of boring instruments, and that the operation, if such -
it were, must have been an exceedingly common one
judging from the numerous skulls that are found with
boles in them. Again, it is known that the Incas were too
timid and probably too superstitious to open the abdomen
for the purpose of taking the viscera from a dead body for
embalming, practising instead the draggiogof the intestines
&c. through the anus, so that it hardly seems probable that
they would have ventured to cut open the skull in the living
subject. Of course, amongst these people, as amongst
others where it is more certain that holes have really been
chipped, scraped, or drilled into the cranium by barbarous
surgeons, the idea probably was to provide an outlet for the
evil spirits which were supposed to cause headaches or other
diseases. In one of the skulls with two apertures there is
between these a kind of pit in shape something like the cells
of a wasp’s nest, which gives one the impression that the
operator after making a commencement there thought better
of it, and began again at a little distance. Two of the
specimens figured present two apertures, and two one only.
Five of the holes are approximately circular, and are in the
parietal bones ; the sixth, which is very irregular, probably
from pathological processes, is in the occipital bone. Most
of them are beveled at the expense of the outer table, and
one is crenate, as if the edge had been filed with a cylindrical
file or cut with a boring instrument, there being sixteen arcs
in the circumference. It is possible this may have been
done after death, with the intention of making an amulet.
PROPOSED DEMOLITION OF AN INSANITARY
AREA AT BRIGHTON.
A ruDLic inquiry has been held in Brighton with a view
to securing a provisional order confirming an improvement
scheme which the Town Council propose to carry out under
the Housing of the Working Classes Act, 1890. Dr. News-
holme, the medical officer of health, has made two repre¬
sentations to the Town Council with regard to the area in
question, and before doing so he fully satisfied himself,
from the high rate of mortality prevailing in it as com¬
pared with the remainder of the borough, and from the
nature of the diseases which occurred there, that it was
necessary that, the area should bo condemned in the interests
of public health. The houses, a number of which are
built back-to-back, are, as a group, damp, dirty, unpro¬
vided with sufficient air-space about them, ill-ventilated,
and generally defective from a sanitary point of view.
They were also reported to be such that no mere altera¬
tions or repairs could make them healthy. In some
instances the upper storeys had been converted into
registered common lodging-houses, whilst the lower por¬
tions were let out as private apartments. The objec¬
tions to the scheme of the Town Council were hardly
such as are likely to be allowed to stand in the way
of an improvement, which will be an obvious boon to the
town, and also, in so far as health Is concerned, to those for
whom other dwelling accommodation will be provided than
that affoi'dM by this unhealtby area.
DANGERS OF SULPHONAL.
Although sulphonal is probably one of the safest, as it is
one of the most efficacious, among the hypnotics recently in¬
troduced , the series of cases pu blished by Bresslauer of Yienna
show clearly that it has certain dangers. Thedegree of peril
is difficult to estimate, as the patients were lunatics, and
were also apparently feeble ; but the fact is significant that
out of seventy-seven patients who were treated with the
drug, no less than seven showed serious symptoms, and in
Dig:...ied by Google
788 Thb Lancet,’
PUBLIC HEALTH AND PROFESSIONAL COURTESY.
[April 4,1891.
Uve of t'hose there was a fatal termination. It ought to
he mentioned that the patients had been taking the drug
for a considerable time in good doses, and had borne it well
until symptoms of disturbance set in, these being great con¬
stipation, dark-brown urine, slow, or in some cases rapid but
feeble pulse, discoloured patches resembling purpura on the
limbs, and great prostration. In the cases which ended
fatally the cause of death was heart failure, with cedema of
the lungs.
AN ISOLATION HOSPITAL SCHEME
ABANDONED.
We regret to learn that a scheme under which joint
hospital provision was to have been provided for Enfield,
Tottenham, Edmonton, Wood Green, and South Hornsey
has had to be abandoned. It appears that opposition before
Parliament was threatened by the Southgate Local Board,
on the borders of whose district the hospital would probably
have been erected; and it was felt that, even if success
attended the efforts of the combining authorities, the appeal
to Parliament would materially increase the cost. The site
appears to be close to the Winchmore Hill Infectious Hos¬
pital of the Metropolitan Asylums Board; and it is not
easy to conceive bow a much less objectionable site, from
the sentimental point of view, could have been secured.
Indeed, Southgate would probably have been wise to have
joined in the scheme, which would, at all events, have given
them the use of a hospital which was not within their own
district. The result of tlie opposition is the more serious
because there are few suburban areas which stand in greater
need of means for the prompt isolation of infectious diseases
than those which had to do with this scheme. In fact, they
run considerable risk if they remain long as they now are in
this respect. _
PUBLIC HEALTH AND PROFESSIONAL
COURTESY.
A CASE of some difficulty is submitted to our judgment,
but as the leading facts complained of have been publicly
issued in the form of a report appearing in the local press,
we feel that the matter may properly be one for comment
by us. The only medical practitioner in Brandon, Norfolk,
draws our attention to the fact that the medical officer of
health for the Thetford rural sanitary district, having to
investigate the circumstances of a diphtheria occurrence,
has reported that the occurrence had its beginnings in four
cases which, he states, were certified by the Brandon practi¬
tioner to have died of “influenza and bronchitis that he
took this step without ever having seen the cases either
before or after death; that in the absence, ns be admits,
“of any other information of a reliable nature" than a
mere localisation of the disease and a record of cases and
deaths, he has publicly reported that these attacks con¬
stituted the “starting-point of the outbreak”; and that
the excessive fatality which attended the outbreak “ was
mainly due to imperfect medical supervision.” And the
Brandon practitioner proceeds to ask us whether such action
is professional, and whether a medical officer of health has
any right to examine cases witiiout the permission of the
medical attendant. Dealing with the last point first,
we would remark that so far as right is concerned no
duty of seeing patients is imposed on medical officers of
health, that this can only be done with the assent
of the sick or of their relatives, and that it must be regarded
as a breach of professional courtesy to take any such action
without some sort of communication with the medical
attendant of the sick. A medical officer of health should
not, without grave cause, undertake to go behind the certi¬
ficate of notification or of death of another practitioner,
and he certainly has nothing to do with the results of treat¬
ment and medical care. There may be occasions when aia
imperative duty is cast upon a public officer to take the
step of questioning a diagnosis; and it is at sucli times*
above all others that extra caution should be taken to^
comply with the common rules of professional courtesy.
This is the first time we have found a public report-
accusing a fellow medical practitioner of faulty diagnosis^
together with a suggestion of faulty medical supervision
and we sincerely hope that there is, in the original report
or elsewhere, something which has been omitted from the*
printed document, which will clear up a difficulty which
is obvious in view of such facts as are before us. The*
duties imposed upon medical officers of health are at times*
very delicate, and one of the first conditions necessaiy to
their proper fulfilment is the maintenance of an attitude of
strict professional courtesy towards all the medical prac¬
titioners in the district which is concerned.
HYSTERICAL FACIAL PARALYSIS.
A CASE, said to be of this nature, was recently communi*
cated to the Socidte Mddioale des Hupitaux by M. Gilbert
Ballet for M. Ed. Boinet of Montpellier. The patient was»
thirty-one years of age, and when she came under observa¬
tion was suffering from right facial paralysis of cerebraEl
type—i.e,, affecting the lower part of the face, associated
with anccsthesia, with rhythmical tremor of the right arm.
The tremor was recent, having come on after injury, but-
the condition of the face dated back as far as seven years.
The diagnosis of hysteria is made upon several grounds, the
strongest of these being the fact that the tremors dis¬
appeared in a few days under suggestion, a sufficient proof
apparently for French authorities that it was hyateiical.
But even if we grant that the tremor was a hysterical
manifestation, it by no means follows that the facial
paralysis is, and however difficult the explanation of the
condition may be there seems to belittle, if any, justification!
for the diagnosis of hysteria, a diagnosis as unsatisfactory
as it is meaningless.
THE HOUSING OF THE SALFORD POOR.
An inquiry has been held at Salford into the accuracy of
the representations of Mr. Charles Edward Paget as to five
unhealthy areas under the Housing of the Working Classee
Act. These areas contain respectively 149, 84, 82, 42,
and 21 bouses, the populations being 615, 240, 110, 90,
and 68 persons. The density of population in each re¬
spectively is 360, 377, 468, 233, and 319 persons per acre.
The average general rates of mortality in the five area©
during the five years 1884-88 ranged between 40 8 and 78 2,
and duringthe same period the death-rates from the principal;
zymotic diseases, including diarrhoea, ranged between 5'8 and
14-5, and from pulmonary diseases, including phthisis, be¬
tween 14-4 and 25'-4. During the years 1889 and 1890 these
high death-rates were maintained. Apart, therefore, fron>)
defective condition of houses in the areas, there was a strong
case against them, but we gather from the report of the-
evidence given at the inquiry thatthehouses were of the back-
to-back kind, and therefore nothing could be urged on their
behalf. As a matter of fact, the schemes were not opposed,
and we assume therefore that no obstacle will be put in the
way of the ISalford Corporation. The schemes proposed
only to rehouse 370 of the 1123 persons who would be dis¬
placed, and Mr. Samuel Joseph Smith, the inspector of the
Local Government Board, who held the inquiry, pointed out
that there was no evidence as to how accommodation was to*
be provided for the remainder. Mr. Paget, however, showed
thatwithinaquarter of a mileof these areas there was already
vacant accommodation for 625 persons. The inhabitants will
therefore not be exposed to any serious inconvenience.
Part II. of the Act gives special facilities to local autho-
Dic:: zed by Google
The Lancet,]
DURHAM DEGREES IN HYGIENE.
£April 4, 1891. 789
rities on this point, and it may he hoped that eventually
Part I. will be modified in the same direction. It is not
unreasonable to require that the land cleared shall be
devoted to houses for the working classes, but it is im¬
prudent in the highest degree to require that an area which
has been cleared at great expense shall be again over¬
crowded with buildings and population. We congratulate
the Salford Corporation and their medical officer on the
step which has been taken, and trust that nothing will lead
them to hesitate to continue to apply the Act until all the
unwholesome spots in their borough have been improved.
THE STRUGGLE FOR LIFE AT THE WRECK OF
THE “UTOPIA.”
In TAe Times of March 25th there appears from an officer
on board the Anson a most graphic account of the Utopia
disaster, evidently written while the terrible scene was fresh
in his memory and its horror still vivid before him. While
the officers of H.M.S. Anson were dressing for dinner the
‘' officers’ call ” sounded, and all were speedily at their posts.
The Utopia was sinking fast, and the waves, washing over her,
were sweeping away people by dozens into the sea around.
Every wave that passed over the ship lessened the numbers
.struggling for life. There was one man hanging by one leg
to some rope aloft quite dead and nearly naked, and around
were others clinging and shrieking for help. Another man
had lashed himself to the sails for security, and was drowned
standing up, while some of those free, and apparently
ia greater danger, were saved. One poor fellow, when the
Utopia first sank, got so excited that, crying out “ Oh !
I can’t stand this,” he jumped overboard. The cold water
brought him to his senses, and he was picked up and saved,
but he had no recollection of what he did. Hero is an
instance of the effect of shock on the senses suddenly
depriving the individual of the power of using them even
to save his own life. We are apt sometimes to under¬
estimate the effect of shock \n accidents leas appalling, and
it is only by such a circumstance as is here described that
we can judge by comparison of those lesser instances of
shock to the nervous system which we are so often called
on to relieve or to estimate the bearing of wuth regard to
the future life of an individual; especially is this so in
railway accidents, in which shock to the nervous system
often forms the most serious part of the injury.
ST. BOTOLPH’S CHURCH, ALDGATE.
In The Lancet of March 21at we pointed out that the
excavations in progress at St. Botolph’s Church, Aldgate, for
the purpose of widening the public roadway at the junction of
Houndsditch with Aldgate High-street, had disclosed a
quantity of human remains. It appears that in the course of
this work no less than 11(3 wooden cases, measuring inside
4 ft. by 1^ ft. by l^ft., each containing the osseous remains of
twelve persons, in addition to forty coffins, each containing
one body, or, approximately, in all, the remains of 1432
persons, had been exhumed on Eriday, the 20th ulb. It is
likely that since then more of these boxes and coHins have
been discovered. This enormous mass of human cor¬
ruption, we were informed by a correspondent in last week’s
issue, has been “reverently and decently” disposed of by
placing it in the vaults beneath the church itself, after !
being smeared with lime and covered an inch thick with
vegetable charcoal. A fortnight ago we protested against
this as “a retrograde movement not admitting of any argu¬
ments in its defence,” and suggested the removal of such
remains to some suburban cemetery. Dr. Sedgwick
Saunders, medical officer of health for the City of London,
also feels “that an earnest protest against such a course
should be entered in the interest of public health.”
He writes: “The floor of these vaults consists of fine dry
earth, intermixed with human bones in great quantities od
and beneath the surface, besides which they contain sunken
brick graves, in all probability containing human bodies in
every stage of decay.” He adds: “We know that no
amount of brickwork and cementing can ensure perfect
sealing of noxious emanations with any certainty.”
Further, the heating apparatus of the church will acfc
as an air pump, by which the foul gases will be attracted
and conducted into the interior of the church. In addi¬
tion to this Inspector Hills reports, that “settlements
have taken place in the brickwork, occasioning cracks
in the arches themselves, which are liable to increase
and add to the danger.” Dr. Saunders recommends that
a representation of these facts be made to the Home
Secretary, with a view to amending the order of th©
Consistory Court, and directing as an alternative th©
removal of the whole of these human remains to the
City of London Cemetery at Ilford, a course, as w©
pointed out previously, which should have been originally
carried out. Dr. Saunders has communicated with the
Home Office, and is authorised to state that Dr. Hoffman^
Medical Inspector, Burials Act Department, is in accord
with these views, lb is a question whether the interment
of human remains within St. Botolph’s Church is not in
direct contravention of an order in Council granted in 1853,
which prohibited any further burials either in the vaults or
churchyard of Sb. Botolph’s Church, Aldgate. But if the
question of the legality of the proceeding is doubtful, it is
more than fifty years since its impropriety and its unwisdom
were settled. In these days of burial reform it is without
defence.
DURHAM DEGREES IN HYGIENE.
A .SCHEME whereby registered medical practitioners over
twenty-two years of age can obtain the degree of Bachelor
or Doctor of Hygiene in the University of Durham has been
approved by the Senate of that University. The course
includes attendance on lectures on public health, attendance
on the clinical practice and lectures, instruction in .the
City Hospital for Infectious Diseases in Newcasble-on-Tyne,
and instruction in sanitary medicine and practical hygiene.
The examination will be conducted by written papers and
practical and viva-voce questions, and will be commenced
on Sept. 14bh, 1891, and again in April, 1892. Particulars
of the syllabus for this examination will be given in our
Students’ Number.
MORVAN’S DISEASE.
This condition, first described about eight years ago by
the physician whose name it now bears, is one of those
apparently spinal diseases associated with changes in sensi¬
bility and nutrition manifesting themselves especially in
the hands. The three symptoms on which at first a
diagnosis was made were pains in the limbs at the com¬
mencement of the illness, paresis and analgesia, especially
of the hands, and the appearance in one linger after another
of whitlows, painless but destructive. Several cases hav©
been described, bub the pathology of the disease is still
uncertain, some physicians regarding it as merely a form of
syringomyelia, while Morvnn and his followers, relying
upon the somewhat unsatisfactory examination of one
specimen, regard it as due primarily to some change in th©
cord associated with thickened arteries, and secondary
changes in the peripheral nerves. In i\ie Journal of the
American Medical Assodationf Dr. Church of Chicago
gives a clinical account of a case which seems to answer
to the description of this disease. The patient is a Swede,
aged thirty-live, the commencement of whose symptoms
date back to ten years ago, when be bad a whitlow on the
Dig!..zed by Google
790 The Lancet,]
DEA.TH UNDER CHLOROFORM.
[April 4,1891.
right ring finger, which was painful, and has left the distal
phalanx stunted, and nail much altered. About this time,
also, his back wai noticed to become bent, although pre¬
viously it had been quite straight. A few years ago, after
bathing in a cold lake and driving afterwards some distance,
his left wrist, hand, and arm became swollen and painful.
The swelling in the wrist has never quite subsided, and the
carpus is now to all appearance d^organised but quite pain¬
less. Three years ago he had a painless whitlow on the
right index finger, in which now the distal phalanx is
completely wanting, as well as a part of the middle one.
In the same year the middle finger of the right hand sirffered
a similar mutilation, also from a painless whitlow. He
now has these deformities in the fingers and the left wrist,
has retention of ordinary tactile sensibility everywhere, but
with loss of the power of distinguishing tactile from painful
impressions in the hands. Above the hands this disability
gradually disappears. There is also present marked lateral
curvature of the spine ; his gait is shambling, but displays
no distinctive peculiarity; his reflexes are normal, and his
mind is unatFected. The case is a peculiarly interesting
one, especially in reference to differential diagnosis from
syringomyelia, but more will have to be known of both
conditions before a certain diagnosis is possible.
CHYLURIA IN HUNGARY.
A CASE of chyluria, the first recorded in Hungary, was
exhibited by Dr. Angydu before the Buda-Pesth Medical
Society at its last sitting. The patient was a man of thirty-
four, who bad noticed his urioe to be turbid for four or five
months, this being especially marked in the latter part of
the day, that passed in the morning being less affected,
and sometimes even quite clear. Occasionally he suffered
from pain in the region of the kidneys. The urine was
found to pass turbid through a filter, but the addition of
ether cleared it. With the microscope, molecular corpuscles
were seen, and also red and white blood-cells. The specific
gravity varied from 1025 to 103G.
DEATH UNDER CHLOROFORM.
A CASE of death under chloroform is reported by Surgeon-
Major Gordon Price, civil surgeon at Burdwan, India, in the
current issue of the Indian Medical Gazette. The fatality
occurred at the Burdwau Dispensary, and the patient, aged
thirty, was about to have a plastic operation performed upon
her face for the restoration of her nose. Physical examina¬
tion revealed no evidence of disease beyond a splenic
enlargement; the heart and lungs were healthy. Surgeon-
Major Price himself administered the chloroform, and used
ell precautions. Upon the patient becoming unconscious,
iie requested his assistant. Surgeon Bibu Guru Nath San,
to undertake farther chloroformisation while he proceeded
with the operation. Assistant Surgeon Sen exclaimed,
“ Wait, her pulse has stopped.” “ How can that be?” was
the reply; “her respiration is all right,” pointing to the
patient’s abdomen, which was rising and falling regularly.
Upon feeling for the radial pulse the statement of tiie
assistant surgeon proved to be correct. “A few seconds
afterwards her breathing, which had been perfectly normal,
almost ceased.” Artificial respiration was sedulously but
vainly tried for an hour, and all efforts to stimulate the
heart and respiration failed. Surgeon-Major Price con¬
cludes: “There was not at any time during the ad¬
ministration of the chloroform the slightest tendency to
otertorous breathing, and the woman’s chest and abdo¬
men could be seen regularly rising and falling, as in
{normal respiration, until some seconds after the exclama¬
tion of the assistant surgeon. The amount of chloroform
cised was not measured, but was not excessive. I have
always believed, even before the time of the Hyderabad
Commission, that in death from chloroform the breathing
was primarily affected, and have, in administering the drug,
paid continual attention to the patient’s respiration, and
have impressed this at all times upon my assistants. In the
present case there cannot he any doubt that the heart was
primarily affected.”
FRIEDLANDER’S PNEUMOCOCCUS AS A
FERMENT.
It has been known for some time that Friedlander’s
pneumococcus is capable of inducing fermentative changes
in suitable solutions of glycoso and cane sugar, this having
been first discovered by Brieger. His observations have
quite recently been confirmed by Dr. Percy Frankland,
Mr. Arthur Stanley, and Mr. William Frew, who have just
communicated a paper on the subject to the Chemical Society
of London. They further found that the organism ferments
maltose, milk sugar, rafilnose, dextrin, and mannitol, but
that, like the bacillus ethaceticus,it does not attack dulcitol.
They made a special study of the fermentations of glucose
and mannitol,^determining quantitatively the proportions in
which the several products are formed. These products are in
each case ethyl, alcohol, acetic acid—generally accompanied
by a little formic acid and a trace of succinic acid—carbon
dioxide, and hydrogen. Both the glucose and mannitol were
in all cases only partially fermented, and the decomposition
of the glucose was especially incomplete, glucose being
apparently less readily attacked by the organism than man¬
nitol and cane sugar. The fermentation was not rendered
more complete by furnishing the organism with a more abun¬
dant supply of nitrogenous food. The products of the man¬
nitol fermentations were not only qualitatively similar to
those obtained in the fermentation of the same substance by
the bacillus ethaceticus, but the relative proportions in which
they were formed were almost identical, the ratio corre¬
sponding closely to the molecular proportions 2 CgHs.OH :
CH 3 .COOH. _
THE INFLUENZA IN AMERICA.
An epidemic of this disease is said to be raging with more
than ordinary virulence in Pittsburgh and in Alleghany.
At Chicago the death-rate has increased to 150 daily.
Hospitals which were intended for the reception of accident
cases or paying patients only have been thrown open to the
sufferers from influenza, and are crowded beyond their
resources. From Cleveland, Ohio, 2000 cases are reported,
and in New York 160 policemen are on the sick list.
THE SECOND CONGRESS OF AMERICAN
PHYSICIANS AND SURGEONS.
This Triennial Congress is to meet at Washington, D.C.,
in September, from Tuesday, Sepb. 22Qd, to Friday,
Sept. 256h, inclusive. Dr. S. Weir Mitchell will preside.
Dr. John S. Billings is treasurer, Dr. William Pepper is
chairman of the executive committee, and Dr. W. H.
Caniialt, Newhaven, Conn., is the secretary. The Congress
is a meeting of certain national medical societies, so arranged
that, while each society meets separately, there are stated
occasions in which the members of all meet and constitute
the Congress. According to the preliminary programme the
chief subjects of discussion will be: Oa the Tuesday, Con¬
ditions underlying the Infection of Wounds, including a
discussion on Disinfection; of the Relation of Bacteria to
Suppuration; of the Resistance of Tissues to the Multi¬
plication of Bacteria; and of the Effects of Antiseptic
Agents on Wounds, by Dr. Welch of Baltimore, Professor
of Pathology in Johns Hopkins University, and Dr. Roswell,
Professor of Surgery in the Buffalo Medical College. On
the Wednesday: The Late Manifestation of Syphilis, by
Digitized by ^OOQ[C
Thk Lanobt,]
THE PUBLICITY OF NOTIFICATION RETURNS.
[April 4,1891. 795
Dr. Phineas S. Conner of Cincinnati, Professor of Surgery in
the Medical College, Ohio, and Dr. Abner Post of Boston,
Instructor in Venereal Disease and Syphilis in liarvard
University. On the Thursday: Fibroid Processes (Chronic
Interstitial InHaromation, Scleroses), their Pathology and
Etiology, with special reference to the InEuence of Diathesis
and Heredity, by Dr. Alfred L. Loomis of New York City,
Professor of Pathology and l^ractice of Physic in the
University of the City of New York, and Dr. William
Osier of Baltimore, Professor of Medicine in Johns Hopkins
University. The programme is well conceived. The con¬
stitution of the Congress warrants that the subjects will be
viewed from many different points, and the executive is a
guarantee of the representation of all that is best in
American medicine and surgery.
“ASTASIA-ABASIA.”
Dr. Graeme M, Hammond of New York reports a case
of this disorder. The patient was a young woman in whom
the symptoms came on after overwork. She had no neurotic
history, she had previously shown no sign of hysteria, and
she was active and energetic naturally. But at the com¬
mencement of her illness she had suffered from aphonia. The
condition described as “astasia-abasia” is one of inability
to stand or walk, but without paralysis—that is to say,
that the patient is able to carry out all movements of the
limbs as she lies in bed, but is unable to walk. This patient
in attempting to walk advanced the left foot, and then
slowly brought the right one up to it, alleging that if she
tried to rest her weight on the right leg she would fall.
An attempt to do so resulted in her turning round to the
right and falling, and the same tendency to turn to the
right was evident to anyone supporting her. There was no
anoisthesia, colour-blindness, or contraction of the visual
fields. The knee-jerks were active, and there was no
ankle-clonus. There appeared to be, however, slight loss
of muscular sense in the right leg. The previously de¬
scribed cases of this disorder have been similar to .Dr.
Hammond’s, although in many there have been various
disturbances of sensibility, consisting in some of an.'oathesia,
in others of hypercesthesia. There seems to be little, if any¬
thing, to distinguish the case from one of so-called functional
paraplegia-—a by no means uncommon condition,—and Dr.
Hammond himself is of opinion that the condition is a
hysterical one. _
THE ACTION OF THE VAPOUR OF ETHEREAL
OILS ON BACTERIA.
Notwithstanding the researches of Schultz, Koch,
Schill, Fischer, Riedlin, Chamberland, and Braddon, the
action of ethereal oils in a state of vapour upon bacteria
is by no means well known. As this is a subject which
bids fair to have practical interest for the physician as
well as for the bacteriologist, a somewhat elaborate re¬
search by Dr. Omelchenko, which is published in the
Frac7i, is a welcome addition to our information. Its
details must have been very carefully planned and carried
out, for it gained -the Pirogoff gold medal of the University
of Kieir. The observations were made upon cultures of the
bacilli of typhoid fever, phthisis, and the Siberian sore
(anthrax) by passing over them with the help of an aspirator
a slow but continuous stream of air saturated with the
vapour of certain ethereal oils, and noting the time which
each different vapour required to destroy the bacilli; the
quantity of each oil used and the volume of air passed over
each tube, as well as the amount of each vapour which the
air was capable of holding, were also noted. It was found
that if the air was not quite saturated, the effect was
very markedly diminished. The bactericidal properties of the
different oils were found to be greatest in oil of cinnamon.
after which the others may be arranged with reference to-
their bactericidal power in the following descending order:—
Oleum focniculi, oleum lavendulm, oleum caryophyllorum^
oleum tbymi, oleum menthm piperitie, oleum anisi, oleum
mentbm ciispae, oleum eucalypti global!, oleum camphorao
japonic®, oleum valerian®, eucalyptol, French oil of tur¬
pentine. The oils of lemons &nd of roses bad an exceedingly
slight action. Bacteria in a dry state were much less easy
to destroy than those which were in their natural state; s*
fresh condition of the sporules of the Siberian sore,
however, weakened the destructive effect of the vapour.
It was found that the protoplasm of the various bacilli
was affected in its chemical constitution in a constant
manner for each kind of bacterium, losing its power
of taking the stain. This change seemed to affect alt
parts of the organism equally. The death of the bacteria,
was shown both by this loss of capacity for taking the>
stain, and also by the tendency to assume a granular con¬
dition. Tables are given of the experiments, from which
we see that oleum cinnamomi and oleum valerian® took the-
same time to destroy the bacilli of typhoid fever—viz., forty-
five hours; but, inasmuch as each litre of air took up only
0-0005 grm. of the former, as against 0 0082 of the latter,,
the total quantity of cinnamon oil used being 0-0646grm.,
while 1-0429grm. of the oil of valerian was required, it i&
evident that the former deserves the higher place in the
scale of bactericidal substances. Experiments by previous-
writers made with emulsions of ethereal oils placed in con-
tact with bacterial cultures have not generally shown that
these possessed a high bactericidal capacity, and Dr,
Omelchenko found that when he passed the air through
emulsions instead of through the oils themselves the amount-
taken up was materially less than in the latter case, and 80 >
it would appear that the bactericidal capacity of any one o3
these substances depends largely upon its volatility.
THE PUBLICITY OF NOTIFICATION RETURNS.
The London School Board have applied to the Metro¬
politan Asylums Board to bs furnished with information-
respecting the occurrence of cases of infectious diseases ia
the metropolis, as shown by the notification returns, and ia
making this demand they are supported by what passed at
a conference of metropolitan medical officers of health in-
December last. We can quite understand the demand of'
the London School Board. Nothing is more evident than.
that diseases such as diphtheria, measles, and scarlet fever-
owe their spread largely to the aggregation that takes place-
in elementary schools, and if any information is available,
enabling this spread to be prevented or diminished, it seeme.
absurd to withhold it. But it can apparently only be
properly utilised if the schoolmasters and schoolmistresses
are, in turn, supplied weekly with the notification lists'
which apply to the localities from which the childrens
attending their schools are derived. And this means an.
abandonment of that avoidance of publicity which is be¬
lieved to have governed the drafting of the Infectious*
Disease (Notification) Act, 1889, and especially of its third
section, by which it was enacted that the returns, instead'
of being sent to the sanitary authority, were to be trans¬
mitted to the medical oificer of health, who could be trusted*
to understand the desirability of maintaining, so far as it-
was possible having regard to the interests of the public,,
an attitude of professional secrecy.
OCULAR TROUBLES IN TABES DORSALIS.
Dr Berger, in the Revue de Mcdecine, htw drawn attentiony
to this subject. He has observed 109 cases of the disease,
and from the results of those observations he draws certain
conclusions. He finds that, in cases in which the condition
has manifested itself in youth or in old age, serious oculat-
Diuitizr;c: by Goog 1C
792 Thk Lancet,]
WORKING WOMEN AND FACrORY LEGISLATION.
[APKlli 4,1891.
troubles are not met with, and that it is when symptoms ol
the disease appear between the ages of twenty-hvo and
forty that those complications for the most part occur. In
half the cases observed the Argyll-Robertson phenomenon
was present. In eleven cases it was accompanied by
mydriasis, in fifteen cases the pupils were of the usual size,
a.nd in two there was contraction of one with dilatation of
the other pupil. He also found in a certain number of cases
€ome irregularity in the shape of the pupil, and be remarks
that when myosis is present with the Argyll-Robertson
phenomenon the instillation of atropine causes a dilatation of
the pupil, which may persist for four or five weeks. Atrophy
-of the optic nerve was found to be present in .33 per cent,
of the cases, and it did not occur simultaneously in the two
nerves. The interval between the commencement of atrophy
.and the establ^hmeot of complete blindness was found by
this author to vary from two months to seventeen years,
&nd he states that it usually begins in the pre-ataxic stage,
And that, this stage once passed, the danger of atrophy
netting in is considerably diminished. Paralysis of the
external muscles of the eye was observed in 38 per cent,
of the cases. It was found occur usually in the pre-
Ataxic stage, to be as a rule transitory, and to bo more
dreguent and more lasting in patients with a clearly specific
history. In conclusion, the author formulates a theory of
the pathology of tabes. In his opinion it originates in
some change in a centre in the medulla regulating the vaso¬
motor condition of the optic nerve and of the spinal cord.
WORKING WOMEN AND FACTORY
LEGISLATION,
The Women’s Trade Union League recently held several
special meetings to discuss the Factory Rills now before
iParliament. The League, from its long and practical
experience of the difficulties under which women labour
who seek to earn their living, was in a good position to
judge the merits of the proposed legislation. This legisla¬
tion, in the opinion of the League, is evidently incomplete.
The discussions are summed up by a series of resolutions
which, we are pleased to note, agree with many of the
suggestions we made during the course of our inquiries on
'the sweating system. For instance, the first resolution
dusists that in factories and workshops each sex should be
provided with separate sanitary accommodation. Then the
League is so impressed with the necessity of a great increase
in the number of factory inspectors that it proposes the
creation of sub-inspectorships. These sub-inspectors would,
we presume, stand in somewhat similar relationship to the
'inspectors as sanitary inspectors do to the medical officers
of health. With respect more particularly to the sweating
•system, the League agrees with us that “the worst
■economic and sanitary evils arise from the impossibility of
saupervising and controlling home workers”; it there¬
fore urges that “home work should be discouraged by
every means available, and that all sucli places, in¬
cluding even bedrooms, where goods are ma-ie up which the
public will be invited to purchase should be put under
■the control of the public, and consequently subjected to the
visits of factory and sanitary inspectors.” This thoroughly
coincides with the principle we have always proclaimed—
namely, that the public has the right to protect itself
Against the danger of infection by controlling the manu¬
facture of the articles it purchases. But in ail this there
are two difficulties to be overcome—the supineness of local
Authorities and the resistance of the working classes them¬
selves. The local authorities are, too often, slow to take
action. The League therefore urges that some central
authority should have the power to stimulate and, if
necessary, to force the hand of the local authority. This,
we take it, is what is implied by the first clauses of
Mr. Matthews’ Bill. There will still remain, however, the
resistance of the working classes themselves, who dread
such sanitary inspection as may lead to interference with
their work and consequently reduce their too slender
earnings. The Women’s Trade Union League, to obviate
this obstacle, recommends that power should be given by
law to local authorities to make grants from the rates in
compensation for loss of work occasioned by the closing of
workshops or factories ordered by such local authorities on
sanitary grounds. This is an important suggestion. We
have often urged that workers, especially home workers,
like tailors, laundresses, &c, who usually earn barely
enough for subsUtence, should, when their work is stopped
for sanitary purposes, such as disinfection, be compensated
by the authorities. Otherwise the laws of self-preservation
and the fear of hunger will tempt workers in this precarious
position to conceal the outbreak of any infectious disease.
They must be made to feel that it is a public duty to give
immediate notice of the presence of infection in their homes
or their workshops, and that the neglect of this obvious duty
will entail severe punishment, but that its due observance
will result in no loss, for due compensation will be forth¬
coming. Altogether it will be seen that the Women’s
Trades Union League has, in its study of the necessary
remedies to mitigate the evils of the sweating system, come
to about the same conclusions as those we were led to adopt
after the disclosures made by the special commissioners of
The Lancet, who visited the principal sweating dens of
East London and the leading provincial towns.
LARYNGEAL COMPLICATIONS IN TYPHOID
FEVER.
In severe cases of enteric fever various throat complica¬
tions have been described, bub their connexion with the
original disease has not been satisfactorily established. In
L’Union Midicale of March lObh, 1891, Professor Peter
describes a case of a man who died of typhoid fever, and in
whom the throat complications were well marked. In com¬
menting on the case he remarks that hyperzemia of the
larynx is a common symptom of typhoid fever, being most
marked on the aryteno-epiglobtidean folds. Ulceration
following this condition was first noticed by Louis
in 1828, who stated that if at a necropsy extensive
ulceration of the larynx was found, and if tuberculosis
could be excluded, typhoid fever lesions should be sought
for. Occasionally, when the laryngitis is intense, Eberth’s
bacilli are found in the glands around the larynx. An
cedematous swelling often appears, and the inflammation
may lead to suppuration, extensive ulceration, and even
destruction of the cartilages. Laryngitis in connexion
with enteric fever assumes two chief forms : the acute and
the chronic. The first-mentioned develops from the fifteenth
to the twentieth day, at the time when the disease ought
to be subsiding. Its onset is marked by local pain, difficulty
in swallowing, and dyspncca chiefly affecting inspiration,
expiration being perfectly easy. The difficulty of breathing
gradually increases, generally requiring tracheotomy to be
performed in order to prevent death by suffocation. Post
mortem there is found sero-fibrinous or purulent infiltration
with commencing destruction of the epiglottis and the ary¬
tenoid and cricoid cartilages. The more chronic form does not
commence until convalescence has been well established,
at least two months after the termination of the attack,
and when the patient is apparently cured. The voice
becomes hoarse, there is evident difficulty in speaking, and
finally symptoms of cedema of the glottis appear. The
prognosis is then very grave; according to Sextier of ton
cases which required tracheotomy all proved fatal. Some
German statistics show that of nineteen cases which required
Digitized by i^ooQle
The Lancet,]
REGULATION OF STREET MUSIC.
[April 4, 1891. 793
operation seven only recovered. Even if a cure is effected
the condition is a very unsatisfactory one, as the cannula
has to remain in position for an indefinite period, and the
cicatrices which form in the lamyx often producing such con¬
striction as to cause almost total obstruction. In short, in all
the parts affected by enteric fever there is a tendency to
ulceration, and this is particularly liable to occur in the
larynx, and if such happens the submucous tissue becomes
infiltrated, and perichondritis follows in its turn. Finally,
there is erosion of the cartilage; and, if the patient survives,
there are premature ossihcation of the cartilages and necrosis
of the epiglottis and of the arytenoid and cricoid cartilages.
Sometimes a small portion of cartilage may be detached—a
very dangerous occurrence, as it is very apt to fall into the
trachea and cause alarming symptoms, and even death from
suffocation. At other times the whole cricoid cartilage
may become detached, and be ejected in the form of a
sequestrum. The only treatment likely to be effectual is to
apply counter-irritants, such as blisters, to the front of the
neck.
REGULATION OF STREET MUSIC.
The nuisance caused by street “ musicians ” is a very
ancient grievance, and it is greatly to be hoped that Mr.
Jacoby will be more successful in his proposed measure for its
removal than others have been before him. His proposal is
that every street “ musician shall, when requested by any
householder to cease playing his “ instrument,” do so, and
remove to a distance of not less than a quarter of a mile.
There are, we believe, other provisions, but this is the one
in which, as caring for the public health and the comfort of
members of our profession, we are most interested. A large
proportion of the inhabitants of these kingdoms must dwell
in large towns or cities, and to all those who do not possess
the power of abstraction, the wear and tear of nerves, the
worry and trial of temper caused by noises, tell very seriously
on the health, and, it may he added, even on the duration
of life. Street noises may he divided into those which
are inevitable and those which can be prevented. To the
former belong those caused by street traffic, to which people
get so used that the quiet of the country is often irksome;
while modern forms of pavements have in recent years done
something to diminish them. The principal noises which can
and ought to be prevented are those caused by street cries
and street “music.” Church bells, too, especially when tolled
in the monotonous manner so familiar to all Londoners, cause
a noise which is very distressing to many invalids as well as
to healthy but nervous people, and which is wholly un¬
necessary. Whether it would be possible to silence the bells
of the established churches by episcopal authority is an open
question; but it may be observed that in churches and
chapels belonging to other denominations and in the Epis¬
copal churches of Scotland large congregations assemble for
worship without any bell summons ; and if the bells in all
the London churches were silent save at the hours, half
hours, and quarters, the congregations would probably be
as large, though there might at lirat be some late arrivals.
We have frequently pointed out that the tolling of bells
previously to any other service than morning and evening
prayers and funerals is not legal, and is certainly without
any use. It is unfortunate that the subject of street
“music” has never been treated either in or out of
the House of Commons with the seriousness which it
merits. Those who complain of it are ridiculed, or a
plea is urged on behalf of the poor who but for these
itinerant “musicians” would never hear that “music” which
“hath charms to soothe the savage breast.” It may be
very safely asserted that the music alluded to by the poet
was very different from the discordant sounds which issue
from German bands and Italian barrel organs. Moreover,
Londoners have this so-called street music inflicted upon
them at any hour of the day, however unseasonable, from
early morn to dewy eve, and even up to nearly midnight.
The late Mr. Babbage, the late John Leech, and others,,
who have earned fame in literature, had their lives harried,
if not shortened, by this pest, and the marvel is tbab
it has been tolerated so long. The Bill proposed by Mr.
Jacoby is, as regards this its moat important clause, similar
to a local Act in force in Liverpool and elsewhere. The-
streets do not belong to any individual or class, but to all,
and nothing can be more reasonable or moderate than that-
any householder should have power to prevent any street
“ musician ” from playing to his annoyance. Care must
he taken to draft the clauses so that there shall be no loop¬
holes left for evasion, and it would be well to have copies of
the Act (if passed) translated into German, Italian, and
such other languages as may include the nationalities of all
street “musicians.” In conclusion, it may be observed that
street bands and organs have been the cause of many fatal
.street accidents. For all which reasons we trust that-
Mr. Jacoby’s Bill will pass.
A REMEDY FOR ANTHRAX.
Me. E. H. HaNkin [Cmtralbl. f. Balder., vol. ix.,.
Nos. 10, 11) of Cambridge University has succeeded in
isolating from the spleen and blood-serum of the rat an
albuminoid substance which destroys bacterial life. It is
a basic body, differing from any bases hitherto known in
being insoluble in alcohol and in water, and in not
dialysing. It is a globulin ; and to its presence is ascribed
the power possessed by the blood serum of the rat of
killing anthrax bacilli. Mr. Hankin thinks it probable
that the immunity which the rat enjoys to anthrax and
diphtheria is, in part at least, to be ascribed to the-
capability of the rat organism of producing this material.
Still further importance is to be assigned to this research
from the conclusion that the bactericidal property of this-
substance can be exerted not only outside, but also within
the body of animals susceptible to anthrax. Hence it is-
possible, he thinks, for the “protective albuminoid body
of rats ” to be utilised as a remedy for anthrax.
JUVENILE SMOKING.
Excellent common sense on the whole directed the-
proceedings at a conference recently held in the Town Hall,
Manchester, to consider the expediency of arresting the
prevalence of juvenile smoking. According to the medical
officer of health for the city this habit is practised by 80 per
cent, of the Lancashire boys, and his rough calculation may
nob be very far from an accurate statement of facts. Any¬
one, or rather everyone, who daily meets with that pre¬
sumptuous atom of manhood, the' boy cigarette-smoker,
must have been astonished at the general distribution of the-
prodigy. Equal, if not greater, is the surprise excited by
his diminutive size and exceedingly tender age. Some
years ago it was the boy of twelve, fourteen, or sixteen
that opened our eyes. Now it is the six or eight years old,
the literal infant who prolongs his still recent privilege of
suction in a fashion undoubtedly hurtful by perverting at a
critical period the sensitive processes of nervous action and
nutritive change. The Manchester conference discvissed
various possible correctives of this mischievous practice.
Among these we may mention education of a homilectic
character, to be carried out in Board schools. Another and
more practical suggestion advised ministers and teachers to
set the example of abstinence in their own persons. As a
last resource, it was proposed that the aid of the law—re¬
stricting, as in Germany, the right to use tobacco to persons
over sixteen years of age—should be called in to strengthen
Digitized by
Google
T9 4 Thb Lancet,]
THE DEATH OF EARL GRANVILLE.
[April 4,1891.
6 be gentler measures already referred to. As regards the
wisdom of this latter step there would seem to be some
question. We are not of those who favour the unnecessary
multiplication of petty laws. There is, in cases of the
Viod in question, no power which in our opinion is either
so natural, so safe, or so effectual as that of judicious
home training, and we are not hopeless of yet seeing its
influence applied far more widely than at present. -
THE DEATH OF EARL GRANVILLE.
We record most regretfully the close of the earthly
'career of the eminent statesman and politician Lord
G^ranville, at the age of seventy-six years. In his last
illness he was attended by Sir Andrew Clark, Sir James
d^aget, and Mr. Reginald Harrison. Some six weeks ago
he caught a chill, from which be never completely rallied.
Being of an extremely gouty disposition, his previous
attacks of that disease had very much enfeebled his
«cuperative powers. From time to time he seemed to.
rally ^nd regain strength; and during the illness he had
an attack of parotitis, which resulted in suppuration of
the parotid gland and necessitated its being opened. This
was the only operation to which he was submitted, and it
did not seem to have very much to do with the fatal issue.
Daring the last week of his illness he manifested a great
distaste for food, and although all kinds of endeavours
were made to administer nourishment they were unsuccess¬
ful. He gradually grew weaker, and finally succumbed
on the evening of Tuesday, March 30th. While all men
owe gratitude to him for the deep interest he took in
educational matters, medical men owe more from the
peculiar interest he took in that profession. Universities
.and colleges, hospitals and medical schools, have alike
derived inestimable assistance from the deceased nobleman.
He occupied the position for the last thirty-five years of
'Chancellor of the University of London, and was president
oi the Royal Medical Benevolent College at the time of his
death. A late president of the College of Surgeons has
spoken of him as “an illustrious statesman, who, as
Chancellor of the London University, is foremost in
the promotion of general education, and President of
the Medical Benevolent College, a president who has
taken a very active part in its welfare.” But in days
dong since gone by, between 1837 and 1846, the period
par excellence of medical reform, when he was a mem¬
ber of the House of Commons, he invariably lent his
assistance to the promotion of those reforms, and has
frequently expressed his admiration of the founder of
The Lancet, and of the efforts made by the late Mr.
Wakley to effect legislation on behalf of the medical pro¬
fession. Those were the days of the Coroners Bill, the
Medical Witnesses Biir, the Factory Bill, the Vaccination
Bill, and the Medical Reform Bill. Infall these legislative
measures, and in many others, the late Earl took an active
part, and accorded his influential support to every measure
of reform which was to benefit the medical profession
generally. And since that period, during the forty years in
which he had occupied a seat in the House of Lords, he con¬
tinued to he an earnest friend and benefactor to our profession.
THE RESPONSIBILITY FOR INFECTION.
It is nothing new to learn that infection may be trans¬
mitted by post, yet we cannot doubt that this fact is often
overlooked and sometimes, as in an instance lately reported,
by persons whose knowledge of the probable consequences
ought to make them more careful. In the case referred to
a hospital matron was censured and fined in costs for
sending to the neighbouring isolation hospital by parcel
post, and without using the needful sanitary precau¬
tions, a package of clothes which had been forwarded to
her by a nurse for disinfection. One can easily under¬
stand the natural dread which prompted this action
as the readiest means of removing from the hospital
premises material so dangerous to the health of its inmates.
The primary fault it must be allowed was not on the side of
the matron. The sender of the clothes and the occupants
of the house whence they were sent were the original
culprits, for, by the terms of the Infectious Diseases Act,
disinfection, Avbere not undertaken by the local authorities,
must be carried out by the owner or occupier of the infected
dwelling. Possibly the clothes in this case were the nurse’s
own, but if so this makes no real difference. They were for
the time being within the infected house, and their purifica¬
tion should have been there provided for. This circum¬
stance does not, of course, excuse the matron, who, having
received the parcel, was responsible for its disinfection; but
it should serve, as it well may, to render any in her position
severely careful that the duties imposed by law in such
matters shall be discharged by those who are in the first
place accountable for their performance.
THE PIGMENT OF MELANOSIS.
Dr. Felix Lagrange, in a paper read before the Socidtd
d’Anatoniie et de Physiologie de Bordeaux on Dec. 8th of
last year, described some investigations he had made as
regards the distribution of the pigment in two melanotic
tumours. One case was that of a melanotic sarcoma
which had been removed from the orbit, and the other was
a tumour of the eyelid. Microscopic examination showed
the same structure in both cases, but the tumour which
had developed in the orbit was more deeply pigmented than
the other, though thedistribution of the pigment was morpho¬
logically the same in each case. Sections of both tumours
exhibited fusiform cells and many embryonic elements. ■ A
few vessels were seen, but there were no hmtnorrhagic foci.
The pigment was intra-eellular. In some cells it was com¬
pletely absent, whilst others were so full as to lose their
characteristics, and to appear as black round masses; other
cells, again, contained in their protoplasm fine black granules.
In order to study the nature of this pigment it was neces¬
sary to isolate it from the cellular elements. By treating a
section with sulphuric acid, the cellular elements were par¬
tially destroyed. Under the influence of this reagent the
sarcomatous tissue became shrivelled, remaining as a
translucent structureless mass, in the centre of which
was the pigment. Nitric acid was next tried; but,
although the structure of the tumour was completely
destroyed, there still remained a whitish residue in which
the pigment remained entangled. In order to obtain
a pure preparation of melanino the following process was
adopted with success. Having treated a portion of the
tumour in which the pigment was abundant with pure
sulphuric acid, it was placed, still saturated with the
reagent, for twenty-four hours in a moist chamber. In this
way the now plastic tissue was partially liquefied, some
glycerine was then added, and the containing vessel closed
for forty-eight hours. At the end of that period there
remained nothing but the pure pigment. It presented
three principal forms. 1. Some black masses, evidently
formed by the union of a series of granules, separated
by unequal intervals, the spaces being filled by a trans¬
parent cement which had been unaffected by the acid.
These masses were the remains of those cells which had
appeared to be entirely filled with the pigment. 2. Fine
disseminated granules, which were rounded and very
numerous. 3. Small irregularly shaped particles, for the
most part angular, but presenting considerable variations
in their form and size.
Digitized by LjOOQle
Thb Lancet,]
SECONDAEY SEXUAL CHARACTERS.
[April 4, le91. 795
FOREIGN UNIVERSITY INTELLIGENCE.
Bxida Pebth. —The medical faculty have drawn up a plan
for altering the medical examinations for the degree of
M.D. Accouling to the new scheme,, which has yet to re¬
ceive the sanction of the Minister of Education, the present
three great Rigoroaen, or “ severe examinations,” will be
replaced by five, as follows:—1. Physics and Chemistry.
2. Anatomy and Physiology. 3. General Pathology, Patho¬
logical Anatomy, and Pharmacology. 4. Clinical Medicine,
Surgery, Midwifery, and Ophthalmology, also Operations.
5. Systematic Medicine and Surgery, Medical Juris¬
prudence, Hygiene, and vivA-voce examination in some
special department of Practical Medicine.
Kiel. —Dr. F, Graf von Spee has been promoted to the
rank of Extraordinary Professor.
Roatock. —Dr. F. Blochmann of Heidelberg has been
appointed to the chair of Zoology, in succession to Professor
Braun, who has accepted an invitation to Konigsberg.
Toulouse. —This school of medicine has been suppressed
by decree, and replaced by a'“faculty.” The following
appointments have been made to professorships:—Anatomy,
M. Charpy; Histology, M. Tourneuxof Lille; Pathological
Anatomy, M. Tapie; Operations, M. Labcda; Forensic
Medicine, M. Duponchel; Clinical Medicine, M. Caubet
and M. Moeeo of Montpelier ; Clinical Surgery, M. Chalot
of Montpelier and M. Jeannel; Clinical Midwifery,
M. Crouzat of Paris; Chemistry and Toxicology, M.
Frdbault; Pharmacy, M. Dupuy.
Vienna. —Dr. M. Kassowitz has been promoted to be
Extraordinary Professor of Children’s Diseases.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced;—Dr.
Maly, Professor of Chemistry in the University of Prague,
at the age of fifty-nine.—Dr. Wilhelm Sohlesinger, a well-
known Vienna medical author, at the age of seventy-nine.—
Dr. Karl Beyerlein, one of the most eminent of the Kissingen
physicians.—Prof. Karl Braun von Fernwald of Vienna, at
the age of sixty-nine.—Dr. N. P. Vasilielf, privat docent
in the Sb. Petersburg Medical Academy, and editor of
Botkin’s Bolniehnaya Gazeta, of cardiac disease, at the age
of thirty-seven. _
Thu Council of King’s College last week elected Dr.
Joseph Priestley, B.A., M.D., D.P.H., as Demonstrator in
State Medicine and Public Health at their new laboratories,
We regret to announce the death, at the age of seventy-
nine, on the 28bh ult., of Deputy-Inspector-General of
Hospitals James Ssinderson, F.R.S.Edin., of the Madras
Army (retired).
SECONDARY SEXUAL CHARACTERS.
The study of biology is perhaps one of the most instruc¬
tive and humanising pursuits in the domain of science, and
scientific medical men have by no means had the smallest
share in the development both of its botanical and zoolo¬
gical departments. Lectures on the subject are rarely
characterised by the two qualities of impressive delivery
and artistic illustration. We have listened frequently
to lectures on this subject, and in many cases have
been fain to admit that, although they were “well
drawn,” the amount of real instruction which has been
received and retained must have been to a large extent the
result of the inherent intelligence of the audience. On
the other hand, llights of oratory dealing with portions of
aubjocts in the shape of popular lectures have proved
through the scantiness of illustration but very insubstantial
mental pabulum. The best lectures are those which,
like the “ object lesson,” combine the qualities of apt¬
ness and facility of illustration with interesting and
impressive statement. A series of six lectures of this
kind has just been delivered in the Royal College
of Surgeons by Professor Charles Stewart, whose artistic
skill and clearness of exposition made the course
a most instructive and enjoyable one. He chose for
his subject “ Secondary Sexual Characters,” a term which
he defined as comprising those features by which we are
enabled to distinguish the male from the female quite
irrespective of the essential organs of reproduction, and
which are not concerned either in the nourishment or in the
protection of the young. He brought together and ex-
nibited a number of preparations illustrating this subject
and forming a series of types taken from the vegetable and
animal world. ILlustrations were chosen from the algoir
and mosses, the liverworts, and the common equisetum.
Further illustrations of secondary sexual characters in
plants were obtained from the cateaetum, the valisneria
spiralis, the fig plant, butcher’s broom, asparagus, many of
the grasses, cannabis iudica, and the common hop. In
like manner types were chosen from the nematodes,
rotifers, Crustacea, arachnida, insecta, fish, amphibia,
reptiles, birds, and mammals, from all of which
the lecturer demonstrated that where a difference of
size was found to exist between the male and the
female it was noticed in all plants, in which there were
secondary sexual characters, that the female was the larger
of the two. The same difference was found in the nem8>-
todes, in the rotifers, and, with few exceptions, in the
crustaceans. Among the insecta very much the same thing
existed. In the mammals it was found that, without any
exception, where a ditierence exists, the male is the larger.
In the reptiles also the male is the larger. In the amphibia,
and nearly all fishes, the female is the larger. Where-
there is a difference of colour, the lecturer showed
that in almost every instance, both in plants and
animals, the more conspicuous and brilliant colour i&
presented in the males. In plants the brilliant coloure
attract the insects, which aid in their fertilisation. Thus,
in the case of plants, by attracting the insect which i»
necessary to convey the pollen to the female, colour operatee
to some extent in bringing about that which is effected
in animals by sexual selection ; and it is a fact that in
both plants and animals it is the male as a rule which is
found to be most conspicuous in colour. As regards tbe
sense organs, it is the male in almost every case that
shows excessive development of these. The antenna? of
insects, the eyes, the hairs, are almost invariably more
developed in tbe male. As regards glands which give off
special odours (as in tbe case of bats &c,), it is found in
almost every instance they are possessed in tbe fullest
extent in the male. This secretion acts very probably a&
a sexual excitant. It may act like a drug, or it may act,
conceivably, by mere association of ideas. In certain fish,,
and many other vertebrates, a marked difference in size
characterises the sexes. The more pronounced and out¬
standing characters are commonly found to be possessed by
the male, so that he is able to defend the female and the
vouDg, or to fight with his rivals for her favours. The
lecturer then considered the question whether the posses¬
sion of a certain structure by the male is to be looked
upon as having been acquired by him or lost by the female.
It has been shown by Poulton that in the cose of the
antennio of insects there was evidence that in manyinstancee
tbe female had lost the large size and complex form of that
sense organ by a process of degradation, and from having
altogether different habits of life from the male. In tbe
case of horns, Austin and others hold that originally both
male and female possessed tbe organa, and that the females-
have lost them. In the case of the reindeer both sexes
have them. For reaeona such as this it is held that the
female has lost the organs, from trusting to the protection of
the male, in whom the horns are more developed. In ante¬
lopes the horns of the male are longer, stronger, more
ringed, and more ornamental than those of tbo female,
showing a tendency to loss and diminution on her part. As-
regards the origin of sex, the illustrations went to prove
that so far as our observation at the present time goes,
most forms in their primitive state were hermaphrodite to
start with. A large number of forma can be shown to be
so, and all distinguishing characteristics of the two sexes
Dio'+^'ed i'v' Google
796 The Lancet,]
REPORTS OP MEDICAL OFFICERS OF HEALTH.
[April 4 , 1891.
are probably the result of the advantage accruing from the
division of labour,” the female being modified to bear the
bulky ova and the male the less bmky, but equally im¬
portant, fertilising element. So that there seems to be an
advantage in the "division of labour” as regards sex.
What, he asked, had brought about and started the division
of sex? The lecturer showed that in plants such as the
bop, cannabis 'indica, and sundry other instances, an
imperfect nutrition of the plant resulted in the formation
of a male plant, whereas a fuller nutrition produced the
more luxuriant female. In crustaceans, rotifers, &c., the
male is very small and does not live long, whereas the
female is larger, more long-lived, and has to carry the eggs
for a long time. In cases high up in the mammalia, it has
been shown by statistics that when a race or a nation
has been in any way depressed below the normal level,
by war or, by famine, a rise in the percentage of
male births at once occurs. That looks as if there were
some direct influence upon the individuals determining the
sex of their offspring; and there are coses in which the male
functions appear when there is less nutritive vigour, and
the female when this vigour has attained its maximum in
the some animal. The lecturer, in concluding, said that he
bad thought it well to bring some of these questions under
the notice of the Fellows and Members of the College, more
especially as it enabled him to bring together certain
illustrations of a biological group whicli he was anxious
to see illustrated in the College museum, and that he
would be exceedingly indebted to any of the Fellows or
Members for any help he might obtain from them, in further
illustrating this section of biology.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OP MEDICAL OFFICERS OF HEALTH.
Barnstaple Itural District. —The death-rate for 1890 was,
according to Mr. Joseph Harper, an exceptionally high one,
reaching 18‘5 per 1000, this result being largely due to
fatality from whooping-cough. Great care seems to be
exercised in investigating the causes of such diseases as
enteric fever, and in amending the conditions with which
they are found associated. Much the same applies to the
action taken in cases of diphtheria. The adoption of the
'Notification Act is said to have worked considerable good,
but the medical officer of health naturally urges his autho¬
rity to make that department of their work complete by
the provision of a hospital for infectious diseases. However
small the provision made at first, it will be found a boon ;
and if the urban district could be induced to join with the
rural area in the matter, nob only would the original cost,
but the cost of maintenance also, be considerably reduced.
If an adequate site be chosen, the question of extending
the number of beds could easily be allowed to stand over
for a while.
King's Norton Rural District. —This district, with a popu¬
lation of over 28,000, has for some years past had a creditably
small death-rate, and Mr. FrancisHollinshead calculates it at
12 per 1000 for 1890, the zymotic rate being also low—namely,
07 per 1000. The system of notification revealed 239 cases
of scarlet fever, and of these 14 died. The isolation hos¬
pital records afford a typical story of the uses to which such
a building, which is properly constructed and administered,
may be put. Thus no less than 371 cases of scarlet fever
were isolated in it last year, 170 of this number coming
from the sanitary district itself, and the remainder from
two neighbouring urban districts. Indeed, the public
demand for efficient means of isolation has rendered neces-
«ary the provision of a third ward pavilion. Mr. Hollins¬
head gives a record of the general sanitary work, from
which we gather that his district is, in fact, still troubled
with water-supplies which are liable to pollution. They are,
however, done away with as soon as they are detected.
Aston Manor Urban District. —Mr. Henry May’s annual
report deals somewhat exhaustively with the sanitary
condition of his district, and, perhaps, more than usually
so in order to afford to the County Council of Warwick
the information which they may need for their purposes
when a summary of the local health reports comes to be
compiled. The general death-rate for the year was
17 per 1000. Under the Notification Act of 1889, adopted
in July, the number of cases of infectious diseases
heard of was 922; no less than 478 of these being
cases of scarlet fever. The number of scarlet fever oases
removed to hospital was 160, but a payment for admission
and other causes seem to hinder this class of work. Measles
was also very prevalent, and it led to some discussion as to
the utility of school closure under such circumstances,
Mr. May holding the opinion that school restrictions were
valuable as a means of prevention. A good deal informa¬
tion is given in the report as to the sanitary circumstances
of the district, and amongst other matters it is stated that
a destructor has been provided for dealing with the refuse.
The population of Aston Manor is increasing steadily, but
with this increase there has also been a corresponding condi¬
tion of progress in matters relating to public health. The
average death-rate for the period 1872-81 was 18-4 per 1000,
that for the period 1882-90 was 157 per 1000.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6849 births
and 4074 deaths were registered during the week ending
March 28bh. The annual rate of mortality in these towns,
which had declined from 24-1 to 21 ‘9 per 1000 in the preced¬
ing four weeks, further fell to 21 -2 lost week. The rate was
19'3 in London and 22'8 in the twenty-seven provincial
towns. During the past twelve weeks of the current quarter
the death-rate in the twenty-eight towns averaged 23‘1 per
1000 , and corresponded with the mean rate in the same
periods of the ten years 1881-90. The lowest rates in these
towns last week were i4-l in Derby, 167 in Nottingham,
17'4 in Bolton, and 17‘9 in Birkenhead; the highest
rates were 29'0 in Blackburn, 29-5 in Preston, 29-9 in Ports¬
mouth, and 34-6 in Huddersfiehi. The deaths referred to the
principal zymotic diseases, which had been 413 and 449 in
the preceding two weeks, declined again last week to 414;
they included 150 from measles, 139 from whooping-
cough, 39 from diphtheria, 35 from diarrhoea, 30 from
“fever” (priucipaliy enteric), 20 from scarlet fever, and
one from small-pox. These diseases caused the lowest
death-rates in Norwich, Derby, Newcastle-upon-Tyne, and
Cardiff, and the highest rates in Halifax, Portsmouth,
Huddersfield, and Blackburn. The greatest mortality from
measles occurred in Bolton, Preston, Bristol, Huddersfield,
Portsmouth, and Blackburn; and from whooping-cough in
Salford, Manchester, Huddersfield, Leicester, and HsJifax.
The mortality from scarlet fever and from “fever”
showed no marked excess in any of the twenty-eight
towns. The 39 deaths from diphtheria included 26
in London and 4 in Salford. One death from small-pox
was registered in Huddersfield, but not one in any other of
the twenty-eight towns; three small-pox patients were
under treatment in the Metropolitan Asylum Hospitals,
and two in the Highgate Small-pox Hospital, on Saturday
last. The number of scarlet fever patients in the Metro¬
politan Asylum Hospitals and in the London Fever Hospital
at the end of the week was 1059, and sliowed a further
decline from recent weekly numbers; the patients admitted
during the week were 81, against 64 and 91 in the preceding
two weeks. The deaths referred to diseases of the respira¬
tory organs in London, which had declined in the preceding
four weeks from 685 to 556, further fell last week to 466,
and were 40 below the corrected average. The causes of
89, or 2'2 per cent., of the deaths in the twenty-eight
towns were not certified either by a registered medical
practitioner or by a coroner. All the causes of death
were duly certified in Portsmouth, Bristol, Leicester,
Sunderland, and in four other smaller towns; the largest
proportions of uncertified deaths were recorded in Birming¬
ham, Blackburn, Hull, and Cardiff.
HEALTH OP SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had been 26‘2 and 25‘9 per 1000 in the preceding two
weeks, rose to 267 during the week ending March 28bh,
and exceeded by 5 6 the rate that prevailed during the
same period in the twenty-eight large English towns.
The rates in the eight Scotch towns ranged from 14'8
in Leith and 15'4 in Pertli to 32-8 in Glasgow and 33‘1 in
Paisley. The 698 deaths in these eight towns show^
an increase of 22 upon the number in the preceding
Coogle
The Lancet,]
INSURANCE ON THE LIVES OF PHYSICIANS.
CApeil 4,1891. 797
week, and included 36 which were referred to meaeleB,
34 to whooping-cough, 8 to diarrhoea, 7 to scarlet fever,
,5 to diphtheria, 3 to “fever,” and not one to small-pox.
In all, 93 deaths resulted from these principal zymotic
diseases, against 79 and 73 in the preceding two weeks.
These 93 ^aths were equal to an annual rate of 3'6 per
1000, which exceeded hy 1'4 the mean rate last week
from the same diseases in the twenty-eight English
towns. The fatal cases of measles, which had increased
from 16 to 24 in the preceding three weeks, further rose
Hast week to 36, of which 21 occurred in Glasgow and 11
in Paisley. The deaths from whooping-cough, which had
fceen 31 and 32 in the preceding two weeks, were 34 last
week, and included 19 m Glasgow, 6 in Edinburgh, and 6
in Dundee. The 7 fatal cases of scarlet fever showed a
« 3 Ught increase upon recent weekly numbers ; 3 occurred in
Glasgow and 3 in Edinburgh. The 5 deaths from diphtheria
•exceeded by 2 the number in the preceding week, and in-
■cluded 2 in Glasgow. The deaths referrea to diseases of
the respiratory organs in these towns, which had been
201 and 194 in the preceding two weeks, further declined
last week to 169, but exceeded by 28 the number in the
cori'eaponding week of last year. The causes of 64, or
(nearly 8 per cent., of the deaths in the eight towns last
week were not certified.
HEALTH OF DUBLIN.
The death-rate in Dublin, which had been 28T and 28-4
S er 1000 in the preceding two .weeks, further rose to 291
uring the week ending March 28tb. During the first
twelve weeks of the current quarter the death-rate in the
city averaged 30*7 per 1000, the rate for the same period
being 22*7 in Lon(ion and 217 in Edinburgh. The 197
deaths in Dublin showed an increase of 5 upon the number
in the preceding week, and included 3 wbion were referred
to whooping-cough, 3 to “fever,” 2 to diarrhcea, and
not one either to small-pox, measles, scarlet fever,
or diphtheria. Thus the deaths referred to the prin¬
cipal zymotic diseases, which bad increased in the pre¬
ceding three weeks from 4 to 11, declined again last week
to 8 ; they were equal to an annual rate of 1'2 per
1000, the rate from the same diseases being 1*6 in London
and 3 0 in Edinburgh. The fatal cases of whooping-cough,
which had been 3 and 5 in the previous two weeks, declined
last week to 3. The deaths referred to different forms of
“fever,” which had been 4 in each of the preceding two
weeks, declined to 3 last week. The 2 fatal cases of diar-
rhcea exceeded those recorded in any recent week. The
197 deaths in Dublin last week included 29 of infants under
one year of age and 58 of persons aged upwards of sixty
years; the deaths of infants showed a slight decline, while
those of elderly persons exceeded those recorded in any
recent week. Ten inquest cases and 8 deaths from violence
were registered; and 62, or more than a fourth, of the deaths
occurred in public institutions. The causes of 14, or 7 per
cent., of the deaths in the city were not certified.
dtomspnkna
“ Audi alteram partem."
INSURANCE ON THE LIVES OF PHYSICIANS.
To the Editors oj The Lancet.
Sirs, —Having for some time past been engaged in col¬
lecting figures for making a comparison between the experi¬
ences of insurance oflices of the lives of medical men and
ethers, I have read with much interest Dr. Muirhead’s
letter of Feh. lOth. Dr. Muirhead comes to the conclu¬
sion that medical lives are as good as those of the popula¬
tion generally. Unfortunately the figures given in his
letter, as far'as they go, point to a considerable inferiority
oflices by the kind indulgence of their managers, pretty well
confirm this result. The method adopted by me was as
follows:—The registers of policies were searched until a
medical policy was found which had resulted in a claim.
Then a non-medical claim was taken out as near as possible
in point of entry to the medical one, and whose former
holder entered in the same quinquennium of age. 1 thus
obtained two claims, the policies of which were taken out
by two men identical (apparently) so far as insurance goes,
except that one was medical and the other non-medicsd.
The pair entered about the same date, and therefore had
the same opportunity of living, and, having the same expect¬
ancy, were charged the same rates. Now, if medical lives
were as good as non-medical ones, a sufficient number of
such pairs being taken, the aggregations of each set should
be identical in every respect with one another.
The adjoining tables give a comparison between these
two sets of lives. It will be seen that at almost every age
Table I. — Comparison of the Duration of Lives, Medical and Non-medical, entering approximately at the same
time and at the same age ; the experience extending over more than SO years.
Total number entering between tlie agea of—
20 & 24.
25 & 20.
30 & 34.
35 & 30.
1 40&44.
45 & 40.
60 & 64.
56 & 50.
Number entering .
8
■ 48
51
38
29
40
20
8
Total duration (Modieab .
lo;!
1023
1103
7S0
650
678
297
90
Total duration (Non-medical) ...
172
900
1208
S29
086
719
843
98
Average duration to \ (Medical)
1
20'5
21-5
22-5
21
22-5
17
16
12-5
half a year /(Non-medical)
-
21'6
20-6
25 T)
23
23-6
18
17
11-5
Total number of lives of each, 24‘2. Total duration : Sledical, 480a
; Non-medical, 5130.
Table II. -
-Derivedfrom Table I.,
hy taking Means of Ages and Durations.
I.ives entering at the ages of—
25.
80. !
35. 1
40.
45.
60.
65.
Average duration (Medical) .. ..
..
» »-•
21
1
21-75 1
21-75
19-75
16
13-75
Average duration (Non-medical)
...
~
21
23 1
23-75 \
23-20
20-76
17-6
13-75
in the lives of the doctors. He shows that in round numbers
(the average duration of the two classes are the same—viz.,
twenty-one years; but it appears that the average age at
which the medical men insured was thirty-live, and the
non-medical thirty-seven. The medical lives should then
have exceeded in duration the non-medical by something
between one and two years; thus the medical lives were in¬
ferior tq the other by something between 6 and 10 per cent.
The figures which I lay before you, collected from four
the medical lives proved inferior, and on the whole the total
years lived by medical men were about G’4 percent, less
than that lived by non-medical policy holders.
The second (derived) table shows a remarkably even
result, and leaves little doubt as to its interpretation.
It may be added that all the cases classed as medical
were medical practitioners described as surgeons, physi¬
cians, or in the older cases sometimes as apothecaries; no
dentists were included. Also, in choosing the cases with
Digitized by ^ooQle
798 TheLanobt,]
THE EFFECT OP DEEP INSPIRATIONS ON THE HEART.
[April 4,1891.
which these were paired, care was taken to avoid clerical
lives, the latter being regarded as above the average. This
result, dleappolnting as it may be in some respects, after all
only emphasises the importance of the subject of iosiirance
of medical men, to the consideration of which you have
devoted so much of your valuable space during the last few
months.—I am, Sirs, yours obediently,
Thos Glover Lyon,
Feh. 21th, 1891. Medical Officer to the Mutual Life Office.
“A NEW TREATMENT AND POSSIBLE CURE
FOR CANCER.”
To the Editors of TiiE LANCET.
Sirs,—U nder this heading I wrote you in June and July.
2889, communicating a method of treating cancer, which I
believed to be likely to prove useful. I did not then dare
to say more than that “the results obtained so far are'
encouTaging.” The time which has elapsed since making
this statement has been employed in watching the effects
and issues of the treatment, and in investigating the facta
in other cases which have fallen under my observation, and
been similarly treated. I say similarly, because later
researches have led to considerable changes in the mode of
exhibiting the remedies. In result of my experience to
this date 1 am able to say: ( 1 ) that none of the earlier cases
have relapsed ; ( 2 ) that scirrhus tumours of large size and
undoubted authenticity have gradually disappeared without
any operative interference; (.3} that the health of patients
has imoroved under treatment, and the cachexia vanished.
I fully recognise the gravity of these statements, and I
feel the responsibility that rests upon me in making them ;
but in face of the evidence I have obtained I am compelled
to say that I tentatively believe cancer to be curable by
this method, and I have no hesitation in again asking the
profession to try it.
The exhibition of the remedies—which mitst he used in
combination, for the reasons assigned in my previous
letter—requires to be specially adapted to each individual
case, as will be obvious to anyone who has given the
modus operandi, as before explained, a serious thought.
The principal modifications I have made are the follow¬
ing :—Instead of “ thailin ” I uso a periodohydrometbyl-
oxychinolio, because that is better borne, and seems to be
more effective than the tetrahydroparaquinaniaol; and I
either inunct, or inject, the tumour with a papain specially
prepared, because 1 have reason to believe that it is not the
proteid elements (either the globulin, the a-phyt.-albumose,
or )3-phyt.-albumo8e, or these in combination), but the
organised ferment of the papaw juice that produces the
effects observed.
The scientific explanation of the phenomena (which 1
am still investigating) would involve too much of the
bacteriological phase of the subject to be discussed here;
meanwhile I reserve, until another opportunity, the ex¬
pression of an opinion which I have formed as to the im¬
portant part played by the papain bacillus, of Rosbach, to
whom, as your readers will remember, we are indebted for
our acquaintance with the properties of papaw juice by a
paper read at the luternational Congress of 1881. I am
aware that some authorities bav^ alleged that the bacillus
found in papain is identical with the bacillus subtilis, but
I believe that conclusion to be erroneous ; and at the proper
time and place I shall be prepared to make my assertion
good. However that may be, of the therapeutic value of
papaw juice, or certain of its elements, as a solvent of the
morbifically indurated tissues in cancer, I have no doubt,
although, as I said at the outset, it is perfectly useless
unless administered or applied in combination with an
adjunct of tlie clas.s which I have previously indicated.
I am, Sirs, yours faithfully,
J. Mortimer Granville.
Ilanover-sriiiare, W,, March 24bb, 1891.
THE EFFECT OF DEEP INSPIRATIONS ON
THE HEART.
To the Editors of The Lancet.
Sirs,—I n his second Lumleian lecture Dr. Broadbent
remarked: “An interesting fact in connexion with breath¬
lessness due to dilatation of the heart is that it is often
relieved by exercise of the voice. I have met with numerous
instances in which a clergyman has climbed into the pulpit
with the utmost difficulty, and has not only preached a
sermon comfortably, but has been all the better for it.’'
The good result, I bake it, in these cases is attributable to
the deep inspirations necessitated by the loud voice used ioi
preaching; and, without touching upon the so-called suctioib
action of inspiration upon the circulation in general, H
would point out that these deep inspirations act beneficially
in the following ways: (a) First and foremost, they favour
the flow of blood from the right to the lejt heart; the righb
heart being thus relieved, the blood is able to flow more
readily into it from the systemic and portal veins ; this
necessarily facilitates the flow from the systemic arteries,
aud consequently the left heart has less work to do. Let it
farther be remembered that the relief brought to a dilated
right ventricle by deep inspirations must enable it the
better to exercise its suction action on the veins, (b) Natu¬
rally the respiratory movements favour the flow of lymph by
diminishing tlievenous blood pressure; but in addition to this
indirect influence on the lymph flow, inspirations, especially
when deep, have a direct influence upon it, for the diaphragm
is itself a lymph pump. Now, whatever favours the lymph
flow necessarily helps the arterial and venous circulation,
(c) Lastly, it is possible that the movements of the diaphragm
may exert a special influence upon the circulation of the
blood through the liver. Not only do inspirations favour
the How of blood through the lungs, but they are absolutely
necessary to proper pulmonary circulation, as is readily
proved by holding the breath for a moment or two, when
the stagnation of the blood in the right heart will provoke
epigastric pulsation and cause the veins in the head and
neck to swell. It is further proved by the fact that the
right heart is found engorged after death from suffocation)
or drowning, or, indeed, vmenever respiration has stopped
before the heart has finally ceased to beat. And we have
here, I believe, the chief factor in the production of those
changes in the right heart which occur secondarily to chronie
lung diseases—in all of which the respiratory movements
are restricted. That such restriction is competent to pro¬
duce these cardiac changes is indicated by the right heart
suffering in spasmodic asthma unaccompanied by lung mis¬
chief. Thus periodic interferences with the respiratory
movements are alone clearly capable of affecting the heart.
The practical conclusion I desire to emphasise is that we
have in the respiratoi'y movements a means of aiding a
weak circulation, and especially in those cases where unduo
work is put upon the right heart.
I am, Sirs, yours faithfully,
Harry Campbell, M.D.
Guilfonl-.Htreot, W.C., March 31st, 1891.
THE HYDERABAD CHLOROFORM COM¬
MISSION.
To the Editors of The Lancet.
Sirs,— In his article published in The Lancet of
March 14tb, Surgeon-Major E. Lawrie, President of the
Hyderabad Commission, emphasises the importance of the
respiration, and totally.ignores the circulation, as a guide
in the administration of chloroform. Undoubtedly the
respiration is essentially important, but my view, after tea
years’ practical experience of amesthetics, is that the cir¬
culation is also sometimes an important guide to the anres-
thetist during an operation, and often most valuable. No
method of administering chloroform will ensure the uniform
behaviour of all patients during the induction of cbloroform-
aniosthesia. The action of chloroform upon a patient ia
inliueneed by mental and physical conditions as well as by
disease. The effects of the cliloroform upon the circulatory,
nervous, and respiratory systems, especially when they are
diseased, as well as the loss of blood and the duration and
nature of an operation (these being the conditions that have
to be met by the practical aniesthetint), influence the
respiration in such a way in some cases as to make it
expedient to obtain all the'information that can be gathered
of the extent of exhaustion, the probable power of endurance,
and the general state of the patienc. This knowledge is to
be obtained from the respiration, the pulse, the pupil of
the eye, the sensibility of the cornea, and the complexion,
all of which may be under observation at the same time-
without discontinuing the chloroform, when it is ad¬
ministered in the manner described by me in a
paper read before the West London Medico-ChirurgicaS
The Lancet,
FACTORY SURGEONS.
IApeil 4, 1891. 799
Society, and which is fully reported in The Lancrt of
March i4tb. The condition of the muscular system, as
to relaxation, is also sometimes useful An anaesthetist
who relies on all these sources for information will
<eometiines be able to continue an administration of
•chlorofojm when, if he relied upon the respiration solely,
he would feci bound to discontinue it. I have on several
■^)cca8ions had the greatest difficulty in satisfying myself
chat respiration was in progress at all, especially in'con¬
nexion with some operations upon the ekuli for depressed
tfracture or other condition in which the functions of the
brain were greatly impaired, and have found the pulse most
valuable as a guide in such cases, justifying me in supply¬
ing sufficient chloroform to prevent Tellex movements of the
patient occuning. As long as respiration is unimpaired
and there is no cyanosis it may not be necessary to go
tfui'ther for information, but early in the progress of ad¬
ministration the breathing may be accompanied by ster¬
torous noises—nob true stertor,—the pupils be dilated or the
■corneal reflex abolished, and yet the anmstbesia may not be
sulficient for operation, and in such circumstances the pulse
will be found quick perhaps, and not the slow pulse of com¬
plete chloroform ancesbbesia. When an operation has been
some time in progress the respiration may still be good
while the patient may have the appearance of extreme
.exhaustion, and the pulse will then enable the anmsthebisb
to judge whether it is necessary to hurry or close the opera¬
tion, or whether stimulants are imperatively called for.
Shallow respiration is not uncommon and, when the respira¬
tion only is relied upon, dangerously misleading, often
when not appreciated giving rise to sudden and alarming
ciymptoms. In practice each of the guides mentioned is
of great service, and without them operators would often
be disturbed, and sometimes unnecessarily prevented from
•completing their operations. The following case throws
great light upon the effect of chloroform upon the heart
and respiration.
In January, 1891, J. B-, aged fifty-one years, came into
'the theatre for radical cure of hernia, and it was my intention
to give him chloroform ; bub on seeing him, as his appear¬
ance presented venous congestion, I gave him ether. After
-about a (juarter of an hour of the operation there was so
much saliva and mucus excited by the ether that it was
impossible to keep the patient properly under, and I there¬
fore changed to chloroform, which 1 administered with
■extra care, for the reason already stated—i.e., in addition
to simply satisfying myself that the respiration was good, I
proceeded with the sprinkled lint lying on the separated
fingers of my right hand in front of the mouth, which enables
one to feel the force of expiration ; with my left middle finger
■on the left temporal pulse and my left thumb holding
up the left upper lid of the patient, and testing the
■oorueal reflex when necessary, watching the respiratory
'.Tiovements of the abdomen (which was exposed), the
complexion of the face, and the pupil of the eye. After
■about half an hour I suddenly missed the temporal pulse,
and found it was also absent from the wrist, notwith¬
standing that the respiration continued. After a few
moments the pulse returned, and the pharyngeal reflex being
present I gave two teaspoonfuls of brandy in small quan¬
tities, which were swallowed. Then continuing the chloro¬
form, guardedly as before, after twenty minutes the pulse
ceased again, and I asked the nurse to give an enema of
half an ounce of brandy with water, called the attention of
those around to the absence of pulse and the continuance of
respiration, which they observed before the respiration
ceased, when alittle artificial respiration soon so far restored
the patient that the operation was continued and com¬
pleted in another twenty minutes. During this latter time
a very little cldovoform only was given when the patient
•had so far recovered as to call out loudly. The patient
afterwards told me he felt nothing of the operation.
This patient’s heart was, so far as could be ascertained,
practically sound. Here then was an operation taking
place under chloroform, during which the pulse of the
patient undoubtedly failed before the respiration on two
occasions, the pulse recovering on the first without cessation
of respiration, and the respiration failing on the second
occasion some seconds after the pulse, and while it was still
not to be felt.
I have endeavoured to show in this letter the importance
of the pulse as a guide to the anreschetisb, under some cir¬
cumstances, during chloroform administration; and it is
not my intention to express an opinion as to which of the
two, the respiration or the circulation, invariably ceases
first in death from chloroform, believing, as I do, that it is
sometimes one and sometimes the other.
t am, Sirs, yours faithfully.
Rickard W. Lloyd.
Eussell-road, Kensington, W,, March ICtli, 1891.
THE TREATMENT OF CHRONIC INFLAMMA¬
TION OF THE UTERINE APPENDAGES.
To the Editors of The Lancet.
Sirs,—T he question whether the majority or minority of
infiammatory lumps in the pelvis tend to spontaneous cure
is one as to which each person who has opportunity must
form Ms own judgment. An investigation in the way pro-
osed by Mr. 'fait would not further our knowledge. If, as
expect would happen, there proved to be little difference
of opinion, in particular cases, between Mr. Tait and some
one of an opposite view as to the general question (I do not
knowwho appointed me the representative of such), iCwould
still be possible for anyone who operated frequently to say
that there was some exceptional cause which brought to
him a large numberof incurable cases ; and, as Mr. Tait has
clearly foreseen, it would still be open to malevolent critics
to say that the surgeon’s opinion as to the course without
operation would be less favourable in cases in which he
would be tlie operator than in those not under his own care.
I need scarcely say that the London Hospital is a public
institution, and if Mr. Tait likes to visit it, 1 shall be very
glad to have the benefit of his opinion and advice; but!
hardly think that, from his point of view, he will find the
advantage commensurate with the trouble. I believe, if he
will pardon my saying so, that he would do more to con¬
vince the profession if be would add to his great services to
medical science by publishing more detailed and exact
reports of his o wn cases. So far as I am concerned, this
correspondence is now at an end.
I am, Sirs, yours faithfully,
Ilavley-stroet, March 24tb, 1891. G. ErNEST HERMAN.
FACTORY SURGEONS.
To the Editors of Til'S, Lancet.
SiR.s,—In Clause 19 of his Factory Bill Mr. Matthews
proposes to abolisli the office of certifying factory surgeon,
and if our services are to be retained an immediate and
united effort must be made by certifying surgeons every¬
where throughout the country. \i> iippeal has been made
by the Association of Certifying '^■i a eons, and circulars have
been sent to hundreds of certifying surgeons asking them to
send to the secretary of the association a list ot rejections
made by them -in their various factories. And with what
result? Although there are nearly 1200 certifyingsurgeons
in the country, yet only thirty-seven have taken the trouble
to send lists of rejections. This carelessness is dishearten¬
ing when we^consider how our opponents are using every
possible means for our extinction. If our office is abolished
it will certainly be in a great measure due to the apathy of
the mass of certifying surgeons themselves. The Standing
Committee who have the Bill in hand do not meet again till
April Oth, so there is still time for useful action. I would
urge all certifying surgeons to do two things—(l)send at
once to the secretary of the Association (Dr. Holmes,
Ouselhurst, Kadcliffe, near Manchester) a list of cases
rejected during the past five years, and (2) to bring all the
pressure they cau to bear on members of Parliament to
oppose Clause 19 of the Factory and Workshops Bill.
I am, Sirs, yours faithfully,
John Barr, M.B.,
Risliton, Bla-ckburn, Miivdi 24th, 1S91. Certifying Surgeon.
“DIPHTHERIA IN ESHER.”
To the Editors o/The Lancet.
Sirs,—I t is quite true that this hitherto healthy village
has for some months been suffering from diphtheria. I
attribute the outbreak entirely to the foul smells emanating
from the man-holes and inWeeptors of the new main
drains, which have been insufficiently flushed. This sewer
was put into use last summer. Up to that time diphtheiia
Dir' ■ Coogle
800 The Lancet,]
HOSPITAL REFORM.
[April 4,1891.
was QQknown here. We had a great niaoy mild cases last
autumn. The hrsi; severe cases took place in September in
a gentleman’s well-ventilated house situated between two
man-holes, which gave out abominable odours. The
mother, five children, and governess took the disease; one
child died. They had no connexion with the village
school. Since then the epidemic has been more severe, and
1 have lost four other children in my practice. These were
in families in which some of the children attended the
Kational Schools. I do not think the fault lies in the
sanitary state of the schools, but that children having
incipient diphtheria communicated it to the other scholars
and the mistresses. The school is now shut up, and most
of the foul interceptors (so called) closed, so 1 hope we may
see an end of this distressing epidemic. The fault has
been in using the sewer before there were sufficient flushing
tanks. I am, Sirs, yours faithfully,
Esher, March SOth, 1891. CHARLES W. IZOD.
HOSPITAL REFORM.
To the Editors of The Lancet.
Sirs,— After the perusal of your leading article of March
7th, in which you support the conclusions of the Birmingham
Committee on Hospital Reform, it was a little straoge to
find reported in the same number Mr. Barker’s assertion that
complaints against out-patient departments come from a
very, undesirable fringe of the profession.” I must confess
to belonging to this abused fringe, which, though “very
undesirable,” must be considered ornamental, as it includes
The Lancet and a not inconsiderable portion of the pro-
fe^ion. But I venture to think that Conclusions IV. and V.
of the committee referred to call for the special attention
and criticism of the profession. The necessity for medical
reform may be obvious to most of us, but it is as necessary
in the dispensary as in the hospital. It will be a grave
pity if, in curing hospital abuses, we increase those of the
dispensary. It is a fact that many dispensailes make
very free use of hospitals without subscribing a halfpenny
towards their expenses. I know of one provident dis¬
pensary the boasted success of which is fairly attributable
to such practices. This institution has over 20,000 mem¬
bers, ancf its scope is not limited by any wage limit system.
It may be reasonable for the dispensary doctor to send his
cases of strangulated hernia and other awkward ailments
into the hospital. It is certainly convenient. But some
acknowledgment should be made for the accommodation
afforded, it does not seem fair that the hospital should
have to treat gratuitously a number of the most serious
dispensary cases, from whom the dispensary has been
receiving premiums, for assurance against illness, for a
number of years. Uf course, if we can secure joint action
of hospitals and dispensaries with an agency for investiga¬
tion into the circumstances of both classes of patients, we
may put a check upon abuses; but experience should warn us
that dispensary managements are apt to attempt too much.
Becoming greedy for a financial success, they commence
touting for patients, repudiate the wage limit system, and
help to turn the noblest of professions into the most miser¬
able of trades. Under such circumstances the dispensary,
as I have tried to show elsewhere, is, even to the public, a
curse rather than a blessing. To the self-respecting general
practitioner who holds to the old traditions of medical
etiquette it is an unscrupulous opponent. Bound by no
traditions, with the conscience of a committee, it employs
agents, scatters advertisements broadcast, and invites all
men to purchase physical salvation for \d. per week. Small
wonder if some of the poorer members of our profession
follow its example. They have not the ghost of a chance
in competitions with such an institution. It behoves us
then, before attempting to relieve the congestion of tlie
out-patient department at the hospital by means of a new
system of dispensaries, to take security that such a system
will be conducted upon equitable principles, and to insist
upon the adoption of a reasonable wage limit.
I am, Sirs, your obedient servant,
March 18bb, 1801. ____ l-'.K.C.S.
ARREST OF SYMPTOMS IN GENERAL
PARALYSIS.
To the Editors of The LANCET.
Sirs, —I was much interested in Dr. Adam’s letter in
The Lancet of last week on “The Arrest of Symptoms in
General Paralysis,” as I have recently had two cases under
my care which exemplify his remarks. Probably it would
be better to use the term “remUsion” rather than “arrest,”
as, if the cases are those of general paralysis, the diseeise is
almost certain to reappear.
Dr. Julius Mickle, in his well-known work on this disease,
points out that Sauze considers that there are three classes
of remissions. The first, in which there is remission of
mental and motor symptoms simultaneously; the second,
in which the remission pertains to mental symptoms only
and the third, and by far the rarest, in which the motor
symptoms subside, with no mental improvement. My first
case—which on admission 1 took to be one of general
paralysis, but, after more careful examination of symptoms
and history, I marked down as one of those peculiar cases
of alcoholic mania resembling in almost all respects
general paralysis—got so far well that he was discharged as
recovered after a stay of six months. Both ment^ and
motor symptoms had apparently quite subsided. However,
my original diagnosis was confirmed, for he came under my
care again nine months after his discharge with definite
symptoms of general paralysis, and one severe fit of au
epileptiform character, and rapidly passing into apoplexy,
the disease caused the end of his life four months after his
readmission.
In the other case there was a < 2 ^ast-remiasion of both
mental and motor symptoms, and though we knew he still
had some grandiose delusions, yet he was able to control
them to such an extent that no one talking to him for hours
together upon general topics would have found anything
wrong with his intellectual powers; and his motor sym¬
ptoms bad much improved. The almost inevitable relapse
has taken place, and one single fit has left him paralysed!
in his lower extremities. Baillarger considers that remis¬
sions are more general when the disease commences
with an acute maniacal attack, but Dr. Mickle explains thi&
on the hypothesis tliat the various forms of simple insanity
often complicate general paralysis at its onset, of which
form mania is the one most likely to terminate in recovery.
To my mind, these remissions, unless rightly diagnosed
as such, are a grave scarce of danger to the family of the
patient. We discharge such a case, and probably a gradual
relapse takes place, and before the relapse is realised, and
steps can be taken to place the case under proper control,
instead of “putting his house in order,” as Dr. Adam
implies he may do, be lands his family in hopeless ruin by
his extravagance, if even he does nob do more, and commit
some terrible crime.—I am, Sirs, yours faithfully,
Bath, March 29th, 1801. LIONEL A. WEATHERLY, M.D.
QUARANTINE AT NEW YORK.
To the Editors o/The Lancet.
SiR.s,—Several Sicilians, all healthy, and coming front
uninfected districts, took ship at Palermo for New York on
Jan. 11th. Those who required it underwent vaccination
with calf lymph. One man, vaccinated on the 22nd or 23rd,
I detected on the 30th with a suspicious vesico-pustular
eruption here and there, slightly umbiiicated on arms, face,
back, and abdomen ; none on mucous membrane of mouth,
throat, or CODjunctivc'o. This eruption commenced on the-
26th on the arms as vesicles. He had had no vomiting or
pain in the back, only a slight headache, and ate well. Hc-
had three large unusually well-marked vaccination vesicles-
on the right arm. Seeing that the incubation period of small ¬
pox had been passed while at sea, that none of the other
Hiciliaus or his immediate steerage neighbours were ill, and
well weighing the above facts, I put the case down in my
olficial log as one of vaccinia, together with my reasons. Oni
arrival at New York on Feb. 8bb the case was taken ashore,
brought back, taken ashore again, experts and inspectors*
from the city called in, and this dilly-dallying went on for
four days. It was decided to be a case of small-pox. Those
immigrants vaccinated by me were allowed to land, the rest,
all of whom showed soars resulting from a vaccination within
eight years, were transferred to Hoffman Island for fourteeri
days. But by this date (Feb. 11th) seventeen days had
elaprcd since the man’s eruption had appeared (Jan. 2Gth),
ana still not a single case of small-pox had occurred, the'
five men who slept around him being in perfect health.
During the inspection I picked out two somewhat similar
vaccinated cases, a boy and a woman, that had twice-
passed unnoticed by the official deputy, who, however,
deemed them of sufficient importance to take ashore. The
boy’s case was stated to be due to vermin, but neither
Coogle
The Lancet,]
MORTALITY OF MEDICAL MEN.—MANCHESTER.
[April 4, 1891. 801
acaniB scabiel or pedicull corporis were present; and the
woman’s to her reinoculating herself bv scratching all over
her body from her vaccinated arm. Now is such a thing
probable, nay, possible? 1 told the othcial I should like
some unbiased opinion. Next morning these two cases
were taken ashore early without my knowledge and per¬
mitted to land. They went privately, and not in the tug
with the others. After this, in my opinion, manufacturing of
a case of small-pox, after this decision of the powers that
be, how did they act ? Verily, like to a wholesale
-small-pox manufactory. Three saloon passengers with
whom I had been in close contact, one of them sharing my
icabin, were allowed to land, not a question bBing asked.
The captain, with permission, went to New York in the
company’s tug, used for passengers by other ships, and con¬
stantly plying about harbour. The pilot daily went to and
fro between his family and the ship, and, to crown every¬
thing, we—i. e., all hands—were free to. proceed unques¬
tioned and unexamined—we, including the Italian and
Sicilian stewards, who bad been in constant hourly com¬
munication with the immigrants. Some sulphur was burnt
in the steerages, none in the room on deck where men had
been placed. A large pile of immigrants’ mattresses on deck,
not disinfected in any way, were passed into Brooklyn. I
claim that if the authorities really thought the case one of
small-pox, their proceedings were illogical, inconsistent, and
desperately dangerous to public health; whereas, if they
thought otherwise, great unnecessary expense was imposed
on the Company, and a vast amount of intolerable iocon-
-venience on the immigrants by tboir detention.
I am, Sirs, yours faithfully,
J. E. S. Baunett, M R.C.S , L.R.C.P.,
Surgeon to ss. Scotia.
Ditchling-i'oad, Brigliton, Mivroh, 1891.
■mortality of medical men.
To the Editors of The Lancjct.
Sirs, —In the article in The Lancet of last week on the
Medical Registers for 1801 it is stated that “ the Registrar
and Dr. Ogle are at serious variance as to the mortcuity of
cnedical men.” Permit me to point out that no contradic¬
tion exists. The Register includes medical men resident in
all parts of the United Kingdom, as well as many abroad,
and doubtless some who have died in previous years;
while Dr. Ogle's figures are based on the number of
'medical men enumerated in England and Wales at the
census of 1881. Dr. Ogle’s death-rates for England and
Wales relate to the three years 1880-82; according to
the figures in the Medical Register the mean death-rate
for those years was 23 per 1000, which, after allowance for
imperfect information as to deaths occurring abroad, and
for possible differences of mortality in the several divisions
of the United Kingdom, does not vary seriously from Dr.
Ogle’s 25 per 1000. Further, the death-rate as shown by
the Medical Register was as high as 28 per 1000 in 1885,
while in the fourteen years 1876-89 it averaged rather more
than 23 per 1000. The exceptionally low mortality recorded
among the medical profession in 1890 is certainly remark¬
able, both in comparison with previous years and in con¬
nexion with the fact that the general death-rate in England
and Wales was higher in that year than in either of the
years 1887-8 9; bub it is remarkable as an exception, and nob
as being at variance with the mortality at another period
of the resident English.part of the profession.
I am, Sirs, your obedient servant,
March 31st, 18!)1. A. C. WATERS.
THE NON-EMPLOYMENT OP MEDICAL MEN
BY MEDICAL BODIES.
To the Editors of The Lancet.
Sirs,—W e have repeated and, it must be admitted,
justifiable bemoanings from the ranks of the medical pro¬
fession regarding the illiberal manner in which its services
are recognised as regaids remuneration dfec.; yet I assert
withont fear of contradiction that there is no other pro¬
fession that does so little, when it has the chance, for its
awn confr&res as the medical profession ; and in support of
such assertion it is only necessary bo point to what daily
occurs—as, for instance, whenever a body of medical men
form themselves into a society or committee &c., it may be
token as granted that if the olllce of secretary, registrar,
&C., is to carry with it any emolument it is not to a medica
man it would be given. There are too many instances of
such ungenerous actions of medical men towards each other
in such cases. If it is argued that it is a lapsus mentis, it
forms no excuse, for the same might be said by anyone who
fails to befriend another. I do not wish to particularise in-
atances—such would not farther in. any way the fact which
I draw attention to. We have barristers, retired military
men, and civilians filling positions as librarians, secretaries,
registrars, &c , which posts could and should, in such
purely medical bodies, be held by medical men. I would
like to hear of any military or legal society or institution,
devoted purely to the researches or duties of either pro¬
fession, that gives remuneration in a single instance to any
medical man in such capacity as cited above; or, furtW,
that would not sneer contemptuously at even the idea of
leaving members of its own profession out for that of
another, such as the medical.—lam, Sirs, yours truly,
March 26th. 1891. _ EbLANA.
MANCHESTER.
(From our own Correspondent.)
The Boyal Infirmary and Owens College.
Non possnmus is the final reply of the Infirmary, os repre¬
sented by its board of management, to the College proposal
to erect a new hospital in Victoria-park. The following is
the exact terras of this reply: “ The board of management
do not feel themselves justified either in appealing to the
public for money or in appropriating any part of the funds
of the Royal infirmary towards the erection and main¬
tenance of such hospital. The board desire to emphasise
the fact that they are already possessed of an ample free¬
hold estate centrally situated on which the Infirmary
can be extended, without entailing on themselves
extraneous obligations by the establishment of a dual
control calculated to interfere with existing executive
and administrative arrangements. Moreover, they think
it neither wise nor desirable to entertain any scheme which
will in their judgment, interfere with the interests of the
sick poor, for whose benefit the Infirmary was established.”
Whether this ultimatum will be endorsed by the public, as
represented in the general body of subscribers, remains to
be seen. Fifteen or sixteen years ago the then board of
management pronounced as decisively for the removal of the
whole of the infirmary from its present site into Oxford-
road, near the spot now offered for a new building, and
tills was as decisively vetoed by the subscribers, and a
new board put in power. Without doubt public feeling
is against any further curtailment of the present small
open space around the Infirmary, and there are strong
arguments iii support of tbe contention that “ the sick pooi; ”
would benefit by tbe establishment of a new building out.
of the centre of the city in the purer air of the Victoria
Park. The advantages to the medical school would be
considerable from a new hospital nearer the College, and
whose staff would be more closely united with the College
than at present is the case. For the present a deadlock
exists, the ultimate result of which it is at present difficult
to forecast.
Owens College.
At the recent half-yearly meeting of the Court of
Governors the rapid and continuous growth of the medical
department was prominently noted. The present number
of medical students on the books is 348. The arts, science,
and law departments show but a slow advance compared
with the medical department for the past few years. Some
time since it was reported as imperative to take steps to
enlarge the accommodation of the medical school, and an
appeal is to be made to tbe public for no less than £60,000
for this object. On the same day, at the above meeting, a
marble bust of Dr. Greenwood, lately principal, was publicly
presented to the College in the library. It has been sub¬
scribed for by the Associates, and is from the chisel of Mr.
Onslow Ford, A.R.A. Mr. Broadfield, in making tbe pre¬
sentation, alluded in graceful terms to tbe long life’s service
of Dr. Greenwood to the College, and especially to the warm
feeling of personal friendship and kindly courtesy that
always existed between him and the students.
Society of Officers of Health.
At the annual meeting of the North-Western Branch of
the Society of Officers of Health, Dr. Thomson of Sheffield
802 Thb1<ancst»]
NOETHERN COUNTIES NOTES.—SCOTLAND.
[Apeil 4,1891.
was appointed president for the ensuing year. A disc\ission
took place upon the proposed Factory and Workshops Act.
Mr. Barr of Bury stated that there were in Lancashire
alone children and young persons at work in mills to the
number of 139,000 “ half-timers ” and over 300,000 ” whole-
timers,” also that 1319 children per annum had been re¬
turned as unfit for work. Upon these and other grounds it
was resolved to petition against the abolition of factory
surgeons.'
Cremation.
The successful establishment of a crematormm in Man¬
chester is now assured, though the whole of the required
funds have not yet been quite subscribed. The promoters do
their best to bring the subject before the attention of the
public, and at a public meeting held recently in Cliorlton-
cum-Harcly (one of our suburbs) the Rev. R. E. Healy,
rector of St. Thomas’s, presiding, a resolution was carried
recording hearty approval of the system of cremation as a
means of disposal of the dead in large communities.
Imptire Air.
The committee appointed to make a scientific investiga¬
tion into the impurities of Manchester air have issued a
preliminary report, which, amongst other things, states that
with a prevalence of fog the mortality from respiratory
diseases at once showed a marked increase. From experi¬
ments made during three days of fog it was calculated that
in the neighbourhood of the infirmary there was carried
down 6 cwt. of sulphuric acid per square mile. No wonder
that leaves and trees rapidly die here.
The late Alderman Schofield, J.P.
Amongst those who, in the early days of sanitary reform,
did good work for Manchester in remedying sanitary mal¬
administration or neglect, the name of the late Alderman
Thomas Schofield stands out prominenblv. For more than
twenty years he was chairman of the Health Committee,
and though of late years the methods pursued by it have
been the subject of mucli criticism, everyone gave him
credit for acting in a thorough and hondfiidc manner in
his efforts to grapple with many of the problems to be dealt
with by the sanitary administrators of a large community
like this. For many years, also, he took a warm and active
interest in the Royal Infirmary and its allied branches, as
well as other charitable institutions of the district.
Mancbeater, April 1st.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Serious Charge against a Proficssor."
A MAN named Edward Moross, aged thirty-seven, who
has been lecturing in Newcastle for' some time in the
•Central Hall and advertising consultations free, under the
style of “Professor Moross, M.E.,” was brought up at the
Newcastle Police-court on Saturday on warrant, charged
with having committed a rape on Isabella Burnley, a
domestic servant aged seventeen. The prosecutrix said she
arranged with the accused to have six private treatments
for deafness for two guineas. She complained to her sister
of what happened at the consulting-rooms of the accused.
Mr. Baumgartner, the police surgeon, stated that be bad
examined the prosecutrix, and her condition might be
due to natural causes or to what she alleged. Prisoner
was further charged with having indecently assaulted
Florence Crossley, eighteen years of age, at the same
place. She stated that there was an agreement with
the prisoner that she was to he treated for neuralgia
in the face in the presence of her sister. The fee was to
be five guineas. The prisoner, however, asked her to come
on the 14th ult. to his consulting-rooms, and said her sister
need not attend. He, it was alleged, closed the door of
his consulting-room when she went in. There was only a
latch on it, but there was a curtain between the door and
the interior, and she alleged he indecently assaulted lier.
The prisoner was remanded, and the magistrates refused to
accept bail.
The Barber-Swgeons and Chandlers of Nciocastle.
The following “ items ” are culled from a continuation of
the paper read to the Newcastle Society of Antiquaries by
Dr. Embleton, and referred to in my former notes; “ Itm.
for wyne and sugar at our dynners, 165. 6(^.; item, for beire
after dynner, 46.; itm. for tobacco, l5. Cd; itm. for the
musick’s dynner, 3s.; item, geven to the musicke, ds.; itm.
for beire the next day at brickfast, 4s.; itm. geven to three
travelers’ cirurgions, 6s.; itm. to the mayd, Is.; itm. geven
to the pore, 2s. ; itm. that night in wyne at George
Horsler’s, 6s. Qd. ; itm. on gallon of brunte claret at George
Mallabarre’s buriall, 4s.”
Newcastle Hospital Jor Women.
The Newcastle Hospital for Women was founded in I866>
and until recently was carried on in conjunction with the
lying-in hospital, but its removal was necessitated by the
ioilux of patients (now about 3000 yearly), and a successful
ba/.aar iu its interests was held last week, having been
opened by the Mayor.
Cumberland.
The question of appointing a medical officer for the county
of Cumberland is said to be under the consideration of a
committee of the County Council. The terms of appoint-
meut suggested are that the county medical officer snould
devote bis whole time to the service of the county,
that he should bold the office at the pleasure of the
Council, and that he should not be entitled on retirement to
a pension or superannuation allowance. It is to be hoped
that the salary (which is not mentioned) may be in propor¬
tion to the responsibility of the office and the extent and
importance of the county.
The Porh-pic Poisoning Case in Carlisle.
The Medical Itoport of the Local Government Board in ¬
cludes a paper'by Dr. Klein on a case of poisoning at
Carlisle, which excited considerable attention about a year
ago. Dr. Klein had submitted to him samples of pork and
ot gravy stock from the same source as the food which
was more than suspected of having caused the outbreak
of illness. As to the pork, it was known to be from the
same animal or animals which was or were believed tO’
have caused the trouble, but of the gravy it could only
be said that it came from the same establishment,
hlice were fed on the gravy and bread, also on the
pork. Bacilli in gelatine cultures were obtained from
the bodies of these mice, and used for experiments on
other mice. Dr. Klein thus sums up:—“ Webaye here t6 do
with a true infective disease, producible by feeding animals
with given samples of gravy stock and pork, and capable
of being propagated by a particular microbe in artificial
culture from the bodies of rodents fed with samples. Tb©
microbe here described is not the same as that described
by me ten years ago in connexion with the Welbeck and
Nottingham meat poisoning, nor is it identical with either
of those to which veal and pork poisoning has been referred
by me in recent reports to the medical officer. It is an
altogether different species, as will be clear from my account
of its morphological and cultural character.”
The Silloth Convalescent Institution.
The annual meeting of the Cumberland and Westmor¬
land Convalescent Institution at Silloth was held last week,
the Bishop of Carlisle presiding. It was shown by the
report that during the year the number of patients admitted
was 047, as against 560 in 1889. The report of Dr. Leitch
showed that 527 patients gained weight and 60 lost weight,
22 left in statu quo, and 32 had left before their time
bad expired.
Sunderland Eye Infirmary.
At the annual meeting of the Sunderland and North
Durham Eye Infirmary cases, it was stated, had been
dealt with during the past year. The new building to be
erected in Stockton-road has received support from the
working men of Sunderland to the handsome amount
of over £800.
NowcasLlis-upoii-Tyne, April 1st.
SCOTLAND.
(From our own CoRREsroNDENTS.)
Edinburgh Sich Children's Hospital.
The directors have decided to rebuild this hospital on its
old site. There were hopes that it might have been
acquired for the extension of the Royal Infirmary; but if the
decision of the Sick Cliildron’s Hospital directors is final,
1 by Google
The Lancet,]
IRELAND.-PARIS.
[April 4,1891. 803
these hopes will be disappointed. The site is considered by
many os not the best for a children’s hospital, the situation
of the building at present used for the accommodation of the
patients being regarded as much more beneficial to the
general health of patients and staff than the old site was.
Health of Edinburgh.
The mortality last week was 122, making the death-rate
^2.3 per 1000. Diseases of the chest accounted for 35 deaths
and zymotic causes for 15, of which 3 were due to scarla¬
tina, 4 to measles, and 6 to whooping-cough. The intima¬
tions for the week were—typhoid fever, 6 ; diphtheria, 7 ;
(scarlatina, 17 ; measles, 91.
Honorary Degrees.
The SenatuB Academicus of Edinburgh University has
offered the degree of LL.D. to the following amongst
others : John Beddoe, M.D., and Sir George M. Humphry,
M.D.
Anderson's College Medical School.
At a meeting of the governors, held within the office of
the secretary, Mr. John Kidston, West Regent-street, on
March 25th, T. Kennedy Dakiel, M.B., C.M., F.F.P.S.,
was appointed to the chair of Medical Jurisprudence,
vacant oy the resignation of Dr. Eben. Duncan; and
D. Campbell Black, M.D., L.R.C S., F.F.P.S., was ap¬
pointed to the chair of Physiology, vacant by the resigna¬
tion of Dr. Christie.
Mdrcli 150th.
IRELAIirD.
{Feoji our own Correspondents^
DUBLIN.
Steevens' Hospital.
Me. William Colles, ex-president of the Royal College
of Surgeons, and Surgeon-in-Ordinary to Her Majesty in
Sreland, has resigned the senior surgeoncy of this hospital,
to which he has been attached since 1834. In that year he
was elected house surgeon, and in 1841 visiting surgeon, or
a service of upwards of half a century. The Board of
Governors have elected Mr. R. L. Swan, F.R.C.S., to the
vacancy. Mr. Swan some years since was resident surgeon,
and since 1876 has been surgeon to the Orthopajdic Hospital,
and is one of the examiners in anatomy at the College of
Surgeons.
A'ssault on a Prison Surgeon.
At the Cork Spring Assizes last week, before Lord Chief
-Justice O’Brien, Ellen Hurley, an inmate of the city
female prison, pleaded guilty to an assault on Mr. Thomas
Moriarty, medical officer of the prison, by striking him with
a bottle under the ear while inspecting the prisoners last
month. The wound was a severe one, and had to be stitched.
She was sentenced to twelve months’ imprisonment with
hard labour.
Charge against a Medical Practitioner.
At the Northern Police Court, Dublin, last week, a
medical practitioner was prosecuted by the Registrar-General
for having signed a certificate of death which contained a
•false statement. It appeared, that the defendant stated
that he was registered in Ireland as a medical practitioner,
which was not the case, he having been registered after he
-gave the certificate. There was also an inaccuracy as
regarded the duration of the illness of the deceased person.
The magistrate held that the offence was proveil, and
•inllicted a fine of £5.
Health of Ireland for December Quarter.
During the December quarter of last year the births
registered were equal to an annual birth-rate of 20 per 1000,
and the deaths to l(i-2 per 1000. The birth-rate was 1-7 under
the average for the corresponding quarter of the previous
ten years, and the death-rate shows a decrease of 0'4. The
public health for the quarter may be regarded as aatis-
factoiy. The principal zymotic diseases v’ere under that fo’'
any quarter since 1886, and wore much below the average
for the fourth quarter of the year. Measles caused 33
deaths; scarlatina 91, against an average of 246; typhus
fever 100 ; whooping-cough 232, or 123 below the average ;
<suteric fever 216, or an excess of 12. Compared with those
for the corresponding quarter of 1889, the returns of
pauperism show a decrease of 1684, or .38 per cent., in the
average number of workhouse inmates on Saturdays during
the quarter, and an increase of 388 in the average number
of persons on out-door relief.
Mr. F. W. O’Connor, F.R.C.S., died on March 26th at
George-street, Limerick, from an attack of pneumonia, aged
forty-nine years.
BELFAST.
The Ulster Medical Society.
At the last meeting of the Ulster Medical Society, Pro¬
fessor Sinclair read a paper on " Intestinal Obstruction,” in
which be discussed the causes, the diagnosis, and treatment
(medical and surgical) of the conditions underlying the
symptoms. He showed a young man who bad been suffer¬
ing from obstruction of the bowels, who had been rescued
from death by the following operative treatment done by
him. After opening the abdomen, Professor Sinclair divided
a series of fibrous bands, tying down the bowel; but in order
to reduce the ileum (the part constricted) he was obliged to
open it and remove a quantity of liquid fmces, after which
he stitched up the aperture with Lembert’s sutures and
closed the abdomen. The patient recovered, and was ex¬
hibited to the members of the Society. An interesting
discussion followed Dr, Sinclair’s paper.
Belfast Ophthalmic Institution.
From the medical report presented by Dr.' Walton i
Browne at the annual meeting of the supporters of this
hospital, held on Monday last, I learn that 1662 cases were
' treated during the year; of these, eighty-four were intern
and the remainder out-patient. Eighteen senior medical
students are receiving clinical instruction, so that the
hospital is performing a double duty : attending to the
Bufferings of the poor and at the same time acting os a
training school for students in the diseases of the eye, ear,
and throat. Special reference was made at the meeting
to the lamented death of Mr. Samuel Browne, who was
connected with the hospital for a period of forty years. A
resolution was passed in which the meeting placed on record
the loss they had sustained in Dr. Samuel Browne’s death.
Hospital for Infectious Diseases.
In one of the local morning papers attention is again
drawn in a strong article to the great want in Belfast of
a hospital for infectious diseases provided and maintained
by the municipal rates. What has been done in this
direction in Glasgow and Edinburgh is pointed out, and
the necessity for the removal of the Union Fever Hos¬
pital from its present site to a more isolated and less
crowded district is urged.
April 1st.
PAEIS,
(From our own Correspondents.)
The Sujply oj Morphine to Moiphinomaniaes.
MoRiMiiNOMANiA being recognised to be on the increase
in France, medical men . nave very generally charged phar¬
macists with supplying the drug somewhat too liberally to
the unfortunate wretches who have become victims to this
passion. It is surmised that a presciiption is made to serve
for years, and it is thought that if the renewing of that
document were made compulsory at stated intervals this
social evil might be curtailed in its extension. Paris
chemists, who os a body are estimable members of
society, resent this charge, and the Benefit Society of
the First-class Pharmacists of the Department^ of the
Seine appointed a Commission to make inquiries on
the subject. The Commission reports that, however
true the charge may have been years ago, when morphia
commenced to be injected hypodermically, very few pbar-
niacista now contravene the law forbidding such a practice.
The Commission, however, formulates the charge against
certain wholesale draggists, who, it is alleged, do not hesi¬
tate to forward large supplies to non-professional customers.
It is also stated that much of the drug comes from beyond
the frontier either as contraband, in letters, or even openly
by post or rail.
Digitized by ^ooQle
04 Ths Lai70BT,1
BEKLIN.—OBITUARY.
[April 4,189t.
New Honours Jor Sir Spencer Wells.
At the last meetiog of the Aca<36iQie de M^deciae there
were elected two oew recruits to the ranks of the foreign
associates of this distinguished body—viz., M. Deroubaix of
Brussels, and our own eminent compatriot, Sir Spencer
Wells. Most of your readers will, with myself, wonder
why the latter should, on tbe first election, have obtained
only four votes as against forty-six accorded to his rival.
At the election for the'second vacant place, Sir Spencer
Wells was, however, elected unanimously.
WAen will the New Medical Law come into Operation
In my letter lastweek I communicated to the readersof The
Lancet tbe gist of the new law on tbe practice of medicine
which had been passed by the Chamber of Deputies. Certain
paragraphs in the measure relating to the right of doctors
practising in remote districts to dispense medicines were
reserved for consideration until the new Pharmacy Act was
discussed. The Medical’Act having been passed at the first
reading, it was hoped that a similar piece of good fortune
awaited the Pharmacy Bill. Such a hope was illusory, for
the Chamber having refused to vote urgency for the latter
measure, a second reading became necessary. It is certain
that the Senate will decline to consider the Medical Bill
until the Lower House has made up its mind on the
paragraphs reserved. Hence a serious delay, and medical
reformers are beginning to despair. It appears that red-
tapeism is as much a Prench as an English article ! In con¬
nexion with the subject, I may mention that the Minister
of Public Instruction has just submitted to the considera¬
tion of the Superior Council of his department a project
calculated to reorganise tbe purely preparatory studies in
the medical curriculum. This scheme provides for the
creation of a special degree for medical aspirants, to be
styled Baccalavr6at is Sciences Naturelles. The prepara¬
tory scientific studies, instead of being conducted, as at
present, at the Faculty of Medicine, will take place in
future at the Faculty of Sciences. This new regulation
will allow four entire years to be exclusively devoted to
medical studies properly so-called.
A Medical Funeral.
Last week there died, of infectious broncho-pneumonia,
one of Professor Brouatdel’s internes at the Charity Hospital,
the disease having been contracted in the wards. The
defunct, Charles Louis, was an indefatigable worker and a
most promising student, and as such, and on account of his
pleasing manners, was greatly beloved. The respect in
which he was held is proved by tbe numerous and
distinguished company who escorted his remains to the
Gare da Nord, en route for bis native village, Cripy.
en-Valois. Amongst the mourners there were noticed
Professor Brouardel, Drs Budin and Horteloup, and
numerous hospital physicians and surgeons. Dr. Peyron,
Director of the Assistance Publique, and the directors of
the Piti6, Bichat, and Charitc hospitals, besidesadeputation
of internes and of pupils of the nursing school of the Pitid,
who had enjoyed since 1888 the privilege of the teaching of
the deceased. At tbe station touching words of adieu were
£ ronoanced by Dr. Pejron, Professor Brouardel, and
[. Chipaulb, the latter being the mouthpiece of the internes
of the Cbarifu. Amongst the wreaths sent was one from
Professor and Madame Brouardel.
The French Surgical Congress.
About three hundred French and foreign surgeons were
f iresent at the International Surgical Congress held in Paris
ast week, among whom were Sir Spencer Welle, Mr. 'Victor
Horsley, Mr. Lawson Tait, Mr. Broadhurst, and Mr. Godwin.
The Congress was opened by Dr. Gayon, who read a paper
on the Progress of Surgery in Modern Times. Mr. Victor
Horsley read a paper on the Operation of Trephining.
Paris, April 1st.
BERLIN.
{From our own Correspondent.)
Measures against the Spread of Tuherctilosis.
A LITTLE tract of fourteen pages, entitled “The
Opinion of the Iloyal Prussian Scientific Department for
Medical All'airs regarding Measures against the Spread of
Tuberculosis,” has been published in obedience to orders by
the Berlin police, which at the same time recommends a
broad sheet entitled “ Measures against the Spread of Con¬
sumption” to public notice. Tbe contents of the latter are
as follows : “ Consumption of the lungs and larynx (tuber¬
culosis) is conveyed to healthy persons by the tubercle'
bacilli contained in the expectorated sputum of patients j
if the sputum dries, it becomes dust, and is thus inhaled.
The excreta of such patients are capable of causing mis¬
chievous effects in the same manner. By rendering the'
sputa and excreta harmless tbe spread of consumption aah
be prevented. In the dwellings of consumptives and in all
houses, on the stair-landings, but especially in buildings-
and public rooms (hotels, restaurants, places of amusement,,
assembly rooms of every kind, schools, &c.), spittoons of
strong smooth glass, porcelain, earthenware, or enamelled
iron, twenty to twenty-five centimetres in diameter, five
centimetres high, with smooth edges a little bent round',,
supplied with water to a depth of from one to two centi¬
metres, with the distinctly legible inscription on the out¬
side, “Spittoon for coughers,” should be placed in large
numbers. Evaporated water must be replaced; the
spittoons are emptied into tbe closets and cleansed daily
with boiling water. The sitting-rooms and bedrooms
of consumptive persons must be furnmbed only with
washable curtains, table-covers, and the like; must be
without carpets on the floors, without woollen carpets on-
the stairs leading to them, and must contain as little padded
furniture as possible with washable and easily removable-
covers ; elastic iron garden furniture with washable covers
or movable cushions is the best substitute for padded furni¬
ture, and facilitates the cleaning and disinmeting of the
rooms and their contents. Bedside carpets should be of
washable jute linen. The whole floor of every such roon>
must be wiped with a damp cloth daily, to remove the dust^
and aired for at least an hour in winter as well as in
summer; the rooms must be thoroughly cleansed every
week, and disinfected every three months according to the
regulations for disinfection in epidemics dated Feb. 7tb,
1887.”
A Portrait of Virchow.
The famous portrait painter Franz Lenbach of Munich is'
painting a portrait of Virchow for the Berlin Medical
Society. It will be unveiled at a festal meeting of the
Society, and presented to the Langenbeck House. There it-
will hang beside a portrait of Langenbeck in the hall
destined for the meetings of the medical societies of Berlin,
for congress asaemblie.s, festal ceremonies, &c.
German Death-rates in the week ending March
Aixia-Chapelle, 25 4; Altona, 326; Barmen, 16'3;-
Berlin, 21 ; Bremen, 21-5 ; Breslau, 24‘4 ; Chemnitz, 32‘5 ;
Cologne, 23'4; Dantzic, 27; Dresden, 20’1-; Dusseldorf,.
25-(); ElberfeW, 21-2; Frankfort, 22'8; Hamburg, 23‘8;
Hanover, 21 ; Konigsberg, 24; Krefeld, 2!)-6; Leipsic, 20‘9;.
Magdeburg, 24-1; Munich, 30-9; Nuernberg, 28‘6; Stettin,
22'4 ; Sbrasburg, 237 ; Stuttgart, 24'2.
lierlin, March aoth, __
WILBEKFORCE ARNOLD, M.R.C r.L, M.R.C.S., J.P-.
We have to announce with regret the death of Mr. Arnold,,
which took place suddenly at his residence, Crescent House,
Belfast, on Monday night, March 23rd, at the age of fifty-
three years. Ever since September last, when he had a-
slight paralytic stroke, he has been in poor health, a fact,
noticed by many of his friends. On Monday night, after
seeing a patient, he complained of feeling faint, and Dr.
Howard Sinclair and Dr. Lindsay saw him soon afterwards,
but be wasin a semi-conscious condition, and died from cardiac
failure. Mr. Arnold was the son of Mr. John Arnold, a
man well known in his time in Belfast, and highly respected.
Mr. Arnold, who was a member of the Royal College of
Surgeons of England, and of the College of Physicians of
Ireland, occupied a good social and professional position in
Belfast. / He was specially distinguished for his religous and'
philanthropic work, aud it was article.? from his pen which-
led to theestablislimenfcofthe Presbyterian Orphan Society,
which has been a great success in Ulster. Mr. Arnold, who
was a justice of the peace for the city of Belfast, leavea-
a widow, three sons, and five daughters.
Di Google
The Lancet,]
MEDICAL NEWS.
[April 4,1S9L 805.
Epsom Collkoe.— H. Boulton, a pupil at the
College, hae just gaioed an open scholarsnip of £50 for
Natural Seience at Clare College, Cambridge.
Medical Magistrates, Queensland.—M r. M. J.
Collins, L.KC.S. Edin., of Clermont, and Mr. E. H. V.
Voss, M.llC.S, of llockhampton, have been appointed
Justices of the Peace for Queensland.
The Gresham Lectures.— The subject of Dr.
Symes Thompson’s lectures, to be delivered on April 7th
and three following days, will be “The Prevention of
Disease,” and will be treated under the headings “The
Access of Disease.” “Infection and Disinfe'etion,” “Diph¬
theria,” and “Contagion.”
Society for the Study of Inebriety.— At the
annual meeting, to be held on April 7th, in the rooms of
the Medical Society of London, 11, Chandos street, Caven¬
dish-square, W., the President, Norman Kerr, M.D., F.L.S.,
•will take for the subject of his annual address, “ Recent
Criminal and Civil Trials, with Inebriate Complications;;
and the Urgent Need for a Reformed Jurisprudence.”
The Home for Lost Dogs, Battersea.—T he
thirtieth annual report, just issued, states that, during the
year 1890, 21,r)9;l dogs had been received into the Home,
showing a decrease of 2550, compare! with the returns of
the previous year, which we^e augmented by seizures under
the muzzling order. But these figures exceed by 4500 those
issued prior to that order. The committee report an almost
entire abjence of rabies during the past year. Reference is
made to the valuable services of Dr. Richardson, who had
generously presenteil to the Home two lethal chambers, in
■which useless dogs met a painless death.
The Publk’- Health Medical Society.—A meet¬
ing of the council of this Society was held on the 24th iilt.,
atlts offices. 101, Great Uussell-street, Bedford-square, Pro¬
fessor W. R. Smith, M.D., vice-president, in the chair.
Amon" the business transacted was the consideration of
various Bills at present before Parliament, and it was unani¬
mously resolved that steps should at once be taken to have
an amendment placed on the paper in connexion with the
Public Health Law Amendment (London) Bill, with the view
of making it compulsory that medical ofBcera of health in
the metropolis should not engage in general practice.
Queen’s Hospital, Birmingham.— Tho report
(the fiftieth, and the jubilee year of the institution) is
highly satisfactory, both in respect to finance and the large
additional good work accomplished during the past year.
There was a balance of income over expenditure of
£2491 l().s , due chielly to the excpptional amount received
in legacies. The in-patients had increased by twelve per
day, the total number for the year was 1948, and 27,750 out¬
patients were tended. Prom the 11 ospital Saturday collec¬
tion £1524 lls. was allotted to the institution (a very
substantial addition on the previous year), and£-t48o 9 j. was
received from the Hospital Sunday Fund. As soon as the
finances of the hospital justify it. the extra space available
by the recent enlargement of the wards will be utilised
to meet the present inadequate accommodation for out¬
patients.
Schools ofSurgery, Royal College ofSurgeons
IN iRlct.ANi). — The following the Anatomical Prize List
for the winter session 1890-91 Drscr/piiyg Anatomy:
Junior—First-class certificates, Messrs Green {1st Prize
and Medal), Meeke (2Qd Prize), E. C. Hayes, G. Davidge,
J. W. Grillio, C. Black, Keating, Marie Goodwin, Odium.
Senior—Messrs. Sweeny {1st Prize and Medal), O’Donnell
(2nd Prize). 1'aylor, Trewhella. F. Matthews, W. Martin.
Practiced Anatomy: .hinior—Messrs. Greene (l.^t Prize and
Medal), Meeke {2iid Prize), E. Hayes, Culligao, L’Mstrange,
GrilUn, Keating, Davidge. Senior — Messrs. Molyneux
(1st Prize and Medal), S^'eony (2Qd Prize), Behan, E.
Tennant, McCann, Grogan, Taylor, Trewhella, Martin,
Matthews, Hothwell. Third year—Messrs. Black (1st, Prize
and Mfdai), Eisner (2 qc 1 Prize), Oliver, Warren, Anderson,
J. Grillin, Miiighau, Clifford, Good, and W. I*". McCann.
The Sanitary Condition of St. Bartholo¬
mew’s Hospital.— A petition having been presented to
the Commissioners of Sewers complaining of the sanitary
condition of this hospital, it has been referred by that body
to the Sanitary Committee for farther investigation.
North-Eastern Hospital for Children.—T he
dinner in aid of the funds of the hospital, at which the
Duke of Connaught has consented to preside, will he
held in the Royal Venetian Chamber, Holborn Restaurant,
on May 15th.
The New Infirmary, Derby.—A n official in¬
timation has been received by the Mayor of Derby that Her
Majesty the Queen will lay tne foundation stone of the new
infirmary on the 2lst prox. The building is estimated to
cost £74,000. The present infirmary, owing to its sanitary
defects, has been condemned.
Congress of Hygiene.—T he Council of the'
Society of Arts, acfcingunder the provisions of the Benjamin
Shaw Trust, have offered two gold medals, or two prizes-
of £20 each, to the Executive Committee of the CongrMs
of Hygiene and Demography, for any inventions or dis¬
coveries of date subsequent to 1885, exhibited at or
submitted to the Congress and coming within the terms
of the trust. Under the conditions laid down by the
donor, these prizes are to be offered for new methods of
obviating or diminishing risks incidental to industrial
occupations.
New Infirmary at West Derby.—T he ccrcmony-
took place last week of laying the foundation stone of the
new infirmary which the West Derby Union Board has
decided to erect in the Mill-road. The main building on
the north side of Mill-road will comprise the administrative
block, in addition to the old lower hospital, which it is-
proposed to leave standing. The several floors of the blocks
will contain a large ward capable of accommodating
thirty-six patients, duty room, and day room. The whole
scheme will be carried out on the latest approved plans of
hospital construction.
University College Hospital.—T his institution
maintains its efficient administration. The report for 1890
states that the year commenced with debts amounting ta
.£14,147, and, unless the charity received additional support,
the committee look forward to grave responsibility. The
yearly reliable income was about £0000, while the expendi¬
ture approached £20,000. In 1890, 2773 in-patients were
admitted. The out-patients numbered 39,478, and the
attendances of the latter, including first attendances,
140,062. The hospital rebuilding fund bad remained
almost stationary. At present £12,000 was in hand, but
£30,000 MAS required.
Bristol Infirmary. — The 1.55th annual report
shows that the finance of the institution ia still unsatlefao-
toiy. A heavy debt remains due to the treasurer. Asregarda
the number of in-patients during the past year there -was
nothing that called for special notice ; but there had been a
remarkable addition in the total of out-patients, which
exceeded the previous year by no less than 4200 (about
16 per cent.), making the total of out-patients attended
30,567. Camden House, which was purchased four years
ago, is now in full operation, and affords accommodation?
for fifty nurses; in connexion with which a Nurses’ Insti¬
tute is' being gradually added to from fully qualified nurses-
who have received their training in the house.
Stogkport Infirmary.—T he anuuiil mooting of
the trustees was held last week. The report for the year
1890, which was read, stated that next year would witness
■ the close of a hundred years since the dispensary was
inaugurated in a humble cottage by Dr. Briscoll. A
Samaritan .Fund had been established to aid poor persons
by sending them to convalescent hospitals. The late Mr.
Allatt Marsland bad bequeathed £500. free of legacy duty,
to this fund. A framed portrait of Dr. Killer, one of the
founders, had been presented to the infirmary. Tho
receipts for the year, exclusive of legacies, had enabled the
committee to increase the assets by £3516, these now
standing at £41,000. The number of cases treated was
51.56, of which 1339 were accidents. There had been 650
in-patients.
Dig-bzed by 'S- lOO^Ic
$06 The Lancet,]
APPOINTMENTS.—VACANCIES.
[April 4,1891.
Bequests and Donations.—M rs. Anne Browne
■of Monkstown has left to the Eoyal Hospital for Incurables
Adelaide Hospital £50, Meath Hospital £50, and
Cripples’ Home, Bray, £50.—Lord Iveagh and Mr. Bathbone
bave given a donation of £100 each to St. Patrick’s
Norses’ Home.
Yellow Fever on a British Steamer.—A n
Exchange telegram reports that the Boyal Mail steamer
Trent has been detained in .quarantine at Southampton,
■owing to four fatal cases of yellow fever on the homeward
voyage from the Biver Plate. A tug was to have taken off
the mails and specie on Thursday, but the order was
countermanded.
Fever in Birkenhead.—A nother outbreak of
lever is reported in Birkenhead, beginning in the Borough
Hospital, three of the inmates of which were struck down
eimmtaneously, and the medical staff deemed their removal
to the fever hospital to be advisable. The fever has not
been officially declared to be typhus, and every pre¬
cautionary measure is adopted in the hospital.
Football Casualties.—I n the Alliance match
•with Bootle on the 23rd ult., at Bootle, three players
sustained severe injuries from kicks. Mr. Jabez Batcliffe,
whilst playing football last week, at Hatbern, fractured
'his right hand. On Monday, a youth, belonging to Cor-
bridge, whilst playing a match between the Acomb Archers
;and the Corbridge Juniors, broke one of bis legs below the
knee, there being a compound fracture. On Tuesday even-
'ing, a youth, a^d seventeen, of Black Heath, was admitted
into the WestBrora^'ieh District Hospital, suffering from
■a fractured thigh whilst playing football.
National Hospital for the Paralysed and
Epileptic.—T he board of management of this hospital
ejinounce that the Bight Hon. the Earl of Derby, ICG.,
will preside at the Biennial Festival on Thursday,
April 23rd, at the Whitehall Booms, H<Uel M6tropole.
Tne special objects of the festival are: to raise a sum of
£2500 to cover deficit on general purposes account and
to prevent the closing of wards ; to raise a sum of £500 to
complete the equipment of the new surgical wing; and to
increase the annual subscription list, which, though actually
10 per cent, more, is, proportionately to the expenditure,
40 per cent, less than before the rebuilding.
Succex^ul applicants/or Vacaneief, Secretaries 0 /Public Institutions, and
others possessing in/ormation suitabie for this eoluum. arc invited to
forward it to I'JIE LANCET Office, directed to the Sub-Editor, not later
than 9 o’clock on the Thursday moi-ning of each week for publication in
the next number. -
Baynes, Jam®, has beon appointed Analyst for the City and Borough
of PetetboroTigh.
Blucke, H. F. S., L.R.O.P. Lord., M.R.C.S., has Iiuen appointed House
Surgeon bo the Toignmouth, DaivUsh, and Newton Infirmary, Dis¬
pensary, and Convalescent Home.
Brown, W. H,, M.R.C.S,, haa been appointed Public Vaccinator for
Colac, Victoria, Australia.
Brown, W. S., M.R.C.S., has been appointed Medical Officer to the
Pajamatta Friendly Societies’ Medical Institute, New Soutli
Wales.
Bra’CE, Alex., M.B., C.M. Glasg., has been appointed Medical Officer
for the Parish of Killin, Perthshire.
CAVERttiLL. T. F. S., M,B.,F.R.C.P. Bclin., ha.s been appointed Medical
Officer for the County of Haddingtonshiro.
•COBU, John Fred., M.R.C.S., ha.s been appointed Public Vaccinator
for East Collingwood, Victoria, Australia, vico Maegibbon.
'Connor, F. G., M.B., C.M. Bdin., has been appointed Medical Officer
to the Lisraore Hospital, Lismoi o, New SoutJi Walo.s.
Deane, John E. J., L.R.C.P. Ir6l.,L,F.P.S. Claag., has lieen appointeil
Puolic Vaccinator for Rutlieigleu, Victori.a, Australia, vico Lang,
resigned.
Dodsworth, F. C., L.R.C.P. Lond,, M.R.C.H., has boon appointed
Medical Officer of Ile.alth for the Chiswiclc Urban Sanitary District
of the Brentford Union, vice Moore, resignod.
Fisher. John A., L.R.C.P. Edin.,L.F.P.S. Glasg., has been l eappointed
Medical Officer of Health for Garston, Lancasliire.
Fisher, Theodore, M.D. Loud., M.R.C..S., has been appointeil
Assistant Medical Officer to the Iiiflrniury of the JSt. Saviour's
Union, vice Muapratt, resigned.
FiTZGERAi.D, J., M.B., C.M. Jfidin., has been appointed Public \'ac-
cinator for the District of Kaitangata, Now Zealand.
FORBE-S, Armitage, L.R.C.P. Edin,, I,.R.C.S, Irol., has been appointed
Government Medical Officer and Vaccinator for tlie District of
Fernmoimt, New i-iouth Wales.
Hodgson, H., L.R.C.P. Lond., M.R.C.S., lias beon appointed Resident
Obstetric Surgeon, Guy's Hospitcil.
Hunter, Rout. R., M.B., C.M. Glasg., M.R.C.S., has been appointed
Govei-ninent Medical Officer, Mount Morgan, Queensland.
Johnston, John, M.B., C.M. Glasg., has been appointed Medical Officer
for the Town of Williauistowii, Victoria, Australia, vice Figg,
resigned.
Kay, Jas. M. M., M.B., C.M. Bdin., has been appointed Medical Officer
to the Workmen of Mesai-s. imeas and Aird, Railway Contractors,
Crianlarich, Perthshire, vice Hodges, resigned.
Lee, Timothy W,, M.R.C.S., has been appointed Government Medical
Officer and Vaccinator for the District of Wollongong, also Visiting
Surgeon to the Wollongong Gaol, Now South Wales.
Leslie, LouisG.,L.R.C.P., L.R.O.S. Bdin., has boon .appointed Medical
Officer for the Rutherglen Borough, -Victoria, South Australia.
Lewls, Percy G,, M.D., has been appointed Honorary Medical Officer
to the Victoria Hospital, Folkestone, and Honorary Assistant
Medical Officer to the St. Andrew’s Convalescent Hospital, Folke¬
stone.
Lewis, Wm. M.^ M.D.. M.Ch., L.M. R.C.P. Irel., has been appointed
Public Vaccinator for Donald, Victoria, Australia, vice Fleming.
Mackintosh, A., M.D., L.F.P.S. Glasg., has been reappointed Medical
Officer of Healtli for the Clay Lane Urban District.
Madin, Wm. T., L.D.S. R.C.S., has beon appointed Dental Tutor to
Queen’s College. Birmingliam.
McGee, William, L.R.C.S., L.K.Q.C.P. Irol,, has been appointed
Medical Officer for Avonsliire, Victoria, Soutli Australia.
Mitchell, John, M.D., L.F.P.S. Glasg., has been reappointed Medical
Officer of Health for the Barnard Castle Urban and Rural Districts
of tlie Toosdale Union.
Morrow, Rouert, M.D., B.Ch. Dub., has been appointed Medical
Officer for the Shire of Woorayl, .Victoria, Australia, vico Mont-
gomovy,
Morton, Selby M., M.R.C.S., has been appointed Government Medical
Officer and Vaccinator for the District of Goulburn, also Visiting
Surgeon to the Goulburn Gaol, New South Wales.
Nasmyth, T. G.. M.D. Bdin.,D.P.n. Camb., has been appointed Medical
Officer for the Cupar District, Fifeshive.
Paul, G. W. F., M.D. Brux., L.R.C.P, Lond., M.R.C.S., has beon
appointed Government Medical Officer for SanUgatc, Queensland.
Ferry, C. E., M.D.Brux,, L.R.C.P. Edin,, M.R.C.S., has been re¬
appointed jledical Officer of Healtli for Sandgato.
Pini.Lii’S, E. E., L.R.C.P. Edin., M.R.C.S., lias been appointed Medical
Officer of Health for the Southend Local Board.
Pope, H. Siiarland, B.A., M.B., B.C. Cantab., has beon appointed
House Physician to the General Lying-in Hospital, York-road, vice
H. B. Osbiirn, resigned.
Rowley, Chas., M.R.C.S.,has beon appointed Public Vaccinator for
the District of Te Awamutu, Auckland, New Zealand.
Sims, (f. S., L.R.C.P. Lond., M.R.C.S,. has been appointed Medical
Officer for the West District of the Derby Union.
Smith, Alkhed P.. L.R.C.P.. L.R.C.S. Irel., has been appointed Medical
Offic;ei' for the Shire of I'lindersand Kangereong, Victoria, Australia,
vice Theed.
WiiJTAKER, Geo.’ Herbert, M.R.C.S., has been appointed Medical
Officer for the Bungay District, Suffolk, vice Jolinson, resigned.
Wilding, Walter P. W., M.R.C.S., L.R.C.P.Lond., and L.M. Coombe,
lias been appointed Medical Officer of Health to the Ilindley Local
Board, vico John Aspinall, resigned.
fstrarits.
For further information regarding each vaca/ncy reference should be made
ts the advertisemeiit.
Birmingham City Asylum, Rubery-hill_, near Bromsgrove.—Clinical
Assistant. Board, lodging, and washing will be provided.
Bridgwater iNrmMARY.—House Surgeon. Salary £80 per annum,
with board and re.sidence.
Cancer Hospital (Free), Fulhnm-road, S.W.—Assistant Surgeon.
CHEI.SEA Hospital i-'OR Women, Fulliam-road, S.W.—Honorary J'atho-
logist,
City ok London Lunatic Asylum, stone, near Dartford, Kent.—
Clinical Assi.stant. Board, lodging, washing, and attendance pro¬
vided.
Deaconesses’ Institution and Hospital, Tottenham, N.—House
Surgeon. Salary £90 per annum, witli board and leHideuce.
East London Hospital kor Children, Shadwoil, E.—House Phy-
siciancy. Board and lodging provideil. .
General Hospital, Birmingham.—Honorary Physician.
Grantham Friendly and Trade .Socib'j'ies’ Medical Institution,—
Re.sidont Medical OUiiier, Salary £150 por annum and midwifery
fees, witli residence, coals, gas, and rates free. (Apply to Mr. 7''
Hiillot, Grantham )
Manchester Hospital for Consumption and Diseases of the
Throat.—R esident Medical Officer atBowdon, Ciiesiiire, Salary
£00, with Imaril, apartineiiVK, and wasliing.
MESSius. ,S. T. Rennie, Son, & Co., i, Ka.st India-aventio, K.C.—Surgeon
for Steamer for three mouths’ voyage to Soutli Africa and !)aclc.
Oxi’ORD IfiYF. Hospital.— House Surgeon. Board, lodging, and hono-
I'arium of £50 at expiration of a year.
Salford Union.—A snistar.t Medical Officer for tlie Union Inflnnary,
Hope, near Kccle.H. talary .-eiyo por anuum, with funiiHlied apart¬
ments in the Jiillrmary. (Apply to the Clerk to the Guardians,
. Union Offices, liccles-now-road, Salford.)
Dig
e
Thb Lakcet,
BIRTHS, MARRIAGES, AND DEATHS.
[April 4, 1891. 807
SUSSEX County Hospital, Brighton.—H ouso Surgeon. Salary £120..
rfsing to £140 per annum, at the rtiacretion of the Committeo of
Management, with reeidenee and board in the Hospital, with bis
washing.
Swansea Hospital.—■R osirtent Medical Officer, Salary £100 per
annum, with board, furnished apartments, coals, gas, laundress,
and attendance.
.West Bromwich District Hospital.—A ssistant House Surgeon for
six months. Board, lodging, and washing in the Hospital.
West Bioino Lunatic Asylum, Waltelield.—Pathologist and insistent
' Medical Officer. Salary :UiOO, advancing £10 annually to £150,
with board, furnished apartments, <&c., and an additional £50 as
Pathologist.
Slamsgts, anfr gratis.
BIRTHS.
Aldous.—O n March 27th, at Charlton House, Plymouth, Devonshire,
< the wife of George Frederick Aldous, Surgeon, of a daughtor.
Daunt.—O n March 24th, at Bxmouth-.street, W.C,, the wife of Francis
Kldon Horsford Daunt, L.It.C.P. <6c., of a son.
De Mi'nuc,—On March 25th, at Kingswood, Uortwell, Weymouth, the
wife of Fleet Surgeon E. V. De Mdric, 11.N. (retired), of a son.
DOWNMAn.—O n March 10th, at Aninburst, Burnham-on-Crouch, tlie
, wife of Charles F. Downman, L.R.C.P. Lond., M.R.C.S. Eng., of a
son.
IfiDWAHDS.—On March 20th, at Wirapole-street, Cavendish-square, W.,
the wife of F. Swinford Jidwards, F.R.O.S., of a daughter.
FOLUY.—On March 20th, at Manuora-road, Hoiiour-road, S.K., the wifo
of C. N. Foley, L.R.C.P. Loud., M.R.C.y., of a son.
MACKiiNZiJ';.—On March 18th, atNorth House, Loci; wood, Hu<ldersfield,
the wifo of P'. L. Mackenzie, M.B., of a son.
Matthews.—O n March 20th, at St. Owen-sbreot, Hereford, the wife of
S. R. Matthews, M.D,, of a daughter.
Minns.—O n March 23rd, at 10, Whitehart-street, Tlietford, the wife of
Allan Minns, L.R.C.P. Lond., of a son.
SEqUEiRA.—On March 20th| at Ingleside, Fair)op-road, Leyton.stono,
the wife of Henry J. Sequeira, M.R.C.S., L.S.A., of a son.
Woods.—O n March 22n(l, at Greenshill, Tim-sbury, Bath, the wife of
I^'ank Woods, L.R.C.P. Lond., M.R.C.S., of a son.
MARRIAGE.
Hunt—Cutler.—O n March 25tb, at St. Luke’s, Chelsea, .fames Sidney
Hunt, M.R.C.S., L.R.C.P., of Hughenden, tjuooiisliiiid, to Lilian
Mona, fourth daughter of W. H. Cutler, of Marnhull, Dorset, and
Duncliffe, Upper Norwood._
DEATHS.
Bolton.—S uddenly, from convulsions, Flora Beatrice, agod 2} year.s,
'I'ho dearly loved and loving child of 'J'eresina and A. irwiu Bolton,
A.B,, M.B., 'I'.C.D., L.R.C.S.l. Kustendjio, Roumania.
Hall.—O n March 24th, at Tlie Lodge, Avenue, Southampton, 'William
Henry Hall, M.D., aged 72.
Leigh,—O n March 30bli, at I.eamington, J'ldwd. P. Leigh, M.R.C.S.
Salter.—O n Mai'ch 26th, at 18, College-road, Leeds, Francis .To.seph
Salter (Frank), L.R.C.P. and L.U,C.S., second son of the late Joseph
S^ter, of Lyddoii-terraco—“ Until dawn.” No cjvrds.
N.B.—A. fee of C$. ia eftarr;!!^ for the Inoertion of Notieea of Births,
Marriages, and Deaths.
METROPOLITAN ASYLUMS BOARD.
Return of Patients remaining in the several Fever Hospitals
of the Board at midnight on March Slst, 1801.
Hospital.
Beds occupied.
Total accommo¬
dation.
Scarlet \
fever.
4
i
Is
I-S
Enterio
fever.
Other
diseases.
1
H
Eastern Hospital .. ..
222
61
40
2
821
442
North-Western Hospital
140
31)
12
3.
203
448
Western ,.
140
•10
12
1
181
224
South-Western ..
1-12
22
14
178
840
South-Eastern „
181
13
20
2*
2Ui
402
Northern „
177
22
8
207
480
Totals .. >. ...
1020
ICO
112
8
1300
2891
Small-pox.—S outh-BasternUospi^il, 3; Affcwhospitalship, 4. Total, 7.
* Infant and mother. .
llfWfal giarj far f|a titsamj Maife.
Blondar, April 6.
Eotal London Ophthalmic Hospital, Moorfields. — OperatloiiD
daily at 10 a.m.
Royal Westminster Ophthalmic Hospital.—O perations, 1.80 p.h,»^
and each day at the same hour.
Chelsea Hospital for Women.—O peraHons, 2.80P.H. ; Thursday, 8.80.
Hospital for Women, SoHO-squARS. — Operations, 8 p.m., and ott
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.h.
Royal Ortiiop.«dic Hospital.—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 8 p.k., and
each day in the week at the same hour.
University College Hospital.—B ar and Throat Department, 9 a.k.;
Thursday, 9 a.m.
Royal Institution,—5 p.m. General Monthly Meeting.
Odontological Socjeiy of Great Britain (40, Leicestor-sq,, W.C.).—
8i>.M. Mr. A. Pearce Gould: Tooth-plate impacted in the Pharynx r
Death from Septlcasmla. Casual Communications Mr. Penfold-;
Movable Mass of Salivary Calculus tolerated for tliree years as an
Incurable Tumour.—Mr. W. H. Coffin : Jaw and Dentition of the-
Irish Giant, Cornelius Mograbh.—Mr. Stocken : .Cases of Absorption
of Permanent Teeth.
Medical Society op London.—8.30 p.m. Mr. Alban Doran : Fibro¬
sarcoma, or Desmoid Growth of the Abdominal Wall.—Mr. Stepbein
Paget; Three cases of Strangulated Cwcal Hernias in Infants.—Dr.
de Haviiland Hall.: Clironic Atrophic Rhinitis (Ozasna).
Tuesday, April 7.
King’s College Hospital.—O perations,2 p.u. ; Fridays and Satordaya
at the same hour.
Guy’s Hospital.—O perations, 1.80 p.m., and on Friday at same hour-
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 P.H.
St. Thomas’s'Hospital.—O phthalmic operations, 4 p.m. ; Friday, 2p.ib.
St. Mark’s Hospital.—O perations. 2 p.m.
Cancer Hospital, Brompion.—O perations, 2 p.m. ; Saturday, 2 p.»,
Westminstf.r Hospital.—O perations, 2 P.M.
West London Hospital.—O perations, 2.80 p.m.
St. Mary's Hospital.—O perations, 1.30 p.h. Consultations, Mondajl
2.80 P.M. Skin Department, Mond;^ and Thursday, 9.80 A.M.
Throat Department, Tuesdays and Fridays, 1.80 P.H. Bleotro-
therapeutics, same day, 2 P.H.
Royal Institution.—3 p.m. Mr. J. Scott Keltie; The Geography of
Africa.
Pathological Society of London.—s.so p.m. Dr. Aldren Turner ani8
Dr. Campbell: Heterotopia of Spinal Cord.—Dr. H. Tooth : Hetero¬
topia of Spinal Cord.—Dr, Newton Pitt: Chronic Intestinal Stricture-
Secondary to Strangulation in a Hernial Sac.—Mr, W. B. Robinson r
Uolumnar-colled Carcinoma of Jaw.—Mr. H. H. Clutton : Osteitis
Deformans of Tibia.—Mr. S. G. Shattock: Thickening of Skull im
Rickets.—Mr. B, 0. Stabb ; Tuberculosis of Tendon Sheath.—Dr.
A. F. Voelcker : Tuberculosis of Lymphatic Glands invading Lung-
by Continuity.—Mr, S. Paget: Carcinoma of Scalp. Card Speci-
roona Dr. Hale White ; Hodgkin’s Disease with Waxy Kidney.—
Dr. Newton Pitt: Pigmented Colon from a case of Lead Poisoning.
WedneBday, April 8.
National Orthopedic Hospital.—O perations, lo a.m.
Middlesex Hospital.—O perations, l p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. BARTUOikiMEW's Hospital.—O perations, 1.80 p.h. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, l.SO P.H.
Surgical Consultations, Thursday, 1.80 P.M.
Charing-cross Hospital.—O perations, S P.H., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.80 p.m. ; Saturday, same hour,.
London Hospital.—O perations, 2 P.M. Thursday ASaturday, same hour.
St. Peter’s Hospital, Covent-garden.—O perations, 2 p.M.
Samaritan Free Hospital for Women and CuiLDRSN.—Operatlomb
2.80 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.30 p.m. ; Skin Depart*
ment, 1.46 P.M.; Saturday, 9.15 a.m.
Royal Free Hospital.—O perations, 2 p.h., and on Saturday.
Children's Hospitai,, Great Ormond-street.—O perations, 9.80 £.«. s
Surgical Visits on Wednesday and Saturday at 9.16 A.M.
Hunterian Society.—8 p.m. Dr. I'. J. Smith : (1) A case of Fibrous
Growths on tlie Hands; (2) A case of Congenital Heart Disease,—
Mr. F. R. Humphrey-^ : '1 ?avo oases of Pneumonia (migrating), with
oomplications —Dr. A. T. Davies; (1) A case of Paralysis Agitans
(2) A case of Graves’ Disease.
Thursday, April 9.
St. George’s Hospital.—O perations, 1 P.M. Surgical Consultations,
Wednesday, 1.80 p.m. Ophthalmic Operations, J^iday, 1.80 P.M.
University Colm',oe Hospital.—O perations, 2 p.h. ; Bar and Throat
Department, 9 a.m.
Rovai. Institution.—3 p.m. Professor Dewar: Recent Spectrosoopid-
Investigations.
British,Gyna-:coi.ogical Society.—8.30 p.m. Adjourned Discussion
on I)r. Bell’s paper (“Tlie 'ITeatraent of Chronic Disease of the-
Uterine Adnexa’*). Mr. Mayo Rolwon: Observations on the Men¬
strual Flo'v in two cases,of Biliary Fistula.
Digitized iiy Google
^08 Tbb Lancet,] NOTES, COMMENTS, AND ANSWEBS TO CORBESFONDENTS. [April 4,1891.
Friday, April 10.
Aotal S017TR London Ophthalmic Hospital.—O perations, 8 p.m.
Clinical Society op London.—8 p.m. Mr. A. T. Norton: A case of
Popliteal Aneurysm iu a youth of seventeen.—Mr. O. R. Turner: A
case of Cancellous Suppression of Urine with Double Pyonephrosi s;
Nephrolithotomy on both aides at one sitting.—Mr. W. H. A.
Jacobson: Bight cases of Nephrolithotomy, with their lessons.—
Mr. Bilton Pmlard : A case of Nephrolithotomy in a boy aged ten
years.
•SOTAL Institution.— 9 P.M. Sir William Thomson: Electric and Mag¬
netic Screening.
Saturday, April 11.
Middlesex Hospital.—O perations, 2 p.m.
Unitbbsitt College Hospital.—O perations, 2 p.m. ; and Shin Depart*
ment, 9.16 a.m.
SOYAL Institution.—8 p.m. Prof. SilvanuaP. Tliompson: The Dynamo.
METEOROLOGICAL READINGS.
(Taken daily at 8..50 a.m. hy Steward'e Instrume^\ts.)
The Lancet Office, April 2nd, 1891.
Date.
Baromotor
reduced to
Sea Level
and S2*F.
Dlrec-
tioa
of
-Wind.
Dry
Bulb.
Wot
Bulb.
Solnr
lladia
in
Vaouo,
MfVkl.
mum
Tomjh
Shade.
Min.
Tomp
Rain-
fall.
Remarks at
S.30 *.u.
Mar. 27
29*62
W.
40
86
84
47
36
Cloudy
„ 28
29-70
N.
42
89
86
64
36
•04
Cloudy
„ 20
29-71
W.
46
48
89
56
39
Cloudy
„ 30
29 79
N.W.
39
88
03
43
33
Cloudy
.. 31
80-02
N.W.
39
86
83
48
38
Cloudy
Apr. 1
29-96
S.W.
87
84
80
60
34
Overcast
.• 2
29-80
S.E.
48
39
66
48
87
Overcast
Holts, Sljori Commtnts, ^ ^itskw to
Cornspflnirtnts.
.It is especially requested that early intelliaence of local
events havwa a medical interest, or which it is desirable
to, bnng under the notice of the profession, may be sent
direct to this Office.
All commtmications relating to the editorial business of the
journal rniist be addressed *‘To the Editors.”
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended for insertion or for private informa¬
tion, must be authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs sho%ild
be marked and addressed ''To the Sub-Editor.”
Letters relating to the publication, sale, and advertisin.g
departments of The Lancet to be addressed “ 'I'o the
Publisher.”
We cannot undertake to return MSS. not used.
“Rude" Health.
6PEECU, as the author of the “ New Cratylus” demonstrated, has its
.pathology as well as the human subject, and there is literally no end
to the “ morbid developments" taken on by words in their passage
'‘per ora virUm." An apt illustration is afforded in the familiar
expression “ rude” health—an expression which will not stand philo¬
logical examination for a moment. Crude health Is what is meant_
as can be shown by its use in Latin as late as the middle of the
sixteenth century:—
“At me fovebis patriH indulgentiii
Crude vigentem robore.”— Buchanan, Psalm acil.
The form or sclietlule which has to be filled up for tlio removal
of insane persons in Scotland to asylums consists of (1) a petition to
the sheriff to grant an order for tlie reception of the patient, tills
being usually signed by a relative of the patient; (2) a statement
containing particulars as to the name, age, &c., of the patient, this
being signed by the peison applying to tlie sheriff ; (3) certificates by
two medical men; and (4) the order granted by the sheriff for the
transmission and reception of the lunatic.
Jfr. C. A. Lutniey (Birmingham).—The block to accompany the descrip¬
tion is being prepared.
Dr. Roherson Day will find the information in our last Issue.
Dr. Jannes Armstrong's letter sliall appear in our next number.
L.R.C.S.I.-Yas.
Practice in the Orange Free State.
A. B. W.—We referred our correspondent's query to Dr. Blyth, the
representative of the Orange Free State in this country, and have
received from him the following reply; —“A medical diploma is
required in the Orange Free State, and most of the men practising
there are very able Germans. I do sot think any British degree
would be otherwise than acceptable to the Government. It is dis-
tlnctV necessary that the gentleman practlelng should receive the
recognition of the State. The general feeling is, however, very con¬
servative towards ‘foreigners'; but there is no reason whatever to
doubt that if a man went there properly accredited he would receive
every attention and consideration at the hands of the Government."
Dr. Ainley.—Vfe know of no recent work specially devoted to climate
in relation to the etiology of disease—a subject dealt witli by Mr. A.
Haviland, in his “Climate, Weather, and Disease," 1866. Much
information may bo gleaned in Hirsch's “ Historical and Geographical
Pathology" (New Sydenham Society's Transactions), and in the works
on “Les Cllmats des Montagues” (3id ed., 1873) and “Traltii de
Climatologle MiSdicale” (1877) by Prof. Lombard.
J. W. F. — \. The first question is answ'ered on p. 686 of our im¬
pression of March 21st.—2. Thisquestion is also practically answered on
p. 677.-8. Crooksbank’s Manual of Bacteriology might be consulted.
Mr. F. W. Kirkham.—lhe only remedy of our correspondent's patient is
in the county court.
Nolens Folens has not enclosed his card.
DISPENSING BY MEDICAL MEN.
To the Fditors q/ The Lancet.
Sirs,—T he subject of dispensing by medical mon has occupied the
attention of the profession for many yeais, but the pros and cons seem
so numerous that the matter is likely to remain in statu quo for some
time. Having had a large general country practice for aoveril years,
with a large amount of dispensing, and having now a prescribing
practice in a town, I feel that I am in a position to soe the various dis¬
advantages of both a dispen.sing and a prescribing practice. There is
no doubt that it would add to tlio dignity of the profession if dispensing
were given up entirely. It would, however, take some time to accomplish,
and necessitate a great change iu the form of contracts for clubs and
unions in country districts. Druggists have told me tlnit they would
not dispense for club and parisli patients for a less sum than medical
men usually get for both medical attendance and medicines com¬
bined. 'J'lie salary of a parish doctor in the country usually pays
him at the rate of IJd. for each lot of medicine supplied, and this
leaves out of tho calculation visits and advice, for which tliore would
be nil. I worked this carefully out some years ago, and, curiously
enough, another surgeon arrived at the same figure, and quite inde¬
pendently of me, Where there is a large dispensing practice a dis¬
penser ouglit to be kopt; otherwise what your correspondent says
is likely to happen—viz., slipshod dispensing and liun'ying over cases
to get home again to dispense. A patient should never bo kopt wait¬
ing for the medicine if no dispensor is kept, but the proscription
forwarded by the patient to the clismist, under cover if preferred, and
marked “To my account.'' The chemist would then retain the pre¬
scription. There are several patients who cannot pay a respectable
fee to the doctor and then pay the druggist also; and, more¬
over, proscriptions are dangerous weapons in the hands of tlio
ignorant. I once gave a pre.scription of small doses of aconite
and salicylate of soda, and told the patient to call and see me
in tliiee days. It appears, however, he did not want to pay me a
second fee, so wont on with his aconite mixture for a month! At
the expiration of that time I accidentally met him, and he complained
of feeling very weak. Again, do patients always get what is pre.scribed
for them ? I fancy not. Who is to say when German salicylate is sub¬
stituted for that which is physiologically pure, or cinchonidine for
quinine, without subjecting the mixture to analysis? I do not ask this
question wi bhout full justification; and although I pre.scribe only, I am
sure my patients would fare bettor if I dispensed for them as well. The
great abuse of sedatives has been almost entirely caused by proscrip¬
tions being given to patients and Iianded about to their friends; and yet
sedatives roust be proscribed in the form of night mixtures now and
again. Tho abuse of many other drugs occurs in the same way. In a
])resuribing. practice consulting fees at tho house iiave to be higher,
because the patients do not come so often. And the same applies
to visits at the house, for it is not uncommon for patients, wlmn they
get the prescription, to quietly tell you that “ they will let you know if
they want you to call again." Having got tho proscription they think
that is all they require until fresh symptoms arise. This, of course,
only applies to the small patients, an^ not the better class. l<'nr these
reasons dispensing practices are more readily transferable, as the pre.
acriptions are hold by the doctor in the same way as dociunent.s are
held by the lawyer; and tho patients are consequently more easily
retained by tho purchaser of such a practice.
Now, how is the proposed alteration to be brought about ? I aiiould
think the first step would be for all club and parish doctors to refuse
to dispense for such patients, and tlien gradually for the dispensing
for private patients to be also refused.—I am. Sirs, yours truly,
Bristol, April 1st, 1891. Pbescrhier.
Dig:...ied by Google
Tbb LamcbtJ
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [April 4,1891. SOd*
A NvRSB’8 Chart.
Messrs. H. Gilbert and Sons of St. Andrews-street, Holborn-clrcus,
have publlsbeil a chart designed by Nurse Marion Pincolfs, drawn up
ao as to be made available for written directions to tbe nurse for the
proper treatment of any patticular patient. Its intention is to ensure
accuracy in following medical instructions—a clinical slate ruled in
the form o( the usual clinical chart, and containing columns for
directions for tbe treatment of the patient, and for recording the
observations of the nurse or medical man at any particular time. It
cannot fail to be found useful. A con'lnued record from day to day
may be made at tbe end of each day on the back of -the slate.
Equity (Biighton).—Our correspondent claims a fee from the I.ondon
School Board for information as to the health of one of the teachers,
granted in answer to a request from the medical ofiQcer of the Board.
We doubt whether lie could enforce such a claim. The information
was asked for as a kind of favour by the medical officer of the Board,
and presumably in the interest of our correspondent’s patient, who
might be supposed liable. The point is a doubtful one, and should
be cleared up.
Dr. flirNSfBradford).—Very soon.
MEDICAL OFFICERS OF HEALTH AND OTHER PRAC¬
TITIONERS’ PRIVATE PATIENTS.
To the Editors o/THE LANCET.
Sirs,—I have been in communication with the Local Government
Board with reference to the duties of medical officers of health,
especially os relates to their behaviour toward medical men certifying
to them under the Infectious Diseases Notification Act, 1889. In reply
I received the following
“ I am directed by the Local Government Board to advert to your
letter of the 7th inst., and to state that Atticls 18(6) of the Board’s ,
order of the lltb of March, 1880, which prescribes the duties of the
medical officer of health, is as follows: ‘ On receiving information of
the outbreak of any contagious, infectious, or epidemic disease of a
dangerous character within the district^ he shall visit the spot without
delay and inquire into the causes and circumstances of such outbreak;
and, in case he is not satisfied that all due precautions are being taken,
he shall advise tbe persona competent to act as to the measures which
mav appear to him to be required to prevent the extension of the disease,
and, so far as he may be lawfully authorised, assist in tbe execution of
tbe same.’ As between sanitary officers and medical attendants, the
Board leave the interpretation of their regulations to be determined by
the circumstances of the particular case, and by the customs that
usually govern the relations of medical practitioners to each other."
As the interpretation of these regulations is what I asked for—especially
as to whether the medical officer of health was justified in seeing without
the permission, or asking it even, of the medical man in attendance,—I
pressed for a further and more definite answer; and in reply to my
second letter I am informed that the Local Government Board have
nothing further to add to their previous letter. Consequently one is
forced to the conclusion that they make rules and regulations of which
they do not know the' interpretation. It is wonderfully clever to ask a
riddle and then calmly say, when asked for the answer, “ We do not
know tbe answer. You must find that out for yourselves. We only
have to ask the riddle; and you—well—you can each of you have your
own answer to it."
I, like your correspondent, " N. E. W.,’’ bad a case of typhoid fever.
The medical officer of health saw it, and reported it to bis board as
“a questionable case” of typhoid. On another occasion ho saw a
typhoid patient of mine which he denied being typhoid; but, mirahile
dictu, some five or six weeks after, another member of the family falling
with it, he said it was “ caught" from the first case. Well, if medical
officers of healtli are allowed to run riot amongst the patients of other
medical men, can you. Sirs, wonder at our protesting against it?
It would be well for some definite and authoritative interpi'otation of
their rules and regulations to be issued by tbe Local Government Board.
Then medical men would understand more clearly than at prefient
their position with respect to medical officers of’iiealth.
Personally, no one could be more willing than I to afford every
information and opportunity to the medical officer of hooltli; but I do
object to having my diagnosis que.stioned, and this published in every
penny weekly paper in the neighbourhood.
I am. Sirs, yours obediently,
March, 1891. Disgusted.
HUMAN AND BOVINE SCARLATINA AND DIPHTHERIA.
To the Editors of THE Lanckt.
Sirs,—T here i.s one point in Dr. Thorne’s Milroy lectures which I
think specially calls for attention—viz., that there has been a higher
death-rate from diphtlioria in urban di.stricLs during the lost, than in
the previous ten years—i.e., it has been higher since milk has been
mainly obtained from the country, than when the cows were kept
stalled In towns, and really, therefore, placed under less favourable
sanitary conditions tiian at the present time. Dr. Klein has tried to
prove that scarlatina and diphthena frequently originate in the cow,
and manifest their existence by surface ulcerations of the udder; but it
would appear to me there are, at any rate, two links wanting in the
proof. 1. The poison from the udder ulceration has never been sliown
to produce either diphtheria or scarlatina In man by direct inocula*
tioD. Tlie milkers, it is said, have had their fingers affected by it,,
but no serious constitutional illness has resulted therefrom. 2. These
diseases can never be shown to have been transmitted from man to
animals. But supposing that these ulcerations of the udder are mani¬
festations of the existence of diphtheria and scarlatina in the cow, a
question naturally arises, Do these diseases orginate in man and
animals, under .any circumstances, from a common cause ? From tbe-
fact that cows were fonnerly placed under much less favourable sani¬
tary con'-litlons than at tbe present time, and that there was then a
lower (leatii-rate from diphtheria, I should say it appears unlikely.
It would be a great thing if veterinary surgeons were to inform us
how many of tbe diseases which are communicable from animals to
human beings manifest tlieir existence by an entirely different set of
symptoms. I am, Sirs, your obedient servant,
Surbiton, March, 1891. F. P. ATKINSON.
OBSTETRIC ENGAGEMENTS.
To the Editors of THE LANCET.
Sir.s,—C an any of your readers inform me whether a general prac-
' titioner who professes to be in tbe actual practice of his profession is-
justlfied in accepting midwifery engagements, and when the labour
happens to take place in the night coolly informing tbe messenger
r'‘questing his attendance “that he does not go out at night," thus-
inferring that the patient may get on the best way she can unaided?
Quite recently I was called to a case under these somewhat peculiar
circumstances, and found that delivery had taken place more than ac>
hour previously. The placenta had not come away, and the uterus war-
slowly filling with blood, tbe patient evincing all tbe symptoms of’
internal hemorrhage. One hardly likes to contemplate the result in-
such a case had the poor woman failed to obtain professional aid.
I am, .Sirs, your obedient servant,
March, 1891. A General Pbactitioneh.
Our correspondent describes a style of practitioner that has been,
met with before in history. Such a practitioner undertaking mid¬
wifery engagements and then declining them wlien they occur at
night Incurs a very grave responsibility. But for our correspondent's
kindness in going to this case a very serious censure might have been
tile lot of the gentleman who accepted the case but did not discharge-
bis part of the contract.—E d. L.
RE INFECTION IN CHICKEN-POX.
To the Editors of The Lancet.
Sirs,—I n August, 1890, T. W-, aged three years, had varicella..
Tliree days later D. W'-, aged four years, developed the same disease.
On March 11th, 1801, their nursery governess had varicella; on tlie 21st
D. W-again sickened, and had distinct varicella next day; and on
the 24tli T. W-also had varicella. A peculiar point In the family
history of these children is that their maternal grandmother had rather
severe niodified small-pox about six years after revaccination.
Unfortunately there is a weak spot in the above narrative. The
diagnosis of (ho first attack, in August lost, rested chiefly on tbe
opinion of a trained nurse and tbe patient's friends, but was in part
supported by medical observation at the time. I am inclined to regard
it as correct. If it is so, then th'se children, having had chicken-pox
last August, .are now (eight months later) going through a second
attack of the same disease. Can any prai:titioner give instances of
second attacks of chicken-pox ?
I am, Sirs, yours faithfully,
London, S.W. Alfred Leach, M.B., M.R.C.P.
CHEAP DOCTORING AND ITS REMEDIES.
To the Editors of The Lancet.
Sirs,— Your correspondent, "General Practitioner," whose letter-
appeared in your last issue, is pleased to see that a General Prac¬
titioners' Union has been formed. I cannot see that such an associa¬
tion can be of any service. We have a lot of ungentleinanly
juen in the profession who are willing to give their services
for the smallest pittance. In this town an F.R.C.S. Eng., a mam
in very large practice, lias contracted with the police to attend the
wives and children of inspectors, sergeants, and constables for the-
magnificumt sum of V.d. per week, wife and child; a whole family, no
matter how large, for iljti. per week. It was proposed at a Court of
Foresters (o increase niy remuneration from is. per member to 6s.
Moinber after member suggested that tliey should pay another
penny per week, and Iiave their whole family attended on the same
terms a.s the Metropolitan Police.
1 am, Sirs, your obedient servant,
March ai.st, 1891. M.D.
CLAIMS ON FRIENDLY SOCIETIES.
To the Editors of THE Lancet.
Sirs,—C an any of your readers inform melf ordinary blindness coming ,
on in a young man, unconnected with any injury or illness, will entitle
tlie patient to take advantage of his club (an ordinary friendly society),.
and receive weekly payment as a sick member ?
I am, Sire, yours faithfully,
March 2Cth, 1801. Friendlt Socieit.
Lioogle
610i Tub Lakobt,;^
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[April 4,1891.
Worcester Qbmerm. infirmary.
In our notice last week of the annual report of this charity the name
of the donor of the cheque for £1000 wae given as Mr Wheeley, It
should hove been Mr. Wbeoley Lea, of Parkfleld, Hallow.
F,RC.S.E.-~-'W6 have no doubt the answer must be in the negative.
IThor.—The usual pate is somewhat under two years’ purchase.
“TRACHBAL TUGGING. "
To the Editors of THE L.».ncet.
Sirs,—W ill you allow me to correct a typographical error in my
«,rticle on “The Diagnostic Value of the Physical Sign ‘Tracheal
Tugging ’ in Thoracic Aneurysm " ? At page B30 it is printed “ tracheal
<tngging is never found when the innominate ie irbotie the seat of
aneurysm." This should read, “ tracheal tugging is never found when
4he innominate is alone the seat of aneurysm."'
I am, Sira, youi-s tn\ly,
Montreal, March 6th, 1801. R. ,L. MacDonnem,.
COMunNiCAiiONS nob noticed in our present number will receive atten¬
tion in our next.
Communications, Letters, dsc., have been received from—Dr. Ber.ly
Thorne, London ; Mr. L. Humphry, Cambridge ; Messr.s. Kemp and
Co., Bombay; Dr. Eider, Nottingham ; Mr. A. Dnke ; Dr. Hingston
Fox, London; Mr. Boobbyer, Nottingham; Dr. Maynard, Brighton;
Dr. Buffer, London; Dr. Weathorley, Bath; Messrs. Richardson and
Co., Liverpool; Dr. Wortsbet, Beyrout; Dr. Stroud; Messrs. Thorp
and Co., London; Dr. Plggott, Teignmouth; Messrs. Roberts and ;
Allinaon, Indianopolis ; Dr. Bowker, Buty; Messrs. Burgoyne and
Co., London; Dr. H. Campbell, London; Messrs. Toxer, Hewitt, and
Co., London; Dr. J. Armstrong, lAvetpool; Messrs. Mitchell and
Co., London; Mr. Nason, Nuneaton ; Mr. Kuhn, London; Dr. Bice
Morgan, Llangyfelach; Mr. A. C. Waters, London; Messrs. McNab
and Co., Leith; Mr. C. B. Paget, Manchester; Messrs. Southall and
Co., Birmingham ; Mr. J. E. S. Barnett, Brighton; Messrs. Bengor
••and Co., Manchester; Dr. Ixod, Esher; Mr. T. Christy; Mr. Usher
Somers, Hadfield; Dr. Stalkartt, Kilburn; Messrs. Rou'iitree and
Co., York; Dr. Coleman, Surbiton; Mr. Eminson, Scotter; Bev.Hart
Smith, Bpaom ; Mrs. E. Bond, Starcross; Mr. Colmer; Messrs, E. and
S. Livingstone, Edinburgh; Mr. A. P. Watt, London ; Messrs. Castle
.-and Lamb, London ; Dn 3. R. Day, Hampstead ; Messrs. Oliver and
Boyd, Edinburgh ; Dr. Potter, London; Messrs. Rock, Hawkins, nnd
Co., Hastings; Mr, Little, London ; Mr. Barr, Leeds; Dr, Paris, Sierra
ILeone; Dr. Mossop, Newbaven; Mr. Blount, London; Messrs. Laxard
a.nd Co., Paris; Dr. McLaugblan, Edgbaston; Messrs. Street and
Co., London; Dr. T. B. Adam, Foochow ; Mr. Pope; Messrs. Keith
rand Co., Edinburgh; Dr. Chandhury, Calcutta; Messrs. Perkins and
Co., London; Mr. De St. Dalmas, Leicester ; Mr. .Scott; Mr. W. M.
J'ones, Wales; M. Feireira, Correio; Dr. Moorhead; Mr. Laban, West
Bromwich; Dr.Scriven,Duffield ; Dr. Perkins,Totnes; Messrs.Davies
And Co., London ; Mr. Dickson, Staffordshire; Messrs, Blondeau et
Cie., London; Mr. Saunders, Mancbo.ster; Messrs. Richardson and
Co., Leicester; Mr. Coombs, Bridgwater; Messrs. Babes, Hendy, and
Co., London; Dr. Bottentuit, Paris; Messrs. Longmans, Green, and
Co.; Dr. Morrison, Bengal; Mr. Gravatt, London ; Messrs, Keene and
Ashwell, London; Mr. Macdonnell, Montreal; Dr. Ffrench, Wickham
Market; Mr. Bawlings, London ; Mr. Eminson, Lincoln; Mr. Rust,
Kidderminster; Lieut.-Gen.Bourchier, Brighton; Dr. Hadden, Horn-
•castle ; Mr. Birchall, Liverpool; Dr. Griffiths, Clifton ; Dr. Atkinson,
.Surbiton; Mr. Brownlow, Bolton ; Dr. Skriinshiro, Norfolk; Mr. R.
Lloyd, London; Mr. Tomlinson, MaldOn; Dr. F. George; Mr. H. W.
Just, London ; Mr. Freer, Llandudno; Mr. Thomas, Liverpool; York
shire College, Leeds; Eblana; Equity; L,B.C.S.I.; D. D.; Norfolk
and Norwich Hospital; Stocker, London; H. M. S., London; Lady
Superintendent, Leicester; Hoyreed, Gibraltar; Secretary, Swansea
Hospital; Medicus, Liverpool; Secretary, Great Tower-street Tea
Co., London; Deaconesses’ Institution, Tottenham; West Riding
Asylum, Wakefield; Srailax, London; ,T. B., London; St. Andrew’s
Hospital, Northampton; L.R.C.P., London ; Maltine Manufacturing
Co., London; London, London; Beaurepor; A. W. B.; Cheltenham
General Hospital.
Letters, each with enclosure, are also acknowledged from—Dr. Gowers,
London ; Mr. Tully, Hastings; Dr. Ball, London ; Messrs. Reynolds
and Branson, Leeds ; Mr. Graham, Lockerbie; Messrs. Hooper and
Co., London; Dr, Downman, Burnhain-on-Croucli; Messrs. Rocke
and Co., London; Mr. Cochrane, Wigtownshire; Dr. Bourke, Earl’.s
Court; Mr. Minns,Thetford; Mrs. Bull, London; Mr.Tyte.Minchin-
hampton; Mr. Thin, Edinburgh ; Mr. Chubb, Tovpoint ; Mr. Crow,
Canterbury ; Mr. Edwards, Birmingham ; Mr. Plummer, Newcastle-
on-Tyne; Mr. Cornish, Manchester; Dr. Vernon, Yeovil; Mr. Thomas,
Hull; Mr. Thomas, Bridgend; Mr. Sbenhouse, Glasgow; Dr. piver,
London; Mr. Corbett, Birkenhead; lilr. Hadden, Horncastle; Mr. J.
Heywood, Manchester; Mr. Hornibrook, London; Mr. Forjett, Lin¬
colnshire; Mr. Gates, London; Mr. Roworth, Grays; Mr. O’Moarn,
Loughboro'; Mr. Graham, Dumfriesshire; Mrs. Moore, Hayward’s
Heath ; Mr. Young,Brighton; Mr. Vine, London ; Messrs. Robertson
and Scott, Edinburgh; Dr. Bingham, Alfreton; Messrs. C. Green and
Co., London ; Mr, Arkle ; Mr. Deane, Ellesmere; Mr. Owen, North
Wales; Mr. Barker, South Hampstead; Mr. Salter, Leeds; Mr. Hide,
New Romney; Mr. Ingle, King’s Lynn; Dr. Mackenzie, Hudders¬
field; Oxford Eye Hospital; Medicus, Manchester ; Price's Candle
Co., London; L.R.C.P., Southgate; Owner, Lancashire; Fleming
Memorial Hospital, Newcastle-on-Tyiie; Medicus, Manchester; The
Coppice, Nottingham; Winchester, London; Pulsomotor Engineering
Co., London; Hydro, London; Studens, London; Secretary, Rochdale
Infirmary; L.R.C.S., London ; E. B., London ; Lex, London; Union
Assurance Co., London; Dexter, London ; Genuine, London ; Lady
Supeiintendent, Ryde; Goldthread, London; C. J., London; Fidelis,
London; Dispatch, London; Bet.a, London; A. B., London ; Sultan,
Hampstead ; W. S. W,, Sheffield ; G. X. T., London; Locum, New- '
port; M.B., Loughborough ; Yorkshire, London ; Severa; Assistant,
London; Cantab., London; A.B.C.,Leeds; G. H. G., London; S. J.,
London; M. A. R., London; W. A. K., Hackney; J. A. B.; X. Y.
Wrexham; A. ,1J. C., London; Alpha, Leeds; B. N., London; M.,
Birmingham; Epsilon, London; M. M., London ; Marischal, London;
A., Tredegar.
Newspapers.— Carlisle Patriot, Newcastle Ouardlan, Surrey Gazette,
Essex Standard, Rugby Adoertiser, Strond News, Poole Herald, United
Seroice Gazette, Hackney Gazette, Cornish TeUgrayh, Scotsman, Sosti-ne.-
^l\out.h Observer, Louth Times, Bolton Weekly Journal, Hertfordshire
Mercury, Weekly Free Press and Aberdeen Herald, Local Government
Chronicle, Western Gazette, Windsor and Eton Express, Malvern News,
Stamford Guardian, Preston Herald, Liveipool Daily Post, Mining
Journal, Insurance Eecord, Rochdale Tinses, SuJ/olk Chronicle, Leeds
Mercury, Sidmouth Observer, Wills Standard, Reading Mercury, Law
Journal, Surrey Advertiser, Essex Times, Dudley Herald, Melbourms
Argus, Boston Independent, Yorkshire Post, Bristol Mercunui, Scottish
Leader, City Press, Chesham Examiner, Labour World, Barrow News,
Corriere D’Italia (Rio de Janeiro), Courier de Londres, The Newspaper,
Yorkshire Herald, Zoophilist, Ac., have been received.
SUBSCRIPTION.
Post Free to ant part of the United Kinodoh.
One Year ^ £1 12 6 | Six Months » — — _..£0 10 I
To China and India _____.OneTear i 16 II
To THE Continent, Colonies, and United
States...... . Ditto lU 8
Post OfflceOrders and Cheques should be addressed to The Publisher,
The Lancet Office, 128, Strand, London, and crossed “London and
Westminster Bank St. James’s-square."
ADVERTISING
Books and PuhUcations (seven lines and imder) ..£0 I 0
Official and General Announcements .0 6 0
Trade and Miscellaneous Advertisements ..046
Every additional Line 0 0 6
Frontpage . per Line 0 10
Quarter Page. .. 1 10 0
Half a Page . 8160
An Entire Page.660
The Publisher cannot hold himself responsible for the return of testi¬
monials .kc. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are req^uested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
An original and novel feature of “ The Lancet General Advertiser'' is a special Index to Advertisements on pages 2 and 4, which not only
affords a ready means of finding any notice, but is in itself an additional advertisement.
Advertisements (to ensure insertion the same week)should be delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing In The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subsorlptlona should be
addressed.
Adrertisementa are now received at all Messrs. W. H. Smith and Son's Railway Bookstalls throughout the United Kingdom Ud all otiK I
Advertising Agents. __
Agent for the Advertisement Department i** Pxance-J. A8TIEE, 66, Eue Caumartln,
Digi'i/ed by Google
THE LANCET, Apeil 11, 1891
THE ANTISEPTIC TEEATMENT OF
TYPHOID FEVER.
Delivered at King’s College Kospitaly
By I. BUENEY YEO, M.D., F.R.C.P,,
SPROFESSOB OF CMNICAL THEUAI’lJtn'JCS IN KfNG'8 COLLEGE, AND
PHYSICIAN TO THE HOSPITAL.
Gentlemen, —If in the practice of medicine we should
ever be able to establish general laws for the treatment of
•disease, and introduce scientific accuracy and uniformity
into our therapeutic methods, it would certainly be in the
treatment of acute diseases that we might first hope to
•attain that desirable end. Acute diseases, and especially
the infective fevers, present considerable uniformity in the
phenomena that accompany and characterise them; they
run a tolerably definite course; from their well-defined and
neatly constant physical characters their diagnosis is com-
.paratively easy ; and, if we are not absolutely certain as to
their precise causation, we are far advanced in such know¬
ledge, and we may believe that at no very distant period
our knowledge of the etiology of acute diseases will be to a
certain extent accurate and complete. It is far otherwise
with chronic maladies, the nature of which is often doubtful,
their origin and causation obscure, their phenomena ex¬
tremely variable, andtheir diagnosis proportionately difficult.
'We know that in many acute diseases the causative agent
is an infective organism, a microbe, introduced into the body
from without—a living propagating poison, growing and de¬
veloping, and multiplying amidst the fluids and tissues of our
bodies, and setting up in the process more or less serious
■disturbances of its functions—disturbances which, in not a
few instances, attain such a magnitude as to destroy the
3ife of the individuals attacked. I may remind you that
.not many years ago the prevailing tendency in the teaching
of some physicians of great eminence was that it was use¬
less, or even worse than useless, to attempt to modify the
course of these acute diseases by any distinct medical treat¬
ment ; and their standpoint, although 1 have always thought
it an utterly illogical one, was, tested simply by the appeal
to practical results, perfectly defensible. And it had, further,
the groat recommendation of sweeping away much false
theory and bad practice in connexion with the management
•of acute disease. These physicians bore the same relation
to the older schools of medicine that the modern agnostic
bears to the theological schools; they practically said,
“ We do not/cuoio; we have no certain grounds either for
^belief or action ; therefore we neither believe nor act.” But
this lack of knowledge no longer exists. "We know that a
•great number of acute diseases are caused by the introduc¬
tion into the body of specific organisms from without, and
that the development, activity, and life of these organisms
'Can be modified and influenced by exposure to conditions
•and agencies over which we have a certain amount of
•control.
Those, then, who take the same view of acute disease as
do, maintain, as I do, that there are two plain and obliga¬
tory indications in the treatment of these affections—one
•general and the other special. The general indication is to
support and strengthen the resisting powers of the organism
attacked while it is passing through a more or less grave
crisis. The special indication is to attempt to iliminish the
igravityof this crisis by opposing or counteracting the activity
of the special morbific microbe with which the organism is
infected. To have obtained this latter definite indication
for the treatment of infective fevers is already a great ad¬
vance in therapeutics. We may not yet be in possession of
the best means of carrying this indication into effect, but
'that is only a question of time. The idea of an antiseptic
treatment of certain forms of disease has been greatly mis¬
understood or intentionally misrepresented by those who
ifor some inscrutable reason dislike it; and we who have
been bold enough to entertain this idea have been credited
with the crude intention of attempting to slay these parasitic
No. 3628.
morbific agents in much the same direct and simple manner
as that practised by a certain renowned but st^ nndis*
covered ofSerator in the district of Whitechapel! and we
have been gravely told that our so-called antiseptic methods
are so murderous that our patients and not the microbes
fall victims to them.^
Now, gentlemep, I have always believed, and I think all
biologists are agreed in believing, that the life history and
the life activities of every living thing are, to a great ex¬
tent, determined by its enviroiiment, by the physical and
other conditions in which it has to live. .Almost inappre¬
ciable differences (inappreciable to ns) in soil or atmospheric
conditions will, we know, exert the greatest possible
influence over the growth and development of many forms of
vegetable life. Every analogy in nature points to the pos¬
sibility of effectually modifying the life history and activities
of all living things by slight modifications of their environ¬
ment. This, then, is the idea entertained by those who
have been searching for methods by which the injurious
activities of the living parasitic agents of infective diseases
may be modified or counteracted, and we shall continue to
search for them, and we shall end in finding them, because,
as I have already said, every analogy of nature points in
that direction. But there is another mode in which anti¬
septic agents may avail us. These morbific microbes appear
to have the power of determining the formation within the
body of certain poisonous animal alkaloids or ptomaines,
and antiseptic methods may act either by preventing the
formation of these ptomaines or by destroying them when
found, or promoting their discharge from the body. The
antiseptic idea, then, is a large, not a small, one, and is by
no means to be confounded with mere microbicide; and we
may hope it will cease to be represented as such. The idea of
an antiseptic treatment of typhoid fever is by no means a new
one. so far certainly as intestinal antisepsis is concerned.
Sir William Jenner, in his admirable paper on the Treat¬
ment of Typhoid Fever, published more than ten years ago,^
says: “When the stools are very oftensive, correctives of
fetor should be given. A teaspoonful of charcoal may be
given two or three times a day.other correctives of fetor
or antiseptics will have as good effect, but this has given
me such satisfactory results that I have not resorted to
other remedies.” "We now possess intestinal antiseptics
which were hardly thought of or known then, less cumbrous
and more effective than charcoal. Murchison formu¬
lates as the first indication of treatment to “ neutralise the
poison and improve the state of the blood,and he says
antiseptic agents “have this to recommend them, that they
might be expected to act directly on the poison in the intes¬
tinal canal.” Niemeyer, like Murchison, commends the
administration of dilute chlorine water in typhoid fever. Sir
Thomas Watson, in whose time the remarkable antiseptic
power of the salts of mercury was unknown, says, in speaking
of the treatment of continued fevers : “In the fevers which
I treated, or saw others treat, in London prior to the appear¬
ance of the more recent epidemics, mercury in one shape
or another was almost constantly prescribed, and a great
number of the patients were brought, sooner or later, under
the specific operation of that mineral, and in these patients
(with one exception only, where the mercury appeared to do
neither good nor harm) a decided improvement was almost
immediately apparent upon the supervention of soreness of
the monih, nnA all such patients ultimately recovered.” In
these cases a rigorous antiseptic treatment had been applied
unconsciously and empirically. But one of the most re¬
markable testimonies on record to the value of antiseptic
treatment in typhoid fever is to be found in the admirable
paper of Dr. "Wilks, of Ashford, published in British
Medical Journal so long ago as 1870. Dr. Wilks had
encountered in his neighbourhood a widely spread and
severe epidemic of typhoid fever. The earliest cases were
mild, and did well with merely expectant treatment, but
soon they assumed a more severe type, and were difficult
to manage. Dr. Wilks had heard of the utility of creasote
in such cases, and he therefore tried it, and witli good results;
but it nauseated some of the patients, and they objected to
it. The case of a strong, healthy, active and temperate
man, who died within seven days of being first seen, and
wlioae bodv putrefied so rapidly that it was difficult to come
near it withiu twenty-four hours after death, and almost
I " Ry treating patients in various wayti by autiaoptic remedies, the
result lias been that the patient, and nob the bni'iUus, liaa succumbed.”
Latham, Ilarvomii Oration, October, 18S8.
- The Lancet, Nov. 15th, ISTii. “ Murchison on Fevers.
e
813 THB laAKCBT,]
DE. I. BURNEY YEO ON TYPHOID FEVER.
[Apbil 1], 1891.
impossible to approach the cothn at the funeral sixty hours
after, so impressed Dr. Wilks with the activity of the putre¬
factive agent or agents within the body, that ne detennined
hencefor^ to introduce some powerful antiseptic substance
into the treatment of these cases. He called to mind the
value of solutions oPchlorine in scarlet fever (he feared the
depressing eil'ect of carbolic acid); but he thought that for
another species of fever poison another kind of antiseptic
might be better, and he-thought of sulphurous acid. He
tried it in some very severe cases, and the results surprised
him. It quickly allayed vomiting and purging, reduced
tympanites, supported the pulse, moistened the dry tongue,
and relieved thirst. He administered it in 170 cases in
fourteen months with signal results. There was only one
death, and that a habitual drunkard, who would not take
his medicine. The acid was given in doses of from three to
twenty minims, according to the age of the patient, every
four hours, and continued for a week or ten days, or even
more, “until the patient complains of tasting, smelling,
and feeling like sulphur or lucifer matches, or, in the case
of infants, until they actually emit an odour of the gas from
their skin and breath.” At this point it was stopped. For
adults twenty minims of sulphurous acid mixed with two
tablespoonfnU of water and a little syrup of orange-peel
every four hours was the usual prescriprion.
“ I will state distinctly,” says Dr. Wilks, “ what I claim
for sulphurous acid in typhoid fever: that it arrests the
further development of the fever poisofi, and, by cootinuiug
this arrest long enough, exterminates the fever. Briefly, it
is an antidote. In some of my early cases I left off this
acid after a few days’ use, because the patients seemed
better. In almost all such cases they had a relapse, which
was again immediattly arrested on the resumption of the
acid. Very possibly,”.be concludes, “I have failed to
convince you of the advantages of using this dnis, but let
me again remind you of the plain fact that of 173 cases of
this fever occurring in our practice during the past fourteen
months, two only died, and those two did not take the
acid ; for the one it was not prescribed, the other was a
drunkard and would take nothing. Of the 171 who took
sulphurous acid, not one lost his life, and there were few
who were not convalescent within fifteen days of commencing
the treatment ” Two well-known practitioners in Dr. Wilks’
neighbourhood called my attention some years ago to this
mode of treatment, and testified to its invariable success
in their own practice. I took an early opportunity of testing
it, and reported some of the results in the Practitioner of
June, 1882. It was not so successful in my hands as
another method has proved, which I shall presently describe.
In one case severe hiomorrhage came on duringits administra¬
tion, which had to be controlled by other means ; this case
ultimately did well. It was a case in which there had been
some dilliculty in diagnosing the disease on account of the
mildness and indefiniteness of tbe early symptoms, and so
the remedy was not commenced until somewhat late in the
course of the fever.
In another ease which we had selected as a test for this
treatment, on account of its severity, the pa'ient died from
perforation on the twenty-ninth day of the fever. He was
a nervous man, and was suffering from great nervous
depression and sleeplessness before the fever attacked him,
because his wife and two children were laid down with
typhoid fever. Even in this case the modifying influence of
the remedy was very remarkable when first administered.
On the fourth day of the fever, when the evening tem¬
perature was 104°, he began the sulphurous acid in half-
drachm doses every four hours. For the next five days the
temperature ranged between 102* and 104°, and on the
sixth day of taking the acid there was a notable fall in the
temperature curve, and for the next three days it did not
rise above 102°; then there was another fall, and for the
next six days the temperature reached on one occasion only
101°;, The remedy appeared to be modifying in a remaik-
able manner the course of the fever. There was no
diarrhcea, no abdominal tenderness or distension. The
general condition was good, except that he was always
nervous, depressed, and apprehensive—an evil progno.sbic
On the nineteenth day he began to complain of abdominal
pain, the temperature rose again, and reached 104" in the
evening, anil remained so for the rest of the illness; the
abdomen became distended, there was diarrhcea, and on the
twenty-fourth day, as tbe remedy appeared to have no
longer any influence over the fever, it was discontinued.
He began to have htemorrhage from the bowels wfith the
diarrhoea on the twenty-sixth day, and on the twenty-ninth'
day he died somewhat suddenly with symptoms of perfora¬
tion. On post-mortem examination there were found
several large and deep ulcers in the ileum, and four of them
had ulcerated completely through the intestine, and there
was considerable extravasation of fmces into the peritoneal i
cavity.
I have dwelt on this case because it showed that, notwith¬
standing the favourable influence of tbe antiseptic agent on
tbe early course of the fever, the local lesion went on, appa¬
rently uncontrolled, to a fatal termination; and this, under
any form of treatment, we must of course be prepared to
occasionally encounter. This patient, moreover, was suffering
from such marked nervous depression before he was attacked
with fever that he was not a hopeful case from the outset.
For the first fortnight his bowels were rather disposed to be
confined, and it might have given him a better chance if,
duiing the first few days of tbe fever, his intestinal canal
had been swept clean by two or three doses of calomel. I
did not pursue the sulphurous acid treatment in any more
cases, chiefly because I have adopted another antiseptic
agent which I like better, and which I shall presently
describe to you. Mr. Kesteven of Brisbane repor^d in the
Practitioner of May, 1885, his conviction of the great value-
of the oil of eucalyptus in the treatment of typhoid fever,
and he repeats that conviction in another communication to-
the same journal in April, 1887. He states that he gave it
in 220 cases, many of whom had a “ bad start,” and that he
bad only four deaths ! His dose was from five to ten minims
of the oil, made into an emulsion with mucilage, every
four hours; and be combined with it half a drachm of
sal volatile, half a drachm of spirits of chloroform, and
half a drachm of glvcerine. By this means he made it
more agreeable to take, and the glycerine covered the rough
gum-resinous taste of the eucalyptus oil. Ho noted as
results of th’s treatment a reduction of the pulse, a remark¬
able lowering of tbe temperature, a rapid cleaning and
moistening or the tongue ; the skin became soft and moist,,
and the duration of the fever was greatly shortened. An
omission of the remedy was attended by a return of tbe un¬
favourable symtoms. The alvine evacuations smelt of the
oil. so that intestinal antisepsis was no doubt a consequence
of its use.
Parallel with these observations of Mr. Kesteven on
the value of oil of eucalyptus in typhoid fever, I should
like to place Professor H. C. Wood’s testimony as to the
usefulness of oil of turpentine in the same disease. He says,
“ Many lives would be saved if the oil of turpentine were
more freely used in this disease.The volatile oils are
absorbed slowly, and .are rapidly vaporised at the tem¬
perature of the human abdomen, so that there can be
no reasonable doubt that, either in the form of liquid,
or more probably in the form of vapour, when given
freely by tbe mouth, they get into contact with the
mucous membrane of the upper intestine.” He gives-
it in every case, beginning about the twelfth day of the
fever, and the following is the formula he adopts : Oleum
caryophylli, gtt. vi.; oleum terebinth., 5 iss.; glycerini,
mncilag. acacire, .iaSss,; syrupi et aqure ad gflii-; a dessert¬
spoonful to be given every two hours during the day, the
patient being allowed to rest during the night. The use of
camphor in typhoid fever, not only as an excellent antiseptic,
butalso as a cardiac stimulant, has been highly commended
by Dr. Janeway of New York; and its very slight solubility
in water ought to ensure its local antiseptic action in the
small intestine. The administration of creasote both by
the mouth and in enemata was waimly advocated by
Pciholier of Montpellier, and he maintained that when
begun early it diminished the intensity and shortened the
duration of the fever. Thymol has been given by Dr. F.
Henry with the same object; he gives a grain and a half
or two grains made into a pill witli soap every six hours.
Owing to its insolubility it passes, he says, into the intes¬
tines, and there neutralises toxic ptomaines which result
from gastro-intestinal catarrh. He has found it lesson
Hiarrhma and lower temperature. The Italian physician,
Testi,'* has also given thymol in 150 cases of typhoid with
good results ; he noted a lowering of the temperature, dis¬
infection of tbe intestinal tract, and a diminution of diar-
rhma and tympanites. Likewise a notable diminution
in the products of putrefaction developed in the intestine
and eliminated by the urine. The importance of attomptlDg:
•» Allg. Wien. Med. /.oitung, No. 9,1880, p. 90.
: ; : f Google
Thb Lancet,]
DR I. BURNEY YEO ON TYPHOID FEVER.
[April 11,1891. 813
to eatablisb intestinal antisepsis in the treatment of typhoid
fever has been especially insisted upon by Professor Bouchard
and Professor (^rancher, two distinmiisbed professors of the
Medical Faculty of Paris, and I will now call your attention
to some of their conclusions and to the methods they adopt.
Professor Bouchard® encountered much difficulty at first in
finding a suitable non-irritating antiseptic agent for this pur¬
pose. He tried charcoal as recommended by Sir Wm. Jenner,
iodoform, carbolic acid, naphthaline, and other substances,
but none of them were quite satisfactory. He now uses and
recommends /S naphthoJ, reduced to a fine powder, and
mixed with salicylate of bismuth. One hundred and fifty
grains of /3-naphthol are mixed with seventy-five grains of
salicylate of bismuth, aud this is divided into thirty powders.
From three to twelve of these are given in the twenty-^ur
hours, enclosed in a wafer, and swallowed with the food. The
/9-naphthol has the advantage of being very slightly soluble
in water, but it is a powerful antiseptic; it therefore
reaches the intestine, where it acts as an intestinal antiseptic.
Professor Bouchard finds that it certainly deodorises the
evacuations. He insists also on the administration of
uinine, which he contends (and in this contention I am
isposed to agree with him) acts as a general antiseptic.
Eberth has shown experimentally that quinine is one of the
most powerful antiseptics against the typhoid bacillus, and
checks its cuUure. Professor Grancber, Pdcholier of Mont¬
pellier, and Voit of Berne, have all published excellent
clinical results from tbe administration or quinine in typhoid.
Bouchard considers its action in lowering temperature in
this fever to be antiseptic rather than antithermic. His
method, then, of treating typhoid fever consists in tbe use of
both a local and a general antiseptic. He checks intestinal
putrefaction by means of intestinal antisepsis, and be
antagonises the infective agent in tbe blood by means of
quinine chiefly. He gives some statistics of tbe treatment
of typhoid cases at the Lariboisibre Hospital, with which
he IS connected. From 1854 to 1886, 12,246 eases were
treated, with a death-rate of 21-15 per cent. In the same
hospital, in the last four years, be has treated 890
cases and lost 46, a mortality of 11*79 per cent. He
states that his mortality only amounts to two-thirds of
the whole mortality rate of the other cases of typhoid fever
treated in the hospital during the period in which his
method has been applied in his service alone. Bouchard
gives the quinine in larger doses than have appeared
to me to be necessary; for I also am an advocate of the
use of quinine in typhoid fever. He gives it after this fashion:
during the first fortnight thirty grains are given in the
evening, in four equal doses of seven grains and a half
each, every half hour, at intervals of three days. Of course,
these intervals reduce the total quantity of quinine to the
moderate average of ten grains a day. In the third week
the thirty grains are reduced to twenty-two grains, and in
the fourth week to fifteen grains. Professor Grancber in
treating typhoid fever in children gives quinine in the same
manner. At five years of age he gives from fifteen grains
to twenty-two grains and a half, divided into three doses,
every half hour, at about 6 or 6 P.M. He finds that this .
method has the advantage of procuring the child sleep
during the night, and that the child waxes refreshed and
cheerful, with a fall of temperature of from 2° to 4“^. He
asserts that its effects with children are remarkable, and he
believes it tohave a specific antiseptic action in typhoid fever.
Dr. Clement Cleveland of New York" has also recorded his
experience with quinine in typhoid fever. He believes it cuts ;
short 801110 cases of the fever, if it is begirn early and given ■
in from five to ten grain doses every fifteen minutes for two
hours, his idea being tlie same as Bouchard’s—viz , to satu¬
rate the system rapidly with quinine, and then leave an
interval. He also at otlier times gives from five to ten grains
every two or three hours, and he points out that as quinine
is rapidly eliminated it is necessary to keep the system
under its influence. Typhoid fever'patients with whom it
acta well lie has observed recover more rapidly, more
permanently, and with fewer sequeJic; aud lie has been
impressed with the fact that tlie death-rate is much
lower with the quinine treatment than with the expec¬
tant plan.
Let me point out, again, limt this is no wcic observation
as to the eilicacy of quinine in typhoid fever. If we refer
to Sir Thomas Watson’s Lectures, at page 855, vol. ii..
» Tliorapeutique ilea Muladies Infectueuse. Paris, 18B!).
i: New York Medical Record, Nov. 20th, 1880.
fourth edition, we find him quoting a Dr. Dundas as
maintaining that “ quinine in large and frequently repeated
doses is a specific cure for continued fevers as we see them
here,” and after referring to the varying reports of its
efficacy received from different practitioners, Sir T. Watson
concludes, "Bat of the cases in which this quinine treat¬
ment is reported to have effected cures, some are expressjy
described as instances of maculated typhus, and others as
instances of ty phoid fever. ” What I would say with regard
to this is, that when you see a remedy returning again and
again into favour, and impressing successive generations
of physicians, from time to time, with the idea of its
value and efficacy, be quite sure there is some truth in.
their observations ; and that what is needed to crystallise,
as it were, into an established therapeutic practice these
observations is a central idea—unchanjging because true—a
generalised induction from observation or experiment;
and this idea is furnished us now by the knowledge of the
retarding influence which quinine, together with other anti¬
septic agents, exercises in the development of morbific
microbes. As tbe administration of quinine forms an
important part in the method of treating cases of typhoid
fever that I have long adopted, I will now describe
that method. I have found, as Murchison had done many
years ago, that of all antiseptic remedies free chlorine is the
most useful. “I have repeatedly found it,” says Mur¬
chison, " to have a beneficial influence upon the abdominal
symptoms,” and he describes how a solution of the gas may
be readily obtained. 1 follow his plan, but I prefer rather
different proportions. Into a twelve ounce bottle put thirty
grains of powdered potassic chlorate, and pour on it forty
minims of strong hydrochloric acid. Chlorine gas is at once
rapidly liberated. Fib a cork into the mouth of the bottle,
and keep it closed until it has become filled with the
greenish yellow gas. Then pour water into the bottle, little
by little, closing the bottle, and well shaking at each addi¬
tion until the bottle is filled. You will then have a solution
of free chlorine, together with some undecomposed chlorate-
' of potash-and hydrochloric acid, and probably one or two
bye products. I greatly prefer this preparation of chlorine
to the liquor chloriof the British Pharmacopceia; it is much
pleasanter to take, and I have had much better results with
it. To twelve ounces of this solution for an adult I add
twenty-four or thirty-six grains of quinine, and an ounce of
syrup of orange peel, and I give an ounce every two, three,
or four hours, according to the severity of the case-;-tha5
will be from twelve to thirty-six grains of quinine in the
twenty-four hours, according to the ease. I have for some
' years past treated all my typnoid fever cases, except the very
j mild ones, which have not appeared to me to require any
' active medical treatment, on this system. They have not
been very numerous, but they have been consecutive cases,
' and they have all done well.
In giving this mixture to a typhoid fever patient one of the
first results you will notice is a remarkable cleaning of the
tongue. You will scarcely ever find a dry, dirty, thickly-
coated tongue in a patient who has been early put on this
mixture. Another roost important change has been noticed
again and again, and reported to me by the nursing sisters
in our hospital: it is that the fetor of the evacuations, which
have often been very offensive, will usually disappear within
twenty-four to forty-eight hours of the commencement of
this treatment. Now this appears to me to be a very interest¬
ing and important point. We should expect that this mix¬
ture would be wholly absorbed in the stomach, and that it
would not reach the lower part of the small intestine directly.
Yet it certainly exerts an antiseptic action on the intestinal.
contents. May it not be that it exerts its antiseptic in¬
fluence in the blood and there encounters and neutralises
some septic substances generated by the typhoid bacillus so
that the excretions into the intestine are modified, and so
an antiseptic effect on the intestinal contents is prodneedv
In this way we not only obtain intestinal but also a general
antisepsis. The illustrative cases I am about to suoniit to
you have enabled us to observe the following effects as result¬
ing from this treatment:—1. A modification and sustained
depression of the febrile temperature. 2. An abbreviation
of the average course of tbe fever. 3. A remarkable main¬
tenance of the physical strength and intellectual clearness of
the patient, so that there has been far less need of stimulants.
4 A greater power of assimilating food. 5. A remarkable
cleaning of the tongue. 6. A deodorisabion of the -evacua¬
tions. 7. A more rapid and complete convalescence.
(To le
814 Thb Lancet,] DK. GEORGE JOHNSON ON THE PHYSIOLOGY OF ASPHYXIA. [ApriHI, 1891.
ON THE PHYSIOLOGY OF ASPHYXIA AND
ON THE ANAESTHETIC ACTION OF
PURE NITROGEN.
By GEORGE JOHNSON, M.D., F.R.S.,
COSSULTINCr PHYSICIAN TO KING'S COIJ.KGK. HOSPITAL, EMERITUS
PKOFESSOK OP CLINICAL MEDICINE, I'HYSIOIAN EXTUA-
OHDINAUV TO ILM. THE QUEEN.
(Ct>ncJw(ieti/roOTi>a<7e 700.)
The explanation which 1 bare before given of these facts
appears to me to he the true one—viz., that during the later
stages of asphyxia, when the blood has become entirely
deoxidised, the pnlraonary arterioles contract and cause the
extreme distension of the right cavities, with ancemiaof the
pulmonary capillaries and a corresponding defective blood-
supply to the left cavities of the heart.
[The extreme distearion of the right cavities of the heart
while the left are flaccid aud comparatively empty, the
minute tissue of the lungs being pale and bloodless,
clearly indicates an impediment to the flow of blood between
the right ventricle and the pulmonary capillaries. Such au
impediment is explained bjr the contraction of the pulmonary
arterioles—tlie vaso-eonstrictors of the lungs. It appears to
me that the phenomena of asphyxia afford a more complete
proof of the powerful action of the pulmonary vaso¬
constrictors than can be derived from any kymographic
tracing. ]
I venture to suggest the following explanation of the
increase of blood pressure in the pulmonary veins, which
has been observed by Mr. Martin and other experiinentera
during the successive stages of asphyxia. In the first stage,
■when, with high systemic arterial tension, the left cavities
of the heart are distended (Fig. 1), there must be a backward
pressure in the pulmonary veins, extending, perhaps, as far
as the pulmonary arteries.^ It is probable, however, that a
concurring, if not the main, cause of the pulmonaiy venous
pressure which continues and sometimes increases iu the
second stage of asphyxia, when the systemic arterial tension
and the distension of the left cavities have passed away, is
the compression of the pulmonary veins by the extreme
collapse of the lung which occurs when the chest is opened
in order to introduce a manometer into one of the pulmonary
vessel trunks.^ Jt is an acknowledged fact that the com¬
paratively slight compression of the pulmonary veins which
occurs towards the end of an ordinary expiration lessens
ttio flow of blood into the left side of the heart. The degree
of impediment to the pulmonary venous current which is
thus occasioned must, however, be very much loss than
that which results from compression of the veins by the
elastic force of the collapsed lung when an opening has been
made in the wall of the chest.
Lastly, it is probable that yet another hindrance to the
onward flow of blood in the pulmonary veins in the second
stage of asphyxia is the impairment in the suction power of
the left auricle, partly by amcmia of the cardiac tissues con¬
sequent on contraction of the arterioles, both pulmonary
and systemic, the coronary included,and partly by
the fact that the small amount of blood with which the
heart is supplied is more or lees completely deoxidised.
[The facts and considerations here stated appear to me to
explain the circumstance that, whereas the immediate
effect of contraction of tlie systemic arterioles is a fall of
pressure in the sj'stemic veins, no such fall of pressure has
been observed to occur in the pulmonary veins when the
increased blood pressure iu tlie pulmonary artery and
anaemia of the capillaries indicate that the vaso-constrictors
of the lungs ate impeding tlie onw'ard How of the blood.
As there is a direct relation between the amcmia of the
minute vessels of the lungs and the collapse of those organs
when the chest is opened, and ae the ancumia is the result
’ This backiv.anl prGs.siiro will account for Hio fact iiioiitioiiod I>y
3>rH. }}ra(lfov(l .tnd Doan (Pnic, itoy. 8oc., vol, xliv., No. 277), tiiab in the
oaiTy stiifio of awpliyxia ihore is a syriclironoiis riso of preasuio in the
Bysteiriic ami pulmonary artoric.s, On tho other liaml, tlm continued
rise of tlio puiinonarv pressure at a ialev stago, wliilo the -systoinh^
pressure is lupir.Hy fallinti, can he explained only hy Clio action of tho
pulmonary vaso-coiistrictor.s.
^ 8oe Dr. M. Foster’s Physiolofiy, fifth edition, p. (118.
ft has iieen proved hy experimeut that in tlm doji speedy arrest of
the lieari.’s action is induced. l>y lijratiiro of one of tho liir(.jer biatichos
of the coMiimy arioiy, J.ectuvc-s on Gencial f'aliioiir,')-,' Colmiieim :
Now Wydenhaiii .Society, vol. i,, p. 028.
of contraction of the pulmonary arterioles, it is obvious that
the greater the resistance resulting from tills arterial con¬
traction the greater will be the pressure to which the pul¬
monary veins will be subjected by the elastic tissue of the
collapsed lungs.]
With reference to the innervation of the pulmonary
vessels, Drs. Bradford and Dean have proved not only the
existence of pulmonary vaso-motor nerves, but also that
they leave the spinal cord higher up than the svstemic
vaso-motor nerves.^ True, these authors remark that “it
is probable that the pulmonary vaso-motor mechanism is
but poorly developed compared with that regulating the
systemic arteries.” It would, however, be a strange and
incredible physiological anomaly if the vessels of an organ ;
through which the entire blood of the body has constantly
I to pass had not the same regulating and resisting power,
compared with the force of the right ventricle, as that.
possessed by the systemic arterioles.
Mr. Martin has found, by introducing a manometer into
a branch of the pulmonary artery of a moderate-sized cat,
while the remaining branches are suddenly obliterated,.
that the blood pressure in the pulmonary artery rose from,
17mm. of mercury to 36mm. But neither this nor any.
other experiment 'which has been hitherto devised can
accurately measure the resisting power of the pulmonary
arterioles or the actual force of the right ventricle, for the.
obvious reason that the arrest or great diminution of the pul¬
monary circulation enfeebles the muscular walls of the heart
by cutting off the blood-supply through the coronary arteries.®
Mr. Martin has also found that during the last stage of
asphyxia the pressure in the pulmonary artery is nearly
doubled, while that in the carotid is rapidly falling. Than
the pulmonary arterial pressure is somewhat less in the last
stage of asphyxia than when the artery ia suddenly and
mechanically compreesed seems to be explained by the fact
that while in the latter case the blood in tbe coronary
vessels is arterial, in the former the muscular walls of the
heart have been weakened by the gradually increasing
venosityof their diminished blood-supply. Iniiirect though
weighty evidence in support of the theory that the anajmia
of the pulmonary capillaries, with distension of tbe right
cavities of the heart, in the last stage of asphyxia is
the result of extreme constriction of the pulmonary arte¬
rioles is afforded by tbe well-known fact that imme¬
diately after the readmission of air to the lungs there
is a great and instantaneous increase of the systemic
arterial blood-pressure ; the most probable explanation of the
phenomena being that tbe reiatroduction of air into the lungs
causes, through the vaso-motor nerves and centre, relaxa¬
tion of the pulmonary arterioles, as a result of which the
blood which had accumulated in the trunks of the pulmonary
artery and in the right cavities of tbe heart ia forced
onwards, at first by the mere elastic resiliency of the dis¬
tended pulmonary arteries and cardiao walls; while later
the vital contractility of the heart is increased, partly by
its lessened distension, and partly by an increased supply
of oxygenised arterial blood.
[If the arrest of tlie circulation were the result of
paralysis of the heart’s walls by the circulation of venous
bI.)od, the arrest would be permanent and irremediable, for
this theory assumes that, in order to renew the heart’s
beats, aerated blood must reach the coronary vessels, an
event which could not be brought about without the
previous restoration of the heart’s action.]
I have before stated that the extreme ana.’mia of the
pulmonary capillaries in the last stage of asphyxia and the
rapid emptying of tho left cavities of the heart, while the
right are becoming greatly distended, are facts inconsistent
vribh the theory which assumes that the distension of the
right cavities of the heart is a result of backward pressure
from the left, consequent on systemic arterial obstruction;
and, on the other hand, the -inHlantancom renewal of the
circulation by the readraission of air into the lungs is not
■* Pioi;. Hoy. Hoc,, vol. xliv., No. 277.
C’ Dr. M. Foster h.YS done me the favour to direct my Attention to a
papor by Professor Knoll (l)er JJIutdruck iu dor Artoria Pulinonalis l>ei
Kajinichon: Sitziinjr.sberichUi der ICiiisoilichen Akrideiiife in Wien,
Band xuvii,, AlitheiluiiK 14, S. 207), In this paper Dr. Knoll describos a
jno'liod of moasuriiifi; the imniial blood pressure iu the pHlmoiiary
artery of rabbits, which is les.s fallacious than the processes which
have more coturaoniy been adopted. He divides the .sternum aud
inlTofiuceH a tidio into the trunk of the ai'lory without wounding tlie
pleura. By this means the blood prossurn is taken, wliilu normal ,
respiration ‘•onLiimeH. Thu author admits, liovvovor. Mint the opuning
of Liie iiiodiastiniiiii and the coiisecfueiit expo.siire of the root of the
artety to atnio^plieiie pius.'oiro may ho .'i source of error.
Dig’::zGd by Google
Thx Lancet,]
SIR WM, B. DALBY ON AURAL SURGERY.
[April 11,1891. 815
to be explained by the theory of the previous arrest being
caused by cardiac paralysis consequent on the circulation ol
venous blood.
Conclusions relating to Astiiyxia.
That the immediate cause of death from asphyxia is the
arrest of the pulmonary circulation appears to be proved by
the following facts:—1. When the chest of an animal is
opened immediately after death caused by ligature on the
trachea, the right cavities of the heart are found enormously
distended, while the left are comparatively empty. 2 When
the heart of an animal is exposed during the progress of
asphyxia the right cavities are seen to become distended,
while the left cavities, which had been previously gorged,
are found to be collapsed and comparatively empty. 3. In
the last stage of asphyxia there is a continuous increase of
pressure in the pulmonary artery, while the systemic arterial
pressure is falling. 4. That the arrest of the circulation
through the lungs is due to contiaction of the pulmonary
arterioles appears to be proved by theinfluence of agents which
are known to paralyse the arterioles—e.g., nitrite of amyl,
atropine, and an excessive dose of curare, the effect of which
is that deprivation of air is unattended by distension of the
right cavities of the heart, and other evidence of obstructed
pulmonary circulation, the life of the animal is prolonged
for several minutes, and death ultimately results from the
toxic action of venous blood upon the cardiac and nervous
tissues.
[6. It is an acknowledged fact that these paralysing
agents act alike upon the systemic and the pulmonary
arterioles, hub the successive phenomena of asphyxia are
absolutely inconsistent with the idea that the distension of
the right side of the heart is a result of systemic arterial
obstruction acting backwards through the left cavities of
the heart and tlie lungs.]
The Anaesthetic Action of Nitrogen alone, or
with a small 1‘llOI'ORTION OF OXYGEN.
I have elsewhere stated that the phenomena which result
from the inhalation of nitrous oxide as an annisthetic by
human beings are strictly analogous with those observed
during the early stages of asphyxia.*^ While some writers
maintain that the aomsthetic action of nitrous oxide is due
to its preventing access of free oxygen to the system, others
believe that it has a “specific anicsthetic action.” It
occurred to me that sojue light might be thrown upon this
subject by the administration of pure nitrogen. Accordingly
I obtained from the Scotch and Irish Oxygen Company of
Glasgow a cylinder containing 100 cubic feet of compressed
nitrogen, in which the proportion of oxygen present was
only O'G per cent by volume, with 0'3 per cent, of CO3. As
a preliminary trial, Mr. h’. W. Braine was good enough
to administer this gas in five instances to members of
the staff of King’s College, who volunteered to submit to the
experiments. The result was in each cafe the production of
complete anlI^sthesia and of general phenomena precisely
similar to those observed from the inhalation of nitrous
oxide. Encouraged by these results, Mr. Braine felt
justified in administering the gas to patients at the Dental
Hospital for anjcsthetic purposes. Nine patients took the
gas. In every case the result was the production of com¬
plete anteathesia, with general phenomena precisely similar
to those observed during nitrons oxide inhalation. The
pulse was first full and throbbing, then feehle. In the
advanced stage the respiration was deep and rapid, and
there was lividiby of the surface; the pupils were dilated,
and there was more or less jactitation of the limbs. The
only difference, in the opinion of some of those present, being
that the ancesthesia was less rapidly produced, and some¬
what less durable, than that from nitrous oxide, though in
each case the tooth was extracted without pain.
On a subsequent occasion the same gas was administered
by Dr. Frederic Hewitt at the Dental Hospital. As before,
nine patients took the gas. The maximum period required to
produce amesthesia was70 seconds, the minimum .GO seconds,
and the mean time 68'3 seconds. In one case two teeth
were extracted without pain. In one case only was pain
experienced, and in that case, the tooth having been broken
up and not extracted, the patient said she felt a “smashing
up.” Having on several occasions witnessed the adminis”
tration by Dr. Hewitt of nitrous oxide mixed with 10
er cent, by volume of oxygen, with the result of pro-
ucing onmsthesia without iLvidity or jactitation, I deter¬
mined to try a mixture of nitrogen with a small pro¬
EsHiiy on As'l'liyxi'i. P 3<».
portion of oxygen. I therefore obtained from the com¬
pany above mentioned a cylinder containing forty cubic
feet of nitrogen mixed with 3 per cent, by volume of
oxygen, and a second cylinder equally charged with a
mixture of nitrogen with 6 per cent, by volume of oxygen.
These gases were administered by Dr. Hewitt to patients
at the Dental Hospital with the following results :—In the
case of the 3 per cent, gas, which was given to five patients,
the time required to produce ansesthosia varied from 00
to 75 seconds, the average time being 67'5 seconds. In
each case the tooth was extracted without pain, the
duration of anresthesia being somewhat longer than with
pure nitrogen. In each cose there was lividity, dilatation
of pupils, and more or less jactitation. On the same day
Dr. Hewitt gave nitrogen with 6 per cent, oxygen to four
patients. With this mixture the time required for the pro¬
duction of anresthesia ranged from 75 to 95 seconds, the
average being 87‘5 seconds. In each case there was com¬
plete amesthesia, duiing which one patient had three
molars extracted, and although she said she “felt the two
last,” the sensation appears to have been that of
a pull, and nob of acute pain. In all of these four cases
there was slight lividity before the face-piece was removed,
but in only one case was there slight jactitation of the limbs.
The other three patients were perfectly quiescent. The ex¬
periments here recorded suffice to prove that nitrogen,
pure dr mixed with a small proportion of oxygen, is as
complete and apparently as safe an anceathetic as nitrons
oxide. It is to be hoped that those who are engaged
in the administration of anaesthetic gases will inves¬
tigate this interesting subject further, with a view
to ascertain whether atmospheric air, partially deprived
of its oxygen, may be advantageously substituted as am
anjcsthetic lor nitrous oxide. For the information of those
who may be disposed to enter upon such an investigation,
I may state that Brin’s Oxygen Company (69, Horseferry-
road, Westminster) are prepared to supply nitrogen con¬
taining from 4 to 7 per cent, of oxygen at the same rates as
they now supply pure oxygen—viz., in quantities of twenty
cubic feet or less at Ad. per cubic foot, of twenty to sixty
cubic feet at 3(f. per cubic foot, and of over sixty cubic feet
at 'Zhd. per cubic foot, in their own cylinders. Below 4 per
cent, of oxygen, nitrogen could be supplied only by special
arrangement, and probably at increased cost. As before
stated, I obtained the gas employed in tny experiments from a
Glasgow firm, and its coat was therefore increased by tiie
expense of carriage from Scotland,
Savile-row, W.
BUBBLE EEMEDIES IN AURAL SURGERY.
By SIR WM. B. DALBY, F.U.C.S., M.B. Cantab.,
AUnAt- SUKOrcON TO ST. OliOUOFAS UOSl’lTAL.
It is probable that all departments of medicine or sur¬
gery are more or less liable to the introduction of what may
be termed “bubble remedies” (using the word “bubble” in
the same sense as it applies to companies), but naturally
my cognisance of them is chieily confined to wlmb I learn
from patients with whom I am brought in contact in the
practice of my own specialty. If I could repeat a half of
their experiences as related to me from time to time during
the past few years, the belief in the credulity of mankind
would become even greater than it must be even now
amongst men who have great knowledge of the world. As
might be anticipated from their nature, the life of these
bubble remedies is brief, tbeiv end is occasionally sudden,
and the recollection of them soon fades away ; but it is, -1
am sure, not altogether useless to occasionally subject them
to the light. They remain in the air for considerable periods
before they attract attention, and then their existence is
made known by the voices of those who have invested their
hopes in them. In the ordinary course of events the hi-story
of any newromedy in medicine or surgery includes a trial at a
hospital, a discussion at a society where physicians and sur¬
geons give theadvantage of theirexperience and knowledge to
aid the introducer and to criticise his conclusions. A fair
trial is given at other hospitals, and it lives or dies according
to the measure of its usefulness. It is very different with
the bubble remedy. Its origin is at times singularly unoiv
trusive, and private patients have the inestimable, or qnee.*
tionable, advantage of an early trial. Its constitution is at
r Coogle
S16 The Lancet,]
SIR WM. B. DALBY ON AURAL SURGERY.
[April 11, 1891.
this period of its lite too delicate to be submitted to the full
blaze of criticism above alluded to. At aoother time a
sma,!! pamphlet is greatly circulated, or a few cases (la
which it has been tried, rather, it would appear, for the
relief of a symptom than a pathological condition) are
loported in a medical journal. These are more suitable
methods of introducing it to the world. What is better
still, is that it should have been at some time previously
tried by some well-known man of good reputation and
subsequently abandoned. It then has an air of respecta¬
bility, and so resembles an after-birth of a child wlio has
failed to shrvive.
I will mention only a few examples. It seems almost
incredible, but is no less a fact, that during the past year or
so a company was floated in the City of London, with a
capital of £100,000, the avowed purpose being to purchase
a business which possessed the exclusive right of selling
what were termed *' artificial ear drums ” it is now over
fifteen years since the use of Toynbee’s artificial membrane
(at the time an excellent contrivance in cases of perforation
of the tympanic membrane) has been given up by aural
surgeons in favour of improved methods. Now practically
any form of artificial membrane that is advocated pre¬
supposes that all perforations which require protection and
pressure cau have them usefully applied by one form, the
fact being that each perforation requires management to
be acquired only by experience, after careful examination,
and, when any support of the kind is wanted, it must be
regulated by the patient, his sensations being the guide in
regard to pressure. Alsu many perforations are quite
intolerant of all forms of artificial covering or pressure.
However, in regard to these “artificial drums,” at first
some time was spent in advertising a simple modification
of Toynbee’s artificial membrane (which, under another
name, was to cure every conceivable sort of ear trouble),
by means of a pamphlet full of testimonials, the value
of which may be judged by the fact that the inventor
quoted a long passage from one of my lectures published in
1873, leaving ic to be inferred that it applied to his “ear
druur” By and by the bubble was floated. The next
episode in its history was an account of a meeting of the
company, the vendor occupying the position of chairman.
It appeared from the report that the harmony of the pro¬
ceedings was somewhat marred by the presumption of an
inquisitive shareholder; and I have not seen any account
•of subsequent meetings. That these ear drums had a con-
Biderable sale I am sure, since numbers of persons who have
consulted me bad bought them, I am bound to say generally
when they had no perforation at all; for if by chance they
had perforations of such a kind as would receive benefit by
Toynbee’s artificial membrane, their hearing might probably
have been helped by the use of this imitation. Now, it
was in this fact that the fractional good so necessary for the
success of this venture is to be found, for who could doubt
that, if some deaf people could be made to hear better, it
might be the case with all ? So much for the ear drums,
and now for electricity.
In July, 1889, when speaking on the subject of tinnitus,
I ."aid : “ Perhaps because tinnitus due to degeneration and
^ome other causes is of a constant character, the kind of
electricity which finds favour amongst its advocates is the
constant current; but whether this or the interrupted is
employed, it is generally tlie personally conducted and con¬
tinuous as long as possible” This is no doubt perfectly
true, but I still think that for a long though fitful life amongst
all bubble remedies, for the ear at least, electricity will
maintain the leading position. I will endeavour to show
why this is by an illustration. Before doing so, however,
lest there should be any misapprehension as to my meaning,
I wish to state most emphatically that my remarks apply
absolutely and entirely to the unscientific use of elec¬
tricity, and it is most necessary to state this, since
the scientific use of this force has achieved so much in
both surgery and medicine during recent years. When
the tympanic cavity becomes the seat of acute inflam¬
mation, if the aqueduct of Fallopius is destroyed by
caries, the portio dura within it is also destroyed, and
facial paralysis is of course in this case permanent. If,
however, the inflammatory process is of a more limited
character, the facial palsy recovers either completely in a
period to be counted by weeks or months, as the inflam¬
matory products aroun<f the nerve disappear. Since many
of these cases are subjected to electricity, those persons who
recover naturally attribute it to the treatment adopted.
Perhaps it may be said that this process of reasoning applies
so often to many other remedies employed in those forms of
disease which have a tendency to recover, that it is unfair
to suggest the possibility of the facial palsy getting well
in tne same time as it there had been no electricity.
It is, however, ditBcult to understand how a current of
electricity passed through muscles can expedite the
absorption of inflammatory deposit in the aqueduct of
Fallopius any more than in hemiplegia it could expedite
the changes in a blood-clot in the brain. The same order
of events—viz, treatment by electricity, and, if recovery,
this attributable to treatment—takes place in so many
nervous and inflammatory troubles connected with the ear
that it is employed for all sorts of symptoms due to perma¬
nent change in tusue down to a general tinnitus, which
often comes with atheromatous arteries, the results being
the same mimts the recovery. It la thus that an agent
intriosically of great value in surgery becomes a bubble
remedy.
Another reason why electricity as a remedial agent
will always be more or lees in request may perhaps be
found in the fact that the minds of many people are pecu¬
liarly liable to its fascinations. The idea is present to them
that we live in an age of electricity, and anything short
of miracles — in which they also believe up to a point—
may be expected from it. The knowledge, too, that
undoubtedly the use of the electric current is of very real
service in some departments in surgery tends to confirm a
possibly waning faith It cau be applied, too, in such
ingenious ways to parts of the body out of sight, and this
is an attractive idea. Again, if the process is attended with
acute pain, the treatment is apt to come to an abrupt con¬
clusion, but as a set olt' to this what a delightful revelation
it is to find that cocaine can be applied to the aperture
which is being acted on—the nose, or some other opening—
and any objection on the score of pain may be disposed of.
To put the matter briefly, is it not within the experience of
most practitioners that those who suffer from progressive
disease, or unrelieved symptoms, and who naturally fly to
something outside the routine of treatment which they have
vainly tried, turn their eyes towards electricity as offering a
better chance than most of the empty helps held out to them
in their dire distress? The same kind of apparent soundness
at the base above alluded to—viz., the recovery under treat¬
ment, nndnot cfMC to treatment—was to be noted in the whole¬
sale injections of deaf people by pilocarpine, which quite
recently took place, hut the faith in which has been rudely
shaken by a paper in Tke Lanckt of Jen. 3rd from Politzer,
who made the original experiments with pilocarpine as far
back as 1879, and who, having subsequently given his expe¬
rience and views on the subject, now finds it necessary to
write in such scathing terms on “the abuse” of this treat¬
ment. He there speaks of “ practitioners who subject their
patients to a long and wearisome course of treatment with
pilocarpine,” and says, “ I feel, it my duty to say that they
are not too conscientious in the discharge of their calling.’’
It is much to be hoped that this protest will be largely and
carefully read, for during the spring and summer of 1890 the
ondition of patients who consulted me after being injected
in this way M'ere almost ludicrous as to the variety of the
ailments for which it had been employed. For the most
part tliese people belonged to tbe unsuccessful division, and
included old gentlemen who objected strenuously to senile
degeneration, the middle-aged and the young whose
hearing was defective from the many causes wuich un¬
happily admit of no alleviation, but they included none
of whom it could be said they bad not given it a fair
trial. One young man out of many I especially remember,
who in consequence of central changes was impervious to
sound of every sorb, both before and after he had been sub¬
jected to eighty injections, and this was after or before
([ forget which, but it is unimportant) a long course of
electricity. It may not unreasonably be asked why such
wholesale injections did not, even before Professor Polibzer’s
rotest, elicit an outspoken disapproval of the practice ?
n the first place, it is a matter of common knowledge that
in the secondary stage of syphilis patients often become
deaf and completely recover under the ordinary consti¬
tutional measures without any especial treatment for the
loss of perception to sound, the conducting power remaining
good. Those who were injected of course recovered their
bearing, and attributed it to the injections. In tbe later
stages of constitutional syphilis, or in the inherited variety
especially, the course of events is different. In the second
place, it must be remembered that the subject of ear
affections does not attract the attention of many, and
Digl'iz3d by ^
’SJhe'Lancet,]
DR. EMIL PFEIFFER ON GOUTY FINGERS.
[April 11,1891-. 817
^0 they did not ieel competent to express dissent or
assent in the matter. In the third place, this is not
the only occasion when injections of fluid have been prac¬
tised with ineuiflcient data, even Avith the highest objects
do view. Indeed, have not recent events shown that there
was for a moment a danger lest a wave of enthusiasm should
swamp the intelligence of the College of Physicians, and
this danger was only averted by the better judgment of a
tinajority and the sagacity of its guiding spirit? This I
conceive to be the explanation of the limited vitality of the
pilocarpine craze—a vitality which has been further limited
©y Dr. Polibzer, who at least, it must be admitted, may
/airly claim to set bounds to the employment of an agent
which he was the first to apply to ear disease.
The bubble remedy, chameleon-like in its hues, occa-
islonally assumes the aspect of a surgical procedure. In
approaching the subject as delicately as possible, let me
■say I have sometimes hoped it may be possible that there
•exists in the human mind a faculty—undeveloped unless
called into'activity—which permits the possessor of it to
persuade himself of the inutility and general harmfulness
•of some portion of the human body (not in the precise
instance of his own body, but in that of others). Unless
■this delusion is within the range of possibility, how are we
to explain the determination with which some practitioners
■extirpate an apparently unoffending portion of the organism
(for reasons which appear to be not only quite illogical, but
which require the profoundesb ingenuity even to enunciate ?
For example, I have been asked to give an opinion somewhat
in this way: “I am suffering from [here follow a variety
of symptoms which include deafness and tinnitus, but by no
means conclude with th^se troubles]. Do you think I
should be cured by the removal of my [right or left] middle
turbinated bone?” This upon examination being found quite
liealthy, the opinion in the negative is given without
much difficulty, without the expenditure of many words or
any comments. The same question has, I know, been asked
of many others besides myself. As a surgical procedure,
this operation is outside the pale of serious discussion, and
I mention it only as an example of a bubble remedy that
the very mention of it may possibly hasten its inevitable
'bursting.
If this operation or mutilation (whichever the reader
may elect to term it) is devoid of plausibility, it was not
iSO ■ with another, which is now defunct—viz,, division
of the tensor tyinpani muscle, but which, at the period
•of its birth and early in its brief and chequered
•career, attracted considerable attention. The conception
was not wanting in brilliancy if the results of the proceed-
'Ing included duiness (in hearing), and it was easy and
iTeasonable at first sight to imagine that the division of
this muscle would relieve permanent tension, especially if
'it had undergone permanent contraction. I have even
heard it alluded to at one of the medical societies in London
•as a recognised operation. It may have been recognised,
but certainly by those who were familiar with its results
<aad especially by those upon whom it was performed) it
was reco^ised as a failure so far as any change for the
better in hearing was concerned, and a very decided change
for the worse in the cases which came before my notice. I
have elsewhere described it as including in its history “ a
flight of the imagination, a brief notoriety, .and a burial iu
oblivion so rapid as falls to the lot of few achievements in
surgery,” and I see no reason to alter this description in
paying a tribute to the dead.
Such are some of the bubble remedies which float over the
area of aural surgery, but Avhich “vanish into thin air ” as
ithey emerge into the clear light of day.
SiavUe-row, W. _
GOXTTY FINGERS.
By EMIL PFEIFFER, M.D., Wieshadkn.
The celebrated English physician, William Heberden, in
Ms Commentaries, published shortly after his death, about
the end of the last century, has a chapter under the heading
‘ ‘ De Nodis Digitorum,”^ the tenour of which runs as follows
“ Nunquam rite intellexi naturam tumorum, qui interdum
nascuntur, ad pisi magnitudinera, prope terbium digitorum
•articulum. Nihil certe illis comimme esb cum arthridite;
* Gulielmi Heberdeni Opera' Medka Coimucntarii, c.ap. xxviii., 1802.
(juoniam in multis reperiuntur, quibus morbas ille est
incognitas. Per hominis astatem manent, vacant omni
dolore, neque spectant ad ulcerationem. Proinde deformiitas
major est quam incommodum: quamquam motusdigitoEum
aliquantulum impeditur.” From this description these for¬
mations have in subsequent publications been named
"Heberden’s nodes,” the name by which they are knovm
at the present day. The accompanying illustration, Fig. 1,
taken from a cast in the museum of St. Bartholomew’s Hos¬
pital, London, and copied from Dr. A. E, Garrod’s work,® rives
a very faithful representation of the affection. Heberden’s
Fig. 1.
doubts regarding the formation of the nodes described by him
were twofold'. While he was unable to determine the exact
nature of the materials of which they were composed, as well
as the parts involved, he could not arrive at a decided
opinion as to the cause of the affection.
As to the first point, we have been informed by the ana¬
tomical investigations of Charcot that the nodes arise from
exostoses round the heads of the second and third phalanges.
These exostoses are well shown by the drawings which this
author has published (Fig. 2).® It is evident from these
Fig. 2.
a rn))ro3ont3 the phalanges from (ho back, and 6 the side
view. For piirpose.3 of comparison ho gives a delinea¬
tion of the dorsal surfaro of a normal phalangeal joint,
shown in c.
engravings that the nodes are formed by real exostoses and
have nothing to do with the tophi of gouty patients.
The second point—the etiology of the disease—has given
rise to much greater difterence of opioion among writers on
this subject. From the little that Ileberden wrote we may
conclude that he had occupied himself mainly with this
question, and that his doubts as to the nature of the nodes
were, perhaps, essentially connected with their etiology;
but he leaves us in no doubt as to his opinion that they
have “no connexion with gout, being found,” as he says,
2 A Treati.SB on Rlieuniatism and Ilheumatoid Arthritis. Loudon:
GritHi), 1890. Fijr. 10, p SJ(1U.
(lOuvres Compmtes, tom. vii, plancho 1, figs. 1, 5, 6. Paria, 1889
Die!..zed by lOO^Ic
818 TheLancbt,]
DR. EMIL PFEIFFER ON GOUTY FINGERS.
fArnii. 11,18OT.
“in persoDB who nfver had it ” The most decided opponeat
to this teacbiog is Besbie/ who, with reference to the above
quoted extract from Heberden’s work, writes
“ Many years have passed since Heherben suggested and
answerea the question thus proposed, and few, I apprehend,
of those who have since perused his writings have felt
themselves disposed to differ from him in opinion, and give
a different answer. Nevertheless, the question, if I mistake
not, admits of a distinct reply; and those little knobs,
which physicians in all ages must have noticed and con-
siderec^ are in reality intimately connected with gout,
though they are often fonnd in those who have never ex¬
perienced a fit of the disease. They are the product of the
gouty diathesis ; they are the deposits of the gouty blood,
and are not less certain indications of the habit than the
enlarged cervical glands and irregular cicatrices which mark
the deposit and progress of tubercle are of the struiiKins
constitution. Both are guides and landmarks to the
inquiring and observing physician ; both are eminently
suggestive as points of diagnosis and as indications of treat¬
ment—not only as regards the individuals themselves in
whom these manifestations appear, but as respects the
many who may he related to them by ties of kindred blood.
I have again and again traced the rise and progress of tliese
little knobs to their full development; I liave seen that
progress slow and almost imperceptible from year to year,
and have seen it equally rapid and observable during the
course of as many months. They are occasionally the
result of an intlaimnatory affection of the
fingers, more or less acute in its character, and
attended by the same constitutional dis¬
turbance which marks the fit of gout; hut
more commonly they are the consequences of
a slow and chronic disorder, in which dys¬
peptic derangement has been chiefly noticed ;
while occasional twitches of pain in the lingers
and a sense of fulness and stiffness there have
been the only forerunners of those morbid
products which are destined to last through
fife. They are found cliielly among the upper
classes, or among the luxurious and well fed
of their dependants, and are seldom or never
found disfiguring the hands c)f the industrious
labourer or of the hard-working mechanic. I
have never seen those knobs but in connexion
with gout or the gouty diathesis, and their
presence in the fingers of a patient or of a blood
relative has often led me to a right diagnosis
of some obscure affection, or been the means
of throwing light on the nature of some ano¬
malous symptoms which bad ballled all at¬
tempts to unravel.”
Charcot,* on the contrary, is of the same
opinion as Ueberden, and denies all con¬
nexion with gout. From hia anatomical investigations
he is led to consider the disease to be a special form
of rheumatoid arthritis. In numerous cases observed at
the SalpCtribre he was able to convince himself that
the disease occurs in many persona who liad never liad
an attack of gout, and that the anatomical changes
were those of rheumatoid arthritis or rheumatic goii^—
i.e., degeneration of the cartilages and exostoses, lie
is, however, compelled to sum up his conclusion with
the words : “ Enlin ces potites nodositiis peuvent coincider
avec lagoutte, ainsi que j’ai eu moi-roCnie I’occasion de le
coDstater rdeemment. Danslecasdont ils’agit les nodosifcs
avaient pr6c6d6 la goutte de plusieuis anii6eB.”
Recent English authors (Drs. Alfred B. Garrod, Duck¬
worth, and Archibald E. Garrod) are much less conlident
as to the cause of the nodes. Dr. Alfred B. Garrod'
believes lleberden’s assertion that “they have no neces¬
sary connexion with genuine gout to he correct and
continues, “ As far as my own experience goes, I have very
seldom seen them in patients who were sulFcrers from
true gout.” Dr. Arcliibahi E. Garrod^ is of the same
opinion ; only he adds that he has himself seen such
nodes in cases in which there were clear histories of gout,
but of DO other articular alfection.” Duckworth*' goes much
* Contrlbutiona to Practicnl Mc<Uf1ne. KdlnlmrKh: Wlack, 1802, p. 28.
•• (lOiivn-s C’oiijpJC-teti, tom. vii., ISSU, p. 217.
9 A Trentiso on Oout iind Rliuuinatic Oout, third edition. I.omlon,
7 A^^'J'roatlse on IMiciiTnatism and Uhoumatold Arthritis. London,
181KI, p. 280.
9 A Trenllse on Oout. LondotB,^889, p. 71.
further than this. He not only contends that in a good
many cases the nodes of Ueberden are undoubtedly of gouty
nature, but even proves by anatomical facts that the changes
in the cartilages and the exostoses found by Charcot are
very frequently of an undoubtedly gouty nature. The
changes m coses of true gout characterised by deposits of
urates may go on to complete bony ankylosis — a result
which also occasionally takes place in Heberden's nodes.
Duckworth quotes a very striking case (of Dr Gee), in
which the third joints of several lingers were stilVened by
bony niikyloais, while all the other joints showed exostoses.
In this case nob only true fits of gout had taken place, bub
the post-mortem examination revealed “unequivocally gouty
changes with small scattered uratic deposits.” The case is
minutely described and illustrated by drawings. The same
point of view is taken by Lecorclxi," who says; “Nous
cro\ona que, chez les femmes, en partionlier, les nndositds
d’Heberden peuvent fort Hen 6tre I'indice de la diathfea©
goutteuse, se traduisanb d’ailleurs par diverses raanifesta-
biona visccrales : asthme, dyspep^ie, sciatique, etc , et sur-
tout par les modifications caracldristiques de I'urine eb du
sang.” As instances in point, he quotes the cases of two
female patients who belonged to gouty families, and in
whom, in addition to the presence of the nodes of Ueberden,
there were many syniptoina of anomalous goub.
For some years past I have observed with special interesb
the nodes of Ueberden on the numerous patients suffering
from gout or rheumatic gout whom I see here at iesbaden.
Fia. 3.— Ui’PEii Part.
Mrs. Doris N-of Rremerfutfen, sixty years of age.
To my mind the nodes of Heherden, as they are represented
in Fig. 1, in the fium of email tumours of ihe size of a pea,
are only a jiart of the changes involving the whole joint.
When we conbider and examine llie lirst stages of tlie
disease, as shown in Fig. .3, we find that the wliole region
of the third joint is enlarged, nob only on tlie back, bub
also on l-lie Hide and towards the volar surface. Un the
back of the lingers the usnal furrows wliich mark the region#
of normal joints when the lingers arestretclud have dis¬
appeared, or are even supplanted by an elevation, the whole
region of the joint forming a kind of buncli or knob This
very singular appearance of the joint becomes still more
nialked when all the third joints of the hand are similarly
(lisfigiired. Even on the volar surface of the lingers the
joints can be felt as thickened knobs or pads. In these
caies at the commencement the heads of the two phalanges
which form llio third joint are enlarged on all sideK, tlie
nodes of Ueberden making their appearance at a muclt
later period of tlie disease, in the form of large exostoses on
the heads of the second phalanges. When we trace the rise
and progress of the allection to its full developmetit, w©
come to tliQ following clinical description : tiometimes
peculiar sensations in tlie lingers precede for a long time
the outbreak of the disease. A Indy was troubled with a
feeling of numbness in the lingers for several years, bub uch
feign of change in the joints conld be detected. AVIien I
saw her again two years afterwards the numbness fetill con¬
tinued, while several of the third joints in both bands
0 T/A-kc de la Oout^. Paris, 1881, p. 122.
OOgP
0 'm-kc de
Digitized :r.' V tOOQ IC
Tuk LXnckt,]
T)Tl EMIL PFEIFFER ON GOUTY FINGERS.
[Aprii. II, 1891. 819
showed the chao^a above described. lo most cases paio is
preHenb in tlie be^'lDoing of the disease. Tlie sbatemeat of
lieberdeii Vacant omni dolore”—is certainly incorrect for
the first stages of the disease, while all authorities are
auaniiiioas in saying that most canes present either epnn-
taneoun pain or pain when the joints are presned or moved.
Id cases in which the morbid processes are dying or have
entirely died out, an not unfrequently happens with people
at an advanced age, the swelling of the joints and the
nodes of Ilcberden remain ; but pain in tlio parts, whether
epontaneous or on pressure, becomes entirely absent. The
paiQB are, ns mentioned above, generally greatest in the
beginning of the disease. The patient from whom Fig. 3 is
taken suflered from severe pains for several years. A
course of baths which she underwent at Eilsen in Germany
gave no relief, and it was not until after a series of baths
taken at Wiesbaden that all pain disanpeared. The putient
from whom Fig. 4 is taken has still very much pain on
pressure, although the ilisease is mneh more advanced. As
time goes on tlie last joints of the fingers usually become
more and more thickened, and ultimately the nodes of
Ueberden make their appearance, accompanied with various
symptoms of a vague or auouialiuis character. In Fig. 4
the alFacbion is shown in a more advanced stage, and in
fleveral of the joints, especially in the little finger of one
hand, the beginning of the nodes is distinctly observable.
Fig. 4.
Mm. 11 -of lliiubiirg, Hfty-ftvo yuars of ago.
As the thickening of the heads of the phalanges continues
to increase the movements of the joiato become more and
more impeded, until in the later stages of the disease
complete ankyloiiis becomes established. In some cases the
afTeebion shows itself in one or two (lagers only, while in
other ca<ie8 all the third joints become involved, the little
finger being not unfreqnently the first to be nllected. In
the very rare cases in which the second joints of the fingers
become implicated similar changes are observed in the joint
of the thumb, I have met wita only one instance of this;
©uck worth’s case above mentioned being another. In other
cases the joint of the thumb remains unall'ected. I have
never observed this affection in the toes.
The persons most liable to be attacked are elderly people
above fifty, but I have seen the disease completely developed
lin a female patient of forty, in whom it had begun at thirty-
si.x years of age, My opinion is in complete accordance
with that expressed by Begbie. I consider the alfectioo to
be a syiiiptom of true gout, for I have not only seen the
disease in a considerable number of cases which had been
preceded by attacks of gout, or in which uratic deposits
were actually present, but I maintain, in opposition to the
opinion of Oarrod and Charcot, that this is frequently the
■case. On the other hand, I must also admit that the disease
is found in many persons who have never been subject to
gout. From Ilebcrdcu's point of view the apparent absence
of gout in so many of these cases wouhf be a sullicient argu¬
ment to preclude entirely the gouty nature of the affection;
but at the present day we cannot look upon certain morbid
processes as having no connexion witli gout on such narrow
grounds, as we know that many vague and various affections
of a gouty nature not unfreqnently occur in persons who
have never had an attack of gout. The symptoms of
anomalous gout are well known to most physicians, espe¬
cially in England, and in many cases a diagnosis can be
established in the absence of decided outbreaks of the
disease or of uratic concretions. An acute attack of gout
can only be considered as one of the most frequent symptoms
of the gouty condition, and not as its invariable and only
certain sign. There is a large number of coses in which the
most extensive uratic deposits are developed in the absence
of acute symptoms or of preceding outbreaks. In the cases
in which nodes are devwoped without acute symptoms of
gout or without uratic deposits, a considerable number arc
found to belong to families in which the gouty condition is
hereditary. Begbie and Lecorcbtl- quote such cases, and
Duckworth relates the case of a physician in whose family
the affection was traceable through three generations. In
one branch of the family it was found to be clearly con¬
nected with gout. A brother of the patient, in whom the
disease bad shown itself very distinctly, had an acute
attack of gout some time ago. Bat even the pronounced
tendency of the disease to be hereditary is in itself a strong
argument in favour of its being a symptom of gout.
Rheumatic affections are no doubt also uereditary, but
never nearly to the same extent. In the former several
successive generations of a family will show precisely the
same changes, and only these; while in hereditary rheu¬
matism in the parts attacked a marked ditference in this
respect is seen to obtain. In one generation the disease
attacks the hands, in another the large joints, and so on.
I am inclined myself to consider the above-mentioned
changes in the third joints of the fingers to be as typical a
symptom of true gout as the appearance of an attack show¬
ing itself in the ball of the great toe. The fact of its being
mainly a disease of advanced life and of the female sex is
quite compatible with its gouty nature, for it is to these
chronic forms of gout that females and elderly people are
more particularly subject. In the male sex and in those
in whom the influence of heredity is very strong, outbreaks
of gout usually occur at an earlier period than in those who,
living more temperate lives, become subject to the chronic
forms of the disease at a later period of life la this con¬
nexion I would raentiou a case described later on, in which
both mother and daughter showed the disease. The changes
in the lingers appeared much earlier in the daughter than
in the mother, a feature which is quite characteristic of
hereditary gout. TJie most conclusive reason which leads
me to consider the disease as being of an entirely gouty
nature is furnished by chemical examination of the urine.
Indeed, in many of these cases the only symptoms of gout
which can he detected are those changes which are seen to
take place in the urine, and which, as described by me in
Tiik Lancbt of .3rd January last, are pathognomonic of
that disease, and alone sufliciont to establish its diagnosis.
I will relate a few cases in illustration of this; with the
exception of the fifth they are those in which no acute
attacks or other symptoms of gout bad occurred.
Mr. 1*-of Athens, eixby-one years old, shows
Ileberden's nodes in one of the third phalangeal joints.
The twenty-four hours’ urine collected at the first bath was
found to be very acid ; it contained 0'.’5988gr. of uric achl;
lOOccra. of it, passed through a filter with O’-lgr. uric acid,
yielded, with strong hydrochloric acid, only the sixth part,
and passed through a filter with 0 2 gr. uric acid only
half of the uric acid originally contained in the urine.
After the twentieth bath the quantity of the uric acid in
the twenty-four hours’ urine was seen to be only()-3.)44gr.
Mrs. N- of Berlin, fifty-three years old, has the
described changes in the third joints of all tlie fingers,
which are painful on pressure. The twenty-four hours’
urine collected before the first bath was very acid, con¬
taining as much asO'O.'il.'jgr. of uric acid; lOOcciu. of it, after
filtration through 0-5 gr. of uric acid, yielded only the
fourth part, and after filtration through O figr. of uric acid
only the third part of the uric acid ongiiially contained in
the urine. After twenty baths the uric acid secreted in
twenty-four hours was only O Jhir)? gr.
Mr. B-, seventy years old, shows the described changes
of the third joints in several fingers. Tlie urine of twenty-
four hours collected at the first bath was very acid, con¬
taining 04440 gr. of uric acid ; 100 com. of it, after filtra¬
tion through 0'2gr. of uric acid, yielded only half of the
original quantity of uric acid with strong hydrochloric acid.
After the twentieth bath the quantity of uric acid secreted
in twenty-four hours was only 0‘0154gr.
Mrs. de S-, from America, fif^-nine years old, has all
820' ThkLaxcst,]
DR. EMIL PFEIFPEU ON GOUTY FINGERS.
[Apnir. 11,1891.
the third joints of both han<l!> implicated. The <liaease
began at fifty years of age. The qnaotity of nric acid
secreted in twenty-four hours was 0-4045 gr.; 100 com. of
the urine passed through a lilter with 0'2gr. of uric acid
yielded no trace of uric acid with strong liydrocbloric acid.
After twenty baths the quantity of uric acid secreted in
twenty-four hours was ontv 0-1 (199 gr.
Mrs. K-, daughter of the above, thirty-nine years old,
has the same changes on tbe lingers of both hands, the
affection having begun live or six years ago. Some years
after the beginning of the disease she bad the first acute
attack of gout in tbe great toe, which has ever since been a
regular occurrence every year. The twenty-four hours’
urine collected before the first bath gave 0-4:i05 gr. of uric
acid : 100 ccm,, after filtration through 0'2 gr. of uric acid,
yielded no trace of uric acid with strongby dro-
chloric acid. After twenty baths the quantity
of uric acid secreted in twenty-four hours was
only 0 0318 gr.
Mrs. M-, from Aix-la Chapelle, seventy
years old, shows the described clianges in tbe
third joints of several bogers of both liand.^.
The twenty-four hours' urine was very acid,
containing 0-iy4(i gr, of uric acid ; 100 ccm.
of it, after filtration through 0 5 gr. of uric
acid, yiehled only some crystBla of uric acid
with strong hydrochloric acid. After a course
o! twenty baths tlie quantity of uric acid
secreted in twenty-four hours was 0 0772 gr.
Professor L-, M.D , of Berlin, seventy
years old, showed the disease in the third
joints of several fingers. Tbe urine of
tweuty-four hours was very acid, and con¬
tained 0 2301 gr. of uric acid ; 100 ccm. of if,
passed tbrou^ a filter with 0-2 gr. of uric acid, yielded
only 39-3 percent, of the quantity of uric acid originally
present. As the patient came to Wiesbaden only for a
short time, tbe inlluence of the batbs cannot be given.
Id these casts it is evident that all of them presented the
conditions of urine characteristic of gout, several of them
showing, indeed, these uiinary changes in a most marked
iiianner; and further, that during a course of baths at
Wiesbaden they showed tite diminution of tbe quantity of
uric acid secreted in twenty-four hours which 1 have de¬
scribed in the above-mentioned paper as being one of the
most certain tests for latent gout. From all these facts we
may conclude that tbe disease in question is of trvf. tjouty
nature and is based only on yovt.
As tbe nodes of Heberden are only a part of the process,
and as tbe first stages of tbe disease, which consist in a
Fig. 5.—Uppek Part.
that the gouty fingers are of a purely gouty nature, and that
in their peculiar clinical appearance, which is in tbe first
stages always connected with changes in, or confined to, the
thini joints of tbe fingers, they are as characteristic a sym¬
ptom of gout as an acute attack in the ball of the great toe.
It is to be noticed that in cases of rheumatoid arthritis is
the bands the third joints of the fingers always remain free-
from changes. But there are cases of gout in which some
joints of the bands are involved while the third joints
remain free; so, altlioueb it can be said that the disease
described as “gouty fingers ' is a certain proof of gout, we
cannot say when there is an absence of morbid changes in
the third joints that the gouty condition is not present.
Figs. 5 and (i will serve to illustrate the difference between
the cases depicted in Figs. 3 aud 4 and those of rheumatoid
Fig. G.—Upper Part.
Mih. K-, from OrcHilen, flfly-fotit years of hko.
general enlargement of the beads of the plialarges, are like¬
wise characteristic, tbe term “gouty fingers” would seem
more applicable than “ Heberden’s nodes,” which term
should be confined to tbe nodes at a mure fully developed
stage of tbe disease; and a further cooclneinn may b« drawn,
MiBS S-, from Wleabfwlen, thirty-two yeara of aRu.
arthritis. They are taken from two well-marked cases of
rheumatoid arthiitis. Tbe nature of tbe disease is not
only proved by the clinical examination, hut also by the
chemical examination of the uiine during a course of baths
at Wiesbaden.
Mrs. K-of Dresijen, before undergoing a course of
bathe at Wiesbaden, secreted in the twenty-four hours’
urine 0‘2805 gr. of uric acid ; after twenty baths the quan¬
tity of nric acid secreted in twenty-four hours was 0'2754 gr.
Miss S-^ of Wiesbaden, previous to a course of
baths there in the summer of 1888, secreted 0‘1552gr. of
uric acid in twenty-four hours, and 0'221G gr. after twenty
days; and in a second course of baths in the summer of
1890 0'2t29 gr. at the first bath, and 0*2152 gr. after
twenty days.
In both these cases we see no diminution of tbe quantity of
uric acid producedby a course of baths; whileln both tbe urine-
contained no “free uric acid ” at the beginning of tbe course-
of batbs, for lOOcciii. of the urine yielded with strong hydro¬
chloric acid just tbe same quantity] erf uric acid after filtra¬
tion through uric acid as without filtration. In these cases
we see tbe joints which are always implicated in “gouty-
fingers” remain entirely free, while all the other joints of
tbe fingers and of the wrist are involved. The third joints
are in tbe same condition as in healthy persons ; they are-
not enlarged, and remain completely movable, all the other
joints of tbe fingers being either swollen or stiU'ened. This-
difference in the hand of rheumatoid arthritis and tliat of
“ gouty fingers ” is a very striking one.
With respect to the treatment of the disease, I would
make the following remarks. In the cases in which there
is no pain tbe only inconvenience Buffered is tbe disfigure¬
ment of tbe hands, especially in the case of ladies ; but as
most of tbe subjects of “ gouty lingers” are at an advanced
age, this disfigurement is not much felt. 'The treatment in
advanced cases is quite hopeless, as tbe changes in the
bones are beyond remedy.
In cases in which the morbid process is only commencing,
we must interfere on account of the pain, the imminent dis¬
figurement, and hindrance in movement, or complete stiff-
net>»>. The best remedies in such cases are repeated courses
of baths, a strict diet, and tbe continued use of an alkaline
mineral water, especially Fachingen. As I mentioned above,
in tbe case of Fig. 3, a single course of baths at Wiesbaden
was the means of freeing the patient from all pain.
The diet is described in exlenso in the above-quoted
treatises on gout, in tbe -work of Ebstein,’” and in my
work,” to which a diet table for gouty patients is appended.
x’ Das RsKimon bei dor Glcht, Wiesbaden : llersiuann. 18S6.
DieOfeht und lbr« erfulgrdche Bebandlung. Wiesba<len: Serg-
mann, J8tl,
Diaitized by
lOogle
Thb Lancet,]
MR. J. KNOWSLEY THORNTON ON HEPATIC SURGERY. [April 11,1891. 821
OBSERVATIONS ON ADDITIONAL CASES
ILLUSTRATING HEPATIC SURGERY.
By J. KNOWSLEY THORNTON, M.C.,
PRESIDENT OP THE MEDICAL SOCIETy.
(Concluded from j>. 7G/i,)
Case 9.—A single lady, aged thirty-four, -whom I saw
in consultation with Mr. Edgcombe Venning, to whose
kind care of the case after operation I am indebted for
being able to add it to the list of successes. I operated on
May 21st, the day following the last case. Attacks of pain
began in 1875, and were always sudden and spasmodic;
sometimes one or two years would pass without an attack.
The attack which led to my being called in began in the
previous November, the attacks of pain and vomiting con¬
tinuing at intervals till I saw her. On opening the abdo¬
men 1 found everything so matted together that I at first
mistook the head of the pancreas for a thickened gall¬
bladder. Finding my mistake, I proceeded to carefully
make my way through some fresh adhesions between the
stomach, the omentum, and the right lobe of the liver, and
at last found the gall-bladder, deeply placed and packed
with gall-stones. In searching for it I opened a small
abscess under the edge of the liver, and let out about
an ounce of thick pus, and cleared away some cheesy
material. The clearing out of the stones was long and
difficult, and required the aid of various scoops and
forceps; when I had finished and washed it out I found that,
as in Case 7, it was impossible either to remove it, suture it,
or suture it into the abdominal opening, and I therefore
merely passed a rubber tube to the bottom of the gall¬
bladder, and brought it out through the abdominal wound ;
this of course leaves the opened gall-bladder open to the
general peritoneum, and 1 therefore made a counter opening
above the pubes, and drained the pouch of Douglas also with
a glass tube. The procedure of leaving the gall-bladder
open seems at first sight very dangerous, but these two cases
prove that with due care in the arrangement of the tube,
and with the auxiliary drainage of the pelvis, it may, when
necessary, be safely resorted to. In both cases the wound
in the gall-bladder w'as slow in closing, as one would expect
from its being so much wider open than when sutured into
the incision; but there was no evidence of any serious
leakage from the open gall-bladder into the peritoneum,
though the discharge of bile-stained mucus through the
rubber tube was very free from the first. I suppose that
when the abdominal incision is sutured, and the abdomen
well strapped up, the adherent viscera round the gall-bladder
or duct, as the case may be, press up to the parietal perito¬
neum, and the fluid finds it easier to escape through the open
tube than to spread into the peritoneum between the surfaces
of these structures. Then in a very short time a firm wall
all round the tube is formed by the adhesion of neighbour¬
ing surfaces. This patient also mode an excellent recovery,
and on recent inquiry writes that she continues “ a walking
advertisement” for surgery.
Case 10. —This case was one of large hydatid cyst of the
liver, which I saw in consultation with Dr. Ransford, and
which had been thought to be some disease of a more serious
kind. I felt perfectly certain of my diagnosis, and verified
it by clearing out a large quantity of hydatids and serai-
purulent fluid, then washing the sac well out with iodine and
water, and draining it wiwi two large rubber tubes. It
was long in closing, and after it had closed the patient
began to have recurrence of shivering and fever, and at
last such distinct enlargement of the right lobe of the
liver that I reopened a small spot in the cicatrix, and
punctured with a long fine trocar, expecting to find recur¬
rence of suppuration. Nothing but dark blood came,
though I punctured deeply in various directions. The result
of this phlebotomy was an immediate drop of the tem¬
perature ; but in a very few days it rose again, and all the
old symptoms—chilliness, nausea, anorexia, &c.—returned.
After a time, however, the patient gradually improved, and
is now, I think, going to get well without further surgery.
The cause of the serious recurrence of symptoms remains a
mystery, as there has certainly been no escape of pus any¬
where. I think it is possible there may have been some
deep effusion of serum, which caused the symptoms by
setting up tension and obstructing the hepatic circulatibn,
and that this has been gradually reabsorbed.
During the time that has passed while completing the above
cases I have also performed five exploratory operations in
connexion with disease of the liver—a large proportion of
explorations in proportion to the number of completed
cases. But this must always be so when one is dealing
with a comparatively new departure in surgery, ana
especially in a field in which positive diagnosis is so
difficult as in the one we are considering. Two of
the cases turned out to he, as I feared they would,
malignant disease. In the first the exact origin of the
disease remained obscure after the exploration owing to the
matting of parts, and the patient, an elderly gentleman in
a very low state at the time, died of complete suppression
of urine. 1 did not myself think this was a gall-stone case,
hut he had many of the symptoms of impacted gall-stone,
including jaundice, and as there was no free fiuid in the
eritoneum, and no distinct evidence of malignant disease,
thought, with Dr. Broadbent, that it was a proper case foi
exploration.
The next case was that of a lady, who bad been
till shortly before I saw her (also with Dr. Broadbent)
in the best of health. There was a small, hard, round,
mobile body in exactly the situation of the gall-bladder,
and here again there was no free fluid, and she herself was
veiy anxious to have the diagnosis made positive by ex¬
ploratory incision. 1 found that the hard body named
above was a little malignant mass projecting from the right
lobe of the liver, with more or less of a pedicle, and that
there were other masses embedded in the liver, so I at once
closed the incision, and she was happily none the worse for
it, and lived for some months.
The next ease was that of a young lady whom I saw with
Mr. Cripps Lawrence, a case with a long history of pain,
and of attacks like gall-stone colic, and 1 certainly expected
to find gall-stones, but there were none, and I could find
nothing very definite to account for the pain. I found,
however, a small hard body, which appeared to me to be a
new growth, but I could not define its exact place of origin,
and I closed the incision with some fear that this might
eventually turn out to be a cose of malignant disease, but
the long history before and her health since seem to contra¬
indicate it. Mr. Lawrence writes on Jan. 29th that the
patient gained flesh and strength after the operation, and
was free from pain for some time, hut had relapses in July
and October, the latter being somewhat severe and pro¬
longed. Still she has gained on the whole in general health,
and there seems no evidence of any serious organic disease.
After my experience with Case 8, an unsuccessful exploration
of this kind, with recurrence of symptoms, naturally made
me wonder whether 1 could possibly have missed a small
stone.
The fourth exploratory operation was performed upon
another cose of Mr. Venning’s, a young gentleman who had
knocked about the world a great deal, and had often been
much exposed in travelling, hunting, and shooting expedi¬
tions. He bad many of the symptoms of gall-stone, and a
very distinct hard and tender swelling in the region of the
gall-bladder; and after careful consideration, as he was
losing health and suffering a good deal of pain and incon¬
venience, we decided to explore the swelling. It turned out
to be a hard, almost calcareous mass, projecting from the
right lobe of the liver just over the gall-bladder, and on
puncture it was gritty and yielded just a trace of cheesy
material on the needle. Below this and on the under
surface of the liver were a number of pinkish, somewhat
translucent nodules, which certainly looked very like malig¬
nant disease. I wasalittleinclined toregard the calcareous
mass as an old hydatid; bus on careful consideration
of the case in the light thrown on it by the exploration, we
were rather in favour of the whole thing being gummatous,
and be admitted that he had had syphilis. This view
proved to be correct, and he got quite well with large doses
of iodide of potassium. In connexion with this case I may
mention another (also a young gentlemen) in which I was
asked to perform paracentesis abdominis, the idea being
that he was suffering from hepatic dropsy resulting from
cirrhosis. After the removal of the ascitic Iluid I found a
greatly enlarged nodular liver—some of the nodules hard,
some soft—and I suggested that they might begummata.
The case is not concluded, but he has improved in health
under the use of large doses of the iodi te, and the li\ or 1. as
le
[Apeil 11,1891.
822 The Lancet,] MR. J. KNOWSLEY THORNTON ON HEPATIC SURGERY.
got markedly smoother and smaller, so that 1 think we are
on the right track.
The fifth case of exploratory incision I saw in consulta¬
tion with Dr. Ord. The lady (middle aged) was a con¬
firmed invalid and constantly attended by two nurses. She
had passed some very large gall-stones, and another was
believed to be present in her gall-bladder, causing much
pain. I could not convince myself by examination or from
the symptoms and history that it was a case of gall stone
colic, but I quite agreed with Dr. Ord that it was a proper
case for exploration. 1 found the gall-bladder and its ducts
and surroundings healthy, but some matting of parts from
previous inflammation. I simply divided the adhesions
and closed the incision, and the patient lost her pain and
is now in good health. This case appears to be identical
with that of the Irish lady, which 1 gave in my previous
paper; both'were exceedingly ill, and both were restored
to health by the exploration and separation of some
adhesions.
I have recently had another ease with Dr. Ord and
Mr. Turner, an officer, aged sixty-three, with an enormous
hepatic abscess; the surface of the liver was slightly
adnerent to the parietes, so that I was able to open it with¬
out exposing the peritoneal cavity, and, in order to avoid
all risk of the liver tearing away as the abscess emptied, 1
put a fine suture through the upper and lower angles of roy
abdominal incision, and the corresponding angles of the in¬
cision into the liver. The abscess had been explored the
day before I saw him with a hypodermic syringe, so I could
not be quite certain of asepsis, and therefore thoroughly
washed out the cavity with a strong solution of iodine and
water. Discharge was very free for the first week, then
steadily diminished for the next, and by the end of the
fortnigut was practically serous, so that the dressings could
he left for two or three days undisturbed, and now, at the
end of three weeks, the cavity has practically closed, and
the patient has gained extraordinarily in the short time in
health and streng' h, a remarkably quick result in a patient
of this age, and with an abscess holding several pints
of pus.
I have given in more or less detail notes of sixteen cases
in which I have operated, let us now consider the lessons
which these cases teach. In ten I expected to find gall¬
stones ; I found them in seven. I diagnosed another case
correctly, but unfortunately failed to find the gall-stone,
though it was there; and in another case the disease was
in the gall-bladder and the symptoms were due to obstruc¬
tion of the ducts, but it was hydatids and not gall-stones ;
in a tenth case I diagnosed hydatids of the liver, and the
operation proved that my diagnosis was correct. In three
other cases 1 explored, not expecting to find gall-stones ; in
two I found what I expected, malignant disease, but I
cannot claim accurate diagnosis because I was in doubt; in
the third case I did not think 1 should find a gall- stone, and I
found merely some adhesions, the result of previous trouble
during the passage of large gall-stones, but the division of
these cured the patient, so that though the diagnosis was
not perfect the result was good. Three cases remain. In
one the diagnosis of gall-stones was not justified by the
exploration, and the patient is little if any better for the
operation; in another no gall-stone was found, but the
exploration led to a new diagnosis, which was proved by
successful medicinal treatment to be the correct one ; and
in the last case the diagnosis had been made for me by
Dr. Ord and Mr. Turner, and verified by puncture before
I operated, and the result of operation has been emi¬
nently satisfactory. I think, then, on the whole series
the results are good, and amply justify the operative
procedures. At the same time there is sufficient un¬
certainty and failure to show that it is to a more perfect
diagnosis that our chief attention must be directed. I
believe that as experience is gained by more frequent
exploration in doubtful cases, we shall advance in cer¬
tainty of diagnosis; bub I think it is too much to
hope that we shall ever retain certainty in all cases.
"VVith regard to gall-stones, I think the chief points to
be noted are the sudden nature of the onset of pain and
its equally sudden departure, the way in which it travels
round the body and through into the back at the angle of
the scapula, and the sense of constriction round the region
of the diaphragm. The presence of a mobile pear-shaped
tumour in the situation of the gall-bladder, or to one or
other side of that situation, which rises and falls with
respiration, variations in size and tension of this swelling
may make diagnosis pretty certain. The above symptoms,
being suddenly complicated by jaundice, especially if a
swelling previously present disappea^rs, make it pretty
certain that the stone has passed through the cystic duct
and become impacted in the common duct.
It is obvious from two of the cases I have given that the
absence of ascitic fluid cannot be relied upon as a differential
diagnostic sign between malignant disease and stone in
either duct, and we must always remember that gall-stone
may be present, and actually occasion a cause of symptoms
along with malignant disease, also causing obstruction of
the ducts, for most interesting notes of such a cose I am
indebted to my friend Dr. Barlow. My absence from town
alone prevented my seeing this case in consultation with
Sir Wra. Savory and himself, and I think it is very likely
that the symptoms would have led me to urge operation;
but the necropsy showed that, though the removal of the
stone might have given some relief, the case would still
have terminated fatally from malignant disease of the
pancreas obstructing the common duct.
The position of the swelling when the cystic duct is ob¬
structed varies so much in different cases that it has but
little diagnostic value; and in cases in which there has been
much inflammation, matting the parts above the gall-bladder,
neighbouring organs, especially the kidney, are so liable to
sympathise that the greatest care is necessary not to be led
astray into considering the renal b} mptoms as the essential
feature of the case. My first case in the present series illus¬
trates this well; it also shows how a patient suffering from
a serious chronic disease like chronic rheumatic arthritis
may have all her symptoms relieved and her general health
improved by the removal of a serious source of local irrita¬
tion. Case 2 illustrates the success which may be obtained
by merely needling up the stones in the common duct and
leaving the fragments to find their own way into the bowel.
To obtain success in needling, however, I think it is essen¬
tial that the stones be not too large, and that they have
some mobility in the duct. Had I needled these stones at
once the patient would have been saved the serious
risk of a difficult cholecystectomy, though now she is
well I think she is more likely to keep so without her
gall-bladder.
Case 3 also illustrates wbat may be done with needling
even after opening of the duct when we have to deal with
a large adherent stone; it also shows, what I believe was
unknown before, that it is possible to operate directly upon
the common duct and suture it securely even though
fragments are left in it. This case and No. 6 (that of
Dr. Maurice) also show that prolonged jaundice and a great
state of emaciation and weakness are no bar to the most
rapid and complete recovery. Prolonged jaundice has been
said to interfere with success, but I have never found it
make any difference.
Case 5 illustrates the difficulty of differential diagnosis
between gall-stones and hydatids when the latter are con¬
fined to the gall-bladder.
Cases 0 and 7 show the advisability of at once opening
the common duct when large stones are found to be
impacted in it; and the intimate adhesion of the stones to
the lining membrane of the duct show not only the futility,
but extreme danger, of attempting to force them down by
external manipulation, as proposed by Di\ Harley, and
practised by him in Case 7 with marked increase of all the
serious symptoms.
Case 8 shows how dangerous it is to be influenced by pre¬
vious history or the opinion of others. I made a correct
diagnosis, but could not divest my mind of the possibility
of malignat disease; the result of this bias was two serious
mistakes in my procedure : 1. I did not prolong my search
for the stone sufficiently. 2 I feared a malignant iistula if
I sewed the gall-bladder into the abdominal incision. Hence
niy patient lost her life, and I spoilt what would have
otherwise been a completely successful record. I have suffi¬
ciently commented on the remarkable fact shown in Cases?
and 9, that the gall-bladder may be left open in the
peritoneum or the duct imperfectly closed if efficient
drainage is provided, without any serious complication
resulting, and without the escape of bile into the
general cavity of the peritoneum. The counter opening
above the pubes and the glass tube in the pouch of
Douglas I commend as a great safeguard in all doubtful
cases, and with perfect asepsis I believe that it in no way
increases the risk.
The above cases, together with those already laid before
cy Coogle
The Lancet,]
SURGEON-GENERAL A. C. C. DE REN2Y ON CHOLERA.
[April 11,1891. 82S
the Society, complete the record of my experience in hepatic
surgery up to the end of January, 1891, and I trust they
Aay be of value to the future of this very interesting branch
of abdominal surgery.
CHOLERA AMONG THE ASSAM TEA
COOLIES.
By SURGEON-GENERAL A. C. C. De RENZY, C.B.
In the Sanitary Report of the province of Assam for
1878 I brought to notice some remarkable facts about
cholera among the coolies who go up the Brahmaputra river
by steamer to work on the tea gardens of Assam. For
many years these coolies had suffered frightfully on the
passage up the river. A voyage unattended with cholera
was the exception rather than the rule, and it was a fre¬
quent occurrence for from 10 to 20 per cent, of a batch of
coolies to die on the short trip of about fifteen days. In the
years from 1871 to 1878 the death-rate on the passage cal¬
culated as for a year was 47-8 per cent, of average strength.
This terrible mortality had continued for so many years, in
spite of all the efforts of the Government to prevent it, that
it came to be regarded as unavoidable, and to be due to some
mysterious influence which was beyond human power to con¬
trol. The most perfect cleanliness was maintained on board
the steamer; the coolies had ample room on decks, covered
by an awning, and open on all sides to the fresh air. They
were well fed and well provided with clothing. When I
came, as part of my official duty, to investigate this case,
I was at first greatly puzzled. My previous experience
had lain almost wholly in the Punjab—a province whose
climate and sanitary conditions differ entirely from those
of Assam. The former has one of the driest climates in
the world, the latter one of the moistest; and the
difference was equally great in other respects. My
Punjab experience had led me to the conclusion that
cholera is almost always spread through the medium
of water; and that in places where the water-supply
was secure against the possibility of excremental pollution,
there was very little fear of an epidemic of cholera,
even though detached cases of the disease might be brought
in from time to time; but that no n>atter how perfect
the sanitary arrangements might be in other respects, if the
water-supply was exposed to contamination, most serious
epidemics were to be apprehended. I was told that this rule
would not hold good in the case of the coolie epidemics,
that the coolies were supplied with perfectly pure water—
the same, in fact, as was used by the European passengers
and the native crews of the steamers, both of which classes
had, for upwards of twenty years, enjoyed almost complete
immunity from cholera. Everyone on board used water
drawn from the river. I was shown the large iron tanks
into which tfie water was pumped for the use of the
coolies, the suspended matter being precipitated by the
use of alum. I could not remain insensible to the force of
this evidence. I began to think that, after all, there must be
something in the explanation of the epidemic among
the coolies, which was universally accepted, or the river.
It was well known, it was said, that non-Aryan races
were specially prone to suffer from cholera, and the great
majority of the coolies were non-Aryans. At the same time
I could not but recall the many occasions on which I had
seen my own Aryan fellow-countrymen, British soldiers,
decimated in a few weeks by cholera in the Punjab, and it
seemed strange that on the Brahmaputra, over a period of
many years, other countrymen of mine, if it were a mere
matter of personal susceptibility, should have shown them¬
selves to be so little liable to suffer from the disease while
travelling on the same boats, on the same decks, with the
sorely alllioted coolies.
A more rational explanation, and one more in accord with
experience in ^1 parts of the world, shortly afterwards
appeared. During one of my tours of inspection I happened
to be on board a steamer with a batch of coolies, among
whom cholera was raging, the crew and my fellow-passengers
being as usual quite unaffected, and as I lay awake one
night in my berth,_thinking what could possibly be the cause
of the mysterious limitationof tUeattacks, I made up my mind
to get up at daybreak and to go aft next morning among the
coolies, note their ways and doings, in the hope that I might
thus obtain some light. I took up ray position in the stern of
the vessel near where the latrine was placed, and soon after¬
wards the coolies began to come down from the upper deck
where they slept. I observed that there was a general
movement towards a tub which was placed alongside the
latrine and was intended for water for ablution after defeca¬
tion. The coolies dipped their drinking vessds into the
water which they used to wash their mouths and faces.
Presently a woman came with an infant on her hip,
washed the child’s clothes in the tub, other coolies came,
filled their vessels with the water in which the clothes had
been washed, gargled their throats and washed their faces
with it, and so it went on for hours. It was at once evident
that the tub was a ready means for circulating the
cholera contagium, and 1 ascertained that the doings 1
have described were of daily occurrence on every steamer
canning coolies. It was true that a pure water-auppl;^ was
provided for their use; but as there was only one tap in the
tank which was to supply four or five hundred coolies, a
erson would often have to wait a considerable time before
e could get supplied, and so tbe poor ignorant people, to
avoid the delay, did not hesitate to use tbe foul water in
the tub. Arrangements were at once made to supply
abundance cf pure water for ablution, as well as for
drinking purposes, under conditions which made it im¬
possible for one coolie to use water which had been in
contact with another, with the effect that the epidemics
which had lasted so many years suddenly ceased. Isolated
cases occurred in coolies who formed part of batches which
were known to be infected on their arrival at the port of
embarkation ; but tbe mortality at once fell to one-third of
the previous average, and remained at a very low figure for
ten years, notwithstanding that in that interval the dis¬
tricts from which the coolies are recruited, and the province
of Bengal generally, had been visited with several severe
epidemics.
Unhappily in 1888 and 1889 there was a return of
the old state of things, and the mortality was truly
lamentable. In 1888 there were 925 deaths among 31,217
coolies, and in 1889 there were 596 deaths among .34,507
coolies. In the two years 252 deaths occurred en route to
Dhubri, the port of embarkation—and 391 at Dhubri itself;
282 died on board the steamers, and 596 at the depots up
the river, at which the afflicted people were landed from the
steamers. Nearly all these deaths were due to cholera. It
has been said that the renewal of the epidemics shows that
the cessation of them was not due to the change in the
system of water-supply above described. I think I can show
that there is no ground for this contention. Before I left
Assam I warned the Government that in order to keep the
epidemics in subjection two things were necessary—U) to
E rovide good water at the halting places en route to
•hubri. So far as the official reporte show this has never
been done, and on leaving the railway station, forty
miles from Dhubri, the coolies have to travel on foot along
a road on which the water is no better than ditch water.
Under such circumstances it is no wonder that the
mortality from cholera en route to Dhubri was so
great. The second measure I insisted on was that the
water-supply at Dhubri itself should be put into a satis¬
factory state. When I left it was in a very dangerous state.
There was a very badly constructed well, the ground round
which was thoroughly polluted by the ablutions of the
coolies, and though the coolies were forbidden to take water
from the stagnant ponds close by, no amount of vigilance
could prevent them from doing so. The water-supply, I
believe, remains as it was, and I have no doubt it was an
important factor in propagating the contagium brought in
by the coolies. The coolies on their arrival at Dhubri are
inspected by a medical officer, and every endeavour is made
to keep back all who show any signs of illness from going
on board the steamers ; but it is obvious that in the case of
cholera it is only when the symptoms have become some¬
what pronounced that it can be recognised, and if large
batches of coolies go on board in the incubation stage, no
matter how perfect the sanitary arrangements may be, the
disease will show itself in due time.
Some high Indian authorities believe that those great
epidemics on the Brahmaputra are due to some widespread
atmospheric influence which hangs over the great river, and
they seem to despair of being able to bring them under
control. I do not share this desponding belief, and I feel
encouraged to take a more cheery view by the results of
the emigration from Goalundo, a port lower down the river
than Dhubri. Tbe coolies embarking at Goalundo have to
pass Dhubri, and if the calamities which befell the Dhubri
coolies wore due to atmospheric influence, we should expect
824 The Lanobt,] DR. A. W. MACPARLANE ON DISTRESSING AWAKENINGS.
[April ll, 1891.
to find tbe Goalundo coolies sutteriog likewise. On the
contrary, we find that they passed up with comparatively
little loss. In 1888 there were 11 deaths, of which 7 were
infants, among 2551 coolies, and in 1889 there were 3
deaths among 1763 coolies. The Goalundo and the Dhubri
coolies were in all respects similarly circumstanced, except
that the former had not been exposed to the unhealthy con¬
ditions existing in the camps m route to Dhubri and at
Dhubri itself.
Assam has unrivalled advantages as a field for the
employment of the poverty-stricken population of the
congested districts of India. But it is idle to expect that
the tide of emigration can set in that direction, so long as
people have to run the gauntlet of such epidemics as form
the subject of this paper, in order to reach the province.
My firm belief is that at a very moderate expense the
Government might remove the obstacle, with immense
benefit to the people of India.
Dublin.
NOTE ON DISTRESSING AWAKENINGS.
By a. W. MACFARLANE, M.D., F.R.C.P. Ed.
Some persons do not know what it is to rise from sleep in
fresh and buoyant spirits; on the contrary, many awake
tired and wearied. A few fare even worse, for they awake
in tbe early morning in great distress, and this feeling is
replaced, after a time, by weariness and depression. Be¬
tween the mental conditions of slight malaise and of morning
misery all grades of discomfort may be experienced ; just as
many shades of mental discomfort are associated with tbe
abnormal states that range from slight degrees of neuras¬
thenia up to the more pronounced conditions of hypochon¬
driasis and insanity. Awaking that is not attended by
feelings of invigoration and bien-atre is abnormal; it betokens
some departure from health, or it points to sleeping in
unhealthy surroundings. Sleep is a conservative or con¬
structive procea^. During tbe activity of daily life the
expenditure of nervous energy is rapid, and it preponderates
over repair; coincidently, waste products are deposited
in the tissues in ratio to tbe work they eiTect. The
katabolic exceed the anabolic processes, hence the need
for sleep. During sleep these conditions are reversed,
the expenditure of energy is reduced to a minimum; the
waste products are removed from the economy, and, the
reparative processes continuing, potential energy is stored
up. When depuration and recuperation are complete,
awaking ensues, and the textures being reconstituted and
well innervated, the sleeper arises full of power and
well-being. A vigorous man awakes full of energy,
because his textures have accomplished these processes.
If, however, such a man curtails his sleep unduly, or if
by excessive fatigue be charges his tissues with a larger
quantity of waste products than he can excrete in the
ordinary hours of sleep, his bodily textures are not ade¬
quately renovated, and he awakens languid and tired. The
feeble and convalescent accomplish such changes slowly
and with difficulty ; they are often unable to effect the
necessary processes in the hours usually allotted to sleep,
so they awake from their night’s repose* tired and jaded.
They consequently feel keenly any curtailment of sleep,
as well as any unusual fatigue, and this they perceive most
on awaking. The personal equation plays an important
part in the recuperation of sleep. Such tired awakenings
are readily intelligible.
The patients to whom I wish to refer are a class of
habitually bad sleepers, who awake every morning more
or less wearied and worn out, but who also from time
to time, after an unusually deep sleep, awake in great
misery. Collectively, they present very similar symptoms,
although these maybe modified to some extent by tempera¬
ment and mental development—in short, by t&e quality
of the man. Tliey awake in the early morning, usually
from 4 to 5 o’clock, in mucli distress, covered with
cold perspiration, and they lie tortured by evil fore¬
bodings for an indefinite time. The mental distress
usually begins before sleep terminates; they are con¬
scious that it awakens them, and occasionally they find
themselves groaning. They do not recollect that the ,
sensation baa its origin in a terrifying dream, nor do they
associate the awakening with dreaming. Tbe acute misery
is followed by depression and dread. They attribute the
awakenings to sleeping “too deeply,” and these hear an
intimate relation to morbid sleep. Two patients who are
so afflicted state that they occasionally awake not koowidl’
who they are, or where they are, and without knowing that
they have slept until they ?ind out bow many hours have
passed ; tbe mental unrest follows. They all agree that the
seizures, if they may be so called, are more prostrating than
lying awake all night. Such awakenings do not recur with
regularity, although in one instance they did so every
seventh or eighth night for a time. The patients who
suffer in this way are invariably neurotic and neuras¬
thenic; some are hypochondriacal. They present widely
different symptoms during the day, but they all exhibit,
in greater or less degree, a lack of mental power and
endurance, and they are introspective, self-conscious,
and desponding. They dread the unknown; frequently
they are restless and yawn and sigh a good deal. They
may he divided into two groups. The first are those who
I have been enervated by excesses, commendable or the
I reverse; the second by malnutrition, due to an altered
blood-supply. One of the chief differences that I have
noted between them pertains to their failing asleep. The
first group become depressed towards bedtime, and posi¬
tively dread going to bed. There is nothing of this in
the second—indeed, before a “bad” sleep there is often a
feeling of exaltation (euphoria). From this they are some¬
times able to predict the occurrence of such sleep. One
patient, who can do so with some certainty, is occasionaliy
deceived, for, in spite of feeling well, too well, and
comfortably sleepy, when he goes to bed be grows restless
in tbe act of faJling asleep, and, beginning to turn, sleep
deserts him. There is a very intimate connexion between
the causes that give rise to broken sleep and those which
induce morbid sleep.
The causes of this morbid sleep are, I believe, twofold :
the one depending on some peculiar condition of the nervonn
system, the other on toxic causes. Morbid sleep occurs in
connexion with many neurotic diseases. Amongst others
may be mentioned hysteria, epilepsy, migraine, and asthma.
It tas also been noticed in pregnancy and at the meno¬
pause. In all these instances it has been observed that such
sleep was not followed by any renovation of the bodily
powers, consequently it may be concluded that the tissues
were unable to effect their depuration or recuperation.
In like manner, those who suffer from morning misery,
from neurotic causes, awake wretched instead of invigo¬
rated, and sometimes they are afflicted with headache and
gastric and biliary derangements. In a lady of advanced
age, who was for many years under ray care, this morbid
sleep was followed by an attack of migraine and a wretched
awaking alternately.
Morbid sleep occurs in many toxic conditions; it is
common when the blood is surcharged with bile, urea,
malarial poison, and it has been noticed to precede an
attack of acute gout, and to follow poisoning by the
products of digestion (ptomaines?). The morning horror
of chronic alcoholism and morphinism is widely reco¬
gnised. In the case of gout such morbid sleep may be
preceded by euphoria, just as that symptom occurs in
the initial stages of puerperal and other septic fevers,
the exaltation being the first symptom of the poisoning.
In tbe second group of cases under discussion euphoria may
precede, and misery follow, the morbid sleep.
Thecauseswhich combine to makesuch awakenings miser-
ablearenumerous. Thenervoustensionthatexistsin a healthy
person during diurnal activity is lessened during sleep. In
the weakly and neurasthenic the store of nervous energy is
small in quantity and easily dissipated daring daily duties ;
at night its recuperation is slow and difficult, so that the noc¬
turnal condition is one of exhaustion. In such a “ hopeful”
disease as pulmonary consumption sinking and distress in
the early morning are often complained of. It is about
4 o’clock that the nervous energy is at its lowest, and death
frequently takes place about that hour. This lack of vigour
is specially felt after morbid sleep.
There are many grades of normal sleep. During sleep
the heart beats more slowly and quietly, the brain becomes
comparatively anmmic, and vascular tension is diminished.
These changes vary with the depth of sleep. Dr. Graves
long ago wrote ; “ It is between three and five in the morn¬
ing that the inclination to sleep is strongest;»it is about
this time that sentinels are most apt to slumber at their
posts, and consequently attacks upon camps or cities, made
with the intention of effecting a surprise, are usually under¬
taken about this period of the morning.” Quito recently
Caoqle
The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[April 11, 1891. 825
Mooninghoff and Piesbergen pointed out that the depth of
sleep iooreased for a second time after four hours and a half,
and continued to grow more profound until the end of five
or five and a half hours. The brain is at this timb com¬
paratively more bloodless. Many kinds of morbid sleep, due \
to toxic causes, terminate at this hour. It is during this '
unusually deep sleep that toxic awaking occurs. The man
who has drunk or smoked too much is then awakened to
repent his folly. The more pronounced anjcmia that then
occurs appears to cause awaking. An anaemic brain
is the source of vacillation and fear. The forebodings
that precede an apoplectic attack accrue from this. The
neurasthenic state is equally the parent of dread, and,
when these conditions are combined, depression and misery
are explicable. In enervated states volition is enfeebled,
and emotion is correspondingly exaggerated by day; in
the early morning, with lessened nervous energy and a
diminished cerebral blood-supply, these conditions must
be accentuated. For, as Baiu writes; “ States of pleasure
are concomitant with an increase, and states of pain with
an abatement, of some or all of the vital energies.” It
has been truly said that it is in the early morning that
the soul holds its inquest in the heart of man. Mosso has
pointed out that in the act of awaking the brain undergoes
a diminution in volume, and contains less blood than
during sleep; this would appear to be coincident with the
sudden dilatation of the pupils that then takes place. It is
probable that this sudden increase of anfcmia may, to some
extent, account for the distressing sensations experienced
on awaking.
Many neurasthenics grow nervous towards night, and to
such an extent that they may be afraid to go to bed after
reading or listening to a terrifying tale. The exhaustion
inseparable from daily activity diminishes the power of
their inhibitory centres. Curtailment of sleep sensibly in¬
creases this lack of control, and this is equally noticeable
after morbid sleep. Awaking in this condition these centres
are unable to resume their functions, and incapacity to think
leads to introspection. One patient under observation
affirms that occasionally he is able to direct his thoughts
out of their ordinary gloomy groove, with the result that
depression and dread soon disappear. The absence
of sensory stimuli probably increases the distress. The
darkness of the night (such awakenings are most com¬
plained of in winter) exerts a material influence. It
reduces many a neurasthenic to the mental level of a child
or a savage. In darkness they are haunted by fears un¬
known to their daily lives. Travellers in northern climes
have insisted upon the depressing effects of the absence of
light upon men and the lower animals. My friend Mr.
Crockett of Wolverhampton, formerly chief surgeon to the
great works at Cyfarthfa, assures me that miners injured in
darkness suffer more from shock than those injured in the
light. During the light and bustle of the day innumerable
impressions are constantly streaming brainwards, and they
serve to correct thought. These are almost in abeyance at
night. Thought uninhibited from within and uncorrected
from without is apt to run riot; moreover, it is liable to
run apace, and so to become intensified from the want of
distracting agencies around. It has been noted that in the
insane thoughts grow far more e-xtrayagant in darkness;
indeed, a form of nocturnal insanity is well recognised,
characterised by restlessness and excitement, and by an ex¬
travagant mental state, symptoms which completely dis¬
appear during the day. Some of the patients under discus¬
sion have curious hallucinations whenever they shut their
eyes. One that seems to be disagreeable is a loss of the
sense of locality ; they think their bed is placed in a dif¬
ferent position &c. The poet who has well described most
things in Nature has not left these awakenings untouched.
The following lines occur in Melpomene :—
“ TheNo pannii-ks whence? And why my bosom tome
With suilciuii torrorH iiovev felt before ?
I>arkii 0 ss iuwraps me vonnd,
While from the vast profounil
limergiiin Hpectrefi, dreadful shapes a.sbumo,
And gloaming on my sight, aihl honor to tlio gloom.
" The fervent prayer was hear<l; with hideous sound
Her ebon gates of darkness open Hew;
A dawning twilight cheers the dTOad profound,
The train of terror vanislies from view.
More mild onciiantinenta rise ;
New scones salute my oyo.s.”
It only remains to add that men and women suffer from
such awakenings in almost equal proportion, and that they
occur chiefly in persons over forty years of age. Those of
the melancholic temperament—designated by Laycock a
degenerate temperament—suffer most acutely. In some
instances these patients gravitate from neurasthenia into
hypochondriasis, and into insanity, hence the necessity of
early recognising the import of the symptom. With proper
management such a sequence should he extremely rare.
Treatment .—It is beyond the scope of this brief note to
consider the treatment of such cases at length, entailing, as
that would do, the hygiene and therapeutics of many diverse
conditions. It will suffice to indicate that it must be of a
twofold description. First, that directed to the condition
of the patient; and, secondly, that adapted to alleviate the
morning misery. The former, which is the essential
element, involves the consideration of measures calcu¬
lated to accomplish restoration of nervous energy, and
the excretion of waste products, in which diet and
regimen exceed medication in value. The latter, being
palliative, is of secondary importance. The indica¬
tion is to flush the brain with blood as speedily and
thoroughly as possible. Thiscan'be done by two methods :
by way of the nervous and of the vascular systems. Mosso
demonstrated that a ray of light falling upon the eyelid of
a sleeping man caused an increased blood-supply to the
brain, ny stimulating activity in the nervous centres. This
accords with the physiological law which decrees that the
blood-supply of an organ is in ratio to its activity, and it
explains to a certain extent the invigorating effects of sun¬
shine. A bright light shortens and decreases the acuteness
of the attack. Equally, warm and stimulating, drinks, by
increasing the frequency and force of the heart’s acrion,
afford much relief. The addition of a grain or two of
caffein, and, in certain carefully selected cases, of a spoonful
1 of brandy, is helpful. In some, full doses of valerian,
j ammonia, and chloric ether act quickly and well. In all
urgent cases, in which the recurrences are frequent and
severe, I advise a light to be kept burning all night and an
attendant to sleep in the same room.
Mancliester-square, W.
% Pirror
OF
HOSPITAL PBACTICE.
BRITISH AND FOREIGN.
Nulla autem esb alia pro certo noscendl via, nisi quampIurimaB et mor-
borum eb dissecblonum historias, bum aliorum bum proprias coUeebas
babere, eb inter ae comparare.—M orqagni De Sed. et Cans. Herb.,
lib. iv. Procemium. — -
SOUTH-WESTERN FEVER HOSPITAL-
A CASE OF PYyEMIA FOLLOWING SCARLET FEVER;
SUPPURATION IN PLEURA AND ELBOW-
JOINT; RECOVERY.
(Under the care of Dr. Caigicr.)
Tub symptoms presented by the patient whose case is
given below, the ulceration of the fauces, offensive nasal
discharge, deeply stained rash, and extensive suppuration
in the cervical region, show the severity of the attack of
scarlet fever, and make it no matter of surprise that
pyromia supervened as a complication of the disease.
Pyromia is rare as a complication of scarlet fever, and when
met with it is in this malignant type of the disease. Inflam¬
mation of the pleura is prone to become purulent, but the
commoner joint complications of scarlet fever do not evince
any proof of infective character or tendency to suppurate.
HiPou^ considered a disease of bone or joint remaining
after scarlet fever as not uncommon, and wrote, “It will
almost always turn out on inquiry that the patient with
diseased bones or joints, as a sequel of scarlet fever
or measles, had had a blow upon the joint, or had
used excessive exercise so as to tire himself and to
lower the vital endowments of the bone or articulation
by overfatigue.” Recovery from this complication of
py.'xmiia is very unusual, and, should recovery ensue,
any joint which may have suppurated is as a rule
more or less firmly ankylosed and its usefulness im-
'■ Tmc LANCtT, vol. ii. !»-'!.
y Google
$26 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[April ll, 1891.
paired as the result of the destructive changes which
have taken place in it. The early recognition of the gravity
of the joint complication, and its prompt treatment hy some
such plan as that adopted hy Dr, Caiger in iiis case, form
most important elements in the prevention of disorganisa¬
tion of the joint and the restoration of its full usefulness.
By .means of early and sufficient incisions, the use of anti¬
septics, and rest of the limb, with appropriate general
treatment and good nursing, we are able to record successes
in the treatment of suppurating joints, even when of this
infective nature, which would not have been considered
possible a few years ago. Our readers are acquainted with
the destructive arthritis which only too frequently super¬
venes in pycemia, whether acute or chronic, when the
joint has not been incised early, or the treatment for some
reason has failed to arrest the local condition. The nsk to
limb is not only much increased, but from the prolonged
suppuration the patient’s chances of recovery are greatly
diminished. The danger is not from too early incision of a
joint, when done with due precaution ; it is from leaving it
distended with purulent fluid until the inflammation nas
extended to the ligaments and other structures which enter
into its formation.
F. H-, aged eight, was admitted on Dec. 26th, 1890,
with severe scarlatina. The temperature instead of falling
to the normal at the end of the first week remained on
Deo. diet at 101 8°. The rash was almost hmmorrbagic,
the fauces much ulcerated, and there was ofl'ensive rbinor-
rbcca. The glands at the angle of the jaw and under the
stemo-mastoid became much swollen, hard, and tender,
with extensive infiltration of brawny character in the
cellular tissue around. Pulse 144. Patient very restless.
Jan. 4tb, 1891.—The swelling was much increased, giving
rise to the appearance known as “ bull neck,” the tempera¬
ture remaining between 102® and 103°. Chloroform was
administered, and free incisions were made into both sides
of the neck. The superficial portion of the swelling was
bard and glistening on section, and yielded a thin ichorous
discharge; pus was found deep down in the neck, and
drainage-tubes were inserted.
8 bh.—The swelling had increased. Temperature 102‘2°.
Under chloroform more incisions were made on the left aide.
The rash remained dark and staining.
9th.—Some relief bad been obtained. Temperature 100°
to 101-4°..
18th.—Has remained much the same since the last note.
Temperature varying from 100° to 103'4°. To-day there
is more swelling on the left side. 'Temperature 102°.
Under chloroform a fresh collection of pus was found deep
down in the left side of the neck ; this was opened and a
tube inserted. Strength fairly maintained with careful
nursing. Taking champagne and essence of beef well.
20th.—Temperature yesterday 101°; to-day 103’2°. Pain
and friction heard in the left Hank. The urine contains
one-tenth albumen.
25th.—Temperature 105°. Vomited. Well-marked pleuro¬
pneumonia of left lower lobe. Pulse 160; albumen one-
sixth. Neck discharging freely; swelling rather less.
31sb.—The condition during the last few days has been
most critical. Temperature, which has remained between
103° and 104°, fell in the night to 100 4° (sixth day of the
pneumonia). Tenderness was complained of in the left
elbow yesterday ; to-day the joint is hot, tense, tender, and
fluctuating. Chloroform administered, and a drainage-
tube pub through the joint, which, after the pus
had been evacuated, was irrigated with 1 in 20 carbolic
acid solution for some time. Strips of lint soaked in
carbolic lotion were tightly applied round the joint, outside
of which were placed several layers of sublimate wool im¬
pregnated with iodoform. The whole was enveloped in a
firm elastic bandage, which kept up considerable pressure
on the joint. The arm was lightly bandaged on to a paste¬
board splint, and the dressing changed every four hours.
Feb. Ist.—No pain in the elbow. Only a heavy trace of
albumen. Temperature 98-8°.
3rd.—Temperature has risen to 100°. Dulnessand loss
of vocal fremitus over lower two-thirds of left lung
posteriorly. Heart displaced outwards. Respiration
over 50. Paracentesis thoracis; three pints of sero-pus
removed; relief.
6 bh.—Tube removed from elbow’-joint. The same treat¬
ment by elastic pressure, exerted on the joint, enveloped in
the antiseptic absorbent dressing, now changed night and
morning, as the discharge is but slight.
9bb.—Temperature has been variable. Breathing again
becoming embarrassed. Right pleura again aspirated.
One pint of pus removed. There is now practically no dis¬
charge 7rom tire elbow-joint, which, except for two small
skin wounds, is healed. The same treatment continued.
16[ih.—Temperature has varied between 98° and 102°.
Right pleura again filling. Under chloroform the empyema
was opened, an inch and a half of the tenth rib resected,
and a doable drain inserted. About two pints of pus were
evacuated, the cavity afterwards being syringed out with
1 in 60 carbolic acid lotion.
17th.—Has stood the operation well. Temperature 98°.
Right elbow now quite sound. Splint discontinued, thongh
elastic pressure maintained.
20th.—The empyema not draining properly. Tubes were
temporarily removed, and about a pound of solid coagulated
lymph evacuated by coughing. Evening temperature
normal.
Since this date recovery has been rapid. The tube was
finally removed from the chest wall on March 27th. On
the 30bh be was allowed to get up. The lung has appa¬
rently quite recovered, and the elbow-joint is as sound as
its fellow, extension and flexion being in all respects com¬
plete. No adhesions seem to have formed within the
joint, slight movements being allowed since Feb. 17th,
when the splint was left off. This was eighteen days from
the time of laying open the joint.
In connexion with this case it is interesting to refer to
another, in which, though the child subsequently died, a
pyfcmic joint was treated by the above method with equal
success.
L. D-, aged one and a half, admitted on July 2Qd, 1890.
Still desquamating after an attack of scarlatina five weeks
previously. The right elbow-joint on admission was tense,
fluctuating, and acutely tender. The joint was at once
opened, the pus evacuated, and the cavity thoroughly
irrigated with 1 in 20 carbolic acid, and a drainage-tube
laid through the joint. On the following day the tempe¬
rature was normal. On July 7th the tube was removed and
elastic pressure maintained by means of a bandage firmly
applied over a strip dressing of carbolic acid surrounded
with alembroth wool sprinkled with iodoform. On the 15tb,
with the exception of two small points in the skin, the
wounds were healed. In this child seven other collections
of pus, mainly in the intermuscular planes, were treated in
the same way by incision, evacuation, antiseptic irrigation,
and elastic pressure. In no case did the pus re-collect.
ROYAL INFIRMARY, NEWCASTLE-ON-TYNE.
A CASK OK K.TSCAL FISTULA ; ABDOMINAL SECTION ;
Ol’ENING IN BOWEI^ SUTUKED ; RECOVERY.
(Under the care of Dr. Arnison.)
Of the various forms of hernia met with in the groin,
that known as “lateral enterocele,” “Littr^’s” or
“Richter’s hernia” is the most fatal, on account of the
frequent absence of symptoms on which reliance is placed
in the diagnosis of strangulated intestine. Of the cases,
fifty-three in number, collected by Mr. Treves, about one-
chird presented the symptoms of ordinary strangulated
hernia. Three of those remaining had persistent diarrho-a
during the progress of the case ; in others flatus and ffcces
were passed for from one to three days after the commence¬
ment of the strangulation. The vomiting was generally less
frequenb and severe than usual, whilst in only six did it
become feculent. In very few was there distension of the
abdomen, and in several the bowels acted after aperients.
The operation of closing the opening in the bowel (usually
the ileum in these cases) was less formidable than when
undertaken for fcooal fistula, usually resulting from gan¬
grene of strangulated intestine. From the nature of the
protrusion it was not necessary to resect the gut before the
sutures were inserted ; the operation therefore took a
shorter time to perform, and the subsequent risk of leakage
was much lessened. For the notes of the case we ate
indebted to Dr. Thomas Beattie, acting house surgeon.
S. B-, female, aged fifty, a charwoman, M'as admitted
into the above institution on Sept. 15th, 1890, complaining
of pain in the lower part of her abdomen and also of two
discharging sinui=es in the right groin. Four years and a
half ago, when lifting a heavy weight, the patient was
The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[April II, 1891.' 827
seized with pain in the lower part of the right eide of the
abdomen, and a “lump” the size of a walnut suddenly
appeared in her right ^roin. This swelling remained,
becoming larger after doing heavy work, and diminishing
in size on resting, but was sometimes very painful. She at
this time had no vomiting or constipation, and never wore
any truss or other appliance. About three months before
admission “ inflammation” set in about tLe swelling, accom¬
panied by great pain and redness. The pain extended
across the lower part of the abdomen ; her abdomen
was swollen. She had complete constipation, but bad
never any vomiting. It was at this time that she
first saw a medical man Three weeks after the
onset of this “inflammation,” an abscess pointed over the
swelling; the abscess burst, and a large quantity of dark-
reddish, ill smelling material was discharged. Her bowels
were not moved until about ten days after the abscess burst.
Two weeks before admission some dark, pulpy, bmised-
plum-Uke substance came away, since which occurrence the
discharge has considerably diminished. When admitted
there was a sinus over the right external abdominal ring ;
and lower down towards the right labium, in the fold of the
groin, on the same side, there was another sinus. These
were found to communicate with one another, and a probe
could be passed through the lower opening, apparently into
the abdominal cavity. The tissues between these sinuses
were red and indurated, and there was some pain on hand¬
ling ; pain was experienced also on pressure above Poupart’s
ligament on the right side. There was a small amount of
brownish-coloured discharge from the sinuses, but it had
no marked ftecal odour; the bowels were regularly moved
per anum.
Oct. 6th.—A director was passed from the orifice of one
sinus to that of the other, and the intervening tissues slit
up. Efccal matter passed freely from the wound soon after
the incision.
Nov. 24th.—The motions as passed through the fistula are
thin and by no means formed, they have a very faint fsecal
odour, the continuous escape of thm faces from the sinus
has so irritated the surrounding skin that it is severely
excoriated and causes considerable pain. Prom the appear¬
ance of the discharge the fistula was believed to communicate
with an opening in the small intestine.
Dec. 2ad.—The patient was put under chloroform, and,
the parts having been carefully shaved and cleaned, an
incision was made through the abdominal walls from a point
about 4 in. vertically above the sinus, extending through
and laying open the sinus, to which a coil of small intestine,
having an opening in it about 1 Jin. in length and ^ in. broad,
was found to be adherent. The long diameter of the orifice
was in the transverse diameter of the gut. Both the parietal
peritoneum and that covering the affected coil of intestine
were thickened. The adhesions between the abdominal
walls and the intestine were now broken down, and the
bowel immediately above the opening was clamped with a
thin rubber tube, and the wound in the intestine closed
by means of Lembert’s sutures, thin silk being used. The
bowel was returned into the abdomen, the irack of the
old sinus carefully scraped with a sharp spoon, and the
f ierifconeal cavity washed out with perchloride of mercury
otion (I in 10,000). A Keith’s glass drainage-tube was
then passed down into Douglas’s pouch, and brought
out of the upper angle of the wound; the parietal peri¬
toneum was sutured with interrupted catgut sutures; a
medium-sized indiarubber drainage-tube was put in, super¬
ficial to the peritoneum, and brought out of the lower
angle of the wound; the superficial structures were united
by interrupted catgut sutures, and the wound dressed anti-
septically. The patient was then put to bed, with the right
leg raised upon a double inclined plane. The mine was drawn
off vvith a catheter periodically. One grain of opium was
administered immediately after the operation, repeated
every six hours during the first day, and from that time
gradually diminished. The patient was given nothing but
ice to suck for the first thirty hours, and after that time a
little soda-and-milk and nutrient suppositories; the diet
was slowly increased in quantity, beef-tea, fish, tea, and
toast being gradually added until ordinary diet was
reached. Flatus was passed per anum from the second day;
the temperature continued normal, and the patient made an
uninterrupted recovery.
5bh.—Dressing removed. About one ounce of blood¬
stained fluid was drawn out of Douglas's pouch through
Keith’s drainage-tube, and Douglas’s pouch was washed out
with dilute Condy’s fluid until the fluid returned perfectly
clear. Both the Keith’s tube and the superficial drain were
removed and the wound again dressed antiseptically.
11 th.—Soap-and-water enema administered, and bowels
moved for the first time since operation. On the following
day bowels again moved. Enemata were again given on
Dec. 17th and 20bh, the bowels not having been moved in
the intervals between these dates.
25tb.—Patient allowed to be up for an hour. Bowels
twice moved without enemata. On the following day she
was up for six hours, and the bowels were again moved
twice. From this date up daily.
Jan. 3rd, 1891.—Patient discharged ; wound quite healed ;
bowels regular.
RemarJ^. — The above history, together with the condition
of the parts revealed by the operation, leaves little doubt
that the case was one of Littr^’s hernia. And we are
justified in assuming that the strangalation took place at
the time when the patient was attacked with the so-called
“inflammation.” An unusual circumstance, however, was
the absence of vomiting, and this no doubt led the medical
man who saw her outside the hospital to look upon the
case as one of perityphlitis, and treat it as such. The case
evidently progressed naturally towards a spontaneous cure,
the portion of strangulated bowel becoming gangrenous, a
fteeal abscess, and eventually a fecal fistula resulting.
TEWKESBURY HOSPITAL.
A CASE OF COMPOUND DEPRESSED FRACTURE OVER TUB
RIGHT PARIETAL AND FRONTAL BONES ;
TREPHINING ; RECOVERY.
(Under the care of Mr. Dever£ux.)
We have not infiequently of late published notes of cases
of compound comminuted fractures of the skull in which
trephining was performed ; and although in the present day
the results with the methods of treatment employed are
nearly always good, these cases generally present so^^e
points of interest. We are also somewhat apt to forget
that the percentage of deaths after similar injuries is high
if we take the record for a period of, say, twenty years, pro¬
bably not much less than 35 per cent, in hospital practice.
In this patient the period of unconsciousness was unusually
prolonged for a case of this description.
William S-, aged fourteen, was admitted to the
hospital on the afteinoon of dan. 12tb, 1891, with the
history of having been kicked on the head by a cart horse.
On admission the patient was in a condition of severe
collapse and was quite unconscious. The surface of the
body was cold, pulse small and very weak. Movement oa
both sides of the body was good, but he kept on moving
the left arm and leg wildly about, and there was marked
twitching on the left side. (Irinding of the t- ebh was very
marked. When not disturbed he lay curled ui, with the
knees and thighs Hexed.
On exarainauion a wound was found very much lacerated,
and extending for about three inches and a half over the
anterior and lateral part of the right parietal bone, and over
the superior part of the frontal bone. On digital e.xamina-
tion an extensive depressed fracture was felt. He was
anfcsthetised, and the wound thoroughly irrigated with
warm perchloride of mercury lotion. On further examina¬
tion it was found chat the fracture was Y-shaped. Two
limbs were situated on the parietal bone, and the portion
of bone between them was much depressed. The third limb
ran forwards over the frontal bone to within half an inch of
the right superior orbital margin. From this limb, near its
junction with the other two, there was a fourth fracture
running vertically downwards. The outer table of the skull,
above the fracture,- was slightly comminuted. A large-sized
tvephino was applied over the meeting point of the fractures
and a circle of bone removed. The depressed bone was then
elevated and the comminuted portions of the outer table
removed. The wound was irrigated and stitched up with
silk, a medium-sized drainage-tube being passed from front
to back. The wound was then dressed with iodoform, pro¬
tective, and pink gauze. He had a fairly good night though
somewhat restless at times, and occasional twitchings on
left side. His temperature was 102-2'’.
Jan. 13th,- The next morning he was still imconeeioua.
828 The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[April 11,1891.
bnc had no more twitchings. Temperature 99; pulse 90.
Tongue clean. Had a good night, the temperature being
99-6'.
14 bb._Is partially conscious, complains of his head, and
tries to get the bandage off. Pulse quiet; temperature
99'2°. Had a very good night. Temperature 99'6°.
15th.—Quite conscious this morning. The wound was
dressed and a smaller drainage-tube inserted. The wound
looks very well. The tube and the stitches were removed
two days later. His restoration to health was uninter¬
rupted, his temperature never rising above 99®, and the
wound being completely healed by Feb. 16bh, when he was
allowed to get up.
Slebkal
PATHOLOGICAL SOCIETY OF LONDON.
Heterotopia of the Spinal Cord.—Chronic Intestinal Stric¬
ture, seco7tdar?/ to Strangulation in a Hernial Sac .—
Columnar-celled Carcinoma of Jaw.—Thickening of the
Skull in Rickets.—Tuberculosis of Tendan Sheath .—
Carcinoma of Scalp.
An ordinary meeting of this Society was held on April 7bh,
the President, Dr. Howship Dickinson, in the chair.
Dr. Aldren Turner read a paper by Dr. C. M.
Campbell and bimself on Heterotopia of the Grey Matter
of the Spinal Cord, which occurred in a human subject.
The patient, who died at the age of twenty-nine, had
suffered for many years from a gradually increasing ex¬
foliative dermatitis. Two years before his death there
developed severe polyarthritis, which was followed by signs
of a transverse myelitis, and the fatal event resulted from |
exhaustion due to repeated attacks of bronchitis and the I
formation of a bedsore. The microscopic examination of ,
the spinal cord revealed evidence of a myelitis, which
affected principally tire segments corresponding to the
tenth, eleventh, and twelfth dorsal nerve roots. Here the
grey matter presented a peculiar arrangement, consisting
mainly in the separation of the horns of grey substance
from each other, combined with a considerable amount of
atrophy. The atrophy of the left grey crescent was more
marked than that of the right. The central canal and
posterior median septum were absent, while the anterior
median fissure was represented by a small and narrow
septum, extending a short distance into the white matter.
The condition of the skin presented some points of interest:
more or less occlusion of the arteries by great overgrowth
of the middle coat, while the prickle cells retained their
nuclei to the periphery, undergoing no coruification. No
abnormality of the dermal nerves was detected. The
author referred to the great rarity of this condition of the
spinal cord, which has been called by the Germans
“ heterotopie.” They further point out the liability to mye¬
litis which this faulty structural arrangement manifested.—
Dr. Howard Tooth showed microscopical sections with
drawings of a spinal cord which had been received from
Dr Woods of the Hoxton House Asylum. It was taken
from the body of a man aged twenty-four, the subject of
general paralysis. At the post-mortem examination a sub¬
dural h;«morrhage from the middle meningeal artery was
found. There was excess of fluid both on the surface and
•in the ventricles of the brain. The convolutions were
flattened and the brain was small. There was old fibroid
phthisis of the lungs. The cord had been hardened in a
2 per cent, bichromate of potash solution. Sections were
carefully stained with picro-carmine and cut in paraffin.
The sections showed patches of softening, the neuroglia
was increased, and many masses of what were probably
micrococci were present. The grey matter showed slight
alterations in shape. The ganglion cells everywbereshowed
great vitality. In those sections in which the inflammatory
processes were least extensive, the grey matter was moved
from its proper position, displaced either by altered or
normal white matter. Below those parts which were most
disorganised there had occurred secondary sclerosis. The
posterior parts of the cord were the most affected. This
was true both of the grey and white matters. The
anterior and posterior nerve roots were normal. Two
conditions appeared to have been confounded under
the term “heterotopia”; a reduplication of parts (Dop-
pelbilding), and that, like the present, probably due
to extensive inflammation of the grey matter. Many, if
not most, of the recorded cases bad been obtained from
lunatic asylums.—Dr. Newton Pitt referred to a cord
with two central canals obtained from a patient with
Friedrich’s disease. The cord was very small, with the
characteristic sclerotic changes of that disease. There was
no acute myelitis.—The President asked Dr. Tooth if
there had been any akin affection in his case, and Dr. Tooth
answered in the negative.—The specimens were then re¬
ferred to a special committee.—Dr. Tooth referred to the
large number of what appeared to be micrococci in his
specimens.—Dr. Turner referred to some sections of a
spinal cord of a rabbit with two canals, with an accessory
anterior horn and with three anterior nerve roots, and in
which there was no myelitis.-Dr. Newton Pitt suggested
that there was an interesting abnormality somewhat allied
to this, in which there were apparently two central canals.
He quoted a case of Friedrich’s disease in which, besides
atrophy,'this condition obtained. He also cited a case of
double central canal in a healthy rabbit.—The President
considered the subject one which might advantageously be
submitted to a special committee, and in this the authors of
the paper concurred.—Dr. Tooth referred to the presence
of micrococci in the specimens.
Dr. Newton Pitt exhibited and described a specimen of
Chronic Intestinal Stricture, secondary to Strangulation in
a Hernial Sac. Symptoms accrued suddenly on an effort,
and pain occurred at intervals, particularly after taking
food. The bowels were irregular, and blood was present in
the motions. Nutrition was maintained by enemata, and
some improvement took place. Later on, operation
being refused, the symptoms increased in severity, death
ultimately resulting from stercoral ulcer. The necropsy
showed a cicatricial contraction at the point of strangulation
of a femoral hernia, with hypertrophy and dilatation of
the intestine above and the presence of stercoral abscess. Dr.
Fagge cites a case of the same sorb, and another was pub¬
lished in the Society’s Transactions some years ago, but the
cases are rare.—The President quoted a case of cicatricial
constriction in the small bowel following strangulation.
Mr. Robinson described a ease of Carcinoma of the Eye¬
lid. He read a report of the Morbid Growths Committee,
to the effect that tiie structure was that of a squamous epi¬
thelioma. The growth recurred and was removed; there
was no suppuration. The structure in the secondaiy growth
was very different from squamous carcinoma, and rather re¬
sembled a sebaceous gland.—Mr. Bowlbv referred to the
former report, and thought the account of the later growth
quite bore out the opinion formed upon the first one.
Mr. SiiAT'i'OCK showed two Skulls from infants, greatly
thickened by the formation of very porous new bone on the
outer aspect. In one there were signs of syphilis, but no
history of that disease in the other. Sections made without
decalcification, and stained in carmine, showed complete
absence of earthy salts. The appearances were like those
of osteo-malaeia. The author contended that the thickening
of the skull, of flat bones generally, and of the shafts of the
long bones are inflammatory, as in osteitis deformans. The
rarefaction of the original substance of the bone in rickets
would point to the same conclusion. There was nothing in
the etiology of rickets that negatived such a view. ^ Thera
I were many instances in pathology, apart from microbial
' o^rigin, in which inflammation was due to morbid alterations
of the blood, such as rickets was generally considered to
be. The characteristic mark of inflammatory productions in
rickets was the want of proper calcification of the new osseous
tissue. The second specimen of thickened skull was from
an infant with congenital syphilis. That syphilis without
rickets might produce widely extended osteo-plastic peri¬
ostitis had been long known, but the formations, as Parrot
had stated, wereof normal firmness. The syphilitic disease
may to a certain extent determine the seat of the disease,
but the rachitic, the imperfect calcification of the new bone,
and the combined conditions may be termed “syphilo-
rachitis.” — Mr. Bowlby dissented from the idea of
rickets being regarded as an inflammatory disease, and
considered that the similarity of resulting histological
appearances was insufficient to prove their identity. The
thickening, of the skullcap, as in the cases exhibited, he
thought was exceptional. In many cases it might be that
the intimate thickening in long bones was compensatory to
their want of rigidity from defective calcification.—Mr.
i Lioocle
The Lancet,]
. MEDICAL SOCIETY OF LONDON.
[April Hi mi. (3?$
Shattock, in reply, said that the term “hypertrophy”
was altogether out of place, and the thickening present
■was structurally quite different from ordinary bone, and was
not necessarily associated with fracture or flexure of weak
hones.
Mr. E. C. Staph read a paper on Tuberculosis of a Tendon-
aheaoh. The patient was a widow aged sixty-six. Two
years ago she ran a fork into the palmar surface of the
.left middle finger. At its base the fork penetrated deeply,
>30 that when the hand was held up the fork still hung from
it, and had to be pulled out. There was no bleeding at the
time. The finger was stifi and painful for some days,
■during which poultices were applied. Two months after¬
wards she first noticed a small lump at the site of the
.puncture, followed shortly by others, which coalesced with
'the first, forming one swelling, gradually increasing in size,
and rendering the finger stiff and useless. She was treated
as an out patient for seven months before admission at
St. Thomas’s Hospital. The diagnosis was compound
.ganglion, and tho swelling was punctured without any
result; but after a small incision a number of semi-
-golatinous melon-seed bodies were expressed on two occa¬
sions. After the second incision the wound filled up with
granulation tissue, and the patient was admitted in
February, 1891, for amputation, which was performed
at the metacarpo phalangeal joint. On examination of
tlie finger after removal the bones and joints were
■found to be normal, but all the soft parts were replaced
by a gelatinous mass, in which the tendons could not
be distinguished. There was one small cavity filled
with caseous material. On microscopic examination of
■the tissue it proved to be tubercular in nature. There
was no family history of phthisis. The patient had
a-lways been a strong and healthy woman, and there
were no signs of disease in her lungs or other organs.
No enlarged glands in the axilla. The clear history
■of a punctured wound, followed by swelling at the
seat of puncture, and the absence, so far as could be
-ascertained, of tubercular disease in any other part of
the body, would suggest the case to be one of inoculation.—
Mr. Kooer Williams mentioned a case in an elderly man
which had a very similar history. The joint ultimately
<ieveloped a typical white swelling.—Mr. Barker said
these cases showed, what was already recognised abroad,
that) diseases of synovial membranes very much resembled
those of joints, though the treatment was not always
■correspondingly careful. He mentioned a case of local
tuberculosis of the same kind in which the patient subse¬
quently died of phthisis.—Mr. Robinson thought tlie
primary inoculation was the most important feature in the
•case, as there was nothing to show whence the tubercular
virus was derived.—Mr. Siiattock referred to cases of local
inoculation of tubercle, but thought that in moat cases the
>3kin was affected.
Mr. SrEi’HEN Paget showed and described a case of
■Carcinoma of the Scalp, which had existed for four years in
an elderly man. The glands were not affected, hut in
■structure and appearance the growth differed in important
respects from that of rodent ulcer.—Mr. Robinson said the
specimen macroscopically resembled the primary tumour lie
had just described. He considered the further history would
determine whether or not the growth was malignant.
The following card specimens were shown :—
Dr. Hale White; Hodgkin’s Disease with Waxy Kidney.
Dr. Newton Pitt: Pigmented Colon from a case of
Lead-poisoning.
MEDICAL SOCIETY OF LONDON.
•Case of Fibrosarcoma, or Desmoid Growth of the Abdominal
Wall.—Strangulated Hernia in Infants.—Chronic Atro¬
phic Rhinitis,
An ordinary meeting of this Society was held on April 6th,
■the President, Dr. Douglas Powell, in the chair.
Mr. Alban Doran exhibited a Tumour of a kind to
which Professor Siinger applied the old term “ desmoid.”
He had removed it from a stout woman, aged twenty-one,
who had suffered from its growth for two years in the left
-groin. Posteriorly the growth was incorporated with the
internal oblique muscle and the transversalis fascia, the
peritoneum being free. Anteriorly it was covered by the
aponeurosis of the external oblique. The tumour probably
arose from the conjoined tendon. After its •removal the
wound was closed by deep sutures and drained; it healed
rapidly. Six months afterwards the cicatrix wasi healthy
and not stretched, the patient being four months pregnant.
The structure of tho tumour was in parts indistinguishable
from sarcoma, being made up of young, rather loose fibrous
tissue, whilst in others it more resembled a dense fibroma.
Recorded cases show that “desmoid” tumours of the ab¬
dominal wall are clinically innocent, and occur far more
frequently in females than in males. There is reason to
believe that in several alleged cases in male patients the
tumour was not of the class in question, but was true
sarcoma. Any of the layers of the abdominal wall, except
the peritoneum, might afford origin to a desmoid tumonr.
Those, however, which had been described as arising in
muscular tissue were possibly sarcomata developed in
ha^matomata. When the tumour was large and adherent
to the peritoneum, the involved portion of serous membrane
must be taken away with the growth. The more superficial
layers of the abdominal wall formed a good covering to the
great aperture made in the course of the operation, and
experience showed that the intestines did not adhere to the
walls over the area whence the peritoneum had been stripped.
—Mr. Sutton expressed astonisbmeut that such an advanced
pathologist as Mr. Doran should use such an antiquated
term as “desmoid.” In his opinion the tumour in ques¬
tion was probably a fibro-myoma springing from the round
ligament. Such growths occurred in the broad ligament,
and sometimes sprang from the urachus or ligament of the
ovary. When similar tumours were met with in men he
thought these were spindle-celled sarcoma.—Sir Hugh
Beevor asked if Mr. Doran did not think the tumour
might be pure fibrous tissue. Under the microscope the
appearance was that of a purely cellular structure.—Dr.
CuLLiNGWORTH thought the clinical history was of the
utmost importance in establishing diagnosis.—Mr. Haslam
mentioned a case in which a tumour had been removed in a
similar situation. There bad been no recurrence since, but
the case only occurred a few months ago.—Mr. Doran, in
reply, defended the term “desmoid,” saying that it was
now specifically applied to growths of this kind. The
origin of the growth from the transversalis fascia was very
distinct, and extended well into the conjoined tendon, and
not towards the external ring. The patient was operated
on last July.
Mr. Stephen Paget read a paper on three cases of
Strangulated Hernia in Infants, which will appear in full
in our next issue.—Mr. ALBAN DoRAN thought that in
interference with the vermiform appendix peritonitis re¬
sulted rather from sloughing after damage to the artery
than, as was often concluded, from sepsis.—Mr. Ballance
said it was formerly thought that ccecal hernia bad no sac.
More recently it bad been shown by Mr. Treves that there
often was a sac, hut instances had occurred in which such a
covering was certainly absent. Hernia in children could
often be reduced by the aid of a hot bath and inversion of
the body with taxis.—In reply. Mr. Paget said the cases
he had reported supported Mr. Treves’ view. In two of the
cases a hot bath had been given without effect.
Dr. De Havilland Hall read a paper on Chronic
Atrophic Rhinitis. He suggested that the term “oziena,”
commonly used as a synonym for this disease, should be
discarded. Age and sex are important etiological factors,
the majority of cases commencing before the sixteenth
year, and females being more frequently attacked than
males, in the proportion of seven to two. Dr. Hall was of
opinion that the disease is met with more especially in
phthisical and anmmic patients. Though there is no
distinct anatomical evidence, the majority of observers con¬
sider that the disease is preceded by a hypertrophic stage.
By some authorities a congenital deficiency in, or an arrest in
the development of, the turbinated bones had been regarded
as tlie cause of the disease, the enlarged nasal passages
allowing mucus to be retained and to undergo decomposi¬
tion. Aa regards the action of micro-organisms there was a
great difference of opinion. Loewenburg had discovered a
micrococcus in the mucous membrane which he considered
to be the cause of the disease. Whether this was the case or
not, there was no doubt that bacteria played an important
part in the prodviction of the fetid odour. After giving a
description of the symptoms and diagnosis of atropnic
rhinitis, Dr. Hall stated that though a complete cure was not
to be expected, the disease could be deprived of its worst
features by carrying out the following treatment. The
Google
880 The Lancet,]
OBSTETRICAL SOCIETY OF LONDON.
[April 11,1891.
noae was to be tborotighly sprayed out with a warm
alkaline solutioo. (MackeD;eie's formula, sodii bicarb.,
sodii chlor., boracia, of each seven grains, and white
sugar fifteen grains, dissolved in two ounces of warm
water, was an excellent one.) Any adherent crusts were
to be removed by the nasal forceps or by the use of the
anterior or posterior nasal syringe with the same solution.
The patient was to be instructed to use the spray at least
night and morning. If improvement followed, the simple
saline spray might be continued. If not, the addition of
Listerine to the lluid might be tried, or weak solutions (from
two to five grains to the ounce) of alum, sulphate of zinc,
nitrate of silver, &c., might be used as a spray after previous
cleansing of the passages. Carbolic acid, as in Dobell’s
solution, would generally remove tbe smell. Insufilationsof
iodoform, iodol, boric acid, and aristol were all useful in
some cases. Dr. Hall had obtained good results from
anointing the interior of the nose with vaseline containing
oil of eucalyptus, in the proportion of a drachm to the
ounce, or tbe nostrils could be sprayed out with a liquid
paraffin—e.g., paraleine. In intractable cases Gottsbein’s
tampon should be employed. —Mr. Spencer Watson agreed
in recognising tbe presence of a hereditary taint, probably
tubercmar, and thought there was some resemblance
between the disease and erythematous lupus. He men¬
tioned a case which had been cured after acute gonorrhoeal
infection.
OBSTETRICAL SOCIETY OF LONDON.
An ordinary meeting was held on April 1st, J. Watt
Black, M.D., President, in the chair.
Extra-uterine Pregnancy at full term; Removal of
Child and Placenta by Abdominal Section; Recover ;/.—
Dr. John W. Taylor, Birmingham, introduced this case
W reference to somewhat similar records published in the
'Transactions of the Society, and pointed out the distinctive
features which separate the present from previously re¬
ported cases. The previous history of the case was detailed,
as written by Dr. Lycett of Wolverhampton. An accounb
was given of the operation of abdominal section for removal
of the child; of the interval between this and the second
operation; of the operation for removal of the placenta on
the twelfth day ; and of the subsequent history of the case
until tbe recovery and discharge of the patient. Tbe author
concluded with a short commentary on tbe case, to which
was added Dr. Lycett’s description of the child.
Extra-uterine Gestation, the Sac being situated in the
Right Broad Ligament; Pre^ancy advanced to the early
part of the fourth month.—t>x. Walter Griffith read a
paper on this subject. The patient, who was under the care
of Mr. Rout of Hornsey, was aged thirty-two. She had
been married eleven years; never pregnant before; previous
health good. Severe illness began in tbe second month,
and was followed by severe attacks of abdominal pain and
faintness. Dr. Griffith with Mr. Rout made out the
diagnosis of extra-uterine gestation in the right broad
ligament. The abdomen was opened, and tbe sac, which
bad ruptured, was opened and emptied, profuse haemorrhage
taking place immediately from the ^acental site. The
breathing was arrested with difficulty. It was impossible
to remove tbe sac, and after tbe abdomen bad been imper¬
fectly irrigated it was closed, and the sac left plugged.
Death occurred an hour after. Tbe specimen removed was
described in detail. Reference was made to tbe anatomy of
tbe placental site, tbe peculiar position of the right ovary
beneath the sac, and to existing disease of the left oviduct;
also to analogous coses of ovarian cysts invading the broad
ligaments and to the cases of Worth and Hart.
Obstructed Labour, in which a Large Fibroma of the
Ovary occupying the Pelvis was mistaken for the Head
of an Extra-uterine Foitus.—ViT. Walter Griffith also
read a paper on this case. The patient was admitted into
the Great Northern Hospital in labour, the tumour liaving
been recognised and diagnosed as the head of an extra-
uterine feetus. Three methods of delivery were discussed:
(1) Ceesarean section ; (2) vaginal section ; (3) craniotomy.
Craniotomy was finally chosen, as it appeared to involve
least risk to the mother. Great difficulty was met with in
extracting after craniotomy until version was performed.
Septic symptoms gradually supervened, and tbe patient
died on tbe eighth day. Tbe characters of tbe uterus and
placental site were described, and tbe author stated his
opinion that in all such cases of great obstruction abdominal
section provided the safest course of treatment.
Extra • uterine Gestation, associated with Sloughing
of the Abdominal Wall, and attempted Extrusion ofes
Matured and Futrid Fwtus near the Vmbilicus. — m.t.
Marmaduke Sheild read a paper on this subject. The
patient was a youog married woman, a piimipara. For
several weeks she had been ill with fever, and for several
months had had a large abdominal tumour. Tbe uterus was
explored and found to be empty. She was seen by Dr. Martin.
There was a considerable circular opening, with slougby
margins, in tbe situation of tbe umbilicus. Through
this protruded a tumour the size of a turnip. It was
black, offensive, and pultaceous. Under chloroform tbe
opening was enlarged downwards and a fcctus extracted,,
along with foul fluid and gas, followed by bright blood.
The placenta was attached deeply behind and above, and
tbe sac appeared to be extra-peritoneal. The bleeding was
stopped % hot-water irrigation. The placenta was removeo)
piecemeal, further hscmorrbage being prevented by irri-
atioD, followed by packing with sponges. The author
iscussed the pathology and anatomy of tbe case, together
with the diagnosis and treatment of ectopic gestation.
Dr. Champneys asked Mr. Taylor as to the results
of auscultation of tbe placenta. His own case has been
wrongly criticised without proper account being taken
of the long interval of practically normal temperature,
which entirely negatived the idea of absorption through
the wound. Tbe absorption was through tbe placenta.
He thought that the cases of Mr. Taylor and Mr. Jesaop
and his own case might have been tubal or tubo-ovarian.
He also called attention to tbe great inferiority of these
feetuses, and said the mother’s life ought not to be endan-
ered in any way for their sake. —Mr. Alban Dorak
oubted whether the operation of craniotomy had done
much more barm in Dr. (Griffith’s case. He had seen the
case with Dr. Griffith, and had advised him to do a cranio¬
tomy. He related a case of extra-uterine gestation mis¬
taken for an ovarian cyst.—Dr. Herman thought the cases
in which the fcctus lay in the peritoneal cavity were ex¬
plained by tearing of tbe amnion from tbe movements of
the child. Prabably if the veinix caseoeo were examined,
bits of amnion would be found in it.—Dr. Griffith, in
reply, thought abdominal section preferable to craniotomy
in cases like the one narrated.—Dr. John W. Taylor also
replied.
The following specimens were shown :—
Mr. Targett : Section of Vertebra; and Sacnini, from o
case of spondylolisthesis.
Mr. Alban Doran: The Uterine Appendages in a case
of Double Htemato-salpinx.
Dr. Wheaton (for Dr. W. Duncan) : Early Malignant
Disease of the Uterus.
CAMBRIDGE MEDICAL SOCIETY.
A meeting of this Society was held on March 6bb,
Mr. Hyde Hills, Vice-President,, in the chair.
OphthalmoplegiaExterna. —Mr. WiiERRYshowed a patient,
a farmer, aged lifty two, from Willingham, sent by Dr. Clox
on Feb. 27th. He then bad diplopia and could not
steer himself in walking with the right eye, which he
always kept lightly closed. The right eye was nearly
stationary in middle position, and there was only very
slight movement visible in tbe ocular muscles, including
the superior oblique. There was no ptosis whatever. The
movements of ine left eye were perfect. In associated
movements tbe right eye seemed rather more free than
when acting alone. Tbe pupils were equal, 3 min., active
to light and accommodatioir. The vision of the right
eye was gS, but very slight movement of the head put the
hoard out of view; no improvement with sph. glasses.
Vision of left eye was normal. No signs of tabes, no
optic neuritis. A week before he had (o sit up ail night
with his cow, and the disorder bad come on gradually next
day. There bed been no illness during twenty years
past, until one year ago he had a bad attack of retening,
thought to be influenza. He drinks a great deal of beer.
There was no history of syphilis ; of two children, one aged
sixteen in good health, the son, aged twelve years, subject
to nocturnal fits, in which he bites his tongue. Iodide o3
potassium was given. A "'eek later, when examined, tbe
movements, very limited iu the right, were more easily
ogic
The Lanobt,]
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.
[April 11, 1891. 831
eeen ; also the eye, when examined alone, made better
movements than when associated with the other eve.
Mr. Wherry gave a biief account of the present knowledge
of the subject of ophthalmoplegia, which should be dis¬
tinguished from the unsymmetrical, complete paralysis of
An ocular nerve. Since Mr. Hutchinson’s paper in 1879
there had been many papers and reports ot caeea; those
especially were mentioned in which p )st-mortem evidence
had been recorded. There was often an association
with tabes and optic nerve atrophy. Ophbhalnroplegia
was due to a variety of causes : degeneration of the
nuclei, gummata. tubercle, bajmorrbage, fluid pressure,
<Sic. A most important set of cases, dependent upon
thrombosis in the cavernous sinus, could be found in the
Opbthalmological Society’s Transactions. Mr. Wherry
was watching with much interest a symmetrical but not
simultaneous ophthalmoplegia in a boy who had uniocular
proptofis and intra-cranial bruit after fracture of the base of
the skull; the ophthalmoplegia appeared more marked
after ligation of the carotid. In Dr. BrUtowe’s remarkable
cases, published in 1885 in Brain, the disorder seemed to be
functional. The many nuclei of the third nerve were
alluded to in explanation of some of the signs. In the case
shown the disorder was only in one eye, there was no ptosis,
and no paralysis of the sphincter pupilJse, probably none of
the ciliary muscle. The lesion was either among the nuclei
of origin of the nerve or near the sphenoidal fissure. Mr.
Wherry thought the nuclei were invaded rather than fibres
of nerve selected so partially. So many cases were of
syphilitic origin 5 these were often symmetrical, partial in
immobility with ptosis. Iodide of potassium was best given
in large doses. Mr. Hutchiosoh reports the extraordinary
•dose of au ounce and a half daily. Mr. Wherry has now a
patient taking 120 grains with success. Tubercular cases
seem to have been helped by iodide doses and iodoform in-
UDctioQ to the scalp.
Paralysis of Right Sixth and Left Facial Nerves. —Mr.
Wherry also showed a labourer aged forty-five, also
from Willingham, seen on February 15tb at Adaeobrooke'a
Hospital He has complete paralysis of the external rectus
in the right eye and facial palsy complete, including the
orbicularis on the left side, doub'ful as to chorda tympanv
in tongue. There has been considerable hemicrania. The
symptoms date back about a fortnight as to the face, but
diplopia was noticed several weeks previously. He observed
his face go wrong in having to change liis pipe to the
other side of his mouth. There are no signs of tabes
dorsalis, nor optic neuritis, and no other signs of disease
or loss of function, except the contraction of the visual
fields; colour sense good. He smokes tobacco and drinks
a deal of beer. In contrast with the case of ophthal¬
moplegia, this is a paralysis unsymmetrical and complete.
Both the sixth and facial nerves are often affected in so-
called rheumatic disorder, and certainly in the face the
orbicularis being so much affected suggests Bell’s palsy, and
that the occurrence of the two together is a coincidence
and curiosity. Against this view is the condition of bis
visual fields, and the fact that the diplopia was noticed so
long before the face disorder.
Symmetrical Hyperostosis of Femora {Specimens skoivn ),—
Mr. Douty showed the femora of a skeleton which were
both enormously enlarged in circumference. He found
them in a aniali museum in Scotland, exhibited as “giant’s
bones.” The enlargement was confined to the shaft, and
the ends were hardly affected at all. There was no
twisting, and the thickening was greatest in the lateral
diameter, to that the bjnes had an appearance of flatten¬
ing. The bones were heavy and very hard, and the medul-
Hary cavity was not encroaihed upon. There was no history
of the bones. The question was whether this sclerosed and
hypertrophied condition was to be regarded as the result of
a chronic periostitis, perhaps .syphilitic, or whether these
bones were parts of a skeleton generally affected with
osteitis deformans. The absence of the twisting, and the
fact that the medullary cavity was not encroacued upon,
were in favour, Professor Sir G. M. Humphry thought, of
the former. The specimens were presented to the Patho¬
logical Mnseuiii.
Mcdiajstinal Sarcoma in a Child. —Mr. F. W. Burton
contributed a cose of mediastinal sarcoma in a child aged
five years. He said that, although sarcoma of the abdomen
was comparatively oommon in children, it was very rarely
met with in the chests of young people. The child had
been ill only about a month with wasting, dyspnoea, and
pain in the left side. On admission into Addenbrooke’s
Hospital, under Dr. MacAlister, it presented all the signs of
effusion into the left pleural cavity, but in addition to
these it was noted that there were induration and
protrusion of the tissues between the left costal carti¬
lages, and that the heart’s impulse waa impalpable;
temperature subnormal. Aspiration in the axillawitbdrew
twenty-nine ounces of straw-coloured serum. This did not
appreciably relieve the dyspnoea, which six days after ad¬
mission suddenly became urgent and of laryngeal type.
Tracheotomy was hurriedly performed, without relief, and
the child bled freely from some minute veins; this was
the only iudlcation of vascular obstruction, excepting the
pleural effusion, though post mortem the whole anterior
mediastinum was found occupied by a mass which com¬
pletely enveloped the pericardium and compressed the aorta
and la'ge veins.
Sections of Female Pelvis .—Dr. Griffiths exhibited
several specimens of sections of the female pelvis showing
the relation of the parts in prolapse of the uterus and other
pelvic disorders.
SHEFFIELD MEDICO-CHIRURGICAL SOCIETY
A MEETING of this Society was held on March 12th, Mr.
W. Dale James, M.R.C.S., President, in the chair.
MoUuscum Copiagiosum. —Mr. Snell showed a child, aged
two years, with well marked mollusca. Large nodules were
situated on the left upper eyelid, and smaller ones on the
forehead and cheek. The duration was twelve months.—
Mr. Snell also introduced a patient, a youth aged twenty-
one, who in October last bad been the subject oi nystagmus.
Eye Injury from a Revolver Bullet. —Mr. H. T. W ightm AN
showed, for Mr. G. H. SHAW, an Eye which bad been
removed in cons^uence of an injury received from a
revolver bullet 'The bullet entered under the left malar
bone, and was found lying beneath the upper eyelid of the
right eye, the left orbit having sustained no damage.
Closure of Cavity after Resection of Ribs. —Mr. R. J. Pyb
Smith showed a boy in whom a large cavity, resulting
from old-standing empyema, had closed after the resection
of portions of the fifth, sixth, and seventh ribs.—Mr. Pye
Stnith also showed a young man, from whose right frontal
sinus he had removed a number of small mucous polypi.
Fragments of the polym removed were shown.
Addison's Keloid.—^r. Burgess showed a man aged
thirty-five, with a scar-like patch, 3 by l^in., of circum¬
scribed “scleroderma” on the back of the neck. When
first noticed, sixteen months before, it was a white spot
about the size of a sixpence. Itching and burning had been
complained of. The induration was then subsiding.
Unilateral Nystagmus —Dr. Burgess also showed a case
of unilateral nystagmus iu a man who had recovered from
an anomalous attack of hemiplegia.
Sarcomata.—Dt. Gwynne showed a girl aged twelve
years, from whom he had removed half the lower jaw on
the left side for a large sarcomatous growth, which had
been noticed six months previously and was growing
rapidly. On the fourth day after the operation the stitches
were removed and the wound had practically healed. The
tumour after removal measured S^in. in length and 7 in.
in circumference. It had apparently grown from the
medullary, cavity and pressed out the bone on all sides.
The microscope revealed a large number of round cells with
some connective tissue, and here and there groups of large
giant cells. The tumour was most probably a myeloid sar¬
coma. Microscopic sections were shown.—Mr. C. Atkin
read short notes of some cases of sarcoma, and pleaded for
earlier exploratory incisions in doubtful swellings. Opera¬
tion, before the state of “fungus hcematodes” had been
arrived at, was strongly advocated, aa recurrence was all but
certainunder such conditions. In one case the growth seemed
to spring from the cutaneo-phalangeal ligament of Cieland,
which passes from the last phalanx of the finger to the
skin. In another case an apparently innocent sebaceous
tumour had taken on sarcomatous development. This was
removed from the axilla ten months ago, and there had
been no recurrence, though the infiltration was of the round-
celled character. In a third case a mixed sarcoma had
grown from the front of the shin of a young married woman.
In all three cases there was a family history of “cancer,”
but, from all accounts, more of the “epithelioid” type.
832 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
CApkil 11, 1892.
aa gg esting a connexion, if not an evolution, amongst
growths of a malignant nature.
Microscopic sections of the growths were shown.
' A meeting of this Society was held on March 26th,
Mr. W. Dale James, President, in the chair.
Optic Nerve A trophy after Injury to the Head and Spine. —
Mr. Snell introduced a young man who, about Christmas,
had been pressed down in the shaft of a coal-pit by a
descending cage. There were some symptoms pointing to
fracture of the skull. Sight was lost immediately. There
was now optic nerve atrophy.
MoUgnant Disease of the Bladder and Kidney. —
Mr. W. F. Favell showed the bladder, kidneys, and ureters
from a man a^d thirty-eight, whom he had seen in consulta¬
tion with Mr. Thorne. The patient had persistent hmmaburia,
for which he consulted a specialist, who ordered injections,
which were followed by acute cystitis. He suffered acute
pain, and catheterisation was necessary on account of the
obstruction caused hy clots and mucus in the urethra. He
died of exhaustion, and post-mortem examination revealed
cancerous infiltration of the coats of the bladder, with a
growth in the right kidnev and dilated ureters and pelves.
No calculus was found, and there was no growth elsewhere.—
Dr. Porter showed for Mr. H. Boynton Lee a Horseshoe
Kidney, discovered in a subject in the dissecting-room.
Changes in Tubercle Bacilli after Injection with Tuber-
cuUn. —Dr. F. J. Green exhibited microscopic specimens
of sputa containing tubercle bacilli from a patient under¬
going the Koch treatment.
Carcinoma Uteri^ with Secondary Growth in the Walls of
the Heart. —Dr. H. Rhodes showed some specimens from a
woman aged thirty-four, who had been under Dr. Dyson’s
care, at the infirmary, for circinoma uteri. She was
admitted on Dec. 2ad, 1890, complaining of lumbar pain,
menorrhagia of one gear’s duration, offensive vaginal dis¬
charge, dimculty in micturition, and obstinate constipation.
On vaginal examination the os was found ulcerated, the
vaginal walls indurated and infiltrated. The heart, lungs, !
and urine were apparently normal. Emaciation was very
rapid, and in a few weeks a hard nodule was discovered in
the right hypochondrium, which increased in size rapidly.
The patient died on March 13th, 1891. At the necropsy the
pelvic viscera were found matted together and infiltrated
with cancer. The rectum was adherent to the uterus and
considerably obstructed. The cervix uteri had entirely
disappeared, and the uterine cavity was opened into
posteriorly. Both ovaries were greatly enlarged and
cancerous. The liver weighed 48 oz. in front of the
right lobe was a large spherical nodule nearly three inches
in diameter. It was adherent below to the transverse colon.
In tbe posterior part of the right lobe was a much larger
nodule, adherent above to the diaphragm. Tho heart
weighed only 4| oz. In the anterior wall of the right ven¬
tricle was a cancerous nodule about the size of a walnut,
and coming to the surface inside the cavity of the ventricle.
The valves were normal. The kidneys were small and pale;
pelvis much dilated at tbe expense of the papillary layer,
which was atrophied ; ureters much dilated and distended
with urine. The left suprarenal capsule was enlarged,
but not cancerous. Mr. A. Jackson, Dr. Keeling, Dr.
Dyson, and Mr. W. F. Favell took part in the discussion.
A few Stirgical Experiences and Warnings. —Mr. W. F.
Favell read a paper on this subject. Mr. James, Dr.
Hunt, Dr. Dyson, Mr. C. Atkins, Dr. S. Matthews, Mr.
Jackson, and Dr. G, Thomson took part in the discussion.
ULSTER MEDICAL SOCIETY.
A MEETING of the Ulster Medical Society was held on
April 3rd, Dr. Dempsey, President, in the chair.
Fracture of the Patella —Dr. O’Neil read notes of the
methods employed in treatment of eight cases of fracture
of tbe patella, and showed several of the patients.—
Specimens: Dr. O’Neill showed a Larynx and Trachea from
a patient who suffered for five years from syphilitic ulcera¬
tion of the larynx and cricoid cartilage in whom tracheo¬
tomy had been performed. Ho also showed the bladder of
a patient who suffered from enlai-gement of the prostate for
eight years.
Puerperal Femer. —Dr. Byers read a paper on puerperal
fevei, in which, after pointing out the great Importance oF
the subject from its high mortality, tbe calamity it brought
on the public, and the seiious loss and annoyance it occa¬
sioned tbe medical attendant, he discussed the questioitr
under three heads: 1. Its nature. Evidence was given in
support of the view that scarlatina, when conveyed to &
lyiog-in woman, bred true, causing tbe same disease, and
not puerperal fever, the so-called puerpeisal scarlatina being
probably septicasniia with a red rash. It was also con¬
sidered that the ordinary form of cutaneous erysipelas (a-
disease analogous to the z;^motic8) had nob any relation
to puerperal fever, but It was his belief that the
phlegmonous variety, being itself a form of septicaemia,
might give rise to the disease. Puerperal fever, he thought,
had no analogy with epidemics, and neither soil, season, nor
situation had anything to do directly in its causation.
Dr. Byers regarded it as a traumatic or wound fever, due-
to the entrance of micro-organisms from without, and in
its manifestations it might take tbe form of a sapreemia, a-
septicosmia, or a pycemia. The nature of the bacteria was-
discussed, and it was shown that modern research was
against the “auto-genetic” or self-infective theory, the
poison coming from without. The various circumstances-
which lead up to our present conception of puerperal fever»
and tbe lessons which the brilliant results ootained by
antiseptic precautions in lying-in hospitals taught, were-
stated. 2. Tbe methods for tbe prevention of the disease-
were given, as well as rules for the guidance of the accoucheur
and nurse. The routine use of douches v'as not considered
necessary in private practice, except under certain circum¬
stances, which were stated, and the desirability of making-
few vaginal examinations was emphasised, the importance
of abdominal palpation during labour, as rendering vaginal)
examinations less frequent, being pointed out. Several
objections which had been made to the use of antiseptics iu
private practice were then considered, and it was shown-
how easily the method might he carried out with very little
trouble or expense. 3. Treatment: Local treatment was-
insisted on as being of the greatest importance, especially
when done early. The value of disinfecting the genital
tract, the use of iodoform crayons, the practice of
curetting, and tbe question of abdominal section in puer¬
peral peritonitis were discussed. General treatment was.
considered; and, finally, the question “How soon after
exposure to sepsis may the accoucheur safely resume prac ¬
tice?” was raised and considered. Professor Dill having
spoken, it was decided to adjourn the discussion of the paper
until May.
|i£lrie,te unit cf
The Micro-organismsof the Human Mouth. By Willoughby
D. Miller, D.D.S., M.D. Philadelphia: TheS.S. White
Dental Manufacturing Company.
At first sight it might appear that a work of over 350
pages devoted entirely to the micro-organisms of the
human mouth could only find its analogy in the use of a
Nasmyth hammer to crack a nut. Anyone, however, who
takes up Professor Miller's book and gives it the attention-
it deserves will soon be convinced that the author has none
too soon taken upon himself tho task of collecting andi
systematising not only the observations contained in his-
own numerous papers, but also the many important observa ¬
tions on the subject that are scattered through a very
bulky mass of periodical literature. The work is intended
to include nob only such matter as will be useful to well-
educated practical dental surgeons, but much that must
necesBarily.be of interest to those who have a love of the
science of their profession. In so far as it is the product of
a man who evidently combines both the practical and
scientific qualifications for the holding of the important
post of professor of dental surgery in a leading Univer¬
sity, the work may be said to fulfil all that the authoe-
claims for it.
The dental and oral pathology of to-day, through the in¬
tervention of the bacteriologist, is a very different thing
: Uoogle
Thb Lakcst,]
REVIEWS AND NOTICES OF BOOKS.
[April 11, 1891. 833
from wbat it was twenty years ago, audit is now recognised
that the micro organisms in the mouth are constantly
exerting most important actions upon both the local and
general health of many patients. It is, therefore, necessary
that not only should the dental surgeon understand the
conditions and results associated with the bacteria that
may find a field for their energies in the mouth, but the
practitioner of general medicine should also make himself
acquainted with the effects determined by those organisms
that may make their way into the mouth from outside when
the patient is apparently under comparatively normal
conditions. As the author says, "not alone are they
[bacteria] responsible for the vast majority of those diseases
of the teeth and contiguous parts which the dental surgeon
is called upon to treat, but they also give rise to other local
and general disorders of the most serious nature. These
various disturbances are produced partly by the direct action
of micro-organisms and their products upon the teeth and
the mucous membrane of the mouth, partly by constant
swallowing of large masses of bacteria, partly by carrying
them into the lungs {particularly in cases of violent inspira¬
tion), and, finally, by their obtaining an entrance into the
blood or lymph vessds ” in various ways.
It is almost impossible to give an idea of the extent of the
ground covered in this work, but we may indicate as briefly
as possible the lines on which Professor Miller has worked
in the completion of his object. After dealing in th^ intro¬
ductory chapter with the morphology of bacteria, the condi¬
tions under which they grow or by which they are influenced,
andtheproducts to which they giveri8e,hediscussesthenature
of the substances contained in the oral cavity that may serve
as media for the nutriton of bacteria, describing the saliva
and the tissues of the mucous membrane and the teeth,
exudations from the gums, and accumulations of particles
of food. He then gives the ordinaiy methods of bacterio¬
logical investigation, takes up the bacteria that are specially
associated with the mouth and teeth, considers the relation
of these to diseased pulps and to the formation of tartar.
He shows how some of them set up different forms of
fermentation, how they disturb the nutrition, set up in¬
flammation, and how they thus cause caries of the teeth.
This subject of caries and dental decay is treated very
exhaustively, and the author certainly gives a more con¬
nected, complete, and rational account than has as yet been
published.
The second part of the book is devoted to a description of
the toxic substances that are found in buccal secretions, and
the relation of these to pathogenic bacteria of the mouth, a
long description of these bacteria being given ; and lastly
conies a chapter on the Entrance Portals of the Pathogenic
Mouth Bacteria. Nothing seems to have escaped the
author} the influence of diet on decay of the teeth, the use
of antiseptics in the prophylactic treatment of decay, the
antiseptic action of filling materials—a subject of very
great importance,—are all gone into very thoroughly. As
a result of his researches on the antiseptic and other
properties of different stopping media, Professor Miller
holds very strongly that copper amalgam fillings are very
much superior to gold, oxychloride of zinc, or oxy-
phosphabe of zinc. He considers that the iilm of oxide
or sulphide of copper around the filling is absorbed by the
surrounding dentine, which is thus protected by the anti¬
septic action of the copper salt. The process of sterilisation
of teeth for the purpose of transplantation and implantation
is fully described, and some most important points are
insisted upon. We have, liowever, said enough to show
the extent of ground covered by this admirable work of
IVofessor Miller, and wo can only strongly recommend a
careful study of its contents to those who are engaged in
carrying on the work of dental surgoiy, and to those who
wish to obtain an accurate conception of what is known
regarding micro-organisms of the human mouth. The hook
is well printed, and profusely illustrated with woodcuts, a
chromo-lithograph, and two micro-photographic plates.
T/ie Siudenfs’ Adas of Artistic Anatomy. By Ch. Roth,
Professor of Sculpture at the Royal Academy, Munich.
Edited, with an Introduction, by C. E. FitzGerald,
M.D., Surgeon Oculist in Ordinary to the Queen in'
Ireland. With twenty-four plates and ten explanatory
figures. London : H. Grevel and Co. 1891.
There is an iinmense satisfaction for the intelligent
artist in the full understanding of that which previonsly he
has been unconsciously drawn to imitate. Art depends
upon science for the means of studying the internal
mechanism of the human body in order rightly to portray,
the outer form, representing the physical expression of the
mind within. The arrangement of limbs, the treatment of
surfaces and outlines, belong rather to the rules and
technique of art, but a correct knowledge of proportion in
the bulk of muscular masses, their limitations and variations
with posture, can only be acquired by a comprehensive'
knowledge of anatomy.
The study of this subject from the cadaver or text-book
has ever been the reverse of attractive to artists; and the
fact, that both technical works and attenuated subjects are
commonly more adapted to convey an intimate knowledge
of particular and deep regions, than to give an explanatory
and forcible illustration of the appearance of a living man,
leaves the field open for some more directly appropriate
treatment of artistic anatomy. Professor Both in the'
present scheme has done much towards supplying such an
educational want.
A living model is posed in imitation of a classic figure,
the addition of a considerable weight to one extended arm
lending force and reality to the effect. This figure serves
as a basis for the anatomical lesson, which includes four
separate views each of the nude figure, a careful prepara¬
tion of the superficial muscles, and the articulated skeleton.
In this treatment of the subject the most striking features
are the correctness of disposition of the limbs, trunk, and
head as regards balance and line of gravity, the proportional
distribution of muscular force, and especially the compen¬
sating curves of the spine. Parallel sketches, with numbered
references to the several parts, facilitate the recognition of
anatomical structures, which are delineated with force and
accuracy. It is a bold experiment to attempt to combine at)
once the classical, natural, and anatomical elements in
drawing from the nude, but in this the author has succeeded
remarkably well. The limitation to a single pose prevents
all confusion and very much facUitates anatomical know¬
ledge, whilst the addition of separate sketches at the end of
the atlas furnishes opportunity for more detailed study of the
limbs and head. The plates are admirably executed, the
engraving being smooth and even, and at the same time
sufficiently vigorous in the contrast of light and shade-'
Dr. Fitzgerald’s translation of ProfessUr Roth’s work is
altogether a valuable aid to the study of artistic anatomy,
and is itself a work of art.
Theory of Physics: a Rectification of the Theories of Molar
Mechanics^ Heat, Chemistry, Sound, Light, and Elec'
tricity. By Camilo Call'eja, M.’D. London t Kegan
Paul and Co. 1800.
" The aim of this work is to rectify the theories upheld
at the present time in the treatises on physics and chemistry,
whose fundamental principles have been by most authors
set forth not only without connexion, but in a manner
notoriously contradictory,” These are the words with
which the introduction to Dr. Calleja’s little book com¬
mences. The learned author having discovered that nearly
834 Thb Lanobt,]
OUR LIBRARY TABLE.
[April ll, 1891.
all physical science is wrong, has devoted himself to the
task of reconstruction, and has succeeded to his own entire
satisfaction. The new discoveries are to he fully described
in a great work on “ Universal Physiology,” of which this
appears to be the second instalment. It is explained that the
word physiology is here restored to its original applica¬
tion in science, in accordance with its just etymological
derivation from the Greek language. We are promised
three volumes in this “ abridged edition “ One, * General
Physiology; or, Physiological Theory of Cosmos,’ compre¬
hending the analysis and synthesis of nature in general;
another, ‘Abstract Biology,' treating of the Special Syn¬
thesis of Living Matter; and another, ‘Theory of Physics,’
which is circumscribed to the special analysis of the different
hinds of material changes." In pursuit of the glorious
aim of universal physiology the author has preferred the
seductive realm of hypothesis to the laborious path of ex¬
periment. He does not seem to have been a profound
reader or a practical worker in physical science. In this
manner he has avoided bias, and thus doubtless he has
quickened his critical insight, for he disposes of great
names, theories, and facts with airy omniscience. We
find with regret that Dr. Calleja does not think much
of Newton’s laws of motion, in which, however, he detects
some germs of truth. But in regard to the nature of sound
he is compelled to adopt a sterner method, by which not
only the early master but also some of his successors are
detected and exposed. In so grave an idictment we- can
only do justice to Dr. Calleja in his own words:—
“ In this work a rigid substitution for old ideas is made,
and it has the light of truth to illuminate it. Therefore,
though the most distinguished physicists like Newton,
Tyndall, Mayer, Helmholz, &c., have admitted and de¬
fended the erroneous hypothesis of corpuscular agitation,
probably for lack of something better, we must proclaim
the theory of progenic oscillation, which is in perfect
correlation with the facts and quantivalent of the inter¬
changes between sound and other phenomena ” (page 105).
Those to whom this kind of scientific writing is attractive
will find plenty of it in the “ Theory of Physics,” and to
them we commend it.
OUR LIBRARY TABLE.
Notes on Pathology: General Pathology. ByJ. Ryland
Whitaker. Edinburgh : E. and S. Livingstone. 1890.—
These “ notes,” which traverse the whole range of general
pathology, have evidently been compiled with great care.
Together, they form an outline of the subject of which it
will not be difficult for the student to fill in such details as
he gathers from his lecturer or his text-book. The author
himself recognises this as the main objectof his publication,
and we may say at once that he has done his work well, and
that it should prove of much utility. In these days of
“compendia” of knowledge, where the aim often seems
to be to condense into as small a space as possible the facte
of science, so that the student may be saved the trouble of
learning them step by step, it is gratifying to find a writer
who takes a higher view of the kind of assistance that the
student needs. The information he conveys in his little
work is considerable, and also accurate; in parts even—
e.g., in the sections dealing with inflammation and the
jiarasites—it is almost, if not quite, as full as is to be found
ip many a text-book. But it would be difficult for the
student to use the work simply for the purpo^je of “cram.”
We believe, moreover, that teachers also may bo glad of so
concise a summary of the subject as Mr. Whitaker has
given.
Twelve Lectures on the Structure of the Central Nervous
System. By Dr. Ludwig Edingeii, Frankfort-on-the-
Haiiio. Translated from the Second Edition by Willis
Hall Vittum, M.D., and C. Eugene Riggs, A.M., M.D.
Philadelphia and London: F. A. Davis.—The high repu¬
tation which Dr. Edingers work has attained in the
original German is ample justification for its translatioti
into English—we had almost written American, hut
of the nation^ity of the translators there is indeed hut
little trace, except in what may be called the occasional
Germanised Eoglish or Anglicised German, which is a well-
known characteristic of much of the American medical
writing of the present day. Of the matter of the work too
high an opinion can scarcely be expressed. The author,
as one who has observed carefully and laboriously the
structures of which he writes, has his own views on several
points, but he does not ignore the opinions of others or treat
them in anything but a scientific way. His horizon is a
wide one; he knows what has been done, and bo recognises
the limits of our knowledge, and all through the work his
intimate acquaintance with all the details of his subject is
manifest. The illustrations are excellent and numerous.
We are reluctant to find fault with them in any way, hut
it cannot be denied that to the reader ignorant of German
there is a drawback in having the illustrations named in that
language, although the translations of epithets furnished
reduce the difficulty to the smallest dimensions. The hook
is a valuable addition to the literature of the nervous
system, and will, we doubt not, be widely read both in this
country* and in America.
Diseases of the Nose and its Accessory Cavities. By W.
Spencer Watson, F.R.C.S. Second Edition. London i
H. K. Lewis. 1890.—The first edition of this well-known
work appeared fifteen years ago, and a perusal of the present
issue indicates the enormous strides made in the branch of
surgery comprised under the title. The new edition con¬
sequently contains much additional matter, though its bulk
is considerably diminished by the smaller type employed,
We find sections added upon skin affections, rhinoplasty, ear
affections, &c., by other authors. The section on ear disease
is a desirable addition, and is admirably discussed by Mr.
Cumberbatch in the small apace allotted to him. Turning
to those points in which the study of nasal disease has
particularly advanced, we are impressed by the elaborate
and instructive article on the forms of chronic rhinitis. Yet
we think that scant justice has been done to the improve¬
ments made in the treatment of hay fever, both in this
country and in America. In fact, the only reference to
this, the most prevalent of all nose diseases among well-
to-do patients, is dismissed in a few words on page 42,
nothing being suggested for the amelioration or treatment
of the affection. Nor in the section devoted to the reflex
neuroses of the nose is any mention made of the subject,
although asthma is discussed, and an admirable risumi
given of the theories maintained by Bosworth of New York.
The sections on polypi remain as admirable as in the first
edition, and the same may he said of ozeena. The account
of post-nasal adenoids is just what is required, and may be
strongly, recommended. The volume is well illustrated,
and the arrangements of the different subjects satisfactory,
though we think an appendix of formulro would be of con¬
siderable advantage to the practitioner. But, taking the
book as a whole, the faults we find are of small importance j
and as a guide to the study of diseases of the nose it cannot
be but strongly recommended.
Materia Medica. Part II. Catechism Series. Edin¬
burgh r E. & S. Livingstone. 1891.—This little book is
primarily intended to aid the student in preparing for
examinations, by “suggesting possible questions that
otherwise might have escaped his notice.” The writer
apparently has but a poor opinion of the powers of “notice”
possessed by the average student, so the questions are very
numerous, and touch upon most details connected vt^lth the
articles mentioned. Moreover, the answers to the ques*
Di TUOglt
The Lancet,]
NEW INVENTIONS,
[April 11, 1891. 835
tiona are arraaged in the type familiar from Brewer’s
“Guide to Science” or Magnall’s “Questions.” There is
considerable danger to the student’s chances of success if he
ventures to reproduce these answers before an astute
examiner—e.g., the strength of Fowler’s solution and liquor
arsenici bydrochloricusis given in an offhand way : “Like
most of the poisonous liquors, 1 per cent.” But no mention
is here given of the names or strengths of the implied ex¬
ceptions. If used only “ the night before the examination”
this catechism may usefully suggest sundry appreciative
gaps; but students would be very ill-advised who relied
upon the cramming it affords in place of a text-book.
Outlines of Practical Physiology. By William Stirling,
M;D., Sc.D. Second Edition, with 234 Illustrations.
London: Charles Griffin and Co. 1890.—We have already
stated the high opinion we entertain of this useful work.
This, the second edition, haa been thoroughly worked up to
date. A large number of well-executed woodcuts have
been added. It may be recommended to the student as one
of the best manuals be can possess as a guide and com¬
panion in his physiological work, and as one that will use¬
fully supplement the course given by a physiological teacher.
An Elementary Text-book of Physiology. By Vincent
T. MuRCHi, Head Master of Boundary-lane Board School.
London : Blackie & Son. Pp. 202.—This little book will
prove useful to those for whom it is intended—namely, the
students following the science and art syllabus. It gives a
short but accurate description of the skeleton, and notic^
briefly the muscles, the organs of circulation, digestion, and
respiration, the nervous system and senses. The woodcuts
as a rule are good, those of the blood-corpuscles (on p. 71)
and of the brain (p. 107) being exceptions. A useful feature
of the book is the large number of questions which, are
interpolated between the chapters.
|t{fo Inittntwns.
AN IRRIGATOR REGULATOR.
The figure shows a clamp for controlling the flow from
the ordinary cistern irrigator. On the glass tube, forming
the nozzle of the irrigator, is slipped the brass ring A, on
the distal ends of the levers, and it is automatically closed
immediately this pressure is relieved. The advantages of
this arrangement over the methods at present in use (clips,
cocks, or pinching between the fingers) are that the one
hand that holds and directs the tube has absolute control
over the stream in diminishing or increasing its force, and
the clamp automatically stops the flow the instant the tube
is laid down or the pressure by the fingers relieved. This
instrument is the design of Mr. T. W. Ogilvie, student of
which are hinged a pair of brass levers (R), each lever carry¬
ing a T-piece (C) at its proximal end. The rubber tube of
the irrigator is nipped and closed between the transverse
bars of the T-pieces, the necessary pressure being .main¬
tained by a rubber band acting at D, or by steel springs at
E. The tube is opened to any degree by simply pressing on
medicine, Aberdeen, and may be obtained from the maker,
Mr. John Stevenson, School-hill. Aberdeen. The clamp is
made with the simple ring A to fit one size of tube, and also
with the screw adjustment shown at a' to fit various tubes.
Alex. Ogston,
ProfosBor of Surgery, University of Aberdeen.
MESSRS. KROHNE AND SESEMANN’S IMPROVED
CHLOROFORM INHALER.
This inhaler is based upon Junker’s chloroform inhaler,
which has been some years before the profession, but is a ‘
very great improvement upon the original apparatus. As
at present made, it consists of a two-ounce bottle, gra¬
duated in drachms, and supplied with an air-tight screw
top, perforated by two tubes : one, the afferent, is con¬
nected by indiarubber tubing with a hand bellows like
that used in Richardson’s ether spray atomiser; and
the other, the efferent, with the indiarubber tubing
connected with the vulcanite face-piece. The afferent
tube reaches almost to the bottom of the bottle, the
efferent only just to half an inch below the stopper.
Four or seven drachms of chloroform are introduced by un¬
screwing the top. The vulcanite face-piece differs from the
original one in having a feather indicator which blows up
in expiration (^d drops in inspiration. This is intended to
act as a respiration indicator. The vulcanite face-piece
also is replaceable by a Skinner’s mask covered with flannel,
the covering being removable for washing or replacement by
a fresh flannel cap which stretches over the wire frame.
An arrangement in the tubes permits of a continuous rather
than an intermittent blast of chloroform vapour entering
the face-piece; further, by having the central tube in the
Skinner’s mask perforated with numerous apertures, the
blast of chloroform is diffused as an atmosphere raciier than
pumped as a jet against the face. There is also a graduated
stopcock in the course of the afl'erent tube, the object of
which is to regulate the amount of vapour passed out of
the chloroform by restricting the supply of air. It is clear,
however, that this object cannot so be obtained, as the
amount of air passed through will not vary directly as the
area of the section of the tube. It is estimated that each time
the hand bellows is completely emptied 5i!) cubic inches of
air are made to traverse the chloroform, and that one minim
of that substance will thereby be volatilised; it is hence
claimed that the percentage vapour of chloroform given off
is always below that which is considered dangerous. The
apparatus as now presented to us is undoubtedly an im¬
provement upon the old inhaler, and affords one of the best
methods at present before the profession for giving chloro¬
form. It may be added that for operations in which the
face-piece cannot be employed Messrs. Krohne and Sese-
mann supply a bent pliable metal tube, which can be used
for auiusthetising through the nose or mouth. The vul¬
canite face-piece is supplied with a movable indiarubber
band fitted with an air cushion for use when the vulcanite
will not readily apply itself to the face.
Digitized by
Google
836 The Lancet,] THE LATEST REVISED SCHEME'OF THE LONDON UNIVERSITY. [April 11,1801.
THE LANCET.
LONDON: SATUMDAY, APRIL 11, mi.
The " latest revised” scheme for the reconstitution of the
University of London, which has been finally adopted by
the Senate as the basis upon which the new Charter will be
prepared, has now been sent to every member of Convoca¬
tion, together with a memorandum explanatory of the
soheme, and it is intended to present the draft of the pro¬
posed new Charter to Convocation for its consideration at
the meeting on May 12th. Convocation will then have to
decide on its acceptance or rejection, for it will not be
possible to introduce amendments into the draft. Before
Convocation says aye or nay, it will be well to see how
far the scheme runs on the lines laid down by the Royal
Commission, and who will be satisfied with its provisions,
should Convocation accede to them, and permit them to be
laid before the Lord President of the Privy Council as the
basis of the new Charter desired by the University of
London for its reconstitution. The Royal Commissioners
recommended the formation of a local metropolitan univer¬
sity which,as an indispensable condition, should include the
teaching institutions in or near London, stipulating, how¬
ever, that any other students (including those from the
provinces or colonies) should not he debarred from becoming
candidates for its degrees; and they specially insisted
on the unwisdom of bringing in other teaching institu¬
tions having no special connexion with London. “The
University, so constituted, would not be what is wanted; it
would not be a Teaching University in and for London.’’
They also definitely remarked that “the great majority of
London medical students, if they take a degree at all, take
it elsewhere than in London, and that is a fact which the
highest representatives of the medical profession view with
regret. It is injurious, not to the men themselves only, but
to the public.” In opposition to these opinions, the new
scheme of the Senate proposes to assign to the provincial
Collegesa position in the University analogous to that given
to the London Colleges; in other words, it endeavours to
bring under the central control of Burlington Gardens all the
University Colleges of Arts and Science in England and
Wales, instead of adapting its organisation mainly to the
London Colleges and medical schools, as was not only
suggested by the Royal Commissioners, but was laid down
by them as indispensable. It makes no alteration in the
degree of M.D.; it retains the present standard for the
Matriculation and Preliminary Scientific M.B. Examina¬
tions, although they are distinctly pointed out by the Royal
Commissioners as requiring modification (par. 33), and
bands over to a joint committee, formed by the Senate and
the Royal Colleges, the other examinations for the Pass
M.B. degree, although the Commissioners most strongly
objected to giving such powers to Colleges which have
no academical character. The constitution of the proposed
new Senate is also absolutely difTerent from that which
was recommended by the Royal Commissioners. We cannot
therefore expect that the Royal Commissioners will be
satisfied with a scheme which is quite opposed in spirit and
in working detail to that which they have advised. If it
is not in accordance with the report of the Royal Com¬
mission, another question arises. Will it satisfy any of
the bodies interested in the question ? The voting of
the Fellows of the Senate shows that an influential
minority is opposed to the new departure, and that this
includes many of the oldest Fellows, who are most regular
in their attendance for the due despatch of the routine work
of the University. A very large section of the members
of Convocation will give their votes against the soheme, for,
as is plainly and fairly shown in a circular sent to the
graduates, the scheme will reduce the representation of
Convocation on the Senate, make the degrees of the Uni¬
versity of variable value, put the private student on a
disadvantageous footing with the Collegiate student,
lower the medical degree, and—most important of all
from our point of view — not relieve the grievance
of the London medical student. The London Teach¬
ing Colleges are not satisfied, and they are about
to place their objections before the Lord President. It
is scarcely to be expected that, since they have been
petitioning to be made constituent Colleges of a local
Teaching University, they will accept a coordinate
position with the provincial Colleges in an imperial Uni¬
versity, especially when the Royal Commissioners have
declared that they are justified in asking for such a posi¬
tion, and when Colleges of similar standing at Man¬
chester, Liverpool, and Leeds have been allowed to foi-m
a University, with marked advantage to general and
medical education in that part of England. The provincial
Colleges are not satisfied, for if they are to have coequal
rights they should have coequal representation with the
London Colleges; and from this point of view they have
obviously been treated very unfairly by the scheme. The
medical representation is worthless; the general represen¬
tation is inadequate. The attempt to secure the control of
these Colleges by the University of London comes rather
late in the day. Birmingham and Wales are already moving
for local Universities; and a glance at Scotland with its
four Universities, and their beneficial action on Scotch
education, is sufficient justification for insisting that these
local movements shall not be choked by a centralised
board in London. The London medical student will
not be satisfied, for the present scheme does not remove
the grievance under which he suffers. In the first place
it will not enable him to call himself “Doctor” unless he
take the M.D. degree, the conditions of which he is
explicitly told will not be changed; therefore his taking
the M.B. Pass degree by passing the Matriculation and
Preliminary Scientific M.D. Examinations will only he
illusory, for even then he will have no proper right to the title.
In the second place, if those preliminary examinations are
kept at their present standard, the average medical student
will obviously be prevented from obtaining a*degree on con¬
ditions similar to those on which it is to be obtained at other
Universities. The Senate of the University has lowered
its standard by its proposals for the Pass M.B. degree, and
has not removed the obstacles which are in the way of the
average London medical student, and which put him at an
Digitized by
Google
Thb Lancet,]
THE LUMLEIAN LECTURES.
Apbil II, 1891. 8S7
unfair disadvantage with his fellow students in Scotland
and the provinces. The Royal Colleges have accepted the
proposed scheme, and as it confers upon them a practical
monopoly in the education, examination, and fees of the
London Pass medical student, it is pot necessary to go
further for their reasons in approving the scheme. The
Royal Colleges will practically obtain everything which
the Royal Commissioners expressly state should not be
granted to them, and we cannot understand how the Senate
of the University of London could have determined to
insert into the scheme provisions which, as every medical
man must know, really transfer the examinations of its
Pass graduates in medical subjects to the medical corpora¬
tions. Convocation cannot possibly be expected to sanction
such an abnegation of the duty of the University.
In his Lumleian lectures Dr. Beoadbent has returned
to the ever-fresh and interesting topic of heart disease.
He directs his attention almost exclusively to structural
changes in the muscular walls of the heart, a department
of the subject at least equal in importance to that of
morbid changes in the valves. The medical student and
the young practitioner are very apt to think that the
recognition and correct classification of cardiac murmurs
are his chief concern, but the wider our experience the
more is the conclusion forced upon us that from the
patient’s point of view—i.e., from the point of view of pro¬
gnosis and treatment,—the essential point is the integrity
or otherwise of the cardiac muscle. Dr. liEOADBENT^says
very truly that cases of structural change in the muscular
walls of the heart are “far more numerous at and after
middle life than those of valvular disease,” and that “the
early recognition of such changes is often of greater service
to the subject of them than in the case of valvular affec¬
tions, since it reveals the tendencies which are in operation,
and often at a time when they can be successfully combated
by treatment.” This subject is further of great interest and
importance since the cases are not few in which, while no
murmur is audible, a careful consideration of all the facts
will lead to the recognition of grave cardiac changes. Such
cases are probably often overlooked, or, as Dr. Beoadbent
says, "the only diagnosis ventured upon is that of ‘weak
heart,’ a vague term which covers the entire ground from
temporary functional debility to disease inevitably and
imminently fatal.” Who has not seen such a diagnosis
made time after time, the real explanation of such tem¬
porising being the reluctance of the practitioner to admit
the existence of organic disease in the absence of any
recognisable murmur ?
Dr. Beoadbent discusses hypertrophy and dilatation at
length, and has much to say that possesses great interest
and importance. In addition to the common and well-
recognised causes of hypertrophy—viz., disease of the
aortic and mitral valves, protracted high arterial tension,
emphysema, and bronchitis,—he enumerates adherent peri¬
cardium, collapse of a portion of the lungs, contraction of
a lung from pleural adhesions, fibroid phthisis, *S;c. The
diagnosis of hypertrophy is comparatively easy. If the hyper¬
trophy affect the left ventricle weshallhave high arterial ten¬
sion, possibly some bulging over the cardiac area, theapexdis-
I placeddownwardsand somewhat outwards, the impulseheing
! “ a circumscribed gentle heave,” an increase in the area of
I cardiac dulneas, some diminution in the distinctness of the
i first cardiac sound, and some increase in loudness of the second
I cardiac sound. With the recognition of hypertrophy there
i arises at once the question whether it is adequate to the •
L maintenance of the efficiency of the circulation, or whether
! any signs] of failing compensation can be detected. This
I is a most vital question, worthy of our utmost attention,
p and some of Dr. Bkoadbent’s hints in this connexion are
of great value. “The sounds of the heart,” he tells us,
“ usually give notice when it is overtaxed by the resistance
to the onward movement of the blood. The interval between
the first and second sound may be prolonged, the systole re*
quii'ing more time than under ordinary circumstances to com¬
plete itself.When the systolic pause is lengthened at the
expense of the diastolic, so that the souDds are equidistant,
the period of repose and reconstitution of the muscular
fibres of the ventricle is shortened, and their nutrition must
in time suffer.” Reduplication of the first sound of the
heart is another sign that the organ is becoming unequal to
the strain upon it. Dr. Beoadbent does nob encourage
the idea of the treatment of cardiac hypertrophy as such;
but with regard to the treatment of the causes of hypertrophy
he remarks that “we shall recognise the necwsity of
diminishing the volume and improving the quality of the
blood by appropriate diet and hygiene, and, if necessary, by
tonics. We shall recognise, also, the desirability of
diminishing the resistance to the onward movement of the
blood in the arterio-capillary network by care in diet, by
aperients, and by eliminants of various kinds.”
The subject of dilatation is even more interesting and
important than that of hypertrophy. Usually both
ventricles are involved, but the condition of the left is the
more important. The practical effect of dilatation is that
the ventricles fail to empty themselves during systole, and
there are varying degrees of this failure. In connexion
with the, etiology of dilatation, it is extremely important
to bear in mind that it often arises quite independently of
any antecedent valvular defect. Violent efl'ort of any
kind, such as mountain climbing, hunting, boat-racing, or
athletics, especially in persons unaccustomed to severe
exertion, may produce dilatation of the ventricles, in¬
competence of the valves as a necessary mechanical
result of such dilatation, and possibly the long train
of symptoms familiar to us as those of gradual
cardiac failure. But such cases often do well under
proper treatment, and may even recover completely.
Among other causes of dilatation Dr. Beoadbent enume¬
rates the onset of acute diseases, mental anxiety, injudicious
hydropathic treatment, the Banting treatment of obesity,
and the inhalation of the fumes of Himrod’s powder for
asthma. The physical signs of dilatation are not difficult
of recognition. The pulse is irregular in rhythm and un¬
equal in force of beat; it is also sudden, short, unsua-
tained, and compressible. The artery at the wrist may
be large or small, and the heat may be either regular or
irregular. The apex may be displaced outwards and
downwards; it is often not detectable by the eye, and
it may be difficult to localise even by palpation. It
lacks the heaving character and the distinct thrust
Digitized by
Google
888 Thb Lancet,] THE STORAGE AND ELIMINATION OF IRON COMPOUNDS.
[April II, 1891.
BO characteristic of hypertrophy. Percussion shows that
the area of dulness is enlarged, and more rounded in
the apex region than normal. The first sound is short, and
usually louder than normal; often there is a systolic apex
murmur. The second sound is often weak, especially in
the aortic area. An abbreviation of the systolic panse
is a serious indication of failure of the ventricles, and,
when carried to an extreme, so that the second sound
follows the first immediately, and almost seems to over¬
take it, is significant of immediate danger.” As regards
prognosis In dilatation of the heart, among the most grave
points are obstinate nausea, loss of appetite, and sleepless¬
ness, long continued and excessive frequency of the pulse,
an approximation of the first and second sounds, a history
of progressive cardiac failure, and a bad family history,
On the subject of treatment, Dr. Broadbent treads
familiar ground, but his remarks are worthy of the most
careful consideration. He thinks the abstraction of blood
is serviceable, chiefiy where there is marked enlargement of
the liver. Purgation, especially by mercurials, he considers
as of great value in lowering arterial tension, and remarks
how commonly other remedies fail until a mercurial purge
has been given. Of the special cardiac remedies be places
digitalis, of course, first, and recommends the addition to
it of ammonia, ether, strychnine, or iron, according to the
drcnmstances of the individual case. Strophanthus he has
found most valuable when digitalis produces much sickness
or fails in its effects. Citrate of caffeine, squills, and
sulphate of spartein have also proved beneficial in his ,
hands. Of convallaria he cannot say much. j
We recommend these very interesting and practically i
valuable lectures to the best attention of our readers, I
It has often been a matter of speculation as to the
nltimate destiny of the relatively large amount of iron
which is ordinarily introduced into the human system
as a tonic, and the good effects of which seem almost
to he proportional to the largeness of the dose. It has
several times been made the subject of expeiimental
investigation, as, for example, by Hamburger, who re¬
gained from the fa>ces nearly the whole of the amount of
iron salts that be had introduced into the stomach of a dog,
s very small quantity appearing in the urine. This would
appear to show that comparatively little of the metal was
really absorbed from the intestine, although it seemed just
possible that some of it might have been taken up and again
eliminated through the same channel. It appears, how¬
ever, that we must not regard the excess of iron in the
urine as an index of the amount absorbed, since even when
iron salts are introduced directly into the blood stream very
little is excreted througli the kidney. This is clearly
shown in a paper by Dr. Carl Jacobi^ of Sbrasburg,
who had already in 1887 published, in bis inaugural
thesis, the details of several experiments ou the point.
A certain quantity of iron salts was injected subcu¬
taneously or into veins, and the urine, as it flowed
down the ureters, was received directly into a sulphide
of ammonium solution. In that way the time of its
1 Ueber das Schlcksal der in das Biut KsianKben Kisensako, Arcliiv
flir Exp. Path. u. Phanii., Bd. xxvlii., Hft. 8 u, 4.
first appearance in the urine, after the injection, could
be accurately noted, as well as the time at which it ceased
to appear; and finally, the total amount of iron thus
eliminated could be gauged. The general result of such
' experiments was to show, after due allowance for normal
excretion, that only between 2 and 4-5 per cent, of the
quantity of iron introduced into the circulation could be
regained from the urine.
The question which Dr. Jacobi now proposed to deter¬
mine was as to the possibility in Hamburger’s experiments
of much of the iron being absorbed and again excreted
through the intestinal wall. He states that Du Cahn
had found manganese introduced into the general circula¬
tion to be largely excreted through the intestinal vessels,
as much as 14 per cent, passing thus within the first hour
of the experiment. Dr. Jacobi’s results do notshow that iron
is thus eliminated to any large extent, for after its injection
into the veins he could regain not more than I'Gand 2‘4
per cent, from the intestinal contents, nor more than 6'35per
cent, and 15’1 per cent, from the intestinal wall (inclusive of
that which its tissues normally contain) in the two
experiments made for this purpose. It was evident- too
that the elimination through the intestinal bloodvessels
took place very slowly, and he did not get any support for
the view that the bile carries off much of the metal. The
next step, therefore, was to determine what becomes of all
the salt which has been introduced into the blood. Is it re¬
tained there, or is it deposited and ‘*fixed”in the tissues? The
experiments on the urinary excretion showed that no more
iron was eliminated after from two to three hours, a fact
which might be explained either on the assumption that the
kidney ceased to act aa an eliminating organ, or else that
the circulating blood bad parted with its excess of this
constituent. It was easy to show that the latter and not
the former explanation was the true one, since a repetition
of the injection into the veins caused a reappearance of
iron in the urine, its presence therein being again limited
to from two to three hours.
The inference that the major quantity of iron taken into
the circulation must he deposited in the tissues was clearly
proved by an analysis of the liver and spleen, which organs
yielded (especially in the cose of the liver) a very large pro¬
portion of the metal, even when due allowance was made for
the blood which was still retained in their vessels. Hence
the general conclusion that not more than 10 per cent, of
iron salts directly injected into the blood is eliminated by
the urine, or the intestinal and biliary .secretions; that
the main quantity—viz., 50 per cent.—is deposited within
the liver, and the rest in the other organs, such as the
spleen, kidney, and intestinal wall,—a deposition that must
be completed within from two to three hours of tlie period
of the introduction of tlie iron into the circulation. These
observations would, therefore, seem to justify the opinion,
long since expressed, that the excess of iron found in the
liver in cases of pernicious anaemia is (in part at least)
derived from previous ferruginous medication. Of course it
does not in any way conflict with the further explana¬
tion offered for the presence of such an excess of iron
in the liver in this disease—viz,, that it is due to blood
disintegration. Furthermore, Dr. Jacobi’s experiments
serve to confirm the fact that the amount of iron absorbed
Digitized by
Google
The Lancet,]
PUBLIC HEALTH AND PROFESSIONAL COURTESY.
[April 11,1891. 839
from the inteatlnal membrane is comparatively small, since
Hamburger’s recovery from the intestinal contents of the
large proportion of the amount introduced into the stomach
cannot be explained by elimination through the intestinal
secretions. Still, it cannot be said that we have as yet any
sound explanation of the empirical fact that the tonic or
heematinic action of the metal is often best exerted when
it is administered in quantity far in excess of that which is
actually absorbed.
We find that a correspondence has recently been pub¬
lished in the public press as to three cases of scarlatina
which were notified by Mr. J. C. O’Hanlon of Tudhoe
to the local medical officer of health. The three cer¬
tificates were returned with the statement that the
health officer had found the attacks to be measles, a
statement which was, however, not supported by Dr.
Frederick Page of Newcastle. But with the diagnosis
we do not concern ourselves so much as with the mis¬
chievous practice of going behind medical certificates of
notification except in cases of a character so grave as to
necessitate such action by a public officer. In this instance
the circumstances were submitted to the judgment of the
Local Government Board, and they have distinctly stated
in answer that “ they do not consider that either the
Infectious Disease (Notification) Act, 1889, or any Order of
the Board imposes on a medical officer of health any obliga¬
tion to visit each case notified to him under the Act, for
the purpose of testing, by personal examination of the
patient, the accuracy of the certificate,” and they go on to
say that it appears to them that “it would usually be
inexpedient” that the medical officer of health “should
undertake such an examination unless he has reason to
believe that the certifying medical practitioner is not
acting in good faith.”
This letter comes opportunely, and we hope that it mey
serve to put an end to a practice which is most objec¬
tionable, and which tends to bring the public health
service into disrepute. We have more than once admitted
that there are possible circumstances when such exami¬
nation of the sick by the medical officer of health may
he necessary, but the Local Government Board have I
materially limited the scope of such action by specify¬
ing the main condition which can be held to justify it.
And we would gladly have it understood that when a
medical officer of health goes behind the back of a fellow
medical practitioner, in order to test his diagnosis, he lays
himself open to the charge that he la regarding such medical
practitioner as not acting in good faith towards the public
and the sanitary authority.
But there is another aspect of the question. A number
of niggardly sanitary authorities, whose main object seems
to be to save the paltry fee by means of which they acquire
information that is of groat value for public purposes,
are only too glad to request the judgment of their
medical ollicers of health on the accuracy of each separate
certificate, in the hope that they may dilier from it, and they
have actually instructed their officers to visit each notified
case on their behalf. No such duty of visiting every case
of infectious disease that was heard of attached to medical
officers of health before the passing of tlie Notification Act,
and the Local Government Board have laid it down on more
than one occasion that, whilst that Act gave to sanitary
authorities and their officers increased sources of informa¬
tion, it imposed no new duties whatever on medical officers
of health. In other words, sanitary authorities have no
power to require compliance with such a request; and
we hope that, for their own protection as well as in
the interests of professional courtesy and of the public health
service, medical officers of health will resist this attempt
to make them serve as detectives in a system of espionage
which is as unwarrantable as it is discreditable to the pro¬
fession. Should occasion ever arise to advise a sanitary
authority to refuse a notification certificate on the ground
of the disease being \Trongly entered, the medical officers
of health who feel compelled to give such counsel should
regard the matter in a serious light; they should set forth
in writing the reasons which have led them to act thus;
and having submitted the case to the sanitary authority
they should leave that body to communicate their decision
to the medical practitioner concerned. Apart from formal
action of this sort no dispute should he allowed to appear
between medical colleagues, and medical officers of health
should bo the first to resent the imposition upon them of
any duty tending in such a direction.
The question of the significance of albuminuria must
still be regarded as, to a certain extent, mb judice. Pro¬
fessor Senator, in the second edition of his work upon
albuminuria, has recently reiterated his views that albumen
in the urine is, in a certain considerable proportion of cases,
physiological in character; while in France the opposite
view has been vigorously maintained by Dr. Lecorohe and
Dr. Telamon. This is one of the cases m which it w
particularly desirable to use terms regarding which there
can be no ambiguity. If we speak of albuminuria as
“ physiological,” we should naturally he presumed to mean
that the presence of albumen in the urine is a normal
occurrence. But we do not apprehend that this is asserted
by any competent authority. The most that has been
urged on this side of the controversy to that in a con¬
siderable proportion of persons, varying from 20 to 25
per 100, apparently in perfect health, albumen may he
found in the urine, if sufficiently exact tests be applied.
W e fail to see how a phenomenon only to be found at the
most liberal estimate in one person out of four or five can
be correctly designated as “physiological.” On the other
hand, if we employ the term “ functional albuminuria,” we
merely imply that albumen may be present iu the urine
without such organic changes in the kidney as can be
detected, and this position is now, we conceive, almost
universally admitted. The real point at issue—and the
controversy, so far from being a verbal one, is really
of the most vital pathological interest and importance—
is whether the renal epithelium, when structurally sound
and functionally efficient, ever allows the transudation
of albumen. Two examples will render the real point at
issue more readily apprehensible. It is admitted that
minute quantities of sugar can be found in the urine with¬
out pathological significance. The question to whether
“functional” albuminuria to to be placed iu he same
Digitized by
Google
%40 The Lakoet,]
THE SIGNIFICANCE OF ALBUMINURIA.
[April 11,1891.
category as this, or 'whether it is rather analogous to those
changes in the gastric secretions which accompany some
forms of dyspepsia, h'ut which pass off without struo*
tural change in the stomach or obvious impairment of'
health.
Senator believes that the aqueous constituents of the
mine are the result of filtration and not of secretion. He
attributes to the endothelial cells of the glomeruli a physical
rather than a physiological function, and compares their
action to that of the endothelium of serous membranes,
which, under the influence of the blood pressure, permit the
transudation of serum containing a certain proportion of
albumen. To this contention Lecorchi^ and Telamon
reply that if the urine is a simple transudation we should
expect to find it, like the serous etfusions, uniformly and
obviously albuminous. They share the view of Heideniiain
that the glomerular epithelium exercises a selective action
and opposes the transudation of albumen. If this be
admitted to be its function, it would obviously follow that
albuminuria can never be a normal phenomenon. Senator
recurs to the analogy of sugar in the urine, and argues that,
just as more exact methods of examination have shown the
presence of sugar where it was not previously suspected,
and in persons in good health, so the same methods show
the presence of albumen under similar circumstances; and
that, if we regard all albuminuric patients as potential
subjects of Eright’s dweaae, so ought we to regard all
glycosuric patients as potential diabetics. Argument from
analogy is usually hazardous, and rarely convinces an
opponent. In order that Senator’s position should be I
maintained it would be necwsary to show that the amount
of albumen in the urine bears some proportion to the
amount of albumen in the blood, just as the amount of
sugar in the urine undoubtedly bears some proportion to
the amount of sugar in the blood. But tbis position
does not seem to be maintained by anyone, and is, indeed,
obviously untenable. It would, further, be necessary to
show that it is possible to have abundant albuminuria
without structural change in the kidneys, since there is
no qaestion that abundant glycosuria may coexist with
integrity of those organs} hut this is unproved and extremely
improbable. On the whole, we are disposed to doubt
whether any useful analogies can be drawn between albu¬
minuria and glycosuria. The pathology of the latter
affection is extremely obscure, but it is certain that the
kidneys are nut the organs primarily at fault.
Senator attaches great weight to the admitted fact that
a considerable proportion of' persons have albumen in the
urine without any other sign of impaired health. But to
infer from this that the albuminuria is “physiological”
is to go beyond the facts. The patient may suffer from
excessive secretion from the nostrils, or from too free per¬
spirations, or from slight habitual looseness of the bowels,
without obvious impairment of health, but we should not,
therefore he justified in designating such symptoms as
“physiological.” We should rather say that there was
some departure from health, hut too slight to derange the
general equipoise of the functions.
It is significant that these cases of transient albuminuria
are most frequent in persons who are undergoing some
severe and unusual strain, whether mental or physic^.
They are common among young men preparing for examina¬
tions and common among soldiers during the period of
military service. The most obvious inference from such
considerations would be that the albuminuria is a sign that
the system is being overtaxed; that it is, in fact, as Pro¬
fessor Gairdner has happily designated it, a “danger
signal.” Another significant fact is the increasing fre¬
quency of albuminuria with advancing years, and with this
fact must be correlated the other significant fact that in
necropsies upon elderly persons organic changes in the
kidneys are the rule rather than the exception.
Senator lays down some points which he regards as
characteristic of “physiological” albuminuria. 1. The
absence of any other morbid sign. 2. The small quantity
of the albumen. He fixes 0’4 or O'd per 1000 parts as the
maximum. 3 The normal composition of the urine regard¬
ing its other elements, and especially the absence of casts
and formed elements. 4. The short duration and transitory
character of the albuminuria. The difficulty is to see how
it is possible to affirm that these characteristics might not
be found in cases of slight but genuinely pathological
albuminuria. The quantity of the albumen is certainly of
itself a sign of no value whatever. Nothing is more
common than to find the albumen decrease in amount in
cases of acute Bright’s disease until the merest trace is
visible. Nor can casts decide the question for us. We
may fail to find them in cases of Bright’s disease; while, on
the other hand, they are probably sometimes present in
otherwise healthy irrine.
This whole discussion, however inconclusive for the pre¬
sent, has undoubtedly served a good purpose in emphasising
the fact that albuminnria is in certain cases a trivial and
transient affection, and that our prognosis must not be too
grave until we have had time to take fully the bearings of
a case and to form a sound opinion ae to its probable course.
I It would, however, be a much greater and more disastrous
error to imagine that albuminuria is ever to be regarded
without apprehension, and without a clear realisation of its
ultimate dangers.
- 4 -
Amongst tlie very many carious and interesting details
revealed in the course of the evidence given before Sir Lyon
PlayI' Air’s Committee on British and Foreign Spirits, few
will cause a more widespread feeling of dismay than those
which indicate the extent to which ether is now being em¬
ployed as an intoxicant in the north of Ireland. For many
years ether intoxication has been noted as a vice which
was rapidly gaining ground. Nearly fifteen years ago the
practice^was first referred to in the columns of The Lancet,
and during the interval there have been frequent indica¬
tions that, in spite of numerous obvious discomforts, the
use of ether has been extending in an insidious fashion.
The vice, although in isolated instances believed to be
rather widely spread, seems to have formed its greatest
stronghold in a comparatively small district in the north of
Ireland. Rather more than two years ago, at a meeting of
the Cookstown Young Men’s Christian and Literary
Association, the prevalence of ether drinking in the
surrounding district led to a resolution, praying that “in
any Bill dealing with the liquor question in Ireland a
clause may be inserted, placing the houses in which ether
Digitized by
Google
The Lancet,]
ETHER INTOXICATION.
[April 11, 1891. 841,
ia aold at present tinder similar restrictions as licensed
spirit dealers’ houses, or else restrict the sale of ether to
houses licensed at present.” That these recommendations
would have been insufficient to check the consumption
of ether may be inferred both from the evidence given
before the committee and from the details in the very
striking article on ether-drinking in Ireland which was
recently published in TAe Times, since it appears that in
country districts supplies of ether are obtained from retail
chemists, from publicans and grocers, and from hawkers
or dealers; it seems that the largest portion is supplied by
the chemists, who of necessity always present the greatest
diihculty to all concerned in the regulation of the sale of
intoxicants and of poisons. The controversies which have
surrounded the sale of the so-called medicated wines have
led to the adoption of stringent measures calculated to make
the unrestricted sale somewhat difficult. It will be remem¬
bered that the Excise authorities considered medicated
wines liable to duty, when the dose recommended appeared
to render it probable that the wine was employed as a
beverage rather than as a drug. The sale of ether is not,
however, surrounded by any difficulties; it does not even
hgure in the schedule of poisons, though the amount of
safety ensured by the schedule is relatively small. Provided
that the purchaser is known to the seller, and that the
former is willing to sign an entry noting the date of
sale, the name and address of the purchaser, the name and
quantity of the article sold, and the purpose for which
it is stated to be required, no one need experience
trouble in obtaining any quantity of any poison named in
the schedule. But for the proper restriction of the sale of
medicated wines and of poisons the only real safeguard ia an
accurate knowledge of the intent of the purchaser. With |
the sale of ether as an intoxicant there can be no doubt of
the intent, and it becomes all the more important in the
interests of the community to devise measures to arrest its
employment.
The chief circumstance which appears to favour the
spread of ether drinking is tlie relatively cheap price of the
fluid. It is asserted that “ methylated ether,” the impure
compound employed, is so very cheap that persons may get
“gloriously drunk” for fivepence. This form of ether is
prepared from methylated spirit which is absolutely exempt
from duty. The immediate effects produced seem co follow
closely those of ordinary intoxication, but they are
more rapid in their onset and in their disappearance.
The quarrelsome stage has not been noted, the wave of
subdued excitement and unsteadiness of gait being quickly
followed by elevated ideas. “The surroundings seem a
veritable fairyland, and the victim for the time being ia
utterly devoid of any care or trouble.” Insensibility
quickly ensues, but lasts only from half an hour to three-
quarters, and then the person awakes dazed, but perfectly
sober and depressed. The quantity required to produce
these effects varies from one to four drachms. Considering
that this amount ia taken neat, only being followed by a
small quantity of water, it ia not aurpriaing to learn that
dyspepsia is a frequent after-effect. More serious than
this, however, is the undoubted increase in insanity in the
districts where the vice ia roost prevalent. So far as is
^own at present, ether dri king does not lead to any
chronic disease of the liver or kidneys, its elimination
during respiration being so very rapid.
The numerical statements made in The Times have already
been challenged as being exaggerated, but it is to be hoped
that this may not binder the object in view. Every cause
which is pursued with crusader-like diligence is apt to
suffer from excess of zeal. The national instinct for fair play
may unconsciously call into existence the advocatvs diaholi,,
who has an easy task in refuting wholesale exaggerations.
Reforms of other kinds of intemperance have before now-
been tendered tedious owing to a few rash statements.
With regard to ether, however, as an intoxicant, numerical
details are of little moment ; the exact proportion of the
population indulging in this practice, or even the identifica¬
tion of their social status, may be disregarded in view of
the obvious importance of arresting the spread of the Vice.
Perhaps one of the most curious contradictions connected
with the spread of the mania for ether is that it has followed
closely upon energetic efforts for stamping out ordinary
alcoholic intemperance.
Ne quid nlmls."
FACTORY SURGEONS AND THE FACTORIES BILL,
The Times of Monday last contained a letter from Mr.
Francis H. Walmsley, President of the Association of Certify¬
ing Surgeons, on the unfortunate proposal of Mr. Matthew?,,
in the Factories and Workshops Bill, to do away with certi¬
fying surgeons. He says it is probable that the average
cost of the work of factory surgeons to each employer does
! not exceed 40^, a year. It is to be regretted that Mr,
Matthews seems to have listened too exclusively to the
representations of the employers in this question. He has
spoken throughout as if the duty of the surgeon were
limited to merely certifying to the age of the person apply¬
ing for employment, whereas the surgeon has to certify to
having personally examined such person, and ascertained
that he is nob incapacitated by disease or infirmity. This
is a very large duty, and the facts adduced in our columns
show that it has been well discharged. Mr. Matthews
would do well to take further evidence from the officials of
the Certifying Surgeons’ Association. The discussions on
the proposals to leave out Clause 19 dealing with this
subject will probably be carried on at the next sitting of
the committee, or at all events on Thursday next, and no
time is to be lost in supplying every individual member of
it, and members of Parliament generally, witli facts illus¬
trating the work that has actually been done by the
certifying surgeons. The whole drift of the evidence is to
show that, so far from curtailing the work and the authority
of the factory surgeon, both should be extended.
A SENSELESS HOAX.
At Plymouth last week a number of letters, all evi¬
dently written by the same person, were posted to tlie
various medical men of the district requesting their
attendance at a given address and hour—one o’clock in the
day. The whole arrangement was of course a hoax, and
the inconvenience and annoyance thus imposed, not only
upon the insulted practitioners, but upon the occupants
of the house in question, can easily be understood. The
trick, however we regard it, has much more disgi-aeed than
it can have gratified its originator. If an effort of spit©
against the householder, it was in this respect, and in its
Digitized by i^ooQle
842 Thk Lancet,]
ARMY MEDICAL EXAMINATIONS.
[April 11, 1891.
total nncoDcern for the time and occnpation of many
beaides, as miserably petty as it was heartless. If a joke,
vt was hut a poor and a clumsy one, beneath laughter, and
but for its practical inconvenience beneath notice. There
is nothing clever in such witless imposture, and the kind¬
ness of true humour is entirely wanting. We have, instead,
only another illustration of the fact that the practical joke
is commonly associated with some badness of heart. Eor
the silly perpetrator there is much to he desired, hut
especially the attainment of moderate wisdom and of
ordinary good feeling, for the injured public such tardy
satisfaction and hope of security in future as would follow
tihe discovery and exemplary punishment of the culprit. The
authorities, we are pleased to learn, are not unmindful of
Che necessity for such remedial treatment.
THE COLLEGE OF PHYSICIANS AND THE
MIDWIVES’ BILL.
The College of Physicians is understood to have reported
in favour of legislation on midwives, but to have urged
inquiry in the first instance hy a select committee. There
is a great consensus of opinion now in this direction, which
will doubtless he duly considered by the Government, on
whom the responsibility now rests. The present Bill is
•down for second readlog on the 14th, bub it is blocked by
three adverse motions, and there is very little probability of
its making further progress.
THE ALKALOID OBTAINED FROM THE
TUBERCLE BACILLUS.
Great interest is naturally attached to the various expe¬
riments which have been made in regojd to the pathological
chemistry of the tubercle bacillus. Although we are now
rn possession of a pretty full knowledge of the mode of action
of the products of the tubercle bacilli as exhibited hy the
recent experiments made in alt parts of the world with
tuberculin, we as yet know comparatively little of the
dhemistry of this substance. An alkaloid was obtained from
the products of the anthrax bacilli by Dr. Sidney Martin,
and Professor Zuelzer has succeeded in obtaining a similar
body from the bacillus of tuberculosis. A short account of
JZuelzer’s mode of isolating the alkaloid is given in the
Wiener Medicinische Wochenschrift, No. 10, 1891. The
entire contents of the tubes in which the pure cultures
were made were repeatedly treated with hot water
acidulated with hydrochloric acid. The solution was
filtered, evaporated, and then several times precipitated
with platinum chloride; the double salt decomposed hy
oulphuretted hydrogen, and the liquid again filtered and
evaporated to dryness. In this way an almost white
crystalline salt was obtained, which was easily soluble in hot
water, but with great difficulty in cold. Its eolation was
light yellow in colour. After keeping for some time the
■dry salt assumed a light-brown colour. The chloride when
injected into rabbits and guinea-pigs exhibited a charac¬
teristic toxic action; about one centigramme injected
•subcutaneously produced after from three to five minutes
an increase in the frequency of respiration, the movements
reaching 180 per minute. This continued for about a
•quarter of an hour, when the rate gradually became
«<lower. The temperature rose in two out of the ten ob-
oervations from normal to 100'2°F. Another constant
■symptom was well-marked protrusion of the eyes, which
also appeared bright and shining, with somewhat dilated
pupils. The sclerotic was considerably injected. It
was remarkable that the protrusion of the eye was more
marked on the side on which the injection had been made
■than on the other. All these appearances disappeared in
feom fifteen to twenty minutes. Toxic symptoms only
showed themselves in three rabbits, and these had received
somewhat larger doses, between two and three centigrammes
having been administered. Death usually occurred some¬
where between the second and fourth days. At the site of
injections there was considerable redness, and small beemor-
rhages were found in the muscles immediately beneath.
Small elfusions of blood were also found in the mucous
membrane of the stomach and small intestine. In two
cases effusion occurred into the abdominal cavity. The
brain was, as a rule, soft and congested. Almost precisely
similar results followed the injection of the alkaloid into
the conjunctiva. _
THE EFFECT OF ASPARAGUS ON THE URINE.
One of the curious by-ways seldom explored by science is
that which Professor Nencki of Berne has lately investi¬
gated Faift. u.Pharm., Bd. xxviii.,Hft. 3u. 4).
It is, namely, the determination of the familiar change in
the odour of urine that follows on the eating of asparagus.
Hilger attempted to isolate the body causing this odour, by
distilling the urine passed after a three days’ diet of this
vegetable, but he could not arrive at a definite result.
Professor Nencki, availing himself of the good offices of
four of the workers in his laboratory, who substi¬
tuted for their midday meal a repast of asparagus,
collected the urine passed by them up to 8 P.M. on
the same day, acidulated it with oxalic acid, and
distilled it over a sand bath. The volatile products
were conducted into a solution of cyanide of mercury,
causing a precipitate therein; and this, together with a
similar deposit obtained by another trial, was collected,
washed, and, being treated with a small quantity of a
6 per cent, solution of hydrochloric acid, was again heated—
the vapour, which had the characteristic odour of methyl-
mercaptan, forming a bright-yellow crystalline deposit in a
solution of plumbic acetate. The odoriferous body in the
urine is therefore in all probability methyl-mercaptan. Pre¬
vious experiments hy Prof. Nencki andM. Sickerhave shown
that this substance is one of the products of fermentation
of albumen, and also of gelatine, and that it forms one of
the constituent gases of the large intestine. ludol and
phenol are also derived from the putrefaction of albumen,
and it is probable that other sulpimr-holdiog bodies are
similarly derived. As to its connexion with asparagus,
Professor Nencki quotes an interesting communication from
Dr. 0. Loew of Munich, to the effect that asparagin contains
an organic sulphur compound, and that it is highly probable
that methyl-mercaptan is formed in the albuminous dis¬
integration which takes place in the germination of the
plant. _
I ARMY MEDICAL EXAMINATIONS.
On Saturday the Secretary for War issued an order
directing that In future no candidate for admission to the
Army Medical Service shall be allowed to compete on more
than two occasions. We presume that the intention of this
is to prevent a rejected candidate from coming up repeatedly
for examination in the hope of being ultimately successful
when he has not in the meantime been really working to
qualify himself for the appointment.
PRESSURE ON THE OPTIC TRACT.
A CASE of some interest is recorded hy Dr. Oliver of
Philadelphia in the “ Archives of Ophthalmology,” vol. xx.,
No. 1. The patient came under observation in April, 1889,
complaining of stiffness and weakness in the right foot.
Six months later he had several attacks of spasm of
momentary duration, affecting the right hand and arm,
associated with extension of the leg on the same side. The
right hand and arm were weak, the knee-jerk on this side
Digitized by ^ooQie
Tub Lancet,]
THE TREATMENT OF SCLERITIS AND EPISCLEIUTIS.
[April 11, 1891. 84S
was exaggerated, and aokle clontis was present; vision was
reduced, and right bomooymous hemianopsia was present,
the left fields being also contracted, much more markedly
on the left side. The colour fields were also reduced in a
similar way, and Wernicke’s hemiopic pupillary reaction
was very well marked. There was a large htemorrhage
over the lower outer quadrant of the right disc, and the
veins were enlarged and tortuous. The diagnosis of a
tumour pressing on the left optic tract was made, with pro¬
bably some irritation of the right tract; and at the necropsy,
which took place some weeks later, a glio-sarcoma was
found invading the left optic thalamus and corpus striatum,
and pressing upon and fiattening out the left optic tract.
FIRE INQUESTS.
We observe that a Bill has been introduced into the
House of Commons by Mr. Brookfield, and read a first time,
to provide for the holding of inquests into the origin of
fires. We shall take an opportunity of expressing our views
on the matter when a copy of the Bill comes before us.
THE TREATMENT OF SCLERITIS AND
EPISCLERITIS.
Dr. Norsa has communicated to the Society Lancisiana
of the Roman Hospitals an account of three cases of scleritis
and episcleritis which he was able to cure completely in a very
short time by means of the medicated galvanic eye-hath,
though they had been treated by ordinary internal and ex¬
ternal methods for some years without success. His idea is
that, whether this affection be of rheumatic, gouty, or syphi¬
litic origin, external remedies applied in the ordinary way
act too superficially, and internal ones too slowly, to do much
good, and that therefore it is necessary to intensify the local
action of whatever remedy is applied locally, which can
best be done by means of the galvanic current. The medica¬
ment he employed was the salicylate of lithia in a 1 or 2
per cent, solution. This was used tepid. The strength of
the galvanic current was from 1 to 3 mUliamp6res.
PATHOLOGY OF MORVAN’S DISEASE.
A CASE recently published seems to place almost beyond
further discussion the pathological anatomy of this curious
disease. Jeffrey showed at a lecture at the SalpfitriCire in
December last a patient with the trophic changes in the
fingers very pronounced. Indeed, several of the phalanges
had necrosed, and the opinion was expressed that although
the condition was what is known as Morvan’s disease, this
was in all probability a form of Bytingomyelia. The patient
died a month or two later, and the necropsy revealed the
presence of the condition which had been predicted. There
was a large cavity in the centre of the cord, the whole of the
central region bad been destroyed, as well as the right pos¬
terior horn, while the left posterior horn and the posterior-
tracts were also affected. The author, on the strength of
this and another case which he has seen, comes to the con¬
clusion that Morvan’s disease is only a clinical form of
syringomyelia. _
THE PULMONARY COMPLICATIONS OF
STRANGULATED HERNIA.
From an article by Dr. J. Lesahaft, of the Berlin Patho¬
logical Institute (Virchow’sylrc/iw,123,iu.),itwouldappear
that the frequency with which pneumonia follows upon the
reduction of strangulated hernia—operated on by taxis
or by herniotomy—and the relation which such lung
trouble bears to the intestinal lesion have both been
variously estimated. Dr. Leasbaft is mainly concerned in
correcting the impression conveyed by Dr. v. Pietrzikowski,
who has recently maintained that pneumonia (as judged by
clinical signs) is comparatively frequent in these oases, and
who further supports the views held by Guseenhauer as to
its causation. These views refer the pulmonary condition
to embolism following upon thrombosis in the veins and
capillaries of the walls of the strangulated bowel, in those
cases at least in which no other explanation—e.g.. by direct
extension from peritonitis or pyiemia—can he afforded.
Dr. Lessbaft, on the contrary, after an analysis of aUt
the fatal cases of hernia examined at the Berlin Pathological
Institute during thirty years, thinks the hypothesis of em¬
bolism is not justified on pathological grounds. He ehowa
that the circumstances under which pneumonia occurs as a
sequel to strangulated hernia, and the character of the
pulmonary lesions, are such as may well be explained by the
entrance into the air passages of vomited matters. The
condition, therefore, is one of Aspiratiom-pneumonie, or
Schluck-pneumonie; and that it should be more liable tcN
occur in cases of severe strangulation, or those in which
gangrene of the gut takes place, is not surprising, since these»
are just the cases in which vomiting is most likely to be
severe. Pietrzikowski has adduced experimental proofs ia
support of his thesis, which, however, are not substantiated
by Dr. Lesshaft, who found that in the rabbit pneumonia^
never followed artificial strangulation of the intestine; and
in the dog it only occurred when it was possible for tb»
aspiration of vomited matter to take place. Indeed^
Dr. Lessbaft is convinced that pulmonary infarctions do>
not occur in connexion with the intestinal changes.
MR. JUSTICE STEPHEN.
The retirement of Mr. Justice Stephen from the judicial
bench, under medical advice, was on Tuesday last made tba
occasion of an impressive ceremony at the High Court oH
Justice. In the presence of the judges, and a large assembly
of members of the legal profession, the Attorney'General
tendered on behalf of the Bar an expression of respect
which will be echoed by a larger circle than the speaker
assumed to represent. The retiring judge responded in a.
few well-chosen sentences, and then withdrew from the
scene of his public labours into what will,we trust, prove to be
an agreeable privacy. Sir James Stephen is, as the^
Attorney-General said, a man not likely to he long ia
quest of an avocation, and it may well be hoped that botb
he and the public, which has learnt to set a high value upom
his literary work, will profit by the cultivation of his well-
earned repose. The custom which obtains among wearera
of the ermine of devoting their entire strength to the duties
of their ofiioe is one which we should hesitate to blame evem
in the gentlest terms; it is so closely associated with the'
virile virtue of single-minded devotion to duty. But there is &•
pleasing dignity in the act of retiremen t when apublic servant
who has fah-]y earned his discharge anticipates the inevitable
hour and betakes himself with unbroken powers to leisure
tasks. It was at one time supposed that Sir James Stepheib
entertained a reluctance to such a course, which, bad the fact
been so, those would most have regretted who respect him
most and most sincerely wish him well. We ate glad now
to learn that his sentiment is very much the reverse, and
that in resolving to retire at once he has been chiefly influ¬
enced by the representation that repose will be conducive-
to his health. We trust that the expectation may prove
well founded, and that he will long continue to adorn the^
society to which from henceforth he will belong in a some¬
what new character.
OPTIC NEURITIS OR PAPILLITIS.
ALTHOUaiT Dr. Bull, in his recent paper in the New Yorkr
Medical Journal, has nothing new to offer in the way of aa
explanation of the pathology of optic neuritis, he gives very
succinctly a description of the different theories which hav*
Digitized by
Googic
044 The Lancet,] PARISH ASYLUMS FOR THE BLIND AND DEAF-MUTE.
[April 11^ 1891.
IjeeB adranced to explain the condition, and he empbasiBes
tnany of the moet important and least known facts in con¬
nexion with it. He recognises three varieties: (1) Simple
'bypericmia or congestion without swelling, a condition of
doubtful significance; (2) papilUtis or codema of the disc;
<3) a more advanced condition than the last, associated
with increased swelling of the disc and the occurrence of
hfcmorrhages, and signs of strangulation of the papillary
-vessels. It is evident that the last condition only differs
in degree from that immediately preceding it, and it
cannot be said that the subdivision helps to elucidate
matters. The most rational division seems to be one
into papillitis and neuritis if the division can be made.
Neuritis in other localities is associated with loss or im¬
pairment of function, and there seems no reason why the
optic nerve should differ from other nerves. Yet it is well
known that many cases are described as optic neuritis in
which there is no evidence of impairment of function in the
-optic nerve, and it is for ophthalmologists to say whether
'those cases are correctly so described or not. It cannot,
'however, be too strongly insisted that a condition which,
in the great majority of cases, is associated with gross
intra cranial disease is often present for months with
out obtruding itself by any subjective visual symptoms,
and that it only becomes manifest on ophthalmoscopic
examination. ___
CHLORIDE OF ETHYL AS A LOCAL AN/ESTHETIC.
As a substitute for ether spray as a local aumsthetic
M. Monnet has introduced a method of freezing by means
of chloride of ethyl, which is highly spoken of by Dr.
C. Rcdard, clinical professor at the Geneva School of
Dentistry. Chloride of ethyl is a colourless liquid possess¬
ing an ethereal odour, with a boiling point of SO” F. It is
hermetically sealed in glass tubes containing ten grammes,
one end being drawn out into a fine point. When required
for use the point is broken off with a pair of forceps, or by
hand, at the narrowest part, which is marked by a tile
scratch on the glass, and the warmth of the operator’s
hand is sufficient to cause a very fine jet of the chloride to
he projected on the part to he antesthetised. One great
-advantage claimed for this method is that no apparatus is
required, and its use is advocated in such cases as tooth
extraction, neuralgia, &c._
PARISH ASYLUMS FOR THE BLIND AND
DEAF-MUTE.
A ciiANOE in the internal management of workhouses
and parish infirmaries is now in contemplation which, if
carried out, should materially aid those affected by it. This
will consist in separating from the other inmates all blind
and deaf-mute persons, whom it is intended to accommodate
in specially appointed institutions. There, by means of
association, recreation, and technical training, it may he
hoped that the tedious leisure of lives now unduly
isolated would he relieved and profitably occupied.
The proposed arrangement is open, so far as we can
see, to no serious objection which might counteract
these advantages. One possible drawback would be
the absence of healthy contact with the seeing, hearing,
and active outer world. This, however, would he by
no means a necessary consequence of the scheme if it
were put in practice. The benefits conferred by an institu¬
tion which would liberate a small alllicted class from the
mass of a relatively sound and somewhat unsympathetic
majority are compatible with all reasonable freedom of inter¬
course. These remarks, however, apply ohieliy to the case
of adults. Institution training has not produced the best
results in the case of destitute children. For any such who
maybe blind ormute the boarding-out system is clearly
preferable wherever it can be combined with the special
instruction provided in certain Board schools for pupils in
their condition. Thus the habits of independence fostered
by ordinary home life would fiourish without check to the
culture of the lacking sense.
CHRONIC RHEUMATISM AND THE NERVOUS
SYSTEM.
A NOVEL and suggestive, if somewhat revolutionary,
theory in reference to the dependence of chronic rheu¬
matic joint changes on a morbid condition of the central
nervous system is advocated in a work by Dr. 'Wichmann,
of which an abstract i^ furnished in a recent number of the
Centralblatt fur Klinische Medicin. The author began his
work six years ago, with the view of explaining the nervous
symptoms associated with rheumatic joint affection, and
the dependence of those upon a central cause was first
suggested by the occurrence of symmetrical phenomena
such as patches of erythema, subcutaneous nodules, &c.
Charcot has explained the occurrence of contractures in
rheumatism by supposing that there is an infiainmation of
the articular nerves, the influence of which is transmitted
to tho centres in the cord, there giving rise to irritation of
the motor roots ; and the fact that the contracture is
usually In the flexed position is explained by the greater
power of flexors as contrasted with extensors. But it is
pointed out that this would not explain the occasional
occurrence of extensor contraction, and that, moreover, in
other conditions giving rise to joint affection, such con¬
tractures do not take place. Further, as supporting the
theory of a central lesion for those conditions, attention is
directed to the occurrence of arthropathies in tabes and
other spinal conditions, and ibis contended that a feasible
explanation of the vaso-motor and trophic disturbances—
such as “ glossy skin,”—as well as of the disturbance of
sensibility, is offered by such a hypothesis.
THE SALE OF NARCOTIC AND ANODYNE
DRUGS.
The evils which result from over-indulgence in narcotics
and anodyne medicines have impressed themselves strongly
on the minds and imaginations of the Ameiican people, and
the opinion seems to be widespread that one of the chief
factors in the perpetuation, if not the production, of the vice
is the facility with which those drugs can he obtained. At
a recent meeting of the American Society for the Cure of
Inebiiety steps were taken with the view of procuring legis¬
lation on the lines of a resolution passed at the meeting.
The resolution recommended that no retail chemist should
be allowed to dispense morphine, chloral, or cocaine unless
they were prescribed by a medical man, and that no pre¬
scription should be repeated without a written order. It is
to be hoped that the Society will be successful in its efforts
to combat a serious and, we fear, a growing evil.
THE EFFECTS OF CERTAIN DRUGS ON THE
RENAL CIRCULATION.
Dr. Alhanese has published in an Italian journal
some important researches on .the effects of caffeine,
chloral, and curare on the circulation in the kidney,
by which he has been led to the conclusion that the
amount of urine secreted is not directly proportional to
the quantity of blood passing through the organ. When
chloral alone was given there was a very marked increase
in the volume of the kidney, though, as is well known,
this drug has an exceedingly slight diuretic action; while
curare, which has a marked diuretic action, was shown to
cause no perceptible increase in the volume. When
caffeine was introduced into an animal already under the
influence of either chloral or curare, it immediately
Diyiiized by
Googic
The LancbtJ
THE FACTORY AND WORKSHOPS’ BILL* 1891.
[April 11,1891. 945
caused a decided increase in the size of the kidheyi and at
the same time induced marked' diuresis. Nevertheless, the
increase in siza produced under these conditions was not
enough to account for the large quantity of urine secreted.
Dr. Albanese does not agree with Schroeder that caffeine
contracts the renal vessels, hut finds that its action is first
to increase slightly the volume of the organ and then to
cause a slight dilatation of the vessels. As there appears
to be no indication that the diuretic action of drugs is due to
■increase in circulation or in volume, he is inclined to refer it
to some change effected in the renal epithelium.
At the annual meeting of the Birmingham General
Hospital, held on March 18th last, the following resolution
was moved and carried unanimously : “ That in considera¬
tion of the eminent services of Sir Walter Foster, he be hereby
appointed a Consulting Physician to this hospital.”
It is satisfactory to learn from the India Office that
Surgeon Calvert, who accompanied the force of 200 men of
the 42nd Regiment and 200 of the 44bh Goorkha Light In¬
fantry in the expedition to Manipur, is safe at Lakbipur,.
near Silchar.
TREPHINING FOR EPILEPSY.
A PAPER by Dr. Yemans in the December number of the
Occidental Medical Times is referred to in the Ceniralbl. fur
Ohir.y No. 14. The paper gives an account of a ease of
traumatic epilepsy, the fits being due to an injury to the
5icacl caused by a stone, the injury in question having been
■intlicted two years before the fits developed. Trephining
was performed, with the result that at the time the case
was reported no return of the fits had taken place. In
■the same paper reference is made to a case recorded by
Wanzer, in which, after the operation, the attacks ceased
tfor a time, but reappeared.
FOREIGN UNIVERSITY INTELLIGENCE.
Innshruck.—iyt. Gabriel Anton, assistant to Professor
Meynert in Vienna, is to have charge of the new clinic for
mental diseases.
Kmigsherg.~-T>r. Samter has been recognised o.%privat
■docent in Surgery.
Prague (Bohemian University ).—Dr. Bobnslav Hellich
lias been recognised as pnvat docent in mental diseases.
Tomsk.—Dr. Gramatikati has been appointed Professor
■of Midwifery and Dr. Yerofeyeff Professor of Ophthalmo¬
logy.
Vienna.—Dr, Egon Braun von Fernwald is giving the
lectures in Midwifery and Gynmcology, pending the appoint¬
ment of a successor to Professor Carl Braun von Fernwald,
just deceased. Dr. Rosthom has been recognised as privat
■docent in Midwifery and Gynascology.
DEATHS OP EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—Pro¬
fessor August Schenk, director of the Botanic Garden in
Leipsic.—Dr. Dmitziyeff, principal medical officer of the
sSaratoil' Hospital.
BlliaADE SURGEO^ Valesius Skipton Goui.dsbury,
M.D., C.M.G. (formerly Administrator of the Gambia), has
^eon appointed by Her Majesty the Queen to be Adminis-
'trator of the Island of Saint Lucia and its dependencies ;
also bo administer the Government of the Windward Islands
'in the event of the absence, I'cc., of the Governor.
Tjik death is announced of Sir Francis Murphy, who for
fifteen years was Speaker in the Parliament of Victoria.
The deceased gentleman studied medicine in Trinity College,
Dublin, and became a Member of the Royal College of
Surgeons of England in 18.32. He received his knighthood
in 1800.
Thk further correspondence between Sir Andrew Clark,
President of the Royal College of Physicians, the British
Medical Association, and the WarOilioe, relative to the
■status of medical oliicers of the army, has been published
and laid before Parliament.
Sir Thomas Crawford, K.C.B., M.D., late Director-
General of the Army Medical Department, has been
appointed a member of Lord Wantage’s Committee on
Recruiting.
Herr Martenson, Master in Pharmacy, PharmsMJist to
the Prince of Oldenburg’s hospital, has been elected Director
of the Sb. Petersburg Pharmaceutical Society.
Professor Corfield has been elected an Honorary
Member of the Imperial Society of Medicine of Constan¬
tinople. __
THE
FACTORIES AND WORKSHOPS BILL, 1891.
Till': Standing Committee on Trade had on Thursday the
Factories and Workshops Bill under consideration. Mr.
Matthews bad charge of the Bill. The amendments to
which each clause is subjected are very numerous, and the
Bill is likely to undergo a rather exhaustive overhauling
before it finds its way again into the House of Commons.
The responsibility which the Bill of the Home Secretary
attempted to saddle upon the occupier of factories and
workshops has been transferred to the owner. Mr.
Matthews thought that the Committee in taking this step
were making the clause so elaborate as to render it imprac¬
ticable. A fresh clause has been inserted providing' arbil^
tration in cases of dispute between the owner and the
sanitary authority. Under the heading of special rules and
requirements Mr. Sidney Buxton moved to bring workshops
under the action of this Bill, a proposal which the Home
Secretary was unwilling to accept. The clause (8), Mr.
Matthewssaid, proposed “a very large experiment, to put
all the factory industry of the country under the nursing care
of the Secretary of State,” and he maintained that if “ work¬
shops” were included “the task would be superhuman.”
He believed it would be mischievous, and mentioned that
he would discharge his functions under this particular
clause with ;the greatest possible caution and discrimina¬
tion, and would only interfere even in the case of factories
in very clear cases. Mr. Howell pointed out, however,
that precautions against what was “ absolutely dangerous
or absolutely unhealthy ” were required even more in work¬
shops than they were iu factories, and urged that every
reasonable thing ought to he dune to secure that end. He
even suggested that so far from exempting “work¬
shops,” the Bill might be improved by exempting the
factories. In its present state, os Mr, Sidney Buxton
pointed out, the Bill leaves out of account all evidence
which bad been laid before the Sweating Commission.
The question was put to a division, and it was agreed by
21 to 20 votes that “workshops ” should be included in the
Bill. This brings the workshops into direct connexion with
the Home Office, as well as with the sanitary authority, and
imposes a responsibility on the Home Secretary which he
is not very willing to undertake. This clause gave rise to
further debate on the proposal of Sir Henry James to
provide a supply of fresh air “sufficient for ensuring the
good health of the persons employed in the factory,’’ an
amendment which was mot by the Secretary of State
with the answer that good health could not be ensured
by Act of Parliament. Mr. Matthews proposed to modify
the expression by the words “sufficient to prevent iujui-y
Digitized by
Cjoogic
846 Thb LakcetJ
MEDICAL PRACTICE IN AUSTRALIA.
[April 11,1891.
to the health of those employed in the workshop,” which
was ultimately adopted, Dotwithstaadiog that Sir Henry
James characterised the proposal as “ insulTicient, ungram¬
matical, and insensible to the object we have in view.”
On Clause 19, which deals with the certifying factory
surgeons, there are ten amendments on the paper, seven of
which propose to leave the clause out altogether.
The following memorial to the Standing Committee on
Trade has been forwarded by a subcommittee of the Man¬
chester Medico-Ethical Association
“Gentlemen, —The undersigned, representing the Man¬
chester Medico-Ethical Association, desire to present to
your honourable committee a copy of resolutions passed by
the Parliamentary subcommittee of that Association on
March 17th, 1891, and to ask for their consideration in
discussing the clauses referred to in the above Bill. L That
in Clause 18 of the Government Bill the words, ‘ without
a medical certificate of fitness,’ be added after the word
‘child.’ 2- That strong opposition bo offered to the
abolition of the office of certifying surgeon as proposed in
Clause 19 of the above Bill. 3. That all examinations
for certificates of fitness be held at the works, so that the
certifying surgeon shall be better able to judge of the
probable effect of the work at which the child is to be
employed.”
The Certifying Surgeons for-the Leeds district have ex¬
pressed the opinion “ that the physical welfare of half-time
workers does not demand any alteration of existing arrange-
meats in the way of supervision. If this supervision ceases,”
say they, “crooked limbs, and spinal curvature will be
much more in evidence than they are at present.”
MEDICAL PRACTICE IN AUSTRALIA.
Mr. Thomas J. Henry, L.R.C.P. and F.IiC.S. Edin.,
medical officer, Warialda Hospital, Warialda, N.S.W.,
has favoured us with the following communication.
In The Lancet of Jan. 17th, “ P. 0. S.” asks for informa¬
tion regarding openings for practice in the Australian
colonies. I trust you will find space for the following, derived
from an experience of practice in Australia for four years.
I speak more particularly of New South Wales, but my
remarks will apply generally to the other colonies. In the
first place, I may inform “F. O. S.” that practices are bought
and sold just as in England, with this difference. In England
the patients-of a practitioner as a ruletransfer their patronage
to the in-coming man; but in Australia the tie between
physician and patients is very loose, and there is no certainty
that patients (unless in unopposed practices, now rare) will
accept the new man. In fact, doubtless from the shihing,
restless character of colonial life, patients seldom remain long
under one doctor, but rueli from one to anotiier to an extent
unknown in the old country.
The population of New South Wales is under 1,200,000.
On the list of registered practitioners in that colony, dated
Dec. Slst, 1890, appear about a score less than 1000 names;
and every weekly mail steamer brings new men from Great
Britain, Fiance, and Germany. It will be admitted that
one practitioner to 1200 population is a good average.
Moreover, in New South Wales there is no Medical Act.
Any person who chooses can assume the title
“Dr.,” or “ F.R.C.S.” He can place it on his door-plate, and
practise to his heart’s content. As a result the colony is
overrun with quacks. In Sydney and suburbs alone there
are over 100 quacks, and a glance at the advertising
pages of the Sydney evening papers shows from two
to three columns daily devoted to the fiaming adver¬
tisements of prosperous quacks. One of these gentry,
who, however, holds the “M.D.” of “the Edinburgh Uni¬
versity of Chicago,” obtained without any attendance at
lectures or personal examinations, admitted to a recent
Royal Commission that he had amassed over £100,000 by
bis practice. He had had no real medical education what¬
ever. Several medical Bills have been introduced, but have
been invariably rejected, and there seems little hope of any
passing for years to come.
Both in Melbourne and Sydney are well equipped medical
schools. In both the course is a five years’ one after all
preliminary subjects are passed. A large number of students
graduate each year at these schools. The resident hospital
appointments at the Melbourne Hospital are “close” to
Melbourne graduates. At tbe Prince Alfred Hospital,
Sydney, the medical superintendent and tbe four residents
are Sydney graduates. At the Sydney Hospital all the
residents except the medical superintendent (M.D.Lond.)
are Australian graduates ; and, though there is no written
rule to that effect, it is well known that no graduate from
outside Australia has much chance of election. The resi ¬
dents’ salaries are: Melbourne and Sydney Piince Alfred
Hospital, £50, with board and lodging; Sydney Hospital,
£100, with ditto. Even the larger country hospitals are
practically “ close ” to Sydney men ; and at Newcastle and
Bathurst (the only country hospitals which have resident
medical superintendents) Sydney men are installed. The
Insane Hospital appointments are also now almost invari¬
ably given to Sydney men or to native-born Australians
returned from study in Britain.
1 quote these instances to show how strong is tbe
tendency to elect Australians. “Australia for the Aus¬
tralians” is the favourite cry. I know of several instances
where in ostensibly open competitions Australians who bad
the Edinburgh or Irish College diplomas defeated English¬
men having M.D. of London and r.R.C.S. England. Clubs
also abound. Tbe average city rate is I5s. per annum, and
the whole family have to be attended. In ihe larger cities
of late tbe clubs have in many instances amalgamated, and
pay a fixed salary to a limited number of men. The Sydney
M.U. Oddfeliowe, numbering several thousand families, pay
£250 each to four men, allowing private practice. For
these posts competition is keen, and from twenty to thirty
men apply for one vacancy. In the outlying districts the hos¬
pitals giveasaJary of £100 to £150 to a practitioner, allowing
him private practice. My appointment is £150. For ic
there were seventeen candidates. 1 am a native of Aus¬
tralia, and that fact undoubtedly assisted my election. I
am eighty miles from a railwaystation bya bad road, and 130-
by a fair road. I often have to ride from forty to sixty miles
to a case. The nearest village is thirty miles, and in some
directions there are none for sixty miles. The average
income of a country practitioner (and no village of over 300
population is without at least one) may be set down as
from £500 to £900. A few in the larger towns make £1500,
but in the smaller few make over £700, and some as low as
£250. The current cost of living is slightly more than in
England, whilst rent and furniture are much more expen¬
sive. In the country one must keep several horses. I have
to keep four in order to have a reserve for emergencies, and.
I take two on all long journeys—i e , over tweniy-five miles
one way. A practitioner with capital can of course always
buy a practice. The price is about one-half that which
would be asked in England. In Sydney and Melbourne
provident dispensaries from 2s 6c^. to is. abound. There
are generally openings for young men to travel with in¬
surance agents, and thus see the country. But in applying
for appointments it is not thought to be a recommendatioQ
to have been “an insurance doctor,” as the la 2 y itinerant
life and living in bush public-houses is not conducive to
professional perfection or personal dignity, albeit many
able and excellent men have travelled for a few months oq
their arrival. Victoria or South New South Wales would
probably suit a case of winter cough best. The nortberri
colonies are too hot in summer.
THE GENERAL PRACTITIONERS’ UNION.
At a meeting of the Committee on Hospital Management
held on Monday evening last it was resolved to send a
circular to tbe general practitioners residing in the
metropolitan district, inviting replies to the following
questions:—1. Is it within your knowledge that hospitals
and public dispensaries are abused ? State particulars as
to cases. No need to disclose names and addresses of
patients. 2. Do you know of any cases where tbe spread of
infectious or contagious diseases can be traced to the out¬
patient departments of hospitals or public dispensaries ?
3. Is it not your opinion that the special departments of
the general hospitals should be so extended and supported
Di n Lioogle
The Lanokt,]
COLONIAL MEDICAL APPOINTMENTS.
[April 11,1891. 847
aa to render special hospitals unnecessary ? 4. Do you
consider any kind of special hospital desirable? If so,
which? 6. Do you approve of vhe paying or part paying
eystem in the general and special hospitals or public dis-
pensarios? If you do, or if you do not, state your
reasons. 6. Do you approve of a central board to
(supervise the existing charities and the licensing of new
ones? 7. Is it not your opinion that public hospitals
and dispensaries should have the power to recover all
expenses incurred for treatment of patients who have
obtained admission to hospitals under false pretences ?
8. Do you think that the number of out-patients seen per
day should be limited ? 9. What further check would you
impose upon the admission of out- and casualty patients?
10. Is it your opinion that the larger field which exists in the
Poor-law infirmaries and dispensaries for the instruction of
medical students should be utilised for their curriculum, more
especially during the fifth year of study ?
The committee will feel obliged if any medical man in a
position to furnish information respecting the above will
communicate with thehoD. sec., 29, Threadneedle-street, E.C.
COLONIAL MEDICAL APPOINTMENTS.
Thouoii complaints are frequently published in the
columns of The Lancet of the grievances of colonial
surgeons, there always seems to be a sufficient supply of
candidates for the comparatively small number of such
appointments as happen to be vacant. April is the month
in which the list of applicants is drawn up for the ensuing
twelve months ; it will therefore be opportune to reproduce
the information on the subject which we have received
^rom the Colonial Office. It varies in some respects from
previous circulars of a similar nature.
lUecJical appointments are from time to time filled up by tbe Colonial
A'tfiee iti the following colonies (—British (iuiana, Jamaica, Trinidad,
Windward I.slinds, Leeward I.slands, liritish Honduras, Fiji, Sierra
Leone, Gambia, Gold Coast, Lagos, Ceylon, Straits Settlements. Hong
Kong, Cyprus, Gibraltar, St. Helena, and the Falkland Islands. In
Ceylon and Jamaica vacancies are almost always filled locally by the
.ippointmont of qualified native candidate.s. It is for the West Indies
•and the West African Colonies that medical officers are chiefly required.
The majority of the West Indian appoiiitmeiias involve medical charge
of a district, including as a rule the care of a hospital, poor-house.
Asylum, or other institution, and free attendance on tho aged and
children.
It should be noted that passage money_ on first appointment, and
leave of absence on half-pay (in case of sickness, or after six years'
service, if tho medical officer has given satisfaction in the dischai'go of
bis duties), are granted to medical officers under the Colonial Begula-
aions ; and those serving in West Africa are allowed six months’ leave,
with full pay and free passages home and out again, after every twelve
or fifteen months of continuous re.sideutial service. With regard to
pension, medical officers are usually on the same footing as other
liovormiicnt servants : but incases where privale practice is allowed,
the rule is that they are not entitled to pension, except in West Africa.
The following is a short account of tne appointments in the separate
•colonies;—
Britixh Gafftna.—Candidates must have liold for at least six months
«. ro-sklent medical appointment in some public institution. Salary £300
to £1)00 per annum.
■/aniaica.—Tho appointments, forty-nine in number, are moiiily dis¬
trict appointments, with private practice allowed; tho salary paid by
Government varies from £1D0 to ,£ 2.')0 per annum, and in most case.s
is .£ 200 .
Trinidad rt-nd ToJiago,—In Trinidad there are twenty-nine appoint-
Biiouts. Officers are appointed in the first instance on two years' pro¬
bation as supernumeraries. They receive a salary at tho rate of .ClOO
C>er annum, with furnished quarters, and aro usually attached to the
Gereriiniont Hospital; tho salary assigned to the district appointments
5.S £300, wliich is increased to .£400 and upwards by various allowances
f-'U' horse, lioiiso, or otherwise; these posts carry; tho right to private
practice ; after every ten years’ service an officer is given an additional
personal allowaiico at tho rate of ,£100 per annum. In tho island of
'Tobago there aro throe distinct appointments with a salary of £150 per
afliiium atf ached.
IJ’iiidi/wrd /stands.—The salaries paid by Government vary from £200
to £400.
Leeward Inlands (Antigua, St. Christopber and Nevis, Dominica,
Montserrat, Virgin Islands'.—The twenty-two appointments are of the
'Same nature as in tlio Windward Islands ; tbe s.'vlaries vary from £150
(o £400 per annum, but in most cases tho pay is £250. As a rule, £30
only i.s allowed for passage money. Tho medical officers are allowed
private practice.
Unlink JJiindiirnti —There are five medical appointments, in all of
which private practice is allowed; the pay is respectively 8EI)0, 81000
<thi'oo), and .'52250.
Fyi,—There aro at present eight medical offloers. of whom tho senior
medical officer receives £000 per annum, tho otliors receiving ,£3U0 per
aninnn and £.50 for house allowance, with private practice.
Su-rrft Leirae —There are three Government meilica) officers, who are
■all allowed to take private practice. Tho pay of the colonial surgeon
is .£500 a year. One assistant colonial surgeon receives £300, and the
other £250.
Gambia .—There are two medical officers, paid respectively £400 and
£300 per annum, and allowed private practice. Quarters are not
provided. •
Gold Coasf.—Tlie pay of the colonial surgeon is £800, rising to £1000
by .£50 per annum, with consultation practice only. The assistant
ciilonial surgeons (thirteen in number) are paid at the rate of £S60 per
annum, rising by triennial increments of £25 to £400. Private practice
is allowed, but there is very little to be had, and it cannot be counted
upon, as the medical officers are liable to frequent change of station.
Free quarters are provided.
Lajiou.—Tho pay of the colonial surgeon is £500 per annum, and he
also receives £100 as health officer. The senior assistant colonial
surgeon receives the same salary as tbe assistants at tbe Gold Coast.
There are two other asnstant colonial surgeons at £260, rising by
triennial increments of £25 to .£300 per annum. Private practice is
allowed in all cases. Free quarters, or allow.ances in lieu tueroof, are
granted to the colonial surgeon and the senior assistant.
N.B.—The special rules as to leave and pension in the case of
Government servants on the West Coast of Africa apply also to medical
officers.
Salary from 1600 Es, to 8000 Ra,
Straits SeUlementa.~-fia]iiry varies from §2400 to $0000 per annum.
Ilono A'ong.—Salary $1800 to $4800.
Gihrixitor.—Salary from about £60 to £1000.
Cj/pru«,—There is a chief medical officer, paid at the rate of £500 per
annum, and two district medical officers, paid at the late of £260 per
annum ; a’l enjoying priva'.o practice : these are tho onlv medical
appointments in the island which are open to English candidates.
Helena.—The colonial surgeon receives £200 per annum, and £80
horse allowance. Private practice is allowed-
Falktand hlandn.—There are two appointments, one of which i.s paid
at tho rate of £300 per annum, and tlie other at the rate of £200 per
annum. Private practice tsallowed in both cases.
In addition to the ordinary medical appointments in these colonies
vacancies also occasionally, thougli very rarely, occur for which spe¬
cialists are required-as, e.g., to take charge of a lunatic asylum;and
the particulars of chief medical officer in some of the larger colonies
have not been given, as tbe headship of tho medical department in
such colonies, re<iuii-ing adniinisltative as well as professional qualifica¬
tions, i.s not reserved to the ordinary medical stafi, but is often ilUed up
directly from the outside.
All applicants for medical employment in tbe colonies must be
betweer* tlie ages of twenty-thi-ee and thirty, and must be doubly
qualified; preference will be given to those who liave held hospital
appointments as house physicians and house surgeons. Certificates of
moral character and of sobriety will be required, and every officer
before being appointed will be medica’ly examined by one of tlie con¬
sulting physicians of the Colonial Office, Dr, Gage Brown, 88, Sloane-
street, London, K.W,; Sir D S. Maclagan, 28, Heriot-row, Edinburgh ;
and Dr, Ilnwtroy Benson, .57, Fit»william-square, Dublin.
Applications for medical employment in the tropical colonies from
persons In tho Unitoil Kingdom must be addressed to the Private
Secretary, Colonial Office, Dowiiing-street, S.W., dining the month of
April ill each year, and notices to that effect will be posted up early in
the year in the leading hospitals and medical schools of Great Britain
and'ircland. Out of tlie total number so applying, a list of candidates
will lie made who will be eligible to fill any vacancies which may occur
during the year, hut no promise wliatever can be held out that candi¬
dates will eventually receive an appointment. It is not possible to
forecast either tlie number or the nature of the vacancies which will
arise in the course of any given year.
Ill tlie course of the year 1880-1800 there wore twelve vacancies, and
ill the following colonies (—British Guiaiui, Fiji, Gibraltar, Gold Coast,
Hong Kong, Lagos, St. Helena. There ^ere about fifty candidates.
In the course of the voar 18D0-1S91 there were seventeen vacancies to
which appoiiitiiiBBts were made from this country. They occurred in
the following Colonics (—British Giiiaiia, British Honduras, Gambia,
Gold Coast, Leeward Islands. Straits Settlements, Windward Islands.
Tlie list of eligible caiirtidabes applying in April, 1890, contained
between fifty and sixty names.
^aWk an)) fain.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF MEDICAL OFFICERS OF HEALTH.
Ketterivg Rural District.—M.r. J. W. Dryland reports
a maintained and severe epidemic of enteric fever at
Desborough, which caused seventeen deaths, and materially
added to the zymotic death-rate of the district. Five other
deaths from the same cause occurred elsewhere in the
rural district. As regards Desborough there were 144
attacks, and it seems as if the disease, once imported,
had been spread by reason of blocked sewers and faulty
drains, these reacting in their turn on certain wells, some
of which have been closed. Flushing action was impeded
towards the close of the year by reason of ,*the severe
frosts, bub a loan is now to be secured for amending the
sewers. Several other villages were likewise affected, and
some of them do nob appear for the first time in connexion
with occurrences of this disease, the cau-sation of which in
this district calls for very exhaustive investigation. Mr,
Dryland, acting on his recent experience, takes occasion
again to urge very strongly the provision of an isolation
hospital.
848 Thb Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[April 11, 1891,
Caxton aud St. Neots Districts. —Mr. T. Poyntz Wright
continueB to maintain an active Bupervision over the sanitary
circumstances of the three districts involved in this area,
and, as on former occasions, he does not hesitate to point
out the conditions that involve risk to public health,
although the death-rate in two of the districts, at least, re¬
mains extremely low. Dealing with the causation of epi¬
demic diseases, Mr. Wright states that in his district
diphtheria has generally followed on a rise in the subsoil
water. His reference elsewhere to the defective quality of
shallow well water would seem to imply that the soil is
polluted, and hence a rise of subsoil water may act by the
expulsion of a sewage contaminated air from the soil into
the atmosphere above, the changing level of subsoil water
thus becoming a factor in the production of diphtheria much
in the fashion indicated recently in our abstracts of the
Milroy lectures on this subject. The large amount of infec¬
tious disease which is brought to light by the Notiiication
Act leads to a renewal of aavice as to the provision of means
of isolation. Now, more than ever, has it become possible
by prompt isolation of first attacks to stay the prevalence
of infectious disease, hence the especial value of the advice
given in this respect.
Dzhridge Eural District. —Mr. Charles Roberts estimates
the death-rate for this district during 1890 as 17 0 per 1000.
The diphtheria which was so seriously prevalent gives dis¬
tinct signs of abatement, the mortality being one-third only
of that for last year. But still, 11 deaths from diphtheria,
with () from membranous croup, together with the amount
of non-fatal throat mischief which these 17 deaths denote,
should lead to very careful precautions as autumn advances,
especially in the exclusion of sore-throat attacks from
elementary schools ; and no amount of work eiTected in
improving drains, sewers, &c., should be allowed to inter¬
fere with such supervision of school attendances. Valuable
as it is to deal with bell-traps &c , there is the still graver
coDsideratioQ attaching to aggregation of children at sus¬
ceptible ages, and the risk ot throat infection acquiring,
under such circumstances, a virulence that it would be
difficult to control.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6231 births
and 4304 deaths were registered daring the week ending
April 4th. The annual rate of mortality in these towns,
which had declined from 24'1 to 21 ’2 per 1000 in the preced¬
ing five weeks, rose again to 22*4 last week. The rate was
20'9 in London and 23'7 in the twenty-seven provincial towns.
During the thirteen weeks of the quarter ending on the 4th
inst. the death-rate in the twenty-eight towns averaged 23 0
per 1000, and slightly exceeded the mean rate in the corre¬
sponding periods of the tenyears 1881-90. Thelowest rates
in these towns last week wereH’l in Derby, 14-5 in Brighton,
17‘6 in Nottingham, and 181 in Birmingham; the highest
rates were 30'2 in Halifax, 30 6 in Portsmouth, 310 in Ply¬
mouth, and 36*5 in Hull. The deaths referred to the
principal ^motic diseases, which had been 449 and 414 in
the preceding two weeks, rose again last week to 468 ; they
included 184 from measles, 149 from whooping-cough,
35 from scarlet fever, 34 from diarrheea, 33 from di^theria,
30 from “fever” (principally enteric), and 3 from small¬
pox. These diseases caused the lowest death-rates in
Norwich, Brighton, and Oldham, and the highest rates in
Huddersfield, Blackburn, and Portsmouth. The greatest
mortality from measles occurred in Leeds, Bristol, Hudders¬
field, Blackburn, and Portsmoutli; from scarlet fever in
Bradford, Bolton, and Halifax; from whooping-cough in
Halifax, Newcastle-upon-Tyne, Plymouth, Salford, and
Leicester; and from “fever” in Wolverhampton. The 33
deaths from diphtheria included 24 in London. Two fatal
cases of small-pox were recorded last week in London, and 1
in Hull; 7 small-pox patients were under treatment in the
Metropolitan Aisylum Hospitals, and 2 in the Highgate
Smail-pox Hospital, on Saturday last. The number of scarlet
fever patients in the Metropolitan Asylum Hospitals and
in the London Fever Hospital at the end of the week was
1026, and showed a further decline from' recent weekly
numbers; the patients admitted during the week were 98,
against 91 and 81 in the preceding two weeks. The deaths
referred to diseases of the respiratory organs in London,
which bad declined in the preceding five weeks from 685 to
466, rose to 489 last week, and exceeded by 12 the corrected
average. The causes of 97, or 2'3 per cent., of the deaths
in the twenty-eight towns were not certified either by a
registered medico practitioner or by a coroner. All the
causes of death were duly certified in Norwich, Plymouth.,
Wolverhampton, Bolton, Bradford, and Carditl'; the largest
proportions of uncertified deaths were recorded in Sheffield,.
Preston, and Liverpool._
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had been 25'9 and 26'7 per 1000 in the preceding two-
weeks, declined to 26‘2 during the week ending April 4th,
but exceeded by 3'8 the rate that prevailed during the
same period in the twenty-eight large English towns.
The rates in the eight Scotch towns ranged from 14-5
in Aberdeen and 16'7 in Leith to SOT in Glasgow and 44-4
in Paisley. The 684 deaths in these eight towns showed
a decline of 14 from the number in the preceding
week, and included 41 which were referred to measles,.
28 to whooping-cough, 14 to diarrheea, 9 to diphthe^ia^
5 to scarlet fever, 3 to “fever,” and not one to small-pox.
In all, 100 deaths resulted from these principal zymotic
diseases, against 73 and 93 in the preceding two weeks.
These 100 deaths were equal to an annual rate of 3 8 pen-
1000, which exceeded by 1*4 the mean rate last week
from the same diseases in the twenty-eight English
towns. The fatal cases of measles, which had increased
in the preceding four weeks from 16 to 36, further rose
last week to 41, of which 20 occurred in Paisley and 1&
in Glasgow. The deaths referred to whooping-cough, which
had risen from 31 to 34 in the previous three weeks, de¬
clined to 28 last week, and included 10 in Edinburgh, 8 icc
Glasgow, and 5 in Dundee. The 9 fatal cases of diph¬
theria showed a further increase upon recent weekly
numbers; 2 occurred in Glasgow, 2 in Dundee, and 2 ih
Paisley. The 5 deallis from scarlet fever were within 2 o?
the number in the preceding week, and included 4 in*
Glasgow. The deaths referred to diseases of the respirp,tory
organa in these towns, which had declined from '201 to-
169 in the preceding three weeks, were 166 last week, and
exceeded by 36 the number in the corresponding week of
last year. The causes of 64, or more than 9 per cent.„
of the deaths in the eight towns last week were not certified.
HEALTH OF DUBUN.
The death-rate in Dublin, which had increased from 28 3
to 29 T per 1000 in the preceding three weeks, declined to
23'9 during the week ending April 4th. During the
thirteen weeks of the quarter ending on Satvirday
last the death-rate in the city averaged 30'2 per 1000, the
rate for the same period being 22-6 in Loudon and 21 &
in Edinburgh. The 162 deaths in Dublin showed a decline
of 35 from the number in the preceding week, and included
3 which were referred to whooping-cough, 1 to “fever,” 1
to diarrheea, but not one either to small-pox, measles,,
scarlet fever, or diphtheria. Thus the deaths referred to
the principal zymotic diseases, which had been 11 and
8 in the preceding two weeks, further declined last week
to 5; they were equal to an annual rate of 0‘7 per
1000, the rate from the same diseases being 1*9 in London
and 2'8 in Edinburgh. The fatal cases of whooping-cough,
which had been 5 and 3 in the preceding two weeks, were
again 3 last week The deaths referred to “fever,” which
had been 4 and 3 in the previous two weeks, further de¬
clined to 1 during the week under notice. The 162 deaths in
Dublin included 28 of infants under one year of age and 48 of
persons aged upwards of sixty years; the deaths both of
infants and of elderly persons showed a decline from those
recorded in recent weeks. Eight inquest cases and 4 deaths-
from violence were registered ; and 57, or more than a third,
of the deaths occurred in public institutions. The causes of
18, or more than 11 per cent., of the deaths in the city were-
not certified.
THE SERVICES.
Surgeon N. Mookerjee, of the 4th Burraah Infantry, willl
accompany the Manipur Relief Column, which is to start
from Tamu.
ARMY Medical Staff.— The following Surgeons-Major
of the Medical Staff who have ranked as Majors will hence¬
forward become entitled to rank as Lieutenant-Colonels:—
L. A. Irving, J. A, M'Cracken, M.D., J. M. Beamish, M,D.>
Coogle
The Lancet,]
THE COMMUNICABILITY OF CHOLEHA.
[April U, 1891. 8i9
J. A. Clery, M.B , J. Coats, M.B,, J. 0. Williamsoa. W. J.
S’aweett, M.B,, H. W. Joynt, W. E. Saunders, D. Leckie,
M.B,, W. J. Charlton, A. H. Antbonisz, M.B., 0. F.
Molloy, R. Exham, J. M'Namara, M.D., R. Harman, M,B.,
■G. O. N. Leake, J. W. O’M. Martin, M.B., P. R, Gabbett,
M. D. O’Connell, M.D., W. Finlay, and E. H. Joynt, M.D.
burgeon J. F. Bateson, M.JJ., has been selected to be
.attached to the Coldstream Guards for bis tour of home
service, vice Surgeon R. H. Cox, who has resigned his
•commission.
Naval Medical Service. — The following appoint¬
ments hsve been made at the Admiralty:—Inspector-
General of Hospitals Edward T. Mortimer to Plymouth
Hospital (dated May 7th, 1891 ; Deputy Inspectors-General
Maxwell Rogers, M.D,, to Malta HospitaX and Duncan
iHilaton, M.D.,to Haslar Hospital (both dated April 4th,
1891). Surgeons Alexander George Pemberton Gipps, John
Hunter, M.B., Robert Mclvor, M.D., and Wm. George
Jack have been promoted to the rank of Staff Surgeon in Iler
Majesty’s Fleet. Staff Surgeons: Wm. H. Patterson to
the Aurora, and Alexander G. P. Gipps to the Soscawen
<both dated April l.Sfch, 1891). Surgeons: George Allen,
M.B., to the Lizard (dated April 1st, 1891); John E. Webb
■to Haslar Hospital (dated March 1st, 1891); George L. Baker
to the Racer, and Edwd. R. D. Fasken to the Lion (dated
April 21st, 1891); James J. Walsh to Chatham Hospital,
and Wm. G. Axfotd to Bermuda Hospital (dated April 7th,
11891).
Volunteer Cores. — Artillery/: 3rd Durham (Western
Division, Royal Artillery): Francis Wm. Sinclair, M.B.,
to be Acting Surgeon (dated April 4th, 1891).— Rifle:
3rd (Cambridgeshire) Volunteer Battalion, the Suffolk
Regiment: Acting Surgeon F. P. F. Ransom, M.D., to be
Surgeon (dated April 4th, 1891).—5th (Deeside Highland)
Volunteer Battalion, the Gordon Highlanders: Robert
Eannie, M.B., to be Acting Surgeon (dated April 4th, 1891).
Cflmspnlrtnrt
“ Audi alteram partem.”
THE COMMUNICABILITY OF CHOLERA.
To the Editors of The Lancet.
SiR.s,—In your notice of the proceedings of the Epidemio¬
logical Society in The Lancet of this date it is reported
that “ though asserting his disbelief in the communicability
of cholera by human agency or material means, Sir Joseph
Fayrer urged bacteriologists to pursue their investigations
in the calm, temperate, and judicial spirit shown by the
lecturer. He differed from many of their conclusions,
o.l_thoughunacquainted[it8houldbepracfj:<;allyunacquainted]
with their methods, but provided they did not ignore otW
•causes of disease their labours could not fail to lead us
nearer to the truth.” The reporter has, I fear, misunder¬
stood, and therefore unintentionally misrepresented, me. I
certainly^ did say that I have not yet been satisfied that
cholera is communicable by direct contagion, by a germ
from one individual to the other, but I did not say that it is
altogether independent of human agency or material means.
Knowing as I well do that local insanitary conditions,
impure water, foul air, certain climatic conditions, together
with overcrowding human beings, are potent factors in the
development of the disease, I yield to no one in my admira¬
tion or the work and discoveries of bacteriologists ; but I
venture to think there is a disposition to too hasty generali¬
sation, and, in the zeal and eothuisiasm of scientific investi-
,'gation, too great a tendency to describe as causes what may
be but epiphenomena, too little recognition of the many
other possible causes of disease wliich lie within and around
us. I venture, in short, to think that though we are well
•acquainted with the nurses, we as yet do not know t\x^mother
•of cholera. I am, Sirs, yours faithfully,
ApriUt!., ISOl. _ __ J. FAYREU.
THE PULSE IN ANGINA PECTOllLS.
To the Editors of The Lancet.
Sirs, —^Through mischance I did not see Dr. Gairdner's
.etber in The Lancet of March 28tli on the subject of the
^nilse in angina pectoris; may 1 now he permitced a few
woras m reply The quotation which Dr. Gairdner cites
must, 1 confess, be taken as the expression of a doubt that
the pulse may be unaltered during sn attack of angina,
though surely the (quotation from Heberden given in the
foot-note justifies an interpretation different from that which
Dr. Gairdner gives. The ground, however, upon which I
stated that Dr. Gairdner definitely accepted the statement
that the pulse might be unafibeted daring an attack of
angina pectoris is the presence, on p. 641, vol. iv.,
Reynolds’ “ System of Medicine,” of the following para¬
graph : “ On the other hand, it must be admitted that in a
few instances the heart has been heard beating in the very
midst of a paroxysm, without appreciable alteration in the
character of the sounds and impulse, and the pulse has also
been said to be regular, and neither rapid nor weak.” This
definite abatement will perhaps justify my use of Dr.
Gairdner’s name, though I must confess that had I been
fully alive to the doubts expressed elsewhere in the article
referred to I should not have quoted Dr. Gairdner in the
sense I did.
May I add that the real object of my letter of March 21s6
was to draw attention to a definite statement, backed by
authoritative names, and to point to the conclusion which
the acceptance of such statement would compel—viz,, that
in some cases at least the seizure of angina pectoris is inde-
pendent of any heartfailure. Of course, after Dr. Gairdner’s
letter the above statement no longer has bis sanction.
I am. Sirs, yours faithfully,
Welbeck-st., W.. April 6th. ISDl, HARRINGTON SAINSBURY.
THE TREATMENT OF CHRONIC INFLAMMA¬
TORY DISEASE OF THE UTERINE
APPENDAGES.
To 'the Editors of The Lancet.
Sirs, —I think Df. Herman is mistaken when he says my
proposed challenge would not further our knowledge as to
whether the majority or minority of inflammatory lumps in
the pelvis tend lo spontaneous cure or not. But that is not
what I proposed to discuss. What I did propose to inves¬
tigate—and I am positive I could settle it definitely in
the way I suggest—is the preliminary question, whether
Dr. Herman and his school are speaking of the same thing
that I am when the phrase “chronic inflammatory disease
of the uterine appendages” is used. Ic must be evident to
all your readers that we are not, and I could prove to
Dr. Herman that he includes a great group of cases of mere
subinvolution and hyperminia which we exclude. Bub he
declines to accept my proposal, and so he must remain in
the realms of daikness. He is good enough to say I might
serve medical science by publishing more detailed and exact
reports of my own cases. Dr. Herman’s memory in my
case must be as strangely defective as it was shown to be in
the case of Dr. Braithwaite, or he must confine his reading
to the Transactions of the Obstetrical Society, in the ranks
of which he is a distinguished leader. But what is the use
of our making appearances at the Obstetrical Society ?
Dr. Braithwaite's paper was refused, and several of mine
have been refused. A few nights ago Dr. Grigg attended
with the preparations of three cases of recent occurrence,
and he gave full details of their clinical histories. I was
prepared to substantiate bis statements and to elaborate
the details of the operations with which he had entrusted
me, but there was a “ conspiracy of silence,” and the very
men who are ever ready enough to abuse us and to mis¬
represent our work when we are not present, were as dumb
as mice when we had them face to face.
I am, Sirs, yours truly,
April Oth, 1801. IjAWSON TAIT.
*** We cannot devote more space to this controversy.—
Ed. L.
EMOTIONAL EXPRESSION.
To the Editors oj The Lancet.
Sirs,— In your last issue you deal with emotional ex¬
pression, and point to the theories advanced by Darwin
relating thereto. I certainly agree with you in admitting
that to a certain extent many things which up to late years
have been allowed to rest as natural, may be and are
becoming daily more satisfactorily explained. Now we
know that blushing may be caused by division of the
cervical sympathetics due to dilatation of the arteries of
the head and neck, and consequent increased How of blood
Die' -sd by Google
850 The Lancet,]
SURGICAL CONGRESS AT BERLIN.
[April ll, 1891.
to these parts, while the reverse obtains should the upper
ends of we divided nerves be stimulated by electricity.
Therefore we say that through the cervical sympatbetics
is exercised an inhibitory action (the centre mr which is
situated in the medulla)over thearteriesof the bead and neck,
which keeps them in a state of tonic contraction. On the re"
moval of tbU inhibitory action, or, as Foster has it, “diminu¬
tion of the normal tonic action of the [medullary] centre,”
dilatation occurs; while, on the other hand, stimulation of
the centre causes “increase of the same normal tonic action
of tlie centre,” and pallor without any lessening of the heart’s
action results. Analogous with the above may be mentioned
lacrymation and salivation, the latter due to increased
vascularity of the salivary glands—in the case of the sub-
maxillary the stimulus paasine down the chorda tympani.
Laughter we may take, I think, as an exaggerated form of
smiling, plus a series of vocal sounds. It we accept the
above explanation as regards blushing and crying, may we
not also assume that the human face preserves its normal
expression owing to certain nerve inllueuces, more or less
subservient to the will according as its possessor can com¬
mand it ? Remove this so to speak inhibitory action, and
the face loses its natural expression and firmness of outline
and comes to wear a peculiar vacant, almost meaningless,
look—a smile. This smile or vacant look is tliat of an
idiot, and as such the perpetual wearer of it would I think
be classed. This is partly borne out by the knowledge of
the fact that the face is a very fair picture of the mind of
its owner, and that a man of strong will may restrain from
laughter if he chooses, whereas the weaker the will the less
able is he to govern his actions. The case of the crying
child tightly shutting its eyes, is not this an exaggerated
form of the wrinkling?
Regarding the cause: these acts are acknowledged to be
governed by centres situated in the medulla, and probably
the immediate exciting cause is the disturbance of the
equilibrium normally existing there. Such may he caused
by various agents apparently — e.g., lacrymation by
emotion, or external stimuli, as touching the eyeball, the
vapour of onions, &c.; salivation by action of certain
drugs, such as calomel, or through the agency of the
nervous system, as is produced by the smell or sight of
food. Again, we know that all these phenomena are much
more prone to occur in persons of feeble intellect, as, for
example, the hysterical.
Darwin’s theory, to which you lastly draw attention—
viz., that “when the sensorium is strongly excited, nerve
force is generated in excess, and transmitted in certain
definite directions,”—appears to be the soundest explana¬
tion as yet volunteered. Doubtless, when this excess of
nerve force is generated it must, as you say, “ find vent in
some outward and physical manifestation,” and impulses
travel and attack those parts of the human organisation
which are in a more or less weaker state than others, and
therefore less able to resist. This will perhaps account for
the same effect being produced by different emotions, such
as crying from either grief or joy. The subject is, indeed,
one which opens a vast field of inquiry, and it will be
interesting to hear the views of some of your readers better
acquainted therewith.
I am, Sirs, yours faithfully,
Southwark, March 17th, 1801. SIDNEY E. AtkiNS.
PUBLIC HEALTH (LONDON) LAW AMEND¬
MENT ACT.
To the Editors o/The Lancet.
Sirs,— Permit me to draw your attention to Clause .35 (1)
of the above Act, which runs thus : “ The power to appoint
the medical officer of a union to be a medical officer of health
is hereby repealed.” On what ground is the district medical
officer singled out to be debarred by law from pursuing that
branch of his profession for which his public position par¬
ticularly fits him? It should be remembered that a great
proportion of the profession either are, have been, or will
be medical officers of a union, and I would venture to sub¬
mit that such officers may justly ask the entire profession,
including the heads of colleges from which they have
obtained the legal right to practise all branches of their pro¬
fession, to assist them in their, I trust united, endeavour to
prevent an act of such gross injustice as well a3,to resent
such a gratuitous and unwarrantable insult.
I am, Sirs, yours truly,
April 8tb, 1801 FAIRPLAY,
THE TWENTIETH SURGICAL CONGRESS,
HELD AT BERLIN.
{From our own Correspondent.)
At noon on the 1st inst. Professor Thiersch opened the
Surgical Congress in the festal hall of Berlin University.
Besides the Berlin surgeons and Professors Koch, Koenig of
Gottingen, Esmarch of Kiel, Bruns of Tubingen, Kuester of
Marburg, Wagner of Kmnigehuette, Mikulicz of Breslau,
Lauenstein of Hamburg, and Roth of Dresden were present,
and the attendance was very numerous. The President
referred to the members who had died since the last
meeting, the most famous of whom were Nassbaum of
Munich and Reyher of Dorpat. The committee was re¬
elected by acclamation, and Prof. Bergmann was elected
president, who reported on the Langenbeck House, an
institution to be established in memory of the great surgeon
whose name it is to bear.
After some preliminary business, the President addressed
the assembly on the subject' of Koch’s method. The
gist of lus remarks was as follows. Local reaction takes
place only in real tuberculosis, whereas general reac¬
tion has been observed in other diseases—for instance,
actinomycosis and softened large sarcomas. In the latter
cases, indeed, it is likely that the patients suffer from tuber¬
cular affections too, and this question ought to be decided
by post-mortem examination. The unfavourable effects of
tuberculin must be judged of with great caution. General
tuberculosis sometimes sets in after extensive surgical
operations in cases of local tuberculosis, and the occur¬
rence of miliary tuberculosis after the application of
tuberculin is perhaps to he compared with such cases
and explained in the same manner. It is at any rate
necessary, before attributing the outbreak of general tuber¬
culosis to the injections, to ascertain that the fever caused by
the latter did not decrease till the termination, and that the
necropsy proved the existence of a single focus, from which
the bacilli spread. One must also prove that the spreading
of the bacilli is fresh, which is no easy matter. He had
observed that in many cases, after apparent cure, new
tubercularulcers and nodes appear at places where they did
not exist before. One may say that latent tubercular
nodules had already existed there which now became
apparent. But the outbreak sometimes occurs so long
after the treatment (from six to ten weeks) that this
explanation presents difficulties. It is still more un¬
fortunate that such new nodes and ulcers resist
Koch's treatment, whereas it might be thought that they,
if any, should yield to it, because tuberculin is said
to be more efficacious in the early stages of tuberculosis.
These incidents at least prove that Koch’s method does nob
protect against relapses, and this concurrence of fairly
regular initial efficacy, with frequent relapse, is one of tho
mostunfavourablefeaturesinthematter. Should the question
he raised whether we ought to abandon the remedy or alter
its application, in order to discover whether the initial
successes can he made permanent, it must be said that the
former course would be premature; considering tho
shortness of the time over which our experience extends, the
latter course should be adopted. At any rate, science will
gain richly by these experiments; just as in the story
of the treasure-seekers in the vineyard, the fertility
of the vineyard was increased by their eflbrts to find
gold. Dr. Koenig of Gottingen spoke more hopefully. He
now injected tuberculin in small doses, beginning with
half a milligramme, and had more cases of improve¬
ment than before. Some patients ought not to be sub¬
jected to the treatment at all, especially those suffering
from multiple tubercular disease, and those with un¬
diagnosed large foci in joints. Many other cases showed
improvement at first, then became stationary, while in others
the effect was excellent. To the latter category belonged,
above all, lupus of the oral cavity, in the treatment of
which tuberculin had already become indispensable. In
agreement with Bergmann, Koenig declared the favourable
effect to be a consequence, not of necrosis, but of the flushing
of the diseased parts with exuded fluids, the anti-bacterial
serum and white blood-corpuscles of which haveatherapeutic
effect. At any rate, there were no other means by which
similar phenomena could be produced, and therefore the ex¬
periments should be continued. Thiersch confirmed Koenig’s
remarks on lupus of the oral cavity. Schede of Hamburg
declared tuberculin to be an invaluable weapon againsB-
’8
The Lancet,]
THE SUN-BATH OF THE SAHARA.
[Apbil 11, 1891. 851
tuberculosis. He had not observed bad effects of a serious
nature. He believed the variations of effect to be due to
differences in the use of the remedy. He had never seen
cases of miliary tuberculosis that could be with certainty
attributed to the administration of tuberculin. The foci that
came to li^ht after the injections v'ere always old ; they
showed caseous contents, and had therefore existed for a
length of time, and only been developed by the treatment.
He used very small doses, and sought to measure them so
as to avoid fever and to render a rapid increase of the doses
possible. He regarded careful tendance, good nourishment,
and plenty of fresh air as very important auxiliaiies.
Lauenstein of Hamburg spoke in similar terms. Eiselsberg
of Vienna reported on a cose of actinomycotic tumour in
Billroth’s clinic that had been cured by tuberculin ; and
Kuester of Marburg on two coses of non-tubercular tumours
;n which local reaction had taken place. The discussion
was then closed.
Senger of Krefeld then spoke on the efficacy of
iodoform injections in surgical tuberculosis. He believes
•that he has discovered the reason why the treatment
of articular tuberculosis with iodoform is sometimes
successful and sometimes not. It is not the iodoform itself,
he thinks, which causes the cure, but the formic acid pro¬
duced by its oxidation. If oxidation take place iodoform
Acts, but not otherwise. On the strength of this theory he has
injected formate of soda and formic sulphuric ether with
good effect. The last speaker was Dr. Kubenstein, who
communicated the results obtained by Professor Schueller
of Berlin in more than one hundred cases of local tuber¬
culosis of the skin, the glands, the bones, and the joints
by a combination of incernal treatment with guaiacura,
partly with surgical treatment, partly (in tuberculosis of
the joints) with injections of iodoform glycerine into the
joints and directly into the tubercular soft parts and bones
Oelongiog to the joints. Of fifteen cases of articular tuber¬
culosis treated in this manner nine are already permanently
cured, As regards the other forms of local tuberculosis
Schueller’s results are of special importance, because in
'many cases of cure there has been no relapse, though years
have passed since the close of the treatment. Some cases
•have been observed for more than eight years.
The second sitting began with a discussion between
Liebreich and Bergmann. In bis speech on Koch’s method
Bergmann had mentioned Liebreieb’s canthavklinate of
potash, and had stated that in several cases of lupus treated
with it in his clinic no result had been obtained. Liebreich
.now maintained that there was improvement in these and
other caseS'—slow indeed, butdistinct. Bergmann declared the
supposed improvement to be nothing more than an erroneous
interpretation of the continual changes characteristic of all
cases of lupus. Liebreich expressed tbehopethatit would soon
be possible to prove the unquestionable improvement more
convincingly. Koenig then spoke on the osteo-plastic treat¬
ment of congenital dislocation of the hip-joint. He had
■tried to obtain a permanent cure by splitting off a plate of
bone from the pelvis and forming an artificial socket to
hold the condyle firmly. He could not report definitely on
the result, mainly because two of the children first operated
on had died of infectious diseases. Schuchardt of Stettin
then reported a case of extirpation of a tubercular kidney,
and several cases in which lupus had at first been supposed
to be cured and had afterwards reappeared were shown.
Urban of Leipsic, on the other band, showed acaso of extensive
lupus of the left temple, cheek, and neck, which had been
■completely cured by extirpation, followed by transplantation
of healthy skin. With reference to this case Tliiersch
.remarked that the transplanted layers of skin grow the
more easily the thinner they are, but the appearance of the
cicatrix is proportionately leas good. In young adults, how¬
ever, engrafted skin shares in their growth and becomes
thicker, so that in such cases the use of thin layers is per¬
missible even from the restbetic point of view. Patients
•in whom Koch’s method had been combined with surgical
treatment were then shown. Though it cannot be said
•that they are completely cured, their general condi¬
tion is so much improved that a gradual, complete,
and permanent cure may be expected. According to
Hahn, who had operated on one of these patients, a very
careful selection of cases is the first condition of success,
And suitable cases are not numerous. Westpbal of Beilin
•then reported three cases of articular tuberculosis, which
■b^^d been successfully treated by Koch's method. Bruns of
T Libingen then spoke on cirsoid neuromas and aneurysms.
Army Surgeon Dr. Benda showed a case of traumatic cortex-
epilepsy, which bad been cured after extensive osteo-plastic
trepanning and the removal of a piece of the cerebral cortex.
■Tbe third meeting began with a discourse by Herzog of
Munich on tbe involution of tbe umbilical vessels. He
regards the process not as a retraction of the distendeci
tissues, but as a partial decay of them, and believes that
thrombosis does not play so definite a part in tbe final
closing of the vessels as has hitherto been ascribed to it,
and that, on the contrary, it may, under certain circum¬
stances, delay involution. Professor Gurlt then reported
the result of a proposal made last year that the members of
the Congress sUould send in statements of tbe number of
anassthetisalions undertaken by them, and of the untoward
accidents observed by them on those occasions. Sixty-six
reports, mostly from Germany, and mostly confined to a
part of last year, had been received. Unfortunately six
German clinics and several gteab hospitals had not yet
reported. The Berlin Charitd, on the other hand, had
reported on a period of twelve years, and the dentist
Ritter of Berlin on 1748 cases. Deducting the Charit4
cases, the number of which was roughly estimated at
12,000, 24,675 coses of anresthetisation had been reported,
22,656 with chloroform, 470 with ether, 1055 with ether
plus chloroform, 470 with ether plus chloroform plus
alcohol, and 27 with bromide of ethyl. Among the
chloroform cases 71 cases of threatened asphyxia and 6
deaths occurred; among the ether cases, none even of
danger; among the ether-chloroform cases, 6 of danger;
among tbe etber-chloroform-alcobol cases, 4 of danger;
among the bromide of ethyl cases, none. The chloro¬
form used was obtained mostly from German and English
chloral factories. Of 2732 narcoses, 278 lasted an nour
or more. The three longest lasted 150, 155, and 180
minutes. The average consumption of chloroform with the
ordinary mask was one gramme per minute; with the
Junker-Kappler mask 0^6 of a gramme. One private
clinic reckoned the average consumption at twenty-five
grammes per case; the maximum consumption was l&O
grammes. Some of the reporters increased tiie narcosis by
injecting morphia. Tbe threatening of asphyxia occurred
in patients of all ages and degrees of strength. Professor
Bruns remarked that the results were not unsatisfactory,
but that better ones seemed not impossible. Greater atten¬
tion, especially, should be paid to ether narcosis. The
materials, too, were not copious enough to admit of safe con¬
clusions. A proposal to continue the inquiry was accepted.
Berlin, April 7th.
THE SUN-BATH OF THE SAHARA.
(From a Holiday Contributor.)
Never within the experience of the oldest hotel-keeper
between Tunis and Constantine, or Constantine and Biskra,
has there been such on.inroad of arrivals as during the
winter now closing. The abnormal cold, which, south of
the Algerian littoral, drove tbe Bouira lion from his den and
made the panther a too familiar object near Bdne, bad
emptied the winter cities of Spain and thesuntrapsof Italy,
and even thinned tbe aprici advence of the French Riviera—
sending all flying southward in quest of sun. The favourite
terminus of these pilgrims was Biskra, and its hotel
accommodation, after being strained to bursting, had to be
supplemented by improvised lodgings in tbe town. Nor
was it the hotel service only that proved inadequate to tbe
demand. Tbe railway arrangements, wretched at all times,
broke down—at least to this extent, that first-class pas¬
sengers had to be thrust into second-class and even third-
class carriages—an experience which many a traveller on
the Tunis-Constantine railway recalls with a shudder. That
ill-starred line runs no exclusively passenger trains, but
simply a few carriages interspersed iiere and therein a long
series of goods waggons. The distance between the two
cities is some five hundred kilometres, which the Flying
Scotsman or the Wild Irishman would overtake (stoppages
included) in seven hours. Not so, however, the “ Flying
Berber ” ! With a top speed of fifteen miles an hour it jogs,
I cannot say “runs," from Tunis to Constantine, from five
o’clock in tbe morning till long after midnight. Break the
journey at intermediate stations like Souk-el-Arbiia or
Souk-Ahras you cannot, the inns at these places being little
852 The Lancet,]
THE SUN-BATH OF THE SAHARA.
[Apbil 11, 1891
better than that one immortalised ia Anne of Gierstem ”
ae kept by John Men^s. The buffets at these and other
stations are provided \nth food which Signor Sued after bis
thirtieth day’s fast would think twice before tackling, and
the beverages would daunt the prowess of the Irishman
who, after a glass of Scotch whisky, felt " as if a torchlight
procession had gone down his throat.” As for such con¬
veniences as even third-class passengers between London
and Edinburgh are accustomed to, the Tunis-Constantine
railway hsks none of them, while the lieux d'aisance along
the line are hardly to be approached, much less entered.
Foot-warmers in first-class carriages are provided only when
you near Constantine, though, as I can testify, the cold
was as keen as any encountered on a winter’s journey
between Moscow and St. Petersburg. Yet even in such
conditions invalid old gentlemen, delicate ladies, and con¬
valescents from every form of lung mischief have, since the
middle of January, been pressing southwards to Biskra,
and when I left that “ islet in the great sand sea ” a few
days ago the cry was “ still they come.”
French colonisation is at beat but a poor affair, and after
sixty years’ occupation of Algeria its railway service and
hotel accommodation are haS a century behind the day.
But competition may supply the stimulus to improvement
for which native initiative has been wanting, and national
jealousy may come in to accelerate both. As year by year
a larger influx of pilgrims in search of warmth invades
North Africa, and pushes ever southwards in quest of what
the Mediterranean seaboard cannot vouchsafe, the resources
of the Sahara as the great sun-bath of Europe will more
and more assert themselves. If France is so olind to her
opportunity as not to ntilise her advantages in catering
for such a public, other countries will not be slow to step
in and oust her. Cardinal Lavigerie, who to the world-
sympathy of a great philanthropist unites the sagacity
of a statesman, has already given his compatriots the
broadest of hints to this effect. *‘A11 the nation^ities of
Europe,” he said the other day, “ are pressing on and into
the Sahara. There are the English viA the Niger, the
Italians from Abyssinia, the Belgians from the immediate
south of the Equator, and Germany from the southern and
eastern sides. We mnst at every cost safeguard our rights
in the Sahara and the Soudan by a complete iron network
of communication to connect our Algerian poseeasions with
the Great Lakes.” That these words have not fallen on deaf
ears may be read in the prolonged debates that have
recently engaged the Corps Ldgislatif on France’s North
African policy, and before the century is out we may have
something like the development as to transit and accommo¬
dation which should have been started when the century
was still young.
As a first step to furthering the resources of South
Algeria in health resorts, the access to the numerous hot
sulphur baths in which it abounds should be facilitated, and
the hotels at these places put on a really civilised footing.
Take, as a typical example, Hammam Meskoutine, on the
line of railway between Constantine and B&ne. That the
Romans had already known and utilieed that wondrous
spring goes without saying — the “Aqum Tibilitinfe,” as
they called it, having baths cut by them out of the living
rock, and still used by hospital patients. “The tempera¬
ture of the water,” says Sir Lambert Playfair, in his excel¬
lent handbook, “is no less than 203“F., which, taking
into consideration the height of the source above the sea
level, is just about boiling-water heat, and is only sur¬
passed by the Geysers in Iceland and Las Trincheras
in South America, the former of which rises at 208°
and the latter at 206° temperature.” The spectacle that
the lime-encrusted rock presents is perhaps unique, only
paralleled, it is said, by a simi’ar development in New
Zealand, now, alas ! spoiled by a convulsion of nature. As
the water gushes from the soil it forms streamlets that find
their way over a steep rock into the glen below, and are
used for cooking and washing by the villagers. But the
edge and facade of the rock itself have the appearance of
“ a torrent frozen in the leap,” the waves of carbonate of
lime in solution having become stiffened and stagnant
just as they descended from above, and hanging down like
folds of drapery, snow-white and occasionally cream-
coloured, over the brook, in which the yet running stream¬
lets unite. Natural scenery in and around Hammam
Meskoutine combines with specific thermal advantages to
make it a favoured resort not only of the gouty, rheumatic,
and neurasthenic, but of the artist and the sportsman, to
say nothing of the archmologist; but even now the railway
service to and from it is such as I have described. Tb&
hotel accommodation (with all goodwill on the landlord’s^
part possible) is insufficient, and the entertainment lb
affords too irregular to be satisfactory three days running.
What wonder if the clients it attracts, instead of remaining;
long enough to get the good it is capable oPyielding, seldom
put up with it more than forty-eight hours ? Not that ite
unique attractions have been appreciated only by Imperial
Rome. In a little grotto quite near the bungalow that does-
duty for a hotel—almost as hidden from the eye ae the*
tomb of Archimedes at Syracuse—I noted the following,
and {sicut mens est mos) transcribed it as another accession)
to the gallery of “Medicine’s forgotten worthies” ;—
Docteur Moreau,
1800-1870,
Ancion Mc^decin des Armies ot dea HOpitaux oivilea de BOne,
Clievalier de la Lc^gion d’Honneur et de rOrtlro de Fraiivol'^ I®'"- d’ltftlie.,
Fondateur de I’Etabliasement Thermal d'Haraman Moakoutlno.
Bcwj'acUndti vixit.
Evidently the good doctor’s initiative has not been followed!
up in the spirit in which be took it, and Hamiiian Meekou-
tine—still without a resident j^ysician l—remains another
example out of many of what Fiance has yet to do before
she can reap the benefit of Nature’s gifts so generously
lavished on her African possessions.
The same bolds equally—or still more—true of the lovely
oases in the desert, sun-baths in the severest winter, whet»
the French and Italian Riviera, and the Mediterranean)
islands, are but a shade less trying to the victim to weak
heart or impaired lung than the sheltered spots on our south
and west coast, which far transcend their continental rivals-
in comfort and civilisation. Biskra, delightful os it is,
might have many counterparts within easy hail of it, if only
French appreciation and enterprise were equal to the occa¬
sion. But, as I have said, the difficulty of getting to and
from the neighbourhood is such that few inv^ids venture ooi
repeating their visit, while the excellent Swiss Hotel and
its French rival are quite inadequate to the require¬
ments of even such a recently frequented resort. The
overcrowding of which Biskra was the scene from the-
middle of January to the end of March (and, I
may safely add, at the present moment) must ere
long incur its Nemesis in blood-poisoning of the too-
familiar kind. Shortly before I left there were fourteen)
cases of typhoid fever reported in the town, one case of
diphtheria, and, in one of the hotels, a case of quotidian re¬
mittent fever, which but for prompt treatment might have
drifted into what Italian physicians call “ typho-malaria.”'
There is no fall from the soil level, and sanitaiy engineering
has yet to meet this obstacle to the speedy removal of the
sewage which drains off from the hotels and pensions. It
is disheartening to have to admit it, but nothing short of
the pressure of competition will stimulate French energy to
the undertakings which appeal from every oasis for prompt)
and effective realisation. That pressure, however, as Cardinal
Lavigerie has already admonished his countrymen, is now
within measurable distance, and, in self-defence, if from
no other motive, France may yet be brought to put the
railway in working order and render the hotels more attrac¬
tive and to multiply the health-resorts, which invalid Europe
has so long been demanding in vain. Even America, repre ¬
sented by numerous patients at Biskra, feels after the late
terrible winters the want of the sun-bath of the Sahara,
and contributes to swell the cry for extended means of
utilising the months of certain warmth, of cloudless skies,
of dry, absorbent, exhilarating air, which may be enjoyed'
at the very door of French Africa. It would, indeed, be
hard to exclude from such enjoyment the compatriots of
him who conceived and prescribed the “rest-cure,” of which
the “islets in the great sand-sea” are the appropriate haven.
LIVERPOOL.
(From our own Correspondent.)
Death follo'wint) a Football Accident at Southport,
Mr. 8. Brighouse, the county coroner, held an inquest
on the 6th inst. upon the body of a painter, twenty-three
years of age, who died in the Southport Infirmary on the
4th from the effects of injuries received in a football match
on Good Friday. The deceased collided with one of hi&
The Lancet,]
LIVERPOOL.-NOBTHERN COUNTIES NOTES.
[April ll, 1891. 85$.
opponents, and fell forward with such force as to cause a
compound fracture of bis left arm. He was at once taken
to the Infirmary, where the arm was set, but it was re¬
garded from the first as a very serious case, and death
resulted from tetanus on the eighth day. There appears to
have been no blame attaching to anyone, and the jury
found a verdict of Accidental death.” The deceased
leaves a widow and child.
The Census and Physicians' Lives.
Among other results of the present census may possibly
be a satisfactory solution of the question now being debated
in The Lancet as to whether the lives of medical practi¬
tioners are or are not equal to those of other professional
men. Liverpool has had in past and present times a
very fair share of practitioners who, notwithstanding a
most laborious life, have lived to a great age. The late
James Dawson lived to be upwards of ninety, and to enjoy
excellent health in his charming retirement at Wray Castle,
Windermere. His colleague, the late Henry Park, who
first performed excision of the knee-joint, lived till some
years past eighty. Coming to more recent years, there is
now amongst us in perfect health a veteran who obtained
the licence of the College of Surgeons. Edinburgh, in
18522, and graduated there in 1826. Mr. F. Worthington’s
death has been but recently chronicled as taking place
in bis eighty-second year, and there are still several who
graduated in the thirties, enjoying excellent health, prac¬
tising, and in the full possession of their faculties. The
number who have passed the threescore and ten is apparently
quite equal to that of clergymen and lawyers. When
life insurance is more gener^ among medical men than it
unfortunately is now, perhaps there will be less difierence
of opinion among actuaries tnan there is at present.
The Medical Jurisprudence of Drowning.
As might be expected in such a city os this, many bodies
are removed annually from the river Mersey, and a smaller
number from the Leeds and Liverpool canal, to the mortuary
at the Prince’s Dock. The coroner invariably orders an
external medical inspection in every case, and, where this
appears to be called for, a post-mortem examination. The
bodies seen in the mortuary comprise every variety of age,
sex, and nationality; the drowning has been suicidal, acci¬
dental, or homicidal, and in many instances the body is not
identified. What is remarkable is that in a tidal river so
many bodies should be found long afterwards in a state of
decomposition near the spot where they were last seen, or
were seen to fall. In some cases it is evident that they have
been kept at or near the bottom of the river by some obstruc¬
tion. In other cases the body has been found remarkably well
preserved in all those parts which have not been exposed to
the air, whilst, from their appearance, the exposed parts
indicate that death took place some considerable time
previously.
The Burial of Stillborn Infants,
Many years ago, in consequence of some grave irregu¬
larity being discovered at St. Martin’s Cemetery in the
case of a newly born infant, the coroner’s ollicer made it a
rule daily to call there and make full inquiries into every such
case. The value of this arrangement has been frequently
demonstrated, and the practice continues now. Ais it is
the parish mortuary where the large proportion of recently
born infants, stillborn or deceaised, are taken, the arrange¬
ment has its advantages, though it becomes a grave question
as to what takes place in other cemeteries where a less strict
rule prevails. Much trouble is no doubt thrown upon the
officials when a medical certificate or coroner’s order is not
produced and a declaration is required. £ut the dangers of
any laxity in this respect are so obvious that it is greatly
to be wished that some uniform system should be adopted
at every burial ground where infants are interred.
Liverpool, AprU 7th,
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
The Serious Charge against a Medical" Electrician.
At the Newcastle Police-court on Saturday last Edward
Moross (whose case I referred to in last week’s “Notes”)
came up before the magistrates on remand. Moross has for
sometimepastbeengivingpublicexhibitionsin Newcastle and
its neighbourhood with demonstrations of patients “cured.”
Some of these patients, however, it was remarked, bore a.
very striking resemblance to patients “ cured ” by former
practitioners of hypnotism and rubbing &c. Moross wa®
again charged with having committed a rape on a girl aged
seventeen, and further with having committed an indecent
assault on another girl aged eighteen. The solicitor for
the prosecutrix said that Moross nad also inflicted upon the
first girl an abominable complaint. The evidence of the-
police surgeon went to support this, and also that given by
a prison warder. The magistrates, after an attentive
hearing of the cases, refused to take bail, but remanded
the prisoner, when, they said, he would be fully committed
to the Assizes, next Thursday. Demonstrations of approval
on this decision being announced were made by some persons
in court, and objected toby the prisoner’s solicitor ; but the
Bench, in reply, said “ they were men, and perhaps fathers.’^
Newcastle Royal Infirmary,
An interesting ceremony took place last week in the Royal'
Infirmary, being the reopening of the Chapel (St. Luke’s)-
after redecoration and rMurnishing, but especially in refer¬
ence to the unveiling of new stained glass windows, the gift-
of Mr. John Hall, a munificent citizen of Newcastle. Dr.
Gibb had defrayed the cost of furnishing and repairs, and
Mrs. Wilkinson the cost of painting art decorations, while
a beautiful oak pulpit lectern was the gift of Mrs. Armstrong,,
in memory of her late husband, Dr. Luke Armstrong, who
was for eighteen years one of the honorary surgeons of the
infirmary.
Middleshorough North Riding Infirmary.
The annual report of the governors of the North Riding
Infirmary has been issued, and it states that the genera-
condition of the infirmary is highly satisfactory. The state¬
ment of accounts shows an increased income amounting to
£269, and an increased expenditure amounting to £293.
The revenue account shows that £93 more than the income
has been spent, chiefly on account of an increase in th©
number of patients, which amounted in the year to 802,
against 734 for the previous year and 694 for the year before
that. The children’s ward still continues a source of
interest and sympathy. Sir R. Dixon had founded a cot
in commemoration of the visit of the Prince and Princess
of Wales, to be called the Alexandra cot, by express per¬
mission of her Royal Highness. Although the infirmary’s
financial position mav seem worse by £93 than during the
previous year, its medical position has materially advanced.
Durham.
A much respected member of our profession. Aider-
man W. Boyd, J.P., M R.C.S., received many honours
from the hands of his fellow-citizens last week. On
Wednesday he was presented with the honorary freedom
of the city, which he has so well served for nearly fifty
years. His record shows that he has been four times mayor
of Durhani, a member of this ancient corporation, and a
medical officer of a large district for nearly fifty years,
and a sanitary reformer when sanitary science was in its
infancy. Alderman Boyd had further honours the next
day (Thursday), when he was presented with a public testi¬
monial in the form of an address, bis portrait, a massive
silver salver weighing 50 oz., together with a gold and dia¬
mond brooch inlaid with pearls for Mrs. Boyd. The Mayor
of’ Durham has presented to the railway employes who have
passed the examination of the St. John Ambulance
Society the certificates awarded to the successful students.
At the close of the proceedings presentations were made to
Dr. Jepson, who lias taught the class, and also to lilr.
Hollins, the secretary.
Another Death from Lead Poisoning in Newcastle.
An inquest hoa been held on the body of a young woman
aged twenty-two, who had been a worker in a white-lead
factory. It was shown that she was taken ill on Feb. 2(ith
with pains in the head and vomiting. She went to the work-
house for a fortnight, and afterwards went Wk to the
factory. Three days following she was again taken ill, and
on Good Friday went back to the workhouse, where she
died on April 1st. It was further shown that she was
engaged at the stoves'—a department in lead-working
which was considered one of the most dangerous. She had ^
only worked sixteen days this year. The stoves affected
some girls sooner than others. Girls had been known tK>
work sixteen to eighteen years in the department. Dr.
Bowlan, the medic^ officer of the workhouse, stated that
C.Hi- le
O
^54 Ths Lancet,]
SCOTLAND.
[April 11,1891.
the girl when admitted waa sufferiDg from lead poisoning,
iftnd the verdict waa in accordance wiHi this evidence.
Berwick Infirmary,
The annnal meeting of the governors of the Berwick
infirmary waa held last week, and it was stated that there
was a balance of £419, against £317 last yea;*. To the
Hospital Sunday Fund sixteen churches contributed, an in¬
crease of one over the previous year. More than 1400
prescriptions were dispensed during the year. There were
over 300 out-door and forty-six in-ooor patients, including
several cases of typhoid and scarlet fever.
Suicide hy Dynamite.
A quarryman, who would appear to have been in a
despondent state of mind from drink, committed suicide on
Saturday last at Rothbury in the following extraordinary
manner. He placed an ordinary dynamite blasting car¬
tridge in the fold of his soft felt hat, set fire to the car¬
tridge, and placed the hat on his head. In a few seconds
the explosion took place, taking away the whole of the
top and back of his skull, but he was found on the ground
with his face uninjured ; of course dead.
Bradford Infirmary.
A meeting of the Board of Management of the Bradford
Infirmary was held on the 3rd inst. After the usual routine
business bad been transacted the Board proceeded to make
some alterations in and additions to the medical staff of the
institution. Dr. J. Lacy Firth, who has been house phy¬
sician, was appointed house surgeon, in place of Mr.
C. F. M. Althorp, M K.C.S., who has resigned; and Mr.
Pettitt, M R.C.S., dispensary surgeon, was appointed house
physician, in place of Dr. Firth. This left the position
of dispensary surgeon vacant, and five candidates, three of
whom were focal, bad been selected by the joint committee
of the honorary staff committee and the house committee.
Ultimately Mr. H. N, D. Milligan, M.B., C.M., was ap¬
pointed to the post. The meeting then proceeded to the
election of an honorary laryngologist, two honorary assistant
medical officers, and two honorary assistant surgeons. Dr.
Adolf Bronner was elected honorary laryngologist without
opposition. Mr. C. F. M. Althorp, M.R.C.S, and Mr.
'William HorrockSjF.R C.S,, were elected honorary assistant
surgeons. There were six candidates for the posts of
assistant medical oHicers, but the list was reduced one-half
by the first voting. Dr. H. Bronn«r and Mr. T. Wilmot,
M.E.C.S., were elected.
Newcaslle-upon-Tj’iie, April Qtli.
SOOTLAm).
(From our own Correspondents.)
EDINBURGH.
University of Edhiburgli.
The Chancellor of the University has appointed Mr.
A'lneas J. G. Mackay, Advocate, to be his Assessor in the
University Court, in succession to the late Mr. T. G.
Murrey, w.S. The second professional examination com¬
menced last week at the University, and is still going on.
The number of failures in both it and the First Professional
are reported as very numerous.
Medical Preliminary Examinations.
This examination, which is now conducted by the Educa¬
tional Institute of Scotland, instead of by the Colleges, was
held last week. There were 152 candidates, of whom eleven
were women.
Ilealth of the City.
The roortalily last week was 119, making the death-rate
22'49 per lOOO. Diseases of the chest accounted for 47
deaths, and 2 ymotic diseases for 14, of which 10 were due
to whooping-cough. The intimations for the week were:
typhoid fever, 5; scarlatina, 11; measles, 120.
The Fever Hospital.
At the invitation of the corporation a large company of
ladies and gentlemen assembled on the 3rd inst. at tbe City
Hospital, on the occasion of the opening of a new hall for
the nurses. The building, which has hitherto been used
for storage purposes. Is situated in the grounds, and is admir¬
ably adapted for the use to which it has been appropriated—
viz., adining- and sitting-room, an additional accommodation
greatly needed by the staff and much appreciated by them.
The hospital and the nurses’ hall had been decorated by many
friends, and handsome presents had been received for that
purpose. The buildings required to be brightened as much
as possible. The occasion of the present assembly was
really that thanks might formally be offered for the assist¬
ance and the gifts thus bestowed.
GLASGOW.
St. Mungo's College.
The winter session of the Medical Faculty of St. Mungo’s
College, Glasgow, was closed on March 27th by a meeting
in the Dispensary Hall, Castle-street. Mr. Hugh Brown,
who presided, mentioned that it was just 100 years since
the Royal Infirmary was founded by Royal charter, when
the population of Glasgow was only 66,000 After briefly
sketching the history of the College, Mr. Brown said that
the numbers this year had 'been greater than last, and they
had every reason to hope that as they grew in age they
would grow in importance. Dr. Blackie liad succeeded in
getting six merchants in Glasgow to offer £1000 each. It
was hoped that with these and other sums the College
would soon be put on a very firm basis. Zoology classes bad
this year been added to the curriculum. The prizes and
certificates were then presented to the successful students.
Queen Margaret College.
The last meeting of the Winter Medical Session took
place on Monday week, when a large number of persons
interested in the medical education of women attended.
Addresses were given hy Dr. R. Perry, Professor Young,
and Professor McKendrick. The report, which was adopted,
stated that the session had been a most successful one.
ABERDEEN.
Graduation Ceremony.
The ceremony of “ capping ” the graduates in medicine
took place in Marischal College on Friday of last week. An
immense gathering of the public filled the hall, and the
undergraduates present made it one of the noisiest cappings
that has taken place for many years. So boisterous was
the fun that the Principal dispensed with the usual address
to the graduates, and the proceedings were brought to an
abrupt termination. Thirteen gentlemen were promoted
to the degree of M.D. The thesis of Dr. G. S. P. Ferdinands
was considered worthy of highest honours, and that of Dr.
Neil M. MacFarlane worthy of commendation. Twenty-
nine gentlemen received the degrees of M.B. and C.M., and
two more passed all the examinations, hut cannot graduate
until they attain the necessary age. Three gentlemen, Mr.
William Findlay, Mr. John Marnoeb, and Mr. George
Tawse, graduated with “highest academical honours,” and
Mr. Dewar, Mr. MacLennan, and Mr. John Wilson with
“ honourable distinction.” Twenty-four candidates passed
the first half of the first professional examination, sixty-
two completed the first professional, and forty-four passed
the second professional examination. The diploma in
Public Health was conferred on Winckworth Tonge-Smith,
M.D., Richard A. S. Eden, M.B.,C.M,, and William B.
Simpson, M.B., C.M.
The Lord Eccior's A.ssessor.
On the recommendation of the Students’ Representative
Council, the Marquis of Hunlly nominated Mr. Peter J.
Anderson, LL.B,, as his Assessor in the University Court in
room of the late Mr. Murray Garden. At a meeting of the
Court held on Saturday last, Mr. Anderson was duly elected.
Health of the City.
During the past week the following cases of zymotic
diseases w'ere notified to the medical ofiicer of health :—
erysipelas, I ; measles, 3; scarlet fever, 10; typhoid fever,
5—a decrease of 3 on the whole, as compared with the
number for the previous week.
IRELAJ^D.
(From our own Correspondeni s )
Factories and Workshops Bill.
The Royal College of Surgeons have petitioned against
the proposal in this Bill to abolish medical certificates of
fitness for the employment of children. They request that
the I9th clause may he eliminated, and that clauses may
Digitized by
Google
The Lancet,]
IRELAND.—PARIS.
[April 11, 1891. 855
be mserfced so ae to extend the functions of certifying
surgeons by admitting of their giving probationary permis¬
sion for the employment of operatives as to whose fitness
doubts might be entertained, and to allow of their specify¬
ing the sort of work to which such persons ought to be
limited. Memorials also have been presented against the
Bill by the University of Dublin, the Irish Medical Associa¬
tion, and the Irish M.ercantile Association, and this evening
the Public Health Committee of the Corporation will discuss
a communication from Dr. C. F. Moore, Vice-President of
the Factory Officers’ Association, bearing on the matter at
issue.
The Irish Census.
The census papers will shortly be collected, and in a few
months we may expect an abstract of the returns. The
commissioners appointed are the Registrar-General (Dr.
Grimshaw), Mr. Matheson, and Dr. T. Bellingham Brady.
His Excellency the Lord Lieutenant paid a visit on Saturday
to Charlemount House, Rutland-square, and inspected the
arrangements made for carrying out the census of 1891.
Health of Dublin in February.
The death-rate for February was very much under the
average for that month, and was the lowest since accurate
registration of deaths commenced in Dublin. The mean
temperature being 2 1° higher than the mean temperature
of February for the past ten years had of course an im¬
portant bearing on the mortality. The zymotic death-rate
was the lowest ever recorded for the month, and was lower
in the city than in the suburbs.
Jervis-street Hospital, Dublin.
The vacancy occasioned by the death of Mr. Robert
McDonnell has, at last, been filled by the election of Mr.
J. Dallas Pratt, M.D., F.R.C.S.I. He was unopposed.
Queen's College, Cork.
In May last the president (Dr. Sullivan) died, and the
report for the Session 1889-90 has only now come under my
notice. The present president (Mr. Slattery) wrote the
report at the end of July, but it was not furnished to His
Excellency the Lord Lieutenant until December last, a
delay which appears ine.xplicable. Daring the Session
1889-90, 238 students were on the college books, of which
167 were entered in the Faculty of Medicine. lu referring
to his predecessor, Mr. Slattery states that during his
seventeen years’ tenure of office he devoted his untiring
energy and wide experience to the promotion of higher
education in the south of Ireland, and especially in the
teaching of chemical, physical, and medical science, while
he initiated improvements which will be the work of many
years to carry to their full development.
Infectious Diseases Prevention Act
The Corporation of Dublin have adopted this Act, which
will become operative in a few weeks. Sir Charles Cameron,
medical superintendent officer of health, strongly recom¬
mended its adoption, and states that perhaps one of the
most important provisions in the Act is tiie clause em¬
powering the detentioii in hospital of an infected person who
is without proper lodging or accommodation, for the section
of the Public Health Act dealing with the compulsory
removal of patients to hospital is silent with regard to their
detention. The Corporation by this Act can provide, free
of charge, temporary shelter or bouse accommodation, with
any necessary attendants, for the members of any family
who may bo compelled to leave their dwellings for the pur¬
pose of enabling disinfection to be carried out.
Fever in Clifdcn.
An epidemic of a severe febrile typo is reported to be
prevailing in the Kenvyle district of the Clifdeu Union.
Mr. Macdonnell, the medical officer of the Kenvyle Dis¬
pensary District, has unfortunately contracted the infection,
and is in danger of succumbing to the attack of what is
pronounced to oe typhus fever.
The Pembroke Township Commissioners have adopted
the Notification of Infectious Diseases Act, and its provisions
are now in operation in the township.
Mr. Mills, senior house surgeon to Jervis-street Hospital,
has been elected medical officer of Rhode Dispensary,
King’s county.
Margaret Braoney, of Downpatrick, has been returned
on the census paper as aged 107 years.
AprU 7t!i.
PARIS.
(From oitb own Correspondents.)
The French Surgical Congress.
The fifth session of this Congress was, as mentioned
last week, inaugurated in the large amphitheatre of the
Faculty on Marcli 30tb, under the presidency of Professor
Guyon. The President delivered a stirring oration, the
first portion of which was devoted to a eulogy of the late
Professor Tr61at, a former President, whose disappearance
from our midst has created such a void in scientific circles.
On the same evening the members of the Congress assem¬
bled in the splendid salons of Madame Guyon in the Rue
Roquepine, where the guests were regaled with excellent-
music and lUtened to a comedy of Meilhac, interpreted by
Mmes. Rdjane and Pierson, of the Oddon and Tbdatre
Franfsis respectively. Thursday morning was devoted to*
visits to divers hospitals, and in the afternoon the pere¬
grinations of the visitors extended to the Institut Pasteur,
the Morgue, the well-known dermatological museum at St.
Louis, and last, but not least, the fine new l^cole Pratique
of the Faculty, with its noble dissecting-rooms, laboratories,
&c. Thursday evening found the members reassembled at>
a banquet at the Lion d’Or. Amongst the most important
papers read at the Congress were two by our countrymen.
Sir Spencer Wells and Mr. Lawson Tait, on the Remote
Consequences of Ablation of the Uterine Appendages for Non¬
neoplastic Affection*. Sir Spencer Wells, in a communica¬
tion, a translation of which was read by M. Pozzi, protested
once more against the modern craze for oophorectomy. H©
is satisfied that affections of the Fallopian tubes are much
less common than is sometimes maintained, and he claims
that salpingitis and pyosalpinx are curable without opera¬
tion. Mr. Lawson Tait pleaded the innocuousness of
salpingo-ociphorectomy, his figures yielding a mortality of
only 3 per cent. He rejects the idea that castration pro¬
duces premature old age, and maintains that the effects of
the operation on the sexual appetite varies with the age at
which it is performed—viz., before or after puberty. Of '2lh
castrations performed for uterine myoma, success was com¬
plete in 257. Performed before the age of forty, the opera¬
tion determined the complete disappearance of the tumour
seventy times out of 100. After forty years the myoma
simply diminishes in v<tlume by a sixth or a third. In
castration for ovaro-salpinx Mr. Tait recoils the difficully
of the operation, and emphasises the necessity of thorough¬
ness in performing it. A frequent complication following
I this operation is the occurrence of rupture of vessels in the
' broad ligaments at what would have been the normal
: menstrual period. After a period of illness characterised
by elevation of temperature and rapidity of pulse, the effu¬
sion is generallyreabsorbedspontaneously. But occasionally
it gives rise to suppuration, and this condition will
necessitate laparotomy and drainage. Formerly Mr. Tait
entertained great doubts as to the expediency of cas¬
tration for the cure of neurotic affections. Now, how¬
ever, he believes the operation justifiable in epilepsy of
menstrual origin, and he cited an instructive case of castra¬
tion for menstrual insanity in the person of the niece of a
celebrated physician, in which the patient recovered com¬
pletely. Professor Le Dentu, who followed, stated that
he had not unfrequently traced the persistence of pain after
operation to the development of a cyst in the portion of
tube left attached to the uterus. These cases, he said, be
treated successfully by uterine dilatation, which determines
the evacuation of the contents of the cyst per vaginam. He
urged the advisability of leaving no portion of the tubes
behind.
Inauguration of the Franco-Dutch Hospital.
The opening on Monday last of this new nosocomial'
venture marlcs an epoch in the efforts made to administer
to the medical wants of the foreign element in the
heterogeneous population of this city. Theinstitution, the
creation of which is due to the generous initiative of
M. Van Lier, Consul-General of the Netherlands, is at pre¬
sent of modest dimensions, containing only twelve beds. It
is intended, however, to construct two additional pavilions,
and M. Van Lier will shortly call a meeting of the repre ¬
sentatives,of foreign powers, with a view of giving prac¬
tical effect to his idea of founding a vast international hos¬
pital where sick foreigners would be treated irrespectively
of creed. For the present the hospital is, as the name implies,,
Coogle
856 The Lancet,] OBITUARY.—ROYAL COLLEGE OF SURGEONS OF EN6LA.ND. [April 11,1891.
reserved for oatients of French and Dutch nationaliby.
The Hertford British Hospital, situated outside Paris,
At Levallois-Perret, wbicb is entirely, supported by
funds left by that noble philanthropist the late Sir
Richard Wallace, is invaluable as a refuge for the sick poor
English. But the aocommodation provided by this palatial
institution is limited, and in times of great sickness
inadequate. Many English people evince an inveterate
dislike to entering a French hospital, and the creation of
an establishment worked on international lines will prove a
great boon to them.
A Moral Seaport!
Toulon is hardly the place one would choose for the
education of one’s sons and daughters. According to the
journal ie Pcfif Var the number of wineshops,
and bouges directed by women of “ easy ” virtue is no less
than 670, without counting similar establishments in the
east end of the town. It is fairly safe to opine that the
'•clienUh of these lu 2 )anars is pretty conversant with such
terms as accidents primiti/s, accidmts secondaires, and it
would seem that Madame la Mar(^cbale would find m this
degenerate town a htbing held for the display of the
evangelisiDg energies of the Armte du Sahit.
The Pasteur Institute.
At a meetiog held last week the secretary of the Institute,
Professor Graocber, stated that of 1546 patients treated
during the year 1890, only 10 died, of whom 6 succumbed
within a fortnight of the commencement of the treatment j
it being conceded that these 6 should not be counted, there
remains a mortality not exceeding 0 26 per cent. It should
tnot be forgotten that the ardent savants attached to the
Institute are devoting much of their time to micro-biological
xesearcbes on infectious diseases other than hydrophobia.
The number of French and foreign savants now pursuing a
course of study at the Institute is ninety. Professor
Grancher says that the results obtained would be greater
were larger funds available.
Paris, April 7tli. _
DR. JAMES EDWARD KERSHAW.
We regret to have to record the death of Dr. J. £, Ker¬
shaw, M.A., M.B.Oxon., M.R.C.S., L.Ii.C.P., which took
place on Saturday, March 21st, at the Hospital for Diseases
•of the Chest, Brompton, of which institution he was resident
medical officer. His illness commenced in the acute form
on the previous Monday, though he had for some time pre¬
viously suffered from .severe headaches and insomnia; out
there had been no reason to anticipate any serious organic
disease until this date. Dr. Kershaw was educated at
Rugby and University College, Oxford. At Oxford he
devoted himself to chemistry, and obtained a second class
in the final school of natural science; while he rowed
in his College torpid in 1875 and 1876. He studied
medicine at St. Thomas’s Hospital, where he held the
post of resident accoucheur, and subsequently he became
one of the clinical assistants at the Brompton Hospital.
Afterwards he became resident medical officer to the Hos¬
pital for Children at Pendlebury, and on leaving that insti¬
tution be was elected assistant resident medical officer at
Brompton, and towards the close of 1890 was appointed
resident medical officer, in succession to Mr. H. H, Taylor,
who resigned. A good deal of extra work and responsi¬
bility was thrown upon him earlier in the present year by
the observations which were rendered necessary by the
introduction into the hospital of Koch’s method of treating
tuberculosis; and he was still in the active discharge of hie
duties when he was seized with the attack whieh proved
fatal. He was rather reserved in manner, and did noteasily
make friends; but those who know him well fully appre¬
ciated his good nature and his generosity, both of which
were exceptional. He was content to carry out his duties
with a quiet and unostentatious industry, which, though it
did nob attract much attention, was very thorough and con-
.scienCious. Chemistry was always with him a favourite
study; he was an enthusiastic photographer, and also
attained very considerable skill in that art. Without
brilliant natural ability, he was content to do the daily
duty which lay before him, and be had always that delight
in life which “work alone can give.”
EOYAL COLLEGE OF SURGEONS OF
ENGLAND.
At a quarterly meeting of the Council of the College
held on Thursday, the 9bh iDst.,the minutes of the ordi¬
nary Council of Feb. 12bh were read and confirmed. The
President announced the adjudication of the Jacksonian
Prize for the year to Mr. William Thorburn, F.R.C.S., of
Manchester, for the Dissertation on “ Injuries of the Spinal
Column and its Contents, &c.” The subject for the prize
of 1892 ia “Diseases of the Ovaries and the Uterine Appen¬
dages, their Pathology, Diagnosis, and Surg^tcal Treatment.”
The Council agreed to the report of the Committee on the
Extension of the College Premises, and adopted their reso¬
lutions in regard to alterations in the fittings of the new
museums. Amongst other resolutions in the report, the
Committee express their regret that, having taken into
consideration Mr. Hutchinson’s offer to present to the
College bis collection of Clinical and Pathological Drawings,
the arrangement of the Museums approved by the Com¬
mittee prevent them from recommending compliance with
the conditions of Mr. Hutchinson’s offer.
The following report of the Committee of Management of
the two Colleges was read, approved, and adopted, subject
to the approval of the Royal College of Physicians : “That
having received from Dr. G. Vivian Poore, Honorary Secre¬
tary General on behalf of the Organising Committee of the
International Congress of Hygiene and Demography, an
application for permission to use the Examination Hall
tor the purposes of the Congress during the week begin¬
ning the lOtli of August, they recommend that the
Colleges do accede to Dr. Poore’s request. The Com¬
mittee also recommend that the Royal Southern Hos¬
pital, Liverpool, which is iu sufficiently cIo*e proximity
to University College, Liverpool, be now recognised as a
‘ Hospital in connexion with a recognised Medical School,’
at which the whole period of attendance on medical and
surgical hospital practice and medical and surgical clinical
lectures may be completed, the authorities of that hospital
having satisfied the Committee that adequate arrangements
exist for the instruction of students.”
The Pre.sident reported that, in pursuance of the pro¬
visions of the Bradshawe Bequest, he had chosen Mr. J. W.
Hulke as the Bradshawe lecturer for the ensuing collegiate
year, and that the lecture would be delivered at some con¬
venient date in November or December, of which due notice
would be given bv circular to members of the Council.
The Council elected Mr. 0. Pemberton as the Morton
lecturer on Cancer and Cancerous Diseases for the ensuing
collegiate year.
It was agreed to give an entertainment by the Council of
the College in August to the members of the International
Congress of Hygiene and Demography, and it wag left to a
committee to fix the date and make arrangements for the
entertainment.
Monday, May 11th, at 3 P.M., was selected by the
Council as the most convenient date for the meeting of
Fellows and Members in reference to the scheme for the
reconstitution of the University of London.
A letter was read from Mr. H. P. Dunn, reporting the
views of the committee of the Association of Fellows on
the opinion of the Attorney-General and Mr. Paget, with
regavd to the powers of the College to call meetings of the
Fellows.
A letter of the 14th ultimo from Dr. James Holmes,
honorary secretary of the Association of Certifying Surgeons,
was read, calling attention to Clause 19 of the Factories
and Workshops Act Amendment Bill, and expressing the
hope that the College would use its inffuence to prevent the
said clause being passed. The President and Vice-Presidents
were requested to take what action they might consider
desirable in the matter.
A letter of the 25bh ultimo from Mr. C. S. Sherrington,
honorary secretary of the Physiological Society, forwarding
a copy of the following resolution adopted by that Society,
was read and laid before the Council—viz,, “ That, in the
opinion of this Society, it is important, in the interests
of the teaching of physiology, that, as recommended by
the General Medical Council, a large portion, if not the
whole, of the additional year which is to be added to the
medical curriculum should be devoted to Elementary
Physics, to Chemistry, and especially Biology,” A reply
was returned to the effect that the subject was already
under the consideration of the Council.
: ; Cjoogle
Thb Lancet,]
MEDICAL NEWS.
[April ll. 1891. 8 57
PtJwral. Ilcfas.
Examining Board in England by the Royal
Colleges of Physicians and Surgeons.— The followiDg
.geotlemen pasKed the Second Examination of the Board at
;a. meeting of the Examiners on the 4tb last.:—
Phytiology onij/.—Alfred II. Hardcaatle, student of Yorkshire College,
Leods; U. Speneer Hughes, of Queen's College, Birmingham; .T.
Alphonsus Dawes, of Queen’s Coilege. Manchester; Stephen ],.
Martin, of London Ilo.spital and Mr. Cooke’s School of Anatomy
and Physiology; II. Myddelton Moore, Horace R. Pring, Henry
Knight, Gerald L. Uanwell, Lancelot M. Breton, Malcolm White,
and Ificlgar C. Peru, of St. Thomas's Hospital; Hamilton Hearndon,
•Tohn J. Culmer, William J. Burroughs, Alfred Alexander, and C.
Melville Greenway, of Guy’s Hospital; Nowriji M. Tarachand, of
Bombay and Middlesex Hospital; A. Eldon .Scott, of Middlesex
Hospital; Walter Allinghain and John F. H. lies, of St. Gooi-go's
Hospital: Robert D. Cox and S. C. Collingwood Fonwicl^ of lit.
Mary’s Hospital; John Moses, of London Hospital; ami Herbert
Jenkins, of University College.
Passed on the 6th inst.:—
Anatomy <md Phyiiiology.—RfginM (1. Hann, student of Yorkshire
College, I.eed.s; Alfred E. Thompson, of Queen's College. Belfast;
Charles Porter, of Qvieen’s College, Cork ; Frodorie W. vVillway, C.
l.’Ostle Miall, A. Bloomfield Donshain, and A. E. Itiif Eubhorford,
of Bristol Medical School; Harold Ashton, of Anderson’s College,
Glasgow; Joseph Cryer, Bimuel A. Archer, W. UiiiUsliaw Budd,
and David D. Btewarb, of University College, Liverpool; J. Hedley
Marsh, J. Ramsay Bishop, Ernest ICnighb, and Arthur Walker, of
Owens College, Manchester; Leonard S. Toinky.-i, of Queen's
College, Birmingham; Walter P, Miller and Ernest H. Drake, of
Guy’s Hospital.
Anatomy on^.—Thomas Astbury and Ambrose H. Palmer, of Queen's
College, Birmingham: John Tilsley, W. A. P. A. V. Price, and P.
D'A, M. Williams, of Bristol Medical School; Arthur K. Symo, of
Melbourne University ; Fiavell Jfiduiunds and Percy Slaclc, of Shef¬
field Medical School; Prank W. Stokes, of University College;
Wlnthrop T. Talbot, of Boston University and liondon Hospital.
Phyniolnyy only .—Bruce Ifi. Edge, Richmond Goulden, Philip Wilkinson,
and t! Loimlng Webster, of Uwens College, Mauehester ; and .las.
H. Gordon, of Glasgow University.
Passed on the 7ch inst.:—
Anatomy and Pkydoloyy.—Goorge V. A. Roliert-son, Richard L. B.
Smith, David Stephenson, ancl Frederick Walker, students of the
Yorkshire College, Leods; F. Want Crossmau, Arthur Hudson,
Edward H. Marsh, and-Fredorick L. Titley, of Bristol School of
Medicine: Kenway T. Williams, Frederick J. V. Hall, T. S. F.
Hudson, W, D'Eate Emery, J. Copeland Poole, Edward A, D.aiido,
and Gilbert W. Charsley, of Queen’s College, Binuitighain ; Edwin
Quaylo, Alan McDougall, Samuel C. Salter, Allieia Tiioi'p, William
J. iloyton, and Joseph Law, of Owens College, Manchester ; Lionel
S. Partridge and U. Ru.asoll Welsh, of Oxford University ; Clement
W. Branson, of Sheffield Medical School; David Moi'rison, of Univer¬
sity College; and Marcus S. Paterson, of 8t. Mary's Hospital.
A.natomii only .—Charles H. Ackland and Albert T. Morgan, of Bristol
Medical School; William H, Cooper, of Bristol Medical School and
Mr. Cooke's School of Anatomy and Physiology; H. Meredith
Harrison, of St. Thomas's Hospital; ami W. Bryce Orme, of Univer¬
sity College.
PhygioLogy only.—Arthur D. Griffithsj of Bristol Medical School;
Stephen Langbon, of St. Mary's Hospital.
Pasfied on the 8th inst.:—
Anatomy and Phygiology.—OooYge E. Barcht, G, Hebb Cowan, and
P'rancis W. Walton, students of Jjondon Hospital; Ki'iiost W.
Oi'tuorod, William II. Symons, Brice Collyer, and Arthur D. Ducat,
of St. Bartholomew’s Hospital; D. Egryaii .Jones, of Trinity
Ooliego, Toronto, and St. Bartholomow’^s Hospital; Edward lb
Jones and A. Wanstall Clarke, of University College; G. Haylett
Lock and Walter H. llaraveaveH, of Mitldlesex Hospital; A. Wins-
more Hooper, Arthur li. Thorpe, and J. Wisomau Laver, of
at. Thomas’s Hospital; Reginald A. Cowie, of Canibiidge Univor-
■sity and St. Thomas’s Hospital; Arthur BousHeld, of King’s
■College; A, Cecil Hovondon, G. .Stanley Hovendeii, and Howard
W. Graham, of Guy's Uo.spital; Arthur G. Bennett, of St. Mary’s
Hospital and Mr. Cooke's School of Anatomy and J’hysiology;
Dossabhoy Nowrojoe, of Madras Medical College; ami Tlioiuas
S. Davies, of St. George's Hospital and Mr. Cooke's School of
Anatomy ami Physiology.
tinatomy onJi/.~Robevb Serjeant, of Guy's Hospibiil; Samuel E,
Price, of London Hospital; and Ar'thur P. Woollright, of St. Bar¬
tholomew’s Hospital.
Physiology only .—Ernest Shepherd, of .St. Mary’s Hospital; liorris
X A. do Odbert, of Middlesex Hospital; Mark R. Taylor, of Sb. Bar¬
tholomew’s Hospital; George W. Gostliirg, of Uuiviir.sity College;
John Challice, of London Hospital.
Royal College of Surgeons of England.—
The following gentleman, having passed the necessary
examinations, and having conformed to the by-laws and
regulations, was at the quarterly meeting of the Council on
'thedtbinst. admitted a Member of the College:
Dumaresq, Mark Bayfield, L.S.A., Streallleld-streob, Burdett-road.
The following gentleman, having previously passed the
necessary examinations, and having now attained the legal
age (twenty-live years), was at the same meeting admitted
a Fellow of the College:
White, Gilbert Benjamin Mower, M.B. Loud.. Ilazolville-road, N.,
Diploma of Member, dated Aug. 2n<l, 1S8S.
University of Aberdeen.—T he following candi¬
dates have received degrees in Mediohie and Surgery:—
Degree 0/Af. 0. — William Alexander, M.A., M.B., C.M., Tarland ;
Edward Bovill, M.B., C.M., Bengal; Thomas JoBeph Compton,
M.B., C.M., Norwich; John Cragie, M.B.. C.M.. Cliard; Geoigo
S. P. Ferdinands, M.B., C.M., Aberdeen; Nell Morrison MacFarlane,
M.B., C.M., Preston; Thomas William Adam Napier, M.B., O.M.,
Egremoiu, Che.shira; John Moysey Rattray, M.A., M.B., C.M.,
Froine ; John Scott, M.A., M.B., C.M., Manchester; Charles Carter
Shepherd, M.B., C.M., Kidderminster; John Taylor, M.B., C.M.,
Boocle; Thomas Harvey Thomson, M.B., C.M., Campbwtown;
Richard Mahoney Townsend, M.G., C.M., Cape of Good Hope.
(The thesis of George 8. P. Ferdinands was considered worthy of
Highest Honours, and that of Nail Morrison MacFarlane of Com¬
mendation.)
Degrees of K.B. and C.A/. — Alex. G. Allan, M.A., Portsoy; James
Bell, Cults, Aberdeen; Alfred EL Bennett, South Australia; Sidney
H. Burnett, Manchester; Wm. H. Clark, Kintore ; James D. Crow,
M.A., Aberdeen; Patrick W. Diaok, M.A., Aberdeen; John P.
Faniuliarson, Aberdeen; *Wm. Findlay, M.A., Aberdeen; James
W, tie Hoedt, Ceylon ; Andrew Hunter, Aberdeen ; Samuel C.
Ironside, Aberdour: John H. Lumsden, Furtrose; George Lyon,
Whitohills, Banff; .lames M'D. M‘Kay, Sutherlandshlre; George
Mackie, Insch; IRoderick M. MacLennan, M.A., Roas-shire; "John
Marnoch, M.A., Aberdeen; Charles Milne, Newliills; Thomas
Pimley, Preston; A. Cumniing Ross, Craigellachle ; David Russell,
Banchory ; Walter W. Sinclair, Banchory : Charles E. O. Simons,
Merthyr Tydfil; George Snell, British Honduras; William H.
Stephen, Newhills ; "George W. H. Tawse, Aberdeen ; Clarence E.
Wigan, Somerset; tJohn T. Wilson, Glasgow. (Robt L. Brander
and tVVilliam J. Dewar, Arbroath, have passed the examination.^
for the degrees of M.B. and C.M., but will not graduate until they
attain tire neces.sary age.)
" With highest Academical Honoiir.s. t Honourable di.stinction.
The diploma in Public Health has been conferred on—
Richard A. S. Eden, M.B., C.M.. Aberdeen; William B. Simpson,
M.B., C.M., Bedale ; Winckworth Tonge-Smith, M.D.
Royal Colleges of Physicians and Surgeons
IN Ireland : Conjoint Scheme — The following have
passed the. Preliminary Examination :
J. Barry, J. Bluett, J. Brogan, M. Ceraher, M. Carroll, D. Clarke,
H. Conyngham, H. Cniinphn, W. Cummins, P. Dempsey, L. Fannin,
IS. Fenton, T, Fisher', J-*. Fitzsirnons, R. Fox, R. (Jlyim, C. Hodgson,
F. Jackson, W. Lawlor, J. Leventon, V. Magee, MardocJt, J.
Murphy, B. McCaul, J. McCartliy, G. McDoiruell, D. Spillaire,
.1. Wallace, and A. Goring.
Physivg. —J. Berraon, M. Carroll, W. Carroll, T. Crean, H. Cruraplln,
G. Creighton, W, Darby, P.Dempsey, R. Fox, R, Glynn, A. Halllgan,
B. Uamrltoir, M. Ilttrly, H. Kennedy, L. Lott, V. Magee, J. Maughan,
W. McCann, B. McUaul, G. McDonnell, J. Neary, J. O'Keeffe,
T. Palmer, J, Pigott, S. .Scott, O. Simpson, J. Smytti, W. Stratton,
J. Tlroirrpson, C. R. Ticltbonre, F. Wtsi-, aird A. Young.
Society or Apothecaries of London. — The
following candidates have passed the recent e.xaminabion in
the subjects indicated :—
Arts.—First Class: C. P. Woodstock, E. M. Leney, B, F. Henry.—
Second Class: G. S. Andrewos, C. J. Armsorr, C. E. Blackstone,
F. B. Cardezo, P. Gator, O. A. Crowe, H. E. F'ryer, H. Hilliard,
■f. Ingram, B. K. Izard, W. R. Kingdon, A. E. Maialrer, B. Rowlands,
11. J. M. VVyllys. ('.L'here wore ifiS carrdidatos, of whotir S were
plar^eil in the First Class and 14 in the Second Class, having passed
til all the siili.iects required for regiatrition as medical students.
10« passed in one or more of the subjects.)
Surgerij.—K. M. Dobiiisoti, Guy's Hospital ; W. B. Duck, M.A. Oxon.,
Oxford Uiiivoraity and St. Mary's Hospital; G. V. M. Gideon,
St. Mary’.s Hospital; C. D. Holmes, Liverpool University College ;
S. 11. Ljute, Glasgow, Middlesex, and London Hospitals ; W. C.
Lattey, St. George's Hospital; W. 8. McQeagh, L.K.Q.C.P.I.,
at. Tliotnas's Hospital; L. K. Parkhurst, B.A. Oxon., Oxford Uni¬
versity arid St. Mary’s Hospital; A. Plumbe, London Hospital;
F. Spurt', Sheffield and Middlesex Hospitals.
Medwne, Piirensieitedicine, and Midwifery.—^. A. R. Covey, St.Bar¬
tholomew's Hospital H. H. Crickitl, St. George’s Hospital; G. V. M.
Gideon, Sb. Mary’s Hospital; 0. Jones, M.A. Oxon., Oxford Uni¬
versity and Loirdon Hospital; A. J. Lambert, Leeds Yorkshire
College and Westmirrstev Hospital; A. E, Mayner, M.D., C.M., Mon¬
treal UiriverstLy ; W. F'. II. Newbory, M.D., C.M,, Trinity Medical
College, Toroirto; A. S. Phillips, St. Tlromos’s Hospital; R. D.
Wagltortt, Westmrnstor Hospital; K. A. Wintberloy, Birmlnghanr,
C)ueen’s College.
Medicine and uiawifm-y. — T. C. Hughes, Westminster Hospital;
L, Roborts, Catnbrtdge University artd St. Mary’s Hospital.
Midwifery. —R. W. Brimacornbe, Birmingham, Queen’s College, and
St. Mary’s Hospital; J. 8. Newingtou, Edinburgh University.
Messrs. Crickibt, Gideon, Jones, Lartrbert, Mayner, New-
bery, Parkhurst, and Waghorn were granted the Diploma
of the Society, qualifying for registration, and entitling
them to practise the three branches of the profession—
Surgery, Medicine, and Midwifery.
Glanders in Hungary.—N ows from Parmiorf,
near Presaburg, states that the whole of the horses in two
stables there had to be killed in consequence of an outbreak
of glanders amongst them. The veterinary surgeon and the
two farmers who owned the animals were wounded in
destroying the horses, blood poisoning supervening to all
three of them, which had been fatal to the veterinary sur¬
geon, and a like result was apprehended to the farmers.
858 Tbb Lancet,]
MEDICAL NEWS.
[APRlt H, 1891.
Medical Magistrate.— Mr.HenryLaver,M.!R.C.S.
&C. , bas been placed on the Commission of the Peace for the
Borough of Colchester.
The Census in India.—T he returns of the census
in India, just completed, show the population of the Indian
Empire to be 285,000.000, being an increase of fully 30,000,000
since the last census, taken in 1881.
Open Spaces.—T he burial ground of the parish
chnrch of St. Giles, situated in the High-street, which bas
been for many years in disuse and closed to the public, has
been taken over by the district board of works, and laid out
as a recreation ground.
Cavendish College, Cambridge. — An exami¬
nation will commence on July 7th for one entrance scholar¬
ship of £50, one of £40, and at least two of £.30, open to can¬
didates who will be under eighteen years of age on Oct. Ist.
Candidates may offer one or more of the following subjects:
classics, mathematics, natural science, modem languages.
For particulars application should be made to the master.
The International Congress of Hygiene.—T he
Government of Denmark has accepted the invitation to be
represented at this Congress, to be held in London in August
next,and has appointed asibs representative Dr. J. Lehmann,
dean of the Royal Sanitary Council. The American Govern¬
ment has also notified its intention to appoint representatives
at the Congress, and will give general-and wide pviblicity to
the Prince of Wales’s invitation, with the view that repre¬
sentatives may attend from learned institutions in the
United States.
Literary Intelligence.—T ho first number of
the Nurses' Journal, the organ of the Royal British Nurses’
Association, has appeared. The contents are as varied as
the aim of the publication will admit of, and are on the
whole interesting.—Anew serial, the Optician, devoted to
the interests of the optical, mathematical, philosophical,
electrical, and photographic instrument industries, has been
commenced by Messrs. flyatt-Woolf and Hayman of Fleet-
street.—Mr. j. W. Kolckmann of Langham-piace announces
that Vol. I. of the Transactions of the International Medical
Congress held at Berlin last year is now ready.
Presentations.—D r. Younger, on recently re¬
signing his appointment on the medical staff of the London
County Asylum, Ranwell, after sixteen years’ service, was
presented by the inspectors and attendants with a richly
chased silver cup, and by the nurses with a handsome and
highly ornate salver, each with a suitable inscription, as
tokens of the high esteem in which he was held by the sub¬
scribers. Also his brother officers gave him individual
presents of value as tributes to his worth.—On April 1st, at
the Huddersfield Infirmary, Dr. E. F, Scougal, the bon.
secretary of the Medical Society, was, on the occasion of
his marriage, presented by the members with a handsome
walnut cylinder writing-table and a library chair. The
table had on it a plate witli the inscription, “Presented to
Edward Fowles Scougal, M.A., M.D., on the occasion of
bis marriage, by the members of the Medical Society of
Huddersfield.”—Mr. P. M. Scatlifi; M.K.C.S,, LII.C.P.
Lond,, has been presented with a handsome pedestal draw¬
ing-room lamp by the ladies who have been attending the
Lordship-lane branch of the St. John Ambulance Associa¬
tion, as a mark of their appreciation of his services as
honorary lecturer to the classes recently concluded.—Dr.
Growse, the medical officer of the Marton district of the
Rugby Union, has been presented with a gold albert chain,
a set of gold studs, and a tankard by the inhabitants of
Marton and the surrounding villages, as a recognition of bis
services as their medical adviser.—At a public meeting held
in the Mission Hall, Sharnbrook, near Bedford, Dr. J.
SomervUle Johnston was presented with a very handsome
walking-stick by the members of the Sharnbrook Branch of
St. John Ambulance Association, as a token of esteem for
valuable services rendered to two very successful classes of
the branch.—Mr. E. Wilmer Phillips, L.li.C.P. Lond.,
M.R.C.S., who has held the office of house surgeon for the
last live years in the Windsor Royal Infirmary, having re¬
signed, to undertake private practice at Southsea, was last
week, before his departure, presented with a valuable gold
watch, subscribed lor cbieily by the staff of the institution,
-with some of the managers and several of the present and
past patients.
The Lord Chancellor has appointed Mr. Francis
William Maclean, Q.C., M.P., a Master in Lunacy, in
the place of Sir Alexander Miller, resigned.
The directors of the General Association of Practi¬
cal Surgical Instrument Makers and Bandagers offer aprixe
of £10 for the best spontanoona movements of the fingers of
an artificial hand in connexion with the elbow-joint. Par¬
ticulars can be had from Instrumentmacher Wilhelm Tasch,
Berlin, Oranienburger-Strasse, 27.
Children’s Hospital, Nottingham.—T he annual
report for 1890 shows an increase in the total receipts for
the year and a growing interest in the institution by the
general public. The total income was £308 in excess of
the previous year. The steady addition in the work of the
hospital bad necessitated an augmentation of the honorary
meaical staff, and the necessary appointments were made.
Colonel Seely bad generously hired a bouse as a Con¬
valescent Home during the summer at Woodthorpe, and
had placed it, free of cost, at the disposal of the committee.
Forty-six children were received there, and greatly bene¬
fited by the change.
Arrow Poison of the Pigmies.—A n intere.sting
account of the various arrow poisons collected by Surgeorti
Parke in the recent African expedition was given by him
to the Pharmaceutical Society on Wednesday night. The-
oisons were reported by Mr. Holmes, the Curator of the
ociety’s Museum, to be extracted from a well-known bark
used as an ordeal poison in several African countries. The-
plant is known as Erythrophlceum Guineense. Another
poison is obtained from the leaf of Palisota Barter!; the
stem of unknown species of Combretum; the stem of
Strychnos Icaja, a shrub which owes its poisonous properties
to strychnine; and the seed of Tephrosia Vogelii, a plant
largely used in Central Africa as a fish-poison.
Football Casualties.—A player in a match at
lioyton, on Saturday, between Helmshore and Iloyton,
sustained a fracture of his left leg.—A young man, aged
twenty-three, who was playing football for the Cburchtown
Football Club, on Good Friday, at Southport, against
Little Lever, died in the Southport Infirmary on Saturday
from lockjaw, supervening on injuries sustained in a charge
during the match.—A young man, aged nineteen, while-
engaged in football in a field in St. Paul’s-road, Birming¬
ham, on Saturday, received injuries, and was taken to the
Queen’s Hospital, where he died on Sunday from a con¬
tusion on the right side of the abdomen and rupture of the-
right kidney.
Volunteer Ambulance School of Instruction.
The following Volunteer medical oilicers, who have beea
under instruction from Surgeon K. K. Sleman, M.A.,
20th Middlesex (Artists) R.V,, and the staff of the school,
have recently passed the proficiency examination : Surgeon
Sir Morel! Mackenzie, M,D., Queen’s Westminster K.V.^
Acting Surgeon D. Key, 1st City of London A.V.; Acting
Surgeon D. Grant, F.R.C.S , 24th Middlesex li.V.; Acting
Surgeon E. Younger, M.D., 3rd V.B. Royal b’usiliers
Acting Surgeon E. W. Stiven, M.D., 21sb Middlesex R.V.;
Acting Surgeon J. H. Griffin, London Irish 11.V.; Acting
Surgeon T. Fennell, 3rd V.B. Cheshire Regiment; Acting
Surgeon F. Ransom, M.D., 3rd V.B. Suffolk Regiment.
The next class will be held in May.
Medical Officers of Health {Society.—A
meeting of the Birmingham and Midland Branch of this
Society was held at the Council House on the 2nd inst.
Dr. A. S. Underhill presided. Mr. H. May (Aston) re¬
ported the result of the interview of the deputation from
the Society with the Sanitary Committee of the SVorcester-
slnre County Council, in respect to the appointment or
offer of the services of the county medical officer to the
district authoritie.s at a reduced salary. It appeared that
the action of the County Council was misunderstood. No-
such offer had been made to the district sanitary authori¬
ties. Mr. May read a paper upon Recent Sanitary
Legislation. He dwelt especially upon the Housing of the-
Working Classes Act. A discussion followed, in which
Drs. Hill and Manley took part. Mr. May afterwards
opened a discussion on the Infectious Diseases Preven¬
tion Act. After some observations by several gentlemen,
a vote of thanks was passed to Mr. May, and the meeting
closed.
V Google
Diaiti.
The Lancet,]|
MEDICAL NOTES IN PARLIAMENT.
[April 11, 1891. 859
Thb British Gynecological Society will hold a
? roTiDcial lufteting on June 18bh and 19ch ab Newcaatle-on-
'yne. Dr. Robert Barnes, hon. president of the Society,
will take the chair at the meetings, which will be held in
the College of Medicine. Dr. R. C. Benington has been
appointed general local secretary, and all communications
are to be addressed to him.
MEDICAL NOTES IN PARLIAMENT.
Public Health (London) Law Amendment and Conenlidation Sills.
On Tue-iday, in tlie House of Commons, Mr. Ritchie moved the
raecond reading of these Bills, which, he said, dealt with the public
health of London, the first being a consoiidating Blli and tlie second
am amending Bill. The state of the law in regard to public health
In London was very unsatisfactory. Whereas the law as to public
Siealth in the provinces had been amended and consoiidated by tiie
Act of 1875. the pulilic health law of the metropolis was scattered
over a number of Acts, beginning with Michael Angelo Taylor’s Act
•of 1817, and was contained in twenty-nine separate statutes. _ Under
the pi-esent law the sanitary autliorities might conti-act with the
imanagers of the Metropolitan A.sylums Board for the provision of
hospital accommodation. In that case the sanitary autliorities
avere liable for expenses, but in cases in which the sanitary authority
'thought them able to do so the patients could be made to pay.
This Bill proposed to extend that provision to hospitals built by
the sanitary authorities themselves. The Bill provided for the im¬
mediate ahatemenb of a nuisance, not only whore it was actually
proved to exist, but also where it was injurious or dangerous to the
public health. At present only the persons alfectod by the nuisaiico
•or the local autlioiity could move in the matter, hut the present
Bill provided tliat any person might give information of a nuisance
with a view to its removal, and under its provisions any person
'found guilty of allowing a nuisance to exist would he held responsible
for doing any work necessary to abate it. Tho Bill also Imposed on the
London County Council the duty of making by-laws for the cleansing of
•streets and the prevention of nuisances. ^Tlris would throw upon the
County Council the duty of making by-laws to put a stop to an intoler¬
able nuisance as to which considerable complaint had justly arisen—
namely, the throwing of salt on tlie streets of tho metropolis in snowy and
frosty weather. The Bill next dealt witli the question of offensive trades,
in which several amendments of an unimportant cliaracter wore intro¬
duced. The Bill provided that wliere a sanitary autliority caused a
inuisance.or didanytlnnginiuriouaor dangerous to health,itmightbe pro¬
secuted, and all the provisions as to nuisances should apply. As to the
•clearance of the footways in times of snow, the law as to footways and
watercourses seemed to be that the occupier was liable to clear the
:snow from before liis house, and to keep the footway and watercourse
properly swojit and cleansed. If the occupier did not perform his duty
after a short interval it would be performed for him by the sanitary
•authority, and the cost put upon him ; besides which he would be also
fliable to a line for the noii-poiforraance of bis duty, Nobody could
fail to be struck, after a fall of snow, witli the numerous cases where a
dargo amount of pavement was left untouched for days and clays;
ana in nine cases out of ben this was in connexion with unoccupied
iiouses, or gardens and squares. Clearly it sliould ho the duty
of tlie sanitary authority to see that tliis state of things should not
■exist, ami tliey wore now given the power, unci tho duty was imposed
upon tliem, of .ascertaining who was liable, and of making him pay
•wherever it was possible to do so. With regard to streets, the J-!ill
required the sanitary authority to perform its duty of sweeping and
-cleansing tho streets, and the sanitary authority was made liable to a
fine if it did not perform its duty as far as reasonably practicable. Tho
Bill did not set out a period within which tho removal must he made ;
■hut the sanitary autliority would bo bound to tlx some proper and
reasonable period for clearing away dust and hou.se refuse, and they
•would be liable to a fine if, proper notice being given, they did not ab
once comply with tlie reqiie.st of the owner. The next portion of the
Bill dealt with the question of unsound articles of food. Tlioy proposed
tfco extend the existing law, which applied only to those wlio exposocl
such articles for sale. This Bill appliecl to every articlo used for food,
and gave power of lioth searcli -and destriiotion. Tlie existing law w.as
•considerably strengthonod. J5y the law as it stood at present it was
■only the individual who exposed tho article for sale wlio was pnnisliablo
by law : tlicy now ]»roposert to make the por.son from whom the food
was bought, as \vi;ll as the person selling it, punishable for the offence.
Then ciuiib tho question of proper water-supply to houses. In his
opinion :i house wit.houb a water-supply was a nuisance and ought to
'be abated, and they now declarocl tliat being witliout a pviipor
supply was a mii.sanco tli.at rendered a house uiiiit for habitation.
They also amenclod the law witli regard to infectious disease.s. The
provision of tiie present law with regard to disinfection was entirely
permi.ssihle. They proposed to make it nooe.ssavy for the .sanitary
authority to provide proper premises for disinfecting liedding, clothing,
•&C., and also vohielea for carrying these articles to and fro. llejne-
sentations had been made to tiie l..ocal Government Board, ospeoiiiily
from Maidstone, iw to pei-son.s selling fruit who had been found
manifestly suil'ering from iiifeclioiis disease. It was eminently
slesirablo to prevent a per.soii suffering from an infectious di.sea.HB
from handling articles of food at all, and therefore tho Bill
Imposed a penalty upon anyone milking, selling fruit, or other¬
wise engaging in an occupation connected with food who knew
himself to be suffering from an iufectioius disease. 'J'liey also
proposed, wilii rcgiiisl to tho notillcation of infocl.ious diseases,
chat the return required to be sent by tlio Metropolitan Asylums
iiianager.s to tho County Connell sliould ho sent by tliem to every
sanitary authority ill I.oiidon, and to tlie London School I'loard, aud io
tho iiiaiiagovs of every public elementary school in i.ondon. Witli
regaril to raortuarios, every sanitary authority must inalce one. At
present tlie law was only permissive, and coiisiilorablo scandals had
arisen in tills respect. Hvory sanitary authorily must also, if veqilirod
by the County Council, jirovide a liuilding for jiost-inortem examina¬
tions. Omi very important iiialtov witli wliicli tlicy dealt in this
Bill was the question of underground or cellar rooms. By the
Public Health Act of 1876 very stringent regulations had been
made to secure ventilation &c. In London, hovrever, so far as under-
gi'ouud dwellings were concerned, tile provisions with regajrd to the
preservation of health were extremely few and weak. By this Bill
ample provisions were made with regard to height, drainage, and
ventilation. The Government's proposal was to apply to under¬
ground rooms the complete Public Health Act of 1876. The pro-
po.sals in the Bill would apply to all underground rooms, with
the reservation that the London County Council might by general
regulation, or on application of the owner of particular rooms,
dispense witli or modify tlie provisions as far as tliey involved struc¬
tural alterations, having due regard to the necessities of the case.
One of tlie proposals of the Bill referred to the inspectors of nuisances
and medical officers of health. Means were provided by which an
adequate number of proper persons should he appointed as inspectors
of nuisances, henceforth to be called sanitary inspectors. Complaint
was made that the number of these inspectors in some parts of London
was not nearly adequate for the area over which they exercised their'
jurisdiction, and it was quite impossible for the sanitary authorities
r.o carry out the law unlessn they bad a sufficient staff of inspectors.
The Bill provided that tlie Local Government Board might, if
satisfied on representation of the London County Council that a
sanitary authority had not appointed a sufficient number of inspectors,
order that siftiitary authority to appoint a.s many more as might
ho deemed necessary. It was also provided, with a view to secure
fit and proper persons as inspectors, that their appointment should
be subject to regulations of the Local Government lloard; and, with
regard to the medical officers of health and sanitary inspectors, it was
provided that they should be removable by tlie sanitary authority
only with the consent of the Local Govornment Board. This provision
had been urged from many quarters, and tliere was much force in the
argument that, unless these officers were to a certain extent indepen¬
dent of tlie local authority, they could not perform their duties with
absolute freedom. Witli regard to the non-performance of duty by the
sanitary authority at present in London, any person might make com¬
plaint against tlie sanitary authority to tlie Local Government Board;
the Local Government Board might hold a local inquiry into such com¬
plaint, and, if aati.sfied of its justice, they might appoint some person
10 perform tiie neglected duty. Under the law as it stood, therefore,
tho London County Council might be appointed ; and the provisions of
tho Bill really made a modification of the existing law in favour of the
vestries. In future it would not be in tho power of any individual to
put the sanitary autliorities to all this trouble, and when complaint was
made it would have to be iiiatle with the authority of a popularly con¬
stituted and responsible body. In many local matters tiie London County
Council rightly had powers of a very extensive character; and it was
light and proper in dealing with a great iiuestion of public health
that the County Council, representing all parts of the ruotropolis,
should bo eligiVile for appointmont with regard to tho performance
of duties which had been neglected by the local sanitary authorities
If the House would assent to tho Government’s proposals, he believed
tliat they would prove to be productive of enormous benefit to the healtli
of London. It was proposed to refer both Bills to one of the standing
committees, and he did not doubt that they would come back from
that committee even better measures tlian tliey were now. He begged
to move tlie second reading.—Mr, Stuart said it was riglit that powers
siiould be given to the County Council in matters in which it did not
supersorte tlie oilier local autliorities, hut ■where it was to frame by-laws
which tliey were to carry out. It was satisfactory to lieav that the
tight bon. gentleman did nob share that distrust of tho County Council
which some Miui.sterialist members for tiie metropolis professed to
entertain. 'I'lie worlc which the Council had done, especially in respect
of tiie housing of tlie poor, was sufficient to sliow that it was wholly
unilesorviiig of sucli di.sfcrust. An article wliich appeared in The Lancet
cmpliasi.sed tho fact tiiat tho I.ondoii County Council had nob tho
powers possessed by any .suiiurban or rural authority with respect to
Insisting upon the open .spaces around houses that wore necessary for
the lieaith of their occupants, and he trusted that this defect would bo
supplioii by an .aiiiendment of ttie Bill. In order to giveofiicioncy to tho
sanitary an-angenients of I.ondon two important reforms were neces¬
sary. The first was that there must bo placed at tlie disposal of tho
local autliorities funds other tliaii those obtained by the rating of occu-
jiiers. The second was that tho local goveriiinent of London must be
completod by tho ostablisliiiiont of tho district councils wliieh were pro-
luist'd ill 1888, and which they had several times licurd from the
right lion, gontieniaii wore provided for by a Bill lie had pre¬
pared, and wliicli tiie House was anxious to see. It might be
said that every part of tlie metropolis was, so to speak, thirst¬
ing for tlii.s. uioaburo, and it was ono tiiat could be introduced
and carried only by the Government of tho day.—Mr. J. R. Kelly said
lie did not think it was wise, or in tho interests of the public, that the
imtiiiuatod system sliould be continued of throwing on tho occupier of
a liouso tiie obligation of sweeping the snow from the pavement in
front of Ills door. If the biirclen were cast on tlio local authority the
result woidd be tliat liundreds of men would get an honest day’s work,
tlie streets and pavements would bo syRtomaticaily swept, and no ono
would liave reason to complain except tiie idio loafer wlio blackmailed
tho unfortunate liouselioldov. Ho tlionght tliat I.oiidon had very little
to gain from the Bill. 'J'liere were provisioii.s so liarassing in thoiv
cliaracter, tiio machinery of tlie common infornicv was so foreign
to tlie KngHsh spirit, there was so little done to relieve tlio
nnfortunate nietiopnliian liousoholdors from tlio foolisli burdens
cast upon tliem, that lie felt disposed, if any hon. niemhur were
to move tlic rejoction of tiio second reading, to support him,—Mr.
J’ickevagill suhmittod, however, that all the subordinate authorities
ill London ouglib to bo subject to those by-laws. (Mr, Ritchie : They
are.) The City of Lomion was exempted from tlio operation, and it
was unfair aud impolitic to exempt it. Tho Bill, as a ivhole, liad many
good features, ami no doubt it would bo improved In its course
thi-ougli commitleo —Sir A. l.lollit said there could not be any
doubt that many of the provisions of those Bills wove
urgently required, ami that they introduced vahiable amondmoiila
in the law. Provisions relating to the public health were
scattered up and down many statutes, ami it would lie of
great advantage to have them consolidated in one measure.
One of Llm defects of the London (iouiity I 'oimcil was that it had lieeii
scarcely able to cope with tlie immense aiuouiit of work which had to
860 Thb Lancet,]
MEDICAL NOTES IN PARLIAMENT.—APPOINTMENTS.
[Apeil 11,189L
be denIt «itb. Yet tlieae Bills would impose uuou it duties which he
thought it would not be ablo adequately to fulAl. While he welcomed
many of the provisions in these Bills, he thouKht that in committee
exception would have to be taken to some of them.—Dr. Farquharson
thought the Bill would do a great deal to remove some of the minor
misenes of life under which Londoners bad been groaning for so many
years. Hon. raerabera had not yet liad time to go thoroughly Into this
Bill, and it would, of course, have to be considered by n committee
upstairs.—Mr. Isaacs, while thanking the right hon. gentleman for in¬
troducing the Billj was vatlier disposed to think that the best course would
have been to previously introduces measure for creating distiict councils,
-Mr. Canston, Mr. W'. Isaacson, and Mr. Whitmore took part in the
debate.—Mr. Ritchie, In reply, said It was not surprising that objection
should be taken to certain details, considering that the Bill dealt with
so many important and difficult questions. Tlie Bill was not going
beyond the existing liw. In some respects, Indeed, it modlfleu the
existing law, because it provided that it snonld not be in the power of
any individual to put that machinery in motion, but the County Council
alone; and the County Council even should not be at liberty to interfere
until they had obtained the previous assent of the Local Government
Board. If in any matter of form or language the Bill was thought
to create undue powers of interference, the Government would be glad
to consider amendments to remove doubts or difficulties in that con-
nexion. He should be the la.st person to do anything calculated to pre¬
vent good men from coming forward to serve on the local Ifbclies. With
regard to medical officers of health and sanitary inspectors, the position
was this—that at the end of the term of their present appointment they
would become officers under this Bill; until the present appointments
ceased tliny would not.—Mr. Canston stateil that many officers were not
subject to reappointment.—Mr. Ritchie wjis not aware of cases in which
they were not reappointed; but, in any event, existing appointments
might be terminated by mutual consent and a new appointment made.
He would only say, in conclusion, that the Governmi-nt did not regard
this Bill as a party one, or in a political sense a contentious ono, and
they should be glad to listen to any suggestions in committee, and to
consider dispassionately, and he hoped favourably, nil pi-oposals which
they thought would be improvements In the Bill, Tlie Bills were then
read a second time, and referred to the Standing Committee on Law.
Certffi/in// Factoiij Surgwm.
On Thursday, Mr. Jacob Bright asked the Secretary of State for the
Home Department, seeing that he had slated that bis opinion in regard
to the certifying surgeon was based upon the beat information, whether
he would inform the House if he had consulted the Chief Inspector of
Factories upon the subject, and also the Superintending Inspector, and
the other inspectors in the districts chiefly interested, as to the advis¬
ability of abolishing the certifying surgeon’s certiuoate of fitness; and,
if not, why not.—Mr. Matthews replied : I have, in the ordinary course,
communicated with the Cliief Inspector of Factories on this subject,
and I have learned through him the views of his department. It i.s
hardly reasonable to suppose that in dealing witli a question of this
kind I should not avail myself and take advantage of all the sources of
information at my disposal.
Volunteer and M'dilia Surgeons.
On the same day Dr. Clark asked the Secretary of State for War
whether Volunteer turgeons are now promoted to brigade rank, and if
so whether it is the intention to promote to a similar rank the senior
Militia surgeons, some of whom had been serving before the Volunteer
force Wis instituted.—Mr. Stanhope replied that the reason why the
Volunteers have this advantage is that they are organised in brigade.s,
and the rank of brigade surgeon is conferred in recognition of the in¬
creased responsibility attached to the principal medical officer of a
brigade.
Opium Consumplvm.
Mr. Samuel Smith asked the Under Secretary of State for India
whether he coulu state what was the total con.smnption of opium in
India in 18HU, and also in Bunnah in the same year; and what were tlie
figures for the latest year for which statistics had been obtained for
India and for Buimah.—Sir Jas. Fergusson, who replied, said the con-
sumption of opium in Madras and Bombay for 1880 could not be given.
In 1889-90 it was UtOi chests. lixcluding Madras and Bombay, but in¬
cluding Lower Bunnah, the total consumption in British India for
1889-81 was .'i{i06 chests, and for 1889-90, 48U0 cliests. In Lower Biirmah
the consumption was for 1889-81, 812 chests, and for 1889-90 it wa.s 791
cliesl.s. The consumption in Upper Biuniah was not known.
METROPOLITAN ASYLUMS BOARD.
Itetum oj Patients remaining in the several Fever Hospitals
of the Board at midnight on April 7th, 1801.
Hospital.
9 C
I?
C 9
DipbtheHa.
eds oc
!-•
cuple<
jj
ss
Other
diseases.
TOt»]e J
Total accommo¬
dation.
Eastern Hospital .. ..
103
47
41
3
2.64
442
North-Western Hospital
139
40
l-l
il
192
448
Western „
149
14
13
177
2S4
South-Western „
190
21
14
18<3
840
Boutb-Eastem „
174
12
19
2
207
462
Northern „
218
22
10
269
480
Totals .. _ ..
903
160
109
8
12UU
2891
.Small-I’OX.-- drios hospital ship, 7.
BOOKS ETC. RECEIVED.
BAiLLiiiBE, TlNDAi.L, & Cox, King William-Street, Strand, London.
Sea-sicknoss. By T. Dutton, M.D.Durh. SecondJSdltion. pp. 79-.
Price Is. Cd.
Cassell <te Co., London.
Matoria Modica and Therapeutics. By J. Mitchell Bruce, M.D-
Lund. 19th Thousand. 1^1. pp. 982.
Davis, F. A., Philadelphia and London.
Medical Symbolism. By Thos. S. Sorinskoy, M.D., Ph.D. Illus¬
trated. 1801. pp. 171. Price Cs.
Kegan Paul, Thench, <& Co., London.
Examination of Water for Sanitary ancl Technical Purposes. By
Henry Lett'man, M.D., Ph.D., and William Beam, M.A. Second
Edition. Illustrated. 1891. pp. 180.
Kemp & Co., Bombay (Loticlon Office, 84, Leadenhall-street).
The Prescriber’s Phavmacoptoia. By Kemp & Co. Second Edition-
1891. pp. 428.
Lewis, H. K., Gower-street, London.
Elements of Ih'actical JIudicine. By Alfred II. Carter, M.D. Lend.
Sixth Edition. 1801. pp. 498.
A Manual of Diseases of the Nose and Tliroat. By P.S. Hutchinson,,
M.R.O.S. Illustrated. 1801. pp. 127.
The Comparative Climatology of London and the chief English-
Health Itesovts. By B. Thornton, M.R.C.S., L.R.C.P. Lond. 1801.
pp. IS.
Pbnti.and, Young J., Edinburgh and London.
Pulmonary 'J'ubercuJosia, Etiological and Therapeutic. By R. W.
Philip, M.A., M.D., F.R.S.E. pp, C6.
Peucival (fc Co., King-street, Covont-garden, London.
The Essentials of School Diet. By Clement Dukes, M.D., B.S. Lond.
1891. pp. 187. Price Us.
Smith, Elder, & Co., Waterloo-place, London.
Dictionary of National Biogiupliy. Edited by Leslie Stephen and
Sidneyl.ee. Vol. XXVI. Henry II.—liindiey. 1891. pp. 448.
The Visit of the Tenant-Farmer Delegates to Canada in 1800 (published
by authority of the Government of Canada, 1891).—The Thermal
Springs District of New Zealand, and the Government Sanatorium at
Roturua; by A. Ginders, M.D. (O. Didsbury, Govonimeiib Printer,
Wellington, 1899).—Cliarter, Constitution, By-laws, and List of Fellowa
of the New York Academy of Medicine (printed for the Academy,
New York, 1891).—Report of the British Chamber of Commerce for
the year 1890 (C. Skipper & liast, Paris, 1801),—A Note for the-
Successful Treatment of Diphtheria, also of the Coryza and Malignant
Sore Throat Of Scarlatina; by Henry Thomas, M.D. (Kegan Paul,
Trench. & Co., London, 1801); price Is.—Modern Abdominal Surgery;
by Sir T. Spencer Wells, Bart., F.R.C.S. (J. & A. Churchill, London,
1891).—Annales de ITnstitiit Pastouv; par M. E. Duelaux ; Tome V.,
No. 3(0. MasfcOii, Paris, 1801) —Archivoa de Miiclocine Bxp^rimontole
eb d’Anatomie Pathologiciue; par MM. Grancher, Ldpine, Straus, et
Jofl'roy (George Masson, Paris, 1891).—Estadistica do las Inocula-
ciones con Mosipiitos contaudnados en Enfermos do Fiebre Amarilla»
par los Dres. Finlay y Delgado (A. Alvarez y Comp,, Ilabana, 1801).—
Behandlung weiblicher Gescdilechtskrankheiton ; von Thuro Brandt
(Fischer, Berlin, N.W., 1891). -Report of the State of the Blood and
the Blooflvesaels in Inflammation; together with a Report on
Lymphatic Hearts ami on the Propulsion of Lymph from them,,
tiu'ough a proper Duct, into their respective Veins ; by T. Wharton
Jones, F.R.S, (London : Bailliero, Tyndall, <& Cox).
^ppintnwnts.
Succesisful applicanln Jor Vacancies, Sccretwries of Public Institutions, and
others possesKinn inforsnalion suilabla for this column, aia invited to-
forward it to THE Lanci-;t Office, directed to the Sub-Editor, not later
y o'clock on the Thursday morning of each -weak for publicatiort in
Ike next number. •
Aui.D, A., M.B,, C.M. Glasg,, has been reappointed Medical Officer for
the lleck District of the T’ontefract Union.
Bt.AiKii-;, A. B., M.B. Climb., L.R.C.P. Lond., M.R.C.S., has been
appointed Medical Officer for the No. 1 District of tho Oswestry
Union.
BitONNiCH, AiiOLi’ii, M.D. Heidolb., M.R.C.S., has boon appointed
Laryngologist to the Bradford Infirmary.
Brunner, Hermann, M.J>. Stra-sburg, has been appointed Honorary
Assistant Medical Officer to tho Bradford Infl)-mai 7 .
BuRDWOOD, J. W., L.F.P.S. Glasg.,lias boenveappomted Medical Officer
of Health for Bourne, Lincolnshire.
Cartwright, J. P,, M.R.O.IS., has been appointed Medical Officer of
O.swostry and the Workhouse.
Coi.UJM, Arciiik T., L.R.C.P., M.R.C.S,, has been appointed House
Jffiysician to Chaving-cress Hospital.
COSEN-s OiiA.s. II. 0., L.R.O.P. Lond., M.R.C.S., has lioou regpDointed
Medical Officer for the Second District of the Wellington Union.
Erskink, Rout., M.I), Q.U. Irel., has been reappointed Medical Officer
(or the Camborne District of the Redruth Union.
Fkaskii, IlERitEUT, L.R.C.P. Lond., M.R.C.S,, has been appointed
House Surgeon to tlie Wlnilsoi- Royal Infirmary, vice Phillipa,,
resigned.
Frv, w; W. B.. M.B., C.M. Kdin., has been appointed Medical Officer
of Healtli for tiio Rural Sanitary District of t he Builth Union.
Dig::.zed by Google
The Lancet,]
VACANCIES.-BIRTHS, MARRIAGES, AND DEATHS.
[April 11, 1891. 861
Ginns, Charles, L.R.C.P., M.R.C.K., has been appointed House
Surgeon to Charing-cross Hospital.
HORROCKS, W. H., Juh,, M.B., F.R.C.S., has been appointed Assistant
Surgeon to the Bradfortl Infirmary.
Hughes, Edgar, F.U.C.S., has been appointed Surgeon to the St.
George’s and St. James’s Dispensary, and Surgeon to the London
Rifle Volunteer Brigade,
JULEli, HenrvK , F.R.C.S., haebeen appointed Consulting Ophthalmic
Surgeon to the London Lock Hospital and Asylum, HaTrow-rnad,
MacGregor, D. A., M B., C.M. Edin., hns boon reappointed Medical
Officer for the Donby District of the Penistone Union.
MacVail, John C., M.D. .st. And., D.P.II, Camb., has been appointed
Medical Officer of Health for the Counties of Stirling and Dum¬
barton.
McIiiNTOCK, James, M.D., B.Sc. Edin., has been appointed Medical
Officer of Health for tlio County of Lanark.
Remery, Leonard, M.A., M.D., B.C. Cantab., M.ll.C.P., has been
appointed Obstetric Physician to Out-patients at the Great Northern
Central Hospital.
Parham, n. G. H., M.R.C.S., L.R.C.P., has been appointed Surgical
Registrar to Charing cross Hospital, vice P. X. Da Costa, resigned.
Riddell, J. S,, M.B., C.M. Aberd., has been appointed Medical Officer
for the VVeat Division of the Oidmachar Parochial Board.
BOLSTON, 'I'. 31., L.R.C.P. Loud,, M.R.O.S,, has been appointed Medical
Officer for the Stoke and Tamar Di.atvict of the Stoke Dainerel
Union.
SiMi'SON, Alex., M.A., M.B., C.M. Aberd., has been appointed Junior
Assistant Medical Officer to the Sussex County Asylum, Hayward’s
Heath.
StONEY, P. B., L.R.C.P. F.din., M.R.C.S.. ha.s beenreappointed Medical
Officer of Health for Milloni, Cumberland.
Sully, A. Max, 1j.H.C.P. l,ond., M.R.C..S., has been appointed Resident
Medical Officer of the Jaffray Suburban Hospital, Birmingham.
Swallow. F. McDonald, L.U.C.P., L.R.C.S. Edin., lias been re¬
appointed Medical Officer for the Silkstone District of the Penistone
Union.
Williams, Wm. Hhnuv, jun., M.R C.S.,L.R,C.I’. Bond.. L.S.A., has been
appointed Medical Officer of Health for the Rural Sanitary Autho¬
rity of the Sherborne Union, Dorset.
WiLMOT, Tlios., L.R.C.P. Lond., M.R.C..S., has been appointed
Honorary Assistant Medical Officer to the 13rndford Infinnary.
Wilson, A. C. J., L,U.C.P. KcHu., M.R.C.S., has been reappointed
Medical Officer of Health for the Peuistoue Rural Sanitary District.
youNGER, Edward George, M.D. Brux., M.U.O.P. Loncl.. has been
appointed an Honorary Physician to the St. Pancras ami Northern
Dispensary.
Young, James, M.I). Glasg.. hns been appointed Assistant Surgeon to
the South Dispensary, Liverpool.
iarroits.
For further ivfwmalion rcpi'-iimj each vacancy reference should be made
Ij the adnerdsoment.
Aluesford Union.—M edical Officer for the Second District. .Salary
£100 per annum, with extra fees and vaccination. (Apply to the
Clerk, Alreaford, Hants.) ,
Alreseoud Union.—M edical Officer of Health for the District of tho
whole Union. Salary £40 per annum. (Apply to the Clerk, Alrosford,
Hants.)
Birmingham City Asylum, Rubery-hill, near Bromagrove.—Clinical
Assistant. Board, lodging, and washing will he provided.
Cancer Hospital (Fri-u-;), Fulham-road, S, W.—Assistant Surgeon.
Charing cross Hospital Medical school. -Demonstratorsliip of
Physiology. Honorarium £100 per annum.
Chelsea.—M edical Officer of Health, Food and Drug* Analyst, and
Gas Examiner. Salary .£460 per annum.
DiovoNSliiRK Hospital, Buxton.—House Surgeon. Salary .ClOO per
annum, with boanl, furnished apartments, and washing.
Devonshire Hokpital, Buxton.—Assistant House Surgeon. .Sa’ary
.£60 per annum, with board, furnished apartments, ami washing.
Guest Hospital, Dudley.—Resident Medical Officer. Salary £100 jisr
annum, with board, residence, attendance, and washing.
General Infirmary, Leeds.—Resident Ilou.'ie I’hysician for twelve
incnths. Board, lodging, and washing provided.
General Infirmary, Leeds,— Two Resident House Surgeons for twelve
months. Board, lodging, and washing provided.
General Infiumarv, Leeds.—A Resident Officer at the Ida Hospital
for six months, with honorarium of £-2b.
Hospital for Consumption and Diseases of theCiikst, Brompton.—
Resident Medical Officer. Salary £2(i0 per annum, with board and
rosidciico.
King's Coi.i.icgic HO-SPITAi., Lomlon.—Sainbrooke 'Medical Registrar.
King’.S COLi.FJiH, l.onrton.—Demonstrator of Public Health.
Lincoln Oddfellows' Medical In.stitute.—A ssistant, out-door.
Halary £121) per annum. (Apply to tlie Kecretavy, 12, Nortli Pamde,
Lincoln.)
North-West London Hospital, Kontish-town-road. - Resident
Medical Officer for six months.
North-West London Hospital, Kontish-town-i-oad.—Assistant Resi¬
dent Medical Oflicer for .six iiioiitlia.
Newcastle-upon-Tyne City Lunatic A.syi.um, Gosport.^Assistant
Medical Officer. Salary £100 per annum, with board, lodging, .and
washing.
Parish of Birmingham (VV()Ukhou.se Infirmary).—J ledical Clinical
Clerk at tho Workhouse Infinnary for six months. Honorarium
16 guineas for tlie six months, also provided with rations (wliii-h do
not include alcoliolic liquoi-.s). coal, gas, apartments, washing, and
attendance. (Apply to the Clerk to tho Guardians, Pari.sli Offices,
Kdmund-strGot.)
St. George’s and St. James’s Dippenbary, (K), King-street, Regent-
street—Third Honorary Physielau.
West Londo.n Hdsimtal, Hammersmith-road, W.—Assistant Surgeon.
glarriagts, anir
BIRTHS.
Audland.—O n April 2nd, at Brooklanda, Wellingborough, the wife of
W, B. Audland, L.R.C.P. &c., of a daughter.
Brand.—O n April 0th, at Invery, Great Driffield, B. Yorks, the wife of
Dr. Brand, of a son.
Brewib.-O n April 1st, atWaratah, Mount Bischoff, Tasmania, thewifa
of R. Adams Brewis, M.D. Edin., of a daughter (stillborn).
Bucicley.—O n April 2nd, at The Poplars, Tlirnpston, the wife of T. W.
Buckley, M.R.C.S., of a daughter.
Hall.—O n April 6th, at Wimpole-street.W., the wife of F. De Havillant)
Hall, M.D., F.R.C.P.. of a daughter.
Lb Cronier. — On April Ist, at Mldvale-road, Jeraey, the wife ot
Hardwick Lo Cronier, M.R.C.S., of a daughter.
SiDF.iiOTiiAM.— On April 3rd, at Erlesdene, Bowdon, Cheshire, the wife
of 15 J. Sidebotham, M.A,, M.B. Cantab., of a son.
Tidev.—O n April 3rd, at Villa Magnolias, Montreux, Switzerland, the.
wife of Stuart Alexander Tldey, M.B., of a daughter.
Turner.—O n April (ith, at Alton, Hants, the wife ot T. B, Turner,
6I.R.C.S., of a (laughter.
MARRIAGES.
Adams—Whyte.— On March 12th, at St. Thomas’s Cathedral, Bombay,
Uharlea Adams, M.B., LL.B. Dub., P.R.C.S I., sou of the late
Andrew Adams, Estp, Terraquin, county Tyrone, to Maude do Wyte,.
second daughter of the late Major John L. A. Whyte, J.P., county*
Clare, and Bray, Ireland.
Amsden—Veueker.—O n April 4tli, at St. Bartholomew's Church,
Duhliii, George Amsden, M.B., of Bssex County Asylum, Brent¬
wood, to Annie J5Uzabeth, daughter of Amos M. Vereker, Estj.,
Wellington-placo, Dublin.
Beauchamp—Sharp.—O n April 4th, at St. Maik’s, Milvorton, Leam¬
ington, Sydney Beauchamp, M.B. Cantab., second son of H. U.
Beauchamp, to Edith, third daughter of the late H. Morton Sharp,
of I.eamingfcon.
Hardyman—Beath.— On Aprfl3rd, at the Parish Church, WestWiekham,
by tho Rev. F. H). Murphy, M.A., Bath, George Hatdymnn, M.B.,
C.M., of Bath, eldest son oi the late John Ilav Hardyman, Esq., of
Heatherwick, W.S., late of the 3rd Battalion Royal Scots, to
Constance Christian, second daughter of David Beath, Esq., Mel¬
bourne, Australia, and of Wood Lodge, West Wickham, Kent.
Hicicly—Maplestonk,—O n April lat, at St. Stephen’s Church. Shep-
herd’s-bush, Arthur Mackenzie Hickly, L.R.C.P. Loud., M.R.C.S.„,
of Melthaui, Yorkshire, to Gertrude i‘'ranc0s, daughter of the late
H. Maplestone, B.I., Shepherd’s-bush, London.
LocKErr—S prent.—O n April 7th, at St. Peter's Church, Southsea, by
tho Rev, C. R. Tompkins, Vicar, John Arthur Pope Lockett, M.R.C.S.,
L R.C.P., of Woolwich, to Isabella Swanson, elder daughter of
Major Sprent, late E.A., of Southsea.
Macdonald—U suER.-<)n April 2i)d, at 18, Lauder-road, Edinburgh, by
the Rev. Robert G. Baliouv, Thomas Ranken Macdonald, M.B.,
Surgeon, Bengal Medical Staff, to Amy Balnier, youngest daughter
of Mr. Thomas 'Usher, of Kdiiiburgh.
Payne—Edhund.s.—O n March 3lst, at St. George's Church, Edgbaston,
Birmingham, Wiliam Arthur Payne, B.A. Pern. Coll. Oxon., M.R.C.S.,
of Selly Oak, Worcustcr.shire, son of F. A. Pryiie, Esq., Pantre Ucho,.
near Oswestry, to Margaret Banks Edmunds, daughter of the late
Henry Edmunds, E8<|., of lOlmstlale, Edgbiiston.
Praqer—Knowles.—O n Marcli 2ath, at Brighton, Alfred Prager,
L.D.S,, of Portnian-street, vv,, to Tere.sa Carlotta Gladys, daughter
of the late Captain ll H. Knowles, U.N. .
ScouGAL—GiusT.—On April 2n(l, at St. looter’s, Huddersfield, by the
Rev Canon Bardsley, M.A., Vicar, assisted by the Rev. Robert
Willan, M.A., Vicar of Golcar. Edward Fowler Scougal, M.A. Aberd.,
iM.D., C.M. Edin,, Hnddersflold, to Edith, second daughter of John
J. Grist, Oakleigli, Edgerton, Huddersfield. No cards.
TniNDKR—M ole,—O n April 7th, at Tutbury Parish Church, Staffonl-
aliire, Alfred I’robus Trindor, M.R.C.S., L.R.C.P., older son of the-
late Rev. Daniel Trindev, Vicar of Highgate, to Mary Maude, eldest
daughter of U. L. Homer Mole, of Rivovdale, Tutbury.
DEATHS.
BaiiingTON.-• On Api-il 2nd, in Lomlon, Surgeou-Miijor Thoma.s.
Babingtoii, Meilical Staff, Retired.
Davidson.—A t Toowoomba, Queensland, John Maxwell Davidson,.
M.B., C.M. Glasg.
I)AVLS.-On April 7th, at 20, Upper Woburn-place, Dr. H. P. Davw„
aged 73. Friends will please accept this, the only intimation.
no\vELL.--On Apill Sth, at Cleevo House, West Hill, Wandswortli,
Bessie, wife of J. Arthur Ives Howell, Es([., and daughter of the
late .lohn Taylor, Es'i., of Gotherington, Gloucestershire, aged'
31 years,
James.--O n April 3i'd, at Ireton 'W’ood, Derbyshire, Henry James,..
M.D. . . .
Stamford.—O n April 3rd, nt Heathfield, near Alfreton, Derbyshire,
Florence Louisa, wife of W. A. Stamford, M.R.C.S. Eng., and
(hiighter of tho late Hugh Kcclea Walker, iM.D., of Chestorflokl,
aged-12 years. , .
Tones.- On April 2nd, at Willciihall, Staffordshire, Joseph ionks,.
M,R.C,S.. aged 3!). . .
Vachell.—O n March 20th, at Victoria, Ebbw Vale, Edward Shearman.
Vachf 11, M.R.C.S,, J.P, for Monmouthshire, second son of the late-
C. R. Vachell, M, D., F.R.C.S., Cardiff, in his .36th year.
Wade.- On April Ist, at Cross, Compton Bishop, .Somerset, Edwora
Wade, Surgeon, aged 81. _
F.B.—A fee of Cs. is charged for the Inierlioviof Notices of Births,
Marriayes, and Deaths.
Dir:' -ed
Google
662 tHB Lanobt,3 notes, comments, AND ANSWERS TO CORRESPONDENTS. [AfEiL 11,1891.
liltitrital giarj for % ensning ®Mlt.
Monday, April 13.
ROTAL London Oputhalmio Hospital, Moorfields. —Operatloiu
daUy at 10 a.m.
Botal Westminsteb Ophthalmic Ho3PiTAL.-~Operatioas, 1.80 p.h.,
and each day at the same hour.
Chelsea Hospital for Women.—O peratlone, 2.80P.H.; Thursday, 2.80.
Hospital for Women, Soho-si)uars. — Operations, 3 p.m,, and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 8 p.m.
Botal Orthop^edic hospital.—O perations, 2 p.h.
CSNTlUL London ophthalmic Hospital.—O perations, S p.h., and
each day in the week at the same hour.
(University Collesb Hospital.-£ arandThroatDepartment,OA.H.;
Thursday, 0 a.h.
Medical Society op London.—8.80 p.m. Mr. Q. Buckaton Browne:
The Importance of the Post-prostatic (or trigonal) Poucli in the
Surgery of the Vesical Calculus, illustrated by several cases.
Tuesday, April 14.
Kino's Collbqs Hospital.—O perations, 2 p.m, ; Fridays and Saturdays
• at the same hour.
Out's Hospital.—O perations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 P.H.
St. Thomas's Hospital.—O phthalmic operations,4 p.m.; Friday,2 p.h,
St. Mark's Hospital.—O perations, 2 p.m.
Cancer Hospital, Brompton.-O perations, 2 p.m. ; Saturday, 2 p.m.
Westminster hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
3t. Mary's Hospital.-O perations, l.SO p.m. Consultations, Monday
2.80 P.H. Skin Department, Monday and Thursday, 9.80 a.h.
Throat Department, Tuesdays and Bridays, 1,80 P.H, Electro-
therapeutics, same day, 2 p.m.
Royal Institution.—8 p.m. Mr. J. Scott Keltic: The Geography of
Africa.
Boyal Medical and CiiinunaiCAL society.- s.so p.m. Mr. j. H.
Hutchinson (for Dr. W. B. Choadle): Measles as a Cause of Endo¬
carditis, being an account of four cases in which Organic Mitral
Murmurs developed during the course of the disease.—Mr. W.
Arbuthnob Lane: Chronic Traumatic Arthritis.
WedseBday, April 10.
iVAHONAi Orthopedic Hospital.—O perations, lo a.k.
Middlesex Hospital.—O perations, 1 p.h. Operations by the Obstetric
Physicians on Thursdays at 2 P.H.
6t. Bartholomew's Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 P.H.
Surgical Consultations, Thursday, 1.30 p.m.
-Cbarino-cross Hospital.—O perations, 8 p.h., and on Thursday and
Friday at the same hour.
St. Thomas's Hospital.—O perations, 1.80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 P.M. Thursday <&Saturday,samehour.
St. Peter’s Hospital, Covent-qarden.—O perations, 2 p.m.
Samaritan Free Hospital for Women and Children.—O perations,
2.80 P.M.
■Great Northern Central Hospital.—O perations, 2 p.m.
University college hospital.—O perations, 1.80 p.m. ; Skin Depart¬
ment, 1.46 P.H.; Saturday, 9.16 a.h.
SlOYAL Free Hospital.—O perations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations, 9.80 a.m. ;
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
Thursday, April 16.
St. George’s Hospital.—O perations, l p.m. Surgical Consultations,
Wednesday, 1.80 p.m. Ophthalmic Operations, Friday, l.SO p.m.
Unitersixy College Hospital.-O perations, 2 p.m. ; Bar and Throat
Department, 9 a.h. ''
illOYAL Institution.-3 p.m. Professor Dewar: Recent .Spectroscopic
Investigations.
Hauyeian Society op London.— 8.30 p.m. Mr. Edmund itoughton:
A case of Hepatic Abscess implicating the Lung, Pleura, Kidney,
and Colon.—Dr. Amand Eouth; The Treatment of tlie Vomiting of
Pregnancy.
Friday, April 17,
BOYAL SOUTH London Ophthalmic Hospital.—O perations, 2 p.m.
Royal Institution.—9 p.m. Prof. A. W. Rucker; Magnetic Rocks.
Saturday, April 18.
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.16 A.H.
ElOYAL Institution.—3 p.m. Prof. Silvanus P. Tiiompson: Tiie Dynamo.
METEOROLOGICAL READINGS.
(Taken daily at 8.30 a.vi. by Steward's Instruments.)
The Lancet Office, April 9bh, 1891.
Date.
Burometor
reduced to
Sea Level
and Sd*F.
Dtreo-
tlon
Ilf
Wind.
Dry
Bulb.
■Wet
Bulb.
Bolor
liitdla
in
Vacuo.
Maxi¬
mum
Teirip.
Shaue.
Hln.
Tump
Bain-
fall.
Bomarks at
S.SO A.U.
Apt.
29'0l
E.
41
89
60
61
89
Overcast
4
29-72
S.E.
46
44
66
64
49
•06
Raining
6
29-00
S.W.
49
47
86
66
43
•46
Cloudv
IS
29-69
w.
46
44
93
60
42
•08
Cloudy
7
29-70
N.
44
42
46
41
Overcast
S
29-93
N.
41
87
80
40
86
Britrht
9t
9
20-97
N.E.
42
41
60
46
40
•99
Raining
Soles, Sljort Coramtnls, i posters to
Co.ras|onlrcitls.
It is especially requested that early intelligence of local
events having a medical interest, or which it is desirable
to bring tinaer the notice of the profession, may be sent
direct to this Office.
All eommnnications relating to the editorial bwnness of the
journal must he addressed ''To the Editors."
Lectures, original articles, and reports should be wHtten on
one side only of the paper.
Letters, whether intended Jor insertion or for private informa¬
tion, must be authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed " To the Sub-Editor."
Letters relating to the publication, sale, and advertising
aepanmcnis of The Lancet to he addressed "To the
Publisher."
We cannot undertake to return MSS. not used.
GENKHAL PllACTIlTONERS’ UNION.
Deanreper, writing on this .subject, says : “ I can most heartily endorse
every word that has been written by your correspondent, ‘ General
Practitioner,’ as to the absolute nocossltyfor the above. The two
great factors tliat we liave to • contend against are overcrowding
and underaeiiing, the one being the outcome of the other. In the
town in whicli I reside there are two lamentable instances of
tho pass to which we have come. One large society, compo.sed prin¬
cipally, but not entirely, of women, pays 3v. per head per annum,
which includes attendance in labour. Amongst its members are in¬
cluded trade.smeii and their wives, publican.s of both sexes, and gentle¬
men’s servants. AnotJier glaring instance. A largo cotton spinning
mill pays its medical officers, of which it has no less than five, sixpence
and oightpence per rjuarter per head. I have vainly tried to put a stop
to this state of things, but am powerless, as there is no unanimity
amongst us. In the Poor-law very much the same thing occurs, and
guardians have no hesitation in informing the discontented medical
officer that if lie is not satisfied they can find plenty of men able and
willing to do his work for half liis pay, and I fear it Is but too true.
The public vaccinator has also to put up with the .same competition,
and is frequently told that Mr. X. oidy puts on two small spot.s
for half-a-crown and calls at tho people’.? house for the purpose, and
has lieen Iriiown not to despise tiro proverbial "bob” when the larger
coin has nob been forthcoming. Tho question of collecting clubs also
requires ventilation, men being frequently employed as touts io
obtain members for the so-called dispensaries."
Qcneml J'raetitumer writes as follows on tho same subject: "May
I bo allowed to suppoi't my statement which appeared in your
issue of March 20th, tliat a General PKictitionei’s' Union would bo of
service lo tho medical profession. In the legal profession there is the
Incorporated Law Society, against which no lawyer dares to fight.
Wo have no such society in tlie medical profos.sion. Of course, there
is the British Medical Association, but its meetings aro attended
chiefly by -consultants and hospital surgeons, tho hulk of general
pnictitionei-s having too much work and too little pay to spare tho
time for attending. Then, .again, it.s meetings are so much taken up
with discussing matters relative to tlisease itself that there is little
time to spare for trying to ameliorate the condition of tlie
mas.s of tJio.se whose work it is to cure disease, I perfectly
agree with ‘ M.D,’ that there are ‘a lot of ungentleinanly men
ill the profession wiio are willing to give their services for tlie
smallest pittance,’ but I hope those men are in the minority.
Jt only wants unanimity on the part of the medical profe.ssion to
Digitized by
Google
Tbi Lancet,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS, [Apeil 11, 1891. 863
improve the poBition of general praotitionera, both aa regards income
and aa regards the respect in which they, as a body, are held by
membera of other profeasiona and society at large. Let us have the
Union, I say, and let us stand by one another in not allowing com¬
petition (owing to the continual increase of our numbers) to cut
down the fees. 'J’here is plenty of room for us all, if we can only
agree to accept fees according to a certain standard, which can be
brought about by forming ourselves into a Union. Then shall we be
able to put down tlie ‘hangers-on' round our profession, bonesetters,
and unqualified practitioners, and, worst evil of all, qualified men
acting as ‘covers’to quacks. If weare only united and rteteixoined
to fight tlie matter out, tliere is little doubt of our success.”
C.—A practitioner with only a surgical qualification is at a legal dis¬
advantage in enforcing payment for services in a medical case. He is
competent, if registered, to give evidence before a coroner, even in a
medical case, the coroner generally contenting himself with inquiring
if the witness is a registered practitioner.
Mr. John A. Sleicher (New York),—We have no special information of
the waters. Application might be made to the editor of the Wien.
Med. Wochens., from which our account was taken.
3/rs. Piper.—K sample should be forwarded, with a statement of its
composition.
Ji, F. P. has not enclosed his card.
HUMAN AND BOVINE SCARLATINA.
To the JUditors <tf THE Lancet.
Sirs,—I n reply to Mr. Atkinson on the above subject in your current
issue, I beg to say it is with great regret that, as a country veterinary
practitioner, I cannot enlighten him on those bovine diseases com¬
municable to the higher animal which manifest themselves by “ an
entirely different set of symptoms," and there are three main reasons
for my inability to do so:—1. The medical officer of health too fre¬
quently forma a theory that the cow is to blame, and omits to notice
important sanitary facts in his seal to saddle her with the odium of
being the origin of an epidemic; or he does not .seek the aid of a
veterinary surgeon to elucidate the mystery of mammary ulcers, which
have probably arisen from the fanner having picked olf small papillo¬
mata with a very dirty tliumbnall, and tried to assist the healing
process by using some strong caustic. Or, if accompanied by a
veterinary surgeon, he is handicapped in his scientific research by the
arguments and theories of a man wliose pathology has become very
rusty, and who in liis ignorance disbelieves in the unity of liuman and
bovine disease. 2. The ignorance of stockowners and their fear of the
Contagious Diseases Act. Many a time have I had to turn sadly auuy
from a case which might liave helped to throw light on this subject
because the owner has been suspicious that my investigations were
being carried on at his expense, or were likoly to damage his milk
trade. 3. An entirely different set of symptoms do not characterise tho
same disease in man and beast. Like produces like; and though there
are minor differences due to difference of surrounding temperature, Ac.,
the symptoms have much in common, and the pathogenic organisms
exhibit a strong family likeness—e.g., malignant pustule of man and
anthrax of sheep; consumption of man, tuberculosis of cattle.
The cow has much to be answerable for; but I fear that her human
neighbours are more frequently to blame, and in their anxiety to screen
themselves either wilfully or ignorantly mislead the soarcher aftor
trutli. I am, Sir.s, yours obediently,
Exmouth, April Oth, 1891. Eras. Evelyn Place, M.R.C.V.S.
Salicylic Acid a.mi Scarlet Fever.
It is stated by Dr. de Rosa, in an Italian medical journal, that salicylic
acid is a valuable prophylactic in epidemics of scarlet fevor. Of
sixty-six children who were all exposed to the contagion, but who
were given from a grain to five grains a day, sixty-three entirely
escaped.
PREHISTORIC TREPHINING.
To the JEditors 0 / TiiE Lancet.
Sirs,--T he very interesting subject of prehistoric trephining, detailed
in your last issue, is pretty fully discussed in one of the “International
Scientific Series”—vol. xliv., I believe, “Man before Metals,” by M.
Joly—and illustrated by engravings of trephined skulls. The explana¬
tion given, if I recollect rightly, is Uiat epileptics were so treated
probably to allow tho demon possession to escape, and tliat those
.skulls after doatli of tho owner were treasured as charms against the
disease. As I left that paid of mylibrai'yin Now/Zealand, I cannot
refer to the volume. I am, Siis, yours obediently,
April 4th, ISOl. John W. Kevwohtii.
LoNfiEvrrv.
In the country district of Ormsklrk one of the medical practitioners
discovered that tho combined ages of the first five cases seen by liiin
last Good Friday morning amounted to 402 years, the respective ages
of the patients being 74, 87,7-1, 74, and 03.
L.11.C.P. should refer to TiiK Lancet of March 21st, p. 08C, as to the
solo of Koch’s Iluid; tho question of quantity may be decided by
reference to the various reports of cases treated by the remedy.
A Scotch Holiday Spoiled.
D. £.—One of the supposed charms of a medical holiday in the Western
Islands of Scotland is a fancied security from summons to a midwifery
case. Our correspondent's interesting letter shows that this security
must not he too much relied on. His kindness in the circumstances-
was great, and his charges were reasonable. An emergency in such
solitudes might call for the gratuitous exercise of professional talents;
but to be at the mercy of violent calls by rich people, involving
attendance on midwifery, crossing moors and mountains, and taking
a journey of sixteen miles on a wet night, giving up holidays, sleeping
a fortnight in the patient’s house, and then guiding and accompanying
I a tender infant 200 or 300 miles by land and sea, is a risk and a.
sacrifice that must have their compensations. In the main we agree-
with our correspondent in his view of his obligation to Dr. K-.
I Dr. K-, being first sent for, cannot be ignored in regard to the-
obstetric case. But our correspondent was personally compelled, a»
' it were, to undertake the infant’s care, and did it, finding it a most-
onerous duty.
ilf.D.—We should say that our correspondent was duly engaged, and i»
entitled to his fee. He should have very strong evidence that a
brother practitioner knew that he was engaged to attend the case
before concluding that he was guilty of unprofessional conduct In
superseding him without notice.
SYMBOLS AND INSIGNIA OF ALCHEMY, CHEMISTRY, AND-
MEDICINE.
To the Editors 0 / The Lancet.
Sir.<,—A gentleman in tho United States is endeavouring to make a.
complete collection of pictorial illustrations of the various badges and
insignia that have been used in timesjiast to characterise or distinguish
the profes.sions of pharmacy, chemistry, medicine, surgeiy, and the-
allied sciences, including alchemy. Can any of your readers assist ia
this matter by describing such signs as may be known to them, or re¬
ferring to publications containing such particulars 7
I am, Sirs, yours faithfully,
April 4th, 1891. G. W.
Tub Friendly Societies' Medical Alliance in Concl-vve.
The twelfth annual Conference of tho Alliance has been recently hold
at IVolvorhampton. Mr. J. B. (iutler presided, and delegates were pre¬
sent from Burton-on-Trent, Gloucester, Bradford, Kidderminster,.
Lincoln, Loicoster, Wednc.sbury, Stouiport, York, and Wolver¬
hampton. Tho President remarked with satisfaction on the more-
friendly spirit with wliich the medical faculty regarded these aassocia-
tions and their methods. With every wish to reciprocate friendly
feeling with the President, and towards .schemes for facilitating goods
medical attendance on working men and tlioir families, we do not-
know on what facts ho bases his satisfaction. The medical profes¬
sion feels deeply tho contemptuous estimate of its services implied in
the terms of these friendly associations, which are accepted for the
most part by tho younger members of the profession, 'fliose terms are-
being commented oniiy the lay pres.s, and are discreditable alike to-
those who offer and to tliose who accept them.
Messrs. Pocke, Toinpsitt, <9 Co.—We regret we are unable to supply the-
address required.
CIVIL SERVICE INSURANCE SCHEME.
To the Editors o/TnE Lancet.
Sirs,—Y our correspondent, “A Medical Civil Servant,” in your issue-'
of tlie 28th ult., in reference to the Civil Service Insurance Scheme,
states that “ all civil servantsiprior to appointment are submitted to a
very extended medical examination; and the medical examiner is-
spociiiJly asked to give tho benefit of any doubt ho may have in regards
to fitness for the service not to the individual, but to the State, and as
a result only tho best men al-e passed.” Will he bo so good as to say in-
which branches of the Civil Service this course la practised '/
I am, Sirs, your obedient servant,
April 7th, 1891. iNiliHRER.
PiucTi-noNERS Dispensing Abroad.
CoJU’LAiNTS are made that the medical men practising in sparsely
populated rural districts in Alsace-Lorraine, who are allowed to-
supply medicines to their own patients when there is no pharmacist-
near, have of late been exceeding tho licence they have, and that
some of them aystoniatically supply medicine when there Is 110 diffi¬
culty ill getting prescriptions made up. Some, too, it is said, oven
sell medicines to per.-sons who are not their patients. Tho phar¬
macists naturally complain that their rights are being infringed, and
the medical authorities have been charged to see that tho law is no
longer set at defiance. It is not, however, intondert to take away the
licence to medical men to supply medicines, as under the circum¬
stances this would be impossible.
Rossnll. —Tho death of Napoleon I, was caused by cancer of the stomach.
Mr W. U. R/'o«>«.--Piol>ably next week.
Dr zed by CjOO^IC
«64 Thb Lanckt,! NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [April 11,1891.
AnVERTISING PRACTITIONEBS IN MILE-END-ROAD.
.A REMARKARI.E banclbill, emanating Irom 140, Milo-end-road, announces
advice and medicine Od., visit and medicine Is., by a duIyqnaliSed
and registered physician and surgeon, &c. It ends with the following
remarkable announcement:—“Late Dr. Hanks, Inventor and Patentee
of the well-known Neuralgia and Nerve Mixture, 146 , Mile-end-road.”
The name of no living person appears in this production, from
which we infer that the author himself is not proud of his connexion
with it.
■Communications not noticed in our present number will receive atten¬
tion in our next.
COMMUNICATIONS, LETTERS, &c., have been received from—Sir Walter
Foster, Edgbaston; Surgeon-General De Kenzy, Dublin; Mr. Lawson
Talt, Birmingham; Dr. Horrocks; Dr. Sainsbury; Dr. Mortimer
Granville, London ; Dr. Herman, London; Mr. Hulke; Prof. Ogstcn,
Aberdeen ; Mr. W. U. Bennett, London ; Messrs. Bowntree and
■Co., York; Dr. M. S. Wade, Victoria; Messrs. Bock, Hawkins and
Co., London; Mr. Weddell, Newcaatle-on-Tyne; Messrs. Burgoyne
And Co , London; Dr. H. 3. 3. Lavis, Naples; Dr. Pierce; Dr, Wood
White, Birmingham; Mr. Marshall, Huddersfield; Messrs. Legray
and Co., Paris; Mr. W. H. Brown, Leeds; Messrs. Laxard Bros, and
Co., London; Dr. W. Hill, London; Mr. Duke, Dublin ; Mr. Hayden
Brown, Edinburgh; Mr. Lawrence-Hamilton, London; Messrs. Hertz
and Collingwood, London; Mr. Place, Exmouth; Messrs. Matthew
Bros., London; Surgeon Sleman, London; Messrs. C. Hearson and
Co.,London; Mr, S. Paget, London; Messrs. Herman, Lescher, and
Co., London; Dr. Dutton, London; Dr. G. Johnson ; Dr. Knox, Bast
Moseley; Mr. Blair, Leeds ; Mr. Oxley, Wisbech; Messrs. Carnrick
and Co., Bloomsbury; Dr. Kingsbury, Blackpool; Messrs. Bailliure
et Fils, Paris; Dr. Alexander, Hanwell; Messrs. Roche, Tompsit, an<l
Co., London; Mr. Hordley, .Stoke-upon-Trent; Messrs. Wright and
Co., Bristol; Mr. Beeves, London ; Mr. J. J. Marsh; Mr. Cleary, New
York; Dr. Scatliff,Brighton; Mr. Cogan,Nottingham ; Messrs. Mann
and Sons, London ; Dr. Keyworth, Southport; Messrs. Abbott and
Barrett; M. Tissier, Paris; Mr. Mercler, London ; Messrs. Keene
And Ashwell, London ; Mr. Sutherland, London ; Mr. H. Hick, New
Romney, Mr. Cocking, Sheffield ; Dr. Ball, London; Senhor Conia
Vaz, Oporto; Mr. G. Vickers, London; Miss Thompson, Tunbridge
Wells; Dr. Wood, Wilmington, N.C., U.S.A.; Messrs. Potter and
;Sacker, London ; Mr. H. Sell; Mr. Lyle, London; Mr, Sleicher, New
York ; Mr. Addiscombe, Glasgow ; Messrs. Duncan, Flockhart, and
Co., Edinburgh; Mr. Edwards, Birmingham; Messrs. Mason and
Co., London; Mr. Wheeler, Chicago ; Dr. Partington, Tunbridge
Wells ; Dr. Poore, London ; Mr. Densham, London ; Messrs. Dulau
and Co., London ; Mr. Davis. London ; Mr. Keary, Preston; Mr. M.
Smith, London; Mr. Jones, Towcester; Dr. Cooper, Mortimer; Mr, L.
Browne, London; Miss Beadon, Plymouth; Messrs. Macmillan and
Co., London ; Mr. Brodie, Newcastle-on-Tyne; Messrs. Cochrane and
Walker, Liverpool; Mr. Mangan, Kensington; Messrs. Coutela and
■Co., Paris; Dr. E. Blake, London; Mr. O. Is. Pitt; Messrs. Deacon
and Co., London; Mr. Dickson, Derbyshire; Messrs. Brown, Gould,
and Co., London; Mr. G. Whltcombe, Gloucester ; Messrs. Brady
And Martin, Newcastle-on-Tyne; Dr. Ryley, London ; Messrs. Savory
and Moore, London; Dr. J. L. Steven, Glasgow ; Messrs. Bloiideau
et Cie., London; Mr. T. F. Raven, Broadstairs; Messrs. Frazer and
■Co., London; Mr. Balding, Boyston; Dr. Wigan, Portishend; Mr. Le
Fevre, Belfast; Mr. T. Dodd, London; Mr. Klihn, London ; Mr, A,
Thomson, London ; Mr. Saunders, Manchester; Mr. Birchall, Liver¬
pool ; Mr. A. Hodson, Brighton ; Mr. Lacy, London ; Dr. Becker, Mil-
waukie; Mr. Hamilton, Brighton; Mr. Hodg.son, London; Mr. T. B.
Browne, London; Mr. G. Brown, London; Mr. J. Poland; Dr. Brown,
Clifton ; Prof. Watson, Glasgow ; Dr. Fullerton, Greenwich; Dr. B.
Howard, Yokohama; Mr, 8. £. Atkins, London; Dr. Piggott, Telgn-
iL’outh ; Dr. Hambloton, London; Dr. W. Hunter, London; Mr. T. J.
Henry, Warnilda; Mr. Boning, Powiok; T., Homerton; M.D,, Cam-
berwell; M.R.C.P.; M.; D. E ; General Practitioner; One of the
Crowd; L.B.C.P.; C.; M.D.; Sussex, London; Birmingham Daily
Pott; W. B. A., London ; Alpha, Manchester; M.M., London; An
Old Subscriber ; Secretary, Geneml Hospital, Cheltenham ; Bradford
Infirmary; Dental Jtecord,'London', F.B C.S.I,, London; Devonshire
Hospital, Buxton ; A. B., London; Falrplay ; Oeddes Manufacturing
Co., London ; Alpha, London; Cash, London; Spes, London; Guest
Hospital, Dudley ; Delta, Manchester; Surgery, London; Spes, Liver¬
pool ; Clerk, Wakefield ; Inquirer.
Letters, each with enclosure, are also acknowlodged from-Dr. Thorne,
London; Mr. Lockwood, Eastbourne; Mr. Field; Mr. Hutchinson,
Belfast; Dr. Browis, Edinburgh ; Mr. Thin, Edinburgh; Mr. Wilson,
Devizes; Mr, Stranaglian, Pontypridd; Mr. Brownlow, Bolton-le-
Moors ; Dr. Nelson, Wandsworth ; Mr. Simmonds, Newry ; Mr. Tully,
Hastings; Mr. Forjett, Caistor; Dr Evans, London ; Dr. Richards,
Ledbury; Mr, Johnston, Bods; Dr. Jones, Towce.ster; Messrs. Leo
and Martin, Birmingham; Mr. Lee'is, Swansea; Messrs. Keith and
Co., Edinburgh ; Dr. Keith, London; Messrs. Richardson Bros, and
Co., Liverpool; Mr. Jenkins, Lincoln ; Mr. Jones, Morley ; Mr. W.
Scott, London ; Miss Symons, Southport; Mr. Heywood, Manchester;
Mr. Tyte, Minchinhampton; Mr. Johnston, Burnley ; Mr. Stamford,
Alfreton ; Dr. Irwan, co. Down ; Mr. Brien, co. Dublin ; Mr. Hale,
Chesterfield; Mr. Bicliardson, Manchester; Dr. Parkinson, Shef¬
field; Mr. Blackburn, Barnsley; Dr. Waller, Peterboro’; Mr. A. W.
Needes, London; Miss Moorhouse, London; Messrs. Paternoster and
Hales, Hitchin ; Mr. Charleswortb, Sheffield; Messrs. Heywood and
Co,, Manchester; Dr. McFarlane, co. Tyrone ; Mr. Withor.s, Shrews¬
bury; Mr, Greville, Sheffield; Mr. Marshall, London; Mr. Knowles,
Leeds; Mr. Waldron, Leicester; Dr. Garman, Kendal; Dr. Gmnville,
London ; Mr. Husbands ; Mr. Barker, Hampstead ; D. Modicinro,
London ; Iota, London ; R. M., London ; Secretary, Medical Aid
Association, Loughborough; Studens, London ; Secretary, Wonford
House Hospital, Exeter ; K., London; Secretary, Hospital for Sick
Children, Bloomsbury; Medicus, Todmorclon ; Lupus, London ; M.B.,
Loughborough; Assistant, London; C.H.,London; AttendantA.G.,
London ; Y. B. J., Maida-vale; Zulu, London ; Cantab, London; K.,
Yorks; 1’. E. B, London; J. W. C., London; M.B., Newcastle-on-
Tyne ; P. L. M., London; X. Y., Abergavenny; Mrs. H., Sheplierd’s-
bush; C., Torpoint; Beta, London; Dunelm, London; Medicus,
Edinburgh ; Lupus, London ; Firtelis, London; G. Y., Londan ; T. R.,
London; Surgeon, London; Mason, London ; Omega, London ; Y. Z.,
Truro.
Newspai’ERS.— AiwAfaiid Star (N.X.), The Newspaper, Liverpool Daily
Post, JiiHurance Record, Heading Mercrn-g, Mining Jownal, IVeet
Middlesex Advertiser, Leeds McrouTy, City Press, Sunday Times, Law
Journal, Briatnl Merenry, Builder, Broad Arrow, West Middlesex
Standard, IJerl/orrishire Mercury, Ouy’s Hospital Gazette, Chemist and
Druggist, MetropnlUan, Spcct<Uor,Saiurday Review, Sui-rcy Advertiser,
Arnhiteet, 'Yorkshire Post Scottish Leader 'Windsor and Eton Gazette,
J'hamnacp.utical Journal, Cape Times, Weekly Free J’ress and Aber¬
deen Herald, Lincolnshire Chronicle, Le Tmnps (J’aris), Wesler7i Daily
Mercury, Spennymoor and Tudkoe CloYinicle, Vegelririan, Windsor and,
Eton Express, Jiirminuham Daily Post, Morning Post, Maidstone
Journal, Midland Evening jfews, Ipm'ieh Journal, Melbourne Daily
Tele'p-aph, Cheltenham Examiner, Observer, Rangoon Gazette, East
Anglican Times, Colchester Gazette, Sheffield Independent, Scotsman,
Oldham Standard, Durham Chronicle, Chorley Guardian, The Owens
Register (Beechworth, Melbourne), Tasriianian Mail, JHoneer Mail
{ Allahabad), &c., have been received.
SUBSCRIPTION.
POST Free to any part op the United Kinodcm.
tOne Tear 6| Six Months » ^ _ £0 10 h
To China AND India ..._»..__...,>..OneTear 110 10
To THE Continent, Colonies, and United
States...... —.. . . . . . . . . Ditto 1 10 o
Post Office Orders and Cheques should be addressed to The Publisher,
"fHB Lancet Office, 428, strand, London, and crossed “London and
Westminster Bank St. James's-square."
ADVERTISING
Books and Publications (seven lines and under) ..£0 • o
Official and General Announcements .Old
Trade and Miscellaneous Advertisements .. B 0 0
Every additional Line 0 0 0
Front Pwe . per Lino 0 10
Quarter Page.1 10 0
Half a Page .2 10 0
An Entire Page.060
The Publisher cannot hold himself responsible for the return of testl*
monials Ac. sent to the office in reply to advertisements ; copies only
should be forwarded.
Notice.—A dvertisers are requested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
An original and novel feature of '• The Lancet General Advertiser ” Is a special Index to Advertisements on pages 2 and 4, which not only
aSords a ready means of finding any notice, but Is in itself an additional advertisement.
Advertisements (to ensure Insertion the same week)should be delivered a( the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Snbaoripttons should be
jiddiessed.
AdvertlsomentB are bow received at all Messrs. W. H. Smith and Son’s BaUway Bookstalls throughout the United Kingdom and aU otbat
Advertising Agents. ____
Agent for the AdTortiMmeiit Depaxtntent in France—J. ABTl£B, 66. Bue Caumartln,
cd, Google
THE LANCET, April 18, 1891.
Jd«w
ON
THE ANTISEPTIC TBEATMENT OF
TYPHOID FEVER.
Deliverad at King's College Hospital,
By I. BURNEY YEO, M.D., F.R.C.P,,
«>IU)FE8SOtt OF CLINICAL TUKRAPEUTICS IN KING'S COLLEGE, AND
PHYSICIAN TO THE HOSPITAL,
(flonaluded from j>. SIS.)
The following cases do not represent the most remarkable
•or the very best results I have observed from this treatment,
4>nt I present them as conseciitive, not selected cases.
Case 1.—L. H-, a young. married woman, twenty
■years of age, was admitted, with well-marked symptoms of
typhoid, into King’s College Hospital. There were albumen
dn the urine, some rhonclii over the left lung, and a loud
systolic murmur over the base of the heart. Her tempera¬
ture was 104'2'’, and it rose to 10.')“ in the evening of
the third day after admission. The day before this
she began the chlorine and quinine mixture, taking a dose
^very four hours. Two days afterwards the temperature
did not rise above 102'4°, and the next day 102'8°. It rose
again, however, on the fourth day to 104“, fell the next
•evening to 10.S'2°, and on the seventh, just a week after
commencing the medicine, to 101-2'', and never again rose
above 101% but fell pretty steadily, and was 98° on the
■evening of the twenty-first day after her admission into the
hospital. She was then practically convalescent, and she
was able to get up just one month after her admission.
■Now this case, at the onset, had by no means a favourable
•aspect. There was a temperature of 105°, much mental
oppression and sluggishness, much abdominal distension
o.nd tympanites, a tremulous tongue, a loud basic murmur,
which disappeared daring convalescence, some albumen in
the urine, a good deal of splenic enlargement, and some con¬
gestive bronchitis of the left lung. I do not think it is
possible to look on this chart showing the progress of this
•case, and not be impressed with the fact that the average
■course of the disease was greatly modified aud favourably
’influenced by the treatment.
Ca.se 2.—H. B-, a young man nineteen years of age,
•svas admitted into King’s College Hospital on March 11th
with the usual symptoms of typhoid fever. His temperature
■on admission was 103°; on the evenings of the 12bh and 13th
it reached 104-4°. There was dlarrhcea, and his motions
were noted as “very offensive.” The chlorine and quinine
mixture was begun on tliel2bh; on the 14tli the tempera¬
ture began to fall, and on the Kith the highest temperature
recorded was 101°; on the evening of the next day it was
fl02-2°, but fell again on the following day, and for the next
three days did not rise above 101 -2°; then, the bowels having
become constipated, the temperature rose on the following
three days to 102°, 102'G°, and 103 '1° respectively. Two
•or three eneniata of olive oil and water were given, and on
th6 24bh, twelve days after the commencement of the treat¬
ment, it began to fall steadily, and reached normal on the
'28th, from which date the convalescence was rapid and un¬
interrupted. Here, again, I do not think one can look at
this chart without seeing that the course of the disease was
greatly and favourably modified by the treatment.
Case 3.—W. H-, a seaman twenty-three years of age,
was admitted into King’s College Hospital with typhoid
fever on March 20tb. It was noted that the motions were
very offensive. The temperature on admission was 103'2°.
Ho began the chlorine and quinine mixture on the 21st, and
on the 23rd it was reported that the motions had lost their
offensive odour. His temperature fell at once and steadily,
and was on the evening of the 23rd 101 8°; it oscillated be¬
tween 101° and 102° till April the oth, when it fell steadily
'to normal, and he was convalescent just three weeks after
his admission.
Case 4.—M. W-, a female nineteen years of age, was
•admitted with typhoid fever on March 22nd. There was
diarrhcca, much abdominal tympanites, and the motions were
'‘very offensive. The temperature was 103-G°. The chlorine
No. 3629 k
and quinine mixture was begun as the 23rd, and on the 26th
the motions had lost tbeir offensive character. On the 25th
the temperature began to fall, and fell steadily to 100° on
the 29bh; it rose again to 101-2° on the Slat, fell to 100-2° for
the next two days, rose to 101° on April 3rd, and to 102° on
the 6bh, and then fell steadily to normal on the 12bh, three
weeks after admission. She made a rapid and uninterrupted
convalescence.
I could bring before you the histories of many other
cases, but they all tell the same story—^great modification of
the temperature curve, deodorisation of the motions, clean¬
ing of the tongue, maintenance of a comparative well being
and much less evidence of a septic state of blood, rapid con¬
valescence, and muchlessloss of strength than isordlnarily ob¬
served after an attack of typhoid fever. I may mention, how¬
ever, another case where I had departed somewhat from my
ordinary prescription, and had ordered liquor chlori with
quinine, instead of the mixture I have described. The tem¬
perature was reduced, and the case appeared to be doing very
well, when unexpectedly the temperature rapidly rose from
101 ‘6°, to which level it had been reduced for three or four
days, to 104-4°. This was disappointing, and I asked to see
the medicine which bad been last supplied, and then 1 found
that in this last supply the dispenser bad substituted aquie
chloroformi for liquor chlori. This was an important obser¬
vation, because it showed that it was not the quinine alone
which was effective, but the combination of chlorine with
quinine. During this interruption of the chlorine the offen¬
sive odour of the stools quickly reappeared, and disappeared
as quickly on the resumption of the chlorine mixture. The
case eventually did well.
In commending this method of treating typhoid fever to
your notice as supporting the idea of the value both of
genera! and local antisepsis in this disease, I am far from
wishing you to conclude that this is the very best method
to follow in all cases, or that a more perfect antiseptic
treatment may not be attainable. It seems probable
from recent observations that various antiseptic methods
may be adopted with advantage, and that some consti¬
tutions may be influenced more readily and favourably by
one method than by another. I will endeavour therefore
now to complete as well as 1 am able the history of the
application of this idea. The important point is that the
idea of an antiseptic treatment of typhoid fever should
take possession of your minds; the methods of applying
the idea will grow more and more perfect as our knowledge
of all the conditions of the problem grows more complete.
The use of /3-naphthol as adopted oy Professor Bouchard
to produce intestinal antisepsis has bad many supporters.
Professor Petresco of B ucharest has borne valuable testimony
to the efficacy of this drug. He had experimented with car¬
bolic acid, salicylic acid, turpentine, benKolc acid, kairin,
calomel, corrosive sublimate, and boric acid without any
very favourable results. He then tried a saturated solution
of sulphide of carbon, with which he was much better
pleased ; and lastly he tried naphthol, fifteen grains three
times a day, and he reports that he had results more
favourable than with any other remedy, that the rate of
mortality was reduced, and the course of the disease favour¬
ably modified. Dr. J. Mitchell Clarke’- of Bristol has also
recorded some observations on the use of /1-naphthol and
also of hydro-naphthoi in typhoid fever. Hydro naphthol is
prepared from /i-naphthol. It is less soluble, and melts at a
lower temperature, and it is said to be absolutely innocuous.
Like /^ naphthol, it has a faint odour of carbolic acid, and
like it, though less so, it leaves a pungent and burning
after-taste in the mouth, lie gave hydro-naphthoi in five
cases of typhoid fever, and all did well; two were severe
and protracted cases. It soon stopped the diarrhcca, and
the stools lost their offensive odour. He gave from three
to four grains every two hours until the diarrlima was
checked, and then every three hours so long as there was
fever. He thus summarises his results from the use of
naphthol in typhoid fever:-—1. A reduction in the average
duration of the fever. 2. Stools become much less offensive.
3. A diminution of abdominal tenderness and meteorism.
4. Early cleansing of tongue and less dryness of mouth and
lips. 5. Absence of albuminuria. 0. Convalescence more
rapid and strength less reduced. 7. Less risk of propa¬
gating the disease to others. 8. Tendency to secondary com¬
plications diminished. In two of Dr. Clarke’s cases he
thought the naphthol caused a milk dyspepsia, and' one of
1 The Practitioner, December, lS88, and July, 1800.
<i. c
866 The Lancet,]
DB. I. BUBNEY YEO ON TYPHOID FEVEB.
[April 18, 1891.
these had a relapse, and he made some experiments with the
drag which showed that it retarded the digestion of egg albu¬
men by peptic fluids, and very slightly that of milk, but that
it bad no effect on the pancreatic digestion of milk or of
albuminates. He suggests that all risk of its interference
wdtb stomach digestion would be avoided by giving it in
pills coated with Keratin. This would also get rid of the
pungent Wrning after-taste it is apt to leave in the mouth
and throat when given mixed with fluids. A French
pharmacist has suggested that it should he given in an
emulsion. It can be dissolved in ten times its weight of
sweet almond oil with the aid of a gentle heat, and then
made into an emulsion with mucilage and syrup. Cream
rather than milk would be a good vehicle for the administra¬
tion of such an emulsion, and this would probably carry it
through the stomach into the small intestine. It has also
been observed to produce a dark-brown colouration of the
urine, and to cause some pain in micturition, due no doubt
to the absorption of a certain quantity frnni the intestine
and its elimination by the kidneys. M. Maximovitch^
recommends a-naphtbpl os preferable to /Snaphthol. It
is three times loss toxic, and as to its antiseptic value, be
found 1 part in 10,000 would prevent the development of the
typhoid bacillus, as well as that of many other septic
microbes, in ordinary cultivation fluids. I)r. Moncorvo of
Bio^ has given /3-napbthol to children by the mouth in doses
of from firbeeu to thirty grains in twenty-four hours, and has
found that tolerance was always perfect on the part of
children. It promptly removed the fetor of the stools,
and diminished or removed the tympanites. He states
he has obtained remarkably good results from intes¬
tinal antisepsis so produced. Dr. Teissier of Lyons also
prefers a-naphtbol for producing intestinal antiseps’s in
typhoid fever. He read a paper recently before the Con¬
gress at Limoges, in which he spoke very highly of the
results he had obtained by this method of treatment. He
f ives it in six-grain doses, combined with salicylate of
ismuth, and be at the same time promotes free diuresis by
cold water enemata. He also gives enemata of quinine and
cmchona as an “ anti-thermic tonic.” He observed that as
.'oou as u testinal antisepsis was established the urine
became green, tbe tempeiature fell, the albuminuria dis¬
appeared, tbe spleen diminished in d^e, and the tongue
became remarkably moist. Convalescence was very rapid.
He considers the napbtbol acts by sterilising the bacterial
products in the intestine. Dr. Schwartz' has demonstrated
that naphthaline administered internally diminishes the
number of bacilli in fmcal matter in the proportion of
one-third to one-fourth. When its administration is dis¬
continued, this proportion increases again. He states
also that he finds calomel increases the efficacy of naph¬
thaline, and he advises a combination of calomel and
naphthaline in the treatment of typhoid fever. He also
confirms the observations of lloucbard and Legroux. Bub
naphthaline is not so safe or suitable an intestinal
antiseptic as /^'Daphthol or a-naphtbol, and in August
last a pharmacien at Grenoble was fioed 500 francs for
substituting naphthaline for j^-naphthol in making up a
prescription for a case of typhoid fever. The advantage
of attempting to establish intestinal antisepsis in the
treatment of typhoid fever was dwelt upon.at a discussion
in the New York Academy of Medicine in January of last
year. Dr. W. H. Thomson, of the Roosevelt Hospital,
. where he had had large opportunities of treating cases of
typhoid fever, advocated it strongly, but his method difl'ers
somewhat from those wo have been considering. In the first
place, he looks carefully to tbe food administered, and that
w an important point, to which I shall presently return,
He never gives miik undiluted, but always mixed with an
equal quantity of lime water, which he believes to be “no
mean antiseptic.” lie objects to beef-tea as setting up
gastro-intestinal fermentation. He gives also ten grains of
saccharated pepsin with ten minims of dilute hydrocWoric
acid every three hours, with tbe object, I presume, of pro¬
moting tbe complete digestion and absorpcion of the food,
and so leaving bub little residue to ferment and decompose
in the small intestine, tbe mineral acid being also an anti¬
septic. He also gives ten grains of subcarbonate of bismuth
every three bouie, sometimes both medicines every two
hours. He regards these (he has used turpentine and
nitrate of silver with advantoge) as the best agents for the
* Nouveaux llomtilea, Non. 4 and lo, Feb. and May, 1888.
" Satellite, Feb.
* llerliner Klin. Woeb,, 1881*, Nos. 2U-22.
purposes of intestinal antieepsia. All the preparation&o?
bismuth are doubtless useful for this purpose, especially
when there is diarrhoea, as they ere very etncacioua in con¬
trolling the intestinal catarrh. Sir William Jennertesblfiea
to the same effect. “ Carbonate of bismuth,” be says, “in
twenty grain doses every four or six hours is one of the best
remedies I know for tbe catarrhal inflammation of the’
bowel itself.” Dr. Thomson also advocated at the end of
the first week a purge of calomel and compound jalap-
powder, and Dr. Scabterthwaite in the same discussion
advised small doses of calomel at the commencement, and
also the use of hydrochloric acid as an antiseptic.
I have already referred to the testimony borne by Sir
Thomas Watson to the efficacy of mercury in the treat¬
ment of continued fever. It is not a little remarkable tO’
find in the present day Liebermeistei" advocating strongly
the use of the same remedy. Indeed, the administration oft
calomel in tbe early days of typhoid fever has now a
considerable number of advocates amongst practical
physicians of eminence. And it has been suggested that
the success of calomel may depend as much upon its
antiseptic as on its purgative properties—indeed, excellent
results have been claimed as foDowiDg the inunction of
mercurial ointment into the abdomen and thighs (fifteen
grains at a time) in tbe early days of the fever."' Lieber-
meister has observed excellent results following the use of
two antiseptic substances, the one iodine, the other calomel.
You will not fail to notice the close chemical relationship-
between iodine and chlorine, the latter of which I have
myself found give such satisfactory results. Liebermeister's
remarks are well worth reproducing here. He sajs : “ Inas¬
much as typhoid fever is a disease which is generated by a
specific poison, the supposition that a specific antidote-
might exist, and tbe consequent search for the same, are
not so absurd as people thought them during that period
when all therapeutic wisdom was supposed to have cub-
minated in the expectant plan of treatment.” And he goe&
on to express an opinion that both iodine and calomel may
possibly have a specific influence over the fever. He used
a solution of iodine in iodide of potassium, and gave a dooe
every two hours. In 200 cases he treated in this way the-
mortality was less than in cases treated at the same time-
similarly in every other respect, bub without the iodine.
So also with regard to calomel. Comparing 200 caseo-
treated with calomel with a large number treated without,
bub otherwise precisely alike, under the calomel treatment-
the rate of mortality was decidedly lower. He gave it m
every case that came under treatment before the ninth day
of the fever, usually about eight grains for a dose three or
four times in tlie iirsb twenty-four hours. He treated 8O0>
cases in this way with such excellent results that he
resolved to continue the method himself and to recommend
it to others. He believes it materially shortens the dura¬
tion and lessens the intensity of the disease. He considers
that an adult should have three or more eight or ten grain
do-es. lie is inclined to conclude that it exerts a speoilk-
inlluenco.
Many physicians have recorded their approval of an initial'
laxative, and no doubt it is well if there is no diarrbcoa to-
begin with one, we shall then have less hesitation in keeping'
the bowels quiet afterwards. Murchison approved of one
or two doses of calomel—three to five grains—during the
first week, and before there was much diarrbcoa ; he believed'
it rendered the disease milder and shorter. Dr. George
Johnson long ago^ called attention to the ill-effects of
locking up the secretions in the bowels in cases of typhoid'
fever by opium and astringents, and pointed out the advan¬
tage of occasionally clearing out the bowels by castor oil or
some other aperient, fndeed, it has been said that “ purga¬
tion and antisepsis are, to some extent, interchangeable
terms.” An aperient expels the poisonous ptomaines and
other decomposing substances from the intestinal canal, and
if given in the early stages may actually prevent subsequent
serious diarrlioea. Bub the use of aperients, to be perfectly
safe, must be limited to the first ten or twelve days of the-
fever, the great risk attending their use, in the Interstages,
is the possibility of the existence of deep ulceration in the
ileum, and in that case, as Sir William Jenner has pointed
out, an aperient may mean the difference between life and
death to the patient. At that period of the disease intes¬
tinal antisepsis can only be safely secured by the use oC
6 Von /iomsHHn’B Cycloi)it(lia «t Prat-tical Madicino.
« ISrit. Mail. .lour,, .Jan. fjfch, 1880.
f Ibid.. Yol. i. 18CT, p. 274.
’8
The Lancet,]
MB. G. BUCKSTON BROWNE ON VESICAL CALCULUS.
[April 18,1891. 887
intestinal antiseptics, snob as naphtbol, thymol, salicylate
of bismuth, &c. Thymol is preferred by some; it is in¬
nocuous in full doses, and possesses an antiseptic power four
times as ^reat as that of carbolic acid. Cantani considers
tannic acid an important intestinal antiseptic, and that it
checks the vegetative activity of the bacteria, and renders
Innocuous the poisonous ptomanies. Mosler agrees with
this view, and advises its administration by the rectum.
I have always, in private practice, when I have found it
advisable to control the diarrhcca, or arrest the tendency to
intestinal bmmorrhage, given small tannin injections per
anum, and with the most satisfactory results. My usual
prescription is from ten to twenty grains of tannic acid, and
from two to five grains of Dover's powder, in two ounces of
thin mucilage, auer each loose action of the bowels.
Finally, it we would maintain intestinal antisepsis, as I
believe we should in all cases endeavour to do, we must look
carefully to the mode of feeding our typhoid fever patients,
which, 1 have reason to know, is frequently ill calculated
for the attainment of that object. I have elsewhere de¬
scribed fully what I consider should be the method of feed¬
ing a fever patient.® I will only now point out a few
things which I think should be avoided. And first, and
chiefiy, let me insist on the fact that no good can possibly
come of pouring down the patient’s throat a quantity of food
that he cannot absorb, and that will only pass through, or
accumulate in the small intestine and ferment and decom¬
pose there, and aggravate in every possible way the mischief
which we desire to lessen or prevent. The typhoid fever
patient in the acute stage of the fever can absoib scarcely
any food by the stomacn ; nearly all his digestion is intes¬
tinal, and that also is certainly gravely impaired. Sir Wm.
Roberts has called attention to this- “In the seriously
sick,” be says, “ the stomach becomes often inoperative, and
digestion becomes almost exclusively intestinal. In the
febrile sick the stomach loses its normal office and becomes
merely a conduit to pass on the liquid food to the duodenum. ”
Sir "Wra. Jenner has expressed his disapproval of the large
quantities of milk that are often given to typhoid fever
patients, to their great detriment, and he has urged upon
practitioners the importance of looking for the presence of
undigested curd of milk in the stools, and to take warning
W its appearance of the mistake they are committing.
Excess of zeal in feeding fever patients is, I maintain,
responsible for much of the intestinal trouble that com-
licates these cases. Strong beef-tea, milk, port wine,
randy, and beaten-up eggs are given the patient in rapid
succession, and they accumulate in his intestinal canal,
and form a fermenting mixture, out of which poisonous
ptomaines may be formed; while pure cold water, one of
the best of eliminators and antiseptics, is often withheld from
the patient. Is it to be wondered at that tympanites and
painful flatulent distension of the bowels frequently arise
after such feeding? I read of practitioners passing a long
tube Into the bowel three times a day for the purpose of
removing “ilatnlent distension and foul faecal accumula¬
tions”—accumulations that never ought to have accumu¬
lated ! In feeding a typhoid fever case you should he guided
by a careful observation of the digestive and absorptive
capacity still retained by the patient, and you should
remember that no good, but harm, is done by giving the
patient more food than ho absorbs. It must be especially
remembered that excellent as milk is as a food, it is a
concentraicd food apt to coagulate into indigestible curd
on encountering any acid secretions in the stomach or in¬
testines. It should therefore never he given undiluted to a
fever patient, and it should be made distinctly alkaline, so
that it may not form an irritative coagulum when it
reaches the stomach, hut pass on in the fluid form into
the duodenum. For this purpose Vichy water is a good
diluent of milk, but a less expensive and very convenient
method is to add to each cup of milk and water (half milk
and half water), an alkaline tabloid composed of bicarbonate
of soda, bicarbonate of potash, carbonate of magnesia (each
two grains), and common salt, three grains. This will not
only assist the digestion of the milk, but it will add certain
necessary salts to the food, which from the absence of vege¬
table foods the patient does not get. Common salt is also an
excellent antiseptic. Let me also protest against the common
ractice of giving very strong beef-tea to fever patients; it
as always seemed to me that the too ordinary practice
of giving concentrated beef-tea .and sweet port wine to a
0 KooiJ in HuniLli anil Disease, p, ISOS.
fever patient was precisely the best means of setting np
troublesome septic changes in the intestinal canal. And
why this desire to .give the8<i very concentrated beef
extracts ? Everyone with any right to speak with authority
on this matter has urged the importance of the free adminis¬
tration of water to carry off the products of metamorphosis,
as an eliminant and antiseptic. Why not give some of this
water in the form of light, clear soups and broths—far more
grateful to the fever patient than strong beef-tea, to which
they soon take a great aversion. I am not speaking against
meat soups and meat juices—I have' argued elsewhere in
their favour,—but I am enforcing their rational use and their
rational preparation. The clear, light, dean-tasting,
nicely flavoured consowimd—flavoured with fresh vegetables
and savoury herbs that every first-rate cook serves at the
commencement of a good dinner—is the kind of food for
a fever patient. But I will not pursue this part of the sub¬
ject further, as 1 have elsewhere fully discussed the principles
that should guide us in the feeding of acute diseases; I will
only repeat the recommendation to limit the food of the
fever patient to that which be is able to absorb.
In the preceding remarks I have thought it my duty to
call your attention to the progress that the idea of an anti¬
septic treatment of typhoid fever is making amongst
physicians in all parts of the world ; authoritative observa¬
tions in this direction are becoming more and more numerous,
and the reported results are uniformly favourable. I say
purposely the idea of an antiseptic treatment, because I do
not wish to lean with any great stress on any particular
manner of carrying this idea out, as we probably have not
yet arrived at the very best means for doing so. But I
think I have been able to make it clear that the possibility
and the duty of maintaining intestinal antisepsis in the
treatment of typlioid fever—even if we may nob hope, as I
think we may, to produce a general antiseptic influence on
the circulating fluids—have been admitted by a great and
rapidly increasing number of careful and experienced clinical
observers and teachers. I believe it is our duty to follow
in the same direction, and that by doing so we shall pro¬
mote the credit of our science by diminishing considerably
the mortality from this disease.
THE IMPORTANCE OF THE POST-PROSTATIC
(OR TRIGONAL) POUCH IN THE SURGERY
OF VESICAL CALCULUS, ILLUSTRATED
BY SEVERAL CASES.^
By (J. BUCKSTON BROWNE.
The surgery of vesical calculus may be considered under
two heads ; first, the finding of the stone, and, secondly, its
removal. Errors in sounding for stone have pethaps
attracted more attention than mistakes in the diagnosis of
any other surgical malady, and the best way of removing a
stone from the bladder is even still a frequent matter for
argument and difference of opinion. The chief cause of all
this difficulty in diagnosis and difference of opinion as
regards the method of removal is the fact that the bladder
is not alwaj's a simple sac, but sometimes has pouches,
pockets, or sacculi opening out of its general cavity, in
which stones may lie, and escape the diagnostician’s sound
or the litbotrite, tube or forceps of the operator. All this is
simple enough and known to every surgeon, but the fact that
vesical sacculi are of very different kinds is not universally
known or appreciated, and great error is caused by speaking
loosely of pouched or sacculated bladders, as if all the
pouches of a bladder were alike. Bladder pouches may be
divided into three varieties; 1. There is the well-recognised
sacculus which we may call the ordinary sacciilus, and
which consists of a protrusion of mucous membrnne between
the muscular fibres of the bladder. Such sacculi are found
in the upper part, at the side, and in the floor of the bladder;
and where this is coveted with peritoneum, they, too, are
covered by the same membrane. 2. A pouch often forms
behind the trigone—i,e., behind a Hue drawn between the
vesical orifices of the ureters. It is part of the general
cavity of the bladder, but is sometimes deep enough to
make difficult the discovery of a stone lying within. This
' A paper renil before (ho PIoiUouI Society of London, April 13th, 18B1
868 1'HS Lancet,]
MR. G. BUCKSTON BROWNE ON VESICAL CALCULUS.
{April 18,1891.
may be called the post-trigonal pouch. 3. There is a post¬
prostatic or trigonal poucn to which I would particularly
draw attention, because 1 believe it has hitherto received
little notice, and because I think it is the chief cause
of error in searching for stone and of imperfection in its
removal, whether by the lithotrite or by the knife. The
post-prostatic pouch is often of extraordinary depth. If the
patient be supposed to be lying down, it may be said to
consist of the trigone of the bladder, pushed down between
the enlarged and projecting prostate in front and a thick¬
ened and firm inter-nretered ridge behind. Where there is
much intra-vesica! prostatic projection, the pouch may
literally be roofed over by this prostatic outgrowth. Calculi
in this pouch cause much pain, since the trigone of the
bladder has a larger nervous supply than any other portion.
Lying as the pouch does in front of and below the orifices of
ureters, it is a perfectly contrived trap for the catching and
retention of renal calculi upon their entrance into the
bladder, and it will readily be seen how favourably the
stones are there placed for growth. That they do lie there
and grow into extraordinary shapes is shown by several of
the stones about to be described. The object of this paper
is to put forward the following two propositions for con¬
sideration, and to relate illustrative cases. 1. That, owing
to the post-prostatic pouch, vesical calculus is often difficult
to detect in cases of enlarged prostate, and that if the pouch
is deep it may be absolutely Impossible to find the stone by
any instrument passed in through the urethra. 2. That,
owing to the occasional depth of the post-prostatic pouch,
litbotrity is sometimes an impracticable operation, it being
mechanically impossible to evacuate the bladder of all ddbris
by urethral instrumentation.
Case 1— D. T-, aged sixty-eight, seen with Dr.
Whittle of Brighton, July, 1886. For seven years all urine by
catheter; urine very fetid. By rectum, prostate found very
large. A tight urethral stricture at five inches from meatus;
urethra nine inches long. Owing to the stricture, catheterism
very difficult. I therefore performed internal urethrotomy.
After this no difficulty; passed Nos. 13 and 14 with ease.—
Feb. 14th, 1887: Patient complains of a pricking pain at
the mouth of the bladder; worse when he rides. Sounded
him and found a small stone.—Feb. 19th: Lithotrity; a
Fig. 1.
Nine calculi, eacii bcarinR a spllco, tlie result of
friction from bciiiR cloudy packed togethov in a post-
prostatic poudi.
most tedious operation. It seemed that as soon as one cal¬
culus was crushed and cleared out the tube and aspirator
would suck out another stone from some sac or pocket, for
immediately after the debris were withdrawn a stone would
rattle against the end of the tube, rendering the reintroduc-
tion of the lithotrite necessary. This was repeated over and
over again, and I entered in my notes at the time that the
bladder must be sacculated. All went well, however, and
in duly, 1888, 1 sounded the patient and found nothing. I
saw nothing more of him for twelve months, when on
June] 3rd, 1889, he came up with symptoms which induced
me to sound him again, and a stone was found. On June 8th,
finding much difficulty in the introduction of instruments,
owing to the stricture, and thinking from the sensation my
sound gave me when in contact wi^ the stone that it was
not a case of calculus free in the cavity of the bladder, I
determined to open the bladder above the pubes and
fonnd a large intra-vesicol prostatic lobe, and below it
a pouch almost entirely cut off from the cavity of the
bladder, and packed with stones. They were removed one
by one, nine altogether, and each bore one curious spik^.
These spikes, well shown in the engraving (Fig. 1), may
simply have resulted from friction, nut of this I am not
perfectly satisfied. The wound was healed in a fortnight,
and on July 12th the patient went home, passing his
catheter every five hours, and entirely free from pain.
During the summer he walked and rode, and swam in the
sea. On July 30th he wrote: “Never better for years.
Can cross my legs now, which I could not before, and can
sit in any position.” On Sept. 13th he came up to London
in a dying condition. He had had a long swim, which bad
been followed by a rigor and severe left renal colic. He
died next day, and on the 15th 1 made a post-mortem
examination. The prostate was found projecting into the
bladder, as already described,^ and under it there was an
enormous pouch containing one calculus. This calculus was
round, had no spike, and was entirely unlike those removed
by the supra-pubie operation. Both ureters were dilated, and
the left kidney was full of large calculi. It was breaking down
into abscess. Fig. 2 shows the prostate and bladder. The
Fig. 2 and Fig. 3.
Fiij. 2.—A, Piece of IwiiRie showing cenu-so of prostatic urethra,
u. Bladder w.al), behind the inter-isreteral riifge (C). Cal., The
nine sp'cate calculi, in post-prostatic pouch. D, The intra-veaica
prostatic growtii. i>, Tiie prostate.
FiO. 3.—Partly diagrammatic to .show how in this case a lithotri
(8) iiitroduced through the urethra failed to reach the ealcul
prostatic projection into the bladder (D) will be readily
noted; under it lie the nine calculi, which I removed nearly
four months before death, but which are replaced to make
the engraving complete. It will be seen what difficulties
such a case must present, owing to the size and depth of
the post-prostatic pouch, both to the surgeon sounding for
stone and to the lithotritUt. It is also conceivable that
lateral perineal lithotomy would not have rid the bladder
entirely of its calculous contents. There are many cases
well known where experienced surgeons have left calculi in
the bladder after the lateral operation, and probably such a
condition as the one described has often been the cause.
Supra-pubic cystotomy here was perfectly successful; the
calculus found in the pouch after death had come down from
the kidney quite recently, and corresponded exactly with
the other stones found in the left kidney.
Case 2.—W. O-, aged sixty-eight. Before this patient
came to me he had undergone five operations of lithotrity
during a period of less than two years, obtaining little, u
an;, relief. He was suffering greatly. 1 opened the
bladder above the pubes, found a stone firmly fixed in a
post-prostatic pouch, and took it out with a spoon exactly
Din' /ed by Google
The Lancet,]
DR. THOS. WHITESIDE HIME ON FACIAL LUPUS.
[April 18,1801. 869
as one would take out half an egg from an egg-cup. The
patient was entirely relieved, and made a good recovery,
xig. 4 represents the stone, which was phospbatio, and
underneath the engraving shows the relations of this cal¬
culus to the bladder and prostate. The stone presented
by a small surface in the bladder, and lay in a pouch
which was not deep enough to make the detection of the
stone difficult by a sound introduced through the urethra,
but was sufficiently deep to make successful lithotrity
impossible.
The following case, however, is still more remarkable, for
while it illustrates the entire futility of lithotrity when the
Fig. 4.
calculus is in a deep post-prostatic pouch, the stone is the
most unusual one I have ever seen, and is really a cast of
the pouch, showing all its irregularities.
Case 3. —The patient was aged ninety-four. Some years
ago he had been subjected to an operation of lithotrity, and
more recently he had again undergone that operation. On
both occasions the operators had been men ot the greatest
eminence. Since the last operation he had suffered con¬
siderably, and there were now present all the signs of
calculus. The effort of rising from his chair brought on
violent vesical spasm. Driving and walking were impos¬
sible on account of the pain they caused, itold him that
he had stone, and begged him to take an anesthetic and to
give me leave to remove the calculus by any means which I
might find best at the time of operation, saying that his
previous experience of the operation of lithotrity showed
that the case was not an ordinary one, but that probably
there was some abnormal calculous condition present.
Nothing, however, would induce him to undergo another
operation, and in throe months he died. Upon post-mortem
examination the remarkable stone shown in Fig. 5 was
Fig. 5.
removed from behind the prostate. The rough portion
marked A was all that presented in the bladder cavity, and
this was evidently the surface from which the successive
litbotritiets had removed the more salient portions of the
stone. In front of this rough surface is a smooth cup¬
shaped cavity, n, in which th^e intra-vesical prostatic pro¬
jection played. It will easily be seen that it was inipos-
I sible to remove this stone by any instruments introduced
I through the natural passages, and that it could have been
thoroughly removed by supra-pubic cystotomy.
(To l/e concluded.) ^
CASE OF FACIAL LUPUS HEALED BY KOCH’S
METHOD.
By THOS. WHITESIDE HIME, BA., M.D., &c.
This patient was discharged from the Home for,Koch’s
treatment, Bradford, on March 13th, 1891, cured of his
.disease, so far as all evidence enabled one to judge. He
bad been nnder treatment by Koch’s method alone since
Dec. 30th, 1890, when he received his first injection,
and he bad received in all twenty-seven injections,
the last on the day of his leaving the Home. He had
received the large quantity of 6'367 grammes of. tuberculin
altogether. The patient is forty-four years old, and a fitter
by trade. His family history shows that several maternal
uncles and aunts had scrofulous glands, and some died of
phthisis, while his father’s side was free from this disease. His
father died of apoplexy, and his mother is alive and para¬
lysed. Two of the patient’s brothers had scrofulous glands
in early life, and a brother, now aged about forty-two, has
sullered from facial lupus for ten or twelve years, and is
now much disfigured by the destructive action of the disease.
The patient was healthy as a child, but when about eighteen
years of age a bard nodule (gland ?) appeared in front of the
right ear. It grew slowly for from three to four years,
and then began to suppurate, and continued to discharge
for from two to three years. There is a white glassy scar
about an inch and a half in diameter, and with some pinkish
lines running across it, at this spot now. The patient has
never had venereal disease in any form. He has a healthy
wife, and is the father of seven healthy cliildren. He has
always been healthy, except for the lupus, and, so far as he
knows, has not been in contact with tubercular coses.
About four years ago a roughness of the skin appeared
between the eyebrows, and a pimple soon after on the edge
of the left nostril. The latter became raw, scabbed from
time to time, and gradually spread over the whole of
the left nostril, end of the no^e, and round to the other
nostril. It also extended up the ala of the left nostril
and about three-quarters of an inch down the cheek from
the angle of the left nostril and cheek. Some months later
“a raw pimple” formed on the cheek about half an inch
from the left corner of the mouth; later, one appeared on
the right upper eyelid, and a few months later still another
appeared one inch below tho right eye.^ In the autumn of
1889 he went into the Leeds Infirmary, under the late
Mr. McGill, who scraped the nose, forehead, right eyelid,
and spot near the mouth, pronouncing the affection to
be lupus. The wounds remained healed for some weeks,
but then became rather u-orse than before, and he returned
to the infirmary, and the parts were again scraped, as well
as the spot below the right eye. The resulting cicatrices
broke out afresh in from five to six weeks, and at Whit¬
suntide, 1890, he entered the Leeds Infirmary for the third
time, and the same parts were scraped, an'd, in addition,
the left upper eyelid. The healed cicatrices broke down
again in from five to six weeks.
When I saw him the terminal one inch and a half of his
nose was of the familiar pnrple-red colour, hard and brawny;
the end was partly scabbed, partly raw, and discharging pus;
the right nostril was deeply red at the lower part, the left
partially eaten away. The right upper eyelid was scabbed
and red; the left re^, but not scabbed ; the spot at the corner
of the mouth Was brawny, red, and discharging, being par¬
tially scabbed. The patient’s general health was goon. He
complained most of the heat and hardness of Jiis nose, apart
from his alarm at the steady extension of the disease. His
left upper lip was much thicker than the right, bub this he
did not complain of; he said it had come on gradually.
On Dec. 30bh, 1890, he received his first injection of Koch’s
1 The facts (if the pationfs history, jncdical amt otlioi' (reatmeiit, I ,
have from himself only.
Digitized by Google
870 The Lancet,]
DR. THOS. WHITESIDE HIME ON FACIAL LUPUS.
[April 18,1891.
taberoulin. The number and amount of bia injections, as
well as the highest temperature reached after each before
the next succeeding injection, were 8^ follows:—
No. of
injec¬
tions.
Date.
Amount in-
iocted in
milligrammes.
Highest
tempera¬
ture.
Maximum
pulse.
1
Dec.
30,1890
0-001
103-O”!''.
92
2
Jan.
3, 1801
O'OOl
103-0
92
3
0 „
0003
103-8
116
4
1*
0-003
irS'O
106
6
16 „
0-01
108-0
99
e
10 „
0-016
102-8
94
7
24
0-023
103-0
97
8
20 „
O-03C
99-8
84
9
30
006
102-0
92
10
Fob.
6 ..
006
102-4
90
11
«
0-083
08-8
82
12
7 „
0-076
99-8
82
13
8
0-1
98-8
86
14
12 „
0"2
98-8
88
10
I* .>
0-36
98-4
80
IG
]8 „
0-6
97-2
76
17
20 „
0-7
98-2
811
18
22 „
0-08
97-4
78
19
24 ..
0-2
97-0
80
80
20 „
0-3
100-0
94
SI
28 „
0-16
97-4
80
S2
.March
2
0-3
97-2
74
23
3 ..
0-4
98-0
80
24
4 „
0-5
98-0
80
ih
6
0-6
97-6
78
SG
0 ■.
0-26
97-2
80
27
>1
13 „
0-S
ilute .—On Dec. SOtb, 1800, the maximnm roepiration was 10.
J t will be noticed that the amount injected was at the
commencement much less than the initial doses frequently
used in Berlin, where 1 centigramme was a common in¬
jection to begin with in faciallupus. The result, I consider,
shows thatO'OUI milligramme was quite sutlicient, and a safer
dose than the heroic 1 centigramme for my patient. The
temperature after the first injections rose to 10.3° or a little
over, which may seem a trivia rise to those who have seen
temperatures of 100° and higher after initial injections.
But the temp^erature is not the only or principal feature of
a reaction. This patient was very much alFecied in various
ways by the early injections, though his temperature was
not excessive. He had severe rigors and headache, and bis
face was greatly swollen ; he could not open bis eyes, and
breathing through the nostrils was almost impossible; his
left upper lip became so swollen as to render the taking of
food very difficult; he was very heavy and drowsy and became
very deaf, this last being an effect which I have never known
to occur in other cases, but which regularly recurred
iu this patient after many injections, passing off in a day or
two. That the patient was profoundly affected, and quite
sufficiently so, and that the injection was sufficient when it
i >roduced such effects, will, I think, be tbe general opinion,
[ndeed, as a result of my own experience with this
and several other cases, 1 would strongly dissuade the
administration of large initial doses. When the extent of
the patient’s general reactive character has been ascertained
by careful trial, and after it has been ascertained where
local reactions will occur, then the injections may be in¬
creased. But if there were no other grounds for caution
at tbe commencement, the fact that most serious local
reactions have occurred where utterly unexpected—e.g., in
the larynx—and even necessitating tracheotomy, should
be a warning. Further, no one can foretell to what extent
the temperature, pulse, and respiration may increase, until
after trial, and no one should risk, especially without any
I'easOD for doing so, tbe tremendous over-action of tbe heart
<up to 180 beats) and lungs which may be brought ou after
an injection, even of moderately large quantities of tuber¬
culin. One should always advance slowly and cautiously
in the administration of this powerful remedy. I would
further add that there are no pounds for supposing that
there is any advantage gainea, so far as the cure of the
local disease is concerned, by inducing such alarming
general reaction os is indicated by extremely high tempera¬
ture, pulse, &c.; and it is certain that tbe generru depression
which ensues lowers the local as well as tbe general vitality,
aud thus delays, if it does not prevent, ultimate cure. The
patient bad no serious symptoms throughout. He took
nourishment well at all times, and bis bowels and kidneys
acted well. The quantity of urine passed was normally
low; during treatment it once amounted to 56 d. oz , this
being the only occasion when it exceeded 43 oz., the
average being about 30 oz. When tbe temperatures were
high at the beginning of the treatment there was at times
a considerable deport of urates (sedimentum lateritium),
and sometimes there was a cloud of excessive phosphates.
The effect of the very first injection was to cause the dark-
red edge of the right nostril to ulcerate, the raw surface
extending for a couple of weeks, when it began to heal.
After the third injection the spots on the right lid and near
tbe mouth were deeply excavated and suppurating. After
the ninth injection tne extensive scabs which covered the
left side of the nose and left upper lip had fallen off, and
the ulcerated Hp and nostril were healed—that is, in one
calendar month and one day from the commencement.
There was never any serious local reaction after this date.
The nose continued to become redder after the injections
for some time, but there was no swelling of any conse¬
quence. Sometimes he bad pains in tbe limbs for a few
hours. After the tenth injection his left moustache, which
was kept cut to prevent scabs gathering, ceased to grow,
every hair fell out, and for a month the left upper lip
was perfectly denuded of bair, and had all tbe appear¬
ance, even when seen under a lens, of being permanently
depilated. However, the hairs began to grow well before
he left the Home. The patient was allowed to go out for
exercise after three weeks, although the weather was cold;
and whenever it was dry he took walks of several miles, at
first on the days between the injections, provided tempe¬
rature, pulse, and other symptoms of general and local
reaction permitted; later on he went out on the day of the
injection also. The appearance of his face on leaving was
greatly improved. There was no scab or raw spot any¬
where. His nose bad entirely lost the characteristic redness,
but also a portion of the tip and of each side of tbe nostril.
The loss of substance, however, was very trivial; the tip
was round and smooth and soft to the touch; the
two sides were also soft, and tbe whole was covered
with a skin of perfectly normal appearance, colour, and
feel. There was no hardness to the touch in either eyelid.
The spot near the lip was white and somewhat depressed,
like a scar left after excision, as was the spot under the
right eye. The left upper lip is very much smaller than at
first, and is hardly larger than the right. The patient had
gained three pounds and a half in weight during treatment,
and left the Home thoroughly happy and satisfied. He is
E articulavly pleased that his nose is no longer .so “ hot and
urning,” and has not the unpleasant brawny feel which
became evident every time he moved any of his features. No
one seeing the patient now for the first time would, I believe,
say he had lupus ; every indication of that disease is gone.
I do not feel qualified to assume the rOU of prophet and
anuouDce now what may be the patient’s state in six
months. But this much is undeniable : no known method
of treatment would produce such excellent results except
Koch’s.
My own experience satisfies me that it is entirely
erroneous to suppose that the administration of tuberculin
ceases to be beneficial when it ceases to produce marked
reactions, either general or local. The same has been the
experience of others well qualified to judge. On the con¬
trary, I have watched the rapid improvement of extreme
local tubercular disease going on for weeks, while there was
no sign of reaction to the injected tuberculin; and in the
treatment of phthisis pulinonalis I have observed the same
thing. 1 have made it a practice in tbe treatment of
phthisis to avoid reaction as much as possible, and this I
notice is now being done also by Guttmann aud Ehrlich at
Berlin, and others, who report excellent results. The
guiding principle in Koch’s method should be arte non vi,
and tbe physician who would attain good results must not
proceed on the routine practice of blindly injecting as much
tuberculin as will produce the maximum of local and
general reaction as the patient can bear without fatal
results. The circumstances of each case must decide the
details of the treatment; aud each must be managed from
day to day in accordance with the conditions to be treated
as they present themselves. It is fatal to success in the
following up of this method of treatment to be guided in
the steps to be taken to-day by merely noting the quantity
of tuberculin injected on the last occasion and the maximum
temperature produced; yet it seems to be the general opinion
that this is all that need be attended to. Such a practice
can only lead to a blind, unintelligent routine, injurious to
the patient, to the method of Koch, so promising in brilliant
-Google
Dir •
Thb Lancet,]
DR. W, E. STEAVENSON ON THE ELECTRIC BATH.
[AphiLlS, 1891. 87t
results, and calculated to sterilise the observing powers of
the practitioner.
Note .—The patient was shown to the Bradford Medical
Society at the beginning of the treatment, and again on
March 17tb, when the treatment terminated.
THE ELECTRIC BATH.
ByW. E. STEAVENSON, M.D.Cantab., M.R.C.P.,
IN CHAKGE OP THE ELECTJIICAL DEPARTMENT, ST. BARTHOLOMEW’S
HOSPI'TAL; EHYSICIAN TO THE GROSVENOR HOSPITAL POU
WOMEN AND CHILDREN.
(Continued from page 711.)
AVhen the interrupted current is used for the electric
bath the primary or the secondary coil may be employed.
Special large faradaic coils are made for use with the bath.
The strength of the primary coil can be regulated by the
core of soft iron wires in its centre being withdrawn to
reduce the strength of the current, or pushed in to increase
its strength ; or the extra current (the one which produces
muscular contraction} con be regulated by a rheostat com¬
posed of resistance colls of known resistance or by a water
rheostat (Fig. 4). The current from the secondary coil can
Fig. 4.
be regulated by the amount of the coil that is allowed to
encircle the primary one. It is always best in the faradaic
apparatus to have the secondary coil after the Da Bois-
Reymond principle—that is, perfectly distinct from the
riraary coil and capable of being moved over it. (See F,
5.)
Bath coil.
The galvano-faradaie hath .—Treatment by the combined
current—constant and interrupted—can be best accom¬
plished,by means of a water bath. The two currents can
Fig. 6.
be passed along the same wire, the secondary current
(faradaic) passing through the constant current battery and
galvanometer without alTecting them, and both currents
can be felt in the bath. The constant current battery.,
giving a current strength of 200 milliamplires, can be em¬
ployed at the same time that a strong secondary current
is being given by a coil worked by another four-celled
battery.
Hot air or vapour electric bath .—It is very common in
America to apply electricity to a patient when in a hot air
or vapour bath. This form of application is said to possess
certain _ therapeutical advantages. Patients who suffer
depression, and are in other ways unable to take the water
electric bath, can often bear, and derive great benefit from,
the dry hot air or vapour electric bath. The bath is given
in a cabinet constructed for the purpose. There is a
stool, on which the patient is seated, connected with
one pole of the battery. The other pole of the battery can
be connected either with the lloor of the cabinet, which is
lined witli zinc, or with special electrodes to be applied
to different parts of the body. The cabinet contains a hot
water coil, which is connected with a boiler and heating
apparatus outside. The condensed steam can be allowed
to escape on the outside, or can be admitted into the
cabinet by a valve, which opens downwards to prevent the
jet of steam playing directly on the patient when seated on
the stool. The coil can, therefore, be used for giving a hob
air bath or for giving a vapour bath. The hot air is used
at a temperature of Jrora 90* to 100* F. It produces perspira¬
tion, and is nsed for chronic rheumatism, stiffness of the
joints, and skin diseases. It is also used at a higher tem¬
perature when employed for internal congestions. The
vapour electric bath cannot be borne at such a high tem¬
perature or for so long a time as the hot air j 106* to
110* is the usual limit, but the hot air can be borne
up to 130*. The stool is raised or lowered so that the
patient’s bead may protrude through a hole in the lid of the
cabinet, and the neck is surrounded by dry warm towels to
prevent the escape of hot air or steam. There are two
boles, protected by valves, in the side or door of the cabinet,
through which the medical roan can pass his bands for the
purpose of adjusting the electrodes to that part of the
patient’s body it is wished to treat. There is often aproject-
ing metal arm, with the end covered by sponge, against which
the patient’s back or epigastrium can be placed. This pro:
jecting arm is fixed to the back or side of the cabinet, and
connected with one of the poles of the battery. A hotair
or vapour electric bath occupies fifteen or twenty minutes.
At the conclusion the patient should be cooled down by a
shower bath. A common watering pot may be used for
this purpose. A drain pipe is connected with the bottom
of the bath to carry off the moisture. Although the patient
is enveloped with hob air or vapour the electricity can only
be conveyed by contact of the electrodes. A series of experi¬
ments were made at St. Bartholomew’s Hospital some years
ago to see if electricity could be conducted by spray. Pure
water and salt-and-water were used, and forced out of a
metal nozzle connected with one pole of a batteiw ; the jet
was directed on to a metal receiver connected with the
otlier pole, and a delicate galvanometer included in what
would have been the circuit had the vapour conducted any
electricity, but deflection of the needle could not be produced.
A hot air or vapour electric bath is therefore nothing more
than the application of electricity to a patient, whose skin
; is rendered a better conductor through the warmth and
; perspiration that are induced. The skin is softened and the
capillaries filled. The vapour electric bath is more relaxing
and soothing than the hot-air bath.
Electricity can be conveyed by drops of water, and is
the meps by which the electrical condition of the atmo¬
sphere is gauged; but as far as medical apparatus is con¬
cerned, we have nob been able to detect the conveyance of
electricity by steam. And it would certainly appear that
no current of sullicient strength to eftect the human body
therapeutically can be conveyed by this means.
Chronic rheumatoid arthritis .—The affection for which
the continuous current electric bath is most useful is
chronic rheumatoid arthritis, a most obstinate complaint
that usually resists all forms of treatment. Electric baths
will not cure inveterate cases, but will arrest the progress
of the diseaae, somewhat reduce the pain and swelling of
the joints, and otherwise produce some amelioration in the
symptoms. Tlie tendency of the disease is almost always
from bad to worse, bub in the worst cases persistent treat¬
ment with the electric bath and passive movements may
result in some improvement. When the stress of the com-
laint has fallen on the hands, and they have become
istorted and useless, besides the plates already described
dk: lOOgiC:
.•,•72 The Lancet,] DR. J. STILLING: THE ANILINE DYES AS ANTISEPTICS.
[April 18,1891,
aa used for electrodes in the bath, a series of metal handles
of different sizes, covered'witb house flannel, have been em-
loyed. (Fig. 7.) Thehandshavegradnallyopenedout. Small
andles are used at first, and gradually increased in size as
the patient’s hand is able to receive them. The handles
are attached to the negative pole of the battery instead of
the foot plate. The current then enters the body at the
spine, and leaves it by the hand which grasps the handle,
and is thus more localised. But this local application of
the current should only be used for about the last five
minutes of the bath ; it should never altogether take the
place of the general bath, which probably inliuences the
Fig. 7.
whole system. The hands may also be made to grasp a
metal bar supported across the bath and covered with
house llannel,^ and attached to one pole of the battery. In
this position the hands are raised out of the water and
probably get more of the current, but the entire current
fiowing through the battery must be very greatly reduced.
When concentrated in this manner on the hands the patient
eannot bear more than ten or twelve milliampcrea. When
any of these changes in the direction of the current are
made the strength has to be previously reduced to zero,
and then increased again after the change has been made.
If the wire were detached from the plate at tlie bottom of
the bath when the full strength of 200 milliampores was
passing, the patient would receive a very unpleasant and
severe shock.
On looking back after the completion of a course of baths
to the condition of the patient before the treatment was
commenced, it is generally possible to notice some improve¬
ment. A patient, for instance, who could only rise from
one step to the next, on going upstairs, by pulling on the
balustrade, can make the ascent without such assistance ;
or a woman who could not hold her needle finds that she is
able to use it slowly. The theory that the origin of chronic
rheumatoid arthritis in many women may be thrcmgh reflex
action consequent upon the irritation of the spinal cord by
prolonged congestion and inflammation of the pelvic organs
is somewhat strengthened by the fact that the sedative
action of the positive pole on the spinal marrow appears
to be followed by some alleviation of the symptoms. The
chances of this theory being probably a correct one led to
the adoption of the use of the positive pole at the head of
the bath. The rheumatoid condition is frequently associated
with catarrhal endometritis. The question arises as to the
relation they bear to each other as cause and effect. The
superiority of the results claimed for the treatment of these
pelvic troubles by electricity, in which the negative pole is
applied to the uterus and the positive to the lower dorsal
vertebra), may also partly be due to the sedative action of
the positive pole on the spinal cord.
H/ieumatic arthritis of hip-, knee-, or shoulder-joints .—
When the larger joints are affected with rheumatic arthritis,
such as the keeee, hips, or shoulders, the current can be
localised by the use of the smaller metal plates (Fig. 2, p. 710),
one being placed on either side of the bath, so as to include
the affected joints between them. The joints should be
afterwards subjected to rubbing and passive movements.
Local arm baths or foot baths are sometimes given when one
limb or joint only is affected. A porcelain or small wooden
bath is the best to employ, and two small metal plates
attached to the respective poles of a battery are placed one
on either side of the affected member and a current allowed
to pass. Sometimes one electrode only is in the water; the
other—a carbon disc electrode attached to the negative
pole—being applied to the affected joint or limb; for in-
.stance, to a rheumatic knee or to the arm in a case of
eervioo-brachial neuralgia. But ordinary galvanising with¬
out the intervention of a bath seems to be more suitable
lor these localised affections, and does not occupy nearly so
long a time or so exhaust the battery.
‘ Vide Rosa, Diaea-aea of the Nervous System, vol. 1., p. 820.
Gonorrhiv-al rheumatism.—Thia affection has also been
treated by electric baths on the same plan as that followed
in the treatment of rheumatoid arthritis, but not with quite
such satisfactory results. The positive pole is placed at
the head of the bath, on the supposition that urethral irrita¬
tion reflected on to the spinal cord may be one of the factors
influencing the incidence of the disease. It is advisable
to employ massage for the affected limbs after the bath.
Gout .—The g-ilvanic bath is said to be efficacious in
gout It helps to effect that mueb-to-be-desired metabolisis
mentioned by Professor Latham—viz., the conversion of
uric acid into urea. In a recent paper on the formation of
uric acid Dr. Latham has sought to prove that llie presence
of Uric acid in the blood is due to the imperfect metabolism
of glycocine, which takes place under certain conditions,
one being an insufficient amount of exercise. When a
proper amount of exercise is taken the glycocine is trans¬
formed into urea and normally eliminated by the kidneys.
He has also sorrght to prove that thiis more to-be-
desired metabolisis is dependent upon a due amount
of nerve force, and that the production of nerve force
is encouraged by exercise. It has also been proved
that the contraction of muscle produces electrical currents.
Urea is due to the oxidation of uric acid, and Pro¬
fessor Dewar of Cambridge has produced urea from urie
acid by making and breaking a current of electricity when
passing through it Professor Dewar has also experimented
upon the electrolysis of urea. In referring to tnis experi¬
ment Dr. Latham makes the interesting remark that “if
there be any correspondence at all between nerve force and
the electrical current this experiment possesses great signi¬
ficance.” From the beneiicial effects of the treatment of
gout by the electric bath these surmises and observations
receive support. The tophi in gout are composed of urate
of soda, and are removed by galvanism, most likely by a
process akin to electrolysis, the urate being split up at the
negative pole.
Lehr says that in gout the electric bath is a palliative of
great value.^
(To he continued.)
THE ANILINE DYES AS ANTISEPTICS.
By J. stilling, M.D.,
PU0I'l«S01l IX TlKi UNIVKU8ITY 0!'' STRASSIUIRC..
Translated and much condensed
By EDGAR STEVENSON, M B. Aiierdeen.
I MUST begin my second article by touching on some
points that have been suggested to me in the various com¬
munications I have received on this subject. It has been
said that irritation follows the application of methyl violet.
I have myself never seen irritation follow the application
of a 1 in 1000 solution of methyl violet in animals, or in men,
though I have treated hundreds of patients with it. I hare
even used 1 per cent, solutions with only a little hypermmia
resulting, which quickly disappeared on diminishing the
dose. This has been confirmed by Drs. Wansclier, Nagues,
and others. In the course of my experiments I have made
large skin wounds in the hacks of rabbits, and by loosening
the connective tissue have produced a cavity which I have
filled with large quantities (two or three grammes) of the
pure substance. These large wounds have healed without
the slightest swelling or inflammation in the surrounding
tissues, and the general condition of the animals remained
unimpaired. For external application in all surgical cases
the substance can be regarded as quite non-poisonous. A
gramme of an aniline dye is, however, on account of its
small weight, so large a quantity that it sulllces to treat a
wound or ulcer of considerable size. Graefe, in the Fort-
schritte der Medicin, June, 1890, says that he has found
methyl violet to have a local inflammatory action, so much so
that a subcutaneous injection of O'Sec. of a 2 in lOOO solution
in a rabbit’s ear has caused an obstinate inflammation. I
can only say that this is entirely contrary to all my results,
and, as I have already stated in my first article, 1 have in¬
jected large quantities of the dye into the peritoneal cavity
of animals without the least sign of inflammation. These
* Erb's Eloctrotherapeuticu, translated by De Wattoville, p. 281.
Digitized by <^ooQle
The Lancet,]
DR. LEONARD G. GUTHRIE ON DIPHTHERITIC PARALYSIS. [April 18,1891. 873
results of mine have been fully confirmed by the investiga¬
tions of Wanscher, Bresgen, and others. Graefe’s lesmts
are probably due to impurities in the dye, such as chloride
of zinc, arsenic, and copper sulphate. The results of my
experiments btielly stated are as follows: — 1. Methyl
violet is about three times as strong as sublimate in its
action on the anthrax bacillus, and quite as eilectual as sub¬
limate in its action on the staphylococcus pyogenes aureus.
2. It is a perfectly non poisonous substance. 3. In con¬
sequence of this, it is immaterial how strong the solutions
may be, even up to the use of the puce substance itself.
4. it does not coagulate egg albumen. 5. It possesses an
extraordinary power of diffusion, penetrating in the eye
like atropin.
In its action on the normal and pathological states of the
cornea the following may be noticed : The normal cornea is
only stained if it be scratched and the substance imme¬
diately applied, whilst the diseased cornea is very quickly
and deeply stained. The more recent the corneitis, the
longer the stain lasts, and the larger the quantity of the dye
deposited from the solution; the staining can then be
observed to gradually fade after a few minutes, and this
warrants a favourable prognosis, the opposite to this being
an unfavourable sign. Granulations of the conjunctiva are
also easily and deeply stained, whilst the normal conjunctiva,
in spite of the superficial layer of cast-off cells, is by no
means so deeply stained as the granulations, lllepbaritis
is quickly cured by the application of a 2 per cent, ointment
or of a pencil to the roots of the hairs. Ic is better in these
cases to use the yellow dye—auramin,—on account of the
slight stain produced by it. Since I began to use the aniline
treatment I have generally cured boxl cases of blepharitis in
a few days.
As regards conjunctivitis I have had (lie very best results
in even the worst forms of the disease by using drops of a
1 in lOUO solution of methyl violet, or by sprinkling with a
2 per cent, yellow or blue powder. This treatment will
practically cure a case in twenty-four hours. I have also
had good results in blennorrhcea, croupous conjunctivitis, and
iritis serosa ; for keratitis pavenchymatosa the methyl violet
solution is almost a specific. Dr. Wanscher of Copenhagen
has obtained excellent results in blennorrbccal and gonor-
rhcoal ophthalmia by pencilling the conjunctiva several times
a day till the tissue was quite blue. In cases of ordinary
acute, subacute, and chronic conjunctivitis I have so far
obtained better results with auramin solution of 1 in 1000
strength than with the other substances. The patients also
prefer it, as they invariably say that it has a very pleasant,
cooling action. Very severe cases of granular lids are not
often seen here, but in the milder cases I find the applica¬
tion of the pencil to the granulations quite sufficient. With
this treatment there are the advantages that the application
is not painful, as is the case with nitrate of silver or sul¬
phate of copper, and also that a cure is more speedily
ellected.
I might here mention that my friend, Professor Goltz,
informs me that purulent iullaniination of the cornea going
on to perforation and destruction of the eye frequently
occurs in dogs after operations on the cerebrum. This
inllammation he has succeeded in curing in a few days by at
once applying the 1 in 1000 methyl violet solution. As regards
the use of methyl violet in ordinary surgical practice, 1 have
received communications from surgeons from all parts of the
Continent, saying that they have been most successful in
the aniline treatment of ulcers, abscesses, burns, iIcc., and
also of wounds, all suppuration being prevented. The sub¬
stance must bo used till the tissues are deeply stained. I
quote one such communication from Dr. Voigt.^ He says
that “ the very best results have followed the use of the
pure powder, which is easily applied with a brush, espe¬
cially in acute suppuration, such as carbuncle, whitlow,
phlegmon, &c., the pain and suppuration being simul¬
taneously stopped. One need not, if it be necessary,
hesitate to make deep incisions in order to bring the sub¬
stance into thorough contact with tho diseased parts. The
blue zone can bo traced for to 2 mm. deep in the tissues.
The following are the prepar».liou.s of tho dyes :—
1. Pure methyl violet. —To be used as powder for large
wounds and ulcers.
2. Laryo pencils. —For small wounds, burns, «S:c. For
purulent'cases the blue pencil is better than the yellow, on
account of its greater antiseptic property.
• Aorzd. Contr. Anz,, 1890, No. 3D.
3. Small pencils .—For application to the eye, in cases of
corneal ulcer &c.
4. Powders .—Of 1 in 1000 strength for mild cases of con¬
junctivitis, and for more severe cases (blennorrhcea) of
2 per cent, strength. These can also be used as a snuff in
affections of the nasal mucous membrane.
6. Ointments .—In strength varying from 2 percent, to
1 in 10.
6. Solutions .—Used in strengths of 1 in 1000 to 1 percent.
The 1 in 1000 solution is to be used for ordinary cases of con¬
junctivitis, keratitis, &c, and in non-purulent cases the
yellow dye auramin may be used, on account of its above-
mentioned cooling properties. The solutions should be
filtered and kept in dark glass bottles, and changed every
eight days.
In conclusion, I must once more call attention to the
necessity of the substances used being absolutely pure.
Stvftssburg.
THE BULBAK CRISES OF DIPHTHERITIC
PARALYSIS OCCURRING IN CHILDREN.
By L. G. GUTHRIE, M B. OxON,, M,R.C.P. Lond.,
ASSISTANT PHYSICIAN, NOlUTt-WUST LONDON HOSPITAL; PHYSICIAN,
RKGKNT'S-PAUK HOSl'ITAI. I'Oil KI'ILUPSY AM) PARALYSIS;
PATTlOlAJOlSr (l.ATK IU-;<)ISTRAH). l>Ain)IN(JTON-GU.eKN
CHILDREN'S HOSPITAL.
The object of this paper is to describe symptoms of diph¬
theritic paralysis which are often unexpected, which may
often bo unrecognised, and which often prove fatal. The
symptoms to which I refer may be described as “bulbar
crises.” They consist in sudden and severe functional dis¬
turbances of the vital medullary centres. They resemble
in some respects the symptoms of so-called acute bulbar
palsy, and it is possible that some cases of the latter disease
may be of unsuspected diphtheritic origin.' I shall presently
describe them fully ; but, first, as to the conditions under
which they occur.
The premonitory symptoms of bulbar crises are as follows.
Children are usually seen in the second or third week of
diphtheritic paralysis. They are then suffering from slight
weakness of the legs and loss of knee-jerks, staggering gait,
a nasal voice, occasional regurgitation of fluids through the
nose, and sometimes a “ squint.” The common reason for
bringing them is that they “fall about,” seem weak, and
“ want strengthening medicine.” The other symptoms are
seldom elicited except on cross-examination. Sometimes,
however, children are brought because their speech has
lately become defective. Tho initial sore-throat is seldom
mentioned, sonietioies it is denied.- They are often well
nourished and healthy looking. They take food well, except
for the occasional return of fluids; they sleep well, and
there may .seem little cause for anxiety as to their
condition. Yet a closer examination will often give
grounds for alarm. Tliere is a peculiar apathy and lethargy
about the patient which is very characteristic. Ho will
lie all day on his back without attempting to move. He
will smile placidly when spoken to, but will not answer
unless pressed to do so. Then, speech is attended by obvious
effort. A deep, sudden inspiration is taken. Thevoiceeecapes
in sudden expiratory gasps ; it is not only nasal, but also
extremely weak and hoarse. The weakness and hoarseness
suggest incomplete closure of the vocal cords (adductor
paralysis); so also does tho occasional loose and almost
noiseless cough. More probably, however, there is a
certain amount of bilateral paresis of the cords.^ The
character of the respirations often affords indications of
danger. They are not usually hurried. They average about
20 per minute, but inspiration is sudden, deep, and forcible,
whilst expiration is short and weak. At intervals there is
a long-drawn sigh. This sign is almost invariably present,
and is highly significant of an approaching crisis. At
1 Cf. Dr. Stretch Dowse, Merh Soc. Trans., .Tan. 29tli. 1877: " Extrome
voriiciousnesa ilistiiiRuiahes onliii.ary bulbar paralysis from tho bulbar
paralysis of diphtlioria.” x
- It may bu objoctinl that in these casos there is no oviaonco that the
Uisoaso is diphthoritlc. A similar ohjoction mi/;lit bo raised to tho
(iiagnoais of woll-marlanl tertiary syphilis, whore no history of chaiuTO
can bo obtained. . , . •
n Tho inspiratory stridor so coracnon after tracheotomy i3 solaom
noticed, except wheu tliis operation lias been perlorrued.
Die;' z-cd by CjOO^Ic
• «74 The Lancet,] ME. JOHN W. WALKER s THE REMOVAL OF GALL-STONES.
[April 18,1891.
the same time mucus begins to collect in the throat, and
a few moist i&Ies may be heard iu the chest. This is also
a grave sign. The diaphragm may not act, or its action
may be irregular; in either case, the dyspnoea is much more
noticeable. The character of the pulse is also important.
Abnormal infrequency of the beat has been noticed in cases
of diphtheritic paralysis by other observers, and is usually
said to be due to irritation of the pneumogastrics. None of
the cases observed by myself have had an abnormally slow
pulse, and whilst the pulse remains between 70 and 90 there
IS no immediate danger. On the other hand, a rapid
but not necessarily irregular pulse (120 to 130) has been
constant in all cases which have developed dangerous
symptoms. Intermittency of beat is often present. Its
chief importance, however, is that it may mark the in¬
creased frequency. Irregularity is not constant; in some
of the worst cases the pulse has been regular and of good
volume (at hrat), in spite of tbe marked rapidity. It is
obvious that a pulse of 120 to 130 occurring in a child over
two years of age, lying absolutely at rest, without rise of
temperature or physical signs which may explain the
symptom, is a grave condition.^ As regards the heart
sounds, murmurs probably of liiemic origin are sometimes
' present, and tbe first sound may be weak. There may be
slight irregularity, but it is by no means constant. Where
albuminuna has existed during tbe initial disease, it some¬
times persists throughout, but it is commonly absent in the
paralytic condition. The temperalirre is usually normal, or
between 99° and 100° F. at the highest.
It is in children presenting the above symptoms—viz ,
(1) marked listlessness and apathy; (2) a weak, hoarse,
and nasal voice ; (3) irregular and sighing respiration ; (4) a
loose, weak, and almost noiseless cough, with commencing
accumulation of mucus in the throat and air passages;
(5) a rapid pulse, together with the other minor signs
of diphtheritic paralysis — that bulbar crises are apt
to occur. Such crises are sudden, acute exacerbations
of the symptoms which prevailed before. Their exciting
cause may be a fit of passion or other emotion, some¬
times a physical exertion; sometimes they occur spon¬
taneously. During a crisis, instead of the occasional
dysphagia which existed before there is complete and
sudden paralysis of deglutition. Instead of moderate
dysphonia there is complete aphonia. Instead of slightly
embarrassed respiration there is the most alarming dyspncea.
Instead of lethargy there is extreme restlessness. The head
is thrown back; the alee nasi work; the mouth is open ; the
pupils are dilated, and the face becomes bluish, or pallid and
sweating. Inspiration is even more sudden, forcible, and
gasping than before. Expiration is also much feebler, whilst
the sighing and irregularity increase. The diaphragm is
often par^ysed. Mucus accumulates in tbe fauces and
trickles through the nose and half-opened mouth. Loud
moist rhles are audible all over the chest. These are due
to hypersecretion into the air passages, large and small,
and this condition might be, and it is probable that it often
is, mistaken for an ordinary attack of capillary bronchitis.
The temperature rises suddenly to 102° or 103°; the pulse-rate
increases to 140 or 150, or even so high as to be uncountable.
There is no loss of consciousness, and the child, though
unable to speak, points to its larynx or epigastrium when
asked if in pain. This suggests a parallel with the gastric
crises of locomotor ataxy, the other symptoms of which—
extreme rapidity of the pulse and violent vomiting—render
the comparison still more complete. For the next constant
and characteristic symptom of a bulbar crisis is copious
vomiting of greenish-brown frothy liquid. The dyspnma
often seems to be relieved by the vomiting, and the
crisis is thereby ended. The patient lies exhausted,
and seems at the point of death, but death seldom occurs
during a first attack. Colour, pulse, and respiration
gradually improve, power to swallow is restored, and for
the time danger is over. Within a few minutes or a
few hours, however, similar attacks recur, during which,
or after which, death may happen from exhaustion, syn¬
cope, cardiac thrombosis, or aosolutely from suffocation
due to the accumulation of mucus in the air passages.
Besides suddenness of onset, therefore, tendency to subside
and to recur is a marked feature of these crises; their
duration varies from a few minutes to a few hours. They kill
according to their severity and continuance, and according
This pulse-rate withovit rise of tenipei'atiirn iiirticates paralysis of
the iiihilurory action of tlie vagus,—Dr. I.uuder JJniiiioii.
to the degree of the patient’s exhaustion. After a period
of about forty-eight ^ours they cease to recur, and if the
patient survives through this time he usually recovers.
They may be expected at any time during tbe first six
weeks from tbe onset of the paralytic symptoms. I have
not seen them occur later.
(To be coTiclvded.)
THE REMOVAL OF GALL-STONES BY
ETHER SOLUTION.
By JOHN W. WALKER, M.R.C.S.ENG., L.R.C.P.Lond.,
SURUEON TO THE CLAYTON HOSPITAL, VVAICEf-TEI.I).
On March 7tb, 1890, I was called to see II. V-, a
married woman, aged twenty-seven. I found that since
the age of nine she had suffered from pain in the body
coming on at irregular intervals, but getting gradually more
and more severe. These attacks were always put down to
indigestion. About four years ago my father, Mr. T. Walker,
first saw her, and came to the conclusion that the pain was
caused by gall-stones. Since that time she has had several
attacks; but the one to which I was called was the
most severe ever experienced. Jaundice, with the usual
concomitant symptoms, soon supervened. On the third
day my brother, Mr. H. S. Walker of Leeds, saw
her for me, and was able to push the stone for.
ward into the bowel by digital manipulation, giviig
instant relief, and the stone was found in the fceces liie
following day; two days later the pain returned, and I
could distinctly feel another stone through the thin abdo¬
minal wall, hut was not able to push it into the bowel,
although I managed to drive it back into the gall-bladder,
giving relief to the patient, who felt it pass on. Seven days
later I was again summoned to her aid, and though I could
feel a stone in the duct I could not move it either way.
Morphia was given hypodermically in large and in¬
creasing doses, but on March 2Gth, as the patient was
getting worn out with the continuous sutl'ericg, and
I could not detect any change in the position of the
stone, I determined to perform cholecystotomy. For
this purpose the patient was removed to the Clayton
Hospital, where, on the afternoon of the 27tb, assisted by
Messrs. T. Walker and W. Stanger, my colleagues, I cut
down upon tbe gall-bladder, making a vertical incision over
the fundus. The viscus sought for, though not much dis¬
tended, was easily brought into view, and on introducing
two finger-s into the abdominal cavity I could feel several
stones within the bladder, and one just within the cystic
duct- On making an incision into the gall-bladder and
introducing a finger, I was able to remove several stones,
and at last came upon the one which had given rise to the
trouble, embedded in the cystic duct, about one-quarter of an
inch from its vesical end. I endeavoured to push this into
the gall-bladder with my fingers inside tbe abdomen, and
pressing along tbe duct, but was unable to move it; taking
a Volckmann’s small sharp spoon I passed it on to the stone
within the duct, and with my finger tip against the stone
succeeded in cutting it in two, the halves being removed by
a little manipulation, as also another small stone which was
found beyond it. Altogether twenty-seven stones, varying
in size from a horse-bean to a mustard seed, were removed.
The edges of the gall-bladder were sutured to the parietal
wound, a rubber drainage-tube inserted into the bladder,
and absorbent dressings applied. The temperature on the
28th was 100° during the day, hut fell to 98 0° at 10 P-M.,
after which it remained normal throughout. On the 29bh
vomiting was very troublesome, a greenish fluid being
rejected; in the evening I removed the drainage-tube,
thinking that by irritation it might be keeping up
the sickness. After this the vomiting ceased, and con¬
valescence advanced uninterruptedly. On leaving the
hospital tbe wound looked perfectly healthy, but was nob
closed, a fluid resembling raw white of egg being daily
discharged through it, no doubt the secretion from the gall¬
bladder itself. The patient went to Scarborough, and after
remaining there a month returned home feeling quite strong,
the fistula, however, remaining. She continued peifectly
well and free from pain until four days after a miscarriage
The Lancet,] DR. R. R. RENTOUL : TRAINING OF THE MEDICAL STUDENT. [Apeil 18, 1891. §75
on Oct. 1st (being then at the end. of the second month of
pregnancy), when severe abdominal pain came on, caused
i)y another stone trying to pass along the cystic duct; there
was no jaundice. The stone could be felt % a probe passed
through the hstula into the duct, and appeared to be about
the size of a split pea. 1 endeavoured to extract it with
-forceps, but failed to do so. 1 then washed out the gall¬
bladder with a warm boric solution, and having drawn one
drachm of a mixture of equal parts of ether and glycerine
into a small glass tube attached to a syiinge, passed the
tube directly on to the stone, which I could distinctly feel,
and injected on to it the ether glycerine, drop by drop.
This gave rise to a burning sensation for some time, and the
patient felt very exhausted during the remainder of the
day, but the pain gradually lessened, and on the second
day later I carefully examined the galbbladder and dnct
with a probe, but could not feel any stone, and the patient
has been absolutely free from pain since.
I believe that the stone which gave rise to this last
attack must have passed on towards the gall-bladder at
some period ulterior to the operation, as I very carefully
washed out that viscus with boric solution at the time and
could not feel anything left behind. I do not know whether
the plan of dissolving stones in sittt has been before attempted
by injecting ether on to them, as in this case; if the wound
had closed it could not easily have been undertaken. I
injected the ether very slowly, and there was sufficient
space by the side of the glass tube for any vapour to escape;
no bad symptoms followed the injection.
Wakefield.
THE TRAINING OF THE MEDICAL STUDENT
IN MIDWIFERY.
By ROBERT REID RENTOUL, M.D., M.R.C.S.
That the present system of training the medical student
in midwifery is sadly deficient few practical persons will
deny. The fact that some old midwives go about boast¬
ing they train “the young doctors in midwifery” is
■s, cruel, but unfortunately true, statement. The fact
that pupil midwives repeat the/ are better trained than
^students sounds strange. The pupil midwife in Glasgow
has to prove that she has attended thirty cases of labour
before being certificated; and the pupil presenting herself
before the Obstetrical Society must show she has attended
•twenty-five labours. What to day are the requirements of
the medical student? The eighteenth recommendation
of the General Council of Medical Education to the
examining bodies under the Medical Act, and which
is a standing disgrace to our profession, runs thus:
■“ Every student should be required to attend for three
months the indoor practice of a lying-in hospital; or
■to have been present at not less than twelve confine¬
ments, at least three of which he should have conducted
personally iwcfcr the direct supervision of a registered prac-
iitioner." Three confinements ! This is the recommenda¬
tion of an Educational Council which is given almost
supreme power bv Act of Parliament in the matter of
■education. The above recommendation is dated May 26bh,
1888. Previous to this (in 1880) the Council of Medical
Education fixed the number of cases at six. I would call
attention to the words, “have been present at,” in the above
recommendation. They mean that the student may just
have looked in at the case and then left, or that he may
have been “taught” his midwifery by a midwife,—or, in
fact, that he may have bungled along with the case as be
•well may. Thus forsooth is he “ taught ” his practical
midwifery.
The following table shows that there is a very grave
•diversity in the manner of teaching midwifery, and of the
requirements demanded by the various bodies which grant
registrable medical qualifications under the Medical Act:—
allow them to give a better training to their students. I
fail, however, to see why the Scotch representatives on the
Council should keep back the hands of medical education.
If the Scotch student cannot be thoroughly trained in mid¬
wifery, then he should go elsewhere. No one expects small
towns like St. Andrews to be ever able to supply a sufficient
number of lying-in cases. Why, therefore, should the re¬
maining bodies wait for St. Andrews? It is to be hoped
that the new arrangements made at the Maternity Hospital
in Glasgow will give the necessary number of cases. One
fails to see why the pupil midwife is made to attend thirty
cases in Glasgow while the medical student attends twelve,
is his midwifery education to be slowly strangled so as to
make room for the midwife ? Nor do the Scotch examining
bodies appear to neutralise their small demand for prac¬
tical iastruction by making the student attend a longer
course of Igctures or clinical instruction. I think there are
a sufficient number of lying-in cases in the large cities
of Scotland, for I find that in 1889 eight medical charities
gave relief to 4716 women in their confinements. Moreover,
surely the hospitals under the Board of Supervision could
be used, in so far as midwifery is concerned, for the teaching
of the student. It is to be noticed also that the University
of Oxford treats with absolute contempt the suggestion that
aspirants for theirdegree should attend any lectures, clinical
instruction, or labours ; while Glasgow and other Scotch exa¬
mining bodies allow’the student to toss up as to whether he
will attend the clinical instruction on diseases of women or
look on at six labours. Verily ours is a splendid system of
medical education in obstetrics ! Is it to be wondered at
that so many women die in childbed? Ia_ it surprising
that the young doctor is absolutely at sea if called upon
to stitch a ruptured perineum; while, on the other hand,
he waxes eloquent over the necessary incisions in tying
the internal iliac, or first stage of the subclavian arteries?
Or is it any wonder the high infant death-rate in this
country is a disgrace to the medical profession ? How many
of the qualifying bodies demand any certificate from the
student to show that he has received any clinical instruction
in diseases of infants and children ? Nobone. The student
is kept grinding at, and paying heavy fees for, attending
lectures on anatomy and physiology, while bis education in
midwifery and diseases of women and infants is reduced to
a dangerous minimum. Thus is the public protected. And
if we go further, and inquire into another very practical por-
Namo of oxaininiiiK body.
Royal Oolleges of Physicians and SuvRoons of England.
Society of Apothcciuies, London .
>Uuivevsity of London .
,, of Oxford .
,, of Cambridge .
„ of Durham .
Victoria University ,. .
Ri>yal College of Surgeons and Apothecaries’ Hall, Ireland.
Royal (-'ollcge of Physicians and Surgeons, Ireland.
University of Dublin .
Royal University of Ireland .
Royal Coll, of Phys. and .Surgs., Kdiii., and ii'ac. of Pliys. andSurgs., fflasgow
University of Edinburgh .
„ of Clasgoiv .
,, of Abordoon .
„ of St. Andrews.. ..
l.ectures on midwifory
and diseases of women
and of cliildroii.
Clinical in.itructiou
on diseases of women.
Number of
labours.
3 montlia
3 months and
20
S
8 I, 1,
20
I course
0
20
0 ..
0
0
1
0 I.
20
3 months
8 I.
20
<■
3 „
an
6 ..
d II 11
SO
u
f* 1. ,1
30
(i ,,
« II
Not stated
e II
8
20
8
0
a
6
8 I. ti
a
0 ..
8 „ or
li
8
3
6
8 ..
8 .1 II
G
The Scotch Examining Bodies seem to bo the most lax.
Indeed, th^ ignore the Recommendation of the Medical
Council. I believe the Scotch representatives on the
Council say they have not a sulficient number of cases to
tion of the future doctor’s practice—viz., pharmacy,—we find
this is equally reduced to a minimum. When it is remem¬
bered that the three months’ lectures demanded by some
examining bodies includes midwifery proper, puerperal dis-
Digi; zed by nj
ooglc
876 The Lancet,]
CLINICAL NOTES.
CApbil 18', 1S91.
eases, diseases of womeo, and diseases of infants, one ques¬
tions how the student when qualihed can poEsibly have any
practical knowledge of these subjects. Or. J. G. Glover,
one of OUT five direct representatives on the Medical Council,
has in his two pamphlets, “The Practical Element in
Medical Education,” and “ The Gaps in Medical Education,”
called attention to the present lamentable defects in mid¬
wifery education; and at the last meeting of the Medical
Council be proposed that each student should attend
thirty cases of labour. This motion was rejected by only
two votes. I would urge that the profession make this big
question, of the more practical trainingof the medical student
in midwifery, a living one. Let every practitioner write to
our five direct representatives—viz., Mr. C. G. Wheelhouse,
Dr. J. G. Glover, Sir W. B. Foster, Dr. W. Bruce, and
Dr. Kidd, urging them to bring this question up at the May
meeting of the Council. Would it be asking too much of
the different obstetrical, gynecological, and medical societies
to discuss this question at their meetings, and to forward a
resolution to the Medical Council praying that they give
immediate attention to this question ? The profession does
not keep sufficiently in touch with the Medical Council. If
we kept in mind that the Council is a Council of medical
education with the power to appeal to the Privy Council,
and with power to refuse to register degrees granted
on insulficient knowledge, we should appreciate the
enormous powers given oy Act of Parliament to the
Council. I would propose the following recommendation
of the Council: “That each student before being admitted to
his final examination be required to produce certificates to
the examining body showing (a) that be has attended a six-
months’ course of lectures, including midwifery, puerperal
diseases, diseases of women and of infants at a recognised
hospital; (i) that he has personally conducted*^irty cases
of labour under the immediate supervision of a registered
practitioner ; (c) that he has attended for three months the
clinical instruction on diseases of women aud infants at a
recognised hospital.” I hope the Medical and Obstetrical
Societies will agree to work for this, and request the
Medical Council to adopt it. It may be argued that a
six-months’ course is too long. I would only say look
at the wide range of subjects. Let us remember this most
important fact, that the examining bodies cannot examine
the student in practical midwifery and puerperal fevers.
Recognising this, it is imperative that the instruction of
the student while at College should he as perfect as
possible. In Germany the student, when passing his
Staats Examen, has to conduct a confinement, attend the
woman and infant for nine days, and then write and send
in a thesis on the case. In connexion with the thirty cases
of labour, I would ask practitioners to remember that the
student has now to study for at least five years, and that
six months of the fifth year may be spent under the tuition
of a medical practitioner recogniseil by the Council. This
would give the senior student—free from attendance on
dissections, necropsies, and fever hospital attendances—
a good chance of learning his practical midwifery. In the
near future, I trust each of our lying-in hospitals will have
paid district medical officers, who will each have a senior
pupil under their immediate charge.
I would here point out that if midwives are given the
power to attend conflnemeDts now conducted by medical
men and medical students in connexion with hospitals, in
the future this would lead to the student receiving his
training in practical midwifery from the midtoife. He
might as well obtain his training in surgery from a bone-
setter, or his medical education from a herbalist.
Liverpool.
Cliitiral Itflhs;
MEDICAL, SURGICAL, OBSTETRICAL, AIH)
THERAPEUTICAL.
INTUBATION IN LARYNGEAL INFLAMMATIONS.
By Harold Stalkartt, M.B.
The subject of this case was a traveller, aged fifty-
two, suffering from marked dyspnoea, very much cyanoeed
and nearly asphyxiated, breathing with the greatest diffi¬
culty. Gouty habit, being attacked every spring. He was
suddenly seized with a difficulty of breathing, which in¬
creased for five days before I saw him; be was then in
extremis, and it was a question of immediate surgical inter¬
ference. Intubation was chosen in preference to tracheotomy.
1 passed the forefinger of my left hand to the upper stratum
and introduced a long tube through the larynx, some way
down the trachea, which afforded instant relief. The
cyanosis and anxious expression gradually passed off as
breathing became re-established. A steam kettle con¬
taining compound tincture of benzoin was now set going,
and a tent put up. The breathing continued to improve.
The tube, which was of gum elastic material and fourteen
inches long, was removed next day, and the patient re¬
covered without a bad symptom. (See Fig.) The opening
B
A, Opening of tube, n, Movable reel.
in the side of the tube prevented blocking on introduction,
and if placed so as to lie to one or other side has less chance
of contact with the wall of the trachea, as the tube tends
slightly to straighten itself in the antero-posterior direction.
Its diameter is about a No. 16 catheter, and it may be fixed
to the beard. There is |l small wooden reel to be placed be¬
tween the teeth, to prevent compression of the tube. Food
enemata or a stomach tube may be used for feeding. I have
used this in all cases of laryngitis and diphtheria requiring
surgical interference with the greatest success. In cases
where vomiting occurs under chloroform and obstruction of
the air passages is seen, could not this be used ? With leech¬
ing and fomentations locally and natural salicylate of soda,
the gouty symptoms abated, the patient being about again.
Kilburn.N.'w. _
TRAUMATIC CONTRACTION OF FINGERS
TREATED DURING HYPNOSIS.
By George C. Kingsbury, M.A., M.D.
T. H-, aged about thirty-six, consulted me on Nov. 28th,
1890. A year previously he cub the palm of his hand at the
outer side, and since then his little finger had been gradu¬
ally contracting, and latterly the ring finger bad been
following. The patient was hypnotised after a good deal
of trouble, possibly due to the fact that he “did nob believe
in it.” During hypnosis the fingers were forcibly extended,
bub not to the full, and absence of pain verbally suggested.
A distinct cracking could be heard as the contracting band®
yielded. The patient did his work next day as usual with¬
out any discomfort. Two days later he was again hypno¬
tised, and the extension was completed. Immediately on
going home he played his violin for two hours, just to test
his lingers, the hand affected being his left. This test
required their constant exercise, yet he felt no pain. He
had nob been able to finger hie violin for nine months pre¬
viously. On Dec. 3rd, 1890, the patient came to report that
his hand remained all right, and there has been no tendency
to relapse since. 1 have no doubt that this case, being
traumatic, the fingers might have been extended under the
inlluence of an ordinary anmsbhetic ; bub, if they had been,
the question arises, would the patient have been so free from
after pain as to be able to fiddle for two hours immediately
after the second extension ? I do nob say positively that
any part of the result was due to hypnotic suggestion, hub
the influence of the mind upon the body is apt to be under¬
estimated. Trousseau, Stokes, Graves, and others have
pointed out that the mind alters nob only the secretions, bub
modifies the nutrition of the organs. Whatever effect the
mind may exert upon the body in the waking state seems
to be greatly intensified during the hypnotic condition.
One great advantage possessed apiparently by hypnotic
anesthesia, where it can be induced, lies in the fact that (so
far as I know) it has never bad a death laid at its door;
whereas the list of fatal accidents with chloroform and
ether is constantly being increased. It is certain that
hypnotism can never replace these agents in general sur¬
gery, for it is limited in its applicability ; but I believe in a
great number of cases demanding minor operations it would,
if properly tried, be found quite as satisfactory and in¬
finitely safer than the usual anoasthetics. Where it can be
Din z -OOg C
The Lancet,
HOSPITAL MEDICINE AND SURGERY.
[April 18, 1891. 877
ap<plied, hypnotic anscsthesia will be found of great value in
another direction; once induced, there is no farther need
for the hypnotist to devote himself to its maintenance, as in
the case of chloroform; and, more than this, the patient will
be able to obey instructions, such as to raise his arm or turn
on his side, quite as intelligently as if in his normal state.
Those who have frequently to operate with very limited
assistance will appreciate these points.
Blackpool. __
CASE OF NITRO-BEN/OLE POISONING;
RECOVERY.
By Algernon Hodson, M.R.C.S.
R. E-, aged forty-eight, registered chemist, had
measured two drachms of nitro-benzole to scent some soap,
and by some mistake drank it at 1 p.m. on March 11th,
1891. He then made a hearty dinner of beefsteak pie, and
felt DO ill elTect from the poison except tasting and smelling
almonds until 2.30; He then became giddy, and was advised
to go home. He was able to walk home, a distance of about
ball a mile, feeling all the time as though intoxicated, being
unable to control his legs or see clearly. On reaching home,
about 3.15, be informed his daughter of having taken nitro-
benzole by mistake. She went for a doctor, and in the
meantime the patient became unconscious. Messrs. Dodd
and Philips came, washed out the stomach, and got rid of
the contents, consisting chiefly of lumps of meat, smelling
very strongly of nitro-benzole, as did the breath and the
whole atmosphere of the room. A hypodermic injection of
ether was also given. He was then sent to the Hove Hos¬
pital. Condition on admission at 4 30 p.m.: Strong, well-
nourished man ; insensible, collapsed, extremely cyanosed,
sshort and irregular breathing. Pulse liardly perceptible, 60.
Pupils contracted, conjunctiva not insensible; no paralysis.
Had defecated involuntarily. Stimulants administered and
heattoextremities. AtOp.M thebreathingwasquiteregular;
pulse 80; still extremely cyanosed; could open his eyes;
'looked vacantly if shouted at. Vomited twice. At 12 A m.
he was in the same condition. Micturated involuntarily.
Temperature 99“. The next day the patient was much
better; sensible, but still very cyanosed. Thirsty, and
-complained of stiffness and soreness over the whole body.
The pupils still contracted ; no headache ; pulse 84 ; respi-
iration 18. OnthelSth the cyanosis was less marked and
the pupils less contracted. Urine drawn off (SGoz.), very
dark mahogany coloured, perfectly clear, no peculiar odour,
apecific gravity 1025. The condition continued to improve
and the cyanosis to decrease until the 19Db, when the man
was discharged cured.
I am indebted to Mr. C. M. Lewis, the house-surgeon, for
obtaining the information and verifying it by inquiry. The
interest in the case seems to be the recovery after so large
-a dose as two drachms being taken and allowed to remain
in the stomach for over two hours, as there are several
cases on record of very small doses proving fatal, and one
case where eight or nine drops proved fatal (Letheby).
Another point of interest was the intense cyanosis.
Brighton. _ _ _
A-CUTE INTESTINAL STRANGULATION DUE TO
VOLVULUS IN A NEWLY BORN INFANT.
By G. Newton Pitt.
An infant came under the care of Mr. Lucas for com¬
plete obstruction, with n greatly distended abdomen, which
was supposed to he due to an imperforate rectum. A left
'inguinal colotomy was performed, and the child died when
two days old. The colon, rectum, and the lower two feet of
■the ileum were normal. The three feet of intestine above
this were distended, black with engorged blood and acutely
inflamed. There was a sharp line of demarcation from the
healthy bowel above, but leas sharp below. No trace of any
band or of an intussusception could be found, and it was
concluded that the acute strangulation was due to a vol¬
vulus, which readily untwisted. Tlie only case on record of
a volvulus in a newly born infant was reported by Mr.
Harrison Cripps in Vol. xxxi. of the Transactions of the
Pathological Society. In this case a Littib's operation was
performed ; the child died when three days old, and at the
post-mortem inspection a volvulus of the ileum was found.
The earliest case otherwise appears to be that of a child
three years old referred to by Keating.
St. Thomas's-sbrest, S.E.
PRIMARY MUMPS OF THE TESTICLE.
By T. F. Raven, M.R.C.S. &c.
A YOUNG man, exposed to the infection of mumps, com¬
plained of pain and swelling of the left testis on March Slst.
On April 4th both parotid glands began to swell, and the
affection of the testicle, which was not severe, subsided
rapidly, and was gone by April 7th. Last August he had
gonorrhoea., succeeded by gleet. On Nov. lObh he had a
sharp attack of orchitis (right), and on December 25bh a
simitar affection of the left testicle. Each of these attacks
lasted for more than a fortnight; but for nearly three
months, prior to the mumps, he had been quite well and
able to take horse exercise frequently. I should imagine
that the previous orchitis had rendered the testicle vulner¬
able, and that the virus effected an easier lodgment there
than in the parotid glands. The mildness of the mum|)8, as
compared with the previous inilammation of the testicles,
may bear out the distinction drawn by Trousseau between
mumps and parotitis. Mumps he regarded as engorgement
[fluxion), but not inflammation of the gland.
Broadstairs.
% Pimr
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
NuUa autem eat alia pro certo noacendl via, nisi quampIuTimas et mor*
borum et dissectionum histovias, turn alionim tum proprias collsctaa
habere, et inter se comparare.—-MonQAONi De Sea. et Catu. Morh.,
Ub. iv. Procemium. -
MIDDLESEX HOSPITAL.
CASES OF INJURIES OF PERIPHERAL NERVES.
{Under the care of Mr. Hulke.)
Suture of severed nerve trunks—immediate wherever
circumstances admit; where these do not allow it, then
secondary suture, unless the interval of time since the acci¬
dent is so great as to remove all expectation of benefit—is
a practice baaed on such wide experience of its usefulness,
and of its freedom from those risks once thought to be
attached to it, that its neglect must be regarded as a grave
omission. Mr. Bowlby’s work, published in 1890, is an
excellent summary of this subject, regarded from a clinical
and an operative standpoint, and should bo read by all
interested in this class of injuries. There will long
remain, however, some matters respecting which ad¬
ditional information is greatly to be desired. To men¬
tion only two points: (a) What is the longest interval
after division of a nerve when suturing may be tried with
some expectation of success? (6) the condition as regards
restoration of function or otherwise at so great an interval
after suturing as to fairly represent the final outcome. As
concerns hospital patients, they seldom remain long enough
under the observation of the same surgeon ; but wandering
from one hospital to another, and leaving London for the
country, they are early lost sight of, so that in many
instances the final results are not known. In the first
of the following cases restoration of function soon began ;
it was not (mvioualy interrupted by the supervention
of suppuration, and it became complete. In Case 2, where
suturing was also immediately practised, restoration of
sensation was imperfect, motor conductivity was greatly
impaired, and muscular atrophy was very advanced ninety-
three days after the date of the injury. Here there had
been considerable loss of blood; the wound bad inflamed, there
was some alougliing, and also free suppuration—all circum¬
stances unfavourame to repair. In Case 3, the nerve not
being completely divided, no suture was applied, the un¬
severed portion appearing to be a siiflicient bond, and the
early result was encouraging. In Case 4, which illustrates
division of the sciatic nerve within its sheath by crushing,
Dic:;'zjd by Google
878 Thb Lancet,]
HOSPITAL MEDICINE AND SUEGERY.
[April 18,1891.
the result of al)steDtion from resection and suture was most
dLtcouragirur; for the hope that the undivided sheath might
act as a suillcient bond, and union of the nerve take place,
was not realised—one reason, perhaps, being the very
damaged state of the nerve ends.
Case 1. Division of the median nerve ; immediate mturo;
oMtcifc recovery of function. —On Dec. 14th, 1887, a school¬
boy aged ten years was admitted under Mr. Hulke with a
deep cut crossing the flexor side of the forearm above the
wrist, caused by pushing his hand through a window-frame.
It reached from three-quarters of an inch above the root
of the thumb obliquely downwards and inwards towards
the ulnar border of the forearm, its lengtli being about an inch
and three-quarters. The distal end of the median nerve and
of the tendons of the flexor sublimis digitorum were pro¬
jecting between the lips of the wound ; their proximal ends
were not visible, having retracted. The house-surgeon
enlarged the wound, found the proximal ends, and sutured
the median nerve and also the tendons, using very fine
silkworm gut sutures. The hand was flexed on the forearm
and this on the arm, and fixed upon a splint. Within
forty-eight hours a slight degree of sensibility to tactile
stimuli was noted, ana on the lOth (four days after the
injury) sensibility was very good in the thumb and slightly
present in the middle finger; it was yet absent from the
index finger. Two days later sensibility was present in the
index. Notwithstanding rigid antiseptic measures, suppu¬
ration ensued, which greatly retarded cicatrisation. On
Eeb. 14th. 1888 (two months from the date of the injury) he
was discharged from the hospital, sensibilityin all the digital
branches of the median nerve being perfectly restored.
Case 2. Wound of forearm, severing the ulnar nerve ;
immediate suture ; imperfect restoration of sensation ; dege¬
neration of motor fibres and muscular atrophy. — J. C-,
aged twenty-seven, an engineer, sustained two deep lacerated
wounds in the flexor side of bis left forearm through his
foot slipping and his hand passing through a window-pane.
A fellow-workman stanched the bleeding by tightly binding
the wound, and brought him to the hospital, into which he
was admitted on Oct. 9th, 1885. The ulnar artery and
nerve were completely divided. Both ends of the bleeding
artery were secured, and the nerve ends were brought
together with fine catgut sutures passed through the
sheath. Antiseptic measures and drainage were strictly
observed, and tne hand and forearm placed in a splint.
Suppuration and slight sloughing ensued. On the 28tb
of the same month the first indications of a return of
sensibility in the cutaneous distribution of the ulnar
nerve were observed, the patient being conscious when
touched with a pencil-point xn this area, but was unable to
localise the spot. Ten days later the improvement of
sensibility was marked in the fifth and fourth fingers, but
the patient complained much of a sense of numbness and of
pain in them and in the hypotbenar eminence. On Nnv. 17 th
the contact of a point was not accurately localised, and
pain was not felt even when a pin was so deeply pricked
into the skin as to draw blood. On Jan. Ilth, 188C,
there was complete ancesthesia of the hypotheuar eminence
and of the extensor surface of the fifth nnger. There was
marked wasting of the interossei muscles. Dr. Pringle (at
that time in charge of the electrical department) reported
that none of the interossei responded to strong faradaic
currents, but they reacted excessively to a weak galvanic
current; the anodal and kathodal contractions were equally
well marked. The patient shortly afterwards went into
the country. His further history is not known.
Case 3. Incised wound of Jorcarm partially dividing
the ulnar nerve. — W. P-> aged twenty-two, a cabinet¬
maker, on Dec. 6bh, 1883, by the slipping of a chisel, cut
his left forearm just above the wrist. The gash extended
from near the root of the thumb almost to the styloid pro¬
cess of the ulnar, being deepest at the inner side. The
radial artery, median nerve, and ulnar artery escaped injury,
but the ulnar nerve was seen to be partially divided. Tfle
ulnar side of the flexor aspect of the ring finger and both
sides of the fifth finger were devoid of sensibility, whilst
the dorsal surfaces of these fingers retained it unimpaired.
Obviously the injury to the ulnar nerve occurred below
where it detaches its dorsal cutaneous branch. The edges
of the wound were brought together by strongly flexing the
wrist, and fixing the hand and forearm on a splint. Three
days afterwards a return of sensibility in the fingers was
noticed, and further improvement was observed at the date
of his leaving the hospital on the 20tb of the same month.
He was directed to return after a further interval, but
omitted to do so, so that his ultimate condition could nob
be ascertained.
Case 4. Division of the sciatic nerve within its sheath;
very incomplete restoration of sensibility ; transitory in some
branches. —E. N-, aged twenty-three, a strongly formed,
healthy-looking Cornish woman, in domestic service in
London, was admitted into Bird ward on May 7th, 1888, for
injuries received by falling through a skylight. In the back
of the left thigh, four inches above the ham, was a trans¬
verse, bruised, torn wound, dividing the deep fascia through*
a rent in which the muscles were bulging. Hcomorrhage,
which had been copious, had nearly ceased. The leg, the-
patient said, felt dead ; voluntary motion was lost, and also-
sensibility of surface in the distribution of the popliteal
nerves and their branches. There was considerable shock,
and great mental dejection, from which she rallied slowly.
On the 12bh the wound was enlarged, the internal
popliteal nerve exposed, and traced upwards to the sciatic
trunk. The continuity of this latter was preserved by
its strong, tough sheath, but a distinct difference in the
consistence of the nerve cord within the sheath made-
evident a very small gap where the cord had been pulped
and praoticaily divided by the injury. Above this the>
sheath was blood-stained, and below it for some distancci
the internal popliteal nerve was also ecchymosed and
swollen. The external popliteal nerve was similarly
affected, but in a less degree. The muscles at the back of the-
thigh were found greatly braised, and both they and the
intermuscular cellular tissue were largely infiltrated with
extravasated blood. In the expectation that the nerve
sheath would maintain the ends of the severed nerve trunk
in very close proximity resection of'their damaged parts-
and suture were abstained from. Notwithtanding careful
measures taken at first to render the fresh wound aseptic,
and also observed at the operation, a free suppuration-
and some sloughiDg followed. On the Kith slight sensi¬
bility to touch was discovered in the distribution of the-
muscular cutaneous division of the external popliteal
nerve on the upper surface and also in the sole of the foot.
The former subsequently was lost, that in the sole and
lantar surface of the toes being retained. It shortly
ecame evident that she was pregnant, and on July 13bh
she left the hospital for an adjoining parochial infirmary to-
be confined, with the understanding that when this wa&
over she should be readmitted into the Middlesex Hospital
for nerve suture in case the condition of the leg had nob
appreciably improved. Unhappily she did not return, and
subsequent inquiry failed to trace her. There were reasons-
for thinking that her fall was suicidal and not accidental.
In the above case later experience supports the view that
it would have been better practice to have at once cutaway
the bruised nerve ends and sutured, for the slight indica¬
tions of restored conductivity in the distribution of nerves-
derived from the internal and from tiie external popliteal
nerve proved as regards the latter very transitory, and
as regards the former, they were scarcely progressive during,
the nine and a half weeks the woman was in the hospital.
LEEDS GENERAL INFIRMARY.
A CASE 01-' GROWTH ('/POLYPUS) IN THE URETHRA; DEATH,*.
NECROPSY; REMARKS.
(Under the care of Mr. W. H. Brown.)
Tumours of the urethra in either sex are extremely rare,,
if we except the vascular caruncle, which is not infrequent
in the female. Writing on this subject,'John Hunter^
says ; “ I have in all ray examinations seen only two, and
these were in very old strictures, where the urethra had
sufl'ered considerably. They were bodies rising from the
surface of the urethra like granulations, or what would be
considered polypi in other parts of the body. It is possible
they may be a species of intenial wart, for I have seen warts
extend lor some way into the beginning of the urethra
having very much the appearance of granulations.” One
specimen- to which lie refers is still in the collection at
the Royal College of Surgeons, and forms the only example
of this condition in the museum, if we except comparative
pathological specimens, amongst which there is a pyriform
1 On tbo Voneroal Disea-se, Works, vol. ii., p, 277. * No. 1422.
f Coogle
The Lancet,]
HOSPITAL MEDICINE AND SURGEEY.
[April 18, 1891. 879
polypus, about two inches long, in the urethra of an ox
■attached to the veru montanum.^ Altogether not more
than thirty examples of these growths are on record, and
'few have exceeded the size of a nut, which was the size in
M. Porget’s patient.* Mr. Brown’s case is, as he says,
without parallel, and shows the symptoms which polypi
produce in this canal, frequent micturition, obstruction to
the stream of urine, occasional haemorrhage, &c. For the
note.H and drawing of the accompanying engraving we are.
indebted to the dresser, Mr. Dixon.
J. W-, aged eighteen, was admitted on Feh. 14th,
,1891, complaining of incontinence of urine. He gave the
following history of his trouble:—For the past two years
and a half he has had difficulty in passing urine; at times
the stream would suddenly stop, and he was obliged to
strain violently and bend double in order to void his urine.
In the intervals between these attacks he was able to mic¬
turate without pain. All his pain was referred to the end
•of the penis. During the night he frequently passed urine
whilst asleep. When walking about the urine was always
dribblingaway. Two years ago, whilst straining tomicturate,
he expelled about two ounces of bright-red blood. He stated
that on this occasion no urine was passed either before or after
the blood. This was the only occasion that blood was seen.
'On admission the patient was a healthy looking boy, but
.appeared to be mucn younger than his real age (eighteen).
There was no sign of hair on the pubes, and the penis and
testicles were of the size of a boy of nine or ten. There
'was a very tight phimosis. On his attempting to pass urine
the stream was observed to ^be very small, and a curious
balloon-shaped swelUug appeared just over the urethra at
the junction of the penis with the scrotum. In front of this
there could be felt a small hard mass, not unlike the feeling
-given by an impacted calculus, but scarcely so hard; this
was thought to be due to hardened cicatrix. The balloon¬
shaped swelling could be emptied by syringing, and the
•urine passed both backwards into the bladder and forwards
out of the urethra. The patient stated that he had been in
the habit of expressing the contents of this swelling, and
this proceeding always relieved his desire to micturate. The
urine was found on examination to be natural.
Feb. 16th.—The patient was put under ether, and
Mr. Brown tried to pass a sound, but the phimosis was so
tight as to render this impossible. The prepuce was there-
’foro slit up, when the sound leadily entered the bladder.
No stone was felt. Nothing more was done.
20bh.—The boy looks ill and is vomiting ; is very cold,
No. 4J23. ■* Lnnd. Monthly Joum, 1!5G2, vol. vii., p, 83.
and has the usual symptoms of uraemic poisoning. A very
email quantity of urine was passed, and on examination
this was found to contain one-fifth of albumen. The
symptoms continued, and the boy died comatose the
next day.
At the post-mortem examination a sound passed into the
bladder without difficulty; a cicatricial-like mass was felt at
the root of the penis. The organs were removed; and the
urethra, having been slit open, was found to contain an
elongated polypus-like body about two inches in length.
Its posterior attachment was to the prostatic region in the
posterior wall of the urethra. The posterior extremity of
the polypus was cone-shaped with the base attached. From
this attachment the body projected outwards along the
urethra, gradually decreasing in size until its middle
was reached, then expanding again to its anterior
attachment. The portions between the attachments were
quite free, and stretched after the manner of a bowstring
in the urethra. That portion of the urethra corresponding
to the extent of the polypoid mass was largely dilated,
being of sufficient calibre to admit almost one’s index .linger;
also its walls in this part stood permanently apart, so that
the channel could be looked down, as it were. The bladder
walls were somewhat thickened, and here and there
roughened. One ureteral orifice was slightly dilated. The
mucous surface of the urethra was quite smooth. The
ureters were not dilated; their walls were thickened by
submucous inflammatory changes (not caseous). The
kidneys were extensively diseased, the left much more so
than the right. The left kidney was about three times its
natural size, and was completely converted into a many-
chambered cyst. The outlines of each cyst indicated on
the surface in such a manner as to suggest that each
cyst had been formed by enormous dilatation of a pyramid
and its extension outwards at the expense of the cortex.
The cysts all inter communicated so far as could be ascer¬
tained, and were completely filled with a thick, creamy,
almost grumous pus, or an exceedingly homogeneous
liquefied caseous material. There was no fetor or cal¬
culous formation. The appearance was undoubtedly not
unlike that of tuberculous disease, but it was thought not
to be really so in nature. The right kidney was in the
same condition, but in quite an eany stage of the change.
Testes normal. All the other organs were healthy.
Remarks hy Mr. BROWN.— I have not been able to find
a record of any case similar to the one just related. The
position of the tumour and its twofold attachment are, so
far as 1 know, without parallel. The history of the cose
and the symptoms, with one exception, did not afford any
ground for diagnosis, nor did the general appearance of the
boy suggest that his kidneys were in such an advanced
state of disintegration. The urine before the operation was
natural. The symptom which might have perhaps guided
us towards suspecting • the presence of new growth was
the one copious hojmovrhage (referred to in the notes)
without the discharge of urine. Such bleedings being
of frequent occurrence in rectal polypi, I am indined to
think that the tumour had its origin in the bladder and
grew as the patient grew, being washed into the urethra by
the outgoing flow of urine, and that its urethral attachment
may have been due to inflammatory adhesions, the result
of the patient’s constantly handling the penis in his efforts
to expel his urine. We miled to elicit any history of injury,
of calculus, or of foreign body. It is, I think, only too
clear that death vvas hastened and the shock occasioned
by my slitting up the prepuce and passing the sound for
the purpose of diagnosis, but I do nob see how such an
acciueut could have been either foretold or avoided.
The Meath Hospital and OouNTy Dublin
Infirmary, —This institution maintains its efficient con¬
dition. All the departments are in excellent working order.
During the past year 1211 patients were admitted. The
dailyaverage number of bedsoccupied was9f>'40. The acci¬
dent cases, treated as out-patients, and the dispensary cases,
numbered 014.0. The convalescent home at Bray, in con¬
nexion with this institution, continued to be utilised with
great benefit to the patients sent there. Improvements in
the dispensary, which is detached from the main building,
had been ettected at a cost of £274 l.')s. It was now com¬
plete as an extern department. The financial statement
showed a balance on the debit side of £52'i 18^. 5c^., including
deficiency of £187 4,?. firf. brought forward from last year.
^8
Di:..:
880 ThbLahcbt,!
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
[April 18,1891.
BOYAL MEDICAL & CHIRURGICAL SOCIETY.
Meashs a$ a Came of Endocarditis.—Clvronic Traumatic
Arthritis.
An ordinary meebiog of this Society was held on April 14th,
the President, Mr. Timothy Holmes, in tbe chair.
A paper by Mr. John H. Hutchinson, on Measles as a
Cause of Endocarditis, was communicated by Dr. Ciieadlk.
The author called attention to the rarity of the occurrence
of endocarditis as a direct result of measles. He recorded
four cases of endocarditis, all of which occurred in an epi¬
demic of measles at aboys’ school:—Case 1; Boy, aged ten,
with a rheumatic family history, developed mitral murmurs
on the second day of the prodromal stage.—Case 2: Boy,
aged nine, suffered from measles complicated with catarrhal
croup and slight bronchopneumonia; a mitral systolic
murmur was heard on fifteenth day.—Case 3; Boy,
aged nine, several of whose relatives had suffered from
heart disease, probably rheumatic, developed broncho¬
pneumonia and pleurisy on the second day of the eruption
of measles, and endocarditis on the fourth day.—Ca.se 4:
Boy, aged eleven, having had repeated attacks of follicular
tonsillibisj but no articular rhematism, whilst apparently
convalescing from a rather severe attack of measles, de¬
veloped a systolic mitral murmur on the fourteenth day.
The author suggested that a rheumatic taint might have been
apredispoeingcause.since the first case hadrheumatichiscory
and had suffered from chorea, the third had family history of
heart disease, and the fourth had follicular tonsillitis.—
Dr. Cheadle said that there was nothing improbable, on
the face of it, that the endocardium should be stirred up by
the poison of measles, just as the mucous membranes were ;
and meningitis, myelitis, and nephritis were known to
happen in its course. This cause might account for a
certain number of cases of so-called “unexplained heart
disease.” He had nob met with any cases in the course of
measles during life, but he had looked up the post-mortem
records of the Children’s Hospital in Great Ormond-street,
and there were only two deaths in which affections of the
heart were found amongst patients who died of measles.
One WM a case of old valvular lesion, and the other was
one of pericarditis and pleurisy. He almost questioned
whether this epidemic might not have been a very severe
one of rdtheln, as he had seen many more grave complica¬
tions with that disorder than with measles. He doubted if
in the first ca.se the cardiac lesion could be put down
to the measles, but the others appeared undoubtedly
to be due to that cause. It was worthy of note that
in none of the cases was there concurrent joint affec¬
tion.—Dr. Sturoes felt rather afraid that the author had
drawn his conclusions from an insufficient number of cases.
He thought it very improbable that endocarditis did follow
measles, and in conjunction with this it should be remem¬
bered that it was often very difficult to say, from physical
signs, whetherendocarditiswaspresentornot.—Dr. Robert
Lee said that if he were asked what disease of the zymotic
class left behind the least changes, he would have said’
measles. He bad never been able to trace a single ease of
disease of the heart to that cause. It had been stated by
older writers, no doubt on clinical evidence, that small-pox,
measles, and scarlatina were causes of heart disease; bub
modern observations did not bear out this statement. He
thought it probable that some latent constitutional tendency
might be aroused into action by the measles poison, and
that this tendency might bring about the veSve mischief.
It should he remembered that negative evidence would also
be most valuable.—Dr. Haig agreed with the author of the
paper that more cases would be found if more were sought
for. He had elsewhere maintained that endocarditis was
due to the action of uric acid on the fibrous tissues of the
heart. The action of the measles as a fever on the uric
acid probably produced the lesion; one would not, however,
expect to find it often in the course of measles, as the fever
was usually slight. It was worthy of note that in two of
the cases the measles was associated with broncho-pneu¬
monia. He suggested that in the fourth case the cause of
the murmur was probably dilatation of the heart.
Mr. W. Arbuthnot Lane then read a paper on Chronic
Traumatic Arthritis. The author wished, in the face of
the recent more accurate differentiation of the clinical
conditions originally comprised under the several terms
“rheumatoid arthritis,” “rheumatic gout,” &e., to separate
from the mass of clinical and pathological material which
was said to be characteristic of that disease, or rather
groups of diseases, a definite variety to which he would
apply the term “chronic tiaumatie arthritis,” to distinguish
it from the two other chief varieties—rheumatoid arthribiB
and rheumatic arthiitis. lie suggested this title for the
reason that its course was a long one and constantly
progressive, and its causation was simply and solely
mechanical. He referred to a paper in the Transactions of
the Pathological Society for 1880 (“The Causation and
Pathology of Rheumatoid Arthritis and of Senile Changes ”)k,
in which lie dealt with many of these changes in detail, and
showed that they were the result of force exerted on one or
several occasions upon a joint. These he stated brielly,
together with other similar conditions which he had
observed, and which he bad described in various papers.—
Mr. Howard Marsh said that he was surprised to hear
the author state that no one had alluded to these cases of
chronic traumatic arthritis, which were usually mixed up-
with those of rheumatoid arthritis. He had certainly
heard these cases described by Sir James Paget thirty years
ego, and he believed that Stanley had also alluded to them.
In the museum of St. Bartholomew’s Hospital there were
hip-joints with the general characters of osteo-arthritiB
where the changes were the result of injury. He saw a-
case recently in a woman aged fifty-four who fell and
bruised herself. She went about for a fortnight and tben
had to lay up. He saw her two months later, and there
was then severe pain in the joint, which was stiff and the
muscles were wasted ; the limb was shortened and the foot
everted. The injury had caused a chronic arthritis with
absorption of the bone. Similar lesions were seen fol¬
lowing injury to the shoulder, knee, great toe, or thumb.
In certain cases a locking of the joint might result,
the injury producing a chronic synovitis with thicken¬
ing of the fringes, vmich got between the articular ends.—
Mr. Lane of Bath remarked that in cases where an injury
set up an arthritis there would be frequently found a-
history of scrofula. In osteo-arthritis there was a quick
pulse and other neuroses which served to distinguish it, bub
these were nod found in chronic rheumatic arthritis. The-
true rheumatoid joint was enlarged and of spindle
shape, but the rheumatic joint was not enlarged, or only
very slightly so. Grating, in his experience, was only found
in the rheumatoid cases. He believed that some few cases-
might owe their origin to injury only, while some were mixed
cases.—Mr. Warrington Haward asked if the causa¬
tion of the disease could be simply and solely mechanical.
It was certain that numbers of people tumbled down
and yet these changes in their joints did not follow.
The true explanation, he thought, was that the iiiecbanical'
disturbances evoked something that was previously there.—
Mr. Golding-Bird asked why these damaged articulatione
could not repair themselves. The disease was said to begin
in the cartilage and result from a trivial blow; but the
changes produced seemed to him impossible to follow from
such a cause. He felt sure that they could only be induced
in people who bad a primary tendency. In cases of
arthritis of the shoulder following injury there was not
the slightest deformity, unless the patient were rheumatic.
In a case were trouble at the hip had followed a blow, h&
found on examination, three years after, stiffness, pain, and
wasting of the muscles, but no shortness or deformity.—
Dr. Archibald Garrod said that the injury was the
starting-point of the lesion, but not its actual cause. He
referred to the case of a patient who had an injury to a
small joint, and this was the starting-point of a general
rheumatoid arthritis. The chronic arthritis resulting from
injury to a joint in young persons did not present the
rheumatoid characters: these lesions would not occur
if the joint were perfectly nourished. In some cases-
the rheumatoid arthritis was local and due to a local
cause, while in others it was general and due to worry
or to some defect of general health.—Mr. Parkin thought)
the three divisions suggested were valuable, the first group,
of traumatic arthritis, occurring mainly in males, affecting
large joints, associated with grating, but without nervous
symptoms. The second affected chiefly young people ?
there were nervous symptoms, the ligaments were affected,
there was sometimes effusion, and the small joints w^e
principally involved. The third class were cases which
The liANCET,]
CLINICAL SOCIETY OF LONDON.
[Apeil 18, 1891. 881
followed on acute rheumatism. The first variety seemed to
Mm deserving of a special name.—Mr. Lane, in reply, said
that he saw no difficulty in locating the change in the
cartilage. If a thigh were fractured with two inches
shortening and the lower fragment set at an angle, the
cartilages in the joints would disappear very rapidly at the
points of altered pressure ; and if this would happen as the
result of several slight oreaaures, he thought it might also
follow aviolenb inj ury. He had seen rheumatoid arthritis pick
out a damaged joint over and over again, but that was an
instance of mere super-position, and differed from the cases
he had deaciibed. He was unaware of the existence of any
literature on this special subject.
CLINICAL SOCIETY OP LONDON.
Popliteal Amurysm.—Lumbar Nephro-lithotomy.
An ordinary meeting of this Society was held on April lOfch,
tlie President, Sir Dyce Duckworth, in the chair.
Mr. A. T. Noeton read a paper on a case of Popliteal
Aneurysm in a youth aged seventeen. A parcel-post boy
had felt pain behind the left knee for five months, and in
March, 1890, being unable to work, he entered St. Mary’s
Hospital. The tumour occupied Hunter’s canal and ex¬
tended down into the popliteal space, which it filled. The
part in Hunter’s canal could not he diminished by pressure
to such an extent as an aneurysmal cavity should be ; there
remained an apparent enlargement of the femur; the part in
the popliteal space was quite as-compressible as an aneu¬
rysm. 'The tumour pulsated and dilated in all directions.
During pulsation a loud systolic murmur was heard over
the whole tumour. The measurement around the tumour
was 14,t iu. as compared with 13 in. in the corresponding
position of the sounalimb. Pulse 60; temperature normal;
urine normal; tongue clean; appetite good; glands in
both groins enlarged, also one under the chin. There was
a difference of opinion as to the character of the tumour,
Mr. Norton considering it unquestionably an aneurysm,
others looking upon it as a pulsating sarcoma, chiefly on
account of the fact that the femur could be felt enlarged in
the position of Hunter’s canal after steady compression of
the tumour and on account of the youchfulness of the
patient. In consequence of the difference of opinion, Mr.
, Norton determined bo watch the tumour for a week, at the
same time treating the patient by Tuirnell’a method. On
March 29bb, finding the pain increasing, Mr, Norton tied
the femoral artery in Scarpa’s triangle. On May 5 th the
sutures were removed, the wound having healed by the first
■intention, and pulsation being re-established fully in the
vessels below. On May Sbh measurement over tumour reduced
one inch ; left thigh, 13.f ; right, 12,?. On June 21s(i, seven
weeks after the operation, both limbs had increased in size,
and both were nearly equal in size. Left thigh, 13^ ; right,
!13J. The position of the popliteal tumour was scarcely to be
recognised, bub in Hunter’s canal could be felt a small
sharp edge of bone or exostosis, whicli in all probability
was the cause of tbe vessel giving way <at that part, and
hence the peculiarity of the aneurysm in a person seventeen
years of age.—In reply to some remarks of the President,
the author said that he regarded the femoral exostosis as
tbe cause of the aneurysm ; there was no heart disease and
no arterial degeneration. He did not propose to deal with
the exostosis surgically, as the aneurysm was cured,
and the growth would probably nob cause any further
trouble.
Mr. (jr- R. Turneji related a case of Calculous Suppres-
aion of Urine with Double Pyo-nephrosis in which nephro¬
lithotomy was done on both sides at one sitting. The
patient, a woman aged forty-five, was admitted into St.
■1 leorge’s Hospital, under the care of Dr. VVhipham, July 21sb,
1890. She had led a very intemperate life, and had suffered
from symptoms of renal calculi for live years, occasionally
^)a38ing stones by the urethra. None, however, had passed
lor the last year. Three days before her admission she
had a severe attack of pain in the right loin and groin, and
for twenty-four hours before she bad passed hardly any
urine at all. She was weak and drowsy on admission, and
'in each lumbar region was a tender, evidently renal,
tumour. The right was the larger of the two. On
July 23rd, after consultation with Dr. Whiphara, Mr.
Turner decided to cut down on both of these from the loin.
The bladder was quite empty, and no urine being passed.
From tbe left kidney a large calculus weighing just under
an ounce was removed. A quantity of extremely offensive
pus occupied the dilated renal pelvis. This was irrigated
with warm water and drained. The right loin was then
dealt with in a similar manner. Pyo-nephrosis was present
here also, bub there was less pus on this side. Two
rounded calculi weighing some five drachms were removed.
In all more than two ounces of calculous matter were
removed from both kidneys. She rallied well from the
operation, a quantity of urine coming away from tbe
drainage-tubes, and about an ounce was drawn off from
the bladder by catheterisation. On July 27bh she passed
3125ec. by the urethra, slightly blood-tinged. The wounds
did well, and her general condition was satisfactory till
August 1st, on which day she became rather suddenly pros¬
trate, and passed no more urine by tbe urethra, though a
quantity of it and increased discharge of pus came from the
loin wounds. Two stones the size of hazel nuts were found
and removed from the right side; none could be felt from
the left loin. Temporary improvement followed, hut the
patient finally died of asthenia on Aug. 3rd, eleven days
after the nephrolithotomies. Post-mortem examination
showed both kidneys to be most extensively diseased, four
more stones in cavities on the right side, and another
calculus on the left side plugging the ureter about one
inch from its commencement. These stones could nob
be felt from the loin incisions. Remarks were made
as to the best treatment for calculous suppression of
urine, and it was suggested that, unless the patient’s
general condition forbade it, or one kidney was obviously
hopelessly disorganised, unfit for any excretory work at all,
both sides should be relieved by operative interference,
not necessarily a nephrolithotomy on the second kidney,
but at any rate a nephrotomy to relieve the mechanical
obstruction.
Mr. W. H. A. Jacobson read a paper on eight cases of
Lumbar Nephro-lithotomy, forming a sequel to a previous
paper on four cases of nephro-lithotomy, published in the
twenty-second volume of the Clinical Socieby’aTransacbions.
Case 1 : Symptoms of renal calculus for five years in a man
aged fifty-three ; lumbar nephro-lithotomy ; calculus (lime
oxalate, H^gr.) removed from upper part of ureter ; re¬
covery. There was a history of five years’ lumbar pain at
intervals, with lucniaburia and frequent micturition. Urine :
sp. gr. 1025 ; abundant lime oxalate crystals ; light amount
of albumen. Nephro-lithotomy performed on Oct. 7bh, 1889.
A small circular hedgehog calculus of lime oxalate was found
and removed; recovery. Patient went out on Dec. 11th;
remains well. The points of interest about this case
were the age, the site of the stone (about liin. below the
kidney), and tbe faqt that percussion, as advised by Mr.
Jordan Lloyd, over the loin at once caused a stabbing pain.
The liability of stone to be detained about two inches below
the kidney, as well as in the narrow orifice of the ureter and
where it bends over the iliac vessels, was pointed out by Mr.
Gocllee.—Case 2 : History of calculus for eighteen years in a
patient aged thirty. Large left renal swelling with stink¬
ing alkaline purulent urine. Nephro-lithotomy performed
in August, 1889. Nine stones removed ; urates, oxalates,
phosphates, 333 gr. First attack of hjcmaturia when twelve
years old, occasionally since. Ten months ago rigors and
urine turbid. Large tender swelling in left loin. Urine
alkaline, stinking, and loaded with pus. No tubercle bacilli.
On Aug. 10th, 1889, nephro-lithotomy was performed.
Kidney enlarged. Eightv-nine rough, foul stones removed,
one jammed in ureter. Patient made a good recovery, but
a fetid sinus persisted, from which a large quantity of
watery urine came away, requiring a lumbar nephrectomy,
which was done in August, 1890. One stone left behind in
uppermost part of kidney; recovery.—Case 3: Calculous
pvelitis closely simulating tubercular pyelitis in a patient
aged twenty-nine. Exploration Nov. Kith, 1889 ; removal of
eight calculi (mixed urates, 39 gr.) and much pus ; complete
recovery by February, 1890; remains well. Patient was a
woman aged twenty-nine, with a much enlarged and tender
riglit kidney. Much pyo-uvia; very scanty history of h.-ema-
turia. Morning temperature 99“; evening 100°. Family
historyof phthisis. ExplorationonNov. 16bh,1889. Removal
of eight stones and much pus. Kidney much expaimed and
damaged; recovery. All soundly healed by Feb. 18th,
1890. Patient remains well.—Case 4: Severe symptoms
due to a very small calculus (lime oxalate, 25 gr.) m
upper part of kidney; nephro-lithobomy; stone found
Dig; T Ajoogle
832 The Lancet,]
CLINICAL SOCIETY OF LONDON.
[Aphil 18,1891
with much difficulty in an upper calyx; recovery. E. S-,
aged eighteen, had had frequent basinaturia, severe pain
in left loin and testicle, for a year. Nephro-lithotomy on
July, 1890. It was only when search was about to be
abandoned that a small lime oxalate calculus was detected,
which was extracted with some difficulty. Wound in
kidney firmly plugged with strips of sal alembrotb gauze ;
recovery. Patient went out five weeks later with a small
sinus. Two weeks later some shreds of gauze presented
themselves in this sinus, and three strips (lin. by 4in.)
were removed by Dr. Lever of Harrogate. Sinus closed
firmly, and patient bas remained entirely well since.—
Case 5 : Strong evidence of renal calculus for five years in
a patient aged thirty-eight; exploration, August, 1890;
no stones found ; descent of two in October, one being
removed from urethra, the other treated by lithotrity.—
M. C-, a shipwright, had been subject to lumbar pain
and bcematuria for five yearn. In 1885 he passed a calculus.
Exploration on August, 1890; good recovery. Went out
on Sept. 15th ; returned to full work in October. Shortly
after a stone was impacted in the urethra and removed by
forceps. Since then micturition has been frequent, painful,
and interrupted. Small stone detected in the bladder and
crashed on Nov. 28th ; crushings weighed 20 gr. Patient
heard of in March, 1891, in good health, and able to follow
his occupation regularly.—Case 6: Symptoms of a year’s
duration; supra-pubic lithotomy in America; nephro-
, lithotomy; kidney very high up; calculus (uric acid
and oxalates, 54 gr.) removed from pelvis; recovery.—
A. C-, aged thirty-three, has had three attacks of
left renal colic in the last year. Nine months ago
his symptoms being thought to point to vesical stone,
supra-pubic lithotomy was performed in the Pennsyl¬
vanian Hospital without any result. Nephro-litho¬
tomy, Oct. 10th. Kidney placed very high up. Stone
easily felt in pelvis, and hooked out with finger. Re¬
covery. Went out on Nov. 15th. Remains well. —
Case 7: Symptoms of ten years’ duration in a patient aged
twenty-five ; nephro-lithotomy ; wound of peritoneum ;
calculus (lime oxalate, 33 gr) removed from pelvis; unin¬
terrupted recovery. C. K. D-, labourer. Kidney
trouble began ten years before; attacks of left side’ and
lumbar pain and hmmaturia frequent. Marked lumbar
tenderness. Nephro-lithotomy, Oct. 17th. Peritoneum
accidentally wounded. The day after the operation, to
ensure safe drainage, the kidney was sutured well up into
the wound. Recovery uninterrupted. Patient went out
on Nov. 23rd.—Case 8 : Fifteen years’ symptoms in a
patient aged fotty. Diagnosis of cystin calculus from
deposit in the urine ; nephro-lithotomy ; grave condition of
shock throughout the operation; four calculi removed,
three of pure cystin ; recovery, but a sinus remained two
and a half months after the operation. Miss R-, aged
forty, seen in December, 1890. For fifteen years increasing
misery with right lumbar pain and tenderness. Occa¬
sional beematuria. Right kidney very movable. Nephro¬
lithotomy on Jan. 25th. Four calculi removed from
dilated pelvis. Operation easy and brief, but patient’s
condition most grave from collapse throughout. Re¬
covery, but a tiny sinus allowing of a slight escape of
urine was present two months and a half after the opera¬
tion. _ Mr. Jacobson suggested the following points to the
meeting: l. That in doubtful cases of tubercular disease,
especially of the genito-urinary tract, where, as in Cases 2
and 3, the diagnosis between calculous and tubercular
j^yelitis remained obscure, the aid of bacteriology—i.e,,
inoculation of the suspected fluid either into the anterior
chamber or beneath the skin of an animal—would readily
clear up the case. He alluded to two cases, one of obscure
cystitis, the other of a lateral lithotomy wound in a child,
which with the inguinal glands became infected, in both of
which the ease was made plain by inoculation by Dr. Wash-
bourn. 2. Information was sought for the best means of
detecting small stones impacted high up in the kidney
itself, Cases 4 and 5 allowing the extreme difficulty that
might be met with here. 3. With regard to the cystin
stones removed in Case 8, Mr. Jacobson sought information
as to the risk of recurrence, and whether there was any¬
thing in the pathology of cystinuria that accounted for the
extreme weakness of the patient, and the very grave
condition of shock which was present throughout the
operation.
Mr. Bilton Poi.LAiiD reported a case of Nephro¬
lithotomy in a boy aged ten. During the past three years ,
the hoy had been subject to attacks of abdominal pain
associated with bmmaturia. The attacks of pain were not
characteristic of renal calculus. The hmmaturia was some¬
times profuse. The urine contained no pus, and when free
from blood it appeared to be healthy. The tight kidney
could be felt; it was not tender on pressure, and there was-
no renal tumour. The boy’s general condition was good,
although he was anffimie. On Dec. 25th, the right kidney
was explored through the lumbar incision at the North-
Eastern Hospital for Children. The stone could be felt
in the pelvis of the kidney by the finger, and was also
struck % the exploring needle. It was easily extracted
through the cortex of the kidney. The stone weighed
twenty-seven grains. The kidney bled rather freely,
but the bleeding was stopped easily by plugging tlae
wound in the kidney with gauze. The gauze was re¬
moved on the following day, and the tube on the
second day after the operation. No blood appeared
ID the urine after the operation, and as the discharge of
urine from the wound did not diminish materially, the renal
pelvis was again explored on the fourteenth day after the
operation, as it was thought possible that it might be-
plugged with blood clot. No clot was found. A line tube
was passed in the direction of the ureter, and some lotion
syringed through it with the object of dislodging a clot if
there was one impacted in the ureter. The quantity of
urine which escaped from the wound now diminished
quickly, and ceased entirely after the fifth day, and the
patient made a complete recovery. It was now sixteen
weeks after the operation, and the patient continued well.
^From inquiries which Mr. Pollard had made, he thought
‘nephro-lithotomy was a rate operation in childhood. Mr.
R. W. Parker had twice operated for renal calculus in
children at the East London Hospital, but no cases of the
kind had occurred in three other London children’s hos¬
pitals, nor yet at the Pendlebury Children’s Hospital. Mr.
Pollard reported the case with the view of ascertaining
the experience of others in regard to renal calculus in
childhood.
Sir Dyce Duckworth referred to the preliminary
medical treatment of renal calculus, alluding to the succesK
which had been met with in large numbers of cases by
“flushing out” the kidneys with indill'erent waters, such as
those of Bath, Buxton, or Contrexcville. He said that the
presence of cystine in the urine was often associated with
severe forms of dyspepsia, but he did not know that it was
connected with a scrofulous family tendency. In the cases
which had been related the occurrence of a loin sinus hadi
been singularly infrequent.
Mr. Parker referred to the ease of a little girl on whom
he had performed nephro-lithotomy, and who for several
years had suffered from indefinite renal symptoms. Stones
had often been found in the kidneys of children post
mortem, when there had been no evidence pointing to
calculus during life. In a boy aged twelve, particulars of
whose case he had published, the first symptoms followed &.
fall over a form at school. He died of suppression of urine,
and at the necropsy the right kidney was found enlarged
and full of stones, while the left was a mere sac, and was
also full of stones. During life there had been no sym¬
ptoms like those of renal calculus. It would be very
interesting if in cases of calculus in adults an accurate
history of the earliest symptoms of stone were invariably
recorded.
Mr. JACOiiSON, in reply, said that in one case he had
operated on a persistent sinus had remained, due, he be¬
lieved, to his leaving a calculous fragment behind. A per¬
sistent sinus would be likely to follow in cases of multiple
stones with pus ; but these, fortunately, were rare. In one-
instance, where the kidney was unusually low down, he un¬
fortunately, during digital examination, opened the peri¬
toneum.
Mr. A. T. Norton said that a calculus might lodge in
the ureter about two and a half to three inches in the
bladder, and this was the explanation of a persistent fistula
which followed in one case in which ho had opened an en¬
larged kidney through the loin. In another instance he had
performed nephrectomy and a persistent fistula had re
suited ; -this also, he felt sure, was due to a calculus lodged
in a similar position ; and the intermittent escape of pus by
^ way of the bladder, which had several times taken place,
was probably from a loculus in the neighbourhood of the
stone. He proposed opening the peritoneum in order ta
discover the source of the obstruction.
Dit
Thb Lancet,]
MEDICAL SOCIETY OF LONDON.
[April 18, 1891. ?,S6
MEDICAL SOCIETY OP LONDON.
The importance, of the Trigonal Pouch in the Surgery of
Vesical Calciilus.
An ordinary meeting of this Soc.lety was held on
April 13bh, the President, Dr, Douglas Powell, in the chair.
Mr. 0, Buckston Buownb read a paper on the import¬
ance of the Post-prostatic or Trigonal Pouch in the Sur¬
gery of Vesical Calculus, and he illustrated bis remarks
by several cases. The first portion of this communication
will be found in another part of our present issue.
Mr. Howaui) Marsu had a case to relate which bore on
the subject of the discussion. An old man of seventy-nine
complained of frequency of micturition, accompanied by
such severe pain that it caused him to kneel on the floor
and grasp any furniture that might be within his reach.
On examination he was found to have a greatly enlarged
prostate. He had suffered from stone for many years, and
lithotrity had bsen performed. The stone could not be
found with the sound until its beak was turned down
behind the prostate where it lay. It appeared impossible
to do lithotrity successfully, and, lateral lithotomy being
quite out of the question owing to the size of the prostate,
he determined to perform the snpra-pubic operation. Four
curiously facetted calculi were found lying under an over¬
hanging prostate, and were removed, the patient making a
good recovery. He himself was impressed in favour of the
supra-pubic operation, even in children, and he failed to
recognise those drawbacks to it which had been expressed
by some surgeons, who appeared to regard it as an exploded
method.
Mr. Reginald Harrison entirely concurred in the two
propositions put forward in the paper. Lithotrity in a
normal bladder was quite a different procedure from what it
was in the cases which had been related. He was sure that
a great many recurrences of stone were due to the fact that
lithotrity had been attempted under what were practically
impossible conditions. As to the selection of supra pubic
cystotomy, he believed that many of these cases could have
been better treated by median perineal lithotomy. He had
practised it many times; it drained a misshapen bladder
better; one was often able to do Boniethiag with the
enlarged and obstructing prostate, and the necessity for
using a catheter was no longer required. He did not go so
far as some in his opposition to snpra-pubic lithotomy, for
indeed he had often performed that operation, but yet he
felt that there was still a place, and perhaps a large’place,
for the perineal method.
Mr. SwiNFORD Edwards failed to see how some of the
calculi could have been removed by the perineal route. One
of the cases described appeared to be a variety of encysted
calculus, and this class of case did not lend itself to litho-
trity. Ho had had one fatality in attempting to crush an
encysted stone, and so also had Mr, Butlin, the junction of
the cyst with the wall of the bladder being damaged. In
another of the cases tho symptoms appeared to him to be
due more to the large and projecting prostatic lobe than to
the small stone behind it. In some instances the stone
could be dislodged by inverting the patient and pressing
the stone from the pouch into the bladder. Ho inquired if
supra-pubic wounds had been found to heal kindly in old
people.
Mr. Pearce Gould referred to the case of an old man
aged seventy, in whose bladder he found a stone in October
last. Lithotrity was performed and the patient left re¬
lieved. Two months later he returned with his old sym¬
ptoms, and after repeated soundinss another calculus was
found. On passing the litbotrite Mr. Gould was unable to
seize the stone. Ho felt inclinod to do the snpra-pubic opera¬
tion, but was persuaded by a colleague to perfornr the perineal
operation. By this route his linger failed to reach tlie post¬
prostatic pouchj but he removed the calculus with the forceps.
The wound again healed, and the patient left, only to return
later with recurrence. 'I’his time supra-pubic lithotomy was
done and seven small calculi removed; the patient died on the
sixth day. There was no doubt that the only ready means
of removing calculi from the post-prostatic pouch was by
supra-pubic lithotomy.
Surgeon-Major KeeGAN felt that the paper would fill a
gap in the literature of vesical calculus He asked if it
was right to perform any operation for stone in a very old
man. He thought that recurienee was extremely likely to
happen. The sound which was exhibited he regarded as a
valuable instrument.
Mr. Campbell Williams related a case in which supra¬
pubic lithotomy was followed by median cystotomy. The
patient, who was sixty-four years of age, and possessed an
enlarged prostate, disliked the crushing operation, and
therefore supra-pubic lithotomy was done. A large stone
was removed, and the bladder being illuminated, it was
certain that it was completely evacuated. Three months
later he came back with his old symptoms, and was eut
from the perineum, three stones being removed. He Avas
certainly worse after the perineal than after the supra-pubic
operation. In one case of supra-pubic lithotomy which
had proved fatal in Mr. Hill’s practice, there was violent
hmmatemeais after the administration of the anmsthetic.
It should be remembered that even inversion might not
remove a stone from the post prostatic pouch.
Mr. Marmadukb Sheild suggested that the spiked
calculi which had been shown were probably oxalates. He
held that It was of value to make a rectal examination at
the same time that sounding was being done. If a patient
presented great irritability of the bladder with occasional
hcemorrhage, he thought exploration was justifiable, even
if the stone could not be felt with the sound.
Mr. Buckston Broavne, in reply, eaid that the case
related by Mr. Marsh had been under his own care seven
years before, and at the lithotrity there was great diiliculty
in clearing the bladder, a perpendicular litbotrite being
used. It was a pity that there was a prejudice amongst
many members of the profession in favour of the lateral
operation, for such prejudices were unsurgicol. The par¬
ticular eases which he bad related were those which dis¬
credited lithotrity, whereas a good search by means of the
supra-pubic method cleared the bladder for certain. The
median perineal cystotomy was a bad operation in cases of
prosbatic enlargement. The case of the old man referred
to by Mr. Edwards was operated on because of the extreme
suffering he was undergoing, and in that case a large
portion of the prostate was also removed. The supra¬
pubic wounds healed remarkably well if but little was
done to them—one stitch being placed in them, the bladder
being left to itself after good drainage was provided.
He held that if an old man suffered much he should
not be denied an operation for vesical calculus on account
of bis age, for death from stone in the bladder was
usually terribly painful. The supra-pubic wound healed
better, there was no bleeJing, there was complete access to
the bladder, there was usually no fistula, and the drainage
was as good as by the perineal route, for the bladder was
nob a pelvic bub ah abdominal organ in cases of enlarged
prostate. The spiked stones had nob been analysed, but
those found in the kidney of the same patient we^e un¬
doubtedly uric acid. It appeared to him to be very difficult
to sound the bladder if a linger at the same time were kept
in the rectum. An independent rectal examination bad
been made in all the cases he had related. He concurred
tiiat the rule prohibiting operation unless a stone were felt
was one requiring modification.
EPIDEMIOLOGICAL SOCIETY.
A MEETING of this Society was held on March 18th,
Jos. Ewart, M.D., E.R.G.l’., President, in the chair.
A Retrospect of the Successive Epidemics of Cholera i%
Europe and America from 1830 to 1890. —Dr. Edwaud F.
Willoughby read a paper on this subject. After
alluding to the doctrine of epidemic inlluences, telluric and
atmospliotic conditions, and other unknown agencies as at
once baseless and needless, and to the opposite delusion,
prevalent in the south of Europe, of its bring infectious in
the same sense as small-pox, he asserted that all independent
and scientific students of the subjectiu Europe and America
were now agreed that the vehicle of contagion was contained
in the evacuations, that it was thus carried by fomitfts
as soiled clothing ikd , while persons suffering from the
disease even in unrecogoised aod mild forms infected the
soil and water of places through whhsh they passed. Insani¬
tary conditions favoured its development, but the most
insanitary towns—as Rome, Seville, and others—had escaped,
since they had been provided with pure water supplies.
The incubation period lie believed to bs as a rule from one
to two days, four being an ample limit for quarantine pur-
Dir;' ed-i'/ Google
S84 The Lancet,]
HUNTERIAN SOCIETY.
[April 18,1891.
poses. Its transportability and conveyance wholly and
soleJy by human intercourse was proved not only oy the
progress of every epidemic having followed the great routes
of trade and pilgrimages, but by the rapidity of this
progress haviirg corresponded to the facilities for travel,
whether by caravans, river boats, railways, or ocean
steamers, quoting in this connexion Ur. de Renzy Rod
others as to the altered circumstances of travel in Northern
India; and be thus explained the immunity of Australia and
Chili, virtually the most isolated communities in the civilised
world. It was, he said, in 1821 that cholera, so far as was
known, first advanced from India westwards, reaching
Astrakhan in 1823, but subsiding until 1827, when a
fresh wave swept over Persia, entering Russia in 1829.
In 1830-31 it was fomented by the war in Poland;
in 1831-32 it spread over the whole of Europe; and in
1832-33 over North America, lingering in each continent for
about two years longer. It was remarkable, and totally
inconsistent with the theory of conveyance by winds,
that, though some cases had occurred on board ships in the
Medway as early as July, 1831, it did not reach London
till February, 1832, having effected a landing at Sunder¬
land and travelled vid Newcastle, Edinburgh, Glasgow,
Belfast, Dublin, and Cork, whence it was at length brought
to London. A wave rolled over Persia, Arabia, and Syria
between 1836 and 1839, but retired again. In 1840 it
entered China, then passed westwards through Central
Asia, re-entering India from Afghanistan and through
North Persia, reaching the Caspian and Black Seas in the
summer of 1847. Following the military road then
in course of construction from the Caucasus to Moscow
and the river highway of the Volga, it was intensified
and spread by the fair at Nijni Novgorod and the
massing of the Russian, Austrian, and insurgent Hun¬
garian armies on the Danube, and in the course of
1848-49 bad attacked every country in Europe except Den¬
mark and Greece, which were saved by stringent quarantine,
it extended to America in 1849, but died out in the course
of the following year. The epidemic of 1854 was not
strictly a separate invasion, but rather a resuscitation of
the last, which had lingered in the south and east of Europe
and the west of Asia until called into fresh activity by
the Crimean war. Every country in Europe and America
was again invaded. The incidents of the outbreaks
in America threw great light on the conveyance of the
disease by fomites. The epidemic of 1865-CG, which was
the first to come wholly by the Red Sea, spread rapidly
over Europe and America ; but had scarcely subsided when
a fresh explosion occurred at the Hurd war fair in India in
1867, whence it was carried to Persia and Russia, being
reintensified en route hy the pilgrimage at Great Mesched
in 1868 and the fairs at Nijni Novgorod in 1869 and 1870.
At the close of the Franco-Germau war every country in
Europe was attacked except Great Britain, and America suc¬
ceeded in averting its importation until 1873 By 1874 it
had, however, disappeared everywhere on this side of India.
In 1881-83 it prevailed in Arabia and Egypt; in 1884 it
made its appearance in France, and soon raged throughout
Italy and Spain. The inlltience of pure water supplies was
brought into special prominence, not only in the case of
single towns in Italy and Spain, but in the almost complete
immunity enjoyed by Germany, which had previously
suffered heavily in every epidemic. Cholera lingered in the
south until the end of 1885, since which date it had been
absent from the continent of Europe until the isolated out¬
break in Spain in 1890. This, Dr. Willoughby was con¬
vinced, was not imported from the East, but was a recru¬
descence of the epidemic of 1884-85, brought about by
excavations in infected ground. Still choleraTiad since 1888
been slowly but steadily advancing by the Persian Gulf and
the extensions of that route. It had last year reached
the shores of the Caspian and Black Seas, and had
raged at Mecca, though Egypt had almost miraculously
escaped, and it had persisted at Aleppo and the Syrian
orbs certainly as late as January of the present year. lie
ad little doubt that, as its march had closely corresponded
with that in 1845-47 we might expect history to repeat itself
in an invasion of Southern and Eastern Europe during
the coming summer, unless, as in 1823 and 1839, it should
retire, after having thus approached the confines of
Europe. If, iiowever, it had not already really died
out, the vast increase of communication between tlie two
continents rendered such recession less probable than
it WM fifty years ago. The paper was illustrated by a
number 6f maps showing the great routes and the course
of each epidemic in Asia, Europe, and America.—Sir W.
Moore gave his experience of an outbreak at Aden follow¬
ing the unloading of cargo which was proved to have
been soiled with cholera excreta at Bombay, the crew
remaining healthy ; and Mr. Muepiiy alluded to Dr. Simp¬
son’s having traced the occurrence of cholera on board
certain ships moored in the Hoogbly to an infected milk
supply.—Surgeon Dawson argued in favour of epidemic
influences, but Dr. WiLLOUGiniV, in reply, urged that in the
case of the ships at sea quoted by Mr. Lawson the crews
who must have been moat exposed to atmospheric m-
fluences escaped, the steerage passengers only being
attacked; while such negative evidence as that of the
Southampton and Theydon Bois outbreaks iu 1865 was
worth nothing. It was’more probable that someone suffer¬
ing from mild and unrecognised cholera bad crossed over
from France, and, leaving the infection behind, had perhaps
returned, than that Mr. Groombridge had inhaled it with
tie sea breezes on Weymouth pier. Such difliciilties were
incident to all coses even of smaU-pox, the source of which no
onedoubted.—ThePBESiDiCNTcomplimented Dr. Willoughby
on having brought within the compass of a single paper a
mass of information hiiherto inaccessible, and on having by
his demonstration of the almost “ postal regularity ” with
which the late epidemic followed the routes of travel by
road, rail, and steamships, regardless of prevailing winds,
but refusing to cross the Scandinavian and Carpathian
mountain ranges in mid-winter, given the co^ip da ffrdce to
the doctrine of atmospheric waves which in the case of this
disease he bad until that evening accepted.
HUNTERIAN SOCIETY.
A MEETINO of this Society was held on March lltli, Dr.
Stephen Mackenzie, President, in the chair.
Phonographic Illvstraiion of Disease. — Dr. Huoiilings
Jackson and Dr. Rivers showed a phonogram recording
the abnormal talking of a patient the subject of dis¬
seminated sclerosis. The phonogram was exhibited by
Mr. Cole, of the Edison United Phonograph Company.
The patient whose talking was reproduced was a man aged
twenty-six, who in the course of about five months became
affected in an extreme degree with the symptoms of dis¬
seminated sclerosis—viz , oscillation of the bead, nystagmus,
coarse jerking of the arms'and legs on voluntary move¬
ment, increased knee jerks, and ankle clonus, as well as a
typical high-strained jerking and syllabic utterance, which
was very well reproriiiced by the phonograph, the first verse
of “Old Mother Hubbard” lieingrendered by the instrument.
Sarcoma of Brain,. —The President brought forward a
microscopical specimen of Tumour of the Brain from a
man aged forty-eight, who died wittf grave cerebral disease,
surmised to be syphilitic. There was found a tumour of
sarcomatous structure the size of a nut, situated between
the medulla and cerebellum, apparently arising from tiie
floor of the fourth ventricle.
Osteo-myelitisof Tibia. —Dr. J. Langton Hewer showed
a specimen of chronic osteo-myelitis of the tibia. A
young man aged twenty had suffered from childhood. Tlte
interest of the case lay in the fact that two operations bad
been performed at seven years’ interval. At both the
di-eased bone was thoroughly removed, and the medullary
canal was fairly cleared out and flushed. The first opera¬
tion was done under strict antiseptic precautions, and the
large aperture left in the bone was allowed to fill witli
blood-clot, which in due time organised. The secontl
operation was made entirely without antiseptics, and the
wound tilled with granulations. Recovery from both was
equally speedy and good, but in the first case a tender
scar was left, which gradually became again painful, and
broke down. The cicatrix left after the second operation
remained firm and sound. Dr. Hewer’s suggested in¬
ference was that sounder tissue was obtained by the method
which involved some inllammation and granulation than by
the aseptic method which excluded inllammation.—Mr. .1.
Poland referred to other cases of osteo-myelitis.—Dr. F. J.
Smith thought this an illustration of the beneficial action
of morbid germ?, lie was reminded of the experiments of
inducing erysipelas for the cure of tumours ; next to these
came the discovery of phagocytes and the strife they wage ;
and surely the next stage would be that physiologists would
C.oogle
Tub Lancbt,]
MANCHESTER MEDICAL SOCIETY.
[Aprii. 18,1891, S85
fully describe the life histories aud uses of micro-organisms,
and we should be enabled to give our patients dosss of
them, much as we now give soda and gentian.
Ulcerative Aortitis. — TURNER showed two specimens
of ulcerative aortitis from surgical eases in elderly women;
one of injury (run over); one of gangrene of the toes. It
is corankon to find slight ulceration of the aorta in cases of
injury, but not, as in these cases, extensive lesions. Sections
were made of the aorta in one case, but no micrococci weredis-
covered, contrary to expectation. Drawings were exhibited
of other specimens observed by Dr. Turner, showing in one
case masses of micrococci in the inner coat of the vessel, and
in another masses of fibrinous coagula attached to the
wall.—The President, Mr. tl. J. B. Stevens, Dr, Calloway,
and Dr. Pitt discussed the specimens and referred to other
cases.
Hydronephrosis.—'D t. G. Newton Pitt showed _ two
specimens of hydronephrotic kidneys, one of them illus¬
trating how aberrant renal vessels, wlien the pelvis is
slightly distended, may cause a kink or bending in the
ureter and obstruct the passage of urine. Massage might
be useful in such a case. The second specimen was from
an infant, dying from some other disorder, in whom one
ureter was found to open into the pelvis by a mere pin
point orifice, and the pelvis was somewhat dilated. The
condition was apparently congenital. In stricture of the
urethra attended with backward pressure it was not un¬
common to find the pressure exerted unequally upon the
two kidneys, one pelvis being distended.—Mr. F. E.
Humphreys referred to a case of congenital stricture in a
boy, where one Kidney was hydronephrotic, the other
granular.
Buccal Lipoma.—M.t. J. Hutciiin.son, jun., showed a
small pedunculated libro-lipoma fruin the inside of the
cheek of an infant. He suggested that it was reallv a
protrusion of a portion of the pad of fat (Cloquet’s pad or
the sucking pad) which lies behind the buccinator.
Sarcoma of Lower Jaw. —Mr. J. HutohiN.son, jun., also
exhibited a soft periosteal sarcoma removed from a man of
thirty-live. There were curious polypoid projections along
the mucous membrane, which had caused some dilliculby in
the diagnosis. The disease had recurred.
Polypus of Recturii.—\AY. J. Hutchin.son, jun., likewise
brought forward a microscopical section showing the
structure of a polypus.
At the close of the meeting Mr. Cole kindly gave some
interesting illustrations of the I’honogiapb, and explained
its mechanism, ____
A meeting of this Society was held on March 25bh.
Tumour of the Neck. — Dr. S. H Ari'ESEORP showed a
case of rapidly growing cervical tumour in a man aged
thirty-three. A large hard mass occupied the lower part
of the neck beneath the right sterno-inastoid muscle, and
there were some hard glands along its hinder edge, The
voice was hoarse.—The I’iu>siuent referred to several such
cases, and thought the diagnosis lay between lymph-
adenoma and syphilitic disease of the glands, inclining to
the former.
Recovery from Hydrocephalus. —Dr. HingstON Fox
showed a boy, now aged six years and nine months, who
had at nine mouths nuichenlargeoientof the head following
imeumonia, a wide median fissure extending ftom two
inches above the root of the nose to near the nape of the
neck, clearing the frontal and occipital bones. The head
was now well ossified throughout, though bulky, 2:U in. in
circumference. Some lateral nystagmus existed, but sight
and heaving were fairly good ; intellect rather babylike. A
favourable prognosis might perhaps have been tased six
years ago on the absence of convulsions or vomiting, the
good family history, teeth formation undelayed, and
perhaps the occurrence after a specific disorder.
Modem Methods of Performing Cicsarcan Section. —Dr.
Galaijin read a paper on this subject. These operations
were more, numerous abroad than in this country, and
statistics must be based on continental experience. Some
would even prefer it to craniotomy, which had indeed at
Guy’s a high mortality—IG per cent, or more,—but he
ascribed this largely to the adverpa effect of previous
attempts to deliver by forceps &e. Forro’s modification in
1876, by which the entire uterus and ovaries were removed,
was described and discussed. Siinger’s method was pub¬
lished in 1882, his object being to close the uterine wound
by a system of deep (muscular) and superficial (peritoneal)
sutures, and so keep the uterine and peritoneal cavities
shut off. Success depended much on the operation being a
primary choice, without attempting other means first. In
a multipara one need not wait for labour to commence,
but it was usually best to puncture the membranes. The
use of an elastic ligature around the neck of the uterus
was on the whole good. Silver wire was preferred for the
deep sutures; the superficial are so arranged as to bring
fiat surfaces of peritoneum in contact. A specimen was
shown in which the uterine wound bad closed well on this
method ; the patient died from accidental opening of the
abdominal wound on the ninth day. Cameron of Glasgow
used no superficial sutures, thus shortening the operation,
and has published ten cases with only one death. Adhesion
of uterus to the wall of the abdomen, which often occurred,
was not altogether undesirable. Sfeiilisation of the patient
by removing ovaries or tying the Fallopian tubes near the
outer end was often advisable. Notes of a successful case
were read : a woman with a contracted and fiattened pelvis,
none of whose children has survived. Siioger’s method was
followed, and except for inertia of the uterus, hmmorrhage,
and later on a sinus at one part of the wound which gave a
little trouble, she did well and recovered. The use of
“delta” metal for the pins and v/ires for the pedicle
in l^rro’s operation was noticed. The mortalities of
the two operations respectively to end of 1889 are:
Sanger's, 23 per cent. ; Porro’s, 58 per cent. Porro’s maybe
the better after long attempts to deliver through the pelvis,
aud ibis simpler to execute for those who are inexperienced. —
Dr. Herman read notes of a recent case in the London
Hospital. A woman, aged thirty-seven, had been in labour
eighteen hours. A hard mass was felt in the left iliac fossa ;
there was oedema of the perineum, and the pelvis was tilled
with a hard elastic tumour. Catheterism was impossible.
On opening the abdomen this tumour was found to be the
full bladder. The uterus was opened, and the placenta on
its anterior wall cut through, and the child extracted by
the feet. Free hjemorrhage occurred. The abdominal w^ls
were held close during extraction, and the application
of sutures of silk aud catgut. The child survived.
Paroxysmal abdominal pains and vomiting continued, and
the patient died on the third day. At an imperfect
necropsy, a large osbeo-sarcoma was found in the iliac
fossa; the uterine wound was well healed. Caesarean
section could never. Dr. Herman said, supplant cranio¬
tomy, the mortality from which ought nob to be higher
than from natural labour. The size of the pelvis can be
measured, therefore risk should nob be iucreosed by trying
other methods. Turning out the uterus added to the risk of
the operation ; the walls could be held by assistants. The
elastic ligature was likely to interfere with the contractile
power of the uterus, as was shown by experiments on
animals, although it lessened the hremorrhage for the time.
The peritoneum must be accurately brought together; it
unites well and is the strongest part of the uterine wall.
Exposure of the bowel was a frequent cause of death, o-s
prouably in bis own case, and this was thechisf drawback of
Ciusarean section ascompared with Porro’soperation, for care¬
ful suture of the uterus was essential and takes a long time. —
Dr. riORUOCKS preferred Cicsarean section to Porro’s opera¬
tion, as much less mutilating aud involving less shock. In
certain cases, as rupture of the uterus or cancer, Porro’s may
be preferable. In a case operated on a year ago he found it
very difficult to apply the elastic ligature before opening
the uterus. Time was of great importance, and on another
occasion he would follow (’ameron and not put in sutures at
all, except about two for the peritoneum ; this shortened
the operation by one half. In his own case he Ued the
Fallopian tubes with kangaroo tendon, following Dr.
Champneys ; no pregnancy had followed. The lumen was
by this means well occluded.
MANCHESTER MEDICAL SOCIETY.
A MEETING of this Society was held on April Ist,
Thomas Jones, M.B , B S., F.li.C.S., in the chair.
Cerebral Abscess. —Mr. SOUTHAM showed a case of
trephining for an abscess situated in the anterior lobe of
the brain, following a punctured fracture of the frontal
bone. On the fifth day after the operation there was a
copious discharge of cerebro-apinal fluid from the w’ound.
This appeared to come from the lateral ventricle, owing to
886 The Lancet,J
WEST KENT MEDICO-CHIRURGICAL SOCIETY.
[April 18,1891.
the formation of a communication between it and the
abscess cavity. After continuinc for a week the discharge
of fluid ceased, and the wound afterwards healed, the
patient making a complete recovery.
Acute Lympho-sarconiatosis (acute Hodgkin’s disease).—
Dr. Deeschkeld related the following case. A man aged
twenty-three was admitted into the Manchester Inlirmary
on Feb. 19bh, 1891, complaining of great weakness, cough,
anddyspnma. He had always enjoyed good health, being
temperate, and never had syphilis. In the beginning of
this year he began to be troubled with a cough, hut went on
with his work till Jan. 23rd, when he had a rigor, followed
by pain in the right side of the chest. He then took to his
bed, but, getting weaker, he sought admission into the in¬
firmary. On admission be was found intensely anfumic.
The examination of the chest showed some dulness over the
upper part of the sternum, extending to the second and
third intercostal ?pace on the right side; there was dul¬
ness on the left side of the thorax behind, extending
to the angle of the scapula, with diminished breathing
and diminution of fremitus ; localised dulness in tlie inter¬
scapular region on the right side with increased fremitus
and crepitations ; there was some muco-purulent expectora¬
tion. The pulse was 110, small, and very compressible; the
liver was found slightly enlarged, likewise the .spleen. The
superficial glands in the neck, axilla, and groin showed no
enlargement. Both retinai showed extensivehamiorrhages ;
otherwise the nervous system showed nothing abnoimal.
The temperature was 100°; the skin dry ■ the body faiily
well nourished. The examination of the blood showed a
marked increase of leucocytes (one to about thirty red
hlood-corpuscles); most of the leucocytes were very small,
mono-nuclear, the nucleus finely granular, flie granules not
staining well with eosin; the red blood-corpuscles showed
numerous microcytes and poikilocytes. Urine, sp. gr. 1020 ;
very pale; contamed a large sediment of urates, which, from
the absence of blood-colouring matter, appeared only very
slightly tinged ; no urobilin. The clinical diagnosis was
intia-thoiacic tumour of the nature of lympho-aarcoma,
elfasion in the left pleura, pneumonia of tight middle lobe,
hyperplasia of spleen and liver with secondary deposits,
acute leiicocytosis. Arrenic was administered, but the
f iatient became worse, the breathing becoming quick and
aboured, and he died on Feb. 23rd. The necropsy
showed a growth of firm consistence, but containing in its
interior a few cysts, in the anteiior mediastinum ; localised
pneumonia of the right lung; the left pleura contained
about a pint of clear serum. The liver was enlarged, the
spleen weighed IG oz.; to the naked eye the spleen and liver
showed no deposits, but in the hilus of the liver several large
soft glands were seen; the retro peritoneal and mesenteric
glands were found considerably enlarged, both kidneys con¬
tained numerous white masses of varying size. Microscopic
examination of the mediastinal tumour showed it to con¬
sist of small mono-nuclear mund cells with adenoid tissue
and firm fibrous tissue; the liver contained small deposits
of round cells round the portal canals ; the growths in the
kidney consisted of similar round mono-nuclear cells.
Numeious small thick bacilli were found in the kidney,
ill iog capillaries and small vtsseU, and also in and around
the capsules of the glomeruli. These bacilli stained readily
with Gram’s method, and differed therefore from those de¬
scribed by Kelsch and Vaillard in a ease called by them
“ acute leucotbymalia.” The case is chiefly interesting on
account of the acute course which the disease ran, and the
large increase of leucocytes in the blood, which had the same
character and appearance as the cGls in the lyrrpho-sareo-
rnata, as if there had been a sudden flooding of the blood
with these cells. Micro oiganiains have now been found by
several observers in Hodgkin’s disease, but their exact
relation to the disease has yet to be made out.
Mr. WlIlTlillliAD showed three specimens of papilloma
he had recently removed from three male patients. lie iiad
aeJectoii them from a considerable number on account of
their illustrating in a marked degree some of the more
important symptoms in bladder growths. Amongst other
features they demonstrated the ordinary fact that the closer
a growth was in proximity to the prostate the greater the
pain usually experienced—that the size of the tumour bore
no relationfabij) with the freq ueney or the amount of hmmor-
rhage, or with the lenglii of time symptoms had been ob¬
served.
Dr. Dixon Mann read a paper on the Elimination of
head in cases of Chronic Lead-poisoning.
WEST KENT MEDICO-CHIRURGICAL SOCIETY.
At a meeting on Friday, March Gth (John Poland,
F.U.C.S., President, in the chaLi),lhe President announced
another list of fifty books recently presented to the library.
Cardiac Faihire and its Treatment .—Professor CUENOW,
M.D., read a paper on this subject. He specially reviewed
the onset of cardiac failure in aortic and mitral valvular
disease, pointing out that precedent to failure dilatation of
the cavities of the heard must have necessarily pccurred,
altering the percussion dulnese, and more .especially the
position of the apex beat. He pointed out the varying
position of this sign in the different forma of valvular disease,
and went on to refer to the modes of dying in these forms.
The dangers of any and every kind of effort or exertion
which might cause cerebral anosmia in aortic disease and of
all pulmonary complications in mitral disease were insisted
on. Fainting and giddiness in aortic aflections, and hremo-
ptysis, bronchitis, aad the earliest signs of dropsy in the
extremities were symptoms of grave import. The various
drugs used in cardiac failure were referred to, and the author
advised a cartful scepticism as to most of the newer ones,
lie much preferred digitalis to strophantbus, which be had
frequently used, although it had not benefited his patients.
Morphia hypodermically and small doses of brandy were
much praised for the relief of iDsomnia and dyspncca, and
special stress was laid on treatment by food and the careful
watching and relief of dyspeptic and other complications.
The paper « as tliscussed by Drs. F. T. TayJer, Cable, Moon,
Ilingston Fox, MacGavin, and Mr. J. Marshall.
At a meeting held on April 3rd,
The President exhibited a lad with deformity of the
leg and foot, and arrest of growth of the tibia following
separation of the lower tihial epiphysis.
Graves’ Disease —Dr. Hingston Fox read a paper on
Graves’ disease, esprc-ally with reference to cardiac con¬
ditions. After speaUirg of the four cardinal symptoms—
rapid heart, tremor, goitre, and exophthalmos, any one or
two of which may be absent in an undeveloped case—he
dwelt on the mtntal condition found in severe cases. The
emotional centres seem to be in unstable equilibrium,
distuibed by slight inlluences, a condiuon allied to hysteria
and to the effects of chronic alcoholism in women about the
climacteric. Muscular weakness and impaired nutrition
with neuralgia and the well-koown eye symptoms were
noted. Severe gastric crises had attended one case, the
patient nearly dying from the vomiting, diarrhcca, &c.,
which appeared to be the effects of “bowel hurry.” Dr.
Hunter Mackenzie’s theory of the pathology of the disease
was adopted, the symptoms being regarded as an expression
of a permanent condition of the emotional nervous centres,
set up in the first instance by terror or fright. Darwin’s
graphic description of the effects of sudden fear upon
animals was alluded to, the thyroid enlargement being the
only important symptom of Graves’disease which is there
unrepresented. The fright may have been sudden, or a
repetition of small shocks. Instances were quoted in illus¬
tration of this. This theory brings us, of course, only one
step nearer the true pathplogy. As regards the heart,
beyond a hccmic murmur, and eventually dilatation, there
is not usually any sign of disorder, except the rapid and
irregular action. Some cases show simply tachycardia,
otheis mainly irregularity; in some the condition is
continuous, in others paroxysmal. The graphic record
of one severe case in a lady aged forty-nine years was shown,
extending ovtr eight months. Here attacks of irregular
and rapid heart action occurred at intervals of a few days
or a week, and la^-teU twenty-four hours or so. For treat¬
ment numerous remedies have been advocated. The author
would lay stress on (I) moral and hygienic care, in its widest
sense; (2) improvement <if nutrition, much milk, cod liver
oil, iron ; (3) of drugs, belladonna in mild and early cases,
iodides in later stages, pushed fearlessly to large doses,
bromides in some cases; (-t) locally, the weak continuous
curren*', following Dr. Sansom in persevering long with its
use ; it hliould be applied to the thyroid with a large plate;
Leiter's cold coil also gives some promise ; (.9) for tracheal
obstruction, tracheotomy, incision of capsule of tumour, or
compression laterally, in some cases inhalation of chloro¬
form ; and lastly, division of the isthmus, often the best
hope of relief.—The paper was discussed by Dr. Moon,
^8
The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[April 18,1891. 887
Dv. Cable, Dr. Horrocke, Dr. MaeOavin, Dr. Fullerton,
Mr. Jeasebt, and the President.
Tlie Surgical Treatment of Carcinoma TJtcri. —Mr. P. B.
.Ikssbtt read a paper on this subject. After briefly describ¬
ing the most usual site in which the disease is found,
the author described the method of treatment adopted by
him in very advanced cases, by which he bad been able to
considerably alleviate the suffering of the patients and re¬
lieve their symptoms. He next discussed the different forms
of operation, condemning caustics as dangerous and unreli¬
able. The actual cautery and galvanic <5craseur he also
thought were not devoid of danger. Supra-vaginal amputa¬
tion of the cervix with scissors He extolled, as being in his
hands the most reliable method of removiog the disease
when limited to the cervical canal, and the mucous mem¬
brane of the vagina unaffected. By this method he claimed
tobeableto cutaway the interior of the uterus to its fundus.
In those cases in which the disease commences in the body
of the uterus he advocated vaginal hysterectomy, so long as
the uterus was freely movable and the vaginal mucous
membrane unaffected.—Dr. MacGavin, Dr. Horrocks, and
Dr. Moon took part in the discussion which followed.
Iltfete mlt flrfias sf ^mb.
The Causes and Prevention of Phthisis {the Milroy Lectures
for 1890). By Dr. Arthur Hansome, P.R.S.
In these lectures Dr. Ransome gives an exhaustive
review of the etiological relations of pulmonary tuberculosis.
The importance of the subject needs no emphasising.
Tubercle is responsible for about 70,000 deaths annually in
the British islands, and kills about one-third of those
who dip at the most useful period of life—viz., between
fifteen and forty-five. Nor, even apart from the fiuestion of
the value of Koch’s treatment, which must remain for the
present sub judice, can it be said that the tubercular
process is so much beyond our control as to make its study
unprofitable. Dr. Hansome agrees with the opinions of
Niemeyer, Pollock, C. T. Williams, and others that a cure
is not so rare as is still commonly believed, and quotes the
pathological researches of Cruveilhier, Hogde, Bollinger,
Sfcandacker, and Harris in support of the opinion that “ a
very large proportion of our population suffers from tuber¬
cular disease and recovers from it.” As regards preventa-
bility, Dr. Hansome believes that much has been already
accomplished, and quotes the returnsof the Hegistrar-General
to show that ‘ ‘ in the last thirty years the annual rate of mor¬
tality from phthisishas been reduced bymore than one-third.”
We should be glad to believe that this statement is literally
accurate, but we are disposed to suspect that a part of the
apparent improvement is due to more careful diagnosis and
the removal from the column of phthisis of cases formerly
included in it.
The question of the pathology of tubercle being now a
closed controversy, we need not follow Dr. Hansome in his
disquisition on this head. His remarks on the affinities of
tubercle are worthy of attention. He points out its analo¬
gies to chronic glanders, actinomycosis, frambeosia, Madura
foot, syphilis, and leprosy. The closest affinities exist
between tubercle, syphilis, and leprosy. “ All these disorders
are of microbic origin, they are capable of varying degrees
of intensity, and possess the power of renewing their
ravages after varying periods of dormancy; tliey pro¬
duce growths that are strikingly similar in pathological
characters, and they are or have been universal in tbeir
distribution, apart from conditions of climate, race, and
habits of life.” This last clause is too sweeping. Habits
of life have a great deal to do with the genesis of tubercle,
as Dr. Hansome fully admits in a subsequent lecture ; they
are also probably potent in the case of leprosy. Climate,
again, has an influence over tubercle, as shown by the com¬
parative infrequency of the disease iq arctic and subarctic
regions and at high altitudes. Dr. Hansome discusses at
considerable length the affinities of tubercle and leprosy,
and shows in an interesting way how many of the con.
troversies now raging regarding the communicability,
hereditary character, &c., of tubercle, have been already
fought out with regard to leprosy.
Lecture 11. is occupied with the topographical distribu¬
tion of tuberiije. The disease is world-wide, and probably
no large aggregations of popirlation are anywhere wholly
exempt from its ravages. As a general rule the disease is
most prevalent in proportion to the density of the popula¬
tion and to the number of persons engaged in unhealthy
trades and occupations. A striking corroboration of the
doctrine that occupation and mode of life are the most
essential factors in the production of phthisis is afforded
by Dr. Ransome’s tables regarding the relative frequency
of tlie disease among males and females. In large towns,
where men are usually engaged in in-door trades, they
suffer most, but in country districts where their avocations
keep them in the fields they suffer much less than women.
We cannot too emphatically teach the doctrine that a con-
I fined in-door life and the close aggregation of persons are
the most fundamental of the conditions that predispose to
tuberculosis. When we consult a map giving the geo¬
graphical distribution of phthisis we find a comparative ira-
munibyfromthediseasein—(lldeserts and sparselypopulated
places; (2) mountain ranges and high plateaux; and (3) arctic
and subarctic regions. These districts are all scantily
populated, but Dr. Hansome points out “ that it is nob
merely the scarcity of possible victims that makes the
disease uncommon, for the proportion of cases to the number
of inhabicants in these districts is also low, so far as we
are able to judge from the imperfect data at our command.”
He endorses the statements of Hirsch, Lombard, Living¬
stone, and others as to the rarity of the disease in Nubia,
Upper Egypt, Abyssinia, Central Africa, South Africa,
Mesopotamia, Syria, Arabia, the interior of Australia,
Tasmania, &c. We are disposed to doubt if the existing
evidence on such points warrants very positive statements.
Dr. Hansome’s assertion that “in the interior of Australia
and in Tasmania tubercle is almost unknown” is certainly
open to question. Bonwick gives the rate of phthisis in
Tasmania, calculated over a period of seven years, as 10'29
per 10,000 living. As regards the immunity of dwellers at
high altitudes, Muller has shown that the occupations of the
people in Switzerland have a much greater influence than
the elevation at which they live. “Industrial in-door
pursuits give a rate varying from 6'5 to 10'2 per cent., and
one of the highest of these rates (9‘8) is at an elevation of
3400 ft. to 4400 ft.” We wish Dr. Hansome could give us
some authoritative information regarding the strong state¬
ments that have been made in many quarters regarding
the extreme rarity of phthisis in the Andes and upon the
Mexican plateaux. If what has been asserted as to the
practical immunity from phthisis enjoyed by the inhabi¬
tants of such large towns as Mexico, Pobosi, Santa F6 de
Bogota, &c., were even approximately true, the beneficial
influence of altitude would be rendered very probable, bub
we must confess that the evidence on the subject seems to
us most unsatisfactory.
As regards the influence upon soil in the production of
tubercle. Dr. Hansome endorses the views of Bowditch and
Buchanan—viz., that ground damp is a potent cause, and
that the best results may often be obtained from a thorough
system of drainage.
Dr. Hansome thinks cold is hostile to tubercle, remarking:
“It is now certain that nob only is there comparatively
little consumption in cold climates, bub that many people
predisposed to the disease, or actually consumptive, derive
great benefit from a sojourn in the keen, dry, cold air of
Canada, or from a winter spent amidst enow and ice at
3
)o^jie
888 7he Lancet,}
REVIEWS AND NOTICES OF BOOKS.
[April 18,1891.
Davos Platz or the Engadine.” Such facts are clear
enough, but it is not so evident that the cold is the
essential factor, although we are not disposed to deny
that it may have some influence. But the humidity of
the air and the general eflect of the climate upon
the habits and mode of life must also be allowed for.
Dr. Ransome does not think that exposure is, ptr s&, a
cause of consumption, and inclines to the view that its
effect is rather protective than otherwise. He discusses
the influence of occupations, which he regards as predispos¬
ing to consumption in proportion as they expose those
engaged in them to — (1) the inhalation of dust; (2)
stooping postures at work; (3} changes of temperature;
(4) bad ventilation. Statistics show that the most
irritating kinds of dust are those derived from steel and
flint, and that next after these come fine cuttings from
bristles and the spicula of glass and porcelain. Dr.
Ransome believes that the moat potent of all the causes
predisposing to consumption is bad ventilation and the
breathing of foul air loaded with organic impurities. In
this view we entirely concur, and its truth is now so well
recognised that we need not reproduce the striking
evidence brought forward by Dr. Ransome in its support.
As regards the influence of heredity. Dr. Ransome
believes that “it has much less to do with consumption
than is commonly supposed.” This is too large a question
to be dealt with cursorily, but it should be remembered
that the influence of heredity has been denied or minimised
by such good observers as Louis and Niemeyer, and that it
is on every ground undesirable to do anything to augment
the already excessive apprehensions that exist on this sub¬
ject amongst the laity.
Dr. Ransome does not think that tuberculosis is often
directly transmitted from one individual to another, and
inclines to the doctrine of Koch and Cornet that the disease
is mainly spread by the inhalation of dried tubercular
material derived from sputum and floating in the air. *
The fourth and last lecture is devoted to the subject of
the prevention of phthisis. The writer discusses with
sobriety and discrimination such questions as the pre¬
vention of the marriages of tuberculous individuals,
the proper rearing of tuberculous children, the value of
free ventilation, the choice of suitable dwellings on proper
soils, the inspection of meat, and the provision of suitable
hospitals or homes for phthisical invalids. On all these
topics he has much to say that is worthy of attention.
Via Zuckerbildung im Thierkorper, ihr XJmfang und ihre
Bedeutung. Professor Dr. J. Sebgen. Berlin: August
Hirschwald. 1890.
Since Claude Bernard first demonstrated the glycogenic
function of the liver in 1853, a great deal has been written
concerning the formation of glycogen and its conversion into
sugar. A compilation of the various views which have been
expressed on this subject would be useful, and such is found
in Dr. Seegen’s work. This book, however, is by no means
merely a compilation, but contains a vast amount of
original .work. Dr. Seegen is already well known for
his researches on the amount of sugar contained in
the blood of animals, and consequently his experi¬
ments and deductions will be read with great interest.
The first four chapters are introductory to the general
scope of the work. In the first full directions are given for
the testing and quantitative examination of sugar in
animal tissues and fluids; in the second we find an admir¬
able disquisition on ferments; in the third the forma¬
tion of sugar in the digestive tract (mouth, stomach, and
small intestine); whilst a fourth contains a very interesting
historical account of the glycogenic function of the liver,
including the writings of Bernard, Pavy, Schiff, Ritter, and
others. The fifth and sixth chapters are taken up with a
discussion on the formation of “liver sugar.” Dr. Seegen’s
own experiments are described minutely, and compared
with those of other writers, such as Boch and Hofl’mann.
The chapter on the occurrence of sugar in the blood would
naturally be expected to be particularly interesting, nor
are we disappointed. Tables are given of the amount of
sugar found in the carotid arteries, jugular veins, and portal
veins of animals experimented upon whilst taking various
forms of diet, the result being that the amount of sugar
present is found to he almost independent of the diet.
The most interesting chapters are of course those on the
glycogenic function of the liver. From bis own observations
Dr. Seegen arrives at some very important and rather
startling conclusions. He shows that the amount of sugar
present in the blood can be considerably raised, even when
the decomposition of glycogen is prevented, and that “the
formation of sugar and disappearance of glycogen do not
stand in an etiological relation to one another,” and con¬
sequently that glycogen is not the source from which the
liver sugar is formed. He further shows that the liver cells
possess the power of decomposing peptones and fat, sugar
being the principal product, but that the main source of
the sugar are the fats of the food absorbed; further,
that this sugar is independent of the carbo-hydrates
taken.
After the perusal of these physiological experiments, we
hoped to find more light thrown on the pathology and
treatment of diabetes mellitus than is given in the chapter
devoted to that disease. In fact, here we can discover very
little that is new. Like many other authors. Dr. Seegen
divides cases of diabetes mellitus into two classes. .In the
first class the constitutional symptoms are slightly marked,
the patients look fairly healthy, and are generally of
middle age; in the second class, the patients are young
and the constitutional symptoms very grave. With the
first class, the glycosuria disappears when sugars and carbo¬
hydrates are omitted from the dietary; with the second
class, the nature of the food makes very little difference.
Dr. Seegen ascribes the first form to the disability of the
liver cells to decompose the carbo-hydrates in the ordinary
manner. In the sacond form he considers that the whole
organism is more or less ailected, and that after the usual
amount of sugar has been formed by the liver there is a
failure to decompose it again for the use of the organism.
With regard to treatment also we learn very little. In
the first form dietary is everything, no sugars or carbo¬
hydrates should be taken ; but in the second class of cases
treatment of any kind is of little use. Dr. Seegen lays no
stress on recommending patients to abstain from fat and all
flesh food, merely repeating that the glycosuria in the more
severe form is hardly affected by the nature of food taken
by the patient.
Maladie de Paget. Par le Dr. Louis Wickham.
Paris: G. Masson.
This is an excellent example of the value of the Paris
system of presenting an original thesis for the doctorate.
In it the author, an internat in the lidpital St. Louis, gives
a complete r($iim6 of previous work in this field, and
supplements this by his own observations, both clinical and
pathological. The second part is especially valuable, as in
it he confirms and extends the observations recently made
by Darier on this subject, who discovered the presence of
psorosperms or coccidia of Leuckart’s class spivozoa; and
he considered that the first excoriated, and then the ulcerated
surface characteristic of Paget’s disease of the nipple is due
to the irritation excited in the tissues by the presence of
these psorosperms in the epidermal cells. The subsequent
cancerous development in the affected region is possibly only
a result of long-continued irritation, though Dr. Wickham
Digitized by
Google
fHB IiANCfiT,]
JjE-W INVfiNTlON.
[Apeil l8,1891. 8S>9
is inclined to ascribe it to a more direct action of the
parasites.
After a few preliminary observations the author gives an
abstract of sixteen previously published, followed by six
unpublished cases, the latter derived from the various
cliniques in the HGpital St. Louis. From these he draws
up a general description of the clinical features and course
of the disease, showing amongst other things that two out
of the twenty-three cases occurred in men, one in the male
breast and one in the scrotum. This last is valuable, as
affording a proof that it is not a disease of the breast
only.
The histological description occupies Pai't II. Commencing
with a review of antecedent observations, the author goes
on to relate his own, made on specimens from the six un¬
published cases and from the scrotal case recorded by Dr.
Crocker. In all Dr. Wickham found psoroaperms in abun¬
dance, contained in the epithelial cells of the epidermis or
glands, and he ascribes to these parasites a primary import¬
ance. The discussion of the pathogeny of the disease occupies
Part III. The treatment suggested by this theory is
of course an antlparasitic one, hut no opportunity for
thoroughly testing it has occurred, though in one case,
in which, owing to the perversity of the patient, it
was imperfectly carried out, Darier obtained sullicient
improvement to afford hope for a successful result in
the pre-cancerous stage, if the treatment was efiiciontly
managed.
Well-executed coloured drawings, both of the clinical and
microscopical appearances, illustrate the work, and there is
a bibliography up to date. The work is in every way a
creditable one to the new school of dermatology in France.
Medical and Surgical Memoirs. By Joseph Jones, M.D.
Vol. HI. 'New Orleans. 1800.
The author of these memoirs, which embrace an infinite
variety of topics concerning the etiology, geographical dis¬
tribution, nature, and treatment of diseases, must certainly
be regarded as one of the most industrious and prolific of
medical writers. From time to time he has issued under
his personal supervision volumes of his collected writings,
which contain an abundance of material gathered from his
own reseai'chee and observations, extending over a period of
nearly forty years. And yet, whilst tliese bulky tomes
speak strongly in favour of his energy and industry, they
are so overladen with facts, so copious in detail, and so dis¬
connected that we fear they will be passed over in favour
of more systematised and less laborious work.
The present volume (whose bulk has necessitated its
issue in two parts, each of great dimensions) consists in the
agglomeration of many monographs and essays bearing
on the sanitary and economic conditions of the State of
Louisiana; on the subject of quarantine, and tlie measures
to prevent the dissemination of infectious diseases ; on vac¬
cination (including reprints of tlie memoirs of Jenner,
Pearson, and Woodville), of which an elaborate and
detailed history is given; several public addresses of great
prolixity and profundity dealing with subjects of epidemio¬
logy, of education, and of the treatment of the insane,
besides special memoirs upon teratology, and some other
physiological topics. Moreover, there are interpolated a
profusion of most elaborate statistical tables relating to the
health, commerce, and climatology of New Orleans, and
maps and charts of the Mississippi delta. When we call to
mind his previous volumes—almost as bulky as these—and
the subjects of which they treated, we cannot forbear
the hope that the learned author will one day be
enabled to present the world with some lees dilluse
and more systematic treatise on some of the many
subjects to which he has given so much thought and atten¬
tion. For in their present form these memoirs are of com¬
paratively small service to the general body of the profession.
They will find a place on the shelves of medical libraries,
and be occasionally referred to by the statistician or the
epidemiologist; but their very exhaustive and elaborate
character, and the general style in which they are com¬
piled, render it most difficult to extract therefrom material
facts. Added to which the lack of an index is of itself
enough to daunt the spirit of the inquirer. The monograph
upon Vaccination, which occupies upwards of 500 closely
printed pages, is especially valuable for the attention given
to the subjects of spurious vaccination and vaccinal syphilis;
and here the author’s experience in the Confederate army
is put to good use, whilst his literary studies are wide and
ample. _
lltto Inteliun.
SINGLETON’S AMBULANCE CHAIR.
This strikes us as a simple and ingenious appliance for
raising and transporting injured persons from situations
such as ships’ holds, engine-rooms, docks, pit shafts, coal
bunkers, and other places difficult of access to the ordinary
ambulance stretchers.
The chair is made of sail cloth, stiffened at the back
with leather and provided at the sides with fixed leather
straps and buckles for securing a disabled person in it.
There are brass eyelet holes at the front and back to which
iron clip-hooks and rope t lings are connected, surmounted
above by an iron ring, to which the rope slings are
Joined. By fastening'a rope to this ring, or, better,
by means of a block and tackle, the chair can be raised
or lowered with a person in it in the most convenient
and comfortable positions. By means of a guide rope
attached to the chair, it is easy to prevent it from coming
in contact with any obstacles or projections when used.
When raised or lowered the disabled person need not be
removed from the chair, but may be at once placed on a
stretcher; or if one be not accessible, a wounded or sick man
may be conveniently moved to any distance by simply
putting a pole or handspike through the ring or under the
slings, with an individual at either end of the pole to carry
him. The apparatus is simple in construction, vwry portable,
not at all likely to get out of order, and is consequently likely
to prove, as it has already proved in practice, extremely
useful in places and under circumstances where other means
of removal and transport could not be applied. It is the
invention of Messrs. Singleton, two workmen of Jarrow-on-
Tyne, who are both medallioniata of St. John Ambulance
Association and officials of the Jarrbw Ambulance Corps.
We can recommend it ai a safe and easy means of transport,
and well adapted for the requirements of large engineering
and manufacturing works.
Loughborough and Distiuct General Hospital
AND Disi’ENsauy.—A t the seventy-second annual meeting
of the governors of this chtxrity, the resignation was i ea
of Dr. William Hutchison, who had been for a long period
one of the honorary medical officers of the institution. In
the committee’s report for 1890 the circumstance is thus
alluded to :—“ The commitlce desire to place on t ecord their
sense of the value of the honore-ry services for many years
readerfd by Dr. Hutchison, who, having left the town,
has placed his resignation in their hands.” At the same
meouog Dr. Hatchison’s son, Mr. William Hutchison,
L. DS., was appointed honorary dental surgeon to the
iiiitiCution.
Digitized by i^ooQle
g 90 ^HfitAifCET.j
tHE LONDON PUBLtO HEALTH BILLJ^.
[Apbil 18,18§1.
THE LANCET.
LONDON: SATURDAY, APRIL 18, 1891.
The London Public Health Bills have been read a second
time in the House of Commons, and referred to the Standing
Committee on Law. It is probable that the same course
will be adopted as in the case of the Bills on the Housing
of the Working Classes—that is to say, the Amendment
Bill will be considered first, and the Consolidation Bill after¬
wards, and then the two Bills will be consolidated.
The clauses have been so carefully drawn that it is
not probable any extensive alterations will be required.
Nevertheless questions will be raised upon them, for already
there is evidence that the provisions of the Bills have not
been fully understood. Thus in our issue of last week a cor¬
respondent, writing under the nom dephimc of “ Fairplny,”
asks “on what ground is the district medical officer singled
out to be debarred by law from pursuing that branch of his
profession for which his public position particularly fits
him?”—or, in other words, why is the provision repealed
which specifies that the Poor-law medical officer may be
appointed a medical officer of health? The answer pro¬
bably is that the provision is superfluous. There is, so
far as we know, no statutory power prohibiting him bolding
the latter office, and so long as he is qualified in accordance
with the requirements of the Public Health Act and of
the Order of the Local Government Board, it is within
the discretion of any sanitary authority to appoint him, and
of the Local Government Board to confirm the appointment.
The position which Mr. Ritchie has assigned to the
London County Council in the health administration of
London was commented on in the House of Commons by
two members representing metropolitan constituencies. But
a little consideration will doubtless show that the course
Mr. Ritchie has adopted is inevitable if London is to be
properly governed. There is an absolute necessity that a
central power should exist for the purposes of the sanitary
requirements of London as a whole, and seeing that mal¬
administration in one district in London may prejudicially
affect the whole county, the right of intervention must be
given to the central authority. Not long ago we com¬
mented on the activity of the sanitary authority of St.
Olave’s in stamping out an outbreak of typhus fever. If
this outbreak had been less energetically dealt with
other districts wonld probably have been affected, and as a
matter of fact the disease did spread to the neighbouring
district. It cannot be held that the administration of one
district does not concern others. London, great as it is, is
but one town. The only question that remains, therefore, is
whether this power shall be exercised by an elected body
like the County Council or by a staff specially appointed
by a Government department. The County Council has
already important health duties under the Housing of the
Working Classes and other Acts, and is empowered to
appoint a medical officer of health for the whole county.
To add to the health duties of this body is, we believe, the
only course open to the Government, and the welfare of the
metropolis necessitates that this should he done completely.
Mr. Ritchie has borne witness to the assistance the
Council has given him in the preparation of the Bills,
and the useful work done by Captain James, the late
chairman of its Sanitary Committee, and by other members
of the Council, has been the subject of favourable comment
in the press. There is therefore no doubt that the
Council is fully impressed with the importance of efficiently
performing any public health duties imposed upon it,
and London will gain by the watchfulness the Council
will exercise over the proceedings of the forty-one au¬
thorities in the administrative county. That there should
be a temporary feeling of apprehension on the part of
those bodies who wish to maintain a position of in¬
dependence is not unnatural; but we have no hesitation in
saying we are convinced this feeling will pass away when
there has been experience of the new conditions.
There are a few points in the Amendment Bill which
we think should be further considered. To one of
these we have already referred on a previous occasion—
viz., the proposal to send to every elementary school
manager the returns of notified cases of infectious disease
prepared by the Metropolitan Asylums Board. If this
intention be carried out, we fear that it may be the
beginning of the end of notification. That the Notification
of Infectious Diseases Act has hitherto worked with very
little friction is, we believe, due to the circumstance that
the information which has been given has been regarded as
confidential. We are not at all prepared to say that there
may not be advantage in providing that other public bodies
than the County Council ehall receive these returns, and that
such bodies would not be able to use the information given
in the interest of the public. But to enact a law re¬
quiring these returns to be sent broadcast over the
metropolis, without any experience as to the effect of
such distribution, is, we think, fraught with danger to
the future successful working of the Notification Act. We
would gladly see this provision mended, giving fall discre¬
tion either to the Managers to determine as to whom the
returns shall bo sent, or to some other authority having
public health functions. It would then be found possible
to modify or cancel any arrangement found to work badly
without the necessity of going to Parliament.
A restriction to be placed in future on the medical officers
of health who will he appointed after the passing of the
Act demands comment. These officers, it is provided, are
to reside within the boundaries or within a mile of the
boundaries of their districts. With regard to this, we would
point out that a feeling is undoubtedly growing, and
especially since the passing of the Notification Act, that
public health duties militate against private professional
practice; and it is nob uncommon for sanitary authori¬
ties to prohibit their medical officers of health from
thus practising. Wo may conveniently cite the case
of Chelsea, a district in which this course has been
taken, as illustrative of our argument. A small salary
is offered, too small to encourage a man of any standing to
devote the whole of his time to the duties of the office.
As he is not now subject to this restriction as to residence,
Digitized by
Google
fHK Lancet,] CER^BRO-SPINAL MENINGITIS IN THE EASTERN COUNTIES. [April l8,1891. 89l
he naay probably add to his income by work of more than
one kind, but there are few who would be able to do this
and to reside in Chelsea or its immediate neighbourhood. We
fear that this restriction is only generally practicable when
the whole of the officer’s time is engaged, and the amount
of his salary is based upon such an arrangement.
The Standing Committee on Law will doubtless find
other points which can with advantage be modified, but
with the Bills as a whole we must express our full satisfac¬
tion, as well as our conviction that Mr. Ritchie deserves
the thanks of all for the sincere eftbrb he has made to give
London a thoroughly effective health administration.
It is now some years since any official report has been
issued in this country with regard to cerebro-spinal menin¬
gitis. Severe outbreaks of that disease occurred in the
villages of the Lower Vistula in 1864-65, and Dr. Bukdon
Sanderson prepared a lengthy report on the subject, which
was published in the report of the then Medical Officer
to the Privy Council; for a number of subsequent years,
however, the subject did not arouse much attention in
England. But there would appear to be some evidence
to show that since 1885 the disease is becoming more reco¬
gnised, if not more common, in different parts of the world.
In the seventh volume of the new issue of the Transactions
of the Epidemiological Society of London there is an ex¬
cellent account, by Colonial Surgeon Bolton C. Corney, of
a serious epidemic of that disease in the Fiji Islands during
1885, and this was followed during 1887-88 by a diffused
but somewhat widely spread prevalence of the disease in
the basin of the Mediterranean. This latter prevalence,
which was reportedon by Dr. Thorne Thorne in the account
of the proceedings of the Medical Department of the Local
Government Board for 1888, affected a number of places
from Cyprus and Asia Minor at the eastern, to Sardinia
near the western, extremity of that basin.
As regards this country, only scattered cases tend to
occur year by year, if we may judge by a few fatal attacks
annually reported by the Registrar-General. They are
very generally distributed over a number of different
counties and places, and they exhibit no disposition to
localise themselves. They have also but rarely been
subject to any detailed investigation as to their causes or
distribution. But, as pointed out by the Medical Officer of
the Local Government Board in 1888, the mere fact that
such occurrences do periodically take place affords a reason
for watchfulness on the part of sanitary authorities, their
officers, and others. And, as if to prove the need for such
warning, we now learn that there has been some localised
prevalence of this fever in certain of the eastern counties.
Reporting on the subject, Dr. Bruce Low' gives some
general description of the sanitary circumstances of a
number of villages and places in Suffolk, Norfolk, Essex,
and Lincolnshire, where cases occurred ; he also states
the symptoms and clinical appearances met with. The
attacks at Oakley in Suffolk, where about a dozen cases
occurred, may be taken as fairly typical of the rest. The
patient was as a rule taken ill suddenly Avith vomiting,
1 OlHdal Report to ttio l.ocat (lovermiient Hoanl, l''ebniary, ISi)!.
Eyre nncl SpoWiswootlo, l.ondoii; .(oliii Menzios and Oo., Iktiuburgh
and Glasgow ; Hodges, Figgis, and Co., Dublin; price id.
vertigo, headache, and great prostration. Next day, or
even later, there were pain and stiffness in the neck and
back, passing sooner or later into complete retraction of
the head, in some cases amounting to opisthotonos. Early
in the illness there was great drowsiness ; in young children
fibs of screaming occurred when they were awakened. There
was rise in temperature, which ranged from 100“ to 103“ F.,
delirium following in most cases. Some suffered from con¬
junctivitis, others herpes of the mouth, and there was usually
great sensitiveness of the skin. All, or nearly all, had more
or less loss of power in the loAver limbs. Emaciation was
rapid, convalescence slow, the pulse was sometimes noticed
to he dicrotic, and the respiration was hurried or inter¬
rupted. Some cases exhibited neurotic sequelm, and a rash
was occasionally seen. In a typical case of death the patient
became drowsyand comatose, and died forty-eight hours after
1 seizure; post mortem the brain presented great congestion
j of the whole of the membranes, the cerebral venous system
was gorged with blood, and both on the upper surface and
j at the base there was evidence of lymph having been thrown
out. There was much serum in the ventricles, and the
substance of the brain was soft. As regards the spinal
cord, the principal lesion observed indicated much con¬
gestion of the membranes in the upper dorsal region.
There appeared to be nothing worthy of much note to
distinguish the sanitary surroundings of persons attacked
from those who escaped, and there were no indications of
privation such as have at times been associated with this
disease elsewhere. Food-supplies, and notably grain foods,
were inquired into without result, and apart from the fact
that two and even three attacks occurred in some house¬
holds, nothing seemed indicated as to method or cause of
spread. Some twenty-four cases in all came under observa¬
tion ; bub apart from these there have been occurrences of
disease which it had been difficult at the time to explain,
and some medical practitioners are inclined to agree with
Dr. Bruce Low that in a number of instances the disease
bad prevailed in a form which had been unrecognised.
Taking the four counties referred to in connexion with
this prevalence, it would appear that only eleven deaths
have been registered from cerebro-spinal meningitis during
the five years 1885-9, nine of these having occurred during
the last three years. As regards England and Wales
as a whole, 132 such deaths occurred during the quin¬
quennium referred to. On the whole, there seem grounds
for believing that in England, as elsewhere, the fatality
varies much ; that a number of mild attacks may only be
recognised on the occurrence of one or more of the type
that has been termed “foudroyante”; and that the disease is
nob so exceptional in this country as the mortality statistics
seem to indicate. This view is taken by Dr. Bruce Low,
who says that fatal attacks are probably certified under the
name of “fever,” tubercular meningitis, or convulsions,
whilst non-fatal attacks are looked upon as sunstroke,
“ violent cold,” and similar ailments. Obviously, there is
need for watchfulness in this respect,
The debate in the House of Commons upon the opium
traffic has brought the question one step further than usual.
Sir J. Pease has succeeded in inducing the House to
Digitized by
892 TriBLANCETj
tHE OEIUM TRAEEiC debate.
[April 18,1891.
recogniBe by its vote that the sj^stem by which the Indian
opinm revenue is raised is morally indefensible. The ques¬
tion was approached from many different sides, and a sem¬
blance of resistance was made, although from the first it was
evident that in point of argument there was no real defence.
The charge is that while opium should be treated and used
as a drug, as a nation we must admit that for the sake of pecu¬
niary gain we have promoted, and directly encouraged, the
growth of the poppy and the sale of opium for other purposes.
Historical assertions were made calculated to diminish the
eelf-esteem of the British subject, but the accuracy of many
of these was disputed. Arguments were adduced from an
economical standpoint, but they mainly resolved themselves
into fears of the possible bankruptcy of India if any restric¬
tions were placed upon the revenue from opium. From
the first the defenders of the opium traffic appeared faint¬
hearted, scarcely in earnest, and almost indifferent, and,
unfortunately for their cause, they seemed not to have
agreed upon any line of defence more definite or more
moral than that of loss of revenue. Apart from this idea,
the lack of logic characterising the speeches was extremely
amusing, and doubtless contributed largely to the resulting
division.
The House decided against the morality of the opium traffic
after a purely academic discussion. At the same time, a
seemingly uncomfortable impression remains that the trade
is declining, and that therefore we can afford to be moral,
even if morality is not forced upon us. The Chinese have
acquired the craving for this drug, and now a large part of
the country is under opium cultivation. In spite of legal
restrictions, contraband supplies are passing overland into
the seaports, while the quantity imported from India is
declining. In the Presidency of Bengal there arc 100,000
acres less of land under poppy cultivation than there were
ten years ago, while the number of chests of opium manu¬
factured in British India is now only 4800, as against
5606. This is not as satisfactory as it appears, since it
merely indicates that the Chinese are growing their own
opium, not that the amount consumed is lees.
Regarded from a medical aspect, there can be no real
difference of opinion about the opium traffic and its
baneful influence. Two speakers only attempted its
defence, hut the defence was weak, and binged mainly
on the comparison of the evils resulting from alcohol and
opium. Thoseof theformerwere graphically described—the
ruin of the liver, the heart, and the brain, and the ultimate
miserable death from the secondary results; while a point
was made of the fact that “ the opium smoker might be
quite useless, but at any rate he was not mischievous ; he
did not beat his wife.” In the same light bantering spirit,
which is surely out of place in dealing with such a serious
question, another speaker said if ” Coleridge had taken
spirits instead of opium, and if he had suffered from
delirium tremens, the Confession would have been ton
times worse, and it was lucky that Coleridge took
opium and not spirits.” And then a little later, in the
heat of debate, forgetting that he had been abusing alcohol,
the speaker described the cultivation in Bengal, and the
care taken to make sure that the opium was not distri¬
buted among the people. “The people had spirits, and
that was thought sufficient for them without opium, and
therefore we made sure that the opium went direct
out of the country. It was for the physical welfare of
the people that the system was carried out.” After all,
there was practically no defence beyond the plea that
the abandonment of the revenue would make India
bankrupt. With such questions we have no concern.
Whether the revenue from opium is increasing, or whether, as
stated, it has fallen from 8,451,000 rupees in 1880-81 to
3,000,000 rupees, matters little from a medical standpoint.
The question is merely whether this drug, which has been
called the gift of God to man, is being legitimately em¬
ployed purely for medicinal purposes. Now, although
reference was made to its tonic effects in small doses in
preventing ague and its influence in lung and bronchial
affections, thosewho took a serious view of the question de¬
clined to pretend or to argue that the large revenue of India
was derived from opium employed for any of these purposes.
There appeared to be a general feeling that the less said the
better about the destination of the opium and the purposes
of its employment. In this country the sale of opium and
its preparations is surrounded with every possible precau¬
tion, clearly for the “ physical welfare of the people.” The
morality of adopting a different code of ethics for the native
races under British rule requires no discussion. Sir J,
Pease deserves hearty congratulations upon the success
that has at last attended his efforts to induce the House to
urge the Indian Government to take measures to restrict
the supply to the legitimate demand for medicinal purposes.
The resolution has not yet been made an order of the day,
since the leader of the House of Commons thinks it requires
much further consideration before it is accepted. Should
further discussion arise, we trust it may be conducted upon
broad principles. The question should be strictly limited
to the amount of encouragement at present afforded to the
opium habit, and not allowed to wander ioto futile com¬
parisons with alcoholic intemperance. The task of dealing
with the one evil at a time will sufficiently tax the powers
of legislation.
The Register of Trained Nurses, which has been in course
of preparation for a period of three years past, is now given
to the public, and its merits can now be discussed not only
from the theoretical point of view, but also in the light of
the plan which it proves actually capable of vindicating for
itself. It may be hoped, therefore, that the discussion
which has already arisen concerning its utility, and which
will certainly be stimulated by the appearance of the first
annual volume, will gain in point, and that the objects which
the promoters of the scheme have in view will now become
clearer to such of their critics as have heretofore attacked
them with more energy than appreciation. It is no disparage¬
ment of the good wo'ik already done by the Registration
Board to say that intelligent criticism may be very usefully
employed upon their labours. The volume now before us
contains about two thousand names of nurses, all of whom
have received more or less training, and most of whom
hold certificates such as will command general respect. That
the registration authorities should not at first be very
exacting as to qualifications was only a thing to he ex¬
pected. The fact could not have been otherwise; nor is it
even desirable that it should. The object of the Register is to
Digitized by
Google
ThbLanobt,] the KEGISTRATIOU of NURSES.~0PEN spaces about houses. [Apeil18,1891. 8S3
identify trained nurses and authenticate their credentials.
If in some cases the credentials themselves amount to a
guarantee of less than could he desired, the remedy for that
should he sought in improved training first, and in restricted
registration only after such an interval as shall have
afforded to the improved facilities of training a reasonable
opportunity of bearing fruit. One very important result of
bringing together in one view the various certificates and
qualifications which nurses rely upon to avouch their com¬
petency will probably be that the inferiority of imperfect
methods of training will be more clearly perceived by the
nurses themselves and those who supervise their education,
and improvements will in the result be introduced
for the correction of these defects. With this ob¬
ject it would, we think, be in itself a good thing
if the Register were supplemented by some explana¬
tion as to the effect of the various certificates placed
upon it. Whether it is practicable to add such a
feature we cannot tell. Its value is obvious, and we doubt
not that the suggestion, if it has not already been con¬
sidered, will receive attention at the hands of the Registra¬
tion Board, But, even while putting it forward, we per¬
ceive that there would be serious difficulties to be sur¬
mounted, and are prepared to learn that for the present at
least its adoption would not be wise. Another suggestion
that occurs to us upon an examination of the present
volume, and one which would probably be with less
difficulty carried into effect, would be the addition to the
present alphabetical list of names of a list arranged
according to localities; The primary object of the
Register is no doubt what we have above stated—
that is to say, the identification of trained nurses and the
authentication of their claims to professional qualifications.
But, incidentally, it would often he a great advantage to
have a ready means of ascertaining the address of a
trained nurse near at hand. Nurses are usually wanted in
emergency, and often the most important of all qualifica¬
tions is the being within easy call. A local list would
greatly facilitate an inquiry directed to this point, and we
hope to see it made a feature of future issues of the Register. I
^nnutatiflns.
” Ne quid nlmla."
OPEN SPACES ABOUT HOUSES.
In the debate on the second reading of the London
Public Health Bills, Mr. Stuart urged that the London
County Council should possess the same power of making
by-laws as to open spaces about houses as was enjoyed by
every urban authority in England and Wales, and referred
to a recent article in The Lancet in which this necessity
was pointed out. The Bills now before Parliament do not con¬
tain these provisions, but this circumstance is to be explained
by thefact that whereasurban authorities generally possess
these powers under a section of the Public Health Act of
1875 which authorises them to make by-laws for new streets
and buildings, the London building provisions are not in¬
corporated in the Public Health Bills. The evident interest
Mr. Ritchie takes in municipal government, and tho zeal
he has shown in consolidating and amending the Housing of
the Working Classes and the Public Health Acts, create the
hope that it is his intention to consolidate and amend the
Building and Metropolis Local Management Acts. There
would then be ample opportunity for incorporating the pro¬
visions as to open space to which Mr. Stuart referred. For
our ov-’n part we thinJc it matter of little importance whether
London is to be dealt with in this respect by by-laws or by
statute. The question is really whether Parliament or the
London County Council would be prepared to make the most
adequate provision. The Council at the present time is so
fully alive to the necessity of air space within the metro¬
polis that there is no doubt the subject would be dealt with
liberally. Whether the next Council will be equally
appreciative of this health necessity in London can only be
seen after the next election in January. On this point we
are quite prepared to trust Mr. Ritchie, who has in his own
department at Whitehall all the experience which would
enable him to frame an admirable measure if he intended
the details to be settled by Parliament. If our hopes are
well founded, we may at no distant time see London in one
way or the other given all necessary opportunity for pre¬
venting the crowding of houses, and for bringing to an end
the preparation of areas for improvement schemes, to which
the London County Council now has to resort, at enormous
cost to the ratepayers. _
HINTS TO BRITISH TOURISTS AND RESIDENTS
IN GERMANY.
There has just been published in the form of a Foreign
Office paper, which may be procured for the modest sum of
one penny, an exceedingly useful collection of suggestions
made for the benefit of British travellers and residents in
Germany, which all who contemplate visiting the Father-
land would do well to peruse. The writer is Acting Consul
General Goldbeck, who has been led by his experience of
his office to believe, we doubt not with good reason, that he
will be rendering a valuable service to those who are in a
sense his special charge by pointing out to them what are
the unpleasantnesses to which they are most readily ex¬
posed, and bow they may best be avoided. He runs over
in a cursory way such topics as passports, the traveller’s
supply of money, Customs’ regulations, disputes with
oabdrivers, tradespeople or lodging-house keepers, taxes
and the like, and he gives some valuable hints as to the
selection of a place of residence. Many hundreds of Eng¬
lishmen will shortly be betaking themselves to the region
within which the writer of this paper exercises his repre¬
sentative office, and most of them will certainly find their
advantage in first acquainting themselves with the rules
which are here submitted for their adoption and observ¬
ance. Not the least valuable of the acting consul’s hints is
that those who know how to set about it will easily
find among the Germans the boon of what our neighbours
themselves call “English comfort.”
POLYNEURITIS OR BERI-BERI AMONG
FISHERMEN.
From time to time during the last few years cases have
been reported in American journals which in their clinical
symptoms are closely analogous to what has until recently
been considered to be a disease of the tropics—viz., beri¬
beri. In an important article in the Journal of Nervous
and Mental Diseases, Dr. Putnam of Boston, taking as
his text a case which had recently come under his observa¬
tion, discusses the nature and etiology of this condition at
some length. The patient was a man of thirty-nine, the
mate of a vessel just arrived from the Grand Banks, who
had enjoyed good health until two weeks before he was
seen. He had then experienced pain on the inner surface
of the thighs. The following day he was sick, and the legs
Digitized by ^OOQ[C
§94 The Lancet,]
INFECTION THROUGH THE SOIL.
[April 18, 1891.
and thighs became swollen, and he was obliged to keep in
his bunk for several days, while a steady diminution of
strength took place in his legs and feet. On examination
he was pale, had difficulty in getting his coat on and oIT,
and walked with a waddling gait There was slight toe-
drop, and difficulty in standing with hia eyes closed.' There
was a feeling of numbness in the legs, but no marked impair¬
ment of sensibility. The inner surfaces of the thighs and the
calves were tender, and there was distinct pitting on pressure
along the shins. The knee-jerk was lost On inquiring
more closely into the conditions under which the illness
commenced, it was found that for nearly six months before
bis illness came on he had been on a vessel engaged in
fishing off the Grand Banks. The vessel was badly pro¬
visioned, and the voyage had been unduly protracted, so
that for a time the rations consisted only of molasses, fried
pork, and pancakes, with bad water. Nine or ten men
besides the patient were attacked with illness, the prominent
symptoms being weakness and swelling of the legs, and one
of them, afterwards seen by Dr. Putnam at the Marine
Hospital, presented the typical symptoms of multiple
neuritis, well-marked ankle- and wrist-drop, impairment of
sensibility in hands and feet, with tenderness on deep
pressure of the muscles. Several other eases were after¬
wards seen, and by means of inquiries among medical men,
information was obtained of similar symptoms in numerous
others exposed to the same conditions, and there seems to
be little reason to doubt that the disease has a strong
analogy to scurvy and to beri-beri, and that bad or in¬
sufficient food and water are important factors in its
causation. _
DISTRIBUTION OF DAIRY PRODUCE.
The Earl of Meath, In an effective paper in the current
number of the Ni’Mtecnth Century, argues for the provision
in London and our large towns of improved facilities for
the distribution of dairy produce. He finds a text in a
description which he gives of the great dairy of Herr Bolle
at Berlin, from which quantities, varying with the season
from 35,000 litres to 50,000 litres of milk in its natural
form, or under the equivalent of milk products, are daily
distributed throughout the city. The salient feature
of the system established and carried on under the
supervisiorl of Herr Bolle is that the most exact care
is taken to prevent any adulteration or alteration of the
substances sold while in the hands of the subordinate
officials whose duty it is to deliver at the customer’s door.
Thus the milk is sent out from the central repository in
locked cans from which it is measured into the customers’
receptacles, an arrangement which doubtless effectually
prevents the watering of the milk. Equally scrupulous is
the care taken to ensure the purity of the other produce, a
result which is the more easily attained by reason of the
vast scale upon which the operations are carried on, It
appears, however, that the beginnings of this large enter¬
prise are very recent, and that ten years ago it originated in a
very small dairy business. Indications of a more or less
similar movement among ourselves are not far to seek, for of
late years there has been a notable improvement in respect
of cleanliness of appearance in the dairies of the metropolis.
Nor is the improvement a matter of appearance alone.
The exposure in The Lancet of adulterations, the
work of inspectors, and the growth of an enlightened
public opinion have done much to carry reform into
the heart of the trade in foods, and in milk particu¬
larly. Still, there is much yet to be done, and though it
would probably be rash to expect that the introduction of
Herr Bolle’s methods into London, for example, would he
followed by success commensurate with that which has
attended them in Berlin, we hope that the suggestions made
by the Earl of Meath will not be wholly without fruit, and
doubt not that they are capable of being not only usefully
but also successfully carried into practice.
INFECTION THROUGH THE SOIL.
The question is often raised whether there is any direct
or indirect proof of the infectivity of the bodies of those
dying from specific fevers, or whether the soil of graveyards
may become really dangerously contaminated thereby ; hut
it is also one to which comparatively little attention has
been given by the experimentalist. One aspect of the
matter has been lately studied by Dr. Justyn Karlinski
of Konjica, Herzegovina; in a series of experiments
{CentralhlaU:f. Bakt&riol, ix,, 13) undertaken to determine
whether the organs of the body undergo any change in tem¬
perature during the natural process of decomposition after
burial in the earth, and especially whether any differences
in this regard are to be met with in the case of infected
subjects. His results show that invariably the putrefac¬
tive process is accompanied by a rise of temperature
above that of the circumjacent soil; and also that
this rise in temperature is markedly higher when
I the parts examined have been taken from the bodies
of men or animals who have succumbed to infective
diseases than it is in the ease of healthy bodies. He
further examined into the question of the survival of
the pathogenic bacteria in the affected parts, and states
that the typhoid bacilli may retain their vitality in the
decomposing spleen for three months, and are only com¬
pletely annihilated by rapid putrefaction and the presence
of a large number of the bacteria of putrefaction. Dr.
Karlinski says that he had previously shown that typhoid
bacilli could retain their vitality for a period of five months
in soil, but that if the earth were thoroughly saturated with
rain water they were destroyed in from seven to fourteen
days. The part played by the soil in the origin of epidemics
should not, he thinks, be under-estimated, since typhoid
bacilli can only exist in water a comparatively short time.
ARMY MEDICAL SERVICE.
We have dealt so recently with the present position of
the service in connexion with the late correspondence
between Sir Andrew Clark and Mr. Stanhope thereon, that
there is no need for further remarks at the present time ;
but it may interest medical officers serving at homo and in
the colonies to know that in India a lively correspondence
has been taking place in the Pioneer and other journals
regarding this subject, and especially regarding army
medical olficers’ rank. The discussion has reference, how¬
ever, to the first, and not the last, portion of the correspond¬
ence between the War Office and Sir Andrew Clark.
CREOLIN IN DENTAL PRACTICE.
An American dental journal publishes a communication
by Dr. Wm. H. Potter on Creolin as an Antiseptic. Creolin
consists of a mixture of the sodium salts of some resiuous
acids with the part of oil of tar known as “ irod oil.” It
is made from English pit-coal by distillation, and is of a
brownish-black colour and syrupy consistence. It is not a
definite chemical compound, hut a mixture of various in¬
gredients. It is insoluble in water, but quickly forms with
it a brownish or milky emulsion. It also mixes with oil
and glycerine, and is soluble in absolute alcohol, chloroform,
and ether. Esmarch’s experiments seem to prove that it
is a more powerful germicide than carbolic acid, and in
quantities likely to he used is non-toxic. It is a reliable
hiomostatic and a powerful deodorant, and does not
roughen the hands or injure instruments. Its disadvan-
^oogle
Digli.ied by
Tee Lakcet,]
THE SANITATION OF TUNIS.
[April 18,1891. 895
tages are that the emulsion, besides being opaque, is
apt to become sticky after being allowed to stand for
any length of time, and so clings to instruments. For
dental purposes it is suggested that it may be of use in
various ways. First, as a mouth wash, one or two drops of'
■crooUn added to half a tumbler of water forms an emulsion |
pleasant to the taste, a powerful deodorant, a reliable
germicide and antacid. A second sphere of usefulness is
in the treatment of fistulous tracts or auy suppurating sur¬
face. In such cases it tends to diminish secretion, and
induce a healthy state of the tissues. It is also a good drug
•for root canals, and will quickly deodorise a dead pulp. A
■minoi' use to which creolin may be put is that of taking
Tust off instruments, to accomplish which the full strength
should be used, and the instrument rubbed with a rough
■cloth. .
DISEASE OF THE CAUDA EQUINA.
llECimiREW has recently met with a case in which he
has diagnosed affection of the conus medullarU and the
cauda equina. An abstract is given in the Ne%irologisches
iJcntralblatt,T^o. 5, 1891. For some weeks before the patient
■came under observation he had suffered from a gradually
-increasing weakness in the legs, together with urinary
•trouble and weakness. On examination there was loss of
-sensibility with regard to tactile and also to painful impres¬
sions on the penis, scrotum, perineum, and gluteal region.
There was also similar impairment on the inner and posterior
aspects of the thighs. There was much muscular weak¬
ness, so that the patient could not walk without the help of
a stick. The knee-jerk was normal, and of the superficial
rellexes none were lost with the exception of the gluteal
There were incontinence of urine and obstinate constipation,
although at times there was involuntaiy defecation. There
•was marked tenderness over the sacrum. The author con¬
cludes that the case is one of lesion of the conus medullaris
and cauda equina, and draws attention to the corre¬
spondence of the clinical symptoms with those produced
■experimentally in dogs by section of the cauda equina.
THE SANITATION OF TUNIS.
Since its annexation by the French ton years ago Tunis
has taken a new departure. The city is being enlarged,
reconstructed, and, not least important, rehabilitated in a
sanitary sense. Hitherto its death-rate has been high, and
the offensive odours from which even its moat fashionable
•ffuarter is seldom free indicate the chief cause of its sickness
■and mortality, Typhoid fever ia almost endemic*, and
though the winter season, when the city is most frequented
by foreigneis, miniraiaes the death-rate from this source,
still the disease constitutes an ever-present danger. The
Lac de Tunia, or El Bahira, as the land-locked sheet of
water between Tunis and its port Goletta ia called, has
for forty centuries been the receptacle of all the drainage
and refuse of the city, insomuch that its depth has gradually
•diminished bo little more than a metre in its deepest part,
and its navigation is impossible for any but the lightest
■craft. The prevailing winds lie between the north and east,
and a glance at the map will make it at once intelligible how
■the air currents between those two points, in passing over
that spacious cesspool, are fraught with foul smells, and'as a
•consequence with lowered vitality, disease, and death. From
a report now before us on “ L’Assainisaement de Tunis,” we
learn that elaborate steps are immediately to be taken
for the suppression of this nuisance. A “grand collecteur”
—a sort of cloaca maxima—destined to reunite the whole
drainage of the city in a common stream will carry the
sewage below the level of the Lac to a great reservoir con¬
structed ad hoc, whence it will be conveyed by special
steam pumps and pipes to a distant point of discharge in
the Lac itself. This, however, is only provisional, the
immediate object being to purge the air of the odours which,
in a north-easterly wind, make the mnch-frequented pro¬
menade of the Avenue de la Marine a far from salubrious
or pleasant resort. The next and more important step will
be to divert the sewage from the Lac and carry it out to
the fields which surround the city on its three sides. The
fertility of these, already great, will he enhanced tenfold
by this accession of their natural manure, and the increased
fecundity of the Tunisian market gardens, famous for the
quality and abundance of their kitchen produce, will be a new
source of wealth to the neighbourhood. Another project for
the development of the attractions of Tunis ia the construc¬
tion of a sanatorium at Carthage, which will enable even the
invalid to avail himself in winter of the advantages of that
ideal site, sheltered as it is from the north and interesting
to all time for its mighty past, of which the relics are being
steadily brought to light by Cardinal Lavigerie and the
Abbe de Lattre. The sanatoiium in winter will be trans¬
formed, in the hot season, into a resort for the seaside
sojourner, drawn thither by the cool refreshing breeze and
the admirable bathing facilities. We hope, however, French
enterprise will stop there, and not assume the developments
it is prone to take at other frequented points of the Medi¬
terranean seaboard — the establishment of casinos and
gambling saloons. That, indeed, would be the ignoblest
fate that has yet befallen the city of Dido.
THE "MEDICAL HAT” QUESTION AGAIN!
In our issue of Feb. 2lst we took occasion to notice a
proposal that a hat of particular make should be used as
a distinguishing mark of medical practitioners. It now
appears that the desire for peculiarity has not been limited
to this country. As if by a side wind of suggestion, medical
opinion in Berlin ha«, it is said, arrived at nearly the same
point. There is a difference, however, and a material one.
This lime it ia not the doctor, but his coachman, who is
about to undergo alteration. In future a white hat will be
for him like the fireman’s helmet—a sign of urgency before
which ordinary traffic will be expected to give way. The
idea, it must be allowed, gives promise of some practical
advantage, and many busy practitioners would be only too
well pleased if by so simple a device they could scatter the
obstructions which in town practice render the daily round
a protracted and a devious task. By the sick whom they visit
it should be hailed as an earnest of speedy relief. If, there¬
fore, any suitable distinction commends itself to professional
taste, no serious objection, we presume, could be urged
against it. There would still remain the uncertainty
whether the charioteers of other interests would be willing
to admit the claim of medicine to precedence on the road.
On the whole, therefore, we should prefer, before advising
the adoption of any scheme of hat reform, to watch the
progress of the new departure in the German capital. The
matter is not so urgent but that it may be still further
considered.
TREATMENT OF PNEUMONIA WITH LARGE
DOSES OF DIGITALIS.
At the last International Medical Congress Professor
Petresco of Bucharest read a paper on this subject. He makes
an infusion of sixty grains of powdered digitalis leaves to six
ounces of water, a little syrup of orange being added to
sweeten it. A tablespoonful of this mixture is given every
half hour. In spite of the largeness of the dose, he says
that he haa never met with a case of poisoning, and
maintains that theso doses are therapeutic, and not
toxic. The best results are obtained in fibrinous or
croupous pneumonia. The author states that if used
in the way he desciibes digitalis will frequently cut
Dici-.^ed by lOO^Ic
896 ThsLakostJ
THE RECURKENCE OF INFLUENZA.
[April 18, 1891.
short) an attack of true croupous pneumonia. In from
tn^enty-four to forty-eight hours after taking the drug a
certain fall of temperature occurred, from lOl^F. to 98°F.;
this being accompanied by a decrease in the frequency
of the pulse and respiration. The digestive tract was.
little aifected. The most marked changes were noticed
in the pulse, which became slow, full, and of high tension.
The conclusions to which Professor Petreaco has come are
published in the Therapeutische Monats/iefte, Feb. 1891.
They are as follows: 1. When given in therapeutic doses
digitalis has a direct antiphlogistic action. 2. The dose
may be raised as high as from GO to 120 grains of the leaves
given as an infusion within twenty-four hours. 3. This
treatment may be continued for from two to four days if the
severity of the case requires it. 4. When improvement
takes place in the circulation and respiration, this is
speedily followed by a disappearance of all local signs and
symptoms. 5. The success of this treatment is confirmed by
the statistics. In an elaborate table of statistics Professor
Petresco shows the superiority of digitalis over the other
methods. Thus the highest mortality in pneumonia (34'5 per
cent.) occurred when bleeding was practised, and the lowest
(3 per cent.) when tonic?, alcohol, (Sso., were employed.
When digitalis, however, was administered the mort^ity
sank as low as 2 06 per cent. 6. From an experience of
a very great number of cases, both of his own and of other
medical men, he maintains that the doses, as given above,
are perfectly harmless. 7. After a comparison of the various
methods of treating pneumonia. Professor Petresco affirms
that the expectant plan is not only without reasonable
foundation, but even dangerous ;^and his experience has
demonstrated that an attack of pneumonia may be aborted
if the treatment is commenced at the very earliest stages of
the disease.
THE RECURRENCE OF INFLUENZA.
During the past few weeks there has been unmistakable
evidence of a return of the influen/a in epidemic form, and
in the United States it has shown a severity surpassing the
outbreak of 1889-90. Chicago seems to have been one of
the hrst cities of importance to have been thus visited, and
in many other important towns of the Western States the
disease is very rife at the present time. It appeared in New
York about three weeks ago, and has been gradually in¬
creasing in intensity, and the latest reports sho w that it ha^
caused a considerable rise in the death-rate there as in
Chicago. In this country, although sporadic cases have
been noted in the metropolis and elsewhere during the past
winter, it has as yet, so far as we know, only assumed the
epidemic form in certain towns and villages of Yorkshire—
notably in Hull, Sheffield, and Driffield—and also in Rir-
mingham, where, however, it is said to be more limited,
and of a milder character than last year. It is hardly to be
expected that the disease will be confined to these localities,
and the coming week may witness a much wider extension
of its area. The occurrence of milder and brighter weather
may possibly serve to check its progress ; but, if the contrary
conditions prevail, the probabilities, judging from past
experience, would be in favour of a severe recurrence of tbe
disease.
A DRAINAGE SYSTEM FOR DURBAN.
The important town of Durban, South Africa, is at last
likely to obtain a system of drainage. The present mode of
disposal of excreta and refuse by pails is very unsatisfac¬
tory and expensive, costing as it does nearly £8000 per
annum for a population of 12,000 Europeans. The engineer,
Mr. Fletcher, has drawn up a scheme for a drainage system
which will cost under £5000 per annum for a population of
20,000, and £5350 even when the population has increased
to 40,000. The difficulty that has always been recognised
in connexion with any system of drainage for Durban is the
disposal of the sewage. The highest point of the town
itself is only twenty-six feet above low water level, an
altitude that hardly suffices for removal by gravitation.
Mr. Fletcher proposes to overcome this drawback by adopt¬
ing the Shone system of pneumatic pumping. The sewage
of the town is to be conveyed by main and subsidiary sewer
pipes to tanks at the Point, where it will be “screened”'
from solid matter. That matter will be at once destroyed
in refuse destructors. The liquid sewage —containing
not more than 2 per cent, of solid matter—will then be
conveyed to the end of the north pier, and ejected into tbe sea
during the first four hours of every ebb tide. Mr. Fletcher
advances evidence tending to show that freshly removed
sewage thus poured out into tidal water is taken out to
sea, anddisposed of without risk, unpleasantness, or pollution
of the waters that wash tbe shore. He considers that tbo
fear that theexcreniental matter thus ejected into the ocean
might be returned to the beach is set at vest by the destruc¬
tion of all solids in the sewage, by the dilution of all fceca^
matter, by the tidal dispersion of tbe outflow, and by the
disinfecting agency of the sea itself. As the number of
persons who go out to South Africa in search of health is
constantly increasing, it is of great importance that one of
its principal seaports should be put into a thoroughlysanitany
condition, and we are sure the inhabitants will never regret,
the initial expense of carrying out such work in a thoroughly
efficient manner. _
THE STANDING COMMITTEE ON TRADE AND
FACTORY SURGEONS.
We offer our hearty congratulations to the Factory
Surgeons on the triumphant vindication of their case before
the Standing Committee on Trade of the House of Commons.
The Home Secretary’s proposal to abolish their office wa&
rejected by the overwhelming majority of thirty-nine
to nine. We are delighted te see that the divisions
on this subject followed no party linos, but that
men of all parties vied with each other in declaring
that the r6le of certifying surgeon was a useful)
one, and essential to the working of sound factory legisla¬
tion. It would be invidious to make fine distinctions,
where so many did well, but the profession will remember
with gratitude the able and persistent part played in this
discussion by Dr. Farquharson, Mr. Mundoila, Mr. Shaw
Lefevre, Mr. Chamberlain, Viscount Cranborne, and
others. Nor are we disposed to be very angry with Mr.
Matthews for making his unfortunate and unreasonable,
proposal. We can easily imagine that he was much pressed
to do so. He should, of course, not have yielded to-
pressure in such a life and death matter as the re¬
moval of tbe only impartial judges of the health-fitness
of children of tender years for factory labour. But he
has indirectly and unintentionally taken a course whicb
should establish the claims of tbe factory surgeons, not only
to have their present uses recognised, but to have their func¬
tions extended rather than curtailed. We cannot doubt that
the Home Secretary will reconsider his views on this subject,
in the light of the evidence that has been adduced, including
the remarkable proofs furnished through Mr. Mundella, by
Dr. Barr, of the way in which many employers have exacted
fees from parents in large excess oven of the charges of the
certifying surgeon—a fact which so well explains the objec¬
tion of some parents to the certifying surgeons. Sir William
Houldsworth’s opposition to the certifying surgeons has very
much surprised some of his friends. Probably the member for-
North-west Manchester has been imperfectly reported, and
we believe he may yet be found favourable to legislation
that will make the work of the factory surgeons still
more real and effective than it is. They must not rest on
their oars. The contest may yet be renewed under other
Di-:: ired by CjOO^Ic
The Lancet,]
PHARMACOLOGY AND THERAPEUTICS.
[Apeil 18, 1891. 89T
forms; but if factory legislation has any justihcation, the
humane and impartial office of the medical expert must be
enaintained.
HEALTH OF PROFESSOR TYNDALL.
Three weeks ago a serious relapse placed Professor
Tyndall’s life in great jeopardy from pneumonia with
double pleurisy. Improvement, however, took place, and
by our last account the chest symptoms bad, to a large
extent, subsided. There remained necessarily much weak-
eiess, but the prognosis is distinctly favourable if no further
relapse should occur.
FOREIGN UNIVERSITY INTELLIGENCE
Berne. —Dr, Tschirsch has been promoted to the Ordinary
Frofessorship of Pharmacognosis.
Ghent.—Dt. Visseber has been promoted to the Ordinary
Professorship of Forensic Medicine.
Paris .—The number of students entering for the diploma
of officicr de sanU during last year was only 358, as against
3'528 entered for the doctorate. Of these last, 114 were
women, mostly Russians.
Pennsylvania. —Dr. George E. de Schweinitz has been
appointed Lecturer on Medical Ophthalmoscopy in the
University.
Prague [German Vnioersity ).-—Professor J. Schnabel of
Gratz has been appointed to the chair of Ophthalmology.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Rull, Professor of Midwifery in the Faculty of Bar¬
celona, at an advanced age.—Dr. Julio M. Rodiguez of
Matdnzas, Cuba.—Dr. Eicke of Lasdebren.
At the usual weekly meeting of the London County
■Council on Tuesday, the Main Drainage Committee pre¬
sented a report with reference to the joint report of Sir
Senjamin Baker and Mr. Binnie, the chief engineer of the
Council, upon the main drainage system of London. They
eiecommended that detailed plans be prepared of the new
sewers on both sides of the river, as proposed in the joint
report. After some discussion thefollowingriderwasadded
to the motion for the adoption of the report; “And that
the committee be instructed to obtain a farther report wliich
shall have special reference to the separation of the rainfall
from the sewage, the better prevention of storm ovevllows
iJnto the Thames and Lea, and the better purifleation of the
diver.” __
A CASE of contenarianism which would probably have
satisfied even the late Mr. W. J. Thoms is afforded by the
instance of Sir Provo William Parry Wallis, G.CB., the
Senior Admiral of the English Fleet, who completed his 100 th
year on Sunday. Ho was horn at Halifax, Nova Scotia, on
April 12th, 1791. He had maintained active habits up to
Christmas, hut since then, from illness, had kept his bed.
It is reported that “the medical authorities of the
University Hospital at Bonn have decided to discontinue
the use of Dr. Koch’s tuberculin, as well as of Dr.
Liebreich’s anti-tuberculosis remedy.” We have not, how-
•ever, seen any official announcement to this effect.
Naval Medical Supplemental Fund.— At the
quarterly meeting of the directors of the above fund, held on
the 14th iast., T. Russel Pickthorn, Esq., Inspector-General,
in the chair, the sum of £45 was distributed among the
several applicants.
PIPERAZIDINE AS A SOLVENT FOR URIC ACID.
It is stated in a German pharmaceutical journal that
piperazidine dissolves uric acid more readily than any
other substance of a basic nature. Urate of lithia require
368 times its own weight of water to dissolve it, but urate
of piperazidine dissolves in fifty times its weight of water.
It may therefore he expected that this drug will become a
fashionable, let us hope too an efficient, remedy in gout and
allied diseases.
THE EFFECTS OF STRYCHNINE ON THE STOMACH.
The effect of nitrate of strychnine on the functional
activity of the stomach has been recently made the subject
of a careful research by Dr. Gamper of St. Petersburg, who
employed for the purpose of hU experiments four healthy
young hospital assistants. He found that strychnine in¬
creased the amount of gastric juice secreted, the general
acidity, and the quantity of free acid in the secretion.
It also hastened the absorption from the stomach, and
strengthened the mechanical movements, Its effect, too,
continued for some time after its administration had been
stopped. Like many other Russian observers, Dr. Gamper
seems to have been highly impressed by the value of strych¬
nine in chronic alcoholism, declaring that it is the most
effective of all drugs in such cases. The thesis contains a
long list of references to the literature of stomach affec¬
tions, published in six or seven languages during the last
ten years.
THE ALKALOIDS IN NUX VOMICA.
The effective strength of preparations of nux vomica is
believed to be very variable, and that there is good ground
for this belief is shown by analyses made by different
observers. Thus, while some specimens of Cfeylon nux
vomica have been fovind to contain as much as 5^ per cent,
of alkaloids, others from a different source have been found
to contain as little as 11. per cent. It is indeed impossible
at the present time, as a pharmaceutical contemporary
remarks, to fix what should be considered a fair average.
CELATINISATION OF INFUSION OF DIGITALIS.
Infusions of digitalis which have been kept some time
occasionally become gelatinous or mucilaginous, the cause
of the change not being very obvious. The matter has
lately been engaging tlie attention of some German
chemists, who have found that the peculiar thickening
referred to depends upon the presence of pectin or some
very closely allied body. It has been noted that this sub-
. stance does not appear when the infusion is made carefully
from leaves whicli have been deprived of their longer
stalks, especially when the process of maceration is stopped
in about fifteen minutes.
THE ACONITE ALKALOIDS.
Tiie subject of the aconite alkaloids was discussed at a
recent meeting of- the Chemical Society, when a paper was
read by Professor Dunstan and Dr. lace. These authors
investigated the alkaloid obtained by them from the root
of aconitum napellus. The yellowish crystals melted at
188-4'’ C., and by crystallisation from the alcoholic solution
were proved to be associated with a small quantity of a
gummy amorphous base. The alcoholic solution was found
to he, contrary to the statements of previous authors,
dextro-rotatory, though the aqueous solution of the hydro¬
bromide is Imvo-robatory. Two aurochlorides were ob¬
tained without difficulty, and these compounds afford a
satisfactory means of identifying aconitine, which maybe
recovered from them in a pure state. It is not appreciably
affected by heating at a temperature below its melting
point, but at this temperature it is gradually converted
into the uncrystallisable base aconite. Prolonged boiling
in an aqueous solution induces a similar change, but not to
the Same extent unless an alkali is present. Boiling with
water acidulated with hydrochloric acid also produces de¬
composition. Dehydraconitine or apo-aconitine is a base
differing from aconitine by the absence of a molecular pro¬
portion of water. It may easily be prepared by heating
aconitine with saturated aqueous tartaric acid in closed
tubes. The crystals melt at 186-5'’ C. It forms crystalline
salts, and in other respects closely resembles the parent
alkaloid. By heating aconitine with water in a closed
tube an amorphous base, apparently identical with aconite,
was obtained. This substance is still under inveatigation
Digitized by ^ooQle
898 Thb Lancet,]
THE SANITARY CONDITION OF ESHER.
[April 18,1891.
THE LANCET
,S)}ett!t[ SHititary Contmissiiiit,
REPORT ON
THE SANITAKY CONDITION
OF ESHER.
In The Lancet of March 2l3t attention was drawn to an
epidemic of diphtheria which has prevailed in the village of
Esher during the last six months, and in our issue of
April 4th we published a letter from Mr. Izod, in which
that gentleman complained of the martyrdom the inhabi¬
tants of Esher have been enduring of late from the horrible
odours arising in .connexion with the establishment of a
new drainage scheme.
Very alarming rumours have been circulated, but on
inquiry the extent of the epidemic proves to bo less consider¬
able than the reports in some of the local papers would
imply. Still, in a population of about 2000, sixteen houses
were invaded, and thirty-two cases were notified between
Oct. 24th and April Gtb, with five deaths. Daring March no
fewer than seventeen children were certified as suffering
from diphtheria; but within ashort time after the closure of
the national schools, on March 20bh, the number of cases
began to diminish, and the hope may be entertained that
the worst is now over.
Whatever the origin of the disease may have been,
there can be no question that an important factor in
its dissemination during March was tbe communica¬
tion of diphtheria from one child to another at the
national schools, and tbe authorities are to be con¬
gratulated on having promptly taken the most practical
means of preventing a further spread of the epidemic.
Esher is some fifteen miles south-west of London on the
Portsmouth road. Ids south-eastern limits are situated on
the London clay, while the higher ground to the south-west
is the Lower Bagsbot sand, and to the north and west are
river drifts. The Mole winds along the western boundary
of the parish through low-lying marshy meadows, in close
proximity to which is the outlying hamlet of Esher, known
as West-End. The village itself is pleasantly situated on
higher ground, over which the Portsmouth road runs on its
way past Claremont Park in gentle undulations, the south¬
western extremity of the parish presenting ground of- the
most considerable altitude; on the south-east a declivity
slopes downwards to anotlier low-lying oll'aboot of the
village known as Hare Lane. Esher has been until the last
few months singularly free from zymotic disease. It derives
its water-supply from the Lambeth Water Company, and
surface wells seem to be things of the past. In ilie matter
of drainage, Esher is passing through a critical period of its
history. Until <iuite lately a cesspool system prevailed,
but within the last two years a new departure has been
made.
The new drainage scheme was designed to deal with
tbe drainage of Esher, Claygate, Thames Ditton, and the
western portion of Long Ditton. The work was commenced
in August, 1889, and has continued with intermissions ever
eince, some of the inhabitants of tbe district manifesting
considerable unwillingness to have their houses “con¬
nected.” Roughly speaking, it is estimated that rather
less than half the houses in Esber are at tbe present time
still unconnected with the new sewers. The local authority,
according to Section 23 of the Public Health Act, has only
power to deal with houses lying within 100 ft. of the sewer,
and in which the drainage is not eil'ectual. Some of the
unconnected houses lie at more than the specified distance
from the sewer, and of those that do not exceed
that distance some have doubtless adequate independent
drainage. There are still, however, situated in close
proximity to the sewers several cottages, the drainage
of which is anything but effectual. The new scheme is
theoretically aperfectone: adequate ventilation is provided,
and the flashing arrangements when complete should secure
all that can be desired ; the effluent is dealt with in a satis¬
factory manner on a sewage farm. Unfortunately, however,
at several flushing points the projected arrangements ha($
not been completed at a time when a considerable number of
houses were already connected with the sewers. The result-
seems to have been beyond anything which language cau
describe. Those who have had experience of the horrible
odours arising from manholes and interceptors express their
inability to convey any idea to the uninitiated of the smells
which prevailed io the village during the early months of
this year. In passing near a manhole “;^ou had to cut your
way with your stick.” This state of things is now happily
past history, and no smells whatever could be detected in
the neighbourhood of manholes in the early days of this-
month. At this time, however, the flushing arrangements
were still not quite completed.
Towards the end of last year more complaints of the
smells, it is said, came from Claygate than fi-om Esher^
but of late tbe brunt of tbe baotle seems to have been
borne by the latter parish. It has been suggested that
inasmuch as Esher lies somewhat higher than the'
rest of the area comprised in the new scheme it would
naturally be expected tosuffer more from the gases which have-
accumulated in the inadequately flushed pipes. Those who-
attribute the outbreak of sore-throat at Esher to the smells
arising from the manholes and interceptors lay stress upon
this point. It has been very justly urged that the new
scheme of drainage dealt with a large area, in only a section
of which deaths from diphtheria have occurred ; and it ha&
been argued if the manholes are responsible for the outbreak
how is it that no death has this year been ascribed to diph¬
theria in Claygate, Long Ditton, or Thames Ditton ? Here,
on the other hand, it is urged the question of relative alti¬
tude comes into consideration, tbe noxious gases manufac¬
tured in the whole area, having found their way to tlief
highest points in the sewer system, have escaped at-
those points and there produced disease. This argu¬
ment appears plausible at first sight, but it must be'
remembered that the difference of altitude in question
is not considerable; again, the free ventilation supplied by
the manholes renders it incredible that foul gases produced,
for example, in Claygate should travel such a distance'
along the sewers as to reach Esher, without escaping by
the manholes on their way ; indeed, the numerous-
complaints of the smells at Claygate strongly militates
against the view that Esher has suffered to any appreciable'
extent from sewer gas conveyed by the pipes from adjoin¬
ing parishes. The non-existence of diphtheria in any other
portion of the drainage area cannot, in point of fact, be dis¬
missed in this manner ; it remains as one of the problems
to be solved by those who attribute the prevalence of
sore-throat in Esher to the opening of the new drainage
scheme.
To turn now to the state of things which tbe new
scheme was designed to supersede. There can be no doubt
that in many parts of Esher there has been a most de¬
plorable development of tbe evils which a cesspool system
is capable of producing. Tbe ground in the immediate
neighbourhood of tenements is in many cases riddled with
cesspools, some of which communicated directly with the-
interior of the house, and many of which no one can
remember ever seeing emptied. No attention, in fact,
was given in many instances to the emptying of cesspoola
until their contents overflowed. One woman was afraid tO'
throw anything down the sink because the neighbours said
“it stirred the cesspool up”; and others describe how they
have noticed solid excrement floating about in the garden.
Much lias been done by the medical men in calling atten¬
tion to these iniquities, but there can be no doubt that
evils still exist which should be promptly remedied. One-
woman states, for example, that her husband’s mother-
noticed fifteen years ago that a smell proceeded from a-
sink which emptied into a cesspool, and that the communi¬
cation was accordingly stopped up, the plan adopted ever
since being to dig holes in the garden for the reception of
slops and waste material.
In the national schools the closets were supplied with
pails, and earth was provided for the children to throw
upon excreta, the pails being emptied twice weekly. The
earth does not appear, however, to have been often used
at all events, the children are almost unanimous in their
complaints of the smells which prevailed. One mother
forbade her child to use the closet on this account, and the
mother of a boy the subject of diphtheritic paralysis, stated
D, ; : Google
The Lancet,] THE SANITARY CONDITION OF ESHER. [April 18,1891. 8*99'
—II I II 1 1 .' I ' ' I . . . '. . ■■ ■ ' ' ' “ ■ 1. 1 « I ——
her son dreaded the smells of the closets so much that he
would puDish himself " rather than use them.
Dr. Gihbes, the medical officer of health, investigated
the system of removal of slops and liquid excreta at the
national schools on Alaroh 19bh, and found that there
were three cesspools, viz.:—No. 1 for the sink of the
master’s house, which had an overflow into No. 2, situated
in the girls’ and infants’ playground, which also receives
the urine and washings from the girls’ and boys’ latrines.
No. 8 received liquid refuse from the governess’ house,
and urine and washings from the infants’ latrines. None
of the cesspools were ventilated. No. 2 had not been
emptied for two years. No. 3 was emptied about two
months ago, because it was found to ne incapable of
holding more. In the girls’ closet there was direct com¬
munication with the cesspool, there being no trap ; in the
boys’ closet and under the master’s sink were placed abso¬
lutely ineffective bell-traps. The stench arising from this
cesspool, conducted by way of the sink to within a few
feet of the master’s door, was at the time of our visit last
week indescribable. The cesspool is now happily emptied, a
complete reform of the national school drainage having
been effected in the last few days.
In the annexed map is shown the situation of the house¬
holds in which cases of diphtheria have been notified io
Esher since the outbreak of the epidemic in October last.
The milk-supply of families in which attacks have occurred
has been ascertained in many instances, and it will at once
be seen that the sources from which milk has been obtained
are most diverse; no less than eight such sources have been
already counted, and there are doubtless others. In no
instance has any expression of dissatisfaction with the
character of the milk been elicited.
To Dr. C. C, Gibbes, medical officer of' health to the
Kingston rural sanitary authority, and to the medical men
of Esher we are much obliged for their kind assistance in
the prosecution of this inquiry. To Mr. Briscoe, assistant to-
Mr. Izod, we are especially indebted, his intimate acquaint¬
ance with the several districts of the parish having been
placed completely at our disposal.
MAP OP ESHEE,
Showing the Situation of Houses in which Cases of Diphtheria have reen Notified.
The capitals A, B, C to Q denote primary attacks of diphtheria in the order of their occurrence; the small letters secondary attacks
occurring in the corrosponding housoliolds. The nine circles indicate sources of luUk-supply.
Digitized by uooQle
900 Lakcbt,]
THE GERMAN CONGRESS OF INTERNAL MEDICINE.
[April 18,1891.
EXTENSIVE ARSENICAL POISONING.
By Alex. Thom, M,A., M.D. &C.M.Ed., D.P.H.R.C.S.E.
Individual cases of poisooiDg by arsenic are not very
uncommon, and have lately attracted considerable atten¬
tion, but such poisoning is fortunately somewhat rarely met
with on an extensive scale, and I think I am warranted in
placing on record an occurrence of that nature where the
symptoms were very characteristic and the materies morbi
was clearly traced to some sugar.
On Saturday, Sunday, and Monday, the 4th, 5 th, and
@bb of April, tne inhabitants of the lower part of Crieff,
known as the Bridgend, were thrown into a state of
consternation by what seemed to them the outbreak
of an epidemic of vomiting with severe pain. The
greater number of the cases, of which there were over a
hundred, occurred within a limited area which might be
embraced by a radius of an eighth or a sixth of a mile, and,
speaking generally, were in families of the artisan class.
The chief symptoms were pain and heat in the
stomach, nausea, retching, and vomiting (the vomited
matter being frequently brown and bilious-looking, and in
some cases streaked with blood), great thirst ami ex¬
treme depression, injection of the conjunctivre, and some¬
times swelling of the face and eyelids. My assistant,
Dr. Andrew Young, who attended the great majority
of the cases (he saw over eighty in the course of four
■days), reports that in some cases severe purging and
tenesmus were marked symptoms at the outset of the
attack, but were not present as a rule, and that stran-
,guiy was complained of only by a few. Several com¬
plained of cramp in various muscles. The symptoms
appeared in from ten minutes to three hours after ingestion
of a meal, which in almost every instance included tea. As
•a rule the more acute symptoms passed off in from thirty-
six to forty-eight hours, though in some instances they
lasted four or five days, but left the patient weak and
depressed. Many suffered for days from severe headache
■and nondescript abdominal pains of a colicky nature.
"Where the symptoms lasted longer there was well-marked
■ccdema of the eyelids and swelling of the face, with white
‘furred tongue, great thirst, also sharp pains in the
intestines and diarrhma, with shreddy mucous discharge
tinged with blood. Many complained of feeling the cold
■acutely, and a few suffered from severe coryza. I regret) to
say that there have been two fatal cases—a wood carter
•aged seventy-two, and his wife aged about fifty-four. Both
tliese suffered severely from purging and tenesmus, with
-great heat in the intestines, and excoriations round the
anus, scrotum, and labia, and in their case retching and
vomiting continued until death, which occurred on the
eight and ninth days respectively.
l^isoning by arsenic at once suggested itself as best
•explaining the symptoms. Indeed, in many of the patients
these were so typical that there was almost no room left
for doubt, and the treatment adopted was in accordance
with that opinion. It was not difficult either to anive at a
•conclusion as to the probable vehicle. The water and milk
•supplies were at once eliminated, and also all the ordinary
articles of diet except tea and sugar. Some of the sufferers
bad noticed that the tea had a dark appearance and a
(peculiar taste, but tbe majority had been using the same
tea for a considerable time, having had a large stock.
All tbe families attacked had got a fresh supply of sugar,
however, on the Friday or Saturday, and from one parti¬
cular merchant. In one family some members took no
■sugar with their tea, and these escaped, while the others who
•did take sugar all suffered. In another family, one member
•had taken no tea and escaped for a time, but suffered like
the rest after having partaken of the sugar along with
pudding. Many other facts pointed directly to the sugar
■<a,s the cause. The merchant in question had got a cargo of
sugar in five bags or sacks (not barrels) about the beginning
•of March, and these were all emptied one after the other
into a large barrel for storage, and from this barrel supplies
were taken as required into the shop for retailing. Nearly
half of tbe barrel had been disposed of to customers and no
ill-health had resulted hitherto when this outbreaksuddenly
■occurred.
On examining the empty sacks, one was found with a
tstain on each side full^ a foot square, which showed plainly
that some fluid material had passed through the sack and
its contained sugar at right angles to its long axis.
Examination of the sugar at the level reached in the barrel
showed a quantity more damp and of a darker colour than
the rest. As I do not possess a laboratory and could not
obtain a supply of sulphuretted hydrogen or other reagents
within a reasonable time, I despatched a portion of this
sugar to my friend Mr. Falconer King, city analyst, Edin¬
burgh, who kindly telegraphed to me on the Tuesday that
the rough tests showed tne presence of arsenic, thereby
confirming our opinion. Mr. King’s report has since then
been confirmed by the county and other analysts. On com¬
municating with the wholesale house, the merchant was
informed that over 100 bags of the same sugar had been
despatched at the same time to various customers, and that
there were no other complaints. It was impossible therefore
to avoid the conclusion that in transit this particular
sack had got part of its contents infiltrated with the
poison. So many lluid preparations, such as one par¬
ticular sheep dip and several weed-killers, contain so much
arsenic, and so often leak, that it is not difficult to imagine
how the impregnation of the sugar could occur. The
patients comprised people of all ages, children suffering
least, probably because vomiting being for them such an
easy process they at once ejected the poison. In tbe cases
where the poison proved fatal a considerable quantity of
the sugar had been partaken of.
Since writing the above I have been informed that the
police and the sugar refiners, acting together, have traced
the course of the sugar during its transit, and are of opinion
that they have discovered tne source of the poison—viz.,
some leaking tins of n liquid weed-killer, with which it is
said the sacks were in contact. Samples of this material,
and also the stained sack, are in the bands of the public
analyse for the county, and the whole matter is engaging
the attention of the authorities.
THE GERMAN CONGRESS OF INTERNAL
MEDICINE.
President's Address. — Dr, Nciunyn on Gall-stones,
The tenth annual meeting of tbe Congress fur innere
Medicin took place at Wiesbaden from the 6 th to the 8bh inst.
Professor Leyden of Berlin presided, and in his opening
address referred briefly to the history of tbe Congress during
the decade of its existence. There had been a notable
increase in tbe number of its associates, although death had
robbed them of many eminent colleagues, as von Frerichs,
von Langenbeck, and lliihle. The practice of having
subjects chosen for discussion, in which the flrst two speakers
were selected beforehand, had been found of great scientific
and practical value. He said that medical science had
continued to advance, and although this had led to in¬
creasing specialisation, yet “internal medicine” would
always continue to be regarded as representative of the
whole science; for it dealt with the whole individual, and
not merely with special regions of the body. The endeavour
towards localisation of disease and the pursuit of local
diagnosis and local therapeutics, which characterises the age,
ought not to replace the study of general conditions.
Curative treatment cannot be limited to local lesions ;
it must be directed towards assisting the whole organism
to withstand the inroads of disease. From antiquity
these two aims had been kept in view—viz , the sub¬
jection of the disease and the treatment of the sick indi¬
vidual ; and the task of our time is to follow both lines.
The first is being met by the new pharmacology, through
various new remedies, and through bacteriology, under
the leadership of R. Koch; it must be the aim of internal
medicine to prevent this tendency becoming too strong.
The tenth year of the Congress had been a notable one in
the history of medicine. It began with the remarkable
epidemic of influenza, then came the Vienna meeting of
this Congress, next the International Congress at Berlin,
and lastly the discovery of tuberculin. We are still noting
the effects of this remedy, and can hardly as yet arrive at
a final judgment upon it.
Professor Quincke (Kiel), Demme (Bernfe), and Naunyn
(Strasburg) were the elected vice-presidents, and Drs. Morig
(Munich), Miibrer (Prague), Reinhold (Freiburg), and Rom¬
berg (Leipzig) were appointed secretaries to tbe Congress.
A dlBcossron upqn Diseases due to Gall-stones was then
Di)j
.oog
Thb Lancet,]
A BURMESE BUDDHIST AND VACCINATION.
[April 18,1891. 901
opened "by Dr. Naunyn, who said that they exhibited
various types iu the typical severe attacks as well as in the
more chronic irregular forms. Since surgery is increasingly,
and with great success, coming to treat these cases, internal
medicine should not be backward, and must seek for new
methods of cure for these very chronic and insidioits forms
of disease. The questions as to the origin and formation of
the calculi are of fundamental importance for treatment,
bub have been very variously answered. Some consider
their formation due to an excess of chulesterio and bilirubin
concretions in the bile, or that the disease depends on the
materials being made insoluble through changes iu the
chemical composition and reaction of the bile. But cholesterin
occurs not only in the bile; it is found in the blood, and
the bile contains almost a constant quantity (2,^ per cent,),
without relation to the kind of nutriment, or of the
amount in the blood, which often exceeds that in the
bile. The amount of lime salts in the bile is also
very constant. Chemical changes determining the precipi¬
tation of certain constituents of the bile are not proved as
indispensable. In the aged there are often bub few sym¬
ptoms, so that during life no diagnosis is made; for whereas
among younger persons 5 to (3 per cent,, or even 10 to 12
per cent, of all bodies examined contain gall-stones, in
aged subjects the proportion is much higher. According to
Schroder, women are allvcted five times as frequently as
men; before thirty they are rare; about 25 per cent, ot the
cases occur after sixty. Women who have borne children
suffer more than others. It is inferred, therefore, that
conditions causing stagnation of bile are the cause of the
afi'ectioD, such as pregnancies, tight lacing, &c. The type
of costal respiration in females is a favouring circumstance.
The frequency of the affection in the aged points also bo
stagnation due to atony. Artificial inspissation of bile does
not form calculi, nor does the precipitation of insoluble sub¬
stances ; but it is far more probable that they arise exclu¬
sively from a change in the epithelium of the mucous
membrane of the bile ducts. The calculi, at first small
and rough, generally possess a central cavity filled with
pulpy material or fluid. Bilirubin and lime salts
are precipitated, and then cholesterin; and the former
may form a sort of shell, within which consolidation
subsequently takes place. Often the cavity contains clear
fluid, and such stones are very friable. Cholesterin is
deposited on the surface, and may penetrate into the in¬
terior; often calculi are quite white from cholesterin.
These soft stones may harden from deposit of carbonate of
lime. The biliary mucous raerabraue is always affected—
desquamative angiocholitis. The condition of stasis also
gives opportunity for the inflamed membrane to become
infected with bacilli (one form resembles the bacterium coli
commune of Escherich), which may sometimes even pene¬
trate the calculi. The phenomena of the disease may be
divided into regular typical cholelithiasis and irregular
atypical forms, the latter often leading to cancer, and
therefore of bad prognosis. As to treatment, he remarked
that but little was to be expected from so-called solvents,
as it had been shown that only very small amounts—of
poisons, for example—passed into the bile. The effect of
“ cholagogue" remedies so generally proscribed had been left
in doubt by experiment. A mi.xed diet causes a larger How
of bile than any drug, and solvent remedies are irrational,
since the bile itself is a complete solvent for material
contained in it. The excretion of bile must be mechanically
aided by improved clothing, The use of salicylic acid &c.
to prevent bacterial infection is not of much service.
Since every error iu diet brings on attacks, a main indica¬
tion is strict dieting. The good effect of Carlsbad waters
is perhaps due to excitation of peristalsis. Surgical treat¬
ment has, owing to the position of the gall-bladder, a fair
prospect of good results, and in many cases the gall¬
bladder should be entirely removed. It is usual in practice
to regard jaundice as the chief sympttuu, but veiy often
there is no jaundice present, and the suffering in such cases
is often only regarded as gastralgia.
(To be continiied.)
A BURMESE BUDDHIST AND VACCINATION.
The readers of The Lancet will be interested to hear
something of the quiet progress of civilisation in Burmah
and measures of Government, apart from punitive expedi¬
tions against hill savages and the suppression of dacoits.
The accompanyiDg letter formed part of a correspondence
which has lately been published in the vernacular issue of
the Government Gazette and widely distributed through the
country. It is optional here with municipal boards to make
vaccination compulsory within their limits. Siuce the
occurrences herein related several of the larger towns have
followed the example of Rangoon and adopted compulsory
vacciuatioD. On his return from leave in October last, Dr.
Pedley found a letter from the Sanitary Comraissioner
waiting for a reply. It stated that the President of the
Township Committee of Allanmyo had failed iu his en¬
deavours to persuade the people of that place to adopt
vaccination, but bad heard that the late Chief Commissioner,,
Sir Charles Bernard, had in Durbar awarded a gold chain to
a Loogyee (head man) for furthering the cause of vaccination
amongst the Burmese. He inquired by what means the
Loogyee had so succeeded.
The following was the reply from Dr. T. P. Pedley,
Health Officer, Rangoon Municipality, to the Sanitary
Commissioner and Superintendent of Vaccination, Burmah:
Rangoon, Oct. 7tli, 1889;
S728
Sir,—I n answer to your letter. No. ^—--- dated Aug-
15 V>
8th, 1889, with enclosures, I have the honour and pleasure-
to give you au account of the valuable assistance rendered
by Oo Dway in furthering the cause of vaccination in
Rangoon. Small-pox was prevalent in this municipality im
1883-84. During this epidemic some 2000 people were
attacked and 885 died ; of these G15 were children.
Vaccination was nob compulsory—in fact, the Burmese
were so prejudiced against the operation that the
municipal committee could nob decide bo have the Act
enforced. When the epidemic began the subject of
vaccination was much discussed among the Burmese,
and a special meeting of the Loogyees was held tO'
consider the matter. I was present, and explained the
advantages of the operation, and begged them to assist me’
in getting the children vaccinated, for many of them werer
dying in the town. I received many promises, but wa^
greatly discouraged, for very few of the men really in¬
terested themselves in the matter. When I and the-
vaccinators visited their quarters they were ready with alii
sorts of excuses, but did little or nothing to use their
influence among their people, so that few children were
vaccinated. Oo Dway, Myogan Loogyee (village head'
man) of Dalla came to me and asked me to pay a-
visit to his village, which is oh the otlier side of
the river, opposite Rangoon. He promised to have a.
number of children ready, and fixed what he considered
would be a fortunate day. I went to Dalla accordingly^
and was most agreeably surprised bo find that the Loogyeei
had gathered, the women and children, with a large crowd of
people, at his house. I was allowed to vaccinate all the-
babies—Oo Dway’s grandchildren first,—which I did witlo
great care and gentleness, promising medicines and special
care if any of them should suffer from the operation.
After this, every child in this large village was vacci¬
nated, for Oo Dway persuaded the other Loogyees, and'
brought me the Sayas (native doctors) and inoculators, whom’
we showed how to vaccinate, and convinced them of the-
eificacy of the operation. This lost was not difficult, for
it soon became known that, while many children in the^
adjacent villages were ill or dying of small-pox, in Dalla-
there were very few eases, and no deaths from it, among the-
children. Oo Dway’s example had a good effect among the
Loogyees in Rangoon, for they began to interest themsmves,
and many of the Sayas threw aside the old practice of
iooculation and learnt how to vaccinate, some of thent
becoming municipal vaccinators. The prejudices against
the operation were broken down; and when the proposal'
was made to the municipal committee the next year to-
enforce vaccination, the Burmese members voted with the
Europeans for it. Since then we have had no trouble, and*
regard the good work of the vaccination department with
pride, feeling convinced that large numbers of lives andi
much suffering have been saved by its ott’orte.
One day after the epidemic had ceased, I asked Oo Dway
how it was that, while the other Loogyees had disappointed
me and given so little assisbaoce in this work, he had come-
forward. I think his reply is well worthy of record, and
his reasons, if widely made known, might do good among
his fellow countrymen. He said that he was present at the
meeting of Loogyees, and came to the conclusion that if
vaccination would, as they had been told, save the lives of
ogit
502 The Lancet,]
REPORTS OF MEDICAL OFFICERS OF HEALTH.
[April 18, 1891.
the children, it was a work of great merit, and worthy of the
best attention of a good Buddhist. Regarding the matter
chus seriously, be m^e special visits to the Sboay Dagon
Pagoda, and in prayer sought the guidance of the higher
powers. One ni^ht about this time he had a dream. He
thought that while sitting on the bank of the river he saw
a number of pieces of wood floating down to the sea. He
■thought it a pity that they should thus be wasted. So.
.getting into a canoe, he paddled out into the stream, and
succeeded in collecting a large quantity, which he piled on
the shore, and was much pleased with his good luck. He
eays he thought much about this dream, wondering what it
might portend. It dawned upon him that the driftwood
meant the lives of the children, which might be saved
■if he could persuade their parents to have them vacci¬
nated. He hesitated no longer about the matter, but
acted as I have above described. I believe Oo Dway to be
a kind-hearted man, who lives up to the best teachings of
his religion. He is much beloved by the people of his
•quarter, and respected by those who know him. I referred
to the assistance he had given me in my Sanitary Report
for 1884, and mentioned the matter to the Chief Oom-
Dnissioner. Sir Charles Bernard expressed great pleasure in
being able to publicly recognise Oo D way’s good work. I
(know that the reward of the gold chain was not expected,
and believe that the highest motives prompted his benevo¬
lent endeavours.
I have the honour to be, Sir, your obedient servant,
T. F. Pedley,
Health Officer, Rangoon Municipality.
^aWit anil ^aar fata.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF MEDICAL OFFICERS OF HEALTH.
Teignmouth Urban District. —Dr. Cecil H. Piggott calcu¬
lates the death-rate during 1890 for the two component
parts of this district as 17'2 per 1000 for Teignmouth and
(19'3 for Shalden; and, in referring to the infectious diseases,
he explains that, the existing means of isolation being
inadecjuate, no cases were removed to the hospital. On the
.question of drainage generally. Dr. Piggott reports that
the authority has every reason to congratulate itself upon
the satisfactory completion of several much-needed im¬
provements. Oddly enough, this same authority, on re¬
ceiving the report, declared that it tended to convey a
“ wrong impression to the outside public as to the drainage
•of the town.” We regret to hear this, for if, as Dr. Piggott
says, the drainage is now a matter of congratulation, the
•authority must know something against it which their
medical officer of health has not reported on. But this seems
hardly possible, and hence we look through the report again
to see this meaning of this warning which the local board
has made so public; and the only other explanation of it
lies in a detailed account of the sanitary circumstances of
a building where enteric fever took place. Happily for
Teignmouth, no general faulty condition was found to he
■concerned in this preventable disease; it was due to local
conditions affecting the actual premises attacked, and Dr.
Piggott, drawing the right and proper inference, suggests
that action should be taken to prevent any further similar
-occurrence. But he adds that in Teignrnouth there are,
happily, few such spots to be found. And yet this officer
is asked for the future so to report as not to prejudice the
health of the town. The things that are prejudicial are
the high death-rate and the resolution of the authority,
■and the one comforting fact is a report which explains
that faulty circumstances affecting public sewers and
house drainage are not allowed to remain when once
•discovered. Fortunately, intending visitors to Teign¬
mouth can, so long as the present medical officer of
health remains in office, feel assured that improvements
•called for in the interests of public health will, as
heretofore, be continued; and that, if the present high
death-rate admits of being speedily reduced, the authority,
and the public electing them as their representatives, will
be openly advised as to the measures that are needed to
this end. The authority would do well to pass resolutions
■which will give confidence to the public, instead of such
auggestive ones as that recently adopted. A resolution, for
example, to provide at once some adequate means of isolation
would be much, more to the benefit of Teignmouth than the
attitude now adopted.
Sutton Coldfield Urban District. —The maintained small
death-rate, averaging some 12 per 1000 per annum, must be
regarded with satisfaction by the Town Council and by
Dr. Bostock Hill, their health adviser; and the small
zymotic rate adds to the satisfactory result. Where prevent¬
able disease occurs, the defects are pointed out and remedied,
and this work is made the more complete by the adoption
of the Notification Act. The carelessness which goes on in
the face of the high mortality from measles in this country
is adverted to, and the action which can be taken in con¬
trolling it by restricting school attendances is pointed out
at some length. Excellent records are embodied in the
report as to the systematic sanitary action and inspection in
progress, and as to the meteorology of the locality ; but the
year’s sanitary history is in one sense satisfactorily brief;
for, as Dr. Hill asserts, Sutton Coldfield for three con¬
secutive years has taken its stand in the first rank of
healtiiy towns, and in 1890 it bad the lowest rate of general
death and of infant death of all the boroughs in the county
of Warwick.
Uxbridge Urban District. —Mr. W. Kayner shows the
excellent use to which the joint hospital for infectious
diseases was put during the past year, and with the steady
isolation of diphtheria, which is evidently in progress, we may
hope that this disease, which some time since was severely
epidemic, may be permanently checked, for inspection of
schools and other allied work seems also to be steadily
maintained. Happily, only one death from any zymotic
disease took place, and where any such coses occurred
cleansing, disinfection, isolation, and removal of insanitary
circumstances were fully carried out.
Stroted Jiziral District. —Some detailed account is given
by Mr. Partridge as to the general inspection of this district
during 1890 and of the results attained, as also of the
causes of death which prevailed. The death-rate from all
causes has been almost continuously falling since 1875, and
it was 14^7 per 1000 last year ; the zymotic rate was also
small—namely, per 1000. Some diphtheria occurred,
and, as is commonly the case, it prevailed chielly amongst
children aggregated in one of the elementary schools.
Occasion was properly taken to remedy a number of
sanitary defects, both at the school and at the houses of
those who were attacked. There were also fifty-three
attacks from scarlet fever, but no death. Some extension
of the public water-service has taken place, but there is
need ot similar progress in respect of public sewers.
Stroud Urban District. —Unlike the Stroud rural district,
this town is stated to be hesitating about the desirability
of learning whether infectious disease is prevailing in its
midst or nob, and at the date of Mr. Partridge’s report noti¬
fication was still in abeyance. The annual death-rate for
1890 was IG'2 per thousand. Steps are being taken to
remedy a deficiency in the public water-supply, and it is to
be hoped that when this is completed no further accounts
of unwholesome supplies will be possible.
Bisley Urban District. —This district is also under Mr.
Partridge’s health supervision, and it had a death-rate last
year of 15 per thousand living. Some cases resembling
enteric fever were found to be associated with defective
sanitary surroundiogs ; the water-supply is from wells,
many of which are of a doubtful character, and this
although a public service would appear to be available.
Reading between the lines of this report, it is clear that the
health officer is of opinion that the death-rate of this little
town is too high, and that there are conditions within it
capable at any time of causing much greater mortality.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In bwenfw-eight of the largest English towns 6615 births
and 4400 deaths were registered during the week ending
April 11th. The annual rate of mortality in these towns,
which had been 21’2 and 22'4 per 1000 in the preceding two
weeks, further rose to 22'9 last week. The rate was 20^0
in London and 25'3 in the twenty-seven provinciaJ towns.
During the thirteen weeks of last quarter the death-rate
in the twenty-eight towns averaged 23 0 per 1000, and
slightly exceeded the mean rate in the corresponding
periods of the ten years 1881-90. The lowest rates in thwe
Coogle
The Lancet,]
THE REVISED SCHEME OF THE LONDON UNIVERSITY. [April 18,1891. 90^
towns last week were 18’3 in Brighton, 19-4 in Birkenhead,
l9’5in Norwich, and 19‘8 in Nottingham ; the highest rates
were 29*7 in Manchester, 34'1 in Newcastle-upon-Tyne,
34-2 in Manchester, and 42’6 in Hull. The deaths referred to
the principal zymotic diseases, which had been 414 and 468 in
the preceding two weeks, declined again last week to 438;
they included 157 from measles, 147 from whooping-cough,
40 from diphtheria, 36 from scarlet fever, 30 from “ fever ”
(principally enteric), 28 from diarrhcea, and not one from
small-pox. These diseases caused the lowest death-rates in
Brighton, Sunderland, Birkenhead, and Wolverhampton,
and the highest rates in Leicester, Blackburn, Huddersfield,
and Portsmouth. The greatest mortality from measles
occurred in Bristol, Blackburn, Huddersfield, and Ports¬
mouth ; from scarlet fever in Bradford ; and from whooping-
cough in Newcastle-upon-Tyne, Leicester, Derby, and
Halifax. The mortality from “fever” showed no marked
excess in any of the twenty-eight towns. The 40 deaths
from diphtheria included 26 in London, 4 in Salford, and 2
each in Manchester, Liverpool, and Sheffield. No fatal
case of small-pox was registered in any of the twenty-eight
towns; 7 small-pox patients were under treatment in the
Metropolitan Asylum Hospitals and 1 in the Highgate
Small-pox Hospital on Saturday last. The number of scarlet
fever patients in the Metropolitan Asylum Hospitals and
in the London Fever Hospital at the end of the week was
1018, and showed a further decline from recent weekly
numbers; the patients admitted during the week were 77,
against 81 and 98 in the preceding two weeks. The deaths
referred to diseases of the respiratory organs in London,
which had been 466 and 489 in the previous two weeks, de¬
clined to 464 last week, but exceeded by 30 the corrected
weekly average. The causes of 94, or 2-1 per cent., of the
deaths in the twenty-eight towns were not certified either
by a registered medical practitioner or by a coroner. All
the causes of death were duly certified' in Portsmouth,
Leicester, Preston, Leeds, and in seven other smaller towns;
the largest proportions of uncertified deaths were recorded
in Salford, Sheffield, Hull, and Liverpool.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had been 26’7 and 2G'2 per 1000 in the preceding two
weeks, further declined to 25 0 during the week ending
April 11th, but exceeded by 21 the rate that prevailed
during the same period in the twenty-eight large English
towns. The rates in the eight Scotch towns ranged from
15‘4 in Perth and 16’4 in Greenock to 30’4 in Glasgow and
52’5 in Paisley. The 653 deaths in these towns showed
a decline of 31 from the number in the preceding
week, and included 33 which were referred to measles,
25 to whooping-cough, 7 to diarrhcea, 6 to “fever,” 5 to
diphtheria, 4 to scarlet fever, and not one to small-pox.
In all, 80 deaths resulted from these principal zymotic
diseases, against numbers increasing from 73 to 100 in
the preceding three weeks. These 80 deaths were equal to an
annual rate of 3'1 per 1000, which exceeded by 0 8 the mean
rate last week from the same diseases in the twenty-eight
English towns. Thefatal cases of measles, which had increased
in the preceding five weeks from 16 to 41, declined again
last week to 33, of which 19 occurred iu Paisley and 12
in Glasgow. The deaths referred to whooping-cough, which
bad been 34 and 28 in the previous two weeks, further
declined to 25 last week, and included 16 in Glasgow and
3 in Leith. The 6 fatal cases of “fever” exceeded the
number recorded in any recent week ; 3 occurred in Glas¬
gow and 2 in Aberdeen. The 5 deaths from diphtheria
showed a decline of 4 from the number in the preceding
week, and included 2 in Glasgow, where 3 of the 4 fatal
cases of scarlet fever were also recorded. The deaths
referred to diseases of the respiratory organs in these towns,
which had declined from 201 to 166 in the preceding four
weeks, were 164 last week, and exceeded by 38 the number
in the corresponding week of last year. The causes of 63,
or nearly 10 per cent., of the deaths in the eight towns last
week were not certified.
HEALTH OF DUBLIN.
The death-rate in Dublin, which had been 29‘1 and 23-9
per 1000 iu the preceding two weeks, rose again to 30-6
during the week ending April 11th. During the thirteen
weeks of last quarter the death-rate in the city averaged
30‘2 per 1000, the rate for the same period being 22-6 in
London and 21‘8 in Edinburgh. The 207 deaths in Dublin
showed an increase of 45 upon the number in the preceding
week, and included 6 which were referred to “fever,” 2 tO’
whooping-cough, 1 to diphtheria, and not one either tO'
small-pox, measles, scarlet fever, or diarrhcea. Thus the
deaths referred to the principal zymotic diseases, which had
declined from 11 to 5 in the preceding three weeks, rose
again last week to 8; they were equal to an annual rate
of 1‘2 per 1000, the rate from the same diseases being 1‘8'>
in London and 0'9 in Edinburgh. The deaths referred
to different forms of “ fever,” which had declined from 4 tu
1 in the previous three weeks, rose again to 5 last week,
and exceeded the number recorded in any week since
January last. The fatal cases of whooping-cough, whiclb
had been 3 in each of the preceding two weeks, were 2 last
week. The 207 deaths in Dublin included 34 of infants^
under one year of age and 57 of persons aged upwards of
sixty years; the deaths both of infants and of elderly
persons showed an increase upon those recorded in the pre¬
ceding week. Six inquest cases and 5 deaths from violence
were registered; and 59, or more than a fourth, of the-
deaths occurred in public institutions. The causes of 24,
or nearly 12 per cent., of the deaths in the city were nob
certified.
“ Audi alteram partem."
THE REVISED SCHEME OF THE LONDON"
UNIVERSITY.
To tfie Editors of The Lancet.
Sirs, —You will, I hope, sufficiently bear in mind the
motto at the head of your correspondence column to allow
me to say a few words in favour of the scheme of the
Senate of the London University to which you are so
strongly opposed. Your first argument against it is that
it is not formed on the lines laid down by the Royal Com¬
mission, and your chief reason for this statement is that-
the new scheme will admit provincial constituent colleges
to the University. This is a mistake. It will not admit-
them; it will only render it possible for them to be-
admitted, for Section 26 says that the admission of
provincial constituent colleges shall be determined by
the Senate, and Section 27 gives the Senate power to
remove provincial constituent colleges. The London and
provinci^ parts of the University are kept so distinct
that the latter may be brought in or taken out without-
any interference with the London Colleges. It is quite
conceivable, and even probable, that either none of the-
provincial Colleges may apply for admission, or that, if they
do, the Senate may not be satisfied with the grounds given
for such admission. The London Constituent Colleges—
viz., University College, King’s College, and the London
medical schools—are, however, constituent colleges in their
own right; so that your statement that “it [t-he schemej
endeavours to bring under the central control of Burlington-
gardens all the University Colleges of Arts and Science in
England and Wales, instead of adapting its organisa¬
tion mainly to the London Colleges and medical
schools,” is incorrect, especially as there is no inten¬
tion of admitting “ all the University Colleges,” for the
chief of them are already affiliated to the Victoria Xmiver-
sity. You next contend that the scheme is at variance-
with the report of the Royal CouimUsion because it does
not alter the M.D. degree. It alters it by making it much
more accessible than it has been hitherto, for it proposes-
that by one set of professional examinations, conducted by
examiners appointed conjointly by the Royal College of
Physicians, the Royal College of Surgeons, and the Univer¬
sity, the candidate may take his L.R.C.P., his M.R.C,S,,
and his M.B,, thus saving expense, diminishing the number
of examinations, and consequently decreasing the risk of
failure. But it does not follow, as you seem to think, that
power to give degrees will thus be handed over to the Royal
Colleges, for while, if the Colleges are satisfied, the candidate-
will be granted his L.R.C.P. and M.R.C.S., he will only be
granted his M.B. if the Senate and the University Board
of Studies are satisfied. I think I have shown that the
scheme is not so opposed to the spirit and working detail
of the report of the Royal Commission as you suppose.
Coogle
904 Thb Lancet,]
THE ARMY MEDICAL DEPARTMENT.
[April 18,1891.
Your second argument is that the scheme will not satisfy
any of the bodies interested. I should have thought it was
obvious that when so many bodies are interested, and
each would like as much as it can get, it would be impos¬
sible to satisfy them all; but surely it speaks well for the
scheme that it has already been adopted by the Senate, the
Royal College of Physicians, the Royal College of Surgeons,
Guy’s, Sb. Bartholomew’s, St. Thomas’s, London, Charing-
cross, Sb. Mary’s, Middlesex, St. George’s, and Westminster
Hospitals, the London School of Medicine for Women, the
Incorporated Law Society, and (with certain reservations
with regard to the provincial colleges) by University and
King’s Colleges. Probably everyone thinks he could
improve the scheme, but it seems to me that it ought to be
strongly supported by Convocation, for it is the only one
which has yet been proposed which commands support
from almost all the bodies concerned. Farther, those who
oppose it should consider what will happen if it is rejected,
^or then one of two things will come to pass: either the
medical faculty of the London schools will be left in its
present unsatisfactory state for many years to come, or a
second university will be founded in London. This will
lead to dangerous rivalry, and probably to the degradation
of the degrees in one or both of the universities. Also, there
will be great confusion between the two London degrees.
I am, Sirs, yours faithfully,
Harley-streot, W. W. HALE WllITE, M.D. Lond.
is immersed, it will be found that the current is consider¬
ably increased under the latter condition. This result is,
however, in no way due to the superior conductivity of the
body, but to the fact that its conductivity is added to that
of the water, since they are practically in parallel circuit,
or the sectional area of that portion of the circuit may be
regarded as thereby increased, and consequently its resist¬
ance diminished. Again, it is quite true that if salt or
acid be added to the water, it will become a better
conductor, but not that the whole of the current will
then pass through it. In fact, but little current will
be thereby diverted from the patient, since as the
resistance of the circuit is diminished the total current is
increased, and will be divided between conductors in
parallel inversely as their resistances; so that whilst the
current through the bath would be increased, that through
the patient would be but little diminished, and that
diminution would not be due to the current selecting the
path of least resistance, but because, by increasing the
conductivity of that portion of the circuit, the gradient of
potential is rendered less steep. I must not be understood
as calling in question the fact that the body may under
some circumstances be a better conductor than the water,
but only as stating that the above experiments have no
direct bearing upon the question.
I am, Sirs, yours faithfully,
Southport, Maruh 30tli, 1891. FREDERICK GeORGE, M.D.
*,* If Dr. Hale White compares the proposed constitu¬
tion of the Senate in the new scheme with that proposed
fcy the Royal Commission he will see that provincial repre¬
sentatives are included in the former and not in the latter.
He should also be aware that the “ latest” scheme differs
from the one before the “latest” in making arrangements
for including provincial colleges, and was introduced as the
outcome of a distinct objection on the part of those colleges to
be excluded from a share in the reconstituted University,
as well as in its management. This is in direct opposi¬
tion to the recommendation of the Royal Commissioners,
who merely suggested “access to the examinations and
degrees” for provincial students, as is now the case.
Unless the scheme lowers the M.D. degree by changing the
earlier matriculation and preliminary scientific examina¬
tions, it cannot render that degree more accessible. It
simply compels every London pass M.B. student to come
under the examination .system of the Royal Colleges, and
that at an increased expense to the intending graduate.
Does Dr. Hale White intend to convey that the members
of the medical staffs of the various London hospitals have
of&cially met to consider the scheme, and that it has been
regularly voted on and agreed to by them ? Dr. Hale White
should not have accepted so readily arguments employed in
an exparle memorandum, which would seem to be drawn
up by the Senate of the University to influence the voting
o{ Convocation on May 12ch next.—E d. L.
THE ELECTRIC BATH.
To the Editors of The Lancet,
Sirs, —The experiment quoted by Beard and Rockwell,
■to which Dr. Steavenson alludes as proving that the body
•conducts the electric current better than water, has little to
do with their relative conductivities, but depends entirely
upon the difference of potential between the two positions
in the bath in which the two hands are immersed. If there
were a difference of 50 volts between the head and foot
•electrodes, and the bands were immersed three feet apart,
there would be a difference of potential of about 20 volts
■between the right and left hanos, and the current through
the body would equal in fractions of an ampbre that voltage
•divided by tberesistancein ohms, and astbedietance between
them is diminished so also will be the voltage and current.
If, however, the hands were placed the same distance apart
across the bath there would be no difference of potential
and consequently no current. Another experiment was
quoted to me a short time ago which was supposed to prove
the same thing, and is as follows. If a galvamometer be
included in the circuit of a galvanic bath and the current
noted, through the water alone and also when the patient
THE ARMY MEDICAL DEPARTMENT.
To the Editors of The Lancet.
Sirs, —An able and lucid article in The Lancet of
March 28th, 1891, concludes as follows : “ We would pro¬
test against the assumption that the profession of medicine
is in need of any reflected dignity. It has every bit as
much title to respect as the profession of arms.” It has
more right to respect than the profession of arms, which is
not a learned profession, but unfortunately in the array,
at any rate, it does not obtain the respect to which
it is entitled, and never will until its officers have
distinct and intelligible military rank and titles. This
is lamentable, but it is tnre, as army medical officers
well know; and it is to this aspect of the case I
crave the powerful support of The Lancet. I wish
you could see the state of things at the station from
which I write. It is a very large one, where society is
exclusively naval and military, and the medical depart¬
ment is at the bottom of the social scale, not from any
peculiarity of its members, many of whom have brothers,
cousins, or schoolfellows among the combatant officers of
the garrison, but solely because they have no military rank
or status. It may be difficult for a civilian to understand
this, but to those accustomed to military habits the question
is simple enough, and they will see that among military
society a man without rank and title is nowhere. I can
assure you that if Sir Andrew Clark or Sir James Paget
formed part of this garrison they would have their corns
trodden upon many times every week. They would find
that they were not considered fit to preside over even a
sanitary committee, of which the most junior subalterns of
tbe station, who might even be their own sons, formed a
part. That they could not form part of a court martial by
which one of their own men was tried, and that they and
their belongings were avoided by society for fear that those
who associated with them might be branded with social
inferiority ; and all this because they have no military rank
and status. How can any olHcers, except they are super¬
human, perform their duties, with zeal and interest under
I such circumstances?
j I am, Sirs, yours truly,
I April 14lh, 1891. MEDICAL STAFF.
PRE-HISTORIC TREPHINING.
To the Editors of The Lancet.
Sirs, —It may interest some of your readers who are in¬
terested in the question of pre-historic trephining to know
that a very full and most interesting account of the operation
is to bn found in Miss A. W. Buckland’s paper, “Surgery
and Superstition in Neolithic Times.” read ad the meeting
of the Anthropological Institute on Feb. 8th, 1881, and pub¬
lished in the journal of the Society, vol, xi., pp. 7-21. On
Coogle
The Lancet,]
NORTHERN COUNTIES NOTES.—SCOTLAND.
[April 18,1891. S05
May 106h, 1887, Mr. Victor Horsley read a paper before the
same Society on “ Trephining in the Neolithic Age,” which
gave rise to a most interesting discussion. The discussion
and an abstract of the paper appear in the Society’s journal,
vol. xvii., pp. 100-107. As your correspondent, Mr. Keyworth,
states, M. N. Joly, in his book, “Man before Metals,’’being the
forty-fourth volumeof the international series, deals very fully
with the subject; he accepts the usual explanation, which
also has the approval of M. Broca, that the operation was
due to the superstition of “possession ” by an evil spirit—a
superstition that long continued, as evidenced by the form of
exorcism which was used during the baptismal service in the
Church of England which appears in the Prayer Book of
Edward VI., A. D. 1549, as follows:—“I commando thee,
uncleane spirite, in the name of the Father, of the Sonne,
and of the Holy Ghost, that thou come out, and departe
from these infantes, whom our Lord Jesus Christo hath
vouohsaned to call to his holy Baptisme, to be made
membres of his body, and of his lioly congregacion. There¬
fore thou cursed spirite, remembre thy sentence, remembre
thy iudgemente, remembre the daye to be at hande, wherin
thou shalt burne in fyio euerlasting, prepared for thee and
thy Angels. And presume not hereafter to exercise any
tyrannye towarde these infantes, whom Christe hath bought
in his precious bloud, and by this his holy Baptisme called
to be of his flocke.”
Children were occasionally credited with being possessed
by good spirits ; such a one was the infant of Kberberg, an
account of whom was published in this city by Dr. Arthur
Jacob in A,D 1823. A great deal of information dealing
with the subject of “ possession ” is contained in Herbert
Spencer’s Sociology, chap, xvii., vol. i,, 2nd edit , A.B. 1877;
Clodd’s “Childhood of Religions,” A D. 1875; Reginald
Scott’s “ Discoveries of Witchcraft,” a.d. 1.584, a reprint
of which by Dr, Brinsley Nicholson was published by Elliot
Stock in A.D. 1880. —I am, Sirs, yours truly,
George Foy, F.R.C S.I.
Cavenilisli row, Ilutland-square, Dublin, April lOtli, 1801.
“ASTASIA-ABASIA.”
To the Editors of The Lancet.
Sirs,— On page 791 of The Lancet there is a record of a
case with a big name, “astasia-abasia,” reported by Mr.
G. H. Hammond of New York. Five cases of a similar
affection were reported by me in the St, Bartholomew’s Hos¬
pital Reports, vol. XXV., p. 201 (copy of which I enclose for
reference), under tbe title “Disuse of Limbs after Severe
Disease : a Pseudo-Paralysis,” and I have just now dis¬
charged from the Colchester Hospital a similar case, a brief
report of which I enclose. The alfection can hardly be
considered a paralysis, for when the weight of the body is
supported by the bed or by nurses, the limbs can be moved.
It 13 rather an exhausted condition of muscles, which
under suitable treatment are easily repaired. The first
point is to obtain the conddence of the patient and to
induce a belief that recovery is certain. The first use of
muscles after a long period of disuse is very fatiguing ; but,
recovery being assured, patients soon find power returning
after efforts made, and, being encouraged by this to proceed,
improvement becomes rapid.
I am, Sirs, yours obediently,
Alexander Wallace.
April 14tlj, 1801. Physician to Essex and Colchester Hospital.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Uncertified Deaths in Durham.
Dr. Jepson, in his annual report to the Durham Rural
Sanitary Authority, notices the large number of uncertifled
deaths. Of .‘$21 deaths 91 were uncertified; and, de¬
ducting deaths from injury where inquests have been held,
he says that 29 per cent, have not been properly accounted
for, and justly remarks that the term “natural causes” is
unacceptable as a registered cause of death. With regard
to an outbreak of scarlet fever in October, he says ic ap¬
peared to be coincident with the return of children to the
various schools.
A Durham County Centenarian.
Mr. Thomas Ironsides, farmer, of Kvbbloawortb, a few
miles from Gateshead, celebrated his lOObh birthday on
Sunday last. He is said to be in robust health, and
exhibits so few signs of decay that it would be difficult
for a stranger to hazard a guess at his age. The farm
which he occupies, of 200 acres, is on the estate of tbe Earl
of Ravensworbli, and the bouse in which he now resides is
the one in which he was born. Mr. Ironsides has a large
' family, most of them living, his eldest son being now over
seventy years of age. He is, although not a teetotaller,
always moderate in his use of alcoholic drinks.
Railway Ambulance Work at Gateshead.
Certificates and badges have been presented to the mem¬
bers of the North-Eastern Railway Ambulance class at
Gateshead. The class is a large one, and has been examined
by Surgeon-Major Halton for the St. John Ambulance Aeso-
ciation. On behalf of the class, Dr. Purdie, its instructor,
was presented with a splendid edition of Sir Walter Scott's
works in twenty-five volumes.
Carlisle Infirmary.
It is stated that the “Jubilee Endowment Fund,” which
Mr. Parker of Carleton Hill, the late treasurer of the
Cumberland Infirmary, Carlisle, raised as a memorial o3
Her Majesty’s Jubilee, has now reached £2225. Lord
Leconfield has just contributed £25.
Sunderland: the Asylum Question,
What is to be done with lunatics chargeable to Sunder¬
land is now a prominent question in the town. Hitherto
the Durham County Asylum at Sedgefield has been able
to receive them, but now even that vast establishment baa
not sufficient room, and declines to take any more from
this borough. It appears that Sunderland has contributed
nearly £1().000 towards the Sedgefield institution, and this
sum is ollbred by Sedgefield as a sort of compensation to
Sunderland, and to enable it to build an asylum of its own,
but Sunderland asks for £.50,000. The difference between
these sums is so great that tbe commissioners appointed
under the Act will have to decide what proportion Sunder¬
land is entitled to. It is quite certain that the autboritiea
will have to build, and build largely, to provide the
requisite accommodation. The local papers publish quite
a large list of subscriptions to the Infirmary, and they are-
for the most part from working men and organised sub¬
scriptions from workshops in the town and district.
Jlorspfiesh.
At the Gateshead Police-court last Friday two men
from Sunderland were fined for ill-treating and working
a horse while in an unfit condition. Evidence for tbe
prosecution showed that while being spoken to as to the
unfitness of the horse for work it fell dead. It transpired
that it was being driven to a tanyard for slaughter, and
that a higher price was given in Gateshead than in Sunder¬
land because the Ilesh was afterwards forwarded in tuba
to Antwerp by steamer.
The Perils of Football.
On Sunday last a young man aged twenty died at
Middlesbrough. On tbe previous day deceased played in a
football match at Haverton Hill, and was injured in the
abdomen. lie walked home, and was afterwards medically
attended, but died rather suddenly. During the progress
of a match at Leasingthorne, on Saturday, one of the home
team had the misfortune to have his leg fractured, and
another broke his collar-bone.
A most successful concert, under the patronage of the
mayor, was given last week for the benefit of the building
fund of the Eye Infirmary.
The Liverpool Sessional Grand .Jury has issued a pre¬
sentment for the demolition of 600 houses which had been
condemned on account of their insanitary condition.
Nowcastle-on-Tyno, April lUtla.
SCOTLAND.
(From our own Correspondents.)
Edinhxirgh University General Cotineil.
Reports have been issued in view of the statutory half-
yearly meeting of the General Council of the University by
committees appointed by the Council, and these reports con¬
tain points of importance as regards the medical faculty.
With reference to examiners and examinations, they
Die ad by lOOglC
$06 Ths LAifCST,]
SCOTLAND.—DUBLIN.
[April 18,1891.
approve of the proposals that (1) the extra-mural teachers
should be included in the list of examiners for their
respective subjects along with qualified persons neither pro¬
fessors nor extra-mural teachers ; and (2) that the number
of examiners should be suJficient to prevent the possibility
of any candidate being examined wholly or chiefly by the
professor or the extra-mural teacher in the subject of his
own lectures. The committee are also in favour of oral
examinations for degrees being open to all members of the
University. As regards the remuneration of professors’
assistants, the committee are of opinion (1) that any fees
derived from instruction given by assistants and not by pro¬
fessors should, after deduction of whatever might be
deemed reasonable for university purposes and class
■expenses, be appropriated to the payment of the assistants
who give such instruction; (2) that the aim should be to
obtain for senior assistants who give their whole time to
university work a salary at least equivalent to that
attached to tutorships at the English universities, which
may be estimated at from £200 to £300 a year, and for
junior assistants payment in proportion to their time
employed.
Edinburgh Public Health Committee.
The statistics submitted to the Public Health Committee
of the Edinburgh Town Council show that the total number
of deaths in the city during the month of March was 513,
making the death-rate 22'35 per 1000, while the average
during the same month for the five preceding years was
19-59 per 1000. The rate differed greatly in the different
districts, it being 17‘29 in the southern district, 19'99 in the
New Town, and 27‘SO in the Old Town. As regards age,
31 •96 per cent, of the total deaths were under 5 years,
ll'll per cent, between 5 and 25, 25 34 per cent, between
25 and 60, and31‘57 percent, above 60 years. The deaths
from diseases of the chest numbered 185, and from zymotic
diseases 52, Of the latter, 5 were from typhoid fever, 6 from
diphtheria, 4 from scarlatina, 9 from measles, 26 from
whooping-cough, and 2 from erysipelas. During the month
521 cases of infectious disease were reported in the city,
as against 1199 in March of last year. The cases included
362 of measles, 91 of scarlatina, 47 of typhoid fever, and
21 of diphtheria. The number of patients in the City
Hospital at the end of the month was 223, of which 51 were
cases of typhoid fever. 8 of diphtheria, 101 of scarlatina,
28 of measles, 11 of whooping-cough, and 10 of erysipelas.
The amount of unsound meat seized or condemned during
the month was 35,4351b. Of 138 carcases seized or con¬
demned during the last fortnight of March,^ 70 were un¬
marketable, 13 tuberculous, and 10 deconiposing.
Extension of Edinburgh Jtoyal Infirmary.
The question of the extension of the Royal Infirmary is
still under consideration, and it is understood that a depu¬
tation waited upon the Estates Committee of George
Watson’s Hospital with a view to the possibility of acquir¬
ing the elementary department of the college for boys. The
difliculty here also is to obtain suitable accommodation for
the juvenile department of the school if the present site and
buildings are disposed of to the infirmary.
Fever Patients at the Leith llosyital.
The directors of the Leith Hospital have given notice to
the Town Council of Leith, as local authority, that they
have resolved to terminate the arrangement under which
-fever patients have been received into the hospital. This
will necessitate the provision by the local authority of a
hospital for the reception of such cases.
Health of Edinburgh.
The mortality last week was 94, making the death-rate
18 per 1000. Diseases of the chest accounted for 34 deaths,
and zymotic diseases for 4. The intimations for tlie week
included 2 from typhoid fever, 2 from diphtheria, 27 from
scarlatina, and 109 from measles.
Death of Dr. Alexander Geddes.
The death occurred at llaokie on the 18th inst. of Dr.
Alexander Geddes from typhoid fever, contracted in the
exercise of his professional duties. Deceased began prac¬
tice in Buckie in July, when he had just graduated M.B.,
C.M , at Aberdeen University. During the course of his
medical studies he obtained distinction in several of the
classes, and acted as demonstrator of anatomy to Professor
Sbruthers for two years. His untimely death at the
beginning of a very pi-omising career is undoubtedly due to
the great devotion displayed by him during the present
outbreak of typhoid fever. He was twent^r-six years of
age, and is survived by a widowed mother, with whom the
community deeply sympathise.
Complimentary Dinner to Dr. J. C. M‘VaiL
On the lObh inst. Dr, J. U. M'Vail, the late medical officer of
health for Kilmarnock, was entertained to a complimratary
dinner in the George Hotel, Kilmarnock, on the occasion of
his leaving town to enter upon hia duties as medical officer
of health under the County Councils of Stirlingshire and
Dumbartonshire. There were about eighty gentlemen present.
Provost M'Lelland occupied the chair, and the croupiers
were Mr. Thomas Kennedy, of Glenfield Works, and Dr.
Alexander Dundonald. The Provost, in proposi^ the toast
of the evening, passed a high eulogium upon Dr. M'Vail
for the valuable services he had rendered to Kilmarnock.
A sura of £1000 has been given to St. Andrew’s Uni¬
versity towards the endowment of a botanical lectureship
or future Chair in the United College.
April
DUBLIN.
! (From our own Correspondent.)
Ether Drinking.
At a meeting of the members of the General Synod of the
Church of Ireland held last week the following resolution
was adopted: “That this Synod thankfully acknowledges
the action taken by the Government for the restriction of
the traffic in ether as an intoxicant, and respectfully urges
that further legislation is necessary for its suppression.”
A Mistake in a Prescription: Damages £200.
An application was made last week before Master Bruce
by Mr. Gray to recover damages laid at £500 against a firm
in Dublin for negligence in compounding a prescription
whereby injury was occasioned to the plaintiff. The prin¬
cipal ingredient in the prescription was aromatic spirits of
ammonia, but on taking the first dose the patient suffered
intense pain in the throat, and for a fortnight was unable
to take ordinary solid food, and his throat since then has
required treatment. Probably instead of the aromatic spirits
of ammonia the solution of ammonia was substituted, and
its corrosive action would explain the symptoms complained
of. There was no statement of defence, and the plaintift’
having marked the usual interlocutory judgment, the jury
assessed the damages at £200.
Irish Branch oj the British Dental Association.
A meeting of the Irish Branch of the British Dental
Association was held at the College of Surgeons last week,
presided over by Mr. Booth Pearsall, l''.R.C.S.I. A vote of
thanks to the outgoing president {Mr. J. C. Clarke of
Belfast) was agreed to, and regiet expressed at his absence
from illness. Mr. Pearsall having delivered the presidential
address. Dr. R. T. Stack read a paper, followed by Dr. A.
W. Baker, on “Some Septic Sequelajof Tooth Extraction.”
Models of abnormal teeth were exhibited by Mr. O’Meehan,
and the proceedings terminated.
Royal College of Surgeons.
Mr. William Thomson has resigned his seat on the
Council of the Royal College of Surgeons, and will probably
be a candidate for an examinersbip in surgery at the elec¬
tions early in M'ay. It is stated that the vacancy on the
Council will be filled up on the 28th inst.
Arbitration in a Case of Insurance Claim.
Mrs, Nicholla of Navan, having claimed a sum of £1000,
being amount of a policy effected by her late son, a medical
man, with the Accident Insurance Company, and he having
died from blood poisoning, the matter was left to arbitra¬
tion. The arbitrators decided, after hearing evidence, that
Mrs. Nicholls’ claim had been sustained; but as no satis¬
factory proof of this had in the first instance been furnished
to the Insurance Company, it was agreed that the company
should be entitled to deduct the costs of the arbitration,
Mr. B, J. Neary, medical officer of the Howth and Baldoyle
dispensary district for nearly a quarter of a century, died
last week at his residence, Howth, aged fifty-three years.
Dublin, April 1-ltli.
Digi zod L, LjOOgIC
Thb Lancbt,];
PARIS.—EGYPT,
[ApriHS, 1891. 907
PARIS,
(Feom our own Correspondents.)
New Proc&dtirc in Abscess Treatment.
The treatment of chronic or cold abscess bjr the method
of aspiration and injection of antiseptic solutions, such as
iodoform dissolved in ether, is a favourite plan of some
French surgeons, and is the one usually adopted for some
time past in the wards of M. Verneuil, now the senior
professor of clinical surgery in the Paris Faculty ; but it
•appears to have been reserved in this country to Dr. Pidchaud
•of Bordeaux to have adapted the method with success to the
treatment of acute inilammatory abscesses. Instead of the
time-honoured free incision of the most dependent part
Dr. Pidchaud aspirates the abscess, after which he injects a
solution of 1 in 1000 of corrosive sublimate. For the. past
ten months be has invariably adopted this method in bis
hospital practice, and, he declares, with njarked success.
Even if the skin over the seat of the abscess be thinned and
undermined, this is no bar to the procedure, for which he
claims as advantages that it is less painful, leads to more
rapid healing, and leaves no traces of scar.
Operative Treatment oj Goitre.
M. Reverdin of Geneva has performed thyroidectomy in
this disease in fourteen cases with only one death. His
eases were composed of ten females and four males. He
•speaks very favourably of the operation, but insists that
•care must be taken not to remove any but pathological
tissue, and that to avoid undue loss of blood each vessel
' must be progressively and securely tied or compressed. He
makes a median incision over the tumour, .and advocates
enucleation for this latter. Before undertaking'operative
measures he advises a prolonged trial of treatment by
iodoform, which he administers internally in the form of
pills.
Cocaine in Minor Buccal Surgery.
M. Combe records 200 minor operations performed on the
mouth with the aid of cocaine as an ancestbetic. He claims
that its advantages over chloroform or other general anaes¬
thetic are as real as they are apparent—with ordinary care
accidents are very rare. He insists on a freshly prepared
solution being used, and ho advises that one centigramme
•only be injected at first, and then a lapse of five minutes
allowed before the next injection is made; for he has
observed that, in those who are disposed to be unfavourably
affected by cocaine, warning symptoms become manifest after
very small doses.
Pathology and Treatment of Sympathetic Ophthalmia.
The procedure proper to be adopted in this grave affection
lis often of serious moment and consideration to the surgeon
•as well as to the patient. The modern microbic theory in
anodicino would appear to fit in very accurately as an ex¬
planation of the pathology of this hitherto insufficiently
•accounted for o.ffection. And this thesis M. Abadie very
ably sustains in the paper which he read at the recent
Congress of Surgery. In effect, the microbes invading the
wounded or diseased eye gain the optic nerve and chiasma,
and so reach the sound organ. At the first sign that the
'latter is involved M. Abadie advises the free cauterisation
with the galvano-cautery of the diseased organ, and the
injection into the vitreous of a drop of a solution of 1 in 1000
•of sublimate, which injection should be repeated in a few
•days if necessary. If this he done well and sulliciently
•early, not only will the sympathetic disease in the sound
•eye be arrested, but the original affection so modified that
it may often be possible to save the other eye. M. Abadie
•points out that success by this method can bo hoped for in
■recent cases only. In any others enucleation is indicated,
•and should be followed by mercurial frictions for a pro¬
longed period.
A Case of Hcrmaphrodittsui.
At a recent meeting of the Academy of Medicine
M. Polaillon read notes of a case of this curious condition,
•of the reality of which histological investigation stood
Svitness. It was a question of a person twenty-five years
•of age, to all external appearanco a female, but who had
never menstruated. The external genital organs were well
tformed, bub the vagina was represented by a little de¬
pression, scarcely two centimetres deep. The uterus was
completely absent. In the inguinal region were two little
tumours, reducible and tender to pressure. These proved
to be atrophied testicles, for on histological examination
the seminal tubules were readily recognised. There was so
trace of prostate.
- The Forthcoming Congress of Hygiene at London.
The Minister of the Interior has organised a committee
charged to assure the participation of France at the Con¬
gress on Hygiene to be held in London next August. The
committee has for its honorary president M. Pasteur, and
president M, Brouardel, Dean of the Paris Faculty; vice-
presidents, M. Mined (director of Public Hygiene at the
Ministry of the Interior), M. Bergeron (permanent secre¬
tary of the Academy of Medicine), and M. Proust (Inspector-
General of Sanitary Services). Amongst the members bf
what appears to be a very inffuential and representative
committee are Professors Cornil and Grancher, of the Pai:U
Faculty, and Dr. Vintros, of the French Hospital in London.
Altogether France promises to be well represented, and to
take an important part in the coming Congress.
Pari.'^, April I4th. _
EGYPT.
(From our own Correspondent.)
The Koch Treatment.
Processor Koch himself was so struck with the advan¬
tages of the climate of Egypt and its beneficial effects upon
his own health that he has persuaded Messrs. Cook and
Sons to construct at Luxor, but upon the west or Thebes
side of the Nile, a few houses which might be utilised for
tuberculous patients and their attendants during the months
of December, January, and February when Cairo is apt
to be both cold and damp. It is thought that numbers of
phthisical patients will come to Egypt in the future, if not
actually to undergo one of the many “cures” now before
the medical world, at least to live through a period of con¬
valescence after treatment. The experiments with tuber¬
culin have been discontinued by Mr. Milton for surgical
cases, but are still being carried on in Mr. Sandwith's
phthisical wards. Dr. Schiess at Alexandria is injecting
very large quantities of tuberculin, with some apparent
benefit to leprous patients.
Smallpox Epidemics.
During the month of March small-pox has been reported
from four provinces of Lower Egypt, but apparently only
eight villages have been attacked, giving a total of sixty
cases, of whom thirteen have died. Thesanitary department
is trying to make vaccination compulsory in -Egypt for
foreigners as well as natives, and for this purpose is intro¬
ducing weekly a supply of animal vaccine from Fiance, this
being found much cheaper than the creation and main¬
tenance of a vaccine institute in Egypt.
Typhus and Belapsing Fevers,
This is the time of year when fevers are reported from
various country districts, and as the native officers of health
are not yet competent to diagnose one fever from another,
they are classed together as “ fibvres typhiques.” Past ex¬
perience has shown that enteric fever is not one of the
component parts of these outbreaks, but that 'typhus
and relapsing fevers often exist side by side in the same
village. In studying the returns, a high mortality
is convincing proof of the prevalence of typhus fever, while
a low death-rate leads one to believe that the cases are
mostly, if not entirely, due to relapsing fever. During the
month of March there have been these fevers in all the six
provinces of the Delta, no less than twenty-five villages
having been attacked. There have been during the past
month sixty-six deaths out of a number of 620 reported
cases, and there remain under treatment now 248 patients.
At the beginning of March the weekly average of new cases
was only seventy-seven among the various villages, but for
the last two weeks the now cases have been returned as 110
and 169. As the sanitaiy statistics do not pretend to be
very exhaustive, we may assume that many more than 620
of the fellaheen have suffered from one of these fevers
during the month of March. No relapsing fever has yet
been seen in Cairo, but several cases of “ tyuhus fever”—a
few real and many spurious—are being treated in tents in the
desert outside the town.
Din-- zad by Google
908 Thb LakcbtJ
AUSTRALIA—OBirUARY.
[April 18,1891.
The New Agricvltural College.
The Egyptian Goveronient has lately opened a new school
under En^ish management, which bids uir to be a great
success. The farmer-peasant of this country works hard,
but he has not yet learnt that there are aids to farming
which his ancestors were not acquainted with. Hence the
intelligent Egyptian pasha is clever enough to see that he
and his friends may gain something by a little insight into
scientific farming, and this accounts for the popularity of
the new school. Out of some 260 applicants fifty-nine have
been selected to work for four years under Mr, 'Williamson
Wallace and his assistants, and the school can already be
congratulated upon having produced three novelties—first-
class butter, good potatoes destined for the London market,
and a native football team. The school is conducted upon
the principle that a young man will be better able to learn
to plough If he goes through a preliminary course of daily
compulsory football.
The manufacture of good butter, which is now sold to the
principal residents of Cairo, is a great boon to the phthisical
vkitor, who until now has always bad to be content with
salted butter or margarine from Europe. A dairy of twenty
Egyptian cows provides milk yielding 10 per cent, of cream
and fresh butter, while the separated milk is being experi¬
mentally tried as a special diet at Kasr el-Aini Hospital for
the native patients to whom ordinary milk acts as an aperient.
Cairo, April &th. _
AUSTRALIA.
(From our own Correspondent.)
The Meeting of the Federal Convention.
The meeting of the Federal Convention at Sydney on
Monday next is the most important event in the history of
these colonies at the present time. From a medical stand¬
point federation is a thing much to bo desired. A federal
government would—thougU not perhaps at first—have many
medical questions to deal with. First and foremost would
comethequestionofquarantine. AsIpointedoutlastmontb,
the quarantine regulations differ in each of the colonies.
Victoria has the reputation of being the most erratic in its
treatment of foreign arrivals. The Victorians assert that the
other colonies are not sufficiently strict in their examination,
and they point out that small-pox, cholera, or any other
dire disease admitted to one of the eastern colonies would
soon spread over the whole continent. It is therefore quite
probable that before long a federal quarantine authority
will be established to watch over the interests of the
colonies at large. Then there is the great q^iestion of
medical registration. Each colony possesses a distinct
register, and the registration certificate of one colony
carries no authority to practise across the border. In New
South Wales, besides producing diplomas, the person
desiring to register must also hand in a recent photograph
with an autograph signature, and appear personally before
the Medical Board. The other colonies are not so exacting.
Many hard-headed people here think it is a far cry to
colonial federation, but at present it is so much in people’s
minds and on their tongues that something is sure to come,
whether it be close political union or only consultative
action. Amongst the delegates it is interesting to note
that the two who stand pre-eminently above their fellows are
Sir George Grey and Sir Henry Parkes, both men who have
spent their lives amidst political turmoil, and are now, when
verging on fourscore years, both eloquent and far-seeing
leaders of men. The only medical man in the convention is
Dr. Cockburn of Adelaide, the late Premier of South
Australia, who is a graduate of the London University.
Koch's Treatment.
The Koch discovery created a great sensation in these
colonies when the announcement was made by cable. The
various colonial Governments immediately appointed medi¬
cal delegates to investigate the subject in Berlin, and
their return has been awaited with much interest.
There are so many phthisical immigrants to these shores
every year that the death-rate from phthisis in Melbourne
and the other large cities is quite equal to that of London.
The spread of the disease amongst the native born Austra¬
lians faas become a very serious matter, and in a country
where charlatanism reigns supreme it was tobe feared that the
Koch treatment would have beenrun for profit. Theaction
of the Medical Society of Victoria, in calling on the Govern¬
ment to cause the Koch remedy to be included in the list
of poisons, and thereby to prevent unqualified persons from
using iti, is much to be commended. 'The authorities of the
Sydney Hospital have refused for the present to allow experi¬
ments to be made in that institution, so that any experience
to be acquired must be gained in private practice. The
attitude of the profession here with respect to the matter
is one of reserve. We are so accustomed to “booms” of
various kinds that this last medical “boom” has not
caused much surprise.
A Typhoid Fever “Specific."
Undeterred by the evil resultsarising from the premature
disclosure of JDr. Koch’aremedy, a Melbourne surgeon of some
standing has announced the discovery of a typhoid fever
specific. It appears thatwhenoperatinglasbyearon acase of
suppurating hydatids in which the pus had a most offensive
odour Dr. O’Hara of Melbourne by some mischance opened
up the chyle duct. Immediately the chyle came in contact
with the pus the stench ceased as if by magic. Dr. O’Hara.
was so much struck by this that he handed a bottle of the
chyle to a bacteriologist, who made many experiments
with a “fungus not unlike common yeast,” which h©
cultivated from the chyle. He found the cerevisia to be a
powerful deodorantand germicide. It was fatal to the cultiva¬
tions of typhoid and diphtheritic bacilli to which itwas added,
and had cured a ease of typhoid fever when given as a last-
chance medicine. On thesequalitiesof chyle becoming known
to Dr. O’Hara,he used the “fungus” which the bacteriologist
had sent him, and, according to his own statement, with
great sirccess. Several patients who were in extremis from
typhoid fever rapidly recovered, and diphtheritic throats on
which the remedy had been sprayed quickly got well. Then
Dr. O’Hara, who is a leader in the profession and a surgeon
to the Alfred Hospital, induced some of his colleagues
to try the “specific.” They did so, but the trials were
carried out in so unsatisfactory a manner that for an
accurate estimation of the value of the remedy they were
quite useless. On hearing what was going on the com¬
mittee of the Alfred Hospital very wisely dissociated the
institution from the whole businesf.
Sydney, Fob. 28th. __
HENRY PARRELL DAVIS, M,D. St. And , M.R.C.&.
We regret to have to chronicle the death, after a painful
illness, of Dr, Henry Parrell Davis. He was born in London
in 1817. His father was a well-known practitioner, who-
lived in Red-lion-aquare. In his early career Dr. Davis
was devoted to the study of classics, and for a few years h©
taught Latin and Greek in a large school at Ealing. He
retained through all his life a great love for these languages,
his favourite book being the Greek Testament, which he
read even on the day he died. He entered Westminister
and Middlesex Ho.spitals, and qualified in 1841. He assisted
his father in a very laborious practice, but in 1840 he married
and settled in the north-west of London, where he remainetJ
in active practice until 1880, when he retired, much to the
regret of his patients, who were deeply attached to him on
account of his simple and unaffected manners. He was
through all bis life a sincere but unostentatious Christian,,
his motto being In Deo spes mea. He leaves behind him
three daughters and two eons ; both the latter are following
their father’s profession. _
WILLIAM ROYSTON PIKE, M.D.Durii.
Dr. Boyston Pike began his professional career by th©
old-fashioned pupilage to Dr. Michael Foster, then of
Huntingdon. He afterwards studied at St. Thomas’s-
Hospital, and became a Licentiate of the Apothecaries’"
Hall in 1870. Dr. Pike then sailed for Australia as “ship-
doctor,” and remained for a short time in practice at
Melbourne as an assistant. Returning to England, he
passed the examination for the membership of the Royal
College of Surgeons in 1872, and shortly afterwards became
visiting surgeon to the out-patients at the Royal Ports¬
mouth Hospital. He had great enthusiasm in his work.
Dir Coogle
Thb Lancet,]
THE ROYAL BRITISH NURSES’ ASSOCIATION.
[April 18,1891. 9(.9
«specially iu operative surgery aod difScult midwifery, and
4). large scope lor practice among the poor was odered to
him by hia appointment as medical officer for the parish of
Southeea. lie also acted for a short time as medical
officer of health for Southsea. Cultivating a largo general
practice, he gave up his paid appointments and acted as
ourgeoQ for out-patients, and afterwards as full surgeon to
the Royal Hospital. By his hospital patients he was regarded
as a friend, and in private practice he was very successful,
gaining the confidence and esteem of an increasing climUle.
Little more than a year ago he graduated as M.I). at the
Barham University, and since ^at time his health has
eteadily failed. Obscure symptoms pointing to some form
of blood-poisoning ended in degenerative disease, with albu¬
minuria and dropsy. After a long rest in the autumn of
1890 Br. Pike struggled on through the winter, attending
several arduous cases, and making a great fight for life and
work. Even when laid aside in uie autumn, and suffering
tfrom urgent dyspnoea, he insisted on accompanying the
writer to a very severe case of hmmatemesis. Many medical
men have fallen at their posts, stricken down as surely as
by the rifle bullet or the eabre stroke, and on that long
death-roll must be inscribed the name of William Koyston
Pike. Br. Pike was, very shortly before his death (which
took place on April 3rd, 1891} appointed senior physician
to the Royal Portsmouth Hospital, with which institution
his name has been in some way associated for twenty years.
BR. GEORGE BEKNARB HOFFMEISTER.
It is with great regret we have to record the death of
53r. George Bernard Hofl'meister, M.A, M.B., M.B.C.S,,
at the early age of thirty-two, thus closing a career
of exceptional promise and ability. His death was
caused by his being thrown from his horse on Tuesday,
March 2tbh, producing concussion of brain, followed by
fight hemiplegia. Mr. Thomas Smith was immediately
summoned, and performed the operation of trephining. The
atient’s condition fluctuated much from day to day, and
id not terminate fatally till the sixteenth day after the
accident, consciousness never having been thoroughly re¬
gained. Br. Hoffmeister was educated at Epsom College,
afterwards at Gonville and Caius College, Cambridge,
whence he proceeded to St. Bartholomew’s Hospital. He
alsostudied at the universities of Bonn and Vienna. Amongst
other honours be obtained the B.Sc. Lond. (first in honours
in Botany), 1879; M.A. Camh., 1884; B.A. (first class
Natural Science Tripos, specially distinguished), 1880;
M.B., 1890; M.R.C.S. Eng, 1884; gold medalist in
Medical Botany of the Apothecaries’ Society, 1883; first
prizeman Natural Science, Caius College, Cambridge,
1877-80, and Natural Science Scholarship, 1877-84;
ShuttlewortU Scholarship. Cambridge University, 1879-81 ;
Gilchrist Scholarship, University of London, 1877-79;
Epsom Scholarship, St. Bartholomew’s Hospital, 1877-84.
Me was surgeon to the Royal Yacht Sijuadron; late
surgeon to the royal mail steamship Bengal, P. & 0. Com¬
pany ; house physician to St. Bartholomew’s Hospital,
1885 ; lecturer on Biology, Royal Medical College, Epsom,
1881-84 Among his contributions were the following:
“Bismuth and Bismuth Compounds ” (/oMm. Med. Soc.,
1881); “The Influence of Race on the Course and
Treatment of Disease,” Pyaciitioner, 1890 A firm believer
in the old quotation, “Mens aana in oorpore sano,” he
"distinguished himself iu the athletic world and secured
anany lionours. He had ever the greatest love for the sea,
and had acquired considerable reputation in the yachting
world by his clever handling of small racing yachts. Ho
accompanied Lord and the late Lady Brassey on what
proved the latter’s last voyage in the yacht Sunbeam, and
was with Lady Brassey at her sad death. He was appointed,
•with his father, the late Sir William Hoffmeister and his
brother, Dr. William Hoffmeister, as one of the surgeons to
4he (.^ueen and Royal Family in the Isle of Wight in 1888.
THE SERVICES.
Armv Medical Staff. —The undermentioned Surgeons-
Major retire on retired pay (dated April 15bh, 1891): Henry
William Joynt and David Leckie, M.B.
Naval Medical Service. — Tlie following appoint¬
ments have been made at the Admiralty;—Fleet Surgeon
Evelyn R H. Pollard to the Orlando (undated); Staff Sur¬
geon Jas. A. Collob to the Superb (dated April 14th, 1891).
Surgeons: Walter H. S. Stalkarbt to the Superb (dated
April 14th,1891); Martin H. Atocktothe OWando (undated);
John H. Thomas to the Orlando (dated April 24th, 1891);
Percy W. Bassett Smith to the Penguin, and John L.
Barrington to the Nankin (both dated April 15bh, 1891);
Mr. H. F, Temple to be Surgeon and Agent at Budleigh
Salberton.
Volunteer Corps. — Rifle: 2ad Volunteer Battalion,
the Suffolk Regiment: Henry Cecil Harper, Gent., to be
Acting Surgeon (dated April llbh, 1891).—2Qd Volunteer
Battalion, the Prince Albert’s (Somersetshire Light In¬
fantry): The undermentioned Acting Surgeons to be Sur¬
geons:—H. M. Keramis and T. L. Laxton (both dated
April 11th, 1891).—2ad (Berwickshire) Volunteer Battalion,
the King’s Own Scottish Borderers: Acting Surgeon T. L.
Crooke resigns his appointment (dated April 11th, 1891).—
2nd Volunteer Battalion, the Worcestershire Regiment:
Acting Surgeon A. C. Keep, M.D., to be Surgeon (dated
April llbh, 1891) —3rd (Dundee Hiehland) Volunteer Bat¬
talion, the Black Watch (Royal Highlanders): William
Kinnear, M.B , bo be Surgeon (dated April 11th, 1891).—
3rd Middlesex: George William Henry French, Gent, to
bo Acting Surgeon (dated April llth. 1891).—Ist Tower
Hamlets (the Tower Hamlets Rifle Volunteer Brigade);
Acting Surgeon J. D. Pratt, M.D., to be Surgeon (dated
April llth, 1891). _
ROYAL COLLEGE OF SURGEONS OF
ENGLAND.
At au extraordinary meeting of the Council of the College,
held on the lObh inst, the Report of the Committee on the
Proposed Regulations and Examinations on the Extension
of the Medical Curriculum to Five Years was considered
and discussed, but the decision on the subject will not be
made public until it has been agreed upon with the
Royal College of Physicians.
THE ROYAL BRITISH NURSES’ ASSOCIATION.
A MEETING of the Royal British Nurses’ Association was
held at 20, Hanover-square on Thursday last, at which Sir
William Savory, Barb., took the cha'r. Her Royal Highness
Princess Christian was present.
Mr. Bedford Fenwick pointed out that the meeting was
convened to consider the position of the Association in view
of recent attacks which had been made upon it by certain
interested bodies because the Association sought to be regis¬
tered under the Companies Acts without the word “limited,”
and without which they would not be legally entitled to receive
and administer trust funds. Sir James Crichton Browne,
Lord Chancellor’s Visitor in Lunacy, in moving the first
resolution, took occasion to refer senatim to the argnments
which had been urged by the opponents of the Association.
He characterised them as “ flimsy and sophistical, and in
many cases distinctly incorrect.” Mr. Brudenell Carter, in
seconding, said he bad been at a loss to conjecture what
reasons could be urged by their opponents against the pro¬
posals. Ho found, however, they had no reasons, bub pretexts
only of the most frivolous character. Mrs. Bedford Fenwick
Dr. Pavy, Dr. Bezly Thorne, and Mrs. Catherine Wood
also gave short addresses. Sir Edward Sieveking moved
and Sir Joseph Fayrer seconded a vote of thanks to Sir
William Savory for presiding. Ou the motion of the chair¬
man, a vote of thanks to Princess Christian for being
present was heartily accorded. We reserve a fuller account
of the meeting for our next issue.
Mkdioo-Psychologioal Association.— At the
next quarterly meeting of the Medico-Psychological Asso¬
ciation, to be held at Brislington House, Bristol, on May Ist,
atSi'.M., the following papers will be read:—Dr. Hack
Take, on “Pritchard and Symonds in especial relation to
Mental Science.” Dr. Weatherly, on “The Use and
Abuse of Hyoscine.” Dr. Bonville Fox, “ Notes on a few
unusual ca^es of General Paralysis.”
MEDICAL NEWS.
IApeil 18,1891.
910 The Lancet,]
ilfhiral itk.
Examining Board in England by the Royal
COLLEGES OP Physicians and Surgeons.— The following
gentlemen passed the Second Examination of the Board ac
a meeting of the Examiners on the 9th inst.
Anatomy and Physiology.—Vi. E. Leetbam Honier, Joseph B. Waite,
T. Villiers Crosby, ami G. H. Cawley Way, of University Col¬
lege ; John W. Haines, Alexander C. Gurney, .1. Burnell Great-
Rex. G. Raymond Pox, Courtney H. Drake, and J. Lyttloton Dalby,
of St. Bartholomew’s Hospital; Edward Bromet, Alfred E. Russell,
Sidney W. F. Richardson, and Henry W. Harding, of St. Tliomas’s
Hospital; Charles J. E. Cock and William T. White, of Cbaring-
oross Hospital; C. Kemble James, of Middlesex Hospital; Nathaniel
D. S. Towne and C. Poulett Harris, of London Hospital; W. Cliar-
rington Wood and Mark A. Saltmarsl), of St. Mary's Hospital;
F. Kenneth Wilson, of Westminster Hospital; and Courtnay R.
. Colley, of Guy's Hospital.
Anatomy only. —Dan Davies, of London Hospital; Leonanl J. Miskin,
of St. M.ary'a Hospital; Charles H. Nicholson, of Middlesex Hos¬
pital ; H. Oallway Larnder, of St. Mary’s Hospital; and Barnet
^\il, of Charin^rosa Hospital.
Physiology oniy.—Hubert Williams, of Middlesex Hospital; A. Walter
Au.sten and William H. Chute, of Westminster Hospital; and
Ernest G. Annis, of Guy's Hospital.
Pasfied on the lOfch inat.:—
Anatomy and Physiology. —L. E. V. Every-Clayton, of Guy's Hos¬
pital ; Albert W. Riley and William H. Thomas, of London
Hospital; Frederic Cecil Robinson, Walter H. Pollard, E. Lawson
Pawlett, Harold B. Meakin, and Thomas Hampton, of St. Bartho¬
lomew’s Hospital; W. West Linington, Antony A. Martin, Robert
Corfe, and Colin D. Lindsey, of St. Mary's Hospital; John Harper
and Arthur Dob.son, of St. Thomas's Hospital; F. Nesfleld Cookson,
of Middlesex Hospital; Charles B. Wallis and Frederick C. Spawson,
of King’s College ; H. Matthew Dowler and C. Dudley Garrett, of
'iVeatminster Hospital; and H. R. Belcher Hickman, of St. George's
Hospital.
Anatomy only. —Hobart J. W. Barlee and Francis H. Bailey-King, of
Middlesex Hospital; Philip G. Williams, of London Hospital; and
Arnold Stockton, of King's College.
Physiology only.—Aitlmr Buinas, of Charing-cross Hospital; Alexander'
M. Watts, of University College ; Fredericlc A. Cooke, of St. Mary’s
Hospital; William E. Leo, of St. Bartholomew's Hospital; and
Archibald J. Campbell, of St. Thomas’.s Hospital.
Passed on the 136h inat.:—
Anatomy and Physiology.—3. Maepherson Stewart and T. Bernard
Stedman, of University College; Charles G. Cory and Sydney
Coniish, of St. Bartholomew’s Hospital; W, Archibald Propert,
of St. George’s Hospital; Wilfred Fleming, of Westminster llos-
pital; Daniel B. Evans, H. Gwynne Lawrence, Edgar J. Morgan,
and G. Bushman Riddick, of St. Mary's HospiLal; J. l-l. Gilbert
Rogers, of London Hospital; Percy J, ProbynaiulT. Blgee Cunily, of
Cliaring-cross Hospital; Cliarles H. Watson and W, Pope Seed, of
Middlesex Hospital; R. Hilton Fagge and Q, Leslie Eastes, of Guy's
Hospital.
Anatomy only.—Leonard Harman, of St. Thomas’s Hospital; A.
Condell Strand, of Middlesex Hospital; Herbert C. Wimble, of
St. Bartholomew's Hospital and Mr. Cooke’s School of Anatomy
and Physiology ; and J. West, Summerhays, of St. Mary’s Hospital.
Physiology only .—T. H. Pryco klorris, of Middlesex Hospital; William
R. Lavbalestier and H. Walker Whitley, of Charing cross Hospital;
H. Nauntoii Robson, of St. Thomas’s Hospital; and Clurles H.
Wilmer, of St. Bartholomew's Hospital and Mr. Cooke’s School of
Anatomy and Physiology.
Passed on the 11th inat.:—
Anat.r/my and Physiology. — William Gardner and John Oavrett.
of St. Mary’s Hospital; Hugh M. Righy, Victor J. Batteson, and
Harry B. B. Porter, of London Hospital; Tiicmas W. W. Burge.ss,
Percy C. Barford, Evelyn O. B. Atlams, Percy E, Adams, Frederick
W. Robertson, and Percy B. Turner, of St, Bartholomew's Hospital ;
Walter F. Henley, of Charing-cross Hospital ; John F. Sarjeant,
William Way, Wilfred 15. Htulleaton, and John Kekwick, of Mid¬
dlesex Hospital; Elias F. Harwood, Arthur P. Nuttivll, John P.
Kitson, and Thomas 11. Llewellyn, of University College ; Frederick
S. Penny, of Kin^s College ; George A. Clai'icsoii, of St. George's
Hospital; and Arthur F. W. King, of St. Thomas's Hospital.
Anatomy oaf//.—Harold J. K. Bamflold, John H. Campbell, anil John
B. Yelf, of St. Mii.ry'a Hospital; Henry A. Andrews, of St. Bartho¬
lomew’s Ho.spital; Edgar J, Rowbothani and Hubert A. Madge, of
Charing-cross Ho.spital; end Walter L. Stuart, of Guy’.s Hospital.
Physiology only. — Moses J. Reubens, of Grant Mtdical Coilogo,
Bombay
Passed on the 15th inst.
Anatomy and Physiology.—"RoggnoXA N. Weekes, H. 'T. M. Whitling,
C. Mackenzie Hewer, and Robert H. Willcin, of St. Bartholomew'^s
Hospital; C. Beauchamp Hall, of St. Mary’s Ho.spital; Moyle
Breton, of St. George’s Ilospital; F. J. Godwin and Edmund B.
Jones, of Charin^-eroHB Hospital; W. David Jones, Adam Cowes,
and J. Lloyd Davies, of University Colloge ; diaries H. Dickons and
P. Clennell Fenwick, of St. 'Thomas’s Hospital; Henry W. Collier,
Guy B. Manning, and Harold P. Batkei', of Guy's Hospital; Martin
W. Loy, of London Hospibi-l; Mark Farrant, of We.'stminstor Ho.s¬
pital ; and Ernest Playfaii', of King's College.
Anatomy only.—'N. Berkeley Murray and Richard S. Olver, of King's
College ; Alfred J. Grant, of St. Thomas's Hospital; and William
Wyllys, of St, Bartholomew's Hospital.
Physiology only. —T. Dobson Bell, of University College; Arthur .T.
MathUon, of Guy’s Hospital; and George I't. Harcourt, of St.
Thomas's Hospital.
University of Glasgow.—T he following gentle¬
men have passed the First Professional Exaimuation for
the degrees of Bachelor of Medicine (M.B.) and Master in
Surgery (C.M.);—
John Ewing Adam, Andrew Phillips Altkon, John Allan, .John Gibson
Anderson, John Bain, David Blair, M.A., James Boyle, Waltei"
Buchanan, Edward Napier Burnett, Archinald Campbell, Thomas
It. A. A. G. Crawford, Thomas Crossan, James Donaldson, Duncan
Drummond, William Moyes Dulf, James Findlay, William David
Findlay, Robert Scott TTew. Robert Uowieson Gemmell, Ernest
William Graham, Thoe, Holmes, William Humphreys Jamison,
Edgar Milwyime Jenkins, John Connan Lauder, John Herbert
Lawson, John Joseph I.owell, James Wm. van Millingen, Alan Muir.
Wm, Edgar Macharg, Chas. M'Kay, John M'Kcnna, Jas. Campbell
M'Neillie, Alfred George Newell, Peter Patton Petrie, M.A.. Wni.
Salmond, .Toaeph Scott, John Selkirk, M.A., Henry Beveridge Smith,
Thos. David Smith, James Thomson, M.A., Robert Nicol White.
The following gentlemen have passed the Second Pro¬
fessional, ExQ.niination:—
Walter Isaac Buchanan, Archibald Prentice Campbell, David James-
MacGoun Uampbell, William Campbell, John Joseph Cavnithers,
David Charters, Thomas Colvin, William Copland, 'william James-
Uouper, Robinson Ruddock Cioyle, James Conway Davies, John
Stanley Davies, AI.A., George Edg.ar, James Domild Finlay, Alfred;
Forrest, M.A.. Honry'Nivon Gardiner, Alfred Alex, Cumming
Grant, David Fraser Harris, B.Sc., William Muim Hunter, .Tames-
Jack, Henry Bdwanl Jones, Alexander Kelso, David Millar King,
William Anderson ICirkwood, .lames Lang, Robert Langmuir, M. A.,
Robert M'Farlane Marsliall, Thomas Burns Marsliall, James Binnie
Millar, David Ramsay Miller, Edward James Morris. John Mon'ison,
Wm. M’Niven Muat, Wm. Muir (Paisley), Colin Campbell M'Call,
Alex. Hutchison M'Oracken, James Morton MacLauchlan, John
Alfred Naismith, George Nicoll, John Paxton, .James Pettigrew,
Eugene Loui.s Pollonais, Archibald Robertson, M.A., Hector
Monteith Robertson, Francis Small, Nathaniel Stevenson, M.A.,
Robert Teiment, James Thomson, Alfred Webster, John Cameron-
Young.
The following gentlemen have passed the Third Pro¬
fessional Examination, including, in the cases marked with
asterisks, the subject of Pathology:—
James Aitken, William Liinont Brown, Adam Guthrie Burrell,
■^Alexander BailUo Craig, .Totin Alexander Creighton, John David
Davies, Donald Stewart Dewar, Robinson Simpson Dickson, Thos,
Divine, 'Noil Downie, 'Andrew Findlay, Robert Forsyth, *David
Frame, M.A,, ’David Wyllio Girvan, ’John Green, John Atkinson.
Harrison, James Hunter, Hngii Kerr, M.A., David Clark Laird,
'Peter Alexander Laird, James Lament, John Lindsay, M.A., Jas.
Buolian Littlejohn, Samuel T. M'Oiintock Lowry, *Robt. Mortimer
Malcolm, 'William Cochrane Murray, Alex. Christie M'Arthur,
Donald Douglas Macdonald, 'Donald Neil Macfarlano, Joiin
M'Gregor, 'Charles Hugh M'llwraitli, M.A., Alexander Johm
M'Kechnie, John Pearson, Henry Joseph Rankin, 'David Smith,
Peter Maclean Smyth, 'Maurice Tancred Stack, 'William Steel,
•William Caldwell Steele, John Stewart, David Robert Thomaoii
Strong, ’George Morvyn Sydenham, 'James Allan Wilson, Oharles*
Fredericlc Wylie.
Royal Colleges of Physicians and Surgeons-
OF Ireland: Conjoint Scheme.—T he following have-
passed the First Professional Examination:—
A. T. Benson, J. G. Berne, C. A. Black, E. A. Bourke, E. A, Culligan,
G. S. Davidge, 0. J. Fallon, Marie Goodwin, R. Ilassard, G. Martin,.
E. J. Moore, D. O'Brien. M. O. Sterling, \V. F. Tliomline, W. A-
Twigg, E. Tynan, and J. H. Walsh.
Royal College of Surgeons in Ireland ;.
Schools of Surgery. —The following prizes have been
awarded :—Prac^'4C60/Afcrftane.- 1. E, J. Goode. 2. Acheson
Aiken and J. A. Walsh (equal). Chemistry: First Prize—
E. A. Bourke and G. Sandys Davidge (equal). Midwifery:
1. S. Kelly. 2. John Gilbert. Surgery: 1. W. J. Trewhella.
2. J. J. Brennan —Mr. A. G. Chance has been admitted a
Fellow of the College.
Pharmaceutical Society of Ireland. — The
following have obtained the licence :—L Murray, S. Adam¬
son, J. S. Wilson, and W. White —The undernamed have
passed the examination to act as registered Druggists for
the sale of the scheduled poisons :—H. C. Backhouse, R. S.
Chapman, T. J. Connery, J. Darcy, D. Donohoe, H. Farrell,.
J. A. Gardiner, T. Gordon, W. Gore, B Haydock, E. M.
Hewetson, F. C. Judge, L. Kingsmill, J. R. Midleton, J.
Mullen, J. J. O’Donnell, J. H. Parker, K. H. Percy, R.
Poole, P. C. Roche, R. E. Scarlett, W. Selkirk, W. Wade,
R. T. White, and W. Willis.
The WAT.T5R-,supply of Ci-iKSTER.—A well-attended
meeting of the Chester Medical Society has been held at the
Chester Inlirmary to discuss the water-supply of the city.
Dr. Roberts presided. Dr. Dobie road a paper on the suIj-
jeeb. He stated his belief that the river Dee was a con¬
taminated source of supply, and to be condemned on that-
ground. He submitted a motion to that effect, and con¬
siderable discussion ensued. Ultimately a resolution was
adopted that the Town Council he requested to ask the
Local Government Board to hold a public inquiry into the
conditions of the water service of Chester.
The Lancet,]
MEDICAL NEWS.
[April 18,1891. 911
Royal College of Surgeons in Ireland.—M r.
Arthur Gerald Chance, having passed the necessary exaiqjl-
nation, has been admitted a Fellow of the College.
Longevity in Ireland.—D uring the December
•quarter there were five deaths of persons registered who
were centenarians. Two of these were 100 years, two 103
years, and one 100 years of age.
Vegetarianism.— The London Vegetarian Society
foes arranged to hold a public debate at the Memorial Hall on
Thursday, April 23rd, when they will maintain the advan¬
tages of pulses, grains, fruits, ana nuts versus fisb, liesh, and
fowl. Supporters and opponents should at once send in their
names to the organising secretary. Memorial Hall, Far-
ringdon-streeb, E.C.
North London Hospital for Consumption.—
Mr. B. L. Cohen presided at the festival dinner of this
institution, held at the Hdtel M^tropole, Whitehall, on
Wednesday. A large company was present. The chair¬
man, in proposing “Success to the Hospital,” urged the
claims of the charity, and solicited a generous response.
The extension of the hospital had become necessary to cope
with the growing demands upon it, and £6500 was specially
desired to be raised for that purpose, and to add thirty new
beds. Towards this object £2500 had already been con¬
tributed. The secretary subsequently announced a long
list of subscriptions.
Society for Relief of Widows and Orphans
OF Medical Men.— At the quarterly court of directors of
this Society, held on April 8th, the President, Sir James
Paget, in the chair, one new member was elected and the
deaths of two reported. A fresh application for a grant
was made by a widow, and an immediate grant of ten
guineas was made pending the inquiry into the case. The
death of one widow was announced, and one had ceased to
«.pply for assistance, and two orphans had become ineligible
through age for further grants. Applications for grants
were read from sixty-two widows, tweVe orphans, and three
orphans on the Copeland Fund, and £1383 lOs was recom¬
mended to be divided among them at the next courb. The
expenses of the quarter were £68 05. The following gentle¬
men were nominated for election as directors at the annual
general meeting:—Dr. Kussell Reynolds, in the place of
Dr. Matthews Duncan, deceased ; and Dr. Ogle, Dr. Church,
Mr. Durham, Mr. Vasey, Dr. Hickman, and Mr. G. E. Keele
•in the place of the six senior directors, who retire. The
annual general meeting was fixed to be held on Thursday,
May 28th, at 5 o’clock.
Bequests and Donations to Hospitals.— The
late Mr. Thos. Walker of Doncaster bequeathed £500 to
the Doncaster Infirmary. — The Companies of Merchant
Taylors and Mercers have made grants of £200 and £500
respectively to the Buildings Completion Fund of the Royal
Free Hospital, Gray’s-inn-road.—Under the will of the late
Mrs. Jane Entwistle of Reading and Tunbridge Wells, the
National Hospital for the Paralysed and Epileptic and the
Hospital for Hick Children, Great Oiniond-street, receive
'legacies of £200each.—The late Mayor, James Atkinson, of
Cleveland-square, London, bequeathed conditional legacies
as under—viz., £2000 to the Royal Hospital for Diseases of
the Chest, £1000 each to St. George’s Hospital and the
Cancer Hospital, and £500 each to the Westminster Dis-
S ensary, the Victoria Hospital for Sick Children, and the
rational Convalescent Institution, Margate.—Mr. W.
Cramond, late of Derby, bequeathed £500 each to the
Derbyshire Infirmary and Children’s Hospital, Derby.—
Mr. Philip Horsman, late of Wolverhampton, bequeathed
£800 each to the Wolverhampton and Staffordshire General
Hospital and theWoIverhamptonEye Infirmary,—The late
Mr. F. B. Ellison, of Hozlecroft, contributed £250 to the
Harrogate Cottage Hospital.—Mr. B. T. Woodd, J. P., of
(Knaresborough, has forwarded a donation of £100 to the
treasurer of the Royal Bath Hospital.—The Company of
'Goldsmiths has made a grant of £1000 towards the comple¬
tion of the buildings of the Great Northern Central Hospital,
Holloway-road. — The late Mr. A. Pickard of Ossett
bequeathed £1000 each to the Leeds Infirmary and Wakefield
'Infirmary, and £250 to the Leeds Hospital for Women.—
The Ciothworkers’ Livery Company has granted a further
■donation of £50 to the National Hospital for Consumption,
Ventnor.
Accidental Death of a Medical Practitioner.
An inquest was held at the Coronet’s Coart, Paddington,
last week, on the body of Mr. George Henry Blackmore,
L.R.C.P. Lond , M.K.C.S. From the evidence ib appears
that on the 30Dh ult., whilst being driven by bis coachman
in the St. Peter’s-ioad, Hampstead, the horses took fright
and bolted. The carriage was upset, and Mr. Blackmore
was dragged along for some distance, sustaining severe frac¬
tures to the ankle and ankle-joint. He died from lockjaw
in the St. Mary’s Hospital on the following Friday. The
coachman was uninjured.
Presentations.—O n Easter Tuesday a very hand¬
some testimonial was presented to Dr. Walter Groaetb
Collins as a parting gift from patients and friends on the
occasion of his leaving Midhurst. The present consists of a
silver tea and coffee service, together with a silver kettle and
stand, the latter bearing a commemorative inscription. The
whole are enclosed in a substantial case of polished zebra
wood.—Dr. G. M. Lowe of Lincoln has been presented by
the ladies of the city and district, composing a class of the
St. John Ambulance Association, with a carriage com¬
panion, containing a clock, memoranda, and the usual
I appendages, as an expression of gratitude for his able in-
I struction to them on rendering first aid to the injured.
King’s College Hospital.—T he annual festival
j dinner of this hospital was held at the Whitehall Rooms
' of the Hotel M^tropole on the 10th inst., when new dona¬
tions and annual subscriptions were announced amounting
to £2388 lOs. (id. The Lord Mayor made a strong appeal
for increased support, especially in view of the recent open¬
ing of two wards of twenty-eight beds, making a total of
220 in daily work. All the beds in the hospital are now
occupied, and the working average is greater than at any
period in the history of the hospitw. The Lord Mayor and
Lady Mayoress had previously visited the wards, and were
much pleased at the many modern improvements which
were pointed out to them, for in late years nearly £10,000
had been spent by the committee in remodelling and
improving the sanitary arrangements.
Small-pox, in St. Louis, Montreal.—A man
stricken with small-pox in a lodging-house was taken to
the City Hospital ana placed in an isolated ward. He died
a few days later. The ward was fumigated and the clothes
burned. A fortnight later two patients were seized with
the disease and hurried to quarantine. The ward they
occupied was fumigated and the clothing destroyed. Sub¬
sequently a waiter in a restaurant, who was a patient in
the hospital, was taken with the malady, and he too went
down to quarantine. The room was disinfected, and his
clothing destroyed. It was now thought the disease was
subdued. But it appeared again at the aforesaid lodging-
house, in the person of a man who had been there when the
first case occurred, and had left, coming back only a few days
afterwards. In this way be escaped the fumigation. At
the same time another case made its appearance at the City
Hospital. This patient was also sent to quarantine, and
was still there.
METROPOLITAN ASYLUMS BOARD.
Return of Patients rennaining in the several Fever Hospitals
of the Board at midnight on Apnl 1/fth, 1891,
Hospital.
Beds occupied.
Total accommo¬
dation.
£
5 9
Diphtheria.
It
•S ■
Other
diseases.
H
Eastern Hospital .. ..
150
40
43
0
244
448
STorth-Weatern Hospital
I2;i
40
14
184
443
Western
148
13
13
1
175
.224
iouth-Westem
147
23
IS
184
840
joutb-Eastem „
174
11
21'
207
468
Northern
i05
16
10
231
480
Totals _
047
168
114
6
1226
8891
Small-pox.—A tlas hospital ship, 7.
* Infant with mother.
Google
912 Thb Lancet,]
THE METROPOLITAN HOSPITALS INQUIRY.
MEDICAL NOTES IN PARLIAMENT.
. The Dispoeal of the Dead.
In the House of Commons on Tuesday night it was the intention of
Bi. Cameron to call attention to the state of the law respecting the
disposal of the dead, but the discussion on local government in rural
(Hsciiots left him no opportunity. Dr. Cameron intended to move for
thfr.appointment of a Select Committee to inquire into the sufficiency
of the existing law as to the disposal of the dead, for securing an
accurate record of the causes of death In all coses, and especially for
detecting them where death may have been duo to poison, violence, or
criminal neglect. Having in view the advanced period of the session,
it is doubtful whether Dr. Cameron will be able to find an opportunity
folr luoying his motion before the prorogation.
r/i« Pharmacy Acts Amendment Bill.
Mr. Hozier has given notice that when this Bill comos on for second
reading he will move its rejection.
Ether Drinking in Ireland.
Mr. Samuel Smith has given notice of a question for Monday next, with
reference to ether drinking in the north of Ireland. He will ask the
Chief Secretary whether he is aware that ether is sold there by
‘‘ chemists, publicans, grocers, and hawkers or ragmen, who go through
the country districts ; and whether the Government can see their way
■''to put down the sale of this drug by reiuiposing the tax upon it, or
otherwise.” .
Stillbirth Interments,
On Thursday theie was ordered, on the motion of Dr. Cameron, a
return showing (l^ the number of stillbirths interred during the year 18B0
in each of the Burial Board Cemeteries in England and Wales enumerated
in the Local Govemment Manual for 1801; (2) the number of such
stillbirths interred in each such cemetery without a certificate of a
registered medical practitioner; (3) the total number of interments
other than of stillbirths; (4) the aggregate number of interments in the
said Burial Board Cemeteries uncler each of the preceding sub-beads;
and (5) the total number of deaths registered in England and Wales
daring tlie year 1890. _____
THB METROPOLITAN HOSPITALS INQUIRY.
The Select Committee of the House of Lords on the Metropolitan
Hospitals resumed their inquiry on Thursday, Earl Sandhurst pre¬
siding.
Staff Appointments in London Hospitals.
_Dr. J. W. Moore, Fellow and Registrar of the Royal College of l‘hysi-
cians in Ireland, came forwanl to give evidence as to the exclusion of
members of that body from tbe start' appointments in Lon<lon hospitals.
He knew of no case, he said, in which a member of hts college had ob¬
tained one of those appointments without first getting a London quali-
flcation, He did not go so far as to say that the rule was universal, hut
there were many hospitals wJieve it applied. He did not know of any
hospital where it did not apply, but he should be sorry to say that it
was universal. In the case or a provincial hospital a griuiuate of the
University of Dublin applied not long since for a start appointment,
and he was declared to be ineligible. A man with perhaps
twenW or twenty-five years' practice, and holding the highest
qualification of his own college, would be very reluctant to subject him¬
self to the lowest grade examination in a sister college in order to
qualify for an appointment. Ho would not care about it. It would
be very unpleasant. His college had not approached the London
authorities, but had sent a statement of their case to various institu¬
tions in England. Until 187U an exclusive rule existed in Ireland with
reference to all the county infirmaries. This rule required that every
successful candidate for county infirmary appointment should bo a
licentiate of the Royal College of SurgeoTis in Ireland. That rule was
abrogated in 1870 by Act of Parliament. ' All tliese appointments were
eagerly sought for by the leading men in Ireland, and were now open
to all registered raedjcal practitioiier.s. What they asked from England
was reciprocity. One of the surgeons in his hospital—Mio Meath-
held no Irish qualification in surgery; ho was a licentiate of
Edinburgh. The exclusive policy adopted by the London hospitals was
felt to be an injustice and a wrong.—By LordMonkswell: The discipline
exercised by the Irisli Colleges was very stringent; it was even more
stringent than that of the I^iidon authorities, (juite I'ccently they had
erased from their roll of licentiates the name of a gentleman who
waa_ accu.sed and convicted of unprofessional conduct. From time
to time it had been his duty as Reglstraroi the College of Physicians to
require explanations from erring licentiates. He did not think there
would be any occasion for putting Irish licentiates under the discipline
of the London authorities were they allowed to hold appointments in
the London hospitals. The powers of the Iri.sh CollegoH and those
of the General Medical Council were sufficient to meet the case.—By
Lord Cathcart: The grievance applied to liceutiatc.s from Scotland,
where the same disaffection prevailed.—By the Earl of Lauderdale'
They had a large number of Scotch practitioners in Ireland, but lie
could nob recall any case.s of English practitioners.—By the Chainnan :
The way he looked at this iiuestion was that the College of Physicians
had 700 or 800 licentiates practising in England, and those men were ex¬
cluded from reaping the reward of their professional knowledge and
experience by this rule. Their education also was interfered with—
The Earl of Airaii: Asa rule, you proferin Ireland having men brought
up in your own hospital to strangersDr, Moore ; As a matter of fact,
the competition for the Dublin hospitals does not materially extend to
England and Scotland. Wo have got very good men in Ireland, bub if
a flrst-claes man came over from Ixmdon his candidature would receive,
every consideration, and if he proved to bo the better man he would
get tbe appointment.
Mr. Henry Gray Croly, President of the Royal College of Surgeons
in Ireland, said that his College felt that their licentiates luul passed a
very stringent examination. Duriiifr the Crimean War tney found that
men who failed to pass that examination went over to London and
cajnc back with diplomas in their pockets. Their examination in
[April 18,1891.
surgery, in fact, was much more stringent than the examination in
London. From the advertisements inserted with regard to Liverpool
and Bristol Infirmaries, his College felt that only English licentiates,
cohld compete for the appointments advertised, Those advertisements
were a reflection upon the Irisli bodies. They considered in Ireland
that their teaching was quite equal to that in London; it was not a nice
thing to say it was superior. He could not give tire name of any
distinguished man who had been refused an appointment In a London
hospital because of tlie want of the London qualification. Ho knew,
however, that if he himself went to Bristol and sought tlie apDolctmenb
in tlie infirmary there, he would bo told that he was ineligible.
The iVest-end Hospital for Diseasu of the N6rmi.s System.
The next witness was Major-General T. W. Mercier, Chairman of the
Board of Management of the West-end Hospital for Paralysis and
Epilepsy. He stated that the hospital was founded twelve or fourteen
years ago. It was not entirely a free hospital, although no person was
refused treatment because of his inability to pay for it. Many of the
applicants desired to make some payment. Last year they received
£497 from patients. The lio.spitaJ was at present being rebuilt, and
would be ready for occupation in June or July, when they wouhl have
forty-five and probably sixty beds available for patients. Tlie funds
were derived entirely from public subscriptions, 'fhey received a gi'ant
from the Hospital Saturday Fund, but nothing from tbe Hospital
Sunday Fund. No reasons had been given for tlie refusal of assistances
from the latter fund. He believed the committee had heard evil
reports of the liospital. There liad been differences of opinion between
file former chairman (Lord Robert Montagu) and the medical staff, and
those differences had led to veiy disagreeable incidents on tlie Board.
Dr. Tibbits, the honorary medicalsupevintondont of the hospital, said
he was the founder of the institution, and the funds in the first instance
c.ame from his friends. The Ice Carnival two years ago yioldeda net profit
of JiUOO, but “The Coming Race” at the Albert Hall resulted in a loss,
which, he might say, fell on his shoulders alone. Ilehadnoidea why the
hospital was refused a gi'ant from the Ho.snital Sunday Fund. For a
time the medical profession made a “deailset” against the hospital.
There was always jealousy in the medical profos.sion when a special
hospital was founded. Ho contended that a medical man had no time
to treat a single patient for three-quarters of an hour, as massage re¬
quired, and that massage demanded special training. Therefoi-e it was
that he trained nurses in the work of massage. The medical profession,
on the other lianil, contended tiiat the doctor only should treat the
patient. It was simply the tiadcs unionism of the mass of the medical
profession that he liad to contend against when ho started the hos¬
pital.—By Lord Cathcart: No woman would over be treated with his
permission for disease of the uterus with massage. It was a
monstrous thing and ought never to be done. Although the build¬
ing had been used as a butcher's shop, it.s drains were put ini
order when adapted for a hospital.—By the Earl of Arran ; The school,
of Massage, he was afraid, did not pay its own expenses. Times were
not prosperous. Any profit would go to the proprietor of the schools,
wiio was his wife. At the end of iior training, the nurse underwent an
examination before she received a certificate of efficiency. As soon as slie
got her certificate she could go anyn'here she liked, and malie wliat charge
for her services she chose. The average fee per hour was live shillings,
but if a nurse could get seven .'iliilliiigs so much the better.—By the
Earl of Kimberley : The only connexion that the school, liarl witfi the'
hospital was that the latter received the gratuitous services of the-
students, and that ho was showed to lecture to tliem iii the hospital.
It was the case that uncertified masseuses wove allowed to treat patients
without the presence of medical men, lint niidor the wiiLton dircctioik
of medical men. This was the only practicalile .system, and he regarded
it as satisfactory in the interest oi the patients.—By the Chairman'.
There liad never been any profit from the hospital for the founder.
It had been a dead loss to him.
Mr. Alexander Dowell, honorary secrolary of the hospital, said ha
did not reside in the institution, but visited it twice a week, and some¬
times oftenev. In the building now demolished, the space 'was so
limited that it became almost impossible to carry on the work. They
could not afford room for re.sideiit officers. Tlie system of appealing to-
the public for funds suited their case. Last year they had a surplus,
which of course wasswallowod up by the expenses of the now building.
They had already spent £5000 upon the building.
The Committee afterwards adjourned.
FACTORIES AND WORKSHOPS BILL,
PJIOI’OSAI. TO AIIOLISII CKKTIl'VIMJ .SUIUJEONS.
The Standing Comraittoe on Trade appointed to consider this Bill
met on Monday, and disposed of the amendments relating to periods of
employment.
On Clause 19 coming up for discussion, Mr. Macartney proposed to-
leave out Subsection 1, whicli states " tliat after tliis Act certificates
of fitness for employment, of cliildrenand young persons shall not bo-
required,” thus abolishing the office of the certifying surgeon.
Mr. Miindella said that this clause hiul ctimo upon the country as a
surprise. The Home .Secretary beliovod that the functions of the
certifying surgeons were practically obsolete, but those Home Secre¬
taries who had the care of the first Factory Acts had insisted on no
point so strongly .as that tlie fartory surgeon should bo maintained.
They had beon of the greatest value in protecting children and persons
who wore in an unfit condition for •ivorking, Tiie right hon, gentleman
had said that since the passing of tiie Act of 1870 tliero was no necessity
for certifyingsurgeouHibut the register up to 1879Biiowod their necessity
by the returns. Now no return was required, but several certifying
surgeons had forwarded to him their own private retuvn-s. In one case
the persons presented numberud ceitil!c.'i.tQS granted 239, and
cliildreii rejected as being unfit for employment 96. A statement was
put into his hands on J’'ri'day, and he had seen some of the gentlemen
whose names appeared on tliat li.st, a list of private records kept by
nineteen certifying surgeon.s since the necessity of keeping a
record was omitted froin the Act of 1870. Dr, Pearce of Man¬
chester liad kept a record for twenty years of every child prosented
to him and of every child viyectod by him, and it sliowa his
avei-ago refusal of children per anmmi, raking the last threo years,
ainoniited to 108 children. Out of children, i;n3 wore re¬
fused. Or. Poarco was present, and was prepaiud to place his
Tbe Lancet,]
FACTORIES AND WORKSHOPS BILL.
[April 18,1891. 913
n()t«8 for the last twenty years in the hands of the Home Secretary.
Instead of abolishing the certifying surgeons, he thought their func-
itions ought to be extended. Another very important document liad
been circulated by the four factory surgeons of I-eeds, in whicli they
spoke of children who had been examnied by them and found to be
autfering from syphilitic sores in the month, scarlet fever, and small¬
pox. lie could go through probably fifteen of tliese documents ehow-
ang the extent of the rejections and the terrible kinds of diseases with
which they liad to deni. He had been connected with factories all his
life, and he could see no reason why the workmen in Lancashire should
take exception to the certifying factory surgeons until he learned tiiat
the operatives had to pay the lee of the certifying surgeon; and be
had heard of a number of cases In which employers had chargoci
parents 2*. Od. for the fee, although only Od. had to be paid to the
aui'geon In respect of each child. The statement concerning the charges
made thero took him by surprise. He had never heard in his life before
that the omployor charged the child for the surgical examination. He
was sorry to say that was the practice in Lancashire. Mr. Cod-
dington: 8uch a thing is unknown in Lancashire. Mr. Mundella:
If the lion, member had only made inquiry of some of his own
friends who were withiu liis Immediate reach, be would have no
difficulty in ascertaining the accuracy of the statement. There had
been certifying surgeons who had brought into discredit the
whole thing by the perfunctory manner in which they have discharged
tbelr duties. He hoped that wlion the next inspectors of factories
were appointed a medical inspector would be cliosen, who should keep
his eye upon the way in which certifying surgeons did their duty.
There were, on the other hand, men who performed their duties under
great difficulties, socially and otherwise, meeting with a good deal
of resistance from employers and otliers. He hoped the Home
Secretary would take care that what had been pronounced by
such met! as Lord Shaftesbury and Lord Gross to bo of import¬
ance in the working of the Factory Acta should bo continued,
.and that it should remain complete and thorough and effectual.
Mr. Matthews, in placing before the committee his position in relation
to the Bill, assured them tliat at the first start in this matter be had no
{ •reconceived opinion at all, but in two successive years, 1S89 and 1890,
le received two deputations of the utmost weight and importance repre¬
senting the manufacturers and the ojierativos of Lancasiiire, who came
and said to him unanimously that this institution of certifying surgeons
had degenerated into a mere fai-ce. Mr. James Mawdsley of Man¬
chester, a working man of twenty years’ experience, said to him, “I
have never in the course of my own personal experience come across
a single case where a child had been objected to by a certifying
surgeon on account of disease, or anytliing except want of age."
<Mr. Mundella; He ought to know belter.) In 1889 similar state¬
ments were laid before him. He then saw a deputation of factory
surgeons, and he was bound to say that the.se gentlemen made out
3 . very miserable case, and none of the figures which we have in
such abundance to day wore forthcoming. Having weighed the
balance of evidence as well as he could, ho came to the conclusion
that this was a burden to the employers anti to the operaiivea, who
are chargpd one-half of the fee. By Subsection IV. of the principal
Act it is provided “ that the employer may deduct the fee or any part
ttheroof, not exceeding in any case 3d., from the wages of the person for
whom the cortiQcaio was granted." Now one of the reasons that acted
upon his mind in putting this clause in the Bill was that this initial
'Certificate of tlie capacity to work either went too far or notfar enough.
It was not satisfactory. Supposing a child changed his employment
from one mill to another four times in a mouth, he must by law have
four cortilicatos of fitness. Altliough there was no change in the cir¬
cumstances of tiie child, there must be a fresh certificate of fitness for
every fresli omployment. And, on the other hand, however long a child
continues in the same employment, ho never comes under review of tile
certifying surgeons again, and therefore this certificate of fitness is of
little use for the purpose for which it is intended, lie could not help
■thinking tliat labour in mines required much more physical strength
and energy than was rociiiired in facLoi'ies, but no certificato of fitness
was required for that labour. It struck him that the clause requiring
examination by factory surgeons was a survival of the early days of Lord
•Shaftesbury, wlion abuses with regard to children wore brought before
Parliament; but tliat state of tilings had passed away, and ivhen this
Bill was drawn the weight of the evidence before him was enonnously
•on the side of those who objected to the contiminuco of the factory
surgeons. Since the Bill has been before the House of Commons these
-gentlemon have been stirred up. lie couhl not got from them anything
like tile pon;ontag 08 of cases tejechid that had boon placed before them
to-day. At the same time, giving them all the consideration he
could, ho did nob think that the benefits iloHved from the certificates
•of fitness were sufllcient to coiiiitorv.ail the burdon placed upon
■tho employers. It seemed to him that if they imposed penaltie.s upon
the eniployors of an unfit child and penalties upon the parent, and gavo
the power to tho inspector which is given in section 29 of the principal
Act, which was rotainotl, they had ilone ivliat iva.s auHicioiit. It was not
a question, however, upon which he felt strongly himself.
Mr. McLean (Oldham) was not fully satisfied iii his own niiiul ii'liethor
it was a good thing to abolish this office. He was in Lancashire the pre¬
vious night, and talking to a iiiimber of workitig men on the subject. He
did not tbink there was tliosamestrongleeliiig in favour of the abolition
of tho certifying surgeons as there was previously. He should not
oppose tho doing away of this clause of the Bill.
Dr. Farquliarson pointed out that though Lancashire wa.s an im¬
portant place, it was necessary to get evidence from otlier parts of the
•country, and tlie ovidonco from other great centres of labour in England,
ivs well as from Scotland and Irolaiid, was of tho most complete and
satisfactory ciisvactor as rogards the retaining of the factory surpeoiis.
Mr. MuiKiella had said that Chore was a oonsideralilo mass of evidence
•of their gooil worli tor the benefit of cliildroii and for the community at
large in rejecting a large number of weakly children wlio ouglit not to
be oniployod, and in chocking infectious rliseasos, which but for the
interposition of the surgeon would frec|uently enter worksliops and
factories. A groat numbri' of tho omployeva of labour wore in favour of
the surgeons. 8ir H. Vivian said that “ tlio'present system worked
well, and ought not to bo lightly changed,’’ Tliey had vory strong
ovicient^e indeed from employers of labour in Stockton, Blackburn,
Belfast, Manchestor, Bristol, Waterford, lladolilfo, Dublin, Preston,
Derby, Bury, Accrington, Ashton, Barrow, and Chipping Norton.
In addition to the large number of children rejected, there were
many who could not be brought forward lu evidence because there
WM the deterrent Influence at work which prevented parents from
bringing up weakly children for examination, since they well knew
that they would be rejected. A great many of these cases were
settled out of court, so to speak; that is to say, the parent would
brine up the child to the doctor and ask whether he thought the child
would pass or not, and very often the answer was, " No.” An opinion
of this kind was usually given gratuitously. He agreed with the Homo
Secretary tliat it would be an advantage that the inspection should be
continuous, and that the surgeon should be able to keep his eye on the
child during the whole period of his industrial employment, so as to
see that the work was not pressed too heavily upon him, and decide hi
some cases that they should change from one employment to anotlier.
He refen’ed to public opinion on the subject. He had presented
petitions from several of the most important medical Institutions,
colleges, and schools, as well as from medical men, in addition to which
he was about to receive one from the Society for the Pi'evention of
Cruelty to Children, showing that the clause was neither a purely
medical one nor one for the employers of labour, but should be viewed
fi'om the standpoint of humanity and general hygiene. It was also
rather a hard thing to deprive so many men of a certain proportion of
their income, a considerable number of whom depended entirely on thi.s
certification for their professional income. Under those circumstances
it would be right and proper to give compensation, wliich, however,
would bo very difficult to assess. Ho referred to the two deputations,
and observed that one of the principal speakers, Mr. Buckley, put
forward as an advocate for retaining llio nineteenth clause, gave evidence
by saying that this Imposed a tax of £80,00o a year on the employers,
and it was necessary for tho Home Secretary to point out that the cost
was only £36,000.
Sir W. Houldsworbli (Manchestor) had hoard nothing from the em¬
ployers except a deteimined desire on thoir part that the certifying sur¬
geons should be done away with, and the statistics furnished within the
last few weeks were complete news to him, and to most of those who
had any expeiienco in factory work. Parents, as a rule, did not unduly
press children who were incapable of doing work. The children were
employed by the piece worfeer, who was, of all persons, tho most
intei-ested in having no child working with him who was unfit for work.
He sympathised with those who view this question upon the grounds
of humanity, but they must go a great deal further than they did.
Periodical and systematic inspection of all the children in factories
was what they had to got. There were very many chUdren working
in the factories who, on the ground of humanity, ought not to be.
It was said that infectious disease might be communicated in factories,
but the same might be said about schools, and there was no medical
inspection of schools. If infectious diseases were to be prevented
schools, much move than factories, would have to be placed under in¬
spection. The fact was, this was a survival of an old arrangement,
introduced when the principle of “ age ’’ was before the mind of Par¬
liament, and it was to assist the doctor in determining the age that a
liitle more discretion was given to him, and so be was allowed to pre¬
vent the child from going to work. If they were allowed to remain it
would impose a very severe tax upon the employer of labour, and upon
the workmen for a very small result indeed. He hoped the present
system would be brought to 'an end, and that gentlemen who hold
the opinion of the member for Shoffield (Mr. Mundellalshouldintroduce
a now clause into tho Bill for the purpose of giving periodical examina¬
tions the expense of which ought not to be borne by the employers or
the operatives, but by the State, on the same grounds as the expense
of the factory inspoetors is defrayed by the State.
Mr. Campbell pointed out that there had been no deputation what¬
ever from Scotland against the continuance of the factory surgeons, and
that this clau.se ought not to apply to Scotland.
Mr. Fenwick was addressing tho Committee when the Committee
was adjourned.
On re.suming the consideration of the clause on Thursday,
Mr. Addison remarked that tliough he did not impugn the good faith
in whicli the lion, member for Sliettield (Mr. Mundella) had made the
.statement concerning the charges made by employers in Lancashire, he
thought tho statement was founded upon very inaccurate information.
That charge was illegal, and it was almost idle to suppose that it could
go on without frequent complaint being made. The practice would not
he tolemtod amongst the men in Lancashire for a nionieiit. He hoped
tho hon. moinbor would withdraw the statement, or give them fuller
particulars about it.
Mr. Mundella said he had been Informed by representatives
of workmen .since the committee had been sitting that such
was the cose, and he hold iu his hands. a letter signed by
a medical man, an M.D., and a professional man of experi¬
ence, which corroborated every word ho had said. If tlie Home
Secretary would give a committee to inciuiro into the office of
certifying surgeons, and how it had been worked in the past, he wouhl
•lace tho evidence lie had before it, or ho was willing to place it in the
lands of the Home Secretary liim.solf. They could not charge him with
making nii unfounded statoiiient M'lien he spoke on the written state¬
ments of profe.ssioual men of standing, of libenil education, who spoke
of tills matter from their own expei'ieiicc. Mr. MundeUa then an¬
nounced that a note from Dv. Barr of Bury had just been placed in
his hands, stating that several cases of siudi unjust payment had
occurred iu his ptactice, and he was present and prepai'od to prove it.
Viscount Cranborne could not help feeling that there wore some
omployer.s who did take advanti^e of the fees, and it was probable
that some parents sent thoir children to mills in an unfit condition.
Under these circumstances, was it a good thing to take away the pro¬
tection which the law pmvide.s, at an expense absolutely trifling, for
those children who, in the case of employers or paronls failing to do
their duty, had nothing to fall back upon except the certifying surgeon 'i
The surgeons did reject large numbers, but even if they rejected few,
those who were nob presented on account of the preventive operation
of the certifying surgeon may i>o very many. 'J’hoiigh his constituency
was decidedly against the retention of tho certifying surgeons, he could
not bring himself to destroy tho protection which may be necessary in
some cases, however few, and ho would support the ainendment.
Mr. McLean (Oldham) said he hold in his bands a list of ninety-one
employers who pursued the pruotico spoken of by Mr. Mundella. He
914 The Lancet,]
APPOINTMENTS.-VACANCIES.
[April 18,1891,
entirely agreed with the remarka of the hon. member (Viacount
Cmnhome). tliat aufBclent evidence had not been placed before the
committee to show that it was desirable to do away with the certifying
sargeons. They must see from the very remarkaole evidence of Dr.
Barr that it was not a farce, and that in many cases sickly and diseased
children were prevented from going to work in mills. He did not think
that public opinion in England would be satisfied if the certifying
surgeons were abolished, so long as children of tender years are at
WOK in factories. It was necessary that there should be some im¬
partial guarantee from without to protect children when necessary
against the greed either of parents or of employers.
^r. Shaw Lefevre said every Home Secretary up till now had con¬
sidered the institution one of the essential elements of factory legis¬
lation. and he could not hut think that the discussion of the subject in
that Committee would have a very great effect upon any future medical
examinations which had to be made.
Mr. Chamberlain said if it was the case that parents were charged
for the certificates it was improper and reprehensible, but it had
nothing to do with the merit-i of the appointment. In Birmingham no
complaints whatever had been received. They were perfectly satisfied
with the existing arrangement. It Avas not necessary, in justifying
factory surgeons, to impute misconduct to parents or employers. It was
quite impossible to hold the employer personally responsible for the con¬
dition 01 health of the children who offered themselves for employment.
Although some cases had been brought to notice involving serious
condemnation of the parents, in some cases the parents themselves
were not aware of the character of the disease or injury from which
the children were suffering; and therefore it was to their advantage,
and to the advantage of the employer, that some experienced imd
thoroughly competent and impartial authority should be called
upon to decide the matter, seeing that the expense ivas so small.
There was undoubted proof that in a very considerable number
of cases serious evils had been prevented by their employment. He
expressed the hope that the Government, who from the evidence in
their possession had brought forward this proposal, would lie willing,
in view of the further evidence now received, that it should be with¬
drawn.
Mr. Byron Resd. Mr. Sidney Buxton, Mr. Barran, Mr. Fenwick, and
Mr. Hoyle having taken part in the discussion, Sir Wm. Ilouldsworth
thought it would be better to stop tlie present system, and to raise the
whole question by amendments or in some other form, and examine it
from an unprejudiced point of view.
Mr. Briggs Priestley strongly opposed the retention of the certifying
factory surgeons. The discussion that moniing had suddenly gdveii a
great premium to the medical profession. They would now want
doctors almost innumerable. They could not atop where they wore.
If he was asked to answer the question, “ What shall we do with our
boys?” he thought the best thing to say was, “Send them into the
medical profession.”
On a division the following members voted ‘ Ay’’for the retention
of the Clause proposing to abolisli the Certnfying SurgeonsMr.
Addison, Mr. Barran, Mr. Coddington, Mr. Fenwick, Sir William
Houldaworth, Mr. Matthews, Mr. Briggs Priestley, Mr. 'I, H. Side-
bottom, Mr. Stuart Worttey.
■The follOAving thirty-nine members voted for its rejection;—Messrs.
Abraham (Rhondda Valley). Baring, Barnes, Brunner, Buchanan,
Sydney Buxton. J. A. Campbell, Joseph Chamberlain, Colman, Craig,
Viscount Craiiborne, Sir Charles Dalrymple, Mr. Dixon-Hartland,
Colonel Byre, Dr. Farquharson, Sir Julian Goldsmiih Messr.s, Howell
Hoyle, George Shaw Lefevre, Lowther, Sir John Lubbock,* Messrs.
Macartney, J. M. Maclean, M’lAgan, Mundella, Sir Stafford Northcote,
Messrs. Oldroyd, Briggs Priestley, Randell. Byron Reed, Edmund
Robertson, Brook Robinson, Samuel Smith, Mark Stewart, Dr. Tanner,
Messrs. Tomlinson, Wallace, Whitley, Stephen Williamson, and Wood.
Suceefts/ul applicants lor Vacaneics, Secretaries of Ptthlie Institutions, and
others possessing infonn-alion suitable for this coluin/n, are invited to
forwwrd it to This Lancet Office, directed Co the Sub-Editor, not later
than 9 o'clock on the Thursday morning of each week for publication in
the next number. -
AsiiwEi.L, Miciiaei. H., M.R-C.S., L.S.A., has been appointed Consult¬
ing Physician to the North Stiiffordshico Infirmary and Eye Hospital,
Stoke-upon-Trent.
Babiiittt, G. L., L.R.C.P. Lond., M.B,C,S.,ha.H been appointed Medical
Officer for tho Spalding Workhouse and the Eastern District of the
Spalding Union, vice Morris, resic^ned.
BERttv, Edmund, L.K.Q.C. P. Irel, L.F.P..S.Gbisg.,haa been reappointed
Medical Officer for Loyland.
Betts, Wii.uam Andhew, M.B., C.M. Edin., has been appointed
Junior House Surgeon to the Royal Southern Hospital, Liverpool.
BiDWELL, L. A., M.R.C.S., liaa been appointed Assistant Surgeon to
the West London Hospital.
BROCK. W. J., M.B., C.M. Edin., B.Sc., F.F.P.S. Glasg., has been ap¬
pointed Medical Officer of Ilealth for the corabineil countie.s of
Mid I.othian, West Lothian, and Peebles.
BrONNEh, Adoi.k, M.D. Heidelb., M.R.C.S., has been appointed
Jlonorarg Laryngologist to the Bradford Inllrmary [not “ Laiyiigo-
logist,” as announced last week|.
Butterfield, U., M B.C.S., has been reappointed Medical Officer of
Health for tho West Kent Combined Sanitary District of the
Seveuoaks Union.
Davies, Edwd., M.D. St. And., M.R.C.S., has boon reappointed Medical
Officer for the No. 2 Rural District of the Wrexham Union.
Davies, K. P., M.E.U.S,, has been appointed Consulting Surgeon to the
Carmarthen Infirmary.
Distin, Howard, M.B.C.S., L.R.C.P., has been appointed Resident
Clinical Assistant at Bethlein Hospital.
Field, Fuedeiuck Arthur, L.R.C.P. Lond., M.R.C.S., has been
appointed House Surgeon to the West Norfolk and Lynn Hospital,
King’s Lynn.
Godpret, H. 3. C., L.R.C.P. Edin., M.R.C.S., has been appointed
Medical Officer for the Second District of the Bridlington Union.
IlESLOP, Wm. J., L.R.C.P.Irel., F.R.C.S. Edin., has been reappointed)
Medical Officer of Health for the Stretford union District.
Lane, J. E., F.E.C.S., has been appointed Surgeon in charge of Out¬
patients to St, Mary’s Hospital, vice Pye.
Lendon, a. a., M.D. Loud., M.R.C.S., has been appointed Honorary
Physician to the Adelaide Hospital, South Australia.
McAlister, W. R. a., M.D,, M.Ch. Irel., has been appointed Medical
Officer of Shells Institution, Carrickfergus.
McLean, Chas, J. Russell, M.D., C.M. Edin,, has been reappointed
Medical Officer of Health to the Yeadon Urban Sanitary Authority.
Morrow, j. S., B.A., M.B,, has been appointed House Physician to-
the Belfast Royal Hospital, vice W. A. Wheeler, resigned.
Neilson, H. j., M.D., C.M. Glasg., has been appointed Surceon to the
Midland Railway employiU for those Districts renderea vacant by
tile death of Mr. W. Maltby.
NiCHOLLS, Hubert, M.R.C.S., M.B. Cantab., has been appointedk
Assistant Physician to the North Staffovdsliire Infiimary and Eye
Hospital, Stoke-upon-Trent.
Nuthall, Rout. L. S., M.R.C-S.. L.R.C.P. Lond., has been appointed
Fifth Assistant Medical Officer to Hanwell Asylum.
OsnuRN, H, B., M.R.C.S., L.R.C.P., has boon appointed Aneesthetist
and Registrar to the Royal Hospital for Children and Women,
Waterloo-bridge-road, vice V. W. Wheaton.
RouiNSON, G. Drummond, M.B., B.S. Lond., M.R.C.S., L.R.C.P., has
been appointed Resident Medical Officer to the Chelsea Hospital
for Women, vice Dr. Mortlock.
Sayres, A. W. F., M.B.C.S , L.R.C.P. Lond., hasbeen appointed Assistant
House Surgeon to the South Devon and East Cornwall Hospital,
Plymouth.
Sturge, W. Howard, M.R.C.S., L.R,C.P., has been .appointed House-
Surgeon to the London Ho.spital.
Swii-T, Harry, B.A., M.D. Cantab., M.R.C.S., has been appointed
Honorai7 Assistant Physician to tho Adelaide Hospital, South
Australia, vice Lendon.
Thorne, J. M., M.R.C.S., L.R.C.P., has been appointed Resident
Medical Officer to tlio Royal Hospital for Children and Women,
Waterloo-bridge-r'^ad, vice Enoch Mo.ss.
Till, Geo. W., L.R.C.P. Edin,, L.F.P.S. Glasg., has been appointed
Medical Officer of Health for the Rural jsanitary District of the-
Worcester Union, vice Strange.
Turney, Horace 0., M.B.Oxon., L.R.C.P. Lond., M.B.C.S., has been
appointed Resident Assistant Physician to St. ’rhomns’s Hospital.
Vann, a. M., M.R.C.S., has been appointed, tro lent.. Assistant Medical
Officer for the Brandon Union District, Durham.
Whittingdai.e, j. F. L., M.B. Camb., M.R.C.S., has been appointed
Medical Officer of Health for Sherborne, Dorset.
Williams, E. R., M.R.C.S., has been appointed Honorary Medical
Officer to the Carmarthen Infirmary, vice E. P. Davies, resigned;
also Surgeon to the Great West Provident Society, vice J. Hughes,,
resigned. _
i'wsltdts.
For further information rega'-iing each vacancy reference should be mads
Ij the advertisement.
Birmingham and Midland Free Uosihtal for Sick Children.—
Extra Acting Physician. Salary ,£00 per annum.
Chelsea.—M edical officer of Health, E'ood and Drugs Analyst, and
Gas Examiner. Salary £450 per annum.
County Borouoh of Bradford Fever Hospital.—R esident Medical
Superintendent. Salary .£200 per annum, with board and residence.
(Apply to the 'fown Clerk, Town Clerk's Office, Bradford.)
Devonshire Hospital, Buxton.—House Surgeon. Salary £100 pap-
annum, with board, furnished apartments, and washing.
Devonshire Hospital, Buxton.—Assistant House Surgeon. Salary
.£60 per annum, with board, furnished apartments, and washing.
Glamorganshire and Monmouthshire Infirmary, Cardiff. Assist¬
ant House Surgeon for six months. Board, lodging, and washing:
provided.
Guest Hospital, Dudley.—Resident Medical Officer. Salary £100 per
annum, with board, residence, attendance, and washing.
Cenerai. Infirmary, Leeds.—Resident House Physician for twelve-
mi>nth8. Board, lodging, and washing provided.
General Infirmary, Le'ed.s,—Two Re.sideiit House Surgeons for twelve-
months. Board, loilging, and washing provided.
General Infirmary, Leeds.—A Resident Officer at the Ida Hospital
for six months, with honorarium of £26.
Hospital for Consumption and Diseases of the Chest, Brompton.—
Resident Medical Officer. Salai-y £200 per annum, with board and
residence.
Hui.ME Dispensary, Manchester.—Honorary Surgeon.
Jenny Lind Infirmary for Sick Children, Nonvich.—Physician.
King's Collegf;, I-ondon.—Demonstrator of Public Healtli.
J-iDDF.i.L Provident Bi.si’ENsary, Jarrow-on-Tyno.—Medical Prae-
titioner. Salary £160 per annum and all midwifery fees.
LOUGIinOKOOHII AND DISTRICT GENERAL HOSPITAL AND DISPENSARY.—
Resident Huu.se Surgeon. Salary £70 per annum, with furnislied-
rooms, attendance, and board.
Lincoln Oddfellows’ Medical Institute,—A ssistant, out-door.
Salary £120 per annum. (Apply to the Secretary, 12, North Parade,
Lincoln.)
Manchester Hospital for Consumption and Diseases of thf..
Throat.—R esilient Medical Officer at Bowdon, Cheshire. S.ilary
£00 per annum, witlr Iward, apartments, and washing.
Noble'S Isle of Man General Hospital and Dispen.sary, Douglas,
Isle of Man.—Ite-sklent Hoiwe Surgeon, Salary £00 per aimum»
with apartments, gas, coal, and washing free.
Nohth-VVf-ST London Hospital, Kontish-town-road,—Assistant Resi¬
dent Medical Officer for six months.
Nottingham Borough Asylum, Mapperley-hlll,—EeHident Clinical
Assistant for six months. No salary, Board and residence pro¬
vided.
Sussex County Hospital.—H ouse Physician. Board and reaidonoe-
in the Hospital, with washing, and a salary of £60, rising to £80--
per annum, at the discretion of the Committee of Management.
Co Ogle
The Lancet,]
BIRTHS, MARRIAGES, AND DEATHS.
(April 18,1891. 915
Wajaasev Dispensary.—H ouse Surgeon. Salary £110 per annum, with
furnished apartments, coal, and gas.
Western Skin Hospital, 170, Great Portland street, W.—Honorary
Physician for twelve months in the first Instance.
West Herts Inpirmauy, Hemel Hempstead.—House Surgeon and
Dispenser, who shall also be Assistant Secwtary, for two years.
Salary £100 per annum, with board, furnished rooms, fire, lights,
attendance, and washing.
Wolverhampton Eye Inpirmary.—R esident Assistant for six months.
Booms, with board and washing, provided.
York Dispensary.—R esident Medical Officer. Salary £130 a year,
with furnished apartments, coal, and gas.
BIRTHS.
Brand.—O n April 6th, at Invery, Great Driffield, E. Yorks, the wife of
Dr. Brand of a son.
Cunningham,—O n April Oth, at De Vere Gardens, Kensington, W., the
wife of Surgeon-General J. M. Cunningham, O.S.I., of a son.
Ellis.—O n March 23rd, at Apsley Villa, Wellington, Somerset, the wife
of Dr. W. Gilmore Ellis, of Singapore, of a son.
Firth.—O n April 7th, at Parroclc-street, Gravesend, the wife of Charles
Firth, M.D., F. R.O.S., of a son.
French,—O n April 8th, at Winterbourne. Hornsey, the wife of George
French, F.R.C.S. Eng., of a daughter.
Evans.—O n April 9ih, at Denmark Lodge, The Grove, Olapham-common,
the wife of Dr. Lewis E^ans of a daughter.
ORIPI'TTHs.—O n April Hth, at Kenaingcon-scpjn'e, the wife of Herbert
X. Griffiths. M.D., of a son.
Petty.—O n March 11th, at Bolgrano. Buenos Ayres, Ai gen tine Republic,
the wife of Dr. Michael John Petty of a daiightor.
.SCOTT,—On April 10th, at Fallowflold, Manchester, the wife of W.
Sawers Scott, M.D., of a son.
Shute.—O n April 8th, at Granby-place, Northfieet, Kent, the wife of
G S. Shut«, M.])., of a daughter (premature).
Stevens.—O n April 16th, at High-street, Stoke Newington, N., tbo wife
of A. Felix Stevens, M.D., of a sou.
MARRIAGES.
BiLHALD—E dmondson.—O n April 9th, at ,St. Mar>'B Pariah Church,
Dolgelly, Richard Atheratone Billiald, L.K.C.P., M.R.C.S., of
Kington, llerefordshire, to Annie Amelia, third .surviving daughter
of Alfred Edmondson, Esq., of Dolgelly.
Bhaye—AYRES.—O n April 2nd, at St. Mary’s Ohmeh, Reading, by the
Rev. s. H. Soole, Vicar of Greyfriars, Reginald James Braye, of
Leicester, J,,.R.C.P., M.R.C.S., youngest son of .lames Harawick
Braye, of Wellington-square, Hastings, to Jessie, younge.st daughter
of the late Chaises Ayros, of Reading.
Cox—ILES.—On April Uth, at Watfoi'd I’ai'ish Oliiircli, by the Rev. R.
Leo James, Alfred Edward Cox, M.lt.C..S,, L.Jt.C.P., youngest son
of the late Willi.am Henry Cox, Estj., of Duffield, Derbyshire, to
Sybil Maud lies, tliivd daughter of the late F. l-I, Wilson lies, M.D.,
of Watford.
Lidurd—SLATER.—O n April nth, at the Friends' Meeting House, Hull,
Sydney Robert J.idiard, of Berkeley House, Anlaoy-roiul, Hull,
M.R.C.S. and L.R.C.P., son of the late .lames I’liomas Lidiard, of
Btixton, to Margaret Slater, of Westhourne-avenue, Hull, youngest
daughter of llie late William Slater, of C.arlisle.
LuSON—L eslie—O n April Oth, at iSt. George's Church, Folia Rule,
Aberdeenshire, Thomas Luson, F.R.C.S.E., of Cromer, Norfolk, to
Mary Walker, second daughter of the Rev. Alex. Leslie, M.A.,
Rector of bVlla Rule.
MOLSON—Leeson,—O il April lltli, at St. Andrew’.^, Wells-street, John
Klsdale Molson, M.JHIantab., son of .s. ICisdale Molson, of Moiitroal,
to Mary, older daiiglitor of A. E. Leeson, M.D,, of Dorset-siiuare.
Savage—BOU si'iELi),—At Cape Town, South Africa, S. Radford Sav;\go,
M.B. <fcc.., Principal Medical Ottlcor, Basutoland, to Mary J. Boustield,
daughter of the Riglib Rev. Bishop of Pretoria, Tran.svaal.
SHEL8WELL—liKRiauoE.—OiiApriiaUi.atSt. l*otei'-ad-Viiicula, Ratloy,
Warwickshire, William Arthur Slielswell, l,.R.C.I*. Lond., M.R.C.S.,
of Slienington, to Ida, tliird daughter of Mr, T. W. Btrridge, of
The Uplands, Baiilmry. _
DEATHS.
Blackmohe.—O n April 7th, at St. Mary’s Hospital, Padiliiigton, the
I'esull ol an accident, George Houvy Blackiuoro, M.R.C.S., L.R.C.P.,
of Worcester Loiige, Shephord’s-bush, second son of the late
Christopher Blackitiore, Esq., of Sliafto.sbury-mad, Hammersmith,
aged -ID.
Bolton.—O n April oth, at Ku.stoml,)ie, Bouuiania, Teresina Arpnlico
Emily Beda, aged 9" years, of diphtheritic scarlatina, a loving and
loved child, daughter of Dr. A. Irwin Bolton and Teresina Bolton,
Hall.—O n March 2-1111, at the Lodge Avenue, pSouthamplon, William
Henry Hall, M,D. Glasg., M.R.C.S., L.R.C.s IroL, aged 72.
HOI-'I-'MELSTEK,—On April litli, at Clifton House, Cowes, George Bernard
llofficoister, M.A., M.D., youngest son of the late Sir William
lloffmoistor. M.D., ageil 32.
Lamii.—O n April 11th, at IS, I’riee-stroot, Birkenhead, Joseph Iiiunli,
M.R.C.S., aged 6U.
Pennington.—A t Pondivoko-place, Liverpool,'!'. RichardsonPennlngtoii,
L. F.J'.S. Gla.sg., aged -IS.
TiZAiii).—Oil April 7th,siitldonly, at Baycliffe, Weymouth, Henry Tizard,
M. D,, aged 67.
Ward.—O n April l-ltti, at Blyth, Northuiuberlaiid, Henry Dobord
Ward, M.D., M.R.C.S., L.M,, soeond son of Gilbert Ward, .M.R.C.S.,
aged 63. _
JV.B.—A fee (if 6«. in chaiyed for the Insertion of Notices of Births,
Marriages, and Beaths,
METEOROLOGICAL READINGS.
(Taken daily at 8.S0 a.m. by Stmard’s Instnmonts.)
The Lancet Office, April leth, 1891.
Date,
Baromotor
reduced to
SuA Level
and 32* F,
Direc¬
tion
of
Wind.
Dry
Bulb.
Wot
Bulb.
Solar
Radia
in
Vacuo.
Maxi¬
mum
Tojdjj.
Shade.
Min.
Temp
Rain-
faU.
RotooikB at
&80A.U,
Apr. 10
30-16
N.E.
43
42
63
61
41
Overcast
» 11
N.E.
42
41
60
80
■n
Overcast
12
N. 8.
42
49
38
Wm
Cloudv
„ 18
E.
42
89
60
49
88
Overcast
H
80-16
N.
48
89
89
62
88
Cloudy
16
30-19
W.
46
43
88
68
42
Overcast
„ 16
30*21
W.
60
46
03
66
43
Cloudy
Slfbital giarj fur maing
Uouday, April 20.
Royal London Opiitualmio Hospital, Moorfislds. —Operation
daily at 10 A.M.
Royal Westminster Ophthalmic Hospital.—O petations, 1.80 p.u.,
and each day at the same hour.
Chelsea hospital for Women.—O peraHona, 2.80 p.m. ; Thursday, 2.89.
Hospital for Women, Soho-square. — Operations, 2 p.u., and ob
T hursday at the same hour.
Metropolitan Free Hospital.—O perations, 2 p.u.
Royal Ortiiop.£Dic Hospital.—O perations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.u., and
each day in the week at the same hour.
University College Hospital.—B ar and Throat Department, 0 a.h.;
Thursday, 9 a.m.
Medical Society of London.—8.80 p.m. Dr. Q. A. Heron: The Use
of Koch's Remedy in Lupus Vulgaris and in Tuberculosis of the
Lung. Patients on view at 8 P.M.
Tuesday, April 21.
Kino’s college Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
Guy's hospital.—O perations, 1.80 P.u., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 p.u.
St. Thomas’s Hospital.—O phthalmic operations, i p.u. ; Fnday, 2P.U.
St. Mark’s Hospital.—O perations, 2 p.m.
Cancer Hospital, Brohpton.—O perations, 2 p.u. ; Saturday, 2 P.u.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.u.
Sr. Mary's Hospital.—O perations, 1.80 p.h. Gonsnltatlons, Monday
2.SO P.H. Skin Department, Monday and Thursday, 9.80 a.k.
Throat Department, Tuesdays and ^days, 1.80 P.U. Electro¬
therapeutics, same day, 2 p.m.
Royal Institution.—3 p.m. Mr. J. Scott Keltie: The Geography of
Africa.
Royal Statistical Society (Lecture Theatre, Museum of Practical!
Geology, Jormyn-st., S.W.),—7.46 p.m. Dr. J. Charles Steele : The
Charitable Aspects of Medical Relief.
Pathological Society of London.—8.30 p.m. Dr. j. C. Mackenzie r
Molano ic Sarcomatosis —Mr. Sydney Jones: Perforation of Gall¬
bladder.—Mr. H. H. Glutton: Osteitis Deformans of 'Tibia.—Dr.
W. B. Hadden : Ulceration and great Contraction of Stomach,—Mr.
■W, H, Battle; Acute Epiphysitis,—Mr. E. Hurry Fenwick : 'ruber-
cularBladder after Koch’s Treatment.—Mr. Solly: Myeloid Tumour
of Tibia with Secondary Growths.—Mr, W. Anderson : Ftecal Fistula
at Umbilicus.—Mr. W. H. Battle : Sarcoma of Femur.—Dr. West:
Secondary Sarcoma of Lung. Card Specimens: —Dr. Howship
Dickinson : (1) Aneurysm of the Abdominal Aorta opening into the-
Duodenum; (2) Aneurysm of the Thoracic Aorta opening into the
Left Bronchus.—Mr. ll, H. Glutton: Extensive Rodent Ulcer of
the Scalp.—Mr. J. H. Targett: Melanotic Sarcoma of Bladder.
Wednesday, April 22.
National ORTrfoPiEDic hospital.—O perations, 10 a.m.
Middlesex Hospital.—O perations, l p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, 1.30 p.m. ; Saturday, same
hour. Ophbhahuio Operations, Tuesday and Thursday, 1.80 P.u.
Surgical (Consultations, Thursday, 1.80 P.M.
CuARiNO-CKOSS HOSPITAL.-Operations, 8 p.u., and on Thursday and
FYiday at the same hour.
St. Thomas's Hospital.-O perations, 1,80 p.m. ; Saturday, same hour.
London Hospital.—O perations, 2 P.M. Thursday&Saturday,3am0hour.
St. Peter’s Hospital, Covknt-garden.—O perations, 2 p.m.
Samaritan Pres Hospital fob Women and Children.—O perations,
2.80 P.M.
University College Hospital.—O perations, 1.80 p.h, ; Skin Deparo-
menb, 1.45 P.M.; Saturday, 9.16 A.M.
Royal Pree Hospital,—O perations, 2 p.m., and on Saturday.
CHILDREN'S Hospital, Great Ormond-street.—O perations,0.80 a.m. j
S urgical Visits on Wednesday and Saturday at 9.16 a.m
I-IUNTEiiiAN Society.—8 p.m. Dr. A. T. Davies will exhibit a case of
Graves’ Disease. Mr. F. R. Humphreys: Two cases of Pneumonia',
(migrating) with complications.—Dr. 15. G. Gilbert: Some Remavks
on Colds.—Dr. -f. Langton Hewer; Extra.uterine Flotation.—Mr.
A. H. Tubby : The Pathology and Treatment of Acute Necrosis of
Thursday, Apiil 23.
St. George’s Hospital.—O perations, l p.m. Surgioal Consultatlona,
'Wednesday, 1,80 p.m. Ophthalmic Operations, FYlday, 1.80 P.H.
University college Hospital.—O perations, 2 p.m.; Bar and Throat
Department, 9 a.m.
Royal Institution.—3 p.m. Professor Dewar: Recent Speoti-osoopic-
Inveatigations.
British Gynajcologicai. Society.—8.80 p.m. Adjourned Discussion
on Dr. Bell’s paper (“The Treatment of Chronic Disease of thfc
Uterine Adnexa , _
Lj 005 vle
916 The Lanobt.J NOTES, COMMENTS, AND ANSWEKS TO COKEESPONDENTS.
[April 18. 1891,
Friday, April 2i,
ROTAI. SOTTTR LONDON OPHTHALMIC HOSPITAL.—OpemHoiU. S P.M.
Clinical society op London.—8 p.m., Living SpecimensMr. Bilton
Pollard: Old (? Congenital) Dislocation ot Patella reduced by
Intra-articular Operation.—Dr. J.1aylor(forDr. Hugblinga Jackson):
Two cases of Muscular Atrophy.—Mr. F. B. Jessett: (1) A case of
Ketlander’s Operation; (2) A case of Qastro-enteroatomy for Pyloric
Cancer.—Dr. Ewart and Mr. W. H. Bennett: A case of Oastro-
jejunostomy for Pyloric Obstruction.—Mr. W. H. Bennett: Sym-
rnetrical Enlargement of Parotid Glands.—Mr. Bruce Clark: Case
showing a New Method of Amputation just below the Knee-Joint.—
Dr. F. Hawkins: Two cases of Congenital Disease of the Heart.—
Mr.W. H. Battle: (1) A case of Recurrent Dislocation of the Patellm;
<2) A case showing Recovery from Lupus Erythematosus after
Internal Treatment only; (8) A case showing the result of Plastic
Operation for Extroversion of the Bladder. 0 I’.M., Papers; Mr.
w. H. Brown: A case of Gostro-isouno-stoiny.—Mr. Arbuthnot Lane:
Two cases of Resection of Intestine by Senn’s Method.—Mr. C. J.
Symonds: Two cases in which a Sequestrum was Removed from the
Neck of the Femur without injury to the joint; recovery in both,
and in one with a perfect joint.
BOYAL Institution.-9 p.m. Rev. Canon Ainger: Eupliuism—Past and
Present. BatUTday, April 25.
Middlesex Hospital.—O perations, a p.m.
University Collboe Hospital.—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.15 A.K.
BoYAL Institution.—8 p.m. Prof.SilvanusP.Thompson: Tlie Dynamo.
Itutes, S|rot Cffmmtnts, # tu
Cromprohnts.
it is especially requested that early intelligence of local
events having a medical interest, or which it is desirable
to br^,ng render the notice of the profession, may he sent
direct to this Office.
All communications relating to the editorial business of the
journal must be addressed *‘To the Editors.”
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, wlicther intended for insertion or for private informa¬
tion, must be authenticated by the names and addresses
of their waiters, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports tw n-ews paragraphs should
be marked and addressed "To the Sub-Editor.”
Letters relating to the pttblication, sale, and advertising
departmenis of The Lancet to be addressed “ To the
Publisher.”
We cannot undertake to return MSS. not used.
A Fatal Result of Baptism nr Immersion.
A MOST distressing-occurreoce is reported in a German medical
journal. A young woman who was a candidate for baptism
by immersion amongst the Baptists, after undressing to her
chemise and stockings in the vestry, put on a cotton wrapper
And came into tlio cliapel to bo baptised. Slie was completely
immersed in the baptistry, whicii was tilled with rain-water at a
itemperature of about 40" F,, the ceremony not lasting above a minute.
After this she walked back into the vestry, but Iminedlatoly became
■sinconscious, and, notwithstanding all possible efforts being made to
resuscitate her, succumijod. The post-mortem examination revealed
•that there was cardiac di.sease. As, lio^vover, there was no doubt
(►hat the immersion wa.s tlie determining cause of death, tlio unfortu-
mate minister who performed the ceremony was at first sentenced to
A week's imprisonment. This was, however, ultimately remitted.
The neighbouring Baptist congregations have, it is said, lakoii
warning by the case, and have arranged to have the water for
nmmerslon always warmed in future, as Is, wo believe, the custom in
this country. Another suggestion naturally arises from such an
occurrence as the above—namely, tliab persons .suspected of heart
disease should have the benefit of a medical examination before
being submitted to tbo rite of immersion.
'The Jlei/iitrar of the CoUeijo of Phynicians and Surt/eons, 0-iitario .—The
information contained in the last Students’Number of Tim Lancet
regarding the requirements as to preliminary education in France,
Germany, and other foreign countries is, we believe, quite correct.
It was collected from official sources and by mean.s of conversation
and correspondence with many foreigners and ICnglishnien who wore
in a position to give trustworthy opinions on the. subject. We do not
■think there is any room for doubt that, speaking broadly, medical
students iii almost every continental country are required to produce
■evidence of an amount of general education quite equal to.lliat which
would obtain for an English student the degree of B.A. The main
exception, tbo case of the French Official, is now on the jioint of boing
abollstied.
Medical Education in India.
The following is taken from tho Madras Times:—
“Dr. Wellington Grey, the Principal of the Grant Medical Col
lege, Bombay, has taken up the old question of raising the standard
of the Entrance Examination, lb has been whispered about for
some time now that Government is pressing for reforms, especially
in regard to those extra qualitications which the University should
insist upon as a preliminary to professional study; and, as If in
view of this demand, Dr. Wellington Grey has laid before the
Faculty of Medicine a comprehensive scheme for dealing with tho
regulations. Dr. Grey’s propositions go further, and cover wider
ground than any previous suggestions on tho subject; but it would
appear that they are not likely to meet with much support f)'om
the University, as, among other things, they suggest the reduction
of the quallflcation of Licentiate of Medicine and Surgery from a
degree to a mere licence, and nothing more.”
Mr. J. Oalloi> alioulcl apply to M. do Clausen, 37, Fitzi'oy-square, W.
DISPENSING BY MEDICAL MEN.
To the Editors of THE LANCET.
Sirs,—Y our correspondent, “ Presoribor,” has given us much of the
•pros and cons of this question, and I am glad to see that, to some
extent, ho agrees with my letter; but I cannot agree with him in tho
proposal that disponaiug by medical men should be given up gradually.
If wo have to wait for gradual processes, I am afraid tho result will be
nothing, Tho whole profession ought to rise and deal with the present
evil at once—as one should deal with all evils—with one voice and one
common act. No one practitioner is likely to give up the practice until
all his rivals have given it up also. Gradual, ono-by-one processes
certainly will not do, “ All together, and at once,” should be the watch¬
word in this matter, the watchword of the profession. From my ex¬
perience of druggists in those parts of the country—e.g., even the noi-th of
Scotland, where they do all the dispensing, and the “doctors” do none—
I am fuUy satisfied that such druggists are perfectly reliable and trust¬
worthy. It i.s in the places where the “doctor.s” do their own dis¬
pensing that druggists may not dispense the occasional prescriptions
which eomo to them exactly as ordered. And why'i’ Because, under
such civcumstaiicos, tho poor struggling druggist cannot afford bo keep
ill stock every representative of the Pliarmacopioia, ofRciual and non-
officiiial, for the sake of occasional prescriptions. I have had to alter my
prescriptions again and again to accommodate thorn to the limited
stock of a druggist’s dispensary. No, the druggist has to keep in .stock,
and rely for his living upon, patent modlcinos, his own stock mixtures
and salves, and his own prescribing. I have nob yet mot witli a single
druggist—and I have spoken witli many about this matter—who would
not be willing to give up all liis present struggle methods, logltimato
and non-legitimate, of making a living, if practitioners would give over
their dispensing to them, 'fhey would give up proscribing, and the
patent medicine trade would probably decay. They would, also, then
be able to afford to keep in stock every best drug and requisite pre¬
scribed by tlie “ doctors.”
As for prescriptions being loft with druggists and appropriated by
them for their own stock inedicinos, and as for patients taking thoic
prescriptions to he “made up ” .again and again witiiout the Jcnowledgo
of tho pre.scriiior, practitioners and druggists sliould bo able to arrange
these inattoi'S mutually and amicably, For instance, the pre.scription
sliould be sent by pvesevibor’s or by patient’s messenger to the druggist;
tho druggist retains tho prescription, he charges tho preacribor a
stipulated amount for dispensing the prescription, and tho prescriber
includos that charge in the foe ho claims of the patient. Tliis works
very well, and quite pays the prescriber in the end, for he may thus
neotl no assistant, and of course no private dispenser. Or, suppose the
]H'actition6r charges a moderate foe for his advico or attendance : the
patient sends the proscilptloii to the druggist, who retains tho jivescrip-
tioii, and charges a moderate fee to tho jiaiiont. Or, presuming tliat tiie
patient pays a larger foo for the prescription, supposo an arrangomeiit
is made whereby the druggist refiisos to repeat tho modicino according
to tho proscription rotaiiiod liy patient uiilass ordered in writing by tho
prescriber. This method would provunt dangerous niodiciiios boing
abused at tlie patient’s ignorant will, as instancud by your correspondent
“Prescriber.” Of course thorc are other alternatives, according to
the particular convonioiioo of doctor.s, druggists, and patients. In
order to secure proper mutual understaiiiling between practitioners and
druggists carrying out one of above methods, oven I'ltliical Associations
with tariffs, Ac., might be fonnod, in which tho two professions would
combine. I think the subject is ripe for careful considoratioii and dis¬
cussion by the whole profession of general practitionors.
One thing more porinit mo to say, and it is this : that it Is surely un-
wiso, if not unjust, in tlioso days, for wo principals to expect qiiaililed
assistants, iiioti ofton of great training and rellnod tastos, in addition to
walking their rounds Ac., to do tho liurried, slopping, manual drudgery
of tlispoiising. Such men, in the receipt ot an honoiiraido salary too,
onglit to be allowed time for general and social culturo, as woil as for
following up tho medical literature and science of these progrossive
days. In this latter direction aiicii geiitleiiion miglit greatly help their
principals, and imich more time might be given, with advantage to
patients, “doctors,” and to soieiico, to the details of diagnosis and
treatment, Certainly no dispaiising practitioner, even witli a qualilloel
medical assistant, should bo witiiout a dispenser, whoso duties should
1)0 only those of dispensing and bookkeeping, on duty in tlio dispensary
tho more Important liours of the daytime.—Yours truly,
April, 1891. ' Drt DiSPKNSINO.
TBM
NOTES, COMMENTS, AND ANSWEBS TO COKEE8PONDENTS. [April 18,1891. ^17
,, , SUPBBNUMEBAIIY PlNGER.
Wb have o-oceived a oommunication from a correBpondent in Cambridge*
port,'Maes., U.S.A., accompanied by a specimen of supernumerary
finger, bub wibliout name and address.
JjFiss A. Pahmi- (Madras).—There is no special training institution of
.the kind alluded to by our coiTespondent. Nurses can receive their
, training at any large, and recognised iiospital. The Army Circular,
, India, of Nov. 6th, .1800, gives full information, and a copy could
probably be obtained by appiication to the Surgeon.Qenerol's Office,
Her Mnjesty's Forces, Madras.
AgBi»ta>it has not stated whether he is qualified or not, and this is an
' important element in the question. Anyway, it is a matter for a
. solicitor to decide, in view of the terms of the agreement.
B. jB.—T he information Is given in our last number.
. MEDICAL PRACTITIONBRS’ UNION AND “ THE DOCTORS’
CLUB."
To the Bdito7-8 q/TltJ5 LANCET.
: Siiia,—If it be true that" It's never too late to mend,” I, with the
majority of general practitioners, hail with satisfaction the formation
of a General PractitionoiV Union, a Union which will have ample
sgope in this country for bettering the lot of the “great underpaid.”
Let us trust it may have equal power. There is no doubt, as your
correspondent says, we sliall succeed if wo are only united. Unfor¬
tunately, our hopes must rest on that little word “ if."
One serious grievance under which wo chronically suffer I would
utgeutly recommend to the notice of the Union—viv,,, tlio indiscriminate
charity which is bestowed on a large section of tlie community under
tile pseudonym of “medical providence.” I allude particularly to
those societies for sponging on medical men—societies whose agents
infest the country and make a regular house-to-house canvass of the
working classes and even tradesmen, and induce them to enter their
wives and children in the “ doctor’s club ” for the paltry pittance of
Id. for a woman and id. for each child per week, in return for medical
attendance and medicines. Sucli a system of insurance may possibly
“pay” the medical officer in the case'of the Oddfellows and Foresters,
in wliicli societies the members are male adults, and are only
admitted If in sound Uealbli. But what are we to say in the case of
women and children, especially Oie latter, who are constantly liable to
illness, and yob, strange to say, pay one-half the subscription paid by
a healthy man V Any insurance company which issued policies with
premiums so small, and where the certainty existed of being called upon
for boneilbs propovtioiiatoly so great, would soon bo insolvent. Yet we
caiTy on such a system witli the same result, the difference being
that tlie benefits we give are in the form of labour instead of money.
The principle, however, remains the same.
Take this iirstiince of the injury done to us by such societies, which
iviiow no such restrictions as wage limit. The wife of a first-class
artisan, who previously has paid her doctor well, enters lier first child
a fow moiitlis old in a modical provident society, of wliich her doctor
is medical officer. Supposing that child never so healthy, the cliances
are it will require medical attendance every year for some years to
come, which means an annual payment of, lot us say, .-ci to the family
doctor; bub by tlie slinplo expedient of paying a miserable 2.v. per
annum, lioy ! jiresto! tiio doctor’s bill disappears. So also tlie doctor’s
profit. It imisL be coiicudod that this is a good bargain for an anxious
mother, with all the liorrors of difficult dentition, mea.sles, convulsions,
iltc., looming in the not far distant future, and tlio IMendly Societies’
Medical AlliPince .solemnly records “with satisfaction the friendly
.spirit ” evinced by both parties to such a contract. Look on tlie otlier
side. -There is a loss of .iLi per annum to the medical profession in this
one case, for it cannot be contended that the donations of the other
moinbera of such a club compoii.satu for this loss when the numereus
and frequent ailments of women and children are conaliierod.
Another far-seeing mobhor will say: “I have oiiiered niy.solf and
all my children in the club, as wo are always having illnoas in
the iiouso”; and this is tho sort of thing on wliich is based that
“friendly spirit" with which the prosidoiit of the Friendly Hocicties’
Alliance says the modical faculty regards its methods. The ques¬
tion naturally presents itself. Why do we !W intelligent members of
society make contracts on torm.s whicii an ignorant labourer would
repudiate as an insult to his intolligonce 'I Tho answer, in my opinion,
is this. IMrstly, we have a minority disloyal to tliemselvos, their pro¬
fession, ami to their alma nuUer, to whom they have vowed to uphold
the honour and dignity of their calling ; secondly, want of union in oiir
ranks. I fool sure statistics in ahinidanco will bo forthcoming bo sliow
dourly the rottennes.s of a system carried on indepoiiduntly of wago-
limit and other safoguanls against abu.se—it system conferring a real
boon, though maybe in some cases a doubtful one, on tho “ benofitod ”
family, and iiiHicting an undoubted curse upon the already underpaid
practittoiior. Tlio iinestiou of tlioso clubs is one equally pressing as
hospital .abuse, and medical men for nil time will owe a largo debt of
gratitude to the Practitioners’ Union of to-day should it bo the means
of renioclying tliis and many oliier glwing abuses wliich are ut tlio root
of a genoral and widespread dissatisfaction amongst us. While bare¬
faced (juaekory flourishes, unipiaHIlod praetico is rampant in our midst,
cliemists usurp our lawful functions, and cheap doctoring is tlie order
of the day. Wo may wait in vain for those results for wliich wo have
toiled and striven and paid so dourly.—I am, yirs, yours faithfully,
April 14th. G. P.
Advbrtisino Pjuctitionebs in Miee-bnd-road.
We have received a letter from Mosers. Francis and Galley, solicitors,
of Austin Friars, who say
“ Our client, Dr, Richai'd Loughroy, in practice at 146, Mile-end-
road, has consulted ns with reference to a publication in your issue
of the 11th inst. (page 864) headed ‘Advertising Practitioners in
Mile-end-road,' commenting upon ‘A remarkable handbill,
emanating from U6, Mlle-ond-road.' We beg to inform you that
our client on the 31st January, 1884, purctiased from the executrix
of the late Dr. Hanks the lease of 146, Mile-end-road, and no such
handbills have since that time (upwards of seven years ago) beent
issued from such premises. If any such handbills were in circular
tion prior to that date, Dr. Loughrey was in no way privy to, or in¬
terested in, tho circulation.”
Of course, if we had been aware of the facts above stated by Messrs..
Francis and Galley, we should not have drawn attention to tlie
matter, though the handbill in itself deserves the comment.
Registei-ed.—l. If our correspondent will refer to tho last Students''
Number of THE Lancet, he will see that several of the colonies-
require a fee on registering a practitioner with British qualifications,,
even though ho has been registered in Great Britain. Some of the-
colonies also, in addition to a large fee (in British Golumbia it is 8100),.
oblige candidates for registration to pass an examination. The-
Jamaica fee of £l is therefore an exceedingly lenient infliction^
compared with that enforced in some otlier colonies.-2. There Is no-
University degree which precludes the Iiolder from dispensing medi¬
cines ; ami it is not very unusual for M.D.'s of Oxford, Cambridge,,
and London to dispense, whether they practise in the colonies or at-
home. An F.R.C.S. may dispense, but must not keep an open shop
Surgeons to London hospitals are usiiiilly precluded by tho hospil^
rules from general practice and fi-nm dispensing. M.R.C.P.’s are-
precluded from dispensing, from making arrangements with chemists,,
from entering into-partnership, and from suing for their fees.
Ai-my Suryeon is tlianked. The erroneous statements to which our-
cori-espoiidont calls attention bad not escaped our notice, and will,
wo imagine, be at once recognised by anyone acquainted with the-
subject. IRIDESCENT COOKED MEAT.
To the Editors of THE LANCET.
Sins,—Cooked and salted meats, as ham, beef, mutton, veal, pork, &c.,.
frequently show iridescence similar to that produced by light falling:
upon tlie scales of freshly caiiEht fish. This iridescence usually affects-
only a part of a cooked or salted joint; but it may possibly be asso¬
ciated with decomposition in another portion of the same joint. This-
iridescence (apparently bacterial) seems due to conditions probably
preceding decomposition, rather than necessarily accompanying putre¬
faction. ^Vhere tho meat has been otherwise sound, sweet, and healthy,
often have I eaten, and seen others eat, iridescent cooked and .salted'
meats without my having been able to trace any subsequent disturbance-
or illness therefrom. However, I consider iridescent meat as sus¬
piciously doubtful, and especially inadvisable where any lesions may
exist along any portion of tho alimentary tract, and above all to be-
avoided where there raiy be ulcerations about tbe intestines. Whilst
myself further investigating this matter, I shall bo grateful to learn of
any clinical, pathological, or bacterial worlc or research on this branchi
of meat inspection—a subject which has received too scanty attention-
from medical men —I am. Sirs, yours faithfully,
Brigliton, April 0th, 1801. J. LawrenCE-Hamilton, M.R.C.S.
Koopmann’s Fire Blocks.
A CORRESPONDENT desires to be informed where tho above fuel, whichi
is said to be smokeless, may be obtained.
J'rescriher. —These questions are discussed very fully in the chapter on-
Dispensing Foreign I'roscriptions in “The Art of Dispensing,”
piibliidiod at tho ChomUt ami Dntyyixt office.
Pr. lienioul'H communication should bo sent to one of our contem-
poravie.s. It would be altogether out of place in our columns.
Dr. James Qaird)ier (Crieff) is thanked. Ho will aoo tliat the lament¬
able occurreiico is fully reported in our present issue.
TIIK RECENT DRAMATIC ENTBUTAINMKNT FOR THE
BENEFIT OFTHIC ROYAI, S11EI-; HOSPITAL.
To the Editors of THE L.vncet.
Slits,—As no notice may liave been sent you of the entertainment
given by the Ainatuiir Dramatic Club of St. Bartholomew’s Hospital ou-
behalf of tho rebuilding fund of the Royal Free Hospital, may I bo per¬
mitted to at least personally express the -warm thanks which are duo to-
tlie Club for tho extreme kindness whloli prompted a large and rich,
hospital tliUB to aid a smaller and loss Indepeiideub noiglibour ? That,
the entertainment at St. Georgu's Hall on the l)th inst. was a great
success, before a crowded audience, is known to all, the performance,
“On Guard,”being roprosentedand placed upon the stage without a.
flaw. Tlie many points of humour and pathos in tho comedy were fiiUy
appreciated. Tho lady orchestra equally well acquitted thomselves in
tho selections of music.—1 am, Sirs, youv.s faithfully,
Frederick J. Gant.
April, 1891. Consulting Surgeon to tho Royal Free Hospital.
Toogie
Di-ir
918 Thb LanostJ NOTBS. COMMENTS, AND ANSWERS TO CORRESPONDENTS. [ApIiil 18,1891.
AGORAPHOBIA AND “IfiBEMOPHOBIA. ’
To ih« Editors THE Lancet.
SiBS,—The modesty which habitually restrains the members of our
e>rofession from rushing into print is so notorious that it will suiprlae
(none of them to bear that I have waited some years to allow someone
■else to do what 1 am at length reluctantly oompelled to undertake.
I propose the abolition of a ittetu! a non lueendo which I discern in
'the word “ agoraphobia.'' I see from a recent number of The Lancet
• that the word is still used in the sense of “ fear of a deserted place.”
I am nearly 7000 miles from my “ Liddell and Scott”; but I fancy I am
■not mistaken in thinking that dyopa means a market-place—i.e., a
densely crowded spot. It is asserted that in such places agorapbobiacs
Yeel no fear, and only suffer it under exactly opposite conditions. I
therefore venture to suggest the word “ eremopbobla'' to describe this
condition, deriving It, of course, from iprjfio^, a deserted place.
I offer apologies in anticipation to all those gentlemen who have
Already made this suggestion.
I am, Sirs, yours faitlifully,
Walter F. Dale, M.R.C.S., L.R.C.P.Lond.
Darwin Harbour, Falkland Islands, Feb. 12th, 1801.
Communications not noticed In our present number will receive atten¬
tion in our next.
Communications, Letters, &c., have been received from~Dr. Hale
White, London; Dr. Steavenson; Mr. F. J. Gant; Dr. Macnaugton
Jones, London; Mr. Poland, London; Mr. S. Snell; Messrs. Griffin
and Co., London; Mr. Eachwege, London; Mr. Stilliard, Birmingham;
Dr. Billinghurst, Mldhurst; Dr. Collier, Oxford ; Messrs. Hardman
and Sons, Bury; Mr. C. C. Becke, Northampton; Messrs. Blondeau
et Cie., London; Mr. Berridge, Loughborough ; Messrs. Francis and
•Calley, London ; Mr. N. S. Manning, Birmingham; Dra. Peacock and
.Pieterson, Klngswinford ; Dr. Pyne, Toronto ; Messrs. Rowntreo and
Co., York; Dr, Auld, Glasgow ; Mr. Maylard, Glasgow ; Dr. Be/.Iy
Thorne, London; Mr. Mossop, Newhavon; Mr. W. F. Dale, Falkland
Islands; Dr. Bentoul, Liverpool; Dr. Coghill,Ventnor; Messrs. .Tohn
Richardson and Co., Leicester; Dr. Cook, Winatree; Messrs, Pound
and Co., London ; Mr. E. A. Piggott, Clare ; Mes.srs. Hoarson and
■Co., London; Mr. Clifford, London; Dr. Thorn, Crieff; Mr. Buckston
Browne, London; Dr. J. B. Pike, Loughborough; Messrs.'Christy
and Co., London; Miss Yates, London; Messrs. Lax.ard Bros, and
Co., London; Mr. J. Berry, London; Dr. MacAlister; Messrs. Byles
and Son, Bradford; Dr. J. W. Allan, Glasgow; Mr. W. Mawer, Wood
Green; Mr. Messum, Pretoria; Mr. Blackett; Messrs. Mitchell and
Co.,London; Dr. Swann, Batley; Dr. J. Oliver, London; Mr. .S. A,
Gill, Formby; Dr. B. Walker, Spondon ; Dr. Kirk, Partick ; Mr. S. S.
Brown, London; Prof. Cliarterls, Glasgow; Dr. H, N. Joynfc, Birming¬
ham ; Dr. Wallace, Colchester; l)r. Malins, Birmingham; Mr, W, G.
Nosh, Plymouth; Mr. Pimm, Poultry; Mr. Grew, Birmingham ; Dr. J.
Gairdner, Crieff; Mr. Garnett, Bloomsbury; Mr. Parkhouse, Wel¬
lington; Dr. Bottentuit, Paris; Dr. Moure, Bordeaux; Mr. Nance,
Hampstead; Mr. Crowthor, London ; Mr. Sampson, York; Mr. Lund,
Bournemouth; Mr. Dayson, Monmouth ; Mr. Frost, London; Dr. W.
Wallace, Crick ; Mr. Cameron, Bayswater; Mr. W. B. Burke, Wolver-
Jiampton; Mr. Birchall, Liverpool; Mr. Watt, London ; Mr. Millard,
Teddington ; Mr. Anderson, Bodmin ; Dr. Skerritt, Bristol; Mr. Wise,
Trowbridge; Mr. Hunt, Manchester; Mr. Storer, Nottingham ; Dr. T.
Williams, London ; Mr. Macadam, Edinburgh; Mr. Weiss, Russell-
square ; Mr. J. 8. Aplin, Yeovil; Dr. McCallen, co. Derry ; Mr. Bead,
Canterbury; Mr. Finlay, Longford; Mr. Griffin, Saltburn; Mr. Heap,
Cheshire; Mr. Radford, Manchester; Mr. Evelyn, York ; Mr. Cooke,
London ; Mr. Woodcock, Bradford ; Mr. Homibrook ; Mr. Edwards,
Birmingham; P E.,Middlesbrough; Surgery,London; O.F.,London;
B. F. P.; Registered; Pontypridd; Sympathy; Secretary, Jarrow
Dispensary; G. P.; Secretary, General Infirmary, Leeds; Maltine
Manufacturing Co., London; Medicus, London; Secretary, Bolton
Infirmary; Caradoc; Hon. Secretary, Noble's General Hospital, Isle
of Man; Spes, Colchester; Omega, Cardiff; Secretary, St. Mungo’s
College, Glasgow; Secretary, General Hospital, Loughborough; Bona
Fides, Brighton; A. M. D.,London; Secretary, Caledonian Insurance
Co., Edinburgh; Medicine, London; lota, London; Secretary, West
Herts Infirmary.
LETTERa, each with efuilo»ure, are also acknowledged from—Dr. Scott,
Manchester ; Mr. Armstrong, London ; Messrs. Towers, Ellis, and
Co., Bayswater; Mr. Sutherland, London; Messrs. Fi-eer, Hett, and
Hett, Brigg; Mr. Gilyard, Bradford; Mr. Bigg, London; Mr. Young
J. Pentland, Edinburgh; Mr. F. E. Hodder, co. Cork; Messrs. Down
Bros., Borough; Mr. W. Coulson, Lincoln ; Mr. Halford, sen,, Upper
Tollington-park; Mr. Bringloe, Stratford; Miss Tliompaon, Tunbridge
Wells; Mr. Scarlett, London; Mr. Lee, Bxmouth; Messrs. Bilbrough
and Kibcliingman, Bradford; Dr. Swift, Adelaide; Mr. Wells, West
Hampstead; Mr.Rust,Kidderminster; Messrs. Herman,Lescher,and
Co., London; Mr. Knowles, Birstall; Mr. Ballance ; Messrs. Benger
and Co., Mancluster; Me. Graham, Dumfriesshire; MeBsra. Austin
and Son, Clifton; Mr. Tyte, MIncbinhampton ; Dr. Rahy, Caterham
■Valley; Dr. Byley, London; Mr. Tully, Hastings; Mr. Savage, South
Africa; Mr. Dixey, Chepstow; Mr. Goodden, Bristol; Dr. Lawrence,
Chepstow; Dr. Sliute, Northfleet; Mr. George, Preston; Mr. Wilson,
Devizes; Mr. Shimmald, Guildford; Mr. Ayres, Beading; Mr. Diver,
Caterham ; Mr. Simpson, Essex; Mr. Buller, Martley; Dr. Simmons,
Newbury; Mr. Baker, Willenhall; Mr. Freer, Rugeley; Mr. Oreville,
Edinburgh; Mr. White, London; Mr. Harvey, Loudon; Messrs. Keith
and Co., Edinburgli; Mr. Branthwaibe, Warwick; Messrs. Ferris and
Co., Uxbridge; Dr. Hyslop, Blackpool; Miss Galloway; Dr. Denme,
Ellesmere; Mr. Christy, Jarrow; Mr. Webster, Bewdley; Mr. Thin,
Edinburgh; Mr. Johnston, Leicester; Mr. Dickson; Mr. Heywood,
Manchester; Chemist, London; F. A. X., London; FideJis, London;
Cymro, London; W. R. V,, Whitby; Garthroy, Loudon; Warneford
Asylum; M.D., London ; Y. 0. G., London; Secretary, Norfolk and
Norwich Hospital; Hydro, Lincoln; A. E. B., Coventry; Hackney
Furnishing Co., London; Assistant, London ; Secretary, Taunton and
Somerset Hospital; A. B. N., London ; E. O. R., London; Mason,
Kensington ; L. D. S., Hayraavket; Alpha, Manchester; Cheltenham
General Hospital; Spes, Loudon ; J, G., Leeds ; Maniporo; Eastern
Counties, London; J., Barnesley; Florence, Yorks; A. B., South
Norwood; Kensington,Loudon; Medicus,Edinburgh ; Medicus,Don¬
caster : Scotus, London ; Prompt, London ; X., York ; M, F. M., Bir¬
mingham ; A. C,, London; Victim, London ; X.Y., Truro; Doctor,
Kensington.
NEWSPAi’EUS.~/llf(!7iV J7idian Mail, Bimiinijkmn /’o-ii, ,Sheffield Tele-
j/raj/h, MancheHei- Ewninn Neu'x, Olasi/ow Herald, Le Temps (Paris),
Huddersfield Jixaminer, Madra.i Times, Builder, Eorlhcrn Daily Mail,
SenUman, .Sunday Tvmes, Bombay Gazette, West Middlesex fitanda/rd,
Surrey Advertiser, Mininy Journal, Arehitect, City l‘resg, Bristol
Mercury, Law Journal, Spectalor, Saturday llevicw, Liverpool Daily
Post, Scottish Leader, Yorkshire Post, Weekly Free Press, Hertfordshire
Mercury, West Middlesex Advertiser, Leeds Mei-cury, Insurance Record,
Beadiny Mercury, Brckenhain Journal, Windsor and Eton Gazette,
Carlisle Journal, West .Sussex Gazette, The jeews-paper, Lincolnshire
Herald, North China Herald (Slianghai), Dxnidas .Sfnr (Canada),
Maidstone .Jnurnal, Farm, Field, and Fireside, Adniiralty and Horse
I Guards' Gazette, The Record, The Labour Wmld, Bath Gazette, Carlisle
I Exp-rcss and Examiner, Dundee Adve-rtiser, Lincolns/iire Chronicle,
j Chester Cmirant, Western Monthly News, Windsor and Eton Express,
1 &c., have been received.
SUBSCRIPTION.
Post Free to ant part of the United Einodov.
One Year 12 6| Six Months _ £0 U 8
To China AND India .OneTear l Ifi lo
To THE Continent, Colonies, and United
States.... ... Dlbtio X 14 o
Poet OflBceOrdera and Cheques should be addressed to The Publisher,
The Lancet Ofifice, 428, Strand, London, and crossed "London and
Westminster Bank St. James’s-square.”
ADVERTISING
Books and Publications (seven lines and under) .. £8 4 0
Official and General Announcements .0 4 0
Trade and Miscellaneous Advertisements ..048
Every additional Line 0 0 S
Front PMe .. .. per Line 0 10
Quarter Page. 1 10 0
Half a Page .2 16 0
An Entire Page.660
The Publisher cannot bold himself responsible for the return of testl.
monials <ko. sent to the office in reply to advertisements ; copies only
should be forwarded.
Notice.— -Advertisers are req^uested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
An original and novel feature of " The Lancet General Advertiser” is a special Index to Advertisements on pages 2 and 4, which nob only
affords a ready means of finding any notice, bub is in Itself an a^itional advertisement.
Advertisements (to ensure insertion the same week) should be delivered ai the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should b*
addressed.
Adverttsementa are now received at all Messrs. W. H. Smith and Son's Railway Bookstalls throughout the United BUugdom and all otbei
Advertising Agente. _
Agent for the AdTertiaement Department in France-J. ASTIER, 66, Bne Caumartln,
Dip - zed byCjOO^Ic
THE LANCET, April 25. 1891.
PART OF
%u
ON
THE NEUROTIC COMPLICATIONS OE
UTERINE DISEASE.
Delivered to the Nottingham Medieo-Chkurgical Society,
By W. S. PLAYFAIR, M.D., LL.D.,
SPROI'SSSOn OF OBSTETRIC MEDICINE IN KING’S COLLEGE, AND
I'HYSICIAN KOR THE DISEASES OF WOMEN AND CHILDREN
XO lUNO’e .COLLEGE UOSl’lTAL.
■Gentlemen,—Id acceptiDg the SatteriDg proposal of
your Society that I shouM address you this evening, 1 have
been greatly embarrassed in the selection of a subject. I
ehould perhaps have fixed on some particular disease among
•the many inviting discussion, and prepared upon it a paper;
but this would have involved an amount of study and
■literary work which the time at my disposal since I received
your invitation did not enable me to undertake, even if 1
bad felt otherwise fit for the task. 1 have, therefore, chosen
a topic which has occupied my attention a good deal of late
years, and chiefly because, independently of its own im¬
portance and interest, ib seems to me suited for the inter¬
change of opinion and debate, which I take it is one of the
chief objects of a Society such as this. Every practitioner
who devotes the slightest thought to bis patiente must have
some experience of the matters 1 propose to discuss, which,
if elicited, will certainly be valuable. The subject, bow-
•ever, is immensely large; to treat it thoroughly would
require a volume. All I can pretend to do to-night is to lay
'before you some reasons for giving it more serious attention
than it has generally received. I wish particularly not to
be misunderstood. 1 trust no one will accuse me of mini¬
mising the importance of local disease of the reproductive
•organs in the female. 1 am profoundly convinced that the
work which has been expended on gynascology within the
past quarter of a century, or little more, has led to more
■substantial advances than any other department of medicine
•can boast of. Whab other specialty, if 1 may use the term
in an unobnoxious sense, has such a record to show ? Are
there not a whole host of some of the moat important dis-
oases which human flesh is heir to, our knowledge of which
bae been entirely gained within the last half century?
‘Before that time gyn.'ecology in its modern sense did not
exist. Our fathers knew that women bad wombs and
ovaries, perhaps some of them knew that they bad
IFallopian tubes, bub there their knowledge ended. Far less
was known of diseases of the reproductive organs in women
than of diseases of the lungs and heart before Laennec’s
immortal discovery of the stethoscope. What other de¬
partment of medicine can show such substantial addition to
its study as is involved in the mere mention of such topics
as ovarian disease, fibro-myomata, hydro- and pyo-salpinx,
and others far too numerous to mention ? It is nob sur-
ijorising, ib is only most natural, thab when so much new
ground has been opened up, so many new diseases formerly
unknown have been made the subject of study, many
•errors should have been made. If the tendency of this
paper is to impress on you the belief that injudicious and
•excessive treatment of local pelvic disease often leads to
much mischief, 'I beg you not to draw the inference thab I
wish to depreciate the importance of such disease in itself.
I believe such errors to be inevitable in comparatively new
and untrodden paths of study. All I wish to do is to point
out the pitfalls that lie in front of us, so that we may try
to avoid them as much as possible.
Now I do not hesitate to say that the one important
lesson which has been impressed on my mind by my pro¬
fessional work of the past few years is the danger, in treat¬
ing the less important of the so-called diseases of women—I
•mean such as do not admit of any operative interference—
of developing a neurosis ; and that is the text on which I
wish to preach ray sermon to-night. In order to appreciate the
importance of this topic ib is above all things necessary
for us to do what the public call “ irndersband the constitu¬
tion” of our patients; and the one thing needful in the work
■of the gymocologisb is that he should thoroughly appreciate,
Nok 3630.
and bear constantly in mind, the highly strung and emo«
bional nervous organisation of his female patients, and the
strong impressions produced on them by any disease, or Bnp>
posed disease, of the reproductive organs, or by any local
treatment or even examination of them. It is perhaps diffi*
cult for any man properly to understand the amazing influ¬
ence which being told that some uterine trouble exists, or of
having local examinations made, has on certain women.
The practitioner means very little when he tells his patient
that her “ womb is displaced,” or that she has “ ulceration
of the cervix,” but whab an awful vista of far-reaphing con¬
sequences is often conjured up by these terms which convey
so litble to his mind, and so much to hers. A medical man
thinks it a trivial thing to introduce a pessary, but whab a
terrible thing is the disease, alas 1 so common, of pessary on
the brain. Some years since my esteemed friend. Dr.
Clifford Allbutt, delivered his excellent Gulsbonian lectures
on the “Visceral Neuroses,’’ which very properly attracted
much attention. In these he gave some very hard hits to
the specialist, particnlarly bo the gynaecologist. There was
very much bo be learnt fiom his words of wisdom.
“ 0 wad some power the giftie gie iw
To see oursels as others see iis I
It wad frae mony a blunder free us,"
is the aspiration of an illustrious Scottish poet. In these
lectures we bad the gift given us free, gratis, and for nothing.
Let us try to benefit from ib if we can. Dr. Allbutt tells us
that whenever anything is found wrong with the womb the
patient “ becomes entangled in the neb of the gyntoeologist,
who finds her uterus, like her nose, a little on one aide; or,
again, like that organ, running a little, or as flabby 83 her
biceps, so that the unhappy organ is impaled on a stem, or
perched upon a prop, or is painted with carbolic acid every
week of the year, except during the long vacation, when the
gynsecologist is grouse shooting, or salmon catching, or
leading the fashion in the Upper Engadine.” Now, I admit
at once that in a certain sense this caustic sentence conveys
a truth which we should all take to heart; it also conveys
an insinuation which is unjust. I believe it to be a fact
that such treatment as is here sketched, which no form of
disease known to me could justify, has unhappily been
often carried out with disastrous results to the patient;
whab I disbelieve is that it is ever carried out with
deliberate intention, as is insinuated, and thab there is more
blame to be attached than error of judgment. In justice to
the specialist, it is right to say also that lie is nob the only
sinner. Very many faults of this kind are due to misdirected
energy of treatment on the part of those who make no pre¬
tension to special knowledge, and on whom a little special
knowledge would not be thrown away. This is, however,
an unpleasant part of my topic on which I do nob care to
dwell.
I should like it to be recognised as an important factor
in uterine disease that there is in almost all women a strong
nervous tendency, and that we should be perpetually on
our guard in any local treatment we may adopt to avoid
anything that may encourage and foster it. In some this is
so exaggerated that treatment perfectly admissible, and even
highly judicious, for certain minor uterine troubles, such
as the use of pessaries and the like, becomes abso¬
lutely pernicious. The remedy in such cases is, in
fact, far worse than the disease, and the judicious prac¬
titioner, recognising the tendencies of the patieut, will
minimise to the utmost all local treatment, or abstain from
using ib altogether. Cases of this kind are, in my opinion,
very common indeed, and could easily be illustrated. Thus
only a week since I saw a young married lady who had been
in the hands of several practitioners for local symptoms.
She had been told that she had a retroflexion, and the dia¬
gnosis was perfectly accurate. A pessary had been intro¬
duced, of suitable shape and, no doubt, well adapted for
relieving other cases of the kiml. In this instance, how¬
ever, the effect had been disastrous. The patient was
chained to the sofa, was afraid to move across the room,
and could think of nothing but the mysterious instrument
within her. Its removal, and the assurance that she had
better do nothing but use hot irrigations, and might go to
the theatre, had the happiest effect. In a couple of days she
was cheerful and bright, and will probably do well without
any further local treatment at all. No doubt this is an
extreme case, bub ib is one of a kind we should always
recognise as possible. We should be careful, however,
not to allow one or two exceptional cases of this kind
to lead us into the opposite error, and generally condemn,
K
oogle
920 Thb Lancet,] DE. G. A. HERON ON KOCH’S TREATMENT IN TUBERCULOSIS. [April 25, 1891.
as some have done, the use of peBearies and other such
measures altogether. No mistake couU be more fatal.
Usually the growth of neurotic complications in connexion
'wi^ uterine disease is more gradual, and is the outcome of
the persistent and slow influence of minor ailments on an
origmally weak constitution. Take the common enough
case of a lady after conflnement with a heavy, subinvoluted
uterus, possibly retroflexed, and with some endometritis.
Under such conditions there is naturally pain, bearing
down, and the like. The medical man properly advises
rest, amongst other measures. He is not, however, always
there to supervise the carrying out of his advice. The teat
is taken, and gradually more and more, until the patient is
eventually hardly ever off her sofa. With this soon comes
the mischief which inevitably attends a case in which no
steps are taken to deprive rest of its evils. As there
is little or no fresh air and exercise, the appetite neces¬
sarily fails, and less and less food is taken. The patient
becomes pale and etiolated like a hot-bouee flower, her
bowels are deranged, her menstruation is irregular, her
sleep disturbed, her mnecles flabby, and in a word her
body is thoroughly out of condition. She must have au
exceptionally well-balanced mind if, under such circum¬
stances, her nervous system does not become out of condition
too, and then is started a state of things which must be
familiar enough to you all. I suppose there is no prac¬
titioner of experience who cannot at once call to mind some |
example of tnis deplorable bedridden, neurotic condition,
which is the curse of so many households, and which, for
want of a better name, has of late received that of
“neurasthenia.” The name has been objected to by high
authorities; why I do not exactly know. It has the objec¬
tion common to all names which assume a theory about
which there is a difference of opinion, but still it is suffici¬
ently descriptive, and some name is required. The im¬
portant thing, however, is to recognise the fact that there
IS a distinct and common morbid state, very insufficiently
described in our medical works, which is not only a fruitful
source of illness and misery, but which, when once tho¬
roughly understood, is readily capable of cure. 1 should
like to point out that this illness is by no means only,
or even chiefly, a result or accompaniment of disease
of the reproductive organs in the female. There are
many other conditions, such as some exhausting form of
illness, shock, mental distress, and the like, which may
cause it. To-night, however, it is mainly its connexion
with uterine disease that I am concerned with. When once
this unhappy state is developed, it is like some noxious
fieed, which, by its unhealthy growth, completely over¬
shadows the original malady, and becomes the main and
all-important factor in the case. I am obliged to say, for I
have seen many illustrations of the fact, that far too often
medical attendance, however well meant, only makes things
worse. Here, again, I do not for a moment impute any
intentional fault, though lack of judgment there often
certainly is. Undoubtedly the position of the ordinary
medical adviser in such a case is most difhcuH The
friends naturally are constantly sending for their doctor.
He. poor man, is at bis wit’s end ; he must do something,
and that something generally resolves itself into endless
prescriptions, innumerable pessaries, visits to health-resorts
if the patient is rich enough to afford them, and other equally
futile recommendations, nine out of ten of which only make
the patient go steadily from one depth to a lower one still
It is fortunate if, in these days of energetic operation, the
desperate reAurce of removing the uterine appendages is
not suggeate" or practised—a remedy the futility of which
under such conditions I have recently elsewhere tried to
prove, and on which I shall not now awell. I should like
to point out particularly that the morbid state thus de¬
veloped is as far removed as possible from the condition
generally described as “hysterical,” if by that is meant
something fanciful, within tlie control of the patient, and
unreal. ’This class of case most often occurs in emotional,
highly strung, and clever women, who have no desire to be
ill, and who would give much to be strong and well if they
only knew how. It is a positive injustice to roost of them
to assume, as is so often done, that they can throw off their
invalid condition by an effort of will. They cannot be
preached into liealtb ; the effort to do so only makes matters
worse. The essence of this disease is a profound defect of
nutrition, the gradual and progressive outcome of the long
continued action of many causes. My main object to-night
is to show how in one part of our work the risk of de¬
veloping the disease may be foreseen and avoided by a*
little common sense. To show at length how to deal with
this state of things when it is unhappily established woul<}
require much more time than I have at my disposal. It ie
by no means an easy task. It requires raueh time, patience,
tact, and the access to certain machinery in the way oF
skilled nurses and the like. Until recently there were no
established principles to guide us. Now and again a chance-
case may have improved ; but, if so, it was certainly more
by luck than good management. Happily that is no longer
tfie case now. To that eminent American physician.
Dr. Weir Mitchell of Philadelphia, undoubtedly belongs
the merit of systematising a method of dealing with sum
cases, based on a common sense appreciation of their
causes, so that they are no longer an opprobriuni medi-
cincc, but are as readily curable as anything can be, pro¬
vided only the treatment is intelligently and thoroughly
carried out, and the cases properly sheeted.
ON KOCH’S TREATMENT IN TUBERCULOSIS
OF THE LUNG AND IN LUPUS VULGABIS.i^
By G. a. HERON, M.D., F.R.C.P. Lond.,
Z'UVSiCIAN TO THK CITY 01' LONDON HOSPITAL FOU DISEASES OF TUF.
CHEST.
I DESIRE, before touching upon the subject of our pro¬
posed debate to-night, to express my thanks to the Council'
of the Society for the honour they have done me in inviting
me to open this discussion. I hope and believe that some gooc^
will come out of it, in the shape of a further clearing up of the-
position which Koch’s remedy for tuberculosis is to occupy
in clinical medicine. To the clear dedning of that position
nothing, it seems to me, will give so much help os a state¬
ment of what is seen to accompany and follow the use of'
this remedy in the human victim of tuberculosis. That
being my belief, it is clearly incumbent upon me to state
to the Society what I have observed in my own practice
in hospital cases, and to travel as little as possible
outside of my own experience in this matter. So much-
bai been already stated in the medical press, both ab
home and abroad, concerning the uses of tuberculin, that
were I now to attempt even to summarise, and to comment'
upon these records of a new subject, I should have to-
occupy much more than the whole of the time allotted
to night to our weekly meeting. What has been published
concerning Koch’s new remedy is, as a matter of couroe^
familiar to all medical men who take interest in the pro¬
gress of medicine. This branch of our discussion to-night
sliould, I app'ehend, come, for the most part, from those-
amongst us who have, from various causes, devoted them¬
selves more to the study of the literature of the subject
than to its investigation at the bedside.
The patipnts under my care at the City of London Hos¬
pital for Diseases of the Chest, were all subjected to tbe
same rules, so far as was possible, both before and during
the time that they underwent Koch’s treatment. Many
of the patients asked to have this treatment followed outr-
in their own case?, and in no instance was it com¬
menced unless the patient had previously .expressed a wish to
have it, and had spent at least one day, and, as a rule, two.
or three days, in a ward where several other persona were
umlergoirg the treatment. The tuberculin used for these-
patients was eent to me fortnightly by Dr. Libbertz of Berlin,
and it was therefore practically impossible that any error of
consequence could have arisen in the important matter of the
trustworthiness of the drug. The remedy was administered'
by means of Koch’s syringe in the usual way—that is to say,
it was injected under the skin between the shoulder bladee
and the line of the spines of tiie dorsal vertebicc, and with
those antiseptic precautions which Koch himself practised.
The doses ranged between 1 mgr. and lOCO mgr. in amount,
and in cases of tuberculosis of the lungs were given, Bi>
nearly as possible, every day. Before the treatment of any
case of suspected tuberculosis of the lung was begun, the
expectoration of the patient concerned was searched daily
for tubercular bacilli. No proof of the presence of tlie
bacillus of tubercle was found, so far at least as the evidence
I A paper read at tlie meeting of the Medical Society of London,,
April 20 th.
Di:
Google
The Lancet,] DR. G. A. HERON ON KOCH’S TREATMENT IN TUBERCULOSIS. [Atril 25, 1891. 921
of Ebrlioh’s test goes, in four of the cases of tuberculosis of
the lung, and one of them had no sputum.
Following another of Koch’s recommendations, the tem¬
perature of each patient about to undergo this special treat¬
ment was taken and recorded for two or three days before
the first dose of the remedy was given. As the treatment
of the case went on, this early record of what had been the
patient’s temperature, when it was uninfiuenced by tuber¬
culin, was found to be very useful for purposes of reference
and comparison.
Choice of Cases for Treatment.
In my selection of cases for the purpose of ascertaining
by their means the value of tuberculin as a remedial agent,
1 was influenced solely by the very explicit statement of
his own views on that important matter, which Koch him¬
self made to me for my guidance. In effect he told me
that, so far as tubercular affection of the lungs is con¬
cerned, be hoped for the best results from his treatment
only in cases in an early stage of that disease. By
this, be explained to me, he meant cases where a
small portion of one lung only was found to be affected
to a slight extent, and where there was no evidence
of excavation. That was the type of case in which
Koch looked for cure of the disease. Where the
tubercular condition was found to affect slightly, in the
way already indicated, small portions of both lungs, tbei-e
too a cure was reasonably to be expected. Any departure
from these types of cases in the direction of increase of the
extent of the disease lessened, by so much, in Koch’s
opinion, the chances of a cure, although even in more
advanced cases amelioration of symptoms was, he believed,
likely to result from the use of the remedy. It required,
however, but a very brief experience to convince me that
the sort of case which, in my opinion, expressed in its
symptoms of disease what Koch meant by his description of
cases likely to be cured, was a kind of case by n^ means
common amongst the people who came to the City of
London Hospibd for treatment. And especially as regards
the male patients was it remarked that, not only among
the in-patients, but also among the out-patients, it was very
uncommon to find examples of these very early stages of
tuberculosis of the lungs. This fact was also ooserved by
several of my colleagues in chargeof the out-patient depart¬
ment, and who have to deal there with a practice which is
considerably larger than that of any other similar hospital
in London or elsewhere. Among the female patients one
was now and then found illustrating perfectly, so far as I
could judge, what Koch had described to me as the typical
case for the use of tuberculin. In the dearth of such cases,
it was often necessary to select, for this special treatment,
those patients whose conditions of disease were least dis¬
tant from those of the typical case. Thirty-seven patients
were treated by means of tuberculin under my supervision
in hospital. It is, of course, practically impossihle for me
to bring all those cases here to-night. 1 propose, therefore,
to speak in general terms of them all.
To the thirty-seven patients witli whose cases we have to
deal (some of them are still under treatment), over 1200
injections bad, up to April 7ch, been given. The smallest
number of injections given to any patient for purposes of
treatment was eight; the largest number was, up to
April 7th, sixty-six. The shortest residence in hospital of
any patient who was treated there was twenty-one days,
and three cases of lupus remain to-day under treatment,
two of whom came into the hospital at the end of November,
and one in the first week of December.
To the pain produced by the prick of the needle of the
syringe all the patients soon became more or less indifferent.
The minimum of pain from this cause is secured by using
only smooth and sharp-pointed needles, and by completing
the puncture quickly. In most cases the local pain or
the puncture soon passes away, but often among the
first injections it begins to return in from three to
twelve hours or even later, and then it will be found to be
among the early symptoms of the beginning of the reaction
which is likely to follow the injection. This pain, when it
sets in with the other symptoms of reaction, is sometimes
very considerable in degree, and it may persist until the
riso of temperature due to the reaction has passed away.
In one case, which was an exceptional one, there were, in
addition to this pain, redness and swelling extending not
only from the site of puncture, but also from the little
swelling which showed where the tuberculin had been
expelled from the needle into the tissues. This swelling
was hard throughout its extent, and very sensitive
when even gently bandied. In this patient these sym*
ptoma usumly set in about eight or twelve honis
after the injection bad been gives, and in thirty-
six hours they had, for the most part, disappeared,
leaving behind them only a slight sensitiveness to gentle
pressure, and a little redness over the site of the swelling.
These exceptional symptoms did not begin to show them¬
selves until after the patient concerned had received four
injections. After the tenth injection they became so trivial
in amount that they were not noted, and they only once
again showed themselves in a marked manner during the
treatment of the case. This patient was an ill-fed-looking,
undergrown girl of sixteen years of age, extremely sus¬
ceptible to ^e action of the drug. Tubercular disease
involved the upper part of both of her lungs, to about the
level of the fourth rib on each side, and the glands on both
sides of her neck. On the left side of her neck was an open
sore, from which, before treatment was begun, there flowed
a considerable discharge of pus. The sore was about the
size of a florin—rather smaller.
In none of the thirty-seven cases, nor in any of the cases,
was there ever, as a consequence of the treatment, any
evidence of abscess. In several of these patients, after
about forty injections had been given, the skin, which had
been so often pierced by the needle, became somewhat
indurated. This was shown by the increased resistance in
certain spots to the passage of the iiee<lle through the
sicin, and by a feeling of toughness of the skin, when
it was gently pinched between fingu'.- and thumb. This
condition of skin was apt to be accompanied by as
increase of sensitiveness to the prick of the needle. As
a consequence of this in eight patients, five men and
three women, the condition of whose backs was mote
or less troublesome, the injections were given below
the skin over the deltoid muscle, and on the outside
of the forearm just below the elbow-joint. In every
instance, within two or three hours, the new site of puncture
became red and swollen, and very tender when touched.
Redness and swelling also appeared about the same time
over the spot where the fluid had left the needle and entered
the tissues. This was all the more remarkable, because no
such symptoms had previously occurred in any of those
eight patients while the remedy was administered between
their shoulder blades. It would seem to indicate that a
local tolerance of the drug bad gradually been established at
the earlier site of the injection while small doses of tuberculin
were being given, which was wanting in the arm when, <m
first puncturing ih, a large dose of the remedy was injected.
Some of the Points noted durbu] Pcaction,
Of the common features of the familiar reaction which
often follows the administration of tuberculin I do not pio-
ose at present to speak, because they are already too well
nown to need further notice now. There are, however,
certain points on which I may be allowed to dwell foi a
short time. From Nov. 2llrd, when tubeicuUn was first used
at the City of London Hospital, until a month after that
time the temperatures of the patients undergoing the
treatment were taken, as nearly as was convenient, every
two hours during t.he day and night. As a rule, the
thermometer was placed under the tongae in the usual way.
The temperatures were taken with great care by Dr. Adam¬
son and Dr. Scott, who for more than three months acted
as my house physicians in connexion with this special work,
and of whose devotion to their duties 1 cannot speak too
highly. It was very soon evident, from ol^ervations made
in the wards, that temperatures taken in the mouth are
more liable to error than those taken in the axilla or in the
rectum. This was found to be especially the case when the
temperatures were taken d uring the night. The thermometers
when placed under the patients’ tongues were occasionally
found to register too low a temperatare. It was noticed
that patients who had been sleeping with their mouths
open, or who had, as sometimes happe;)e«l, drunk a little
cold milk or water just before using the thermometer,
returned temperatures of between 95“ and 96“ F., when
llieir temperature in the axilla was ascertained to be a point
or two above 97“ or below 98°, and in the rectum below 9S°.
Dr. Adamson, who is a healtliy man twenty-live years of
age, found that the temperature under his tongue was only
95° in the morning after his cold bath, .and that the ther¬
mometer remained persistently at that point until he sat
down to breakfast, about a quarter of an hour after he had
D : Coogle
MR, G. BUCKSTON BROWNE ON VESICAL CALCULUS.
CApbil 26, 1891.
922 The Lancet,]
bathed. AIt>ef that meal, the aame thermometer placed
^der his rose to the ordinary temperature of the
body. These low temperatures were taken or checked by
tnstuuments tested at ICew. Of course the patients
lio whose temperatures reference is here made were, as
a rule, more or less under the influence of tuberculin;
' 'and many of our obserrations show that temperatures of
from 96'd* up to 97° are not very rare in such cases, espe¬
cially when the temperature has reached its lowest point
after a reaction. These lov temperatures generally occurred
between midnight and 4 A.M., and were not noticed to
bring with them symptoms of any kind. What has just
been said was well Ulustrated in the case of a girl of
fourteen years of age, referred to in The Lancet and
British Medical JournaZ under the initials H. D.
Another case, also mentioned by those journals, is that
of B. W-, a man aged twenty-two years, whose tempera¬
ture, instead of rising, habltumly began to fall in fire or
seven hours after the injection of tuberculin, and often
reached as low a point as 96° in from nine to twelve hours
after the injection. In this case twenty-seven injections
of tuberculin were given in six weeks, in doses beginning
with 2 mgr., and ending with 100 mgr., which was the
amount given in each of his last ten doses. On three occa¬
sions only did this patient’s temperature rise above 99°;
once it rose to 99'S* after a dose of 5 mgr. of the remedy,
and on two occasions well-marked reactions followed the
injection of 100 mgr.
Another patient, F. S-, a man twenty-two years of
age, received flfteen injections in fifteen days, in doses
ranging from 2 mgr. to 20 mgr. He never showed any
symptom clearly caused by the remedy, for bis tempera¬
ture only once reached as high as 99‘S®, and on only
three other occasions it touched 99 6°, a point to which,
however, it had risen before he began to use tuberculin.
On two occasions he had very trivial headache, but it could
not be certainly ascribed to the use of the remedy. He left
the hospirai because the treatment did not affect him as he
saw it affect others.
These two cases were instances of tuberculosis of the
lungs, and in both of them tubercular bacilli were found
repeatedly, and in large numbers, in the sputa. F. S-is
an undoubted illustration of the fact, that certain cases
of well-marked tuberculosis of the lung do not react in an
unmistakable way to tuberculin in moderate doses. In ad¬
dition to the fact that F. S-had numerous tubercular
bacilli in hie sputum, all the time that he was in the hos¬
pital, the physical signs of bis disease were plainly marked,
and indicated, surely, tubercular infiltration of about one-
third of the left lung in its upper part; and one or two
patches of crepitation in the same lung towards its base
were due, in all probability, to the same cause.
Very severe reactions with high temperatures are, as a
rule, consequences of large doses of tuberculin given at the
beginning of treatment. Where treatment is commenced
with doses of 1 or 2 mgr. it is exceptional, in my ex¬
perience, to find that there result either very high
temperatures, or other symptoms of very severe reac¬
tion. Therefore I have seen, in my own practice, very
little indeed of those symptoms of apparently serious
depression which have often followed the administration of
tuberculin. In only one of my patients have any of these
symptoms been present. That was an instance of lupus in
a young girl twenty-one years of age, whoso case is referred
to in The Lancet and British Medical Journal under the
initials L F. Hers was the first case treated by means
of tuberculin in this country. Following the Berlin prac¬
tice, I began her treatment with a dose of 10 mgr. The
reaction which followed was moderately severe, and it was
only on the sixth day after the giving of the injection that
the temperature again touched the normal line. Twenty-
four hours after the administration of the tuberculin, the
temperature in the rectum was 104°. On the ninth day of
treatment a second injection was given. The dose (10 mgr.)
■was taken from the same specimen of tuberculin which had
been used for the first injection. Eight hours afterwards
^ the temperature in the rectum was 10.')‘8''. That high
temperature had been preceded by three severe rigors,
great nausea, and delirium, besides the ordinary symptoms
of a severe reaction. I had seen in Berlin several reactions
to tuberculin more marked by nervous symptoms than was
the case here. This experience, however, decided me never
again to begin the use of tuberculin by the administration
of a large dose of it, and so 5 mgr. of the drug have
since then marked the limit of my largest first dose, for, as
occurred in this instance, end as indeed often bap^ieiis,
much more violent effects are apt to follow the secona dose
of the remedy than have resulted from a first dose of it of
the same strength. I have been guided iu increasing the
dose iu all cases, more by the presence of such symptoms
as rigor, nausea, vomiting, headache,, and marked joint
pains than by a rise of temperature unaccompanied, to
a moderate extent, by any of these symptoms. The dose
should never be increased until tolerance of the dose in use
is shown to be established by the absence of these sub¬
jective symptoms, and then the dose can be increased by
10, 20, 50, or even, towards the end of treatment^ by
100 mgr. daily. With proper attention to these points
I am strongly of opinion that tuberculin can be administered
with safety.
There was in this case of L. F- another condition
which was often seen amongst my cases in a modified form,
but only in her case were its characteristics markedly
exaggerated, especially on three occasions. This condition
has neen noticed by others, and its chief features are marked
increase of the rate of respiration, with a striking softness
of pulse and of radial arteries. The pulse-rate was not at
these times materially quickened in this case, nor was it
irregular. It varied then between 72 and 96, while the respi¬
ration numbered from 60 to 96. There was no dyspneea, bu t
merely extreme rapidity of breathing, which recalled to my
mind what we have all noticed in dogs on a hot summer’s
day, when they sit panting in the sunsnine, with the excep¬
tion that, of course, the patient’s tongue was not protruded.
If a dog in this condition have his attention arrested by any
cause, he ceases for the time to breathe quickly. So it was
with my patient, because when she was spoken to while in
this condition the rapid breathing ceased at once, and she
conversed without elfort of any kind, and in her usual tone
of voice. It seemed as if she breathed in this way because
it was a comfort for her to do so. She has not shown any
symptom during the five months that sbe has spent in hospital
which, in my opinion, could be called hysterical. The sym¬
ptoms referred to above occurred as a rule while the tempera¬
ture was between 101° and 102°, and falling after a reaction
and after all other subjective symptoms had passed oft'.
These special features first showed themselves prominently
thirty-four hours after the administration of the second dose
of tuberculin, then the pulse was 96, and the respira¬
tions numbered 60 per minute. On another occasion the
pulse was 96 and the respiration 90, and on a third occasion
the record stands: pulse 72, respiration 96. These sym¬
ptoms lasted from half an hour to less than an hour at a
time. The instances just quoted are the most marked
ones, bub putting pulse-rate first and that of respiration
second, 50 and 30, 60 and 24, 130 and 60, 120 and 40, were
rates often noticed in the case of L. F. These conditions
were unaccompanied by any other symptoms.
{To he concluded.}
THE IMPORTANCE OF THE POST-PROSTATIC
(OR TRIGONAL) POUCH IN THE SURGERY
OF VESICAL CALCULUS, ILLUSTRATED
BY SEVERAL CASES.
By G. BUCKSTON BRO'WNE.
(Concluded from pofje SCO.)
The next illustrative case is also one where the stone
was of remarkable shape, being like half a bird’s nest, with
a loose stone like a bird’s egg in it. The calculi consisted
of solid uric acid, the larger one in reality presenting a cast
of a nob very deep posb-prostatic pouch.
Case 4.—V. B-. aged seventy. Seen with Dr. G. D.
Thane, November, 1883. The patient suffered from great
irritation of the bladder. He was often disturbed every
ten minutes to pass urine ; riding in a carriage caused great
distress, bub there was no pain after micturition, and blood
had never been seen in the urine. I sounded him, found a
stone, and thought that perhaps there were several stones.
Three days after the patient was anfesthetised, and the
stone seized with a lithotrite, but I was at once conscious
that the calculus was fixed and nob free in the cavity of the
bladder, and therefore at once proceeded to supra-pubic
Google
The Lancet,]
MB. G. BUCKSTON BROWNE ON VESICAL CALCULUS.
[Apbil 25, 1891. 923
libhotomy. When the finger entered the bladder I had
reason to congratalate myself upon the decision, for there
was a cup-shaped mass of uric-acid stone (Fig. (i) lying
underneath a prostabic projection together with a small free
uric-acid stone. It would have been impossible thoroughly
to crush and evacuate this stone by lithotriby, it was far
too firmly and too deeply fixed. I removed it with a scoop.
Fig. 6.
and the patient made a good recovery, and he has remained
well ever since. The larger stone presents anteriorly a
cup-shaped hollow, in which the intra-vesical prostatic pro¬
jection lay.
The following case is of perhaps greater x)rofessional
interest than the others, for the patient had been in several
hands before he came to mine, and during the time he was
under my care I had occasionally to contend with the
greatest difficulties due to the depth of the post-prostatic
pouch ; owing, however, to the fact that this condition was
thoroughly realised, these difficulties were always success¬
fully overcome. When at last the patient died, I was
allowed to examine the parts concerned ; and am therefore
able to give a complete account of the case.
Case 5,—B. V-, aged seventy, seen with Mr. H.
Fraser Stokes. Retention of urine, Aug. 1887, and ever
since all by catheter. In July, 1888, Mr. Stokes wrote
asking me to see the patient, and saying; “He has been
sounded several times by Mr.-and Mr.-, and by
myself, and nothing can be detected.” On the 24ch I visited
him. The catheter was passed every three hours; there
was much spasm and great pain in the penis; the
urine was acid, with much pus; sp. gr. 1018. I sounded,
and at first felt nothing; but after a little search
found a stone, apparently on the lloor of the bladder.
On July 27bh Mr. Moss administered ether, and I
seized a medium-sized stone with reversed blades and
crushed it. The operation was satisfactorily completed, and
the patient made a very good recovery. The stone weighed
2 drachms 25 grains, and consisted of an oxalate centre with
phosphatic incrustation. January, 1889: The patient had
been very well, going six hours between his catheterisations,
but he now complained of pain before and after using the
catheter. He was sounded, nothing found, and the bladder
washed out with a No. 16 tube and lithotrity aspirator,
obtaining no result nor bearing the smallest rattle of stone
against end of the tube. The symotoms continuing, I
was asked to sound him again, and on Feb. 5th did so, and
found a atone apparently on the lloor of the bladder, andwibh-
drew the sound. Mr. Stokes, \vbo was standing by, said he
had not heard the stone, and asked if 1 would let him hear it.
So the sound was reintroduced ; but no stone could be felt,
nor was it until after careful search had been made for
several minutes that the beak of tlie sound seemed to find
its way into a pouch on the lloor of the bladder, and imme¬
diately there encountered the stone. Next day lifbotrity
was performed. The stone was clilliculb to find, bub was
seized with reversed blades, and tlien carried into the cavity
of the bladder. While held there we discussed the question
of performing lithotrity or of opening the bladder above the
pubes, and we decided io favour of the former. The stone
was therefore crushed and entirely removed, a rectal bag
being introduced into the bowel to press up the (loor of the
bladder, and to prevent as far as possible d6bvis from falling
into the pocket behind the prostate. The patient made a
good recovery, and continued very well and active until
October, when he began to experience again a little pain after
catheterism. On the 25th I sounded and found stone. The
urine was very offensive, and there was )uuch spasmodic pain
before and after catheterism. Next day lithotrity was per¬
formed, and two calculi were successively picked out from the
pouch on the floor of the bladder, with which I was now very
lauiiliar. Great pains were taken to evacuate every particle,
and no trace of more stone in any part of the bladder could .bd
felt; and although the patient’s consent had been obtained
to supra-pubic cystotouty, if necessary, we thought it well to
be content. Unfortunately he was not at all relieved by
this operation, and the spasms continued before and aft^
each catheterism, which had to be performed every hour.
This went on until Nov. 4tb, when he was so ill that I de¬
cided to open the bladder, and next morning performed the
usual supra-pubic operation. Directly the finger entered the
bladder it found an intra-vesieal prostatic growth as large Os a
chestnut, growing from below and rather to the right of the
vesical urethral orifice; and under the growth, at the bottom
of a deep pocket, there was a calculus as large as a pea. The
prostatic outgrowth offered itself temptingly for removal,
Wt taking into consideration the patient’s weak state we
reluctantly left it alone. He was so ill afterwards with
vomiting and bxmatemesis that we were very glad we had
done so. He slowly recovered, and on the 29th the wound
was firmly healed. During the middle of December ho ha.>l
a severe attack of right renal colic, and on the 21st I
washed out of the bladder a distinct calculus through a
No. 15 evacuating lithotrity tube. During January, 1890,he
enjoyed good health, frequently held his urine seven hours,
and was entirely free from pain. On Feb. 1st lie had another
severe right renal colic with rigors, and gradually passed
into a dying condition, and sank on Feb. 12th. Oh
Feb. 14th I made a post-mortem examination, and
obtained the bladder and prostate shown in the engraving
(Fig. 7). A stone has been put in to show where the stone lay
Fig. 7.
4, Piece of lioiigie lying in uroUiia. ii, BlacUler wall—poat-
ttigonal poucti. c, Thci calculus. D, Intra-vesieal prostatic
growth. 1 ’, 'I’iie prostate, ii ti, Tlio vesical openings of. the
ureters, r r, Intor-urcteral ridge.
during life, and it will readily be seen why difficulty was so
frequently experienced in the detection of the successive
calculi and in their removal through the urethra, and how
it was that one calculus was never touched until the bladder
was opened supra-pubically. The intra-vesical prostatia.
growth completely roofed over the post-prostatic pouch,
and was practically in contact with the well-developed
inter-ureteral ridge, so that exploring instruments were
only with great difficulty, and even uncertainty, passed
into the pouch. At the post-mortem examination, the deep
post-prostatic pouch was entirely free from calculus. The
ureters were only slightly dilated, and the right ureter was
almost blocked by a calculus about an inch below the
kidney. This was the only stone to be found. The kidneys
were congested and passing into an interstitial suppurative
condition. This patient evidently from time to time passed
stones into his bladder from his right kidney, which were
trapped by the post-prostatic pouch—indeed, they had not,
a chance of escape by the urethra. It was unfortunate that
his vital powers failed when they did. for there was only
one more renal stoue to be passed, and that was engaged iu
the ureter at the time of his death.
Case 6.— The stones in the case just related were only
small, and it may be urged that that was one reason, at any
^8
Thb Lakcbt.I
DR. W. E. STEAVENSON ON THE ELECTRIC BATH.
[Apsil 25, 1891.
tale, why they were nob easily fonnd, bat really large stones
sometimes lie in (his pouch and escape detection. Fig. 8
represents a calculus weighing thirteen drachms and a half,
which I recently removed by supra-pubic lithotomy from a
patient aged eighty. He lived eight weeks after the opera¬
tion. The stone was hidden awayin apost-prostaticpouch.
Fig. 8.
. Ji.
An excellent surgeon had within a few months performed
litbotrity in the general cavity of the bladder without, it
may fairly be assumed, ever toacbing this large calculus.
The next case (Case 7) is one of a uric-acid calculus
weighing fifty grains, and shown in Fig. 9, which I entirely
failed to find % soanding, in the bladder of a gentleman
aged eighty, althougU I examined him thoroughly three
Fig. 9.
times, once when he was anaesthetised, using litbotrity
tubes and aspirator and sounds of various sizes and curves.
My conviction that he bad a stone was, however, not
shaken, and as his suiTerings were severe he suboiitted to
supra-pubic cystotomy. On entering the bladder with the
finger the stone was found with great difficulty, owing to
the depth of the posfc prostatic pouch in which it lay. The
diagram represents the parts as I found them. This case is
an important illustration of what I maintain to be a fact—
vix., that vesical calcnlus may exist under such conditions
as to be absolutely out of the reach of all instruments
introduced through the urethra.
If time and space permitted I could give further examples
of a more ordinary character from ray practice, where I and
others have failed tc find stones when sounding in the usual
w'ay, owing to their lying in post-prostatic pouches. In one
case the bladder was opened by lateral perineal cystotomy
for drainage and exploration, and the stone was not felt by
the staff or detected until the finger entered the bladder;
but I think enough has been related to illustrate the im¬
portance of the post proatatic pouch in the surgery of atone
in the bladder, ard to prove the two pvopjsibions with
which 1 commenced this paper.
The practical outcome of my paper is therefore—1. The
insistance in all doubtful cases of vesical suffering, where
the prostate is enlarged, upon careful searim being
made behind that organ. In sounding in such cases
it is not enough merely to reverse the beak of the
sound, but thorough examination must be made, with
the reversed beak, for the slit-like opening between the
intra-vesical proatatic growth and the inter-ureteral ridge,
which may be the sole means of access to a la^e post-
prostatic pouch, when such a pouch exists. For this
investigation a sound I have designed with a beak like
a flat-bladed lithotrito will be found useful. The broad
flat beak is easily reversed when in the bladder, and it slips
with greater facility than the beak of an ordinary round-
ended sound under the projecting lobe of the prostate,
allowing the space under it to be as fully explored as is
possible by any instrument passed in by the natural passage.
Fio, 10.
Bladder sound, with broad fiat beak (the author’s).
Help may sometimes be afforded in this exploration by intro¬
ducing a rectal bag into the bowel beforesounding, or by an
assistant making upward pressure with his finger in the
rectum. The endoscope, as in too many of the really obscure
troubles of the bladder, is here of no use; nor is distension
of the bladder with fluid, which in the case of a post-
trigonal pouch is always useful, of any avail when the stone
lies concealed in a post-prostatic pouch. 2 When there is
reason to believe that there is a deep post-prostatic pouch it
will be well, save in very exceptional cases, not to attempt
litbotrity, for it is when petfurmed under such conditions
that litbotrity is likely to be discredited, because it may
be impossible to clear the pouch of all stone by instru¬
ments passed in by the urethra. Case 4 is a good example
of this. Here litbotrity was abandoned in favour of supra¬
pubic lithotomy. It is reasonable to believe that such astone,
situated as it was under a projecting prostatic mass, could
not have been entirely removed by litbotrity, and the result
has justified the decision, for the patient has had no return
since the operation, two years and a half ago, of calculous
troubles. 3. Finally, when calculous symptoms and vesical
distress continue in spite of treatment, and no stone can be
found by the usual methods of examination through the
urethra, and also in cases where a stone is found, but lying
deeply in a post-prostatic pouch, it is urged that the bladder
should be opened by supra-pubic incision in preference to all
others, for, combined with firm upward rectal pressure, the
surgeon thns obtains complete command over the post-
prostatic pouch, such commaud indeed as can be obtained by
no other cystotomy, while at the same time it is incom¬
parably safer than any perineal operation, being almost
oloodless, in cases which by their very nature (great pros-
tatic enlargement) are certain to bleed freely if any incision
is made from between the legs.
THE ELECTRIC BA.TH.
By W. E. STEAVENSON, M.D.Cantab., M.R.C.P.,
IN CIIAROR or TIIK KLirCTIlICAr. DEPARTMENT, ST. lUHTHOt.OHBW’S
HOSPITAL; PHYSICIAN TO THE OROSVENOR HOSPITAL FOR
WOMEN AND CHILDREN.
(Conchtded from pat/e 872.)
Lateral sclerosis .—This is another affection that appears to
be greatly benefited by electric baths. The bath is given in
the way already described for giving a general galvanic bath.
The direction of the current is not specially indicated in the
treatment of most affections by the electric bath, but In
rheumatoid arthritis and lateral sclerosis the positive pole
should always be placed at the bead of tbe batb, so that
the current enters tbe spinal cord between the shoulders. It
seems to have some specific action upon the cord, and in
the case of lateral sclerosis appears to reduce the tendency
to increased reflex excitability. Under this treatment the
spastic gait is improved, and the tendency to tonic spasm
in the limbs reduced. Early experience led to the belief
Dipiti/ed by
Google
The Lancet,]
DE. W. E. STEAVENSON ON THE ELECTRIC BATH.
[April 25, 1891. 9 25
that these cases of spastic rigidity, accompanied by severe
tremblings and sudden contractions of the limbs in bed,
were more amenable to treatment when the result of injury
to the brain or spinal cord by direct violence, but latterly
cases due to lateral sclerosis and descending irritative
lesions of the lateral columns have also been found to
greatly improve by treatment with electric baths.
Metallic poisoning, plumbism, &c. —A method of removing
poisonous metals from the body by means of an electro¬
chemical bath has been employed. The method was intro¬
duced by Yergnds of Havannah. He had a bad ulceration
on his band, produced by metallic irritation in consequence
of the process of electro-plating. He connected his hand
with the positive pole of a battery, and placed it in a bath,
and immersed in the bath a metal plate connected with the
negative pole. After a current of electricity had been
flowing for fifteen minutes, he found that the negative
plate had on it a thin film of gold or silver. He repeated
this hand electric bath a few times, and found that his ulcer
healed. For the removal of metallic imparities from the
body, it is best to use a bright copper bath, which is
attached to the negative pole of a battery, the patient hold¬
ing out of the water a handle covered with house flannel
(Fig. 7), first in one hand and then in the other, for eight or
ten minutes, or the patient may grasp the metal rod before
mentioned; but the rod cannot be allowed to rest on the
sides of the copper bath; it must have some special in¬
sulated supports, and be connected with the positive pole.
When the metal is lead that has to be removed from the
body, the water in the bath has to be acidulated with
sulphuric acid. When gold or silver is to be removed,
then the water should be acidulated with nitric acid. When
a copper bath is unobtainable, a porcelain one may be used
with a large sheet of copper immersed in the water, and
connected with the negative pole. The current enters the
• patient’s arms, passes through his body and then to the
copper, taking with it the metal, and depositing it on the
surface of the bath or copper plate. Some of the metallic
poison is also said to remain in the water, and to be capable
of detection in the air of the room from evaporation.
Mercurial tremors are also treated by electric baths. As
many as five and twenty have been required to produce a
cure, but alcoholic tremors can often be cured by six or
eight baths.
The introduction of medicinal substances, chiefly metallic,
into the body, has been recently revived by Dr. Cagney of
St. Mary’s Hospital. The system was advocated and prac¬
tised by Vergnos in 1855. He employed phosphate of iron
and nitric acid. The patient w’as made to sit in a hath
containing a solution of one of these substances, and the
bath, or the solution it contained, made positive, the
patient in this instance holding the negative pole out of the
water. The current has to pass through the water into the
patient, and out at the arms ; in its passage it carries some
of the substance in solution into the patient. Drs. Beard
and Rockwell say “there is little question that the
passage of the current through the body immersed in
certain medicated solutions aids in the absorption of some
portion of the compound. Weakly and anaemic patients
might in this way be made to absorb phosphate of iron.
Dr. Cagney in his recent paper referred to the experiments
of von Bruns and Hermann Munk.- A saturated solution
of the substances experimented with was placed in two of
Dubois’ conducting tubes, and the tubes closed with pieces
of clay soaked in the solution ; they were then applied to
the part of the body it was especially wished to inlluence.
The direction of the current was reversed every five or six
minutes, because more is absorbed by this means. If the
current is continued too long in the same direction, it is
retarded through polarisation' taking place in the tissues.
It is therefore necessary to charge both electrodes with the
solution it is wished should enter the patient. ■ The current
should be fairly strong and kept flowing for from fifteen to
forty-five minutes. A considerable quantity of a drug can
by this means be introduced into the system, and it is
introduced in a nascent state, and therefore in a condition
of maximum activity; traces can be discovered in the saliva
and urine for several hours afterwards. The drug which
gives the best results when administered in this way is the
iodide of potassium, and when only one charged electrode
can be used it should be attached to the negative pole,
1 Medical Electricity, p. 738.
* Erb'a Electrothevapeulics, translated by Do Wattcville, p. 127.
because the iodine is electro-negative and has a tendency
to travel towards the positive pole. It is the iodine
which can be successfully introduced in this way; for
instance, in goitre or strumous glands. It has also been
used in cases of labyrinth deafness and in lead palsy,^ also
in syphilitic gummata and diseases of the skin. Iodide of
potassium can be employed in this way when it disagrees
with the stomach, and the effects of the iodine can be more
distinctly localised.
Baynaiid’s disease, —The electric bath is most nseful in
all cases of bad circulation, including those cases of local
asphyxia described as Raynaud’s disease, in which the
extremities often become blue and very liable to chilblains,
and sometimes become gangrenous. The galvanic bath is
the one to be employed, and should be used as previously
described. (Seepp. 710,71L) The patient’s general nutrition
and circulation will be found to have im{)roved at the end
of a course, and the tendency to chilblains lessened. The
complete bath is the best, but Dr. Thos. Barlow^ in bis
appendix to the translation of Raynaud’s two. essays on
Local Asphyxia,‘‘ recommends local arm electric baths in
the following words :—“ The use of the constant current,
as recommended bv Raynaud, has been adopted with
advantage by several observers in cases of local asphyxia.
The method which has been found most satisfactory by
the translator in four separate cases has been the fol¬
lowing. Immerse the extremity of the limb which is the
subject of local asphyxia into a large basin containlog
salt and water; place one pole of a constant current battery
on the upper part of the limb and the other in tire basin,
thus converting the salt and water into an electrode.
Employ as many elements as the patient can comfortably
bear; make and break at frequent intervals, so as to get
repeated moderate contractions of the limb. In a typical
paroxysmal case, if the two limbs are similarly affected, it
will be found that the limb which is subjected to the above
treatment will more rapidly recover than the o^e which is
simply kept warm. It will also generally be found that the
patient can tolerate the above mode of stimulation much
more readily than he can hear friction with the band, and,
that the use of galvanism in the way indicated, or by
simply ‘painting’ with two sponge electrodes held on the
limb at a short distance from each other, will so far diminish
the pain that the patient becomes able to bear sham[>ooing
afterwards. In chronic cases, although the relief is not
so obvious, there can he no doubt at times as to the
value of this measure in improving the nutrition of
the limb and in keeping the threatened gangrene at
bay. Even when gangrene in the limited form which
Raynaud describes has supervened, galvanism to the
parts above and around may be tried with advantage.
Shampooing ought certainly to be employed in conjunction
Vith galvanism, especially in the chronic cases in which the
extremity of the limb undergoes a degree of atrophy, or in
which contractions and fibrous ankylosis take place." If
the local arm bath is used, it is best that the electrode out
of the water should be applied to the nape of the patient’s
neck so that the whole nervous supply of the arm may
be in the circuit. When the complete bath is employed
there should be no breaking and malcing of the circuit, for if
this were done the patient would receive a most unpleasant
shock, and there seems to he no particular advantage to be
attached to the direction of the current.
Sciatica and lumbago are sometimes treated by electric
baths, but much better results can be obtained in the treat¬
ment of these affections by appljying electricity locally.*
The monopolar galvanic bath might prove very useful in
the treatment of some obstinate forms of neuralgia. It is
hardly applicable to the treatment of neuralgia of the sciatic
nerve, as it would be difficult in a bath to keep the region
over the sciatic nerve out of the water, but in cases of
cervico-brachial neuralgia, or facial neuralgia, a labile
application with the positive pole might easily be made to
the painful area. Galvanism applied in the ordinary way is,
perhaps, the beat means we possess for treating sciatica ; it
is unnecessary, and certainly less satisfactory, to complicate
the treatment by applying it through the medium of a
bath.
Therapeutical uses of the intenmpted current bath.—As a
■* Dr. Cagney ; Brit. Mod- Jour., Nov. IGth, 18S9, p. 1102
•' Heloctud Mniiographs. Tvansla,tion putlwliod by tlio Now Sydenham
Sodnty, pp. 10a, 109,
>■> Vide The Lancet, Jaii. 19th, lS8d, p. 105 ; and July I7tb, 1880,
p. 113.
R 2
936 The Lancet,] MR. SIMEON SNELL ON OPHTHALMIA IN THE NEW-BORN.
[April 26,1891.
general tonic the intermitted current bath is preferable. It
ean be used most beneficially in many hysterical conditions
and In neurasthenia, and may with' advantage be combined
with massage. The secondary current can ne more easily
regulated than the primary, and is the better stimulant.
Its use is indicated in hysterical afTections. The faradaic
bath is also of use in alleviating the distress connected with
the discontinuance of the morphia habit. The following con¬
clusions have been arrived at by the various observers on the
effects of the galvanic and faradaic electric baths:—“ Meta¬
bolism is promoted considerably by the dipolar, slightly by
the monopolar, bath (Lehr); and there is increased secretion
of urine. Appetite and digestion are improved. The genital
Junctions are stimulated. Circulation and nutrition are
benefited, sleep notably restored, and new vigour imparted
to the mental and physical faculties. In short, the electric,
and especially the faradaic, bath is credited by all with
powerful invigorating and refreshing action upon the human
frame.”®
“There can be no doubt as to its efficacy in states of
debility and imoaired nutrition, and especially in the
various functional neuroses—e.g., neurasthenia of any kind,
and particularly sexual neurasthenia, nervous dyspepsia,
palpitation, hysteria, hypochondria, Basedow’s disease,
&o. Fui-ther, it is beneficial in tremulous states (mercurial
and alcoholic tremor, &c ), and even in paralysis agitans,
where it will effect at any rate a deciaed alleviation of
symptoms. It has been known to do good in the spasms
and rigidity of hemiplegia and spastic spinal paralysis
(Lehr).” “In muscular rheumatism and old and chronic
forms of articular rheumatism it has been given with great
advantage (Bouillon-Lagrange, Barth, Schweig, Lehv).”^
THE PREVENTION OF OPHTHALMIA IN
* THE NEW-BORN. 1
By SIMEON SNELL,
01>IITHAI.MIC SUaCEON TO THE SIlEEnELD OICNEHAL INViaMAKY AND
TO THE INSTITUTION I'OU THE HUM); CONSULTING OPHTHALMIC
SURGEON TO THE ROTHEIllIAM HOSJ’ITAL.
There are few things more sad in my experience than to
witness infants of only a week or two old brought for
treatment with one or both eyes either already lost or irre¬
parably damaged. Nor is this feeling rendered less by the
reflection that the disease which has led to such dive results
could have been in the first instance prevented, or if that
opportunity had passed, timely’ treatment would have
brought about recovery of sight. The subject is a distinctly
obstetrical one. Therefore, though my own practice lies clear
of obstetrics, I offer no apology for bringing it under the
notice of those who either as specialists or as general prac¬
titioners must feel an interest in a matter of so much
concern. The importance of the subject will not I think
be contested. A moderate estimate gives 30 per cent,
of all cases of blindness as due to this disease alone. The
census of 1881 gave the total of blind as 22,832, and there¬
fore no less than 7000 of this number must be considered as
being rendered blind from ophthalmia neonatorum ; 30 per
ewt. is, however, a rather low proportion—my o wn statistics
place it higher. I have kept a record of all children
admitted into the Shellield School for the Blind since its
opening. I find that after excluding three (which were nob
seen by me, or for some other reason) there is up to the
present a total of 110. Of these in no fewer than forty-six
can the cause of their hlindness be traced to the disease of
which we are speaking—a percentage of 39 (5. The employes
at the workshops of the Institution for the Blind give a
rather lower estimate. These are adults ; and causes such
as accidents, and to which I need not further here refer,
have come into force which had nob done so, or in a less
degree, in the cases of the children. But with this deduc¬
tion the proportion is left at fully one-third of every
hundred blind that I have examined at the two in¬
stitutions. But mention has been made thus far only
« Erb’s IflecitrofclierapeuticH. translated by Do WatLevIIlo. n 280
7 Ibid.,p. 28
before tho North of EiiKland Obstetrical and Gyntuco-
yheffleld, June 20tb, 1800.
‘ A paper road
logical Society at
of those who have been rendered blind in both eyes,
and have in this way become fitted as inmates of or
workers at a blind institution. What means have we
of estimating the number of others suffering from the
loss of one organ, or with one or both more or less
damaged ?
It is needless to discuss now the means of treating the
disease when once it has been set up. It is sufficient to say
that it is recognised that, if adopted promptly, treatment is
eminently satisfactory. My object is rather to deal with
the important question of prevention. The present is
peculiarly a time for preventive medicine and surgery, and
in few instances can, I think, there be found a brighter
field for recognising and obviating the causes of disease
than the affection which if neglected leads to the disastrous
results already set forth.
We may divide the subject into two portions. 1. Pre¬
vention of the disastrous results of the disease. 2. Prevention
of the onset of the disease.
1. Ignorance as to the nature of the malady. —The igno¬
rance prevailing as to the serious character of the disease is
great. Much, then, can be done by diffusing information
as to the dire effects of neglect of early treatment. The
Ophthalmological Society some years ago appointed a depu¬
tation to wait upon the Local Government Board, with the
object of obtaining the assistance of the Poor-law and birth
registration organisations. It was proposed to cause the
distribution of a paper at the time of birth registration
with brief directions setting forth the gravity of the eifection
and the need for early treatment. This, however, led to
no result. Butin the absence of an elaborate scheme much
can be done in simpler ways. Por instance, for the last
few years every parent or friend bringing an infant suffering
from ophthalmia neonatorum to the Slieffield General In-
firmar;y has been presented with a card with directions some¬
what similar to, but more brief than, those suggested by
the Ophthalmological Society. They are desired to pre¬
serve it and to show it to their friends. It reads as
follows:— '^Important: If a baby’s eyes run with matter and
look red a few days after birth, take it at once to a doctor.
Delay is dangerous, and one or both eyes may he destroyed
if not treated immediately.”! The words in italics are
printed red. Dr. Swan M. Burnett of Washington,
who wished me to furnish him with samples of this
card, has recently written an article® in which he urges
the distribution of one similar to it by the Health
Department, District of Columbia. In Bradford, Dr.
Bell has secured the voluntary assistance of the registrars,
in distributing a slip with directions of similar import (copy
of directions of Ophthalmological Society) attached to the
birth certificates. Copies have also been sent to me of a slip
of printed directions, which is being distributed by the
registrars (I think) in Scotland, but I do not know how
widely. By all these means we shall by degrees extend a
knowledge of the gravity and of the curability of the
disease I do not think we need as yet quite give up the
Local Government Board. In a discussion on this subject
at the British Medical Association meeting at Leeds last
year, I suggested the adoption in the Ophthalmological
Section of a resolution,® probably on the same lines as that
arrived at by the Ophthalmological Society, and then getting
it adopted at a general meeting, as, indeed, has been done
on previous occasions—notably the subject of colour-blind¬
ness in railway and marine employes. Action by so powerful
an association sliould have much more force than that of an
isolated society, however eminent.
2. Prevention of the disease.—I cannot doubt that much
of what I am about to say must be quite familiar to many
or probably roost of you. I do not hesitate to make these
observations, however, because an inspection of works on
midwifery,_manuals for midwives, and nursing books would
appear to indicate that, whatever the authors themselves
might know or practise, they have certainly failed in
these works to inculcate either tho importance of using
means for preventing the disease or insisting on its reco¬
gnition and immediate treatment. I cannot and do
not pretend to have searched all works, hut I have
had the assistance of friends in Wming the conclusion
I have done. My views, moreover, find support from
8 Medical Kecord, Feb. 12t]i, 1800.
^ At tiie annual meotiiig at WrminKham in August, 1800 the idea
was so far anted upon that a committee, coneisting of the President of
tlie Section (Mr, Lloyd Owen), Dr. tlrossinan, and myself, was appointed
to iwoparo resolutions for the next annual moeting.
The Lancet,]
DR. L. G. GUTHRIE ON DIPHTHERITIC PARALYSIS.
[April *25,1891. $27
the article of Dr. Swan M. Rurnett, to which reference*
has already been made. He says, " 1 am not aware to what
extent the teachers of obstetrics in our schools throughout
the country dwell upon the importance and necessity of the
revention and early and prompt treatment of this affection,
ut 1 have had an examination made into the text-books on
Midwifery, from some of which the American student is ex¬
pected to obtain the knowledge requisite for the proper care
of the lying-in chamber. Dr. Gill, resident of the Emer¬
gency Hospital, who was kind enough to make this research
for me, found that in more than thirty standard works on
obstetrics in English in the library of the Army Medical
Museum there were only four which considered the preven¬
tive measures of which we have spoken. These were the
Encyelopmdia of Obstetrics and Gynrocology, and the
treatises of Barnes, Lusk, and Ca^ceaux and Tarnier. In
only six others, and they were mostly old works, was there
any consideration given to the treatment of the disease
when once it had been established.” It appears to me of
the highest importance that in lectures, text-books for
students, as well as for midwives and monthly nurses,
reference should prominently be made to the disease
and its prevention and treatment. Cred6 showed several
years since (1881) at Leipzig how prevention was much
more within the range of the obstetrician than the
ophthalmologist. The plan he advocated, as is now well
known, was directly tne umbilical cord was severed,
the eyes were cleansed, and a two per-cent, solution
of nitrate of silver was dropped into the eyes. By this
means he succeeded in reducing the percentage of the
disease from thirteen to lees than one per cent., and with
even better results later. Others have witnessed to the
efficacy of this method, which is practically an absolute
preventive of ophthalmia. Cred6 thought at first that the
child became infected during birth from the maternal secre¬
tions. With the object of overcoming such influences, in-
jeotions of carbolic and salicylic acids were used before and
at the time of delivery. This, however, appeared to
diminish but not abolish the disease. Hence his resort to
direct cleansing of the eyes, as before mentioned. His
opinion, moreover, is supported by others. Ludwig Korn®
discusses this subject, and goes further than Credo. The
method he employed at the Dresden Clinic for Women was
thorough irrigation with solution of perchloride of mercury;
during parturition the irrigations were repeated several times
before and after every digital examination. As soon as the
head was born the eyelids and surrounding parts were
scrupulously cleansed by means of cotton soaked in hydrant
water. Especially all the smegma was removed. The
cotton was rubbed from the outer to the inner can thus, until
the lids were perfectly clean. It was tried to prevent any
opening of the eyes until the cleansing was finished. The
results were very good. But as it seemed evident that no
infection could take place during the passage of the child,
the irrigations were gradually dispensed with. When no
examination was made, no sublimate was used ; and as it
was thouglit that no infection took place during the birth
of the child, nitrate of silver was not used. Irrespective of
the cleansing of the parturient mother, the eyes of all
infants bom in the clinic were washed in the manner spoken
of. The results were excellent. Three cases of ophthalmia
only occurred in 1000 instances—one in the last 700, and
not one in the last 420. I was able to mention in a paper
on this subject, read before the Yorkshire Branch of the
British Medical Association" in February, 1888, that pre¬
viously to the publication of these observations of Korn’s a
very simple but efficacious plan had been in use at the
Jessop Hospital for Women in Sheffield. Iwas indebted to
Mr. J. M. Willey, late house surgeon, for kindly supplying
me with the particulars, which I then gave as follows:—
V The patients are among the poorest; some are inmates of
the hospital, but the great majority are confined at their
own homes. The midwives have received instructions that
immediately the head is born attention must be directed to
the baby’s eyes. Then with little pieces of lint moistened
in tepid water the eyes are carefully washed, as well as the
eyelids and parts adjoining. Subsequently in washing the
child care is taken to guard against reinfection. During
the last three years there have been 2212 labours amoi.'<'
the in-patients and out-patients. In the first 200 there
•* Modiciil llocord, Fob. 12th, 1800.
Archiv f. OynocolnKio, Tmnslatod In Aiiiorican Journal of Opli-
thahiiology for Noveinbor, 1887,
« The Lancet, vol. ii. 1888, p. 412.
were a few cases of purulent ophthalmia, but in the last
2000, since the method has been systematically adopted,
not a single case occurred. Directions were also given to
the nurses that if a child’s eyes looked red it was to be taken
at once to the hospital for adrop of nitrate of silver solution
to be dropped into the eye.” The plan depends for its efficacy
on simple cleansing, and its success seems to be well worthy
of note.
From all this it appears, then, established that the
ophthalmia of the new-born is a disease which permits
01 distinct prevention, and that even careful cleansing
with plain water is sufficient. There may be reasons
against entrusting such a strong solution of nitrate of
silver as Credd advocated to nurses, but a much weaker
solution would suffice. It may, however, be perhaps as
well to use some antiseptic with the water employed for
cleansing, in the manner used at. the Jessop Hospital.
Directions are now freely given to nurses and midwives as
to the employment of antiseptics for the lying-in woman,
and the sublimate solution freely ordered will do excel¬
lently for bathing the infants’ eyes. Some of us who
see the terrible ellecbs of the disease are earnestly im¬
pressed with the importance of doing all we can to
prevent its occurrence. As far as we are able we must
spread knowledge as to the dangers of delay and the
benefit resulting from early treatment. The obstet¬
rician has, however, the opportunity of preventing the
disease. The teacher can find occasion to bring the
subject before his pupils, and the writers of text-books,
whether for medical students, midwives, or monthly nurses,
should urge the importance of the afFection and give
directions as to the means necessary for prevention. No
text-book should, I think, be published without some such
teaching. The disease is particularly met with among the
poor—much less fre(^uently among the well-to-do. Hence
the importance of midwives, who by degrees are acquiring
a better and more recognised status, receiving thorough
instruction in the subject.
THE BULBAR CRISES OF DIPHTHERITIC
PARALYSIS OCCURRING IN CHILDREN.
By L. G. GUTHRIE, M.B. OxON., M.R.C.P. Lond.,
ASSISTANT I’UYSICIAN, NORTII-WRST I.ONOON HOSPITAL; PHYSICIAN,
llWiKNT’S-PAlUt HOSPITAL i-DR KPILHP.SY AND PARAl.VSIS;
PATIlOI.OlH.ST(LATK REtiLSTRAR), PADDINGTON-GREEN
CHILDREN’S HO.SPITAL.
(Co7iclude(l from pa</c S7/i.)
Pathology .—Both the symptoms of diphtheritic paralysis
and the pathological changes discovered after death point to
a disturbance of function occurring in the nerve centres and
in the nerve fibres, rather than to the existence of inflam¬
matory mechanical or essentially destructive lesions. The
functions of the diaphragm, for instance, are frequently
modified. The muscle acta feebly, or even not at all, during
respiration. For a time it may seem absolutely paralysed,
then again it acts spasmodically. Vomiting or hiccough
is present. With equal caprice it is found acting normally.
So, again, the phenomena which suggest paralysis of the
vagus and other bulbar nerves ate present one moment and
may be gone the next. As regards the pathological changes
observed^, the central ganglia have been found in various
stages of granular and fatty degeneration, sometimes swollen
and cloudy, sometimes vitreous, and sometimes atrophied
and empty (vacuolation). This last change Dr. Percy Kidd
regards as typical of that which occurs in cells, the nutri¬
tion of which has been gravely altered. The changes in
the nerve fibres are “parenchymatous”—they are precisely
similar to the trophic changes seen in the distal end of a
divided nerve (Diijerine). Sometimes the central ganglia
appear perfectly healthy, whilst extensive degeneration lias
. taken place in tlie nerve fibres. This condition, together
with the fact that the nerve changes usually predominate
over the ganglionic, lends support to the theory that
diphtheritic paralysis is essentially a peripheral neuritis,
lint it seems unnecessary to suppose that the peripheral
>.liaDges are other than secondary to the ganglionic.
“ Transient and slight lesions of cells cause considerable de¬
generation in nerve fibres” (Gowers),' The integrity of
function and nutrition of nerve fibres depends upon a like
928 TheLakcbtJ
MR. STEPHEN PAGET ON STRANGULATED HERNIA.
[Apbil 26, 1891.
iDtegtit^ of the central nuclei. This, again, depends upon
the ocourrenoe of certain chemical changes in the nuclei
themselves. “ The function of organic matter and, par ex-
teilence, of nervous matter.is to assimilate material
having potential energy (anabolism), and to decompose that
matenal (katabolism), with liberation of energy.”^ This
material is assimilated from the fluid in which the cells are
bathed, and according to the constituency and condition of
the surrounding fluid, the cell functions are modifled in the
direction of excessive or defective action.
Stagnation of the surrounding medium—on Dr. Jackson’s
theory—causes exc^aive chemical activity in the cells of
the motor cortex, nitrogenous or phosphorous bodies becom¬
ing more nitrogenous, and thus produces the variety of
epileptiform convulsions which bears his name. Hyper-
physiological activity in the cells may also be pro¬
duced by poisons such as strychnia, or those of tetanus
and hydrophobia, with certain distinctive characters
about the symptoms, according to the selective action
of the three poisons on special centres. In none of the
above cases are the macroscopical or microscopical changes
discovered adequate to account for the symptoms. Simi¬
larly the hypo-physiological condition may be produced
in the cells hy the circulation of poisons, such as that of
diphtheritic paralysis. The effects of the poison upon the
nutrition and function of the ganglia may be comparatively
slight and transient, but yet sufficient to cause extensive
degeneration of the nerve fibres. The ganglia may com¬
pletely recover; but the effect on the nerve fibres may be
more lasting, and may prevent them from obeying the
stimuli to which they formerly responded. On the other
hand, should the poisonous dose be large and continuous
the ganglia themselves may be irreparably damaged.
Finally, it is obvious that extremely slight interference with
the function and nutrition of important centres, such as the
medullary, may cause death, and yet leave no pathological
changes which can be discovered even by aid of the micro¬
scope.
Treatment.
1. General principles .—Absolute rest in bed is indi¬
cated during the first six weeks from the onset of para¬
lysis, even in the absence of the symptoms of failing
vitality which I have described, for dangerous symptoms
may occur on the slightest provocation. After tins time,
should the pulse and respiration remain normal, tlie open
treatment usually recommended may assist in completing
recovery. Abundant nutritious food, tonics, especially
strychnia, should form part of the treatment from the first.
2. The treatment of the crises .—Their nature is to subside
and to recur; therefore the utility of any special treatment
is open to question. Death is due to the paralysing action
of a poison upon the cardiac and respiratory centres, but
this action is not persistent, and were it not for the hvper-
secretion of mucus into the air passages recovery might be
the rule. So an antidote which both stimulates the failing
centres and arrests the flow of mucus must be sought.
Strychnia is a powerful stimulant to the respiratory and
cardiac centres. Atropia arrests pulmonary and other
secretions, but to produce this effect large doses are
necessary, and these might still further increase the risk
of cardiac failure.* This objection may be met by com¬
bining the two drugs. Three cases observed by myself,
in which the characteristic crisis occurred, were treated
on Henoch’s plan by strychnia injections alone; two
of these died. Three cases were treated by injections of
strychnia and atropia, of each -iU gr.; two of these re¬
covered. The latter remedy is worth a further trial, and
perhaps the best results might be obtained by giving larger
doses of strychnia to ,,’5 gr.), combined with smaller
doses of atropia (-fH to lU gr.) The physiological eft'ects of
atropia are rapidly produced in a child by a single dose
of 1^(7 gr.; whilst belladonna in the form of the tincture is
practically inert. The nasal tube has always been em¬
ployed in these eases as soon as deglutition failed. Owing
doubtless to the anaesthesia of the naso pharynx, little or
no discomfort is caused by its use. A stronger objection
to its use is that digestion is probably much impaired at
these times. Predigeated food only should therefore be
administered, and in the smallest quantities. It would be
perhaps better still to rely entirely on rectal alimentation.
1 Hughlln^s JacksoHj Lumleiaii Lecture, IL, 1890.
- Of. Von Bezold: 'i'on dein EinfUiswe <les Atropias auf liio Urspraiige
des llerz Vagus.
As regards the death-rate in diphtheritic paralysis,
Landouzy gives the mortality as 16 in 117 oases, Lorain and
Lupine give 12 per cent, of fatal cases. Drs. Bristowe, Eustace
Smith, and Hilton Fagge are all agreed that deaths from
diphtheritic paralysis are extremely rare, but the value of
the last named author’s statements is lessened by the fact
that the nature of two fatal cases which he quotes remained
unrecognised duri^ life. The statistics of Paddington-
green Children’s Hospital (whence the materials for this
Draper have been obtained) give the following result
Excluding a very large number of cases in wnioh death
occurred before the symptoms of the initial diphtheria had
subsided, although the majority of these might well be
included uuder the head of “ deaths from diphtheritic
paralysis”; twenty-nine cases have been treated from 1885
up to the present year. Eight deaths have occurred, giving
a mortality of 2’7‘4 per cent. Statistics based on such
small numbers as these are, perhaps, not of great value.
But in addition to this high rate of mortality there are
other reasons for believing the death-rate of diphtheritic
paralysis to be under-estimated. As mentioned above, one of
the most prominent symptoms of a bulbar crisis strongly sug¬
gests an attack of capillary bronclritls. A medical man called
In for the first time to see a case at the height of a crisis could
hardly avoid the error of diagnosing “ bronchitis or con¬
gestion of the lungs and cardiac syncope,” especially in the
absence of a history of diphtheria. A verdict to this effect
is sometimes seen in the reports of coroners’ inquests held
on children who have died within a few hours of seeming
perfectly well. But children suffering from bronchitis or
congestion of the lungs do not seem well, within a few
hours of death, neither do they die of syncope from these
causes until many days after they have been obviously and
seriously ill. It is possible that diphtheritic paf’alysis may
account for some of these otherwise mysterious deaths. The
treatment advocated by the authors of the leading text¬
books must tend to withdraw the patient from observation,
and may also hasten his death. Adults are too often
allowed to follow their daily work with the disease upon
them. Many of the children brought to the hospital
had been running about by doctors’ orders, although they
were known to have recently suffered from diphtheria.
The early and minor signs of diphtheritic paralysis are
seldom regarded as indications or a disease which may
rapidly prove fatal. Fresh air and exercise are prescribed
when absolute rest in bed should be enjoined. A
confident prognosis is given when the greatest reticence
and caution should be observed.
Upper George-street, W.
THREE CASES OF STRANOULATED HERNIA
OF THE C^GUM IN INFANTS.'
By STEPHEN PAGET, M.A., F.K.C.S.,
A.SSISTANT 8UaOKON TO THE WEST I.ONDON IIOSIMTAL, A^D TO TIIe’
METROPOLITAN UOSPITAU
It is an old saying that if a man gets one curious
case he is sure to have another like it soon. By
an odd cliance of this kind, I have had in the last three
months three cases of strangulated hernia in infants;
and all three were cases of hernia of the ctecum. Mr.
Howard Marsh, in the tenth volume of the St. Bar¬
tholomew’s Hospital Reports, has collected forty-seven
cases of strangulated inguinal hernia in children. In
thirty-four the sac was opened at the operation. Out of
these thirty-four, only one was a hernia of the ccecum. As
regards the anatomy of the parts concerned in hernia of the
cioeum, it has been described by Mr. Treves, in the tenth
volume of the Transactions of this Society, and by Mr..
Lockwood, in his Lectures on Hernia. They draw attention
to two facts:—]. The existence of a proper sac in these
cases. 2. The existence of a fold of peritoneum, contain-
ingmuscular fibres—the plica vascularis,—which passes
down floin the ctecum along the back of the sac, and helps
to ..tiuae the liernia by drawing or guiding the ciecum into
Dhe sac. Both these observations are illustrated by my
cases, which are as follows
Case Jan. 27bh, a male infant one year old, strong
1 A paper read before the Medical Society of F.oiidon, April 7th, 1391.
Di.,. )g
Tbb Lakcet,]
ME. STEPHEN PAGET ON STEANGULATED HERNIA.
[April' 25» 189i.' 929 '
cind well-nouriBhed, was admitted to the West London Hos-
Ital with strangnlated right scrotal hernia. The rupture had
een noticed soon after birth; the child had worn a truss.
The day before admission the rupture came down; the child
vomited several times and had difficulty in micturition. On
admission it looked well, and was not in pain. The hernia
was large and tense; there was no impulse; the scrotum
was red and inflamed. I operated at once. There was a
iproper sac ; it contained a loop of small intestine and some
omentum, and above-these, at the neck of the sac, was the
cmcum. There was no fluid in the sac. The intestine looked
bruised, but was not discoloured, I divided the stricture
and reduced the cmcum, and then the small intettine ran
back of itself. The bowels acted twice that evening, and
the child did well.
Case 2.— On Eeb. lltb, a male infant three months old
was admitted to the same hospital with strangulated right
ecrotal hernia. The rapture had been noticed three weeks
after birth ; the child had worn a worsted truss. The day
before admission the rupture came down; there was repeated
vomiting, and retention of urine. It was a very small baby,
a seven months’ child, and the thirteenth in the family, it
looked free from pain,, and was not collapsed. The hernia
was large and tense ; there was no impulse. 1 operated at
once. There was a proper sac, with about a drachm of clear
•colourless fluid; in it was the ceecum. The vermiform
appendix, whicii was unusually long, came forward
'from the lower aspect of the caecum. The cmcum was
very slightly congested, I divided the stricture, letting
out some more fluid. Then the infant’s legs were held up
high, and the caecum was reduced. The bowels acted a
few hours later. The wound healed, and the bowels acted
regularly ; but the infant had been brought to the hospital
in the middle of a frosty night, and four days after the
operation it showed signs of acute bronchitis, and of this it
died on Feb. 23rd, tw^ve days after the operation.
Case ,3 —On Dec. 18th, a male infant three months old,
neglected and starved, was admitted to the same hospital
with strangulated right scrotal hernia. There was vomiting,
and some retention of urine. The hernia was large and
•tense, and without impulse; there was acute inllammation
of the scrotum. With chloroform I reduced the hernia,
•and could now feel that the testicle and the cord were
.greatly swollen. After this all went well for eleven days ;
the bowels acted freely and regularly; the infant took a
quart of milk daily, and gained flesh. But on Dec. 29th
'the scrotum was again inflamed, and on the 30th it
was acutely inilamed and distended, and resonant on
.percussion ; the child vomited once; the bowels acted
•freely. On Dec. Slst the infant was restless; it vomited
twice ; the bowels acted freely. The scrotum was intensely
inilamed, and at one spot, the size of a sixpence, it
•was thinned and soft. It was resonant on percussion.
The prepuce was cedematous; the penis was twisted. In
'the inguinal canal was a bard cylindrical swelling; the sper¬
matic cord could not be felt. Hnder chloroform the swelling
■was partly reduced, with a loud gurgling sound ; the scrotum
was now less tense, and the testicle and the cord could be
felt again. But in a couple of hours things were as bad as
ever: the codema of the prepuce was increased, and there
was distinct emphysematous crackling at the bottom of the
scrotum. It was plain that the bowel had given way. I
cub down carefully, and found no distinct sac. The bowel
and the sac were all matted together ; at the lower part of
the bowel was a ragged opening; the tunica vaginalis was
■full of ffcces, and the testicle u'as acutely inflamed. I
passed a director in at a pinhole opening which I had made
'in the bowel during dissection, and out at the ragged open¬
ing lower down, and laid the two openings into one, and
stitched the bowel in the wound. For about a month the
infant did well; the cavity of the tunica vaginalis granulated
■up, the bowels acted twice daily through the wound, and
'there was never any groat prolapse. But at the end of a
month the infant began to lose flesh, at the rate of a quarter
of a pound a week, and it died between live and si-v weeks
after the operation.
These cases seemed to me worthy of the notice of this
Society, because strangulated hernia seldom occurs in in¬
fancy. Mr. Marsh says, “ Many surgeons have passed
tlirough a long career of hospital practice without meeting
•with any instance of it, and I believe the only case in which
•an operation has been performed at the Hospital for Sick
«Cluldren in the course of the last twenty-three years is that
which 1 have just recorded.”
In a very large majority of Mr. Marsh’s cases the hemiO':
was congenital; indeed, so far as the notes tell us, only four.
were not congenital. The hernia was more freqnent on the
right side than on the left, in the proportion of three to one.
As regards the contents of the sac in Mr. Marsh’s cases, the
sac was opened in thirty-four out of the forty-seven cases.
Of these thirty-four cases one was a hernia of the colon,
one was a ccecal hernia on the left side of the body, and one
was a hernia of the sigmoid flexure; and two were cases of
hernia of the ovary.
As regards the symptoms of strangulated hernia in infants,
I may point out that in my cases there were two symptoms
which we seldom find in adults. One of th^e was the
retention of urine; the other was the acute inflammation of
the skin of the scrotum.
Of my three cases the first made a good recovery. The
second case recovered so far as the hernia was concerned.
But it was a seven months’ child, and the thirteenth in a
poor family ; it was brought to the hospital in the middle
of a cold night; and I am sorry to say that after the opera¬
tion it was put in a cot near a window, instead of in a
basket near tbe fire. From these causes it caught the bron¬
chitis of which it died. The specimen (Fig. 1) from this case
Fig. 1.
shows the plica vascularis passing down into the sac. The
sac is contracted, fhere is no communication between the
sac and the tunica vaginalis. The great length and free
mobility of tbe vermiform appendi.x suggest that it may
have made its way first into the sac, and so may have
drawn the ciucum after it; and we know that cases have
occurred where the appendix alone was found in the sac at
the time of operation.
In the third case I cannot doubt that I really reduced
the hernia when the child was admitted. There was
distinct slipping back of the bowel under my fingers, with a
loud gurgle. The vomiting stopped for eleven days; the
infant took a quart of milk daily ; the bowels actei freely
and regularly. They continued to act freely up to tbe
time of operation, when the bowel had actually burst into
the tunica vaginalis. It is therefore impossible to say
exactly at what time the emeum came down again and
became strangulated.
As regards the treatment of this case, it appears from
Mr. Marsh’s paper that it would have been better to
have done less. He gives two cases. In one of them the
hernia had been stiangnlatei for many days; the scrotum
Dip’: zed by Google
S30 The Lakobt,] MR. P. E. HARE: QUININE AS A CARDIAC STIMULANT.
[Apbil 2&, 18M.
bad giren way, aod there was a free discharge of foeces.
No operation was done, the openings in the scrotum gra-
dnally closed, and the child recovered. In the other case
the bowel was found to be gangrenous, and firmly adherent
to the sac. It was poulticed, and came away in a few hours.
Twelve days later the bowels acted the right way, the
wound closed, and the child recovered. Perhaps therefore
it would have been better in my cose to have done nothing,
or to have simply incised the scrotum. There might thus
have been no prolapse of the bowel. On the other hand,
as it was a hernia of the ctecum, the continuity of the
bowel would perhaps not have been restored as it was in
the cases quoted by Mr. Marsh. The specimen (Fig. 2) shows
Fig. 2.
A, Largo intestine, ii, Small intestine, o. Roil passeilinto
large intestine, o. Rod passed into vermiform appendix.
, K, Rod passed into small hitesbine.
the prolapsed ccocum, of a curious hammer-headed shape. A
very fine rod is passed into the everted mouth of the
vermiform appendix. A rod is passed into the ascending
colon, which is contracted from disuse, and a rod is passed
along the ileum.
In all three cases there was a complete hernial sac. In
the third case this, of course, could not bo made ouc at the
operation, but it is clearly seen in the specimen. As regards
the question whether in these cases there was any communi¬
cation between the sac and the tunica vaginalis, there was
no communication in the first two cases; the third case is
of course uncertain.
I wish, in conclusion, to express my thanks to Mr. Eccles,
the house surgeon, for bis constant care of the children,
and for liis help in putting these notes together.
Wimpolo-Htreet, W.
QUININE AS A CARDIAC STIMULANT.
Ry F. E. HARE,
KlJ.Sn)ENT MUniCAI. 01'1'ICEil (ON MiAVE), IIHISUANK llOSl’ITAr.,
(1Uki;nsi,ani(.
At the last general meeting of the British Medical
Association at Birmingham, Sir Walter Foster stated that
he had found quinine of great service for reducing the pulse-
rate in Graves’ disease, when given in sufficiently large doses.
This action of quinine is, I believe, but little known, and
yet it is one that is in many cases so marked and of such
great utility that it is difficult to see how it has so generally
escaped recognition. In typhoid fever, at any rate, there is
no drug that possesses anything approaching its power.
At the Brisbane Hospital the cold bith treatment of
typhoid fever Las been cariied out in its entirety for
the last three years. Baths usually reduce the febrile
temperature with ease, but in some cases, owing to its
obstinacy, they fail. In these some antipyretic drug
is evidently indicated. Quinine was therefore commonly
given for tliis purpose, in doses of from thirty to forty grains,
as recommended by Liebermeister. Now, of course, any¬
thing wiiich depres.se8 the temperature reduces the pulse-
rate. Biitlis have this effect in common with all the
antipyretic drugs; but such reduction is almost alwayB'
temporary, and in proportion, roughly speaking, to the fall
in temperature, passing off as soon as the latter has
regained its former elevation. In those cases, how¬
ever, in which quinine had been the antipyretic given,
it was gradually observed (1) that the pulse-rate^
although it rose with the returning temperature, almost
always failed to attain its previous frequency ; (2) that-
sometimes it remained slower, in spite of the tem¬
perature having gained an even greater elevation; and
(3) that not uncommonly, when the drug failed altogether
as an antipyretic, the pulse-rate was markedly atiected..
These observations seemed to point to an action on the hearo.
independent of the antipyresis. Experiments were accord¬
ingly made to discover if this effect could be gained from
doses too small to have any appreciable iniluence on the
temperature; for if so, the independence of its action on
the circulation would be established. The anticipation was
fully realised. The following is an illustrative case.
Mrs. S. B-, aged forty, was admitted to the Brisbane
Hospital on the fifth day of typhoid fever. During the nexc
three days she had nineteen baths, of from fifteen to twenty
minutes’ duration. On the last of these her pulse bad
varied between 124—with a temperature of 103° F. oefore the
bath—and 110, with a temperature of 101 •4° half an hour after
the bath. Three grains of quinine were ordered every three
hours. The following day (the eighth of the attack) her pulse
varied between 110—with a temperature of 103° before the
bath—and 100, with a temperature of 100-8° half an hour
after. Ninth day of fever: pulse 108, with temperature of
103*4°before bath; half an hour after, pulse 96, tempera¬
ture 102-4°. Thenceforward no further anxiety was felt
concerning the pulse, which continued to range between 110
and 92, although the case did not convalesce until the thirty-
first day. The effect on the pulse is not limited to a reduc¬
tion in frequency; the beats become stronger, more sustained,
and more distinct, and the change is especially striking in
a case where the pulse had been inclined to “ run.” The'
explanation appeared to be that the drug acted as a power¬
ful tonic or stimulant to the heart. It was determined to
treat systematicallv in this way every case that commenced
to exhibit signs of cardiac failure, and the following rule
was laid down—three, five, or seven grains of quinine to be
given every three hours whenever the pulse-rate commenced
to range above 120.
The first case was treated on April 15bh, 1889. From
that date to the end of the year 306 cases were admitted.
Of these, sixty-nine came under the rale. Of the 306,
eighteen died, a mortality of under 6 per cent,; but eleven
of these were from perforation, two from profuse hemor¬
rhage, and three from dysentery. In the latter, extensive
ulceration of the rectum was disclosed post mortem, so that
in all of the sixteen death was the direct result of the
intestinal lesion. Two only therefore remain to be con¬
sidered. One of these succumbed to acute double lobar
pneumonia, coming on suddenly before any sign of cardiac
lallure had appeared, and proving fatal in less than twenty-
four hours. The other was altogether unusual. The patient,
a young girl, had convalesced and been allowed to get up,
wlten suddenly the temperature rose, a painful infiammatory
swelling developed in the right submaxillary region, and
she rapidly sank with hyperpyrexia in spite of treatment.
The above analysis of the eighteen fatal cases is enough
to show that during the eight months and a half no patient
died of the usual form of cardiac failure, which under ordi¬
nary eii-cumstances is the most frequent cause of death.
Most of this result is undoubtedly due to systematic bathing,
which exerts a most powerful check upon the tendency tO'
progressive enfeeblement of the circulation. The bath, how¬
ever, occasionally fails, and it is always more potent as a
prophylactic in this respect than as a remedy when once
the condition is developed. Consequently quinine is espe¬
cially useful in those cases admitted late in the course of
the fever. Alcohol is, of course, given in the same cases as
the quinine, but these are the ca^es in which alcohol always,
has been administered; and certainly the amount found
necessary during the included period has been vastly less
than formerly. Only quite exceptionally has more than
four or six ounces of whisky been given even in severe
cases, whereas previously eight, twelve, and even sixteen
ounces were no infrequent quantity.
8ome points in connexion with the action of quinine on
the heart are worth noting. 1. The slowing of the pulse-
rate is tardy in appearing, usually twenty-four uoura
Die .Google
The Lancet,]
MR, LANE: PAIN IN ANTERIOR EXTREMITY OF URETHRA. [April 25, 1891. 931
(jlapsiog before its effect is distioctly perceptible. 2. The
effect, when obtained, is somewhat permanent, so that if
the drug be withheld the pulse does not attain its previous
rate for two or three days. Both of these are in contrast
to its action on the temperature, which is never prolonged
beyond thirty-six hoars, by even the largest antipyretic
dose. 3. Its action is not limited to typhoid fever. 1 have
obtained similar results in the last stages of phthisis, in
croupous and broncho pneumonia, and in surgical cases
with hectic. I venture to think that the recognition of this
use of quinine is a point of great importance, and that by
it alone many lives might be saved. The difficulty of
meeting the emergency of heart failure in fevers is testihed
io by the number of drugs that have at various times been
recommended for it. I have given the great majority of
these a more or less extended trial, without ever being able
to satisfy myself that I obtained any result, except, perhaps,
from digitalis. Digitalis, however, had nothing like the
effect of quinine, while it appears to have, in doses sufficient
to reduce the pulse-rate, dangers peculiar to itself.
Most works on therapeutics seem to imply that quinine
is a cardiac depressant. What is the influence of this
teaching on practice? A case of typhoid fever is being
treated with small doses of quinine, two or three grains
every few hours (a common routine treatment). Later on,
in the usual course of events the pulse becomes weaker
and more frequent. The drug is then probably with¬
drawn on the supposition that it is weakening the heart’s
action, whereas this is the very time that the dose should
be doubled or even more largely increased. All this has,
at any rate, frequently happened to myself.
Aberdsun.
VERY SEVERE PAIN IN ANTERIOR EX¬
TREMITY OF URETHRA.
SUPRA-I’umc CYSTOTOMY; FORCIBLE DILATATION OF
CONTRACTED PROSTATIC URETHRA; RECOVERY.
By W. ARBUTHNOT LANE, M.S.,
ASSISTANT 9UROEON TO OUY'S HOSPITAL AND TO THIS HOSPITAL POH
SlUIC CHILDREN, GREAT OKMOND-STREKT.
J. W. P-, aged forty-two, builder’s foreman. His
mother died from consumption, and his six brothers
and sisters from various diseases—two from inflammation
of tlie lungs, one from abscess in the side, one from blood
poisoning, and two from convulsions in infancy. He was a
married man, and had always been stout and vigorous till
the onset of his present symptoms. These developed
about the middle of 1888j and consisted of almost un¬
bearable pain in a position corresponding to the floor
of the anterior extremity of the penile urethra. This
■pain was so violent and constant as to make it impos¬
sible for him to continue his occupation. He was unable
to eat his meals and he lost flesh rapidly. He stated
that he was for some time an out-patient in St. Peter’s
Hospital, whore nothing was found, and his pain was not
relieved. I saw him at the out-patient department of
Guy’s Hospital, and admitted him into the hospital under
the care of a colleague. When under observation, it
was seen that though the man complained of constant pain,
he was subject to violent exacerbations lasting from a few
minutes to three or four hours. During these attacks he
appeared to be in the greatest agony. Though the pain
was increased by his getting about, yet he had severe
attacks when kept perfectly at rest. The right testicle was
undescended. Nothing could be made out by examination
with the cystoscope, sound, finger, &c., either at this time
or on subsequent occasions. His weight was about 8 st.,
and he appeared wasted and distressed. His usual weight
was about 10 st. His urine was acid, sp. gr. 1008, and con¬
tained no blood or pus. Some crystals of triple phosphate
were present. He was treated with various drags, dieted,
and kept in bed for some time, and apparently with some
benefit. He left the hospital on Sept. let.
He was readmitted under my care on Sept 2‘2ad, having
spent) three weeks at a convalescent home. He assertea
tlialj it was impossible to continue life in bis present con¬
dition. Considering that the cause of the pain might be
some condition of the prostate not apparent by the cystoscope,
sound, or finger, in the rectum, I determined to open the
bladder above the symphysis, and examine it bimanually.
I may say that I bad carefully examined the position of the
kidneys and ureter, and made him take violent exercise of
a varied nature, to find if possible any complaint of pain
elsewhere than in the end of the penis, or any alteration in
the urine, without any success. Therefore, on Oct. 22nd, I
opened the bladder above the symphysis, and found its
interior healthy, as we had previously found it on examining
it with the cystoscope. On attempting to introduce the tip
of the little finger into the prostatio urethra, the greatest
resistance was felt, and it was only after using muen force,
both with the finger and with instruments, that it was possible
to dilate up this portion of the urethra. Nothing abnormal
could be detected-in the prostate except that its right
lobe was smaller than the left. Hardly daring to hope that
this dilatation of the prostatic urethra would be of any service
to the patient, I introduced a drainage-tube and closed the
wound. On Nov. 1st the drainage-tube was removed, and
he passed urine through the urebnra. (The reason I took
the unusual course of introducing a drainage-tube into a
healthy bladder was that I wanted to keep the proatatic
urethra at rest for a few days.) He was delighted to
find that he had lost the pain since the operation. He
left the hospital on Nov. 8bh, with the object of
spending some weeks at the sea-side. I 6aw him
aoout the beginning of this year, and found him looking
strong and in much better condition. At times he said
he felt a very slight pain in the position of his old
trouble, but it did not seem to cause him any concern.
I felt that this case deserved to be put on record because
of the obscurity of the causation and pathology of the con¬
dition of the prostatic urethra, of the apparent causal con¬
nexion of the proatatic stenosis with the local penile pain,
and of the happy termination, almost accidentally arrived
at, of a complaint which would not only have considerably
abbreviated the course of the man’s life, hut would also have
rendered it exquisitely miserable, if in all humau proba¬
bility the intensity of his misery did not lead him to termi¬
nate his existence. I trust that this communication may
lead others to publish accounts of some similar cases they
may have observed, which may help to throw light upon
this condition, apparently a very rare one. Should the pain
recur in this case 1 will dilate the prostatic urethra forcibly
and extensively with a suitable lithobrite.
I regret to say that after a time the local pain returned,
but with less severity than before. I'orclble dilatation of
the prostatic urethra relieved this pain, though it did not
remove it. No further light has been thrown upon the
condition since the first operation.
St. Thomas’a streofc, S.K.
€lmml
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
H/liMATURIA IN EAST CENTRAL AFRICA.
By 11, F. Castle, M.B., B.C. Camb.,
LATE MEDICAL OKl'lCER, USAHKARA DISTRICT, EAST CENTRAL AFRICA.
Hyp.MATURiA is certainly one of the commonest causes of
complaint both amongst the natives and the Europeans
resident in Zanzibar and on' the adjacent mainland.
The hmmaturia may be roughly divided into two great
classes—one dependent on the presence of a parasite, the
other not. TixQ parasitic form is due to the presence of the
trematode bilharzia ha3inatobia in the body, and the ova
can invariably be seen in the urine, although the latter
may appear to be free fronr blood. The persons who suffer
from this disease are very numerous, are usually of
the male sex, and are almost invariably under the age
of thirty ; after that age the symptoms seem to disappear.
All the cases which came under my observation were
directly traceable to the patients drinking water from one
of two small rivers which drain part of the Usamhara
district. In both these rivers I have found the free-swimming
embryo. In other parts of the same district where water
was scarce and the natives derived their whole supply from
mud-holes the disease was apparently unknown. The
Europeans living iu this district are in the habit of boiling
and filtering their water before using it; consequently none
suffer from thedisease. Again.anativewxll drink three orfour
times as much water in tne day as a European will, a small
Diij
.oog
983 The Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Aphil 26, 1891
boy taking, as a matter of course, a quart bottle of water to
bed with him and finubing it before the morning. Therefore
a native always runs a greater risk than the European does.
The only treatment which 1 found to be of any use was
small doses of buolin and opium freely diluted. This seemed
to allay the irritability of the bladder (which was the pro¬
minent symptom) better than anvthing else. The non-
^rasitic form of hrematuiia was always associated with a
high temperature. The usual course of a iiypical case was
as follows: First, a rise in temperature ranging from 103'
to 105°; this would last for about two hours, oy which time
the patient had probably gone to bed. Secondly, a severe
rigor, lasting perhaps twenty minutes; about an hour after
the rigor the temperature falls to about 102' (probably
influenced by antipyretics). Thirdly, a feeling of faintness
comes on, marked oy great pallor; the first quantity of urine
which is passed after'thiswill be absolutely black, and is found
to contam a large quantity of grumous material, composed
of disintegrated blood-cells. At this stage of the disease no
actual blood-cells can be discovered by the microscope ; but
as the patient recovers, and the amount of blood passed is
less in quantity, it becomes more like real blood in its
appearance, and cells more or less altered can be readily
made out. The hcemorrbage usually continues for about
three days uuder treatment; perhaps it would last longer if
not treated, but naturally one did not cate to try. And
then follows, fourthly, the stage of couvalescence; the
hmmorrhage has ceased, but there is still a temperature of
about 102°, which may persist for a month or until the death
of the patient. Probably the system, M’eakened by the great
loss of fblood, is unable to resist the malarial poison as
it otherwise would; for an African fever is generally
sudden both in its onset and in its retrocession ; the
man who has been moaning with pain and delirium,
with temperature 106' one day, will in two days’ time be
out stalking antelopes. This, however, is not the case after
an attack of hrematuria; recovery is then always very
slow and tedious. This disease is common amongst the
Europeans, but rare amongst the natives, although
they are frequently attacked by ordinary malarial
fever. 1 have heard of another form of hmmaturia in
this district (hemoglobinuria), but as I have not had a
case under my care I give no description of it.
Darfleld, near Barnsley, Yorks.
TREATMENT OF ULCERATED SCARLET FEVER
AND DIPHTHERITIC THROATS BY IRRIGATION.
By N. S. Manning, F.B.C.S.,
MEDICAL SUPEIIINTENDENT OK THE CITY HOSPITAL, UIRMINGHAM.
I HAVE used the following method of treatment in the
ulcerated throats of scarlet fever and diphtheria in the
Birmingham City Hospital for about two years and a half.
The appliances necessary are a small indiarubber bag syringe,
4 or 6 oz,, according to the size of the patient, two small
basins, and a towel. The medicament used is boric acid
dissolved in hot water (about 105° F.). In order to facilitate
the solution of the boric acid, I have a saturated solution in
glycerine, prepared by Messrs. P. Harris and Co., Edmund-
street, Birmingham, of which the following are the pro¬
portions : Powdered boric acid, four parts ; glycerine
(sp. gr. 1260), three parts. The glycerine should be
heated by steam, and the boric acid (best quality, care¬
fully powdered) stirred in till the solution is perfect. Of
this solution, a large tablespoonful is dissolved iu about
a pint of hot water. The method of procedure is as
follows:—Place the patient sitting up, or, if too weak to sit
up, place him on his side with his face over the edge of the
pillow. Apply the towel round his neck to keep him dry if
any water accidentally gets spilled ; withdraw the nozzle
from the syringe before filling it, and fill with the solution ;
replace the nozzle, and direct the patient to open his moutli;
then put it into the mouth well over the back of the tongue,
and forcibly empty the syringe; at the same time receive
the water which rushes out of the mouth and nose into the
empty basin. In this way the mouth, fauces, pharynx, and
in some cases the posterior and anterior nares, are irrigated.
The operation is repeated till the parts are washed quite
clean. In cases of purulent discharge from the nose or
nasal diphtheria, the same procedure is applied to the
nostrils. Tlie irrigation may be performed every two or
four hours as circumstances require. In this hospital during
two years over 1500 cases of ulcerated scarlet fever and
diphtheritic throats have been treated by this method.
From this experience I can recommend it as superior to any
other I have ever tried. I believe its efRcacy is due to the
fact that it is founded on the rational principle of washing,
away all septic discharges with a non-irritating, non-
poisonous fluid. It is not in any way disagreeable to-
patients; on the contrary, when the mouth is dry or foul, it
is most comforting. The solution is rendered sweet by the
glycerine, so that only a small percentage of even very
young children offer any objection to it. Occasionally
children swallow some, but without any subsequent ill
effects. It should be borne in mind that, in order to prevent
any septic matter being sucked into the syringe, the nozzle
should always be withdrawn when filling.
Birmingham. _
A CASE OF AINHUM.
By Gordon Mkssum, M.R.C.S., L.R.C.P. Lond.,
CONSai-TINO MEDICAL OKKICER TO THE VOLKS’HOSPITAL, AND DISTRICT'
SURGEON Ol' PRETORIA.
This complaint is commonly met with amongst the-
natives (Kaffirs) of South Africa, especially in Northern
Transvaal, and is usually limited to the little toe; botli-
feet are, however, generally attacked, though not simul¬
taneously. The toe at its junction with the foot has the
appearance of being gradually cut off by means of the con¬
tinuous pressure of a ligature tied round the toe at that
spot. The following is an example, extracted from my
note-book, of the usual history attached to such cases.
Tozini, aged thirty-four, married. The little toe of hia
left foot is already gone. About a year ago the dorsum and
outer side of bis right foot swelled up to a considerable
extent and gave him much pain of a burning character, the-
pain running down into the little toe. The swelling gra¬
dually subsided, leaving a small pustule on the inner and
dorsal aspect of the metatarso-phalangeal joint of the little
toe. This pustule, on evacuating the matter, assumed the-
appearance of a crack, which slowly extended round the
toe, eating deeper and deeper through the tissues ; all feel¬
ing gradually left the toe, though the foot remained very
ainrul until the toe dropped off (or in some cases gets acci-
entally knocked off). The wound quickly healed and gave
no more discoraforb. The complaint appears to be one of
nerve origin, and differs entirely from the “ mutilans” form
of leprosy. The only cure consists in amputating the toe.
Pretoria, S.A. Republic.
% Itimr
OP
HOSPITAL PKACTICB,
BRITISH AND FOREIGN.
Nulla autem eat alia pro certo noacendivla, nisi quamplurimasetmop-
borum eb diaaoctionum hiatorlas, bum aliorum bum propriaa collecbaa
habere, eb Inber ee comparare.— Morgagni De Sea. et Caus. Morb.,
Ub. iv. Prooemium. ____
MIDDLESEX HOSPITAL.
CASES OK INJURIES OP PERIPHERAL NERVES {continued)^
(Under the care of Mr. Hulke.)
We continue below the interesting series of injuries to
peripheral nerves which we commenced at page 877 of
our last issue. The cases already brought forward include
two of wound of the ulnar nerve, one of recovery of function
after immediate suture of median, and one of division of
the sciatic nerve within its sheath followed by very incom¬
plete recovery of function.
In Case ■'5 the presence of small sensitive islands in the
palm was singular, in presence of the fact that the divided’
ends of both median and ulnar nerves were separated by
not inconsiderable intervals. The relatively early return of
sensibility in the palmar distribution of the median nerve
after suture, although the ends of this could not be brought
into contact, iiflperfecb as it was, and transitory as it proved
in some branches, is a remarkable circumstance. In Case 0,
the position of the smaller and posterior of the two scars in-
Digitized by" _i oogle
Thb Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[Apeil 26,1891. .933
the ham, taken in connexion with the distinct gap in
the tendon of the biceps, plainly told of a tenotomy of
this muscle ; whilst the condition of the parts supplied by
the branches of the external popliteal nerve was strongly
suggestive of the accidental simultaneous division of this
nerve. Were this so, the longer scar might probably mark the
incision for a subsequent suture of the nerve, the final result
•of which left much to be desired. In this case the scars about
the hip unquestionably marked excision of the upper end of
the femur, probab^ with removal of portions of the os
■innominatum. In Case 7, a gunshot injury, it must remain
uncertain whether the nerve was severed by the bullet
or by a splinter of bone, or was compressed by an excess
of callus. The completeness of loss of function made the
•former more probable. At the late date of the patient’s
entry into the Middlesex Hospital little expectation could
he entertained of benoSt from nerve suture, even had the
patient been willing to allow it to be attempted. Case 8
exempUhes nerve irritation from interference by a fragment
in a case of comminuted fracture. Case 9 is an instance of
trophic lesions consequent on implication of nerve fibrils or
•a scar. It is suggested, as advocated by Mr. M. Baker,
that for whitlows of the terminal phalanx a lateral incision
is preferable to a median incision in the pulp of the finger.
Instances of this are not very infrequent.
Case 5. Late suture of the median and ulnar nerves;
very imperfect restoration of sensibility, and this in some
branches transitory .—On Oct. 22nd, 1888, E. C-, aged
twenty-three years, a general servant, was admitted into
Bird ward for the effects of an injury of the right forearm
austained six months previously. Crossing the anterior
surface of the forearm from near the radial styloid process
•obliquely inwards and upwards to the inner border of the
forearm was a scar, which apparently implicated all the
structures down to the bones. The muscles forming the ball
of the thumb were wasted, as were also all the interossei.
The thumb and all the fingers were Hexed and rigidly con-
'tractured. Separation and closure and flexion and extension
of the fingers were lost. The scar was tender. The small
triangular area of the forearm between the scar and the
wHst, the palm, and three small oval areas continuous
with the palm in the clefts between the four fingers
retained a slight degree of sensibility; the patient was
conscious when touched with a needle within the limits
indicated, but she could not localise with any precision the
(part touched. The palmar surface of the two phalanges
of tlve thumb and tliat of all the fingers, excepting the
ulnar half of the little finger, and that of the dorsal surface
of the terminal and midale phalanges of the three outer
fingers, was devoid of sensibility to touch and to stimuli
with hut and cold substances. iJr. Pasteur, at that time in
charge of the electrical department, found that all the
•niUBcles on the distal side of tbo scar did not respond either
to favadaic or to galvanic stimulation. Sbo stated that
the scar was the result of a gash occasioned (six ’) months
roreviously by the accidental breaking of a pane of glass at
East London in the Cape of Good Hope. A local doctor closed
the wound with silver wire sutures and sent her into a
hospital, where a week later the stitches were removed.
Two days after this bleeding recurred, and having recurred
on the following two days the wound was reopened and the
vessels were tied. In consequence of this she was in bed
during a month. Her band remained useless. Galvanism and
massage proving useless she was sent back to England, and
two days after landing entered the Middlesex Hospital. On
Oct. 30th the trunk of the ulnar nerve was exposed ; it was
'found to have been divided a short distance below where
it gives off its dorsal digital branch. The interval
between the two ends of the nerve (about three-quarters
of an inch) was bridged by a slender band of con¬
nective tissue ; the proximal end was distinctly bulbous
and the distal tapering. The trunk of the median nerve
was less readily found. The upper bulbously swollen
end had retracted to a much greater extent than had that
of the ulnar nerve. A cicatricial band passing distally
from it divided near the wrist, one slip being attached
to the tendon of the flexor carpi radialis, and the other
.slip connected with the distal end of the nerve, very close
to the anterior annular ligament. The interval between
the two ends of the severed nerve was estimated to be two
"inches. The altered ends of each nerve having been removed,
the sectional surfaces of the ulnar were brought into close con*
■tact by sutures passed through the nerve itself, other sutures
taking up the connective sheath of the nerve only proving in¬
sufficient to withstand the strain. Actual coaptation of the
ends of the median nerve was impracticable, an interval of
quarter of an inch remained after stretching the proximal part
of the trunk, and bringing up the distal end by strong flexion
of the hand. Strict antiseptic precautions were observed
at the operation and in tne subsequent dressings. On
Nov. 9th the dorsal surfaces of the terminal and middle
phalanges of the two middle fingers were found slightly
sensitive to tactile stimuli, and the sensitiveness of this
surface of the thumb, which had previously seemed blunted,
was increased. Sensitiveness, previously limited to the
ulnar half of the palmar surface of tlie little finger, was
now verified for the whole of this surface of this linger.
On Nov. 10th the palmar surfaces of the second, third, and
fourth fingers, were found sensitive to the touch of a needle.
On Nov. 15th the palmar surface of the index finger was
found sensitive, and on the I9th it was noted that the
sensitiveness of all the parts of the finger and thnmb pre¬
viously inBensihle had become well marked. Later this
sensitiveness to a tactile stimulus diminished. Sensitive¬
ness to the contact of hot and cold objects never returned.
On one occasion she scorched her finger-tips whilst toast¬
ing a piece of bread, The operation incisions healed slowly,
and a small superficial granulating part remained open
when, on Feb. 26bh, 1889, repeated insubordination made
it obligatory on her to leave the hospital. Massage and
electrical treatment had proved useless. The fingers
then had the tapering, smooth, glossy bluish-red appear¬
ance characteristic of the trophic impairment follow¬
ing nerve injuries. The patient subsequently entered
St. Thomas’s Hospital under Mr. Croft. It is greatly
to be regretted that in this case the severed nerves
and also the tendons were not each securely united by
sutures by the person who saw the recent wound and
closed it; but the place where the accident occurred and the
other attendant circumstances must be accepted as ex¬
tenuating this grave omission. Doubtless also the secondary
repeated hemorrhages were adverse to the union of the
nerve ends, which may take place even in the absence of
suturing. As we are as yet unable to fix in any particular
case a term after which union of nerve and restoration
of function are impossible, it seemed right to attempt the
unionof thenerve ends, notwithstanding theadvanced trophic
disturbance present when the patient entered the Middlesex
Hospital. The return of sensitiveness to touch in the
parts before insensible to this stimulus, ascertained first
on the tenth day after the operation, and subsequently
verified by frequent testing, is a remarkable circumst^ce
in connexion with the fact that the ends of the divided
' median nerve could not be brought together, but an interval
of a quarter of an inch remained between them. It had
been intended to intercalate a piece of a living nerve, and
I an animal was at hand for this purpose, but an unexpected
I difficulty happened at the last moment, and this design had
to be abandoned. Other noteworthy circumstances were
the presence of three small sensitive islands at the palmar
ends of the digital clefts, and of the ansesthetic areas on
the dorsal surfaces of the fingers in the distribution of the
radial nerve not itself implicated in the injury. A satis-
I factory explanation of these seeming anomalies cannot be
I offered.
Case 6 . Division of the external popliteal nei-ve whilst
dividing the tendonofthe biceps; suture: imperfect restoration
of sensation only. —B. M-, aged nineteen, seamstress, was
admittedintothehospitalonApril4fch', 1889. The right lower
limb was seven inches and a half shorter than the left ; of this
shortening five inches represented the disparity of the
thighs. ,^ril the imrts of the right limb were ill developed in
comparison with the corresponding parts of the left j the
muscles were limp and llabby. When standing the outline
of the limb was obviously curved, the concavity looking
forwards, the summit of the curve being at the knee. The
foot presented the deformity characteristic of equiuo-varus.
There wore extensive scars about the liip. One of these
extended from below the middle of Pouparb’s ligament
round the inner side of the thigh to its posterior surface,
and another reached from the tuber ischii to the situation
of the great trochanter, and thence four inches down
the thigh. Another scar nearly two inches long was present
over the outer hamstring, two inches above the lowest
point of the femoral condyle, and behind this was a fourth
smaller scar. All these scars had the distinctive characters
of those of surgical incisions. A palpable gap was present
in the bicipital tendon corresponding to these lower scars.
,-> Coo;;le
934 Thb Lanobt,
HOSPITAL MEDICINE AND SURGERY.
[April 26, 1891.
All the muscles ionerrated by the external popliteal nerve
were completely functionless, and the sensibiUty of the
cutaneous area supplied from this trunk was very markedly
impaired. The patient stated that she was supposed to
have hurt her hip when six years old by falling out of a
carriage. One year afterwards she entered a hospital with
hip disease, where, in the course of two years, she under¬
went several operations.
Case 7. Paralysis of ths musculo-spiral nerve resulting
from a bullet wound. —L. N-, aged twenty-nine, a
strong hale man, a French polisher, formerly soldier, was
admitted into Founder ward on May 17lh, 1890, for the
results of an injury to his right arm, received, he said, at
the battle of Tel-el-Kebii'. At the date of this note the
marks of the injury were—a small, depressed scar on the
front of the arm, three inches below the shoulder; a larger,
rayed scar at the middle of the back of the arm, having
close to it the opening of a small sinus, from which a small
quantity of serum could be pressed; obvious irregularity
and thickening of the humerus between these scars; evident
wasting of the extensor muscles on the back of the forearm,
with wrist-drop; slightly impaired tactile sensibility of the
surface along the radial border of the forearm and the pos¬
terior surface of the thumb and forefinger; slightly dimi¬
nished range of flexion of forearm on arm, and distinct
weakness of grasping power of the right hand.
The following memorandum on the electric reactions was
written by Dr. Wynter:—“The extensor muscles of the
right forearm exhibit complete absence of irritability to the
faradaic and the galvanic current, indicating complete
wasting of the nerve ends and trunk, the stage of pro¬
gressive degeneration being passed. There is considerable
wasting of this group of muscles. The flexors appear to be
in a normal condition, as electrically compared with those
of the other forearm.” The patient stated that at Tel-el-
Kehir he was shot through the arm ; the bone was broken.
An abscess formed in the wound and burst three weeks
later whilst on his voyage to England. At Haslar Hospital
the fracture which had united was lehroken and reset, the
bone being found in a faulty position. His impression was
that the wrist-drop instantly followed the injury. Early
in May, 1890, an abscess again formed in the site of injury,
leaving the existing sinus at the back of the arm as its sequel.
Whilst the symptoms were conclusive as to the occurrence
of an injury to the trunk of the musculo-spiral nerve the
history was not sufficiently precise to warrant a positive
opinion as to whether the lesion was the immediate
severance of the nerve by the bullet or by splinters of the
broken humerus driven before it; or if it was the compression
of the nerve by the displaced ends of the broken bone or by
callus. To the patient’s impression that his wrist-drop
dated from the moment of the injury little value could be
attached, since it was judged improbable that he could, under
the circumstances of the moment, have correctly dis¬
tinguished between the dropping of his whole arm when
the humerus was broken, and the dropping of the
wrist apart from this. In the presence of the advanced
atrophy of the peripheral branches of the nerve and
of tne extensors, little benefit was expected from an
attempt to reunite the ends of the severed trunk or to
extricate it from compression. This, as a tentative measure
involving little risk, appeared justifiable, but the patient
would not allow it; nor would he permit the exploration of
the sinus, though the occurrance of this suggested the
presence of a sequestrum, or perhaps a splash of lead. He
soon left the hospital, and his subsequent history is not
known.
Case 8 . Irritation of the median nerve hy the displaced
fragment of a comminuted radius ; extrication of nerve ,
good result. —M. C -, aged fifty, a hale-looking country
woman, whose raven hair was slightly streaked with grey,
was admitted into the Middlesex Hospital onFeb. 1 st, 1883,
for a sequel of an injury to her forearm sustained four
months previously by a fall in which she struck this fore¬
arm against the edge of a stair. The radius and ulna had
been oroken in their lower third, and tne former com¬
minuted. Good union, with slight angular deviation of
the axis of the bone, h^ occurred ; but a detached piece of
the radius, about half an inch wide and somewhat longer,
projected so strongly at the flexor side as to press upon and
raise the integument. Here and for some distance around
it there were great tenderness and pain, and severe pain
was felt also in the palmar surface of the two middle fingers.
She said that the pain was so intense that it made her
quite unable to use the limb, and it prevented her working.
On Feb. 3rd the projecting piece of hone was laid bare and
cut away. It had pusbea the median nerve—which was
found resting in a groove in the outer border of the frag¬
ment—out of its normal course. A fortnight later she
returned home. The wound had very nearly healed. The
pain had ceased.
Case 9. Painful scar of an incision into a whitlow;
wasting of finger; amputation. —E. S-, aged twenty-
one, an anmmic brunetie, a cook, was admitted into Bird
ward on March 16tb, 1887, for a painful state of the
middle finger of the left hand, which prevented her working,
the pain being sometimes so acute as to oblige her to drop
whatever she held in this hand at the moment. Nearly in
the long axis of the palmar surface of the terminal phalanx
of this finger was the depressed scar of an incision
made for a whitlow eighteen months previously. This
phalanx was shrunken, tapering markedly in figure; its
skin smooth, glossy, and red ; and its temperature 0’50° F.
lower than that of the other fingers. The middle phalanx was
affected similarly, but in a less degree. The pain, she said,
never ceased, and it was increased by cold. Topical
sedatives, electricity, massage, and tonics had been tried
without benefit. Under these circumstances the finger was
amputated, and the woman soon left the hospital perfectly
relieved.
LEEDS GENERAL INFIRMARY.
A CASE OF POLYPOID GROWTHS IN THB KNEE-JOINT;
REMOVAL.
(Under the care of Mr. A. W. Mayo Robson.)
This case is of interest not only on account of the rapid
recovery following such an extensive operation in the interior
of the knee-joint, but because of the unusual nature of the
disease for which operation was performed. The tumours
seemed to be genuine fibroid polypi arising from the deeper
layer of the synovial membrane, and not the ordinary hyper¬
trophied fringes, which may become pedunculated, but which
are seldom seen to attain so large a size. For the account of
this case we are indebted lo Mr, Basil Hall, house surgeon.
J. R-, aged thirty-eight, a sailor, was admitted on
Oct. 27th, 1890, with the right knee-joint greatly distended
From inner incision.
From outer incision.
with fluid. The history was that the knee was struck two
ears previously by a heavy piece of timber. He remained in.
ed, and was treated for sixteen weeks, after which he
Dig ^
The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
April 25, 1891 935
worked for some time, although the knee remained weak
and painfal. Although the swelling subsided after the
aecidenc, it appeared again after a few weeks. Latterly
’it increased very considerably, and on admission he was
onable to walk. When admitted the joint was very much
distended with fluid ; more especially was it noticed that
4he prolongation beneath the quadriceps extensor seemed
to be more tightly distended than the rest of the joint.
No foreign body could be felt in the joint. For a
month rest on a splint, lead lotion, and counter-irritants
were tried without success. As there was no redness or
'heat about the joint it was aspirated, and four ounces of
thick straw-coloured fluid were drawn off. A movable
mass could then be felt for the first time on the inner side
of the joint above the patella, and a second tumour on the
outer side just below. The first was as large as a hen’s
egg, the second about one-third the size. A week later
(Dec. 4th) the knee-joint was opened first on the inner side,
.and the mass, which was a fibroid polypus attached by a
broad base to the synovial membrane, was removed, together
with the disc of membrane from which it sprang. A
smaller growth was also found and removed. Exploration
by the finger revealed a third polypoid growth on the outer
<side of the joint, which was removed through an external
incision. A drainage-tube was inserted and an antiseptic
-dressing applied, the knee being placed on a back splint.
The growths were of an irregular shape (see appended
•engravings) more or less lobulated, and composed of fibrous
tissue covered with synovial membrane. They were all
pedunculated. On the third day the drainage-tube was
'removed. On the tenth day the wounds were healed. On
the fourteenth day a Thomas’s splint was applied, and two
days later the patient went to a convalescent home. Five
weeks later the patient walked without limp into the
hospital, carrying bis splint under his arm, and describing
himself as perfectly well. He was then following bis occu-
ipation as a seaman. The movements of the joint were
perfect, and there was no swelling or tenderness.
Sleliital Srattws.
PATHOLOGICAL SOCIETY OF LONDON.
Melanotic Sarcomatosis.—Perforation of Gall-bladder .—
Osteitis Deformans. — Ulceration and Contraction of
Stomach.—Tubercular Bladder after Koch's Treatment .—
Myeloid Tumorvr of Tibia. — Umbilical Fcccal Fistula.
An ordinary meeting of this Society was held on April 2l8t,
the President, Dr. Dickinson, in the chair.
Dr. J. C. Mackenzie contributed a paper on Melanotic
.Sarcomatosis, the specimens being shown for him by Dr.
Woodhead. The patient was seventy-five years of age, and
an inmate of Morpeth County Asylum. The primary
growth occurred in the left iris ; there was infiltration of the
optic nerve, bub the brain and spinal cord were free. The
general symptoms observed during life did not bear on the
pathology of the case. There was extensive infiltration,
with secondary nodules, of the skin of the chest and abdo¬
men, and at the necropsy secondary deposits were found in
the substance of the heart, the inner surface of the peri¬
cardium, the lungs, the pleura;, diaphragm, liver, gall¬
bladder, pancreas, speen, adrenals, kidneys, intestines,
atomach, bladder, mesenteric glands, testes, thyroid body,
portal vein, and left pulmonary veins. The rarity of
secondary growth in several of these situations was com¬
mented on, and it was pointed out that the chief interest of
the case lay in the very wide distribution of the malignant
deposits.
Mr. SvDNioT Jones exhibited a Perforation of the Gall¬
bladder, the specimen being taken from a lady aged fifty-
three, of phthisical history and delicate, who had suffered
at times from attacks of “spasms.” Twelve months ago, in
one of these attacks, she became jaundiced, but she had
..since been in good health. On Feb. 16bh she had an attack
of severe abdominal pain, with vomiting and symptoms of
obstruction, and two days later there was well-marked
acute general peritonitis. Later still obscure fluctuation
was detected on the right side, and on incision a quantity
of fluid was evacuated, together with blle-ooloured lymph.
The left parotid gland, which was also swollen, was incised,
and sero-purulent fluid removed. The right parotid likewise
swelled, out it was not incised. The patient died tbirtv*
one days after the commencement of the symptoms. At
the necropsy fifty-three stones were found in the gall¬
bladder, varying in size from a mustard seed to that of a
pea, together with some bile. At tbe bottom of the gall¬
bladder was a minute perforation. No stones had escaped,
but tbe peritonitis appeared to have been set up by tbe
leakage of a small quantity of bile into the peritoneum.
The walls of the bladder were thickened, but tbe lining
riiembrane was free from ulceration. He referred to a case,
shown at the Society in December last, in which perforation
of tile gall-bladder followed upon a general ulcerative con-
ditiqn, unaccompanied by the presence of stones.—Dr.
Sharkey remembered seeing post mortem a case of single
ulcer of tbe gall-bladder, which caused death by perforative
peritonitis. No calculi were present.
Mr. H. H. Glutton showed a specimen of Osteitis
Deformans of the Tibia. A vertical section showed enlarge¬
ment from one end to the other with the exception of the
articular extremities. The medullary canal was almost
completely filled up with new bone, which was as dense as
the wall of the shaft. A few pits and spaces were filled in
the recent state with granulation tissue. The specimen
was removed by amputation from a woman aged thirty-five,
who had been an out-patient at St. Thomas’s Hospital for
ten years. No other bone was affected, and there was no
history of syphilis ; no old or recent syphilitic lesion conld
at any time oe discovered. She suffered from a great deal
of pain, but obtained no relief from anti-syphilitic remedies
given over long periods and in full doses. Mr. Glutton was
inclined to look upon it as an unusual cose of osteitis
deformans: 1. From the absence of any evidence of syphilis
either in the history or in the examination of the patient
over a long period. 2. From the pathological appearances
of the bone, which were as much in favour of osteitis
deformans as of syphilis. Objections, he thought, might
be raised : 1. From the age of the patient; but in one of
Sir James Paget’s cases evidences of the disease were
first noticed at the age of twenty-eight. 2. From the
fact that only one bone was affected; but in the
Pathological Society’s Transactions (1883) Mr. Bowlby
bad recorded a similar case in an elderly subject, and he
' (Mr. Glutton) had himself recorded one in 1888, in which
tbe bones were unsymmetrioally involve!. .3. From the
absence of any curvature of the bone. In answer to this
objection, he stated that the patient scarcely ever pub her
foot to the ground except to come to the hospital. She was
a pensioner, and had an angular curvature of tne spine;
and only one bone being affected, she naturally stood on
the sound one, and never leant heavily on tbe leg that was
so painful—Mr. Sydney Jones asked if a microscopical
examination of the bone had been made.—Mr. Barker
inquired as to the cause of the angular curvature of the
spine.—Mr. Glutton, in reply, said he had nob made a
microscopical examination of Che bone, as he failed to see
that it could throw light on its causation. The angular
curvature was of tubercular nature.
Dr. Hadden showed an extremely Gontracted Stomach,
which was taken from the body of a woman aged thirty,
who had suffered for several months before death from
vomiting. She lived on liquid food only, which she took
with marked slowness. The walls of the stomach were
much thickened from a chronic and oedematous condition of
tbe submucous coat. There was some ulceration of the
lower half of the tesophagus and the first two inches of the
stomach. There was some chronic broncho-pneumonic con¬
solidation of the upper lobe of the left lung, with a cavity of
rather recent date. The condition of the stomach was
probably due to extensive ulceration with subsequent con¬
traction. It was probable that the ulceration might have
been due to the action of some corrosive poison, although
the history, which was indefinite, did not furnish informa¬
tion on the point.—Dr. Longhurst asked if there had been
any haematemesis.—Mr. Williams called attention to the
excellent series of specimens of ulceration of tbe stomach
which were to he found in the museum of St. Thomas’s
Hospital.—The President asked if there was any evidence
of morbid growth in the gastric walls.—-Dr. Hadden replied
that there was no mencion of haimatemesis in the history of
tbe cases and microscopically there was no evidence of
malignancy.
Mr, Hurry Fenwick showed the Urinary Tract of a
966 T£tB
MEDICAL SOCIETY OF LONDON.
[April 25, 1891.
man aged thirty-two. Obscure symptoms, apparently of
-urinary tuberculosis, had been observed for two years, and
yet only very slight vesical ulceration was found after
death. Before Koch’s injection the tubercle bacillus was
discovered in large numbers in the urine, but none could be
detected in any part on microscopical examination of the
diseased tissues. Instrumental interference was considered
unadvisable, from the constant presence of the bacillus, so
1 milligramme of tuberculin was injected. The reaction
was immediate and moderate. But vomiting and profuse
bsematuria set in, and the patient sank sixteen days after
with symptoms of pyelo-nephritis. On post-mortem exami¬
nation the left ureter was found congenitally occluded
and the left kidney atrophic. The right kidney was of
large size and pyelo-nephntic; the bladder was ulcerated,
and there were several small submucous abscesses in the
apex of that viscus. Mr. Fenwick did not consider the
death to be due to tuberculin, though he thought it had
hastened it.- He had injected another case, and had
watched the nlceration change very markedly, but no
permanent benefit seemed to have resulted, although a
temporary improvement took place.—Dr, Woodhead asked
if there was any histological evidence of tubercle in the
pelvis of the kidney or in the walls of the small abscesses.—
The President supposed that the shrunken kidney wes an
instance of simple atrophy from obstruction.—Mr. Taeoett
said that the right kidney was an instance of simple dilata¬
tion ; on the other side the abscesses were pyelo nepbritic
and non-tubercular. At the neck of the bladder there was
giant-celled growth, with small round cells.
Mr, Solly showed a specimen of Central Myeloid Sar¬
coma of the Shaft of the Tibia, situated a little above the
centre of the bone. The patient was a lad aged seventeen,
who had only noticed the growth fourteen days before the
leg was amputated, and at the operation the popliteal glands
were found to be infected. Kecovery appeared complete
for about five months, but secondary growths became
evident in the lungs and axillary glands, and death took
place six months after the operation. Secondary deposits
very rarely followed central myeloid sarcomata of bone,
but the statistics of Gross and others showed that they
were most frequent in tumours springing from the dia¬
physial part of the hone rather than from the epiphysial
ends.
Mr. William Anderson brought forward a case of
Frecal Fistula at the Umbilicus, with Imperfect Develop¬
ment of the Large Intestine. The patient, a seven months’
child (male), was found on the day after birth to have a
fascal fistula at the umbilicus and an absence of develop¬
ment of the lower part of the large intestine. He died of
asthenia a fortnight afterwards, the functions in the interval
having been discharged normally, and the bowels evacuated
without difficulty through the umbilical aperture. The
post-mortem examination showed a hernia of the ileum at
the umbilicus, at a point an inch and a half from the
crecum. The umbilical orifice was single, but the probe
passed freely into the intestine in both proximal and
distal directions. The large intestine was filled with
faeces, and terminated in a blind conical extremity about
six inches from the ileo-cjocal valve. There was little
donbt that the umbilical protrusion consisted of a kind
of Littre’s hernia (the result of persistence of the condition
which normally obtained during the early period of fojtal
life^, a portion of which had been cut off when the cord was
divided. Its adjacency to the cmcum made it probable that
the hernia was determined by a persistent Meckel’s diverti¬
culum, which drew the ileum close up to the umbilical
aperture, and favoured its escape when the ventless gut
became filled with accumulated excretion. The placental
end of the cord was unfortunately not preserved,—The
President referred to a child which had been under his
care at the Children’s Hospital with habitual discharge of
faces from the umbilicus. Nothing was attempted in the
way of treatment, and the child left the hospital in much
the same condition.—Mr. Barker had seen several cases
where fmcal fistuho had lasted a long time, and had then
closed spontaneously.—Dr. Woodhead looked upon the
case rather as one of persistence of the omphalo-mesenteric
duct than of true fistula.—Mr. D’Arcy Power asked if
any swelling was visible in the cord before division, which
might have been a caution against dividing it too closely
to the umbiUcu8.~Mr. Anderson, in reply, said that a
swelling was noticed in the stump of the cord after the
scissors had been used. Perhaps the opening of the gut at
the time was the most fortunate thing for the child, an
there was no other outlet for the fioces.
The following card specimens were shown:—
Dr. Lee Dickinson: (1) Aneurysm of the Abdominal
Aorta opening into the Duodenum; (2) Aneurysm of the
Thoracic Aorta opening into the Left Bronchus.
Mr. H. H. Glutton: Extensive Rodent Ulcer of the
Scalp.
Mr. J. H. Tarqbtt: Melanotic Sarcoma of Bladder.
MEDICAL SOCIETY OF LONDON.
Debate on iJie Use of Koch’s Remedy in Lupus and
Pulmonary Txiberculosis.
An ordinary meeting of this Society was held on April 218b;.
the President, Dr. Douglas Powell, in the chair.
Dr. G. A. Heron read a paper on the Uee of Koch’a
Remedy in Lupus Vulgaris and in Tuberculosis of the
Lung, which is published in another part of our present
issue. Ad exhibition took place of many of the patlenta
whose cases were described in the paper.
Dr. Theodore Williams considered that the author had
taken a very moderate view of the value of this treatment.
He himself bad not had so many cases under his care. Of
those which had been treated at the Brompton Hospital at
present no report had been published, and he would only
refer to his own cases. He went over to Berlin to study
the treatment, and he came back with the impression that
he bad not seen many material successes; only a small
number appeared to be genuinely improved. He bad had
fourteen undoubted cases of phthisis under this treatment -;,
all were under treatment for a considerable time, none less
than six weeks, and others as long as ten. P'or the most parb
they were injected three times a week, in quantities varying;
from a milligramme to a decigramme. In live cases the
disease was in what Dr. Heron would describe as the first
stage; one was a case of softening, five had single cavities, and
three had double cavities. Only six out of these fourteen
improved generally in weight and strength during the injec¬
tions; the rest were all decidedly worse. As to the effect oii
the lungs in the five cases of the first stage, four of them
showed cavity formation somewhat rapidly, tubercle bacilli
became more numerous, and lung tissue was constantly
found in the sputum. In the excavation cases also exten¬
sion of the disease was observed, and in one of the double
cavity cases two other cavities formed. At the end of the treat¬
ment excavation was found in twelve of the cases, excava¬
tion accompanied by tubercular spread in six, and tuber¬
cular spread without excavation in one. In two of the
cases the cavities appeared to contract, and the patients
left the hospital better, but the others could not be said to-
have done at all well; in fact, they could not compare with
the results of the ordinary expectant treatment. He re¬
marked on the extraordinary effect the drug appeared to-
exercise in ihereasing the amount of lung tissue expec¬
torated. It was found in the sputum in almost all the
cases, and was detected as long as the patient reinaine<5
under treatment. He had observed when at Berlin that
at most of the hospitals they did not appear to look for
lung tissue. In most of the cases there was also an increase
in the number of bacilli expectorated. As regards diagnosis,
it might prove very useful, but he observed that in two-
cases of laryngeal tuberculosis, though there was general,
there was no local reaction. The searching nature of this
remedy might be made use of by combining other drugs with
it, and so eventually attacking the bacillus in its own nest>
after it had been hunted thither by the tuberculin.
Dr. Radclikfe Crocker desired to direct his remarks to-
the treatment of lupus by this drug. He ijuoted a case
which showed the advantage of giving the injection
locally, for reaction was obtained after the ordinary injec ¬
tion in the back had ceased to have effect. In one case,
in a boy, who left the hospital with scarcely any percep¬
tible lupus, he hoped he had obtained a cure, for all that
remained were some little brown nodules below the level
of the skin. After three weeks at the seaside, however,
the nodules had appeared above the skin, and showed signs
of incrustation. As regarded permanence, therefore, tliis
remedy did not compare favourably with scraping alone.
But in the treatment of lupus he had for some time nob
only scraped, but had swabbed the surface with sulphuric,,
or carbolic, or some other strong acid, and by this means
The Lancet,]
NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY.
[April 25, 1891. 93T
he had found the time before" recurrence considerably
lengthened. The great drawback to Koch’s treatment was
that it seemed to stop short just where one hoped it would
go on. He hail recently adopted a modification. He scraped
away as much as he could and then injected, and the result
80 far in one case was very good. He thought we could
only look on it as a supplementary treatment which would
nut replace other methods. He had treated a marked case
of lupus erythematosus by injections, and the patient, a
woman, had great general and but little local reaction, and
there was only slight improvement in her condition.
Dr. WATERiiousii referred to some experiences in general
practice. His first case was that of a lady far advanced in
phthisis; she died two months after treatment, and her
death did not appear to be accelerated by it. In another
case the patient was in the second stage; she was not at
resent well, but she was in a very satisfactory condition,
aving gained strength, and the expectoration being very
much diminished. He observed that the immediate result
of the injection seemed to be often for a time to make the
lung appear to be much worse than it was. He had treated
four cases of tubercular disease of the joints in children;
one was a hip case with extensive sinuses, which refused to
heal. These sinuses were closing in, and the progress
towards recovery had been more in two months than it had
been for two years before.
Dr. Bagshaw, of St. Leonards, referred to the case of a
gentleman who had tubercular pneumonia of the right lung,
the sputum containing a number of bacilli. Thirteen injec¬
tions of Koch’s fluid were given, and then, no decided result
being obtained, he paused. The middle lobe then broke
down into a large cavity, and following this an ulcer formed
under the tongue. There was swelling of the joints, sym¬
ptoms indicating probably some ulceration of the bowels,
and biBQiatnria. All these conditions had now altered for
the better; the pulmonary cavity had practically healed up,
and there was little or no expectoration. He was unable
to decide whether the treatment had done the patient good
or harm.
Dr. Theodore Acland desired to ask one or two
questions. Had those cases done best in which toleration
of the drug had been established, or were the results better
when the patients were injected once or twice a week, a
reaction being obtained each time ? He presumed that the
cases referred to were, while undergoing this treatment,
provided with warm clothing, good food, and the other
comfortable surroundings of hospital treatment. Could
the author, therefore, he sure that the good which had
followed was the result of the drug, and not of the other
measures ? This chance of error should certainly be
eliminated, and he had found that the investigations of
most of his friends were in this respect as unscientific as
his own. It was remarkable that we were still discussing
what was practically a secret remedy. He felt that a
rotest should be made against the great and irreparable
arm that this secrecy was doing to the cause of science
and of medicine.
Dr. Heron, in reply, said that the patients not only
expressed themselves generally improved, but there was
evidence of it in the condition of the lung; the coarse
sounds got finer and the moist sounds drier; that,
generally staced, was the condition of the lungs of
the first class of cases, and it applied also to the
others. In his experience he had not found in any
instance satisfactory evidence that a new cavity had
formed in any part of a lung. There was only one
case in which tuis remained doubtful. He thought
that Dr. Williams’ experience of tuberculin as a cavity-
maker was an exceptional one. He had often found a con¬
siderable amount of lung tissue as well as bacilli, but not
to such an extent as Dr. Williams had described. He could
not demonstrate in any instance extension of the disease in
the lungs while under treatment. He had found the injec¬
tion in the back to be quite as satisfactory as local injec¬
tion in lupus. It was remarkable that, though the patient
might remain quiescent at first, a marked reaction might
take place after a fourth or fifth injection, and this might
be the herald of a beneficial result. He had obtained the
best results with those patients who reacted well at first with
the drug, and who soon ceased to react at all. Often where
there was no general reaction, a local reaction was
observable after the injections, and this was a valuable
indication. lie said that, as a rule, his cases had not been
treated at first in hospital by ordinary means, but they
came In direct .from the out-patients’ department. Re¬
ferring to the question of ethics, he said that it was quite
enough for him to know that a man like Dr. Koch wished
to keep a certain part of his work to himself. He felt sure
that this was not done for a selfish motive, but for the
benefit of mankind at large.
The President desired to add one remark to what had
been said. He thought it was much to be regretted that
Dr. Koch (though perhaps for reasons not altogether within
his own control) bad at first kept this remedy secret. But
DOW he had published its composition and the general
grounds on which it was prepared, and he hadgivenhis reasons
for not publisbing the further particulars which he bad
withheld.
SUNDERLAND AND NORTH DURHAM
MEDICAL SOCIETY,
The usual monthly meeting of this' Society was held oa
Thursday, April 16bh, J. Adamson, M.D., President, in the
chair.
The Value oj Perimeter Measuretnents in the Diagnosis of
Brain Diseases. —At the invitation of the Society, Dr. Byrom
Bramwell of Edinburgh delivered an address on the above
subject. Owing to the limited time at his disposal Dr.
Bramwell, after a brief r6sum6 of the most recent knowledge
of the deep origin and connexions of the optic nerve, dis¬
cussed chiefly that form of bemiopia which is a symptom
and physical sign of cortical lesion of the ophthalmic lobe.
He snowed perimeter charts, and read the notes of cases in
which the above diagnosis was made, and verified post
mortem. Other forms of amblyopia were briefly alluded to.
Dr. Bramwell pronvised that the full text of his address
would be published. A vote of thanks to the lecturer,
moved by Mr, Morgan and seconded by Dr. Brady, brought
the proceedings to a close.
NOTTINGHAM MEDICO-CHIRURGICAL
SOCIETY.
A meeting of this Society was held on March 18th, Mr,
Joseph White, F.R.C.S., in the obair.
Rupture of Intestines. —Mr. Anderson read notes upon
several cases of this accident, drawing special attention to
the difficulties attending diagnosis in almost all of them.
He insisted upon the practical worthlessness for diagnostic
purposes of the presence or absence of liver dulness. In
conclusion, he strongly urged the desirability of speedy
operation after the diagnosis had been determined.—Dr.
Elder gave ■ an account of a case in which an accidental
rupture of the first part of the rectum took place through
forcible separation of old adhesions in the course of an
ovariotomy, but in which complete recovery supervened
without suture of the opening in the gut, a large drainage-
tube only being inserted through the abdominal wound.
Colotomy. —Mr. Anderson further read notes upon cases
illustrating several varieties of this operation, and strongly-
advised the adoption of that in the inguinal region when¬
ever possible.
Naivus.~Mx. W. E. Tresidder exhibited and described a
case of nrevoid condition of the skin of unilateral distri¬
bution in a boy aged twelve- The right side of the face and
trunk and the right arm and leg showed an ordinary capillary
najvus, the left side being practically free, the port wine
stain, however, passing across the middle line on the
back to a slight degree. In one or two places the
abnormal state showed a tendency to Tbecome caver¬
nous. There was also some abnormally large and much
distended superficial veins, the most marked being
a prominent venous arch extending across the lower
part of the abdomen from one saphenous opening to the
other. The condition was congenital. The unilateral dis¬
tribution appeared to indicate that the etiology of the con¬
dition might be some vaso-inotor nervous disturbance of
central origin, and occurring early in intra-uterine life.
Granulations on Mitral Valve. —Mr. 'rRHSlDDEU also
showed a heart with granulations on the auricular surface
of its mitral valve. The patient was the subject of chorea
and acute rheumatism; with the latter was associated fever,
and on the onset of chorea the fever subsided, recurring,
however, again with the rheumatism. The patient died
^8
938 ThbLa^tcbt,]
REVIEWS AND NOTICES OP BOOKS.
[April 25,1891.
auddealy.—Dr. BbookhoUSE sxiggested that the cauae of
the 8U<{aeQ death was the involvement of the heart in
choreic movements. There was no appearance of myo¬
carditis. The heart at the necropsy was dilated and full of
dot, some of which appeared to be ante mortem.
TAe Midwifery Contract. —Dr. Elder read notes of cases
seen in consultation illustrative of the inadequate pro¬
tection to the beat interests of the patient and the reputa¬
tion of the medical attendant given by the present general
acceptance of the obligations of the midwifery contract,
and suggested, amongst other matters, a supervision—more
or less continuous, according to the health condition—of the
patient during gestation and for a month or six weeks
following parturition.
Actinomtjcosis.—Dv. William B. Ransom gave an
account of a man aged forty-four, who was passing spherules
of actinomyces in his uriue and fmces, and specimens of the
fungus were shown. The case was still unuer observation.
Brain of a Case of Hemianopia. —Dr. Ransom also
described the case of a woman aged sixty-two who bad
right hemianopia for a year after a sadden stroke. She
died from extensive thrombosis of cerebral arteries, and
the necropsy revealed old softening and shrinking of the
left occipital lobe, posterior part of angular gyrus, and of
superior temporal convolution.
aitlf
Researches on Micro-organisms'. By A. B. Griffiths,
Ph.D., F.R.S.Edin., F.C.S. Illustrated with fifty-two
figures. London; Baillibre, Tindall, & Cox. 1891.
Under the above title, Dr. A, B. Griffiths has given an
interesting outline of what is at present known of bacteria.
Some parts of the work, however, deserve to be styled
something more than an outline, and, as one would expect
from the dedication of the book to Dr. Armand Gautier and
Dr. P. Miquel, two special features are the consideration of
the distribution of microbes in the atmosphere and in
water, and the biological chemistry of these organisms,
especially that which may be looked upon as the outcome
of work done in the French and Italian schools. A con¬
siderable number of the original observations have already
been published in the Proceedings of the Royal Society of
Edinburgh and in the Proceedings of the Chemical Society,
but the author has expanded most of his papers very con¬
siderably, and has added much new matter, more par¬
ticularly in the way of bringing his work and references
thoroughly up to date.
Dr. Griffiths commences with a description of the birth of
bacteriology, gives an outline sketch of the theories of fer¬
mentation and a general consideration of the relations of
microbes to disease. After a chapter on methods come a
general classification of microbes, a description of their
characters, their pleomorphisrn or monomorphism; then
follows a good chapter on the distribution of microbes, in
which the various methods as given by Miquel, Frankland,
Gautier, and Hesse for the determination of microbes in the
air, microbes in the soil, and the processes of nitrification
are described. The animal alkaloids are very fully de¬
scribed, and an account of the researches of Gautier, Etard,
Guareschi, Mosso, Brieger, and others is given; the
ptomaines from infectious diseases are also described. The
chapters on soluble ferments, on pigment formation, phos¬
phorescence, the action of heat, light, electricity, and
various gases on micro-organisms, on vaccination, on
germicides, and anti-parasite therapeutics are all inte¬
resting.
The latter part of the hook deals with the biology of
some of the more important microbes, but the descriptions of
these, with one or two exceptions, are rather too sketchy to
be of any very great value. Dr. Griffiths has devised a
method of treating phthisis, but it is difficult from a rimmi
cf the cases he gives to say how far his method of treat¬
ment has been successful, He found that by causing the
patient to inhale iodine and by the injection of natural
salicylic acid (obtained from certain members of the
vegetable kingdom, such as meadow sweet, winter green &c.)
into the blood, he was able in certain cases, apparently, to
interfere with the rapid course of this disease. This acid,
which Dr. Griffiths considers has no detrimental action on
the blood and tissues, has, he thinks, some curative action
OD the local lesions in consequence of its germicidal power.
There is an enormous amount of material in the book, and
the author has taken great trouble to collect a large
number of the references bearing on the points be mentions.
The work must serve rather as one for reference than for
continuous reading, as except in one or two of the chapters,
as already mentioned, we have little more than collections
of bare facts somewhat disjointedly strung together. We do
not say this in disparagement of the work, for it is impos¬
sible in a book of the size of the one before us to give all
the information it contains in anything more than mere out¬
line form.
Journal of Researches into the Natural History and Geology
of the Countries visited by H.M.S. '^Beagle." By
611AELES Darwin, M.A.,F.lt.S. A New Edition, with
Illustrations by K. T. Pritchett of places visited and
objects described. London : John Murray. 1890.
We are delighted to see a new edition of this charming
book published with excellent illustrations. Like White’s
“History of Selborne,” it is a book that eminently lends itself
toillustration. Darwin’s accounts of the scenery, the inhabit¬
ants and their habits, the animals and plants of the various
regions he visited, have a perennial value. They are still
novel, still in most instances rare, always interesting. No
page can be opened which does not bear witness to bis ex¬
ceptional power of observation. The Fuegians, he says,
speaking of South America, are excellent mimics ; as often
as “ we coughed or yawned, or made any odd motion, they
immediately imitated us. Some of the party began to squint
and look awry, but one of the young Fuegians, whose whole
face was painted black, excepting a white band across his
eyes, succeeded in making far more hideous grimaces.
They could repeat with perfect correctness each word in
any sentence addressed to them, and they remembered such
words for some time.All savages appear to possess to
an uncommon degree this power of mimicry.How can
this faculty,” he adds, “ be explained ? Is it a consequence
of the more practised habits of perception and keener
senses common to all men in a savage state as compared
witli those long civilised?”
It is exceedingly interesting to see how the observations
here recorded were gradually shaping themselves into the
connected chain which afterwards reappeared as the * ‘ Origin
of Species.” For example, in speaking of the geological
features of Patagonia and the vast gravel beds found in this
region, Darwin is lost in wonder at the time that must have
elapsed in the process of their formation. “ When we con¬
sider,” he says, “ that all these pebbles (forming a bed 200
miles long by fifty feet in depth), countless as the grains of
sand in the desert, have been derived from this slow falling
of masses of rock on the old coast lines and hanks of rivers,
and that these fragments have been dashed into smaller
pieces, and that each of them has been slowly rolled,
rounded, and far transported, the mind is stupefied in
thinking over the long absolutely necessary lapse of years.”
But these beds of gravel lie on a peculiar white stone which
extends for more than 500 miles, and is in some places
800 feet thick, and which is composed to a considerable
extent of infusoria. Below this, again, are beds with tertiary
shells. In the same chapter he dwells on the changed state
of the American continent, pointing out that formerly it
must have swarmed with great monsters, gigantic sloths.
Din' 'ed by Cj OOg IC
Tbb Lancet,]
OUR LIBRARY TABLE.
[April 25, 1891. 989
and armadillo-like creatures; whilst now it is occupied,
apart from such animals as the horse, which has been
lately introduced, with mere pigmies. The illustrations by
Mr. Pritchett, which are upwards of 100 in number, are
excellent, and very materially add to the interest of the
text. We can pay them no greater compliment than by
saying that we wish their number had been doubled.
OUR LIBRARY TABLE.
Janner-Literatur; Catalog der Bibliothek. Von Dr. L.
Pfisipfbr in Weimar.—The enormous amount of literature
that has arisen out of the discovery of vaccination since
the days of Jenner is well represented in the valuable
collection originated in 1830 by Dr. von Bulmerincq in
Warsaw, and continued down to 1890 by Dr. L. Pfeiffer of
Weimar, in whose possession the library now is. It con¬
tains upwards of 2000 volumes, monographs, essays, &c.,
upon variola, inoculation, and allied topics, as well as
portraits and drawings; and it is proposed to dispose of it
as a whole in the hope that it may find a permanent estab¬
lishment as a memorial of the illustrious man whose ideas
have borne such fruit. The collection is one of great value,
and its acquirement by Jenner’s countrymen would be fitting,
if it were feasible.
Asthma, considered specially in relation to Nasal Disease.
ByE. SCHMIEGELOW, M.D London : II. K. Lewis. 1890.—
The discovery by Professor Hack of the relationship between
many cases of spasmodic asthma and nasal disease has been
undoubtedly of great service in the successful treatment of
the former affection. Comparatively little attention has
been given to the subject in this country, and therefore
we are grateful to the author of the work before us
for producing an English edition of it. The argument is
based on the conception of asthma as being a “bulbar
neurosis,” which may develop after debilitating circum¬
stances, or may be excited by reflex irritations. Among
the latter the nasal mucous membrane is a frequent seat,
and local treatment of this tract may, in conjunction with
general tonic measures, succeed in curing the tendency. For
the development of this thesis we must refer to the work
itself, which deserves careful study.
Home Nursing, By E. Margery Homersiiam,
Lecturer for the National Health Society and Forsyth
Technical College. London: Allman and Son.—We are
glad to see a second edition of this excellent little hand¬
book from the pen of so thorough and practical a nurse
and so able a teacher as Miss Homersham. The book is
published under the auspices of the National Health Society,
and is an attempt to epitomise such knowledge as a nurse
ought necessarily to possess for her guidance in the sick
room. A good nurse is marked out by the amount of
importance and weight which she attaches to those appa¬
rently trifling circumstances, the attention to, or neglect of
which, in a sick room tends so much to soothe or to vex the
sufferer. A special feature of Miss Homersham’a work is
the careful and scientific manner in which the necessity of
attending to these innumerable details is set forth. The
arrangement of the sick room and the details of nursing
are indicated in a style at once attractive and instructive.
In the present edition the chapter on diet has been enlarged,
and many useful directions have been added in the way of
preparing food for invalids, Chapter IV., on External
Applications, such as poultices, mustard plasters, fomenta¬
tions, blisters, and rubbing, is added in the present
edition. Only they whose experience has shown them the
stupendous ignorance which exists in many directions on
this subject, and the fearful consequences resulting from
the erroneous application of such remedies, can appreciate
fully the attempts made by Miss Homersham to set forth
in a concise form knowledge which may be of the utmost
consequence in periods of domestic trouble. Chapter VIL,
on the Complications which are likely to arise in the Course
of a Disease, is especially worthy of attention. Miss
Homersham’s little book should occupy a place in every
household library.
Barker's Facts and Figures, 1891. London: Fredlc.
Warne and Co. — A large body of information, chiefly sta¬
tistical, upon matters of current and permanent interest has
been brought together by Mr. Thomas P. Whittaker under
this title. Handbooks of much the same general character
have been greatly multiplied of late, and it is not easy to
hit off in a word or a sentence the distinctive character of
the present compilation. It is perhaps enough to say that
it seems well adapted to take rank among standard books
of reference relating to moral, social, economical, and poli¬
tical subjects.
Saint-Raphacl, with Valescure andBoulourie, as a Winter
Health Resort. By Howard D. Buss, M.K.C.S. Eng.,
L.S.A. Lond. St. Raphael: V. Chailan.—This is an
unpretending little book, intended to point out the
attractions of St. Raphael to those invalids who seek abso¬
lute seclusion and are regardless of such festivities as
exist at Nice or Cannes. Mr. Buss claims that St. Raphael
is well sheltered from the cold winds by the Esterel
and Maure Mountains, but that this protection is so far re¬
moved as to avoid the stuffy closeness or stillness which charac¬
terises the more perfect wall of mountaia at such a place
as Mentone. Doubtless there is some point in these argu¬
ments, and they apply with great force when speaking of
the early spring or late autnmn. To those who have enjoyed
the greater heat, the much more certain shelter of such
places at Beaulieu, Petite Aftique, Monte Carlo, and
Mentone—Sb. Raphael will be very useful as a breezy break
before reaching northern climates. There are numerous
pleasant excursions to be enjoyed in the neighbourhood, and
to archfcologists the Roman ruins at Frijus will prove a
great attraction. To such visitors the guide-book Mr. Buss
has published will be acceptable.
The Insurance Year-book, 1891. London: Simpkin*
Marshall, Hamilton, Kent, and Co,, Limited.—This compila¬
tion of insurance statistics will be chiefly interesting to
those more immediately connected with the subject of
insurance; but it is illustrated by a number of articles
written for the general reader, and dealing in an elementary
way with the principles of insurance in its various branches.
The paragraphs devoted to the several offices give in a*
compendious and collected form statistical information
which is thus brought into a very available form.
The Insurance Blue Book and Guide, 1890-91. London :
Cbampness and Co.—This collection of insurance statistics
is planned upon the method of putting its materials in
tabular form, an arrangement which enables the facts to
be exhibited very perspicuously, but makes the process of
referring somewhat too laborious for the general reader.
Ittto Infentions.
A NEW SAFETY CHLOROFORM INHALER.
Any form of inhaler which will contribute to the safety
of chloroform administration should be welcomed by the pro¬
fession. The results of the Hyderabad Chloroform Commis¬
sion, though questioned, still have directed more attention to
the importance of watching the respiration equally if nob
more than the pulse. The illustration represents what I
have named the “Safety Inhaler for Chloroform Administra¬
tion,” made for me by Messrs. Arnold and Sons, London, who
have taken a great deal of trouble to perfect my idea, the
Dir zed' GOOgIC
HO The Lakcet,]
NEW INVENTIONS.—ANALYTICAL RECORDS.
tAPBiL 25, 1891.
main advantage being that every inspiration and expiration,
however faint, will cause the valves through which the air
must pass to produce a sound audible to the administrator,
and so give immediate notice of danger both to himself and
the bystanders at the operation. I hnd it a good plan to
apply the mask with no chloroform in it at first, and allow the
patient to breathe naturally through it for a few momenta,
which establishes confidence and banishes a great deal of
the nervousness usually met with. The cage of wire con¬
taining a small cup sponge being separate, the amount of
ehlorotorm considered advisable can be poured on and the
receptacle (attached by bayonet joint) fixed in an instant
without removing the mask from the face of the patient.
With nervous patients I consider ic advisable, and it has
always been my practice (where possible to do so), to give,
half an hour previously to the operation, half a glass to a
glass of whi8% in a cup of hot milk, taken in mouthfuls,
with a few minutes’ interval. I have remarked when this
is done the patient faces the ordeal more cheerfully, and
there is (as a rule) no sickness of stomach or vomiting. 1
have always preferred chloroform to ether, having had
personal experience of both. I think my inhaler, if given
a fair trial, will be found a great saver of anxiety, if
nothing else.
Dublin. Alexander Duke, F.11.C.P.I,, «S:c.
APPARATUS FOR CLINICAL DETECTION OF
MICRO-ORGANISMS IN BLOOD, SPUTUM,
AND URINE.
* It has occurred to me in the course of ordinary work that
ib would be very convenient, especially for those engaged in
hospital practice, to have in a small compass p^nd bandy
form all the materials necessary for the staining of micro¬
organisms in the excretions and in the blood. When the
xeagents are not thus gathered together there is often much
time wasted in finding the particular ones required for a
given investigation. At my suggestion Messrs. Ferris
and Co. of Bristol have devised a small box which
contains, coriveniently arranged, the materials most com¬
monly required. The box is of small size, so as to
be easily carried about. Briefly, it contains the follow-
iug:—Ziehl-Neelsen fluid, with solution of nitric acid
for decolourising, and methylene blue solution for ground
stain (tubercle bacilli); the materials for making the
Weigert-Ebrlich fluid, which requires to be freshly made,
and is one of the most generally useful staining fluids; Gram’s
solution of iodine and iodide of potash for use with the
Weigert-Ebrlich fluid, and a solution of acetic acid
(1-5) for use with the same staining fluid for the ex¬
amination of blood after Gunther’s method ; the methy¬
lene blue is also very useful as a general stain for
micro organisms. The box also contains bottles of dis¬
tilled water, absolute alcohol, and Canada balsam dissolved
in xylol; vesuvin and Bismarck brown in powder to be dis¬
solved in water as required for use ; needles, pipettes, glass
rod, forceps, glass measure of 10cc. capacity; funnel
and filter papers, watch glaases, test tubes, microscopic
slides and cover glasses. There is a spirit lamp and a box
with close-fitting cover, in which the cover glasses can
be left to dry. A support for carrying a watch
glass above the lamp can be pushed out when the
box is open. There is an extra bottle which has been
purposely left empty for the addition of any particular fluid
that the owner may desire in addition to those enumerated
above. 1 think that the box contains everything that is
ovdinarilyTrequired, and will he found a ^eat convenience
for the purposes for which it is intended. The box, fittings,
and bottles are strongly made, and arranged so as to he
portable, and to bear carrying about without injury.
Clifton. J. Michell Clabkb, M.B., M.R.C.P.
%u\l‘aa\ lltm'bs.
yliSCULAP HUNGARIAN NATURAL MINERAL WATER.
(The ./Kscui-ap BirrEii Water Comi’any, Limited, (51, Fakiukodon.
STIIEET. K.C.)
TEsculap enjoys a world wide reputation. This maybe
attributed in a great measure to the constancy which is
exhibited from time to time in its composition. A recent
I analysis carried out in our laboratory practically agrees
I with that made some years since by the Government
I analyst of Buda Peath, in which place the spring has its
I origin. The total solid constituents of one litre dried at
100“ C. weighed 47 grammes. They were found to consist
chiefly of the sulphates of sodium, magnesium, and calcium,
with chloride and carbonate of sodium; while manganese and
iron are present in quantities which may be regarded as
more than mere traces.
COCA WINE.
(Wateus and Son, 33, Ea.stc!ieai>.)
Coca, it is now generally Known, acts when given internally
as a stimulant, t^ic, and restorative. Whatever substance
this action may be due to, chemiets have shown the
existence of two alkaloids in the plant—viz , cocaine and
eegonine, the former body of course being known as a local
aniesthetic. The following are our emalytical notes, which
show the genuineness of the preparation under notice:—
Ether, after being made alkaline with carbonate of soda,
became tinged with green (chlorophyll), and on evaporation
yielded a residue bitter to the taste and producing on the
tongue the local amostbetising efl'ect of cocaine. Treated with
hydrochloric acid characteristic crystals of hydrochlorate
were identified under the microscope. Alcohol 14-45 per¬
cent, by weight, 17-81 per cent, by volume; extractives
1-21 per cent.; mineral matter 0-53 percent. The wine
exhibits a mingled flavour of coca leaves and good port.
PEPTO-PAPAIN POWDJ'IR, LIQUOR, AND TABELL/I?.
(Perkins & Co., 9 a, Piccadilly, W.)
It is stated that the advantage attaching to these pre¬
parations is that, by virtue of the papain contained in them.
#
Digitizeij by
Google
The Lancet,]
ANALYTICAL RECOKDS.
[April 26, 1891. 941
the peptonieing procese not only takes place in the acid juices
of the stomach, but also in the juices of the intestines,
where an alkaline reaction is exhibited. According to our
experiments this statement is not without foundation, as
we had little difficulty in showing that the pepto-papain
rapidly dissolved small sections of hard-boiled egg. Experi¬
ments like these do not always of course represent the pre¬
cise and often complicated action which must really take
place in the human body. Nevertheless, pepto-papain seems
to us likely to rank amongst useful aids to digestion.
PARADOX DIETETIC BISCUITS AND PARADOX DICESTIVE
SALT.
(Walter Thorp and Co., Paiudox Works, Glossop.)
A very slight examination serves to show of what Paradox
Digestive Salt is principally composed. It is saline to the
taste, elfervesces on the addition of acid, and gives a marked
reaction for soluble pl^osphate. As acorrective in excessive
acidity of the stomach this salt may probably be used with
advantage, but we have not gained any decided evidence
which would enable us to regard it as a digestive agent
se. Paradox salt is intended to be used as and in lieu of
table salt, a form of administration which is both simple
and convenient. Paradox biscuits are said to contain meat
fibrine and albumen, as well as extractive, together with a
preparation of malted food, all of which would evidently
contribute towards the amount of nitrogen constituent.
Our analysis shows 1‘90 per cent, nitrogen (equal to 12'02
nitrogenous matter)—an amount little superior to that
contained in good bread. The microscope shows the pre¬
sence of a trifling quantity of meat fibre, and we agree that
the biscuits are rich in bone-forming material, as the ash,
amounting to 1 '70 per cent., consisted largely of phosphate.
MOUNTAIN DEW SCOTCH WHISKY, FINEST OLD.
(Ed. Young & Co., Ltd., Seel-street Distillery, Liverpool.)
Unfortunately the age of a whisky cannot satisfactorily
be determined by chemical analysis; it can only, and then
not with certainty, be indicated. The palate, as is well
known, is the best guide. Mountain Dew whisky is evi-
dently a sound and wholesome spirit, and of satisfactory
alcoholic strength. The results of analysis were as follows :
Alcohol by weight, 42 -48 per cent.; by volume, 50-01 per cent.;
equal to proof spirit, 87-64 per cent.; extractives, 0-14 per
cent.; mineral matter, 0-01 per cent.
■' VIGOROSO" TONIC WINE.
“ Vigoroso” is, we j udge, a light port of excellent character,
possessing a slightly bitter flavour derived from a herb which
is said to give to it tonic properties. Our analysis yielded
the following figures: Alcohol, 16'54 per cent, by weight;
20-33 per cent, by volume; extractives, 7-52 per cent,
(chiefly glucose); mineral constituent, 0-08percent. Chloro¬
form extracted a small quantity of bitter substance.
COD-LIVER OIL EMULSION WITH HYPOPlIOSPIUTlfiS.
(Q. MELLIN, 10, PiCCADII.LY-CIRCUS, W.)
It will suffice to give briefly the results of our examina¬
tion in order to show the excellence of this preparation.
In appearance and consistence it is like cream, the taste
pleasant, with obvious cinnamon flavouring. Reaction to
test paper was perfectly neutral. The microscope showed
an infinite number of- tiny oil globules of uniform size,
resembling closely the condition of fat in milk. The
emulsion permits dilution with water just as does milk,
without undergoing any separation of fat. Alcohol
yielded a coagulura, and the filtrate gave testimony to
the presence of hypophosphite. The residue on evapora¬
tion reduced silver nitrate to black (silver), gold chloride to
blue (gold), and perchloride of mercui-y to white (calomel).
With strong sulphuric acid the emulsion gave a magnificent
purple colour. The more perfect the emulsion, the more
readily is cod-liver oil absorbed. This preparation, there¬
fore, may be held to be of great value in the treatment of
those chronic diseases which are attended by wasting.
THE SUSSEX PATENT BROMOFUME AND lODOFUMB
NIGHT-LIGHTS.
(UeR-I'Z AND COLLINGWOOD, 4, SUSSEX-PLACE, LEADENHALL-
STREET, E.O.)
The steady diffusion of iodine or bromine vapour into the
air has been hitherto a matter of no easy or convenient
accomplishment. It may, however, be done by incorporat¬
ing certain bromo- or iodo-organic compounds with the
paraffin wax of an ordinary candle. Then when
combustion ensues both halogens are steadily given off
in the condition of element. This is the ingenious method
which is adopted by Messrs. Hertz and Collingwood. We
have carefully tested the action of the night lights,
and we find that both are active in evolving iodine or
bromine vapour. On placing a moistened starch paper a
few inches above the “iodofume” candle a blue colour was
almost immediately developed. Starch paper moistened
with iodide gave a similar result when placed over the
“broraofume” light. Of course iodine and bromine, like
chlorine, are well-known antiseptics and deodorants, but
while it is probable that these candles may be useful in the
treatment of throat and cheat affections, and for general
aerial disinfection, in no instance should they be used
without the approval of the medical adviser.
MINERAL WATERS.
(Bangor City Mineral Water Works.)
The water used in the production of these aerated drinks
is evidently of a high standard of purity. We obtained no
evidence of organic matter, or of injurious metals like lead
or copper, which, through careless working, are occasionally
found in artificial mineral waters. The soda water con¬
tained at least the amount of bicarbonate of soda stated on
the label—viz , 15 gr. per pint, our analysis giving 16igr.
The lemonade, though somewhat thin, which some may
prefer, was excellent in flavour. The seltzer water Is
evidently genuine, for both magnesia and sodium chloride
as chief constituents were found, but the manufacturers
would do well to increase the proportion of potass and
lithia carbonates in the respective waters, as examination
showed that the amount of the active ingredients was con¬
siderably less than that prescribed in the Pharmacopceia.
PAPAIN.
(Dr, Finkler and Co. Depot : B. KOhn, 3(1, St. Mary-at-Hill,
London.)
Papain or papayolin is obtained from the juice of the
leaves and fruit of the Cavica papaya (Papaya vulgaris).
This preparation affords very satisfactory results, for experi¬
ments conducted in our laboratory demonstrated how
easily it digested hard-boiled egg either in weak acid,
alkaline, or neutral solution. It is evidently a trust¬
worthy product, and one which may be relied upon for
uniformity of digestive power.
DIABETIC CHAMPAGNE.
(Patented uy Seckiiacii & Co., Frankfort-on-Maine.)
In spite of the fact that this champagne contains practi¬
cally no sugar, the analysis conducted by us gave results
which exhibit in other respects a close approximation to
the composition of ordinary champagne. Alcohol by weight,
10-15 per cent,; by volume, 12-58 per cent.; extractives,
1-90 per cent.; mineral matter, 0-14 per cent. The flavour,
which there seems no reason to doubt is derived from the
grape, is good, though somewhat sharp. This champagne
is offered as a drink that may be useful in cases of diabetes
on account of its freedom from sugar.
11 3
Dir:' -edbyCjOO^IC
942 This Lancet,] THE REWARDS AND RESPONSIBILITIES OF MEDICAL PRACTICE. [Apkil 26, 1891.
THE LANCET.
LONDON; SATUBDAY, APRIL S5, 1891.
There will soon be no excuse for persons rushing
into the niedical profession under any delusions in regard
to its merits as a calling. That it has great attractions
to certain classes of minds is undeniable, and many a
man will be found toiling in it with little worldly advan¬
tage, w'ho >vill frankly avow his satisfaction and declare
that had he his life to begin again he would study medicine.
But it is well for all persons to understand what to expect
in it, and what is not to be looked for. An article of much
interest and aiming at giving a fair representation of the
rewards and responsibilities of medical practice will be
found in the April number of the Quarterly Review. It
is obviously written by one who is himself a medical man,
and not the least interesting parts of it are those in which
the writer gives an account of his own case and experience
as a practitioner. We shall give briefly a rtsvmt of his
principal points, and such comments on them as occur to us.
His article is based on Mr. Sidney Young’s recent work
on the Annals of the Barber Surgeons of London, from which
he culls various extracts. These are of great interest, but
they must not detain us from the chief feature of the
article—its account of the rewards and responsibilities of
the practice of medicine as at present seen. He deals first
rather with the responsibilities, about which there can be
no doubt. Many of our brethren will be able to say,
“Well, I have seen plenty of the responsibilities of the
profession, but as to its rewards I cannot speak so freely.”
The author highly approves of the lengthening of the
period of study to five years, and advocates the raising
of the age at which a qualification can be obtained
to twenty-two. Touching the complaint that there is no
court of honour, no court of appeal to adjudicate on dis¬
putes and questions of behaviour, he does not think that
such a court, even possessing legal status and authority,
would have much advantage. We are not so sure of that.
Whenever the corporations or the General Medical Council
do exercise their authority it has a decided influence; and
if itwere asserted a little more frequently and strongly there
is reason to believe that the occasions for its exercise would
become more infrequent. Many a young man drifts into
unprofessional ways from the want of a kindly word of
warning and remonstrance from his college or university.
Such a word might be fitly spoken much more frequently
than it is, and would have much more weight than the
remonstrances of mere neighbours, who might be credited
with jealoirsy and other unworthy motives. If our pro-
fession is to maintain its high reputation, these powers
will have to be exercised. Yet it is notorious that the
universities scarcely possess them, and that some of the
corporations are either without them or afraid to use them.
The public has an enormous interest in the morale and
honour of the medical profession being held high. Such
powers as medicine confers should involve suj^jection to
certain constituted authorities, and the competitions and
complications of professional life only make it more neces¬
sary that such authorities should both exist and act. In
any really serious attempt to place our medical institutions
on a strong and satisfactory basis, their disciplinary powers
should be strengthened and provision should be made for
cases in which the bodies are reluctant to use these powers.
Many professional scandals would be averted or remedied
in this way.
The author’s account of the sources from which the pro¬
fession is recruited and of the earnings of the profession
will be read with interest. He thinks the middle class that
which mainly supplies the ranks of the medical profession.
He makes much of the fact that while ^he other professions—
the Army, the Church, the Bat—are confessedly not to be
relied on as sources of income, the medical profession is
thought to be a calling which will insure a good income in
any part of the kingdom. He adduces many facts to
greatly qualify this estimate. Reverting to the calcula¬
tions of Dr. Paget Thurstan three years since, based on
the average value of 175 practices advertised for sale in
The Lancet, which gave £625 as the gross annual value
of those practices, he argues that this should be reduced in
various ways to a net value of £355, and that by including
members of the profession who have no saleable or actual
or independent practice, which he placesat almost half
the profession—such as assistants and ship-surgeons,—we
should arrive at an average of £200 a year; and that
even this, apart from purchase, will not in ordinary
circumstances be reached in a dozen years. He descants
on the enormous amount of gratuitous work done by
young consultants, and the miserable pay for attendance
on the poor and the working classes. Many graduates
of Oxford and Cambridge are obliged to do club and
parish work. The members of the profession increase
apace, from the double fact of the diminishing mortality
of the profession and the increased numbers of those entering
it. Moreover, the expenses of practice, even where the
income is large, as in the high-class general practice
of great tou’ns, eat up the income and even more. Not
only are the emoluments of practice slight, but its burdens
and anxieties are great. The rivalries, the scientific diffi¬
culties, the ever recurring demands on time by day and
night, making holidays impossible and even ordinary
social engagements almost impracticable, make the pro¬
fession different from, and more arduous than, every
other. After all this lamentation the author depicts, or
rather quotes Canon Liddon to depict for him, the singular
authority, nobleness, and glory of the calling of medicine
when practised by men of culture and in the spirit of
Christianity. It cannot be denied that it is discreditable
to the public, and even to the working classes, that men
whose preliminary and professional education is bound now
to extend over eight or ten years are so lightly regarded
and so inadequately remunerated. The sweating system
is being applied by some of the great Friendly Societies
in combination to medical attendance in a way of which
individually they would be ashamed. One of our corre¬
spondents lately said that druggists have told him that
they would not give the mere drugs to club and parish
Digitized by
Google
Thb Lancet,]
THE VALUE OF TUBERCULIN IN THERAPEUTICS.
[April 25, 1891. 9 43
patients for the sum that medical men usually get for
both medical attendance and medicines combined. This is
a most signihcant statement, and may well cause guardians
and the advocates of cheap medical associations to reAect.
Such low terms are inconsistent with justice either to
patients or practitioners. They tend to lower the medical
profession and its morale, on which far more depends than
is dreamt of in the philosophy of economists who think
themselves shrewd in rewarding intellect with what will
not even satisfy labour. The author of the article seems
to think that the medical profession does not have the
same place in society as the other professions. If this
be so, so much the worse for that which is pleased to call
itself society. There are social and even political dis¬
advantages, but the profession may well stand on its own
dignity; and it is certain that if its members walk in the
lines of its own high traditions and pursue their own science
and art for their own sake, society will be ready, as all
judges of men have been, to see in medical men material
for the very best company.
We recently had occasion to notice the experiences of lead¬
ing physicians and surgeons in Germany with regard to the
employment of Koch’s tuberculin as a remedy for tubercular
disease. Few of the trials recorded in those official reports
extended beyond the close of last year, when the nature of
the remedy was still unknown, and when, too, it had hardly
passed out of the phase of indiscriminate eulogy and sanguine
anticipation with which it was first received. We are now
in a position to appraise its value more correctly, thanks
to the proceedings of the German Congress at Wiesbaden
(recorded in another column) and to the statement of his
observations before the Medical Society last Monday by
Dr. Heron, as well as to the debate on Dr. Bristowe’s
paper last week at a district meeting of the Metropolitan
Counties Branch of the British Medical Association, In
dealing with the subject it would be well if we could all
follow the advice of Professor Curschmann to the
Wiesbaden Congress, to view impartially and calmly a
remedy that seems to be sharing the fate of many a vaunted
cure, and rapidly passing from a stage of violent and enthu¬
siastic adoption into one of total neglect, and even denial
of the least that has been claimed for it. It ought to be
possible to treat it dispassionately now that the glamour
has passed away and left us with clearer vision.
In closing a fairly exhaustive review of the abundant
literature that has appeared on the subject of tuberculin.
Dr. L. Gallard^ arrives at the conclusion that it is of no
use either as an aid to diagnosis or in therapeutics, and that
it should foi-thwith return from the pharmacist’s shop to the
laboratory whence it had too prematurely escaped. This is
the real question at issue. Has the experience of its
trial been such as to justify its continuance, or has
it been so discredited thereby that it can no longer
be held worthy of a place among our medicaments ?
We have no hesitation in ranging ourselves with those
who still contend that it can occupy a place hitherto
unfilled in therapeutics; but we equally believe that a
great part of the discredit now attaching to tuberculin is
J Revue (Ion Scieueos MuUiciilus, xxxviii., '2, Api'll, iai)l,
due to the exaggerated estimate formed of its capabilities.
Dr. Heron was careful to remind his hearers of the precise
conditions formulated by Koch as essential to its curative
effect. We venture to say that those conditions have seldom
been fulfilled in the treatment of cases of pulmonary
phthisis, of which now we only propose to speak. Even
Dr. Heron himself has treated cases of marked infiltration
of the lung and of excavation with this method, but he
justly remarked that few hospital patients are seen in the
earliest stages of the disease. Throughout it has seemed
to be futile to expect any notable effect in a curative
direction from a remedy that can obviously only be
efficacious (on the experiments which led to its intro¬
duction) in those earlier stages of the disease which
are almost beyond the reach of physical diagnosis. No
unequivocal cure has been reported in cases of more
advanced tuberculosis. A certain proportion, it is true,
have much improved in health, but we seek in vain for
convincing evidence of amelioration in local signs, whilst
no small number have pursued the steady downward course
so common to the disease. Dr. Theodore Acland’s
reminder of the well-kno>vn fact that under improved sur¬
roundings many a phthisical patient gains in health—at least
for a time—should hardly have been necessary if a less ex¬
alted notion of the powers of tuberculin to influence morbid
processes had been borne in mind. In spite of this, however,
the fact remains, clear and unmistakable, that in this sub¬
stance Koch has produced an agent that can so hasten the
necrotisation of tubercle as to justify its use in cases where
the deposit is limited and recent.’’ Such a limitation of its
employment may to some seem tantamount to its entire
abandonment; but surely, if sufficient attention be paid to
incipient phthisis, cases might frequently be selected for its
trial.
It is somewhat remarkable that the most damaging
criticism upon the use of tuberculin as a -remedy—that,
namely, which was made on the authority of Professor
Virchow— should have been passed over in silence by Dr.
Heron. It was one of the strongest arguments employed
by Dr. Bristowe in the previous week in his plea against
the use of tuberculin; it forms the main ground for its
rejection advanced by Dr. Gallard. It is, of course, most
difficult to prove that an exacerbation of the disease,
or the supervention of pneumonia or of miliary tuber¬
culosis, occurring in the course of any case of phthisis,
is due to the treatment employed. That tuberculin, which
exerts so powerful a disintegrating effect upon tubercle,
might well be accused of producing such accidents is reason¬
able. Still, apart from the effects of this or any other
remedy, such occun'ences form some of the ordinary modes
of termination of the disease. Dr. Heron’s contribution
was very largely occupied with the effects of the injections
as clinically noted, and all praise is due to him and his able
assistants for the painstaking records they have compiled.
The interpretation of these efi'ects is left open, so that it
may be quite possible to claim for some of them an indica¬
tion in favour of Virchow’s contention. At Wiesbaden
2 The view that its properties tire simply those ol a septic poison was
forcibly argued by Drs. Rristowe and H. Mackenzie, but it lacks
the evidence derived from observation of the action of known .septic
agents upon tulrerclc aiui allied diseases.
Digitized by
Google
944 The LahobtJ
SANATORIA IN THE DESERT.
[April 25, 1891.
this p&rb of the subject was clearly enunciated by Professor
ZiEOLBR, who admits that the special action of tuberculin
involves the risks necrasarily attendant upon rapid softening
of a tubercular focus without destruction of its contained
bacilli.
We do nob propose here to enter minutely into all the points
raised in the consideration of this subject, but we cannot
fail to note marked discrepancies in the results obtained by
various observers. Especially we would remark on the
favourable opinion expressed by Dr. Moritz Schmidt of
its effect in laryngeal tuberculosis, as contrasted with the
experience of Dr. Heron. Its value in lupus was clearly
shown by Dr. Crocker to be subsidiary or rather comple-
mental to other methods of dealing with this disease. Pro¬
fessor Heubner, at Wiesbaden, pointed out that it had
hardly any action upon tuberculous glands, and that thus
its application in childhood was much restricted. Oppor¬
tunity will be afforded next week for a fuller discussion of
its effects in surgical affections,-after the reading of Mr.
Watson Cheyne’s paper at the Royal Medical and
Chirurgical Society, which comes opportunely to supple¬
ment the views of German surgeons at the Surgical Con¬
gress lately held in Berlin under the presidency of Professor
V. Bergmann.
In an admirable report to the Government of Victoria,
summarising his personal experiences of the use of tuber¬
culin in Germany and England, Professor H. B. Allen
makes some just observations as to the spirit in which the
new remedy should be approached. He goes on to say
that It may prove to be a great addition to the resources
of the medical practitioner, but it does not supplant in any
degree the teachings of old experience. Every remedy that
was useful before will be useful still.” We may now
trust that it will take its rightful place, not being wholly
discarded, bub being employed with most careful discrimina¬
tion, and certainly with less extravagant hope of attaining
the unattainable than has hitherto marked its adoption.
Our columns have recently contained some very interest¬
ing communications regarding certain sanatoria in Southern
Algeria, upon the edge of the Great Sahara. Of these
Biskra is the best known, and, in spite of many and grave
drawbacks, is probably also the best adapted to the needs
of the invalid or holiday traveller. Biskra is connected
with Algiers by rail, and is reached by the East Algerian
(Algiers and Constantine) Railway, vid El Guerrah. Erom
Algiers to El Guerrah is a distance of 2651: miles, and 125^
miles intervene between El Guerrah and Biskra. Unfor¬
tunately, travelling on the Algerian railways is extremely
slow. The run from Algiers to El Guerrah occupies about
sixteen hours, aud from El Guerrah to Biskra seven hours,
unless some acceleration has very recently been achieved.
Nor can much be said for the comfort of travel, or for the
conveniences to be found en route, which are about on a par
with the speed. But we may safely reckon on some early
improvement in these matters. The English-speaking
races, who in so many parts of the world constitute decidedly
the most influential section of the travelling public, will
sooner or later succeed in insisting upon reasonable comfort
and decency in any resort which they frequent either for
health or pleasure, and they are the more likely soon to
obtain their desires, inasmuch as they are both able and
willing to pay.
A holiday contributor in The Lancet of April llbh,
though almost bluntly candid regarding the drawbacks
of these desert sanatoria, draws a seductive picture of
the attractions of Biskra. “Its stillness, its estrange¬
ment from the fever and the fret of the populous
European centres, its pure exhilarating atmosphere, its
varied inducements to open • air life, are all in the
invalid’s favour, while its natural and historical interest is
sufficient to keep the intellect in gentle activity.” As
regards climate, for six months in the year Biskra is
all that can be desired. Its mean temperature on an
average of ten years is 73® F., rain seldom or never falls,
and the only objectionable feature is the occasional pre¬
valence of high winds more or less charged with sand.
Everyone familiar with Egypt will recognise a description
which would apply without essential alteration to portions of
the Nile Valley. While climatically analogous, Egypt and
Biskra differ in other important points. Egypt is one of the
oldest sites of primeeval civilisation, and has been, and still
is, one of the great marts and highways of commerce of the
world; Biskra is a solitary outpost on the edge of the Great
Sahara, with its vast expanse of silent sand, broken only
here and there by an oasis, or intersected by a camel track.
The water-supply of Biskra is, we are informed, ample even
in the driest seasons, thanks to the boring of artesian wells
by the French, and the vegetation of the oasis is abundant
and varied. Another resource of Biskra is its sulphur
baths, of a temperature of 112° F., which were known to the
Romans, who possibly on this account made Biskra one of
the outposts of the Third Legion. Northern Africa is some¬
what rich in hot mineral springs. The baths of Hamman
RTrha, close to Bon Medfa, a station on the Algiers aud
Oran Railway, fifty-six miles and a half from the former
town, are well known in this country. They possess hot
sulphur waters, and the climate is excellent in spring, bub
somewhat cold in winter, owing to the considerable eleva¬
tion. Our correspondent draws attention to another and
less known sulphur bath, Hamman Meskoutine, on the lino
of railway between Constantine and BOne. This bath, the
“ Aquee Tihilitin® ” of the Romans, has a temperature of
203° F., and contains sulphur and large quantities of car¬
bonate of lime. Unfortunately here also a bad railway
service and inadequate hotel accommodation are serious
deteiTenbs to intending visitors.
Time was when it seemed a “ far cry ” to the Sahara,
but that time is no longer. The globe-trotter and the
sportsman who go everywhere, and the invalid who receives
without demur marching orders for Colorado or Tasmania,
will think little of a few days run to Southern Algeria.
There can be no doubt that these desert sanatoria have
some decided advantages over their European rivals. As
our correspondent points out, they are “ sun-baths in the
severest winter, when the French and Italian Riviera and
the Mediterranean islands are but a shade less trying to
the victim to weak heart or impaired lung than the
sheltered spots on our south and west coasts.” In fact, as
travelling invalids are fond of saying, they pay for sun¬
shine, and whereas on the northern shore of the Mediter*
Digitized by
Google
The Lancet,]
THE NAIL AND CHAIN MAKERS’ DEPUTATION.
[April 26,1891. 945
ranean auDshine in winter ia only a probability, on the
Boutbem shore it is a certainty. The *'islets in the great
sand sea ” have a winter climate which is practically in¬
variable, and of which the chief characteristics are sun-
ahine, warmth, and rainlesaness.
There remains for consideration the important question
regarding the classes of persona for whom the desert sanatoria
are most adapted. With the case of the globe-trotter and
sportsman we have little concern. , The victim of over¬
strain, especially of commercial or professional life, and the
neurasthenic invalid, constitute one of the classes surest to
benefit by these resorts. The profound calm and restfulness
of the desert, the absence of the customary excitements and
distractions of civilisation, the open-air life, and the
stimulation of the constant sunshine, are points of great
importance. In some of these particulars th e life in the
desert is comparable to life on shipboard, very different as
are these two modes of existence in other respects.
Anmmia, general debility, “ weak heart,” some forms of
rheumatism, and incipient cases of Bright’s disease and of
phthisis will often be benefited by the air of the desert. On
the other hand, marked hysteria or great nervous irritability
is a contraindication, the general effect of the climate being
on the whole stimulating. Hepatic disease, very grave
dyspepsia, and ophthalmia are likely to be aggravated
rather than benefited by the climatic conditions of the
desert. It is hardly necessary to point out that, while
early and uncomplicated phthisis will often do very well in
Southern Algeria or Upper Egypt, the discomforts of trav el,
the nature of the hotel accommodation, and the absence of
efficient medical care, are peremptory reasons for declining
to send thither cases of active and progr^sive disease.
A DEPUTATION of women employed in the nail and chain
making trade, for which Cradley Heath and the Black
Country have acquired an unenviable reputation, waited
upon the Home Secretary last week. The object of the
deputation was evidently to prevent any check being placed
on the work of women who, at the sacrifice of their own
health and that of their offspring, labour at a price
which no man would accept. A few stalwart women
were selected and brought up to impress Mr. Matthews
with the healthiness of the trade in which they are engaged.
But we have no very precise details given us as to the nature
and duration of the work these women perform, as to the
number of children that have been born to them during the
time they have worked at the trade, as to whether the
aocouchements were satisfactory and normal, and as to
how many of these children are now in the enjoyment of
good health. Also, we should be curious to know who
paid the expenses of this deputation to town. Was the
cost defrayed by persona defending the interests of
labour and of public health, or by those who act with
those votaries of the “dismal science” who so believe
in the virtues of laisscr fairo and laisscr passer that
not only would they refuse to sanction such legislation
as might prevent starvation, hut who think we should also,
rather than interfere with what they call the liberty of the
subject, give free passage to death and disease ? The argu¬
ments generally adduced arc that women should enjoy
equal liberty with men to earn their living. This principle
we also are willing to accept, but we see in this no reason
for falling from one extreme to the other. At one
time it was thought that women should do absolutely
nothing but remain at home and attend to their domestic
duties. Now it is recognised that, in many instances, women
are justified in entering the labour market and seeking to
earn their living. This, however, no longer seems to satisfy
some advocates of women’s rights. They want women to
be even more free than men. There are any number of
laws to restrict and regulate the work of men when such
work is found to be injurious to the workers themselves
or to their neighbours. Yet when a law, based on the
same principle, ia proposed so as to protect the health of
women workers, a great outcry is raised. We are told that
women are unfairly dealt with, that men in their selfishness
are driving them out of the market, that there should be
equal laws for both sexes, &c.
With regard to the nail and chain makers, we maintain
that the work is physically nnsuited to women 5 that the
work should be checked because, economically, it is pro¬
ductive of starvation. Men would, and do, earn better wages
when engaged in the heavier work which is now destroying
the health of so many women. But more especially it
should be checked because of its physical effect on the
women. Women have to spring on the treadle of the
Oliver hammer, throwing the whole weight of their body on
the one leg and foot, and this many hundred times every day.
They have to carry very heavy weights on their heads and
shoulders, with the result that spinal disorders occasionally
ensue. Medical evidence clearly establishes that accouche-
meuts are difficult, false presentations very common, and that
instruments have to be used more frequently with the chain
and nail makers than with other workwomen. The death-
rate of children under five years is appallingly high through¬
out the district.
These facts cannot be refuted because a few healthy-
looking women have been brought up from the nail and chain
making district to interview the Home Secretary. One of
our Commissioners, when investigating tlie matter at Cradley
Heath, came across a very hesilthy-looking chain maker;
but, on questioning her, found that for one or two days a
week she worked as a charwoman, and for this compara¬
tively light occupation she received much higher pay. This
woman was therefore able to live in greater comfort,
and had thus so far preserved her health. The special
reports we issued on the chain and nail makers of Cradley
Heath and neighbourhood have never been seriously con¬
troverted. These were published on the 9th and 16th of
March, 1889, and one of our Special Sanitary Commissionei-s
gave evidence on the subject before the House of Lords' Com¬
mittee on Sweating on March 22nd of the same year. In
the Worcester portion of the sanitaiy district, which includes
Cradley, there were thirty-eight deaths of infants under one
year old out of 100 deaths in 1887, instead of 14‘6, the pro¬
portion throughout all England. In the Cradley Heath
district the mortality of children under five years was
about double that of England as a whole. These fatal
consequences must result, in a great measure, from the
nature of the work performed by the mothers of these
children. Instead of the few healthy women, many of them
Digitized by
Google
946 Thb Lanobt,! THE RECONSTITUTION OF THE UNIVERSITY OF LONDON.
[April 26, 1891.
belonging to a previous and more prosperous geneiu-
tion, who were presented to Mr. Matthews, we
could bring together a crowd of wretched, half-starved,
stunted, chicken- or fiat-breasted women, with angular,
sinewy limbs and colourless cheeks, that would certainly
shock by their appearance the humane susceptibilities of the
Home Secretary. The district which Mr. Ruskin described
as the most dipmal and dreary in the civilised world has
nob earned its evil repute undeservedly. The degradation,
especially of the women workers, is a disgrace to our modern
civilisation and a danger to the coming generations.
^nrarfstmiw.
” Ne quid niinls."
THE RECONSTITUTION OF THE UNIVERSITY
OF LONDON.
More than 700 graduates have sent in their names in
opposition to the “latest revised scheme” of the Senate
for the reconstitution of the University, and a second
list is being formed, so that it is evident that the lines upon
which this last scheme is drawn are far from meetingwith the
approval of the general body of the graduates, whilst among
the opponents are several teachers in the metropolitan
medical schools, as well as many of the most infiuential of
the Don-olficial members of the University. University
and King’s Colleges have definitely decided by their
Councils to oppose the scheme, and will at once send in their
objections to the Lord President of the Privy Council. The
Birmingham and Sheffield Colleges also officially refuse to
accept conditions under which they would be admitted to
the scheme, and their objections will be supported by other
provincial colleges. The Fellows and Members of the Royal
College of Surgeons will meet on Monday, May Uth, to
discuss the scheme. As the meeting of Convocation w'ill
take place on the following afternoon, It would seem that
the Council has selected a date when these deliberations
can have but little importance and no official bearing on
this most important question. The opinion of the body
corporate of Fellows and Members cannot then possibly alter
or affect the action of the Council of the College, or have
its due effect on the decision of the University.
THE FIVE YEARS’ CURRICULUM.
The difficulties which will occur to everyone as to the
best means of utilising the extended period of education
of the medical student are strikingly shown in the report
of the Committee of Management of the Examining Board
in England which has just been issued, and which will
come on for discussion at the next meetings of the
respective authorities of the two colleges. The committee
are generally agreed on the subjects of the curriculum,
but differ as to the number of examinations which should
be held during the five years of study. The six members
have three different views as to this point, and so three
schemes will be submitted to the two colleges for their
decision. Under the first scheme, recommended by the
medical representatives of the Committee of Management,
there would be three examinations, as at present: the first,
after six months’ attendance at a medical school, would
embrace chemistry and physics, pharmacy, elementary
human anatomy and elementary biology; the second, at the
expiration of the second winter session, would ijiclude
anatomy and physiology; the final, after the expiration of
three winter and three summer sessions from the date of
the candidate passing the second examination, would deal
with medicine, surgery, and midwifery. During this
last period the student must have received clinical
instruction in fevers and small-pox. This scheme practi¬
cally alters but very little the present arrangement, except
that elementary biology is added to the first examination,
that courses of lectures on public health and therapeutics
must also be attended, and that a special paper on
forensic medicine, public health, and general therapeutics
forms part of the examination. The second scheme, pre¬
sented by two of the surgical representatives, is similar
so far as the first and second examinations are con¬
cerned, but the third examination is to be passed at
the expiration of two years from the date of passing the
second examination, and consists of medicine, surgery,
and midwifery, as at present; but the latter subject
may be taken at the fourth examination if the candidate
elect to do BO. Under this scheme the final year is to be
devoted simply to an extra year’s attendance at a hospital
(to include attendance at a fever hospital), and a fourth or
final examination in clinical medicine and surgery must then
be passed. In the third scheme drawn up by the remaining
surgical members of the committee the student is required to
pass a series of annual examinations, the first in chemistry
and physics, elementary human anatomy, and elementary
biology; the second in anatomy, physiology, and elementary
' pathological anatomy; the third in anatomy, including
histology, physiology, pathological anatomy, pharmacy,
and elementary knowledge of drugs; the fourth in the
principles of medicine and surgery and in pathology;
whilst the fifth or final embraces the practice of medi¬
cine, the practice of surgery, the practice of mid¬
wifery and diseases of women, and the elements of
forensic medicine and of public health. Doubtless there
will be many differences of opinion as to the relative value
of the schemes, but at present we would only point out that
they all agree in introducing into the curriculum the sub¬
ject of elementary biology; that ophthalmology, diseases of
children, and mental diseases are unmentioned; that there
is no provision made for spending the fifth year with a prac¬
titioner as a pupil, but the extra year practically becomes
merely an additional year of ordinary hospital study and
hospital work, except that a certain unspecified time is to
be given to fevers. We question if these arrangements are
such as were anticipated by the General Medical Council
when they passed the resolution insisting on this fifth year
of medical education. _
THE SANITARY STATE OF ST. BARTHOLOMEW’S
HOSPITAL.
In reference to the allegations that diphtheria and other
diseases at St. Bartholomew’s Hospital have been due to
defective sanitary circumstances connected principally with
the main drains of the institution, an important statement,
signed by the whole of the medical and surgical staff, lias
now been issued. In it the staff assure the governors that
the statements which have been made are not justified by
any existing evidence, and they base this declaration both
on the experience of their daily visits to the wards, and,
especially, on the absence of those unfavourable results
after surgical operations which are known to ensue on such
conditions as have been alleged to exist. As regards
diphtheria, it is opposed to all onr knowledge of this
disease that it should be limited to a single class of such a
large community as that of St. Bartholomew’s Hospital,
unless it could be shown that that one class was more than
another exposed to some one special cause. The drainage
conditions are common to a community of about one thou¬
sand persons, including patients, and are in no way special
to one class; the diphtheria was almost exclusively limited
to the nursing and ward staff who had actually been
D:, zed ' . fOO^IC
Thb Lanobt,]
RESPIRATION AND THE CARDIAC IMPULSE.
[April 26, 1891. 947
exposed to infection whilst on duty in the diphtheria ward,
or elsewhere attending on diphtheria patients. It was
doubtless this exposure to infection that gave rise to the
disease in the nursing staff, and it calls for some reorganisa¬
tion of the nursing staff in respect of attendance on
infectious cases; but there is surely no warrant for making
use of such an occurrence in order generally to condemn
the sanitary arrangements of the hospital. The statement
issued on the authority of the medical and surgical staff
cannot fail to give confidence as to the general health of
the hospital, the more so as it is understood to be the
outcome of a lengthened and very detailed inquiry into the
circumstances of each case of disease that has supervened
in either nurse or patient. At the meeting of the Commis¬
sioners of Sewers on the aist insb.. Dr. Sedgwick Saunders,
the medical oflicer of health, made a statement on the
subject. He said that at the last meeting of the sanitary
committee he laid before them the plans relating to the
sanitary arrangements of the hospital, and pointed out the
existence of certain structural defects. He intimated,
however, that in his judgment there was nothing to show
that to these defects were to be attributed any attacks of
disease which had appeared in the institution. After some
discussion, the matter was referred back to the sanitary
committee for further consideration.
THE QUEEN’S VISIT TO GRASSE.
Hkr Majesty’s stay at Grasse is now drawing to a close,
and, if certain rumours which reach us from a source on which
we have good grounds to place reliance are true, the country
will have additional cause to rejoice that Her Majesty
returns to England in excellent health. As has been
announced, Miss Reynolds, one of the Queen’s attendants,
recently died at Grasse from blood-poisoning following a
alight injury to her hand. We now learn that there have
also been a comparatively large number of cases of such
illness as is generally traceable to insanitary surroundings.
Moreover, we understand that small-pox has been prevalent
about Grasse, and was so at the time of the Queen’s
arrival there. Doubtless Her Majesty’s advisers take
measures of precaution when she visits foreign places,
but we would point out that where a life of paramount
importance to our country is concerned it is absolutely
imperative that the most eminent experts in sanitary
science should be called in to testify to the hygienic con¬
dition of any town or locality proposed to be made the
temporary abiding place of our Sovereign. The Queen her¬
self, we have reason to believe, has enjoyed capital health
during her sojourn at Grasse, but this is far from having
been the case with regard to her entourage.
RESPIRATION AND THE CARDIAC IMPULSE.
It is a well known fact, which is stated in all text-books,
that the cardiac impulse changes its position with expira¬
tion and inspiration. By most authors this is considered to
be due to the movement of the diaphragm. Eichhorst says,
in his text-book of clinical examination, that if by any
means the movement of the diaphragm is paralysed, the
changes in position of the heart’s apex no longer occur.
Riegel and Tuczek observed some cases in which during
inspiration the apex beat became stronger and more per¬
ceptible, whilst the reverse took place with expiration.
After death adhesions were found between the pleura and
pericardium. Eichhorst has also recorded a case in which
the same symptoms were noticed when a diffused bronchial
catarrh was present, being especially severe in the anterior
and lower part of the left lung. In accordance with the theory
generally accepted, these phenomena are difficult to explain,
but Dr. P. E. Livierato^ brings forward some observations
which seem to show that the explanation of the variations in
the position of the cardiac impulse with respiration is not,
after all, the correct one. After describing the apparatus
employed in his investigations, he gives the following con*
elusions at which he has arrived: (1) The heart may
undergo, under normal circumstances, considerable changes
in its position, which are due to extraordinary movements
of the lungs in respiration; (2) in ordinary respiration
these changes are not appreciable; (3) the alterations in
position of the heart are brought about chiefly by the in¬
crease in size of the lungs with inspiration, especially the
left; (4) the influence of the diaphragm is only secondary;
(5) the same changes of position of the heart can be pro¬
duced in the dead body by artificial respiration when the
diaphragm has no action ; (6) in forced inspiration the heart
moves to the right, downwards, and forwards; (7) the
greatest changes are noticed when the subject is in a sitting
position ; (8) the movement of the heart to the right is more
marked when the expansion of the right lung is prevented
by some pathological condition ; (9) the movement towards
the right is always the one most easily observed, next the
downward, the anterior movement being the least; (10)
Dr. Livierato claims that such cases as were quoted above—
namely, those of Riegel, Tuczek, and Eichhorst, add addi¬
tional support to his theory ; for in these cases the forward
movement becomes very marked, since, owing either to the
pleuro-pericardial adhesions or to the infiltration of the lower
part of the lung, when a deep inspiration is taken the lung
tends to push the heart apex more to the front, and con¬
sequently accentuate the anterior movement. It is to be
concluded from this that this phenomenon is not diagnostic
of pleuro-pericardial adhesions as Riegel and Tuczek
maintained.
CLINICAL STUDY OF INFECTIOUS DISEASES
AT GLASGOW.
Wb have often bad to report with satisfaction on the
organisation of clinical teaching in infectious diseases in
Glasgow. The work continues. It is still done by Dr. Allan,
the physician superintendent of the Belvldere Hospital, but
it is now carried on by him under the immediate authority
of the police commissioners of the city of Glasgow, who have
taken the matter mto tlieir own control. From May, 1890,
to March, 1891, the actual number of students was 146.
Ten of these took a second course, making the number of
tickets issued 156. About two-thirds took the courses in
the summer term. The maximum number that can be
undertaken in a year is 150, so that the limit has been
practically reached, and students had to be refused from
time to time. Dr. Allan reports that, so far as is
known to him, none of the students have contracted any
infectious disease. He acknowledges the valuable assist¬
ance of Drs. Carslaw and Roxburgh. It would be dilficult
to exaggerate the value of such a course of instruction to
the students who are wise enough to take it.
BROMIDES IN EPILEPSY.
Dr. SiiuuiN, of New York, in his interesting lectures on
the treatment of neuroses, directs attention to several
points of importance in connexion with the administration
of the bromides in epilepsy. Patients, he says, vary much
in their susceptibility to the drug, so that a dose of tliirty
grains will produce a marked degree of broniism in some,
while no such effect is observable in other patients.
Children bear a much larger relative dose than adults, and
as a general rule there is in adults a certain proportion
between the size and weight and the susceptibility to the
J Coiitjulblatt fiir KJiiiiseho Meiikm, 18U1, No. U.
Digitized by
Google
948 The LanobtJ
THE ROYAL BRITISH NURSES’ ASSOCIATION.
[April 26, 1891.
drag. He is of opinion that organic cerebral disease and
also cardiac disease increase the susceptibility to bromides,
and he points out the fallacy of regarding the occur¬
rence of acne as in any way indicative with regard
to dosage. Dr. Seguin is in favour of a standard
solution of the drug in the methodical treatment of
epileptics for the sake of convenience, and he regards its
large dilution with water as of great importance, both on
account of its being thus more easily absorbed, and as
tending to produce less gastric disturbance if administered in
this way. It is also less unpleasant to take than if combined
with syrups or other flavouring agents. Simple water, or
better, a slightly alkaline water, may be used, and the
administration ought to be regulated so as to render the
taking of the drug unnecessary as far as possible during
working hours, while the best effect will probably be
obtained by giving a large dose four to six hours before the
time at which the attacks are likely to occur. Of course
regularity in the administration from day to day is insisted
upon, but this, unfortunately, except in epileptics under
observation in hospital, is very dfficnit to cany out. It is
too much the fashion bo prescribe bromide in a rough-and-
ready fashion for epilepsy, and Dr. Seguin, from his large
experience, can speak with authority as to the importance
of those apparently minor details.
INCREASING ALCOHOLISM IN FRANCE.
We have repeatedly alluded to the increasing consumption
of alcohol in France. Our contemporary, the Globe, says
the consumption per head has steadily increased since 1830,
when it was one litre per annum, to four litres, which is the
present rate of consumption. Normandy is by far the worst
in this respect. In the region around and west of Paris the
consumption amounts to six litres per head per year. In
Gers and Savoy, on the other hand, it is less than one
litre. Our contemporary says the consumption is greatest
in the educated, or at least the industrial, centres.
THE ROYAL BRITISH NURSES’ ASSOCIATION.
The special meeting of this Association, of which a
report appears in another part of our impression, was held
under distinguished auspices, and pervaded by a sanguine
confidence amply justified by the circumstances of the
gathering and of happy augury for the future of the
Society. The supporters of the Society had legitimate
ground of congratulation upon the excessive zeal that has
precipitated their assailants, as we pointed out a few weeks
ago, into an attack which is wholly premature and largely
mistaken. The advertisement which appears to-day (p. 63)
invites “ any person, company, or corporation ” objecting
to the application which is being made on behalf of
the Association to the Board of Trade to address the
assistant secretary of the railway department upon the
subject. The application iteelf is merely for leave to
omit from the title of the Association the inapt word
“limited,” and on this issue the only considerations which
the board can take into account are such as go to show
whether the revenues of the Society are to be turned'to
profit for its members or exclusively employed in the pro¬
motion of some useful object. If we rightly understand the
terms in which its objects are set out, it is bo this latter
class that they must be referred, and no doubt can exist in
any mind that the intention of the promoters is to foster
not private gain, but public advantage and charitable relief.
If this is made clear upon the application now pendiog, the
assent of the Board of Trade to the promoters’ request cannot
be withheld, and critics who propose to enlighten the
assistant secretary as to their private views upon col¬
lateral matters, such, for example, as the utility of
the new Register, would do well to spare their pains
and save their objections for another tribunal. It Is
transparently clear that the opposition which has been
organised at the present moment is not directed to those
financial considerations which alone are material to the
discussion of the question whether the Association shall be
entitled “limited” or not. Bub the supporters of the
movement were well advised, we think, to go beyond
the limits of strictly relevant argument, and meet the
criticisms which have been levelled at their scheme with
such very satisfactory answers, based on the merits of
their case, as found expression in the speeches of Sir James
Crichton Browne and his colleagues on the platform at the
British Nurses’ Association meeting.
THE PANCREATIC JUICE IN THE HUMAN
SUBJECT.
No exact analysis of the pancreatic juice in the healthy
human subject having been published, advantage has been
taken by Dr. Zavadski of a case recently operated on in
Warsaw to obtain such an analysis. The patient was a
young woman with a cystic tumour of the pancreas. This
tumour was removed by Professor Kosinsky by means of
the thermo-cautery. On the seventh day the tampon
which had been put in was taken out, and a drainage-tube
inserted. At first the discharge was purulent, and then for
a time watery, but subsequently it consisted of the pan¬
creatic juice alone. Before the wound healed, which it did
in about seven weeks after the operation, the secretion of
twenty-four hours was collected and examined. It was a
somewhat tenacious, yellowish, turbid liquid, with a marked
alkaline reaction. On analysis it gave—water, 86-405 per
cent. ; organic compounds, 13*251 per cent.; albuminoid
bodies, 9'205 per cent, j extractive matters soluble in alcohol,
estimated as nitrogen, 0’827 percent. Salts: carbonates,
chlorides, phosphates, and sulphates of sodium, potassium,
calcium, and iron, 0-344 per cent. At a temperature of
100° F. the juice actively converted starch into maltose,
egg aloumen into peptone, and olive oil into an emulsion.
On the whole, the human pancreatic juice was found, on
comparing it with that of other animals, to resemble most
nearly that of the dog according to Schmidt’s analysis.
OPEN SPACES FOR NORTH LONDON.
Those who wish to increase the pleasure and the
healthiness of life in this crowded metropolis, especially for
the poor, have no more urgent duty than bo preserve open
spaces and every tree that can be snatched from tlie heart¬
less blow of the speculative builder. We are glad bo see an
effort to extend the area of Highbury Fields and to include
many fine and rook-harbouring trees. The vestry and the
County Council will be well within their duty, as will the
inhabitants, in making this effort effectual.
DR. RUSSELL ON PRACTICAL TEACHING IN
SANITARY WORK.
An interesting “Memorandum on Practical Instruction
in Sanitary Work of Candidates for Diplomas in Public
Health,” signed by Dr. Jas. B. Russell of Glasgow, has
been sent to us. The Faculty of Physicians and Surgeons
had very properly brought under the notice of the
Town Council of Glasgow the resolution of the General
Medical Council of November last, requiring every
candidate for a medical oflicership of health, after
obtaining a registrable qualification, to personally study
the duties of out-door sanitary work under the medical
officer of health of a county or a large urban district, unless
he had personally held the office of medical officer of health.
Dr. Russell reports to a subcommittee of the Town Council
on the subject. We are glad to say that his report is
Dic::'=Jd by LjOOQIC
The Lancet,]
SMALL-POX AT COLCHK8TER.
f April 25, 1891. 949
favourable to the principle of practical teaching: be calls
it pupilage or apprenticbship. He does not think it would
0)5 possible or desirable for the medical officer of health for
Olasgow to take more than two such pupils. Others would
have to get their practical teaching elsewhere. We should
have thought that in Glasgow more pupils could have been
■taken. But it is much to liave got Dr. Russell’s approval
of the principle, and to have this endorsed by the other sani¬
tary officials and accepted by the subcommittee to which
it was referred. He makes the following suggestions
•concerning such pupils. 1. They shall be called pupil
assistants. 2. They shall be appointed by the medical
officer for not less than six months or more than twelve,
and their names reported from time to time to the Com-
tnissioners. 3. They shall pay no fee and receive no salary,
but shall assist in the work of the department in so far as
may seem expedient, subject to the medical officer, and in
return shall have every opportunity of studying the duties
both of in-door and out-door work. We are glad to see that
Dr. Russell includes in-door work in his suggestion.
ANOTHER STREET DANGER.
There is no condition of life which has not a conceivable
•connexion with danger, a connexion which is also to a
great extent unpreventable. Bat, after admitting this fact,
it is clear that much of w'hat we describe as accidental is
the mere consequence of our own carelessness. Nor need
we travel far to find instances which prove at once the
value and the daily neglect of caution. The traffic of our
streets affords us hourly proofs of such neglect. Only a
few days ago a cab horse, frightened by the noise of a drum
and hfe band, upset a passing bicycle and caused the death
of its rider. On another occasion a bicyclist narrowly
•escaped inflicting most serious injury upon a woman who
'happened to cross the line of his rapid progress. It is much
to be regretted that the otherwise wholesome practice of
oycle riding should have to be classed among the dangers of
the streets, but we fear there is, under present conditions,
mo doubt upon the subject. So long, indeed, as due regard
is had to the regulation of speed, the risk should not be
great, and what exists affects chiefly the rider himself. Bii'i:
unfortunately such consideration for surroundings does not
by any means distinguish all members of this class. Speed
is exhilarating, and it is a luxury far too commonly in¬
dulged in. We are therefore distinctly of opinion that
cycle riding in crowded thoroughfares like those of the
City should be subjected to police regulation. In this lies
the pedestrian’s only guarantee of safety from awkward
and dangerous collisions, and on this depends also to a
large extent the security of the rider and the furtherance of
'the general traffic. _
HEMIANOPSIA.
Tni.'S interesting but intricate subject is considered by
Dr. Noyes of New York in an exhaustive paper in the
Nc%o York Medical Record, b'rom a consideration of
various cases already published by several authors, and of
certain points in others which he has seen himself, he
•draws several conclusions, of which the most important
«,re the following: (1) That there is a want of uniformity
'in the exact position of the boundary between the blind
•■and seeing portions of the fields in hemianopsia; (2) that
•in several cases of double hemianopsia there is persistence
of a small central field in each eye; (3) that sectorial
•defects of homonymous character are most likely to have
their origin in the cortex of the occipital lobe, and that in
•such cases there may be absence of other significant sym¬
ptoms, except possibly agraphia, mental blindness, or word
blindness; (4) that sectorial defects may originate in the
subcortical part of the occipital lobe, in which case the
defect is not likely to be so well defined as when the lesion
is cortical, and the loss of light sense will probably be less
complete; (6) that from certain casespublished itappearsthat
sectorial and quadratic defects may arise from lesion of the
optic tract; (6) loss of either colour or form perception, with
retention of light perception, implies a cortical lesion of the
visual centre; (7) Wernicke’s symptom, or the hemiopic
pupillary inaction, signifies that the lesion is in front of the
corpora quadrigemina; (8) that there seem to be positive
grounds for concluding that there is a topographical corre¬
spondence between the cerebral visual centre and the
retina, and that it is precise and extends to details. Thus
one case, in which there was found to be blindness of the
upper part of the opposite halves of the retinm, was found
to have the lesion in the lower part of the cuneus. Other
facts seem to point to a similar correspondence between
segments of the retina and parts of the occipital cortex.
SMALL-POX AT COLCHESTER.
A RECENT occurrence of small-pox in Colchester has led
to some difference of opinion as to the source of the disease,
the responsibility for it being variously allotted between
Harwich, Colchester, and the Great Eastern Railway. Dr.
Brown, in reporting to the Colchester Town Council on
the subject), states that he regards it as absolutely proved
that the disease was imported from Rotterdam by means of
a Great Eastern steamer, and he alleges that a great lack of
caution was shown in allowing it to spread uncontrolled
on board and amongst the employis of the company. For¬
tunately the occurrence may now be regarded as at an end
and for this result Colchester has probably largely to thank
itself for having bad at hand a hospital to which the cases
were removed. There are, however, indications of a
tendency to increase of small-pox elsewhere, and in the
metropolis itself the notified cases have suddenly gone up
beyond anything within recent times.
CERTIFYING SURGEONS AND THE FACTORY
ACTS.
It will be well, while the incidents of last week's victory
are fresh in the jnind, to reverb to one or two of its
lessons. Not the least lesson is one of gratitude to those who
took the trouble to fight. Amongst these, Mr. Mundella
deserves the highest praise. Dr. Farquharson did well,
as he was doubtless impelled to do by his professional
knowledge and sympathy. But even he will confess that
Mr. Mundella set himself to the work of saving the
certifying surgeons with great purpose and effect, and that,
as a layman, as a representative of a manufacturing town,
and as a member of the late Government, he did the cause
a very great and effective service. He might easily have
excused himself doing so on the ground that it was a
doctor’s question and no business of his. He took the
larger view, and with it the larger trouble of stoutly
fighting against the Home Secretary, and in doing so
he has gained the thanks of the profession and of all who
wish to see children proteclel under the Factory Acts.
Another lesson to be gained from the whole incident is the
necessity of certifying surgeons magnifying their office a
little more than they have been in the habit of doing. They
have been so little obtrusive in tbe discharge of their duties
that the owners of factories have underrated tbe amount
and importance of their work. The very quietness with
which they have acted has been misunderstood, and made
a ground of complaint and disparagement. Doubtless in
the future certifying surgeons will make more apparent the
reality of their functions. Even under the existing system
there is room for this. There will be yet more room if the
Digitized Lioogle
950 The Lancet,}
THE INFLUENZA.
[April 25,18»1.
following two clauses which Dr. Farquharson is to move
should be carried, as they certainly deserve to be
“After the passing of this Act certihcatee of fitness
for employment of children and young persons shall be
subject to revocation by the certifying surgeon, if upon
inspection he shall certify in the prescribed form that
the continued employment of the child or young person
named therein is dangerous to the health of such person,
and the certifying surgeon shall be bound to make a
periodical inspection of all children and young persons
holding certincates at prescribed intervals, and snail be
entitled to the prescribed fees.”
“Every certifying surgeon actingunder this or the principal
Act shall in each year make at the prescribed time a report
to the Secretary of State as to the persons inspected during
the year, and the results of said inspection, and also as to
the number, sex, and age of all children and young persons
employed in factories and workshops inspecced by him at
the time of his last inspection, and the nature of their em-
ploymeut and their rates of wages, with such other parti¬
culars as may be prescribed from time to time, and such
reports shall be presented to Parliament annually.”
The effect of these clauses will be to secure periodical
inspection of the children by the certifying surgeon, to
give him the power of revoking certificates of fitness to
work, and to provide yearly reports of the result of his
inspection to the Home Secretary. If these points be
secured, there will not be much risk of any future Home
Secretary thinkbg that the work of the surgeons is confined
to ascertaining the age of those whom he examines.
Finally, it is gratifying to learn that the opposition to the
retention of certifying surgeons was comparatively limited
in the area from which it proceeded, and that the repre¬
sentatives of such towns as Sheffield, Birmingham, &c.,
had no mandate in that direction.
THE INFLUENZA.
We look anxiously to receive detailed medical accounts
of the influenza in Chicago, Pittsburg, and New York,
which eeems to have been attended with a fatality far
beyond that of wliich we have had experience in this
country, or that of other grippe epidemics in the United
States. So far, such accounts are conspicuous by their
absence. The Medical Record of New York—where, the
telegrams of The Times tell us, the deaths on April 2lst
were 251 (100 more than on the preceding day), twenty-
seven being credited to influenza — in its number of
April ilth has practically no information of the present
epidemic, either in that city, or in Chicago, or Pitts¬
burg. Our contemporary has had of late several general
articles on influenza and its epidemics, and we shall doubt-
ess not have long to wait for some explanation of the
excessive business of undertakers in the American cities of
which we have lately read so much. The Record of
March 28th has an interesting article on the fasts of last
year’s la grippe, as reported from different military homes
in the States to General Franklin, the President of the
Board of &!^nagers, on inspection of such homes. One in
particular gives an admirable abstract of cases treated by
Dr. K. Humphrey Stevens, surgeon in charge of the
Michigan Soldiers’ Home Hospital. The chief features of
the cases in the home (575) were lassitude and prostration,
followed by fever and pain in the head, chest, or back.
Then the malady assumed one of the following forms:
First, affecting the sensory nerves, of which there were
351 cases; secondly, affecting the mucous surfaces, 153
cases; thirdly, affecting the muscular system, 71 cases.
Coses unchecked by treatment almost invariably passed
through the three forms sooner or later. All the cases
recovered. Twenty-seven of the first group developed
glandular swellings, generally of the throat and neck, but
in one case of the groin, and in another of the testicle.
Of the second group, twenty-five developed pneumonia.
Physico-chemical and meteorological observations were made
at the same time, which Dr. Stevens expresses mathe¬
matically thus : the prevalence of inlluenza is proportional
to the increase in weight and humidity, and inversely to
the amount of ozone and the electrical condition of the
atmosphere. When the fever runs high the specific gravity
of the urine increases; with increase of urea and urates the
urine becomes acid and crystals of uric-acid urates and
oxalates appear. In view of the intense nerve depressioa
resulting from uneliminated organic oxcrementitious pro¬
ducts in the blood—which all the reserve nervous force-
of the body endeavours to throw off and burn up—the
too-popular antipyretic sedative treatment is unwarrant¬
able and nnscientific. Fatal prostration and heart failure
in la grippe Dr. Sbevens thinks more often to he due to-
drugs than bo the disease itself. More benefit is derived
from tonic and eliminative remedies than from all else.
Hob air and hot water, externally and internally,
followed by anti-periodic alkaloids, are also useful. We-
think there is much wisdom in these views of Dr_
Stevens, and the practical results could not be better.
In this country during the past week there has been
unequivocal evidence of the spread of influenza to
other parts of Yorkshire and Idncolnshire. Driffield,.
Pontefract, Leeds, York, and Grimsby are among the
places especially visited. Several cases have occurred in
London, where, however, it can hardly be said as yet to-
have attained epidemic proportions. Children, who were
very slightly affected in the great epidemic of last year,
seem to furnish many cases. It has been said that such
a recurrence of influenza is contrary to previous experi¬
ence, but it may be ri^marked that isolated epidemics of
often arise apart from great pandemics, such as
that which visited the globe in 1889-00 ; and the progress
of the present outbreak cannot be compared to the rapidity-
with which that epidemic swept over whole continents.
SANITARY PROGRESS IN FRANCE.
M. Henri Monod, who is at the head of the Public
Health Department attached to the French Ministry of the
Interior, is determined to do all he can to promote the
welfare of his countrymen in the matters which come under
bis especial supervision, and he is rapidly acquiring the
considerable influence in this respect to which his marked'
abilities and his persevering energy entitle him. At a
recent meeting of the Comitd Consultatif d’HygifcaePablique
de France he brought forward a number of vital statistics
which he had cotn^led, and amongst these was a list of
twenty-one communes in which some substantial diminu¬
tion of mortality had taken place within recent years. lo.
the commune of Beaseges, where the general rate of mor¬
tality had reached 32'4 per 1000 living during the period
1881-84, there had been a reduction of no less than 13 4 per
cent, in the period 1885-90 ; and it is pointed out that the
substantial saving of life which thus resulted had followed
on the provision of a wholesome public water service, the
distribution of which commenced in 1885. Unfortunately
France does not easily lend itself to comparisons in
the matter of vital statistics, for no general system of
registration of causes of death exists; and great labour
is involved in preparing even minor data on which to
form a judgment. M. Monod thus finds himself unable to
speak with the necessary precision as to the diseases which
have been most diminished in the commune referred
to; bub he is able to say generally that typhoid fever, for
which France retains an unenviable notoriety, has hardly
been present at all since the completion of the new works.
And looking back upon this experience, he exclaims with
an energy which could hardly be devoted to a higher cause ;
“ How many are the cities of France, where the general
.oot^le
Dir:' 'ed by
The Lancet,]
THE PREVENTION OF OVERLAYING.
APB1L25, 1891. 951
mortality is excessive and where typhoid fever is normally
endemic, which would best serve their interests by following
the example set them by poor rural communes ? How much
longer will it be before they understand, before their popu¬
lations perceive, that if there is an expenditure which is
justifiable, perhaps indeed obligatory, and at the same time
reproductive, it is above all that which has for its certain
result the preservation of human life?” M. Monod has
often done this country the honour of setting its example
before bis countrymen in the matter of the saving of life
and the prevention of disease as the outcome of well con¬
sidered expenditure in the sanitary service. Recalling our
own experience, we would urge that France is, above all
things, crippled by the lack of correct statistical information
as to causes of death, and M. Monod’s services could not
be better utilised than in insisting that his Government
should forthwith institute a system of registration of death
somewhat on the lines of that which we found necessary
over fifty years ago. _
THE PREVENTION OF OVERLAYING.
In spite of coroners’ admonitions, and the still graver
warnings impressed by numerous fatal accidents, if the
phrase be permissible, many parents will persist in taking
their infant children to bed with them. A variety of
excuses might no doubt be urged by those who seek them
in favour of this practice. Either there is no crib and no
money to buy one, or perhaps feeding is easier with the
child in bed, or the infant, having been accustomed,
•wr 9 Dgly, to sleep in the mother’s arms, will not lie quietly
alone. No subterfuge of argument, however, will suffice to
condone a fault the fatal tendency of which has been often
proved, and which has lately, during one week, and in the
metropolis alone, cost the lives of eighteen overlaid children.
Mere education cannot be relied on to provide an effectual
remedy. Present need requires more energetic action, and
a measure empowering judges to punish as culpable neglect
this indiscriminate association of infants with slumbering
and often intoxicated mothers would not be at all too
severe for the requirements of the case.
BACILLI IN SYPHILIS.
Dr. von Marschalko, who has been working in the
pathological laboratory of the Buda-Pesth University at
the subject of the bacteriology of syphilis, has devised a
method of staining by which bacilli may be found in
syphilitic growths of various kinds, such as papules on the
skin, the indurated base of a chancre, and condylomata, as
well as in the secretion of primary sores, while he has not
"been able to find them in non-syphilitic growths or in the
secretion of soft chancres. Whether they are really
inseparably connected with syphilis can of course only be
decided by a prolonged series of observations, but there
would at least appear to have been a primA-facit case made
out for further investigation. The method employed is by
double staining, as follows The object, after having been
hardened in alcohol, is immersed for thirty-six hours in an
alkaline solution of methyl blue; it is then rinsed well with
water, and re-stained by a concentrated solution of veauvin
in water. The bacilli are stained blue, and can be easily
distinguished from the tissues, which are brown.
MUSIC AS A REMEDY.
Most of us have at one time or another been convinced
by personal experience of the fact that perception of pain
and of grief depend in great measure on our mental attitude
for the time being. It grows under observation, wanes if
neglected, and is even obliterated for a time if our emotions
are strongly acted on by some shock or counter attraction-
It is clearly in this way that we must explain the ansesthesia
of hypnotism and the soothing effects of harmony in sound.
This very sense of calnt has, moreover, as a form of rest, a
distinctly curative tendency, so that music may to this ex¬
tent be regarded as a remedy in illness. The ancient
healers understood this, and we find accordingly that hardly
any prescription or course of treatment was by them re¬
garded as efficacious unless agreeably combined with the
allurements of melody or quaintly blended with an incanta¬
tion. Egyptians, Indians, Greeks, and Romans in turn wooed
in this manner the vis medieatrix, and, we cannot doubt,
with a fair measure of success. It need hardly excite com¬
ment, therefore, that the same attraction of melody has
bpen credited in our own days with a curative property.
One of the latest notes on this subject is one which applauds
music as an anodyne in gout. The reference, of course, is
to the pain endured rather than the malady which occa¬
sioned it. This latter is beyond the control of merely
neurotic forces. What refinements of molecular change in
the sensotium underlie the ancosthesia so readily induced
there is as yet no evidence to show. Whatever their
nature, however, we may take it for granted that they do
occur, and the process which gives rise to them is perhaps
not altogether unworthy of experimental use now and then
by the modern practitioner.
FOOLHARDY PERFORMANCES.
Many things are done, and have been done from time
immemorial, in the way of acrobatic display with regard to
which the definition of a right and natural attitude of
public opinion, and its crystallised result, legislation, is not
quite a simple matter. For our own part, we had rather not
invoke the restrictions of authority wherever they can be
dispensed with. Human skill, it is fortunate, can often be
so perfected as sufficiently to minimise for the individual
performer the possibly disastrous issues of a hazardous
calling. But, allowing this, we must still remember that
there are limits even to human skill. In this and other
matters the word “impossible” may be ignored, but it finds
a place in every language notwithstanding. When accord¬
ingly we are forced to conclude in regard to any practice
that the balance between skill and personal risk ioclinea
decidedly towards the latter, when, moreover, the implied
advantage or utility of any practice is clearly dwarfed in
the presence of the merely curious and extraordinary, and
when life or limb has to pay the penalty of threatened
failure—it is clear that sense and reason call for its restraint.
The muscular exhibitions of an athlete in themselves
entail no mischievous consequence, and require no censor.
It is otherwise with some of their more remarkable elabora¬
tions. When, for example, a female acrobat fails to grasp an
“invisible wire” and is nearly killed io consequence, as
happened the other day in Paris, or when life-long injury
follows an error on the trapeze, it U quite within the pro¬
vince of law to prevent a recurrence of the revolting inci¬
dent. If, therefore, other and sufficient means cannot be
devised which will secure the safety of performers, there re¬
mains no alternative but prohibition of the display.
THE PUBLIC HEALTH (LONDON) BILLS.
The proposed aro.endments to the Public Health (London)
Bills, of which notice has already been given, are such as
sufficiently to satisfy anyone conversant with the subject
that very littleis to be said against thesemeasuresas prepared
by Mr. Ritchie. Sir Albert Rollit has evidently failed to
understand metropolitan requirements, and were his amend¬
ments to be accepted, London would continue in its present
condition until some opportunity occurred in the remote
future for amending the Health Laws. His amendments
D:: ‘ :!ed hyGOOglC
^52 The LakCSt,]
THE GERMAN CONGRESS OF INTERNAL MEDICINE.
[April 25,1891.
would perpetuate all the troubles and I'rievauces of those
whose fate it is to submit to offensive odours in streets,
nuisances from overflowing dustbins, and maladies which
now from time to time develop as the result of local apathy.
It is not probable that Mr. Ritchie will allow a really useful
measure to be rendered abortive by those who would per¬
petuate existing conditions which have been again and
again condemned.' We hope, therefore, to see almost
every one of Sir Albert Rollit’s amendments rejected. We
note a proposal by Mr. Powell to require that sanitary
inspectors shall be properly qualified ; and although there
maybe difficulty just now in the way of determining by
law that the certificate of any particular body should be
regarded as a qualification, nevertheless we would
gladly see power given to the Local Government Board
to prescribe the qualifications of a sauitary inspector.
A proposal that the powers of the County Council should
extend over the City as over any other sanitary district
indicates undoubtedly, from a public health point of view,
the only proper way of dealing with the county. It
may be expected, however, that other considerations
will be allowed to have weight, and that the excep¬
tional position of the City will be preserved yet awhile.
But in view of the fact that the medical officer of health of
the City is required at the preseut time to send to the
County Council any special report which he presents to his
own authority, it is obvious the Council should have a
general power of inquiry iu the City as elsewhere. In¬
fectious disease, for instance, iu the City is not less
important to London as a whole than infectious disease in
any other district. _
CHARING-CROSS HOSPITAL.
The members of the staff of Chariog-cross Hospital,
together with the students past and present, have resolved
to mark the esteem in which the late Dr. Pollock and the
late Mr. E. Bellamy, the two senior officers of the hospital,
whose death occurred within six months of each other, were
held by their colleagues and by the students. A memorial
fund has been inaugurated, and Mr. Stanley Boyd, the dean
of the medical school, will act as the representative of the
staff, Mr. R. C. Ackland for the past students, and Mr.
G. T. Bishop, secretary of the student’s club, for the
present students, in concerting measures to commemorate
adequately the long services of the two deceased officers and
teachers.
FOREIGN UNIVERSITY INTELLIGENCE.
Lemberg. —This university, situated in Gallicia, where
Polish is spoken, has hitherto been without a medical
faculty, an omission which the Austrian Government is now
about to remedy.
Buda-Pesth. —The remalus of the great Hungarian obste¬
trician, Professor SeraraelweUs, who was a great advocate
for the employment of antiseptics in midwifery, have been
brought from Vienna by the professional senate and buried
in Pesth, where it is proposed to erect a monument to the
deceased professor.
Dorpat. —Dr. Chish, of the Panteleimon Lunatic Asylum,
is likely to be appointed to the chair of Mental Diseases
in succession to Professor Kraepelin.
St. Petersburg (Medical Academy). —Dr. Kianovski has
been recognised as privat docent.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:_
Dr. Pappajohanuu, Professor of Anatomy in the University
of Athens.—Dr. Parkes, Professor of Surgery in Rush
College, Chicago.—Dr. Edward Goltdammer, of the Betha-
nien Hospital, Berlin, of carcinoma, at the age of forty-
eight. __ _
The municipal authorities in Paris recently sold as waste'
paper to tradesmen a quantity of documents relating to the
causes of death of persons (whose names were given in full)
who had died as lately as 1873. A good many unpleasant
secrets have thus been made public which certainly ought
to have been considered, for a much longer period at-
least than eighteen years, as sacred.
Surgeon Pierson, of the Indian Medical Service, has-
fallen a victim to the fever which has broken out amongst-
the coolies employed on the Khojak tunnel. Mr. PieraoQ
was surgeon in charge of the men engaged on the works»
and contracted the disease during his professional attend¬
ance on the sufferers from the malady.
A CONVERSAZIONE Will be given by the President and
Council of the Medical Society of London at their Rooms,
Chandos-street, Cavendish-square, on Monday, May 4bh»
An oration will be delivered at 8.30 by Sir Joseph Lister,
Bart., F.B.S. The string band of the Royal Horse Guard®
will attend.
A CORRESPONDENT at Beirut writes :—“ The cholera,
which has been dormant for some time throughout Syria-
and Asia Minor, is said to have again started on its insidious-
progress north-west of Marash, in the district of Anderson.
Only a feiv cases have occurred, but the disease seems to
be progressing.” «___
Lord Harris performed the opening function of the new
Laboratory for Medical Research in connexion with the
Grant Medical College and a new Home for Nurses, ab-
Bombay, on Feb. I7th. _____
Mr. Peyton T. B. Beale, F.KC.S. Eng., has beets
appointed Demonstrator of Physiology in King’s College,
London.
THE GERMAN CONGRESS OF INTERNAL
MEDICINE.i
{Continued from p. 001.)
Discussion on Gall-stone.—Tuhercnlin and its Effects.
Dr, Furrringer (Berlin) followed Professor Naunyn,
and analysed the histories of sixty-four cases of gall-ston©
(thirteen males and fifty-one females) treated by him at the
Friedrichshain Hospital. Contrasting such cases with
renal calculus, he commented on the frequency with which
the former are latent, since during five years no fewer than?
500 times were gall-stones found in post-mortem examina¬
tions. He described the symptoms of biliary colic, noting
that with the jaundice the liver was generally swollen and
the gall-bladder palpable. Of forty-one cases fever was
present in twenty-four, the pulse often being slow. Icterus
is by no means constant. The failure to find gall-stones in
the fioces did nob set aside the diagnosis, for they may pass
back into the gall-bladder, or be vomited, or otherwise'
escape. Abortive attacks, seldom recognised, are of im¬
portance. The effects of permanent occlusion of the'
duct, and the differentiation of inflammatory sequelm,
as cholangitis, cholecystitis, suppurative hepatitis, and
perforation, were then considered. Especial stress was laid
OQ the occurrence of intermitting pyaimic fever in association-
with jaundice and local signs. 'The pains increase, notably
with extension of inllammation to the peritoneum, and
perforation rapidly ends fatally from suppurative peritonitis.
Gall-stones may escape externally through fistula; lit the
^ Frnit) a report in the Miinchener Medit'inisohe Wocliensclmit,
April I4th.
Digitized by i^ooQle
Thb Lancet,]
THE GERMAN CONGRESS OF INTERNAL MEDICINE.
[April 26,1891. 953
abdominal walls whicH give free exit to bile. From their
escape into the duodenum by ulceration may arise intes¬
tinal obstruction or perityphlitis. Other results are inter¬
stitial hepatitis and adhesions between the liver and neigh¬
bouring parts. As to diagnosis, he remarked that the
f tains might be in any part of the body, and that chole-
Lthiasis was often confounded with other painful abdo¬
minal affections—gastric ulcer, gastralgia, intestinal and
renal colic, and hepatalgia. The solubility of cholesterin
in hot alcohol was a useful test for doubtful masses in the
stools. The differential diagnosis from renal tumours was
given, but diagnostic puncture of the gall bladder was
deprecated, although an exploratory laparotomy might be
justifiable. The intermitting fever might be confounded
with typhoid or malaria. Prognosis, always serious, had
been improved by surgical measures. Of his cases, 34 per
cent, recovered, 42 per cent, improved, 10 per cent were un¬
relieved, and 14 per cent. died. Of six desperate cases,
four were saved by operation. As to treatment, morphine
and opium were best for the colic ; chloral and chloroform
narcosis next. It is impossible to dissolve the stones;
neither Durand’s methoa nor the use of biliary salts
had succeeded. The alkaline mineral waters were most
approved, and salicylate of soda and the oil treatment were
worthy of trial. The quantity of food rather than any
special form of diet was to be regulated. He did not re¬
commend the process of “ kneading” out the stones.
Surgical treatment was described as of great value, and a
study of the question led him to the conclusion that the
results of medical treatment are not bad enough, nor those
of surgical treatment good enough, to justify resort to the
latter in the circumstances advocated by ‘ annexionelustige’
operators.” Bub serious danger threatens from the results
of gall-stone with which internal medication cannot cope.
Then is the time for the patient to seek the aid of modern
surgery.— In the discussion that followed, Dr. Riedel
(Jena) spoke of the surgical aspect of the question, advo¬
cating cbolecystotomy in two stages, and describing the
means to be adopted in cases of stones impacted in the
ducts. Out of thirty-two cases, sixteen without icterus
were cured, the stones being seated in the gall-bladder or
cystic duct; sixteen with icterus gave ten cures, two still
under treatment, and four deaths.—Dr. M0SLER(Greif8wald)
spoke of the prevalence of gall-stone in North-east Germany,
which he mainly attributed to gastro-intestinal catarrh.
Among determining causes he laid much stress upon tight
lacing as tending to promote obstruction to the free exit
of bile from the gall-bladder. Catarrh of the ducts is a
common source of concretions, and the invasion of bacteria
from the duodenum was doubtless answerable for inilam-
niation of the ducts. He advocated large injections of
warm water into the intestine for the treatment of catarrhal
jaundice as well as of gall-stone, with the addition of
alkalies, and stated that such injections had been proved
to increase the flow of bile experimentally.
Papers were read by Dr. Knoll (Prague) on certain Circu¬
latory Disturbances, and also one on the Morbid Changes of
Striped Muscle; by Dr. ScilOTT (Nauheim) on the Differential
Diagnosis between Dilatation of the Heart and Pericardial
Effusion. His main points were the diminution of dulness
observed in the former under digitalis or muscular effort
(gymnastics) and the results of exploratory puncture, which
was nob dangerous.—Dr. Furiikinger concurred as to the
utility of the last means, and declared that, carefully done,
there was no risk of perforating the heart, and that simple
puncture of its wall was harmless.
The third sitting, on April 7th, was wholly occupied by
the subject of Koch’s Treatment. It began with a paper
by Dr. CURSCHMANN (Leipzic), who said that any impor¬
tant novelty in medicine is wont to pass through a period
of enthusiasm, after which come doubts and objections,
Bometintes ending in absolute denials of there being any
value in such discovery after all. , Then is the time for a
calm and critical review of the matter, and it has now been
reached in this case. The exaggerated hopes excited all
over the world by the announcement of a new method of
dealing with a dreadful scourge, opening up new paths and
prospects in therapeutics, were based on nn erroneous ana¬
logy between the simple conditions of animal experimenta¬
tion and the complex conditions met with at the bedside.
It was especially in regard to pulmonary tuberculosis that
the capabilities of the treatment had been too highly esti¬
mated. Hence the numberless failures, disasters, and
fatalities which had in their turn evoked a real panic. We
are now passing through a stage of depression into the stage,
of quiet study. It is more and more clear that the great
question—which quite wrongly was described as being pre¬
maturely published by Koch—can only be matured at the
bedside. Apart from unimportant questions, we are alS
unanimous m holding that in Koch’s remedy we have for
the first time been given a substance which exerts a specific
action on tissues attacked with tuberculosis—a funda¬
mental discovery, end indubitably one of the greatest which
therapeutics has yet seen. There is no blinking this fact„
and it remains for the future to demonstrate its applicability.
—Professor v, Jaksch (Prague) spoke of its diagnostic
and therapeutic results from an experience of seventy-two
cases observed during four months. Of these, twenty-eight
were injected for diagnostic purposes. They showed that
tuberculin can reveal small tubercular foci, although excep¬
tionally tubercular cases do not react, and healthy subjects
may react. The second or therapeutic group comprised cases
of severe pulmonary tuberculosis, which were not improved,
and whose unfavourable course could hardly be attributed to
the tuberculin. Of the moderately severe cases the majority
improved; some gob worse. No subsidence of infiltration
was noted, but often the formation of cavities. Eight
slight cases without bacilli, but with manifest phyaicat
signs, all improved. Three cases of lupus were notably
improved, not cured. One case of ostitis fungosa of the
hand got well after removal of sequestra. One tuberculous
conjunctivitis, apparently cured, recurred, and was again
treated and cured. Peptonuria is common. He had never
found bacilli in the blood; nor bad he seen any serious
complications. There could be no doubt as to the diagnostic,
and above all the scientific, importance of the discovery.
Therapeutically the remedy had not done what it had
promised to do.—Professor Ziegler (Freiburg) dealt with nhe
pathological aspect of the matter. He propounded three
questions: 1. What changes do the injections produce in
tubercles? 2. Are these of a curative nature, or do they
involve risks? .3. What are the ascertained anatomical
results? As to the first, Koch’s statement that there is
necrosis of tubercle is a priori improbable, since tubercle
is non-vascular. The action must be in the vicinity
of the tubercle leading to infiammation with exuda¬
tion and emigration of leucocytes, and that to sup¬
puration, secondarily destroying the tubercle. Secondly,
cure may arise from casting off of the tubercles from their
degeneration and resorption, or their encapsulation, or their
conversion into normal tissue. The last is improbable.
As to dangers, he remarked that tuberculin does not destroy
the bacilli; by detachment the tubercles may set free
bacilli to penetrate raw surfaces'; by softening, the bacilli
may be taken up and disseminated in blood and lymph, or
the focus may break into cavities (pleura, pericardium,
peritoneum), or the detritus be inhaled into other parts of
the lung. However, it does not follow that all escaped
bacilli can excite tuberculosis. Encapsulation of the tubercle
is without danger. As regards the anatomical facts, the
detachment of tubercles which occurs in the lungs, intestine,
and skin, may occur spontaneously, apart from the effect of
tubsiculin, which can only hasten it. So also the softening
and resorption had often been erroneously attributed to its
action. The same holds with encapsulation, and the pro¬
bability is that many of these changes are simply the
natural process of-cure. Tuberculin only acts on processes
which occur spontaneously, and then occasionally lead to
cure; perhaps it hastens them. If it do not cure it
may cause a dissemination of tuberculosis through the
absorption of bacilli. Tuberculin apparently only acts
on certain predisposerl parts.—Professor Heubner (Leipzic>
spoke of tuberculin in the treatment of children, who,
he said, are not more susceptible to small doses than
are adults. Diagnostically it was of value Therapeutic¬
ally it was limited to incipient tubercle. This in children
is more common in the glands (35 per cent.) and bones
(42 per cent.) than in the lungs. The paths of entrance
are the so-called strumous affections—keratitis, conjunc¬
tivitis, eczema; and these generally are rapidly cured by
tuberculin. But, as a rule, the treatment is not applied
until the glands are involved ; and he found the remeay to
have very little influence on these glandular affections.
Still, he would not term tuberculin valueless. In more
advanced conditions of implication of bronchial glands or
lungs, the use of tuberculin is dangerous from disseminatioa
of the tubercular virus, or perforation of bronchi or blood¬
vessels. Tuberculin might be used as a prophylactic in
95t TheLakcbt.I the TEEA.TMENT of tuberculosis by KOCH’S method. [April 26.1891.
hereditarily disposed childreo, with suspected tubercle, but
without physical evidence of it. The action of tuberculin
in intestinal tubercle may be to cause perforation, but not
often; and the difficulty rests rather in tbe lack of influence
on the infected mesenteric glands. Miliary tuberculosis
and tubercular meningitis are always fatal, and nothing is
known of the elfect of the remedy in renal and genital
tubercle.—Dr. MoritzSchmidt (Frankfort) dealt with
tuberculin in laryngeal tuberculosis, giving some favourable
.results. It produces swelling of the affected parts, a
transient greyish-white deposit, formation of fresh ulcers,
and then their cicatrisation. He bad never seen such
swelling as to need tracheotomy. Seven coses pre¬
viously cured by curetting and lactic acid had shown
no local reaction after the injections. One case of
lupus of the larynx healed, and so did tbe lupus of
the palate in tbe same case, ivhilst that of the nose im¬
proved. Ten cases of laryngeal tuberculosis, nob ulcerated,
were all healed. Altogether, of thirty-nine mild cases
•eighteen were healed ; of twenty-two severe cases seven
were healed and one improved. Compared with previous
kinds of treatment, he considered that tuberculin acted more
favourably than any other known remedy. Some of Jlie
unfavourable results observed may be due to the employ¬
ment of too large doses.—Dr. Dbttweiler (Falkenstein)
ispoke of Koch’s method in relation to climatic treatment.
He had had four months’ experience with 128 patients.
Of these, four, or .3‘1 per cent., were discharged quite
cured and free from bacilli; improved, forty-three, or
53'6 per cent.; stationary, fifty-one, or39'6 percent.; worse,
twenty-four, or 19 per cent.; and six died, or 47 per cent.
These results are very small in comparison with those
hitherto obtained at Falkenstein, and even lower than
•formerly. His statistics were based on fifteen years’
•experience. His conclusions were: 1. That tuberculin
■exerts an action in tuberculosis different from that of any
remedy hitherto known. 2. The manner of its action
'(good as well as bad) is not to be estimated beforehand in
any individual case. 3. It is uncertain in diagnosis, since
•indubitable cases of tubercle do not react. 4. Tbe risks
involved are not great, but sometimes surprising, and
anxious accidents occur. 5. Its curative effect is but small.
It might be better if only very small doses were given. He
discountenanced its use in moderate and severe cases.
•6. The remedy was not a true specific, since it did nob
render the lung immune or kill the bacilli. 7. At present
a final judgment is not possible, and we are still entitled
to expect a curative effect in the smallest foci under a care¬
ful use of the remedy.—Dr. Sonnknrurg (Berlin) spoke of
tbe tuberculin treatment and pulmonary surgery. He
related a case where a cavity had been opened in the right
infra-clavicular fossa ; tbe patient had greatly improved in
■general condition and there were no longer any bacilli.
When the tuberculin treatment commenced the cavity
which had been laid open enlarged from softening of its
circumference ; then it shrank and finally healed up. He
had operated in six cases, of which one was healed, two.
nearly healed, and two had died. Only cases of isolated
■cavities were suitable, and their diagnosis was very difficult.
Adhesion of the pleura was essential, bub this always
•existed over a cavity.
(To be continued.)
THE TREATMENT OP TUBERCULOSIS BY
KOCH’S METHOD.
A MEETiNCf of the Metropolitan Counties’ Branch of the
British Medical Association, South London District, was
'held on April 15th, J. W. J. Oswald, vice-president, in the
chair. Tbe meeting was held by permission of the treasurer
in the court-room of St. Thomas’s Hospital, and was largely
attended.
A discuBsiim on the Koch treatment of tuberculosis was
opened by Dr. Bhistowe, who commenced by saying that
he had hitherto refrained from giving public ubterauce to
his opinions concerning Koch’s remedy for tuberculosis, and
that from the first he had been highly sceptical as to its
value and an amused spectator of what was going on. He
observed that infective diseases might be roughly divided
■into two categories—namely, first, those which bad a limited
duration, and were in a greater or less degree self-protective,
such as small-pox and scarlet fever; and, second, those like
tuberculosis and leprosy, which wore persistent and ingra¬
vescent, and in no sense self-protective. He then pointed
out that it was in relation to the former diseases that dis¬
coveries had hitherto been made, by means of which the
inoculation of an attenuated variety of the disease pre¬
vented recurrence; in support of which statement he had
called attention to the inoculation for small-pox, to vaccina¬
tion, and to Pasteur’s discoveries in respect of the attenuation
of anthrax and hydrophobia. He considered that we knew
nothing concerning the real nature of the protective in¬
fluence thus imparted ; but he held that in all such diseases
it was not the mere presence of the specifle organisms which
caused mischief, hut the poisonous matter which these
organjsms discharged, and he quoted the observations of
Sanderson in regard to septiciomia and septic poisoning, and
as to the deleterious influence which the poisons they manu¬
facture tend to exert over the organisms themselves, and
the more recent researches of Wooldridge, Hankin, and
Sidney Martin, which show that the specific poison of the
bacilli anthracis produces the same effect as the bacilli
themselves, though only for a limited time, and equally
with attenuated bacilli protects from recurrences. Then
adverting to such diseases as leprosy and tuberculosis, be
contended that if these are to oe cured by injections, it
can scarcely be by the injection of an attenuated virus,
as they are persistent and ingravescent diseases not
tending to cure, and that if curatively dealt with it must
be on other principles than those governing the other
class of diseases. He said that when he first heard
of Koch’s remedy he believed, as he thought many
others did, that he had discovered something which
was inimical to the bacilli. But that when he told us
in November last that his remedy had no effect on the
bacilli, but only tended to imprison them in an excess of
inflammatory products, his scepticism became profound;
and that this mental attitude became still more pronounced
when his last instalment of confidence was given to the
f irofession. For he could not but feel that it was much less
ikely that aggravation of inflammation would checkmate
the bacilli, than that it would tend to encourage their growth
and diffusion. He went on to observe that Kochs fluid
tended to cause some temporary febrile disturbance and
aggravation of ioflammation around tubercular deposits,
but that these actions were very uncertain; that the general
febrile disturbance did not occur in tubercular cases alone,
but also under other conditions; and that the local reaction
not only did not develop itself in every case of tuberculosis,
but occurred in other granulomata, such as leprosy. Indeed,
he suspected that further observation would show not only
that Koch’s fluid had no specific influence over tubercle,
but that it was a property of septic inflammation generally
to cause a limited attack of general fever, and to aggravate
inflammation in parts already inflamed ; and that the effects
of Koch’s fluid were not specific in any degree as against
tubercle, but belonged to the same class of phenomena.
Tbe inutility and danger of using Koch’s fluid in internal
tuberculosis were demonstrated in Virchow’s account of the
necropsies in the fatal cases of tuberculosis treated by
Koch’s fluid, which account fully justifies the worst fears
that had been entertained; and Mr Hutchinson’s lecture
showed that nooe of the cases of lupus treated in this
metropolis had been cured.
Dr. Hawkins, who showed a number of cases of lupus
which had been treated by Koch’s method in St. Thomas’s
Hospital, furnished a report of nearly all the cases which
had been treated there on the medical side. Five
cases of lupus of the face or neck had been so treated,
and of these four had shown slight improvement at
first, but soon became stationary, and subsequent treatment
by scraping &c. bad been necessary in all ; while the fifth
had refused to continue the treatment after the third injec¬
tion. One case of lupus of the hand showed slight improve¬
ment, subsequent treatment by other methods having, how¬
ever, been necessary. Five cases of phthisis had been
' treated. In two early cases the result had been doubtful,
but the disease apparently had not increased. In one case
with well-marked excavation no apparent change had
taken place. In two cases in which the larynx had been
also affected the pulmonary and laryngeal disease had
made rapid progress, one case having proved fatal; but no
post-mortem examination had been made. One case of
scrofulous glands had been treated without apparent result.
Google
The Lancet,]
THE TREATMENT OF TUBERCULOSIS BY KOCH’S METHOD. [April 26,1891. 95&
In a case of tubercular peritonitis increased pain and
tenderness, with continued fever, followed the injection of
O'OOl cc., and the treatment had not been continued.
Dr. Hector Mackenzie said the South London district
might congratulate itself on having had such a calm judicial
opinion as that of Dr. Bristowe on the important subject of
the Koch treatment for tuberculosis. He thought that
now, when tuberculin direct from Dr. Koch’s laboratory
was advertised as on sale at the chemist’s, it was high time
the medical profession should learn what was thought of
the remedy by those who had had the opportunities of
seeing its effects in hospitals. He contrasted Koch’s state¬
ments at the International Medical Congress last August with
those in his now famous communications of November, 1890,
and January, 1891. Koch had said that hitherto physicians
had failed to cure tuberculosis because they had gone about
it the wrong way, and tried the effects of various remedies
on man instead of on the parasites themselves in their pure
cultures, and then on the lower animals. Koch, after men¬
tioning that he bad tried various substances which hinder
the growth in media, but were absolutely without effect in
tuberculous animals, made the sensational announcement
that he had at last hit upon a substance which had the
power of preventing the growth of tubercle bacilli not
only in a test tube, but in the body of an animal. The
credulity with which statements as to the rapid curing
of cases of lupus and phthisis were receiv(!d about the time
when Koch made his communication in November was
altogether phenomenal, and within a few weeks we bad the
spectacle of Berlin crowded with medical men from all parts
of the globe to learn the new treatment, and with consump¬
tives struggling to get injections at so many marks apiece
from Dr. Cornet and his assistants. Koch talked of speedy
cures of lupus and of early eases of glandular bone and joint
tuberculosis, and regarded it as certain tbab phthisis in the
beginning was curable by hia remedy. Koch had led us to
suppose that he had himself fully tested this wonderful
remedy of his; that he had found that it prevented the
growth of the bacilli in the test tube ; and we were surely
not wrong in supposing that he had made numberless
experiments with regard to its effect on tuberculosis in the
lower animals. Two months were allowed to elapse before
Koch admitted us to his confidence as to the nature of bis
remedy and the experiments on which he had satisfied
himself of its power. During this time the remedy
was employed in probably every hospital in Europe.
The account of the fluid in Koch’s further communication
was bald in the extreme. He gave no indication of the
length of time he had experimented with it, and the only
experiments he told us of were a few on guinea-pigs.
Surely, if he had made the experiments on animals which
he had led us to assume he had done, he would have told
US of them. The conclusion forced upon us was that he
had suddenly left science for empiricism, and, after a few
observations on. tuberculous guinea-pigs, had proceeded at
once to this gigantic experiment on tuberculous man. The
official report on the results of the Koch treatment in
Prussia formed a striking commentary on the couleur de rose
communication of November : 5 alleged cures of lupus out
of 215 treated, 13 alleged cures of internal tuberculosis out
of 1061 treated, 884 out of 1769 acknowledged as un¬
improved, and 65 out of the same number dead ! Dr.
Mackenzie had watched the effect of treatment on
patients at the Brompton Hospital under the care of his
colleagues. Some of these patients before and after the
treatment had been under his own care, and he had had
therefore the best opporiunities of fonning an opinion
as to the effect of the treatment. He had seen no case
of cure. Some were in statu quo, some were distinctly
worse, some had proved most intolerant of the remedy, so
that the injections had to be given up. In some in which
there was apparent improvement the signs of disease had
become more extensive, and pointed to more active dis¬
integration going on in the lung. The results of the treat¬
ment with Koch’s remedy compared, he thought, most
unfavourably with tiie results obtained on the usual lines
with tonics, cod-liver oil, good food, and good hygienic
surroundings. What had been the practical outcome of the
whole matter? Honours and decorations to Professor
Koch, a brief harvest of marks to his assistants and to the
Berlin hotel keepers, loss of time and money to medical
practitioners in ail parts of the world, a few doubtful cures
of lupus, hundreds of patients made to undergo a course of
treatment which at least temporarily increased their suffer¬
ings, the hopes of thousands raised to the highest pitch,,
only to be bitterly disappointed, and a number hastened t»
the grave.
Dr. PiiiNEAS Abraham, while expressing pleasure at
listening to Dr. Bristowe’s address, could not go quite sO'
far, especially as Dr. Mackenzie had done, in denouncing
Koch and bis remedy, believing that Koch’s hand had been
forced some eight months ago, and that he was hardly re¬
sponsible for the exaggerated statements of cures and the^
extraordinary puffing by some of the Berlin doctors and-
newspaper reporters. Although Dr. Abraham had had four
months’ experience of the Koch treatment, having injected
between forty and fifty patients (twenty-one being cates of
lupus), he could not yet speak very definitely on the sub¬
ject, the inquiry being, in his opinion, still in the experi¬
mental stage. Most of the lupus cases had more or leser
improved, three in so marked a manner as to be regarded
almost as practical cures. In a few there was no very
obvious improvement at any time, one being a case of'
eiythematous lupus of sebaceous type in which there was
considerable constitutional disturbance, but only little
local reaction. The injections here caused several
crops of chilblains on tbe hands and feet. Besides
the transiently alarming pyaemia &c, he had not met
with the appsdling results recorded by the French sur¬
geons, and be agreed with Dr. Leslie Phillips in think¬
ing that the St. Louis report was just a little premature.
In one case severe facial erysipelas set in just after Boxing-
day, when a number of visitors bad been in tbe ward, and
the patient also complained of catching cold from a window
near her being left open. Tbe injections were commenced
again, and then left off, and some ten days or so after the
last another attack of erysipelas came on. Tbe connexion
of the erysipelas with the treatment was therefore not clear.
One case, an old man of over seventy, with supposed lupus,
who received one injection of one milligramme, chiefly for
diagnosis, subsequently died in about a fortnight. Thee^
reaction bad subsided, but the injection was not repeated
because of his age and chronic bronchitis. Many other old
people in the infirmary succumbed about the same time
from the severe weather and terrible fogs, and it was there--
fore hardly fair to put down this death to the Koch fluid.
In none of the lupus cases had Dr. Abraham pushed the
remedy beyond twenty milligrammes, generally commencing
with two milligrammes. A few of them showed skin rashes,,
the most severe being a scarlatiniform eruption in a boy,
and leading to copious desquamation over the greater part
of the body, this case turning out one of tbe best results.
According to his experience, those cases act best in which'
the lupus is hypermmic and ulcerative; and for such, espe¬
cially when the disease is extensive and not easily reached
by other means, be believed that we had in Koch’s-
tuberculin a remedy of some real value for lupus; bub-
he was now combining with tbe method the application
of other remedies — salicylic and resorcin ointments.
He thought there was much in what Mr. Hutchinson said'
as to the failure of the treatment to act on the myxomatous
or “apple jelly” tissue of lupus ; but he had seen in a few
coses desquamation and diminution to some extent of such
tissue.
Mr. H. B. Robinson exhibited a case of Lupus treated
by Koch’s injection. The fluid bad been used in increasing:
doses for three months, and bad been discontinued one
month before the exhibition of the patient. Although the-
case had improved greatly, it was feared that tbe disease
was already recurring. Cases of injection in tuberculous
bones and joints were referred to; but the success obtained
had been limited, occurring to any certainty only in one-
case where there was on old discharging sinus. It was
suggested that the injections might be of benefit in such
cases.
Dr. ‘Wheaton said that he bad had the opportunity of-
watching a large number of coses treated by Koch’s fluid,
and had made post-mortem examinations in two cases subse¬
quently fatal. In no case had he seen a permanent improve¬
ment, but in nearly all cases a temporary improvement
occurred. The remedy certainly had no effect upon the bacilli,
and tbe cbanges described in them, such as beading and dis¬
integration, occurred in cases not so treated. In several case»
of phthisis be had found the bacilli more numerous after-
the treatment, and in tubercular glands he had been sur¬
prised to find a great increase in tbe number of bacilli'
in them under similar circumstances. He agreed with
Dr. Bristowe in saying that tbe fluid acted as a septic:
$56 The Lancet,]
ROYAL BRITISH NURSES’ ASSOCIATION.
[April 25,1891.
poison, and instanced the various rashes, tonsillitis, the
suarked disturbance of respiration, the enlargement of
the spleen, congestion of the lungs, anaemia and wasting
following the injections, as all pointing to a septic
jioisoning. In answer to the question has the fluid any
effect in tuberculosis, he would say that it certainly
caused the disintegration of caseous material, and mentioned
a case of tubercular peritonitis where large nodular masses
of tubercular deposit were felt on palpation. After several
injections the abdomen became greatly distended, acute
peritonitis set in, the temperature rising to 105°, and the
umbilicus ruptured, from which pus continued to be dis¬
charged up to the time of the patient’s death, which occurred
eix weeks later from asthenia. At the post-mortem
exantlnatioD no tubercular deposit was found in the body
•except a few suppurating glands in the iliac fossa; but there
were three distinct collections of fetid pus in the abdominal
•cavity in the positions formerly; occupied by the nodular
masses. In another case of phthisis of the left apex and old
sinuses persisting after excision of the hip the patientdied five
weeks after the last injection had been given, from obstinate
vomiting and diarrbeoa, after an operation for the scraping
•of the sinuses. Post mortem the lung was found to be
shrunken, the pleura adherent, and its upper lobe infiltrated
with caseons miliary tubercles, which were evidently under-
-I'oing resolntion, and had in great part become converted
into nodules of fibrous tissue; no other tubercular disease
•existed except of the bip-jolut. These cases differed from
those reported from abroad in that no general tuberculosis
had been set up by the injections. In conclusion, he said
that the treatment was not justifiable except in cases where
there was a ready exit for the products of the breaking
-down caseous material and no risk from the danger of a
•collection of pent-up pus.
THE ROYAL BRITISH NURSES’ ASSOCIATION.
The Princess Christian was present at a meeting of this
Association, presided over by Sir Wm. S. Savory, Bart., on
Thursday, the 16bb inst., called to consider the action to be
•taken by the Association in view of certain attacks which
(had been made upon it by the managers of some nurse,
training schools and others.
Dr. Bedford Fenwick said the chief object of the
Association was to provide for the registration of nurses
who produced evidence that they bad received systematic
training. The Association had been strongly opposed ; the
members had been called the “scum of the nursing pro¬
fession” who took refuge in this Association to obtain
“ pseudo-respectability,” and in private, nurses who would
have joined the Association had been intimidated against
doingso. Lady Bloomfield and hercommittee were desirous
to transfer tbeir annuity fund for nurses, which bad an
invested capital of £4000 to be managed by the Asso-
oiatioh, but this could not be touched unless it was
registered under the Companies’ Acts. They could not
legally receive and administer trust funds, and therefore
db was decided to apply for incorporation. The opponents of
the Association had done their utmost to prevent Lady
Bloomfield’s fund from being received. They had circulated
■documents to hospitals throughout the country asking them
to condemn the Association unheard. The registration of
courses was entirely outside the question. The Register had
been compiled and could be published annually to the end
■of the world, in spite of all opposition, as it had already
been without the Association being incorporated. The
addition of the word “ limited” stamped the Association as
a business concern in the eye of the law, and no member of
the Royal Family could be officially connected with it. The
■object of the opposition was either to prevent the Associa¬
tion becoming incorporated at all, and so to prevent
it receiving Lady Bloomfield’s fund, or to force it to be
registered as a trading concern, and so lead to the retirement
•of the President, H.R.H. the Princess Christian—a con¬
tingency which they absolutely declined.
Sir James Crichton Browne, Lord Chancellor’s Visitor
in Lunacy, said be was somewhat shocked when he read
•that a “committee of observation ” had been formed to pre¬
vent the Association from carrying out its proceedings.
This was simply a new manifestation of an old animosity
of which they had ceased to have any dread. Its imme-
•diate cause was an application to the Board of Trade to
sanction the registration of the Association with the
omission of the word “limited” in order to have facilities
for carrying on the business of the Association for re¬
ceiving and dealing with the gifts and benefactions for
the benefit of nurses, which would, he trusted, flow iu
upon them bountifully in time to come. He deprecated
the hidden tactics and misrepresentations which had been
made against them. The opposition was a little premature,
as their ^plication had not been advertised in the public
prints. The time for opposition arose when that bad been
done. Their articles of association, which had not yet
been approved by the Board of Trade, had by some extra¬
ordinary means been obtained, and bad actually been printed
by their opponents and extensively circulated throughout the
country. Notwithstanding all opposition, the Royal British
Nurses’ Association with its 3000 members was an accom-
lished fact, and be had no doubt that the application would
e successful in spite of all the attacks that malice and envy
could direct towards tiiem. He thought the expression
“scum of the profession” was a printer’s error for
“ cream of the profession.” The Association was capable
of taking care of itself. The opposition to them was
opposed to the great principles of social evolution.
All development implied ditterentiation of structure and
functional and gradual organisation. In the simplest
organism every cell performed every function. As division
of labour goes on the duties of the separate cells 8>re
oourdioated. So in social development bodies of persons
are set apart for special duties, professions, trades, crafts,
scattered throughout the country, working iu isolation and
individually. In the course of time they establish com¬
munication between each other, coalesce, organise round a
centre and assume a corporate existence, not only for their
own benefit, but for the benefit of the body corporate.
Nurses were no exception to that rule, and, in obedience to
that inexorable law, they bad begun to organise. The
opposition to this principle came, too late in the day;
it was contrary to all great principles of biology, and
ran counter to the public interests of this country,
for it aided in depriving the public of securities and
safeguards which they have long needed and to which
they are well entitled. He could not understand why
the public had not made a peremptory demand for the
registration of nurses long ago. It was a recorded fact that
the training institutions sometimes sent before the public
women who were raw and immature and imperfectly
educated, as well and thoroughly trained nurses. What
were the objections which had been urged against this
Association V The first was “ that the duties and qualifica-
’ tions of a nurse are so difierent from those of all other kinds
of bodies of persons seeking a public registration, and so much
depends upon the character and disposition, apart from mere
technical skill, that to place nurses upon a Register would
I merely be to mislead the public regarding their efficiency.
He affirmed confidently that while deposition and character
were of the utmost importance, they were not of more im¬
portance to them than to other-professions that were
already registered—e.g., medical men who were compul¬
sorily registered by Act of Parliament; and he had never
heard it said that the Medical Register was of no use to the
public because it contained no reference to the character
and disposition of the medical man. Was not the
teacher’s disposition and character of some account?
and yet Parliament was considering whether they
’should not be registered. Then surely technical know¬
ledge and skill ought to count for something as well as
moral character and disposition. A nurse may have
the sweetest disposition in the world, but if she
allowed a sufferer to bleed to death it would not ’be
•much consolation for him to rellect upon her sweet dis¬
position and unblemished character. He went further, and
said that the Register did contain some indication of
'character, and that the objection was altogether flimsy and
'sophistical. The second objection was like unto it. It
was that the authorities of the nurse-training schools are
alone, by their position,' capable of understanding the
qualifications and character of nurses, and of giving infor¬
mation regarding them, and that all these authorities
opposed registration. Was that statement correct? Some
of the great training schools were represented on the
Council and upon the registration board of this Associa-
'tion. Hethouglitifc was not a proper thing to go before
the Board of Trade with a statement which-was distinctly
incorrect. He asked if nursing was to be a free profeasion, or
to be confined to a series of litue close corporations under the
The Lancet,]
INEBRIETY AND CRIME.
[April 26, 1891. 957
thumb of the nurse-training schools ? This Register would be
a most important check upon the training schools, and would
confer in the end great freedom upon the nursing profession,
and put into their pockets large shares of their earnings
which in the meantime were going to the training schools.
Another objection seemed to mean that because there was
a movement going on for the registration of midwives this
movement for the registration of nurses should be put a
atop to. The fourth objection was that the registration of
nurses would lead to discord, and prove inimical to the
great work of the training schools. It was for the training
schools to put a stop to that discord. He believed that,
so far from interfering with the work of the training schools,
the Association would have the very opposite effect. It
would prevent practices which had been objectionable in
the past, and it would be of advantage to the sick of this
country. He concluded by moving a resolution to the
effect that the Association should be registered under the
Companies Act of 1867, without the addition of the word
“ limited.”
Mr. Brudenell Carter, in seconding the resolution, said
he had not been able to conjecture what reasons could be
alleged against the proposals of the Association. He found
their opponents had given no reasons, but only pretexts,
most conspicuously coloured, which reminded him of the
coloured air balloons sold in the parks by itinerant toy
dealers. The opposition came from a somewhat tainted
source, because while the efforts of the Royal British
Nurses’ Assocation had been, and would be to-the end,
addressed to raise the status, to improve the education, and
to increase the earnings of nurses; and to combine them for
that mutual protection and support, which the professions
carried on by men had found it necessary to secure for
themselves, it was notorious that the training schools were
not conducted in the interests of individual nurses, but on
a basis of totally different motives. Any opposition
coming from them should be looked upon by nurses and by
the public with extreme scepticism. The nurses should rely
upon their own powers of observation, and claim that privi¬
lege of effectual combination which the law had given them.
Mrs. Bedford Fenwick supported the motion, and con¬
tended that the private registers kept in the training
schools did not protect the sick from women who chose to
term themselves trained, nor from women certided as
efficient who afterwards proved unworthy of trust.
The resolution was carried unanimously.
Dr. Pavy moved: “That the Register will be valuable
to the public, to medical men, and to nurses, by protecting
them from ignorant and untrustworthy nurses by affording
an easily consulted guaranteeof a nurse's technical elHciency,
and as the first attempt ever made to remove from the call¬
ing those who discredit their fellow-workers.
Dr. Bezly Thorne seconded, and said their opponents
must be aware that the registration board would not enter¬
tain any application from a nurse who could not produce
evidence of moral character.
Miss Catherine Wood said that the hospitals which had
opposed the registration had been for some time past sound
asleep, and wore at present in the condition of a person
who had been rather suddenly awakened. They did not at
present exactly know what kind of work was before them.
The resolution was carried unanimously.
Sir Edward Sieveking proposed, and Sir Joseph
Fayrer seconded, a vote of thanks to Sir Wm. Savory for
presiding.
Sir Wm. Savory, in reply, said that he rejoiced at the
opposition which the Association had met, because opposi¬
tion was inevitable to all progress ; but it must ultimately
enlarge its success. It was most fortunate to have these
dilficulties to encounter. They were determined to triumph
over them. They liad existed three years, and had enrolled
‘1000 members and registered 1700 nurses. Those who
opposed the movement might as well attempt to stem the
rising tide. In concluding, he moved a vote of thanks to
the Trincess Christian for her presence at the meeting.
Tiie vote was carried with enthusiasm.
INEBllIETY AND CRIME.
At the annual meeting of the Society for the Study of
Inebriety held recently, after an address from the Rre-
sident. Dr. Norman Kerr, on “Recent Criminal and Civil
Trials with Inebriate Complications,” the following resolu¬
tions were agreed to, on the motion of Dr. Lord, seconde(S
by Mr. Hilton.
1. In all criminal trials in which the alleged criminal act
has been committed by the accused when under the infiur
ence of liquor or has been committed by an inebriate, there
should be an investigation into the previous medical history
of the prisoner. There should also be an inquiry into the
family nietory, so as to elucidate the heredity with especial
reference to inebriety, insanity, and other neurotic affec¬
tions, syphilis, and gout. This twofold inquiry should be-
entrusted either to a medical expert or to a mixed com¬
mittee composed of a medical and a legal expert acting;
conjointly. The object of this investigation is to ascertain
how far the accused has been cognisant of bis alleged
criminal offence, and as to whether, if so cognisant and so-
competent, be was able to resist the criminal impulse. Such
an expert inquiry should be provided for the accused, what¬
ever the circumstances, as a judicial provision to ensure a-
fair and just trial.
2. The appointment of a mixed Commission of judges,
counsel, solicitors, and medical experts for the consideration
of the question of dealing with inebriates who have been
convicted of a criminal offence. This inquiry should have
special reference to the best procedure to be pursued,
whether, (1) if penal, by cumulative punishment or other¬
wise; or (2) if curative, by medical treatmentfor a diseased
condition, with due provision for classification, occupation,,
hygienic measures, and elevating influences. By some
researches of this kind such light might be thrown upon
the genesis of crime complicated witii drinking and the
morbid conditions which precipitate not a few individuals-
into inebriate criminality, as might aid in the prevention
of crime, as well as improve the criminal’s cliances of
reformation, and increase the iniluence and dignity of the
law by avoiding even the semblance of injustice.
GENERAL PRACTITIONERS’ UNION.
A MEETING of the Executive Committee was held on
the 15bh insb., Mr. George Brown, M.R.C.S., in the chair.
The following members were also present; Dr. F. H,
Alderson ; Mr. T. li. Atkinson, M.R.C.S.; Mr. J. B. Cook,
L.Il.C.P.Edin.; Mr. F. H. Corbyu, M.K.C S.; Dr. James-
Dawson; and Dr. Hugh Woods. Forty-four general practi¬
tioners, having been duly proposed and seconded, were
elected members of the Union.
It having been suggested that it would greatly facilitate
the work of the Union if the metropolis were divided into-
districts, with a secretary for each, it was decided to carry
out tlie suggestion, and the following district secretarles-
were appointed
DinirUit. Honorar;/ Seeretarji.
East Contral .W. E. Dawson, L.R.C.P.I.
Ilainmorsmith ami Shepherd's Bush.. P. II. Alderson, M.D.
South Ken.sington.T. R. Atkinson, M.R.C.S.
Kilburn.. ..11, C. Shnw, L.R.O.I'.LomU
St. John’s Wood.F. II. Corhyn, M.R.C.S.
lliffhRate and Upper Holloway .. .. Hugh Woods, M.D.
Islington .J. B. Cook, L.R.C.P. lid.
Canonbury .and Stoke Newington .. .1. Dawson, M.D.
West Ham and Barking.Percy Rose, J..R.C.P. Loud.
Camberwell and Peckham.Campbell Boyd, J..R.C.P.I.
District secretaiies will be appointed for other parts of
London and for the provinces as soon as practicable.
IPjtWit Pealt| anil |pnnr fain.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF MEDICAL OFFICERS OF HEALTH.
Went Hartlepool Urban District .—On an estimated popu¬
lation of -10,000 the general death-rate for 1800 was ISper 1000,
the zymotic rate being 2 per 1000. According to Dr. Goutley,
the system of compulsory notification is working well, but
tbo uses to which it can be pub are naturally very limited
in the absence of an isolation hospital. Amongst the dis¬
eases notified last year there were 2-16 of scarlet fever, of
which I.*) were fatal. There were also 5*1 cases of enteric
fever, of which 9 terminated fatally. In one house eight
persons were attacked, and it was found that they derived
their milk from next door, where a previous case had
Dir-- zed by Google
95^ ThsLaitcet,]
REPORTS OF MEDICAL OFFICERS OF HEALTH.
[April 25, 1891.
existed. New pablio slaughter-house arraagements are
stated to be oecessary, many of the existing establishments
Wng out of date, dilapidated, and unwholesome.
Hereford Combined Sanitary Districts .—No general report
comparing the several districts which make up this com¬
bination IS issued, each district being dealt with without
reference to the others. A number of the reports also deal
-almost exclusively with statistics and occurrences of disease
and death. In dealing with the Leominster rural district,
however, Mr. Vavasour Sandford reminds the authority
‘that no action has been taken to amend the faulty con¬
ditions of sewerage and drainage at Kiogsland, and he urges
that the matter should be dealt with before the risk of
disease Is incurred, and before the hot weather ensues.
Withington Urban District .—If the population of this
district is correctly estimated by Dr. Railton. its general
death-rate during the past year did not exceed 12-9 per 1000,
and its zymotic rate was correspondingly low. In view of
a prevalence of measles, and the conviction that lb was
largely associated with school attendances, Dr. Railton
gives some excellent advice as to the detention at home of
children who are suffering from preliminary symptoms
which are alike premonitory of colds and of measles, and he
urges that, whatever the outcome, gain to the child and
doubtless to the community will result. Improvement is
still called for in the matter of the pollution of streams;
but the general sanitary work of the district would appear
to be well maintained.
Carlisle Urban District .—This district exhibited in 1890
a slight rise in its general rate of mortality, which was 19*5
per 1000 Jiving. There is thus need for reduction, but
when compared with the last decennium, great changes for
good have been, effected in this respect. No less than 578
coses of scarlet fever were notified, but the mortality was
comparatively small—namely, 22 in all. The disease was
essentially confined to the working classes; and Mr. Wm.
Brown details the action taken by way of excluding
scholars from the elementary schools in cases where the
disease prevailed in their homes. Unfortunately the results
which sQOuld have followed were frustrated partly by the
number of mild attacks which only came under medical
cognisance late in the attack, and partly by the failure of
the Carlisle rural authority to adopt compulsory notification.
Detailed accounts are given of occurrences of enteric fever
and diphtheria, and of the action taken in consequence.
‘But little isolation in hospital was resorted to, only 58 cases
in all being thus dealt with The general sanitary work of
the district is briefly referred to, and an account of the vital
statistics adds materially to the value of the report.
Ashton-in-MaherJield Urban, District. —Mr. N. Hannah
has occasion to refer to the difficulty experienced in pro¬
perly controlling such a disease as scarlet fever by reason of
the non-recognition of mild attacks and the utter careless¬
ness and disregard of people as to infection. In a number
of cases hardly anything was known as to the existence of
disease until the occurrence of secondary nephritis and of
desquamation. A full account is given of disease occurrences
month by month, and action is advised as to unwholesome
places before reported on, but not yet dealt with, as to proper
scavenging arrangements, as to the provision of public
latrines, and as to improvement in dealing with the sewage
eflluent. Some improvements have been carried out during
the past year; the hospital has proved beneficial in a
number of instances; out Mr. Hannah, speaking of a
lengthened acquaintance with the sanitary circumstances
of the district, is obliged to admib that the township is not
now in so good a state as on some former occasions. The
death-rate, which was 19'5 per 1000 for 1890, is showing a
alight tendency to rise, and the authority should be careful
to act on the warnings which this report and its vital
statistics afford.
South Shields Urban District .—According to Dr. Campbell
Munro the death-rate for 1890 was 22-8 per 1000, or 2 per 1000
above themeanrateforthe decade jusfccomple.fced ; this result
being regarded as largely due to acute pulmonary disease and
heart disease following the epidemic of influenza. The
death-rate from zymotic diseases, which respond of all others
to advance in sanitation, happened, however, to be low last
year. But, at the same time, there is much positive evi¬
dence of the continuance of circumstances which tend to
increase rather than to reduce preventable mortality and
sickness. The nuisance inspectorial staffis conspicuously in¬
sufficient ; the building by-laws, which appear to have been
under consideration for a number of vears, are most defec¬
tive; outlying hamlets remain witnout proper means of
drainage; and together with Leeds and Gateshead, the
corporation of South Shields, who also claim the dignity
of a County Council, still refuse to adopt the system
of compulsory notification of infectious diseases. These
are only some of the matters which the sanitary authority
appear to have a faculty of shelving ; thus a visit of inspec¬
tion with regard to a modified hospital scheme, which was
decided on some time since, is reported as not having been
aid. Dr. Campbell Munro with this report has resigned
is office, and it is a somewhat melancholy leave-taking to
find him writing that after eight years and a half of labour
he takes this step “ with the mournful consciousness that
most of what I had honed to accomplish remains undone.”
That part which is realty mournful is that the county borough
of South Shields should have had so little regard to advice
which on the face of it was sound, which was based on
scientific knowledge, and which came from an officer who,
by reason of the character of his labours in South Shields,
has deservedly acquired the reputation of an expert in
public health. _
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 63C3 births
and 4321 deaths were registered durin;^ the week ending
April 18bh. The annual rate of mortality in these towns,
which had increased from 21-2 to 22-9 per 1000 in the pre¬
ceding three weeks, docllned again to 22'5 last week. The
rate was 20‘5 in London and 24-1 in the twenty-seven pro¬
vincial towns. During the thirteen weeks of last quarter
the death-rate in the twenty-eight towns averaged 23-0
per 1000, and slightly exceeded the mean rate in the
corresponding periods of the ten years 1881-90. The lowest
rates in these towns last week were 167 in Wolver¬
hampton, 17'3 in Birmingham, 17‘9 in Brighton, and
18-2 in Derby and in Bradford; the highest rates were
27'G in Halifax, 27’9 in Hull, 31-0 in Newcastle-
upon-Tyne, and 33-9 in Sheffield. The deaths referred to
the principal zymotic diseases, which had been 468 and 438 in
the preceding two weeks, farther declined last week to 420;
they included 150 from measles, 141 from whooping-cough,
42 from diphtheria, 36 from diarrhcea, 27 from “ fever ”
{principally enteric), 24 from scarlet fever, and not one from
small-pox. These diseases caused the lowest death-rates in
Wolverhampton, Birkenhead, Brighton, and Plymouth,
and the highest rates in Salford, Sheffield, Blackburn,
and Portsmouth. The greatest mortality from measles
occurred in Preston, Bristol, Leeds, Huddersfield, Black¬
burn, and Portsmouth; and whooping-cough in Birmingham,
Halifax, Liverpool, Newcastle-upon-Tyne, Nottingham,
Derby, and Sheffield. Themortalityfromscarletfeverandfrom
“fever” showed no marked excess in any of the twenty-
eight towns. The 42 deaths from diphtheria included 26
in London, 3 in Manchester, 3 in Preston, and 2
each in Liverpool, in Nottingham, and in Salford. No fatal
case of smoll-pox was registered in any of the twenty-eight
towns; 15 small-pox patients were under treatment in the
Metropolitan Asylum Hospitals and I in the Highgate
Small-pox Hospital on Saturday last. Tlie number of scarlet
fever patients in the Metropolitan Asylum Hospitals and
in the London Fever Hospital at the end of the week was
949, and sliowed a further decline from recent weekly
numbers; the patients admitted during the week were 84,
against 98 and 77 in the preceding two weeks. The deaths
referred to diseases of the respiratory organs in London,
which had been 489 and 464 in the previous two weeks, rose
again to 504 last week, and exceeded by 78 the corrected
weekly average. The causes of 81, or 1-9 per cent., of the
deaths in the twenty-eight towns were not certified either
by a registered medical practitioner or by a coroner. All
the causes of death were duly certified in Portsmoutli,
Leicester, Salford, Cardiffi, and in five other smaller towns;
the largest proportions of uncertified deaths were recorded
In Sheffield, Bristol, and Liverpool.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had declined from 267 to 25 0 per 1000 in the preceding
three weeks, further declined to 22'6 during the week end¬
ing April 18th, and almost corresponded with the rate that
prevailed daring the same period in the twenty-eight large
English towns. The rates in tlie eight Scotch towns ranged
from 6'2 in Perth and 17*8 in Greenock to 25*9 in Glas-
Coogle
ThbLanobt,] proposed reconstitution of the LONDON university. [April 25, 1891. 959'
gow and 38'0 in Paisley. The 590 deaths in these towns
showed a decline of 63 from the number in the preceding
week, and included IL which were referred to measles,
25 to whooping-cough, 9 to diphtheria, .3 to diarrhoea, 2 to
scarlet fever, 1 to **fover,” and not one to small-pox.
In all, 81 deaths resulted from these principal zymotic
diseases, against 100 and 80 in the preceding two weeks,
These 81 deaths were equal to an annual rate of 3'1 per
1000, which exceeded by 0-9 the mean rate last week
from the same diseases in the twenty-eight Eoglish towns.
The fatal cases of measles, which bad oeeu 41 and 33 in
the preceding two weeks, rose again last week to 41, of
which 22 occurred in Paisley, 15 in Glasgow, and 4 in
Edinburgh. The deaths from whooping-cough, which had
declined from 34 to 25 in the previous two weeks, were
again 25 last week, and included 10 in Glasgow and 6 in
Edinburgh. The 9 fatal cases of diphtheria exceeded by
4 the number in the preceding week ; 6 occurred in Glas¬
gow and 3 in Edinburgh. The 2 deaths from scarlet fever
showed a further decline from those recorded in recent
weeks, and included one in Glasgow and one iu Aberdeen.
The deaths refeii'ed to diseases of the respiratory organs in
these towns, which had declined from 201 to 164 in the
preceding five weeks, farther fell to 142 last week, aud were
12 below the number in the corresponding week oi last
year. The causes of 53, or 9 per cent., of the deaths in the
eight towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate In Dublin, which had been 23'9 and 30'6
per 1000 in the preceding two weeks, declined again to27‘5
during the week ending April 18th. During the thirteen
weeks of last quarter ^e death-rate in the city averaged
30‘2 per 1000, the rate for the same period being 22 6 in
London and 21-8 in Edinburgh. The 186 deaths in Dublin
showed a decline of 21 from the number in the preceding
week, and included 7 which were referred to whooping-
cough, but not one to any of the other principal zymotic
diseases. These deaths were equal to an annual rate of
I'O per 1000, the zymotic rate during the same period being
1-8 in London and 2'5 in Edinburgh. The fatal cases of
whooping-cough, which had been 3 and 2 in the preceding
two weeks, rose last week to 7, a higher number than in
any week since March, 1890. During last quarter the
death-rate from the principal zymotic diseases in Dublin
did not exceed 1-1 per lOOO, and was below that in the
corresponding period of any year on record. The 186 deaths
in Dublin last week included 28 of infants under one year
of age and 50 of persons aged upw’avds of sixty years; the
deaths both of infants and of elderly persons showed a
decline from the numbers in the preceding week. One
inquest case and 3 deaths from violence were registered;
and Gl, or nearly a third, of the deaths occurred in public
institutions. The causes of 23, or more than 12 per cent.,
of the deaths in the city were not certihed.
THE SERVICES.
The Queen has been pleased to give directions for the
appointment of Francis Lovell, Esq., Chief Medical Ollicer
of the Colony of Mauritius.
The Duke of Cambridge has approved of Surgeon H.
llayner, of the Grenadier Guards, being permitted to
accompany Lord R. Churchill to Mashonaland. Reside
acting as medical olficer of the expedition, Surgeon Kayner
will report generally on the climate of the country traveled
and on other matters which may be of military value.
Army Medical Staff.—R rigade Surgeon Jas. Young
Donaldson, M.D., to be Deputy Surgeon-General {ranking
as Colonel), vice J. Landale, M.D., retired (dated Dec. 10th,
1890). The promotions of the undermentioned Oincers are
antedated as follows:—Deputy Surgeon-General (ranking as
Colonel) Edward Corrigan Markey, C.B, (dated Sept. lUb,
1890), vice S. B. Roe, M B., C.B., retired; Deputy Surgeon-
General (ranking as Colonel) Geo. E. Will (dated Nov. 136h,
1890), vice J. G. Fiiught, promoted; Brigade Surgeon (rank¬
ing as Lieutenant-Colonel) John Maturin, E.R.C.S.I. (dated
Sept, llth, 1890), vice E. C. Markey; Brigade Surgeon
(ranking as Lieutenant-Colonel) Roht. Collins, M.B. (dated
Nov. 13ch, 1890), vice G. E Will; Brigade Surgeon (rank¬
ing as Lieutenant Colonel) Thomas O’Farrell, M.D. (dated
Nov. lObh, 1890), vice J. Y. Donaldson, M.D., promoted;
Surgeon-Major (ranking as Lieutenant-Colonel) George
Andrew, M.B., to be Brigade Surgeon, vice J. Wilson,
M.B., F.F.P.S. Glasgow, retired (dated Feb. 14th, 1891).
Indian Medical Service, —Deputy Surgeon-General
Rudd, Array Medical Service, has been transferred from
Allahabad to Meerut, to which station be has been posted
in the place of Deputy Surgeon-General Collis, whose term
of Indian Service has expired.—Surgeon-Major Bull, in
medical charge of the 3rd Bombay Cavalry, has beea
appointed to the Civil Surgency of Poona.
Naval Medical Service. — The following appoint¬
ments have been made at the Admiralty:—Staff Surgeon
Henry L. Crocker, to the Boscawen, for Portland Sipk-
quarters (dated May 3rd, 1891); Mr. Benjamin Browning,
to be Surgeon and Agent at Weymouth (dated April 2l8t,
1891),—In accordance with the provisions of Her Majesty’s
Order in Council of April Ist, 1881, Fleet Surgeon James-
Bradley has been placed on the Retired List of his rank
(dated April 13th, 1891); Surgeon Richd. Edmund Biddulph,
B.A , M.B., has been promoted to the rank of Staff Surgeon-
in Her Majesty’s Fleet (dated March Slst, 1891).
Volunteer Corps. — Artillery: 3rd (Dumfries) Volun¬
teer Battalion, the King’s Own Scottish Borderers: Peter
Murray Kerr, M.B., to be Acting Surgeon (dated April ISth,
1891). — Ist Herefordshire; Surgeon and Surgeon-Major
(ranking as Lieutenant-Colonel) T. Turner resigns his com¬
mission; also is permitted to retain his rank, and to con¬
tinue to wear the uniform of the Corps on his retiremenb
(dated April 18bh, 1891).—5th (Glasgow Highland) Volun¬
teer Battalion, the Highland Light Infantry: Surgeon,
and Surgeon-Major (ranking as Lieutenant-Colonel) T. D.
Buchanan, M.D., resigns his commission ; also is permitted
to retain his rank, and to continue to wear the uniform ofi
the Battalion on his retirement (dated April 18bh, 1891).
Ctomspiiknn.
“ Audi alteram partem."
THE PROPOSED RECONSTITUTION OF THE-
LONDON UNIVERSITY.
To the Editors of The Lancet.
Sirs, —In your remarks on my letter published in-
Thb Lancet last week you ask me whether f “intend to-
convey that the members of the medical stalls of the
various London hospitals have otiicially met to consider the
scheme, and that it has been regularly voted on and agreed
to by them.” I meant what I said—namely, that the scheme
has been adopted by the medical schools I mentioned, and
the ground for my statement is that the Senate have
received a letter dated March 3rd, 1891, which says, “ the
medical schools of Charing-cross Hospital, Guy’s Hospital,
London Hospital, Middlesex HospitaX St. Bartholomew’s
Hospital, St. George’s Hosptial, St. Mary’s Hospital,
St. Thomas’s Hospital, and Westminster Hospital, having
considered the revised scheme for the reconstitution of the
University of London, desire to express their acceptance of
the scheme as it now stands.” This letter is signed by an
authorised representative of each of the above schools. la
spite of your criticism I still think the scheme renders the
M.B. and M.D. degrees more accessible. I do not under-
stand what you mean by the phrase “the examination
system of the Royal Colleges,” but a candidate can, under
the new scheme, take his M B. without his L R C.P. and
M,R.C.S,,nnd vice versA. ISome of the examinations will
be conducted conjointly by the University and the Colleges
merely for the convenience of the candidate who wishes to
be examined by both, but each body will independently
determine whether the candidate shall receive its diploma.
I do not know how you arrive at the conclusion that there
will be “an increased expense to the intending graduate,”
for no scale of foes applicable to this scheme has yet been
published. As a man will be able to obtain the diploma of
the University and the Colleges by the same set of examina-
tioD.s, the risk of failure will be decreased, and there¬
fore to many men the expense will be diminished. Any¬
how, it is absurd to suppose that if a candidate wants
only his M.B,, or only his M.R.C.S. and L.R.C.P., he will
be compelled to pay for both. I can assure you I have not
accepted the arguments I use so readily as you think. I
have compared the latest scheme and the one before it, and
:;:r Coogle
9*60 ‘ ThbLakcbt,]
EXCISION OF TH.YKOID FOR MALIGNANT DISEASE.
[April 26, 1891.
am well aware of the differences between them; hat the
possible inclasion—for the Senate are nob compelled to in¬
clude them—of a few small provincial colleges is, to my
mind, an unimportant matter; and it will be a thousand
pities, because of this, to wreck this scheme, which commands
the support of nearly all the bodies interested, and gives a
just share in the govemnienb of the reformed University to
the medical profession. I am, Sirs, yours faithfully,
W. Hale White, M.D. Lund.
Harley-street, W., April 20tli, 1S91.
%* Dr. Hale White seems to have abandoned the con¬
tention in his former letter that this “latest scheme” is not
opposed “in spirit and in working detail” to that recom¬
mended by the Royal Commission. He does not answer
our question as to whether the staffs of the various London
medical schools have officially met to consider the scheme.
We would remind him that a report of the Committee of
Delegates was placed before the Royal Colleges last year,
in which the fee, to he paid to those Colleges for the two
professional examinations for the pass M.B. degree only were
fixed at 25 guineas. The present fees for the corresponding
examinations at the University of London are flO.
This is how we “ arrive at the conclusion that there will be
an increased expense to the intending graduate.”— Ed. L.
“THE REMOVAL OF GALL-STONES BY ETHER
SOLUTION.”
To the Editors of The Lancet.
Sirs,— In The Lancet of April 18th I notice a short
paper by Mr. J. W. Walker under the above heading, in
which he says : “ I do not know whether the plan of dis¬
solving stones in stfuhas been before attempted by injecting
ether on them.” It may perhaps interest Mr. Walker and
others to know that the dissolution of gall-stones has been
attempted on other occasions through the fistula left by
cholecystotomy. I believe Dr. Taylor of Birmingham told
ane that he had employed a solution of ether and turpentine
to effect this ; and last year having a case of stones impacted
in the common duct, where on account of ex^teneive adhe¬
sions I bad been unable to crush or otherwise remove them,
I injected a solution of ether on two occasions with the
effect of clearing the passage ; but, as most severe pain was
produced by the injections, I am not sure that the violent
eristalsia set up by the irritation was not the real agent in
ringing about the desired effect. On another occasion I
employed a few drops of turpentine dissolved in ether, bub
this produced such severe irritation that I should not dare
to venture a repetitioif of the experiment.
A want of leisure has only prevented me from completing
some experiments which I have been thinking over for some
time, to ascertain the best solvent for gall-stones should
the surgeon be obliged to leave them in the ducts after the
operation of cholecystotomy, and I think in all probability
one will be able to find some agent which will he capable of
dissolving the concretions without injuring the mucous
membrane. It seems to me that difficulty will very seldom
arise with regard to stones in the cystic duct; at all events,
my own experience in a considerable number of operations
would lead me to this conclusion; but with regard to calculi
impacted in tbecommon duct difficulties must often arise, as
it certainly is not always possible to crush them, and it is far
•from an easy and safe procedure to incise the duct, and
effect their removal.—I am, Sirs, yours faithfully,
Leeds, April Zlst, 1891. A. W. MAYO RoBSON.
EXCISION OF THYROID FOR MALIGNANT
DISEASE.
To the Editors of The Lancet.
Sirs, —In The Lancet of April 4bh, Mr. Pepper gives a
very interestiug account of the successful removal of a
large bronchocele described as malignant. With all due
respect to Mr. Pepper, I venture to suggest that the report
of the pathological appearance of the tumour docs not
point by any means conclusively to malignancy. The pre¬
sence of “alveoli filled with cubical cells ” and surrounded
by fibrous tissue does not in the thyroid gland necessaiily
indicate carcinoma, but rather one of the fibro-adenomatous
tumours so frequently found in innocent goitres. Nearly a
year ago I removed from a middle-aged lady a solid thyroid
tumour weighing nineteen ounces. On section the tumour'
presented in places the same appearances as those described
by Mr. Pepper—namely, fibrous tissue with numerous
alveoli occupied by cubical cells. I did not consider this
to he evidence of malignancy, and did not remove the
opposite lobe of the gland. The patient, when I last saw
her a few weeks ago, was in perfect health, and had
had no return of the disease. Again, it is stated that
in Mr. Pepper’s case the malignant portion of the
growth formed two masses “distinctly marked off from
the neighbouring tissue.” Now, it is surely not usual
to find primary carcinoma occurring in any situa¬
tion as two separate masses. I have seen some fifty
mus6urn. spocimcDs of malignaut dise&se of tho thyroid but
have never found the above condition present. Innocent
solid tumours, however, which are so commonly met with
in goitres are often definitely encapsulated and frequently
multiple. Excellent examples may be seen in the museums
of the College of Surgeons, St. Bartholomew’s Hospital, the
Royal Free Hospital, and in many others. I should not have
considered it necessary to draw attention to Mr. Pepper s
case were it nob for the important, question of treatment
involved therein. On the ground that the right lobe of the
gland contained a malignant tumour, Mr. Pepper appears
to have performed a total excision. Now, the propriety of
completely removing a goitrous thyroid gland, even for
malignant disease, is at least doubtful. But total excision
of the gland which contains innocent tumours only is
nowadays almost universally admitted to be an unjustifiable
operation. It is not for me to assert that the tumour in
Mr. Pepper’s case was not a malignant one. What is clear,
however, is that the description given would apply equally
well to one of the commoner innocent tumours, tf the
tumour be really malignant, the case is an exceedingly rare
one ; indeed, it is probably unique. It may be that
Mr. Pepper has further evidence of the malignant nature of
the tumour. If so, be would do well lo give it. It is to
my mind highly undesirable to encourage the performance
of' total excision without much stronger proofs of malignancy
than are afforded by the description of Mr. Pepper’s case.
I am. Sirs, yours faithfully,
Wclbcck-streot, W. J AMES BeBRY.
POISONOUS PROPERTIES OF PRIMULA
OBCONICA.
To the Editors of The Lancet.
Sirs,—A s attention has lately been directed to the
poisonous properties of Primula obconica, perhaps the
following note of a case of poisoning by this plant, which is
becoming a favourite for its pretty fiowers and foliage, may
prove of interest.
On the 14bh insb. a lady consulted me about her right
hand, which was swollen and much inflamed, presenting all
the appearances of the early stage of acute eczema, which
I at first thought she was suffering from. She complained
mostly of intense itching and burning pain iir the fingers.
There was no constitutional disturbance. On further
questioning she said she had been cutting llowers the pre¬
vious day, and on giving her the name of the plant which I
thought might have caused the mischief her gardener at
once identified the primula in question as the one she had
been working with, and stated that his own hands had been
sore for some days. He had been engaged in repotting it.
With the use of an evaporating lotion and saline purgative
all the symptoms had disappeared by next day. From its
appearance the irritation caused by handling this plant
might easily be mistaken for acute eczema or erysipelas,
and perhaps this note may help to eliminate a new source
of error in the diagnosis or these complaints.
I am. Sirs, yovits faithfully,
ailfov<I, CO. Down, April I7th, 1801. S. A. L. SWAN, M.D.
LIVERPOOL.
(From our own Correspondent.)
Wholesale Destruction of Insanitary Property.
A'l' the City Sessions recently held the grand jury were
engaged in an inquiry with reference to over five hundred
houses in the city scheduled by the Corporation under the
Liverpool Sanitaiy Amendment Act, 1804, and the Liverpool
Google
Dirv
The Lancet,]
LIVERPOOL.—NORTHERN COUNTIES NOTES.
[Apeil 25, 1891. 961
Smprovement Acts of 18(57, 1871, and 1882. This property,
which has been reported by the medical oflicer of health, Dr.
Taylor, to be insanitary, is situated off one of the main
'thoroughfares of the northern part of the city, and, in
Allusion to the names of the streets has been sarcastic¬
ally styled “ Poet’s Corner,” these streets being named
(respectively Addison, Southey, Pope, Milton, Cavendish,
.&C. A more unpoetical snot could not be imagined,
and it is a melancholy instaDce of the rapacity of
landlords that they could ask for and receive rent
[for such wretched dwellings. In addition to Dr. Taylor’s
■evidence, there was that of Dr. Littlejohn of Edin¬
burgh, who ffave it as his opinion that the houses in question
were a scandal to the country and the city. Decency was,
he urged, impossible under the circumstances. Professor
Uorfield considered them unfit for human habitation. Dr.
Hope found that the court houses contained a double
quantity of foul air. The jury presented the property for
■demolition, as requested by the medical officer of health.
An Epidemic of Wounding.
At the assizes held in February, Mr. Justice Day con¬
gratulated the grand jury upon the absence of the many
severe cases of wounding with knives which he remembered
at former assizes here; and only last week the recorder
<Mr. Charles H. Hopwood) congratulated the grand jury
on the absence of stabbing and of violence producing wounds.
Unfortunately at the very time when Mr. Justice Day was
speaking there had commenced a series of wounding cases
which have continued so as to assume the character of an
■epidemic. Mr. George Hamilton, honorary surgeon to the
Northern Hospital, in a letter to the daily papers, gives
some startling details which rudely dispel the bright vista
pictured by the learned judge and recorder. The following is
Mr. Hamilton’s short list of some of the more serious cases
admitted into the Northern Hospital during the last seven
weeks : (1) Wound of arm, dividing main artery ; (2) wound
of abdomen, with protrusion of bowels ; (3) wound of chest
-and diaphragm, exposing spleen ; (4) compound fracture of
■skull caused by knife ; (5) severe wound of chest; (6) frac-
tui'e of lower jaw; (7) dangerous wound of chest; (8) wound
■of arm, dividing main artery; (9) stab at upper part of
chest; {10} kick, destroying eye, the other eye having been
previously destroyed in a similar way; (11) dangerous
wound of chest; 02) wound of eye, necessitating removal.
These are only the more severe cases admitted as in¬
patients; many other cases have been treated as out¬
patients, and Mr. Hamilton’s opinion is that wounding has
been greatly on the increase. He adds that the cases which
■come before the courts are by no means all which occur.
Some injured persons are deterred by threats; in other
-cases the charge is dismissed by the magistrate in despair
■of being able to determine upon whom to fix the blame.
The police surgeons, moreover, see many constables wounded
where the assailant has made good his escape and is un¬
known. Clearly the hospitals and dispensaries would prove
a better barometer as to the prevalence of wounding than
ibhe experience of judges, recorders, or even magistrates.
T/ie Disposal of the Dead in Liverpool.
Since the publication of Dr. Hope’s paper, alluded to in
ta recent letter, a correspondence has been going on in the
Liverpool Daily Post as to the respective merits of crema¬
tion and burial. The largo proportion of burials (probably
75 per cent.) takes place in three local cemeteries, and it is a
very significant fact that some diilioulty is now experienced
no procuring the reinterment even in the more recently
formed cemeteries of those remains removed from time to
'time from those local churchyards portions of which are
required for city improvements. Were it only the remains
' -themselves, there would probably be no difficulty at all;
■but unfortunately there are also leaden coffins, which have
already monopolised the ground for many years past, and
will of course continue to do so for many more to come; and
'there are also the wooden coffins, which in the past have
been far too strong and imperisliable, especially where the
■soil is damp, as in so many old churchyards here and else¬
where. Still, however, these strong, massive, imperishable
■coffins continue to be used, and there is much truth in the
'remark of a clergyman that cremation has been suggested
in despair of proper burial being ever adopted. The feeling
in favour of cremation is very strong here, and is increasing.
Deaths of Local Medical Practitioners.
The deaths of Mr. Joseph Lamb of Birkenhead and of
Mr. Thomas R, Pennington of this city, both comparatively
voung men, have caused much sorrow to their professional
brethren and much sympathy with their surviving relatives.
The past winter will be remembered as a most fatal one,
attacking fatally the old, young, and middle-aged.
Livon)ooI, April 21st.
NORTHERN COUNTIES NOTES.
(From our own Correspondent.)
Influenza at Newcastle.
Influenza has been prevalent in Newcastle and district
now for a few weeks past; large numbers are laid up with
it, and I have heard of twenty persons from one establishment
being absent from this cause. So far the epidemic does not
seem so severe in its effects on individuals as that of last year.
Gastric symptoms have been, perhaps, more severe, and
head complaints less common. Convalescence has been
scarcely so tardy and relapses less frequent.
Ambulance Work.
The great works of Sir Wm. G. Armstrong, Mitchell, &
Co. at Elswick have inaugurated their eighth session of
ambulance instruction, and at the meeting held last week
the following figures were given for last year: the classes
opened with 185 students ; of that number 135 qualified
for examination, 121 passed. During the year 1059 accidents
happened throughout the whole of the Elswick Works, and
that number received “ first aid ” before being taken to the
infirmary or elsewhere. Mr. R. Clark Newton gave a
lecture and demonstration on ambulance work, and cer¬
tificates and medallions were presented to the students.
Port Sanitary Matters.
At a meeting held last week of the Tyne Port Sanitary
Authority it was reported that during February and March
a total of 2164 visits had been made to vessels ; in 87 cases
there were sundry sanitary defects, and with the exception
of 10 they had all been attended to ; 40 cases of sickness had
been inquired into, and six old beds burnt. The drinking
water of two vessels had been changed and fresh tanks
supplied. Calcutta was reported as affected with cholera.
There had been a large increase of emigrants arriving from
the Continent en route to America. All were well.
The Projected Hospital at llehhum.
It is stated that the scheme for providing a hospital at
Hebburn-on-Tyne is progressing most satisfactorily, and
assistance is being extended on all sides. The majority of
the men in the large •works in the neighbourhood have
agreed to give systematic subscriptions; also the various
cooperative societies in the district. It is quite certain,
notwithstanding all that has been written adverse to the
project, that the men have set their minds on having the
hospital.
Cumberland and Westmoreland Asylum.
The annual report of the Medical Superintendent of the
Cumberland and Westmoreland Lunatic Asylum at
Garlands, together with the reports of the Visiting Com¬
mittee and of the Lunacy Commissioners and the statistical
tables of the institution for the year 1890, have been issued.
The report was ready for publication a year ago; but in con¬
sequence of the Government auditor not having audited
the accounts till March, 1891, the issue was delayed. Dr.
Campbell shows that the daily average number of patients
during the year was 579, and the recovery rate, calculated
on the admissions, was 44 per cent, for men and 43
per cent, for women. He shows that the recovery rate
for pauper patients was 45'7 per cent., while for private
patients it was only 27‘7 per cent., and he attributes
this circumstance to two causes. In the first place, there is
a reluctance to send private patients to an asylum except as
a last resource, and often after the period for skilled treat¬
ment would have been of avail; and in the second place
several chronic cases were transferred to Garlands from
other asylums. I’orty-nine deaths occurred during the year,
the death-rate calculated on the average number resident
having been 8'4 per cent. About a third of the deaths
were from cerebral or spinal disease. The Lunacy Com¬
missioners conclude their report with the remark that “ the
asylum continues to be managed with energy and efficiency,
while the assistant medical officers should receive praise for
the carefully noted case-books.”
Cumhcrland Infirmai'y, Carlisle.
An inliuential meeting, at which the Bishop of Carlisle
Coogle
9'62 Th£ Lancet,]
NORTHERN COUNTIES NOTES.-SCOTLAND.
[Apkil 25,1891.
{ tresided, has been held to consider a plan for raisin;; funds
or increasing the accommodation of the nursing staff of the
Cumberland Infirmary, Carlisle. It was mentioned that
more than £2000 would be required for the proposed enlarge¬
ment of the infirmary, so as to embrace a scheme for nurses
employed at the institution, including night nurses, as well
as private and district nurses.
Death oj Dr. H. D. Ward of Blyth.
I heard with regret last week that Dr. H. D. Ward of
Rlythhad died at his residence on the 14th inst. Dr. Ward
was in his fifty-third year, and was a partner with his
father, the venerable Mr. Gilbert Ward, F.R.C.S , who is
in his eighty-sixth year, and who survives him. Dr. Ward
was M, D. St. And., M. K. C. S., and L. S. A. He was surgeon
and trustee to the Knight Memorial Hospital at Blyth, in
which he took a great interest, also medical officer of health
and port medical officer for Blyth. The Wards were a
well-lcnown medical family at Blyth, and at the time of
the Hartley accident greatly distinguished themselves.
Dr. Ward's funeral took place on Saturday last, and the
occasion was one of general mourning in tbe town, as be
was greatly esteemed by all classes of bis fellow-townsmen,
and likewise by bis professional brethren in tbe north,
many of whom were present at his interment. Dr. Ward
was a bachelor. Much sympathy is expressed for his aged
father.
Painful Case at Durham Prinon.
A coroner’s inquest was held at Durham touching the
death of a prisoner who bad died in the gaol hospital that
day. lb appeared that the deceased, a labourer aged
forty, was committed by the county magistrates at Bishop
Auckland to seven days’ hard latiour for begging. The
prison surgeon deposed that deceased when admitted was
suffering from heart disease and dropsy, chronic disease of
the kidneys, and bronchitis, and in such a perilous condi¬
tion that any medical man seeing him would at once have
admitted him to hospital instead of prison. The coroner
made some very strong remarks, with which the jury
agreed, on the harshness of sending a poor dying wretch
like deceased to prison for a technical offence; and although
it did not appear that there had been any medical man on
the magistrates’ bench when the man was committed, it
would have been easy to have had him seen by a police
surgeon or any surgeon in tbe neighbourhood.
The Middlesbrough Football Fatality,
An inquest was held in tbe case of the fatal football case
noted in my last letter as having occurred in Middles¬
brough. It appeared that the deceased was going very
quickly, and came in contact with the goal-keeper’s knee,
the knee striking his abdomen, when he dropped in the
field, and died the next day from shock and abdominal
injury. The coroner said that such rough practices at
football should be discouraged, and the rules adhered to
which prohibit raising the knee, and that the jury had
almost decided to send the goal-keeper for trial, bub re¬
quested him to give a reprimand instead.
By the will of the late Mr. Robert Thomas Wilkinson of
Rose Dene, Sunderland, and Holystone, Northumberland,
various sums have been left to charitable institutions—
amongst others, £000 to the Sunderland Infirmary, £ 100 to the
Monkwearmoubh Dispensary, and £100 bo the Nurses’ Home.
Newcastle-on-Tyne, April 23r(l.
SCOTLAND.
(Feom our own Correspondents.)
Royal Scottish Society of Arts.
At the last meeting of this Society Mr. W. P. Buchan,
Glasgow, read a paper on tlie Ventilation of Schools, in
which he pointed out tlie defects in the ventilation of
Board schools both in Glasgow and Edinburgh, the faults
being in the direction of tbe want of proper means for
carrying away vitiated air and the imperfect system for the
introduction of fresh air. He attributed much of the sick¬
ness amongst children at school to bad ventilation. He
also made a comnmnieation on tbe “ Smoke Test for Drains,”
and pointed out that the introduction of this test had led
to an immense improvement in the sanitary conditions of
houses.
St. Bernard’s Well.
The sources of the mineral water-supply of this well have
been undergoing a thorough investigation at the instanoe*
of the Edinburgh Town Council. It has been found that
with regard to the four springs which supplied the well in
onljr two of them were sulphuretted hydrogen and iron,
which are the medicinal constituents of the water, present
in considerable quantity; while in the other two the
quantities were small. It has been arranged to restrict
tbe supply of tbe well to the two richer springs. It is
also stated that no contamination with organic or other
deleterious matters was present; bub after the operations
are completed, it is proposed to make farther anaylaes of
the water.
National Registration of Plumbers.
The annual meeting of the registered plumbers in the.
Edinburgh and East of Scotland district was held in Edin¬
burgh last week, Professor Armstrong presiding. In moving:
the adoption of the report, the chairman dwelt upon the
necessity of plumbers being educated in the scientific and'
sanitary aspects of their work, and said that an incom¬
petent and Inexperienced workman might be described as
a “pestilence that walketh in darkness,” and it was to
remedy this that the Association had arisen. Sir Douglas.
Maclagan was re-elected President.
Royal Maternity Hospital, Edinburgh.
Mr, T. Stevenson Balfour, M.B., C.M., and Mr. H. G.
Langwill, M.B., C M., have been appointed house surgeons
to this hospital, and enter upon their duties on May 1st.
Edinhtirgh Royal Physical Society.
At the meeting of this Society last week, Dr. Forbescue
Fox read a paper on the Climate of Strathpeffer Spa, in
which he compared the annual mean differences and tbe
average dilferences between night and day temperatures
with those in London and at Greenwich.
Health of Edinburgh.
The mortality last week was 109, making the death-rate
21 per 1000. Diseases of tbe chest caused 42 deaths and
zymotic diseases 13, of which 3 were due to diphtheria, 4’
to measles, and 6 to whooping-cough. The intimations fpr
the week comprised from typhoid fever, 5 from diphtheria,
25 from scarlatina, and 07 from measles. The mortality in
Leith for the week was 31, making the death-rate 20‘15
per 1000.
Health of Aberdeen.
In his report for the month of March, Dr. Matthew Hay,
the medical officer of health, states that tbe death-rate was
19'38 per 1000, being 8'35 less than in the corresponding
month of last year. The lowness of tbe total death-rate
during the month is mainly attributable to the distinct
abatement of tbe present epidemic of scarlet fever, and also
to a low mortality among aged people, in spite of the
inclemency of tbe weather. During the month 24 patients
were admitted into tbe city hospital, and the average
daily number of patients was 61. There was 1 death, that
of a child, who was admitted suffering from severe post-
scarlatinal dropsy. During the week ending April ISbh,,
the following cases of zymotic diseases were notified to the
medical oifleer :—Puerperal fever, 1; erysipelas, 3 ; measles,
2; scarlet fever, 6; diphtheria, 2; typhoid fever, 1; whooping-
cough, 4.
The County Medical Officership, Aberdeen.
By a majority the County Council resolved to approach
the Town Council of Aberdeen with the view of coming bo-
some arrangement whereby Dr. Matthew Hay could under¬
take the duties of the county medical officership in addition
to his present duties as medical officer for the city. The
subject was discussed at a meeting between the Public
Health Committee of the city and a deputation from the
County Committee, with the result that the former sub¬
mitted a report to the Town Council opposing the pro¬
posal. In the report there is the following statement:—
“The committee are of opinion that it would not be a
satisfactory arrangement for the Town Council if the
proposal indicated by the County Council were carried
into effect. The large amount of work falling to be per¬
formed by the city medical officer renders it necessary that
the gentleman holding the appointment should devote his
whole time and attention to the duties. The work is also
of a most responsible character, and requires to be caiTied
out in the most efficient manner possible, and this the com¬
mittee fear could not ‘be attained if the city medical officer
were also to hold a similar appointment for the county.”
At the meeting of the Town Council held on the 2l8b the.
report of the committee was unanimously adopted.
rootle
The Lancet,]
IRELA.ND.--PARIS.
[April 25, 1891. 963
The Summer Session at Aberdeen.
The medical summer session at Mariachal College com¬
menced on the 2ist inst. There is a large attendance of
students. In opening the class of Medical Jurisprudence
Professor Hay gave, as an introductory address, a short
historicai account of the building of Marischal College.
The buildings had their origin in the monastery of Grey-
friars in 1598, it having been built nearly a century before
the foundation of the College.
The Crieff Poisoning Case.
Samples of the sugar, to which the poisoning in the above
case was traced, have been submitted to analysis by the
public analyst of Greenock, and found to contain 14‘69 per
cent, of arsenic calculated as arsenlous acid. The weed¬
killer” has also been subjected to examination, and the
tests appear to have distinctly revealed the presence in it
of a large amount of arsenic, to the extent of 22 per cent.
At a targe and influential meeting held in Inverness last
week it was decided to form a branch of the Jubilee Institute
of Nurses for Inverness.
IRELAND.
(From our own Correspondents )
Resignation of the Begitts Professor of Surgery.
Mr. Colles, M,D., F.TI.C.S.I., who has recently retired
from Sbeevensa Hospital, has resigned the Recius Pro¬
fessorship of Surgery in the School of Physic, University
of Dublin, a position which he has occupied for the past
sixteen years. The name of a distinguished Dublin surgeon
has been mentioned as his successor.
Royal College of Su/rgeons.
By Mr. Thomson’s resignation as member of the Council
a vacancy has arisen, which will be filled up on the 28th inst.
There are three candidates—Messrs. Lentaigne, Myles,
and Nixon—all of whom are hospital surgeons
national Society for Prevention of Cruelty to Children:
Dublin Branch.
soon as the funds permit. The expenditure on the year s
working as compared with income shows a loss of £548.
Presentatations to Mr. Ormsby, M.D., F.R.C.S.I.
Last week the lady superintendent, sisters, and proba¬
tioners of the lied Cross Society attached to the Meath
Hospital presented Mr. Ormsby with an address, accom¬
panied by a silver claret jug, in recognition of his efforts
in establishing and promoting the efficiency of the organisa¬
tion. At a dinner given by Mr. Ormsby in honour of the
winners of the hospital football cup at the Wicklow Hotel,
he was presented oy the students, past and present, with
a massive silver salver and an address in tolcen of their
esteem.
Society of Chemical Industry.
A meeting of the committee formed for the reception of
the Society of Chemical Industry this year in Dublin was
held last week in Trinity College, when it was resolved to
invite the Society to hold its annual conference in Dublin
in July next. Dr. Emerson Reynolds has been appointed
chairman of the executive committee, and Sir Charles
Cameron a vice-chairman.
Hydrophobia in Ireland.
An outbreak of hydrophobia has occurred within the last
few days in the counties of Wexford, Carlow, and Kilkenny.
In Wexford the disease has attacked nob only dogs and cats,
but horses, donkeys, and cows. The outbrealc was first
noticed in some sheep-dogs belonging to a farmer residing
about ten miles from New Ross. These bit a donkey,
which burst out of its stable and attacked several horses,
cows, and pigs, and was shot in a bog some days after about
six miles from where it started. In several townlands all
dogs have been destroyed.
Mr. Jonathan Pirn has been elected resident surgeon to
JerviS'Street Hospital.
April Slat. _
PARIS.
(From our own Correspondents.)
So far the Dublin branch has not been self-supporting,
but has had to depend upon the liberality of the London
committee ; bub it is hoped that when the usefulness of the
Society is better known^here, it will be able to exist inde¬
pendently of the assist'ance it at present receives. The
report for the past year very truly remarks that it is a
satire 6n oiir Christian civilisation that such a society
should be necessary in our midst. Proceeding, it says:
It is enough to make us bow our heads in shame to think
that there are men and women amongst us who have so far
poisoned the springs of parental instinct within them that
they lay their hands in passionate cruelty upon their
ofl'spring, and be the very means of their death. We who
send our sons and daughters to heathen lands to save
children, we by whose naval strength the traffic in human
blood in Africa is being crushed, have here at home a story
of human woe as touching as any slavery, and a ‘ cry of the
children ’ as pathetic, calling on us to save them from those
■who blight their young lives, stamp a double measure of
"their own iniquity upon them, and cast them into a civilised
bondage, to be the slave and sport of every passion evil
engendered in their nature.”
The late Mr. B. J. Nca/ry.
The following resolution was adopted last week “That
we, the guardians of the North Dublin Union, have learned
with the deepest regret of the death of Dr. Neai'y, medical
•officer of Howbh and Baldoyle Dispensary, and that the
clerk be directed to convey to the members of his family our
sincere condolence in their present ailliction.”
City of Dublin Hospital.
During the past year 1088 patients passed through the
wards, and l-t,578 wore attended to at the extern depart¬
ment of the hospital. The mortality was sixty-one, about
T) per cent., but as a large number of serious accidents were
admitted, besides fever cases, scarlatina, «&c., the result
cannot bo regarded as unsatisfactory. There are but few
pay-patients admitted, the board considering, and very
properly, that the benefits of the charity, except under
special circumstances, should be reserved for the poor and
sullering. In order to increase the accommodation the
adjoining house has been purchased, and will be utilised as
Yet another Neio Treatment of Phthisis.
Now that the Koch treatment of tuberculosis no longer
monopolises attention, clinicians are striving to discover
other methods of overcoming the dread bacillus. The
latest is that of M. Germain-S6e, who shuts his patient
up for two, three, or more hours daily in a hermeti¬
cally closed metallic chamber, into which is slowly ad¬
mitted a current of compressed air, which, having passed
through a mixture of creosote and eucalypfcol, is saturated
with the vapour of these substances. Since August last ten
cases of phthisis have been submitted to this treatment, all
of which cases, with one exception, had reached the period of
softening, and bacilli had been detected in the sputa. The re-
siiltsobtained were: returnof appetite, even in advanced cases,
gain of weight and strength, fall of temperature to the
normal in a week or two, disappearance of hremoptysis,
diminution of cough and of purulency of sputa, cessation of
dyspneea. It is claimed that the method reduces the
malady to a purely local lesion, all the general symptoms
disappearing, even though rAles may persist. M. See
related the history of seven of his cases, all of which were
relieved, and some actually cured. The treatment has
been found efficacious in fetid bronchitis (dilatation of tlie
bronciii). It is worthy of note that the communication has
been lying in a sealed envelope at the Acaddmie de
Mcdecine since Nov. 4bh, 1890, the envelope having, at
M. Sera’s request, been opened at the last meeting of that
learned body.
Artificial Quinine.
This is the discoveiy of the week ; indeed, we may say of
the year. The synthesis of that useful, nay, indispensable
substance, quinine, has long been a desideratum, and now,
thanks to MM. Crimaux and Arnaud (the former Professor
of Chemistry at the iJlcole Polytechnique, and the latter
having succeeded the late illustrious centenarian, Chevrenl,
at the Miis6nni d’Histoire Naturelle) the chemical dream
has been realised. The method adopted by these gentle¬
men is as follows:—The base cuprein contained in the
shrub Kemijia pedunculata growing in Braril is treated
with sodium, then the combination thus obtained is
chloride of methyl. The product is quinine absolutely
identical with the substance with which we are familiar.
Digitized by Google
564 THELiVNCET,]
BERLIN.—OBITUARY.
[April 25, 1891.
This important discovery should have the effect of brineing :
down the price of quinine, and of rendering us independent
of supplies from the usual sources. The diecovery presents
a further interest in that, by the substitution in the afore¬
going process of compounds of ethyl and other higher
alcohols for those of methyl, new bodies analogous to
quinine may be manufacturea—bodies whose therapeutical
value may be great.
Thz TeaJmiccd Instmction of Surgeons oj the Jtese>‘ve Forces.
In the present condition of high military tension obtain¬
ing in this and other continental States, we are always
menaced with a sudden declaration of war, and it behoves
army medical officers of the active, and even of the reserve,
forces to keep themselves in times of peace au courant with
the duties tnat would devolve on them in such a con¬
tingency. A movement intended to achieve this purpose,
as regards the surgeons of the reserve forces, has recently
been set on foot in Paris, under the presidency of Dr.
Kuhff. A reunion is held monthly at the Cercle Militaire—
the club in the Avenue de I’Opi^ra founded by General
Boulanger,—at w'bich matters relating to military surgery,
medicine, and hygiene are discussed. At the first meeting,
held in February, Dr. Kuhff lectured on the organisation of
medical aid to the different ichelons of an army corps.
The second lecture was delivered on Wednesday last by
Dr. Picqa6, who chose as his subject “Antisepsis at the
Front, and the Treatment of Wounds of the Joints.”
A New Faculty of Medicine.
To the Faculties of Medicine already existing in this
country there must now be added that of Toulouse, which
has only recently been created. Some few weeks ago
Government sent down to that town Professors Brouardel
and Proust to give advice on the organisation of the new
centre of learning. A staff of professors has been appointed,
and on Thursday last these gentlemen were formally in¬
stalled in the presence of numerous prefectorial and muni-
cipai notabilities. Of the 500 students who attended one
was a lady. The official inauguration of the Faculty is
deferred until a later date, when the President of the
Republic will perform the ceremony, and the event will be
celebrated by splendid fGtes, at which the Paris Faculty
will doubtless be fitly represented.
Paris, April 2l9t. _
BERLIN.
(From our own Correspondent.)
Hygiene in the Middle Ages.
The Hamburg ophthalmologist. Dr. Kotelmann, has pub¬
lished a book of 276 pages on the Hygiene of the Middle
Ages, for which he derived his materials from sermons of
the thirteenth, fourteenth, and fifteenth centuries, a period
in which the clergy of the Catholic Church, then in the
zenith of its power and authority, gave their hearers advice
on all manner of subjects, with a plainness of speech which
would greatly surprise the church-goers of our day. It
seems that the priests of the middle ages were of Carlyle’s
opinion that healthy and holy are the same.
A Newly Discovered Anatomical Essay hy Goethe.
Professor Karl Bardeleben of Jena has made an important
discovery in the Goethe and Schiller archives at Weimar—
viz., a hitherto unknown account of the comparative anatomy
of the skulls of mammalia by Goethe. From the hand¬
writing and other circumstances, Dr. Bardeleben concludes
with certainty that it was written between the autumn of
1793 and the autumn of 1794, probably in the summer of
1794. He will give further particulars of his discovery at
the Anatomists’ Congress at Munich in the middle of next
month. Goethe was profoundly interested in osteology,
as he was in botany, optics, mineralogy, and geology, and
his writings contain a considerable number of short essays
on oflteological subjects. The discovery of the inter¬
maxillary bone, which he announced to Herder in 1784, had
been published by Vicq d’Azyr five years before; but it
was Goethe, says Lewes, who thoroughly worked out the
discovery, and gave it a definite place in science.
A Lexicon of the Natural Sciences and Medicine.
A so-called “hand lexicon”—i. e., a compendious
cyclopredia—of the natural sciences and medicine is being
published by the firm of Beclihold of Frankfort-on-the-Main.
Its authors are Dr. A. Velde, Dr. W. Schauf, Dr. D.
Loewenthal, and Dr. Bechbold
The Medal of the Berlin Medical Congress.
The great memorial medal of the Tenth International
Medical Congress of 1890 is now being struck iu silver and
in bronze. Its diameter is seven centimetres, and its design
is the joint work of Professor Virchow and the Government
architect Jaffd. Its obverse is adorned with a vigorously
modelled ^Isculapius sitting on a throne erected on a globe
representing the earth. The inscription is, “Tenth Inter¬
national Congress, Berlin, 1890.” The reverse represente
the city of Berlin as seen from the Column of Victory, with
the arms of the city adorned with laurel twigs, surrounded
by the arms of the nine moat largely represented States an(i
the names of the other thirty-one. Above the view of the
city is stamped the name of the member of the Congress for
whom the particular medal is destined.
Dr. Eduard GoUdammer.
Dr. Eduard GoUdammer, head physician in the Bethanieni
(Bethany) Hospital here, died on the 14th instant. He wa»
assistant to Christian August Bartels there from 1866 tO'
18G9, and recintered the service of the hospital as Bartels’^
successor in 1873. The subjects on which he has enriched
medical literature with his pen are typhus fever, with special
reference to intestinal hiemorrhage, spinal apoplexy, spinal!
paralysis, heart diseases, pulmonary diseases, epilepsy, the
operative treatment of pleurisy, ileus, and the application
of salicylic acid in articular rheumatism. He was the
author of the article on hospitals in Eulen burg’s great-
“ Cyclopeedia of Medical Science,” and of a treatise om
eating-houses and lodging-houses for the poor. He wa»
born in Berlin in 1842, and graduated here in 1864.
German Death-rates in the week ending April Jfh.
Aix-la-Chapelle, 17‘9; Albona, 26-5 5 Barmen, 17;7
Berlin, 18-2; Bremen, 25-6; Breslau, 25'3; Chemnitz,'
33-6; Cologne, 23'4; Dautzic, 24; Dresden, 19-9; Dvissel-
dorf, 21-4; Elberfeld, 17-5; Frankfort, 20-8; Hamburg,
20'8; Hanover, 17-6; Kiioigsberg, 18'2; Krefeld, 22-8?
Leipsic, 19; Magdeburg, 20-8; Muaioh, 33-3; Nuernberg,
21-8 ; Stettin, 24-6 ; Strasburg, 23-7 ; Stuttgart, 21-4.
Berlin, April 21st. '
JOHN SPEAR, M.R.C.'S., L.R.C.P.
It is with much regret that we have to announce th&
death of Mr. John Spear, Medical Inspector to the Local
Government Board, at the early age of forty years. Mr. Spear
commenced the career in which he distinguished himself
when he was appointed medical officer of health for South
Shields, Jarrow, and Hebburn districts under the Actof 1872,
and his labours in that capacity soon marked him as a leading
health officer. Especially did bis work in counexion with a.
prevalence of typhus fever in his northern district give proof
of signal ability ; and in 1880 he was offered and accepted
the official post at Whitehall which he occupied up to th&
date of his death. Mr. Spear’s contributions to the etiology
of disease have been numerous and important. To their
preparation he devoted much labour and pains, and this-
often in disregard of his health and comfort; and the
results of his work in this respect form a memorial of
which his colleagues and his family may well feelf
proud. At the onset of his official career he was-
deputed to investigate the subject of anthrax in man,
in connexion with a prevalence of woolsorter’s disease
at Bradford and in neighbouring places in the West-
Riding of Yorkshire, and it was at that early date that, the
resence of the bacillus anthracis in both affections having
een established, its causative relation to anthrax was
demonstrated by experiments on animals. Study of the-
same subject was continued when Mr. Spear investigated
an occurrence of malignant pustule among persons engaged
in the London hide and skin trades; and such wa&
the character of the exhaustive reports which he sub¬
mitted to the Medical Department of the Local Govern¬
ment Board on this subject, that he was at once regarded
as the principal British authority on the etiology of the
diseases in question. Unfortunately, during some of the-
pathological investigations at which he assisted in the course
of this work, he himself became infected, and it was at the
time feared that his life might have been sacrificed to the per¬
formance of his official duties. He was removed to St.
Thomas’s Hospital, and after a severe and somewhat-
Google
The Lancet,]
MEDICAL TRrAL.--MEDrCAL NEWtj.
[April 25, 1891. 965
teagtheoed illaess recovered. His early experiences of
typbaB fever, and the immunity be had thus acquired against
the infection of that disease, led to the choice of bis ser¬
vices in inquiries as to its prevalence in different parts of
the country ; and on a number of occasions he was ^ble
to detect the existence of typhus fever, and to secure its
isolation and prevention, when the nature of the disease
had remained unrecognUed. His inquiry into the pre¬
valence of typhus fever at Fulham, in 1888, was
typical of the value of his services in this respect. The
■'‘fever ” was locally supposed to he one due to some neglect
of sanitary circumstances; for London had been so long
free from epidemic typhus that the nature of the malady
lemained undetected until bis arrival on the scene. In
November, 1887, he prepared an able report on a case of
Meat Poisoning at Retford, and bis contributions to the
natural history of such diseases as diphtheria aud measles,
•as also bis forcible manner of exposing maintained neglect
and inefScieut sanitary administration, call for notice.
Amongst the latest experiences which he recorded were the
circumstances attending an outbreak of enteric fever at
Mountain Ash, the localisation of which he was able to
attribute to infection of water in its passage through a pipe,
du bis official report on this subject he explained the
mechanism of this infection, and at a subsequent meeting
of the Epidemiological Society he proved experimentally how
'Suction into water pipes took place, even when these were
fully charged with flowing water, a condition of things which
'had up to that date been regarded by many as impossible.
In many senses Mr. Spear was typical of the class of man
who is needed for the purposes of the Medical Department
of the Local Government Board. Never content to act the
part of a mere administrator, who bases his advice on
current knowledge acquired here and there by others, he
put the need for further scientiflc research in the fore¬
front of every piece of work he undertook, and as the
result the department in which he served was able to
utilise his labours in advancing the public health. In this
eense alone he will be deeply missed by his colleagues. His
energy was untiring; and if it ever needed to be checked, it
<was either with a view to bis taking more leisure from his
work or by reason of a manliness which prevented him
^^om glossing over practices which, in his belief, tended to
damage and ninder the cause to which he had devoted all
■the best years of his life. His death, which took place on
■the 20th inst., was due to the formation of a rapidly growing
tumour, and was preceded by an illness of comparatively
^orief duration. His funeral, which was attended by repre¬
sentatives of the several branches of the public health
iservices in which he had laboured, took place on the 24th
at Elmers End Cemetery. Mr. Spear leaves a large family
'to mourn his early decease.
THE FORTHCOMING MEETING AT THE
ROYAL COLLEGE OF SURGEONS.
The Central Committee of the Association of Members
of the Royal College of Surgeons unanimously resolved, on
Thursday, to support at the forthcoming meeting of tbe
■College (May lltli) the following resolutions to be pro¬
posed by the Association of Fellows of the Royal College
of Surgeons;—
“1. That this meeting regrets that the Council of the
College has not seen fit to place before the Fellows and
Members the scheme for the Reconstitution of the Univer¬
sity of London before formally accepting this scheme in the
name of the College.
“ 2. That no increase of the power aud influence of the
Council of the College over medical education and examina¬
tion is desirable until the constitution of the College has
been so amended as to make the Council adequately repre-
Ksentative of the body corporate.”
These two resolutions covering the whole ground, the
Association of Members of the Royal College of Surgeons
■will not move an independent resolution.
MEDICAL TRIAL.
COPPIN V. RENTOUL.
On April 4th, at Wandsworth County Court, an action
wastrieu before his Honour Judge Lushington, in which the
plaintiff, a collector, claimed £5 5s. from Dr. R. R. lientoul
of Liverpool, for services alleged to have been rendered in
procuring signatures to a petition against tbe Midwives
KegistratioD Bill. It appeared that Dr. Kentoul bad taken
a leading part in promoting and organising opposition to
tbe Bill, and had sent to about 800 medical practitioners
a circular letter, in which he urged them to get petitions
siraed against the Bill, and mentioned that he him¬
self found that the best way to do so was to pay a man
5s. a day to cauvass for signatures. A local practitioner at
Wandsworth had adopted that course, except as regards
the payment of the man, which latter obligation he had
endeavoured to impose upon Dr. Renfcoul. Hence this
action, which was brought by the canvasser on the
ground that Dr. RentonI bad authorised his employment.
The local practitioner gave evidence that he bad re¬
ceived a letter from Dr. Rentoul promising to pay 6s.
per day, and that Dr. Rentoul bad also verbally pro¬
mised that he would hear the expense of employing a
man to get signatures. He, however, admitted that tbe
letter to which he referred was the above-mentioned
circular, which (os the jndge held) contained no such
romise Dr. Rentoul absolncely denied on oath that he
ad ever authorised the employment of the plaintiff* on his
behalf or promised to pay any expense which might be
incurred. It was mentioned that although the circular
bad been sent to about 800 practitioners, this was the only
case where a claim of the Rind bad been made upon Dr.
Rentoul. His Honour gave judgment for the defendant,
with costs. The plaintiff* was represented by counsel and
Dr. Rentoul was defended by Mr. T. B. Woods, solicitor.
Steltital Ite&rs.
Royal College of Surgeons.—A t the last meeting
of the Council Mr. Thomas Turner (Hereford) and Mr. Denis
Francis Keegan, of the Bengal army, were elected by ballot
to Che fellowship of the College under tbe section of the
Charter relating to Members of twenty years’ standing.
Examining Board in England by the Royal
Colleges of Physicians and Surgeons.— The following
gentlemen passed the Second Examination of the Board at
a meeting of the Examiners on the 16tb inst.:—
Anatomy ;and Phyai.oloffv.—'E, F. Herman Hardenberg:. H. Allcroft
Dviffott. and Jolin A. Howard, of Guy’s Hospital; Aslett Baldwin,
of Midcllesex Hospital; T. Harold Woodfleld, of St. Bartholomew's
Hospital; R. Llewelyn Jones and Thomas Harrison, of University
College; Edward \V. .loscelvne, of St. Mary’s Hospital; Arthur F.
Goldsmith, of St. George’s Hospital; J■'seph A. Edwards, O. Moore
HetUeviugtoii, .J. SmedTey Boden, and William R. Bryett, of Hinge’s
College : and G. Mansell Dawkin, of London Hospital.
Anatoin;/ onl'i.—A. Morris Wilkinson, of Westminster Hospital; A.
Godfrey luue ami William Rscombo, of Charing-cross Hospital;
Courtney C. I’arsons, of St. Mary's Hospital; W. Ilartland Horton,
of 8t. Bartholomew’s Hospital; and R. Arura Fegan, of St. Bar-
tliolomeWs Hospital and Mr. Cooke's School ot Anatomy and
Physiology.
Pkiimoloijy oftt?/.—O.'iwald 0. Williams and J. Grant Fowler, of London
Hospital; John Grech, of Si. M'lry's Hospital; Henry Hewotson, of
Guy s Hospital; ami William J. Robertson, of Charing-cross Hos¬
pital.
Passed on the 17 th inst.:—
A^witomu only. — H. Wrangel Clarke and Edward S. Chilcott, of
St. Mary’s Hospital; George II. Steele, Augustus White, aud Edwin
S. Hoare, ot Guy’s Hospital; C. Milner Spain, W. Sidney Mayne,
and Maxwell Dick, of University College; Samuel R. Wright,
Msrvyn T. Atchdall, Ernest Parsons, and Percy C. Spark, of
Charing-cross Hospital; It Wentworth Dillon, C. Westbrooke
Gi'ant-Wilson, Henry W. Oborii, and F. W. .Tervis Goodhue, of
St. Thomas’s Hospital; Charle-i Uorbeii, of St. Bartholomew’s Hos¬
pital ; and 0. Head Hannon, of King’s CoUoge Hospital.
In Anatomy and Physiology 320 candidates presented
themselves, of whom 184 passed in both subjects; 45 in
Anatomy only, and 35 in Physiology only; 56 were referred
in both subjects In Anatomy only, 29 candidates pre¬
sented themselves, 21 of whom pasaeii ; in Physiology only,
there were 2S candidates, of whom 24 passed.
Uni'Versity of Durham; Faculty of Medicine.
At the second examination for the degree of B-vchelor in
Medicine, the following candidates satisfied the Examiners:
Honours {First Class ).—James Atkin Honton White, (iueen’s College,
Birmingham .—Honours {Sccowi Oiass): Arthur W. fclcott, Yorkshire
Collego, Leeds; Gilbert C. Burriiigton Kempe, C. Hilary Bryant,
Frederick il. Browne, Harold Ernest Gamlon, Stanley MoCouU,
ami Bedllngton Howel Morris, College of Medicine, Newcasble-
upon-Tyiio.
Pa^x-iu'f.—Edward Bromley, Yorkshire College, I-eods; Alfred Glover
Cooley, Shoflield .School ot Medicine ; Wm. Honry Daniel Patrick
D'Esterre and Harold Darwin Hey, St. Mary’.s Hospital; Francis
W. Fullerton St. Thomas’s Hospital; Thomas Hartlgan, Medical
D'fJiT
966 Thb LA17CST,]
MEDICAL NEWS.
CAfbil 25 , im .
School, Catholic University, Diibltn; H. Douglas Johns, M.B.C.S.,
L.R.C.P., Charing-cross Hospital: Qeo. Kdwyii Middleniist and
Morgan Richards, London Hospital; Thos. James Selby, Edinburgh
School of Medicine; Frank W. Stokes, University College, London ;
John Braithwaite, John Stratford Hall, W, Edmund Harker,
Arthur Samuel Hedley, Daniel Noel Jackson, Rowland Venables
Lloyd-Williains, Henry Bannerman Morison, Alfred Yarker Richard¬
son, Harry Smurthwaite, Arthur B. Thompson, Thomas Christoffel
Vieser, and Ogden Watson, College of Medicine, Newcastle-upon-
Tyne.
At the examination for the Licence in Sanitary Science,
the following candidates have satisfied the Examiners:—
Walter 11. Cheethain, M.D. ; Robt. Plenderleith Shearer, M.B,, CAf.
Glasgow ; Thomas Smaites, M.R.C.S., L.R.C.P. Edin.; and Chiis.
Hermann'Tattei-sall, M.R.C.S., L.R.C.P. Loud.
Royal Colleges of Physicians and Surgeons
OF Edinburgh and Faculty op Piivsioians and Sur¬
geons OF Glasgow.— The quarterly examinations took
place in Edinburgh during April, with the following results:
Fint Examinatton.—Of 31 candidates, the following 21 passed
Alfred Arthur Hill, Norwich; Arthur Holmes Field, Yorkshire;
John O’Connell, County Kerry; Edward Augustin Rowan, Kilkenny;
Samuel Walter Pitcher, Talbot, Australia; Griffith Hugh Williams-
Parry, Carnarvon; .T.ames M’Korrow, Liverpool; George Prentice,
Carnwath; Henry William Vaughan, Torrington; Thomas Parker
Powell, Talgarth; Clyde Harold van Strauben/-ee, Dover; Grace
Haxton Giffen, Roxburghshire ; Mary Janet Dodds. Covstorpbine ;
Patrick Sullivan. County Cork; William-Joseph Rear!, Dubbn : John
Adam Campbell, Victoria; Patrick Joseph Murphy, Cork; Walter
Sheffield Harvi.son, Now South Wales : Adele Jeanne Uhrostien,
Akyab, India; Melville Gorman Wilkins, Madras; and Joshua
Henry Fellows, Weduesbury.
Second ^xoratiMilion,—Of OU candidates, the following 30 passed
Arthur William Hall, Lincolnshire ; Edward Joliii Winston-Wators,
New Zealand; James Joseph Gray, Dublin; Thomas Messenger,
Sillotb; William Allan Lloyd-Davies, Abergole ; Charles Albert
Smith, Leeds; Thos. Wm. Bartlett, Southsea; Ralph Harry Frank
Bostock, Leicostershire; Gerald Herbert Johnstone, liclper; Alio
Phillips, Coventry; Robert .Fames Black bam, Belfast; Robt. Morris,
County Cork ; Fredk. .John Turnbull, Eilinburgh; Willie Wardraan,
Yorkshire; Henry Alfred Joires, County Cork; Henry Campbell,
County Antrim; John English, Armagh; Allen Perry .Stinson,
County Armagh; Philip B'rancis Evans, Cork; Edith Grace Collett,
Madras; Octavius Studdert Maunsell, County Waterford: Robert
Dundonald Jameson, 'Trinidad; William Robt. Tlirower.TasiuJinia ;
Lawrence Corcoran Murphy, Melbourne; William Lyons Lovett,
TuUamore, Ireland ; John Thos. M'Artliur, County Tyrone ; Joseph
Ryan, County Limerick; Peter Russell Cairns, Galashiels; Alex.
Aviet Feimie, India: and Arihur James Troughton, Norfolk.
Final Exa7/n7ta(w7i:—Of 70 candidates, the following :iS passed, and
were admitted L.R.C.P. & S.Ed. and L.K.P. .S.Ulas. Beatrice
Mary Harrison, Brighton; William David Sweeny, County Mayo ;
Gilbert Stewart Crawford, County Antrim ; James Orr, County
Antrim; Stewart ICirkpatrick, Sligo; Pestanji Ukarii, Bombay;
Chrietian Jacobus van Coller, Cape Colony ; Thomas John Davies
Llanrwst; William Thyne, Loiitlon; Percy Stainsljy, Saltaire;
Valentine Evelyn Barrow, Madras ; Alexander Anderson MacLeod,
Greenock; John Reid; Argyllshire; Walter Buck, Boston, Lines;
William Melville, Bowneas; Jas, Burnett Smith, Montrose ; Patrick
^gan, Crofton, County Roscommon; David Livingstone Heggio,
Brampton, Canada; Louis David Leopold Ellis, Manchester;
Ardesar Byr.ani.i Masani, Bombay: Patrick George Mahoney,
Maliopuram ; Piers James Hatton, Birkenhead; William Burslem
Rotheroo, Queenstown ; John White, Ea.sdale, Argyllshire; Arthur
Dennison, Leeds ; Railton Johnson, York ; William John Evans,
County Limerick ; Margaret Ida Balfour, Edinburgli; Cliavles
Rudin^ Martin, Dublin Arthur Henry Barstow, Spofforth, Harro¬
gate ; Tom Balleny Brooice, Cambridgeshire ; James Alden Fink,
Calcutta; Michael Benjamin Gorman. C'astletownroclie, Cork;
.Fames William Lewis, Caniigansliire; Thomas Hamilton, County
Tyrone ; Jeremiah Barry, Ireland ; William Robert Wallace James,
Bangalore ; and Roderick Maclean, Alness, Ross-shire.
University of Sr. Andrpiws. — Tho following
gentlemen, having passed the required examinations, had
the degree of Doctor of Medicine conferred upon them on
April lUth :—
James Wallace Anderson, L.F.P.S., L.M. Olasg. (Glasgow); Ricbaid
Henry Barker, M.R.C.S., L.S.A, Loud, (Hiingcrford); Andrew
Graham, L.R.C.P., L.R.C.S. Edin. (Currie); Francis Ilollinsliead,
M.B.O..S., L.S.A. Lend. (Solly Oak) ; .Fohii Hay Honeyman,
L. R.C.P., L.R.C.S. Edin. (Auckland, New Zealand); Jolin FJotclier
Horne, L.S.A. Lond., L.F.P.S. Ulasg., F,R.C..S. Eilin. (Barnsley);
Lawrence Storrar Mackenzie, L.U.C.1^, r>.R,O.S. Edin. (Bradford);
John Nairn, L.R.C.S. Edin. (Glasg,>w); Frederic La Cotiue Thorne,
M. R.C.S., L.S.A. Loud. (Leamington); Albert Wheeler, L.S.A. Loud.,
M.R.C.S., L.R.C.P. Lond. (London).
Royal Oollecjes of Physicians and Surgeons
OF Ireland: Conjoint Scheme.— The following have
parsed the Second Professional Examination:—
H. C. Beasley, W. Burke, J. P. Cassidy, T. C. Cummins, T. .S. F’agaTi,
II. S. Falknor, T. IV. I'. Hayes, P. J. Houegan, A. X. liavertim-,
F. P. Linde, W. L, Martin, M, M. Mauehan, J. Maunsell, jun.. A,
J. Moran, J. Morgan, C. E. Mui-phy, A. K. McCann, J, I>. O’Doiinoll,
W. O'Donnell, P. Peatoeke, J. F. Sneppard, U. Smitli, and W. A.
E. WUls.
University College, London.—D istribution of
prizes in the Ficulty of Medicine will be held on Thursday, I
May 14th. Sh Richard C^uaio, Bart., M.D., F.KS, will]
take the chair at 2 r M. j
Literary Intelligence.—M essrs. Skeffingbon wil5
shortly publish, in their well-known shilling series, “My
Doctors,” by a patient, with frontispiece by Da Maurier.
Rabies in Hampshire, — Replying to a eorve-
spondent, the President of the Board of Agriculture writes
that, as five cases of rabies have occurred in Hampshire during
this year, the last so recently as March 4th, the Board regret
that they are unable to revoke the muzzle order at present.
Yellow Fever.—T he Cuiiard steamer Serma
which arrived at Qaeenatown on the 19ch inst, brought-
intelligence that the Liverpool s.s. Drydcn arrived at New
York from Santos and Rio Janeiro with yellow fever among
the crew, three of whom had died from the disease during
the voyage.
New Sbweracje System, Balmoral.— A new
system is being laid down at Balmoral Castle for tbe--
thorough filtration of the sewage before it reaches the Dee,
as required by the Aberdeen authorities, for the preventioii
of the pollution of the river. The most recent and best-
approved sanitary appliances are being utilised in the work.
The Birmingham Water-supply.—T ho Birming¬
ham City Council, on the 21st inst., practically unanimously
approved of a scheme proposed by the water committee for
the initiation of proceedings to obtain an additional supply
of water from the watersheds at the Rivers Elan aacl
Claerwea in Radnorshire.
Water-supply in India.—T ho coremony of open¬
ing the Allahabad Waterworks was performed on the
2(i:h ult. by the Viceroy. Lucknow also is soon to possess
a system of waterworks of its own. The waterworks will
be on the model of those at Agra, Allahabad, and Benares.
The artesian well experiment, after a cost of not less than
a lakh of rupees, is to be given up.
North of JEngland Obstetrical and Gynaico-
LOGiuAL Society.— At a meeting of the Council held ab
Manchester in January last it was resolved to hold the
regular meeting of the Society for the month of June in
Hull. Arrangements are accordingly being made to hold
the meeting on June 19ch. Dr. Lowson, 15, Albion-sbreet,
Hull, will act as local secretary.
The MorlbyAVaterworks Scheme.—O n Satur¬
day the Mayor of the borough, in the presence of a large
assembly, performed the ceremony of catting the first sod
of these new waterworks ab Mytholmroyd. The water
service has hitherto been supplied from Leeds, bub the rapid
growth and progress of Morley has rendered an independent
supply necessary. The cost of tho works is estimated ab
about £100,000.
Royal Meteorological Society.—T ho usual
monthly meeting of this Society was held on the 15bh inst »
at the institution of Civil Engineers, Mr. A. Brewin, Vice-
President, in the chair. Mr. E. J. Brodio read a paper
entitled “Some Remarkable Eeatures in the Winter of
1890-91.” He pointed out that the season might be called
the “ anticyclouic winter ” on account of the prolonged
frost, high barometric pressure, and the undue prevalence
of breezes from the cold quarter. Mr. E. R. Wallis gave
an account of the rainfall of February, 1891, characterising;
it as one of the driest months upon record. Mr. H. F.
Blandford contributed a paper on the Variations of the
Rainfall ab Cherra Poonjee in the Khasi Hills, Assam, a-
place which has long been notorious as having a heavier
rainfall than any other known place on the globe. The
author placed the rainfall ab a little over 509 inches.
St. Mar'v’s Hospital, Manchester.—T he annual
meeting was held on the 13 th inst. The medical report recorded
another year’s satisfactory work. More patients had been
admitted and more operations performed than in any pre¬
vious year since the foundation of the hospital. Important
work had also been accomplished in the training of women
for attendance in midwifery cases. The net income for 1890
was £3334, and the expenditure £3425. The board of
management were now able to announce that an eligible
site in Oxford-street for thenewhospibal had been acquired
ab a cost of £15,600. The plans will be prepared for the
original scheme of 100 beds, bub pending the receipt of"
farther subscriptiuns it is proposed to proceed with sixty
beds, leaving a section or wing to be completed, when the-
funds are adequately replenished. Tlie present calculation
points bo a deficiency of between £10,000 and £15,000.
Thb Lakoet,]
MEDICAL NOTES IN PARLIAMENT.
[April 25, 1991. 967
Medioal Magistrate. — Mr. Frederick Hero
SimmoQs, M.R.C.S. Eng., L.R.C.P. Lond., bas been ap-
^inted a justice of the peace for “Karreekloof” District,
Hope Town, South Africa.
The Sanitary Institute.—A t an examination for
insneotors of nuisances, held in London on April lObh and
lltn, eighty-nine candidates presented themselves, of whom
eixty were certified to be competent as regards their sanitary
knowledge to discharge the duties of inspector of nuisances.
Eoyal Institution.— Dr. E. E. Klein, F.K.S.,
Lecturer on Physiology at St. Bartholomew’s Hospital will,
on Tuesday next, April 28 th, begin a course of three lectures
on “Bacteria, their Nature and Functions” (The Tyndall
Lectures); and Mr. H. Graham Harris, M.Inst.O.E., will,
on Saturday, May 9bh, begin a course of three lectures on
the “Artificial Production of Cold.”
A Mad Wolf.—N ews from Vienna states that on
the 19th inst. a wolf appeared in the village of Rohozna,
near Czernovitz, and bib everyone coming in its way. The
enimal was not killed until it had wounded no less than
thirty-two persons. An inquiry was set on foot, and it is
believed the wolf came from the neighbouring province of
Deasarabia, suffering from rabies. The injured persons, it is
stated, will be sent for treatment to the Pasteur Institute,
Paris.
Football Casualties.—A man named Barlow
<the Sleaford professional bowler), whilst playing football,
severely injured his knee-cap.—At Killimer, West Clare, on
the 13th inst., during a football game, a player was fatally
injured in the abdomen, and died shortly afterwards.—A
member of the Spatkbrook football team, aged twenty, of
Birmingham, in a match on the 11th inst. between the Spark-
brook team and the Worcester Hovers, fractured his collar¬
bone.—Daring a practice on Easter Tuesday of the St.
PauUnus’s football teams, in the Borough Park, Dawgreen,
a young player sustained a broken ankle.
Medical Defence Union, Limited.— The flr.st
annual meeting and dinner in connexion with the South
Wales and Monmouthshire division took place at the Park
Hotel, Cardiff, on April 8th. Although this division has
only been in existence for twelve months, it numbers ninety-
eight members. The president of the Union, Mr. Lawson
Tait, and Dr. Leslie Phillips were both present at the dinner
and delivered very interesting speeches. The after-dinner
proceedings were enlivened by the singing of Miss Alice
■Gomez. Other districts would do well to copy the example
:seb by the South Walians, and establish a branch of this
useful society in their midst.
The Metropolitan Asylums Board.—T his Board
met on Saturday at the London County Hall, Spring-
gardens, Sir Edward Galsworthy presiding. The chairman,
^referring to the returns of fever and small-pox cases, said
that with regard to fever there was a reduction of 90 cases
as compared with the previous fortnightly return, when
there were 1295 cases under treatment, l^oposals came
before the managers for the purchase of a site for an
additional fever hospital for 400 patients. The hospital
was required for the relief of the Eastern Hospital, which
bad been almost continuously full for years. The only
acceptable offer received was a site in the neighbourhood of
Stamford hill, fifteen acres, the price of which was £12,000,
The committee iu their report recommended that a contract
'Should be entered into for the purchase of this site, subject
to the approval of the Local Government Board. The report
of the committee was agreed to.
MEDICAL NOTES IN PARLIAMENT.
The Indian Opimn Traffic.
In the House of Coimnons, on Monday last, Mr. MaoLean askod the
■First I.ord of the Traasiii'y whether, considering the anxiety cansod in
India by tho division of last Friday night, and the necessity for Iclting
■the Indian (loyernmenb know wliat are the real intentions of Mio House
•of Commons with regard to the opium roveniio, he will give a day for
the dibcussioii of thu main riueatlon raised in tlio resolution of the iion.
Laronet the nieinbov for tlie Ihvrnard Castle Division of Durham, and of
the amendment proposed by tho right lion, baronet the member for tho
"City of London.—Mr. \V. 11, Nniitli atpresont saw no prospect of being
/able to find time for the renewal of the discussion in order that a
■definite decision on tho whole (piestioii may bo arrived at, — Sir .Joscpli
Peaso announced that it was not his intention to ballot in order to
place his motion on the paper aa a substantive motion before the House,
as he felt it would be extremely inconvenient to introduce tbe subject
at this period of the session.
Jiritish Medical Mm in France.
Dr. Tanner asked the Under-Secretary of State for Foreign Affairs
whether, under the provisions of the recent medical law enacted by the
French Government, no British medical man would he permitted to
practise in Fiunco wittiout having obtained the diploma of doctor of
medicine in one of tho State faculties, except when a special dispensa¬
tion was granted by the Minister of State ; and whether French medical
men were permitted to practise tbelr profession in England.—Sir J.
Forgusson: We are not aware in what form the Bill in question has
passed the French Ledslature, or if it has passed, bpt inquiry is being
made. French and other foreign medical men are free to practise their
profession in this country, subject to certain disabilities, unless they are
registered under the Mectlcal Act of 1886; but the provisions of that
Act in this respect do not take effect unless the country to which they
belong has conceded reciprocal privileges.
Army Medical Officerg.
Mr. Bartley asked the Secretary of State forWar whether he proposed
to grant to army medical officers the composite titles Huggesteil by Lord
Camperdown’s Committee. — Mr. E. Stanhope: I am quite ready to
recommend to Her Majesty the grant of composite military and medical
titles if such a concession meets the wishes of officers of the Army
Medical Staff; but I am met with the difficulty that this concession,
although asked for in Sir Andrew Clark’s letter of January 17th last,
appears to be repudiated In his later letter of March 7th. These officers,
I should state, have not approached me or his Royal Highness the
Commander-in-Chief through any recognised official channel, but I
assume that %iir Andrew Clark is expressing their opinion on the
subject. _
THE METROPOLITAN HOSPITALS INQUIRY.
The Select Committee of the House of Lords on the Metropolitan
Hospitals resumed their inquiry on Monday, Earl Sandhurst pre¬
siding.
The Relniiong of Oeneral and Special Hospitals.
Dr. Stretch Dowse, examined by the Chairman, said he was a phy¬
sician, and practised tis a specialist in nervous diseases. As a student
ho had attended Chai-ing-cross Hospital, and to several special hospitals
he had been attached. He had been connected with the West-end
Hospital for Nervous Diseases. Ho resigned his appointment about
eighteen months ago. To his mind the hospital was not being managed
as such an iostilution ought to be managed. During his connexion with
the liospital there was a great deal of difficulty and disturbance. Several
other moinbers of the staff were almost entirely opposed to the views of
Dr. Tibblts as to liow a hospital should be conducted, and that
g ave rise to a great deal ot disturbance. They never had the
ospital properly organised. iHometimes they bad a chairman and
sometimes they had not. He objected to the management of
tlie hospital, not to the treatment adopted by Dr. Tibblts.—
TIte Ctiairman ; You objected to liie unbusiuesBlike organisa¬
tion V—Witness: That is the very word to give it. There was no
business about it. He did not think that the subscribers knew very
much about the hospital. They gave them money as an act of
charity, All those special hospitals had begun in a very small way,
possilijy in a house of two rooms. The necessity for them arose
irora liie presence of disease rttiier than from the interests of
medical men, aitliough iu his opinion nearly all the special hos¬
pitals were started by medical men. It occtured to a medical man
that he could moke Jiis mark by c.stablisluug a hospital for special
diseases, and he did so. As arule, he staited under difficulties. He began
with two or three rooms, and if successful ho soon made a largo hospital.
Many men of high position in London at tiie j)resent time owed their
success in a large measure to their originating or being attached, to
.special hospitals. To be -successful, the thing must be a commercial
success. T'iie medical man received no direct financial profit from the
hospital he started, but ho gained indirect financial pi’ofit and reputa¬
tion. Only a dislionest man would make profit out of the funds of the
hospital Being himsolf a specialist, he was in favour of special hos¬
pitals. He did not think the community could do without them. He
did not ttiinlc that special hospitals had been started in order to create
a demand. Oeneral hospitals were not equal to the demand made on
them. Some years ago no man on the staff of a general hospital would
for a .second be permitted to act on the staff of a special hospital. Now
thei-e was scarcely a special hospital in London, certainly not a special
hospital which had gained any reputation, that bad not one of the
general hospital men on its staff-—Tlie Chairman : Has it ever occurred
to you that there could be a certain amount of cooperation between
general and special ho.spitalsV Assuming that a very bad nervous case
were taken to a general hospital, re<)Uiring massage or other special
treatment, would it not bo possible to have some method of organisa¬
tion by which tho case might be passed on to a special hospital ?—
Witness ; I do not see how it could be done very well, but
although it is not done openly at present, I think it is done in
oLlier ways.- Tho iTiainnau ; Is it not the case that instead of those
various institutions working with one another they aro all competing
against one anotherV-Witness : It is so. I quite agreo that there is a
feeling among the stall of Die general hospital against the staff of the
speciul lio.spiUil—Tho Chairman ; Why could there not be a working-iu
of these two classes of hos))ital'' Is it because of jealousy V—Witness;
'i'lio (liiiiculties of organisation wouhl bo too great. It might, however,
1)0 done.—'JTio (Tminnan: Might thero not t)6 a consultative com¬
mittee ? 1 would rather have a consultative committee made up
of tho lay govoinors, who I'ould ai'vango for cases being passed
from place to place.—Witness : 'I'liat is quite so, but before that
could j>ossil)ly come to ]iasH I thinic you wtnihl have to organise
and niako uso of those Ktato hospibtls and Poor-law intlnnaries.
I liiink that the ntilising of those inlinunrios might in all pro¬
bability engender a nucleus which might work something of the kind yon
suggest.—The Chairman; Do you think that medical men keep hold of an
intorosting case rittiier tl)an pass it ouV—Witness : Distinctly that is
BO. They would not send away to another hospital a valuable teaching
case. Continuing his eviileuco, Dr. Dowse said that in his opinion the
growth of special hospitals ought to be chocked. ITo did not think it
-slionld be in the power of any riian to start a special hospital and
968 Tbb Lancet,]
THE METROPOLITAN HOSPITALS INQUIRY.
[April 25,18tl,
appeal to the public for charity nnleaa It were made evident that the
hoapitid waa worthy of charity and conducted upon straightforward and
buBinesslike lines. At the present time any man could a^rb a hospital.
Witness could get a committee together from among: bis own friends,
as In the case of the West-end Hospital. Dr. Tibbits used to attend
the annual meeting. His wife was matron, his brother-in-law was the
secretary. The whole thing wan therefore a little family paity. That
was a thing which he could not recognise at all. He condemned every
hospital which was of a proprietary nature.—By the Earl of Kimberley:
There were twenty-four Poor-law infirmaries in London, containing
over 12,000 beds, '^hose institutions were well officered and well
managed, bub the organisation might be greatly iniproved, and
what waa known as Gathorne Hardy’s Act should be thoroughly
and consistently carried out. They should be managed and
controlled by the County Council, and steps should he token to organise
a staff of visiting physicians and surgeons to give clinical instruction
to advanced memcal students. If the present superintendents did not
feel sufficient confidence to undertake teaching there were many young
men of talent and position who would be glad of the opportunity. He
would strongly protest against such men being selected as teachers if
they held appointments in general hospitals. His reason for suggesting
the County Council as the managing body was that he wished to avoid
undue partisanship for particular patients. He wished to have a perfectly
independent body.—By Lord Save and Sele: Any evidence he bad given
must not be regarded as peraonally antagonistic to Dr. Tibbits.—I^ Lord
Thring: If a hospital were ostracised by the Hospital Sunday luind it
was ostracised by the medical profession, and ought to be ostracised by
the public.—By the Chairman: He considered that the out-patient
system was abused, and should be better oigatiised. Much of the
medicine given at the hospital was not taken by tlie patient for whom
it was prescribed. He was told that people wishing cod-liver oil for a
friend went to a hospital for it.
The Hetropolitan Hospital Provident Pkind.
Mr. Arthur Henry Sandiland, licentiate of the Royal College of Phy-
siciws &c., examined by theChairraan, said beresided in Sontligate-roaa,
and practised in the neighbourhood of the Metropolitan Hospital. He
wished to enter his objection to the statement made to the Committee
that the medical men in the neighbourhood of the hospital had witli-
drawn their opposition to the provident scheme now in force. He did
not know tliat any of them had withdrawn their opnosition. This
scheme was of no use to the poor, because, after a man had made one
visit to the hospital, be was told that he must either contribute to the
S rovident fund or go somewhere else. It was an injustice to local prac-
tioners, because people able to pay for medico treatment in the
ordinary way were admitted to the scheme. It was utterly untrue that
the local practitioners acquiesceil in the scheme. They had made no
complaint, for the simple reason that they had no one to whom to com¬
plain. He and other practitioners held that the hospital authorities
had no riglit to devote the funds given them for the sick poor to this
provident scheme. The institution remained no longer a free hospital.
Mr. George Locke, M.R.C.S , &c., of Kingsland-road, gave evidence of
a con-oborative character. This provident scheme, ho said, was under¬
mining private practices. He had no sympathy with provident schemes.
St. Peter's Hospital for Stone.
Mr. Walter E. Scott, secretary to St. Peter’s Hosnltal for Stone,
examined by the Cltairman, said there were in the hospital twenty-
four.beds and two private wards. Last year in the out-patient depart¬
ment each attendance cost lOid. and each bed cost £130. The grant
from the Hospital Sunday Pund being very small, the authorities
refrained in 1883 from making an application for it. They had,
however, renewed their application this year. It had certainly
been hinted that a grant would be refused altogether. The institu¬
tion was in no sense a proprietary hospital. The income was applied
to the expenditure of the year or funded. Many of the patients
insisted on making a payment towards the cost of their treatment.
Those patients wl>o required expensive drugs were asked to pay for
them. Each patient in the out-patient department was asked to pay
Is. for drugs. He was not always able to make the payment, out
received treatment all the same.
Mr. Hurry Fenwick said he was asmclated both with St. Peter’s and
the London Hospital, and it was his habit to draft patients from the
general to the special hospital. He found no opposition to this practice
on the part of ms colleagues. Witness explained to the Oommittee the
mediau organisation of St. Peter’s Hospital.
The Committee then adjourned.
The Committee mot again on Thursday, Earl Sandhurst presiding.
St. Peter's Hospital for Stojia.
Mr. Hurry Fenwick attended in order to amplify bis evidence with
regard to this hospital. Usually he said the cases dealt with in the
hospital were chronic cases which had passed through the hands of
ordinary practitioners, and which required special treatment. A good
deal of the educational value of the special hospitals could be utilised
if those institutions were affiliated with tlio general lio.spitals, and
much of the antagonism to the special hospitals wi>uld in this way be
removed. Special hospitals withdrew from conaultiog mombera of tlie
profession a great amount of special material useful for their own
experience and for teaching purposes. They affected other
m^bers of the profession in a monetary way. He did not
think that the profession oiijected to specialism in the ab¬
stract. Every medical man was at heart a specialist, but what
be objected to was that specialism should be abused. Ho believed
that the word “hospital” could an<l should be most strictly
S uarded. No place should use the word unless midor a apecial
ceuce. All hospitals should bo licensed, tlie licensing body to
consist of the heads of tho profes.sion. who would bo in a position to
judge without bias of the merits of the proposed hospital, and the
necessity for its establishment. Ho considered special hospitals to be
a'growing evil. There were a number of tliein which sliould not exist.
All the teacliing at tho special hospitals should lie made open, not only
to students hut to pracLillonors. At present most of the special hos¬
pitals were closed in thi< respect.—By Lord Thring; He thonght the
medical profession should have the power of vetoing a special hospital.
A quack hospital would not come within the province of tlie profession.
Such an institution should be repressed by law. He spoke merely from
a professional point of view. By the Chairman ; St. Peter's Hospital
was founded about twenty years ago. it conimencecl in a very small
way. An anonymous donor gave £10,000 for the erection of the pteseaii
building.
The Hospital for Sick Children.
Mr. Arthur Lucas, vice-chairman of the Hospital for Sick Children-In
Great Ormond-street, and Cromwell House, Higbgate, examined by the
Chairman, stated that the institution was fouudedin 1862. He objected
to describing it as a special hospital; it was a general hospital with a
limit of age. They had 127 beds at present, and when the wing now
being built was complete, they would have about ninety more. The
House Committee met once a month, and oftener if necessity arose.
There wasatrohle check of theaccounts. The audit was done by chartered
accountants, who reported four times a year to the Committee, and
they had also an audit by the Finance Committee. When the new
wing was complete, they proposed to allow wards where infection had
broKen out to be fallow for a time. There wore in London fourteen
hospitals devoted to children; his hospital was practically a free
hospital. Disease waa the qualification for admission. The in-patlente
last year numhored 20,604 and the out-patients 11,670. Their expendi¬
ture amounLed to £12,045 and the income to .£12,074. Their endowments
yielded an annual income of £431. They had a lady superintendent,
eight sisters, eleven staff nurses, eleven probationers, eight lady pupils,,
and seven sisters engaged in private nursing outside the hospital. All
new hospitals should, in his opinion, be licensed. He should not wish
without fui'lher consideration to express an opinion is to the composi¬
tion of the licensing board ; but he cert«,iniy thought it should not be
composed entirely ot doctors, because they would be Influenced by pro¬
fessional .jealousies. New hospitals undoubtedly sprang up where they
were not wanted. He thought the abuse of out-patient department
had been exaggerated.—By tlie Earl of Kimberley : He would not con¬
nect the licensing board with any local body.—Lord Cathcart: Can youi
a d all the giist that comes to your mill ? — Witness: Yes, with
culty in connexion with the out-pacient dejiartment.—By the Chair¬
man ; His board thought of giving up the Convalescent Institution at
Hiahgate, its .situation being now practically in London. They did not.
think of erecting a new building, but of affiliating themselves with
some existing institution.
Dr. W. B. Cheadle, senior surgeon of tlie hospital, said he waa in.
favour of separate hospitals for the treatment ot cliildren. A certain
number of students received instruction in the hospital. The fees went
direct to tho lecturers, who received proportions in accordance with the
work they did. There wore also some female clinical clerks. Several
of the staff were attached to other hospitals. Affiliation of the provident
dispensario.s with the hosjiitais was very desirable, although there were-
many difficulties in the wav of affiliation. In all hospitals be thought
there was a tendency to maico nurses work too long hours.
The West London Hospital.
Mr. B. 3. C ilbort, Secretary of the West London Hospital in Hammer¬
smith, examined by the Chairman, said that the institution was fovmdedt
in 1866 as a dispensary, and In 1801) as a hospital. There were 101 beds,
of which ten were in special wanla. All in-patients must bring a
letter of recommendation. If an out-patient came without a letter oC
recommendation, and was found to be in urgent need of treatment, he-
was treated at once and told to bring a letter of recommendation. The-
average number of new cases in the out-patient department for the last
three years was 21,000. Ho received a salary of .£260 with a house-
allowance of £60. The hospital was assessed at £310.
The Committee afterwards adjourned.
METROPOLITAN ASYLUMS BOARD.
Return of Patients remaining in the several Fever Ilospitala
of the Board at midnight on April ^Ist, 1891.
Hospital.
Beds occupied.
Q
u
3-^
o
EH
Is
>
U 9
1
'q
a.-
ss
B 9
S'”
l|
o|
Total,
Eastern Hospital .. ..
146
49
.18
2
234
442
North-Western Hospital
130
43
13
1
187
448
Western „
147
If.
11
1
174
220
South-Western ..
141
81
14
1
187
840
South-Eastern „
162
12
21‘
196
462
Northern ,,
176
10
8
108
480
Totals .. _ _
900
ICO
105
1171
2891
S.'ULL-ro.x.—Atios hospital ship, 18.
* Infant with mother.
SueccHsful applicants for Vacancies, Scoreta/ries of Public Institutions, amA
others possassini/ inforiiialion suitable fur this column, are inoited to-
forwa/rd it to Till'; Lancht Office, dweeted to the Sub-Editor, not later
than 0 o’clock on the Thursday tnorning of each week for publication tjj
the next nwi/iMer. •
Bai.i-OUR, T. S., M.B., C.M. Edin., has been appointed House Surgeon,
to tho Kcliiiburgh Koyal Maternity and Simpson Memorial Hospital,,
vice Marshall.
BAUNKft, L. J. J., MD., L.B.C.S. Ire!., has been appointed Medical!;
Officer for the Erith Cottage Ho.-pital.
n
The Lancet,]
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS.
[Apeil 26,1891. 969
Bakon, H. N., L.R.C.P.Lond., M.R.C.S., haa been appointed Medical
Officer lor the Sixth District of the Lutterworth Union, vice
Dickinson.
Bennet, C. J., M.R.C.S., has been reappointed Medical Officer of
Health for the Chapel-en-le-Frith Union.
Clarke, Ernest, M.D., B.S., haa been appointed Surgeon to the Eyo
Department of the Miller Hoapital.
Coke, wm. H., L.B.C.P. Lend., M.R.C.S., has been reappointed Medical
Officer of Health for Ashford, Kent.
DE Watteville, W. F. R., M.B., Ii.U.C.P., L.R.C.S. Edin., has been
appointed Assistant Medical Officer for the Kingussie District,
InveineaS'Shlre.
Eaton, James, M.R.C.8., haa been reappointed Medical Officer of
Health for the Grantham Rural Sajiitary District.
Evans, W. Arnold, M.D. Lond., M.E.C.S., has been appointed MetUeal
Officer of Health for Bradford.
Plover, Wm. W., M.B. Lond., M.R.C.S., haa been appointed Medical
Officer for the Kgham and Thorpe Districts of the Windsor Union,
Fuller. Andrew, L.R.C.P. Edin., M.B.O.S., haa been appointed
Certifying Factory Surgeon to the Districts comprising Iieyford,
Stowe, Mascot, Bugbrooke, and Dodford (Weldon).
Garry, W. a. M., L.K.Q.C.P., L.R.C.S. Irel., has been appointed
Assistant Medical Officer for the Hope Infirmary, Salford.
GRANT J., M D., C.M. Aberd., has been appointed Assistant Medical
Officer for the Abemethy and Duthil DistrictH, Inverneas-shire.
UOWDEN, Robert, M.B., CM.Edin., has been appointed Medical
Officer for the Parishes of Abevlady, Bolton, and Haddington,
Jamie, R. W., M B., C.M. Edin., haa been reappointed Medical Officer
of Health for the Ashby-de-la-/;Ouch Rural Sanitary District.
Kyle Thomas W., M.D. Q.U.I., D.P.H. R.C.S.Irel., has been re¬
appointed Medical Officer of Health for the Ashby Woulds Urban
District. „
Langwill, H. G., M.B., C.M. Edin., has been appointed House Surgeon
to the Edinburgh Royal Maternity and Simpson Memorial Hospital,
vice Alexander.
Lloyd, Perceval A., F,R.C.S. Eng., has been appointed Surgeon to
the Pembrokeshire and Haverfordwest Infirmary.
Madgshon, Minnie, M.B. Lond., has been appointed Resident House
Surgeon to the Clapliam Maternity Hospital.
MURIUY, R. M., M.B., C.M. Edin., F.R.C.P. ICdin., F.R.S.E., haa been
appointed Assistant Physician to the Edinburgh Royal Maternity
and Simpson Memorial Hospital, vice Barbour.
O'Connor, E. M. H., L.K-Q.C.P., L,R.0.S. Irel., has been appointed
Certifying Surgeon to the Factories in the neighbourhood of Market
O’Donaqhue, Patrick, L.RC.P. Irel., L.R.C.P., F.R.C.S. Edin., has
been appointed Medical Officer to tlie Macroom Dispensary
(Macroom Union), vice White.
Peake, W P.. L.R.C.P. Lond., M.R.C.S.,has been appointed Medical
Ottlcer'for the Fourth District of the Leicester Union.
Priestley, Jos., M.D. Edin., D.P.H., M.R.C,S., has been appointed
Chief Sanitary Inspector for Camberwell.
Ring C G., L.R.C.F. Edin., M.R.C.S., has been reappointed Medical
Officer of Health for tlie Keswick Urban Sanitary District.
Simon Rodt. M., M.D. Camb., M.R.C.P. Lond., M.R.C.S., has been
appointed Honoi-ary Physician to the Birmingham General Hospital,
vice Sir W. Foster, M.P., roaignod.
Smith, Mary, L.RC.P. & S.E(Un., L.F.P.S.Glasg,, has been appointed
Assistant J^liysician to the Claphain Maternity Hospital.
Smyth, Wm., M.B., C.M. Edin., has been appointed Medical Officer for
the North Togston Colliery, Northumberland.
SouTTER, Jas., M.R.C.S., has boon appointed Medical Officer for the
Sproalley District of the vSkirlauglLUnlon.
Underhill, C. E., M.B. Cantab., F.R.C.P. Edin., M.R.C.S., has been
appointed Physician to the Etlinburgli Royal Maternity and Simpson
Memorial Hospital, vice Hart.
VERNON, RiCHAiti), M.D., C.M. Clasg., has been reappointed Medical
Officer of Health for the Audloy Urban Sanitary District.
Williams, C. R., M.B., C.M, Edin., has been reappointed Medical
Officer for tlie Second and Tliird Districts of the Ashby-de-la Zoucli
Union.
Williams, William Robert, L.R.C.P., L.R.C.S., has been appointed
Medical Officer for the Penegoes District of the Machynlleth Union,
vice A. 0. Davies. Also Surgeon to Llwyiigwern (iuany.
Wilson, C. W., L.R.C.P., L.R.C.S. Edin., has been appointed Medical
Officer for tlie Third District of the Bridport Union.
fuaittwi
For/urlhar information repa'-Ung each mcancy refamxcc should be made
tj the actucrtmincnt.
New Hospital for women, 144, Euston-road.—Two Clinical Assistants-
for Out-patient Department.
Norwich City Asylum, Hellesdon, near Norwich.—Assistant Medical!
Officer for one year, in-doer. Board, lodging, and washing. Salary
£liiO per annum.
Nottingham borough Asylum, Mapperley-hill.—Resident Clinical'
Assistant for six montiis. No salary. Board and residence pro¬
vided.
Parish of Kennom’ay, Fifeshire.—Medical Officer. (Apply to tho
Inspector of Poor.)
Royal LONDON Ophthalmic Hospital.—C linical Assistants for oae
year. Junior Assistantships for six months.
Sussex County Hospital, Brighton.—House Physician. No salary,.,
but residence in tlie Hospital, with board and washii^.
Sussex County Hospital, Brighton.-Assistant House Surgeon. No-
salary, but residence in the Hospital, with board and washing.
Sick Children’s Hospital, Newcastle-upon-Tyne.-Resident Medical
Officer. Salary £<J0 per annum, with board, lodging, and laundry.
Wallasey Dispensary.—H ouse Surgeon. Salary £H0 per annum, with-
furnished apartments, coal, and gas.
West Herts Infirmary, Hemel Hempstead,-House Surgeon and'
Dispenser, who shall also be Assistant Secretary, for two years.
Salary £100 per annum, with board, furnished rooms, fire, lights,
attendance, and washing.
Wolverhampton Eye Infirmary.-R esident Assistant for aix{montbs.
Rooms, with board and washing, provided.
York Dispensary.—R esident Medical JOfficer. Salary £130 a year,,
with furnislied apartments, coal, and^as.
damages, ani 5tat|s.
BIRTHS.
Chambers.-O n April 20tli, at 1, Wilinington-square, W.C., the wife of
Ebev Chambers, M.B. &c., of a dauglitor.
Qreathead.— On Marcli 28th, at Graliam.stown. South Africa, the wife ■
of J. B. Greathead, M.B. Edin., M.R.C.S., of a son.
Pardinqton.—O n April 18tli, at Mount Pleasant, Tunbridge Wells, the-
wife of Geo. Lucas Pardington, M.D., of a son.
Stai-'I’ORD.—O n April 13th, at College-gardens, Belfast, the wife of Dr.
T. J. Stafford, Local Government Inspector, of a son.
Stivbns.—O n April 16th, at Kensington-gardens-square, W.,the wife of/
B. Lyne Stivens, M.D., of a daughter.
Thomas.—A t Berwyn, Bolingbroko-grove, S.W., the wife of Arthur W.
Tlioinas, M.D., of a daughter. .
MARRIAGES,
Boyd—Bicrkeley.— On April 22nd, at the Parish Church, Wave, Herts.
Alexander James Boyd. B.A., M.D., B.Ch,, third son of Samuel.
Boyd, J.P., of llloi'ton, Killiiiey, co. Dublin, to Constance Mary,,
elder daughter of Brackenbury Comyns Berkeley.
Corbin- Peel.— On April ir-cli, at St. Paul's, Beckenham, Eustace
Rhodes St. Clair Corbin, M.B. Lond., M.R.C.S, of Merlv^e,
Beckoiiliam, youngest son of the late Dr. Charles Corbin, of Belair,
Barbadoes, to Linda Augusta Jaiio, daughter of tlie late Captain
Robert Mooie Peel, otli Iniiiskilling Dragoons, Moore House,
Bcckoiiliain, Kent.
Diiake-Brockman—Chesnaye.— On March Hist, at St. Mary Magda¬
lene's Church. Mean Moor, Punjab, H. B. Drake-Brockmaii,
F.R.C.S.E.. Surgeon H.M. Bengal Medical Service, to May Katlileea,
only daiightevot' DeputySurgeon-Geiiei'al (!. C. Chesnaye, F.R.C.S.I.,.
H.M. Bengal Medical Service, P.M.O. Lahore District, and Honorary
.Surgeon to U.B. the Viceroy of Indin.
Francis—Makcon.— On April Ubh^ at St Paul's Church, St. Leonard’s-
on-S6!V, Alfred George Francis, B.A. Cantab., M.B., B S. Lond.,
F.R.C.S. Eiig., of Huti, son of the late Charles W. Francis, 9f
Soutlicliurch, iissox, to Frederica Jane, daughter of the late Rev.
Walter Marcon, M.A. Oxon., Ilect.or of I'klgetleld, Norfolk,
Mackenzie—Garden, —On April iSth, at St. Barnabas Church, Ken¬
sington, Ernest Mackenzie, M.D., of Cheadle, Staffordshire, fo
Ethel Margaret, younger liaughtor of the late Brigade-Surgeon.
Alexander Garden, M.D., Bengal Army.
Shone- FORSTER.— On March 17Ui, at at St. I'eter'a, Glenelg, South
Australia, William Vernon Shone, M.R.C.,S., L.R.C.P, Lond., eldest
.sou of Brigade-Surgeon Shone, of Marlow, Bucks, to Annie Jane •
Cochrane Forster, eldest daughter of Robert Cochrane Forster, Es(^,
F,(!.S., late of Rock CasUe, Iiuiishauiioii, co. Cork.
Beta, Tup. Lancet office, 428, Strand, W,C.—Resident Assistant
Medical Ofticoi- in a Metropolitan J’rivatu Asylum.
CHELSEA llosi’mi. FOR WOMEN, FuHiam-i'oad, B. W.—Honorary Patho¬
logist.
Cancer Hospital (Free), Fulham-road, S.W.—IIouso Surgeon, Assist¬
ant House Surgeon and Itegistrar for six uioutlvs. Salai-y at the
rate of £60 ii.nd ,£60 a year ro.spectively, with board and luaidoiice.
City of London I.iinatic Asylum, stone, near Dai-lford, Kent.—
Clinical Assistant for six months. Board, lodging, washing, and
abiendanco,
Coventry Provident Dusi'Ensary.—S iirgoon.
Gold Mining Company, Lowur Siam.—Medical Officer.
Great Yarmouth IIosi-itai,.—R esident House Surgeon. Salary to
commence at .£1)0 por annum, witii board and lodging.
Hospital for Women (London school of GYNyECOLOOYj, .Soho-
square, W.—Clinical Assisiantsin both Out-patient and In-patienb
lYoiiartnionts. _ ,
New Hospital for Women, l-l-l, Euston-road,—Resident Medical
New TiosI’ITai. for Women, 144. Eu.ston-road.—A qualified Medical
Woman as Assistant Pliysiciaii in the Out-patient Department.
DEATHS.
Ai.linciiam.—O n April 13tli, at Pisa, Italy, after a short illness,.
Chrisuana, Mile of Wm. Alliiigliam, F.R.C.S. Eng., of Grosvoiior-
atreet, W.
BOL'i'ON.—Oil March 27th, at Kustoiuljio, Roumania, Flora Beatrice,
aged 2.j years; on April 8tli, Toresina Arualico Emily Biida, aged
l) years; on April Stli, Eleanor Jane Dditamia, aged 7 years; on.
April 14th, 'fei'osina Carlotta I.ouisa, aged 34 years ;—daughters and
wife of Dr. A. J. Bolton, from diplitlieritlc scarlatina.
Heai.e.—O n April iCth, at Hollingtou Loilge, near St. Leonard's-on-Sea,
James Newton Ileale, M.D., late of Winchester, aged 80.
Jones.—O n April 2lst, at Haiiovor-stroet, W., Evan Bunioll Jones,.
M.R.C.S., Hged 72,
McCarthy.—O n .Tan. 27th, at Secunderabad, Brigade Surgeon D. J.
McCarthy, M.D., F.RC.S. Irel., 1st Madras lancers.
Speak.—O n April 20th, at Flaxted, bhi-quliar-roaci. Upper Norwood,,
John Spear, Medical Inspector, Local Government Board, Whitu-
liiUl, aged 40. _
if.B.—A fee of 68. is charged for the Insertion of Xotiees gf Births^
Marriages, and Deaths.
Dini
d ..Google
970 LakobtJ notes, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [April 25, 1891.
Ptbkal iiir % mning Meti
HoadaT, April 27.
BOTiL LOKDON Ophthalmic Hospital, Moobpiblss. —Operations
dally at 10 a.u.
BOTAL Wbsthinsteb Ophthalmio HOSPITAL.—OperaUoiu, 1.80 p.h.,
and each day at the same hour.
Chelsea Hospital fob WouEN.—OperatlonB, !.80 p.ii. ; Thursday, 2.so,
Hospital fob Women, Soho-squabb. —Operations, S p.h., and on
Thursday at the same hour.
Mbtbopolitan Fees Hospital.—O perations, 2 p.h,
Botal OBTHOP.SDIC HOSPITAL.—Operations, 8 p.h.
Central London Ophthalmic Hospital.—O perations, 8 P.M., and
each day in the week at the same hour.
Hnitebsitf College Hospital.—E ar and Throat Department, 9 a.m.:
Thursday, 0 A.H.
Medical Society op London.—8.80 p.m. Dr. T. Elliott (Tunbridge
Wells): A case of Ectopia Vlscetum.—Mr. W. Whitehead (Man¬
chester) : One Hundred cases of Entire Excision of the Tongue.
Tuesday, April 28.
Kino's College Hospital.— Operatlens, 2 p.h. ; Fridays and Saturdays
at the same hour.
QuT's Hospital.—O perations, 1.80 p.h., and on Friday at same hoar.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 P.H,
St. Thomas's Hospital.— Ophthalmic operations, 4 p.m. ; Friday, 2p.m.
UT. Mark’s Hospital.—O perations, 2 p.m.
Cancer Hospital, Brompton.—O perations, 2 p.h. ; Saturday, 2 p.h.
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
Sr. Mary’s Hospital.—O perations, 1.80 p.m. Consultations, Monday
2.80 P.M. Skin Department, Monday and Thursday. 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 p.m. Electro¬
therapeutics, same day, 2 p.h.
SOYAL Institution.— 3 p.m. Dr. Edward E. Klein: Bacteria, their
Nature and Functions. (Tyndall Lecture.)
&OYAL M^lCAL AND ClIIRURGICAL SOCIETY.—8.80 P.M. Mr. William
Watsofl Cheyno: On the Value of Tuberculin in the Treatment of
Surgical Tubercular Diseases. A selection of patients will be shown
in the North Room at 8 p.m.
Wednesday, April 29.
National Orthopedic Hospital.-O perations, 10 a.m.
Middlesex Hospital.—O perations, 1 p.m. Operations by the Obstetric
Physicians on Thursdays at 2 p.h.
St. Bartholomew’s Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour. Ophthalmic Operations, Tuesday and Thursday, 1.80 p.m.
Surgical Consultations, Thursday, 1.80 p.m.
Charino-cross Hospital.—O perations, 8 p.h., and on Thursday and
Friday at the same hour.
ST. Thomas’s Hospital.— Operations, 1.80 p.m. ; Saturday, same hour.
London Hospital.— Operations, 2 P.M. Thursday&Saturday.samehour.
St. Peter’s Hospital, Covent-oardbn.—O perations, 2 p.m.
Samaritan Free Hospital for Women and Children.—O perations
2.80 P.M. ■
Gbeat Northern Central Hospital.—O perations, 2 p.h.
Chivebsity College Hospital.—O perations, 1.30 p.m. ; Skin Depart¬
ment, 1.46 P.H.; Saturday, 9.16 a.m.
Boyal Free Hospital.— Operations, 2 p.m., and on Saturday.
Children's Hospital, Great Ormond-street.—O perations, 9.80 a.k. |
Surgical Visits on Wednesday and Saturday at 0.16 a.m.
Thursday, April 30. *
St. George’s Hospital.—O perations, l p.m. Surgical Consultations,
Wednesday, 1.80 P.M. Ophthalmic Operations, Friday, 1.30 p.m.
University College Hospital.—O perations, 2 p.m. ; Bar and Throat
Department, 9 a.m.
Qoyal Institution.-3 p.m. Professor Dewar: Recent Spectroscopic
Investigations.
Friday, May i,
ROYAL South London Ophthalmic Hospital.—O perations, 2 pm
Royal Institution.—D p.m. Annual Meeting. 9 p.m. Mr. James H
Harting: Hawks and Hawking.
West London Medico.Ciiiburgical Society (Board-room, West
London Hospital).—8 P.M. Ordinary Meeting. Dr. Syraons Brcle.s •
Chronic Rheumatic Arthritis.-Mr. J. R. Limn : Notes of two
cases of Appendicitis.-Mr. Towers Smith: The Dietetic Treat¬
ment of Obesity.
Saturday, May 2 .
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital,—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.15 a.m. ^
Goyal Institution.—3 p.m. Prof. Silvanua P.Thompfon; 'Tlie Dynamo.
METEOROLOGICAL READINGS.
(Taken daily at 8.S0 a.m. by Stmofl-d’a JnstrumenCs.^
THE Lancet OEdee, April 23rd, 1891.
Date.
Baromotor
reduced to
Sen Level
And sa‘F.
Dlreo-
tiou
of
•Wind.
Dry
Bulb.
Wet
BulU
Bolor
Rndia
in
Vaouo.
Miul-
mum
Tomp.
Sbado,
Min.
Temp
RaIq-
IaU.
Remarks at
e.S0A.u.
Apr. 17
30’J7
N.
45
41
97
66
40
Oloudv
„ 18
30'22
N.E.
40
42
100
58
40
Oloudv
10
80-22
E.
45
41
92
60
40
Cloudv
„ 20
30-31
E.
45
41
88
r>i
40
Cloudy
21
80-27
E.
47
43
101
67
41
22
80-09
S.E.
46
42
80
64
40
.. 28
30-04
E.
49
46
108
60
41
Fine
Sute, Cumnunts, ^ %nktxB to
dffCTftpitknto.
It is especially requested that early mtelliaence local
events having a medical interest, or which it is desirahle
to b'nmg under the notice of the profession, may be sent
direct to this Office.
All communications relating to the editorial business of the
joumial must be addressed “To the Editors.”
Lectures, original articles, and reports should he tvriUen on
one side only of the paper.
Letters, whether intended Jor insertion or for private informa¬
tion, must be authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
he marked and addressed “To the Sub-Editor.”
Letters relating to the publication, sale, and advertising
aepanmcnis oj Thb Lancet to he addressed “To the
Publisher.”
We cannot undertake to return MSS. not used.
More Instances ok Audacious Advertising.
The following remarkable card, extensively circulated in Brixlon, has
been forwarded to ns for our opinion. Dr. Reynolds explains to us
that he knows notliingof tbeadvortisors and has liaclno communication
witli them. The unprofessional nature of the card is too apparent.
But tho liborty taken with Dr. Reynolds’ name is unprecedented. It
is no slight injury to ono who has always acted with due regard to the
honour of tho profe.s.sion to use Jii.s name in this sort of fashion. How¬
ever, in tlie estimation of all good judges it is not he who will suffer
by such practices.
“New Branch Surgery.—Dr. Partridge, Dr. Frye, and Dr.
Shopord, Physicians, Surgeons, and Accoucheurs, of 888, Old Kent-
road, S.IC., have taken tho Surgery lately occupied by Dr. Reynolds,
309, Coldliavbour-Iane, corner of Somerleyton-road, midway between
Brixton and Loiighborough-park Stations. Consultation hours:—
morning, D.OO to 12.30; evening, 0.30 to 9.30. Sundays: 10 to 12 a.m.,
, 7 to 9 I’.M. Urgent cases seen at any hour. Every patient and
every case of midwifery attended by a qualified medical man. Dr.
Frye will rosideon tho proinisesat 309, Coldharbouv-Lane, corner of
Somerleyton-road. Tho charge for advice and medicine will bo as
low as is consistent with oxporionce and skill.”
We liavo recoivod more than one specimen of tlie following:—
"A Card.—Dr. Haiti has removed from Elms Hoiiso, Clapham
Common, to Consulting Rooms nl Mr. Merrick, Chemist, 10, Clap-
ham Common, next to Clapham Common Post Office. Hours from
ten morning, and six to .seven evening. Messages answered at any
hour. Rosicloiico, 114, Clapham Park-road, adjoining Park Hill and
near Die J'ilniH IC.stato. 'J'o contradict reports. Dr. Raitt takes tlii.s
oiiporUinity of stating that ilia charges are the same as any ordinary
medical practitioner. ('I'liesday and Friday evoning.s lialf foe.) Ho
devotes .Saturday ovoiiing.s at hi.s residence free to these really
deserving pdov who bring s.atisfnctory ‘ roconiraends.’ ”
rTivn.-Thovo are several .Hinall guides to urine testing—o.g., Wickham
Legg, 'lysoii, Whitaker, A. Husband, Coiipland—any of which might
serve cmr covrcspondent'.s purpose,
INSTRUCTION IN MIDWIFERY.
To ihe Editors of TiiF- Lancet.
Sms,—Allow me to point out a mis-statement in Dr. RentoiiTs letter
in your last issue. I'lio course of lectnre.s at Aberdeen on midwifeiy
and diseases of women extends over six months, and oinbraces one
hundred lectures. Dr. Rortoul in liis table gives only a half.
I am, Sirs, yours faithfully,
Manchester, April 20th, 1891. W,M. H. Uicwr.KTT, M.B.
Digitized by
Th* LaN08T»} notes, comments, and answers to correspondents, [April 25, 1891. 971
' DlSl'ENSlNtt BY MliDICAIi MEN.
The pi'tiasure on onr space will nob allow us to print tho whole of the
letter of M.]X,\L.}i.C.S.E,, but the concluding portion will serve to
express iiis views on the subject :~
“Human nature is dreadfully ignorant and superstitious where
medicine is concerned; and although it may be a toss of time, it is
no loss of dignity to 'make up’ the physio with or without tire
assisttince of a dispen.ser. When your ooirespondent, ‘Sick of
Dispeiising,’ complains of ‘ qualified assistants of taste and feeling’
objecting to ‘ manual drudgery,’ Ac., ho only l>oti'ays his ignorance of
tlie requirements of English general practice, in which one of tlie
chief duties is dispensing; and it is impossible to characterise as
‘drudgery’ any act whicii can be called a duty. 1 yield to no man
in my admiration for ‘ general and social culture’ in our profession;
bub these are not to bo gained at the expense of the interests of our
patients, and the theory and pra<;tice of good and accurate dis¬
pensing concern the patient as much as, or porliaps more tlian, the
■ theory of medicine and tlie hollow conventionalities of society.
Few practitioners can afford the luxury of a dispenser, and not one
in n thousand a qualified assistant who cannot or will not do dis-
■ peusing.”
UNDERSELUNG PRACTITIONERS.
To the Editors of The Lancet.
Suis,—Attention is often drawn in THE Lancet to the miserable con¬
dition of the ranks of our profession. Our internecine squabbles will
never allow us to bring about reform by combination or “trades
unionism”: for there are always men amongst us ready to rob their
brethren hy underselling. Amelioration of the lot of the “ undesirable
fringe” can only be accomplished by Act of Parliament. May I suggest
wliat the Act or Acts should bring about? 1. Tho establishment of a
Central Examining Board or States Examination, the diploma to be
M.D. Great Britain, without which no one to be regi-stored. 2. No
person to be qualified before his or her twenty-fifth year. S. Tho
abolition of patent medicine bu.siuesaes as at present carried on. 4. Tho
rendering punishable by imprisonment without option of fine any
kind of unqualified pi-actice. 6. Prevention of dispensing by medical
men, except under very special circumstances. 0. The fixation of a
minimum fee. 7. The levying of an annual registration foe. There
are many things to explain with regard to each proposition, of course;
but my letter is already long enough.
I am, Sirs, your obedient servant,
April0th, 1891. Onb ok the Ckowd.
Has our correspondent ever considered tho feasibility of getting
an ordinary Member of Parliament—to say nothing of a Cabinet
Minister—to assent to legislation on such lines?—K». L.
A GENERAr, PUACTITIO.NEHS' UNION.
On tho above subject liural writes
“ Just to give some idea of the state of things, I will describe my
own case. When I first commenced practice in a town I found my
nearest opponent, an M.D., did a g(Jod private practice, and, not
content with that or in order to keep r>ut others, employed a man
to canvass for his Id. weekly club among the hotter class of
artisans, many of whom, but for the inducement of tho canvasser,
could and would liave paid a general practitioner a modeiato fee.
One man does it; others follow .suit, on the pretext that it saves
making bad debts and that it helps tho poor. Many of these
.so-c^lod poor evidently lliink a weok'.s medical attendance and
medicine less in valuo than the price of a glass of hoev. This
degrading and pauporising stylo of carrying on professional work is
solely the result and fault of ]ion-unity among tho meinbora of the
profession. Our philanthropic .spirits would be doing more real
good by ende.avouring to bettor the condition of tho general prac¬
titioner than liy attempting to establisli a now order of iniilwifury
practitioners.”
OONSULTAN'TS ANi) (ilCNMItAI, ITIAITITIONKUS.
'To the Editors of The L.vncet.
Si Its,—I shall be obliged if you would give publicity to tho following.
Last Saturday I was called in to see an infant suffering from croup,
and yesterday morning, tho child getting worse, a consultation was
proposed, and Dr,-was culled in. Ho prescribed after consulta¬
tion, and I left to dispense the medicine. Dr. _, I may state
has attended tho same family as family doctor. A few hours after
my leaving I received a note stating tliat the mother of tlie child
desired that Dr. -should contimio to attend tiirougli the child’s
illness, and this that gentleman ha.s done without paying lao tlie com¬
pliment of asking whether I was agreeable or not. I must say I con¬
sider this a very oxtraorilinary proceeding on the part of a consultant.
Treatment such as blio above ought to make the general pvactitionor
careful in calling in consultants. I am. Sirs, yours truly,
April 16th, 1891. Vehitas.
'.»* 'The relationship of the parties Iiero was, it must be admitted, some¬
what complicated and unusual. It would have been bettor if the
case liad been left in tho liands of tho practitioner first called in,
and Dr. - had attondod throughout as a consultant. But It
scarcely seems to us to justify the conclusion of our correspondent.—
Ejj. L.
Drink and Untimely Death in Melhournb.
The Fall Mall Gazette gives the following analysis of the facta of tli»
deaths in the record of the Melbourne Morgue for 1890. It is a
miserable record, and .shows, as was Icnown before, that the drink
factor In the colonies is not less opei-ative than it is at home.
“Inquests were held on 41(1 bodies, and in thirty-eight cases a
verdict of suicide was returned. Ttiei-e were thirteen murders and
168 fatal accidents; alcoholism claimed fifty-one victims by suddoD
death. And these drink statistics are interesting; Of the eight
suicides by shooting, four were directly traceable to drink; all the>
six seif.poisonerswere drunkards ; and all those wlio drowned them¬
selves had vainly tried to drown their sorrows while they lived. Of
the eight who hanged themselves, three were drunkards; of the eight
who cut their throat.s, four were of tbe sanie'inclinaUon; one of
those who lay down in front of a railway engine drank heavily;
three of the six inanslaughtered drank, seven of tbe twenty acci-
dontally killed by the railways, six of the fifteen accidentally
drowned, four of the nine tramway vietiins, ten of the twenty-
three run over on the streets, and seventeen of tbe twenty-eighfc
‘ found dead’; and on through to the end of tbe chapter, drink waa-
the ruHng passion.”
/iiiqiiircj-.—It is against the unwritten law of the profession. Such a>
(bourse has been taken ; and we have seen tlie apparatus thus-
patented placed beyond the reach of the poorer classes of patients oa
account of the royalty required by the patentee.
J)r. M. Bainew.—Tho list of Members of Parliament who voted against
and in favour of the abolition of certifying surgeons respectively was-
publisbed in our last number, page 914.
L.R.C.E.I. — 'R. L. I’olk and Co., 280, Broadway, Now York; pric#
seven doilars.
HOMES FOR INCURABLES.
To the Editors of Tmc Lancet.
Sirs,—C an you tell me of a home or hospital for incurables where a.
congenital idiot girl, aged twenty, con be placed? She is almost desti¬
tute, but above the workliouse, having property (in house) bringing its
only Ss. per week. This her guardians will willingly hand over to any
institution which would give her a home.
I am, Sirs, yours faithfully,
April, 1891. Sympathy.
Specialism and the M.D. Deqhek in Russia.
It is proposed in Russia that specialists shall in future be obliged tO'
have taken up the particular subject of their specialty for their
doctor’s degree. The ordinary practitiener'.s diploma of vrach having
been taken, a further examination of a more .severe nature has to be
passed and an elaborate thesis or dissertation published, which
together with various other propositions, must he defended against
tlie criticisms of some official opponents. Tbe dissertation more fre¬
quently than not refers to some minute physiological or histological
detail, and might wltli advantage be more generally on a matter of
clinical moment. If tho proposed change is made, it is probable that
clinical observations connected with various brandies of practice wil
be more in f.avour with candidates for the doctor’.s degree.
B. F. y*.—1. The treatment of the diseases of these structures is so
essentially surgical that it can only bo found satisfactorily discussed
in works on surgery.—2. The most recent is that by Mr. Bryant.
The answer to tho first quostion applies equally to this one.
Asmtant must consult a solicitor.
The PnoPOSEi) a-Isculapian Lodge ok Freemasons.
Hr. 'Thomas DnKon (P.M.) asks us to state that the above lodge haa-
not been abandoned; but that, on tho contrary, tho petition will be
presented to the Grand Lodge next month, praying for a warrant,,
and lie adds that any medical Mason desirous of becoming a founder
may have full particulars by applying to him. An impression appeara
to prevail that tho Oaleii Lodge (ciioniists and druggists), wliicln
recently obtained a wanaut, has taken the place of the Aisculapian.
Lodge. Hie report, it is surmised, originated from the fact that tha
first W. Master of tho Galon Lodge was a medical man.
I'arish .—The contention of our correspomlont is somewhat of a moot
point. We should not advise him to risk a law suit on it, tliough he-
might fortify his claim by getting from the authorities of tho Loudon
College a statement of the legal value of tlieir diploma.
Mr. Sanderson J/c?ftir.—Sloughing of tlio tonsils, uvula, <Sc., is a well-
recognised oceurronco in severe diphtheria.
Errata.—I n our report last week of tho proceeilings of the Lords''
Committee on Hospitals, page 912, for “Major-Coiioral Movcier" read
Ma)or-GeneraI J/crcc.r.—In tho report of Dr. Hingston Fox's paper,
read at the tVest Kent Medico-Chinirgical Society and printed in our
last issue, p. 886, by an error Dr. Hunter Mui'kcnzie was referred to
as the propouiuler of a theory of the pathoh'gy of the disease, iiisteaii
of Dr. Hector Mackenzie.
DigiTized by Google
'972 Thb Lanobt.] KOTBS, COMMENTS, AND ANSWERS TO CORRESPONDENTS. CAprii. 25, 1891.
<H)UHi;nicauons not noticed in our present number will receive atten¬
tion In our next.
COUMUNTCATiOKS, LETTERS, &c., have been received from—Sir Joseph
Fayrer, London; Dr. H. Snow; Dr. T. Dutton, London; Mr. Watson
Cbeyne, London; Dr. Sinclair, Manchester; Dr. Castle; Dr. Hale
White,London; Mr. Ashdown; Dr.Bentoul,Liverpool; Dr.Theodore
Williams, London; Dr. MacFarlane, Preston; Mr. S. Mellor, West
Mailing; Dr. Harrison, Haslingden ; Mr. M. M. Bowlan, Newcastle-
on-Tyne; Dr. Hewlett, Manchester; Dr. Ooghill, Ventnor ; Mr. R. J.
Oilbert, London; Dr. A. Yule, Guildford ; Mr. W. A. Ellis, London
Dr. E. Beilis; Dr. Baines, London; Mrs. Ritchie, London; Dr. John
Shaw; Miss Yates, London; Dr. Reynolds, Brixton; Messrs. Tliorp
end Co., Glossop; Dr. P. J. Smith, London ; Mossi-s. Richardson and
Co., Leicester; Mr. W. Drewett, Esher ; Miss Pencoffs; Mr. Sherman
Bigg, London; Mr. Burghard, London; Mr. R. B. Smith; Mr. Mayo
Robson, Leeds; Mr. F. W. Joy, Brandon; Messrs. W. H. Smith and
Son, Burnley; Mr. Robertson, Glasgow ; Dr. W. M. Elliott, Moreton
Hampsteatl; Dr.Ferrier,London; Dr.Ormsby,Dublin; Messrs.Black
and Co., London ; Dr. J. W. Taylor, Scarborough ; Messrs. Reynolds
and] Branson, Leeds; Mr. O. Barling, Birmingham; Messrs. Rayner
and^Cassell, London ; Mr. M. Kirby, London; Messrs. Robertson and
Scott, Edinburgh; Mr. Dowie, Edinburgh; Messrs. Clarke, Son, and
Platt, London; Mr. H. E. Armstrong, Newcastle-on-Tyne; Dr. Hector
Mackenzie, London; Mr. A. Burdett, London; Messrs, G. Street and
Co., London ; Mr. Haiinaford, London; Messrs. Wood and Co., New
Fork ; Dr, H. S. Lunn, London ; Mr. Browne, London ; Mr. Cripps
Laurence, London; Dr. Morton, Edinburgli; Mr. A. Hind, South
Molton; Dr. Bottenbuit, Paris ; Mr. Eastwood, Hull; Messrs. Hertz
md Collingwood, London; Mr. Greville, Sheffield; Mr. Leech, Great
■i^armoubh; Mr. Gibson, Newcastle-on-Tyne; Messrs. Cooper and
Brodie, Edinburgh; Mr. Wintel, Haverstock-bill; Messrs. Keene and
Ashwell, London'; Mr. Silverlock, Blackfrtars; Mr. W. Turner, West
Brighton; Mr. Hewlett, Harrow; Mr. Rintoul, Fife; Messrs. Smith
and Co., Portsea; Mr. MouHin, Soho-square; Messrs, W. H. Smith
and Son, London; Mr. Matthews, Greenwich; Messrs. Orridge and
Co., London; Dr. Ward, Oxford; Mr. Hyde, London; Messrs, Oliver
and Boyd, Edinburgh; Dr. Cogbill, Birmingham; Messrs. Lee and
Martin, Birmingham; Mr. Sequeira, Hampstead; Messr.s, Rudger
:^d Co.,Homburg; Mr.Hornibrook; Mr.T. B. Browne; Mr.Leonard
Mark, London ; Mr. Tate, Huntingdon; Mr. Lancaster; Dr. O’Dell,
TTorquay; Dr. Davies, Leicester; Dr. O'Hanlon, Durham; Dr. White,
Dartford; Mr. Brear, Bradford ; Mr. McKay, Fortrose ; Mr. Rawlins,
Liverpool; Mr. Cornish, Manchester; Mr. R. C. Bennington. New-
•castle-on-Tyne; Mr. Birchall, Liverpool; Dr. Damaine, Trinidad ;
Mr. Pennington, Hyde ; Veritas; Parish ; The Hartlepools Salt Brine
Co.; L.R.C.S.I.; M.D., L.R C.S.E.; Zeta, London; Sussex County
Hospital; B. M., London; M.D., Leeds; Secretary, Royal College
•of Physicians, Dublin ; Doctor, London ; M. S. A., London ; Omagh
District Lunatic Asylum ; M.D., London ; C. C., London ; Expectans,
London; Wren.
CiETXERS, each with enclomre, are also acknowledged from—Dr. Scott,
Fallowfleld; Mr. Jones, Anglesea ; Mr. Swan, Gilford; Mr. Weekes,
Chatham ; Mr. Hutchinson, Belfast; Mr. Sampson, York ; Mr. Heap,
Discard; Mr. Sleath, Coventry; Mr. Hamilton, Brighton; Dr. Dixon,
Northampton ; Mr. Branthwaite, Warwickshire; Messrs. Bilbrough
and Co., Bradford; Miss Millard, Teddington ; Mr. Mason, Pateley
Bridge; Mr. Lorette, Paris; Mrs. Aplins, Yeovil; Messrs. Blondea
et Cle., Kentish Town; Mr. Morton, Queensbury; Messrs. Brady and
Martin, Newcastle-on-Tyne; Dr. Quinton, Yorks; Mr. Dayson, Ebbw
Vale; Mr. Parkhouse, Somerset; Dr. Hyslop, Salop; Messrs. Bailly
and Coates, London; Miss Dandison, Chester; Mr. Nicliolls, Bury
St. Edmunds; Mr. Brooks, Lambeth; Mr. Elliott, Devon; Dr. Wilson,
Wolverhampton; Mr. Holmes, Derby; Mr. TuUy, Hastings; Dr. Wise,
Trowbridge; Dr. Campbell, London ; Dr. Laird, Nunhead; Mr. Tyte,
Minchinhampton; Mr. Lockwood, Huddorsfleld; Dr. Dobbs, South-
gate ; Dr. Williams, London; Miss Armstrong, Ryde ; Mr. Bschwege,
London; Mr. Maw, Doncaster; Mr. Harris, Norwich; Messrs. Condy
and Mitchell, London: Mr. Brown, Dalmally, N.B.; Messrs. McNab
and Go., Leith; Dr. Chambers-Owen, Doncaster; Mr. Bowler, Man>
Chester; Mr. O’Meara, Shepshed; Mr. Stainsby, Bradford ; Mr. Thin,
Edinburgh; Mr. Gastello, Taunton; Mr. Cane, Mexboro'; Mr. Le
Fevre, Bedford; Dr. Lawrence, Chepstow; Mr. Thompson, South
Hampstead; Mr. Corcoran, Loughborough; Mr. Graham, Dumfries¬
shire ; Mrs. MacRosty, Esher; Dr. O’Meara, Carlow; Mr. St. Dalmas,
Leicester; Capt. Pead, Dulwich; Mr. Bethell; Mr. Hey wood. Man¬
chester; Mr. A. H. Robinson, Bradford; Alpha, London; Borough
of Salford; Jamrack, London; Garthroy, London; Secretary, County
Lunatic Asylum, Burntwood ; Fides, Brighton; Secretary, Bradford
Infirmary and Dispensary; Kensington, London; Secretary, County
Asylum, Shrewsbury; Q., Clifton; Victim, London; Great Eastern
Railway Co., London; M.D., Radnorshire; Secretary, West Riding
Lunatic Asylum, Wakefield; Beta, London; Secretary, Royal Victoria
Hospital, Bournemouth; Sussex, London; Vega; Secretary, Queen’s
College, Birmingham; N. B., London; S. P., London; Secretary, The
Retreat, York; Surgeon, Loudon; Laertes, London; Matron, Stock-
port; J.L. S.,Dublin; P.P., London; Locum, Pontypridd ; M.B.,
Loughborough; C. M. A., London; M.B., C.M,, London; Trustee,
London; Doctor, London; Assistant, London; Lake, London ; O. R.,
London; B. M., London; Surgeon, Coventry; Sigma, London; J.D.,
London ; Medicus, Manchester; F. F. D., Derbyshire; G. P, O., Old¬
ham ; Matron, Ventnor ; Deaconesses’ Institute, Tottenham; Alpha,
London; Zircon, London; L. D. S., London; Doctor, Kilbiirn; Fidelis,
London; D. C. E., London; Medicus, London; Doctor, Kensington;
C. M. II, London ; Medicus, Crewe ; Assistant, Lancashire; Veritas,
London; Masseur,London; BastRidingAsylum,Beverley; Graduate,
London; Medicus, Colchester.
Newspapers —Sheffl.eld Telegraph, L^eda Mercury, Morning Poat, York-
shire Post, Methodist Times, Scottish Leader, Bristol Mrnniry, Olasgow
Evening Citizen, Western Morning Mem, Northern Whig, Sussex Daily
Neivs, Liverpool Daily Post, Manchester Courier, Melhoumo Leader,
Hampshire Independent, Inauranoe Record, City Press, Local Govern¬
ment Chronicle, IFwidsor and Eton Express, Reading Mercury, Weekly
Free Press and Aberdeen Herald, Hert/ordshire Mereui-y, Windsor and
Eton Gazette, Labour World, Sunday Times, Sim-ey Advertiser, Thg
Newspaper, Mining Journal, Architect, West Middlesex Standard, Law
Journal, Spectator, National Bulletin, West Middlesex Advertiser,
Corriere D'Jtalia (Rio de Jaivciro), Norfolk Daily Standard, South
Wales Daily News, Journal dcs Debats (Paris), 3Ianchester Guardian,
flinrioo Patriot (Calcutta), La Presse Mddicale (Bruxelles), Leighton
Buzzard Observer, Sydney Morning Herald, Derbyshire Advertiser, The
Therapist, Scotsman, Poole Herald, Durham Advertiser, Ashton-undor-
Lyne Reporter, The Times (Richmond, Virginia), Optivian, La Patria,
Schoolmaster, i:c., have been received.
SUBSCRIPTION.
POST Free to ant part of thb United Kinodom.
XtaeTear___£112 6 | Six Months_.£016 3
To China and India ............ .One Tear 1 16 10
TO THE Continent, colonies, and United
States........... .. IMtto 116 0
Post Office Orders and Cheques should be addressed to The Publisher,
Chb Lancxt Office, 628, Strand, London, and crossed “ London and
Westminster Bank St. James's-square."
ADVERTISING
Books and Publications (seven lines and under) .. £l • Q
Official and General Announcements .0 19
Trade and Miscellaneous Advertisements .. .. 16 6
Every additional Line 0 0 6
Front Pue .. .. per Line 9 10
g oarter Page. 110 0
alf a Page . .. 2 16 0
An Entire Page.660
The Publisher cannot hold himself responsible for the return of testi*
monials Ac. sent to the office In reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are req^uested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters address^ to
Initials only.
An original and novel feature of "The Lancet General Advertiser” is a special Index to Advertisements on pages 2 and 6, which not only
sJtords a ready means of finding any notice, but is in Itself an additional advertisement.
Advertisements (to ensure insertion the same week)should be delivered at the Office not later than Wednesday, accompamed by a remlttanoe.
Answers are now received at this Office, by special arrangement, to Advertisements appearing In The Lancet.
Terms for Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subsorlptloiu shonld bt
Addressed.
Advertlsementa are now received at all Messrs. W. H. Smith and Son’s Railway Bookstalls throngbout the United Kingdom and ail ottiw
Advertising Agents. __
Agent for the Advertleement Department in France—J. ASTIER, 66, Rue Caumartin, Paris.
Digitized by ^ooQle
THE LANCET, May 2, 1891
Clinical fccto
ON THE
CURABILITY OF PULMONARY
PHTHISIS.
Ddi-OGred at the Royal Infirmary, Manchester,
By THOMAS HARRIS. M.D.Lond., M,R.C.P.,
ENIOH ASSISTANT PHYSICIAN TO TTILI INI'IRMAltY, AND PHYSICIAN TO
TIIK HOSPITAL POR CONSUMPTION AMI DISICASLS OP THE
THROAT, MANCllESTKn.
The majority of physicians at the present day believe in
the curability of the most comiuon variety of pulmonary
phthisis—the tubercular. But although there is almost
unanimity in that belief, we are not nearly so agreed as to
the frequency with which such a favourable result ensues.
There are doubtless a large number, who have had an
■extensive clinical and pathological experience, who, although
a.ccepting the view of the curable nature of the disease,
deny that it is a common result; whilst others with similar
opportunities for gaining experience believe that it is no
uncommon thing for phthisis to end in recovery. To these
two groups may be aided a group of pathologists who have
lieen guided more especially by the experience of the post¬
mortem room as to the frequency with which signs of
involuted tubercle, in the form especially of old caseous and
■calcareous foci, are found in the lungs of those who have
died from various diseases and injuries. This class of
pathologists may maintain that pulmonary phthisis not
occasionally, but very frequently, becomes arrested, and
even cured, when it is limited and in a very early stage.
It is extremely difficult in a disease like phthisis, which
may run a very prolonged course, during which temporary
improvements of longer or shorter duration take place, to
solve the problem as to the frequency with which a favour-
•able result ensues. We may, however, by considering the
■evidence on which our belief in the curable nature of the
malady is founded, arrive at some idea, although not a very
exact one, as to the frequency of a favourable termination
of cases of consumption. The evidence of the curable nature
ef tubercular disease of the lungs is in part clinical, in part
pathological. The clinical experience lias been obtained by
watching cases of phthisis over a number of years, and also
by the consideration of the history of cases of phthisis, from
.a study of which wo frequently find that the disease was
■arrested for a longer or shorter period. The pathological data
•consist in the frequency with which signs of obsolete tubercle
are observed in the lungs of persons dying from different
■diseases.
We possess many records by reliable physicians of the
■cure of cases of phthisis, cases where the physical signs
and the symptoms have been very definite, and where we
•could not doubt the existence of phthisis, and in which
at a later date all symptoms and signs of activity of the
•disease have disappeared and remained absent for a
sufficiently long period to warrant the conclusion that the
•case was not one of temporary arrest only, but of actual
cure. Such evidence has in some cases lleen still further
fltrengthened by subsequent post-mortem examination,
which has proved that the phthisis had become perfectly
<irrested. Such cases are now fairly numerous and form
valuable evidence of the curable natuie of consumption,
and encourage not only unfortunate sufferers from that
disease, but show that certain lines of treatment, especially
the climatic one, have the best of evidence, a favourable
result, in their support.
Another piece of clinical evidence is one to which less
attention has been drawn; but it is one of consider-
■able value. Careful inquiry into the previous health of
consumptive patients not unfrequontly elicits the fact
'that at some period before the illness for which they are
•consulting us began they had some chest trouble, from
which they apparently entirely recovered and had a period of
,good health between that affection and the onset of their
present illness, -fn many such cases we ate able to feel
vairly confident, from the details given of the nature of the
.attack, that the illness from which they thought they had
aecovered was of a tubercular nature, which had become
quie.scent for the time. The former attack has usually not
No. 353\.
been recognised as of a phthisical nature, but has been
believed to be bronchitis, inflammation of the lungs, or
even some disease unconnected with the respiratory appa¬
ratus—for instance, typhoid fever. Such cases of unre¬
cognised attacks of localised tubercular disease in the lung
are probably far from being uncommon.
The pathological evidence of the curability of phthisis is
even stronger than the clinical. Nearly everyonewno has had
much experience in pathological work has noticed the fre¬
quency with which old caseous and calcareous foci, associated
with more or less fibrous tissue, are found in the lung apices
of those who have died from various diseases. There can be
little doubt that these lesions represent foci of former active
tubercular disease which has become quiescent. It is
difficult to be certain as to the exact frequency with
which such signs of involuted tubercle are found, as the
statements of difi'erent observers differ considerably as
to their frequency. As a result of some observations
made in the post-mortem room of the Manchester Koyal
Infirmary during the twelve months from Oct. lat, 1887, to
Sept. 30th, 1888, 1 found that no less than 38‘84 per cent, of
the cases of persons above twenty years of age presented
such lesions.^ In other words, 38 84 per cent, of all the
bodies over twenty years of age which were examined had
had one or more foci of active tubercular disease which had
become quiescent, and in the majority of instances such
lesions had nothing to do with the cause of death. This
high figure bearing upon the curability of phthisis is cer¬
tainly remarkable. The results obtained show that local
tuberculosis of the lung is not only common, but that it
very frequently ceases to extend, and becomes quiescent.
There are certain facts in conne.xion with these caseous and
calcareous foci which have an important bearing upon the
question under consideration, and must be considered. All
the fibrous cicatrices with and without caseous or calcareous
foci which are found in the lungs, and which are regarded
as indicating former active tubercular disease, are not per¬
fectly quiescent. Many, which to the naked eye appear
quiescent, are found on microscopical examination to show
signs of activity at their peripliery, and cannot therefore be
regarded as examples of involuted tubercle, but rather as
very slowly progressing tubercular foci. In addition, those
foci which contain caseous material which is not perfectly
calcified are a decided source of risk to the person in whose
lungs they exist. They may, and probably not unfre-
quently do, set up either au extensive destructive pul¬
monary tuberculosis or are the source of infection for a
general acute miliary tuberculosis. This danger is un¬
doubtedly a real one, as post-mortem examination, espe¬
cially in cases of acute tuberculosis, occasionally clearly
proves. This danger of a local or general infection from
these small centres in the lungs is readily understood when
we know that tubercle bacilli have frequently been found “
in such old caseous foci, and that tuberculosis has been
repeatedly set up in animals by inoculation with caseous
material from such foci.“ Cases where no tubercle bacilli
can be found may yet be capable of producing tuberculosis
in consequence of the presence of the spores of those bacilli
which cannot be recognised by our usual methods of staining
micro-organisms. Prom the teaching of experimental patho¬
logy^ we are compelled to regard all old tubercular foci in
the lungs which contain non-calcified caseous material as
dangerous to the organism. Only those foci can be regarded
as perfectly healed, and as true examples of cured phthisis,
which are vepiesented either by fibrous tissue alone or by
completely calcided caseous matter. Caseous foci which
are imperfectly or not at all calcified are probably always a
source of danger, and may at any time give rise to a destruc¬
tive pulmonary tuberculosis or a general acute miliary
affection.
In considering the foci of obsolete tubercle in the lungs
we cannot forget that the area of disease is nearly always
exceedingly small. It is not common for the caseous or
calcareous focus to be larger than a walnut, and usually it
is much less than that. It is probable that at an earlier
date it was more extensive, and that in consequence of the
I A ilelailcii account of tho result of thi.s investigation, witli an
attempt to explain the disw-epaiicy between dlfferoiit observers as to
the frecfueiicy of hoaloil phthisis, was puhlUheil in the IJviti.sh Medical
Journal. December, 1889.
■■* Ddjorine : Roehorches ties Bacilles dans la Tuhcrculose Calciflde et
Cas(^o-calciHce, Rovuo do Mod., vol, iv., p. Ii21, 1884.
Ifui'low : Uobor die Jloilbarkoit. iler Luiigeutuherculoso, Deutsches
Archiv flir Klin. Mod., vol. xl., p. 487,1889.
■* Havvi.s ; British Medioal .lournal, Dooeinbev 1831). Kiirlow : Ibid.
S
.Google
D :' •
974 Thb LANCar,] DR. G. A. HERON ON KOCH’S TREATMENT IN TUBERCULOSIS.
[May 2,1891.
shrickiDg of the fibroas tissue which was formed its dimen-
sioQB were coosiderably reduced. We have no means of
estimating the number of cases from among these instances
of obsolete tubercle, where distinct symptoms and signs of
hthisis at au antecedent date were present. Probably,
owever, the great majority of cases had occasioned neither
symptoms nor physical signs of phthisis, whilst a minority
had done so. At the same time it is probable that the
early physical signs of phthisis are due to the surrounding
catarrh quite as much as, if nob more than, to the
focus of tubercular dieease itself And as such simple
catarrh varies in extent and may completely disappear with¬
out leading to further destructive changes in the lung, we
can easily understand that what appears to us as a focus of
obsolete tubercle, too small fo produce any signs or sym¬
ptoms, may have given very definite indications of its pre¬
sence at some prior date.
There is yet another consideration which offords evidence
of the curable nature of pulmonary tuberculosis. Cases of
phthisis dilTer very much in their acuteness, in the rapidity
with which thedestructivechangesintbelungs are effected,
and consequently the duration of life likewige varies. In
some the aestructive processes are very acute, and the life
of the victim is a very short one; in others the destructive
change is a slow one, and life is prolonged may be for very
many years. In the former class of cases, the acute ones,
we find that very little fibrous tissue has been formed in the
lungs, whilst the softening is very marked and has pro-
ceded rapidly. In the latier class, the clironic cases, we
find that much fibrous tissue has been formed, and in some
instances an excessive amount, so much that during life the
case has presented many of the features of true fibroid or
non-tnbercular phthisis. 'We cannot avoid the conclusion,
from a consideration of the course of the disease and the
changes found in the lungs, that these chronic cases are
really instances where there have been attempts to arrest
the destructive processes, and that the fibrous tissue really
represents a conservative change, au attempt to effect a
cure. Many of these ca«es do become arrested for the time,
as a careful consideration of the course and the clinical
history will often shoM'. All such fibroid changes in cases
of Dulmonary tuberculosis are to be regarded as favourable
ones, ana ihe more marked they are the more slow has been
the progress of the disease and the longer has life been
maintained. Thefrequencythereforewithwhichsuch casesof
cbronic tuberculosis, accompanied by the formation of much
fibrous tissue in the lungs, are met with is an argument
of considerable weight in favour of the curability of
phthisis.
In reference to this question of the curability of con¬
sumption, we may recognise three classes of cases:—
1. Cases of very limited tubercular disease of the lung,
where the lesion is small, and is eventually replaced
either by fibrous tissue alone or by fibrous tissue
and a completely calcified caseous focus. As far as our
experience goes, such cases are always instances of very
localised and very small foci, and the disease is never an
extensive one. These cases are the only ones which can
be considered as perfectly healed, and where the lesiou
(cicatrix or calcareous focus) which remains does not involve
a risk to the possessor, such lesions, so far as we know, not
being liable to set up either a local or general tuberculosis.
These lesions are not unfrequently found in the lungs of
persons who have died of various diseases and from injuries,
but it is not known how frequently the tubercular change
has been extensive enough to cause distinctive signs and
symptoms of pulmonary tuberculosis. Probably the majoiifcy
of the persons in whose bodies such foci of obsolete tubercle
are found have at no period of their lives presented the
usual signs or symptoms of consumption, the lesion having
been very small. 2 Cases similar to the above, but where
the remains of flie tubercular disease is not at all or
only imperfectly calcified. Although the physician, from
the examination of the chest and the consideration that
all the symptoms of phthisis have disappeared, may
regard such cases as cured, they cannot be so considered
by tbe pathologist. The latter knows from the micro¬
scopical examination of such foci, and from the results
of inoculation experiments with animals, that such foci are
dangerous, and may at any time give rise to further
destructive changes in the lungs or bo general miliary tuber¬
culosis. They are cases, however, in which if the person
Temaina under favourable conditions for preserving health,
may pass on to a complete cure, and then deserve a place in
Class 1. 3. Cases which run a prolonged course often withr
periods when tbe disease remains quiescent and which are
characterised pathologically by the formation of much
fibrous tissue, lb is some of tnese cases which are so mis¬
leading to tbe medical man, and cause the hopes of the.
sufferer not only to be raised, but cause him to believe that
he is cured. This feeling is a consequence of the disease
having become either temporarily arrested, or, as is pro¬
bably more frequently tbe case, by its progressing extremely
slowly and being associated with few {uiysical signs and
symptoms of extending disease. Very many cases of phthisis
come under this beading, and it is rare for a case of cbronic
phthisis to be continually progressive ; nearly all such forms
of the disease are associated with periods of relative good
health when the disease appears to be quiescent. The
fact that many cases of phthisis belong to this class renders
any conclusions as to the good effects of any particular
treatment so fallacious. Tbe enthusiastic therapeutist is.
very prone to conclude that the favourable results are the
consequence of tbe treatment adopted, and to forget that
tbe favourable symptoms and signs may be explained as-
manifestations of the natural course of the disease. The
history of the treatment of pulmonary tuberculosis is full of
such fallacies.
Prom a consideration of tbe above classes it follows that
some cases of phthisis are completely cured, but that the
disease in such instances has never been a very extensive-
one. Tbe majority of cases of phthisis we are compelled to-
consider belong to tbe last-mentioned classes, and conse¬
quently to be cases which often show a tendency to cure.,
but rarely perfectly attain that end. Tbe tendency, how¬
ever, in very many cases of phthisis is towards arrest, and it
is the evidence on this point, together with the absolute proof
which we have that in some cases a complete cure doe®
result, that gives us encouragement to persist in fcrea^^ment,
and warrants us in holding out good hopes of recoveiy t(.'
the unfortunate sufferers in tbe early stages of the disease.
ON KOCH’S TREATMENT IN TUBERCULOSIS-
OP THE LUNG AND IN LUPUS VULGARIS.
By G. a. HERON, M.D., F.R.C.P. Lond.,
I’llVSlClAN TO THK CITY OF LONDON HOSPITAL FOll DISEASES OF Tlir--.
CHEST.
{Coi\duded from page
Increase and Extension of certain Physical Si^ns dwivg the-
Use of Tuberculin.
In many of the cases there was noticed increase of tbe-
raucouB iiMes after the use of the remedy, when their then
condition was compared with what it had been before treat¬
ment was commenced. The increase was expressed in this,
that the moist sounds became certainly coarser, and there
seemed to be more of them at the site of the disease. Also, in-
parts of the lung where certainly no evidence of tbe exist¬
ence of disease had been observed before tuberculin was used,,
there were noticed thereafter, in many instances, crepitationa-
which were undistinguishable from those usually heard over
thesite of early tuberculosis of the lung. This was observed
in several instances in those patients who were suffering
from tuberculosis afi'ecting apparently one lung only, and
in them it was often observed about the apex of the lung
which had seemed healthy. These features were noticeable
after a reaction had set in, and they continued probably for
twenty-four or thirty-six hours. It was hardly possible to-
be sure as to tbe period of their duration, becanee as
soon as the temperature fell to the normal limit, another
injection of tuberculin was given, and then these physical
signs usually repeated themselves. In most of these in¬
stances the new signs were noticed to disappear as the
treatment progressed, but in exceptional instances they
certainly remained for one or two weeks after the beginning
of treatment; though even in these cases the newly deve¬
loped sounds, it was noticed, always rapidly diminished in
amount and in extent. In no case did these new physical
signs exist when the patient left the hospital. I was able-
to satisfy myself that these now physical signs were some¬
times, but not al ways, accompanied with increase of dulnesa
on percussion. These conditions of lung may be reasonably
The Lancet,}
DR. G. A. HERON ON KOCH’S TREATMENT IN TUBERCULOSIS. [May 2, 1891. 975
explained by comparing what probably takes place there
with what we see going on in and around patches of
lupus vulgaris. The marked swelling of the affected parts,
and of apparently healthy tissue for some distance from
them, which forms so familiar a characteristic of the
effect of tuberculin on this skin disease, may verv well
have its counterpart in the tubercular lung, ana this
would account, it seems to me, for all these new physical
signs, although it is difficult to understand why evident
dulness on percussion should not always form one of them.
In parts distant from the first recognised lesion of the lung,
and having no continuity of tissue with it—as, for instance,
the apex of the opposite lung,—it may very well be the case
that the existence in them of centres of disease, not detect¬
able by the stethoscope, explains the reason why, when
tuberculin acts, new patches of crepitation are developed
there. It is only reasonable to believe that in every case of
tuberculosis of the lung there are, especially in the be¬
ginning of the disease, affected portions of tissue which do
not convey the evidence of their condition to our senses.
SJcin Eruptions.
The patient L. E-, already mentioned, was the only
one under my care who showed that peculiar skin eruption
which Dr. Radcliffa Crocker has so well described in
Thb Lancet of Nov. 22ad, 1890. She had it on two
occasions early in her course of treatment. There was
nothing in these attacks to distinguish them from the many
others like them, that have been often mentioned in
connexion with the use of tuberculin. Another patient,
A. H-, a woman aged twenty-eight, had tuberculosis of
about one-half of each of her lungs, with cavity at the apex
of the right lung. After she had been twenty-nine days
under treatment, and bad received twenty-two injections
of the remedy, there appeared a purpuric rasb, which
affected in patches her thighs and legs from the groins to
the ankles. It began with small groups of papules, which
I noticed in one or t wo instances were at first colourless, but
gradually became red or reddish-brown in colour. Between
the groups—they did not lose their colour on pressure—was
apparent^ healthy skin, and at first the little groups of
papules varied in si/e from that of a pin’s head to that of a
farthing. At the same time that this eruption first ap¬
peared, there was slight tenderness and swelling iu the right
wrist, and at the outer and back part of the right elbow
there was a little puliiness, with bluish discolouration.
Between the radius and ulna, abo«t half-way down the right
arm at its posterior aspect, there was distinct swelling, but
without tenderness. There was also pain in both knee-
joints, and in the legs, »nd in the left elbow. In four days
both ankles were swollen, and there was swelling of the
right forearm in front, in its upper third. The right arm at
the level of the swelling measured half an inch more than the
left one. There was no evidence of abnormality in the liver
or the spleen. On the sixth day these swellings disappeared,
and the rash, which had meanwhile become confluent all
over the lower limbs, began to fade. On the seventh day
after the appearance of the rash there was slight puffiness
over the forehead, extending from the middle of the left
to the outside of the right orbit, and from above the eye¬
brows to the roots of the hair, and measuring 4^ in. by 2 in
The puliiness had more the appearance than the feeling of
a swelling, and was without discolouration of skin. This
swelling disappeared in two days, and did not return. The
hicmorrhagic rash, which had seemed to fade for a short
time, recurred, and covered practically the whole of the :
lower limbs. In this condition the patient, at her own wish,
returned to her home. She wrote to me on April 8th, say¬
ing : “ Occasionally the rash reappears, and when it does I
am unable to walk about for a day or two, bun that has
only happened twice during the six weeks I have been at
home. ” On one occasion only was albumen detected in this
patient’s urine, and then there was but a mere trace of it.
Her urine as a rule amounted to between 35 oz. and 50 oz.,
and presented no feature of special interest. It was
examined three or four times a week. This woman received
no injection after the purpuric rash appeared. Her highest
dose of tuberculin was eight milligrammes, and she had
eight marked reactions in response to the twenty-two doses
given to her.
Condition of Urine.
It may be convenient to state at this point, that only in
eight of these thirty-seven cases was albumen found in the
urine, and its presence was always temporary. No observa¬
tion of consequence was made when the urine was exa¬
mined under the microscope.
Other Complications.
Of these there were but three of any importance. A girL
whose case is referred to in the journals under the iniuals
H. D., whose age was fourteen years, received on the
twenty-first day of treatment a dose of 8 mgr. of the remedy,
' and to it there was no symptom of reaction. On the day
following the girl’s temperature began to rise, and no reason
for this could found. It was a rule in the wards, that when a
patient who was using tuberculin showed any important sym¬
ptom which could not be readily accounted for, tlien, at once,
the use of the drug was stopped. To that rule there was never
an exception. Accordingly, the treatment was discontinued
whenever this unexplained rise of temperature was noted.
This girl developed pleurisy of the left side, with a moderate
amount of effusion; and it ran an ordinary course. In a
fortnight the treatment was resumed and continued until
thirty-six injections bad been given, the last three of
these having been doses of 100 mgr. each. The girl had
abundant tubercular bacilli in her sputa, and both of her
lungs were tubercular, the infection extending, without
excavation of lung tissue, on the left side to about the level
of the fourth rib in front and the sixth one behind, and on
the right side to about tbe level of the second rib in front,
and behind to about the line of the spine of scapula. This
patient did very well; and I hope there has been an
opportunity for you to examine her to-nigbt. Another com¬
plication occurred in the case of a girl (S. M-), eighteen
years of age, who had coarse r.Hes over the upper naif of
her left lung, in front and behind, and a slighter affection
of her right one. She, after having been two weeks under
treatment, and on tbe day after she had received her ninth
injection, developed a pneumothorax of the left side. She
blamed the treatment for this condition, and in accordance
with her own wish she was not again submitted to the
injections. In a few days she passed under the care of my
colleague, Dr. Eustace Smith, whose patient she had pre¬
viously been, and made a good recovery so far as the
pneumothorax is concerned. With regard to the cases of
laryngeal tuberculosis, they are too few in number amongsn
these patients to justify a decided opinion being formed about
them in connexion with the use of tuberculin. It is, however, a
fact that not one of these cases did well as regards the throat
condition ; indeed one of them, the man referred to in the
table under the initials A. D., aged twenty-seven, became
rapidly worse while under that treatment. Mention is mad©
in the table of a prominent ^art that was played by the ap¬
pearance of a hectic condition in certain cases. Of course
patients with tuberculosis of the lungs frequently undergo
exacerbations of temperature- Dr. Chaplin, the resident
medical officer at Victoria-park Hospital, Kindly looked up
for me one hundred ordinary cases of phthisis, which had
not been treated by Koch’s method. He found that during
a residence of six weeks iu hospital eight of the hundred
bad exacerbations of temperature. It will be noticed that,
with one exception, all my patients who showed hectic sjm-
ptoms had done so before treatment was commenced. So
far as this experience goes, it merely shows that tuberculin
did not cure the hectic stale of these patients. In all the
cases where it occurred, in these patients, the exacerbation
of temperature, after lasting for a varying number of days,
gradually passed off. But, undoubtedly, it showed its usual
tendency to recur, in spite of tuberculin, whether given in
large or small doses. In the case of one patient, A. H-,
we nad her blood examined by Ehrlich’s test while she was
undergoing an attack of marked hectic, and at the height
of her purpuric eruption, but no tubercular bacilli were
observed, although very careful search was made for them.
In the table submitted for your inspection I have divided
my patients into three classes. In the first class are placed
those who come within the limits, as 1 understand them, of
Koch’s category of those consumptives in whom cure might
reasonably have been hoped to follow the use of the remedy.
I cannot say that any one of iny patients has been cured
beyond danger of relapse. Nor did Koch himself regard
such cases, even when tbe host results had been obtained
from treatment, as safe from relapse. He emphasises that
opinion of his very strongly in his well-known paper of
Nov. 13th of last year. In my second class of cases—those
designated as being in the second stage—I include patients
whose conditions of lung disease place them outside of that
class of people who ate suffering from tuberculosis of the
?7e: lancet,] DE. G. a. HEEON on KOCH’S TI® ATMENT in TUBEECULOSIS. [May 2,1891.
UiDg itS: eommencement. Tiie .physic^ siens.of their
disease, and their general symptoms, showed'&at without
anv evidence of cavity being detectable they had consider¬
able tracts of lung tissue involved in the tubercular process,
(figs. 1 and 2} In my third class are those who had
evidence of cavity in tneir lungs. In every patient of
three, classes, judging £rom< general symptoms and
V . j 0<' Fig. 1.
i 0,1 '
some cough and night sweats, and by a material, and.
sometimes very mdraed, increase in the patient’s sense of
freedom of breathing power. It was remarKable how several
of these patients themselves observed this indication of
improvement in their condition, and drew attention to the
fact that they could walk about the hospital grounds for an
hour or so, and then go up to their wards without once
Fig. 2.
Figs. 1 aiid 2 graphically reproseut the condition of G. M-, on the first page of the tables, after a course of treatment, on April 7tb.
Fig. 3. Fig. 4.
Figs. 3 and 4 represent the condition of A. T)-, aged forty, the fourth ca.so in the second page of the tables, at the beginning of
the treatment, and Figs, e and 6 the condition of the same patient on April 7th.
from physical signs, the tubercular process was not
tending towards cure, nor was it stationary before treat¬
ment was commenced. The contrary of these con¬
ditions obtained in every instance. The table indi¬
cates that a certain number of these patients have im¬
proved in health — some more, eoTie less—under the use
of tuberculin. (Fics. .3, 4, 5, and 6. This improvement
Nvas best manifested by a gradual disappearance of trouble¬
stopping to rest by the way because of their shortness of
breath, and without being subject to fits of severe cough
after the exertion of coming upstairs. Before treatment
these patients had been unable to walk even upstairs to the
wards without stopping several times on the way to cough
and rest.
Tiien, as regards the evidences of improvement which
had their expression in the physical signs of thes
Digitized by LjOOQle
Thk Lancet,]
Dll. a A. HERON ON KOCH’S TREATMENT IN TUBERCULOSIS,
|May2,1891. 977
CASES OF TUBERCULOSIS OF THE LUNG.
u
9
U
<
Sex.
'©
ubercular
bacilli.
Simtinii lie- 1
oreased. '
1
0 0
li
g
to
** Z-
.c a
No. of
reactions.
Coinplica-
lions.
Weight.
1 i
II
2 g
Reaulls.
Heniiir'ks.
S'®
a a
C
H
X--
0-
.
—
—^ ^-1
Kroiii t<»
1 iained.
Lost.
Days.
Kleven weeks after treat¬
K 8.
2>
M.
iMlntagu.
Very
2 (Ir. . Hcanty.
15
21)
None.
None.
•2 lb.
->
10
(Ireat im-
many.
pruviAueiil.
ment iinproveinenl luiiin-
1 talned. At work 7 weeks as
1
1 packer. Tubercle bacilli,
1 ninny.
aiM.
27
M.
UtNiage.
None.
j-loK.. .nnaltelreil.
1
- 20
SO
10, all
below 10 1
None.
Un-
iilterert.
Vn-
altered
86
Improve-
indnt.
Sputa examined again ami
dgaiii; no tubercular bacilli
*"0>/ t
, , 1
milligrmo. '
dose.
6 below 10 ■
fbuiid,
1 j. -
20
' !
iHt aUi.gu.
Many.
1 oz. . - scanty.
30
100 1
Ilocticiind
Vn-
Vii-
70
Un¬
Has not 1>ecii seen sineu
inilHgrme. .
abdominal
altered.
altered.
improved.
treatment ended.
. 1 *. 1
dose; 4
paiu; sore
‘
.f). •
•3citl- ■
nr -rt oi
above.
1
over
xiphoid. 1
Impmverl
mateHially. 1
, 31
M. I
lot Ntago.
Many.
1 -3oZi.. ul)t.
. 4-1
350
0 below 10 !
milligrme. ,
None.
14 lb.
00
dose; U <
J.k.
85
M.
lat stage.
None.
4 oz. .. scanty. '
:>f
1000
above.
13
None.
-
311),
67
Ib-Hdfid im-
' provepient.
Trcatn.enb just ended.
T. H.
■J .1..
25
M.
let stage.
Few to
many.
1-4 oz. .. uiiahil.
18
21.1
! .5 below 10
nillligrino.
dose; 1
Hectic he
fore,during,
and after
1
1
71b,
32
, Beciine
1 worse.
Hectic before, during, and
after treatment. Hailattai kK
of (ii'irrhiea with pain «u
above.
treatment.
4 days.
tA'jLtki.
24
M. 1
' 1st stage.
Very
many.
1 OR. .. .J »s^
40
•too
3 below 10
inilligrine.
l^uryiigeal
tuDer-
10 lb.
1 —
00
Improved
in long;
dose2
culosis.
j
larynx,
.^u -
Mt- 1 U
II. D.
t , ■ ,1
1
above.
1
1
trifling im-
p'ovoiiient.
14
1
V.
let itUige.
Very
many.
4-loz. .. scailty.
30
11)0
8, all up
to 10
Fleurlsy;
old Lip-
12 lb.
' 42
(Ireat im¬
provement. 1
II.’ ■ 1
railllgrme.
joinc.
1
1
1
dose.
disease.
Excellent health two
muntliH after treatment. In
11. B.
28
F.
1st stage.!
Many
l4oz. .. none.
82
100
, 4 up to 10
niillignne.
None.
I 10 lb.
—
' i
Very great!
improve- 1
‘ ik
1
dose.
nient.
in work as a general servant.
M.tleW.
2S
F.
11st stage.
Many.
4 oz. .. 1 »lr.
31
50
10 uptolO
inilligrine.
Tonsillitis;
tiivial 1
84ll>.
— 1
42 1
Improve¬
ment.
—
dose; 2
attack, 1
I
21 ,
F.
1st stage.
Few.
Sciinty .. scanty
00 i
801)
above.
;[) up to 10
-iiiiiiigrme.
None.
t
04 lb.
, -
12c
(Irea^ im-
pruvemeiil.
Still in hospital.
t •
t 1
dose; 0
1
1
L. B.
23
!'•. .
let stage.
Very
many.
4 oz... scanty.
! 88
UK)
above.
4 up to 10
1 milligrme.
Hectic
before 1
Oil).
-
so
Improved
muterialiy.
Hputura after treatment
roased. All viscid mucus.
dovu; U
treatment,
Hectic before trealmciil.
,i|
above.
:2i) j
F. 1
1
Ist .stage.
Very
many.
2oz. .. 14 dr.
24 !
100
3 up to 10
milligrino.
ilo9^ • 4
Hectic
liefore
treatment.
I’ll-
filtered.
Un¬
altered.
52
Improve-
iiient,
Still in
Uecllc before treatment
begun. Tra:e of albumin
on flve occssions, four of
above.
lios]>itnl,
them before treatment. Hail
1
1
1
rheumatic lover 12 months
age. , .
20
•■M
,lst stage.
None. '
None. j
10
4 1
7
None.
I'n-
altered.
Un¬
altered.
30
Un¬
improved.
ill llie hospital 2 years ago
with history of bmuioptysis.
JiCft hos¬
No sputum then.
1
1 i
1
pital at
iier own
, 23
M. ;
2iul .stage.
Very
many.
1 dr. .. Bcaiity.
38
100
' 8 up to 10 '
, inilligrine.
Hectic
after
; -
241b.
! 41
reiiuest.
Iniprove-
nient.
Sixth evening after treat
ment patient lircaum bei'tic.
dose ; 1
above.
trealmcut.
remaining so 6 days. For 20
days tlierealter tciuperatui'o
normal,
u. w. '
22 '
M.
2ntl stage.
Very
many.
rnaltured ;
' (1 oz. ,, z oz.).
27
iim '
2 up to 10
miliigrnic.
Ijavyngeal
tuber-
21b.
1
—
30
Improve¬
ment.
Laryngeal comliliuti uniui-
proS'cd.
, dose ; 2
culosis.
i
ICQ-.
liU
M.
2iiil stage.
Very
many.
2oz... nnaltered.
47
600
above.
1 8 up to 10 '
1 miUlgnne.
1 1 3
Syphilis.
-
00
Improved
materially.
Hectic before treatment
After sevunth injection treat¬
ment stopped, there Imviog
1
1 above. 1
been 110 reaction up to IZiiin.
Iodide of piUiishium given for
10 days. Beaclions followed.
■ ■\ .
n. N.-
38
M.
2nil stage.
Few ;
4 oz. .. un.aUcred ;
38
100
12 up to 10 1
None.
' r.lb.
—
52
Unaltered.
—
none
imu'us
milligrme.
fotinil
only ;
dose ; 4
after In¬
purulent
after.
; .
20
M.
2n(l stage.
jection.
Many.
liefuro.
4 oz. .. 14 oz.
33
100
10
None.
24 lb.
-
51
Improved
slightly.
la able to return to work
as luuseuiu atiendaut.
-l-f'
45
M.
2iul stage.
Many.
24 oz. .. 1 oz.
34
100
1
4 up to 10
mluigrmu.
None.
1
3411).
—
• 43
1
Improved
imiterially.
•'Vttd •
T-'L' '
'40
M.
2n(l stage.
Many.
1 24 oz. .. Uoz.
22
m
dose \ 1
above.
2 UJ) to 1(1
Twisted
lOJ lb.
35
Improved.
Twisted arteries.
inilligniie.
arteries.
^.1 IE
dose 1 5
above.
■
- ^ —,
• Hee Figs. 1 aiwl 2.
Digitized by LjOOQle
DK. G. A. HERON ON KOCH’S TREATMENT IN TUBERCULOSIS.
[May 2,18M,
97g TheLaKcktJ
Cases of Tuberculosis of the Lung—( conim'Ksd).
.13
4)
<
g
CO
Condition of
disease.
11
r
Sputum de¬
creased.
of
s
ii
•9 •
^ .
u
.1!
No. of
reactions.
Complica¬
tions.
Weight.
Duration of
treatment.
Besults.
Remarks.
From
to
Gained.
Lost.
Days.
A. A.
16
P.
2nd stage.
Many.
4 dr. .
. none.
40
20
21 up to 10
milngrme.
dose; 1
above.
Tubercu-
oaie, glands
of neck;
sore left
side.
4lb.
84
Improved.
Sore
healed.
Lungs both affected. Pby-
eical signs unaltered.
A.
_
_
_
_
_
—
—
_
Still under treatment.
K.
_
_
_
_
_
_
_
_
_
—
—
_
Still under treatment.
A. D.»
40
M.
Cavity.
Many.
1 OK. ..
scanty.
44
100
3 up bo 10
miiligmie.
dose;2
above.
Hectic
before
treatment.
81b.
52
Great im-
provonient.
Signs of
cavity gone.
Slight hectic before treat¬
ment. At work at the docks
os a stevedore. Temperature
now normal (April 7th).
A. D.
2^
M.
Cavity.
Very
many.
loz. .. 6oz.;
increased.
33
70
1 up to 10
milligi'me.
dose; 1
above.
Laryngeal
tubercu¬
losis ;
hectic.
Un¬
altered.
Un¬
altered.
66
Became
worse.
Ulceration of vocal cords,
witii irregular granulations
developed during treatment.
Ana-mio epiglottis. Aryte¬
noid cartilages and both
cords hypercomic before treat¬
ment. Marked hectic from
beginning to end.
A. W.
23
M.
Cavity.
Many.
ioz.
. 11 oz.
40
40
11 up to 10
millignne.
dose;9
above.
Hectic
from first.
11b.
02
Trivial im¬
provement.
Hectic from the first.
C. M.
2)
M.
Cavity.
Very
many.
6oz.
. idr.
8
3
a
Hectic
before
treatment.
Un-
altoted.
Un¬
altered.
9
Improved
consider¬
ably.
Improvement not due to
treatment probably. Had
marked hectic (102'4°) before
treatment. Muchlessmarked
since.
S. M.
19
F.
Cavity.
None.
1 dr. .. 4dr.;
increased.
41
1.50
14 up to 10
milltgmie.
dose; 3
above.
Hectic
before
treatment.
7J lb.
79
.Slight im¬
provement.
Slight hectic before treat¬
ment. None for a week after
treatment. Occasional trace
of albumen.
S.M.
18
F.
Cavity.
Very
many.
2 dr. .. 2oz.;
increased.
9
0
4
Pjfeumo-
thorax,left
lung.
Un¬
altered.
Un¬
altered.
14
Became
worse.
Pneumothorax occurred 4
days after patient discon¬
tinued treatment at her own
request.
Trace of albumen on four
occasions during rash.
A. H.
28
F.
Cavity.
\’ery
many.
I oz.
.. 1 dr.
22
8
12
ANri
Purpura.
:mia.
51b.
36
Bocaine
wornc.
A. D.
13
F.
Aiicemia.
15
1 30
1
]
7 up to 10
niilugnne.
dose.
LUPUS V
None.
ULGARIv
81b,
5.
23
Very
irreat im¬
provement.
Injected, with her consent,
as a control caso at first,
afterwards because of un¬
expected reaction.
A. N.
16
F.
Face ;
elbow.
, 50
, 1000
13
I Un-
1 altered
1
1
Un¬
altered
104
Arm very
greatly im¬
proved,
face much
improved.
Beyond very slight head¬
ache on 2 or 3 occasions, this
patient had no subjective
symptoms of general reaction.
K. F.
57
F.
Face ;
band.
I GO
I
400
S
10 lb.
124
Much
improved.
llelapse.
During last weeks of treat-
mentfroshcentres of infected
skin noted on right temple
and on nose.
E. E.
27
F.
Patch
under
chin ;
] face.
50
1000
9
10 lb.
_
128
Mucli
improved.
L. F,
21
V.
1 l‘'ac0,
jnoHc, and
lips.
59
1 1000
0
18j lb.
135
Great im¬
provement
relap.se.
Signs of reiapso during last
month of treatment ; fresh
spots below riglit nostril, at
root of nose, and on right
chock.
.7. B.
27
F.
Riffhtslde
of liose 1
right
cheek.
1
, 35
i 1000
1
0
03
Vory good.
Slight case.
' Nee Figs. 3, 4, 0, and ((.
N.B.—Whei) tlii.-i paper was read before the Medicftl .Society, these tallies wore to have been shown in the (onii presented here. It was, however, found
that bile tab e as it ls given in these pages would have been unwieldy on the walls of the Necieby’s room; lienee certain addiiiuns bo the tables are now
published.—O. A. Iloioii.
patients. Weight, as a rule, was gained. This, however, is
a condition comuiun to most consumptives during their sojourn
in hospital, whether they are or are not treated by tuberculin,
Evidences of improvement in the lung itself were found in a change
in moist souLds beard there before treatment was commenced.
This change consists in a gradual lessening of those qualities of a
idle, which enable the trained ear to distinguish between moist
crepitations and the dry cracklings associated with sounds due to
friction. The moist sounds are heard to approach in quality
nearer and nearer to the dry ones, and to become, at least to my
ear, indistinguishable from them. In patients who do very well
under the treatment there comes a great diminution of both moist
and dry sounds; for in a month or six weeks of treatment with
tuberculin it is often to be noticed in these cases that, during ordi¬
nary respiration, no idles, dry or moist, are audible, although
when the patient coughs there come little showers of crepitations,
which, however, are only to be heard during the first two or three
inspirations that follow the cough. In not one of my patients have
these signs absolutely disappeared, though in four of them they
have all but gone. In order to ascertain the exact value of these
diflerent degrees of improvement much more time and prolonged
observation of these cases are necessary before, in my opinion, we
can gauge with accuracy, and with justice to all concerned, the real
woruk of tuberculin as a healer of tuberculosis of the lung. In cases
Digitized by LjOOQle
The Lancet,]
MR. WILLOUGHBY FURNER ON (ESOPHAGOTOMY.
[May 2,1891. 971)
at tho very commencement of that disease, and when
it is not seemingly quiescent, I think the remedy should
be tried, because no drug is known to have anything
like the beneficial effect of tuberculin upon those tuber¬
cular diseases which can be seen and handled, and
evidence, it seems to me, is accrimulating tending to
show that the beneficial effects which we see produced
in lupus and other similar conditions by the use of
tuberculin are also produced in tho diseased lung which
we cannot see. And another reason for its use in very
early stages of lung disease is that, in cases of this
kind, there is, so far as I know, no evidence to show
that there is material risk in employing tuberculin. The
remedy has been already used in several of these early
cases, end no evil, but, on the contrary, material good, to
the patients concerned has resulted in no inconsiderable
number of these early instances of lung disease. In such
cases as these, I can see no reason why there should be any
hesitation in using tuberculin as a remedial agent. In
lupus vulgaris, however, the beneficial effects following the
proper use of tuberculin are so evident and so marked, that
1 feel sure this remedy will very soon become an essen¬
tial part of the treatment of that disease. In two of my
cases of lupus fresh points of infection were distinctly
evident, and these manifested themselves to me, and to the
patients and others, during the last four weeks or so of the
five months’ course of treatment to which these patients
were submitted, and while they were taking daily increasing
doses of tubercnlin ranging between 200 and 1000 ragr.
The cases now referred to are those marked on the table as
L. F. and E. F. In the former case the points of fresh in¬
fection were observed upon the upper lip and right cheek,
and in the latter over the right temple. These two cases
both show, as is indeed already well known from other
sources, that in spite of the excellent results which, up to a
certain point, practically always follow the use of tuber¬
culin in lupus vulgaris, danger of the reappearance of the
disease is so great that, as Koch himself says, we must
make “use of all other auxiliary methods to assist the
action of the remedy.”
From a paper of this kind it is inevitable that much that
is of importance and of interest must be omitted. I have
tried to indicate certain points in this question concerning
the value of tuberculin as a remedy, but of necessity I have
left very much unsaid.
I congratulate the Society upon the fact that you. Sir,
preside over our debates, for there is no one else into whose
hands the conduct of our proceedings could be better con¬
fided, or in whose sense of what is just and right to all
concerned we could more surely place a perfect trust.
NOTE ON A SUCCESSFUL CASE OF CESO-
PHAGOTOMY FOR REMOVAL OF A TOOTH-
PLATE IMPACTED IN THE (ESOPHAGUS
FOR FIVE YEARS AND NINE MONTHS.
By WILLOUGHBY TURNER, F.R.C.S.,
SCJftOEON TO TUB SUSSEX COUNTY HOSPITAL,
The longest period of impaction of a foreign body in the
CDiophagua removed successfully by operation which I can
find recorded is three years and a half: the patient was a
child ; the foreign body a halfpenny. The case is recorded by
Mr. Bennett May.^ In the woman whose case I relate now
theforeign body was a silver-gilt tooth-plate with three gold
hooks, and carrying three teeth, and had been swallowed
five years and nine months before the date of operation.
E. B-, aged forty-four, married, mother of a family,
was admitted for the first time into the Sussex County Hos¬
pital on Nov. 0th, 1889, She complained of dillieulby in
swallowing, was thin, but fairly nourished. She said that
on tho morning of May 4th, 1884, whilst suckling her infant,
and turning in bed, a tooth-plate slipped from its posi¬
tion In the upper jaw to the back of the throat; she felt
almost suffocated, and being unable to seize the plate
u«hed it down her throat. Afterwards she experienced
iIRculty in swallowing and could only take liquid food,
occasionally thickened with minced meat or bread crumbs.
Annals of Surgery, 1887.
The dysphagia varied, but was always present and had
much increased lately. She referred the seat of obstruction
to a point about an inch and a half below the episternal
notch. There had been occasional dy.spncoa, lasting only for
short periods, a minute or two. She was quite sure of
the date of the accident, as she was at the time suck¬
ling her youngest child. A probang passed down the
ccsophagus met with obstruction ten inches and a half from
the teeth ; a coin-catcljer got hold, bub traction only seemed
to tilt the plate into the surrounding tissues. One pair of
long ccsophageal forceps gripped the body firmly, but mipped
off, and no fresh hold could be obtained. Further measures
were then proposed, but the patient wished to return home.
Slie was readmitted on Jan. 30bh, 1890. On Feb. 17bh,
under chloroform, maophagobomy was performed. The
usual incision was made, about three inches in length,
along the anterior border of the left sterno-mastoid muscle.
The omohyoid muscle was divided. The carotid sheath
having been drawn outwards and the trachea and thyroid
gland in the opposite direction, the ccsophagus with
the recurrent laryngeal nerve on its surface was then
exposed; a full-sized bougie was now passed through
the mouth down to the obstruction, and the oesophagus
opened on its posterior surface. On passing the finger
into the wound the foreign body could just be reached
lying somewhat obliquely to the canal of the tube, the
upper part projecting into the canal, the rest of the plate
lying in a sac to the right of the gullet. The irregular
surface of the plate was so closely surrounded by the walls
of the sac that great difficulty was met with in its extrac¬
tion, Various forceps were tried, but slipped off. It
was finally grasped by a strong straight pair, and by a com¬
bined movement of pulling and rotation, requiring consider¬
able force, it was at last removed. About an ounce of
bright arterial blood followed the removal of the plate. The
wound was well washed with weak carbolic lotion. One
small artery to the sterno-mastoid required ligature; the
ccsophagus was not sutured. The upper two-thirds of the
external wound were closed, the lower one-third left open,
and a drainage-tube reaching up to the ccsophagus was fixed
in the lowest part of the external incision.
There was only slight shock, but no vomiting, after the
operation. The wound was frequently syringed with boric
acid solution {ten grains bo an ounce of water), some of
which the patient was directed to swallow occasionally; the
teeth and gums were also cleansed with the same solution.
No nourishment was given by the mouth during the first
two days, but four ounces of pancreatised beef-tea were
administered per rectum eveiy four hours. In spite
of all, the wound became offensive, the saliva flowin'
from it copiously. On the third day, as the wound
showed no sign of repair and the patient was losing
ground, an attempt was made to introduce food into the
stomach through a No. 8 gum elastic catheter passed from
the mouth. The mere passage of the instrument down the
ccsophagus produced retching, and although only about an
ounce of milk had passed into the stomach, it all returned
through the wound. No further attempt was then made to
feed through the mouth until the morning of the fifth day
from the time of operation. A small soft catheterwas then
passed through the mouth into the gullet beyond the
wound, but not into the stomach. A little cold milk was
then allowed to trickle by degrees through the catheter,
but it all regurgitated through the wound. The presence
of the catheter in the ccsophagus so long unused to solids
seemed to produce spasm. During the day the patient
became much feebler and very restless, and complained of
great hunger. The wound was now covered with greyish
exudation, and the whole side of the neck down to the
clavicle in front, and to the level of the spine of the scapula
behind, was red and puffy. It was determined to make
another attempt to get food into the stomach, and on the
evening of the same day, the fifth from the operation, the
patient was raised and supported in bed, and leaning slightly
forward was given some milk to swallow in the natural
way. She drank ravenously ton ounces of milk, only about
a teaspoonful coming through the wound, which was then
syringed out in tho sitting posture. From that time she
began to recover. She took her food, consisting of niilk
only, or with an egg and brandy, always in the sitting posi¬
tion. The wound soon discharged copiously, and the red¬
ness and puiliness of the neck gradually subsided. On the
twenty-first day from the operation she swallowed bread-
and-milk; on the twenty-fourth day she took fish; on the
S 2
Coogle
980 The Lancet,] DR. BA.TTEN : THE EYE AND THE CARDIO-VASCULA.E SYSTEM. [May 2,1891.
twenty-eighbh day the wound was healed. The patient was
discharged well a few days later with no alteration of the
voice. When seen some mouths afterwards she was stout
and well, and could take food without any trouble.
Eemarks .—Out of just 100 cases recorded, including my
own, 1 find twenty-three deaths. In nearly all the fatal
result was due to exhaustion and cellulitis of the neck.
The two most important questions, therefore, in the after-
treatment of these cases are feeding the patient and keeping
the wound clean. There are many different opinions as ro
the heat means of feeding the patient. Barton^ and
Markoe® are in favour of reeding through a tube intro¬
duced into the oesophagus through the wound. This plan
involves disturbance of the wound, the more so if the
GBSophagus be incised on its posterior surface, which may be
regarded as the seat of election if the position of the recurrent
laryngeal nerve be considered. Southam,'* in his two suc¬
cessful cases, fed by enemata for the first fourteen days,
and subsequently by a soft tube introduced through the
mouth. I tried this in my own case and failed. Abbd''
approves of closing the oesophageal wound and advocates
feeding through a tube protruding from the mouth from the
first. Ledlard^ allowed rectal alimentation for the first three
days, and then Iluida by the mouth. Dr, Geo. Fischer^ says
every patient, whether the oesophagus has been closed or
not, may be allowed to swallow fluid diet a few hours after
operation without the aid of the stomach-tube. So far as the
experience of a single case may justify an opinion, I would
advise that the patient be fed by peptonised beef-tea
enemata, with or without brandy, for the first twenty-four
hours or less until the risk of vomiting from the anccsthetic
has subsided, and then be allowed to swallow milk. If the
incision be made in the posterior portion of the cesophagus,
and the patient drinks in a sitting position, very little
escapes by the wound, even if the edges of the gullet have
not been sutured; no irritation seems to be produced, bub
vomiting and retching are most injurious. The wound
may be syringed out with a weak solution of carbolic acid
f 1 in forty) whilst the patient is sitting up, if the cesophagus
has been incised posteriorly, without any harm resulting. In
my case strong boric acid solutions failed to keep the wound
sweet. The carbolic lotion was much more effectual. Two
teeth have been broken away; one probably when the first
attempt at extraction was made with the cesophageal
forceps, the other at the time of the operation.
West Brighton.
SOME POINTS ON
THE RELATIONSHIP OF THE EYE TO THE
CARDIO-VASCULAE SYSTEM.^
By RAYNER D. BATTEN, M.D.. B.S.Lond.,
CLINICAL ASSISTANT, KOyAL LONDON OPHTHALMIC HOSPITAL.
Some points of connexion between the eye and the cardio¬
vascular system are already well established. Eye sym¬
ptoms occur in chronic albuminuria, syphilis, diabetes, and
ancemia; also in some cases of chorea and epilepsy, megrims,
and exophthalmic goitre. Various drugs affect both —
e.g., alcohol, tobaceo, atropine, lead. Dr. Broadbent, in
writing on high-tension pulse, mentions glaucoma as one of
the conditions associated with high arterial tension, of
which he regards it as a consequence, although the
mode of causation is nob clear. There being, then, some
jyrim&-facie evidence for a connexion between the eye
and the cardio-vascular system, I propose to offer some
observations tending to show that the connexion is more
intimate than it is at present usually considered to be.
Dr. Saundby, in his Lectures on Bright’s Disease,
speaking of optic neuritis, says : “ Neuritis probably
occurs as an idiopathic affection, especially in hyper¬
metropic eyes.” And again, speaking at Birmingham :
“I would express my belief that children with hyper¬
metropic eyes are especially liable to severe attacks of optic
neuritis, which may be accompanied by headache, vomiting
and giddiness, so as to .simulate some coarse intra-cranial
■i Ibid., July, 1887. » Ibid., Sopt., 1880.
* The 1/ANCk.t, Dec. 28tli, iSai).
0 New York Mod. .Tour., 1880, " Clin. Hoc., vol. xviii.
T Deutocho /.eitschiift Cliir., JJd. xxv., Uoft 0.
1 A paper read before the Harveian Society, Nov. Oth, 1800.
disease, the whole phenomena being, however, directly re¬
ferable to the visual disturbances.”® Dr. Gowers writes:
“ One other fact must be mentioned in connexion with the
diagnosis of the cause of optic neuritis, In many cases in
which slight neuritis of chronic course is associated with
symptoms which would scarcely suggest the existence of
disease such as would cause neuritis, bypermetvopia exists.
This combination may be noted, for instance, in chlorosis,
in epilepsy, apparently idiopathic, and other slight sym¬
ptoms of cerebral disturbance. It is doubtful, in the present
state of our knowledge, what shave is to be attributed to
the hypermetropia in the production of the neuritis, and
from the commonness of hypermetropia the coincidence may
have been accidental; but the fact deserves notice.”® In
cases of optic neuritis in anmmia mentioned by other ob¬
servers, it is also generally noted that the refraction was
hypermetropic. And personally I think hypermetropia of
frequent occurrence in anremia. Dr. Stevens^ of New York
considers that chorea is caused by hypermetropia, and Dr.
Gowers has noted the connexion of optic neuritis and hyper¬
metropia in chorea.
Now, while this association of hypermetropia with diseases
causing optic neuritis has been recognised, I do not think
sufficient importance has been attached to the signihcauce
of it, especially when taken in conjunction with the fact
that optic neuritis from all causes occurs with far greater
frequency in the hypermetrope than in the myope, or, I
believe, in the emmetrope. Optic neuritis in the myope is,
in my experience, unknown, and in the experience of others
an occurrence of extreme rarity. So far, I have collected
three cases only of optic neuritis in which myopia was
noted. Now this fact, if fact it he, of the exemption of
myopes from optic D,euriti8, while interesting in itself, may
not at first sight appear to have any connexion with the
subject before us. But the whole contention of my paper
is that we are wrong in considering hypermetropia and
myopia as merely local conditions; they are the outward'
and visible sign of an inward and vascular state. I hold
that both are associated with certain general conditions,
that the changes which lead to myopia are nob limited to
tlie eye, but are part of a general change, and that the
arrest of development in the hypermetropic eye corresponds
with similar partial development in other structures—in
short, that there is a myopic and a hypermetropic cardio¬
vascular system. Following on this, it might not be un¬
reasonable to expect that myopes may be free from certain
diseases affecting hypermetropes, and also vice versd.
Two explanations have been given me of the absence of
optic neuritis in myopes: 1. The comparative rarity of
myopia itself. 2. That local disease must have a local
cause. I admit that the frequent connexion of optic neuritis
with hypermetropia may be partly accounted for by the far
greater frequency of hypermetropia than myopia ; but this
does nob, to my mind, oifer anything like a sufficient explana¬
tion of the total absence of optic neuritis in the myope,
save from exceptional causes. Myopia may indeed be
rare, bub surely nob so rare as to prevent common dis¬
eases, such as frequently cause optic neuritis, having been
observed in myopes, and the occurrence of optic neuritis
in a certain proportion of these cases. The extreme
rarity of optic neuritis in myopes would appear to point to
one of two things—either a structural difference in the
myopic eye, or a structural difference in the body of the
myope, rendering him less liable to this form of disease.
Occasional cases of optic neuritis in myopes, from excep¬
tional causes, show that the condition is not structurally
impossible. But on the point as to whether the myope
enjoys any exemption from chronic albuminuria and other
diseases giving rise to optic neuritis, I can make no state¬
ment.
I propose, then, to give shortly thechain of observation which
led me to the conclusion that myopia and hypermetropia
ought to be considered as indicating a general, instead of a
local, condition, and it may he well to (ffiserve that my con¬
clusion was arrived at as the result of my observations, and
that it differed entirely from my original theory. Amongst
other differences between the two classes of hypermetropes
and myopes, the mental and physical differences are early
forced on one’s notice. But while I had for a long time
made mental notes on the two classes, and had from time to
Saundby: Optic NouritLs in Children, Birminffham Med. Review.
1886, xviii.
* Medic.il Oplibhalmoacopy, p, 85.
•* New York Medical Record, Aug. 12th, 1870.
Google
The Lancet,]
DR. W. ESSEX WYNTER ON TUBERCULAR MENINGITIS.
[May 2, 1801. 981
time endeavoured to reduce my mental notes to words, I
bad made no serious attempt to investigate the physical
state. I had, however, long puzzled over an observation of
Mr. Mills on the subject of heart failure during the opera¬
tion of division of the internal rectus in cases of strabismus—
i.e., in hypermetropes ; and when a case of cardiac irregu¬
larity, due apparently to an error of refraction, was narrated
to me by Dr. Batten of Gloucester, and corresponded closely
with similar cases of my own, I determined to endeavour to
work out what was the connexion between cardiac irregu¬
larity and hypermetropia, and from this I was led on to the
larger subject—namely, the relation of the eye to the
cardio vascular system.
As the result of my observations I have come to the
following conclusions:—
I. First, os regards the peculiarities of what 1 will for the
present term the hypermetropic circulation.
1. In the young. — Under this head I include all those
not fully developed, and I consider this period of longer
duration in the hypermebrope, who, to my mind, reaches
his full development later than the myope, (a) The
pulse is a quick one, and is easily accelerated by any
cause, and varies rapidly; bub the pulse-rate does not vary
so much with the degree of hypermetropia as with
the amount of accommodation. Thus, with latent byper-
nretropia I expect a quicker pulse-rate than with a
high degree of manifest hypermetropia. The pulse is soft
and compressible, not easily counted, and the tension is
generally low. But in high degrees of hypermetropia with
bad vision the pulse is often markedly slow. (, 8 ) The heart,
in the few eases in which I have attempted to take measure¬
ments—which I have done by measuring the distance of the
apex beat and the nipple from the middle line of the
sternum—is, I consider, a small one ; bub this is not con¬
stant, as in some cases the heart appears dilated, and the
apex displaced outwards. ( 7 ) The heart sounds are gene¬
rally regular, but with more or less marked accentuation of
the first sound. In a certain number, I note a rhythm vary¬
ing with the respiration, and murmurs of a variable and
functional character occur. I have also noted loud apical
systolic murmurs with more than average frequency. The
heart symptoms, in fact, closely resemble those noted in
chorea.
2. The young adult with hypermetropia is not a frequent
patient for refractive purposes, but 1 consider him more
liable to local infiammatory disease than the emmetropo, and
still more so than the myope.
3. In the middle-aged and old hypermetrope, I notice, as
Dr. Brunton has noted, the failure of optical accommodation
taking place at the same time as the failure of the vascxdar
accommodation, and hence ilushings, giddiness, noises in
the ears, &c. I note in addition marked cardiac irregularity
and intermission, in some cases disappearing with the use of
glasses. Dr. Broadbent has mentioned high tension pulse
with glaucoma, and I am inclined to associate it with liyper-
metropia in the old.
(To be concluded.)
rouli CASES OF TUBERCULAR MENINGITIS
IN WHICH PARACENTESIS OP THE THECA
VERTEBRALIS WAS PERFORMEI) FOR
THE RELIEF OF FLUID PRESSURE.
By W. ESSEX WYNTER, M. D., B. S., M.R, C. P., F. R. C. S.,
MKUIt'At. HEOlSl'llAU AT TIIU AIIIUII.ESEX IIOSMTAL.
In many fatal cases of tubercular meningitis coma super¬
venes with great rapidity and with all the signs of cerebral
pressure, whilst after death little can be found besides an
excess of cerebro-spinal Iluid, often at a considerable
positive pressure, to account for the symptoms and fatal
issue. The possibility of recovery in this class of cases,
where there is commonly little development of tubercle,
together with the foaRibility of draining away the Iluid
continuously by the theca veitebralis, suggested this mode
of procedure.
The first case iu which the method was tried was in
February, 1889, in a boy, G. L-, aged three years, who
had manifested the usual symptoms, and became comatose
on the eighth day. On the next he developed Cheyne-
Stokes respiration, became cyanosed and unable to swallow.
A consultation was held, and it was decided to endeavour
to relieve the pressure which was apparently answerable
for the coma. No ancesthetic was needed; the child was
supported in a sitting posture, a tiny incision was made in
the skin beside the spine of the second lumbar vertebra, and
a Southey’s tube and trocar inserted till the point impinged
against the lamina; the point was then directed slightly
downwards and was pushed through the ligamentum sub-
llavum and theca with an inclination towards the middle line.
Clear fluid at once welled up into the tube on withdrawing
the trochar, a fine indiaruhber tube was arranged for con¬
tinuous drainage, and the child put back to bed. During
the next twenty-four hours four drachms of fluid were col¬
lected, besides what escaped along the cannula in the
wound; the breathing became regular, the colour good,
and the child swallowed some milk. Unfortunately the
improvement was not maintained, the fluid ceased to
escape, and the case proved fatal. The necropsy showed a
considerable amount of tubercle at the base, with some
opaque lymph, but no excess of fluid. It was not possible
to discover the prick in the theca, and no evidence existed
of any damage to the cauda equina. The iluid collected
had a specific gravity of 1006, and contained only a trace of
albumen.
The second case was that of J. L-, admitted to the
Middlesex Hospital on Feb. 12Eh, 1890, under the care of
Dr. Cayley. Tne patient, a girl aged eleven, had pertussis
two years previously, and since that had suffered from ear¬
ache, sometimes with discharge. She had been ailing for
nine days with headache, anorexia, and latterly vomiting.
There had also been photophobia and delirium. After
admission the patient remained drowsy, tache c 6 r 6 brale was
noted, and she vomited at intervals, and Hushed occasionally.
On Feb. 2l8t Mr. Hnlke cut down on the second
lumbar vertebra, removed the spine and right lamina,
and punctured the theca with a fine knife. Clear fluid
escaped with some force, a drainage-tube was inserted in the
vertebral canal, and the wound dressed antiseptically. On
the following day the temperature had dropped from 102 ® to
normal. The patient could be rovised, and took liquid food
well. The dressings were saturated with moisture and had
to bo changed. On the 23rd there was less escape of fluid,
and on the 21 th the dressings were nearly dry, and there
was an increase of drowsiness, with development of squint.
Death occurred from coma at .3 A.M. on the 25th, three days
and a half after the operation. The necropsy showed that the
aperture in the theca had closed, and when the membrane
was incised the contained Iluid spurted out in quantity; very
little tubercle could be discovered.
The third c.aae was a boy, B. V-, aged two years and
four months, admitted under Dr. Coupland, after a week’s
illness, with headache and vomiting. There had also been
a slight fit and tendency to squint. On June 15th, two
days after admission, respiration became irregular and there
was'some twitching of the arms. On the 2lst drowsiness had
deepened into coma, temperature i02'4®, pupils dilated and
not reacting to light. Pressure symptoms being urgent, Mr.
Pearce Gould cut down upon and divided the laminm of the
first lumbar vertebra. The theca was fully exposed and in¬
cised, some drachma of fluid escaped, the flow being increased
with each expiration. A small drainage-tube was inserted
in the subdural space and the margins of the theca attached
to the sides of the wound. It was noted daring the opera¬
tion that as soon as the fluid was liberated the pupils,
formerly diluted and inactive, contracted and regained
their reflex activity at once. Twelve drachma of clear
alkaline fluid were obtained, having a specific gravity
of 1004, containing a large quantity of chlorides, but
giving no reaction to tests for albumen or sugar, though
a red-brown deposit in Fehling’a solution occurred on stand¬
ing. Subsequently the temperature rose to 104’8, the pulse
became rapid and weak, and the child died five hours after
the operation.
The fourth case, a girl aged thirteen months, was ad¬
mitted under Dr. Cayley on April 13bh, 1891. She had
been ailing for a fortnight, but four days previously had
been taken with convulsions, and there was a thin discharge
from the right ear. On admission the child was semi¬
conscious, breathing irregularly, and with a pulse of 160.
The foutanelle was rather sunken, and tache cbrcbrale
readily obtainable. On April 15th convulsions occurred,
and there was retraction of the head.
At 2.45 a Southey’s tube was introduced into the theca
C-oogle
S82 TheLanoetJ
DB. r. W. BOBINSON ON HYDATID OF THE LIVEE.
[May 2,1891.
yertebralis between two lambar spines, and four ounces of
cerebro-spinal fluid were withdrawn, the lewt two ounces
being bloodstained. The fontanelle sunk in. Death
occurred at 6.30. The fluid was alkaline, loaded with
chlorides. It gave no reaction to tests for albumen or
sugar, and had a specific gravity of 1006. The necropsy-
showed acute general tuberculosis, especially marked in the
lungs. The prick in the theca could not be found, but
there was slight blood extravasation on its outer surface.
The cauda equina was unhurt. Though none of these cases
were ultimately successful, no harm in any one resulted
from interference. In some there was temporary relief of
symptoms, and the necropsy in each case showed ample
reason for the fatal termination, either in general tuber¬
culosis or failure in maintaining the drainage. It is much
to be regretted that the aperture was allowed to close in the
second case, which promised well till pressure was renewed
by reaccumulation of fluid. Further experience will no
doubt enable a better selection of cases to be made, and the
treatment to be carried out more effectually.
A EABE FORM OF HYDATID OF THE LIVER
TREATED BY THE CAUTERY.
By F. W. ROBINSON, M.B., M.R.G.S.
The following case of abdominal tumour presents so many
remarkable and unusual features that I venture to give its
history in some detail. The patient is a young, spare man,
aged twenty-four, who bad always enjoyed good health up
to the time that he presented himself to me in December
last. For the previous six months, although be was con¬
scious of an enlargement in the abdomen, he was in every way
well, carrying on his ordinary occupation, that of a draper’s
assistant, without any inconvenience. He first noticed that
be was getting stout; this gave him no uneasiness, how¬
ever, and the tumour would probably have been allowed to
grow had he not been attacked with severe abdominal pain
about a week before be came to me. He has always been a
steady man and very abstemious. There is no history of pre-
viousillnessor of syphilis. Hebelongatoaconsumptivefamily,
twoof bis brothers havingdiedof phthisis. The painfor which
he consulted me was felt mostly over the region of the left
hjrpochondrium and was severe, keeping him awake at
nights. It usually lasted for some hours and then left him.
In the intervals he was perfectly well. Physical examina¬
tion showed his organs to be quite healthy, and with the
exception of slight inspiratory dyspncca, caused by the
upper limit of the tumour preventing the descent of the
lung, I could find nothing abnormal. His urine was
healthy, his appetite good, and his bowels regular. The
tumour in the abdomen was very extensive, and, the
patient being a thin subject, its outlines were well defined.
It occupied a large area, extending on the right side as low
as to within an inch of the crest of the ilium. From this
point it stretched obliquely across the abdomen to the left
iiypochondrium, disappearing behind the left lower ribs,
which were pushed forward considerably. In this course
the tumour crossed two inches below the umbilicus. On the
left side in front it extended as high as the fourth rib, the
heart’s apex beating in the third intercostal space a little to
the left of the sternum. On the right side in front it was
continuous with the liver diilness. Behind on the right side
the ribs were more prominent than on the left, and there
was dulness from the angle of tlie scapula downwards to
within an inch of the crest of the ilium. On the left side
behind there was no dulnes.s, and the respiratory murmur
was normal. The parts then rendereil most prominent by
the tumour corresponded to the ribs behind on the right side
below the angle of the scapula and the left lower ribs in
front. The lower limit of the tumour in front presented to
the touch a well-defined margin, which felt like the rounded
border of the liver. There was transmitted pulsation over
the front of the tumour. The surface was smooth, but not
equally resistant, the parts of the tumour to the left of the
umbilicus being firmer and more resistant than those to the
right. Auscultation revealed no friction sound, and there
was no fluctuation at any part. The tumour did not descend
M'ith inspiration. The greatest circumferential measure¬
ment was a line crossing immediately below the xiphoid
cartilage—viz., thirty-five inches.
From the above it will have been gathered that the
bulk of the tumour occupied the right side in front and
behind. During the time previously to the operation that
the patient was under my care the pain was very severe,
and was evidently undermining his health. He became
very prostrate, and was entirely confined to his bed, any
movement giving him great pain. This was always referred
to a region over the left lower ribs in front. From the above
history I suspected hydatids, and Dr. Wardrop Griflith,
who kindly saw the case for me, was also of this opinion.
An exploratory needle was introduced and some clear fluid
drawn off; this on examination pave a specific gravity of
1007 and an abundance of chloride of sodium. 1'hero was
no albumen or bile. Unfortunately, no booklets could be
found. On Januaiy 4th, after a needle had been |)assed
and fluid drawn off', I made an incision about four inches
long from the xiphoid cartilage downwards. After exposing
the tumour and isolating the peritoneal cavity with sponges,
I incised the cyst wall to the length of the abdominal
incision ; several ounces of clear, limpid fluid escaped. Tlie
walls of the cyst were <^ite an inch in thickness and of
cartilaginous hardness. The size of the cyst was about that
of a “ closed hand,” and quite free from any communication
with the rest of the tumour. It was somewhat irregular in
shape, and was lined by a smooth membrane. Its walls
were eveiyM’bere bard and resistant, and the surface some¬
what reticulated. There was considerable hannorrhage from
the thick walls of the cyst, which it was found impossible to
check, and it could only be controlled by sponges. I then
examined the tumour with my hand in the peritoneal cavity.
The sharp anterior edge of the liver could be easily felt, and
rising from its upper surface immediately above this a
smooth, globular, extremely hard mass extended over all
parts within reach of the hand. In the hope of establishing
a communication with other cysts, I pushed a carved rectsfl
trocar through the right wall of the cyst in a direction
downwards and outwards, and drew off several ounces of
clear fluid. The patient was so collai)3ed from loss of blood
at this stage that it was thought advisable to conclude the
operation. The peritoneal cavity was well washed out, and
tbe cyst wall stitched to the abdomen. Very severe shock
followed tbe operation, and be subsequently had a sharp
attack of peritonitis, which, however, subsided in the course
of a week.
On Jan. 14th his temperature rose to 103°, and he com¬
plained of great pain; this, however, subsided under treat¬
ment, and the improvement continued until the 17th, when
the pain and increased fever again recurred. As I con¬
sidered that his symptoms pointed probably to suppuration
in the cysts caused by septic infection through the opening
made in tbe previous operation by the trocar, and which
had now almost closed, I reopened the channel with a large
trocar, letting out a quantity of pus, and then forcibly
dilated the passage with forceps. I could now pass my
finger into a cyst in all respects resembling the one first
described, only smaller—that is to say, it had the same hard
resisting walls, a smooth lining membrane, and a reticulated
surface, and, with the exception of variations in size, this
description will apply to all cysts opened up during the
progress of the case. There was an immediate relief to all
his symptoms, the pain completely subsiding and his tem¬
perature falling considerably; the improvement was only
temporary, however, for in a few days all his symptoms
recurred and gradually increased. On the 27th they became
very urgent, his temperature was 106°, and his pulse very
feeble and rapid. Tbe pain was very severe and tbe pros¬
tration extreme. I determined therefore, if possible, to
open up a communication through all parts of the tumour,
and for this purpose I used the benzoline cautery. With
the finger of my left hand passed through the trocar
opening into the cyst previously opened up, and with my
other hand on the surface of the tumour externally, I was
able to form some conception of the amount of tumour in¬
tervening between my two bands. With the knowledge
thus gained, I passed the cautery through the cyst wall in a
direction downwards and outwards towards the right lumbar
region, and opened up a .large cyst exactly similar in
character to the others described. A large amount of pus
escaped. Adopting the same precautions as in the above,
I now turned the cautery somewhat backwards, and
opened up another large cyst from the floor of the last, pus
also escaping from this. T then withdrew tbe cautery and
The Lancet,] MR. J. W. TAYLOR: DIGITAL EXPLORATION OF THE PYLORUS. [Mat 2, 1891. 983
{lasBed it in a direction upwards and outwards through the
right wall of the original cyst, opening another large cyst
with a similar llowof pus. I then passed the cautery vertically
downwards for about an inch or an inch and a half, but
without result; and the same negative result followed
when I attempted to pass it though the left wall. I was i
able, however, to open another cyst in the direction of the
jright hypochondriura. In all these cases pus escaped. The
cautery in each instance passed through at least half an inch
to an inch of dense cyst wall, and its entry into the cyst was
'indicated by a distinct slip followed by a flow of pus.
Altogether six cysts, counting the original one, were opened
■up in this manner; all were situated to the right of the
•tumour, all were of the character described above, and all
had a large capacity.
The progress of the case after this operation has been one
of uninterrupted improvement. Suppuration was very
profuse for about a fortnight; the temperature, however,
rarely exceeded 101°. During this time the lining membrane
of the cysts was detached inlong shreds of slou^, and after
this process was completed suppuration ceased, and the
whole of this portion of the tumour seemed to collapse to its
present dimensions. On the left side, in the situation
■of the punctures which failed to enter cysts, suppuration
■continued active, all the tissue between the punctures
'becoming involved in the process and breaking down to
form a large cavity, from which pus continued to be dis¬
charged profusely for many months and in a diminished
quantity up to the present time. It has, however,
gradually granulated up so that now it is represented
by only a small cavity.
It remains to say a few words about the size of
the tumour and the present condition. For the last
six months the lower margin of the tumour has occu¬
pied a situation of two inches above the umbilicus,
whereas before the operation it reached two inches below.
The greatest circumferential measurement is thirty-one
inches, against thirty-five before the operation. The
■respiratory murmur has returned over the back of the
right lung. The heart has not descended from its abnormal
position. For many months the patient has enjoyed as
good health as he did before the operation, and he has been
quite free from pain. The failure to find booklets and the
absence of anything like daughter cysts in this case, throw
4 ome little doubt upon the diagnosis of hydatid disease;
but its cystic character and its evident relation to the liver
make it, I think, impossible to have been anything else.
■One can only speculate as to the form of hydatid represented
in this case. That there has been an exceptional develop¬
ment of cysts is manifest, but the difficulty is to decide
whether these cysts have been extruded from the wall of
the parent cyst—as in the exogenous variety of hydatid,—
or whether they have formed within the parent cyst.
Ziegler alludes to both varieties under the names of
“echinococcus granulosus” and “echinococcus hydati-
dosus” respectively. The points of special interest in this
case are the size and number of the cysts forming the
'tumour, the thickness and hardness of their walls, and the
success which has attended the treatment by the cautery.
Hucldctsfleld.
A CASE OF DIGITAL EXPLORATION OF
THE PYLORUS.
By JOHN W. TAYLOR, KR.C.S.,
SURGEON TO THE IlIRMlNairAM AND MIDLAND IIOSIMTAI. FOR WOMEN;
CONSULTING SURGEON TO THE WOLVERHAMPTON HOSPITAL I'OH
WOMEN ; AND CONSULTING QYN/ECOLOGICAL SURGEON TO TUE
BIRMINGHAM AND MIDLAND SKIN AND LOCK HOSPITAL.
M. P-, aged forty-three, married, no children, came
from a distance to consult me in July, 1889. She had history
of vomiting for several months, the vomit being copious,
acid, and frothy. For six weeks the vomiting had been
constant after every meal. On exanrination, the stomach
appeared to be moderately dilated. On careful palpation it
was thought that a small amount of thickening in the
neighbourhood of the pylorus could he detected, but
this was always doubtful. The patient was consider¬
ably ernaciatcii; her general condition, apart from this,
/appeared to be satisfactory. On inquiry into her past
history, she stated that she had suflero^ from ulcer of
the stomach with hrematemesis fifteen years ago, but that
since that time until the date of her present illness her
health had been good. The illness fifteen years ago had
been severe, and she was treated largely by hypoflermio
injections of morphia, the marks of which are still visible.
A diagnosis was made of pyloric obstruction with moderate
dilatation of the stomach, and it was considered highly pro¬
bable that the gradual contraction of an old cicatrix follow¬
ing gastric ulcer might be responsible for her present sym¬
ptoms. For two months the case was under occasional
observation. She was treated first of all by a mixture con¬
taining carbolic acid and bromides, and afterwards by
washing out the stomach, but without any success. The
vomiting persisted, and the patient steadily but slowly de¬
creased in weight week by week.
As the case appeared to be a suitable one for Loreta’s
operation, and no benefit bad been obtained by other
means, I proposed to open the stomach and examine the
pylorus, dilating this if 1 found it to be contracted. This
proposal was accepted by the patient, and on Sept. 18th of
the same year I opened the abdomen above the umbilicus. No
tumour was found on external examination of the stomach
and pylorus, but the former was dilated and extended for some
little distance below the umbilicus. The incision was
enlarged downwards to the loft of the umbilicus, and
having drawn out the stomach I opened it midway between
the curvatures at the pyloric end, inserted my finger and
searched for the internal opening of the pylorus. For a
considerable time I could not find it, the stomach from
within feeling like a closed sac. When discovered, over
a sharply defined ridge of mucous membrane at the
highest part of the stomach on the right side, the finger
entered it easily and could pass without difficulty down
into the duodenum. There seemed to be hut little, if
any, increase of muscular structure in this situation, and
the stomach and intestine were so acutely bent at the
pylorus that the orifice was completely obscured until
the stomach had been raUed and a thorough search
was made. With so limited an experience of digital ex¬
ploration from within the stomach, I would not presume to
say how much this differed from the normal; but on careful
consideration of the case the kinking of the gut—which
only thorough distension of the stomach in the recumbent
position seemed able to undo—must, I think, have been the
cause of the gastric dilatation and the prolonged and per-
.sistent vomiting. I closed the wound in the stomach with
a continuous Lembert suture, and the incision in the parietes
with silkworm gut. The patient recovered from the explora¬
tion without any untoward symptoms, nutrient suppositories
being used exclusively for several days as food. From this date
the vomiting ceased, and the patient has had no return of it.
This is now more than a year ago. In a few months after
operation she had increased two stones in weight, and when
I showed the case at the recent meeting of the British
Medical Association the improvement had been well
maintained. Although I did not sew the stomach to the
abdominal wall, adhesions have probably taken place be¬
tween the site of the stomach incision and the under-surface
of the liver or the parietes, it being the rule to find adhesions
after intra-abdominal suture. If so, this has held the stomach
at a higher level, and the passage of food from the stomach
into the small intestine has been rendered less difficult.
The kinkiug of tubular viscera, such as bowel or ureters, is
evidently a much more common cause of obstruction than has
hitherto been generally recognised. In a case of enormous
dilatation of the stomach with pyloric tumour which was
under the care of Dr. Foxwell and myself the real obstruc¬
tion was found after death not to be directly due to the
tumour, but to a fold or kink of the intestine below the
pylorus, and secondarily to the tumour, which was the
cause of the kink. VVithin recent years (since 1886)
Gliioard has described a series of intestinal displacements,
or “enteroptoses,” as accompanying gastric neurasthenia
with moderate dilatation, and his writings on euterop-
tosis, or Gldnard’s disease, have been either defended
or thoughtfully considered by several other writers —
by Professor Dujardin-Beaumetz, by F6r6ol, Trastour,
Cuilleret, and Sanctis. According to his view many
cases of gastric neurasthenia are due to direct mechanical
causes ; and although he places his fundamental lesion
in prolapse of the right Ilexure of the colon, it is evi¬
dent from his illustrations that, if these have any basis of
fact, acute pyloric flexure, less in degree, but such as I have
been describing, must play no unimportant part in the pro-
984 The Lancet,]
CLINICAL NOTES.
[May 2,1891.
dactioQ of gastric symptoms. When a flexure as marked
as in the case I have reported is found during operation,
there can, I think, be little doubt that the attachment
of the intestinal tube above the flexure at a slightly
higher level will be likely to afford the most permanent
reuef to the patient.
Birmingbam.
Cltitkal Bote:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
THE PREVENTION AND TREATMENT OF
SCARLET FEVER.
ByW. BezlyThorne, M.D,St. And,, L.R.C.P.Lond.,&c.
The prevention, treatment, and, perhaps I may venture
to add, the cure of scarlet fever are subjects of so great
importance to the medical profession and the public at large
that I venture to offer for publication the following
brief notes of a case which was under my care at the com¬
mencement of this year. If it stood alone, I should be com-
elled to admit that no practical conclusion could safely be
rawn from it; but I have since gathered, from the perusal
of a paper read before the Epidemiological Society by Mr. J.
BrendonCurgeaven,‘ that many other cases of the samedisease
have been somewhat similarly treated with like striking
results, and I think that it cannot fail to serve a useful
purpose to invite others who have practised the treatment
advocated by Mr. Curgenven to bring forward the results
which they have obtained. I ought to add that, now that
I have had, the advantage of becoming acquainted with the
method adopted by that gentleman, I should modify my
treatment so as to bring it more into harmony with his.
The patient, fourteen years of age, but of the physical
development of ten, was seen within little more than an
hour of the appearance of the rash, and was reported to
have been “bilious and shivering over the fire” for some¬
thing more than two days. The face was flushed and dotted
with asearlatiniform rash; theeyes were red and suffused, and
both tonsils swollen, inflamed, and ulcerated ; the pulse was
120 and the temperature 103". She was immediately ordered to
take internally every four hours five minims of the oil of
eucalyptus globulus emulsified with powdered acacia, to use
every hour a gargle of carbolic and tannic acids suitably
diluted, to undergo daily inunction with an emulsion of
eucalyptus oil of ihe strength of half a drachm to the ounce,
and made up with glycerine, to promote adhesion to the
skin, and to have the scalp and hair daily sprinkled with a
spirit lotion containing eucalyptol, with a small quantity
of almond oil. On the following morning—that is, in rather
more than twelve hours—I found that the rash had receded
from the face. I inquired of the nurse whether any was to
’ Loiidoi): II. K. LewiH, tiower.streot.
be seen on the chest, which she had washed and an<nntedl
two hours previously, and was informed that it was “ welS
out,” but on examining that region found that it presented
absolutely none. It was at that time making its appearance
on the lower extremities, was well marked in the evening,
and OB the following morning bad entirely disappeared.
No desquamation followed. The chart tells the rest with
sufficient detail. It should be added that although the
house was occupied during the illness and up to the
departure of the patient to the seaside on the twenty-second
day by six full-grown adults and four younger persons
wiiose ages range from nineteen to six, besides the sick one,
the infection has not spread. A sheet, which was from time
to time moistened with a dilution of sanitas, was fixed by
the nurse to the door of thesick room in accordance with th©
instructions of the institution from which she was sent.
Soutli Kensington._
SERPIGINOUS ULCER OF BOTH CORNEAi CURED
BY SCRAPING.
By A. G, Mossor, L.K.Q C.P.I., L.R.C,S.I., M.R.C.S., &c,
Mrs. A-, aged sixty-five, consulted me on the 2ibh of
last November. The history given was of having a cold
in her eye for a fortnight. On examination I found an
ulcer having a diameter of about two millimetres, situated
on the outer part of the left cornea, and extending on to the
conjunctiva. The outline was circular. There was great
photophobia and pain, with congestion of the conjunctiva
and marked debility. I prescribed internally quinine
and iron; locally atropine (four grains to the ounce),
three times a day; belladonna lotion (two drachms of the
extract to a pint of water, with an equal quantity of warm
water), to be used frequently. I blistered the left
tecnple and covered the eye. I continued this treatment for
five weeks, with occasional blisters. The patient frequently
suffered from intense photophobia, which was invariably
relieved by the iodine liniment painted on the fore¬
head and temples. During this time the ulcer had
gradually enlarged in all directions, implicating the whole
of the outer half of the cornea and neighbouring con¬
junctiva, the latter being greatly congested, and showed
no signs of healing in any part. At times there was much
pain in the eye, for which cocaine (4 per cent.) was freely
used. I had previously tried the yellow oxido of mercury
(twenty grains to one ounce of vaseline) for two or three
days, hoping that stimulation would cause the ulcer to
heal; but as the eye became much more irritable it was
discontinued. The patient suffered greatly from pain up
the left side of the head, and as the ulcer had become very
deep there seemed great danger of perforation of the cornea.
At this period an ulcer appeared on the outer edge of the
right cornea. On Dec. 31st (rather more than live weeks,
after I first saw the patient) I placed a drop or two of
cocaine in both eyes and thoroughly scraped the ulcers,
using a sharp spoon, and then covered the surfaces with
powdered boracie acid. Next day all pain had disappeared
from the eyes and head, and the patient expressed herself as
greatly relieved. Both ulcers healed completely during the
Digitized by
Google
Thb Lancet,]
CLINICAL NOTES.
[May 2, 1891. 985
next fourtecQ days without any further trouble. After
the scraping, atropine alone was used three times a day.
.4 good deal of opacity was left on the cornea first attacked,
which has been greatly improved by iodide of potassium (five
grains to an ounce of water), dropped into the eye three
•times a day. In fact, at the present time there is hardly
any opacity, the patient having very good vision. This is
the first case in which I have scraped an ulcer, and the
iresulb appears to me to be very aatisfactoi-y. I have
been frequently very much impressed by the marked inliu-
■ence iodine liniment, painted on the forehead and temples,
has in relieving photophobia, and by the value of iodide of
potassium (five grains to the ounce), locally, in clearing up
old opacities due to ulceration. I think the great power
possessed by the cornea in recovering itself after severe
ulceration or injury is very well shown in this case.
Nowliaven. __ __
A RARE CASE OF WATERY DISCHARGE FROM
THE UTERUS.
By Skenh Keith, M.B., F.R.C.S. Edin.
In the month of September, 1888,1 saw, in consultation
•with Dr. Gregory White of Bournemouth, an unmarried
?ady, thirty six years of age. Dr, White wrote that he had
known the patient for eight or nine years, and that for a
dong time before that period she had suffered from a profuse
watery discharge from the uterus, “so profuse as to be
beyond anything I have heard or read of.” In 1885 a well-
Ccnown abdominal surgeon was consulted, but did not
recommend any (Operation. Later on another gentleman
was seen. He curetted the uterus, and the operation was
repeated twice by Dr. White, the result being that after the
last scraping there was little or no discharge for three
months. Dr. White was of opinion that nothing short of
•removal of the ovaries was likely to do permanent good ;
everything else had been tried, and had completely failed.
It was found that the lady was in a highly neurotic condition.
For many years all her dresses had to be lined with waterproof
cloth, and every night her bed had to be made up as for a
■confinement; otherwise the mattress was certain to be
destroyed. The discharge was thin, had a heavy sickly
odour, and was like dirty water. Menstruation was regular,
and had commenced at fifteen. At the age of twenty, and
<after a severe attack of inllamniation of the lungs, men¬
struation ceased for some months. It was at this time that
■the watery discharge first commenced. It came then at
irregular intervals and in gushes. Three years afterwards
•the discharge became more violent, and the lady suggested
that this might have been owing to a chill caught while
working in her district in rainy weather and during men¬
struation. The general health was not good. Prom this
time onwpds the watei'y discharge would cease during
menstruation if the patient lay perfectly flat in bed; but
if she got up the flow became very violent, and the hjomor-
rhagic discharge either ceased or at least appeared to
do so. For ten or twelve years the discharge has been
constant, night and day, with frequent sudden gushes
in addition. The patient said that it was quite impossible
to describe the amount of the floodings. Her description
is, “it was greater than I can tell, drenching one from
head to foot many times a day.” The general health
•was entirely broken down, and largo doses of bromidia
were taken every night, The friends of the patient were
most anxious that something should be done, and she her¬
self looked forward to an operation as a perhaps speedy
•end to her unhappy condition. On examination, the uterus
was found to be somewhat larger than natural, and on the
ieft side a distinct swelling was to be felt. This, however,
turned out to be a thin-walled cyst of the parovarium.
There was therefore little in the local examination to guide
one as to treatment, bub the fact that the discharge had
ceased for three months after curetting the uterus seemed
to indicate that that organ was at fault; and if it could bo
Tendered inactive, a cure would be the result. It was at the
same time evident that the condition was not one of fluid
collecting in a Fallopian tube and discharging at intervals,
as there was a constant flow of the liquid. Removal of the
ovaries was therefore advised, and was performed on
Sept. 22nd, 1888. The uterus was flabby and larger
than natural; the ovaries were somewhat small but
apparently healthy; and the Fallopian tubes were soft,
amecnic, and dilatable, and admitted an ordinary cedar
pencil for some distance from the fimbriated end. No
additional light was thrown on the origin of the disease by
the operation. All discharge entirely ceased within a week,
and there was not any abdominal disturbance. The patient,
however, nearly died from an attack of double pneumonia,
strophanthuB apparently saving her life. Return to health
was slow, but now, two years after the operation, the patient
is able to write “ my life is simply perfect happiness.”
Cliarles-afcreet, W.
SEQUEL TO A CASE OF ABDOMINAL SECTION.
By Edward Malins, M.D , M R.C.P.,
OltSlIiTKlC I’lIVSICIAN TO Tllli OKNERAIi HOSPITAL, IlIRMINOUAM.
Some years ago I published in The Lancet (Nov. Ist,
1884) a series of cases of abdominal section for various
purposes. Among these was one of a girl upon whom an
exploratory opening was made, but the ovaries, apparently
showing DO signs of disease, were not removed. The
following was the history then recorded:—“A girl aged
nineteen attended the out-patient department of the hos¬
pital for several months, complaining of severe abdominal
pain on micturition and defecation. Nothing abnormal
could be found in the rectum or bladder. The uterus and
ovarian regions were very sensitive. She became an in¬
patient for five weeks, was subjected to a variety of treat¬
ment, and discharged. Several weeks later her mother
came and begged for something more to be done for
her, as the pain was intense at times. She was
readmitted and the abdomen opened. I examined the
ovaries, which were intact, and therefore not removed;
nothing wrong could be found elsewhere in the pelvis; it
was washed out, and tho wound closed. The pain never
recurred, and the patient got quite well. Some time
: later she returned to' say that her health was better
' than it bad ever been, and to express her thanks for the
operation.” The case was briefly entered in the hospital
“Record of Consultations and Operations” as follows:—
“Uterus and appendages appeared normal on examination;
nothing removed. Cavity of peritoneum opened by incision
an inch and a half long between pubes and umbilicus. On
digital examination the uterus and its apnendages appeared
to De normal. The abdomen was carefully closed with silk
sutures (gauze); salicylic wool dressings; hmmorrhage
trifling; no spray (ether).” On the strength of these facts,
as above narrated, the case was puhUslied as one of neurosis
or functional disorder, cured apparently by the effect of an
exploratory operation. It seemed, however, that this im¬
provement, so hiarked at the time, was not maintained,
and, the girl relapsing, she was taken by her mother
to the Women’s Hospital, under the care of Mr. Tait.
On Jan. 22nd, 1885, Mr, Tait states that he opened the
abdomen again, and makes this assertion:—“I found that
her statement [the patient’s] was accurate. The uterine
appendages on tho left side had been completely removed;
I found tlie ligature which was applied to the pedicle in its
place ; I picked it off and have it in my possession now. I
found the disease, which I assumed as existing on the left
side in July, 1884, very fully advanced on the right side, and
I accordingly removed the appendages there.” He addressed
a printed letter to the chairman of the General Hospital
Committee, which was also circulated outside, embodying
this statement and commenting with undisguised vigour
upon what he called an extraordinary mistake in the records
of the hospital. The opportunity was taken in the same
letter to discuss the question of hospital mortality “chiefly
with a view to what he believed the real public welfare, and
not from any spirit of antagonism to this great and valuable
institution,” The accuracy of the hospital record, I main¬
tained at the time, was without doubt. It was attested by
the house surgeon, Mr. Awdry, who wrote as follows :—
“The case was one I corresponded with Mr. Tait concerning.
If that be so, I am prepared to swear that no ligature was
applied, and that no ovary was removed. If it was, you
slipped it up your sleeve unobserved by me. I remember it
very well, and in my letter to Mr. Tait I told him an ex¬
ploratory incision had been made for purpose of diagnosis,
and nothing else done.” Some members of the committee
also .satisfied themselves as to the truth of tho entered
record by evidence from those present at the time of the
operation. There was no motive in the account written by
D\z-VZr^
Google
986 TbsLancbt,]
HOSPITAL MEDICINE AND SUKGERY.
[May 2,1801.
the house surgeon and signed hy me, and no reason for its
not being strictly correct.
Now, as to the sequel. The patient returned to my care
at the General Hospital shortly afterwards as bad as ever.
I have kept her under observation and treatment for
years—indeed, ever since this alleged occurrence of both
ovaries—“ uterine appendages”—being completely removed.
She has menstruated regularly; as she described it, “ as
regular as the clock.” In the beginning of the year 1890
she was married, and on Dec. 24th in the same year gave
birth to a full-grown living child. She brought the child to
the hospital on Feb. 6th last as a living comment upon her
previous illness and long-continued pain. The case is
interesting; but I simply desire to state the facts as
they happened, and to do so in order that those who
are in possession of the printed letter referred to may
add to this the subsequent history of the patient, and
draw their own conclusions.
Birmingham. _
% Pirm
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autem est alia pro certo noscendl via, nisi quamplurlmas et mot.
borum et dissectionum historias, tnm aliorum turn proprias collectaa
habere, et inter se comparare.—M orQaoni De Scd. et Cans. Morb.,
Ub. iv. Ptoaemium '
LONDON HOSPITAL.
A CASE OF OSTEO-SARCOMA OF THE PELVIS NEARLY
FILLING THE PELVIC CAVITY } LABOUR AT
TERM ; CAESAREAN SECTION.
(Under the care of Dr. Herman.)
We have during the last few years published severa^
cases illustrating the treatment of patients hy the Cfesarean
section, or that method followed by Porro’s plan of removing
the uterus, for deformity with contraction of the bony
pelvis, the result of rickets. The most frequent condition
which requires this operation is undoubtedly some deformity
due to disease of the pelvic bones, and it is rare to meet
with a state such as that seen in this patient, where a large
sarcomatous growth made any chance of delivering the child
hy the natural-passages an impossibility. By the operation
the life of the child was saved, and that of the mother not
materially shortened; indeed, the partial examination made
post mortem proved the success of the operation, so far as the
parts more immediately involved were concerned. In cases
such as this under the care of Dr. Herman the necessity
for the operation is so evident that the question of delivery
hy any other method than through an abdominal incision
does not require consideration. In malignant disease of the
cervix, discovered only when full time approaches, it has
been possible to remove the diseased uterus^ and prolong
the life of the mother, but the disease is usually too far
advanced to admit of more than hysterotomy.'^ For the
notes of this case we are indebted to Dr. E. 0. Ashe,
resident accoucheur, and Mr. J. Pugh Jones, clinical clerk.
H. S-, aged thirty-seven, was admitted into the
London Hospital on March 2nd, 1891. When admitted, she
was said to have had labour pains for eighteen hours. She
could not say whether the membranes had ruptured or not.
Her husband said that neither he nor his wife had supposed
that she was ill until the advent of labour.
On admission, the patient was thin and cachectic-looking.
The uterus reached to the ensiform cartilage. Between
the pains a hard mass could be felt filling the loft iliac
fossa; in front of this a fluctuating swelling (the
bladder). The perineum was pressed down and ccdema-
tous. Both labia were swollen and oidematous, the left
the more. On vaginal examination, the pelvis was
found 80 filled with a hard elastic tumour bulging from
its left wall that the fingers could not be inserted between
the right pelvic wall and the greatest diameter of the
tumour. The urethra seemed blocked; a catheter
could not be got through it. At 2.30 A.M. the patient was
3 BrancaniRt, Sajojw, vol. i»., 1890, p. 17.
2 Oandell, Phil. Med. Tiroes, 1890.
put under ether and Ccesarean section performed hy
Dr. Herman. On opening the abdomen the fluctuating-
tumour above mentioned was seen to be the full bladder.
On opening the uterus, the placenta was found attached to
the anterior uterine wall. It was cut through, and the
child extracted by the foot. The placenta was then
extracted, partly by digital separation and partly by com¬
pression of the uterus. The uterus was not turned out of
the abdomen before it was opened, but the abdominal walls
were pressed close to it by an assistant, and after the
child had been extracted the uterus was expressed from the-
abdomen and the lips of the abdominal incision held close
together behind it while the sutures were being put in..
After the child and placenta had been removed a cabhetei-
was passed and the bladder emptied. A hypodermic injec¬
tion of ©rgotin was then given. The uterus was tnen
sutured (after its interior had been swabbed out witbi
sublimate solution), first with interrupted silk sutures-
passing through the peritoneum about one-third of an
inch from the edge of the incision, and nob including
the decidua, and then with a continuous catgut suture,
entered and brought out on each side through the peri ¬
toneum, so as to bring the peritoneal surface close together
throughout the whole length of the wound. The abdo¬
minal wound was then closed in the usual way. After tha
operation the pulse was 140, but in half an hour it haili
come down to 100. The child was living and survived.
During the following three days the pulse varied between-
120 and 140. The temperature showed a slight gradual
elevation, reaching on March 5th lOO'G", which was the
maximum. The patient complained a good deal of severe
paroxysmal abdominal pain, which, except as to its un¬
usual severity, seemed to be like after-pains, but there was
no continuous pain and very little abdominal tenderness.
From March 3rd onwards there was frequent vomiting and
a good deal of flatulent distension of the abdomen. There was-
throu|;hout need for the catheter, and great pain and difli -
culty in passing it. There was never more vaginal hfcmor -
rhage .than after an ordinary confinement. The ccdema of
the vulva and perineum persisted.
The patient died on March 5th, at G p.m. A complete
post-mortem examination was refused, bub the abdominal
wound was reopened, and an examination of the pelvis and
E arts concerned in the operation was made by Dr.
harlewood Turner. There was no peritonitis. The uterine
wound was perfectly healed, the sutures being buried and-
covered with a layer of smooth shining lymph. The mass
in the iliac fossa and pelvic cavity was an osbeo-sarcomatous-
giwbh, the interior of which was broken down into a
cavity containing blood and pus. As the necropsy was-
incomplete, the precise mode in whicli death was brought
about remained unascertained.
Remarks by Dr. HERMAN, —In this case C.'usarean section,
which was absolutely necessary, failed to save the patient’s-
life. Yet if we leave out of sight the disease from the effects
of which the patient died—although the precise mode of
death, the necropsy being incomplete, cannot be defined—-
and look at the operation only, the case was perfectly suc¬
cessful. There'was no peritonitis, the uterine wound was-
well healed ; there was no h-Tcmorrhage. Had the patient
been healthy there is no reason to doubt that she would/
have recovered.
MANCHESTER ROYAL INFIRMARY.
TUMOUR OF THE BLADDER; OPERATION; RECOVERY.
(Under the care of Mr. SOUTIIAM.)
The case illustrates the facility with which a vesicaE
growth may be removed through the perineum when it is of
small size, of soft consistence, and situated near the neck of
the bladder, so as to be easily within reach of the finger.
If on exploring the bladder the tumour, on account of its-
size or situation, is found to be not removable by this route,
the perineal opening is no bar to the performance of supra¬
pubic cystotomy, but is rather useful than otherwise, inas¬
much as it affords a means of combining free drainage in
the most dependent position during the after-treatment of
the case.
James T-, aged sixty-five years, was admitted on
Aug. 13th, 1890. He had enjoyed good health until about-
six months previously, when he began to suffer from a pain¬
less hreraaturia, which at first was intermittent. Latterly
Die' -sd dy ClOO^IC
The Lancet,<0
ROYAL MEDICAL AND CHIKURGICAL SOCIETY.
[May 2, 1891. 987
the bleeding had become continuous and very profuse, so that
he was in a very feeble condition. The urine was acid in
reaction, and of a bright-red colour owing to the presence
•of blood in considerable quantity. It was passed without
any pain or straining, and micturition was not increased in
frequency. More blood was present at the end than at the
■commencement of the act, and it was often passed in the
form of distinct clots. The history of the case and the
character of the bleeding pointed to the presence of a vesical
tumour, probably of the nature of a papilloma, and the
diagnosis was conlirmed on careful examination of the urine,
•for on several occasions minute particles were found floating
in it, which, examined microscopically, showed the typical
•structure of villous procea.sea. Removal of the growth
having been decided upon, it was resolved to maKe the
attempt through a perineal opening, for on account of the
weak state and advanced age of the patient it was thought
’that perineal urethrotomy would be a less serious procedure
than supra-puhic cystotomy. If, however, this was found
'impracticable, then at once to proceed to open the bladder
from above the pubes.
August 28th.—Perineal urethrotomy was performed in
the usual way. On introducing the finger into the bladder
•a, sessile tumour the size of a walnut was felt on the left
-side at a little distance from the neck. It was of such soft
•consistence that it was easily removed by scraping with the
finger nail and a Volkmann’s spoon. Somewhat free
'bleeding attended the process, but it was arrested on
washing out the bladder with hot water. The perineal
wound was somewhat slow in healing, urine escaping
through it until the end of the fourth week. After this
■date it was completely closed, and the patient left the
■hospital a fortnight later, passing all his urine by the
natural channel, there having been no bleeding since the
operation. Microscopical examination of the growth removed
showed it to be of the nature of a papilloma.
Feb. 1891.—There has been no recurrence of the hajmor-
■rbage. The patient remains in a feeble condition, but is
entirely free irom bladder symptoms.
SAMARITAN HOSPITAL FOR WOMEN,
BELFAST.
TWO CASES OP RETENTION OP URINE, CAUSED BY THE
I’RESSURE OF PELVIC TUMOURS AND FOLLOWED
BY SUPPRESSION.
(Under the cave of Dr. W. K. McMordie.)
The following cases demonstrate the fact that advanced
■chronic disease of the kidneys, the result of obstruction to
the urinary passages, whether by stricture of the urethra
■or the pressure of growth from outside, not uncommonly
proves fatal from suppression of urine when the patient is
•subjected to operation. That the operation was necessary
in each case there is no doubt; it is to be regretted that
tite patients did not submit themselves at an earlier date,
-for it is probable that in both success would have been
attained had they done so. The second case illustrates
some of the risks attending tapping ovarian cysts.
Ca.SE 1. Vaginal Jihroid, causing complete retention .—
M. F-, aged forty, a single woman, was sent to the hospital
on July 30ch, 1890, by Mr. Beck. He stated in a letter
“that the vagina was blocked up with a tumour, that she
could not micturate, and that there was no room even for
the smallest catheter.” In addition to what was described
An his letter the abdomen was distended with a fluctuating
tumour reaching as far as the umbilicus. Both lower ex¬
tremities were swollen and codematous. For a year previously
to her admission she had suffered from constant bfcmor-
rhage, a frequent desire to micturate, and pain in the hypo¬
gastric region. She was weak and antemic. For seven days
^)reviouBly to her admission she had been unable to pass any
urine. Temperature 101”. Under the influence of an
•anmsthetic the tumour was successfully removed. It grew
by a short thick pedicle about one inch in breadth from the
fundus uteri, Over three quarts of fetid ammoniacal urine
were drawn off. Only a very small quantity of urine was
•secreted for some days. This was followed by complete
suppression, and she died from uraamic poisoning on
Aug. 13th.
iicinar/c.?.—Such a state of matters as is here described
caused by pressure must be very rare ; butt partial retention
caused by pressure of pelvic tumours and adhesions is a
frequent cause of the bladder troubles so common in female
ailments. With partial retention in existence for some
time, then complete retention suddenly coming on would
be more likely to act quickly on the kidneys.
Case 2. Bladder cyst caused by an adherent ova/rian
cyst. —S. W-, aged fifty-six, with a large ovarian
tumour, was sent to the Samaritan Hospital for operation
by Dr. Forsythe of Coleraine. The measurement round
the umbilicus was forty-nine inches. The patient had been
tapped once three years previously to her admission to
hospital. She complained of a constant dribbling of mine,
and on passing the catheter not more than an ounce of
urine was at any time drawn off. Sp. gr. 1015. On
July 8th, the usual incision for an ovariotomy having been
made, twenty-eight quarts of thick dark fluid were drawn
off. No separation in any direction could be made between
the cyst wall and the peritoneum. What appeared
to be a second cyst protruded from the pelvis into
the cavity of the large cyst. A trocar was passed,
and three pints of fetid urine were drawn off. The
hole in the bladder was carefully sutured with fine catgut,
and no trouble followed from this mishap. A drainage-
tube was left in and the large cavity daily washed out with
a 1 per cent, solution of horacic acid. The cavity steadily
contracted without an unpleasant symptom for four weeks,
when no more than three quarts of water could be injected.
The patient could walk about and her recovery seemed
assured, when suddenly symptoms of urmmic poisoning
appeared and she died on Aug. 14th.
liemarks. —At the operation the anajsthetic was adminis¬
tered by Dr. McKinney and Dr. Henry O’Neill assisted.
The very intimate adhesion between the cyst wall and the
peritoneum was no doubt caused by the long continuance of
the tumour and the fact that it had been tapped three years
before I saw her. Tapping ovaiian cysts is even yet an
operation frequently performed in this part of the kingdom.
In cases of simple cysts often repeated again and again, it is
one of the great difficulties operators have to contend with.
ROYAL MEDICAL & CHIRURGICAL SOCIETY
The Value of Tuberculin in the Treatment of Surgical
Tubercular Diseases.
An ordinary meeting of the Society was held on
April 28tb, the President, Mr. Timothy Holmes, in the chair.
Mr. Watson Cheyne read a paper on the Value of
Tuberculin in the Treatment of Surgical Tubercular
Diseases, of which the following is an abstract. In this
preliminary communication the author referred in the first
place to the method of administering the drug. In most of
his coses the mode of administration was that recommended
by Dr. Koch, in which the occurrence of reactions was the
guide to the dose. The objectionsto this method were pointed
out, and another plan, which the author had been using for
some time, was described. It consisted in establishing
tolerance as regarded the general action of the drugas quickly
as possible, and then repeating the doses in rapid succession
so as to keep up a constant local action. For example, if
the initial dose of, say, two milligrammes produced fever,
the second dose of the same amount was given as soon as
the fever had subsided, probably in two days; so with a
third : and in most cases after four or five injections no
further febrile reaction occurred with this dose. The same
quantity was then injected twice (daily, and after two or
three days thrice daily. After three or four days the
amount was increased, till ultimately doses of one to two or
more decigrammes were given thrice daily; in this way a
large amount of the fluid could be rapidly introduced with¬
out the patient suffering from fever after the first three or
four doses, and with marked improvement as regarded the
local condition. Another method of administering thefluid
was that of giving considerable doses at long intervals so as
to avoid the establishment of tolerance. The method moat
commonly employed of giving small doses at considerable in¬
tervals was condemned as being one hardly likely to do any
good, and not unlikely to increase the risk of dissemination of
Dii: zed by
988 Thb IlANCet,]
CLINICAL SOCIETY OF LONDON.
fMAY 2, 1891.
the disease. The various phenomena observed after injec¬
tion were referred to very shortly, and the dangers were
then discussed. It was pointed out that the danger of dis¬
semination of the disease had been greatly exaggerated,
and that the main danger was where the tubercular disease
was combined with sepsis, and was due to extension, not of
the tubercular, but of the septic process. The (Question as to
what the treatment could do was discussed on the basis of the
microscopical appearance of tissues removed after treatment,
of experiments on animals, and of clinical observations on
man, and the following conclusions were arrived at:—In
the lirst place, in the majority of cases the first effect of the
treatmentwas to produceimprovement as regarded the tuber¬
cular disease, the degree of ihiprovement varying according
to the circumstances of the individual case and the mode in
which the remedy was applied ; but it was very rsrely that
this improvement went on to complete cure unless aided by
other measures. In most cases, after improvement had gone
on for some time it came to a standstill, and if the treat¬
ment was given up at this stage, or within three months
and a half (the limit of the author's experience), relapse
would almost certainly occur. The great question, one
which, however, affected medicine more than surgery, was
whether by continuing the treatment the disease could be
kept at a staodstlll. The facts observed by the author
seemed to show that by continuing the treatment with this
object in view the condition of standstill could be maintained
in a number of cases for a considerable time. As regarded
the length of time, the author could only say four months and
a half, the length of bis experience; but it seemed not impro¬
bable that it could be maintained longer, and of course the
longer it was maiptained the greater the probability that
the tubercle bacilli would die out, and the improvement
become permanent. As had just been said, this question
affected medicine more than surgery, for in surgery matters
could generally be hastened in other ways. The aiagnostic
value of the remedy was then considered. As regarded
surgical practie« the conclusions provisionally come to were
the following : In cases of intractable lupus tuberculin was
of great value when combined with other measures. In
tubercular glands it hardly repaid the trouble and incon¬
venience except in so far as it might reduce the periadenitis,
and thus pave the way for operative measures. In diseases
of joints the question as to its place could hardly as yet
be definitely settled, but the author was inclined ibo think
that it was best not to employ it in the early stages,
but to reserve it as a means, after operation, of aiding
the prompt healing of the wound. It might also be of value
in enabling the surgeon to perform less severe and radical
operations than he might otherwise do. In cases of osseous
disease it would probably only be useful after operation.
In genito-urinary tuberculosis it could seldom come into
play on account of the great frequency with which these
diseases were combined with sepsis, and for other reasons.
In tubercular laryngitis it appeared to be of use in certain
cases. While admitting the small value which could be
attached to his opinion as regards phthisis, the author could
not but think that the dangers of tuberculin in that disease
were being unduly magnified and its benefits unduly
decried. Some of the imperfect results were no doubt
due to timidity in the application of the remedy,
Mr. Cheyne showed, by means of the magic lantern, some
excellent photographs, taken by Mr. Andrew Pringle, of
microscopical preparations of tubercular lesions at various
stages during the treatment. They exhibited well-marked
retrogressive changes, the epithelioid cells becoming dis¬
integrated, the intermediate zone being invaded with small
round cells, and the gradual development of thete into
fibrous tissue.
The debate on this paper was adjourned to a special
meeting of the Society on Thureday, May 7th.
CLINICAL SOCIETY OF LONDON.
Old Dislocation of Patella reduced by Intra-articular Opera¬
tion. — Pseudo ■ hypertrophic Paralysis. — Estldnder's
Operation. — Gaitro-jejwioatomy for Pyloric Obstruc¬
tion.—Congenital Heart Disease.—Becurrent Dislocation
of Patella!.—Luptts Erythematosus cured by Internal
Treatment.—Plastic Operation for Vesical Extroversion,
An ordinary meeting of this Society was held on April 24tb,
the President, Sir Dyee Duckworth, in the chair.
Mr. Bilton Pollard showed a girl with old (con¬
genital ?) Dislocation of the Patella reduced by an intra-
articular operation. There was a history of injury in the
year 1885, but the limb had been weak as long as slie could
remember. An operation for genu valgum had been done,
but this did not improve the position of the patella. He
first cut down on the outer side and divided the vastus ex ■
ternua, and then an incision was made on the inner side of
the patella and the joint opened. The outer border of the
trochlear surface of the femur was removed with the chisel!
and a broader articular surface cut. A portion of the-
capsule on the inner side was resected in order to
brace up the structures in that situation. The result
was a perfect restoration of the functions of the joint.
Dr. J. Taylor showed, for Dr. Hughlings Jackson, two-
coses of Pseudo-Hypertrophic Paralysis. The first was a-
hoy aged thirteen, who had enlargement of the calves,
wasting about the shoulders and thighs, characteristic gait,,
lordosis, and inability to go upstairs without help. The
lowest part of the trapezius was paralysed; the displace¬
ment of the scapula, however, was not characteristic of this
lesion only, but was due to concomitant paresis of th©
levatores anguli scapulro. A boy aged eleven, the brother
of the preceding, was also exhibited. Ho was sufiering
from the same disease, but of a much less advanced form.
No other members of the family were affected.
Dr. J. Taylor likewise showed, for Dr. Bastian, a girH
aged fourteen affected with the same disease in a very
marked form. There were weakness and atrophy of the
biceps, of the muscles about the scapula, and hypertrophy of
the triceps, deltoid, and calf muscles. The case was shown
on account of the occurrence of a pseudo-hypertrophic con¬
dition of the first dorsal interosseous muscle in each hand
and of the marked enlargement of the tongue. Both con¬
ditions were uncommon, the former, according to Dr.
Gowers, being extremely rare. There was here also no
family history of similar affection.
Mr. F. B Jkssett exhibited a girl, aged seventeen, on
whom he had performed Estlilnders Operation or Thoraco¬
plasty. In 1880 she was attacked by pleurisy in the left
side, followed by empyema, for which drainage-tubes were
inserted. In 1888, an intractable sinus being present, and
the patient losing ilesh, an incision was made, and con¬
siderable portions of the third, fourth, fifth, sixth, and
seventh ribs were removed. After a few months the sinus
closed, and she was at present quite well, there being very
little battening of the chest and only a slight degree of
spinal curvature.
Mr. Jessett also brought a woman, aged fifty-six, on
whom Gastro-enterostomy had been performed for pyloric
cancer. She had complained of dyspepsia for some years,
and in 1889 felt a lump in the epigastrium, which had
slowly increased in size, causing paiu and vomiting. In
April, 1890, the growth having much increased and the
stomach being greatly dilated, gastro-iejunostomy was per¬
formed, the incision being iu the right linea semilunaris.
Senn’s plates were used, a few Lembert’s sutures being
added for precaution. She made a good recovery, and was
at present taking solid food, which she could not do before
the operation.
Dr. Ewart and Mr. W. H. Bennett likewise showed a
case of Gastro-jejunostomy two months after operation.
The patient, a drayman aged fifty-two, was admitted into
St. George’s Hospital under the care of Dr. Ewart oa
Feb. 14th, 1891, with symptoms of pyloric obstmetion.
There were great emaciation, frequent vomiting, and a con¬
stant feeling of discomfort and distension over the whole
abdomen. The stomach was much dilated, the vomited!
matters very acid, and to the right of the umbilicus a hard
movable mass, about three inches in its longest diameter,
could be felt. Ou Feb. 27th, Mr. Bennett performed
abdominal section through the middle line above the-
umbilicus, and found the pylorus involved in a movabl®
tumour free from adhesions, the nature of whicli was not
quite clear, although it was probably malignant. Gastro¬
jejunostomy was then perfoiined, Senn’s decalcified bone
plates being used. The patient quickly rallied from the
immediate effects of the operation, and made a rapid ancSl
uninterrupted recovery. Food was given by the mouth
within twelve hours after the operation, and retained with
comfort. No dyspeptic symptoms of any kind had occurred
since, although the patient’s appetite was very large. Th®
size of the stomach was only about half of that prior to
the operation. The motions, formerly very pale, were now
natural in colour, and up to the present date there had
been an increase in weight of two stones and a half. In spite
D'
e
The Lancet,]
MEDICAL SOCIETY OF LONDON.
[May 2, 1891. 989
of careful exauuQation of the motions, nothing had been
seen of the bone plates or the sutures used in approximating
them.
Dr. F. Hawkins showed two cases of Congenital Heart
Disease. The first occurred in a boy aged twelve, and was
regarded as an instance of pulmonary stenosis with regur-
.gitation. It was peculiar in that the heart lay to the right
side, while the other viscera were not displaced. The second
patient was a girl aged nineteen, and the lesion was pul-
ninnary stenosis.
Mr. W. H. BattJjK exhibited a woman aged twenty-one,
who was the subject of llscurrenb Dislocation of the
Patella. It was curious that it did not come on till she
was sixteen years of age. She was able to keep the bones
in place by a splint, to which was attached a semilunar pad
on the outer side.
Mr. Battle also showed a woman aged twenty-seven
who had been the subject of Lupus Erycheiuatosus, which
had been cured by internal treatment only. The drugs
used were liquor arsenicalis in doses increased from three to
ten minims, and combined with increasing doses of the
eyrup of iodide of iron.
Mr. Battle likewise showed a third case of Plastic
Operation for Extravasation of the Bladder in a boy aged
ten, the result being a very good one. On March 7bh a flap
was turned down from the median part of the abdomen, the
scrotum was dragged up, and the penis brought out through
a hole made below it. On April 1st the skin covering the
ftbdominal walls was separated laterally and brought
•together in the median line. There was no suppuration,
the boy was weaving a urinal and walked with comfort.
Dr. Samuel West sent a case of Spontaneous Fracture
of both Calcanea in a case of tabes dorsalis. The patient
was a woman aged fifty-one, who had been tabetic for five
years. Six weeks ago, on attempting for the first time to
walk with assistance, after lying in bed for three months,
she noticed something snap in her right foot. Three days
later, on again attempting to walk, she experienced a
oimilar snap in the left foot. It was found on examination
that a semilunar fragment two inches long and an inch
broad was detached from either calcaneum and drawn up
about one inch by the calf muscles. There was fibrous
union on each side, with some bony union also on the left.
The fracture was attributed to the fact that in walking the
heels were brought forcibly to the ground. There was a
history of gout.
Mr. W. H. Brown of Leeds read a paper on a case of
<ja8tro-jejunoetomy. The patient, a woman aged fifty-six,
had suffered from dyspeptic trouble for twelve months.
Vomiting had commenced and excruciating pain followed
on the introduction of the smallest quantity of liquid into
the stomach. There was a well-defined sausage-shaped
owelling to the right of the umbilicus, and the outline of
the distended stomach could be readily seen. The abdomen
was opened in the middle lino, and the growth made out to
he involving the pylorus and first part of duodenum. A
piece of jejunum was seized and opened, and a second
opening was made in the anterior wall of the stomach and
Senn’s plates introduced. The patientbore the operation well,
and the pain entirely disappeared. She was able to take
liquid food well. She lived four months after the operation
in comfort, the pain only returning a few days before death,
which was due apparently to the extension of the disease.—
Mr. F. B. Jessett asked if care had been taken to make
the opening in the jejunum as high up as possible. The
directions usually given to find the upper part of the
jejunum were misleading; for, the colon being hooked
up, the omentum should be drawn over to the right,
and not to the left, as generally recommended. He bad
performed this operation live times, with three successes,
two of the patients being at present alive. He inquired
as to the material used for sutures. He had at first
used, silk for all the sutures, but finding it in one case
undigested he had since used chromicised catgut, wliich
answered admirably. In one case it was on record that the
<!ommunication had closed up; therefore the opening both in
the stomach and the small gut should be large, and the sutures
placed near the opening. The patient might be fed next
day with perfect safety. He haa generally used from three
to'six Lombert’a sutures to prevent tilting of the plate.—
Mr. W. It. Bennett said that these cases showed the
greatest conceivable improvement after this operation,
though of course it left the disease behind. As compared
with pylorectomy and the modified Loreta’s operation,
was far superior under any circumstances, even if
the disease were not malignant. It diverted the flow
of digestive fluid from the seat of the fiisease, and the
patient was as well oil' with the artificial as with a
real pylorus. If pains were taken to get near the duo¬
denum no harm to the digestive process resulted from
this short-circuiting. It was very important to feed these
exhausted patients very early. He agreed that the
omentum should be drawn over to the right, and not to the
left, and that accessory Lembert’s sutures were useful to
prevent tilting of the plates. In the plates themselves he
recommended catgut for the lateral and silk for the end
sutures. He asked the reason for the vertical incision in
the stomach,—Mr. Sxiii'iiEN Paget understood that
swelling of the parotid was observed. This was not to be
considered as a sign of sepsis, for he had found that in other
casesof abdominal section it had been of innocent character.—
Mr. C. J. Symonds said he had performed this operation
two days ago. He had difficulty in finding the jejunum, for
he had pushed the omentum over to the left. He was a
little afraid that the plates he had used might give him
trouble owing to their size ; the small intestine looked very
fiat after the plate was inserted. To prevent kinking he
had also fixed the jejunum to the stomach a short distance
beyond the plates.—Mr. Lane said he had been in the
habit of reinforcing the plates by secondary sutures, and
as he fixed the posterior ones before he drew the plates
together, heliad nodifficulty in getting them in place.—The
President remarked that Mr. Paul of Liverpool had been
recently using a cylinder of decalcified bone for this purpose,
and the opinion in that town seemed to be that it was a
great improvement on the previous methods —Mr. W. H.
Brown, in reply, said that he found the top of the
jejunum by turning the omentum to the right and tracing
the small gut up to its origin. He used silk both for the
bone plates and the extra sutures. He was glad to know
that Ssnn in a recent paper had advocated the use of these
accessory sutures. He performed, previously to the opera¬
tion, several experiments in the post-mortem room, and
from what he saw there he was convinced that the vertical
incision in the stomach was the best, and the parts appeared
to He more naturally afterwards. It was the fourth time
that he had observed intercurrent parotitis in abdominal
operations, the others being two simple cases of ovariotomy
and one of exploratory laparotomy. He was glad to hear
early feeding so well spoken of, as he was warmly criticised
for adopting it in his case.
MEDICAL SOCIETY OF LONDON.
Gcmc Rec'urvatum,—Ectopia Visccrum.—Excision of
Tongue.
An ordinary meeting of this Society was held on
April 27th, the President, Dr. Douglas Powell, in the chair.
Me. Edmund Owen showed an Irish girl of three years
and three-quarters who had been the subject of congenital
Genu Recurvatum. The mother had had typhus fever
seven or eight months before the confinement, when she
had imagined herself to be a fish, It was improbable that
this active imagination had any influence in causing the
physical defect. The child had evidently been badly
packed in utero, for though it was a “head first” presenta¬
tion, the feet emerged resting upon the shoulders. On
admission to the Great Ormond-street Hospital the child’s
favourite attitude was sitting, with the back of each foot
resting upon the collar-bone, the knees being lunged with
the salient angle backwards—like a stork’s. The heads of
the tibiso were displaced so far forwards upon the trochlear
surfaces that the back of the femoral condyles and the
interoodylar notch could be clearly defined in the popliteal
space. There was a transverse farrow at the front of the
knees, in the retiring angle, close above which the patellco
could be made out. Flexion of the knees in the proper
direction was absolutely impossible ; even when the child
was under the influence of chloroform the legs could not
be brought into a line with the thighs. On Feb. 11th Mr.
Owen divided the quadriceps extensor on each side by a
free transverse incision, which fully exposed the trochlear
surfaces. The wounds were closed with continuous
sutures and dressed with sublimate gauze, the limbs
being fixed straight in a box splint. The incisions
healed promptly. The knees could now be flexed to a
right angle, and the child was acquiring some power over
them, Mr. Sydney Jones, the registrar, noting on April 2lBt
Coogle
990 Thb Lancet,]
MEDICAL SOCIETY OF LONDON.
[Mays, 18W.
that she could easily stand os the right leg. Massage and
manipulation were still being employed. Mr. Owen remarked
upon the comparative rarity of the deformity. The instances
wnich he had previously met with bad been in infants; be
had never seen so marked a case as this, nor one which
could not be remedied by treatment less severe than that of
myotomy. This operation had been preferred to tenotomy
of the ligamentum patellae, as possibly promising a better
immediate result and permanent improvement.—Mr. Adams
congratulated Mr. Owen on the excellent result he had ob¬
tained, though be himself would have preferred to have
done the operation subcutaneously.
Dr. T. Elliott of Tunbridge Wells read a paper on,
and showed a specimen of, Ectopia Viscerum in a newly born
male infant. The mother had had a favourable labour.
She was thirty-eight years of age, had borne seven
children before, and the only one presenting any abnor¬
mality was the eldest son, who had a slight deformity of
the left ear. There was no history of “maternal im-
f ression.” The child was born at full term and was well
eveloped and perfect in every respect, except in the region
of the abdomen. It weighed Gib. 6oz., and was eighteen
inches high. In the abdominal wall there was a large
opening situated to the right of the attachment of the
umbilical cord, measuring lour inches and three-quarters
in circumference. The organs which had protruded through
the opening and were lying outside included the lower
three'quarters of the stomach, the whole of the small intes¬
tine and colon to within three inches of the anus, the testes,
and mesorcbia, and a part of the bladder. All the coils of
the intestine were matted together by recent lymph, and
the remaining viscera which protruded were similarly
covered.—Mr. Edmund Owen had seen two or three
examples of this surgical curiosity, and it was not uncom¬
mon every now and tnen to see a small coil of gut in the
roximal end of the cord. He had always found a thin
Imy membrane covering the bowel, but in the case under
discussion this film appeared to have been ruptured in the
act of birth.
Mr. Whitehead of Manchester read a paper on 104
cases of entire Excision of the Tongue, which will he
published in full in our next issue.—The President in¬
quired if there was any difficulty in deglutition after removal
of the tongue, necessitating food to be taken in tbe semi-solid
form. He asked also if there were any danger of food
regurgitating into the trachea and whether recurrences
were commoner in silxc or at distant parts. The chief object
of the operation was the relief of suffering caused
by the local disease in the mouth, and if recurrence in
situ were commonest and the patient stood the chance of
having the same suffering in the mouth in a month or two
he would, perhaps with some reason, he reluctant to
submit to an operation; but if recurrence took place
in a distant part, then death generally happened In a
gentler manner. He inquired whether the very large dose
of morphia had been administered by mouth or sub¬
cutaneously.—Dr. Purcell said he had adopted this
method of operating since the appearance of Mr. White¬
head’s first paper on the subject. He preferred to have the
J iatient with his head hanging over the end of the table,
or this gave better light and facilitated manipulation. He
did not find that dividing the jaw after Syine’s method was
a satisfactory procedure, for recurrent disease soon attacked
the hone, and the state of the patient was made worse. He
referred to operate with the galvano-cautery, the wire
eing passed from outside the neck through between the
two pillars of the fauces, and the amount of electricity
being limited to one cell of a Groves’ battery in order to
cut slowly. Kocher’s method of operating was efficient in
bad cases. After the operation he was in tbe habit of
feeding bj; the oesophageal tube.—Mr. Bryant said
that his ideas on this subject were in accord with
those of Mr. Whitehead. In his early days he used the
galvanic ^craseur, and was so pleased with it that, after
once abandoning it, he returned to it again. But later still
he had discarded it once more on account of the septic
condition in which it left tlie mouth after the operation.
The scissors or the knife was preferable, and he had in¬
variably adopted Mr. Whitehead’s method for the last few
years. He pointed out that a finger placed at the back of
the tongue readily controlled the lingual arteries, and they
could he then picked up and twisted. The operation conld
thus be made practically bloodless. It was perfectly right
to remove the glands when one could, but he had not always
done this at the same time as the ablation of the tongue j
he preferred, especially in old subjects, to leave it till a few
days later. He looked upon tbe ligature of the linguals
from tbe neck as an unnecessary procedure, though the
same incision was bandy for removing tbe glanda
beneath tbe jaw. As to taking away infiltrated glands
deeper down, he had grave doubts whether this was-
altogether justifiable, and he should not have much faith in
recommending it. As to results : he knew of a great many
of his patients who were alive at the present time whos&
tongues be had removed ten or twelve years ago. Referring
to the recurrence ■ of growth in situ, he thought that
usually it was the continued growth of something which
had been left behind at tbe first operation. He always
recommended an early attack on such cases, and he quoted
three instances where excellent results had followed these
second removals, one being alive thirteen years after¬
wards, one six years, while the third had not been
heard of since three years after the operation. He con¬
sidered that death in two-thirds of the cases occurred
through involvement of the deeper set of cervical glands.
As a varnish, he had been in the habit of using the
ethereal solution of iodoform with collodion, and into
this he dipped bits of iodoform gauze, which he placed'
on the abuTup,—Mr. Butlin, referring to the classification-
of cases, said that it was nob so much the comparison of
cases where half or the whole of the tongue had beea
removed, as to whether or nob there were complications
present, such as adhesion to the jaw or involvement of
glands. He was astonished at the number of cases in
which Mr. Whitehead had removedlthe entire tongue. In
the London hospitals, if there were growth anteriorly, it
was the custom to remove only a portion of the tongue, and
recurrence after this partial operation was rare. He re¬
marked that it was very difficult to tell where the secondary
glandular affection would occur. Operations on what
would be called hopeless cases were not usually practised^
bub operation was only done where there was a reasonable
chance of removing tbe whole of the disease in the month.
In one case he dissected extensively in the neck and laid
bare the carotid sheath; but he regretted doing so, for
the wound did nob heel, and he believed that the
atient died somewhat earlier than he otherwise wouhil
ave done. Our hopes usually lay in cases which
allowed a small operation for removal of limited cancerous
disease. He asked the author if he had adopted the bringing
together of the two sides of the wound. He himself usually
covered it over with iodoform, and fed either witli an
oesophageal tube or with a feeder to which a rubber tube
was attached. The mortality after the operation for
removal of the tongue was at present very small, and the
deaths from septic pneumonia had diminished very largely
under modern methods of treatment.—Mr. WHiTEHiiiAD, in
reply, said he had allowed his patients to swallow food
naturally on the day after the operation without any adven¬
titious aid whatever. Recurrence was usually confined to
the cervical glands. As he had had to tie the linguals in
every case in which he had used the galvanic eeraseur, this
led him to abandon that method and remove with scissors,
the arteries being twisted. He urged the importance of re¬
commending the patients to submit to early removal, and
nob to wait until the glands were involved. He had never
found it necessary to apply pressure to the back of the
tongue. For checking hasmorrhage be employed torsion
only, and he had never once had secondary haemorrhage
since he had adopted it. When tbe disease extended to the
glands their removal was practised to relieve pain. As for
the danger of operating on the neck, every vessel and
nerve on one side might be cub and the patient be practi¬
cally none the worse for it, and he saw no reason why iri'
removal we should stop short of any boundary save that
which limited the disease itself. He had practised sewing
up the wound by bringing the mucous membrane together
from before backwards, but he had found this impede con ¬
siderably the movements of the epiglottis.
HAKVEIAN SOCIETY.
Offensive Lochia. — Leueorrheca.
A MEETING of this Society was held on March Gth^^
Mr. H. Cripps Lawrence, President, in the chair.
Dr. Boxall, referring first to coses of sepsis after child ¬
birth without fetor, related a case in which the patient
died of septic infection, although the lochia procecdeci
Coogle
The Lancet,]
HARVEIAN SOCIETY.
[May 2,1891. 991
naturally without oftensive smell. Turning next to eases
without sensis, he related other cases in which fetor was
present witnout septic symptoms or illness of the patient.
He remarked that xn the life history of saprophytic germs
lay the explanation of fetor, and that in them and their
liability to be associated in various ways, according bo cir¬
cumstances, with pathogenic organisms was to be found the
reason why fetor U often present, but sometimes absent, in
cases of septic infection (septiceemia). And, further, that,
as toxic principles evolved during the process of putrid
decomposition were by no’means necessarily absorbed into
the system of the patient, septic intoxication (saprmmia)
did not invariably take place even when the discharges
became offensive. He had tabulated a series of 120 cases
of offensive lochia which occurred among 640 patients
under close observation in the General Lying-in Hospital,
where they were all placed under similar conditions, the
whole series being completed before the introduction of
sublimate as an antiseptic. By the aid of these tables he
showed the inffaooce of the character of labour on the
incidence of fetid discharges daring the puerperium. He
discussed the relation of fetid discharges to elevation
of temperature, and proved that, though fetor was as
a rule associated with fever, the rise of temperature
almost invariably precedes the altered character of the
lochia. He further discussed the relation which fetor bears
to sepsis, and demonstrated that as an indication of septic
infection (sepbicoemia) or even of septic intoxication
(saprmmia), the presence or absence of fetor in the loohial
discharges is by no means an infallible guide. He remarked
that in every case of offensive lochia, as fetor invariably
indicates a failure to maintain local asepsis, vigorous anti¬
septic measures should be at once instituted. He depre¬
cated the use of mere deodorants, and recommended that
the vulva and vagina should be first washed and cleansed
with a potent antiseptic such as sublimate, and that only
after this has been done and where real necessity exists
should the cleansing be extended to the interior of the
uterus.—The President commented on the importance of
remembering that fetor did nob necessaiily imply sepsis and
vice versd.
Dr. W. S. A. .Griffith, F.R.C.S., read a paper on
Leucorrhma. The author defined a vulvar discharge of
mucus to be Icucorrhcea where the quantity exceeds that
which can be removed by the usual daily bath. Any dis¬
charge causing cutaneous irritation, or which is offensive
though not excessive, he also regarded as leucorrhcca.
Leucorrhcca might arise in three ways: (1) By the for¬
mation of an excessive quantity of an otherwise normal
secretion ; (2) by alterations in composition, as well as in
quantity, of the ordinary secretions ; (3) by the addition of
some extraneous secretion. The normal secretions were, he
said, almost entirely formed by the mucous membrane and
glands of the uterus. The vagina bad no glands, and being
lined with true skin, nob mucous membrane, could have no
proper secretion, though it is possible that even in health
there may be some transudation of fluid from its vessels.
Vaginal mucus was uterine mucus retained in the vagina,
and its acidity was due to decomposition. The mucus formed
in the body of the uterus differs very slightly, if at all, from
that formed in the cervix ; it was perhaps less viscid. At
the vulva the mucus of Bartholin’s glands was added to that
from the uterus; the other glands of the vulva were seba¬
ceous and sudoriparous. The conditions which gave rise to
leueorrhcea were described in detail, as well as inllammatory
collections of fluid (pus or serum), which opening into the
genital tract may also give rise to leucorrhcca. In the large
majority of cases leucorrhcca comes from an intra-uterine
source, and all such cases are divided into two classes:
(1) those in which the mucous area of the uterus is enlarged;
(2) those in which it is nob enlarged. Dr. Griffith, in reply
to Mr. D’Arcy Power, stated that in one caseof myxmdema,
whose uterus he had examined after death, there was present
a cystic .adenomatous degeneration of the mucous membrane,
with a large secretion of mucus, but whether this was in
any way connected with the major disease he could not say.
The meeting on March 19bh was a “clinical evening,” Mr.
II. Cripps Lawrence being in the chair.
Mr. SiLcocK showed a man who had suffered from Dis¬
tension of the Frontal Sinus, which not only caused pro¬
minent bulging of the bone over the left eyebrow, bub also
great protrusion of the eyeball and external strabismus.
Trephining over the sinus was performed, the mucoid
material filling the sinus removed, and drainage by a tube
passing into the infundibulum re-established with marked
amelioration of symptoms and of disfigurement. In reply
to questions by several members, Mr. Silcock said that the
infundibulum was blocked, and nothing short of trephining
would have succeeded in removing the viscid mucoid fiuid.
Slight optic neuritis had been present. Recurrence did
not take place after thorough drainage.
Dr. Batten showed : (1) A child recovering from dry
catarrh of the trachea with crusts visible by laryngoscopy;
(2) a woman, aged twenty-five, with symptoms somewhat
resembling disseminated sclerosis. She suffered from epi¬
leptic fits, and had had slight right hemiplegia and ^hasia.
The right side of theface was smoother than the left. Tremors
of the bead and hand had come on after recent parturition.
Testing for the exaggerated reflexes had induced an epi¬
leptic attack. The patient’s peculiar gait and movements
were demonstrated.—Dr. Handfield Jones suggested
that the case was one of hysteria after recent delivery.
The Symptoms oj Shaking Palsy in a Hysterical Subject,
by Dr. Ewart. —The patient, a woman aged forty-two,
had been weakened by dental trouble and by basic pleurUy
and congestion, immediately after which her tremor and
peculiar stoop began (three years ago). She also had influ¬
enza in December, 1889. Eleven weeks ago she had pain
and slight swelling in her knuckles, followed by general
pains, weakness, and ultimately inability to stand. When
she was admitted, the slight arthritic affections, the stooping
attitude, and the blank facial expression, suggested early
rheumatoid arthritis. The two latter signs, coupled with
the tremor, on the other hand, were equally in favour of
beginning paralysis agitans. But the progress of the case
entirely justified the diagnosis which was made of hysteria
induced by weakness, and causing besides globus and right
hypochondrial pain, a fine tremor of the right hand, and a
spontaneous foot clonus of the same side, apt to arise in the
sitting posture. Thanks to valerian and galvanism, the
patient was now able to stand and to walk almost erect.
The foot clonus and the tremor of the right hand, aggravated
by attention, were still, however, present. The tremor
never affected the left hand unless the tight hand w{^
steadied by an observer.
Friedrich’s Disease, vjith Increased Knee-jerk, by Dr.
Ewart. —In spite of the absence of any history of ataxia
in the ascendants or in the collaterals of tiie patient
(female, aged nineteen), the above diagnosis was made on
the followinggrounds : Slight tremor of the hands
on purposive movement, slight lateral nystagmus, marked
ataxiaof the lower limbs, with very slight loss of sensibility,
alight temporary affection of articulation (which had now
become quite normal again), integrity of the cerebral
functions, without any trace of hysterical manifestations ;
and on the following negative grounds: Absence of the
papillary and visceral symptoms of tabes, absence of the
spastic features of ataxic paraplegia, and absence of
suflicienb tremors, nystagmus, and cerebral affection to
justify a diagnosis of disseminated sclerosis. The sym-
ptoms had begun at the age of sixteen, after which men¬
struation had become irregular, and had finally ceased.
Some general gain in strength and in weight, and some
improvement in the power of standing and of walking, and
in the steadiness of the hands had resulted under rest,
tonics, and massage. It was noteworthy that the affection
of speech present a year ago had quire ceased, and that
under the treatment above mentioned the right leg, which
was previously the weaker, had improved at a quicker rate
than the left, and was now the stronger. The exaggerated'
knee-jerk was the only feature not favouring the diagnosis,
but this was a condition specially mentioned by Dr. Gowers
and by Dr. Bastian as having been noted in exceptional cases.
In reference to Dr. Ewart’s second patient, Mr. D’Arey
Power mentioned that he had seen four members of a family
affected with this disease whose patents were free from dis-
ordersof the nervous system and of speech.—Dr. Handfield
Jones commented on increased knee-jerk in hysteria,-—Mr.
Keetlky showed a case of inbra-articular exostosis of the
knee, which latter he had removed as a loose body by
operation.—Mr. Power and Mr. Roughton considered the
structure removed more of the nature of an osteo-phytic
growth from rheumatoid arthritis than of a true exostosis.-
Dr. Maguire trought forward, according to promise, a
youth suffering from functional nervous disease, whom he
had shown at the Society one year previously, and whose
condition was then fully recorded. Time had not cleared
up much that was obscure in the case. The President, Dr.
Ewart, and Dr. Cleveland made some remarks.—Dr.
;;^t.Cooo|e
O
992 The Lancet,]
ROYAL ACADEMY OF MEDICINE IN IRELAND.
[May 2,1891.
Phillips showed a case of congenital atalectasis of long
with displaced heart, which excited much interest.—The
President and Dr. Ewart spoke.
ROYAL ACADEMY OP MEDICINE IN IRELAND.
A MEETING of the Section of Medicine was held on
March 6th.
The Diagnostic Significance of Venous Hum in the NeeJe:
a Study in Statistics. —Dr. Bewley read a paper on this
subject. He said he had been induced to collect statistics
bearing on it by reading a paper by Dr. R. Apetz, “On the
Significance of Venous Humming Murmurs for the Diagnosis
of Amemic Conditions,” in Virchow's Archiv, vol. evii. He
called attention to the difTerences oi opinion held on this
subject—some writers attributing considerable diagnostic
importance to the presence of a murmur, others believing
the phenomenon to be oneof no importance. Dr. Bewley then
related the details of his investigation. He examined only
healthy individuals between the ages of sixteen and twenty-
six, age having an important influence on the produc¬
tion of these murmurs. All the cases were examined
either sitting or standing. He divided his cases into three
classes: 1. Anremic. 2. Slightly or doubtfully anieraic—
i.e., cases which presented no appearance of amemia, but
yet suffered from some of the symptoms of this condition,
or vice versd. 3- Not anmmic. He examined in all 51
young men and 149 young women. Of these, 22 belonged
to the ametnic class, 31 to slightly anmmic, and 147 to the
non-ancemic. In22 anmmic there were 19 murmurs,= 86'4
per cent. In 31 slightly anmmic there were 27 murmurs,
= 87T per cent. In 147 non-anmmic there were 85 murmurs,
= 57'9 per cent. Dividing the non-anjemics into male
and female—in 104 females there were 64 murmurs, = 6T5
per cent.; in 43 males there were 21 murmurs, = 48 8 per
cent. The conclusions Dr. Bewley drew from these
statistics were the following: I. Murmurs are more
common in the anajmic than ]n the non-ancemic. 2. More
than half of those young persons who are not anreniic
have a venous hum in the neck. 3. The presence
of a hum is not of any diagnostic importance in any
individual case. The loudness of murmurs is not a matter
of much diagnostic importance. In his cases Dr. Bewley
noticed 15 very loud murmurs, distributed as follows: in
22 aniemie, 3 loud murmurs, = 13-6 percent.; in 31 slightly
amemic, 5 loud murmurs, = IGT per cent.; in 147 non-
antemic, 7 loud murmurs, = 4‘8 per cent. He had noted
some of the loudest murmurs in particularly rosy and full-
blooded persons, and therefore did not attribute any dia¬
gnostic value to even the loudest murmur. He added that
Dr. Apetz’s conclusions, based on very elaborate statistics,
were almost identical with his own.—Dr. Wallace Beatty
remarked that be had, in some cases, heard cervical venous
murmurs in patients who certainly did not appear anmtnic.
Still he thought that the presence of this murmur might
be a help in treatment. lu one patient under his care, who
suffered from persistent headache for months, and who had
not an anasmic appearance or symptoms, the discovery of an
anemic murmur led to treatment by administration of iron,
which brought about a rapid cure, a great number of other
remedies having been previously tried in vain.—Dr. Walter
Smith expressed his general concurrence with the views
put forward by Dr. Bewley. Admitting as a fact that over
50 per cent, of non anmmic subjects present venous hum in
the neck, still we have to deal with the occurrence of
venous hum in over four-fifths of undoubtedly anmmic
cases. Hence we should look for an explanation of this
eoincidence in the mode of causation of these murmurs, and
the present theories as to the production of these pheno¬
mena could scarcely be regarded as satisfactory.—Mr.
Patteson remarked that his expfiience corroborated that
of Dr. Bewley. From the observation of a large number of
patients in a general out-patient department, he had long
ceased to attach importance to the presence or absence of a
venous hum from a diagnostic standpoint in anmmic cases. —
The President concurred in the view expressed as to the real
basis for coming to a conclusion being the physical conditions
which produce such murmur, and until these were settled
its variation must be a matter of theory. He celled atten¬
tion to the existence of venous murmurs under the first
bone of the sternum, which by position was removed from
the fallacies of extraneous influences. They were very much
more rare in this situation than in the neck, and were, as
far as be could depend upon his memory, invariably asso¬
ciated with some of the graver and more pronounced forms
of anjomia.—Dr. Bewley, in reply, stated that be had pur¬
posely not entered on the discussion of the causation of
venous murmurs, because he did not think these murmurs
could be satisfactorily explained.
A Case of Myelogenous Lcucocythwmia. —Dr. WALLACE
Beatty reported a case of myelogenous leucocythremia,
which had been under his care in the Adelaide Hospital in
September, 1890. The patient, an unmarried woman,
dressmaker by occupation, had been in ill-health for about
three months. Seventeen days before she came into
hospital she was attacked with erythema nodosum in her
legs. On admission to hospital she was very anmmic;
cardiac and cervical venous anrumic murmurs were present;
the sternum was exquisitely tender. Dr. Bewley examined
her blood ; he found the white corpuscles greatly inci-ea-sed
in number, the proportion of white to red being 1 to 5. The
red corpuscles were diminished in number, being one million
to a cubic millimetre. There was no enlargement of the
lymphatic glands, and the spleen could not be felt. Dr.
Bewley made the post-mortem examination. The spleen
weighed lOoz. Under the microscope it was normal,
except that there was evidence of increased hcemolysia in
sections stained with ferrocyanide of potassium and hydro¬
chloric acid. There was no enlargement of the lymphatic
glands. The marrow of the femur was red and fairly
firm, not fatty. Under the microscope were found
numbers of mononucleated white corpuscles, large and
small red corpuscles (some normal, some irregular in
shape), a few nucleated, spindle-shaped, connective-
tissue cells, and a few oil drops. The liver was enlarged.
On microscopic examination the liver cells were found atro-
hied in places, and there was a large number of leucocytes
etween the liver cells. There was no evidence of iron in
the liver.—Dr. Graves asked what kind were the white
cells found in the blood; also whether the red cells were
altered in appearance. Dr. Jakach states that it is pro¬
bable that no case of pure myelogenic leucocytbfcmia has yet
been recorded, and he mentions that one case which he saw,
in which there were changes found in the medulla of the
long bones similar to those mentioned by Newman, there
was disease of the kidnejs. In Dr. Beatty’s case there
was disease of the kidneys also.—Dr. Wallace Beatty,
in reply, said, except that there was a great increase in the
white corpuscles and a diminution in the red, there was
nothing unsual observed by examination of the blood. The
cloudy swelling of the renal epithelium he considered
accounted for by the fever which was present.
ftfltias of
Aphorisms in Applied Anatomy arid Operative Surgery.
By Thomas Cooke, F.11.C.S. London and New York :
Longmans, Green, and Co.—In the preface to this little work
we find it stated that it is intended as little more than a
syllabus of the work done in the author’s courses of
operative surgery, preceded by a few notes on the leading
points in applied anatomy and surface marking. When
the book is used in this manner, as an aid to the memory
of work done in some class, instead of note-taking by the
student himself, it will answer a useful purpose. The book is
divided into three parts :—1. “Surface marking,” intended
to be read, and its statements verified on the living sub¬
ject. To this part are also added some tablets on the
surgical anatomy of inguinal hernia, Scarpa’s triangle, the
ischio-rectal region,*and the male perineum. 2. “Operative
surgery.” “Only those operations are referred towhichithas
been considered most advantageous for the average student
to perform, and these are outlined only, and mainly from the
cadaveric, as opposed to the practical surgical, standpoint.”
Hence, we do not find many important operations mentioned.
3. Comprises a series of 100 “typical vivd-voce questions.”
These will prove of use to the diligent student who takes
trouble to work them out, for they are frequently asked at
examinations, being of considerable practical importance.
Id a work which is admittedly compressed as much as pcs-
sible, it is surely unnecessary to say of the external condyle
of thehumeruB thatit is less prominent than the internal and
Coogle
The Lancet,]
NOTICES OF BOOKS.
[May 2, 1891. 993
situated a little lower, when the preceding sentence informs
the reader that the internal condj'le is more prominent than
the external, and situated a little higher. To speak of
“Bryant’s test” as a comparison of the vertical distance be-
tweenthe anteriorsuperioriliacspineand the great trochanter
on the two sides does not convey much idea of Bryant’s ilio¬
femoral triangle to the student. In one or tM’o other parts
clearness of expression is sacrificed to brevity. In excision
of the hip no mention is made of the anterior incision, the
one which is much more frequently used than the external;
whilst of amputations at the knee reference is made but to
the methods of Carden and Gritti. In the next edition we
shall hope to see depicted (or described) the lines of the
important nerves, as well as the landmarks in the various
tenotomies and osteotomies which are performed, which
are not easily remembered by the student, though some¬
times asked by the examiner. As an appendix to the
aphorisms in applied anatomy and operative surgery, the
author has brought out a small volume of seventy to
eighty pages on Surgical Descriptive Anatomy, which many
will find of considerable use when working for examinations.
Are the Effects of Use and Dmise Inherited? An Exami- ''
nation of the View held by Spencer and Darwin By
Wm. Platt Ball. London; Macmillan and Co. Nature
Series. Pp. 156.—This work is a critical examination of the
arguments for and against the dictum of Herbert Spencer
that the effects of use and disuse are inherited in kind,
and of that of Darwin, that use in our domestic animals
has strengthened and enlarged certain parts and disuse
diminished them, and that such modifications are inherited;
and the author has brought together a very well selected, as
well as very numerous, series of cases which tell against the
hypothesis. He endeavours to show that the instances on
which Spencer and Darwin rely may be, and probably are, the
result of other causes than use or disuse—such, for example,
as sexual selection. Mr. Ball discusses many interesting
points, such as the inferiority of the senses in Europeans,
short-sight in watchmakers and engravers, the large hands
of the children of labourer’s, and the thickened soles of
infants. lie thinks that use-inheritance is normally so
weak that it appears to be quite helpless when opposed
to any other factor of evolution, and he points out that
natural selection develops seldom-used horns or natural
armour just as readily as constantly-used hoofs or teeth. Use-
inheritance therefore seems to be unnecessary, as its opposi¬
tion is ineffective. But one of his strongest arguments is the
almost universal non-inheritance of mutilations, which leads
the author to speak of the true relation of parents and off¬
spring. The parent he considers to be only the trans¬
mitters of types of which they and their offspring are alike
more or less moulded resultants. A parent, he says, is a
trustee. “ He transmits, not himself and his own modifica¬
tions, but the stock, the type, the representative elements
of which he is a product and a custodian in one.” Weiss-
man ingeniously likens a parent and child to successive off¬
shoots thrown up by a long underground root or sucker, and
it is intelligible that, if the bestgemmules are used up in the
development of an individual, weaker gemmules are left to
continue the race, and deterioration consequently ensues.
Mr. Ball’s work, though short, is interestingly and thought¬
fully written.
Lcf^ons de Clinviue M6dicalc faites d VH6pital Saint Eloi
de Montpellier. Par le Dr. J. Gras.set. Montpellier:
Camille Carlet. Paris: G. Masson. 1891.—The Univer¬
sity of Montpellier is of ancient repute. At one time the
medical doctrines enianabing from its professors exerted no
small influence upon prevailing opinion; and although in
comparison with other and newer centres of learning
Montpellier may not have quite its former prominence, it
yet contains within it several men well qualified to sustain
its old position. Among them may be reckoned Dr. (1 rasset,
who is well known as an original and thoughtful ob¬
server. This volume of clinical lectures abounds in
interest for the scientific physician. In the opening
lecture on Pneumonic Pyrexise the author claims for
the Montpellier school the credit of having always
contended that pneumonia should he more correctly
regarded as a specific fever than as a mere inflam¬
mation of- the lungs. On the other hand, he en¬
deavours to show that there are varieties of pneumonia
depending upon malaria, typhoid fever, and other in¬
fluences, and he enters fully into the discussion of these
types. Several lectures deal with subjects in connexion
with disease of the nervous system. There is, for instance,
a very thorough study of hystero-traumatism, in which the
special features of this class are clearly pointed out. A
case of male hysteria, with astasia-ataxia—a peculiar
oscillating gait, increased by effort, in which the heel is
brought down forcibly to the ground—is very completely
analysed. The differences from tabes, disseminated sclerosis,
paralysis agitans, myoclonus, Thomsen s disease, and other
conditions are all in turn discussed. Astasia-abasia
(i.e., inability to maintain erect position or direct move¬
ments in walking) was first described by Blocq in 1888, and
three types are distinguished—one characterised by mus¬
cular weakness, another by incoordination, and a third by
rhythmical movements. Hypnotism and many other cases
illustrative of hysterical neuroses are also treated in these
lectures. The volume includes, further, an account of
“la Grippe” of 1889-90, and the meuroir on Cardio-vascular
Vertigo, by which Dr Grasset quite recently added to our
knowledge of the results of arterial sclerosis. In addition
to these lectures and essays, there are several clinical
records of cases mostly of nervous disease, the whole
forming a volume which may be perused with much profit.
Air Analysis. A Practical Treatise on the Examination
of Air, with an Appendix on IlluminatiDg Gas. By
J. Alfred Wanklyn and W. J. Cooper. London : Kegan
Paul, Trench, Triibner, and Co., Limited. 1890.—This
book will be useful to those who would wish to make a rapid
and at the same time fairly accurate analysis of air or other
gases. Nothing could be simpler than the methods of gas
analysis which are described. The apparatus, too, is of the
simplest kind, consisting merely of a eudiometer, pressure
tube, and an absorption pipette. There are many forms of
simple eudioiuetric apparatus in use, but perhaps Hempel’s,
which is advocated here, is the most convenient. Instruc¬
tions are laid down for the analysis of respired air, air from
furnaces (containing carbon monoxide), and illuminating
gas. For the estimation of small quantities of carbon
monoxide the authors give an original process. They
pass a large volume of air through subohloride of copper,
after which the copper solution is placed in a suitable
apparatus and acid bichromats added. The monoxide is
thus expelled, and may then be collected and measured-
The historically interesting method adopted by Priestley and
Cavendish for determining the proportion of oxygen in the
air has been revived, and, in the authors’ hands, gives very
satisfactory results. It will be remembered that in the
classical experiments of Priestley and Cavendish nitric oxide
(NO) was used to combine with the oxygen of the air.
Nitric peroxide (NO^) was then formed and absorbed by
alkali, or, as the authors prefer, by water.
Atti della R. Accademia dei Fisiocritici di Siena. Ser. IV.
Vol. 11. h’dscicoli 3-1 e 5-6. Siena: 1890.—The first of
these parts contains an article by G. F. Novaro, on the
Surgery of the Stomach, and a very good meiuoirby L. Guaita
entitled Anatomical and Clinical Investigation on the
I Exenteration of the Eye. The second part contains the
following memoirs: Grimaldi Siro, on Diamylphenyl-
hydrate; Staderini liutilio, on Anatomical Observations;
Viti Arnaldo, on Endocarditis according to Modern Microbic
Theories; and lastly, Orecchia Carlo, on So-called Albu¬
minous Periostitis.
Digitized by
994 Thb Lahcet,]
THE FIVE YEARS’ CURRICULUM.
[May 2,1891.
THE LAJSCET.
LONDON: SATURDAY, MAY S, 1891.
The consideration of the three proposed schemes of the
Committee of Management of the combined Examining
Board in England, which was intended to be brought
before the Comitia of the Royal College of Physicians on
the 30bh ult., was postponed until their next meeting.
As we showed lost week, the schemes differ very much
from one another and from the suggestions of the
speakers in the debate at the meeting of the General
Medical Council, at which a five years’ curriculum for
future medical students was decided on. As the lengthened
curriculum will noUinterfere with those students who are
educated at the different universities, but only with
those who are candidates for the diplomas of the
various medical corporations empowered to grant licences
to practise, it would have been well if the conditions of
study for the two classes of candidates had been approxi¬
mated as closely as was pcsslble. The time spent in a
medical education and the expenses will now be as great in
the one case as in the other; and as almost everyone is in
agreement that the Univerdty system is the better, the
nearer the other boards can assimilate their course to that
system the better educated will the future practitioner be
generally, scientifically, and clinically. The first reform
should be in the Preliminary Examination. A certificate of
the College of Preceptors in the second division, in which the
subjects of an inferior schoolboy’s education can be passed
piecemeal, should not be accepted by the General Medical
Council, and many other preliminary examinations which
allow a student to be registered are not one wbib better
than the one mentioned. The General Medical Council
should raise the standard of entry into the profession.
An ill-educated student cannot intelligently approach the
study of the sciences which he afterwards has to learn, or
understand the language in which those sciences must be
taught; and it is such medical students who bring discredit
on the teachers, are rejected again and again by the
examiners in science and in medicine, and, if they subse¬
quently contrive to become qualified, appear to an educated
public as the blots on a learned profession. Mechanics, as
not being generally taught in schools, should be placed
with the preliminary sciences. A year should he devoted
to these subjects, and until an examination has been passed
therein a student should not be permitted to enter on his
medical career. If he cannot pass an examination in
elementary physics, mechanics, chemistry, and biology, he
should be definitely stopped, and this would be at a period
of his life when he might readily change his plans, and
before his parents or guardians had expended a large sum
on his professional education, and thereby be tempted to
urge him to continue in a career for which he is evi¬
dently unfitted. Elementary human anatomy and phar¬
macy have no proper place as subjects for a first exa¬
mination in a well-drawn scheme. Indeed, we would
ask bow a proper knowledge of “pharmacy” is to be
tested except by the Pharmaceutical Society or by a
practising druggist. Therapeutics and the actions and
doses of remedies, and the manner of their prescription and
combination, can only be among the later acquirements; and
surely the mere dispensing of prescriptions cannot he meant
under the term “pharmacy.” If so, it is extremely un¬
fortunate that this should have to be passed at the
same time as the elementary sciences. The second
examination should consist of anatomy and physiology, and
the candidate could fairly be expected to have obtained a
sufficient knowledge of these important subjects in a year
and a half—that is, after devoting two winter sessions and
one summer session to their study. The remainder of tlie
curriculum should he entirely given up to the various
subjects included under systematic and clinical medicine,
surgery, and midwifery; and as these subjects are those
with which he will be concerned on entering practice,
and which he must pursue for the whole of his pro¬
fessional career, they should be taken together at the
end of his student life. No final examination is fair
which does nob permit an industrious and intelligent
student to pass in these three subjects—in their prin¬
ciples and their practice—at the same time; and one
of the most baneful tendencies of the modern examina¬
tion system is to encourage the candidate to study
these all-important branches of medicine separately, and
to pass in them one by one. The examination in
each is rendered unnecessarily detailed and severe, and
the student finds coaching and cramming surer passports
into the profession than a good all-round professional
education. During this late period attendance at lectures
on therapeutics and public health should be insisted
on, and there should be a sufficient guarantee that the
candidate is familiar with ophthalmic and aural surgery,
with febrile diseases, and the distinctive features of psycho¬
logical medicine. A separate paper on the principles of
public health, general pathology, and therapeutics is abso¬
lutely essential. The great difficulty is that examinations
for medical diplomas are not thorough ; if the authorities of
hospitals object to their institutions being used for the
systematic clinical examination of candidates, there is no
sufficient reason why the workhouse infirmaries should not be
utilised for this purpose. For the education of the future prac¬
titioner acute diseases and injuries are as requisite as chronic
cases, and all examinations wherein he is nob brought face to
face with both classes of cases are unjust to the public and
unfair to the candidate. There are many details, to which
we may subsequently refer, but it is very important that
the general principles on which the education of a well-
instructed medical practitioner must rest should be clearly
stated at the present time, when the greatest change, since
the abolition of the apprenticeship system, is being intro¬
duced into our educational curriculum, A scheme of yearly
examinations, such as is proposed by Mr. Hutchinson,
would, considering the varying powers of students, be too
rigid to be workable, for hardly any number of students,
beingat differentstages of their examinations, would be avail¬
able to attend at tlm same time a given course of lectures.
A REPORT which has been submitted to the Local
Government Board by Dr. BlaxaRL, upon the sani¬
tary condition and administration of the rural sanitary
Digitized by
Google
Thb Lancet,}
LONDON WATER AND STAINES CESSPOOLS.
tMAY2,18B1. 995
dletricb of Staines,^ deals, as a matter of fact, inci-
deotally with a question of first importance to consumers
of water derived from the River Thames ; and, having
regard to the Parliamentary inquiry into this subject which
is now in progress, the report could hardly have been issued
at a more opportune moment. It is with reference to this
aspect of the question that we especially draw attention to
the subject.
The subsoil of the district is gravel, and this special
soil, upon which people are so apt to pride themselves, has
been so treated from time immemorial that, as in number¬
less other places having similar geological features, the
gravel has become a leading source of danger. In short,
it is in many portions of this district permeated with
cesspools which have for generations received the liquid
filth of the population ; some few of these cesspools
are shallow and open, bub they are mostly covered
in and sunk some feet into the soil, thus facilitating
storage of excreta, and admitting of fhe oozing away of
their contents. And it is reported that, notwithstanding'
the obvious risks likely to ensue on such practice, the
authority have been content to allow old cesspit-privies to
continue in use regardless of the attendant evils of filth-
pollution of earth, air, and water. The pollution of the
air, with its attendant evi) smells, the rooms of houses
“stinking with privy ellluvia,” the resulting "nausea,
sore-throats, and the like,” we must for the present leave
as a matter of local consideration. But as regards pollu¬
tion of water and fouling of the earth, in so far as this
latter hears upon water, there is a much wider interest to
be consulted.
Considering first the mere local effects of this cesspit
system on earth and water, we find that cesspools, privy-
pits, and wells are sunk in the common gravel within a few
feet or yards of each other; that as the water rises and falls
in the subsoil, so does the Staines liquid filth rise and fall
in these receptacles ; that when the subsoil water is low,
soakage of filth into the gravel bed takes place readily, and
when the water rises, this stuff is washed on into wells and
elsewhere. The natural result is, as the medical officer of
health has reported, that well water becomes so impure as
to be unfit for drinking and domestic purposes. One of the
remedies locally relied on seems to be to clean out the wells;
but the Staines people must be easily satisfied if such a
practice contents them, whilst the fouling of the sources of
the water—i.e., of the gravel bed—continues as before.
Here again, however, we leave such considerations to those
who have the responsibility of electing a local authority
to look after their sanitary interests.
But, adds Dr. Blaxall, " the general filthiness of soil
and water in the Staines rural district is probably a matter
of more than local concern.” The water which courses
through this gravel bed, and into which are washed the
contents of "several thousand cesspools purposely dug
into it ” for local convenience, passes after such befoul-
ment, directly or indirectly, into the Thames; the main
flow of the subsoil water through the gravel bed in its ten
miles passage tlirough this district being apparently from
* Byre A Sipofctlswoode, Bust Harding-streefc, Lomlon, E.C.; .Tohii
Monzies & Co.,Edinburgh and Glasgow; Hodges, Figgis, & Co.,Dublin.
Frico 2i{,
west to east, and its discharge being mmnly into the lower
portion of the boundary river, in the neighbourhood of
Sunhury. And this aspect of affairs assumes the importance
of a metropolitan question, for at a short distance below
this very neighbourhood, on the southern bank of the
river, “ are situated the pumping stations of certain great
London water companies.” Dr. Blaxall does not pro¬
fess to'measuro the amount of impurity which actually
reaches the river from this gravel bed and its cesspits,
neither does he attempt to discuss the question as to
what depuration may possibly go on as the water flows
through the gravel. But he does take occasion to utter
a warning as to the risk of enteric fever, a disease known
to disseminate itself essentially through the medium of
water-supplies. It is abundantly clear that the water, as
drawn from the Staines gravel bed, is capable of conveying
and communicating the infection of that disease, and, judging
by the death-rate, it seems that the Staines rural district
has had some 500 attacks of enteric fever during the past
seven years. But at this special moment we would leave it
to the experts who will be called before the Parliamentary
Committee on the London water-supply to deal with the
question of risk to metropolitan water consumers, merely
recording the fact that we have often adverted to the
danger of drawing water-supplies from streams which are
liable to receive a specific contagium which is undiscoverable
by any known processes of chemical analyses, whilst we
have urged that its importance should not be underrated
by reason of proof of its effect being often obscured owing to
the chances of escape from its influence which result from
the wide diffusion of a particulate material through large
bodies of water.
The foundations of our knowledge of the physiology
of ga'stric digestion were undoubtedly laid by the care¬
ful study of the historical case of gastric fistula by Dr.
Beaumont— the case of Alexis St. Martin. Animal
experimentation and the test-tube reactions of the labora¬
tory cannot be compared in accuracy to observations made
directly upon the living human organism, when these rare
opportunities arise which permit of such a study. Then,
too, it may happen that a considerable rectification of
current physiological doctrine has to be made, and the
laboriously gathered results of many observers have to be
replaced by those made upon a single ease. Much depends,
then, upon the skill and choroughneas with which the study
of the processes in the human subject are undertaken. It
must be admitted that these qualities are conspicuous iu the
recently published records of a study of the chemical processes
of the small intestine by Drs. MacFadybn, Nbncki, and
SiEDER.^ The subject of their researches was a female
patient under the care of Professor Kocher, in whom an intes¬
tinal fistula had resulted from excision of a portion of gan¬
grenous intestine due to strangulated hernia. The false anus
was situated in the ileum just above the ileo-cmcal valve, so
that the materials escaping thereby were wholly composed
of the chyme which had passed through the whole length
of the small intestine. For a period of nearly six months
the woman lived under these conditions, permitting of a
I Ai'cliiv £, Exp. Path, u. PbarmacoloRie, Bd. xxvifi., Hft, 8 , 4 .
Digitized by Google
996 Thb Lanobt,] physiology OF THE SMALL INTESTINE.-SELF-INDULGENCE. [May 2,1891.
loQg series of observations relative to the time and character
of intestinal digestion under varying forms of diet &c.
At the’ end of that time Professor Kocher re-established
the natural channel by means of an operation which
proved perfectly successful. It may be remarked at once
that during the whole period when there was practically
no large intestine the patient gained in weight, and, as
the urinary analysis showed, eliminated a fairly normal
quantity of urea.
The procedure consisted in adapting a flexible tube to
the fistulous outlet, so as to collect all the material that
escaped, and to note its characters under varying circum¬
stances. In consistency this “chyme”—if it may be so
termed—was more fluid and diarrhcoal when the diet was
albuminous than when it was mainly of a vegetable
nature. It was seen that the flow of chyme from the
small into the large intestine is steadily continuous, being
least marked during the night, owing to no food being
then taken; and by some ingenious experiments (e.g., the
addition of hard beans to the food, or of salol, which
allowed of the detection of salicylic acid in the matters
escaping) it was shown that the passage of foods from
mouth to cmcum occupies at the least two hours; but all
traces of the substances introduced did not disappear for
from nine to fourteen or even twenty-three hours. The
rate of flow, of course, bears much relation to the con¬
sistency of the intestinal contents. As regards the nature
and properties of the evacuated materials, it is noticeable
that they were almost free from odour, containing hardly
any products of albuminous disintegration, such as indol
and sulphuretted hydrogen ; they were slightly acid in
reaction, tinged yellow by bilirubin, and, according to the
predominance of flesh or starchy matter in the food,
showed muscle fibre, albuminous granules, vegetable
fibres, starch granules, &c., and invariably a large number
of various forms of bacteria. The filtrate yielded albu¬
men, mucin, peptone, dextrose, the two forms of lactic
acid, acetic acid, and the biliary acids and bilirubin. The
authors enter very fully into the characters of the
bacteria they find, many forms being special to the small
intestine, others existing also in the mouth; but, passing
over these, which would entail a full description to be in¬
telligible, we may glance at the main results of their
researches, which somewhat modify accepted physiological
teachings. One point of interest is the fact that albumen
is hardly, if at all, decomposed in the small intestine. Even
the action of the trypsin of the pancreatic juice is small,
for leucin and tyrosin were not to be found. Probably,
in health, albuminous disintegration takes place chiefly in
the large intestine, and it is only in disease that it occurs
in the stomach or small intestine. Amongst the products
of such decomposition are iodol, skatol, phenol, sulphuretted
hydrogen, carbonic acid, methylmercaptan, &c., all of which
maybe regainedfrom the large intestine. The bacteria of the
small intestine are concerned in the disintegration of the
carbo-hydrates into lactic, acetic, and ^uccinic acids,
and also into ethylic alcohol. The authors, in noting this
last-named fact, cannot avoid a thrust at the total ab¬
stainers. It is generally believed that the chyme is rendered
alkaline by the secretion of the small intestine, but they
find that, owing piol^ably to the reinforcement of gastric
acidity by the organic acids resulting from sugar, the total
quantity of acid is more than can he neutralised by the bile,
pancreatic, and intestinal juices. If, however, the alkalinity
of these fluids be diminished, the intestinal contents are
hyper-acid, and mucin is precipitated instead of being inter¬
mingled with the chyme. This explained the diarrhmal
quality of the evacuations noted to he associated with a
large amount of sugar and organic acids in the chyme. On
the other hand, an excess of alkalinity favours putrefactive
decotuposition, the acids apparently holding in check
the bacteria concerned in albuminous disintegration. A
marked contrast in this respect was exhibited between the
small and large intestine. Putrefactive bacteria could
hardly be at all isolated from the former, whilst they
abounded in the latter; hut this is not owing to the influ¬
ence of bile, which Nencki showed to have no real anti¬
septic property. The part played by bacteria in intestinal
digestion is limited probably to the fermeutation of sugar
and carbo-hydrates generally, the excess of acid resulting
from this fermentation being neutralised by the alkaline
intestinal juice. Put, much as bacterial life abounds in the
intestinal canals, varying according to the kind and
quality of the ingeata, it does not appear that the pro¬
cesses initiated by these organisms are of such value or im¬
portance in nutrition as the chemical ferments. Certainly
the patient who was the subject of these observations gained
in flesh, although for six months she was deprived of all
the bacterial processes that go on in the large intestine.
What with the recent debate upon opium, the letters
upon ether drinking in Ireland, the investigations of the
Select Committee on Pritisb and Foreign Spirits, and the
serious and elaborate, though probably fallacious, calcula¬
tions of the number of pipes smoked in excess of previous
years, attention is at the present time being very
vigorously directed to the increase in the forms, and
possibly also in the amount, of self-indulgence. The habit
of self-indulgence is deemed to be detrimental to the
individual, and therefore to the State; and it is being
pursued and exposed to abuse, to censure, and, if
practicable, to legislation. The instinct is more wide¬
spread than the above enumeration indicates. Most new
remedies pass through a perilous stage in which their capa¬
bilities of furnishing new forms of self-indulgence are tested;
the sway of opium and morphine, although they cannot
yet be said to have had their day, has been successively
threatened by chloral, by cocaine, by antipyrin, and more
recently by the newer. hypnotics. Many regard with
anxiety the consumption of absinthe in France, of ether in
certain parts of Ireland, of opium in China and Burmah,
and of alcohol in parts of the globe too universal to
specify; if some of the substances mentioned create less
alarm it is probable that the cause is to be sought in the
relative infrequency and secrecy of their employment.
A correspondent from Bombay wishes us to invite a
general discussion from medical experts as to the “ proper
scope of the medicinal value of alcohol,” and be formulates
a series of questions for consideration. Many of these ques¬
tions, if devoid of any particular novelty, are sufficiently
suggestive. Thus, for example, no medlcerl man would feel
Digitized by Google
The Lancet,]
AN apology por Hospital A^tfsfis.
[MAY 2,1891. 997
any difficulty in answering the following: “ Is it advisable
to recommend the use of alcohol without restriction, or is
it necessary to restrict its use like that of other medicinal
agents, boldly prohibiting it in certain cases, and giving
clear directions as to dose and mode of administration ?”
But the writer’s probable views may be gathered from
the wording of another question: “Is the regular daily use
of alcohol, in doses generally supposed to be moderate,
beneficial or baneful upon tho whole ? ” And in bis final
question be leaves no shadow of doubt about the matter:
“ Are not the doctors who unnecessarily and unreservedly
recommend moderate drinking morally responsible for the
ultimate outcome of such recommendation, since they are
expected to know something about the frailties of human
nature on the one hand and the charms of alcohol on the
other ? ” This indeed lays a heavy charge at our doors, but
the subject is scarcely so simple as it would appear. The
reference to the frailties of human nature and to the charms
of alcohol is not convincing, and the question of self-
indulgence in any form must be argued equally with that
of alcoholism. Granted that of all forms of preventable
disease none are so sad as those which result from self-
indulgence, yet it must equally be granted that the down¬
ward progress is gradual, and that it must have had a
definite starting point. This our correspondent would, in
many cases, assign to some careless medical advice, but this
is certainly not true for the vast majority. The relief of
pain, physical or mental, has often been urged as the deter¬
mining cause, but this is the extenuating circumstance
put forward as an excuse by the habitual drunkard; surely
during the time that the seeds of the habit of self-indulgence
are sown, during the youth of the individual, he is rarely
so sadly situated with regard to pain, physical or
mental. The gratification of the sense of taste is still
more fallacious during the early stages. The taste
may be acquired and cultivated, but probably the start¬
ing point for nearly all forms of self-indulgence is
a spirit of bravado. The process by which the taste is
acquired is frequently painful, as witness the common ex¬
perience with tobacco, or the effect of the first mouthful of
raw spirit; still from a desire for emancipation these dis¬
comforts are braved, often in spite of warnings of the
dangers of thraldom, but with youthful trust in strength of
will to resist. Most forms of self-indulgence involve ques¬
tions of habit, of lack of self-control fostered by habit, of
example of an undesirable nature, and often too they
appear largely to be the result of simple drifting from care¬
lessness. Charity looks for reason or explanation in vain;
the truth is that the tendency to self-indulgence, regard¬
less of consequences, is one of the weaknesses inseparable
from humanity.
Recognising this tendency as one of the frailties of human
nature, is the attitude of the medical profession towards
forms of self-indulgence at all ambiguous ? In spite of all
denunciations of the excessive use of alcohol and of the
misuse of drugs, grave accusations are still made, which
we are invited to discuss. All broad charges require
to be reduced to specific issues before they can be met
with any chance of success. To accuse the medical
profession of favouring habits of intemperance, directly
or indirectly, is too serious ^ matter to be lightly dis¬
regarded. Perhaps occasionally, rarely, a hurried and
misunderstood piece of advice may be alleged to have
led to habits of intemperance, but on inquiry the truth
usually appears to be that the individual sufferer possesses
an unenviable personal or inherited alcoholic history. On
the other hand, there can be very little doubt that the
members of the medical profession incur great responsi¬
bility for many of the forms of self-indulgence characterised
by the perverted employment of drugs, and it is difficult to
see how tliis responsibility is to be avoided under the
present conditions of practice and of public interest in
medical matters. The general practitioner who dispenses
his own medicines sends a sleeping draught, and declares or
conceals its active ingredient according to his knowledge of
the patient; but when a prescription is given, especially
when given by a consultant, with little probability of
being able to follow out its subsequent history, the remedy
is in the hand of the patient to use or abuse at pleasure.
' Dr. Steele, who is well acquainted with the problems of
hospital administration and their relation to the public
welfare, has recently given his representation of the
subject to the Statistical Society. He is a medical man
with large experience of the subject in one of the largest
hospitals of England, and with a similar experience as to
Scotland, where they manage hospitals, as other things,
a little more economically than we do here. He may
appear to some to be somewhat prejudiced in this matter.
The great hospital which he represents has put on a petty
charge for medicines to out-patients, a course which many
think but little calculated to bring either hospitals or those
who administer them into greater respect. At any rate, if
the people apply the principle of proportion in estimating
the value of medical help, their estimate of the value of
the ordinary practitioner must be lowered. They must be
tempted to say, “If we can get ail the learning and skill of
Guy’s Hospital’s physicians and surgeons for threepence, the
value of our medical neighbour, albeit a man of education
and one who has been well tortured by the examining bodies,
must be something less.” Thu logic is difficult to resist.
Nor will such objectors be much conciliated by Dr. Steele
saying that by this charge they are applying the thin edge
of the wedge of selj'-hclp. The end of the wedge here is
certainly very thin. It would be far better to let the out¬
patients of Guy’s Hospital understand plainly that they are
being served charitably, and that self-help means a very
different thing. Dr. Steele, however, at other parts
of his address sufficiently let the cat out of the bag,
and practically admitted that it was the exigencies of
medical education which necessitated the upholding of
the out-patient system. He did not deny its demoralising
effects on the patients, and he admitted that some means of
repression were necessitated. But he maintained that i1»
educational advantages were such, and that the advantages
to the population of consulting experts were such, that it
could not be seriously curtailed. Mr. Timothy Holmes’s
opinion, that the out-patient department should consist of
serious or difficult cases referred from medical men or pro¬
vident dispensaries, was rejected by the superintendent of
Guy’s Hospital on the grounds we have mentioned. He
Digitized by
Google
M tdfe tiAKOlCT,]
OSOLERA AND TflE RURDWAB EaIR.
[May 2,1891
was eqnallj iagenious in finding reasons for rejecting the
system of the Scotch hospitals in giving advice only and
not medicines to the out-patients.
Dr. Steels seems to find a further argument for the
petty charges at hospitals and dispensaries in the fact that
they yield a total of £47,708, a larger sum than the yield of
the Hospital Sunday Fund. He had a word of praise, too,
for the Metropolitan Hospital, which is the home of a pro¬
vident dispensary at Kingsland, and which competes as a
metropolitan hospital with all the neighbouring practi¬
tioners, though he admitted, what we can scarcely ailect
to regret, that it is not a financial success. He is too
shrewd a man not to have his own doubts whether, apart
from asystemof efficient imiuiry as to fitness, a petty charge
is likely toseriouslyreduce the number of out-patients. He
admits that at Guy’s Hospital it has had, in one sec¬
tion at least, an opposite effect. It would be strange if
it were otherwise. If the leading butchers of the Borough
were to offer their prime cuts at Zd. a pound, after the
manner of Guy’s Hospital threepenny charge, instead of
the ordinary charges which even the working classes pay,
and can pay, for their meat, they would not find the
number of their customers diminish. It is the same with
medicine es with meat. The ordinary practitioner, on
whom the working classes rely in all the great experiences
of life, cannot compete with the consultants of Guy’s Hos¬
pital and their threepenny terms. Dr. Steele did not
attempt to deny that a strict inquiry system had been found
to be practicable and effective at Manchester, and had re¬
duced the unfit cases from 42 per cent, to 7 per cent, of the
applicants. But ho has another theory on which he
justifies the petty charges of his own and other hospitals,
which give the more respectable section of the patients the
comfortable feeling that they are paying for their benefits,
He speaks as if “ the working desses were to be reckoned
among the poor. ” This is not complimentary to the working
olasBes, A respectable working man does not admit this
theory; and, unless we are to demoralise these classes
beyond hope of recovery, we must reject it. The classes
who constitute the great friendly societies are not poor.
They can pay for everything else, save on occasions
of misfortune—for meat, education, tobacco, beer. On
what theory are they to be excused from paying for the
medical attendance required by themselves and their
families? 'Werejectthe theory that “the working classes
are to be considered among the poor.” Many of them are
BO by their own fault. In that case they must be pitied
and treated as such. But it is an insult to the working classes
to say that this is their general position, and to cater for
them as paupers in respect of the supply of their ordinary
medical wants. There remains the other great argu¬
ment advanced—the educational advantages of the out¬
patient department. This argument .cuts two ways, and
comes with doubtful grace from the representative of a
great school which turns out yearly a considerable propor¬
tion of the men qualifying as medical practitioners. It
is a poor compliment to educate men at Guy’s Hospital
and then send them out to find the very hospital that
nurtured them competing with them for cheap practice,
and justifying its competition by the suggestion that the
hulk of the people require the advice of consultants on
pauperising terms. We leave this subject for the present
not without a strong impression that Dr. Steele does not
seriously differ from us on the great moral and professional
questions which are involved in the enormous and morbid
development of the out-patient department. It is obvious
thatmedical students must see practice, but it is monstrous
that this practice should be found for them in arrange¬
ments that degrade the poor and impoverish the profession.
Annotations.
'* Ne quid nlmla."
CHOLERA AND THE HURDWAR FAIR.
An opportune note of warning has been issued by the
Indian Medical Gazette in connexion with this year’s
Hurdwar fair. A fair takes place at Hurdwar every year,
buta peculiar sanctity attaches to theKumbh Mela held there
in the spring of every twelfth year. It was this latter occasion
that was in 1879 associated with a disastrous epidemic of
cholera, and it is this special fair that this year has again
brought with it. The town is hemmed in to the west by the
Sewalik Mountains and the Ganges, and the vast number
of pilgrims attending it have hitherto been in excess of any
arrangements made for the prevention of disease. The
camping-out grounds among the spurs of the neighbouring
hills and the bathing arrangements have been essentially
such as to cause the diffusion of cholera when once it has set
in ; and this has been especially the case as regards the pro¬
cess of ablutions, which involve the casting of ashes and
other offerings into the water, an external washing, and
then a draught of the same filthy fluid to complete the
effectual cleansing from sin. In 1879 the dispersion of the
pilgrims after the occurrence of cholera was followed by a
wide diffusion of the disease in epidemic form; the experi¬
ence of 1867 being largely followed in this respect. There
has been much dispute as to the coirect interpretation of
the facts relating to the coincidence of epidemic cholera
and the Hurdwar fairs; but one thing is certain, that condi¬
tions which favour the diffusion of that disease have hitherto
been intimately associated with these gatherings and their
dispersal, and though it may be impossible to deal with
some of the religious practices that tend to spread disease,
yet much can be done under energetic local supervision to
diminish the risks involved. For some months past certain
preparations have been in progress to this end, and we trust
that they may be successful, both as regards Hurdwar and
in their general inlluenoe on the central and local adminis¬
tration of sanitary law in our Indian empire.
KOCH’S TUBERCULIN.
The literature of Koch’s tuberculin has already attained
considerable proportions, and has received contribu¬
tions from some of tbe most distinguished members of
the profession. Tbiere is a general opinion, however,
among those who heard Mr. Watson Cheyne’s paper at the
meeting of the Medical and Chirurgical Society on Tuesday
last, that it is the most weighty and valuable criticism
of Koch’s method that has yet been made.. Mr. Cheyne
has proved himself superior to the iniluence alike of
the unreasoning furore which immediately followed upon
Koch’s first paper and the reaction which is now so marked.
But starting with a set purpose to investigate the action
and the value of the new remedy, and to devote his
wards entirely to this study, he has prosecuted his work
in a calm, judicial, unprejudiced, and scientific spirit.
His paper does not profess to be a final statement on
Digitized hv
Google
The tANOfiT,]
PROPEKTY IN PRESCRIPTIONS.
[Mays, 1891. 993
the matter, but only a preliminary one baaed on the
results obtained in some lifty-flve cases. So far, however,
Mr. Cheyne has obtained some important results. He has,
he thinks, made a considerable improvement in the method
of using the drug, by which he is able to obtain a maximum
of local effect with a minimum of constitutional disturb¬
ance—a matter of great importance. By his pathological
investigations, which have been carried out alongside of his
clinical studies, he has shown what changes the remedy
produces in the tubercular growth, and these he not
only described but demonstrated by means of micro-photo¬
graphy and a lantern. Of the more important clinical
results obtained we cannot speak in full now, but we may
say that they tend to narrow the limits within which tuber¬
culin is useful in surgical tuberculosis. The whole even¬
ing was occupied hy tlie reading of Mr. Cheyne’s paper, and
the discussion upon it is to be taken at a special meeting of
the Society called for Thursday, May 7th.
PROPERTY IN PRESCRIPTIONS.
An esteemed correspondent, signing himself “ Seuex,”
calls our attention to a matter which he thinks of import¬
ance to the public as well as to the profession. His letter
is too long for insertion, but the gist of it is this. Some
thirty years ago be received from a physician a prescription
of a powder for the- relief of “ rheumatic pains. ” He valued
the medicine so highly that he has never since ceased to
have recourse to it whenever he deemed it necessary; and
on several occasions, notably when leaving for a long
sojourn in India, he obtained copies of the prescription from
the chemist who dispensed it. On his return home a few years
ago he again had the powder dispensed by the same chemist
several times j hut on asking for a copy of the prescription
recently, as he was leaving London, the chemist has declined
to furnish him with one without the prescriber’s sanction,
so long a period having elapsed since it was prescribed. Our
correspondent believes the physician to bo dead, and wishes
to know whether the chemist has any right to refuse him
a copy of what he considers to be his own property.
The question is apparently a simple one, turning solely upon
the proprietary right of the chemist to the copy of a pre¬
scription which he made, not solely as a matter of con¬
venience or for the heneht of his customer, but of his own
will ami with the intent of its becoming part of his stock-
in-trade. We are of opinion that if the chemist takes the
trouble to register the prescriptions sent to him, it is quite
within his right to decline to furnish copies of his entry,
oven at the request of the person for whom the medicine is
prescribed. No chemist is bound to keep such a register
(excepb in the case of prescriptions containing poisons), and
he would always be at liberty to destroy it at any time. No
doubt it is to his advantage to file prescriptions, and no
doubt also he would seldom refuse copies to the patient or
the prescriber aa a matter of courtesy. The physician cer¬
tainly parted with his right in the prescription to the
patient, who, by the way, seems to have had several
opportunities of taking care that a document so valuable
to himself should be preserved. Thus, though we may
sympathise with “ Senex,” we cannot hlamo the chemist
for adhering to the rule of his establishment, which
has a good deal to be said for it, from the point
of view of the patient as well as from that of the
medical man. There are occasions, indeed, when a chemist
would bo fully justified in declining, not only to favnish a
copy of a prescription, but even to dispense it a second time
without a reference to the prescriber. The practice in some
countries for the original prescription to be kept by the
chemist clearly shows that there at least it is recognised
that he who dispenses the medicine has a property in it,
rather than he for whom it is dispensed.
AN ENORMOUS OVARIAN CYST.
There has recently been a patient in the obstetric ward
of St. Thomas’s Hospital, under the care of Dr. Cullingworth,
suffering from an enormous ovarian cyst. She was a widow
aged forty-five, who had bad no children, and who had been
the stewardess on a well-known line of Channel steamers for
many years. The swelling of the abdomen was first
noticed nine years ago; for three years and a half it
had been so large that she had been unable to go
beyond her own garden; for two years she had not left
her room, and for six months she had not been out
of bed. She had persistently refused operation until
recently. After admission on April 9th the abdomen was
found to be urriformly and enormously distended by a
fiuctuating swelling, consisting of one large cyst, distending
the lower part of the thorax, and hanging down, as she satin
bed, as far as the knees, completely concealing the thighs.
The girth l^in. above the umbilicus was 67 in.; the measure¬
ment from the ensiform cartilage to the symphysis
pubis was 38 in. The body was greatly emaciated;
she presented a most remarkable appearance, but
was very cheerful. There was some albuminuria. On
April 13bh, preparatory to operation and in order to
diminish the shock, the abdomen was punctured by a
fine trocar, attached to a long indiarubber tube, with
the lower end placed under a measured quantity of solution
of carbolic acid, and the Iluid from the cyst allowed to flow
away for seven hours. Seventy-four pints of thick
grumoua chocolate-coloured fluid escaped, containing much
altered blood. The day after this an attempt was made,
I under ether, to remove the tumour. The whole of the
anterior surface of the cyst was adherent to the abdominal
wall. There were comparatively few adhesions pos¬
teriorly, bub more in the pelvis. At the end of
half an hour the patient became seriously collapsed,
and the cyst was quickly extracted, lb was a large thick-
walled single cyst of the left ovary. The patient died
before the closure of the abdominal wound had been com¬
pleted, in spite of persistent efforts at resuscitation. The
total weight of the tumour and its contents—including that
of the fluid removed on the previous day—was 164i lb., or
11 st. i Ib. The weight of the patient was nob ascertained,
but njust have been much leas than this. This is probably
the largest abdominal tumour of which there is any record;
the largest mentioned in the aeries of 1000 by Sir Spencer
Wells did nob weigh more than 125 lb.
MORAL OR MORBID?
Happily, in one sense, it is not often that a play is pre¬
sented for public approval dealing almost wholly with an
erratic emotional state of mind akin bo insanity; but this
enjoyment, if enjoyment it be, has been provided with much
earnestness in the performance of Ibsen’s “Hedda Gabler.”
Of late much has been said of Ibsen as a moral teacher, but
the moral of this play is rather hard to find. It is a very
forcible character sketch in which the interest centres
round the heroine, all the others sinking into relative
insignificance, although they are each and all sufli-
cionbly true to life. The play deals with the career of
a young married woman, who from childhood has been
in some respects strange and frightening. At school she
was always, torn by an insane desire to burn the
hair of a younger girl. Later she shows an eagerness to
know tiro dobaila and intricacies of the forma of vice finding
favour with a young literary man, and then, as ib ia
expressed, when he wishes to change the relationship of
comrades, she threatens him with a pistol. Subsequent
events are left a little vague, but she has made a sudden,
I unaccountable mgrriage with a man for whom she has no
Di::' 'edby iOOQIc
lOOO fSB IiANOilT.J
RaILWaV accidents in 189o.
[May % 1891.
affeotdoD, and when the play commences she has just
returned from an inordinately long honeymoon, in which
she has been mortally bored by being everlastingly in the
company of one and the same person. At first the purely
selfish side of her character is displayed. All her plans
appear to be arranged solely for her own gratification, and
the causes of her tnnui and her changeful moods are difficult
to fathom. She is wantonly rude to her husband’s relatives,
and excuses herself because these things come into her
head and she cannot help doing them. She describes herself
as a coward at heart, with a hatred for witnessing disease
and death, and most strongly averse to any form of
open scandal, and little by little the secret of her past
creeps out. The former lover, whose alcoholic habits
had been reformed by a new liaison, is, under Hedda’s
encouragement, induced to lapse into a drunken bout,
in the course of which a valuable manuscript is lost. In
despair he comes to Hedda and announces his intention
of committing suicide, and is then merely told to “do this
gracefully,” and the pistol, that had been presented at him
before, is given him “as a souvenir.” It is needless to
follow the story further. The cause of the trouble is
abundantly evident before the curtain falls. And yet,
after all, the pre-occupation, the childish whims, and the
recklessness are found to be indications of a morbid state
rather than of any mere emotional condition. The heroine’s
actions are not characterised by reason, but by aimless
transitions from one subject to another remotely linked to
it, as in a nightmare. There is a disregard of consequences,
an absolute {esthetic delight in making all go wrong, and in
not realising the final catastrophe which is inevitable when
the results of her actions crowd around her. All this is
essentially morbid, essentially a study of conditions which
are only too familiar to medical observation. To see in
action the previous history, the predisposing causes, and
the symptoms of a simple case may be novel to the public,
but not to the profession. Whether any good can result
from it all is another matter. Although dramatic criticism
is beyond our usual province, a tribute of admiration must
be accorded to the marvellous acting of Miss Elizabeth
Kobbins in the title r6U. This fact remains beyond dispute,
even to those who venture to doubt the healthy influence
of Ibsenism as here represented.
RAILWAY ACCIDENTS IN 1890.
The Board of Trade Returns of Railway Accidonte for
the past year give as usual an account, which is upon the
whole very satisfactory, of the results of railway working
during that period. The number of accidents recorded is
not excessive when regard is had to the immense volume of
the traffic in connexion with which they arise, and what is
no less important than the control of their number is the
miuimising of their severity when they do occur. The
great improvement which has been effected within recent
years in the brake apparatus furnished to trains has
had a marked effect in this direction. By increasing the
control which the officials in charge of a train have over its
movements in a moment of emergency they have diminished
in more than equal proportion the severity of the con¬
sequences of such mishaps as do and must occur. It
appears from the report that even in this direction
something yet remains to be done, for inefl’ocfcive
brakes still constitute an appreciable source of danger
to the traffic. Much mor@ serious, however, than the
danger from failing brakes or other defective parts of
the machinery and plant are the perils incurred by placing
excessive confidence in the presence of mind and diligence
of officials who are often overworked. The forgetfulness of
signalmen figures over and over again in this report as the
primary cause of a disaster, and in one noticeable instance a
collision is referred to the failure of a guard to give to his
engine-driver the assistance in putting on the brake which
the latter was entitled to expect. This failure Is accounted
for on the hypothesis that the guard was at the time asleep
in his van, a circumstance which is rendered the more
probable by the undoubted fact that he had been doing
upwards of twelve hours’ duty. Indeed, although we
find less reference in this than in some previous reports
to the mischief of overworking servants who are charged
with these highly responsible duties, it is abundantly plain
from these pages that the railway companies are still sadly
wanting in the due appreciation of their public and private
duties in respect of the apportioning of work among their
servants, and the maintenance of a sufficient staff to deal
without undue strain with the work that has to be done.
RESEARCH AT THE LABORATORY OF THE
ROYAL COLLEGES,
Erom a report of the Laboratories Committee submitted
to the Colleges of Physicians and Surgeons we learn that
the following are at present working, or have received per¬
mission to work, in the laboratoriesDr. Pavy, F.B.S.,
and Mr. Rowntree, Researches on Glycogen and Sugar;
Mr. D’Arcy Power, Cancer; Mr. C. A. Ballance and Mr.
S. G. Shatfcock, Malignant Tumours; Dr. Howard H.
Tooth, Paths of Sensation in the Brain; Dr. A. W.
Macfarlane, Anresthetics and Hypnotics; Mr. Watson
Cheyne and Mr. Cheatle, Tuberculous Disease; Mr.
Douglas Stanley, Cancer; Dr. M. A. Ruffer, Immunity,
against Infectious Diseases; Dr. James Galloway, Malig¬
nant Diseases affecting the Peritoneum; Dr. A, E. Wright,
Coagulation of the Blood; Mr. R. Cozens Bailey, Surgical
Treatment of Wounds of the Intestine; Dr, Vincent Harris
and Df. W. Gow, the Structure and Function of the Pan¬
creas; Dr. W. P. Herringham and Mr. E. Groves, the
Execration of Uric Acid and Urea; Dr. Sidney Martin,
the Chemical Products of Infective Micro-organisms.
THE VALUATION OF MEAT PEPTONES.
An important discrepancy in the method adopted by
chemists for the analysis of peptones is pointed out by
M. A. Denaeyer in a pamphlet of recent issue. In the well-
known Kdnig process no regard is paid to the determination
of gelatine, whicli it appears is a common constituent of
commercial peptone of meat; and as sulphate of ammonia
is used for the precipitation of albumose (gelatine being pre¬
cipitated by the same reagent), the proportion of albumose-
peptone is exaggerated. If, as the author states, gelatine
enters largely into the composition of many of the prepara¬
tions in commerce, it becomes a matter of fundamental im¬
portance to be able to determine the amount of this body,
inasmuch as it is said to present the nutritive value of
neither the albumens nor their peptones. The process now
published by M. Denaeyer admits of the estimation of all
three bodies—viz., gelatine, albumose, and peptone. The
following is a Hsum& of the method which he adopts. Two
grammes of dry peptone in 10 cubic centimetres of water
are treated with 90 cc. of 90 per cent, alcohol. The alcohol
precipitates the albumose, peptone, and normal jellifiable
gelatine, while it takes up the salts and extractive bases and
allotropic injellifiablc gelatine. The coagulum obtained by
alcohol is then dissolved in hot water, any residue of albu¬
mens which have been rendered permanently insoluble by
the alcohol being filtered off and weighed. To the dissolved
portion, whicli is carefully neutralised, an excess of saturated
solution of bichloride of mercury is added. This reagent
throws down albumose and peptone, the gelatineremainingin
solution. After filtration the clear solution may befreed from
mercury by means of sulphuretted hydrogen. It is then
filtered, and the gelatine, after concentration of the fluid, pre*
DiL, LjOOgIC
The Lancet,]
“ QUARANTINING A HOSPITAL.
[May 2,1891. 1001
oipitated by a saturated solution of ammonium sulphate.
On raising the mixture to boiling, the gelatine firmly
adheres to the sides of the vessel. It may be washed quickly
with cold water and weighed; the weight of the vessel and
the entangled sulphate of ammonium being deducted, the
amount of normal jellifiable gelatine is given. The quantity
of adherent ammonium sulphate is determined by dissolving
the coagulum in warm water and triturating with a standard
solution of barium chloride. The weight of gelatine so ob¬
tained is deducted from the weight of the precipitate given
by adding saturated ammonium sulphate directly (as in the
Konig process) to a fresh solution of the alcohol coagulum.
As ammonium sulphate precipitates both gelatine and
albumose, this last difference gives the albumose. For the
estimation of peptone proper two grammes of peptone, freed
in the same way from insoluble albumens and extractives,
are treated with a solution of acid phosphotungstate of
soda, which precipitates the normal gelatine, the albumose,
and the peptone. The precipitate is collected on a tared
ashless filter, washed well with water containing hydro¬
chloric acid, dried, and weighed. It is then ignited in a
muille until complete incineration is effected. The weight
of the residue and that of the filter are deducted from that of
the dry precipitate. This gives the gelatine, albumose, and
peptone. On deducting the amount of gelatine and albumose
the weight of peptone is gained. The alcohol employed
for the precipitation of the albumens and peptones is
divided into two portions — one in which allotropic
injellifiable gelatine is estimated by evaporating to
dryness, taking up with water and treating with am¬
monium sulphate in the manner already indicated; the
other portion is evaporated, and the residue dried to con¬
stant weight. From this is deducted the weight of gelatine
(injellifiable), and the amount of creatine and salts is arrived
at by difference. The process is evidently based on accurate
and painstaking observations, and it certainly seems to
promise in the hands of careful operators a means for the
satisfactory separation and estimation of albumose, pep¬
tone, and gelatine. This last body, the author states,
whether normal or injellifiable, is not identical, chemically
or physiologically, with peptone or albumose, in that it has
a greater percentage of nitrogen, and, unlike them, is not
organically assimilable. It is therefore desirable to know
the proportion of gelatine contained in preparations of this
kind, seeing that they are largely advocated and employed
as nutrients in the treatment of disease associated with
enfeebled powers of assimilation and digestion. M. Denaeyer
appears to have been one of the first to recognise the pre¬
sence of gelatine in meat peptones, and his process will in
all probability prove a contribution of no little importance
to the analytical domain of chemical science.
OPERATION FOR TUMOUR PRESSING ON THE
CAUDA EQUINA.
In the Neu/rologisches Centralblatt of April Ist Dr. Leopold
Laquer of Frankfurt gives an account of a case in which,
from the symptoms and history, he was able to diagnose
some growth in the sacral canal exerting pressure on the
roots of the cauda equina. The patient was a young man
of nineteen, with an excellent family history, and in whom
any specific affection could be excluded. Ho began in
September, 1888, to suffer from severe pain in the middle
of the sacrum. This spot was also very sensitive to pres¬
sure. The pain, although for the most part confined to the
spot mentioned, not unfrequently.spread to the knees on
each side, and no impression could be made upon it with all
the antirheumatic and other drugs which were tried. It
was much worse at night than at other times. Counter¬
irritation and galvanism effected temporary improvement. '
The pain was always worst when sitting or lying down,
and he was able to walk for an hour or two without much
trouble. This was when he first came under observation.
At this time all the movements of the different joints could
he carried out, the knee-jerks were present, and there was
no trouble with the sphincters. There was no muscular
atrophy, no disturbance of sensibility, and all the muscles
reacted well to both currents. After the temporary im¬
provement following counter - irritation and galvanism,
his condition became progressively worse; the pains were
more severe, there was some wasting of the quadriceps, the
knee-jerk could only be obtained with difficulty on one side
and was absent on the other, there was pain upon defeca¬
tion and micturition, and there was difficulty in emptying
! the bladder. Power of progression also was more difficult,
and the patient was much bent when he walked. There
was no impairment of sensibility to be discovered. The
electrical reactions were unchanged. A diagnosis was made
of a new growth in the sacral canal, compressing the cauda
equina. The operation of opening the canal wsa effected
by Dr. Louis Rehn, and a cavernous lymphangioma was
formed which was extra-dural, hut had pressed the dura and
the cauda equina from before backwards. The patient
made an excellent recovery, losing his pain and regaining
all his former power.
“QUARANTINING A HOSPITAL."
Under the above heading the New York Herald
announces a curious piece of sanitary administration. If
our contemporary has been correctly informed, the
English Hospital at Elizabeth, New Jersey, was on
April 10th placed under strict quarantine for two weeks
at least, or until the typhus fever there had been
entirely stamped out; and the nature of this quarantine
may he judged of by the announcement that none of
the physicians, nurses, employes, or patients will be
permitted to leave the institution until the quarantine
has been raised. This is the first time that we ever heard
of such action in the case of typhus fever in a hospital; and
experience in this country goes to show that such restric¬
tions are quite uncalled for. Typhus fever is highly infec¬
tious at close quarters, and the attendants on the sick run
considerable risk of contracting the disease. Rut whilst
this was tlie case at the London Fever Hospital during
the last typhus fever prevalence, it was also proved, as the
result of an investigation published in the Local Government
Board Report of 1882 on Infectious Hospitals, that whereas no
less than 18,073 cases of typhus fever had been treated in that
hospital, which is surrounded by a thickly peopled part of the
metropolis, some living within from forty-nine to eighty-four
feet of the buildings, nob a single case of typhus fever could,
as the result of two house-to-house inquiries, be found to
have occurred amongst the population around the hospital.
And this fact becomes the more striking when it is remem¬
bered that between 1802 and 1869 the number of typhus fever
patients received into that hospital in several years varied
between about 1800 to 2500 cases. Since 1871 we have nob
had much typhus fever in London; of late years it has been a
rarity, hub we have always been able at once to check it by
ordinary hospital isolation, and without any imprisonment of
the hospital staff.
THE INTERNATIONAL CONGRESS OF HYGIENE.
As we foretold in our criticisms of the organisation of the
forthcoming International Congress of Hygiene, the con¬
fusing connexion established between demography and
industrial hygiene has already occasioned strong protests.
An organisation which has very greatly contributed to
the popularity and the success of these International Con¬
gresses of Hygiene is the French Society of I'uhlic Medicine
and Professional Hygiene. This organisation publishes the
Die .oogle
1002 TctLanost,]
THE POLICLINICO AT ROME.
[May 2,1801.
Reniw ^Hygidne as its official organ, and the last issue of
this paper gives the programme of the Congress. -It also
explains that the French Government, being desirous to
ensure a large participation of the French nation at this
important gathering, has instituted, by a decree issued by
the Minister of the Interior, a special committee, thus com¬
posed :—Honorary President, M. Pasteur; President, Dr.
Brouardel; Vice-Presidents, Drs. Bergeron, Chauveau, H,
Monod, and Proust; Secretaries, Drs. Napias, A. J. Martin,
De Valbreuze; Assistant Secretary, Dr. L. Vintras.
Then there is a numerous committee comprising some of the
best known names among the sanitary reformers of France.
This committee is about to hold meetings regularly to
organise the participation of France in the labours of
the Congress. The first act has been the publication in
the Revue d’Hygi^e of the programme of the Con¬
gress, preceded by the following remarks “The Con¬
gress will have two divisions: the first, consecrated to
hygiene, will have nine sections; the second is solely
devoted to demography, which, according to the pro¬
gramme of the Congress, shall comprise industrial
hygiene. This decision appears most singular. It will
throw into confusion those persons who wish to discuss
subjects concerning professional or industrial hygiene;
and doubtless it will be necessary to create a new and
special section for this purpose.” We trust that the organ¬
ising committee, in response to the protest received from
the Continent, will create another and separate section or
subdivision, devoted exclusively to industrial hygiene, and
independent of demography.
TRIGEMINAL NEURALGIA AND IODIDE OF
POTASSIUM.
In the last number of the Neurologisches Centralhlatt
reference is made to some interesting facts related by
Dr, S. Ehrmann as to the occurrence of severe facial
neuralgia after the administration of even small doses of
iodide of potassium. In the first case mentioned the patient, a
strong working man of thirty-five, sufi'ered most intense pain
in the forehead and in the teeth, with sensitiveness over
the whole distribution of the fifth nerve, after taking
fifteen grains of the drug. A second patient after
taking thirty [grains had much pain in the region of
the upper jaw, with pain and tenderness in separate
branches of the nerve, and also ccdema of the eyelids
on the left side. A third and a fourth patient also
suffered from similar symptoms after similar doses. There
were associated in all the cases much lacrymation and
injection of the conjunctiva, bub the symptoms rapidly
vanished, and did nob reappear on a further admini¬
stration of the drug. The cases are not only interesting,
but important, for it is desirable to know as much as
possible regarding any peculiar effects likely to be produced
by a drug which is so frequently administered as is iodide of
potassium. _
THE POLICLINICO AT ROME.
An Italian correspondent writes under date of the
I6th ulb.: — “Among Italy’s public institutions whicli,
either contemplated or already begun, have had to be
postponed or suspended, in compliance with its present
policy of retrenchment, the great hospital of the Poli-
clinico at Rome is, I am sorry to say, one of the
most conspicuous sufferers. Dr. Baccelli, to whose initia¬
tive the undertaking is due, and to whose energy it
mainly owes the advanced stage towards completion
it has already attained, has appealed to tlie newspaper
press to aid him in averting the loss and disgrace
to Italy its temporary abandonment would entail. The
representatives in Rome of the leading journals of the
Peninsula were invited by him to a friendly collation in the
hall of the Ufficio Teenico of the institution, and heard
from him a statement of the objects with which the Poli-
clinico had been started, and of the means required to carry
it speedily and effectively to completion. He produced
evidence to show that the self-abnegation of his colleagues
of the architectural and engineering departments had been
rewarded by the estimates nob having been exceeded by a
single centime, and be farther demonstrated that the
obstacles thrown in the way of the works already in pro¬
gress were of purely bureaucratic origin—obstacles pro¬
ceeding from so short-sighted and arbitrary a financial
policy that unless removed or neutralised by the pressure of
public opinion, he and his fellow-commissioners on the
undertaking would have to resign. This announcement,
which no one acquainted withDr. Baccelli’s resolute character
could fail bo appreciate, means, practically, the suspension
sine die of the Policlinioo. And yet, as he pointed out,
Rome, both city and province—nay, Italy itself, were never
less prepared to meet such a calamity. The local hospitals
are quite inadequate to the public demands on them, and
recent examples have not, he said, been wanting of patients
far gone in disease, little short, indeed, of moribund, being
turned away ft'om the threshold of the cliuiques. Nob only
so, but he reminded his audience that Italy’s amour propre
was in danger of being compromised. In 1893 Rome will be
the seat of the great International Congress of Medicine
and Surgery, and will harbour within her walls the men of
light and leading in the profession from every quarter of
the globe. Is Rome, is Italy, he asked, prepared to exhibit
to these men and to the world the spectacle of a magnificent
PoUclinieo arrested within sight of completion by a policy
of ignoble and short-sighted economy ? From official
obstruction and apathy, he appealed, therefore, to the
Italian public through their leading journals to make the
institution independent of bureaucratic caprice, and to inter¬
vene with substantiab aid for the furtherance and comple¬
tion of a magnificent undertaking worthily begun. Dr.
Baccelli’s eloquent words were seconded by a visit to the
wards, laboratories, and lecture-rooms already in working
order, in the course of which intelligent admiration was
evoked by the amplitude and fitness and general eifioiency
of the plan and the details of the building. It is to be
hoped that on this, as on other occasions, the public of Italy
will show itself a more enlightened interpreter of its wants,
and a more effective vindicator of its dignity, than its
' official representatives.” _____
THE POLICE AND STREET ACCIDENTS.
As far as mere theory is concerned, the necessity of
obtaining prompt and efficient medical assistance in cases
of accidental injury will be universally acknowledged. It
is when we come to deal with actual emergencies that errors
of judgment occur and practical minutice may include the
whole future of results. Let us briefly quote in illustratiou
the history of a case which was recently the subject of an
inquest at St. Thomas’s Hospital, and which proves the
importance of arriving at a clear understanding on this very
critical matter. The deceased, a man of middle age, fell
from a tramcar and was laid unconscious on the footpath.
Shortly after he was seen by a medical man, who, finding no
I evidence of serious injury, gave a somewhat hopeful
I prognosis, but advised his removal to the police station for
: farther examination by the divisional surgeon. Thither lie
I was taken accordingly. , Since he smelt of drink, however,
! and since the view taken of hia case was not very grave, he
! received there no further medical attention. After some
hours he was taken home, and thence on fresh advice was
transferred to the hospital, where he died almost on ad¬
mission. In this unfortunate incident the old confusion
Dic!..^ed by ' lOOQ Ic
The Lancet,]
THE INFLUENZA EPIDEMIC.
[May 2,1891. 1003
\Detween the coma of drink and that of death is again
evident, and the police have not escaped a sharp censure
at the hands of the coroner and hia jury for their
slowness to provide for the more urgent condition.
In our opinion, the j nstice of this reprimand is not altogether
■above cf^aestion. The deceased while at the station was
undoubtedly dying, and should have been under medical
■supervision. Bat could the police be expected to know
this? We think not. Ground for suspicion there may
fixave been, but even this was not so evident as to alarm the
practitioner first called to the case. Unfortunately, but not
unnaturally, the police officers did not recognise the imme¬
diate need of obtaining, as advised, a further medical opinion.
There is not a doubt that in any case the injured man, who
had fracture of the base of the skull, would have died,
though the lessons which his death teaches ought not there¬
fore to be overlooked. Any blame attributable in this case
should rest upon the course pursued in removal. Errors of
.judgment like that above recorded would probably best be
avoided by establishing a rule that in future any person
injured in the streets shall ba removed with the least pos¬
sible delay either to the custody of his friends or to the
(nearest hospital. The responsibility of the police would thus
be clearly defined. __
THE INFLUENZA EPIDEMIC.
The official returns from Sheffield during the past week
allow very strikingly the extent and severity of the outbreak
•of influenza in that town—the mortality from bronchitis and
pneumonia, as well as that from the inlluenzi itself, having
attained serious proportions. That the outbreak, which is
believed to have affected one-third of the population, is of a
■far more virulent character than that of last year is shown
by the fact that for the week ending April 25tU the
■death-rate reached the extraordinary figure of 57 per
1000, whilst the highest weekly death-rate during the
il890 epidemic was 38 per 1000. Whilst, in accord¬
ance with its usual character, the disease is abating in
•some of the towns first attacked, it has appeared
with considerable severity in others—-Liverpool, Bolton,
Tontefracb, York, Huddersfield, Stockton, Gainsborough,
fSpalding, and Nottingham being especially noted. Its
extension over the country in general has not been charac¬
terised by the rapidity of the 1890 epidemic, when it ap¬
peared almost simultaneously in widely separated districts ;
but there can bo no question as to its having occurred
•during the past week both in North and South Wales, as
well as in the Eastern counties, whilst several cases have
'been under treatment in the metropolis. So far, however,
^London has fortunately not had a repetition of its last
year’s experience, but it would bo singular if it should
■escape as severe a visitation as it then suffered.
THYROID GRAFTING IN MYXCEDEMA.
It may be remembered thit some fifteen months ago,
•encouraged by the experimental results of von Eiselberg,
l^rofessor Horsley suggested that in transplantation of the
thyroid of the sheep into the peritoneal cavity, a method
imight be found to arrest the progress of myxccdema. In
Paris bhesuggestion was put into practice by M. Lannelongue^
who grafted a portion of sheep’s thyroid in the subcu¬
taneous tissue of the infra-mammary region of a myxceje-
mabous cretin, and in the same city later in the yeai-
M. Walbher' obtained a rather striking result from the
like procedure in a well-marked case of myxccdema,
We now learn that, on the 2a(l ulb., at the Temper¬
ance Hospital, Harapstead-road, Dr. W. J. Collins brans-
1 See TiiK L.vNCKT, vol. i. 18f)0, p. 404.
n Ibid., vol. it. p. 1192.
planted the whole thyroid gland from a sheep into the
submammary region of a woman suffering from myxcedema.
The organ, which weighed from six to eight ounces, must
have become quite “ vitalised,” as there was no suppuration,
and the wound healed by first intention. It is of course
too early to speak of any marked result; but, in the four
weeks that have elapsed since the operation, the patient’s
general condition and appearance are stated to have im¬
proved. We are nob aware of any other case in this country
in which this procedure has been pub in practice, except one
by Mr. E. H. Fenwick, where the disease was boo far ad¬
vanced to admit of any satisfactory inference being drawn
as to the efficacy of the method.
PROFESSOR TYNDALL.
Professor Tyndall has been again obliged to return to
his bed in consequence of venous thrombosis in the right
lower extremity. He has been suffering considerably from
broken rest, but his strength is fairly maintained.
OPERATION FOR EPILEPSY.
A CA.SE is published in a recent number of the New York
Medical Journal in which an operation was undertaken
with the view of relieving epileptic attacks to which the
patient had been subject for some years. The attacks
alway.s began with movement of tho right thumb, and
movements of the wrist, elbow, and shoulder followed
in succession. At times the leg also was affected and con¬
sciousness lost, hut as a rule the attacks were limited to the
hand and arm, and consciousness was retained. There was
no optic neuritis, and no history of injury to the head to
which the onset of the attacks could be attributed. The
usual remedies were tried, with occasional temporary
benefit, but at last operation was resorted bo at the desire
of the patient and his friends. The details of the operation
it is unnecessary to enter into. The arm centre and part
of the face centre are said to have been removed, the
area being discovered by means of faradaic stimulation.
The buttons of bone were replaced. After the operation
the patient rallied well. He had complete paralysis of the
right arm, and after two days there was no recurrence of
the seizures. In about a week, however, the temperature
rose, there was a discharge of cerebro-spinal fluid, and one of
the pieces of bone was found loose. At the necropsy
extensive inllammatory change was found, the left hemi¬
sphere was bathed in pus—a condition in all probability
of septic meningitis. It is unfortunate that the favourable
promise of the first few days after the operation should
have been followed by such a catastrophe, which the
author ascribes to the occurrence of a hernia cerebri leading
to meningitis. _
REFORM IN RAILWAY CARRIAGE
ARRANGEMENTS.
The last few years have witnessed the introduction of
important reforms both as regards the comfort and the
wholesomeness of railway carriage accommodation. On
most of the main lines provision has been made on a scale
which is even liberal for rest, sleep, refreshment, and clean¬
liness, and it might be supposed ihat, for a time at least,
we have reached the limit of improvement. Tliat this is
nob the case we are reminded by an interesting paper lately
read before the Dresden Society of Engineers by Herr
Ffuetzner. Ilis remarks on ventilation are especially note¬
worthy. As regards this matter, he shows that we are
landeti in a practical difficulty which is only too familiar to
all who interest themselves in this subject—namely, that of
obtaining sulliciontfresh airwibhout draught. The amount
of air space provided on the Prussian State railways, if wo
Digitized by ^ooQle
1004 Thb Lanobt,]
PARAFFIN OIL AND ALCOHOLISW.
[May 2.1891.
allow for the average percentage of passengers, is—for the
first class, 278, for the second, 184, and for the third,
120 cubic feet respectively. In order to maintain even a fairly
wholesome atmosphere containing no more than 1 per 1000
of carbonic acid, an average amount of 1055 cubic feet of fresh
air per hour must be allowed for each passenger. In other
words, the air of a carriage must be changed in the first class
nearly 3^, in the second absut 5|, and in the third nearly 9
times per hour, in order to prevent its becoming close. Thus,
with the exception of the first class, which on German rail¬
ways is but little used, the required atmospheric displace¬
ment is essentially draughty. This characteristic, indeed,
we may take to be practically inseparable from railway
travelling. The rapidity of transit in itself, though it can¬
not, in spite of closed windows and ventilation panels, avail
for due ventilation, must necessarily cause draughts at every
outlet. Another suggestion contained in this paper—i.e.,
the expediency of warming by hot-water pipes—if generally
adopted, is calculated to minimise, if not entirely to
obviate, this difficulty., Though we can hardly expect to
see any great and immediate advance as the result of Herr
Pfuefczner’s observations, we gladly welcome them as indi¬
cating a future brighter chan the present as regards health
and comfort in railway travelling.
LONDON POST-GRADUATE COURSE.
This course has steadily developed, until there are now
nine institutions associated with its work. In addition to
the five original hospitals—viz , the Hospital for Consump¬
tion, Brompton; the National Hospital, Qaeen-square ; the
Hospital for Sick Children, Great Ormond-street; the Royal
London Ophthalmic Hospital, Moorfielda ; and the Hospital
for Diseases of the Skin, Blackfriars—there are now the
Royal Bethlem Hospital, the London Throat Hospital, the
Bacteriological Department, King’s College, and the
Pathological Department, Groat Northern Hospital, also
associated in the work. The hospitals have given special
facilities to members of the course who can only remain in
town for a limited period, enabling them to attend the
hospital practice at proportional fees. The entry was well
maintained during the winter term, notwithstanding the
increase of work which the severe weather entailed on many
practitioners who desired to benefit by the instruction pro¬
vided for them. There were fifty-three entries, and the
new regulations enabled seven naval surgeons to attend the
entire course. The practitioners attending were chiefly
British and colonial, including a considerable number of
army surgeons and American practitioners.
FRANCE AND CHOLERA RESTRICTIONS.
Dk. Proust, in reporting to the ComU6 ConsuHatif
d’Hygibne Publique de France on the state of public health
abroad, refers to the passage in quarantine through the
Suez Canal of British vessels on which cholera has occurred
before arrival in the Red Sea, a practice to which it
is evident, both from the wording of his report and
from the general attitude which he and other leading
French epidemiologists have assumed in this matter, he
strongly objects. So long as British vessels pass directly
from the East to British ports, surely it cannot concern
France whether the crews and passengers are sick or
healthy. We are prepared to take any risk that is involved ;
and we have half a century’s experience to show that
even if cholera prevails in England, it does not spread
thence to France. If France and other Mediterranean
Powers choose to act otherwise as regards vessels
bound for their ports, the matter is an entirely different
one. That is their business, and so long as they know
that their Mediterranean ports are in a sanitary state such
as will not justify any risk being incurred, we have nothing
to say to the contrary. Bub we have in this country done
a vast amount of sanitary work in our ports as elsewhere;
and it is somewhat intolerable that we should he put on the
same footing as some of the southern ports of Europe, which
have so recently been condemned by French sanitarians,
amongst others, as having done nothing to amend their
faulty conditions since cholera last prevailed in them.
Amongst those who voted recently against allowing British
vessels bound for British ports to pass through the Suez;
Canal without touching land and under the supervision of
the quarantine officers was the French delegate—a course
of action we can hardly regard as justifiable. It is certainly
in marked contrast to our attitude in this country when
cholera last prevailed as an epidemic in Paris, and when the
French service to England was maintained without restric¬
tion, and also without any resulting mischief.
PARAFFIN OIL AND ALCOHOLISM.
The number of remedies—not to say nostrums—whicb,
have from time to time been vaunted as specifics for
alcoholism is legion, some of the latest being red cin¬
chona, strychnine, ichthyol, phosphorus, hydrohromate
of hyoscine, and hydrastis. The most recently sug¬
gested remedy is petroleum, or paraffin oil, to which the
attention of the St. Petersburg medical authorities waa
called by an accident. It appears that a labouring man,
who had been drinking heavily for four days and nights,,
entered in a complete state of intoxication a grocer’s shop,
without being conscious of where he was or what he was
doing. Unnoticed by the shopkeeper, he staggered up
to an open cask of petroleum, and began drinking from it.
■\Vibh difficulty be was dragged away from the cask, and„
seeing the large quantity of petroleum he had imbibed, it
was expected he would fall down senseless, and be seriously
ill. Instead of this, however, it is related that the petro¬
leum had cured him of all the ill effects of over-drinking,
the nausea, unsteadiness of gait, and headache disappear¬
ing as if by magic. In fact, it is stated he left the shop
sober, and quite another man as compared with what hewa&
before he took the draught of petroleum !
ACUTE ASCENDING PARALYSIS.
The term “acute ascending paralysis,” or “Landry’s-
paralysis,” is one which has been applied to a collection of
symptoms, the most prominent of which are sudden losa
of motor power, which then increases gradually, irn-
associated with marked sensory disturbance, or with dis¬
turbance of the functions of the bladder or rectum, and
without any muscular atrophy. Some authors, however,
have been of opinion that sensory impairment may occur
in this disease, and others have held that the organic
reflexes may be disturbed, and that trophic changes may
occur. While in the majority of cases no morbid
appearance has been found corresponding to the sym¬
ptoms, in a few, changes of the nature of myelitis
have been described, and in at least one case the
medulla was found diseased. Dr. Eiehberg of Cincin¬
nati has reported in the New York Medical Record-
an important case in reference to the pathology of this
disease. The patient was a man of twenty-one, who four
days before admission to the hospital had discovered weak¬
ness in the right leg, with pain in the back and lower-
limbs, which prevented him from getting out of bed. The
weakness soon extended into the left log and also into the
arras. There was some shooting pain in the limbs, but no
impairment of sensibility to touch, although the tempera¬
ture sense was very defective. The plantar rellexes were
retained, the knee-jerks were absent, there was inability to
Digitized by i^ooQle
Thb Laucbt,]
THE GUNPOWDER EXPLOSION IN ROME.
[May 2, 1891. 1005
«mpty the bladder, and trophic disturbances over the
sacrum, buttocks, and feet were manifested. Before death,
which took place six days after admission, there were com¬
plete loss of power, delirium, inactive pupils, and profuse
perspiration, and death took place by failure of respiration.
The organs, except the cord, were found normal, but it is to be
regretted that neither the medulla nor the basal ganglia were
submitted to a microscopical examination. In the cord was
found a condition of marked congestion with numerous
capillary hmmorrhagea, and at one point a small abscess in
the lumbar region. The change was most marked in the
anterior horns, more slightly in the posterior horns, the
cells being either broken down altogether or considerably
altered in character; the pia mater had also undergone
inflammation, The case in its clinical characters resembles
closely the type of the so-called Landry’s paralysis, and the
presence of a well-marked morbid condition in the cord is
eiguificant. The author is of opinion that the process is an
infective one, and this explanation seems the most likely,
especially in view of the close resemblance between this
condition and paralytic rabies. What the character of the
poison is remains for future research to determine.
A GERMAN MILITARY SURGEON ON THE
TREATMENT OF INFLUENZA.
As influenza is again in our midst, it may be opportune
to mention that Dr. Ijorenz, staff surgeon in the Prussian
Army, has reported that great relief was obtained in eighty
cases of undoubted influenza after a single inhalation of a
2 per cent, solution of ichthyol. For this a steam spray
apparatus was used, and it was repeated twice a day for a
quarter of an hour or twenty minutes at a time. In
addition to this, ichthyol was ordered internally in the form
of pills containing a grain and a half each, one to hvebeing
taken daily. Also a vessel containing a 2 per cent, solu¬
tion of ichthyol was kept in the room, and from time to
time made to boil by applying a spirit lamp underib. In
almost all the cases the symptoms are said to have entirely
auhsided in two or three days, but if the treatment were left
off, then the cough and running at the nose were liable to
recur.
THE GUNPOWDER EXPLOSION IN ROME.
An Italian correspondent writes under date, Home,
April 24th: “Italy, in her present critical state —
financially, politically, and socially—could ill brook such
a terrible disaster as yesterday’s explosion, with the far-
reaching misery it must produce. This is the third calamity
of the kind she has had to bear within comparatively few
months, insomuch that suspicion is aroused as to its being
"due to quite other causes than the spontaneous slow
comhustiou to which it has been attributed. Pending
official investigation into the circumstances, it may be in-
Ceresting to note the scientific aspects of the explosion
as just communicated by Professor Pietro Tacchini, the
well-known meteorologist and chemist. ‘You cannot,’he
eays, ‘ have an explosion of 265,000 kilogrammes of gun¬
powder without the production of physical phenomena
which convey the impression of an earthquake,’ and this
was precisely the ffret conclusion to which the Roman citizens
came. The action of the explosion on the barometric column
revealed itself in a depression of from 15 to 16 millimetres;
or, to pub it more familiarly, the action was equivalent to a
force which in an instant produced a variation of weight
of about 240,000 kilogrammes on every square metre of
flurface. The action, moreover, says Professor Tacchini,
showed itself in the seismograph as a telluric movement—
oven at Rocca di Papa on the Alban Hills (twenty
miles to the south of Rome), the seat of a seismic
station, there were windows broken by the shock, and
a railway train advancing on the metals experienced
such a violent concussion that the engine-driver, think¬
ing it had collided with some obstacle, lowered the
brakes and came to a full stop. The material damage has
been tremendous—460,000 lire being the estimate of the
Communal Councilaloneoftheexpensesitmustincur; while
the injuries done to St. Peter’s, St. Paul’s outside the walls,
and other basilicas and churches will run the total up to
2,300,000 lire. The hospitals have had their accommodation
strained to burs ting, and yet have proved inadequate to admit
all the cases of contusion, fracture, and concussion brought
to them from the scene of disaster. Such an unwelcome
confirmation of his warning as to the need of the Policlinico,
which still lingers on the way to completion, Dr. Baccelli
could nob have contemplated. Meanwhile, the mortality
from the explosion has been small, thanks to the splendid
coolness and courage of Captain Spaccamela, who, on first
realising the danger, dismissed every man from the powder
magazine to apprise the neighbourhood, in house and on
highway, of the impending shook, and left himself but
fifteen minutes to effect hisown escape. At 300 yards from
the powder magazine he was felled to the ground by a stone
and conveyed to the Consolagione Hospital in the carriage
of the King—first, as always, on the spot to tender assist¬
ance. The energy and skill of the surgeons at all the hos¬
pitals have been conspicuous, and their reports, when in
due time made public, will have a wider than local interest
for the profession at large.”
IMPORTANT IMPROVEMENT IN MICROSCOPIC
LENSES.
It U stated that an immense improvement has recently
been effected in the manufacture of glass for optical instru¬
ments by means of the addition to the ordinary materials of
phosphorus and chlorine, which in some as yet unexplained
way cause the glass to be very much more transparent, and
enable it to receive a much higher degree of polish than any
optical glass hitherto manufactured. Thus microscopes can
be made which will render objects of the diameter of only
the one-eight millionth of a millimetre visible, whereas
with the best instruments now in use the diameter of the
smallest object that can be seen is one-sixbeen thousandth
of a millimetre. ’ __
TEMPORARY LIFE ASSURANCE.
When writing in November last on the subject of Life
Assurance for Medical Men, we observed that “in many
cases it would be a great convenience to a proposer to be
able to provide against prerqature death by means of a
temporary assurance running for twenty, twenty-five, or
thirty years, while he undertakes the accumulation of his
own capital by means of investments which he could keep
under his own management and control.” Acting on this sug¬
gestion, the directors of the Royal Exchange Assurance Cor¬
poration have prepared a table of premiums for policy con¬
tracts of the kind indicated, which should prove of great value
to those for whom it is intended. The advantage of such a
form of life assurance is thus rendered very manifest. For
example, we find on reference to the table that a pro¬
poser of thirty years of age can secure a policy running
for a term of thirty years at an expenditure less by
about a fourth than he would have to pay upon the
lowest-priced table for a policy of equal amount running
for the whole duration of his life. The importance of this
facility cannot well be overstated. With many men, if
not indeed with most, the chief purpose of a life-assurance
policy is to secure dependants against the pecuniary
disaster of the bread-winner’s premature decease. This, in
many cases, is done as effectively by a policy that
will run for thirty years as by one that will last tha
Digitized by ^ooQle
1006 Thb Lancet,]
THE ROYAL BRITISH NURSES’ ASSOCIATION.
[May 2,1891.
entire lifetime, since the period is q^nite long enough
to secure the fruits of professional success. In the
meantime, the amplitude of the provision made may he
augmented in a very important proportion, since the amount
of the annual premium is almost always the limiting factor
in these arrangements. In this respect the policy of shorter
duration is more useful than that of a longer term, and to
the scheme of the Royal Exchange Assurance Corporation
belongs the merit of havingplaced this important advantage
within the reach of all who desire it.
DRAINAGE OF SPINAL CANAL IN ACUTE
HYDROCEPHALUS.
The cases recorded in another part of this issue from the
Middlesex Hospital by Dr. Essex Wynter, will he read
with interest in connexion with the communication made
at the Wiesbaden Congress by Prof. Quincke. Although
these cases terminated fatally, they demonstrated the
feasibility and simplicity of the method employed to drain
the cerebral ventricles in cases of tubercular or basal
meningitis, by means of paracentesis of the spinal sub¬
arachnoid channels ; and Prof. Quincke’s more favourable
result is encouraging in favour of a procedure which, if it
do not always prove successful in a curative sense, may
reasonably be expected to relieve the comatose symptoms
attributable to the compression of the brain by theventricular
distension. It may be remarked that these cases seem to
show that there is no necessary occlusion of the foramen of
Magendie in basal meningitis.
UNQUALIFIED PRACTICE.
Every now and again some unwary unqualilied
assistant finds himself impelled by certain motives to plume
himself in borrowed feathers, and to give himself titles to
which he has no claim. A gentleman, who had passed all
examinations except the final, recently found himself in
this condition, that “he, being a medical assistant, prac¬
tising at Arundel, did make a false statement on
a certain medical certificate, bearing date Dec. 29th,
1890, by inserting therein certain qualifications as
‘registered’—viz., L.R.C.S.Ed.,—with intent to have the
name entered in the register of births and deaths of the
district.” He pleaded guilty, and expressed his regret for
the offence. We quite agree with the opinion of the Bench
that it was a very serious offence, which might have led to
grave consequences. A fine of £5, with £2 ?>.f. Gd. costs,
will perhaps act as a useful deterrent to anyone who may be
similarly tempted. •
THE ROYAL BRITISH NURSES’ ASSOCIATION.
The discussion which has arisen concerning the applica¬
tion made on behalf of this institution to the Board of
Trade for leave to register without the word “ limited ” as
a part of its title has now received formal expression in two
letters which have already appeared in the daily press, and
will be found to-day in another column. The party
of the opposition do not, indeed, lay down the grounds
upon which they proceed j on the contrary, they adopt the
view that it is not necessary “ at the present moment ” to
discuss these matters, and they accordingly confine them¬
selves to a statement of the perfectly well-known fact
that they do oppose. It is, no doubt, their business to
judge of the proper time and mode of putting their arguments
forward ; but we for our part cannot pretend to understand
this somewhat enigmatic reference to the requirements of
the hour. We should have supposed that the occasion of
announcing the opposition would be the most suitable
occasion for adducing arguments in support of it. One
I consequence of their declining the controversy in this way
is that the supporters of the institution are left, for the^
present at least, in possession of the field, and no one-
who is swayed by the arguments pub forward in the-
two manifestoes which we to day publish will hesitate'
to lend his sympathies to the promoters of the applica¬
tion. Indeed, a careful reading of the letter emanat¬
ing from their opponents leads us to suspect that even
its signatories have not in every instance paid minute-
attention to what they have been asked to authenticate.
For example, there is a eulogistic reference to “the>
guidance of his Grace the Duke of Westminster” in con¬
nexion with the management of the Lady Bloomfield Fund,
which stands curiously over the duke’s signature, and is-
cerbainly by no means in the approved form of polite letter
writing. If signatures have been appended by inadvertencer
one can without difficulty understand that a number of dis¬
tinguished persons may have signed what they will find it-
hard to justify. And this appears the more probable wheno
it is borne in mind that the signatures in question are with
one exception those of persons unconnected with the medicals
profession. _
DEATH OF MR. T. H. BARTLEET, FR.C.S., OF
BIRMINGHAM.
Wii regret to record the death, on the 29th ult., off
Mr. T. H. Bartleet, from pneumonia, after a brief illness.
Up to within a few days of his last illness Mr. Bartleet wa&
seeing patients as usual. An influenza cold developed with
rapidity into pneumonia, and to this disease he suc¬
cumbed. We hope to publish in our next issue a sketch of
the professional career of the deceased surgeon.
FOREIGN UNIVERSITY INTELLIGENCE.
Ghent. —Dr. von Vischer has been promoted to the-
Ordinary Professorship of Forensic Medicine.
Kazan. —Dr. Fortunatolf, Extraordinary Professor ia
Tomsk, is to be offered the chair of Anatomy.
Marseilles .—The Municipal Council has passed the voteu
required for the erection of a Faculty of Medicine.
Munich .—The new Surgical Clinic has just been publicly-
opened.
Prague {Bohemian Unioersity). —Dr. Kabrhel has beens
appointed to the chair of Hygiene. Dr. Hellooh has been,
recognised as prioat docent in Mental and Nervous Diseases...
St. Petersburg {Helena Paulovna Clinical Institute ).—
Dr. V. N. Reitz has been appointed Professor of Children’s
Diseases.
Tomsk. —Dr. Burzhinsky, of the Medico-ChirurgicatJ
Academy of St. Petersburg, has been nominated to the-
chair of Pharmacology.
Wurzburg, —Dr. Gaetschenberger, a Kissingen physician,
who recently died, has left nearly £1000 to he appropriated
to the endowment of a chair of Balneology and a Balneo¬
logical Institute. Dr. Schultze has been appointed to ar»
Extraordinary Professorship of Anatomy.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Joseph von Pircher, a well-known physician at Meran,.
to whoso exertions visitors to that health resort owe the-
erections of the Curhaus and the excellent water-supply;;
Dr. Mandon, Professor of Therapeutics in Limoges; Dr.
Albarellos, formerly Professor in the Faculty of Medicine
of Buenos Ayres; Dr. Luozkiewicz, formerly Professor oS
I General Pathology in the University of Warsaw.
Digitized by <^ooQle
Tna Lancet,]
THE GERMAN CONGRESS OF INrERNAL MEDICINE.
[May 2, 1891. 1607
We read in the last number of the Orvosi Hetilap that
the remains of the late Dr. Semmelweis have recently been
transferred from Vienna to Hungary, his native country, and,
agreeably to the express wish of the family, were, on the
17 th ult,, quietly committed to their final rest in the Kerepesi
Cemetery, at Buda Pesth, in the presence of relatives, pro¬
fessional friends, and the rector of the university 3 the staff
of the Hospital of St, Rochus and the Hungarian Medical
Society sent representatives, who deposited wreaths on the
grave. Dr. Semmelweis, the originator of antiseptic treat¬
ment in puerperal women, which treatment has since been
extended to the domain of the whole of surgery, died, as we
know from his biography, in an asylum at Vienna, on
July 20bh, 1865. It is intended to perpetuate the resting-
place and memory of this distinguished Hungarian physician
in a manner worthy of his struggles and achievements.
Under Dr. Cameron’s advice the Leeds Corporation have
greatly increased their arrangements for disinfection. Some
time since they acquired one of the steam disinfectors made
by . Messrs. Washington Lyon and Co. 5 they have now
added to this one of Messrs. Goddard and Massey’s steam
chambers, this apparatus being in some respects improved by
modifications introduced by Professor deMeyerof Utrecht.
Dr, Alex. Edington, who has been selected by Sir
Charles Mills, K.C.M,G., the Agent-General for the Cape
of Good Hope, to inquire into the subject of the ravages
of the phylloxera in the wine districts, is about to pro¬
ceed to Capetown in the Union Steamship Company’s
K.M,S. Moor. _
An Italian Pharraacopcoia is about to be published.
This will be the first national formulary, those hitherto in
use having beep of the most varied description, consisting
largely of more or less correct translations of French
formularies, and having no general or official recognition.
THE GERMAN CONGRESS OF INTERNAL
MEDICINE.
{Coiilinued from pa^je 95,’i.)
TiibercuUn and its Eff'eefs.—Ancfina Pectoris.—Treatment
of Hydrocepkalits.
Professor v. Zcemsskn (Munich) protested against
Df. Dettweiler’s assertion that tuberculosis, prior to Koch’s
treatment, had never been thoroughly considered in clinics
and hospitals, and he warmly upheld the value of the induc¬
tive method in medicine and the splendid services of
Koch. Although he had several failures, on the whole the
general result was satisfactory. Some change in the
method, the better separation of toxic substances from
the lymph, i&c.. may lead to progress. lie had often seen
good results subsequently become worse, due probably to
too frequent and large injections. It was very important to
select suitable cases, and he referred to Dr. Vogl’s expe¬
rience {Munchener Med. TVoo/t., Nos. 9 and 11) as showing
the value of small doses and good hygiene, witli selection
of incipient cases. Good results had been seen at Meran.
Many, no doubt, on return to their occupation and sur¬
roundings, lost ground gained during the treatment, showing
that it should be repeated. In adulcs the initial dose should
be 1 mgr., and the rise should be slow, never exceeding
.50 mgr., or sometimes nob more than 10.
Dr. FiiRRRiNQiSR (Berlin) found that of more than 100
cases treated at Friedrichshaia Hospital 6 per cent, lost all
symptoms, 40 per cent, sliowed unusual improvement,
35 per cent, were scarcely improved, and 25 per cent, did
nob improve or grew worse; mortality, 15 per cent. The
cases or marked improvement included some with marked
infiltration, which, under similar conditions, would, apart
j from tuberculin, have certainly grown worse. He did not
ignore the risks of the injection: (1) marked weakness of
bad cases; (2) occurrence of acute, but resolvable, catarrhal
pneumonia; (3) outbreak of tubercle around old foci;,
(4) liability to perforation of pleura, peritoneum, &c. The
question whether tuberculin can excite caseous pneumonia,
and miliary tuberculosis in remote parts of the lung or in
other organs was shown by a tabular comparison of eleven
post mortem examinations on subjects treated with tubercu¬
lin, and sixty-nine without this treatment.
Treated by Not treated by
Tuberculin. Tuberculin.
1. More or less general miliavy tuber-TO
c«lo,si 3 in.. .. ..|18pe*cent. lapercent.
2. Unusual miliary tubercle in lungs.. 36 „ .... 0 „
3. Exceptional extension of caseous
pneumonia .•’ - >•
He said that during the past five weeks under better selec¬
tion of cases his results had improved.
Dr. Naunyn (Straaburg) asked whether the risks in¬
volved could be avoided. He had seen disasters occur under
the greatest care and with a dosage according to Koch’s
prescription. Continued fever followed on violent reaction^
sometimes death. Such dangers were unavoidable; they
depended on the degree of reaction, which varied with the
individual, not with the close. One (not severe case) was
injected from January to March, with dose increasiDg from
i tugr. to 6 mgr., without notable reaction (only once 38® C.);
then suddenly, after a dose of from 6 to 7 mgr., permanent-
fever, above 40° C. , and death in a fortnight. He had seen five
such cases out of eighty treated, and although he had also-
had favourable results, he had on this account abandoned
the treatment.
Dr. Kast (Hamburg) saw in the contradictory view3*ex-
pressed that the discussion on the therapeutic value of
tuberculin was premature; but it might now be decided
whether it involves any risk. The weapon employed was
not known. Was the lymph always uniform ? Could its
dosage be exactly estimated ? Of 188 cases of phthisis
treated at the Hamburg Hospital, 3 percent, lost symptoms,
22 per cent, improved, 61 per cent, were unaftected, and 14-
per cent, grew worse.
Dr. Cornet {Berlin) had treated 420 cases. He bad seen
very large doses borne without such accidents as he had
formerly seen with smaller ones; but following the stream,
he would now return to the latter. He had administered io-
by inhalation (Jahr’s apparatus), with the effect of producing
even stronger reaction than by injection. He had never
found bacilli in the blood. His statistics were very
favourable.
Dr. WciiULTZE (Bonn) agreed with Drs. Detbweiler and
Naunyn. The hopes he had at first had not been fulfilled,
80 that since February he had injected no cases, and wilt
nob inject any more until more precise explanations con¬
cerning tuberculin are made. He protested against frequent-
surgical operations upon cavities, which may be compared
to hollow trunks in a wood eaten up by caterpillars.
Dr. Frbymutu (Dant/.ic) was also opposed to Kocli’a
method. In no case had he found objective signs of im¬
provement after the treatment, in spite of an apparent result.
Diagnostically it was uncertain, and its composition is un¬
known. For the presunb, at least, it should no longer be
used in practice.
Dr. Peiper (Greifswald) had found it uncertain in diagnosis,
for healthy people used to small doses. A toleration was-
rapidly established.
Dr. Turher (Davos) had, contrary to Dr. Debtweiler, seen
good results from the combination of climatic with tuber¬
culin treatment, in unselected cases. Of 53 cases 1.
died, 1 grew worse, 4 were unchanged, and 47 improved. In
14 cases the bacilli disappeared from the sputum.
Df. Thomas (Freiburg) was, on the whole, opposed ta
the treatment, although in some cases he had seen im¬
provement.
Da Veuriest (Lowen) held that more details of Koch’&
experiments should be published, and the experiments on.
animals be repeated before tuberculin was generally adopted
as a remedy.
Dr. Leniiartz (Leipsic) also urged the publication of
further details, especially of the composition of the-
“lymph.” His experience in the policlinic had nob been
unfavourable.
Dr. Stintzino (Jena) pointed out that diaguostically
(1) the non-appearance of fever after injection is no proof
against tubercle, and (2) the occurrence of fever is only &
Die ed 1 lOO^Ic
1C08 The Lancet,]
DR. KLEIN ON BACTERIA.
[May 2,1891.
proof when ib follows doses below 5 mgr. His therapeutic
results were better than in other methods; but of 130 cases
only 5 could be described as relatively cured.
Dr. WoLT'P (Gbrbersdorf) said in his experience selected
cases did well under a combination of climatic treatment
and that by tuberculin.
Professor Naunyn summed up the discussion. There
was general agreement that diagnostically tuberculin was
of less value than therapeutically. On the latter point
observation varied essentially in laryngeal and pulmonary
cases ; for whereas no one had controverted, the favourable
results obtained in the former by Dr. Moritz Schmidt, on
the latter there were most divergent views. On many sides
there seemed to have been more favourable results at the
clinics this winter; but whereas some of the speakers
ascribed this solely to the action of tuberculin, others con¬
sidered it due to the greater in-rush of patients seeking
treatment, which yielded better statistics, which are not
comparable with those of previous years.
At the morning sitting on April 8th a discussion on
Angina Pectoris was opened by Dr. A. Fraenkel (Berlin).
He described its etiology and clinical history, and its
relation to disease of the bloodvessels and other organs. It
is sharply distinguished from cardiac dyspncca (cardiac
asthma of Heberden), which, like bronchial asthma, may
arise suddenly in heart disease (and granular kidney), hut is
characterised by severe dyspocea. The distinction is diiliciilt,
as the two conditions frequently concur, for pure, well-
marked cases of angina pectoris are rare (Stokes). Arising
late in life, and more often in men than women, it is
especially associated with sclerosis of the coronary arteries
and valvular disease (mostly aortic). Gout, diabetes,
syphilis, heredity, emotional disturbance, were causative of
it, and he had seen it after acute infective disease. He
described a typical seizure, the substeroal pain and its
irradiation down the arm or to the neck, shoulder, and
-elsewhere. The pulse during the attack is variable, may
be irregular or slowed, or accelerated, or even normal. The
heart sounds often have a fmtal character, the action of the
heart may be “fluttering.” Sometimes only a sense of
oppression is felt. The attacks last from seconds to minutes,
and even hours. The first attack may be fatal; often a
patient may have a series of attacks in one morning,
or he may be free for years from a second attack.
The chief anatomical lesions are sclerosis of coronary
arteries; then aortic valve defects and aortic aneurysm.
The coronary disease may lead to softening and fatty
changes in the heart wall, or fibrous changes and cardiac
aneurysm. Cohnheim and others have shown that closure
of the coronaries causes arrest of ventricle in diastole, fol¬
lowed by fluttering, contraction, and then death. The theory
of Pavy and Traube explains angina by the sudden occur¬
rence of weakness in an already enfeebled heart, causing
dilatation of the ventricle and stretching of the nerves in
the heart wall. This sudden weakening may be caused by
anything producing a rise in arterial pressure. Against
-this view is the fact that objective evidence of cardiac
weakness is not always present, for the pulse may remain
normal. Potain attributed the pain to the supervention
of antemia of the heart muscle from interference with the
coronary circulation. The attempts to refer angina to a
neuritis of the cardiac plexus or vagus may be considered as
exploded. Conditions allied to these were to be described as
pseudo-angina” of nervous origin, and independent of vas¬
cular disease, such as attacks arising from the abuse of
tobacco, coffee, tea (rare); or in dyspepsia, liver disease,
lead colic; or in tabes, hysteria, and Nothnagel’s angina
pectoris vaso-motoria.
Dr. ViERORDT (Heidelberg) dealt with diagnosis, prognosis,
and treatment of the disease. He noted the difficulty in
differentiating it from cardiac asthma, and said some cases
of angina passed into the latter. He distinguished (1) angina
'vera from sclerosis or syphilis of coronary arteries; (2) angina
sfrom organic heart disease, pericardial adhesion, aneurysm ;
<3) toxic angina (lead and tobacco); (4) nervous, reflex,
hysterical angina. In favour of organic angina (I and 2) are
the age of the patient and the presence of arterial sclerosis ;
whilst against it is the occurrence of an aura, the frequency
of attacks, and the readiness with which they are borne.
(Prognosis is difficult and delusive in both the apparently
slight as well as severe cases. The purely nervous form
has a good prognosis, but that due to tobacco is less
certain. Therapeutically in nervous angina narcotics,
especially morphine injections, should be used. In organic
angina first stimulation should be employed (injec¬
tions of camphor) and then careful use made of nar¬
cotics. Morphine holds the first place. In England
nitrite of amyl and nitro-glycerine are much used, but
Dr. Vierordt would not employ them in organic cases; they
were preferably used in nervous angina, especially in the
vaso-motor form. Derivatives to heart and extremities were
often of value. In the intervals, iodide of potassium and
regulation of exercise. As to pathogenesis, he could not
admit the theory of cardiac weakness, since it was not
always present, and it was more associated with cardiac
asthma. He thought the attack rather due to the action
on the heart of some unknown agency, which if the muscle
be healthy excites pain alone, and if it be diseased causes
both pain and weakness.
The discussion which followed was shared in by Drs.
Curschmann. v. Frey, Nothnagel, v. Ziemssen, and Schott.
Professor Quincke (Kiel) read notes of a case of Hydro¬
cephalus treated, with relief, by trephining and puncture
(six times repeated during one month). In another case,
with meningitic symptoms, he had produced improvement
of symptoms, and finally recoveiy, by puncture of the
subarachnoid space of the spinal cord which communicates
with the cerebral ventricles. In another case of an adult
with symptoms of cerebral compression, possibly due to
chronic hydrocephalus, 80 ccm. of cerebro spinal fluid were
evacuated through puncture in the lumbar region, with
improvement in symptoms. A Pravaz syringe is inserted
between the arches of the third and fourth lumbar vertebrje,
and introduced to a depth of about 2 cm. in children, of
from 4 to 6 cm. in adults. The cauda equina being at this
spot, there is no risk of injury to the cord. The operation
is indicated in cases of acute rise in the cerebro-spinal
pressure, especially in tubercular meningitis. Perhaps
permanent drainage of the spinal canal might be advan¬
tageous.
Dr. Baumuer (Freiburg) thought that this idea of Pro¬
fessor Quincke was one which raised hopes for the cure of
tubercular meningitis, just as laparotomy had cured tuber¬
cular peritonitis.
{To be continued.)
DR. KLEIN ON BACTERIA.
The first of a series of three lectures on Bacteria ; their
Nature and Functions, was delivered at the Royal Institu¬
tion on Tuesday last by Dr. E. Klein, F.R.S. He said
that perhaps in no branch of biological science had
advances in the methods of research within the last twenty-
five or thirty years been so enormous as in this subject. In
1828 Ebrenberg recognised the existence in water of minute
mobile organisms which he considered to belong to the
group of animalculce known as infusoria, an assumption
which was now known to be erroneous. In 1837 Schwann
demonstrated the presence in atmospheric air and in dust
of living microscopic beings, which he showed by direct ex¬
periment to be endowed with the power of producing in
certain fluids those chemical changes termed alcoholic
fermentation or putrefaction. Pasteur fully established
the proposition that the different fermentations, such
as alcoholic, butyric, acetous, mucous, and lactous fermen¬
tations, and also the decomposition of putrescible matter,
were caused by definite and different species of such
minute living beings—microbes,—and that without them
such changes did not occur. This proposition implied
that these changes were dependent on and ultimately
bound up with the life and growth of these microbes,
and if these were prevented from gaining access to
such fermentative matters, they would remain unchanged
or sterile. This was the principle which Sir Joseph
Lister had applied in surgery, with the well-known
brilliant results. The rOle of these microbes in atmo¬
spheric air had been minutely worked out and beautifully
illustrated by Professor Tyndall, whose share in finally
establishing that with these simple organisms, belonging
almost to the world of fthe infinitely small, the same funda¬
mental principle obtains as in other living organisms of
plant and animal life, be they ever so large and complex—
namely, that each organism had descended from an ante¬
cedent parent organism, and that no such thing as their
tv Ga ’g
The Lancet,]
REPORTS OF MEDICAL OFFICERS OF HEALTH.
[May 2, 1891. 100ft
origin from non-living matter occurred. Within compara¬
tively recent times it had been shown that a variety of
the most importantand extensive processes of oxidation and
reduction occur in nature, such as the oxidation and reso¬
lution of dead animal and vegetable matter, the breaking
up of complex nitrogenous materials—such as albuminous
substances, and their ultimate change into nitrites and
nitrates, so essential to the life and growth of plants;
that specific fermentation, so important in food stuffs
and articles of diet, and many other processes are caused
by, and intimately connected with, the growth and
life of microbes. Though the importance of some
species as useful agencies in nature is recognised, the
importance of other species, as being the cause of disease
affecting plants, animals, and man, is not less. The term
micro-parasite is given to this latter group, Amongst the
microbes there is one great group to be dealt with in par¬
ticular, called “ bacteria,” because it possesses more or less
the shape of a minute rod. Like the true or higher fungi,
they are free from chlorophyll, and are composed of cells,
a cellular membrane with living matter or protoplasm
within, and they multiply by fission, for which reason they
are called “ fission fuogi.” Bacteria could then be defined
as microscopic elementary organisms, composed of a cellu¬
lose investment of the protoplasmic contents, and which
multiply by simplefission. They are classified into micrococci
or cocci, bacilli and spiral vibriones, according to whether
they are spherical, cylindrical, or curved and spiral. The
lecturer exhibited a large number of micro-photographs of
bacteria, prepared by Mr. Andrew Pringle and Dr. Bousfield.
All these organisms, when they have found suitable nidus,
multiply with enormous rapidity. It has, for example,
been found from observation—all conditions of moisture,
medium, and temperature being favourable—that some
multiply in twenty minutes, others in thirty minutes, and
others in forty minutes. Staphylococcus aureus, which in
its growth produces a peculiar golden-coloured filament,
grows with great rapidity when sown in a medium-like,
faintly alkaline broth at a temperature of 37° C. Into a
sterile broth tube a definite number of organisms are put—
say, eight cocci per cubic centimetre. If placed in an
incubator for twenty-four hours at 37° C. and then
counted, it is found that 1 cc. coutains G40,000—that is to
say, one organism has multiplied eighty thousandfold in
the first twenty-four hours. It would not bo expected that
the same rate would obtain in the second twenty-four
hours, because the materials had been used up. After
forty-eight hours’growth the counting yielded 248 millions
per cubic centimetre—that is, only four hundredfold. In
seventy-two hours it was found that there were 1184 millions
per cubic centimetre—that U to say, during the last day each
had multiplied only fivefold. As the material is used up
the rate or multiplication decreases. Another instance of
the rapidity of growth was given. A rabbit was inoculated
subcutaneously with 20,000 bacilli of fowl cholera, and died
in twenty-four hours. It was found that 15,150,000 microbes
were contained in 1 cc of the blood of the animal. The whole
of the blood contained twelve hundred millions, showing
that each bacillus in twenty-four hours had multiplied sixty
thousand times. Those organisms which have their habitat
in ordinary temperatures grow very rapidly. Professor
Ferdinand Cohn was the first to study the rate of multipli¬
cation on the bay bacillus. He calculated that in two
days the number of these would be so great that the whole
Atlantic Ocean would be densely peopled by them if there
was sufficient nutriment, which, fortunately, there is not,
and therefore many of them had to go to the wall.
By the motility of bacteria is understood active locomo¬
tion. They spin round, tliey darh to and fro, and pass
rapidly over the field of the microscope, and that is on
account of their possessing one, two, 'three, or even a
multitude of fine hairs. The organism of typhoid fever
possesses several of these fiagelho. It has been shown
that for retaining this motility a plentiful supply of
oxygen is required. If, in a chamber, at one end oxygen is
supplied, and at the other nitrogen or hydrogen gas, the
organisms will all move towards the end where the oxygen is.
If the oxygen is replaced by nitrogen or hydrogen the move¬
ment gradually ceases. If water is covered with a scum,
it is most probably a motile bacillus which grows in the
Iluid, and which is driven to the surface, where it can
derive the best supply of oxygen. In many cases the
motility of the organisms is interfei-ed with by their own
chemical products.
Within certain of these organisms, but not in all, arc
formed peculiar corpuscles, which bear the same relation
to the organisms as the seed does to the plant. This spore
formation is almost entirely ILmited to the order of bacilli,
and in this group there are very many species which do-
nob possess this power. In a number of diiferent species of-
bacilli, some of which are capable of forming spores and
others not, those which have this power may look on very
quietly, while those that do nob will exhaust all the nutritive
material present, growth and multipUcation will then cease,
and they will gradually die a way. Those which form spores-
have a much better chance of bringing forth new generations
than the others.
When organisms do nob find suitable materials for fchein
growth, certain changesare brought about called “involution
changes.” When the bacillus ceases to possess that high-
degree of vitality that the normal typical bacillus possesses,
it gradually undergoes changes wnich lead to its death.
Illustrations were given of what had been described as invo¬
lution changes, but which were nob so. For instance,
tubercle bacilli grown under not very favourable conditions*
may be swollen, and others m^y appear branched. Some
observers took these changes to indicate the death of the-
organism, but the lecturer was not quite sure that such-
were “ involution changes.”
In all these considerations, particularly in reference to
the formation of spores, there were a number of facts of
very considerable practical importance. The germina¬
tion of those organisms which form spores takes place-
on the same principles as the germination of the spores
in the higher fungi. The envelope is broken, the proto¬
plasm contained within it shoots out in the shape of a*
rod, which when it is fully formed elongates, divides, and
multiplies as in the case of the parent. In this way one*
bacillus, by repeated multiplication, forms a new crop.
When these have reached a certain phase of developmenb-
they again form spores which go bo start a new generation.
These spores have a much greater power of resistance than is-
possessed by the non-spore-bearing organisms, and can
withstand high temperatures, diyness, and the influence of
light, so much so that it has become almost a recognised
method of determining whether a particular species of
bacilli forms spores by subjecting the suspected organism to-
a temperature of 95° C. or 100° C. If they survive thie-
exposure, and if they survive drying, it may be taken a&
established that the growth is spore-forming.
IptiWk anil faft.
LOCAL aOVERNMEN’T DEPARTMENT.
REPORTS OP MEDICAL OlfPICERS OP HEALTH.
Torquay Urban District. —Mr. Karkeek devotes a con¬
siderable portion of his annual report for 1890 to the cir¬
cumstances of the influenza epidemic, which was the cause-
of an increase in the rate of mortality. That rate was-
17-1 in 1890, but after making deduction fordeaths amongst
temporary visitors it is only 15. The zymotic rate was
0-8 per 1000, a rate which many towns of 25,000 would envy
bud Mr. Karkeek says it is the highest one for five years-
past in Torquay. The sanatorium has maintained its useful;
work ; bakehouses, dairies, &c. have been regularly visited,
112 houses have been systematically inspected, and a con¬
siderable number of minor improvements have been effected.
On the whole, Torquay has not much to complain of, even
though a small rise in the general rate of mortality has
taken place for a single year.
Chelmsford Rural District.—la. referring to an increased
death-rate for this rural district—namely, a rate of 15‘(J-
per 1000—during 1890, Dr. Thresh notes a somewhat
excessive infantile mortality and an excess of deaths both
from measles and whooping cough. He also draws attention
to the high rate of mortality in Ingatestone and in-
Fryerning. which occurred mainly amongst children, but
which lie finds it dillicult to explain. The results of school-
closure in measles have been very various in different parts
of the country, and the experience which Dr. Thresh records-
must be added to the list of the failures, for in one village
where the schools were ordered to be closed for one month it
is stated that during that period every child in the villagOf
Coogle
1010 The Lancet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[May 2,1891.
contracted the disease. The account given of thirty-five
attacks of diphtheria is interesting, and it is typical of the
careful records kept as to the cirourastances associated
with other forms of infectious diseases. Nearly all the
complications and surroundings which make diphtheria
■difficult of explanation marked this group of attacks. In a
number of cases polluted water seemed the most prominent
circumstance ; but, on the other hand, there were instances
in which this cause seemed suggested, bat in which
aore-throats, the character of which had been unrecognised,
had preceded the attack which had drawn attention to the
water. On this subject it is well worth remembering that
Dr. Klein’s experience, as recently announced at the Koyal
'Institution, is to the effect that the bacillus of diphtheria
“is killed when kept for a few days in pure water,”
although the water to which Dr. Thresh refers may doubt¬
less have lacked the character of chemical purity. Then,
again, these Chelmsford cases were associated, some with
csewage effluvia, some with emanations from su-c&l^ed
London manure, and others with allied conditions. “ Drain
sore-throat,” as this affection is sometimes termed, pre¬
ceded some attacks, and emanations such as we have
'referred to may have conduced to produce a condition of
throat liable to receive diphtheritic infection. But sources
-of error often need elimination in this class of cases; and
Dr. Thresh mentions one instance in which certain mani-
pulations of London manure were suspected as a cause
■of diphtheria, but it was subsequently found that of
the group of eight cases in question, the first one attacked
only reached home the day after the manure operations
•commenced, having arrived from a hospital ward where
Another child lay ill of diphtheria.
Malden Rural District. —Dr. Thresh gives the death-rate
Tfor 1890 as 16‘1 per 1000 living, against a mean of 14‘8 for
1;he ten years 1881-90. In referring to a prevalence of
whooping-cough Dr. Thresh points out that school managers
and teachers rarely report any outbreak of disease until it
■has spread amongst the scholars, and then they want a
medical order for closing the school. In one case he was
-aaked to give such a certificate antedating the order for
■closure, apparently so as to secure the grant for the period
•antecedent to the intervention of the medical officer of
health ; but this was very properly refused. During the
year 27 cases of fever came under notice, 24 of them being
-enteric fever; but they were widely distributed, and no
•common cause seems to have been in operation in their
■causation. No less that S3 cases of diphtheria and croup
were notified, by far the majority having taken place in
Heybridge, Tolleshunt, D’Arcy, and Tolesbury, and the
'incidence of the disease is discussed at considerable length.
A number of sanitary defects were discovered and remedied,
bat their connexion with the prevalence was not made
-clear. In three instances scarlet fever and diphtheria are
stated to have appeared synchronously in houses; and
having regard especially to the fact that the diphtheria
’Somewhat preceded the scarlatina in two of the three in¬
stances, Dr. Thresh is inclined to look upon the two diseases
■as having some intimate association. The report includes
4 k detailed account of the sanitary work and administration
•of the district.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns 6079 births
And 4661 deaths were registered during the week ending
April 25bh. The annual rate of mortality in these towns,
which had been 22-9 and 22-5 per 1000 in the preceding
two weeks, rose again to 24 3 last week. The rate was
■21'0 in London and 27'0 in the twenty-seven provincial
towns. During the first three weeks of the current quarter
the death-rate in the twenty-eight towns averaged 23’2
per 1000, and exceeded by 1'4 the mean rate in the cor¬
responding periods of the ten years 1881-90. The lowest
rates in these towns last week were 110 in Brighton,
16‘2 in Derby, 17'7 in Salford, and 18 0 in Bristol; the
highest rates were 33’0 in Preston, 33 9 in Halifax, 36’5 in
Hull, and 67'8 in Sheffield. The exceptionally high rate in
the last-mentioned town was due to a severe epidemic of
influenza. The deaths referred to the principal zymotic
diseases, which had declined in the preceding three weeks
from 468 to 420, rose again last week to 428; they included
151 from whooping-cough, 122 from measles, 51 from
diarrhcea, 36 from scarlet fever, 35 from “fever” (prin¬
cipally enteric), 33 from diphtheria, and not one from small¬
pox. These diseases caused the lowest death-rates in
Brighton, Sunderland, Norwich, and Derby, and the
highest rates in Nottingham, Plymouth, Bradford, and
Portsmouth. The greatest mortality frommeaslesoocurred in
Salford, Blackburn, Plymouth, Oldham, and Portsmouth;
from scarlet fever in Halifax and Bradford; and from
whooping-cough in Nottingham, Newcastle-upon-Tyne,
Plymouth, Bradford, and Leicester. The mortality from
“ fever ” showed no marked excess in any of the twenty-
eight towns. The 33 deaths from diphtheria included 28
in London, 3 in Cardiff, and 2 in Liverpool. No fatal case of
small-pox was registered laatweek in any of the twenty-eight
towns; 19 small-pox patients were under treatment in the
Metropolitan Asylum Hospitals and 1 in the Highgate
Small-pox Hospital on Saturday last. The number of scarlet
fever patients in the Metropolitan Asylum Hospitals and
in the London Fever Hospital at the end of the week was
940, and showed a further decline from recent weekly
numbers; the patients admitted during the week were 85,
against 77 and 84 in the preceding two weeks. The deaths
referred to diseases of the respiratory organs in London,
which had been 464 and 504 in the preceding two weeks,
declined last week to 471, and exceeded by 83 the corrected
weekly average. The causes of 109^ or 2'3 per cent., of the
deaths in the twenty-eight towns were not certified either
by a registered medical practitioner or by a coroner. All
the causes of death were duly certified’ in Portsmouth,
Norwich, Derby, Bolton, and Cardiff; the largest proportions
of uncertified deaths were registered in Nottingham and
Sheffield.
HEALTH OP SCOTCH TOWNS.
The annnal rate of mortality in the eight Scotch towns,
which had declined from 26'7 to 22'6 per 1000 in the preceding
four weeks, further fell to 22‘1 during the week end¬
ing April 25th, and was 2 2 below the mean rate that
prevailed daring the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns ranged
from 10’8 in Perth and 12‘2 in Leith to 27'3 in Glas¬
gow and 46‘0 in Paisley. The 586 deaths in these towns
showed a slight decline from the number in the preceding
week, and included 43 which were referred to measles,
32 to whooping-cough, 7 to diarrhoea, 4 to diphtheria, 3 to
“fever,” 1 to scarlet fever, and not one to small-pox.
In all, 90 deaths resulted from these principal zymotic
diseases, against 80 and 81 in the preceding two weeks.
These 90 deaths were equal to an annual rate of 3'4 per
1000 , which exceeded by 1‘2 the mean rate from the
same diseases in the twenty-eight Eoglish towns. The
fatal cases of measles, which bad been 33 and 41 in
the preceding two weeks, further rose last week to 43, of
which 24 occurred in Paisley, 13 in Glasgow, and 6 in
Edinburgh. The deaths from whooping-cough, which had
been 25 in each of the previous two weeks, rose to 32
last week, and included 20 in Glasgow and 5 in Dundee.
The 4 fatal cases of diphtheria were fewer than those re¬
corded in any recent week, and included 2 in Glasgow.
The deaths referred to different forms of “fever,” which had
been 6 and 1 in the preceding two weeks, increased to 3 last
week. The deaths referred to diseases of the respiratory
organs in these towns, which had declined from 201 to 142
in the preceding six weeks, were 143 last week, and 13
below the number in the corresponding week of last
year. The causes of 49, or more than 8 percent., of the
deaths in the eight towns last week were not certified.
HEALTH OP DUBLIN.
The death-rate la Dublin, which had been 30'6 and 27'5
per 1000 in the preceding two weeks, further declined to
27‘0 during the week ending April 25th. During the first
three weeks of the current quarter the death-rate in the
city averaged 27'0 per 1000, the rate for the same period
being 20‘5 in London and 17‘7 in Edinburgh. The 166
deaths in Dublin showed a decline of 30 from the number
in the preceding week, and included 4 which were referred
to whooping-cough, 1 to “fever,” 1 to diarrhcea, and not
one either to small-pox, measles, scarlet fever, or
diphtheria; in all, 6 deaths resulted from these principal
zymotic diseases, against 8 and 7 in the preceding two
weeks. These 6 deaths were equal to an annual rate of
0'9 per 1000, the rate from the same diseases being
Coogle
The Lancet,]
PUBLIC HEALTH AND PEOFESSIONAL COURTESY.
[May 2, IbOl. 1011
l‘9in London and 17 in Edinburgh. The fatal cases of
whooping-cough, which had been 2 and 7 in the preceding
two weeks, declined again to 4 last week. The 156 deaths
in Dublin last week included 24 of infants under one year
of age and 59 of persons aged upwards of sixty years; the
deaths of infants showed a further decline from those re¬
corded in recent weeks, while those of elderly persons
showed an increase. Three deaths from violence and 5
inquest cases were registered during the week, and 43, or
more than a fourth, of the deaths occurred in public
institutions. The causes of 20, or nearly 13 per cent., of
the deaths lost week in the city were not certified.
THE SERVICES.
Army Medical Staff. —Surgeon-Major H. Archibald
Fogerty, M.D,, is placed on temporary half-pay (dated
April 15th, 1891).
Indian Medical Service.— Brigade Surgeon Hamilton
is appointed to the administrative charge of the Allahabad
District in place of Deputy Surgeon-General Rudd; Brigade
Surgeon Graves succeeds Deputy Surgeon-General Hindo at
Poona; Deputy Surgeons-General Warren and Walsh are
under orders for India, the former for Poona and the latter
for Allahabad.
Naval Medical Service.— In accordance with the pro¬
visions of Her Majesty’s Order in Council of April 1st, 1881,
Deputy Inspector-General of Hospitals and Fleets William
Jas. Eamos has been placed on the Retired List at his own
request, with permission to assume the rank of Inspector-
General of Hospitals and Fleets.
Volunteer Corps. — Artillery: 1st Glamorganshire:
George Herbert Hopkins, Gent., to be Acting Surgeon
(dated April 25th, 1891),— Bijle: Ist Volunteer Battalion,
the Royal Warwickshire Regiment: Richd. Arthur Newton,
Gent., to be Acting Surgeon (dated April 25tb, 1891).—
4th Volunteer Battdion, the Cheshire Regiment: Surgeon
W. E. S. Burnett is granted the rank of Surgeon-Major,
ranking as Major (dated April 25bh, 1891).—2nd Volunteer
Battalion, the Cameronians (Scottish Rifles): Surgeon and
Surgeon-Major (ranking as Lieutenant-Colonel) J. Loudon,
M.D., resigns his commission; also is permitted to retain
his rank, and to continue to wear the uniform of the
Battalion on his retirement (dated April 25fcli, 1891).
" Audi alteram partem.”
“THE PROPOSED RECONSTITUTION OF THE
LONDON UNIVERSITY.”
To the Editors of The Lancet.
Sirs,—P ermit me to make a brief comment on a state¬
ment in Dr. Hale White’s letter published in your last issue.
Dr. White states that the Senate of the University of
London received a letter dated March 3rd, 1891, expressing
the acceptance of their last promulgated scheme by certain
London medical schools (named). 1 was at the epoch men¬
tioned, and am still, a member of the Medical Council of
one of these (named) hospitals and of the governing body of
the medical school attached thereto. I am sure that the
project of the Senate has never been considered by the one
nor has it appeared on the agenda paper of the other of these
bodies. I am forced to conclude that the letter in question
does not afford very reliable support to the views expressed
by Dr. White. I am equally sure that I am not alone
among my colleagues in the belief that whilst the scheme
in question will destroy the value of the degrees of the
London University, it will not meet the legitimate demand
of the London medical student.
I am, Sirs, yours faithfully,
London, April 21tla, 1891 . M.D.LOND., F.ll.C.P.
PUBLIC HEALTH AND PROFESSIONAL
COURTESY.
To the Editors of The Lancet.
Sirs,—I n your impression of April 4bh, 1891, and
amongst the annotations, is to be found the above, and
upon which you comment. In view of your not having had
a copy of my report in extenso I beg to enclose you one,
whicn I will ask you to carefully peruse, and specially that-
part of it relating to the outbreak of diphtheria at Brandon.
This part of it is, seriatim, a copy of the special report-
which I presented to the Thetford Rural Sanitary Authority,
under whom I act, and also to the Local Government Board,,
at their request in June last, 1890. Neither of these-
councils have asked me for an explanation of any of the
paragraphs, and therefore I conclude they interpreted thent
in the light intended by me, but to which exception seems
to have been taken by your correspondent. No one has
been more astonished than myself at the misconstruction
which has been placed upon them, and I can only regret
that your correspondent should have imputed to me the-
charges of professional discourtesy.
I distinctly deny that any part of the report was intended
as a reflection upon the conduct of the cases of diphtheria,
by the medical attendant, but it was rather an admonition
to the public generally and a repetition of the tenets
which I have repeatedly advocated in former reports, in-
order that early and timely medical advice should be
obtained, and thus give the medical attendant a fairer-
prospect of conducting bis case to a successful issue,
and also to facilitate the work of the health officials.
In the paragraph of which complaint is made, I was
led to infer this (a) from the personal statement of the-
medical attendant to me, and (6) his admission by letter,
which I possess, “ that it is a great question whether sepsis
may not account for the bronchitis.” Under this suggestion
had I not reasonable grounds for regarding its possible-
origin in the illness at Leeder’s house? And this eliminates
the charge of my going behind the certificate of death.
With regard to the examination of the infectious coses,.
I admit having seen some of them, hut at his reguest, as he-
was anxious about the serious phase the cases assumed. It
must be evident there could be no particular wisdom in court¬
ing infection myself, except for some mutual or ulterior
good purpose. I have endeavoured to lay before you a
hond-fide statement, which I feel persuaded will enable you
to absolve me from the charge of which I have been,
accused.—I am, Sirs, yours faithfully,
Brandon, Norfolk, April 20bli, ISOl. FREDERICK JOY.
We are glad to receive Mr. Joy’s letter, which-
was unfortunately crowded out of our last issue. Our
comments were largely based on such expressions as that-
“ the element of fatality in every case, save one, which
attended the outbreak was mainly duo to imperfect medical-
supervision,” and the assurance of our correspondent that
the medical officer of health “ never saw, either ante
mortem or post mortem, the children Leeder and Dyer.”'
But it would seem clear that such wording of the report as
appeared to imply slight were never so intended, and we feel
conlident that Mr. Joy’s assurance to that effect will be-
accepted in full.— Ed. L.
THE TREATMENT OF GALL-STONES : A
SUGGESTION.
To the Editors of The Lancet.
giRS,—Mr. Walker’s case of “ Removal of Gall-stones by
Ether Solution,” -which -was published in your issue of the
18bh inst., has been specially interesting to me. For some
live or six years ago, when a student in the class of physio¬
logy and pupil to a surgeon, under whose care I had seen
a case of biliary colic, the idea struck me that if ether were
to be injected’ with a hollow needle direct into the gall¬
bladder gall-stones might be dissolved in situ. Amt
ever since then I have been very anxious to test this
method, and have mentioned it to several friends with
the hope of meeting with a suitable case, but so far I have
not been successful. The few cases of biliary colic which I
have bad the opportunity of seeing have yielded quickly
to opiates and general treatment. Of course, in a case such
as Mr. Walker reports, where there is a sinus leading into
the gall-bladder, the treatment- he adopted was as simple as-
it was ingenious and rational. But, on the other hand,
grave difficulties surround the injection of solvent fluids
direct into the gall-bladder by the “hypodermic’'
method. In the first place, we must have a case in which
the gall-bladder can be localised against the abdominal
Google
Dir-
1012 The Lancet,] INTERNATIONAL CONGKESS OF HYGIENE AND DEMOGRAPHY. (May 2,1891.
wall; secondly, we should have the facilities for imme¬
diately performing the operation of cholecystotomy should
any symptoms of general peritionitis &c. threaten.
Next, as to the dangers of intra-cystic injections :
-<1) Inflammation and suppuration of the gall-bladder
and its sequelco ; (2) the needle prick might pos¬
sibly (the obstruction not yielding) lead to extrava¬
sation within the peritoneal cavity, though probably
adhesions would ere this have been contracted or lymph
have closed the aperture. How might these dangers he
obviated? (1) By being careful not to inject too irri-
'tating a solvent •, (2) by, if possible, removing some
of the fluid from the gall-bladder previously to inject¬
ing the solution. I have always intended injecting a
mixture of ether in olive oil with the hope that the oil
would do away with the risk of causing inflammaiion &e.
To this a little chloroform might be added. I should feel
unolined always to employ a solution containing some
-alcohol in addition to the above. For when bile stagnates
for any length of time the bilirubin is transformed into bill-
verdin, which is only slightly soluble in ether and not at all
•in chloroform. But biliverdin is soluble in alcohol,
whereas cholesterin is soluble in either ether, chloroform, or
warm alcohol, and bilirubin is soluble in chloroform.^ And
the composition of gall-stones is well known to be either
pigment or cholesterin separately; or both these combined.
I feel that the method of treatment which I have thus
endeavoured to explain may be at least worthy of a trial;
and I cannot but think that had Mr. Walker’s patient been
subjected to intra-cystic injections of such a solvent as I have
suggested it might have so lessened the obstructing stone as
to nave allowed it to pass into the intestine; and that even
possibly underrepeated injections theremainingcalculi might
nave gradually been dispersed; and thus the operation of
eholecystotomy not been required. (Of course, experience
only can show whether or not intra-cystic injection would
not be more dangerous than cholecystotomy.) The fact
that there is no reference whatever to intra cystic injections
for gall-stones in the standard works of medicine, or in
Dr. Neale’s “Digest,” may he a sulficient apology for the
above suggestions which I offer for the consideration of your
-readers. I am. Sirs, yours faithfully,
Marcus M. Bowlan.
Workhouse Hospital, Newcastle-on-Tyne, April 22ncl, 1891.
TACHYCARDIA.
To the Editors of The Lancet.
Sirs, —In an article appearing in the March number of
the Univarsity Medical Magazine (Philadelphia) Professor
H. C. Wood has effectively delineated a class of cases
interesting alike by reason of rarity and obscure origin.
They are the more worthy of note at the present time, when
the general subject of angina, to which they are akin, has
in the Medical Society of London elicited so various
opinions. Dr, Wood proposes the restriction of the name
“ tachycardia” to those cases in which very violent heart
action occurs without obvious reason, and remarks that
“most of them belong to one of three classes : first, those
in which there is paralysis of the pneumogastric or inhibitory
nerve; second, those in which the cardiac disturbances are
reflex ; third, those in which the affection may be considered
as strictly a neurosis. Of the second variety he observes
that he has never himself seen a case, “though Rommelaere
reports one in which he asserts that an extremely rapid
action of the heart was due to the irritation caused by
biliary calculus.” An instance of this form of tachycardia
came under recent observation in the person of an American
lady visiting the family of a friend in my immediate
vicinity. Sue was an intelligent woman of middle age, of
healthy configuration, but at the moment of my entrance in
apparently great distress. Orthopncca and a degree of
cyanosis were present, and her account was rendered in
whispers, delivered in an ejaculatory manner.
This was her fourth attack, all of them occurring within
a period of two years. They had come on always imme¬
diately after a hearty meal, lohich had included piclcles or
fruit, and which followed upon considerable physical fatigue.
She had had skilled attendance, and a variety of treatment
during the attacks, but nothing availed until the stomach
was emptied medicinally. The pulse was hardly to be felt
at the wrist, and was estimated under auscultation at 200.
Respiration was hurried and short, and the dyspncea was
1 Vide Landois and Stirling, 3rd edition, pp. 208-9.
painful to witness. At her urgent request I administered
emetine in full dose, with a draught of warm water. Upon
the first copious emesis the pulse reappeared in full beats,
iving five or six impulses at a rate of 48, then, within a
alf minute, falling into a rhythm of 80, which continued
during my observation. All difficulty of respiration passed
away with this recovery of the pulse, and in a very short
time the patient expressed herself as being “ perfectly com¬
fortable.” Careful examination detected no evidence of
organic disease of the heart, and no other diagnosis now
appears so appropriate as that of “ reflex tachycardia.”
I am. Sirs, yours truly,
H. Webster Jones, M.D.,
Lfl-iigliara-streot, W., April 27th, 1891, Yale University.
INTERNATIONAL CONGRESS OF HYGIENE
AND DEMOGRAPHY.
To the Editors of The Lancet.
Sirs, —Will you allow us to draw the attention of the
readers of The Lancet to the forthcoming International
Congress of Hygiene and Demography which will be held in
London in August next under the presidency of H.R.H. the
Prince of Wales. The last meeting of the Congress took
place in Vienna in 1887, where members from all countries
were most hospitably received and entertained. Experience
of former congress meetings shows that the necessary
expenses of the arrangements for the reception of from 3000
to 4000 members, the printing of transactions, corre¬
spondence and postage, cannot be kept lower than £6000 or
£7000. We venture to appeal therefore to all those who are
interested in the progress of hygiene, the improvement of
public health, and the amelioration of the conditions under
which the inhabitants of towns and other groups of popula¬
tion exist, to aid the committee in their endeavours to
make the London meeting of the International Congress
not only a success, bub worthy of the country which has
always been distinguished not only for its hospitality, but as
a power in the worlc of practical sanitation. All donations
from members of the medical profession will be acknow¬
ledged in The Lancet. —We are, Sirs, yours faithfully,
Douglas Galton,
(Jhainnan of tho Organising Coinmitfcee.
W. Eobt. Cornish,
Chairman of the finance Committeo.
G. V. Poore,
Hon. Sec. General.
N.B.—Full particulars and list of donations will befound
on pages 6-3 and 64 of our advertisement columns.
CLINICAL INSTRUCTION IN INFECTIOUS
DISEASES.
To the Editors of The Lancet.
Sirs, —As you are drawing attention to the facilities
afforded to medical students for becoming acquainted with
the symptoms and treatment of infectious diseases, I think
it opportune to remind your readers and the President of
the Society of Medical Olficers of Health, who also has
been alluding to this important subject, that no difficulties
have ever attended instruction in this department of
medical study so far as Edinburgh is concerned. From the
first the corporation insisted on clinical instruction being
given in the City Hospital. Classes have been successfully
carried on during tne last five years, and nearly 200
students annually take advantage of them, from six to
eight separate courses being given during the session. I
am informed by Dr. Wood, the medical superintendent,
that “two years ago it seemed highly probable that one
student contracted scarlatina.” This is the only case in
which there has been any suspicion of infection having
been contracted in connexion with these classes.
I am, 8irs, yours faithfully,
Henuy D. Litti,e.ioiin,
Edinburgh, April 29th, 1891. Medical Oflteor of Health.
“THE VALUE OF TUBERCULIN IN
THERAPEUTICS.”
To the Editors o/The Lancet.
Sirs,—I should feel obliged to you if you would kindly
allow me to refer in a few lines of the next issue of
oogic
Dir:' ;^d :
Thb Lanobt,
BIRMmGHAM.-MANCHESTEE.
[May 2,1891. 1013
The Lancet to a remark made in one of your leading
articles to-day.
The first sentence of the paragraph, beginning half-way
down page 943 of The Lancet, runs thus: “ It is some¬
what remarkable that the most damaging criticism upon
the use of tuberculin as a remedy—that, namely, which
was made on the authority of Professor Virchow—should
have been passed over in silence by Dr. Heron.” Whatever
Professor Virchow may say concerning a matter of im¬
portance in pathology is entitled to be received by every
medical man with the greatest respect. My reason for
passing over in silence his criticism, to which you refer, is
that I nave never seen such cases as those mentioned by
Professor Virchow. Until I have seen such cases, or untu
the evidence touching them is completed, it would, I think,
ill become me to express any opinion about them,
I am. Sirs, yours faithfully,
Havley-stroet, W., April 266 h, 1891. G. A. HeRON.
THE ARMY MEDICAL STAFF.
To the Editors o/The Lancet.
Sirs,— Mr. Stanhope having intimated his willingness
to confer military and medic^ titles upon officers of the
medical staff in accordance with the recommendation of his
own committee, the earlier re(}uest of Sir Andrew Clark,
and presumably with the concurrence of the Director-
General, it is to be hoped that you will use your powerful
inlluence in protesting against the refusal of a concession
which must have cost “my military advisers” a consider¬
able twinge. The ranks would be better defined, and, as
a first step in the direction of a corps of Iloyal Surgeons,
these titles would be of undoubted advantage in familiarising
the public and the army to a change which must come
sooner or later. The concession would satisfy a large pro¬
portion of the officers, and, if substantive titles with the
present limited command, were distinctly laid down,
should allay agitation in a profession which can point to
quite as honourable a history as that of the profession of
arms. I am. Sirs, yours faithfully,
April 20ch. 1891. SeNIORES.
BIRMINGHAM.
(From our own Corre.spondent.)
Small-pox.
After having had no cases of small-pox for two years,
the Health Committee report an outbreak in one quarter of
the city occurring in four houses. Seven patients were
implicated ; these were promptly removed to the Borough
Hospital aud the houses disinfected. It is believed to
have been introduced by a traveller, who brought it from
Lisbon in his clothes, one who himself escaped the disease.
Of course this is somewhat difficult of proof. The out¬
break has caused some consternation, and has elicited a series
of letters in the local press.
Dr. Koch’s Treatment,
A largely attended meeting was recently held at the
Medical Institute to hear the results of various local expo¬
nents ;of this treatment. The discussion was opened by
Mr. Barling, who gave an interesting aeries of cases treated
by him in the General Hospital. Various other speakers
also gave instances, and their respective views were received
with considerable attention. On the whole, the tendency
of the discussion showed that though in many instances
marked benefit had been obtained, there was yet not sufficient
evidence of the remedy affording permanent cure. Aprojyos
of this meeting, indignation has been freely expressed at a
report of it appearing in an evening paper of the following
day.
Midland Counties Idiot Asylum.
The annual meeting of this useful institution was held
this year at Slirewsbuiy, under the presidency of the
Mayor. According to tlio most recent figures, the number
of idiots and imbeciles iu Shropshire was 1730, in Warwick¬
shire 1516, Leicestershire 1311, Worcestershire 1109, ami
Staffordshire 116-1. The institution is situated at Kuowle, I
near Birmingham, and receives fifty patients. A sub- '
co)mnitteo was appointed to consider the question of enlarge¬
ment, and it was resolved to proceed as soon as £2000 had
been raised. The financial report was fairly satisfactory^
and much good had been done cowards improving the con¬
dition of the patients.
Prosecution, under the Medical Act.
An important prosecution undertaken by the Medical
Defence Union took place at Aston on the 28Ch inst. A
Mr. S. E. L. Smith, whose name is on the Register as an-
L S.A., was the defendant. It was shown that he had on
many occasions signed himself us M.D.; on a brass plate
outside his house he is described as “ Physician and Sur¬
geon,” and on another plate as “ Dr.” Smith. The defence
set up was that the Act was not meant to punish duly quali¬
fied practitioners from assuming a higher title than that-
possessed, but for the prevention of quackery and against
those holding no qualification at all. Defendant passed
the examination of the Society of Apothecaries in 1885,
and in addition obtained the degree of M.D. of Indiana¬
polis. Some amusement was caused in court by the reading,
of a testimonial in favour of a certain wine being suitable
for invalids, and signed with the defendant’s name, andthe-
initials of M.D., L R G.P., L.M., and L.S.A. (Eng.). On
being asked the meaning of the second series, the defendant
replied that it meant Legally Registered General Practi¬
tioner. Some discussion followed, and eventually the defen¬
dant was fined the maximum penalty of £20 without costs.
In two other cases defendant was also fined 40$. and advo¬
cate’s fee, and in each instance a case for appeal was granted.
Birmingham, April 27th.
MANCHESTER.
(From our own Correspondent.)
The Infirmary. — Nurses' Pensions.
At present there has been no new development with
regard to either the proposed extension of the infirmary or
the erection of a new hospital upon the site offered by the
College; in fact, both bodies are, in Yankee phrase, for the
time being, “lying low.” But all those interested in the-
question are looking forward with considerable interest to
the next move on either side, and periodically communica¬
tions appear in the daily papers, notunfrequently in strongly
worded epistles. Thus one gentleman, speaking evidently
from the college standpoint, asks whether “there is less
smoke and sulphurous acid in the neighbourhood of the
infirmary now than some few years ago, when the site was
unanimously condemned by the staff aud governing body?
Whetlier it has been discovered that the conditions which
have killed the' hollies and shrubs around the infirmary
are favourable to human invalids? Is fog found to be
a wholesome counter-irritant, or are the noise and
racket of Piccadilly excellent tonics for weak nerves?”
That the Infirmary Board feel they owe their consti¬
tuents a more explicit statement of the reasons which have
led them to decline the College offer was practically ad¬
mitted by the chairman at the board meeting held yester¬
day, for he said that a statement was in course of pre¬
paration defending their position, and would shortly be
placed in the bands of the whole body of subscribers. At
the same meeting the Board established a scheme of pen¬
sions for their nurses which provides an annuity cf £25
per annum to those who have been on the staff for twenty-
live years, and who shall have attained the age of fifty-
five. It also provides for gratuities or pensions to nurses
of ten years’ service whose health shall break down whilst
in the discharge of their duties so as to unlit them for further
nursing work. Hitherto the pensioning and relief of old
servants have been carried out in a rather haphazard way,
without any fixed or definite rules being laid down.
Air Polhiiion.
A further report upon the impurities of our atmosphere
bos been issued by the “ Noxious Vapours Abatement)
Association.” Samples of rain water were examined from
the centre of the city and from the middle of Ancoats, one
of the murkiest and most air-polluted of our districts. The
analyses show that the suspended matter is three times
more in Ancoats tlian in the centre of the city. Of the
matters in solution, the organic matter was much greater
in the city than in Ancoats, but the free ammonia, sul¬
phurous and other acids were largely iu excess in the latter
district. The figures, for which Mr. William Thompson*
Di; zed by CjOO^IC
1014 ThbLakcet,]
MANCHESTER.—NORTHERN COUNTIES NOTES.
[May 2,1891,
one of oar w^l-known analytical chemists, is responsible,
are as follows:—
Suspended matter
which is composed of—
Mineral matter...
Soot, organic matter, combined water, &c. ...
Total solid matter in solution ' .. : . . ..
which is composed of—
Organic matter, combined water, &c..
Mineral matter.
Free ammonia.
Albuminoid ammonia .
Chlorine .
Oxygen contained in permanganate of potash
required to oxidise organic matters Ac.—
Acting at 80 deg. F. during 15 minutes ... ...
Acting at 80 d^. F. during 4 hours ... ... >.
Sulphurous acid. » ...
Fi-ee acid calculated as sulphuric acid ... ..
Grains per gallon
rain water from
Ancoats. Manchester.
27-194 ..... 9'330
13-962 ..... O-0S5
13-232 ..... 9-245
27-194 9-330
6-440 .... 6-80
2080 .... 6-24
4-380 .... 1-56
0-546 .... 0-202
traces .... traces
0-268 .... 0-833
0-2786 . 0-S997
0-3828 ..... 0-8571
0-4004 .... none
1-029 .... 0-2058
The same subject came up for discussion at the recent
meeting here of the North-western Society of Medical
Officers of Health, when Dr. Thompson, the President for
the year, took it as his text for an inaugural address. In
the discussion that followed, many of the speakers, including
magistrates, engineers, as well as officers of health, con¬
tended that the time was fully come when public authorities
should deal vigorously and determinedly with this plague
of our large towns, that there were ample powers for so
•doing, and that practical means were available for very
largely abating this unwholesome factor of town life.
Trained Nurses in Workhouse Hospitals.
We have recently had a public meeting (presided over by
the Right Hon. J. T. Hibbert) to support the work of the
Northern Workhouse Nursing Association. We have now
’for so many years in Manchester been used to find properly
trained nurses in the sick wards of our workhouse that
one was apt to think an equally satisfactory condition
of things existed generally elsewhere. From the statements
and remarks made by various of the speakers it appears
that this most desirable, and one might almost say humane,
arrangement is far from being universal. If it could but
be instilled into the brain of the average guardian, in every
Poor-law union, that skilled nursing is in the end more
economical than the makeshift, inefficient arrangements
which have in the past been far too prevalent, the desired
ohange would be quickly brought about. But a question
of this sort ought nob to depend merely upon £ s. d. An
influential and representative committee was appointed for
'furthering the aims of the Society.
Salford Hospital d:e.
Upwards of half a dozen times have the Salford Guardians
had the appointment of a resident medical officer to their
hospital at Hope before them ere they could make up their
minds upon the subject. It has at last been settled by the
appointment of Dr. Garry, and it is to be hoped that things
at this institution may now proceed more smoothly than
has been the case during the past few years. At the last
meeting the Town Council ordered the closing of twenty
cellar dwellings. Few people fully realise what cellar
dwellings really imply to those who are unfortunate enough
to inhabit them. It is stated that some 200 of these still
exist in our neighbouring borough—at least, Manchester has
nottbu sanitary sin upon its shoulders.
Manchester, April 28th.
NORTHEEN COUNTIES NOTES.
(From oub own Correspondent.)
The Increased Death-rate of Newcastle.
With regard to the high death-rate recently noted in
Newcastle (31 per 1000), the medical officer of health, Mr.
H. E. Armstrong, reported to the Sanitary Committee of
the Corporation that in a total of 205 deaths daring the
fortnight ending April 18th, the principal factors were—
zymotic diseases 13 (including 10 from whooping-cough) and
diseases of the respiratory organs 53; the remaining causes
of death were comprised in phthisis, scrofulous diseases,
diseases of the heart, diseases of the brain and nervous
system, and old age. Excepting with regard to whooping-
cough, the zymotic death-rate has not been high.
The Chief Constable on Crime in Newcastle City.
Captain Nicholls, in his report to the Watch Committee,
says that the condition of the city as to serious crimes has
been satisfactory, but that a comparison of the quarter
with the corresponding one of 1890 shows that an increased
number of about 600 persons had been proceeded against.
The large increase, he explains, is made up by greater
vigilance as to drunkenness and parents ill-treating their
children. Visits had been made to 177 families, the parents
of whom had been proceeded against under the Act of 1889;
the families represent 625 children. An experienced con¬
stable visits these families, and has so gained their con¬
fidence that they now look upon him as cheir benefactor,
and often seek from him advice and assistance.
The Influenza in the North of England.
Since I last wrote the influenza epidemic has considerably
extended its area in the north of England, and it may be
said to reign from the Humber to the Tyne. Hull has felt
it severely; also Scarborough and many of the North
Yorkshire towns and villages, especially Ripon and the
Northallerton district. In the Hartlepools, and indeed on
both sides of the Tees, it has been rife, many of the resi¬
dent practitioners being much overworked.
Stockton and Trained Nurses.
An influential meeting has been held at Stockton to con¬
sider a scheme suggested by Lady Londonderry for an
institution for trained nurses for Stockton. The Mayor
presided, and there was a very representative meeting. It
was proposed and decided to start with four nurses, who
would cost about £400, to attend the sick poor in the
Parliamentary borough, and that such institution should
be established irrespectively of politics or creed.
Darlington and the Cremation Question.
The people of Darlington had the cremation question
very fully presented to them at a public meeting at which
the Mayor presided, and an able address was given by Pro¬
fessor A. W. Hare, in which he showed that there was no
subject which had a more direct sanitary bearing than the
disposal of the dead, and that its importance would become
greater and greater as from decade to decade the census
showed an increase in the population of the country. A
motion in favour of cremation and of a crematorium being
erected in Darlington was carried with only a few dis¬
sentients. Mr. Manson, surgeon, in proposing a motion,
mentioned that in Darlington and the district they had
heard for some years about the pollution of the river Tees
and the consequent pollution of the drinking water.
Amongst other pollutions was the drainage from eighty
churchyards, and he pointed out that “wherever places of
sepulture were they were to be drained, and the Darlington
people were drinking the liquid.” He said the fact should
bring home to their minds that earth burial was dangerous
to everyone of them, and that cremation was to be advo¬
cated on sanitary grounds.
Middlesbrough.
At a late meeting of the Middlesbrough Fever Hospital
Committee it was stated that there were now in the hospital
twenty-four patients, and that the expenditure for the past
year would exceed the estimate by about £500, owing to the
epidemic of typhoid fever with which the town had been
visited. At a meeting of the Port Sanitary Authority
Dr. Malcomson was reappointed medical officer. A large
number of foreign and home vessels had been visited, and
seamen found suffering from infectious diseases had been
removed to the floating hospital. The annual meeting of the
North Ormesby Cottage Hospital near Middlesbrough has
been held, and a record of good work has been presented, the
medical officers and sisters receiving the warmest thanks of
the council. Owing to the great increase in the number of
patients in the out-door department, it had become neces¬
sary to extend the hospital buildings, there being 9000 at¬
tendances during the year. An appeal made to the working
men of the district had produced over £600. The house-
surgeon’s report showed that 483 in-patients had been
admitted, and that the increase of in-patients over the
previous year had been forty-one.
South Shields.
A numerously attended meeting of representative mem¬
bers of the various friendly societies has been held at South
Shields, at which the Mayor presided, for the purpose of
promoting the Friendly S'jcieties’ Convalescent Home lately
Google
Thb Lakobt,]
SCOTLAND.—IRELAND.
[May 2,1891. 1015
established at Grange-over-Sands. The Mayor thought it
would be au improvement in the management if honorary
members like himself could have tickets to use for some of
the poorer workmen, and with this suggestion the meeting
.appeared to agree.
Th& Sigh Death-rate at the Durham County Asyhim,
Sedgefield.
Dr. Smith, the superintendent of the Sedgetield Asylum,
in his yearly report, in reference to the high death-rate of
•the asylum, says “ deaths had been very numerous. There
was an alarmingly large proportion of disease found in
patients who had been a long time in the asylum, and who
'on their admission showed no trace of disease; 37 per cent,
•of the disease was lung disease. Where large num¬
bers of people congregated in a bouse there was
•always a tendency to lung disease, and especially if
the rooms were badly ventilated, or, what was the same,
•overcrowded.” Dr. Smith says that another factor in the
production of lung disease was the abstraction of oxygen
'from the atmosphere owing to the use of coal gas as an
dlluminant, and the escape of its poisonous products into
the rooms. This, he believed, was a much more frequent
•cause of lung disease than was usually thought. Daring
■the year the large number of 1‘190 patients had been
■under treatment, of whom 147 had recovered. Dr. Smith’s
•opinion of the New Lunacy Act is that it would merely
dnorease the work and expense.
J?ewcastle-on-Tyne, April 27th.
SCOTLAND.
(From our own Correspondents.)
EDINBURGH.
Opening of the Summer Session,
The summer session in the Faculty of Medicine, Edin-
5)urgh, opens on Monday, the different classes, both in the
University and the extra-mural school, being advertised to
begin on that day.
Medical Officers of Health Society.
Last week a meeting of the medical officers recently
appointed by the County Councils was held in the rooms of
<)he Royal Medical Society of Edinburgh, at which it was
resolved to form a society of medical officers of health, and
that medical men holding diplomas in Public Health might
be associated with it. A committee was appointed to draw
■up a constitution for the Society, and it was resolved that
meetings should be held alternately in Edinburgh,.Glasgow,
•and Perth.
Health of Edinburgh.
The mortality last week was 90, making the death-rate
517 per 1000. Diseases of the cheat accounted for 26 deaths
And zymotic diseases for 8, of which 5 were due to measles
And 3 to whooping-cough. The intimations for the week were
2 from diphtheria, 19 from scarlatina, and 114 from measles.
A new University Hall at Edinburgh.
There has recently been founded in connexion with Edin¬
burgh University a “ University Hall,” the object of which
'is to inaugurate among Edinburgh undergraduates a system
■of social residence such as obtains in the English Uni¬
versities. Two buildings have been taken overfor thispui-
j> 08 e—one at Mound-place, another at Riddle’s-court, and
•already there are nearly thirty residents.
GLASGOW.
The Census and the Death-rate.
At the last meeting of the Town Council the fact was
[pointed out that duiing the last decade the estimate of the
population made by the medical officer of health and that
made by the Registrar-General had differed very consider¬
ably, and that the result of the census had shown that the
anedical officer was very much nearer the truth than the
Registrar-General. The figures given by the latter as the
•estimated population of Glasgow in 1890 were 532,282. The
census of those within the municipal boundaries made it
•564,975, the estimate of the medical officer having been
•567,656. The result of this difference in the estimate of the
population had been that the death-rate of the city had
appeared to be during the last few years 1'5 per 1000 higher
(than it ought to be.
St. Mungo's College.
At the annual meeting of this institution, held last
Monday, it was stated that 100 students had attended the
medical classes alone. Referring to the subject of affilia¬
tion to the University, the Principal pointed out the
absolute necessity of placing the College on a firm founda¬
tion financially. Some progress had been made in securing
endowment; of the sum of £20,000 aimed at, already £7000
bad been subscribed.
Dr. E. Duncan on Tlvmbers.
In a lecture delivered recently on “ The Sanitary Aspects
of the Plumber’s Work,” Dr. Duncan summed up the results
of his inquiries as follows:—“(1) Plumbers are not more
liable than other persona to the class of zymotic diseases
usually supposed to arise from sewage emanations; (2) that,
although they do not suffer from typhoid fever or diphtheria,
they donotsufferfromminor ailments, such as sickness, vomit¬
ing, diarrh(3ja, and sore-tbroat, in consequence of exposure to
offensive emanations from choked drains and soil-pipes;
(3) that plumbers in Glasgow, like their brethren elsewhere,
suffer to a considerable extent from the toxic effects of lead.”
Id discussing some of the dangers to which plumbers are
exposed in dealing with drains, Dr. Duncan observed that
“neither decomposing typhoid excreta nor decomposing
sputum, whether diphtheritic or tubercular, can give rise
to any more noxious gas than any other piece of decompos¬
ing organic matter. There is, in fact, no gas in a sewer
that you may nob find outside of it. The air of a sewer,
when it is properly ventilated, is much better from the
chemical point of view than the air of crowded churches and
schools, or even than the air of the houses in which one-half
of the population of Glasgow lives.”
Samaritan Hospital.
The fifth annual meeting of subscribers to this hospital
was held on Tuesday last. From the report it seems that
the number of patients during the past year was 635. Of
these, sixty were in-door patients, 575 out-door. On the
in-door patients sixty-two surgical operations were per¬
formed ; in the out-door department there were 127 minor
operations. Two patients died in hospital during the year.
The financial statement was fairly satisfactory. The
bazaar in aid of the building fund had yielded £5300; a
sum of about £2000 is needed to complete the fund.
lEELAND.
(From our own Correspondents.)
DUBLIN.
Royal College of Surgeons.
An election for a member of Council in the room of
Mr. Thomson, resigned, took place on Tuesday, when Mr.
Myles, surgeon to the Richmond Hospital, and Professor
of Pathology R.C.S., was elected by a majority of votes.
The annual elections of examiners for the ensuing year will
probably take place next week, and for the vacancies
in anatomy and surgery a very large number of candidates
will compete.
Royal Uniaersity of Ireland.
During 1890 the total number of candidates for the various
academical examinations was 2845, as compared with 2970 in
18S9, or a decrease of 125. The absentee candidates were
less than in the preceding year, while the number who
passed the several examinations was greater both absolutely
and relatively, being 1803 in 1890 au<i 1625 in 1889.
Suicide from Phosphorus.
A lad aged nineteen died in Mercer’s Hospital last week
from phosphorus poisoning, self-administered. The deceased,
who was subject bo epileptic fits, took the poison while in a
state of temporary insanity, and a verdict to this effect has
been recorded by a coroner’s jury.
Criminal Statistics for Dublin.
The total number of indictable offences committed within
the Dublin district last year was 2465, against 3067 in 1889,
or a decrease of 602. The charges of drunkenness not com¬
bined with other offences numbered 11,319, against 11,144 in
the_ year preceding. Of the 27,069 persons arrested by the
police, 283 were under 10 years of age, 491 under 16, 2431
under 20, 4897 under 25, 5028 under 30j while 985 were 60
years and upwards. These returns indicate an increase of
Die:- /e(Jby‘ ':-iOOglC
1016 The Lancet,]
lEELAND.—PARIS.
[May 2,1891.
mvenile crime, while the large number of arrests for
drunkenness is also a serious motor in the statistics for
1890.
Health of Dublin during March.
As compared with February, there were slight increases
In the mortality from whooping-cough, diphtheria, and
typhoid fever; but in both months the deaths from zymotic
diseases numbered the same—viz., 31.
Death of a Medical Coroner.
Dr. Thomas J. M'Grath, coroner for the East and South
Divisions of Tyrone, died on Tuesday, April 28th, from an
overdose of a narcotic.
The Bishop of Down and Connor, president of the Royal
Irish Academy, has given £500 towards the expense of pub¬
lishing the “Book of Armagh.”
An election for a visiting surgeon to Jervis-street Hos¬
pital will take place on Thursday, the 7th inst.
The Irish Cyclists’ Association will hold a meeting on
May 23rd, in aid of the funds of the Dublin hospitals.
Surgeon-General Thomas P'arrant, A.M.S.,wa3 lost week
sworn in as a Justice of the Peace for the County Cork.
Dublin, April 28th. _
BELFAST.
Professor Gairdner in Belfast.
At a meeting of the Ulster Medical Society, held in the
Museum on Wednesday, April 22Qd (the President, Dr.
Dempsey, in the chair). Professor Gairdner, who had been
invited by the Council, delivered an address on “Remedies,
New and Old ; Errors and Fallacies; with Suggestions for
the Improvement of Therapeutic Methods.” Having thanked
the members for the honour they bad paid him, and having
complimented Dr. VVhitla, the new professor of Materia
Medica, as being the right man in the right place. Dr.
Gairdner pointed out how few of them had the means of
testing thoroughly any one great therapeutic advance. He
dedared that to be compelled to undertake personally a
comparative investigation of any one of the scores of new
claimants along certain well-understood lines of progress
would more than exhaust the resources he had at disposal
as a teacher and hospital physician in any reasonably limited
period. Hence he advocated the cooperation of medical
men for purposes of unbiased and independent judgment in
regard to new remedies. In describing the errors and fallacies
attaching to the new remedies, and their application to
disease, it would notappearto them surprising or incongruous
if he attempted to point a moral in a few instances from
some of the older ones. He then referred to the
chequered history in the past of mercury and antimony.
In reference to the newer remedies, he was afraid, instead of
diminishing, they were rather adding to the difficulties of
medical men. He did not think they could possibly over¬
take the flow of new remedies. Dr. Gairdner then referred
to Koch’s new treatment for tuberculosis, saying that, what¬
ever judgment might be ultimately arrived at on the matter,
few of them would be disposed to deny that they were now
in the very trough of a wave of reaction, or rather dis¬
couragement, from the hopes and expectations entertained
in November last. Criticising the cases recently reported
from Berlin, he said the results were less favourable than
those obtained twenty years ago in the Brompton Consump¬
tion Hospital. He advocated the principle of scientific
cooperation for the investigation of new remedies. A
therapeutic committee sitting in London, or a multitude
of such committees dispersed over the country, would
be an education in itself for the persons concerned in
it, which could not fail sooner or later to leaven the
entire profession with a new kind of fellow feeling,
and also a sense of responsibility, for the fate of new
remedies which was at present greatly lacking with many
of them. In conclusion, Dr. Gairdner asked if they—some¬
what upon the lines of his discourse—could do anything
towards initiating or devising a better way of dealing with
new remedies. Dr. Cuming, Professor of Medicine, Queen’s
College, Belfast, in moving a hearty vote of thanks to
Dr. Gairdner, spoke in the highest terms of the address,
but said that personally he was not so sanguine as the pro¬
fessor seemed to be as to the advantages to be derived from
cooperative research in reference to the value of new drugs.
The vote of thanks was seconded by Dr. Lindsay, and
passed most cordially. In the evening Dr. Gairdner was
entertained at dinner in Thompson’s Restaurant by the
Ulster Medical Society. Dr. Dempsey presided, and there
were over seventy members of the profession present, in
addition to the Mayor of Belfast and the President of
Queen’s College. Dr. Dempsey proposed “ The health of
Our Guest, Dr. Gairdner,” who, after replying, gave the
toast, “Queen’sCollegeandBelfastMedicalSchooi,”towhich
Dr. Hamilton (President) and Professor Cuming replied.
Professor Dill proposed “The City of Belfast,’’and the
Mayor replied. The health of the President of the Ulster
Medical Society was proposed by Dr. Whitaker, medical
officer of health for Belfast, and Dr. Dempsey responded.
An admirable programme of music was excellently ren¬
dered. Too much praise cannot be given to Dr. McCaw,
secretary of the Ulster Medical Society, for the great trouble
and pains he took to make the dinner so successful.
The Royal Hospital.
I understand the following bequests have been left to
the Royal Hospital: £500 from Lady Johnston and £1000
from Mr. Howard and Mr. Garrett Campbell, being the
amount received by them as trustees of the will of the late-
Henry Campbell, which trusteeship they have now resigned.
PAKIS.
(From our own Correspondents.)
Ccesarean Section twice successful in the same subject.
At the last meeting of the Academy of MedicinOp
M. Crimail of Pontoise recorded the somewhat rare
occurrence of the successful performance twice running of
Ccesarean section on the same patient. The woman was a-
dwarf twenty-four years old, whose pelvis, while it bote no
evidence of rickets, was, as might be imagined, very much
contracted. Her first pregnancy took place in 1888, when
she was subjected to the first operation, and on its suc¬
cessful issue she was warned as to the consequences of future
pregnancies. Notwithstanding this, she again became
pregnant, and in February of this year it was found neces¬
sary to subject her once more to this formidable procedure.
On this occasion, however, M. Crimail, with a view to pre¬
venting future pregnancy, ligatured the Fallopian tubes in
two places, and divided them between the ligatures. She
made an excellent recovery. It may be mentioned that
the sirtures were composed of carbolised silk, and that
the dressings consisted of iodoform dusted on the wound,
and the whole covered with iodoform gauze and cotton wool
impregnated with the same antiseptic. It is interesting,
too, to add that both the infants thus brought into tha
world survived, and are perfectly well.
Illegal Practice of Phar'oiacy by a Sister of Charity.
The Society of Pharmaciens of the Lyons and Rhone dis¬
tricts recently instituted a curious indictment against a
Sister of Charity of illegally practising pharmacy. Tho
Sister, it appears, had a remedy for a rather common com-
lainb—viz., anmmia,—and this nostrum she was in tho
abit of selling for money amongst her friends, acquaint¬
ances, and others. The pharmaciens, considering this an
encroachment upon their privileges, objected, and insti¬
tuted legal proceedings. The Court of First Instance took a
lenient view of the affair, and declined to condemn the
amateur pharmacien; bub the Society insisting on an ap¬
peal, the higher Court responded by fining the Sister a
small sum for illegal practice, and cautioning her as to heir
future conduce.
A Step in Advance.
Many things ate, no doubt, managed better in France
than on your side of the Channel, but by no means all. It
is true we escape income-tax, but the imposition of this tax
cannot be said to contribute to shutting out from our dwell¬
ings the light and breath of heaven, and the consequenfe
respiration of a vitiated atmosphere. The tax on doors and
windows which is levied in this otherwise enlightened
country may, on the other hand, be fairly held to have
this effect, especially in country and poor districts where
all possible thrift and economy are practised. Th©
Council General of the Gironde is evidently at last of this
opinion, for it has voted that all taxes on doors and
windows should be suppressed as contrary to the due
observance of the laws ol hygiene.
Correction. —In the paragraph headed “Artificial Cjainine”'
in my letter last week an error has crept in which ib is de-
The La-ncbt,]
BERLIN.—CANADA.—BOYAL COLLEGE OF PHYSICIANS. [MAYS, 1891. 1017
sirable should receive correction. The sentence commencing
on the ninth line of that paragraph should run thus : “ The
base cuptein contained in the shrub Remijia pedunculate,
rowing in Brazil, is treated with sodium, then the com-
inatioD thus obtained is fwrtker treated with chloride of
methyl. The product is quinine.”
Paris, April 28th. _
BERLIN.
(From our own Correspondent.)
Professor Koch.
It will be remembered that the Minister of Education
®nd Medical Affairs freed Professor Koch from his pro¬
fessional duties during the past winter session, to enable
him to devote his undivided attention to the study of tuber¬
culosis. The private lecturer, Dr. von Eamarcb, a son of
the famous surgeon of Kiel, lectured on hygiene in his
stead, and conducted the practical work in the Hygienic
institute. In his speech in the Prussian House of Deputies,
the Minister, Herr von Gossler, stated that this arrangement
■was only temporary, and that the chair of hygiene should
afterwards be entrusted to a new ordinary professor, in
order to allow Professor Koch to devote himself exclusively
to his new institute for the study of infectious diseases.
This appointment, however, has not yet been made, owing
p^erhaps to Herr von Gossler’s resignation, and Dr. von
Esmarcb will take Koch’s place this session also both in
the University and in the Hygienic Institute. The usual
lectures on bacteriology, however, will not be delivered.
Death of Dr. Julius Jensen,.
The eminent alienist. Dr. Julius Jensen, died here last
Friday, aged forty-nine. He was head physician of the
East Prussian asylum of Allenberg for about ten years, and
of the great Berlin asylum at Dalldoif for about a year.
The most important of his writings are—a treatise on the
furrows and convolutions of the human cerebral hemi¬
spheres ; investigations into the relations between the cere¬
brum aud mental derangement; a report on 453 brains of
insane East Prussians divided and weighed by Meynert’s
method; reports of remarkable observations made at the
necropsies of insane persons, of a case of arrested develop¬
ment of the tonic sphere, of defects in the parietal
and frontal lobes -without obvious disturbance of motion
during life, of prenatal soars in the right cerebral hemi¬
sphere, of a microcephalous skull, &c., an essay on prognosis
in mental disease, an answer to the question, “What is the
meaning of the word insane ? ” an article on insanity with
'dgidity of muscles in Ersch and Gruber’s Encycloprcdia,
and two popular lectures on “Dreaming and Thinking”
and on “Doing and Acting.”
German Death-rates in the Week ending April llth,
Aix-la-Cliapella, 28-4; Altona, 22-2; Barmen, 19; Berlin,
C18-6 ; Bremen, 22-8; Breslau, 30‘0; Chemnitz, 28'5; Cologne,
22'3; DanGzic, 21'9; Dresden, 23'4; Dasseldorf, 23'2;
Elberfeld, 21)'3; Frankforb-on-the-Maine, 19-6; Hamburg,
with its suburbs, 19'5; Hanover, 21'3; Kbnigsberg, 20'4;
Krefeld, 23'8; Leipsic, 16'7; Magdeburg, 24'1; Munich,
.29'0; Nurnberg, 19-3; Sbetbiu, 24-2; Strasburg, 28‘7;
(Stuttgart, 21 •4.
Berlin, April 28t;li. _
CANADA.
(From our own Correspondent.)
Montreal Medical Notes.
. At the annual Convocation for conferring degrees, held
April Ist, the M.D. C-M. degree was conferred upon forty-
eight graduates. Of this number nineteen were residents of
the province of Ontario. The number in attendance in the
medical department was 260. The Convocation of Bishop’s
College Medical School was held on March 3lst.
University of Toronto,
The examinations in the medical department commenced
on April Ist. During the session the classes have been well
attended, the register showing: Fourth-year, 05; third-
year, 00; second'year, 81; first^-year, 78; being a total of
284. The sum of $1200 has been offered by seven of the
city bonks as endowment of a scholarship in the first year
in the department of political science. Rebuilding opera¬
tions are steadily progressing, the roofing-in of the main
portion being nearly completed, while the site of the old
convocation hall presents evidence of the stonemasons’
work in that direction.
Medical M.P.’s.
Already seventeen doctors have been gazetted members
of the House of Commons—certainly a useful number to
see that the enactments of that body are of a “healthful
nature.”
Asylums of Ontario.
The annual report of the Inspector of the Lunatic and
Idiot Asylums of the province has just been issued. At
the close of the official year—Sept. 30bh, 1890—there were
upon the books 3318 patients, against 3181 upon the same
date last year. The average number in residence during
the year was 3266. Comparing this with the numbers
given in the first report, 1877, there has been a yearly
increase of 103. Of the 669 admissions during the year
256 were of other than Canadian birth.
Medical Health OJieer for Toronto.
After months of delay the post of health officer for the
city has been filled by the appointment of Dr. H. Allen.
The Lakeside Home.
Through the liberality of Mr. J. Ross Robinson this
summer home for invalid children is to be enlarged to
accommodate 250, at a cost of $10,000, thus providing for
the many applicants who, for want of space, have previously
been refused.
Medical Missionary Magazine.
Not satisfied with supporting a medical missionary in
Corea, the missionary board of the Medical Students’
Young Men’s Christian Association of Toronto decided to
publisb a small magazine, The Medical Missionary, the
first number of which appeared last month. It is to
be hoped it may be the means of arousing sympathy
and of helping t^is commendable work.
April 4th.
ROYAL COLLEGE OF PHYSICIANS.
A COMITIA of the College was held on Thursday last,
Sir Andrew Clark, Bart, President, in the chair. At
this meeting nine gentlemen were elected Fellows of the
College and nine were admitted to the Membership. The
lists will be found in another column. Licences were
granted to the ninety-seven successiul candidates.
A communication was received f rt m the Manchester and
Salford Sanitary Association suggesting that the College
should join in the attempt to put the practice of hypnotism
under some restrictions similar to those which affect the
practice of vivisection. It was decided that the letter
should lie upon the table.
The President being desirous of entertaining at dinner
representatives of the International Congress on Hygiene
and others in August next, the Fellows resolved to sanction
the use of the College for that purpose.
After some discussion, it was resolved that the course of
medical study required for the Licence of the College
should be extended to a period of five years.
The report of the Committee on the Midwives’ Regis¬
tration Bill was then considered, and although the Bill has
been withdrawn, it was thought well to direct that the
report should be printed aud sent to members of the House
of Commons, to the Local Government Board, and to the
General Medical Council.
It was announced that Dr. Francis Warner had been
selected as Milroy Lecturer.
Reports from the Finance Committee, the Committee of
Management, and the Laboratories Committee were re¬
ceived and adopted.
The Deputy-Ooronership for Anglesey, vacant
by the death of Mr. J. Cemlyn Jones, solicitor, Bangor, has
just been filled by Mr. R. Jones RoWts, the coroner, who
has appointed Mr. Roland Philip Williams, L.ll.C.P. Edin.,
Holyhead, his deputy. Mr. Williams is a member for Holy-
bead on the Anglesey County Council, a member of the
standing joint committee, and has just been re-elected a
member of the Holyhead board of guardians.
Digitized by <^ooQle
r018 Thb Lancet,]
MEDICAL NEWS.
[May 2,1891.
Steiriral |leliis.
Eoyal College of Physicians of London.—
The followiog gentlemen have been elected Fellows of the
College:—
, William Allen Sturgo, M.D.Lonel.; Alfred Henry Carter, M.D.Loncl.;
Richard Grainger Uebh, M.D. Camb.; Sidney Philip Phillips,
M.D, Load.; John James Pringle, M.B. F.din.; William Pasteur,
M.D. Lond.; Sidney Harris Cox Martin. M. D. Loud.; Archiljald Hdw.
Garrod, M.D. Oxon.Samuel Herbert Haberslion, M.D. Camb.
The following gentlemen have been admitted to the
Membership:—
William Gordon, M.B.Camb; George Redmayne Murray, M.Tl.
Camb.; Bedford Pierce, M.D. Lond.; Samuel Otway Lewis Potter,
M.D. Jefferson Coll.: James Taylor Robb, M.D. Aber.; Gustave
Isidore Schorstein, M.B, Oxon.; W. Knowsley Sibley, M.B. Camb.;
Ernest Henry Starling, M.D. Loud.; Dawson FVers Duckworth
Turner, M.D. Edin.
University of Durham: Faculty of Medicine.
At the Convocation held on April 28ch the following were
recommended for the degree of Doctor in Medicine for
Practitioners of fifteen years’ standing:—
Norman Bruce Elliot, F.R.C.S. Eug.: John Hamilton, F.R.C.S.,
L.R.C.P. Bdin., L.F.P.S. Qlasg.; Fredk. K. Marsh, L.E.C.P. Edin.,
L. F.P.S. Glasg.; Willoughby Furner, F.R.C.S. Eng.
The following were recommended for the degree of M. D.
George Berwick, M.B., B.S. Diirh.; Henry Luther Ewons, M.B.,
B.8. Durh., M.R.C.S., L.R.C.P. L^nd.; Alfred .John Gregory, M.B.,
B.S. Durh., M.R.C.S., L.S.A.; Francis llv. Mead, M.B., B.S. Durh.,
M. R.C.S.; George New.stoad, M.B., B.S. Durh,; Charles Patrick
O'Counov, M.B. Durh., M.R.C.S.; Nathan Raw, M,B., B.S., L.S.Sc.
Durh.; Louis Robinson, M.B. Durh., M.R.C.S,, L S.A.; Jas, Scott
Tew, M.B., B.S. Durh., M.R.C.S., L.S.A,, D.P.H.Camb.
The following were recommended for the degree of Bachelor
in Medicine (M.B.):—
Honours {Second Class ).—Edward Cocil Willcox, College of Medicine,
Newcastlo-on-Tyne.
Walter Reyner Brunton and Win. .Arthur Rudd, Loudon
Hospital; John Clay, Alfred Cox. Arthur Jaa. Dale, Thomas
Hartley, Wm. Cyril Haswell, John Dobson Wardale, Algernon
Kdwd. Luke Wear, Robt. Anthony Welsh, College oi Medicine,
Nowcastle-on-Tyne; Henry Wm. James Cook, Charing-cross Hos¬
pital; Ramsay Lamy Daly, Chi.s. b'ersyth, and Arthur John
Gardner, M.R.C.S., L.R.C.P., Yorkshire Collego, Leeds; Robert
Dunmore Hotchkis, M.A., St. Bartholomew's Hospital; Joseph
Wood, Owen.s College, Mancliester.
The following were recommended for the degree of Bachelor
in Surgery (B.S.):—
Percy Rutherford Adkfna, M.B. Durh., St. Thomas’s Hospital;
Frederick Carden Brodie, M.B. Durh,, M.R.C.S., L.R.C.P., L.S.A.,
Middlesex Hospital; Henry Wm. James Cook, Cliaring-cross Hos-
f 'ital; John Clay, Alfred Cfox, Arthur James Dale, William Cyril
laawell, George Grahamsley Howitt, M.B. Durh., .John Dobson
Wardale, Algernon Edward Luke Wear, Robt. Anthony Welsli, and
Edward Cecil Willcox. College of Medicine, Newcastle-on-Tyne;
Ramsay Lamy Daly and Chas. Forsyth, Yorkshire College, ].,eods ;
Harry Fowler, M.B.Durh., Owens Collego, Manchester; Robt.
Dunmore Hotchkis, St. Bartholomew’s Ho.spital; and Joseph Wood,
Owens College, Manchester.
Royal University of Ireland.— The folloAving
have passed the third examination in Medicine of the
University.—
Upper Pass ZMumon.—Michael Boyle, Alexander Jamison, George
.Johnston, Robert Leatham, John McGee, and .John C. Rowan. (The
above may present themselves for the further examination for
Honours.)
. Pass JJieision.—James Aiighin, Richard Baile, James F. Barrett,
Robert M. Beatty, Eliza G. Bell, Francis H. Clements, Michael J. B.
Costelloe, Richard B. Crosbio, Thomas II. Delaney, Hugh J. Dickey,
Victor G. Ihelden, Hugh Fialier, .James (>raham, Hicliard Hoaril,
William H. Heard, Benjamin Hosfoui, 'i'liomas How.ard, John Lane,
William I^ylo, William T. Meagher, John O'Donnell, Thus. B. J-*edlow,
Laurence Rowan, .Jainos Stevenson, Eihviii Tojiping, Edward T.
Vint, and John J. Yorke.
Royal Colleges of Physicians and Surgeons
IN Ireland: Conjoint >Sciieme.— The following have
passed the Third Professional Examination:—
J. Armstrong, E. H. Beaman, H. Flynn, T). II. Foley, P. W. Foott,
P. J. Garland, F. J. Groeves, li. W. Guinness, L, A. .Jameson,
W. W. Kane, G. Q. I,Bnnane. E. A. Malculntson, J. S. Proctor,
G. Russell, and J. A. Thornliill.
Tlie undemamed additional candidates have been allowed
the Second Professional Examination—viz :
C. R. Chichester and T. IL Law Hewitt.
Society op Apothecaries of London. — Tho
following passed the first examination in Chemistry,
Materia Medica, Botany, and Pharmacy during April:—
R. Hall, University of Durham.
The following passed in the subjects indicated ;—
Materia Medica, Botany, and Pharmacy.—H.. K. C. Dolamotto, Bilin-
burgh; J. Edwards, London Hospital; T, llopps, Manchester,
Owens CollogB; and G. H. Nowell, B.A., Cambiidgo and Weat-
minater Hospital.
Materia Medica and Botany.— B. Rou.ae, University College.
The following passed the second examination in the subjects-
indicated—
Anatomy and Physiology.—U. Berne, Sydney University ; P. II. Bosl.„
B.A., Cambridge and University College; B. H. Carpenter, St. Bar¬
tholomew's Hospital; 0. D. Garrett, We.stminstor Hospital; J.
Garrett, St. Mary’s Hospital; E. L. Greone, Royal Free Hospital;
H. Herbert, I.ondon Hospitfvl; J'). P. Hewitt, St. Mary’s Hospital -
F. Konnody, KcUnbui'gh Univeraity ; C. A. Marrett, Charing-evoss
Hospital; IX. J. Neatby, Leeds, Yorkshire CoUogo; J. H. Nowoll,
B.A., Cambridge and Weatmiiister Hospital; L. C. L. Raymond.
Charing-cross Hospital; W. J. Woods, St. Bartholomew’s Hospital;
and E. M. Wright, Sheffield.
Anatmny.—Ot. C. Schultz, St. Mary’s Hospital; H. C. Venis, Calcutta-
and St. Mary’s Hospitel; and J. F. W. Waters, Middlesex Hospital.
Physiology. —G. 13. Douglas. St. Mary's Hospital; W. R, Ffshciv
London Hospital; J. M. Gleeson, Dublin and London Hospital;.
J. Joule, London Hospital; S. I.iangtoii, St. Mary’s Hospital; G.
Jjowsloy, St. Bartholomew's Hospital; T. W. O’Reilly, St. Thomas's
Hospital; and C. C. Pratt, St. George's Hospital.
Surgery. —W. Anderson, M.D., California University, San Francisco
F. J. A. Baldwin, London Hospital : J. F. Brown, B.A., M.D., C.M ,
Toronto ; R. J. Colmer, London Hospital; H. B. Falconer, King's-.
College; A. F. Gervis, St. Thomas's Hospital; M. J. Houghton,
Birmingham, Queen's College ; W. II. Kershaw, London Hosoital ;
G. F. Knipo, Liverpool, Univov.sity Collego; L. J. Mintor, King’!-'-
College : W. II. Savery, Sheffield ; JI N. A. Taylor, B.A., Cam¬
bridge University and Norfolk Hospital; C. F. WaiTOii, St. Mary’s
Hospital: and E, C. Wimberley, Birmingham, Queen's College.
Medicine, Forensic Medicine, and Midivij'aiy.—C. D. Ilolmos, Llver-
S iool, University College ; H. Knevitt, London Hospital; A. W.
lead, St. George's Hospital; 13. M. Rooke, Guy’s- Hospital ; A-
Richardaon, Edinburgh University ; II. do V. St.acpoole, St, Mary’.x
Hospital; P. Sharp, King's College ; G. R. Stilweil, St. Thomas's-
Hospital; 11. N. A. Taylor, B A., UauibvidgoUniversity and Norfolk.
Hospital; W. A. Williams, L.M.S., Calcutta and Middlesex Hos¬
pital; and F. C. Wood, I,.S.A., London Hospital.
Medicine and Forensic Medicine.—B,. S. Freeland, L.R.C.P., M.R.C..S.,.
Guy's Hospital; and G. F. ICuipe, Liverpool, University CoUogo.
Medicirusand Midwifery. —B. Jackson, London Hospital; C. P. Morgan,.
Guy's Hospital; B. F. Pari.sh, St. Mary’s Hospital; and H. J -
Thomas, Bristol Medical School and Guy’s Hospital.
Forensic Medicine.—V.. A. Humphreys, Manchester, Owens Collego.
Midwifery.—?,. H. R. De Groot, King’s Collego; and A. G. Keeling,.
St. Thomas’s Hospital.
The following were granted the diploma of the Society,
riualifying for registration and entitling them to practise
Surgery, Medicine, and Midwifery:—
Messrs. Colmer, Holme.s, Houghton,Knevitt, Miuter,Sharp, Stacpoole,.
Stilweil, Taylor, Wimberley, and Wood.
Dublin Hospital Flower Mission.— Last year
18,580 little bouquets, besides lavender bags, were dis¬
tributed to inmates of the Dublin Hospitals. The present
session will last from April 28th until the end of September.
Evelina Hospital for Sick Children.—A
meeting of the governors and subscribers of this institution
was held at the hospital, Southwark Dridge-road, on the
22ad ult. Baron F. do Rothschild, M.P., the president, occu¬
pied the chair. The charity is surrounded by a dense popula¬
tion,'and no other hospital south of the Thames receives-
exclusively the children of the poor. No paying patients are-
admitted. The sixty cots in the wards are nearly always-
occupied, and the average daily attendance of out-patiente-
is about 100. More accommodation is urgently needed, and
the president has generously purchased some adjoining pro ¬
perty, the site of wiiich it is intended to utilise for the-
erection of anew wing. Meantime an appeal is made for
additional pecuniary support, since for the past five years-
tho invested capital has been encroached upon to the extent-
of £1000 per annum to meet current expenses.
University of London.— Tho following gentlcmcD
were on the 29bh ult. elected Examiners in Medical sub¬
jects;— Practice of Medicine: J. F. Payne, M.D., B.Sc.^
and Prof. F. T. Roberts, M.D.. B.8c. Surgery: Prof.
Marcus Beck, M.S., M.B., and II. G. Howse, M.S , M.B-
Anatomy; R. Clement Lucas, M.B., B.S., and Prof. Alex¬
ander Macalister, M.D., M.A., F.R.S. Physiology: Prof.
W. D. Halliburton, M.D., B.Sc., and J. N. Langley, M.A.,.
F.K.S. Obstetric Medicine : C. J. Cullingworbh, M.D., and
Alfred L. Galabin, M.D,, M.A, Materia Medica and
Pharmaceutical Chemistry: Frederick Taylor, M.D., andi
Prof. N. 1. C. Tirard, M D. Forensic Medicine: J. D. Mann,
M.D., and Prof. G. V. Poore, M.D., B.S. Chemistry:
Prof. H. E. Armstrong, Ph.D., F.R.S,, and Prof. \V. A.
Tilden, D.Sc., h'.R.S. Botany and Vegetable I’liysiology:
Prof. Daniel Oliver, F.R S., and Prof. H. M. Ward, M.A ,
F.R.S. Comparative Anatomy and Zoology: Sydney J.
Hickson, Esq., D.Sc,, M. A., and Adam Sedgwick, Esq.j.
M A., F.R.S,
Coocle
O
The LakobtJ
MEDICAL NEWS.
[May 2,1891. 1019
Hampton Wick.— Dr. Langdon Down, J.P,, has
been appointed by the Middlesex County Council one of the
two delegates to represent that body at the International
Congress on Hygiene.
The freedom of the Plumbers’ Company has been
presented to Dr. Farqaharson, M.P., for the special services
rendered by him for many years past to the cause of sani¬
tation.
Birmingham Water-supply.—T he Birmingham
City Council has unanimously adopted a scheme for obtain¬
ing a new water-supply from the Elan and Claerwin rivers,
Bn Mid-Wales, these rivers being tributaries of the Wye.
Yorkshire Sanitary Association.—T here is
shortly to be opened in Leeds a branch of the Yorkshire
Sanitary Association, one of whose chief objects is to secure
to householders an easy and inexpensive means of ascertain¬
ing the general sanitary condition of their dwellings, and
practically of ensuring themselves against the risks of de¬
tective sanitation.
Fatal Chlorodynb Drinking.— At an inquest
held on Monday at Monkwearmouth on the body of a
woman aged fifty-three, who died at her residence on the
previous day, the evidence was to the effect that the de¬
ceased had taken to excessive drinking, and on Saturday
she purchased at a chemist’s shop a pennyworth of cbloro-
dyne, being at the same time informed that she should nob
take more than ten drops. She was afcerwarda discovered
lying unconscious in her house, and subsequently died.
The medical evidence attributed death to coma, the effect
of an overdose of chlorodyne.
University College Hospital.— On Tuesday,
the festival dinner in aid of this charity was held at the
Hotel M6^ropole, Lord Keay presiding. The chairman, in
proposing “ Prosperity to the Hospital,” urged the claims
of the institution to liberal public support. A debt existed
to the extent of £8000. The Hospital rebuilding fund
bad remained stationary. It amounted to about £12,000.
The annual reliable income was only £0000, while the ex¬
penditure approached £20,000. During the evening con¬
tributions were annouuced (including £500 from Mr, J. T.
Chance, for the rebuilding fund) to just upon £2000.
The City of London Truss Society.—I n the
absence of the Lord Mayor, the Rev. Prebendary
Whittington occupied the chair, supported by the Sheriffs,
at the eighty-fourth annual festival of the members of the
Society, held on Tuesday at the Albion Tavern, Aldersgate-
streeb. In proposing the toast, “ prosperity to the City of
London Truss Society,” the chairman remarked on its long
existence (founded in 1807) and the ever-growing augmenta¬
tion in the annual demands upon it; adding that one at
least out of thirteen of the general working population was
attlicted with hernia. The subscriptions were only suffi¬
cient to discharge the cost of the appliances supplied, and
the expenses of management of the charity had to be met
by the interest received from the capital invested. Sub-
aoripbions were announced amounting to £800.
Football Casualties.—D uring a recent football
match {Askam against Rochdale St. Clements) a player sus¬
tained a simple fracture of the collar-bone —Whilst playing
football in a park near Blochaku Steel Works, (ilasgow,
last week, a player slipped and fell, sustaining a fracture of
the right leg.—In an Association football match played at
Heywood on the 25bh ulb. between the two principal town
clubs, three players were badly injured by kicks.—A young
man aged twenty-one, while playing on Saturday in a
match at Gravelhole, near Rochdale, received injuries to
his spine and head, from which he died the following day.—
A youth, during a game at football on Poundbary, !')jr-
chosber, fell and badly sprained bis ankle.—In a football
match at Grona, co. Tipperary, a young man received a kick
in the abdomen, and died shortly afterwards.—As the semi-
iinal tie of the Fylde Junior Cup was recently being
jolayed between Blackpool Olympic and Marbon, at Raikes
Hail, a player had his knee badly twisted.—A young man
aged twenty-four has died in the Southport Infirmary
from injuries lately received in a football match at Soiibh-
porb. He sustained a compound fracture of the left arm;
Jockjaw supervened, from which he died.
Medical Magistrates.— Arthur Mussen, M.D., of
Glenavy, Lisburn, has been placed on tbe Commission of
the Peace for the county of Antrim.—At the adjourned
quarter sessions, held at Maidstone on the 15th ult., Charles
Lovegrove, M.D., Hybhe, qualified as a justice of the peace
for the county of Kent.
Mrs. Hodgson Burnett, authoress of “ Little Lord
Fauntleroy,” has recently endowed a cob at the St. Monica
Hospital for Children, Brondesbury Park, in memory of her
little boy Lionel, who died on the Riviera of consumption
during the last winter, and whose pretty little sayings and
doings suggested the Lord Fauntleroy which baa such
marked success.
Sale of Diseased Meat.— An important decision
to meat salesmen was given last week in the case of Barlow v.
Terrett. This was an appeal against a decision by a magis¬
trate who had convicted appellant of exposing bad meat for
sale in the Central Meat Market. The court, consisting of
J usticea Day and Lawrance, unanimously decided that, much
to their regret, they were against tbe conviction, inasmuch
as, the meat having been deposited, and not exposed by
hanging up, the conviction was bad. The conviction was
accordingly set aside without costs.
Ilkley Hospital and Convalescent Home.—
The anuual report for 1890 states that the hospital was
opened last year towards the end of March, and had been
closed on the 7ch of November, a period of thirty-two
weeks, during twenty-eight of which it had been full. Tbe
number of aamis.sions, including renewals, was 1122, tbe
largest reached in one year. Since the erection of the
hospital in 1861 the total number of admissions and re¬
newals was 20,964. The cash statement showed an adverse
balance of £116, to be carried forward to tbe current
Manchester and Salford Sanitary Associa¬
tion.—D r. Ransome presided at a meeting of the com¬
mittee recently. Tbe subcommittee appointed to con¬
sider the desirability of placing the practice of hypnotism
nnder legislarive control reported that they had obtained
through the Foreign Office information as to the attitude
of various Continental Governments towards the question,
and tbe committee are in communication with tbe various
Colleges of Physicians and Surgeons in the kingdom with
the view of securing their cooperation in any action that
may be agreed upon. The subcommittee appointed to con¬
sider the resuscitation, under an independent organisation,
of the work of house inspection, reported favourably on
the proposal. In reference to the abatement of noxious
vapours, it is intended to convene a public meeting to
obtain an expression of opinion by the ratepayers on the
proposed reduction of the charges for gas within the city to
cost price, the object being to enconrage its use instead of
coal for heating and other purposes, to obviate the present
pollution of tbe atmosphere.
Presentations.—M r. C. F. M. Althorp, L.R.C.P.
Lond., MR.C.S., lately house surgeon, and recently
appointed honorary assistant surgeon to the Bradford In-
lirmary, and who purposes to commence practice on his own
account, has been presented by the nursingstaff and servants
of the institution with a walnut writing cabinet from the
nursing staff, a table gong from the servants, and a
china afternoon tea service from the patients in the
Jenny I’Jrilipp and Macturk wards, as tokens of esteem,—
Dr. J. lligttet of Workington, Cumberland, has been
presented by the members of the Workington Ambu¬
lance Class, in connexion with the London and North-
W(5Stern Railway Ambulance Corps, with a handsome
walking stick ns a mark of appreciation of his services and
instruction in first aid to the injured.—Dr. F. R Russell
of Guildford has been presented by the members of the
Guildford Ambulance Class, in connexion with the County
Police Force, with a silver inkstand for his instruction in
ambulance work. — Mr. G. H. Patterson, L R.C P. Lond.,
M R.C.y , of Dalton-in-Furness, has been presented by the
members of the Limlal Ambulance Classes with a timepiece
and an aneroid barometer as an acknowledgment of his able
lectures to them on ambulance work. — Dr. F. C. MaeNalty,
of Greenodd, Ulverston, has been presented with a hand¬
some dining-room clock by the members of the Crake Valley
St. John Ambulance Classes in appreciation of his instruc¬
tions to them on first aid.
D'
Coogle
1020 Thb Lanobt,]
MEDICAL NOTES IN PARLIAMENT.
[May 2,1891,
Dbep-sba Fishermen.— The Corporation of the
City of Londoo bas made a grant of lUO guineas to the
Mission to Deep-sea Fishermen.
The Sweating System in New York.—A ttention
is directed in the annual report of the New York State
Board of Mediation and Arbitration to the iniquitous hours
of labour imposed upon shirt-makers and otlier cloth-workers
in New York City. Certain foreigners, who con speak bub
little English, are reported to be labouring like slaves ”
for twelve and eighteen hours a day. Tliey live and work
in wretched crowded tenements, destitute of proper light
or ventilation, and live in squalor, forming an exact parallel
to the method adopted by the Jew sweaters in England.
Sunderland Corporation and “Sweating.”—
The Sunderland Corporation has, on the recommendation of
their Watch Committee, decided, after very lengthy dis¬
cussion, that in future all persona tendering for corporation
contracts shall be expected to pay to the workmen whom
they may engage in carrying out such contracts the reco¬
gnised scale of wages current in the district in which the work
IS done. The recommendation was the result of an agita¬
tion by tbe Sunderland Trades Council, who alleged that
the police clothing had been made in London on the
“ sweating ” system.
Royal Berkshire Hospital, Reading. — The
annual report for 1890 is satisfactory in respect to its
augmented utility and tbe large work accomplished during
the year. The number of patients treated was 4778, and
tbe resources and accommodation had alike been severely
taxed. The proposed enlargement of the hospital by build¬
ing additional wards bad for the present been postponed.
The financial result of tbe year’s work was a dellcit of
£437 13s. 3rf. The private nurses’ establishment continued
to more than pay ics expenses. A sum of £300 was added to
the invested capital in 1889, and the profits of 1890 will be
sufficient to invest about the same amount this year.
Burial Reform.— The Archbishop of Yoi'k ha.s
written as follows to the Dean of York, chairman of the
Executive Committee of the Church of England Burial,
Funeral, and Mourning Reform Association:—“I have
much pleasure in accepdng the office of Joint President,
with the Archbishop of Canterbury, of the Church of Eng¬
land Funeral Reform Association. I have already on pre¬
vious occasions expressed my entire sympathy with its
objects, and lam glad of this opportunity of doing so again.”
The Duke of Westminster will preside at the thirteenth
annual meeting of this Society in Grosvenor House, on
Tuesday, June 2Qd.
The London Water-supply.— On Tuesday the
Select Committee of tbe House of Commons appointed to
deal with the London Water Bills fmet for the first time.
The Londoo Water Commission Bill, introduced by Sir
Robert Fowler, the late Mr. T. C. Baring, and Bir John
Ellis, to constitute a public authority to promote Bflls in
Parliament to improve the wateT supply &o., came on
for consideration. There are forty six petitions against the
measure. Counsel for the City Corporation and representa¬
tives of various companies having been heard, the chairman
said the committee bad come to the conclusion that no Bill
could satisfactorily deal with tbe questions referred to this
committee, which merely constituted a public authority to
promote Bills in Parliament, so that tbe committee could
not see their way to pass the preamble of the Bill.
MEDICAL NOTES IN PARLIAMENT.
McUi'iialed Spirilx Driukinft.
In the House of (Commons, on Tues<lay la-st, in rejiJy to Mr. O'Neill,
the Chancellor of the Kxclioquer Maid : 'I'iio Hoard of Inland Revenue
intend to render mcthylaieil spirit sold by retail moro nauseous
in character. They also intend, when tliere is reason to believe that
methylated sphit is beinp purchased from any retailer for potable pur-
poaes, to cause such reluilor to J(oep a stock account, giving the date
of aalo and rjuaiitity sold on each occasion, together with the name
and address of the purclia^er, ami, if any such purcliasor bo Icnowii to
be using the methylated spirit as a beverage, the vendor will be warned
that proceedings will be taken against him for recovery of the line <if
£100 under Section 130 of the Spirits Act, isSO, if ho continuca to soil
methylated spirit to tire said purchaser. I can assuro tlio lion, mombor
that every possible precaution will bo taken to put a stop to the piaetice.
MoTtidity in Lvnalie AnylmuK.
Dr. Fai'cjuharson .asked the Home .Secretary whether it ivould be
practicable for the Commisaioners in Lunacy to append to future iiisues
of their reports a table showing the ciueoe of death of all lunatics
dying in all lunatic asylums, publio and private, in registered lunatic
hospitals, and in workhouses in England and Wales.—Mr. Matthews:
I am informed by the Lunacy Commissionors that no returns are made
to them as to deaths of lunatics in workhouses, and they have no power
to call for them. They have considered, and will aga*n consider,
whether they can, and how soon, insert tables showing the causes of
death in lunatic asylums, registered hospitals, and licensed houses, but
this would involve much additional clerical work, and the existing staff
is already hard pressed owing to tbe great increase of work cast upon it
by the operation of the Lunacy Act, 1800.
The Brilish Institute of Preventive Medicine.
Major Easch has given notice that on Thursdavnext he will ask'Sir
M. Hicks Beach whether a decision has yet been given by the Board of
Trade on the application for a licence for the British Institute of Pre¬
ventive Medicine, and, if so, whether be will state, the form anil conditiona
of the licence.
Tuberculosis.
In the House of Gommona on Thursday, Sir Thomas Sutherland ad¬
dressed a question to the President of the Local Government Board
with reference to the Royal Commission unpointed to inquire into the
subject of tuberculosis in cattle.—Mr. Ritchie in the course of his reply
stated that the Commissioners had bem sitting since July last, and
were now engaged in carrying out an exhaustive aeries of exporlnieiitH,
tbe results of which could not be determined for some metwths.
(Quarantine Arrangements at Suez.^_
Mr. Conybeare asked tlie Under Secretary of State for India whether
his attention had been called to the following statement, in the public-
press, that, “ at the sitting of the Committee of Public Health at Paris
on April 21 st, it was declared that cholera is increasing in Calcutta,
the fact being shown by tbe arrival at Suez of a great number of
ships liable to quarantine measures. Conformably, however, to the
'wishes of the English, who are in the majority upon the sanitary
council, these vessels pass without sanitary measures being taken.
One English ship from Calcutta was mentioned as having had eleven
cases of cholera on board, ten of which had terminated fatally before
she reached Colombo. On her arrival at Suez she only remained in
the roadstead during the time necessary to make repairs." And,
whether, if these matters are »s stated, ho will take steps to enforce a
strict quarrantine at Suez.—Sir James Kergusson made the following
reply on behalf of the Government: Any such statement would be
inconsistent with fact, for by the last accounts the deaths fromi
cholera at Calcutta were far below the quinquennial average. The case
mentioned is evidently that of a ship which had eleven cases of choler.n.
on board between Calcutta and Colombo. .She then underwent nine
days in quarantine, and was thoroughly disinfected. No further sick¬
ness occurred on board, and accordingly when she reached Suez, after
a voyage of fourteen days, she was allowed to pass through the Canal
in quarantine.
lixperiimnte with Phth isical Sputum.
Mr, Samuel Smith asked the Home Secretary whether his attention
had been drawn to the experiments with phthisical sputum reported by-
Mr. Watson Cheyne in the Ilrilish Aledical Journal or the 11th of April,
involving the boring of holes into the knee-joints of living rabbits; and
wliethor the Homo Office possessed a report of such experiments ; if so,
ditl this report show wlietlicr Mr. Watson Cheyne hold a cerlitlcate
disjiensing liim from the use of anirsthetics in the peHonnance of
such experiments; whether the holes were bored into the legs
of the animals while they were sensitive to pain;;and hoiv long
their joints were allowed to inilaine and swell throuich the action
of the diseased material stated to have been injected.—The
Homo Secretary said he had seen the report of those exporiments ;
■ they wore made in the years 1887 and 1888, and a summary of them
appeared in tbe Annual Report of the Inspector prosentud to Parlia¬
ment for those ye.ars. It appeared tnat they wore performed under cer-
titlcate which authorised experiments without anrosthetics, and which
was granted on the supposition that the experiments were simplo
inoculations, He was informed by the inspector that tho groat majority
(Of tho exporiments wore simple inoculations ; hut in any case whoio tlio
operation was performed on the bone tho animal was fully under chlo¬
roform.
THK METROPOLITAN HOSPITALS INQUIRY.
Tho Coinmitteo investigating the condition of Metropolitan Ho.spitale
resumed on Monday, 27111 inst.
Hospital for Wotnen, Sohn-syuare.
Mr. David Cannon, secretary of the hospital, was exaininod. Uo
stated that tho hospit!i.l contained sixty-six beds divided among fifteen
.wards, an arrangement which explained the apparently oxcossive
expeniUtnru per bed at this hospital. Hinall wanls were ranch more
expensive to work than large ones, and reqiiirod more nurses propor¬
tionately to the number of patients. The balance sheet showed a
grand total of exponditiire, including Uio deficitfor tho previoiis year, of
£8.308. hut the average annual expenditure amounted to £0800. They
had raan.aged to reduce the mortgages on their property from .£ 18,800
CO .£10.800, and liopoil iiextyoar to clear o(f tho whole debt by means, of
legacies &c., ami to occupy their own freehold. The aniiu.al snlj-
Hcriptiona amounted to £10,000 on an average. They received assistance-
from railway companies, corporations, and, before tho Charity Com-
nmsioners intoiforucl, they used to gel as.swtanco from tho parishes in
Llie City. At present tlioy considoroil thomselvcs badly off in the mattoi-
of legacies, 'i’ho sonior medical officer was tho only nicdic.il meinber.of
the Committee of Management, which meets oiicea month..The witness
did not think that General Booth’s schemo had intin-fered niatorially
with the funds of tho ho.-pUal. As a matter of fact, the donations liaii
not falloo olf.—By l.oid Spencer ; A large number of patieiit.s camo
from tho Ka.st-end of London, and wore mostly poor people. Thu
hospital was founded because tho general honpiwls <lid not make
any special provision for such cases at that time. Since the establish¬
ment of those special hospitals, the general hospitals had started
wards for these ^recial cases. Alany qualified men came to the lios-
ital to study, among whom were numiiers of Amorican graduates,
'hey wore not taught in the wards, hut only in tho out-patient rooms.
’I’ho averiige number of such students was between twenty-five ami
thirty in the year.—By Lord Monksweil: Some of the beds woru.paiil
for, some weie partly paid for, and others were free—twenty-six paying
The Lancet,]
METEOPOLITAN HOSPITALS INQUIRY.
[May 2, 1891. 1021
beds and forty free, but In each case the attendance was precisely the
same. The question of throwinK two or three of the smaller wards
into larger ones had not been coueiderod during his tenure of office.—
By Lord Lauderdale; The average number of beds oecupled last year
was fifty, and the average cost per bed was 2sl Cd. per week —By
the Cliairman; No plan of the drains was kept in the office. If any¬
thing was out of order it would at once be reported to him. Ho looked
upon himself as being responsible to the comniittee, and there was no
special sanitary officer employed to inspect the buildings.
Miss Squler, the matron of the hospital, gave an account of the nursing
armngements of the hospital. They hod four sisters, three staff nurses,
ten ordinary probationers, and two paying probationers. Theyocca-sion-
ally sent out nurses, but only on the recommendation of the doctors.
Mr. Eichard T. Smith. M.D. Loud., M.R.O.P., saw no reason why
members of the staff of the general hospital should not be on the stan
of the special hospital. Special hospitals could with much advantage
coiiperate witli the general hospitals.. Notwithstanding the groat
advance that had been made by the general hospitals, he was of
opinion that the necessity for some special hospitals was as great as
ever, hecanse there was difficulty in providing accommodation for
students in the general hospital, and women objected to bo examined by
a great many medical students; therefore the number of students who
could take a deep and personal interest in the cases was rather limited.
His hospital Umited the number of students taking an active part to four
inoneday, to Bomeextontout of consideration to the patient, andolsofrom
want of space. Special provision would have to be made even in general
hospitals for the performance of special gynmcological operations.—
In reply to Lord Kimberley, the witness stated that thongli he had no
objection to special operations being performed in general hospitals, he
would except cases of abdominal surgery, which, in his opinion, should
be done in separate buildings. As regard.s the study of disease, he
thought special hospitals promoted science, and possibly led to new
discoveries.—By Lord Thring: The witness personally would not
object to women being admitted as students into this hospital.—
Lord T'hving: Doctors object to these hospitals because they injure
the schools, and not because they injure tlie patient. They say special
hospitals are bad because they prevent the aci^uisition of a knomedge
of these particular diseases.—The Witness: Of course it takes away a
cortain number of patlent.s from the general hospitals. With regard
to the education of a medical man, the witness thought that no young
m.an ought to study any speciality until he was thoroughly vomed in
general medicine.
Gordon IIoxpilalfoT Fistula.
Captain Hincks, secretary of the hospital, said that the patients
were admitted for tlie most part free, but many of them paid. There
were only twenty-flve out-pationts daily. It was originally called
the Western HospitnJ, iind the name was changed by the cohi-
mittee to the Gordon Hospital. The witness could give no par¬
ticular reason for the existence of such a hospital, except that many
patients came tliore who were unable to pay the surgeons’ foes, and
who objected to being treated at a general hospital. They did not
receive the full grant from the Hospital Sunday I'lind, on account of
the expenses of manngouient being too great. They raised money
through appeals in the ordinary way. —By Lord Lauderdale: Tlie
hospital consisted of eight rooms, and was taken on a twenty-one
years’ lease in the name of two of the surgeons, Mr. Boutliam, who was
since dead, and Mr. Whitmore.—Lord Sandhurst: Do you tliink that
as a general principle the work of a hospital, witli an average of
nine working Beds, could not bo undertaken as well in a general
hospital ?—The WItne.ss : I should very n\ucii like to seo the work of the
Gordon Hospital extended. It meets the wants of those patients who
would not go to a general hospital.
Mr. Whitmore, F.ll.O.S. lidin., said he started the hospital in view of
the great want of such a hospital in London. In answer to the (pies-
tion wliother patients could not be treated as well at the general hos¬
pital he read the following letter, dated l‘'ebruary, ISDl, and addressed
to the secretary of the hospital;—“I beg, through you, to bring my
case under the notice of tho Gordon Hospital Committee, ami to bear
testimony to the very efficient manner in which I was treated at that
hospital. In Seiitomber, 1880, I became ill. Shortly aftenvar<\s I
entered a hospital here, and underwent an operation, and remained
six weeks. In .laiiuary, 1890, I went into another hospital, where I was
again operated on, an<i was iletainod nearly twelve weeks, and without
receiving any honollt whatever. In May I obtained admission to the
Gordon Hospital, wliuve I was operated on for tietuln. and where I was
under J'rovidoiico cured.”—By Lord Sandhurst: He was not in a
position to contrast or criticise tho treatment in the general hospitals
as compared with tho troatment in this ho.spital. Ho maintained that
the expenses of the paid oHicials, as comparetl witli other hoapitiils,
were merely nominal, and tho hospital itsolf was in embryo. He had
advanced a sum of money for tho promotion of tho hospital, whicli ho
would never bother tlio committee to repay unless ho saw they had
sufficient, fimcls. He consideVed it moiiay well spont.- Lord Kim¬
berley : I asked yon whether it was ilesinibio that hosplt.als should bo
establishnd on so .small a scale that tho expenses are too largo for tho
maiiitenaiU'O of the establishment'/- Tho \Vitiiess: itap]>oarstoiuothat
it is in proportion to the aoiount of good that is obtained. Ho was in
favour of sfiocial hospitals for all diseases; they wouhl not detract from
the educational value of the general hospitals. Students could sUnly a
subject imicii bettor at the head centre of .specialism tliaii at tho general
hospitals if the theory were carried out fully. 'I'he large hospitals, he
tliought, wore at present running to seed.—By l-ord Gathcart: Tho
name '■ Gordon” was not given ns a nnmo witli which to oiitii’B tho
public, but because it was considered a good name by tho eoininittee.
On the Committee I'esiimiiig on Thursday,
Mr. Findoriek Wallace, L.U.C.P., M.E.O.S., a general practitioner in ,
Shoreditch, gave ovidonte to the oll'ect tiiat the estahlishiiieiit of the '
provident dispensary department of the Metrojiolitan Hospital at .
Shoreilitcli had ilamagod tho practitioners in that district. He ropro-
Monted a numhov of gonoml practitioners in tliatdistrict who considered
that it was in no way intemlod when the hospital was established that
.there should Im attached to it this provident dispensary. It had un¬
doubtedly produced serious cotuoiiiieiice.s among the practitioners in
tho iinighbourhood. Ho complained of those dispoiisavles which were
conducted by ciiinlilled men acting as assistants to anotheriiiedical man
svho had puvhap.s as many as twenty or twenty-live of these estahllsh-
nuonts. He tlionght it must pay, as it had gone on now for some years.
They were ca’Ied L'. a week dispensaries. His objection to them was
that tho advice was inferior, and that it in many cases led to the
offence called “covering.” Be presented’ a book in which he
had collected various handbills advertising these dispensaries. The
advertisements were issued by qualified men, but the cases coming to
the dispensary were sometimes left to be attended by unqualified men.
He mentioned the name of a medical inaii who had a large
number of these dispensaries, but he believed they were attended
by properly qualified medical men. He objected to such establisb-
inunts, because these medical men were constantly leaving tliis employ¬
ment, hiid frequent changes were bad for the patient, and because they
tended to sweat the profession.—Lord Thrmg: Does not the very
nuTuber of those dispeiuaries show tliat they supply a public want ?—
The Witness: I thiiilc there is a public want of a properly organisrd pro¬
vident scheme.—Lord Thring; But supposing tliat a man has twenty-flve
dispensaries handledby properly qualinedmenfor tliebeneflt of the publio,
what more do you want'!—The Witness : They cut into the local general
practitioner and sweat him.—Lord Thring: In other words, it is compe¬
tition.—The Witness: It is competition that we consider to be unfair.—
Lord Thring: Why can’t you set up oppo.sition dispensaries?—The
Witness: We could not do that. I should bo very sorry to start a
shilling dispensary.—Lord Thring: It would be infra din I —The Wit¬
ness : Certainly. If the patients got the full value for their money I
should not have much to say against them.-Lord Thring: Does it not
amount to this, that it is a professional objection; tliat a certain class
of men advertise in a way that is not thought consistent with tho
dignity of the medical profession ? — The Witness: Yes — Lord
Lauderdale: Do you suggest that doctors should not be allowed to
advertise, or what? Is the present law regarding qualified assistants
not properly enforced ?—The Witness ; That is so. I would like to see
it enforced. The General Medical Council had pro.seciited only a few
of tlie cases of covering because of tho difficulty tiiere was in obtaining
siifflciont evidence. Per.sonally, he did not think it was worth bis
while to obtain this evidence —By Lord Monkswell: The rea.son why
he did not go to the General Medical Council in this matter was simply
that lb would be extremely difficult to get at tlie real facts.
Queen ChaTlotte's Lyinn-in. Iloepilal.
Mr. G. 0. M. Ryan, the secretary of the hospital, gave an account of
the arrangements, income, and exponditure of tlio hospital. The nursing
arrangements wore also tletailed.
William Hope, M.D., M.ILC.P., M.E.CS.Kng., senior physician to
the hospital, said that the evil reputation which the hospital had
fifteen >ear.s ago was due to its insanitary condition and tho want of
a knowledge of antiseptics. The mortality in single women was
greater than in married ones, probably on account of the very young
age of the patients. These patients varied in age from fourteen to
twenty-flve. They had cases as young as twelve, and to these tho shock
was very great. Such patients were taken into homes now, where
they are very carefully fed and cared for before they come to the hos¬
pital. A gentleman named Mr. Bousfleld, who had given evidence,
liad stated tliat the presence of students was detrimental to lying-
in cases. That statement lie distinctly repudiated. Since medical
students had been in Queen Charlobte’.s Hospital the mortality had
decreased. The patients considered themselves better attended to
wJien medical stiiclents were present. Ho would like to .see in all lying-
in hospitals a resident medical officer on tho regular visiting staff.
London Fever Hospital.
Lord Balfour of Burleigh, tho President, said they divided the
patients into ward patients and private patients. The ward patients
pay three guineas for the whole ca-so, the jn'iv.ato patients pay three
guineas per week. The faiuilio.s and servants of governors were
admitted free. The hospital contracted with large firms for the treat¬
ment of tlieir emplofFii provided they subscribed to the ho.spital. His
lordship gavo an accoiuit of tho history of the hospital from its
foundation in 1802. 'J'liis hospital at tho present time does its work
lietween the two social extremes, and assists those who could pay
something. Those who could pay the cost were treated at a less cost
to themselves in tho hospital than in their own homes. The hospital
oiFered advantages to tho sulferor and also to tho family in which
tho case had broken out, as well as to the community by removing a
source of danger. All infectious diseases were taken in except sinall-pox.
Major Christie, the secretary, was examined, and gave particulars of
the financial condition of the liospital.
10. 0. Hopwood, M.D. Oxon., the resilient medical officer, said no
nur.se had died from infections disease during his period of office. Day
nurses were on duty for thirteen houre and niglit nurses for eleven hours.
The matron was responsible for the conduct of the nurses. She was ap¬
pointed at a salary ot ,CS0, rising to ,tl00or£l20. They could not send out
their imr.sos with advantage to tlio hospital. The percentage mortality
in 1889 fioiii scarlet fever was 1'2, for enteric fevor r)'2, diphtheria 17'0.
Ill 1890 the mortality from acarlot fevor m’us 2'8, for enteric fever 9,
for diphtheria 4'.'), and for moasles f>'S. These he considered very low
averages, quite Oil per cent, below tlie average of the Metropolian
Asylums Board hospitals, and he atlribuiod those low averages to the
class of patients treated iu this hospital.
^pinlmrats.
Succesiful applicants for Vacancies, Secretaries of Public Institutions,and
others possessiiiy xaitafdc for this column, are invited to
forward it to Tint LANCiiT OlJicd, directed to the Sub-liditor, not later
than 0 o'clock on the TImrsday numwny of eaeh week for publicaliott in
the 7icxt nuiiibor. •
Andhiison, JAiints, L.R.C.P., L.U.C.S. Edin., has been appointed Public
Vaccinator ^mi tent, for Pootscray, Victoria, Australia.
Buim'ixiniAM, C. E. Skhmmss, L.E.P.S. Olasg., has been appointed
Medical Officer of Ilualth for tho Eastern Division of tho Willitou
Union.
Brown, Wm. H., M.R.O.S . Ins been appointed Medical Officer for the
portion of the Colao Bhiro south of tlie boundary of tho Counties of
Polwarth ami South Gronvillo, Victoria, Australia.
BcRTON-liANNiNii, K. W., M.B. ChU tah, (formeilv known, a.s F. \V.
Burton), ha.s boon appointeil Honorary Pby.sician to the Norfolk
and Norwich liospital, Norwich.
1022 The Lancet,]
VACANCIES.—BIKTHS, MARRIAGES, AND DEATHS.
[May 2,18M.
Caiujwbll, Thomas, I<.R.0.P. Bdin., M.R.C.S., has been appointed
Medical Officer for the Bopsley Oiatriot ol the Grantlmm Union, vice
Moore. '
Clibbobn, Wm., M.D., L.B.C.S. Ire]., has been appointed Surgeon to
the Police Force, Bridport, vice Evans, deceased. j
DoOLAN, Denis, L.R.C.P,, L.R.C.S. Edln., has been appointed Public
Vaccinator for North Carlton, Victoria, Australia.
DowLiHQ, J. E., M.D. Irel., L.R.C.S. Bdin^ has been appointed Medical
Officer for the Tuam Workhouse, vice Turner, deceased.
Eales, G. Young, M.R.C.S., L.R.C.P. Edin., has been appointed
Honorary Physician to the Western Hospital for Consumption,
Torquay, vice Dr. Wills, resigned.
Elak^ W. H., F.R.C.S. Eng., has been appointed Surgeon to the Cancer
Hospital, Brompton.
Elliott, E.. I..R.C.P. Edin., M.R.C.S., has been appointed Public Vac-
dnator for the Bromsgrove District and Workhouse of the Broins-
grove Union, vice Kidd.
FoSTBR.t-MiCHAEL Q., M.A., M.B. Camb., has beenappointed Physician
to tike Kursasil Maloja (upper Engadine).
Fox, Oeorob Martin, L.B.U.P, Lond., M.R.C.S., E.S.A., has been
appointed Medical Officer and Public Vaccinator for the Willenhall
District of the Wolverhampton Union.
Fulton, T. J. K., L.R.C.P.. L.R.C.S. Edin., L.F.P.S. Glasg., has been
appointed Public Vaccinator for the Surrey Hills and Doncaster,
S^otoria, Australia, vice Perceval, resigned.
Gamgee, Leonard Parker, M.B,c.S., L.lt.C.P., has been appointed
House Surgeon to the Queen's Hospital, Binningham.
Gunn, A. L., L.R.C.P. Edin., L.F.P.S. Glasg., has been reappointed
Medical Officer for Swinefleet, Whitgift, and Ousefleet Sanitary
Districts, vice Bruce.
Guthrie, L. G., M.A., M.B. Oxon., M.B.C.P. Loud., has been appointed
Assistant Physician to the Paddir^ton-green Children’s Hospital.
Hyde. G. E., L.R.C.P. Lond., M.B.C.S., has heon reappointed Medical
Officer of Health for the Mai tley Rural District.
Lewis, Wm. M., M.D., L.K.Q.C.P. Irel., has been appointed Medical
Officer for the Shire of St. Arnaud (Donald District), Victoiia,
Australia, vice Fleming, resigned.
Marsh, Byding, M,D. Lond., M.R.C.vS., has been appointed Honorary
Medical Officer to the Jirighton, Hove, and Preston Dispensary.
May, F. H., L.R.C.P. Lond., M.R.C.S., has been appointed Medical
Officer for the Aston Manor District of the Aston Union.
Morris, Colin Dwight, L.R.C.P., L.S.A. bond., M.R.C.S., has been
appointed Medical Officer for the No. 5 District of the Staines
Union.
Owen, H. B., L.R.C.P.Loud., baa been appointed Medical Officer for
the Eighth and Ninth Di'tricts of the Kingsbridge Union.
PaRKES, Louis COLTMan, M.D. Lond., D.P.H., M.R.C.S., has been
i^pointed Medical Officer of Health, Food and Drugs Analyst, and
Gas Examiner for the Parish of Chelsea, vice Dr. Seaton, rosignecl.
Remfry, Leonard, M.A., M.O., B.C. Cantab., has been appointed
Obstetric Physician to Out-patients at the Great Northern Central
Hospital, vice Dr. W. R. Dalcin. resigned.
BOIHNSON, A. H., M.R.C.S., has been aopointed Medical Officer for
Wyke and part of the North Bierley Union.
Bowdotham, a. j , M.R.C.S., has been reappointed Medical Officer for
tile Dunham District of the Fast Retford Union.
Stonf.house, John, L.F.P.S. Glasg., has been appointed Medical
Officer for tiie Second District of the Whitby Union.
Sturoee, a. H., M.R.C.S., has been appointed Medical Officer for the
East Riding ol the Shire of Mornington, Victoria, Australia.
Ward, W. F., L.B.C.P. Lond., M.R.C.S., has been reappointed Medical
Officer for Scrosby, Retford.
Watson, John W.. M.D., M.Ch. Irel., has been appointed Medical
Officer for the West Riding of the Sbire of Mornington, Victoria,
Australia.
Williams, F. M., D.P.H. Camb., has beon appointed Medical Officer of
Health for the County Borough and I'ort of Plymouth.
Wilson, J. S., M.D. Glasg., D.P.l-I. Camb., lias been appointed Hono¬
rary Surgeon to the Walsall District Hospital, vice Shore.
For further iii/ormation refia-linyeach vacancy reference Bkould be made
tv the adoertieeinent.
Birmingham City Asylum.—R esident Clinical Assistant. Board,
lodging, (fee. No salary.
Birmingham City asylum.—A ssistant Medical officer. Salary £120
per annum, with board &c.
County of Caithness —Medical Officer of Ilealtli for the County.
Salary £300 .sterling, with £.‘50 for tfavelllng and other expense.s,
except forms and official stationery and yio.stages. (Apply to Mr.
Brims, County Clerk, Thurso.)
Camberwell Provident Dispensary, S.E.—Vacancy on tlie Medical
Staff.
Cumberland Infirmary, Carlisle.—House Surgeon for one year,
friary £70 per annum, with board, lodging, and washing.
Cancer Hospital (Free), FulhamDoad, S.W.—Honorary J’athologiat.
Cancer Hospital (Ii'ree), I'lilhaui-road, S W.—Siu'geon.
Cancer Hospital (Frf.e), Fulbam-road, S.W.—House Surgeon, Assist¬
ant House Surgeon and Registrar for six months. Salary at the
rate of £00 and £.10 a year respectively, with lioardand losidence.
City of London J/UNatic Asylum, Stone, near Hartford, Kent.—
Clinical Assistant for six months. Board, lodging, washing, and
attendance.
Farringdon General Dispen.sary and Lvinu-in CiiAiuTy, 17, Bart-
lett’s-buildings. Holborn, K.C.—Honorary Pliysiciii.n.
Norwich City asylum, Hellosdon, near Norwich,—Assistant Medical
Officer for one year, iti do-n'. Board, lodging, and wasliing. ,Salary
£1 (j 0 per annum,
ToniiAY Hospital and Provident Dispknsauv, Torlkay, —Junior
House Surgeon and Dispenser.
BIRTHS.
Baumgartner.—O n April 28rd, at SavUIe-pIace, Newoastle-on-Tyne^
the wife of Henry S. Baumgartner, M.B., of a daughter.
Gilpin.—O n April 24th, at Bengeworbh, Evesham, the wifeof B. Harrison-
Gilpin, L.R.C.P. Lond., M.R.C.S., L.S.A., of a daughter.
Lamrert.—O n April 26th, at-Ealgowan, Newland, Lincoln, the wife of
Frederick Samuel Lambert, M.R.C.S,, L.R.O.P. Loud,, of a daughter
(prematurely).
Langhorne.—O n February 28th, at Millicent, S. Australia, the wife of
T. Grant Langhorne, M.R.C.S., L.R.O.P., of a daughter.
MacBonnell —On April 28rd, at Gledhow-gardens, South Kensington,,
the wife of Mark Antony MacDonnell, M.D., of a son.
NlCHOLl.3.—On April 23rd, at Tlie Moat, Basthourne, the wife of
Howard Hill John Nicholls, M.R.C.S., of a son.
Pope.—O n April 20th, at Bvoomsgrove Villa, Goldliawk-road, W., the-
wife of H. Campbell Pope, M.D. Lond., F.R.C.S., of a daughter.
Turnbull,—O n April 2(5th, at Ladbroke-grove, W., the wife of George
Lindsay Turnbull, M.A., M.B., of a daughter.
Walker.—O n April 20th, at Gi-ove House, Lowestoft, the wife of Henry
Bournes Walker, Surgeon, of a son (stillborn).
Wood.—O n April 2l3t, at Lees Lodge, Yalding, Kent, the wife of E. J>
Wood, M.B. Cantab, ifec., of a daughter.
MARRIAGES.
Fawsseit—SPR iNQi-VfT.— On April 23rd, at the Parish Church, Hawk-
hurat, Fi-ank Fawssett, M.B., B.S. Lond., of Lewes, Sussex, to
Margaret Louisa, elde.st daughter of the late Augustus Springett,
Ksq., of Ashfleld, Hau-khurst, Kent.
Murrav-Aynsley—Key.— On April 27th, at Christchurch, New Zoa-
land, John Henry Murray-Ainsley, M.R.C.S., L.R.C.P. Loud,,
eldest sou of II. P. Miirray-Ainsley, Esq,, of Christchurch, t<^
Klizabeth Anderson, only daughter of Andrew Key, M.D., of
Montrose, N.B. (By cable.)
Parkinson—P n.LMAN.—On April 27th, at Christ Church, Movningside,
Edinburgh, by the Rev. C. M. Black. B.D. T.C.D., Thomas Wright
Parkinson, M.B., C.M., third son of the late T. H. Parkinson, of
Kaituna, Canterbury, New Zealfliid, to Euphemia Jessie, eldest
sm-viviiig daughter of Mervyn Pillman, Tossberry, Nile Grove.
(Australian and New Zealand papers please copy.)
Pn.KiNGTON — Lloyd. —On March 13th, at St. Clement’s Church, Moss-
man’s Bay, Sytiuey, by the Rev. Ernest Claude Beck, Fi-ancis
Sergenb Pilkington, L.R.C.P. Lond.. M.R.C.S. Eng., youngest son of
tbo late F. 8. Pilldngton, Leyland, Lancashire, to Marie, third and
only surviving daughter of the late W. Griffiths Lloyd, of Cevrig-y-
Driiidion, North Wales. _
DEATHS.
Browne.— On April IStli, at Wentworth House, Aldbrough, Hull, after
a brief il'noss, William Henry Browne, L.R.C.8., L.R.C.P. Edin.,
aged 60.
Cawtuorne.— On April 23rd, at Bivkwood, Weston, Bath, Beiijamin-
Cawthonio, M.R.C..S. Eng., aged 70,
Hensley.—O il April 2l3t, at Circus, Bath, Henry Hensley, M.D.,
aged 73.
Kay.— On March 2:ird, 1801, at Avocjv House, Victoria Coy., Natal,
S. Africa, of acute meningitis, in her lObh year, Janet McKinlay
Kay, sixth daughter of John McIntyre, M.D., formerly of Rother-
fleld, .Sussex, England.
Trull.—O n April 21th, John Trull, M.D., of New Brighton, Cheshire^
aged 36.
TuLK—On April 25th, at Forest Prospect, Tunbridge Wells, /Mfred
Talk, M.R.C.S., F.L.S., aged 71.
if.B.—Afee of 5s. is charged for the Insertion qf Notices of Births,
Marriages, and Deaths.
BOOKS ETC. RECEIVED.
A. Alvarez y Compania, Uabana.
Premier Congreso Medico-Regional de la Isla de Cuba, celebrado-
on la Habaiia on enero do 18»ii. pp. 000.
Considor.arinne.s Medico-logales acerca de la Muovto por la Elec-
tricidad Industrial. Por Eduardo F. I’la. 1391.
Black, Adam <fc Charles, London.
An Introduction to Iho Study of Mammals, Living and i?xtincl.. Bv
W, U. Flower, C.B., F.R.S., and Richd. Lydekker, F.U..S., h'.Z.S.
1891. pp. 703.
Bi.ACKiE & .SiiN, Old Biiiley, London.
Blackio's Elemoutary 'I’ext-books: Elomontary Chemistry. By
Joromo Harrison, F.G.S. ]3l)i). pp, 1-14.
Churchill, J. & A., New Burllngton-streeb, London.
A Short Dictionary of Medical Terms; being an Abridgment of
Mayne's Vocabulary. 1391. pp. lOO.
The Proclivity of Women to Cancerous Diseases. By U. Snow,.
M.D. Lond. 1891. pp. 58.
Digitized iiy' Google
The Lanobt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [May 2, 1891. 1025
Davis, F. A., Philadelphia and London.
Fevev; ita Pathology and Treatment by Antipyretics. By H. A.
Haro, M.D,, B.Sc. 1891. pp. 106. Price Off.
OniFPiN, C., <fe Co., Exeter-stroet, Strandj London.
Year-book of the Scientific and Learned Societies of Great Britain
and Ireland. Eighth Annual Issue. 1891. pp. 210.
LONGHAIS.S, GiiEiSN, & Co., London.
A Dictionary of Anplied Chemistry. By T. E. Thorpe, B.So. Viet.,
Ph.D., F.ll.S. In Three Volumes. Vol. H.; Kau—Nux. 1891.
pp. 714. Price 2 guineas,
The Watering-places of the Vosges. By H. W. Wolff. With a Map.
1891. pp. 168. Price 4s. 6d.
Pentland, Young J., Edinburgh and London.
Pulmonary Tuberculosis, Etiological and Therapeutic. By R. W.
Philip, M.A., M.I>., F.R.S.E. 1891. pp. 66.
Smith, Elder, <6; Co., Waterloo-place, London.
Collected Contributions on Digestion and Diet, By Sir William
Roberts, M.D., F.R.S. 1801. pp. 261.
Vogel, E. D., Easton, Pennsylvania.
The Modern Antipyretics; their Action in Health and Disease.
By Isaac Ott, M.D. 1891. pp. 62.
Wood, Wm., & Co., New York.
Text-book of Bactorio’ogy, By C. Fraenkel, M.D. Translated and
Edited by .1. H. Linsley, M.D. Tliird Edition, 1891. pp. 876.
Practical Treatise on Electricity in Oyntec'>logy. By E. H. Grandin,
M.D., and .J, II. Gunning, M.D. lllustr.ated. 1801. pp. 171.
Uber Eciiinokokkiis der Pleura; von Professor Dr, Carl Maydl (Josef
Safar, Wien, 1891). — Report on tlie State of the Blood and the Blood¬
vessels in Inflammation ; by T. Wharton Jones, F-R.-S. (Baiiltiire,
Tindall, and Cox, Loiulon, 1891); price 2*, Oil. — Le llemdde de Koch ;
par 11. W. Miild 0 niloii){J. B. Baiil uro at Fiis, Paris, 1891).—Handels-
Bericht; von Gohe & Co. in Drosden-Noustadt, April, 1891 (C. C.
Meinhold & Siiline, Dresden)—Do I'Einpy^me Latent de I’Antro
d'Highinore; par la Dr, J. M. .loanty (Ferot at Fils, Bordoaux, 1801).—
Dio Blennovrhde «ler .Sexualorgaiie mid ibra (ioinpliuationen ; dar-
gescollt von Dr. K. Finger (F. Dautlcke, Leipzig und Wien, 1891).—
Index Motlictis, Authors and Subjects, Vol. XIII., No. 8, March, 1891;
also Index to Vol. X(L (TrUbner & Co, and Lewis, I.ondon).—
Problems in Cardiac Pathology ; Thesis for tlio Degree of M.D. Oxon. ;
by F. J. Smith. M.B., M.R.G.P,, F.R.C.K. — Archives of Surgery;
by Jonathan Hutchinson, LL D., F.R.S., Vol, II,, No. 8, April, 1891
(J. & A. Churchill, l.ondon); price 2x, (id.—KUule Ilistorique sur los
Organes Gdnitanx de la Fomino; par G. PeilUin, M.D. (C. Berthier,-
P.aris, 1891).—Boitvago zur Augonlioilkunde; herausgogoben von
Professor Dr, R, Deutschinann; Iloft 11. (Leopold Vos.s, Hamburg
und Leipzig, 1891).—Wil.snn’s Legal Handy Books ; Tlie Law of Wills;
by C, E. Stewart, Bavrister-at-Law ; second edition (Effingham Wilson
& Co., Loinlon); price lx. Od.—Boitriigo zur Pabliologie und Thorapie
derGallonsloinKrankheit; von Dr. F'. Kraus-Karlsbad (A. ilirsrhwald,
Berlin, 1891)-—Ei Metodo de Koch en las Tuberculosis Locales ; por
el Doctor Diogenes Decoiul (Jacoho Penser, Bnenos Aires, 1801),—The
Cabinet Portrait Gallery, Part XX, (Cassell ifc Co,, Limited, London);
price 1*.—Book of Surgical Instruments (Maw, Son, & Thompson,
Aldersg.ate-stroet) —I’rocoedings of theSocietyforPsychicalResearch,
April, 1891 (Kogan Paul, Trench, & Co., London); price 2x. 6d.—
Transactions of the Obstetrical Society of London. Vol. XXXII., for
the year 1890 (The 01)nLetrica! Society, Hanover-,sr|uare, London);
price Off.—The Verulam Review, April—June, 1891 (E. Stock, Pater-
noster-row, London); price lx.—Magazines for May: Good Words,
Sunday at Home, Leisure Hour, Sunday Magazine (Isbister); Boy’s
Own Paper, Girl’s Own Paper (Religious Tract Society); Scribner’s.
METROPOLITAN ASYLUMS BOARD.
Eeturn of Patients remaining in the several Fever Hospitals
of the Board at midnight on April 2Sth, ISDl.
Beds occupied.
o
Hoaplta).
7? V
is
to--
4
1
3g
“C
St
a o
w-
If
Total
h
s®
S
Eastern Hosnital .. ..
168
6(1
37
2
247
442
North-Western Hosnital
129
89
12
1
181
448
Western
146
19
14
1
179
South-Western
MO
83
12
186
840
South-K.aetern
167
17
19*
2(1.6
Northern „
169
13
0
178
480
Totals .. _
171
109
7
1170
2891
Small-pox .—Allan hospital ship, ly.
* Infant with mother.
METEOROLOGICAL READINGS.
(Taken daily at B.SO a.m. by Sleward't Instruments.)
The Lancet Office, April 80th, 1891.
Date.
Baroitiotor
reduced (o
Sou Level
and 82 ’ If,
Dlroc-
tloa
of
■Wind.
Dry
Bulb.
Wot
Bulb.
Solar
Sadia
in
Vaouo.
Maxi¬
mum
Tamp.
8hauo.
Min.
I'omii
Bain-
fall.
Bemoiks at
8.30 «.u.
Apr. 24
30-17
E.
4S
42
94
67
87
Bright
„ 26
80 17
E.
44
41
76
61
40
Overcast
.. 26
80-06
N.B.
44
40
87
63
87
Caoudv
„ 27
29-82
K.
44
43
106
61
37
Hazy
„ 28
29 63
S,F„
67
47
103
66
41
Hazy
„ 29
29 81
s.w.
61
4S
03
60
42
Cloudy
„ SO
29 69
s.w.
60
50
112
05
44
Cloudy
Itflte, Cflmmcnts, ^ tu
€mwpnkuts.
It is especially requested that early intelligence of local
events having a medical interest, or which it is desirable
to brmg under the notice of the profession^ may be sent
direct to this Office.
All conwnunications relating to the editorial business of the
journal must he addressed “To the Editors.”
Lectures, original articles, and reqwrts should be written on,
one side only of the paper.
Letters, whether intended for inse/rtion or for private informa¬
tion, must he authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or ncivs paragraphs should
be 7narked and addressed "To the Sub-Editor.”
Letters relating to the publication, sale, and advertising-
aeparimenis of The LANCET to be addressed “ To the
Publwher. ”
We cannot undertake to return MSS. not used.
A Poisonous Spider.
Mr. Andrew Ro.ss, M Jh, practising in New South Wales, writes:—
“It has generally been supposed that spiders are very harmless'
insects, anti totally void of any daugorous or poisonous effects;
but tne history of the following remarkable case tends to-
establish quite a contrary opinion. About 0 o’clock in the'
evening of Jan. 24th, a hoy of about five years of age was sitting
on the doorstep eating some bread-and-butter, when all of a
sudden ho cried out and complained to his mother that some¬
thing had bitten him on the neck behind the lobe of the ear. The
boy at once puUetl his hat oil his liea<l and threw it on the ground,
and the mother, on picking it up to see if anything was inside, dis¬
lodged a large black spider with a large round belly and red spot
on the back, which she inst.antly killed. The boy said the spider
liad bitten him, and very shortly after he commenced to scream
with pains in his u«ck and also running down his legs and feet.
He was brought to my surgery, ami on examining the neck I found
a largo eryUiomatous circle at the .spot whore the spider was sup¬
posed to have bitten him, which I scarified and bathed with
the usual remedies- I adininisterod ammonia and brandy, but the-
cliild continued to scream with pain. The case continued under
my care for a week, and is one of so singular and remarkable
a character, and surrounded witli symptoms and sufferings so-
amnzingly violent and peculiar, that 1 deem it my duty to lay the-
full history of the case before the public as a warning to beware
of such supposed innocuous insects.”
THE NUR.SE-TRAININO vSOHOOLS AND THE ROYAL BRITISH
NURSES’ A.SSOCIATION,
To the Ediluni of The Lancet.
Sms,—At a mooting of tho Royal British Nurses’ A.ssnciatiou, hold
on the letli of this month, the proceedings of which have been reported
in several of the daily papers, more than one of the principal speakers,
including tho cliairman and honorary secretary, spoke in strong terms
of the persecution which, us they allege, thi.s Association sulfereil at
tlie hands of tl\e Nur.so Training School.s and their ropresentativoa, and
coinpiaiii Uiat this oppo.sitlon ainiod, amongst other things, at rendering
the presidency of Her Royal Highnc.as the I’rincess Christian impos¬
sible, and at provonting Lady Bloomfield’s pension fund for nurses being
haiiiled over to it.
It would bo making too great a demand on your space to ask tho use
of your columns, and at the present moment this seems hardly neces¬
sary, ro di.scuas at length the grounds of tho opposition of tho Nurse
'Training Schools and largo hospitals to that which la the main object
of tho Royal British Niiraes’ Association—viz., tho foi-niatlon ami
control of a goncml register of nurses, having an authoritative
character, or to dwell upon the evils both to the public and to nursing
which they foresee as tho conseiiuenco, inasmuch as in all jirobability
the matters in diapulo will have to be fouglit out before tho President,
of tho Boanl of Trade.
Dr-' zed by Google
1024' TM Lancm,) notes, COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[May 2,1891.
But meanwhile we, the repreaentatives of the leading Nurse Training
Schools, feel it out duty to protest against the 'charge of using “ secret
means,” and the term “persecution” being applied to the actions of the
bodies we represent. It is to the Nurse Training Schools that the
great advance which has taken place during the po^t thirty years in the
quality of^nurses and nursing and in the position of nurses is wholly
<lue, and it is to these that we must look in the future for the main*
Cenance of the high standard of excellence which has been thus attained.
Can it be seriously, then, charged against the authorities of these
schools, all of whom have worked in the interests of nurses and of
-nursing, and many have devoted themselves to the subject for years,
and are themselves trained nurses, that they are the persecutors of
nurses, or that they are perversely opposing schemes which are
“obviously for the advantage of the nursing profession.”
They do not oppose, and never have opposed, the formation of any
nnstitutlon established for the purpose of thrift, mutual beneSt, or of
isocial intercourse, but believing, as they do for reasons which they liave
•elsewhere fully explained, that the establishment of such a Register and
-the grahtiog by such a body as the Royal British Nurses'Association of
certificates of competency to nurses will be detrimental to the interests
•of nurses and misleading to the public and medical profession, they cer¬
tainly have opposed and will continue to oppose the attempt of the
Association to obtain from the Board of Trade the privilege which it
•seeks, and by which a “legal status ” would be accorded to it.
With regard to the Lady Bloomfield Fund, not one single word has
been said by the nurse training schools or hospitals on the subject.
'The Lady Bloomfield Fund has a most distinct and valuable object in
view, and, with her ladyship as its head and under the guidance of his
Grace the Duke of Westminster, will without doubt be most success-
■fully and carefully managed ; whether its transference to any other
aseociation would be wise or not can only have been brought into the
<liacus3ion for the purpose of diverting attention from tlie real question
At issue.
While recognising in full the great interest talceii by Her Royal High*
viess the Princess Christian in the welfare of nurses and its value to
muraes, they cannot but regard the manner in which Her Royal High¬
ness’s name has been introduced into the discussion as wholly uncalled
tfor and unworthy of the spirit of (air discussion.
Westminster. I'residont of Metropolitan and National Asso¬
ciation and Westminster Hospital and Txaining School.
Rutiirreohd Ai.cocK, Vice-President Westminster Hospital
and Training School.
Harry Verney, Chairman of the Council of the Nightingale
Fund.
J. G. Wainwricht, Treasurer of St. Thomas’s Hospital.
K. H. Lushinoton, Treasurer of Guy's Hospital.
Ji. M. INU, Chairman of the l.ondon Hospital.
H. Wage, Chairman of Committee of Management, King’s
College Hospital.
W. Bathuone, President of the Livei-pool Training Sclioofand
Home for Nurses. _
To the Editors o/Ti!E Lancet.
Sirs,—W e, the undersigned, regret to find it necessary to call the
attention of the public to the following tacts
At the present moment any woman—even if she is destitute of know¬
ledge or of character, or of both—can term herself a trained nurse, and
•can obtain employment in that capacity. There is, moreover, no means
of preventing any certificated nurse who ha,s proved lierself unworthy of
trust from continuing her occupation. It is unnecessary to point out
the danger to the side involved in this state of affairs. Three years ago
the Royal British Nurses’ Association was founded “ in order to unite
murses for their mutual help and protection, and for the advance¬
ment in every way of their professional work.” It has been
•already joined by many inllueiitial medical men, by the matrons
of l&O important English and colonial hospitals, and by nearly
3000 nurses. Its primary object has been to compile and issue a
’Register of Trained Nuv.ses, the first annual volume of which has just
ibeen published, and can be obtained tlirougU any bookseller, or from
•the oihees of the Association. It contains the name.s of 1700 nurses,
their addresses, and tlio place and length of the hospital training
which each lias receiveu. Tliese women have voluntarily applied for
-enrolment, and their certificates of technical knowledge and personal
•character have been carefully scrutinised by the infiuential Board
-appointed by the Association for the purpose. If any one of these
nurses hereafter proves to be unworthy of confidence, her name can at
•once be removed from the Register.
The Association only deals with nurses wlio have completed tlieir
'training. It does not therefore in any way interfere with the Nurse
Training Schools.
We greatly regret that some hospital authorities and a few private
■individualB, misapprehending the objects of the Association, have
•exhibited their opposition to tlie system of registration by most iinu.sual
methods. Many nurses have been prevented from joining the Associa-
'tion, or have been compelled to resign their membership. Its members
(have been persistently assaiiod in print. A simple proposal to incor¬
porate the Association under the Companies Acts, in ordor that it may
'take over.and administer ti-ust funds, has now been seized upon to send
broadcast over the country documents marked “Private and Confi¬
dential,” requesting the committees of provincial ho.spitals to oppo.se
the Association. Failing any other opportunity of meeting sucii
attacks, wo are compelled to call public attention to tho matter, and to
•express our very decided conviction—
(1) That tlie sick should be protected from ignorant and untrust-
woitby nurses.
(2) That nurses have a perfect right to demand that their calling should
bo cleared, as far as possible, from those who now disevedit it and them.
(3) That the registration of nurses as carried out by the Association
would accomplish that end, exactly as the registration of members of
other callings has proved to be of similar advantages to them.
(4) That the Royal British Nurses’ Association, therefore, deserves
the most earnest support of the public and the medical profession.
(5) That tho nurse training schools, which havo no control over
those who ate not in their service, have no legal or moral right to pre¬
vent nurses from enrolling their names upon a register if they choose to
do so. Nor liave they any possible right to prevent the sick being pro¬
tected in any measure, however small, from the acknowledged dangers
to which they are at present subjected.
We are, Sirs, your obedient servants,
Wm. S. Savory.
T. Sl’ENCER Wej-ls.
Richard Quain.
James Crichton Browne.
J. Fayrer.
Dyce Duckworth,
Edward H. Sievekind.
ALI-RED GaRROD.
Edwin Saunders.
B. Douglas Powell.
Wm. Cayley.
A. Pearce Gould.
Sidney Courland.
ANDREW Clark (F.R.C.S.)
Octavius Sturoes.
F. W, Pavv.
N. Davies-Colley.
Robert Barnes.
T. Pickering Pick.
April 28tli, 1801.
E. Brudenell Carter.
W. B. Cheaule.
G. ANDERSON Critchett.
HERitEiiT w. Page.
Thomas Buzzard.
Arthur E. Barker.
Wm. O, Priestley.
F. J. Gant.
Harrington Sainsburt.
Chas. Gage-Brown.
Wynn Westcott.
W. Bezly Thorne.
■SEl’TIMUS W. Sirley.
Alfred t. Schofield.
Lovell Draqe.
Edwd. a. Fardon.
Kdgar Willett.
Bedford Fenwick.
THE METROPOLITAN HOSPITAL INQUIRY.
To the Editors of 'The Lancet.
Sirs,—T he evidence given before the Select Committee in the above
inquiry has been abundantly interesting, and will doubtless be ably
summarised in The Lancet at the conclusion of the investigation. I
wish, however, to draw attention to that part of Mr. Hurry Fenwick’s
evidence whore, after stating he was associated with both St. Peter’s
and the London Hosjiitals, he says, “ it was his habit to draft patients
from the general to tho special hospital.” Further on the same witness
states, with commendable frankness, that “.Special hospitals withdrew
from consulting members of the profession a groat amount of special
material useful for their own experience and for teachinij jmrposes";
that “they alfected other members of tho profession in a monetary way.”
Now, I think most private practitioners are painfully alive to the
truth of the latter paragraph, and I would only add to it by affirming
that general practice ia rapidly losing its interest by the craze for
specialists which the creation of special hospitals has given rise to. I
wish, however, to ask how can a general hospital pretend to give a
complete education to its students in return for tlie foes paid, when
the authorities allow an important class of cases to lie drafted to a
special hospital six or seven miles away '! It is bad enough for the
general practitioner to suffer in income from the present state of
things, and in much of the pleasure in his work, by the absorption of
cases by “specialists.” But to deprive the student of clinical material to
feed a distant special hospital would seem to be a distinct breach of
contract. I am. Sirs, yours obediently,
April, 1801. Paterfamilias.
MICROSCOPICAL WORK.
To the Editors of THE Lancet.
.Sirs,—N o doubt there are many young gentlemen who are better
versed in luicroscopical work than old men, and could kindly give a
few instructions, as just now there is a bacteriological “craze” going
on in the profession. Having furnished myself with a new microscope,
I find that I cannot work satisfactorily the “immersion lens.” I went
up to London tho other day, thinking the maker could give me the
necessary information, but was surprised he could not do so. How
much oil should bo put in? ahould tho lens be cleaned every day’/
Should the aperture in tlie diaphragm bo large or small for a l-12th lens?
What distance should the lens be from tiio top of the mica cover?
Any other information I should esteem an obligation, as it ia a hard
matter for a lad to havo a toy and not be able to use it.—Yours truly,
April 27tli, 1801. M.B.
DiSTRinUTION OF TESTIMONIALS.
M.B. —It is a most unprofessional practice to send testimonials round
a neighbourhood, and it is even worse to send tliem directly to
the Icnown patients of other medical men. We are speaking on an
ex parte statement of tlie case, hut if tho gontlenian wlio does so lias
no explanation to offer, or apology, it would lie jnstiflaldo to decline
professional rolation.s with him.
Mr. JJarlin;/ (Hartshill).—Yes, shortly.
MEDICAL WORK ON liO.-VUD SHIP.
To the Editors of ’THE Imncet.
8IR.S,— A Fi'ench colleague of mine, a wMecin de marine, wants to
know of the best work in English on tho rok of the naval surgeon, and
especially on the dift'orent methods of tran.sport of the wounded on
board a man-of-war in action. Any informaiinn on this head would
greatly oblige. Your obedient servant,
Paris, April 2()Ui, 18C1. J- H. Barnard, M.D.
.oogie
Die
Tqb Lancet,}
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS, [May 2,1891.1^1025
Medical Rkuee Ordeks.
The Bury wnd Norwich Poit of April 21st contains the report of a
long discussion at the Thetford Board of Ouardians, based on a
complaint of Mr. Minns, one of the medical officers, that bis orders
for relief were not regarded by the relieving officer. Two cases in
particular were stated. The reply of the relieving officer was that
Mr. Minns ordered much more meat than the other medical officers,
that one of the orders came on a .Sunday, and that in the course of
seventeen years’ office he had never been troubled by such orders on
a Sunday. The guardians sided with the relieving officer. They
pointed out to Mr. Minns that his orders were only recommendations,
and that in the long run the responsibility of refusing to give what is
ordered rests with the relieving officer. It is very trying to medical
men to witness the misery of sickness intensified by want, not less so
on Sundays, and to bo met by an niisympathetic relieving officer.
Meantime, all that Mr. Minns can do he has done.
THE CLERGY AND HOSPITAL ABUSE.
To the Editors of The Lancet.
Sirs,—A t the present time, when so much interest is taken in the
question of hospital abuse, it may be well to consider whether the
clergy are not in a small degree responsible for such abuse. Speaking
from my own experience, I am driven to the conclusion that they are,
unwittingly perhaps, assisting to pauperise the public. •* Why not take
your child to Victoria-park ?” “ If I were in your place, I should go to
the Throat Hospital.” “Why do you have this operation (for fistula)
done at home, when there are sjrecial hospitals for such cases 1" Such
are the remarks made to patients by various reverend gentlemen, fol¬
lowed in too many instances by the offer of the necessary hospital
letter. A patient of mine, in coinforfable circumstances, told me that
she was so urged to go to Brompton that she finally accepted the
proffered letter, and went to the hospitivl once, just to “ pacify” the
clergyman. The medicine and cod-liver oil were thrown away.
Now, I believe our clerical friends are acting with the very best
intentions; but unfortunately, they have not a due appreciation of
tlieir responsibility in this matter. I wish something could bo done to
make quite clear two facts; (1) That the distribution of hospital letters
is a most important trust confided to them, and (2) that to give hospital
letters to those who are well able to pay for medical attendance is a
gross abuse of this important trust. Yours faithfully,
Hatcharo, S. 10., April, 1891. E. F. BiNUi.oss.
DISINFECTION AFTER DIPHTHERIA.
To the Editors o/TiiB Lancet.
Sirs,—W ill yon kindly answer the following inquiry in your next
issue? Is it absolutely necessary to thoroughly disinfect a room after
being occupied by a diphtheria patient? -Vours faithfully,
April 26th, 1831, Ai’PETiTUS Rationi Parent.
In the present state of our knowledge as to the natuml history and
tenacity for life of the diphtheria bacillus, it is extremely difficult to
declare any process of prevention to be “abselutoly necessary” in all
circumstances. But we know enough to indicate that the infection
clings to premises and to clothing and tlierefore adeipiate disin¬
fection ouglit, in our opinion, not to be omitted as one of tlio pre¬
cautions against the further spread of diphtheria.—ItD. 1.,
MANAGEMENT OF METROPOLITAN HOSPITALS.
To the Editors q/Tna Lancet.
Sirs,—I n The Times of this date I read as followsDr. Hurry
Fenwick, a member of tlie stalf of St. Peter's Ho.spital for Stone, advo¬
cated tlio licensing of all hospitals by a board composed of the leading
members of biro medical profession who liad the interests of tliose
institutions at lioart.” Were this excellent suggestion adopted, I
apprehend that St. Petor's Hospital would be one of the fiist to be
closed. Tire general hospitals woiihl bo only too glad to provide
accommodation for all these cases, and the students'education would
be rendered tlio move complete by their seeing them umlor treatment
in tire clinical wanls. I am, Sirs, yours obediently,
April 24th, ISDl. Management.
INHALERS FOR UtJE IN PRODUCING AN.-ESTHESIA.
To the litUlors of TliK LaNCET.
Sues,—The great advantage claimed by Mr. Duke in your issue of
to-day for his cliloroform inhaler, that “tlie respiration cau.ses the
valves through wliich the air must pas.s to produce a sound audible to
tlio administrator,” was the main feature in the inlialer that was
devised by ray father for otiiev in 1817, the yo.ar before clilorofonn was
introduced. 1 am, Hirs, yours faithfully,
Harley-streot, W,, April 25th, 1801, Heywooo Smith.
IODIDE OF GOLD IN PHTHISIS.
To the Editors of Tin.; Lancet.
Sirs,—W ill any brother practitioner who has tried the above be good
enough to give the profession the benefit of bis experience ?
I am. Sirs, yovu-s obediently,
April 27tli, ISOl. G. P.
Ptliifal §iarjf fiir tfet ensninj
HondaY, May 4.
ROTAL London Oputhaluio Hospital, UooaFiELDS. —Operatlow
dally at 10 a.h.
BOTAL WESTMINSTER OPHTHALMIC HOSPITAL.—OperaUoOS, 1.80 P.H..
and each day at the same hour.
Chelsea Hospital for Women.—O perations, 2.80P.H.; Thursday, 8.80.
Hospital fob Women, Soho-squabb. — Operations, 8 p.h., and o&>
Thursday at the same hour.
METRJ3POLITAN FREE HOSPITAL.—Operations, 2 p.M,
Royal ORTiioPiEDic Hospital.— derations, 2 p.h.
Central London Ophthalmic Hospital.—O perations, 8 p.M., ani>
each day in the week at the same hour.
University Collboe Hospital.—B ar and Throat Department, 9 a.m. ;
Thursday, 9 a.h.
London Post-qraduate Course.—H ospital for Sick Children, Great
Ormond-st.: 4 p.m., Dr. W. B. Clieadle: Errors of Feeding and FoodI
Diseases of Childhood.—Royal London Ophthalmic Hospital, Moor-
fields; 1 P.M., Mr. R. M. Gunn: External Examination of the Eye.
Royal Institution.—6 p.m. General Monthly Meeting.
Odontologicai- Society op Great Britain (40,Leicest6r-sq.,W.C.).—
8 i‘.M. Mr. D. E, N. Causii: Exostosis (with microscopic slides an<P
pliotographs). Casual CommunicationsMr. J. Bland Sutton:
Odontome in a Horse.—Mr. Morton Smale: A case of Injury to
Temporo-maxillary Articulation at three years and a half causing.
Closure of the .Taw.—Mr. Stocken: Cases of Absorption of Permanent.
Teeth-—Mr. David Hepburn; A case of Attrition in the First Den¬
tition.—Mr. C. V. Cotterell: Convertor for Electric Mallet.
Society of Arts.—8 p.m. Mr. Hugh Stannus; The Decorative Treat¬
ment of Natural Foliage. (Cantor Lecture.)
Medical Society of London.—A nnu^ Conversazione. Oration at.
8.3U P.M., by Sir Joseph Lister, on the Coagulation of the Blood
in its Practical Aspects.
Tuesday, May 5,
Kino’s College Hospital.—O perations, 2 p.m. ; Fridays and Saturdaye
at the same hour.
Guy’s hospital.—O perations, 1.80 p.h., and on ^day at same bout.
Ophthalmic Operations on Monday at 1.30 and Thursday at 2 P.M.
8t. Thomas’s Hospital,—O phthalmic operations,4 p.m.; Friday,2 p.h>.
8t. Mark’s Hospital.—O perations, 2 p.m,
Cancer Hospital, Brompton.—O perations, 2 p.m.; Saturday, 2 p.Ku
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.m.
St. Mary’s Hospital.—O perations, i,30 p.m. Consultations, Monday
2.80 p.m. Skin Department, Monday and Thursday, 9.80 a.h.
Throat Department, Tuesdays and Fridays, 1,80 P.H. Electro-
tberaneutics, same day. 2 p.h.
London Post-graduate Course.—B ethlem Hospital: 2p.M.,Dr.Percy
Smith : Hypochondriasis and Melancholia,—Hospital for Skin Dis¬
eases, Blackfriars (the lecture will bo delivered at tire Ex.aminatioi>
Hall, Victoria Embankment) ; 5 p.m., Mr. J. Hutchinson : Oi»
Raynaud’s Disease and Allied Affections.
Royal Institution.—3 p.m. Dr. Edward E. Klein: Bacteria, their
Nature and Functions, (Tyndall Lecture.)
Society of Arts,—8 p.bi. Capt. Buchan Telfor: Armenia and the'
Armenians.
PathologicalSociety OF London.— 8.30P.M. Dr.S.Delcipine: Melano-
mycosi.s of Skin.—Dr. J. S. Bristowe : Black Tongue.—Dr. Albert
Wilson ; The Micro-organisia of Diphtheria, with Experimental Re¬
sults in Animals.—Dr. S. Sharkey; Ulcerative Colitis.—Mr. W. H.
Battlo : Acute Epiphysitis.—Dr. N. Pitt: Gummatous Meningitis:
Gumma of Heart.—Dr. A. F. Voelckev: Tuberculosis of Mediastinal
Glands invading Lung.—Mr. E. W. Roughton: Lipoma of Spermatic-
Cord with Hernial Sac.—Mr. H. B. Robinson : Columnar-celled
Carcinoma of .law,—Dr. H. D. Rolleston : Myocarditis limited to*
Right Side.—Dr. F. Payne ; Syphilitic Caries of Calvaria in an Infant.
fJard Speoinions ;—Mr. A. Doran: Hydronephrosis ; Nephrectomy.
Mr. J. II. Targott: Symmetrical Hemiatropliy of Gastrocnemius.—
Dr. II, D. Rolleston : Necrosis of Skull-cap ; Fracture of Krst Rib.
Mr. S. G. Shattock; Bilhatzia, Bladder.
Wednesday, May 6.
National Orthop/Bdic Hospital.—O perations, 10 a.m.
M1DDLE.SEX Hospital.—O perations, 1 P.M. Operations by the Obstetric
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, 1.80 p.m. ; Saturday, sama
hour. Ophthalmic Operations, Tuesday and Thursday, 1.83 P.M
Surgical Consultations, Thursday, l.SO P.M.
Chaiung-cross Hospital.—O perations, 8 p.m., and on Thursday and
Friday at the same hour.
ST. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same houK
London Hospital.—O perations, 2 P.M. Thursday* Saturday, same hour
St. Peter’s hospital, Covent-garden.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Childben,—O perationst.
2,30 P.M,
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.80 p.m.; Skin Depart¬
ment, 1.46 P.H. : Saturday, 9.16 a m.
Royal Free Hospital,—O perations, 2 p.m., and on Saturday.
CHILDREN'S Hospital, Great Ormond-street.—O perations,9.80 A.M-l
S urgical Visits on Wednesday aud Saturday at 9.16 a.m.
Royal Sociisti'.—C oiiversazioiie.
LONDON Post-graduate Course.—H ospital for Consumption, Bromp¬
ton : 4 P.M., Dr. F.T. Robeids : Clinical cases in relation to PliysieaP
Conditions .and Symptoms.—Royal London Ophthalmic Hospital:
8 P.M,, Mr. A. Q. Silcock : Glaucoma.
Obstetrical society of I,ondon (20, Hanovor-square, W.).—8 p.m.
Specimens will be shown by Dr. Lowers, Dr. Godson, and others.
Dr. Dakin : Tetaiw in Pregnancy.-Dr. Jolin Phillips : On a case of
Death following V.iginal Injection of Acid Nitrate of Mercury.—Mr.
Alban Doran: Sequel to the case of Anturior Serous Perimetritis
simulating Ovarian Sarcoma.
Society of Arts.—8 p.m. Mr. E. L, Fleming: The Sources ami
Applications of Borax.
--y Google
1026 Thb Lanoxt,] notes, comments, AND ANSWERS TO COBRESPONDENTS.
[May 2,1891.
niQXBda 7 , May 7.
St. Oborge’b Hospital.—O perations, 1 p.h. Sai^oal Consoltatloiu,
Wednasd^, 1.80 P.M. Ophthalmic Operations, niday, 1.80 p.k.
TJniveksity Colleqs Hospital.—O perations, 3 p.h.; Bar and Throat
Department, 9 a.u.
ElOYAL Institution.—S p.m. Professor Dewar: Becent Spectroscopic
Inrestigations.
liONDON Post-qraduatb COURSE.—Hospital for Sick Children, Great
Orn>ond-8t.: 4P M.,Dr. W. B. Cheadle: Common Errors and Fallacies
of Medical Treatment In Children'sDiseases.—National Hospital for
taeParaiyseaand Epileptic: 3 p.m.,D r.Tooth; TheDiagnosisbetween
Fnnctional and Organic Diseases of the Nervous system.—London
Throat Hospital, Gt.Portland-st.: 8P.M., Mr. W.B. H. Stewait: The
Examination of Ear Cases.
Barveian Society op London.— 8.3fi p.m. Mr. J. W. Malcolm: Some
Complicated cases of Abdominal Section.
Ophthalmolooical Society op the United Kingdom.—8.80 p.m.
Patients and Card Specimens at 8 p.h.—M r. R, Williams : Arterio¬
venous Aneurysm of the Orbit.—Mr. George Wherry: Paragensia
with Ophtbatmoplegia.—Mr. T. Thompson: Emphysema of Con¬
junctiva —Mr. Lawford (for Mr. Johnston of Vancouver): Penetra¬
tion of Eyelash into Anterior Chamber.—Mr. Ernest Clarke: Intru¬
sion of Eyelash into Anterior Chamber.—Dr. P. H. Mules; On Anterior
Cerebral and Pyramidal Capsulai' Cataracts.—Mr. Kenneth Scott:
On Perchloride of Mercury in Couiunctival Disease. Card Commu¬
nications :—Mr. Lawford: Thrombotic Retinitis.—Mr. R. Williams:
Dermoid of Cornea.—Mr. Eruest Clarke: Total Absence of Iris.
ftOYAL Medical and Ohiruroical Society.—S.SUP.H. Adjourned Dis¬
cussion on Mr. Watson Cheyne’s paper on the Value of Tuberculin
in the Treatment of Surgical Tubercular Diseases.
Friday, May 8.
BOYAL South London Ophthalmic Hospital.—O perations, s p.h.
t.ONDON Post-graduate Course.—H ospital for Consumption, Bromp-
ton; 4 P.M., Dr. F.T. Roberts ; Clinical cases in relation to Physical
Conditions andSymptoms.—Bacteriological Laboratory,King's Col¬
lege: 11 A. M. to 1 P.M., Prof. Crookahank: The Microscope for Bic-
teriological Work (Cover-glass Preparations). — Great Northern
Central Hospital: 8 p.m , Dr. Galloway: Heart-Valvular Lesions,
with their consequences (demonstration).
Olinical Society of London.—M r. ArbuthnotLane: Two cases of Re¬
section of Intestine by Senn’s Method.—Mr. C. J. Symonds; Two
cases in which a Sequestrum was removed from the Neck of the
Femur without Injury to the Joint; recovery in botli, and in one
with a perfect joint.—Dr. T. J. Maclagan: Cases of Neuritis and
Spurious Arthritis.—Mr. Stephen Paget: A case of Cerebral Abscess
twice Trephined ; Heniia Cerebri; recovery.—Dr. Sidney Phillips :
A case 01 Typhoid Fever with Occlusion of the Femoral Artery
during Convalescence, and with Acute Maniacal Attacks.
Royal Institution.—9 p.m. Prof. W. Ramsay: Liquids and Gases.
Saturday, May 9.
Middlesex Hospital.—O perations, 2 p.h.
Hmivbesity College Hospital.—O perations, 2 p.h, ; and Skin Depart
ment, 9.16 a.m.
London Post-graduate Course.—B ethlem Hospital: 11 a.m., Dr, Percy
Smith: Clinical Demonstration.
BOYAL Institution,—3 p.m. Mr. H. Graham Harris: The Attiflcial
Production of Cold.
Communications, Letters, Ac., have been received from—Dr. J. W.
Ogle; Mr. E. Owen; Mr. W. H. Bennett, London; Dr. lleywood
Smith; Dr. Minns, Tbetford ; Dr. Yule, Guildford ; Messrs. Keene
andAshwell; Dr. Bennington, Newcastle-on-Tyne; Messrs. Cooper
and Holt; Dr. Dudley, London ; Dr. P. Little ; Messrs. Richardson
.and Co., Leicester; Dr. A. Ross, Molong, N.S.W.; Messrs. Hertz and
'Collingwood: Mr. Kilner, Flimgoe; Rev. Dr. Rigg; Messrs. Oliver
and Boyd; Dr. Pocklingbon, Wimbledon ; Messrs. Smith, Elder and
Co.; Mr. Heslop, Blackpool; Dr. B. Fenwick; Messrs. Brims and
Mackay, Thurso ; Mr. Bindloss, Ilatcham ; Messrs. Kegan Paul and
Co.; Mr. Silcock ; Dr. Littlejohn, Edinburgh; Mr. Jubb ; Mr. Wood
'White, Birmingham; Mr. Lund, Manchester ; Messrs. Oppenheiiner
and Co.; Mr. Wainwright, London ; Dr. Wynter ; Messrs. Bryce and
Rumpff; Mr. Dobie, Brampton; Mrs. Wallace ; Dr. Sleeves, Toxteth
Park ; Dr. J. Adams, Eastbourne ; Mr. E. C. Htabb ; Messrs. Lane
and Co. ; Dr. Bond, Gloucester; Dr. Auld, Glasgow; Messrs. Read
and Co., Bristol; Dr. L. E. Stevenson, Jedburgh; Dr. Bowden, South
Hampstead; Mr. Barling, Hartshill; Dr. Duka; Mr. J. Armstrong,
Liverpool; Mr. J. P. Richards; Mr. A. Robottom; Dr. G. M. Gould,
PbUadelphia; Dr. Zangzer, Zurich; Mr. Jeaffroeon, Newcastle-on-
Tyne; Dr. Robinson, Huddersfield; Dr. Cooke, London; Mr. Man,
Doncaster; Mr. Hornibrook, London; Mr. Mosse, London; Mr. Read,
Canterbury; Messrs. Cox, Brighton ; Mr. Joy; Dr. A. de Giacoma,
Naples; Mr. Bailey, Hanipsteod; Mr. Murdock, Eohuca; Dr. Brewis,
Tasmania; Mr. Hemming, Bridgend; Mr. Orr, Dresden; Mr. Beard,
Wandsworth; Mr.Sedlmayr; Mr.Webb; Mr.Pennington; Mr.Smith,
Brighton; Seiiiorea; G.P.; Paterfamilias; Management; C.Cli.; City
Asylum, Norfolk; M.D. Lond , F.R.O.P.; W.; Z. ; Omega ; Hanover
Institute; S. H.; R. L.; L. G. B.; 0. F. ; Dunelm ; M.D.; Bouillon
Fleet Co.; An Ex-Priest; Appetitus Ratloni Parent,
Letters, each vhth e7iclosv,r8, are also acknowledged from—Mr. Nash
Dublin ; Mr. Earlam, Brewood; Mr. Swain Hitchln; Messrs. Kilner
Bros., King’s-cross; Dr. Horne, Scarborough; Mr. Langliorne, South
Australia; Miss Pratt, Derby; Mr. George, Preston; Messrs. Moat
Bros., Belfast; Dr. Warburton, Treherbert; Messi's. Heilgers and
Co., London; Mr. Finley, Longford; Mr. H. Waters; Messrs. Cohen
and Sons, London; Mr. Lockwood, HuddersBeld ; Messrs. Drew and
Son, Newton lo-Willows; Dr. Harding, Whittlesea; Messrs. Watson
and Co., Hull; Dv. Liveing ; Miss Lloyd, Hawkhurst; Dr. Appleton ;
Dr. McLauchlan; Mr. Tyte, Mincbinliampton; Messrs. James and
Williams, Aberdare ; Major Leadbetter, Wrexham; Messrs. Smith
and Co., Povtsen; Mr. Merck, Dannstadt; Mr. Thompson, South
Hampstead; MissBeadon; Mr. Tuliy, Hastings; Messrs. Roberts
and Jones, North Wales; Mr. McKay, Fortrose; Mr. Humphreys,West
Ham; Dr. Foster, Winchester; Mr. Rentoul, Kennoway; Mr. Dobbs,
Southgate; Dr. llolfmami, Swansea; Mr. Davis, Sidcup ; Dr. Lyon,
Durham; Mr. Lamb, Edinburgh; Dr. Mackay, Durham; Mr. Thin,
Edinburgh; Mr. Pilkington, Littlemore; Miss Weeks ; Mr. Orgers,
London ; Mr. Maylott, Uxbridge; Mr. Brockelbank ; Mr. Cawthorne,
Welshpool; Dr. Hunter, Pontypridd ; Mr. Holder, Hull; Mr. Selby,
London; Mr. Forjett, Caistor; Mr. Davies, Leicester; Mr. Heywood,
Manchester; Miss Mathews; Mr. Cochrane, Wigton; Mr. Sergeant,
London; Mr. Odell, Torquay; Mr. Pennington, Hyde; lli'. Wilcox,
Woolwich; Dr. Osburne, Hythe; Mr. Gilpin, Evesham; Mr. Griffin,
Saltburn ; Mr. Stephens, Rangoon ; Mr, Ernst; Dr. Grombie, Brent¬
ford ; Mr. Burgess, Sutton; Mr. Christian, Hammersmith; Dr. Still,
Loughborough; Mr. Branthwaite, Brdington ; Dr. Hales; Dr. Deane,
Ellesmere ; Dr. Davies, Glamorgan; Alpha; Secretary, Royal Albert
Hospital, Devonport; H.: J. D., London ; W., Bayswater; Haydock
Lodge Retreat; vSister, Plymouth ; Adoption ; Senex ; Hollingbrook
House, Littleborough; W. R., London; Theodora; Wolverhampton
Infirmary; Secretary, Jerusalem, Clapham; M. F. A.; Secretary, Ocean
Accident and Guarantee Corporation ; Matron, Manchester; British
Syphon Co.; Alpha, London; A. T, T., Norwich; College of State
Medicine: X. Y., Abergavenny ; Manager, Great Tower-atroot Tea
Co. ; Recipe ; J. E , Carnarvon ; R. M. S,; Mutual Life Assurance
Co.; D P. O, ; Syntax ; J. W. P. ; Medicua, Liverpool; A. B., South
Norwood: F. F. F. ; A. O ; F.; Forceps; Secretary, Royal College
of Physicians ; Spea; M.D.■ Liverpool; Statim; Denaoyer's Peptone
Co.; M. S. A. : Secretary, Royal Infirmary, Manchester.
NEWSi'Ai'EKS,—Djtndee Advertiner, LeedR Mercury, Liverpool Daily Post,
Methddixt Times, Vorksnire J‘ost, lirisM Mercury, Insurance hecord,
ScoUisli Leader,Sheffield hidependent, Sussex Daily Haws, Windsor and
EUm Gazette, South IFafeN Weekly Pews, lAverpool Courier, Glasgow
Herald, Worcesicishire Jicho, La Te-mps (Paris), Hast Anylian Times,
Minintj Journal, Porih BrUish Daily Mail, The Peivspape.r, Seotsma/n,
Surrey Advertiser, M'eekly Free Press and Aberdeen Herald, Beckenham
JirarnaL Ilerl/ordshire Me.reury, Jleadiny Mercury, La Patria (Rio de
Janeiro), Latmvr World, ll'mfisor and Ji/on Hxyress, National Press
(Dtddin), N wsiny Record, Worlliiny Gazelle, Raker's Record, Spaldiny
Free Press, Courier de Lnndres, Bury and Norwich Post, Maidenhead
AdoerlUer, Ornukirk Advertiser, New Xcaland Herald, NiyIU and Day,
Reji /,Sussex Gazelle, WarrimiUm Guardian, Greenock Te.leyrayh, Mel
bourne Aryus, The Moriist, The Optician, .Uc., have been received.
SUBSCRIPTION.
Post Free to any part of the United Kinodoh.
One Year_£1 12 6 | Six Months £0 Ifl 3
To China AND India __-..One Year 1 Ifl 10
To THE Continent, colonies, and United
States....--. ..... mtbo 1 U 0
Post OfficeOrders and Cheques should be addressed to The Publisher,
The Lancet Office, 428, Strand, London, and crossed " London and
Westminster Bank St. James's-square."
ADVERTISING
Books and Publloations (seven lines and under) .. U i 0
Official and General Announcements .0 8 0
Trade and Miscellaneous Advertisements .. .. B A 0
Every additional Line 0 0 fl
Frontpage - .. petUne 9 10
g uarter Page. ... 1 10 0
alfaPage .. ..2 16 0
An Entire Pago.660
The Publisher cannot hold himself responsible for the return of teatl*
monials &c. sent to tbe office in reply to advertisements; copies only
should be forwarded.
Notice.-A dvertisers are requested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
An original and novel feature of “The Lancet General Advertiser” Is a special Index to Advortisemonts on pages 2 and 4, which not only
affords a ready means of finding any notice, but is in itself an additional advertisement.
Advertisements (to ensure insertion the same week) should be delivered at the Office not later than Wednesday, accompanied by a remittance.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
I'erms lor Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should be
Addressed.
Advertlsementa are now received at al> Messrs. W. H. Smith and Son’s Railway Bookstalls throughout tbe United Kingdom and all otfaei
{Advertising Agents
Agent for the Advertisement Department in France- J, ASTIER, 66, Rue CaumarWn, Paris.
THE LANCET, May 9, 1891.
€lmml fditu
, ON
MALIGNANT DISEASES OF THE BREAST.
Delivered in University College Hospital,
By CHRISTOPHER HEATH, F.R.C.S.,
HOLME PROFESSOR OF CLINICAL SURGERY.
I HAVE to-day, gentlemen, to speak of malignant diseases
•of the breast, and of course in malignant disease we nowa-
•days include the sarcomata as well as the carcinomata.
Until within the last ten or twelve years it was hardly
irecogniaed that the sarcomata formed a group by them-
iselves, almost as malignant in many features as the carci-
momata, so that you will lind in all but the later books and
lectures on diseases of the breast that they are not mentioned
-as a specihc class, but clearly they are almost as malignant as
the carcinomata. We do not see them often. I show you
-a photograph of a case of sarcoma of the breast which
we had here a short time ago. Some of you may re¬
member a woman with an enormous growth, a very large
mass of disease of a soft character, in which there was no
-enlargement of the glands of the axilla. That is a point
to which I wish to call your attention as distinguishing the
:sarcomata from the carcinomata—I mean as regards the
'breast. I do not think that the rule about sarcoma nob
involving the lymphatics holds good in every case. You
probably know that one form of sarcoma particularly, the
melanotic, involves the lymphatics rather than the vessels;
but as a class the sarcomata do not readily involve the
lymphatic glands; certainly in cases of sarcoma of the
breast you may be sure that you will not have the lymphatic
.glands enlarged. Given, then, a rapidly growing soft
tumour of the breast, the chances are that if the glands of
the axilla are not enlarged it is a sarcoma. It makes no
'difference with regard to the treatment, but it is important,
•of course, with regard to the prognosis. You must remove the
"rowtb, but the great misfortune is that the tendency to recur
'locally is very great. In the photograph that I show you
you see the fourth growth which the poor woman had had
lemoved. She had certainly been operated upon twice, and,
1 think, three times by another surgeon, and then he declined
to do a further operation. The woman came here in a bad
•condition, with a very large growth, which had already
ulcerated through the skin, and 1 thought it nuite justifiable
to operate once more. I think it is a picy to leave an
-unfortunate woman with a great protruding mass of disease
immediately below the face to end her days in misery. Of
•course, it may be that you will kill the patient by the
•operation; and I really can hardly say that it is to be
•regretted. But as a rule they do not die ; they do remark-
jably well. If you clear away the whole of the soft growth,
'the wound granulates up tolerably easily, and for some
weeks, or perhaps months, the patients are relieved from
their trouble. This was an example of spindle-cell sarcoma
which had ulcerated through the skin, and which must have
fled to great misery before it terminated the patient’s life.
I do not know what the end of the case was, but certainly
’the patient went out of the hospital relieved. That is a
•comparatively rare form of malignant disease. The common
'form, which we see so much of in the hospital, is of course
the ordinary scirrhus. The cases which come to the hospital
413 a rule are well-marked cases of scirrhus, and you are
•sometimes rather surprised that they Lave not been re¬
cognised before, and that the patients have not been treated
■earlier. But that is too often the case with hospital patients;
they go on much longer than they ought to do before they
apply for relief; and I want to impress upon you, as prac¬
titioners who will see these oases in quite the early stage,
to observe the importance of recognising and treating
acirrhus early.
Now let us go into the diagnosis of a case of scirrhus before
’referring to the treatment. A woman varying in age from
thirty to fifty (about forty is the most likely age) has a little
lump in the breast. It is astonishing how'long women will
go on with a lump in the breast and not notice it. In
performing their ablutions they must necessarily manipulate
the breast to a certain extent; still they do not notice that
No. 3532.
there is a lump in the breast until possibly there is a slight
accidental knock, or something of that kind, which calls
attention to it, and then they always say, I believe with a
perfectly good conscience, tliat the lump has followed the
blow. That is so commonly said that you cannot but
suppose that sometimes it must be true. I believe that a
patient with a cancerous diathesis will start a cancer upon
receiving a blow; but, on the other hand, I am equally sure
that there are cancerous tumours of the breast which have
been growing for weeks or months without being found out.
Someiimes there is a shooting pain in it that calls attention
to the part, and then It is found that there is a little lump.
If the lump is on the surface of the breast, as it most
generally is, immediately beneath the skin, in a very few
weeks it will produce an effect upon the skin, which we all
recognise as so exceedingly characteristic — namely, the
dimpling of the skin when you pinch it up with your
finger and thumb. But then you must bear in mind that
there are cases where scirrhus is not on the surface of the
breast, hut in a deep part. I was particularly struck with
that lately when holding an examination for the M.B.
degrees of the University of London. We had a woman
there for the examination who bad undoubted scirrhus of
the deep portion of the breast. I say undoubted because she
bad a number of enlarged glands in the axilla, and Iwas
rather surprised that gentlemen, presumably of advanced
knowledge, failed entirely to recognise what the case was.
They could not believe it was scirrhus because there was
no dimpling of the skin, and of course no retraction of
the nipple- With regard to the retraction of the nipple,
if the growth is on the surface of the breast, and just
beneath the nipple, in a few weeks you will find that the
nipple is somewhat fixed, and in a few more weeks it is
drawn in. But if the disease is not in the central portion of the
breast at all, bub on the inner or the outer side, then it follows
as a matter of course that you have no retraction of the
nipple whatever. You have first, then, the hardness, then the
tendency to involve the skin, and then the retraction of the
nipple. Then, I think, I should put the pain next. Now,
pain in a scirrhous breast is very marked, being of a stabbing
or lancinating character. You need not ask whether it is a
stabbing pain or not; the patients will tell you without
prompting that it is just as if a knife were being run into
them, and you cannot have a better definition of a lancinating
pain.
Given, then, these features, I think you ought not to
hesitate about pronouncing the case to he scirrhus. Of
course, the lymphatic glands are not always involved, and
to wait for the glands of the axilla to become involved is to
do your patient a direct injury; and it is to be regretted
that medical men are apt to wait for the involvement of
the glands before making their diagnosis. Of course the
patient is then so much the worse, because not merely
have the glands become infiltrated with cancer, hut no
one can tell how much further beyond the glands the
lymphatics may already have become afiected. _ If you have
any doubt about a case, make an incision into it, which will
at once settle whether it is cancer or not. Do not wait
and dally with a case, and apply belladonna and things
of that kind, which are all very well for simple tumours,
but cannot in any way affect the growth of cancer,
which all the time is making progress and doing the worst
possible for the patient. We will presume, then, that you
have a case which does not involve the glands, and that
you are going to operate. Shall you remove the tumour, or
shall you remove the breast ? and if you remove the breast,
shall you remove also the axillary glands? Now I think
that where you have a single outlying nodule of dis¬
ease at the margin of the breast, it is justifiable to cut out
that nodule and leave the breast; but in by far the
great majority of cases where the mammary gland is in¬
volved more or less in the central portion you ought to take
out the whole breast. You see here the breast I removed
last Wednesday, and you will observe a nodule of scirrhus
close by the side of the nipple. You will remember that this
was a case of a somewhat unusual character, the nodule
being so entirely localised and the skin so'firmly bound down
to it. You can see here the hard pear-like appearance of
scirrhus, and you will see it better if 1 make a fresh section.
In a fresh specimen you may notice that the surface becomes
somewhat concave from tlie contraction of the tissues. In
such a ease I advise you to remove the entire breast, and let
me say it is not such a simple thing to remove the entire breast
as some men suppose. I am sure tliat in many operations
T
: Coogle
1028 The Lancet,] MR. C. HEATH ON MALIGNANT DISEASES OF THE BREAST.
[May 9;. 189S.
tbe margin of the breast is left, and it is a great mistake to
leave it. Tbe central mass of tbe breast with disease in
it is easily recognised ; but when you get to the margin it is
not quite so easy to see it, and tbe operator, if working
boldly with a knife, may readily cut through the margin of
the breast, and leave it behind. That is why you will notice
in my operations that I always use the fingers a good deal
after 1 have first reflected the skin with the knife. 1 usually
reflect the skin by a double incUion, and then with the
fingers tear away tbe skin until I feel that I have got to
the margin of tbe breast. You can with a little practice
with your finger recognise the edge of the breast, which is
perfectly regmar, and pull it up with a nail, and dissect or
tear it away from the pectoral muscle. There is also
another advantage, because we get less basmorrhage. You
may notice that I have seldom to tie or twist mote than
one or two vessels after removal of a breast.
Now comes the question, Shall you or shall you not turn
all the glands out of tbe axilla ? On this point I may say
that there has been a good deal of discussion of late years.
Twenty years ago or more, if tbe glands in the axilla were
enlarged, that was considered to negative an operation.
You will find that surgeons like Mr. Syme and Sir William
Fergusson, if they had a case of cancer of tbe breast with
enlarged glands, declined to operate. We have improved
upon that, because whenever tbe glands are enlarged we do
not hesitate to take them away. For the last ten or fifteen
years all operating surgeons have come to tbe conclusion
that it is perfectly easy to turn out these glands from the
axilla, and clear out as much as may be necessary—in
fact, to clear the axilla. But tbe question that has been
discussed a good deal by Mr. Mitchell Banks of Liverpool,
and by other surgeons, is whether in all cases it would not
be wise to turn out the whole of the glands of the axilla,
because it is possible that they may be involved I am
perfectly certain that you may have glands involved and
not be aware of it; 1 mean that it is impossible through
thet kin to be always sure whether there is enlargement of
cne glands or not. Therefore I always make a point of
putting my finder into tlie axilla and under the pectoral
muscle, and feeling whether there are or are not any per¬
ceptible glands. If there are, I take them away. At the
same time 1 do not think it is justifiable in a simple case of
scirrhus—a small nodule of scirrhus of the breast with no '
perceptible enlargement of tbe glands of the axilla—to turn
out the whole contents of tbe axilla. Mr. Banks thinks
that it is. He says it is better to kill a few patients by
an operation of that magnitude than to leave a large ;
number of them with possible germs of cancer still in j
the axilla. But I think you can make out pretty I
clearly whether there are germs or not, and if there are
you ought certainly to remove the glands.
With regard to removing the glands, you have seen me do
it many times, because the cases which come to the hospital
are generally, I regret to say, cases in which the glands
are already involved, and you will have noticed that after
making an incision upon tbe edge of the pectoral muscle, I
generally torn out tbe whole mass of the glands with the
finger. I think in that way you rnn much less risk of
doing harm than you would by using the knife. If you use
the knife freely, you are apt to cut more vessels and to get
considerable hasmorrhage. At the same time, you have to
be cautious, because the first thing you come upon is the
axillary vein, and if you tear that it is a rather serious
matter. I have torn it before now, and had to put two
ligatures upon it, which is a thing one would rather not do.
Then, of course, immediately behind the vein there is the
axillary artery. 1 do not think you conld tear the artery in
that position, but it is possible to tear a branch of
it, particularly the subscapular artery. You should be
careful about the position of it, and avoid tearing it or the
corresponding vein, which, as I have said, would give rise
to a good deal of haemorrhage. With these precautions, I
think you may turn out tbe contents of the axilla, as far
as they are diseased, with very great advantage to the
patient. You may have seen me even put my finger up
under the pectoral muscle, and get the glands out from the
osterior triangle. There was a case last summer in which
did that. You will bear in mind that those glands are
sometimes enlarged as a consequence of axillary disease.
Some writers advise that the pectoral muscle should be
divided ; but I have never found any necessity to do that.
I may say, however, that I have removed the greater part
of the pectoral muscle before now, where it has been
involved in the cancer. Because you must remember that
a cancerous breast tends to form adhesions to the pectorafi
muscle ; and not infrequently in lifting up tbe breast you
find that some fibres of the superficial portion of the<
pectoral muscle are adherent to it, and then you
tear or divide them, or pull them away. But I have known
cases, particularly cases of soft cancer of the breast, where
the whole of the pectoral muscle was involved ; and then it.
is necessary, if you are to do anything at all, to cut the-
muscle away, which makes it a serious operation, attended
with very considerable risk, and it should only be under¬
taken in extreme circumstances, where there is alarge raase
of disease which is fungating or tending to fungate, andi
which you are obliged to remove as a temporary relief for
the patient. Those cases are relieved for the time, but I
have never known one that lived many months after such
a serious operation.
So much, then, for the proceeding with regard to the-
renioval of tbe breast. I ought perhaps, in speaKing of the
operation, to have made some remark with regard to tliC'
incision. The ordinary incision which I suppose most sur¬
geons make is the double elliptical incision, following pretty
closely the fibres of the pectoralis. Mr. Beck, however, has
used another incision, which you will find mentioned in
Mr. Erichsen’s book. Here the elliptical incisions sur¬
rounding the nipple are carried across the pectoral to meet
another going straight up into the axilla. There is no-
doubt that Trbis incision gives better drainage, and it
is because I have been dissatisfied with the drainage
afforded by the elliptical incisions that you may have?
noticed latterly in my cases I have put the drainage-
tube not into the wound at all, but through the pos¬
terior flap. I think either way—putting it through the
posterior llap or using Mr. Beck’s incision — is better
than the old elliptical incision. If you have the elliptical
incisions, and the drainage-tube is put in the usual’
way at the top, it is difficult to make the patient lie
down anfficiently to cause the fluid to gravitate from that
part. Theoretically it is all very well; the patient is
supposed to be perfectly flat in bed, and then no doubt ther
drainage-tube would work ; but practically we know that
the patient is supported with pillows, and it is difficult tc-
get thorough drainage. If you put the tube through the
posterior lUp you can have ellicient drainage, or if you put-
it, as Mr. Beck does, at the end of the incision, you have a.
large amount draining both from the axilla and from that
portion of the wound.
Of course there may be other incisions. It is absurd to-
suppose that you can remove every breast by the same-
incision. If the skin is involved at any one particular part-
you must meet that by surrounding it by an incision.
Many times before now I have made a vertical incisioa
surrounding the nipple and including the skin which’
happens to be attached above or below the nipple in the
central portion of the breast. A surgeon must be prepared’
to modify his incisions according to circumstances, so as to-
make quite sure that he gets rid of the whole of the disease.
Tbe great point is tliat the whole of the breast sliould be-
removed, and the whole of tbe glands, so far as tliey cac-
poesibly be reached ; because I may remind you that there
are glands which you cannot reach. If you have cases of
cancer of the inner side of the breast, the chances are that-
tbe glands in tbe mediastinum are already diseased. Yom
cannot help that; it relieves the patient, and it certainly
does good, to remove the breast, but unfortunately in these-
cases too often recurrence takes place in the lymphatics of
the mediastinum and the patient dies from that cause.
With regard to the healing of tbe wound, we always aim>
of course, at immediate union. Everybody is pleased when-
tbe parts unite by first intention, and the patient gets well’
and is out of the hospital in perhaps a fortnight. I am nob-
sure, however, that this is always tbe beet thing ultimately for
the patient, and for this reason—one too often finds in
these cases which do so well little nodules of disease
springing up soon afterwards. I have been much die-
appointea in some of my cases which have done admirably,
the patients leaving in a fortnight quite well, to find within
three months little nodules of cancer springing up here and
there, not necessarily in the cicatrix, and therefore not
showing that anything has been left behind, but springing;
up in different positions. I am not at all sure, though I
do not lay it down, but merely express an idea passing in
my mind, whether many of these cases would not do better
if we let the woi si suppurate, and therefore possibly'
D'
O
The Lancet,]
DR. JOHN W. OGLE : CONCERNING BLOODLETTING.
[May 9, 1891. 1029
allowed all these little bits of diseased tissue to be thrown
off in the discharges. I believe that some of these cases of
suppurating wounds after removal do better in the end than
the very pretty cases of immediate primary union. Then
supposing that the patient recovers from the operatiou,
for the risk is not great, though of course if you have to
remove the axillary glands it is increased, what are
the prospects in regard to recurrence? Mr. Morrant
Baker some years ago collected a number of statistics from
Sir James Paget’s practice, and those statistics give four,
teen months as the average date of return in scirrhus and
seven months in medullary disease. It is notorious that
medullary cancer of the breast is more rapid than scirrhus,
both as regards primary growth and as regards recurrence.
This is a point of very great importance, because naturally
the patient and her friends before the operation often say
to you, “ What are the chances for this patient? If we go
to the expense, trouble, and anxiety of an operation, what
can you promise?” Well, you cannot promise anything.
Anybody who holds out a prospect to the patient of
absolute cure in a case of cancer is behaving very unfairly
to her. All that you can say is that you may hope for
about two years, on the average, of complete relief. You
cannot promise or hope for more. Mr. Baker’s statistics
give fourteen months, but I think we may take it a little
longer for the average run of cases if they are taken pretty
early. Then, unfortunately, there may be nodules form¬
ing in the cicatrix or in the neighbourhood ; there
may be a re-development which may admit of further
operative interference; there may be enlargement of
the glands, if the glands have not been already removed ;
still it does not follow that the patient cannot be relieved
even then. I have operated twice or three times in cases of
scirrhus. Only the other day I operated upon a lady for the
third time. There was a large nodule which had sprung up
in the cicatrix beginning to ulcerate, and I was afraid that
if I did not remove it it would give considerable trouble.
Every now and then, indeed, you are fortunate enough to
find a case which goes on very much longer ; the patients
live for many years afterwards, and you really seem to have
eradicated the disease, but you cannot tell beforehand which
those cases will be.
Then let us take the prospects for a patient as regards the
whole history of the case. In the first place let me quote
Sir Astley Cooper’s views with regard to that point. He
gave as the result of his experience two years tor the full
development of cancer of the breast, and from six months
to two years more as the limit of a patient’s life. I think
he is quite right with regard to the two years for the deve-
velopment of cancer in the breast, but I think that the
period of from six months to two years is rather low with
regard to the limit of the patient’s life, because, although
you may have recurrence in a cicatrix or elsewhere,
those patients do not necessarily die; they live on
for some months, although there may be a certain
amount of suffering from the disease. Mr. Sibley many
years ago investigated the statistics of the cancer wards
of the Middlesex Hospital, and let me say that the cancer
wards of the Middlesex Hospital differ from ordinary
wards in the fact that the patients admitted with cancer are
kept there till they-die. Mr. Sibley’s statistics gave fifty-
three months as the average of life when the primary disease
is once removed, and only thirty-two months when the case
is loft to nature. That is a very important point. You are
asked by the patient, and particularly by the friends, “ Will
the operation prolong the woman’s life?” I think it will.
You may say that, provided the first risk of the operation
is got over, the patient’s life will certainly be prolonged, and
the statistics I have mentioned go to show that that is the
case. But those statistics are statistics of cases of cancer
taken all together. Mr. Baker’s statistics, to which I before
alluded, separate scirrhus from medullary cancer, which of
coarse is rather important, because they are different groups
of cases, and they show that when a case of scirrhus is left
alone the average duration of life is forty-three months,
and when it is operated upon fifty-five months, and that in
the case of medullary disease when left alone the average
life is twenty months, and when operated upon forty-four
months, so that the gain is very considerable; and if sur¬
geons would only be impressed very strongly with what I
said at the beginning of the lecture, that cases should be
taken early and operated upon before the glands are
affected, I believe we should have even better results than
are here recorded. Patients, too, have not the fear of opera¬
tion that they used to have, because nowadays, what with
anmstheticB and antiseptics, patients have so very little
suffering that they hardly seem to appreciate surgery as
they ought to do, and when it comes to a question of sign¬
ing a piece of grey paper they sometimes seem to think
that they have not had enongh for their money.
Medullary disease, of which we have not had a case
lately, is of course the most rapid form of disease in the
breast, and it is also the most serious for the natient. It is
one in which you find the skin becoming rapidly implicated
and the glands in the axilla becoming involved. That is
what distinguiehes it mainly from cases of sarcoma. Given
then a case of medullary disease where the skin becomes
rapidly brawny, and where, if you do not interfere, it gives
way, you will have a large fumigating mass, which consti¬
tutes the fungus hcematodes of tne older authors. It is a
thing that you hardly ever see now, because both surgeons
and patients do not allow cases to go to that extent, but
that is what would happen if the case were not soon
relieved. It is because of that tendency to fungate
that I strongly advise an operation in these cases, although
you know that you cannot save the patient’s life, hut
you can get rid of the mass of fuugating, offensive, dis¬
charging disease, which will make the patient’s remaining
weeks of life very miserable. In a case of that kind yon
should operate freely, and clear away the whole of the skin
that is involved. There, again, modern surgery allows os to
take great liberties, because by the lead plates of Sir Joseph
Lister you can draw the skin together and transplant a flap
when necessary, or if there is an open wound its granulation
can be aided by grafting portions of healthy cuticle. In
these cases alwavs take away the glands, because they are
certain to be infiltrated. And there is this peculiarity with
regard to these medullary cases, that it is not merely
isolated glands, as in scirrhus, that are affected. In scirrhus,
when you enucleate the glands you can see each gland
separately; but in the case of medullary cancer the whole
mass of tissue is infiltrated by disease, and you have
really to clear out glands, cellular tissue and all, and
expose the axillary vessels very freely, and that of course
is one of the dangers of the operation.
CONCERNING BLOODLETTING.
By JOHN W. OGLE, M.D., F.R.C.P.,
CONSUL'l'INO PHYSICIAN TO ST. GEORGE’S IIOSPITAI..
The discussion upon the paper recently read at the Royal
Medical and Chirurgical Society by Dr. Pye-Smith upon
Venesection, and published in The Lancet for Jan. Slst,
1891, has induced me to place on record the following case
which occurred a few years ago in ray private practice, and
which shows in a striking manner the immediately beneficent
results of a timely adoption of venesection.
The patient, a gentleman aged thirty-three, a total
abstainer, of strong build and healthy and ruddy appear¬
ance, had always enjoyed good health. After being for
some time in a very hot and close room, at the end
of a hard day’s work in the month of April, he had
been exposed, about 10 p.m., to a temperature of .35*
or 40°. On returning home, not many minutes after his
exposure, he was suddenly seized witn intense shivering,
for which, as he said, he would have taken some hot alco¬
holic liquid had he not been a teetotaller. He went to bed and
slept, but in about an hour’s time he was awakened by
sharp vomiting accompanied by extreme cliilliness. He
bad but little rest during the night. On the following day he
could not eat any breakfast, but managed to go out and do
some work, though feeling very ill; and soon after
noon he had to take to his bed again. He stated that, for
two or three nights and days subsequently, he could procure
no sleep. “ After this,” he wrote, in alluding to his case,
“ I was told that I became unconscious; at any rate, I re¬
member nothing further until seeing you at my bedside
after the venesection had been performed, and from that
time I had an uninterrupted recovery, many thanks to your
valuable advice.” On the morning that I visited him, in
consultation with two medical practitioners who were in
attendance, he was extremely drowsy, with a very dusky
and anxious countenance, exceedingly rapid breathing,
1030 ThbLakcbt,]
DB. JOHN W. OGLE: CONCERNING BLOODLETTING.
[May 9,1891.
alight hacking cough, and expectorating, with much
dimoulty, glutinous piune-jui'ce-coloured phlegm. All the
physical signs of aggravated double pneumoniaTwhich I need
not here give in detail) were present, and the urine was
exceedingly albuminous. Sundry suitable remedies had
been “exhibited,” and plentiful hot linseed and mustard
poultices applied. After prescribing for my patient I
arranged to visit him again on the evening of the day
following, which I did. At this visit 1 found that all
his symptoms were intensified. He was struggling
for breath, and appeared to be unconscious, and scarcely
able to free the lungs from any of the bloody and
dimy sputa with which the bronchial tubes were being
rapidly clicked. As it was obvious that the disease could
not be controlled by drugs, and that death was imminent,
I proposed that we should take blood from the arm without
dday. My cplleagues in consultation agreed to the pro¬
posal provided that I took the responsibility of the pro¬
cedure. This I said I would do if the relatives would sanc¬
tion OUT action, which, seeing how rapidly the patient was
sinking, they did without hesitation.^ Of my consulting
colleagues, one had never performed the operation of phle¬
botomy ; but the other bad been accustomed to perform it
in tropical climates, and he undertook to bleed the patient.
The operation had, however, to be delayed for twenty-live
or thirty minutes, {» no lancet w'as at once forthcoming. At
last, an instrumenthaving been found and the patient propped
up in bed, be was bled to nearly 30oz. " fleno rivo."" His
condition at once, so to say, answered to the remedy; the
pulse quickly improved, becoming fuller and slower, and
the breathing became easier, and in the course of the next
hour, to my great pleasure, he was considerably relieved.
On the following day but one I again went down to see
him, and found him sitting up in bed consuming a good-
sized basin of strong soup. His recovery proved to be com¬
plete, and in due course of time he was able to take a
voyage to Gibraltar, and on his return from his cruise
appeared, as he said, “ to show himself,” well and hearty.
It had been ray duty on many previous occasions to
counsel venesection in various cases of disease, notably in
heart and lung affections; but I do not remember to have had
experience of any other instance in which so absolute and
prompt a coup de gr&ce to diseased action was obtained.
This result was the more memorable as the patient’s con¬
dition was apparently hopeless; and the more gratifying,
as the patient was an old and very worthy pupil of mine,
Dr. Harrison, now settled at Ealing. Never before bad I
realised so forcibly the phrase of Sydenham, who quaintly
described the operation of venesection in such cases as
1 This measure was entirely in conformity with the admonition of
Celsus, who, when writing on Bloodletting (see Book II,, cap. x.),
reinarke; “ Sed, si nullum tatnen appareat aliiul aiisilium, ponturus
<iue sit, qui laborat, nisi temeiaria quomio via fuerit ad.jiitus, in hoc
-statu honi tnedici est ostondore, quam nulla .spes sine .sanguinis detrac-
tione sit; fnturiquo, quantus in hac ipsa re metus .sib ; et dum demum,
si exig.atur, Hangninein roittore.”
^ The famous Dr. (Iregory, in his “ Tlieory and Practice of Medicine,”
states that in case.s ot pneumonia the orifice ought to be largo enougli
to allow .a pound of blood to How in live, or at furthe.st six, minutes.
Being intoresteci in ascertaining, if possible, what wa.s known to liave
been the largest quantity of blood taken by venesection at one time, I
may say that it is recorded that Galen saw more than three pints
abstracted at once in a case of hajmeptysis. (See Syd. .Soo. 'I'rans.,
P. Atgin., ii., p. Watson (see Lectures, i., p. 21.7) says that on one
occasion .at Udiiiburgli ho saw “not without trembling” the vein kept
open until 72 oz. (i.e., four pints and a l!aif)of blood had issued from it—
“and then, and not till tlien, did the patient become faint.” The patient
had general dropsy, which had come on suddenly, and i-ecoverod ;
and ].)r. Bicliardsoiidescribestliecaseofaman.siiiroringfroiu .sunstroke,
who was bled to nearly four pints, and very quickly recovered. (Son
Practitioner, vol. i., p. 281.) lie also records a ca.so of h.'Rinorrhago
from tiie roof of the mouth from diseased bone, in whh’h six pints of blond
were lost at once. 'Die p.atient entirely recovered. In Twoedio’.s “ System
of Practical iMedicliio,'’ vol. i., p. 103, it is stated, on the aiitliority of
Dr. Gregory, that a isiedical man by his own directions was bled to the
extent of 127 oz. in twenty-seven hours (102oz. of tliese witliinfive hour.s)
for pneumonia, and recovered. Gregory mentions the case of a man
who had 392 oz, of blood taken from the arm in tlie course of tliree
months. Mydenham said that he liad rarely soon a confirmed pleurisy
in an adult subject cured with the loss of much less than 40 oz. of
Ydood, that “ ricli and luxuriant liquor,” as he calls it. One of tlie most
reniark.abJo case-s on record showing the extent to wliich ijJoodletting
was carried formerly is, I .suppose, that related by «ir Risdon Bennett,
in vol. xviii. of the .St. Thomas’s Hospital Reports, of a young woman
with simple hypertrophy of the heart, who, in the c;ours 0 of treatment
for twenty-seven years by diverse doctors, was cupped and bled 1)62
time.s, liaii WJ leeches applied, and lost U.'iue oz. of Idood irrespective of
what was abstracted by leeclies. She also bad 080 blistei-s apjdied, and
bad three sotons. In .some manuscript note.s of lectures by Dr. Gregory,
taken by my late friend Dr. Waterllehl in 1813, wliich I po.ssess, he
relate : one case in which venesection was performed sixteen times in
throe weeks, at each time 24oz. being tiikcn, making 444 oz, In another
case 103 oz. were lost in twenty-six hours ; in another, 123 oz. in twenty-
four hours.
“ doing the work of the windpipe.”^ This it really did, as
by its means respiration was satisfactorily restored, and
consequently the blood was enabled to become properly
aerated.
Not having been present, unfortunately, at the reading
of Dr. Pye Smith’s paper, above referred to, I do not know
more of it than what 1 have read in the printed discussion ;
but it was interesting and satisfactory to find that so much
stress had been laid by the speakers upon the use of vene¬
section in certain cases, sohhj with a view of relieving a
congested or overloaded right side of the heart. The vwue
of the operation performed with this object might well he
illustrated by the experiments upon dogs and rabbits of
Professor John Reid of Edinburgh, who deraon8trated‘‘ the
good results which, in certain cases of poisoning occasioning
enfeeblement or suspension of the heart’s contraction, were
produced by freely opening the external jugular vein, and
so disgorging or unloading the right side of the heart,
renewing its action and promoting a return of circulation.
This result had been shown to be possible by Haller.
Professor Reid refers to the long-known practice of bleed¬
ing from the external jugular vela in cases of asphyxia
and suspended animation, for the purpose of renewing
the heart’s action.® The above experiments were con¬
firmed by Dr. Cormack and Dr. H. Lonsdale. I may allude
here, also, to the observation on jugular venesection in
asphyxia by Strutbers (1850j, who showed that one can
generally disgorge the right side of tho heart by the process,
and that the operation will prove useful in resuscitation
after drowning. References are made to King’s well-known
researches on the safety-valve of the human heart. The
servicedonein mechanically relieving an over-distended heart
by opening a vein, and still more by cupping over the cardiac
region, was pointed out by the late Dr. T. K. Chambers in
his Lectures, chiefly Clinical (see p. 588). Again, at p. 223,
in describing the treatment of pneumonia, when contrasting
the strong action of the heart caused by the unwonted
amount of venous blood in its cavities with the weakened
force of the pulse at the wrist, he writes: “ Take away some
of the blood from the veins, and the balance is restored;
the pulse becomes, in technical phrase, ‘freer,’—that is to
say, the heart being relieved of the undue crowd in the right
side, is not checked in its contraction, but is able to
clench upon its contents, and supply them steadily to
the arteries.”" Dr. Hare, in his little work, “Good
Remedies out of Pashion,” 1883 (p. 39), lays stress on
" .See Syd. Soc. Trana., vol, i,, p, 248-60. In the original “ et orificium
a phlebotomo inciaum tmcheiu vices anbiro eoRatuv." In some places
tlie translator of Sydenham I'endors “ venam incidore,” “ to breathe a
vein,” meaninf' thereby venesection. The etymology of this expression
is not very obvious. Drydon, wbo was contemporary with Sydenham,
uses it when translating Virgil’s prescription for diseases of the feet of
■sheep, as adopted by the Scythian shepherds:
“ The ready cure to cool the raging pain
Is underneath the foot to breathe a vein.”
* Georgies, ill., 480.
And Murray, in his new Philological Dictionary, under tho sixteenth
and last heading of his explanation of tho verb “ breathe,” quote.s
several authors who use the expression, from 1862 to Marryatt in hia
“ Japliot in Search of a Wife,” 1830. Dr. Murray looks on the phrase as
archaic, or hein^ now ol)solote. He informs me that ho considers that
“ breathing a vein ” is equivalent to “ taking into it breath or air”; in
other woids, “ giving it vent.” If this be ao, tho phrase la used without
reg.ard to physiological facts, as of course no air escapes from the vein,
and any entrance of air into the vein is rigidly to be avoided. Dr.
Mni-my does not cite tlie quotation from Dryden above given. I found
tho allusion in Johnson, and I see that Dungli-son, in his Diction:i,ry of
Medicine, has the expression " breathing a vein." (iay, the poet, in bis
fable “Tlie Goat and his Board,” has tho line, “who shaved, drew
teeth, and breathed a vein.”
* See Edinburgli Medical and Surgical .fournal, April, 183C.
<■' Tho opening of the .jugular vein, I behove, I havo never wit¬
nessed. It has boon in former times much practisod in children in
ciusos of croup and cerebral congestion. In such cases Mr. J. H. .laiiios,
ill a highly interesting volume “On the Distinctive Cliaractoristica of
External Inllammations, mi Inflammatory h'ever, and the Results of
Tliirty-six years’ JCxperionco of the ICH'ects of Bleeding,” &e. (p. 73), .say.s
that ill cases like the aimvo ttieve is no adequate substitute for opening
the jugular vein. He gives tho cautions ve<iuirod in norformiiig the
operation, which .are no doubt much needed. Medical historians tell
us that the jugular vein was first oiionod by Trallianus in the sixth
century, a.I).
« Dr. Ghambei'S wisely points out tliat much of tlie sad effects of large
bleeding Is due to tlie starvation whicli i.s practised at tiio same time.
Botalliis, in his work “Do fiiiratioiio pur Wangiiiiiifi Mis.sioneia,” 1683,
after saying that not more tlian five pints of lilood should be removed
ill one day. ailiidos to the necessity of giving nourishment (eggs and
moat bi'olifi) along with tlie hleoding. Ho says that Galon bled to six
lints in the ilay, presumably ; anil tliat he had seen ten pints of blood
i,sL in one day by liiemorrhago, and recovery lake place, food having
been given. He tlguros tlie lancet in u.so in Ids time in France, Spain,
and Italy as having a sheath identical with wlial wo now use; whilst in
Germany and Holland the ordinary lancet was shaped like our gum
lancets.
The Lakoet,]
DR. JOHN W. OGLE : CONCERNING BLOODLETTING.
CMay9, 1891. 1031
the importance of venesection in cases wherein the right
ade of the heart is engorged with blood. I cannot
bub remember also the timely lessons which my former
venerated and venerable master, the late Dr. J. A. Wilson,
taught me, when, in the medical session 1848-49, I acted as
hie clinical clerk at St. George’s Hospital, as to the expe¬
diency of taking away a few ounces of blood from the arm, or
by cupping between the shoulders, in cases of htemorrbage
from the lungs dependent upon cardiac valvular obstruction.
Guided by tne relief which very often in such instances
follows natural hmmoptysis, even if slight, compressing bis
thin and decisive lips whilst writing on the prescription
card, “Fiat ventesectio ad uncias sex vel septem,” he
would observe, “ Yes, yes ! Let us say, if you please, ‘ Fiat
hiemoptysis.’ ” And many is the time that I have seen great
relief to pain, dyspncoa, and palpitation of the surcharged
heart follow such a procedure, quickening what Dr. Samuel
Johnson described as “the slow current lingering at the
heart.
Another valuable lesson Dr. Wilson was in the habit of in¬
culcating, as to the value of venesection—namely, the help to
be derived from it, in certain cases, in assisting and increasing
the action of drugs, especially of diuretic drugs. I do not
think this specific use of the abstraction of blood is generally,
or at any rate sufficiently, attended to by medical practi¬
tioners and teachers. Watson, in his Lectures,® when de¬
scribing the treatment of enteritis, mentions the fact that
very often purgatives will not act until venesection has
been resorted to. He instances the case of himself, who
was the subject of this form of disease, and in whom a
copious venesection was required before purgatives would
act.® Professor Alison, in his interesting “Outlines of
Pathology and Practical Medicine,” p 83, when discussing
the action of remedies and their efficacy, refers to the
effect of bloodletting, as promoting the action of those
remedies which increase the secretions and excretions, or
removing the cause—viz , fulness of the bloodvessels and
vigorous circulation through them—which opposes their
operation. Dr. Paris, in his “ Pharmacologia,” after
referring to the diuretic effect of remedies consequent on
dimiuisbed arterial action, observes that venesection may, on
the same principle, occasion a discharge of the accumulated
fluid, in certain eases of dropsy (see page 220, ninth
edition); and he alludes to venesection as accelerating the
absorption of mercury. Magendie had written on the same
subject (see his “ Memoire sur le Mcehanisme de TAbsorp-
tion” «&c.,1820). Dr. Billing, in his “First Principles of Medi¬
cine ” (see footnote to p. 199), refers to bleeding as assisting
diuretics in producing their effect, and instances cases in
which leeching the abdomen in ascites greatly assisted the
action of diuretics, rendering the contemplated operation
of tapping unnecessary. Dr. T. K. Chambers, in his
Lectures above cited (see p. 589), refers to the use of blood¬
letting in making remedies more efficacious, especially in-
stauciug cases of lepra, lichen, and eczema, in which
immediate renewal of healthy skin followed its employ¬
ment, after internal remedies had been duly tried.
What Dr. Broadbent said at the discussion on Dr. Pye-
Smith’s paper as to the various changes of practice in the
adoption of bloodletting by the medical profession, being
the result, not of experience, but of theory, was, I think,
eminently true. Or rather, might it not be asserted that
these revolutions of practice rested on hypothesis or con-
r In valation to this point, a passaso in l.ha writings of Dv. I’arry of
liabli in, his " Kloments of Pathology,” pn. is worth reforring to.
After a-sRing the tpiotitioii. “ Why, for the purpose of carrying on the
ch'Owlatlon, veu!\’, Ciiviv. and pulmonary veins are not furnished with
valves into tho auriides," and cnimnonting on the circumstance, he
romarks that “ valves at the torniinati<)n of the cavnj might he injurious
hy prevontiiiff tlie right auricle from discharging part of its blood in a
retrograde direi’tlon, as it now usually does, whon congestion acci¬
dentally occurs in tho vessels of tho lungs, and conseiineut rosistauco to
tho free ovatruation of tho right ventricle takes place."
“ See vol. ii., p- 4S1).
« It is OM recoril that vonesootion had given I'elief also to l)rs.
RadcUffe, Gregory, and Alison; and Galon had, he said, bled himself
to a pint, thus saving his own life. If I may be .so egotistical, I may
say that I wear a cicatrix of tho baailica vein-—the i-oyal vein, as Sir
'I’liomas Jlrowno spoils it—at inv right olbow, tho result of tlie operation
E arfonnod, whon a child, for whooplng-cougb. Van Ilelinotit is said to
avo died for the wajit of vonasoction,
Abercrombie describos the case (soe Case (!0) In his “ Palliological
anil Practical Eosuavches of Disoasos of the Brain, *c.,” of inilaniina-
mation of tho brain, in which all romoclioa failed to relieve until vono-
section was resorted to. He remarks ; “ Ono bloodingfrom tlie arm gai'O
an immediate turn to this case ; the headache was relieved ; tlio pulse
caino down; the vomiting ceased; the bowels wore Ireely acted upon
by tho medicine which they had fonnorly rosislod.”
jecture, oftentimes of the wildest kind.^^ Such conjecture
not only determined the use or non-use of venesection, hut
was a guide as to the parts of the body from which blood
should properly be abstracted, in different diseases. In most
cases, I suppose, the idea of “derivation” or “revulsion ”
controlled the advice. This was a very ancient notion,
having been entertained by Hippocrates, Galen, and others,
and has been also held by many recent writere. Aretseus says
that in recent inflammations we must bleed from opposite
parts of the body; iu chronic forms from the adjoiniog
parts. In (liseases of the bead we are to open the humeral,
in those below the neck, the alar vein. In affections of the
spleen we must open the bloodvessel between the small and
the middle fingers of the left hand ; and in affections of the
liver, those of the right hand, as occasioning a more
powerful revulsion. Galen adduced the useful results of
venesection in the arm in cases of epistaxis as showing
that the operation was beneficial by “revulsion.”'® By
Aretoius, Galen, and also by the later Arabian authorities,
it was considered to be injurious to abstract blood when the
stomach or bowels were loaded with impurities, and before
they were duly emptied by purging, especially by emollient
clysters; as otherwise veins, being emptied of blood, attract
and suck up the crude and putrid superfluities.'®
Thegreat Sydenham, when writing on Nephritic Paroxysm,
counsels bleeding on the side of the kidney in certain cases,
and from the right arm in hmmoptysis ; in bruises from the
side affected ; in asthma, from the right arm. Again, Hunter,
referring to the supposition that venesection on one side,
for the relief of iDllammation on the opposite one, was
serviceable on the supposed principle of derivation, says'*
that the subject “is not determined.” In more recent
times, Watson'® speaks of the “ revulsive” use of bleeding.
After alluding to the action of local bleeding in diverting
the flow of blood from an affected part, he describes general
bleeding as “incidently” having the same action. And
Aitken'* alludes to tho loss of blood generally, as having,
among other results, “a derivative influence upon the blood
in the part about to become the seat of effusion.” “ This
has been known,” he says, “ to occur in experiments upon
the transparent parts of animals.” Heberden was sceptical
as to the “ revulsive ” action of venesection in arresting
hmmorrhage (see papers read at the College of Physicians,
Dec. nth, 1771).
In bringing my remarks to a conclusion I would say that
I was sorry that Dr. Pye-Smith, by the title of his paper,
limited consideration to “ venesection,” not including
cupping and the use of leeches.'^ I feel assured that a more
u Medical historians 1*11 «8 of a very famous fiuan el amouR physicians
in France, Spain, and Portugal in the beginning of tliesixteeiitli century,
arising out of this doctrine of rovulsioh loading to tlic performance of
venesection in cases of pleurisy on the side opposite to lli.at in wtiicii tho
disease existed. At that time a Frotich physician, Brissob (who took
his degree in Paris in “ not content with custom and tradition,”
taught that the prevailing practice, gathered from the teaching;-of tho
Arabian schools, of bleeiliug on the side opposite to that which was
the seat of disease, was contrary to reason and to the doctrines of
Galen and Hippocrates. Briasnl “ went about to reform physic," and
.Imirneyeil to J'ortugal, where lie taught his views upon veueseelion.
This led “ to a civil war ” among the followers of A'lsculaphis, and the
question was brought before the University of Salamanca, where even¬
tually tlio li’.aculty determined to accept the toaching of Brissnt.
.Suhsociuently the secular arm was appealed to on the iiiiostion,
Brissot’s views wore eventually strengthened by the de.ath of tho Duke
of Savoy, who had boon bled in luj attack of pleurisy on tho side
opposite to tho iid'octod one. It appears that the word pleurisy iu
tlioso days included what wo call pneumonia. The above information
I have oxtrjtcted from Uayle's “ Dictioimaive Historique et Gritniue."
as transcribed from l.lio Life of Brissot by itoiiatus ftlovo.in. At the
conclusion of Mie notice, to show how disinterested Brissot w.as, it is
stated that, " U se soucioit si pou du gain, qu'on dit qu'etaut apelle
voir dea malades, ii veganloit daiis sa bourse, ot s’il y trouvoik deux
tuaton.s refu.soit cotto pratique ”
This writer thouglib that tho diiferenco iu the colour of the blood,
depondod upon its being jjioro or loss heated.
Sue tho Oommoiitaries by W. Adams in the Sydoiiliam .Society's
Transficdioiis. Cf. 1*. /Uaineta, vol. ii., pp. 31(l-‘2'l.
*1 Vol. iii,, p. ;i82, of his works by Paliuor. liooturos, vol. i., p. 210.
Vol. i., p. l.W, of his Sciunco and J'ractico of Medicine.
In his work above quoted J)r. Haro gives .ioiiio very intorosting
statistics as to the comparative expense ineurrod at dld'eient periods iiy
tile various hospitivls in the iiurcliaae of leochoa. I wiii not <|Uote all
his figures, which give rise to much reflection; but coniine myself to
ono or two only, h'or oxamplo, it appears bhiiL, taking niy own hospital
(iSt. George’s) in tho several tenth years, from 1842 to 1882, the amount
expended iu leeches was siUl, .-CSS, .W, 14.v., and .C2 i;>x. at the
London Hospital in 183!) the leeches cost no loss than .Ch'fi, with a
sudden drop in 1842 to .U180, finally, in 1882, costing only .-CV 12v. At
St. George’s, in 1832, 21,800 leeches wore used; in 1882, only "54. In
1800 the number of leeches at Sc. George’s HosplUvl used was (iB2. costing
fC'l IDs. lid., as I am told by our .secretary, Mr. Todd. In 1880, 400
loeclios were used, (a)8ting Ail 12v. It seems tliat whereas one firm of
druggists sold 1023 leeches in 1814, they sold only 214 iu the year 1804.
1032 Tbb Lakobt,] MR. W. WHITEHEAD ON ENTIRE EXCISION OF THE TONGUE. [May 9,1891.
frequent resort in our practice to the “cucurbitnleo cruentte”
than now obtains, would be good, aod that in this matter to
go “backward” would be to go “forward.” In modern
days the physician has difficulty In finding one who can cup,
and greater difficulty iu finding one who can do so rapidly
and adroitly, “cito, tute, ac jucunde.” As respects the
fact of the student of the period not being, as a rule, able
to bleed with the lancet, I am bound to say that I know of
a house surgeon who a few years ago managed to break his
instrument in opening a vein at the arm. So apposite was
the remark of Watson, when comparing the relative merits
and advantages of cupping and of leeches, be artfully
remarks: “But, on the other hand, the leeches seldom
bungle in the operation; while the surgeon often does.”
Cavendish-square, W.
KEPORT OF 104 CASES OP ENTIRE EXCISION
OF THE TONGUE FOR CANCER.^
By WALTER WHITEHEAD, F.R.C.S.. F.R S Edin ,
SENIOR SORQEON TO THE MANCHE.STER ROYAL IM'IRMARY.
During the last twenty years my operations upon the
tongue for cancer amount to 139 cases. I find that out of
these 139 cases of which I have a record there have been
119 recoveries aod 20 deaths, which gives a mortality of 14‘3
per cent. As the main object of my communication, how¬
ever, is to place before the profession an accurate and reli¬
able record of my personal experience in excision of the
entire tongue with scissors, I shall discard, in the first place,
ten of the successful cases, as they were operated upon with
the galvanic dcraseur. 1 shall also exclude twenty-live suc¬
cessful partial excisions, for although the excisions were
performed with scissors, I am anxious to adopt a definite
standard by which the merits of the operation may be duly
estimated, and more easily contrasted with tbe results of
other methods of operating for the same object- Hitherto
it has been the custom to place the results of total and
partial excision in parallel columns, ignoring tbe palpable
fact that the risks and difficulties in the two instances are
certainly not identical. Where the disease has advanced
beyond the tissues of the tongue the operation is also
much more severe, and attended with muon greater danger.
By this arrangement I reduce, the number of my total
excisions to 104, with a mortality of twenty, or a per¬
centage of 19'21, against 14’3 in the gross number of my
cases. Id estinatiug these results it has been thought de¬
sirable to draw a clear distinction between cases in which
tbe tongue alone was excised, those in which the tongue
was removed together with the glands, and those in
which division or removal of portions of the jaw was an
additional part of tbe operation. Unquestionably the risks
and dangers of these different operations are not the same,
and it is misleading aod unjust to classify them together.
Taking my own cases as an example, in excision of the
tongue alone the death-rate is only 4‘5 per cent., compared
with 77 and 57 per cent, respectively when glands and jaw
have been involved.
I cannot better illustrate the misleading influence of group¬
ing together all these different and distinct operations than
by referring to the statistics published by Mr. Butlin in bis
work on Diseases of the Tongue. Mr. Butlin stated, which
is perfectly true, that I supplied him with my statistics of
tongue excisions in 1884, and they represent forty-eight
cases with nine deaths, but although the entire tongue
was excised in every case, there was nothing to show or
explain how much more than the tongue was removed.
On referring to these cases, I find that in only two was
tbe operation confined to excision of the tongue alone;
in every other case it was complicated with either the
removal of glands, portions of the jaw, or some other
addition to simple excision. To show more clearly how
valueless statistics compiled on this basis must be, Mr. Butlin
contrasted the results of my excisions with those of
Mr. Baker, who classifies amongst his returns cases in
which a portion only of tbe tongue had been removed. If
we may be guided by the tames I produce, it may be
roughly estimated that the mortality from simple excision
of the tongue amounts to only a point over 4 per cent.; for
* A imper r ead at tlie Medical yociety of London, April 2nd.
they clearly show that sixty-six patients may lose their
tongues with a possible loss of three. Now 1 consider that
I am entitled to draw marked attention to the particulars
of these three patients who died. In the first place,
the youngest was fifty-six and the oldest seventy, and
the average age of the three sixty-four. One was a mas
with advanced phthisis, who died on the second day from
the rupture of a pulmonary abscess; another died on the
twelfth day from syncope, after tbe floor of the mouth had
completely healed ; and tbe third was a woman seventy
years of age, who died on tbe fourteenth day from inanition.
When we take into consideration the ages and causes of
death in these cases, I think that these tablesvery effectually
show what a slight risk there is in excising the tongue
when the operation is not complicated by the removal of
conti^ous structures.
Before I proceed farther I wish to acknowledge the debt
of gratitude I owe to my colleague, Mr. Alexander Wilson,
for collecting and arranging my statistics. In order to
present my cases in as accurate and trustworthy a
form as possible I handed to Mr. Wilson all my notes and
memoranda. He communicated with every patient whose
address could be traced, and with tbe representatives, when
it was possible to find them, of those patients who had not
survived. I am also indebted to Mr. Wilson for the
several tables which he has compiled with infinite patience
and industry. 1 think I ought to state, in justice to
myself, that throughout my practice I have operated upon
cases indiscriminately, and that I have never allowed the
extent of the disease or tbe emaciated condition of the
patient to deter me from operating when 1 have seen any
reasonable prospect of prolonging life or giving even the
slightest prospect of temporary relief to sufiering. Had I
selected my cases, and operated only in the more simple and
hopeful, to the exclusion of others, I venture to Wieve
that tbe mortality might have easily been reduced to a
very much smaller percentage. I do not know that I have
much to amend in tbe description I gave in 1881 of the
operation for excising tbe tongue with scissors ; but I will
first of all briefly recapitulate tbe essential features of the
operation, and later I will enter a little more fully into some
of tbe important details.
1. The patient should he completely under the influence
of the anaesthetic during the first) stage of the operation, hut
afterwards only partial insensibility should be maintained.
2. The mouth should be securely gagged, and kept fully
open throughout tbe operation. 3. The head should be
supported in such a position that, whilst the best light is
secured, tbe blood tends to gravitate out of the mouth
rather than backwards into the pharynx. 4. A firm liga¬
ture should be passed through the tip of the tongue for the
purpose of traction. 5. The first step in the operation con¬
sists in dividing the reflection of mucous membrane be¬
tween the tongue and the jaw and tbe anterior pillars of
the fauces. 6. Rapid separation of the anterior portion of
the tongue from the floor of the mouth. 7. Securing, if
possible, the lingual arteries with Spencer Wells’ forceps
prior to division. 8. Passing a ligature through the glosso-
epiglottidean fold before nnally separating the tongue.
9. Tbe application of a mercurial solution to the floor ot the
mouth, followed by painting the surface with an iodoform
styptic varnish.
When once it has been decided to remove a patent’s
tongue, the sooner it can be done the better; at the same
time it may be occasionally judicious, especially with those
who are in a state of feeble health, to sacrifice a few days
for the purpose of generous feeding, and more especially to
obtain a cleanly condition of the mouth. With such patients
digestion is often deranged, tbe bowels loaded, the skin
inactive, the teeth foul and coated, all iniluences which
have a tendency to lessen the chances of recovery, p'or an
amusthetic I recommend the use of chloroform, although I
know of DO objection to ether, which I think has an
advantage in feeble subjects. The important point is to
obtain deep ausestbesia before commencing the operation.
The effectual gagging of the mouth is a point of great
importance, for on the one hand it is necessary to keep the
mouth wide open, whereas on tbe other we must avoid so
pressing back the jaw as to embarrass the respiration. In
fact the aim in gagging tbe mouth should be to place the
jaw, as it were, in the position it occupies in semi-luxation
forwards. As much depends upon the position of tbe
patient daring tbe operation, I hope 1 may be excused if I
dwell rather fully upon a detail which I have found by
D'
O
Thb Lakcet,] MR. W. WHITEHEAD ON ENTIRE EXCISION OF THE TONGUE. [May 9, 1891. 1033.
experience to afford the greatest convenience to the operator.
In the first place, the patient’s head must be neither too
high nor too lo w ; the mouth ought to be, roughly speaking,
on a level with the surgeon’s axilla. The head should be
firmly held erect with a slight inclination forwards, in such
a position that the light will fall well into the mouth It
is, of course, always desirable to take advantage of the
best obtainable light. Great inconvenience is generally
caused by the persistent tendency of the patient to slip
down on the operating table, and the best means to j^revent
this is for the patient to recline on an almost perpendicular
back-rest, with the thighs bent at a right angle over the
elevated central portion of an ordinary operating table.
In private practice any joiner will readily improvise a sub¬
stitute for this arrangement. A sand-bag makes a very
convenient support for the head. The ligature passed
through the anterior portion of the tongue is a great aid
throughout the operation, and much depends upon the
dexterity of the assistant in anticipating the intentions of
the operator, and in always making traction in exactly the
right direction, his aim being to make tense those tissues
which are immediately to be divided.
The first step in the actual operation consists in the
separation of tne tongue from its attachment to the floor
of the mouth and the anterior pillars of the fauces, and I
would lay stress upon the way in which this is done, because
the ease with which the operation is continued depends
largely upon the freedom with which this separation is
carried out. The two structures principally responsible for
the retention of the tongue within the mouth are the frrenum
and the anterior pillars of the fauces, and if these are com¬
pletely divided in the first instance, the tongue may be so
freely drawn from the mouth that the operation is practi¬
cally converted into an extra-oral excision. Extended
practice has made me conduct this part of the operation
with less deliberation and more rapidity than was my habit
in my earlier cases. Instead of the cautious snipping I
originally advocated, I now boldly cut until I get close to
the vicinity of the main arteries, disregarding ail bleeding,
unless an artery distinctly spurts, when I twist it and pro¬
ceed. The more profuse the general oozing the more rapidly
I proceed, my object being to get as qui<3cly as possible to
the main arteries, as I have confidence that all subsidiary
bleeding wull cease immediately after their division.
There is, in reality, no difficulty in determining the actual
position of the lingual arteries, as they are practically in¬
variably found in the same situation, and it requires very
little experience to seize them with a pair of forceps
before dividing them. If this be done, there need not be the
slightest hmmorrhage from this source. When once the
vessels are effectually twisted, the rest of the tongue may
he removed without any further anxiety about hcemorvhage;
but it is desirable, before finally severing the last attach¬
ments, to pass a loop of silk through the glosso-epiglottidean
fold, as a provision^ measure of security, in case it may
become necessary to make traction on the posterior floor of
the mouth either to assist respiration or to arrest any
possible consecutive hasmorrhage. Traction on this ligature
of itself arrests hmmorrhage, and makes it an easy matter
to secure any bleeding vessel. As the retention of this
ligature is a source of some annoyance to the patient, I
always remove it at the end of twenty-four hours. As a
matter of fact, I cannot recollect its having been required
in more than two cases, and but for the certain sense of con¬
fidence it gives to those who are left in charge of the patient
I should dispense with the precaution altogether, were I
influenced smely by the amount of benefit I have derived
from its use.
The treatment of the floor of the mouth after the tongue
has been removed is a matter of considerable moment. The
first object is to make the cut tissues as far as possible
aseptic, and for this purpose I am still in the habit of
swabbing the parts with a mercurial solution, and, after
drying, finally painting the surface with the iodoform
styptic varnish which I introduced in 1881. This prepara¬
tion, in addition to its antiseptic properties, has the aavan-
tage of lessening the discomfort which follows when the
surface is left unprotected, and it also enables the patient
to take food in the ordinary manner almost immediately
after the operation. The mercurial solution I prefer is that
of the biniodide, and the strength 1 am in the habit of using is
1 in 1000. I haverecentlymade.andithink with advantage,
a slight addition to the iodoform varnish. My original
custom was simply to substitute for the spirit ordinarily
used in the preparation of Friar’s balsam a saturated
ethereal solution of iodoform, but now I prefer to mix with
the ether one volume in ten of turpentine. This addition
has a very marked inlluence in promptly checking the
capillary oozing, which occasionally prevents a dry surface
being quickly secured.
I was at one time in favour of suspending all alimenta¬
tion by the mouth for the first four days, and feeding the
patient entirely by nutritive enemata; but for some years I
have entirely abandoned this practice, and I now feed the
patient with liquids by the mouth as freely and as early
as possible, only using enemata when it is necessary to
supplement the amount of food the patient is otborwise
able to take; and I find that if .a coat of the varnish is
applied daily, patients rarely have any difficulty in taking
an adequate amount of sustenance. It fortunately happens
that the patients appreciate rather than object to the appli¬
cation of the varnish, and they will often ask for its use
more frequently than once a day. Instead of keeping the
patients in bed and recumbent, my aim is to make them
sit up from the first, and in fine weather I encourage them
to walk out, if there be sunshine, the day after the opera¬
tion, and I have never seen any ill consequences, but great
advantage follows the adoption of this plan. There is cer¬
tainly no worse practice than keeping the patients lying
on their backs in bed, and I am sure that I have seen the
evil consequences of doing so in several of my earlier
cases'. Under the above treatment the average time of
convalescence is about seven days, and in uncomplicated
cases no patient need be detained in hospital after this time.
It is only reasonable that I should state the grounds upon
which I prefer excision of the tongue with scissors to
its removal by the galvanic or any other form of ccraseur.
In the first place, I consider that it is more in conformity
with the elementary principles of surgery to make use of a
sharp-cutting instrument, it being desirable to leave a clean
surface—a surface which, it must be acknowledged, is in the
best condition for healing. To employ an instrument whose
purpose is effected by bruising leaves a surface in the very
condition we are most anxious to avoid in the ordinary
practice of aseptic surgery. The wound, in fact, left after
the use of the dcraseur embodies every condition calculated
to engender those putrefactive changes which it should he
our primary aim to avoid. I fail to see any special danger
in the operation of excising the tongue which can justify
such a departure from surgical practice, and I cannot
recognise any good reason why we should employ an instru¬
ment for excising the tongue which no surgeon would at
the present day ever think of making use of in any other
region of the body—an instrument which almost every
surgeon of eminence in the past has made a point of con¬
demning. With scissors absolute precision can be obtained,
whereas the erratic course of the dcraseur wire is absolutely
beyond the control of the operator. I am fully alive to the
dangers which may result from blood gaining access to the
lungs, even in small quantities, in patients with bankrupt
constitutions ; and although I am aware that some sirrgeons
advocate a preliminary iaryngotoray or tracheotomy, I
believe that it is possible to guard against this danger by
measures attended with much less risk than those inci¬
dental to either laryngotomy or tracheotomy. At any rate,
my own cases conclusively show that better results can he
obtained without than with these preliminary measures.
It unfortunately happens that it is precisely in those
cases in which the danger from blood getting into the air
passages is the greatest, the risks incurred in opening the
trachea are also at a maximum. In one of my own cases,
in which I performed laryngotomy on the day previously to
that fixed for excision of the tongue, the patient died during
the night in consequence of the first operation- If the
head of the patient is properly arranged during the opera¬
tion, and if the tongue has been thoroughly detached as
recommended, when the arteries are divided, the blood,
unless the precaution has been taken to secure the vessels
beforehand, will spurt directly out of the mouth, without
any disposition to How backwards. We must also bear in
mind that the entrance of blood into the air passages is
only one, and not the most important, determining factor
in the causation of septic lung mischief. Patients suffering
from cancer of the tongue with putrid discharges not unfre-
quently die from septic pneumonia apart from any opera¬
tion or the entrance of any blood into the air cells, and.
farther, under an aniosthetic, large quantities of blood
frequently finds its way into the trachea during the extrae-
'IS n
1 ^
CoiH le
O
1034 Thb Lancbt,] MR. W. WHITEHEA.D ON ENTIRE EXCISION OF THE TONGUE. [May 9,1891.
tion of teeth; but how rarely do we meet with instaDces
of septic pneumooia from such a cause. The skill with
which the admluistration of the aamstbetic is conducted
k) also largely responsible for the amount of blood which
may enter the trachea. For instance, as I have just
stated, whilst it is desirable to have the patient thoroughly
under the amustbetic at the commencement of the opera¬
tion, it is a mistake to give more than will just suilice
to restrain bis movements daring the later stage. If
this practice is adhered to, the patient’s rellex power of
guaraing his own air passages is never altogether in
abeyance, and no dangerous amount of blood will remain
m &e lungs at the termination of the operation, as it
is practically completely expelled by the act of coughing.
Take my sixty-six cases of simple excision of the tongue.
In not a single instance were ill effects observed which
eould be attributed to the entrance of blood into the lungs—
a record which tends conclusively to show that the tongue
ean be safely excised without a preliminary laryngotomy.
When we come to consider w’hat we can fairly and
reasonably claim to be gained by excising the tongue, we
have two questions to answer. Does excision prolong life?
0 r, failing this, does it render the remainder of his life
more endurable to the patient ? From my own experience,
f can bear the strongest and most emphatic testimony that
in the maj'ority of cases excision gives very great relief:
and in support of this I could produce numerous letters I
have received from patients ana preserved for the purpose
of answering this question. As to the prolongation of
life, it is only necessary to turn to the statistics I pro¬
duce, when it will be clearly seen what proportion of
patients lived beyond the ordinary tenure of life after
the advent of malignant disease of the tongue. It has been
shown that twenty-six patients out of the eighty-four suc¬
cessful cases were traced, and found to have lived a year and
upwards after excision; and I think that we are reasonably
entitled to add to this number a certain percentage of the
forty-one of whose fate nothing could be ascertained, and not
to take it for granted that in every instance the patients had
succumbed. Although cases unsuited for operation, and
those where the disease has recurred after removal are not
exactly within the scope of my communication, I cannot
avoid taking advantage of this opportunity to make
a fow remarks upon this much-neglected subject. We
Imve it on good authority that in cancer of the tongue
ueath 'generally takes place before dissemination has
extended beyond the limits of the cervical glands—that,
m fact, up to the very end the extent of the disease
is withih the range of eradication. Surgeons not unreason¬
ably feel deterred from operating by the contemplation of
the important vessels and nerves occupying the region
traversed by the lymphatics, and it is no matter of surprise
that so few efforts are ever made when the glands in the
neck are invaded. In addition to this, patients have usually
been reduced to such a degree of emaciation that by the
time the glands are affected the prospects of recovery are
very discouraging. If attempts are never made to follow
the disease to its utmost limits, the possibilities of surgery
can never be ascertained. 1 have on several occasions in
desperate cases, and in response to the wishes of patients,
cleared out the anterior triangle of the neck, and in two
mstancea excised a portion of the common carotid artery,
with, however, fatal results in both cases. This experience
is naturally disappointing; nevertheless I have not altogether
abandoned the idea that I may yet meet with more common
results. In fact, I have recpufly operated npon a gentle¬
man brought to me by Dr. Vaudrey of Derby, which has
stimulated my hopes. The patient bad his tongue excised
in May last under most unfavourable circumstances, there
being at the time extensive gland infiltration. The opera¬
tion temporarily fulfilled the purpose for which it was per¬
formed, and relieved him from a foul mass of sloughing
tissue within the mouth. He received so much benefit that
he afterwards consented to have the glands removed,
and this was partially carried out by another surgeon.
The wound rapidly healed, but his sufferings were not
entirely relieved by what bad been done. At the request
of Dr. Vaudrey I again saw the patient, and proposed
as a means of relief that I should attempt to remove
the tension which was apparently the origin of the pain.
With this object I removed the sterno mostoid muscle
from its origin to its insertion, and cleared out large
quantities of diseased glands, and it appeared possible to
have removed every visible particle had it not been found
that the msophagus was too extensively implicated to
justify any further proceedings. During the course of the
operation tiie external and internal jugular veins had to
be sacrificed, and the full extent of the carotid sheath
exposed. The patient recovered from the operation, and
lived absolutely free from pain for several mouths. It is
an interesting fact, and worth mentioning, that the loss of bis
steroo-mastoid did not appear to occasion him the slightest
inconvenience or in any degree interfere with the move¬
ments of his neck.
There is another subject in connexion with cancer of
the tongue which is constantly and painfully being brought
under our notice, and that is, the singular view held by,
a large section of the profession, that in cases of cancer
the means of relieving pain are limited by the maximum
dose of any sedative authorised by the British Pbarma-
copccia. It is a constant experience to find that a patient
suffering incessant and intolerable agony is ordered the
paltry dose of a grain of opium at bedtime, and it is the
rare exception to find sedatives administered on lines pro-
orbionate to the amount of suffering. In contrast to this
may mention one of my own cases. A gentleman suffer¬
ing from cancer arrived at the stage when be began to
suffer pain, and be commenced with a quarter of a grain
of morphia, which at first gave relief; by degrees this dose
bad to be gradually increased until be eventually took as
much as thirty grains three times daily. This kept him
entirely free from pain, without at any time interfering with
his intellectual interest in bis daily surroundings. The total
amount of morphia this patient consumed during the twelve
months preceding bis death amounted to 3512 grains. He
also inhaled during the last four days of his life five pounds
weight of chloroform, and my firm belief is that this patient
would have died much sooner had not this sedative treat¬
ment been adopted from the first.
Tables which I have prepared show that out of 104 cases a
history of cancer in the family was only obtained in six
cases. A definite history of syphilis was obtained in seven,
and a doubtful account in another seven cases. In sixteen
patients the origin of the . cancer was attributed to an
injury. Sixty-one out of the 104 were ascertained to be
smokers, and in the majority of these the cancer commenced
on that side of the tongue on which the pipe was usually
smoked. In thirty-three cases the irritation of teeth is
recorded as being the exciting cause of the disease. In
marked contrast to these cases one man had never smoked
in bis life and had not possessed a tooth for twenty years.
The difficulties of ascertaining the duration of life after
operation are very great. Patients, especially hospital
cases, rarely remain for any length of time in the same
bouse or even in the same locality. Mr. Wilson has
succeeded in obtaining positive evidence in sixty-one cases;
fifteen patients survived the operation one year ; four, two
years; two, three years; four, five years; and one, six years;
and I may incidentally mention that the patient whose case
1 published in 1880 lived fourteen years, notwithstanding
the fact that she was sixty-two years of age at the time of
operation. If we believe that cancer of the tongue can be
permanently cured by early excision, and that there are no
other effectual means of eradicating the disease, we cannot
too persistently urge these convictions upon those who have
the earliest opportunity of detecting it, with the object of
inducing them to adopt prompt measures and give the
patients the only possible opportunity of having their lives
saved. It cannot be too frequently reiterated that the loss
of time in the interval between the discovery of the disease
and its removal by operation beam a direct ratio to the
death-rate, and, conversely, that the earliest excisions give
the most favourable results. The sooner patients can be
made to realise how insignificant is the loss of their tongue
compared with the loss of life, and that they have to weigh
the two in the same balance, the quicker they will be to
decide in favour of operation. This resolution will be taken
with less reluctance when they are assured that the risks
from excision are comparatively slight, and also that the
inconveniences of being without a tongue are of small
moment, as this organ is neither essential to speech nor to
the sense of taste.
Probable predisposwrj and cxcAtinff cames .—A probable
family history of cancer wa.s obtained in six cases out of the
104:—1. The patient’s brother died from cancer of the
tongue. The patient himself smoked cigars to excess, and
there were indicarioos of the tongue having been irritated
by a tooth. 2. Patient’s father died from cancer of the
Thb Lancet,] DR. BATTEN: THE EYE AND THE CABDIO-VASCULAR SYSTEM. [May 9,1891. 1C35
(SBopbagus. The patient himself was a smoker, and had
carious teeth. 3. Patient’s mother died from cancer. Patient
was a moderate smoker. 4. Patient’s uncle died from
cancer of the lip. In this case there was no apparent
exulting irritation—the patient did not smoke—the teeth
had disappeared long before the onset of the disease.
5. Patient’s mother’s uncle had cancer of the lip. Patient
smoked a clay pipe. 6. A cousin of patient’s mother died
from cancer. Patient had irritating teeth.
Syphilis.—Oyit of the 104 cases of cancer a definite history
of syphilis was obtained in seven cases, and a doubtful
historv in seven. In live cases actual syphilitic disease
preceded the epithelioma. In one of these cases the ulcer
was first brought on by irritation of decayed teeth, and
subsided under treatment with iodide of potassium ; three
years later an epithelioma developed in the scar.
Exciting causes .—Out of the 104 cases, in sixteen instances
the patients distinctly traced the origin of the disease to
some injury. 1. In five cases the tongue had been bitten.
2. In three instances the disease originated in dyspeptic
ulcers. One of these patients was a glass-blower. 3. The
repeated irritation of a simple ulcer with caustic gave rise
to the disease in one case, and in another the scar left after
the application of creasote was the site of the growth.
4. In five cases a definite history of repeated laceration of
the tongue by carious teeth was obtained. This was well
marked in the case of the youngest patient, a woman aged
twenty-five years. 5. In one case the irritation of a plate
of false teeth was the assigned cause.
Smoking. — In the 104 cases a note as to smoking or
non-smoking is made in seventy-nine. Of these, sixty-two
were smokers, of whom forty-one habitually smoked clay
pipes, and thirteen are described as “ very heavy smokers.”
In some cases it was reported that the disease begata on
that side on which the pipe was usually held. In thirty-
three cases the existence of carious teeth is mentioned as
well as the habit of smoking, and in the fifteen cases in
women two occurred in smokers.
SOME POINTS ON
THE RELATIONSHIP OF THE EYE TO THE
CARDIO-VASCULAR SYSTEM.
By RAYNER D. BATTEN, M.D., B.S.LOND.,
CLINICAL ASSISTANT, ROYAL LONDON OPHTHALMIC HOSPITAL.
(Co7ioluded from page 9Sl.)
H. With regard to myopia, I find that it is usually
associated with some form of cardiac and vascular change,
(a) The pulse is a comparatively slow one, and is not readily
accelerated by conditions that would naturally quicken it.
The artery is large and full, the pulse tension is often
raised, and I have frequently noticed a recurrent pulse.
(&) The heart’s second sound is accentuated, and some form
of cardiac murmur is not unfrequently found, (c) The heart
measurements show a slight increase in size, the apex beat
being in or outside the nipple line, {d) In high and pro¬
gressive myopia, with an unhealthy fundus, and with vision
nob greatly improved by glasses, the pulse is sometimes very
rapid, and palpitations frequent.
Of elderly myopes, my experience is too limited to warrant
ray drawing any definite conclusiims, but vascular changes
are generally found. The action of atropine, locally applied,
I at first thought would have been of much help to me, but
I have found it most dltficulb to know which symptoms to
attribute to its local and which to its constitutional effect.
The rapid hypermetropic pulse atropine generally slows,
and sometimes in a very marked degree, a pulse of 120
dropping to 88 under its action. A slow pulse, on the
other hand, is sometimes quickened or generally left much
as it was. In myopia the alow pulse is but little altered by
atropine, and I have not seen the slowing of the rapid
myopic pulse under its action.
As regards the treatment of the two conditions by glasses
and its after-effects, I regret that I am unable to give you
any full information, for the hospital out-patient, having
obtained his glasses, generally disappears. I have, however,
seen the pulse fall and cardiac irregularity disappear in
hypermetropia with their use. Bub in the reverse cases, by
which I mean those in which patients have come under
treatment for cardiac symptoms and in which I have fonnd
well-marked hypermetropia, which I assigned as the canse
of the cardiac sj^mptoms, 1 was disappointed to find that the
correction of the hypermetropia by glasses or the paralysing
of the accommodation with atropine did not markedly slow
the pulse. This at first appeared to me to he fatal to the
theory that hypermetropia was the cause of the heart hurry.
Bub with the view that the cardio-vaacular system itself is
hypermetropic, it seems reasonable that, although the use of
atropine and glasses might remove the source of irritation,
it could not alter the structure of the cardio-vascular
system.
Mr. Mills, cbloroformisb at St. Bartholomew’s Hospital,
kindly answering ray letter, writes as follows : *' During the
operation for the division of the internal rectus in squint
cases, I have very often noticed an alteration in the pulse.
In some cases one beat was omitted, in others two or more.
In some cases the heats became very feeble, and remained
so for some seconds j in many cases there was very severe
syncope, lasting some minutes. This always came on
suddenly ; in most cases at the moment of division of the
internal rectus; in a few it occurred when the tendon was
ut on the stretch before division. There have been many
eathsunder chloroform during operations for strabismus.”
These cardiac intermissions, then, appear to occur only on
division of the internal rectus, and only in internal
strabismus cases—i.e., only in cases of hypermetropia, or
at all events mainly so. Hence there would appear to be
some condition of heart, or nerve connexion with the heart,
special to hypermetropes, rendering them liable to this form
of cardiac irritation.
Mr. Priestley Smith,^ speaking on the causes of myopia,
compared it to a kind of rickets, but apparently considered
it as a local rickets, dependent on loc^ causes. I would
also consider myopia a kind of rickets, but, like ricketa,
having a constitutional cause, and producing its effects on
other structures besides the eye; and that the treat¬
ment of myopia by glasses alone is much on a par
with treating rickets with irons and splints alone. Of
course, hygienic defects are often referred to as the cause
of myopia; but,as far as I know,no attempt has been made
to classify or state what the effects of this faulty hygiene
are, what class of concomitant symptoms we are to expect.
In fact, the eye, as the main symptom, has completely
overshadowed all others, and until we have a more
thorough knowledge of the causes and symptoms, other
than the eye, of this disease, I do not think much progress
con be made towards its treatment or its prevention.
Myopia, with its local and general changes, has, like the
rickets of bone, its period of activity, runs its course, and
produces effects more or less severe, and as the period of
its active progression comes to an end, the tissues, more
or less damaged and altered in shape, recover their con¬
dition, and are more or less capable of carrying on their
functions. Bub, again, in later life, in a few myopes,
I have known cardiac and vascular changes to assert them¬
selves, and in one case to progress to a fatal termination,
along with increase of the myopia. Of course I do not
mean to hold that a general constitutional cause of myopia
can be found in all cases, as it is obvious that many must
be due to some local cause—e.g., those in which one eye is
myopic, whiiab the other is emmetropic or hypermetropic.
Also the causes which lead to astigmatism would seem of
necessity to be local.
I have already expressed my opinion that the hyper-
metrope reaches his full development later than the myope,
and he appears to carry some or his youthful characteristics
far into adult life, and as far as my experience goes I should
say attains a greater age. All young children are said to
be hypermetropic, and I think it is reasonable to consider
tliat when the condition persists into adult life the eyes
may be said to retain their youthful characteristics. And
if it can be proved that the cardio-vascular system is
associated in any way with the eye in its development, it
does nob seem unreasonable to me that the hypermetropes
should be liable to take their illnesses with youthful
characteristics, or, at all events, with differences from those
in whom the cardio-vascular system is fully developed or
over-developed, as in myopes.
And here I would like bo ask whether the usually received
theory as to the sedentary habits of the myope is wholly
correct. The reason commonly given is that ho sits still
' Cause and Tvoatmeut of Myopia : Biit, Mod. Sept. 27th, ISOO.
1036 The Lancet,] DR. JOHN WORTABET ON CHOLEEA IN NOETHERN SYRIA.
[May 9,1891.
liecause be cannot see to take active exercise. But the
most obvious is not necessarily the moat correct explana¬
tion, and I would suggest that he sits still because his
vascular system does not enable him to take active exercise
with comfort.
Treatment .—I now come to the subject of treatment of
the bypermetrope and myope, and by treatment I mean the
constitutional treatment as opposed to mere local treatment
by glasses. Not that I have at present anything to state
on this subject, for I have felt that my theory was not
sufficiently proved to warrant my starting a course of treat¬
ment either to aid the developmental deists of the hyper-
metrope or to check the progress of the myope. But I am
convinced that the present method of treatment, in the case
of myopes at least, is irrational, and lays itself open to severe
criticism. In a case of progressive myopia, we order glasses,
more or less fully correcting the defect, according to the
surgeon’s view of their local effect in increasing or prevent¬
ing increase of the myopia. And then the patient goes
away for a time, only to return with weaker vision,
requiring a stronger glass. It is true that when the
atient’s sight declines rapidly, or when no glass will help
im to see clearly, we do give other treatment; but, as far !
as 1 have seen, it is given empirically, or only with local:
indications. We blister his temples or leech him, give!
him coloured glasses, order quinine and iron, and forbid
him to use bis eyes for near work or to stoop. The
treatment may of course be the very best we are
capable of, but I must confess I should like to know the
reason of my failure, and not to rest content simply to
watch it helplessly because it progresses slowly, and there
is always a hope that it may become stationary. Correction
of refraction by glasses has done much to aid the physician
in the diagnosis and treatment of headaches, and will, 1
trust, in the future help still further in the diagnosis, if not
treatment, of some forms of heart disease. It is time that
the physician lent his aid to the surgeon in refraction cases,
for in this, as in some other diseases, the most obvious sym¬
ptom is not always the one most requiring treatment. The
physical signs should be of use in establishing the diagnosis
between arrested and progressing myopia, the quick pulse
of the progressive markedly contrasting with tlie slowish
pulse of the stationary myope. As to what may be done to
aid the bypermetrope to overcome his defects, I am not
yet clear, but I am convinced that he sometimes requires
constitutional as well as local treatment.
In this paper I have called attention almost exclusively to
the refraction side of the subject. But I have done so pur¬
posely, not because I do not realise that there are points of
more obvious connexion between the eye and the cardio¬
vascular system, and perhaps of even greater importance.
In conclusion, then, I hold that there is evidence of an inti¬
mate association and connexion between the eye in its
muscular, nervous, and vascular structure, and the cardio¬
vascular system. And in this connexion, that as regards
hypermetropia there is a hypermetropic form of circulation,
partly structural, partly functional. This form of circula¬
tion IB liable to inlluence the type of disease in the indi¬
vidual; and thirdly, it gives rise to cardiac irritation and
functional disease, leading to mal-nutrition. As regards my¬
opia, that the changes which lead to it produce also a change
in the circulation, mainly structural. That the form of cir¬
culation so produced appears to render the individual less
liable to some, and more liable to other, forms of disease.
Finabury-dreus, B.O.
CESSATION OF CHOLERA IN NORTHERN
SYRIA.
By JOHN WORTABET, M.D.,
COHRESPONOING MEMHIIR OPTUE El’injiiVUOl.OO JCALSOCIKTV Ol' I.O.NDON
AKO OE TUK MEOlCO-ClIIItUIUJlCAI. SOClErV OI‘' KOINUtUlOil.
In a communication on Cholera in Northern Syria, which
appeared in Tub Lancet of Jan. lOtb, 1891,1 stated that
beginning at Aleppo on Sept. 13bh, 1890, where thedisease had
been imported from Mesopotamia, it had extended to Hamath
early in October, and from that town and in the same
month first to Antioch and then to Homs. The number of
deaths which I gave for these several places was drawn
from official reports, but it appears to have been very much
understated ; for on the authority of well-informed persons
there were no less than 3000 fatal cases in Aleppo, perhaps
as many, if not more, in Hamath, and 2000 in Homs. The
mortality in Antioch is not known, but it was probably in
the same proportion. In each of these towns the epidemic
seems to have lasted from eight to twelve weeks,.—the
ordinary period which it has generally lasted in previous
visitations. Why it should run this definite time, exhibit
the same regular stages of rise, height, and fall which
we observe in many acute diseases, and, having ceased
in one spot it does not return to it, though it may be raging
in its neighbourhood, are interesting questions ; but we are
still ignorant of their solution. The same difficulty of
explaining the germ theory in relation to the natural his¬
tory of an individual disease—typhoid fever, for example—
meets us in the phenomena of a cholera epidemic.
In continuing an account of the epidemic since the date
of my first communication, there is fortunately only one
other place to which it spread. The last fatal case in
Homs is supposed to have occurred on Dec. 2Gt-h. On the
6 th of that month, during the decadence of the disease, and
when it is said that the cordon between Homs and Tripoli
was relaxed, a shepherd, who had brought some sheep from
Homs, died in Tripoli from cholera. A negro, who lived near
the fold where the sheep were kept, died on the following
day of the same disease, and two butchers who inspected
the cattle were the next victims. The disease soon spread
into the town, stayed nine weeks, the last fatal case being
on Keb- ISth, and is supposed to have caused the deaths of
about 500 out of a population of 25,000. Whethertheinfection
was brought by the shepherd, or in the fleece of the sheep,
is uncertain; bub it is a remarkable fact, if the report he
true, that the weavers of Homs suffered most from thn
ravages of the epidemic. The drinking-water supply of
Tripoli is from a fountain, about five miles distant, at the
base of the Lebanon, conveyed in open aqueducts. A medi¬
cal friend, who was there during the epidemic, told me that
in a girls’ school, where nineteen pupils lived with their
teachers and attendants, whose drinking water was always
boiled, there were five cases of diarrhoea, which was promptly
stopped by opiates, and that he did not see a single case of
recovery after collapse had set in. The only mountain district
in the vicinity of Tripoli to which the epidemic spread was
that of Dunnyieh, agroupof villages inhabited by poorpeople,
but its duration there was short. This accords "with our past
observation, that the villages of the Lebanon and all moun¬
tain heights are unfavourable to the extension of cholera,
and thQ,t when it was imported to them from the plains
the outbreak was very limited, and never lasted more than
a few days. This immunity is so well established in Syria
that at every visitation of cholera the richer inhabitants of
infected towns seek refuge in the villages of the Lebanon ;
and while they are thus saved the risk of contracting the
malady, the poorer population who are left behind are freed
from the dangers of overcrowding, and encounter the epi¬
demic in a mitigated degree.
The epidemic seems t^o have ceased entirely more than
a month ago not only in Tripoli, but in the whole of
Northern Syria ; and the Government has lately abolished
the very rigid cordon which it had imposed on the
infected district of that town. All communication with
Damascus and Beyroub had been effectually stopped,
and it is very probable that owing to this means
the further extension of the disease was prevented. It yet
remains to be seen whether the cholera germs may nob be
lurking in some unobserved s^ot, to break again into a
renewed epidemic; bub as the evidence now stands it appears
that the scourge has ceased, and that the interrupted com¬
munication between the north and south of Syria was the
only means of checking its progress. The escape of the two
towns on the coast, Latakyieh and Alexandretba, must be
accounted for, however, if possible. The first of these places
was protected not only by a cordon, whatever that may
have been, but chiefly by a wild mountainous range which
made it difficult of access to inland communication, while
its water-supply is from numerous spring wells. No
attempts were made bo protect Alexandretba, which is
the seaport of Aleppo and Antioch, and there were a
few imported cases — nob more than three or four,—
but the disease did not spread among the inhabitants,
whose number may be about 3000. This remarbable
escape is probably due to their water-supply, which has
been recently brought to the town by iron pipes from
an excellent covered spring not far ofl'; and a gentleman
L.OO'- le
O
The Lancet,]
DR. BENJAMIN HOWARD ON INFLUENZA AND CHOLERA. [May 9,1891. 1037
who was there while the epidemic was raging in Aleppo
told me that the inhabitants believed that they owed
the inimimity which they had enjoyed to the purity of their
drinking water. The same explanation is probably true in
(regard to the unexpected escape, in 1883, of Beyrout, whose
water-supply is from the Dog river, conveyed in iron pipes
to a distance of about eight miles. Cholera was then in
Egypt, and more than 200 refugees came over and were put
into quarantine. There were three cases of death from un¬
doubted cholera among them, and a sentry at the lazaret,
^md two washerwomen, who washed their clothes, died soon
after. Beyrout was pronounced officially to be infected,
and was put into quarantine; but, to the amazement of
everyone, there was no further extension of the disease.
Beyrout. _
PERSONAL OBSERVATIONS OF THE COURSE
OF INFLUENZA AND OF CHOLERA IN
ASIA DURING THE RECENT EPIDEMICS
OF THESE DISEASES.
By BENJAMIN HOWARD, M.A., M,D., F.R.C.S.E.
Tub following contribution to the history of recent
epidemics as observed by me in Asia may be deemed
worthy of a place in The Lancet.
On leaving London in the autumn of 1889 for a prolonged
detour in India and other parts of Asia, influenza was in
the metropolis becoming the prevalent complaint. During
November and December I encountered it in Naples and
in Florence — the event moat conspicuous in my mind in
connexion with this epidemic in Italy being the death of
Browning, the poet, who from a bronchitis following this
disease died in Venice a few days after my arrival in that
city. At Brindisi I took a steamer which had come direct
from London. Oo board this steamer was a gentleman who
landed with us in Bombay, still suffering from a severe and
.prolonged attack of influenza. As this was the only case on
board, it became quite a subject of speculation whether or
no he might not inoculate Bombay with his influenza. In
Bombay, within six weeks, and before I left the hotel we
were both staying at, influenza was common amongst
the many regular residents of that hotel, and soon after
c-ppeared among the villa residents on the neighbouring
suburban hills. From India there are three passenger steam¬
ship lines running to the healthy little port of Kobe, in
Japan. After spending the following summer in the Okotsk
Sea and Eastern Siberia, I returned in the end of autumn to
Kobe, and immediately was myself attacked with influenza,
with which about 30 per cent, of the inhabitants were con¬
fined to their houses, and many to their beds. From
Kobe to Yokohama, the furthest eastern port, is a run of
about thirty-six hours. Here nearly every house, European
as well as Japanese, has been invaded by influenza, and of
so severe a type that during my stay here many Euro¬
peans have died from it, many of the victims being
men comparatively young, and of such robust habit that,
from the ignoring of the disease, they invited the relapse
which proved fatal. The only difference between the disease
as it appeared in Japan and as I saw it both in London and
India, is that in Japan the constitutional depression has
■been much greater, several weeks’confinement to bed having
'been not unusual.
Now for the cholera, which we know has been so severe
throughout the greater part of the Japanese Empire the
rpast year. In Bombay during the latter part of the
winter of last year there was amongst the general public
certainly nob a thought about cholera. I was the more
assiduous, therefore, to test the statenrenb made to me by
several medical officers to the effect that in the Bombay
Presidency that disease is rarely or never totally absent. I
was at last rewarded by finding a case in the city of Bombay.
There had been rice-water discharges and cramps, and the
identification of the disease had been endorsed by the
■removal of the patient to the cholera section of the General
Hospital whore I found it. I have spoken of the direct lines
of mail steamers running from India to the various ports of
Japan, Nago-saki, Kobe, «fcc., having their terminus at
Yokohama. The July following cholera was reported to ho
at the first of these ports of call, Nagasaki. To this place I
went, where the reputed four or five cases I found by actual
inspection to mean forty-five cases. Being myself en route
for Siberia and a summer cruise in the Okotsk Sea, I took
first the mail steamer route, the only line iu direct commu¬
nication with the eastern ports of Corea. Of these ports,
Fusan and Jinsan, it was difficult to say which was the
filthier, but both of them surpassed in this respect the
dirtiest city I had seen even in China. One could nob avoid
the apprehension that, should cholera break out in either of
these places, the whole population must he swept away by
it. At Vlaclivostook, the first Russian port, and the ter¬
minus of this only lino in direct communication with
Japan, there appeared to be at first sight fairly good
sanitary conditions. 1 soon found, however, that, although
the situation is particularly good, all the water used
is surface water, and this has to he paid for at so
much a bucket, as everywhere in Siberia. Sewerage there
is none. On the very next trip of this same steamer from
Nagasaki, one of the passengers died of cholera, and the
fire was lighted all along its route, including Vladivostock.
Of Japan alone is it possible to give even proximate
statistics; but, strange asitmayeeem,in Fusan and Jinsan—
the Corean ports, where the corner of every street is an
open and overflowing privy—the mortality has not been
reported as astonishing. At the northerly Siberian port
of Vladivostock the mortality was as great as in Japan,
bub the cases were comparatively few. In Japan, from
July to Dec. Slsb last, the total of reported cases was
45,034; deaths, 31,484, giving a mortality of over 69 percent.
These travelling companionships I hope I have been in no
way responsible for, bub the coincidences mentioned have
been interesting, and, as contributions to the history of
these epidemics, may be deemed worth recording.
Yokohama, .Japan.
HERNIOTOMY, OR ABDOMINAL SECTION?
By harry LUPTON, L.R.C.P.LoNn., M.R.C.S.ENG,,
SUIIQEON TO THE STRATEORD-ON-AVON HOSPITAL.
! I AM anxious to place on record the following two cases,
and shall be only too pleased if their nai-ration leads to the
expression of opinions more authoritative than my own.
My own bias is, and yet not strongly, to the abdominal
method. I must let the cases speak for themselves.
On Sept. 28bh, 1890, my friend, Mr. Fenton of Kineton,
sent to me Mrs. B -> aged fifty-three, with a history of
obstruction; no hernia could he detected at the usual seats ;
bub her symptoms becoming so urgent that he considered
abdominal section offered the only chance of recovery,
she was admitted to the Stratford-on-Avon Hospital, and
at once seen by the staff in general consultation. We
could add nothing to Mr. Fenton’s history of the case;
and, as it was evident if the patient was nob relieved
she had only a few hours to live, it was agreed that I
should at once open the abdomen, and endeavour to
relieve the obstruction. This I did, and found a very
small piece of small intestine, perhaps a third or a half
of its circumference, nipped tightly in the right femoral
ring. I withdrew it with very little difficulty, and found it
dark hut distinctly reducible, and returned it. Every pre¬
caution as to cleanliness was adopted, but no spray. The
wound was dressed simply with absorbent wool. The opera¬
tion was just done in time. For a time she looked almost
like dying on the table; but the pulse improved with the
withdrawal of the intestine from the ring, and half an hour
after the completion of the dressings she was able to be
removed from the table back to her ward. For the rest
there is nothing to write abouc. Her symptoms were
relieved, and she simply went on getting better. She was
discharged cured on Oct. 28th, and has since been busy in
her dairy. “Look on that picture and,” alas ! “ on this.”
Mrs. G-,aged fifty-seven,was admitted to the Stratford-
on-Avon Hospital on Dee. let, 1890, suffering from strangu¬
lated femoral hernia. Her symptoms were urgent, anil a
consultation of the full staff agreed that immediate operation
was necessary. When the patient was under chloroform,
one of my colleagues, remembering the excellent result
obtained in the case of Mrs. B-, said, “How are you
going to operate, Lupton?” The same question was strongly
at the moment present in my mind. I had been deeply
impressed by the result of the former case, and was
1038 The Lancet,] MR. T. W. J. ALLEN ON ERASION OF THE KNEE-JOINT.
[May 9,18W.
half inclioed to operate hy the abdomen. But there
was an obvious femoral hernia before me, and perhaps
I lacked moral courage to depart from the beaten track. 1
therefore did an ordinary herniotomy, coming first to a piece
of omentum, about the size of a walnut, nrmly adherent
along the margin of the ring. This was raised out of the
wound, and under it was a knuckle of intestine, firmly
gripped, but in no wise worse than in the case of Mrs. B-.
Gimbernat’s ligament was rather freely incised with Smith’s
combined hernia director and knife (to my mind one of the
best surgical inventions of modern times), and the intestine
returned without much difficulty. Thefinger followingproved
the ring to be free, and 1 bad good hopes of the success of the
^ration. The operation was completed about midnight.
On visiting the hospital the following morning, I found her
symptoms, to my great disappointment, unrelieved. 1 was
sure that I had i^reed the ring and returned the intestine;
but, as apparently the only thing to be done, I opened
the wound, passed my finger in, and found the ring free;
no protrusion of intestine. The poor woman was too far
gone to admit the question of any further operative means,
and she died a few hours later. I obtained permission for a
post-mortem examination, but on the following day my en¬
gagements were such as to entirely prevent my making it.
It was therefore made by my assistant, Mr. Ivatts. He
found the protruding omentum adherent along Poupart’s and
Gimbernat’s ligaments anteriorly. Behind and within the
abdomen was the returned knuckle of intestine; but behind
the adhering omentum was a mass of adventitious tissue, the
result, apparently, of an old localised peritonitis. Through
an opening in this the intestine had passed, and thence on
to and through the femoral ring. The intestine was held,
but not firmly, in the upper opening, and was withdrawn
without much traction being necessary. Mr. Ivatts stated
that the capacity of the mass, in which the intestine lay,
was about that of a small hen’s egg. I deeply regret the
result of this case, for I can but feel that, bad 1 operated
by the abdomen, 1 could easily have withdrawn the intes¬
tine from both its constricting rings. No doubt the state
of the parts found was very unusual. Can it be of sufficient
frequency to justify the abandonment of the old operation
for the new ? Again I say I shall be glad to hear opinions
more authoritative than my own on the subject. I should
be wanting in courtesy, no less than in gratitude, did I not
refer to the kindly and able assistance rendered me by my
colleagues, Messrs. Nason, Norbury, and Greene, in the
treatment of the above cases.
Stratford-on-Avon.
NOTES ON TWO CASES OF ERASION OF THE
KNEE-JOINT.
By T. W. J. ALLEN,
HON. SlfUGEON TO THE GRIMS13Y HOSPITAL.
Case 1.—E. A. S-, aged nineteen, was admitted into
the hospital on Sept. 2ad, 1889. He had had a swollen
knee for about twelve months. There was great pain on
moving the joint, and nocturnal starting pains. He had
been unable to work for the last three months. No history
of an injury, and no family history of phthisis. The joint
was slightly flexed and much swollen. There was also a
sinus running upwards for three or four inches along the
outer side of the external condyle of the femur. On
Sept. 10th arthrectomy was performed. After applying
Esmarch’s bandage and tourniquet the usual horsesnoe-
shaped incision was made, the ligamentum patella? divided,
and the joint widely opened. The synovial membrane was
much thickened, bad grown partly over the cartilages, and
was caseous in places. The whole of this pulpy granulation
tissue, together with the infiltrated capsule, was dissected
off; the crucial ligaments and cartilages, articular and
inter-articular, were carefully scraped. The sinus was
thoroughly scraped. The tourniquet was removed and the
spurting vessels secured, and the tourniquet was then re¬
applied. The joint was thorougblyswabbed out with I in 40
carbolic. Iodoform crystals were rubbed into the recesses
of the joint, the ligamentum patellm was sutured with
catgut, a drainage-tube inserted into the joint on either
side and into the sinus, acd the external incision was
sutured with silver wire. The dressing was composed
of carbolic gauze and carbolised wool, and a Gooch’s back
splint. The limb was elevated at right angles to the.
body for twenty-four hours, and the tourniquet reraoveiS
The temperature remained about normal until the fifteenth
day, and on the seventeenth d^ was 102°. The joint was
then dressed for the first time. The external wound looked
healthy, and good union had taken place. There was no
pus. The drainage-tubes and wire sutures were removed.
Temperature remained normal after this. The next dress¬
ing was on the fortieth day after the operation. The joint
was then perfectly healed and sound. The patient left the
hospital in January, 1890, wearing a simple back splint.
His general health has much improved, and now, fourteen
months after the operation, he nos a sound, useful limb,,
with movement to the extent of about 45°. He is working
in a saw-mill, his duty being to feed a circular saw, and he
is standing about ten hours a day. He says his leg feel&
tired at night, but he has no pain or swelling.
CA.SB 2,—A. W. S-, aged ten years, was admitted on
Sept. 5th, 1889, in a very poor state of health, very thin
and anmmic. Swelling and pain commenced in the
left knee two years previously. It was first noticed that
he limped a little, and complained of pain after exertion.
The joint was very much flexed, there was a marked dis¬
placement of the head of the tibia backwards, and somo
outward rotation of the leg. The lower end of the femur
appeared to be much expanded. There was no family
history of tubercle and no liistory of injury. Arthrectomy
was performed, as in the preceding case, on Sept. 17th, On
freely opening the joint a small amount of pseudo-purulent
matter escaped. The synovial membrane was caseous in
many places and extremely thickened, the fibro-cavtilages
had entirely disappeared. The articular cartilages were per-
Digitized by .oogle
The Lancet,]
CLINICAL NOTES.
[May 9,1891. 103 9
forated on both surfaces of the tibia, and that on the external
condyle of the femur was entirely destroyed and a caseous
mass exposed. The peripheral portion of the patellar car¬
tilage was undermined and necrosed. The whole of the
diseased synovial tissue was removed, the crucial ligaments
carefully cleaned, and the caseous centres in both tibia and
■femur thoroughly scooped out, so much so that the external
condyle was a mere shell. In this case the tourniquet was
not slackened, but pressure and elevation were relied upon
to prevent hsemorrhage, the tourniquet only being removed
on the completion of the dressing, with the limb fixed as
before. Drainage-tubes and dressings as in Case 1. The first
dressing was removed fourteen days after the operation,
when the tubes and sutures were removed. The greater
part of the superficial wound bad united. The second
dressing was on the forty-fifth day after the operation, and
the wound was completely healed. The temperature never at
any time exceeded 100® P. The boy left the hospital early
'in February, 1890. His general condition has wonderfully
improved, and he is very active on the foot. The knee is
slightly flexed, quite stiff and firm, and the leg slightly
rotated out. I am greatly indebted to my nephew, Mr. C.
B. Turner of University College Hospital, who assisted me
with the operations and with the notes of these cases.
•Grim.nby.
Cliitkal Itflks:
MEDICAL, SURGICAL, OBSTETRICAL. AND
THERAPEUTICAL.
CASE OF LEAD COLIC.
By M. M. Bowlan.M.B., ’
ASSISTANT MKDICAL OFl'ICKIl TO TUK UNION HOSPITAL AND
WOKKIIOUSE, NEWCASTLE-ON-TINE.
In this case there existed no gum line, and this absence
was due, doubtless, to the use of the tooth-brush and a
■table salt dentifrice. I append a note on the cause of the
blue line. ’
Mary T-, aged twenty-eight, white-lead worker, was
admitted on October Gth, 1890, under the care of Mr. T. A.
Dodd, the visiting surgeon, to whom I am indebted for per¬
mission to publish these brief notes. On admission she was
suffering from a slight attack of lead colic and constipation,
which, after three or four days, became very severe. There
was no gicgival discolouration, neither “line ” nor “dots.”
No wrist drop or other paralytic symptom ; her eyesight
was good. No headache or fits. Urine free from albumen.
She lias worked at lead works for one year, with the ex¬
ception of being absent “an odd week now and again.”
This is her second attack of colic, the first seizure having
been six months ago, and was not so severe as the present.
She worked chiefly at the “white beds”—i.e., carrying
white lead to the rollers to be ground. She has never
lost power in her hands, &c. While I was searching
for tJie gum line she spontaneously explained that
its absence might be due to her using a tooth-brush
and thus cleansing her mouth and teeth daily with table-
salt after returning from work. This habit she had
practised some time previously when engaged in a dusty
occupation (at a papermill: dirty dusty rags), as she had
'been told it would preserve her teeth. She says she had no
intention of misleading the surgeon at the lead works. She
was discharged quite well on Oct. 20tli, 1890, the colic
having yielded to an opium and sulphate of magnesium
•mixture. I was not aware until to-day (Feb. 28rd, 1891)
■that allusion is made to similar cases in Fagge’s Treatise on
Medicine. But as our case appears to be unique in having
such a very definite cause, perhaps it may be none the less
worthy of brief record. The gum sign is admitted to be
.generally present in chronic plumbism, and also in white-
lead workers who have been exposed for any length of time,
-even though no toxic symptoms have developed. This case
has some bearing on the proximate cause of the “blue
line for if local cleanliness prevent its formation, it must
bo either by removing or neutralising some factor or factors
cjasential to its production. Now, the generally received
opinion appears to be that the lead is excreted by the I
vessels of the papillm of the gums (and I presume as a j
complex albuminate), and that it is here precipitated as a
sulphide by the H. 2 S evolved in the decomposition of animal
matters contained in the pores of the tartar on the teeth.
And it is reasonable that local cleanliness should, by pre¬
venting the accumulation of tartar and the stagna^on of
the secretions and food detritus, hinder the formation of
sulphides in the mouth. There can be no doubt that the
saliva itself contains sullicient sulphur-charged proteid
matter to generate, by decomposition, the required sulphide.
But there is one other possible source, I think, of this
sulphur without having to draw upon the disintegration of
albuminoid bodies—viz.: that we have always present in
the month as a constituent of healthy saliva a compound
sulphide—potassium sulpbo-cyanide; and some 130 milli¬
grammes of this are secreted daily. ^ This salt “in aqueous
solution decomposes with the evolution of ammonia at ordi¬
nary temperatures.”- Watts makes no mention as to what
becomes of the sulphur when a watery solution of KCNS
thus breaks up, bucit seems to me not improbable that it is
a contributor, if not the actual source, of the sulphide which
precipitates the lead in the gum. Doubtless microbes take
part in this process of chemical change. From this stand¬
point the cleansing of the mouth prevents any discoloura¬
tion of the gums by preventing the formation of that
nidus for stagnant and decomposing animal matters
and sulpho cyanides —the tartar of neglected teeth. And
these matters gain access to the tartar in two ways:
(1) By being carried down with the lime salts when the
tartar is being deposited on the teeth; (2) by absorption
into the pores of the tartar subsequently.
Newcasfcle-onTyne._
THE EXTRACTION OF BROKEN NEEDLES.
By Chakles Steele, M.D., F.R.C.S.
All who have had much to do with this minor operation
know how frequently a satisfactory result fails to be ob¬
tained unless the indications for a safe operative procedure
are strictly observed. It is most unpleasant, after cutting
and probing with the finger and forceps, to be obliged to tell
a patient who has endured some pain and much discomfort
that further attempts are useless, and that the fragment is
still there; and perhaps suggest as the best consolation that
the needle has a more free opening by which to work its
way out. I have for many years declined to cut unless I
could make out the situation of a point, and that the other
end bad a firm bearing to rest upon ; giving the assurance
that patience and watching are the proper treatment for the
time being;
Lately I have adopted a very simple, painless, and
reliable plan, and have regretted that I nad not thought of
it in many previous instauces. Last autumn, when I was
visiting a child, a young lady, bis sister, came into the
room using her right foot naturally, but resting only on the
toes of her left foot, and explainea that she had gone about
in this way for fully three weeks, as she had broken a
needle into her left heel, and the slightest touch gave her
great pain. The point of entrance was visible in the middle
line in front of the tuberosities of the os caleis ; the end of
the fragment could be recognised through the skin, but the
slightest pressure made it recede. I declined to operate, but
directed that two thick felt corn plasters, one on the other,
should be applied, with the puncture occupying the
central hole, and that she should walk freely and bear
well upon the heel. This she did with perfect ease, and
after ten days the needle presented, and was withdrawn
readily. It was the eyed end, and almost an inch long.
Soon after this I saw a little girl, aged three years, who
when away from home in the summer had also trodden upon
a needle, which broke and entered between the ends of tlie
metatarsal and tarsal bones. A surgeon saw her promptly,
cut down, and tried for some time to extract, but failed.
She often felt no inconvenience, but at intervals limped
suddenly, and complained of pain. She was persuaded to
wear a corn plaster, and after three weeks the portion of
needle, which had been in more than three months, after
producing a little superficial irritation, showed itself, and
her nurse drew it out. The wrist and ball of the thumb are
not unfrequently punctured, and if the fragment enters
obliquely, or lies close to arteries or nerves, and cannot be
forced into prominence, attempts at extraction are, to say
1 Landois and Stirling. ’-s Watts’ Dictionary of Chemistry.
1040 Thb Lancet,]
HOSPITAL MEDICINE AND SURGERY.
[May 9,1891.
the leaat, undesirahle; whereas by adopting this simple
method, after the manner of removing a thorn with the pipe
of a key, and producing pressure with an elastic wristlet or
slight steel spring like a small truss, the fragment will work
out, and not give pain from any knocks while under the
skin. In that awkward position, the soft parts by the sides
of the ligamentum patellm, this plan can be used. It re¬
commends itself to everyone’s common sense, and has the
great advantage of not leaving any cicatrix,
ton. _
A FAMILY OF DWARFS.
By G. Oscar Jacobsen, M.R.C.S., L.K.C.P.
The following case of a dwarfish family has come under
my notice:—
The dwarfs are three children, two girls and one boy, the
father being a well-developed man, height 5ft. 4 in., the
mother (his first wife, now dead) having been about
4 ft. 10 in. The ages and heights of the children are as
follows:—Chaa. T. w-, a boy of fourteen years and a half,
height 47 in. He is a very sharp lad, passed a year back
the sixth standard of the School Board, but is generally
small. Except for his mental powers he is in every way
backward in development, there being no sign of hair about
the pubes or axillm, and his ideas are all rathei' childish.
Nelue W-, eleven years old, height .3(54-iQ- The child
is fairly sharp, but very puny and delicate, having to
be kept away from school during the winter months.
Bertha W-, age thirteen years, height 44^ in. This
girl is sharp and has passed the fourth standard, but
has no signs of puberty and has never menstruated.
I may say wiat both the girls are knock-kneed, but to no
such extent as to make any great difference in height. The
boy, thefather tellsme, whenyounger, “had something wrong
with bis ankles,” which necessitated his being three years in a
hospital. In contrast to these dwarfed children, I give the
heights of the children of the same father by a second wife,
who is about the same height as his first wife was. F.va
yf -, four years old, height 40m., or 3;f in. taller than
the child of eleven years by the first wife. Lucy W-,
eight years old, 44^ in. in height, being as tall as the child
of thirteen years by the first wife. These last two children
are also growing yearly, whereas the two dwarf girls have
not grown for the last two years. Ann S-, daughter of
the second wife by a first husband, is six months younger
than the boy dwarf, but is fifteen inches taller, being
5 ft. 2 in. in height. She, moreover, has development of
mammae, has hair under the axillcc and on the pubes,
and has menstruated for the last three months. The height
is nob alone wherein the children suffer, but their limbs are
all small and in proportion to their miniature size, their
heads being rather large. There is no other instance of
dwarfs in either the father’s or mother’s families previous to
this, and the mother is said to have always been a healthy
woman. The mother was between twenty-four and twenty-
five when she married, and had three brothers and three
sisters, all of whom married and had healthy children,
except one sister. All of the mother’s children were born
at full term, and no comment was made upon their size.
Huntingdon.
CASE OF CONGENITAL PHIMOSIS, LEADING TO
DEATH AT THE AGE OF EIGHTY-THREE.
By Arthur S. Taylor, M.B. Cantab., F.R.C.S.
John F- , aged eighty-three, was found dead in a field
in which be bad been working. I made a post-mortem
examination on the coroner’s order, and found the following
interesting condition
Lungs slightly congested with a little old pleurisy on each
aide. Heart large bub healthy. The first part of the aortic
arch was dilated, but for a man of eighty-three the artery
wall was exceptionally good. Both kidneys were remark¬
ably cystic, with enormously distended pelves and ureters.
The bladder was greatly distended by urine, and in two or
three places only the peritoneum prevented rupture into the
abdominal cavity. There was no stricture of the urethra,
though the middle lobe of the prostate was much hyper¬
trophied. There was congenital phimosis, the circumference
of the aperture when slit open and stretched being one inch.
On opening the skull, I discovered submeningeal bmmor-
rbage covering the base of the brain, running down the-
vertebral canal, and spreading over both frontal areas. I
could discover no small aneurysm, nor the actual vessel
which had given way. The interest of the cose lies in the
slow but sure progress of the disease. Doubtless, the end
was hastened by the hypertrophy of the middle lobe of the
prostate. At tne inquest, the deceased was said to have
enjoyed very good health. He had had an attack of
dropsy a year previously, and shortly before his fatal
apoplexy sufiered from epistaxis. The arteries at the
base of the brain were rather rigid, but by no means
bsid. He had had several children.
Surbiton Hill.
% Piuor
OF
HOSPITAL PRACTICE,
BRITISH AND FOREIGN.
Nulla autera est alia pro certo noBcendl via, nisi quainplurlmasetmo^r.
bonioi et dlssectionum blstorias, tuiu alloruin turn propriaa collectao
babere, et inter ae compaiare.— MOROAONI De Sea. et Cevue, Uorb.,
Ub. iv. Procemium -
ST. THOMAS’S HOSPITAL.
TWO CASES OF DISLOCATION OF THE UI.N/VR NERVE.
The condition of nerve described in the account of these-
two cases is one which has not hitherto been recognised in
the literature of this country. No mention is made of it-
in our works on surgery, even when they treat of the sub ¬
ject of nerve injury in a special manner. The only contribu¬
tion on the subject we can find is one by Dr. F. J. Lutz,^
who wrote of a case of habitual dislocation of the left ulnar
nerve. This account will be read with much interest, more-
especially the parts which describe the operative measures
which were successfully undertaken to secure the nerves in
their normal position. For the notes of the cases we are
indebted to Mr. E. C. Stabb, surgical registrar.
Case 1. — E. N-, aged twenty-eight, married, was-
admitted under the care of Mr. Croft on March 7th,
and left the hospital on April 9tb, 1891. Six weeks-
ago the patient fell, grazing her right elbow against the
edge of a bucket. This injury was followed by cellulitis,,
limited to the region of the elbow, and she was ad¬
mitted to St. Thomas’s liospital twelve days after the
injury, and an abscess opened just above the internafi
condyle of the humerus. She left the hospital well at
the end of a week. A few days after this, on com¬
mencing to work again, she felt pain on the inner side of
the same elbow, shooting down to the hand, whenever she
Hexed the forearm. On March 7th she was readmitted,
and on examination it was found that on slowly Hexing
the forearm, when this movement reached to about
a right angle, what appeared to be the ulnar nerve
slipped forwards over the internal condyle, taking up a-
position in front of it, and causing pain to the patient.
On extending the forearm again the nerve resumed its
anatomical position. There was no local tenderness or
loss of sensation, or wasting of muscles, but the grasp of
tlie right hand was distinctly more feeble than that of the
left. On the 16th Mr. Croft exposed the nerve by a semi¬
lunar incision. It was slightly thickened, and freely
movable over the internal condyle. He then stitched the-
sheath of the nerve to the inner margin of the triceps
tendon, and finally attached the edge of the same to the
periosteum covering the internal condyle, leaving the nerve
completely embedaod. The arm was fixed in plaster-of-
Paris splints in the extended position. Thedayaftertheopera-
tion the patient complained of sensation of pins and needles
in the fourth and fifth fingers. Sensation was almost
absent from the fifth finger. The wound healed by first
intention, and sensation gradually returned.
On discharge from the hospital the nerve was quite fixed
in its normal position. There was no pain on flexion of the-
1 St. Louis Medical and Surgical Journal, 1879-80, vol. xxxviii., p, OBO.
Die: ed ■ y CjOO^Ic
Thb Lancbt,]
HOSPITAL MEDICINE AND SUEGERY.
[Mayo, 1891. 1041
olbow, and complete restoration of the functions of the nerve
had taken place.
Case 2.—C. M‘G.-, aged thirty, a bookkeeper, was
admitted under the care of Sir William Mac Cormac on
Feb. 14th, and left the hospital on March dbh, 1891. The
patient has always had a great deal of writing to do, and
lor the last two years has felt his right arm to be getting
weaker, preventing him from holding a pen for long without
rest. Five months ago while in Egypt his arm suddenly
became much worse without any apparent cause, and he
could only write with the greatest difficulty. On this
account he had to resign his post in the Customs. At this
time he first noticed that something slipped forwards on
the inner side of his right elbow. There is no history of
’injury to the elbow.
On admission to St. Thomas’s Hospital what appeared to
be the ulnar nerve slipped forwards to the front of the internal
condyle of the humerus almost as soon as flexion of the
forearm was commenced ; this caused no pain, bat a feeling
cf uselessness in the hand and inability to hold anything
-for long with the fingers. On Feb. 17th Sir William
Mac Cormac exposed the nerve by means of a longitudinal
incision, and having made a species of bed for the nerve by
dividing the fibrous structures behind the internal condyle,
fixed it in its usual position by means of two kangaroo
tendon loops passed through the inner margin of the triceps
tendon, and somewhat loosely round the nerve. Several
catgut sutures were also used to unite the divided margins
of the fascial expansion of the triceps, superficial to the
nerve, which was thus firmly supported- The arm was put
np in the extended position in plaster-of-Paris splints.
Feb. 19th.—The patient complains of tingling in the
■fourth and fifth fingers of the right hand. No loss of
eensatlon.
23rd.—Wound nearly healed.
On discharge from the hospital the ulnar nerve was quite
fixed in its normal situation, which it maintains in all
{positions of the limb. The patient can now write fairly
well, and the functions of the nerve are entirely restored.
LANCASTER COUNTY LUNATIC ASYLUM.
A CASE OF CARDIAC THROMBOSIS, WITH MULTIPLE EMBO¬
LISM OF THE LUNGS ; NECROPSY.
This case shows the difficulty which often complicates
the diagnosis of disease in the insane. In many instances
cne has to depend entirely on the physical signs, the
patient often being quite unable to give any informa¬
tion, and more frequently than not offering an active or
passive resistance to examination. Another point which
must be borne in mind is that very often it is late in
the progress of the disease when attention is first called
■to the patient, and the initial lesion may be thus
obscured or even masked by complications. He com¬
plains of nothing, and apparently suffers nothing. The
post mortem examination frequently reveals the presence
of acute disease neither complained of nor suspected
during life. One can understand, therefore, how neces¬
sary it is to cultivate the senses employed in physical
examination, as in many cases it is all we have to depend
upon for a diagnosis. However trifling the change in
attitude, gait, complexion, respiration, I'tc., of the patient,
examine him, and, though often your suspicion that there
is something wrong may prove on investigation to be
incorrect, there is the satisfaction of knowing that your
physical diagnosis of necessity becomes more delicate and
accui-ate. Nowhere is physical diagnosis of more im¬
portance than in asylums, for the reasons already specified.
In the present case effusion of fluid into the left pleural
cavity, with displacement of the heart to the right,
pericarditis, and a localised dulness in the lower lobe of the
light lung were diagnosed. No light, however, could be
thrown on the case by the patient either as regards histoiy
or symptoms, and hence the diagnosis depended entirely on
the physical examination, and eveo that bad to be con¬
ducted under disadvantages which do not obtain in the
-sane. What, therefore, was the primary lesion could only
be guessed. Malignant tumour or the lung and aneurysm
cf the aorta were both considered, and uismiesed as un¬
tenable. One feature of the case which was rather puzzling
was the extreme feebleness of the radial pulse, not in keep¬
ing with the patient’s general appearance. A possible
explanation of this is offered. For the account of the case
we are indebted to Mr. Jas. F. Gemmell.
G. H-, a dement, aged forty-three. The attention of
Mr. Gemmell was called to this patient on account of the
difficulty he seemed to have in breathing. The following
were the chief points observed on a general inspection:
Extreme dyspnoea: Uvidlty of lips; engorgement and pulsa¬
tion in the veins at the root of the neck, and oedema
of the inferior extremities, especially marked on the
right side, where it extended the length of the limb.
Expression was anxious and restless; coDjunctlvm slightly
icteric, and complexion sallow and cachectic. The move¬
ments of the left side of the chest were not so
free as those of the corresponding part on the right.
There was no cough, but very occasional aud difficult
expectoration of a small quantity of a tenacious mucous
material of a black-currant-jelly colour. No difficulty in
swallowing, and the body was well nourished. Interroga¬
tion of the patient as to what was wrong and bow long he
had felt ill was futile. Further examination revealed a very
complicated condition. The percussion note over the whole
of the left side of the chest, with the exception of about
three inches of the apical region, was absolutely dull, thk
line of dulness not being altered by changing the position
of the patient. Over the right side of the chest the note
was clear, with the exception of a localised dulness a little
below and in a line with the angle of the scapula. There
was no increase of hepatic dulness upwards, but the inferior
border of the left lobe was perhaps a little lower than usual.
The right border of cardiac dulness was increased towards
that side. The left could not be distinguished from the
dulness existing over the left lung, and the upper border
was normal. No cardiac impulse could be felt, nor any
splenic enlargement detected. The cardiac sounds were
only faintly, if at all, audible in the apex region; but
approaching the median line they became more distinct,
and at the ensiform cartilage, and for some distance up the
sternum, were attended by a pericardial friction murmur.
Nothingof the nature of a valvular murmur could bedetected,
but systole was accompanied by a most peculiar flapping
sound, which, however, was not always audible. Generffl
action of the heart was feeble and distant. The respiratory
murmur over the right lung was healthy except over the
localised dulness, where it was attended by fine dry crepitant
rfiles, and approached the tubular in quantity. Over the
left lung behind, except at the apex, where it was normal,
the respiratory murmur was vesicular, but much weaker
than over the corresponding lung. It could be heard down
to almost the base of the lower lobe, where, however, it was
extremely faint. It was accompanied by obscure crepitus.
From the posterior axillary fold round to the mammary
lino, and extending well up into the axillary region, the
murmur was inaudible, except over the front of the apex,
where it was normal. Vocal fremitus and resonance could
scarcely be said to exist over the dull area on this side. No
pulse was obtainable at either wrist or temples, but in the
groin it numbered 84, respiration 52, and temperature normal.
The urine could not be obtained for examination. Peri¬
carditis, effusion of fluid into the left pleural cavity, with a
patch of consolidation in the right lung (probably pneu¬
monia) were diagnosed. The left cavity of the cheat was
aspirated by Allan’s pump, and eighty ounces of a serous
fluid tinged with bile drawn oft’. This appeared to give
the patient some relief, and resulted also in a return of the
vesicular murmur and clear percussion note. The respira-
toiy murmur was attended by coarse and fine crepitant
rfilea.
Dec. 1.3th.—Breathing not so laborious, respiration 40;
pulse 120, felt at both wrists, but very feeble. His general
appearance, however, did not betoken cardiac weakness to
such an extent as indicated by the feebleness of the radial,
brachial, and temporal arteries. The temperature has
never been above 100° F. Percussion note over the upper
third of the left lung gives a resonant note, but below tnis
it gradually disappears, and at the base is quite dull. The
respiratory murmur can be heard all over the lung, though
over the dull area it is extremely faint. It is vesicular, and
attended by fine crepitant rilles at the upper part of the
dull area. No change in cardiac condition.
l()th.—Rather worse today; dyspnosa increased. Respi¬
ration GO; pulse 112 ; temperature normal. Heart still
displaced to the right, where the sounds, though feeble, are
best heard. There is little alteration detected in the condi-
D
1042 Thb Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[May 9, 1892.
tioD of the left long, except that metallic tlokle is heard
very distinctlv a little belonr and to the outside of the
nipple line. Gildenia of the inferior extremities still marked,
and in addition the left hand and wrist have become
similarly affected. The dyspncea became steadily worse,
and the patient died the same day.
Necrop$y. —The following conditions were revealed.
Becent embolism of the left vertebral artery at its origin
from the arch of the aorta. It was also blocked by an old
embolus as it entered the skull through the foramen
magnum. Slight pleuritic adhesions at the apices of the
lungs, and the anterior margin of the left pleura was
adherent to the pericardium and the chestwall. On break¬
ing this down the lefc lung for about three-fourths perhaps
of its extent was found to be shrunken and firm. Both visceral
and parietal layers of the pleura were covered by a thick
fibrinous deposit which could be easily detached, and
about the junction of the upper with the lower three-fourths
both layers were adherent, above which the lung was normal.
The left pleural cavity contained about fifty ounces of
turbid serous fluid, in which floated numerous flakes of
lymph. The consolidated and shrunken portion of the lung
was found to be the seat of numerous hmmorrhagic infarc¬
tions of various sizes and in various stages. They occupied
chiefiy the lower lobe, but several smaller ones existed at
the anterior margin of the upper lobe. There were also
two in the lower lobe of the right lung, one about the size
of a small orange, evidently corresponding to the dull area
delimited W percussion. The rest of the right lung was
healthy. I'he heart was enlarged, weighed twency-two
ounces, and was displaced towards the right. Its right
cavities were engorged, the mitral and tricuspid orifices
were dilated, and the muscular substance was healthy
in appearance. At ^e apex of the left ventricle was
a large white thrombus undergoing softening; right
cavities and valves healthy. The sac of the pericar¬
dium contained almost three ounces of clear serous fluid,
and the two layers were roughened, and on the anterior
aspect of the heart were adherent to, though easily separ¬
able from, each other. The liver weighed fifty ounces, and was
fatty; the spleen (8itoz.) was hard and dark coloured, and
the right and left kidneys weighed fijoz. and S^oz. re¬
spectively. The capsules were firmly adherent, kidney
substance sclerosed, and the right one exhibited a cica¬
trix, the result of a former embolism. There was
thrombosis of the right internal and common iliac veins.
In both arms was a high division of the brachial, and
the two radials were unusually small, accounting perhaps
for the feebleness of the pulse at the wrist. The ulnars
also appeared to be of somewhat smaller calibre than
usual. The left vertebral, as stated elsewhere, took
its origin from the arch of the aorta between the common
carotid and subclavian arteries of that side. An examina¬
tion of the vessels of the inferior extremities was, for reasons
of expediency, not made, nor was the examination of the
brain detailed.
PATHOLOGICAL SOCIETY OF LONDON.
Melano-mycosis of SJcin. — Micro-organism of Diphtheria .—
Acute Epiphysitis.—Gummatous Meningitis. —-Guinma
of Heart.—Tuberculosis of Mediastinal Glands invading
Lung.
An ordinary meeting of this Society was held on
May 6th, Dr. W. H. Dickinson, President, in the chair.
Dr. S. Del^pine read a paper on Melano-mycosis of
the Skin, with microscopical and macroscopical preparations
exhibiting the fungus in the tissues and a number of cultiva¬
tions showing the influence of temperature on the growth
of aspergillus niger. The case from which the original
fungus was obtained was a man with a fractured thigh who
went to St. George’s Hospital, where the limb was fixed
in the usual way with strapping. When the strapping was
removed the skin beneath it was found in two places to be
covered with brownish-black dust; in the centre of each
of these patches there was an ulcer, around which the skin
was moist and the cuticle peeled off easily. This black
dust was found to consist of spore-like bodies somewhat
smaller than, but otherwise closely resembling, the red blood-
corpuscles. Some of this was sown on glycerine and on agar-
agar, with the result of producing typical aspergillus niger
growths. After giving the history of pathogenic moulds, he
detailed the results ot inoculation with tho spores obtained
in the present case. The experiments were performed by Dr.
Woodhead, who inoculated the anterior chamber of the
eye and the peritoneal cavity of a rabbit, with the result
that in less than forty-eight hours after inoculation there
was distinct inflammation of the eye, and there were
tubercles of various sizes along the course of the lymphatics
in the peritoneal cavity. These tubercles contained nests
of spores, some germinating, others simply crenated. He
also mentioned that he bad grown an aspergillus, the spores
of which had been removed from the ear of a woman by
Mr. Bull. He had chosen for experiment aspergillus nigeir,
because of its slight pathogenic power, to study the changes,
fermentations, &c., which occurred iu the nutrient medid
in which it was grown. He suggested that amylolytit
fermentative power and hydrolytic action were inherent
properties of all living protoplasm. During his researches
be discovered that when the filaments of mycelium came to
the surface, they had the power of altering the media ini
which soluble lime salts were dissolved into fluids from
which oxalate of lime was precipitated.
Dr. Albert Wilson read a paper on the Micro-organism
of Diphtheria, with experimental results iu animals. He
referred first to the loose way in which the term“diph-
theritic” had been used; it been employed to cover cases
of sore-throat not of true diphtheritic character. He then
reviewed some of the recent researches into the nature ci
the disease, dealing especially with the investigations of
Dr. Klein, which he criticised adversely, as in the inocula¬
tions into animals Dr. Klein bad failed to produce lesions
in the pharynx or larynx, nor did paralysis result. H®
next dealt with the experiments he bad himself performed.
He showed that in ordinary cases of diphtheria a thin grey
exudation preceded the membrane formation, and this exu'-
dation he believed contained the causative micro-organism.
He inoculated tubes, and there first appeared a funnel-
shaped depression iu the gelatine, followed by liquefaction
and the formation of an orange-coloured deposit. The germ
present proved on examination to be a pure cultivation of
a small micrococcus. Pigeons were inoculated from this, and
in them true diphtheria was produced, they having both
membrane exudation and paralysis. As to the influence of
chemicals, the organisms grew best in a neutral or faintly
alkaline medium, and acids were injurious to their growth.
Growth was prevented by a 2 per cent, solution of boracic
acid, a 5 per cent, solution of salicylate of soda, a 2 per
cent, solution of peroxide of hydrogen, a 5 per cent, solutio:#
of hydrochloric acid, a 2 pet cent, solution of liq^uor ferri
pereWor., a 1 per cent, solution of lactic acid, a solution of
corrosive sublimate 1 in 5000, and a solution of iodine of 1 in
500. On the other hand, it was found that a 10 per cent,
solution of chlorate of potash, a 20 per cent, solution ci
permanganate of potash, and a similar strength of sulpho-
carbolate of sodium were useless in preventing growth. A
solution of sulphurous acid of 5 per cent, was also useless,
probably because of its volatility. He added, in conclusion,
that diphtheria was primarily a constitutional disease, of
which the local manifestation was the throat affection
hence the importance of internal remedies combined with
local treatment. For the latter chlorate and permanganate
of potash should be banished in favour of hydrochloric,
lactic, and boracic acids, salicylates, and hydrogen peroxide.
The administration by injection of pilocarpin in doses of
gr. he had found very useful iu loosening membrane.—Dr.
vViLLiAM Hunter asked where the injections were made.
He referred to the recent researches of Roux and Yersin in
France, and of Brieger, Fraenkel, and Behring in Germany,
with regard to LoIIler’s bacillus. They had cultivated this
micro-organism, filtered the pure cultures, and injected the
filtrate which was free from bacilli. In this way they had
P roduced the disease in animals with resulting paralysis,
t appeared to him that diphtheria was really the result of
a mixed infection.—Dr. Wilson, in reply, said that the
inoculation bed been made into the skin under the pectoral
muscles. He believed that after inoculations with LoHler^s
bacillus no throat symptoms had been produced.
Mr. W. H. Battle showed specimens of Epiphysitis
obtained from long bones in infants under one year of age,
with disease at one or both articular ends. The accom¬
panying suppuration took place in the contiguous joint
but once in the immediately adjacent soft tissues. The
The Lancet,]
PATHOLOGICAL SOCIETY OF LONDON.
[May 9,1891. 1043
'disease had apparently in every instance started at the
^nd of the diapbysis, the epiphysis was only secondarily
alTected, and was in no case completely separated from the
diapbysis. The superlicial opening of the suppuration did
cot correspond in size with the cavity of the ulcer, the
interior of which was filled with pus, and there were granu¬
lations on the wall. In one specimen there was also con¬
siderable destruction of the cartilage covering the epiphysis,
hut in this case it was impossible to say definitely if there
&ad been any primary disease of the epiphysis. In only
one of the patients was there any evidence of congenital
syphilis, and there was no clear history of inj ury in any of the
oases. The author had examined a series of similar specimens
At the Hospital for Sick Children, Great Ormond-street,
And elsewhere, and he held that the specimens supported
the following conclusions with regard to the disease:
1. That it was essentially an osteo-myelitis of the very
vascular growing end of the diapbysis, of the long bones
of the extremities, the characters of which were simply
modified by the conditions of the bones in very young
children. 2. Although the disease usually commenced in
the growing end of the diaphysis, it might affect the epi¬
physis primarily, but usually extended towards it from
the commoner starting-point in the diaphysis, and caused
secondary changes ending in the partial or complete
destruction of the epiphysis. As in later life, the whole
of the diaphysis might be destroyed; this was, however,
rare. 3. That the disease was not a pyremic condition,
properly speaking, for although the lesions might be
multiple, they were confined to the bones in the first
instance, and the suppuration in the joint was dependent
on the bursting of a local abscess into the joint, and was
not the result of a pymmic infection. The patients usually
died from exhaustion, and if there was any coexisting
internal inllammation, such as a pneumonia, it did not
present the characters of inilamnlation due to pyremic
infarcts. The percentage of recoveries was much higher
under appropriatis treatment than that obtaining in pymmia.
4. The Doues which are most commonly affected were the
femur and humerus ; in the former, both articular ends ; in
the latter, the upper one. 5. The disease might give rise to
pyremia, as osteo-myelitis at a later period of life might do.
6. The acute arthritis of infants was a condition of joint
which might result from several causes, of which the form
of osteo-myelitis (under consideration) and pycemia were
the most common. Localised osteo-myelitis must not be
excluded as a possible cause for an acute arthritis until
sections of the articular ends of the bones forming the joint
had been made, and its absence thus proved, for the open¬
ing by means of which pus escaped into the joint was some¬
times very minute, and might escape observation.—Mr.
Macnamara agreed with the author’s conclusions. In
very young children the epiphysis was more commonly
affected than the diaphysis, while later the diapbysis was
first attacked. The great practical lesson to be learnt from
these cases was to cut down early in all doubtful iustances,
so as to save the joint, and prevent death from pymmia.-—
Mr. Bbodie had seen a child aged seven weeks, in wWh
the whole of the upper end of the femur had been destroyed
in a very short time.—Mr. Jonathan Hutchinson, jan.,
referred to a case of epiphysitis over the lower end of the
tibia in which, after incision, a cure resulted.—Mr. Stephen
Paget asked the author where he thought the lesion began
in the ordinary syphilitic epiphysitis of children.—Dr. J. J.
Clarke considereu that the cases of epiphysitis which ran
on to pyremia resembled cases of general tuberculosis
following a local deposit. He did not regard all secondary
pyiomic abscesses as infarcts, bub thought they might be
induced by the in ibation of micro-organisms.—Mr. Battle,
in reply, said that the disease appeared to start, both in
eyphilibicand non-syphilitic cases, in the growing end of the
diaphysis, where the vascular changes were most intense.
The osteo-myelitis was not of itself a pycomia, but it might
give rise to that disease.
Dr. Newton Pitt showed for Dr. Cuff a specimen of
Extensive Chronic Gummatous Meningitis of five years’
duration. Since 1884 or 1885 the patient had had frequent
attacks of intense pain over the left temporal bone culmi¬
nating in general convulsions without unconsciousness.
Their frequency had been variable, bub he had never been
two months free from attacks. He was first seen by Dr.
Cuff in 1887, when he was very emaciated; when he
attempted to walk he reeled about; no paresis of the limbs
could be detected; he had as many as thirty attacks
daily. There were old adhesions from iritis in the left eye,
with commencing optic neuritis. He improved greatly
upon large doses of iodide of potassium, and six months later
be had an average of two fibs daily. There was still
intense temporal pain, and the optic neuritis was double;
his visiou was After some time he had left-sided
epileptiform convulsions lasting- for a minute or so,
followed by a hysterical condition; the loss of conscious¬
ness was very transient. He was under the care of Dr. Pitt
in Guy’s Hospital for seven weeks in 1889, during which
time he had three attacks of left-sided twitching, followed by
a highly hysterical condition. At the necropsy a year later
the dura mater adhered over the whole of the right side,
there was a fibro-caseous gummatous thickening over the
angular, supra-marginal and the central portions of the
ascending and frontal convolutions. The cortex of the
two former were severely infiltrated and there were a few
spots in the lower part of the ascending convolutions. The
long duration of the disease and its wide distribution were
the features of interest; also the fact that in 1889, with
the exception of occasional attacks, there were no physical
signs except partial optic atrophy and a unilateral hemiopia.
Dr. Pitt also showed a specimen of Gumma of the Heart.
The patient, a man aged twenty-eight, fell down at work
and died. At the inspection a diffuse gummatous infiltra¬
tion involved the posterior part of the septum and the
musculi papillares of the mitral valve, which were much
enlarged. A gummatous mass at the apex of the left
ventricle had yielded and formed an aneurysm, which had
ruptured into the pericardium. There was another gumma
on the surface of the right ventricle. The aorta was
atheromatous, and the testicles fibroid. The case was
similar to one described by Dr. Goodharb in the Trans¬
actions for 1887, but the condition was a very rare one.
The patient, till the time of his death, had been able to
work hard without inconvenience.—Mr. F. S. Eve had mete
with a precisely similar specimen.
Dr. Arthur Voelcker read notes of three cases, and
showed the specimens illustrating the involvement of the
lung by caseous bronchial glands. The cases had all
occurred in the Hospital for Sick Children, Great Ormond-
street. In the first case, a child aged ten months had a
strong tubercular history. At the necropsy a large msiaa of
caseous glands was found above the left bronchus, and a
cavity the size of a walnut was found in the left upper
lobe, in direct continuity with the caseous gland. In the
second case, in a patient aged nineteen months, a cavity in
the right lower lobe of the lung was in relation to a caseous
chain of glands extending from the roof of the right lung.
The third case occurred in a child aged twenty-three
months. The middle lobe of the right lung was converted
into a caseous mass, as the result of the ulceration of a
caseous gland into the bronchus leading to it. Dr. Voelcker
remarked that, although caseous glands were frequently
found extending far into the lung, these were merely the
pulmonary glands which existed normally and which had
become caseous. His cases differed from these in the fact
that in his cases the lung tissue appeared to be destroyed
by the invasion of the caseous glands. He remarked on the
frequency of caseous bronchial glands in children, having
found them in 110 cases in tbe last 300 necropsies he
had made at the Children’s Hospital, and expressed
a doubt as to their occurrence apart from some tuber¬
cular affection either of the lung or some other pare.
He also urged that the relation of the glands to
the lung lesion, its particular distribution, and tbe fact
that the glands become caseous often without any casea¬
tion in the lung, made him regard the destruction of lung
lesion as secondary to the gland changes. It was striking
that all three cases were under two years of age.—Dr.
Payne said that these cases showed that tubercular disease
was commoner in very young children than was supposed.
It would be interesting to search systematically for the
disease still earlier, for it had been maintained that the
di-sease might be congenital. Fmtal tuberculosis was not
unknown in calves.—^r. Walter Carr said that at the
Victoria Hospital for Children he bad met with ten cases in
which it appeared that the disease in tbe lung started from
tubercular glands; of these, seven were under three years
of age. He had not met with any cases in very young
children in which tubercular lesions existed in the pulmonary
apices.—Dr. Voelcker, in reply, referred to a necropsy he
had made on a child only three months old, in whom
there was extensive tubercular disease of the lungs and
1044 T9B Lancet,]
SOCIETY OF MEDICAL OFFICERS OF HEALTH.
[May 9,1891.
bronchial-glands. His experience was that cavities were
not unusual in children, and caseous masses might be
scattered through the lung independently of tubercular
masses lying at the root.
The following card specimens were shown:—
Mr. A. Doran : Hydronephrosis ; Nephrectomy.
Mr. J. H. Targett : Symmetrical Hemiatrophy of
Grastrocnemius.
Dr. H. D. Rollbston : Necrosis of Skull Cap; Fracture
of First Rib.
Mr. S. G. Shastock : (1) Bilharzia, Bladder; (2) Heart
with Biiid Apex.
Mr. L. A. Dunn : (1) Ossifying Epulis of Lower Jaw ;
(2) Defective Development of Lower Jaw.
Mr. Raymond Johnson : (1) Vesical Calculi with
threads from Catheter as Nuclei; (2) Nasal Calculus ;
(3) Cystic Horseshoe Kidney in a ease of Spina Bifida.
SOCIETY OF MEDICAL OFFICERS OF HEALTH.
Infectious Diseases Notification Act.
A MEETING of this Society was held on April 10th,
H. E. Armstrong, President, in the chair.
The evening was devoted to the discussion of questions
connected with the working of the Infectious Diseases
Notification Act. The discussion, in which several pre¬
sent and past officers of the Asylums Board took part,
brought out clearly that no new powers were conferred by
the Notification Act, compulsory removal being possible
only under Section 124 of the Public Health Act, 1875, by an
order from a magistrate; that admission to such a hospital
did not pauperise, even though the Board should remit the
payment they were entitled to recover; that no patient
was taken iu without a medical certificate, except in the
case of children brought by their parents, or such as pre¬
sented themselves at the doors, when the medical officer
would certify from his own examination; and that though
occasionally patients were admitted in a moribund condi¬
tion, the medical attendant might certify that a patient was
not in a fit condition for removal; while the nurses who
came with the ambulance bad strict orders to call in a
medical man if it appeared to them that removal might
endanger the patient’s life. The question of including
measles among the diseases to be notified gave rise
to an animated discussion. Messrs. Bernals, Whitaker,
and Lovett opposed it on the grounds of expense,
of BO many cases not being seen by any medical mao,
and of the prejudice which they feared sucii a course
would create against the Act in general. Dr. Willoughby
supported it, since no disease so seriously allected school
attendance. The chief end of notification would be, he urged,
attained irrespective of hospital treatment. Diagnosis
being so easy and concealment almost impossible, the
parents could scarcely fail to notify. If any difficulty
were found to arise, it might be solved by devolving the
administration on the School Boards and managers, an
alternative which Mr. Bemajs and other dissentients
approved. Several members urged that the grave
results of measles among the poor justified the admis¬
sion of severe cases to the hospitals. The President
insisted that in a matter of such importance to the public
welfare the question of expense should not be enter¬
tained, for the absolute mortality from measles far exceeded
that from any other infectious disease. The dual system
met the alleged difficulty arising from the general absence
of medical attendance, the sole reason why househoiders
did nob now notify being that in the diseases at present
scheduled medical advice was always sought. On every
ground he strongly urged the inclusion of measles. The
further consideration of this question was adjourned.
Drs. Thresh and Reid, Messrs. Bernays, Milsom, and others,
thought that the notification of erysipelas was needless,
the cases reported being few, and many of these probably
only erythema. Dr. Gibbon, on the other hand, held
that it was one of the most dangerous of infectious diseases,
allied in its origin to diphtheria and puerperal fever. In this
Dr. Willoughby concurred, denying the existence of so-called
idiopathic cases, which he believed to arise from the access
of the microbes to some slight abrasion unnoticed, but dis¬
coverable byoareful inquiry. Erysipelas was an infective
disease, always traumatic, and mostly, though not invari'
ably connected with insanitary conditions. The majority
present were, however, adverse to the retention of erysipelae
in the schedule. The expediency of rendering the adop¬
tion of the Act compulsory on all sanitary authorities
M'as affirmed unanimomly, and almost without discussion.
The President insisted on the question of notification and
of hospital provision being kept distinct, and that only
by notification could the prevalence of a disease and the
extent of hospital accommodation required be ascertained i.
while Dr. Willoughby maintained that since the one
belonged to the domain of preventive and the other to that
of curative medicine, their aims were not in all respects the
same, and that notification alone might in the case of some
diseases, as measles, be productive of the greatest good.
MIDLAND MEDICAL SOCIETY.
A MEETING of this Society was held on April Ist,
Mr. A. Messiter, President, iu the chair.
Aphemia of Nine Months' Duration cured by Hypnotism .—
Dr. Stacey showed this patient again. When before thie
Society some weeks ago he was quite unable to speak. Now
he was able to do so without difficulty.
Specimens. —Mr. Messiter showed; 1. A Typical Oxalate
of Lime Calculus, successfully removed. 2. A specimen of
Compound Fracture and Dislocation of Vertebra; the
injury had been cub down upon, and several of the pro¬
cesses of the vertebra removed, but the fragments were
firmly locked, and could not be reduced. The patient lived
for over a week after the operation.—Mr. Christopher
Martin showed a Sarcoma of the Ovary.
Paralysis of the Larynx. —Mr. BarlING showed a case
of double abductor paralysis of the larynx in a girl of
twenty, apparently a hysterical condition grafted on to a.
slight catarrhal laryngitis. The respirations had been as
rapid as 50, and nearly a year ago tracheotomy was per¬
formed for very severe dyspnoea occurring at night. With
faradaisin and tonics there was subsequent recovery' of
the abductor function, bub this failed again later, and
at the present time the patient is nearly as bad as
ever. The present treatment is by tonics, faradaism to
the neck, and occasional intubation, slow improvement
resulting.
Hydatidiform Mole. — Mr. J. ROUND showed this
specimen ; it consisted of an ovum about two months old,
with a hydatidiform mole attached. The patient froira
whom the specimen was taken was a primipara, who had
been under treatment for antemia, which had existed during
nearly the whole of her married life. After the mole was*
removed the patient had no bad symptom except a most
fetid discharge, which yielded readily to injections with a.
solution of Condy’s fluid.
Dr. Short read a paper on the Action of Urethan, Sul -
phonal, and Paraldehyde, clinically illustrated.
ROYAL ACADEMY OF MEDICINE IN IRELAND,
A MEETING of the Obstetrical Section was held on
March 13th.
Subperitoneal Myoma of the Uterus. —Mr. 0’Cali.aghan
exhibited a subperitoneal myoma of the uterus, removed
from a patient aged thirty-five. Hiemorrhago was easily
controlled by deep stitches; the edges of the capsule were
turned in and united by an uninterrupted suture, a
Kccberlc’s drain was introduced, and the patient made a
perfect recovery. Mr. O’Callaghan also showed a fibro-cystic
tumour of the uterus, which weighed 24 lb. In this-
case, after progressing favourably for five days, com¬
plete obstruction of the bowel took place, owing to con¬
striction of the colon by dragging of the pedicle. He re¬
opened the wound and performed a median colotomy, bub
the patient sank soon after. Mr. O’Callaghan also exlubited
a submucous fibroid of the uterus. Afterdiiatingtheuterus
with Tait’s dilators, he made an incision around the
base of the fibroid and enucleated it successfully. Good
recovery.
New Instruments for Intra-uterine Worlc. —Dr. More,
Madden gave an account of a new roller pessary, and
also exhibited a new instrument for intra-uterine work.
Coogle
The Lanoet,]
NOTICES OF BOOKS,
[May 9,1891. IC45
combioiDg the action of the ordinary curette with that of
a tenaculum. In this instrument the desired action, either
as a curette or as a tenaculum, can be exactly and easily
regulated and directed from without by a peculiar form of
screw adjustment worked from the handle.
Endo-uterine Therapeutics —Dr. More Madden read a
paper on this subject. With regard to the methods of
modern uterine treatment and the conditions by which
this is called for, the author’s observations are founded on
a clinical experience extending over many years, and
embracing upwards of 10,000 gyntecological cases treated
in hie wards or in the extern department of the Mater
Misericordim Hospital, Dublin. Of the cases admitted into
those wards during the last fifteen years, endo-uterine treat¬
ment was found necessary in 35 per cent. The two essential
points in all such treatment are, first, that the orifice and
cavity of the uterus, if not already sufficiently dilated,
should be mechanically expanded; and, secondly, that what¬
ever application is resorted to should be brought into direct
contact) with the diseased endometrium. For the first pur-
oae the slow, painful, and hazardous methods of dilatation
y sponge or laminaria tents have been long abandoned by
Dr. More Madden, who employs in their stead the rapid cer¬
vical dilator which Messrs, Arnold havebrought out in accord¬
ance with his suggestion, and wliich he finds more eft'ective
and quicker in ics action than Hegar’s or other similar
dilators. The second object is especially necessary as a
preliminary to endo-uterine treatment in cases of congestive
hypertrophy and chronic subinvolution, in which the lining
membrane of the uterus is commonly overlaid by an im¬
pervious pseudo-membranous albuminoid neoplasm evolved
from the proliferating cilia of the diseased surface. Or
else the endometrium, in many cases, is so thickly bathed
in the tenacious morbid secretion therefrom, as effectually to
protect the underlining tissues from the action of any re¬
medial agent introduced into the uterine cavity until that
pseudo-membrane and secretion are removed by the curette.
For these objects Dr. More Madden recommends, first, the
use of Duke’s cervical curette to cleanse out the entrance
to the womb; and, secondly, the employment of his own
adjustable uterine curette, by which the endometrium may
be thoroughly denuded, and at the same time by the
hicmorrhagic discharge thus occasioned the congestion of
the hypermmio and hypertrophied organ may be most
effectually relieved. In the treatment of subinvolution the
author advocates the introduction, in some instances, of a
small tampon saturated in a combination of tannic acid
and turpentine, which he terms “ tanno-terebinth.” This
acts as an immediate stimulant and astringent on the uterine
structures, and in suitable cases is allowed to remain in the
cavity from twelve to twenty-four hours, unless sooner
expelled from the then generally much contracted uterus.
The vaginal glycerine saturated tampon commonly employed
in cases of this kind, although unquestionably serviceable
in many instances, is messy and troublesome in its use both
to patient and praciitionev, and hence for some time past
Dr. Madden has generally adopted the boric acid, or “dry
treatment,” recommended recently by Dr. Duke, and which
he has found generally very satisfactory as a substitute for
the older method of treatment. He also strongly depre¬
cates the employment of the ordinary syphon syringe
for any endo-uterine purpose, and believes thkt this
should be replaced by an irrigator such as the one
he suggested many years ago, and which, having been
since appropriated by others, without any acknowledg¬
ment, is depicted in the paper of which this is an abstract.
The foregoing measures must, however, be supplemented by
more active agents in those more serious cases of long¬
standing, fundal, or corporeal endometritis and subinvolu¬
tion in which the disintegrated and eroded endo-utevine
mucous membrane becomes the seat of various pathological
changes, extending to the submucous structures and
utricular glands, and often associated with those .so.called
fungosities resembling papillary epithelioma, whieh if
unchecked may ultimately degenerate into that condition.
In such cases it is that the cautery, actual or potential—
the first in the form of igni-puncture, and the latter in the
shape of the stronger caustics, aci<l, nitrate of mercury,
fuming nitric acid, or chromic acid, &c.—may be justifiably
resorted to in endo-uterine treatment. In conclusion. Dr.
More Madden brielly details tlie result of his clinical expe¬
rience of these various applications, the circumstances that
indicate their use, the dangers that may attend their abuse,
and the methods of their employment.
of ^ooy.
Bacteriological Technology for Pkysicianst uoith seventy-
two Figures. By Dr. C. J. Salomonsen. Translated by
William Trelease from the Second Revised Danish
Edition. New York: William Wood & Co. 1890.—It is
the fault of most works on bacteria that they are written
by men who have worked only in large laboratories, and
who have been accustomed to find everything they might
‘require ready to hand. Such authors have followed oht the
methods in use in the special schools in which they haYe
been trained, and the consequence is that we have
elaborate treatises on the special methods adopted by Koch
or on the Pasteurian methods, the one being fully
expounded, but very little reference being made to the
other. In the hook before us, however, we have an
admirable compendium of most of the methods that
are used in bacteriological work. Such a work, based
as it is upon personal observation and experience, cannot
but be useful to all who are interested in the study of
bacteriological technicology, and to those who wish to engage
in the examination and cultivation of micro organisms in
their own private laboratories, and with comparatively small
outlay, this little book will prove invaluable. The author
does not attempt to give elaborate descriptions of the
various micro-organisms, nor does he add much extraneous
matter in setting forth the methods and apparatus that are
used in bacteriological investigation; but in terse and lucid
terms he explains the simplest and most easily managed
apparatus and methods of cultivating, aerobically and
anaerobically, of examining bacteria, of sterilising appa¬
ratus, of separating bacteria from their products by filtration,
of disinfecting clothing, and of making pure cultivations. All
these general methods ate treated pretty fully, and simple
and inexpensive apparatus by means of which they may be
carried out are suggested. The special methods of examina¬
tion of air, water, and soil are also well described, as are,
indeed, most of those operations that come within the
range of the bacteriologist. From a careful study of the
work, which is apparently based on the author’s own ex¬
perience and observation, we feel that it is undoubtedly the
beat of its kind (taking size into consideration) that has yet
appeared on this subject. Hueppe’s work on Bacteria
approaches it more nearly than any other, but it is very
much larger, and is in some parts so theoretical, though
always suggestive, that it sometimes loses its value as a
reference book for the practical worker. A little book
of this kind, showing the simplicity of most of the
methods, and the cheapness of the essential apparatus,
will do more to advance the study of bacteria amongst
medical men and veterinary surgeons than all the elabo¬
rate text books put together. Dr. Salomonsen has been
fortunate in his translator, who has placed before English
readers an account of bacteriological methods, and of
methods of sterilising bedding, clothing and furniture (to
which a special chapter is devoted) which should prove of
very great value indeed. This work first appeared in
English in Wood’s “Medical Library,” but is now pub¬
lished in separate form, and should have a much wider
circulation than it has hitherto enjoyed. It is well printed,
and the illustrations, though not finished in the very highest
style, are all of them good.
The Microtomist's Vade Mccum. By Arthur Bolles Lee,
SecondEdition. London: J. & A. Churchill. 1890. Pp.‘fl3,—
Those who wish to acquire a knowledge of the various
methods by which sections can be cut, stained, and mounted
cannot do better than purchase this work. It gives the
most recent information on the best dyes and their manner
of application, precise directions as to hardening and eni-
1016 The Lancet,]
NEW INVENTIONS.
[May 0,1891.
bedding, aad the most approved modes of preserving speci¬
mens. The author has tried everything, and gives the
reader the benefit of his large experience. We give an
example of the mode in which he writes by inserting a
xeoapitulatioD of the paraffin method, as recommended to
be practised: “Put into a small test tube enough oil of
eedar to cover your object. On to the oil pour carefully the
same quantity of absolute alcohol. Take your (already
dehydrated) object, and put it carefully into the alcohol.
Leave it until it has sunk to the bottom of the cedar oil.
Then put it into paraffin, kept at melting point in a watch
glass. Aftera timechange the paraffin (i.e., put the object
into a fresh watch-glass with clean paraffin) once or
twice if the object be at all large. As soon as the object is
thoroughly soaked with paraffin, float the watch glass on
cold water. When cool cut out a block of paraffin contain¬
ing the object, and fix it with a heated needle on a cone of
paraffin already mounted on the object carrier of the micro¬
tome. Pare it square, and as close down i;o the object on
all sides except the one turned towards the knife. This
bad better have a wall a millimetre or two or more, accord¬
ing to the size of the object, left standing. Set the knife
square; set the block square to the knife edge. Cut sec¬
tions in chains or ribbons, collodionising them if necessary.
Mount them in serial order on a slide prepared with
Scbaellibaum’s collodion or Mayer’s albumin. Warm, and
remove the paraffin with naphtha.” Schaellibaum’d
eollodion is on another page explained to be a mixture of
©ne part of collodion and three to four volumes (according
to the consistence of the collodion) of clove or lavender
oil, and directions are given for using it. In regard
to microtomes, Mr. Bolles Lee prefers the Thoma
sliding one, the Becker microtome, and the Cambridge ;
socking microtome. Capital chapters are devoted to
cements and varnishes and to injections. He gives
the composition and mode of using nearly forty kinds
©f injection material recommended by Gerlach, Thiersch,
Hoyer, Davies, Fol, Bobin, Ilanvier, Briieke, and others.
The book is also especially adapted for the working
naturalist, who will find in it the exact account of such
methods as those of v. Beneden for the fixation of the
tunlcates, gasteropoda, arthropods, vermes, and protozoa.
A valuable feature of the book is the excellent bibliography.
Nearly every process has a reference to the original paper.
Mr. Bolles Lse has succeeded in producing a very useful
book.
Lehrhuch der Physiologisohemmd Patkologischen Chemie.
Von Professor G. Bunob. Leipzig: F. C. W. Vogel.—The
amount of chemistry found in physiological and patho¬
logical text books Is sufficient for the needs of most
students, but for purposes of deeper study and research
some larger treatise is necessary. Not many of such books
are to be found, and Professor Bunge s work can be heartily
lecommended to such as wish to make a closer acquaintance
with physiological and pathological chemistry. Though
Bot an exhaustive treatise, as the author states in his pre¬
face, it contains a vast amount of information, clearly
stated and without the superabundance of complicated
formulft which fill so many pages of similar works.
This book consists of twenty-one lectures, the physio¬
logical and pathological portions being not taken in
separate lectures (with tbe exception of the one on
diabetes mellitus), but being considered together—
by far the most convenient method. One of tbe most in¬
teresting lectures is that on “ferments” in reference to
digestion. The function of the pancreas, of course, leads
ap to this subject, and we find the whole matter dealt with
in a thoroughly practical manner. There is much that is
new in this chapter, especially with regard to “unformed
ferments,” and to the action of ferments at different tem¬
peratures. The section on coagulation of the blood hardly
comes up to the excellence of tbe rest of the work, and we
are surprised that so little reference is made to Wooldridge’s
' important researches on this subject, although Professor
Bunge quotes freely from most of the other authorities. The
hook concludes with a lecture on diabetes mellitus. The
author assumes at once that glycosuria is due to an increase
Qf sugar in the blood, brought about by the wonted destruc¬
tion of sugar not taking place as usual, and thus gradually
producing an accumulation. He brings forward many argu¬
ments in support of this view, but disposes of the alterna¬
tive theory—that this condition may be due to an increased
production of sugar—by saying, “This proposition is not
maintainable,” and in a few lines explains this rather arbi¬
trary statement by showing that the quantity of food taken
is inadequate to account for the excess of sugar, and con¬
sequently we must seek elsewhere for the cause. The book,
as a whole, will well repay perusal, and for the sake of those
who have not been able to acquire a sufficient knowledge of
German to read in that language with ease, we should like
to see the work translated into English.
A Series of Chemical Problems, with Key, for use in
Colleges and Schools. By T. E. Thorpe, B.So. Viet., Ph.D.,
F.H.S. Revised and enlarged by W. Tate, Assoc. N.S S.
(Honours), F.C.S. New Edition. Loudon: Macmillan and
Co. 1891.—This is another edition of Professor Thorpe’s
brochure, vffiich might well be called the Barnard Smith
or Colenso of chemical arithmetic. The problems are
carefully chosen, and the examples which precede them
clearly explained. Useful data, including the atomic
weights, a table of logarithms, and certain constants are
given in the appendix. Sir Henry lloscoe has written that
by no method can accuracy in a knowledge of chemistry be
more surely secured than by attention to the working of
well-selected problems. If this be so, and we do not demur,
both teachers and students of tbe science will do well to
secure a copy of the new edition of chemical problems,
which has been revised and enlarged by Professor Thorpe’s
colleague Mr. Tate.
2'he Comparative Clim'itology of London and the Chief
EnglishllealthPesorfs. ByBEUTRAMTiiORNTON.M.E.C.S ,
L.R.C.P. London: H. K. Lewis. 1891. Pp. 15 (reprinted
from Ti-iE Lancet).— The writer has expanded bis contribu¬
tion to our pages, and added some tables of mean tempera¬
tures and humidity. The former will cause some surprise
at the slight difference between places reputed to be warm
or cold. This pamphlet reminds us of Pettenkofer’s remark
that “we do not go for change of air, but for change of
soilindeed, it is a study of the comparative geology of
health resorts that is really wanted, the soil determining
humidity, radiation, evaporation, and a host of factors
constituting the “climate ” of a place.
ftjto |nfeit&ns.
AN IMPROVED IRRIGATOR REGULATOR.
The instrument illustrated, originally designed by me,
and modified by Mr. F. W. Parker, formerly house surgeon
at St. George’s Hospital, was made by Messrs. C. Wright
and Co,, 108, New Bond-street. I have employed it constantly
for several years at St. George’s Hospital and at the Belgravn
Hospital for Children. It consists of a conveniently shaped
ebony handle. A, through which a length of indiarubber tubing
passes. A length of eight or ten feet of tubing, attached to
tbe glass-elbowed tube, E, connects the handle with a cistern
irrigator. Simple pressure on the thumb-lever, li, regulates
the How of solution used, and on removal of pressure the fiow
is automatically checked by the indiarubber bands. The
Digitized by
Google
The Lancet,]
NEW INVENTIONS.
[May 9, 1891. 1047
handle is provided with a conical glass nozzle, c, for
washing out cavities &c., and a glass rose-bead, D, which is
connected to it by a short piece of rubber tubing; the
nozzles and rose-beads are made in white and ruby coloured
frlass, one being used in dealing with abscess cavities, whilst
the others are used for ordinary wounds. I have always
found that the spray (which is now, 1 suppose, generally
tioDs without once touching the wound with a sponge,
merely washing away the blood ; in the case of children
this method is especially valuable. The instrument is
cheap, light, easily kept perfectly clean, and not at all
liable to get out of order. The cistern or reservoir i*
made of tin, japanned, covered with thick felt as the
means of retaining the necessary heat, and should!
discarded), while otherwise harmless, had the great dis¬
advantage of chilling the wound, and for that reason it is
my practice, by means of this instrument, to irrigate with
hot antiseptic fluids during the whole of an operation, partly
to keep the wound aseptic, and partly to keep it warm.
The rose-head is used for irrigation, and £ have not in¬
frequently performed amputations and such like opera-
hold about two gallons; glass vessels are liable to crack
when filled with solution heated to 102® F., which I
have found to be the best temperature; the requisite
pressure is obtained by raising the cistern, which at
St. George’s Hospital is aceomplUhed^by a pulley and
cord.
Brook-street, W. CLINTON T. Dent, F.R.C.S.
NOTE ON A SIMPLE ASEPTIC HYPODERMIC
SYRINGE.
The principal advantages of Dr. Koch’s well-known
syringe are that there is no piston plug to become con¬
taminated, and that the syringe can be easily maintained
in a perfectly aseptic condition. During a somewhat ex¬
tensive experience in its use, however, I have found certain
drawbacks, of which the chief is the necessity for the
operator to use both his hands, one to keep up the pressure
on the elastic ball, the other to turn the stopcock, while
the needle is meanwhile left to look after itself, and
possibly to become wriggled out by a young and restless
patient, or loosened from the nozz'e of the tube. The
apparatus, moreover, is in three distinct parts, and I have
more than once seen the whole come to pieces during an
operation, and an indefinite amount of iujeotion lost.
I may also remark that many of the Koch syringes
imported from Germany are not only badly fitted but are
inaccurately graduated. Two obtained from a German
firm, and marked on the case “ Dr. Koch’s Official Syringe,”
were found to be imperfect, and one purchased for me by a
friend in Berlin actually has the supposed cubic centi
metre divided into eleven instead of ten parts, although
the usual numbers “5” and “10” are engraved on
the glass. It occurred to me that a simple syringe might
be devised which could be easily kept aseptic, and
could be worked by one hand, leaving the operator’s
other band free to manipulate the needle and the skis
in the neighbourhood. I have bad such an instrument
made by Messrs. Burroughs, Wellcome, and Co., which
appears to answer all requirements, and 1 have now been
using one constantly for six weeks. The glass tube is
somewhat similar to that of Dr. Koch’s syringe, but longer,
and carefully graduated to deliver 1-5 cm. In place of the
elastic ball there is an asbestos piston, which can be kept
THE SIMPLE ASEPTIC SYRINGE.
aseptic either by heat, or more conveniently by frequent
rinsing in absolute alcohol. The asbestos can be tightened
up by a screw arrangement in the piston rod. The tube is
graduated both metrically into tenths of a cubic centimetre
and for “minims,” and the figures are engraved not upside
down. Id using the syringe, I always keep a layer of air
between the piston and the top of the liquid, and of coarse
wash out, before and after each injection, with absolute
alcohol and carbolised water. P. S. Abbaham, M.D.
WHAT SHALL BK DONE WITH THE FIFTH
YEAIU-A PLEA.
To the Editors of The Lancet.
Sirs,—F or the General Medical Council to decide upon
lengthening the curriculum was a simple enough matter,
but now that the time is approaching when it becomes
necessary to give efTacb to this decision, enormous differences
of opinion are found to exist as to the best means of em¬
ploying the extra year. In your very excellent article upon
the subject (May 2od) you very rightly insist upon the im¬
portance of “ a good all-round professional education”; and,
further, that “there should be a sufficient guarantee
that the candidate is familiar with ophthalmic and
aural surgery, with febrile diseases, and the distinctive
features of psychological medicine.” It would not, of
course, be becoming for me to express any opinion as
to the relative claims of the subjects thus mentioned
by you, but I would venture to ask that at least the
“guarantee” suggested should be made to include “ anies-
thetics.” The interest which you have yourselves taken in
the subject of anresthetics emboldens me to put forward
this plea, for although the opinions expressed in your
columns may differ widely upon theoretical points and
matters of detail, yet those who have taken part in the
controversy appear to agree in thinking that students should
receive greater encouragement to study and practise the
various methods of administration employed. As the
matter at present stands, ample opportunities, both in the
shape of material and teaching power, already exist in
the majority of our schools; but, with almost pardonable
neglect, the medical student of the present day prefers to
devote his energies simply and solely to matters contained
in the official curriculum, and does not learn until after he
has qualified that “there are more things in heaven and
earth than are dreamt of” in the philosophy even of
examiners In putting forward this claim for the systematic
study and teaching of anjesthetics, I feel sure that I shall
have your powerful support, for it is hardly possible to deny
that sucli study and teaching are very essential elements di
“ a good all-round professional education.”
I am. Sirs, yours faithfully,
Weymouth-street, W., May 8t]i, 1891. J. Fredk. W. SILK.
Digitized by
Google
1048 The Lancet,]
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.
[May 9,1891.
THE LANCET.
LONDON: SATURDAY, MAY 0, 1891.
It is to be hoped that the general meeting of Fellows
and Members of the College, summoned for Monday next,
the 11th lost., at 3 P M., to consider the scheme for the re¬
constitution of the University of London, will be largely
and inhuentially attended. As this scheme, however, is
not submitted for approval or rejection, but is merely
placed before the corporate body after ratification by the
Council, it is only too probable that many who would have
been present if they had had any real control over it will
stay away, considering it to be a solemn farce to consider
that which they have no power to amend or alter. Under
a proper constitution the Fellows and Members would
naturally be consulted during the progress of the
negotiations, and not after their completion ; and
a resolution will be moved to the effect “that this
meeting regrets that the Council of the College has
not seen fit to place before the Fellows and Members
the scheme for the reconstitution of the University of
London before finally accepting the scheme in the name of
the College.” Such a motion ought to be passed unani¬
mously ; but at the College of Surgeons, where there are
many aspiring Fellows who can only become office-holders
through the goodwill of those in power, and many who are
directly interested in maintaining the present autocratic
r6gime, the most obviously reasonable resolution is liable to
have a show of opposition against it. Some therefore may
be found holding up their hands against the resolution when |
put to the meeting; but we doubt whether anyone will be !
found who will venture to speak against it, if for no other
reason than the difficulty of finding any plausible arguments
to support the other side of the question. These remarks
apply to a second resolution which it had been in contempla¬
tion to submit to the meeting. It will be found that
the scheme will considerably increase the power and in¬
fluence of the Council of the College over medical education
and examination, and it is felt by the thoughtful portion
of the constituency to be in the highest degree objection¬
able to make a practically irresponsible Council more
powerful than it is at present. Hence it was proposed to
submit a resolution to the meeting, to the effect “ that no
increase in the power and influence of the Council over
medical education and examination is desirable until the
.constitution of the College has been so amended as to make
it adequately representative of the body corporate.” When
this resolution was sent to the College it was discovered that
it would be out of order, and we believe counsel’s opinion
was taken on the subject. It will therefore be modified
so as to conclude with the words “ desirable under existing
circumstances.” Resolutions of this kind have a far-
reaching significance, and go to the very root of the
question of the reform of the constitution of the College,
and it is for this reason that we urge all Fellows and
Members favourable to constitutional progress to attend the
meeting. Some may say that the details of the scheme are
of a special and technical character which are beyond their
range of knowledge, and not of sufficient interest to the con¬
stituency at large. No greater mistake could be made. If it
should even be granted that the scheme is perfect, it would
not affect the principles involved in these resolutions, and
no special knowledge of the constitution of the University
of London or of the negotiations and discussions which
have been going on for so long a period is needed to
excite the interest of the Fellows and Members of the
College.
We doubt whether a more important meeting has ever
been summoned than that which will take place on Monday
next, for the consideration of the scheme not only opens
out, as we have just pointed out, the fundamental principles
contended for by the reforming section of the constituent
body, but will raise the question of the rights and position
of the extra-metropolitan schools of medicine and the
status of the Society of Apothecaries. The relation of the
provincial schools to the College of Surgeons is a very old
question, and any inequality of privilege between the
provincial and metropolitan schools under this scheme
would only be a remnant of the ancient monopoly, which
reserved all offices of place and profit for the surgeons at the
metropolitan hospitals. The scheme does not deal equally
with the provincial and metropolitan schools, and therefore
it was proposed that a resolution should be moved to the
following effect: “That no scheme for the establishment
of a degree-granting body in connexion with the Royal
College of Surgeors and the metropolitan medical schools
can be regarded as satisfactory which does not confer upon
all extra metropolitan schools rights, privileges, and represen¬
tation which shall be equal in all respects to those conferred
on schools within the metropolitan area.” We are not certain
whether this resolution will come before the meeting or not.
The three foregoing resolutions, if moved as intended, will
probably receive the support of the Associations of Fellows
and Members, and a fourth resolution has been submitted
to the authorities of the College by Mr. Lawson Tait, and
has been accepted as pertinent to the business of the meeting.
The resolution runs as follows: “That in theopinion of this
meeting no scheme for amalgamation with the University
of London for the granting of a medical qualification, and
no scheme for. a conjoint examination with the College of
Physicians for such or a similar purpose, can be satisfactory
so long as the Society of Apothecaiies is not included in
such scheme.” The aim of reformers of medical education
and examination has always been the reduction of qualify¬
ing examining bodies to three, one for each division of the
United Kingdom, and to secure uniformity of examinations
and equality of fees. This involved the conjunction of
existing medical and surgical licensing bodies, and it will
be remembered that the Bill introduced into Parliament
by Lord De Grey in 1870 provided for the compulsory
formation of Conjoint Examining Boards. The withdrawal
of the Bill was followed by the efforts to form conjoint
schemes in the three divisions of the kingdom under the
auspices of the General Medical Council, including the
Universities and the Societies of Apothecaries. Various
obstacles, legal and otherwise, had to be surmounted, la
Digitized by
Google
Thx Lakobt,]
MODERN VIEWS UPON IMMORTALITY.
[May 9 , 1891. 1049
the caee of the English scheme no less than three
Acts of Parliament were required—viz., an Enabling Act
for the University of London in 1873, an Act to amend the
Apothecaries Act ,in 1874, and a College of Surgeons
Enabling Act in 1875. In May, 1877, the scheme received
the sanction of the General Medical Council, and would
have come into operation on Oct. lat, 1878, but for the
introduction into Parliament of the Duke of Rich¬
mond’s Bill to amend the Medical Act of 1858. After
the failure of the Duke of Richmond’s Bill through a
change of the Government came a Select Committee of
the House of Commons in 1880, a Royal Commission in
1881, the report of the Royal Commission in 1882, and a
Bill founded on that report in 1883. When the last Bill
was withdrawn the Colleges of Physicians and Surgeons
hastened to combine, and the Apothecaries’ Society was
left out in the cold, only to assume a few years after¬
wards a higher position by being enabled to grant a
complete qualihcation in Medicine and Surgery through
the operation of the Medical Act of 1886. The Society
of Apothecaries, strong in the fact that it had been
admitted to the conjoint scheme of 1877, applied to
the Royal Colleges to be allowed to participate
in this last conjoint scheme, and in 1887 the General
Medical Council even passed a resolution affirming the
desirability of this arrangement, on the ground that it
would be contrary to the interest of the public to have
two competing examining boards sitting in London, but
the Colleges turned a deaf ear to the appeal. The evil of
having two separate and complete examining boards in
London remains, when it might have been extinguished by
the quiet absorption of the Apothecaries’ Society without
injury to the Colleges, and with great advantage to the
public and to the profession. Doubtless, it was thought
that the exclusion of the Society would lead to its death by
inanition as a medical authority, but the qualification is so
cheap and accessible that this policy has failed. We regard
now, as previously, the omission of the Society as a grave
error, both on public and professional grounds, and we
trust that Mr. Lawson Tait’s motion will be carried, if
not nnanimously, by a very large majority, and that the
Senate of the University of London will not persevere in
ignoring the fair claim of the Society to a representation on
the new Conjoint Board proposed in their Supplemental
Draft Charter, but will give more attention to such a just
demand than the correspondence published on p. 1063
would seem to imply it has so far received.
A NEW candidate for the favour of the reading public
in America contains a remarkable article by Dr. George
M. Gould of Philadelphia upon the subject of the
Immortality of the Soul. The writer deprecates the
attitude towards this great doctrine which he believes
has become very common iu modern times — the atti¬
tude, namely, not of hearty acceptance or positive
rejection, but of indifferentism, “ the majority of people
slowly settling towards an agnostic non-committalism that
is destructive of all intellectual and moral earnest¬
ness.” Dr. Gould regards this attitude as culpable
and dangerous. He observes that “ if we live after
death, it is of tremendous importance; if we do not,
it is of no less vital import, and the belief, or 'disbelief,
or the evasion is of the most constant influence, un>
consciously, subtly, upon every thought and act of every
day’s living.” He proceeds to analyse the popular concep¬
tions upon the subject, and has little difficulty in convicting
them of vagueness and self-contradiction. He asks those
who hold by the belief that the material body will survive
to say what age they would choose as best representing the
ideal body of the resurrection—childhood, youth, maturity,
or old age, and points out that unless by the flat of
an extra-mundane deity the only moment possible to
fix the bodily form in the mould of eternity would
be the death moment;” yet “this would be the most
undesirable of all seasons, since at that hour the body is in
the weakest, most useless, and most wretched condition of
all the hours it has served us.” Again, he says the ques¬
tion is virtually decided by the consideration that “ all the
organic matter of the world has been used over and over
for bodies, and the earth has not enough hydro-carbons to
fit out again with bodies a small fraction of the souls that
have lived upon it.” He condemns the old dogma as “ the
crudest materialism, wholly unworthy of those who pre¬
tended to believe that God was a spirit, and that they were
his children.”
Dr. Gould proceeds to remonstrate with those who
would desire to perpetuate for ever either their intellectual
or moral nature. He points out the crushing evidence that
exists of human folly and imperfection, the illusions and
delusions of men, their love of error, their prejudices and
blind self-satisfaction, and asks with a touch of scorn
whether this is the kind of mental equipment that we
should wish to stamp with the seal of eternity. In reply to
the obvious retort that most men look for a transformation
of their nature in the passage through death, he
replies that if ’ we have neglected our opportunities
for intellectual and moral progress here, “Why should
God suddenly endow you with a perfect intellect
ready-made? Is it God’s way in this world to give
excellences unasked and unearned? Rest assured, He
will not do it at your dying hour. It is no particular
merit in you to die; why should you be rewarded with a
new intellect, then?” Dr. Gould regards the desire to
perpetuate our individuality, our peculiarities physical,
intellectual, and moral—transformed, it may be, but still
essentially the same—as base and contemptible, and, at
bottom, materialistic. “As you become freed from the
cramping littleness of self-love and the bonds of self-
gratification, as you rise into the life of the spirit, you find
yourself less individual. One fitted for a true heaven
would not care for the old immortality. What is good to
carry over into the future life is not so much personal
identity as personal non-identity, not so much the imper¬
fections that make us individuals as the perfections that
free us from individualism. We must lose our life to find
it. We have over-estimated the value of individuality.”
We must not conclude from such passages as the above
that Dr. Gould rejects the belief in immortality. Heaims
not at destroying that belief but at reshaping it, at
transforming and revivifying a doctrine which he regards
T 3
Digitized by
Google
1050 The Lancet,] THE COMMITTEE UPON BRITISH AND FOREIGN SPIRITS.
[May 9,1891.
as being in danger of sinking beneath the accretions
of error and superstition that have gathered round it. It
is not easy, however, even for those familiar with the
literature of such questions to put his view clearly and
briefly. The fundamental conception that governs his
hypothesis is that of ever-present all-powerful life, “ever
the same, persisting, unchanged through all change, giving
unity to diversity, moulding, making, discarding, choosing,
healing, working to far away ends with blind and dead
and obstinate materials.” According to this view
materialism is altogether out of court, and the funda¬
mental fact of the universe is that mysterious some¬
thing which we call Life, whicli we try to conceive as
Force seeking objectiflcation in material forms, whose laws
we can to some extent formulate, but of whose inner essence
or nature (if we must use question-begging terms) we are
profoundly ignorant. “Why, or how, or whence life comes
to us we do not know now, but the transcendent miracle is
ever before our eyes ; inSnitely rich and free, life is Ailing,
thrilling, surcharging every molecule of matter to which
with wondrous power and ingenuity it can gain access. ” The
writer proceeds : “ To matter, then, life Arst brought and still
ever brings the power of organisation, of adaptation, of spon¬
taneous energy, and of movement. But when the death of the
organisation takes place, the life that preceded and formed
it is not lessened or affected.Just as matter
and force are indestructible, various forms of force being
interchangeable, so must it be with life. There must be a
conservation of life-energy just as rigid, and this truth
must remake and remould the whole conception of immor¬
tality. When a mechanical force disappears in one phase, it
at once reappears in another aspect. So vegetable, animal,
and mental life are but different aspects of life-force, and
suffer no loss when transformed one into the other, or when
the body disappears altogether. And as it is the inherent
nature of force never to rest, so there is no rest for life.
Banishment of life to a heaven of inaction is as impossible
as it is absurd.”
We have endeavoured to state Dr. Gould’S position as
fairly and as lucidly as possible, and so far without com¬
ment. To subject to an adequate examination the great
problems thus raised would lead us far beyond the limits
of an article like the present. We need not inform the well-
instructed reader that the ideas put forward with signal
ability in Dr. Gould’s article are not original, but
are part of that mass of profound and philosophic thought
with which Buddhism has endowed humanity. It is easy
to ridicule such doctrines, which have but a slight
affinity for the Western mind in its present stage of de¬
velopment, but no one who knows the extraordinary power
which they have exercised over “ the brooding East ” will
be disposed to put them brusquely aside as either foolish or |
unintelligible. They have a very definite meaning, though
that meaning is difficult to grasp, and still more difficult
to explain. Whatever may be their positive value, they
seem likely to make themselves felt in the modern world
as a corrective of those mechanical and physico-chemical
conceptions of the universe which some eminent thinkers of
our own time have so rashly regarded as the last word of
philosophy. “ The Highest cannot be spoken of in words,”
eaid Goethe, and probably the ultimate secret of the
universe is beyond our powers either of conceiving or ex¬
pressing ; but if the present influx into the West of the
hoary philosophy of the East does something to discredit
those crude mechanical conceptions of the Cosmos which
have been too long in vogue amongst us, that influx will be
a matter for congratulation, and not of regret. A philo¬
sophy which reduces to a minimum the import of mind,
which strives to interpret the universe in terms of arithmetic
and mechanics, which believes that the microscope and the
spectroscope will ultimately explain everything that is
worth knowing, such a philosophy is fore-doomed to
extinction.
We have regarded this question purely in its philosophical
bearings. Its religious side lies beyond our province.
Whether a future life divested of individuality, and con¬
sisting virtually of a reabsorption into the general life of
the universe, can satisfy any of those aspirations which
have grown up under the influence of Christianity, or is
worthy of the title of immortality at all, must be left to
the judgment of our readers. That Dr. Gould’s views
are not inconsistent with a fine ethical glow is evident
from his concluding remarks. “ Every day you have a
hundred opportunities to give, without lessening your own
supply, some of your own life, to increase the quantity and
to elevate the quality of the general stock of the world’s
life. Help the young—they inherit the world and will use
it well or ill according to your teaching and example.
Stop cruelty to animals—they are your brothers, filled with
the same life as your own. Fight the political ruin we are
preparing for ourselves by partisanship, bribery, and class
legislation. Discourage war and intemperance, and lessen
the tyranny of the strong and wealthy. Wage a ceaseless
war to the death against luxury, the poison that is eating
and rotting the hearts of all of us. Love trees, meadows,
clear brooks, the mountains, and silences of Nature. Love,
not so much your own or another’s individual life, as life
itself. There is otherwise no immortality.”
The report of the Committee upon British and T’oreign
Spirits has at length been presented to the House and pub¬
lished in the daily press. It is characterised by extreme care
and accuracy, and its conclusions seem to be marked by a
conviction that it is easier to disturb and harass trade than
to control and regulate public taste. Upon the whole, the
report will not prove a surprise to the medical profession,
or indeed to those who have followed the course of
the evidence submitted. Very many curious things
have been disclosed in the course of the inquiry,
and many popular fallacies have been corrected, but
the report is equally impartial to both sides of the
alcohol controversy. Any questions connected with alcohol
are usually approached with too much party spirit to allow
of fair discussion. The subject is removed from the sup¬
posed calm of scientific research and treated with an
amount of acrimony which alienates interest. The use of
alcohol as a drink is regarded as altogether wicked, or else
it is defended in an apologetic spirit, which, while reco¬
gnising the evils of intemperance, pleads that the use of
alcohol may be desirable if it can be obtained of sufficient
purity, and if its employment; b© Umited to jpod^r^t©
Digitized by ’ ooQle
tfHB UiJcBT,] LONDON UNIVERSITY AND tHE LONTDON MEDICAI STUDENT. [May 0, 1891. 1051
quantities. From this controversy the report intentionally
keeps clear. The Committee did nob think that it was
within the range of the inquiry to collect evidence as to
whether total abstinence from the use of spirits is better
for the public health than taking them in moderate
amount as a stimulant. The Committee was appointed to
consider whether, on grounds of public health, it is desirable
that certain classes of spirits, British and foreign, should
be kept in bond for a definite period, and to inquire into
the system of blending British and foreign spirits, into the
sale of ether as an intoxicant, and into the propriety of
applying certain legislative measures. In the report details
are given of the production and consumption of spirits,
together with the differences between the whis]^y obtained
from “ pot-stills,” in which the heat of a fire is applied to
a still containing the fermented liquid, and that obtained
from “patent” or “coffey” stills, in which a mixture of
malt and grain is fermented with the aid of heat derived
from steam. The former contains more of the substances
which give taste and aroma, as well as more of those com¬
pounds which are to be mellowed or removed by ageing.
The evidence, however, points to an increased demand for
whisky of a milder and cheaper kind, and thus accounts for
the blends of pot-still and patent-still w'hisky which give
a mixture containing less fusel oil and other bye-pro¬
ducts. With regard to the differences between various
forms of spirits, the report speaks in general terms
and avoids anything approaching to a legal definition.
All spirits contain as their basis water and ethylic alcohol,
together with more or less “fusel oil,” a terra used to include
propylic, butylic, amylic, and other alcohols, in addition to
small quantities of ethereal bodies and empyreumatic com¬
pounds. Although so much has been said of these bye-
products and their deleterious influence, it is stated that
while a wineglassful of spirit at proof contains about 1000
grains, it is rare to find commercial spirits containing
mote than one or two grains of bye-products in the
glass. Still more gratifying and surprising is it to learn
that this proportion held good even when samples were
examined which had been procured from public houses,
shebeens, and fairs, under conditions which are generally
supposed to favour pernicious adulterations. The speci¬
mens varied greatly in strength, but the spirit was normal.
The argument against the bye-products w’as further de¬
stroyed by the assertion that this small quantity, added to
a glass of water and taken as a dose, would have no sen¬
sible physiological effect. Upon the whole, the Committee
viewed the question of blending in a favourable light, as an
attempt to meet the taste and demand, which, even if it
reduced the amount of bye-products present, was to be
viewed as a dilution rather than as an adulteration.
So, too, with regard to bonding; they thought it would
harass trade to impose any restrictions, even though it was
admitted that whisky would improve in bond. The fact is
that no scienbilio explanation of this improvement was
afforded. Various hypotheses were put forward, notably
the possible formation of some new bodies, hitherto un¬
recognised by chemical analysis, but the Committee decliued
to be drawn into the region of conjecturo, and no “ estab¬
lished truths” being forthcoming, they very wisely pre¬
ferred to leave the subject alone.
Far more interesting to medical men is the report on the
evidence connected with the effects of spirits on public
health. Dr. Pavy and Dr. Lauder Brunton agree that old
mellowed spirits are less irritating to the stomach than
newly distilled spirits; hut Dr. Pavy thinks that silent
spirits are innocuous, although they are insipid and dis¬
agreeable, and that the bye-products are to be regarded
as the condiments of the patent or silent spirits. Although
his views are thus stated in the report of the Committee,
they must not be construed too literally, otherwise they
might lead to very erroneous inferences, when taken in
conjunction with some of the earlier statements. It might
indeed be imagined, since the small quantity of bye-
products, when mixed with water, produces no deleterious
effects and the silent spirit is innocuous, that the mixture
of the two would also possess no injurious effects—a con¬
clusion which is contrary to the commonest experience of
the prolonged and inordinate employment of any form of
alcohol.
The next meeting of Convocation of the University of
London will, as we have already announced, be held on the
12bh inst., and will prove to be the most critical meeting
of the members in the annals of the University. After the
formal elections of the Chairman and Clerk of Convocation,
to whose re-election no objections have been taken, and a
reference to the death of the late Lord Chancellor, Earl
Granville, in succession to whom the Earl of Derby has
now been duly nominated by the Crown, the Draft Supple¬
mental Charter will be laid upon the table, and its approval
will then be moved by Lord Hersciiell and seconded by
Sir Richard (.jUAiN. Neither the report of the Annual
Committee nor of the Special Committee, which is supple¬
mented by a further report of dissentient members, can be
considered until after the acceptance or rejection of the
proposed Draft Charter, and by that time their interest will
have become simply historical. These documents have
recently been forwarded to the members of Convocation,
who will thus have had the various bearings of the
question so fully put before them, both offlcially and by
the comments of the public journals daring the past
six years, that there will be no excuse for any hesitation os
to their voting. The members present when the division
is taken will decide on the question of approval or non¬
approval. The widely signed protest may be used as au
argument before the Privy Council, but has no deter¬
mining power. The votes which are given in Convocation
alone will affect the progress of the scheme for reconstitu¬
tion. We have again and again pointed out that the
provisions of the scheme are quite inadequate for the
establishment of a Teaching University for London, and
that they are opposed to the lines laid down by the Royal
Commissioners, who strongly recommended the formation of
such a university ; and this contention is allowed both in
the memorandum issued by the Senate and in the report of
the Special Committee of twenty-five, which latter is
signed by ten members only, of whom four are Fellows of
the Senate, and either the framers of, or deeply committed
to, the scheme. We are now concerned with the disouasit n
of the question, which to us has been always the primary
consideration, whether the proposals will remedy the
Digitized by ,ooQ e
1652 The IaNckt,] LIFE ASSURANCE WITHOUT MEDICAL EXAMINATION.
[ilAY 9,18^1.
grievance of the London medical student of average
diligence and intelligence, and give him facilities for
obtaining the title and degree of Doctor of Medicine on
conditions similar to those on which it is granted by the
other great Universities. It was to redress this grievance
that the late Drs. Moxon and Wilson Fox, with many
other London medical teachers still living, started this
agitation, and all other questions are to ns quite subsidiary
to this main one. We notice with some astonishment that
delegates from the various London medical schools, with
the exception of King’s and University Colleges, have
accepted the scheme on behalf of those schools, and
more especially when we find, as stated by a teacher in
one of those schools in our last issue, that no general
meeting of the members of the teaching staff had been
summoned for its consideration. Surely signatures should
not have been allowed to be appended to such a docu¬
ment without the cognisance of every official teacher in
the various medical schools, as an unwarranted appear¬
ance of support has thereby been given to the scheme,
and is being strongly urged as one, if not the chief,
reason for its acceptance on the 12th inst. The interests
of the schools—which, when the proper moment arrives,
we are prepared jealously to guard—would seem to have
taken precedence of the interests of the student. The
memorandum issued by the Senate says, “No alteration is
now made in the degree of M.D.,” and the Calendar of the
University explicitly states that Bachelors of Medicine
have no right as such to assume the title of Doctor of
Medicine. The Doctorate, therefore, remains on its old foot¬
ing, and Pass M.B. graduates will still remain without the
walls, and be unable to enter therein on any different con¬
ditions of examination than at present. It is obviously
intended that the barrier between the M.B. degree, which
does not carry the title of Doctor, and the M.D. degree,
which does, shall be kept up as fixedly as at present, if not
even more so.
We will now examine the conditions for the M.B. degree.
In Honours we presume no change will be made, and we
hope no increased expense will fall on the candidate. For
the Pass M.B. degree the Senate will “ enter into arrange¬
ments with the Royal Colleges for a combined examina¬
tion in those subjects which are common to that examina¬
tion and the diploma examination of the Royal Colleges.”
These subjects are anatomy, physiology, organic chemistry,
and materia medica in the Intermediate, and medicine,
surgery, and obstetric medicine in the Pass Examination.
We need hardly point out that therapeutics, general
pathology, and forensic medicine are practically ignored
by the Royal Colleges. The subjects of organic chemistry
and materia medica can be passed at the Conjoint Board
before a student enters a medical school, hut we suppose a
further knowledge will he required for his Pass M.B. degree,
and in the other professional subjects it can surely not be
contemplated to substitute the existing conjoint examina¬
tions for the much more thorough and prolonged tests of
the University. We fail to see how the University^ can
carry out these examinations in combination with the Royal
Colleges without lowering its standard. Indeed, if the/change
is merely to prevent a needless repetition in Subjects
common to the degree and the diploma, the solution is at
once found by the Royal Colleges accepting the higher
examinations of the University of London in every subject
in lieu of their own. But we find no trace of this ; the
University meets the Colleges; the Colleges remain in
statu quo, and the increase of expense to the intending Pass
M.B. graduate will he the difference between the lesser fees
of the University and the greater fees of the Corporations.
Moreover, how is a candidate, who has passed only the
University examinations and so is a graduate with
Honours, to differentiate himself from him who has passed
the minor examination in combination with that for his
diploma? Is he to ostentatiously write “M.B. Lend.
(Honours)” after his name? Nothing more unworkable
could he devised than to have two sets of graduates:
one wholly examined within the University, and the
other partly by an extraneous body. Such a proposal
must create inevitable confusion, and when it is ex¬
plained that the diplomates of the Colleges have under¬
gone a part of the same examination, hut have no degree
whatever, the confusion becomes evenworseconfounded. The
Preliminary Scientific M.B. Examination remains as before.
If this be not modified, the concessions as to the M.B. Exami¬
nations will be to the average London student virtually
useless. A scientific harrier to his progress in medical
study is placed before him, which is infinitely more
difficult for him to surmount than any similar ex¬
amination in the kingdom, or any other examination
for the M.D. degree. The Senate of the University,
wliilst apparently trying to persuade the profession,
on the one hand, that it is endeavouring to redress the
grievance of London students, is, on the other, practically
saying to its graduates, “We will take care that no real
checks towards the obtaining of our degrees shall be re¬
moved.” The proposed Supplemental Draft Charter is based
on no definite principle, and satisfies nobody. It endeavours
to prevent the formation of a Teaching University; it
depreciates the Pass M.B. degree by specially contrasting it
with that in Honours; it keeps the M.D. unapproachable
by all but the exceptional student; it lessens the severity
of the professional and technical subjects of thecuiTiculum,
whilst it maintaius the highest standard of scientific and
literary preliminary requirements. It is antagonistic to
the amour propre of its own graduates, and confers no real
advantage on the London student.
Our readers were made aware through these columns
that in the autumn of last year one of our large life assur¬
ance offices—the North British and Mercantile—had entered
into an arrangement with a committee of civil servants by
which special advantages in connexion with the assurance
of their lives were conferred upon members of the service.
Among these advantages was that of being admitted to
the membership of the office without medical examination,
and, indeed, without any inquiry as to health, on the
assumption that civil servants in active work would average
as first-class lives. This feature of the scheme was much
discussed at the time and very generally condemned,
for it was felt that the results obtained in actual
practice by submitting proposers to medical examination
are such as to prove beyond contradiction I or cavil
Digitized by .
^HB tANCBT.j RECHUITING. [May 0,1891. 105^
that this precaution is indispensable to the success of
a Life Assurance Society. The directors of the North
British thought, however, that the circumstances of the
case with which they were dealing were so far exceptional
that they might fairly forego the ordinary precaution in
this instance, and, on the principle of taking the bad with the
good, open their doors to all comers within the compass of
their scheme. The step was a bold one, but the persons
who took it were people of great experience in the business
and were doubtless entitled to their opiniAn. It is therefore
with the greatest interest that we have awaited their report
upon the operations of the year 1890, for although it could
not he supposed that the short period of time within that year
during which the scheme was in operation would afford any
sufficient test of its merits, it seemed, nevertheless, possible
that some indications would be discernible of what the results
of more extended experience are likely in the long run to
establish. Such indications we think we can perceive in
the annual report which has now been given to the public;
and if we appreciate them aright, they are of no good
omen from the point of view of those who have made
themselves responsible for the success of the experiment.
The plan has proved popular, we learn, even beyond the
most sanguine expectations. The civil servants have come
in their thousands, and the revenues of the Society have been
augmented by upwards of £43,000 a year from this quarter.
But we also observe that the directors have found it
expedient to recede from their original position, and are
now insisting upon a declaration and certificate of health
from new entrants. It is true that the certificate is not a
professional one, and, therefore, probably of little worth;
but the declaration will no doubt afford the office some
protection, and if the necessity of a declaration is once
conceded the importance of a medical examination cannot
he brought into question. We also remark that the
directors, whilediscussing the new scheme and its operation
at considerable length, abstain from giving any figures as
to the mortality, and do not even say in general terms that
it has been satisfactory. The aggregate figures of their
published accounts afford, of course, no details of this
particular department ; but even the aggregate figures are
remarkable, and, if we mistake nob, highly suggestive. We
find, for example, that the Company's income from
premiums during the year 1890 having been augmented
not only by the large accession of civil service premiums,
but also by the ordinary growth of business in a very pros¬
perous year, has mounted up to a figure in excess by
nearly £132,000 of the preceding year’s account under the
same head. But on turning to the other side of the account,
and comparing the payments made in the two years
respectively in respect of claims, we discover that in this
item there has been a much more than commensurate
growth, for the company has credit for a sum so paid ex¬
ceeding by above £132,000 the amount correspondingly
entered in the previous year’s account. So that sub- ;
sbantially it comes to this: the growth of loss in respect
of claims has been equal to the growth of premium income
in a year of extraordinary prosperity in the history of the
company.
Such a result la, wo should think, without a parallel in
the history of life assurance within this realm. That it is
wholly due to the ill-omened scheme to which we have
above referred we cannot suppose—the misfortune is on so
large a scale. But it is very singular that, with a fact
like this demanding explanation, the directors should, in
their published report, have afforded no information as to
the Civil Service mortality, and vouchsafed no comment
even upon the extraordinary growth of their claim account.
Speaking professionally we feel placed under some obliga¬
tion to the North British directors. An inarticulate notion
has been gaining ground of late that some advantage might
be secured by leaning less upon the medical examiner than
the life assurance offices have been accustomed to do
heretofore. The experiment now under discussion was a
bold one, excellently well devised to test this view, and it
looks very like being conclusive, and concluding the
argument, moreover, in a sense to which medical prac¬
titioners cannot possibly object. Not many rival offices,
we imagine, will be eager to share with the North British
the advantage of saving a few medical fees at the cost of
adding to the annual mortality loss a sum equal to the
whole income from new premiums which such ad captandunt
measures may enable the offices to secure.
A COMMITTEE, Under the presidency of Lord Wantage,
is considering the subject of recruiting. The general annual
return of the British Army just presented to Parliament
will furnish its members with some interesting data to work
upon. If we learn, on the one hand, that the total effective
strength of the army is much greater than it was, it seems,
on the other, that its real effective strength, as represented
by its manhood, is less. What is wanted is a larger number
of grown men and fewer lads in the ranks.
This question of recruiting is a recuning one, and the
problem how to attract a larger class of men physically fit
for the army is constantly cropping up. The country-bred
recruit, who walks with a slouch and is slow and uncouth
in manner, although somewhat phlegmatic in temperament,
has a ruddy cheek and a steady equable heart beat. He is
always welcomed by the examining medical officer; hut he
is, unfortunately, becoming rare. In place of him the slim,
active, impressionable lad, with a sharp and rapidly acting
heart, tendered irritable by strong tobacco and city breeding,
is much more common.
If the nation requires a larger number and better
quality of recruits, it is quite clear that it will have
to give better pay for them, and this is naturally the
last thing the Treasury wants to do. It is, however,
obvious that if the monetary advantages offered by Govern¬
ment he substantially less than the fair market price the
Government will not get the men. There is no doubt that,
all things considered, the army does offer several advantages
to young men, but then young men commonly weigh or
consider only one thing at a time, and they are often induced
to join the army thoughtlessly and under the temporary
pressure of necessity. As to any prospective advantages
in the shape of deferred pay, the majority of recruits pro¬
bably never regard the future at all; the present is quite
enough for them. We strongly suspect that the existing rate
of pay will have to be raised. But the most important thing of
all probably is the publication of an extremely simple clear
Digitized by OOQ
l054 TMtANCBf,]
■^ITItDRAWAL OF HUE MlDWlVFS BILt.
[May d, 18dl.
contract, the terms of which must be absolutely so plain
as to admit of no manner of doubt. The recruit has
very keen intelligence in respect of his pay and rights,
and to his mind the conditions of service, as he practically
finds them after enlistment, are not such as they were repre¬
sented to be, or, at any rate, as he understood them, and he
begins his military life with a feeling of distrust. It would,
we imagine, be far better to do away with the deferred pay,
and add it to the present rate of ^y—possibly in yearly
increments contingent on good behaviour. A good sum of
money in the shape of deferred pay only acts as an induce¬
ment to retire from the service, and the system is not bene¬
ficial to the men themselves, for it tends to develop the
spirit of improvidence.
The character of the army in these modern days has
altogether changed from what it was in days gone by.
There was a time when the Ishmaelites of society, sturdy,
turbulent young fellows, with a hatred of steady, hum¬
drum work, but with a keen relish for adventure and ex¬
citement, turned to the army because they could not or
would not get employment elsewhere. They had strong com¬
batant tastes; the restraints of military discipline made them
good soldiers, and saved them, and society, it may be, from
worse things. These have to a great extent disappeared.
The men of the present day are far more respectable and
intelligent and they are quite as brave, but they are less
matured physically and far more sensitive to the loss of
liberty, the military restraints, and the petty worries of
army life than their predecessors Avere. And here we touch
on a subject which requires the careful consideration of
the committee. Of course discipline is discipline, and we
cannot have an army worthy of the name without it; but
has military life kept pace with the times, and has every¬
thing been done that can he done in the way of the curtail¬
ment of unnecessary restraints, the exercise of great care
and judgment in the infliction of punishment for petty
crimes, and—where recruits and very young soldiers are con¬
cerned—in the diminution of sentries at night in garrisons
in times of peace, and by the cultivation of sympathy of a
worthy, manly kind—not of course the hypocritical feeling
arising out of love of popularity—between officers and men
Be it for better or worse, the world has been greatly
advancing in these respects, and the great aim of legislation
nowadays should he to And out how much discipline is
absolutely needed for safety and efficiency, and to provide
that and no more.
^nnrfatiijns.
" Ne quid nliulB."
WITHDRAWAL OF THE MIDWIVES BILL
The withdrawal of the Mid wives Bill will scarcely be
regretted by any person. Even those who are most deeply
impressed with the mischief and misery associated with
the practice of midwives who have had no training in
midwifery will admit that the Bill was inadequately pro¬
vided with safeguards against the very evils it was intended
to remedy. It contained very faulty provisions for securing
either the training of midwives or their discipline and
supervision when trained. Under these circumstances, and
with the pressure of work in Parliament, adequate amend¬
ment was impracticable, and the withdrawal of the Bill
was wise. There is now breathing time which will enable
those who are interested in the matter to formulate a Bill
which shall do the greatest amount of good and the least
amount of harm. But there is a consensus of opinion that
before anything is done a select committee to investigate
the matter should be appointed. Meantime, painful inci¬
dents are reported from week to week. We have before
us the report of an inquest at Nuneaton, where the midwife
was said to be guilty of very great negligence, and was, at
the request of the jury, severely censured by the coroner.
THE NEWINGTON VESTRY AND THE
NOTIFICATION ACT.
Londoners are prepared to acknowledge that there is
much which needs amendment in the sanitary government
of the metropolis, but the conduct of the vestry of New¬
ington and of its officers in respect of their duties under the
Notification of Infectious Diseases Act, which has just been
brought to light, is calculated to increase the distrust with
which some local administrations are now regarded. Sir
Vincent Barrington, at the meeting of the Metropolitan
Asylums Board which was held on the 2ad inst., announced
that the vestry of Newington had instructed its medical
officer of health nob to forward to the managers copies of
any certificates received by him under this Act other than
those which relate to cases which were removed to hos¬
pital. In other words, the statistical returns, which the
managers have compiled respecting the prevalence of in¬
fectious disease in London, and particularly in Newington,
have been absolutely misleading as the result of the action
of the vestry of Newington, which has instructed its
medical officer of health not bo carry out one of his
statutory duties, The feeling of indignation which thU
conduct has created is fully jastified by the circumstances
of the case, and it may be hoped that this timely discovery
will lead Mr. Ritchie to amend his Public Health Bill, so as
to attach some penalty for neglect to comply with an obliga¬
tion of so much importance to the metropolis. The
circumstances of this action of the vestry of Newing¬
ton demonstrate the wisdom of Mr. Ritchie in deter¬
mining that an authority having jurisdiction over the
whole area shall bake cognisance of the proceedings
of the several administrative bodies within the county.
Mr. Ritchie’s proposals are being strongly contested
by certain metropolitan members of Parliament. We
do not doubt that the best motives are the basis of
their objections; but they are evidently ignorant of the fact
that, while many districts are well administered, there are
others for which the watchfulness of the county authority
is necessary, and that neglect in one district may endanger
the rest of the county. The vestry of Newington has
evidently failed to realise the intentions of the Notification
Act, and to understand the use to which the information it
gives can be put. The vestry has regarded the operation of
the Act in Newington as concerning Newington alone, and
not a matter of importance to the whole of London. We
would gladly see this lesson taken to heart by those who
are opposing certain important clauses in the Pvrblic Health
(London) Law Amendment Bill. Mr. Ritchie is far better
informed as to metropolitan necessities than they are, and
it will be a public misfortune if he is nob permitted to carry
out his intentions. ___
CHESTER AND OTHER RIVER WATER-SUPPLIES.
Dr. Ballard’s recent report on the prevalence of enteric
fever in (Jhestor embodied a warning as to the use of the
river water as a supply for the city, the importance of
which was emphasised by the lesson of the epidemic in the
valley of the Tees, where the water-supply was also drawn
Digitized by ’ oogle
The Lancet,]
MUSIC IN THE TREATMENT OF NERVOUS DISEASES.
[May 9,1891. 1055
from a river liable to eewage pollution. Fortunately the
Chester warning has not gone unheeded, and the s^ient
points to be borne in mind have been under discussion by
the Chester Medical Society, the subject being opened up
by a paper from Dr. Dobie. The extent to which varying
causes of enteric fever in Chester have been in operation
has not been free from doubt, and Dr. Kenyon has all along
taken a view as to this which tends to exonerate the river
water. Thus in 1888 he set out the view that heavy rains fol¬
lowing on great heat and long-continued rain “reacting on
surface conditions” had in the main led to the result reported
on. But it is evidentfrom Dr. Dobie’s paper that Dr. Kenyon,
who is regarded as the most prominent “apologist” for the
Dee water, in no way sets aside the need for Dr. Ballard’s
warning as to that water, but only indicates that there are,
in addition, conditions of surface hlth which take their share
in the causation of disease, and so tend to obscure the true
relation of this water-service to the maintenance of enteric
fever in Chester. Dr. Kenyon’s apologies go very far. Thus,
as quoted by Dr. Dobie, he says that there is not “one word”
in Dr. Ballard’s report directed against the Dee as a source
of water-supply. If this were so, it would be extraordinary
that so much anxiety as to the water-supply has arisen since
the issue of the report. But, as a matter of fact, the report
teems with argument against the water-supply. Indeed, Dr.
Ballard says that the Company themselves are aware of
the risk of the water above the weir being more or less
polluted, when the “bore forcibly sweeps before it sewage
and other foul material.” He goes on to refer to certain
measures of precaution taken against this; he then ex¬
presses his conviction as to their inadequacy, and he con¬
cludes by saying that “it is certain that the sewage dis¬
charged into the river contains the contagium of enteric
fever whenever that fever prevails in the borough, and
that at certain seasons this is washed up with the tidal
water to above the waterworks intake.” Well nray
Dr. Dobie say that he must doubt Dr. Kenyon’s con¬
clusions. But we learn something on the general
question from Dr. Dobie’s paper. Dr. Ballard has appa¬
rently found himself confronted with the fact that London
also draws a large portion of its supply from a river that
is not free from the risk of sewage pollution, and he has
evidently not failed to include the metropolis within the
lines of his Chester warning. Though unable to JifTeren-
tiate, whether in Chester or in London, between the
several conditions calculated to ditl'use and to maintain
an excess of enteric fever, he does not hesitate to state,
in a communication which was read to the Chester Medical
Society, that he is morally sure that in both instances
the sources of water-supply are an element in the
causation of the disease, and be adds that the water-
supply has more to do with the “continued presence” of
enteric fever in the metropolis than the public recognise.
It is to be hoped that, whether Cheater, the Tees Valley,
or the metropolis be in qirestion, the time will soon have
passed when people, knowing that they are supplied with
and have to use a water-supply the sources of which are
subject to obvious pollution, will be willing to accept as a
valid argument against change the mere fact that chemical
analysis has failed to supply any evidence as to the exist¬
ence in individual samples of those elements of disease |
which chemistry has never yet discovered under any circum¬
stances.
MUSIC IN THE TREATMENT OF NERVOUS
DISEASES. j
Among the accessories ;of directly medicinal treatment, I
and side by side with sucn health-promoting agencies as |
rest, exercise, and change of surroundings, a delinite place i
is due by right of its character and history to music. It'
js trqe that in later, as well as in early times, the sister art'
has been associated rather more with what is mythic and
visionary in medicine than with its accredited or scientific
practice. Miracle workers, mystics, and charlatans have in
all ages made much of its infiuence on the minds of the
impressible, whether truly suffering or not. There can be
no doubt also that they have, as a class, been indebted in
no small degree to their appreciation of this and the like
natural aids for an apparent mastery of physical effects too
commonly imputed to other personal and mysterious gifts
of healing. In this respect they may teach us a lesson.
The possession of a refined musical taste or a so-called
“ ear ” may be denied to many persons. Some conception
of harmony is probably almost universal. This under¬
standing differs, as it must, with different minds and moods,
but it exists in some degree and form, we should say, in every
human being. Each temperament knows and could show, if
intelligence and language were adequate, the terms of its
own simplest musical coefficient, and perhaps even some of
its remembered variations. The cheerful rhythm that
lightened for him an hour of gloom, the flowing cadence
that absorbed his petulant irritation, are as the kindred
spirits of a man’s family. What wonder, then, if music be
found equal to the treatment of some of his diseases—
those, namely, which concern his mental and nervous
condition. In connexion with this subject Dr. G. H. Lilley
sends us a short and interesting paper on the Therapeutics
of Music in Mental Diseases. He discusses with considerable
force the effect of this ancient remedy on those disorders of
nutrition which explain so many departures from the
normal health of mind and body. A brief and lucid
argument illustrates the close resemblance in physiological
action between music and other stimuli which regulate the
vaso-motor activity employed in tissue nutrition. Some
general observations on the mode of applying the treatment
suggested are likewise worth reading, and the paper as a
whole forms a useful and practical, if somewhat irregular,
contribution to the hygiene of the nervous system.
MULTIPLE NEURITIS FOLLOWING INFLUENZA.
Amongst the sequela? of inlluenza few are more striking
and important than those affecting the nervous system. The
degree of nervous prostration produced by the poison is often
considerable, and insomnia is not an infrequent legacy left
by this most searching agent. More grave are the in¬
flammatory lesions—myelitis, meningitis, and neuritis—
which have been authenticated in this connexion. A con¬
tribution to the last named lias lately been made by E. Hom6n
in the FinsJca Ldharesdllskapets Handlingm, Bd. xxxii.,^
in which is mentioned the case of a man aged twenty-
nine, previously healthy, except for an attack of typhoid
fever when twenty years old, who was attacked with
influenza in January, 1890. Whilst convalescing he expe¬
rienced weakness and numbness of the right arm, and
a few weeks later of the right leg. Then muscular
wasting set in, and the same series of phenomena developed
in the left limbs. Tlie weakness and atrophy continued to
progress for a period of from four to six weeks, when
they became arrested. "When admitted into hospital
in August all the limbs were found to be paretic ; he could
neither walk nor stand without assistance, and could only
move his hands and arms to a sliglit extent. The muscles,
especially of the hands, were extremely atrophied, and also
those of the shoulder girdle; and though notably dimi¬
nished in electric reaction quantitatively, there was only
slight qualitative change in this respect. Sensation was
slightly diminished in the affected parts, and the nerve
trunks were tender to pressure. There was no vesical or
rectal incontinence. It is noteworthy that the patellar
reflexes were present. The patient much improved under
1 Abstract hr Fortschribta der Medicin, No. 9,1801.
Dkr -en i:'. tOO^^C
1056 Thb Lancet,]
MICRO-ORGANISMS OF MALARIA.
[May 9,1801,
electricity, massage, and tooics. It is added that bo
bad never had syphilis. A brother of this patient,
who was attached with influenza at the same time, and
who had a relapse a few months later, was almost suddenly
affected with paralysis of the left arm, followed by atrophy
and sensory disorder, attributed to neuritis. He rapidly
improved. __
“COVERING” IN NORTH LONDON.'
Mb. Robert Williams Humphreys, M.R.C.S., sum¬
moned by the Registrar-General for giving a false certificate
of the death of a child named Ruth Thornton for the pur¬
poses of registration, has been dned £5 and £1 Qd.
costs. Mr. Humphreys did not see the child till two hours
after its death, but gave a certificate. The child was seen
by a neighbouring chemist named White, and the mother
knew no one but White, whom she called “Dr. White,”
unqualified. Mr. Humphreys’ defence was that he was
justified in giving the certificate, he having been ill at the
time, and the details of the case and prescriptions having
been brought to him for his acquiescence. We are soriy to
see another practitioner fall into such an error, after the
clear warning given by other prosecutions and the General
Medical Council.
MICRO-ORGANISMS OF MALARIA.
The mode of propagation and other characteristics of
malarial fever have long since given rise to the idea that it
is caused by a specific organism, but although many have
been described by various observers, none of them have been
able to stand the test of Koch’s postulates. The first dis¬
covery of organisms which had any constant connexion with
malarial manifestations was made by Laveran in 1880.
Klebs and Tommasi-Crudeli obtained a bacillus from the
earth and air of malarious districts, which, when inoculated
on rabbits, produced an intermittent form of fever, with
enlargement of the spleen and formation of pigment in the
spleen and liver. What they found was probably a mixed
culture, but Schiavuzzi, working on the same lines, but
employing Koch’s methods of cultivation, isolated an
organism from the earth of malarious districts which pro¬
duced the same effects on animals. Shortly afterwards
Cuboni and Marchiafava announced that they had found
bacilli morphologically similar to those described by Klebs
in the blood of malarial patients. In 1883 Marchiafava and
Celli, by examining cover-glass preparations of blood stained
with methylene blue, found amceboid bodies (plasmodia) en¬
closed within the red corpuscles, but they were not able to cul¬
tivate them outside the body. From the above investigations
it is difficult to arrive at any satisfactory conclusion, but the
paper lately read by Surgeon J. Fenton Evans, I.M.S., before
the Royal Society, on the “Demonstration by Staining.of
the Pathogenic Fungus of Malaria, its Artificial Cultiva¬
tion, and the results of Inoculation of the same,” places the
matter on a more satisfactory footing. After an enumera¬
tion of the various organisms which have been found in the
blood during or after attacks of ague. Dr. Evans proceeded
to describe his method of staining, the advantage of which
lies in the fact that by it the organisms can be permanently
stained, all previous methods having afforded a temporary
and unsatisfactory staining, The stain used is an anilised
alkalised solution of rosaniline hydrochloride after treat¬
ment with bichromate of potash, or an anilised alkalised
solution of Weigert’s acid fuchsin after treatment with
dilute sulphuric acid. By these staining methods the
organisms have been demonstrated in the blood, and also
in the tissues. The existence of the plasmodia within the
red corpuscles was negatived; they were shown to be super¬
ficial, but closely applied to the corpuscles. The isolation
of the organism and its artificial cultivation were success¬
fully carried out, and the author showed that this result
depended entirely for its success upon the fact that the
nutrient media must be inoculated with living blood—
that is, before rigor mortis has set in. Alteration in the
chemical composition of the nutrient medium elicited the
interesting result that the organism could pass to a more
highly developed stave, displaying the structure and fructi¬
fication of a highly organised fungus, appearing to the naked
eye very similar to the ordinary mucor, but differing from
it very materially under the microscope. Inoculation of
animals with the growths produced a frequently fatal
disease, which displayed in a number of instances a de¬
finitely intermittent character. It was further invariably
accompanied by the appearance of the characteristic
organisms in the blood drawn after death from the right
ventricle. While, naturally, we shall await with consider¬
able interest the corroboration or otherwise of Dr. Evans’
researches at the hands of those workers who have already
paid attention to this subject, yet there are one or two
seemingly contradictory observations that already call for
notice. They are specially those which concern the part
played by the organism in the production of intermittent
fever. That the appearance of the organism in the blood
as a general rule coincides with an attack of ague all
are agreed. Similarly all observers concur in stating
that to its multiplication in the blood malarial cachexia
is due. Dr. Vandyke Carter, however, has made the some¬
what startling statement that the organisms previously pre¬
sent in the blood may entirely disappear during an attack
of ague. Dr. Evans goes even beyond this in affirming the
constant presence of the organisms in the blood of the inhabi¬
tants of malarious districts, both in the blood of those who
are apparently healthy and have never suffered from ague
and in the blood of those who have previously been
attacked. Further, the intermittency of the disease, which
followed the experiments on animals, was accompanied in
these animals by reduction of temperature below the normal.
This may, however, be due to the circumstance that rodents
were used for experimental purposes. But, apart from this,
the question now calling for further investigation is. What
are the circumstances under which an organism which has
gained entry into the body may in one instance induce fever
and in another ansemia leading to cachexia, or be present
without injury to health '1 Possibly in the solution of this
question lies a remedy for a disease which, except in its
acute manifestations of fever, is at present only curable by
change of climate. ___
DOUBLE STAINING.
In a note in the Deufsch. Med. Wochenschr., No. 15,
1891, Professor B. Fraenkel stirs up a storm in a teacup,
and objects to what, though comparatively rare in England,
is of very frequent occurrence in Germany. He complains
that Dr. Gabbett has made an unimportant modification of
his method of double staining, and although complaining that
Dr. Gabbett had not seen an accountof his work, he apologises
for returning to the subject at such a late date by saying
that he himself had not seen Dr. Gabbett’s account. In the
first place, tlje method was found out entirely independently;
in the second, it differs quite as much from any other used
as do many of those to which in Germany a special name
is given j and in the third place, Professor Fraenkel’s note
contains internal evidence both of how systematically many
German writers ignore English work, and of the very rare
occurrence of any work in this country being borrowed, even
indirectly, from German authors without full acknowledg¬
ment being made. To set matters straight, we would suggest
that Professor Fraenkel should receive all the credit for
using nitric acid mixed with methylene blue instead of sepa¬
rately where the Weigerb-Bhrlich method is used j and that
Dir edl CjOOgIc
The Lancet,]
WOMEN AS CHEMISTS.
[May9,J891. 1057
Dr. Gabbett, who made perfectly independent observations
and experiments, should receive the credit for mixing the
sulphuric acid with the methylene blue where the Ziehl-
Neelaen method is used. Professor Fraenkel should then
be satisfied. In any case the modifications are so evidently
necessary for rapid work that if Professor Fraenkel and Dr.
Oabbett had not made these modifications, or at any rate had
not published them, other observers would, as the method
had certainly been used by other observers before it was
published by either; and while of course every credit should
be given to both of these gentlemen for making generally
available such a convenient method, it cannot but be felt
that Professor Fraenkel is making a great fuss about a very
email matter.
WOMEN AS CHEMISTS.
It has always, sioce the claim for equality was first put
forward, been a subject for speculation why women should
press so eagerly into circles for which their physical charac¬
teristics to a large extent unfit them, while they neglect
otlier forms of occupation for which they might be thought
to be peculiarly adapted. With certain noteworthy excep¬
tions, they do not take kindly to microscopic work, which,
with all its neatness of manipulation and pleasing results,
would seem to open a field to those requiring employment.
In this country there has hitherto been no decided rush
'upon chemistry, although many of the terms employed in
connexion with “ elegant mixtures,” and the pleats and folds
of the paper wrappers, appear almost intentionally designed
to appeal to the artistic sense of the fair sex. It is therefore
the more interesting to find that in Germany, where the
'Social status of women is far below that in Eogland, an
active move has been made in the form of a petition to the
Prussian House of Representatives to demand the admission
■of women to the practice of the profession of chemist. The
petition sets forth their historic right, and makes much of
their dexterity and deftness in all manual operations; it
also refers to the absence of any demand for severe bodily
•exertion, and, in terms which might almoso be supposed to
possess sarcastic significance, it states that in this oceupa-
tion “an unwomanly entrance into publicity” is by no
means a necessity. Provided that women are iu earnest in
their desire for this work, and that they are ready to fit them-
•aelves for this calling by scientific study and faithful appli¬
cation, there is no reason for desiring to limit their aspira¬
tions or to confine their sphere of usefulness to Germany.
SERIOUS SYMPTOMS FOLLOWING MORPHIA
AND COCAINE.
De. Julio San Martin of Havana describes in the
‘CrOnicaMidicn-Quimirgica a somewhat singular case, where
very serious effects followed the application of morphia
lotions, associated with cocaine ointment, to the vulva, in the
case of a stout lady who had for some years been the subject
of diabetes. At the time when the above medication was
prescribed there was a considerable quantity of sugar in the
urine, the amount passed varied from one to four litres in the
'twenty-four hours, and the pruritus had become unbearable.
The treatment was found to give so much relief that the
patient began to resort to it five or six times a day. Very
soon she began to suiVer from sleeplessness, general excite¬
ment, and restlessness, and a terrible sense of impending
•death. There were, too, delusions—as, for example, that
'the right side was paralysed, which was not the case. She
•complained of a sensation of pricking in both arms, and of
•something which she thought was the “ bone of the heart”
moving about inside tbe chest. Once these symptoms were
!3o severe that Dr. San Martin was called up at night. He
igave some bromide at first, and, after having ascertainc'l
■that the urine contained a trace of albumen and nearly
8 per cent, of sugar, prescribed chloral and morphia in¬
ternally. This treatment unfortunately appeared only to
produce an exacerbation of the excitement, and it then
occurred to him that the symptoms might be due to the
previous medication. Drugs were therefore given up and
recourse had to hot baths, under which the patient became
much calmer and improved in every way, even the sugar in
the urine decreasing in a very marked degree. Dr. San
Martin has frequently prescribed morphia or cocaine for
tbe severe pruritus vulvee sometimes observed in diabetic
patients, without noticing any toxic effects such as occurred
in the present case. He remembers two cases in which
neither of the two drugs appeared to be of much use by
itself, but where a satisfactory cure was obtained for tbe
itching by combining them. The absorption of a sufficient
quantity of cocaine to produce toxic effects from an oint¬
ment is certainly rare, and Dr. San Martin ia disposed to
think that in this case the fact of the kidneys having to
excrete a large quantity of sugar may have produced a con¬
dition favourable to the absorption of cocaine, or perhaps
that the patient had an idiosyncrasy making her peculiarly
susceptible to email quantities of this drug.
THE MEDICAL SOCIETY OF LONDON.
The annual conversazione of this Society took place on
Monday evening, May 4th, under the presidency of
Dr. Douglas Powell. A large number of Fellows of the
Society listened to tbe oration delivered by Sir Joseph Lister
on the Coagulation of the Blood in its Practical Aspects,
and this was followed by a reception by tbe President, the
string band of the Royal Horse Guards (Blue) playing a
selection of music in the vestibule. The rooms were
brilliantly illuminated, and the walls decorated with a
number of paintings and drawings kindly lent for the
occasion. The phonograph was in use; and Professor
Stewart, of the Hunterian Museum, sent a case of insects,
showing characters by which the sexes are distinguished
in some animals indef endently of those organs concerned in
reproduction. _
CANCER OF THE TONSIL
Dr. Onody showed at a recent meeting of the Buda
Pesth Medical Society an old man with a tumour of the
right tonsil as large as a small egg, which gave but little
trouble, and did not interfere either with respiration or
deglutition. It was evidently a scirrhus, but was not
operated on on account of the patient’s great age and weak¬
ness. Subsequently Dr. Josef Neumann mentioned to
the Society that he had seen no less than three other cases
of primary cancer of tbe tonsil in the Rochus Hospital.
THE REGISTRATION OF BAKEHOUSES.
We ate glad to note that the Bakers’ Federal Union of
Scotland are agitating for the compulsory registration of
bakehouses. In the midland counties also the bakers’
societies have been assisting medical officers of health to
discover and to visit insanitary bakehouses. The Birming¬
ham and Midland Bakers’ Society adopted tbe following
resolution : “ That in order to secure a proper sanitary in¬
spection of bakehouses, it is necessary that any baker,
confectioner, or other person using them for the purpose
of manufacteiing bread, biscuits, small goods, pastry, &e.,
should be compelled to register the same, the local
authorities having power to withhold a licence in case of
unfitness.” This resolution was also approved by the
Birmingham Trades’ Council, and then forwarded to the
Staffordshire County Council, to the Birmingham City
Council, and to the chairman of the Health Committee.
The bakers of the midland counties now urge that what
has been clone in Birmingham should be attempted in all
Google
Digit r-
1058 ThbLancbt,]
CIUARETTE SMOKING.
[May 9, 1891.
other parts of the kiogdom. A pressure might thus be
brought to bear that would be irresistible. Already the
Home Secretary and a number of members of Parliament
have received letters from bakers urging that a very slight
alteration in the wording of the Factory Bill would suffice
to ensure the registration of bakehouses. This is very
essential. Sanitary inspectors must not be left to find out
where bread, biscuits, pastry, &o , are baked. We do not
doubt the zeal of such officers, but know they are already
overworked. An insanitary bakehouse might exist for
some considerable time before it was discovered, and even
when the facts are revealed it is always more difficult to
remedy than to prevent an evil. The bakers, therefore,
are right in demanding that registration should be com¬
pulsory. Anyone desiring to bake bread for public sale
should send a notice to the sanitary authority, and be
licensed to make bread only after the bakery has been care¬
fully inspected and found in good sanitary condition. These
are points on which we have always insisted, and now that
the attention of Parliament is so largely devoted to questions
of this description, the moment has come when the claims
of the bakers should be pressed forward. The health of
bakers is seriously compromised by the insanitary condition
of many bakehouses, and bread made in such places cannot
be safely consumed. _
SUPERNUMERARY MAMM>E.
Mr. W. Roger Williams, F.R.C.S., contributes to
vol. XXV. of the Journal oj Anatomy and Physiology
a short but interesting paper on supernumerary raamm®,i
in which he combats the view that has lately been
suggested that these structures are “sports.” He rightly
considers this view opposed to the principle of heredity,
and thinks the evidence adduced in its favour quite
inadequate to account for the sudden appearance of such
highly specialised organs, which have taken long periods
of time to attain their present degree of perfection. He
holds that the mamma is the representation of a single
sebaceous gland, and that the nipple, as shown by its
absence in the ornithorhyncus, does not develop until
after the glandular elements have been formed. The
occurrence of more than one pair of niammte in the
human female has been frequently observed, and a careful
examination of these cases has led Mr. Williams
to the conclusion that our early progenitors had at least
seven pairs of mammse on the ventral aspect of the trunk,
of which only the present pectoral pair have survived. Of
the six lost pairs three were situated above and external to
the present normal pair, and three below and internal to
them. Mr. Williamj describes many other remarkable
cases which he has exhumed from periodical literature, and
discusses the bearing of these abnormalities on neoplastic
formations. He shows that of fifty cases of fibro-adenoma
of the mammary region, seven (14 per cent ) originated in
supernumerary mammary structures, whilst nearly the same
proportion of cases of cancer originated in the same parts.
CIGARETTE SMOKING.
In spite of their popularity, cigarettes have long been
regarded with suspicion. The quality of the tobacco em¬
ployed has often been questioned, and sceptics have even
doubted whether any tobacco is to be found in some of the
cigarettes ordinarily sold. The irritating effects have been
attributed to this cause, or to the practice of “ inhaling,” or
sometimes to the paper; but if the details of a Dalziel
telegram from Milwaukee are to be credited, cigarette
smoking is fraught with other dangers also. The telegram
J Polymastisra, with special relerence to Mammce Erraticoe, and the
Development of Neoplasms from Supernumerary Mammary Structures.
states that a post-mortem examination of two boys who
died from excessive cigarette smoking showed that there
was phosphorus in the stomach, and that the symptoms
indicated that death was caused by this substance, com¬
bined with nicotine and an arsenical solution used in the
preparation of the paper wrappers of the cigarettes. The
presence of phosphorus is not accounted for, nor are any
details given of the mode by which the combined poisoning
by phosphorus, nicotine, and arsenic could be determined.
These difficulties require elucidation before the charge can
be regarded as proven. It will be remembered that
The Lancet Analytical Sanitary Commission on Egyptian
Cigarettes found the paper to be free from arsenic.^
“TROPHIC CENTRES IN THE CORD.”
Under this title M. Brissaud has contributed an im¬
portant and suggestive paper, which appears in a recent
number of the Archives de Neurologic. The paper deals
primarily with the subject of alcoholic neuritis, and the
subject discussed is whether associated with the changes,
which are acknowledged to be present in the peripheral
nerves, there may not coexist in the spinal cord some change
in the cells of the anterior horns of the grey matter. It is not
denied that the chief force of the poison seems to expend
itself on the peripheral nerves in alcoholic paralysis, as io
other forms of toxaemia in which weakness and muscular
wasting are observed, such as lead palsy; but the author
contends that, as in some of those oases, there certainly are
changes in the grey matter of the cord; so, it may be, similar
or analogous changes may at times be recognisable in cases
of multiple neuritis from alcohol. Changes of this.
nature have actually been described by d’Oettinger and
Korsakoff, and by Finlay and Sharkey, and the author
points out the probability of such changes occurring
especially when the symptoms of muscular weakness and
wasting with localised pain are confined to the region of
distribution of a certain nerve or plexus of nerves. And
even if changes in the cord are not recognised, it does not
follow that they are nob present, for it may be that changes
do exist which by our present methods are still unreco¬
gnisable. A carious fact in this connexion is that men¬
tioned by M. Raymond, who produced artificially a slight
degree of myelitis in animals, the symptoms of which soon
disappeared. When the animals were killed a year or
eighteen months later examination could reveal no brace of
the original myelitis, bub the nerves in connexion with the
injured segment of the cord were nob unfrequently found to
have undergone profound alteration.
THE PREVENTION OF FLOODS IN ITALY.
Denuding the hillsides of their woods and the torrential
rainfall that inundates the plains below is in Italy par¬
ticularly so much of an “antecedent and consequent ” as to
have already attained the dignity of “ cause and effect.”
The Italian Legislature has frequently had the subject
under consideration, and, with a view to encourage the
replanting of those uplands where tree-felling has been most
ruthlessly practised, it has announced a series of prizes to
be competed for by the local proprietors who shall produce
the best examples of restored forest growth and regulated
water-flow. The provinces of Lucca, Pisa, Legliorn, Flo¬
rence, Arezzo, Siena, Grosseto, and Perugia are the first in
which the competition is declared open, and the operationa
proposed to the competitors are divided into two cate¬
gories, according to the amplitude of tne soil ia
which they are carried out. For the first category
the prizes assigned are a first class diploma with the
sum of 1000 fr. (£40), and two second-class diplomas with
1 The Lancet, vol. ii., 1888, p. 786.
Digitized by
Google
The Lancet,]
HEMtATKOPHY OP THE TONGUE.
[May 9, 1891. 1059
600 fr. (£20) each, for the replanting of hillsides; a first-class
diploma with 2000 fr. (£80), and two second-class diplomas
with 1000 fr. (£40) each, for the regulation of the water-ilow
down the slopes. Por the second category the prizes are a
first-class diploma with 500 fr. (£20), and two second-class
diplomas with 300 fr. (£12) each, for replanting ; and a
first-class diploma with 800 fr. (£32), and two second-class
diplomas and 400 fr. (£16) each, for regulating the water-
(low. Less successful competitors will be encouraged with
silver and bronze medals to renew their efforts for the
higher awards. All this is as it should be, and comes not a
moment too soon. In the last Parliamentary field-day on
the subject it was demonstrated that the climate of whole
provinces had been changed for the worse by the steady
destruction of their woods, Umbria being a conspicuous
example ; while, in the Venetian territory particularly,
autumnal inundations are expected with the regularity of
Atlantic gales on the shores of Western Europe.
PHYSIOLOGICAL EFFECT OF BATHS IN
TYPHOID FEVER.
Dr, Kurkutoff, who has examined the physiological
effects of baths administered to typhoid fever patients
in Professor Manassein’s clinic in St. Petersburg, finds
that such baths exert only a slight effect on the
assimilation of the fatty constituents of foods, which, as in
other fevers, is notably less than in healthy persons, and
indeed varies directly with the gravity of the case; but
there seems to be a good deal of difference as to the power
of assimilation of fatty matter in different cases, probably
depending on the functional disturbance in the bowel and
on the amount of the individual peculiarities of the patient.
In the graver cases the effect of the baths was to improve
somewhat the assimilation of fat to the average extent of
nearly 4 per cent. In slight cases, however, the effect was,
apparently at least, to dimmish the assimilation to the
average extent of rather more than 6 per cent.
FOREIGN EPIDEMICS.
11UMOUR.S have been current as to a recrudescence of
cholera near Marash in Syria; but though the fatal attacks
have been designated under that name, there are reasons for
suggesting that the disease in question has been typhoid
fever. In the Assyr plague is reported to have broken out,
notably at Beni-sbeir and at Ebba; but here, again, the sym¬
ptoms are not very clear. Thus, whilst there are somewhat
typical hiiemorrhages, the characteristic bubo has not been
noticed. __
HEMIATROPHY OF THE TONGUE.
A CASE in which this rare condition was present is re¬
corded by Dr. Birkett in the Montreal Medical Journal.
The patient was a young man of twenty-three, and when
his mouth was opened the tongue was seen lying on its
floor with the tip pointing to the left, the right half
appearing more bulky, and in front of the left half,
which appeared retracted. On protruding the tongue
-.quite an opposite condition of parts was present. The
tip now deviated to the right side, the right half
was much smaller, its surface being in numerous folds,
and of a yellow colour, and very llabby to the touch.
On phonation the palate deviated to the left, there
was abolition of tactile sensibility over the fauces, but
the tongue retained both its special sense aud ordinary
tactile sensibility, and sensibility of the lips and the
buccal mucous membrane was retained. The right vocal
cord was in the cadaveric position, and on phonation
ffemained almost immobile. Sensibility was dimiuished
as low down as the epiglottis. There was inequality of
pupils, the left being the larger. The patient referred the
commencement of his illness to an attack of mumps nine
years before, after which he had had a swelling on the
right side of his neck. A few years later he noticed that
pressure over the seat of this swelling produced flushing and
sweating of the right side of the face, together with extreme
dryness of the throat. On examination a swelling,
apparently an enlarged and hardened gland, was found at
the anterior border of the right sterno-mastoid, and
pressure over this produced redness of the right side of the
face with sweating, and at the same time a sensation of
dryness in the throat, and the author regards this swelling,
which he supposes to exert pressure on the hypoglossal
nerve, the pharyngeal plexus, the accessory nerve to the
vagus, and the superior cervical ganglion of the sympathetic,
as the cause of all the symptoms.
CONGRESS FOR THE STUDY OF
TUBERCULOSIS.
The programme of the Second Congress on Tuberculosis,
which will take place in Paris from July 27th to August 2Qd,
under the presidency of Professor Villemin, comprises the
following subjects: (1) On the identity of human tuber¬
culosis with that of bovines, the gallinacea, and other
animals ; (2) the bacterial and morbid associations of tuber¬
culosis ; (3) on hospital treatment of the tuberculous;
(4) prophylaxis of tuberculosis in man and animals;
(5) agents which are capable of destroying Koch’s bacillus
without injury to the organism, in regard to the prophy¬
laxis and treatment of human and animal tuberculosis.
Df. L. H. Petit, 11, Rue Monge, is the secretary, aud Mr.
G. Masson, 120, Boulevard Sc. Germain, the treasurer, of
the Congress. _
ARMY MEDICAL SERVICE.
A CONFERENCE was held at the House of Commons on
Tuesday, May 5th, between Sir Andrew Clark, Bart.
(President of the Royal College of Physicians), Mr. Mao-
namara, and Dr. Farquharson, M.P., and the Secretary
of State for War. The proceedings were of a moat cordial
and friendly character, and Mr. Stanhope promised to give
careful consideration to the points laid before him by Sir
Andrew Clark and Mr. Macnamara, and furnish an early
reply.
FOREIGN UNIVERSITY INTELLIGENCE.
Nancy. —Dr. Schmitt has been promoted to the Pro¬
fessorship of Theraiieutics and Materia Madica, aud Dr.
Baraban to that of Histology.
St. Petersburg. —Dr. Zamshin has been recognised as
privat-docmt in Obstetrics and Gyncecology, and Dr.
Kianovski as ■primt-docmt in Medicine, in the Medico-
Chirurgical Academy.
Strasburg. —Drs. Minkowski, Pfitzner, and Ulrich have
been recognised as prioat docenten ia Medicine, Anatomy,
and Ophthalmology respectively.
Wiirzburg. —Dr. Oscar Schultzc has been promoted to an
Extraordinary Professorship of Anatomy.
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
the medical profession abroad have been announced:—
Dr. Joseph Leidy, Professor of Anatomy in the University
of Pennsylvania ami of Natural History iu Swartbmore
College. He was also President of the Academy of Natural
Sciences of Philadelphia and Director of the Department of
Biology in the University.—Dr. Sieber of Berlin.—Dr.
Liebert of Charlottenburg.—Dr. F. Bierraann of Prague, in
hU eighty-eighth year.
Digitized by i^ooQle
1060 THB LA17CET,]
PHARMACOLOGY AND THERAPEUTICS.
[May 9,1891.
The report of the resalta of analyses of the metropolitan
water-snpply during March, 1891, by Dr. E. Frankland,
F.R S., shows that the water abstracted from the Thames
by the Chelsea, West Middlesex, Southwark, Grand Junc¬
tion, and Lambeth Companfej, which was so seriously
polluted by vegetable organic matter in February, had in
every case returned to about its normal condition at this
season of the year. It was efficiently filtered before delivery.
The bacteriological examination by Dr. Koch’s process of
gelatine-plate-culture gave the following results : — One
cubic centimetre of each water collected in sterilised vacuous
tubes on the same days as the samples for chemical analysis
developed the following numbers of colonies of microbes:
West Middlesex 38, Southwark 56, Kent 116, Lambeth 160,
East London (river supply) 214, New River 230, Chelsea
278, and Grand Junction 470.
The past and present students of the Birmingham
Medical School and the professional friends of Sir Walter
Foster propose to entertain him at dinner on Wednesday,
May 13tth, at the Midland Hitel, Birmingham, on the
occasion of his retirement from the post of physician to the
Birmingham General Hospibil, and an address signed by
some 300 practitioners will be presented the same even¬
ing. Mr. H. R. Leech, M)Qument-road, Birmingham, is
receiving the signatures aud applications for dinner tickets.
iNSl’ECrOR-GENEUAL OF HOSPITALS RODERT LAWSON,
half-pay, has been appointed Honorary Physician to the
Qieen, in the place of Surgeon-General T. G. Balfour,
M.D., F.R.S , retired pay, deceased.
A Pan-American Congress of Physicians aud Surgeons
has been suggested by Dr. C. A, Reed of Cincinnati, to be
held probably in Chicago in 1893.
Dr. Da Costa has resigned the chair of Practice of
Medicine at Jefferson College, Philadelphia, a post which
be had occupied for twenty-six years.
ant %\mputus.
COMMON THYME IN WHOOPING-COUGH.
Common thyme, which was recommended in whooping-
cough three or four years ago by Dr. S. B. Johnson, is
regarded by Dr. Neovius, who writes a paper on the subject
in a Finnish medical journal, as almost worthy of the title
of a specific. During an epidemic of whooping-cough he
had ample opportunities of observing its effects, and be
came to the conclusion that if it is given early and constantly
if invariably cubs short the disease in a fortnight, the
symptoms generally vanishing in two or three days. They
are, ne finds, liable to return if the thyme is nob regularly
taken for at least two weeks. Regarding the dose, he
advises that a larger quantity than Dr. Johnson prescribed
be taken. He gives from one ounce and a half to six ounces
per diem combined with a little marshmallow syrup. He
never saw any undesirable effect produced except slight
diarrhcea. It is important that the drug should be used
quite fresh.
IODINE COMPOUNDS OF ANTIPYRETICS.
Dr. E. Miinzer has recently made some observations in
Professor von Jaksch’s wards in Prague on iodantipyrin or
iodopyrine, which was first prepared by Dittmar some five
or six years ago. It is a crystalline substance, very slightly
soluble in water or alcohol, and, chemically speaking, is
simply antipyrin in which one atom of hydrogen is replaced
byiomne. It appearedtohavemuchthesameantipyreticand
analgesic properties as antipyrin itself, but produced no
unpleasant effects. In one case where there was very severe
frontal headache, probably of syphilitic origin, its action
was remarkably prompt, a single dose of fifteen grains suf¬
ficing for a permanent cure. In a case of subacute rheuma¬
tism, too, a couple of doses entirely cured the patient.
Observations with iodacetanilide were also undertaken, but
no antipyretic or analgesic effects could be detected.
ARISTOL IN KERATITIS.
Dr. Bourgeois strongly recommends the employment of
arUtol in ulcerative and suppurative keratitis when nO'
complications exist and when operative procedures are out
of the question. He applies the powder directly to the
cornea, either with a brush or with the insulHator, and
keeps the eyelids closed with an antiseptic dressing. He
has never found the patients complain o! pain having been
caused by the aristol; indeed, they scarcely seem aware
that there is any foreign body under the lids. The results
obtained are stated to have been remarkably good.
SULPIIONAL IN TRISMUS NEONATORUM.
Dr, Ber^nyi mentions a case of trismus neonatorum in a.
child of a week old, which was completely cured by
enemaba containing three grains of sulphonal supplemented
by the internal use of the same drug. No injurious effects
were observed, though the child took in the course of six:
days more than 150 grains of sulphonal.
HYDROCHLORATE OP PIIENOCOLL.
Dr. Hertel, assistant in Professor Gerhardt’s clinic, has-
published an account of some trials of a new antipyretic,
hydrochlorate of phenoooll, a white crystalline powder
which is readily soluble in water. The dose required i»
from seven grains and a half to fifteen grains, and this re¬
duces the temperature from O'D” to 2-7° F. without pro¬
ducing rigors, sweats, or any other disagreeable symptoms.
The effect was very marked on some cases of rheumatic-
fever which had been treated without result by antipyrin,
salicylates, phenacebin, and anbifebriu. Here seventy-seven
grains were given during the twenty-hours, and appeared
to reduce the pam in the joints as well as the temperature.
In a case of severe gonorrhccal rheumatism, however, no
effect was produced. In phthisis seventy-seven grains
during the twenty-four hours soon reduced the temperature
almost to normal. It was noted that more effect was pro¬
duced by the drug on the temperature during the day than on
the eveningrise. There was noinj urious effect on the kidneys^
bub the urine was coloured a deep reddish-brown by seventy-
seven grains.
STRYCHNINE INJECTIONS IN DIPHTHERITIC PARALY'SI.S.
Dr.W. llozenzweigof Neuwiedreporbsf ourcases of paralysis-
of the soft palate after diphtheria, occurring in children of
from six bo twelve years old, in which a rapid cure was
effected by the hypodermic use of strychnine. The doses-
were from two to three milligrammes, and were injected into
the neck. In one case a remarkable improvement was pro¬
duced by the first injection, and in another a complete cure
was obtained by three daily injections. In none of them-
was treatment required beyond a week.
EFFECT OF QUININE ON THE HBAI.ING OP WOUNDS.
Dr. Sokoloff has published some interesting observations-
on the effect of quinine administered to a wounded anirnaf
on the granulation and cicatrisation of the wound. The
experiments were conducted on rabbits. The fur was shaved
from a portion of the paw, and an incision made through
the skin and into the muscular tissue, the external wound
being then sewn up and the whole dressed antiseptically.
Subsequently microscopical observations were made on
sections including the wound. Twenty-four rabbits which-
were experimented on in this way were treated with hydro ¬
chlorate of quinine, half a grain of which was given per
diem for each kilogramme of body weight. A similar
number of control rabbits were operated upon in precisely the
same manner, bub were not given quinine. Dr. Sokolofl'
gives a detailed description of the microscopical appear¬
ances observed each day for eight days in the two sets-
of cases. The effusion of blood was much the same in
both, but there was a marked difference in the condition
of the muscular tissue. la the control animals this
lost its striped character, the portions in the immediate
vicinity of the wound presenting the appearance of an
amorphous homogeneous substance containing here and
there a few muscular fibres or breaking up into separate
pieces as in coagulation necrosis. Besides this, the muscular
tisBue gradually disappeared, leaving sheaths of sarcolemma
either empty or filled with cells. In contrast to this state
of things sections taken from the animals treated with
quinine presented little or no sign of muscular degenera-
Digitized by
Google
The Lancet,]
THE INFLUENZA EPIDEMIC.
[May 9,1891. 1061
bion, the fibres preserving their proper structure. With
regard to the cellular elements in the control animals, two
forms were found in the neighbourhood of the wound—a
large number of multi-nuclear leucocytes, and a much
smaller number of large round or oval cells with a single
large nucleus. The mean diameters of these cells after
three days were 19,t4 and 16/4, after five days 17/4 and 13/4,
and after eight days 18/4 and 15/4. During this period the
nuclei presented various karyokinetic figures. In animals
treated with quinine there were no multi-nuclear cells, all
being oval, with a single nucleus and smaller than the
corresponding cells in the control animals, the mean
diameters being after three days 13/4 and 10’5/4, after five
days the same, and after eight days 14/4 and 11/4. The
cells were, moreover, more numerous than in the control
observations. In the quinine-treated animals the karyo-
kinetic process commenced and finished earlier than in the
others, the chromatin filaments being also less numerous
but thicker. Altogether there was less infiammation with
quinine than without; in short, without quinine there was
Zenker’s degeneration, with quinine none.
THE INFLUENZA EPIDEMIC.
The outbreak of inlluen^a, which first made its appear¬
ance in this country about a month ago, and was for a few
weeks confined within a comparatively limited area, has
now spread over the whole country. The disease has gained
considerable footing in the metropolis, but not to the extent
that it did in January of last year. Many promiuent men
iu the State have been attacked with it, and some of the
functions of Parliament have been suspended. The illnesses
of Lord Derby and Lord Sandhurst have interfered with
the work of Committees on which they are engaged;
and amongst other members of Parliament who have been
incapacitated by it may be mentioned Mr. Henniker
Heaton, Mr. Mundella, Mr. Stuart Wortloy, Professor
Stuart, and Mr. Akers Douglas. The severe loss sustained
by the Church and Parliament in the death of the Arch¬
bishop of York must, we fear, be attributed to the same
insidious disease; whilst the Par has been deprived of one
of its ablest members in the death of Mr. Lindsey M.
Aspland, LL.D., QC., who was also a member of the
Council of University College and a prominent member of
Convocation of the University of London.
Dr. Wightwiek, the medical officer of health to
St. Olave’s district, in a report presented to the board,
stated that, so far as his experience went, the nervous type
of the disease, complicated with severe lung symptoms,
was more frequent than last year. This is borne oat by
the exceptional rise in the mortality from bronchitis and
pneumonia in the towns which have been most affected.
Sheffield still holds an unenviable pre-eminence in this
respect, its mortality rate having last week advanced to the
extraordinary figure of 70 per 1000 ; but we are glad to
learn that the virulence of tiio opidemic is now on the de¬
cline in that town. It has now spread to all parts of York¬
shire, but is especially prevalent in the East Riding. There
does not appear to be much abatement of it in Leeds and
Bradford and the surrounding districts.
It continues to prevail severely iu Lincolnshire, and lias
spread to the midland and eastern centres. Our corre¬
spondent at Leicester, writing on the 4bh inst., says :
“ Influenza has appeared here during the past week, and is
at present pretty prevalent, with, in many instances, very
severe symptoms.”
In Liverpool it seems to be much on the increase, and to
be interfering with the trade of the port. It has been
found necessary to discharge the inmates of the Woolton
Convalescent Home and to close the institution.
From all parts of Wales accounts have oeen received of
its extension to country districts as well as in the towns.
It is very prevalent in Cardiff, and Mr. Garrett Horder
writes that “ in several cases there has not been so much
gastric disturbance as in the epidemic of last year, and in
cases uncomplicated with severe lung afi'ection convalescence
has been more rapid.”
In the west*, cases are recorded from Somersetshire; and
in the south-eastern counties Kent seems to be at present-
the chief centre of the disease.
So far, then, as compared with the epidemic of 1889-90,
its spread has not been so rapid, but it has been none the
less sure; and there has been considerable variation in the
severity of the type of disease, some districts which furnish
many sufferers having a much lower mortality than others.
On the whole, however, we fear that there can be little
doubt as to its virulence being greater than last year’s
epidemic, which, contrasted with previous outbreaks, was-
comparatively mild, and was not responsible, either directly
or indirectly, fur so great a mortality as has occurred in this-
country during the past few weeks, especially from acute
diseases of the I'espiratory system.
Direct and Indirect Influen;ja Mortality in London.
The last weekly return of the Registrar-General affords-
undoubted evidence of indirect mortality from influenza in>
London, in addition to the thirty-seven deaths that were
directly referred to that disease in the week ending lost
Saturday. The Registrar-General’s annual summary
for London and ocher great towns in 1890, recently
issued, furnishes some important statistics upon the
indirect result of the influenza epidemic in London
in January of that year. It is pointed out that the
temperature in January was high, and exceeded the
average for that month by 7'1“F. Notwithstanding this-
marked excess in the temperature, the mortality in
January, more especially from lung diseases, showed
“an enormous and sudden increase,” and exhibited unusual
features which undoubtedly pointed to some exceptional
influence. The increase in tlie mortality from lung diseases,,
which invariably takes place in winter, ia usually far mor&
marked under the heading “Bronchitis” than under the
heading “Pneumonia.” In January, 1890, however, nob-
only was the excess of lung mortality unusually great,
notwithstanding the high temperature, but while the-
excess of mortality from bronchitis was 6-t per cent,
above the January average, the excess from pneu¬
monia was 07 per cent. Again, it is pointed out that-
during this month the increased mortality occurred-
mainly among persons aged between twenty and sixty years,
whereas the ordinary winter excess of mortality from lung-
diseases occurs mainly among persons aged upwards of sixty
years. Thus the mortality from bronchitis in London in
January, 1890, was higher than in four selected cold perioda
of 187-4 1878, 1870, and 1880, while the rate of mortality
from pneumonia during the same month was very con¬
siderably more than twice as high as in the same four'
selected cold periods. The connexion between this ex¬
ceptionally high mortality from bronchitis and pneumonia _
during the first month of last year (notwithstanding
the high temperature) and the influenza epidemic does
not seem to admit of a doubt. These facts give increased
interest to the Registrar-General’s statistics of niortality
from lung diseases in London last week. It appears tbab
the deaths referred to diseases of the respiratory organs,
which had been 604 and 471 in the preceaing two weeks,
rose last week to 589, and were 220 above the corrected
average. The largest part of this excess was shown in the
deaths referred to pneumonia, which numbered 241, and
exceeded the average by 112, while the 281 deaths referred
to bronchitis exceeded the average by 75. It should be
pointed out, however, that while the mortality from,
all causes last week did not e.xceGd 23-3 per 1000 in
London, the rate was 32 in Bradford, 3'2-9 in Preston,
35-1 in Manchester, 42'1 in Halifax, and 70 5 in Shellield,
the excess in each of these towns appearing to be mainly
due to the direct and indirect effect of the influenza
epidemic.
The extent to which the influenza epidemic is making
itself felt in London may be in some measure gauged by the
subjoined figures showing the numbers treated at vatiouft
metropolitan hospitals during the past week. At Charing-
cross Hospital there were 60 cases treated, at St. Mary’s
Coogle
JOBS The Lancet,]
THE GERMAN CONGRESS OP INFERNAL MEDICINE.
IMay 9, 1891.
Hospital 106, at Univerbitv College Hospital 18, at the
Loadon Hospital 154, at King's College Hospital 7 cases
hare been under treatment, at St. Thomas’s Hospital about
68 patients applied for relief, at St. George’s 16, at West¬
minster 16, and at the Middlesex the number of applicants
was about 80. At the time of going to press the returns
from Guy’s and St. Bartholomew’s Hospitals had not reached
us. The cases have continued to increase in numbers,
.generally speaking, from April 28bh up to the present time.
THE GERMAN CONGRESS OE INTERNAL
MEDICINE.
(Continued fi-om page 1008 .)
Dr. Sandmeyer (Marburg) gave some short reports on
recent researches in the Marburg Physiological Institute.
Microscopical examinatiou of the organs from a child,
aged nine, who had died of diabetes, showed no notable
change in the pancreas, but the liver contained glycogen.
The fourth ventricle, pons, and medulla were normal, but
there was some degeneration in Goll’s column of the cervical
cord. There was also fatty degeneration of the heart, and
some glycogenic degeneration of the renal epithelium.
iZ. He announced the discovery in the urine, before and
during the onset of diabetic coma, of slight amounts of
albumen, with numerous casts, hyaline and granular.
-3. On the secondary degeneration of the spinal cord after
excision of the motor centres.
Professor VON Jaksch (Prague) described a Method for
the Detection of small quantities of Bile in the Blood. From
0.0 to 15 ccm. of blood are filtered through asbestos by
means of a cupping glass, and the serum coagulated in a
test tube at 70° to 80° C. In keeping this serum in an
incubating chamber at 40°, a bright-green tint will develop
from oxidation of biliverdin. Hneiuoglobinmmia gives a
^jrown colour.
Professor Litten (Berlin) showed an Apparatus for the
rapid Separation of the Formed Elements in Urine by cen-
•vfifugal action.
Professor Eichhorst (Zurich) made a communication
upon the Patellar-tendon Reflex in Tabes Dorsalis. Ac¬
cording to AVestpbal this reflex is absent when the cord
lesion is seated at the junction of the dorsal and lumbar
ortions. One might expect that in cases where the disease
egins in the cervical region the reflex would be retained ;
but Eichhorst mentioned one such case where it was lost,
although in another it was increased. In a case he had
himself observed, where there were typical signs of involve-
■ment of the cervical and upper dorsal regions, the absence
■of the reflex was explained by marked and severe neuritis
of both crural nerves.
Professor v. Frey (Leipsic) spoke of the Electrical Resist¬
ance of the Human Body, and described a method for its
determination devised by himself and Dr. Windacheid.
Dr. Leubu.scher (Jena) reported some Clinical Observa-
'^iions on the Excretion of Acids in Mental and Nervous
Disease. The amount of hydrochloric acid in the gastric
^uice was estimated in the subjects of melancholia, mania,
and general paralysis, with somewhat variable results, but
sufficient to show that there is an undoubted relationship
between nervous processes and such secretion.
At the sitting on April 9ch Dr. Euelf.sen (Kiel) dis¬
cussed the question of the Origin of the Vesicular Murmur.
The theory of Baas and Penxoldt is that vesicular breathing
is due to the transmissioa of the glottic sound through the
■apongy lung tissue. But in emphysema the breathing does
not become more bronchial, as might be expected from the
diminution in the number of alveoh. Edelfsen thinks rather
-that the sound is produced at tiie infundibula
Dr. Kronig (Berlin) gave a demonstration on Clinical
Bacteriology; he also gave the results of an examination of
1^00 subjects to define by percussion the anterior limits of
the lungs.
Dr. Wolff (Gorbersdorff) propounded the question, What
■is meant bv Cure of Pulmonary Tuberculosis ? He said it
was difficult or impossible to prove this clinically. Patients
are considered to be cured when they yield negative signs
and the patients felt quite well. He related a case, however,
in which the signs of bilateral inflltration had disappeared ;
'but when, a year after, the patient died from an operation
for fibioid tumour, bacilli were found in the pulmonary
cicatrices. Latent tuberculosis is remarkably frequent;
absolute cure is extremely rare.—Professor V. Ziemssen
(Munich) concurred in the views expressed, referring to the
liabilitv to recurrence and the detection by Bollinger and
Kurloff of bacilli in apparently healed tubercle. He spoke
of the importance of prophylaxis, and eulogised the services
rendered therein by the late Dr. Brehmer.
Dr. Schmaltz (Dresden) described a method for the
estimation of the Specific Gravity of the Blood in small
amount. In health there is very slight variation, but in
anajinic conditions the specific gravity (which seems to be
proportional to the amount of hojmoglobin) is greatly
diminished.
Dr. Mordhorst (Wiesbaden) spoke of the Diagnosis and
Treatment of Gout, pointing out the higher acidity of the
urine in gout than in rheumatism and its greater richness
in uric acid, and advocating the alkaline waters of Wies¬
baden in its treatment.
Dr. Posner (Berlin) made some observations on Diabetes,
especially as to the hourly excretion of sugar, and the
influence on this of syzigium jambolanum (it notably
decreased the maximal amounts, but did not cause the sugar
to entirely disappear).
Dr. Fleiner (Heidelberg) described the Changes of the
Sympathetic and Cerebro-spinal Nervous System in Addison’s
Disease, as observed in two cases. In one case the supra-
renals were tubercular, and in the other the left organ was
the seat of an angio-sarcoma. In both there was marked
inflammation of the sympathetic nerves from the semilunar
ganglia to the spinal ganglia, with degeneration of
medullated fibres and ganglion cells. The spinal cord was
normal.
Dr. Moritz (Munich) read a paper on Alimentary
Glycosuria. Repeating the experiments of Worm-Muller,
he found that dextrose and levulose when ingested in excess
passed as such into the urine. Cane sugar sometimes
passed unchanged; sometime-s it appeared as grape sugar.
Lactose appeared as grape sugar. Starch does not cause
glycosurla~at least, when taken in any practicable quan¬
tity. A certain individual disposition is necessary to pro¬
duce alimentary glycosuria; and lactose is the most ready
to cause it, grape sugar the least. Many can take 200 grm.
of the latter without having glycosuria, which may follow
on the ingestion of only 50 grm. of milk sugar.
[/Voie .—For the preceding account of this interesting
Congress we have been mainly indebted to the excellent
reports in the MuncKon&r Mcdicinische Wochenschi-ift.}
THIC
SANITARY STATISTICS OF THE CUSTOMS’
FORCE OF LONDON FOR 1890.
Although the record of the Registrar-General in the
recently published summary of the deaths in London last
year is very unfavourable, showing the mortality rate
(20‘3 per 1000) to have been higher than in any of the pre¬
ceding five years, there is reason to believe that the victims
have been chiefly found among those who readily succumb
to disease by reason of their extreme youth, old age, or
constitutional debility, and that the year 1890 has not been
unduly fatal to the adult male working and wage-earning
sections of the community. Facts are not wanting that
point to this conclusion. For instance, in the Customs
establishment of the Port of London, where elaborate
statistics of the sanitary condition of the inferior out-door
oilieers have been kept for more than thirty years, the
amount of disease in the past year has been unprecedentedly
small, and the exemption from mortality has been most
remarkable. Of the 600 men composing that force, the
average dailynumber incapacitated by illness was less than
3 per cent,; not one death occurred in the period, and of the
five cases of invaliding from physical infirmity, only one
was caused by necessarily fatal disease—viz., cancer. This
singular immunity from all mortal illness is the more note¬
worthy, inasmuch as in the beginning of the year these oflicers
underwent an acute visitation of influenza. Sixty-five cases
of the epidemic occurred between Dec. 15th, 1889, and
March Ist, 1890. its maximum intensity being attained in
the second week of January, when forty-five cases were
Coogle
Di(. I
Thb Lanobt,]
THE EXHIBITION OF THE ROYAL ACADEMY OF ARTS. [May 9,1891. 1063
aimultaneously under treatment. Eleven per cent, of the
force were affected, but all recovered satislactorily, though
In a few cases, owing to pulmonary complications, conva¬
lescence was protracted, and the mean duration of each case
was fourteen days. Customs officers, as a rule, are exempt
from zymotic diseases, which rarely exhibit a ratio of more
than 5 per cent, on the whole amount of sickness. In
1890, however, in consequence of this epidemic, the annuai
ratio increased to 20 per cent. No other zymotic disease of
importance appeared except one case of diphtheria in
November, which an officer contracted from his sick child.
He recovered, but the case is worthy of note as the only
one of that formidable malady which has come under the
notice of the medical inspector during his tenure of office
and observation of probably 25,000 cases of disease, a proof
of its rarity among the adult male population of the
metropolis. A large proportion of these Customs officers are
men well advanced in life, and their work is often of a
laborious character, involving much exposure to the weather
and to great vicissitudes of temperature in examining the
lower parts of steamships &c. Diseases of the respiratory
organs, rheumatism, and gout, sooner or later involving the
heart and lungs, are the most prevalent forms of illness, and
in ordinary years account for one-half of the total araountof
sickness and mortality of Customs officers. In the pastyear
the Registrar General ascribes the heavy mortality amongthe
general population of London to the exceptional frequency
and fatality of bronchitis, and more especially of pneu¬
monia, which caused 50 per cent, more deaths than in the
preceding year, chiefly coincident with the epidemic of in-
nuenza in the beginning of the year, when the ratio of
death from pneumonia was actually doubled. To that
zymotic influence rather than to climatic causes he rightly
considers the high death-rate to be due, for the mean tem¬
perature of January was seven degrees above the average,
and the increase of mortality was more marked among
persons between twenty and sixty than in those of greater
age and less power of resistance to cold.
More singular, therefore, is the immunity which the
Customs officers enjoyed from serious pulmonary disease,
notwithstanding their having had a fair share of influenza
while it lasted. The proportion of all respiratory diseases
throughout the year was considerably below the average,
and the mortality from these, and indeed all other diseases,
was absolutely nil. Even phthisis, which normally inflicts
3 or 4 deaths per 1000, was in abeyance. This was
doubtless an exceptional year, the usual death-rate ranging
from 5 to 12 per 1000, and the invaliding, or prema¬
ture superannuation rate, being about half as many. Dr.
Dickson considers the meteorology of 1890, though trying
to persons having a weak point in their armour, to have
been on the whole propitious to health. A mild January,
a dry February, followed by warmth in March and May, a
cold wet summer till September, which was the finest and
warmest month of the year, succeeded by a dry autumn
with intense cold in the last six weeks of the year, form a
combination of weather which in former years has been
observed to prove salutary to men of sound constitution,
inured to labour and spending much of their lives in the
open air, who can procure all the necessaries, and many of
the comforts, but none of the luxuries of life. In several
such years there has been a high standard of health rriain-
tained, but in none so high as in 1890, which has been
characterised by the Registrar-General, from his study of
the mortality tables, as the most disastrous of recent years
to the population of London.
Within the last throe weeks twelve cases of influenza
have been received nt the Custom House, of the same
character as in last year, but in some instances accompanied
by sore-throat, which was then seldom met with. Now as
then there is no precise evidence as to its causation or mode
of diffusion.
FINE AETS.
THE EXHIBITION OF THE ROYAL ACADEMY
OF ARTS.
From a purely medical point of view there are not
many subjects requiring our notice in the present exhi¬
bition. lb is, indeed, singularly deficient in portraits of
contemporary celebrities of the medical profession. There
is a striking likeness of Sir George Humphry in gallery
No* 8) bub with this exception we did nob notice the por¬
trait of any member of the profession in whom out
readers are likely to take particular interest. Bub there
is a picture by Mr. Luke Fildes, R.A,, which is so
remarkable in power and truth that we must draw
special attention to it. It is bung at the west end
of the large room, and is called “The Doctor.” The-
scene represented is the interior of a cottage. A sick
child is lying on an improvised bed, made up on a couple of
chairs, whilst its parents in the background of the picture
await the verdict of the doctor, which will either pluDg&
them luto despair or fill them with hope for their little oue’&
recovery. The mother, worn out with watching, baa buried
her face in her hands, unable to bear the suspense, whilst
the father, standing by her side, in an attitude of exquisite-
tenderness, encourages her with manly fortitude. It is
evident that some change has occurred in the condition of
the child at the.approach of dawn, and the doctor has been-
summoned. He is seated, and regards the little patlect-
with a face full of the most anxious consideration.
Opinions will vary as to the judgment which he is likely
to pronounce. The painter does nob help us to decide. He-
pictures the doubt and difficulty which we have all felt in
certain conditions, and the intensity of interest in the pro¬
blem which lies before him. It is a struggle between disease-
and the healing art. Mr. Fildes has painted a pathetic-
and singularly truthful picture, and in the person of the
doctor has given ua the type of man to whose heart suffer¬
ing and danger appeal with irresistible force. The pro¬
fession of medicine will be grateful to him for this evidence
of sympathy with their arduous calling. In “The Crisis,”'
by Mr. Frank Dicksee, another aspect of the subject which
comes home to the experience of most of us is depicted with
the painter’s accustomed force. In the lecture-room is a.
group by the President, “An Athlete struggling with a.
Python,” which is very remarkable for its intensity and the-
truthfulness of its muscular anatomy.
Medical men of artistic taste with half an hour to spare-
would be gratified by a visit to Mr. L. H Lefevre’s Gallery
in King-street, St. James's, where there are on view
several works of real merit, no less distinguished by charae-
ter than by fidelity in execution. The “Roman Chariot
Race,” by the Spanish artist Ulpiano Checa, Rosa Bonheur’s-
“ After a Storm in the Highlands,” and a very careful pic¬
ture by 'W. Dendy Sadler, entitled “ For He’s a Jolly Good
Fellow”—each in their several manners give evidence op
skill in arrangement and in the management of light and
colour, and of studious treatment of details. 'We shouldj
nob omit to mention another, the latest admirable produc¬
tion of Willem Geets, “Anne Ascough preaching in London.”'
The four works form a group which will endure and repay
a careful and critical inspection.
RECONSTirUTION OF THE UNIVERSITY OP
LONDON.
The following correspondence has been sent to us for-
publication :—
Society of Apothecaries, E.C., Blackfriars, Nov. 18th, 1860.
My Loan,—The attention of the Society of Apothecaries of Loudoii>
has been drawn to tlie Scheme for a Teaching University for Londoiii
prepared by the University of London. Such scheme, so far as it excludes-
the Society from representation on the Senate, and also apparently from.-
taking any part in the teaching or examining functioJis of the propoaecVi
University, appears to be defective for the reasons which 1 am desirert-
to lay before your Lordship.
If yon will refer to p. xxu. of the Appendix to the Report of the Royal.
Commission made in 1886, you will find ii. very accurate summary of the-
petition presented by the .Society ngsiust tho grant of the Charter
sought for by tbe Royal Colleges of Physicians and Svirgeons.
'Die facts therein stated ai-o the main grounds on which, without-
again repeating them, the Society contends that a vory strong case is-
made in its favour for ronresentation both in the Senate and Uie other
departments of tho Teacning University.
The Society is aware that the report of the Commissioners does nob
specially assign a representative to the Society on the Senate of the-
pvoposod University, but it is urged that such report did not profess to-
lay down any hard or fa.st linos on which the Senate should be framed,
and further tlint the University of London has itself departed from the-
suggestions of the Ommisaioners by increasing tho number of proposed,
members of that body.
Tho very fact that tho University of l.ondon feels itself at liberty to-
alter tho scheme of tho Commissioners in this i-ospect give.s tlie Society
tho opportunity of pressing its claim, that the scheme should be sbilL
further arnomlod by giving representation to tho Soiuety. .
The Society feels that it has been placed somewhat at a disadvantage
by what occurred bofoi-o the Royal Commissiou. The origin of that
Commission wins mainly the consideration of tlio petition for a charter
for a Medical University presented by the two Royal Colleges of
Physicians and Surgeons. The whole weight of the Society’s petitiooi
Coogle
1064 Thb Laitcet,]
REPORTS OF MEDICAL OFFICERS OF HEALTH.
[May 9,1891.
and evidence waa directed againab such charter being granted, and in
that respect it entirol)[ succeeded,
But it was not specially invited to give its views, and never, in fact,
did give its views in any way on the constitution or function of a general
(teaching university for London. Had it done so it would doubtless
have been able to show olfectually that a very close analogy exists
between the position held by tlie Incorporated Law Society (to whom
the report or the Cointnissioners hasosngaed representation) as regards
the iaw, and that of the Society as regards medicine. The solicitor
may be termed the “ peneral practitioner ” of tlie law, and if the body
which represents him la to be entitled to representation and to all the
advantages arising therefrom, tbera would seem to be the strongest
reason for placing tlie Society of Apothecaries of London in an equally
^ood position.
Lastly, if the Senate or committees formed out of the Senate, as
-•suggested by the report of the Commissioners, are to elect the examining
•boards for the various faculties, tlie exclusion of tlie Society from the
^Senate of the proposed university seems still move diflScult to under-
•stand. The Society urges with confidence that a teachingorexamining
board in the medical faculty, from which any influence of tlie Society
is to be absolutely and altogether excluded, would be imperfect, un-
[practical, and wanting in tliat lilieral and broad basis which is essential
to its efficiency.—I have the honour to bo,
Your Lordship's very obedient servant,
To the Lord Presidentof the Council. Edwin Chmiot (Master).
Society of Apothecaries, London, E.C., Deo. 9th, 1890,
Sir,—A t the suggestion of the Lord President of the Council, who
states that he has no ofilcial knowledge of the scheme referred to in
the letter addressed to him by the Master of the Society, of which I
•enclose a copy, I am instructed to send you such copy, and to ask you
to be so good as to lay same before tbe Senate of the University of
London, or other the body delegated by the University of London, to
deal with the achonio for a Teacliing University for London.
I am further instructed to state that the views of tlie Society on tlie
subject are so fully embodied in tliat letter that it seemed the simplest
• and most convenient course to furnish you witli a copy of it, rather than
■to restate the whole matter, practically in tlie same words, to the
University of London.
I am, Sir, your most obedient servant,
•Tames B. Upton,
The Registrar of the University of London. Clerk to the Society.
University of London, Burlington-gardens, \V.,
Dec. 10th, 1890.
SiH,—I beg to acknowledge the receipt of your letter of the 9th inst..
with copy of a letter addressed by your Society to the Lord President of
•the Council, and I will submit these communication.s to the Senate in
•due course. I am, yours faithfully,
To the Clerk, Society of Apothecaries. Aimiuu Mii.man.
THE LATE PROFESSOR JOHN MARSHALL,
F.R.S.
As already announced, the friends of the late Professor
John Marshall wish to establish a memorial of him in con¬
nexion with his alrtxa mater. University College, London.
It is proposed that primarily tbe memorial should take the
-fomi of a bust, to be placed within the College. In the
•event of the contributions to the fund which is being raised
for this purpose being more than enough, the surplus will
'be set aside for the foundation of a prize in the Medical
H^aculty of tbe College, to be called the “ Marshall Prize,”
Those who wish to cooperate in this attempt to perpetuate
the memory of Mr- Marshall’s labours are requested to send
their contributions to the treasurer of the fund, Mr. John
Tweedy, 100, Ilarley-street, W. Subjoined is the first list
of subscriptions ;—
£ s. d.
•Mr. W. Anderson .. .. Z a 0
Mr. A. B, Barker .. .. 2 2 0
Dr. Barlow.2 2 0
.Mr. Samuel Barnett.. ..110
'Mr. H. G. Barron .. .. 110
Dr. Bastian.2 2 0
Mr. Marcus Beck .. ..220
•Dr. J. W. Bond.2 2 0
Mr. Stinley Boyd .. ..110
Mr. C. Bradlcsv.2 2 0
'.Dr. O. Buckniil.110
Mr. C. Ji. Claxton .. .. 0 10 0
Messrs). Collinsand Collins 2 2 0
Dr. C. d’A. Ceilings .. .. 10 0
Mr. T. W. Dix.0 0 0
Dr. A. Downes.110
Dr. W. T. Edwards .. ..110
Mr. J. B. Erichsen .. .. 2 2 0
Dr. t’earnside .10 0
SDr.H. P. A, Gabb .. .. 0 10 C
Dr. .f. G. Glover. 110
Mr. .T. B. Godioe .. .. 2 2 0
Mr. A. P. Gould. 110
Profes.MOr Halliburton ..110
•Dr. C. J. Haro .. ..330
Dr. Geo. Harley.110
Mr. U. Harlock. 110
’Bev. S. Haughton, M.D.. 110
Mr. Cliristopiior Heath ..220
Dr. (Jraily Hewitt .. ..110
Mr. Iterkoley Hill ..220
Mr. F. Hinds .1 1 0
Vlr. Victor Horsley .
Vir. S. J. Hutchinson
Sir W. .(enner .. .
t'he Prnprietor.s of
Lancet .
Dr. T. W. P. Lawren
Dr. Louis Parkes
Mr, AwdryPeck
-Mr. Biltoii Polhu’d .
Dr. G. V. Poore,. .
Dr. Fredk. Bol)orts .
Sir WiJlia)!) Roberts
Dr. A. H. Uoi)irison .
Mr. Bernard Roth .
Sir Will. S. .Savory,
Mr. .f. B. Seriven .
Dr. Ed. Seaton .. .
Mr. Buxton Shiliitoe
Mr. S. Sibley ,. ,
Mr. Balinaiino Squire
Professor Thano
Mr. T, W. Thompson
Dr. Thorowgood
Mr. .Tas. Tiirle .. .
Mr. J, ,1. Tweed
Mr. .John Tweedy .
Dr. A. ]•'. Voelckor .
Dr, J. Waggett., .
Dr. Walshe.
Mr. lilwin Williams,
Mr. .lohn Williams .
Dr. W. Wood .. .
21 0 0
110
1 ]. 0
110
110
2 2 0
2 2 0
2 2 0
110
2 2 0
2 2 0
110
2 2 0
2 2 0
2 2 0
110
2 2 0
2 2 0
0 10 0
110
1 1 0
0 !> 0
1 1 0
110
2 2 0
2 2 0
2 2 0
0 6 0
Jitalil ani |poor fate.
LOCAL GOVERNMENT DEPARTMENT.
REPORTS OF MEDICAL OFFICERS OF HEALTH,
Saltley Urban District. —On an estimated population of
9200 the death-rate from all causes was 16'1 per 1000 during
1890 and the zymotic rate reached 2‘6, although this rate
was nob in excess of the average. Mr. W. G. Cresswell
points out that use is made of the Aston Fever Hospital for
Isolation purposes, and that the authority have availeii
themselves of the advantages of the Infectious Disease
(Prevention) Act of last year. A somewhat complete
account is given of the general sanitary administration of
the district and of the action taken under the Sale of Food
and Drugs Act, and attention is drawn to the need for
the abatement by the Corporation of Birmingham of the
nuisance caused to Saltley by reason of the emission of
dense fumes and smoke from the gasworks belonging to
that borough.
Watford Urban District. —Dr. Brett reports an unusually
low zymotic rate, and he gives an account of the means for
isolation afforded by tbe two hospitals vested in the
guardians and in the joint sanitary authorities respectively.
The state of the market-place, which is often a source of
considerable nuisance, is again referred to. After deductions
for deaths in the workhouse infirmary «&:c. of people not
belonging to the district, the death-rate for 1890 was 13'2
per 1000 living.
Grantham Urban District. —According to Dr. Poole Berry
the death-rate for this borough was 14-8 per 1000 last
year, and although there was a prevalence of scarlet fever
and certain occurrences of enteric fever, the maintained
absence of any prevalence of diphtheria is recorded.
Perhaps, however, too much trust is placed on this absence
as an indication that the sanitary circumstances are efficient,
for where the same has obtained schools have often led to
diffusion of imported infection, and places in a bad
sanitary state have, on the other hand, escaped for many
years. The sewer ventilation evidently needs some amend¬
ment, and the circumstances which have brought this into
prominence appear to indicate local defects of sewers or
of house drains communicating with them. The sewage
farm seems a success in Grantham, and good sanitary work
is in progress. But the references to isolation point to the
absence of any proper provision for infectious diseases or
for disinfection of bedding &c.
River Tyne Port District. —Mr. Henry Armstrong’s
report on this port district during 1890 contains, like his
previous ones, a full account of the action taken as regards
infectious diseases, their isolation in the port hospital,
disinfection, and, where necessary, communication with
British consuls abroad. The improvements effected in the
sanitary condition of ships are explained, and tbe record
is once again typical of the sort of supervision and admini¬
stration which is so useful in our jiorts, both for the pre¬
vention of disease and the amelioration of the conditions of
those afloat.
St. AlbarCs Urban District, —Both the general and the
zymocic death-rate were somewhat in excess last year, the
former being 16T and the latter 2-4 per 1000 living, and to
a large extent the excess was due to measles and whooping-
cough. The near prospect of a hospital for infectious
diseases is referred to by Dr. Morison, and reference is made
to the prospective value of tbe two sanitary Acts of last year.
The water-supply for tbe town is stated to be good, and the
drainage is reported as satisfactory.
St. Alban's Rural District. —Here the general death-rate
is given by Dr. Morison as 12'7, and the zymotic rate as
0'5 per 1000. There is little of public interest in the report,
but it is evident that the measures adopted tend to the
maintenance of the diminished mortality of 1890.
Tendring Rural District —Some improvement is in pro¬
gress as to refuse removal, especially at Parkeshore; but
filthy refuse holes are referred to at Lawford. Wherever
people have nob suilicient garden ground on which week by
week to deposit excreta and refuse without risk of nuisance,
the sanitary authority should themselves undertake the
work of scavenging. In the same way, whilst substantial
progress is being made as to sewerage in certain localities,
much-needed improvements are called for elsewhere. And
as regards water-supply the same may be said. But if
The Lancet, J
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[May 9, 1891. 1065
every year a sitnilar record can be given of progress in one
or other directions, the ultimate good will be considerable.
During 1890 the general rate of mortality is given by Dr. J.
W. Cook as 16-7 per 1000 living.
VITAL STATISTICS.
health of ENGLISH TOWNS.
In twenty-eight of the largest English towns ^849 births
and 6153 deaths were registered during the week ending
May 2nd. The annual rate of mortality in these towns,
which had been 22'd and 24'3 per 1000 in the preceding
two weeks, further rose to 26'8 last week. The rate was
23'3 in London and 29'7 in the twenty-seven provincial
towns. During the first four weeks of the current quarter
the death-rate in the twenty-eight towns averaged 24-1
per 1000, and exceeded by 2*5 the mean rate in the cor¬
responding periods of the ten years 1881-90. The
lowest rates in these towns last week were 15'0 in
Birkenhead, 16'8 in Norwich, 17‘3 in Bristol, and
19‘5 in Brighton; the highest rates were 36-1 in
Leeds, 385 in Blackburn, 42'1 in Halifax, and 705
in Leeds. The exceptionally high rates in the last-
mentioned towns were due to a severe epidemic of
influenza. The deaths referred to the principal zymotic
diseases, which bad been 420 and 428 in the preceding two
weeks, further rose last week to 462; they included
188 from whooping-cough, 127 from measles, 63 from
diarrhcea, 37 from diphtheria, 31 from “ fever ” (principally
enteric}, and not one from small-pox. These diseases
caused the lowest death-rates in Derby, Birkenhead,
Norwich, Bristol, and Sunderland, and the highest rates
in Leicester, Blackburn, Manchester, and Portsmouth.
The greatest mortality from measles occurred in Plymouth,
Preston, Huddersfield, Blackburn, Bolton, and Ports¬
mouth ; from scarlet fever in Halifax ; and from whooping-
cough in Halifax, Newcastle-upon-Tyne, Plymouth, Man¬
chester, and Leicester. The mortality from “fever" showed
no marked excess in any of the twenty-eight towns. The
37 deaths from diphtheria included 21 in London, 5 in Man¬
chester, and 3 in Newcastle-upon-Tyne. No fatal ease of
small-pox was registered lastweek in any of the twenty-eight
towns; 21 small-pox patients were under treatment in the
Metropolitan Asylum Hospitals and 1 in the Highgate
Small-pox Hospital on Saturday last. Thenumberof scarlet
fever patients in the Metropolitan Asylum Hospitals and
in the London Fever Hospital at the end of the week was
927, and showed a slight further decline from recent weekly
numbers; the patients admitted during the week were 100,
against 84 and 85 in the preceding two weeks. The deaths
referred to diseases of the respiratory organa in London,
which had been 604 and 471 in the preceding two weeks,
increased last week to 588, and exceeded by 219 the corrected
weekly average. The causes of 105, or 2'0 per cent., of the
deaths in the twenty-eight towns were not certified either
by a registered medical practitioner or by a coroner. All
the causes of death were duly certified in Plymouth,
Preston, Sunderland, and in three other smaller towns; the
largest proportions of uncertified deaths were recorded in
Liverpool, Leicester, Shelfield, and Halifax.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had declined from 26'7 to22‘l per lOOOin the preceding
five weeks, rose again to 23‘1 during the week end¬
ing May 2Qd, but was 37 below the mean rate that
prevailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns ranged
from 14'3 in Greenock and 16-1 in Leith to 27 7 in Glas¬
gow and 38-8 in Paisley. The 603 deaths in these towns
showed an increase of 17 upon the number in the preceding
week, and included 30 which were referred to measles,
26 bo whooping-cough, 10 to diarrhcea, 9 to scarlet fever, 4
to dipbthena, 2 to “fever,” and not one to small-pox.
In all, 80 deaths resulted from these principal zymotic
diseases, against 81 and 00 in the preceding two weeks.
These 80 deaths were equal to an annual rate of 3‘1 per
1000, which exceeded by 07 the mean rate from the
same diseases in the twenty-eight English towns. The
fatal cases of measles, which had increased from 33
to 43 in the previous three weeks, declined to 30 last
week, of which 16 occurred in Paisley and 13 in Glasgow.
The deaths from whooping-cough, which had been 25 and
32 in the previous two weeks, declined last week to 25,
and included 12 in Glasgow, 5 in Dundee, 3 in Edinburgh,
and 3 in Leith. The 9 fatal oases of scarlet fever exceeded
those recorded in any week since the beginning of March
last; 5 occurred in Glasgow, 2 in Edinburgh, and 2 in
Aberdeen. The deaths from diphtheria, which had been
9 and 4 in the preceding two weeks, were again 4 last
week, and included 2 in Glasgow. The deaths referred to
diseases of the respiratory organs in these towns, which had
been 142 and 143 in the preceding two weeks, were 14&
last week, but were 13 below the number in the corre¬
sponding week of last year. The causes of 76, or nearly
13 per cent., of the deaths in the eight towns lost week
were not certified. _
HEALTH OF DUBLIN.
The death-rate In Dublin, which had declined in the pre¬
ceding three w'eeks from 30 6 to 23 0 per 1000, rose again to-
24‘4 during the week ending May 2nd. During the first-
four weeks of the current quarter the death-rate in the
city averaged 2C'4 per 1000, the rate for the same period
being 21-2 in London and 18'9 in Edinburgh. The
165 deaths in Dublin duriog the week under notice-
showed an increase of 9 upon the number in the preceding
week, and included 2 which were referred to “fever,”
2 to diarrhcea, and not one either to sraall-pox, measles,
scarlet fever, diphtheria, or whooping-cough ; in all, only 4-
deaths resulted from these principal zymotic diseases,
against numbers declining from 8 to 6 in the preceding three
weeks. These 4 deaths were equal to an annual rate of
0-6 per 1000, the rate from the same diseases being
1*9 in London and 1-3 in Edinburgh. The 2 fatal cases of
“ fever,” and the 2 deaths referred to diarrhcea, exceeded
those recorded in either of the preceding two weeks. No fatal
case of scarlet fever has been registered in Dublin since the
beginning of February last, and not one of measles since
the first week in March. The 165 deaths in Dublin last
week included 21 of infants under one year of age and 43 of
persons aged upwards of sixty years; the deaths both of
infants and of elderly persons showed a decline from the
numbers in recent weeks. Five inquest cases and 3 deaths
from violence were registered during the week, and only
15, or 9 per cent., of the deaths occurred in public institu¬
tions. The causes of 16, or nearly 10 per cent., of the deaths
last week in the city were not certified.
CALCUTTA AND ITS AREA OF SUBURBS.
According to a memorandum published by the health
ofiicer’s department Dr. W. J. Simpson states that the
total number of' births registered in January last was 665,
giving an annual ratio of 18'4; the total number of deaths
(exclusive of stillbirths) was 1264, against 1.3.37 in the pre¬
ceding month, showing an annual ratio of 35-0 against
37 '0 per 1000 of the population. The monthly total exceeds
all the corresponding figure.? of the past decade excepting
1883. There were 134 deaths from cholera, against 167 in
the preceding month, which exceeds the corresponding
figures in six of the last ten years, and in excess of the
decennial mean by 23 In the amalgamated area of the
suburbs there were 3.36 births, giving au annual ratio of
23'9 per 1000. The total number of deaths registered
in January was 893, giving an annual ratio of 63-7 per
1000. Of these deaths 126 were from cholera. From
the weekly sick return ending March 7th it appears
that the general death-rate of the week for the town of
Calcutta was 33 0 per 1000 ; that for the amalgamated area
of suburbs was 621 per 1000, the general death-rate of
the combined area being equal to 38-3. The general death-
rate of the week ending March 28th was, for the town of
Calcutta, 26-5 per 1000, against 27-9, the mean of the last
five years; that of the amalgauiated area of suburbs was
50'6 per 1000 per annum, against 44 7, the mean of the last
five years. The general death-rate of the combined area
was equal to 33-2.
THE SERVICES.
Army Medicat, Reserve of Officers. — Surgeon-
Major Thomas John Aubin, M.D., 3rd Regiment, Royal
Jersey Militia, to be Surgeon-Major, ranking as Major
(dated May 6th, 1891); Surgeon Frederick Vasey Adams,
1st Lanarkshire Rille Volunteer Corps, to be Surgeon,
ranking as Captain (dated May 6fch, 1891); Acting Surgeon
David Thomas Key, Ist London Artillery Volunteers, to
he Surgeon, ranking as Captain (dated May 6th, 1891).
D, r, Google
1066 Thb Lakcbt,]
THE RECONSTITUTION OF LONDON UNIVERSITY.
[May 9,1891.
Naval Medical Sbrvicb.— Fleet Surgeon Walter Reid,
M.D., has been promoted to the rank of Deputy Inspector-
Oeneral of Hospitals and Fleets in Her Majesty’s Fleet
i<dat.ed May 1st, 1891) —In accordance with the provisions
of Her Majesty’s Order in Council of April Ist, 1881, Fleet
Eurgeon Wm. Brown has been placed on the Retired List
of his rank at his own request (dated April 25 th, 1891).—The
following appointments nave been made at the Admiralty:—
€baff Surgeon James T. W. S. Kellard, to the Invincible
(dated May 5th, 1891). Surgeons: Geo. A. Dreaper to the
Defiance May 28th, 1891); George D. Trevor Roper
to Haslar Hospital (dated May 7th, 1891); John S Fogerty.
M.D., to Plymouth Hospital (dated June 6bh, 1891); and
Edgar R. Dimsey to the Vivid (dated June 6bh, 1891).
Volunteer Corps. — Royal Engineers: 1st Lanarkshire:
Harry Watt Robinson, M.B , to be Acting Surgeon (dated
May 6bh, 1891).—1st Sussex: Charles Lenox Cunningham,
Gent., late Surgeon, Royal Navy, to be Acting Surgeon
i(dated May 6bh, 1891).— Rifie: 2nd (Prince of Wales’s)
Volunteer Battalion, the Devonshire Regiment: Acting
Surgeon W. Square resigns his appointment (dated May 6th,
1«91). _
(forrrspnknn.
" Audi alteram partem."'
THE RECONSTITUTION OF LONDON
UNIVERSITY.
To the Editors o/The Lancet.
Sirs,— The attitude you have taken up on this question in
your recent leading articles has been so reasonable and just,
end is evidently in harmony with the views of some eleven
hundred and more of the members of Convocation, that it is
not surprising that those who have attacked your position
have failed to upset it. Sir Philip Magnus, in the columns of
The Times, has warned graduates to study well the report
of their Special Committee before committing themselves to
-an opinion upon the new charter. Such a warning is
•scarcely well tiuied, when we remember that an ex parte
memorandum in favour of the scheme was circulated by the
Senate more than a month ago. Moreover, by Standing
Order 14, Section 9, relating to business of Convocation, the
proposal toapprovetheDrattSupplemental Charter will, un¬
less otherwise determined by special vote, have precedence of
the reception and discussion of the report of the Special Com-
mitteeon May 12 th. Indeed, on theagenda paper now to hand
the proposal of Lord Herschell and Sir R. Quain to approve
the new Charter stands immediately after the formal busi¬
ness, and the Special Committee’s report follows that of the
Annual Committee, neither of which is likely to come on for
diecussioD at all. Will Sir Philip Magnus move that the
reception of the report of his Special Committee have pre¬
cedence of the motion to approve the Draft Charter, so as
to. give Convocation “ an opportunity of discussing the
whole situation” as he has always promised and advised?
f f not, then the House will be asked to concur in approving
a complete resolution of the University without any
opportunity of effective d^cussion or amendment. Such
a course might be fair if the Special Committee’s report
were unanimous, but it is not so. The resolution “ gene¬
rally approving” the last revised scheme on Feb. 9bh,
5891, was carried in committee by 6 to 2; the adoption
of the report of the Special Committee on April 16bh last
was carried by 10 to 2, or, deducting senators, 6 to 2, no
medical graduate being amongst the six. On the other
'hand, the memorandum appended by the minority objecting
to the adoption of the scheme and the report is signed by
aix members, of whom three are medical graduates. No
doubt Lord Herschell, in proposing the approval of the
Charter, will say, and say well, all that there is to be said
in favour of the scheme, “admittedly a compromise,” in
“ opposition to the report of the Royal Commission,” and
not approved by University and King’s Colleges.
Sir Richard Quaio'e support of the reconstitution is less
clear; before tue Royal Commission he appeared as the
apologist for things as they are, and he rebutted the
charges of Sir Andrew Clark upon the medical examina¬
tions. Then, at any rate, he had scant sympathy
collegiate courses and examinations; “his own experience
was that be lost rather than gained by attending lectures ;”
“he wonld prefer that students came up, aa they do now,
to the University of London to show the knowledge they
had acquired with very little reference to where they had
gained it”; he was not deceived by the phrase “ a teaching
university.” “ The London Colleges will be no more of ‘ a
teaching university’ than they may be now if they think
fit to continue for the purpose,” he said (Q. 1986, page 211).
He went on to demonstrate that London University exa¬
minations, especially the medical, “were as thoroughly
practical aa they could be made ” (!M02), and that it turned
out as many doctors as it should, and of excellent quality
(2001 and 2003). It is true he did not wish to see another
licensing body in London, but he pointed out that, if such
should be created, the “University of London, which is
provided for by the State, is in no fear of failing; it will not
have to battle.” Many like myself thought the above
contentions were sound in 1888, and think that they are
still sound to-day, but would hardly consider them con¬
sistent with the retrograde policy embodied in the Draft
Charter. I am. Sirs, yours faithfully,
W. J. Collins, M.S., M.D., B.Ss.Lond.
Albert-fcerrace, ReRent's-park, May 5tb, 18DX.
To the Editors o/Thk Lancet.
Sirs, —It may interest you to know that we are issuing
to morrow a second list of members of Convocation who
have “expressed their dissent from the proposed reconstitu¬
tion of the University of London upon the Hues of the
Senate's scheme.” The first list contains 709 and the second
346 names, a total of 1055. The two lists contain the
names of about 290 medical graduates, 24 of whom are on
the full staff of one or other of the twelve London hospitals
with medical schools attached, and two on the consulting
staff.—I am. Sirs, yours faithfully,
J. Walter Carr, M.D,, Hon. Sec.
Blooroabury-square, W.C., May 0th, 1891.
THE “ MEDICAL GRIEVANCE ” AND ITS
REMEDY.
To the Editws of The Lancet.
Sir.?, —Stated briefly, the “ medical grievance ” is that the
degrees of M.D. and M.B. aretothemedicalstudentinLondon
relatively less accessible than to the students in other
centres of medical education, and that in consequence
students who otherwise would come to the London schools
go elsewhere. The remedy advocated for this unsatisfactory
st<ate of things is the establishment in London of a degree
of lower standard than the present M.B, Lond., on the
argument that the examinations for the degree of the
existing university are too severe for the average student.
Particularly, it is argued that the so-called Preliminary
Scientific Examination is too difficult. From seven or eight
years’ experience of teaching biology to students for this
examination I claim to be able to speak authoritatively
on this point, and I say emphatically that this examination
is not too difficult for the average student, if he is properly
taught. If an academical year is given to the study of
elementary science under proper teachers, 80 to 90 per cent,
of the stvidents will pass, and this has been the average
percentage of passes amongst my students for the past
seven years. If, then, as I contend, the scientific parts of
the curriculum for the M.B. Load, are not too severe,
what is the cause of the relative inaccessibility of the
degree? It is, in my opinion, to be found in the fact that,
speaking in general terms and without reference to any
particular school, the education in the more scientific
portion of the curriculum is at fault, and the remedy
is to be found, not in any attempt to lower the exist¬
ing University degree, but in making proper pro¬
vision for educating the students up to its require¬
ments. If London, as a centre of medical education, were
as efficient in the way of appliances for the more
scientific education—i.e., were provided with suitable
scientific teachers and properly equipped laboratories—as is
the case in Cambridge, Oxford, Edinburgh, Manchester,
Durham, and the other provincial centres, the “ medical
grievance” would gradually vanish. Speaking in general
terms, the provincial universities, colleges, and schools are
much better equipped for the scientific parts of medical
education than London, and vice versd. London has
facilities for clinical work which none of the provincial or
Scotch centres can possibly possess. The proper policy,
then, is clear: the London schools should remedy their
oo^ie
Thb Lanobt,]
THE ANTISEPTIC TREATMENT OF TYPHOID FEVER.
[May 9, 1891. 1067
defective appliances for the more scientific parts of the
curriculum. The scheme for reorganising the existing
University provides in no way for improving the teaching
machinery, and cannot, in my opinion, be a final solution
of the University question for London.
I am. Sirs, yours truly,
T, W. Shore, M.D,, B Sc.Lond.,
Lecturer on Comparative Anatomy and Biology at
May 4tb, 1801. St. Bartholomew’s Hospital.
*** general we agree with Dr. Shore, but he omits to
say that his students have already undergone selection by
the Matriculation Examination, which is acknowledged to
be the most difficult entrance examination in Arts in the
kingdom, and are therefore probably far above the average.
Is it not, also, the case that the present standard in
Experimental Physics is too high for an average medical
student ?—Ed. L.
SEQUEL TO A CASE OF ABDOMINAL
SECTION.
To the Editors of The Lancet.
Sirs,—T he interesting narrative published by Dr. Malins
in your columns of Saturday last requires a slight addition
and commentary to make the case intelligible. The girl in
question was brought to me by her mother with the state¬
ment that the left ovary had been removed by Dr. Malins
at the General Hospital on account of persistent pain ; that
after the operation the pain had been relieved, but that it
subsequently returned on the other side. After communi¬
cating with Dr. Malins and after much discussion of the
case, I reopened the abdomen, found the left sot of appen¬
dages missing, picked a silk knot from off the re¬
mainder of the broad ligament, and then removed the
right set of appendages. After this second (or it may
be, if the full truth were known, third) operation, the
girl remained quite well for a considerable time, but after
about a year she became as bad as ever. Now as to the
sequel. A few weeks ago I heard a surgeon of unimpeach¬
able veracity assert that in his own recent experience a lady
had been, beyond all possible or probable shadow of doubt,
impregnated by her nusband years after the removal of
both of his testicles. Concerning one of Dr. Battey’s early
cases, it is established that removal of both ovaries failed
to relieve symptoms which were long afterwards promptly
cured by the birth of a child. A second case of this kind
has occurred in America. And to this interesting though
astonishing list Dr. Malins adds a third; so that, fortu¬
nately, the days of miracles do not yet seem to be past.
Dr. Malins seems to have been somewhat rufiled by a
correspondence which he himself made necessary upon this
case after the second (or as I have said perhaps the third)
operation, and he desires those who have a particular letter
in their possession, or have seen it, to draw their own con¬
clusions. I wish precisely the same result; but, that they
may do so, they ought to know the facts which Dr. Malins
seems to forget. So strangely short are the memories of
these obstetric physicians, that before I operated upon the
patient I did, as I have said, communicate with Dr. Malins,
telling him the story she and her mother brought to me,
and asking for information concerningit or for its correction.
The letter in question failed to obtain any information con¬
cerning the case; in fact, the usual rule which obtains in
such cases, when one practitioner applies to another for in¬
formation concerning a patient from a previous attendant,
was entirely disregarded. Fatting aside the foolish rude¬
ness of such conduct, I have to point out that, whatever sub¬
sequent blundering there may nave been in the treatment of
this case, it is to Dr. Malins, and to him alone, that the re¬
sponsibility must be accredited ; and why he should choose
to rake up a question of this kind in his own career, I, for
one, am at a loss to imagine.
I am, Sits, yours faithfully,
May 6th, 1301. LAWSON TAIT.
THE ANTISEPTIC TREATMENT OF TYPHOID
FEVER.
To the Editors of The Lancet.
Sirs,—I n Dr. Burney Yeo’s lecture he gives the prefer¬
ence to chlorine, after enumerating a variety of other treat¬
ments by vaiioirs authors having the same object—viz.,
general antisepsis of the body, and of the intestinal canal
in particular. As I have used the remedy which be advo¬
cates, and prepared precisely as he directs, I can contribute
some information as to its composition, for, in answer to a
letter twelve years ego. Dr. Alfred Swayne Taylor wrote me
as follows: “Strong hydrochloric acid deoxidises by its
hydrogen the chloric acid of the chlorate of potash, some
chlorine is set free, and, with this, peroxide of chlorine
mixed according to temperature with some protoxide of
chlorine, or what Davy, who made the discovery, called
eucblorine. The gaseous mixture is of a yellowish-greem
colour, suffocating, and explodes with a flash of light
when a red-hot wire is plunged into it. On filling,
the bottle with water there would be a solution ot
chlorine, eucblorine, and perhaps some peroxide, with any
undecomposed chlorate. The solution would have bleach¬
ing properties and, if strong, corrosive properties.” The
solution should be freshly prepared each time, as it under¬
goes change under the iniluence of light, becoming colour¬
less. I have prescribed it for fiatulence, foul stomach, and
diarrhoea, but have no experience of it in typhoid fever. I
desire to add my small mite of testimony to the principle
advised by Dr. Yeo as the most rational—that is, the routine
adoption of an antiseptic treatment as a general indication.
The success recorded after the many various antiseptics
named certainly points to this sensible departure, whatever
theory of niicrobicide or germ-destroyer may ultimately be
found correct, and we may hope to have this definitely de¬
cided in the not far distant luture. The list of remedies
enumerated by the lecturer is not wanting in length or
strength, but I should like to call attention to another, and
solicit for it a trial in these cases. I allude to salol. Its-
merits are not yet sufficiently well known, more especially
for the purpose under discussion—viz., general antisepsis of
the system, and of the intestinal and urinary tracts m
particular.
A case of chronic cystitis in an old man of seventy-two,,
with enlarged prostate, and requiring catheterism five or
six times in the twenty-four hours, who was gradually
sinking under ordinary treatment, including daily washing
out of the bladder with boric acid solution, with dry tongue,
anorexia, and the sickly sweet odour of the breath, charac¬
teristic of purulent absorption, and Avith urine like pease
soup with a lot I of mucus, got quite Avell in two or three
weeks on fifteen-grain doses of salol three times a day. The
tongue at once commenced to clean, appetite returned, and
the urine became quite clear; I last saw the old man
gardening. Salol we learn passes unaltered through the
stomach, and is split up by the pancreatic juice into it&
phenyl and salicil elements. In addition to its antiseptic,
it has jintipjretic properties. Its general antiseptic pro¬
perties are shown by the above case, and its local will be
first exhibited in the bowel; if so, is it not theoretically an
ideal remedy in typhoid fever, that its energy should first be
liberated at the spot where we want it—viz., in the small
intestine? It has also the advantage of being a pleasant
remedy. It has a slightly aromatic odour and not
unpleasant taste. Adults like it in the form of
powder placed on the tongue and sucked down or
triturated against the palate by the tongue; for children
it is better to emulsify it when it is readily taken. The
motions are rendered inoffensive, the manufacture of gas
ceases, and the loc^l action on the congested or ulcerated
Peyer’s glands is beneficent and healing. (It is an excellent
topical application for ulcers and as a gargle.) We shall
find that ulceration, bceraorrhage, and perforation will
become things of the past if this treatment be adopted as
routine from the beginning. I have met with no toxic
effects from its use ; the urinemaybecomesmoky or cloudy,
so that we can easily keep touch of saturation with the
remedy, but I have seen no inconvenience arise from this.
I use it without the quinine, which I should expect to
produce quinism if given in from twenty to thirty grains per
diem ; it is too potent a remedy to take into partnership in
estimating results. Besides, I have not required it, and use
other defervescents in the shape of alkaloids—aconitine,
veratrine, and digitaline, whilst the vitality is maintained
by the exhibition of arseniate of strychnine. The three
indications in the treatment of typhoid fever are then:
(1) General and local antisepsis by means of salol; (i?) the
reduction and control of the pyrexia by defervescents;
(:{) the sustaining of the vitality of the patient.
I am. Sirs, yours truly,
Spondon, Dorby, April 13Ui, 1801. B. WALKER.
D..; ' , VJvjO^lC'
106 i The Lancet,]
THE NAIL AND CHAIN MAKERS’ DEPUTATION.
[May 9,1891.
THE NAIL AND CHAIN MAKERS’ DEPUTATION.
To the Editors of The Lancet.
Sins,—In an article in j'our issue for April 25bh, you
express a desire for further information with regard to the
deputation of women engaged in the nail and chain trades
which recently waited on the Home Secretary, and also
curiosity as to how the expenses of the deputation were
defrayed. The deputation was the outcome of a largely
attended meeting of nail and chain makers (male and
female), which was held to consider the proposals affecting
their peculiar industry, as contained in tbe Bills of Lords
Dunraven and Thring and that of the Home Secretary.
The expenses of the deputation were defrayed by Lady
Goldsmith, who was represented at the meeting by a depu¬
tation of two ladies. The meeting was attended by the
borough member, and was quite in harmony with the
suggested sanitary reforms and other proposals affecting
tbe welfare of the workers, and was unanimous in
supporting restrictions preventing women taking work
beyond their strength. The article goes on to state:
First, that nail and chain-making is work physically
unsuibed to women; secondly, that the work should be
checked, because, economically, it is productive of starva¬
tion. In support of the first statement, we are informed
that the heavier work is destroying the health of the
women; that the working of tbe Oliver involves undue
physical strain; that spinal disorders ensue; and that labour
IS frequently difficult and abnormal.
With regard to these assertions, I should like to say that
hardly any of the heavier work is now done by women, and
that the people of the district are in favour of its total
prohibition; that the observations of daily practice show
that spinal affections are extremely rare, whilst phthisis
and other tubercular diseases are much less frequent than
in most other districts. If special difficulties with regard
to accouchements exist, I can only say that I have failed
to meet with them, and others of very large experience in
midwifery in this district confirm me in this state¬
ment. If special difficulties in labour do exist, ought
they not rather to be attributed to the premature age at
which marriages are contracted ? I had always considered
that difficult and prolonged labours were more frequent
amongst those women of the upper classes who lead
luxurious and enervating lives than amongst their sisters
whose muscular systems are more developed by bodily toil.
I have very frequently watched women working the olivet,
and have tried it myself on several occasions, and from
what I have been told and from personal experience I cannot
regard the ordinary use of tbe Oliver as involving any undue
strain. We are told by Professor Fo.ster that the strength
of a woman is to that of a man as 5 is to 9. The largest chain
made by women is barely § in., but the usual size is what is
known an No. 1 chain—that is, iron of about ;):in.
in diameter. If such work is excessive for women,
surely the making of a large cable 2^ in. in diameter
involves a still more excessive strain upon men, yet we hear
nothing of their physical incompetence. The article goes
on to draw a highly sensational picture of crowds of
stunted, gaunt, chicken- or fiat-breasted women, with
angular limbs and colourless cheeks, and reports one case of
a healtby-looking chain-maker, whose healthy appearance
we are asked to attribute {I do not know whether facetiously
or not) to the invigorating and recreative influences of the
washing-tub, at which she worked when not chain-making.
Those acquainted with the district (otherwise than by a
flyingvisit to Cradley Heath) will, I think, be quite unable
to endorse this picture. There is an extremely high infant
mortality, but, considering the hod sanitary conditions
prevailing, the general health is remarkably good, and I
think that the female nail and chain-makers would com¬
pare most favourably in physique with many of their more
fortunately situated sisters. I should regard them as a class
as more than usually robust. With regard to the economic
difficulties, it is certainly undesirable that women should
supply cheap labour to the detriment of men ; but this in¬
dustry is of long standing, and its sudden total prohibition
would most probably only drive tbe trade to foreigu competi¬
tion, and without helping tbe men, by depriving the women of
their only available field of labonr, produce, at all events,
grave temporary distress, and render the last state of the
workers worse than the first. Those who have the welfare
of the women of this district at heart would surely find
better scope for their philanthropic endeavours in the
inauguration of strong trades’ unions amongst the women,
which would enable them, as the^ have men in the past,
to secure better sanitary conditions and more adequate
remuneration without crippling a legitimate and only avail¬
able source of industry.—I am, Sirs, yours faithfully,
Thomas E. Mitchell, M.B., B.C.
Netherton, near Dudley, April 20th, 1891.
%* We print tbe above letter, but must maintain our
view that such work as our Commissioner described—and
the description is not falsified by being characterised as
“ sensational -is unsuitable for women, and must neces¬
sarily entail, sooner or later, serious physical—to say
nothing of moral—evils on the workers. Bad customs or
conditions are not to be let alone because they may happen
to be of long standing, nor should the fear of imaginaiy
consequences operate as a bar to prudent and well-devised
efforts to alter them.—E d. L.
LEGISLATION FOR MIDWIVES.
To the Editors of The Lancet.
Sirs,—T aking up the thread of your Liverpool corre¬
spondent from The Lancet of March 14fch, I think it
must bq the wish of tbe profession “to improve the status
of the midwife.” From this standpoint it is most desirable
for the Legislature to enact such as the following, so as to
make a start: 1. That all certificated mid wives be regis¬
tered. 2. That uncertificated midwives in practice be
allowed to offer themselves for examination, and, if success¬
ful, be registered. .3. That those already in practice and
those unable to pass the standard examination be allowed
to continue in practice, but nob to register. (P.S.—That
“registered midwife”b 0 put on the door-plate,) 4. That
from the date of legislation no uncerfcificated midwife be
allowed to put up her name or practise as a midwife
under a penalty of £50, so that in the course of nature
the present handy woman may be stamped out. 5. That
the future training, examining, and control of mid¬
wives be in the hands of a committee (medical) and
five or seven subcommittees (medical). 6. That the com¬
mittee be formed of three representatives from London
and one from each of the respective subcommittees.
7. That a subcommittee exist in every examining centre, of
which there shall be five or seven—e.g., in London, Liverpool
or Manchester, Newcastle or Durham, Birmingham, &o.
8. That the laws and by-laws be framed by the committee
(medical). 9. That a copy of the by-laws relative to mid-
wives be given to every successful candidate along with her
certificate.
Immediate legislation for midwives is most pressing, as a
large influx of the uncerbificated class may be expected now
that “they know” deterrent legislation is looming ahead,
so as to claim vested rights.—I am. Sirs, yours faithfully,
Liverpool, May 4th, 1891. J. ARMSTRONG.
LIVERPOOL.
(From our own Correspondent.)
The Property Eight of Prescriptions.
A paragraph in the London letter of a local daily
paper alluded to the question as to whether the right
to a proscription belonged to the prescriber or patient.
A local practitioner gave prominence to the fact that
he refers all bis patients to a certain number of selected
chemists, who are required by the prescriber to keep
all the prescriptions, returning them to him periodi¬
cally. He justifies this position by the improper practice
which patients have of lending prescriptions to friends. The
question is one of much interest here, since comparatively
few practitioners in Liverpool dispense their own medicines,
the majority writing prescriptions and allowing patients to
lease themselves as to where they take them. It may have
een, pecuniarily speaking, a mistake for practitioners to
give np dispensing, bub it is too late in the day to lament
this now. Undoubtedly it is hard upon practitioners that
patients should make so improper a use of prescriptions as
that indicated, and that chemists should prescribe. Still, a
prescription belongs to the patient, who has a perfect right
to decline any suggestion, still more any dictation, as to
where it is to be taken. In this, as in other matters, it is
The Lancet,]
LIVERPOOL.-NOBTHERN COUNTIES NOTES.
[Mat 9, 1891. 1069
-well to remember that medicine is a noble profession but a
■vile trade.
^'Before the Magistrates for the Two Hundred and
Eighteenth Time"
The following case shows the fearful indifference to which
those accustomed to the sight of intemperance may arrive.
The recently appointed stipendiary magistrate, Mr. W. J.
•Stewart, had lately before him a wTCtched-looking woman
charged with having broken eight panes of glass at the
Liverpool Workhouse. The prisoner is a cripple, and uses
•a crutch, which, on a former occasion, she threw at the
magistrate; hence on this occasion it was kept from her.
The prisoner said it was no use hersaying anything, asahe was
ill ways being brought up, and the magistrate remarked that
to his mind she was more lit for a lunatic asylum than for the
workhouse or gaol. The police sergeant, who kept the record,
informed the court that the doctors could not certify that she
was insane, and thatahehad been 217 times before the court.
The magistrate thought this of itself sullicient proof of
uDsanity. He remanded her for a week for examination as
to her mental condition, and, as the gaol surgeon could not
pronounce her insane, she was sentenced to two months’
'imprisonment, the utmost the magistrate could give her.
St appears that the term of imprisonment is regulated by
tbe amount of damage done.
The Assizes,
A fourth assize is held here annually. It commenced on
the 4bh inst., Mr. Justice Grantham presiding in the Crown
Court and charging the grand jury. In the course of his
remarks he alluded to the serious cases of wounding or other
violence which almost invariably occur here in the imme¬
diate proximity of public-houses where drinking has been
carried up to the point when men and women become
quarrelsome, violent, and even maniacal. His lordship
observed that if the publicans were made to pay the costs
of the prosecution such excessive drinking would in all pro¬
bability soon cease, and with it the crimes of violence also.
Justice Grantham also observed that there were several
•cases of criminal assaults on young children, and expressed
his strong opinion that corporal punishment was the only
proper sentence for such crimes.
More Wounding.
In confirmation of what was stated in a previous letter as
to the experience of Mr. George Hamilton at the Northern
Hospital, and in anticipation of the above remarks, another
serious case of stabbing occurred on the 2Qd inst. It
was the result of drink, and occurred nob far from
the Northern Hospital, to which institution the un¬
fortunate man dragged himself, leaving stains of blood
as he walked along. Ho was found to be suffering
from a dangerous wound in the neck and from great loss of
blood. An epidemic of stabbing was checked many years
ago by the prompt action of the head constable, magis¬
trates, and judges. The former had bills published in
various languages cautioning foreign seamen and others
from wearing knives in their belts when they came ashore.
The magistrates gave severe sentences in those cases where,
the wounds being slight, summary jurisdiction was per¬
missible ; the more serious cases being sent to trial, and
very severely dealt with. It is very desirable that similar
siieasnres should be taken now, since nothing is more firmly
established by experience than that criminals find imitators,
cinless the latter are deterred by severe warnings.
• erpool, May 5Ui.
NORTHEEN COUNTIES NOTES.
{From our Own CoRUESPONDEN'i'.)
The Influenza in the North.
Tub epidemic of inlluenza in the north of England has
greatly extended since my last letter. I believe it is far
more diffused than the outbreak last year, for it has re¬
turned to places before attacked, and visited fresh ground.
Whitby has been severely visited, and it is curious that so
long as the north and north-east winds prevailed it was
comparatively free from the complaint, but when the wind
changed to the west there was a coincident outbreak.
Although largo numbers have been prostrated in the Whitby
■district, fatalities have been few. I believe that, coming
more north, Sunderland and Gateshead have suffered more
severely than Newcastle, where we have, however, a very
large number of cases.
The Population and Health of Newcastle.
The report of tbe city engineer, Mr. W. G. Laws, for the
year ending March 25bh last has just been issued, and in it
be estimates the population at 185,000, and on this basis he
contends that the general death-rate would come out at 22’9
and the zymotic at 1 -8 per 1000, the first being 8 per cent,
above, and the latter 35 per Cent, below, the rates of the large
towns. Of course, although we are yet without the official
returns of the census, it is understood that there has been a
very large increase of population in the city ; one district,
(Byker) has increased 21,000. and another at the opposite
end of the city (Elswick) 25,000, so that there is a pro¬
bability that the population will reach close upon 200,000 ;
but to decide this and many other questions we must wait
for tbe official returns.
Newcastle Hospital Sunday Fund.
A meeting of the management and distribution of the
Hospital Sunday Fund has been held, and the statements
given are very satisfactory. The ccllecbions at places of
worship this year have been over £2000, and at manufac¬
tories about £2400, and with special contributions the total
amount has reached over £4500, being an increase on tbe
previous year, and making the largest collection in the
history of the fund.
Alternative Staircases in WorJchoities.
At the last meeting of the Newcastle Guardians a letter
was read from the Local Government Board, stating that
the Local Government inspector had called the attention of
the guardians to tbe want of alternative means of escape
in case of fire from certain of the sick wards, and also from
some of the nurses’ rooms, and requested to be informed
“ what steps had been taken in the matter by the
guardians.” The guardians have taken the matter very
coolly, and directed their clerk to reply that they did nob
think that alternative staircases were required, but that
they would give the matter further consideration. The
guardians have accepted a heavy responsibility in this
matter, for should a fire take place a disaster may occur,
and there will be little time for consid eration on tbe part of
the unfortunate patients and nurses.
A Savage Intruder.
A curious case occurred at a f armliorrso near Durham last
week. A pig entered a kibclien where a baby lay in a
cradle and attacked it savagely, overturning the cradle,
and biting the child’s arm and cheek seriously. Mr. Me Ardle,
who dressed the wounds, says that fortunately none are in
vital parts.
Sunderland Infirmary.
The physicians and surgeons of the Sunderland Infirmary
brought forward many cases of interest on the occasion of
the branch meeting of the Association held there last
Thursday, and the meeting was thoroughly enjoyed by all
who attended. The following were amongst the cases :—
Mr. Maling: A very well marked case of Molluscum.
Dr. Squance : A case of Lupus treated by Koch’s method ;
also a lantern microscope. Dr. Robertson : A case of Lupus,
also under Koch’s treatment; au electric lamp, and a case
of Disease of the Antrum. Dr. Drummond : Gall-stones
discharged through the abdominal walls ; Aneurysm of the
Arch of the Aorta; Abscess Cavity in Lung of Child.
Dr. Murphy : A Complete Series of the Diseases of the
Uterine Appendages, which he had removed at the Sun¬
derland Infiniiary, including tubal pregnancy, pyo-aalpinx
of the ovary, parovarium of the broad ligament, and
an enormous round-celled sarcoma of the ovary removed
from a girl aged sixteen two years ago, the patient
still keeping well and at -work. Owing to the interest
of the specimens and tbe time taken up in their dis¬
cussion, the long list of papers to be read was not reached,
and the meeting broke up to dine at the Queen’s Hotel,
Dr. Middlemiss presiding. A word should be said here in
recognition of the kindness of the medical staff of the
Sunderland Infirmary and the hospitality which they ex¬
tended to their visitors.
The Sillotli Convalescent Institution has received £100
bequeathed by Mrs. Mary Davidson, late of Allonby.
Newcastlo-ou-Tyne, May Dili.
Digitized by
Google
1070 I'HB LaitcstJ
SCOTLAND.—IRELAND.
[May 9,1S91.
SCOTLAND.
(From our own Correspondents.)
The Summer Session in Edinburgh,
The Summer Sessiou in the Medical Faculty commenced
on Monday, in the usual matCer-of-facc style. From the
number of men about there would not appear to be any
falling off in the attendance at the school.
Bananas as Food and Medicine,
Dr. John Dougall, of St. Mungo’s College, Glasgow, has
a letter in a recent issue of the Glasgow Herald on the
banana. He quotes from Stanley’s “ In Darkest Africa,”
showing that “for infants, persons of delicate digestion,
dyspeptics, and those suffering from temporary derange¬
ments of the stomach, the flour, properly prepared, would
be of universal demand.” During Stanley’s two attacks of
gastritis a slight gruel of this dour, mixed with milk, was
the only material that could be digested. It is odd, also, as
pointed out in Stanley’s book, that in most banana lands—
Cuba, Brazil, West Indies—the valuable properties of the
banana as an easily digested and nourishing food have been
much overlooked. Dr. Dougall has made some experiments
in making banana flour. He concludes that it should be
made from the ripe fruit at its place of production. In
trying to make it from bananas purchased in Glasgow, he
obtained, on drying the pulp, a tough sweet mass like
toasted figs, an appearance probably due to the conversion
of starch into sugar. Bananas contain only about 50 per
cent, of pulp, and of this about 75 per cent, is water ; they
would yield, therefore, only one-eighth part of flour.
Physiological Action of Carbon-monoxide of Nickel Ni(CO) 4 ,
At the last meeting of the Philosophical Society at
Glasgow Professor M'Kendrick and Dr. Snodgrass sub¬
mitted a short paper on the above substance. It is a
clear, colourless liquid, wliich is very volatile, readily
decomposing into metallic nickel and carbonic oxide.
It is intensely poisonous, and, when present in the
atmosphere to the extent of one-half per cent., proves
fatal to animal life. Injected subcutaneously, even in
minute quantity, it acts as a respiratory poison, giving
rise to ^mptoms similar to those produced by carbonic
oxide. ’The spectrum of the blood of an animal poisoned
with it is similar to that of carbonic-oxide hmmoglobin.
Uniting with the haemoglobin of the blood, it apparently
prevents the tissues from being supplied with a due amount
of oxygen, and oxidation being interfered with, there is a
large and prolonged fall of temperature. The extremely
oisonous nature of the substance and its pronene.ss to
ecomposition render it as yet unsuitable as an antipyretic;
but means may be devised of diluting it so that it may be
of value in the reduction of abnormally high body tempe¬
rature.
Milk-poisoning from Colostrum.
In connexion with an outbreak of milk-poisoning which
took place a few weeks ago in the west-enu of Glasgow, an
outbreak marked chiefly by great prostration, vomiting, and
purging, a report has been issued which traces the affection
to the use of milk from newly calved cows. Dr. Russell in
his report says : “ To send for sale as human food the milk
of a newly calved cow is always inadvisable. All well-
conducted milk companies have a clause in their contracts
with farmers prohibiting this. The usual words are: ‘No
milk to be sent from a newly calved cow,’ but one company
prescribes ‘four clear days from the date of calving.’
Another, in Copenhagen, requires an interval of twelve
days. The normal constitution of cow’s milk is peculiar
for several days; Fleming says ‘for five or six.’ The phy¬
siological purpose is to purge the calf, and it is not surprising
that the efiect on human children may be violent even
when the cow is doing well, especially when by any acci¬
dent the milk is not freely mixed with other milk.”
Convalescent House, Arbroath.
This Convalescent House at Jennyswells, in connexion
with the Arbroath Infirmary, was formally opened for the
reception of patients on the Ist inst. The infirmary
patients are to be admitted free of charge, but it is also
open bo other patients on payment of a small weekly sum
aa board. The House is the gift of the late Mr. Alexander
Duncan, of Rhode Island, United States, and his brother,
Mr. John Duncan, of Park-hill, Arbroath. It has cost
about £1500*
Health of Edinburgh.
The mortality last week was 84, making the death-rate
IG per 1000. Diseases of the chest caused 50 deaths, and
zymotic diseases 7. The intimations for the week comprised
typhoid fever 5, diphtheria 1, scarlatina 19, and measles 83b
IRELAND.
(From our Own Correspondents )
DUBLIN.
Boyal College of Surgeons.
The annual elections for examiners usually take place od
the first Monday in May, but this year they have been
postponed to a later date. Mr. John Cranny, M.D. Diib.^
F.R.C,S.I., has intimated his intention of becoming a can¬
didate for the Vice-Presidency of the College in June next.
There is a probability that Mr. William Frazer, ex-member
of Council and examiner, may also be induced to become a.
candidate for the vice-presidency.
. Dublin Main Drainage.
At a meeting of the Dublin Corporation the following
resolution was unanimously adopted:—“ That inasmuch as
the present condition of the River Liffey renders it a public
nuisance owing to the constant discharge of sewage from
the city and some of the townships into it, and as the recent-
consolidation of the city debt places the Corporation in a
favourable condition to deal with the pollution of the river
and the main drainage of the city, that a Main Drainage
Committee be appointed to make inquiries as to the best
scheme of main drainage for the city of Dublin, and report
to Council with as little delay as possible.” A perfect
system of main drainage is abmlutely necessary, and must
be undertaken sooner or later, the only reason for the delay
being the enormous cost of such an undertaking. If the
adjoining townships—viz., Clontarf, Kilraainham, Pem¬
broke, Rathmines, &c.—bear their proportion of the cost,
the expense to the Dublin ratepayers would be considerably
lessened, and the purification of the entire Bay of Dublinj
be undertaken, while probably assistance might be obtained
from Government for so important a local object. At all
events, the appointment of a committee to examine into the
matter carefully and wisely cannot be underrated, and must
rove of great benefit to the citizens of Dublin and the in-
abitants of the adjacent townships.
Irish Emigration Returns.
The emigration from Ireland for the past year was con¬
siderably less than that for 1889. The decrease amounteci
to 9365—viz., 4998 males and 4367 females. The totaJ
number of emigrants, natives of Ireland, who left Irish
ports from May Ist, 1851, when the Registrar-fjeneral’s
returns were first issued, up to the end of last year wa&
.3,407,893.
The Corporation have erected a pillar box close to Carlisle
Bridge for the receipt of newspapers and periodicals for the
use of patients in the infirmary of the South Dublin Union
Workhouse.
Her Excellency Lady Zetland entertained nearly one
hundred nurses belonging to the Dublin hospitals ac the
Viceregal Lodge last week.
Dr. Thomas F. Farrelly died at Bailieboro’, County
Cavan, on the28bh ult,, from fever contracted in the dis¬
charge of bis professional duties, aged thirty-three years.
Mr. William Greene has been elected medical officer of
Howth dispensary district, in the vacancy caused by the
death of Mr. Neary.
At a recent meeting of the Royal Hibernian Academy^
Mr. Booth Pearsall, F.K.C.S, was elected an honorary
member of the Academy. Mr. Pearsall’s artistic abilities
are well known and appreciated in Dublin, and this yoar he
has two pictures on exhibition in the Academy.
Mr. Robert H. Woods, M.B., who obtained the Surgical
Travelling Prize last year at the University of Dublin, is on©
of three students who have been elected by their fellow-
students to attend the f&tes at Lausanne on the 17th inst.
and four following days. _
BELPPT. '
The Royal Hospital.
On Wednesday, April 29bh, at an “ At Home ” given ir»
Belfast Castle, the leading citizens of Belfast and district
assembled to present an illuminated address and silver
Diy,.,,
lOogie
The Lancet,]
PARIS.
[May 9.1891. 1071
casket to the Earl of Shafteebary on hie comiDg of age.
The Mayor of Belfast presided, and after the address had
been read, the gift presented, and the young Earl had
replied, his mother, the Countess of Shaftesbury (daughter
of the late Marquis of Donegal), delivered a most eloquent
speech in which she announced a very generous gift to the
Iloyaf Hospital, as a memorial of the events of that day.
She said the Royal Hospital was held under her by a ter¬
minable lease made by her grandfather in 1813, and in
twenty years that valuable property would again become
art of the estate. Knowing how the advantages of the
ospital reached all sections of the community, and that
its efficient maintenance was most desirable, she and her
son (the present Earl) had arranged a new lease to the Cor¬
poration of the Royal Hospital for 10,QUO years, at the
nominal rent of 2s. Qd peryear,to commence immediately in
lieu of the present rent. Further, should it be decided to
build a new hospital on another site, as more advantageous,
(she would consent to a sale of the present building freed from
<all obligations as to its use for the 10,000 years’ terra
at 2s. Qd. a year, the sum realised to go to toe building
of the new hospital. The Countess having handed the lease
'to the Mayor of Belfast, he thanked her in the warmest
terms on behalf of the citizens, and gave the document to
Mr. Wakefield Dixon (chairman of the Board of Manage¬
ment of the hospital), who returned thanks to the Countess
•and the Earl of ShaResbury for the munilicent gift. At
the usual meeting of the City Council, held on May 1st, it
'<ivas unanimously decided to send a vote of thanks to the
'Countess for her great kindness and generosity to the city
of Belfast; and the Board of Management of the Royal
Hospital have passed the following resolution:—“ The
Board of Management of the Belfast Royal Hospital, while
anxious to avail themselves of the first opportunity of
placing on record their gratitude for the handsome gift to
the hospital by the Countess of Shaftesbury and the Earl
of Shaftesbury of the hospital property practically free of
rent for 10,000 years, defer until a meeting of the Corpora¬
tion, which will be held on Monday, the 25th inst., the
passing of a resolution conveying to Lady Shaftesbury and
Lord Shaftesbury their appreciation of the value of the gift
v/bich they have made to the inhabitants of Belfast in con-
mexion with an institution which endeavours to alleviate
all those suffering from accident or disease, more especially
in connexion with the working classes.”
Queen's College.
The council of the college has nominated Mr. Benjamin
Moore, B.A., a distinguished student of chemistry, for the
ocholarship lately placed at their disposal by the Commis¬
sioners of the 1851 Exhibition. The scholarship is worth£150,
and is tenable for two or, in special cases, for three years.
Mr. Moore intends to study chemistiy at Leipsic during his
tenure of the scholarship.
The Summer Session.
The summer session commenced on May 5th, when clinical
■beaching was resumed at the Belfast Hospital for Sick
Children. The gold medal at the close of the session was
awarded to Mr. Scott.
PARIS.
(Fiiom our Own Correspondents.)
Treatment of Wounds of the Abdomen.
The importance of the above subject in these days of
j^iant armaments and repeating rifles is self-evident, and it
is not surprising that deductions gathered from civil prac¬
tice should provide occasional matter for discussion at our
learned societies’ meetings. In 1887 Dr. Barnard, at the
suggestion of the late Professor Tr61at, took this subject as
the theme of his inaugural thesis. In that opuscule he
pronounced strongly in favour of the formation of an early
diagnosis (penetration or non-penetration) by means of a
flexible probe, or, if necessary, an exploratory dissection of
the wound down to the peritoneum. Penetration being
proved, he advised immediate laparotomy through the llnea
alba for the purpose of suturing any wounds of the
stomach, intestines, or bladder that might he discovered,
or, what is of equal importance, of tying any wounded
bloodvessels, removing clots and foreign bodies, and clean¬
ing the peritoneal cavity. Dr. Barnard’s views were at
the time attacked by M. Reclus in his Clinique Chirur-
.<!icalc de I'B6tel-Dieu, and it would appear from a dis¬
cussion at the Soci6td de Chirurgie, held on the 29th ult.,
that this surgeon has not changed his opinion. Araongso
the speakers, M. Reclus was supported by only one confrire,
M. Berger, while the opponents of the opium and ex¬
pectant treatment were MM. Terrier, Pozzi, and Lucas-
Oharopionnibre. M. Terrier, in citing three eases of abdo¬
minal knife wounds (in one of which laparotomy revealed
no lesions, and the patient made a rapid recovery), pro¬
phesied that the riactionnaires would end by coming over
to the opposite camp.
I An Improved Hypodermic Needle.
I How often does it happen that when one wishes to use
: the hypodermic syringe the needle is found impermeable,
and consequently useless. Steel needles are in effect very
liable to oxidise and rust, and are, moreover, difficult to
disinfect. Many attempts have been made to replace them
by needles composed of gold or platinum—metals which
have unfortunately the inconvenience of being costly, of
becoming blunt, and of easily bending. M. Debove has
recently bad manufactured for him needles made of an alloy
of platinum and iridium—a combination which is very hard,
and which does not oxidise. These needles resist the heat
evolved by the flame of a spirit lamp (disinfection), and the
passing of a wire through the bore in order to maintain its
patency is unnecessary. Add to these advantages the fact
that they are hardly more costly than the steel article—
indeed, being more durable, the ultimate cost is probably
less- and practical men will appreciate the advance made
in this direction.
•A New Antiseptic.
At the Acad(^mie de Mbdecine, on April 28bh, M. Polaillon
read a paper contributed by Dr. Berlioz of Grenoble
on a new antiseptic agent called “ microcidine,” which
is composed of 75 per cent, of napbtholate of sodium and
25 per cent, of naphthol and phenyl compounds. It is
a white powder obtained by adding to fused /S-naphtbolhalf
its weight of caustic soda, and allowing the mixture to
cool. It is soluble in three parts of water, and the solution,
which is cheap, is said to possess considerable antiseptic
powers, without being toxic or caustic or injurious to
instruments or linen. The antiseptic properties of micro¬
cidine, while inferior to those of corrosive sublimate
or naphthol, surpass those of carbolic and boracic acids ten
and twenty times respectively. Microcidine is eliminated by
the kidneys, and is antipyretic. M. Polaillon has experi¬
mented with this new agent largely in his wards as a dressing
to recent and other wounds, utilising as a dressing, after a
preliminary cleansing of the raw surface, with a 3 per cent,
solution, gauze soaked in the same, and covered with a layer
of oiled suk and a thick pad of cotton-wool. The results are
reported to have been excellent.
A Comparison of the Medical Population of Paris, Vienna,
and Biissia.
La France Medicate gives in its current number some
interesting figures in reference to the above subject. It
appears that Vienna, with a population of 800,000 for the
town proper, and 400,000 for the suburbs, counts 1315 and
177 doctors for these respective divisions—i.e., 1 per GOO
inhabitants of the town, and 1 per 2250 of the suburban
population. In Russia, there were in July, 1890, 12,112
male and 700 female practitioners, 2629 of the former
being attached to the army and navy. This gives a
proportion of one practitioner for 100,000 inhabitants.
Paris is poorer in doctors than the Austrian capital, for,
with a ^population of 2,300,000, there are only 2200 medical
men, being about 1 per 1000. As might be expected, the rich
arronclissements possess more doctors than the poor hut
more populous districts.
International Courtesies.
The delegates appointed by the General Council of the
Faculties to represent France at the fetes to be held at
Lausanne next month to celebrate the conversion of the
Faculty of that town into a University are MM. Planchon,
Director of the Ecole de Pharmacie; Brouardel, Dean of
the Paris Faculty of Medicine ; Lannelongiie, Riohet, and
Strauss, Professors at the same Faculty ; the Dean of the
Faculty of Law; and M. Liard, Director of Higher Education.
The Seine Sanitary Board has, in its turn, nominated as its
representatives at the forthcoming International Congress
of Hygiene in London the following gentlemen : MM. Lan-
cereaux, Brouardel, Pochard, L6on Colin, Nooard, Schutzen-
berger, Bezanpon, Leon Faucher, Jungfleisch, and Voisin.
Paris, May 4th.
Dw n Google
1072 Thb Lancet,]
NEW ZEALAND.—OBITUARY.
[May 9,1891.
NEW ZEALAND.
(From our own Correspondent.)
An idea of thepresent state of derelopmeot of the medical
sciences in this colony may be gained from the following
synopsis of the contents of recent issues of its one medical
journal.
The New Zealand Medical Journal has now reached the
middle of its fourth volume, and as it is the organ of the
New Zealand Medical Association its value to the medical
men practising in the colony unable to attend the various
medical meetings is of the first importance. Each volume con¬
sists of four numbers issued (Quarterly. 1 have before me the
last three numbers issued. J. Wilkie and Co., printers of
Dunedin, are the publishers, and the editorial chairis occupied
by Dr. Colquhoun of Dunedin. Auckland is represented by
Dr. E. Robertbn, Christchurch by Dr. Thomas, Nelson by
Mr. Cressey, Wellington by Dr. Fell, Invercargill by Dr.
Gloss, Blenheim by Mr. Cleghom, and Dunedin by Dr. de
Zoucheand Mr. Davies. These gentlemen communicate the
medical news in their respective districts to Dr. Colquhoun
quarterly. In this way it is clear that the whole colony,
from a medical point of view, is brought together, and
that practitioners residing up country are kept in touch
with the transactions of the local branches of the Asso¬
ciation. The editor is empowered by the Association
to use his discretionary power regarding the insertion
of contributions forwarded to him for publication. This
is a very wise and prudent coarse to adopt, and one,
moreover, which is absolutely necessary. Considering the
number of cities in the colony, all much on a par as regards
population, and >0 widely scattered, it is a matter of eon-
gtatulation to ail members of the New Zealand Medical
Association that they have been fortunate enough to
obtain the services of Dr. Colquhoun as editor of their
journal. His heart seems to be in the work, and hia
tact in the management of the journal generally is highly
appreciated. Each volume has about275 pages. Tiiejournal
is printed on good paper with excellent type, and the
management in this respect leaves little to be desired. The
last October number contains a description from the pen of
Dr, fl. Widenham Mauneell, lecturer on surgery at the
Otago University, of a “new method of excising the
tongue,” which has been read with much interest through-
out the colony, The article is copiously illustrated, ex¬
plaining the context, which makes the various steps of the
operation very apparent. During the past two years
Dr. Maunsell has performed this operation four times
for cancer. All the stumps healed by first intention,
and the patients made a rapid convalescence. He
claims, first, that the final step of the operation
carries out merely one of the first principles of surgery—
viz, the mucous membrane on the floor of the
month is fixed to the mucous membrane on the dorsum of
the base, and covers the entire surface of the stump, which
it holds well forwards and downwards towards the floor of
the mouth”; secondly, that the patients find no difficulty in
swallowing after the operation ; and thirdly, that the epi¬
glottis is so controlled by pressure that the operation is
rendered almost bloodless. In the same number is an
excellent account of the Proceedings of the Canterbury
branch of the Association, presided over by Mr. Hacon of
Christchurch, who delivered a lengthy and veryaole address
on scientific advance generally at the close of bis year of
office as President of this branch of the New Zealand Associa¬
tion. Dr. ColquhounintbeJuly issue describes a case of “Cere¬
bral Tumour in the Itolandic Area,” which he successfully
removed. The total weight of the tumour was about four
ounces and a half; it probably had its origin in the dura
mater, and on section showed the cells characteristic of small
spindle-celled sarcoma. The case is very well described,
starting with the symptoms of Jacksonian epilepsy to the
final departure of the patient convalescent six weeks after
the operation. A number of books are reviewed in this
issue. Especial attention is drawn by the reviewer to “the
Transactions of the second session of the Intercolonial
Medical Congress,” held in Melbourne in the previous
January. The New Zealand Medical Journal describes
this work “ as the most valuable book on Colonial medi¬
cine that has yet appeared, and one which every medical
man practising in the colony will find most useful.”
The January number, 1891, contains an article read before
the general meeting of the New Zealand Association last
year by Dr. Frederic King, medical superintendent of the
Seaclift' Asylum, on the Degree and Distribution of Sensory
Paralysis in Lesions of Median and Ulnar Nerves. The
subject is well illustrated by cases, and the histology of
sensory nerves is minutely inquired into. The New Zealand
Cancer Statistics, by Mr. MacDonald, to which I have>
already referred in a previous contribution, is further dis¬
cussed. A map of the colony is added to the article, showing;
the various towns in the colony where cancer is: (1) very
commonly found, (2) commonly found, (3) notcommonly found.
All the lai'getowQsin the north island are branded No. 1, while'
the South Island’s chief towns so marked are only Nelson^
Hokitika, and Dunedin. Mr. MacDonald adds “ that it ia
commonly asserted that cancer is much more common ia
the Colonies generally than in the Old World. This is,
however, not the ease. In 1888 the percentage of death®
from cancer in England was about 1 in 15t'0, whilst in New
Zealand it was about 1 in 2500.” The same number con-
tains an article by Dr. G. R. Saunders of Wanganui on
Alcoholic Neuritis, giving his clinical experience of these
cases. Dr. Guthrie describes two cases of Exostosis and
Placenta Prosvia; and Mr. A. Osborne Knight of Auckland
gives clinical details, very carefully compiled, of a case
of Acute Intussusception of the Ccecum and Appendix,
followed by Mortificalion. A rtunmi of the Principles and
Treatment of Diabetes Mellitus by Dr. Pavy, as described
by him at the late Berlin Congress, is found in this issue of
the journal. An article which cannot fail to give satisfac¬
tion to every right-thinking person, be he a professional
man or otherwise, is that entitled “ A Plea for Sfcringenb
Legislation in the matter of Corrupt and Immoral Pub¬
lications,” by Dr, King. This is a subject which few men-
care to tackle. I congratulate the author on his courage'
in so completely unfolding to the gaze of the colonial
public the startling and daring quack advertisements and
publications of unprincipled persons who are constantly
spreading their nets to catch the unwary. Corrupt ptib-
licatioDs are circulated freely among the youth of the
colony. It is a matter of sincere regret that colonial news¬
papers exist which allow such corrupt advertisements to
appear in their columns, publications which convey false
and immoral ideas. Legislation must sooner or later step-
in and check this growing evil. I shall return to the subject
on a future occasion. Meanwhile let me draw attention to
the fact that the Auckland Branch of the New Zealand
Medical Association has made certain suggestions regarding:
the conduct of the journal generally. The journal as at
present conducted does not seem to give entire satisfaction
to the northern members. Various questions have been
asked by them, with the object of raising a discussion, to
see if anything can be done to augment tbe value of the
journal as a whole. These suggestions have been replied
to in an editorial article. One sentence in this seems,
to me to answer all those suggestions, and it is this i
“The journal is entirely the servant of the Association,
and it is for the Association to decide as to the fitness of
the editor and the lines on which it is to be conducted.”'
This can only be carried out by discussing the lines on
which the journal is to be carried on at the annual Congress.
This is a matter of the greatest importance, and the subject
should be, as I trust it will, thoroughly thrashed out at
Nelson on March 3l8t next. On the whole, the New Zealand
Medical Journal is a credit to the colony; its value as a
professional record is great, and so long as it is as ably
edited as it is at present its future is sure to be bright. Let.
me add one word more; let us all work harmoniously
together for its good and our own.
THOMAS HIRON BARTLEET, M.B.Lond,, F.R.C.S.,
Bjkminouam.
As briefly noted in The Lancet of May 2nd, tbe death
of Mr. Bartleet took place on April 29bh, after a short
illness. The eon of Mr. Edwin Bartleet, a highly esteemed
practitioner in Birmingham, he was born in 183'7, and from
an early age was destined for the medical profession. Edu¬
cated at the Grammar School in the town, he became after¬
wards a pupil of Queen’s College, and subsequently entered
at King’s College, London. In 1860 be obtained the degree-
of M.B. Lond., after a brilliant career, in which be obtained
the gold medal in surgery of the University. In 1871 h&
passed the Fellowship* of the. Royal College of Surgeons.
He was elected surgeon to the Children’s Hospital previously,
■ ^8
The Lancet,]
MEDICAL NEWS.
[May 9. 1891. 1073
end retained this appointment until 1867, when, after a close
contest, be obtained the post of surgeon to the General Hos-
pita,!. He was wont to refer to this appoiutoient with pride
mingled with regret at the mode of the election, the ex-
peme of which cost him as much as £800. Sdectling down
In practice, Mr. Bartleet took au active interfsi in nis pro¬
fession. He became lecturer on physiology at Queen’s
•College, later professor of operative surgery, and in 1887
xngleby lecturer for the year. He was an expert operator,
pursuing with confidence the plans he had laid down- Politi¬
cally he associated himself with the Conservative party, of
which he was an ardent exponent, though always just
and candid in allowing the arguments of the opposite side
-As a magistrate for the borough he was equally fair and
acrupulously attentive to the duties of his office, in which
lie allowed nothing to interfere with the exercise of
what he considered to be a public duty. Possessing
in a marked degree the higher qualities of a noble
character, of high principle, and able intellectual power, he
gave a tone of honour and probity to the circle in which he
moved; while his generous mind and firmness of expression,
-ever ready to do justice to the opinions of others, rendered
his influence a marked one over those with whom he came
in contact. His ready sympathy and genial beariog
endeared him to his patients, commanded their regard in
an exceptional degree, and made him most beloved by those
who knew him best. Loyal in his friendships, steadfast in
the pursuit of wbat he believed to be right, frank and open
'in his dealings, he became honoured as a citizen and le-
<"arded as a firm opponent of all things mean and base
He married the daughter of Mr. Samuel Berry, F.E.C.S .and
has left a family of two sons and three daughters, who, with
his widow, remain to lament their too early loss. His funeral
took place on the 6th inst. The first part of the service at
St. George’s Church, Edgbaston, was attended by a large
number of bis friends and representatives of public bodies
with which he was connected ; the concluding part at the
family vault at Chipping Campden, in Gloucestershire, where
his remains rest.
UniversityofCambridge.—T he following degrees
have been conferred:—
Doctnrit of Medicine.—.lumea Keri', Sb. .John's ; Benjamin Bleomflolcl
Connolly, (ionville and Caius ; Ilerbevt Tinihrell Biilsti'ode,
Emmanuel; and Philip Hicks, Cavendish Hostel.
Bauhelorx o/ Medicine and Baihelore of i'wrfl'ec.i/.—Geoffrey Edward
Hale, King's ; Charles Percival While, Clare ; Ernest Alan Uobevt
Newman, Coiiville and Cains; and Edward Hiirman Peck, Christ’s.
Hachelor of —Benjamin Bloomfield Connolly, Gonville and
Caius.
University of Edinburgh.—T he following is the
official list of candidates who have passed the under¬
mentioned examinations:—
First Professional Jixamination.—W. D. Adams, C. C. Aitkon, 1£,
de M. Alexander, James Audovsou, II. W. Beesley, William
Begg, B.A.; William Bethnno, J. L. Bovans, ‘ J. 10. Bowes, F. W.
Broadbent, R. 'T. Bruce, Morton Burnot, A. P. Chapman, Joseph
Cookson, B. R. Craig-Christie, Edward Crarer, J. M. bal/.iol, •!. K.
Dodds, H. 0. Dougall, H. W. Dun, Alexander Edwards, U. P. lOIliot,
David Evans, ITioinas Finlay, John Forbes, J. V. Forrest. J. S.
Fraser, Simon Fraser, W. H. Gaunt, Thomas Gibson, Australia; J.
D. F. Gilchrist, M.A.; P. E. H. Giuseppi, J. U. Glovur, J. E. Good,
'D. J. Graham, J. H, K. Griffiths, VVilluxm Haig, Henry Halton,
Cooper Havdcaatle, John Harris, R. T. lleiximan, Arthur Ileys,
Edward Higinbothain, C. W. Holme, Archer Hoaking, John Hume,
F. C. M. Hutchinson, T. H. Jameson, Henry Jones, T. II. Jonos, J.
X3. Kay, J. W. Keighley, B. C. Kelly, T, B, Kenny, J. W. Kippen,
D. F. l.aidlaw, .John Laurie, T. G. Lewis, O. R. Livingston, T. G.
Lusk, W. G. W. M'Dowell, C. J. R. MacFadden, John Maciver, .7,
•C. Mackenzie, W. II. Mackenzie, Roderick Mackiniion, J. G.
Macmillan, Donald Matbeson, Sidney Messulam, Joseph Michael,
■C. H. D. Moore, E. S. Mowat, M. G. Naidu, B.A.; F. B. Ohphant,
David Orv, K. L. Owon, J. L. ()wen, G, W. S. Paterson C. W. Poach,
Fred. Porter, W. A. Potts, B.A.; F. G. Proudfoot, J. C. Rail, David
Ranldne, M.A.; A. M, Rattray, William Riach, R. G. Robson, W,
C. Rowlands, Robert Samut, James Scott, R. G, Selby, J. H, Seoii,
'T. D. S. Shaw, T. R. S. eibbald, B. S. Skinnor, B.A,; George Smith,
M.A.; S. H. Smith, H. W. Somovvlllo, W. L, Stevenson, Thomas
•Stuart, J. W. Butcliffe, F. W. Taylor, A. G. P. Thomson, A. S.
Trapaga, D. A. Turkhud, W. 10. Turnbull, G. D. de Waal, James
Watson, W. H. Watson, Daniel Watters, K. C. Watts, J. R. Whait,
Alexander Whytt, P. W. Wilkinson, E. 1). NYill'aius, J. M. Wishavt,
J. B. Wood, J. J. H. Wood, M. Zorab.
Second Professional Jixamination.—O. W. Ancrum, G. B. Anderson,
W. C. Anderson. M.A.; J. R. Armstrong, R. 11. Arnistroiig, W. D.
Barrow, Artlmv Beecroft, H. P. D’A. Benson, 0. H. Bond, M. R,
Bow, D. H. Burn, Goo. Butters, Albert Cameron, Daniel Campbell,
W. 8. Campbell, Peatheraton Cargill, J. F. Carnithers, J. G. Christie,
M.A.; P. G. Cilliers, G. P. Coldstream, H. D, Coles, A. B. J. Coope,
•Tames Cowie, J. W. Craig, S. O. Dividson, M. A.; J. L, Dick, George
Dickson, Al»x. Douslas, Sl.A.; R W. Duncan, G. H. Uupont, *D. C.
Ediiigr.on, C R. Edmondson, J. J. Evans, J. U. Ewart, ‘Arthur
Fells, J, L, Fewia, William Fitzgerald, W, T. Fox. F. W. Foxcroft,
David Fraser, J. A. Fullarton, Archibald Gardner, T. U. Ooldie-Scot,
W. B. Gow, T. A. Granger, H. F, Green, Vincent Green, *G. K.
Qrinnner, W, B. Harry, J. B. Hawthorn, T. B. Hoarder, D. B Hewat,
R. L. Guthrie, J. A. Hamilton, L. B Hardy, F. J. Hare, B.Sc.; Geo.
Hodges, <>, H. Hogg, ‘George Home, 'Robert Hutchison, F, H. G.
HutchiDBon, 8. P. Hyam, J. H. Johnston, J, L. Jones, H. W. G.
l.ander, Thomas Lawson, Frederick Lishman, H, O. Lloyd, G. O. M.
Lunt. J^araes M'Clew James M'Donald, James Maclean, M.A.; A.
H. M. Macoaoi-ian, *G. W, F. Msenaughton, *P. O. Malabre. J. C.
Maxwell, M.A,; Raymond Maxwell, David Melville, J. E, Moorhonse,
M.A., B Sc.; D. G. M. Miinro, J, II, Murray, P. W. Nicol, Athelstane
Nobbs, A. A. O'Hara, I. J. H. Oldmeadow, John Owen, G. W. Park,
Charles Parker, F. R. Patterson, H. J. Pechell, W. H. Pimblett, C.
F. Ponder, Robert Proudfoot, M. M. Rattray, G. P. Richards,
Alistair Ro'^ertson, H, A. Roberlson, J. F. Robertson, William
Robertson, J. L. Russell, W, A. Rutherford, William Scott, Thomas
Sidehottoin, A. T. Simpson, J. P. Somerville, A. G Soainberg,
St. John Stanwell, Riccardo Stephens, -A. G. Talbot, M. W. Talbot,
O. D. S. Thom. J. L. Thompson, J. B. Thomson, A. C, Turner, 0.
C. B. Tyrie, A, H. H. Vizard, F. J. Walden, Andrew Walker, M.A.;
.Tohti Wallace, D, C, Watson, J. K. Watson, W. T. Wearing, Evan
Williams. J. Williams, Reginald Williams, J. C. Wilson, Meredith
Young, William Young.
* With distinction.
Royal Colleges of Physicians and Surgeons
OF Edinrubgh and Faculty of Phy.'?icians and Sur¬
geons OF Glasgow—T ne folldwiDg shows the result of
the April examinations held in Glasgow:—
First lixatnination.—0( 41 candidates the following 29 passed;—
Kate K Paton, Gla-gow ; Robert P, Snodgrass, .Montreal; Stanley
ii. Oulton, Liverpool; Janet R. Wells, Glasgow ; Catherine Howie,
Gla-sgow ; Wm. E. Blakely, Aughnacloy; John M'Lean, Glasgow ;
Malcolm Stewart, Kilwinning; Henry Marmion, County Down;
Win, Bond, Lancashire; Thomas B. Whicelaw, Kirkintilloch;
Herbert P. Weston, Mauchester ; Gertrude N. O’Flaherty, Galway ;
Abraham .J. Boulger. Ookhes'er; Jean M. Grant, Banff; James
Fenwick, Accrington ; John D. Ballantyne, Dundee ; Thomas J.
Evans, New Quay, Wales ; Thomas Heaps,Preston ; Thomas French,
County Cork; Richard C Wilson, Birkenhead ; Martin P. Corkery,
Bombay ; William Corkey, County Arm igh ; Luther T. Myers, York-
."ihire ; Cuthbert Rutherford, Northumberland ; James U. Robinson,
Southport; Samuel T. Brooks, Farnwovth; Stanley B. Siddall,
Stanley, Liverpool; and George Hill, Glasgow.
Scevnd J'Uaudnaiion.—Oi 60 candidates the following 30 passed :—
Jame.s P. T. Burke, Ireland ; Henry de Courcy O’Neale, Barbadoes ;
Alexander M'Afee, B.A., Ballymoney ; Henry Joseph Cosgrove,
Dumfries; William M. Fox, Cork; Robert Martin, County Down ;
Andrew M, Stewart, Alloa ; Andrew J, M'Mickle, County Tyrone;
John M, M'MiHan, Argyllshire ; George M Wikockson, Derbyshii-e ;
■J'homius W. Waddell, Uemerara; Janette F. A. Wallace, Inverness-
shire; Thomas Dawsmi, Mid-l.othian; George C. Giles, York;
Samuel W, Pitcher, Talbot, Austr.ali.a; John Lainont, Argyllshire ;
Rnginald H. Wright, Cheshire; Henry L. M'Cndoch, Melbourne;
William L. Crowdsoii, Edinburgh ; Kees T. Jones, Glamorganshire ;
John C. EdwavrU, Denbighshire; Ralph T. Clark, Harrington;
William Walker, Abeideenshire ; Jeanie Grant R. Duggan, Edin¬
burgh : John Feathorstone, Northumberland ; Archibald M'Kellar,
lilasgow ; Michael Lnby, Liinorick ; Thomas C. Hunter, Glamorgan¬
shire ; Arthur James Neill, Melbourne ; and D. C. Lionel Williams,
Breconshire.
Final Examioiaiinn.—Oi 30 aiiiclidates the following 16 passed
Daniel Doherty, Bnucrana, Derry ; Thos. Marshall, South Shields;
Edith Mary Blown, Croydon ; John Lane Gurraue, Fernioy ; George
Billing, Blackpool; Iloiiry OoSHer, Carbro k ; John Hodgson,
Burnley; Edmund Hartley, Heywood; Jogendra nath Banerjee,
Bengal ; Charles N. Macquarie, Kilmuir ; 0. Blair Lucas, Cavmyle ;
Heniy D’Ainim Bhuuberg, Edinburgh ; Joseph E. Joner Pegg, Bir¬
mingham ; P. Algernon Shore, Walsall; and Simon -Martyn, Bombay.
Faculty of Physicians and Surgeons of
Glasgow. — The following candidate was admitted a
Diploniate in Public Health at the April examination :—
Arthur P. Luff, M.D. Lond,, Weymouth street, London.
Royal Colleges of Physicians and Surgeons
IN Ireland: Conjoint. Scheme.—T he following have
passed the Final Examination:—
Mark Francis Cahill, Richard Atkinson Crawford, Henry Michael
Culliiian, Frederick Francis Iilahon, John Colfey Ryan, James Arthur
Thompson, and Albert William Lambert Zimmer.
The undernamed were candidates for a portion of the exa¬
mination, and passed : —
W. M. Meeke, H. Moore, and W. E. Moore.
Royal University of Ireland.—T ho following
have passed the second examination in Medicine of the
University:—
F 2 >per Pass IHoision .—'Robert Allen, Patrick Brady, 'Joseph A.
Corbett, "Emily Winifred Dickson, William Hanna, 'lYilliaiu
McMath, and John Sliine. (Those marked with an asterisk may
present Ihem.-ielvos for Honours.)
Pass DiutM'ojt.—Michael H. Aiclcen, Wilberforce Arnold, Charles Bir¬
mingham, Charles Blue, James M. Biowne, Alfred G. Caldwell,
Joseph H. Cleiiionts, John G. Clokey, James Colville, Mina L.
Dobbie, Albert E. Donniey, Joseph W. Furey, John B. Johnson,
Tliomas S. Kirk, Thomas .1. McKendry, John McMullen, John
Mathewson. Marlin O'Dea, Patrick J. O'Keetfe, Henry L. Ormerod,
Albe t A. Peel, Michael J. Ryan, Patrick J. .Scannell, John H.
Thoinp.son, and John J. Wallace.
^8
Di
1074 Thb Lanobt,]
MEDICAL NEWS.
[May 9,1891.
Univeesity of Oxfoed.— Mr. W. T. Brooks, M.A.,
M.B. Lond., and Mr. A. Winkfield, F.R.C.S., have been
nominated Litchfield clinical lecturers in medicine and sur¬
gery respectively.
A CSNTENAElAN. —A woman named Oberry died
last week in Dungannon Workhouse at the advanced age
of 110 years. She distinctly remembered the Bebellion of
1798, which occurred when she was a young girl.
Eoyal Society.— The following members of the
medical profession have been nominated by the council to
be recommended for election into the Society on the
4th prox.;—Mr. W. Anderson, F.R.C.S., Professor D. J.
Cunningham, and Dr. W. D. Halliburton. Professor
P. F. Frankland’s name is also in the list.
Decimal Association.— A joint deputation from
the Associated Chambers of Commerce and the Decimal
Association will be received by Mr. Goschen and Sir Michael
Hicks-Beach to-day (Friday) at one o’clock, to urge the
Government to take the necessary steps for rendering com¬
pulsory the adoption of the metric system of weights and
measures, now generally adopted in other countries, as the
first stage in the introduction of a complete decimal system.
TJnive^ity of Cambridge.— The Special Board
for Medicine, in accordance with Regulation 10 for the degree
of Bachelor of Medicine, publish a schedule defining the
range of the examination in pharmaceutical chemistry, and
give notice that the schedule will come into force at the
beginning of the next academical year (Oct. 1st, 1891). The
examination will be practical, and will have reference to the
chemical principles involved in the preparations named in
the schedule.
Brighton Home op Rest for Nurses.— On
Monday Princess Christian visited Brighton for the pur¬
pose of opening a home of rest for nurses in Bussex-sqaare,
founded by herself, and carried on by a committee of which
Mrs. Bedford Fenwick is honorary secretary, the Lord
Mayor of London treasurer, and the Duke of Abercorn and
Mr. Justice Jeune are trustees. The Princess observed that,
being connected, as president, with the Royal British
Nurses’ Association, one of the largest nursing associations
in the kingdom, she had much pleasure in coming to Brighton
to open the new home, which will allbrd accommodation for
sixteen visitors.
.The Association of Public Sanitary In¬
spectors OP Great Britain.—D r. B. W. Richardson,
the president, delivered a lecture at the monthly meeting
of the Association held in the Carpenters’ Hall, London
Wall, on Saturday, on “ National Main Drainage.” There
was a large attendance. Dr. Richardson dealt with the
question in considerable detail, observing that national
main drainage meant the complete return of temporary
dead matter to the living earth over the widest possible
area, and the application of temporary dead material for
the reproduction of food. The accomplishment.of this plan
could oe effectively carried out by and through a capillary
network laid out for another purpose, so that, if starting
anew, they could not do better. This scheme would settle
the question of a pure water-supply once and for all.
City op London Hospital for Diseases of the
CflEST.—A public meeting in aid of the City of London
Hospital for Diseases of the Chest, Victoria Park, was held
on Monday at the Mansion House. The Lord Mayor, who
presided, said that the object of the meeting was to make a
special appeal for £10,000 to remove from the interior of the
building the lavatories and sanitary offices, and to place
them in two towers at each end. This work was absolutely
necessary, and would greatly promote the healthy occupation
of the various wards. The hospital was founded forty years
ago, and since then it had received over 24,000 in-patients,
while the number of out-patients amounted to about half a
million. A motion by Sir Robert Fowler, M.P., pledging
the meeting to use every endeavour to assist the com¬
mittee of management in obtaining funds to carry out
the proposed scheme for improvement in the drainage
and sanitary appliances of the hospital, was seconded by
the Bishop of Bedford and supported by Sir J. RUdon
Bennett, one of the original staff of the hospital, and carried
unanimously. Contributions were announced of £50 from
Her Majesty the Queen, £25 from the Duke of Connaught,
and several other donations, the proceedings closing with a
vote of thanks to the Lord Mayor.
Workhouse Infirmary Nursing Association.—
Princess Mary Adelaide, Duchess of Teck, will distribute
the medals and gratuities to the nurses of the Association at
their eleventh annual gathering to be held at 9, Conduit-
street, Regent-street, on the 14ch lost., at eight o’clock.
Dishorning Cattle.— The judges of the Queen’s
Bench Division in Ireland have just given their ruling in a
case of appeal against the decision of the magistrates at
Kells on the above question. The Lord Chief Justice, in.
giving judgment, held that the magistrates were right in.
concluding that the pain inflicted by dishorning was not
inflicted without good reason, and were justified in dis¬
missing the complaint. In this ruling the other judges
concurred.
Dwellings of the Poor.— At a meeting of the'
Mansion House Council on the Dwellings of the Poor, held
on Wednesday, a report was read by Mr. John Hamer
(hon. sec ) which stated that cases of insanitation had been
dealt with in the City, Whitechapel, Old Ford, Strand,
Islington, and St. Pancras. The annual report was presented
and ordered to be circulated. Letters were read from the-
Hammersmith Vestry stating that they were most anxious
to do all the law permitted to remedy the complaints of the'
Council.
The Medico - Psychological association at
Bristol—O n the let inat. a meeting of this Association
was held at Brisllngton House. A conference followed the-
meetings for the transaction of the purely business part of
the Association work, at which Dr. Yellowlees of Glasgow
presided. Dr. Hack Take read a paper on “Prichard and
Symonds in especial relation to Mental Science.” Dr. Lionel
Weatherley followed with a paper on the “ Use and Abuse
of Hyoscine,” and Dr. Bonville Fox with one on “ Generab
Paralysis.” Discussions ensued on each paper, and th&
meeting terminated.
Victoria Hospital for Children, Chelsea.—
The twenty-fifth anniversary of this hospital was celebrated
by a festival dinner at the Hotel M6bropole on the Ist inst..
Lord Brassey presiding. On proposing the toast of the
evening, the chairman asked for support chiefly in aid of the-
proposed convalescent home at Broadstairs, in connexion
with the hospital. Fourteen years ago the committee of
management opened such a home at Margate, and 2400
children had been treated there with very satisfactory results.
Another similar institution was now found necessary ; £6000
was required for the purpose, a large portion of which had
yet to be subscribed. The secretary announced donations,
to the amount of £1820.
Royal Free Hospital, Gray’s-inn-road.— The--
Ear! of Lathom presided at a festival, held at the Hotel
MoDropoIe on Saturday, in support of the building com¬
pletion fund of this hospital. His lordship briefly traced
the history of the hospital, which was started in 1828 by
the late Dr. Marsden, on the then entirely new idea of free-
and unrestricted admission of patients. To that principle
it has steadfastly adhered. At the present time there were-
160 beds. Since its foundation two millions of patients had
been treated. It was proposed to rebuild the front of the
hospital at an estimated cost of £20,000. In adverting to-
the Committee on Hospitals his lordship stated that the
institution had come out extremely well. The treasurer
announced donations amounting to £8000, of which £3000*
was a special bequest towards the rebuilding thefrontof the
hospital.
Royal Hospital for Children and Women.-^
In aid of the funds of this institution a festival dinner
was held on Monday at the Hotel Mctropole, the Duke
of Clarence and Avondale occupying the chair. In pro¬
posing “ Success to the Royal Hospital for Children and
Women,” his Royal Highness adverted to the foundation
of this hospital seventy-live years ago by his great grand¬
father, the Duke of Kent. Siice its establishment three-
quarters of a million of patients had received its gratuitous
medical and surgical treatment, there being no paying
wards. The ordinary income was under £2000, and the
expenditure upwards of £3000 a year. He appealed for
a nearty and liberal support to so worthy and excellent
a charity. The secretary announced subscriptions amount¬
ing to £1105. It was the subject of remark that a re¬
cognition of the-services of the medical staff—a compli¬
ment which is usually paid at such gatherings—was
omitted on this occasion.
The Lancet,]
MEDICAL NOTES IN PARLIAMENT.—APPOINTMENTS.
[Mat 9, 1891. 1075
St. Bartholomew’s Hospital-—A t a meeting of
the City CommissioD of Sewers held at the Guildhall on
Tuesday, a report of Dr. Sedgwick Saunders, the medical
officer of health, on the sanitary condition of St. Bartho-
9omev’s Hospital was read and ordered to be printed, but its
consideration was adjourned until the next meeting.
Presentation.— On Monday, at a meeting of the
Dispensary Committee of the Johnson Hospital, Spalding,
Dr. Edwin Morris was presented with a handsome silver
aalver, on his retirement from the medical staff, after the
completion, and in recognition, of fifty years of gratuitous
professional services rendered to the institution.
Meath Hospital, Dublin.—T he following prizes
have been awarded for the winter session, 189^0-91:—
Medicine: William Scarlett, first prize; Hugh Hunter,
second prize. Surgery—Senior: Alfred Power, first;
Edward Frazer, second. Junior: William Taylor, first;
J. W. Watkins, second. Prize for bandaging and applica¬
tion of surgical appliances: Gordon M. Thompson, first;
William Taylor, second.
The Maghull Home for Epileptics. — The
Bishop of Liverpool occupied the chair at the second annual
meeting of this Home on Saturday last. After a two years’
trial the committee concluded that the Home provided a
long felt want, and would soon be the centre of a happy
colony, where a benefit would he bestowed on a very help¬
less class of persons. The patients’ payments during the year
amounted to £719 17s., the subscriptions were £105 4s. Qd ,
and the donations £84 13s. There had also been special
"disbursements, amounting to £146 9s. 6rf. for furniture and
alterations. 'The annual report was adopted.
Football Casualties.—D uring a match between
the Everton Athletic and Walton Breck Clubs on the
^bh ult., a player of the Athletic teem had his leg badly
broken below tne knee, the bone protruding in two places.—
In a match between the Partick Thistle andXinthouae Clubs
at Govan on the 30th ult, a member of the former club
sustained a fracture of hie right leg.—A young man of
Newbey, aged twenty-one, died on Sunday morning from
injuries received during a match at Gravel Hole on the
previous Saturday. He fell with his head under him,
another player falling on him.
MEDICAL NOTES IN PARLIAMENT.
Institute of Preoentwe Medicine.
In tlw House of Commons on Thursday Major Rascli asked tlie Pre-
.«ident of Uio Board of Trade whether a decision had yet been given by
the department on the application for a licence for the British institute
of Preventive Medicine. Sir M. Hicks Beach replied that, having con¬
sidered the application and the important objections thereto which he
Ehad received, he had not been able to grant tbo licence.
'J'ke Injiwnza..
Mr. Hobliouse asked the President of the Local Ciovernment Board
whether, in view of tlie renewed outbreak of iiiflueir/.a, he will take
immediate steps to coimnunicate, in a convenient form, to the medical
fprofeesion and the public any information as to the causes of that
disease and its remedies which may be in the possession of the depart-
nnent and iU medical officers. — Mr. Ritchie replied; An extensive
iiiquii-y has been made by Dr. Parsons and Dr. Bruce Low, two of the
medical inspectors of the I.ooal Government Board, and inquiries from
‘the medical officers of health tlrroughout the country, but no informa¬
tion has been obtirined to prove the origin of iniluenza. The disease
would appear to have been introduced from abroad. The phenomena
•of distribution may, for the most jiart, be explained by re¬
garding influenza as an infective disease liaving a short incnba-
'tion period, and having an infective quality at its earlier stages
‘(perhaps before destructive syiuploms of intlneiiza have appeared), and
, ifiiding the large majority of persons auscoptible to its infection. Tlie
•question of remedies from a medical point of view is not one witliin the
.scope of the dopai'tment. On the reappearance of iulliienza last month
.some further local inquiries woro mode on behalf of the Board by Dr.
Bruce Low, principally in Yorkshire and Linc^olnshive. Tlio general
^belief is tliat the disease was in some way brought to Hull in the course
of the inontii of February. No new light, however, has by these in-
•riuiriea boon thrown on the conditions of influenza. Careful watcli is
being kept for anything wliicli may throw any further light upon the
subject.
Trcaimeiit of Epileplio Pnsosicrs.
Dr. Tanner asked the Chief Secrotai'y to the Lord I.ioutoiiant of
Ireland wliotlier prisoners wlio suffer from epilepsy, and wliose con¬
dition is known to the prison doctor in Clonmel Gaol, are still conflnod
lin ordinary cells in tliat prison,—Mr. A. J. Balfour replied that- the
General Prisons Board Imd made careful inquiry, aiul had reported that
tiioro was no ground for tiie allegation contained in tlie question.—Dr.
■J'annor said tlio answer was contrary to his own experience.
Small-pox.—A tlas hospital ship, 28.
• Infant with mother.
Swxestful applicants for Vacancies, Secretaries of Public Institutions, and
others possessing information suitable for this column, are invited to
forward it to The Lancet Office, directed to the Sub-Editor, not later
than 9 o'clock the Thursday morning of each week for puiilication in
the next number. —
Bailey, T. Ridley, M.D. Edin,, has been reappointed Medical Officer
of Healtli for liilstou.
Baldwin, T. A., M.D., L.R.C.S. Irel., has been appointed Medical
Officer for the Oottingliam District of tlie Sculcuates Union, vice
Chambers, resigned.
Bakton, F. W,, L.K.G.l’. Lond., M.R.C.S., has been appointed Medical
Officer to the Marston District of tho Rugby Union.
Boswell, John .1., M.D. Lond., I 1 .R.C.P., M.B.C.S., has been reap¬
pointed Medical Officer of Health for the Borough and Port of
Faverahaiu.
Coats, 'Vm. henry, M.A., M.B., M.R.O.S., L.B.C.P., L.S.A., L.S. Sc.,
F.C.S., has been appointed Medical Officer for the Patrington,
.Skeffliiig, Easington, Welwick, and Kilnsoa Districts of the Pat-
riiigtou Union ; also Public Vaccinator for the same districts.
Davies, Sidney, M.D. Oxford, D.P.H. Camb., M.R.C.S., has been
appointed Modii'al Officer of Health for Plumstead.
Elam, W. II., F.U.C.S., has been appointed Medical Officer for the Ea.st
Barnet Sanitary District.
Eustace, J. N., M.B,, C,M. Diib., hasbeen appointed Clinical Assistant
to tlie Royal Asylum, Edinburgh
Fahsset, j. D., M.D. Dnb., L.M. iftL.S., tias been appointed Medical
Officer of Health for the Fleetwood Urban Banltary J>istrict of Che
Fylde Union.
Fowler, (!. H., M,B.C.S,, L.R.C.P., has been appointed Resident
Medical Officer to tlie North-west London Ho.spiial, Kentish Town-
road, N.W.
GinsoN, J. H., L.R.C.P.Lond., M.R.C.S., has been appointed Medical
Oflicev for the Aldershot District of tho Fanihani union, vice Yomig,
resigned.
Graham, John T., M.D. Olasg., M.B.C.S., has been appointed Medical
Offii^er to the Perthshire County Council.
Grey, ‘l’. Campiiell, M.R.C.S., L.R.C.P.Lond., has been appointed
Resident Medical Officer to the Swansea Hospital, vice G, Herbert
Hopkins, resigned.
IIARRINOTON, HENRY NaZEDY, M.R.O.S., L.R.C.P. Irel., has been
appointed Medical Officer to the Birkenliead l^oat-office.
HicuENS, Frank, M.D. Lmul., M.R.C.S., has been reappointed Medical
tlfficer of Health for the Stithians Distiict of the Redruth Union.
IIOLME.S, T. D. H., M.B., C.M. Edin., has been appointed House
Surgeon to the Bridgwater InWrmary.
Dr * zed by CjOO^IC
1076 Thb Lancet,]
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS.
[May 9,18«l,
HOBJUOCKS, Pbter, F.B.O.P., Examiner in Obstetrics at the Royal
College of Surgeons, has been appointed Physician to the Royal
Maternity Charity, Mnsbury-square, for the Eastern Division of
Loo don.
Jameson, a. S., M.B., C.M. Aber., has been reappointed Parochial
Medical Officer of Slains, Aberdeenshire.
JOLLYE, F. W., M.B.C.S., L.R.C.P., D.P.H.Lond., has been appointed
Medical Officer and Public Vaccinator to the No. 2 District of the
Airesford Union, and Medical Officer of Health to the Alresford
Union.
Kidd, Archiuald, M.R.C.S., L.KC.P., his been appointed House
Surgeon to the Middlesex Hospital.
Laird, Thomas, M.B., C.M. Glasg., has been appointed Medical Officer
of Health for the Soothill Upper Urban Sanitary District of the
Dewsbury Union, vice Clay.
Langford, P. P., M.B.C.S., has been appointed Medical Officer for the
Bast Finchley Sanitary District.
Little, William Maxwell, M.D., C.M. Bdin., late Senior Assistant
Medical Officer, Norfolk County Asylum, has been appointed Dis¬
trict Surgeon for Selangor, Straits Settloiuents.
LOWNDS, C. J., L.R.C.P.. L.R.O.S. Edin., L.F.P.S. Glasg., has been
appointed Medical Officer of Health for the Farnley Tyas Urban
Sanitary District of the Hudderafleld Union, vice H. A. Lowndes,
resigned.
Lucas, ft clement, B.S., M.B. Lond., F.R.C.S., has been appointed
Examiner in Anatomy to the University of London.
Muriel, C. J., L.R.C.P. Lond., M R.C.S,,ha3 been appointed Assistant
Surgeon to the Norfolk and Norwich Eye Infirmary, vice Morse,
Resigned.
Panting, John, M.A. Cantab., M.R.C.S., L.R.C.P.,has been appointed
House Physician to the Middlesex Hospital.
Potts, W. J., L.R.C.P. Lond., M.R.C.S., has been appointed Resident
Medical Officer at the Mancheste*" Workhouse, and also Assistant
Medical Officer at the Crumpsall Workhouse.
Pye-Smitii, R. j., F.R.C.S., L.R.C.P. Lond., has been reappointed
Honorary Surgeon to the Sheffield Hospital and Dispensary.
Radford, W. J., L,R.C.P.Lond., M.R.O.S., lias been appointed
Resident Medical Officer at the St. Marylebone General Dispensary,
77, Welbeck-street, W.
Robertson, J. Begg, M B., C.M. Edin., has been appointed Assistant
Medical Officer to the Hfe and Kinross District Asylum.
Robertson, Rout., M.B., C.M. UUsg., has been appointed Medical
Officer to the Lanarkehiie iStoei Company’s Works, Flemington,
Motherwell.
Sevier, A. H., M.B., C.M. Edin., has been appointed pm tern, (pending
Dr. Mitchell’s absence from ill health) Medical Officer for tlie
Barnard Castle Urban and Rural Sanitary Districts.
Stott, H., L.R.C.P. Lond., M.R.C.S., has been appointed Medical Officer
for the Ih-iera Barnet Sanitary District.
VallaNCE, Ernest, L.R.C.P. Lond., M.R.C.S., has been appointed
Assistant Medical Officer for the Workhouse of the West Ham Union.
Vickery, W. H.. M.RC.S., L.R.C.P., has bMen appointed Assistant
Resident Medical Otiicer to the North-West London Hospital,
Kentish Town-road, N.W.
^atandts.
For furthtr iv/ormation each vacancy reference should be made
ta the aduertUement.
Borough of Plymouth.—M edical Officer of the Borough Lunatic
Asylum. Salary £400 per annum, with furnished house in the
Asylum al Blackadon, near Plymouth, where the Medical Officer
will be required to reside. Gas, coal, and vegetables.
Cancer Hospital (Free), Fulham-road, S.W.—Honorary Pathologist.
Cancer Hospital (Free), Fulham-road, S W.—.Surgeon.
Cumberland Infirmary, Carlisle.—House Surgeon for one year.
Salary £70 per annum, with board, lodging, and washing.
Derby Amalgamated Friendly Societies’ Medical Association.—
Assistant Surgeon. Salary £100 per annum (out-door), with addi¬
tional fees for Midwifery of 5s. 3d. in each case. Salary to be
advanced under certain conditions.
Eccles and District Medical association.—A ssistant Medical
Officer. (Apply to the Secretary, 16, Byron street. J’atricroft.)
Glamorganshire and Monmouthshire Infirmary and Disfensarv,
Cardiff.—Honorary f’athologiet.
Glamoroanshire and Monmoutushire Infirmary and Dispensary,
Cardiff.—Honorary Dental Surgeon.
Hants County Asylum, Knowle, Farehaia—Third Assistant Medical
Officer, r alary £100 per annum, increasing to .£125 alter twelve
months’ service, with furnished apartments, board, washing, ami
attendance.
Hartlepool Union.—M edical Officer and Public Vaccinator for tho
District of Greitham. Proposed salary, exclusive of extras, £60
perannum. (Apply to theClerk,Board-room, MunicipalBuildiiigs,
West Hartlepool.)
Holloway sanatorium Hospital for the Insane, Virginia Water.—
Fourth Assistant Medical Officer.
Parish of St. Leonards, Shoreditch.—Resident Assistant Medical
Ollicer for the Workhouse and Infirmary. .Salary £100 per annum,
increasing £10 annually to .£120 per annum, with rations, furnished
apartments, and wasliing in tho Infirmary. (Apply to the Clerk to
the Guardians, 213, Kingsland-road.)
Royal Berks Hospital.—P hysician.
Royal college of surgeons of England.—E xaminer for Part I.,
and an Examiner for Part II., of the Examination in Public
Health.
Royal Collegb of Surgeons of England.—E xaminers in Elementary
Anatomy and Elemirntaty Physiology.
Royal Wbstminstbr Ophthalmic Hospital, King William-atreet,
West Strand.-House Surgeon.
Royal COLLEwrF, op Surgeon-s of England.—E xaminers in Anatomy
and Physiology for the Fellowship.
SlilULAUGll Union.—M edical Officer and Public Vaccinator for the
District of Aldbrough. Salary £40 per annum, exclusive of the
authorised fees for Surgical and Midwifery cases, visiting lunatic
paupers, and vaccination. (Apply to the Clerk to the Guardians,
Beverley.)
Torbay Hospital and Provident Dispensary, Torbay.—Junior
House Surgeon and Dispenser,
Warneford Hospital, Leamington Spa.—House Surgeon. Salary
£100 per annum, with board, washing, and lodging.
Slsrriagts, snlr
BIRTHS.
Andrews.—O n April 25th, at Lynton House, 43, Brixton Hill, S.W.,.
the wife of W. Stiubford Andrews, M.B. Lend., F.R.C.S. Eng., of a
daughter.
Carter,—O n April 14th, at Broadview, N.-W.T. Canada, the wife of
Ernest Carter, Surgeon, of a son,
Chetham-Strodf..—O n April 30th, at Bebhune-road, Sbatnford-hill, N.,
the wife of It- Chetham-Stvode, M.B , of a son.
Crossfibld.—O n April 20th, at Broadstoue House, Dartmouth, the wife,
of A. Kyflin Croasflelcl, L.R.C.P., of a son.
Dickinson,—O n May 4th, at Croxtoth-road, Liverpool, the wife of Ed.
H. Dickinson, M.D., of a son.
Holt.—O n April 6tli, at Piotermaritaburg, Natal, the wife of Surgeore
M. Percy Holt, Army Medical Staff, of a son.
IIOOLB.—On May 3rd, at Cliisholm-road, Richmond, the wife of Dr. H.
Hoole, of a son.
Kemp.—O n April 2>th, at Worksop, Notts, the wife of G. Lajus Kemp,
M.R.C.S., L.R.C.P. l.ond., of a son.
Matheson.—O n May 3rcl, at Gibson-square, London, N., the wife of
John Mathesou, M.A., M.D.. of a daughter.
Nankivell.—O n April 29th, at Langham-atreet, W., the wife of Herbert-
Nankivell, M.D., of I'enincllyn, Jlouriiomouth, of a son.
Selby.—O n April noth, at (Jreen-atreet, Kent, the wife of Pridoaux
George Selby, M.R.C.S., L.R.C.P. Lmd., of a son.
MARRIAGES.
Bone—Smith.—O n April 30th, at St. Peter’s, Lutton-place, Edinburgh,
Douglas John Mayhew Bone, M.B,. C.M., eldest son of tbe Rev.
Jolm Bone, Vicar of St. Thomas', Lancaster, to Mary Campbell,,
second daughter of Daniel Smith, Ksq., of Livuder-road, Grange,
Edinburgh.
Cameron— Hall.— On April 28th, at St. Baldred's Church, North
Berwick, N.B., Robert W. D. Cameron, B.Sc., C.M., M.D. Edin.,
son of Robert Cameron, Esq., of West Letterfinlay, to Matilda.
Elimboth Helena, second daughter of the late Colonel Hall, of
Killean, J.P. and D.L., Argyllahire.
Griffiths—AXFORD.—O n April 30th, at St. John Baptist’s, Bathj
Charles Thomas Griffiths, L.R.C.P. Lond., M.R.C.S., of Hands-
worth, Birmingham, youngest son of the late Thomas Griffiths,,
Bishop’s Castle, to Eliza Kate, eldest daughter of the late Richard
Axford, M.R.C.S., .J.P., Bridgwater, .Somerset.
HiL!.—B rass.—O n April 2!)6h, at the Chapel Royal, Savoy, William
John Hill, M.B. Cantab.. D.P.H,, of New Broad-street, E.C., and
Croydon, younger son of the late Henry Hill, Esq., Solicitor, London,,
to Mary Anne, younger daughter of the late William Brass, Esq.,
of Streatham, Surrey.
iNQi.is—S teevens.— On April 29th, at the Parish Church, St, Mary’s,
Cheltenham, Ale.xandor Inglis, M.D., of Auchendinny and RedhalK
Midlothian, to Ella Shirley, eldest daugliter of Lieut.-Colonel
Nathaniel Stoevens, late 20th and 8Sth Regimeiiba.
SIMPSON— S’roRER-—On May 2nd, at St. Gile.s's, Cambnrwell, Samuel,
Simp.son, M.B., only son of Alexander J. Simpson, of Dublin, to Ada
Jane Caroline (AdOle), younger daughter of Egbert Storer, of
Fleurior, Switzerland.
DEATHS.
BiVRTI.ket.—O n April 2()tti, siidolenly, of acute pneumonia, Thomas-
llirnn Bartloet, .M.ii., F.R.C.S., of Hatfield, Hagley-road, Bir¬
mingham.
BuRNiK.—On May 1st, at I-Ioughtoii House, Bradford, Wm, Burnie,
M.D., in im 7(itli year.
XlARTi.F.v,—On April 20th, at his residence, Accrington, Doctor Hartley,
M.R.C.S., aged 57.
Henry.—O n March lOtb, at Wellington, N. Zealand, Ellen Margaret,,
wife of Dr. J. Henry, and fourth ilaughter of the late A. Armstrong.
Esq., Soutbaea, Hants, formerly of K.M. 13tli Light Dragoons and
87th (R. I. Fusilier.s) Regiment,
JosEi’H.—On April 24th, at Little Bay Mine, Newfoundland, Alice, wife
of Louis Joseph, M B., C.M. (By cablegram.)
MAN30N.—On April SOth, at his residenco. Old Castlogate, Banff, Alex.
J. Munson, M.D. Aberd., M.R.C.S., agod 80.
Ron.—On May Otli, at Kensiiigton-eourt, W., the residence of his step¬
son, Athelstan Riley, Esq., Wm. J. G. Hamilton Roe, M.B. Oxoin,
of Harrington-gardens, S. W.. agod 04,
Russell.—O n April 24th, at his rosidonco, Roslin-torrace, Aiierdeen,
Dr. Peter Russell, aged 70.
Selous.-O n May 5th, at West-hill, Sydenha'm, Brigade Surgeon Edric
Sslous, M.D.
Shute,—O n May 4th, at Groom’s Hill, Greenwich, Gay Shute, F.R.C.S,^
in his 7l)th year.
,STE\VART.—On April 28th, at Larkhall, Lanarkshire, Cljarles Stowart,
M. B., L.R.C,.S.Edin.
Wainwight,-O n April 2l)tli, at Marina, St. Leonards, John Wells
Wainwight, M.D., aged 7(1. __
N. B. —4/i!€ of 5e. is charged for the Insertion of Notices of Births,
Mari-iayes, and Deaths.
DigiLi£^:d by
Tbb Lanobt,]
NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [May 9, 1891. 107T
Stfbiral §iarj for % mdng Merfe.
Monday, May ii,
BOTAL London Ophthalmic Hospital, Mookfiblds. —Operatiloiu
dally at 10 a.m.
Boyal Westminsteb Ophthalmic Hospital.—O peratlonB, 1.80 p.h.,
and each day at the same hour.
Chelsea Hospital roa Women.—O peraMona, 2.80 p.m. ; Thuraday, 2.80.
Hospital foe Women, SoHO-stjUABE. — Operations, 2 p.h., and on
Thursday at the same hour.
Metkopolitan Free Hospital.—O perations, 2 p.m.
Boyal OaTHOP.EDlc Hospital.— derations, 2 p.m.
Central London Ophthalmic Hospital.—O perations, 2 p.h., and
each day in the week at the same hour.
University College Hospital.—B at and Throat Department, 9 a.m.;
Thursday, 9 a.m.
London Post-graduate Course.-H ospital for Sick Children, Great
Ormond-at.: i p.m., Mr. B. Owen: Early Stages of Disease of the
Spine.—Boyal London Ophtnalmic Uospltai, Moortields: 1 p.m.,
Mr. W. Lang: Lacrymal Diseases.
Tuesday, May 12.
King’s College Hospital.-O peratlons,2p.M,; Fridays and Saturdays
at the same hour.
Guy’s Hospital.—O perations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 p.h.
Bt. Thomas's Hospital.—O phthalmic operations, 4 p.h. ; Friday, 2 p,h.
St. Mark’s Hospital.—O perations, 2 p.m.
Cancer Hospital, Brompton.-O perations, 2 p.m.; Saturday, 2 p.h,
Westminster Hospital.—O perations, 2 p.m.
West London Hospital.—O perations, 2.80 p.h.
St, Mary’s Hospital.—O perations, 1.80 p.m. Consultations, Monday
2.80 P.H. Skin Department, Monday and Thursday, 9.80 A.M.
Throat Department, Tuesdays and Fridays, 1.80 P.M. Bleotro-
theraDeutics, same day, 2 p.m.
London Post-graduate Course.—B ethlem Hospital: 2P.M.,Dr.Tlieo.
Hyslop: Delirium, Mania,—Hospital for Skin Diseases, Blackfriars
(the lecture will be delivered at the Examination Hall, Victoria Em¬
bankment) ; 6 P.M., Mr. J. Hutchinson; Syphilis in relation to Vac¬
cination.
Boyal Institution.—3 p.m. Dr. Edward B. Klein: Bacteria, their
Nature and Functions. (Tyndall Lecture.)
Boyal Medical and Ciiirurgical society.—8.30 p.m. Mr. Anthony A.
Bowlby: Thirteen cases of Paget's Disease of the Nipple, with Special
Reference to the Causation of the Malady by Psoroapenns.—Mr, J,
Hutchinson, jun.: Paget's Disease of the Breast. (The papers will
be illustrated by projections on the screen, and by a microscope
exhibit ) Wednesday, May 13 .
NATIONAL ORTHOP.fiDlc HOSPITAL.—Operations, 10 A.M.
Middlesex Hospital.-O perations, Ip.h. Operations by the Obstetrlo
Physicians on Thursdays at 2 p.m.
St. Bartholomew’s Hospital.—O perations, 1.80 p.m. ; Saturday, same
hour. Ophthalmio Operations, Tuesday and Thursday, 1.80 P.M
Surgical Consultations, Thursday, 1.80 P.M,
Charing-cross Hospital.—O perations, 8 p.m., and on Thursday and
Friday at the same hour.
St. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same hour
London Hospital.—O perations, 2 p.m. Thursday&Saturday,samehout.
St. Peter’s Hospital, Covent-oarden.—O perations, 2 p.m.
Samaritan Free Hospital fob Women and Children.—O perations,
2.30 P.M.
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.80 p.m.; Skin Depart¬
ment, 1.45 P.M.; Saturday, 9.16 a m.
Royal Free Hospital.—O perations, 2 p.k,, and on Saturday.
Children's Hospital, Great Ormond-street.—O perations, 9.80 a.m. j
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
London Post-graduate Course,—H ospital for Consumption, Bromp¬
ton ; 4 P.M.,Dr, P, Kidd : Indurative Affections of the Lung —Royal
London Ophthalmic Hospital; 8 p.m., Mr. Lawford; Colour Blindness.
Thursday, May 14 .
St. George’s Hospital.—O perations, l p.m. Surgical Consnltatlons,
Wednesday, 1.80 p.m. Ophthalmic Operations,^iday, 1.80 P.M.
University College Hospital.—O perations, 2 p.m. ; Bat and Throat
Department, 9 a.m.
Royal Institution.—3 p.m. Professor Dewar: Recent Spectroscopic
Investigations.
London Post-graduate Course,—H o.spital for .Sick Children, Great
Orinond-st.; 4i'.M.,Mr.E.Owen: LateStngos of Disease of the Spine.
National Hospital tor the Paralyseo and Bpileptic: 2i’,M,, Dr. (lowers:
Symptomatic Signals and How to Use 'riiem.—London Throat Hos¬
pital, Gt. Portland-st.: 8 P.M., Dr. B. Law ; The Examination of the
Throat and No.se.
British Gyn/EColooical Society.—8.30 p.m. Specimens will be shown
by Dr. lleywood Smitlr and Dr. Godson. Dr. Holland: Remarks
on a series of Abdominal Sections.
Friday, May 16 .
Royal South London Ophthalmic Bo 8 Pital.—O perations, 2 p.m.
London Post-qraduatr Cour.se.—H ospital for Consumption, Bromp¬
ton: 4 P.M., Dr. P, Kidd: Indurative Affections of the Lung.—Bac¬
teriological Laboratory, King’s College ; 11 a.m. to 1 p.m,, Prof.
Crookahank : Anthiax and Malignant (Edema (Sections of Anthi-ax
by Gram’s Method),—Groat Northern Central Hospital; R p.m., Dr.
Galloway : Taings—Inllainmatoiy, Tiibovcular, and other I.esiona.
Royal Institution.—9 p.m. Prof. O, D. Liveing; Crystallisation.
Saturday, May 16 .
Middlesex Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 2 p.m. ; and Skin Depart
ment, 9.16 a.m.
London post-graduate Course.—B ethlem Hospital; llA.M,,Dr. Theo,
Hyslop ; Clinical Demonstration,
Royal Institution —3 y.M, Mr. II. Graham Harris: The Artificial
Production of Cold. ,
METEOROLOGICAL READINGS.
(Taken daily at 8.S0 a.m. by Steward's Imtrwmmts.)
The Lancet Office, May 7th, 1891.
Date.
BaroiDetoT
reduced m
Sea Level
and 32" F,
Direc.
tlou
of
Wind.
Dry
Bulb.
Wot
Bulb.
Solar
Badia
in
Vacuo.
.Maxi¬
mum
Temp.
fibaao.
Min.
Temp
Rain¬
fall.
Remarks at-
8.30 A-U.
May
1
29 (1.8
8.W.
6.6
62
92
61
46 I
Cloudy
2
29 67
s.w.
63
60
97*
68
49
-22
Raining
3
29-96
w
61
47
108
60
40
-19
Cloudv
4
29-07 ;
S.W,
63
49
97
61
45
Cloudv
5
80 17
E.
6’2
49
101
81
60
Overcast
(i
80']3
E.
47
48
97
65
41
Cloudv
>>
7
29 97
E.
65
49
106
68
- 46
Fine
Itrfts, tfummints, i %u\sm to
Comspiikuts.
It is especially requested that early intelliqence of locah
events haviny a medical interest, or which it is desirables'
to hr’.ng under the notice of the profession, may be sentf
direct to this Ofice.
All commxinications relating to the editorial business of tho
journal must he addressed "To the Editors."
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended Jor insertion or for private informa¬
tion, must be authenticated by the names and addressee
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed " 2’o the Sub-Editor."
Letters relating to the publication, sale, and advertising,
aeparimenis oj The Lancet to be addressed “ I’o tho
Publisher."
We cannot undertake to return MSS. not used.
COMliATANTS AND NON-COMHATANTS.
The following paragraph is from the Broad Arrow of tlio 2nd instant :—
"Apropoa of the subject of medical officers and tlie assumption of
a combatant position, perhaps one of the most extraordinary in-
.stances on record occurred during the Indian Mutiny, when a
medical officer carried tire colours of a regiment, tho circumstances
of which must be famili.ar to many officers still living. If we mis¬
take not, it was on the occa'ion of the as.'ault on Lucknow, under
Havelock, on 25th September, 1867, when the 78th Highlanders-
advanced under a heavy lire. Lieutenant Kirby, who carried the-
Quuon’.s colour of tho old Ross-shire Buffs, was shot down ; as he
fell, the colour was grasped by a bandsman named Glen, from
wlioni it was wrested by Sergeant Reid, of the Grenadier company,
who carried it but a short distance, Aftor a few paces ho was also -
struck, when tho colour was seized by Assietant-Surgeon Valentine
M. MeJIaster, wha continued to carry it until the regiment halted-
near the Residency gate. Dr. McMiistoi', who received the V.C. for-
a subseiiuent act of gallantry, died in 1872, then surgeon of Have¬
lock’s favourite Ross-shire Buffs,”
Surgery ami /’.N.—The qualification i.s as complete as any other for alii
legal purposes in medicine, surgery, and midwifery, including, of
course, the making of a post luovtom.
Dr. Nason (Nuneaton),—Tho paper is marked for insertion.
PROSECUTION FOR AS.SUMRTION OF MAJOR TITLES.
'Vo the Editors 0 / The Lancet.
SiU3,—Will you allow us to say that the Medical Defence UnioRc
(Limited) did not originate or inspire the recent prosecution in
Birmiiighani of a Mr. S. E. L. Smith, ami that it had nothing what¬
ever to do with the niattor '!
Tliis letter has become necessary in order to rectify the impreasioi^
wrongly conveyed by press notices which have misled your local'
coiTespomleiit. We are. Sirs, yours very truly,
Ll-:-l.lE PlIlLLU'.S,
A. (!. Bateman,
May 5th, 1891. Hon. .Secs,, .Medical Defence Union, Limited.
FEES FOR AMBULANCE LECTURES.
'Vo the Editors 0 / Tin-; Lancet.
Sins,—May I trouble you, or any one of yoiir roailers conversant witlii
the subject, to inform me what becomes of the fees paid by a St. John-
Ambulance Class after paying expenses of lecture-room, fee to oxaininer,,
<fcc.; whether the lecturer retains the residue ; and further, such being:
the case, if such remuneration should be included and accounted for in.
the receipts of a partnership ?
I am, Sirs, yours faithfully,
May cUi, 1891. Junior Partner.
Dir:' /eiJ by Google
1078 Thb LaNOJCT,] notes, COMMENTS, AND ANSWEBS TO CORRESPONDENTS.
[May 9,1891,
Terrible Ebsults of Wuolesalb Quackery.
Although the practice of the healing art ia fenced about with manjr
more restrictions abroad than in this country, where it ia virtually
free, provided there is no false assumption of titles, it is to be hoped
that we shall have to wait a long time before we see such widespread
Rud permanent disaster as is now reported from Brussels as having
followed the steps of a notorious “quack.” It may be remembered that
several weeks ago it was mentioned in THE Lancet that an Asiatic
eye doctor, who, though he said he had a diploma from Singapore,
seems to have been interdicted from following his calling in Italy and
France, bad commenced practice in Brussels with the concurrence of
the municipal authorities and of some medical man who had so far
'forgotten what was due to the dignity of his profession as to “ cover"
the Oriental. His method of practice was to daub a brush dipped
into an extremely weak boracic acid solutiou into the eyes of all the
patients who presented themselves, no matter whether they were
suffering from glaucoma, iritis, purulent ophthalmia, or any other
disease, the same brusli and the same .solution being used for all
«aaes. The result has been tliat the number of patients recently
presenting themselves at the ophthalmic clinic is reportecl by
Dr. Legros, assistant surgeon in Dr. Lebrun's clinic, as being about
four times as many as usual during the same part of the year. Most
of the patients were found, on looking through the old case legisters,
to have been formerly treated at the clinic for some comparatively
unimportant eye affection, such as myopia, and upon lieing questioned
admitted that they had in the meantime been to the “Singapore
doctor.” The eyes had doubtless been inoculated with the virus of
;graDular lids, and this after a few weeks had produced the disease;
so that by going to the quack a very laige number of peraon.s ha<'e
been unfortunate enough to convert a simple error of refraction
or slight inflammatory affection into a most obstinate and painful
disease. Let us hope that if this or any other eye "quack”
should pay our shores a visit, offering to infect all comers witli
his concentrated culture of the virus of granular lids or gonorrlneal
opbtlialiuia, the British public, forewarned by the fate of the too
confiding Brussels folk, will not permit themselves to be made tire
subjects of such a terrible experiment.
Dr. Slanle.y Walker. —’S\v> Health Insurance Corporation, Limited,
which has its head office at 65, Charing-cross, effects insurances
against sickness and accident. Another Institution doing business of
the same class is the Sickness and Accident Assurance Association,
Limited, having its head office at 4, York-plaue, Edinburgh, and a
London office at 1, Arthur street West, King William-street, E.C.
W. M. M. should consult his usual medical attendant. do not
prescribe.
PROPERTY IN PRESCRIPriONS.
To the Editors of The Lancet.
Sirs,—I read in your last issue (p. 99f)): “Thepractice in some countries
for the proscription to be kept by the chemist clearly shows.... tliat he
■who dispenses... .has a property in it." As far as Geneva is concerned,
ithe reason for the chemist's keeping the prescription is the following,
About twenty-five years ago a nursu obtained a prescription for atropia.
With that prescription she wont from one chemist to another, and got
large quantities of this drug, with wliich she poisoned many of her
patients. She was tried and condemned. The autliorities deemed it
prudent to pass a law obliging the chemist to keep the presciiptions,
thinking by it to avoid any crime of the sort in tlie future, but without
:any idea of deciding about the property of the prescription. Tills fact
may be interesting to your readers. In my opinion, this law does not
(prevent the danger it is intended to avert; for tlie chemists never
refuse copies, with which the patients can go to another chemist, and
so on till they get any quantity of medicine they want. The fact you
mention is no doubt a very exceptional one; for I have seen repeatedly
prescriptions or copies from chemists of England, America, Russia,
■Germany, &c. In Rome the chemist has to give back tlie prescription,
having previously taken a copy of it In a book which he is obliged to
keep for fifteen years. The prescriptions in the book must follow each
•other without space (I do not know the correct expression in English—
T. Dowault, “ L’OfBcin,” which I quote from memory). The fact you
mention, besides, seems to me to favour tlie view of the prescription
being the property of the physician, ratlier than that of the chemist;
•for you say, “The chemist declined_without the prescriber'ssanc¬
tion.” 1 am, Sirs, respectfully yours,
Geneva, May 8rd, 18D1. A. Cokdes.
When a chemist, in declining to give a copy of a pre.scriptlon, refers
the patient to the prescriber, he does so, wo imagine, because he very
properly does not wish to take tho respon.sibility ot assisting the
patient to prescribe for birnself. The most desirable thing would be
a general recognition bytlie community of tho fact that a prescription
is written for the treatment of the ailment as it existed at tho time
•of the consultation; and it might often save a groat deal of subse¬
quent useless, and often dangerous, self-doctoring were It possible to
adapt the simple rules obtaining in hospitals to patients treated by
private practitioners.—E d. L.
The Medical Controversy at Kbiouley.
Du. Roberts oontinues bis very unprofessional positiou as the advocate
of “ Count Mattel's remedies.” He professes to guarantee more cures
with these secret and most susplcious looking “remedies'’than his
professional brethren. We trust sincerely that bis claim to bo
readmitted to the honorary medical staff of the Keighley Cottage
Hospital will be disregarded. The more secrecy of tho preparations
is enough to prejudice a sound professional mind. But the whole
system by which tlioy are sold and administered forbids their being
regarded seriously.
Senex —The document handed by tho physician to the patient is cer¬
tainly the latter’s property, and we presume it was returned to him
by the chemist. Had our correspondent taken care to preserve this,
he would not have lieen compelled from time to time to apply to the
olieruist for a copy, which was made for the convenience of the patient
as well as of the chemist. Of course, if the chemist has a copy of the
prescription, ho ia enabled to supply the medicine to his customer
without unnecessary trouble; but it by no means follows that he
should be bound to give up his copy on demand in order that the
medicine may be dispen.sed elsewhere. Although in the case of so
old a customer as our correapondont the chemist might have waived
his rule about referring to the prescriber, we cannot but think that
in the welfare of tho patient such a rule is a salutary one, and might
often bo enforced moro stringently.
MICROSCOi'lCAL WORK.—USE OF IMMERSION LENSES.
To the Editors of THE LANCET.
Siiis,—In reply to your rorre.spondont, “M.B.,”! beg to make the
following observations ; 1. It i.s necessary to use a condenser to focus
the light upon the object. I use a strong eyepiece, accurately centred,
as close to the glass slide upon which the object is mounted as it is
possible to got it, with the largest hole of the diaphragm. I find this
method very efficient. 2. The object to he examined, if bacterial, is
mounted upon a thin cover glass—not mica—placed upon a glass slip
3 in. by 1 in. This is then put upon the stage, then a drop of water (if
a water immer.sion lens is used, cedar oil if an oil immersion) is put
upon tho upper side of the cover glass. If you have dropped oil into
the objective, you must send it to tho maker to bo cleaned. S. By
means of tlie coar.se adjustment lower tho lens into tho drop of water
or oil until it nearly touches tho cover glass. Then focus the light
until all tho field is clearly illuminated. Then, with the coarse ad¬
justment withdraw the len.s very gradually until the object is clearly
defined, and focus for details with the lino adjustment, i. I found my
itnmoi-aion lens to ivork best wlien tlie distance l>0tween the upper lens
of the eyepiece and the front lens of the objective is ten inches. This
can be done by using the draw tube if there is one, or if not by lifting
up the eyepiece until this distance is obtained. 6. When done with wipe
tlie front lens very gently with an old silk handkerchief.
I am. Sirs, yours faithfully,
J. L. KEiiH, M.D., C,M„ F.R.S.K(I.
Crawsha^vboofch, Manchester, May 4th, 1891.
To the Editors of The Lancet.
Sirs,—I think the following information will be sufficient to enable
"M.B.” to use his new 7'2-inch immersion lens. Lot him first take a
general survey of his object with a low power—say, ^-inch. Afterwards
let Ihm pick out ttie particular spot in tlie preparation whicli he wishes
to examine, with a dry lens of about i-inch focus. Having removed the
li-incli, lot him then place on tho cover, precisely over the selected area,
a single drop of tho proper oil, whicli was, or ought to hivo-been, sup¬
plied him with his lens. Tho best method of applying tho drop is with
tile end of a small glass rod. After applying the drop of oil, lot him
arm his microscope with the immoi'sioii lens, and, taking care nob to
shift tho position of tho slide upon the stage, carefully lower tho Ions
into the centre of the drop by means of tho coarse adjustment. The
focu.s is very near the cover, nearer than tliat of tho dry A-in. It should
bo found by screwing down the fine adjustment very carefully and
gradually. Carolessnoss means a broken cover, a spoiled object, and
possibly a scratched Ions. After use tho lens should be cleaned. For
this purpose I use a very fine and soft I'ag of old silk.
I am, Sirs, yours faithfully,
Kirkby Lonsdale, May 4th, 1891. Ex-Lhithher.
To the Editors of The Lancet.
Sirs,—Y our correspondent, “ M.B.,” seems to be midor a niisappre-
heusion relative to the use of immersion lonse.s, by the question ho asks
.as to tlie quantity of oil to bo put into them, and furthermore whetlier
tho lens should be cloaued every day. If he has been putting oil into
his lens, I do not wonder lliat it does not work .satisfactorily. Lot him
put a small drop of cedar oil on the front surface of his immersion len.s
and then focus down till the drop of oil and the cover glass of his slide
aro in contact, and he will overcome tho difficulty.
I am. Sirs, your.s faitlifullj’,
Belgrave-i-oad, S.W., May 4Lh, 1891. T. Charters White.
Other letters to tho same effect as tho above have reached us on
this subject. Wo may here direct attention to Mr. Bolles Lee's book,
a notice of which ajipeara in our present issue.—E d. L.
Digitized Cjoogle
The Lancet,]
NOTES, COMMENTS, AND ANSWEES TO CORRESPONDENTS. [May 9, 1891. 107&
» THE Valuation oe Meat Peptones."
The pamphlet to which we rererrecl in our annotation of laat week on
the above subject is published by Messrs, fttraker and Sons, 124,
Fenchuvch-street, IC.C.
Pauper.— The acceptance of the Poor-law appointment mentioned
seems a breach of the rules of the hospital, and unfair to local
practitioners. The kindest thing in the first instance would be
for-our correspondent to remonstrate privately with tho gentleman in
question. Failing to get satisfaction, ho would be justified in directing
the attention of the authorities of the ho.spital to the obvious broach
of the rules.
ADVERTISEMENTS OF HOSPITALS AND DISPENSARIES.
To the Editors of THE Lancet.
Sirs,—I venture to send you a cutting from a Sunday paper, com¬
prising twelve advertisements of hospitals and dispensaries. Some of
tliose refer to perfectly respectable institutions so far as I know ; others
have a strong aavonr of charlatanism about them, while Nos. 1, 3, 4, and
C seem to me to be instances of tlio most barefaced advertising quackery.
To take the latter somewhat seriatim: No. 1 “dispensary" is, I find,
located at the house of a qualified and registered practitioner. You will
see that ho treats stricture and urinary disease, and specially treats
“ nervous debility.” He supplies medicines at is. per bottle, and pub¬
lishes a treatise, price 1«. The “ hospitals ” named in advertisements
;5 and 4, though separately ailvertised, rejoice in one and the same
address, and, while posing as special hospitals, they together embrace
a pretty wide area of thoraiieutics, including diseases of tho eye, oar,
nose, throat, and nervous system. Again, the “hospital” and tho
“homo” advertised in Nos. 0 and 7 are at one address, and are evi¬
dently engineered by ono proprietor, who I observe is tho only “doctor”
having the courage to append his name, and this I fail to find in either
Register or Medical Directory. He is indeed an all-round man, his
specialties embracing stricture and urinary diseases (more of them)
with spray treatment; homeopathic home for women; chest, nose,
throat, and skin diseases with treatment by inhalatio n; a book of cases
for Is. ; a treatise (of course a treatise) for another Is., and yet one more
book at Is., with fees ranging from Is. to 21s. Truly a “ largo order.”
I suppose tliat until tho present law is altered notliing can be done
to stop this impudent uxivertising and irregular practice ; but in tho
meantime tho regular practitioner is left wondering which among those
of whom I send you samples is the greater enemy to him and to the
public—the brazen quack with no qualilications at all, who pulls
liimself as a specialist and advertises shilling treatises and books of
cures, or tlie qualified man who descends to the same shameful level of
wringing a liveliliood out of tho fears and fancies of tho ignorant and
gullible ones.
I have no personal knowledge of any of the parties whose advectiso-
ments I enclose. 1 am, Sirs, your obedient servant.
May, 1891. E. 0. Y.
HOSPITAL ABUSE.
To the Editors of TUB LANCET.
Sirs,—A great deal is being written just now concerning tho under¬
selling done by medical practitioners, but I am certain that this cannot
be remedied until the abuse whicli is being daily perpetrated by
hospital authorities i.s prevented. Many people who are perfectly able
to pay, and who are being correctly treated by general practitioners, go
to hospitals, as they can there get tlie same treatment free. This
applies more particularly to special hospitals. No questions are asked
regarding the civcumstancoH of tlio patient, and though it is obvious
that the patient lias already uiidorgono treatment, it is never suggested
tliat ho sliould return to his medical advisor. I vemembur a lady (who
kept a carriage) astonish me by slating that sho was going to iMoor-
fialds Eye Hospital to consult an eminent oculist, and though I in¬
formed lier that the hospital was intended ftir tlio poor, she stated that
sho was not going to pay for .anything when sho could lecoivo the same
for nothing. During the last few weeks several of my patients have
been admitted to hospitals for treatment. In ono ease (scirrlius of
mamma) tlie date of opoiation was fi.'cod.and foe arranged, but on a
friend’s advice she want to tho Cancoi'Hospital; no queslioii.s wore
asked, and she was treated free, llundrods of sncIi cases could lie
inontionod by medical men. The special liospitals are tho chief
dolimiuents. Many of tho patients are dressed in a superior manner, amt
even clorgymon are not ashamed to enter them and rocoivo .advice free.
Not niicommonly ono finds that ladies send their children for treatment
nnder tlio care of their maids. It is because of this that medical men
have to struggle to make a living. Hospitals might to bo restricted
to tlie jioor instead of admitting anyone, whatever his or hor position,
U» free treatment. Many people soem to think there is a special healing
virtue in the walls of such buildings, as exemplified by tlio recent letter
of mi episcopal clergyman to the Daily Tdeyrapk. I am quite certain
he could have been as well treated at his own home by the same
surgeon as !io was in the hospital. It is by the loss of hundred.s of
such fees that medical men find the struggle for existence becoming
keener every day.
Hoping that the hospital authorities will taka the matter in hand,
I remain, Sirs, yours truly,
May 6lh, isul. A .Siii''rKKKH
A Bran Cradle for Infants.
A WRITER in La Normandie Mcdicale strongly recommends that Infants
should not be enveloped in binders and swathing clothes as at present,
but simply be dressed in a little shirt, bodice, and vest, leaving tho
abdomen and legs free, and then laid in a cradle full of wheatea
bran, with a hair pillow and a coverlet of woollen material, or a.
sheepskin well fastened at the sides to prevent the child kicking it.
oil. A hot'water bottle at the feet is an advantage. It is found that
the child, even when it is pretty active, does not bury Itself in th»
bran, as one would be inclined to expect, hut remains on the surface,
scarcely ever even eucceecling In burying a foot. When it is put to the.
breast it is wrapped in something loose and warm, and when it is.
taken out in the open air little drawers and woollen socks are worn,
and over all a loose warm garment. The advantages of this mode of’
bringing up infants are that they have plenty of freedom for their
limbs and the movements of the body generally, there is always,
warmth and yet a constant change of air all round the body, and the>
skin is always dry, the urine and fteces being soaked up by the bran,
as soon as they are passed. It is found that the infants are very con¬
tented, and do not cry, except when they are left too long without
being given the broaat. Tlie portions of bran contaminated by the"
excretions are removed by the hand once a day; but there is no
unpleasant smell about the cradle or in the room, and there is no>
need to change the whole of the bran more than about once in a.
fortnight. The small quantity of bran that adheres to the nates is, ot
course, washed oif every day when the child has its bath. In many
houses the saving in the washing expenses is an important considera¬
tion ; for the cost of tho bran is a trifle compared to these. The bran,
cradle is not, of course, recommended for children of more than
about a year old.
Merlin. —The certificate is clearly not explicit enough, for, althougla
tho attack of apoplexy may liave been the primary cause, it is.
obviously not the sole factor in tlie fatal result which ensued twelve-
months afterwards.
METROPOLITAN HOSIHTALS INQUIRY.
To the Editors of The Lancet.
.Sirs,—I n your issue of May 2nd, p. 1024, “Paterfamilias” writes as
follows: “I wish to draw attention to that part of Mr. Hurry Fen¬
wick’s evidence before the Select Committee, where, after stating he was
associated witli both St. Peter's and the London Hospitals, lio says ‘ it.
was his habit to draft patients from the general to the special hospital.’
I wish to ask how can a general hospital pretend to give a complete-
education to it< students in return for the fees paid when the autho¬
rities allow an important class ot ease to be drafted to a spociiU hospital
six or seven miles (sio) away ? Is not tliis a distinct broach of
eontr.act ? ”
I am forced to conclude that " Paterfamilias ” is neither acquainted
with my work at tho London Hospital nor with tho verbatim report of
my ei’idence before tlie Select Committoe. Had lie road tlio verbatim
report he would have seen that when the chairman asked me if I ever
draftcii cftses from the l.ondon Hospital to St. Peter's I answered.
“ Yes,” and explained the reason why. The purport of that answer was
as follows. A large number of hospital cases of obscure urinary
disease are sent to me by practitioners in order to obtain a diagnosis-
and guidance as to treatment. Those coming from tlie East-end
usually await my arrival on my visiting days at the London Hospital
’X'hoso from the We.sb-ond apply at St. Peter's Hospital. They are
examined and serve for clinical instruction, and return to the medical
man with a note from me. If, however, tho practitioner requests me
to treat the case, I look upon that patient as my personal property
for tho time being, to hold and to treat to the best of my ability until
I return that patient to tho medical man who sent him to mo. In
smno cases the pressure on my beds at the London Hospital will not
allow me to admit them, an<l I thcruforo draft these personal case®
on to St. Potor'.s Hospital. It is, howevor, quite otherwise with thosi?
ui.ses which apiily haphazardly at tlio hospital, and are Uikcn into my
wards hy my juniors. These are, so to speak, tho property of tho hos¬
pital for the time being. They are invariably treatod in the London
Ho.spital, and have wver hoeii drafted to St. Peter's Hospital for
operative work, This is clearly lirouglit out in the verbatim report.
I am. Sirs, yours truly,
I'l. Hurry Fenwick,
May, 1891. Surgeon to tho Loudon and St. Peter's Hospitals.
“MEDICAL ADVERTISING.’'
To the Editors of The Lancet.
Sirs,—I n reference to your paragraph in The Lancet of April 2r>th,.
hoadod “ More InsUncea of Atrocious Advortisiug,” I bog to state that
I have noihing wliatovor to do with 3U9, Ooldharbour-lane. I practiso
at the address given below only. As one of tho few Partridges in prac¬
tice in London, I ask you, as an act ot justice, to insert this in your
next issue. I am, Sira, yours faithfully,'
AVll.LIAM T. JhlRTRIDGE.
97, Albany-road, Camberwell, S.E., May .Ith, 1891.
Coogle
Die;
1080 Tbb Lancet,] NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS,
[May 9,1891,
INHALERS FOR USE IN PRODUCING AN ASS THESIA.
To the Editors of THE LANCET.
Sirs,—M y attention Iiaving been cailed to a letter from Dr. Hey wood
Smitb in the laat number of The Lancet, I must state, in self-
defence, that I never saw the late Dr. Prothero Smith’s inhaler, nor did
1 ever hear of any inhaler having been made with sounding valves. I
«appose I must congratulate myself on having conceived a similar
idea to that of the late Dr. Prothero Smith, but aa liis was designed in
•1847, before chloroform- leae introduced, it cannot bo stated that ray
•chloroform safety inhaler is a copy or infringement of hia idea.
I am, Sirs, yours'faithfully,
Dublin, May, 1801, Alexander Duke.
USE OF CORROSIVE SUBLIMATE.
To the Editors o/The Lancet.
Sirs,—I would like to ask if any of your readers know of a case where
(medical man has suffered from mercurial poisoning as tbo result of
lusing solutions of corrosive sublimate as an antiseptic lotion in mid-
•wifery. Also, what is the best application to prevent it destroying the
skin of the hands, or to restore the smoothness and liealth of the skin ?
"Would a saturated solution of boric acid with strict cleanliness boas
•eflScient? I am. Sirs, yours truly,
Newcastle-on-Tyne, April 30th, 1891. J. Wm. Dai.gliesh, M.D.
A MEDICAL HAT.
To the Editors of The Lancet.
Sirs,—I see that the medical hat Is again to the front. May I suggest
■that this elegant head gear would be rendered more effective at night
’by the simple addition of a luminous hatband? The name, quali-
'^cations, and address of tlie wearer might be impressed in red thereon,
'thus proving useful to suffering humanity both by niglit and day !
I am, Sirs, yours truly,
April, 1801. C. Ch.
OOMMUNiCATiONS, LETTERS, &c., have beoH received from—Dr Sharlcey,
London ; Dr. Cordes, Geneva ; Dr. Silk, London ; Dra, L. Phillips
.and Bateman, Birmingham; Mr. Ericlisen ; Messrs. W. H. Smith and
Son, London ; Dr. Dalgliesh, Newcastle-on-Tyiio; Me.ssra. Hertz and
Collingwood ; Dr, T. E. Mitchell. Notherton; Messrs. I-Iopkinson
and Co., Nottingham; Mr. J. B. Curvengen; Messrs. Fenwick and
Chinery; Dr. llarkin, Belfast; Dr. Lilley, Portland; Messrs. Green
and Son, Beverley; Dr, Armstrong, Liverpool; Messrs. Mitchell and
Co., London; Mr. F. A. Milton; Mr. J. C. White ; Messrs. Lee and
Martin, Birmingham; Dr. Garland ; Mr. Tay, Bristol; Mr. D'Arcy
Power; Rev. H. A. Soames; Dr. Nason, Nuneaton; Messrs, Ilaigh
•and Co., Liverpool; Brigade-Surgeon Hector, Anerloy; Messrs. Keith
.and’Co., Edinburgh ; Dr. Coghill, Ventnor; Mr. Bezly Thorne, South
Kensington; Dr. O. S. Walker, Woolwich ; Dr. Shore ; Messr.s. Biddle
-and Co. ; Mr. H. Dutch ; Dr. Boughton, London; Messrs. Christy
.and^Co.; Dr. Dobrashain, Constantinople; Messrs. W, H. Smith and
Co., Birmingham; Dr. J. W. Collins; Dr. Pago, Redditch; Dr. Carlo
Gangitano, Naples; Mr. Meadows, Hastings ; Messrs. G. Street and
•Co.; Dr. Arthur, Dover ; Mr. Currie, Columbia; Messrs. Orridgo and
Co.; Dr. Steele, Florence; Mr. Warner, London ; Messrs. Richardson
and Co., Leicester ; Mr. Cornish, Manchester; Messrs. Kogan l-'aul and
■Co.; Mr.Green,London; Mr.Outram,Liverpool; Messrs.Richardson
Bros, and Co., Liverpool; Dr. J. L. Kerr, Manchester ; Dr. Lindsay,
Relfast; Dr. Johnstone, Canada; Dr. Stewart, Bristol; Mr. Reade,
•Canterbury ; Mr. Blackwood; Mr. Gordon, Woodford; Di'. Webb,
Waterford; Dr. Cormick, Tabriz ; Mr. White, Sheffield ; Mr, Maggs,
Chelsea; Messrs. Stern ; Messrs. Churchill; Mr. Wand ; Mr. Jones,
Abergavenny; Mr. Lamb; Mr. Wade, Somerset; Mr. Pentland, Edin¬
burgh ; Mrs. Harvey ; Mr. Bullivant, Derby ; Mr. Colman, Walliam
Green; Mr. Green, Bournemouth; Mr. Sell; Mr. Warren, Leamington
.Spa; Dr. Hassall, Lucei-ue ; Mr. Warde ; Dr. Philipps. Virginia
Water; Mr. Coleman, Cardiff; Mr. F. E. Humphreys; Mr. Lawson
Tait, Birmingham; Dr. Pearse; Dr. W. Carr; Messrs, Paine and
Co., St. Neots; Mr. Leech, Birmingham; Dr. P. Abraham; Dr. O.
Horrler, Cardiff ; Mr. Cheeaewriglit; Mr. Burrldge; Dr. Taylor, Sur¬
biton ; Mr. H. Prynne ; Mr. Partridge, Camberwell; Mr. Whitehead
Manchester; Dr. Coombs, Somerset; Dr. Bird; Mr. Tate; Mr. T. G.
Brodie; Mr. Neecb, Tyldersley; Mr. Collum; Mr. Boswell; Eeadinff
Mercurii; M.B. 4C.M. ; Senex; Pharmaclen; E. G. Y. ; Surgery and
P.M.; H. D.; Orient; J, D.; Conjoint; Matron, Norfolk and Norwich
Hospital; L. S. and Son; M.D., London; Secretary, Hants County
Asylum; Clerk, Hartlepool Union ; Spes ; J. L. A.; Western Daily
Mercury Co., Plymouth; York, Londnn; A Sufferer; Merlin; Malted
Milk Co., London; Pauper; Bx-l.ectiirer; Router Agency; K. A.D.
Letters, each with enclosure, are also acknowledged from—Mr. Forjitt,
Caistor; Mr. Tally, Hastings; Dr. Jennings, Derby; Messrs. Green
and Son, Beverley; Mr. Tyte, Minchinhampton; Messrs. Robbins
and Co., London; Mr. McArthur. Blandford; Messrs. Hooper and
Co.; Mr. Andrews, Bvixton; Mr. Freeman, Worcester; Messrs. Back
and Co., London ; Mr. O'Meara, Loughborough; Messrs. Keene and
Aahwell, London; Mr. Horuibrook, Bloomsbury; Messrs. Hill and
Son, London; Mr. Buffer, Martloy; Miss Tobias; Messrs. Read and
Co., Bristol; Dr. Orr,Godaiming; Dr, Smith,Bristol; Messrs. Brear
and Co., Bradford; Mr. Christian, Hammersmith; Messrs. Lloyd and
Co., Leicester; M)'. Hughes, Hanley; Mr. Hay, Hull; Messrs. Oliver
and Boyd, Edinburgh ; Mr. Macdonald, Manchester; Messrs. SUiigor
and Son, York; Mr. Bertram, Bristol; Mr. Weston; Mr. Bryden,
Shipley: Dr. Slurp, Walsall; Mr. Ramsdale Patricroft; Mr. Hart,
London ; Dr. Cunningham, Bristol; Mr. Stark, London ; Mr. Maw,
Doncaster; Dr. McMordie, Belfast; Mr. Owen, London; Mr. Boase,
Plymouth; Miss Boadon, Cornwall; Mrs. McRos'y, Esher; Mr.Thin,
Edinburgh; Dr. Williams, Oxford ; Mr. Spencer, London; Mr. Green,
Bournemouth; Mr. Jossop, Leeds; Dr. Jones, Yorks; Mr. Southwold,
Dawlisli; Mr. Blatchley, London ; Mr. Brantiiwaito ; Mr. Thompson,
Hampstead; Dr. Davies, Glamorgan; Mr. Branthwaite, Stockton-on-
Tees ; Mr. Heywood, Manchester ; Mr. Bobnke, London ; Dr. Welsh,
Chesliire ; Dr. Garinan Kendal; Dr. Palmer, Woking ; Mr. Williams,
Binninghain; Rev. Mr. Wilcox, Glasgow; Mr. Acktill, Harrogate;
Mr, Ferdinand, Aberdeen ; Mr. Borrelt, Portsmouth ; Mr. Hud.son,
Sheffield ; Dr, C.arr, Omagh ; Mr. Wado, Uxbridge; Rev. Mr. Jones,
Swaffham; Mr. Naylor, Rotherham ; Surgeon, Devon; Ciel; B.A. ;
R. L., London; H., London ; S- H-. Manchester; Socrotary, Radcliffe
Infirmary; M.D..Ripley; C. C., London ; Secretary, Atlas Association
Co.; Alpha, .Sudbury ; Medicus, Liverpool; Forceps, London ; Gold
Iodide, Brighton ; W., Bristol; 0 , London ; Secretary, Grimsby
and District Hosoital; II, M,, London ; Haider, Hull; Orleans Parish
Medical Society, U,S.A.; L. T., OldOatn; Adoption; Vaccine Lymph
Association; Expectans, London; Vico, London; N., Wandswortli-
road ; Tutor, Newcastle on-Tyne ; J. D,, London ; Z,, ijondon ; M,D,,
I,ondon ; A.M,, M.B , London ; Omega, London ; Lombard ; Statim,
London; Nemo, London : F, K,, CaerswH ; Castle, London ; H. R.,
London ; F. O,, Bath ; Matron, Manchester ; Pets, London ; Doctor,
Loudon ; S. G. II , London ; T, C. D,, London ; Paraldehyde.
NEWSl’Ai’i'RS.— Daily Post. Leeds Ueroury, Surrey Advertiser,
SuuUish Leader, Bristol Uercury, Yorkshire Post, Law Journal, West
JUiddlesez Standard, Jleadiny Mercury, Insurance Record, Windsor and
Eton Express, Mininy Journal, ilerifordshire Mercury, Weekly Free
Press and Aberdeen Herald, The Eewspaper, Hampshire Independent,
Observer and Chronicle (Bournemouth). East Jmndon Disjiatch, West
Middlesex Adveiluier, Labour World, Windsor and Eton Gazette, Poole
and Bournemouth Herald, SovUt Wales Exprests, Shields Daily Gazette,
Eorfolk Daily Standard, Admiralty Gazette, Leicester Post, Scotsman,
MelbouTnc Aryus, Bamct Press, Weekly Times and Echo, Observer,
Worcester Chrotiicle, ErUbane Teleyraph, WakrjleUl Free Press, Cape
Aryus, Bombay Gazelle, Svulhampion, Times, Soarborouyh Gazette,
H'f//£ovi Advertiser, Colchester Gazelle, Pete.rborouyh Express, Somerset
CityJAail, Eastbourne Gazette, Indian Daily Fews (Calcutta), Pioneer
Maii (Allahabad), Public Opinion, Doncaster Gazette, Bedford Record,
Spaldiny E'ree Press, Child's Guardian, •itc., have been received.
SUBSCRIPTION.
ADVERTISING
Post Free to ant part op the United Kinqdoh,
One Year_.-_~w£112 6 | Six Months £0 U 3
To China and India --..One Year 1 10 10
To THE Continent, Colonies, and United
States.. ...... IMtbo 1 14 8
Post Office Orders and Cheques should be addressed to The Publlshet,
(7 bb Lancet Office, 428, Strand, London, and crossed “London and
Westminster Bank St. James’s-square.’'
Books and PnbUcatlons (seven lines and under) .. M i 0
Official and General Announcements .0 4 0
Trade and Miscellaneous Advertisements .. ..440
Every additional Line 0 0 8
Front P^e .. .. .. per Line Old
Quarter Page. 1 10 0
Half a Page .. ..2 15 0
An Entire Page.650
The Publisher cannot bold himself responsible for the return of testi¬
monials <kc. sent to the office In reply to advertisements; copies only
should bo forwarded.
Notice.—A dvertisers are requested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
initials only.
An original and novel feature of “ Tub Lancet General Advertiser" Is a special Index to Advertisements on pages 2 and 4, which not only
alords a ready means of finding notice, but is in Itself an additional adve rtlsement.
Advertisements (to ensure Insertion the same weekjshould be delivered at the Office not later than Wednesday, accompanied by a remlttanoe.
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms for Serial Insertions may be obtained ol the Publisher, to whom all letters relating to Advertisements or Subscriptions should bo
Addressed.
Advertiaemanti are now received at all Messrs. W. H. Smith and Son’s Railway Bookstalls throughout the United Kingdom and all otbn
Advertising Agents, _ _ _
Agont for the AdvertUement Department in France-J. A8TIER, 60, Rue Oaumartin, Paris.
Dir: -n-:l by Coogle
THE LANCET, May 16, 1891
'ONITHE COAGULATION OF THE BLOOD IN
ITS PRACTICAL ASPECTS.
The Annual Oration delivered before the Medical
Society of London, May 4th, 1891,\
By SIE JOSEPH LISTEK, Bart,, F.E.S.,
PROFKSSOR OF CI.INICAL SURGERY IN KING’S COLLEGE, LONDON.
Mr. President and Gentlemen,— Thirty years ago
(Dr. Alexander Schmidt of Dorpat enunciated a totally new
view of the coagulation of the blood. Having rediscovered
the fact observed many years before by Dr. Andrew
Buchanan of Glasgow,^ that hydrocele fluid, uncoagulable
dn itself, is made to coagulate by the addition to it of the
serum of blood already coagulated, and pursuing extended
(researches in the line thus indicated, be came to the con-
.clusion that fibrin does not exist as such in solution in the
plasma, but is composed of two albuminoid substances ; one
present in the Ii(][uor sanguinis, to which he gave the name
•of “fibrinogen”; and the other a constituent of the blood cor¬
puscles, and this he termed the “fibrino-plastic substance.’’®
It might be objected to Professor Schmidt that the hydro¬
cele fluid and the various dropsical effusions with which he
/ha.d worked were not fairly comparable to liquor sanguinis;
that they were transudations through the walls of vessels,
*nd that the liquor sanguinis might have become in one
way or another altered in the process of transudation. This
■objection was, as I believe, removed by an observation made
by myself about the same period.^ It had fallen to my lot
«bo observe that in mammalia, whereas the blood usually
•coagulates soon after death in the heart anil the main vas¬
cular trunks, in the secondary vessels it remains fluid for
<in indefinite period, and that, not only in those of small
calibre, but, if the animal be largo, in large vessels also,
'ffhis being understood, I proceeded as follows. Having re-
•moved a portion of the jugular vein of a horse with the
blood contained in it, buoween two ligatures, I suspended
•this segment of the vein in a vertical position, in the
'blood of the horse the red corpuscles behave in a totally
■different manner as, regards their aggregation from
■those of a healthy man or of the ox. In the horse,
'instead of the red corpuscles assuming the condition of a
'delicate network of rouleaux, they become aggregated into
■demse spherical masses, often visible to the naked eye, like
•coarse grains of sand. And these densely aggregated cor¬
puscles, falling more quickly than the rouleaux in the liquor
•aanguinis, as hailstones fall more rapidly than snowflakes,
;3oon leave the upper part of the fluid comparatively free
fr(jm corpuscles, so that within about half an hour the upper
third, or it may be half, of the blood is a transparent
'liquid.* When I had ascertained through the translucent
w^la of the vein that this state of things had occurred,
d punctured the upper part of the vessel, so as to
let out some of the clear fluid, and found that it
was very slow in coagulating. la about three-quarters of
•an hour it had only begun to coagulate, whereas a little of
'this same clear fluid, to which a small portion of coagulated
‘blood was added, clotted in a very short period. That the
•clear fluid^did coagulate at all was sullioiently explained by
microscopical examination, which showed that there were
present in it some red corpuscles and numerous white cor-
(pusoles. It was obvious that if we could have separated
the corpuscles absolutely from the liquor sanguinis, there
would have been no coagulation at all; and as the separa¬
tion of the corpiianles from the plasma bad occurred, not by
■transudation through vascular walls, but simply as the
result of gravity, it could be no longer doubted that
'Schmidt’s cnclusions were essentially right.
During the time that has since elapsed various en-
1 ProcoiKlinRN of blio flla.sRow Philosophical Society, Feb, lOtii, 1845.
a See Arehiv fUr Anal.. Phys, &c., isci and 1802.
» See the Cvooninn Lecture by the author, on the Coaculation of the
IRlood proceediiiKs of the Royal Society, June lltli, 1800, p. ono.
< Ibe same thing is so(»n in the mixture of .serum and corpuacles
• fihtainod by st.irnng the blood during coagulation. In that from the
UioTHB the ml (torpuHcles Bubsido from about the upper third of the liouid
within Inlf an hour ; whereas that from tiio ox shows only a thin liiyor
■ of serum after tlie lapse of twenty-four hours, 1 am surprised to vee
ttJiat In some toxt-books the huffy coat is attriimfod to slowno.s of
•ooagulation, with which it has nothing whatever to do.
No. 3533
deavours have been made to ascertain the precise natuie
and mutual relations of the constituents of the liquor san¬
guinis and the corpuscles thus concerned in the formation
of the fibrin. This inquiry cannot be said to be yet ter¬
minated, and it is at tne present time uncertain whether
Schmidt’s simple original view may not be correct—that there
are two albuminoid substances, one in the plasma and one in
the corpuscles, which combine to constitute fibrin. These
Investigations, most valuable as they are, have, as it seems
to me, somewhat overshadowed the question which is, after
all, the most interesting to us as practitioners—namely,
What are the circumstances that aetermine the mutual
reaction of these two constituents ? What are the conditions
under which the corpuscles are induced to give op their
element of the fibrin to combine with the element in the
liquor sanguinis? This subject engaged a large share of
my attention many years ago, and though I am afraid I
have not much of novelty to communicate regarding it, yet,
in consequence of its very great importance, I have thought
that it might perhaps be nob unworthy of the circumstances
in which the kindness of your Council has placed me this
evening.
Shortly before my investigations began, Professor Briicke
of Vienna had conducted an inquiry into the conditions
which determine coagulation, and had arrived at conclu¬
sions which, to a certain extent, resembled those to which
I was led.'’ He found, as I also did, that there is a world¬
wide difference, in their relations towards the blood, between
the walls of the living vessels and ordinary solid matter;
and Briicke concluded, as Sir Astley Cooper and others had
done before him, that this difference consisted in an active
state of the living vessels; that the bloodvessels, by an
action which they exerted upon the blood, prevented it
from coagulating. My inve-stigations, on the other hand,
led me to conclude that healthy blood has no spontaneous
tendency to coagulate ; and that the walls of the blood¬
vessels are not active, as Biucke supposed, but passive in
their relation to coagulation; that ordinary solids induce
coagulation by an attractive influence—comparable perhaps
to that wiiich a thread exerts in causing the deposition of
sugar-candy from a solution of sugar,— while the healthy
living tissues differ from ordinary solids in being destitute
of this attractive influence.
Out of many experiments tending to this inference,
published long ago,“ I may be permitted again to describe
one which not only appeal’s to me conclusive on the
point at issue, but is also of interest otherwiBe. A por¬
tion of the jugular vein of an ox with the blood in it being
field vertically, I cut off the upper end, taking scrupulous
care that the wounded part of the vessel did not come in
contact with the blood, and then passed down into the
vein a tube composed of very thin glass of a calibre rather
less than that of the jugular vein, its upper end being stopped
by a perforated cork, in which was inserted a narrow glass
tube, winch again was continued with a short piece of
vulcanised indiarubber tubing. The tube was pressed with
the utmost steadiness down into the vein, so as to disturb
the blood as little as possible. In the course of time, the
vein being a little squeezed, blood made its appearance in
the narrow glass tube and then at the end of the indiarubber
tube. When this was the case, the indiarubber tube was
secured by a clamp, and the whole apparatus was rapidly
inverted and the piece of vein withdrawn. Waterproof
tissue was then tied over the open end of the large tube, to
prevent evaporation and exclude dust, and the tube was
securely fixed and left undisturbed. Thus we had blood
present in a vessel consisting entirely of ordinary solid
matter, but having been subjected in a minimum degree
to the inlluence of the ordinary solid: and the result
was, that when I came to examine the blood after the lapse
of ten hours, I found it still fluid, with the exception
of a crust of clot lining the wall of tbe vessel. This,
gentlemen, seemed to me of itself to afford sufficient
evidence that healthy blood has no spontaneous ten¬
dency to coagulate, requiring to be kept in check by an
action on tbe part of the walls of the living vessels. This
blond had been entirely withdrawn from the vein, and yet
it remained fluid except M’here in contact with the ordinary
solid.
This conclusion has been comparatively lately strikingly
confirmed by the experiments of more tnan one observer.
I would esppcial'y allude to one performed by Professor
See Bi'iii.sli and Foreign Medical Review.
B See the Crooniaii I.oeture, Froceediiiga of the Royal Society, loc. ciU
U
1082 Thb Lancet,] SIR JOSEPH LISTER ON THE COAGULATION OF THE BLOOD. [May 16,1891.
Berry Haycraft.^ He has found that if a drop of blood ia
introduced under suitable precautions into a deep narrow
jar of castor oil, and before the drop, which falls slowly
through this oil, has reached the bottom of the vessel, the
jar ia inverted and the drop made to retrace its steps
without having touched the glass, this process being
repeated again and again, the drop of blood, having never
come in contact with an ordinary solid, remains fluid for an
indehnite period. This experiment may perhaps appear to
some of you even more conclusive than mine, inasmuch as
no coagulation whatsoever occurs in the drop of blood
under these circumstances. Certainly it seems to me that
it confirms in an absolutely unmistakable manner the view
to which I had been previously led.
But there is also this interesting circumstance in Pro¬
fessor Haycraft’s observation. It had been shown amply
by myself that the gases of the atmosphere are incapable
of inducing coagulation of the blood; bat experiments
like those of Professor Haycraft show that the same
is the case with neutral or chemically indifferent liquids.
Thk seems to me to be an exceedingly interesting fact—
viz., that the active living tissue, such as lines the wall of
a healthy vessel, in its relation to the coagulation of the
blood, resembles the mobile particles of a liquid.^ I say the
active living tissue, for when the living tissue becomes im¬
paired in vital enei-gy it behaves towards the blood like
an ordinary solid. That is the case not only when a
vessel is wounded, bat also when it is subjected to
some influence which, without actually woundmg it, is
calculated to suspend or impair its vital activity. A good
illustration of this is afforded by a fact which I have
never before referred to, but which I have often noticed.
A very valuable field for simple and instructive observa¬
tions regarding the conditions that determine the coagula¬
tion of the blood was afforded by the feet of sheep, removed
afterthe animals have been killed, the blood being retained
in the vessels by a bandage applied below the part where
the foot is removed by the butcher. The blood remains
fluid for days in the veins of such feet; while, at the same
time, the persistent vitality of the vessels is shown by the
fact that they contract when exposed by reflection of the
skin.^' Now it happened that the butcher, in order to keep
the sheep from struggling, always tied the feet together
with a firm cord, applied below the part where my bandage
for retaining the blood was passed round; and I in¬
variably found the blood coagulated in the superficial
veins at the part where they bad been pinched between
the cord and the bone. There is no reason to suppose
that the temporary application of the cord had deprived
the veins of their vitality at the part subjected to its pres¬
sure. If the sheep had been released I have no doubt what¬
ever that the veins would have remained alive. But though
the vessels had not been wounded, but only squeezed,
only had their vital energies temporarily impaired, never¬
theless the blood had coagulated in them at the parts so
treated. Just as by pinching a portion of the web of a
frog’s foot with the padded ends of a pair of dressing forceps
you can induce, if you press hard enough, a degree of
intense inflammatory congestion by which the pigment cells
for the time being have their vital functions of diffusion
and concentration of the pigment perfectly suspended, and
yet are in a condition which is recoverable,^" so had
these veins been subjected to an agency—the pinch¬
ing by the cord—which did nob actually wound them, but
merely impaired or suspended for the time being their vital
power. Thus it appears that the living tissues which, while
in a healthy active state, differ from ordinary solids in not
occasioning the coagulation of the blood, when lowered in
their vital power, themselves act like ordinary solids and
induce coagulation.
Another point to which my investigations were at that
time directed was the behaviour of the blood-clot in rela¬
tion to coagulation. I came to the conclusion that an un¬
disturbed eoagulum resembles living tissue in its behaviour
with regard to coagulation ; that an undisturbed clot does
not induce coagulation in its vicinity—a moat important
7 Hee .Journal of Ariatmny and Pliysiology, voi, xxii,, p, D82.
8 Dr. Freund of Vioiiiia aliiio«t Mhiiultaneouely and indopendontly
observed this relation of inert liquids to coagulation. See Jabrew-
berichte filr Anatoinio imil riiysioloKie, 1880.
f The blood in tlio amputated limb becomes gradually impaiiod in its
coagulating property. A fe'v hours after amputation it ia found to clot
more slowly than at first when exposed to the iofiuenco of ordinary
solids, and after some days fails to coagulate at all.
W a paper hy the iimlior on the Early Stages of Inflammation
Phil. Trans, for 18.08, J-'ai-t II., p. 082.
truth, if it be such. This is well illustrated by th&
fact with regard to the sheep’s foot to which I have-
already referred. We have seen that, on the one-
hand, where the tight cord had pressed the veins,,
coagulation occurred in those veins; but, on the other hand,,
that the blood remained permanently fluid in other parts ofi
the same vessels. In other words, the clot induced by the-
aebion of the cord upon the veins had not been able to-
spread, although the blood in the veius was perfectly at
rest; the clotbould not propagate itself. The same thing;
is seen in any amputated limb in which the bloodvessels are-
sound. If such a limb is examined, say, twenty-four houra
after amputation, you will find that there exist clots in the
vessels where they were wounded by the knife in the opera¬
tion, but that elsewhere the blood remains fluid and’
coagulable. I came therefore to the conclusion that an
undisturbed blood-clot is unable to induce coagulation ici
its vicinity; and I think that the instances I have given
demonstrate that such is really the case.
Yet in the experiment which I have described, where a.
glass tube was slipped down into the jugular vein, the-
coagulum did propagate itself. I found on examining sucb
a tube, ten hours after it had been charged with blood, that
the crust of clot which lined the tube was only a thin one
but in another experiment, nearly two days having been
allowed to pass before examination, the clot was thick, and
there remained only a small channel in the middle of it,,
with the blood still fluid and coagulable. How is this
difference of behaviour between the clot within the vessels-
and the clot outside them to be explained ? At the time
when I performed the experiment I was disposed to think
that it must be due to some imperfection in the mode of'
performing it; that in spite of all the care that I had taken
in very steadily pressing down the very thin glass tube,,
nevertheless the mood must have been influenced by the-
glass for some considerable distance.
T am now inclined to believe that another explanation'
must be given. It was ascertained by Schmidt that (to-
adopt provisionally his original nomenclature) the flbrino-
plastic substance emitted by the corpuscles is greatly in<
excess of what is required in order to combine with the
fibrinogen of the liquor sanguinis. This, in fact, is obvious-
from the fundamental truth that serum expressed from a--
shrinking clot, when added to hydrocele fluid, induces-
coagulation. The blood is coagulated already, the fibrin is*
already formed in it, and yet the serum contains fibrino-
plastic substance in solution free to combine with the
fibrinogen of the hydrocele fluid. Such being the case, we
can readily understand that, in the experiment with the
glass tube, the clot first formed, shrinking, squeezes out a.
little of its serum containing fibrino-plastic substance, and)
this combining with the fibrinogen of the adjacent liquoF
sanguinis, fresh fibrin is formed, and the clot goes on per¬
petuating itself indefinitely, however slowly.
But how are we to explain the non-extension of the clot'-
within the vessels in the eases referred to ? IIow are we tc-
explain the fact that it did nob spread from the vicinity
of the tight cord in the sheep’s foot, and does not extend
beyond the vicinity of the wound in the amputated limb;:'
Again, why is it that the eoagulum never propagates itself
from the wound in the vein after phlebotomy? That-
wound, intentionally made somewhat gaping, is certainly
in the first instance occupied hy blood-clot. The equable-
llow of the venous blood does not disturb it. It is an un¬
disturbed eoagulum. But it must often happen that tbe-
clot projects more or less into the calibre of the vessel, in
which case the blood at its lee side will lie at rest in contact
with it. Yet the indefinite extension of the eoagulum,,
which the analogy of the blood in the glass tube would lead
us to anticipate, never occurs, and we reckon with confidence
on the wound in the vein simply healing without inter¬
ference with its calibre.
These remarkable differences between the behaviour of
a eoagulum in a glass tube and within the living vessels
may perhaps have light thrown upon them by a fact which
I have on a previous occasion brought before the attention-
of this Society.'^ I first observed it eighteen years ago, in
an attempt that I made to obtain pure blood serum from a
horse, letcing blood, with antiseptic precautions, from the-
carotid artery into a flask that had been purified by heating
it to a very high temperature. To my great astonishment
I found that, although the blood of the horse coagulated as
usual in the flask, the clot did not shrink in the least,.
i .See Tin-; Lancct. Oct. 25th, p. 725.
The Lancet,] SIR JOSEPH LISTER ON THE COAGULATION OF THE BLOOD. [May 16,1891. 1083
Though I kept it for many days, yet there waa not a drop
of serum to be seen upon its surface, and the sides of the
clot remained in contact 'vs'ith the wall of the flask. This
was made particularly striking by the circumstance that
cnasses of aggregated red corpuscles, resembling grains of
sand, as before described, were to be seen touching the
iglass in the lower part of the huffy coat. This, I need
hardly say, astonished me immensely, and 1 imagine it
was the first time that a blood-clot waa ever seen nob to
■shrink and press out serum.
It seemed scarcely credible that this result could be due
-to the destruction of micro-organisms in the flask, although
the heat had been applied for that purpose. It was sug-
.gosted to me that perhaps it might arise from some physical
change in the glass due to the very high temperature to
which I had subjected it. It had been observed by Liebig
that, whereas a super-saturated solution of sulphate of soda
is, under ordinary circumstances, made to start into a
•crystalline mass by contact with a glass stirring-rod, no
■such effect is produced by the rod if it is heated in the
illameof a spirit lamp and allowed to cool—a» result attri-.
buted by Liebig to some temporary physical change pro¬
duced in the glass by the heat. Might it be, then, that
■the fibrin of the clot failed to shrink in consequence of a
different molecular arrangement assumed under the in¬
fluence of the glass altered by heat? That view, how-
•ever, has been exploded, because it has been proved—as
illustrated by some striking experiments shown at a
conversaKione of the Royal Society some years ago
by my colleague, Professor Thomson—that the cause
of the crystallisation of the super-saturated solution of
■sulphate of soda is not the contact with the glass as such,
hut the accidental presence on the glass of minute quantities
of sulphates isomorphous with the sulphate of soda; and
'■that the effect of the heat is to drive off the water of
■crystallisation of those salts and make them no longer
isomorphous with it, and therefore no longer able to induce
the crystallisation. And so a mystery in physics was cleared
'away and made a very simple matter. Thus the suggested
•explanation fell to the ground.
The same absence of shrinking of the clot had been
brought about by different means in the example which I
■exhibited to this Society five years ago. A glass jar,
not especially clean, had been purified by means of a
■solution of corrosive sublimate in SCO parts of water.
Blood had been let into this jar from the jugular vein
of a horse, under antiseptic precautions, forty-one days
before; and the members of the Society had the oppor-
■■tunity of seeing that, just as in the case of the flask
■subjected to a high temperature, the clot had not shrunk ;
'the serum had not been squeezed out of it. And
although it seems unlikely that in the short time that
-elapses between the shedding of tlie blood and the com¬
mencement of shrinking of the clot, under ordinary circum-
•stances, the micro-organisms present could have had such
an inffuence on the blood, yet when we see that two agencies
so different in their nature as a high temperature and a
■solution of corrosive sublimate, but both powerfully
tgermicidal, led to the same result, one is almost inclined
to think that surely it must be so. No other explanation
has been offered, although I know that physiologists have
been much interested in the subject. If we admit that
unicro-organisms are the cause of the shrinking of the clot,
dt follows that a coagulum formed within the body under
healthy conditionsotherwise.boing free from micro-organisms,
will not shrink ; and, therefore, that the clot, not squeezing
out the serum, will not induce coagulation in its vicinity.
Il^ibriuo-piastic substance exists no doubt in the serum in
the substance of the clot. But the experiments of the late
Mr. Graham showed that diffusion of liquids is an exceed¬
ingly slow process, even between a strong saline solution
and water ; and it must be a very plow process indeed
between two liquids so nearly allied as liquor sanguinis and
■cerum. I do not say that this is really the true explanation ;
but it fieeras to harmonise with the facts.
While an undisturbed clot resembles healthy and active
'living tissue with respect to coagulation, an injured
■clot acts iu this relation like wounded tissue. And
as a coagulum is an exceedingly lacerable and very
easily injured substance, we often see coagulation
■induced by a blood-clot that has been disturbed. This is
■perhaps most strikingly seen in aneurysm. Let us take,
(for instance, a traumatic aneurysm. The blood escapes
ifrom the wounded artery into the surrounding tissues, and
these having been injured, the blood coagulates in contact
with them. Every successive portion of blood driven in by
the force of the ventricle stretches and lacerates the clot so
formed. It is an injured clot, and induces coagulation in
its vicinity; and the result comes to be that while, on the
one hand, the force of the heart tends perpetually to distend
the sac, inferior as it is in elasticity to the walls of the
bloodvessels, there is, on the other hand, a constant ten¬
dency to deposition of fibrin upon the interior of the sac,
as if the blood were whipped, and thus the wall of the sac
is perpetually strengthened, exhibiting, a counteracting
agency tending to recovery.
A beautiful converse of this state of things is pre¬
sented, as it seems to me, by some cases of varicose
aneurysm, such as used to be a not uncommon result of
careless venesection. Here the communication with the
vein was sometimes so free that the blood driven in by
the heart distended the sac comparatively little, so that
the aneurysm had no tendency to increase, but was
merely a source of annoyance from the purring sensation
caused by the arterial blood driven into the vein. And if
an operation was performed on such a case, the remarkable
fact was disclosed that, instead of the aneurysmal sac being
lined with layers of fibrin, it resembled in its interior an
artery or a vein.^- The force of the blood not being able
to tell upon the clot and injure it, the clot ceased to induce
further coagulation, and became organised and invested
with endothelium.
We see the same thing illustrated in the different be¬
haviour of the blood-clot above and below a ligature applied
upon an artery in its continuity. When such a ligature
was applied in the old-fashioned way in the shape of a
silk thread, used without any antiseptic precautions, with
the ends left long, it had to come away by suppuration,
and there was serious danger of secondary haemorrhage.
But if this did occur, it was commonly not, as might have
been expected, from the cardiac side, where the seat of
ligature was subjected to the full force of the ventricular
contractions, but from the distal side, where the pressure
was comparatively feeble. The ligature having been
applied sufficiently tightly to rupture the internal and
middle coats, there necessarily occurred as an immediate
result a certain limited amount of coagulation upon the
injured tissues. On the cardiac side, where the force of
the blood driven by the heart against the obstruction told
povverfully at every stroke, the clot was perpetually dis¬
turbed, and infallibly coagulation occurred up to the first
considerable branch, that carried the stream away and
made further coagulation impossible. But at the distal
side, if the circumstances of the anastomosing circulation
were such that there was no pulsation, there might be no
extension whatever of the undisturbed primary coagulum,
so that a mere trace of clot was found on pathological
examination.
I have hitherto referred to the view first advanced by
myself, and now, I believe, generally accepted, that the
Iluidity of the blood is not due to an active operation of the
living'vessels. But I am far from holding the opinion that
there is no part of the vascular system that actively opposes
coagulation. If transfusion is practised in the ordinary
manner, say, by filling a syringe with blood and ^inject¬
ing it into the vessels of the patient, the blood is sub¬
jected to the inlluence of an ordinary solid, which would
inevitably induce coagulation within the vessels, unless
there were some counteracting inlluence at work. It is
astonishing how very short a period of contact with an
ordinary solid determines the mutual reaction of the cor¬
puscles and the liquor sanguinis. Yet no coagulation occurs
as the result of such an operation. It is, I presume, in the
capillary system that the correcting inlluence is exerted.
Again, when intense inflammatory congestion is pro¬
duced by the application of some irritant substance to
the web’ of a frog’s foot, we see that the corpuscles, both
red and white, adhere to one another aud to the walls
of the vessels, and block the capillaries. Mechanical
violence is one of the many irritating agencies which
produce .such congestion; and from what wo know of the
effects of the pressure of the cord upon the vessels of a
sheep’s foot, we cannot doubt that the blood must be coagu¬
lated in the congested vessels; that between the corpuscles
there must be cementing fibrin. The distinguishing charac¬
teristic of acute inllamniabory exudation is of itself pretty
.Suo Symw'.-i I'l'imiplos of Sui-gery, ilfUi t-ilitlon, p. MO.
1084 The Lancet,]
DR. MACNAUGHTON JONES ON TINNITUS AURIUM.
[May 16,1«91.
clear evideoce of this effect. The exudations in intense in¬
flammation differ from those of dropsy by being coagulable.
Hence the brawniness of tissues that are intensely inflamed,
or the lymph in acute pericarditis. How can this coagulable
character of the effused liquor sanguinis be explained.except
by supposing that the walls of the capillaries have acted
for the time being like ordinary solid matter, and that,
as a consequence of this behaviour of the capillaries, the
corpuscles have given up to the liquor sanguinis (to use
Schmidt’s language] the necessary fibrino-plastic substance ?
And if the exuded liquor sanguinis coagulates, we cannot
doubt that the plasma which remains in the capillaries is
also coagulated. Nevertheless, if the irritant has not been
ushed so far as to cause the death of the part on which it
as acted, the tissues in due time recover, and we see the
corpuscles gradually detaching themselves from each other
to pass on into the circulation. And we may surely say
that, not only do the corpuscles recover their original non¬
adhesive character, but the fibrin which binds them together
is redissolved.
I believe, therefore, that although in the larger vessels
the vascular walla are negative as regards the coagulation
of the blood, in the capillary system there must be potent
agencies counteracting any tendency to clotting induced by
abnormal conditions, and capable even of redissolving fibrin.
THE
DIFFERENTIAL DIAGNOSIS AND PROGNOSIS
OF TINNITUS AURIUM (NOISES IN THE
HEAD AND EARS).
By MACNAUGHTON JONES, M.D., F.R.C.S.I.&Ed,,
EX-UNIVERSIIV I'ROl-'ESSOa IN 'rillL liUEEM’S UNIVERSIIV,
IIIEIAND.
In a communication made by me last year on the etiology
of tinnitus, based on a classification of 260 cases, I
endeavoured to support the following etiological classifica-
tior on anatomical and physiological grounds.
Class 1 .—Impulses originating in the temporal lobe, or
superior temporal gyrus, the cerebsllum, or the auditory
nuclei (in the medulla or pons), and referred as impressions
to various situations, as the labyrinth or certain parts of the
head. Such acoustic impressions may or may not be attended
by deafness. These impulses may be associated with
lesions in these areas—as tumours, apoplexies, effusions,
thrombi, or possibly lesions in the adjacent portions of the
occipital or parietal lobes. Such impulses may result also
from reflected irritations of any of these parts.
Class 2 .—Itupuhes due to irritation direct or reflected in
any portion of the auditory nerve. This latter would include
bypeiajstbesia, atrophy, eclerosis, traumatism, vaso-motor
(dilator or constrictor) effects, morbid blood-supply to the
nerve, as in uraemia, anmmia, or the circulatory changes
which occur during preguanoy. These latter causes may
also operate under Class 1
Class 3 .—Impulses originating in the peripheral ends of
the auditory nerve, due to : (a) Increase or dimiuntion of
labyrinthine pressure, increase or diminution cf, or encroach¬
ment upon, the perilymph or enilolymph from abnormal
pressure on either of the fenestraj. This latter cause would
include rigidity of the membrane of the roucd opening and
fixation of the stapes against the oval opening. ( 6 ) Vus-
c^ar changes—increase or diminution of blood pressure,
frequently associated with narciac disease — hypereeniic,
anaemic, or toxaemic states of the blood circulating in the
labyrinth; apoplexy and extravasations, (c) Morbid nerve
conditions—hypeiiesthesia, paresis (organic or functional),
atrophy, scleiosis, traumatisms, (cf) Rheumatic, gouty, or
syphilitic states of the walls and vessels of the labyrinth,
(e) Reflected disturbance through the spinal cord or cerebro¬
spinal nerves, as occurs in uterine aisordtrs, pregnancy,
gastric derangements, gout, disorders of the liver, flatulence,
spinal neuroses, dental, nasal, and ocular irritations in¬
volving the fifth and facial nerves.
Class 4 .—IrritalioDS arising from interferences with the
intra-tympanic muscles — tensor tympani and stapedius.
Such interferences would include any spasm of these
muscles—abnormal changes in the membrana tympani or
* the mucous membrane of tympanum—reflex irritation trans¬
mitted from the facial or trigeminal nerves.
Class 5.—Irritations transmitted hy altered conditions 0 ?
equilibration of the air in the tympanic cavity. This would
include enervation of the tubal muscles of the Eustachian
tube, and altered relations between the air in the tympanio
cavity and the blood in its vessels or. those of its membrane *.
also pathological states of the membrane.
Class 6 .—Irritations due to disease in the middle ear and
labyrinth. This would embrace atheromatous changes
the arteries, aneurysmal dilatations, blood extravasations,
venous congestion within the lateral sinuses, disease of the
mastoid cells, and disease of the petrous portion of the
temporal bone, exudations, and tumours.
Class 7 .—Irritations arising in the external ear, including
inflammation and abscess, ceruminous collections, eczema¬
tous inflammation, exostosis and hyperostosis, othmmatoma,
foreign bodies. Some of these causes act by direct irritation
of the nerves supplying the external auditory meatus or.
tympanic membrane, as in inflammatory attacks and exos¬
tosis, others, as cerumen or foreign bodies, by the influence
they exert on the sound waves, or by the pressure due to
their presence on the membrana tympani, and thus con¬
veyed to the ossicles and labyrinth.
Class 8. — True aural hallucinations — subjective im¬
pressions arising in the psycho-sensorial brain centres and
having no objective cerebral or aural source of origin. Sucb
hallumnations may become insane hallucinations. The.
latter may be divided into two distinct forms, (a) Halluci¬
nations which arise subjectively in the brain when the aurah
apparatus and auditory nerves are healthy. ( 6 ) Hallucina¬
tions which are scondary to objective changes in the auralf
apparatus and in which a tinnitus is developed that leads-
up gradually to a fixed illusion.
Class 9 .—Therapeutical causes of tinnitus aurium. Ther
action of such drugs as ergot, nitro-glycerine, alcohol,,
ether, quinine, salicine, cafteine, apomorphine, nitrite of
amyl, tobacco, iodine, iodoform, chloride of barium, digitalis,,
convallaria, atropin, veratrin, duboisin, gelsemin, jaborandi,
pilocarpine, monobromide of camphor, hydrobromic acid.
Some of these diugs may act by direct stimulation of the^
auditory nuclei in the medulla, as caffeine, gelsemin, iodo¬
form, salicin, and quinine; others, as digitalis, jaborandi,
nitrite of amyl, chloral hydrate, by their action on the^
vaso-mortor centre; others, as quinine and digitalis, con¬
vallaria, by their secondary effects on the auditory circula¬
tion through their action on the heart.
I desire to supplement this classification by adding a few
observalioDS on a differential diagnosis on the lines above laid?
down. It is difficult in many cases to do this accurately
and with confidence, but in a very large number of patients.
we can come sufficiently near the reference of the individual
case before us to a special class, or it may be the borderlands
of two distinct classes of tinnitus, to enable us to give a>
correct prognosis of the chances for or against recoveiys,,
and to indicate the correct line of treatment to be pursued.
To return to the etiological classification I have tentatively
laid down, we may summarise the clinical evidence on
which,' after a careful examination, we are enabled to-
include a particular case under any of these heads.
Class 1 .—Most of those who would come under this class-
are likely to have some evidpnce of the implication of the-
other nerves of sense in reflex disturbances, in muscular
paresis, cutaneous amcsthesia or hypercesihesia, or in oculo¬
motor symptoms and pupillary changes. Such causes as-
apoplexies, effusions, thrombi, or cerebral lesions, acting!
by inhibition, are most likely to reveal themselves
in objective signs in ihe parts in correspondence or
associated with these cerebral centres, lb is probable-
that in such reflected excitations we have an explana¬
tion of a tinnitus without deafness, as in cases of dentafi
caries, dental periostitis with neuralgia, spinal tabes,
uterine disorders, as versions and flexions, and in the func¬
tional sexual disorders of the menopause or pregnancy
(though in the latter it is more often to be attributed to-
arterial tension and hremic changes).
Class 5.—We may expect to find similar symptoms to those,
referred to in Class 1 with more direct evidence of a lesion
or excitation in 1 he auditory nerve itself. In bypersestbesia,
the hyper-sensitiveness and pain attendant upon certain
sounds, though there may be normal acuteness of hearing
in traumatism, the history of some injury, as a blow on
the ear, a railway collision, a nasal fracture; in sclerosis
and atrophy, the absolute deafness and the negative re¬
sponse to the watch or tuning fork, even by conduction,
added to the history of pre-existing aural symptoms andl
le
The Lancet,
DR. MACNAUGHTON JONES ON TINNITUS AUEIUM. [May 16, 1891. 1085
progressive deafness or possibly vertigo; in irritation of
the vaso-motor centre, vaso-motor disturbances of the laby¬
rinth due to reflected excitations arising in the spinal cord
or in the nuclei or branches of the fifth nerve, with all such
evidences as spinal neurosis, spinal and ganglionic irrita¬
tion, oculo-motor symptoms, visual disturbances, gastric
crises, headache, possibly thyroid changes, flushings of the
face, dental neuralgia and associated dental affections, as in
eruption of the wisdom teeth, eruption of ocular and laryn¬
geal migraine.
Urine of low specific gravity, with a radial pulse of high
tension, albuminous urine or that charged with excess of
uric acid, the characteristic urtemic complications with the
associated altered blood of pregnancy, require only to be
remembered as coming under this class to secure their de¬
tection on examination.
In Class 3 we confront more clearly local causes of the
tinnitus. Such peripheral auditory nerve excitations are
usually associated with some abnormal states of the middle
ear or the meinbrana tympani. These, in a case of diminu¬
tion of labyrinthine pressure from changes in the perilymph
or endolyraph, with accompanying rigidity of the round
membrane or fixation of the stapes, have most frequently
as their consequences tinnitus, deafness with vertigo, and
often nausea. The ossicula frequently are involved, the
joints are ankylosed, the membrane is fixed, its pockets are
altered in shape; the malleus is sharply defined, or if the
case be an old one its head alone is visible, the normal
division of the membrane into pockets is absent, the
pyramid of light is either blurred or imperceptible, and
the membrane may have lost its translucent look. But
at other times this is not so, and though there is clear
evidence from the tuning fork, watch, and acoumeter
that the auditory nerve is affected, the membrane pre¬
serves its traoslucency, and there is but little deviation
from the natural appearances. Then there are the cases
in which the hearing distance is normal or a fair degree
of hearing is preserved, and still we have tinnitus, and
possibly vertigo superadded. There may or may not be
local evidences of gross middle ear changes. We at
once suspect vascular tension, increase or diminution of
blood pressure, and we search for evidence of organic
cardiac changes or altered states of the circulatory fluid
in ansemic or byperaemic conditions. This suspicion may
be verified by the discovery of a feeble systole, the
presence of a cardiac murmur, or valvular disease. The
urine requires to be carefully tested, and such toxic states
as are likely to influence vascular tension may be detected.
Such toxic or haemic sources of tinnitus are frequently the
forerunners of deafness, and the occurrence of Mdoiure’s
symptoms, following on extravasations and apoplexies. Aural
vertigo rarely occurs without the associatea “ noise in the
ears.” The first attack may occur suddenly and without
previous warning, but generally there has been some pre¬
existing tinnitus with impairment of hearing.
Class S .—Peripheral lesions in the labyrinth are often
attended with loud noises, and not infrequently the patient
will describe two or three different kinds of noise, one of
which is a musical tone or note. But we look in vain in
these cases, as distinguished from those in Classes 1 and 2,
for any evidence of serious cerebral complications or such
causes as uraemia, anmmia, or pregnancy. Gout and rheu¬
matism occasionally may cause tinnitus ; but this symptom
is associated with evidence of gouty changes in the meatus
or on the membrane, and the uric-acid diathesis is mani¬
fested by the evidences of gout elsewhere in the body, and
the presence of free uric acid in the urine. A pasty meatus,
shedding of epithelium, and possibly a slight discharge, are
often seen in such gouty cases. Also, we may find on
inspection thac some cretaceous deposits have occurred,
which are seen as irregular white coatings on the mem¬
brane. Such cretaceous masses I have frequently observed
in gouty patients.^ I must say that in iny experience
I have rarely found tinnitus and deafness arising from
changes in the middle ear as a result of acquired syphilis.
This is not so true in the case of the labyrinth. If they are
caused by specific disease there are other signs of syphilis
present, most probably in the skin or palate and pharynx,
or the nose, and there is the history of a past syphilitic
attack. Mere reflected disturbances of the labyrinth, which
arise in uterine disorders, during pregnancy, in various
forms of dyspepsia, hepatic congestion, flatulent distension
1 Atlas of Diseases of the Mombrana Tympani. J. A A. Churchill,
Loudon.
of the bowel, or in various visceral neuroses, obviously
form but one of the groups of symptoms which are met
with in such conditions. More particularly has it to be
remembered that tinnitus has its possible origin in dental
irritation, in astigmatism and associated asthenopia,^ in
nasal turbinate abnormalities, since such starting points of
excitation are specially apt to be overlooked. This remark
applies more particularly to the nose. In every case of
tinnitus the septum and turbinate bones have to be carefully
explored. In many instances it will furnish an explanation
of the aural condition.
Class J ^.—Here we realise a source of tinnitus which has
its direct origin rather in a muscle than in a nerve.
Obviously any abnormal action of the tensor tympani or
stapedius, causing increase or diminution of pressure and
alteration in the equilibration of the labyrinthine fluid, may
start a tinnitus. Kemembering this, we most not omit to
seek for the starting point of the mischief in some direct or
reflected irritation in the facial or fifth nerve. It is not
necessary in such cases that we should find any indication
of an afi'ection of the middle ear or the labyrinth. Thus the
hearing may be but slightly affected, or, on the other hand,
the influence on the muscles may be caused by gradual
changes in the mucous membrane of the tympanic cavity
and the ossicular ligaments, with accompanying changes in
the mobility, position, shape, and consistency of the mem¬
brane. If these latter are present they will be visible with
the speculnm.
Cfoss 5.—In this class we find the commonest causes of
tinnitus, both with and without deafness. Both in this
and in the last group we may have, in the tympanic mem¬
brane, in displacement and obliteration of its segments,
rigidity and immobility, or in varying degrees of collapse
{the consequences of chronic catarrhal attacks), evidence of
gross changes in the middle ear, which are associated with
ankyloses of the ossicles and fixation of the stapes. The
patient will often complain of inability to join in general
conversation in society, may hear better in a railway
train, or omnibus (Paracousis Willisii) and cannot
synchronously distinguish two distinct tones, as, for
instance, the ticking of two clocks in the same room. On
watching the membrane when Valsalva’s method is prac¬
tised, it may not in the least, or but very slightly, yield on
inflation. The cone of light is but little altered, or we may
detect but the slightest movement of either pocket with
Siegle’s speculum. On the other band, the membrane may
appear thinner than normal, the malleus may be altogether
displaced, so as to give the appearance of one large
' pocket which is blown bladder-like out on inflation.
But it by no means follows that such pathological signs
! must be present, even though there be considerable impedi¬
ment in the Eustachian tube from imprisoned secretion,
collapsed walls, stenosis, or obstruction from other cause.
! Slight deviation from the normal position and trausluceucy
of the membrane may be detected, but it is only on listening
with the otoscope (auscultation tube) to the inflation of the
' tympanum, and by careful obseivatlon of the membrane
through Siegle’s speculum, that we are enabled to discover
, obstruction or collapse of the Eustachian tube. Examina¬
tion of the nose and throat may give the clue to the inter¬
ference with the tympanic ventilation. In the nose, spuis
or deviation of the septum, enlarged turbinates, hyper¬
trophic mucous membrane, polypus, rhinolith (both the
latter rarely); in the throat, relaxed and feeble palatal
muscles, congestion of the palatO'pharyngeal mucous mem¬
brane (with probably elongated^ uvula), tonsillar hyper¬
trophy, adenoid growths, are among the more frequently
occurring and accompanying conditions which explain the
Eustachian interferences and account for the altered rela¬
tions of the air in the tympanum to the blood in its vessels,
as well as the pathological conditions of the vessels
themselves.
Class C .—I have included under this head those more
serious middle ear complications which follow upon disease
of the arterial tissues—local apoplexies, extravasations of
blood, lymph exudations, congestion of the venous sinnses,
arising from pressuie or in caidiac diseases. To it also we
refer lliose noises arising from obstructed pulmonic circula¬
tion and deficient oxygenation. There are those more
serious inflammations of the mastoid and petrous portions
of the temporal bone which lead to both exudations and
suppuration. The recognition of such states is not generally
" Taper by Uio author on DontalReHoxB.s : DciUiil Record, August, 1890.
1086 The Lancet,] DR. J. G. SINCLAIR COGIIILL ON KOCH’S TREATMENT.
[May 10,1881.
difliculc. A careful examination of the tj'mpanum with the
specolum, showing possibly intra-tympanio growths, granu¬
lations, or polypi, and the presence of a fetid discharge
will at once arouse suspicion of a deeper-seated cause for
the pain, giddiness, or tinnitus than that recognisable
with the speculum. Pain, tenderness, and fulness over
the mastoid, with projection of the auricle, will gene¬
rally be present when there is threatening of mastoid abscess;
pain more violent and diffused over the head, possibly pupil¬
lary changes, optic neuritis, tendency to delirium and
secondary lung complications, if the disease has extended
deeper and has involved the petrous portion of the temporal
bone, or baa possibly implicated the lateral sinews.
Class 7 .—Thecausesof tinnitus included inClassTareeasily
discovered, and hence the greater need for their being the first
sought for and not overlooked. It may not be amiss to say
a few words on each of these outer ear sources of tinnitus.
Inflammation and abscess are easily recognised by the
local symptoms of pain, severe heat, throbbing, swelling,
and occlusion of che meatus, tinnitus and deafness.
Such inflammation and abscess may lead to inflammation
of the membrana tympani and perforation of it. These
acute perforations are frequently attended by severe pain
and loud tinnitus. They may occasionally be seen, if
viewed through the speculum, to pulsate. Dead ddbris of
purulent collections, epithelium, or cerumen, is apt to be
loft behind and cause chronic irritation in the ear passage,
and may possibly lead to the occurrence of aspergillus or
perforation of the membrane. A persistent tinnitus may
be tbeconsequence, which a little local attention will remove.
Eczema of tne meatus, especially of the gouty type, which
is started by irritation of its walls, may be the sole
cause of the tinnitus, and is frequently incurred by the
entanglement of the desquamated particles of cuticle in
cerumen and discharge which clog the lumen of the
meatus and impinge on the membrane. Both exostosis
and hyperostosis may set'up a tinnitus by the irrita¬
tion they cause. But it is rare to find these as a sole '
cause of tinnitus, and they are frequently present without
it. More often we can trace the occurrence of the noise to
associated middle-ear catarrhal conditions, a gouty dia¬
thesis, or some Eustachian obstruction. In gouty patients
there is at times a distinct neurotic exaggeration of
symptoms, which includes a dwelling on, and morbid
apprehension of, any tinnitus that maybe present. Over-
indulgence in alcoholic drink, and, possibly, excess of
tobacco-smoking, contribute to increase the loudness and
intensification of such noises. It is necessary to refer to
otho^matoma (insane ear) as a cause of tinnitus, inasmuch
as its etiology and pathology demand separate treatment.
Class S .—Of the therapeutical sources of tinnitus, the
only one I propose to delay over is quinine. That a tem¬
porary tinnitus, deafness, and giddiness follow on the pro¬
longed use, or larger doses, of quinine is well known. At
times this amonncs to that condition known as “quinine
intoxication. ’ Burnet insists, and with this view I quite
agree, that in most of the cases in which any permanent
effects have been noticed as following the use of quinine
there have been other causes present quite suflicient to
account for the tinnitus or deafness independent of the
quinine. IStill, the fact that quinine can produce aural
disturbances of function, and that many of those who have
taken quinine in large quantities complain of tinnitus and
deafness, added to the possibility of its producing a con-
ge.stive state of the veseels of the labyrinth, independently
of its irritating effect on the hearing centre, is suflicient to
point to quinine as a probable and predisposing cause of
tinnitus.
PnofiNOSis.
It has to be confessed that in the present .state of our
knowledge it is difficult, in defining the grounds on which
we arrive at a prognosis in cases of tinnitus aurium, to
follow the lines of the classification that has been suggested.
Yet that attempt at a dill'erentiation of the causes of
tinnitus may be of use in confining the proposed thera¬
peutical steps to certain clinical and pathological condition.s
which may justify us in hoping for relief, if not cure,
following on their treatment. 1. We may, in the first
place, fairly exclude froto the category of curable cases
those noises which attend on cerebral tumours, lesions,
apoplexies, and degenerations which are secondary to the
occurrence of thrombi. It is, however, conceivable tliat
certain cerebral eflusions may yield to time and such
special remedies, as, for instance, iodide of potassium and
mercury. 2. Atrophy, sclerosis, and traumatic lesions of the
auditory nerves. 3. Rigidity of the membrane of the
round opening, and fixation of the stapes against the oval
opening. 4. Extravasations in the labyrinth. 5. Organised
effusions in the labyrinth. (5, Traumatism of the labyrinth.
7. Rheumatic, gouty, and syphilitic degeneration of the
walls and vessels of the labyrinth. 8. Organic changes in
the periphery of the auditory nerve. 9. Certain chronic
and irremediable conditions of the intra-tympanio muscles,
loading to atrophy, rigidity, or spastic contractions.
10. Many cases of chronic catarrhal inflammation, with
corresponding and evident changes in the tynpanum, in
which a considerable degree of deafness attends on the tin¬
nitus, and in which there is a history of progressive deaf¬
ness extending over a considerable time, with possibly
hereditary deafness in the patient’s family. 11. Perma¬
nent closure, on occlusion of the Eustachian tube, may be
included under this head. 12. Many oases of chronic
M^nibre’s affection (true labyrinthine vertigo) in which,
after the more acute symptoms have subsided, there still
persists deafness, occasional attacks of migraine and
tinnitus. 13. Tinnitus consequent upon aneurysmal con¬
ditions of the auditory arteries on atheromatous changes in
their tissues. 14. Exudations and tumours of the mastoid
cells—say, of a syphilitic and gummatous nature,—or disease
of the petrous portion of the temporal bone consequent
upon chronic suppurative catarrh of the tympanum.
15. Distinct aural hallucinations attendant upon or fol¬
lowing gross changes in the middle ear and Iab;yrintb.
Turning now to those cases in which we may hope for
amelioration, if not complete cure of the tinnitus, we may
thus classify them :—1. Tinnitus arising out of any reflected
local or systemic irritations of the auditory centre or
auditory nerve, which are due to deficient morbid blood-
supply, or vaso-motor disturbances in the auditory areas.
2. Tinnitus arising out of simple primary hypertemia of
the labyrinth or a hypevajmia which is secondary to
certain fevers as intermittent fever, puerperal sepsis,
so-called “cerebral” fever, and the continued fevers.
3. Tinnitus consequent upon temporary alterations of
the labyrinthine equilibration, whether due to altered
conditions of tension of the fenestr® or increase or
diminution of blood pressure, and frequently associated
with cardiac functional disorders; simple hypertosthesia
acoustica. -4. Tinnitus which has its origin in rheumatic,
gouty, and syphilitic conditions, whether in the labyrinth
or middle ear; in the urcemia of pregnancy or Bright’s
disease. 5. Tinnitus due to abnormal states of the intra-
tympanic muscles, as enervation, spasms, altered muscular
tension (from defective middle ear ventilation and equili¬
bration), producing conditions and positions of the mem¬
brana tympani and accompanying deviations in the
normal relations of the ossicles, which have their con¬
sequent effects on the labyrinth through the fenestrce.
6 Tinnitus arising out of enervation of the tubal muscles
of the Eustachian tube, collapse and closure of the
walls of the tubes, temporary obstruction of the tubes from
catarrhal conditions of the mucous membrane, or accumula¬
tion of mucus in the tube. 7. Tinnitus arising from irrita¬
tions in the external ear. 8. Tinnitus arising from thera¬
peutical causes. 9. Aural hallucinations which occur inde¬
pendently of any acoustic or cerebral trouble, and which
may be associated with visceral or pelvic neuroses. Such
hallucinations, if they become insane hallucinations, dis¬
appear with tbe mental alienation.
Ilai'ley-stroct, W.
KOCH’S TREATMENT AT THE ROYAL
NATIONAL HOSPITAL FOR CON¬
SUMPTION, VENTNOR.
iW J. G. SINCLAIR COGHILL, M.D., E.R.C.R. Edin.,
SKNIOIl IMIVSICIAX TO Till-: IIOSI'ITAL,
Foil some time past, unfortunately, the very justifiable
enthusiasm, or, as others put it, “the outburst of feeling
uncontrolled by reason,” with which Koch’s great discovery
was received, W been followed by a reaction as unwise as
id is regrettable. The principal contributory causes of this
change are not dillicult to recognise, although it must be
conceded that this therapeutic method has not realised all
D Google
The Lancet,]
DR. J. G. SINCLAIR COGHILL ON KOCHS TREATMENT. [May 10, 1891. 1087
tha,t “was anticipated of it, even by Koch himself. It is,
hovrever, both unscientific and unreasonable, because success
does not come up to first expectations, to decline to accept any
portion of what value remains. Neither the profession nor
the public, in the wave of excited expectation by which both
were carried away, halted to distinguish between the precise
and cautiously guarded statements of Koch and those
hazarded by irresnonsible enthusiasts in his name. Koch,
however, evidently realised his position, for he expressly
stated in his well-known “Weitere Mittheilungen” that
from the premature publication of his method many im¬
portant q^uestions must be left open; and he also says,
*‘I would earnestly warn people against a conventional
and indiscriminate use of the remedy in all cases of tubercu¬
losis”; and further on, “In all forms of tuberculosis medical
art must have full sway by careful individualisation, and
making use of all other auxiliary methods to assist the
action of the remedy.” Nothing can be more cautious than
his statement of the comparatively limited scope of bis
remedy in pulmonary tuberculosis. From the necessarily
incomplete state of his investigations at the date of their
announcement, it happened that the potency of the remedy
itself was under-estimated, and that the therapeutic signi¬
ficance of the so-called reaction was erroneously appraised.
We have learned that the dose of the now called tuberculin
has been much too large, too rapidly increased, and too fre¬
quently repeated, and that the intensity of the reaction
should not be regarded as the measure of benefit derived
from the inoculation.
I was painfully struck with the physical suffering exhibited
during and the extreme prostration following the excessive
reactions I saw in Berlin. The heavy draft on the con¬
stitutional powers involved in the repeated production of
these high temperatures must necessanly tend to lower
still further that already deficient vitality of the tissues,
which has in the beginning permitted the inception of
tubercular degeneration. My own experience in the ac¬
companying, as also in a larger number of private cases, has
convinced me that the best results have been attained when
the temperature of reaction is not allowed to exceed 100°F.
The pathological significance of the so-called secondary re¬
actions claims brief attention. Should they not be regarded
as the expression of a secondary infective process, re.sulting
from the absorption of a larger amount of septic material
liberated at the seat of disease under action of the tuber¬
culin than the system can tolerate ? They would seem to
indicate that the dose of tuberculin in tlie first place was
too large, and that a greater time should elapse between
each inoculation. In this connexion the necessity of antici¬
pating or rediiciog this secondary infective process suggests
itself, if only we could sterilise the blood and the tissues
through it, by introducing into the system, either by
the mouth or by inoculation, a sufficient quantity of some
otherwise innocuous material for this purpose. This subject
has long engaged my attention, and I have found in
guaiacol, especially when used hypodermically, as first
suggested to me by my friend Dr'. Shetilig of Nervi and
Homburg, results of the most encouraging character. In
some cases of pulmonary tuberculosis in my private practice, ,
more advanced than I felt justified in treating among my |
earlier hospital patients, I have prefaced Koch’s treatment
with daily inoculations of pure guaiacol, in doses, according
to tolerance, of from 5 to 15 minims, until the system was
saturated, as shown by the taste of the remedy being
recognised by the patient, and I have also been able to
reduce the secondary reactions, even wlien they assumed
the regular hectic range, by iDtennediate inoculations
of the same material, and this in some instances with
most encouraging results. These cases I hope shortly to
publish.
In submitting the following report of ten cases of pul¬
monary tuberculosis treated by Koch’s method in the Royal
National Hospital, Venbnor, t beg to express my indebted¬
ness to Dr. Hawkes and Dr. Wood, the resident and
assistant resident medical officers, for the assiduous and
sustained attention with which the cases were observed by
them, and for the full and accurate records they kept
during the whole period of treatment. My colleagues,
Drs. Robertson and Whitehead, assisted me in the selection
of the cases, and we kept in view the desirability of choosing
such as would be fairly representative of the dillerenb stages
of phthisis, but as much as possible uncomplicated Ijy
other grave diathetic lesions. Observations of tempera¬
ture, pulse, and respiration, and other details, were taken
every three hours, and recorded carefully at the time.
Spbygmographic tracings of the pulse were also regularly
taken before, during the height of, and after the reactions.
Careful instructions as to regimen &c. were carried out, so
that the patients were placed under the most favourable
conditions for treatment as well as for observation. Adi tbe
patients bad already been a sufficient time in the hospital,
not only to allow of their idiosyncrasies, physiological and
pathological, beiog ascertained, butto aidmib of fixed points
of departure being determined for comparison between the
efiecta of the general treatment, to which they had been
previously subjected, and tbe new method to which they
were now submitted, for the direction of which I am solely
responsible. In carrying out this treatment, I scrupulously
endeavoured to follow in every detail tbe instructions laid
down by Professor Koch in his “Weitere Mittheilungen”
of November, 1890, aided by such valuable lessons as 1 was
able, through the generous courtesy of my distinguished pro¬
fessional friends in Berlin, to learn, during my boo brief visit
to tbe hospitals and private clinics of that city in December
of last year, when experience of the method bad attained
some maturity, aud a calmer and more rational judgment
was being brought to bear on its study. It is to be hoped
that still later experiences, which may now be brought tor-
ward, will help further to determine the true therapeutic
value of Professor Koch’s remedy. The statistics published
in the “Official Report on the Results of Koch’s Treatment
in Prussia” cannot be otherwise than fallacious for this
purpose. It refers for the most part only to cases treated down
to tne end of 1890, during a period when the properties of
tuberculin and themetbod of employing it were comparatively
unknown, and both therefore were passing through the pre¬
carious process of experiment. These cases of course include
a very large number, complicated with other grave diseases,
which should never under any circumstances have been sub¬
mitted to this, or indeed to any other active treatment with
any prospect of success; others in which tuberculosis was
far too extensive or too advanced, and the constitutional
powers too reduced, to be suitable for inoculation; and,
thirdly, many in which the excessive doses employed exer¬
cised an unfavourable, or even a disastrous, efl'ect. The
treatment of the following cases was undertaken just at the
time when the safety of the tuberculin inoculations had
been so gravely impugned by the alarming statements of
Professor Virchow, and were not intended to determine the
full therapeutic scope of tbe remedy. I would refer with
due respect to any opinion expressed by tbe greatest
pathologist of tbe age ; bub I cannot umlerstand bow such
disastrou.s results attributed by him to the lethal energy of
the lymph should liave been observed in so comparatively
small a number of instances among the many hundreds
of patients who were subjected to the same treatment
under similar circumstances concurrently in the Berlin
hospitals.
Case l.—Marion H-, aged thirty-six, single ; admitted
on Dec. 1st, 1890. Father and one sister died of phthisis. In
the autumn of 1888 her health began to fail, feeling weak
and languid. Cough, which had been troublesome previously,
became persistent in August, 1889, with much frothy ex¬
pectoration. In February, 1890, she had wliat she calls
“ bronchitis,” with dyspnma, pain in left shoulder and back,
with blood-stained sputum. She lost flesh, but there were
no night sweats. These symptoms continued. Condition
before inoculation ; Height 5 ft. ^ io -1 weigltt 7 st 8 Ib. 8 oz.
Anicmie; flatulence and pain after food ; appetite good.
Menstruation regular. Urine: .“p. gr. 1010; phosphatic
deposit; trace of albumen. Pulse 9“ (regular and soft).
Heart sounds normal. Breath-rate 28. Physic.al signs
in lungs: Right, anteriorly percussion note impaired
at right apex to third rib, and posteriorly to angle
of scapula. Left lung; Expansion defective anteriorly;
impaired percussion note, with scattered crepitations
to margin of third rib. Amphoric breathing above clavicle.
Posteriorly correspondinsr indications, with large coarse
crepitations to base. The patient was inoculated with
O'OOl grm. of tuberculin at 10,8.5 A.>i- on Dee. 27th, 1890.
Reaction commenced at 8 I’.M., with headache, pains in
back and thighs. Rigors at 8 P.M,; hand.? and feet cold;
vomiting of frotby mucus at 9 r.M., when highest tempera¬
ture (102'8‘') was reached. The pulse rose t-o 120, and tlie
breath-rate to 80; Next morning (28th) “felt comfortable.’
Urine contained no allnimcn. Crepitations were detected
in dull area of right lung both in front and behind. In the
left lung crepitation.s were present from apex to base.
1088 Thb Lancet,] DR. J. G. SINCLAIR COGHILL ON KOCH’S TREATMENT.
[May 16,1891.
Expectoration greatly increased. On the 30th the chest
sounds were much drier, and cleared up over both lungs pos¬
teriorly. On Jan. 5rh, 1891, large patch of herpes appeared
round the right angle of the mouth. Another patch appeared
on the 22nd. The patient appears to have oeen suilering
from catarrh, now developing. The expectoration has
varied from an ounce and a half to two ounces in twenty-
four hours. The chest, hack and front, was rubbed
with et^ual parts of lin. crotonis co. and lln. acet. terebinth.,
until a large pustular rash was produced,, which greatly
relieved the symptoms. The highest temperature reached
was 104 3°, on Jan. 19tb, from an inoculation while men¬
struating of 0-00.5 grin. There was great dyspnma, the
expectoration was 2^ oz , smelling offensively. To April 3rd
there were eighteen injections, the largest 0 08 grm. The
total amount of tuberculin injected was 0-442 grm. The
subsequent reactions were much milder in character with
very little distress, and since the inoculation of 0 03 grm. on
Feb 14tli there have been no reactions, although the dose
has been increased to0-08grm. Presentcondition, Aprill4th,
1891: Weight, 7 St. 9 lb., a gain of 51b 8oz. Right lung,
anteiiorly, note not impaired at apex, tbe breath eouous
are rough, with occasional dry sibilant rhonchi; posteriorly
thesameconditioDstoangleofscapnla. Leftlung: Anteriorly
movement impaired, with slight flattening over upper half,
note impaired from apex to cardiac dolness. Cavernous
breathing and whispering pectoriloquy above tbe clavicle,
with rough inspirating murmur and frequent sonorous
rhoncbi below Posteriorly percussion note slightly higher
in pitch than over the right side, the respiratory murmurs
exaggerated with occasional rhonchi. The second cardiac
Bouud is accentuated in all areas, and very slightly redupli¬
cated. The expectoration has much lessened in quantity,
and seems to consist of frothy bronchial mucus. The
patient’s condition is greatly improved, and she is no longer
anremic. She feels stronger and much better. The case
seems to have been one ot chronic catarrhal ptreumunia in
which secondary tubercular changes progressed to cavi¬
tation at the left apex above the clavicle. Whether
tbe tubercular character of tbe case has been effec¬
tually and permanently altered time alone can decide.
There can be no question of the improvement, both in
subjective and objective symptoms, effected under Koch’s
method.
CAoE 2 —Ellen S. J-, aged twenty-four; married two
years, one child ; florid complexion, dark hair; teeth very
defective and decayed ; height 5 ft. 3| in ; weight 8 st. 5^ lb.
Admitted Oct. 27tb, 1890. Mother (still alive) has had
ha?moptysi8. Subject to colds; discharge from ears since
measles in childhood. Four years ago her health began to
fail, during which time she has lost 2 st. 11 lb. Had cough,
w'hich became worse after her confinement, with thick yellow
expectoration. Three or four months ago had profuse night
sweats. Condition before inoculations: Appetite not good,
cough very troublesome, and the expectoration (yellow and
nummulated and blood streaked) amounts’to two ounces a
day. Menstruation scanty ; she suffers from leucorrhcea;
urine, sp.gr. 1012, acid, no albumen. Pulae84,regular, full, and
compressible; respiration 18 per minute. Physical signs in
lungs: Right, anteriorly flattening at apex; note impaired ;
expiration prolonged, and vocal resonance exaggerated to
seond interspace; cwernous breathing and pectoriloquy
below clavicle; corresponding conditions posteriorly, with
sonorousrhonchiatbase. Leftlung: Anteriorlymovementde-
ficient at the base; expiration prolonged and vocal resonance
increased above tbe clavicle- Posteriorly note impaired
below angle of scapula ; scattered crepitations at base,
with feeble breath sounds; vocal fremitus diminished. The
patient was inoculated with 0-001 grm. of tuberculin about
10, .30 A. M on Dec 27th, 1890 Maximum temperature only
99'2° at 6 I' M Cough and expectoration much increased.
Next day the urine was alkaline and contained phosphates.
Moist crepitations heard at right apex anteriorly and in
interscapular region. Crepitations beard over the whole of
the left lung behind, more numerous towards the base, also
a few rhonchi at the apex and base in front These con¬
ditions repeated thernsmves in a less degree after each sub¬
sequent inoculation. This patient was usually very drowsy
after injection, and slept better the same night. The ex¬
pectoration showed the'effect of the inoculations, often
amounting to a drachm and a half during the subsequent
tw’eniy-four hours, and then dropping to nil within the next
two days. Twenty inoculations were given to March 24tb,
graduallyincreasedtoO-08 grip., equal to 0 -4235 grm of tuber¬
culin. The highest reaction tbe eighth. Temperature 104'2*
was recorded on Jan. 17th. Tbe previous inoculation on the
12th was 103-6°. On two subsequent occasions only, even
with increasing doses of lymph, did the temperature of
reaction reach 100°. Condition on leaving: Weight 9 st. 4 lb.
This gain was continuous, and amounts to 21 lb. since the
first inoculation. She looks and says shek exceedingly well;
she has no cough and hardly any expectoration; only one
somewhat doubtful bacillus could be found in the last sputum
examined. There is no dyspncca or night sweats; appetite
good ; no dyspepsia; sleeps well. Menstruation has become
normal. Pulse 70 to 80. First cardiac sound reduplicated
in mitral area. Right lung: Depression in supra clavicular
region, but expansion fairly good at apex. The vocal
fremitus is slightly exaggerated under the clavicle; the
note is impairea to the second rib. Breath sounds somewhat
muffled. Kesonauce increased and pectoriloquy. At the
extreme base in tbe anterior axillary line the breath sounds
are indistinct, and a few scattered crepitations are heard
along the inferior margin of lung. Left lung: At the
apex the note is markedly affected, but there is pro¬
longed expiration and increased vocal resonance to the
second rib. The chest movement is defective, and there
is dulness on percussion, and at tbe end of tbe deep
expiration crepitations are heard at the base. Posteriorly
crepitations are audible below the spine of scapula, increased
by coughing.
Case 3.—Annie W - , aged twenty seven ; married at
twenty-four, and has one child. Tubercular diathesis;
aniemic, and inclined to low spirits; height 5 ft. 5| in.;
weight 8st. 8 lb. 12 oz. Admitted 17th Dec. 189'). Always
delicate, and had slight cough from childhood. Was in bed
three weeks with an attack of hosmoptysis ten years ago.
Fourteen mouths ago cough became worse, with yellowish
expectoration, occasionally blood-streaked. Had pain in
both apices, especially the right, and also dyspncca. Has
no nigbt sweats now, but has lost weight. Menstruation
normal. Thyroid enlarged. Urine, sp. gr. 1010, neutral re¬
action, phosphates on boiling, no albumen. Pulse 104,
regular but small; first sound in mitral area reduplicated
and accentuated, and systolic bruit in pulmonary area. Re¬
spiration 24 per minute. Chest boat-shaped. Physical
signs in right lung: Anteriorly flattening with cavernous
breathing under clavicle. Note impaired to nipple ; no moist
crepitations were now present. Posteriorly note impaired
to lower angle of scapula, with prolonged expiration and
increased vocal fremitus. Left lung: Flattening under
clavicle, note impaired to cardiac dulness; exaggerated
expiration over the whole lung bub no moist crepitations;
expectoration. The patient was inoculated with 0 001 grm.
of tuberculin about 10 A.M., Dec. 27ch, 1890, the maximum
temperature being 99 2° at 9 r.M. To March IGth, 1891,
seventeen inoculations were given, gradually increasing to
0 07 grm., equal in all to 0-3M5grm. of tuberculin. The
highest temperature of reaction was 104 2° on Jan. 17th from
0 0^05 grm. of the lymph. The maximum temperature was
reached at 6 p.m. on thirteen, and at 9 pm. on four,
occasions. On Feb. 15bh the sputum showed numerous
leucocytes, in some of which apparently bacilli were being
absorbed. In the course of the treatment moist crepita¬
tions with increased expectoration of frothy character fol¬
lowed some of the reactions, and pain in the joints, especially
ofihelowerextremibieB,wibhheadache8weredeveloped. Con¬
dition on leaving, March 23rd: Weight 9 st. 41b. 2 oz , a gain
since commencing treatment of 10 lb. 9 oz , and a total gain of
12 lb. 10 oz. on lowest weight recorded (Jan. 1 Ibh). Patient
says she never felt better in her life, and has very greatly
improved in appearance and condition. Physical signs:
Heart first sound reduplicated in pulmonary area with
second, short, ilappy, and accentuated. Riglit lung:
anteriorly movement deficient at right apex. Note slightly
dull to second rib ; expiration prolonged, and vocal resonance
increased bo third rib. Amphoric breathing under clavicle.
Posteriorly dulness to spine of scapula, with amphoric
breathing in supraspinous fossa. Leftlung; Anteriorly
note slightly impaired under clavicle. A few superficial dry
crepitations can be heard at extreme right base; removed
by coughing. No cough ; expectoration very scanty, con¬
taining a few stunted bacilli. This patient was examined
in London on April 7bh by a distinguished physician, who
had reported on her case on Nov. 11th, 1890. He states
that there was “ a wonderful change ” in the condition of
her lungs.
(To be co7itinued.
The Lancet,] MR. REEVES : ABNORMAL ANUS AND INTESTINAL FISTULA. [May 16, 1891. 1089
ABNORMAL ANUS AND INTESTINAL
FISTULA.
By H. a. reeves, F.R.C.S. Edin.,
SUOGBON TO THE IIOSPITAI. POU WOMEN, AND 3ENIOXV ASSISTANT
SURGEON TO THE LONDON HOSPITAL.
1 FIND that students and many qualified men have hazy
notions as to the precise meaning of the term most com¬
monly used in our text-books—viz., “fcecal fistula”; and in
looking over most of the larger and smaller works on sur¬
gery and on rectal and intestinal surgery this want of
clearness on their part is easily explained, for the subject,
important though it be, has not been thought, apparently,
of sufficient iuteresb to necessitate clear definition and dis¬
criminating exposition. I propose, as briefly as possible, to
endeavour to methodise our ideas, and to arrange and
define these maladies on the basis of pathological
anatomy and clinical experience. I admit that the diifer-
once between an intestinal fistula and an abnormal
anus is frequently but one of degree, yet it will be
found that for the practical purposes of the surgeon
it is highly important to differentiate them accoi^ing
to the various conditious which have been met with during
operations or at post-mortem examinations. The subject is
becoming one of the surgical questions of the day, as the
success of modern methods of operating on the intestines
will embolden surgeons to deal much more successfully with
these conditions than has hitherto been the vogue. In fact,
these infirmities have been regarded to a large extent as a
sorb of nolirtic tangere ; hut I think there can belittle doubt
that the resources of modern intestinal surgery will be equal
to the task of dealing radically with them, especially if the
various proceedings to be described be undertaken early.
For the purposes of this paper I leave out of view fistuhc
connected with all that portion of the alimentary canal
above the stomach, and 1 use the word “intestinal” in a
strictly limited sense, confining it to the hollow viscera
vulgarly known as the “bowels.”
Tnese fistula? may be classified according to their position
into gastric and intestinal (those of thesmallgut), colic, appen¬
dicular, and rectal; and these may be complete or incom-
S lete. To the latter perhaps the term “sinus,” used by
Ir. Ball in his excellent Manual on Diseases of the Rectum,
may well be applied, and it will serve to prevent confusion.
The terms “complete”and“inooraplete”referto pathological
conditions, and each may be converted into the other as an
incomplete fistula or sinus may open into the peritoneal
cavity, or into another hollow viscus forming what is known
as fistula bimucosa, or it may open into the peri-peritoneal
tissue when connected with a portion of bowel uncovered
by peritoneum, or it may open through the skin; and a
complete fistula may, by natural or artificial processes, such
as closing of the external orifice, be converted temporarily
and, under certain conditions, permanently into an in¬
complete one. The majority of intestinal fistula? are intra-
peritoneal, but the rare form just mentioned, where the
fistula occurs at a spot uncovered by peritoneum, is extra-
peritoneal; and if these latter forms were common their
anatomical relations would have an important bearing on
any operation for their cure. Among the complete forms
are those in which one portion of bowel communicates with
another, or with another hollow viscus such as the vagina
or urinary or gall-bladder, and even with the uterus or with
a cyst or abscess of a solid organ as of the kidney or
ovary. Of this last rare form there was a very interesting
example some years ago at the Hospital for Women, under
Dr. II. Smith and myself. In this instance the small gut
had become adherent to an ovarian abscess, and both were
attached to the abdominal wall. The abscess pointed ex¬
ternally to the left, about two inches below and ontside the
umbilicus, and on opening it there came a free gush of air
and foul-smelling pus. Of course, an abnormal or unnatural
anus belongs to the complete form. A good definition of
this variety of fistula, and an important one in view of ope¬
rative measures, is that abnormal anus signifies a condition
in which the whole or nearly the wliole of the intestinal
contents passes through the preternatural opening, whereas
in ordinary fistula? only a small, sometimes only a minute,
quantity gets exit through the fistula. There are certain com¬
plex forms in which various complications have arisen which
will be dealt with presently; but I will now relate a case
which is, I believe, the only instance of permanent success
following one of the modern plans of operating on the bowel,
the chief object of which is to continue the circulation of
intestinal contents, and of course to avoid the formation of
an artificial anus, and also to shorten the time occupied by
operation. I may just mention that the causes of abnormal
anus aretraumatic, pathological, developmental, andsurgical.
These terms sufficiently explain themselves.
Case 1. Cyit of broad ligament, extensive adhesions, partial
removal of cyst, reeoveri/, formation ot f cecal fistula about
six weeks after. Second operation, for closure of fistula,
artificial anus made of opening in sigmoid, 'Third operation
about three months after to cure artificial anus, ileo-rectosto-
tomy, recovery. —L. S-, aged sixteen, was admitted into
my ward at the Hospital for Women on June 25tb, 1890,
for an abdominal tumour which she first noticed twelve
months ago, but which has since increased in size slowly. It
caused her a good deal of pain of a more or less paroxysmal
character and used to prevent her getting about. The
tumour extended above the umbilicus on the left aide, and
there Avas a free, thin wave on percussion. Catamenia
regular, began at fourteen, but for the past year she has
lost less, her periods lasting from six to seven days instead of
eight. No trouble with bladder or rectum. On vaginal
examination the left fornix bulged downwards by the tumour.
The diagnosis was cyst of broad ligament or unilocular
ovarian tumour. On July 3i'd a median incision below the,
umbilicus was made, the cyst tapped, and a clear, greenish
fluid, with some flakes of lymph, evacuated. There were ex¬
tensive adhesions po.steriorJy, and coils of intestine and one of
the sigmoid had to be cautiously separated. In spite of great
care the peritoneal coat of the sigmoid, which was firmly;
adherent to the posterior layer of the broad ligament, which
latter was closely incorporated with the cyst wall, was sepa¬
rated for about two inches, and the oozing from the mus¬
cular walls was stopped by light touches with Paquelin’s
cautery. Anteriorly the bladder was stripped off the tumour
in the endeavour to remove the latter entire, and as this
was firmly adherent to the pelvic floor, I determined to
remove as much as possible of the cyst wall, and to drain
the cavity. As there was considerable oozing in the posi¬
tion whence the bladder was separated, a smaller glass-tube
was introduced here, and the wound closed, after cleansing
the periboneunr with salt solution. At night there was no
pain. Pulse 130, temperature 100°, and a good deal of
oozing from the dressings. Next day the pulse was 134,
temperature 101°; neither pain nor sickness; took milk-
and-water well. At 5 1 *. M. I was sent for by Mr. C. E
May, the house-surgeon, because the patient was faint, and,
all her dressings soaked with blood. I reopened the lower
part of the wound, removed some clots, washed her with,
salt solution (1 per cent.), stuffed the bleeding cavity in front
with boracic lint, and closed the part of the wound above
the plug. Morphia subcutaneously for the first two nights.
On the early morning of the fifth she bad not been sick, and
had had a good night without pain. Tongue moist; tem¬
perature 103'4°, but pulse too rapid to count. Gauze re¬
moved and cavity irrigated, and some sloughs removed. On
the 6th the abdomen was rather distended ; tongue dry and
brown ; pulseless frequent; temperature 101°. The patient
had neither pain nor sickness, and took nourishment well.
Late on the 7th one ounce of white mixture was given
and it acted five times on the 8bh. On the 10th she
had solid food. The cavity was irrigated every four
hours on account of the free discharge. On the 14th
all symptoms much improved. No more sloughs, cavity
closing, tubes removed; sent into general ward. On Aug. Gth
/a?cal discharge was first noticed to come through the
unclosed fistula, but from the 15th to the 19bh no fmcal
matter passed through it. At this date the cough became
troublesome. Nodnlness; afewifiles at both bases. On
the 20bli a great quantity of fmcal discharge again appeared.;
and, in the hope that tiie opening in the bowel was small,
the fistula was kept clean, pressure maintained, and the
bowelsregulatod. The patientimproved locally and generally
for a time ; but as the discharge of pus and fivees increased,
and as she had high temperatures and pulse with much
pain and,some albuminuria, and as her general health
was beginning to give way, I gave up attempts to heal the
fiocal fistula without operation, and on Oct. 16th, after
previously cleaning the fistulous track and dieting her for
two days previously to operation, I reopened the wound,
and after a search of half an hour, occasioned by many
adhesions and matting togpHipr of neighbouiing bowel
u 2
1090 The Lancet,] MR. REEVES: ABNORMAL ANUS AND INTESTINAL FISTULA. [May 16,1891.
coils, and of the sigmoid to the cyst wall, I succeeded in
finding the opening and isolating enough of the sigmoid,
in which the opening was, to bring it just to the surface.
There was free oozing. On inspecting the bowel, it soon
became evident that the loss of serous coat which occurred
at the first operation, added to the infiamraatory condition
subsequent to it, had rendered it impossible to close the
opening by lateral enterorrapby ; because to got sound
serous membrane would have necessitated entering the
needles at a distance apam of full three inches, and it is
obvious that in drawing the sutures together a great kink
and stricture would have been produced. Excision of the
affected part and circular enterorraphy was also prohibited
because of adhesions preventing approximation of the
divided ends, so I had to content myself with stitching
the opening in the sigmoid to the lower part of the
abdominal Incision, and forming an artificial anus for a
time. A drainage-tube was passed into the remains of the
original cyst, the peritoneal cavity cleansed, and the wound
closed. One-third of a grain of morphia was given twice a
day. On the 18bh, much offensive pus passed through and
around the tube; cavity well irrigated; very little
pain. — 23rd : Bowels acted ; abdominal wound almost
healed; sinus much contracted. All feces pass through
artificial anus—Jan. 17tb, 1801: Since last note patient
has progressed most favourably; now, fully formed dark-
eoloured motions pass entirely through abnormal anus and
none viA the rectum, as a good spur has formed. Patient
being much depressed at her condition and anxious for
closure of the artificial anus, I fully explained to her and to
her father and mother the very grave risks she would run,
and as all were anxious to have an attempt made to
relieve her of her unenviable condition, I set thinking
of some milder measure than ileo-eolostomy, which might
answer the purpose. Plastic cutaneous operations with so
large an opening seemed quite out of court, and I could
not endeavour to clamp and destroy the valve like spur
because of the very close proximity, and possible actual con¬
tact, of adherent sn-all intestine—as seen at the second opera¬
tion—at the bendot the posterior wall of theattachedsigmoid,
and as lateral enterorrhaphy could not be done for reasons
already explained, I determined to try if I could separate
enough of the large bowel to enable me to excise and suture
the divided ends, and if this could not be done to adopt one
of Senn’s methods for short-circuiting of the intestinal canal.
With these views I kept the patient on slop diet for a
week before operation, administered a powder composed of
naphthol, salicylate of bismuth, and magnesia carbonate
(equal parts), in wafer paper, four times a day for a week
prior to operation, and had both upper and lower openings
of the artificial anus thoroughly syringed out for three days
before operation. After thoroughly mastering Mr. Jessett’s
papers, I practised the various operations on the fingers of
ola gloves and on rubber tubing, and then took counsel with
him. He agreed that the best thing would be to try to
do the minor operation just mentioned if possible, but
from my account of the case be was not sanguine that
it could be done, and thought that I had best be fully
S ared for ileo-sigmoidostomy or reotostotomy. Accord-
_ y, on Jan. 29bh I made an elliptical incision around
the artifical anus rather more than one-eighth of an
inch from the junction of skin and mucous coat, and
dissected carefully down until I came to the union of
parietal peritoneum with the bowel, then the peritoneal
cavity was carefully opened upwards and the gut freed all
round. On attempting to still farther separate the sigmoid
it soon became clear that its adhesions to the cyst wall and
neighbouring small intestine were so intimate that injury
would probably be done to the latter in persevering, so f
gave up the attempt, and at once proceeded to do the major
operation. The ileum being traced to the crecum, a pair of
pressure forceps was passed through the mesentery about
three inches on either side of the place of division of the
gut, and a piece of solid rubber cord, about one-eighth of an
inch in diameter, carried through. These were gently
knotted and a pressure forceps applied to keep the knot
from slipping, if the intestines have been kept empty and
■well disinfected there will not be need even of an assistant’s
fingers, as any slight secretion from the divided gut can be
sponged away. A flat sponge being passed beneath the gut, it
and its mesentery were divided about four inches from the
ofecum, and all bleeding points ligatured with fine catgut.
The incision in the mesentery was continuous with that in
the gut—notwedge-shaped- and a good inch in length. The
cGBcat portion of the ileum was then invaginated and sutured
with a continuous catgut suture. A rubber ring about tiV in¬
thick and about ;l in. in depth, was cut from a piece of rubber
of sufficient length, when its ends were united to tit the lumen
of the gastric end of the divided ileum, and this was stitched
to the lower end of the bowel by means of a continuous
catgut suture. Through its upper end, and from within
outwards, a long piece of catgut, with a needle at each,
was passed, using each needle separately, about a quarter
of an inch from the upper end of the ring, through it and
the bowel coats at the free or convex side of the gut,
and also on either side of its meseuterio attachment. A
longitudinal opening of sufficient extent, just to allow the
ileum to be implanted, was made on the tight side of the
upper part of the rectum. The four long sutures were held
by the fingers while the ileum was being invaginated, and
Fig. 1.
Diagram of tlie proper iiiodo of implanting small into
largo intestine, c is colon, i is ileum. The clotted lino
represents peritoneal coat. For clearness' sake the other
coats of the ileum and the rulihor ring arc omitted.
Mr. Jessett’s finger being introduced into the lower opening
of the artificial anus was able to make out that the im¬
planted gut was in proper position. As the opening made
in tbe rectum was slightly smaller than the calibre of the
ileum with the rubber ring inside, a small part of the
serous coat of the rectum became turned in, and apposed
to that of tlie ileum, as represented in Fig. 1. I dis¬
cussed the propriety and probable advantage of this
before operation with Mr. Jossettt, and it appears to be an
additional security against leakage, and a modification of
some practical importance. The sutures through the ring
in the ileum were passed through the serous and muscular
coats of the rectum before invagination, and gradually
tightened as the ileum was getting into place, and when
in sittt they were secured and two additional stitches were,
for farther security, passed laterally* and all were cut short.
On introducing my finger through the abnormal anus, to
Diagram of the opei-ation and it.sresults. aa. Artificialanu.s, it,I leum.
Tlie crecal end iiiv.agiiiatort and sutured, tlie proximal end with R ; a
rubber ring Implanted into the upperpart of tho rectum, M indicates the
inverted aiidsiitnredmucoiiscoat of tbe rectum. The figures to the right
show the complete operation as intended, 'i'tie upper one represents
the abnormal anus excised, tho lower one the .si^nnoid and roctum
invaginated .and HUtureii. The abdominal incision is wrongly repre¬
sented as extending to tlie umbilicus, The shading shows that tlia
whole of tlio largo intestine is abolished by tbe operation.
Digitized hy i^ooQle
The Lancet,] MR. W. ARBUTHNOT LANE ON RUPTURE OF GALL-BLADDER. [May 1G, 1891. 1091
ascertain the condition of parts, I thought the aperture in
the implanted ileum was too small, as it would only admit
the little linger. Evidently tighteninpr of the sutures had
caused puckering; but a second’s reflection consoled me,
for the contents of the small gut are usually semi solid or
liquid and the opening would suffice. Now I should have
liked to have excised the abnormal anus and invagi-
nate both ends of the sigmoid as in Fig. 2; but, as
already explained, there was not enough peritoneal coat on
the bowel, and the adhesions prevented this; so that I
had to content myself with cutting circularly through
the mucous cuac of the sigmoid below the artificial
anus, and after* stopping bleeding to turn it in, as
in the diagram, and suture. The artificial anus was
then stitched to the lower end of the abdominal wound,
the peritoneal cavity washed with salt solution, the
wound closed, and dressings and a many tailed bandage
applied. The object of invaginating and suturing the
mucous membrane was to shut off and prevent any leffux
in case the rectum did not act well. The operation lasted
an hour and three-quarters. It is inmortant to mention
that in closing the abdominal wound I could scarcely get
hold of any parietal peritoneum, only a slender bit here and
there, and had to trust to union of the musculo-cutaneous
structures. Small intestine was adherent to and flattened
out against the parietes, and only the greatest care pre¬
vented my puncturing it when applying sutures to the
abdominal incision. It will be observed that the serous
and muscular coats of the posterior wall of the sigmoid are
still continuous, and that only the mucous lining of the
upper part of the rectum has been invaginated. The patient
bore the operation pretty well, was put into a warm bed
with hot bottles to the feet, and had one-third of a grain
of morphia subcutaneously. At night she had rallied
well, but had been slightly sick from the ether. The next
day, however, she became very ill, the pulse running up to
152 and the temperature 102°. On Feb. Ist the pulse was
120; temperature 98'6°. She was frequently slightly sick,
and took very little nourishment. There was a good deal of
discharge from the wound. The stitches at the upper part
of the wound bad given way, but the peritoneal cavity
was shut off by granulations. Has had one hypodermic
injection of morphia daily. On Feb. 2Dd the lower part
of the incision, above the sigmoid, had given way, and
a large granulating surface was left. Intestinal contents
escaped from the lower part of the wound, showing
that the inverted mucous lining of the rectum had not
united. On Feb. 5th a small solid ffecal mass passed
per rectum, which contained a fair amount of light-
coloured intestinal contents, as ascertained by rectal ex¬
amination. A small soap-and-water enema was given,
and much of it came through the lower part of the abdo¬
minal wound. On the twelfth or thirteenth day after
operation she was sent into the general ward. The rubber
ring had not yet come away, but she had passed per rectum
on two or three occasions small masses of fmces. She was
cheerful, aud ate and slept well. —Feb, 24th : Wound filling
up well; general health excellent; rectum acts slightly, but
until the ring has passed it is unlikely to assume its full
functions.
Anyone reading the above account will notice that I
had an unusually difficult and complicated case to deal
with, and will see that my hand was forced to the
adoption of an operation of which I bad no personal expe¬
rience. There were extensive adhesions at the first opera¬
tion, and these were aggravated and increased at the second
and third operations; so that, as already pointed out, no
milder proceeding was open to me. So far what I did has
proved successful; I do nob, however, forget that my patient
is young, and that until the rectum acts properly and the ring
is passed I cannot claim a complete success; but it must
be recollected that her health was not of the best after two
serious operations and some months’ residence in hospital.
Though this is the first successful case of intestinal
implantation, yet the ffccal fistula above the implantation
must close or be closed before I am entirely satisfied with
the result. Had I been permitted by the pathological con¬
ditions to do what I intended—i.e., to excise the artificial
anus and invert and suture the divided ends of the sigmoid,—
I can have no doubt that a rapid practical cure would have
resulted. M'y succejs shows surgeons that with better
pathological conditions better results may be obtained, and
this case demonstrates that even with unpromising circum¬
stances as much as could be endeavoured to be done com¬
pletely succeeded. A glance at Fig. 2 will show that the
result of the operation is to shut off four inches of the
ileum and the whole of the large intestine, except the
rectum, from the intestinal circulation. In process of time
this will atrophy, and should she live for years will probably
be converted into a fibrous cord. The opening at the
proximal end of the sigmoid is now inactive, and I expect
that its swollen mucous membrane will ulcerate and ulti¬
mately unite. As soon as the rectum acts well, and the
fistula at thelower part of the wound left in the track of one
of the drainage-tubes ceases to be soiled by intestinal con¬
tents, it will close, and the patient will be much in the
state I wished, had I been able, to leave her in at the close
of the operation—i.e., with the sigmoid completely shut off.
I may point out that the fistulous communication with the
remains of the broad ligament cyst complicated very much
the second and third operations. No antiseptics were used
inside the peritoneal cavity in either of these three long and
serious operations, unless the weak salt solution be called
an antiseptic. I have been puzzled by the curious-minded-
ness of believers in antiseptics, as on the one hand they
claim everything, even simple cleanliness or hot water, as
antiseptics if successes follow their use ; and on the other,
if failure follow the use of the most vaunted antiseptics in
the hands of thorough believers, they say there was some
flaw in the process. I fear too much credit is given to
chemical means and too little to the much more important
matter of experience in dealing with difficult and compli¬
cated abdominal cases.
In my next paper I will take up the subject of intestinal
fistulm and illustrate their various forms, as well as the
operations most suited for their abolition.
EUPTUKE OF GALL-BLADPER.
RETENTION OF A CONSIDERABLE QUANTITY OF BILE
IN THE PERITONEAL CAVITY FOR FIVE WEEKS;
OPERATION; RECOVERY.
BY W. ARBUTHNOT LANE, M.S., F.R.C.S.,
ASSISTANT SURCiUO.V, GUY'S HOSPITAL, AND TO TUB HOSPITAL FOR
SICK CHILDREN, GREAT ORMO.ND-STREET.
Tins case illustrates so well the influence that bile exerts
upon the peritoneum when retained in a free state in a
considerable quantity in that cavity for a period of five
weeks that I will offer no apology for putting it on record.
It is certainly quite unique in my e.xperience, and but a
very few similar cases have been described by others.
A. B-—-, a lad aged eighteen, was admitted Into Guy’s
Hospital under my care on May lObh, 1890. I saw him a
few minutes after his admission, and found him apparently in
a moribund condition. His face was cold, and bis cheeks
and lips of that livid colour which indicates a rapidly
approaching dissolution. His pulse was hardly perceptible
at the wrist. The abdomen was very distended, and
obviously contained much fluid. The lad was practically
unconscious and was quite unable to give us any
information. We gathered from a woman who came
with him that five weeks ago he had received a blow
on the abdomen, that he bad been in a hospital for
four weeks, and that during the week following his dis¬
charge he had got very rapidly worse. Though I felt and
said that I did not think the boy would survive any opera¬
tive interference, and would die on the table, on the ground
that one should give the patient any chance, however small,
an operation was determined on. He was anaesthetised
without delay, and during this process ether and brandy
had CO be given frequently subcutaneously. On making an
incision into the abdomen below the umbilicus, about three
gallons of fluid, very deeply stained with bile, were removed.
On examining the margin of the liver with the finger, no
irregularity or adhesion could be felt along its outline. The
gall-bladder was empty, as were all the intestines. A
Keith’s tube was inserted, aud its extremity connected with
a vessel containing carbolic lotion. During and after the
removal of the fluid the boy’s condition improved rapidly,
and by the time the dressings were applied his appearance
was such as to make us hopeful of his recovery. About a
pint of the same deeply stained liquid came away through
1092 The Lancet,] DR G. ELDER: AMENDMENTS OF THE MIDWIFERY CONTRACT. [May 16, 1891.
the tube, and within twenty-four hours, as the discharge had
quite ceased, the glass-tube was removed. After this the boy
made rapid progress to recovery. He gave us the following
details of his history. On April 8tb, at 5 P.M., be was struck
in the upper part of the abdomen, just above the umbilicus,
by the pole of a van. He fell down and became unconscious,
rememoering nothing till he was taken into a hospital,
where he remained for four weeks. He suffered great pain
in the abdomen for a day or two. He was kept in bed for
upwards of a fortnight. After this be was up and per¬
forming small duties in the ward for the twelve dajis
preceding his discharge on May 2nd. The patient stated
that ever since the injury his abdomen had steadily in¬
creased in size, and that it we3 very tense and uncom¬
fortable when he left the hospital, so much so that
he was unable to eat except in small quantities. When
washing him on his return home bis mother noticed the
great distension of the abdomen. The discomfort which it
caused him was so great that be was unable to lie on his
back, but was obliged to recline on either aide. The disten¬
sion increased even more rapidly after his return from the
hospital, and he found himself unable to take any food. He
was sick several times, vomiting a dark-brown liquid. He
became very much worse on the 9th, and was admitted
into Guy’s Hospital on the following day in the con¬
dition already described. No fluid re-collected in the
general peritoneal cavity, but there appeared a gradually
iucreasing area of dulnesa in the position of the liver.
ThU on May 3lst extended for a considerable distance
into the right chest and downwards towards the umbi¬
licus, It was aspirated, and about six pints of bile and
fluid removed.
On June 8tb, as the abnormal area of dulness bad again
returned, though to a less extent, I made an incision into it
below the margin of the thorax, and introduced my Anger
into what was obviously an adherent and distended gall¬
bladder. Afthe time it was first tapped, owing to the
position of the dulness, I suspected that 1 was dealing with
a collection of bile localised in a portion of the peritoneal
cavity, that cavity being possibly in communication with a
bile-duct in the liver by a fistulous opening. ThU supposition
the more complete subsequent operation negatived. Why the
distension of the gall-bladder should have produced a
tumour in the thorax rather than in the abdomen was not
quite obvious, except on' the ground that its lower portion
had become fixed to the anterior abdominal wall at an early
date. The liver was displaced backwards, its anterior
margin not reaching forwards beyond the centre of the
diaphragm. During the whole period of his stay in the
hospital his motions .were normal. The drainage-tube,
which was placed in the gall-bladder, soon ceased to dis¬
charge any bile, and it was removed on June 16th. The boy
is strong, gets up, and has gained a great deal of flesh since
his admission. The explanation 1 would suggest is that the
gall-bladder was ruptured at the original injury, that bile
continued to escape through the tear in its wall till the peri-
toneal cavity was drained, that the wound in the gall¬
bladder was then closed by its adhesion to the aSdo-
minal wall or adjacent viscera, and that this adhesion
exerted traction upon its oriflce in such a manner as to
interfere with the escape of its contents from it without
obviating the passage of bile into it. By what means the
bile got into the peritoneal cavity is, however, of little im¬
portance as compared to the fact that a very considerable
quantity of it may remain free in the abdomen for a period
of flve weeks and produce no other symptom than a serous
effusion, whose deleterious influence upon the organism
was apparently simply mechanical, all discomfort disappear¬
ing at once, and permanently, with the removal of the
nii-xture of bile and serum. This fact alone will give one
much more courage in interfering with abnormal conditions
of the gall-bladder and bile-ducts than formerly, and will
completely remove the dread experienced of the imaginary
risks which were involved by the escape of a considerable
quantity of bile from the gall-bladder, or even from the
common bile-duct, In the latter case it is of especial im-
p r ranee in the removal of gall-stones.
I am informed by Dr. Pavy that when making expeti-
nitacs on the secretion of bile in dogs and rabbits be found
no barm result from the escape of even a considerable
quantity into the peritoneal cavity, and he had concluded
tuat, as far as these animals were concerned, bile exercised
no irritant action upon the peritoneum.
«t. Thomas's street, S.E.
SUGGESTIONS WITH REGARD TO THE
AMENDMENTS OP THE MIDWIFERY
CONTRACT.^
By G. elder, M.D.,
StIRGKON TO THK SAMARITAN HOSPITAL FOR WOMEN, NOTTINOIIAM.
Some few weeks ago I saw in consultation a primipara,
the subject of puerperal eclampsia, with the following
history. Seven years previously she had a severe attack of
post-scarlatinal nephritis, from which a-seemingly perfect
recovery had been made, and, as a matter of fact, no
professional assistance had been required until the night
prior to my visit, when the onset of the convulsions caused
the family doctor to he sent for. He ascertained that
pregnancy had advanced to the eighth month, that up to
the seizure her health had appeared to be as good as usual,
and that the renal function was all but suppressed. Despite
every possible effort, consciousness never returned, and the
case had a fatal issue shortly after my arrival. I believe
that had this woman’s health been supervised during her
pregnancy, a catastrophe might have been averted by the
induction of premature labour as soon as the kidneys
threatened to cease their function, and thus, in all pro¬
bability, the maternal life at least would have been
saved.
Shortly following the above case I saw an example of
puerperal peritonitis, also in a primipara, where the labour
had oeen natural, and every needful precaution taken by
the medical attendant to prevent septic infection, and ver,
despite what might seem in the eyes of some needless jne-
cautions, sepsis declared itself, and rapidly destroyed her
life. It afterwards transpired that on the evening of the
day of her confinement the patient’s mother came from
attending upon her husband, who was suffering from a
severe attack of facial erysipelas, to look after the daughter,
so that what had seemed an inexplicable case was made
clear by the knowledge of this fact.
These two cases, taken at random from my own practice,
and which no doubt might be supplemented by others,
illustrate grave defects in the interpretation which is now
put by the laity, and also by the medical profession, on the
obligations of the midwifery contract, an interpretation
which is so limited in its application that in tiie vast
majority of cases it leaves the nearly eleven months, ranging
from the beginning of pregnancy to the tetminatiou of
normal uteiioe involution, absolutely unprotected, with the
exception of the week or ten days dating from labour
onwards—a system which is responsible for not only a large
amount of preventable disease, bub also waste of life, and
which leaves the door open for the popular voice to lay to
the charge of the medical profession blame which, in many
cases, is undeserved and unjust.
Let us for a moment consider the mode of making and
fulfilling an ordinary midwifery engagement. Personally
or by proxy, a pregnant woman requests a doctor to attend
her, and beyond noting her name, residence, and date of
expected confinement, few, if any, other inquiries are made ;
none at least with the view of carefully estimating the
woman’s power to carry a child to the end of gestation
safely, or, if she is a nullipara, of gauging her pelvic
capacity, so that the woman is allowed to go her way,
stumbling through the weary months in front of her as
best she can until labour sets in, when the second interview
with the doctor takes place. Now it seems to me that if
at the firat visit, and as a matter of routine, a careful
examination into the previous life-history of the patient
and her existing state of health was made, as well as a
elvic examination in the case of a woman who had not
orne a child, or where she had had one and there had
been obstructive difficulty, an infinity of needless anxiety
would be spared the medical attendant, and, what is more,
a substantial benefit would be derived by the patient.
Doubtless, the major number of women so examined would,
beyond general hygienic directions such as ought to be
common knowledge to every woman, require no further
attention during utero-gestabion; but there would still re-
’ A paper read before the Nottingham Medico-Cbirurgical Society on
Maroli lltJi.
Digi^i Google
Thb Lancet,]
CLINICAL NOTES.
[May 16,1891. 1098
main a considerable residuum suffering from cardiac, renal,
or lung troubles, acquired or inherited blood taints, &c.,
requiring almost continuous observation and treatment
<iuring tne whole period. This broad and, as I venture to
oubmit, proper view as to one’s relation with one’s patients
■at this crisis of their lives would be fruitful in the preven¬
tion of an incalculable amount not only of maternal, but also
of infantile ill-health and mortality.
Secondary only in importance to the satisfyingoneself as to
'the possession of needful strength on the part of one’s patient
to undergo the ordeal of gestation and parturition is the
'Control of the selection of the nurse, upon whose obedience
■and intelligence the issue of a labour case largely depends—
the necessity for thig control being greater in first cases
than in others, inasmuch as the young and inexperienced
mother is as a rule plastic in the hands of those
who are about her; and that she very frequently suffers
from this trustfulness is attested by the verjy large pro-
.portion of pelvic troubles which date from first conune-
ments. The custom which now largely prevails of the
patients choosing their own nurses is mainly responsible for
a great deal of puerperal disease and death, and that this is
c30 my second case illustrates very markedly. A very large
number of women, more especially in country districts,
diake to monthly nursing without any special qualification
or training for the task, and without the most elementary
notions of the hygienic requirements either of the lying-
in chamber or the lying-in patient; and, unfortunately
for the medical profession at large, the harm which
'these women often do is never found out till it is too late,
whilst the blame is fre<iueutly wrongly laid at the
•doctor’s door. Did medical men only make it an
•essential part of the contract that they should have the
selection of the nurse, and satisfy themselves not only of
her capability, but also of her freedom from the danger of
infection, puerperal accidents would undergo a very sub¬
stantial diminution. Closely connected with the matter of
the nurse is also, when the social position of the patient
will allow it, the choice of the lying-in chamber. This
•ought clearly to be as carefully chosen as if a surgical
operation hail to be undergone. Especially should a badly
lib, ill-ventilated room be avoided, or one where, by reason
■of proximity to a watercloset or bath-room with suspicious
sanitary ariangements, danger bo the patient is likely to
follow. The satisfactory recovery of the patient after
parturition, it must never be forgotten, depends largely
lupon her environment.
Finally, instead of the visits terminating at the eighth
■or tenth day after labour, they ought to be spread
over the whole period of normal uterine involution—
that is to say, from four to six weeks; in fact, the
patient ought not to be left until local examination has
.proved that a satisfactory recovery has been made. The
present mode of liiniting the after-visits to four or five,
•or it may he six, leaving the patient’s future actions to be
regulated by her feelings or the advice—good or otherwise—
of those who are about her, is largely responsible for much ill
health. No uterine trouble is more common in our hos¬
pitals than subinvolution, nor one which so clearly has for
its cause premature getting up of the parturient woman,
•and with which there are others, though less common,
which might be equally well avoided by the medical
■attendant insisting upon the needful time being given to
the parts to recover from the damage necessary by the
birth of the child. In opposition to what has thus been
somewhat imperfectly sketched out, the medical profession
■may with justice say that the remuneration which now is
occasionally grudgingly i)aid by the public, and is in a large
number of instances, to my mind, totally inadequate to the
responsibility and the time spent, renders the scheme imprac¬
ticable ; but to this I may he allowed to answer that, although
■I have carefully refrained fronr touching upon the matter of
the monetary equivalent for such services, they have not been
•forgotten by me, and that the time has now arrived when
such a scheme, or some modification of it, should be adopted
by the medical profession at large. My own feeling is chat
instead of the present system a fee, according to the posi¬
tion of the patient, should be charged for attendance upon
the confinement itself, and that attendances before and
after this date should bo charged as ordinary visits. In
•conclusion, I hope that at least this paper will draw the
attention of the profession to a question which is of grave
and every day importance.
Nottlngliain.
Clmtal Itfltes:
MEDICAL, SUEGICAL, OBSTETBIOAL, AND
THEEAPEUTIOAL,
NOTES ON A SERIES OF CASES OF INFLUENZA..
By William Stanwbll, M.R.C.S.
In the belief that small contributions, even if premature,
may be of some service, I forward the notes of fifty-three
cases of influenza that I have had under treatment from the
8th of April to the 11th of May (fifteen in April, thirty-eight
in May). The incubation period seems to be from three to
seven days. This conclusion is derived from a study of the
following facts:—1. Cases on the following dates all had
opportunities of transmitting to one another, April 8bh,
lltb, 15th, 23rd, 24th, 29th, May 2nd, 2nd, 5bh. 2. Where
more cases than one have occurred in one house on different
days, the following are dates of occurrence:—
House A.—April 16bh, 23rd, 27th, 27th, May 8th.
„ B.—May Ist, 1st, 7th.
„ C.—May 2Qd, 5th, 6th, 9th.
„ D.— May 3rd, 3rd, .3rd, nth.
„ E.—May 4th, 11th.
„ F.—May 5th, 10th.
,, G.—May 8th, 11th, 11th, llth.
In B. case on May 7th and in F. case on May 10th had no
opportunity of contracting elsewhere, an incubation of five
days in one, six days in the other. In C. there is very little
chance of a second contagion from without.
The invasion is marked by chilliness, shivering, feeling
of cold water down the back, occasionally rigor, followed
by a rapid rise of temperature to 102'5° or lOS'S’ (highest I
have taken 105'1°), with intense headache, aching in back
and limbs of more or less severity, suffused eyes, varying
degree of sneezing and coryza, sometimes none; laiyngew
sore-throat with hoarseness and cough, secretion as
a rule very scanty; in some cases vomiting; natural
emesis seems beneficial. In the majority of cases the
temperature falls in from twenty-four to thirty-six hours
to normal, the fall being accompanied as a rule by profuse
perspiration; with this fdl of temperature the various aches
very rapidly disappear, and a varying amount of prostration
and debility remains for a short time. The appetite for
food, which has been at zero, rapidly rises, and in from six
to ten days in uncomplicated cases the patient is -well. In
fifty-three cases I have had two cases of pneumonia, one
very severe ; and one case in which twelve days after the
first attack a relapse or second attack supervened, in every
way identical with the first. As yet I have had no fatal
cases. In several cases 1 have seen during convalescence a
tendency to vertigo, and in a large number of cases slow
pulse (40 to 50) occurs, and lasts for some days after the fall
of temperature.
Treatment. —Bed, with abundance of covering, to en¬
courage free perspiration, which appears to bo desirable.
Five grains of sulphate of quinine in powder in the fever
stage brings down the temperature more quickly than is
the case where no antipyretic is given ; this seems to be of
importance, as the intense pains disappear with the lowering
of the temperature, and the curtailing of the pains is the
consummation most devoutly wished for by the sufferer.
Afterwards I prescribe tincture of Indian hemp, with or with¬
out iodide of potassium, and thetincturesof bark and rhubarb,
or the tincture of bark with acids. In the present epidemic, as
in that of last year, I have found the tincture of Indian hemp
of the greatest value in almost all cases, but more particu¬
larly in the more debilitated cases, with slow pulse, and very
little, if any, inclination for food or energy. Diet: Alcohol
and beef-tea I forbid, as they seem to aggravate; milk and
soda-water, tea and toast, and light gruel are all that is
desired for the first twenty-four hours, nor does it seem
necessary to press food; afterwards, under judicious treat¬
ment, the appetite soon returns, food is relished, and con¬
valescence complete.
Eodulalo.
1094 The IiAncetJ
HOSPITAL MEDICINE AND SURGERY.
[May 16,18M.
AN UNUSUAL SYMPTOM IN MIDDLE EAR
DISEASE.
By E. Lake, F.R.C.S.
That sound caused by air entering the middle ear on
inflation can usually only be heard by means of the
diagnostic tube, induces me to put the following case on
record. Gruber says, speaking on this point, “ for the more
dutinct perception of which [sound] the otoscopic tube is
employed.Politzer, “which [sound] can be perceived
either by placing the auricle immediately to the concha
of the person,” and also “this blowing sound has various
degrees of strength and distinctness.”^
The patient, a young lady of twenty-one, was under
treatment with middle ear catarrh due to Eustachian
obstruction ; air would not enter the cavities of the tym-
pani either by Valsalva’s or Politzer’s method, and could
only be driven in through a very fine catheter ; the finest
Eustachian bougie failed to enter the tube at all. Hearing
(watch) left normal, and right four inches; after inflation
eighteen inches. On Feb. 20bb, 1891, I examined the naso¬
pharynx under ether, and, finding some adenoids, they
were removed with Daly’s scraper, and a week afterwards
the nose was irrigated with an alkaline solution. After
this had been employed daily for some days, my patient
informed me, that when she blew her nose her left ear made
a noise which her sister heard “across the room.” I
examined the ear, and found the drum apparently normal;
the hearing of the right ear was now five feet. On April 6bh
I was sent for and told the noise was again present. On
my arrival the patient used her saline solution and inflated
her tympanum. I then heard the sound, and though I
stood twenty feet away, I still heard it distinctly. It
resembled the sudden inflation of a small bladder. Testing
the Eustachian tubes, a large-sized bougie entered freely.
Eanias, S.W._
CASES OF CONCURRENT SCARLATINA AND
MEASLES.
By N. Moerison MacFarlane, M.D.
These diseases, though sometimes epidemic together, are
rarely found concurrent in the same person. Such a con¬
dition occurred in three cases in children of the same family
under my care, and, as the coexistence of specific fevers is
always interesting, I have been induced to record them.
J. S-, aged four years and a half, was suddenly seized
with sickness at school on Dec. 5th, and sent home. When
seen the next day the sickness had abated, but his tempera¬
ture was 10-1°, pulse 180, skin dry and pungent, tongue
covered with a white fur, and he complained of headache
and a sore-tbroat; no rash visible. Next day the charac¬
teristic rash of scarlet fever made its appearance, and in¬
creased in intensity till the following day, when the skin
presented an almost uniform blush. On the evening of the
8th he commenced to cough, and there was coryza and
suffusion of the eyes. On the lObh ihe rash began to fade,
but on the following day the skin presented an unusual
appearance. The red points of the scarlatinal rash were
still visible, but there was likewise a purple papular erup¬
tion which presented all the characters of that of measles.
On the 15bh the scarlatinal rash had vanished, but that
of the measles persisted for several days after desquamation
had commenced. Beyond a slight swelling of the glands of
the neck and suppuration of the right middle ear, which re¬
tarded convalescence for a short time, he made a good re¬
covery. A younger brother aged three years was taken ill on
the 23rd with sickness, sore-throat, and pain in the head ;
and on the 25th there was a well-marked scarlatinal rash,
which was followed in three days by that of measles. He
S ressed favourably till the Slsc, when the glands of the
and under the jaw became much swollen. The throat
and mucous membrane of the nose became greatly iDiUmed,
and showed patches of false membrane. He gradually got
worse, convulsions supervened, and he died on Jan. 4th. A
younger brother aged one year and a half was seized in the
1 Cviilicr, EtiKlish edition, p. 177.
2 Politzer, Englisb edition, pp. ilO and 132.
same way as the other two on Dec. 27 th. The scarlatina
came first, followed in four days by the measles. Both ran
their course without any untoward symptom, and he was
progressing favourably until Jan. 12th, when his neck
became much swollen and iofiamed. Suppuration and
sloughing ensued, and he died exhausted on Jan. lOth.
Preston. _
A CASE OF POISONING BY CAMPHOR.
By Sidney E. Atkins, L.S.A.
I WAS called one day last week to see C. A-, aged five,
who, I was informed, had swallowed some spirit of camphor.
On arrival, I found the child lying on the sofa deeply con¬
vulsed, pupils widely dilated, pulse 120, very weak and
small, extremities very cold and face livid. From what I!
could gather, about two and a half or three drachms ofi
spirit of camphor had been taken, which would represent
about fifteen or eighteen grains of the pure drug. I imme¬
diately gave an emetic of mustard-and-water, followed
by, as soon as I could obtain it, half an ounce of ipecacuanha
wine. This produced vomiting of lightish brown fluid',
having a strong smell of camphor. Hot flannels were applied
to the feet, and as soon as the vomiting ceased two tea¬
spoonfuls of castor oil were administered. The patient mad©
a rapid recovery, with the exception that for the next two-
or three days she complained of nausea and pain in the-
epigastrium, and was unable to retain anything in the
stomach but a little beef-tea or soda-and-milk. This 15
attribute to a slight attack of gastritis.
Sunmer-street, S,B.
% Ilium-
or
HOSPITAL PKACTICE,
BRITISH AND FOREIGN.
Nulla autem est alia pro corto noscendi via, nisi quampluvimas etmor-
bonnn ot dissoctionuni historias, turn alioruni turn propriaa colioctas-
habera, ot inter se i-omparare.—MoiiCAOKI l>e Scd. cl Caus. Morb,,
lib. iv. Protemium. -
KING’S COLLEGE HOSPITAL.
A CASE OF BILATERAL APOPLECTIFORM DEAFNESS ;
REMARKS.
(Under the care of Dr. Ferrier.)
With regard to the exact nature of these coses of idio¬
pathic disease of the internal ear, Roasa writes {loc, infreo
cit.)‘. “It is perhaps not so clear as that of the traumatic
variety ; but judging from those which I have seen, we may
fairly adopt the following heads, hccmorrhogic and inflam¬
matory. The hmmorrhagic or apoplectiform are those
that occur very suddenly, and, so far as we at present
know, hcemorrhage may occur into the cochlea and semi ¬
circular canals in persons who have previously been in
good health and in whose bloodvessels there are no other
evidences of breaking down. A priori we should conclude
that patients suffering from Bright’s disease might have
hcemorrhage into the labyrinth, but as a clinical fact, in
the few cases that have been observed of hjemorrhage into
theear in Bright’.s disease the bleeding occurred in the middle
and not in the internal ear.” The case to which Dr. Ferrier
alludes was that of a woman aged forty-seven, and there
was an interval of three years between the attacks. Lucao
has published the cose of a hoy aged three years and a half,
who became suddenly deaf on both sides. The attack wae-
preceded by tinnitus, but unaccompanied with dizziness.
At the necropsy a hmmorrhage in each labyrinth and in the
canals was found. The following case is worthy of record
as an example of an affection of which few are to be founcJ
in the records of aural disease.
Douglas C——, aged tiiirty-six, a railway guard, was
admitted into the Todd ward on Feb. 2nd, 1891. Apart
from venereal disease, which iie contracted thirteen years
previously, he had always enjoyed excellent health. H©
had never had any affection of hearing until eighteen months
ago, when, without any warning, something, ho said>
Digu;4ed by vj ooQle
The Lancet,1
HOSPITAL MEDICINE AND SURGERY.
[May 16,1891. 1095
suddenly “ wont pop” in hia head, and he found that ne
had all at once become totally deaf in the right ear. He
has remained so up to the present time. On Jan. 16th of
thia^ year, whilst scrubbing a floor, he was seized with
■dizziness, and a tendency to fall, he thinks, towards the
eight side. This soon passed off, but on Feb. 1st he had
another similar attack, and all at once something “seemed
to go crash” in his head, and he became unconscious. On
coming to, at the end of six hours, he found himself abso¬
lutely deaf on the left side as well as on the right side.
The attack of unconsciousness was not accompanied by
any convulsive phenomena, or by any other symptoms
■except the deafness. The patient, a heaUhylooking,
well-nourished, florid complexioned man, complained of
total deafness and slight giddiness on movement, but
otherwise he felc perfectly well. He was examined care¬
fully by Dr. Pritchard, who reported: “The external
meatus is normal, the membrana tympani slightly re¬
tracted, but otherwise normal. A tuning fork sounded
loudly on the left mastoid is very faintly perceived, on the
right not at all. Both Eustachian tubes are patent.” The
patient could only be communicated with oy signs and
writing, which be read and replied to in a high-pitched
'voice, clearly and intelligently. He complained of a con-
«tant slight roaring sound in his bead. He walked cau¬
tiously, with the feet rather widely separated, but all bis
■movements were coordinated with precision. There was no
paralysis of motion or sensation anywhere. The tendon
creactions and superficial reflexes were normal. Sight was
unimpaired; the optic discs normal, and the pupils reacted
to light and on accommodation. The thoracic and abdo¬
minal viscera were normal. The urine had a specific gravity
of 1010, and contained neither sugar nor albumen. The
'treatment cousisted mainly of blistering behind the ears
and the administration of large doses of iodide of potassium.
No improvement of the hearing resulted, however, though
the patient’s gait became more secure. He left the hospital
-on April 10th, and was just able to recognise a shrill sound
made in close proximity to his left ear, but could not dis-
'tinguish words.
Remarks by Dr. Ferrirr — This case is in all probability
one of hfemorrhagic eft'uaion into the labyrinth, first on the
one side and then, at an interval of eighteen months, on
the other. Several cases are on record of hcemorrbagic
•effusion into the labyrinth, proved post mortem, as well as
many others presumably of a similar character. Some of
these have been associated with vertiginous symptoms
'(Mdnihre), others not. The rarity of this case consists in
the bilateral nature of the affection (a similar one has been
reported by Roosa, American Journal of the Medical
Hciences, Oct. 1874, p. 386, Case 14), preceded and accom¬
panied by vertiginous symptoms and followed by disorder
■ef equilibration lasting at least several weeks. That the
pathology of this case was an effusion into the internal ear
is indicated by the practically total loss of hearing,
'tympanic and perosseous, and the absence of symptoms
which would have been caused by intra-cranial effusion;
for though there appears to have been a period of uncon-
'sciousness, this was probably indirect rather than due to
effusion into or on the hrain’itself. There was uo Bright’s
■disease or constitutional condition predisposing to hcomor-
rhago, and there was no indication that the syphilitic
infection had led to any local affection of the auditory
Apparatus antecedent to the onset of deafness.
SUSSEX COUNTY HOSPITAL.
A CASE OP RIGHT PIAPURAGMATIC HERNIA; DEATH;
NECROPSY.
(Under the care of Dr. W. A. Hollis.)
Phrenic or diaphragmatic hernia may take place (1) as a
■consequence of weakening of the diaphragm in some part,
permitting of the protrusion of some of the abdominal con¬
tents into the chest; (2) through a congenital defect in
the muscle; (3) through one of the natural apertures ;
‘(4) through an opening which has formed as the imme¬
diate or remote result of a wound or laceration of the
muscle. By far the largest number of recorded cases of this
form of hernia have been through a congenital defect on
the left side of the diaphragm. In fact, it is extremely
rare to meet with this condition on the right side, and the
anatomical arrangement of the viscera of the abdomen
readilyaccountsforthis. Dr.E. CornelPandDr Hillier®have
described cases in which from congenital defect the protrusion
took place into the right chest. The patient of the former
was a female aged ten months; all the iDtestines bad escaped
into the right pleura through a hole two inches and a half
in circumference, situated on the posterior right side, and
an inch and a half from the spine ; the stomach and rectum
alone remained in the abdomen. Dr. Hillier’s patient was
also a female, aged seven months. Nearly all the small
and two-thirds of the large bowel had escaped throuch an
opening one inch in diameter. This opening, which bad a
sharp tendinous margin, was placed in the right half of
the diaphragm, but its'exacfc situation is not given. Dr.
Murchison^ had a man, aged fifty-five, under his care in
1865, who died in the London Fever Hospital. He was
admitted in a state of collapse, with signs of pneu¬
monia at the right base. Pie lived eight days. At the
necropsy a circular opening about six inches in diameter was
found in the right side of the diaphragm, through which
almost the whole of the right lobe of the liver and the gall¬
bladder were protruded into the cavity of the right pleura.
The margin of the opening was well-defined. The local
condition, with presence of deep cicatrices in the liver,
suggested to Dr. Murchison that the hernia was probably
due to an old rupture of the parts. Death was from pleuro-
neumonia on the right aide, the cause for which could not
e ascertained. P'or the notes of the following case we are
indebted to Mr. E. F. Maynard, assistant house surgeon.
J. H--,a boy aged sixteen, was admitted on March 10th,
1891, at 12.30 P.M., complaining of severe abdominal pain.
Three hours before admission he was found lying in the
street doubled up with pain. When attacked he was
sweeping snow from the pavements, but, according to his
own account, was working easily. He was perfectly well
up to the time of the seizure, and had had nothing hut
bread-and-butter and tea within the last twenty-four hours.
He was described as having always been a “hearty” boy.
On admission he was in a state of collapse; his face was
blanched; pupils dilated; pulse 66 and weak; temperature
OS’S”; tongue furred, white, and he complained of pain in the
abdomen. He said his bowels were opened in the morning,
previously to the onset of pain ; that the pain was of a dull,
aching character; that he had retched several times since,
but had not vomited. His heart’s apex was two inches out¬
side the nipple line in the sixth interspace; and there was re¬
traction of the fifth and sixth spaces with the systole. There
was no bruit. Harsh puerile breathing was heard all over
the left chest. There was a subtympanitic percussion note
all over the right chest, suggesting pneumothorax. The
breath sounds were distant and cavernous. There was
absolute loss of vocal fremitus, and vocal resonance as high
as the angle of the scapula. The abdomen was retracted
and boardy, and the percussion note almost dull. In bed
he lay oa his left side with his knees curled up on his
abdomen. Urine acid, sp. gr. 1035; no albumen or sugar,
but a thick deposit of urates. He was put on milk and
broth diet. At 6 I’.M. he was still in a good deal of pain ;
twenty minims of tincture of opium were given; he had
retched frequently since admission but had not vomited.
At 11 r.M. pain was still more severe in the abdomen,
and he complained of pain in hU right chest and asked
that it might be rubbed ; his breathing was rapid and
shallow, his countenance bluish, and pulse very weak. His
condition being grave it was decided to aspirate, the sym¬
ptoms pointing to air, and possibly fluid, in the right pleura.
Accordingly a large aspirating needle was introduced
between the sixth and seventh ribs about the posterior
axillary fold; the needle being withdrawn, there was no
outflow through the cannula. A probe-pointed stylet was
then thrust down the cannula, and on its withdrawal air and
a brownish fluid with abundant flakes were drawn off to the
amount of five ounces and a half. The fluid had a grumous
smell, like that of stomach washings, was strongly acid, and
on microscopic examination was found to contain oil
globules, starch granules, muscular flbre, and numerous
bacilli, "rhe patient was much relieved, the pulse improved,
and he was free from pain for about one hour. Nothing was
given by the mouth, but nutrient eneniata wore ordered
every four hours. AtlA.M the pain had returned.
Morphia was given hypodermically along wilh a morphia
suppository and hot fomentations were applied. Half an
hour after the first enema he vomited, the vomit consisting
r Amei'ioin Mad. Rec., i'liila., vol. viil. 182C, p. 230;
TUK Lanukt, voL i. ISOl, p. 81)1.
» Tmna. Path. Soc., 1800-00, vol, xvil., p. 104.
: c Uoogle
1096 Thb Lancet,
HOSPITAL MEDICINE AND SURGERY.
[May 16, 1891.
sioD, and gave no impulse on coughing. The pubes wae
shaved and washed, and at 5.15 P.M. methj'lene was given,
and Mr. Whipple made au incision over the upper awellingp
and a dark-coloured tense sac was exposed. This was
opened and some blood-stained fluid gushed out. A dark,,
cfaret-coloured coiled mass presented, and after careful
examination this was made out to be a much-enlarged
strangulated epididymis. Lying in the lower half ol*
the sac was the body of the testis, about normal size,
and attached to it and forming a circle round its hilum was
a band of omentum. This tag was torn through. The-
epididymis appeared to be twisted twice on its own axis.
This was pulled down and untwisted ; the proximal part of
the omentum, which was unaltered in appearance, wau-
returned within the abdomen through a large inguinal
canal. The epididymis was ligatured as high up as pos¬
sible, and it and the testis were removed. The pedicle wa&
dropped back into the abdomen. The sac was ligatured in
two halves and cut away, and the pillars of the external
abdominal ring sutured. A small tube was inserted and the:>
wound sutured, On the 24th the tube was omitted, on the
27th sutures were removed. The patient got up on Feb. 2Qd,,
and was discharged on the 7 th. The specimen removed
was sent to the Museum of the Royal College of Surgeons
of England, where Mr. J. H. Targett veiy kindly examined'
it, and reported as follows: “On re-examining the speci¬
men, I can see no other explanation than that you nave-
offered—viz., that the epididvmis, or, to speak mote accu¬
rately, the mesorchium, has become twisted rather like an-
ovarian pedicle may do, and so the circulation has become-
obstructed, for there is a well-marked groove at the base of'
the epididymis, where, I presume, the twisting has taken.
f dace. I have not met with a similar complicated strangu-
ated undeacended testicle, nor do I know of any case
recorded in the ordinary text-books.”
EcmarksbyM.T. W. G. Nash,— There seems to be no doubt-
that this was a case of strangulation of the epididymis, and-
not traumatic or gonorrhceal inllammation. The strangula¬
tion was caused by swelling, due to twisting of the
epididymis (mesorchium). The seat of strangulation was-
the external abdominal ring. The epididymis, as is usually
the case in these misplaced testes, did not assume the usuat
canoe shape or bear its usual relations to the testis.
The body of the testis itself was nob altered in appear¬
ance. The cause of the incomplete descent of the testis,,
no doubt, was the band of omentum which surrounded
the hilum of the testis. I have looked through the surgeries-
of Gross, Ashhurst, Holmes and Hulke, Eiicbsen, Rryant,
and Heath, and cannot find any similar case, bub several
instancesof inflammation of misplaced testes are found, one or
two of which gave rise to very similar symptoms. Curling^'
mentions a case in which a testis in the groin became in¬
flamed, was mistaken for a strangulated hernia, and
operated on. "When the nature of the case was discovered
castration was performed. Jacobson^ relates two cases of
inflamed testes in groin, one of which proved fatal from-
peritonitis. With regard to the diagnosis of hernia in our
case, the existence of an hour-glass-shaped swelling in the
groin, the lower half of which was the testis and the uppet-
a tense elastic swelling, giving no impulse on coughing,
lying over the external abdominal ring and extending along
tlie inguinal canal, taken with the general symptoms of
strangulated hernia, pointed very strongly to this being the.
nature of the case.
of a brown material similar to that drawn off with the
aspirator. He steadily became worse, breathing growing
more difficult, irregular, aud at last gasping; cyanosis
increased, and he died at 6 A.M.
Necropsy, thirty hours after death. —Post-mortem dis¬
colouration most marked. Body fairly well nourished.
On opening the thorax the right pleura was seen to contain
a brownish sour-smeiling fluid. The right lung was
collapsed, bub easily dilatable with the air-pump. It was
found lying above, and internal to bowel and mesentery in
the upper part of the right chest, immediately to the right
side of the middle line. The right chest was also seen to
contain omentum, mesentery, and both large and small
bowel; these were traced from the abdomen through an
aperture between the external arched ligament and the
central tendon of the diaphragm. The openiog had a well-
defined, rounded, smooth edge to the touch, and there was
no evidence of any recent rupture of the parts. The bowel
contained in the chest was of a dark-slate colour, and both
viscera and mesentery were in places mottled and green.
The whole length of the intestines, excepting the first part
of the- duodenum, the descending colon, sigmoid flexure,
and rectum, was in the right thorax. The large bowel
contained scybala, the small bowel was empty, and both
were deeply congested. The large intestine was found lying
along the whole length of the chest, with the mesentery
anteriorly, the small intestine being posterior to them.
On opening the abdomen the peritoneum was found to con¬
tain a few ounces of clear, dark-greenisb fluid. Tbestomacb
wM much congested and eccliymosed, with a punctiform
hiemorrhage on its anterior wall. The viacus contained
brown semi-digested food, similar to that drawn off by the
aspirator. There can be little doubt that at the time of
aspiration the stomach was in the thorax, and that it was
from this organ that the fluid was withdrawn. The nature
of the fluid and the presence of the above-mentioned puncti¬
form heemorrhage go far to confirm this supposition. All
the other organs were healthy.
SOUTH DEVON AND EAST CORNWALL
HOSPITAL, PLYMOUTH.
STRANGULATED EPIDIDYMIS OF INCOMPLETELY DESCENDED
TESTIS PRODUCING SYMPTOMS LIKE THOSE OF STRAN¬
GULATED HERNIA ; CASTRATION ; CURl?.
(Under the care of Mr. Whipple.)
A SURGEON is not uncommonly asked to see a patient
with supposed hernia, which on examination is found to be
an epididymitis, possibly of a retained testis, but has
usually no difficult in distinguishing one from the other.
Cases in which the resemblance is as close as in the cases
under Mr. Whipple here recorded are, however, very rare.
Dr. H. H. Johnson’ reports a general inflammation of the
spermatic cord mistaken for hernia, and treated at first
with a truss. He found a hard swelling extending from
midway between the anterior superior spinous process of
the ilium to the pubes down to the testis. He removed the
testis and cord. The latter measured seven inches in cir¬
cumference, and was well advanced towards suppuration.
Recovery was uninterrupted. Dr. P6goud“ has also pub¬
lished a case in which a suppurating cyst of the epi¬
didymis was mistaken for hernia. Other examples are
referred to in the remarks appended to the case. For the
notes we are indebted to Mr. W. Gifford Nash, house surgeon.
A, H-^-, aged sixteen, was admitted to hospital on
Jan. 2l8t, 189Z, at 4.45 P.M. He stated that for seven or
eight years he had noticed a lump in bis left groin which
occasionally disappeared within his abdomen. This he
believed to be his left testicle. On the previous day at
4 P.M. he strained himself and felt something give way in
the left groin. At2A.M. on the morning of admission he
noticed a lump in the groin, and at 8 a,m. began to vomit.
He consulted a medical man, who diagnosed a strangulated
hernia, and sent him to the hospital with a note to say he
bad had stercoraceous vomiting. Bowels acted slightly at
2P.M., before that two days ago. In the left groin there
was an hour-glass-shaped swelling. The lower half of this ;
was the left testicle lying in the upper part of the scrotum.
The upper, lying over the external abdominal ring, about
the size of a hen’s egg, was very tense, (^uite dull on perous-
r SajouB, -i-ol. iii., c. 27,1880. Boston Med. and Sure. Journal, May
2nd, 1888. 2 La France M(3<Ucale, Jan. 14tb. 1888.
litHral SflMts.
ROYAL MEDICAL & CHIRURGICAL SOCIETY.,
Paget’s Disease of the Nipple and Breast.
An ordinary meeting of this Society was held on
May 12bb, the President, Mr. Timothy Holmes, in the chair.
Mr. Bowlby road a paper on Thirteen Cases of Paget’s
Disease of the Nipple, with special reference to the causa¬
tion of the malady by psorosperms. lie gaveashorbaccount
of thirteen cases of Paget’s disease of the nipple, and, after
a brief review of cases already recorded, analysed those
described by himself. A more complete description of the-
special clinical characters of the disease as demonstrated by
the cases detailed was then given. The histology of the
" DiHeanoH of TenUs, p. 8
-* Holmeu and Hulkc : System of Surgoi-y, vol. iii., p. 470
^8
D
Thb Lancet,]
KOYAL MEDICAL AND CHIKURGICAL SOCIETY.
[May 16, 1891. 1097
(morbid tUaues waa described, and the observations of
Messrs. Wickham and Darier as to the presence of bodies
•reseiublingpsorosperms were commented on. The authori'e-
marked that bodies of the same nature as those described by
ithe French observers were to be found in all the cases which
formed the subject of thepaper, and expressed the opinion that
these bodies were probably psorosperms. The pathology of
i^Aget’s disease was then discussed; and after giving reasons
•for believing that all changes in the breast were secondary to
those in the nipple, and were not in any way causative of
fthe so-called eczema, the author expressed the opinion that
the disease was parasitic in its origin, and then discussed
the influence of the psorosperms in causing cancer. He
concluded by expressing the opinion that there was no
evidence that the cancerous growths in the cases under
consideration were directly due to any specific action of the
psorosperms, and gave various reasons for such a oonclusion.
Mr. Jonathan Hutchinson, jun,, likewise contributed
•a paper on Paget’s Disease of the Breast. He reported the
results of examination of five cases of chronic eczema of the
breast with reference to the occurrence of parasitic bodies
in that disease (coocidia or psorosperms), Specimens were
shown illustrating various appearances in the surface
epithelium, which the writer believed confirmed M. Darier’s
'Statement that coccidia were to be found, and sometimes
in great numbers. These appearances had not been found in
cases of eczema other than the chronic disease known as
Paget’s disease; neither were they found in all supposed
■examples of the latter. The writer had observed them in
three out of the five cases examined. Brief reports of each
were given, and the subject was illustrated by lantern
•demonstrations of micro-photographs, &e.
Mr. D’Arcy Power said that he had been working at
the origin of cancer by inoculating portions of malignant
growth into animals. He had taken a piece of affected tissue
urom the last case Mr. Bowlby had described, and hacl
inoculated it into a rat. On the fourth day a thin putiform
■discharge appeared containing epithelial cells and many
bodies like those described in the paper. The discharge
had since disappeared and reappeareci at the inoculation
wound on two or three occasions. He had inoculated other
varieties of cancer into animals without producing any
iiesulb. He remarked that in the rabbit, if psorosperms were
inoculated, a similar puriform discharge would result.
Dr. Thin remarked on the increaseilknowledgewehadof
this disease since the publication of the papers by Mr.
Butlin and himself ten years ago. At that time it was the
.generally received doctrine that the disease was a true
eczema, which eventually led to cancer of the breast. The
view which he had advocated that the disease was not an
eczema nor any lorra of recognised akin disease was soon
afterwards confirmed, and was now universally accepted.
The hypothesis which ho had suggested that the destructive
dermatitis was due to a change at the mouths of the ducts,
■essentially cancerous in its nature, although a long time
might elapse before it led to proliferation of cancerous
epiclielium was, he held, although not proved by anatomical
investigation, still one that had much to recommend it. The
•destructive agent, of whatever nature it was, was sufficiently
powerful to destroy the epidermis and break up the connec¬
tive tissue in the papillary layer of thesldn—eflfects which were
reconcilable with the hypothesis that the poison was can¬
cerous. He considered the continued use of tbeterm “eczema”
■objectionable, as possibly leading to delay in operative inter¬
ference. He had recently examined the tissues in a patient
of his own with the special object of detecting the appear¬
ances described as characteristic of psorosperms. He had
found thorn absent. On examination of the preparations
■from his early cases, he had found all the characteristic
•appearances recently described, but saw no reason to
•consider that they were duo to the presence of parasites, as
he was able to trace them in an unbroken series of changes
which took place in the cells of the epidermis, the first set
of changes being unmistakably in true epidermic coils, and
the sequence up to the most developed appearances being
continuous. Similar changes were found in other condi¬
tions, and he specially referred to drawings of cells in
-epithelioma in his paper in the fifty-ninth volume of the
Medical and Chirurgical Transactions, which resembled in
every respect the so-called typical psorosperms recently
■described.
Mr. JONA'I'HAN IIUTCHINSON, jun., admitted the diffi¬
culty of deciding whether these bodies were really coocidia
or not. In the next case in the living subject that ho met
with he would take a scraping and examine it on a warm
stage, to seewhetberamceboidmovements could be observed
such as could be demonstrated in the coccidia from the
rabbit’s liver. The difference in their reaction to dyes
might be due to the fact that they were different varieties of
organisms. Though he preserved an open mind with regard
to them, he thought they fitted in very well with the patho¬
logy of the disease. _
Adjourned Debate on the Treatm&nt of Surgical Tubercular
Diseases by Tuberculin.
An extraordinary meeting of this Society was held on
7th, the President, Mr. Timothy Holmes, in the chair.
The debate was resumed by Mr. Barweli.., who could
not help contrasting the tone of the paper with the
results which had been proclaimed elsewhere, and he
animadverted on the facts that a fluid the nature of
which was kept quite secret was vaunted as a certain
cure for one of the most formidable complaints, that
trivial improvements in the condition of tuberculous
patients were freely circulated as indications that the cure
of deeper mischief might be obtained, and that hiindreds
and thousands of people were induced to undertake a long
and perilous journey to undergo a treatment which could at
the best only be beneficial in as many months as they could
stay weeks. Mr. Oheyne’s paper took a very different tone,
but it was the more incumbent that his conclusions should
be carefully examined. Beginning with the action of the
drug, the pyrexia induced by the first two or three injec¬
tions, which was .sometimes so intense as to prove fatal,
was frequently alarming. He was unable to make out any
essential difference between these febrile attacks and those
which followed the absorption or injection of septic matter.
He alluded to the case of wounds in the course of which
signs of pyrnmia came on, which could be at once stopped if
the wound could be thoroughly washed out and cleansed so
as to prevent the formation of any fresh sepsis, and conse¬
quently of any fresh absorption. In fact, these attacks
were very like, if not identical with, those which fol¬
lowed injections of Koch’s fluid. These febrile attacks
(induced by Koch’s lymph) were usually accompanied
by albuminuria; frequently, nay generally, by enlarge¬
ments of the spleen and liver, together with purpuric
and other forms of skin eruption, and sometimes by an
icteroid or earthy discolouration of the skin. He did not
wish to be understood to say more than he really meant.
He did not say that Koch’s lymph was only sepsin, for that
was evidently not the case. It consisted of glycerine, a
certain or rather an uncertain amount of peptone, some ex¬
tractives, with its essential principle, an alkaloid, which
Koch estimated to be present to the extent of 1 per cent.
This alkaloid vvas extremely poisonous, and was, he thought,
closely related to sepsin. He did not gather what means
! there were of regulating or standardising the strength, nor
' did he know of any means by which this could be accom-
i plished. He urged that under these circumstances the pro-
' duct must necessarily be of uncertain composition; they
I migiit measure with the utmost care the bulk of the fluid
! which they injected, and yet have a very vague idea as to
the amount oi poisonous alkaloid they were about to ad¬
minister. This explained many of the alarming and some
of the fatal ^mptoms which followed the first and second
injections. To make matters still more difficult, they were
tolcl that if the operator began with a small dose he was apt
to produce that tolerance of which Mr. Cheyne had spoken as
f rustratingany furtherhopes from subsequent treatment. He
observed that this particular alkaloid had never, like that of
anthrax, been isolated or crystallised out. Going back to the
transient septic.'omia to which he had alluded as a compli¬
cation of wounds, he pointed out that during such an attack
the granulations underwent certain changes, sometimes be¬
coming dry and shrivelled, but usually increasing in size and
undergoing gelatinisation. If thefever were high the granula¬
tions probaWy shrivelled or sloughed away. Mr. Cheyne had
shown them some very beautiful photographs of tubercular
granulations undergoing inflammation as a consequence of
the injections, but he confessed to an inability to detect any
signs of a peculiar or specific action. It was true that in
most of these specimens the tubercle was undergoing infil¬
tration by leucocytes, and was possibly in the way of dying
or being destroyed thereby. He did not admit, however,
that this was the result of such injections. They would
want a control experiment where the effects of other sorts
of inflammation were observed. He might be told that
1093 The Lancet,]
EOYAL MEDICAL AND CHIEURGICAL SOCIETY.
[May 16, ISOl-
these other forms of inflammatiou did not attack tubercular
tissue ia particular, while it was asserted that tuberculin
did bO with such certainty as to prove a valuable means of
diagnosis; but there bad been too many cases reported in
which precisely the opposite effects had been noted. It
was not claioied that the injections deprived the bacilli
of their infectious qualities, nor did it confer upon tissues
any additional powers of resistance, and this might account
for the widespread tuberculous dissemination testified to
by Virchow and confirmed by Volkmann. After all, how¬
ever, it was by the clinical and practical results of the
injections that the method would stand or fall. Without
going abroad for statistics, it was significant that Mr.
Hutchinson, with his vast opportunities, bad not seen a
single case of cured lupus, ana Dr. Heron’s cases of phthisis
afforded no instance of cure. As to Mr. Cheyne’s ten cases
of lupus, one had been sent out of the hospital in December
last, but came back in two months for treatment; more¬
over, eight out of the ten cases had been subjected con¬
currently to pretty severe surgical treatment. As to hi&
joint cases, in these, too, surgical measures were resorted
to, and he could not see that the fluid had in any way
assisted. There were two cases of dactylitis, presumably
strumous, neither of which was benefited. He concluded
with the remark that the promises made in respect of this
fluid bad been unfulfilled.
Dr. Douglas Powell observed that the paper was full of
details and observations of the highest merit, and it seemed
to raise the subject upon a platform, and to place the
matter in such a position as to authorise the hope of their
being able to build up further observations. His own ex¬
perience of this treatment had been but small compared
with that of the author, and comprised cases which from
their very nature were much less adapted for combined
clinical and pathological observation than those which the
author had placed before them. He did not think that one
could speak at present from any mature conviction in
respect to the results to be obtained by this method of treat¬
ment, but one was obliged to express a certain measure of
disappointment at the results obtained so far. Yet he was
bound to say, and it was his reason for speaking, that his own
feelings with regard to the treatment were nob in accordance
with those which had just been expressed. His own cases
of tubercular lung diseases were thirteen in number, and
they were cases which had been thought suitable for treat¬
ment when it was first introduced into this country in the
beginning of December. He alluded briefly to these cases,
merely giving his impressions with regard thereto. One
was a case of double tubercular pleurisy with effusion,
associated with a hectic temperature and signs of tubercular
mischief at one apex. This patient did not improve under
treatment; the hectic temperature remained the same, and
after twelve inoculations he appeared exhausted by the
treatment, which was discontinued. He was unable to say
that the patient’s condition was materially altered by the
treatment. He died five weeks after its cessation, death
being due to acute general tuberculosis, which declared itself
three days before his death. Then there were two cases of
active double second-stage tubercular pulmonary phthisis;
in one the disease went on unchecked, while in the other
there was some temporary improvement, which might or
might not have been due to the treatment. This patient
was now, three months after the commencement of the
treatment and three weeks after its cessation, presenting
some slight but decided advance in her physical signs.
There was one case of active third-stage phthisis, marked
by the rapid formation of cavities, high temperature, night
sweats, &c. This patient was injected a few times, but
there were no results, and so the breabraenb was not per¬
sisted in. There was one case of old tubercular excavation
in the right lung, with commencing tubercular deposit in
the left, the patient being the subject of syphilis. The old
lung disease did not in any way react to treatment so far as
one could judge, but the other lung with recent disease
seemed to be improved. After some fifty or sixty inocula¬
tions, extending over a period of several weeks, they came to
the conclusion that no benefit was likely to attend con¬
tinuance of the treatment. They were influenced also by
the view that by continuing the treatment, which apparently
gave no hope of benefit, they might enfeeble the patient, and
leave him to his old enemy, the syphilis. After a while they
ut him on tonics, and he left the hospital in fairly good con-
itlon. In one case there was a history of tubercular phthisis
of two years’intermittent duration; this patient decidedly
improved in general health, and was under treatment fon-
two months; she then became pregnant, and it was thought-
advisable to discontinue the treatment. Another case was-
one of dense tubercular consolidation of the middle portion
of the right lung without necrotic foci, bub there were-'
bacilli in the sputum and the usual collateral symptoms...
After continuing the treatment for some six weeks, the
softening process in the right lung seemed to be accelerated
at one time this case caused them very considerable
anxiety on account of the rapid softening of the lung and of
the increased septic symptoms that arose. She had rheu¬
matic pains in her joints, a temperature which became
hectic, and there was slight albuminuria with profuse-
sweating and obstinate vomiting; although these symptome-
came on twelve or fifteen days after the Injections had been
discontinued, he thought they were due to contamination
from the rapid process of softening. Then be began treat¬
ment ; expectoration diminished, the hectic diminished,
and she picked up appetite, health, and strength, and was
now in a better condition than when first taken in hand.
One case was of scattered caseous phthisis, most marked
about the right upper scapular region, and with a hectic
temperature ;.the cough was not very troublesome and wae
scanty, but bacilli were present in the sputum. This patient-
improved in general health, the cough diminished, the
phthisical signs which were scattered through the luDgs-
gradually cleared up, and the physical signs in the right
scapular region were represented by a small cavity. She
had been more or less under treatment since Dec. 15th,
and they bad recently made out that during that time-
she had lost three pounds in weight. There were four
cases of ancient one-sided phthisis, all of which did
extremely well; his only difficulty in regard to theses
cases was whether they had done well in spite of the
treatment, or whether that had assisted them on the road
to recovery. He then alluded to three cases of lupus, in two
of which marked improvement resulted at first; on ceasing^
the treatment, however, they had relapsed considerably; they
were now adopting other measures. In the third the lupue
was limited to the eyelid ; there was a history of hlinciness
consecutive to illness attended by acute headache, and eacb
time they injected her she had very severe headache. They
were afraid of lighting up an abscess in the brain, so they
desisted. He had kept no account of the much more nume¬
rous cases in which he had declined to adopt this method
for sufficient reasons. He did not pretend that this was a.
very brilliant series of cases, bub throughout all the inocu¬
lations he had never experienced any of those terrible cate.-
strophes which one heard of in connexion with this treatment.
In only one case, of lupus, was he at all anxious in conse¬
quence of reaction after a dose of seven milligrammes ; the
reaction was very severe, but the patient recovered perfectly
after three or four hours, and the symptoms did not recuF
subsequently. The only case in which he felt any anxiety
in regard to the treatment was one in which theresultsseemed
to be excessive, and to have involved the danger of pyremia.
He observed that the chief incident in the second stage of
phthisis was sepsis. He did not know of any symptoms in the"
second stage which could not be explained by the absorption
of retained material. If they could clean them out they
would have none of the second-stage hectic symptoms. These
were, then, a necessary condition of the eliminatory period of
phthisis, and their whole treatment of this period was to-
sustain the patient by those measures flippantly alluded to
by the author under the head of “expectant” treatment.
T^hese were the only measures which were attended with
any amount of success. The question was, could they
hasten this process of elimination? Personally, he was
convinced they could. The question was, in what par¬
ticular cases could they do so ? In some cases the elimina¬
tion appeared to him to be too stormy and rapid ; but he
believed there wae a certain number of ceses in which one
might employ tuberculin without danger. That v/as a
question purely for experience to decide. lie raised the
question as to whether the employment of the frequent and
repeated doses advocated by the author was adapted to the
treatment of internal tuberculosis. It must be borne in
mind that they were unable to follow these cases like the
surgeon could follow hie, and therefore repeated and too-
frequent employment of inoculations would pro])ably be
found unsuitable for many of these cases. What was their
object in using tuberculin in these cases? It seemed to>
him to be to stimulate the diseased tissues, and to enable
the tubercular tissue to get the better of the enemy. The
^8
The Lancet,]
KOYAL MEDICAL AND CHIKURaiCAL SOCIETY.
[May 16,1891. 1099
«.ubhor had shown them sotne most interesting pictures of
the battie&elds in which the phagocytes were engaged in
-dealing with the tubercular cells. The only upshot of this
■stimulation of the tissue surrounding the tubercle was to
bring about a fibroid change, which they knew was the
natural safeguard against the further spread of the in¬
fection. He was afraid that this formation of fibroid
tissue w'as seriously imperilled by the continuance of
'the treatment for too long a time or by too frequent
repetitions. He referred to a very interesting observa¬
tion of Dr. Dreschfeld, in which it was pointed out
that extending tubercle was frequently led up to or preceded
by a catarrh which provided the material on which the
bacilli could feed. In early cases of tubercle, in which
there were small scattered tubercles over restricted areas
surrounded by lobular catarrh, the natural process was a
multiple necrosis; here he thought tuberculin might success¬
fully be used to hasten the process and to stimulate the
■secondary occurrence of fibroid changes. He thought that
when they had obtained a certain measure of success it
was better to hold their hand and to trust to hygienic and
general measures to complete the obsolescence of the
tubercle. The author suggested that the standstill might
be maintained for a considerable period of time by the
occasional repetition of the inoculation; he doubted, how¬
ever, whether this standstill was really to be attributed to
the treatment. They all knew that this tendency to
arrest and recurrence was part of the natural history or the
disease. The author's observation as to the actioij of
tuberculin in bringing about the healing of wounds was
most interesting and instructive, and at first sight rather
told against what he (the speaker) had been saying. He
was still hopeful that tuberculin might in some cases of
internal tuberculosis aid in rendering the disease quiescent.
Mr. Howard Marsh said it was one of the best papers he
bad ever listened to, being at once judicial and temperate;
but they were ail anxious to know what were the author’s
conclusions as to the practical value of this method of treat¬
ment. They were anxious to know whether it was a plenary
remedy, able to deal single-handed with the disease—to be
regarded in the light of an antidote, like mercury for
oyphilis, or, failing that, whether it was a useful accessory
to other forms of treatment. With regard to the first ques¬
tion, he feared that it was necessary to come to the con¬
clusion that it was not. He observed that the author dis¬
couraged recourse to this treatment in the early stages of
disease That was disappointing, and seemed to him an
abandonment of the position altogether; because if a remedy
was powerless against incipient disease, there was little
likelihood of its being of service at a later stage.
As to the second question, he observed there were
two methods by which surgical tuberculosis was treated.
In the first place, there was the treatment by rest
and change of air &;o. Many of them were convinced
nowadays that this method could be thoroughly relied
upon, and a very satisfactory result could he obtained.
He was prepared to produce a considerable number of
children who had been suffering from tuberculous disease,
who after a time had quite recovered with freely movable
joints. These, too, were cases which would be five, ten, or
fifteen years old, so that ample time bad elapsed to see
whether they were really cures or not. The treatment by
rest must be carried through, the eases passing through
several well-defined stages; indeed, the great objection to
that treatment was the time over which it extended,
taking as it did from six months to a year. It would
have been very satisfactory if the author could have
assured them that by the use of tuberculin, associated
with this treatment, the months could bo reduced to
weeks. Tliafc, however, was evidently not the case, be¬
cause he disadvised the remedy in the early stage. The
second plan was the operative method of treatment of
surgical tuberculosis; the principle of this method was to
cut away the diseased tissues, rather than to preserve them
by killing the disease ; this method was certainly open to
serious objections. The deposit of tubercle in the joint of
a child was not limited to the synovial membrane, but in¬
volved the articular ends of the bones. Cases in whicli this
treatment by free excision has been carried out had not
been freely recorded, but they would be full of interest. It
was clear that if a joint was treated in this way the
epiphyses must be sacrificed and the ultimate issue of the
case unsatisfactory. It would, indeed, be happy if this
sacrifice of necessary structures could be avoided. There
was no evidence that the extent of these operations could
be circumscribed. Then there was the radical objection to
this method that it did not cure the disease, hut simply
cut away the parte which were diseased. He instanced the
case of a patient with a tuberculous testicle; the surgeon
said to him, “ I must remove it, and then I will expedite
the healing of the wound with injections of tuberculin.” If
the disease recurred in the other testicle, the procedure
would have to be repeated. That looked very much like
locking the stable door after the horse had been stolen, and
if he were the surgeon he would feel disposed to say, with
the general, “ One more such victory as this and I am un¬
done.” He believed that the rapid way in which these
wounds healed had had a very misleading effect on their
estimate of the cases. Surgeons were so pleased with the
rapidity of cure after excision that they did not study
sufficiently what the ultimate condition of the limb was
likely to ne. If Koch’s treatment did nothing more than
help in the healing up of an aseptic wound, then it did
not amount to much, for they were accustomed to seeing
the wound after aseptic excisions heal by primaiy union.
Df. DKLiiiPiNE snowed various microscopical sections
bearing on the changes which took place in tubercles after
inoculation. When he saw the photographs on the screen
it occurred to him that he had specimens showing the same
kind of thing of his own, and he had looked out specimens
arnong diseases of synovial membranes in which decaying
epithelioid cells were found which closely resembled the
micro-photographs shown by the author. These were taken
from cases operated on six years ago, before Koch’s treat¬
ment was known. They were therefore interesting in view
of the possible use that'might be made of the pathological
facts that had been brought forward to show that the
changes were simply those of an ordinary inflammatory
rocess. He observed that there was a tendency to attri-
ute to tubercle a number of properties unknown to patho¬
logists before. When Koch published his first communica¬
tion he ventured to show that such changes as he proposed
to give as characteristic of the action of this fluid on
tubercle were rather against than in favour of his method.
These specimens seemed to show that there was nothing
specific in the action of the fluid, and the author held the
same opinion. The action of the injections was therefore
neither specific nor selective.
Dr. Hime of Bradford said he had not heard the original
paper, but on reading the abstracts he had been sbrucK by
the caution displayed by the author. It seemed as if
Mr. Cheyne was sitting on the rail and was keeping himself
ready to drop on either side. That position he thought was
highly meritorious. He thought it would be exceedingly
unwise of anyone to express a definite opinion on such an
important matter at the present juncture. He need nob
tell them that cases of phthisis were not to be pronounced
cured in a day, and the same remark applied to lupus. He
commented upon the very different views expressed, and
the exceeding laudation on the one hand and the exceed¬
ingly depressing views on the other. He thought they
might congratulate themselves upon not having rushed to
conclusions ; the public might have been misled by extra¬
vagant claims in the daily press, but the profession had
taken some time to make up their minds. He ventured to
differ chielly upon matters of fact with the gentleman who
led off the discussion. He (Mr. Barwell) said that the
reaction which resulted from the injection of the tuberculin
was indistinguishable from that of septicseraia ; that was a
remarkable statement, and one of gravity. (Mr. Barwell
protested that he said “very like,” but not “ indistinguish¬
able.”] The actual words were “very little difference,”
but with all respect he submitted that there was a very
great difference. First of all, the blood did not become
septic, there were never any metastatic abscesses, the
temperature was not similar, and the whole picture was nob
that of septic infection. Moreover, it was not characteristic
of septic infection that the larger the dose and the oftener
it was given the less was the result. Again, Mr. Barwell
had said that albuminuria was a frequent result. [Mr. Bar-
well remarked that he said it sometimes occurred.) He
accepted the correction, but he had taken the words down.
In any case it was not his experience, or that of the
majority of observers who had tried the method. He
hoped, too, that they would not accept Mr. Harwell’s
assertion that the tubercle bacillus was an animal that
sometimes died infected by its own poisons. The nature of
the reaction and its specific character was what they had
1100 Th® Lancet,]
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
[May 16,1891.
before them. To curative reeults, both here and abroad,
he could not then refer; but he himself had seen results
which he thought were very gratifying. It was impossible
to say at this stage that the cases were definitely cured,
but when a patient came, having lost from one to one and
a half pound a week for months, with night sweats,
anorexia, and bacilli in sputum, and when at the end of
some six or eight weeks these symptoms had disappeared,
the patient having gained in weight and the general con¬
dition being satisfactory, he was inclined to call this result
gratifying. Had he obtained the same result from cod-
flver oil, steel, &c., he would have felt very grateful. It
was enough for him that the patient got better. Every day
that he continued in this improved condition of health the
greater were his powers of resistance and the better able
was he to resist the inroads of the “animals,” as Mr.
Barwell called them—the bacilli. He had seen one or two
cases in which anomalous effects had occurred, but he had
seen none of the alarming results reported by other ob¬
servers. He could quite understand that they should occur
with doses such as he had seen administered at Berlin. He
referred to a patient of his own to whom he had adminis¬
tered one milligramme for lupus; that produced very severe
general and local symptoms, the temperature running up
to 105° F., with stupor &c. He asked what would have been
the result if, instead of a milligramme, he had given a centi¬
gramme. He insisted on the importance of smaller doses.
Dr. Theodore Williams said he would not have spoken
had the author not introduced the element of internal
tuberculosis in the form of phthisis. He observed that
the moderate tone of the paper contrasted strikingly
with Koch’s original contribution. They were told that
incipient phthisis could he cured in from four to six weeks,
and that any recurrence could be treated in the same way.
There was nothing of this kind in the paper presented by
the author, which was expressive less of satisfaction at the
results obtained than of those which ib was hoped might he
obtained in the future. He thought the author’s modified
treatment was au improvement on the original, but he
observed that his difficulty was to get the temperature
down and to arrive at a state of tolerance. None of his
own cases had been of this character. He mentioned a
typical case of initial phthisis with slight physical signs at
the apex of one lung, so slight as to be almost a matter of
doubt were it not that he had found bacilli in the sputum.
There was at first no pyrexia, but the second time he saw
her the temperature was up to about 100° F. They com¬
menced the treatment with this slight consolidation at one
apex, the dose being a milligramme, subsequently increased
to 1’5 mgr. There was always a reaction, and he was sorry
to say the case did very badly ; after from ten to fourteen
injections a considerable cavity formed in the lung, and then,
to his horror, after the fifteentli injection phthisical signs
appeared on the other side. This might, it was true, have
occurred anyhow, but it was not in accordance with his
experience of such cases. Treatment was carried out on
the precise lines laid down, and the lymph had been procured
from Berlin. He inclined to the view that the patient |
under ordinary treatment would not have been in that state.
They heard nothing in the paper about curing the disease,
only about keeping it at a standstill. Tliey all knew that
phthisis was not to be cured in a hurry. He was unable to
congratulate the author upon his cases; two of them, de¬
scribed as hopeless at the beginning, died. This was scarcely
the status quo. He had read the cases very carefully, and
thought they were a very melancholy series. He had sub¬
mitted four cases to the treatment, most of them being
typical cases of incipient phthisis. There was no sign of a
cavity, they all had a few bacilli in the sputum, and there
was a certain amount of pyrexia, and in one or two the
physical signs were doubtful. In each, within three or four
weeks, distinct cavities formed. The bacilli did not decrease
in numbers, the great feature being that the sputum con¬
tained great quantities of lung tissue. It might be said
that tins was the natural way of curing the disease—namely,
by setting up a necrosis and getting rid of the dead pro¬
ducts. But he urged that the formation of cavities dis¬
tinctly lessened the patient’s chance of recovery. In every
one of the cases in which there was a pre-existing cavity dr
cavities, it either extended or there was evidence of exten¬
sion of the tuberculous process to other parts of the lung.
These cases had been carefully examined, more so probably
than any other series of cases. He pointed out that these
first-stage cases as a rule did well under any treatment, and
mentioned a cose in which a residence at St. Moritz since'
January had brought about a cessation of all symptoms.
That was the class of case which Koch said could be cured
by his method; on the contrary, while they might he-
arrested in a number of ways, his way was vhe way to kill
them. He thought that the treatment might possibly become-
of use, but it would have to be modified.
Dr. Abraham said he felt the same disappointment aa
many others at the results, which liad not fulfilled their
expectations. He thought, however, in spite of what he had
heard, that most of those who had tried tuberculin in a.
systematic way would have to admit that some benefit bad
accrued. In the cases he himself had to deal with they had
not been uninfluenced for good by the treatment, but one
or two had been decidedly worse. The large majority,,
however, had distinctly improved temporarily, if not per¬
manently. He used small doses at intervals of several
days. He said that if tuberculin had a specific effect upon
tissues produced by the presence of bacilli, they would
expect some relation to exist between the amount of such
tissue and the intensity of the reaction. No such ratio,
however, was observed. In some cases with a small amount-
of tuberculous tissue he had seen severe local and constitu¬
tional symptoms, and vice versd. In other cases, althouglu
there had been abundance of bacilli in the sputum and
physical signs in the lungs, there had been scarcely any
reaction. He thought that the primary action of tuber¬
culin was upon the nervous centres, and considered that the'
microscopical specimens shown favoured the view that the
changes produced might be obtained by any method which
set the leucocytes free. In fact they werepureiy inflamma¬
tory. He thought the author’s plan of treatment bj’
multiple injections was likely to prove irksome, and could
not be employed unless ib could be shown that the game-
was worth the candle. He agreed that there was small'
danger of the disease being disseminated. In only one case
had he observed any increase of the tubercular disease. He
mentioned that of the two guinea-pigs brought before the
Pathological Society by Dr. Crookshank, one died shortly
afterwards with its organs full of tubercle, while the other
one, treated in exactly the same way, was still living. Mr.
Cheyne had said little as to the diagnostic value of the
remedy, which indeed did not seem to amount to much.
Two cases of lupus which he was treating by a combination
of Koch’s treatment and resorcin were doing remarkably
well.
Dr. Duysdale alluded to the rush to Berlin, but thought-
that a little enthusiasm was pardonable when ib was a-
question of curing a disease which killed one-fifth of our
population. He had been allowed to visit the LondoiXi
clinics, but the impression left upon his mind wos most
unfavourable. He expected from what he had read to see a
remedy which would be as safe and as certain as iodide of-
potassium in tertiary syphilis, the patient getting well and
not being injured in any way. He was quite unable to say
that he had seen anything Jilce a cure in any of the cases.
As to the patients reported as benefited, ho observed that
it was a common experience for such patients to improve
for a time with or without treatment. Of the cases of'
lupus he bad seen, only two were benefited at all, and even
these were nob cured. He had been anxious to employ the-
method, hut after what he had seen he would not feel justi¬
fied in doing so. He mentioned that a gentleman who bad-
examined a thousand specimens of sputa at Davos had been-
unable to detect any change in number or behaviour of
bacilli consequent on the treatment.
Dr. Wethered said one could not form an adequate idea
of the treatment by casual visits to hospitals. He had fol¬
lowed out carefully fifty cases, thirty-five of them being of
phthisis—seventeen of the first stage, nine of the second,,
and nine of the third. In not a single case did any harm
result. Though his numbers were small, they justified
the conclusion that in the first and second'stages of
phthisis some improvement might be expected. He had
seen no instance of the formation of a cavity. He insisted
upon the great amelioration of symptoms which occurred.'
during treatment, more especially in respect of the cough,
of which he gave two remarkable examples. The breathing
also improved, the night sweats disappeared, and the
appetite improved. He did not anticipate any good effects
from large doses, doses of from two to three milligrammes-
every two or three days, so long as there was a reaction,
being sufficient. He never carried the dose beyond twenty
milligrammes, and he thought it was a mistake to exceed
The Lancet,]
CLINICAL SOCIETY OF LONDON.
[May 16,1891. HOI
these doses. He thought this treatment had been pre¬
maturely cried down.
Dr. Squire said he had used this remedy continuously
since the first week in December, His results were not
very satisfactory in his surgical cases, and he could not
pretend to be able to judge whether the cases had gotbetter
under this thau under ordinary treatment. In any case,
the surgeons had t iken the first opportunity of discontinuing
the treatment. He admitted that perhaps with larger
doses or by some other method more satisfactory
results might have been obtained. He pointed out that
the question of doses was one of very great importance ;
if increasing doses were required in surgical cases, they
would not do in medical cases. They did not want in
phthisis to produce rapid destruction and elimination of
tubercle, but a slow process which would allow the fibroid
changes to hem in the infective tissues. This result, he
thought, was more likely to be obtained by small than by
large doses. He remarked that the non^ulcerative lupus
was apparently not affected in all. In ulcerative cases there
was some considerable improvement, but not of a perma¬
nent kind.
Mr. Hurry Fenwick said that after an experience of
about ninety cases of genito urinary tuberculosis he started
using Koch’s treatment, and described his result under
three heads: (1) dangers ; (2) ocular appearances of
mucous membrane; and (3) therapeutic value. The
dangers were certainly real. In his first case there was
septic pyelitis, and the man died in a fortnight. There was
also danger of swelling taking place in the urethra or neck
of the bladder, leading to retention or suppression of urine.
Lastly, there was the danger of rapid sloughing out of
material from the bladder followed by profuse hmmorrhage,
an instance of which he mentioned. With regard to the
ocular appearances, he had noticed the formation of small
mulberry plilyctenuhe, and, what was more extraordinary,
the formation of deposits which had not been previously
seen. In regard to its therapeutic value, he thought id
might be of use in a very early stage of tuberculosis of the
bladder, kidney, or prostate, and its effect might be accu¬
rately watched by means of the cystoacope.
Mr. CiiEYNE, in reply, admitted that he was still sitting
on a rail, and did not propose to get down for the time
being. He would have liked to have asked Mr. Harwell
where his extraordinary investigations took place. By
sepsis he only meant the process due to the specific organism.
Ho pointed out that his own method bore on the frequency
rather than the amount of the dose. He would be quite
content to go on with half a milligramme for several weeks.
He would like to see physicians try that plan before aban¬
doning the method. They were under no obligation to
give all the injections themselves. He said tliat in his own
cases when he left off the treatment the disease recurred,
and that was what he meant by a standstill. He did not
argue against the remedy in incipient disease, but he would
not advise its use- In reference to Dr, Del6pine’s remarks,
he pointed out that the specific nature of the remedy was in
the selection rather than in any special changes- He him¬
self had plenty of specimens showing the same thing. He
did not agree that cases of phthisis naturally inclined to
recovery. If phthisis were such a curable disease, it was
surprising that physicians should have made such a rush to
Berlin to learn something about its treatment. It was the
physicians, and not the surgeons, who had led the way
there.
CLINICAL SOCIETY OF LONDON.
Beseotion q/ Intestine by Senn's Method. — Seqir,cstrotoiny.
Trcjphining for Cerebral Abscess.
An ordinary meeting of this Society took place on May 8bh,
Mr. Berkeley Hill, Vice-l’resident, in the chair.
Mr. Arkutiinot Lane read a paper on two cases of Ile-
soction of Intestine by Senn’s Method. The first was a case
of Littre’s hernia occurring in a woman aged fifty-three.
It was femoral, and situated on the right side. On expos¬
ing the sac it was found to be much inllaraed, its contents
stinking and pultaceous, and the knuckle of bowel in an
obviously irrecoverable condition. Having thoroughly
cleansed the bowel and sac, tite abdomen was opened in the
middle lino, and the loop of intestine, whose segment had
been strangulated, was drawn out from the abdomen, the
constriction at the femoral ring having been previously
divided. It was then seen that only a portion of the calibre
of the bowel had been included in the sac, and that its con¬
dition was irrecoverable. Subsequent examination of the
strangulated portion showed that, though there wasnoobvious
perforation, nothing remained in many parts of its wall but
tbe peritoneal coat. About three inches of the bowel, in¬
cluding the strangulated area, were excised, and the
mesentery belonging to it ligatured. The divided ends of
the proximal and distal segments of the intestine were
closed by inverting their coats and by running along them
a continuous Lerubert’s suture. Incisions were made in the
convexities of the segments about three inches from their
closed ends, and into these Senn’s plates were introduced.
The apertures were then brought accurately together by
means of the silk ligatures. After this two continuous
Lembert’s sutures were applied to render the apposition of
the plates more perfect, and a broad graft of omentum was
placed around and fixed by means of several fine silk sutures.
For a few days the patient was nourished by enemata,
and later by peptonised milk. Twelve days after the opera¬
tion she was enjoying a fiah dinner. She experienced no pain
or discomfort worth mentioning, and her abdomen remained
soft and comfortable throughout. It was necessary to give
her some opium for a few days after the operation to restrain
a tendency todlarrhcoa. She left the hospital three weeks
and four days after the operation. The second case was in
a woman aged fifty-five, who bad suffered from a strangu¬
lated femoral heruia for five days before her admission.
She was very collapsed, and her abdomen was much dis¬
tended. It was at once apparent that she could not stand
any very prolonged operation. The sac was much inllamed,
and contained a quantity of pus and fteces and a perforated
loop of small intestine. This was ligatured and carefully
cleansed, the constriction being then divided. The abdomen
was opened and the damaged loop drawn out. About four
inches of bowel were e.xcised, and the ends closed and the
plates inserted. It was then found that the proximal
gut was very rotten, and the sutures attached to tbe
plates tore through the softened bowel frequently. Finally,
the plates were brought together in much haste, as the
patient had become moribund, and a graft of omentum
was attached. Mr. Lane regretted very much that he had
not time to remove a farther portion of the proximal bowel,
but the patient’s condition rendered any further delay im¬
possible. She lived five days and two hours, the bowel
yielding two hours before her death, which resulted from tbe
escape of the intestinal contents into the peritoneal cavity
through a small slough in the proximal bowel. Mr. Lane
urged that the following treatment should be adopted in
future :~1. That in cases where strangulated loop of in¬
testine was gangrenous or ulcerated, the proximal and
distal portions of the intestine shoulcTbe short-circuited by
means of Senn’sqilates, the proximal portion being at the
same time relieved of much of its contents. If the condi¬
tion of the patient were such as to permit of farther opera¬
tive interference, and provided the adhesion of the intestine
to the neck of the sac and its vicinity were not too ex¬
tensive, the damaged loop should be resected at the same
time, otherwise it should only be incised and freely
drained. 2. That, as a very large proportion of cases
of strangulated hernia died from obstruction after hernio¬
tomy, owing to the strangulated loop not recovering
itself sufficiently to allow of the passage of the contents of
the bowel through it, in any case in which the condition of
the strangulated bowel aroused suspicion in the mind of
the operator as to the possibility of its not recovering, the
abdomen should be opened in the middle line, and the con¬
dition of the damaged intestine, as to its transmissibility,
fully explored. That if there were any doubt about it
the intestine should be sliort-circuited ; and if the condition
of the damaged loop were such as to suggest ulceration and
subsequent perforation, it should be excised also. He con¬
sidered the present mortality after herniotomy a disgrace to
the surcery of the present day, and only to be obviated by
more ellieient and thorough treatment than that at present
adopted.—Mr. Jessett said that it appeared to him that the
second case was seen too late, when the chance of successful
operation was remote. It was a matter for regret that a
larger portion of intestine was not removed. He had
operated successfully on two coses—one of communication
of the small intestine with the roof of the vagina, and one
of intestinal obstruction. In a third case of ulceration of
intestine following the pressure of an ovarian cyst, a fatal
result ensued twenty minutes after the completion of the
Coogle
1102 The Lancet,]
CLINICAL SOCIETY OF LONDON.
[May 16,1891.
operation. He thought that when these cases were seen
very late, the stomach should be iirst washed out and the
operation postponed for a few hours until the patient was
revived by brandy and nutrient eneraata. He referred to
the difficulty in approximating the intestine in cases of
obstruction where the proximal gut was much dilated and
the distal very contracted.—Dr. Morotti showed a specimen
of the intestine of an animal which had been operated on ac¬
cording to a method described by Dr. Halsted of the Johns
Hopkins Hospital, Baltimore. He held that for simplicity and
rapidity of performance, combined with safety, it had no
rival. He had performed different operations for intestinal
anastomosis ten times, and in each case the animal had
made a good recovery.—Mr. Lockwood said that at St.
Bartholomew’s Hospital the taxis was always tried before a
strangulated hernia was operated on, and the mortality in
the total number of cases was 2.'> per cent ; but the mortality
in the cases in which the gut was gangrenous came nearer
90 than 80 per cent. The cause of death among these
when analysed showed that the old treatment was un¬
scientific, for the patient usually died unrelieved, or, if
relieved, the gut had given way or gangrene had spread
along it. Peritonitis bad not been so frequent a cause of
death as might have been imagined. Another great
objection to the old method was that one could never be
sure where the gut was opened. He asked what had been
the experience of surgeons as to the other method, which
Senn had proposed, that of lining the upper end of the gut
with indiarubber and then intusauscepiing it with four
sutures ; be had found it possible to do this on the cadaver
in under ten minutes. Whatever operation were done, he
preferred to do it through the original wound. It was a
great question what would be the ultimate result in these
eases of anastomosis ; in at least one it was known that the
opening made had closed up again.—Mr. H. II. Glutton
spoke in favour of Mr. Lane's proposal, as he was convinced
that the treatment of the gut by the old method was
hopeless. He advocated a median abdominal incision, and
attributed Mr. Lane’s successto this procedure.—Mr. Parkin
had been over the statistics of Guy’s Hospital for ten years,
and found that there had been 272 operations for strangulated
hernia with seventy-nine deaths. The mortality, taking
all the cases, including those notoperated on, was 22 per
cent., while taking only those operated on it was 3-1 per cent,
in twenty-two cases there was gangrcoe of the gut, and of
these, twenty-one or 94 percent, died : sixteen of perito¬
nitis and live of exhaustion. In eleven of the cases an
artificial anus had been formed, and these lived on the
average seven days —Mr. Symonds thought that the new
operation described as Dr. Halsted’s was very much like
that which had been described before by Mr. Barker.—Mr.
Harrison Crirps had had twoor three of these cases in bis
practice, and wibli one exception they had proved fatal.
The case which recovered was that of an elderly woman,
and be cut the gangrenous loop entirely away, and with a
eatheter passed into the proximal end let out quarts of fecu¬
lent material. She died live orsix weeks later from bedsores.
He protested against the older methods being stigmatised as
barbarous, and he thought that, if a patient were moribund,
to do such a proceeding as Mr. Lane had desciibed would
destroy the last spark of life left. He held, on the con¬
trary, that under these circumstances as little as possible
should be done.—Mr. Lank, in reply, still held that theold
treatment was barbarous. Mr. Cripps’only successful case
died in a few weeks, probably because the gut had been
opened very high up, and everyone admitted that the
mortality under the old method was enormous. He held
that in any case the bowel should be connected above and
below,and,ifthepatient’a8breDgth allowedit, the gangrenous
part should be cub away. The advantage of the median
incision was that the bowel could be taken well out of
the abdomen and thus risk of soiling the peritoneum was
greatly diminished.
Mr. Charters Symonds related two cases in which a
sequestrum was removed from the neck of the femur
without injury to the joint, and in which recovery with a
perfect joint resulted in both. Both cases were children,
one aged three and the other five. In both there was a
large chronic abscess on the front and outer aspect of the
thigh, without any joint pain. Both children could run
about without pain, and with only a very slight limp. The
movements of the joint in each case were only slightly
impaired, and nob more than could be attributed to the
mechanical presence of the abscess. In the first case the
presence and situation of the sequestrum were suspected, in
the second it was searched for after the abscess was
opened. In both a minute sinus was found leading through
the front of the neck into a cavity in the neck. The
channel was enlarged by gouging away a little bone
from the outer aide, and the sequestrum removed. In both
the capsule was seen lifted up by the abscess; in the
first, it was accidentally opened by a slip of the knife; in
the second, it was intentionally pricked, and in both cases
a few drops of clear fluid escaped. Both sequestra involved
the epiphysial aspect of the neck, and in the first case was
of considerable size- In the first case, operated on in 1887,
the wound was stuffed and drained, and the child was not
well for more than a year. In the second, operated on in
May, 1889, according to the method introduced by Mr.
Barker, the large abscess, after being scraped out, was sewn
up and was followed by primary union. Both children were
shown. The elder, a boy of seven, had a perfectly useful
joint, possessing all the normal movements, and, moreover,
there was no shortening and no irregular growth. The
other, the first operated on, had a limb of the full length,
but the joint was fixed. Mr. Symonds attributed the
superiority of the result in the second case to the method of
operating employed, and thought the ankylosis in the first
case due either to the result of chronic synovitis extending
from the cavity, or to the fixation caused by the splint.—
Mr. Barker said that the advantage of attacking the
disease at this stage was that it could be dealt with by a
comparatively small operation, whereas if it were left till
later an extensive resection would probably be required.
He referred to the case of a girl aged six whom he saw last
September, with distinct symptoms of hip-disease. He had
seen her again recently, and six weeks ago she had begun
without leave to go about without the double Thomas’s
splint with which sbe had been provided. A large abscess
now existed in front of the trochanter, and from the absence
of pain when gently jarring the heel or knee, and the freedom
of movement without grating in the joint, he was inclined to
regard it as a case like chat the author had described. He
made an anterior incision, opened the abscess, and a
probe entered the bone, the joint not being in the
least degree involved The trochanter was nob swollen,
nor was the limb shortened.— Mr. Watson Cheyne
thought that these cases must be comparatively rare.
So far as he had examined the pathology of the affec¬
tion, in most cases the seguestrum extended to the
surface of the bone near the epiphysial line, and the joint
was then necessarily involved. He bad in six cases renioverl
sequestra without excision, and in one he had attacked ic
through the trochanter without opening the joint. He
suspected that in the case the author had described the
sequestra were in the substance of the neck rather than
in the usual position.—Mr. Symonds, in reply, said that
in the case of the boy notliing but a thin shell of bone re¬
mained, and the sequestrum contained no compact tisaus.
The larger sequestrum shown undoubtedly did involve the
anterior surface of the neck. He thought that a good many
of the chronic abscesses of the thigh were of this nature, the
sinus leading to the bone being overlooked. It should be
searched for at tlie extreme upper limit of the abscess.
Mr. Stephen Paget described a successful case of Cere¬
bral Abscess in which he had twice trephined. A boy aged
twelve, after a discharge from the left ear, had for some
weeks intense headache, with giddiness and strangeness of
manner; there were also points of exquisite sensitiveness in
the left temporal, malar, and occipital regions. A week
after admission to the West London Hospital sudden
vomiting supervened, then right facial paralysis, weakness of
right arm, partial aphasia, and lefc optic neuritis. Mr. Pa'. e'i
trephined over the left fi.ssure of Kolando, and let out an
ounce of pus. Eleven days after, the abscess having re¬
filled, he trephined again lower down, on a level with
the lower opening. Two days later an offensive blood clot
was found in the discharge, probably from the meningeal
h.'cmorrhago which had occurred five days after the fir.ib
trephining. The abscess cavity was now syringed through
daily with perchloride. There was for some time after this
a small hernia cerebri at the upper wound, but this was
cured by elastic pressure. The wounds healed soundly,
and the boy made a good recovery, save for some paralysis
of the right side of the face. Mr. Paget called attenbiun
to the chief surgical features of the case, and to the curious
sort of ajihasia from which the boy had suffered, being
unable to give the right names to objects, though he
The Lancet,]
OBSTETRICAL SOCIETY OF LONDON.
[May 16, 1891. 1103
recognised the names when he heard them. It was also to
be observed that all through his illness, even at its height,
the boy had a voracious appetite, eating and drinking
enormous quantities of food. Mr. Paget quoted five pub¬
lished cases in which the same voracity for food and
drink had occurred after severe injuries or the front part
of the brain. He thanked Mr. Eccles, the house surgeon,
for his devotion and skill in the management of the case.—
Mr. Barker congratulated the author on the result he had
obtained, but hoped that he would indicate more exactly
the situation of the abscess. He asked why the first
trephine hole was made so high up. In a child the usual
position to trephine was about an inch and a quarter above
and behind the external auditory meatus.—Mr. Dunn re¬
ferred to a case of old ear disease in which the mastoid had
been trephined. The patient returned later with a discharge
from the ear and a high temperature. An abscess was
opened and the middle ear cleaned out. The temperature
did not go down, and as paralysis of the arm supervened, he
trephined over the fissure of Rolando, but with a negative
result; he then trephined lower down and let out foetid
pus. The boy died ten days later of meningitis, and it was
found that the abscess in the right hemisphere had opened
posteriorly.—Mr. Symonds asked whether in cases of high
temperature, accompanied by paralysis, it was wise to
operate.—Mr. Bruce Clarke referred to a case in which
the temperature was 104"!''., apd he cub down and found
an abscess in the bone, and under the dura. The patient
made an excellent recovery, but the brain was not involved.
—Mr. Paget, in reply, recurring to the voracious appetite
in these cases, wondered if there were any centre for hunger
and thirst which had been affected. The patient at the
present time had deafness on the opposite side. The rise
of temperature he attributed to an attack of pleurisy.
OBSTETRICAL SOCIETY OF LONDON.
An adjourned meeting of this Society was held on
May Gth, Dr. J. Watt Black, President, in the chair.
Tetany in Pregnancy. —Dr. Dakin read a paper on this
subject. Tlie author gave a brief definition of tetany or
tetanilla, and then narrated a case. In addition to the
fact that it was an instance of a very rare disorder of
pregnancy, the case had the peculiarity that the spasms
never completely relaxed during the three days of the
disease. The contractions were accompanied by, and
were probably due to, very severe vomiting, and the
two diseases combined led to a fatal issue, in which
the tetany dealt the final blow by involving the muscles
of respiration. The autlior then, from the few recorded
instances of the disease during pregnancy, constructed a
typical case, with which lie compared the case detailed in the
paper. The differential diagnosis between this disease and
other spasmodic ali'ections which might be confounded with
ib (tetanus, hysteria, spinal meningitis, uru-mia, one form
of epilepsy, and ergotism) was discussed, the treatment
briefly referred to, and general conclusions drawn. A table
of all accessible recorded cases was appended and references
given to authors who had treated the subject generally and
in special aspects.
Death following Injection of Acid Nitrate of Mercury .—
Dr. John PniLLiP.s read a paper on this subject. The
patient was a married niultipara, aged bwenby-iive, when
first under observation, her complaint being sterility and
dysmenorrhooa. Three years later whilst separated from her
husband she became pregnant, and with tho object of
ridding herself of the nine or ten weeks’ conception about a
tablespoonful of acid nitrate of mercury was injected into
the vagina. The same evening vomiting set in and intense
pain, for which morphia and cocaine were given. The face
was pinched and of a markedly abdominal type. Tempera¬
ture 102° F., and the pulse 112, wiry but irregular. The stools
became frequent and blood-stained ; the urine was scanty, and
was passed involuntarily. Tho vagina was in a sloughy
condition. The vaginal douche brought away some blood¬
stained flakes. The uterus was enlarged and the os soft
and patient. Carbonate of ammonia was administered, but
she sank and died. A post-mortem examination was made
by Mr. I’epper. The bladder contained bloody urine, the
blood evidently derived from the kidneys. The folds of the
vaginal mucous membrane were covered by a hardened
slough. The cervix was untouched, but there was some
slight detachment of the decidual membrane. The uterus
contained a ten-weeks’ foabus, with its membranes intact.'
The mucous membrane of the whole of the large intestine
and the lower part of the small intestine was blackened
and in a state of superficial slough. Peritonitis had
commenced The mucous membrane of the 8toma.ch was
healthy. Dr. Phillips remarked that the peritonitis was
due probably to absorption from the sloughy mucous
membrane of the vagina. He pointed out that there was
no fetor of breath, no sponginess of gums, and no enlarge¬
ment of the cervical glands.—Dr. BOXALL thought it
hardly fair bo say in the present case that no wound existed,
as an eschar was produced. In mercuvialism from vaginal
douches the symptoms were generally abdominal pain,
diarrheea, and tenesmus, and only rarely salivation or
spongy gums.
Sequel to a Case of Serous Perimetritis. —Mr. Alban
Doran read a paper on this subject. Tho first paper on
this case was published in the twenty-first volume of the
Obstetrical Transactions. The patient died in August,
1890, about three years after the exploratory incision. The
irl grew tall, but became ill and weak and emaciated. Dr.
lott of Bromley watched the case to its termination. She
showed tubercular disease of chest as well as abdomen,
pyrexia, cough, sweats, hectic. Tubercle was found in the
abdomen and chest. Both ovaries were much enlarged and
converted into cysts filled with dirty, yellow, puitaoeous
material. The Fallopian tubes were swollen into two ovai
fluctuating cysts. Mr. Targett had examined the specimens
microscopically, and could find no bacilli. He thought the
condition was due to chronic inflammatory disease of- gonor-
rbceal origin The girl, although unmarried, admitted coitua,
and HO there was a possibility of gonorrhoea. She never men
sbruated again after tlie operation. If she had had gonorrhcoa
it is possible that the parts were thereby prepared for the
easy invasion of tubercle. The probability of primary
tubercular disease of the tubes is far greater. There was a
family history of tubercle. Reference was made to the
writings of Pozzl. Kelterborn, and others. In all proba¬
bility the disease began as tubercular salpingitis, which set
up tubercular peritonitis. This was relieved by the
abdominal incision. The patient finally succumbed to pul¬
monary phthisis. The dull yellow spongy tissue cut into
at the operation was not found at the necropsy.—Dr.
Horrocks remarked that the case was of great interest, as
it had been so well and so patiently followed to its termina¬
tion. He did not think that when bacilli were nob found
in a specimen one could say that the case was not tuber¬
culous.—Dr, Giuefith referred to eases recorded by Bernut*
and Goupil in which pelvic infiaiumation was apparently
connected with tubercular disease, and remarked on the
apparent infrequency of this connexion in England.—Mr.
Doran replied.
Tho following specimens were shown.
Dr. Wm. Duncan: (1) Extirpation of the Uterus for
Cancer; (2) Broad Ligament Cyst.
Dr. OitiEFiTii: Double Hydro-salpinx.
EPIDEMIOLOGICAL SOCIETY.
The Relation of Modification oj Function of Micro organism
to the Virulence and Spread of Specific Injective Diseases.
A MEETING of this Society was held on April 16bh, Joseph
Ewart, M.D., President, in the chair.
Dr. Sims Woodiiead read a paper on the above subject.
After referring to the relations between saprophytes and
parasites indicated in the paper read by Dr. Louis Parkes at
ihe meeting in P'ebruary, he said that the modification of
habit consequent on the acquired adaptation of a micro¬
organism to changed conditions of pabulum, temperature,
access of air or of light, &c., exerted considerable influence
on its biological and pathogenetic functions, and that aero¬
bism or anaerobism depended greatly on tho nature of the
food supplied. The constituents of culture lluids were the
several forms of albumen and gelatine, ammonia, sugar
vegetable acids, &c., and the addition of glycerine had olteo
a remarkable influence. Microbes long accustomed to one
set of conditions might be unable to resist a sudden transi¬
tion, but if the change were gradual might grow luxuriantly
under the new conditions, though perhaps exhibiting great
modifications of function, virulence, and so on. These facts
lay at the foundation of all prophylactic inoculations, the
. : Coogle
1104 Thb Lancet,]
HUNTERIAN SOCIETY.
[May 16,1891,
first of whicb, since the discovery of vaccination by Jenner,
yras the attenuation of the bacillus anthracis effected by
Professor Greenfield inl880, who cultivated it in the aqueous
humour of the ox, and which was soon utilised by Toussalntfor
conferring on cattle immunity against this disease. Such en-
feeblement might show itself in the production of weaker
to:;ioes, or, as in the case of the cholera bacillus, when
cultivated anaerobically in lessened reoistance to germicides,
including the digestive secretions. The alteration of func¬
tions in the cholera group of bacilli was extremely complex
and interesting, especially the intensification of their viru¬
lence by deprivation of oxygen, which was attended ^ari
passu with increased susceptibility to germicidal agents.
Ur. Woodhead discussed the bearing of these phenomena on
Pettenkofer’s theory of the influence of the ground water
on the prevalence of cholera and enteric fever, on the greater
infectivenesH of the soiled clothing after the lapse of some
days, as well as on the various degrees of persistency of the
infection in diffVrent localities. Long before the dawn of
bacteriology Sir J. Simpson had suggested the communica¬
bility of tetanus, which he compared to septicaemia.
Nicolaier identified its bacillus in 1883, but the earlier
experiments were unsatisfactory; and it was only within
the last year that MM. Vaillard and Vincent, following up
the work of Kitasato and others, had elucidated most of
the phenomena of this disease. They had shown that thesym-
p^oma were due to the formation of a subscance closely asso¬
ciated with a peptonising enzyme produced by the bacillus,
only under certain conditions of anaerobism, pabulum, and
temperature, and that thesporesthemselveswereinert, though
if iDje6ted along with certain organic substances, as lactic acid
or Che culture nnids of some other bacilli, tetanus followed
within a few days. Any doubts that might be enter¬
tained as to the reality of these alleged modifications of
pathogenetic functions must he dispelled by an appeal to
the visible phenomena exhibited by the colour forming
micro-organisms. Thus the bacillus pyocyaneus under
normal conditions gave rise to a blue pigment and to a green
fluorescence in the culture fluid ; the addition of glycerine
prevented the formation of pyocyanin, in peptone gelatine the
flaorescence was lost, and in the presence of glucose the
appearance of both was checked. These phenomena of
chromogenism, though more palpable, were not more real
than the modifications of patbogenism effected by analogous
means. The observations of Loffier, Roux, and Yersin
on the diphtheritic and pseudo-diphtheritic bacilli seemed .
to throw light on the marked changes of type seen in the .
course of epidemics of that disease. It was probable that
certain conditions and surroundings, among which might be
the presence of some other bacilli and their products, were
necessary to evolve the malignant out of the comparatively
harmless, though morphologically indistinguishable, forms,
and that these conditions might operate out of as well as
in or on the living body. The power of emitting light
possessed by some bacteria was evidently dependent rather
on the presence of certain pabula than on that of oxygen ;
while, on the other hand, t-ho influence of light on the
colour-forming function of some bacteria and on the de¬
velopment of others was very striking, as was that of tem¬
perature, alike on their growth and on their functional
activity, as seen in the transformation of the micrococcus pro-
digiosus from a pigment-forming organism into a lactic acid
ferment. On several putrefactive and pathogenic bacteria
light alone, wholly irrespective of the pabulum or of the
supply of oxygen, exerted an injurious action. This was
conspicuously seen in the case of the bacillus of enteric
fever, which was killed by a few hours exposure to direct
sunshine and grew but feebly in diffused daylight—these
effects being produced, as the experiments of Janowski
showed, by the chemical rays of the spectrum.—Dr. WiL-
LOUCJHiiY expressed his conviction that the modification of
the functions of micro-organisms affected by their sur¬
roundings, so ably treated by Dr. Woodliead, presented the
only satisfactory and complete solution of the phenomena
of epidemics of diphtheria, the progressive virulence of
successive cases, and the concurrent prevalence of sore-
throats of every degree of severity, whicli had long been the
puzzle of clinicians and pathologists, as well as of those of the
“recurrence and recrudescence” of the disease described some
time since by Dr. Gresswell. The photophobia, as he might
call it, of the enteric bacillus went far to explain the general
association of that disease with sewers and cesspools, and
of diphtheria rather with surface deposits of filth, as shown
by Soyka at Munich, and confirmed by common experience
enteric fever being emphatically a thing of darkness. He
would suggest that we might thus reconcile the frequency
of outbreaks of enteric fever from recent specific contamina¬
tion of reservoirs with the rare occurrence of such results
from the use of rivers undoubtedly polluted in like manner
as sources of the public water-supply of towns, thus con¬
trasting strongly with cholera, otherwise so like in its
etiology, by supposing that the bacilli perished rapidly
through exposure to the light of day. lie then gave a
summary of the researches of MM. Vailleid and Vincent,
alluded to by Dr. Woodhead, on tetanus, its bacillus and
its toxine, one practical lesson from which was the neces¬
sity for the strictest asepsis in the treatment of all
suspicious wounds—viz., those to whicb earth or dirt had
gained access, since the spores, which alone were acci¬
dentally introduced, were incapable of germinating in the
healthy tissues, requiring the presence of pus and unhealthy
discharges for their development, and the production of
tebanin, the immediate cause of the disease.—Mr. Siiirlky
Murphy said that there were a few recorded instances of
enteric fever consequent on river pollution, one of the
clearest being that of the outbreak at Gloucester following
one at Kidderminster, twenty miles higher up the Severn —
Dr. Pringle quoted a remarkable instance in a Scottish
town where an outbreak followed the discharge of the
excreta of a single case some little way below the intake,
but under peculiar circumstances, such that the contami¬
nated water was drawn back into the pumps, having been
held back by a weir.
Dr. Thresh read a paper, illusbrated by maps and tables,
on the Distribution of Enteric Fever in the County of Essex.
HUNTERIAN SOCIETY.
A CLINICAI. MEETING of this Society was held on April 8tb,
Dr. Stephen Mackenzie, President, in the chair.
Ringed Eruption —Dr. George Carpenter showed a
boy aged sixteen months with an eruption on the buttocks
and adjacent parts, composed of rings one to two inches in
diameter, with raised striated edges, and of the colour of
raw ham. The enclosed surfaces were quite healthy, and the
rings nearly a quarter of an inch broad. He had snuflles
and a rash on the buttocks at six weeks. The ringed rash
was of about four months’ duration, and had improved
greatly under mercury. The trichophyton had been well
searched for, bub in vain. There were no other signs of
syphilis.—Dr. Cor.cOTT Fox agreed in believing the erup¬
tion syphilitic. The resemblance to ringworm was great,
bub the broad margin with a line retiform structure was
unlike. Ringed syphilidea were in rare cases met with both
in the congenital and acquired disease—The Prk.sident
differed as to the diagnosis. Failure to find the fungus was
no proof of its absence. Thera were no confirmatory signs
of syphilis, and he thought it probably a case of tinea
circinata.
Cranio-tabes and Parrot's Nodes. —Dr. CARPENTER also
showed two infants witli congenital syphilis to illustrate
cranial conditions. The first was a boy aged eleven months
with snuftles since birth and an eruption at fourteen weeks.
When seen six months ago there were enlarged liver and
spleen and some thickening of the spermatic cords. Cranio-
tabes affected nob only the occipital bub the parietal and
squamo-teraporal bones. This condition was, however, no
longer demonstrable. The boy’s sister, aged two years,
was also shown. She had snulllas since birth, and was
decidedly rachitic, with enlarged liver and spleen and
cranio-tabes at the parietal bonea. Parrot’s nodes were well
marked. Dr. Carpenter considered that both cranio-tabes
and Parrot’s nodes were usually syphilitic manifestations,
although some authors class them under tickets; 74 per
cent, of cases of cranio-tabes were syphilitic.
Fibrous Growths on the Hands. —Dr. FliED. J. SMITH
showed a cate of unusual growths on the bands in a young
woman, also exhibited several months ago. The nodules
were now more distinct and isolated, with less erythema
around. He had excised one and found it consisted of
fibrous tissue.—Dr. Colcott Fox regarded the case as very
singular; a similar one was published by Dr. Bury of
Manchester. He thought it an indolent inflammatory
eruption which had become fibrous in course of time.—
The President still inclined to the diagnosis of rheumatic
nodules'
Dioiiized by ^ooQle
The Lancet,]
NOTICES OF BOOKS.
[May 16,1891. 1105
Congenital Heart Disease. —Dr. SMITH also exhibited a
boy aged twelve years with marked cyanosis of face and
lips, the latter nearly black, and 0oj^er-ends much clubbed,
There was no bruit, and the particular defect of heart
present, which was discussed by Drs. F. Hawkins, (1.
Carpenter, and Dundas Grant, and Mr. Tatham and the
President, must remain uncertain.
Paralysis Agitans. —Dr. A. T. Davies showed a man
aged forty-nine years, exhibited before the Society three
years ago. The symptoms were then confined to the right
arm and leg, and some doubt was raised as to the diagnosis.
Within the last two years similar symptoms had developed
on the left side, and the case now presented a typical
appearance.
multiple Lipoinata. —Dr. A. H. RoniNSON brought
forward a men aged thirty-three years with numerous
small fatty growths scattered over the trunk and limbs
of ten years’ duration. His father bad some similar
tumours.
CerxHcal Tumour. —Dr, ROBINSON also showed a man aged
seventy-one years with an old tumour close below the
occiput, supposed to be a lipoma. There was an irritable
condition of the upper hbres of the trapezius, amounting
almost to spasmodic torticollis.
A meeting of this Society was held on Wednesday,
April 22Qd, l)r. Stephen Mackenzie, President, in the chair.
Graves' Disease, —Dr. A. T. Davies showed a patient aged
twenty-six years who had been under his observation for
three years and a half. She was originally frightened by
burglars. Cough, palpitation, and prominent eyes came
on gradually, with anmmia, and some fulness of thyroid.
Von Graefe’s sign was present. Pulse 140. General marked
pigmentation of the skin then appeared, such as to suggest
Addison’s disease, and in illustration of this a portrait
from St. Bartholomew’s Hospital mirseum was now shown,
labelled “Exophthalmic goitre, with Addison’s disease.”
In course of time the pigmentation had to a great extent
faded, the eyes had become less prominent, the heart rate
was now only 80, and there was very slight fulness of the
thyroid gland. The disease had thus become quiescent.—
Mr. Denton Caroew had found there was abnormal
increase of pigment in 70 per cent, of cases of Graves’
disease, occurring both in the axillm and in parts liable
to pressure, as by a garter. He had found vitiligo and
alopecia areata also common. Until a lesion of the supra¬
renal bodies is proved post mortem, he would doubt the
coexistence of Addison’s disease in such cases.
Fixation of Thorax and Head. —Dr. Appleford ex¬
hibited a man aged thirty-seven years, in whom stiffening
of the chest, head, neck, and right arm had been coming
on for two years. He had suffered from rheumatism often,
not rheumatic fever. A brother died of phthisis, and he had
had much cough himself, and had wasted. The thorax
was rigid, respiration being diaphragmatic; the head could
be turned only slightly to either side; the right arm could
not be raised to a right angle with the trunk. Increased
knee-jerks and clonus were present, bub no spinal tender¬
ness.— Mr. Poland attributed the fixation to osteo-
arthritic disease, and pointed out that there was marked
creaking in various joints.—Dr. P. J. SMITH hesitated
between rheumatoid arthritis and a local pachymeningitis
of the cord.
Acute Necrosis.—yit. A. H. Tuidiy read a paper on the
Pathology and Treatment of Acute Necrosis of Growing
Bone. After some remarks on the structure of the epiphy¬
sial line and the neighbouring parts, he said that, in view
of the mode of onset, of the concurrence of periostitis and
endostitis, and of the early separation of the shaft, with
necrosis of its whole thickness, some region other than the
periosteum or the medulla must be the site of the earliest
inliammation. This region he believed to be the vascular
layer of young growing bone, the juxta-epiphysial junc¬
tion. Inilaramation commencing here spread upwards and
downwards to the medulla, and outwards to the periosteum,
being assisted by the peculiar disposition of the periosteum
at the epiphysial line. The following three points were
advanced:,!. The disease variously known by many
synonyms, but for convenience here called “acutenecrosis,” is
due to the irritation and suppuration occasioned in growing
bone by the entrance and development of micro-organisms,
the staphylococcus and sbroptococcu,s pyogenes aureus.
3. In cft“03 of total death of the diaphysis the destruc¬
tive process is most marked at the extremities, and
further, there is a loss of tissue liere, so that the dead
shaft no longer fibs accurately into the periosteal and
epiphysial cap. This point was supported by record of
cases, notably those of Mr. Macnamara. 3. If the origin
of the disease as a juxta-epiphysitis be conceded, then
the method of treatment should he more thorough and
radical. Mere incision of the periosteum is not sufli-
cient, but tunneling the hone near the end of the
shaft is necessary, to give exit to the products of the in¬
flamed medulla, and to relieve the tension in the juxta-
epiphysial region. With particular reference to the relative
liability of the periosteum, medulla, and growing hone to
inflammation, Mr. Tubby gave an account of some experi¬
ments, in which pure cultures of the micro-organisms placed
in contact with these structures gave rise to inllammatory
and suppurative changes, first of all near the growing line,
before the periosteum became at all affected.—In the
discussion which followed, Mr. J. Poland and Dr. F. C.
Turner referred to a different class of cases, in wliich
necrosis followed specific fevers. Here the process was
much less acute, was localised, and was probably due to
thrombi in veins.
Migratory Pneumonia. — Mr. F. R. Humphreys read
notes of two cases of Pneumonia with complications, in
which the congestive process affected one lobe after another
in both lungs. The first case died on the fifteenth day with
lung softening and heart failure; the second recovered after
a long course, including some cerebral mischief.
Itotias of ^flols,
Manual of Bacteriology. By Edgar M. Crookshank,
M.B. Third Edition. London: H. K. Lewis. 1890.—The
call for a third edition of Crookshank’.? “Manual of
Bacteriology” in less than four years after the appearance
of the second proves that this work has supplied a felt want
in bacteriological literature. In bringing out a third edition
Professor Crookshank has seized the opportunity of slightly
enlarging the scope of liis work, of correcting some errors
that appear in the old edition, and of generally bringing
it well up to date. He has added a short historical account
(based apparently on that given by LtilUer) of the germ
theory of fermentation and disease, lias taken up the
subject of special fermentations, and has described all
the recent modifications of staining and cultivation,
especially those adopted by the German school of bacterio¬
logists. The French bacteriologists and their methods
are not so fully represented, so that the impression
is encouraged that the author has received the greater
part of his technical training in the German schools.
The literature in this edition is much better arranged than
in the previous volumes, as, in addition to classifying the
works of writers under different headings, such as
“methods,” “morphology,” “immunity,” “bacteria asso¬
ciated with disease in man and animals,” &»., the works
under each heading are arranged in chronological order.
This, however, would be more useful still had the author
given an alphabetical index of authors’ names. The index
is brought up to 188G, after which time the amount of
literature is something enormous, and Professor Crookshank
has very wisely not attempted to increase the bulk of bis
hook by adding such a mass of literature. As in previous
editions, the book is well printed, and the illustrations are
numerous.
Comment on fait Paiicr les Sourds-mucts. Par L.
GOGUir.LOT, Professeur h I’lnstitution Nationalo des
Sourda-muets de Paris. Paris: G. Masson, Boulevard St.
Germain. 1889.—In this book wo find explained in full
detail the oral process of educating deaf-mutes as carried
out in the National Institution of Paris. A preface by
Dr. Ladreit de la Charrihre contains a short but instructive
V 8
Coogle
Di(. I
1108 TsbLanoht,]
NOTICES OP BOOKS.
[May 16,1801.
account of the preraleuce, causes, and socio-legal relations
of the deaf-mute condition. Historical details and general
information as to schools &c., with a chapter on the Physics
of Sound and the Physiology of the Voice, introduce the
reader to a more practical subject—the preparation of the
vocal apparatus and the senses of sight and touch for the
actual course of instruction. The total disuse of signs is
wisely insisted on. The method of teaching the accurate
use of sight and touch, and of training and observing the
breathing power as here explained, clearly illustrates the
author’s belief in the essential value of tact in a teacher.
In Part III., the means of evoking the voice, its faults,
and their remedies, are discussed at length. Part IV.
contains some of the most interesting chapters in the
whole book—namely, those which treat of the elements
of speech and the methods employed in teaching them.
This section is illustrated by a series of excellent diagrams
representing the impressions left by the tongue in the
movements of articulation upon an artificial vulcanite
palate coated with a preparation of chalk, the invention of
Messrs. Oakley-Coles and Kingsley. With the help of
these, the mechanism, faults, and linguistic variations of
speech are fully considered. We may notice as particularly
noteworthy the passages which deal with the sounds ch, j,
h, and gu. Further useful hints will be found in the last
chapter of this part, the whole of which is characterised by
practical thoroughness. Later, in Part V., the grouping of
simple sounds to form syllables is described. In this con¬
nexion we would specially notice the composite sounds
of ill and gn and the mute final e, which have been
treated with careful and scientific appreciation. The
remarks on graphic equivalents of sounds, on orthography
for deaf-mutes, on the grouping of words, punctuation,
and accentuation, are also worth reading, and a well-
written treatise, at once full in its theoretical and clear in
its practical details, is fittingly closed by a concise but
careful summary of its method. The English reader must
of course make due allowance for the peculiarities of
French pronunciation, but he cannot fail in any case to
profit much by the perusal of this little work.
The pages of the April number of the Veterinarian are
occupied by a few remarks on the “Recent Outbreak of
Equine Inlluenza,” by W. F. Barrett, M.R.C.V.S.; anumber
of reports on the “Action of Tuberculin, and its use in the
Early Diagnosis of Bovine Tuberculosis,” collected from dif¬
ferent sources; a leading article devoted to the same subject;
extracts from British and foreign journals; and reports of
meetings of the Royal Agricultural Society of England, of
the Royal College of Veterinary Surgeons, and of the
various veterinary medical societies and associations. The
most interesting reports are those of the discussions on Pro¬
fessor Walley’s paper on “ Penetrating Wounds in the Foot
of the Horse,” and on Mr. C. Stevenson’s paper on “Endo¬
carditis in the Pig,” to which Mr. Arup makes a most inter¬
esting contribution. He gives a description of the various
forms of swine fever met with in Denmark and in Germany,
and points out some of the distinctive characteristics of
the acute and chronic forms of Rothlauf and of Scimein.
seuche, mentioning the special pathological conditions and
the bacteria associated with these diseases. The May
number of the same journal, with the exception of tlie
first six pages, is also made up entirely of reports of the
Royal Agricultural Society and of the Veterinary Medical
Associations, Mr. William Littlewood gives an interesting
note that the temperature of camels in health [is appa¬
rently about ranging from 36 4° to 37-8°C. It is
stated by the editor that the Compulsory Slaughter Act,
allowing of post-mortem examination in the ease of a large
number of cattle, has revealed two very important facts:
first, that many animals euifer from pleuro-pnoumonia, even ^
when there are no indications of the presence of this disease
during life; and, second, that tubercle exists to a very
much greater extent than had previously been stispeoted.
Professor Walley’s paper on the Recent Outbreak of Equine
Influenza is one of the most interesting items in the
number. The author looks upon this disease as a periodic
epizootic, and considers that the virus is received into the
system most largely by inspiration, that rise of tempera'
ture and nerve depression are the most marked features; but
that in addition there are local manifestations of the dis¬
ease, such as conjunctival oedema, cellular oedema of the
limbs, acute dropsy of the joint capsules, and inflammatory
lesions of the respiratory organa, the feet, and the bowels; be
gives a very full account of the clinical characters, complica¬
tions, and treatment. Mr. R. Reid contributes a paper on
a similar subject. From the reports of the meeting of the
Royal College of Veterinary Surgeons it may be gathered
that some of the discussions are of a pretty lively nature,
and that veterinary surgeons, like other people, do not
always see eye to eye where questions of education and
examination are under discussion.
Journal of the Xtoyal Agricultural Society of England.
Vol. II. London: John Murray, Albemarle-street.—This
part has a far wider interest than its title might indicate.
The first article, “Jethro Tull: his Life, Times, and
Teaching,” by Earl Cathcart, tliough of special interest to
the scientific farmer, also has much to commend it to those
whose tasks are biographical. “ Indian Agriculture in its
Physical Aspects,” by Professor Voelcker, is the result of
careful observation and inquiry in the regions of which he
treats. The paper on “ Acidityin Milk,”byDr. F. T. Bond,
is apparently the outcome of the offer of a prize by the
Society for the ready determination of the degree of acidity
in milk which plays such an important part in the processes
concerned in cheese-making. Dr. Bond uses a neutraliser
of caustic potash equal to one-eighth the strength of the
normal oxalic solution. As an indicator he uses phenol
phthallein; he finds that the results obtained are suffi¬
ciently accurate. By using, in addition to this, alazarin
he is able to indicate not only the total acidity, but
also the proportion of volatile acid, and, by subtract¬
ing one from the other, to determine the fixed acidity
caused by lactic acid and the acid phosphates. Professor
Crookshank contributes a well illustrated paper on the
tubercle bacillus, its chemical products, and the action of
tuberculin. Other articles on “Farm and Poultry,” on
“Technical Agriculture,” on “Modern Bee-keeping,” and
a very interesting article on “Agriculture and the House of
Russell ” by the editor, make up a most readable general
part of the volume. The official reports to the Society and
meetings of the monthly council for February form the
remainder of this part.
Bristol General Hospital,—T he special appeal
made by Mr. Proctor on behalf of this institution is
receiving a very satisfactory response. The amount already
promised has reached between £19,000 and £20,000. This
sum will enable the committee to relieve the hospital of
debt, although it will be inadequate to free the future work
of the institution from embarrassment.
German Hospital, Dalston.—B aron von Schroder
(the treasurer) presided at the forty.sixth anniversary
dinner of this institution, held on Monday at the Hotel
Metropole. On proposing the toast, “Prosperity to the
German Hospital,” the chairman earnestly appealed to
the sympathy and liberality of the meeting, stating that
the charity possessed no endowment. The past year’s ex¬
penditure had exceeded the income, which was due to a
large increase in the number of patients. Nearly £10,000
had been expended, and the receipts amounted to about
£9000, Subscriptions were announced to upwards of £3500,
including £200 from the Emperor of Germany, £.50 from the
Emperor of Austria, and^lOO froqj the chairman,
Dii zr^ribyCjOOglC
LANOE'f,]
fHE KOYAL COLLEGE OF SUliGEONS OP ENGLAND.
CMayIS, 1891. 1107
THE LANCET.
LONDON: SATURDAY, MAY 16, 1891,
Our forecast of the general meeting of the Fellows and
Members at the Royal College of Surgeons of England on
Monday lasb was fully verified. The extraordinary course
pursued by the Council in accepting the doomed scheme for
the reconstitution of the University of London in the name
of the Pellows and Members, and summoning them to
consider it after instead of before its final acceptance,
thinned the attendance of the Fellows and Members. By
some this action was regarded, erroneously, as we think,
as a studied insult; by others as a mischievous farce;
whilst a large number even of those who were actually
present were at a loss to understand the exact
object of the meeting. The President’s opening address
made it perfectly clear that it was in accordance
with a resolution passed at a general meeting some years
ago that the Council bad been making efforts to facilitate
the acg^uisition of medical degrees by London medical
students, and in this respect the President and Council
were fully entitled to the recognition which was accorded
to them by Mr. Nelson Hardy, whose blessing was not
less unexpected than that of the son of Beor. The
address did not, however, offer any explanation or throw
any light on the peculiar period selected for the general
meeting, nor even explain clearly the precise end which
the general meeting would serve; and, overpowered by the
sense of its aimless character. Dr. Danford Thomas felt
compelled to appeal to the President to explain the
purpose of the assemblage and to thank him in advance
for the expected information. Throughout the pro¬
ceedings the President and the Council seemed to feel
themselves to be in a false position. The resolution
which stood second on the agenda paper, and which
was moved by Mr. Holmes, to the effect that it was
not desirable under present circumstances to increase the
power and influence of the Council as was proposed
under the scheme, was evidently distasteful to the Pre¬
sident and Council, who are not only the actual
possessors of power, but regard it as very improper
for anyone to say or move that it is desirable that
this autocracy should come to an end by the amend¬
ment of the constitution of the College. No motion could
have been more pertinent to the object of the meeting as
announced by the President himself—viz., to consider the
relations of the College to the scheme—or more gennano to
the discussion of that scheme. The President, however, for
a considerable time appeared to be dubious as to whether it
was in order, although he ultimately agreed that it should be
discussed if the meeting wished it. The usual result followed.
The resolution was adopted by an overwhelming majority,
and none of its few hesitating opponents had the courage
to explain the reasons which led them to hold up their
hands against it. The skilful fencing of Mr, Holmes with
the President was not the least amusing part of the after¬
noon’s proceedings.
Through some private communications not under the
cognisance of the officials connected with the Association of
Fellows, the order of the resolutions on the agenda paper had
been altered, and Mr. Lawson Tait opened the discussion
by moving a resolution condemnatory of the exclusion of
the Apothecaries’ Society from the metropolitan conjoint
scheme for granting medical qualifications. The majority
in this instance was very narrow, the meeting being almost
equally divided on a question which is not thoroughly
understood. Some of those who have approved of the
exclusion of the Apothecaries’ Society, and even one of the
speakers on Monday in favour of this course, have been
under the mistaken belief that the Society would continue
to grant its separate licence even if it were a participator
in the Conjoint Examinations. Nothing can be more
erroneous than this. The object of including the Apothe¬
caries’ Society is to extinguish it as a separate medical
authority, and there is no other method by which
this virtual extinction can be accomplished. The Society
would probably be satisfied with a very humble rOle, and
the evils which result from the present competition and
the existence of two qualifying licensing bodies in London
would be removed. The Apothecaries’ Society was called
into existence as a qualifying medical authority by the
Colleges of Physicians and Surgeons in 1815; it was
accepted as a participator in the conjoint scheme of 1870-
1876, and obtained an Act of Parliament for the pur¬
pose of taking part in it. It is specially protected by
the Act of 1886 ; and how it can be removed from its
independent position, except by friendly absorption, it is
beyond our power to conceive. According to its means
and lights the Society has done its work well, and the last
body in the world to deny its just claims and to treat it with
disdain should be the Royal College of Physicians, which
wilfully handed over the general practitioner to the Society
of Apothecaries in 1815, abandoned its great position as the
head of the medical profession, and devoted all its energies
to the narrow end of jealously conserving the interests
of a smalt body of consulting physicians. Its late repent¬
ance and entrance on a better and higher course of exist¬
ence should render it all the more tolerant and tender
towards a body which has done its best to promote the
general and professional education of medical students, and
whose examinations were conscientious and creditable when
those of other licensing bodies were extremely lax and
defective.
Fortunately, the narrow margin by which Mr. LawsoN
Tait’.s resolution was carried did not affect the voting on
the two other resolutions, which were mildly condemnatoiy
of the proceedings and policy of the Council. Indeed, it
could only have been by an entire abandonment of common
sense, and a spirit of blind acquiescence in the course pur¬
sued by the majority of the Council, that the resolution
proposed by Mr. Rivinuton and seconded by Dr. Danford
Thomas—“T hat this meeting regrets that the Council
of the College has nob seen fit to place before the
Fellows and Members the scheme for the reconstitu¬
tion of the London University before formally accepting
this scheme in the name of the College ’’—could have
Digitized by
1108 tHE LA:lTCBt,3
tH£ Decent DisctJssioN on TtBERcUUN.
[kIay 14, iEi4i.
been defeated. This resolution and that proposed by
Mr. Holmes were drafted by the Committee of the Fellows’
Association in the knowledge that all discussion on the
details of a scheme which had been accepted by the Council
in the name of the Corporation, before being submitted to
the Corporation for approval, would be entirely misplaced.
The assertion of just, right, and reasonable principles of
action and policy, and the continued iteration and reitera¬
tion of those principles, is the only course by which the
reform of the constitution of the College can be secured.
The Council as a body must feel sufhciently uncomfortable
when they find that in general meeting after general meet¬
ing, whether the number present be large or small, their
policy is condemned by overwhelming majorities, and
reasonable opinions, calmly and temperately expressed, as
they were at the general meeting on Monday, have weight
and gain adherents even in the ranks of the Council itself.
The main danger to the cause of progress is that those who
have advocated and those who have rallied round the advo¬
cates of constitutional development may grow weary on the
march when the goal is not yet in sight. It is a dreary and
desert region which has to be traversed, and one after another,
some by the hand of death, some by sheer exhaustion, drop
out of the ranks. Even the leaders may sometimes be dis¬
couraged, for in a profession like that of medicine, where
there are daily and urgent claims of duty and occupation
and practice to be satisfied, it is not possible always to bring
all into the field who are in sympathy with the movement.
But we ate greatly mistaken if those who have been in the
van will he discouraged or fail when success lies within
measurable reach, and satisfactory indications exist that
there are younger men who will come to the front and
take the lead when the older men have ceased from their
labours.
ALTHOuaii the discussion on Mr. WaTson Chkvne’s
paper at the special meeting of the Medical and Chirur-
gical Society on the 7th inst. was extended beyond the usual
time, we cannot say that the speakers added materially to
our knowledge of this subject or threw much light upon the
questions which gather round the proper estimation of the
value of Koch’s tuberculin. Mr. Ckeyne, like all other
observers, is impressed with the desirability of securing the
local benefits of the remedy with a minimum of constitu¬
tional disturbance, and he has sought for a means of
obtaining this result. He believes that it is possible to
procure general tolerance of the remedy long before local
tolerance occurs, and he repeats the inoculations as rapidly
as safety will allow, with a view of arriving at a condition
ia which further injections of tuberculin cause no general
disturbance of the system, and yet produce a local re¬
action. He lays stress upon the frequency of the inocula¬
tion rather than upon its strength, and also upon the long
continuance of the remedy. Mr. Cueyne states that he
has not found any clilficulty in establishing this partial
tolerance of tuberculin, but Dr. C. T. Williams spoke
of bis inability to obtain it in patients sull'ering from
phthisis, and other observers have expressed their doubts
on this point. It may be that the septic complications in
so many cases of phthisis have interfered with the action
of the remedy. At any rate, Mr. Cheyne has established
a claim to have his method well and carefully tried,
especially by surgeons, and in cases where there is no septic
complication. As to the efiects of, or need for, a long con¬
tinuance of the use of tuberculin, it is of course much too
soon to speak, and only patient observation can clear up
that matter. If it is found to be necessary to repeat the
inoculations for many months, or even a year or two, after
apparent cure of the local tubercular disease, this fact will
afibrd an argument against the use of the drug. The draw¬
backs of such a remedy are too apparent to need comment
here and now.
In one way it ia a hopeful fact that it is a debateable ques¬
tion which is thebestmodeof administering the new remedy,
for it is possible we have not yet found the way to obtain
the best results from it. It is clear that the method recom¬
mended at first by Kocii has not satisfied the expectations
his statements led us to entertain, and it may be that Mr.
Chey^Ne’s mode of using tuberculin, or even some further
modification still, may ensure its good effects and minimise
its ill results. This, however, is a matter to be worked
out. On the supposed and alleged dangers of tuberculin
Mr. CiiEYNB had much to say. His own cases furnish no
evidence in support of the view that this treatment in¬
volves a risk of the general dissemination of tubercular
disease; and he thinks this risk is a very small one,
even if it exists at all, and that it depends upon its
causing the disintegration of a tubercular deposit involv¬
ing a vessel wall. He holds that there is no evidence
to show that the tubercle bacilli multiply more rapidly
under Koch’s treatment. On the other hand, he believes
that the changes attending the local reaction may favour
the local dissemination of tubercle, and this in more than
one way. Thus a tubercular deposit may be opened into
the synovial cavity, or the tubercle bacilli may float away
from a primary centre in the abundant exudation of serum
that attends the local inflammation set up by the remedy.
As an example of this result a case of tubercular laryngitis
was cited, in which, during the treatment, fresh ulceration on
the epiglottis and also near the original ulcer appeared. It is
in cases of phthisis, however, that this risk of local dissemi¬
nation of the disease is greatest. But I^r. Cheyne’h best
point in reference to the dangers of the Koch treatment
was that in nearly all cases it is contraindicated by the
complication of sepsis along with tubercle. He believes
that tuberculin increases the symptoms produced by
sepsis, and that the local reaction it excites must be
regarded as attended with the effusion of a large
amount of serum, which acts as pabulum for the septic
organisms, and so promotes their life, while this inflam¬
matory change weakens the resisting power of the tissues,
and so favours the penetration of the septic organisms. It
is clear that if septic cases of tubercle are to bo excluded as
unfit for this treatment, it will limit very materially its
field of usefulness, and particularly in those forms of disease
which usually come under the notice of the physician, such
as pulmonary and renal tubercle. The actual results
obtained can only be appreciated by those who have care¬
fully watched the cases; but thus far in his experiments
Mr. CiiKYNB has found that the treatment usually produces
some local improvement, perhaps from the arrest of the
sun-ounding inllammation. The tubercular disease may
Dinitized by
Google
I'HE NATUKE of influenza.
f fife LANofeiP.j
tMAYi6.l891. 1109
- - .
then remain at a standstill or undergo a slight and gradual
improvement.
Coming now to the results obtained in the treatment of
particular forms of tubercular disease, Mr. Chbyne thinks
it very rarely cures in lupus, and that its action is more
beneficial upon isolated nodules than upon wider infiltrations.
As a sequel to a careful scraping operation tuberculin will
probably be of some use ; but if relied upon as a sole treat¬
ment for lupus disappointment will ensue, either because it
altogether fails to produce a true local recovery, or from the
liability of the disease to recur in the same parts. On
tubercular glands but slight effects have been observed.
The diseased glands themselves do not appear to undergo
any decided changes, but the periadenitis clears up, and
this greatly facilitates any subsequent operation for removal
of the glands. In diseases of bones and joints a probability
of a cure from tuberculin alone, even if used quite early
in the disease, is but small; and later on, if sepsis compli¬
cates the case, tuberculin should certainly not be employed.
After an operation has been performed, however, it may be
of use, especially to obtain the rapid and sound healing of a
wound or sinus. In such a case the treatment should be
employed for a long time.
It is only fair to point out that Mr. Cheyne’s paper
must be regarded only as an interim report on his cases.
Sufficient time has not yet elapsed to allow him to speak
confidently of the later results of the treatment; and,
again, his total number of cases is too small to draw final
conclusion from. Allowing for this, however, we are com¬
pelled to admit that experience has by no means verihed
the hopes which this remedy at first held out to the profes¬
sion. The most we can now see our way to say of tuber¬
culin is that it may prove a useful adjunct to the surgical
treatment of tubercle in aseptic cases. How to best employ
it, and how long the treatment is to be continued, are
questions the answers to which are still in the womb of
the future.
The records of epidemics of influenza reach back to com¬
paratively remote periods. Professor Hirsch, in his in¬
valuable work on Historical and Geographical I’athology,
lias given us a tabular statement of such epidemics ex¬
tending over seven hundred years. With eveiy allowance
for incompleteness and inaccuracy of observation, it may
still be allowed that so remarkable an affection, which
exhibits the epidemic character to the fullest extent, has
varied but little during the progress of the centuries, and
that directly or indirectly it has contributed very largely
to shorten the average duration of human life. In spite
of its having been so often observed, it is unques¬
tionable tliat the nature and origin of the disease still
remain veiled in obscurity, whilst now, as of yore, the
profession is still quite undecided as to the mode of its
diffusion over the world. The fact is that its occurrence
seems to have been independent of known meteorological
and climatic conditions; for when all the authentic records
are compared, it is found to have arisen under the most
varied circumstances in these respects. As yot it has not
been possible to formulate any “law” of its occurrence;
and although to a certain extent this may be true of
many other acute febrile disorders, the origin of which
may hypothetically be relegated to some few common
sources, it is impossible to explain on any evolutionary
hypothesis the apparently capricious character of the
morbid influence that has such striking features, both
as to its mode of spread and as to the symptoms it pro¬
duces and the morbid associations it possesses. Of the
latter we have during the past two years had ample
experience, and the clinical history of influenza has
become familiar to every practitioner. In what follows
we shall attempt to see whether any light as to its
nature can be gained from the study of this aspect
as distinct from that of its epidemiology.
The present outbreak may be regarded rather as a fresh
manifestation of the pandemic of 1889-90 than as a totally
new invasion; and it will be well to guard against the
fallacies that beset the theory of a purely contagious mode
of propagation in the case of a disease which seems to
be in some unexplained manner linked with atmospheric
influences. It is the old question of miasm versus
contagion, and one rendered all the more difficult of
solution by the complex conditions of modem civilisation
and the vastly increased facilities for human intercourse.
Regarding, however, its clinical manifestations and
morbid associations, we have in influenza, in the first
place, an acute febrile disorder which differs from other
known acute specifics in the brevity (or, perhaps, even
absence) of a stage of incubation, and in not affording pro¬
tection from subsequent attacks, Tlie duration of the
fever is, in uncomplicated cases, limited to within three or
four days; hut there is a great tendency to relapse, and so
marked a tendency to complications that it is not easy to
separate these from the essential manifestations. Yet
when we consider the multifarious nature of these compli¬
cations, it seems more scientific to detach them from the
elemental disturbance as not strictly belonging to it, but
being remarkably prone to develop in its course.
The vast majority of these manifestations are of an
inflammatory nature. Predominant among them is respi¬
ratory catarrh and pneumonia, to the prevalence of
which during epidemics of influenza so much of the
heightened mortality is due. We shall allude presently
more especially to its association with pneumonia, but we
would point out that the term “ epidemic catarrh ” is not
strictly conterminous with “influenza,” and that ib will
conduce to clearness if we banish the notion that catarrh is
an essential feature of the disease. The confusion has, wo
fear, become too deeply rooted to be easily dispelled, for ib
has been fostered by the popular phraseology adopted in
reference to any severe form of coryza.
The catarrhal manifestations are not limited to tho
respiratory tract; they may appear from the outset as
markedly in connexion with the gastro-intestinal mucous
membrane, and such disorder may concur witli the former
or be independent of it. On the other hand, every practi¬
tioner must have seen cases in which neither of these kinds
of catarrhal inflammation has occurred. Indeed, if we were
to seek for one cUoLcal feature which more than any other
seems to form an essential part of influenza, we should find iC
in the nervous system. The characteristic pains—out of pro¬
portion to the pyrexial state—experienced in various parts of
the body, the frequently marked nervous depression and
Digitized by
Google
L'ilAY 16,189J.
lilO Mb LAlJCat,3 THE RfiCONSTlTUTIOJ^ OF TIlE UNiVJlESiTV OF LONDON.
prostration, and the powerful impress so often left by the
disease upon the nervous system, as illustrated in a variety
of eonditions, seem to show that the poison acts with
especial proclivity thereon. And through the nervous
system the organs of circulation may be seriously implicated.
The late Dr. Strange of Worcester, in the graphic account
of his first attack of angina pectoris (the affection which
ended his life a few months later), which he gave
at the Medical section of the Birmingham meeting
last year, showed clearly that in him the influenza
was the fom et origo of his fatal malady; and his
Inference that possibly a stronger dose of the poison might
carry off multitudes of victims, and reproduce the features
of the Black Death and other fatal epidemics of the Middle
Ages, may have had some truth in it. We are persuaded
that the fatality of influenza amon^t the feeble and the
aged is not solely to be ascribed to bronchitis and pneu¬
monia, but quite as often to cardiac asthenia, to which the
pulmonary congestion may sometimes itself be due. Finally,
of those who recover from the attack itself, several are
more or less affected in one way or another. For
months they may experience a lassitude and lack
of energy previously foreign to them, or in other cases
the influenza may have formed the initial factor in
disturbing the balance of health, and its victims become
invalided and prone to ailments on the slightest provoca¬
tion. As to the numberless conditions which are more
directly related to an attack of influenza, we may simply
note here the liability to inflammations of nerve centres
and nerves, or of more obscure affections, involving
perhaps the sensory organs; the liability to inflamma¬
tions of the ear and eye, and the rarer occurrence of
nephritis. Indeed, there are few organs of the body which
may not become the seat of inflammatory lesions, either
as direct complications or even indirect sequelm, a
singular exception perhaps being the endocardium and
pericardium—singular, that is, because of the undoubted
probability of the blood being the medium for the diffasion
of the poison.
We consider, then, that infliienxa depends upon the
entrance into the body of a specific poison, and that its place
is with the acute specific disorders. But when we contrast
its manifestations with those of others of this group we
are struck with their greater variety and extent. Its rela¬
tionship to croupous pneumonia (for although broncho¬
pneumonia is quite as frequent, there is no doubt that
croupous pneumonia is a very common concomitant), and
the growing evidence in support of the latter being
of the nature of a specific fever, invite a comparison
between the two affections. In acuteness of onset, in
brevity of duration, and in the liability to inflammatory
complications, the two alfectioDS fairly coincide, but with a
far greater tendency to such complications, on tbe part of
infiuenza than of pneumonia. Pneumonia affords no pro¬
tection from a second attack; neither does influenza.
Pneumonia, although never pandemic, is certainly more
frequently epidemic than is usually admitted. And tbe
commingling of the two affections during the prevalence
of influenza epidemics is a fact which admits of but
little explanation except in some hitherto unknown
dependence on similar conditions We lay no stress on tbe
results of bacteriological inquiry, which are too discordant
to be of much avail in the argument, and we merely hazard
the suggestion that there may be more in common between
these two diseases than is ordinarily suspected.
The meeting of the members of Convocation of the
University of London this week was the largest in the
history of the University, and the majority which re¬
jected the scheme placed before tbe House by the
Senate was a decisive one. Members to the number
of 197 supported the motion " that the scheme be ap¬
proved,” whilst 461 voted against it. Lord Herschbll’s
speech in its favour was purely apologetic, and he must
have felt bow little could he urged for the cumbrous scheme
when he pressed its acceptance on the graduates, not on
account of tbe principles embodied therein, if there were
any, hut seeing that it must have some good in it because
it satisfied nobody. The Senate has not fully grasped the
significance of the fact that the University of London has
been allowed by its founders and supporters to become a
free and open examining board for the empire; indeed, it
has done its work in this direction most thoroughly and
admirably, but it is too late now to endeavour to engraft
on it teaching [institutions. Such a course would hinder
their development and injure its own peculiar functions.
Centralisation of University teaching in arts, science, and
medicine, even at Burlington-gardens, is out of joint with
the times, and local centres of education, if not too
numerous, must have their chance. “ A fair field and no
favour ” is a wise policy in higher education as in other
matters. The Lord President of the Council must be con¬
sulted on the formation of a new University, or on any
serious change in an old one, and we need not yet fear
such a multiplication of degree-giving universities as to
unduly lower the prestige of degrees. Sir Kicuard
Quain’s arguments about the matriculation examination
principally told against the course he was endeavouring
to persilade the House to agree to, and Dr. Pye-Smith’s
contention that the scheme would bring into harmonious
working all the medical schools, and that it would make
the medical degrees more accessible without lowering the
standard, was not seriously received by his audience. It
is somewhat surprising that the supporters of the scheme
did not make a better case for it, and Mr. Hutton’s
witty description, “that it had an enormous number of
ganglia and no cerebrum,” so happily hit ol! its complex
arrangements in standing committees and methods of
graduation that its rejection was at once assured.
Two stages have now been passed. The report of
the Iloyal Commission marks the end of the first
stage. It asserted the necessity of the formation of a
University intended to have, as to teaching, a proper
metropolitan character, and stated that the existing
University is not a London University in any practical
sense. It also put on record the conclusions of the
Koyal Commissioners that the so-called “ London medical
grievance” not only existed, but that it demanded a remedy.
“A man who can call himself a Doctor of Medicine
possesses certain practical advantages over a man, how¬
ever distinguished, who cannot.” “The great majority of
Digitized by
Google
THB LjWOET,]
THE DISPOSAL OF THE DEAD.
[May 16,1801. 1111
London medical students, if they take a degree at all, take
it elsewhere than in London.It is injurious not to the
men themselves only, hut to the public.” A reasonable
time for the University of London to adapt itself to these
conditions has been granted, and after two years (for
the report is dated April 29bh, 1889) the authorities have
signally failed to reach this end. We look upon the vote of
Tuesday as decisive, for although Sir James Paget said on
Presentation day that the voting lists would be considered by
the Senate, and it is now rumoured that a new scheme on
the lines suggested by the Koyal Commissioners is con¬
templated, we cannot believe that any further attempt
will be made to transform the character of so important
an institution. We have always held that the Senate
was trying to perform an impossible task by under¬
taking the duties and functions of a Teaching University
as well as its own special work, in which belief we had
the support of the practical educationists on the Eoyal
Commission; now it is time that all other bodies in¬
terested should put forth their proposals, and a path be
cleared for them. This marks the end of the second
stage. In any real Teaching University for the metro¬
polis, we must have a degree for London medical
students on fair and equitable terms, and we trust that
this difficulty will be met fairly, and not in the half¬
hearted manner which had so much to do witii the
failure of the Senate’s scheme.
^tnurfattons.
“Ne quid nimia.”
THE ASSOCIATION OF FELLOWS OF THE ROYAL
COLLEGE OF SURGEONS OF ENGLAND.
The first annual dinner of the Association of Fellows of
the Eoyal College of Surgeons was held on Monday at the
Criterion, Piccadilly-circus. Mr. Pollock, the President,
occupied the chair. After the loyal toasts, the Chairman pro¬
posed, “ Success to the Association of Fellows,” coupling the
toast with the name of Mr. Holmes, as representative of
the Metropolitan Fellows, and with that of Mr. Lawson Tait
as representative of the provincial Fellows. Mr. Holmes
believed that the Association was gradually gaining
ground, and would succeed in its objects if it followed the
example of Abraham Lincoln, and kept pegging away; and
Mr. Tait urged the importance of the Association formu¬
lating a definite policy, and using every effort to support
those candidates for seats on the Council whose views were
in harmony with their own. Mr. Pollock’s health was
proposed by Mr. Macnamara in highly eulogistic terms,
and was very warmly received. The services of Mr. Dunn,
who has recently succeeded Mr. H. W. Alllngham as
secretary, were duly acknowledged. The committee of
the Association will meet shortly to take into consideration
the course of action that should be adopted in view of the
approaching election at the College.
THE DISPOSAL OF THE DEAD.
At the instigation of Mr.'William Holder, M.E.C.S,, the
Burials Committee of the Hull Corporation has been induced
to petition the President of the Local Government Board to
bring in a Bill to allow corporations, as buiial authorities,
to provide for the erection of crematoria for tlio better
sanitary disposal of the bodies of such persons as may have '
expressed a desire to be so resolved to their ultimate
elements. Corporations under the present Burials Act are
unable thus to use their funds. Although, as a method of
disposing of the dead, we give the preference over con¬
sumption by fire to the “ earth-to-earth” system, as being
apparently more in accord with the indications of natnre,
yet we cannot hut congratulate Mr. Holder on the success
of his appeal, and the corporation on its public-spirited
action. Far better cremation than the senseless and
injurious mode heretofore adopted of confining bodies
within lead and oak, and thus retarding as long as possible
a process which the demands of both health and expediency
require to he consummated without let or hindrance.
THE INFLUENZA EPIDEMIC.
Whether in consequence of the exceptionally warm
weather or for some other reason, it is noteworthy that the
spread of the influenza in the metropolis this year has been
by no means so rapid or extensive as in the early weeks of
January, 1890. This is illustrated by the returns furnished
from the various general hospitals, which are given below.
Nevertheless, the epidemic is sufficiently marked to attract
considerable attention, and it is certainly a remarkable fact
that BO many members of the Legislature should have been
attacked, including Mr. Gladstone. His Eoyal Highness
the Prince of Wales was prevented attending the drawing¬
room and lev6e this week owing to a mild attack of the
disease. Lord George Hamilton, Sir John Lubbock, Mr.
T. W. Eussell, Sir F. Mappin, Dr. Tanner, and Mr. Gully
are among the members of the House of Commons who
have also been suffering from it. The large proportion of
members of the House who have been thus prevented from
performing their duties has given rise to doubts as to the
condition of the House itself, and in reply to a question put
to him on Tuesday Mr. Plunket said that it was intended
to fumigate the building with sulphur. The deaths
attributable to influenza this week comprise those of
Mr. W. M. Barbour, M.P., Mr. H. A. Brassey, and
Mr. W. G. T. Preston, high sheriff for Lancashire.
The Kegistrar-General’s mortality returns for the week
ending May 9th show an increase of 433 deaths in London
above the average number in the corresponding week of the
last ten years. The deaths primarily attributed to in¬
fluenza, which had been 10 and 37 in the preceding two
weeks, rose to 148, or 21 in excess of the highest weekly
number during the 1890 outbreak. The deaths from
diseases of the respiratory organs were r)84, or 240 in excess
of the average ; of them 230 were attributed to pneumonia
and 302 to bronchitis. The death-rate for the metropolis
during last week amounted to 24'0 per 1000, and the follow¬
ing very exceptional rates in certain towns may be noted:—
Weekb ending
Braclfoi'cl ►.
April 2f>tli.
May 2nd.
May Ofch.
. 8B-8
lludilei'sfleld
Leeds .. ..
Manchester ..
Oklhani .. ►.
Piosbon ,. ..
Slioftield
. 37 •?
.. .. 2'’9 ..
. 37-3
... 70'6 .
. 69-3
Sheflield heads the list, bub the epidemic is now subsiding
there, although the disease continues to spread with much
virulence in other parts of Yorkshire, especially in the
vicinity of Leeds, Bradford, and Skipton. In Chester¬
field it has been very marked, and as severe in its
effects as in the neighbouring town of Sheffield, the
death-rate for the past fortnight being 63 per 1000.
In Liverpool and other towns in Lancashire the cases are
still very numerous, whilst in North Wales, and especially
in Carnarvonshire, it is extremely prevalent. The type of
the disease in the midlands an eastern counties does nob
Digitized by
Google
1113 ThbLakcbt,]
OXYUEN IN SUSPENDED ANIMATION.
[May 16,1801.
seem to be so severe as that in Yorkshire, and the same
seems probably true of London itself. It is to be remem*
bered, however, that fatalities are largely favoured by
surrounding insanitary conditions, and by eximsure or
exhiustioD.
The number of patients suffering from influenza who
have been treated at the hospitals in London daring the
past week has steadily increased. At Charing-cross Hos¬
pital 120 patients were treated, at Westminster Hospital
118, at University College Hospital 100, at the London
Hospital 864, at Guy’s Hospital 90, at King’s College Hos
pital 92, at Middlesex Hospital 180, at St. George’s Hospital
24, at St. Thomas’s Hospital 227, whilst at St. Bartholo¬
mew’s Hospital the number has not exceeded 20 daily.
OXYGEN IN SUSPENDED ANIMATION.
Our contemporary Nimteenih Centiii'y has published,
from the pen of Lleutenaut-Colonel Elsdale, B.E,, a paper
on the Application of Oxygen Gas as a Remedy in a case
of Suspended Animation induced by the Inhalation of
Coal Gas. In the year 1884 it was reported to Colonel
Elsdale at Chatham that a sapper engaged under his com¬
mand, in emptying a war balloon inflated with coal gas, had
been overpowered by the gas. The Colonel ran to the spot,
and found that the man was lying under many folds of the
half empty balloon quite insensible, having “ been breathing
an atmosphere of coal gas for an unknown time” before his
position was discovered. The man was rescued from his
position, and, the day being warm, “ was placed where he
got full benefit of a fresh breeze.” “ The man,” says the
Colonel, “was to all appearance dead.” There was “no
action of the heart that could be felt and no per¬
ceptible breathing.” In this emergency Colonel Elsdale
sent for a tube of compressed oxygen, placed the nozzle
of the valve of the tube in the sapper’s mouth, and
gently turned on the valve “ as little as he could manage.”
“That little, however, was quite enough to inlUte
every comer of the patient's lungs with oxygen in
the briefest possible time.” The effect was to cause the
patient instantly to revive and clutch the nozzle of the
valve convulsively with his teeth. Some difficulty now
occurred iu getting the man’s mouth open and drawing
away the tube, and, as the gas was still rushing out, the
lunge would have given way from the pressure had it nob
been for the escape provided by the open corners of bis
mouth. To a layman a phenomenon of rallying from deep
insensibility like that described is naturally strange, and,
as the sapper made a good recovery, Colonel Elsdale
may well be pardoned for the enthusiasm he displays
in the record of his achievement. Unfortunately, layman
like, he goes into too warm an ecstasy in his comments on
the medical side of the question—assuming, in fact, that he
has observed something which we of medicine have over¬
looked. In sober truth^ he was observing one of those
curious phenomena of.reanimatipn from deep anaesthesia
which are being seen, perhaps daily, in the adminis-,
tration of 'anesthetics, if' all the experience of such ad¬
ministration. , o.ver the. wide wor}.cl .QouXd .'be day by day
recorded. The sapper was anesthetised-by a comparatively
insoluble and light gaseous compound, and the day was
warm. He was not dead; his heart, although it could
not be felt, was still beating at low tension — the
tension of hibernation, catalepsy, syncope. There was
still some circulation through the pulmonic circuit; the
vitality of the muscles, which is always well sustained
under coal-gas anaesthesia, was present. The conditions
for the escape of the gas contained in the lungs were
good so soon as the liberation of the body and its exposure
to the warm open air was secured ; and the very rapidity
with which the recovery took place is proof that the suspen¬
sion of the vitality altogether was very slight. The oxygen
gas emptied the lungs of the coal gas, and, taking the place
of the coal gas, the recovery was expedited; but it would in
all possibility have followed spontaneously, and it would
certainly have followed gentle efforts of artificial respira¬
tion. In the lower warm-blooded animals we have seen
many tim^s spontaneous recovery from apparent death
after inhalation of coal gas, and by artificial respiration
with warm air we have resuscitated from the narcotism of
this gas eleven minutes after all the indications of life
bad ceased. To our practical minds, then, the pheno¬
mena recorded by Colonel Elsdale are not remarkable;
neither are the phenomena of recovery, the straggling
and the quick return to power, to which he refers. The
fact on which be Ungers, that the man was able to walk
calmly to his barracks after he bad regained conscious¬
ness, is precisely what would be expected, and is no more
wonderful than the spectacle of a man walking out of the
dentist's operating chair after a deep insensibility attended
by convulsive struggles, induced by nitrous oxide gas. At
the same time there are one or two hints afforded by the
narrative which should not be thrown away. The livid
appearance of the sapper suggests that he was suffering
partly from suffocation as well as from coal gas, since cool
gas, owing to the carbonic oxide which it contains, causes
redness of the tissues and of the vessels of the skin rather
than lividity; bub the suggestion should nob be lost for
repeating some of the old and now almost forgotten experi¬
ments with the gases which make up coal gas in order to
determine, more conclusively than has yet been determined,
their anjesthetic value. Another question is revived—
namely, whether the violent administration of oxygen or air
into the lung in suspended animation is good or bad
practice. In the case named, as the man’s nostrils
and mouth were open, there was no undue pressure
on the pulmonary surface, and his lungs were rather flooded
than compressed with oxygen. Bub if they had been com¬
pressed, what would have been the result? We know by
experiment. We know that the lung tissue would have
given way under the pressure, and that universal emphysema
would have been a cause of inevitable death. While, there¬
fore, we entirely coincide with the advice that it is useful
bo extend the practice which has for some time past been
instituted, of keeping pure condensed oxygen in hospitals,
ready for immediate use, we could not commend the
practice of using the gas under pressure for purposes of
reaniraation until all the tests necessary for such an appli¬
cation have been reduced to rule and order. Even then we
doubt if such remarkable results of resuscitation would
ensue as have already been obtained by the action of
gentle, efficient, and long-continued artificial respiration.
THE EXCLUSION OF WOMEN FROM COURT
DURING TRIALS FOR CRIMINAL ASSAULTS.
Mr. Justice Wright, the newly appointed judge, took
a course during the recent assizes in Liverpool which has
occasioned some comment. As junior judge, ho sat in the
Nisi Prius Court, bub during a break in the civil business
be relieved Justice Grantham, who presided in the Crown
Court, by trying soma prisoners charged with criminal
assaults on females. In accordance with the usual custom,
women and boys were excluded from the court by the
police officials stationed at the door, and when tiiis came
to the knowledge of the judge he rebuked the officers,
severely, and nob only ordered the doors to be opened for
females, but more than hinted that they might gather in¬
structive information from the trials. He approved of the
exclusion of boys. Bub on the following day Mr. Justice
Grantham, dealing with precisely similar cases, ordered all
females to leave the Court. The decision of the senior
judge is certainly more in keeping with tht^t of mostleftrped
DiG::'zed 1- Coogk
The Lancet,]
ETHERISATION IIS CROUP.
[May 18,1891. 1113
;iadgeei, nor is this exclusion of females limited to the cases
in question. When the brothers Wainwright were tried at
the Central Criminal Court for the murder of Harriet Lane,
the late Lord Chief Justice Cockburn plainly intimated
that he should expect females to retire when the medical
witnesses were called, and when, in spite of this warning,
several females remained, the High Sheriff went up to them
and peisuaded them to retire. In a more recent case,
Icnown as the Ince murder, where the evidence was of a
peculiarly horrifying character, involving sexual details of
a most disgusting character, all females—and it is needless
to add children—were rigidly excluded, with the perfect
approval of thepresiding judge, the late Baron Huddleston.
Of the propriety of such exclusion there can be no question,
the only modification which perhaps might be justified being
that eachfemale witness should be accompanied by one female
relative or friend, so as to be spared the trial of being the only
female present. It is extremely unpleasant for medical
witnesses to have to give evidence in such cases before a
mixed audience of members of both sexes, and we must
•confess our surprise that Justice Wright should have inau¬
gurated his accession to the judicial bench by giving so
•extraordinary a direction. It must be remembered that
the proceedings in the inferior courts are modelled upon
'those in the superior, and it is well known that a magistrate
•can, and not unfrequently does, hear cases in his private
•room. Moreover, there are other cases tried at most assizes
which can only bo hinted at even in a medical paper, where
'it would simply be an outrage to admit women. Indeed it
is to be lamented that they cannot bo heard in private. It
is not likely that Justice Wright’s example will be followed
by other judges ; the rule, even if an unwritten one, is too
wholesome to be abrogated. And there are many other cases
tried where ladies are permitted to be present, and in which
-fustiee Maule’s scathing rebuke might be fittingly applied,
All respectable females have left the court long ago.”
ETHERISATION IN CROUP.
Dr. F. Bktz contributes an article to the current issue
■of Mcmorahilicn, which, though founded on only one case
where etlieiisation was tried as a treatment for croup,
is yet of suHicient interest to merit notice. He com¬
mences by pointing out that in croup the tendency towards
■death is by no means commensurate always with the
morbid condition of the larynx anatomically considered,
■the nervous system often playing a considerable The
■case he describes was that of a child thirteen months
■old, to whom he was called by another practitioner in
order to assist in the performance of tracheotomy. The
■child was breathing with the greatest difficulty, expira¬
tion and inspiration being equally noisy; the hypo-
■chondriac regions were strongly drawn in at each inspira¬
tion, also the lower intercostal spaces anteriorly; the alee
nasi were working strongly, and the child kept clutching at
‘its throat, where the larynx was very prominent, and at its
■ears, and twisting its head round as if there were both pain
and a sense of obstruction. It would not drink or stay in
bed, the face wore an anxious expression, and the head was
■retracted. No membrane could be detected in the throat,
■and there was no sound of air entering the lungs when
-auscultated from behind. On the left side percussion was
■dull from want of expansion of the lung. Altogether the
•case was apparently hopeless. Notwithstanding the
•ilangerouB character of tracheotomy in children so young,
preparations were made for its performance, when the writer
suggested that ether inhalations should first be tried. A
mixture was ordered of three parts sulphuric ether, one part
■acetic ether, and one-tenth part menthol, of which three \
■drops were given as an inhalation on a folded handkerchief I
•every quarter of an hour. The idea was by means of the |
vapour of ether and menthol to act on the mucous
membrane of the larynx, which, ^ is well known, lies
somewhat higher than usual in croup, and thus to contract
the bloodvessels, to lower the temperature of the part, to
decrease the cedema, to lessen secretion, and to allay the
irritation in the larynx by the production of some amount
of local anaesthesia. In addition to these. Dr. Betz had the
further object in view of inducing partial generaLantes-
tliesia so as to give the child rest, and to allay the spas¬
modic contractions of the muscles connected with respira¬
tion. In a couple of hours a decided change for the
better had taken place, the child being quieter, and
some air evidently entering the lungs. The inhalations
were continued therefore, but at intervals of half an hour.
Six hours later the respiration had become much less noisy,
the contractions less, and the dyspnoea far leas urgent, en¬
abling the child to drink. The face had regained its proper
colour, and the child was apparently pretty comfort¬
able, so that there was no longer any need to think
of tracheotomy. The regular administration of the in¬
halation was stopped, but another mixture of a somewhat
similar character, containing three-tenths of a part of
menthol, was ordered, in ease of any recurrence of the
alarming symptoms. Fortunately the subsequent progress
was so uniform that no recourse to this was required. The
object of increasing the menthol was to obtain greater
refrigeration and to enable it to penetrate further into the
air passages. The writer remarks that Trousseau used to
prescribe chloroform inhalations in croup, but he is disposed
to prefer his own mixture of ether and menthol. Whether
such etherisation has any power to loosen false membranes
further experiments must show ; but when tracheotomy or
intubation is for any reason inadmissible in undoubtedly
membranous croup, this treatment may, he thinks, very
fairly he tried. The inhalations ought not to be continuous,
but intermittent, and the medical man should for the first
hour or two administer them himself.
THE ADMINISTRATION OF QUININE TO
CHILDREN.
The difficulty of giving quinine to children, especially
when it is desired to administer somewhat large quantities,
has of course frequently been remarked. In order to
obviate this it has been proposed by various physicians
accustomed to practise among children to order external
applications either in the form of ointments or lotions, with
the view of getting the quinine absorbed by the skin, and
several continental writers have reported that this system
has given good results in their hands. The amount of
quinine absorbed under these circumstances, however, was
not Icnown, contradictory views on the subject being
entertained, whilst many of the best works on children’s
diseases omitted all mention of the external form of adminis¬
tration. Dr. Troitski recently undertook a long series of
observations in the children’s department of a poor-house
with the object of ascertaining what was the best form of
external application and how far absorption is possible
under these circumstances. His experiments, which were
conducted on healthy children, about fifty in number, are
published in the current number of the Vrach. He made
some trials with ointments of which the bases were
vaseline, lard, or lanoline, but very soon discarded
this form of application, as he found that in order
to get any appreciable quantity of the drug absorbed
it was necessary to spend a long time rubbing in the
preparation, which M'as not only tedious to the operator
but very fatiguing to the child. Contrary to what most of
the writers on the subject have advised, the region of the
body selected for the application was the back of the thorax.
Solutions of quinine were then tried, with rather more
Digitized by
Google
1114 ThxLakobt,]
HEALTH OF THE PRINCE OF WALES.
[May 1G, 1891.
success, 1 part of the bydrochlorate of (xuiniQe beiog dis¬
solved in 30 of rectified spirit, or in 20 of spirit and 10 of
glycerine. Of this a teaspoonful or a teaspoonful and a
hyf was rubbed in twice a day until the skin became quite
dry, the precaution having been previously taken of wash¬
ing the child well. The urine was examined both by the
chlorine water and by the iodine tests, and observations
made of the comparative results in the same children. The
conclusion come to was that, though the drug is undoubtedly
absorbed by the skin from such solutions as were used,
the amount was so small and uncertain as to render it im-
polsible to administer the dose that may he desired by the
external method. The good effects that are said to have
been produced in fever by the lotions Dr. Troitski would
ascribe, mainly at least, to tne refrigerating action of the
spirit on the skin. _
HEALTH OF THE PRINCE OF WALES.
We understand that H.E.H. the Prince of Wales has
been suffering for about ten days from a slight attack of
influenza, which has naturally left him somewhat weak and
exhausted. We are glad to be in a position to add that
he is benefiting from the rest from public and otlier duties
which he is now permitting himself.
THE BOARDING-OUT OF WORKHOUSE
CHILDREN.
The Lord Mayor could not have given the sanction of
the Mansion House to a better cause than that of promoting
public interest in the Association for Advancing the
Boarding-out of Workhouse Children, by which they are
extricated from pauperising associations and placed in
family conditions, at a leas cost than that of keeping them
in workhouses or in pauper schools. It is lamentable
to think that we are behind Scotland and our own colonies
in such a matter. Only 4549 children out of 41,290
children—orphan, or deserted, or relieved apart from their
parents—are so boarded out. Only 22 per cent, of the
children so treated turn out badly. The Lord Mayor was
supported by H.R.H. the Duchess of Albany, Viscount Cran-
brook, the Earl of Meath, Lord Brassey, Lord Norton, the
Hon. S. J. Way, Chief Justice of South Australia, and
others. We wish the association every success.
THE NEW BABY FARMING METHOD.
Wb take this opportunity of directing attention to a
phase in the widespread system of baby trading, of which
the case of .Toseph and Annie Iloodhouae, recently tried
before the Recorder, furnishes a gigantic illustration.
The method pursued by this exemplary couple must be
familiar to many of our readers. It will be remembered
that they were not mere farmers of infant life, but stood in
the position of ordinary middlemen. The novelty of their
practice in this respect indeed is due rather to the extent
than to the character of their operations. The children
received under pretext of adoption were soon conveniently
lost sight of in a third home, but the clothes and payments
for maintenance were somehow absorbed in the transfer.
In this way the accused are said to have obtained at least
thirty-five children, representing actual money receipts to
the amount of £219, and £35 worth of jewellery, besides
clothing. Advertisement as usual played a prominent part
in each transaction, and it is to fraudulent representa¬
tions made in this way that the prisoners owe their past
success in crime and their conviction. The utter badness
of their case may be judged from the absence of even
an attempt at defence against the charge preferred against
them. The nearest approach to resistance was a poor
excuse in favour of the male prisoner, that he had failed in
other efforts to gain an honest living. It is the old story
that one must live by hook or crook, and the end, if suc¬
cessful, will justify the means. The fallacy of the argu¬
ment, and its hard and selfish injustice, in this case permit
of no defence. The additional fact that of the thirty-five
children ten have died is in itself suggestive, and shouliH
materially qualify any movement of pity originated by an
illogical effort at exculpation. As regards the prevention
of the disgraceful trailic in its various forms, we may take
some encouragement from the very evidence of its pre¬
valence, for this bears testimony to the vigilance employed
in its detection. We have suggested in The Lancet of
March 21st a method of organising such effort by instituting
a system of registration, with inspection of attendant cir ¬
cumstances in each case where the public press is employed
to assist in the transfer of young children. We take it thak
no pretence of liberty could well be alleged in opposition to
sneb a scheme, which at least bids fair to check the growth
of a rank and luxuriant iniquity.
BLACK VOMIT FEVER.
The nature of black vomit fever, or jiebre de bon'cts, is by
no means well ascertained, and different writers do nob
agree altogether in their descriptions of the clinical history
of the cases they have met with. Dr. Bellot, writing in 185^
stated that there was never albuminuria, and that all the
individuals attacked were children under nine years of
age. He did not consider the affection as identical with
yellow fever. Dr. Reyes, writing in 1881, contested the
belief that the fever in question was of a contagious origin,
and adduced several facts in support of his view. He de ¬
scribed nearly the same clinical history as Dr. Bellot, but did
nob deny the existence of albuminuria, though he^said that-
it was always much less in amount than in yellow fever.
Dr. Albuerne more recently has suggested that the fiehre da
boiras is a kiumorrhagic form of bilious malarial fever.
Dr. F. Suarez Garro has just published in the Crdnica
M4dico-Qicirurgica of Havana nine cases, all occurring in
members of the same family, most of them being children.
Id these cases there was a great deal of albuminuria, espe¬
cially in the two which proved fatal. Dr. Garro believes
that the affection is a modified form of yellow fever which
occurs in creoles. He supports this view by referring to
the sudden invasion and the similarity of the symptoms
during the first period, the coexistence of persistent vomit¬
ing with pain in the epigastrium and in the back, also by the
coffee-ground vomit, which of course is not pathognomonic
of yellow fever, but is, nevertheless, highly characteristic of
it. The albuminuria, which in some cases amounted to eight-
tenths, is also, when taken togetherwith the other symptoms,
an important element in the case. Lastly, the two childrcD
who died presented perfectly clear signs of un-emia, just ae
it only too often appears in yellow fever. The Havana
Society of Clinical Studies is anxious to obtain as much
information on the subject of this disease as possible, and',
as we have before menbioned.^has issued a series of questiono,
to which it invites replies before the end of September.
PRIVATE SLAUGHTER-HOUSES.
AccoiiDiNO to the Vegetarian Federal Union oxbensiv©
reform is called for in our present system of replenishing thei
moat market. They condemn strongly the existence of
private slaughter-houses on the grpund that in them, owing
to the difficulty of efficient supervision, many cruelties are
perpetrated on the animals killed, while from the same
cause diseased meat readily passes into the hands of con¬
sumers. They have therefore presented to Parliament a
i The Lancet, Sopt. 27th, 18oo. p. 708.
Digitized by L^ooQle
The Lancet,]
THE GENERAL MEDICAL COUNCIL.
[May 16,1891. 1115
petition advocating the exoluaive employment of pnhUc
abatboire which would be subject to regular inspection.
Assertions by a society of this kind on such a subject will
naturally be accepted with a modicum of reserve, but this
fact does nob disprove their substantial accuracy. The idea
contained in the above proposal is nob a now one. Ic
is already embodied in all its details in the customs
observed in this particular by the Jewish community.
There is much to bo said in its favour and little
in opposition if a guarantee be also provided that
meat once killed shall be removed forthwith to its
intended place of sale. Little, if any, inconvenience need
be incurred by butchers if the change proposed were carried
out. On the contrary, there would be in their case a con¬
siderable saving of trouble. The question as to how far the
statements made by the Union are capable of accurate
proof can only be settled by an official inquiry, and this
appears to be on every ground advisable. Without it the
Legislature would hardly be justified in moving, and we
can readily understand that, whatever its ultimate result,
tke public interest would be served by such investigation.
St would be too much to regard the butcher’s poleaxe as the
wholly blameless instrument of humanity and of health.
HEALTH OF MR. GLADSTONE.
We are glad to be able to state that the Right Hon. W. E.
Gladstone is progressing favourably in all respects, with
the exception that the temperature still remains somewhat
Ihigher than normal. _
THE GENERAL MEDICAL COUNCIL.
Tint General Medical Coirncil is summoned to meet on
Tuesday, May 2Gth, in accordance with the standing orders.
<3ne of the first duties of the Council will be to appoint a
President in place of the -late Mr. John Marshall.
THE SANITARY STATE OF BORSTALL.
For some time past the neighbourhood of the Borstall
Convict Prison, liochesber, has been regarded as unsatis¬
factory, and various endeavours have been made to induce
•the local sanitary authority to deal with the matter.
Apparently at the initiative of the War Office, definite
complaint was a short time since made to the Local
Government Board on the subject, and as the result a local
inquiry was held. The Local Government Board have now
informed the Corporation that tliey find the complaints to
have been well founded, and they therefore call upon them
to bake the necessary remedial measures. This, doubtless,
amounts to an order under Section 299 of the Public Health
Act, 1875, disobedience of which is commonly followed by
application for a mandamus.
THE GERMAN EXHIBITION.
The German Exhibition, the opening of which took place
■on Saturday last, promises to be no less interesting and
■successful than its predecessors which were arranged by
the same director, Mr. J. R. Whitley. The Lord Mayor
performed the opening cerentony, which in itself was marked
by an enthusiasm which bodes well for the success of
the underbaking. In future issues we hope to be able to
give a description of some of the recent improvements in
those departments which cpme more immediately within our
province. The grounds promise to be admirably laid out,
and oven a cursory glance will show how carefully every
detail in which the comfort of the public is involved baa
been considered and attended to.
FOREIGN UNIVERSITY INTELLIGENCE.
■ Brcsla^l—ThQ new surgical clinic has just been pro¬
nounced by the Professor of Surgery, Privy Councillor
Mikulicz, to be the best arranged clinic of the kind in
Germany.
Turin. —Dr. Second! has qualified as privat docent \n
ophthalmology. _
DEATHS OF EMINENT FOREIGN MEDICAL MEN.
The deaths of the following distinguished members of
bhe medical profession abroad have been announced:—
Dr. Obhon Saunier, chief medical officer of the Greek
Navy.—Dr. V. Datbilo, formerly Professor of Operative
Surgery in Naples.—Dr, Hugo Tansig, one of the medical
officers of the Prague General Hospital, of typhus fever,
contracted by attendance on patients suffering from it.—
Dr. Thatcher, Professor of Physiology in Yale.
An important series of eight practical lessons on the Use
of the Ophthalmoscope and on the Estimation of Refrac¬
tion will be given by Dr. Hill Griffith in the post-graduate
class at the Royal Eye Hospital, Manchester, on Wednes¬
days, at 4.30 P.M., commencing May 20bh.
Three lectures on the Physiology of the Vaso-motor
System will be given at the Royal College of Surgeons
during the present month, by Dr. J. R. Bradford (Arris
and Gale Lecturer), on Monday, Wednesday, and Friday,
May 25 bh, 27 th, and 29 th, at 5 P.M. each day.
At the meeting of the London School Board on the
7bh inst., the recommendation of bhe Salaries Committee that
the minimum salary of their medical officer should be £400
per annum, and that it should increase by £50 a year until
£600 was reached, was carried by 19 votes to 12.
The Croonian Lectures will be delivered at the Exami¬
nation Hall on June 2ad, 9bh, 16th, and 23rd, by Dr. Burdon
Sanderson, who will take for his subject, “ The Progress of
Discovery relating to the Origin and Nature of Infectious
Diseases during the last twenty-five years.”
Du. C. Tjieodore Williams’ period of office as physician
to the Brompton Hospital for Consumption having expired,
bhe Committee of Management have unanimously re-elected
him for a further term of five years.
Dr. Theodore Thomson, medical officer of health for
Sheffield, has been appointed to an inspectorship in the
Medical Department of the Local Government Board, ren¬
dered vacant by the death of Mr. Spear,
In consequence of the rapid extension of leprosy In Russia,
the Town Council of Riga has voted a sum of 60,000 roubles
to establish a Hospital for Lepers, which is bo be inaugurated
in July.
This Devonshire Hospital, Buxton. — Dr.
Robertson presided at the annual meeting held at the
hospital on bhe 2nd inst. The annual report stated that on
April 30bh, 1890, there wore 151 patients in the hospital,
and since May Ist, 1890, 2363 patients had been admitted,
2263 of which were discliarged as improved- Of the 2514
received from May Isb, 1890, to April 30th, 1891, 517
suffered from heart complications and rheumatism. The
cases of a rheumatic or gouty character were equal to six
out of every seven in the hospital, which testified to the
value of the Buxton mineral water in the relief of such
cases. Six cases only of accident were received during the
year, of whom two died. Two annual life subscribers had
been recently received, and the total subscriptions exceeded
those of the previous year.
Digitized by i^ooQle
1116 ThbLanobt,]
THE UNIVERSITY OF LONDON.
[May 10,1891.
THE UNIVEBSITY OF LONDON.
CONVOCATION AND THE REVISED SCHEME.
At a crowded meeting of Convocation of the London
University, held on Tuesday evening, the Right Hon. Lord
Herschell, B.A., moved that the Draft Supplemental
Charter embodying the proposed scheme be approved. He
said that whatever might be the merits or defects of the
Charter which they had to consider that night, he could assert,
without fear of contradiction, that it had been the result of
as much patient and careful thought, of as much anxious
desire to arrive at a just and sound conclusion, as had ever
been bestowed on any similar document. It bad been con¬
sidered and reconsidered not only by the committee
appointed by the Senate itself, but the committee
had conferred again and again with all those whose
interests were affected, or supposed to bo affected,
and they sought light from eve^ quarter from which
they thought it possible that it might come. They were
assisted by a committee appointed by Convocation, with
whom they conferred on several occasions ; and therefore,
without for a moment suggesting that the pains that had
been bestowed upon it were a ground for its acceptance, it
was at least entitled to respectful and careful consideration;
and he could but express some regret that, before the viev^a
of the Senate had been really placed before the members
of Convocation, an attempt should have been made to
pledge members of Convocation beforehand to dissent from
it on what would seem to him an ex parte view of the sub¬
ject. He did not say this by way of blame. Thosewhotook
this course no doubt thought it a desirable course, bub none
the less he thought that on a matter so important as this, in
which the future of the University was so vitally concerned,
it would have been well that, before the members of Convo¬
cation pledged themselves to any particular view, they
should at least have had an opportunity of fully hearing and
considering both sides of the case. He appealed to some
perhaps who had signed that document to listen, notwith¬
standing, with open mind to the arguments that would be
used. Of course there was a widespread opposition to this
scheme. He had only one consolation, and that was that
its opponents were at least as much opposed to one another
as they were to the scheme. To the adherents of the London
Colleges it had been pointed out that they had good ground
for being aggrieved that the provincial colleges should find
any representation on the Senate; whilst, on the other
hand, the provincial colleges were excited by the state¬
ment that they did not get representation enough,
and that the large body of graduates who did not belong
to the colleges, either provincial or London, had their
interests to look to, because if the London or provincial
colleges obtained too much representation they were in a
worse position. These objections were of a kind which, if
left to their own instincts, would devour one another, bub
they had been dexterously caged and united in an olFensive
alliance. Unless the antecedent history of the University
was carefully considered, it would be impossible to form
any just appreciation of the action of the Senate. In
1884 an association had been formed, including many
eminent men and some very energetic men, who adv<)-
cated the formation of a Teaching University for London.
They were convinced that the non-existence of such a
university was not creditable to this city. Various reso¬
lutions bad been collected in the documents which had
been circulated in connexion with this meeting. One of
these, which appeared to have been overlooked as passed
by Convocation on h'eb. 24tli, 1885, was in these terms:
‘ ‘ The obj sets of the Association—tliat is, the Association for
the Teaching University—would, if carried into elfecb by
this University, add bo its usefulness and importance.’'
Before matters had merged into a more critical position, that
was the view adopted by the Convocation of the University.
A petition was then presented from King’s College and
University College praying for incorporation in a new Uni¬
versity. The Royal Colleges petitioned that they should have
a University power to confer degrees. Upon this a Royal
Commission was appointed to guide the Government, who
had to determine what course had to be taken in regard to
these petitions. The main recommendation of the report
of this Committee undoubtedly was that the aims of those
who desire a Teaching University would be better effected,,
more in the interests of the public and education, by a
modification of the constitution of the London Univer¬
sity, which would enable the work to be done by and
through it, than could be done by a competing univer¬
sity in London; and then those members of the Commis¬
sion who had doubts as to the practicability of this plan
expressed their objections, a summary of which is to be>
found in the 16bh paragraph of the report. It appeareii
to him that this question of the creation of anew University-
in London which should be a teaching and examining Univer¬
sity, and give its degrees alongside of this University, was
the real crux of the whole problem with which they were
concerned. They had not to consider the question as it>
might have come to be considered if no such proposal had
been made, or if they were to make a tabula rasa, and
sweep out of existence all existing institutions. They had
to deal with things as they are. The founding of such a.
University was pri>peily viewed in two aspects—its effect on
their University and its effect on education generally. He-
regarded the latter as by far the more important question
of the two. If there were any conflict between the>
public interests and those of the graduates, he admitted
at once that any privileges that may have been enjoyed
or acquired by members of their University must giv©
way before the interests of education. He believed the'
creation of such a new University would be mischievous-
in its effects on the existing University, and nobody could
question that it would be a disadvantage to have another
university, which would be claimed to be the Teaching
University of London. (A voice—“Why of London?”)
Because whatever you call it and however much yoi»
attempt to prevent its being connected with the name
London, that is what it would be sure to beloalled. (Cries
of “No, no.”) Well, it was a matter of opinion, and the fact
that there had recently been bitter complaints from the
University of Dublin and Trinity College that their degrees
were being confounded with the degrees of the Roya^
University of Ireland indicated that a similar thing was
likely to happen in London. If the establishment of a new*
University in London would improve the education of
London or the country they ought not to hesitate for a-
moment if the degree were twenty times confounded with
that of the London University ; hut his belief was that the
foundation of such a University would inevitably tend to
lower the standard of degrees and of education, however
much those who promoted it might really and truly desire
the contrary. Thera was the danger of multiplying, and
especially of creating, small universities ; and although there'
might be some who could resist the attractions of competi¬
tion, yet not see that considerable danger of competitions
the effect would bo to lower the standard of degrees and
react upon the standard of education. If the teaching;
bodies were to be gathered up into small universities in
that way, the tendency would be that this University would
become a mere examining body, more detached than-
now from the teaching institutions of the country, and
that would be extremely deleterious to the work and
usefulness of the University. When the report of
the Royal Commission was Issued, it was found that
the two Colleges, University and King’s, were by
no means satislied with it. Surely no member of Con¬
vocation would have desired the Senate simply to have-
held its hands and sheltered itself behind the report of the
Royal Commission. On the contrary, the Senate thought-
they ought to consider how the wishes of the two Colleges-
could be consulted. There was a difficulty with respect to-
the conduct of the intermediate examinations by the
colleges. That dilliculty was met by the appointment ok
joint examiners—by the Colleges and the University. Then,
again, the provincial colleges objected to the proposals of
the Royal Commission, which would have given exclusive
representation on the Senate to the London Colleges
and deputations from the provincial colleges had come
to protest against their exclusion. Accordingly, on
Jan. 21st last year. Convocation passed a resolutiorh
expressing a sense of the injustice of the exclusion of
provincial colleges. The Senate thought that by the pro¬
posed Royal Charter they haff reconciled conlUcting
interests. They did not claim that it would create an>
ideal or perfect system ; but they thought it was the best'
attainable, that it was a just and equitable solution.
Opposition had come from many different quarters. But-
that was Inevitable. The scheme was of necessity a con>
D'
The Lancet,]
THE UNIVERSITY OF LONDON.
[May 16,1891. H17
f iromise. It met the legitimate desire of the London Col-
eges, and would bring the examining and teaching elements
into closer intercommunication. No doubt many objections
might be raised. Some said the standing committees
would deprive the Senate of all control; others contended
that these committees would become the mere creatures of
the Senate. Both objections could not be realised, and ho
thought the truth, as usual, would be between the two
extremes. He did nob believe either that the inlluence
of Convocation on tiie Senate would be diminished.
Upon the subject of the medical part of the scheme he
thought it had been the subject of a good deal of mis¬
apprehension. He could nob understand anyone enter¬
taining a doubt that the most important part of the scheme
would be of the highest value by bringing the great medical
schools of London into close touch and connexion with the
University of London, between which hitherto there had
existed a pretty wide chasm. He was quite certain the
closer connexion would be to the advantage of both Uni¬
versity and schools. There had been ungrounded fears with
regard to the examinations being left in the hands too much
of the Colleges of Physicians and Surgeons. The scheme
could not have been understood by those who so regard it.
This part of the scheme only gave the power to begin with.
It depends upon an agreement to be come to between the
Senate and the colleges, and it cannot have any effect until
the subject has been weighed thoroughly and the exact
form of the agreement determined upon. And unless the
Senate and the colleges come bo see a practical and benefi¬
cial course, the Senate would not give it their sanction. If
they could not trust the Senate to look after the interest of
medical education, and if it was thought that they were
likely to surrender the cause of medical education to the
Royal Colleges or to anybody else, of course the Senate
would have to submit bo te distrusted. Would it not be an
advantage if an arrangement could become toby which the
number of examinations could be diminished ? For his part
he did nob think the multiplication of the examinations
was nob a great evil. If a joint examination could be
arranged for qualifying a student, whilst the University
should give a degree only to the most distinguished licen¬
tiates after further examination, he did not see how it
would lower the degree. He thought the effect would be
to raise the standard, because men would strive to pass as
well as they could in the hope that they might obtain the
degree as well. It was said that the scheme was compli¬
cated and would nob work, bub nothing but experience
could determine that matter. Everything had been proved
to be impossible in its time, and when he was told that
a thing was impossible, he desired to wait and see.
The matter was nob in their bands to dictate what
was to be done if the scheme was approved by the
meeting. They were not masters of the situation, though
he wished they were. The scheme might be materially
modified when it came before the Lord President of the
Council. If Convocation refused to pass the scheme, the
problem would remain unsolved, and this University would
undoubtedly have lost very much of its power. (Cries of
“ No, no.”) If the “noes” only represented facts, he should
rejoice at it. lie was as much behind the scenes as any¬
body is likely to be, and he could guess what was likely to
happen. If they voted against the scheme on the supposi¬
tion that the matter would then be in their hands to frame a
new one, they would be grievously disappointed. There was
obviously no alternative scheme on which any considerable
number were agreed. The time for conferences 'wa-s past.
A single university in London in close connexion with the
teaching bodies enabled them better to fulfil their func¬
tions and to promote the cause of higher education in the
metropolis. It would be none the leas able to discharge its
old functions in relation to the provincial colleges, and
would even bring them into closer relationship with the
Ihiiversity, and in would still be able to discharge the im¬
portant work in relation to the nou-collegiate students from
all parts of the British Empire, possibly more elliciently on
account of the change, than was done before. He saw, on
the other hand, the possibility of a creation of another
University, resulting in a diminution in the inlluence of
this University, and mischievous ell'ects upon the higher
education of the country.
Sir RicilAttD Quain seconded the proposal as a graduate
of this University for fifty years, who bad watched its
progress and seen how the Senate had conducted the
University through all its difficulties to its present position.
With respect to medical degrees, those who were not in the-
profession could not realise the grievance which the medical
students of London felt themselves to be sustaining by 'the
present state of things. Hundreds of capable men were
driven to seek in Scotland, at Newcastle, and elsewhere
the medical degrees which they ought to have obtained
in London. Men who wished to graduate in medicine
in the University of London bad to get through the
chevaux de ,frise of a matriculation examination. There
was DO desire to diminish the excellence of the medical
degrees of London, but It was desirable to bring the Senate
into touch with the Colleges of Physicians and Surgeons
and the other examining and educational bodies. The twe
Royal Colleges had accepted the draft scheme, and he
warned them that if it was not accepted, ste|)s might be
taken under the Medical Act, 1858, to compel union between
the University of London and other colleges. He hoped)
the scheme would be accepted as the most satisfactory
settlement attainable under present conditions.
Mr. Bompas, Q. C. , as an old member of Convocation,,
wished to give a few reasons why the House should refuse
assent to the motion. The scheme had to be considered ou;
its merits, and not on the merits of its mover and seconder.
The scheme would endanger the higher education of the
country. What had the Royal Commission—which con¬
sisted of six members, three of whom were lawyers, and
therefore not practically acquainted with the working of a
University, and three practical men—said ? The three men
who were practically acquainted with educational mattera
were Sir W. Thomson, Professor Sir Gabriel Stokes, and
Mr. Welldon. These three had emphatically pronounced
against any charter and against the possibility of combining
the functions which the University had hitherto so admir¬
ably performed with those of a local London Teaching
University. These three gentlemen had also said that any
such University must be in one place, and that its degrees
should be granted by the University solely upon its own
examination. Lord Herechell's idea, in fact, of an Imperial
degree-granting University for the Empire, with its system
of London and provincial colleges, was a chimera. He waS'
an M.A. of Cambridge, but that was no evidence that he-
knew more than a third orfourth-form boy in a school. He
was also an M.A. of London, and that did show that he
had some knowledge. An Oxford or Cambridge degree wae
evidence that a man had for some years been subjected to
the humanising influence of contact with cultivated and
refined minds by residence in the University. The Univer¬
sity of London had discharged the function of granting
a degree which was real evidence of knowledge. It had
done much, too, to raise the standards of the older Univer¬
sities. But the new scheme would give the counbryf
graduates who would not gain either the peculiar advan¬
tages of the older universities or the evidence hitherto-
afforded by the University of London of the possession of
real knowledge. The scheme would divide responsi¬
bility, and all experience showed that divided respon¬
sibility meant failure. It was absurd to suppose that
two bodies who were hostile or suspicious towards each
other could unite to conduct examinations together
satisfactorily. He would appeal to Convocation to reject
the scheme, and thereby finally save their University.
But if it was not accepted, the whole matter would be left
tO'the arbitrament of alien bodies. Their desire was that-
there should be one university, and not two or three miser¬
able bodies contending for the name—that there should not
be a Dutch auction for degrees. With regard to the medical
question, it was in the power of Convocation to do irreparable
barm to the cause of medical education in London. He would
ask the graduates who were not medical graduates not
hastily to thwart the attainment by the medical profession
of the end which they had been aiming at for the last
twelve or fifteen years. Their desire was to bring into
harmonious working all the medical schools, and, secondly,
to make the medical degrees more accessible without lower¬
ing the standard. The standard need not be lowered if there
were an economy of examinations, and no needless going
over the same ground more than once. The University had,
at all events, brought into joint action the two Colleges of
Pliysicians and Surgeons, each of which was anxious not to-
lower, but to raise the medical standaid.
Mr. R. H. Hutton said the one point which was the
real flaw was that the charter would give the degree-giving
power to a body which did not brieve in the present
degree, and wished to establish a dillerent and purely col-
Coogle
1118 TheLakcbt,]
THE ROYAL COLLEGE OF SURGEONS.
[May 16,1891.
l«giate standard of degree. The new Senate would oonsist
of people most of whom wanted an altogether new kind of
degree. They were inventing a scheme which bad an
enormous number of ganglia and no cerebrum at all. It was
of importance to retain the confidence of the non-collegiate
candidates, and this the scheme would not do. It was a
mere hybrid which would not maintain the reputation of
the University.
Dr. Sansom said the scheme was calculated to impart
a delusive hope rather than to remedy any memcal
grievance. It nad in it elements of exceedingly great in¬
equality and injustice. It reminded him of the words of
Virgil—Monstrum ingens informe cui lumen adeniptum.
Mrs. ScHARUEH, M.D., said that the women members
of Convocation, and especially those in the medical pro¬
fession, were unanimous iu wishing to reject the scheme
proposed. It satisfied but a very small minority of them.
Dr. W. J. Collins, on behalf of those who opposed
the scheme, recalled almost the last words Lord Gran¬
ville bad addressed to them—first, that they should retain
the Imperial character of the University, and secondly, that
they should maintain the standard of the degree. He opposed
the scheme because he firmly believed, and fully agreed with
Lord Herschell, that the higher interests of education must
be put before the interests of this University. These two
points were frustrated by this scheme, and be hoped they
would reject it.
Lord Heeschell having replied, a division was taken,
and the scheme was rejected, 461 members voting against
it, and 197 voting in its favour.
PRESENTATION DAY.
Although the increasing numbers of new graduates and
of the recipients of honours at the University of London
were evident from the well-filled benches of the large
theatre, and the consequent curtailment of the space
allotted to visitors, nevertheless the proceedings of Pre¬
sentation Day (the ISth lost.) were briefer than usual. The
ceremony had unfortunately been deprived by the prevailing
epidemic of the presence of the newly appointed Chancellor
of the University, the Earl of Derby, and also of that of the
representative of the University in Parliament, Sir John
■Lubbock, who is usually called upon for a speech on this
occasion. The Vice-Chancellor, Sir James Paget, per¬
formed the duty of conferring the degrees, and in the too
brief speech with which he closed the proceedings spoke in
graceful and befitting terms of the services rendered to the
■University by the late Chancellor, Earl Granville, whose
presence on these occasions was always so welcome. For
thirty-five years Earl Granville had presided over the Senate,
and in that space of time the University had progressed so
much that the number of candidates for matriculation had in¬
creased ninefold, and of graduates tenfold. Sir James Paget
spoke of the admirable qualities of the late Chancellor and
of the manner in which he devoted himself to the interests of
•the University, pointing out that to his efforts was largely
-due the admission of the graduates to a share in the
government of the University, and ten years ago the
admission of women to degrees. In expressing regret at
the cause of Lord Derby’s absence, Sir James Paget read
e letter from the Chancellor intimating his intention to found
a scholarship to perpetuate the memory of Earl Granville
in the University. Sir James Paget excused himself from
discussing the vote passed by Convocation on the pre¬
vious day, since the Senate had yet had no opportunity of
•considering it, and he passed on to congratulate those who
had gained honours and degrees, after, as he trusted, having
•obtained them by surmounting difficulties. For, as he said,
that only is worth having which is secured with difficulty.
MEETING OF FELLOWS AND MEMBERS OF
THE ROYAL COLLEGE OP SURGEONS.
A WELL-ATTENDED meeting of the Fellows and Members
of the Royal College of Surgeons was held in the theatre of
Ahe College, Lincoln’s-inn-fields, on Monday last, at 3 r.M.,
by invitation of the Council, to consider the University
•of London Scheme.
Mr. Bryant, the President, on the part of the Council,
^eeted the Fellows and Members with all good feeling
and with some hope that they would as a body support the
Council in its prolonged efforts to help the rising generation
of medical students to obtain a degree. He reminded the
meeting that the action of the Council was in harmony
with a resolution passed at a meeting of Fellows and
Members of this College on March 2-4bb, 1884: “That this
meeting of the Fellows and Members of the Royal College of
Surgeons of England begs most respectfully to recommend
that the Council of the College do obtain a charter to enable
the College to combine with the Royal College of Physicians
of London, with a view to the amalgamation of the two
Colleges into one great College of Medicine, to be endowed
with authority to examine and grant licences to practise in
all branches of medicine and surgery, and to confer on its
licentiates the degrees and titles of Doctor of Medicine and
Master of Surgery.” He simply recorded the fact that appli¬
cation had been made to the Government in the usual way,
and the powers asked for had been very definitely refused,
but not before n Government Commission, called the
University of London Commission, had been appointed by
the Crown, under the presidency of Lord Selborne, and a
thorough investigation of the whole question of degrees had
been considered and some important conclusions reached.
The conclusions were the following. The Commissioners
were satisfied that a great demand existed for medical
degrees attainable in London, and thatitwas right that the
demand should be met, and that, whatever difficulties there
might be in supplying the demand, “ those difficulties
might be more easily overcome if the ground were occupied
by one University only, and not by two”; and lastly, that
the constitution of the existing university might be adopted
for that purpose. “On these lines, therefore,” continued
the President, “our College, in conjunction with the Royal
College of Physicians, has been steadily working with the
University of London to formulate and perfect the scheme
which is now in your hands. We believe it to he
entirely consistent with the views of the University of
London Commission, and we ask you, therefore, care¬
fully to consider it on its own merits; indeed it is for such
a purpose, and such alone, that we have called you
together. To tell you that this is the very best scheme which
could be devised by the ingenuity of man would be
absurd. To say that it has not some weak points in
its constitution, would also he untrue. To believe that
many before me conscientiously think that they could, in
their own armchairs, sketch out a far better arrangement
than the one now presented to you would not be very wild.
But we submit that by the scheme before us the objects
we bad in view at starting will he satisfactorily attained,
and our London students will be materially assisted to
attain a high degree, and the standard of the examination
of the two Colleges be raised and not lowered; whilst
at the same time the influence of the teachers will be in¬
creased, aod none of the interests of any of the institutions
which have been brought under the scheme have been made
to suffer materially if at all. By the scheme the two Royal
Colleges simply help the University of London togive adegree.
The formation of a second and rival University was a con¬
sideration which influenced the Council in their exertions ;
for there could be no question that should this scheme
break down, or fail to satisfy the requirements of the Com¬
missioners and the Government, a second University would
be erected by the side of the older institution, when, as a
result, a competition for giving degrees will of necessity
arise, which must act in an injurious way, for we cannot
fail to recognise the fact that whilst competition in teach¬
ing tends to improve all who are engaged in it, a competi¬
tion in giving degrees can but act downwards, to the detri¬
ment of the profession, and consequently to the public
interest. On the present occasion we ask you to consider
the scheme more particularly in relation to our own College,
to weigh its advantages and disadvantages with respect to
the interest of the College and its members, and to give the
scheme your approval, if you believe with us that by it the
position of our College will he maintained, and the future
aspirants will be helped towards the attainment of a degree
which in itself will be a mark of honour and an indication
of a liberal education.
Mr. Lawson Tait moved “That in the opinion of
this meeting no scheme for amalgamation with the
University of London for the granting of a medical qualifi¬
cation, no scheme for a conjoint examiaation with the
College of Physicians for such or a similar purpose, can he
satisfactory so long as the Society of Apothecaries is nob
included in such scheme. ” He said, while personally thanking
^8
Thb Lanost,]
THE ROYAL COLLEGE OF SURGEONS.
[May 16,1891,
the Council very sincerely for the new policy of consulting
the body corporate in a matter of this kind, he only re¬
gretted that the consultation bad been deferred until the
patient was in articulo mortis. He felt, whether his
prognosis was correct or not, that he must regard the
scheme from a totally different standpoint from the Pre¬
sident, and that therefore the conclusions regarding it were
diametrically opposite. How the scheme before the meet¬
ing was ever to grant a degree of M.D, to anybody in
London which was not obtainable now he failed lo under¬
stand. His view was confirmed by an able article in The
Times, which pointed out that “the University would not be
a London university, it would not be a provincial university,
it would not, lilce the present institution, be a mere
examining University. It would be an attempt to combine
all three, and it would do efi'ectually the work of neither.”
Concerning the medical relations of the scheme, he pointed
out that the Senate carefully explained that in the arrange¬
ment proposed no alteration is now made in the degree of
M. D. If that were the case, and if students were merely to
get a cheap M.B , and not to he allowed facilities to obtain
the M.D , what on earth was the use of the scheme to any¬
body? Matters stood exactly where they were. He had
followed very closely the changing development of this
question of medical reform, and it seemed that the
initial mistake was made at the very beginning, the evil
results of which were growing daily, and that was the
mistake of not including the Society of Apothecaries in the
scheme. He had been informed that the exclusion of the
Apothecaries’ Company was nob due to the action of the
Royal College of Surgeons, but to that of the Royal College
of Physicians. They could easily understand that line of
aetioB, as the College of Physicians was a sort of successor
of the Apothecaries’ Company. He described the history of
the Company, and pointed out that at one time the diploma
of that body was even superior in public estimation to the
diploma from the College, and that even now certain Govern¬
ment appointments were open to those holding the diploma
of the Company, which were not open to those holding only
the diploma of the Royal College of Physicians. He quoted
the section of the Medical Acb of 188f), which empowered
the Society of Apothecaries to grant a statutory diploma in
Medicine, Surgery, and Midwifery, and read the diploma
granted by the Company at the present time, which
certifies the candidate, after deliberate and careful examina¬
tion, to possess the knowledge and skill requisite for the
efficient practice of medicine, surgery, and midwifery. He
had been actively engaged in endeavouring to repress the
f tracbice ot those who assumed titles to which they had no
egal right, and after a good deal of trouble means had been
devised for effecting this. Rut it was found that in this
diploma the Licenciate of the Apothecaries’ Company is
entitled to call liimaelf physician and surgeon, and they
were not quite sure that he was not entitled to call himself
“doctor.” He said the exclusion of the Apothecaries’
Society would act in the direction so clearly expressed
by the President of “a competition downwards,” which
of all things they deprecated, and if they wished to
prevent this they must stop the legitimate growth of
the Apothecaries’Company. It had been said that exclu¬
sion from the scheme would kill the Apothecaries’ Com¬
pany ; but it was difficult to kill a corporation in Loudon
that dated its Charter from the time of -lames L, and
instead of killing the Company they were granting it a new
lease of life, and making it more powerful than ever. If
reform in the method of education, training, and qualifica¬
tion was aimed at, either in London or elsewhere, they would
have to begin again, and include the Apothecaries’ Com¬
pany in whatever scheme might be devisea.
Mr. Josiii'U Smith seconded the motion, and wished to
know what the result would be if the meeting did not
confirm the scheme, and why the invitation to the meeting
had not been circulated among the Members as well as the
Eellowa.
The PurcsiDENT : Seeing that 15,000 men are Members of
this College, it was a serious matter to circulate so many
prospectuses. At the same time there was no difficulty in
obtaining them. With reference to the first part of the
question, the decision of the meeting would bo referred back
t j the Council for their further consideration.
Surgeon-Major Ince opposed the motion, and said nothing
surprised him more than to find one of the ablest provincial
surgeons advocating the interests of a commercial company.
He should have expected that he would have taken steps
to elevate the profession, and not to degrade it to thei
standard of a trade.
Mr. N EI.SON Hardy, os the seconder of the original resolu¬
tion, passed seven years ago, alluded to by the President, said»
he hoped that in the end they had produced some inAuence od>
the mindsof the Council, and although, like all great bodies,,
they moved slowly, be thought they might be encouraged)
in the hope that some good would ultimately come fromtheif
efforts. He entirely objected to Mr. Lawson Tait’s proposal.
Notwith8tandingtDeL.S.A. beingadoublequalification an^
being registrable under the Acts of 1886, it nevertheless was.
one which the best of its holders had not been content with-
in the past, and he ventured to prophesy they would not be
content with it in the future. If they passed this resolutioci
to-day they would certainly delay the matter for another-
seven years, Before it was finally decided he thought it
would be advantageous to have an impartial opinion upom
this matter. He hoped the motion would be negatived by
a large majority.
Mr. Lawson Tait, in reply, maintained that the-
Apothecaries’ Society was a qualifying body, and the more
it was degraded by the Council the more it would qualify in
a downward direction, and that therefore there was more,
need to include it in this scheme.
On the vote being taken, twenty-three members voted for
the motion and twenty-one against it. As is evident from-
the numbers, many of those present abstained from voting.
Mr. Walter Kivington moved: “That this meeting
regrets that the Council of the College has not seen fit to-
place before the Fellows and Members the scheme for the-
reconstitution of the London University before formally
accepting this scheme in the name of the College.” After
relating the various steps by which the necessity for calling:
meetings of the Fellows and Members had been impressed-
upon the Council, he described what had occurred at a.
recent deputation of the Fellows’ Association who were,
received on this question, and who had had an opportunity
of discussing various points. They recommended that
the Council should at least call the Fellows together to-
consider the scheme of the University of London before-
it was finally accepted, a proposal, however, which was not
adopted by the Council. The reason was given by one of the-
chief speakers, who said that it was a very intricate question,
and that few of the Council understood it at all. And
since that was the condition of affairs on the Council,,
it would be useless to place a scheme of this kind before-
the Fellows and Members, who would be worse off as re¬
gards enlightenment than the Fellows themselves. It was
a case of the blind leading the blind, and botii might fall-
into the ditch. The scheme would not remedy the medical'
grievance, for the obstacle of the two preliminary ex¬
aminations was left'untouched. If 200 medical students-
were to go up to the matriculation examination, 100 of them,
would fail, and of these fifty would fail to pass the preliminary
examination ; but in the later examinations, on purely
medical subjects, the percentage of failures would be very
much less. It was too late to make any suggestions now
for the improvement of the scheme. He thought the con¬
duct of the Council bad placed them in a most injurious-
position in the eyes of the public. The proper course
would have been to call the Fellows and Members together'
and ask them to appoint a committee to make suggestions,
and to confer with the Council in the name of the Fellows,
and then they would have been quite sure that no effort-
would have been spared to solve this very difficult and intri¬
cate question. It was not a question which should excite
any party feeling at all, and it would have been a graceful-
act on the part of the Council to consult the Fellows and
Members while there was yet time to consider the scheme.
The scheme resembled the island of Laputa, the people of
which lived in the air, and had their attention called to-
what was going on in t-lie earth by lUppers. He himself
held no other position except to act as a humble Happen
His motion commended itself to all whether they were for
or against the scheme.
Mr. Dankord Thomas, in seconding, thought the Council'
had, by calling them together under such circumstances^
hardly acted in a polite manner, and had placed them in
a very anomalous position.
Dr. W. J. C0LLIN.S, in supporting, said ho had nevey
at any former meeting of this kind presumed to address those
present, but on this occasion he felt bound, both as a.
graduate of the London University and as a Fellow
of the College, to express his regret that there had'
DiC:iT:-5j
ai20 Thb Lancet,]
THE ROYAL SOCIETY.
[May 16,1891.
fflot been any opportunity given of making effectual sug-
^BtioDs before the Council had accepted the scheme in
the name of the College. The late Lord Granville, in one
of his happiest moods, compared the London University,
subsisting upon Government grants and threatened with
a Royal Commission, to an old lady who was so blind
that she could not see, so deaf that she could not
hear, and so lame that she could not walk, but who
stiJi thanked God that she had two teeth, one exactly
opposite to the other. He did not know to what special
matter Lord Granville was alluding, but at any rate
there was one advantage which the graduates of the
’University possessed over and above the Fellow.s of that
College, and that was the opportunity of discussing reso¬
lutions before they were carried and of making amendments
before.final action had been taken. At present they were
called together for an absolutely useless purpose, when the
matter had been decided over their he^s. If an oppor¬
tunity had been given, some profitable suggestions might
have been made. They had beard that there had not
been claimed for the Council a monopoly of knowledge
:and wisdom with regal’d to this question, and that was a
reason for giving the rest of the Fellows an opportunity of
■discussing it. He had every reason to expect the vote of
Convocation would not be favourable to the scheme. He
•did not know who had asked for it. It wasutterly destruc¬
tive of higher education, and would tend to destroy the
unity and value of the past degrees of the University of
London. Lord Justice Fry, in his letter to the newspapers,
•said that if the University were to go wrong to-morrow—
which means if it did not agree with him—it would be
& veritable Esau, and find no room for repentance. _ lo
was dangerous to indulge in Old Testament analogies;
^ut if it was desired to find an analogue which would repre¬
sent the action of the Senate in tampering with past degrees,
he would say that they resembled Potiphar’s wife, by
endeavouring to rob them of their only decent garment.
Mr. George Brown and Dr. Robert Barnes having
addressed the meeting, the resolution was carried by alavge
cnajority.
Mr. Timothy Holmes moved: “ That no increase of the
jtower or influence of the Council of the College over
medical education and examination is desirable under
.presentcircnmstances.” He recapitulated the circumstances
which rendered it undesirable that the Council should have
any larger influence upon medical examination and educa-
■tion which they sought to have through this scheme, and
he trusted that if the Members of the College thought with
<him they would voce to that effect. The late history of
cnedical education had been rather that of a curriculum in
which fresh obstacles were continually being placed in the
way of learners. That was a state of things which ought
•to be put a stop to, and if the Council consulted the Fellows
and Members of their College before devising fresh regula¬
tions in this very important mattef it would be put a
•stop to-
Mr. Cable having seconded the motion, thirty voted for
^nd six against it.
Mr. Timothy Holmes moved, and Mr. Joseph Smith
seconded, a vote of thanks to the President, which was
•cordially agreed to.
THE ROYAL SOCIETY.
professor CROOKES’ RESEARCHICS.
The soirees held from time to time by the Royal Society
•always prove of interest from the fact that the exhibits are
generally illustrative of the more recent advances that have
been made in the various departments of science. In view of
•tbe possible importance that the future application of any
•new discovery may have in its relation to the arts «&c., the
principal exhibits at least may be accredited as worthy of
more than mere passing notice. Although at the soiree
held at Burlington House on the 6th inst. the number of
■exhibits was smaller than on previous occasions, they were no
aess interesting in character; and it was scarcely surprising
to find that electrical science has of late proved the more
attractive field of investigation. Electricity and higli
■vacua, radiant matter spectroscopy, and the genesis of the
■elements are subjects which have been, and probablj' will
ever be, associated with the name of the distinguished
physicist, Professor Crookes. On the present occasion be
showed the remarkably brilliant phosphorescent display
exhibited by the diamond; the colours varying, it was
explained, according to the origin of the gems. Thus under
the influence of the induction spark in high vacua, Cape
diamonds are seen in the glass vacuum tubes to phosphoresce
blue; Brazilian diamonds phosphoresce red, orange, blue,
and yellow; and Australian diamonds yellow, blue, and
green. The ruby phosphoresces of a strikingly brilliant
red colour, but the most brilliantly phosphorescent body
yet met with is sulphide of zinc, the hexagonal blende of
Sidot. The specimen shown by Professor Crookes gave
splendid effects. In the stream of electrified molecules it
begins to phosphoresce at an exhaustion of several inches
below a vacuum. At first only a green glow can be seen ;
but as the exhaustion gets better, a blue phosphorescence
appears on the edges. On passing the current at a high
exhaustion, the green and blue are about equal in brightness;
but the blue glow vanishes immediately the current stops,
while the green glow lasts for an hour or more. Apparatus
was also exhibited showing bow the phenomena of radiant
matter, such as the projection of molecular shadows,
mechanical energy, production of beat and phosphorescence,
can be produced in tubes without inside electrodes; also
experiments were shown illustrating that the resist¬
ance of vacuum tubes is dependent on the material sur¬
rounding the poles. In demonstrating this a double vacuum
tube was shown, one side containing carbon and the other
yttria. The fact of whether the vacuum tube contains
yttria or carbon is found to make a difference of 21,160 volts
in the electro-motive force required to cause a discharge
between the terminals. But of still greater interest, per¬
haps, was the apparatus showing the return of exhausted
molecules after having been sliot off from the negative
pole. The free path of the molecules — that is, the dis¬
tance they traverse before colliding with others, as
enunciated in the kinetic theory of gases, which assumes
that collision of molecules in every direction is constantly
taking place—must needs be longer in a space approaching
vacuity, and they are consequently freer to move. In this
condition, and under the inlluenceof the inductionspark, they
are made to pass througli a small hole in a glass diaphragm,
and to actually turn a mill by their impact, and in return¬
ing, passing through another hole, the molecules are seen to
turn a second mill. This was the subject that formed the
beautiful theme of Professor Crookes’ intensely interesting
address delivered early this year before the Institution
of Electrical Engineers. “Electricity in transitu from
Vacuum to Plenum” was the curious title. The genesis
of the elements was illustrated by the well-known model
of the lemniscate curve, a subject upon which was founded
Professor Crookes’ remarkable address as President to
the Chemical Society in 1888. Specimens of minerals
containing the rare earths were also shown. Professor
Crookes has, it is generally known, considerably expanded
our modern ideas of the nature of the atoms, and he has
found the induction spark of immense service in dis-
criniiDating one element from another, and in indicating the
presence of hitherto unknown elements in other bodies, in
quantity far too minute to be recognisable by other means.
So the discovery of the rarer elements and their behaviour
under the influence of the induction spark in high vacua
led him to the famous conception that there are several
ranks existing in tue elemental hierarchy, and that besides
the well-defined groups of chemical elements there are
underlying subgroups to which have been given the name
of raeta-elements.
A very interesting application of electricity was exhibited
by Mr. Shelford Bidwell. It has been known for some time
that the resistance of selenium to a current of electricity in
the dark is diminished to one-half or less by the action of
diffused daylight or by the light of a gus Ilame. Taking
advantage of this curious fact, Mr. Bidwell has constructed
a selenium lamplighter, which will light an incandescent
lamp automatically when darkness comes on, and a selenium
alarm bell for calling attention to the accidental extinction
of a ship’s light or railway signal-lamp. The electric
current passing through the selenium cell is varied by the
action of light sufficiently to make it work a delicate relay,
by means of which a bell may be rung or an incandescent
lamp turned on. A very beautiful series of the alkaloidal
products, the so-called ptomaines, formed by bacteria from
animal tissue, was shown by Dr. W. Hunter. There were
the platinum salts of most of the series, and others were
C-oogle
Thb Lancet,
MEDICAL DEFENCE UNION.
[May 1(5,1891. 1121
seen to consist of crystals of a very definite character,
Mr. J. Howard Mummery, M R.C.S., showed specimens
illustrating some points in the structure and develop¬
ment of dentine. They appeared to indicate that
dentine is formed on a connective tissue foundation,
calcification taking place in the meshes of a connective
tissue stroma ; the bundles of fibres are seen springing from
the dentine substance with which they appear to be incor¬
porated by calcification in or around them. The specimens
showed these bundles of fibres in human dentine, in ivory,
rodent dentine, and in the vaso-dentine of the hake. The
much-speculated-upon subject of colour photography found
illustrationin the firstcolour elfectobtained by M. Lippmann.
who showed the photograph of the spectrum. The red and
green were very marked, but the blue where the actinism is
greatest was not so satisfactory. Professor Emerson
Reynolds exhibited some beautiful specimens of compound
aramonia sulphur-urea preparations. One of them, tetra-
thio-carbamide ammonium bromide (HflNjCSjiNBr, isfound
to effect a very remarkable change in the photographic
image. Thus in the development of the negative in a solu¬
tion containing but r Jug*'- per ounce of the compound urea a
positive is produced. A series of six small photographs
were shown, in which the process of reversal was inter¬
rupted at different stages, so that the transition from a
negative to positive can he traced. At the meeting of the
Chemical Society last week, Professor Reynolds suggested
the phenomenon to be due to sulphurisation of the more
or less changed silver. Amongst other things exhibited of
a less technical but very interesting character were the
iron tools and utensils of the Roman period, recently found
together in a pit in the Roman British city at Silchester,
Hants, and bronze objects of the Roman period found in
the same place. These were exhibited by the executive
committee of the Silchester Excavation Fund, by per¬
mission of the Duke of Wellington. Professor Carrington
Bolton showed specimens of musical sand, so called as on
sudden pressure it yielded a musical sound. The specimens
were from Arabia, the United States, and the Hawaian
Islands. Remains of anomodont reptiles from the Trias
of Karoo, Cape Colony, were exhibited by Professor H. G.
Seeley. This splendid fossil has been very cleverly chiselled
from the matrix by Mr. Richard Hull, by permission of the
trustees of the British Museum. Lastly, during the evening
Mr. Arthur W. Clayden entertained the company with a
demonstration, by means of the electric lantern, of some
very fine meteorological photographs. The photographs of
clouds were taken by rellection from a mirror of black glass,
placed in front of the camera, so that the plane of its
surface made the polarising angle with the axis of the lens.
MEDICAL DEFENCE UNION.
An adjourned meeting of the East Anglian and Midland
Divisional Executive Committee of the Union was held at
the council chamber of the urban sanitary authority,
Alexandra-street, Cambridge, on Friday, May 8th. Dr.
Barnes, divisional president; Mr. Beckett, president for
(Jambridgeshire ; Dr. Grove, for Huntingdonshire; Mr.
Balding, for Hertfordshire; and others were present.
On the motion of Dr. Barnes, who was unavoidably pre¬
vented presiding at the last meeting, Mr. Balding reoccupied
the chair. The honorary secretary, Dr. Mead, read a copy
of the letter which had been addressed to Mr. Joy, in
accordance with the resolution at the last meeting, request¬
ing information as to the grounds upon which Mr. Joy
appeared to question the accuracy of certificates of
death given in four fatal cases; also Mr. Joy’s letter,
in which he repudiated any intention to cast any rellection on
the accuracy or hona Jides of Mr. Fegen’s action
in case.? undoubtedly of great dilliculty and obscurity
in their origin, and expressed his regret that any interpre¬
tation had been placed upon the wording of his report in
any way hostile to Mr. Fegen, especially as at the time
they were on very friendly terms. A letter was also road
from tlie Central Council of the Union advising on the
matter. The Chairman and other gentlemen expressed
their satisfaction at Mr. Joy's letter, and also at the
thorough retractation of any statements likely to be in¬
jurious to Mr. Fegen, published by the editor of the
Thetford Times. Dr. Barnes proposed, and Dr. Grove
seconded, the following resolution: “That this meeting
is of opinion that the explanations are satisfactory, and
they hope that medical oflioera of health will be careful'
so to word their reports as to avoid a meaning being
attached to them prejudicial to their medical confrires;.
and they are of opinion it is not advisable that the names
of sufferers from infectious diseases should be incorporated-
in a report intended for publication.” This was carried
unanimously.
Dr. Mead meptioned the ease of amedical officer of health
in Essex who was threatened with proceedings by an owner
of property for having spoken of the insanitary condition of
certain properties to intending occupiers, stating that in>
such cases, for the medical officer to secure complete
immunity, it would be advisable for him to mention the
facts in his report, and direct any inquirer to the paragraphs-
of such report relating to the properties rather than make-
any statement. In the case mentioned, the committee
were of opinion, if any proceedings were taken against the-
medical officer, he should be defended by the Union. The
committee unanimously resolved to thank Messrs. Barnes,
Beckett, Balding, Beverly, and Mead for the great troublfr
and lengthened correspondence they had incurred in getting,
this matter amicably settled ; also the Mayor of Cambridge
and Dr. Anningson for the use of the Council Chamber. The-
honorary secretary, Dr. Mead, was requested to confer with
Dr. Anningson, the honorary secretary of the district branch
of the British Medical Association, and arrange for the-
holding of a meeting of the division during the June-
meeting at Cambridge. Dr. Barnes proposed, and Mr.
Beckett seconded, that copies of these resolutions be for¬
warded to the medical journals.
In reference to the recent prosecution of Mr. S. E. L. Smith
of Aston, Birmingham, which resulted in his being convicted,
under Section 40 of the Medical Act, 1858, in a penalty of
£20 for " unlawfully, wilfully, and falsely using the title of
M.D.,” and in two further penalties of £2 each for illegally
assuming the titles of “physician” and “surgeon,” Dr.
Leslie Phillips writes to us as follows : “I trust you will’
again allow me to state thatthe Medical Defence Union bad
nothing whatever to do with the prosecution in any shape
or form. The only connexion of the Union with the matter-
is that, the Council having from time to time received
several complaints of the illegal use of medical titles as.
above by Mr. Smith, in consequence the solicitors of (he
Union were in October, 1890, instructed to write to him
pointing out that the course he was piiraiung ‘might place
him in an undesirable position.’ Mr. Smith replied, ‘Ido
not assume anything which I do not possess, or which I
have not honourably and legally obtained.’ The Council of
the Union, having given this warning in consequence of the
complaints they had received, decided to take no further
steps in the matter either by prosecution or otherwise .
It was not until some live months after the termina¬
tion of the correspondence above referred to that the
magisterial proceedings which resulted as above men¬
tioned were taken, at the instance of someone else. I desire
to state most explicitly that neither the Union, nor the
Council, nor any officer of the Union bad anything what¬
ever to do with the prosecution, and that not a farthing of
the funds of the Union, had been or will be applied, directly
or indirectly, for the purposes of that prosecution. Several
questions, however, of considerable interest to the pro¬
fession have arisen out of the proceedings. Thus it has.
been contended that the penal provisions of Section 40 of
the Medical Act, 1858, cannot be brought into operation
against any duly registered medical practitioner. No doixbt
the section was primarily intended to meet the case of un¬
registered quacks, for whoso suppression it is as a rule
employed ; and it is obvious that cases whore a duly quali¬
fied and registered medical practitioner assumes medical
titles which he does not possess must necessarily be of
happily rare occurrence. I may say that the legal advisers
of the Union are clearly of opinion that Section 40 is wide
enough to include in its net all offenders in this respect,
whether registered or unregistered. That this view is
correct seems clear from the remarks of Baron Bramwell irt
18()0, in the well-known case of Ellis Kelly, 30 L. J. M. C.
35, where that learned judge said : ‘ It appears to me that,
on the true construction of Section 40, if any person
wilfully and falsely call himself a Doctor of Medicine
he would be liable to a penalty, although he was in
^8
1.122 Thb Lancet,]
CERTIFICATES OF STILLBIRTH.
[May 16, 1891.
reality a member of the College of Surgeons or of the
Apothecaries’ Company, and wasso registered. ’ The only ques¬
tion, therefore, is what constitutes ‘wilfully and falsely.’
The same learned judge, in a later case, decided in 1872,
Andrews v. Styrap, 26 L. T. N. S. 704, expressed his entire
agreement with the following exposition of these words by
Baron Martin in his judgment in the same case—viz,
•loilfiiUy (for he did it on purpose) and falsely (because he
pretended thereby to be on an equal footing with any
regularly bred physician or M.I).).’ The law, therefore, is
■clear, and the rule of jjracfice approved by some of the lead-
'ing medical corporations is in accordance with it. By way
of a single illustration, I may refer to the following resolu¬
tion passed by a general meeting of the Royal College of
Physicians of London, held on April lOtb, 1876:—‘No
Pellow, Member, Extra Licentiate, or Licentiate of the Col-
'lege is authorised or entitled by virtue of any diploma or
•licence granted by the College to assume the title of doctor
or to append to his name the title of Doctor of Medicine or
■the initial letters M.D., or any other letters indicating that
he is a graduate in medicine of a university, unless he has
obtained a degree in medicine from a university recognised
•W the College, and legally entitled to confer such degree,'
There is no doubt thatmedical, like public, opinion changes
rapidly, and of late years it has become common, in some
parts of the country, at any rate, for medical men who
would not for a moment think of using the title ‘ M.D.,’ to
style themselves ‘ Dr.’ on their brass plates, visiting cards,
&c., although they do not possess any—or any legally
recognised—degree of M.D., or even M.B. It may be urged
that nine persons out of ten address their medical man as
*J)r.,’ but that of itself seems to afford no sufficient reason
for the medical man so styling himself, if he be not legally
entitled to do so. Speaking generally, it may be said that
no diploma, and indeed nothing short of a registrable
M.D degree, can confer the right to use the title‘of ‘ Dr.’
Whether fresh legislation is necessary or desirable is a
moot point on which considerable difference of professional
Opinion will no doubt be found to prevail.”
CEETIFICATES OF STILLBIRTH.
Allusion was made some months ago to the want of
printed forms of certificates of stillbirth for the use of those
medical practitioners who, having large obstetric practices,
or holding appointments to lying-in and maternity charities,
«ire frequently called upon to give such certificates. It
appears that for sometime past books of forms, each con¬
taining twenty certificates with counterfoil for the use of
the certifying practitioner, have been printed for the
Registrar-General. These forms are in every way different
from those for certificates of death, for which they
•cannot be mistaken. The outer cover is blue instead of
light brown, the paper of the certificate is blue instead of
white, while the shape more nearly approaches a square,
'being 3 in. shorter but 2^ in. wider. The wording, moreover,
is of course totally dilf'erent, and each form consists of two
portions numbered respectively 1 and 2. The first is for use
vffien the certifying medical practitioner was in attendance
at the birth, and commences in the usual way, “ I
hereby certify that;” then follow the words “on the”
and a blank space for the date of the birth. Another
blank space follows for the name of the mother, and after
the word “of” a third blank space for the residence. After
this come the words “ was delivered of a child, that I was
'in attendance at the birth of such child, and that such child
was not born alive." The second portion of the form, which
•comes next, is for the use of any practitioner who has
examined the body of the child, but who mtub not in
attendance at the birth. This is worded as follows: “I
have examined the body of a child of which I am informed,
and believe that - of-was delivered on-, 189-,
and I hereby certify that such child was not horn alive."
Below this are the usual spaces for the date, signa¬
ture, qualifications, and residence of the certifying prac¬
titioner; and at the foot this notice: “This certiucato
must be delivered to the superintendent of the cemetery,
•sexton, or other person having control over or burying in
the burial ground to which the body of the stillborn chilk is
takenfor interment.” On the back of each form is a notice
tosuperintendentsofcemeteries, burial board officers, sextons,
and others, giving the whole of Section 18 of the Births and
Deaths Registration Act, 1874. This provides that the
officials in charge of burial grounds shall not permit the
burial of any deceased child as if stillborn, or that of any
stillborn child without (1) a written certificate that the
child was stillborn, signed by a registered medical prac¬
titioner who was in attendance at the birth, or who.has
examined the body; {2)ad6claration signed by a person quali¬
fied according to the statute to give information of a birth,
stating that no registered medical practitioner was present
at the birth, or that bis certificate cannot beobtained, and that
the child was not born alive; or (3), if there has been an in¬
quest, au order of the coroner. Any person acting in con¬
travention of these provisions is liable to a penalty of £10.
Another notice on the outside cover informs registered
practitioners that these forms are supplied gratis upon
application to the registrar of births and deaths for the
subdistrict in which they reside. But registrars cannot
be expected to be very enthusiastic about a subject which
does not concern them and from which they will nob
benefit either directly or indirectly. This probably explains
why these certificates are so little known. They constitute
a step in the right direction, and every registered practi¬
tioner who wishes to have them will know how they may
be procured. There is one great omission which should
be rectified in any future issues. No space is left for the sex of
the child, a most important detail which ought not to have
been overlooked. It would be interesting to know whether the
certificates given by midwives, under which many bodies of
infants are buried, come under the second subsection of
Section 18, and constitute a declaration. Upon these and
other details we shall no doubt have at least some light
thrown by the returns recently called for by Dr. Cameron,
M.P. The registration of stillbirths has for many years
been urged by chose most competent to judge of its necessity,
and cannot be delayed much longer. The present Registrar-
General, Sir Brydges 1’. Henniker, is said to be willing to
listen to suggestions; and when his labours in connexion
with the recent census are over, he would be well advised
to take this matter vigorously in hand. It will not
require any new department .or any marked departmental
changes, the present machinery amply sufficing for this
purpose. A very large proportion of the total number
of stillborn infants will be both delivered and certified
to by registered practitioners; a large additional number
will be medically certified after an external examina¬
tion, though it will be well for young and inexperi¬
enced practitioners to observe great caution, otherwise
they may certify that a child which has lived some time
was not born alive. A third, and we fear a large proportion,
will be delivered by midwives more or less competent, or by
“ handy women,” and declared to. The difficulty hitherto
urged has been as to the foetal age which is to determine
registration, bub this need cause no difficulbyat all. People
are only too glad to bury the bodies of infants, whether still¬
born or deceased, and whatever requires burial requires
registration. As for the coroner's order, it must not be
forgotten that many, if nob moat coroners, are chary of
holding inquests on bodies which are palpably those of
sbillbirtlis, and for which inquests they may have no re¬
muneration, and be surcharged with the expense.
VIRCHOW TESTIMONIAL FUND.
Tllii following additional subscriptions have been re¬
ceived : —
& a. d.
A. O. 1C. Hams, F.R.C.fil. 110
j'i-ankShearor,M.B.,C.M. 110
James Rosn, M.J)., LL.D. 110
A. II, VoiMiK, M.D. 110
F. Chance, M.B,, F.E.C.P. ‘2 2 0
C. K. Bbhvoi', M.B. 110
Sir Geovgo Porter, M.D.,
LL.D.2 2 0
Surgeon • Major ])avicl
Wilkie, I.M.,S.110
Ooorge F. Creoke. M.D.,. 110
SirDycoDut-kwoiihjM.D. 2 2 0
Samuel West, M.D. 110
P. H. Pyo Sinitli, M 1). ..220
John Chieiie, M.D.,
F.R,C.S.1C. 110,
Byrom Bramwell, M.D... 1 1 o[
£ 8. rf.
Sir William Aitken, M.D.,
LL.D.
Sir iSnoncer Wolls.Bart.,.
1
2
1
2
0
0
S. C, Shattock.
1
1
0
Walter Borimrd, F.R.C.P.
1
1
0
C. Sims Wootlhoatl. M.D.
2
2
0
T. Pridgin Teale, F.R.C.S.
0
2
0
H. A, Shiifor, F.R.S.
1
1
0
Pathological Society oC
Manchestor, per iL R.
Hutton, Hon. Ti-oasurer
2
2
0
Sir William Turner, F.R.,S.
1
1
0
W. Mitchell Banks, M.D.,
F.R.C.S.
2
2
0
E. Markham Skerritt,
M.I>.
1
1
0
Die;
The Lakoet,]
HEALTH OF ENGLISH AND SCOTCH TOWNS.
[May 16,1891. 1123
THE CASE OF WILLIAM KERR.
The following correspondence has been forwarded to us
for publication :—
41, Lowther-stroofc, Carlisle, April 28tli, 1801.
Sins,—When on February lltrh you declined to wait for a reply to
your letter dated the 4th, I came to the conclusion that you dirt not
desire to receive my answer. I have now had an opportunity of seeing
the independent testimony you mention, and desire to deal wUh the
parts of paragraph 0 of the memorandum to which you have objected.
‘‘That no tear was discovered before the removal of the womb and
vagina” was an inference drawn from the wording of your own
report, together with tho fact that there was no evidence of bleeding,
which, to my mind, there would have been had tho toars been
Inflicted during life. The “macks” which showed “recent effusion
of blood " I take to be submucous extravasations of blood. The tears
are described as having been met with “ on fiirUmr examination," and
nota word imiicatos that they had bled. Small effusions of blood are
mentioned as occurring in the mucous membrane beyond the tear, but
no mention of abrasion of the mucous membrane is found. Surely
abrasion.s elioulil have been met with. It is true that report speaks of
smearing of blood over the genitals, and that tlie chemise was stained
apparently with ficcal matter and blood, but I gathorfrom your letter to
THE Lancet that you recognise the absence of bleeding from the vagina,
and explain it by saying that tho woman died so quickly after the assault.
The memorandum does not say that you removed tho womli and vagina
in any special way, and I refer you back to paragraph 0, as you will
then see that “ was” and “ is” are two dilfovent words. In whatever
way pelvic organs are I'ODiovotl, I take it that strain and liability to
rupture would be an accompanying circumstance. These are the main
considerations which induced mo to believe that the stjitoments and
inferences complained of in the sixth paragraph ^vero correct, but of
course I accept the statement made by your.selves and J)r. Walcot.
tliat you saw what appeared to bo tears in tho mucous membrane, and
on further examination—i.e., after removal of the parts—yonr surmise
E roved to be con-ect, a,nd the tear.s wore discovered in the places you
ad indicated. That -soft parts may show traces of iocoralion and rup¬
tures in tlio cour.SH of post-mortom oxatninatioiis is haially open to
doubt, whatever part of the body is concerned, and in making the sug¬
gestion that la fmmd in the memorandum no imputation of carelessness
was implied or oven thouglit of, and I regrob that I should have sug¬
gested anything which bore to you that meaning.
I am, airs, yours faithfully,
Hr.s. Barnes and Maclaren, Carlisle. U. A. LicdIakd.
Carlisle, May 0th, 1801.
Sir,—W e are in roooipt of your letter of the asth ult., which has
received our caroful consideration. When we wrote to you on Fob, Obh
it seemed to us that tlvo days ivas sufiicient time for tho retractation of
the allegations which wo specified in our letter of Feb. 'Jth, and which
we informed you were entirely unfounded. Having recently had tho
opportunity of perusing tho independent evidence referred to by us in
our Ilvst letter, you now forward what appears to us a retracta¬
tion, and we of course accept both your statement that “in
making the suggestion which is fouinl in the meinorandum
no imputation of carelessness was implied or even thought
of,” and also your expression of regret that you should have
suggested anything whicli bore to us that meaning. Wo aro sorry,
however, that in ilealiiig with tho statements in Paragraph (j in the
earlier portion of your letter wo are unable to accept as correct either
your f.acbs or your inferences. Our olfort was to make as lliorough an
investigation as possible, and to state all the facts and appearances
that came under our iiotico, whether they told for or against Kerr ; and
we should have had pleasure in placing at your service, at any stage of
yourelforts on behalf of the convict,correct information on any point
which aoomod to you to need further elucidation.
As you seem to have forwarded copies of the meniorandum to the
press, and as a dill'orent interpretation has been put upon your words
in leading arbiele.s, and by many of our friends, we iulund to send thi.s
letter for publication, and if you wish it, and inform us of the wish
before to-morrow night, we shall be glad to forward a copy of your
letter also.—Yours fiuLlifully, Henry Barnes,
To Dr. Lodiard. Uodeiuck Maci.aren.
41, Lowbhor-sti'oet, Carlisle, May 7tii, ISOi.
Sirs,—' fliero can 1)0 ho objection to the entire correspondence being
published in the medical pipors in full, ami in the local papers in »s
full a manner as is coiisistoiit with puhlic decency. You must not mis¬
understand mo. however. At no time did I say. nor did I wish to
imply, that Uiero had heun negligonl or incapable conduct on your
part. If any words would sooin to boar that con.stritction, I ropmliato
them. Jhit.[ Iiavo not tnodiliod my bolioC that you were mistaken in
the conclusions you arrived at; ami in the intere-sls of public justice I
jntoiul to adopt tho suggestion made U> me—i.e., to petition the Colleges
of J’hysicians and .Surgeons of England to consider the case of William
Kerr.—I am. Sirs, yoiu’.s faithfully. If, A, l,i;niARi).
Drs. Barnos and Maclaron, Carlisle.
VITAL STATISTICS.
HEALTH OF ENGLISH TOWNS.
In twenty-eight of the largest English towns (1155 births
and 5555 deatlis were registered during the week emiing
May 9th. The annual rate of mortality in these towns,
which Jiad increased from 22’5 to 26'8 per 1000 in the pre¬
ceding three weeks, further rose to 28'!) last week, which,
with three exceptions, was higher than that recorded in
any week since 1882. Tho rate was 210 in London and
32'9 in tho twenty-seven provincial towns. During the
first five .weeks of the current quarter the death-rate in
the twenty-eight towns averaged 251 per 1000, and ex¬
ceeded by 3'7 the mean rate in the corresponding periods
of the ten years 1881-90. The lowest rates In these towns
last week were 18 0 in Bristol, 19'2 in Brighton, 19'2
in Bolton, and 23‘3 in Sunderland; the highest rates
were 40'0 In Bradford, 43 6 in Manchester, 48 3 in
Leeds, and 59 3 in Sheffield. The very high rates in the
last-mentioned toivns were due to the severe epidemic of
Inlluenzi. The deaths referred to the principal zymotic
diseases, which had increased from 420 to 462 in the
preceding three weeks, declined last week to 442; they
included 189 from whooping-cough, 112 from measles,
43 from diarrhma, 34 from “ fever ” (principally enteric),
32 from scarlet fever, 31 from diphtheria, and one from
small-pox. These diseases caused the lowest death-rates
in Brighton, Cardiff, Norwich, and Derby, and the highest
in Iladdersliold, Leicester, Manchester, and Portsmouth.
The greatest mortality from measles occurred in Bradford,
Preston, Bristol, Huddersfield, and Portsmouth; from
scarlet fever in Bradford; from whooping-cough in Liver ¬
pool, Oldham, Plymouth, Leicester, and Manchester; and
from “fever” in Leicester. The 31 deaths from diphtheria
included 21 in London and 2 in Manchester. Small-pox
caused one death in Liverpool, but not one in any of the
other twenty-eight large towns; 33 small-pox patients
were under treatment in the Metropolitan Asylum Hos ¬
pitals, but not one in the Higbgate Small-pox Hospital
on Saturday last. The number of scarlet-fever patients
in the Metropolitan Asylum Hospitals and In the London
Fever Hospital at the end of the week was 911, and
allowed a slight further decline from recent weekly num¬
bers; the patients admitted during the week were 79i,
against 85 and 100 in the preceding two weeks. The deaths
referred to diseases of the respiratoiy organs in London,
which had been 471 and 588 in the preceding two weeksn
were 584 last week, and exceeded by 240 the corrected
weekly average. The causes of 95, or 17 per cent., of tho
deaths in the twenty-eight towns were not certified either
by a registered medical practitioner or by a coroner. All
the causes of death were duly certified in Portsmouth^
Norwich, Plymouth, Wolverhampton, and in four other
smaller towns; the largest proportions of uncertified death?
were recorded in Liverpool, Oldham, Sheffield, and Hull.
HEALTH OF SCOTCH TOWNS.
The annual rate of mortality in the eight Scotch towns,
which had been 22-1 and 23'i per 1000 in the preceding
two weeks, further rose to 23'9 during the week end¬
ing May 9th, but was O'O below the mean rate that
prevailed during the same period in the twenty-eight large
English towns. The rates in the eight Scotch towns ranged
from r2'3 in Perth and 13 0 in Greenock to 29'3 in Glas¬
gow and 31 5 in Paisley. The 625 deaths in these towns
showed an increase of 22 upon the number in the preceding
week, aud included 25 which were referred to whooping-
cough, 22 to measles, U to scarlet fever, 6 to diarrhoea, 5-
to “fever,” 3 to diphtheria, and not one to small-pox.
In all, 72 deaths resulted from these principal zymotic
diseases, against 90 and 80 in the preceding two weeks.
These 72 deaths were equal to an annual rate of 2'8 per
1000, which exceeded by 0'5 the mean rat-e from the
same diseases in the twenty-eight English towns. The
fatal cases of whooping-cough, which had been 32 and
25 in the previous two weeks, were again 25 last week,
of which 11 occurred in Glasgow, 6 in Edinburgh, and 6 in
Dundee. The deaths roferrea to measles, which had been
43 and 30 in the preceding two weeks, further declined last
week to 2'2, and included 10 in Glasgow, 8 in Paisley, and 4 in
Edinburgh. The 11 fatal cases of scarlet fever showed a-
further increase upon recent weekly numbers; 7 occurred
in Glasgow and 2 in Aberdeen. Of the five deaths re¬
ferred to “fever,” 2 were recorded in Aberdeen. The 5
fatal cases of diphtheria were fewer than the number in
any recent week, and were ail recorded in Glasgow. The
deaths referred to diseases of the respiratory organs in these
towns, which had been 143 and 146 in the preceding two
weeks, further rose to 157 last week, aud exceeded by
28 the number in the corresponding week of last year.
The causes of 53, or more than 8 per cent., of the deaths
in the eight towns last week were not certified.
HEALTH OF DUBLIN.
The death-rate In Dublin, which had been 23'0 and 24’4
per 1000 in the preceding two weeks, further rose to 26'4
Coogle
1124 Thb Lancet,]
THE BRITISH INSTITUTE OF PREVENTIVE MEDICINE.
[May 16,1891,
daring the week ending May 9bb. During the first five
weeks of the current quarter the death-rate in the city
averaged 26‘4 per 1000, the rate for the same period being
21'8 in London and 19*7 in Edinburgh. The 179 deaths
in Dublin during the week under notice showed an
increase of 14 upon the number in the preceding week,
and included 4 which were referred to whooping-cough,
1 to “fever,” 1 to diarrhoea, and not one either to small¬
pox, measles, scarlet fever, or diphtheria; in all, 6
deaths resulted from these principal zymotic diseases,
against numbers declining from 8 to 4 in the preceding four
weeks. These 6 deaths were equal to an annual rate of
0'9 per 1000, the rate from the same diseases being
a in London and 2'8 in Edinburgh. The fatal cases of
whooping-cough, which had declined from 7 to 0 in the
previous two weeks, were 4 last week. The mortality from
■“fever” and from diarrhcea showed a decline from that
recorded in the preceding week. The 179 deaths in Dublin
last week incluaed 29iof infants under one year of age and
48 of persons aged upwards of sixty years; the deaths
both of infants and of elderly persons showed an increase
upon the numbers in the previous week. Two inquest
•cases and 2 deaths from violence were registered during
the week, and 56, or nearly a third, of the deaths occurred
in public institutions. The causes of 19, or more than
10 per cent., of the deaths last week in the city were no
certified.
THE SERVICES.
Akmy Medical Staff. — Surgeon-Major Poole Robert
■Gabbett is seconded for service on the Stafi (dated Jan. 23rd,
1891).
Naval Medical Service. —The following appointment
has been made at the Admiralty: — Surgeon Percy W.
Bassett-Smith to the Penffuin (dated April i7th, 1891).
Volunteer Corps. — Rifle; 1st Cadet Battalion, the
Manchester Regiment: Acting Surgeon A. Hopkinson
resigns his appointment (dated May 9th, 1891).—1st Volun¬
teer Battalion, the Royal Scots Fusiliers: Surgeon W.
Frew, M.D., is granted the rank of Surgeon-Major, rank¬
ing as Major (dated May 9bh, 1891).
" Audi alteram partem.”
THE BRITISH INSTITUTE OF PREVENTIVE
MEDICINE.
To tJiA Editors of The Lancet.
Sirs,—A t a meeting held at the Mansion House on
Dec. 5th, 1889, an Executive Committee was formed to take
measures for the purpose of establishing in England a
British Institute of Preventive Medicine. The work to be
undertaken in the Institute was to be similar to that
carried out in the Pasteur Institute in Paris and in the
Hygienic Institute in Berlin. The Executive Committee
comprises Sir Spencer Wells, Sir James Paget, Sir James
Crichton Browne, Sir George Humphry, Sir Henry Koseoe,
Sir James Wilson, Professors Brown, Huxley, Horsley, Kay
Lankester, and Pemberthy, Dr. Bridgwater, Dr. Holman,
Mr. Jonathan Hutchinson, Mr. Watson Cheyne, Dr. Donald
McAlister, Dr. Withers Moore, Mr. E. Hart, Mr. Sidney
Turner, and myself, with Professor C. S. Roy and Dr.
Armand Ruffer as secretaries.
On Feb. 13bh. 1891, Messrs. Hunter and Haynes, the
solicitors to the Executive Committee, made an application
to the Board of Trade, praying that the Institute might
be registered as a limited liability company with the
omission of the word “ limited,” in order that the
public, who are to be asked for subscriptions, should be
impressed with the fact that the objects of the Institute
were of a purely charitable and solentilic nature.
Shortly afterwards our solicitors were informed by Mr.
Courtenay Boyle, Secretary to the Jioard of Trade, that
a number of petitions had been sent in praying the
Board to withhold its licence on the ground that experi¬
ments on living animals would necessarily be per¬
formed in the Institute. The Executive Committee then
requested me to write a letter—a copy of which I enclose—
to the President of the Board of Trade, pointing out why,
in their opinion, their opponents should not gain tuelr point.
This letter was posted oy our secretary. Dr. Armand Ruffer,
on Wednesday evening, May 13tb, 1891; but, on the same
day, the solicitors to tbe Committee received a communica¬
tion from the President of the Board of Trade to the effect
that the Board, without giving any reason whatsoever, had
decided to withhold its licence from the Institute.
As chairman of the Committee, I now write to you. Sirs,
asking you for some space in your columns to point out
these facts to the medical profession, and to ask their sup¬
port in this struggle against prejudice and ignorance. The
Committee have asked the President of the Board of Trade
to receive a deputation in order to lay the matter fully
before him, and, should be agree to do so, they hope that the
medical profession will help them in rendering the deputa¬
tion as influential and representative as possible. In any
case, they hope their medical brethren will assist them in
bringing’this matter before Parliament and the public if
necessary. I am. Sirs, your obedient servant,
JosEi'ii Lister.
P.S.—The Executive Committee of the British Institute
of Preventive Medicine would be glad to receive sugges¬
tions &c. from gentlemen willing to help them. All letters,
communications, &c., should be addressed to Dr. Armand
Ruffer, 19, Iddesleigh Mansions, Westminster, London, S. W.
12, Park-ci'osconl, Portlai)d-plac 0 , London, 'W.
PRITIHU INSTITUTE OF PREVENTIVE MEDICINE.
To the Right Honourable Sir Michael IIi<;k3-lJoach, Bart., President
of the Board of Trade.
Sir,—O n the 13th of February of the present year Messrs. Hunter
and Haynes, Solicitors to the Executive Committee of the British
Institute of Preventive Medicine, applied to the Board of Trade
for permission to have the Institute registered as a limited
liability company with the omission of tlie word “ limited."
The olyecta for wliich the Committee are anxious to establish the
Institute are sufficientiy explained in the “Memorandum of Associa¬
tion," and in making the application tlioy wish to impress the public,
who are to be asked ?or subscriptions, with the fact tliat tho ob.jects of
the Institute are of a purely charitable and scicntilie nature.
Shortly stated, the work to be undertalcen by the British Institute of
Preventive Medicine would be the same as is carviod out in similar
Institutions in Fi-ance, Germany, Italy, Roumania, Austria, Turkey, and
Brazil. In all those countries bacteriological institutes have been
founded by tho State. The advantages to tlie community at large from
scientittc worlc in hygiene has led to tlie endowment of such institutes
with land and capital in order that bacteiiotogical investigations may
be carried out by skilled workers under the best possilrle conditions.
The Committee do not expect that tho J'lnglish Government will do the
same for them, but tlroy may roasonahly expect that it will not impede
a charitable and scientific schomo. Tho Committee has been informed
by Mr. Courtenay Boyle, Secretary to the Board of Trade, that a number
of petitions have been sent in, praying that the Board of Trade may be
inoix'd to withliold its licence from the proposed assoc iation; and, tlianks
to tlie courtesy of the same gentleman, they have been able to obtain a
copy of these petitions, which copy was considered by tiio members. To
their great astonishmont, they found that the only olijeotion brought
forward w.'us the fact that it is proposed to perform experiments on living
animals in the Institute. It is not thoir intonlion to diacu.ss here tho
ethics of vivisection, but to point out wliy, in their opinion, the
petitioners should not be allowed successfully to opjioso tho application
of tlie Committee. The (fommittee do not a.sk the Board of Trade to
grant tlioin a licence to perform such experiments. It would be abso¬
lutely u-seiess for them to do so, for the granting of vivisection licences
is, and always lias been, under tho control of the Swrotary of State
for tliellomo Department, wlio, slionld tliey wish topor/onnexperiments
on animals, may or may not allow them to do so. Tho Board of Trade
has not tho power of giving a vivisection licence. What tho Gommittoo
do ask from tho Boarti of Trade is that it .shall permit tho Institute to
bo rogistcrod under iSectioii 23 of the (.'ompanios Act, 18117, so that
they may ask the public for subscriptions to an underlaking of
i national impovtanco. Tho case of tho Marino Biological Association is
parallel; no difficulty or question was raised about tlio Board of Trade
granting thoir perniissiOD to that body to register in lire way above
hotorl, but .should tho members wish to imrtorm experiments on living
animals, they bavo to got tho pormission of the Homo Office. The (Jom-
mittoo liugtliorotoro to submit that the granting by the Board of Trado
of tlie Ik'onco asked for would not in any way encroach upon tlie
{ irovincooftho Homo Office, as the question of vivisection will come
leforetho Home Secretary if ever a licence to perform oxperimouts on
living animals is applied for.
One of the reasons which make the Gommitteo anxious to obtain the
licence of the Boar<l of 'J'rado is that it appears that the Institute can¬
not he registered undor tho Companies Act. 1802, as a limited liability
: company without serious interference with its prospects. They gucIosh
' oonnaol’s written opinion, wlioroin it is evhleiit that, should the Institute
' bo so registered under the Act, it would at any time be po.ssible for tlie
members to wind up the company and divide tlie money. No one would
onclow tlio Institute witli fiunis under siicli conditions; whereas tho
Board mightmako it a condition of granting tlieir licence that all tho
propoi’ty of tiio Institute sljonld l>o applied to the ailvancemont of
science and kiiid-ed subjects only, ami int be distributed among tho
members. In tliia way a security would be given lliat the funds would
bo applied for tho piiiiioses iiitemled.
Tlie question is one of great jniblie interest and importance, and the
I Commitleo trust that, if you hesitate to comply with their request to
t Goocle
The Lancet,)
THE influenza.
[May 16,1891. 1125
Dermit the Institute te he reciatevod as a limited liability company with
the omission of the word '‘limitod,” you will do them the honour to
receive a deputation in order that the facts may he more fully placed
before you. Iloqiiestinff the favour of an early reply,
I have the honour to be, your obedient servant,
JO.SKl’lC LiSTKtt,
May I3th, 1891. Chairman of the Executive Committee.
THE INFLUENZA.
To the Editors of The Lancet.
Sms,—The recent return of influenza- in the epidemic
iform marks the present time as appropriate for recording
the impressions which have been gathered since the disease
began to spread over the country towards the close of the
year 1889 ; and it seems to be the more desirable to do so
as the catarrhal symptoms which occasionally coincide with
an access, and the grave complications which too often
follow in its train, have a tendency to withdraw atten¬
tion from the essential nature of the malady and from those
(precautions which are so much needed in that stage which
is too often assumed to be one of recovery, but which is, in
fact, an integral and perilous phase of this insidious
■disease. In order to make my meaning clear, I would call
attention to the theory which was broached in the columns
■of The Lancet, though not for the first time presented to
medical opinion, rather more than a year ago. I allude to
'the view that influenza is essentially an affection of the
cerebro-spinal nerve centres, and that the various catarrhs
and local inflammations which are apt to accompany or to
follow pvimaiy attacks, and may precede as well as follow
subsequent accesses, are of the nature of complications and
the natural outcome of a condition which is pregnant with
.grave, although it may be unexpected, possibilities. In
support of that theory, f will do no more than briefly review
•the symptoms which disclose the true nature of influenza in
both its stages, although it must be conceded that in some
■of the milder cases, especially among the very young, they
may be so faintly marked and so transient as to elude
observation. The more conspicuous may be summarised as
•follows. In the first stage, pain in the post-orbital and frontal
regions, extending to the vertex and occiput and thence to
the back, loins, and extremities, and rapidly followed in a
•considerable proportion of instances by tenderness evoked by
percussion of the spinal region, more particularly of the
situation of one or more of the medullary enlargements;
in the second, altered cerebration and abeyance or perver¬
sion of the functions of the spinal centres as indicated by
impaired power of mental concentration, loss of memory,
■depression of spirits, irritability, difficulty of verbal ex¬
pression, vertigo, night terrors and illusions, polyuria, loss
■of ocular accommodation, rapid wasting and anmmia,
difficulties of respiration, cardiac debility and irregularity,
rgeneralvaso-motor paralysis,causeless sweating, general loss
of muscular tone and energy, and even of correlation,
peripheral ncurose.? too numerous to be specified, and lastly,
but not least important, loss of body heat, either continuous
■or induced, by even slight exertion of either mind or body,
■and ranging from one to four or more degrees below normal.
Leaving aside the consideration of the catarrhal ailections
■of the respiratory and digestive tracts, induced mainly, as
I believe, by the direct contagion of fluids which travel
■along their channels, I ask, Can it be matter for surprise
that the organism so gravely attacked in the very
■centre of its life should fall an easy prey to influences
•which under other circumstances would bo harmless or
•insignificant, or that a condition, which is too often
regarded as one of recovery, should need the protec-
•tion of such nurturing care, as many have not the
■patience to endure, unless seriously warned of the dangers
which carelessness may entail? It would appear to be
■sufficiently obvious that the loss of flesh and depression of
body heat indicate that the second and really perilous
stage of influenza is one in which power of repair is not
competent to make good the daily waste, and the diiiunu-
•bion of healthy tissue change (due possibly to damage
inflicted on the trophic centre) reduces the body heat to a
point which, even it those two conditions stood alone, might
•easily involve danger to health and to life. Such I hold to
be the case, and, further, I believe that this period of vital
■depression may be indefinitely prolonged by ellbrts to resume
habits of mental or bodily activity before the temperature
ceases to be liable to subnormal depression, ana a pro¬
gressive increase of body weight affords indication that the
balance of waste and repair has been duly adjusted. In
fine, influenza bears the stamp which is common to diseases
which involve damage to important nerve centres, and
demands, as a condition of staole convalescence, a longer
period of functional repose than do those in which less
delicately organised structures are primarily involved; and,
as might be expected from the universality of the mischief
it inflicts on the nervous system, it exhibits an exceptional
tendency to visit impatience and imprudence with the
penalty of relapse, or even of deabh-
I am. Sirs, yours faithfully,
May 9fcli, 1801. W. BeZLY ThORNE.
To the Editors of The Lancet.
Sirs,—W e hear that authorised inquiry is being, very
properly, made into the causation &c. of this malady. But,
meanwhile, cannot someone competent to speak on the
subject of isolation and disinfection generally advise us as
to the probable utility or otherwise of subjecting our bodies,
clothes, and houses to processes usual after invasions of
other diseases of an infectious character? I am bold,
perhaps, in thinking that no one who has persistently and
consistently applied heat or sulphurous acid fumigations
after such outbreaks can doubt a very pronounced efficacy.
But hitherto we have relegated influenza to the limbo of
diseases impossible to be dealt with by isolation, and with
no attempt to minimise the quantity of poison diffused.
Even while nob attempting to isolate measles and whooping-
cough on a large scale, we still often succeed in preventing
their spread within the very narrow limits of a not very
large dwelling, and by so much limit the outside spread.
The present Attorney-General once said to me “that he
had come to the conclusion that any place as large as
London must be so filled with infectious germs of all kinds
that any person presenting an appropriate nidus could
hardly ever escape.” But why do we hear recommendations
of immense expenditure on isolation and disinfection, in
almost every large community, if there be no more virtue
in them than sometimes appears in the scamping builder or
the perfunctory clerk of the works ? I do very earnestly hope
that some discussion of this matter in respect of influenza
may kindle some better hope in the breast of the anxious,
who now are partially comforted only by prophylactic doses
of ammoniabed tincture of quinine and assurances that
“really, after all, the mortality is nob so very great
relatively." I am, Sirs, yours truly,
Wolverliaiiipton, May lOfch, 1891. FREDERIC E. MANHV.
THE USE OF CHLOROFORM.
To the Editors of The Lancet.
Sirs,—D r. Dudley Buxton cannot be allowed to depart
from his original statement. He described bis method of
giving chloroform in the following precise terms (the italics
are mine): "My plan is to use Lister’s open method or
Krolme and Seseraann’s useful modification of Junker’s in¬
haler. I also make it a rule to test the vigour of respiration
by placing my hand on the mouth, and to keep a finger
upon an artery.” lb is thi.s plan which I ridiculed. Dr.
Buxton now dexterously tries to make it appear that my
criticism was directed against Junker’s inhaler, and that he
gives chloroform on Syme’s principles, though Syme never
took the pulse aa a guide. Dr. Dudley Buxton’s plan is
impracticable, and its absurdity is only surpassed by
the absurdity of the method of another specialist, Mr.
ilickard W. Lloyd. Mr. Lloyd proceeds to give chloroform'
“ with the sprinkled lint lying on the separated fingers of
my right hand in front of the mouth, which enables me to
feel the force of expiration, with my left middle linger on
the left temporal pulse, and my left thumb holding up the
left upper lid of the patient and testing the corneal reflex
wl:en necessary.” Mr. Lloyd thus endeavours to obtain
information as to the state of the patient from three if not
four distinct tactile impressions at the same time, which
is just as dangerous as it would be for one of my
students to administer chloroform to three or four patients
all at once. Dr. Dudley Buxton further states that I must
have had many cases of heart failure under chloroform
which I have overlooked, because “Surgeon-Major Lawrie
has never felt the pulse during cbloroformisabion.” The
1 Vido Tiil; Lancut, Apnl 4Ui, 1S9I.
L.oogle
1126 Thb Lancet,] THE COMMITTEE ON BRITISH AND FOREIGN SPIRITS.
[May 16,1891.
whole of this atatement is a gratuitoi\s invention. All my
operations are performed in public; I have never had a case
of heart failure, and I frequently take the opportunity of
demonstrating that the action of the heart and the pulse
are invariably regular when chloroform is properly adminis¬
tered. I do not allow the pulse to be taken as a guide as to
the effect of chloroform, because 1 know it is no less useless
than dangerous.
Finally, Dr. Dudley Buxton asserts that the Hyderabad
Commission has not proved that there is no such thing as
chloroform syncope, because *‘its conclusions are based upon
purely negative evidence.” If Dr. Buxton were as familiar
with the A B C of logic as he would have us believe he is
with the A B C of the chloroformist’s duties, he would know
that proof of the absence of anything must always be
negative proof. The rest of Dr. Dudley Buxton’s letter con¬
sists of a bald statement of creed, unsupported by any
explanatory reasons, and does not call fur further notice.
I am, Sirs, jour obedient servant,
May nth, 1891. Edward Lawkie, Surgeon-Major.
THE COMMITTEE ON BRITISH AND FOREIGN
SPIRITS.
To the Editors of The Lancet.
Sirs,—I quite agree with the remarks contained in a
leading article in your last week’s issue on the report of the
British and Foreign Spirits Committee. As yet no
authorised report of the committee has been published, but
the one which has appeared in the newspapers contains the
passage: “Dr, Pavy considers that the silent spirits are
innocuous as regards health, although they are insipid
and disagreeable.” As you rightly observe, under the line
of argument taken, such a statement brings the spirits of
common use into the position of producing no injurious
effects. I am not, however, responsible for the wording of
the report in question, and the word “innocuous” was not
used by me, and nowhere appears in the shorthand writer’s
notes of my evidence; nor did I speak of an “insipid”
article as being “disagreeable.” What I did say was
that plain or silent spirit is more innocent than spirit with
the by-products, and that the insipid plain spirit
is rendered agreeable through the presence of the by¬
products in the same way as insipid food is rendered
agreeable by condiments.
I am. Sirs, your obedient servant,
Grosvenor-streot, May 13th, 180L F. W. PavY.
PRIVATE DRAIN VENTILATION.
To the Editors o/’Thb Lancet.
Sirs,—T he statement of Dr. E. Duncan, as quoted in
your issue of May 2nd, to the effect that “ there is, in
fact, no gas in a sewer that you may not find outside of it,”
and that “the air of a sower, when it is properly ventilated,
is much better from the chemical point of view than the
ait of crowded churches and schools, or even than the air of
the houses in which one-half of the population of Glasgow
lives,” is worthy of a far more extended practical applica¬
tion than is given it by sanitary authorities in Europe. The
writer, as a sometime sanitary inspector in a large American
city, baa been often surprised at the opposition made here
and on the Continent to a plan of ventilation moat com¬
monly in use in the United States, and, so far as he knows,
almost uniformly successful. Its principle involves the
use of conduits and conductors arranged in the shape of an
inverted syphon, the long arm of which is the “standpipe,”
into which all closets and bathe discharge, which passes
directly into the open above the roof in equal calibre as
below, and which ascends always in the immediate proximity
of a chimney flue in constant use. So far, continental and
insular engineers agree with us, but the crux of the whole
matter lies in the position of the shorter syphonic arm,
which opens at the ground level through a grating, and
communicates of course outside the house with the main
drain, the latter being trapped between such communica¬
tion and the street sewer. I have often tested these
adaptations both in winter and summer, the Ilame of
burning paper being uniformly sucked down through the
gratings and blown upward from the roof pipes, thus prov¬
ing the existence of perfect ventilation, with all the security
it affords. The fact that I have, in many years’ inquiry,
never seen such effective arrangements in England must be
my excuse for calling attention to the important and un¬
doubtedly true assertions of Dr. Duncan.
I am. Sirs, yours very truly,
H. Webster Jones, M.D. Yale, U.S.A.
Cavendiflli Mansions, May 0th, 1801.
“ THE BREATHING OF A VEIN.”
To the Editors of THE Lancet.
Sirs,—I n an interesting and learned article “ Concerning
Bloodletting” published in to-day’s issue of The Lancet,
Dr. John W. Ogle recalls Sydenham’s description of the
operation of venesection in certain cases, as “ doing the
work of the windpipe”; and in a footnote states that the
translator of Sydenham sometimes renders “ venam
incidere ” “ to breathe a vein.” Dr. Ogle further remarks
that the etymology of this expression is not very obvious,
hut quotes the opinion of Dr, Murray, editor of the New
Philological Dictionary, to the effect that the words “breath¬
ing a vein ” are equivalent to “taking into it breath or air.’”
But, as Dr. Ogle shrewdly observes, “if this be so, the
phrase is used without regard to physiological facts.”
Some years ago I endeavoured to make out the meaning
and origin of this expression which occurs in Dryden's
Poem on the death of Oliver Cromwell.
“ War, our consumption, was their gainful trade ;
We inward bled, whilst they prolonged our pain;
lie fought to end our fighting, and assayed
To stanch the blood by breathing of the vein.”
I arrived at the conclusion that the word “breathing” in
this connexion was related to the Welsh word brathu (pro¬
nounced “biilth'e”), “to pierce,” “brathu gwythen,’”
meaning to pierce or open a vein. The Welsh word “to
breathe ” in the sense of respiring is “ anadlu.”
I am. Sirs, yours truly,
Harley-street, W,, May 9th, 1301. JOHN TWEEDY.
RARITY OF PHTHISIS IN THE MEXICAN
PLATEAUX.
To the Editors of The Lancet.
Sirs,—I read in The Lancet of the 18th insfi. your
notice of the “ Causes and Prevention of Phthisis,” by
Dr. Ransome. Your reviewer wishes for some authorita¬
tive information regarding the extreme rarity of phthisis
in the Andes and Mexican plateaux. Havipg practised
many years (twenty-four) at BogotA, United States of
Colombia, my experience there is that phthisis is almost
unknown, only one case in a native resident coming under
my observation during that time. There can be no doubt
as to the comparative immunity of its inhabitants from this
disease in the elevated regions mentioned. English visitors
have much improved in health, the progress of the disease*
apparently being arrested.
I am, Sirs, yours faithfully,
South KensingtoD, S.W., April 27tb, 1801. W. L. DUDLEY.-
BIRMINGHAM.
(From our own CoRiiEsroNDENT.)
Complimentary Dinner to Sir Walter Foster, M.P.
On the 13th inst., at the Midland Hotel, Birmingham, a-
large number of students and practitioners gave a dinner to
Sir Walter Foster, M. P., on his retirement from the acting staff
of the General Hospital. The chair was taken by Mr. Jordan
Lloyd of the Queen’s Hospital, and he was supported by
Dr. Rickard.s, Dr. Simon, and Dr. Malins of the General
Hospital, with Dr. Snckling, Dr. Carter, and Dr. Purslow
of the Queen’s Hospital. The chairman referred in eulogistic
terms to Sir Walter Foster’s long and eminently successful
career in Birmingham. Mr. Leonard Ganigee then read the
following address, which was signed by over three hundred)
names:—
To «1K WALTER FOSTER, K.R, M.P.,M.D,, F.R.C.P.
{ConsvlUnf/ Pli’jsician to the Clcneral Ilosjiilal, Smior Professor of
iledidne in Qwu7i's CoUene, IJCrininf/ham, Member of
the Oenaral McdicaC Counoil.)
We, the undersigned Past and Pi'oaeut SUidenta of the Bivminghan}
School of Medicine, and other morabers of the inodlcal profession, feel
that we cannot lot pass the occasion of your rosignatiou of tlie post of
Digr /■ uy lOO^IC
The Lancet,]
NOKTHERN COUNTIES NOTES.
[May 16,1891. 1127
lionorn.ry physician to the Qonoral Hospital without expressing our
appreciation of tile benefits we iiave received at your hands, and of tlie
valuable services you have rendered to the Birmingham Medical School.
Your connexion with the (Juoen’s and General Hospitals—extending
over a period of twenty-five years,—the value and originality of your
clinical lectures, the soundness of your teaching, and your never-failing
kindness and courtesy, have been such as to merit the highest esteem
of the suceossive generations of students who have proUtod by your in¬
struction. Wo trust that you may be spared for many years to enjoy
health and prosperity, and may continue an active member of that
profession which you have .served so faithfully and so well.
In reply. Sir Walter Foster alluded in feeling terms to the
friendsiiips he bad formed and the universal consideration
he had always met with from the students of the Birming¬
ham School of Medicine. He still hoped to spend many
more years of active service among them, and to continue
his duties as Professor of Medicine in the College.
Hospital Saturday in Birmingham.
Strenuous efforts have been made this year to bring the
total amount of this collection to £10,000. There is every
reason to believe that this will be more than realised when
the returns are finally made up. If so, it will be a splendid
commentary upon the energy and activity of those who
have organised and conducted such a laudable enterprise.
Birmingbam, May 18th.
NOETHERN COUNTIES NOTES.
(Feom our Own Correspondent.)
Opening of Dame Margaret's Home at Washington.
Some few years ago, as noted in this correspondence. Sir
Lowthian Bell made an offer of his seat, Washington Hall,
near Durham, to the Corporation of Newcastle, to be used
as a Convalescent Horae. Some legal difficulties, I under¬
stand, prevented the Corporation from accepting the
generous offer. Meantime, Sir L. Bell's intentions as
regards the purposes of the hall in the future have not been
allowed to drop. Cn Saturday last it was opened by the
Mayor as a Homo for Waifs and Strays, under the title of
“Dame Margaret’s Home.” Theworkof this charity hasbeen
carried on at C-osforth, a suburb of Newcastle, by Miss
Watson, the philanthropic lady who originated it; and
now Sir Lowthian Bell’s desire is fulfilled, and the name
of his departed wife, as he feelingly expressed it, will in
the future be associated with this beneficent work. As well
as the poor children received under the wide term of waifs
and strays, it is also intended to receive nearly 100 children
in the year from the Royal Infirmary, Newcastle, and other
medical institutions of the live northern counties in the
year as convalescents. American tourists will still visit
Washington, county Durham, from its associations with
the family of their great general and patriot, for fi-om the
the family of Wessington, who held this manor {temp.
Richard III,), John Washiogton was descended, from whom
the ninth in descent was the famous George Washington,
first President of the United States.
Cumberland.
At the last meeting of the Carlisle Microscopical Society,
the President, Mr. C. S. Hall, M. R. C. S., gave an interest¬
ing lecture on the Leech and its Work, and he mentioned
incidentally that formerly, when leeching was more pre¬
scribed than at present, their gathering used to be regularly
carried on in ponds in Cumberland. The treasurer of the
Cumberland Infirmary, Carlisle, has received £200 from the
executor of the late Thomas Nelson, Esq. Sunday last was
Hospital Sunday in Cumberland and Westmoreland, and
collections were made on behalf of the medical charities of
the two counties—namely, Cumberland Infirmary, Carlisle
Dispensary and Fever Hospital, Cumberland and West¬
moreland Convalescent Institution at Silloth, and the
Workington Infirmary. This last institution has received
the offer of £500 from Mrs. Curwen towards building a
new wing, the present accommodation being inadequate.
The offer is maae as a memorial of Mrs. Curwen’.s eldest
son, Mr. E. D’Arcy Curwen, and has come when the com¬
mittee has been much straitened for means to undertake
the extension. The population of Carlisle is said to be
39,176, as compared with 35,SOS in 18S1. The increase in
the population in the last decade has therefore been .3311.
Sotith Shields.
At the late meeting of the South Shields Town Council,
Dr. T. Eustace Hill, the medical officer of health, reported
tliat the death-rate for the month corresponded to an
annual death-rate of 25'9 per 1000, and the zymotic rate
was 2'7 per 1000; but the births, Dr. Hill said, of 335 in
five weeks, seemed to indicate that the population of
South Shields (72,000) was considerably under-estimated.
It is contemplated at South Shields to take an important
sanitary step by using salt water for the streets and
flashing the sewers. The Shields people, too, are about
to bring the advantages of their town as a watering place
before the public t^bis season by systematic advertising.
Certainly the place has been immensely improved and
developed during the past few years, and possesses very
fine baths, a park, and a pier hardly to be surpassed,
but the public require reminding of these things.
A Broad-minded Board of Guardians.
The Sunderland Board of Guardians have sent a cheque
for £100 to the Infirmary of their town, and also one for
£25 to the Monkwearmouth and Southwick Hospital. This
they justify by saying that the support of these hospitals is
true economy, as these institutions are the means of
ultimately saving the pockets of the ratepayers by pre¬
venting the sick poor from becoming public burdens.
Nowcastlo-upon-Tyno, May 13tli.
SCOTLAND.
(From our own Correspondents.)
EDINBURGH.
Edinburgh Medieo-Chirurgical Society.
At the meeting of this Society last week the principal
paper was by Dr. Alexander James on Putrid Pleural
Effusions,” He divided these into three groups: (1) Gan¬
grenous effusion, with gangrenous tissue present in the
effusion from separation of the gangrenons tissue; (2) cases
in which gangrene was diagnosed as accompanying the
putrid effusion from the fetid expectoration; and (3) cases
in which there was neither fetid expectoration nor discharge
of gangrenous lung through the opening in the cheat-wall.
After enumerating the antecedent causes which are reco¬
gnised as sometimes leading to putrid effusion, he dealt more
especially with those in which there was no evidence of gan¬
grene discoverable during life or perhaps after death. He
was disposed, however, to regard these as really due to a
localised area of pulmonary gangrene, as he considered an
organism could not be carried through the normal lung and
pleura to the seat of the inflammation. He gave details of
a number of cases be had seen, and referred to cases recorded
by other observers. As regards treatment, he advocated
immediate operation. Amoni the speakers, Mr. Caird
thought washing out the pleura was unnecessary; Dr. W.
Russell discussed the etiology of the condition with
reference to suggestions he had made in a paper written
a number of years ago; and Mr. A. G. Miller contended
that there was evidence which favoured the view that the
putrefactive organism might pass through the lung tissue
to the seat of the pleurisy and determine its putridity.
The Water-supply.
Some months ago it was intimated here that engineers
were appointed by the Edinburgh and District Water
Trustees to examine the Edinburgh water-supply, and to
report whether they considered it necessary to augment the
supply, or if additional supply might not be obtained by
talcing efficient means to check waste. The report has
reached the trustees, and it is said the engineers are
unanimous in their opinion that an additional water-supply
should be arranged for without delay. The text of the
report will nob bo made public until it is printed and in
the hands of the trustees.
Health q/ the City.
The mortality last week was 115, making the death-rate
22 per 1000. Diseases of the chest accounted for 4-4 deaths,
and zymotic diseases for 10, of w’hich 6 were due to
whooping-cough. The intimations for the week comprised :
typhoid fever 5, diphtheria 3, scarlatina 10, and measles 118.
In Leith the number of deaths was 24, making the mortality
18'35 per 1000. _
GLASGOW.
Population and Death-rate of Glasgow.
In his last report to the Health Committee, Dr. J. B.
Russell makes special reference to the recent census. He
oogle
Dir:' rfd •
1128 The Lancet,]
DUBLIN.-PAHIS.
[May 16,1891.
notes that the census figures do not include the population
of the harbour, the schedules for which were collected by
the officers of H.M. Customs and transmitted direct to the
Registrar-General, with this explanation; the uncorrected
summation of the population of (municipal) Glasgow on
April 5bh was 664.975; on April 4bh, 1881, the popula¬
tion, including shipping, was 511,415, so that as they stand
the figures show an increase of over 10 per cent. Between
1871 and 1881 the rate of increase was only 4 per cent.
The census is taken at the beginning of the second
quarter in the year. For statistical purposes it is the
population at the middle of the year (June 3oth) that is
required, and in order to get this a quarter’s increase at the
inter-census rate must be added. At present also we must
add something for the shipping, and shall assume that it
remains at the same figure as in 1881. We thus have the
following:—
Population April 5th. 564,975
Increase to June 30bh. 1,339
Add for shipping . 700
Population June 30bh, 1891 567,014
Dr. Russell’s estimate of the population at midsummer,
1890, was 567,666. During the ten years 1881-90 there
were 131,406 deaths registered, an average of 13,140 per
annum. The mean population is 538,000, so that the mean
death-ratein the decade was 24 4 per 1000. The following
shows the mean death-rate in successive periods since the
commencement of registration in 1855 :—
6 years, 1855-60
... 29-9
Increase.
Decrease.
10 years, 1861-70 ...
... 30-4
0-6 !!
_
10 years, 1871-80 ...
... 28-6
... _
1-8
10 years, 1881-90
... 24-4
—
.. 4-2
A decrease of 4'2 per 1000 per annum means 22,590 lives
saved in the ten years. The death-rates will in future be
calculated on a population of 567,000. The results of
sanitation shown in the above statement are most satis¬
factory, and encourage the hope that, as the steady applica¬
tion of the somewhat limited powers hitherto exercised by
the local authority has produced such elleots, so in the next
decade the additional power conferred by the Glasgow
Police (Amendment) Act and the Housing of the Working
Classes Act, which come into operation this year, may lead
to still further progress in the same direction.
DUBLIN.
(From our Own Correspondent.)
Royal College of Surgeons in Ireland.
A MEETING of the Fellows will be held on Friday, the
I5th inst., to witness the election of examiners for tbe
ensuing year. For tbe Letters Testimonial and Fellowship
there will be four examiners in anatomy and surgery, two
examiners in physiology, histology, and pathology, and one
each in midwifery, chemistry and physics, and ophthal¬
mology. For the diploma in midwifery three examiners, five
for the diploma in public health, six for the diploma in
dentistry, and two in general education. A meeting also
of the Fellows will be held on; May 30bh to receive the
annual report of the Council. For the examinerships in
anatomy and surgery a large number of candidates may be
expected, and the contest will be a close and exciting one.
The President, Vice-President, and Council have named
Dr. Henry Fitzgibbon. J.P., and Sir Charles (Cameron as
representatives of the College at the International Hygienic
Congress.
Mercer’s Hospital.
It is a subject of regret that this institution, which is
doing good work, expended last year £1220 10.9. 4c/. beyond
its income. Some of this expenditure, however, was due to
the rebuilding of portions of the old fabric nob immediately
connected with the new wing, at a cost of £.529 lOs. Id.
There was a falling off last year in the amount received
from bequests and donations.
Outbreak of Fever in TuUamore Prison.
In consequence of the occurrence of typhoid fever among
the prisoners confined in this gaol, those with a short
sentence to run have been released, and the rest distributed
among other prisons in adjoining counties. The only
serious case was that of Mr. Cullinane, who at the outset
was suspected to be suffering from influenza, but his illness,
turned out to be typhoid fever. Complaints have been made
' against tbe medical officer of the prison of carelessness or
incapacity for not recognising the disease in the commence¬
ment, but surely this is moat unfair and unjust. To make
a positive diagnosis in the very early stage of typhoid fever
is difficult, if not often impossible; and, in corroboration, it
may he mentioned that two other medical practitioners,
both friends of Mr. Cullinane, also concurred in the treat¬
ment and diagnosis.
Lady Combermere’s Bequest of £25^000 to the North
Infirmary, Cork.
The petition of the trustees of this hospital is before the
courts in Dublin, and it is anticipated that it will be per¬
mitted to allocate the greater portion of the bequest for
building a new hospital, while tbe residue will be invested
and tbe yearly dividends applied to the maintenance of the
inmates of the infirmaiy.
Outbreak of Rabies,
The outbreak of rabies which commenced about six weeks-
ago near New Ross, eo. Wexford, still continues. The
guardians of the Union have adopted a resolution requesting
the Lord-Lieutenant to issue a proclamation embracing the
whole of Ireland to restrain dogs either by muzzle or con¬
finement for the length of time necessary to effectually
stamp out tbe disease.
Limerick Union.
By the death of Mr. O’Connor, F.R.C.S,I., a vacancy had
arisen for a dispensary medical officer, and for the past few
weeks active canvassing has taken place by the five candi¬
dates who competed for the appointment. Two members
of the committee travelled from London to record their
votes, Ultimately Dr. P. F. Graham was elected.
Mr, Louis A. Byrne, F.R.C.S.I., has been elected surgeors
to Jervis-street Hospital.
The medical faculty of the Catholic University have’
nominated Dr. C. Nixon and Mr. Antony Roohe,M.R.C.P I ,
delegate.^ to the International Sanitary Congress.
The annual meeting of the Dublin Ladies’Sanitary Asso¬
ciation takes place to-day at the Royal College of Physicians-
Diibliii, May 12lh. _
PARIS.
(From our Own Correspondents.)
Experimental Enterica.
The exact etiology of typhoid fever may be said to be
still a moot question. The consensus of opinion amongst,
physicians of che British school would appear to be that it
yet remains to be proved what rule —whether as cause or
effect—the micro-organism known as the bacillus of Eberth
plays in the pathology of this common disease. That its
presence may be generally demonstrated by the methods of
modern bacteriology seems to be admitted on all sides. It
is in the estimation of its value as a pathological factor that
opioionsdiverge. OntheContinent, where what may betermed
applied bacteriology—in contradistinction to the earlier
but more theoretical views of our great Jenner and Lister,,
<cc., in England—sawthe light, and where its teachings are
more readily and perhaps universally embraced, the bacillus-
of Eberth has assigned to it a place of the first importance.
To this view the experiments lately carried out by
MM. Gilbert and Girode lend further weight. Briefly,
they succeeded in producing what they term experimental)
typhoid fever, by inoculating guinea-pigs with the bacillus-
of Eberth. The resemblance between the enteric disease-
set up in the animals and enterica as observed in the human,
being was very marked. Of two guinea-pigs experimented
upon one died in lourteen and the other in thirty-two days.
Both displayed tbe usual clinical history of typhoid fever—
(liarrhcca, fever, Sec. Post mortem the small intestine was
found red and inflamed. Peyer’s patches were injected and
tumefied, while many presented well-marked ulcers. The
liver, spleen, and mesenteric glands were likewise swollen.
Histologically the ulcers involved tbe whole thickness of
the mucous membrane. The muscular coat was redematous-
and numerous thrombi were observed in the neighbourhood
of the ulcers and in the mesenteric glands. The bacillus of
Eberth was found in abundance in the ulcerations and
Digitized by ^ooQle
The Lancet,]
OBITUARY.—ROYAL COLLEGE OF PHYSICIANS.
[May 16,1891. 1129
(ihrombosed vessels. In brief, the evolution, duration,
seat, lesions, and clinical history of the communicated
disease were typical of ordinary typhoid fpver in the
human subject, and in the opinion of MM. Gilbert
and Girode they were identical. In judging the value
of these experiments to sustain the premises taken up—
viz , that the microbe in question is the raison d'Ure of
typhoid fever—one may be permittdd to ask whether, in
the process of inoculating animals with this virus, it is
chemically and physically possible to be absolutely certain
that the fluid injected does nob contain a something plus
the bacillus, and that this something may not, after all,
turn out to be the real materies morhi. However this may
be, it is interesting to note that the foregoing observations
go to show that it is by no means essential to the evolution
of enterica that the poison be conveyed to its seat of
development by way of the mouth (through the air breathed
or the aliments ingested), and which may be termed
'the vice naturales of typhoid fever. In the experiments
under consideration the inoculations were made under the
.-skin of the back of the animal, bub the poison, as we
shave seen, soon found its way to its usual seat of evolution.
An Ungrateful Patient.
Dr. Lassalle, physician to the hospital of Villefranche and
member of the General Council of the Department of the
Rhone, was recently the victim of a cowardly attack on
his life by a hospital patient. It appears that the individual
in question, whose disease was successfully treated under
the care of Dr. Lassalle, was discharged from the hospital as
perfectly cured. Having made himself comfortable at home
in the institution, he was furious at being obliged to leave,
<ind vowed vengeance, which he quickly carried into effect.
He waylaid the man who had re-established his health, and
deliberately fired a revolver at him. Luckily the bullet
missed its mark, and before he could fire again he was dis¬
armed and handed over to the police. Dr. Lassalle is
charitable enough to believe that his would be assassin may
be insane, although no signs of mental alfection were ob-
^served while he was under treatment.
The New Governor-General of Tonkin.
M. Lanessan, the recently appointed Governor-General of
Tonkin, is, like many more of tne public men of France, a
member of the medical profession. He was Member of
Parliament for one of the constituencies of Paris in the
present Chamber of Deputies, resigning this distinction on
his new appointment. He was formerly a surgeon in the
'French Navy, and a diligent student of natural science, in
which section be was a past Assistant- Professor in the Paris
Faculty of Medicine. His new post will be by no means a
sinecure, for it is admittedly one of the most important and
•tlifficult in the French Colonial service. He goes out to it
armed with the fullest powers, and accompanied by a
fliumerous civil and military staff. It will be recollected
that French medical science has already been similarly
represented in the Far East, for the distinguished and
regretted physiologist, Paul Bare, was also Governor-
‘Ueneral of French Indo-China.
}\'iris, May 12th. __
G AY SHUTE, F.ll.C K.
Few members of the medical profession had a wider circle
of acquaintances or were better known to the senior metro¬
politan consultants than Mr. GayShuteof Greenwich. He
had one of the largest practices in the district, and was
also the father of the profession there, having been in
practice at Greenwich for forty-eight years. Gay i^hute
was an old University College man, having entered as a
student so long ago as 1829 He was admitted a Member
of the Royal College of Surgeons in 1834, and a Member and
Licentiate of the Society of Apothecaries in 1836. In 1860
be obtained a Fellowship of the Royal College of Surgeons.
He was also consulting surgeon to the Miller Hospital at
Greenwich. On gaining his qualifications he went as liouae
surgeon to the Chichester Infirmary, where he remained for
five years. This experience gave him a taste for surgery,
and m the early days of his practice especially he used to
perform many operations of various kinds. Throughout his
career be was looked upon by his professional brethren as
an obstetrician of special skill and capacity, a circumstance
which brought him a ^eat deal of the consulting midwifery
practice in the district where be resided. He was muen
respected and widely esteemed in Greenwich and Black-
heath, and at bis funeral on Saturday the Church of St.
Alphege was crowded, many hundreds of people being present
in order to testify their respect. His partner and friend,
Mr. Harbt, received the sympathetic condolences of the very
numerous patients who called in order to express their
esteem for his late partner.
ROYAL COLLEGE OF PHYSICIANS.
At a Comitia of the College on the 14th inst., the Pre¬
sident, Sir Andrew Clark, Bart., in the chair, Drs. A. H.
Carter, R. G. Hehb, Sydney Phillips, J. J. Pringle,
W. Pasteur, S. Martin, A. Garrod, and Habersbon were
admitted to the Fellowship.
A communication from the Public Health Medical Society
with reference to a proposed amendment of Clause 35 of the
Public Health (London) Law Amendment Bill was received.
Dr. Farquharson, M.P., explained that an amendment with
respect to the place of residence of the medical officer had
been rejected by the Standing Committee on Law, and
stated that Mr. G. Bruce’s amendment, requiring that
medical officers should nob engage in private practice as
general practitioners during their term of office, had been
withdrawn.
Sir Dyce Duckworth was re- elected the Representative of
the College in the General Medical Council.
A report was received from the Committee of Manage¬
ment on the alterations in the curriculum and examinations
necessary for an extension of the period of study to five
years. The report contained the draft of three schemes,
which differed mainly in respect of the number and form of
the examinations. There was general agreement as to
the curriculum and the provision for more clinical study;
but whereas the first scheme signed by the three medical
members of the committee retained three examinations, as
at present, with, however, an interval of three years
between the second and final examination. Scheme No. 2,
signed by two of the surgical members, suggested a practical
and clinical final examination in all stffijects, and the
intervention of a third examination at the close of the fourth
year. The Registrar, in moving that the report be referred
to the Council, readcoinmunicationsfrom the Royal College
of Surgeons, to the effect that Scheme No. 2, with some
modifications, had been accepted by the Council of that
College. A letter from the Physiological Society, urging
the College to utilise the fifth year iu increasing the pre¬
liminary studies in biology and chemistry, was also read.
In the discussion, Drs. Priestley and Playfair urged the
extension of class instruction in obstetric medicine to six
months, and Sir H. Pitman expressed general preference
for Scheme No. 2. The motion was then carried, the
Council being empowered to confer with Fellows not
members of the Council upon the question.
The quarterly report of the examiners for the licence was
received. •
THE ROYAL COLLEGE OF SURGEONS OF
ENGLAND.
At an ordinary meeting of the Council, held on Thursday,
the 14bh inst., the minutes of the quarterly meeting of the
9bh April, and of the Extraordinary Meeting of the Council
of the lObh April, were read and confirmed.
Mr. Thomas Thorburn was introduced, and the President
handed to him the Jacksonian Prize for bbe past year.
In making their Quarterly Report to the two Colleges,
which was approved and adopted, the Laboratories Com¬
mittee stated that five new applications for permission to
work in the laboratories had been received, and that of
those who had been at work since the Committee made
their last Quarterly Report, all but three had applied for
permission co continue their researches.
The President reported the result of the meeting of the
Dif- u by Google
11,80 The Lancet,]
MEDICAL NEWS,
[May 16,1891,
Fellows and Members held on the lltb Inst., and read the
resolutions proposed at the meeting, which will be found
xe^rted on page 1118.
The Secretary called the attention of the Council to the
fact that in the Calendar of the College are to be found the
names of 176 Members of the College who, according to the
dates of their membership, up to the year 1822 inclusive,
would be at least ninety veara of age, and of whom he
could trace only six as stul living, and be was authorised
to remove from the list in the Calendar the names of the
remaining 170 Members.
The annual meeting of Fellows of the College for the
election of members of the Council to be held at the College
was fixed for Thursday, July 2ad next, at two o’clock P.M.,
and the naual resolutions were passed as to the sending
of notices and the publication of advertisements of the
meeting. A letter was read from Dr. Liveing reporting the
adoption by the Royal College of Physicians of certain
resolutions with regard to the employment of the fifth year
of medical study.
A letter was read from the chairman, honorary secre¬
taries, and secretary of the Manchester and Salford Sani¬
tary Association, inquiring whether the Council consider
that the practice of hypnotism ought to be placed under
control similar to that of vivisection, and, if so, whether
they are prepared to support an effort to secure such
control. To this question the reply was returned that the
Conncil did not consider it expedient to take any action
in the matter.
The President reported, on behalf of the Conversazione
Committee, that they had arranged for the conversazione
to be held at the College on Monday, August lObh, the
date which they found would be the most convenient to
the International Congress of Hygiene and Demography.
A letter was read from Dr. Francis J. Allan, Honorary
Secretary to the Public Health Medical Society, requesting
the Council, on behalf of that Society, to assist Mr. Gains^rd
Bruce, Q.C., M.P., by petition, and by securing the support
of Members of Parliament, in introducing the following
words into “ The Public Health (London) Law Amendmenc
Bill,” viz.;—“Shall nob be engaged during the time he shall
hold office as such medical officer in the practice of his pro¬
fession as a general practitioner, and.” It was not con¬
sidered advisable that the Council as a body should petition, i
A letter from Dr. J. Holmes, Honorary Secretary of the
Association of Certifying Surgeons, was read, thanking the
Council for the action they had taken in reference to Clause
19 of the Factories and Workshops Bill, and expressing the
hope that the Council would continue their assistance in the
event of any attempt being made to reintroduce the clause.
The President stated on behalf of himself and the Vice-
Presidents that they would still continue to watch the pro¬
gress of the Bill. _
Sljlikal Ittlus.
Royal College of Sukgkons of England.—
The following gentlemen, having passed the necessary
examinations, and having conformed to the by-laws and
regulations, were at the ordinary meeting of the Council on
the 14bh inst. admitted Members of the College:—
Abram, Geo. Stewart, L.R.C.P.Lond., University CoJIoko Hospital.
Allan, Alexander William, L.U.C.P.Loiirl,, Thornton Heath.
Allott, John Kniest Cecil, Ij.Il.C.P.Loiid., Old Keiit-ioad.
Ashworth, William Riishtoti, Ij.ll.O.P.Loiui,, Stoke-on-Trent.
Atkey, Percy James, L.R.C.lM.ond., Putney.
Barber, George Wiilber, !..H.C.P.Lonii., Thornton Heath.
Bartlett, Frank Whinfielit, L.R.C.P.Lond., Brixhain, Devon.
Baskett, Bertram Ooo. iVIortimer, h.R.C.P.LoniL, Cothain, Jki.stoi
Boake, Basil, L.K.C.IM.ond.. Ouldiii.
Box, Charles Richard, L.R.C.P.Lnnd., Hnhiiwood, Surrey.
Brett, William George, L.U.C.P.Loiul., Slieplierd’s-busli-road.
Brown. Rrigitiald, L.R.C.P.I.ond,, St. Bartliolomew's IlospiUl.
Busftold, .James, L.K.C.P.Lorid., (iiapham .Junction.
Carling, Albert, T,.R,C.P.I.ond., Wands wortli-road.
Clegg, Richard, L.R.C.P.Lond., Accrington, Lancs
Collinga, Edward Berosford, P.Lond., iianisloy, Voi ks-
Colllns, Ricliard Ilawtrey, L.R.C.P.Lond., Brixton.
Colyer, Arthur Reginald, L.R.C. P.Lond., SDeatham Hill.
Constant, Thomas Edward, L.R.C.I'.Loiid., Gravesend.
Corner, Albert, L.R.C.P.Lond., Poplar.
Cornish, Kciward, J..R,C.I’.r>onii.. Dovonport-road.
Cory, lirnost Richard Haines, li.R.C.P.Lond., Buckhui-st Hill.
Dale, Cuthijert Bracey, L.R.C.P.I.ond,, I’ercy-circus.
Dal/.ell, Aiithonj', L.R.C.P.Lond., VVorkingtm, Cmiiborland.
Davies, David l-ivingstone, L.R.C.I'.Loud., JlIaiK'hesler.
Dawson, Cecil Lacey, L.R.C.P.Lond., llegeiit’.s-park-road.
De Renzi, Henry Carter Castriot, L.R.C.P.Lond., Wandsworth,
De Segundo, Chas. Sempill, L,B.C.P.Lond., Atdridge-road Villas.
De Silva, Appu Hennedfge C., L.R.C.P.Lond., Newcastle-on-Tyne.
De Wet, Peter Christian, L.S.A., Vincanb-square.
Dudgeon, Robert Henry Beaiichamp, L.R.C.P.Lond., I.lverpool.
ElUs, John Constable, L.R.C.P.Lond., Llanfairfechan.
Featlieratoue, Geo. Wm, Beaumont, L.R.C.P.Lond., Wandsworth.
Finch, Ernest James, L.R.C.P.Lona., Notting-hill.
Ford, Frank Chubb, L.R.C.P.Lond., Woburn-square.
Fox, Arthur Claude, L.R.C.P.Lond., Hampstead.
Francis, John, L.R.C.P.Lond,, Grimsby.
Francis, Louis Arthur, L.R.C.P.Lond., Paddington.
Freeman, John, L.R.C.P.Lond., Bristol.
Gardener, Wm. Frederick, L.R.C.P.Lond., South Lambeth-road.
Gornall, John Guest, L.R.C.P.Lond., Limbeth Palace-road.
Hale, Geoffrey Edwd., L.R.C.P.Lond., St. George's Hospital.
Hull, John Moore, M.B. R.U.I., Old Ford-road.
Halsted, Denis Gratwielce, L.R.C.P.Lond., Arundel.
Harden, Edwd, Hy. Thornborough, L.R.C.P.Lond.. Camden-roadL
Hawke, Edwd. Drummond Hay, L.R.C.P.Lond., King Henry’s-riL
Hawley, Arthur, L.R.C.P.Lond,, Coventry.
Hebblethwaito, Alfred.George, L.R.C.P.Lond., Yorkshire.
Hey. Charles Edward Milnes, L.R.C.P.Lond., Sireatham.
Hoffman, A. Wm. Wistingliausen, L.R.C.P.Lond., Hammersmitlx
Holton, Geo. Waddiiigtoii, L.R.C.P.Lond., Staffs.
Home, John Armistoad, L.RC.P.Lond,, Kew,
Ilott, Arthur Talman, L.R.C.P.Lond., Covent garden.
James, Leo Edward, L.R.C.P.Lond., Stockwell.
Jeffreys, Alfred, L.R.C.P.Lond., South Wales.
Johnson, Frederick, L.R.C.P.Lond., Sevenoaks.
Jones, Henry Thomas, L.R.C.P.Lond., South Wales.
Jordan, .)bhn Furneaux, L.R.C.P.Lond , Birmingliain.
Kcyworth, Arthur Foster, L.K.Q.C.P.L, Marple,
Kirton, Charles Stanley, L.R.C.P.Lmd., Forest-gate.
Knovitt, Herbert. L.R.C.P.Lond., Surrey.
Landei-, Francis Joseph, L.R.C.P.Lond., Nottingham General Dis¬
pensary.
Lansdowii, Chos. Ewbank, L.R.C.P.Lond., Bromfleld-road.
J.awson, Arnold, L.R.C.P.Lond., Cavendish-square.
M’Connell, James, M.B. R.U.I., Peterborough.
Marshall, Francis Edward, L.R.C.P.Lond., Kingston.
Milton, VVui. Fredk. Edward, L.R.C.P,J,oiid., Fentiman-roaiL
Olivey, Wm. James, L.R C.P.Lond., Stormont-road.
Patterson, Charles Sumner, L.R C.P.Lond., City-ro.ad.
Powell, Charles Marten, L.R.C.P.]<ond., Funiival's-inii.
Porter, Charles, M.D. R.U.I., Co. Cork.
Price, Arthur Echvard, L.R.C.P.Lond., Folkestone.
Rake, Alfred Theodore, L.R.C.P.Lond,, Henie hill.
Kannie, James, L.R.C.P.Lond., Aberdeen.
Rawes, Charles Kinsmanr, L.R.C.P.Lond., Ponge.
Richardson, Horace, L.R.C,P.ljond., Highbury Now-park.
Rider, Alonzo George, L.R.C.ILLond., Highl)ury-lull.
Rodd, Montague Louis Bonchier, L.R.C.P.Lond., Stimehonae'.
Rogers, William Gusterson, L.R.C.J-*. Lond., Borougli.
Rowland, Frank Mortimer, L.R.C.P.Lond., Wolverhampton.
Rudd. Arthur, L.R.C.P.Lond., Charlton.
Sanmlers, .John Harry, M.B. Molb., Maida N'ale.
Scudamore, Leonard Ooorgo, L.R.C.P.Lond., Blacklioath.
Seton, Bruce Gordon, L.R.C.P.Lond., Anerley.
Sinitli, Erne.st Newlyn, L.R.C.P.Lond., Huntingdon.
Spensley, .James Ricimrd.son, L.R.C.P.Lond., Htoke Newington.
Sj.mrr, JaniGs, Ji.S.A,, Wood Green.
Spurrell, William Dewing, L.R.C.P.Lond., FalraouLli-road,
Slilwoll, Geo. Kobt. Fabris, L.R.C.P.Lond., St. Tliomas’s UospitaL
Swinton, Frauds Edward, L.R.C.P.Jjoml., Blackheath.
Syrett, Erne.st Frank, L.R.C.P.Lond., Victoria.
Tebbs, William Henry Alisouu, L.R.C.P.Lond., New Cross-road.
Thomas. Abraham, L.R.C.P.Lond., St. Paul-sheet.
Tliorpe, Reginald, L.R.C. P.Lond,, Higlibnryhill,
Thurston, Hugh Stanley, L.R.C.P.fjond., Cholsea.
Watts, Thomas, L.R.C.P.Lond., Bolton.
WoRiiigton, Richard Honsiowo, L.R.C.P. liOnd., Fellows road.
West, Jjionel Fi-ederick, L.R.C.P.Lond., Leeils.
Wilks, Herbert Lorraine I^al•lo, L.R.C. P.Loml., Arbnthuot-road.
Williams, Hari'y Bowen, L.R.C.P.I/omi., Tyrwhitt-road.
The following gentleman having previously passed the neces¬
sary examinations, and having now attained the legal age
(twenty-five years), was admitted a Fellow of the College :—
Tliomirsoii, Walter, L.R.C.P.J-ond., The Urango, Taduastor, Yorlw,
Diploma of Member dated Nov. lOth, 1887,
Royal University of Ireland.—T ho following
candidates have passed the undermentioned examinations:—
J)iict(ir ill iVi’iliciriK. —Edmond .J. MeWeenoy.
Bachplni'K in Sleiliclne., Snruenj, and Obulalncn: Uppnr Paxf l)ioixion.~
'Anna h. Church, 'Thomas Jonos, .Limes B, Mcl.arcn, Charles G.
McVicker, '"Hester D, Russell, and ‘•Edward .1. VVnlker. Cf'hose
marked with an asterisk may present themselves for liouonr.s.)
J'OKH Diniiiion. —Hugh I.. Atkinson, RohertBoyrt, Cliiistoplmr Bnntoti,
Robert Oai'se, Francis L. Dick, John DckUI, P.atrick Gool<l, .Ss.nmel
JIaiiiilton, Wm. HartUuid, .Joseph F. Kelly, Nathaniel (). MeCoinioll,
John .McLoish, Thomas H. MeSwinoy, Stephen E. Mo.vloy, llonry
O'Uoilly, Joseph A, O'Sullivan, Alexander O. Robb, Richartl G.
'Thornton, Robert Jk Wagner, and Joliii T. Wallace.
Univershy of Dublin, — At the Trinity Terra
commencements last week the following gentleman obtained
the degree of Doctor in Medicine
•Fohn Hugh Hubert (iluim.
Superannuation Allowance. — Mr. W. T.
Hudson, M.K.C.S., lately medical officer. South District,
Clerkenwell, has been awarded by the Holborn guardians
a superannuation p-lJowance of £G1 5*'.
: Google
Thb Lakobt,]
MEDICAL NEWS.
[May 16,1891. 1131
A HOSPITAL, containing accommodation, it is said,
foi from 1000 to I.'jOO patients, has been opened at Con¬
stantinople.
The Royal Vaccination Commission.— Another
sitting of this Commission was held on Wednesday, Lord
Herschell occupying the chair. Mr. Maskell, vaccination
officer of the Leicester Union, and Mr. Hopwood, Q.C.,
Recorder of Liverpool, were under examination. The Com- i
mission is now adjourned for the Whitsuntide recess.
Metropolitan Open Spaces. — Tho Commons
Preservation Society, the Kyrle Society, the Metropolitan
Public Gardens Association, and the London Playing Fields
Committee recently held a conference at the rooms of the
Society of Arts, to consider the future provision of open
spaces for London. The attendance was large and influen¬
tial. A paper was read on the “ Taxation of New Ground
Rents to provide Open Spaces for London.” It was urged
that a fund appropriated specially to the supply of addi¬
tional spaces was required, and the taxation of new ground
•rents was suggested for raising the necessary means.
Royal Sea - BATi-imti Infirmary, Margate. —
On Monday the Marquis of Lome occupied the chair at tho
festival dinner, held at the P’reemasons’ Tavern, Great
<Queen street, in support of this institution, which was
founded at Margate in 1701 for the treatment of scrofula.
The insufficiency of the ordinary income had necessitated
the absorption of a large portion of the small invested
capital, which now amounted to only £6791. The directors
were anxious to establish a special centenary endowment
fund of £50,000, in view of the growing demands from the
continual increase in the number of patients. Lord Lome
earnestly supported the claims of the charity for additional
public generosity. Donations were announced amountingto
£2152, an anonymous friend contributing £1000, Mr. C. A.
Swinburne £250, and Mr. Thomas Dunn 100 guineas.
National Society for the Prevention of
Cruelty to Children.— The Lord Mayor presided at
the annual meeting of this Society, held at the Mansion
House on Tuesday. The Princess Louise and a large in-
^uential company attended. The annual report showed
that the past year had been one of considerable progress
■financially, and the sphere of the Society’s work had been ex¬
tended. The income had risen from £8871 to £19,421, albeit
there was a deficiency of £092, It had sixty aid committees
in England, two in "Wales, and three in Ireland. During
the two years of its existence the Society had dealt with
i0,109 cases of alleged cruelty, of which 8810 were not
doubtful. It had given warning in 5054 cases, while 908
were taken into the magisterial courts, 92 per cent, con¬
victions being the result. The report was adopted.
Bequests and Donations to Hospitals.—T he
late Mr. Robert Thomas, solicitor, Sunderland, bequeathed
£500 to tho Sunderland Inlirmary.—The Duke of Rutland
has given £300 towards the rebuilding fund of the
Derbyshire Infirmary,—Mrs. Benyon of Reading has sent
a donation of 600 guineas towards the expenses of the
RotoI Berks Hospital,—The late Mr. William Cramond
of Derby left by his will £500 each to the Derby Infirmary
and Derbyshire Children’s Hospital.—Mrs. M. F. Burgess,
late of lUvkeiihead, bequeathed £100 each to the Eye
and Ear Institution and the Sick Children’s Hospital,
Birkenhead, and £200 to the Birkenhead Borough Hos¬
pital.—Mrs. Rogers, of Woodfields, Weston-under-Fenyard,
baa given £100 to the capital fund of the Cottage Hos¬
pital, Ross.—The Corporation of London has granted
:50 guineas to the City Orthopmdic Hospital and 100 guineas
eacu to Queen Charlotte’s J.ying-in-lloepital and Ihe
Royal Hospital for Children and Women.—The late Miss
Jarman of Slough bequeathed £1000 to the Windsor Infir¬
mary.—The Clotliworkers’ Livery Company has given £50
to the Great Northern Central Hospital Building Corn-
letion h’and.—The committee of the Worcester Infirmary
as received a donation of £50 from Mr. (ireswolde
Williams for the benefit of convalescent patients.—Tho
workmen of Sir W. G. Armstrong, Mitchell, and Co., at
Elswick, Newcastle, havecontributed for the quarter ending
March 31sb tire sum of £344 ITs. .3d. to tlie medical
charities.—The workmen of Messrs. Hawthorn, Le.sUe, and
Co., St. Peter’s and Forth Banks, Newcastle, have con¬
tributed for the quarter ending April 18bh the sum of £72 Gs.
to the medical charities.
Medical Magistrate.—D r. Hughes of Bethesda
has been placed on the Commission ot the Peace for the
county of Carnarvon.
Football Casualty.—D uring a match at Govan,
on the 0th inst., between the Mayfield and Claremont Clubs,
a youth had bis collar-bone fractured.
Adulterating Medicine.—A chemist of St.
John’s Hill, Shrewsbury, has been fined in each of two cases
for selling two quantities of Friar’s balsam, as medicine for
internal use, in the manufacture of which methylated spirit
had been used, instead of spirits of wine.
Nottingham and MidlandEyb Infirmary.—T his
institution maintains its career of usefulness. Year by
year it bestows its benefits to a steadily increasing
number of patients. During the past year the number of
new cases was 3354, thirty over the previous year, and the
largest number treated since the establishment of the
infirmary. There were 291 in-patients, 698 operations of a
serious nature were performed, and 319 were supplied with
spectacles. The building fund now amounts to about
£1600. The institution is in a sound financial condition.
The New Duffbrin Hospital, Calcutta.—
Her Excellency the Marchioness of Lansdowne performed
the ceremony of opening this new hospital for women and
children on March 4th in the presence of a large and
distinguished assemblage of both Europeans and natives.
The present structure is a two-storeyed building, with two
wards each, containing nine beds on each floor. The lower
floor will be reserved for Hindoo patients and the upper
floor for Mahommedaiis and others. The arrangements of
each floor are complete in tberaselve-s. The total cost of
the land and building amounts to about 107,000 rupees.
Increased Hospital Accommodation in Man-
oHESTicii. —The board of management of the Manchester
Royal Infirmary have rejected the offer of the Council of
Owens College of a site for an extension of the hospital on
the Stanley Grove estate, chiefly on the ground that the pro¬
posed new hospital would be much more costly than the pro¬
vision of an equal number of beds in connexion with the
present infirmary site ; that it would not be more, but less,
convenient for advanced students thai>.an extension of the
present building; and that it would not be so convenient
to the poor and those requiring the inlirmary as an enlarged
building on the presenn site. The board consider it an
essential thing that a hospital in a place like Manchester
shall be accessible to those employed in factories and work¬
shops or brought in.from neighbouring parts by railway, and
think that the present site answers much more to this re¬
quirement than the proposed one. The Medical Board of
the infirmary have issued a statement, signed by Dr. James
Hardie (chairman) and Dr. James Ross (vice-chairman),
strongly approving the action of the Board of Management,
and emphasising the great facilities for clinical insturction
afforded at the present time, which, with the proposed
extension, would meet any demands likely to be made even
by a large augmentation of the medical school. They
declare that the infirmary is as free from septic disease as
any hospital in England, and they quote the opinion of the
late Mr. John Netten Radcliffe, that the disadvantages
attaching to the present site are not of a nature to out¬
weigh the more serious consideration which attaches to
readiness of access to a surgical hospital for the population
it is intended to serve.
MEDICAL NOTES IN PARLIAMENT.
F(Tccin«<io7».
In tho House of f.ords, on Monday last, T.oi'cl .Stanley of Aldovley
oallod tlio attontion of tho House to portions of tho hocoiuI report of
tlio Uoyivl (’oinini.ssioii on Vn<-oiiiatioii. anil asked the Governmojib
whether they would jinivide debtor’.s bveivLiiient Justoacl of ei-hninal
tvoatmout for persons eouvieted uiuler tlio Vaceinatioii A(4s. Ho did not
wish to raise any luediral disrussiou on tho subject, hut merely to urge
that from tho ovidouco parents who refused ohedioiioe to the vaccina-
tiou law.H had, in many cases, good grounds for thoir refusal. Of
twenty-oight witnesses oxainined, sixteen had refused to allow their
childron to he vaccinafod liecauso they know of twenty-four oases of
children dead or injured by vaccination. These twenty-eight witnesses
had boon siibjoctod to 41:1 prosecutions,—Lord do Ramsey said that in
all oases but one tho proceedings wore strictly legal. Prisoners who
were convicted, not of an oll'ence, but with a lum-cmupUance with an
order of tlio court, were now treated under tho rules of tho Secretary of
State, and wore subject to tho special rules applyingto debtor prisoners.
Coogle
H32 The Lancet,]
APPOINTMENTS—VACANCIES.
[May 16,1801.
Eoi/oZ CvmmMBion on Tubereulogk.
In the House of Commons, on Monday last, Mr. Rowntree asked that
the medical officers of health who had furnished contributory informa¬
tion towards the preparation of the report oo the Royal Commission
on Tuberculosis should each be furnished with a copy of the report.—
Mr. Eitchie replied that the Local (lovernmont Board were in the habit
of forwarding copies of such reports on local inquiries to local officers
who had given assistance to the Board’s inspectors in the inquiries. It
is also the practice of the Board to distiibutea certain number of
copies of the annual report of the medical officer of the Board. Any
application that the Board may receive for such reports would be con¬
sidered with the desire to meet them, as far as is practicable, with the
limits which may be fixed by the Treasury.
Infiwnza.
In reply to questions by Mr. Caldwell and Mr. Vincent, Mr. Plunket,
the First Commissioner of Works, stated that he was well aware of the
ravages which the prevailing epidemic had made amongst the members
of this Rouse, and he had given directions that the committee rooms
should forthwith be fumigated wicli sulphur. He would adopt at once
the same process in such other parts of the House as it may seem pos¬
sible at once, and would avail himself of the recess for completing the
operation.—The Chancellor of the Exchequer; With regard to the
J iUestion put to mo, I have seen the report to which the hon. member
or Sheffield refers, and the House will, I am sure, feel sympatiiy with
the sufferings of the population from this disease. But I am glad to
see in the very paper to which the hon. gentleman has called attention
that there is universal testimony to the fact that the number of cases
is declining, and that in most of the works and places of business the
pressure is passing away. I see that oue medical man who had been
overworked has now only two coses on his hands, so I trust that the
bon. member will find that the disease is declining among his con¬
stituents. _
THE LONDON WATER-SUl’l'LY.
The Select Committee on this Bill resumed on Wednesday under the
presidency of Sir Matthew White Ridley. The Bill of t he Southwark and
Vauxhall Water Company was proceeded with. Mr. Balfour Browne,
Q.C., complained that in the question put at the previous sitting
by Mr. Freeman there was an allegation that, because tlie intakes were
below Staines, the water was not tit for consumption in London. No
one had ever dreamed that the question of the purity of the river would
be brought up under this Bill. Mr. Freeman, for the London County
Council, said that the Bill proposed to raise money for filtration pur¬
poses, and it was to that point that his q^uostions were directed. .Mr.
Stonehain, assistant secretary to the Board of Trade, was examined by
the chairman. General Scott, water examiner of the Local Government
Board, in reply to the chairman, considered that the water supplied by
this company stood very high as regards qtiality.
METROPOLITAN ASYLUMS BOARD.
IRetum oj Patients remaining in the several Fever Hospitals
of the Board at midnight on May 12th, 1891.
Hospital.
h
T
eds oc
Is
l3Upl6d
■Sd
52
ca 9
S'"
Other
diseases.
Total. J
6
I ^
£
o
H
Eastern Hoaoltal .. ..
177
50
3
46
281
442
North-Western Hospital
138
34
H
1
134
443
Western „
136
13
14
1
103
224
South-Western
13!)
27
9
1
170
840
South-Eastern
130
10
20*
178
402
Northern „
166
10
166
480
Totals _
883
J60
3
00
3
1147
2801
Small-pox.—A tlas hospital ship, 36.
* Infant with mother.
Si^essful applicants for Vacancies, Secretaries of Public Institutions, and
others posscssini/ in/ortnation suitable for this column, are invited to
foruiard it to TiiK Lancet Ojlce, directed to the Sub-Editor, not later
than 'J o'clock on the Thursday inominy of each week for publication in
the next number. __
AuitAilAM, P. S,,*M.A., M.D., B.Sc., lias been appoiuteii Honorary
J'hysician to the Western Skin Hospital, Oimt Portiand-street.
Allan, F, .f,, Ml)., has been appointed Clinical Assistant to the
We.steru Skin Hospital, Great Portland-.streot,
ALLDEN, SiONKV, M.i). Durh., has boon appointed llesident Medical
Olftuor 10 the Hospital for Consumption and Diseases of the Cliest,
liroinpton.
Benson, annetj'K M., M.D., B.Sc. Lond., has been appointed Rosidont
Clinical Assistant to tlie Paddington Iiillrniary, Harrow-road.
Biernacki, .John, M.B. Giasg., L.it.C.J’, S. Kiliu., Ac., has been
appointed Resident Medical Officer to tiic Hospital for Oonsuuiptlon
and Diseases of llio 'J'hrciat, Mancliester.
Brodie, Thomas S., M.R.C.S., L.R.C.P., baa been appointed Demons
strator of Physiology to King’s College, London.
Burton-Fannino, F. W., M.B. Camb., &c., has been appointed Phy¬
sician to the Jenny Lliid Infirmary for Sick Children, Norwich.
Crouch, E. T., M.R.C.S., L.S.A., has been appointed an Honorary
Sumeon to the Royal Portsmouth, Portsea, and Gosport Hospital.
Dick, Jambs, M.D. Giasg., L.R.C.S. Edin., has been appointed Medie^
Officer for the Harrington District of the Whitehaven Union.
Dodson, Arthur E., M.R.C.S., L.R.C.P., has been ^pointed Medical
Officer to the Royal Victoria Patriotic Asylum for Girls, Wandsworthi
Common.
Eyton-Jones, J. a., L.S.A., has been appointed Medical Officer for the’
Gringley District, Yorks.
GiusON, E. V., M.B., C.M., has been appointed House Surgeon to the
Devonshire Hospital, Buxton.
Giles, O., L.R.C.P. Lond., M.R.C.S., has been reappointed Medical
Officer of Health for the Sleaford Rural and Urban Sanitary Dis¬
trict^ Lincolnshire.
Gilimn, Frank, M.R.C.S., has been appointed Medical Officer, Strat-
ford-on-Avon.
gray, M. D., L.R.C.P., L.R.C.8.Ediu., L.F.P.S. Giasg., has beeiv
appointed Medical Officer to tlie Drumlish Dispensary, co. Longford.
Grii'I'Itus, Gilbert H., M.B.C.S., L.R.C. P. Lond., has been appointed.
House Surgeon to tlie Wallasey Dispensary, vice Dr. Wbiteloy.
Henderson, Jane B,, L.R.C.P., L.B.C.S. Edin., L.F.P.S. Giasg., hag.
been appointed Tbitd Assistant Medical Officer to the Holloway
Sanatorium, Virginia Water.
KEii, ALICE J- S., L.K.Q.C.P.Irel., L.R.C.P,, L.R.C.S, Edin., has been
appointed Honorary Surgeon to the Birkenhead Lying-in Hospital,
vice Lamb, decsaseil.
Lainu, Charles F., M.B., C.M. Giasg,, has been appointed Assistant.
Medical Officer to the Greenock Parochial Asylum and Poovhouse’
at Sinithstoii, vice G. A, Banuetyne, resigned.
Louan, Thus., M.J). Aberd., L.F.P.S, Giasg., has been appointed.
Medical Officer, North Briorley Union.
Lumlev, B., M.R.C.S., has been reappointed Medical Officer for the
Northallerton District of the Northallerton Union.
MoNTEaule, II. W. B., M.D., Giasg., has been appointed Medical
Officer to tlie Manchester and Salford Provident Dispensaries
Association.
O'Gorman. R. P., L.K.Q.O,I’,, L.R.C.S.Irel., has been appointecl
Medical Officer to the Manchester and Salford Provident Dispen¬
saries Association.
Oldham, Montague VV.,M.R.C.S.,L,R.C.P, ,L.S.A.,ha8beenappointed■
Sll^geon to the Coventry Provident Dispensa’ y.
Powell, G, W., M.B., C.M. Dubl., has been appointed Physician to
the Birmingham Childreii'.s Hospital, vice Suckling, resigned.
Robinson, James, M.D. Brussels, L.R.C.P. Edin., M.tt.C.S., has been,
reappointed Medical Officer of Health for tlie Turton Urban Sanitary
District.
Rutiiereoku, Tiio.s., M.B., C.M, Giasg., has been appointed Medical
Officer for the County of Bute.
Salter, F. .1., L.B.C.P., L.R.C.S. Edin., has been appointed Assistant.
House Surgeon to tiie Devonshire Hospital, Buxton.
Smith, Henry, M.B., C.M. )urh., lias been appointed Medical Officer
for the St. Nicholas District of the Durham Union.
Tiplady, VVm., L.ll.C.P., L.R.C.S. Edin., L.F.P.S. Giasg. L.M., has.
been appointed Acting Surgeon to the 6th V.B. Royal Highlanders..
§mnm.
For further information Teya-iinn each vacancy reference should be made
to the advertisement.
Borough oe Plymouth,-M edical Officer of the Borough Lunatic-
Asylum. Salary .ttOil per uniiurii, wit.li furnished house In the
Asylum atBlackadon, near Plymouth. Gas, coal, and vegetables..
Blackburn and East Lanca.siiire Inj'irmary.—J unior House Sur¬
geon. Salary £50 per annum, witii board, washing, and lodging.
Cancer Hospital (Free), P'ulham-road, S.W,—Honorary Pathologist.
Cancer Hospital (Free), Fulhain-rooii, S W,—Surgeon.
City op I-ondon Hospital tor Diseases op the Chest, Victoria-
park, K—Hou.se Physician. No salary. Board and ro.sideiico and
an ailowaiico for washing. (Apply to the Secretary, at the Office,
34, Fin.shuvy-circUB, E.C.)
County Asylum, Wluttingliam, Preston, Lancs.—Assistant Medical
Officer and Pathologist. Salary £200 a year, witli board, lodgings,
wasliing, and attendance.
County Borough oi’' Siiepfjeld.—M edical Officer of Health for the-
Borough, Salary £600 per annum. (Apply to Dr. J. W. Pyo Sjnith.
Town Clerk, Stieffiold.)
County of Caithness,—M edical Officer of Health for the County.
Salary £300 storling, wilti £60 for travelling and other expenses,
except forms ami otnciiil stationery and postages. (Apply to Mr.
Brims, County Clerk, Thurso,)
Deiuiy Amaixja.matki) Friendly Societies’ Medical Association.—
Assistant Surgeon. S.alary £160 per annum (out-door), with addi¬
tional fees for Midwifery of f>K. 3d. in each case, salary to bo-
advancod under certain conditions.
DuN.sTAULic Friendly Societies’ Medical Association, Dunstable,
Beds,—Dispenser. Salary £60 per annum.
Dun.stadle Friendly societies’ Medical Association.— Rosident
Modical Officer, Coinmoncing salary £1S0, rising .Ell) per annum,
to C220, with rosidonco, ganten, and consorvatory (ratc.s and taxes
free). Conveyance provided. (Apply to the Hon. Secretary, Princos-
stroot, Dunstablo, Beds.)
General Hospi-ial, Birmingham.—Assistant Physician for tlueeyeara.
Honorarium £100 per annum.
(iENERAL Hospital, Birmiugiiam.—Honorary Surgeon.
General hospital for sk k Children, Penalo’bury, Manchester.—
Junior Resident Medical Officer for one year. Salary .£80’ pex
animiii, witli board and lodging,
DiC -I'-: V-- Google
The Lancet,]
BIRTHS, MARRIAGES, AND DEATHS.
VMay 16,1891. Il3a
Hants County Asylum, Knowle, Fareham.—Third Assistant Medical
Officer. Nalary £V00 per annum, increasing to £125 after twelve
months’ service, with furnished apartments, board, washing, and
attendance.
Hartlepool Union.—M edical Officer and Public Vaccinator for the
Oistrict of Greatham. Proposed salary, exclusive of extras, £50
per annum. (Apply to the Clerk, Board-room, MunicipalBuildinga,
West Hartlepool.)
Kidderminster Infirmary.—H ouse Surgeon. Salary fiuo, increasing
by £10 per annum to £170, with rooms in the Iiffirmary and atten¬
dance.
Liverpool Royal Inpirmarv.-H onorary Assistant Surgeon.
Leamington Amalgamated Friendly Societies’ Medical Associa¬
tion.—R esident Medical Officer. Salary £200, £50 allowed for
cab fare, or towards horse and trap, midwifery fees, &c., with resi¬
dence, coachhouse and stable, rent and taxes free. (Apply to the
Secretary. 9L, Oiioen.street, Leamington.)
M.I>.,caro or P, Uixon, Esq., 13, Gray’s-inn.square, W.C.—As.sistant
Medical Officer in a large Metropolitan Lunatic Asylum. Salary to
commence at £100 a year, with board, lodging, washing, &c.
North Stapfordshire Infirmary and Evk I-io.spital, Hartshill,
Stoke-upon Trent.—Assistant House Surgeon. Board, apartments,
and wasuing. No salary.
Nottinqiiam borough asylum.—L ocum Tenens for a month.
Romunoration .£2 2s. per week, with apartments, board, and wasli-
ing.
NOTriNQiiAM Borough Asylum.—A ssistant Medical Officer Salary
£126 per annum, with apartments, board, and washing.
Royal Berks Hospital.—P hysician.
Royal Westminster Ophthalmic Hospital, King William-street,
West Strand.-House Surgeon.
Salford Union.—A ssistant Medical Officer for the Union Infirmary,
Hope, near liccles. Salary .£130 per annum, with furnished apart¬
ments in tlie Infirmary. (Apply to the Clerk to the Guardians,
Union Offices, Bccios-new-road, Salford.)
University of Glasgow.-A ssistant F.xaminer in Physiology. The
annual fee for the Examinership is ,£30. (Apply to Mr. Clapporbon,
01, WestRegenb.streen, Glasgow )
Ve.stry of Fulham,—V lod'cal Officer of Health for tho parish of
Fulham for one jear, Salary £100 per annum. No fees allowed
for tra^'eHing in the parish. (Apply to the Clerk of the Vestry,
Town Hall, Walham-gceon.)
Waknepord Hospital, Leamington Spa.—House Surgeon. Salary
,£100 per annum, with board, waihing, and lodging.
Carriages, aaii §tat|s.
BIRTHS.
HOFPMEiSTER.— On May 4tli, at High-street, Gosport, the wife of Dr.
John B. Hoilmeisoer of a daughter.
Hunt.—O n May 7tli, at Cronclied O'l'iavs, Colciiester, the wife of Edgar
A. Hunt, M.K.C.N., of a son.
Johnson.—O n M ty 3th. at Cortina, Netherhall-gardenH, N.VV., tho wife
of George Lindsay Johnson, M.D., F.ll.C.S., of a son.
MARRIAGES.
Bautliott— Sim.icY.— On May 0th, at All Souls’ Church, liangham-placo,
Hodley C. 15 irflott, M.li.C.-S., I<.II.C. P., of Saffron Walden, to Flora
Alice, third d iughtsr of Septimus W. Sihloy, lisq., of Harloy-stroeb.
Frazsr—Fothekgii.L. —On Miy 9tli, at Josmond Church, Neweastle-
on-Tyne, I’eter Thomas Frazer, Army Medical Stall', Retired, to
Mary, widow o' .losooh Fotliergill, and youngest dauglitor of the
late William Ilitson Drycloit, of Cottingham, Etsb Yorkshire.
POUF.TER—Vom.iov.—On May ntli, at St. Alban's Cathedral, Arthur
Heginalil Paulter, M.It.CS., L. Ll.C. F. l.-ind., fourth son of F.
IJrOfel Poiiltor, of The Hawthorns, Shovtlands, Kent, to May, eldest
daughter of William Vorley, of N’ortoii Hoiiho C imtleii road.
Stirling—Bromley.— On MayOth at st. George’s Church, Bloomsbury,
by tho Rev. A. B. Boyd Oarpoiitov, M.A., Hector of the Parish,
Alexandor Williamson Stirling, M.I)., C.M. Bdiii., D.F.II. Lond., of
Slinftodmry il uiso, llrays, Kasax, eldest son of the late Robert
Stirling, Twenl Green, I’eebles, N.B,, to Nora, only daughter of
Charles Bi'omloy, Bello Vue House, Goolo, Yorks.
DEATHS.
Brinton.—O n May 7th, at 7, Collogo-tenaco, Bol.sizo Park, N.W.,
Mary, widow of tho lato William Briiitim, M.D., F.R.S., Fhysician
to si. Mary's Hospital, in her ({2tid year,
BURNIH.—On May Isi, at his roHiih-ncu, llaughtoii House, Bradford,
William Burmo, M. O. ICdiit., L. R.C.Kdiii., in tho 7l)th year of h'w
ago.
Burton.—O n May (Ith, at Kolso, John Burton. M.D, Kdin.
DAV1R3.— On May 0th, at hh residoiico, Wost-stroot, llyo, Robert Coker
Nasli Davies, M.lt.C.S. F.., in Ins (12nd year.
Davies,—O n April iuth, at Rernson.street, Now York, Bartholomew
Watson Davies. M.D, Edin , of Kingston, Jamaica.
Frazer.—O n May lotli, at Avinagh, Henry Frazor, M.D. (Ilnsg,
L. K.Q.C.F., L.U.C.S.Ircl , Medical OlHcor of tho Onaagh Woi'k-
houae
MOR'i'ON.—Ou May llrd. at 14, Hill-Utm, SimthampLon, of infiuotiza nnd
congastion of the lungs, to the inexpreHiiolo griqf of his family,
John lioiiry Morton, Surgeon, of Now Brompton, Kent, aged
54 years.
Roe.—O n Mav 8th, at West-hill, Wandsworth, Richard Roe. Siirgoen,
late of Kcidos, l,>nea.s)iire, in his 82ad year.
Walker.—O il May 7th, at The Paragon, Bath, Win. Searlo Walker,
M. lt.C.s. _
S.B.—A/ee o/5s is chan/H/nr the /Msoj-'mn o/ Notices o/ Births,
Marria<jcs, and Deaths.
SltJiiral for % ensninj ®teL
Monday, May 18.
Royal London Ophthalmic Hospital, Moorfiblds. —Operation!
daUy at 10 a.m.
Royal Westhinstsb Ophthalmic Hospital.—O perations, 1.80 p.h.,
and each day at the same hour.
Chelsea Hospital fob Women.—O perations, 2.80P.H.; Thursday, 8.80.
Hospital for Women, Soho-squarb. — Operations, 8 p.h., and on
Thursday at the same hour.
Metropolitan Free Hospital.—O perations, 8 p.m.
Royal OitTHOPiEDic Hospital.—O perations, 2 p.m. .
Central London Ophthalmic Hospital.-O perations, 8 p.h., and
each day in the week at the same hour.
University Colleob Hospital.—E ar and Throat Department, 9 a.h.)
Thursday, 9 a.m.
London Post-graduate Coursb.—H o^ital for Sick Children, Great
Ormond-st; 4 P.M., Dr. Voelcker: 1416 Pathology of Tuberculosis'
in Children (Demonstration).-Royal London Ophthalmic Hospital,
Mourfieids: 1 P.M., Mr. R. Marcus Gunn ; Affections of the Cornea..
Tuesday, May 19.
King's College Hospital.—O perations, 2 p.m. ; Fridays and Saturdays
at the same hour.
Gut’s Hospital.—O perations, 1.80 p.h., and on Friday at same hour.
Ophthalmic Operations on Monday at 1.80 and Thursday at 2 P.H.
St. Thomas's hospital.—O phthalmicoperations.lP.M.; Friday,2P.H.
8t. Mark's Hospital.—O perations, 2 P.M.
Cancer Hospital, Brompton.-O perations, 8 p.h. ; Saturday, 8 p.h.
Westminster Hospital.-O perations, 2 p.m.
West London Hospital.—O perations, 2,80 p.m.
St. Mary's Hospital.-O perations, 1.30 p.h. ConsultatlonB, Monday
2.80 P.H. Skin Department, Mond;^ and Thursday. 9.80 a.m.
Throat Department, Tuesdays and Fridays, 1.80 P.h. Electro¬
therapeutics, same day, 2 P.M.
London post-graduate Course.—B ethlem Hospital: 2 p.m.. Dr. Percy
Smith: Mental .Stupor, Dementia.—Hospital for Skin Diseases Black-
friars (the lecture will be delivered at the Examination Hall, Victoria
Embankment); 6 X’.M., Mr. J. Hutchinson ; Prurigiiious Affections,
of the Skin.
Pathological Society of London.—8.80 p.m. Mr. II. B. Robinson t
Cy.sbic Tumours of Jaw.—Mr. C. A. Bailatice: Large Aural Exostosis.
Mr. B. Roughton: Lipoma of Spermatic Cord with Hernia.—Dr. S.
Sharkey: Ulcerative Colitis.-Dr. J. P. Payne: Syphilitic Caries of
Calvaria in an Infant.—Dr. F. vSemon : Anomalous Tumour from
Aryepiglottidean Fold.—Dr, H. D. Rollcston : Myocarditis limited to
the Ivighb Side.—Dr. .S. Deliipine : Cultures of Psorespermia.—Mr.
C. A. Ballance and Mr. S. G. Shattock : Negative Results of Psoro-
spennial Inoculation in Animals. Card Specimens Dr. S. West:
Secondary .Sarcoma of Lung,—Dr. A. F. Voelcker : Tuberculosis of
Tliyruiri —Dr. Uolleston ; Lung invaded wibli Colloid Carcinoma.—
Mr. H. B. Robinson : Ulcerative Colitis.
Wednesday, May 20.
National Orthopedic Hospital.—O perations, lo a.m.
Middlesex Hospital.-O perations, 1 p.m. Operations by the Obstetrla
Physicians on ThuriidayB at 2 p.m.
St. Bartholomew's Hospital.—O perations, I.so p.m. ; Saturday, same
hour. Ophtbalmio Operations, Tuesday and Thursday, 1.80 p.h
S urgical (Jonsultabions, Thursday, 1,30 p.m. •
Charing-cross Hospital.-O perations, 8 p.m., and on Thursday and
Friday at the same hour.
St. Thomas’s Hospital.—O perations, 1.80 p.m. ; Saturday, same hour
London Hospital.—O perations,2 p.m. ThursdayiftSaturday.samehout.
St. Peter’s Hospital, Covent-gardf.n.—O perations, 2 p.m.
Samaritan Free Hospital f'or Women and Children.-O perations,
2.30 P.M,
Great Northern Central Hospital.—O perations, 2 p.m.
University College Hospital.—O perations, 1.80 p.m. ; Skin Depart¬
ment, 1.46 P.M.; Saturday, 9.16 a m.
Royal Free Hospital.—O perations, 2 p.M., and on Saturday.
Children s Hospital, Great Ormond-street.—O perations, 9.80 a.m. }
Surgical Visits on Wednesday and Saturday at 9.16 a.m.
London Post-graduate Course.—H ospital for Consumption, Bromp¬
ton : 4 p.M., Dr. .r. Kingston Fowler: Arrest of Pulmonary Tuber-.
cu)o«iH(wibh cases).—Royal London Ophthalmic Ho.spltal: 3 P.M., Mr.
A, Ciiiarry Silcook : Glaucoma.
Roval ftlETKOROUXiiCAL SOCIETY.—7 P.M. Mr. W. H. Dines : On the
Vertical Circulation of the Atmosphere in relation to the Forraationi
of Stm'ins.—Mr. A. W. Clayden : On Brocken Spectres iu a Lcndoip
l''og.~Mr. H. Coupland Taylor: An Account of the “Leste,” or-
Hot Wind of Madeira — Mr. Slielford Bidwoll will exhibit an Bxperi-
ment showing the effect of an Electrical Discli.argo upon the Con¬
densation of Steam,
HpiDKMioLomcAL ,so(:n-:Tr op London.—8 p.m. Mr. A. Campbell
Munro ; Measles, an Kpiilemiological .Study.
Royal Micro.scopical Socik'I'V.-8 p.m. Mr. K. M. Nelson: Illumi-
uivliiig Apparatus.—Mr. T. B. Rossltor: On a new Cysticorcus ami
the 'i'tcnia produceti from it.
Thursday, May 2i.
St. George's Hospital.—O perations, l p.m. Surreal Consultations,
Wednesday, 1.80 P.M. Ophthalmic Operations,In-iday, 1.80 p.m.
University College Hospital.-O perations, 2 p.m. ; Ear and Throat
Department. 9 a.m.
London Post.graduate Course.—H ospital for Sick Children, Oreat-
Onnond-st. : 4 p.m., Dr, Barlow: Rheumatism in Children.-NationaJ,
Hospital tor the ParaiyseUand Epileptic :2P.M., Dr.CliarltouBastiaur
Helected cases of Disease of the Brain.—London Throat Hospital, Ot.
Vortland.st.: 8 P.M., Mr. Stoker: Syphilis and Plithisis of the Larynx.
Harveian Society of London.—3.30 p.m. Clinical Bvoning. Oases wilh
be shown by Messrs. Squire, Hill, Julor, Pepper, Spicer, and obhers..
Digi zen ny LiOOgle
1134 Thb Lanobt,] notes, comments, AND ANSWERS TO CORRESPONDENTS.
[May 16,1891,
Friday. May 22 .
BOTiL Soxrra London Ophthalmic hospital.—O petattona, 2 p.*.
London Post-oraduatb Cov&se.—H ospital for Consumption, Bromp-
ton: 4 P.M., Dr. J. Kingston Fowler: Arrest of Pulmonary Tuber¬
culosis (with cases).—Bacteriological Laboratory, King’s College :
11 A.M. to 1 P.M., Prof. Orooksliank: Cultivation of Bacteria (exa¬
mination of various cultivations).—Great Northern Central Hospital:
8 P.M., Dr. Galloway: Liver and Spleen.
Clinical Sociext of London.—L iving Specimens at 8 p.m. Mr. Bruce
Clarke: Case showing a New Method of Amputation just below
the Knee-joint.—Mr. W. H. Bennett: Symmetrical Enlargement of
Parotid Glands.—Dr. Calvert: (1) Case of Congenital Cranial Synos¬
tosis ; (2) Case of Hysterical Hiccough.—Mr. W. H. Battle: Case of
Fffical Abscess after Operation.—Mr. B. H. Fenwick: Case of Con-
rgenital Scrofula.-Dr. flerringbam : Case of Hereditary Chorea in
an Elderly Man.—Dt. Bolton Tomson (introduced by Dr. Savill):
Two cases of Hereditary Muscular Spasm.—Mr. Brodhurst: Case of
Scoliosis with Rotation.—Dr, Savill; Case of Hysterical Rachialgia.
Papers at 0 P.M.Dr, Sidney Phillips: A case of Typhoid Fever with
Occlusion of tlie Fomoral Artery during Convalescence, and with
Acute Maniacal Attaclts.-Dr. Ord and Dr. Copeman: A case of
Leucocytluemia under observation nearly three years. — Dr.
Maclagan ; Cases of Neuritis and Spurious Arthritis.—Dr. Remfry:
A case of Pulmonary Embolism.
Saturday, May 23.
MiDDLSSBZ Hospital.—O perations, 2 p.h.
Dniteesity College Hospital.—O perations, 2 p.m. ; and Skin Depart¬
ment, 9.16 A.M.
LONDON PosT-r.iUDUATE COURSE,—Betlilem Hospital: 11 A.M., Dr. Percy
Smith: Clinical Demonstration.
METEOROLOGICAL READINGS.
CTaAe7h daily at S.tfO a.m. by Steward's Instruments.)
The Lancet Office, May 14th, 1891.
Date.
Barometer
reduced to
Sea bovul
and 32* F.
Direc¬
tion
of
Wind.
Dry
Bulb.
Wot
Dull).
Solar
Uiidla
in
Vacuo.
Miixl-
irium
Tomji.
Sliauo.
Min.
Tuini)
Rain¬
fall.
Remarks at
8.S0 a.u.
Way 8
29 63
s.w.
63
.50
92
02
48
■02
Overcast
..
29 74
N.E.
54
49
96
69
48
Bricht
„ 10
29’80
N.R.
6(1
49
67
65
49
•02
Overcast
.. 11
30'00
N.E.
66
62
114
70
49
Cloudy
12
80-28
N.E.
64
61
112
80
40
Hazy
13
30-17
N.E.
63
.58
117
81
63
Hazy
30-09
N.E.
68
64
97
05
55
Cloudy
Sljrot Comments, # ^nsters to
Comspnknts.
It is especially reqxtested that early intelligence of local
events having a medical interest, or which it is desirable
to brvng under the notice of the profession, tnay be sent
direct to this Office.
All CQjnmunicatiom relating to the editorial business of the
journal must be addressed “ib the Editors.”
Lectures, original articles, and reports should be written on
one side only of the paper.
Letters, whether intended Jor insertion or for private informa¬
tion, must be authenticated by the names and addresses
of their writers, not necessarily for publication.
We cannot prescribe or recommend practitioners.
Local papers containing reports or news paragraphs should
be marked and addressed "To the Sub-Editor.”
Letters relating to the publication, sale, and advertising
aeparimcnts of The Xanckt to be addressed "To the
Publisher.”
We cannot undertone to return MSS. not used.
■‘CHARITY BEGINS AT HOME.”
To the Editors of The Lancet.
Sirs,—O n May 2Sth tho annual meetings of the Governors of Hio
Royal Medical Benevolent College (Epsom) and of the Society for
Relief of Widows and Oi-pliansof Medical Men will be held at the same
hour, but under somewhatdill'erciitcircumstances. Tlie Epsom Council
will declare the poll for tlie election of three pensioners out of a list of
■nineteen deserving candidates, and of el-iven scholars out of a list of
forty-four needy oi-phans of medical men. The Council of tho Widow.s
and Orphans will simply transact routine business connected witli the
tslxei (withno canva.SbW!/) (A sixty-four widows of docea.sed members
and fifteen orphans. Tho extraordinary thing is that the number of
•the members paying two guineas annually to this valuable society has
diminished from 182 to 170 during the last year, and yet the Epsom list
..gives the names of nineteen Jh-sl applicatiwtH on behalf of the sons of
medical nion who havo died leaving their families inoro or les.s unpro¬
vided for, notwithstand iug tho fact that for two guineas a year many of
them might liave insured LtO per annum to bis widow and £ir, to each
child. Verl/im sap. I am, Sirs, yours obediently,
May, 1891. if_
The Wrong Use of Medical Titles.
An Indignant Apothecary is very angry at the Medical Defence Union
for prosecuting Mr. S. E. L. Smith, who, on tho basis of possessing
the L.S.A. Eng., constructed the following row of titles after his
name—M.D., L.R.G.P., L.M., & L.S.A., as described in our Birming¬
ham Correspondent’s letter of May 2nd. " An Indignant Apothecary ”
will have noticed in our columns adisclaltner from the honorary secre.
taries of the Medical Defence Union pointing out that the Union
had neither originated nor inspired the recent prosecution. Our cor.
respondent admits that Mr. Smith ouglit to have indicated the
American source of the degree, and considers tlie examination for the
Apothecaries' licence as difficult as that for the Conjoint Bodies of
Scotland or Englaml, and that Mr. Smith ivas right in regarding tlie
title of L.S.A. as obsolete. Our correspondent is an entire stranger
to Mr. Smith, but has sent a subscription towards his expenses. It
should bo noted tliat Mr. Smith’s licence dates from 18S5, before the
time when the examination was made to qualify in all three branches
of the profession. Those who pass the examination now in its
enlarged and improved form may very well resent the limitation of
the title acquired, and they may fairly urge tiieir Society to demand
of Parliament to create a titio moio expressive of the full qualifica¬
tion it gives. A title conferred by Act of Parliament must be altered
by the same authority, and by that only. Licentiates will not advance
their good cause by defending such title-making as Mr. Smith in¬
dulged in, including a most questionable M.D. of Indianapolis, about
which and tho terms on whicli it was granted we should like to have
certain information.
Hr. W. B. Gri^/tA.—We would recommend our correspondent to apply
to the Secretary of the St. John Ambulance Association, St. John’s
Cato, Clorkonwell.
Ir ir. will enclose his card we will .answer his question.
BLOODLEITING.
To the Editors of The LaNCF.T.
Sirs,—I n a footnote to Dr. Ogle’s interesting and valuable article in
your paper of May 9th, he refers to llio ” Civil war ” in medicine during
the sixteenth century on tlie question of bloodletting. In connexion
witli tills subject I send you the followingquotatioufrom Freiiid'a letter
to Dr. Mead (Part II., p. 215,1720 Edition)
“ That absurd and extravagant controversy, which in the beginning
of tho fiftoontli Contuary ilistractod the judgements of all the Physicians
in Europe, about bleeding in the dii-oct or opposite .side in a Pleurisy.
Tiiey (the Arabians) follow’d it, it seems, the opinion of Areliigones and
Aretious, and inclin’d to the latter J^ractico; and for tiiat reason were
rail’d at as Revolters from the doctrine of Hippocratos and Qalen, tlio’
neither of these lays down any constant unvariable rule iu this point.
'J'ho University of !8aiainanca indeed took part with tho Arabians, and
made a decreo, that no one in tiiis case should dare to lot blood in the
contrai 7 arm j and to add authority to their decree, tliey einlcavour’d to
procure an edict from diaries the Fifth to second it, alleilging the other
method to be of no less ill consequence, than that of Luther’s heresy.
Experience indeed has shewn, that the Arabian.s had as good reason
for thoir opinion, as thoir adversaries had for theirs : and M. Curtins,
who was one of tlie most '/.ealous writers .against them, found his heart
fail, when lie fell ill himself of this distemper, and chose to act counter
to his own notions and writings, rather than not save his life by the
Arabian Practice.”
Ill Biiilein's work, reprint of the 1573 edition, p. ■fO, Mecliens detailing
his method of treatment to Antonius, say.s, “ Note this ; that what side
be infected lot blood on that side.”
Might I suggest to Dr. Ogle that tho humoral pathology and tlie
mediioval ideas as to tlio composition, of tlie blood may, perliaps,
o.xplain tlie phrase “to breathe a vein.” Bulloin considers “molancholic
to bo caused hy “twoo aboiindauuco of euill humours,” and rocommond.s
bleeding to liberate tlie ovil liuraoiir. “Blood must he le.Ltou iuthe
beghinyiig of tiie sickenesse; example, like as a pot is clensed of the
scumnic or fome in the lioginning when it plaiotli on the lire.” Vicary,
lepriiit, 1.577, p, 21, gives very fully tho existing theory of hi.s day,
telling us of tho artovy, from wliich patients wore often purposely bled,
“ a vessel of Wood .spiritual or vytal."—I am, iSirs, yours truly,
Dublin, May 9th, 1891. (JEOiu.iK Fov.
H/KMORIUfA<ilC IN NNW-IIORN ClUI.DRE.V.
Dr. Kitiiss publishes in the Gyogydszat an account of six cases of
iiaiiuorrhagc from tho genitals in new-born female infants occurring
recently in tlie First Obstetrical Clinic in ,Buda Pcsth. Oiio only of
the children died, and she was piomnturo, oy.anotic, and unable to
suck. Hminorrliage coninioncod on the third day, and she died on the
fourth. Tlio uteru.s ivas small, and the mucous inembiane aa well ;is tho
peritoneal covering were deeply injected, small extrav-i-sations of blood
existing in places. 'I'ho Fallopian tubes were very tortuous. In tho
right parovarium thiu'o were a few cysts containing soruni. 1 lie other
live children were wcll-dcvelopcil, and in all these tho hu'morrhago
ceased after a very few day.s.
rin.^icanu*.—Will our correspondent say from wliat point of view he
wishes tile word ''hazardous” to be regurdod
Tb^Lancbt,]
NOTES, COMMENTS, AND ANSWERS TO COBllESPONDENTS. [May 16,1891. 1135
The Midwives Bill.
Dr-. Jtentoul calls our attention to an error which, he states, appeared
in one of our contemporaries on May 2nd—namely, that the Lord
President of the Privy Council liaa given a virtual pledge to grant a
Select Committee for the consideration of the whole subject. Dr.
Hrentoul wrote to the Lord President and asked him if it were true.
His lordship replied that the statement wae unauthorised, and that
neither be nor ths Government bad given any pledge.
Dr. Lewim.—la drawing attention to Dr. Gould's paper, we did not
propose to open a discussion on the subject dealt with therein. Such
a discussion, while, to satisfy disputants, it must occupy unlimited
space, would, it seems to us, inevitably leave the question pretty
much where it is now.
SAWXBLr. FUND.
To the Editors of The Lancet.
Sma,—Will you kindly allow us to acknowledge in your columns the
following subscriptions, which have been already paid in or promised
in answer to the appeal which was sent out on behalf of the widow and
children of the late T. H. Sawtell, M.D.Lond., M.R.C.P., M.R.C.S.,
who died in February last of pulmonary consumption, after several
years' illness, leaving very inadequate provision for his family.
Sir Andrew Clark ..
£r,
6
0
Mrs. Barlow .
£1
0
0
Sir Dvee Duckworth
3
3
0
Mr. George Brown..
2
2
0
Sir -Tames Paget ..
2
2
0
Mr. Webber .
i
1
0
Sir William Savory..
6
B
Dr. L. Heath.
1
8
Mr. Morrant Baker
f.
6
Mr. Patmore Sheehy ..
B
5
1)
Mr. Howard Marsh
f)
0
0
Mr, Walter Pye .. ..
1
0
Mr. Harrison Crlppa
r.
0
Miss Edelston.
0 10
(j
Dr. Champneya
0
0
0
Dr. Kirsopo .
0
10
6
10
0
Dr, Albert Venn .. ..
3
3
0
Mr. Percy Sliadbolt
f>
0
Mr. G. H. Hames .. ..
3
3
0
Mr. Robert Bruce ..
1
0
Cl
Mr. Kingston Barton ..
2
2
0
Dr. Brunton .. ..
2
2
0
Mr. W. H. Hatfield
1
0
Mr. Dublin.
5
0
Mr. G. S. A. Waylen
Dr. W. Collingridge
3
8
0
(DevizeO.
5
0
0
Mr. Cumberbatcli ..
6
0
0
Mr. Bowater J. Vernon..
3
3
0
6
0
0
Mr. 11. W. W. Goodsall,.
1
0
Dr. Clement Godson
15
0
0
Mr. (hecy I’ariiell .. ..
2
2
0
Dr. Waltor Griffith..
1
0
Dr. W. G, Buniies .. ..
2
2
0
Mr. F. A. Hall.
Mr. E. Howley Palmer..
10
0
0
Mr. R. E. W. Brewer ..
r>
6
0
Dr. Frederick Orton
10
HI
<1
Mr. W. M. Burgess.. ..
1
0
Dr. F. de H. Hall ..
2
2
0
Mr. Wm. Odell CTorauav)
1
1
0
Dr. V. D. Harris ..
5
5
0
Mr. Alban Doran ..
2
2
0
Dr.Norman Moore..
2
2
0
Mr. 1-'. l-l, Carter .. ..
3
3
0
Mr. Henry Power ..
i)
0
0
Dr. A. Folix Stevons
2
2
0
Mr. T. Smith .. ..
f)
0
Dr. G, Ilendle fDarwen)
2
2
0
Dr. Herbert Taylor..
f)
5
0
Mr, Mark II. H. \ onion
2
0
Mr. Willett .. ..
6
0
Dr. .Taires Adams .. ..
1
0
Dr. F'ii-tli.
2
2
0
Dr. C. I'l. Harrison .. ..
3
3
0
Mr. Lockwood .. ..
1
1
0
Mr. H. Goodsall .. ..
3
3
(1
Dr. Ormerod -.
2
2
0
Dr. M. J. Anderson
1
0
Dr. Samuel West ..
2
2
0
Mr. Joseph Mills .. ..
2
2
0
Dr. George R. Howat
f)
(J
u
Dr. T. G. Aldovton.. ..
1
II
Dr. H. Tliompson (Hull)
2
2
0
Dr. A. Baklock .. ..
1
0
.Dr, K. .lepson ,.
1
0
Mr. F. VV. Stnignoll
3
3
0
Mr. Horace Kent ..
r>
0
Mr. Colliver .
1
(1
Dr. William Fairbank
1
0
Dr. H. Lewis -Tones
6
0
0
])r. J, Abererombio
1
0
Dr. It. 0. Criims .. ..
1
0
Dr. William Peaeoy
0
Mr. Bruce Clarke .. ..
1
0
Mr. P. S. Eve .. ..
o
2
0
Mrs. .lohn Rail! .. ..
B
0
II
Dr. Thomas Biiznard
3
3
1)
Mr. Walsham.
5
B
0
'>
Mr. Alfd. Peace (Bridge-
Rev. Mr. Robertson
2
0
water) .
2
2
0
Mr. Maefadvan .. ..
3
3
0
Dr. 1'. W, Shoro
2
2
9
Rev. C. W. Edmondstone
2
2
0
Mr. Edward Barnett
1
0
As it i.s proposofl to close the list of subscriptions at tho ond of this
month, we slumhl bo much obliged if all subscriptions not already sent
ill be forwarded as soon as possible.—Yours truly,
V. 1). Hakiii.s, Wimpolo-stroot, W.,
(i. T. Penni. Oaklicdd-road, N.,
May, ISOl. II. Tavlou, Keuniiigton-park-imd, S, P.
I’llOKESSOn BUNdE'S ‘‘I.RUUmiCH nV.H PlIYSlOLOtllSCllliN l’Nl>
PATII()l.O<llSCnE.\ CHEMIl.;."
In our notice of the above-named book last week our reviewer, by inad-
vorteuco, exprossoil a wish that tho work might appear in an I'higlisli
dross. Our readers, howevor, will recall that a translation has
already ajipearod, and was, in fact, roviowotl iti our columns a fovv
montlis ago.
Jtfr. K T. JI. Parkc8.--ThQ extra-transparent optical glass referred to in
our last issue is nofi apparently as yet in the market. It i.s a Swedish
invention, and our amiouncement was made on tho authority of a
publication issued in Northern tluvope.
Dr. Tawers-Smilh.—'^ho article entitled “Howards of tho Profession,"
jjublished in a recent number of TiiE Lancet, was based cm a paper
in tho Linuhiii Quarti’iiy Eerimv.
Dr. paper is maiicod for in.sertion.
Paradox has forgotten to enclose bis card.
. “Save mb fsoh my Friends.”
Dr. Roberts of Chester owes but little thanks to his so-called friend,
Mr. 0. O. Williams, who writes in the Chester Chronicle a fulsomd
account of his visit to the skin dispensary over which Dr. Roberts
presides. As Mr. Williams lets us know that be is himself a B.Sc.
and a medical student, we may candidly tell him that we hope, unless
he is going to abstain from advertising himself and bis friends ia
the lay press, that he will never get beyond the student stage.
Dr. Roberts is the president of the Medical Society at Chester; so he
doubtless has the respect of his professional brethren, and we would
not put such a slight upon him as to suppose that he Is In any way a.
party to such offensive hattering. But he owes it to himself to let his
friend understand that the old proverb is still true—“He that blesseth
his friend with a loud voice, it shall be accounted a curse unto him.”
It will probably also make him careful not to invite men outside th&
profession to Iris clinic.
L.R.C.S.I.—A disclaimer from the hon. secretaries of the Medical De¬
fence Union was inserted in our last number, page 1077.
HOSPITAL ABUSE.
To the Editors of THE LaNCKT.
Sirs,—I n your issue for last week you publish a letter from “A
Sufferer "bringing grave and sweeping charges against special hospitals.
1 hope that some of tho older members of the profession will take up-
the cudgels on their behalf, but meanwhUe I trust you will allow me to
moat emphatically deny his sweeping generalities on behalf of myself
and colleagues at the Royal Chest Hospital, City-road. If I see thero
patients who strike me as not being suitable cases (pecuniarily, I mean).
1 invariably inquire as to whether they have had previous medical attend¬
ance ; if their reply be afflruiative, I next write to their family doctor-
and ask him whether they really cannot afford to pay for further-
advice. If the practitioner thinks I ought to do so, 1 allow them to-
cdiitinne in attendance; if, on the other hand, I am told that the
patients can still afford to pay a fair price for advice and medicine, I
tell them that they need not renew their letter (each letter lasts six
weeks only), and advise them to return to their previous doctor, writlng:
him my views on the case. This is, I think, the fairest way to act im
the interests of evei-ybody, and I have already received several letters^
from practitioners tliankiog me for the procedure. If the staffs of all
special liospituls would act thu.s, I feel sure that all friction would soon.
cea.se. I am, Sirs, yours truly,
Fiusbui-y-square, May, 1891. Fred. J. Smith.
AN EXPLOSIVE MIXTURE.
To the Editors of The Lancet.
SiR.s,—The following note may be wo .thy of publication in your-
journal
Having occasion to make a disinfectant liuicl to apply to an offen¬
sive surface on a body awaiting post mortem oxaniination I chiiiced to
select permanganato of potash. Thinking the solution might dry too-
tpiickly and inetficieutly deodorise the part, it occurred to me to add
glycerine on acccount of its hygroscopic^ powers. Putting a drachm of
the crystals into a threc-onnee bottle I added two ounces of water and
one of glycerine, and agitated the mixture. To my groat surprise the-
cork and part of the contents were vioiontly ejected, and the remaining
portion develepod great heat. Everyone is familiar with tho danger
of mixing glycerine and nitric acid; I have not, however, saen any men¬
tion of a combination of it and permanganato o( potash, I observed
the mi.Kture became brown, loiiiig its purple colour like a deoxidised
solution of the salt; and ns no effervescence took place, it is probable
that the glycerine combined with the oxygen liberated by decomposi¬
tion of the-salt, and that, further, it posso.sses by some affinity of its own
the power of producing rapid decomposition of the permanganate.
Perhaps .some chemist will kindly explain.
I am, Sirs, yours obediontly.
May ntii, 1891. JOH.N Grant, M.B., C.M.Bdin.
FEES FOR AMBULANCE LECTURES.
To the Editors of Tin-; Lancict.
Sirs,—A lecturer only receives one guinea for each lecture delivered-
to a St. John Ambulance class, and his tiavelling expenses. Any-
balanco that remains after the payment of expenses goes to the Order
of St. John of.) erusalein, to help to defiuy the expenses of those classes,
whicli aro unable to pay anything towards tlieir cost, such as those
given to tbo worliing classes and poor lads attonding night schools.
I am, Sirs, yours faithfully.
May, 1891. ■ F.R.C..S.
ENGLISH MEDICAL SERVICE IN THE LATE RUSSO-
TURKISH WAR.
To the Editors of The I.ancet.
Sirs,—P erhaps some of your readers may bo able to supply me with
an answer to tho following question, Did the I'lnglish surgeons who-
served witli tho Turki.sh Army during the Ru.sso-Turkisli war receive
any reward in tho shape of medals ? If so, what were they, and are
they allowed to bo worn here in uniform ?
I am. Sirs, your.s faithfully,
Stockport, May 11th, 1801. .1 f venal.
Digitized by
Google
1136 Thb Lancet, J NOTES. COMMENTS, AND ANSWEKS TO COKEESPONDENTS. [May 1G, 1891
CIVIL MEDICAL SERVICE IN INDIA. I
To the Editors The Lancet. '
Sirs,—I shall feel obliged by your publlahing the followingFor
some time past private agencies have been in the habit of procuring
medical men from England, Scotland, and Ireland to till the posts of '
civilian surgeons and physicians in various districts in India. Splendid '
promises are made, and some senior man is usually asked whilst in the
old countries to do the part of procuring the services of the poor unfor*
tunate. On arrival in India the victim finds the people here in no way
responsible by document for the words of the gentleman seen at home,
and by degrees the whole venture turns out a huge fraud. Only lately
it was remarked in a case where a medical man was to be got out on a
small salary with amaximum amount of work, “ If a man is fool enough
to come out and work for so little, why should we offer more induce¬
ments.” My advice is to every man intending practising in India or the
colonies to accept no post whatever unless all agreements are previously
signed “at home,” and duly vouched a-s to honesty and .so on. As
matters are conducted now, the medico is a lamb to be ill-treated by
‘an unsympathetic” public. I beg to enclose my card.
I am, Sirs, your obedient servant,
India, April 22nd, 1891. Victim.
Errata.— In Dr. Collin.s' letter, published in our last issue, p. 1000,
line 25 from bottom of first column, for “ resolution," read revohitiori;
and in lino 8 of next column, for “ continue,” read oombins. — In
Dr. A. Cordes’ letter, published last week, p. 1078, for “ Rome,” read
Erance ; and for “ v. Dorwault li'Oflicin,” read t>. Eorvault L'Ojficine.
Communications, Letters, Ac., have been received from—Dr. Wilks,
London ; Dr. Towera-Smith ; Dr. Steele, London ; Dr. Macnaughton
Jones; Dr, Handford,Nottingham; Dr. Harkin, Belfast; Mr. D'Arcy
Power: Dr. Thin, London ; Mr. Tweedy ; Dr. Horrocks; Mr. Lawson
Tait; Sir Morell Mackenzie; Dr. Delilpine; Mr. Duke; Dr. Hiugaton
Pox; Mr. More Madden ; Dr. Leslie Phillips, Birmingham ; Mr. .John
Poland ; Dr, Theodore Williams ; Dr. Pavy, London ; Mr. W. H, Clark,
Plymouth; Mr. Hartt, Greenwich; Mr. Mlehelli, London ; Dr. Baines ;
Dr. Halliburton, London ; Mias Yates, London; Messrs, Margrave
Bros., Llanelly; Surgeon-MajorLawrie, Hyderabad; Messrs. Thorp
and Co.; Dr. Grant, Bingwood; Mr. Bridgman ; Messrs, Oliver and
Boyd ; Mr. Feeny, Walsall; Dr. Roberts, Cheater ; Me.ssrs. Pearson
And Co., Stepney ; Brigade-Surgeon Amesbury, Brighton ; Mr. Pagan
Lowe, Bath; Dr. Anderson, Spennymoor ; Messrs, llrossloy, Moir, and
■Go.; Mr. Todd, London; Dr. SpUJer, London ; Messrs. Kegan Paul and
Co.; Dr. Boteman, London; Dr. Joll; Rev. N. Bromley; Dr. Gordon
Hill, Brighton ; Mr. J. W. Taylor, Birmingham; Messrs. Evans ami
Walter, Chippenham; Mr. Mackenzie, London ; Messrs. Battle and
Co.; Dr. Barnes, CarlLle ; Dr. Malcolm, London ; Msssrs. Griffin and
Co.; Mr. E. Morgan; Messrs. Constable, Edinburgh ; Messrs. Salter
Bros., London; Dr. W. J. Collins ; Mr. G. Foy, Dublin ; Dr. Albert
Wilson, Leytonstone ; Mr. Lionel Stretton, Kiddonnin.ster; Mr. Jolin
Gay, Putney ; Dr. H. W. Jones, London ; Dr, Buvdon-Sanderson, Ox
dord; Dr. Bampton, Ilkley ; Mr. Paul, Livorpml ; Dr. F. J, Smith,
London ; Mr. Page, Bedditch ; Dr. Bannatyne, Greenock ; Dr. Auld,
Glasgow; Dr. Lewins; Mr. Manby, Wolverhampton ; Mr. Martindale,
London; Mr. Milhado, London; Mr. Stainwell, Rociidale; Dr. Malins,
Birmingham; Dr. Maclaren, Carlisle ; Mr. Collurn, Loudon; Mr. J.
.'Smith, Stafford ; Mr. Whitfield, London; Mr. Boswell; Mr. Elsdale,
London; Dr. Rentoul, Liverpool; Dr. Strehz, Chicago; Messrs. Lee
and Martin, Biimingham ; Mr. Griin, London ; Messrs. Keene and
Ashwell, London ; Mr. G. Fullerton, Hanwell; Messrs. Barker and
Bon, London ; Mr. Lupton, Stratford-on-Avon ; Messrs. Ander.son and
•Co., London ; Dr, Austen, London ; Mr. Holder, Bull; Messrs. Keith
-and Co,, Edinburgh ; Mr. Honlley, Stoke upon-Trent; Messrs. Allden
and Johnson, Southampton; Mr. Tasker, London; Messrs. Thomas
and Co., Bristol; Dr. Prout, Edinburgh; Mr, Griffith; Mr, Clarke,
Hastings ; Dr. J. Gordon, Aberdeen; Mr. Stirling, Essex ; Mr. Little,
London; Mr. Stoner; Mr. Pentland, Edinburgh; Mr. Hargreaves,
London; Dr. Zangger, Russell-square; Mr. Ormond, Newcaatle-on>
Tyne; Mr. Homibrook, London; Mr. Hagan, Plymouth ; Mr. Adams,
Eye; Dr. Moorhead, Nottingham ; Mr. Coleman, Cardiff; Mr, Orr,
Dresden; Mr. Gwynn, Brighton; Mr. O’Dell, Torquay; Mr. Coghill,
Birmingham ; Mr. Richardson, Leamington ; Mr. Branthwaite, Rlck-
mansworth; Messrs. Richardson, Liverpool; Dr. White, Sheffield ;
Mr. Oliver, Manchester; Mr. Eastwood, Blackburn ; Mr. Scott, Man*
Chester; Mr.Sell, London; Mr.T. A. Jones, Aberavon; Clerk, Borough
of Sheffield; Victim; E, B.; F.R.C.S.; L.R.C.S.L; Liverpool Lock
Hospital; Anglicanus; Jet, London; Medical Superintendent, County
Asylum, Preston: Matrom Nurses'Home, Cornwall; Bank Brewery
Co.. Sowerby Bridge; J.R. P., London ; Matron, London ; Bouillon
Fleet Co.; S. II.. Manchester; Z. O.; Triplex; Bachelor; Western
Daily Eercnry, Plymouth; L.R C.P.; M.D., London; 0. H. ; Devon.
Letters, each with enclosure, are also acknowledged from—Dr. Diver
Derby; Mr. Wood, Skibbereen ; Dr. M. Jones; Messrs. W. H. Smith
and Son, Birmingham ; Mr. Morgan, Harborne ; Mr. Morton, New
Brompton; Mr. Tu'ly, Hastings; Mr. Primrose, Durham; Messrs. Lee
and Nightingale, Liverpool; Mr. Forjitt, Lihcoln; Messrs. Woollams
and Co., London ; Mr. Mendelsohn; Messrs. Burroughs, Wellcome and
Co., London; Mr. Tyte, Minebinhampton ; Mr. Lockwood, Hudders¬
field ; Mr. Bayley, Tipton; Dr. Evans, Llanerchymedd; Mr. O'Meara,
Loughborough ; Mr. Cra’g, Wick ; Mr. Greville, Brixham ; Dr. Poison,
Sutherland; Mr. McCulIen, co. Antrim; Mr. Godfrey, Northampton;
Dr. Cunningham, Bristol; Mr. Moore, Camberwell; Mr. Graham,
Carnfoi'th Mr. Banford, Uttoxeter; Mr. Butlin ; Mr. Rhodes, Not¬
tingham ; Miss Gallaher; Mr. Daily, Bond-street; Messrs. Grace,
Bristol; Dr. Croke, Yorks; Mr. Branthwaite, Brdington ; Dr. Fertar,
Cheshire ; Dr. HUliard, Aylesbury; Mr. Gosport; Dr. Taylor, Not¬
tingham ; Mr. Smith, Brighton; Mr. Guthrie, London ; Dr. McCallen,
CO. Derry; Miss Debenham, St. Albans; Mr, Bray, St. LeonardS'on-
Sea; Mr. Maclehose; Dr. Couldrey, Doncaster; Mr. Edwards, Ponty¬
pridd; Mr. Bryden, Shipley; Dr. Buck, Clapton ; Me.ssrs, Pownceby
and Co.; Mr. Baily, Tipton ; Mr. Green, Devon ; Messrs. Porteousand
Co., Glasgow ; Mr. Christian, Hammersmith ; Mr. Henderson, Dum¬
fries; Mr. Westbrook, Reading; Mr. Bell, Leytonstone; Mr. Qorst,
Liverpool I Mr. Thoaipson, Hampstead; Mr. Cochrana, Wigtown-
sliire ; Mr. Mooney, Margare; Mr. White, Dunstable : Mr Edwards,
Birmingham ; Mr. Tliin, Edinburgh ; Mr. Brinton ; Dr, Cooke, Shef¬
field ; Dr. Atkinson, Lurgau; County of Lanark; Delta, London;
Secretary, General Hospital, Birmingham ; L. S. ; Secretary, College
of 1‘receptovs; V, A.; J. L. A.; Exchange ; M.R.C.S., Clifton ; North
Staffs Infirmary; Cantab., London ; Surgeon, Manchester; Kur und
Bade Verwaltung, Homliurg ; J. W. P.; Sic Vos ; Secretary, Union
A.ssociation, Cornhill; Phosphates; M.R.C.S., London; Harpenden
Hall, Herts; Medicus, Manchester; S. G.; Birkonliead; Hallfleld
Cnrtage, Hanley ; Medicus, A.0. ; Skllbock ; E. M. ; HeadingMerexi/nj
Office; Class Rooms, Edinburgh ; York,London ; Hackney Furnishing
(!o, , Beta, Loudon ; W., Manchester ; Fides ; Medicus, Deal; Beech
Hur>t, Hanley : f^tatim, Liverpool; Beta, Sheffield ; A. lil. ; Borough
of Devizes ; Os Fronti.s ; M.O.H.; County Asylum, Preston; Hamilton
Association.
Newsuai’EHS.—F'.' oA'iwan, Birtninghain Daily Poet, Capo Timss, Irish
’fl.niei, Unos, WeMem Times, Liaerpnol Daily J’ost, Leeds Meroiirj/,
Sunday Times, Scottish Leader, Yorkshire J’ost, Iteadiny Mermrg,
Bristol Mercury, Labour World, Mininy Journal, Windsor and Eton
Gazelle, Weekly Free J'rass, Surrey Advertiser, Ball Daily News, The
Chrislian. Ifert/ordshire Mcrounj, Windsor and Jihni Mapress, New
/.calami Herald, l■:cho(S1|dney), Klyin Couranl, Tioerlon Gazette, Mei-
hiriime. Daily Telegraph, West Middlesex Slandaxd, Leicester Daily
J‘(isl, Northern Whig, Kaslern Press, Si. Stephen's Beuiew, Dundee
Adoertise.r, Ashton Standard. Shields Daily Gazette, Admiralty Gazette,
Londonderry Bentinei, lioyal Cornwall Gazette, Darwen J'osi, Durham
Chronicle, Lssex County Chronicle, Derby Heporter, Teesdale Mercury,
Cambridge. Chionicle, Devizes Gazette, Belfast News Letter, Le Temps
(Paris), Nursing Hecord, Stamford Guiiraian, WorthisigGazette, Here¬
ford Times, Chester Chronicle, <yc., have been received.
SUBSCRIPTION.
Post Free to any fart of the United Kinqdom.
One Year_____ £1 12 6 | Six Months 8
To China AND India --Year 1 18 lo
To THE Continent, Colonies, and United
States ......... . Ditto 1 14 s
Post Office Orders and Cheques should be addressed to The Publisher,
The Lancet Office, 128, Strand, London, and crossed “ London and
Weslmlnster Bank St. James’s-square."
ADVERTISING
Books and Publications (seven lines and under) ..£1 I 0
Official and General Announcements .0 f 0
Trade and Miscellaneous Advertisements .. ..118
Every additional Line 0 0 8
Front Pua .. „ ... .. per Line 0 10
Quarter Page. ^ 1 10 0
Half a Page .. ... .. ... 8 16 0
An Entire Page.580
The Publisher cannot hold himself responsible for the return of testi¬
monials dtc. sent to the office in reply to advertisements; copies only
should be forwarded.
Notice.—A dvertisers are requested to observe that It Is contrary to
the Postal Regulations to receive at Post Offices letters addressed to
Initials only.
An original and novel featnre of " The Lancet General Advertiser" la a special Index to Advertisements on pages 8 and 4, which not onI«
affords a ready means of finding aiw notice, but is In itself an additional advoftisenient. ’
Advertisements (to ensure Insertion the same week) should be delivered at the Office not later than Wednesday, accompanied by a remittance
Answers are now received at this Office, by special arrangement, to Advertisements appearing in The Lancet.
Terms lor Serial Insertions may be obtained of the Publisher, to whom all letters relating to Advertisements or Subscriptions should be
Addressed.
Advertlsemanbs are now received at all Messrs. W. H. Smith and Son's Railway BookstaUs throughout the United Klnedon and all othn
Advertising Agents. _
AeeDt for the Advertiaement Department in France-J. ASTIER, 66, Rue CaumarMn, Paris.
Dir zed by
THE LANCET, May 23, 1891.
ON A
cm OF PKIMARY HAEMORRHAGE INTO THE
SPINAL CORD.
Delivered at St. Thomas's Hospitaly May Gth, 1891,
By SEYMOUR J. SHARKEY, M.D. Oxon.,
PHYSICIAN TO THE HOSPITAL,
Gentlemen, —In the first of a short course of clioical
lectures which I propose to give duriug this summer session,
5 shall bring before your notice an instance of a very rare
•disease—primary hasmorrhage into the spinal cord. How
infrequent it is you may judge from the following extracts;—
“Sanguineous apoplexy of the spinal cord. The older
writers spoke of this in order to account for the occurrence
of sudden paraplegia; but the event must be excessively
Tare, as I have never seen a well-marked fatal case of it”
^(Lectures on Diseases of the Nervous System, by Dr. Wilks).
Primary heemorrhage into the spinal cord, sufficient to
produce symptoms, is a very rare disease, and it is even
more rare than is suggested by the cases now and then
■recorded as such.It is certain that the history of primary
•haemorrhage has been largely written from uncertain data,
•and will need extensive revision when a sufiicient number
of exact observations have been accumulated” (Gowers).
As a primary lesion this is very rare, so rare indeed that
'Charcot and Hayem have recently expressed doubts as to
whether it has ever been observed, and have endeavoured to
•show that in all thecases which havebeenrecorded as examples
•of it there was an acute central softening, the result of mye¬
litis” (Fagge). “In the large haemorrhages it seems at present
•quite doubtful whether the aft'ection is a primary idiopathic
haemorrhage, and not rather a haemorrhagic myelitis. We
are decidedly of opinion, particularly on the ground of
■clinical symptoms, that primary haemorrhage of the cord
also occurs ” (Ziemssen’s Cycloptedia). The less frequent a
disease the less opportunity we have of studying it, and the
dess ready we are to diagnose it. I think there were other
reasons, which I shall presently put before you, why we
failed to recognise the disease in the present case ; and it is
'largely because we did fail that I bring it before you; for it
has often been said with great truth that we learn more by
•our failures than by our successes, always provided that we
have done our best, so that the circumstances attending the
•failure may make a striking impression upon our minds.
J. S-, a schoolboy aged thirteen, was admitted into
Arthur ward under my care on Jan. lOth and died on
•Jan. 15bh, 1891. His family history was particularly good,
and bis own showed him to be a healthy member of n
healthy stock. The account of the illness which brought
'him to the hospital was nob as clear as one could have
•desired, bub what the boy told me was that be bad been
skating and had had a good many falls, of which he
thought very little. The last one he had was a heavier
•one, and occurred three days before admission ; but ho
did nob at the lime of it feel hurt, though he left the ice,
thinking he had had enough skating. He walked home,
•and it was only on getting there that he felt pain in his
left shoulder, abdomen, and legs. This was succeeded
by gradual loss of power in his lower extremities, so that
■after an interval of two hours he could nob walk and had
to be carried to bed. There he remained for two days,
and was then brought to the hospital. On admission, he
was found to be a somewhat delicate-looking lad, com-
.plaining of pain in the abdomen and legs, inability to
move the latter, of great thirst, and retention of urine.
The pulse was 144 in the minute and weak, but there was
cno evidence of cardiac disease. Bronchitic aovinds were
heard pretty generally over the lungs. The bladder was
found to be distended, reaching very nearly as high as
the umbilicus. The abdominal viscera were healthy, bub
■ the bowels had not been opened for four days. The urine
was acid, sp. gr. 1012, and contained no albumen. The
temperature was 101 •8°!’. On examination of the spine,
•no tenderness on percussion or deformity was found.
'iTbe legs were completely paralysed, and sensation was
No. 3534.
impaired in them, and, indeed, upwards as far as the fourth
or fifth dorsal spines. The upper limit of amBsthesia on
the right passed from this point, sloping forwards in the
direction of tlie ribs, and reaching the level of the sixth rib
in front; on the left it reached the level of the fifob; there
was just above the line of amnsthesia a small zone of byper-
ocsthesia. Some numbness was likewise complained of in the
left band. The knee-jerk on the right was completely absent;
on the left it was present, but not well marked. No ankle
or patella clonus. Abdominal and cremasteric reflexes were
absent; plantar fairly brisk. Pupils were both small, andf
did not contract to light. During the rest of his life, which
terminated on the 15Eh after an illness of eight days, the
bronchitic sounds increased in number; pneumonia of
the left lung supervened on the 13th, and the right became
affected a little later; respiration was rapid, reaching
36 in the minute. The pulse to the end was greatly
accelerated, beiog never less than 140 in the minute,
and reaching 160 before death. He had persistent re¬
tention of urine, and his bowels were very confined.
His temperature was persistently high, reaching 104®, and
nearly 105° F. The pain in the left arm and shoulder con¬
tinued, and definite loss of power in that arm subsequently
supervened. He was also much troubled with bad pain
in the head. The paralysis of the legs remained complete,
but the amesthesia became less, and was finally only patchy.
No optic neuritis was present. The right patellar reflex re¬
mained in abeyance and the left varied, being sometimes
absent and sometimes present. From time to time he was
troubled -wath painful twitchings and spasms in the affected
limbs. He died on the eighth day of his illness.
A’ecro/Jsj/(perfmmedbyI)r. Hadden); Bodyfairlynourished;
no sign of external injury to back. Brain much congested
all over the surface: puneba cruenta unusually prominent.
Grey matter congested. A little stickiness over the cbiasma
was evident on removing the brain, hut no other sign of
meningitis. Mediilla oblongata normal. No h.-emorrhage
and no apparent degeneration. Spinal cord : No bruising,
laceration, or hremorrhage found affecting the spine or its
membranes. The pia mater, front and back, was much
congested, but free from lymph. At the level of the third
dorsal pair a hard localised swelling was felt, and the cord
here was bulged. Above aud below the cord felt soft, and
the surface had a slightly yellow tinge. On making a
section an extravasation of blood was found occupying
nearly all the transverse extent of the cord. A little of the
white and grey matter on the right side only could be made
out. The blood was coagulated and slightly decolourised at
one spot. Above the hcemorrhage as far as the upper
cervical region and below as far down as the mid-dorsal
region the anterior and posterior cornua of the grey matter
on the left side were converted into a cavity containing
liquid black blood. The white matter was unaffected.
' The lumbar and sacral regions of the cord were normal.
The heart was free from disease. Lungs : The left lower
' lobe was solid, dull red in colour, and nodular on section,
; being in the red stage of broncho-pneumonia. Along the
i posterior border of the right upper and lower lobes there
I was also some broncho-pneumonia in a similar stage of
i development. Liver, spleen, and kidneys were natural.
Microscopic examination showed that the hemorrhage was
I the only pathological condition present in the cord. There
I was not the slightest evidence of inilamraatiou or any other
i disease.
In giving the history of the onset of the attack in the
I present case I have, perhaps, strained a point somewhat,
owing to the light which the post-mortem examination shed
upon it. I refer to the rapidity with which the symptoms
followed the fall on the ic?. The history was particularly
didicult to elicit, because the friends tended to exaggerate
the falls which the boy had, as they attributed his illness to
them, whereas the patient thought nothing of them, as he
considered they were no worse than he expected to get, or
than ho saw his comrades getting. We did not know whose
account to believe before death, but naturally after the
post-mortem revelations I have rather accentuated the
friends’ view. In any case the disease, though it showed
. Itself by its symptoms rapidly, didnot dosoinsrantaneously.
Accepting the falls on ihe ice as the probable cause, the
effect did not supervene for an hour or so, and did not reach
its maximum for two or three hours. But the symptoms
were, from any point of view, acute, and clearly pointed to
one of the acute diseases which affect the spinal cord. First
came pain in the abdomen and legs, then rapid and cona-
X
; ; Goode
O
It38 ThbLancet,] DR. SEYMOUR J. SHARKEY ON PRIMARY HEMORRHAGE.
[May 23,1891.
plete paralysis of lege, and retencioD of urine. Oo hie
admission on the fourth day of the disease these symptoms
-were present, together with constipation, aniosthesia as
high as the fourth or fifth dorsal spine, absence of the
right knee-jerk, very rapid pulse and respiration, con¬
tracted and inactive pupils, a high temperature, and
some painful twitching and spasms of the affected limbs.
Later paresis of his left arm supervened, and the bronchitic
sounds, which were present from the first, gave way to the
physical signs of pneumonia. Now let us consider the
meaning of these symptoms separately. First of all, there
w(u no evidence, such as local tenderness on percussion or
distortion of the spinal column, to suggest any injury to
bone; but the fact that the ancesthesia reached as high as
the fourth or fifth dorsal vertebra showed that the lesion,
whatever it was, was a little above that level. The absolute
paralysis of legs and bladder showed that the cord was
pretty completely disorganised by the disease. The con¬
tracted and inactive pupils would point to the same region as
the seat of disease, for this phenomenon pointed to paralysis
of the sympathetic nerves supplying the pupil-dilating
muscles. Landois and Stirling say; “The ciUo-spinal
centre connected with the dilatation of the pupil lies in the
lower cervical part of the cord, and extends downwards to
the region of the first to the third dorsal vertebrm.” It is
also not at all improbable that the very rapid pulse which
the patient had may have been in some way connected with
an affection of the accelerator nerves which issue from
the upper dorsal region of the cord. Landois and Stirling
say that the accelerated fibres of the heart “pass from
the mednlla oblongata through the spinal cord, and leave
the cord through the rami communicantes of the lower
cervical and upper six dorsal nerves, to pass into the
sympathetic nerve.” The rapidity of the heart’s action
would only he explained by irritation, and not by paralysis
of the accelerators. But we must remember that the
hmmorrhage was only large enough to completely dis¬
organise the cord about the level of the third dorsal
vertebra, and that above and below this level it only
occupied a part of the grey matter, and the effect of it in
those regions might easily have been irritation rather than
paralysis.
It was clear, then, from an analysis of all the symptoms,
that one had to deal with an acute destructive disease of
cord in the upper dorsal region. The presence of an-Tisthesia
and paralysis of thebladder proved thacit could not be limited
to the grey matter—could not, in fact, be an anterior polio¬
myelitis; but must be a lesion which disorganised the whole,
or nearly the whole, transverse area of the cord. The only
acute diseases likely to do this were a complete rupture
of the cord, bfumorrhage into it, or acute myelitis. Now,
the only means of diagnosis in such cases, or, at any
rate, the important factor in the diagnosis, U the sudden¬
ness of the attack. In the case of rupture, of course, it
would be absolutely sudden. Speaking of brnmorrhege
as opposed to inyelittg, Gowers says: “The actual onset
is always sudden; the symptoms attain a considerable
height in the course of a few minutes. The sudden¬
ness of onset is characteristic of ihe disease.We
are not justified iu regarding as primary bremorrhage
any case in which premonitory symptoms existed for more
than a few minutes, unless those symptoms were so pro¬
nounced and sudden in onset that they might have been
due to a small extravasation. Initial fever in any case
makes myelitis probable.” One finds, again, in Ziemssen’s
Cyclopiodia of Medicine: “One specially characteristic
feature of spinal apoplexy is the way in which a complete
and severe paraplegia will develop in the course of a few
minutes or an hour.Iu diagnosis, the main difficulty is
with central myelitis. The only point of distinction con¬
sists in the rapidity with which the symptoms develop.
’The paraplegia requires hours or days in simple myelitis, in
hsDQiato iiiyelia minutes or quarter-hours.” Dr. Frederick
Taylor says the onset is sometimes quite sudden ; in other
cases the symptoms may he more gradually developed in
the course of a few hours. Symptoms are subsequently
those of acute local myelitis. The diagnosis depends «)n tlie
sudden onset of the .'yrnptoms. Prodromal symptoms of
even very short duration and fever make myelitis probable.
In the case with wdiich we had to deal the symptoms
appeared to take hours, and nob ininutes, and in addition
fever was present. Consequently the conclusion arrived at
was that the case was probably one of acute myelitis. The
fever, however, was misleading; for it probably depended
upon a commencing pneumonia, and it increased as th9
latter became more extensive. What was the cause of tho
pneumonia? I think it probably depended directly upon
the nerve lesion. In Quain’s Anatomy you will find it
stated that “ behind the root of the lung the pneumogastrio
nerve becomes flattened, and gives several branches of much-
larger size than the anterior branches, which, with the fila¬
ments derived from the second, third, and fourth tboraclo
ganglia of the sympathetic, form the posterior pulmonary
plexus.” Trophic lesions, as thejr are generally called, occur
not infrequently in the case of injury or inflammation of the
peripheral or central nervous system. In the case of acute
myelitis affecting the lower parts of the spinal cord the
alteration in the capabilities of tissues to resist the most
ordinary pressure is shown in the acute central bedsores
which form over the sacral region, on the heels, and other
parts which are subjected to pressure as the patient lies'
in bed. With the retention or incontinence of urine one
' often sees acute cystitis and suppurative nephritis making
their appearance, and adding greatly to the perils of
the myelitis; and yet in cases in which there is a similar
affection of bladder without cord disease these infiammations
do not ordinarily occur. Hence acute bedsores and acute
cystitis are looked upon as effects of altered nutrition owing
to the nerve lesion. Again, in the disease called herpes
zoster, a superficial inflammation of skin occurs in the course-
of the affected nerve; or it may sometimes happen that the
inflammation affects the tissues much more deeply placed.
Speaking of this subject. Sir James Paget says in his “Studies
of Old Case-books”; “Ordinarily, with considerable preceding
or associated pain, there is only so much local necrosis as is
expressed in the death and separation of the epidermis of'
the minute vesicles and the shallow ulceration indicated by
the little scars; but this ulceration may be deep, and V.
have seen one case in which, with herpes in the range
of the second division of the right fifth nerve, there
was necrosis of the portion of the alveolar border of the
upper jaw, and of all the teeth receiving branehes from,
that nerve.” The rapid atrophy and nutritive changes
which occur in infantile paralysis, alcoholic paralysis,,
and other nerve diseases, belong to the same class. Con¬
sidering how rapidly the patient under consideration
developed broncho-pneumonia, having apparently no pre¬
disposition to chest disease, I cannot but think that this-
inflammatory affection may be put down to the injury to
nerves proceeding from the site of the haraorrhage to the
lungs. It is interesting to note with reference to this point
that the grey matter of the cord was far more extensively'
disorganised on the left than on the right side, and the left
lung was the seat of a much more complete and widespread
inflammation than the right. The fact that the left arm
was partly paralysed while the right remained free, finds-
its explanation in the extension of the hcomorrhage in the
grey matter upward,s and downwards on the left and not on
the right. Another interesting point in this case is the,
total and permanent disappearance of the right knee-jerk.
You often have the increase in the tendon rellexes pointed'
out to you in the wards as occurring when a lesion involves-
the lateral columns of the cord above the lumbar enlarge¬
ment, so that the lumbar centres and fibres remain,
intact. This alteration of the knee and other reflexes
in the way of excess is looked upon as being duo to-
the interruption of the communication between the intra¬
cranial centres and those in the anterior cornua of the-
cord, the connecting fibres which run in the antero¬
lateral columns of the cord being disorganised. This
condition of affairs is certainly the rule even in very
.severe destructive lesions high up in the cord, and I think
I have myself mot with increased reflexes, and finally
tonic spasm of the limbs, wliere there was no clinical
evidence of the passage of eitlier sensory cr motor stimuli
through the cord. Lately, however, very strong evidence'
has been adduced {bvBastian, Bowlby, and others) to show
that in complete transverse lesions, such ns occur from-
accidents or softening of the cord, reflexes, both deep and
superficial, are completely abolished so soon as all nerve-
conduction between the brain and lumbar centres comes to-
an end. The disappearance of one knee jerk in the present
instance may therefore be supposed to depend on conditions
similar to those existing iu other sudden lesions of the
cord. In curious contrast to cerebral biomorrhH.ge, spinal'
h.'i'morrhage occurs mostly between the ages of ten and'
forty. "Wby this should be so it is at present impossible to-
say; for its occurrence one at least of three conditions
The Lancet,]
DR. SAMUEL WILKS ON BLOODLETTING.
[May 23,1891. 1139
seems to be necessary : disease of vessels, sudden
hyperocmia, or violence. In scurvy and small-pox, for in¬
stance, disease of vessels probably plays the must import¬
ant part, as it does also in myelitis when complicated by
hmmorrhage. Sudden hypermmia appears to be the effec¬
tive cause in those cases which arise in connexion with
exposure to cold, extreme physical exertion, and sudden
alterations of atmospheric pressure, such as occur in the case
of divers. Pinally, in cases such as the one I have taken
for the subject of this lecture a strain or injury seems to
produce the accident without causing any tangible altera-
non in the bones or spinal membranes, but in what manner
it gives rise to hmmorrhage is not very clear. The case
which I have now brought before your notice is the first I
have met with in which simple primary hrcmorrhage of the
cord has been shown by post mortem examination to have
the lesion which has proved fatal.
ON BLOODLETTING.
By SAMUEL WILKS, M,D.,F,R.S.
Dr. Ogle having given you in an interesting communica¬
tion his opinion on the value of bloodletting, I should in
like manner be pleased to offer you my own experience,
which is highly confirmatory both of his and that of Dr.
Pye-Smibh, Dr. Broad bent, and other eminent medical men.
During the whole of my professional life I have occasionally
used bloodletting as a remedial measure, and have probably
adopted venesection in about thirty cases. In some lectures
on Chest Diseases, published many years ago, for the use of
students, I said, As regards bleeding, there cannot be a
doubt that in former times, from the truthful character of
the records, its use was often attended with a strikingly
good result. We read of persons sitting up in bed with
great oppression of breathing, their faces gorged with blood,
and the surgeon coming in with his lancet, bleeding in a
full stream, and immediately quieting the respiratory pro¬
cess and relieving the circulation. In such cases there may
have been pneumonia, bronchitis, or heart disease, but the
results were nevertheless the same. This seems to show
that in cases of great engorgement of the lungs or of the
right side of the heart bleeding will afford relief, and there¬
fore in similar circumstances I should advise you to have
recourse to the measure. When you find the venous system
gorged in primary affections of the lungs, or in secondary
congestions, as in heart disease, or from paralytic conditions,
as in apoplexy, you cannot be wrong in bleeding; you
relieve riie venous system as well as ^e heart, and allow
the circulating apparatus to right itself. The objection
sometimes made that the patient is too weak, as indicated
by the pulse, is futile, since, owing to the small amount of
blood which reaches the left ventricle to be propelled on¬
wards, the pulse is natu^lly small.” Again, in my lectures
on “Diseases of the Nervous System,” I devote several
pages to the consideration of bloodletting and its use when
the lungs are gorged from paralysis of the chest or other
cause. I may make the following quotation Many of
you saw the case of epilepsy which one of my clerks bled a
few months ago. The man was a strong agricultural
labourer, and came here suffering from severe epileptic fits.
One afternoon, on going round, we were informed that he had
never been out of a tit for four hours. We found him lying
in bed with constant convulsive movements, but the most
striking and alarming condition was the engorgement of the
lungs and increasing lividity of the surface of the body. I
requested that he should be bled, and one of you, wisliing
to distinguish himself at his first attempt, or from the
lancet being over-sharp from disuse, fulfilled my object to
the utmost; tho blood poured out in a torrent, the face
rapidly became pale, the man opened his eyes and spoke
for the first time since the morning, the interval having
been a blank to him. The effect was the most striking I
have ever witnessed, and it is worthy of note also that he
had no fit for a long time afterwards.”
It was very early in my student days that I was impressed
with the value of bloodletting. I accompanied a general prac¬
titioner to see a little boy suffering from bronchitis after
whooping-cough. He was lying half raised on a pillow
asping for breath, his face livid, eyes starting out of his
ead, and the superficial jugular making itself most appa¬
rent. The doctor, after gazing at this vein and feeling it,
pulled out a lancet, and in spite of the protestations ot the
father opened it and let out several ounces of blood. The
lividity passed away, the child sank back on the pillow in a
tranquil sleep, and from that time speedily recovered. I have
no records by me of the cases in which bleeding was adopted,
but certain instances are deeply rooted in my memory. For
example, a young woman was brought into the hospital in
a dying state, gasping for breath, and livid ; there was a
mitral bruit, engorgement of the lung with hosmoptysis,
albuminous scanty urine, and dropsy. We bled her from
the arm, and the effect was immediate, the breathing
became tranquil, lividity passed from the face, and improve¬
ment continued from that time^ In cases of uraemic con¬
vulsions the effects of bleeding are very striking; the right
heart is relieved, and poisoned blood is removed from the
system. One case of this kind, indelibly fixed in my memory,
is that of a neighbouring dressmaker, who, I believe, is still
alive. I was asked a few years ago to see this patient early one
morning by her medica\ attendant as a satisfaction to him
and her friends ; she had been in convulsions all night, but
he did not wish to disturb me before daybreak, believing the
case to be hopeless. I found a middle-oged woman in constant
convulsive movements, froth issuing from her mouth, quite
comatose, and almost pulselsss. The whole body was livid
and the extremities cold. The doctor said she was dying,
and allowed me therefore to bleed her. I took away a
small wash-hand basin of blood, and while flowing the
lividity passed off, the convulsions ceased, the body gradu¬
ally became warmer, and when I saw her in the middle of
the day she was calm, and conversed with me. Her life
was as clearly saved by the bleeding as if I had dragged
her drowning out of the water : and this is more than I can
I say from the use of drugs. Dr. Ogle writes that little _was
said at the discussion about the use of leeches and cupping.
I can remember a good example of treatment by each
method. I was once asked to see a well-grown child a ypar
old suffering from inflammafion of the lungs. He was lying
on his mother’s lap, respiration being from 50 to 60 a minute,
with deep episternal and hypogastric depression, inflated
nostrils, lips blue, &